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Library of Congress Cataloging-in-Publication Data

Clinical guide to cardiology / edited by Christian F. Camm, A. John Camm.
      p. ; cm.
   Includes bibliographical references and index.
   ISBN 978-1-118-75533-4 (pbk.)
   I. Camm, Christian F. (Christian Fielder), editor.   II. Camm, A. John, editor.
   [DNLM: 1. Heart Diseases–diagnosis.   2. Heart Diseases–therapy.   WG 141]
   RC682
   616.1′2–dc23
                                                                     2015025343

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: iStockphoto/© Nerthuz

CONTENTS

Contributors

Acronyms and Abbreviations

About the Companion Website

PART 1 Examination Techniques

1 Examination Techniques
1. 1.1 Common conditions to be looked for on the examination
2. 1.2 Clinical examination – peripheries
3. 1.3 Clinical examination – the praecordium
4. 1.4 How to present your findings
5. 1.5 Eponymous signs and symptoms
6. Note

PART 2 Approach to Presenting Complaints

2 Chest Pain
1. 2.1 Definition
2. 2.2 Diagnostic algorithm
3. 2.3 Differentials list
4. 2.4 Key history features
5. 2.5 Key examination features
6. 2.6 Key investigations
7. 2.7 When to call a senior
8. Key clinical trials
9. Guidelines
10. Further reading
3 Shortness of Breath
1. 3.1 Definition
2. 3.2 Diagnostic algorithm
3. 3.3 Differentials list
4. 3.4 Key history features
5. 3.5 Key examination features
6. 3.6 Key investigations
7. 3.7 When to call a senior
8. Guidelines
9. Further reading
4 Loss of Consciousness
1. 4.1 Definition
2. 4.2 Classification
3. 4.3 Differentials list
4. 4.4 Key history features
5. 4.5 Key examination features
6. 4.6 Key investigations
7. 4.7 When to call a senior
8. 4.8 Key clinical trials
9. Guidelines
10. Further reading
5 Palpitations
1. 5.1 Definition
2. 5.2 Diagnostic algorithm
3. 5.3 Differentials list
4. 5.4 Key history features
5. 5.5 Key examination features
6. 5.6 Key investigations
7. 5.7 When to call a senior
8. Guidelines
9. Further reading
6 Cardiac Murmurs
1. 6.1 Definition
2. 6.2 Classification
3. 6.3 Differentials list
4. 6.4 Key history features
5. 6.5 Key examination features
6. 6.6 Key investigations
7. 6.7 When to call a senior
8. Key clinical trials
9. Guidelines
10. Further reading
7 Shock
1. 7.1 Definition
2. 7.2 Diagnostic algorithm
3. 7.3 Differentials list
4. 7.4 Key history features
5. 7.5 Key examination features
6. 7.6 Key investigations
7. 7.7 When to call a senior
8. Key clinical trials
9. Guidelines
10. Further reading
8 Oedema
1. 8.1 Definition
2. 8.2 Diagnostic algorithm
3. 8.3 Differentials list
4. 8.4 Key history features
5. 8.5 Key examination features
6. 8.6 Key investigations
7. 8.7 When to call a senior
8. Key clinical trials
9. Guidelines
10. Further reading

