Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine

Cover
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine
Copyright
Dedication
Contributors
Preface
Preface to the First Edition
Acknowledgments
Contents
Video Contents
Part I: Foundations of Cardiovascular Medicine
Chapter 1: Cardiovascular Disease: Past, Present, and Future
The Birth
Emergence of a Specialty
Cardiac Imaging
The Past
The Present
Invasive Procedures
Cardiac Catheterization
Percutaneous Coronary Intervention
Cardiovascular Surgery
Comments
Hypertension
The Past
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Valvular Heart Disease
The Past
The Present
Transcatheter Aortic Valve Replacement
Arrhythmias
The Past
The Present
Dyslipidemias
The Past
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Acute Myocardial Infarction
Coronary Risk Factors
Heart Failure
The Past
The Present
Assisted Circulation
The Past
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Genomics and Genetics
The Present
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Primordial Prevention
The Present
The Future
Inflammation
The Past
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Clonal Hematopoiesis
Artificial Intelligence
The Present
The Future
Conclusions
References
Chapter 2: Global Burden of Cardiovascular Disease
Shifting Burden
Epidemiologic Transitions
Stage of Inactivity and Obesity: A Fifth Phase
Different Patterns of Epidemiologic Transition
Current Variations in the Global Burden
High-Income Countries
East Asia and Pacific
Demographic and Social Indices
Burden of Disease
Central and Eastern Europe and Central Asia
Demographic and Social Indices
Burden of Disease
Latin America and the Caribbean
Demographic and Social Indices
Burden of Disease
North Africa and Middle East
Demographic and Social Indices
Burden of Disease
South Asia
Demographic and Social Indices
Burden of Disease
Sub-Saharan Africa
Demographic and Social Indices
Burden of Disease
Risk Factors
Tobacco
Hypertension
Lipids
Diabetes
Obesity
Diet
Physical Inactivity
Aging Populations
Genetic
Fetal Influences
Environmental Exposures
Economic Burden
Cost­Effective Solutions
Established Cardiovascular Disease Management
Risk Assessment
Policy and Community Interventions
Tobacco Use
Salt, Dietary, and Lipid Reductions
Summary and Conclusion
References
Chapter 3: Impact of the Environment on Cardiovascular Health
Global Footprint and Impact of Pollutants on Human Health
Air Pollution
Composition and Sources of Air Pollution
Particulate Air Pollutants
Gaseous Pollutants
Particulate Matter Sources, Composition, and Cardiovascular Risk
Household Versus Ambient Air Pollution
Assessment of Exposure
Exposure-Response Function of Air Pollution, Mortality, and Cardiovascular Events
Cardiovascular and Metabolic Effects of Air Pollution
Ischemic Heart Disease and Cerebrovascular Events
Blood Pressure and Hypertension
Insulin Resistance and Diabetes
Heart Failure
Arrhythmia
Venous Thromboembolism
Chronic Kidney Disease
Mechanistic Insights Into Air-Pollution and Cardiovascular Risk
Windows of Exposure, Susceptibility, and Vulnerability
Air Pollution Alerts and Approaches to Communicate Risk
Societal and Personal Strategies to Mitigate Cardiovascular Effects of Air Pollution
Climate Change
Noise Pollution and Cardiovascular Disease
Synthetic Chemicals and Cardiovascular Disease
Metallic Pollutants and Cardiovascular Disease
Challenges and Outlook For the Future
References
Chapter 4: Clinical Trials in Cardiovascular Medicine
Clinical Trials Versus Other Types of Studies
Components of Clinical Trials
Rationale and Study Background
Study Design
Study Execution
Randomization
Blinding (Masking)
Inclusion and Exclusion Criteria
Endpoints or “Response Variables”
Statistical Considerations in Trials
Analysis of Primary and Secondary Endpoints
Power and Sample Size
Ethical Considerations and Informed Consent
Equipoise in Clinical Trials
Randomization to Placebo and Standard of Care
Potential for Harm in Clinical Trials
Monitoring of Data and Data Safety
Novel Approaches to Clinical Trial Design and Execution
Pragmatic (Large Simple) Trials
Use of Electronic Medical Records in Clinical Trials
Adaptive Designs
Interpretation of Clinical Trials
Registration and Reporting of Clinical Trials
Understanding the Primary Results
Secondary Endpoints
Interpretation of Subgroups
Post-hoc Analyses
Conclusion
References
Chapter 5: Clinical Decision-Making in Cardiology
Diagnostic Decisions
Therapeutic Decisions
Deciding When to Change Clinical Practice Based on New Clinical Research Findings
Shared Decision-Making
Monitoring the Quality of Clinical Decisions
System 1 and System 2 Thinking
Teaching Clinical Reasoning
Conclusion
Classic References
References
Online-Supplemental References
Chapter 6: Impact of Health Care Policy on Quality, Outcomes, and Equity in Cardiovascular Disease
What is Health Policy
Insurance Coverage and Access Policy
Payment and Delivery System Policy to Improve Quality and Reduce Costs
Public Reporting
Value-Based Payment Programs: Hospitals
Value-Based Purchasing: Outpatient
Alternative Payment Models
Inequities in Cardiovascular Disease Risk, Care, and Outcomes
Racial and Ethnic Minorities
Income
Urban-Rural Geography
Conclusions
References
Part II: Individualizing Approaches to Cardiovascular Disease
Chapter 7: Applications of Genetics to Cardiovascular Medicine
Key Principles of Human Genetics
Central Dogma
Heritability
Genetic Architecture
Genetic Variation
Characterizing Human Genetic Variation
Gene Discovery
Family-Based Studies
Hypercholesterolemia and Coronary Artery Disease
Metabolic Syndrome and Coronary Artery Disease
Case-Control and Population-Based Studies
Genome-Wide Association Studies for Lipids
Genome-Wide Association Studies for Coronary Artery Disease
Population-Based Discovery of Rare Protein-Coding Variants Associated with Coronary Artery Disease
Causal Inference of Epidemiologic Associations
Mendelian Randomization Principles and Applications
Causal Inference for Lipoproteins
Causal Inference for Adiposity
Mendelian Randomization Assumption Assessments
Disease Risk Prediction
Pathogenicity Assessments and Monogenic Risk
Monogenic Coronary Artery Disease
Polygenic Risk Scoring
Polygenic Coronary Artery Disease
Therapeutic Response Prediction
Target Discovery and Clinical Trial Prediction
On-Target Therapeutic Side Effect Prediction
Precision Medicine
CYP2C19
Familial Hypercholesterolemia
Polygenic Coronary Artery Disease
Next-Generation Technologies and Therapeutics
Somatic Genomics
Epigenetics
Single-Cell Ribonucleic Acid Sequencing
Therapeutically Targeting the Genome
Future Perspectives
References
Chapter 8: Proteomics and Metabolomics in Cardiovascular Medicine
Novel Technologies in the Identification of Biomarkers
Introduction to Proteomics and Metabolomics
Analytic Challenges for Proteomics and Metabolomics
Overview of the Discovery Process
Applications of Mass Spectrometry–Based Discovery to Cardiometabolic Disease
Future Directions in Biomarker Discovery
References
Chapter 9: Principles of Drug Therapeutics, Pharmacogenomics, and Biologics
Risk Versus Benefit of Drug Therapy
Clinical Trials Can Define Unexpected Adverse Drug Reactions
Classes of Adverse Drug Reactions
Pharmacokinetics and Pharmacodynamics
Molecular and Genetic Basis for Variable Drug Response
High-Risk Pharmacokinetics
Other Important Pharmacogenetic Effects
Optimizing Drug Doses
Plasma Concentration Monitoring
Dose Adjustments in Disease
Drug Interactions
Incorporating Pharmacogenetic Information into Prescribing
Future Perspectives
References
Chapter 10: Biomarkers and Use in Precision Medicine
Overview of Biomarkers
Clinical Applications of Cardiovascular Biomarkers
Novel Technologies in Biomarker Identification
Clinical Measures of Biomarker Performance
Sensitivity, Specificity, and Positive and Negative Predictive Value
Discrimination, C-Statistics, and Receiver Operating Characteristic Curve
Accuracy and Calibration
Risk Reclassification
External Validation and Impact Studies
Practical Example: High-Sensitivity C-Reactive Protein, Lipids, and Reynolds Risk Score
Conclusion
References
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Part III: Evaluation of the Patient
Chapter 13: History and Physical Examination: An Evidence-Based Approach
The History
The General Physical Examination
General Appearance
Skin
Head and Neck
Extremities
Chest and Abdomen
The Cardiovascular Examination
Jugular Venous Pressure and Waveform
Measuring the Blood Pressure
Assessing the Pulses
Inspection and Palpation of the Heart
Auscultation of the Heart
Heart Sounds
First Heart Sound (S1)
Second Heart Sound (S2)
Systolic Sounds
Diastolic Sounds
Cardiac Murmurs
Systolic Murmurs
Diastolic Murmurs
Continuous Murmurs
Dynamic Auscultation
Integrated, Evidence-Based Approach to Specific Cardiac Disorders
Heart Failure
History
Physical Examination
Jugular Venous Pressure
Third and Fourth Heart Sounds
Rales and Edema
Valsalva Maneuver
Other Findings
Patient with a Left Ventricular Assist Device
Valvular Heart Disease
Mitral Stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Tricuspid Valve Disease
Pulmonic Valve Disease
Prosthetic Heart Valves
Acute Coronary Syndromes
Pericardial Disease
Pericarditis
Pericardial Tamponade
Constrictive Pericarditis
Future Directions
Acknowledgments
References
Chapter 14: Electrocardiography
The Normal Electrocardiogram
Atrial Activation and the P Wave
Atrial Activation and the Normal P Wave
Atrial Repolarization
Heart Rate Variability
Atrioventricular Node Conduction and the PR Segment
Ventricular Activation and the QRS Complex
Normal QRS Complex
The Normal ST-T Wave
The QT Interval
Other Repolarization Waves
The U Wave
The J Wave
Normal Variants
The Abnormal Electrocardiogram
Chamber Enlargement and Hypertrophy
Atrial Abnormalities
Left Atrial Abnormality
Diagnostic Criteria
Right Atrial Abnormality
Left Ventricular Hypertrophy
Diagnostic Criteria
Clinical Significance
Right Ventricular Hypertrophy
Diagnostic Criteria
Clinical Significance
Biventricular Hypertrophy
Intraventricular Conduction Delays
Fascicular Blocks
Left Anterior Fascicular Block
Left Posterior Fascicular Block
Other Forms of Fascicular Block
Left Bundle Branch Block
Electrocardiogram Abnormalities
Clinical Significance
Right Bundle Branch Block
Electrocardiogram Abnormalities
Clinical Significance
Multifascicular Blocks
Myocardial Ischemia and Infarction
Repolarization (ST-T Wave) Abnormalities
QRS Changes
Evolution of Electrocardiogram Changes
Other Ischemic ST-T Patterns
Electrocardiogram Localization of Myocardial Ischemia and Infarction
Electrocardiogram Diagnosis of Myocardial Infarction with Bundle Branch Blocks
Atrial Infarction
Electrocardiogram Differential Diagnosis of Ischemia and Infarction
Noninfarction Q Waves and Related Depolarization Changes
ST-T Changes Simulating Ischemia and Infarction
Drug Effects
Electrolyte and Metabolic Abnormalities
Calcium
Potassium
Clinical Issues in Electrocardiographic Interpretation
Indications
Reading Competency
Technical Errors
Computer Interpretation
Future Perspectives
References
Guidelines: Electrocardiography
Patients Without Known or Suspected Cardiovascular Disease
Patients with Known or Suspected Cardiovascular Disease
Special Populations
Persons with Dangerous or Physically Demanding Occupations
Preoperative Evaluation
Screening of Athletes
Cardioactive Drug Administration
References
Chapter 15: Exercise Physiology and Exercise Electrocardiographic Testing
Exercise Physiology
Total-Body Oxygen Uptake
Myocardial Oxygen Demand and Supply Relationships During Exercise
Technical Components of Exercise Testing
Patient Preparation
Patient Assessment
Symptom Rating Scales
Electrocardiographic Lead Systems
Exercise Test Modality and Protocols
Exercise Test Supervision
Risks of Exercise Testing
Exercise Testing in Coronary Artery Disease
Exercise-Induced Symptoms
Functional Capacity
ST-Segment Changes
ST Depression
Upsloping ST Depression
Lead aVR ST Elevation
ST Adjustments
ST Elevation
Pharmacologic Influences on Interpretation
Digitalis Glycosides
Beta Adrenoreceptor Blockers
Diagnostic Value
Sensitivity and Specificity
Positive and Negative Predictive Values
Pre-Test and Post-Test Probability of Disease
Assessment of Anatomic and Functional Extent of Disease
Testing in Women
Prognostic Value
Predictive Variables
Post–Myocardial Infarction Evaluation
Preoperative Evaluation in Noncardiac Surgery
Assessment of Therapy
Exercise Testing in Nonatherosclerotic Heart Disease
Valvular Heart Disease
Aortic Stenosis
Severe Acquired Aortic Valve Stenosis
Moderate to Severe Congenital Valvular Aortic Stenosis
Mitral Regurgitation
Hypertrophic Cardiomyopathy
Adult Congenital Heart Disease
Additional Uses for Exercise Testing
Chest Pain Units
Physical Activity and Exercise Prescription
Evaluation of Peripheral Artery Disease
Patients with Diabetes
Summary
Acknowledgment
Classic References
References
Chapter 16: Echocardiography
Principles of Ultrasound and Instrumentation
Principles of Image Generation
Physical Principles of Ultrasound
Doppler Echocardiography in Practice
Assessment of Flow and Continuity Equation
The Standard Adult Transthoracic Echocardiographic Examination
M-Mode Echocardiography
Assessment of Cardiac Structure and Function
Left Ventricular Structure: Size and Mass
Left Ventricular Systolic Function
Left Ventricular Diastolic Function
Mitral Inflow Patterns
Doppler Tissue Imaging
Pulmonary Venous Doppler Flow Patterns
Color M-Mode and Flow Propagation
Assessing Diastolic Function in Clinical Practice
Right Ventricular Structure and Function
Left and Right Atria
Transesophageal Echocardiography
The Standard Transesophageal Echocardiographic Examination
Three-Dimensional Echocardiography
Ultrasound Enhancing Agents
Myocardial Infarction
Practical Considerations in Assessment of Regional Wall Motion
Echocardiographic Prognostic Indicators After Myocardial Infarction
Cardiomyopathies
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Other Cardiomyopathies With Regional or Global Variations in Myocardial Composition
Left Ventricular Noncompaction
Arrhythmogenic Cardiomyopathy
Restrictive Cardiomyopathies
Heart Failure
Assessment of Ventricular Synchrony
Assessment After Orthotopic Heart Transplantation
Lung Ultrasound in Heart Failure
The Athlete’s Heart
Stress Echocardiography
Limitations of Stress Echocardiography
Risk Stratification with Stress Echocardiography
Assessment of Myocardial Viability
Coronary Flow Reserve and Perfusion
Stress Echocardiography in Valvular Heart Disease
Valvular Heart Disease
Mitral Valve
Mitral Stenosis
Echocardiographic Features
Quantification of Severity
Patient Selection for Balloon Valvuloplasty
Mitral Regurgitation
Primary (Degenerative) Mitral Regurgitation
Secondary (Functional) Mitral Regurgitation
Quantitation of Mitral Regurgitation
Aortic Valve
Aortic Stenosis
Quantitation of Severity
Low-Gradient Severe Aortic Stenosis
Aortic Regurgitation
Tricuspid Valve
Acquired Disorders of the Tricuspid Valve
Quantitation of Tricuspid Regurgitation
Pulmonic Valve
Quantitation of Valve Dysfunction
Prosthetic Valves
Pericardial Disease
Pericardial Effusion
Pericardial Hematoma
Constrictive Pericarditis
Diseases of the Aorta
Focal Aortopathies
Aortic Emergencies
Pulmonary Hypertension
Infective Endocarditis
Role of Echocardiography in Surgery for Endocarditis
Cardiac Masses
Secondary Tumors
Alternative Diagnoses
Pseudoneoplasms
Intracardiac Thrombus
Adult Congenital Heart Disease
Atrial Septal Defect
