Comprehensive Cardiovascular Medicine in the Primary Care Setting (eBook)

Peter P. Toth, MD, PhD, FAAFP, FAHA, FACC Dr. Toth is the Director of Preventive Cardiology at the Sterling Rock Falls Clinic in Sterling, IL. He is has authored and coauthored over 100 scholarly articles and chapters. He is also a visiting Clinical Associate Professor in the Department of Family and Community Medicine at the University of Illinois School of Medicine. Christopher P. Cannon, MD, FACC Dr. Cannon is a Senior Investigator for the TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Associate Professor of Medicine at Harvard Medical School. A prominent figure in the field with an outstanding body of book and journal article publications, he is also the Series Editor for the book series Contemporary Cardiology published by Humana Press.

Foreword 6
Preface 7
Contents 9
Contributors 11
Part I Cardiovascular Disease Risk Factors 14
1 Cardiovascular Epidemiology and Characterization of Atherosclerotic Disease Risk Factors 15
Key Points 16
1.1 The Burden of Atherosclerotic Cardiovascular Disease in the United States 16
1.2 Cardiovascular Epidemiology and the Investigation of Risk Factors 16
1.3 The Framingham Heart Study 17
1.4 Atherosclerotic CVD Is a Worldwide Pandemic 17
1.5 Development and Evolution of the Atherothrombotic Process 18
1.6 Prediction Versus Causation 19
1.7 Population Attributable Risk Fraction 20
1.8 Dyslipidemia 21
1.8.1.Measures of Atherogenic Lipoprotein Burden 22
1.8.2.Measures of Antiatherogenic Lipoproteins 23
1.8.3.Ratios of Atherogenic to Antiatherogenic Lipoproteins 24
1.8.4.Triglycerides and LDL Particle Size 24
1.8.5.Lipoprotein (a) 25
1.9 Hypertension 25
1.10 Smoking 26
1.11 Overweight, Obesity, and Body Fat Distribution 26
1.12 Metabolic Syndrome and Diabetes Mellitus 27
1.12.1.Diabetes Mellitus 28
1.13 Diet and Physical Activity 29
1.13.1.Dietary Factors 29
1.13.2.Alcohol Consumption 30
1.13.3.Physical Activity 30
1.14 Inflammatory Markers 30
1.15 Measures of Subclinical CVD 31
1.15.1.Coronary Calcium 32
1.15.2.Ankle-Brachial Index 32
1.16 Hemostatic Variables 32
1.17 Nonmodifiable Risk Factors 32
1.18 Psychosocial Factors 33
1.19 Sleep Apnea, Sleep Quantity and Quality 33
1.20 ConclusionsTranslating Risk Factor Identification into Prevention 33
References 34
2 Arterial Hypertension 37
Key Points 37
2.1 Introduction 38
2.2 Definition 38
2.3 Epidemiology of Hypertension 38
2.4 Mechanisms of Hypertension 39
2.4.1.Hemodynamics 39
2.4.2.Renal 40
2.4.3.Neurohumoral Factors 40
2.4.4.Baroreflexes 40
2.4.5.Aging 40
2.5 Etiology of Hypertension 40
2.5.1.Essential or Primary Hypertension 41
2.5.2.Secondary Hypertension 41
2.5.3.Chronic Kidney Disease (CKD)---Renal Parenchymal Hypertension 42
2.5.4.Renovascular Hypertension 43
2.5.5.Primary Hyperaldosteronism 44
2.5.6.Pheochromocytoma 44
2.6 Complicated Management Problems in Hypertension 45
2.6.1.Resistant Hypertension 45
2.6.2.Hypertensive Emergencies and Urgencies 45
2.7 Blood Pressure Measurement 47
2.7.1.Office Blood Pressure Measurement 47
2.7.2.Home BP 48
2.7.3.Ambulatory BP 48
2.8 Evaluation of Hypertension 49
2.9 Treatment 51
2.9.1.Diuretics 57
2.9.2.Beta-blockers 57
2.9.3.ACE-inhibitors 58
2.9.4.Angiotensin II Receptor Blockers 58
2.9.5.Direct Renin Inhibitors 58
2.9.6.Calcium Channel Blockers 58
2.9.7.Alpha-1 Blockers 58
