Current diagnosis & treatment cardiology

Contents Authors xiv Preface xvii 1. Approach to Cardiac Disease Diagnosis 1 Michael H. Crawford, MD General Considerations 1 Common Symptoms 1 History 2 Physical Findings 3 Physical Examination 3 Diagnostic Studies 7 2. Lipid Disorders 14 Christian Zellner, MD General Considerations 14 Lipoproteins and Apolipoproteins 14 Clinical Findings 16 History 16 Physical Examination 16 Laboratory Assessment 17 Treatment 17 LDL Goals 17 Non-HDL Goals and Hypertriglyceridemia 18 HDL and Lipoprotein(a) 19 Nonpharmacologic Approaches 20 Pharmacologic Therapy 21 When to Refer 24 3. Chronic Ischemic Heart Disease 25 Michael H. Crawford, MD General Considerations 25 Pathophysiology & Etiology 25 Clinical Findings 26 Risk Factors 26 Symptoms 26 Physical Examination 27 Laboratory Findings 27 Diagnostic Studies 27 Choosing a Diagnostic Approach 29 Treatment 30 General Approach 30 Pharmacologic Therapy 31 Revascularization 34 Selection of Therapy 35 Prognosis 37 4. Unstable Angina/Non-ST Elevation Myocardial Infarction 38 Prediman K. Shah, MD & Kuang-Yuh Chyu, MD, PhD General Considerations 38 Background 38 Clinical Spectrum 38 Pathophysiology 38 Clinical Findings 40 Symptoms and Signs 40 Physical Examination 41 Diagnostic Studies 41 Differential Diagnosis 42 Acute Myocardial Infarction 42 Acute Aortic Dissection 42 Acute Pericarditis 42 Acute Pulmonary Embolism 43 Gastrointestinal Causes of Pain 43 Other Causes of Chest Pain 43 Treatment 43 Initial Management 43 Definitive Management 49 Prognosis 50 5. Acute Myocardial Infarction 51 Andrew J. Boyle, MBBS, PhD & Allan S. Jaffe, MD General Considerations 51 Pathophysiology & Etiology 51 Clinical Findings 52 Symptoms and Signs 52 Physical Examination 53 Diagnostic Studies 53 Treatment 56 Pre-hospital Management 56 Emergency Department Therapy 56 Reperfusion Therapy 57 In-hospital Management 59 Primary PCI versus Fibrinolysis 60 Fibrinolytic Agents 60 Adverse Effects of Fibrinolytic Therapy 63 Complications of Myocardial Infarction 64 Cardiogenic Shock 64 Congestive Heart Failure 64 Acute Mitral Valve Regurgitation 65 Acute Ventricular Septal Rupture 65 Cardiac Rupture 65 Recurrent Ischemia 66 Pericarditis 66 Conduction Disturbances 66 CONTENTS Other Arrhythmias 67 Mural Thrombi 68 Aneurysm and Pseudo-aneurysms 69 Right Ventricular Infarction 69 Prognosis, Risk Stratification, & Management 70 Risk Predictors 70 Risk Assessment 70 Risk Management 71 6. Cardiogenic Shock 73 Edward McNulty, MD & Craig Timm, MD General Considerations 73 Definition 73 Etiology 73 Pathogenesis 74 Cardiogenic Shock after Acute MI 74 Mechanical Complications of Acute MI 74 Right Ventricular Infarction 75 Arrhythmias 75 Other Causes of Cardiogenic Shock 76 Clinical Findings 76 History 76 Physical Examination 76 Laboratory Findings 77 Diagnostic Studies 77 Left Heart (Cardiac) Catheterization 78 Treatment 78 Acute MI 78 Mechanical Complications 80 Right Ventricular Infarction 80 Arrhythmias 81 Prognosis 81 7. Aortic Stenosis 82 Blase A. Carabello, MD & Michael H. Crawford, MD General Considerations & Etiology 82 Bicuspid Aortic Valve 82 Tricuspid Aortic Valve Degeneration 82 Congenital Aortic Stenosis 82 Rheumatic Fever 82 Other Causes 83 Clinical Findings 83 Symptoms and Signs 83 Physical Examination 84 Diagnostic Studies 85 Treatment 88 Pharmacologic Therapy 88 Aortic Balloon Valvuloplasty 88 Surgical Therapy 89 