Inpatient Cardiovascular Medicine E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Hospital Medicine - Current Concepts
• Sprache: Englisch

Seitenzahl: 490

Veröffentlichungsjahr: 2013

Beschreibung

The first book developed specifically for hospitalists managingthe growing number of patients with cardiovascular disorders Cardiovascular disease is a major cause of hospitalization andmortality worldwide, and will account for approximately twentymillion deaths in 2015. Due to this growing problem, many patientsare being managed by non-cardiovascular physicians in the inpatientsetting. As a result, hospitalists and other inpatient physicianswithout specialized training in cardiology are faced withuncertainty when contemplating the proper management of thesepatients. This book focuses on inpatient cardiovascular medicine in ahighly algorithmic and evidence-based approach, so that users willbe able to care for their hospitalized patients directly, using thebest contemporary evidence available. It emphasizes the practical,immediate application of principles and treatment recommendationsinto everyday clinical inpatient practice, while simplifying theapproach to these patients by utilizing visual aids such ascarefully designed charts, illustrations, and diagrams. Inpatient Cardiovascular Medicine features thoughtful,comprehensive coverage by top experts in the field. Topicsinclude: * Cardiovascular History and Physical Examination * Introduction to Electrocardiography * Non-invasive Cardiac Imaging * Cardiac Stress Testing and the Evaluation of Chest Pain * Perioperative Cardiac Evaluation * Cardiac Resuscitation * Acute Coronary Syndromes: Unstable Angina and Non-ST ElevationMyocardial Infarction * Acute ST-Elevation Myocardial Infarction * Chronic Coronary Artery Disease * Peripheral Arterial Disease * Thoracic Aortic Disease * Systolic Heart Failure * Diastolic Heart Failure * Dilated and Restrictive Cardiomyopathy * Hypertrophic Cardiomyopathy * Heart Transplantation and Left Ventricular Assist Devices * Syncope * Approach to the Patient with a Narrow Complex Tachycardia * Approach to the Patient with a Wide Complex Tachycardia * Atrial Fibrillation and Atrial Flutter * Antiarrhythmic Drug Therapy * Cardiac Pacemakers and Implantable Defibrillators * Valvular Heart Disease * Infective Endocarditis * Pericardial Diseases * Pulmonary Hypertension * Cardiac Tumors

Leseprobe

Contents

Contributors

Preface

Chapter 1: Cardiovascular History and Physical Examination

1.1 HISTORY

1.2 PHYSICAL EXAMINATION

1.3 BEDSIDE MANEUVERS

KEY REFERENCES

Chapter 2: Introduction to Electrocardiography

2.1 INTRODUCTION

2.2 INITIAL APPROACH TO THE ECG

2.3 LIMITATIONS

2.4 ECG PATTERNS

KEY REFERENCES

SUPPLEMENTARY ECGS

Chapter 3: Non-invasive Cardiac Imaging

3.1 INTRODUCTION

3.2 NON-STRESS IMAGING STUDIES

KEY REFERENCES

Chapter 4: Cardiac Stress Testing and the Evaluation of Chest Pain

4.1 INTRODUCTION

4.2 CHEST PAIN EVALUATION

4.3 POST-MYOCARDIAL INFARCTION

4.4 CARDIOVASCULAR STRESS TEST MODALITIES

4.5 EXERCISE STRESS TEST

4.6 RADIONUCLIDE IMAGING

4.7 STRESS ECHOCARDIOGRAPHY

KEY REFERENCES

Chapter 5: Perioperative Cardiac Evaluation

5.1 OVERVIEW

5.2 RATIONALE FOR PERIOPERATIVE CARDIAC EVALUATION

5.3 EVALUATION OF RISK

5.4 PERIOPERATIVE MEDICAL MANAGEMENT

5.5 PERIOPERATIVE STRESS TESTING AND CORONARY REVASCULARIZATION

5.6 OTHER STUDIES: PREOPERATIVE ECG AND LEFT VENTRICULAR FUNCTION ASSESSMENT

5.7 POSTOPERATIVE SURVEILLANCE

KEY REFERENCES

Chapter 6: Cardiac Resuscitation

6.1 EPIDEMIOLOGY

6.2 PHASES OF IN-HOSPITAL RESUSCITATION

KEY REFERENCES

Chapter 7: Acute Coronary Syndromes: Unstable Angina and Non-ST Elevation Myocardial Infarction