PART 3 Conditions

9 Acute Coronary Syndrome
1. 9.1 Definition
2. 9.2 Underlying concepts
3. 9.3 Key data
4. 9.4 Clinical types
5. 9.5 Presenting features
6. 9.6 Differentials
7. 9.7 Key investigations
8. 9.8 Management options
9. Key clinical trials
10. Guidelines
11. Further reading
10 Stable Angina
1. 10.1 Definition
2. 10.2 Underlying concepts
3. 10.3 Key data
4. 10.4 Clinical types
5. 10.5 Presenting features
6. 10.6 Differentials
7. 10.7 Key investigations
8. 10.8 Management options
9. Key clinical trials
10. Guidelines
11. Further reading
11 Heart Failure
1. 11.1 Definition
2. 11.2 Underlying concepts
3. 11.3 Clinical types
4. 11.4 Heart failure with reduced ejection fraction
5. 11.5 Heart failure with preserved ejection fraction (HF-PEF)
6. Key clinical trials
7. Guidelines
8. Further reading
12 Infective Endocarditis
1. 12.1 Definition
2. 12.2 Underlying concepts
3. 12.3 Key data
4. 12.4 Clinical types
5. 12.5 Presenting features
6. 12.6 Differentials
7. 12.7 Key investigations
8. 12.8 Management options
9. Key clinical trials
10. Guidelines
11. Further reading
13 Arrhythmias
1. 13.1 Definition
2. 13.2 Underlying concepts
3. 13.3 Clinical types
4. 13.4 Atrial fibrillation
5. 13.5 Atrial flutter
6. 13.6 Supraventricular tachycardias
7. 13.7 Ventricular tachycardia
8. 13.8 Other arrhythmias to be aware of
9. Key clinical trials
10. Guidelines
11. Further reading
14 Valvular Heart Disease
1. 14.1 Definition
2. 14.2 Underlying concepts
3. 14.3 Clinical types
4. 14.4 Mitral regurgitation (MR)
5. 14.5 Mitral stenosis (MS)
6. 14.6 Aortic stenosis (AS)
7. 14.7 Aortic regurgitation (AR)
8. 14.8 Other murmurs to be aware of
9. Key clinical trials
10. Guidelines
11. Further reading
15 Cardiomyopathy
1. 15.1 Definition
2. 15.2 Underlying concepts
3. 15.3 Clinical types
4. 15.4 Presentation
5. 15.5 Hypertrophic cardiomyopathy
6. 15.6 Dilated cardiomyopathy
7. 15.7 Restrictive cardiomyopathy
8. 15.8 Other cardiomyopathies
9. Guidelines
10. Further reading
16 Hypertension
1. 16.1 Definition
2. 16.2 Underlying concepts
3. 16.3 Key data
4. 16.4 Clinical types
5. 16.5 Presenting features
6. 16.6 Differentials
7. 16.7 Key investigations
8. 16.8 Management options
9. Key clinical trials
10. Guidelines
11. Further reading
17 Pericardial Disease
1. 17.1 Definition
2. 17.2 Underlying concepts
3. 17.3 Clinical types
4. 17.4 Acute pericarditis
5. 17.5 Constrictive pericarditis
6. 17.6 Pericardial effusion
7. Key clinical trials
8. Guidelines
9. Further reading
18 Congenital Heart Disease
1. 18.1 Definition
2. 18.2 Underlying concepts
3. 18.3 Atrial septal defect
4. 18.4 Ventricular septal defect
5. 18.5 Coarctation of the aorta
6. 18.6 Other forms of congenital heart disease
7. Key clinical trials
8. Guidelines
9. Further reading

PART 4 Imaging

19 Electrocardiogram
1. 19.1 Definition
2. 19.2 Outline of procedure
3. 19.3 Indications
4. 19.4 Peri-procedural management
5. 19.5 Key features
6. 19.6 Interpretation
7. 19.7 Potential complications
8. Guidelines
9. Further reading
20 Transoesophageal Echocardiogram
1. 20.1 Definition
2. 20.2 Outline of procedure
3. 20.3 Indications
4. 20.4 Peri-procedural management
5. 20.5 Interpretation
6. 20.6 Potential complications
7. Guidelines
8. Further reading
21 Trans-Thoracic Echocardiogram
1. 21.1 Definition
2. 21.2 Outline of procedure
3. 21.3 Indications
4. 21.4 Peri-procedural management
5. 21.5 Interpretation
6. 21.6 Potential complications
7. Guidelines
22 Cardiac MRI
1. 22.1 Definition
2. 22.2 Outline of procedure
3. 22.3 Indications
4. 22.4 Peri-procedural management
5. 22.5 Interpretation
6. 22.6 Potential complications
7. Key clinical trials
8. Guidelines
9. Further reading
23 Cardiac CT
1. 23.1 Definition
2. 23.2 Outline of procedure
3. 23.3 Indications
4. 23.4 Peri-procedural management
5. 23.5 Interpretation
6. 23.6 Potential complications
7. Key clinical trials
8. Guidelines
9. Further reading
24 Cardiac Catheterization
1. 24.1 Definition
2. 24.2 Outline of procedure
3. 24.3 Indications
4. 24.4 Peri-procedural management
5. 24.5 Interpretation
6. 24.6 Potential complications
7. Guidelines
8. Further reading

