Clinical Cardiology: Current Practice Guidelines

768 Pages·8.8 MB·english

by  Katritsis D.G.

Clinical Cardiology
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Clinical Cardiology
Current Practice Guidelines
Demosthenes G. Katritsis, M D, PhD, FRCP, FACC
Athens Euroclinic, Athens, Greece
Bernard J. Gersh , M B, ChB, DPhil, FRCP, FACC
Mayo Medical School, Rochester, MN, USA
A. John Camm, M D, FRCP, FACC
St George’s University of London, UK
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Foreword
Over the years I have had the pleasure of writing forewords for a number of books that I considered to be timely and to
fulfill important objectives. Without hesitation, I would say that Clinical Cardiology: Current Practice Guidelines, by D.G.
Katritsis, B.J. Gersh, and A.J. Camm, is the most outstanding book for which I have had the pleasure to write a foreword.
Further, this is probably the book that better serves the cardiovascular specialist in day-to-day practice than any other
written in the last two decades. This is not just a textbook; it is an extraordinary “toolkit” in the context of an evidence-
based cardiovascular practice in the midst of rapidly evolving scientific knowledge and guidelines.
Because of the need to integrate current knowledge on evidence-based cardiology, about three years ago, under the
auspices of the American Heart Association, we published a book that included the most recent guidelines by both the
ACCF/AHA and the ESC. I believe that such integration was a step forward for the practicing cardiologist; indeed, in a
“synopsis” fashion, this aspect is well served in Clinical Cardiology: Current Practice Guidelines. However, in the excel-
lent compendium of my colleagues, three new components are incorporated, which we can describe as the “jewel” of the
book: a very succinct definition, classification, pathophysiology, diagnosis, management, and need of specific clinical in-
vestigation (including genetics and molecular biology) of the various disease entities; a regularly updated online version
on the most recent developments; and, most importantly a “user friendly, at a glance” presentation. These additional three
components, that make Clinical Cardiology: Current Practice Guidelines so unique, deserve a brief description.
1) In regard to the various disease entities, general textbooks tend to employ, from definition to management, a
rather long and descriptive format. In contrast, Clinical Cardiology: Current Practice Guidelines consolidates many
of the topics, regardless of their complexity, from definition to management, in a clear, concise and instructive way,
intermixed with the most recent guidelines. Thus, over 600 easily accessible tables dissect and summarize the key
points of all the latest ACCF/AHA and ESC guidelines.
2) R apidly evolving scientific knowledge, including the value of new diagnostic and management approaches and
their incorporation in practicing guidelines, makes it difficult for the cardiovascular specialist to be aware of the
latest clinical evidence-base. Written by three leading authorities in the field, its biannually updated online version
provides the solution.
3) A novelty of this book is the “user-friendly, at glance” way of presentation that it makes it very useful to the practic-
ing cardiovascular specialist. Useful because of its combination of succinctness and clarity, the book is up to date
in every aspect of the cardiovascular science, and particularly on the most recent recommendations from both
sides of the Atlantic. Thus, these recommendations are summarized in tables derived from the guideline docu-
ments and incorporated in the appropriate diagnostic or management sections of the 85 comprehensive chapters.
For example, when confronted with complicated clinical issues that appear in everyday clinical practice (such as
modern antiplatelet therapy of ACS, differential diagnosis of wide complex tachycardia, or management of stable
CAD in view of COURAGE, FREEDOM or STICH) physicians consult general textbooks or, often several journal
articles, in order to obtain this information in a rather loose form. In contrast, Clinical Cardiology: Current Practice
Guidelines consolidates such topics in a summarized, succinct, and clear way.
This book is a tribute to the skill of the three editors who also served as the only authors. This limited, but unified and
hardworking internationally known authorship is, without doubt, a great part of the success. It is with great pleasure that
I pen these words to relate my enthusiasm for their work as a remarkable addition to the cardiovascular field.
Valentin Fuster
P hysician-in-Chief, Mount Sinai Medical Center
D irector, Mount Sinai Heart
ΠΑΝΤΕΣ ΑΝΘΡΩΠΟΙ ΤΟΥ ΕΙΔΕΝΑΙ ΟΡΕΓΟΝΤΑΙ ΦΥΣΕΙ
All humans by nature desire to know
Aristotle
Th e Metaphysics
Prologue
The entire field of cardiovascular medicine has witnessed an era of rapid scientific progress, accompanied by continu-
ous technological and applied innovation. This occurs against a backdrop of increasing emphasis on the importance of
evidence-based practice, and rapid development of guidelines by major professional societies. The resultant expansion of
our body of knowledge by evidence-based recommendations interjects a new set of challenges for the practicing clinician
with ever-extensive clinical responsibilities.