7.1 INTRODUCTION

7.2 ETIOLOGY AND PATHOPHYSIOLOGY

7.3 CLINICAL PRESENTATION

7.4 EVALUATION AND DIAGNOSTIC STUDIES

7.5 TREATMENT

7.6 HOSPITAL DISCHARGE AND POST-HOSPITAL CARE

KEY REFERENCES

Chapter 8: Acute ST Elevation Myocardial Infarction

8.1 INTRODUCTION

8.2 EPIDEMIOLOGY

8.3 PATHOPHYSIOLOGY

8.4 EVALUATION

8.5 TREATMENT

8.6 COMPLICATIONS

KEY REFERENCES

Chapter 9: Chronic Coronary Artery Disease

9.1 INTRODUCTION

9.2 PATHOPHYSIOLOGY

9.3 RISK FACTOR ASSESSMENT

9.4 CLINICAL MANIFESTATION

9.5 PHYSICAL EXAMINATION

9.6 LABORATORY AND ECG ASSESSMENT

9.7 NONINVASIVE TOOLS FOR RISK STRATIFICATION

9.8 EMERGING NONINVASIVE TESTS FOR RISK STRATIFICATION

9.9 MEDICAL TREATMENT OF CHRONIC STABLE CORONARY DISEASE

9.10 ROLE FOR REVASCULARIZATION FOR CHRONIC ANGINA

KEY REFERENCES

Chapter 10: Peripheral Arterial Disease

10.1 INTRODUCTION

10.2 EPIDEMIOLOGY, ETIOLOGY, AND NATURAL HISTORY

10.3 CLINICAL MANIFESTATIONS AND EVALUATION

10.4 TREATMENT

10.5 OTHER CONDITIONS AND VASCULAR EMERGENCIES

KEY REFERENCES

Chapter 11: Thoracic Aortic Diseases

11.1 THORACIC AORTIC ANEURYSM

11.2 ACUTE AORTIC SYNDROMES

KEY REFERENCES

Chapter 12: Systolic Heart Failure

12.1 INTRODUCTION

12.2 INCIDENCE/PREVALENCE

12.3 MORTALITY

12.4 PATHOPHYSIOLOGY OF LV SYSTOLIC DYSFUNCTION

12.5 CAUSES AND RISK FACTORS

12.6 CLINICAL HISTORY AND PHYSICAL EXAMINATION

12.7 OUTPATIENT MEDICAL MANAGEMENT

12.8 IMPLANTABLE CARIOVERTER-DEFIBRILLATOR (ICD) ± CARDIAC RESYNCHRONIZATION THERAPY

12.9 INPATIENT MEDICAL MANAGEMENT – FLOOR STATUS

12.10 INPATIENT MEDICAL MANAGEMENT – INTENSIVECARE UNIT STATUS

12.11 INPATIENT MEDICAL MANAGEMENT – INTENSIVE CARE UNIT STATUS WITH TRANSPLANT FOR ASSIST DEVICE CONSIDERATION

KEY REFERENCES

Chapter 13: Diastolic Heart Failure

13.1 INTRODUCTION

13.2 EPIDEMIOLOGY

13.3 PATHOPHYSIOLOGY

13.4 ETIOLOGIES

13.5 CLINICAL PRESENTATION

13.6 EVALUATION AND DIAGNOSTIC STUDIES

13.7 RISK STRATIFICATION

13.8 TREATMENT

13.9 TRANSITION TO OUTPATIENT CARE

KEY REFERENCES

Chapter 14: Dilated and Restrictive Cardiomyopathy

14.1 INTRODUCTION

14.2 DILATED CARDIOMYOPATHY

14.3 RESTRICTIVE CARDIOMYOPATHY

KEY REFERENCES

Chapter 15: Hypertrophic Cardiomyopathy

15.1 INTRODUCTION

15.2 PATHOPHYSIOLOGY

15.3 PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS

15.4 EVALUATION AND DIAGNOSTIC STUDIES

15.5 TREATMENT

KEY REFERENCES

Chapter 16: Heart Transplantation and Left Ventricular Assist Devices

16.1 HEART TRANSPLANTATION

16.2 VENTRICULAR ASSIST DEVICES

Chapter 17: Syncope

17.1 PATHOPHYSIOLOGY

17.2 ETIOLOGIES

17.3 CLINICAL PRESENTATION

17.4 EVALUATION AND DIAGNOSTIC STUDIES

17.5 TREATMENT

KEY REFERENCES

Chapter 18: Approach to the Patient with a Narrow Complex Tachycardia

18.1 INTRODUCTION

18.2 DIFFERENTIAL DIAGNOSIS

18.3 NOMENCLATURE

18.4 ATRIAL FLUTTER WITH 2:1 CONDUCTION

18.5 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIAS

18.6 MECHANISMS

18.7 ELECTROCARDIOGRAPHIC DIAGNOSIS

18.8 PHYSIOLOGIC DIAGNOSIS

18.9 PHARMACOLOGIC DIAGNOSIS

18.10 DIAGNOSTIC ALGORITHM

Chapter 19: The Approach to the Patient with a Wide Complex Tachycardia

19.1 INTRODUCTION

19.2 OVERALL MECHANISMS

19.3 VENTRICULAR TACHYCARDIA

19.4 SUPRAVENTRICULAR MECHANISMS

19.5 BENIGN FORMS

19.6 DIAGNOSIS

KEY REFERENCES

Chapter 20: Atrial Fibrillation and Atrial Flutter

20.1 INTRODUCTION

20.2 PATHOPHYSIOLOGY

20.3 ETIOLOGY

20.4 CLINICAL PRESENTATION

20.5 EVALUATION AND DIAGNOSTIC STUDIES

20.6 TREATMENT

KEY REFERENCES

Chapter 21: Antiarrhythmic Drug Therapy

21.1 INTRODUCTION

21.2 PHARMACOLOGY

21.3 DISEASE-SPECIFIC THERAPY

21.4 ATRIAL FIBRILLATION AND ATRIAL FLUTTER

21.5 SUPRAVENTRICULAR TACHYCARDIA

21.6 SUMMARY

KEY REFERENCES

Chapter 22: Cardiac Pacemakers and Implantable Defibrillators

22.1 BACKGROUND

22.2 COMPONENTS OF A PACEMAKER OR ICD

22.3 INDICATIONS FOR THE IMPLANTATION OF PACEMAKERS AND ICDS

22.4 POST-IMPLANTATION CARE

22.5 EVALUATION OF AN EXISTING DEVICE

22.6 PERIOPERATIVE MANAGEMENT

KEY REFERENCES

Chapter 23: Hypertension

23.1 INTRODUCTION

23.2 ASSOCIATION WITH CARDIOVASCULAR OUTCOMES

23.3 EVALUATION

23.4 DIAGNOSIS

23.5 WORKUP

23.6 TREATMENT

23.7 MANAGING HYPERTENSION IN THE HOSPITAL

23.8 HYPERTENSIVE CRISIS

KEY REFERENCES

Chapter 24: Valvular Heart Disease

24.1 INTRODUCTION

24.2 AORTIC VALVE

24.3 MITRAL VALVE

24.4 RIGHT SIDED VALVE DISEASE

24.5 PROSTHETIC VALVES

KEY REFERENCES

Chapter 25: Infective Endocarditis

25.1 EPIDEMIOLOGY

25.2 PATHOPHYSIOLOGY

25.3 CLINICAL FEATURES

25.4 DIAGNOSIS

25.5 MICROBIOLOGY

25.6 ANTIMICROBIAL THERAPY

25.7 SURGICAL THERAPY

25.8 RESPONSE TO THERAPY

25.9 PROPHYLAXIS

25.10 CARDIOVASCULAR DEVICE INFECTION

KEY REFERENCES

Chapter 26: Pericardial Diseases

26.1 ACUTE PERICARDITIS

26.2 PERICARDIAL TAMPONADE

26.2 CONSTRICTIVE PERICARDITIS

KEY REFERENCES

Chapter 27: Pulmonary Hypertension

27.1 INTRODUCTION

27.2 ETIOLOGIES

27.3 PATHOPHYSIOLOGY

27.4 EPIDEMIOLOGY

27.5 CLINICAL PRESENTATION AND PHYSICAL EXAMINATION

27.6 EVALUATION AND DIAGNOSTIC STUDIES

27.7 TREATMENT

27.8 CARE OF THE CRITICALLY ILL PAH PATIENT

KEY REFERENCES

Chapter 28: Cardiac Tumors

28.1 INTRODUCTION

28.2 EPIDEMIOLOGY

28.3 CLINICAL MANIFESTATIONS

28.4 DIAGNOSTIC EVALUATION

28.5 TREATMENT

28.6 OTHER UNCOMMON PRIMARY CARDIAC TUMORS

KEY REFERENCES

Supplemental Images

Index

Hospital Medicine: Current Concepts

Scott A. Flanders and Sanjay Saint, Series Editors

1. Anticoagulation for the Hospitalist

Margaret C. Fang, Editor

2. Hospital Images: A Clinical Atlas

Paul B. Aronowitz, Editor

3. Becoming a Consummate Clinician: What Every Student, House Officer, and Hospital Practitioner Needs to Know

Ary L. Goldberger and Zachary D. Goldberger, Editors

4. Inpatient Perioperative Medicine Medical Consultation: Co-Management and Practice Management

