Oxford American Handbook of Cardiology About the Oxford American Handbooks in Medicine The Oxford American Handbooks are pocket cl inical books, providing practical guidance in quick reference, note form. Titles cover majo r medical spe- cialties or cross-specialty topics and are aimed at students, residents, int ernists, family physicians, and practicing physicians within speci \201 c disciplines. Their reputation is built on including the best clinical information, com- plemented by hin ts, tips, and advice from the authors. Each one is carefully reviewed by senior subject exp erts, residents, and students to ensure that content re \202 ects the reality of day-to-da y medical practice. Key series features \200 Written in short chunks, each topic is covered in a two-page spread to enable readers to \201 nd information quickly. They are also perfect for test preparation and gaining a quick overview of a subject without scanning through unnecessary pages. 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Published and Upcoming Oxford American Handbooks Oxford American Handbook of Clinical Medicine Oxford American Handbook of Anesthesiology Ox ford American Handbook of Cardiology Oxford American Handbook of Clinical Dentistry Oxford American Handbook of Clinical Diagnosis Oxford American Handbook of Clinical Drugstore Oxfo rd American Handbook of Critical Care Oxford American Handbook of Emergency Medicine Oxford American Handbook of Geriatric Medicine Oxford American Handbook of Nephrology and Hyperte nsion Oxford American Handbook of Neurology Oxford American Handbook of Obstetrics and Gyne cology Oxford American Handbook of Oncology Oxford American Handbook of Otolaryngology Oxfo rd American Handbook of Pediatrics Oxford American Handbook of Physical Medicine and Rehabi litation Oxford American Handbook of Psychiatry Oxford American Handbook of Pulmonary Medic ine Oxford American Handbook of Rheumatology Oxford American Handbook of Sports Medicine Ox ford American Handbook of Surgery Oxford American Handbook of Urology Oxford American Handbook of Cardiology Edited by Jeffrey R. Bender, MD Robert I. Levy Professor of Preventive Cardiology Associate Chief, Ca rdiovascular Medicine Yale University School of Medicine New Haven, Connecticut Kerry S. Russell, MD, PhD Associate Professor of Cardiovascular Medicine Yale University Sc hool of Medicine New Haven, Connecticut Lynda E. Rosenfeld, MD Associate Professor of Medicine and Pediatrics Section of Cardiovasc ular Medicine Yale University School of Medicine New Haven, Connecticut Sabeen Chaudry, MD Fellow, Section of Cardiovascular Medicine Yale University School of Med icine New Haven, Connecticut with Punit Ramrakha Jonathan Hill 1 3 Oxford University Press, Inc. publishes works that further Oxford University \200\231s obje ctive of excellence in research, scholarship and education. 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 Chile Czech Republic France Greece Guatemala Hungary Italy Japan P oland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright 2011 by Oxford University Press, Inc. Published by Oxford University Press Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press First published 2011 All rights reserved. No part of this publication may be reproduced, stored in a retrieval s ystem, or transmitted, in any form or by any means, electronic, mechanical, photocopying, r ecording, or otherwise, without the prior permission of Oxford University Press Library of Congress Cataloging-in-Publication Data Oxford American handbook of cardiology / edited by Jeffrey R. Bender [et al.]. p. ; cm. \200\224Other title: American handbook of cardiology Adapted from: Oxford handbook of neurology / Hadi Manji [et al.]. 2007. I ncludes index. ISBN 978-0-19-538969-2 1. Cardiovascular system \200\224Diseases \200\224Han dbooks, manuals, etc. I. Bender, Jeffrey R. II. Title: American handbook of cardiology. [DN LM: Cardiovascular Diseases \200\224Handbooks. WG 39 O98 2011] RC669.15.O94 2011 616.1 dc2 2 2010003761 9 8 7 6 5 4 3 2 1 Printed in China on acid-free paper This material is not intended to be, and should not be considered, a sub- stitute for medic al or other professional advice. Treatment for the con- ditions described in this material is highly dependent on the individual circumstances. And, while this material is designed t o offer accurate infor- mation with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is c onstantly evolving and dose schedules for medications are being revised continually, with n ew side effects recognized and accounted for regularly. Readers must therefore always check the product informa- tion and clinical procedures with the most up-to-date published prod- uct information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. Oxford University