Prognosis 92 Coincident Disease 93 Follow-up 93 8. Aortic Regurgitation 95 William A. Zoghbi, MD, FASE, FACC & Michael H. Crawford, MD Etiology 95 Pathophysiology 95 Chronic Aortic Regurgitation 95 Acute Aortic Regurgitation 95 Clinical Findings 96 Symptoms and Signs 96 Laboratory Findings 97 Diagnostic Studies 97 Treatment 102 Acute Aortic Regurgitation 102 Chronic Aortic Regurgitation 103 Prognosis 105 9. Mitral Stenosis 106 Robert J. Bryg, MD General Considerations 106 Clinical Findings 107 Symptoms and Signs 107 Physical Examination 107 Diagnostic Studies 108 Treatment 110 Medical Therapy 110 Percutaneous Mitral Balloon Valvotomy 110 Surgical Therapy 111 Prognosis 112 10. Mitral Regurgitation 113 Michael H. Crawford, MD General Considerations 113 Clinical Findings 114 Symptoms and Signs 114 Physical Examination 114 Diagnostic Studies 116 Differential Diagnosis 118 Treatment 119 Pharmacologic Therapy 119 Surgical Treatment 119 Prognosis 121 11. Tricuspid & Pulmonic Valve Disease 122 Brian D. Hoit, MD & Subha L. Varahan, MD Tricuspid Valve Disease 122 General Considerations 122 Pathophysiology & Etiology 122 Tricuspid Regurgitation 122 Tricuspid Stenosis 124 Clinical Findings 124 Symptoms and Signs 124  CONTENTS v Physical Examination 124 Diagnostic Studies 125 Treatment 133 Medical 133 Surgical 133 Postoperative Management 134 Prognosis 134 Pulmonic Valve Disease 134 General Considerations 134 Pathophysiology & Etiology 134 Pulmonic Regurgitation 134 Pulmonic Stenosis 135 Clinical Findings 135 Symptoms and Signs 135 Physical Examination 135 Diagnostic Studies 136 Treatment 136 Prognosis 136 12. Infective Endocarditis 137 Bruce K. Shively, MD* & Michael H. Crawford, MD General Considerations 137 Pathophysiology & Etiology 137 Cardiac Infection—Vegetations 137 Extracardiac Disease 138 Clinical Syndromes 138 Clinical Findings 142 Diagnostic Criteria 142 Symptoms and Signs 143 Physical Examination 143 Diagnostic Studies 144 Management 147 Initial Decisions 147 Antibiotic Therapy 147 Management of Complications 149 Management of High-Risk Endocarditis 150 Surgery 151 Follow-up after Endocarditis 151 13. Systemic Hypertension 153 William F. Graettinger, MD, FACC, FACP, FCCP General Considerations 153 Pathophysiology & Etiology 153 Natural History 154 Ethnic and Socioeconomic Factors 154 Clinical Findings 154 Initial Evaluation 155 Physical Examination 155 Diagnostic Studies 155 Organ Involvement 156 Treatment 157 Nonpharmacologic Therapy 157 Pharmacologic Therapy 157 Management of Complicated Hypertension 161 Prognosis 163 14. Hypertrophic Cardiomyopathies 164 Pravin M. Shah, MD, MACC General Considerations 164 Pathophysiology & Etiology 164 Systolic Function 165 Diastolic Function 165 Clinical Findings 165 Symptoms and Signs 165 Physical Examination 166 Diagnostic Studies 167 Treatment 169 Medical Management 169 Surgical Myectomy 170 Chemical Myectomy 170 Pacemaker Implantation 170 Cardioverter Defibrillator Implantation 170 Prognosis 170 Future Prospects 171 15. Restrictive Cardiomyopathies 172 John D. Carroll, MD & Michael H. Crawford, MD General Considerations 172 Definitions and Terminology 172 Pathophysiology 172 Etiology 173 Clinical Findings 174 Symptoms and Signs 174 Physical Examination 174 Diagnostic Studies 174 Differential Diagnosis 176 Treatment 176 Diastolic Dysfunction 176 Cardiac Complications 178 Underlying Disease 178 Prognosis 178 16. Myocarditis 