2.9.8.Central Alpha-2 Agonists and Other Centrally Acting Drugs 59
2.9.9.Direct Vasodilators 59
2.10 Guidelines for Treatment of Hypertension 59
2.10.1.Joint National Committee VII Guidelines 59
2.11 Recent Landmark Hypertension Trials: Implications for Evidence-Based Medicine 60
2.11.1.Intervention as a Goal in Hypertension Treatment 60
2.11.2.European Lacidipine Study on Atherosclerosis 61
2.11.3.Comparison of Amlodipine Versus Enalapril to Limit Occurrences of Thrombosis 61
2.11.4.Controlled Onset Verapamil Investigation of CV Endpoints 62
2.12 Valsartan Antihypertensive Long-Term Use Evaluation (Value) Trial 62
2.13 Anglo-Scandinavian Cardiac Outcomes Trial (Ascot) 62
2.13.1.Conduit Artery Function Evaluation (CAFE) Trial 63
2.14 Trial of Prevention of Hypertension (Trophy) 63
2.15 Accomplish Trial 64
2.16 Hyvet 64
2.17 On Target 65
2.18 Case Studies 65
2.18.1.Case Study 1---Hypertensive Emergency 65
2.18.1.1.Laboratory Data (Initial Tests) 66
2.18.1.2.Issues and Discussion Points 66
2.18.2.Case Study 2---Chronic Poorly Controlled Hypertension with Patient Referred to a Hypertension Specialist 67
2.18.2.1.Laboratory Tests 67
2.18.2.2.Issues and Discussion Points 68
References 34
3 Management of Dyslipidemia 71
Key Points 71
3.1 Introduction 72
3.2 Lipoprotein Metabolism and Atherogenesis 72
3.2.1.Low-Density Lipoprotein and Very Low-Density Lipoprotein 72
3.2.2.High-Density Lipoprotein 74
3.2.3.Triglycerides 76
3.3 Dyslipidemia 76
3.4 Therapeutic Lifestyle Change 79
3.5 Pharmacologic Management 80
3.5.1.Statins 81
3.5.1.1.Statin Myopathy 87
3.5.1.2.Statin Hepatotoxicity 88
3.5.2.Ezetimibe 89
3.5.3.Bile Acid-Binding Resins 90
3.5.4.Fibrates 91
3.5.5.Niacin 92
3.5.6.Fish Oils 95
3.6 Case Studies 95
3.6.1.Case 1: Heterozygous Familial Hypercholesterolemia 95
3.6.2.Case 2: Severe Hypertriglyceridemia 96
3.7 Conclusion 96
References 34
4 Obesity and Therapeutic Approaches to Weight Loss 102
Key Points 102
4.1 The Burden of Obesity 103
4.2 Assessment of the Overweight and Obese Patient and Identification of Risk 103
4.2.1.Cardiovascular Disease 106
4.3 Medical Management of the Overweight and Obese Patient 108
4.3.1.The Goal of Therapy 108
4.4 Lifestyle Management 109
4.4.1.Diet Therapy 109
4.4.2.Physical Activity Therapy 110
4.4.3.Behavioral Therapy 110
4.5 Pharmacotherapy 111
4.5.1.Centrally Acting Anorexiant Medications 111
4.5.2.Peripherally Acting Medication 112
4.6 Bariatric Surgery 112
4.7 Case Study 114
4.8 Case Study 114
4.9 Conclusion 114
References 34
5 Inflammatory Markers and Novel Risk Factors 118
Key Points 118
5.1 Introduction 119
5.2 Traditional Prediction of Cardiovascular Risk 119
5.3 Disease Pathology and Relevance to Novel Biomarkers 119
5.4 Emerging Inflammatory Markers 120
5.4.1.C-Reactive Protein 120
5.4.2.Myeloperoxidase 122
5.4.3. Lipoprotein-Associated Phospholipase A2 123
5.4.4.Additional Markers 124
5.4.5.Matrix Metalloproteinases 124
5.4.6.ADMA 125
5.5 Emerging Thrombotic Markers 125
5.6 Additional Markers 126
5.6.1.Homocysteine 126
5.6.2.Brain Natriuretic Peptide 126
5.6.3.Oxidative Stress 127
5.7 Measures of Renal Impairment 128
5.8 Panels of Multiple Novel Biomarkers 128
5.9 Summary 129
References 34
6 Deciphering Cardiovascular Genomics and How They Apply to Cardiovascular Disease Prevention 135
Key Points 135
6.1 Why is Genomics Important 136
6.2 A Brief Introduction to Molecular Biology 136