PART 5 Interventional Therapies

25 Pacemakers and Implantable Cardiac Defibrillators
1. 25.1 Definition
2. 25.2 Outline of devices
3. 25.3 Outline of procedure
4. 25.4 Indications
5. 25.5 Peri-procedural management
6. 25.6 Potential complications
7. Key clinical trials
8. Guidelines
26 Percutaneous Coronary Intervention and Angioplasty
1. 26.1 Definition
2. 26.2 Basic principles
3. 26.3 Outline of procedure
4. 26.4 Indications
5. 26.5 Peri-procedural management
6. 26.6 Interpretation
7. 26.7 Potential complications
8. 26.8 Thrombolysis
9. Key clinical trials
10. Guidelines
11. Further reading
27 Valvuloplasty
1. 27.1 Definition
2. 27.2 Outline of procedure and devices
3. 27.3 Indications
4. 27.4 Peri-procedural management
5. 27.5 Potential complications
6. Guidelines
28 Transcatheter Aortic Valve Implantation
1. 28.1 Definition
2. 28.2 Outline of procedure and devices
3. 28.3 Indications
4. 28.4 Peri-procedural management
5. 28.5 Potential complications
6. Key clinical trials
7. Guidelines
8. Further reading
29 Cardiac Ablation
1. 29.1 Definition
2. 29.2 Outline of procedure
3. 29.3 Indications
4. 29.4 Peri-procedural management
5. 29.5 Potential complications
6. Key clinical trials
7. Guidelines
8. Further reading

PART 6 Pharmacology

30 Anti-Arrhythmic Agents
1. 30.1 Adenosine
2. 30.2 Amiodarone
3. 30.3 Flecainide
4. 30.4 Digoxin
5. 30.5 Atropine
6. Key clinical trials
31 Beta-Blockers
1. 31.1 General notes
2. 31.2 Non-selective
3. 31.3 Cardioselective
4. Key clinical trials
32 Calcium-Channel Blockers
1. 32.1 General notes
2. 32.2 Cardiac selective
3. 32.3 Action primarily on vascular smooth muscle
4. Key clinical trials
33 Nitrates
1. 33.1 General notes
2. 33.2 Oral nitrates
3. 33.3 Nitrates used as an infusion
4. Key clinical trials
34 Drugs Targeting the Angiotensin Axis
1. 34.1 General notes
2. 34.2 ACE inhibitors (ACEi)
3. 34.3 Angiotensin-receptor blockers
35 Diuretics
1. 35.1 Loop diuretics
2. 35.2 Thiazides and thiazide-like diuretics
3. 35.3 Potassium-sparing diuretics
4. Key trials
36 Anticoagulants
1. 36.1 Heparin
2. 36.2 Low molecular weight heparins (LMWHs)
3. 36.3 Fondaparinux
4. 36.4 Warfarin
5. 36.5 Novel oral anticoagulants
6. Key trials
37 Antiplatelets
1. 37.1 Aspirin
2. 37.2 Clopidogrel
3. 37.3 Novel antiplatelets
38 Lipid Regulation
1. 38.1 Statins

Index

EULA

List of Tables

Chapter 1

Table 1.1
Table 1.2
Table 1.3
Table 1.4
Table 1.5
Table 1.6
Table 1.7
Table 1.8
Table 1.9
Table 1.10
Table 1.11
Table 1.12
Table 1.13
Table 1.14

Chapter 2

Table 2.1
Table 2.2
Table 2.3
Table 2.4

Chapter 3

Table 3.1
Table 3.2
Table 3.3
Table 3.4
Table 3.5
Table 3.6

Chapter 4

Table 4.1
Table 4.2
Table 4.3
Table 4.4

Chapter 5

Table 5.1
Table 5.2
Table 5.3
Table 5.4

Chapter 6

Table 6.1
Table 6.2
Table 6.3
Table 6.4

Chapter 7

Table 7.1
Table 7.2
Table 7.3
Table 7.4
Table 7.5
Table 7.6
Table 7.7
Table 7.8

Chapter 8

Table 8.1
Table 8.2
Table 8.3
Table 8.4
Table 8.5

Chapter 9

Table 9.1
Table 9.2
Table 9.3
Table 9.4
Table 9.5
Table 9.6
Table 9.7
Table 9.8
Table 9.9
Table 9.10
Table 9.11
Table 9.12
Table 9.13

Chapter 10

Table 10.1
Table 10.2
Table 10.3
Table 10.4
Table 10.5

Chapter 11

Table 11.1
Table 11.2
Table 11.3
Table 11.4
Table 11.5
Table 11.6
Table 11.7
Table 11.8

Chapter 12

Table 12.1
Table 12.2
Table 12.3
Table 12.4
Table 12.5
Table 12.6
Table 12.7
Table 12.8
Table 12.9
Table 12.10
Table 12.11
Table 12.12

Chapter 13

Table 13.1
Table 13.2
Table 13.3
Table 13.4
Table 13.5
Table 13.6
Table 13.7
Table 13.8
Table 13.9
Table 13.10
Table 13.11
Table 13.12
Table 13.13
Table 13.14
Table 13.15
Table 13.16
Table 13.17
Table 13.18
Table 13.19

