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Unformatted text preview: Current Diagnosis & Treatment in Cardiology 2nd Ed: Michael H. Crawford by McGraw-Hill/Appleton & Lange, 2002 By OkDoKeY CURRENT Diagnosis & Treatment in Cardiology Contents Editor Authors Preface 1. Approach to Cardiac Disease Diagnosis Michael H. Crawford, MD 2. Lipid Disorders Peter C. Chien, MD & William H. Frishman, MD 3. Chronic Ischemic Heart Disease Michael H. Crawford, MD 4. Unstable Angina Prediman K. Shah, MD & Kuang-Yuh Chyu, MD 5. Acute Myocardial Infarction Allan S. Jaffe, MD & Wayne L. Miller, MD 6. Cardiogenic Shock Craig Timm, MD 7. Coronary Revascularization Kathleen M. Allen, MD 8. Aortic Stenosis Blase A. Carabello, MD & Michael H. Crawford, MD 9. Aortic Regurgitation William A. Zoghbi, MD & Imran Afridi, MD 10. Mitral Stenosis Chad Stoltz, MD & Robert J. Bryg, MD 11. Mitral Regurgitation Michael H. Crawford, MD 12. Tricuspid and Pulmonic Valve Disease Brian D. Hoit, MD & Michael D. Faulx, MD 13. Systemic Hypertension William F. Graettinger, MD 14. Hypertrophic Cardiomyopathies Pravin Shah, MD 15. Restrictive Cardiomyopathies John D. Carroll, MD & Michael H. Crawford, MD 16. Myocarditis Mohammed Zaher Akkad, MD & John B. O'Connell, MD 17. Pericardial Diseases Samer S. Kabbani, MD & Martin M. LeWinter, MD 18. Congestive Heart Failure Enrique V. Carbajal, MD & Prakash C. Deedwania, MD 19. Supraventricular Arrhythmias Barry M. Weinberger, DO, Roger Marinchak, MD & Peter R. Kowey, MD 20. Atrial Fibrillation Melvin M. Scheinman, MD 21. Conduction Disorders & Cardiac Pacing Nora Goldschlager, MD 22. Ventricular Tachycardia Masood Akhtar, MD 23. Syncope Christopher S. Cadman, MD 24. Sudden Cardiac Death John P. DiMarco, MD, PhD 25. Pulmonary Embolic Disease Samuel Z. Goldhaber, MD 26. Pulmonary Hypertension Robert A. Taylor, MD 27. Congenital Heart Disease in Adults Nikola Tede, MD & Elyse Foster, MD 28. Chronic Anticoagulation for Cardiac Conditions Richard W. Asinger, MD & Richard D. Taylor, MD 29. Infective Endocarditis Bruce K. Shively, MD 30. Cardiac Tumors Edmond W. Chen, MD & Rita F. Redberg, MD 31. Heart Disease in Pregnancy Syed W. Bokhari, MD & Cheryl L. Reid, MD 32. Endocrinology and the Heart B. Sylvia Vela, MD 33. Connective Tissue Diseases and the Heart Carlos A. Roldan, MD 34. The Athlete's Heart J.V. Nixon, MD 35. Thoracic Aortic Dissection Jorge A. Wernly, MD 36. Thoracic Aortic Aneurysms John A. Elefteriades, MD 37. Evaluation and Treatment of the Perioperative Patient Helge U. Simon, MD, Alvin S. Blaustein, MD & Laura F. Wexler, MD Editor Michael H. Crawford, MD Professor of Medicine Mayo Medical School Rochester, Minnesota Consultant in Cardiovascular Diseases Mayo Clinic Scottsdale, Arizona Authors Imran Afridi, MD, FACC Attending Cardiologist, North Texas Cardiovascular Associates and Methodist Hospital of Dallas, Texas Aortic Regurgitation Masood Akhtar, MD Clinical Professor of Medicine, University of Wisconsin Medical School, Milwaukee Clinical Campus; Aurora Sinai Medical Center and St. Luke's Medical Center, Milwaukee, Wisconsin [email protected] Ventricular Tachycardia Mohammed Zaher Akkad, MD Attending Physician, Division of Cardiology, Harper Hospital, Detroit, Michigan Myocarditis Kathleen M. Allen, MD Assistant Professor of Medicine, Division of Cardiology, The University of New Mexico School of Medicine, Albuquerque [email protected] Coronary Revascularization Richard W. Asinger, MD Professor of Medicine, University of Minnesota Medical School-Minneapolis; Director, Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota [email protected] Chronic Anticoagulation for Cardiac Conditions Alvin S. Blaustein, MD Associate Professor of Medicine, Baylor College of Medicine; Chief, Cardiology Section and Director, Non-invasive Laboratory, Veterans Affairs Medical Center, Houston, Texas [email protected] Evaluation and Treatment of the Perioperative Patient Syed W. Bokhari, MD Fellow, Cardiovascular Diseases, Division of Cardiology, UCI Medical Center, Orange, California [email protected] Heart Disease in Pregnancy Robert J. Bryg, MD Chief, Division of Cardiology; Associate Chairman of Medicine, University of Nevada School of Medicine, Reno, Nevada [email protected] Mitral Stenosis Christopher S. Cadman, MD, FACC Assistant Professor of Medicine & Director, Arrhythmia Service, University of New Mexico School of Medicine, Veterans Administration Medical Center, Albuquerque, New Mexico Syncope Blase A. Carabello, MD Professor of Medicine, Veterans Affairs Medical Center, Houston, Texas [email protected] Aortic Stenosis Enrique V. Carbajal, MD Assistant Clinical Professor of Medicine, University of California, San Francisco Medical Education Program; Assistant Chief, Cardiology Section, Veterans Affairs Central California Health Care System, Fresno, California [email protected] Congestive Heart Failure John