Practical Cardiovascular Medicine

Preface xx Abbreviations xxi About the Companion Website xxiv Part 1. Coronary Artery Disease 1 1. Non- ST- Segment Elevation Acute Coronary Syndrome 1 I. Definition types of myocardial infarction and pitfalls 1 II. Clinical features ECG cardiac biomarkers and echocardiography in ACS 6 III. Initial approach to acute chest pain presentations and the use of conventional and high- sensitivity troponins 8 IV. Management of NSTEMI 10 V. General procedural management after coronary angiography: PCI CABG or medical therapy only 14 VI. Discharge medications in NSTEMI 14 VII. Prognosis 17 Appendix 1. Complex angiographic disease- Moderate disease progression 17 Appendix 2. Women and ACS elderly patients and ACS CKD 18 Appendix 3. Bleeding transfusion patients on chronic warfarin or NOAC gastrointestinal bleed 19 Appendix 4. Antiplatelet and anticoagulant therapy 20 Appendix 5. Difference between plaque rupture and plaque erosion 23 Appendix 6. Spontaneous coronary artery dissection 23 Appendix 7. Harmful effects of NSAIDs and cyclooxygenase- 2 inhibitors in CAD 25 Appendix 8. Additional ideas on the physiology of hs- troponin- Role of hs- troponin in primary prevention 25 Questions and answers 25 2. ST- Segment Elevation Myocardial Infarction 38 1. Definition reperfusion and general management 39 I. Definition 39 II. Timing of reperfusion 39 III. ECG phases of STEMI 40 2. Stemi Complications 50 I. Cardiogenic shock 50 II. Mechanical complications 53 III. Recurrent infarction and ischemia 55 Appendix 1. Out- of- hospital cardiac arrest: role of early coronary angiography and therapeutic hypothermia 60 Questions and answers 62 3. Stable Ischemic Heart Disease and Approach to Chronic Chest Pain 74 I. Causes of angina and pathophysiology of coronary flow 74 II. Diagnostic approach 75 III. Silent myocardial ischemia. Is there a role for screening asymptomatic patients and post- PCI patients? 78 Appendix 1. Notes on various surgical grafts 86 Appendix 2. Coronary vasospasm (variant angina Prinzmetal angina) 88 Appendix 3. Microvascular endothelial dysfunction 90 Appendix 4. Women with chest pain and normal coronary arteries 90 Appendix 5. Diagnostic strategy for ischemia with non- obstructed coronary arteries (INOCA) 91 Appendix 6. Myocardial bridging 91 Appendix 7. Coronary collaterals chronic total occlusion 92 Appendix 8. Hibernation stunning ischemic preconditioning 92 Questions and answers 93 Part 2. Heart Failure (Chronic and Acute Heart Failure Specific Cardiomyopathies and Pathophysiology) 103 4. Heart Failure 103 Definition Types Causes and Diagnosis of Heart Failure 104 1. Definition and types of heart failure 104 I. Heart failure is diagnosed clinically not by echocardiography 104 II. After HF is defined clinically echocardiography is used to differentiate the three major types of HF 105 III. Two additional types of HF 107 2. Causes of heart failure 107 I. Systolic HF or HF with reduced EF (HFrEF) 107 II. HF with preserved EF (HFpEF) 108 III. Right HF 110 3. Diagnostic tests 110 I. Echocardiography 110 II. BNP 111 III. ECG 112 IV. Coronary angiography and other ischemic tests 112 Chronic Treatment of Heart Failure 113 1. Treatment of systolic heart failure 113 I. Treat the underlying etiology: target BP and CAD 113 II. Value of revascularization in ischemic cardiomyopathy: STICH trial 113 2. Treatment of HFpEF 124 Acute Heart Failure and Acutely Decompensated Heart Failure 126 I. Triggers of acute decompensation 126 II. Profiles of acute HF: congestion without low cardiac output congestion with low cardiac output 127 Appendix 1. Management of isolated or predominant RV failure 135 Questions and answers 138 5. Additional Heart Failure Topics 156 1. Specific cardiomyopathies 156 I. Arrhythmia- induced cardiomyopathy 156 II. Viral myocarditis 157 2. Advanced heart failure: heart transplant and ventricular assist devices 163 I. Stages of HF 163 II. Cardiac