Chapter 14

Table 14.1
Table 14.2
Table 14.3
Table 14.4
Table 14.5
Table 14.6
Table 14.7
Table 14.8
Table 14.9
Table 14.10
Table 14.11
Table 14.12
Table 14.13
Table 14.14
Table 14.15
Table 14.16
Table 14.17
Table 14.18
Table 14.19
Table 14.20
Table 14.21
Table 14.22
Table 14.23
Table 14.24
Table 14.25
Table 14.26
Table 14.27
Table 14.28

Chapter 15

Table 15.1
Table 15.2
Table 15.3
Table 15.4
Table 15.5
Table 15.6
Table 15.7
Table 15.8
Table 15.9
Table 15.10
Table 15.11
Table 15.12
Table 15.13
Table 15.14
Table 15.15
Table 15.16

Chapter 16

Table 16.1
Table 16.2
Table 16.3
Table 16.4
Table 16.5
Table 16.6
Table 16.7
Table 16.8
Table 16.9
Table 16.10
Table 16.11
Table 16.12

Chapter 17

Table 17.1
Table 17.2
Table 17.3
Table 17.4
Table 17.5
Table 17.6
Table 17.7
Table 17.8
Table 17.9
Table 17.10
Table 17.11
Table 17.12
Table 17.13
Table 17.14
Table 17.15

Chapter 18

Table 18.1
Table 18.2
Table 18.3
Table 18.4
Table 18.5
Table 18.6
Table 18.7
Table 18.8
Table 18.9
Table 18.10
Table 18.11
Table 18.12
Table 18.13
Table 18.14
Table 18.15
Table 18.16
Table 18.17
Table 18.18

Chapter 19

Table 19.1
Table 19.2
Table 19.3
Table 19.4
Table 19.5
Table 19.6
Table 19.7
Table 19.8
Table 19.9
Table 19.10
Table 19.11
Table 19.12
Table 19.13
Table 19.14
Table 19.15

Chapter 20

Table 20.1

Chapter 21

Table 21.1

Chapter 22

Table 22.1

Chapter 23

Table 23.1
Table 23.2

Chapter 24

Table 24.1
Table 24.2

Chapter 25

Table 25.1
Table 25.2

Chapter 26

Table 26.1

Chapter 27

Table 27.1

Chapter 28

Table 28.1

Chapter 29

Table 29.1

Chapter 36

Table 36.1
Table 36.2

List of Illustrations

Chapter 1

Figure 1.1 The examination circuit.

Chapter 2

Figure 2.1 Algorithm for the diagnosis of chest pain.
Figure 2.2 Stanford classification.
Figure 2.3 ECG changes of acute anterior ST-Elevation MI.

Chapter 3

Figure 3.1 Diagnostic algorithm for shortness of breath.
Figure 3.2 Examination findings in acute pulmonary oedema.
Figure 3.3 Examination findings in pulmonary embolism.
Figure 3.4 Examination findings in pneumothorax.
Figure 3.5 Examination findings in asthma.
Figure 3.6 Examination findings in pneumonia.
Figure 3.7 Examination findings in pleural effusion.
Figure 3.8 Graphical representation of restrictive and obstructive pulmonary function test results.
Figure 3.9 ECG of a patient with a pulmonary embolism showing the classic S1,Q3,T3 pattern.
Figure 3.10 CXR showing a pleural effusion.
Figure 3.11 CXR showing a right upper-lobe pneumonia.
Figure 3.12 CXR showing a right sided pneumothorax.

Chapter 4

Figure 4.1 Classification of T-LOC aetiology
Figure 4.2 An ECG showing complete dissociation of atrial and ventricular systole. This is consistent with third-degree (complete) heart block. These patients often present with syncope – so-called Stokes Adam's attacks.
Figure 4.3 CT pulmonary angiogram showing a filling defect in the right and left pulmonary arteries consistent with bilateral pulmonary emboli.

Chapter 5

Figure 5.1 Flow chart for evaluation of palpitations.
Figure 5.2 A REVEAL™ device – used for palpitations/syncope of unknown origin.