179 John B. O’Connell, MD & Michael H. Crawford, MD General Considerations 179 Pathophysiology 179 Clinical Findings 180 Symptoms and Signs 180 Physical Examination 181 Diagnostic Studies 181 Treatment 183 Prognosis 184 *Deceased Specific Forms of Myocarditis 184  vi CONTENTS Chagas Disease, or American Trypanosomiasis 184 HIV 184 Toxoplasmosis 185 Cytomegalovirus 185 Lyme Myocarditis 185 Giant Cell Myocarditis 185 Sarcoidosis 185 17. Pericardial Diseases 187 Martin M. LeWinter, MD General Considerations 187 Normal Pericardial Anatomy and Physiology 187 Pericardial Pressure and Normal Function 187 Pathogenesis 187 Infectious Pathogens 187 Iatrogenic Causes 189 Connective Tissue Disorders 190 Other Causes 190 Acute Pericarditis 192 General Considerations 192 Clinical Findings 192 Symptoms and Signs 192 Physical Examination 192 Diagnostic Studies 192 Treatment 194 Pericardial Effusion 194 General Considerations 194 Clinical Findings 194 Symptoms and Signs 194 Physical Examination 194 Diagnostic Studies 195 Treatment 195 Cardiac Tamponade 195 General Considerations 195 Clinical Findings 195 Symptoms and Signs 195 Diagnostic Studies 196 Treatment 197 Constrictive Pericarditis 197 General Considerations 197 Clinical Findings 198 Symptoms and Signs 198 Physical Examination 198 Diagnostic Studies 198 Differential Diagnosis 200 Treatment 201 Effusive-Constrictive Pericarditis 201 18. Congestive Heart Failure 203 Prakash C. Deedwania, MD & Enrique V. Carbajal, MD General Considerations 203 Pathophysiology & Etiology 203 Types of Heart Failure 204 Causes 206 Clinical Findings 206 Symptoms and Signs 206 Physical Examination 207 Laboratory Findings 208 Diagnostic Studies 209 Differential Diagnosis 209 Treatment 210 General Measures 210 Pharmacologic Treatment 210 Nonpharmacologic Treatment 218 Prognosis 220 19. Heart Failure with Preserved Ejection Fraction 221 Sanjiv J. Shah, MD General Considerations 221 Pathophysiology 222 Diastolic Dysfunction 222 Left Ventricular Enlargement and Increased Intravascular Volume 222 Abnormal Ventricular-Arterial Coupling 223 Left Ventricular Hypertrophy 223 Coronary Artery Disease 223 Clinical Findings 223 Risk Factors 223 Symptoms and Signs 224 Diagnostic Studies 224 Differential Diagnosis 228 Prevention 229 Treatment 229 Nonpharmacologic Therapy 229 Pharmacologic Therapy 229 Prognosis 232 20. Supraventricular Tachycardias 233 Byron K. Lee, MD & Peter R. Kowey, MD General Considerations 233 Pathophysiology & Etiology 233 General Diagnostic Approach 236 Sinus Tachycardia & Sinus Node Reentry 236 Sinus Tachycardia 236 General Considerations 236 Treatment 237 Sinus Node Reentry 237 General Considerations 237 Treatment 238 Atrial Flutter 238 General Considerations 238 Pathophysiology 238 Clinical Findings 238 Prevention 238 Treatment 239 Conversion 239 Rate Control 239  CONTENTS vii Catheter Ablation and Other Modalities 239 Stroke Prophylaxis 240 Multifocal Atrial Tachycardia 240 General Considerations 240 Treatment 240 Prognosis 240 Atrial Tachycardia 241 General Considerations 241 Treatment 242 Pharmacologic Therapy 242 Ablation 242 General Considerations 242 Pathophysiology 242 Prevention 243 Treatment 243 Vagal Maneuvers 243 Pharmacologic Therapy 243 Radiofrequency Modification in Slow–Fast AVNRT 243 Junctional Tachycardia (Accelerated AV Junctional Rhythm) 246 General Considerations 246 Clinical Findings 246 Treatment 247 Bypass