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It furthers the Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico Cit y Nairobi New Delhi Shanghai Taipei Toronto With of \201 ces in Argentina Austria Brazil C hile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore S outh Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York Oxford University Press, 2012 Punit Ramrakha and Jonathan Hill (Editor \200\231s cont ribution), 2012 The moral rights of the authors have been asserted Database right Oxford Un iversity Press (maker) First edition published 2006 Second edition published 2012 All right s reserved. 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Enquiries concerning reproduction outside the scop e of the above should be sent to the Rights Department, Oxford University Press, at the add ress above You must not circulate this book in any other binding or cover and you must impo se this same condition on any acquirer British Library Cataloging in Publication Data Data available Library of Congress Cataloging-in-Publication-Data Data available Typeset by Cenv eo, Bangalore, India Printed in China on acid-free paper through Asia Paci \201 c Offset L td ISBN 978 \200\2230 \200\22319 \200\223964321 \200\2239 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and c linical procedures with the most up-to-date published product information and data sheets p rovided by the manufacturers and the most recent codes of conduct and safety regulations. T he authors and publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misap- plication of material in this work. Except where othe rwise stated, drug dosages and recommendations are for the non-pregnant adult who is not br eastfeeding. v Contents Contributors vii Symbols and abbreviations ix 1 Cardiac investigations 2 Drugs for the heart 3 Valvular heart disease 4 Infective endocar ditis 5 Coronary artery disease 6 Cardiac catheterization and intervention 7 Heart failure 8 Heart muscle diseases 9 Pericardial diseases 10 Arrhythmias 11 Invasive electrophysiology 12 Congenital heart disease 13 Multisystem disorders 14 Cardiovascular disease in less-dev eloped 1 81 143 187 211 309 367 417 459 477 541 589 617 countries 653 673 697 709 783 831 15 Heart disease in pregnancy 16 Eponymous syndromes 17 Cardiovascular emergencies 18 Pract ical procedures Appendix: Clinical trials Index 837 This page intentionally left blank vii Contributors Dominic Abrams St Bartholomew \200\231s and Great Ormond Street Hospitals, London, UK Tev \201 k Ismail Royal Brompton Hospital, London, UK Graham Jackson Guy \200\231s and St Thomas \200\231 Hospitals, London, UK Zoe Astroulakis King \200\231s College Hospital, London, UK Ajay Jain Barts and The London NHS Trust, London, UK Richard Campbell King \200\231s College Hospital, London, UK Andrew Kelion Royal Brompton and Hare \201 eld NHS Foundation Trust, London, UK Navin Chandra London Deanery, UK Jo Chikwe Mount Sinai Medical Center, New York, USA Paul Leeson John Radcliffe Hospital, Oxford, UK Christopher Critoph The Heart Hospital, London, UK Bongani Mayosi Groote Schuur Hospital, Cape Town, South Africa Shay Cullen The Heart Hospital, London, UK Catherine Nelson-Piercy King \200\231s College London and Imperial College Healthcare Trust , London, UK Mark Early St Bartholomew \200\231s Hospital, London, UK Andrew B Goldstone University of Pennsylvania, Philadelphia, PA, USA Michal Papadakis St George \200\231s University, London, UK Patrick Gordon King \200\231s College Hospital, London, UK Sanjay Prasad Royal Brompton Hospital, London, UK Daniel Heaton University College Hospital, London, UK Eberhard Ritz Ruperto Carola University of Heidelberg, Germany Steve Humphries University College London, London, UK Toby Rogers King \200\231s College Hospital, London, UK viii CONTRIBUTORS Sanjay Sharma St George \200\231s University of London, London, UK Helen Williams Southwark Health and Social Care and South London Cardiac and Stroke Network s, London, UK Muzahir Tayebjee Leeds Teaching Hospitals NHS Trust, Leeds, UK ix Symbols and abbreviations 4 5 7 8 9 i d n l p s * b Y 2D 3D AAD Ab ABG ABL AC ACC ACE ACE-I A2Ch A3Ch A4Ch A5Ch ACLS ACS ACT ACUITY male female approximately equal to plus or minus increased decreased normal leading to prim ary secondary degrees cross-reference internet reference two-dimensional three-dimensional antiarrhythmic