Press and the authors make no representat ions or warranties to readers, express or implied, as to the accuracy or completeness of th is material, including without limitation that they make no representation or warran- ties as to the accuracy or ef \201 cacy of the drug dosages mentioned in the material. The auth ors and the publishers do not accept, and expressly disclaim, any responsibility for any li ability, loss, or risk that may be claimed or incurred as a consequence of the use and/or a pplication of any of the contents of this material. This page intentionally left blank vii Preface Preface Despite major advances in prevention and treatment, cardiovascular dis- ease remains the le ading cause of death in the United States. There are greater than 1.4 million myocardial in farcts per year. Furthermore, the incidence of atrial \201 brillation and of heart failur e is rising, in part due to increased survival following acute coronary events, to our agin g popu- lation, and to other undetermined factors. Management of cardiovascu- lar disease s pans a wide range, from acute care of the hemodynamically unstable patient, interventions d irected at acute coronary obstructions and electrically unstable rhythms, to disease preven tion and care of the chronically ill. In an era of genome-wide scans and growing lists of c ardio- vascular disease genes, we still require a careful and detailed understand- ing of d isease pathophysiology and management. In this Handbook, we attempt to represent this wide range of cardio- vascular disease. We a re fortunate to practice in this era of evidence- based medicine, in which care algorithms are developed and therapeutic approaches are carefully de \201 ned. The chapters of this H andbook provide the pathophysiological basis for many of these approaches, followed by deli neation of management. Although these chapters will not replace the time-dependent accumula tion of experience in clinical care, we hope that this Handbook provides easy and rapid acc ess to many major day-to-day management approaches to patients with cardiovascular problems . We hope it will appeal to a broad range of clinicians in many settings, includ- ing the c oronary care unit, interventional laboratories, emergency depart- ments, and medicine units , both inpatient and outpatient. It is designed to be a rapid reference guide for practicin g cardiologists, internists, and relevant trainees. There should still be suf \201 cient space in white coat pockets for a hand- book such as this one. It is our hope that pearls of cardiovascular care will be easily removed from the se white pockets and extracted from our Handbook of Cardiology. viii Acknowledgments We, the four editors of the Oxford American Handbook of Cardiology, would like to express o ur gratitude to all contributors. This includes the chap- ter authors, who are all members of the Yale University Cardiovascular Medicine Division, either junior faculty or senior fe llows. They carefully have reviewed the most recent data and recommendations for cardiovas- cular care, incorporating the latest large clinical trials and published rec- ommendations of our largest cardiovascular organizations, the American Heart Association and the Americ an College of Cardiology. Thus, this represents the most up-to-date guidelines and recommen dations. We also acknowledge all involved at Oxford University Press, most notably Andrea Seils, Sen ior Editor of Clinical Medicine. We are particu- larly grateful for Andrea \200\231s patien ce, as the coordination of this handbook production took longer than expected. Most importantly, we want to formally and emphatically display our gratitude to Professors Ramrakha, Hill and all the authors of the original, U.K. version of the Oxford Handbook of Cardiology. They all did extraordin- ary work, assembling the original Handbook. Much of th at work has been retained in the U.S. version. As noted, we have attempted to incorpor- ate U.S. guidelines and recently published data into the new Handbook. However, many of the or iginal chapters remain state-of-the-art, and required very little editing or conversion. Th e work done by the U.K. authors was more than the foundation for the U.S. version. If appro val and commendations are upcoming, as we hope they are, these must be directed to both the U.K. and U.S. authors. Jeffrey Bender Kerry Russell Lynda Rosenfeld Sabeen Chaudry ix Contents Detailed contents xi Contributors xxv Symbols and Abbreviations xxvii 1 Cardiovascular emergencies and practical procedures 2 Coronary artery disease 3 Peripheral vascular disease 4 Valvular hea rt disease 5 Heart failure 6 Preventive cardiology 7 Diseases of the myocardium and pericar dium 8 Congenital heart disease 9 Arrhythmias 10 Heart disease in pregnancy 11 