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Manual of Cardiac Diagnosis
Kanu Chatterjee
CHAPTER 1:
History
THE HISTORY
General Approach
Analysis of Symptoms
Chest Pain or Discomfort
Dyspnea
Palpitation
Syncope
Edema
Cough
Hemoptysis
CHAPTER 2:
Physical Examination
GENERAL APPEARANCE
Examination of the Skin
Examination of the Musculoskeletal System
MEASUREMENT OF ARTERIAL PRESSURE
Examination of the Jugular Venous Pulse
Estimation of Jugular Venous Pressure
Jugular Venous Pulsations
Arterial Pulse
Examination of the Precordial Pulsation
AUSCULTATION
Third (S3) and Fourth (S4) Heart Sounds
Pericardial Knock
Ejection Sounds
Midsystolic Click
Early Diastolic High-frequency Sounds
Artificial Valve Sounds
Auscultation of Heart Murmurs
Ejection Systolic Murmurs
Innocent Murmurs
Pulmonary Outflow Obstruction
Regurgitant Murmurs
Diastolic Murmurs
Early Diastolic Murmurs
Mid-diastolic Murmurs
Mitral Stenosis
Tricuspid Stenosis
Austin Flint Murmur
Carey Coombs Murmur
Continuous Murmurs
CHAPTER 3:
Plain Film Imaging of Adult Cardiovascular Disease
INTRODUCTION
CHEST FILM TECHNIQUE
OVERVIEW OF CARDIOMEDIASTINAL ANATOMY
CARDIAC ANATOMY ON CHEST RADIOGRAPHS
CARDIAC CHAMBER ENLARGEMENT
Left Ventricular Enlargement
Right Ventricular Enlargement
Left Atrial Enlargement
Right Atrial Enlargement
RADIOGRAPHIC MANIFESTATIONS OF CONGESTIVE HEART FAILURE
CARDIAC CALCIFICATIONS
ACQUIRED VALVULAR HEART DISEASE
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Regurgitation
Pulmonary Valve Stenosis
Pulmonary Valve Insufficiency
Tricuspid Insufficiency
PERICARDIAL DISORDERS
Pericardial Effusion
Pericardial Cysts
Congenital Absence of the Pericardium
CHAPTER 4:
Electrocardiogram
INTRODUCTION
BASIS OF ELECTROCARDIOGRAPHY
COMPONENT PARTS OF THE ELECTROCARDIOGRAM
LEAD SYSTEMS USED TO RECORD THE ELECTROCARDIOGRAM
COMMON ELECTRODE MISPLACEMENTS
Left Arm
Right Leg Electrode
OTHER LEAD SYSTEMS
A Systematic Way of Looking at the Interpretation of the Electrocardiogram
A Systematic Way of Looking at the Rhythm
IDENTIFICATION OF ATRIAL ACTIVITY
CHARACTERIZATION OF QRS COMPLEX
ST–T WAVE ABNORMALITIES
“U” WAVE
QT INTERVAL
Abnormalities Suggesting Right or Left Atrial Enlargement, Dilatation, or hypertrophy
CHAPTER 5:
ECG Exercise Testing
INTRODUCTION
BEFORE THE TEST
Indications for Exercise Testing (Patient Selection)
Exercise Testing for Diagnosis
Exercise Testing for Prognosis
Class I (Definitely Appropriate)
Class IIb (May Be Appropriate)
Exercise Testing Patients presenting with Acute Coronary Syndromes
Exercise Testing Patients with Heart Failure
Exercise Testing Patients after Myocardial Infarction
Contraindications to Exercise Testing
METHODOLOGY OF EXERCISE TESTING
Safety Precautions and Equipment
Pretest Preparations
Exercise Test Modalities
Bicycle Ergometer versus Treadmill
Exercise Protocols
Add-ons to the Exercise Test
DURING THE TEST
Physiology Review
Oxygen Consumption
Metabolic Equivalents Term (MET)
Acute Cardiopulmonary Response to Exercise
Central Factors