Amir K. Jaffer and Paul J. Grant, Editors

5. Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

James C. Pile, Thomas E. Baudendistel, and Brian J. Harte, MD, Editors

6. Hospitalist’s Guide to the Care of Older Patients

Brent C. Williams, Preeti N. Malani, and David H. Wesorick, Editors

7. Inpatient Cardiovascular Medicine

Brahmajee K. Nallamothu and Timir S. Baman, Editors

Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New JerseyPublished simultaneously in Canada

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Library of Congress Cataloging-in-Publication Data:

Inpatient cardiovascular medicine / edited by Brahmajee K. Nallamothu, Timir S. Baman.        p. ; cm. – (Hospital medicine : current concepts ; 6)    Includes bibliographical references and index.

    ISBN 978-0-470-61000-8 (pbk. : alk. paper) – ISBN 978-1-118-48473-9 (Mobi) – ISBN 978-1-118-48478-4 – ISBN 978-1-118-48481-4 (ePub) – ISBN 978-1-118-48482-1 (ePdf)    I. Nallamothu, Brahmajee K., editor of compilation. II. Baman, Timir S., editor of compilation. III. Series: Hospital medicine, current concepts ; 6.    [DNLM: 1. Cardiovascular Diseases. 2. Inpatients. WG 120]    RC674    616.1′0231–dc23

2013017943

Cover image: Top left hand image – iStock file #3643872, middle left hand image – iStock file #10486652, bottom left hand image – iStock file #17324827

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1

Contributors

Keith Aaronson, MD, MS, Professor of Internal Medicine, Medical Director, Heart Transplant Program and Center for Circulatory Support, University of Michigan, Ann Arbor, MI, USA

Craig T. Alguire, MD, Assistant Professor, Michigan State University and Spectrum Health, Grand Rapids, MI, USA

William F. Armstrong, MD, Franklin Davis Johnston Collegiate Professor of Cardiovascular Medicine, Director, Echocardiography Laboratory, University of Michigan, Ann Arbor, MI, USA

David S. Bach, MD, Park W. Willis III Collegiate Professor of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA

Auroa Badin, MD, Assistant Professor of Clinical Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA

Timir S. Baman, MD, Assistant Professor of Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA

Anna M. Booher, MD, Assistant Professor of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA

Sanders H. Chae, MD, Assistant Professor of Medicine, University of South Florida, Tampa, FL, USA

Stanley J. Chetcuti, MD, FACC, Associate Professor, Eric J. Topol Collegiate Professor of Cardiovascular Medicine, Director, Cardiac Catheterization Laboratory, University of Michigan, Ann Arbor, MI, USA

Jennifer A. Cowger, MD, MS,Assistant Professor, Medical Director Mechanical Circulatory Support Program, Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA

Thomas C. Crawford, MD, Assistant Professor of Medicine, The University of Michigan, Ann Arbor, MI, USA