Multisystem disorders 12 Stress testing and cardiac imaging 13 Invasive electrophysiology 14 Cardiac ca theterization and coronary 1 85 133 173 211 245 285 329 353 405 427 445 511 intervention 549 597 647 15 Major trials in cardiology 16 Special populations: women and elderly Index 659 This page intentionally left blank xi Detailed contents 1 Cardiovascular emergencies and practical procedures 1 Cardiovascular emergencies Adult basic life support 2 Adult advanced life support 5 Universal treatment algorithm 7 Ac ute pulmonary edema: assessment 9 Pulmonary edema: causes 11 Pulmonary edema: management 12 Pulmonary edema: speci \201 c conditions 15 Acute aortic regurgitation 16 Acute mitral re gurgitation 18 Deep vein thrombosis: assessment 20 Deep vein thrombosis: management 22 Pulm onary embolism (PE): assessment 24 Pulmonary embolism: investigations 25 Pulmonary embolism : management 27 Fat embolism 29 Hypertensive emergencies 31 Hypertensive emergencies: manag ement 33 Drugs for hypertensive emergencies 35 Hypertensive emergency with retinopathy (acc elerated and malignant hypertension) 37 Hypertensive encephalopathy 39 Aortic dissection: assessment 40 Aortic dissection: investigations 43 Aortic dissection: management 45 Acute pericarditis: a ssessment 48 Acute pericarditis: management 50 Cardiac tamponade: presentation 51 Cardiac t amponade: management 53 Practical procedures Central line insertion 55 Internal jugular vein cannulation 57 Subclavian vein cannulation 59 Pulmonary artery catheterization 61 DETAILED CONTENTS DETAILED CONTENTS xii Indications for temporary pacing 66 Temporary ventricular pacing 68 Temporary atrial pacing 71 AV sequential pacing 72 Temporary pacing: complications 73 Pericardiocentesis 75 DC car dioversion 78 Intra-aortic balloon counterpulsation 80 2 Coronary artery disease 85 Angina pectoris 86 Acute coronary syndromes 89 ST elevation myocardial infarction (STEMI) 9 1 STEMI: diagnosis 93 STEMI: general measures 96 STEMI: reperfusion therapy (thrombolysis) 98 STEMI: reperfusion by primary PCI 101 Surgery for acute STEMI 103 STEMI: additional meas ures 104 Right ventricular (RV) infarction 105 STEMI: predischarge risk strati \201 cation 107 STEMI: complications 109 Ventricular septal defect post-MI 111 Acute mitral regurgitat ion post-MI 113 Pseudoaneurysm and free wall rupture 114 Cocaine-induced MI 115 Ventricular tachyarrhythmias post-MI 117 Atrial tachyarrhythmia post-MI 117 Bradyarrhythmias and indic ations for pacing 118 Bradyarrhythmias post-MI 118 Hypotension and shock post-MI 119 Cardio genic shock 120 Non-ST elevation myocardial infarction (NSTEMI)/unstable angina (UA) 122 NSTEMI/UA: diagnosis 124 NSTEMI/UA: risk strati \201 cation 125 NSTEMI/UA: late risk strat i \201 cation 127 NSTEMI/UA: medical management 128 NSTEMI: invasive vs. noninvasive strat egies 131 Discharge and secondary prevention 132 DETAILED CONTENTS DETAILED CONTENTS xiii 3 Peripheral vascular disease 133 Introduction 134 Epidemiology 135 Risk factors 136 Natural history 137 Pathophysiology 139 Clinical presentation 140 Testing for peripheral artery disease 141 Prognosis in peripheral artery disease 147 Acute limb ischemia 152 Cerebrovascular disease 155 Renovascular diseas e 157 Aortic disease 161 Noninvasive and invasive vascular diagnostic tools 166 Further rea ding 170 4 Valvular heart disease 173 General considerations 174 Acute rheumatic fever 176 Mitral stenosis 179 Mitral regurgitati on 183 Mitral valve prolapse 186 Aortic stenosis 188 Aortic stenosis: management 190 Aortic regurgitation 193 Right heart valve lesions 197 Prosthetic heart valves 200 Prosthetic hea rt valves: complications 203 Infective endocarditis 204 5 Heart failure 211 Introduction 212 Forms of heart failure 215 Causes and precipitants 217 Diagnosis and initi al workup 219 Management 222 Diuretics in heart failure 224 ACE inhibitors for heart failur e 226 B-Blockers for heart failure 229 DETAILED CONTENTS DETAILED CONTENTS xiv Angiotensin II receptor antagonists for heart failure 232 Aldosterone receptor antagonists in heart failure 233 Digoxin in heart failure 235 Vasodilators in heart failure 235 Phospho diesterase inhibitors in heart failure 236 Positive inotropic support 236 Antiplatelet agen ts and anticoagulants 236 Miscellaneous drugs for heart failure 236 Device therapy for hear t failure 237 Surgery for heart failure 238 Palliative care for heart failure 240 Worsening heart failure 241 Diastolic heart failure 242 High-output heart failure 244 6 Preventive cardiology 245 Background 246 Atherosclerosis: pathophysiology 247 Development of atherosclerotic plaques 249 Epidemiology 251 Assessment of atherosclerotic risk 252 Risk factors for coronary arter y disease 256 Hypertension 262 Treatment of high blood pressure 264 Combining antihypertens ive drugs 