Practical Cardiovascular Medicine

2021·36.67 MB·english

by  Hanna

PRACTICAL H A N N A
SE C OND E DI T ION
E L I A S B . H A N N A
CARDIOVASCULAR MEDICINE
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A R
Providing a complete but succinct overview of the information cardiologists and cardiology trainees
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need to have at their fingertips, Practical Cardiovascular Medicine, Second Edition is an everyday S E C O N D E D I T I O N
primary guide to the specialty. D C
• P rovides cardiologists with a thorough and up-to-date review of cardiology, from I T PRACTICAL
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pathophysiology to practical, evidence-based management I
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• A bly synthesizes pathophysiology fundamentals and evidence-based approaches to V
CARDIOVASCULAR
prepare a physician for a subspecialty career in cardiology A
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• C linical chapters cover coronary artery disease, heart failure, arrhythmias, valvular disorders,
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pericardial disorders, congenital heart disease, and peripheral arterial disease
MEDICINE
• P ractical chapters address ECG, coronary angiography, catheterization techniques, C
echocardiography, hemodynamics, and electrophysiological testing U
• I ncludes over 730 figures, key notes boxes, references for further study, and coverage
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of clinical trials
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• R eview questions help clarify topics and can be used for Board preparation — over 650
questions in all! R
The second edition has been comprehensively updated with the newest data and with both the
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American and European guidelines. More specifically, 20 clinical chapters have been rewritten
and extensively revised. Procedural chapters have been enhanced with additional concepts and
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illustrations, particularly the hemodynamic and catheterization chapters. Clinical questions have
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been revamped, new questions have been added, including a new, 259-question section at the end
of the book.
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Practical Cardiovascular Medicine, Second Edition is an ideal reference for the resident, fellow,
cardiologist, and any professional treating patients with cardiovascular disease. I
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Elias B. Hanna, MD, FACC, is Associate Professor of Medicine (Cardiovascular Medicine E
and Interventional Cardiology) at the University of Iowa, Iowa, USA. He has authored multiple
cardiology books and has extensive fellowship teaching experience.
SE COND
EDIT ION
www.wiley.com/go/hanna/practicalcardiovascularmedicine
Cover Design: Wiley
Cover Image: © Science Photo Library - PIXOLOGICSTUDIO/Getty Images,
Courtesy of Elias Hanna
www.wiley.com/wiley-blackwell
Practical Cardiovascular
Medicine
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Practical Cardiovascular
Medicine
Second Edition
Elias B. Hanna, MD, FACC
Associate Professor of Medicine
Division of Cardiovascular Medicine
Division of Interventional Cardiology
University of Iowa School of Medicine
Iowa City, Iowa, USA
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This edition first published 2022
© 2022 John Wiley & Sons Ltd
Edition History
John Wiley & Sons Ltd (1e, 2017)
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Library of Congress Cataloging-in-Publication Data
Names: Hanna, Elias B., author.
Title: Practical cardiovascular medicine / Elias B. Hanna.
Description: Second edition. | Hoboken : Wiley, 2022. | Includes index.