Peripheral Factors (Arteriovenous Oxygen Difference)
Autonomic Control
Neural Control Mechanisms
Autonomic Modulation during Immediate Recovery from Exercise
Clinical Correlations
Hemodynamics
Heart Rate
Exercise Capacity
Recovery after Exercise
Women
Diagnostic Scores
AFTER THE TEST
Ecg Interpretation: Factors Determining Prognosis
ST-segment Analysis
Silent Ischemia
Exercise-induced Arrhythmias
Prognostic Utilization of Exercise Testing
SCREENING
CONCLUSION
CHAPTER 6:
Left Ventricle
INTRODUCTION
SYSTOLIC FUNCTION
Left Ventricular Ejection Fraction
Linear Measurements in the Assessment of LV Function
Components of Ejection Fraction
End-systolic Volume
Physiologic Basis of Left Ventricular End-systolic Volume
Left Ventricular End-systolic Volume and Clinical Outcomes
End-diastolic Volume
CONTRAST-ENHANCED ECHOCARDIOGRAPHY
OTHER ECHO-DERIVED INDICES OF LV SYSTOLIC FUNCTION
STRAIN-DERIVED INDICES
RECOGNIZING THE ETIOLOGY OF CARDIAC DYSFUNCTION
DILATED CARDIOMYOPATHY
Echocardiographic Findings
Ischemic Cardiomyopathy
HYPERTROPHIC CARDIOMYOPATHY
Primary Hypertrophic Cardiomyopathy
Echocardiographic Features
Secondary Hypertrophic Cardiomyopathy
Echocardiographic Features
RESTRICTIVE CARDIOMYOPATHY
Diabetes Mellitus
Amyloid Infiltrative Cardiomyopathy35
Endomyocardial Fibrosis
LEFT VENTRICULAR NONCOMPACTION
VISUAL QUALITATIVE INDICATORS OF SYSTOLIC DYSFUNCTION
Left Ventricular Mass
DIASTOLIC FUNCTION
Technical Aspects of Recording and Measurement of Diastolic Parameters
Transmitral Flow
Propagation Velocity of the Early Diastolic Flow in the Left Ventricle
Pulmonary Venous Flow
Doppler Tissue Imaging of Mitral Annular Motion in Diastole
Left Atrial Volume and Index
Types of Diastolic Dysfunction
Impaired Relaxation of the Left Ventricle
Pseudonormal Filling
Restrictive Filling (Grades 3 and 4 Diastolic Dysfunction)
Evaluation of Left Ventricular Filling Pressures
Formulae that Attempt to Provide Quantitation of LV Filling Pressure
CONCLUSION
CHAPTER 7:
Ventricular Function—Assessment and Clinical Application
INTRODUCTION
DETERMINANTS OF LEFT VENTRICULAR PERFORMANCE
Preload
Afterload
Ventricular–Arterial Coupling
Contractile State
Measures of Maximum Rate of Pressure Development
Velocity of Contractile Element
LEFT VENTRICULAR PUMP FUNCTION
Ventricular Function Curve
Ejection Fraction
Techniques for Assessment of Left Ventricular Ejection Fraction
Echocardiography
Cardiac Computed Tomography
Nuclear Scintigraphy
Cardiac Magnetic Resonance Imaging
Contrast Ventriculography
Pressure–Volume Relations
HEART RATE
DIASTOLIC FUNCTION
Techniques of Measurement of Diastolic Function
Echocardiography
Nuclear Scintigraphy
Cardiac Magnetic Resonance Imaging
Left Ventricular Functional Assessment during Stress
RIGHT VENTRICULAR FUNCTION
CONCLUSION
CHAPTER 8:
Transthoracic Echocardiography
INTRODUCTION
CHAMBER QUANTITATION
DOPPLER ECHO
DIASTOLIC FUNCTION
PULMONARY HYPERTENSION
PERICARDIAL DISEASE
VALVULAR HEART DISEASE
Aortic Stenosis
Aortic Regurgitation
Mitral Stenosis
Mitral Regurgitation