Tracts & the Wolff-Parkinson-White Syndrome 247 General Considerations 247 Epidemiology 247 Pathophysiology 247 Anatomy 247 Cardiac Electrical Conduction 248 Mechanism 249 Treatment 251 Vagal Maneuvers 251 Pharmacologic Therapy 251 Radiofrequency Catheter Ablation Therapy 254 Surgical Ablation Therapy 255 Other Bypass Tracts 255 Sinus Node Arrhythmia 256 Other Supraventricular Arrhythmias 256 General Considerations 256 Treatment 256 Wandering Atrial Pacemaker 257 General Considerations 257 Treatment 257 21. Atrial Fibrillation 259 Melvin M. Scheinman, MD General Considerations 259 Epidemiology 259 Clinical Findings 259 Symptoms and Signs 259 Physical Examination 259 Treatment 260 Rate Control 260 Long-Term Antiarrhythmic Therapy and Elective Cardioversion 260 Antiarrhythmic Drug Therapy for Atrial Fibrillation 261 Nonpharmacologic Treatment of Atrial Fibrillation 265 22. Conduction Disorders & Cardiac Pacing 267 Richard H. Hongo, MD & Nora Goldschlager, MD General Considerations 267 Pathophysiology & Etiology 267 Sinus Node Dysfunction 267 Atrioventricular Nodal-His Block 268 Clinical Findings 268 Symptoms and Signs 268 Physical Examination 270 Diagnostic Studies 273 Treatment 278 Cardiac Pacing 283 Pacing System Malfunctions 293 Assessment of Pacing System Function 296 23. Ventricular Tachycardia 299 Nitish Badhwar, MD Diagnostic Issues 299 Underdiagnosis 299 Misdiagnosis 299 Diagnostic Approach to the Patient with Wide QRS Complex Tachycardia 300 Atrioventricular Relationship 301 QRS Complex Duration 301 Specific QRS Morphology 301 QRS Complex Axis 303 History, Physical Examination and 12-Lead ECG 303 Monomorphic VT in Association with Idiopathic Dilated Cardiomyopathy 304 Monomorphic VT in Arrhythmogenic Right Ventricular Cardiomyopathy 305 Monomorphic VT in Patients with Congenital Heart Disease 306 Monomorphic VT in Other Forms of Structural Heart Disease 306 Idiopathic Left Ventricular Tachycardia or Fascicular VT 307 Outflow Tract Ventricular Tachycardia 307 Annular Ventricular Tachycardia 308 Diagnostic Studies 308 Immediate Termination 310 Prevention 310 Pharmacologic Therapy 310 Nonpharmacologic Therapy 311 Polymorphic Ventricular Tachycardia 311  viii CONTENTS Polymorphic VT in the Setting of Prolonged QT Interval 311 Clinical Findings 311 Management 312 Polymorphic VT with a Normal QT Interval 313 Prognosis 313 24. Syncope 315 Michael H. Crawford, MD General Considerations 315 Pathophysiology & Etiology 315 Cardiac Causes 315 Neurocardiogenic Causes 316 Orthostatic Hypotension 317 Psychiatric Disorders 318 Neuralgia 318 Syncope of Unknown Cause 318 Clinical Findings 318 History and Physical Examination 318 Noninvasive Diagnostic Studies 320 Invasive Electrophysiology Studies 322 Differential Diagnosis 323 Seizure 323 Metabolic Disorders and Hypoxia 323 Cerebral Vascular Insufficiency and Extracranial Vascular Disease 323 Psychiatric Disorders with Hyperventilation and Pseudoseizure 324 Treatment 324 Pharmacologic and Nonpharmacologic 324 Electrophysiologic Therapies 325 Prognosis 325 25. Sudden Cardiac Death 327 John P. DiMarco, MD, PhD General Considerations 327 Pathophysiology & Etiology 327 Coronary Artery Disease 327 Hypertrophic Cardiomyopathy 328 Nonischemic Dilated Cardiomyopathy 329 Other Cardiac Diseases 329 Inherited Arrhythmia Syndromes 329 Drug-Induced Arrhythmias 330 Other Arrhythmias 330 Management of Cardiac Arrest: Initial Resuscitation 