WOMEN AND HEART DISEASE 653 Nurse \200\231s Health Study, which showed a relationship between folate and B6 intake and incidence of CHD events. The concern that the observed relation of homocysteine and vitamin B6/folate to CHD risk ma y actually represent unrecognized confounders rather than a true causal relationship has le d to the development of rand- omized clinical trials. Similar to the HRT and vitamin E stor y, randomized controlled studies evaluating the role of vitamin B6 and folate in the sec- o ndary prevention of CHD have been negative (NORVIT trial). The role of these vitamins in the primary prevention of CHD, however, is still a question. Until a randomized, clinical trial addresses this issue, the routine use of these supplemen ts in primary prevention of CHD in women is not recommended. Role of omega 3 fatty acid supplements The observation that populations with a high intake of \201 sh have a lower rate of cardiovascular disease initially led to the hypothesis th at \201 sh con- sumption may have a protective effect for atherosclerosis (Box 16.2). Several prospective epidemiological studies in men have lent support to this hypothesis. Si milar risk reductions were also observed in women in the Nurse \200\231s Health Study cohor t. Although these epidemiological data are compelling, to date, there are no randomized con trolled clinical trials to support the role of \201 sh or \201 sh oil in the primary pr evention of CHD events in women. Currently, the JELIS investigators are following 10,796 postmenopausal women and 4204 men w ho were free of CHD, in a trial of eicosapentae- noic acid (EPA), a component of \201 sh oil, in addition to treatment with a statin in hyperlipidemic patients for 5 years. The pri mary end points in this trial are major coronary events (sudden cardiac death, fatal and no nfatal MI, unstable angina, and coronary revascularization). The initial results of this trial, which were presented at the American Heart Association s cienti \201 c session in 2005, revealed a 19% risk reduction in major cardiovascular event s (RR 0.81, 95% CI 0.69 \200\2230.95) in the group treated with EPA plus statin therapy, co mpared to statin therapy alone, and a 24% risk reduction in unstable angina (RR 0.76, 95% C I 0.62 \200\2230.95). In contrast to the dearth of data from randomized controlled trials on the role of \201 s h oil in the primary prevention of CHD, there have been sev- eral observational trials and randomized controlled clinical trials showing Box 16.2 Proposed biological mechanisms for omega 3 fatty acid CV protective effects \200 \200 \200 \200 Reduced susceptibility of the heart to ventricular arrhythmias Antithrombogenic properties Lowering of triglyceride levels Retardation of atherosclerotic plaque growth via reduced ad hesion molecule expression Reduction in platelet derived growth factor Anti-in \202 ammato ry mediator Promotion of NO-induced endothelial relaxation \200 \200 CHAPTER 16 Special populations: women and elderly 654 a bene \201 t of \201 sh oil on the secondary prevention of CHD events (GISSI- Prevenzio ne trial). The low number of female subjects participating in these trials, however, limits the applicability of the results to women. Although the data are limited in women at this time, it is reasonable to recommend the use of n-3 omega fatty acids for the secondary preven- tion of CHD events in women who have rec ently had an MI. The recent results from the JELIS study also support the recommendation of adding \201 sh oil to the treatment of hyperlipidemics in the primary prevention of CHD events. Aspirin use in women Aspirin for primary prevention in women The role of aspirin in the sec ondary prevention of cardiovascular events is well established in both men and women. The r ole of aspirin in the pri- mary prevention of cardiovascular disease in women, on the other hand, is not clear. The Physician \200\231s Health Study, which was the \201 rst trial to uncover a sig- ni \201 cant 44% reduction in \201 rst MI with aspirin use only included men in its subject population. The data from the Hypertension Optimal Treatment Study (HOT) and the Primary Pr evention Project, (each trial included about 50% women) present a less than convincing argu ment for the use of aspirin in the primary prevention of MI in women. The Women \200\231s Health Study sought to \201 nally answer this question in women. This study enrolled 39,876 women who were free of cardiovas- cular disease and had low-risk car diovascular pro \201 les. The investigators found a nonsigni \201 cant 9% risk reduction in major cardiovascular events, with no signi \201 cant effect on fatal or nonfatal MI and with a concomitant increase in the rate of bleeding complications in those taking aspirin. Only in the subgroup of women over the age of 65 did they \201 nd a signi \201 cant red uction in major