267 Lipid management in atherosclerosis 269 Lipid-lowering medications 272 Goals of lipid-lowering therapy 274 Diabetes and atherosclerosis 277 The metabolic syndrome 280 M etabolic syndrome: management 282 Aspirin for primary prevention 283 7 Diseases of the myocardium and pericardium 285 Myocardial diseases Classi \201 cation 286 Dilated cardiomyopathy 288 Hypertrophic cardiomyopathy 290 DETAILED CONTENTS DETAILED CONTENTS xv Restrictive cardiomyopathy 295 Arrhythmogenic right ventricular cardiomyopathy 297 Ischemic cardiomyopathy 299 Valvular cardiomyopathy 299 Hypertensive cardiomyopathy 299 Alcoholic c ardiomyopathy 299 Metabolic cardiomyopathy 299 Takotsubo cardiomyopathy ( \200\234broken he art syndrome \200\235) 300 General system disease 301 Nutritional cardiomyopathy 301 Muscul ar dystrophies 301 Neuromuscular disorders 302 Sensitivity or toxic reactions 302 Peripartu m 302 Myocarditis 303 Pericardial diseases Etiology 305 Syndromes of pericardial disease 306 Acute pericarditis without effusion 307 P ericardial effusion tamponade 309 Constrictive pericarditis 311 Effusive \200\223constri ctive pericarditis 312 Calci \201 c pericarditis without constriction 312 Viral pericardit is 313 Tuberculous pericarditis 313 TB constrictive pericarditis 314 TB effusive \200\223co nstrictive pericarditis 314 TB pericardial effusion 315 Uremic pericarditis 317 Neoplastic pericardial disease 318 Myxedematous effusion 319 Nontuberculous bacterial (purulent) peric arditis 320 Radiation pericarditis 321 Drug- or toxin-induced pericarditis 321 Postcardioto my syndrome 322 Postinfarction pericarditis 322 Rheumatic fever 322 Autoimmune pericarditis 323 Traumatic pericarditis 323 DETAILED CONTENTS DETAILED CONTENTS xvi Fungal pericarditis 323 Amoebic pericarditis 324 Constrictive pericarditis vs. restrictive myocardial disease 325 Pericardial \202 uid analysis 326 Pericardiocentesis 326 Further r eading 327 8 Congenital heart disease 329 Introduction 330 Assessment of patients with CHD 332 Speci \201 c signs in patients with C HD 336 Surgical operations for CHD 337 Percutaneous transcatheter interventions for CHD 341 Speci \201 c management issues 343 Atrial septal defect 346 Ventricular septal defect 346 Atrioventricular septal/canal defect (endocardial cushion defect) 346 Pulmonary stenosis 347 Left ventricular out \202 ow tract (LVOT) obstr uction 347 Coarctation of the aorta 347 Anomalous pulmonary venous drainage 348 Transpositi on of the great arteries 348 Tetralogy of Fallot 349 Fontan patients 349 Congenitally corre cted transposition of the great arteries 350 Ebstein \200\231s anomaly of the tricuspid val ve 350 Extracardiac complications 351 9 Arrhythmias 353 The cardiac conduction system 354 Bradyarrhythmias: general approach 356 Sinus bradycardia 358 Sinus pause 359 Sick sinus syndrome 359 Atrioventricular block 360 Bundle branch block 362 Tachyarrhythmias: general approach 363 Tachyarrhythmias: classi \201 cation 365 DETAILED CONTENTS xvii ECG diagnosis of tachyarrhythmias 367 Tachycardia: emergency management 369 Drug treatment of tachyarrhythmias 371 Supraventricular tachycardia 372 Sinus tachycardia 373 Sinus nodal reentrant tachycardia 373 Atrial tachycardia 374 Atrioventricular nodal reentrant tachycard ia (AVNRT) 375 Atrioventricular reentrant tachycardia (AVRT) 376 Junctional tachycardia 377 Atrial \201 brillation 377 Atrial \201 brillation: evaluation 379 Atrial \201 brilla tion: management 381 Ventricular tachycardia 384 VT in the normal heart ( \200\234benign \200\235 VT) 385 VT with impaired LV function 387 Arrhythmogenic right ventricular cardiomy opathy (ARVC) 388 Brugada syndrome 389 Bundle branch tachycardia 390 Long QT syndrome 391 L ong QT syndrome: management 395 Arrhythmia in special situations 396 Permanent pacemakers 3 98 Which pacing modality? 400 Complications of pacing 401 Pacemakers for chronic heart fail ure 403 10 Heart disease in pregnancy 405 Basic principles 406 Physiological changes in pregnancy 407 Normal \201 ndings in pregnan cy 409 General considerations in pregnancy 410 Pulmonary hypertension and pregnancy 411 Mar fan \200\231s syndrome and pregnancy 413 Valvular heart disease in pregnancy 414 Mitral ste nosis and pregnancy 415 Other valve lesions 416 Mechanical heart valves in pregnancy 417 Is chemic heart disease 419 Hypertrophic obstructive cardiomyopathy (HOCM) 420 DETAILED CONTENTS xviii Peripartum cardiomyopathy 421 Arrhythmias in pregnancy 423 Cardiac arrest in pregnancy 424 Endocarditis prophylaxis 425 11 Multisystem disorders 427 Libman \200\223Sacks endocarditis 428 Marfan \200\231s syndrome 430 Ghent criteria for Marf an \200\231s syndrome 431 Ehlers \200\223Danlos syndrome 432 Kawasaki disease 434 Takayasu arteritis 436 Polyarteritis nodosa and other systemic vasculitides 438 Ankylosing