drug antibody arterial blood gas(es) abetalipoproteinaemia attenuation corre ction American College of Cardiology angiotensin-converting enzyme angiotensin-converting e nzyme inhibitor apical two-chamber apical three-chamber apical four-chamber apical \201 v e-chamber advanced cardiac life support acute coronary syndrome activated clotting time Acu te Catheterization and Urgent Intervention Triage Strategy trial afterdepolarization adenos ine deaminase asymmetric-dimethyl arginine AD ADA ADMA x SYMBOLS AND ABBREVIATIONS ADP AF AFB AFL AFP AFCAPS/ TexCAPS AHA A-HeFT AI AICD AIDS AIH AIIRA AIRE ALCAPA adenosine diphosphate atrial \201 brillation acid-fast bacilli atrial \202 utter alpha- feto protein Airforce/Texas Coronary Atherosclerosis Prevention Study American Heart Associ ation African-American Heart Failure Trial aortic insuf \201 ciency automated implantable cardioverter de \201 brillator acquired immune de \201 ciency syndrome aortic intramural haematoma angiotensin II receptor antagonist Acute Infarction Ramipril Ef \201 cacy anomal ous left coronary artery arising from the pulmonary artery Antihypertensive and Lipid-Lower ing Treatment to Prevent Heart Attack alkaline phosphatase advanced life support alanine am inotransferase acute myocardial infarction adenosine monophosphate antinuclear antibodies a nti-neutrophil cytoplasmic antibodies anteroposterior atrial premature complex anistreplase Angina Prognosis Study in Stockholm activated partial thromboplastin time aortic regurgita tion angiotensin receptor blocker acute respiratory distress syndrome arrhythmogenic right ventricular myopathy aortic stenosis Anglo-Scandinavian Cardiac Outcomes Trial atrial septa l defect American Society of Echocardiography asymmetric septal hypertrophy Atenolol Silent Ischaemia Study ALLHAT ALP ALS ALT AMI AMP ANA ANCA AP APC APSAC APSIS aPTT AR ARB ARDS ARVC AS ASCOT ASD ASE ASH ASIST SYMBOLS AND ABBREVIATIONS xi AST AT ATLAS aspartate transaminase antithrombin Assessment of Treatment with Lisinopril and Survival (s tudy) antitachycardia pacing transthyretin molecule aortic valve/atrioventricular atriovent ricular node atrioventricular nodal effective refractory period atrioventricular node re-en trant tachycardia arginine vasopressin aortic valve replacement atrioventricular re-entrant tachycardia anterograde Wenckebach cycle length Bypass Angioplasty Revascularization Inves tigation bundle branch block blood-borne virus broad complex tachycardia twice daily ATP ATTR AV AVN AVNERP AVNRT AVP AVR AVRT AWCL BARI BBB BBV BCT bd BEAUTIFUL Morbidity \200 \223Mortality Evaluation of Ivabradine in Patients with CAD and Left Ventricular Systolic Dysfunction Beta-blockers Heart Attack Trial British Hypertension Society basic life support Becker \200\231s muscular dystrophy body mass inde x bare metal stent British National Formulary B-type natriuretic protein blood pressure bea ts per minute body surface area British Society for Antimicrobial Chemotherapy coronary art ery bypass graft coronary artery disease BHAT BHS BLS BMD BMI BMS BNF BNP BP bpm BSA BSAC CABG CAD CAPRICORN Carvedilol Prospective Randomized Cumulative Trial CAPRIE Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (study) Collaborative Ato rvastatin Diabetes Study Cholesterol and Recurrent Events Cardiac Resynchronization in Hear t Failure CARDS CARE CARE-HF SYMBOLS AND ABBREVIATIONS xii CARISA Combination Assessment of Ranolazine in Stable Angina Randomized controlled Multicentre Tri al Calcium Sensitizer or Inotropic Agent or None in Low Output Heart Failure calcium-channe l blocker congestive cardiac failure Canadian Cardiovascular Society coronary care unit car cinoembryonic antigen complex and fractionated atrial electrogram color Doppler \202 ow p ropagation Congestive heart failure, Hypertension, Age >75, Diabetes mellitus and previous Stroke) Candesartan in Heart Failure \200\224Assessment of Mortality and Morbidity Effects of Candesartan in Patients with Chronic Heart Failure and Preserved Left Ventricular Ejecti on Fraction complete heart block coronary heart disease/congenital heart disease congestive heart failure creatine kinase chronic kidney disease Cardiac Insuf \201 ciency Bisoprolol Study cardiac MRI cytomegalovirus central nervous system cardiac output Clopidogrel and Me toprolol in Myocardial Infarction Trial Comparison of Medical Therapy, Pacing and