transplantation 163 3. Pathophysiology of heart failure and hemodynamic aspects 166 I. LV diastolic pressure in normal conditions and in HF (whether systolic or diastolic) 166 II. Definition of afterload 167 Questions and answers 173 Part 3. Valvular Disorders 181 6. Valvular Disorders 181 1. Mitral regurgitation 182 I. Mechanisms of mitral regurgitation 182 II. Specifics of various causes of mitral regurgitation 182 2. Mitral stenosis 192 I. Etiology and natural history 192 II. Diagnosis 193 III. Treatment 197 3. Aortic insufficiency 199 I. Etiology 199 II. Pathophysiology and hemodynamics 200 III. Diagnosis 200 4. Aortic stenosis 203 I. Etiology 203 II. Echo and catheterization diagnosis pitfalls and hemodynamics 204 5. Tricuspid regurgitation and stenosis 213 I. Etiology of tricuspid regurgitation 213 II. Natural history of TR 215 6. Pulmonic stenosis and regurgitation 216 I. Pulmonic stenosis 216 II. Pulmonic regurgitation 216 7. Mixed valvular disease; radiation heart disease 217 I. Mixed single- valve disease 217 II. Multiple valvular involvement (combined stenosis or regurgitation of two different valves) 217 III. Radiation heart disease 217 8. Prosthetic valves 218 I. Bioprosthesis versus mechanical prosthesis 218 II. Determinants of valve degeneration and valve thrombosis; anticoagulation guidelines 218 III. Particular cases: women who wish to become pregnant and dialysis patients 220 IV. Echocardiographic follow- up of prosthetic valves 221 V. Complications 221 9. Auscultation and summary ideas 223 I. Auscultation and other physical findings 223 II. General ideas and workup 226 Questions and answers 227 Part 4. Hypertrophic Cardiomyopathy 243 7. Hypertrophic Cardiomyopathy 243 I. Definition and features of HCM 243 II. Natural history and mortality 245 III. Symptoms and ECG 246 Questions and answers 253 Part 5. Arrhythmias and Electrophysiology 257 8. Approach to Narrow and Wide QRS Complex Tachyarrhythmias 257 I. The unstable patient 257 II. Initial approach to any tachycardia 257 9. Ventricular Arrhythmias: Types and Management Sudden Cardiac Death 274 I. Premature ventricular complexes 274 II. Ventricular tachycardia 276 III. Polymorphic ventricular tachycardia 278 Questions and answers 288 10. Atrial Fibrillation 294 I. Predisposing factors 294 II. Types of AF 295 III. General therapy of AF 295 X. AF burden as a correlate and a driver of HF progression 303 Appendix 1. Optimal heart rate and AF rate for optimal cardiac output 303 Appendix 2. Antiarrhythmic drug therapy 303 Appendix 3. Catheter ablation of atrial fibrillation surgical ablation AV nodal ablation 305 Appendix 4. INR follow- up in patients receiving warfarin- Non- vitamin K oral anticoagulants 306 Appendix 5. Bridging anticoagulation in patients undergoing procedures 308 Appendix 6. Management of elevated INR values 309 Appendix 7. Left atrial appendage surgical and percutaneous closure 309 Appendix 8. A common situation: AF and symptomatic pauses or bradycardia 309 Appendix 9. DC cardioversion in patients with a slow ventricular response 310 Appendix 10. AF occurring post- cardiac surgery and AF related to acute transient triggers 310 Appendix 11. Brief asymptomatic runs of AF on device interrogation and association with stroke. Role of rhythm monitoring after cryptogenic stroke 310 Questions and answers 311 11. Atrial Flutter and Atrial Tachycardia 319 I. Atrial flutter 319 II. Focal atrial tachycardia 322 III. Multifocal atrial tachycardia (MAT) (or chaotic atrial tachycardia) 325 Questions and answers 326 12. Atrioventricular Nodal Reentrant Tachycardia Atrioventricular Reciprocating Tachycardia Wolff–Parkinson– White Syndrome and Junctional Rhythms 329 I. Inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) 329 II. Atrioventricular nodal reentrant tachycardia (AVNRT) 329 III. Atrioventricular reciprocating tachycardia (AVRT) and Wolff–Parkinson–White (WPW) syndrome 332 Questions and answers 342 13. Bradyarrhythmias 