Secundum Atrial Septal Defect
Primum Atrial Septal Defect
Sinus Venosus Atrial Septal Defect
Coronary Sinus Atrial Septal Defect
Ventricular Septal Defect
Membranous (Paramembranous) and Outlet Ventricular Septal Defects
Inlet Ventricular Septal Defects
Muscular Ventricular Septal Defects
Transcatheter Interventions
Future Directions
Multimodality and Fusion Imaging
Handheld Echocardiography (Point of Care Ultrasound)
Recent Echocardiography Techniques
Artificial Intelligence
References
Appropriate Use Criteria: Echocardiography
References
Chapter 17: Chest Radiography in Cardiovascular Disease
Overview
PA and Lateral CXR
Approach to CXR Evaluation
Radiographic Densities
CXR Anatomy
PA Radiograph
Lateral Radiograph
Common Anatomic Variants
Azygous Lobe Variant
Aortic Arch Variants
Localization Within Cardiac Silhouette
Fat
Calcifications
Pulmonary Vasculature
Support Lines and Devices
Specific Cardiovascular Conditions
Congenital Heart Disease
Acquired Heart Disease
Valvular Heart Disease
Coronary Artery Disease
Heart Failure
Advanced Imaging in ICU
References
Chapter 18: Nuclear Cardiology
Principles of Imaging
Single Photon Emission Computed Tomography
Conventional SPECT
Novel Image Reconstruction Software
Novel SPECT Scanners
Positron Emission Tomography
Hybrid SPECT/CT, PET/CT, and PET/MR
SPECT and PET Image Acquisition
Radiotracers and Protocols
Physiologic Basis for Stress Testing
Stress Testing Protocols
Exercise Stress
Pharmacologic Stress
Imaging Protocols
General Principles
SPECT Protocols
Myocardial Perfusion Imaging
Transthyretin Cardiac Amyloidosis Imaging
PET Protocols
Myocardial Perfusion Imaging
18F-FDG Metabolic Imaging Protocols
Reducing Radiation Dose
Patient-Centered Clinical Applications
Ischemic Heart Disease
Principles of Perfusion Imaging
Suspected Stable Coronary Artery Disease
Patients with New-Onset Chest Pain
Risk Stratification with Radionuclide Myocardial Perfusion Imaging
Symptomatic Patients Without Angiographic Obstructive Coronary Artery Disease
Evaluation Before Organ Transplantation
Suspected Acute Coronary Syndrome
Patients with Nondiagnostic Electrocardiogram and Troponin Elevation
Patients with Known Stable Coronary Artery Disease
Patients with Prior PCI and Recurrent Symptoms
Patients with Recent Myocardial Infarction Evaluated for Potential Staged PCI
Patients with Prior Myocardial Infarction and Ventricular Arrhythmias
Patients with Chronic Total Coronary Artery Occlusion
Heart Failure and Cardiomyopathies
Patients with Newly Diagnosed Left Ventricular Systolic Dysfunction
Patients with Ischemic Cardiomyopathy and Heart Failure
Pathophysiology of Ischemic Left Ventricular Dysfunction
Radionuclide Imaging Approaches to Assess Myocardial Ischemia and Viability
Myocardial Viability Imaging to Guide Revascularization in Patients with Ischemic Heart Failure
Infiltrative Cardiomyopathy: Amyloidosis
Inflammatory Cardiomyopathy: Sarcoidosis
Infective Endocarditis
Cardio-Oncology
Assessment of Ventricular Function
Evaluation of Coronary Artery Disease
Evaluation of Primary or Metastatic Cardiac Neoplasms
Machine Learning and Artificial Intelligence
Translational Molecular Imaging
Aortic Valve Disease
References
Chapter 19: Cardiovascular Magnetic Resonance Imaging
Principles of Magnetic Resonance Imaging
Basic Physics of Magnetic Resonance Imaging
Clinical Applications of CMR
Coronary Artery Disease
Assessing Stable Chest Pain Syndromes
CMR Assessment of Myocardial Viability and Benefit from Coronary Revascularization
Cardiomyopathies
Overall Approach to Undiagnosed Cardiomyopathy
Hypertrophic Cardiomyopathy
Arrhythmogenic Cardiomyopathy
Myocarditis
Cardiac Sarcoidosis
Cardiac Amyloidosis
Idiopathic Dilated Cardiomyopathy
Other Cardiomyopathies
Valvular Heart Disease
Aortic Stenosis
Aortic Regurgitation
Mitral Regurgitation
Tricuspid Regurgitation
Pericardial Disease
Novel CMR Imaging Techniques and Future Perspectives
References
Chapter 20: Cardiac Computed Tomography
Basics of Cardiac Computed Tomography
Different Types of Cardiac Computed Tomography Exams
Coronary Artery Calcium Testing
Test Performance and Acquisition
Clinical Data
Special Populations
Clinical Indications and Management Recommendations
Clinical Indications
Management Recommendations
Limitations of Coronary Artery Calcium Testing
Coronary Computed Tomography Angiography
Diagnostic Accuracy
Prognostic Implications
Plaque Burden and Prognosis
Coronary Computed Tomography Angiography in Acute Chest Pain
Coronary Computed Tomography Angiography in Non–ST Elevation Myocardial Infarction
Coronary Computed Tomography Angiographyin Stable Chest Pain
Selecting Appropriate Candidates for Coronary Computed Tomography Angiography
Pretest Probability of Obstructive Coronary Artery Disease
Patient Outcomes Following Coronary Computed Tomography Angiography
Hard Clinical Outcomes
Use of Invasive Angiography Following Coronary Computed Tomography Angiography
Coronary Computed Tomography Angiography Plaque Characteristics
High-Risk Plaque Characteristics
Low-Attenuation Plaque
Positive Remodeling
Napkin-Ring Sign
Spotty Calcifications
Plaque Characteristics and Incident Risk
Perivascular Fat Attenuation
Physiologic Evaluation of Coronary Artery Disease
Computed Tomography Fractional Flow Reserve
Diagnostic Accuracy
Clinical Effectiveness
Coronary Tomography Perfusion
Stress Computed Tomography Perfusion
Comparing and Integrating Different Techniques
Implications of the ISCHEMIA Trial for Coronary Computed Tomography Angiography
Patient Management Considerations
Patient Management Recommendations
Special Populations
Guidelines
Assessment of Cardiovascular Structure and Function
Pericardial and Myocardial Disease
Valvular Heart Disease
Shunts
Use of Cardiac Computed Tomography for Structural Heart Disease Interventions
Pre-Transcatheter Aortic Valve Replacement
Post-Transcatheter Aortic Valve Replacement
Evaluation Pre-Transcatheter Mitral Valve Replacement
Evaluation of Left Atrial Appendage (for Thrombus, Pre-Left Atrial Appendage Occlusion Devices)
Evaluation of Cardiac Masses
Future Directions
References
Chapter 21: Coronary Angiography and Intravascular Imaging
Indications for Coronary Angiography
Appropriate Use Criteria
Coronary Arteriography Technique
Patient Preparation
Access Sites
Basic Technique
Catheters for Diagnostic Procedures
Ventriculography
Left Ventriculography
Aortography
Right Ventriculography
Selection of Contrast Media
Automatic and Manual Injection of Contrast Media
Angiographic Projections
Coronary Anatomy
Coronary Artery Anomalies
Pitfalls of Coronary Angiography
Myocardial Bridging
Coronary Artery Spasm
Angiogram Evaluation
Syntax Score
Quantification of the Stenosis
Evaluation of Microvascular Blood Flow
Special Lesion Considerations
Chronic Total Occlusion
Calcific Lesions
Thrombotic Lesions
Bifurcation Lesions
Coronary Dissections
Coronary Intravascular Imaging
Intravascular Ultrasound
Procedure
Interpretation
Clinical Data
Plaque Lipid Core Detection
Optical Coherence Tomography
Clinical Applications
Normal Vessel Wall
Stable Coronary Artery Disease
Plaque Morphology
Acute Coronary Syndrome
Procedure Planning and Lesion Preparation
Assessment After Percutaneous Coronary Intervention
Co-registration of Intravascular Imaging and X-Ray Angiography for Patients Undergoing Percutaneous Coronary Intervention
Acknowledgments
Classic References
References
Chapter 22: Invasive Hemodynamic Diagnosis of Cardiac Disease
Introduction to Invasive Hemodynamic Diagnosis of Cardiac Disease
Indications for Cardiac Catheterization and Hemodynamic Assessment
Complications and Risks
Vascular Access
Arterial Access
Percutaneous Radial Artery Technique
Percutaneous Femoral Artery Technique
Venous Access
Percutaneous Femoral Vein Access
Percutaneous Brachial Vein Access
Percutaneous Internal Jugular Vein Access
Transseptal Catheterization
Left-Heart Catheterization
Right-Heart Catheterization
Technical Aspects and Artifacts of Pressure Measurements
Fluid-Filled Pressure Systems
Micromanometer Catheters and Pressure Sensor Guidewires
Computations for Hemodynamic Measurements
Cardiac Output Measurements
Thermodilution Method
Fick Method
Normal Right and Left Heart Waveforms and Valvular Hemodynamics Including HOCM (LVOT Gradients)
The Cardiac Cycle and Generation of Pressure Waves
Normal Pressure Waveforms
Atrial Pressures
Pulmonary Capillary Wedge Pressure
Aortic and Pulmonary Artery Pressure Waveforms
Ventricular Pressure Waveforms
Evaluation of Valvular Heart Disease
Calculation of Stenotic Valve Orifice Areas
Aortic Valve Stenosis
Low-Flow, Low-Gradient Aortic Stenosis
Hypertrophic Obstructive Cardiomyopathy
Mitral Valve Stenosis
Pulmonary and Tricuspid Valve Stenosis
Aortic Regurgitation
Mitral Regurgitation
Pulmonary and Tricuspid Valve Regurgitation
Septal Defects and Left-to-Right/Right-to-Left Shunts
Pericardial Disease and Restrictive Cardiomyopathy
Normal Pericardial Function and Pathophysiology of Constriction
Cardiac Tamponade
Physiologic and Pharmacologic Maneuvers and PV Loops
Exercise Provocation
Dynamic Exercise
Static Exercise
Pacing Tachycardia
Physiologic Maneuvers and Volume Challenge
Pharmacologic Challenges
Dobutamine
Isoproterenol
Pulmonary Vasodilators
Nitric Oxide
Nitroprusside
Pressure-Volume (PV) Relationships
Acknowledgment
References
Chapter 23: Anesthesia and Noncardiac Surgery in Patients with Heart Disease
Assessment of Risk
Ischemic Heart Disease
Hypertension
Heart Failure
Hypertrophic Cardiomyopathy
The Decision to Undergo Diagnostic Testing
Risk Calculators
Tests to Improve Identification and Definition of Cardiovascular Disease
Overview of Anesthesia for Cardiac Patients Undergoing Noncardiac Surgery
Regional Anesthesia
Monitored Anesthesia Care
Intraoperative Hemodynamics and Myocardial Ischemia
Postoperative Management
Postoperative Response to Surgery
Surveillance and Implications of Perioperative Cardiac Complications
Strategies to Reduce the Risk Associated with Noncardiac Surgery
Coronary Artery Revascularization
Percutaneous Coronary Intervention and Noncardiac Surgery
Pharmacologic Interventions
Beta-Adrenergic Blocking Agents
Statin Therapy
Other Therapies
Conclusion
Classic References
References
Part IV: Preventive Cardiology
Chapter 24: The Vascular Biology of Atherosclerosis
Overview and Background
Structure of the Normal Artery
Cell Types Composing the Normal Artery
Endothelial Cells
Arterial Smooth Muscle Cells
Layers of the Normal Artery
Intima
Tunica Media
Adventitia
Atherosclerosis Initiation
Extracellular Lipid Accumulation
Leukocyte Recruitment and Retention
Focality of Lesion Formation
Intracellular Lipid Accumulation: Foam Cell Formation
Evolution of Atheroma
Innate and Adaptive Immunity: Mechanisms of Inflammation in Atherogenesis
Smooth Muscle Cell Migration and Proliferation
Smooth Muscle Cell Death During Atherogenesis
Arterial Extracellular Matrix
Angiogenesis in Plaques
Plaque Mineralization
Complication of Atherosclerosis
Arterial Stenoses and Clinical Implications
Thrombosis and Atheroma Complication
Plaque Rupture and Thrombosis
Thrombosis Caused by Superficial Erosion of Plaques
Thrombosis and Healing in Progression of Atheroma
Diffuse and Systemic Nature of Plaque Susceptibility to Rupture and Inflammation in Atherogenesis
Special Cases of Arteriosclerosis
Restenosis After Arterial Intervention
Accelerated Arteriosclerosis After Transplantation
Aneurysmal Disease
Infection, the Microbiome, and Atherosclerosis
References
Chapter 25: Primary Prevention of Cardiovascular Disease
Overview
Trends in Cardiovascular Disease and Risk Factors
Global Trends
Trends in the United States
Types of Prevention: Primordial, Primary, and Secondary
Cardiovascular Disease Risk Assessment
Cardiovascular Health and Life’s Simple 7
Global Risk
Lifetime Risk
Vascular Imaging in Preventive Practice: Coronary Artery Calcium and Coronary Computed Tomographic Angiography
Society Guidelines for Cardiovascular Risk Assessment and Statin Therapy
Risk Factors for Cardiovascular Disease
Traditional Risk Factors
Smoking and e-Cigarettes
Hypertension
Guideline Recommendations
Interventions to Reduce Blood Pressure
Drug Therapy
Metabolic Syndrome, Insulin Resistance, and Diabetes
Interventions to Reduce Cardiovascular Risk among Patients with Diabetes
Obesity
Family History
Risk-Enhancing Factors
Social Determinants of Health
Psychosocial Factors
Ankle-Brachial Index
Biomarkers
Lipids/Lipoproteins
Standard Lipid Testing
Fasting versus nonfasting
LDL Cholesterol
HDL Cholesterol
Triglycerides
Alternative Lipid Measures
Lipoprotein(a)
Homocysteine
High-Sensitivity C-Reactive Protein and Other Biomarkers of Inflammation
Cardiovascular Prevention in Women
Premature Menopause and Pregnancy-Associated Conditions
Menopause and Postmenopausal Hormone Therapy
Lifestyle Factors and Interventions
Nutrition and Diet
Low-Risk Populations
High-Risk Populations and Randomized Trials of the Mediterranean Diet
Alcohol Consumption
Physical Activity
Sedentary Behavior
Interventions to Increase Physical Activity
Pharmacologic Therapies
Shared Decision-Making
Statins
Monitoring of Therapy
Aspirin
N-3 Fatty Acids
Primary Prevention
High-Risk Primary Prevention
Updated Meta-Analyses and Summary
Novel Approaches to Preventive Cardiology
The Polypill in Current Practice
Precision Medicine Versus Preventive Care
Community Interventions
Mobile Health, Remote Monitoring, and Wearables
Gaps in the Evidence and Future Perspectives
Regional and International Perspectives
References
Chapter 26: Systemic Hypertension: Mechanisms, Diagnosis, and Treatment
Definitions of Hypertension
Epidemiology
Pathophysiology
Pressure Natriuresis and Salt Sensitivity
Renin-Angiotensin-Aldosterone System
Sympathetic Nervous System
Natriuretic Peptides
Endothelium
Arterial Stiffness in Hypertension
Immune System in Hypertension
Factors Involved in Predisposition to Hypertension
Genetics
Obesity
A Diagnostic Approach to Primary Hypertension
History and Physical Examination
Blood Pressure Measurement
Office Blood Pressure Measurement
Office Versus Home Blood Pressure
Clinical Use of Ambulatory and Home Blood Pressure Monitoring
Integrating Home Blood Pressure Into Clinical Practice
Laboratory and Other Complementary Tests
Echocardiography
Evaluation of Sodium and Potassium Intake
Renin Profiling
Diagnostic approach for Secondary Hypertension
Endocrine Causes
Primary Hyperaldosteronism
Apparent Mineralocorticoid Excess States
Hyperaldosteronism Associated with Sleep-Disordered Breathing
Pheochromocytoma
Hypercortisolism (Cushing disease)
Thyroid Dysfunction
Acromegaly
Nonendocrine Causes
Lifestyle Factors
Drug-Induced Hypertension
Sleep Deprivation and Sleep-Disordered Breathing
Nonlifestyle, Nonendocrine Causes
Intrinsic Kidney Disease
Renovascular Hypertension
Coarctation of the Aorta
Therapeutic Options and Approaches for Primary Hypertension
Goals of Therapy
Blood Pressure Guidelines
Dietary Approaches
Effect of Lifestyle Intervention in the Older People (>65 years)
Blood Pressure–Lowering Medications
Therapeutic Options and Approaches For Subgroups of Hypertension
Pharmacologic Intervention in the Older People (>65 years)
Management of Hypertension in Chronic Kidney Disease
Blood Pressure Management in Patients Undergoing Dialysis
Heart Failure
Resistant Hypertension
Nondrug Therapy for Resistant Hypertension Device Therapy
Renal Denervation
Baroreceptor-Activation
DEBuT-HT
Rheos Pivotal Trial
Barostim Neo Trial
MobiusHD Device for Baroreflex Amplification
Hypertensive Urgency and Emergency
References
Chapter 27: Lipoprotein Disorders and Cardiovascular Disease
