Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Acute Heart Failure and Pulmonary Edema

Introduction Acute heart failure (AHF) is a clinical syndrome of new or worsening signs and symptoms of heart failure (decompensated), often leading to hospitalization or a visit to the emergency department. Patients with AHF represent a heterogeneous population with high hospital readmission rates. The most common reason for hospitalization is significant volume overload and, subsequently, congestive symptoms. Fewer patients present with hypotension and symptoms of reduced…

Conduction Disturbances in Acute Myocardial Infarction

Infarction or ischemia of myocardial conduction tissue and/or autonomic imbalance that results in altered conduction through the heart can dramatically alter the presentation, management, and outcomes of patients presenting with an acute myocardial infarction (MI). Immediate recognition of conduction disturbances in the acute phase of MI is of prognostic and therapeutic significance. The nature of any conduction disturbance not only gives clues to the location of…

Supraventricular and Ventricular Arrhythmias in Acute Myocardial Infarction

Introduction Cardiac rhythm abnormalities occur in 72% to 95% of patients with acute myocardial infarction (MI) ( Table 16.1 ). Because arrhythmias tend to occur early and before the patient receives medical attention, the incidence may even be higher. Mechanisms for the various arrhythmias seen in MI include reentry, automaticity, and triggered activity. These mechanisms may be exacerbated or caused by certain characteristics of the clinical…

Mechanical Complications of Acute Myocardial Infarction

Early and effective reperfusion of acute myocardial infarction (MI) has resulted in a substantial decline in the incidence of mechanical complications, including free wall rupture, ventricular septal rupture, and papillary muscle rupture resulting in acute mitral regurgitation. However, mechanical complications remain important causes of morbidity and mortality in the peri-infarct setting. Mechanical complications are frequently associated with cardiogenic shock; approximately 12% of patients with cardiogenic shock…

Right Ventricular Infarction

Infarction of the right ventricle is now known to be a common clinical event, occurring in one-third of patients with inferior myocardial infarction (MI). Right ventricular (RV) infarction confers a worse prognosis in patients with inferior wall MI. Because of the requirement for different treatment strategies in right ventricular myocardial infarction (RVMI), prompt recognition and appropriate treatment require a thorough understanding of the unique anatomy and…

Postmyocardial Infarction Cardiogenic Shock

Dramatic advances during the past several decades in diagnosing, monitoring, and treating patients with acute myocardial infarction (MI) have decreased hospital mortality rates by 50%. The organization of coronary care units in the 1960s to treat lethal arrhythmias and the development of fibrinolytic therapy in the 1980s to reduce infarct size were the biggest breakthroughs. Cardiogenic shock, not arrhythmia, is the most common cause of death…

Adjunctive Pharmacologic Therapies in Acute Myocardial Infarction

Acute myocardial infarction (MI) remains a major cause of death and disability worldwide. While advances in primary reperfusion therapy have resulted in significant reductions in morbidity and mortality among patients with acute MI, adjunctive pharmacologic therapies continue to play a vital role. The rapid initiation of adjunctive therapies in the cardiac intensive care unit (CICU) setting are indicated in the acute and convalescent phases of management…

Reperfusion Therapies for Acute ST Elevation Myocardial Infarction

Introduction Historical Perspective Thrombosis was implicated as the cause of acute myocardial infarction (MI) almost a century ago. However, the pathophysiology remained obscure and, as recently as 44 years ago, many investigators believed that thrombosis was a secondary event. Chazov and Rentrop demonstrated that recanalization was achievable pharmacologically with favorable clinical consequences. Thus the concept of reperfusion therapy for acute ST elevation myocardial infarction (STEMI) was…

Use of the Electrocardiogram in Acute Myocardial Infarction

Introduction The term electrocardiogram was first coined by Einthoven at the Dutch Medical Meeting of 1893. In 1901, he successfully developed a new string galvanometer with very high sensitivity, which he used in his electrocardiograph. His device weighed 600 pounds ( Fig. 10.1 ). Sir Edward Schafer of the University of Edinburgh was the first to buy a string galvanometer electrograph for clinical use in 1908.…

