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Hypertensive crisis

1 What is a hypertensive crisis? Hypertensive crises have historically been classified as hypertensive emergency or hypertensive urgency, although the latter term is potentially misleading. When evaluating patients with severe elevations in blood pressure, the primary consideration in determining the need for rapid treatment is the presence of acute target-organ dysfunction. Target organs affected predominately include those of the cardiovascular, renal, or central nervous systems. Although…

Cardiac tumors

1 Which are more common, primary cardiac tumors or metastatic tumors to the heart? Overall, cardiac tumors are rare, and metastatic tumors to the heart, also called secondary tumors, are markedly more common than primary cardiac tumors. Metastatic involvement of the heart is reported to be 20 to 40 times more prevalent than primary cardiac tumors. Primary cardiac tumors are extremely rare, occurring in one autopsy…

Adult congenital heart disease

1 What are the three main types of atrial septal defects, and what are their associated anomalies? The three main types of atrial septal defects (ASDs) are secundum (80%), primum (15%), and sinus venosus (5%). The secundum ASD is a defect involving the floor of the fossa ovalis of the atrial septum. It usually presents as an isolated anomaly. The primum ASD is a defect at…

Hypercoagulable states

1 What is hypercoagulability? Hypercoagulability is a state of increased risk for thrombosis; it is also commonly called “thrombophilia.” Increased risk may dispose to venous, arterial, and microvascular thrombosis, and thrombosis risk is measured (and usually different) for both initial and recurrent events. There are inherited and acquired hypercoagulable states. Hypercoagulability is a predisposing factor separate from other risk factors for atherothrombotic disease (such as smoking…

Pulmonary embolism

1 Who first described pulmonary embolism? Pulmonary embolism (PE) was probably first reported in the early 1800s clinically, but Rudolf Virchow elucidated the mechanism by describing the connection between venous thrombosis and PE in the late 1800s. He also coined the term embolism . 2 How common are pulmonary emboli, and what is the mortality rate? PE is the third most common cardiovascular disease after stroke…

Deep vein thrombosis

1 What three primary factors promote venous thromboembolic (VTE) disease? Development of venous thrombosis is promoted by the following ( Virchow’s Triad ): Venous blood stasis. Injury to the intimal layer of the venous vasculature. Abnormalities in coagulation or fibrinolysis. 2 List the risk factors for thromboembolic disease. The numerous risk factors for thromboembolic disease include surgery, trauma, immobility, cancer, pregnancy, prolonged immobilization, estrogen-containing oral contraceptives…

Hemorrhagic stroke and cerebral venous sinus thrombosis

1 What are the three basic causes of stroke? The most common basic causes of stroke are ischemic stroke and hemorrhagic stroke. Less commonly, cerebral venous sinus thrombosis (CVST) can also lead to stroke. Ischemic stroke can be due to large vessel atherosclerosis, intrinsic small vessel disease, and cardioembolic stroke. Hemorrhagic stroke includes intracranial hemorrhage and subarachnoid hemorrhage (SAH). Hemorrhagic stroke and CVST are addressed in…

Ischemic stroke

1 What is a stroke? Stroke is a focal disturbance of blood flow into or out of the brain, classified primarily as ischemic (87%) or hemorrhagic (13%). Stroke is not a single disease, rather the end result of many different pathophysiologies leading to either cerebrovascular occlusion or rupture. The key clinical feature of a stroke is very rapid symptom onset: “it hit me like a ton…

Carotid artery disease

1 Describe extracranial carotid artery anatomy. What are the common causes of carotid artery disease? The carotid arteries originate as the common carotid artery (CCA) from the brachiocephalic trunk on the right side and from the aortic arch on the left side, ascend up the neck, and bifurcate into the external carotid artery (ECA) and internal carotid artery (ICA). The carotid bulb is a dilated portion…

Aortic dissection

1 What is the definition of an aortic dissection? The classic feature of aortic dissection is a tear in the intimal wall with subsequent subintimal hematoma formation, which can then propagate proximally and/or distally. However, it is now recognized that primary hemorrhage in the medial wall itself—without an inciting intimal tear—occurs more commonly than previously believed. In both instances, the result is the creation of a…