De \201 brillation in Heart Failure chronic obstructive pulmonary disease Carvedilol Prospective Ra ndomized Cumulative Survival (study) Controlled Rosuvastatin Multinational Trial in Heart F ailure Clinical Outcomes Utilizing Revascualrization and Aggressive Drug Evaluation trial c yclo-oxygenase 2 continuous positive airway pressure cardiopulmonary resuscitation CARMEN CASINO CCB CCF CCS CCU CEA CFAE CFP CHADS CHARM CHARM-Preserved CHB CHD CHF CK CKD CIBIS CMR CMV CNS CO COMMIT COMPANION COPD COPERNICUS CORONA COURAGE COX-2 CPAP CPR SYMBOLS AND ABBREVIATIONS xiii CPVT catecholaminergic polymorphic ventricular tachycardia creatinine clearance calcinosis, Rayn aud phenomenon, oseophageal dysmotility, sclerodactyly, and telangiectasia C-reactive prote in cardiac resynchronization therapy coronary sinus computed tomography chronic total occlu sion CT pulmonary angiography Clopidogrel in Unstable Angina to Prevent Recurrent Events CrCl CREST CRP CRT CS CT CTO CTPA CURE CURRENT-OASIS7 Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent Events/Optimal Antiplatelet Strategy for Intervention cardiovascular cereb rovascular accident central venous catheter cardiovascular disease central venous pressure (line) cardiovascular system continuous wave chest X-ray disability-adjusted life year Dani sh Acute Myocardial Infarction diastolic blood pressure direct current dilated cardiomyopat hy drug-eluting stent diastolic heart failure dihydropyridine disseminated intravascular co agulation Digitalis Investigation Group diabetes mellitus/dermatomyositis disease-modifying anti-rheumatic drug Duchenne \200\231s muscular dystrophy dimensionless obstructive index Driver and Vehicle Licensing Agency deep vein thrombosis Epstein \200\223Barr virus CV CVA CVC CVD CVP CVS CW CXR DALY DANAMI DBP DC DCM DES DHF DHP DIC DIG DM DMARD DMD DOI D VLA DVT EBV SYMBOLS AND ABBREVIATIONS xiv ECG ECHO ED EF eGFR ELISA ELISPOT ELITE EMD EMF eNOS EOA EOL EP EPHESUS electrocardiograph/electrocardiogram echocardiography erectile dysfunction ejection fractio n estimated glomerular \201 ltration rate enzyme-linked immunosorbent assay enzyme-linked immunospot Evaluation of Losartan in the Elderly electromechanical dissociation endomyocar dial \201 brosis endothelial nitric oxide synthase effective ori \201 ce area end of lif e electrophysiology Eplerenone Post-Acute Myocardial Infarction Heart Failure Ef \201 cacy and Survival Study erythropoietin Estrogen Replacement and Atherosclerosis elective replac ement indicator Ef \201 ccacy of Ranolazine in Chronic Angina equilibrium radionuclide ven triculography effective regurgitant ori \201 ce effective refractory period European Socie ty of Cardiology ejection systolic murmur Estrogen in the Prevention of Reinfarction Trial erythrocyte sedimentation rate endotracheal European Trial on Reduction of Cardiac Events w ith Perindopril in Stable Coronary Artery Disease FFR vs. Angiography for Multivessel Evalu ation focal atrial tachycardia full blood count Food and Drug Administration fresh frozen p lasma fractional \202 ow reserve fetal growth retardation familial hyperlipidaemia/hyperc holesterolaemia 5-lipoxygenase activation protein French gauge facioscapulohumeral muscular dystrophy EPO ERA ERI ERICA ERNV ERO ERP ESC ESM ESPRIT ESR ET EUROPA FAME FAT FBC FDA FFP FFR FGR FH FLAP Fr FSH SYMBOLS AND ABBREVIATIONS xv GFR GGT GI GISSI glomerular \201 ltration rate gamma glutamyl transferase gastrointestinal Gruppo Italiano per lo Studio della Sopravvivenza nell \200\231Infarto Miocardio general practitioner/glyc oprotein glyceryl trinitrate Global Utilization of Streptokinase and Tissue Plasminogen Act ivator for Occluded Coronary Arteries Haemophilus , Actinobacillus , Cardiobacterium , Eike nella , and Kingella spp. hemoglobin glycosylated hemoglobin hepatitis B immunoglobulin hep atitis B virus human chorionic gonadotrophin hypertrophic cardiomyopathy hepatitis C virus high-density lipoprotein high-density lipoprotein cholesterol high-dependency unit Heart an d Estrogen/Progestin Study heart failure heart failure with normal ejection fraction heart failure with reduced ejection fraction human immunode \201 ciency virus human leucocyte an tigen heart-to-mediastinum ratio hypertrophic obstructive cardiomyopathy Heart Outcomes Pre vention Evaluation GP GTN GUSTO HACEK Hb HbA 1c HBIG HBV HCG HCM HCV HDL HDL-C HDU HERS HF