D. Carroll, MD Professor of Medicine, University of Colorado Health Sciences Center, Denver, Colorado [email protected].edu Restrictive Cardiomyopathies Edmond W. Chen, MD Cardiology Fellow, Division of Cardiology, University of California, San Francisco Cardiac Tumors Peter C. Chien, MD Assistant Professor of Medicine, New York Medical College; Director Adult Primary Care Center, Westchester Medical Center, Valhalla, New York [email protected] Lipid Disorders Kuang-Yuh Chyu, MD, PhD Assistant Professor-in-Residence, Department of Medicine, University of California, Los Angeles; Staff Cardiologist, Cedars-Sinai Medical Center, Los Angeles, California Unstable Angina Michael H. Crawford, MD Professor of Medicine, Mayo Medical School; Consultant in Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona [email protected] Approach to Cardiac Disease Diagnosis Chronic Ischemic Heart Disease Aortic Stenosis Mitral Regurgitation Restrictive Cardiomyopathies Prakash C. Deedwania, MD Chief, University of California, San Francisco School of Medicine, Cardiology Section, Veterans Affairs Central California Health Care System [email protected] Congestive Heart Failure John P. DiMarco, MD, PhD Professor of Medicine, Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville [email protected] Sudden Cardiac Death John A. Elefteriades, MD Professor & Chief, Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut [email protected] Thoracic Aortic Aneurysms Michael D. Faulx, MD Fellow, Division of Cardiology, Case Western Reserve University and University Hospitals of Cleveland, Ohio [email protected] Tricuspid and Pulmonic Valve Disease Elyse Foster, MD Professor of Clinical Medicine & Anesthesia, University of California, San Francisco; Director, Echocardiography Laboratory and Adult Congenital Heart Disease Service, Cardiology Division, Department of Medicine, Moffitt-Long Hospital, San Francisco, California [email protected] Congenital Heart Disease in Adults William H. Frishman, MD, MACP Barbara & William Rosenthal Professor of Medicine; Chairman of Medicine & Professor of Pharmacology, New York Medical College; Chief of Medicine, Westchester Medical Center, Valhalla, New York [email protected] Lipid Disorders Samuel Z. Goldhaber, MD Associate Professor of Medicine, Harvard Medical School; Director, Venous Thromboembolism Research Group & Director, Anticoagulation Service, Brigham and Women's Hospital, Boston, Massachusetts [email protected] Pulmonary Embolic Disease Nora Goldschlager, MD Professor of Clinical Medicine, University of California, San Francisco; Director, Coronary Care Unit, ECG Department and Pacemaker Clinic, San Francisco General Hospital [email protected] Conduction Disorders & Cardiac Pacing William F. Graettinger, MD, FACC, FACP, FCCP Professor & Vice-Chairman, Department of Medicine, University of Nevada School of Medicine; Chief, Medical Service, Veterans Affairs Sierra Nevada Health Care System, Reno, Nevada [email protected] Systemic Hypertension Brian D. Hoit, MD Professor of Medicine, Case Western Reserve University and University Hospitals of Cleveland, Ohio [email protected] Tricuspid and Pulmonic Valve Disease Allan S. Jaffe, MD Professor of Medicine & Consultant, Divisions of Cardiology and Laboratory Medicine, Mayo Clinic, Rochester, Minnesota [email protected] Acute Myocardial Infarction Samer S. Kabbani, MD, FACC Assistant Professor of Medicine, Cardiology Unit, University of Vermont College of Medicine, Burlington [email protected] Pericardial Diseases Peter R. Kowey, MD Professor of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania; Chief of Cardiology, Lankenau Hospital and Main Line Health System, Wynnewood, Pennsylvania Supraventricular Arrhythmias Martin M. LeWinter, MD Professor of Medicine & Director, Heart Failure Unit University of Vermont College of Medicine, Burlington [email protected] Pericardial Diseases Roger Marinchak, MD Clinical Professor of Medicine, Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania; Clinical Electrophysiologist, The Heart Group and Lancaster General Hospital, Lancaster, Pennsylvania [email protected] Supraventricular Arrhythmias Wayne L. Miller, MD, PhD Associate Professor of Medicine, Consultant, Division of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota [email protected] Acute Myocardial Infarction J.V. Nixon, MD, FACC Professor of Medicine & Cardiology; Director, Echocardiography Laboratories and the Heart Station, Medical College of Virginia at Virginia Commonwealth University, Richmond [email protected] The Athlete's Heart John B. O'Connell, MD Professor & Chairman, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan jo'[email protected] Myocarditis Rita F. Redberg, MD, MSc, FACC Associate Professor of Medicine & Director, Women's Cardiovascular Services, Division of Cardiology, University of California, San Francisco Medical Center [email protected] Cardiac Tumors Cheryl L. Reid, MD Associate Professor of Medicine; Director, Noninvasive Cardiology, University of California, Irvine [email protected] Heart Disease in Pregnancy Carlos A. Roldan, MD Associate Professor of Medicine, Cardiology Division, Veterans Affairs Medical Center and University of New Mexico, Albuquerque [email protected] Connective Tissue Diseases and the Heart Melvin M. Scheinman, MD Professor of Medicine, Division of Cardiology, University of California San Francisco [email protected] Atrial Fibrillation Pravin Shah, MD, MACC Clinical Professor of Medicine, Loma Linda University School of Medicine, Loma Linda, California; Medical Director Non-Invasive Cardiac Imaging and Academic Programs, Hoag Heart Institute, Newport Beach, California [email protected] Hypertrophic Cardiomyopathies Prediman K. Shah, MD, FACC Shapell and Webb Chair & Director, Division of Cardiology and Atherosclerosis Research Center, Cedars-Sinai Medical Center;Professor of Medicine, University of California, Los Angeles Unstable Angina Bruce K. Shively, MD Associate Professor of Medicine & Director, Adult Echocardiography, Oregon Health Science University, Portland [email protected] Infective Endocarditis Helge U. Simon, MD Cardiology Fellow, University of Cincinnati Medical Center & the Veterans Affairs Medical Center, Cincinnati, Ohio [email protected] Evaluation and Treatment of the Perioperative Patient Chad Stoltz, MD Cardiology Fellow, Department of Cardiovascular Medicine, University of Wisconsin School of Medicine, Madison Mitral Stenosis Robert A. Taylor, MD Assistant Professor of Medicine, University of New Mexico Health Sciences Center [email protected] Pulmonary Hypertension Richard D. Taylor, MD Staff Cardiologist & Director, Arrhythmia Management Program, Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota [email protected] Chronic Anticoagulation for Cardiac Conditions Nikola Tede, MD, FAAP Pediatric Cardiologist, California Pacific Medical Center, San Francisco; Clinical Faculty, Department of Pediatrics/Cardiology, University of California, San Francisco Congenital Heart Disease in Adults Craig Timm, MD Associate Professor of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque [email protected] Cardiogenic Shock B. Sylvia Vela, MD Associate Professor of Clinical Medicine, University of Arizona Health Sciences Center; Program Director, Phoenix Citywide Endocrinology Fellowship, Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona [email protected] Endocrinology and the Heart Barry M. Weinberger, DO Clinical Electrophysiologist, Attending Community Medical Center, Toms River, New Jersey Supraventricular Arrhythmias Jorge A. Wernly, MD W. Sterling Edwards Professor & Chief, Division of Thoracic and Cardiovascular Surgery, University of New Mexico Health Sciences Center, Albuquerque [email protected] Thoracic Aortic Dissection Laura F. Wexler, MD Associate Dean, Student Affairs & Admissions; Professor of Medicine, Division of Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio [email protected] Evaluation and Treatment of the Perioperative Patient William A. Zoghbi, MD, FACC Professor of Medicine, Baylor College of Medicine; Director, Echocardiography Laboratory, The Methodist DeBakey Heart Center, Houston, Texas [email protected] Aortic Regurgitation Preface Current Diagnosis & Treatment in Cardiology is designed to be a concise discussion of the essential knowledge needed to diagnose and manage cardiovascular diseases. Current Diagnosis & Treatment in Cardiology cannot be considered a condensed textbook because detailed pathophysiologic discussions are omitted; there are no chapters on diagnostic techniques; and rare or obscure entities are not included. Also, it is not a cardiac therapeutics text because diagnostic techniques, prevention strategies, and prognosis are fully discussed. INTENDED AUDIENCE Current Diagnosis & Treatment in Cardiology is designed to be a quick reference source in the clinic or on the ward for the experienced physician. Cardiology fellows will find that it is an excellent review for Board examinations. Also, students and residents will find it useful to review the essentials of specific conditions and to check the current references included in each section for further study. Nurses, technicians, and other health care workers who provide care for cardiology patients will find Current Diagnosis & Treatment in Cardiology a useful source for all aspects of heart disease care. COVERAGE The 37 chapters in Current Diagnosis & Treatment in Cardiology cover the major disease entities and therapeutic challenges in cardiology. There are chapters on major management issues in cardiology such as pregnancy and heart disease, the use of anticoagulants in heart disease, and the pre-operative evaluation of heart disease patients. Each section is written by experts