spondylit is 440 Polymyositis and dermatomyositis 442 Rheumatoid disease 443 12 Stress testing and cardiac imaging 445 Exercise ECG 446 Transthoracic echocardiography (TTE) 449 Transthoracic Doppler imaging 453 The standard TTE 456 Assessment of wall motion 460 Assessment of LV systolic function 462 Assessment of LV diastolic function 464 Echocardiography in aortic stenosis 468 Transesopha geal echocardiography (TEE) 470 TEE for a cardiac source of embolism 474 TEE in aortic diss ection 475 TEE in endocarditis 476 TTE/TEE in mitral regurgitation (MR) 478 Mitral valve pr olapse 480 TEE in chronic ischemic MR 482 TTE/TEE for mitral stenosis 482 TEE for prostheti c valve dysfunction 483 TEE assessment of mitral valve prosthesis 484 Echocardiography in a ortic regurgitation 486 TEE for aortic valve prosthesis 487 Intraoperative TEE 489 DETAILED CONTENTS xix Echocardiographic assessment of cardiac masses 491 SPECT perfusion imaging 492 PET scanning 497 Equilibrium radionuclide angiography (ERNA) 501 Cardiac CT 503 Cardiac magnetic resona nce imaging (CMR) 505 Metallic prostheses and CMR 508 13 Invasive electrophysiology 511 Mechanism of tachycardias 512 Mechanism of arrhythmias 514 The electrophysiology study (EPS ) 516 Uses of the EPS 518 Programmed ventricular stimulation 522 New technologies 524 Cathe ter ablation 525 Catheter ablation: complications 527 Atrial tachyarrhythmias: mechanism 52 8 Ablation of atrial tachycardias 530 Catheter ablation of atrial \201 brillation 532 Mec hanism of AV reentry tachycardias 534 AV reentry tachycardias: ablation 536 Ablation of ven tricular tachycardia 538 Accessory pathways (Wolff \200\223Parkinson \200\223White syndrome ) 540 Accessory pathways: localization 542 Accessory pathways: management 543 Implantable c ardioverter de \201 brillators (ICDs) 544 Indications for ICD implantation 545 ICD therapi es 546 ICD: trouble shooting and follow-up 547 14 Cardiac catheterization and coronary intervention 549 Radiation protection in the catheter laboratory 550 Vascular access: the femoral artery 551 Vascular access: the radial artery 553 Vascular access: site management 555 Coronary angio graphy 556 Interpreting the coronary angiogram 558 Angiographic study of grafts 560 DETAILED CONTENTS xx Complications of angiography 561 Right heart catheterization 564 Cardiac output and LV func tion 566 Cardiac catheterization in valve disease 567 Intravascular ultrasound 569 Angiopla sty and coronary stenting 571 Restenosis following PTCA 573 Drug-eluting stents 574 Stent t hrombosis 576 Physiological assessment of coronary \202 ow 578 Primary angioplasty for ST EMI 580 Primary angioplasty: procedure 581 Invasive assessment of vulnerable plaque 583 Com plex coronary angioplasty 584 Left main stem angioplasty 586 Adjunctive therapy for angiopl asty and stenting 587 Embolic protection devices 589 Thrombectomy 591 Mitral valvuloplasty 592 Glossary of terms and abbreviations 594 Further reading 596 15 Major trials in cardiology 597 ACUITY 598 ADMIRAL 598 AFCAPS/TexCAPS 598 AFFIRM 599 AHEFT 599 AIRE 600 AIREX 600 ALLHAT 60 1 ASCOT-LLA 601 ASSENT-1 602 ASSENT-2 602 ASSENT-3 and ASSENT-3 PLUS 603 BARI 603 CADILLAC 604 CAMIAT 604 CAPRIE 605 CAPTURE 605 DETAILED CONTENTS xxi CARE 605 CARE HF 606 CARMEN 606 CHARM 607 CIBIS 607 CIBIS II 607 COMET 608 COMPANION 608 CO PERNICUS 609 COURAGE 609 CREDO 610 CTOPP 610 CURE 611 DANAMI 611 DANAMI II 612 DAVID 612 DI AMOND 613 DIG 613 DIGAMI 613 DINAMIT 614 EMIAT 614 EPILOG 614 EPISTENT 615 ENHANCE 615 EURO PA 616 FRISC 616 FRISC II 617 GISSI-I 617 GISSI-2 617 GISSI-3 618 GISSI-Prevenzione 618 GUS TO-1 619 GUSTO IV-ACS 619 HOPE 620 HORIZONS-AMI 620 HPS 621 ICTUS 622 ISAR REACT 622 ISIS-1 623 ISIS-2 623 DETAILED CONTENTS xxii ISIS-3 624 ISIS-4 624 JUPITER 624 LIFE 625 LIPID 626 MADIT 626 MADIT II 626 MERIT-HF 627 MI CRO-HOPE 627 MIRACL 627 MIRACLE 628 MIRACLE ICD 628 MOST 629 MUSTIC 629 MUSTT 630 OPTIMAAL 630 PASE 630 PCI-CURE 631 PRAGUE Trials 631 PRISM 632 PRISM PLUS 632 PROGRESS 633 PURSUIT 6 33 RACE 634 RALES 634 RAVEL 635 REVERSAL 635 RITA-2 636 SAFE T 636 SAPPHIRE 637 SAVE 637 SI RIUS 638 SOLVD 638 SSSS (4S) 639 TAXUS 639 TIMI 1 640 TIMI 2A 640 TIMI 2B 640 TIMI 3A 641 T IMI 3B 641 DETAILED CONTENTS xxiii TIMI 4 641 TIMI 5 641 TIMI 6 641 TIMI 7 641 TIMI 8 641 TIMI 9A 642 TIMI 9B 642 TIMI 10A 642 TIMI 10B 642 TIMI 11A 642 TIMI 11B 642 TIMI 12 642 TIMI 14 642 TIMI 15A 642 TIMI 15B 642 T IMI 16 643 TIMI 17 643 TIMI 18 643 TIMI 22 643 TIMI 28 CLARITY 644 VANQWISH 644 V-HEFT II 6 45 WOSCOPS 645 16 Special populations: women and elderly 647 Women and heart disease 648 The elderly and heart disease 656 Index 659 This page intentionally left blank xxv Contributors Sarah Levin, MD Fellow Section of Cardiovascular Medicine Yale University School of Medicin e New Haven, Connecticut Brian J. Malm, MD