cardiovascular events and in MI event rate. Based on these data, there does not appear to be a clear role for aspi- rin in the primary prevention of cardiovascular disease in women in the low-risk female population. There may be a bene \201 t in the elderly female population. However, given the risk of bleeding complications, this needs to be fur- ther evaluated wit h a large-scale trial dedicated to answering this question. Although there is no clear role of aspirin use in the primary prevention of CHD events in women, this does not negate its use in women with estab- lished coronary artery disease, especially in the setting of acute myocardial infarction or post-angioplasty and stenting. Cholesterol and in \202 ammatory biomarkers of CHD in women Optimal lipid levels in women for secondary prevention of CHD The role of LDL cholesterol in the development of atheroscl erosis has been well established. However, the best lipid parameter for predicting CHD even ts in women continues to be an issue of some debate. In a nested case \200\223control study from the Nurse \200\231s Health Study cohort, the data suggest that measurements of both L DL and HDL are essential in the prediction of CHD events in women. WOMEN AND HEART DISEASE 655 A similar contribution to the prediction model was seen when the ratio of total cholesterol to HDL was added (ROC increased to 0.72). This ratio re \202 ects the proportion of ather ogenic-to-antiatherogenic lipid fractions and appears to be a powerful tool for predicting CHD in postmenopausal women. From these data it follows that lowering LDL cholesterol and rais- ing HDL cholesterol shou ld play a role in CHD prevention in women. Accordingly, the data from secondary prevention randomized controlled trials of statin therapy have shown reduced risks of CHD events in wo men placed on statin therapy. The female subgroup analyzes of the 4S trial, the CARE trial, and the PROVE-IT-TIMI22 trial have all shown signi \201 cant reductions in major coronary events in women with known CA D who are placed on statins. Based on observational and clinical trial data, the goal LDL i n women with a history of CHD or diabetes should be (cid:100)70 mg/dL. Role of CRP in predi cting CHD risk in women In addition to LDL and HDL cholesterol, recent data have shown that vari- ous markers of in \202 ammation are also potent predictors of CHD events in women. Women in general have higher CRP levels than those in men, and black women have signi \201 cantly higher CRP levels than white, Hispanic, or Asian women. These higher CRP levels may provide insight into the pathogenesis of angina in women with n onobstructive coronary disease and further aid in assessing CHD risk in women. Using the Women \200\231s Health Study cohort (27,939 women), both CRP and LDL were identi \201 ed as strong, independent predictors of cardiovascular events, each measurement ident ifying different high-risk groups. Screening for both markers provided better information t han either measurement alone. In fact, 77% of \201 rst cardiovascular events occurred in women with an LDL <160 mg/dL and 46% occurred in women with LDL <130 mg/dL. The addition of CRP measurements would have helped to identify at-risk women that were missed by the stand ards set by the National Cholesterol Education Program. The JUPITER trial, a prospective, randomized controlled study of the use of rosuvastatin in the primary prevention of cardiovascular disease in patients with low LDL cholesterol leve ls (<130 mg/dL) and elevated CRP levels ((cid:116) 2 mg/L), has recently con \201 rmed the se observational data. By tar- geting women with elevated CRP, even in the absence of signi \201 cant LDL elevation, we will be able to identify more women who are at risk of CHD an d be able to aggressively treat them with statin therapy. CHAPTER 16 Special populations: women and elderly 656 The elderly and heart disease Coronary heart disease (CHD) Coronary heart disease is the le ading cause of death in the United States in patients older than 65 years of age. Patients over the age of 65 account for greater than 50% of all myocardial infarctions, CABG procedu res, and about 45% of all percutaneous coronary interventions. As the life expectancy of Americans continues to increase, the popula- tion at risk for CHD and its complications will also increase. It is therefore imperative to pursue aggressive primary and secondary prevention meas- ures in these patients to determine any unique inter action or considera- tions for this group and to establish standard preventive and therapeu tic strategies in this growing segment of the American population. Treatment of dyslipidemia in the elderly Given that the absolute risk for CHD increases wit h age, the absolute numbers of people bene \201 ting from cholesterol lowering is greater in the elderly patient population. As with a