BLUEPRINTS IN CARDIOLOGYBLUEBRRSTS | in CARDIOLOGY Editor Eric H. Awtry, MD, FACC Assistant Professor of Medicine Boston University School of Medicine Director of Education, Section of Cardiology Boston Medical Center Boston, Massachusetts Authors Arjun V. Gururaj, MD “Teaching Fellow in Internal Medicine Boston University School of Medicine Fellow in Eleetrophysiology Division of Cardiology Boston Medical Center Boston, Massachuseus Blackwell Publishing Melanie Maytin, MD Teaching Fellow in Medicine Boston University School of Medicine Fellow, Section of Cardiology Boston Medical Center Boston, Massachusetts Michael W. Tsang, MD ‘Teaching Fellow in Medicine Boston University School of Medicine Fellow; Section of Cardiology Boston Medical Center Boston, Massachusetts Benoy J. Zachariah, MD, MRCP “Teaching Fellow in Medicine Boston University School of Medicine Clinical Fellow in Interventional Cardiology Boston Medical Center Roston, Massachusetts Faculty advisor Joseph Loscalzo, MD, PhD Wade Professor of Medicine Boston University School of Medicine Chairman, Department of Medicine Boston Medical Center Boston, Masachucetts© 2003 hy Blackwell Science a Blackwell Publishing company Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5018, USA Blackwell Science Ltd, Osney Mead, Oxford OX2 OFL, UK Blackwell Science Asia Pry Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia Blackwell Verlag GmbH, Kurfirstendamm 57, 10707 Berlin, Germany Al rights reserved. No part of this publication may be reproduced in any form or by any electronic or mechanical ‘means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review. 02 03 0405 54321 ISBN: 0-632-04628-7 Library of Congress Caraloging-in-Publication Data Blueprints in cardiology / editor, Erie H. Awtry ; authors, Melanie ‘Maytin .... fet al} p-€m.—(Blueprints series) ISBN 0-632-04628-7 (pbk) 1, Heart—Diseases—Outlines, syllabi, ete. 2. Cardiology—Outlines, syllabi, etc. [DNLM: 1. Heart Diseases—Outlines, 2. Cardiology—Outlines. WG 18.2 B6S8 2002] HL. Maytin, Melanie. III. Blueprints. R682 .B558 2002 1G.12-U21 ‘A catalogue record for this title is available from the British Library Auquisitions: Naty Duly Development: Angela Gagliano Production: Debra Lally Cover design: Hannus Design ‘Typesetter: SNP Best-set Typesetier Ltd, Hong Kong Pinned and bound by Capital City Press in Versant, USA For forther information on Blackwell Publishing, visit our website: wwwblackwellscience.com Notice: The indications and dosages of all drugs in this book have been recommended in the medical literature and conform to the practices of the general community. The medications described and treatment prescriptions suggested do not necessarily have specific approval by the Food and Drug Administration for use in the diseases and dosages for which they are recommended. The package insert for each drug should be consulted for use and dosage 28 approved by the FDA. Because standards for usage change, it is advisable 10 keep abreast of revised recommendations, particularly those concerning new drug L. Awtry, Eric. 2002005758Contents Preface vii Admowledgments ix Reviewers x Abbreviations xi Signs and Symptoms wv Important Cardiovascular Formulas xvi I History and Physical Examination 1 1 Chest Pain 3 2. Dyspnea 7 3. Palpitations 10 4 Physical Examination of the Cardiovascular System B IL Diagnostic Modalities 19 5 The Electrocardiogram 21 6 Stress Testing 26 7 Echocardiography 32 $ Cardiac Catheterization 35 nn tN en nnw Blueprints in Cardiology it Vv 9 10 Diagnostic Modalities for Arrhythmias Other Imaging Modalities Coronary Artery Disease MW 12 13 14 15 16 Coronary Artery Disease—Pathophysiology Dyslipidemia Chronic Stable Angina Unstable Angina and Non-S'T Elevation, ‘Myocardial Infarction ST-Elevation Myocardial Infarction Complicatic s of Myocardial Infarction Heart Failure 7 18 19 20 21 Cardiovascular Hemodynamics Mechanisms of Heart Failure Clinical Manifestations and Treatment of Heart Failure Myocarditis ‘The Cardiomyopathies Arrhythmias 22 23 24 25 26 27 Mechanisms of Arrhythmogenesis ‘Tachyarrhythmias