Chapter 6

Figure 6.1 Flow-chart of potential underlying causes for murmurs based on timing.
Figure 6.2 Heavily calcified aortic valve (AV) in a patient with severe aortic stenosis. There is concentric hypertrophy of the left ventricular (LV) wall and post-stenotic dilatation of the aorta (A). LA, left atrium.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.3 Mitral regurgitation. Doppler shows a jet of blood passing from the left ventricle (LV) into the left atrium (LA). RV, right ventricle; RA, right atrium.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.4 Aortic regurgitation, Doppler imaging shows a jet of blood directed back into the left ventricle (LV) from the aorta. AV, aortic valve; LA, left atrium; RA, right atrium.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.5 Mitral stenosis. The mitral valve (MV) is heavily calcified. The left atrium (LA) is dilated. LV, left ventricle.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.6 Ventricular septal defect (VSD), Doppler imaging shows the movement of blood across the opening. RV, right ventricle; RA, right atrium; vS, ventricular septum; LV, left ventricle; LA, left atrium.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.7 Atrial septal defect (ASD), Doppler imaging shows the movement of blood across the opening. RA, right atrium; LA, left atrium; aS, atrial septum; RV, right ventricle.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.8 Vegetation (V) on aortic valve in a patient with infective endocarditis. LV, left ventricle; MV, mitral valve; LA, left atrium.
Source: Harpreet Kaur Sahemey, Echocardiographer, Hammersmith Hospital.
Figure 6.9 Work-up of a patient who presents with a murmur.

Chapter 7

Figure 7.1 Diagnostic flow chart for shock.
Figure 7.2 Pneumocystis pneumonia (PCP) – a potential cause of septic shock in immunocompromised patients. Source: Daniel Hughes, FY2 Doctor in Radiology, Queen Elizabeth Hospital, Woolwich.
Figure 7.3 A large right-sided pneumothorax; if this begins to tension it could become a cause of obstructive shock.

Chapter 8

Figure 8.1 Flow chart detailing the pathophysiology of oedema.

Chapter 9

Figure 9.1 The development of acute coronary syndrome.
Figure 9.2 Diagram of coronary occlusion, due to an atherosclerotic plaque and associated thrombus, with downstream infarction.
Figure 9.3 Cardiac markers: approximate levels vs. time of onset post MI.
Figure 9.4 Diagnostic algorithm for differentiating different forms of ACS.
Figure 9.5 Cartoon representation of the pathological features following myocardial infarction.
Figure 9.6 Conditions mimicking non-ST-elevation myocardial infarctions.
Figure 9.7 ECG changes seen over time in ST-elevation myocardial infarction.
Figure 9.8 Management of patients with ACS.
Figure 9.9 Simplified platelet activation pathway.

Chapter 10

Figure 10.1 A partially occluded coronary artery.
Figure 10.2 Modifiable and non-modifiable risk factors for coronary artery disease.
Figure 10.3 Right hand showing nicotine stains on the index and middle fingers.
Figure 10.4 ECG showing ischaemic changes of someone with stable angina.
Figure 10.5 Investigations for stable angina.

Chapter 11

Figure 11.1 The Frank–Starling curve.
Figure 11.2 Chest radiograph showing pulmonary oedema. Note the presence of cardiomegaly, bilateral pleural effusions and ‘bat's wing’ appearance of the hili.
Figure 11.3 Enlarged chest radiograph showing Kerley B lines. These are short horizontal lines seen at the periphery of the radiograph and are a feature of pulmonary oedema.
Figure 11.4 Diagnostic algorithm for heart failure.
Figure 11.5 Flow chart for the management of heart failure.

Chapter 12

Figure 12.1 Aortic valve vegetation from infective endocarditis. Source: Mr Gopal Soppa, Academic Clinical Lecturer in Cardiothoracic Surgery, St. George's University of London.
Figure 12.2 Hand signs of infective endocarditis.
Figure 12.3 Clubbing. Source: Patrick Jahns, King's College Hospital NHS Foundation Trust.
Figure 12.4 First-degree heart block.
Figure 12.5 Trans-thoracic echocardiogram showing vegetation on the mitral valve.

Chapter 13

Figure 13.1 Normal conduction within the heart.
Figure 13.2 12-lead ECG showing atrial fibrillation.
Figure 13.3 ESC rhythm control flow chart. Source: Camm 2012. reproduced with permission of Oxford University Press. CAD, coronary artery disease; CHF, congestive heart failure; HT, hypertension; LVH, left ventricular hypertrophy.
Figure 13.4 12-lead ECG showing atrial flutter.
Figure 13.5 Supraventricular tachycardia starting in a patient.
Figure 13.6 12-lead ECG showing ventricular tachycardia.
Figure 13.7 12-lead ECG of multifocal atrial tachycardia.

Chapter 14

Figure 14.1 Diagrammatic representation of heart chamber and valves. Note the mitral valve is the only valve with two leaflets.
Figure 14.2 Auscultation locations for cardiac valves.
Figure 14.3 Auscultatory findings in mitral regurgitation.
Figure 14.4 Auscultatory findings in mitral stenosis. Note the presence of presystolic potentiation due to atrial systole (increased amplitude of murmur in figure), which is only seen in sinus rhythm.
Figure 14.5 Auscultatory findings in aortic stenosis.
Figure 14.6 Auscultatory findings in aortic regurgitation.