Tricuspid Stenosis
Tricuspid Regurgitation
Pulmonic Stenosis
Pulmonic Regurgitation
INFECTIVE ENDOCARDITIS
INTRACARDIAC MASSES
CONTRAST ECHOCARDIOGRAPHY
CARDIAC RESYNCHRONIZATION THERAPY
CHAPTER 9:
Stress Echocardiography
INTRODUCTION
USING STRESS ECHOCARDIOGRAPHY IN CLINICAL DECISIONS
Pathophysiology Involved in Stress Echo
Stress Echocardiography and the Diagnosis of Coronary Artery Disease
Exercise Stress Echo (ESE)
Pharmacologic Stress Echo
Stress Echocardiography and Estimating Risk or Prognosis in Coronary Artery Disease
Assessing Prognosis—Introduction
Exercise Stress Echo (ESE) and Prognosis in Coronary Artery Disease
Dobutamine Stress Echo (DSE) and Prognosis in Coronary Artery Disease
Stress Echo and Myocardial Viability
Stress Echo and the Assessment of Hemodynamics of Valvular Disease
FUTURE OF STRESS ECHO
CHAPTER 10:
Transesophageal Echocardiography
INTRODUCTION
HISTORY
GUIDELINES
PERFORMANCE
SAFETY
VIEWS
MAJOR CLINICAL APPLICATIONS
Source of Embolism
Masses
Passageways for Paradoxic Embolization
Propensity for Thrombus Formation
Atrial Fibrillation
Endocarditis
STRUCTURAL VALVE ASSESSMENT
ACUTE AORTIC DISSECTION
PROCEDURAL ADJUNCT OR INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY
CONCLUSION
CHAPTER 11:
Real-time Three-dimensional Echocardiography
INTRODUCTION
TECHNIQUE
CLINICAL APPLICATIONS
Determination of Left Ventricular Volumes and Function
Determination of Regional Wall Motion and Dyssynchrony
Applications to Stress Imaging
Myocardial Contrast Imaging and Quantification of Perfusion
Determination of Left Ventricular Mass
Assessment of Right Ventricular Volumes and Function
Assessment of Left and Right Atria
Assessment of Valvular Disorders
Mitral Valve
Aortic Valve
Other Valves
Prosthetic Valves
Miscellaneous Conditions
Guidance of Percutaneous Procedures
FUTURE DIRECTIONS
LIMITATIONS
CHAPTER 12:
Intravascular Coronary Ultrasound and Beyond
INTRODUCTION
INTRAVASCULAR ULTRASOUND
Basics of IVUS and Procedures
Normal Vessel Morphology
IVUS Measurements
Tissue Characterization
Insights into Plaque Formation and Distribution
Interventional Applications
Preinterventional Imaging
Balloon Angioplasty
Guidance of Procedures
Bare Metal Stent Implantation
Guidance of Procedures
Insights into Long-term Outcomes
Drug-eluting Stent Implantation
Guidance of Procedures
Insights into Long-term Outcomes
Safety
Future Directions
OPTICAL COHERENCE TOMOGRAPHY
Imaging Systems and Procedures
Image Interpretation
Clinical Experience
Detection of Vulnerable Plaque
Safety and Limitations
Future Directions
ANGIOSCOPY
Imaging Systems and Procedures
Image Interpretation
Clinical Experience
Detection of Vulnerable Plaque
Safety and Limitations
Future Directions
SPECTROSCOPY
Imaging Systems and Procedures
Experimental Data
Clinical Experience
Safety and Limitations
Future Directions
CHAPTER 13:
Cardiovascular Nuclear Medicine— Nuclear Cardiology
INTRODUCTION
PATHOPHYSIOLOGIC CONSIDERATIONS
Lesion Severity
Owing to Stress Testing Deficiencies
The Ischemic Cascade