6.3 The Principles of Human Genomics 138
6.4 Practical Uses of Genomics Studies 140
6.5 Genetic Testing and Disease Risk Prediction 141
6.6 Pharmacogenomics 142
6.7 Risks of Genetic Testing 144
6.8 Conclusion 144
6.9 Case Study 1 144
6.10 Case Study 2 145
6.11 Recommended Reading 145
References 34
7 The Metabolic Syndrome: 2009 147
Key Points 147
7.1 Definition 148
7.2 Prevalence of the Metabolic Syndrome 148
7.2.1.United States and Canada 148
7.3 Pathogenesis 151
7.3.1.Normal Insulin Action 151
7.3.2.Central Obesity and Insulin Resistance 151
7.4 Approach to the Patient with the Metabolic Syndrome: Case Studies 152
7.4.1.Case 1: A Patient with the Metabolic Syndrome and Atherogenic Dyslipidemia 152
7.4.1.1.Case 1 Discussion 153
7.4.2.Case 2: A Patient with the Metabolic Syndrome and Impaired Fasting Glucose 161
7.4.2.1.Pharmacologic Interventions for Diabetes Prevention 162
7.4.3.Case 3: A Patient with Polycystic Ovary Syndrome 163
7.4.3.1.Pharmacologic Treatment of PCOS 165
References 34
8 Chronic Kidney Disease in the Primary Care Setting: Importance for Estimating Cardiovascular Disease Risk and Use of Appropriate Therapies 174
Key Points 174
8.1 Background 175
8.2 Why Is There a Relationship Between CKD and CVD 176
8.3 Reduced GFR as a CVD Equivalent 178
8.4 What Must We Do Differently to Screen Patients for CKD 179
8.5 Why Is Microalbuminuria Such a Powerful Predictor of CVD Outcomes 181
8.6 Treatment Strategies of Traditional Risk Factors 182
8.7 Diabetes Control 182
8.8 Hypertension Control 183
8.9 Hyperlipidemia Control 185
8.10 Nontraditional Risk Factors for CVD 186
8.11 Summary 187
8.12 Case Studies 187
8.12.1.Case 1 187
8.12.1.1.Laboratory Data 188
8.12.1.2.Issues 188
8.12.1.3.Discussion Points 188
8.12.2.Case 2 188
8.12.2.1.Physical Examination 188
8.12.2.2.Laboratory Results 188
8.12.2.3.Issues 189
8.12.2.4.Discussion Points 189
References 34
Part II Coronary Artery Disease 193
9 Evaluation of Chest Pain and Myocardial Ischemia 194
9.1 Introduction 194
9.2 Initial Presentation 195
9.3 Chest Pain and Respiratory Distress 196
9.4 Chest Pain and Shock 196
9.5 Evaluation of the Stable Patient with Chest Pain 196
9.6 Conclusion 199
9.7 Case Studies 199
9.7.1.Case 1 199
9.7.2.Case 2 199
References 34
10 Unstable Angina and Non-ST Elevation Myocardial Infarction 201
Key Points 201
10.1 Introduction 202
10.2 Definitions and Classification 202
10.3 Pathophysiology 202
10.3.1.Thrombosis 203
10.3.2.Role of Platelets 204
10.3.3.Plasma Coagulation System in Acute Coronary Syndrome 204
10.3.4.Dynamic Coronary Obstruction 205
10.3.5.Progressive Mechanical Obstruction 205
10.3.6.Secondary Unstable Angina 205
10.4 Clinical Presentation 205
10.5 Initial Evaluation and Risk Stratification 207
10.5.1.ECG 207
10.5.2.Cardiac Biomarkers 208
10.5.3.Cardiac-Computed Tomography 209
10.5.4.Cardiovascular Magnetic Resonance 210
10.5.5.Risk Stratification in NSTEACS 210
10.6 Management of NSTEACS 213
10.6.1.Routine Initial Measures in NSTEACS 213
10.6.2.Anti-ischemic and Analgesic Therapies 213
10.6.2.1.Nitrates 213
10.6.2.2.Morphine 213
10.6.2.3.Beta-Adrenergic Blockers 213
10.6.2.4.Calcium Channel Blockers 214
10.6.2.5.Angiotensin-Converting Enzyme Inhibitors 214
10.6.2.6.Lipid-Lowering Therapy 214
10.6.3.Antiplatelet Therapies 215
10.6.3.1.Aspirin 215
10.6.3.2.Clopidogrel 215