Chapter 15

Figure 15.1 Clinical types of cardiomyopathy. (a) Normal heart. (b) HCM with the characteristically enlarged ventricular walls. (c) DCM characterized by enlarged ventricles which attempt to compensate for ventricular dysfunction. (d) RCM characterized by infiltration which stiffens the ventricular walls and causes diastolic dysfunction.
Figure 15.2 Pathophysiology of HCM.
Figure 15.3 12-lead sinus rhythm ECG in HCM patient showing prominent left ventricular hypertrophy (Sokolow criteria). Source: TP Mast, MD, and MJM Cramer, MD, University Medical Center Utrecht, the Netherlands.
Figure 15.4 TTE in HCM. Parasternal long-axis TTE in HCM patient showing prominent septal hypertrophy (A and B), as well as septal anterior motion (anterior leaflet of mitral valve touching the septum in systole, B). Source: TP Mast, MD, and MJM Cramer, MD, University Medical Center Utrecht, the Netherlands.
Figure 15.5 Pathophysiology of DCM.
Figure 15.6 Chest X-ray in DCM patient showing enlarged heart with cardiothoracic ratio (CTR) >0.5. Source: BK Velthuis, MD, University Medical Center Utrecht, the Netherlands.
Figure 15.7 MRI IN DCM. Cardiac magnetic resonance imaging in DCM patient in the four-chamber (A) and short-axis (B) view showing an enlarged LV (end-diastolic volume 330 mL) with reduced wall thickness and reduced function (ejection fraction 28%).
Source: BK Velthuis, MD, University Medical Center Utrecht, the Netherlands.
Figure 15.8 Pathophysiology of RCM.

Chapter 16

Figure 16.1 Autoregulation. Blood flow in an organ is maintained constant despite fluctuations in blood pressure through means of myogenic and metabolic mechanisms. In chronic hypertension there is a rightward shift in this relationship making them more vulnerable to hypoperfusion with lowering of blood pressure.
Figure 16.2 Management of hypertension. Source: NICE 2011. Reproduced with permission of NICE.

Chapter 17

Figure 17.1 12-lead electrocardiogram from a patient with acute pericarditis showing widespread ST-segment elevation and PR-segment depression.
Figure 17.2 Flowchart of acute pericarditis management.
Figure 17.3 CT chest showing pericardial effusion.
Figure 17.4 Chest X-ray showing a large pericardial effusion.
Figure 17.5 Trans-thoracic echocardiogram of a pericardial effusion.

Chapter 18

Figure 18.1 Atrial septal defect.
Figure 18.2 Ventricular septal defect.
Figure 18.3 Diagram of Fallot's tetralogy.
Figure 18.4 Diagram of transposition of the great arteries.

Chapter 19

Figure 19.1 Image of lead placement both within the limbs and on the chest.
Figure 19.2 Direction of ECG limb leads.
Figure 19.3 The view each lead provides of the heart. Note the two separate axes (coronal and axial).
Figure 19.4 ECG waves and segments.
Figure 19.5 ECG graph paper detailing the technical aspects of an ECG.
Figure 19.6 Axis of overall ventricular depolarization.
Figure 19.7 Standard information found on most ECG print outs. Axis of the atrial (P) and ventricular (QRS) depolarization are displayed as the fourth item on the list.
Figure 19.8 P-wave morphology. (A) Normal morphology. (B) ‘Pulmonale’ P-wave due to right atrial enlargement. (C) ‘Mitrale’ P-wave due to left atrial enlargement.
Figure 19.9 ECG – sinus rhythm.
Figure 19.10 ECG – sinus arrhythmia.
Figure 19.11 ECG – supraventricular tachycardia.
Figure 19.12 ECG – left bundle branch block.
Figure 19.13 ECG – right bundle branch block.
Figure 19.14 ECG – polymorphic ventricular tachycardia (torsades de pointes).

Chapter 20

Figure 20.1 TOE probe.
Figure 20.2 Positioning of TOE probe.
Figure 20.3 TOE image of an aortic dissection.
Figure 20.4 Copy of a TOE report.

Chapter 21

Figure 21.1 Echocardiogram machine.
Figure 21.2 Parasternal long-axis view (TTE) showing the left ventricle (LV), left atrium (LA), and right ventricle (RV). The mitral and aortic valves are also seen.
Figure 21.3 Parasternal short-axis view (TTE) showing typical mitral valve ‘fish mouth view’.
Figure 21.4 Sub-costal view. Showing the left (LA) and right (RA) atria and the left (LV) and right (RV) ventricles.
Figure 21.5 Sample TTE report.