Stress Testing
Dynamic Exercise Testing
Pharmacologic Stress Testing
MYOCARDIAL PERFUSION IMAGING
Image Acquisition Protocols
Image Display
Gated—Myocardial Perfusion Imaging
Interpretation
Diagnostic Accuracy and Cost Effectiveness
Indicators of Multivessel Coronary Artery Disease and Related Risk
Nonperfusion Indicators of CAD-Related Risk— Lung/Heart Ratio
Transient Ischemic Dilation
Dense Cavitary Photopenia
Clinical Applications of Myocardial Perfusion Imaging in the Emergency Department—with Acute Chest Pain Syndromes35,36
Unstable Angina/Non-ST Elevation Myocardial Infarction
Follow-Up after Initial ACS Evaluation Strategy
RISK ASSESSMENT OF GENERAL AND SPECIFIC PATIENT POPULATIONS
General Principles
Preoperative Evaluation for Noncardiac Surgery
The Evaluation of CAD in Women
Diabetics
Myocardial Perfusion Imaging in the Elderly
Postrevascularization
Heart Failure47
Appropriateness Criteria for Perfusion Imaging
POSITRON EMISSION TOMOGRAPHY PERFUSION AND METABOLISM
PET and SPECT Technology
IMAGING MYOCARDIAL VIABILITY
The Principles
NonScintigraphic Imaging Options
Scintigraphic Imaging Options—Perfusion Related
Scintigraphic Imaging Options—Metabolism Based
IMAGING PERFUSION
Rubidium (82Rb) Chloride
Nitrogen (13N) Ammonia
QUANTITATION OF REGIONAL CORONARY FLOW AND FLOW RESERVE
BLOOD POOL IMAGING—EQUILIBRIUM RADIONUCLIDE ANGIOGRAPHY AND FIRST PASS RADIONUCLIDE ANGIOGRAPHY
Guidelines
Introduction
Labeling the Blood Pool
FIRST PASS CURVE ANALYSIS
Ventricular Function
Left-to-Right Shunt Analysis
EQUILIBRIUM GATED IMAGING—ERNA
THE VALUE OF FUNCTIONAL IMAGING
PHASE ANALYSIS
IMAGING MYOCARDIAL SYMPATHETIC INNERVATION
RADIATION CONCERNS
CHAPTER 14:
Cardiac Computed Tomography
INTRODUCTION
TECHNICAL ASPECTS
Basic Principles of Computed Tomography
Radiation
Image Analysis
Image Quality and Artifacts
Contrast
CORONARY ARTERY DISEASE
Noncontrast CT and Coronary Calcifications
Contrast CT and Coronary Angiography
Appropriate Indications
Coronary Stent
Coronary Bypass Grafts
Anomalous Coronary Arteries
Other Coronary Findings
MYOCARDIUM AND CHAMBERS
PULMONARY VEINS
CARDIAC VEINS
VALVULAR DISEASE
PERICARDIUM
MASSES
Malignant Cardiac Neoplasm
NonCancerous Masses
Ventricular Thrombus
Hiatal Hernia
Lipomatous Hypertrophy of Intra-Atrial Septum
INCIDENTAL FINDINGS
FUTURE
CHAPTER 15:
Cardiovascular Magnetic Resonance
INTRODUCTION
Information Provided by Cardiovascular Magnetic Resonance
DIAGNOSIS OF EPICARDIAL CORONARY ARTERY STENOSIS
ASSESSMENT OF GLOBAL AND REGIONAL LEFT VENTRICULAR FUNCTION AT REST AND DURING INOTROPIC STRESS
MYOCARDIAL PERFUSION IMAGING
CARDIOVASCULAR MAGNETIC RESONANCE CORONARY ANGIOGRAPHY
UNRECOGNIZED MYOCARDIAL INFARCTION
DILATED CARDIOMYOPATHY
Etiology
Coronary Artery Stenoses
Myocarditis
Prognosis
Ischemic Dilated Cardiomyopathy
Prognosis in Idiopathic Dilated Cardiomyopathy
HYPERTROPHIC CARDIOMYOPATHY
Diagnosis
Prognosis
Correlative Findings
RESTRICTIVE CARDIOMYOPATHY
Diagnosis
Etiology
CARDIOVASCULAR MAGNETIC RESONANCE-GUIDED THERAPY