Lipoprotein Transport System
Biochemistry of Lipids
Lipoproteins, Apolipoproteins, Receptors, and Processing Enzymes
Lipoprotein Metabolism and Transport
Low-Density Lipoproteins
High-Density Lipoprotein and Reverse Cholesterol Transport
Lipoprotein Disorders
Definitions
Genetic Lipoprotein Disorders
Low-Density Lipoproteins
Familial Hypercholesterolemia
Low-Density Lipoprotein Receptor Gene
Familial Defective Apolipoprotein B
Proprotein Convertase Subtilisin/Kexin Type 9
Polygenic Hypercholesterolemia
Lipoprotein(a)
Triglyceride-Rich Lipoproteins
Polygenic Hypertriglyceridemia (also Known as Familial Hypertriglyceridemia, Formerly Type IV Hyperlipoproteinemia)
Combined Hyperlipoproteinemia (also Known as Familial Combined Hyperlipidemia or Formerly Type 2B Hyperlipidemia)
Dysbetalipoproteinemia (Formerly Type III Hyperlipoproteinemia)
Monogenic Chylomicronemia Syndrome (Formerly Familial Hyperchylomicronemia Syndrome or Type I Hyperlipidemia)
High-Density Lipoproteins
Disorders of High-Density Lipoprotein Biogenesis
Apolipoprotein A-I Gene Defects
Tangier Disease and Familial High-Density Lipoprotein Deficiency
Disorders of High-Density Lipoprotein–Processing Enzymes
Lecithin-Cholesterol Acyltransferase Deficiency
Cholesteryl Ester Transfer Protein Deficiency
Secondary Causes of Hyperlipidemia and Metabolic Syndrome
Hormonal Causes
Metabolic Causes
Renal Disorders
Liver Disease
Lifestyle
Alteration in Lipids by Medications
Pharmacologic Management of Lipid Risk
Hydroxymethylglutaryl–Coenzyme A Reductase Inhibitors (Statins)
Mechanisms of Action
Pharmacology and Lipid Effects
Safety, Tolerability, and Monitoring
Clinical Trials and Cardiovascular Outcomes
Use of Statins in Particular Populations
Adults with Diabetes
Older Adults
Women
Race and Ethnicity
Advanced Heart Failure and Chronic Kidney Disease
Pro-Protein Convertase Subtilisin/Kexin Type 9 Inhibitors
Mechanisms of Action
Effects on Lipids
Safety, Tolerability, and Monitoring
Clinical Outcomes Trials with Monoclonal Antibodies
Clinical Recommendations
Ezetimibe
Fibric Acid Derivatives (Fibrates)
Nicotinic Acid (Niacin)
Bile Acid–Binding Resins
Fish Oils and Pure Eicosapentaenoic Acid
Phytosterols
Novel Medications
Bempedoic Acid
Rare diseases: Novel approaches for Homozygous Familial Hypercholesterolemia and Monogenic Chylomicronemia Syndrome
Inhibition of APO CIII
Inhibition of Angiopoietin-­Like Protein 3 (ANGPTL3)
Inhibition of Lp(a)
Clinical Approach to the Treatment of Lipoprotein Disorders
Lifestyle Changes: Diet
Treatment of Combined Lipoprotein Disorders
Residual Cardiovascular Risk
Clinical Recommendations for Assessing Residual Risk
Future Perspectives
Gene Therapy
Societal Changes
Guidelines
References
Chapter 28: Cardiovascular Disease Risk of Nicotine and Tobacco Products
Health Effects of Tobacco
Cardiovascular Effects of Tobacco Products
Cigarettes
Electronic Cigarettes
Heated Tobacco Products
Classic References
References
Chapter 29: Nutrition and Cardiovascular and Metabolic Diseases
Energy Balance
Foods
Fruits and Vegetables
Nuts and Beans
Whole Grains, Refined Grains, Starches, Sweets
Fish
Red Meats
Poultry, Eggs
Dairy
Plant Oils
Beverages
Sugar-Sweetened Beverages
Milk
Coffee, Tea
Alcohol
Macronutrients
Carbohydrates
Fats
Total Fat
Saturated Fats
Monounsaturated Fats
Polyunsaturated Fats
n-6 PUFA
n-3 PUFA
Trans Fats
Dietary Cholesterol
Protein
Micronutrients
Sodium, Potassium
Dietary Patterns
Emerging Areas
Food Processing
Microbiome
Personalized Nutrition
Changing Behavior
References
Chapter 30: Obesity: Medical and Surgical Management
Epidemiology
Traditional Definition of Obesity
The Puzzling Relationship of Excess Body Weight and Fat with Cardiovascular Disease
Risk Assessment in Overweight/Obese Patients: Waistline as a Vital Sign
Evolving Focus from Adipose Tissue Mass to Quality and Functionality
Visceral Obesity
Marker of Ectopic Fat Deposition
Portal Free Fatty Acid Hypothesis
Visceral Adipose Tissue as an Endocrine Organ
Visceral Adipose Tissue: Marker of Dysfunctional Subcutaneous Adipose Tissue
Key Factors Associated with Visceral Obesity
Age and Sex
Sex Hormones
Genetics
Ethnicity
Hypothalamic-Pituitary-Adrenal Axis and Endocannabinoid System
Drugs
Lifestyle: A Key Contributor to Visceral Obesity
Clinical Tools to Identify Individuals at Cardiometabolic Risk
Clinical Management of Cardiometabolic Risk
Key Nutritional Factors (Toward a Food-Based Approach)
Physical Activity and Exercise
Sleep and Stress Management
Pharmacotherapy
Severe Obesity: A Rapidly Expanding Subgroup of Obese Patients
Summary and Perspectives
References
Chapter 31: Diabetes and the Cardiovascular System
Scope of the Problem
Diabetes Mellitus
Atherosclerotic Vascular Disease
Heart Failure
Atrial Fibrillation
Risk Stratification
Coronary Heart Disease in the Patient with Diabetes
Mechanistic Considerations Linking Diabetes and Atherosclerosis
Prevention and Treatment of Coronary Heart Disease and Its Complications in the Patient with Diabetes
Lipid Management
Statins
Ezetimibe
PCSK9 Inhibitors
Fibric acid derivatives (fibrates)
Omega-3 fatty acids
Inclisiran
Hypertension Management
Renin-Angiotensin-Aldosterone System Antagonists
Angiotensin-converting enzyme inhibitors
Angiotensin II receptor blockers
Calcium Channel Blockers
Thiazide Diuretics
Beta Blockers
Antihypertensive Therapy Summary
Antiplatelet Therapy
Daily Aspirin
P2Y12 Receptor Antagonists
Glucose Management
Cardiovascular Effects of Selected Medications for Diabetes
Metformin
Sulfonylureas
Insulin
Dipeptidyl Peptidase 4 Inhibitors
Glucagon like peptide-1 receptor agonists
Sodium-Glucose Cotransporter 2 Inhibitors
Other Glucose-Lowering Medications
Cardiovascular Effects of More Intensive Versus Less Intensive Glucose Control Strategies
Summary of Glucose Management and Treatment Guidelines
Acute Coronary Syndromes
Screening for Diabetes in Acute Coronary Syndrome Patients
Insulin Administration and Glucose Control
Antiplatelet Medications
P2Y12 Receptor Antagonists
Renin-Angiotensin-Aldosterone System Antagonists
Beta-Adrenergic Blocking Agents
Primary Invasive Strategy for Non–ST-Segment Elevation Acute Coronary Syndrome
Primary Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction
Coronary Revascularization Considerations
Optimal Medical Therapy Versus Revascularization in Diabetes
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting
Heart Failure in the Patient with Diabetes
Scope of the Problem
Mechanistic Considerations
Ischemic Heart Disease and Hypertension
Prevention and Management ofHeart Failure in Diabetes
Therapy of Heart Failure with Preserved Ejection Fraction in Diabetes
Therapy of Heart Failure with Reduced Ejection Fraction in Diabetes
Modulation of the Renin-Angiotensin-Aldosterone System
Angiotensin Receptor-Neprilysin Inhibition
Beta Blockers
Heart Failure Considerations for Glucose Management Strategies and Antihyperglycemic Medications
Atrial Fibrillation
Summary and Future Perspectives
Guidelines
References
Chapter 32: Exercise and Sports Cardiology
Historical Perspective
Cardiovascular Risks of Exercise
Effects of Habitual Physical Activity on Cardiovascular Risk
Cardiovascular Risks of Exercise
The Pathology of Exercise-Related Cardiovascular Events
The Relative and Absolute Risk of Exercise
Approach to Common Clinical Problems in Sports Cardiology
Decreased Exercise Capacity
Abnormalities Found on Screening
Cardiovascular Complaints in Athletes
Determining Athletic Eligibility
Advising Adult Athletes with Atherosclerotic Cardiovascular Disease
Valve Disease
Elevated “Cardiac Enzymes”
Atrial Fibrillation in Endurance Athletes
Accelerated Atherosclerosis
Myocardial Fibrosis
Noncompaction Cardiomyopathy
Exercise in Arrhythmogenic Right Ventricular Cardiomyopathy
Conclusion
References
Chapter 33: Comprehensive Cardiac Rehabilitation
Evolution of Cardiac Rehabilitation
Elements of Cardiac Rehabilitation Programs
Structural Elements
Multidisciplinary Team
Facilities, Equipment, and Technology Tools
Value of Cardiac Rehabilitation
Recovery from a Cardiovascular Disease Event
Physiologic Improvements
Cardiovascular Disease Risk Factor Control
Cardiovascular Events
Hospital Readmission
Fatal and Non-Fatal Events
Safety of Cardiac Rehabilitation
Cost-Effectiveness of Cardiac Rehabilitation
Future Directions for Cardiac Rehabilitation
Efforts to Reduce the Cardiac Rehabilitation Participation Gap
Additional Patient Groups
Improving the Cost-Effectiveness of Cardiac Rehabilitation
Summary
Classic References
References
Chapter 34: Integrative Approaches to the Management of Patients with Heart Disease
Integrative Cardiology
Utilization of Additional Therapies
Why Is Integrative Cardiology Important
Need for Interprofessional Collaboration
Integrative Strategies for Specific Cardiac Conditions
Ischemic Heart Disease
Nutrition
Mind/Heart Connection
Meditation
Tai Chi
Supplements
Omega-3
Multivitamins
Antioxidants
Hypertension
Nutrition
Dietary Approaches to Stop Hypertension (DASH): Diet, Potassium, and Sodium
Physical Activity
Mind/Heart Connection
Breathing Exercises
Meditation
Acupuncture
Dyslipidemia
Nutrition
Physical Activity
Heart Failure
Nutrition and Lifestyle
Supplements
Coenzyme Q10
Arrhythmias
Comprehensive Lifestyle Approach
Yoga
Integrative Self-Care for the Cardiologist
Conclusion
References
Part V: Atherosclerotic Cardiovascular Disease
Chapter 35: Approach to the Patient with Chest Pain
References
Chapter 36: Coronary Blood Flow and Myocardial Ischemia
Control of Coronary Blood Flow
Determinants of Myocardial Oxygen Consumption
Coronary Autoregulation
Determinants of Coronary Vascular Resistance
Endothelium-Dependent Modulation of Coronary Tone
Nitric Oxide (Endothelium-Derived Relaxing Factor)
Endothelium-Dependent Hyperpolarizing Factor
Prostacyclin
Endothelin
Paracrine Vasoactive Mediators and Coronary Vasospasm
Coronary Vasospasm
Structure and Function of the Coronary Microcirculation
Intraluminal Physical Forces Regulating Coronary Resistance
Myogenic Regulation
Flow-Mediated Resistance Artery Control
Right Coronary Artery Flow
Physiologic Assessment of Coronary Artery Stenoses
Stenosis Pressure-Flow Relation
Interrelation Among Distal Coronary Pressure, Flow, and Stenosis Severity
Flow-and Pressure-Derived Indices ofCoronary Reserve
Perfusion-Based Indices of Stenosis Severity
Absolute Flow Reserve
Relative Flow Reserve
Indices of Stenosis Severity Based on Coronary Pressure
Vasodilated Pressure Measurements: Fractional Flow Reserve
Resting Coronary Pressure Measurements: Instantaneous Wave-Free Ratio
Noninvasive FFRCT Using Computed Tomography and Computational Fluid Dynamics
Pathophysiologic States Affecting Microcirculatory Coronary Flow Reserve
Coronary Collateral Circulation
Arteriogenesis and Angiogenesis
Regulation of Collateral Resistance
Metabolic and Functional Consequences of Ischemia
Irreversible Injury and Myocyte Death
Reversible Ischemia and Perfusion-Contraction Matching
Acute Perfusion-Contraction Matching During Subendocardial Ischemia
Short-Term Hibernation
Functional Consequences of Reversible Ischemia
Chronic Hibernating Myocardium
Future Perspectives
Classic References
References
Chapter 37: ST­Elevation Myocardial Infarction: Pathophysiology and Clinical Evolution
Changing Patterns in Incidence and Care
Improvements in Outcome
Limitations of Current Therapy
Pathologic Findings
Plaque Formation and Disruption
Acute Coronary Syndromes
Heart Muscle
Gross Pathologic Findings
Ultrastructural and Microscopic Findings of Ischemia
Patterns of Myocardial Necrosis
Coagulation Necrosis
Necrosis With Contraction Bands
Myocytolysis
Apoptosis
Current Concepts of the Cellular Events During Myocardial Infarction and Healing
Modification of Pathologic Changes by Reperfusion
Coronary Anatomy and Location of Infarction
Right Ventricular Infarction
Atrial Infarction
Collateral Circulation in Acute Myocardial Infarction
Myocardial Infarction with Nonobstructive Coronary Arteries
Nonatherosclerotic Causes of Acute Myocardial Infarction
Stress (Takotsubo) Cardiomyopathy
Pathophysiology
Left Ventricular Function
Systolic Function
Diastolic Function
Circulatory Regulation
Ventricular Remodeling
Infarct Expansion
Ventricular Dilation
Effects of Treatment
Pathophysiology of Other Organ Systems
Clinical Features
Predisposing Factors
Circadian Periodicity
History
Prodromal Symptoms
Nature of the Pain
Other Symptoms
Differential Diagnosis
“Silent” or Atypical Presentations of ST-Elevation Myocardial Infarction
Physical Examination
General Appearance
Heart Rate
Blood Pressure
Temperature and Respiration
Jugular Venous Pulse
Carotid Pulse
The Chest
Cardiac Examination
Palpation
Auscultation
Heart sounds
Murmurs
Friction rubs
Extremities
Neuropsychiatric Findings
Laboratory Findings
Serum and Plasma Markers of Cardiac Damage
Recommendations for Measurement of Circulating Markers of Cardiac Injury in ST-Segment Elevation MI
Other Biomarkers
Other Laboratory Measurements
Serum Lipids
Hematologic Findings
Electrocardiography
Q Wave and Non−Q Wave Infarction
Ischemia at a Distance
Right Ventricular Infarction
Imaging
Radiography
Echocardiography
Magnetic Resonance Imaging
Nuclear Imaging
Computed Tomography
Estimation of Infarct Size
Electrocardiography
Cardiac markers
Noninvasive imaging techniques
Future Perspectives
References
Chapter 38: ST­Elevation Myocardial Infarction: Management
Prehospital Management
Prehospital Care
Emergency Medical Service Systems
Prehospital Fibrinolysis
Management in the Emergency Department
General Treatment Measures
Aspirin
Control of Cardiac Pain
Analgesics
Nitrates
Beta-Adrenergic Blocking Agents
Oxygen
Limitation of Infarct Size
Dynamic Nature of Infarction
Routine Measures for Limitation of Infarct Size
Reperfusion Therapy
General Concepts
Pathophysiology of Myocardial Reperfusion
Reperfusion Injury
Reperfusion Arrhythmias
Late Establishment of Patency of the Infarct Vessel
Fibrinolysis
Effect of Fibrinolytic Therapy on Mortality
Comparison of Fibrinolytic Agents
Effect on Left Ventricular Function
Complications of Fibrinolytic Therapy
Late Therapy
Intracoronary Fibrinolysis
Catheter-Based Reperfusion Strategies
Surgical Reperfusion
Selection of Reperfusion Strategy
Referral for Angiography with Intent of Revascularization after Initial Fibrinolysis
Patients Not Eligible for Reperfusion Therapy
Anticoagulant and Antiplatelet Therapy
Anticoagulant Therapy
Effect of Heparin on Mortality
Other Effects of Heparin
Disadvantages of Heparin
Hirudin and Bivalirudin
Low-Molecular-Weight Heparins
Parenteral Factor Xa Antagonists
Oral Factor IIa and Factor Xa Antagonists
Recommendations for Anticoagulant Therapy
Adjunctive Anticoagulation for Primary Percutaneous Coronary Intervention
Anticoagulation with Fibrinolysis
Patients Treated Without Reperfusion Therapy
Antiplatelet Therapy
Antiplatelet Therapy for Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction
Antiplatelet Therapy with Fibrinolysis
Combination Pharmacologic Reperfusion
Recommendations for Antiplatelet Therapy
Hospital Management
Coronary Care and Intermediate Care Units
General Measures
Physical Activity
Pharmacologic Therapy
Beta Blockers
Recommendations
Selection of Beta Blockers
Inhibition of the Renin-Angiotensin-Aldosterone System
Recommendations
Nitrates
Recommendations
Calcium Channel Antagonists
Other Therapies
Magnesium
Glucose Control During ST-Elevation Myocardial Infarction
Other Agents
Hemodynamic Disturbances
Hemodynamic Assessment
Monitoring of Pulmonary Artery Pressure
Hemodynamic Abnormalities
Hemodynamic Subsets