Chapter 22

Figure 22.1 Line drawing of a typical MRI scanner.
Figure 22.2 Normal cardiac MRI.
Figure 22.3 Delayed gadolinium hyper-enhancement.

Chapter 23

Figure 23.1 Multi-detector CT uses multiple rows (often ≥ 64) of detectors opposite the X-ray beams. The more detectors present the faster the speed of image acquisition. The ring is known as the gantry. This rotates around the patient as the patient passes through the ring at a set speed.
Figure 23.2 Axial slice of a cardiac CT for calcium scoring demonstrating a calcified plaque in the right mid stem of the RCA. The Agastson score was 115 for this vessel.
Figure 23.3 Axial slice of a CT contrast coronary angiogram demonstrating the left main stem which is unobstructed.
Figure 23.4 CT contrast coronary angiogram is used to create a 3D reconstruction of the coronary arteries to allow detailed views of the anatomy.

Chapter 24

Figure 24.1 Cardiac catheterization suite.
Figure 24.2 Sample cardiac catheters.
Figure 24.3 Fluoroscopic imaging: left ventriculogram.
Figure 24.4 Fluoroscopic imaging: aortogram.

Chapter 25

Figure 25.1 Line drawing of a single-chamber pacemaker in situ.
Figure 25.2 Line drawing of a dual-chamber pacemaker in situ.
Figure 25.3 Line drawing of a bi-ventricular pacemaker in situ.
Figure 25.4 Line drawing of an implantable cardiac defibrillator. The LV and RA leads are optional.
Figure 25.5 Selection of pacemaker systems for patients with atrioventricular block. Source: Adapted from Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol. 2008;51(21):2085–2105.
Figure 25.6 Selection of pacemaker systems for patients with sinus node dysfunction. Source: Adapted from Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol. 2008;51(21):2085–2105.
Figure 25.7 Chest radiograph of a permanent pacemaker with leads in the right atrium and right ventricle.

Chapter 26

Figure 26.1 Coronary artery anatomy.
Figure 26.2 Origins of the right and left coronary artery (from above the aortic valve).
Figure 26.3 Stenosis of the proximal left circumflex artery.
Figure 26.4 Left circumflex artery post stent insertion.

Chapter 27

Figure 27.1 Fluoroscopy image of guide wire inserted across the aortic valve.
Figure 27.2 Fluoroscopy image of catheter balloon opening the aortic valve.

Chapter 28

Figure 28.1 Insertion of a TAVI valve into place (line drawing).
Figure 28.2 A TAVI valve (Edwards Sapien®). Source: Image kindly provided by Edwards Lifesciences LLC, Irvine, CA. Edwards SAPIEN is a trademark of Edwards Lifesciences Corporation.
Figure 28.3 TAVI valve being inserted and expanded using a transfemoral approach.
Figure 28.4 TAVI valve being inserted and expanded using a transapical approach.
Figure 28.5 TAVI complications.

Chapter 29

Figure 29.1 Pulmonary vein isolation.
Figure 29.2 Ablation of accessory pathway conduction ECG; note disappearance of δ-wave (last two beats).
Figure 29.3 Chest CT showing left-sided pulmonary vein obliteration following pulmonary vein isolation ablation.

Chapter 30

Figure 30.1 Structure of adenosine.
Figure 30.2 Structure of amiodarone.
Figure 30.3 Structure of flecainide.
Figure 30.4 Structure of digoxin.
Figure 30.5 Structure of atropine.

Chapter 31

Figure 31.1 Chemical structure of propranolol.
Figure 31.2 Chemical structure of bisoprolol.

Chapter 32

Figure 32.1 Chemical structure of verapamil.
Figure 32.2 Chemical structure of amlodipine.

Chapter 33

Figure 33.1 Chemical structure of isosorbide mononitrate.
Figure 33.2 Chemical structure of glyceryl trinitrate.

Chapter 34

Figure 34.1 Structure of ramipril.
Figure 34.2 Structure of losartan.

Chapter 35

Figure 35.1 Structure of furosemide.
Figure 35.2 Structure of bendroflumethiazide.
Figure 35.3 Structure of spironolactone.

Chapter 36

Figure 36.1 Structure of fondaparinux.
Figure 36.2 Structure of warfarin.
Figure 36.3 Structure of rivaroxaban.

Chapter 37

Figure 37.1 Structure of aspirin.
Figure 37.2 Structure of clopidogrel.
Figure 37.3 Structure of ticagrelor.