younger patient cohort, total choles- terol, l ow HDLc, and high LDLc have all been shown to be signi \201 cant risk factors for CHD in t he elderly. Although it was previously thought that it would take several years to see a potential bene \201 t from statin therapy on the course atherosclerosis, there- fore limiting its use in an elderly population, it has now been shown that the clinical bene \201 ts of statins ca n be seen as early as 6 months and that they can improve endothelial dysfunction within 3 d ays of initiating therapy. The secondary prevention trials of LDLc-lowering therapies have shown signi \201 cant redu ctions in cardiac events in the studied populations. The applica- bility of these results, however, to an elderly patient population is somewhat limited secondary to the small number of elderly subjects in these studies. In subgroup analyzes of the studies that did include elderly patients, there does appear to be a similar bene \201 t to lipid lowering in this cohort of elderly patients to that for younger patients (see Table 16.2). Similarly, the limited data available for the use of st atins in the primary prevention of CHD in the elderly also supports its use in this group. Currently, lipid-lowering therapy is markedly underused in the elderly. In the absence of o ther contraindications, lipid-lowering therapy should be initiated in the elderly following the same ATP III guidelines used to guide therapy in a younger patient population. Treatment of hypertension in the elderly Similar to dyslipidemia, hypertension (HTN) is a c ommon problem in the elderly, with a prevalence of over 60% in patients over the age of 60 years. There is a large body of literature supporting the bene \201 t of treating HTN in t he elderly, including patients over the age of 80 years. In a meta-analysis of trials of tr eatment of isolated systolic HTN, it was found that only 19 patients over the age of 70 wou ld need to be treated for 5 years in order to prevent one cardiovascular event. When initiating antihypertensive therapy in the elderly, there may be several potential lim iting factors, namely postural/postprandial hypo- tension and sluggish baroreceptor and sym pathetic nervous system THE ELDERLY AND HEART DISEASE 657 Table 16.2 Lipid-lowering therapy in those over 65 years old Study No. of elderly subjects Results 4S 1021 subjects >65 years old 34% lower all-cause mortality, 43% lower CHD mortality, 34% lower MACE, 41% lower revascula rization procedures CARE 1283 subjects between 65 and 75 years old For every 1000 elderly patients treated, 225 CV hospitalizations and 207 CV events were pre vented. LIPID 3514 subjects between 65 and 75 years old Absolute bene \201 t was greater in the elderly compared to the younger patients (fewer pa tients needed to be treated to prevent a death, MI, or stroke). HPS 20K patients age 40 \200\22380 years old Similar reduction in CV events in patients above and below age 65 CARDS N/A 38% reduction in \201 rst CV event in subjects older than 65 years Box 16.3 Antihypertensive therapy in the elderly \200 \200 First line: thiazide diuretics Second line: ACE inhibitor/ARB or long-acting dihydropyridin e calcium channel blocker (i.e., amlodipine) B \200 Blockers should not be used as primary therapy for hypertension in the elderly in the absen ce of another speci \201 c indication (i.e., prior MI or CHF) responsiveness, as well as impaired cerebral autoregulation, which neces- sitates cautious initiation of therapy to prevent or minimize ischemic and orthostatic side effects (see Box 16.3). Therefore, when starting antihypertensive therapy, lower initial doses should be used (about one-half the dose used in younger patients). Valvular heart disease in the elderly Aortic stenosis Calci \201 c or degenerative aortic valve disease is the most common valvular abnormality seen in the elderly. The prevalence o f at least moderate aortic stenosis (AVA <1.2 cm2) in patients aged 75 \200\22385 years old was 5% in the Helsinki Aging Study. Currently, the recommendations for aortic valve placement in aortic stenosis are the same a s in the younger patient population, namely devel- opment of symptoms, severe AS in patient s undergoing CABG or other valve surgery, or severe AS with LVEF <50%. However, when considering aortic valve replacement in the elderly, it is important to note that elderly patients typically have poorer preop- erative status than that of younger pati ents, leading to higher in-hospital CHAPTER 16 Special populations: women and elderly 658 mortality, ranging between 5% and 18% in various studies with age being a very important de terminant of outcome. Elderly patients also have more nonfatal complications and longer peri- operative hospitali zations than a younger patient cohort. However, if the elderly patient survives the periope rative period, the patient typically