Identifiers: LCCN 2021028069 (print) | LCCN 2021028070 (ebook) | ISBN
9781119832706 (paperback) | ISBN 9781119832713 (adobe pdf) | ISBN
9781119832720 (epub)
Subjects: MESH: Cardiovascular Diseases
Classification: LCC RC667 (print) | LCC RC667 (ebook) | NLM WG 120 | DDC
616.1–dc23
LC record available at https://lccn.loc.gov/2021028069
LC ebook record available at https://lccn.loc.gov/2021028070
Cover Design: Wiley
Cover Image: © Science Photo Library - PIXOLOGICSTUDIO/Getty Images, Courtesy of Elias Hanna
Set in 8.5/10.5pt FrutigerLTStd-Light by straive, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
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To my mother Marie, my sister Eliana, and my beautiful
nephew Marc‐Elias and nieces Clara and Elya,
the joys of my life
To my mentors and my fellows, and to all who
share my passion for cardiology
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Contents
Preface, xx
Abbreviations, xxi
About the Companion Website, xxiv
PART 1. Coronary Artery Disease, 1
1. Non- ST- Segment Elevation Acute Coronary Syndrome, 1
I. Definition, types of myocardial infarction, and pitfalls, 1
II. Clinical features, ECG, cardiac biomarkers, and echocardiography in ACS, 6
III. Initial approach to acute chest pain presentations and the use of conventional and high- sensitivity troponins, 8
IV. Management of NSTEMI, 10
V. General procedural management after coronary angiography: PCI, CABG, or medical therapy only, 14
VI. Discharge medications in NSTEMI, 14
VII. Prognosis, 17
Appendix 1. Complex angiographic disease- Moderate disease progression, 17
Appendix 2. Women and ACS, elderly patients and ACS, CKD, 18
Appendix 3. Bleeding, transfusion, patients on chronic warfarin or NOAC, gastrointestinal bleed, 19
Appendix 4. Antiplatelet and anticoagulant therapy, 20
Appendix 5. Difference between plaque rupture and plaque erosion, 23
Appendix 6. Spontaneous coronary artery dissection, 23
Appendix 7. Harmful effects of NSAIDs and cyclooxygenase- 2 inhibitors in CAD, 25
Appendix 8. Additional ideas on the physiology of hs-t roponin- Role of hs- troponin in primary prevention, 25
Questions and answers, 25
2. ST- Segment Elevation Myocardial Infarction, 38
1. Definition, reperfusion, and general management, 39
I. Definition, 39
II. Timing of reperfusion, 39
III. ECG phases of STEMI, 40
IV. STEMI diagnostic tips and clinical vignettes, 40
V. Specific case of new or presumably new LBBB, 41
VI. Reperfusion strategies: fibrinolytics, primary PCI, and combined fibrinolytics–PCI, 42
VII. Coronary angiography and PCI later than 24 hours after presentation-role of stress testing, 45
VIII. Angiographic findings, PCI, and cellular reperfusion; multivessel disease in STEMI, 46
IX. Antithrombotic therapies in STEMI, 47
X. Other acute therapies, 48
XI. Risk stratification, 49
XII. LV remodeling and infarct expansion after MI, 49
XIII. Discharge, EF improvement, ICD, 49
2. Stemi Complications, 50
I. Cardiogenic shock, 50
II. Mechanical complications, 53
III. Recurrent infarction and ischemia, 55
IV. Tachyarrhythmias, 55
V. Bradyarrhythmias, bundle branch blocks, fascicular blocks, 57
VI. LV aneurysm and LV pseudoaneurysm, 58
VII. Pericardial complications, 59
VIII. LV thrombus and thromboembolic complications, 59
IX. Early and late mortality after STEMI, 60
Appendix 1. Out- of- hospital cardiac arrest: role of early coronary angiography and therapeutic hypothermia, 60
Questions and answers, 62
3. Stable Ischemic Heart Disease and Approach to Chronic Chest Pain, 74
I. Causes of angina and pathophysiology of coronary flow, 74
II. Diagnostic approach, 75
vii
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III. Silent myocardial ischemia. Is there a role for screening asymptomatic patients and post- PCI patients?, 78
IV. Medical therapy: antiplatelet therapy, 79
V. Medical therapy: antianginal therapy and risk factor control, 79
VI. Indications for revascularization, 81