Bradyarrhythmias (Bradycardia and Heart Block) Syncope Sudden Cardiac Death Pacemakers and Implantable Cardioverter Defibrillators. Valvular Heart Disease 28 Rheumatic Fever 41 St 57 62 67 71 75 81 83 87 90 97 99 105 107 it 117 122 127 131 135 137Vu IX Blueprints in Cardiology 29 Disorders of the Aortic Valve 30 Disorders of the Mitral Valve 31 Infective Endocarditis 32 Prosthetic Heart Valves Pericardial Diseases 33 Pericarditis 34 Cardiac Tamponade 35° Constrictive Pericarditis Vascular Diseases 36. Ilypertension 37 Peripheral Arterial Disorders 38 Diseases of the Aorta 39 Carotid Arterial Disease 40 Deep Venoi Embolic ‘Thrombosis and Pulmonary “ase 41 Pulmonary Hypertension Congenital Heart Disease 42. Congenital Cardiac Shunts 43 Cyanotic Congenital Heart Disease Other 44 Pregnancy and Cardiovascular Disease 45. ‘Traumatic Heart Disease 46 Cardiac Tumors Questions Answers Index 141 145 150 157 161 163 166 169 173 175 180 184 192 195 200 205 207 211 215 217 221 224 227 252‘Today's medical trainees are faced with the seemingly insurmountable task of mas- tering an ever-expanding body of knowledge. Not only is the student expected to understand the pathophysiological basis of dis ase, but also to recognire the diceace in the clinical setting, determine the appropriate tests with which to fully evaluate the disease, interpret the results of these tests, and apply all of this information to the development of an appropriate treatment plan. These skills are then tested both at the bedside and in a series of USMLE examinations. While no student can be expected to know every aspect of medicine, certain fundamental principles must be identified and learned. This can be difficult given the current state of information overload. In no specialty is this truer than in the field of cardiology. The past several decades have witnessed the introduetion of a vast array afincreasingly more complex diagnostic modalities and the development of innumerable pharmacological and non-pharmacological therapies. In addition, a veritable tidal wave of clinical trials has been performed, aimed at determining the appropriate use of these diagnostic and therapeutic options. In this new addition to the Blueprints series, we have attempted to cover the ‘core competencies in cardiology. We have discussed those skills that are essential t0 success in clinical rotations (including key cardiac symptoms and physical find~ ings, as well as the interpretation of cardiac tests), and have covered a broad array of cardiac disorders that consistently appear on the board examinations. Although memorization of specific facts is an essential component of the learning process, wwe strongly feel that 2 true understanding of disease requires knowledge of disease process. Throughout the text, we briefly review the pathophysiology of cardiac diseases and use this review as a guide to understanding the clinical presentation and treatment of these diseases. We hope that you find Blueprints in Cardialogy informative and useful. We welcome feedback and suggestions you may have about this book or any in the Blueprints series. Send to bluc@Hlacksci com. Eric H. Awtry Arjun V. Gururaj Melanie Maysin Michael W. Trang Benoy J. Zachariah Joseph Lasealro vilt‘To my wife, Sandhya Wahi-Gururaj, MD, MPH., and my parents for all their support. AG. ‘To my wife Nina and daughter Roshini for their support and patience while T was working on this book. BL. ‘To E-HLA. for keeping me on track and for understanding when T wasn’t. To J.L. for affording me the opportunity. To D.L.B. and M.TS. for being consummate mentors and wonderful friends, and for always pushing me to “raise the bar.” —MM. T would like to thank the students and residents of Boston Medical Center, whose enthusiasin for learning make teaching so enjoyable and projects such as this so rewarding. Te my co-authors and editor: thank you for your insight, expertise, and commitment to this project. Finally, I would like to thank my wife Kyle and children Jake, Nicholas, and Zachary for their endless support, patience, and encouragement. BHA.