345 I. AV block 345 II. Sinus node dysfunction 354 Questions and answers 359 14. Permanent Pacemaker and Implantable Cardioverter Defibrillator 363 I. Indications for permanent pacemaker implantation 363 II. Types of cardiac rhythm devices 363 Appendix. Cases of PM troubleshooting 381 Questions and answers 386 15. Basic Electrophysiologic Study 390 I. General concepts; intracardiac electrograms 390 II. AV conduction abnormalities 390 16. Action Potential Features and Propagation: Mechanisms of Arrhythmias Antiarrhythmic Drugs 403 I. Action potential 403 II. Action potential propagation and mechanisms of arrhythmias 403 Part 6. Pericardial Disorders 411 17. Pericardial Disorders 411 1. Acute pericarditis 412 I. Causes of acute pericarditis 412 II. History and physical findings 412 2. Tamponade 414 I. Definition 414 II. Pathophysiology and hemodynamics 414 3. Pericardial effusion 417 I. Causes of a pericardial effusion with or without tamponade 417 II. Management of asymptomatic effusions and role of pericardiocentesis 418 4. Constrictive pericarditis 421 I. Causes 421 II. Pathophysiology and hemodynamics 421 Questions and answers 429 Part 7. Congenital Heart Disease 435 18. Congenital Heart Disease 435 1. Acyanotic congenital heart disease 435 I. Atrial septal defect (ASD) 435 II. Patent foramen ovale (PFO) 439 2. Cyanotic congenital heart disease 444 I. Pulmonary hypertension secondary to shunt 444 II. Tetralogy of Fallot 445 3. More complex cyanotic congenital heart disease and shunt procedures 447 I. Functionally single ventricle and Fontan procedure 447 II. Transposition of great arteries (TGA) 449 Questions and answers 452 Part 8. Peripheral Arterial Disease 457 19. Peripheral Arterial Disease 457 1. Lower extremity peripheral arterial disease 457 I. Clinical tips 458 II. Clinical classification of PAD: critical limb ischemia acute limb ischemia atheroembolization 459 2. Carotid disease 466 I. Assessment of carotid stenosis 466 II. Medical therapy of carotid stenosis 467 3. Renal artery stenosis 469 I. Forms of renal artery stenosis 469 II. Screening and indications to revascularize renal artery stenosis 469 III. Notes 470 Questions and answers 470 20. Aortic Diseases 476 I. Aortic dissection 476 II. Thoracic aortic aneurysm 480 III. Abdominal aortic aneurysm 484 Part 9. Other Cardiovascular Disease States 487 21. Pulmonary Embolism and Deep Vein Thrombosis 487 1. Pulmonary embolism 487 I. Presentation of pulmonary embolism and risk factors 487 II. Probability of PE 488 III. Initial workup 488 2. Deep vein thrombosis 494 I. Types 494 II. Diagnosis 494 3. Immune heparin- induced thrombocytopenia 494 I. Incidence 495 II. Diagnosis 495 Questions and answers 495 22. Shock and Fluid Responsiveness 499 1. Shock 499 I. Shock definition and mechanisms 499 II. Goals of shock treatment 500 2. Fluid Responsiveness 503 Appendix. Hemodynamic equations transfusion and miscellaneous concepts 505 Questions and answers 507 23. Hypertension 511 1. Hypertension 511 I. Definition 511 II. ACC and ESC targets of therapy and rationale 512 2. Acute severe hypertension: hypertensive emergencies and urgencies 521 I. Definitions 521 II. Treatment of hypertensive emergencies 521 Questions and answers 523 24. Dyslipidemia 529 I. Indications for therapy 529 II. Notes on LDL HDL and triglycerides 530 Questions and answers 534 25. Pulmonary Hypertension 538 I. Definition 538 II. Categories of PH 538 Questions and answers 543 26. Syncope 547 I. Neurally mediated syncope (reflex syncope) 547 II. Orthostatic hypotension and postural orthostatic tachycardia syndrome 548 III. Cardiac syncope 549 Questions and answers 556 27. Chest Pain Dyspnea Palpitations 561 1. Chest Pain 561 I. Causes 561 II. Features 562 2. Acute Dyspnea 564 I. Causes 564 II. Notes 565 III. Management 566 3. Palpitations 567 I. Causes 567 II. Diagnosis 567 28. Infective Endocarditis and Cardiac Rhythm Device Infections 570 1. Infective