does very well with good long-term survival and signi \201 cant improvement in symp- toms (similar survival to the general population of age-mat ched subjects). Therefore, more and more elderly patients are being considered for aortic v alve surgery as surgical and supportive techniques continue to improve. In addition, for patients who are considered too high a risk for surgical correction, percu taneous aortic valve replacement techniques are cur- rently being developed in Europe and S outh America and may eventually be a viable alternative therapy in the elderly patient popu lation. Aortic regurgitation Aortic regurgitation is less common in the elderly than calci \201 c aortic ste- nosis or mitral regurgitation and is most often associated with aortic ste- nos is or dilation of the ascending aorta from long-standing hypertension. Although prophylactic aortic valve surgery is usually recommended for asymptomatic patients with severe aortic insuf \201 ciency (AI) and evidence of LV dysfunction, in the elderly (especially patients over the age of 80), it is recommended that aortic valve surgery be re served for those patients with symptoms and severe AI, given the increased risk of operativ e and long-term mortality with increasing age. Mitral regurgitation Mitral regurgitation (MR) is the second most common indication for val ve surgery in the elderly, accounting for 30% \200\22335% of cases. Myxomatous degeneration of the valve and ischemic heart disease are the two most common etiologies of mitral regur gitation in this patient population. Similar to aortic regurgitation, it is preferable to refer patients over the age of 80 for mitral valve surgery only if they are symptomatic, as the 30-day mor- tality in patients ov er the age of 80 is >10% with mitral valve replacement. The outcome after surgery varies on the basis of patient age, comor- bidites, and disease s everity and is improved with mitral valve repair com- pared to replacement. In addition, it has been shown that functional MR secondary to ischemia may improve signi \201 cantly wit h CABG alone, thereby simplifying any potential procedure in this higher-risk patient popul ation. Mitral stenosis Mitral stenosis remains a disease primarily of younger patients, with rheu- matic heart disease being the most common etiology. In elderly patients the most common ca use of mitral stenosis is impingement on the mitral valve by mitral annular calci \201 cat ion. The preferred surgical treatment for mitral stenosis is mitral commis- surotomy. However, t his is often not possible in the elderly, necessitating mitral valve replacement. The ideal treatment for those elderly patients with favorable valvular morphology is percut aneous valvotomy. However, the number of eld- erly patients who have valvular morphology am enable to this technique is quite limited. 659 Index Chapter 2 Aortobifemoral bypass, penetrating aortic ulcer, 12 lead ECG and rhythm, 150 \200\2231 163 \200\2234 356 Area Length method, 462 Arrhythmias, 59 \200\22360, 344 \200\2235, thoracic aortic aneurysm (TAA), 161 Aortic dissection, 40 \200\2232 assessment, 40 \200\2232 classi \201 cation, 40 differential diagnosis, 47 presentation, 40 \200\2231 A ACE inhibitor, 37 Acute coronary syndromes, 348,396 \200\2237 Cardiac arrhythmias, 217 ECG diagnosis of tachyarrhythmias, 367 \200\2238 89 \200\22390 conditions mimicking ECG diagnosis of Commonly used pain, 90 tachycardia, 368 classi \201 cation systems for, 164 nomenclature, 90 Fascicular tachycardia, 385 Junctional tachycardia, Adult Treatment Panel conditions associated (ATP), 274 377 with, 40 Advanced cardiac life support pulseless 8 Narrow complex investigations, 43 \200\2234 diagnostic, 43 \200\2234 general, 43 tachycardias (NCTs), 367 \200\2238 Airway Management Insertion of Nonsustained ventricular tachycardia (VT), 73 management, 45 \200\2237 medical therapy, 46 TEE, 475 nasopharyngeal airway, 6 reperfusion, 99 Right ventricular out \202 ow Alcohol Aortic intramural hematoma chronic alcohol excess, tract (RVOT) tachycardia and sinus rhythm, 386 (AIH), 475 299 Aortic regurgitation, 193 \200\2235 septal ablation, 293 \200\2234 Alcoholic cardiomyopathy, Acute, 16 \200\22317 causes, 16 diagnosis, 16 management, 16 \200\22317 presentation, 16 ca uses, 193 sinus bradycardia, 358 causes, 358 management, 358 sinus nodal reentrant tachycardia, 373 s inus node reentrant 299 American College of Cardiology/American Heart Association (ACC/AHA), 137 Amoebic pericarditis , 324 Angina pect oris, 86 Angiotensin II receptor blockers (ARBs), 232 angiotensin-converting enzyme (ACE), 14 Anion-exchange resins, 273 Ankle-brachial indices Aortic Root disease, 193 Valvular, 193 tachycardia (SNRT), 373 diagnostic test, 194 echocardiography, 486 incidence, 193 sinus pause, 359 sinus tachycardia, 373 supraventricular, 366 tachycardia: emergency manage ment, 369 \200\22370 Ventricular tachycardia, aortic Root disease, 193 physical Exam, 193 \200\2234 prognosis, 194 symptoms, 193 treatment, 195 (ABI), 141 384 Ankylosing spondylitis, VT in the normal Aortic stenosis, 188 \200\2239 440 \200\2231 heart( \200\234benign \200\235 VT), 385 calci \201 c, 188 causes of Valvular AS, 188 differential diagnosis Antibiotic prophylaxis, 178 Antioxidant vitamins, 260 Antiplatelet therapy, 149 Aortic dise ase, 161 \200\2234 abdominal aortic VT with impaired LV function, 387 of LVOT obstruction, 188 Wolff-Parkinson-White [WPW], 367 \200\2238 echocardiography, 468 \200\2239 incidence, 188 management, 190 \200\2232 pathophysiology, 1 89 physical exam, 189 rheumatic, 188 symptoms and aneursym (AAA), 161 aortic atheroembolism, Arrhythmogenic right ventricular cardiomyopathy (ARVC), 297 \200\2238, 388 Arteriovenous Fistulas 161 aortic dissection, 161 Diagram of deployment of an aortic stent graft, 163 Systemic arteriovenous \201 stulas, 244 presentation, 189 Aortic valve replacement incomplete aortic rupture, ASCOT study, 267 aspartamine transferase 164 (AVR), 190 management of abdominal aortic aneuryms, 162 percutaneous, 192 (AST), 95 INDEX 660 Conduction System Brugada syndrome, 389 The Asymptomatic Anatomy of the normal conduction system, 355 \202 ecainide challenge, 389 Bundle branch block, 362 common causes of, 362 Bundle branch tachycardia, Carotid Atherosclerosis Study (ACAS), 155 The cardiac conduction The atherogenic process, system, 354 \200\2235 His-Purkinje system, 390 247 Atherosclerosis, 139, 161 354 \200\2235, 362 CAD risk equivalents, 255 Cellular interactions in the development and progression of ather osclerosis, 250 C Calcium antagonists, 104 The Canadian Congenital heart disease (CHD), 330 assessment of patients with, 332 \200\2234 Cardiovascular Society (CCS), 5 \200\2236 Cardiac Arrest Rhythms, 7 \200\2238 corrected transposition, pathophysiology, 247 plaques, development of, 350 disease complexity and hierarchy of care for adults, 331 249 \200\22350 risk assessment, 252 \200\2235 Cardiac resynchronization therapy (CRT), 237, 403 Atrial \201 brillation (AF), 93 \200\2234, Imaging modalities in, 335 percutaneous 377 \200\2238 Cardiogenic shock diagnosis, 120 management, 120 \200\2231 evaluation, 379 \200\22380 management, 381 \200\2232 Atrial \202 utter (AFL), 374 Atrial septal defect, 346 Atrial tachyarrhythmia transcatheter interventions for, 341 \200\2232 Cardiomyopathy, 72 dilated, 288 hypertensive, 299 ischemic, 299 metabolic, 299 nutritional, 301 peripartum, 30 2, 406, S13 restrictive, 295 valvular, 299 cardiopulmonary speci \201 c management issues, 343 \200\2235 post-MI, 117 speci \201 c signs in patients Atrial tachycardia, 374 with, 336 focal, 374 macro-reentrant, 374 Atrioventricular block, 360 surgical operations for, 337 \200\2239 in adults, 331 causes of, 361 Continuous positive airways pressure (CPAP), 13 Coronary artery bypass graft failure, 489 C oronary Artery Bypass Atrioventricular nodal reentrant tachycardia (AVNRT), 375 atrioventricular node resuscitation (CPR), 2 \200\2234, 5 \200\2236 Cardioversion, DC, 78 \200\2239 Carotid artery disease, 155 Carotid endarterectomy, (AVN), 354 Grafting Atrioventricular reentrant tachycardia (AVRT), 376 emergency, 103 155 Coronary artery disease Catheterization, Cardiac, 181, 184, 190, 198, 202, 310 (CAD), 141 \200\2232, 259, 288 Atrioventricular septal/ Coronary artery disease (CAD): Coronary thrombosis, 249 \200\22350 Risk Factors, 256 \200 \22361 Counterpulsation, 80 canal defect (endocardial cushion defect), 346 Austin Flint murmur, 193 \200\2234 Automatic ity, 354 AV sequential pacing, 72 Central line insertion, 55 \200\2236 Central vein cannulation, 5 \200\2236 central venous catheter, 13, 29 \200\22330, 61, 111 Central Venous Pressure measurement, tips & B Bariatric surgery, 259 Barlow \200\231s syndrome, 186 Bifascicular block, 362 Blalock-Tau ssig shunt, D Deep vein thrombosis pitfalls, 56 Cerebrovascular disease, (DVT), 20 \200\2231 Above knee, 22 \200\2233 assessment, 20 \200\2231 155 chronic obstructive pulmonary disease (COPD), 9, 12, 88 CK-MB isoenzyme, 94 Claudication causes of, 139 Clopido grel, 104 Coanda effect , 478 Coarctation of the aorta, 337, 349 investigations, 20 \200\2231 presentation, 20 Bolus agents, 98 \200\2239 Bradyarrhythmias Below-knee DVT, 22 \200\2233 management, 22 \200\2233 indications for pacing, 118 general, 356 \200\2237 post-MI, 118 anticoagulation, 22 De \201 brillators The Branham sign, 244 broken heart syndrome, automated external (AEDs), 5 \200\2236 337 see Takotsubo cardiomyopathy ( \200\234broken heart syndrome \200\235) implantable cardiac (ICDs) Cocaine-induced MI, 115 \200\22316 237, 387, 395 diagnosis, 115 management, 115 \200\22316 Diabetes and atherosclerosis, 277 \200\2239 INDEX 661 medical therapy, 208 microbiology of infective, Framingham risk scoring system