HFNEF HFREF HIV HLA H/M HOCM HOPE HORI ZONS-AMI Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial Hypertension Optimal Treatment Heart Protection Study Heart Protection Study: Treatment of HDL to Reduce the Incidence of Vascular Events heart rate high right atrium hormone replacement therapy His synchronous ventricular premat ure beat hypertension HOT HPS HPS-THRIVE HR HRA HRT HSVB HT SYMBOLS AND ABBREVIATIONS xvi IABP IAP ICD ICegram IE IgA IgG IGF IHD IJV IM IMAGE 123 I-MIBG IMPROVE-IT intra-aortic balloon pump incremental atrial pacing implantable cardiac de \201 brillator intracardiac electrogram infective endocarditis immunoglobulin A immunoglobulin G insulin-l ike growth factor ischaemic heart disease internal jugular vein intramuscular International Multicenter Angina Exercise (study) iodine-123-metaiodobenzylguanidine Improved Reduction of Outcomes: Vytorin Ef \201 cacy International trial inch international normalized ratio Impact of Nicorandil in Angina Irbesartan in Heart Failure with Preserved Ejection Fraction Ionizing Radiation Medical Exposure Regulations in-stent restenosis international unit sec ond International Study of Infarct Survival intensive therapy unit intravenous inferior ven a cava intravenous immunoglobulin incremental ventricular pacing intravascular ultrasound/u ltrasonography Judkins Left 4 (catheter) Judkins Right 4 (catheter) Justi \201 cation for the Use of Statins in Primary Prevention jugular venous pressure/pulse left atrium/atrial l eft atrial appendage left anterior descending (coronary artery) left atrial enlargement lef t anterior hemiblock left anterior oblique (projection) long axis (view) in. INR IONA I-Preserved IRMER ISR iu ISIS-2 ITU IV IVC IVIG IVP IVUS JL4 JR4 JUPITER JVP LA LAA LAD LAE LAHB LAO LA X SYMBOLS AND ABBREVIATIONS xvii LBBB LCA LCB LDH LDL LDL-C LEADERS left bundle branch block left coronary artery left coronary bypass (catheter) lactate dehyd rogenase low-density lipoprotein low-density lipoprotein cholesterol Biolimus-eluting stent with biodegradable polymer versus sirolimus-eluting stent with durable polymer for coronar y revascularization trial liver function test limb-girdle muscular dystrophy Losartan Inter vention For Endpoint reduction left internal jugular left internal mammary artery Long-term Intervention with Pravastatin in Ischaemic Disease left inferior pulmonary vein linear lea st squares estimation left main coronary artery left main stem (coronary artery) low molecu lar weight heparin left pulmonary artery lipoprotein(a) left posterior hemiblock long QT sy ndrome Lipid Research Clinics Coronary Primary Prevention Trial left sternal edge left supe rior pulmonary vein left ventricle/ventricular left ventricular assist device left ventricu lar end-diastolic pressure left ventricular end-diastolic volume left ventricular ejection fraction left ventricular function/failure left ventricular hypertrophy left ventricular in ternal diameter in diastole left ventricular internal diameter in systole left ventricular non-compaction left ventricular out \202 ow tract left ventricular systolic dysfunction ma jor adverse cardiac events LFT LGMD LIFE LIJ LIMA LIPID LIPV LLSE LMCA LMS LMWH LPA Lp(a) LPHB LQTS LRC-CPPT LSE LSPV LV LVAD LVEDP LVEDV LVEF LVF LVH LVIDd LVIDs LVNC LVOT LVSD MACE SYMBOLS AND ABBREVIATIONS xviii MADIT MAOI MARISA MD ME MEF2A MERIT-HF Muiticenter Automatic De \201 brillator Implantation Trial monoamine oxidase inhibitor Mon otherapy Assessment of Ranolazine in Stable Angina muscular dystrophy mid-oesophageal myocy te enhancer factor 2A Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Fa ilure MERLIN-TIMI Metabolic Ef \201 ciency with Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes \200\223 Thrombolysis in Myocardial Infarction m yocardial infarction minimum inhibitory concentration Myocardial Ischemia Reduction with Ac ute Cholesterol Lowering Multicenter InSync Randomized Clinical Evaluation Migraine Interve ntion with Star \202 ex Technology trial main pulmonary artery myocardial perfusion scinti graphy mitral regurgitation/modi \201 ed release/magnetic resonance magnetic resonance ang iography magnetic resonance imaging meticillin-resistant Staphylococcus aureus mitral steno sis multislice computed tomography milli-Sievert mulitgated acquisition Multicenter Unsusta ined Tachycardia Trial mitral valve mitral valve area