330 Management of Cardiac Arrest Survivors: In-Hospital Phase 331 Complications of Resuscitation 331 Diagnostic Studies 332 Treatment of Cardiac Arrest Survivors 333 Antiarrhythmic Drug Therapy 333 Revascularization 333 Surgical or Catheter Ablation 334 Implantable Cardioverter Defibrillators 334 Identification of Patients at Risk 335 Risk-Assessment Studies 335 Primary Prevention of Sudden Death 336 26. Pulmonary Embolic Disease 337 Rajni K. Rao, MD General Considerations 337 Etiology 337 Thrombophilia 337 Women’s Health 338 Clinical Findings 338 Symptoms and Signs 338 Diagnostic Studies 339 Prevention 345 Risk Stratification 346 Treatment 346 Heparin 346 Low-Molecular-Weight Heparin 347 Thrombolysis 347 Embolectomy 348 Inferior Vena Caval Filters 349 Warfarin 349 Adjunctive Measures 350 Venous Thromboembolism in Pregnancy 350 Counseling 350 27. Pulmonary Hypertension 352 David D. McManus, MD & Teresa De Marco, MD General Considerations 352 Classification & Pathogenesis 352 Pulmonary Arterial Hypertension 352 Pulmonary Hypertension with Left-Sided Heart Disease 355 Pulmonary Hypertension Associated with Lung Diseases and Hypoxemia 355 Pulmonary Hypertension due to Chronic Thrombotic or Embolic Diseases 356 Miscellaneous 356 Pathophysiologic Consequences of Pulmonary Hypertension 357 Clinical Findings 358 Symptoms and Signs 358 Physical Examination 359 Diagnostic Studies 359 Differential Diagnosis 363 Treatment 365 Pulmonary Arterial Hypertension 365 Pulmonary Hypertension with Left-Sided Heart Disease 369 Pulmonary Hypertension Associated with Lung Disease or Hypoxemia 370  CONTENTS ix Pulmonary Hypertension due to Chronic Thrombotic or Embolic Disease 370 Prognosis 370 28. Congenital Heart Disease in Adults 371 Ian S. Harris, MD & Elyse Foster, MD General Considerations 371 Acyanotic Congenital Heart Disease 400 Congenital Aortic Valvular Disease 373 General Considerations 373 Clinical Findings 373 Symptoms and Signs 373 Diagnostic Studies 373 Differential Diagnosis 375 Prognosis & Treatment 375 Pulmonary Valve Stenosis 376 General Considerations 376 Clinical Findings 377 Symptoms and Signs 377 Diagnostic Studies 377 Prognosis & Treatment 378 Atrial Septal Defect 379 General Considerations 379 Clinical Findings 380 Symptoms and Signs 380 Diagnostic Studies 381 Prognosis & Treatment 384 Ventricular Septal Defects 384 General Considerations 384 Clinical Findings 385 Symptoms and Signs 385 Diagnostic Studies 386 Prognosis & Treatment 386 Patent Ductus Arteriosus 388 General Considerations 388 Clinical Findings 389 Symptoms and Signs 389 Diagnostic Studies 389 Prognosis & Treatment 389 Coarctation of the Aorta 390 General Considerations 390 Clinical Findings 391 Symptoms and Signs 391 Diagnostic Studies 391 Prognosis & Treatment 392 Ebstein Anomaly 393 General Considerations 393 Clinical Findings 394 Symptoms and Signs 394 Diagnostic Studies 394 Prognosis & Treatment 395 Congenitally Corrected Transposition of the Great Arteries 396 General Considerations 396 Clinical Findings 397 Symptoms and Signs 397 Diagnostic Studies 397 Prognosis & Treatment 399 Other Acyanotic Congenital Defects 399 Cyanotic Congenital Heart Disease 400 Tetralogy of Fallot & Pulmonary Atresia VSD 401 General Considerations 402 Clinical Findings 403 Symptoms and Signs 403 Diagnostic Studies 403 Prognosis & Treatment 403 Eisenmenger Syndrome 405 General Considerations 405 Clinical Findings 