VII. CABG and CABG vs. medical therapy, 82
VIII. PCI and PCI vs medical therapy, 82
IX. PCI vs. CABG in multivessel and left main disease, 83
X. High- surgical- risk patients, 85
XI. Role of complete functional revascularization, 85
XII. Hybrid CABG–PCI, 85
XIII. Enhanced external counterpulsation, 86
XIV. Mortality in CAD, 86
Appendix 1. Notes on various surgical grafts, 86
Appendix 2. Coronary vasospasm (variant angina, Prinzmetal angina), 88
Appendix 3. Microvascular endothelial dysfunction, 90
Appendix 4. Women with chest pain and normal coronary arteries, 90
Appendix 5. Diagnostic strategy for ischemia with non- obstructed coronary arteries (INOCA), 91
Appendix 6. Myocardial bridging, 91
Appendix 7. Coronary collaterals, chronic total occlusion, 92
Appendix 8. Hibernation, stunning, ischemic preconditioning, 92
Questions and answers, 93
PART 2. Heart Failure (Chronic and Acute Heart Failure, Specific Cardiomyopathies,
and Pathophysiology), 103
4. Heart Failure, 103
Definition, Types, Causes, and Diagnosis of Heart Failure, 104
1. Definition and types of heart failure, 104
I. Heart failure is diagnosed clinically, not by echocardiography, 104
II. After HF is defined clinically, echocardiography is used to differentiate the three major types of HF, 105
III. Two additional types of HF, 107
2. Causes of heart failure, 107
I. Systolic HF or HF with reduced EF (HFrEF), 107
II. HF with preserved EF (HFpEF), 108
III. Right HF, 110
3. Diagnostic tests, 110
I. Echocardiography, 110
II. BNP, 111
III. ECG, 112
IV. Coronary angiography and other ischemic tests, 112
V. Diastolic stress testing, 112
VI. Endomyocardial biopsy, 112
VII. Cardiac MRI, 113
Chronic Treatment of Heart Failure, 113
1. Treatment of systolic heart failure, 113
I. Treat the underlying etiology: target BP and CAD, 113
II. Value of revascularization in ischemic cardiomyopathy: STICH trial, 113
III. Role of viability testing and ischemic testing, 113
IV. Drugs that affect survival in EF<40%, 115
V. Specifics of drugs that affect survival, 116
VI. Drugs that improve symptoms and morbidity, 120
VII. Devices, 122
VIII. Other therapeutic measures, 123
IX. Prognosis, 124
2. Treatment of HFpEF, 124
Acute Heart Failure and Acutely Decompensated Heart Failure, 126
I. Triggers of acute decompensation, 126
II. Profiles of acute HF: congestion without low cardiac output, congestion with low cardiac output, 127
III. Treatment of acute HF: diagnosis and treatment of triggers, 127
IV. Treatment of acute HF: diuretics, cardiorenal syndrome, aggressive decongestion, ultrafiltration, 128
V. Treatment of acute HF: vasodilators, 132
VI. Treatment of acute HF: IV inotropic agents, 132
VII. In-hospital and pre-discharge use of ACE-I/ ARB, angiotensin-neprilysin inhibition, and β-blockers, 133
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VIII. Treatment of acute HF: O, non-invasive ventilatory support (CPAP, BiPAP), intubation, 134
2
IX. Summary: keys to the treatment of acute HF, 134
X. Discharge, 134
XI. Inability of severe HF to tolerate vasodilatation or hemodialysis, 135
XII. Outpatient monitoring of HF and prevention of hospitalization, 135
Appendix 1. Management of isolated or predominant RV failure, 135
Questions and answers, 138
5. Additional Heart Failure Topics, 156
1. Specific cardiomyopathies, 156
I. Arrhythmia- induced cardiomyopathy, 156
II. Viral myocarditis, 157
III. Acute eosinophilic myocarditis, 158
IV. HIV cardiomyopathy, 158
V. Chagas disease, 159
VI. Sarcoidosis, 159
VII. LV non- compaction, 160
VIII. Takotsubo and other stress- related cardiomyopathies, 160
IX. Infiltrative restrictive cardiomyopathy: Amyloidosis, 161
X. Other infiltrative restrictive cardiomyopathies, 162
2. Advanced heart failure: heart transplant and ventricular assist devices, 163
I. Stages of HF, 163
II. Cardiac transplantation, 163
III. Left ventricular assist devices (LVADs), 164
3. Pathophysiology of heart failure and hemodynamic aspects, 166