Assistant Professor Section of Cardiovascular Medicine Yale University Sc hool of Medicine New Haven, Connecticut Carlos Mena, MD Clinical Instructor Section of Cardiovascular Medicine Yale University Scho ol of Medicine New Haven, Connecticut Rebecca Scandrett, MD Clinical Instructor Section of Cardiovascular Medicine Yale Universit y School of Medicine New Haven, Connecticut This page intentionally left blank xxvii Symbols and Abbreviations AAA ABC ABG ACC ACE ACLS ACS AD AED AF AFB AFP AHA AICD AIH AMI ANA ANP AP APC AR ARB ARDS ARVC ARVD AS ASA ASD ASH AST ATP AV AVN AVNRT AVR AVRT BB Abdominal aortic aneurysm airway, breathing, circulation arterial blood gas American Colleg e of Cardiology angiotensin-converting enzyme advanced cardiac life support acute coronary syndrome; acute ST change after-depolarization automated external de \201 brillator atrial \201 brillation acid-fast bacillus A-fetoprotein American Heart Association automatic im plantable cardioverter de \201 brillator aortic intramural hematoma acute myocardial infar ction antinuclear antibody atrial natriuretic peptide accessory pathway atrial premature co mplex aortic regurgitation angiotensin II receptor blocker acute respiratory distress syndr ome arrhythmogenic right ventricular cardiomyopathy arrhythmogenic right ventricular dyspla sia aortic stenosis acetylsalicylic acid atrial septal defect asymmetric septal hypertrophy aspartamine transferase Adult Treatment Panel atrioventricular atrioventricular node Atrio ventricular nodal reentry tachycardia aortic valve replacement atrioventricular reentry tac hycardia B-Blocker SYMBOLS AND ABBREVIATIONS xxviii bid BLS BMI BMS BNP BP bpm BUN CABG CAC CAD CAP CBC CCB CCS CCU CEA CHB CHF CHD CK CMR CMV CNS COPD CPAP CPR CRP CRT CS CSNRT CT CTO CVD CVP CW CXR DBP DCM DES DFT twice a day basic life support body mass index bare metal stent B-type natriuretic protein blood pressure beats per minute blood urea nitrogen coronary artery bypass graft coronary a rtery calcium coronary artery disease community-acquired pneumonia complete blood count cal cium channel blocker Canadian Cardiac Society coronary care unit carcinoembryonic antigen c omplete heart block congestive heart failure congenital heart disease creatinine kinase car diac MRI cytomegalovirus central nervous system chronic obstructive pulmonary disease conti nuous positive airway pressure cardiopulmonary resuscitation C-reactive protein cardiac res ynchronization therapy coronary sinus corrected sinus node recovery time computerized tomog raphy chronic total occlusion cardiovascular disease central venous pressure continuous wav e chest radiograph diastolic blood pressure diluted cardiomyopathy drug-eluting stent de \201 brillation threshold testing SYMBOLS AND ABBREVIATIONS xxix DI DIC DM DT DVT EBCT EBV ECG ECHO EDD EF Egram EMD EPS ERNA EROA ERP ERT ESD ESR ET ETT FD A FFP FFR GFR GI gp Hb HDL HIS HOCM HR HRA HRT HSVPB HTN IABD ICD ICMP ICU dimensionless index disseminated intravascular coagulation diabetes mellitus deceleration t ime deep vein thrombosis electron beam computed tomography Epstein \200\223Barr virus elect rocardiogram echocardiogram end diastolic dimension ejection fraction electrogram electrome chanical dissociation electrophysiological study equilibrium nuclide angiography effective regurgitant ori \201 ce area effective refractory period estrogen replacement therapy end systolic dimension erythrocyte sedimentation rate endotracheal exercise treadmill testing U .S. Food and Drug Administration fresh frozen plasma fractional \202 ow response glomerul ar \201 ltration rate gastrointestinal glycoprotein hemoglobin high-density lipoprotein H is bundle hypertrophic obstructive cardiomyopathy heart rate high right atrium hormone repl acement therapy His synchronous ventricular premature beat hypertension intra-aortic balloo n pump implantable cardiac de \201 brillator ischemic cardiomyopathy intensive care unit SYMBOLS AND ABBREVIATIONS xxx IE IGF IHD IJV IM INR IO ISFC ISR IV IVC IVP IVRT IVUS JVP LA LAD LAO LBBB LDH LDL LFTs LMS LMWH LQTS LV LVAD LVEDP LVF LVH LVOT MACE MDCT MI MPI MR MRA MRI MVP MVR NCEP infective endocarditis insulin-like growth factor ischemic heart disease internal jugular v ein intramuscular International Normalized Ratio intraosseous International Society and Fed eration Cardiology in-stent restenosis intravenous inferior vena cava intravenous push isov olumic relaxation time intravascular ultrasound jugular venous pressure left atrium, atrial left anterior descending (artery) left anterior oblique left bundle branch block lactate d ehydrogenase low-density lipotprotein liver function tests left main stent low-molecular-we ight heparin long QT syndrome left ventricular left ventricular assist device left ventricu lar end