Diagnosis of Acute Myocardial Infarction

Myocardial infarction (MI) describes the process of myocardial cell death caused by ischemia or the imbalance between myocardial oxygen supply via the coronary arteries and demand. In the United States each year, an estimated 1.1 million people experience an acute MI or die from coronary heart disease. In 2016, it was estimated that approximately every 34 seconds one American would have a coronary event and about…

Regulation of Hemostasis and Thrombosis

Overview and Definitions Coagulation is the clotting of blood or plasma. Hemostasis is the process by which bleeding is stopped and is the first component of the host response to injury. Its product is a hemostatic plug or hemostatic clot. Thrombosis is inappropriate clot formation within an intact vascular structure. Its product is a thrombus. Thus blood coagulation can occur at a site of injury (hemostasis),…

Pathophysiology of Acute Coronary Syndromes: Plaque Rupture and Atherothrombosis

The acute coronary syndromes (unstable angina, myocardial infarction [MI], sudden cardiac death) are a major cause of morbidity and mortality in developed countries. MI alone is the major cause of death in most Western countries. The rapidly increasing prevalence in developing countries, specifically South Asia and Eastern Europe—coupled with an increasing incidence of tobacco abuse, obesity, and diabetes—is predicted to make cardiovascular disease the major global…

Coronary Physiology and Pathophysiology

A clear understanding of the physiologic control of coronary blood flow is essential to considering and treating the underlying pathophysiology in patients who are acutely ill with an acute myocardial infarction (MI) in a cardiac intensive care unit (CICU) or in patients with other severe systemic illnesses and underlying coronary artery disease (CAD). Determinants of Myocardial Oxygen Consumption The working myocardium requires a coronary blood flow…

Regulation of Cardiac Output

The cardiovascular system includes the four-chambered heart, arteries, veins, and lymphatics. Pulsatile arterial flow supplies tissues with oxygen and metabolic substrates, and nonpulsatile venous flow removes carbon dioxide and other metabolic products. The lymphatics ensure conservation of volume at the microvascular level. The functional integration of all these active and passive components (venous circulation, right heart, lungs and pulmonary vascular system, left heart and arterial circulation)…

Role of the Cardiovascular System in Coupling the External Environment to Cellular Respiration

The cardiovascular system exists primarily to transport oxygen and nutrients to the various body tissues and to transport carbon dioxide and other waste products from the tissues to the lungs, kidneys, or liver for disposal. It is a component of the oxygen transport pathway, linking the environment via the lungs (and chest wall) to the tissue cells by the heart and the vascular network. The focus…

Physical Examination in the Cardiac Intensive Care Unit

In the cardiac intensive care unit (CICU), the ubiquitous presence of advanced technology and highly sensitive laboratory assessments/testing has resulted in an overreliance on imaging and testing at the expense of the skills required to examine critically ill patients. Yet, at the moments of initial patient contact, acute decompensation, and serially after therapeutic interventions, the ability to integrate an outstanding physical evaluation into the diagnostic assessment…

Ethical Issues in the Cardiac Intensive Care Unit

Ethical challenges abound in intensive care units (ICUs). Treatment in ICUs represents one of the costliest and most aggressive forms of Western medicine. ICU patients are the sickest and the most unstable, and they often cannot participate in health care decision making. Patients' families and loved ones are often left reeling by the sudden onset of serious illness. These factors bring to the ICU a host…

Evolution of the Coronary Care Unit: Past, Present, and Future

Originating during a time of recognized unmet medical need and advances in medicine, the coronary care unit (CCU) emerged as one of the most important advances in the care of patients with life-threatening cardiovascular conditions. It has evolved further with technology, including mechanical circulatory support, to become a portal of entry for critically ill patients requiring a high level of support and vast resources. The emergence…

Cardiovascular Manifestations of Autonomic Disorders

Additional content is available online at Elsevier eBooks for Practicing Clinicians The critical role of a balanced autonomic nervous system for appropriate function and responsiveness of the cardiovascular system is often overlooked. The interrelationship of these two systems is often thought of predominantly through the lens of abnormalities in blood pressure and heart rate in response to internal and external stimuli in patients with structurally “normal…