multivessel disease myocardial oxygen consumption mitral valve prolapse mitral valve replacement sodium iodide activated by non- radioactive thallium nil by mouth non-bacterial thrombotic vegetations non-communicable dis ease MI MIC MIRACL MIRACLE MIST MPA MPS MR MRA MRI MRSA MS MSCT mSv MUGA MUSTT MV MVA MVD MVO 2 MVP MVR NaI(Tl ) NBM NBTV NCD NCEP-ATP National Cholesterol Education Program \200\224Adult Treatment Panel narrow complex tachycardia NCT SYMBOLS AND ABBREVIATIONS xix NG NICE NNT NO NSAID NSF NSTEMI NSVT NTproBNP N-terminal pro-B-type natriuretic hormone NTS C NVE NYHA OASIS 5 nasogastric National Institute for Health and Clinical Excellence number needed to treat ni tric oxide non-steroidal anti-in \202 ammatory drug nephrogenic systemic \201 brosis non -ST-segment elevation MI non-sustained ventricular tachycardia National Television Standard Committee native valve endocarditis New York Heart Association Fifth Organization to Assess Strategies in Ischemic Syndromes oral contraceptive pill opti cal coherence re \202 ectometry optical coherence tomography once daily obtuse marginal OCP OCR OCT od OM ONTARGET Ongoing Telmisartan Alone and in combination with Ramipril orthopentamogram OPG OPTIME-CHF Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations o f Chronic Heart Failure opening snap omni \202 ow vascular graft pulmonary artery peripher al arterial disease/pulmonary artery diastolic plasminogen activator inhibitor phase altern ating lines polyarteritis nodosa partial pressure of carbon dioxide in the arterial blood p artial pressure of oxygen in the arterial blood Placement of Aortic Transcatheter Valve tri al periodic acid \200\223Schiff pulmonary artery systolic pressure percutaneous balloon mit ral valvuloplasty percutaneous coronary intervention Percutaneous Coronary Intervention \200\224Clopidogrel in Unstable angina to prevent Recurrent Events polymerase chain reactio n OS OVG PA PAD PAI PAL PAN P a CO 2 P a O 2 PARTNER PAS PASP PBMV PCI PCI-CURE PCR xx SYMBOLS AND ABBREVIATIONS PCSK9 PCWP PDA PDE-5 PDGF PE PEA PEEP PEFR PEP PEP-CHF PES PET PFHB PFO PLA PLATO PM PMBV P MT PMV PO POBA PPAR-A PPI PPM PRAGUE-2 proprotein convertase subtilisin/kexin type 9 pulmonary capillary wedge pressure patent duc tus arteriosus phosphodiesterase type 5 platelet-derived growth factor pulmonary embolism p ulseless electrical activity positive end-expiratory pressure peak expiratory \202 ow rat e post-exposure prophylaxis Perindopril in Elderly People with Chronic Heart Failure paclit axel-eluting stent positron emission tomography progressive familial heart block type I pat ent foramen ovale parasternal long axis Platelet inhibition and Patient Outcomes trial poly myositis percutaneous mitral balloon valvuloplasty/valvotomy photomultiplier tube percutane ous balloon valvuloplasty/valvotomy per os (oral) \200\230plain old balloon angioplasty \200\231 peroxisome proliferator-activated receptor alpha proton pump inhibitor patient-pro sthesis mismatch Primary Angioplasty in patients transferred from General community hospita ls to specialized PTCA Units with or without Emergency thrombolysis pulmonary regurgitation when required Predictors of Response to CRT Prospective Randomized Study of Ventricular Fa ilure and Ef \201 cacy of Digoxin Pravastatin or Atorvastatin Evaluation and Infection The rapy pulmonic stenosis parasternal short axis/prostate-speci \201 c antigen presystolic mu rmur prothrombin time percutaneous transluminal coronary angioplasty PR prn PROSPECT PROVED PROVE-IT PS PSA PSM PT PTCA SYMBOLS AND ABBREVIATIONS xxi parathyroid hormone PTH point-to-point PTP pyrexia of unknown origin PUO pulmonary valve/pu lmonary vein PV post-ventricular atrial refractory period PVARP prosthetic valve endocardit is PVE pulmonary vascular resistance PVR four times a day qds right atrium/rheumatoid arthr itis RA right atrial appendage RAA RAD right anterior descending (coronary artery) RADIANCE Randomized Assessment of Digoxin on Inhibitors of ACE Randomized Aldactone Evaluation Stud y RALES right anterior oblique RAO renin \200\223angiotensin system RAS right bundle branch block RBBB right coronary artery RCA randomized controlled trial RCT Randomized Multicente r Evaluation of Intravenous REVIVE Levosimendan Ef \201 cacy rheumatic fever/rheumatoid fa ctor/radiofrequency radiofrequency ablation right femoral vein rheumatic heart