I. LV diastolic pressure in normal conditions and in HF (whether systolic or diastolic), 166
II. Definition of afterload, 167
III. Cardiac output, relation to preload and afterload, 168
IV. LV pressure–volume relationship in systolic versus diastolic failure: therapeutic implications, 169
V. Optimal heart rate in HF, 170
VI. Mechanisms of exercise intolerance in HF, 170
VII. Pressure–volume loops, 171
VIII. Additional features of HF with preserved EF, 171
IX. High- output HF, 172
Questions and answers, 173
PART 3. Valvular Disorders, 181
6. Valvular Disorders, 181
1. Mitral regurgitation, 182
I. Mechanisms of mitral regurgitation, 182
II. Specifics of various causes of mitral regurgitation, 182
III. Assessment of MR severity, 188
IV. Natural history and pathophysiology of organic MR, 188
V. Treatment of organic (primary) MR, 189
VI. Treatment of secondary MR (ischemic and non-i schemic functional MR), 190
VII. Treatment of acute severe MR related to acute MI, 192
VIII. Percutaneous mitral valve repair using the Mitraclip device (transcatheter edge- to- edge repair), 192
2. Mitral stenosis, 192
I. Etiology and natural history, 192
II. Diagnosis, 193
III. Treatment, 197
3. Aortic insufficiency, 199
I. Etiology, 199
II. Pathophysiology and hemodynamics, 200
III. Diagnosis, 200
IV. Natural history and symptoms, 202
V. Treatment, 202
4. Aortic stenosis, 203
I. Etiology, 203
II. Echo and catheterization diagnosis, pitfalls, and hemodynamics, 204
III. Low- gradient AS with aortic valve area (AVA) ≤1 cm2 and low EF<50%, 206
IV. Low- gradient AS with aortic valve area (AVA) ≤ 1 cm2 but normal EF: paradoxical low-f low/ low- gradient severe AS and
normal- flow/low- gradient severe AS, 207
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V. Pressure recovery phenomenon, 208
VI. Symptoms, 209
VII. Natural history, 210
VIII. AS should be differentiated from subvalvular and supravalvular AS in children or young adults, 210
IX. Treatment, 210
5. Tricuspid regurgitation and stenosis, 213
I. Etiology of tricuspid regurgitation, 213
II. Natural history of TR, 215
III. Treatment of TR, 215
IV. Tricuspid stenosis, 216
6. Pulmonic stenosis and regurgitation, 216
I. Pulmonic stenosis, 216
II. Pulmonic regurgitation, 216
7. Mixed valvular disease; radiation heart disease, 217
I. Mixed single-v alve disease, 217
II. Multiple valvular involvement (combined stenosis or regurgitation of two different valves), 217
III. Radiation heart disease, 217
8. Prosthetic valves, 218
I. Bioprosthesis versus mechanical prosthesis, 218
II. Determinants of valve degeneration and valve thrombosis; anticoagulation guidelines, 218
III. Particular cases: women who wish to become pregnant and dialysis patients, 220
IV. Echocardiographic follow-u p of prosthetic valves, 221
V. Complications, 221
9. Auscultation and summary ideas, 223
I. Auscultation and other physical findings, 223
II. General ideas and workup, 226
Questions and answers, 227
PART 4. Hypertrophic Cardiomyopathy, 243
7. Hypertrophic Cardiomyopathy, 243
I. Definition and features of HCM, 243
II. Natural history and mortality, 245
III. Symptoms and ECG, 246
IV. Exam, 246
V. Invasive hemodynamic findings, 246
VI. Echocardiographic findings, 246
VII. Provocative maneuvers, 248
VIII. Genetic testing for diagnosis; screening of first‐degree relatives, 248
IX. Differential diagnosis of LVOT obstruction, 248
X. Differential diagnosis of severe LV hypertrophy, 249
XI. Treatment of symptoms, 250
XII. Treatment: sudden cardiac death risk assessment and ICD therapy, 252
XIII. Athlete’s heart, 253
Questions and answers, 253
PART 5. Arrhythmias and Electrophysiology, 257
8. Approach to Narrow and Wide QRS Complex Tachyarrhythmias, 257
I. The unstable patient, 257
II. Initial approach to any tachycardia, 257
III. Approach to narrow QRS complex tachycardias, 258
IV. Approach to wide QRS complex tachycardias, 259
V. Features characteristic of VT, as opposed to SVT with aberrancy, 260