406 Symptoms and Signs 406 Diagnostic Studies 406 Prognosis & Treatment 406 Transposition of the Great Arteries 409 General Considerations 409 Clinical Findings 410 Symptoms and Signs 410 Diagnostic Studies 410 Prognosis & Treatment 410 Tricuspid Atresia 411 General Considerations 411 Clinical Findings 411 Symptoms and Signs 411 Diagnostic Studies 411 Prognosis & Treatment 412 Pulmonary Atresia with Intact Ventricular Septum 401 General Considerations 413 Clinical Findings 413 Prognosis & Treatment 414 Other Cyanotic Congenital Heart Defects 414 Palliative Surgical Procedures 415 Genetic Counseling & Pregnancy 415 Recommendations for Exercise & Sports Participation 415 Acquired Heart Disease in Adults with Congenital Heart Disease 415 29. Long-Term Anticoagulation for Cardiac Conditions 417 Richard D. Taylor, MD & Richard W. Asinger, MD General Considerations 417 Anticoagulants 417 Risks of Anticoagulant Therapy 418 Pathophysiology & Etiology 418 Pathogenesis of Intravascular Thrombi 418 Embolization of Thrombi 419 Diagnostic Studies 420 Treatment of Cardiac Conditions Requiring Anticoagulation 421  x CONTENTS Atrial Fibrillation 422 Native Valvular Heart Disease 425 Prosthetic Heart Valves 426 Left Ventricular Thrombus 427 Aortic Atheroma 429 Paradoxical Emboli Associated with Patent Foramen Ovale 429 Pacemakers, Implantable Cardioverter Defibrillators, and Other Intracardiac Devices 429 Special Considerations 430 30. Cardiac Tumors 432 Bill P.C. Hsieh, MD & Rita F. Redberg, MD, MSc, FACC, FAHA General Considerations 432 Metastatic Cardiac Tumors 432 Primary Tumors 432 Clinical Findings 437 Symptoms and Signs 437 Physical Examination 438 Diagnostic Studies 438 Differential Diagnosis 441 Treatment 441 Pharmacologic Therapy 441 Radiation 442 Surgery 442 Pericardiocentesis 442 Cardiac Transplantation 442 Prognosis 443 Metastatic Tumors 443 Primary Tumors 443 Cardiac Toxicities from Oncologic Treatments 443 Chemotherapy 443 Radiation 444 31. Cardiovasular Disease in Pregnancy 446 Kirsten Tolstrup, MD, FACC, FASE General Considerations 446 Cardiovascular Physiology of Normal Pregnancy 446 Blood Volume 446 Cardiac Output 446 Intravascular Pressures and Vascular Resistance 447 Etiology & Symptomatology 447 Congenital Heart Disease 447 Valvular Heart Disease 450 Myocarditis 452 Cardiomyopathy 452 Coronary Artery Disease 454 Arrhythmias 455 Pericardial Diseases 456 Pulmonary Hypertension 456 Diseases of the Aorta 457 Hypertension 458 Clinical Findings 458 History 458 Symptoms and Signs 458 Physical Examination 458 Diagnostic Difficulties 458 Diagnostic Studies 459 Treatment 460 Pharmacologic Treatment 460 Surgical Treatment 462 Labor and Delivery 462 Prognosis 463 32. Endocrinology & the Heart 464 B. Sylvia Vela, MD & Michael H. Crawford, MD Thyroid & the Heart 464 Hyperthyroidism 464 General Considerations 464 Clinical Findings 465 Symptoms and Signs 465 Physical Examination 466 Diagnostic Studies 466 Treatment 467 Prognosis 468 Hypothyroidism 468 General Considerations 468 Clinical Findings 468 Symptoms and Signs 468 Physical Examination 469 Diagnostic Studies 469 Treatment 470 Prognosis 470 Effect of Heart Disease on Thyroid Function 471 Cardiovascular Drugs & the Thyroid 471 Parathyroid & the Heart 472 Hyperparathyroidism 472 General Considerations 472 Clinical Findings 473 Symptoms and Signs 473 Physical Examination 473 Diagnostic Studies 473 Treatment & Prognosis 