Melinda B. Davis, MD, Lecturer, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA

Sharlene Day, MD, Assistant Professor of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

Kim A. Eagle, MD, Albion Walter Hewlett Professor of Internal Medicine, and Director, Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA

Dana P. Edelson, MD, MS, FAHA, FHM, Assistant Professor, University of Chicago Medical Center, Chicago, Illinois, USA

Anubhav Garg, MD, Lecturer, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

Zachary D. Goldberger, MD, MS, Assistant Professor of Medicine, Division of Cardiology, University of Washington School of Medicine/Harborview Medical Center, Seattle, Washington, USA

Sascha N. Goonewardena, Lecturer, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

P. Michael Grossman, MD, FACC, Associate Professor, Director, VA Ann Arbor Cardiac Catheterization Laboratory, University of Michigan, Ann Arbor, MI, USA

Sanjaya Gupta, MD, Assistant Professor of Internal Medicine, University of Missouri-Kansas City, and St. Luke’s Hospital, Kansas City, MI, USA

Hitinder S. Gurm, MBBS, Associate Professor of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

Peter G. Hagan, MB, Assistant Professor, Director, Cardiovascular Disease Fellowship Program, University of Michigan, Ann Arbor, MI, USA

Shea E. Hogan, MD, Cardiology Fellow, University of Michigan, Ann Arbor, MI, USA

Scott L. Hummel, MD, MS, Assistant Professor of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan and Staff Cardiologist, Ann Arbor Veterans Affairs Health System, Ann Arbor, MI, USA

Karl J. Ilg, MD, Cardiac Electrophysiologist, Genesys Heart Institute, Grand Blanc, MI, USA

Renuka Jain, MD, Assistant Professor, University of Minnesota, Minneapolis, MN USA

Yogendra M. Kanthi, MD, Fellow, Cardiology and Vascular Medicine, University of Michigan, Ann Arbor, MI, USA

Christos Kasapis, MD, Interventional Cardiology Fellow, University of Michigan, Ann Arbor, MI, USA

Fareed U. Khaja, MD, Professor of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

Gerald C. Koenig, MD, PhD, Assistant Professor of Medicine, Wayne State University and Henry Ford Hospital, Detroit, MI, USA

David C. Lange, MD, Fellow, Division of Cardiovascular Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA

Preeti N. Malani, MD, MSJ, Associate Professor of Internal Medicine, Divisions of Infectious Diseases and Geriatric Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA

Vallerie V. McLaughlin, MD, Professor of Medicine, Division of Cardiovascular Medicine, Director, Pulmonary Hypertension Program, University of Michigan, Ann Arbor, MI, USA

Brahmajee K. Nallamothu, MD, MPH,Associate Professor of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

Hakan Oral, MD, Frederick G. L. Huetwell Professor of Cardiovascular Medicine, Director, Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI, USA

Francis D. Pagani, MD, PhD, Otto Gago, M.D. Professor in Cardiac Surgery, Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA

Amir B. Rabbani, MD, Cardiovascular Institute, DMC Harper University Hospital, Detroit, MI, USA

Michael C. Reed, MD, Interventional Cardiology, St. Patrick’s Hospital, Missoula, MT, and University of Washington Affiliate, Seattle, WA, USA

Adam M. Rogers, MD, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA

Sara Saberi, MD, Lecturer, University of Michigan, Ann Arbor, MI, USA

Michael J. Shea, MD, Professor of Internal Medicine, Section Head, Cardiovascular Medicine Outpatient Service and Clinical Education, Co-Director, Aortic Valve Clinic, University of Michigan, Ann Arbor, MI, USA

Nicklaus K. Slocum, MD, Traverse Heart & Vascular, Traverse City, MI, USA

Njeri Thande, MD, Assistant Professor of Cardiology, Albert Einstein Medical School, Montefiore Hospital, Bronx, NY, USA

Michael P. Thomas, MD, Lecturer, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA

Thomas T. Tsai, MD, MSc, Director, Interventional Cardiology, Denver VA Medical Centerand Assistant Professor, University of Colorado Denverand Investigator, Colorado Cardiovascular Outcomes Research (CCOR) Group, Denver, CO, USA