for women, 254 Diabetes mellitus (DM), 277 \200\2239 205 Therapeutic pathogenesis, 204 physical Exam, 204 \200\2236 prognosis, 208 prosthetic valve, 203 risk fa ctors, 205 subacute bacterial, 63 \200\2234 symptoms, 204 systemic embolization, fresh frozen plasma (FFP), recommendations for CV prevention, 279 Diaphragmatic pacing, 74 Dietary Guidelines (U.S.), 417 \200\22318 Friedreich \200\231s ataxia, 302 261 G General system disease, 301 Glenn shunt, 337 Glitazones decrease insulin resistance at ta rget tissues, 282 Dual-chamber pacing with short AV delay, 293 \200\2234 Duke criteria system, 207 Duplex son ography, 157 Dyssynchrony, mechanical, 206 TEE, 476 \200\2237 World Health 403 Organization 2001 guidelines for prophylaxis, 178 Endothelial dysfunction, 247 Endotracheal (ET) intubation, 5 \200\2236 Epidemiology, 135, 251 Erythema marginatum , Gore-Tex tube, 337 E Ebstein \200\231s anomaly of the tricuspid valve, 350 H Heart Failure Echocardiography ACE inhibitors for , 226 Algorithm summarizing Cardiac Masses, 491 doppler, 188 Intraoperative TEE, 489 M-mode, 450 prosthetic aortic valv es, recommendations for the diagnosis of heart failure, 220 176 \200\2237 in rheumatic fever, 177 Exercise ECG, 446 \200\2237 angiotensin II receptor antagonists for, 232 antiplatelet agents and anticoagulants, 236 causes of false-positive 488 tests, 448 The standard TTE, 456 \200\2239 stress, 462 \200\2233 Transesophageal External cardiac pacing, 357 Extracardiac complications, B-blockers, 229 causes and Precipitants, 351 \200\2232 echocardiography (TEE) , 18, 43, 470 \200\2233 Transthoracic Doppler imaging, 453 \200\2235 217 F Fat embolism, 29 \200\22330 clinical features, 29 differential diagnosis, 29 investigatio ns, 29 management, 29 \200\22330 fatty streaks, 249 \200\22350 Fibroelastomas, 491 \201 b romuscular dysplasia conditions mimicking, 216 de \201 nition, 212 device therapy for, 237 diagnosis and initia l workup, 219 \200\22321 Transthoracic echocardiography (TTE), 18, 43, 449 \200\22351 Ehlers-Danlos syndrome, diastolic, 242 \200\2233 assessment of, 242 digoxin in, 235 diuretics in, 224, 225 drug the rapy, concomitant, 432 \200\2233 Eisenmenger syndrome, 346 Eisenmenger \200\231s syndrome, 411 \200\22312 Electrocardiogram, 88 Electromechanical (FMD), 157 \200\2239 \202 oppy mitral valve syndrome, 186 Fluoroscopy, 200 \200\2232 \202 uoroscopy guidance, 68 \200\22370 focal pulmonary oligemia, 25 Fontaine, Rene, 135 Fon tan operation, 339 Fontan patients, 349 foot and leg ulcers, 217 etiology, 218 forms, 215 dissociation (EMD), 28 Endless loop tachycardia (pacemaker-mediated tachycardia [PMT]), 401 acute vs. chronic heart failure, 215 high-output vs. low- endocardial edema, 73 Endocarditis, 204 \200\2239 output heart failure, 215 antibiotic prophylaxis during dental procedures, 208 right vs. left heart failure, 215 differential diagnosis of, 140 systolic vs. diastolic heart failure, 215 cardiac complications, 206 diagnosis, 207 echocardiography, 207 epidemiology, 204 extracard iac Framingham criteria for management, 222 miscellaneous drugs diagnosis of heart failure, 221 for, 236 Framingham Heart Study, Pacemakers for chronic heart failure, 403 \200\2234 palliative care for, 240 Pathophysiolog y of, 214 phosphodiesterase inhibitors in, 236 manifestations in infective, 206 251 Framingham Offspring indications for Surgery, Study, 257 208 Framingham risk scoring system for men, 253 Libman-Sacks, 428 \200\2239 INDEX 662 arrest algorithm, 8 basic, 2 \200\2234 stages, 2 positive inotropic support, Equilibrium radionuclide angiography (ERNA), 501 236 side effects of drugs, 241 stages, 213 surgery for, 238 vasodilators in, 235 worsening, C20 Limb ischemia, 152 Lipid management in Gated SPECT, 493 Magnetic resonance atherosclerosis, 269 dyslipidemia and risk of atherosclerosis, 269 lipids and risk assessme nt, angiography, 43, 157 MR pulmonary Heart valves as viewed from above with the atria removed (top) and in a coronal section (bo ttom), 175 angiography, 26 Pulsed Doppler imaging, 269 453 \200\2235 Lipid-lowering medications, Radioisotopes used in 272 \200\2233 nuclear cardiology, 492 SPECT perfusion imaging, lipid-lowering therapy: Hemorrhage Goals, 274 Intracranial, 99 492 \200\2236 Lipoproteins Heparin-free hemodialysis, Inferior vena cava (IVC) high density (HDL), 256 low density (LDL) , 247 Long QT syndrome, 391 Acquired LQTS, 391 co ngenital, 391 management, 395 317 \201 lter, 28 Homocysteine, 260 hypercholesterolemia, 87 Inhibitors of intestinal inotropic support, 18 \200\22319, 28 insulin resistance syndrome, 280 cholesterol absorption, 273 Internal Jugular vein cannulation, 57 \200\2238 basic approaches to IJV cannulation, 57 \200\2238 tips and pitfalls, 57 \200\2238 Hypertension, 262 \200\2233 Emergency oral therapy, M Marfan \200\231s syndrome, 430 36 grading of, 263 malignant, 262 treatment, 149, 264 \200\2235 