VI. Features characteristic of SVT with pre‐excitation, 264
VII. Role of adenosine in establishing a diagnosis, 265
VIII. Differential diagnosis of a wide complex tachycardia on a one‐lead telemetry or Holter monitor strip, 266
IX. Various notes, 266
X. General management of SVT, 266
XI. Non‐tachycardic wide complex rhythms, 267
XII. Practice ECGs of wide complex tachycardias, 267
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9. Ventricular Arrhythmias: Types and Management, Sudden Cardiac Death, 274
I. Premature ventricular complexes, 274
II. Ventricular tachycardia, 276
III. Polymorphic ventricular tachycardia, 278
IV. Congenital long QT syndrome (LQT), 280
V. Indications for ICD implantation, 282
VI. VT with no obvious heart disease: VT related to subtle, overlooked cardiomyopathy, 283
VII. VT with no obvious heart disease: VT related to electrical disorders and channelopathies, 284
VIII. VT with no obvious heart disease: idiopathic outflow tract PVC or VT and idiopathic left fascicular PVC or VT, 286
IX. Sudden cardiac death and athlete’s ECG screening, 287
Questions and answers, 288

10. Atrial Fibrillation 294
I. Predisposing factors, 294
II. Types of AF, 295
III. General therapy of AF, 295
IV. Management of a patient who presents with acute, symptomatic AF, 297
V. Peri- cardioversion anticoagulation management, 298
VI. Antiarrhythmic management after the acute presentation, 298
VII. Decisions about long-t erm anticoagulation, role of clopidogrel, role of triple therapy, 299
VIII. Special situation: atrial fibrillation and heart failure. Optimal heart rate in heart failure, 301
IX. Special situation: atrial fibrillation with borderline blood pressure or non- AF- related hypotension, 302
X. AF burden as a correlate and a driver of HF progression, 303
Appendix 1. Optimal heart rate and AF rate for optimal cardiac output, 303
Appendix 2. Antiarrhythmic drug therapy, 303
Appendix 3. Catheter ablation of atrial fibrillation, surgical ablation, AV nodal ablation, 305
Appendix 4. INR follow- up in patients receiving warfarin- Non- vitamin K oral anticoagulants, 306
Appendix 5. Bridging anticoagulation in patients undergoing procedures, 308
Appendix 6. Management of elevated INR values, 309
Appendix 7. Left atrial appendage surgical and percutaneous closure, 309
Appendix 8. A common situation: AF and symptomatic pauses or bradycardia, 309
Appendix 9. DC cardioversion in patients with a slow ventricular response, 310
Appendix 10. AF occurring post-c ardiac surgery and AF related to acute transient triggers, 310
Appendix 11. Brief asymptomatic runs of AF on device interrogation and association with stroke. Role of rhythm monitoring after
cryptogenic stroke, 310
Questions and answers, 311
11. Atrial Flutter and Atrial Tachycardia, 319
I. Atrial flutter, 319
II. Focal atrial tachycardia, 322
III. Multifocal atrial tachycardia (MAT) (or chaotic atrial tachycardia), 325
IV. Ectopic atrial rhythm, 326
Questions and answers, 326
12. Atrioventricular Nodal Reentrant Tachycardia, Atrioventricular Reciprocating Tachycardia, Wolff–Parkinson–
White Syndrome, and Junctional Rhythms, 329
I. Inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS), 329
II. Atrioventricular nodal reentrant tachycardia (AVNRT), 329
III. Atrioventricular reciprocating tachycardia (AVRT) and Wolff–Parkinson–White (WPW) syndrome, 332
IV. Junctional escape rhythm and accelerated junctional rhythm (or non‐paroxysmal junctional tachycardia), 340
Questions and answers, 342
13. Bradyarrhythmias, 345
I. AV block, 345
II. Sinus node dysfunction, 354
III. Bundle branch blocks, bifascicular and trifascicular block, 357
Questions and answers, 359
14. Permanent Pacemaker and Implantable Cardioverter Defibrillator, 363
I. Indications for permanent pacemaker implantation, 363
II. Types of cardiac rhythm devices, 363
III. Pacemaker intervals, 367
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