10.6.3.3.Glycoprotein IIb/IIIa Inhibitors 216
10.6.3.4.Anticoagulation 217
10.6.3.5.Unfractionated or Low-Molecular Weight Heparin 217
10.6.3.6.Direct Thrombin Inhibitors 217
10.6.3.7.Fondaparinux 217
10.6.3.8.Warfarin 218
10.6.3.9.Fibrinolysis 218
10.6.4.Invasive versus Conservative Strategy 218
10.6.5.Predischarge Non-invasive Risk Stratification After UA/NSTEMI 220
10.7 Secondary Prevention Measures After NSTEACS 221
10.7.1.Pharmacologic Measures 221
10.7.1.1.Aspirin 221
10.7.1.2.Clopidogrel 221
10.7.1.3.Beta-Adrenergic Blockers 221
10.7.1.4.ACE Inhibitors 221
10.7.1.5.Statins and Lipid-Lowering Therapy 222
10.7.2.Medications of No Benefit or Harm Following ACS 223
10.7.2.1.Vitamins/Antioxidants 223
10.7.2.2.Hormone Replacement Therapy 223
10.7.2.3.Non-steroidal Anti-inflammatory Drugs 223
10.7.3.Therapy for Co-morbidities Following NSTEACS 223
10.7.3.1.Diabetes Mellitus 223
10.7.3.2.Hypertension 224
10.7.3.3.Depression 224
10.7.4.Lifestyle Modifications 224
10.7.4.1.Smoking Cessation 224
10.7.4.2.Diet/Nutrition and Weight Loss 224
10.7.4.3.Alcohol 224
10.7.4.4.Physical Activity 225
10.8 Case Studies 225
10.8.1.Case 1 225
10.8.1.1.Management Strategies 225
10.8.2.Case 2 226
10.8.2.1.Management Decisions 226
10.9 Further Reading 227
References 34
11 ST Elevation Myocardial Infarction 232
Key Points 232
11.1 Introduction 233
11.2 Patient Evaluation 233
11.2.1.History 233
11.2.2.Physical Examination 233
11.2.3.Electrocardiogram 233
11.2.4.Cardiac Biomarkers 233
11.2.5.Echocardiography 234
11.3 Differential Diagnosis 234
11.4 Therapy 234
11.4.1.Pre-hospital Care 234
11.4.2.General Treatment Measures 235
11.4.3.Reperfusion Therapy 236
11.4.4.Primary PCI 236
11.4.5.Rescue PCI 237
11.4.6.Coronary Angiography 237
11.4.7.Antiplatelet Therapy 238
11.4.8.Antithrombin Therapy 238
11.4.9.Routine Prophylactic Therapies in the Acute Phase 238
11.5 Complications 238
11.5.1.Hemodynamic Complications 238
11.5.1.1.Hypotension 238
11.5.1.2.Left Ventricular Failure 238
11.5.1.3.Right Ventricular Failure 239
11.5.1.4.Cardiogenic Shock 240
11.5.2.Mechanical Complications 240
11.5.2.1.Free Wall Rupture 240
11.5.2.2.Ventricular Septal Rupture 240
11.5.2.3.Mitral Regurgitation 240
11.5.2.4.Left Ventricular Aneurysm 241
11.5.3.Electrical Complications 241
11.5.4.Ischemic Complications 241
11.5.5.Embolic Complications 241
11.5.6.Pericardial Complications 241
11.6 Prognosis 243
11.7 Follow-Up 243
11.8 Case Studies 244
11.8.1.Case 1 244
11.8.2.Management Decisions 244
11.8.3.Case 2 244
11.8.3.1.Management Decisions 245
References 34
12 Coronary Artery Stenting 247
Key Points 247
12.1 Introduction 248
12.2 Stent Technique 248
12.3 PCI in ACS 249
12.4 Acute Myocardial Infarction 250
12.5 Stable CAD 251
12.5.1.Role and Limitations of Medical Therapy 251
12.5.2.Multivessel Disease 254
12.5.3.Diabetic Patients 255
12.6 Ischemic Burden and Revascularization 256
12.6.1.Recommendations and Guidelines 257
12.7 Post-stent Care 258
12.7.1.Restenosis 258
12.7.2.Stent Thrombosis 259
12.8 Case Studies 261
12.8.1.Case Study 1 261
12.8.2.Case Study 2 262
References 34
13 Coronary Artery Bypass Surgery 266
Key Points 266
13.1 Background 267
13.2 Assessment of Functional Status 272
13.3 Current Treatment Options and Indications for CABG 274
13.4 Patency Rates of CABG Grafts 275
13.5 Alternative Approaches 276
13.6 Case Studies 277
13.6.1.Case Study 1 277