VALVULAR HEART DISEASE
Valve Stenosis
Valvular Regurgitation
DISEASES WITH RIGHT VENTRICULAR PREDOMINANCE
INTRACARDIAC SHUNT
Pulmonary Artery Hypertension
Arrhythmogenic right ventricular cardiomyopathy
MISCELLANEOUS CONDITIONS
Cardiac Thrombi
Cardiac Masses
Left Ventricle Trabeculations and Noncompaction
Pericardial Disease
CHAPTER 16:
Molecular Imaging of Vascular Disease
INTRODUCTION
MOLECULAR IMAGING FUNDAMENTALS
MOLECULAR IMAGING MODALITIES
MOLECULAR IMAGING OF VASCULAR DISEASE PROCESSES
Atherosclerosis
Inflammation
Oxidative Stress
Neovascularization
Apoptosis
Calcification
Thrombosis
Clinical Imaging of Fibrin-Rich Thrombi
Preclinical Thrombus Imaging Strategies
Aneurysm
Clinical Aneurysm Inflammation Imaging
Preclinical Aneurysm Imaging Investigations
Vascular Injury
Outlook
ACKNOWLEDGMENT
CHAPTER 17:
Cardiac Hemodynamics and Coronary Physiology
INTRODUCTION
CARDIAC CATHETERIZATION—THE BASICS
Right Heart Catheterization
CATHETERIZATION COMPUTATIONS
Cardiac Output
Fick Method
Indicator Dilution Method
Vascular Resistance
Intracardiac Shunt Ratio
CARDIAC CYCLE PRESSURE WAVEFORMS
Atrial Pressures
Ventricular Pressures
HEMODYNAMICS IN VALVULAR HEART DISEASE
Aortic Stenosis
Aortic Regurgitation
Chronic Aortic Regurgitation
Acute Aortic Regurgitation
Mitral Stenosis
Mitral Regurgitation
Pulmonic Stenosis
Pulmonic Regurgitation
Tricuspid Stenosis
Tricuspid Regurgitation
HEMODYNAMICS IN CARDIOMYOPATHY
Hypertrophic Obstructive Cardiomyopathy
Restrictive Cardiomyopathy
HEMODYNAMICS IN PERICARDIAL DISEASE
Constrictive Pericarditis
Cardiac Tamponade
CORONARY HEMODYNAMICS
Fractional Flow Reserve
Coronary Flow Reserve
Index of Microcirculatory Resistance
CHAPTER 18:
Cardiac Biopsy
INTRODUCTION
HISTORY AND DEVICES
TECHNIQUES
SAFETY AND COMPLICATIONS
ANALYSIS OF EMB TISSUE
Light Microscopy and Stains
Cardiotropic Virus Detection
INDICATIONS
DISEASE STATES
EMB in Cardiomyopathy
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Restrictive Cardiomyopathy
Arrhythmogenic Right Ventricular Cardiomyopathy
EMB in Special Cardiac Disease States
Sarcoidosis
Amyloidosis
Hemochromatosis
Storage Diseases and Myopathy
Drug Toxicity
Neoplasms
Cardiac Infections
CARDIAC TRANSPLANTATION
SUMMARY
CHAPTER 19:
Swan-Ganz Catheters: Clinical Applications
INTRODUCTION
HISTORICAL PERSPECTIVE AND EVOLUTION OF CATHETER DESIGNS
PLACEMENT OF BALLOON FLOTATION CATHETERS
NORMAL PRESSURES AND WAVEFORMS
ABNORMAL PRESSURES AND WAVEFORMS
CLINICAL APPLICATIONS
Cardiac Catheterization Laboratory
Acute Coronary Syndromes
Non-Acute Coronary Syndrome
Chronic Heart Failure
Pulmonary Hypertension
INDICATIONS FOR PULMONARY ARTERY CATHETERIZATION
COMPLICATIONS
CONCLUSION
CHAPTER 20:
Coronary Angiography and Catheter-based Coronary Intervention
INTRODUCTION
INDICATIONS FOR CORONARY ANGIOGRAPHY
CONTRAINDICATIONS FOR CORONARY ANGIOGRAPHY
PATIENT PREPARATION
SITES AND TECHNIQUES OF VASCULAR ACCESS
Femoral Artery Approach
Transradial Approach
Brachial Artery Approach
CATHETERS FOR CORONARY ANGIOGRAPHY
Judkins-Type Coronary Catheters