473 Hypoparathyroidism 473 Adrenal & the Heart 474 Pheochromocytoma 474 General Considerations 474 Clinical Findings 474 Symptoms and Signs 474 Physical Examination 475 Diagnostic Studies 475 Treatment 475 Prognosis 476 Adrenal Insufficiency 476 General Considerations 476 Clinical Findings 476  CONTENTS xi Symptoms and Signs 476 Physical Examination 477 Diagnostic Studies 477 Treatment 477 Cushing Syndrome 477 General Considerations 477 Diagnostic Considerations 478 Treatment 478 Primary Hyperaldosteronism 478 General Considerations 478 Diagnostic Considerations 478 Treatment 478 Acromegaly & the Heart 479 General Considerations 479 Clinical Findings 479 Symptoms and Signs 479 Physical Examination 479 Diagnostic Studies 479 Treatment 480 Growth Hormone Deficiency 480 Carcinoid Tumors & the Heart 480 General Considerations 480 Treatment 481 Diabetes Mellitus & the Heart 481 General Considerations 481 Clinical Findings 481 Treatment 481 Estrogens & the Heart 482 Hormone Replacement Therapy 482 Oral Contraceptives 483 33. Connective Tissue Diseases & the Heart 484 Carlos A. Roldan, MD Systemic Lupus Erythematosus 484 General Considerations 484 Valvular Heart Disease 485 General Considerations 485 Valve Vegetations, or Libman-Sacks Endocarditis 485 Valve Thickening 485 Valve Regurgitation 485 Clinical Findings 485 Symptoms and Signs 485 Physical Examination 486 Diagnostic Studies 487 Treatment 487 Specific Antiinflammatory Therapy 487 Long-Term Anticoagulation 487 Other Therapy 487 Pericarditis 487 General Considerations 487 Clinical Findings 488 Symptoms and Signs 488 Laboratory Findings 488 Diagnostic Studies 488 Treatment 488 Medical Therapy 488 Surgical Therapy 488 Myocarditis or Cardiomyopathy 488 General Considerations 488 Clinical Findings 489 Symptoms and Signs 489 Diagnostic Studies 489 Treatment 489 Specific Antiinflammatory Therapy 489 Other Therapy 489 Thrombotic Diseases 489 General Considerations 489 Clinical Findings 489 Symptoms and Signs 489 Laboratory Findings 490 Diagnostic Studies 490 Treatment 490 Specific Antiinflammatory Therapy 490 Other Therapy 490 Coronary Artery Disease 490 General Considerations 490 Clinical Findings 490 Symptoms and Signs 490 Diagnostic Studies 490 Treatment 491 Specific Antiinflammatory Therapy 491 Other Therapy 491 Cardiac Arrhythmias & Conduction Disturbances 491 General Considerations 491 Treatment 491 Specific Antiinflammatory Therapy 491 Other Therapy 491 Prognosis 491 Rheumatoid Arthritis 492 Rheumatoid Pericarditis 492 General Considerations 492 Clinical Findings 492 Symptoms and Signs 492 Laboratory Findings 492 Diagnostic Studies 492 Treatment 493 Prognosis 493 Rheumatoid Valvular Heart Disease 493 General Considerations 493 Clinical Findings 493 Physical Examination 493 Diagnostic Studies 493 Treatment 493 Rheumatoid Myocarditis 494 General Considerations 494 Clinical Findings 494 Physical Examination 494 Laboratory Findings 494  xii CONTENTS Diagnostic Studies 494 Treatment & Prognosis 495 Rheumatoid Coronary Artery Disease 495 General Considerations 495 Clinical Findings 495 Symptoms and Signs 495 Diagnostic Studies 495 Treatment 495 Conduction Disturbances 495 General Considerations 495 Clinical Findings 496 Symptoms and Signs 496 Diagnostic Studies 496 Treatment 496 Rheumatoid Pulmonary Hypertension 496 General Considerations 496 Clinical Findings 496 Symptoms and Signs 496 Diagnostic Studies 496 