13.6.2.Case Study 2 277
References 34
14 Cardiac Rehabilitation 283
Key Points 283
14.1 Introduction 284
14.2 The Graded Exercise Test 285
14.2.1.The GXT for Diagnostic Purposes 286
14.2.1.1.The Positive Exercise ECG Tracing 286
14.2.2.The GXT for Prognostic Purposes 287
14.2.2.1.Cardiorespiratory Fitness 287
14.2.2.2.The Exercise ECG for Prognostic Purposes 287
14.2.3.The Use of the GXT for Therapeutic Purposes---Modifying the Exercise Prescription 288
14.3 Cardiac Care in the Outpatient Setting: Behavioral and Therapeutic Strategies 289
14.3.1.Assessment of Risk in the Cardiac Rehabilitation Setting 290
14.3.2.Assessment and Modification of Risk in the Clinic Setting 290
14.3.2.1.Bringing Attention to the Behavior 290
14.3.2.2.Discussion of the Behavior in the Clinic with the Patient 291
14.3.2.3.A Series of Clinic Visits Become a Program for Behavior Change 291
14.3.2.4.Follow-Up at the Next Encounter---The Importance of Contracting 292
14.4 Summary and Outstanding Questions 292
14.5 Summary 292
14.6 Patient Examples 295
14.6.1.Patient Example 1 295
14.6.2.Patient Example 2 295
References 34
Part III Peripheral Forms of Venous and Arterial Disease 297
15 Carotid Artery Disease 298
Key Points 298
15.1 Introduction 299
15.2 Diagnostic Testing 299
15.3 Medical Treatment 300
15.4 Carotid Endarterectomy in Patients with Symptomatic Carotid Stenosis 301
15.5 Carotid Endarterectomy in Patients with Asymptomatic Carotid Stenosis 303
15.6 Carotid Angioplasty and Stenting 305
15.7 Summary 307
15.8 Case Study 308
References 34
16 Peripheral Arterial Disease 311
Key Points 311
16.1 Introduction 311
16.1.1.Pathophysiology 312
16.1.2.Prevalence 312
16.1.3.Risk Factors 312
16.2 Prognosis 313
16.2.1.Limb Outcomes 313
16.2.2.Cardiovascular Events 313
16.2.3.Death 313
16.3 Diagnosis 313
16.3.1.History and Physical 313
16.3.2.Performing an ABI Test 314
16.4 Medical Management of PAD 316
16.4.1.Diabetes Management 316
16.4.2.Smoking Cessation 316
16.4.3.Lipid Lowering Therapies 317
16.4.4.Hypertension 317
16.4.5.Antithrombotic Therapy 317
16.4.6.Symptomatic Therapy 318
16.4.7.Interventional Therapy 318
16.4.8.Acute Limb Ischemia 318
16.5 Case Studies 319
16.5.1.Case 1 319
16.5.2.Case 2 320
References 34
17 Deep Venous Thrombosis and Pulmonary Embolism 324
Key Points 324
17.1 Introduction 325
17.2 Epidemiology 325
17.3 Risk Factors 325
17.4 Thrombophilia Testing 328
17.5 Malignancy Testing 329
17.6 Diagnosis of DVT 330
17.7 Treatment of DVT 332
17.7.1.Initial Treatment 332
17.7.2.Duration of Anticoagulation 333
17.7.3.Outpatient Treatment of DVT 334
17.7.4.Thrombolysis 334
17.7.5.Isolated Calf DVT 335
17.8 Post-thrombotic Syndrome 335
17.9 VTE Prophylaxis in Hospitalized Patients 335
17.10 Diagnosis of PE 337
17.11 Treatment of PE 338
17.11.1.Initial Treatment 338
17.11.2.Duration of Anticoagulation 339
17.12 Anticoagulation Dosing 339
17.13 Inferior Vena Cava Filters 341
17.14 VTE and Travel 341
17.15 Case Studies 342
17.15.1.Case 1 342
17.15.2.Case 2 343
References 34
18 Pulmonary Hypertension and Cor Pulmonale 352
Key Points 352
18.1 Introduction 353
18.2 Scientific Framework 353
18.3 Classification 353
18.4 Epidemiology 354
18.5 Familial Pulmonary Artery Hypertension 354
18.6 Patient Assessment 356
18.6.1.Screening 356
18.6.2.Diagnostic Algorithm 356
18.6.3.History 356
18.6.4.Physical Exam 357
18.6.5.Electrocardiogram 358