diastolic pressure left ventricular failure left ventricular hypertrophy left ventr icular out \202 ow tract major adverse cardiac event(s) multidetector computed tomography myocardial infarction myocardial perfusion imaging mitral regurgitation; magnetic resonance magnetic resonance angiography magnetic resonance imaging mitral valve prolapse mitral val ve replacement National Cholesterol Education Program SYMBOLS AND ABBREVIATIONS xxxi NCT NG NO NPPE NPPV nREM NSAID NSTEMI NYHA OCP OCT OM OTC OTW PA PAD PAN PCI PCWP PDA PDEI PDGF PE PEA PEEP PEFR PEG PET PFO PHS PISA PLAX PMBV PMT po PR prn PS PSAX PTCA PTFE narrow complex tachycardia nasogastric nitric oxide negative pressure pulmonary edema nonin vasive positive pressure ventilation non-rapid eye movement sleep nonsteroidal anti-in \202 ammatory drug non-ST elevation myocardial infarction New York Heart Association oral c ontraceptive pill optical coherence tomography obtuse marginal brach over-the-counter (drug s) over the wire pulmonary artery peripheral arterial disease polyarteritis nodosa percutan eous coronary intervention pulmonary capillary wedge pressure posterior descending artery p hosphodiesterase inhibitor platelet-derived growth factor pulmonary embolus pulseless elect rical activity positive end expiratory pressure peak expiratory \202 ow rate percutaneous endoscopic gastrostomy positron emission tomography patent foramen ovale Physicians Health Study proximal isovelocity surface area parasternal long axis percutaneous balloon mitral valuloplasty pacemaker-mediated tachycardia orally/by mouth pulmonary regurgitation as requ ired pulmonary stenosis parasternal short axis percutaneous transluminal coronary intervent ion polytetra \202 uoroethylene SYMBOLS AND ABBREVIATIONS xxxii PV PVE PVR qid RA RAS RBBB RBC RCA RF RFA RHC RIJ rtPA RV RVA RVAD RVF RVH RVOT RVSP SACT S AH SAM SAN SBE SBP SC SCD SCM SCV SK SL SLE SND SNRT SPECT SR SS STEMI SV pulmonary valve prosthetic valve endocarditis pulmonary vascular resistance four times a da y rheumatoid arthritis; right atrium, atrial renal artery stenosis right bundle branch bloc k red blood cells right coronary artery radiofrequency; rheumatoid factor radio frequency a blation right heart catheterization right interior jugular recombinant tissue-type plasmino gen activator right ventricular; regurgitant volume right ventricular apex right ventricula r assist device right ventricular failure right ventricular hypertrophy right ventricular o ut \202 ow tract right ventricular systolic pressure sinoatrial conduction time subarachno id hemorrhage systolic anterior motion sinoatrial node subacute bacterial endocarditis syst olic blood pressure subcutaneous; subcostal sudden cardiac death sternocleidomastoid subcla vian vein streptokinase sublingual systemic lupus erythematosus sinal node dysfunction sinu s node reentrant tachycardia single photon electron computed tomography sinus rhythm supras ternal ST elevation myocardial infarction stroke volume SYMBOLS AND ABBREVIATIONS xxxiii SVC SVG SVT TAA TB TCL TDI TdP TEE TFT TGF-B TIA tid TOF TR TS TSH TST TTE TV TVI UA UFH VF VLDL VMA VPB VPC V/Q VSD VT VVI WBC WCL WCT WHO WMSI WPW superior vena cava saphenous vein graft supraventricular tachycardia thoracic aortic aneury sm tuberculosis tachycardia cycle length tissue Doppler imaging torsades de pointes transes ophageal echocardiography thyroid function test transforming growth factor B transient isch emic attack three times a day tetralogy of Fallot tricuspid regurgitation tricuspid stenosi s thyroid-stimulating hormone tuberculin skin test transthoracic echocardiogram tricuspid v alve time \200\223velocity index unstable angina unfractionated heparin ventricular \201 brillation very low density lipoprotein vanilmandelic acid ventricular premature beats vent ricular premature complex ventilation \200\223perfusion ratio ventricular septal defect ven tricular tachycardia ventricular demand pacing white blood cells Wenckebach cycle length wi de complex tachycardia World Health Organization wall motion score index Wolff \200\223Park inson \200\223White (syndrome) This page intentionally left blank 1 Chapter 1 Cardiovascular emergencies and practical procedures Hypertensive encephalopathy 39 Aortic dissection: assessment 40 Aortic dissection: investig ations 43 Cardiovascular emergencies Adult basic life support 2 Adult advanced life support 5 Universal treatment algorithm 7 Ac ute pulmonary edema: Aortic dissection: management 45 Acute pericarditis: assessment 48 Acute pericarditis: mana gement 50 Cardiac tamponade: presentation 51 Cardiac tamponade: management 53 assessment 9 Pulmonary edema: causes 11 Pulmonary edema: management 12 Pulmonary edema: speci \201 c conditions 15 Acute aortic regurgitation 16 Acute mitral regurgitation 18 Deep