Treatment & Prognosis 496 Scleroderma 497 General Considerations 497 Coronary Artery Disease 497 Pathophysiology 497 Clinical Findings 497 Symptoms and Signs 497 Diagnostic Studies 497 Treatment 498 Myocarditis 498 General Considerations 498 Clinical Findings 499 Symptoms and Signs 499 Diagnostic Studies 499 Treatment 499 Prognosis 499 Conduction Disturbances & Arrhythmias 499 General Considerations 499 Clinical Findings 499 Symptoms and Signs 499 Diagnostic Studies 499 Treatment 500 Prognosis 500 Pericarditis 500 General Considerations 500 Clinical Findings 500 Symptoms and Signs 500 Diagnostic Studies 500 Treatment 500 Prognosis 500 Valvular Heart Disease 500 Secondary Scleroderma Heart Disease 500 Ankylosing Spondylitis 501 General Considerations 501 Aortitis & Aortic Regurgitation 502 General Considerations 502 Clinical Findings 502 Physical Examination 502 Diagnostic Studies 502 Treatment 502 Medical Therapy 502 Surgical Therapy 502 Conduction Disturbances 502 Clinical Findings 503 Physical Examination 503 Diagnostic Studies 503 Treatment 503 Specific Antiinflammatory Therapy 503 Other Therapy 503 Mitral Valve Disease 504 Myocardial Disease, Pericardial Disease, & Bacterial Endocarditis 504 Prognosis 504 Polymyositis/Dermatomyositis 504 General Considerations 504 Clinical Findings 504 Myocarditis 505 Arrhythmias & Conduction Disturbances 505 Coronary Arteritis 505 Valvular Heart Disease 505 Pericarditis 505 Pulmonary Hypertension, Cor Pulmonale, & Hyperkinetic Heart Syndrome 505 Treatment & Prognosis 505 Mixed Connective Tissue Disease 505 General Considerations 506 Clinical Findings 506 Symptoms and Signs 506 Diagnostic Studies 506 Treatment 506 Prognosis 506 34. The Athlete’s Heart 507 Cedela Abdulla, MD & J. V. (Ian) Nixon, MD, FACC, FAHA General Considerations 507 Physiology of Exercise Training 507 Acute Responses to Exercise 507 Effects of Systematic Exercise Training 509 Morphologic Responses to Training 510 Electrocardiography 512 Racial Differences in Response to Training 512 Detraining 512 Sudden Death in Athletes 513 The Preparticipation Physical Examination 513  CONTENTS xiii 35. Thoracic Aortic Aneurysms & Dissections 516 John A. Elefteriades, MD Aneurysms 516 General Considerations 516 Etiology 516 Clinical Findings 520 Natural History 520 Symptoms and Signs 524 Physical Examination 524 Diagnostic Studies 524 Treatment 525 Risks of Aortic Surgery 525 Indications and Contraindications 526 Surgical Techniques 526 Specific Clinical Scenarios and Issues 528 Aortic Dissection 529 General Considerations 529 Terminology 529 Anatomic Classification 531 Clinical Findings 531 Symptoms and Signs 531 Diagnostic Studies 531 Differential Diagnosis 532 Treatment 533 Pharmacotherapy 533 Surgical Treatment 534 Prognosis 535 36. Evaluation & Treatment of the Perioperative Patient 536 Sanjiv J. Shah, MD Preoperative Risk Assessment 536 Algorithms 536 Intermediate Risk Patients 537 Understanding Cardiac Complications 539 Treatment to Reduce Perioperative Risk 540 β-Blockers 540 Statins 540 Clonidine 540 Calcium Channel Blockers 540 Maintanence of Normothermia 540 Deep Venous Thrombosis Prophylaxis 540 Endocarditis Prophylaxis 540 Perioperative Medication Management 541 Prophylactic Coronary Revascularization 542 Special Populations 543 Vascular Surgery 543 Aortic Stenosis 543 Heart Failure 543 Pulmonary Hypertension 543 Pacemakers and Defibrillators 543 Index 545