Amplatz-Type Catheters
Multipurpose Catheter
CATHETERS FOR BYPASS GRAFTS
Transradial Specific Catheters
ARTERIAL NOMENCLATURE AND EXTENT OF DISEASE
ANGIOGRAPHIC PROJECTIONS
NORMAL CORONARY ANATOMY
Left Main Coronary Artery
Left Anterior Descending Artery
Left Circumflex Artery
Right Coronary Artery
Right Dominant Coronary Circulation
Left Dominant Coronary Circulation
Co-Dominant or Balanced Coronary Circulation
Coronary Collateral Circulation
CONGENITAL ANOMALIES OF THE CORONARY CIRCULATION
Anomalous Pulmonary Origin of the Coronary Arteries
Anomalous Coronary Artery from the Opposite Sinus
Coronary Artery Fistulae
Congenital Coronary Stenosis or Atresia
Myocardial Bridging
GENERAL PRINCIPLES FOR CORONARY AND/OR GRAFT CANNULATION
Left Main Coronary Artery Cannulation
Right Coronary Artery Cannulation
Coronary Bypass Graft Cannulation
Saphenous Vein Grafts
Internal Mammary Artery Grafts
Gastroepiploic Artery
Standardized Projection Acquisition
FLUOROSCOPIC IMAGING SYSTEM
CHARACTERISTICS OF CONTRAST MEDIA
Contrast Media Reactions
CONTRAST-INDUCED RENAL FAILURE
ACCESS SITE HEMOSTASIS
COMPLICATIONS OF CARDIAC CATHETERIZATION
Access Site Complications
Other Complications
LESION QUANTIFICATION
Quantitative Angiography
Lesion Complexity
Lesion Length
Ostial Lesions
Bifurcation Lesions
Angulated Lesions
DEGENERATED SAPHENOUS VEIN GRAFTS
LESION CALCIFICATION
Thrombus
Total Occlusion
Coronary Perfusion
PHYSIOLOGIC ASSESSMENT OF ANGIOGRAPHICALLY INDETERMINATE CORONARY LESIONS
Fractional Flow Reserve
CLINICAL USE OF TRANSLESIONAL PHYSIOLOGIC MEASUREMENTS
NONATHEROSCLEROTIC CORONARY ARTERY DISEASE AND TRANSPLANT VASCULOPATHY
Coronary Artery Spasm
Spontaneous Coronary Artery Dissection
Vasculitis
Transplant Vasculopathy
POTENTIAL ERRORS IN INTERPRETATION OF THE CORONARY ANGIOGRAM
Inadequate Vessel Opacification
Catheter Induced Spasm
Incomplete Study
Coronary Anomalies
Total Occlusion of a Coronary Artery
Eccentric Stenoses
Superimposition of Vessels
Microchannel Recanalization
PERCUTANEOUS CORONARY INTERVENTION
PHARMACOTHERAPY FOR PCI
Antiplatelet Therapy
Aspirin
Thienopyridines
IIb/IIIa Platelet Receptor Inhibitors
PARENTERAL ANTICOAGULANT THERAPY
Heparin
Enoxaparin
Bivalirudin
EQUIPMENT FOR CORONARY INTERVENTIONS
Guide Catheters
Guidewire
Balloons
General Use Balloons
Other Specialized Intracoronary Balloons
Cutting Balloon
Perfusion Balloon Catheter
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
CORONARY STENTS
TYPES OF STENTS
STENT DEPLOYMENT
ADJUNCTIVE CORONARY INTERVENTIONAL DEVICES
Thrombectomy
Rotational Coronary Atherectomy
Directional Coronary Atherectomy
EMBOLIC PROTECTION DEVICES FOR VENOUS BYPASS GRAFT PCI
Distal Embolic Filters
Distal Occlusion Devices
Proximal Occlusion Devices
CLINICAL OUTCOMES
DES versus BMS
PROCEDURAL SUCCESS AND COMPLICATIONS RELATED TO CORONARY INTERVENTION
COMPLICATIONS SPECIFIC TO PCI
Threatened or Acute Closure
Perforation
No-Reflow
Acute Thrombotic Closure
INDEX
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