disease righ t internal jugular right internal mammary artery Radiofrequency Interstitial Tumor Ablation ribonucleoprotein regurgitant ori \201 ce area right pulmonary artery respiratory rate re lative risk ratio right superior pulmonary vein recombinant tissue plasminogen activator ri ght ventricle/ventricular right ventricular apex right ventricular end-diastolic pressure r ight ventricular fuction right ventricular hypertrophy right ventricular in \202 ow tract RF RFA RFV RHD RIJ RIMA RITA RNP ROA RPA RR RRR RSPV rt-PA RV RVA RVEDP RVF RVH RVIT SYMBOLS AND ABBREVIATIONS xxii RVOT RWCL 4S SA SAH SAM SAN SaO 2 SAVE SAX SBE SBP SC SCA SCD SCD-HeFT SCM SCV SENIORS right ventricular out \202 ow tract retrograde Wenckebach cycle length Scandinavian Simvas tatin Survival Study sinoatrial subarachnoid hemorrhage systolic anterior motion sinoatrial node arterial oxygen saturation Survival and Ventricular Enlargement (study) short axis (v iew) subacute bacterial endocarditis systolic blood pressure subclavian/subcostal Society o f Cardiovascular Anesthesiologists sudden cardiac death Sudden Cardiac Death in Heart Failu re Trial sternocleidomastoid muscle subclavian vein Study of the Effect of Nebivolol Interv entions on Outcomes and Rehospitalization in Seniors with Heart Failure sirolimus-eluting s tent sex-hormone-binding globulin Systolic Heart Failure Treatment with I f Inhibitor Ivabr adine Trial streptokinase systemic lupus erythematosus sinus node re-entrant tachycardia St udies of Left Ventricular Dysfunction single photon emission computed tomography slow relea se/sinus rhythm suprasternal selective serotonin reuptake inhibitor sick sinus syndrome ST- segment elevation MI short tau inversion recovery stroke volume structural valve degenerati on superior vena cava saphenous vein graft systemic vascular resistance SES SHBG SHIFT SK SLE SNRT SOLVD SPECT SR SS SSRI SSS STEMI STIR SV SVD SVC SVG SVR SYMBOLS AND ABBREVIATIONS xxiii SVT SYNTAX supraventricular tachycardia Synergy between Percutaneous Coronary Intervention with Taxus and Coronary Surgery tesla half-time Thrombus Aspiration during Percutaneous Coronary Inter vention in Acute myocardial Infarction transcatheter aortic valve implantation tuberculosis technetium-99m total cholesterol tissue Doppler imaging torsades de pointes three times a day thyroid function test transgastric/triglycerides transposition of the great arteries tr ansforming growth factor-beta transient ischaemic attack thallium-201 therapeutic lifestyle changes target lesion revascularization Total Ischaemic Burden European Trial transient is chaemic dilatation Thrombolysis in Myocardial Infarction troponin tumor necrosis factor alp ha Treating to New Targets transoesophageal echocardiography tissue plasminogen activator t otal parenteral nutrition thiamine pyrophosphate tricuspid regurgitation T t TAPAS TAVI TB 99m Tc TC TDI TDP tds TFT TG TGA TGF-B TIA 201 Tl TLC TLR TIBET TID TIMI Tn TNF-A T NT TOE t-PA TPN TPP TR TRITON-TIMI Trial to Access Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel \200\224 Thrombolysis in Myocardial Infarc tion transthoracic ECHO tricuspid valve time \200\223velocity interval unstable angina urea and electrolytes TTE TV TVI UA U&E SYMBOLS AND ABBREVIATIONS xxiv unfractionated heparin UK Prospective Diabetes Study upper limit of normal ultrasound ultra sound scan Department of Veterans Affairs High-density Lipoprotein Cholesterol Intervention Trial ValHeFT Valsartan Heart Failure Trial VALIANT Valsartan in Acute Myocardial Infarcti on Trial 3VD three-vessel disease VE venous embolism VERP ventricular effective refractory period VF ventricular \201 brillation VLDL very low-density lipoprotein VMA vanillyl mand elic acid VPC ventricular premature complex V/Q ventilation/perfusion VPB ventricular prema ture beats VSD ventricular septal defect VT ventricular tachycardia VWF von Willebrand fact or WBC white blood cells WCC white cell count WCL Wenckebach cycle length WHI Women \200 \231s Health Initiative World Health Organization WHO WOSCOPS West of Scotland Coronary Pre vention Study WPW UFH UKPDS ULN US USS VA-HIT Wolff \200\223Parkinson \200\223White (syndrome) 1 Chapter 1 Cardiac investigations Exercise ECG 2 Cardiac computed tomography 6 Clinical applications of cardiac CT 8 Transtho racic echocardiography 10 Transthoracic Doppler imaging 14 The standard transthoracic