endocarditis 570 I. Clinical diagnosis 570 II. Echocardiography: timing and indications 570 III. Organisms 571 2. Cardiac rhythm device infections 574 I. Organisms and mechanisms of infection 574 II. Diagnosis 574 29. Preoperative Cardiac Evaluation 577 I. Steps in preoperative evaluation 578 II. Surgical risk: surgery’s risk and patient’s risk 578 III. CARP and DECREASE V trials 579 Questions and answers 581 30. Miscellaneous Cardiac Topics: Cardiac Masses and Tumors Pregnancy HIV and Heart Disease Cocaine and the Heart Chemotherapy and Heart Disease Chest X‐Ray 584 1. Cardiac masses 585 I. Differential diagnosis of a cardiac mass 585 II. Cardiac tumors; focus on atrial myxoma 585 2. Pregnancy and heart disease 586 I. High‐risk cardiac conditions during which pregnancy is better avoided 587 II. Cardiac conditions that are usually well tolerated during pregnancy but in which careful cardiac evaluation and clinical and echo follow‐up are warranted 587 3. HIV and heart disease 590 I. Pericardial disease 590 4. Cocaine and the heart 590 I. Myocardial ischemia 590 II. Other cardiac complications of cocaine 591 5. Chemotherapy and heart disease 591 I. Cardiomyopathy 591 II. Myocardial ischemia 592 6. Chest X‐ray 593 I. Chest X‐ray in heart failure 593 II. Various forms of cardiomegaly 594 Questions and answers 596 Part 10. Cardiac Tests: Electrocardiography Echocardiography and Stress Testing 601 31. Electrocardiography 601 I. Overview of ECG leads and QRS morphology 601 II. Stepwise approach to ECG interpretation 604 III. Rhythm and rate 605 Appendix 1. Supplement on STEMI and Q‐wave MI: phases and localization 653 Appendix 2. Spread of electrical depolarization in various disease states using vector illustration 658 Questions and answers 659 32. Echocardiography 666 1. General echocardiography 666 I. The five major echocardiographic views and the myocardial wall segments 666 II. Global echo assessment of cardiac function and structure 666 III. Doppler and assessment of valvular regurgitation and stenosis 676 2. Transesophageal echocardiography (TEE) views 703 Appendix. Note on LV mechanics and myocardial tissue strain 713 33. Stress Testing Nuclear Imaging Coronary CT Angiography cardiac MRI cardiopulmonary exercise testing 714 I. Indications for stress testing 714 II. Contraindications to all stress testing modalities 715 III. Stress testing modalities 715 Part 11 Cardiac Tests: Invasive Coronary and Cardiac Procedures 733 34. Angiographic Views: Coronary Arteries and Grafts Left Ventricle Aorta Coronary Anomalies Peripheral Arteries Carotid Arteries 733 I. Right coronary artery 733 II. Left coronary artery 734 III. Coronary angiography views. Recognize the angle of a view: LAO vs. RAO cranial vs. caudal 735 Questions and answers 765 35. Cardiac Catheterization Techniques Tips and Tricks 768 I. View for the engagement of the native coronary arteries: RAO vs. LAO 768 II. Design of the Judkins and Amplatz catheters 768 III. Engagement of the RCA 768 36. Hemodynamics 790 I. Right heart catheter 790 II. Overview of pressure tracings: differences between atrial ventricular and arterial tracings 790 III. RA pressure abnormalities 790 Appendix 1. Advanced hemodynamic calculation: a case of shunt with pulmonary hypertension 808 Questions and answers: Additional hemodynamic cases 809 37. Intracoronary Imaging 815 1. Intravascular ultrasound (IVUS) 815 I. Image basics 815 II. Plaque types 818 2. Optical coherence tomography (OCT) 823 38. Percutaneous Coronary Interventions and Complications Intra‐Aortic Balloon Pump Ventricular Assist Devices and Fractional Flow Reserve 826 I. Major coronary interventional devices 826 II. Stent thrombosis restenosis and neoatherosclerosis 828 III. Peri‐PCI antithrombotic therapy 830 Questions and answers 845 Appendix: General review questions 851 1. Questions 851 I. NSTEMI and STEMI 851 II. Stable CAD 855 III. Heart failure and cardiomyopathies 858 2. Answers 901 Index 931