Scott H. Visovatti, MD, Lecturer, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA

Preface

In the United States, the number of hospital admissions in which cardiovascular diseases play a significant role is increasing due to an aging population. The care for these patients also is becoming more complex with an ever-increasing amount of novel drugs and devices being introduced that target or impact on the heart. At the same time, many patients with cardiovascular diseases are now being managed by non-cardiovascular physicians in the inpatient setting when they are admitted for other diseases. As a result, hospitalists and other inpatient practitioners are increasingly exposed to these patients but faced with anxiety and uncertainty when contemplating their proper management. Current texts may discuss various cardiovascular diseases in detail, but less often convey to the reader how to best incorporate this information most effectively into everyday clinical practice. They also rarely discuss the secondary role of cardiovascular diseases during a hospitalization, when conditions like pneumonia or peptic ulcer disease can be strongly influenced by the presence of coronary artery disease or heart failure. This book focuses on cardiovascular medicine from the perspective of the busy inpatient practitioners. It is highly practical and algorithmic in nature, and our hope is that the reader will be able to care for his or her patient directly using contemporary evidence.

We have provided a format that we believe can be easily integrated into the daily practice of a broad range of non-cardiovascular physicians (e.g., hospitalists, internal medicine residents, nurse practitioners). We have divided the book into five major sections: 1) General Principles and Conditions in Cardiovascular Medicine; 2) Ischemic Heart and Vascular Disease; 3) Heart Failure and Cardiomyopathy; 4) Syncope and Arrhythmias; and 5) Special Topics for the Inpatient Practitioner. These sections serve as broad categories so that the reader can search for their specific topic of interest. Within each section, chapters are integrated with one another. We hope this flow is apparent and useful for readers utilizing the book. We have intentionally limited the text in the chapters as much as possible. We understand the busy nature of clinical practice and tried to place a special emphasis on the integration of charts, diagrams, and algorithms to make the book more user-friendly and applicable to daily patient care. We believe this approach also allows inpatient practitioners to immediately relay information back to the patient. Finally, we highlight several important points throughout the book, reflecting the informal but critical nature of a “Take Home Point” that is so familiar to clinicians everywhere.

Of course, we hope you will find our work interesting to read, but mostly that you find it useful for your patients.

Chapter1

Cardiovascular History and Physical Examination

Melinda B. Davis and Michael J. Shea

Despite enormous technological advances in cardiovascular medicine, optimal care of patients with heart disease begins with a focused and thorough history and physical examination. Such an approach is needed not only to diagnose conditions but to relate findings obtained from additional testing into appropriate clinical context. A successful history and physical examination also establishes a foundation for a strong patient–physician relationship, which can greatly assist in complex discussions regarding therapeutic options.

1.1 HISTORY

Cardiac disease can masquerade in many different forms but classic symptoms include chest discomfort, fatigue, edema, weight gain, dyspnea, palpitations, syncope, cough, hemoptysis, and cyanosis. Symptoms of vascular disease include claudication, limb pain, edema, and skin discoloration. Patients’ descriptions of symptoms yield a great deal of information and should never be discounted (Table 1.1). Basic elements of the history include the symptom onset, the nature and severity, duration, frequency, precipitating and relieving factors, impact on daily life and employment, and similarity to prior episodes. Major risk factors for coronary artery disease include age, male gender, family history, tobacco use, hyperlipidemia, hypertension, sedentary lifestyle, obesity, and diabetes mellitus.

Table 1.1Cardiovascular Symptoms and Conditions. Patients should be questioned about the following common cardiovascular symptoms. Different features in the history can provide valuable diagnostic information.

Symptoms and conditions

Patient descriptions

Paroxysmal nocturnal dyspnea

Occurs 2–4 hours after falling asleep, causes the patient to sit upright or stand, and resolves over several minutes

Palpitations

Fluttering, skipping, pounding heartbeat; differentiate between fast and sustained versus isolated beats

Orthopnea

Shortness of breath when lying flat, typically measured by the number of pillows needed to sleep

Sleep apnea

Loud snoring, or periods of interrupted breathing

Pulmonary embolism

Usually acute onset of dyspnea

Cardiac syncope