Hypertensive crisis, 31 Hypert ensive emergencies, Intra-aortic balloon counterpulsation, 80 \200\2233 grading of, 431 Masses, Cardiac arterial waveform variations during 1:2 IABP therapy, 8 Echocardiographic assessment of, 491 31 \200\2232 operation of, 81 McConnell \200\231s sign, 25 Metabolic syndrome, 280, Metabolic syndrome: management, 282 conditions presenting Ischemic heart disease as, 31 (IHD), 5 \200\2236 management, 33 \200\2234 Hypertensive emergency with retinopathy (accelerated and malignant hypertension), 37 \200 \2238 ATP-criteria, 280 K Kartagener syndrome, 334 Kawasaki disease, 434 \200\2235 Kussmaul sign, 295 Mitral regurgitation, 113, 183 \200\2235 Acute, 18 \200\22319 causes, 19 diagnosis, 18 measures Hypertensive encephalopathy, 39 diagnosis, 39 management, 39 symptoms, 39 L left ventricular assist devices general, 18 speci \201 c, 18 \200\22319 presentation, 18 causes, 183 acute, 183 chronic, 1 83 Hypertensive retinopathy, (LVAD), 238 38 Left ventricular function Assessment of wall motion, 460 Hypertensive urgency, 31 Hypertrophic cardiomyopathy, 290 \200\2234 management, 184 \200\2235 pathphysiology, 183 LV diastolic function, clinical signs, 292 Dynamic maneuvers to assess LVOT obstruction, 294 464 \200\2235 chronic, 183 LV ejection fraction, 462 LV systolic function, 462 \200\2233 left ventricular hypertrophy physical Examination, 183 Hypovolemia, 489 Hypoxemia, 343 prognosis, 184 symptoms, 183 TEE in chronic ischemic (LVH), 15, 87 Life support advanced, 5 \200\2236 asystole, 7 MR, 482 testing, 184 TTE/TEE in, 478 I Imaging post resuscitation care, 5 \200\2236 Mitral stenosis, 179 \200\22382 Comparison of PET with conventional SPECT imaging, 500 pulseless electrical activity(PEA) , 8 ventricular \201 brillation/ ACC/AHA Guidelines for Surgery, 182 clinical features, 179 pathophysiology, 179 CT pulmonary angiography pulseless ventricular tachycardia, 7 (CTPA), 26 INDEX 663 P PA (Swan-Ganz) catheter, see central venous catheter Pacemakers NSTEMI/UA: risk Percutaneous mitral strati \201 cation, 125 post-MI, acute mitral regurgitation, 113 balloon valvotomy (PMBV), 182 physical exam \201 ndings, 180 Physical signs, 180 radiographic features recurrent, 109 \200\22310 right ventricular, 105 shock post-MI, 119 ST elevation myocardial infarction (STEMI), 91 \200\2232 algorithm to select the of, 181 testing, 181 treatment, 182 TTE/TEE for, 482 The mitral valve, 174 Mitral valve pro lapse, 186 \200\2237, optimal pacing mode, 400 checklist for pacing wire insertion, 68 complications, 401 \200\2232 epicardial wires, 67 indications for temporary STEMI additional measures, 104 complications, 109 \200\22310 diagnosis, 93 \200\2235 genera l measures, 96 \200\2237 poor prognosis, factors associated, C 2.B2 480 \200\2231 causes, 186 examination, 186 pathphysiology, 186 prognosis, 187 symptoms, 186 testing, 186 treatment, 187 pacing, 66 \200\2237 indications for temporary transvenous cardiac pacing, 67 predischarge risk insertion of a ventricular strati \201 cation, 107 \200\2238 reperfusion by primary pacing wire, 69 Pacemaker syndrome, 401 permanent pacemakers, PCI, 101 \200\2232 Multiple-gated (MUGA) reperfusion therapy (thrombolysis), 98 \200\223100 surgery for, 103 blood pool imaging, see Imaging, Equilibrium radionuclide angiography [ERNA] 398 international code, 398 PET scanning, 497 \200\2238 Temporary pacing: Ventricular septal defect post-MI, 111 \200\22312 Muscular dystrophies, 301 Mustard and Senning operations, 339 Myocardial diseases Classi \201 cation, 286 Myocardial infarction (MI), complications, 73 \200\2234 Temporary ventricular Ventricular pacing, 68 \200\22370 tachyarrhythmias post-MI, 483 Myocardial ischemia, 86 \200\2238, ventricular demand pacing (VVI), 66 Paget \200\231s disease, 244 Percutaneous Coronary Intervention (PCI) 89 \200\22390, 217 Myocarditis, 303 \200\2235 Causes of, 304 89 \200\22390 Localization of infarcts from ECG changes, 93 rescue, 102 Myxedematous effusion, Pericardial aspiration, 76 Pericardial effusion, 109 \200\22310 Pericardial effusion tam ponade, 309 \200\22310 Pericardial \202 uid analysis, 319 natural history of aortic regurgitation, 194 Myxomas, 491 Non-ST elevation myocardial infarction (NSTEMI)/unstable angina (UA), 122 \200\2233 clinical presentation, 1 22 integrated management N The National Cholesterol Education Program (NCEP), 277 \200\2239 NCEP Adult Treatment 326 Pericardiectomy, 314 Pericardiocentesis, 317, 75 \200\2237 plan, 122 \200\2233 complications of, 77 NSTEMI: Discharge and Panel III LDL goals: 2004 update, 275 Pericarditis secondary prevention, 132 acute, 48 \200\2239 causes, 48 management, 50 without effusion, 288 Autoimmune pericarditis , Neoplastic pericardial NSTEMI: invasive vs. disease, 318 Nesiritide, 235 Neuromuscular disorders, noninvasive strategies, 131 NSTEMI/UA: diagnosis, 302 323 124 The New York Heart calci \201 