ECHO 17 The standard transthoracic ECHO: continued 18 Assessment of wall motion 20 Assessment of LV systolic function 22 Assessment of LV diastolic function 24 Echocardiography in aortic stenosis 28 Transoesophageal echocardiography 30 TOE for a cardiac source of embolism 34 TO E in aortic dissection 35 TOE in endocarditis 36 TOE for mitral regurgitation (MR) 38 TOE f or mitral valve prolapse 40 TOE for mitral valve repair 41 TOE in chronic ischaemic MR 42 T OE for mitral stenosis 43 TOE for assessment of cardiac masses 44 TOE assessment of mitral valve prosthesis 46 TOE for aortic valve prosthesis 48 Intraoperative TOE 50 Basic principl es of nuclear cardiology 52 Myocardial perfusion scintigraphy: technical 54 Myocardial perf usion scintigraphy: clinical 56 Other nuclear cardiology investigations 58 Positron emissio n tomography scanning 60 Basic principles of cardiac MRI 62 Making CMR requests 64 CMR safe ty 66 Cardiomyopathy assessment 68 Myocarditis 72 Assessment of cardiac iron status 73 Isch aemia and viability assessment 74 CMR in valvular heart disease 76 CMR for congenital heart disease 77 CMR for pericardial disease 78 CMR evaluation of cardiac masses 80 2 CHAPTER 1 Cardiac investigations Exercise ECG A commonly used test involving a treadmill, blood pressure (BP) meas- urement, and continuous electrocardiograph (ECG) monitoring. Overall sensitivity for coronary heart disease is around 68 % and speci \201 city is 77 % . This increases when considering prog nostically signi \201 cant disease, which has a sensitivity of 86 % . The test improves to have a predictive accuracy of > 90 % in intermediate- to high-risk patients (older men wit h ischaemic symptoms). The test is of least value in populations that are least likely to b e suffering from ischaemic heart disease; e.g. asymptomatic middle-aged women have a positi ve predictive value of <50 % . Indications \200 Diagnosis of ischaemic heart disease (IHD): intermediate- or high-probability IHD, vasospastic angina. Post-myocardial infarction (MI): pre-discharge (submaximal test in days 4 \200\2237 to assess prognosis, decide upon exercise program, and evaluate treatment) , late post-discharge (symptom-limited 3 \200\2236 weeks). Pre- and post-revascularization. \200 Evaluation of arrhythmias: optimizing rate-responsi ve pacemaker function, evaluation of known or suspected exercise-induced arrhythmias, and e valuation of treatment of above. Contraindications \200 Fever/acute viral illness. \200 Myocarditis/pericarditis. \200 Severe aortic stenosis. \200 Aortic dissection. \200 Uncontrolled hypertension. \200 Overt cardiac failure. \200 Unstable angina or acute phase of MI. \200 Signi \201 can t resting arrhythmia (e.g. uncontrolled atrial \201 brillation or complete heart block). Known severe left main stem (LMS) or LMS equivalent disease. \200 Physical disability. \200 ECG abnormality rendering interpretation of ST segment dif \201 cult (e.g. left bund le branch block (LBBB), left ventricular hyphetrophy (LVH) with strain or digoxin ECG chang es). When to stop \200 Target heart rate achieved (tests have better sensitivity and speci \201 city if the target heart rate is reached ( > 85 % of 220 minus age in years for men or 210 minus age in years for women). \200 Worsening angina or excessive breathlessness. \200 Dizziness. \200 Fatigue/patient requests to stop. \200 Atrial arrhythmia other th an ectopic beats. \200 Frequent ventricular ectopic beats or ventricular tachycardia (VT) . EXERCISE ECG 3 Worsening ST segment shift (elevation or depression) at least 2 mm depression but up to 5 mm depression. BP fall or failure to rise. \200 Exaggerated hypertensive response to exercise (systolic blood pressure (SBP) > 220 mmHg). New high-grade atrioventricular (AV) block or bundle branch block. Criteria for a positive test Normal Upsloping ST depression Planar ST depression Downsloping ST depression Planar or downsloping ST depression of at least 1 mm 80 ms after the J point (junction between the QRS and ST segment). ST elevation. * \200 Increase in QRS voltage (ischaemic left ventricular (LV) dilatation) . \200 Failure of BP to rise during exercise (ischaemic LV dysfunction). * \200 Ventric ular arrhythmias. * \200 Typical ischaemic symptoms during exercise. \200 Inability to increase heart rate. * Features that are indications for urgent angiography: Also ST depres sion at low workload (<<6 minutes Bruce) in multiple lead groups, persisting into recovery, > 2 mm, downsloping pattern. Causes of false-positive tests \200 Cardiomyopathies. \200 Hypertension. \200 LVOT (l eft ventricular out \202 ow tract) obstruction. \200 Mitral valve prolapse syndrome. \200 Hyperventilation. \200 Resting ECG abnormality (LBBB, pre-excitation, digoxin). \200 Electrolyte abnormalities (hypokalaemia). \200 Tricyclic antidepressants. \200 Sy ndrome X. \200 Coronary artery spasm. \200 Sympathetic overactivity. 