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Diagnostic Coronary Angiography

The ability to directly visualize arteries with an injection of a radiopaque contrast agent was a seminal advance in the history of modern medicine and led directly to the development of the concept of transluminal angioplasty (first performed in 1964), coronary artery bypass grafting (CABG; first performed in 1967), per­cutaneous transluminal peripheral balloon angioplasty (first performed in 1974), and percutaneous coronary intervention (PCI; first performed in…

Cardiac Computed Tomography and Magnetic Resonance Imaging

The past decade has seen rapid development in cardiovascular imaging technologies coupled with novel clinical applications. Noninvasive cardiac imaging technologies currently allow for assessment of cardiac morphology, function, perfusion, and metabolism. Both cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging have interesting and unique advantages compared with alternate imaging modalities. Understanding the applications and limitations of these modalities will permit their optimal and efficient…

Stress Testing and Nuclear Imaging

Stress ECG and stress imaging studies are widely used noninvasive procedures that provide important information on cardiac function and the presence of hemodynamically significant coronary artery disease (CAD). The correct use of stress testing is critically important for the cost-effective management of patients with known or suspected CAD. When the most appropriate procedure is performed, it provides important diagnostic and prognostic information that determines the optimal…

Echocardiography

Echocardiography is a highly reproducible, safe, and widely available noninvasive imaging technique integral to the practice of modern clinical cardiology. With the use of high-frequency ultrasound to image cardiac and great vessel structure and blood flow, this method provides definitive anatomic and hemodynamic information crucial to the diagnosis and management of patients with a wide range of cardiac and vascular conditions. Although often considered a mature…

Chest Radiography

Technical Aspects Chest radiography was one of the first clinical studies to use x-rays, which were discovered in 1895 by Wilhelm Conrad Roentgen. X-rays are typically generated by passing a current across a diode, which results in the generation of electrons. The electron beam is aimed at a metal anode, and the resultant interaction produces x-ray photons. The x-ray beam diverges as it exits from the…

Electrocardiography

It is now >100 years since the Dutch physiologist Willem Einthoven recorded the first ECG in humans. Although the number of recording leads has increased from 3 leads to at least 12 leads, and the recording instruments have evolved into sophisticated automated digital recorders capable of recording, measuring, and interpreting the ECG waveform, the basic principles underlying the ECG are unchanged. The electrocardiograph is basically a…

Stem Cell Therapies for Cardiovascular Disease

Myocardial infarction and congestive heart failure are the leading causes of morbidity and mortality worldwide, despite great therapeutic achievements in the treatment of cardiovascular diseases. The inability of the heart to regenerate lost cardiac muscle, coupled with a robust fibrotic repair response, contribute to adverse ventricular remodeling and decline in postinjury cardiac function. Consequently, much of the research of the last three decades has focused on…

Cardiovascular Epidemiology and Risk Prediction Models

Cardiovascular epidemiology studies the determinants and distribution of cardiovascular disease (CVD). The overarching goal of CVD epidemiology is to reduce the incidence and prevalence of CVD within the population. Cardiovascular epidemiology has provided vital bidirectional connections between basic mechanistic science and clinical research. Through these types of investigations, our understanding of the extent of CVD and its natural history, mechanisms, and underlying pathophysiology is expanding greatly,…

Effects of Exercise on Cardiovascular Health

Although there has been a 25.3% decline in cardiovascular disease (CVD) mortality between 2004 and 2014, coronary heart disease (CHD) is still the leading cause of mortality and morbidity in the United States. It is estimated that >92 million American adults have ≥1 type of CVD. Physical inactivity is a global issue, identified by the World Health Organization (WHO) as the fourth leading risk factor for…

Genetics in Cardiovascular Disease

In 1953, Watson and Crick published their landmark paper on the molecular structure of nucleic acids and a particularly prescient comment was made: “It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.” The pace of technological innovation and our resulting understanding of the relationship of genetics to human disease continues to increase…