Hypotension in the Prehospital Phase
Management
The Hyperdynamic State
Left Ventricular Failure
Therapeutic Implications
Hypoxemia
Diuretics
Afterload Reduction
Nitroglycerin
Oral Vasodilators
Glucose-Lowering Agents
Digitalis
Vasoactive Medications
Beta-Adrenergic Agonists
Other Positive Inotropic Agents
Vasopressors
Cardiogenic Shock
Pathologic Findings
Pathophysiology
Diagnosis
Medical Management
Mechanical Circulatory Support
Intra-Aortic Balloon Counterpulsation
Percutaneous Left Ventricular Assist Devices
Complications
Revascularization
Shock Teams
Recommendations
Right Ventricular Infarction
Diagnosis
Noninvasive Assessment
Treatment
Mechanical Causes of Heart Failure
Free Wall Rupture
Pseudoaneurysm
Diagnosis
Treatment
Rupture of Interventricular Septum
Rupture of a Papillary Muscle
Differentiation Between Ventricular Septal Rupture and Mitral Regurgitation
Management
Arrhythmias
Hemodynamic Consequences
Ventricular Arrhythmias
Ventricular Premature Depolarizations
Management
Accelerated Idioventricular Rhythm
Ventricular Tachycardia and Ventricular Fibrillation
Prophylaxis
Management
Prognosis
Bradyarrhythmias
Sinus Bradycardia
Management
Atrioventricular and Intraventricular Block
First-Degree Atrioventricular Block
Second-Degree Atrioventricular Block
Complete (Third-Degree) Atrioventricular Block
Intraventricular Block
Isolated Fascicular Blocks
Right Bundle Branch Block
Bifascicular Block, Including Left Bundle Branch Block
Use of Pacemakers in Patients with Acute Myocardial Infarction
Temporary Pacing
Asystole
Permanent Pacing
Supraventricular Tachyarrhythmias
Sinus Tachycardia
Atrial Flutter and Fibrillation
Management
Other Complications
Recurrent Chest Discomfort
Recurrent Ischemia and Reinfarction
Diagnosis
Prognosis
Management
Pericardial Effusion and Pericarditis
Pericardial Effusion
Pericarditis
Dressler Syndrome
Venous Thrombosis and Pulmonary Embolism
Left Ventricular Aneurysm
Pathogenesis
Diagnosis
Prognosis and Treatment
Left Ventricular Thrombus and Arterial Embolism
Management
Convalescence, Discharge, and Post-Myocardial Infarction Care
Timing of Hospital Discharge
Counseling
Assessment at Hospital Discharge
Assessment of Left Ventricular Function
Assessment of Myocardial Ischemia
Exercise Testing
Assessment for Electrical Instability
Prophylactic Antiarrhythmic Therapy
Secondary Prevention After Acute Myocardial Infarction
Cardiac Rehabilitation
Lifestyle Modification
Depression
Modification of Lipid Profile
Antiplatelet Agents
Inhibition of the Renin-Angiotensin-Aldosterone System
Beta-Adrenergic Blocking Agents
Nitrates
Anticoagulants
Calcium Channel Antagonists
Hormone Therapy
Nonsteroidal Antiinflammatory Drugs
Future Perspectives and Emerging Therapies
References
Chapter 39: Non–ST Elevation Acute Coronary Syndromes
Epidemiology
Pathophysiology
Clinical Assessment
History
Physical Examination
Electrocardiography
Laboratory Testing: Biomarkers
Imaging
Noninvasive Testing
Invasive Imaging
Risk Assessment
Residual Risk
Natural History
Risk Assessment Scores
Management
General Measures
Anti-Ischemic Therapy
Nitrates
Beta-Adrenergic Receptor–Blocking Agents
Intravenous Beta Blockers
Oral Beta Blockers
Calcium Channel Blockers
Antiplatelet Therapy
Oral Antiplatelet Drugs
P2Y12 Inhibitors
Clopidogrel
Prasugrel
Ticagrelor
Selection and Duration of DAPT Regimen and NSTE-ACS Treatment Strategy
Switching Between Oral P2Y12 Inhibitors
Intravenous Antiplatelet Agents
Anticoagulant Therapy
Heparin
Low-Molecular-Weight Heparin
Heparin Reversal
Direct Thrombin Inhibitors
Patients with Indications for Both Oral Anticoagulant and Antiplatelet Therapy
Combination of Chronic Oral Anticoagulant and Antiplatelet Therapy Post NSTE-ACS
Bleeding: Risk Assessment, Prevention, and Treatment
Anti-Inflammatory Therapies
Invasive Versus Conservative Management
Timing of an Invasive Approach
Predischarge Risk Stratification in Patients Managed with an Ischemia-Guided Strategy
Percutaneous Coronary Intervention
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting
Lipid-Lowering Therapy
Discharge and Posthospital Care
Groups of Special Interest
Older Adults
Women
Diabetes Mellitus and Glucose Intolerance
Heart Failure
Vasospastic Angina
Management
Cardiac Syndrome X
Cocaine, Amphetamines, and Psychoactive Substances
Future Perspectives
Guidelines: Non–ST Elevation Acute Coronary Syndromes
Initial Evaluation
Early Risk Stratification
AHA/ACC Class I Recommendations
Early Hospital Care
Initial Antithrombotic Therapy
Ischemia-Guided Strategy Versus Early Invasive Strategies
AHA/ACC Class I Recommendations
Anti-Ischemic Therapies
Antiplatelet Therapy
Combined Postdischarge Oral Anticoagulant and Antiplatelet Therapy
Renin-Angiotensin-Aldosterone Inhibitors
Risk Factor Modification
Evidence Gaps
References
Chapter 40: Stable Ischemic Heart Disease
Magnitude of the Problem
Stable Angina Pectoris
Clinical Manifestations
Characteristics of Angina
Assessment and Classification of Angina Pectoris
Differential Diagnosis of Chest Pain
Esophageal Disorders
Mechanisms of Anginal Pain
Biliary Colic
Costochondritis
Other Neurologic and Musculoskeletal Disorders
Other Causes of Angina-Like Pain
Physical Examination
Pathophysiology
Angina Caused by Increased Myocardial O2 Requirements
Angina Caused by Transiently Decreased O2 Supply
Importance of Pathophysiologic Considerations in Configuring Therapy
Evaluation and Management
Biochemical Tests
Biomarkers of Myocyte Injury, Ischemia, and Hemodynamic Stress
Inflammatory Biomarkers
Genetic and Transcriptomic Biomarkers
Noninvasive Testing
Resting Electrocardiogram
Resting Echocardiography
Chest Roentgenography
Stress Testing
Computed Tomography
Cardiac Magnetic Resonance Imaging
Invasive Assessment
Catheterization and Coronary Angiography
Limitations of Angiography
Advanced Structural Coronary Imaging
Functional Assessment
Integrated Invasive Assessment in Patients Without Obstructive CAD
High-Risk Findings from Coronary Angiography
Extent of Coronary Artery Disease
Other Angiographic Findings
Natural History and Risk Stratification
Risk Stratification and Risk Models
Medical Management
Treatment of Associated Diseases
Reduction of Coronary Risk Factors
Hypertension
Coronary Artery Ectasia and Aneurysms
Coronary Collateral Vessels
Myocardial Bridging
Cigarette Smoking
Management of Dyslipidemia
Low High-Density Lipoprotein Cholesterol
High Triglycerides
Management of Diabetes Mellitus
Estrogen Therapy
Exercise
Obesity
Inflammation
Counseling and Changes in Lifestyle
Pharmacologic Management of Angina
Beta Adrenoceptor–Blocking Agents
Adverse Effects and Contraindications
Calcium Antagonists
Mechanism of Action
First-Generation Calcium Antagonists
Nifedipine
Adverse Effects
Characteristics of Different Beta-Blocking Agents
Selectivity
Intrinsic Sympathomimetic Activity
Lipid Solubility
Alpha Adrenoceptor–Blocking Activity
Effects on Serum Lipid Levels
Verapamil
Diltiazem
Second-Generation Calcium Antagonists
Amlodipine
Nicardipine
Felodipine and Isradipine
Nitrates
Mechanism of Action
Pharmacology of Nitrates
Effects on the Coronary Circulation
Redistribution of Blood Flow
Cellular Mechanism of Action
Nitrate Tolerance
Mechanisms
Management
Nitrate Withdrawal
Types of Preparations and Routes of Administration
Adverse Reactions
Preparations
Short-Acting Nitroglycerin (Nitroglycerin Tablets and Oral Spray)
Isosorbide Dinitrate
Isosorbide 5-Mononitrate
Topical Nitroglycerin
Other Issues Related to Oral Nitrates
Interaction With Cyclic Guanosine Monophosphate–Specific Phosphodiesterase Type 5 Inhibitors
Other Pharmacologic Agents
Ranolazine
Other Antianginal Therapies
Other Considerations of Medical Management of Angina Pectoris
Choice of Initial Therapy
Relative Advantages of Beta-Blocking Agents and Calcium Antagonists
Selection of Therapy
Other Antianginal Agents
Ivabradine
Nicorandil
Metabolic Agents
Combination Therapy
Synthesis of an Integrated Approach to Management of Patients with Stable Angina
Nonpharmacologic Treatment Approaches
Revascularization Approaches in Stable Ischemic Heart Disease
Approach to Decision Making Regarding Revascularization
Other Antianginal Strategies
Enhanced External Counterpulsation
Spinal Cord Stimulation
Patient Selection for Revascularization
Presence and Severity of Symptoms
Significance of Coronary Lesions (and Other Anatomic Considerations)
Fractional Flow Reserve
Presence of Left Ventricular Dysfunction and Extent of Ischemia
Risks Associated with the Procedure
Percutaneous Coronary Intervention
Restenosis and Late Stent Thrombosis
Comparisons between Percutaneous Coronary Intervention and Medical Therapy
PCI Guided by Coronary Artery Hemodynamic Data
Selection of Percutaneous Coronary Intervention for Revascularization
Coronary Artery Bypass Grafting
Minimally Invasive Coronary Artery Bypass Surgery
Arterial and Venous Conduits
Patency of Venous and Arterial Grafts
Distal vasculature
Progression of Disease in Native Arteries
Effects of Therapy on Vein Graft Occlusion and Native Vessel Progression
Antiplatelet Therapy
Lipid-Lowering Therapy
Patient Selection
Surgical Outcomes and Long-Term Results
Operative Mortality
Perioperative Complications
Relief of Angina
Effects on Survival
Perioperative Complications
Myocardial Infarction
Cerebrovascular Complications
Atrial Fibrillation
Renal Dysfunction
Surgical Treatment in Special Groups
Women
Older Patients
Renal Disease
Patients with Diabetes
?Patients with Associated Other Vascular Disease
Patients Requiring Reoperation
Comparisons between Percutaneous Coronary Intervention and Coronary Artery Bypass Surgery
Observational Studies
Randomized Trials
Coronary Bypass Surgery in Patients With Associated Vascular Disease
Implications of Combined Coronary Artery Disease and Peripheral Artery Disease
Carotid Artery Disease
Management of Patients With Associated Vascular Disease
Choosing between Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Medical Therapy
Single-Vessel Disease
Multivessel Disease
Need for Complete Revascularization
Other Manifestations of Coronary Artery Disease
Prinzmetal (Variant) Angina
Angina and Ischemia Without Obstructive Epicardial CAD
Microvascular Dysfunction
Evidence of Ischemia
Abnormal Pain Perception
Clinical Features
Clinical and Diagnostic Assessment
Prognosis
Management
Silent Myocardial Ischemia
Heart Failure in Ischemic Heart Disease
Ischemic Cardiomyopathy
Mechanisms of Silent Myocardial Ischemia
Prognosis
Detection and Management of Silent Ischemia
Left Ventricular Aneurysm
Mitral Regurgitation Secondary to Coronary Artery Disease
Management
Left Ventricular Aneurysm
Detection
Left Ventricular Aneurysmectomy
Cardiac Transplantation–Associated Coronary Arteriopathy
Future Perspectives
References
Chapter 41: Percutaneous Coronary Intervention
Background
Indications
Clinical Presentations
Stable Ischemic Heart Disease and Stable Angina
Acute Coronary Syndromes
Asymptomatic or Minimally Symptomatic Patients
Preoperative Considerations
Patient-Specific Considerations
Extent of Jeopardized Myocardium
Specific Lesion Subsets
Left Main Disease
Multivessel Disease
Chronic Total Occlusions
Saphenous Vein Grafts
Bifurcation Lesions
Lesion Calcification
Thrombotic Lesions
Diabetes Mellitus
Cardiomyopathy/Left Ventricular Dysfunction
Ischemic Cardiomyopathy
Role of Left Ventricular Dysfunction in PCI
Role of PCI in Cardiogenic Shock
Renal Dysfunction and Other Comorbidities
Coronary Devices
Balloon Angioplasty
Coronary Stents
Drug-Eluting Stents
Zotarolimus-Eluting Stents
Everolimus-Eluting Stents
Sirolimus-Eluting Stents
Paclitaxel-Eluting Stents
Zotarolimus-Eluting Stents
Everolimus-Eluting Stents
Bioabsorbable Polymer Drug-Eluting Stents
Bioresorbable Vascular Scaffolds
Coronary Atherectomy
Rotational Atherectomy
Orbital Atherectomy
Excimer Laser Angioplasty
Thrombectomy and Aspiration Devices
Embolic Protection Devices
Drug-Coated Balloons
Coronary Physiology
Mechanical Aspiration
Intravascular Imaging
Mechanical Circulatory Support
Vascular Access
Complications
Vascular Closure Devices
Antiplatelet Agents
Aspirin
Adenosine Diphosphate (ADP) Receptor Antagonists
Complications of Femoral Access
Glycoprotein IIb/IIIa Inhibitors
Antithrombin Agents
Unfractionated Heparin
Low-Molecular-Weight Heparin
Bivalirudin
Factor Xa Inhibitors
Outcomes After Percutaneous Coronary Intervention
Early Clinical Outcomes
Mortality
Myocardial Infarction
Urgent Revascularization
Angiographic Complications
Stent Thrombosis
Late Clinical Outcomes
Outcomes Benchmarking and Procedural Volumes
Future Perspectives
Acknowledgments
References
Guidelines: Percutaneous Coronary Intervention
Clinical Features
Adjunctive Pharmacotherapy
Appropriateness Criteria for Percutaneous Coronary Intervention
Chapter 42: Diseases of the Aorta
The Normal Aorta
Anatomy and Physiology
Physiology
Evaluation of the Aorta
Aortic Aneurysms
Abdominal Aortic Aneurysms
Pathogenesis
Clinical Features
Diagnostic Imaging
Ultrasound/Computed Tomography/Magnetic Resonance Imaging/Aortography
Screening
Genetics/Molecular Genetics
Natural History
Ruptured Abdominal Aortic Aneurysm
Management
Surveillance/Medical Therapy
Surgery
Techniques and Outcomes
Endovascular Abdominal Aortic Aneurysm Repair
Thoracic Aortic Aneurysms
Cause and Pathogenesis
Genetically Triggered Thoracic Aortic Aneurysm Diseases
Degenerative Aneurysms
Aortic Dissection
Kommerell Diverticulum
Syphilis and Aortitis
Clinical Manifestations
Diagnosis
Natural History
Management
Surgical Treatment
Ascending Thoracic Aortic Aneurysms
Aortic Arch Aneurysms
Descending Thoracic Aneurysms
Thoracoabdominal Aneurysms
Endovascular Repair of Thoracic Aneurysms
Medical Management
Aortic Dissection
Classification
Cause and Pathogenesis
Clinical Manifestations
Symptoms
Physical Findings
Laboratory Findings
Diagnostic Techniques
Computed Tomography
Magnetic Resonance Imaging
Echocardiogram
Transthoracic Echocardiography
Transesophageal Echocardiography
Aortography
Selecting an Imaging Modality
The Role of Coronary Angiography
Integrated Diagnostic Evaluation and Management Algorithms
Management
Blood Pressure Reduction
Management of Cardiac Tamponade
Definitive Therapy
Long-Term Therapy and Follow-Up
Aortic Dissection Variants
Aortic Intramural Hematoma
Penetrating Atherosclerotic Aortic Ulcer
Aortoarteritis Syndromes
Bacterial Infections of the Aorta
Primary Tumors of the Aorta
Future Perspectives
References
Chapter 43: Peripheral Artery Diseases
Epidemiology
Risk Factors for Peripheral Artery Disease
Pathophysiology of Peripheral Artery Disease
Factors Regulating Blood Supply
Skeletal Muscle Structure and Metabolic Function
Clinical Features
Symptoms
Physical Findings
Categorization
Testing for Peripheral Artery Disease
Segmental Pressure Measurement
Ankle-Brachial Index
Treadmill Exercise Testing
Pulse Volume Recording
Doppler Ultrasonography
Duplex Ultrasound Imaging
Magnetic Resonance Angiography
Computed Tomographic Angiography
Contrast-Enhanced Angiography
Other Measurement Tools
Prognosis
Treatment
Risk Factor Modification
Diet
Smoking Cessation
Treatment of Diabetes
Blood Pressure Control
Lipid-Lowering Therapy
Antithrombotic Therapy for Reduction of Major Adverse Cardiovascular and Limb Events
Antiplatelet Monotherapy
Dual Antiplatelet Therapy with Aspirin and P2Y12 Inhibition
Combination Antiplatelet and Anticoagulant Therapy
Other Combination Therapies
Treatment of Symptoms and Prevention of Limb Vascular Events
Smoking Cessation
Supervised and Home-Based Exercise Training
Pharmacotherapy to Improve Claudication
Vasodilators
Other Medical Therapies