Aortic aneurysms

1 What are the common pathologies affecting the thoracic aorta? Aneurysm and dissection are the most common pathologies affecting the thoracic aorta. The incidence of aneurysm is probably underestimated. A Swedish population study demonstrated incidence of 16.3 per 100,000 per year in men and 9.1 per 100,000 per year in women, with trends demonstrating an increase in diagnoses. Congenital aortic diseases that may present in adulthood…

Sleep apnea and the heart

1 How much sleep is typically needed? The American Academy of Sleep Medicine Consensus statement recommends 7 or more hours of sleep regularly for optimal health including cardiovascular health. Sleeping 7 or less hours of sleep is associated with an increased risk for weight gain and obesity, diabetes, hypertension (HTN), heart disease, and stroke. Average sleep of less than 6 hours or more than 9 hours…

Heart disease in women

1 Are there sex differences in the epidemiology of acute coronary syndromes? Women comprise approximately 40% of all acute coronary syndrome presentations. According to the Heart Disease and Stroke Statistics reported by the American Heart Association, in 2016, there were 661,000 acute coronary syndrome principal diagnosis discharges, of which an estimated 409,000 were men and 252,000 were women. Women present with coronary artery disease up to…

Heart disease in pregnancy

1 What cardiac physiologic changes occur during pregnancy? Hormonal changes cause an increase in both plasma volume (from water and sodium retention) and red blood cell volume (from erythrocytosis) during a normal pregnancy ( Fig. 52.1 ). A disproportionate increase in plasma volume explains the physiologic anemia of pregnancy. Maternal heart rate (HR) increases throughout the 40 weeks, mediated partially by increased sympathetic tone and heat…

Heart disease in the elderly

1 Who are “the elderly”? The average US life expectancy is 76 years for men and 81 years for women. Elderly in the context of most clinical guidelines refers to patients age 65 years or older. There is variation arising from different age limits used in clinical trials such as 75 years or older or 80 years or older to describe very old, as well as…

Cardiovascular sequelae of COVID-19

1 What is the pathophysiology of COVID-19 and its effects on the cardiovascular system? Coronavirus Disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus infects its host via the spike subunit of SARS-CoV-2, which engages angiotensin-converting enzyme-2 (ACE2) on the surface of cells as an entry receptor ( Fig. 50.1 ). SARS-CoV-2 has tropism for the respiratory tract, given…

Cocaine and the heart

1 How common is cocaine use in the United States? Cocaine is one of the most commonly used illicit drugs in the United States. Between 2011 and 2015, there was an increased prevalence of cocaine use in individuals aged 12 and older of 20%. Additionally, in 2015 alone about 968,000 individuals aged 12 and older initiated cocaine use. This was the largest increase in cocaine use…

Cardio-oncology

1 What is type I versus type II cardiotoxicity? Type I drugs cause irreversible cell loss and cumulative dose-related cardiotoxicity. Anthracyclines are type I drugs. Clinical manifestations of irreversible damage may not present for years owing to compensatory mechanisms. Stress factors such as hypertension and coronary artery disease (CAD) might later lead to cardiac decompensation. Other type I drugs include mitoxantrone and cyclophosphamide. Type II drugs…

Cardiac manifestations of rheumatologic disorders

1 What is the leading cause of mortality in patients with rheumatoid arthritis (RA) and what are the most common cardiac manifestations of RA? Ischemic heart disease is the leading cause of mortality in patients with RA. Compared to the general population, patients with RA have a 50% increased risk of cardiovascular mortality. Other common cardiac manifestations of RA include pericarditis, myocarditis, and valvular thickening resulting…

Cardiac manifestations of HIV

1 How have the cardiac manifestations of human immunodeficiency virus changed over the years? Until the early 1990s, cardiac manifestations of human immunodeficiency virus (HIV) and associated acquired immunodeficiency syndrome (AIDS) frequently included overt and often acute viral and inflammatory presentations, such as pericardial disease, myocarditis, dilated and infiltrative cardiomyopathies, pulmonary hypertension, arrhythmias, and endocarditis. As continuous, uninterrupted antiretroviral therapy (ART) as soon as possible after…