The History and Physical Examination

The ability to determine whether disease is present or absent—and how that patient should be treated—is the ultimate goal for clinicians who evaluate patients with suspected heart disease. Despite the number of diagnostic tests available, the importance of a careful history and physical examination has never been greater. Opportunities for errors in judgment are abundant, and screening patients for coronary risk using a broad and unfocused…

Basic Anatomy and Embryology of the Heart

Origins of Cardiac Precursor Populations Heart development begins as the primary germ layers—ectoderm, mesoderm, and endoderm—are induced and progressively changed to various cell types during the morphogenetic process of gastrulation. Combinatorial networks of intercellular signaling events cooperate with massive tissue migrations and internalizations to lay out the basic body plan of the vertebrate embryo. Mesoderm-derived cardiac precursors are among the first cell populations to internalize, coalescing…

Acquired Heart Disease

Structure of Coronary Arteries The coronary arteries are susceptible to atherosclerosis as well as its complications, particularly intravascular thrombosis, often resulting in myocardial infarction. Atherosclerosis is a form of arteriosclerosis characterized by initial involvement of the inner layer of the arterial wall, or intima. The intimal localization of early atheromas helps to differentiate the atherosclerosis type from other forms of arteriosclerosis, such as Mönckeberg's medial sclerosis…

Congenital Heart Disease

Physical Examination Although many forms are not seen in adult patients, cardiologists often do see simple clues to the diagnosis of certain forms of congenital heart disease (CHD), usually acyanotic or cyanotic and postoperative. Any child with or suspected with CHD should be seen by a pediatric cardiologist at an institution with interventional pediatric cardiologists and cardiac surgeons. Adult patients with CHD should be seen and…

Embryology

Early Embryonic Development In humans, as in most other primates, fertilization takes place in the distal part of the uterine tube, near its fimbriated end, about 12 to 24 hours after ovulation. The fertilized ovum, or zygote, is transported to the uterus by rhythmic contractions of the tube, aided by the action of the cilia of the epithelium. During this passage down the uterine tube, which…

Imaging

Radiology and Catheter-Based Angiocardiography Radiology Radiologic examination is an essential part of the evaluation of cardiac disease. The size of the heart and identification of chamber enlargement and pericardial, cardiac, and coronary calcification, as well as information on heart function and hemodynamics, can be determined from chest radiography, fluoroscopic examination, and angiocardiographic observations. The myocardium, valves, and other heart structures have similar radiodensity and therefore cannot…

Physiology

Cardiovascular Examination Events in the Cardiac Cycle: Left Ventricle The events occurring during the cardiac cycle are driven by the left ventricular (LV) pressure. The mitral valve closes and results in the first heart sound (S 1 ) when LV pressure rises above left atrial (LA) pressure (see Plate 2-1 ). The aortic valve opens when LV pressure rises above aortic diastolic pressure and is the…

Anatomy

Thorax Before describing the anatomy of the heart, it is helpful to review other anatomic features of the thoracic cavity and organs. The thorax proper constitutes the upper part of the body or trunk, with a shape between a barrel and a truncated cone that is functionally favorable. Although the intrathoracic pressure is often subatmospheric, the chest wall is still able to retain its integrity by…

Tackling the Problem of Adverse Ventricular Remodeling After Myocardial Infarction

Introduction Improvement in the acute treatment of myocardial infarction (MI) has made it possible for many patients to survive an initial MI and subsequently be exposed to the risk of recurrent MI and/or of heart failure (HF). The acute ischemic and reperfusion myocardial injury (see Chapter 24 ), as well as the acute hemodynamic effects of MI (see Chapter 25 ) and the potential complications of…

Clinical Practice/Controversy: Antiplatelet Therapy After Myocardial Infarction

Introduction Myocardial infarction (MI) is caused by atherothrombosis (see Chapter 3 ), with platelets playing a pivotal role in the initial onset of MI and its recurrence. Antiplatelet therapy targets this key element in the pathobiology of cardiovascular ischemic events. Patients who have suffered an MI have a sustained heightened risk for recurrent ischemic events and therefore have the potential to benefit from long-term antiplatelet therapy…