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Antihypertensive Therapies

Introduction The formal classification and blood pressure (BP) threshold to define an individual as having hypertension continues to vary based on available evidence. The appraisal of such evidence by professional associations and societies has led to different BP thresholds adopted in guidelines worldwide. Given that the thresholds by which we define hypertension can and will continue to evolve, it is less helpful to think of hypertension…

Drugs for Ischemic Heart Disease

Introduction The contemporary management of patients with ischemic heart disease demands a sound understanding of the pathophysiologic precipitants of both angina pectoris and myocardial ischemia from which the principles of pharmacotherapy can be applied and tailored to the specific causes underlying these perturbations of myocardial oxygen supply and demand. This chapter details several broad classes of drug therapies directed at both symptom relief and ameliorating the…

Cardiovascular Disease in the Elderly

Aging is a normal physiological process associated with a decline in organ system function. Changes of cardiovascular physiology intertwine with pathophysiology of cardiovascular disease (CVD). Although disease should not be misconstrued as an inevitable consequence of aging, distinctions are often arbitrarily defined, and the difference between diminished biological reserve and overt dysfunction can be thought of as quantitative rather than qualitative. Although the role of genetics…

Cardiovascular Disease in Women and Vulnerable Populations

The US population continues to become more diverse, and because of this diversity there are challenges in providing good cardiovascular care. The emerging diversity necessitates a broader understanding of cardiovascular disease (CVD) in special and underserved populations. These populations include women, older adult patients, various ethnic groups, and an often forgotten population, the intellectually disabled. Looking at sex alone, in 2014, there were 125.9 million women…

Sleep Disorders and the Cardiovascular System

Normal Sleep Physiology The state of sleep is determined by an array of coordinated neuronal processes. Sleep is typically divided into stages based on electroencephalographic (EEG) features, eye movements (electrooculography), and muscle tone (electromyography). Stages N1 through N3 are collectively called nonrapid eye movement sleep. Stage N1 sleep is frequently associated with the perception of drowsiness and is characterized by EEG features of mild slowing and…

HIV and the Heart

HIV and AIDS affect >36 million people worldwide. Increased survival among HIV-infected persons who have access to effective combination antiretroviral therapy (ART) and rising rates of new diagnoses among older adults have resulted in growing numbers of older people living with HIV. Some cardiac manifestations more commonly seen before availability of effective ART, such as dilated cardiomyopathy (DCM), myocarditis, and pericarditis, are now relatively rare in…

Pulmonary Hypertension

Etiology and Pathogenesis Pulmonary hypertension (PH) is elevated pressure in the pulmonary arteries, which is hemodynamically defined as a mean pulmonary artery pressure (MPAP) of ≥25 mm Hg. It may occur in response to many different mechanisms. Regardless of how PH is uncovered, whether as part of a differential diagnosis or incidentally on an echocardiogram or right heart catheterization, a search for the etiology, and thus, the…

Cardiac Tumors and Cardio-Oncology

Cardiac Tumors Before the second half of the twentieth century, cardiac tumors were diagnosed almost exclusively at autopsy, and no treatment options existed for those rare instances of antemortem discovery. Despite advances in cardiac imaging that improve detection, cardiac tumors remain rare, although the advent of cardiopulmonary bypass has facilitated curative surgical therapy in selected cases. Clinical Presentation The clinical presentation of a cardiac tumor depends…

Connective Tissue Diseases and the Heart

Etiology and Pathogenesis Autoimmune rheumatic diseases include a wide variety of illnesses, such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), in which changes to both the innate and adaptive immune system lead to tissue damage. The etiologies of these diseases are believed to be multifactorial. Genetic susceptibility is believed to play an important role, but is not sufficient for the development of disease. Environmental…

Cardiovascular Manifestations of Endocrine Diseases

Endocrine system diseases generally affect multiple organ systems, because hormones secreted into the general circulation act on multiple tissues that are distant from their sources of synthesis and secretion. Nearly all hormones and accompanying hormonal disorders may be associated with a pathophysiological disarrangement of some component of the cardiovascular system. This chapter focuses on the most common disorders and those with the most important deleterious consequences…