Percutaneous Transluminal Angioplasty and Stents
Peripheral Artery Surgery
Vasculitis
Thromboangiitis Obliterans
Pathology and Pathogenesis
Clinical Features
Diagnosis
Treatment
Takayasu Arteritis and Giant Cell Arteritis
Fibromuscular Dysplasia
Popliteal Artery Entrapment Syndrome
Acute Limb Ischemia
Prognosis
Pathogenesis
Diagnostic Tests
Treatment
Atheroembolism
Pathogenesis
Clinical Features
Diagnostic Tests
Treatment
Acknowledgment
References
Chapter 44: Treatment of Noncoronary Obstructive Vascular Disease
Approach to the Patient with Peripheral Artery Disease
Quality of Evidence Evaluating Endovascular Treatments
Endovascular Technologies
Balloon Angioplasty
Bare-Metal Stents
Drug-Eluting Peripheral Stents
Drug-Coated Balloons
Controversy About Paclitaxel-Coated Balloons and Stents
Covered Stents
Thrombolysis
Mechanical and Aspiration Thrombectomy
Rotational, Orbital, and Directional Atherectomy
Laser Atherectomy
Cryoplasty and Intravascular Lithotripsy
Medical Therapy to Improve Endovascular Durability
Planning an Intervention
Vascular Imaging
Vascular Access
Endovascular Treatment of Arterial Disease
Peripheral Artery Disease of the Lower Extremities
Aortoiliac Disease
Femoral-Popliteal Artery Disease
Tibial Disease
Cervical Artery Disease
Extracranial Carotid Disease
Vertebral and Subclavian Artery Disease
Mesenteric and Renal Artery Disease
Mesenteric Artery
Renal Artery
Endovascular Treatment of Venous Disease
Extremity Deep Venous Thrombosis
Superior Vena Cava Syndrome
Future Perspectives
References
Chapter 45: Prevention and Management of Ischemic Stroke
Classification of Ischemic Stroke
Stroke Risk Factors and Prevention
Antithrombotic Agents for Stroke Prevention
Antiplatelet Therapy for Primary Prevention
Stroke Prevention in Atrial Fibrillation
Secondary Prevention of Ischemic Stroke
Antiplatelet Therapy
Anticoagulant Therapy
Management of Acute Ischemic Stroke
Intravenous Recombinant Tissue Plasminogen Activator
Endovascular Therapy
Anticoagulation Therapy for Acute Ischemic Stroke
Infective Endocarditis
Diagnosis and Treatment of Patients with a Transient Ischemic Attack
Conclusions
Classic References
References
Part VI: Heart Failure
Chapter 46: Mechanisms of Cardiac Contraction and Relaxation
Microanatomy of Contractile Cells and Proteins
Ultrastructure of Contractile Cells
Subcellular Microarchitecture
Mitochondrial Morphology and Function
Contractile Proteins
Titin and Length Sensing
Molecular Basis of Muscular Contraction
Actin and Troponin Complex
Myosin Structure and Function
Graded Effects of [Ca2+]i on Cross-Bridge Cycle
Length-Dependent Activation and the Frank-Starling Effect
Cross-Bridge Cycling Differs from Cardiac Contraction-Relaxation Cycle
Force Transmission
Calcium Ion Fluxes in Cardiac Contraction-Relaxation Cycle
Calcium Movements and Excitation-Contraction Coupling
Calcium Release and Uptake by Sarcoplasmic Reticulum
Sarcoplasmic Reticulum Network and Ca2+ Movements
Junctional Sarcoplasmic Reticulum and Ryanodine Receptor
Turning Off Ca2+ Release: Breaking Positive Feedback
Calcium Uptake into Sarcoplasmic Reticulum by Sarcoendoplasmic Reticulum Ca2+–Adenosine Triphosphatase
Sarcolemmal Control of Ca2+ and Na+
Calcium and Sodium Channels
Molecular Structure of Ca2+ and Na+ Channels
T-Versus L-Type Ca2+ Channels
L-Type Ca2+ Channel Localization and Regulation
Sodium Channels
Ion Exchangers and Pumps
Sodium-Calcium Exchanger
Sodium Pump (Na+, K+–Adenosine Triphosphatase)
Adrenergic Signaling Systems
Physiologic Fight-or-Flight Response
Beta-Adrenergic Receptor Subtypes
Alpha-Adrenergic Receptor Subtypes
G Proteins
Cyclic Adenosine Monophosphate and Protein Kinase A
Adenylyl Cyclase
Protein Kinase A
Beta1-Adrenergic and Protein Kinase A Signaling in Ventricular Myocytes
Cholinergic and Nitric Oxide Signaling
Cholinergic Signaling
Nitric Oxide
Contractile Performance of the Heart
The Cardiac Cycle
Left Ventricular Contraction
Left Ventricular Relaxation
Left Ventricular Filling Phases
Contractility Versus Loading Conditions
Contractility
Preload
Afterload
Starling’s Law of the Heart
Venous Filling Pressure and Heart Volume
Frank and Isovolumic Contraction
Preload and Afterload Are Interlinked
Force-Length Relationships and Ca2+ Transients
Anrep Effect: Abrupt Increase in Afterload
Wall Stress
Heart Rate and Force-Frequency Relationship
Treppe or Bowditch Effect
Physiologic Force-Frequency Relationship and Optimal Heart Rate
Myocardial Oxygen Uptake
Work of the Heart
Measurements of Contractile Function
Measurements of Contractile Function Force-Velocity Relationship and Maximum Contractile Function in Muscle Models
Isometric Versus Isotonic Contraction
Pressure-Volume Loops
Limitations of the Concept of Contractility
Left Ventricular Relaxation and Diastolic Dysfunction
Right Ventricular Function
Atrial Function
Future Perspectives
Acknowledgment
References
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Part VII: Arrhythmias, Sudden Death, and Syncope
Chapter 61: Approach to the Patient with Cardiac Arrhythmias
General Approach to the History and Physical Exam
History
Physical Examination
Signs and Symptoms
Palpitations
Syncope, Presyncope, and Altered Level of Consciousness
Sudden Cardiac Arrest and Aborted Sudden Cardiac Death
Clinical and Laboratory Testing
Resting Electrocardiogram
Cardiac Imaging
Stress Electrocardiography
Long-Term Electrocardiogram Recording: Holter Monitoring, Event Recording, and Insertable Loop Recorders
In Hospital Electrocardiographic Recording
Ambulatory Electrocardiographic (Holter) Recording
Event Recording
Head Up Tilt
Invasive Electrophysiologic Testing
Complications of Electrophysiologic Studies
Guidelines
References
Guidelines
Ambulatory Electrocardiography
Diagnosis
Assessment of Risk for SCD
Efficacy of Antiarrhythmic Therapy
Assessment of Pacemaker/ICD Function
Monitoring for Myocardial Ischemia
Clinical Competence
Electrophysiologic Procedures for Diagnosis
Evaluation of Sinus Node Function
Acquired Atrioventricular Block
Chronic Intraventricular Delay
Narrow–and Wide–QRS Complex Tachycardia
Prolonged QT Intervals
Wolff-Parkinson-White Syndrome
Nonsustained Ventricular Tachycardia
Unexplained Syncope
Survivors of Cardiac Arrest
Palpitations
Electrophysiologic Studies For Therapeutic Intervention
Clinical Competence
Chapter 62: Mechanisms of Cardiac Arrhythmias
Foundations of Cardiac Electrophysiology
The Functions of the Cardiac Electrical System
The Cardiac Action Potential
Physiology of Ion Channels
Normal Automaticity
Molecular Structure of Key Cardiac Ion Channels and Transporters
Gap Junction Channels and Intercalated Discs
Structure and Function of the Cardiac Electrical Network
Sinoatrial Node
Atrioventricular Junctional Area and Intraventricular Conduction System
Atrioventricular Node
Bundle of His (Penetrating Portion of Atrioventricular Bundle)
Bundle Branches (Branching Portion of Atrioventricular Bundle)
Terminal Purkinje Fibers
Innervation of Atrioventricular Node, His Bundle, and Ventricular Myocardium
Pathways of Innervation
Effects of Vagal Stimulation
Effects of Sympathetic Stimulation
Arrhythmias and the Autonomic Nervous System
Mechanisms of Arrhythmogenesis
Disorders of Impulse Formation
Abnormal Automaticity
Triggered Activity
Delayed Afterdepolarizations
Major Role of Intracellular Ca2+-Handling Abnormalities in Delayed Afterdepolarization Generation
Early Afterdepolarizations
Long-QT Syndrome
Disorders of Impulse Conduction
Anatomic Reentry
Functional Reentry
Specific Arrhythmias Illustrating Mechanistic Principles
Atrial Flutter
Atrial Fibrillation
Spatiotemporal Organization and Focal Discharge
Remodeling of the Atria
Sinus Node Reentry
Atrial Reentry
Atrioventricular Nodal Reentry
Preexcitation Syndrome
Ventricular Tachycardia Caused by Reentry
Brugada Syndrome
Catecholaminergic Polymorphic Ventricular Tachycardia
Arrhythmogenic Right Ventricular Cardiomyopathy
Ventricular Fibrillation: Fibrillation Initiation and Maintenance
References
Chapter 63: Genetics of Cardiac Arrhythmias
The QT-Opathies
Long QT Syndrome
Clinical Description and Manifestations of Long QT Syndrome
Phenotypic Correlates for the Three Canonical Long QT Syndrome Genotypes
Calmodulinopathic Long QT Syndrome
Triadin Knockout Syndrome
Timothy Syndrome
Clinical Description and Manifestations of Timothy Syndrome
Cardiac-Only Timothy Syndrome
Short QT Syndrome
Clinical Description and Manifestations of Short QT Syndrome
Genotype-Phenotype Correlates in Short QT Syndrome
Drug-Induced Torsade de Pointes
Clinical Description and Manifestations of Drug-Induced Torsade de Pointes
hERG/KV11.1 Channel Blockade and Cardiac Repolarization Reserve
Common Ion Channel Polymorphisms and DI-TdP Risk
The Other Channelopathies
Andersen-Tawil Syndrome
Clinical Description and Manifestations of Andersen-Tawil Syndrome
Phenotypic Correlates in KCNJ2-Mediated Andersen-Tawil Syndrome (ATS1)
Ankyrin-B Syndrome
Brugada Syndrome
Clinical Description and Manifestations of Brugada Syndrome
Phenotypic Correlates of SCN5A-Mediated Brugada Syndrome
Catecholaminergic Polymorphic Ventricular Tachycardia
Clinical Description and Manifestations of Catecholaminergic Polymorphic Ventricular Tachycardia
Calcium Release Channel Deficiency Syndrome
Early Repolarization Syndrome
Clinical Description and Manifestations of Early Repolarization Syndrome
Familial Atrial Fibrillation
Clinical Description and Manifestations of Familial Atrial Fibrillation
Idiopathic Ventricular Fibrillation
Clinical Description and Manifestations of Idiopathic Ventricular Fibrillation
Multifocal Ectopic Purkinje-Related Premature Contractions
Progressive Cardiac Conduction Disease
Clinical Description and Manifestations of Progressive Cardiac Conduction Defect
Sick Sinus Syndrome
Clinical Description and Manifestations of Sick Sinus Syndrome
Conclusions
Future Perspectives
References
Chapter 64: Therapy for Cardiac Arrhythmias
Pharmacologic Therapy
General Considerations Regarding Antiarrhythmic Drugs
Drug Classification
Class 0
Class IA
Class IB
Class IC
Class ID
Class II
Class III
Class IV
Clinical Use
Adverse Effects
Proarrhythmia
Antiarrhythmic Agents
Class IA Agents
Quinidine
Dosage and Administration
Indications
Adverse Effects
Procainamide
Dosage and Administration
Indications
Adverse Effects
Disopyramide
Dosage and Administration
Indications
Adverse Effects
Ajmaline
Class IB Agents
Lidocaine
Dosage and Administration
Indications
Adverse Effects
Mexiletine
Dosage and Administration
Indications
Adverse Effects
Phenytoin
Class IC Agents
Flecainide
Dosage and Administration
Indications
Adverse Effects
Propafenone
Indications
Adverse Effects
Class II Agents
Beta Adrenoceptor–Blocking Agents
Dosage and Administration
Indications
Adverse Effects
Class III Agents
Amiodarone
Dosage and Administration
Indications
Adverse Effects
Dronedarone
Dosage and Administration
Indications
Adverse Effects
Sotalol
Dosage
Indications
Adverse Effects
Ibutilide
Dosage and Administration
Indications
Adverse Effects
Dofetilide
Dosage and Administration
Indications
Adverse Effects
Class IV Agents
Calcium Channel Antagonists: Verapamil and Diltiazem
Dosage and Administration
Indications
Adverse Effects
Other Antiarrhythmic Agents
Adenosine
Dosage and Administration
Indications
Adverse Effects
Digoxin
Dosage and Administration
Indications
Adverse Effects
Ranolazine
Dosage and Administration
Adverse Effects
Ivabradine
Dosage and Administration
Side Effects
Antiarrhythmic Effects of Nonantiarrhythmic Drugs
New Antiarrhythmic Agents
Electrotherapy for Cardiac Arrhythmias
Direct-Current Electrical Cardioversion
Technique
Indications
Results
Complications
Implantable Electrical Devices for Treatment of Cardiac Arrhythmias
Ablation Therapy for Cardiac Arrhythmias
Cooled-Tip Radiofrequency Ablation
Radiofrequency Catheter Ablation of Accessory Pathways
Location of Pathways
Indications
Results
Radiofrequency Catheter Modification of AV Node for AV Nodal Reentrant Tachycardias
Indications
Results
Junctional Tachycardia
Radiofrequency Catheter Ablation of Arrhythmias Related to the Sinus Node
Indications
Results
Radiofrequency Catheter Ablation of Atrial Tachycardia
Indications
Results
Radiofrequency Catheter Ablation of Atrial Flutter
Indications
Results
Ablation and Modification of Atrioventricular Conduction for Atrial Tachyarrhythmias
Indications
Results
Radiofrequency Catheter Ablation of Atrial Fibrillation
Radiofrequency Catheter Ablation of Ventricular Arrhythmias
Indications
Results
Surgical Therapy for Tachyarrhythmias
Supraventricular Tachycardias
Ventricular Tachycardia
Idiopathic Ventricular Tachycardia/Premature Ventricular Complexes and Nonischemic Cardiomyopathy
Ischemic Heart Disease
References
Chapter 65: Supraventricular Tachycardias
Definitions
Assessment of the Patient with Palpitations
Supraventricular Arrhythmia Types
Atrial Premature Complexes or Ectopic Beats
Atrial Tachycardias
Focal Atrial Tachycardia
Diagnosis and Differential Diagnosis
Anatomic Distribution
Sinus Node Reentry
Inappropriate Sinus Tachycardia
Atrial Flutter or Macroreentrant Atrial Tachycardia
Epidemiology
Classification of Atrial Flutter
Paroxysmal Supraventricular Tachycardia
ECG Characteristics and ECG Classification of PSVT
Clinical Presentation
Typical AVNRT
Atypical AVNRT
Treatment of AVNRT
Acute Management
Chronic Management
Tachycardias due to an Accessory Pathway
Accessory Pathway Epidemiology
The WPW ECG
Arrhythmias Associated with Accessory Pathways
Orthodromic AVRT
Antidromic AVRT
Preexcited Tachycardia
Treatment of AVRT
Acute Treatment of Preexcited AF
Chronic Therapy in AVRT
Asymptomatic WPW
Differential Diagnosis of Wide Complex Tachycardia
References
Chapter 66: Atrial Fibrillation: Clinical Features, Mechanisms, and Management
Electrocardiographic Features
Classification of Atrial Fibrillation
Epidemiology of Atrial Fibrillation
Mechanisms of Atrial Fibrillation
Genetic Factors
Causes of Atrial Fibrillation
Clinical Features
Diagnostic Evaluation
Prevention of Thromboembolic Complications
Risk Stratification
Aspirin
Warfarin
Direct-Acting Oral Anticoagulants
Low-Molecular-Weight Heparin
Excision or Closure of the Left Atrial Appendage
Acute Management of Atrial Fibrillation
Long-Term Management of Atrial Fibrillation
Pharmacologic Rate Control Versus Rhythm Control
Pharmacologic Rate Control
Pharmacologic Rhythm Control
Rhythm Control with Agents Other Than Antiarrhythmic Drugs
Nonpharmacologic Management of Atrial Fibrillation
Risk Factor Modification
Pacing to Prevent Atrial Fibrillation
Catheter Ablation of Atrial Fibrillation
Catheter Ablation Technique and Outcomes of AF Ablation
Indications for Ablation and Selection of Patients
Surgical Ablation of Atrial Fibrillation
Ablation of the Atrioventricular Node
Specific Clinical Syndromes
Postoperative Atrial Fibrillation
Wolff-Parkinson-White Syndrome
Congestive Heart Failure
Hypertrophic Cardiomyopathy
Pregnancy
Future Perspectives
Guidelines
References
Guidelines: Atrial Fibrillation
Prevention of Thromboembolism
Pharmacologic Rate Control of AF
Cardioversion of Atrial Fibrillation
Maintenance of Sinus Rhythm
Special Considerations in Atrial Fibrillation
Postoperative Atrial Fibrillation
Acute Myocardial Infarction
Catheter Ablation in Heart Failure
Atrial Fibrillation in Wolff-Parkinson-White Syndrome
Hyperthyroidism
Atrial Fibrillation During Pregnancy
Hypertrophic Cardiomyopathy
Pulmonary Disease
Obesity and Weight Loss
Device Detection of Atrial Fibrillation and Flutter
Chapter 67: Ventricular Arrhythmias