c without NSTEMI/UA: late risk strati \201 cation, 127 NSTEMI/UA: medical Association classi \201 cation (NYHA), 219 constriction, 312 constrictive, 311 constrictive vs. restrictive Niacin, 273 Nitroprusside, 39 management, 128 \200\22330 myocardial, 325 Drug- or toxin-induced pericarditis, 321 Effusive-constrictive, 312 fungal, 323 granulomatous, 323 anti-ischemic therapy, 128 \200\2239 O Obesity, 259 visceral, 280 antiplatelet therapy, 129 antithrombotic therapy, 130 thrombolysis, 130 organ donation, 5 \200\2236 INDEX 664 Pseudoaneurysm and free Polymyositis and Nontuberculous bacterial wall rupture, 114 dermatomyositis, 442 Positive end-expiratory (purulent), 320 Postinfarction, 322 radiation, 321 TB constrictive, 314 TB effusive-constri ctive, Pulmonary angiography, 26 pulmonary artery catheter, pressure (PEEP), 63 \200\2234 Postcardiotomy syndrome, 5 \200\2236 Pulmonary artery 322 Pregnancy catheterization, 61 \200\2235 pulmonary capillary wedge pressure (PCWP), 407 Pulmonary Edem a, 9 \200\22310, 314 anticoagulation, 418 aortic Regurgitation, 416 aortic stenosis, 367 arrhythmias, 423 Cardia c Arrest, 424 Cardiac Disease, 406 Endocarditis prophylaxia, TB pericardial effusion, 315 \200\22316 traumatic, 323 tuberculous, 313 uremic, 317 viral, 313 119 assessment, 9 \200\22310 causes, 9 initial rapid assessment, 9 presentation, 9 urgent investigations for Peripheral Artery Disease 425 (PAD), 134, 135 general considerations, clinical presentation, 140 on Examination, 140 symptoms, 140 diagnosis and treatment of asy mptomatic, 145 diagnosis and treatment of critical limb ischemia, 148 all patients, 10 410 causes, 11 management, 12 \200\22314 speci \201 c conditions, 15 Pulmonary embolectomy, Hypertrophic obstructive cardiomyopathy (HOCM), 420 Ischemic heart disease, 419 28 Marfan \200\231s syndrome and pregnancy, 413 Pulmonary embolism, 24 diagnosis of acute limb assessment, 24 causes, 24 prognostic Features, 24 signs, 24 symptoms, 24 investigations, 25 \200\2236 mechanical heart valves, ischemia, 153 417 \200\22318 diagnosis of claudication and systemic risk treatment, 146 Limb ischemia, 81 \200\2232 Path ophysiology of PAD pathophysiology, 139 Prognosis in, 147 \200\22351 percutaneous translumi nal angioplasty and stents, 150 mitral regurgitation, 416 mitral stenosis, 415 normal cardiac \201 ndings, 409 general, 25 speci \201 c, 25 \200\2236 management, 27 \200\2238 symptoms, 24 thrombolytic therapy, 27 Physiological changes in, 407 pulmonary hypertension, 411 \200\22312 valvular heart disease Pulmonary stenosis, 347 Pulmonary Veins, in, 414 peripheral arterial surgery, Pressure half-time (PHT), 150 \200\2231 anomalous drainage, 348 482 treatment, 147 \200\22350 risk, 136 testing, 141 \200\2233 ankle brachial index (ABI), Prosthetic heart valves, 200 \200\2232 R Renal Artery Stenosis(RAS), assessment of prosthetic valve function, 200 \200\2232 141 \200\2232 computed tomographic 158 Common types of heart valve prostheses, 201 angiography (CTA), 143 contrast Angiography, 143 duplex ultrasound imaging, Renovascular disease, 157 \200\2239 diagnostic Testing, 157 indications for renal Complications, 203 endocarditis, 203 hemolysis, 203 systemic embolization, 203 valve thromb osis, 203 echocardiographic 142 revascularization, 160 magnetic resonance revascularization, 159 angiography (MRA), 142 Restrictive Cardiomyopathy Causes of, 296 treadmill exercise testing, Rheumatic Fever, 176 \200\2238, assessment of, 488 mechanical Valves, 200 TEE for a cardiac source of embolism, 474 TEE for aortic valve prosthesis, 487 142 322 treatment of Acute Limb clinical features, 176 \200\2237 Diagnostic criteria (Jones Ischemia, 154 treatment of claudication, criteria), 178 epidemiology, 176 pathology, 176 prognosis, 178 treatment, 177 147 Ultrasonography, 143 TEE for prosthetic valve dysfunction, 483 The Physician \200\231s Health Study (PHS), 283 tissue Valves, 200 types, 200 valve hemodynamics, 200 Polyarteritis nodosa Rheumatoid disease, 443 Right heart valve lesions, and other systemic vasculitides, 438 \200\2239 197 \200\2239 INDEX 665 Transplantation, Cardiac, pulmonary regurgitation, Systemic lupus 238 199 erythematosus (SLE), 301, 323 Transposition of the great pulmonic stenosis, 198 \200\2239 tricuspid regurgitation arteries, 348 treatment algorithm, 268 Trendelenberg position, (TR), 197 \200\2238 T Takayasu arteritis, 436 \200\2237 Takotsubo cardiomyopathy tricuspid stenosis (TS), 197 59 \200\22360 right interior jugular (RIJ) approach, 68 \200\22370 Right ventricular out \202 ow Trifascicular block, 362 Troponins, 95 tumor necrosis factor ( \200\234broken heart syndrome \200\235), 300 tract (RVOT) tachycardia, 385 (TNF), 212 Diagnostic criteria, 300 risk factors for Tamponade cardiovascular disease, 136 Cardiac, 51 \200\2232, 73, 309 management, 53 \200\2235 investigations, 53 management, 53 s pecial Cases, 54 \200\2235