18.6.6.Chest X-Ray 358
18.6.7.Echocardiogram 359
18.6.8.Functional Assessment 359
18.6.9.Additional Diagnostic Work-Up 359
18.6.10.Laboratory Evaluation 360
18.6.11.Cardiac MRI 360
18.6.12.Cardiac Catheterization and Pulmonary Vasodilator Testing 360
18.6.13.Prognostic Indicators 361
18.7 Management of Pulmonary Hypertension 361
18.7.1.General Supportive Care 361
18.7.2.Pulmonary Vasodilator Therapies 361
18.7.2.1.Calcium Channel Blockers 361
18.7.2.2.Prostanoid Therapies 361
18.7.2.3.Endothelin Receptor Antagonists 362
18.7.2.4.Phosphodiesterase Inhibitors 362
18.8 Treatment Algorithm 362
18.9 Atrial Septostomy 364
18.10 Lung Transplantation 364
18.11 Non-cardiac Surgery and Anesthetic Management 364
18.12 Health Maintenance in PAH 364
18.13 Cor Pulmonale 365
18.14 Quality of Life in Pulmonary Hypertension 366
18.15 Case Study 366
References 34
19 Diagnosis and Management of Ischemic Stroke 371
Key Points 371
19.1 Introduction 372
19.2 Diagnosis 372
19.3 Acute Thrombolysis and Treatment 375
19.4 In-patient General Medical Care 377
19.5 In-patient Ischemic Stroke Evaluation 378
19.6 In-patient Management of Neurologic Complications 380
19.7 Stroke Prevention 381
19.8 Summary 383
19.9 Case Studies 384
19.9.1.Case Study 1 384
19.9.2.Case Study 2 384
References 34
20 Aortic Aneurysms 389
Key Points 389
Thoracic Aneurysms 389
Abdominal Aortic Aneurysms 390
20.1 Introduction 390
20.2 Aorta 390
20.3 Aortic Aneurysms 390
20.4 Thoracic Aortic Aneurysm 391
20.4.1.Etiology and Pathogenesis 392
20.4.2.Clinical Manifestations 393
20.4.3.Diagnosis 393
20.4.3.1.EKG 393
20.4.3.2.Chest X-Ray 393
20.4.3.3.CT, MRA, and Aortography 393
20.4.3.4.Echocardiography 395
20.4.4.Natural History 395
20.5 Management 395
20.5.1.Surgical Treatment 395
20.5.1.1.Open Surgical Repair Versus Endovascular Stent-Graft 396
20.5.2.Medical Management 397
20.6 Abdominal Aortic Aneurysm (AAA) 397
20.6.1.Etiology and Pathogenesis 398
20.6.2.Clinical Manifestations 399
20.6.3.Physical Examination 399
20.6.4.Diagnosis and Sizing 399
20.6.4.1.Plain Film 399
20.6.4.2.Ultrasonography 400
20.6.4.3.Contrast-Enhanced Computed Tomographic (CT) Scanning and Magnetic Resonance Angiography (MRA) 400
20.6.5.Screening 401
20.6.6.Natural History 401
20.7 Management 402
20.7.1.Surgical Treatment 402
20.7.1.1.Open Aortic Aneurysm Repair Versus Endovascular Aortic Aneurysm Repair (EVAR) 402
20.7.2.Preoperative Risk Assessment 403
20.7.3.Medical Management 403
20.8 Case Studies 404
20.8.1.Case Study 1: Thoracic Aortic Aneurysms 404
20.8.2.Case Study 2: Abdominal Aortic Aneurysms 404
20.9 Conclusions 405
References 34
21 Erectile Dysfunction 408
Key Points 408
21.1 Definition, Prevalence, and Causes of Erectile Dysfunction 409
21.2 Cardiovascular Risk Factors in Erectile Dysfunction 409
21.3 Brief Overview: Physiology and Pathophysiology of Erectile Function 411
21.4 Evaluation of a Patient Presenting with Erectile Dysfunction 411
21.5 Treatment of Cardiovascular Risk FactorsTherapy for Erectile Dysfunction 412
21.6 The Cardiovascular Patient Presenting with Erectile Dysfunction 413
21.7 Risk Stratification (First and Second Princeton Consensus Panel) 414
21.8 Treatment of Erectile Dysfunction 415
21.9 Summary 416
21.10 Case Studies 416
21.10.1.Case Study 1 416
21.10.2.Case Study 2 417
References 34
Part IV Cardiac Disease 420
22 Valvular Heart Disease 421