Premature Ventricular Complexes, Nonsustained Ventricular Tachycardias, Couplets
Electrocardiographic Recognition
Clinical Features
Management
Idiopathic Premature Ventricular Complexes/NSVT with No Structural or Electrical Heart Disease
Premature Ventricular Complexes in Structural Heart Disease
Premature Ventricular Complex Induced Cardiomyopathy
Accelerated Idioventricular Rhythm
Electrocardiographic Recognition
Management
Sustained Ventricular Tachycardia
Monomorphic Ventricular Tachycardia
Electrocardiographic Recognition
Ventricular Tachycardias Versus Supraventricular Tachycardia with Aberrancy
Mechanisms and Clinical Correlations
Scar—Related Ventricular Tachycardia
Bundle Branch Reentry and Other Purkinje System—Related Ventricular Tachycardias
Focal Origin Ventricular Tachycardias
Clinical Features
Acute Management of Sustained Monomorphic Ventricular Tachycardia
Electrical Storm
Evaluation and Long-Term Management
Long-Term Therapy
Specific Ventricular Tachycardias
Ischemic Cardiomyopathy
Nonischemic Dilated Cardiomyopathy
Arrhythmogenic Right Ventricular Cardiomyopathy
Congenital Heart Disease
Hypertrophic Cardiomyopathy
Inflammatory Heart Disease
Cardiac Sarcoidosis
Myocarditis
Chagas Disease
Idiopathic Ventricular Tachycardias
Outflow Tract Arrhythmias
Annular Arrhythmias
Crux Arrhythmias
Papillary Muscle Arrhythmias
Left Fascicular Reentrant Tachycardia
Polymorphic Ventricular Tachycardia
Electrocardiographic and Clinical Features
Management
Specific Disorders with Polymorphic entricular Tachycardias
Acute Myocardial Infarction and Ischemia
Acquired Long QT Syndrome and Torsade de Pointes
Inherited Long QT syndrome
Management
Inherited Short QT Syndrome
J Wave Syndromes: Brugada and Early Repolarization Syndromes
Brugada Syndrome
Management
Early Repolarization and J Wave Syndromes
Management
Catecholaminergic Polymorphic Ventricular Tachycardias
Ventricular Fibrillation
Electrocardiographic Recognition
Clinical Features
Management
Ventricular Flutter
References
Chapter 68: Bradyarrhythmias and Atrioventricular Block
Bradyarrhythmias
Sinus Bradycardia
Electrocardiographic Recognition
Clinical Features
Management
Sinus Arrhythmia
Sick Sinus Syndrome
Electrocardiographic Recognition
Chronotropic Incompetence
Tachycardia-Bradycardia Syndrome
Management
Atrioventricular Block (Heart Block)
First-Degree Atrioventricular Block
Second-Degree Atrioventricular Block
High-Grade Atrioventricular Block
Third-Degree (Complete) Atrioventricular Block
Clinical Features
Management
Atrioventricular Dissociation
Electrocardiographic and Clinical Features
Management
Autonomic/Neurally Mediated Bradycardia
Electrocardiographic Recognition
Clinical Features
Management
References
Chapter 69: Pacemakers and Implantable Cardioverter-Defibrillators
Types of Devices
Device Radiography
Types of Pacemakers
Indications for Pacemakers
Capture and Sensing
Capture and Stimulation
Electrograms and Sensing Function in Pacemakers
Hemodynamic Aspects of Pacing
Pacing Mode and Timing Cycles
Definitions
Common Pacing Modes
Rate Responsive Pacing
Choosing a Single- or Dual-Chamber Pacing Device
Pacemaker Troubleshooting
Failure to Capture
Failure to Pace
Unexpected Pacing at or Near the Upper Rate
Unexpected Drop in Pacing Rate
Pacing-Induced Proarrhythmia
Pseudo-Malfunction
Implantable Cardioverter-Defibrillators
Types of ICDs
Indications for ICDs
Secondary Prevention
Primary Prevention
ICD System Selection
Dual- versus Single-Chamber Transvenous ICDs
Transvenous versus Subcutaneous ICD Systems
ICD Therapy
General Considerations
ICD Troubleshooting
Ventricular Oversensing
Shocks: Diagnosis and Management
Approach to the Patient with Shocks
Unsuccessful Shocks
Failure to Deliver Therapy or Delayed Therapy
ICD Lead Failure: Presentation and Management
Clinical Presentations
Imaging
Approach to the Patient
Complications
Vascular Access Complications
Lead Placement Complications
Pocket Hematoma and CIED Infections
Subcutaneous ICD Complications
Leadless Pacemaker Complications
Follow-Up and Management
Remote Monitoring
CIED Diagnostics for Atrial Fibrillation
Device Clinic Follow-Up
Electromagnetic Interference
Common Clinical Issues in CIED Patients
Psychosocial Issues
Lifestyle Issues
Driving
Participation in Sports
Drug Interactions
References
Chapter 70: Cardiac Arrest and Sudden Cardiac Death
Perspective
Definitions
Epidemiology
Epidemiologic Overview
Population Pools, Risk Gradients, and Time Dependence of Risk
Population and Subgroup Risk Versus Individual Risk Assessment
Biologic and Clinical Time-Dependent Risk
Age, Race, Sex, and Heredity
Age
Race
Sex
Heredity
Risk Factors for Sudden Cardiac Death
General Profile of Risk for Sudden Cardiac Death
Functional Capacity and Sudden Death
Lifestyle and Psychosocial Factors
Left Ventricular Ejection Fraction in Chronic Ischemic Heart Disease
Ventricular Arrhythmias in Chronic Ischemic Heart Disease
Emerging Markers of Risk for Sudden Cardiac Death
Causes of Sudden Cardiac Death
Coronary Artery Abnormalities
Atherosclerotic Coronary Artery Disease
Nonatherosclerotic Coronary Artery Abnormalities
Anomalous Origin of Coronary Arteries from the Wrong Sinus of Valsalva
Embolism to the Coronary Arteries
Coronary Arteritis
Mechanical Obstruction of Coronary Arteries
Coronary Artery Spasm
Ventricular Hypertrophy and Hypertrophic Cardiomyopathy
Cardiomyopathy and Systolic and Diastolic Heart Failure
Acute Heart Failure
Valvular Heart Disease
Electrophysiologic Abnormalities
Long-QT Syndromes
Brugada Syndrome
Early Repolarization and Sudden Cardiac Death
Sudden Infant Death Syndrome and Sudden Cardiac Death in Children
Sudden Cardiac Death in Competitive and Recreational Athletes and During Intense Exercise
Mechanisms and Pathophysiology
Pathophysiologic Mechanisms of Lethal Tachyarrhythmias
Coronary Artery Structure and Function
Acute Ischemia and Initiation of Lethal Arrhythmias
Transition from Myocardial Instability to Lethal Arrhythmias
Bradyarrhythmias and Asystolic Arrest
Pulseless Electrical Activity
Clinical Features of Patients with Cardiac Arrest
Prodromal Symptoms
Onset of the Terminal Event
Cardiac Arrest
Progression to Biologic Death
Survivors of Cardiac Arrest
Hospital Course
Clinical Profile of Survivors of Out-of-HospitalC ardiac Arrest
Postresuscitation Electrocardiographic Changes
Left Ventricular Function
Coronary Angiography
Blood Chemistry
Long-Term Prognosis
Management of Cardiac Arrest
In-Hospital Interventions
Community-Based Interventions
Impact of Tiered Response Systems
Initial Assessment and Basic Life Support
Chest Thump
Basic Life Support—The Initial Steps in Cardiopulmonary Resuscitation
Circulation
Concept of Cardiocerebral Resuscitation
Airway
Breathing
Early Defibrillation by First Responders
Advanced Life Support
Defibrillation-Cardioversion
Pharmacotherapy
Bradyarrhythmic and Asystolic Arrest; Pulseless Electrical Activity
Stabilization of Cardiac Rhythm after Initial Return of Spontaneous Circulation
Postcardiac Arrest Care and Postcardiac ArrestSyndrome
Cardiac Arrest in Patients with Hemodynamically Stable Acute Myocardial Infarction
Cardiac Arrest in Patients with Hemodynamically Unstable Acute Myocardial Infarction
Risk Identification by QT Interval Prolongation after Cardiac Arrest
Long-Term Management of Survivors of Out-of-Hospital Cardiac Arrest
General Care
Prevention of Cardiac Arrest and Sudden Cardiac Death
Methods to Estimate Risk for Sudden Cardiac Death
General Medical and Cardiovascular Risk Markers
Strategies to Reduce Risk for Sudden Cardiac Death
Antiarrhythmic Drugs
Surgical Intervention Strategies
Catheter Ablation Therapy
Implantable Cardioverter Defibrillators
Application of Therapeutic Strategies to Specific Groups of Patients
Secondary Prevention of Sudden Cardiac Death after Survival from Cardiac Arrest
Primary Prevention of Sudden Cardiac Death in Patients with Advanced Heart Disease
Primary Prevention in Patients with Structurally Normal Hearts or Molecular Disorders of Cardiac Electrical Activity
Prediction and Primary Prevention in the General Population
Sudden Death and Public Safety
References
Chapter 71: Hypotension and Syncope
Definition
Classification
Vascular Causes of Syncope
Orthostatic Hypotension
Reflex-Mediated Syncope
Neurally Mediated Hypotension or Syncope (Vasovagal Syncope)
Carotid Sinus Hypersensitivity
Cardiac Causes of Syncope
Neurologic Causes of Transient Loss of Consciousness
Metabolic Causes of Transient Loss of Consciousness
Diagnostic Tests
History, Physical Examination, and Carotid Sinus Massage
Physical Examination
Carotid Sinus Massage
Laboratory Testing: Blood Tests
Tilt-Table Test
Cardiac Imaging
Stress Tests and Cardiac Catheterization
Electrocardiography
Cardiac Monitoring
Electrophysiologic Testing
Electrophysiologic Testing Protocol
Test to Screen for Neurologic Causes of Syncope
Approach to the Evaluation of Patients with Syncope
Management of Patients with Syncope
Neurally Mediated Syncope
Cardioneuroablation for Treatment of Neurally Mediated Syncope
Future Perspectives
References
Part VIII: Diseases of the Heart Valves
Chapter 72: Aortic Valve Stenosis
Epidemiology
Causes and Etiology
Calcific Aortic Valve Disease
Bicuspid Aortic Valve Disease
Rheumatic Aortic Stenosis
Clinical Presentation
Symptoms
Physical Examination
Auscultation
Diagnostic Testing
Echocardiography
Disease Course and Staging
Progressive Aortic Stenosis (Stage B; Mild to Moderate Valve Obstruction)
Classification of Severe Aortic Stenosis
Asymptomatic Severe Aortic Stenosis (Stage C)
Symptomatic Severe Aortic Stenosis (Stage D)
Symptomatic Severe High-Gradient Aortic Stenosis (Stage D1)
Symptomatic Severe Low-Flow, Low-Gradient Aortic Stenosis with Reduced LVEF (Stage D2)
Symptomatic Severe Low-Flow, Low-Gradient Aortic Stenosis with Preserved LVEF (Stage D3)
Treatment
Aortic Valve Replacement
Surgical Aortic Valve Replacement
Transcatheter Aortic Valve Replacement
Patient Selection for TAVR or SAVR
Postprocedural Issues
Classic References
References
Chapter 73: Aortic Regurgitation
Causes and Pathology
Valvular Disease
Disease of the Aortic Root and Ascending Aorta
Chronic Aortic Regurgitation
Pathophysiology
Clinical Presentation
Symptoms
Diagnostic Testing
Echocardiography
Cardiac Magnetic Resonance
Angiography
Disease Course
Asymptomatic Patients
Symptomatic Patients
Treatment of Chronic Aortic Regurgitation
Medical Therapy
Surgical Treatment
Indications for Valve Replacement
Symptomatic Patients
Asymptomatic Patients
Operative Procedures
Acute Aortic Regurgitation
Pathophysiology and Clinical Presentation
Classic References
References
Chapter 74: Transcatheter Aortic Valve Replacement
Epidemiology, Natural History, and Treatment Alternatives for Valvular Aortic Stenosis
History and Background of Transcatheter Aortic Valve Replacement (TAVR)
Predicate Technologies Including Balloon Aortic Valvuloplasty
The Proof-of-Concept First-in-Human Case
The Early Years of TAVR
Outcomes in Patients Not Suitable for Surgery Using Early TAVR Technologies
Patient Surgical Risk Profiles and Comorbidity Assessments
Introduction to the Heart Team
TAVR Evidence-Based Clinical Research
An Ecosystem for Aortic Valve Clinical Research
Randomized Clinical Trials According to Surgical Risk Strata
Primary Clinical Endpoints
Key Secondary Outcomes
Echocardiographic Findings
Quality-of-Life Assessments
National TAVR Registries
Society-Based Guidelines and Appropriate Use Criteria
TAVR Technology Evolution
Anatomy (Components) of a TAVR System
Rapid Progression of TAVR Technologies to the Modern Era
Other TAVR Systems and Comparative Device versus Device Studies
Accessory Devices for TAVR
TAVR Procedural Maturation
Computed Tomography Imaging for Procedural Planning
Echocardiography for Diagnosis, Procedure-Planning and Follow-Up
Minimalist Approach (Including Conscious Sedation Anesthesia)
Alternative Vascular Access Strategies
TAVR-Associated Complications
Intraprocedural Complications
Coronary Obstruction
Vascular Complications
Postprocedural Complications
Neurologic Events
Conduction Disturbances
Paravalvular Regurgitation
Prosthesis–Patient Mismatch
Other Complications
TAVR and Concomitant Cardiac Diseases
TAVR in Surgical Bioprosthetic Aortic Valve Failure
Gaps in TAVR Knowledge and Ongoing Controversies
Durability of TAVR Systems
Aortic Stenosis and Multivalve Disease
Aortic Stenosis and Atrial Fibrillation
Aortic Stenosis and Coronary Artery Disease
TAVR in Low-Gradient Aortic Stenosis
Treatment of Bicuspid Aortic Valve Disease
TAVR for Aortic Regurgitation
Managing the Young, Low-Risk Patient with AS
Subclinical Leaflet Thrombosis
Optimal Antithrombotic Therapies
Future TAVR Directions
Next Generation Valve Technology
Expanded Clinical Indications
Asymptomatic Severe Aortic Stenosis
Moderate Aortic Stenosis
The Modern Era Heart Team
References
Chapter 75: Mitral Stenosis
Epidemiology and Secular Trends
Rheumatic Mitral Stenosis
Nonrheumatic Mitral Stenosis
Definition of Disease and Severity
Rheumatic Mitral Stenosis
Pathology
Clinical Pathophysiology
Left Atrial Pressure
Left Atrial Function
Left Ventricular Function
Right Ventricular Function
Natural History
Diagnosis
Clinical Presentation
Physical Examination
Echocardiography
Additional Diagnostic Investigations
EKG and Chest X-Ray
Exercise Testing in MS
Other Diagnostic Tests
Associated Conditions
Atrial Fibrillation
Pulmonary Hypertension
Pregnancy
Diagnosis and Treatment
Percutaneous Balloon Mitral Valvuloplasty
Treatment
Medical Therapy
Transcatheter Interventional Therapy
Complications
Long-Term Results
Surgical Intervention
Comparison with BMV
Nonrheumatic Mitral Stenosis
Degenerative MS Related to Mitral Annular Calcification
Associated Aortic Stenosis
Natural History
Treatment
Radiotherapy-Induced MS
MS Following Interventional and Surgical Therapies
Classic References
References
Chapter 76: Mitral Regurgitation
Mitral Valve Anatomy
Mitral Annulus
Mitral Leaflets
Mitral Valve Chordae and Papillary Muscles
Mechanisms of Mitral Regurgitation
Normal Mitral Valve Physiology
Primary Mitral Regurgitation
Clinical Presentation
Symptoms
Physical Examination
Echocardiography
Quantification of MR Severity
Transesophageal Echocardiography
Exercise Echocardiography
Natural History
Left Ventricular Volumes and Systolic Function
Mitral Annular Disjunction
Symptoms
Management of Primary Mitral Regurgitation
Medical Therapy for Primary Mitral Regurgitation
Surgical Therapy for Primary Mitral Regurgitation
Transcatheter Therapy for Primary Mitral Regurgitation
Edge-to-Edge Repair
Investigational Devices
Secondary Mitral Regurgitation
Pathophysiology
Clinical Presentation
Management of Secondary Mitral Regurgitation
Medical Therapy for Secondary Mitral Regurgitation
Surgical Therapy for Secondary Mitral Regurgitation
Transcatheter Therapy for Secondary Mitral Regurgitation
Investigational Devices
Classic References
References
Chapter 77: Tricuspid, Pulmonic, and Multivalvular Disease
Tricuspid Stenosis
Causes and Pathology
Pathophysiology
Clinical Presentation
Management
Tricuspid Regurgitation
Causes and Pathology
Clinical Presentation
Management
Pulmonic Stenosis
Causes and Pathology
Clinical Presentation
Physical Examination
Management
Pulmonic Regurgitation
Causes and Pathology
Clinical Presentation
Management
Multivalvular Disease
Surgical Treatment of Multivalvular Disease
Triple- and Quadruple-Valve Disease
References
Chapter 78: Transcatheter Therapies for Mitral and Tricuspid Valvular Heart Disease
Mitral Stenosis
Mitral Balloon Valvuloplasty
Indications
Mitral Regurgitation
Rationale for Transcatheter Therapy