Neuromuscular Diseases and the Heart

Neuromuscular disorders are a subset of neurology that affects the peripheral nervous system, including lower motor neuron projections from the spinal cord, spinal nerve root, peripheral nerve, neuromuscular junction, and muscle. A number of neuromuscular diseases have effects on the heart. Most often, diseases of muscles (myopathy), both acquired and hereditary, can affect cardiac muscle and therefore cause cardiomyopathy or conduction disease. Peripheral nerve disease can…

Cardiovascular Disease in Pregnancy

Cardiovascular conditions are among the most common causes of maternal mortality in the United States. As more women delay childbearing into their thirties and forties, the interaction among coronary disease, its risk factors, and pregnancy is becoming increasingly important in prenatal care. In addition, more women with congenital heart disease are reaching childbearing age. Thus, a multidisciplinary approach is needed to achieve optimal maternal and fetal…

Deep Vein Thrombosis and Pulmonary Embolism

Etiology and Pathogenesis Venous thromboembolism (VTE) is common and has an annual incidence of approximately 0.1% in the general population. VTE is a broad term used to include patients with both deep venous thromboembolism (DVT) and pulmonary embolism (PE). These conditions warrant consideration together because up to 90% of PEs are secondary to DVT in the iliac, femoral, or popliteal venous systems. Less common sources of…

Diseases of the Aorta

There is a wide spectrum of diseases that can affect the aorta. Aneurysmal disease is the second most frequent disease of the aorta after atherosclerosis. The most common location for aneurysmal disease is the infrarenal aorta, but it can also affect the thoracic, ascending, and arch portions of the aorta, as well as the iliac vessels. Typically, aneurysmal disease is a silent pathology that is found…

Carotid Artery Revascularization

Cerebrovascular accidents (CVAs) are a major cause of disability and death worldwide. There are two broad categories of stroke: hemorrhage and ischemia. Hemorrhage is characterized by bleeding within the closed cranial cavity, whereas ischemia is regarded as too little blood to supply the needed amount of oxygen and nutrients to a specific part of the brain. The morbidity caused by a CVA can be debilitating, causing…

Surgery for Peripheral Vascular Diseases

Peripheral vascular disease (PVD) encompasses the pathologies of both the arterial and the venous circulations. Advanced disease of either system can be debilitating and disabling. The clinical presentation and therapeutic choices for patients with PVD vary widely, depending on the vascular distribution involved and the severity of the disease. This chapter focuses on the common problems that require surgical intervention. Although PVD includes venous pathologies, these…

Interventional Approaches for Peripheral Arterial Disease

Charles Dotter and Melvin Judkins first introduced catheter-based interventions for atherosclerotic disease in 1964. Major technological advances now make interventions possible for a vast array of conditions, benefiting millions of patients with coronary, cerebral, or peripheral arterial disease. Percutaneous interventions have greatly expanded therapeutic options, often complementing and occasionally replacing drugs or surgery. This chapter reviews the indications for endovascular therapy for relatively common extracardiac arterial…

Renal Artery Stenosis and Renal Denervation

Obstructive disease in the renal arteries can decrease blood flow to the kidneys, which can result in activation of the renin-angiotensin system, hypertension, ischemic nephropathy, and other pathological changes. Technological advances, including intraarterial stenting, have generated enthusiasm for revascularization as a treatment for hypertension and progressive renal dysfunction caused by renal artery stenosis (RAS). However, there is no effect on mortality, and measurable beneficial outcomes (e.g.,…

Pericardial Disease: Diagnosis and Hemodynamics

Normal Pericardial Pathology and Physiology The pericardium can be conceptualized as a “balloon” with the heart being a fist pushed into it. The visceral pericardium adheres to the heart itself and is separated from the parietal pericardium by a space, the pericardial cavity. The entire structure is housed in the fibrous pericardium. The serosal space normally holds a small collection of approximately 50 mL of fluid that…

Pericardial Disease: Clinical Features and Treatment

The pericardium is a two-layered sac that encircles the heart ( Fig. 56.1 ). The visceral pericardium is a mesothelial monolayer that adheres to the epicardium. It is reflected back on itself at the level of the great vessels, where it joins the parietal pericardium, which is the tough fibrous outer layer. Under normal conditions, a small amount of fluid (~5–50 mL) separates the two layers and…