In order to practice evidence-based medicine, information must be easily accessible and, more importantly, easily
retrievable when the need arises; this may not always be easy with the current pace of dissemination of knowledge. The
rationale for writing this book reflects exactly this need, both ours and that of our potential readers: to organize our
continually evolving knowledge on often diverse cardiology issues, in our environment of networked and facilitated com-
munication. In other words, to provide a clinical tool that can be used in everyday clinical practice as a concise guide to
what we know and, more importantly, what we do not know, and what we think we know. To quote Mark Twain, “what
gets us into trouble is not what we don’t know, it is what we know for sure that just ain’t so.”
The prerequisites of informed clinical practice are: a satisfactory background of basic knowledge of disease entities,
remaining up-to-date on important clinical trials and emerging scientific evidence that shape current diagnosis and
therapy, and acquaintance with current practice guidelines from established professional societies such as the American
College of Cardiology Foundation/American Heart Association (ACCF/AHA) and the European Society of Cardiology
(ESC), among many others.
Each chapter of this book has therefore been structured around the following parts:
1. A clear definition and modern classification of disease entities, followed by updated, focused information on
recent developments on the epidemiology and pathophysiology of each condition. Recent original articles and
reviews from leading journals were consulted and a summary of the most relevant information is included. Special
care was taken not to omit the most recent information on medical genetics, an expanding and promising aspect.
2. A description of the clinical presentation of the disease, with instructions on necessary clinical investigations.
Clinical investigations are presented in the context of recent evidence that dictates their current value or obsoles-
cence. An effort has been made to include the very latest published knowledge on the clinical value of existing and
evolving tests, based on recent randomized clinical trials and guidelines by both ACCF/AHA and ESC.
3. R ecommendations on management as derived from the most recent evidence available to the authors. Because
of the comprehensive nature of guidelines offered by learned societies, it was decided to provide the most recent
recommendations in a summarized, tabulated format. These are not readily accessible since overlapping guidelines
may appear on the same condition from different working groups, and updated documents are continually appear-
ing. Thus, all guideline documents and their updates published in the US and Europe were scrutinized and classi-
fied according to year of publication. The most recent recommendations were defined, extracted and tabulated. The
resulting tables provided in the book offer the most recent recommendations on each disease entity by both ACCF/
AHA and ESC. Where appropriate, new evidence that questions the validity of specific recommendations, as well
as the opinions of established experts, and other data, such as FDA alerts are included.
4. P ractical advice on “what and why to do”. Therapies, drug doses and selection of procedures are presented in a
clear and user-friendly way.
5. C arefully chosen references. Major randomized clinical trials and seminal scientific studies that define evidence-
based practice are included for further reference. In addition, recent, scholarly reviews are provided, which to-
gether with the contents of the book should allow in-depth study of specific entities that may interest the individual
reader.
6. P resentation of all recent guidelines. Guidelines are referenced and presented separately in order to guide the
reader to the most recent publications by ACCF/AHA and ESC.
An inherent disadvantage of a medical textbook is inability to keep up-to-date with recent developments. To overcome
the problem, the online version of this book will be updated, initially on a 6-monthly basis.
This book would have never been possible without the wholehearted support and commitment of Helen Liepman, our
Senior Editor at Oxford University Press. We are grateful for her acceptance of our view of a “next generation textbook”.
We also thank Imogen Lowe, Mark Knowles, and Richard Martin of Oxford University Press. Their professionalism and
assistance throughout the production process is much appreciated.
D emosthenes G. Katritsis
B ernard J. Gersh
A . John Camm
Contents
List of abbreviations xxv
Part 1 Grown-up congenital heart disease
1 Grown-up congenital heart disease: general principles 3
Definition 3
Epidemiology 3
Aetiology 3
Clinical problems in GUCH 3
Imaging techniques and investigations 4
Principles of management 5
2 Ventricular septal defects 9
Definition and classification 9
Epidemiology 9
Aetiology 9
Pathophysiology 9
Presentation 10
Physical examination 10
Investigations 10
Therapy 10
Pregnancy 11
3 Atrioventricular septal defects 12
Definitions and classification of AVSDs 12
Ostium primum ASD 12
4 Atrial septal defects 15
Ostium secundum ASD 15
Sinus venosus defect 17
Patent foramen ovale 17
5 Patent ductus arteriosus 19
Definition 19
Epidemiology 19
Aetiology 19
Pathophysiology and natural history 20
Presentation 20
Physical examination 20
Investigations 20
Therapy 20