Leaflet Repair with MitraClip Device
Transcatheter Mitral Valve Replacement
Tricuspid Regurgitation
Pathophysiology
Treatment
Leaflet Clip Devices
Valve Spacer Devices
Caval Devices
Tricuspid Valve Replacement Devices
Summary
Conclusion
Classic References
References
Chapter 79: Prosthetic Heart Valves
Types of Prosthetic Heart Valves
Mechanical Valves
Tissue Valves
Stented Bioprosthetic Valves
Stentless Bioprosthetic Valves
Homografts
Autografts
Transcatheter Bioprosthetic Valves
Medical Management and Surveillance After Valve Replacement
Antithrombotic Therapy
General Principles
Interruption of Antithrombotic Therapy
Pregnancy
Infective Endocarditis Prophylaxis
Clinical Assessment
Echocardiography
Evaluation and Treatment of Prosthetic Valve Dysfunction and Complications
Prosthesis-Patient Mismatch
Structural Valve Deterioration
Paravalvular Leak
Infective Endocarditis
Hemolytic Anemia
Classic References
References
Chapter 80: Infectious Endocarditis and Infections of Indwelling Devices
Infective Endocarditis
Epidemiology
Pathogenesis
Clinical Presentation
Predisposing Cardiac Conditions
Symptoms
Physical Examination
Diagnosis
Diagnostic Testing
Electrocardiogram
Imaging
Imaging for Diagnosis of Infective Endocarditis
Imaging for Delineation of Complications of Endocarditis
Local Valvular Destruction
Perivalvular Extension of Infection
Approach to Echocardiographic Imaging
Other Advanced Imaging
Embolism
Indications for and Timing of Surgery
Surgical Intervention
Outpatient Management and Follow-Up Evaluation
Cardiovascular Implantable Electronic Device Infections
Epidemiology
Clinical Syndromes
Microbiology
Pathogenesis
Diagnosis
Management
Prophylaxis
Left Ventricular Assist Device Infections
Microbiology
Management
Prevention
Guidelines
References
Guidelines: Infective Endocarditis
Prevention
Indications for Echocardiography
Surgery for Active Endocarditis
Chapter 81: Rheumatic Fever
Epidemiology
Pathogenesis
Clinical Features
Arthritis
Carditis
Valvulitis
Myocarditis
Pericarditis
Sydenham Chorea
Cutaneous and Subcutaneous Features
Erythema Marginatum
Other Manifestations
Diagnosis
Evidence of Preceding GAS Infection
Natural History
Management
General Management
Antibiotic Treatment
Aspirin and Other Anti-Inflammatory Drugs
Antibiotic Prophylaxis
Prevention
Primordial Prevention
Primary Prevention
Secondary Prevention
Future Perspectives
Classic References
References
Part IX: Diseases of the Myocardium, Pericardium, and Pulmonary Vasculature Bed
Chapter 82: Congenital Heart Disease in the Adolescent and Adult
General Considerations
Access and Delivery of ACHD Care
Transition to ACHD Care
Clinical Evaluation
Noncardiac Complications in the ACHD Patient
Congenital Anatomy
Congenital Nomenclature
Cardiac Development
Genetic Considerations
Long-Term Considerations
Arrhythmias in Adult Congenital Heart Disease
Demographics and Prognosis
Diagnostic Testing
Types of Arrhythmia
Bradyarrhythmia
Sinus Node Dysfunction
Heart Block
Tachyarrhythmias
Interatrial Re-Entrant Tachycardia
Atrial Fibrillation
Ventricular Tachycardia and Sudden Death
Pacemakers and Implantable Defibrillators
Heart Failure, Transplantation, and Mechanical Circulatory Support
Epidemiology
Clinical Features
Pathophysiology
Medical Therapy
Cardiac Resynchronization
Transplantation
Mechanical Circulatory Support
Palliative Care
Aortopathies in Congenital Heart Disease
Subacute Bacterial Endocarditis
Pregnancy in Women With Congenital Heart Disease
Exercise and Sports Participation
Benefits of Physical Exercise
Individualized Exercise Programs
Competitive Sports
Specific Defects
Left-to-Right Shunt Lesions
Atrial Septal Defects and Partial Anomalous Pulmonary Veins
Anatomic Description and Prevalence
Clinical Features
Repairs
Long-Term Outcomes and Complications
Atrioventricular Septal Defects
Anatomic Description and Prevalence
Clinical Features
Surgical Repairs
Long-Term Outcomes and Complications
Ventricular Septal Defects
Anatomic Description and Prevalence
Clinical Features
Repairs
Long-Term Outcomes and Complications
Patent Ductus Arteriosus
Anatomic Description and Prevalence
Clinical Features
Repairs
Long-Term Outcomes and Complications
Ebstein Anomaly of the Tricuspid Valve
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Long-term Outcomes and Complications
Unrepaired Ebstein Anomaly
Tricuspid Valve Repair and Replacement Surgery
Transcatheter Atrial Septal Defect/Patent Foramen OvaleClosure
Ventricular Dysfunction, Heart Failure, and Transplantation
Pulmonary Stenosis
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Surgical Repairs
Long-Term Outcomes and Complications
Indications for Intervention or Re-Intervention
Tetralogy of Fallot
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Surgical Repair
Long-Term Outcomes and Complications
Anatomic Sequalae
Ventricular Dilation and Dysfunction and Heart Failure
Arrhythmia and Risk Stratification for Sudden Cardiac Death
Transposition of the Great Arteries
Anatomic Description and Prevalence
Clinical Features
Surgical Repairs
Atrial Switch Operation
Arterial Switch Operation
Rastelli Operation
Long-Term Outcomes and Complications Following the Atrial Switch Operation
Ventricular Dysfunction
Baffle Complications
Atrial Arrhythmia
Long-Term Complications Following the Arterial Switch Operation
Coronary Artery Stenosis
Aortic Dilation and Regurgitation
Supravalvar Pulmonic Stenosis
Long-Term Complications Following the Rastelli Operation
Congenitally Corrected Transposition of the Great Arteries
Anatomic Description and Prevalence
Clinical Features
Surgical Repairs
Late Complications
Double Outlet Right Ventricle
Anatomic Description and Prevalence
Clinical Features
Repairs
Long-Term Outcomes and Complications
Truncus Arteriosus
Anatomic Description and Prevalence
Clinical Features
Repairs
Long-Term Outcomes and Complications
Cor Triatriatum
Anatomic description and prevalence
Clinical Features and Diagnostic Testing
Long-term Outcomes and Complications
Subvalvular Left Ventricular Outflow Tract Obstruction
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Repairs
Long-Term Outcomes and Complications
Supravalvar Aortic Stenosis
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Repair
Long-term Outcomes and Complications
Coarctation of the Aorta
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Long-Term Outcomes and Complications
Interrupted Aortic Arch
Vascular Rings
Anatomic Description and Prevalence
Clinical Features and Diagnostic Testing
Surgical Repairs
Long-Term Outcomes and Complications
Anomalous Coronary Artery From the Pulmonary Artery
Single Ventricle
Anatomic Description and Prevalence
Surgical Palliation
Clinical Features and Diagnostic Testing
Long-Term Outcomes and Complications
Ventricular Dilation, Dysfunction, and Heart Failure
Arrhythmia
Cyanosis
Protein-Losing Enteropathy and Plastic Bronchitis
Abnormalities of the Aorta and Pulmonary Arteries
Fontan-Associated Liver Disease
Pulmonary Hypertension and Eisenmenger Syndrome
Demographics and Prognosis
Classification
Eisenmenger Syndrome
Clinical Features
Management of Eisenmenger Syndrome
References
Chapter 83: Catheter-Based Treatment of Congenital Heart Disease in Adults
Valvular Interventions
Pulmonary Valvuloplasty
Pulmonary Valve Replacement
Pulmonary Valve Systems
Melody Valve
SAPIEN Valve
Arterial Interventions
Pulmonary Angioplasty
Stenting for Coarctation of the Aorta
Septal Interventions
Techniques for Closure of Atrial Septal Defects
Amplatzer Devices
GORE Devices
Techniques for Closure of Superior Sinus Venosus Atrial Septal Defects
Techniques for Closure of Ventricular Septal Defects
Treatment of Patent Ductus Arteriosus
Amplatzer Duct Occluders (First- and Second-Generation)
Amplatzer Vascular Plugs (Second- and Fourth-Generation)
Nit-Occlud Device
Standard Coiling
Future Perspectives
References
Chapter 84: Cardiomyopathies Induced by Drugs or Toxins
Alcohol
History
Epidemiology
Pharmacology and Pathophysiology
Alcoholic Cardiomyopathy
Cardiac Arrhythmias
Alcohol and Lipid Metabolism
Alcohol and Coronary Artery Disease
Alcohol and Hypertension
Electronic Cigarettes
The Effect of Electronic Cigarettes/Vaping on the Cardiovascular System
E-Cigarette or Vaping Product Use Associated Lung Injury
Cocaine
History and Epidemiology
Pathophysiology
Clinical Presentation
Aortic Dissection
Myocardial Dysfunction
Cardiac Arrhythmias
Other Cardiac Stimulants
Amphetamines and Methamphetamines
Khat and Cathinones
Marijuana
Atrial Arrhythmias
Ventricular Arrhythmias
Acute Coronary Syndromes
Neurologic Events
Cannabidiol Oil
Energy Drinks and Caffeine
Opiates
Heavy Metals
Future Directions
Acknowledgment
References
Chapter 85: Cardiovascular Abnormalities in HIV-Infected Individuals
Cardiovascular Risk Factors in People Living with HIV
Dyslipidemia
Lipodystrophy, the Metabolic Syndrome, and Obesity
Diabetes
Hypertension and Chronic Kidney Disease
Smoking
Mechanisms of HIV-Related Atherogenesis
Features of Atherosclerosis in People with HIV
Coronary Disease in HIV Subjects
Epidemiology
Clinical Presentation
Treatment
Antiretroviral Therapy and Cardiovascular Disease
Treatment of Lipids in the Setting of HIV
Risk Assessment and Screening for Coronary Disease
Other Cardiovascular Conditions Associated with HIV
Pulmonary Hypertension
Heart Failure
Arrhythmias and Sudden Cardiac Death
Cerebrovascular Disease
References
Chapter 86: Pericardial Diseases
Acute Pericarditis
Definition, Causes, Epidemiology, and Pathophysiology
History and Differential Diagnosis
Physical Examination
Laboratory Testing
Diagnosis, Natural History, and Management
Recurrent Pericarditis
Pericardial Effusion and Cardiac Tamponade
Etiology
Pathophysiology and Hemodynamics
Clinical Presentation
Laboratory Testing
Management of Pericardial Effusion and Tamponade
Pericardial Fluid Analysis
Pericardioscopy and Percutaneous Biopsy
Constrictive Pericarditis
Physical Examination
Laboratory Testing
Echocardiography-Doppler Examination
Cardiac Catheterization and Angiography
Computed Tomography and Cardiac Magnetic Resonance
Differentiating Constrictive Pericarditis from Restrictive Cardiomyopathy
Management
Effusive-Constrictive Pericarditis
References
Chapter 87: Pulmonary Embolism and Deep Vein Thrombosis
Epidemiology
General Considerations
Clinical Risk Factors
Cancer and Venous Thromboembolic
Venous Thromboembolic in the Pediatric Population
Hypercoagulable States
Other Conditions Associated with Venous Thromboembolic
Long-term Complications of Venous Thromboembolic and Risk of Subsequent Adverse Events
Pulmonary Embolism in COVID-19 Infection
Pathophysiology
Classification of Pulmonary Embolism
High-Risk Pulmonary Embolism
Intermediate-Risk Pulmonary Embolism
Low-Risk Pulmonary Embolism
Pulmonary Infarction
Paradoxical Embolism
Nonthrombotic Pulmonary Embolism
Post-Pulmonary Embolism Syndrome
Chronic Thromboembolic Pulmonary Hypertension
Diagnosis
Clinical Presentation
Differential Diagnosis
Nonimaging Diagnostic Methods
Plasma D-Dimer Assay
Electrocardiogram
Imaging Methods
Chest Radiography
Lung Ultrasound
Chest Computed Tomography
Echocardiography
Venous Ultrasonography
Lung Scanning
Magnetic Resonance Imaging
Pulmonary Angiography
Contrast Venography
Overall Strategy: An Integrated Diagnostic Approach
Therapy
Risk Stratification
Parenteral Anticoagulation
Unfractionated Heparin
Low-Molecular-Weight Heparin
Fondaparinux
Heparin-Induced Thrombocytopenia
Warfarin Anticoagulation
Warfarin Overlap with Heparin
Dosing and Monitoring of Warfarin
Warfarin “Bridging”
Novel Oral Anticoagulants
Evolution of Oral Anticoagulants for Pulmonary Embolism and Deep Vein Thrombosis Treatment
Managing Bleeding Complications from Anticoagulants
Optimal Duration of Anticoagulation and Selection of Optimal Anticoagulant
Risk of Recurrent Venous Thromboembolism after Discontinuation of Anticoagulation
How to Determine the Optimal Duration of Anticoagulation
Selection of an Optimal Oral Anticoagulant for Extended-Duration Anticoagulation
Advanced Therapy for Acute Pulmonary Embolism
High-Risk Pulmonary Embolism
Advances in Catheter-Based Therapy
Surgical Embolectomy
Inferior Vena Cava Filters
Deep Vein Thrombosis Interventions
Therapy in Patients with Cancer
Treatment of Superficial Thrombophlebitis
Therapy in Patients with Antiphospholipid Syndrome and Factor V Leiden
Therapy in Pediatric Populations
Emotional Support
Prevention
Rationale for In-Hospital Venous Thromboembolism Prophylaxis
Rationale for Venous Thromboembolism Prophylaxis at Hospital Discharge
In-Hospital Risk Factors for Venous Thromboembolism and Bleeding
Primary Prevention of Venous Thromboembolism in High-Risk Patients with Active Cancer
Mechanical Prophylaxis in Medically Ill Patients
Advances in Venous Thromboembolism Prophylaxis in Major Orthopedic Surgery
Future Perspectives
References
Chapter 88: Pulmonary Hypertension
Normal Pulmonary Circulation
Pulmonary Circulatory Physiology
Effect of Aging on the Pulmonary Circulation
Pulmonary Venous System
Pulmonary Circulatory Physiology During Exercise
Classification of Pulmonary Hypertension
Hemodynamic Classifications
Isolated Post-Capillary Pulmonary Hypertension Clinical Classifications
Heart Failure and Cardiomyopathy
Valvular Heart Disease
Pre-Capillary Pulmonary Hypertension Clinical Classifications
Pulmonary Arterial Hypertension
Hereditary Pulmonary Artery Hypertension
Toxin-Induced Pulmonary Artery Hypertension
Systemic Sclerosis with Pulmonary Artery Hypertension
Infectious Pulmonary Artery Hypertension Subtypes
Congenital Heart Disease
Lung Disease and Sleep Disordered Breathing
Chronic Thromboembolic Pulmonary Hypertension
Pulmonary Venoocclusive Disease
Portopulmonary Hypertension
Combined Pre- and Post-Capillary Pulmonary Hypertension
Left Heart Structural and Functional Disorders
Pathology
Pathobiology
Pathophysiology
Right Ventricular Dysfunction
Systemic Manifestations of Pulmonary Hypertension
Patient Presentation and Clinical Assessment
Patient Medical History
Physical Examination Findings
Approach to Diagnosis
Pulmonary function tests and sleep study
Computed tomographic chest imaging and nuclear ventilation/perfusion (V/Q) scintigraphy
Cardiac magnetic resonance (CMR) imaging
Positron emission tomography
Exercise testing
Cardiac catheterization
Risk Stratification
Integrated Approach to Diagnosing Pulmonary Hypertension
Pulmonary Venoocclusive Disease
Chronic Thromboembolic Pulmonary Hypertension
Treatment
Pulmonary Arterial Hypertension
Initial Management of Treatment-Naïve Pulmonary Arterial Hypertension Patients
Therapeutic Escalation and End-Stage Disease
Genetic Counseling
Chronic Thromboembolic Pulmonary Hypertension
Pulmonary Hypertension from Left Heart Disease
Special Clinical Circumstances
High-Altitude Pulmonary Edema
Sarcoidosis
Sickle Cell Disease
Pregnancy
Perioperative Management
Future Perspectives
Acknowledgments
References
Chapter 89: Sleep-Disordered Breathing and Cardiac Disease
Definitions
Pathophysiology
Pathophysiology of Obstructive Sleep Apnea
Pathophysiology of Central Sleep Apnea
Risk Factors for and Recognition of Sleep-Disordered Breathing
Pathophysiologic Mechanisms That Link Sleep-Disordered Breathing to Cardiovascular Diseases
Sleep-Disordered Breathing and Hypertension
Sleep-Disordered Breathing and Coronary Heart Disease
Sleep-Disordered Breathing, Cardiac Function, and Heart Failure
Sleep-Disordered Breathing and Cardiac Arrhythmias
Future Perspectives
References
Part X: Cardiovascular Disease in Select Populations
Chapter 90: Cardiovascular Disease in Older Adults
What is Aging?