Key Points 421
22.1 Introduction 422
22.2 Aortic Stenosis 422
22.2.1.Etiology 422
22.2.2.Pathophysiology 423
22.2.3.Symptoms 423
22.2.4.Physical Findings 424
22.2.5.Diagnostic Testing 424
22.2.5.1.ECG 424
22.2.5.2.Chest X-Ray 424
22.2.5.3.Echocardiography 424
22.2.5.4.Cardiac Catheterization 425
22.2.6.Natural History 426
22.2.7.Treatment 426
22.2.7.1.Medical Treatment 426
22.2.7.2.Surgical Treatment 426
22.2.7.3.Percutaneous Aortic Balloon Valvotomy (PABV) 427
22.3 Aortic Regurgitation 427
22.3.1.Symptoms 428
22.3.2.Physical Findings 428
22.3.3.Diagnostic Testing 428
22.3.4.Treatment 429
22.3.5.Acute Aortic Regurgitation 429
22.4 Mitral Regurgitation 429
22.4.1.Etiology 429
22.4.2.Pathophysiology 430
22.4.3.Symptoms 430
22.4.4.Physical Findings 430
22.4.5.Diagnostic Testing 431
22.4.6.Treatment 431
22.4.6.1.Medical 431
22.4.6.2.Surgical 431
22.5 Mitral Valve Prolapse 433
22.6 Mitral Stenosis 434
22.6.1.Physical Findings 435
22.6.2.Diagnostic Testing 435
22.6.3.Treatment 435
22.6.3.1.Medical Therapy 435
22.6.3.2.Mitral Valvotomy and Replacement 436
22.7 Tricuspid Regurgitation 436
22.8 Prosthetic Heart Valves 437
22.9 Preventing Infective Endocarditis 438
22.10 Case Studies 438
22.10.1.Case Study 1 438
22.10.2.Case Study 2 439
References 34
23 Pericardial Diseases 441
Key Points 441
23.1 Introduction 441
23.2 Anatomy/Physiology 442
23.3 Acute Pericarditis 442
23.3.1.Case Study 1 442
23.3.1.1.Epidemiology and Etiology 443
23.3.1.2.Clinical Presentation 444
23.3.1.3.Physical Examination 444
23.3.1.4.Electrocardiogram 445
23.3.1.5.Chest X-Ray 445
23.3.1.6.Blood Studies 445
23.3.1.7.Echocardiogram 446
23.3.1.8.Treatment 446
23.3.1.9.Triage 446
23.4 Recurrent Pericarditis 447
23.5 Pericardial Effusion 448
23.5.1.Case Study 2 448
23.5.1.1.Etiology 449
23.5.1.2.Pathophysiology 449
23.5.1.3.Clinical Presentation 449
23.5.1.4.Physical Examination 449
23.6 Pulsus Paradoxus 449
23.6.1.Procedure to Measure Pulsus Paradoxus 450
23.6.2.Electrocardiogram 450
23.6.3.Chest X-Ray 450
23.6.4.Echocardiogram 450
23.6.5.Treatment of Pericardial Effusion with Cardiac Tamponade 451
23.6.6.Management of Pericardial Effusion Without Tamponade 451
23.7 Constrictive Pericarditis 451
23.7.1.Etiology and Pathophysiology 451
23.7.2.Clinical Presentation 451
23.7.3.Physical Exam 452
23.7.4.Laboratory Studies 452
23.7.5.Treatment 453
23.7.6.Constrictive Pericarditis Versus Restrictive Cardiomyopathy 453
References 34
24 Common Atrial and Ventricular Arrhythmias 455
Key Points 455
24.1 Introduction 455
24.2 Clinical Arrhythmias 457
24.2.1.Supraventricular Arrhythmias 458
24.2.1.1.Atrial-Based Arrhythmias 458
24.2.1.2.Bradyarrhythmias 458
24.2.1.3.Wandering Atrial Pacemaker, Premature Atrial Contractions, and Ectopic Atrial Rhythm 459
24.2.1.4.Tachyarrhythmias 460
24.2.2.Atrioventricular Chamber-Associated Arrhythmias 470
24.2.2.1.Bradycardic Arrhythmias 470
24.2.2.2.Tachyarrhythmias 473
24.2.2.3.Ventricular Origin Associated Arrhythmias 474
24.2.2.4.Special Considerations in Evaluation of Arrhythmias 477
24.3 Conclusion 482
24.4 Case Studies 482
24.4.1.Case Study 1 482
24.4.1.1.Clinical Testing 482
24.4.1.2.Discussion 483
24.4.2.Case Study 2 483
24.4.2.1.Clinical Testing 483
24.4.2.2.Discussion 483
References 34
25 Evidence-Based Management of the Patient with Congestive Heart Failure 493
Key Points 493