in the particular area, but has been extensively edited to insure a consistent approach throughout the book and the kind of readability found in single-author texts. Since the first edition the book has grown somewhat. Each chapter has been thoroughly revised and the references updated. Also, there are three new chapters in areas that have increased in importance in the last 5 years: coronary revascularization, atrial fibrillation, and aortic aneurysms. My hope is that the book is found useful and improves patient care. Also, I hope it is an educational tool that improves knowledge of cardiac diseases. Finally, I hope it stimulates clinical research in areas where our knowledge is incomplete. Michael H. Crawford, MD Scottsdale, Arizona November 2002 1 Approach to Cardiac Disease Diagnosis CURRENT Diagnosis & Treatment in Cardiology Approach to Cardiac Disease Diagnosis 1 Michael H. Crawford, MD General Considerations Physical Findings General Considerations The patient's history is a critical feature in the evaluation of suspected or overt heart disease. It includes information about the present illness, past illnesses, and the patient's family. From this information, a chronology of the patient's disease process should be constructed. Determining what information in the history is useful requires a detailed knowledge of the pathophysiology of cardiac disease. The effort spent on listening to the patient is time well invested because the cause of cardiac disease is often discernible from the history. A. COMMON SYMPTOMS 1. Chest pain—Chest pain is one of the cardinal symptoms (Table 1–1) of ischemic heart disease, but it can also occur with other forms of heart disease. The five characteristics of ischemic chest pain, or angina pectoris, are Table 1–1. Common symptoms of potential cardiac origin. Anginal pain usually has a substernal location but may extend to the left or right chest, the shoulders, the neck, jaw, arms, epigastrium and, occasionally, the upper back. The pain is deep, visceral, and intense; it makes the patient pay attention but is not excruciating. Many patients describe it as a pressure-like sensation. The duration of the pain is minutes, not seconds. The pain tends to be precipitated by exercise or emotional stress. The pain is relieved by resting or taking sublingual nitroglycerin. 2. Dyspnea—A frequent complaint of patients with a variety of cardiac diseases, dyspnea is ordinarily one of four types. The most common is exertional dyspnea, which usually means that the underlying condition is mild because it requires the increased demand of exertion to precipitate symptoms. The next most common is paroxysmal nocturnal dyspnea, characterized by the patient awakening after being asleep or recumbent for an hour or more. This symptom is caused by the redistribution of body fluids from the lower extremities into the vascular space and back to the heart, resulting in volume overload; it suggests a more severe condition. Third is orthopnea, a dyspnea that occurs immediately on assuming the recumbent position. The mild increase in venous return (caused by lying down) before any fluid is mobilized from interstitial spaces in the lower extremities is responsible for the symptom, which suggests even more severe disease. Finally, dyspnea at rest suggests severe cardiac disease. Dyspnea is not specific for heart disease, however. Exertional dyspnea, for example, can be due to pulmonary disease, anemia, or deconditioning. Orthopnea is a frequent complaint in patients with chronic obstructive pulmonary disease and postnasal drip. A history of “two-pillow orthopnea” is of little value unless the reason for the use of two pillows is discerned. Resting dyspnea is also a sign of pulmonary disease. Paroxysmal nocturnal dyspnea is perhaps the most specific for cardiac disease because few other conditions cause this symptomatology. 3. Syncope and presyncope—These signs (light-headedness, dizziness, etc) are important symptoms of a reduction in cerebral blood flow. These symptoms are nonspecific and can be due to primary central nervous system disease, metabolic conditions, dehydration, or inner-ear problems. Because brady- and tachyarrhythmias are important cardiac causes, a history of palpitations preceding the event is significant. 4. Transient central nervous system deficits—Deficits such as transient ischemic attacks (TIAs), suggest emboli from the heart or great vessels or, rarely, from the venous circulation through an intracardiac shunt. A TIA should prompt the search for cardiovascular disease. Any sudden loss of blood flow to a limb also suggests a cardioembolic event. 5. Fluid retention—These symptoms are not specific for heart disease but may be due to reduced cardiac function. Typical symptoms are peripheral edema, bloating, weight gain, and abdominal pain ...
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