Age-Associated Changes in Cardiovascular Structure and Function
Geriatric Domains Pertinent to Cardiovascular Care
Precepts of Patient-Centered Care in Older Adults
Diagnosis and Risk Assessment
Disease Management and Care Coordination
Application of Guidelines
Shared Decision Making
Care Transitions, Skilled Nursing Facilities, and Long-Term Care
Palliative Care and End-of-Life Care
Deprescribing
Coronary Heart Disease
Epidemiology
Presentation
Risk Stratification and Diagnosis
Management
Ischemia with Nonobstructive Coronary Arteries (INOCA)
Acute Coronary Syndromes (ACS)
Epidemiology
Presentation
Diagnosis
Management
Revascularization-STEMI
Revascularization-NSTE-ACS
Post-ACS Care and Discharge Planning
Heart Failure
Epidemiology
Pathophysiology
Diagnosis
Lifestyle HF Management
Pharmacotherapy for Chronic HFrEF
Nonmedicinal Options for Chronic HFrEF
Heart Failure with Preserved Ejection Fraction
Cardiac Amyloidosis
Pulmonary Hypertension
Valvular Heart Disease
Aortic Stenosis
Cardiac Rhythm Abnormalities
Supraventricular Arrhythmias
Atrial Fibrillation
Venous Thromboemblic Disease
Epidemiology and Diagnosis
Management
Syncope
Background
Clinical Features and Etiology
Evaluation
Management
Prevention
Hypertension
Hypertension Management
Dyslipidemia
Diabetes
Tobacco
Physical Inactivity
Physical Activity Prescription
Cardiac Rehabilitation
Obesity
Diet
Noncardiac Surgery and Perioperative Management Considerations in Older Adults
Background
Risk Assessment
Perioperative Management
Specific Complications
Discharge Planning
Peripheral Arterial Disease, Abdominal Aortic Aneurysm, Aortic Dissection
References
Peripheral Arterial Disease, Abdominal Aortic Aneurysm, Aortic Dissection
Lower Extremity Peripheral Arterial Disease (LE-PAD)
Epidemiology
Diagnosis
Management
Abdominal Aortic Aneurysm
Epidemiology
Diagnosis and Management
Aortic Dissection
Clinical Presentation
Diagnosis and Management
References
Chapter 91: Cardiovascular Disease in Women
Background
Sex, Gender, and Genetic Differences in Cardiovascular Disease
Cardiovascular Risk Factors in Women
Cardiovascular Disease Risk Assessment
Ischemic Heart Disease in Women
Symptoms of Ischemia
Delays in Care of Women
Diagnosis of Ischemia in Women
Interventions and Medical Therapy for Ischemic Heart Disease in Women
Ischemic Heart Disease: Beyond Obstructive Coronary Artery Disease
Ischemia with No Obstructive Coronary Artery Disease
Myocardial Infarction with Nonobstructive Coronary Artery Disease
Takotsubo Cardiomyopathy
Cardiac Surgery
Coronary Artery Bypass Graft
Valvular Heart Surgery
Transcatheter Aortic Valve Intervention
Transcatheter Mitral Valve Repair
Peripheral Arterial Disease
Heart Failure
Peripartum Cardiomyopathy
Heart Failure Diagnosis
Heart Failure Treatment
Device Use in Heart Failure
Mechanical Circulatory Support
Cardiac Transplantation
Arrythmia and Sudden Cardiac Death
Cardiovascular Disease Prevention
Acknowledgments
References
Chapter 92: Pregnancy and Heart Disease
Cardiovascular Changes in Pregnancy
Evaluation Prior to Pregnancy and During Pregnancy
Cardiac Findings During Normal Pregnancy
Role of Cardiac Testing During Pregnancy
Evaluation and Counseling Prior to and During Pregnancy
Risk Stratification
Management Planning
General Management Principles
Specific Cardiovascular Conditions
Hypertension
Cardiomyopathies
Myocardial Infarction and Ischemic Heart Disease
Native Valvular Heart Disease
Prosthetic Valves and Management of Anticoagulation
Arrhythmias
Congenital Heart Disease
Cardiac Shunts
Left-Sided Obstruction
Complex Congenital Lesions
Unoperated Complex Congenital Lesions
Ebstein Anomaly
Congenitally Corrected Transposition of Great Arteries
Complex Congenital: Repaired
Repaired Tetralogy of Fallot
Repaired Transposition of Great Arteries
Fontan
Cyanotic Congenital Heart Lesions
Pulmonary Hypertension
Marfan Syndrome and Inherited Aortopathies
Contraception
References
Chapter 93: Heart Disease in Racially and Ethnically Diverse Populations
Epidemiology of Cardiovascular Disease in Heterogeneous Populations
Cardiovascular Disease in Racial and Ethnic Groups
Hypertension
Type 2 Diabetes
Cardiovascular Disease in Other Population Groups
Cardiovascular Disease Management
Hypertension
Coronary Heart Disease
Heart Failure
Potential for Emerging Scientific Research to Address Group Disparities in Cardiovascular Disease
Acknowledgments
References
Part XI: Cardiovascular Disease and Disorders of Other Organs
Chapter 94: Endemic and Pandemic Viral Illnesses and Cardiovascular Disease: Influenza and COVID-19
Introduction
Influenza and Cardiovascular Risk and Disease
Epidemiology of Influenza and Cardiovascular Disease
Influenza and Acute Myocardial Infarction
Influenza and Heart Failure
Influenza and Arrhythmia Risk
Influenza and Myocarditis
Influenza Prevention and Therapy
Influenza Vaccine Formulations
Antiviral Therapies for Influenza
SARS-CoV-2 and COVID-19
Epidemiology of COVID-19 and Risk Factors
Comorbidities and COVID-19 Illness
Racial and Ethnic Influences on COVID-19 Illness
Clinical Cardiovascular Manifestations of COVID-19
Atherosclerotic Cardiovascular Syndromes: Acute Coronary Syndromes and Stroke in COVID-19 Patients
Myocarditis due to COVID-19
COVID-19 and Heart Failure
Arrhythmias in COVID-19
Venous and Arterial Thromboembolism in COVID-19
Multisystem Inflammatory Syndrome in Children
Biomarker Evidence of Myocardial Injury
Biomarkers Suggestive of Prothrombotic State
Cardiac Imaging Findings in COVID-19
Effects of the COVID-19 Pandemic on Cardiovascular Health More Broadly
Treatment of COVID-19 and COVID-19-Related Complications
Antiviral Therapy
Anti-SARS-CoV-2 Monoclonal Antibodies
Corticosteroid Therapy
Other Management Considerations
Role of Anticoagulation in COVID-19
Anticoagulation Strategies in COVID-19
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in the Setting of COVID-19
Prevention of COVID-19: Vaccines
Postacute Sequelae SARS-CoV-2 Infection
References
Chapter 95: Hemostasis, Thrombosis, Fibrinolysis, and Cardiovascular Disease
Hemostatic System
Vascular Endothelium
Platelet Inhibition
Anticoagulant Activity
Fibrinolytic Activity
Platelets
Adhesion
Activation
Platelet Aggregation
Coagulation
Extrinsic Tenase
Intrinsic Tenase
Prothrombinase
Fibrin Formation
Contact System
Fibrinolytic System
Mechanism of Action of Tissue Plasminogen Activator
Mechanism of Action of Urokinase Plasminogen Activator
Mechanism of Action of Thrombin-Activatable Fibrinolysis Inhibitor
Thrombosis
Arterial Thrombosis
Venous Thrombosis
Inherited Hypercoagulable States
Factor V Leiden
Prothrombin Gene Mutation
Elevated Levels of Procoagulant Proteins
Antithrombin Deficiency
Protein C Deficiency
Protein S Deficiency
Other Hereditary Disorders
Acquired Hypercoagulable States
Surgery and Immobilization
Advanced Age
Obesity
Cancer
Pregnancy
Estrogen Therapy
History of Previous Venous Thromboembolism
Antiphospholipid Syndrome
Treatment of Thrombosis
Antiplatelet Drugs
Aspirin
Mechanism of Action
Indications
Dosages
Side Effects
Aspirin Resistance
Thienopyridines
Mechanism of Action
Indications
Dosages
Ticagrelor
Mechanism of Action
Dosages
Side Effects
Indications
Cangrelor
Dipyridamole
Mechanism of Action
Dosages
Side Effects
Indications
Glycoprotein IIb/IIIa Receptor Antagonists
Mechanism of Action
Dosages
Side Effects
Indications
Vorapaxar
Anticoagulants
Parenteral Anticoagulants
Heparin
Mechanism of Action
Pharmacology of Heparin
Monitoring the Anticoagulant Effect of Heparin
Dosages
Limitations of Heparin
Side Effects
Bleeding
Thrombocytopenia
Osteoporosis
Elevated Levels of Transaminases
Low-Molecular-Weight Heparin
Mechanism of Action
Pharmacology of Low-Molecular-Weight Heparin
Monitoring of Low-Molecular-Weight Heparin
Dosages
Side Effects
Bleeding
Thrombocytopenia
Osteoporosis
Fondaparinux
Mechanism of Action
Pharmacology of Fondaparinux
Side Effects
Parenteral Direct Thrombin Inhibitors
Argatroban
Bivalirudin
Oral Anticoagulants
Warfarin
Mechanism of Action
Pharmacology
Monitoring
Dosages
Side Effects
Bleeding
Skin Necrosis
Pregnancy
Special Problems
Direct Oral Anticoagulants
Mechanism of Action
Dosages
Monitoring
Side Effects
Periprocedural Management
Management of Bleeding
Pregnancy
Novel Anticoagulants in Development
Fibrinolytic Drugs
Streptokinase
Anistreplase
Urokinase
Alteplase
Tenecteplase
Reteplase
Future Perspectives
References
Chapter 96: Endocrine Disorders and Cardiovascular Disease
Pituitary Hormones and Cardiovascular Disease
Growth Hormone
Cardiovascular Manifestations of Acromegaly
Diagnosis
Growth Hormone Deficiency
Prolactin Disease
Adrenal Hormones and Cardiovascular Disease
Adrenocorticotropic Hormone and Cortisol
Cushing Disease and Cushing Syndrome
Diagnosis
Primary Hyperaldosteronism
Diagnosis
Addison Disease
Diagnosis
Treatment
Pheochromocytoma and Paraganglioma
Diagnosis
Parathyroid Hormone and Cardiovascular Disease
Hyperparathyroidism
Diagnosis
Hypocalcemia
Vitamin D
Thyroid Hormone and Cardiovascular Disease
Cellular Mechanisms of Thyroid Hormone Action on the Heart
Diagnosis of Hyperthyroidism
Cardiovascular Manifestations of Overt and Subclinical Hyperthyroidism
Atrial Fibrillation in Overt and Subclinical Hyperthyroidism
Heart Failure in Overt and Subclinical Hyperthyroidism
CHD in Hyperthyroidism
Pulmonary Hypertension and Autoimmune Cardiovascular Involvement
Diagnosis of Overt and Subclinical Hypothyroidism
Cardiovascular Effects of Overt and Subclinical Hypothyroidism
Coronary Heart Disease
Amiodarone and Thyroid Function
Changes in Thyroid Hormone Metabolism That Accompany Cardiac Disease
Future Perspectives
References
Pituitary Function and Cardiovascular Disease
Chapter 97: Rheumatic Diseases and the Cardiovascular System
Atherosclerosis and the Rheumatic Diseases
Endothelial Dysfunction and Vascular Injury
Rheumatoid Arthritis
Atherosclerotic Disease in Rheumatoid Arthritis
Systemic Lupus Erythematosus
Atherosclerotic Disease in Systemic Lupus Erythematosus
Atherosclerosis in Association With Other Rheumatic Diseases
Vasculitides
Large-Vessel Vasculitis
Giant Cell Arteritis
Pathogenesis
Diagnosis
Cardiovascular Complications
Takayasu Arteritis
Pathogenesis
Diagnosis
Cardiovascular Complications
Kawasaki Disease
Pathogenesis
Diagnosis
Cardiovascular Complications
Treatment
Idiopathic Aortitis
Treatment of Large-Vessel Vasculitis
Medium-Vessel Vasculitis
Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome)
Cardiovascular Complications
Investigation
Treatment
Polyarteritis Nodosa
Cardiovascular Complications
Treatment
Granulomatosis With Polyangiitis (Wegener Granulomatosis)
Microscopic Polyangiitis
Investigation
Treatment
Pericarditis and Myocarditis
Pericarditis
Systemic Lupus Erythematosus
Rheumatoid Arthritis
Systemic Sclerosis
Pericardial Fluid Analysis
Treatment
Myocarditis
Systemic Lupus Erythematosus
Systemic Sclerosis
Myositis
Other Causes of Myocarditis
Treatment
Valvular Heart Disease
Systemic Lupus Erythematosus
Treatment
Seronegative Spondyloarthropathies
Treatment
Rheumatoid Arthritis
Takayasu Arteritis
Cardiac Conduction Disturbances
Systemic Lupus Erythematosus and Sjögren Syndrome
Systemic Sclerosis
Spondyloarthropathies
Polymyositis and Dermatomyositis
Rheumatoid Arthritis
Pulmonary Arterial Hypertension
Systemic Sclerosis
Pathogenesis
Screening
Treatment and Outcome
Systemic Lupus Erythematosus
Pathogenesis
Clinical Findings and Diagnosis
Treatment and Outcome
Rheumatoid Arthritis
Sjögren Syndrome
Takayasu Arteritis
Thrombosis in the Rheumatic Diseases
Antiphospholipid Syndrome
Cardiovascular Disease
Treatment
Behçet Disease
Treatment
Antirheumatic Drugs and Cardiovascular Disease
Relationship Between Drug Treatment and Cardiovascular Disease
B Cell Depletion
Methotrexate
Other Disease-Modifying Antirheumatic Drugs
Glucocorticoids
Statins
Nonsteroidal Antiinflammatory Drugs
Future Perspectives
References
Chapter 98: Tumors Affecting the Cardiovascular System
Clinical Manifestation of Cardiac Tumors
Initial Clinical Decision Making Regarding Cardiac Masses
Classification of Cardiac Tumors
Benign (Nonmalignant) Primary Cardiac Tumors
Simple Benign Tumors
Myxomas
Etiology and Pathophysiology
Clinical Manifestations
Laboratory Testing
Treatment
Fibroelastoma
Rhabdomyomas
Lipomas
Cystic Tumor of the AV Node (Previously Called Mesothelioma)
Other Very Rare Benign Cardiac Tumors
Complex Benign Tumors
Paragangliomas
Fibromas
Treatment
Malignant Primary Cardiac Tumors
Sarcomas
Clinical Manifestations
Laboratory Investigations
Treatment
Heart Tumor Team
Secondary Cardiac Tumors
Treatment
Direct and Indirect Complications of Neoplasia
Pericardial Effusion
Cardiac Tamponade
Constrictive Pericarditis
Superior Vena Cava Syndrome
Future Perspectives
References
Treatment of Sarcomas
Right Heart Sarcoma
Left Heart Sarcoma
Pulmonary Artery Sarcoma
References
The Superior Vena Cava Syndrome in Cancer Patients
Anatomy
Clinical Diagnosis
Laboratory Investigation
Treatment
References
Chapter 99: Psychiatric and Psychosocial Aspects of Cardiovascular Disease
Acute Stress and Emotional Arousal
Stress and Emotional Triggers of Acute Cardiovascular Events
Cardiovascular Responses to Everyday Stressors and Emotions
Mechanisms Underlying Acute Stress Effects
Cardiovascular Consequences of Chronic Stress
Childhood Adversity
Socioeconomic Status
Occupational Stress and Unemployment
Social Discrimination and Stigmatization
Caregiving
Combinations of Chronic and Acute Stress
Mental Health and Psychiatric Disorders
Mechanisms
Shared Features Across Mental Disorders
Anxiety
Posttraumatic Stress Disorder
Depression
Cognitive Impairment
Evaluation and Management of Mental Health in the Cardiac Patient
Current Guidelines
Serotonin and Norepinephrine Dual Reuptake Inhibitors
Monoamine Oxidase Inhibitors
Antidepressants with Other Mechanisms of Action
Antidepressants and Drug-Drug Interactions
Mindfulness
Exercise
Chapter 100: Neuromuscular Disorders and Cardiovascular Disease
Neuromuscular Diseases
Muscular Dystrophies
Duchenne and Becker Muscular Dystrophy
Genetics and Pathogenesis
Clinical Presentation
Cardiovascular Manifestations
Electrocardiography
Imaging
Arrhythmias
Treatment and Prognosis
Myotonic Dystrophies
Genetics and Pathogenesis
Clinical Presentation
Cardiovascular Manifestations
Electrocardiography
Imaging and Heart Failure
Arrhythmias
Treatment and Prognosis
Emery-Dreifuss Muscular Dystrophy and Associated Disorders
Genetics and Cardiac Pathology
Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Limb-Girdle Muscular Dystrophies
Genetics and Pathophysiology
Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Facioscapulohumeral Muscular Dystrophy
Genetics and Pathophysiology
Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Friedreich Ataxia
Genetics and Pathophysiology
Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Less Common Neuromuscular Diseases Associated with Cardiac Manifestations
The Periodic Paralyses
Genetics and Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Mitochondrial Disorders
Genetics and Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Spinal Muscular Atrophy
Genetics and Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Myofibrillar Myopathies
Genetics and Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Guillain-Barré Syndrome
Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Myasthenia Gravis
Clinical Presentation
Cardiovascular Manifestations
Treatment and Prognosis
Myoglobinopathy
ABCC9-Related Intellectual Disability Myopathy Syndrome
Epilepsy
Cardiovascular Manifestations
Treatment and Prognosis
Acute Cerebrovascular Disease
Cardiovascular Manifestations
Treatment and Prognosis
Conclusions/Future Perspectives
References
Chapter 101: Interface Between Renal Disease and Cardiovascular Illness
The Cardiorenal Intersection
Chronic Kidney Disease and Cardiovascular Risk
Implications of Anemia Due to Chronic Kidney Disease
Contrast-Induced Acute Kidney Injury
Prevention of Contrast-Induced Acute Kidney Injury
Cardiac Surgery Associated Acute Kidney Injury
Acceleration of Vascular Calcification
Renal Disease and Hypertension
Diagnosis of Acute Coronary Syndromes in Patients with Chronic Kidney Disease
Renal Dysfunction as a Prognostic Factor in Acute Coronary Syndromes
Reasons for Poor Outcomes After Acute Coronary Syndromes in Patients with Renal Dysfunction
Treatment of Myocardial Infarction in Patients with Renal Dysfunction
Cardiorenal Syndromes
Chronic Kidney Disease and Valvular Heart Disease
Renal Function and Arrhythmias
Consultative Approach to Severe Kidney Disease and Hemodialysis Patients
Evaluation and Management of the Renal Transplant Recipient
Summary
References
Chapter 102: Cardiovascular Manifestations of Autonomic Disorders
Ovewview of Anatomy and Physiology of the Autonomic Nervous System
Sympathetic, Parasympathetic, and Intrinsic Neuronal Control
Baroreflex
Chemoreflex
Diving Reflex
Pathophysiology
Autonomic Dysfunction in the Setting of a Structurally Normal Heart
Autonomic Dysfunction in the Setting o fIntrinsic Cardiac Disease
Proarrhythmia
Atrial Fibrillation
Ventricular Tachycardia/Ventricular Fibrillation
Investigations and Diagnosis
Orthostatic Blood Pressure
Valsalva Maneuver
Cold Pressor Test
Plasma Catecholamines
Neuromodulatory Therapies
Pharmacologic Therapy
Sympathetic Modulation
Thoracic Epidural Anesthesia/Percutaneous Stellate Block
Renal Denervation
Cardiac Sympathetic Denervation
Augmentation of Parasympathetic Drive
Vagal Nerve Stimulation
Spinal Cord Stimulation
Baroreceptor Stimulation
Future Perspectives
References
Disclosure Index
Relationship Codes
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Index
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