25.1 Epidemiology of Congestive Heart Failure 494
25.2 Pathophysiology of Congestive Heart Failure 494
25.3 ACC/AHA Classification of Congestive Heart Failure 496
25.4 Pharmacologic Therapy of Congestive Heart Failure 496
25.4.1.Heart Failure with Normal Ejection Fraction (HFNEF) and Diastolic Dysfunction 496
25.4.2.Asymptomatic Left Ventricular Systolic Dysfunction 497
25.4.3.Symptomatic Left Ventricular Systolic Dysfunction 498
25.4.4.Angiotensin Converting Enzyme Inhibitors (ACEI) 498
25.4.5.Angiotensin Receptor Blockers (ARB) 499
25.4.6.Aldosterone Blockers 501
25.4.7. ß(Beta)-Blockade in Heart Failure 502
25.4.8.Digoxin Therapy in Congestive Heart Failure 503
25.4.9.Mechanical Treatment of Stage C Heart Failure 504
25.4.9.1.Cardiac Resynchronization Therapy 504
25.4.9.2.Implantable Cardioverter Defibrillators 504
25.4.9.3.Miscellaneous Therapy 505
25.4.9.4.Management of the ACC/AHA Stage D Congestive Heart Failure Patient 505
25.4.10.Mechanical Support of the Failing Heart 506
25.5 Case Studies 507
25.5.1.Case Study 1 507
25.5.2.Case Study 2 507
25.6 Conclusion 508
References 34
Part V Cardiac Imaging 515
26 Screening for Coronary Artery Calcium 516
Key Points 516
26.1 Introduction 517
26.2 Prognostic Role of Coronary Artery Calcium in Asymptomatic Patients 518
26.2.1.General Population 518
26.3 Vascular Age 521
26.4 Special Populations 521
26.4.1.The Elderly 521
26.4.2.Patients with Diabetes Mellitus 521
26.4.3.Screening of Asymptomatic Women 522
26.4.4.Patients with Chronic Kidney Disease 522
26.5 The Prognostic Value of No Coronary Artery Calcium (Calcium Score 0) 523
26.6 Calcium Screening in Symptomatic Patients 524
26.7 Coronary Artery Calcium Progression 524
26.8 Conclusions 525
References 34
27 Cardiac Computed Tomography 530
Key Points 530
27.1 Introduction 531
27.2 Technical Background 531
27.3 Electrocardiographic Synchronization 534
27.4 How to Perform a Cardiac CT Examination 536
27.4.1.Step 1 536
27.4.2.Step 2 536
27.4.3.Step 3: Scanner Technology 537
27.4.4.Step 4: Scan Protocols 537
27.4.5.Step 5: Immediate Pre-scan Requirements 537
27.4.6.Step 6: Protocol Initiation 537
27.4.7.Step 7: Data Reconstruction and Post-processing 538
27.4.8.Step 8: Scan Reporting 538
27.5 Radiation Dose 538
27.6 Cardiac Anatomy 540
27.7 Post-processing Techniques 542
27.8 Cardiac CT Artifacts 544
27.9 Indications for Cardiac CT 545
27.9.1.Assessment of Suspected Coronary Artery Anomaly 545
27.9.2.Assessment of Coronary Artery Calcium 546
27.9.3.Elective Assessment of Native Coronary Artery Disease 547
27.9.4.Elective Assessment of Coronary Artery Bypass Grafts 549
27.9.5.Emergency Assessment of Non-specific Chest Pain and Acute Coronary Syndromes 549
27.10 Emerging Indications 552
27.10.1.Radiofrequency Pulmonary Venous Ablation 552
27.10.2.Preoperative Valvular Replacement Assessment 552
27.10.3.Left Ventricular Function 553
27.10.4.Perfusion Imaging 554
27.10.5.Atherosclerotic Plaque Assessment 555
27.10.6.Pericardial Assessment 557
27.11 Cardiac CT Present and Future 557
References 34
28 Cardiac Magnetic Resonance Imaging 562
Key Points 562
28.1 Introduction 563
28.2 General Indications 563
28.3 Specific Indications 564
28.3.1.Discussion of Technique 564
28.3.2.Imaging Cases 566
28.4 Safety Considerations 568
28.5 Training in CMR and Other Practical Issues 572
28.6 Future Prospects 573
References 34
Index 575