vein thrombosis: Practical procedures Central line insertion 55 Internal jugular vein cannulation 57 assessment 20 Deep vein thrombosis: management 22 Subclavian vein cannulation 59 Pulmonary artery Pulmonary embolism (PE): assessment 24 catheterization 61 Pulmonary embolism: investigations 25 Pulmonary embolism: management 27 Indications for temporary pacing 66 Temporary ventricular pacing 68 Temporary atrial pacing 71 AV sequential pacing 72 Temporar y pacing: complications 73 Pericardiocentesis 75 DC cardioversion 78 Intra-aortic balloon Fat embolism 29 Hypertensive emergencies 31 Hypertensive emergencies: management 33 Drugs for hypertensive emergencies 35 Hypertensive emergency with retinopathy (accelerated and malignant hypertension) 37 counterpulsation 80 CHAPTER 1 Cardiovascular emergencies 2 Cardiovascular emergencies Adult basic life support Basic life support (BLS) is the backbon e of effective resuscitation follow- ing a cardiorespiratory arrest. The aim is to maintain adequate ventilation and circulation until the underlying cause for the arrest can be reve rsed. A period of 3 \200\2234 minutes without adequate perfusion (less if the patient is hy poxic) will lead to irreversible cerebral damage. Occasionally you will be the \201 rst to discover the unresponsive patient, and it is imp ortant to rapidly assess the patient and begin cardiopulmon- ary resuscitation (CPR). The v arious stages in BLS are described here and summarized in Figure 1.1. CHECK RESPONSIVENESS Shake and shout OPEN AIRWAY Head tilt/chin lift If breathing: recovery position Look, listen, and feel CHECK BREATHING BREATHE 2 effective breaths ASSESS 10 secs only Signs of a circulation CIRCULATION PRESENT continue rescue breathing NO CIRCULATION Compress chest Check circulation every minute 100 per minute 30:2 ratio Send or go for help as soon as possible according to guidelines Figure 1.1 Stages in basic life support. For further information, see BLS/ACLS AHA/ACC guid elines. ADULT BASIC LIFE SUPPORT 3 1. Assessment of the patient \200 \200 Ensure safety of rescuer and victim. Check whether the patient is responsive ask loudly, \200\234Are you all right? \200\235 \200 \200 . Gently shake the victim and If the victim responds, place them in recovery position and get help. If the victim is unre sponsive, shout for help and move on to assess airway (see below). 2. Airway assessment \200 Open the airway tilt the head up. If this fails, place your \201 ngers behind the angles of the lower jaw and apply steady pressure upward and forward. Remove ill- \201 tting dentures and any obvious obstruction. If the patient starts breath ing, roll patient over into the recovery position and try to keep the airway open until an orophyrangeal airway can be inserted. Use jaw thrust without head extension, if trauma is s uspected (see Fig. 1.2). . With two \201 ngertips under the point of the chin, Jaw lift to open the airway Jaw thrust (thrust the angle of the mandible upward) Figure 1.2 Opening the airway. Reproduced with permission from Ramrakha PS, Moore KPK (2004 ). Oxford Handbook of Acute Medicine. Oxford, UK: Oxford University Press. CHAPTER 1 Cardiovascular emergencies 4 Keep the airway open; look, listen, and feel for breathing chest movements, listen at the v ictim \200\231s mouth for breathing sounds, and feel for air on your cheek (for no more tha n 10 seconds). \200 . Look for If the patient is breathing, turn patient into the recovery position, check for continued b reathing, and get help. If the patient is not breathing or is making occasional gasps or we ak attempts at breathing, send someone (or go for help if alone). (On return) Start rescue breaths by giving two slow effective breaths, each resulting in a visible rise and fall in the chest wall; a mouth-to- barrier device may be used. 3. Assessment of circulation \200 Assess signs of circulation by feeling the carotid pulse for no more than 10 seconds. \200 If there are signs of circulation but no breathing, continue rescue breaths and check for s igns of breathing every 10 breaths. If there are no signs of circulation, start chest compr ession. Combine rescue breaths and compression at the rate of 30 compressions to two effect ive breaths, repeating this cycle 5 times in approximately 2 minutes. The ratio of compressions to lung in \202 ation remains the same for resuscitation with tw o persons. ADULT ADVANCED LIFE SUPPORT 5 Adult advanced life support It is unlikely that an effective spontaneous cardiac activity w ill be restored by BLS without more advanced techniques (intubation for effective ventilati on, drugs, de \201 brillation, etc.). Do not waste time. As soon as help arrives, delegate CPR to someone less experienced in advanced cardiac life support (ACLS), so that you are a ble to continue. \200 