4 CHAPTER 1 Cardiac investigations National Institute for Health and Clinical Excellence (NICE) guidance 2010 \200\224 chest pain of recent onset 1 Historically, exercise ECG testing has been the cornerstone of inves - tigation of patients presenting with stable anginal chest pain. However, sensitivity and speci \201 city are poor compared with other investigations. Recent UK guidelines discoura ged the use of exercise ECG in patients without known coronary artery disease. Instead, NICE recommended cardiac computed tomography (CT) for patients with low likelihood of signi \201 cant coronary artery disease, a func- tional test such as dobutamine or exe rcise echocardiography for those with intermediate likelihood, and invasive coronary angiog raphy for those with high likelihood. 1 National Institute for Health and Clinical Excellence (March 2010). Chest pain of recent onset , Y http://guidance.nice.org.uk/CG95. This page intentionally left blank 6 CHAPTER 1 Cardiac investigations Cardiac computed tomography In the past decade, major advances in CT technology have enable d cardiac CT to emerge as a non-invasive alternative to conventional invasive coro- nary an giography. Coronary artery calcium scoring Calci \201 ed coronary plaque represents approximately 20 % of the total coro- nary artery plaque burden. Therefore, the degree of coronary calci \201 cation can be used as a surrogate for coronary artery atherosclerosis. A calcium score is obtained through a low-radiation unenhanced (i.e. no iodinated contrast) scan. The degr ee of calci \201 cation in each coronary vessel is then expressed as a \201 gure and sum med to give the total coronary artery calcium score, commonly using the Agatston scale. A s core of 0 corre- lates with a low risk of coronary artery disease, whereas a score of > 400 correlates with high risk of signi \201 cant atherosclerotic plaque burden. Clinical studies have shown that the calcium score provides addi- tional information for ca rdiovascular risk strati \201 cation above and beyond traditional factors such as age, sex , hypertension, family history, hyperlip- idaemia, and diabetes. CT coronary angiography CT coronary angiography is performed by injecting iodinated contras t into the peripheral veins. When the level of contrast in the aorta reaches a speci \201 ed level, the scan is launched and images are acquired. The images are then analyzed using computer software, which allows manipulation in two dimensions and three-dimensional (3D) r econstruction of the cor- onary arteries and cardiac chambers, also known as \200\230volum e rendering \200\231. Technical considerations Temporal versus spatial resolution The principal challenge to imag ing the coronary arteries using CT is to achieve high temporal resolution. Temporal resolut ion is de \201 ned as the time taken to acquire an image. As the beating heart moves, it n eeds to be \200\230frozen \200\231 during image acquisition. Motion is greatest during sys tole, whereas the heart is relatively still during diastole. Images acquired during diastol e are therefore most likely to be motion free, allowing accurate interpretation and diagnos is. A CT scanner must therefore be capable of acquiring images rapidly during the short dia stolic phase when the heart is motionless. Imaging small structures such as coronary arteries requires high spatial resolution. Spatia l resolution is de \201 ned as the narrowest distance between two objects that can be dist inguished by the detector. CT spatial resolution is determined by the voxel size (i.e. 3D p ixel). Heart-rate control The duration of systole is relative \201 xed at different heart rates, but the duration of diastole varies greatly. A slow heart rate (i.e. <65 bpm (beats per mi nute)) is preferable, to ensure motion-free imaging of the coronary arteries. CARDIAC COMPUTED TOMOGRAPHY 7