Chapter 38

Figure 38.1 Structure of simvastatin.

Contributors

Laura Ah-Kye

King's College Hospital, London, UK

Kristopher Bennett

Whipps Cross Hospital, London, UK

Lucy Carpenter

Barts Health NHS Trust, London, UK

Yang Chen

Imperial College Healthcare NHS Trust, London, UK

Ji-Jian Chow

Queen Elizabeth Hospital, Woolwich, UK

James Cranley

Royal Brompton & Harefield NHS Foundation Trust, London, UK

George Davies

Oxford University Hospitals NHS Trust, Oxford, UK

Akshay Garg

King's College Hospital, London, UK

Harminder S. Gill

King's College Hospital, London, UK

Katie Glover

Conquest Hospital, Hastings, UK

Stephanie Hicks

King's College Hospital, London, UK

Fritz-Patrick Jahns

King's College Hospital, London, UK

Sophie Maxwell

Walsall Manor Hospital, Walsall, UK

Blair Merrick

Hammersmith Hospital, London, UK

Madeline Moore

King's College Hospital, London, UK

Sarah Morrow

Hammersmith Hospital, London, UK

Rahul K. Mukherjee

King's College Hospital, London, UK

Anna Robinson

King's College Hospital, London, UK

Arvind Singhal

Imperial College Healthcare NHS Trust, London, UK

Nicholas Sunderland

King's College Hospital, London, UK

Anneline te Riele

University Medical Centre, Utrecht, The Netherlands

Maria Tsakok

Hammersmith Hospital, London, UK

Robert A. Watson

North West London Hospitals NHS Trust, London, UK

Acronyms and Abbreviations

2D	two-dimensional
3D	three-dimensional
A2	aortic valve component of heart sound 2
AAA	abdominal aortic aneurysm
ABG	arterial blood gas
ABPM	ambulatory blood pressure monitoring
ACC	American College of Cardiology
ACE	angiotensin-converting enzyme
ACEi	angiotensin-converting enzyme inhibitor
ACR	albumin:creatinine ratio
ACS	acute coronary syndrome
ACTH	adrenocorticotropic hormone
ADP-P2Y	adenosine diphosphate-P2Y receptor
AF	atrial fibrillation
AHA	American Heart Association
AI	angiotensin I
AII	angiotensin II
AKI	acute kidney injury
ALD	alcoholic liver disease
ALP	alkaline phosphatase
ALS	advanced life support
AMA	American Medical Association
AMB	acute marginal branch
AMTS	Abbreviated Mental Test score
APS	antiphospholipid syndrome
aPTT	activated partial thromboplastin time
AR	aortic regurgitation
ARB	angiotensin-II receptor blocker
ARDS	acute respiratory distress syndrome
AS	aortic stenosis
ASD	atrial septal defect
AST	aspartate aminotransferase
ATP	adenosine triphosphate
AV	atrioventricular
AVN	atrioventricular node
AVNRT	AV-nodal re-entrant tachycardia
AVPU	alert/responsive to voice/responsive to pain/unresponsive
AVRT	atrioventricular re-entrant tachycardia
AVSD	atrioventricular septal defect
BAH	bilateral adrenocortical hyperplasia
BAV	balloon aortic valvuloplasty
BCS	British Cardiovascular Society
BD	twice a day
BE	base excess
beta-hCG	beta human chorionic gonadotrophin
BM	Boheringer-Mannheim – capillary glucose test
BMI	body mass index
BNP	brain natriuretic peptide
BP	blood pressure
BPH	benign prostatic hyperplasia
bpm	beats per minute
CABG	coronary artery bypass graft
CAC	coronary artery calcium
CAD	coronary artery disease
Cath Lab	(coronary) catheterization laboratory
CCB	calcium-channel blocker
CCF	congestive cardiac failure
CCP	cyclic citrullinated peptide
CCU	cardiac care unit
CK-MB	creatine kinase – MB isoform
CKD	chronic kidney disease
CMV	cytomegalovirus
CN	coagulase negative
CNS	central nervous system
CO	cardiac output
CoA	coarctation of the aorta
COPD	chronic obstructive pulmonary disease
COX	cyclo-oxygenase
CPAP	continuous positive airway pressure
CPR	cardiopulmonary resuscitation
CRP	C-reactive protein
CRT	cardiac resynchronization therapy
CRT-D	cardiac resynchronization therapy + cardiac defibrillator
CT	computed tomography
CTPA	computed tomography pulmonary angiogram
CTR	cardiothoracic ratio
CV(S)	cardiovascular (system)
CVA	cerebrovascular accident
CVD	cerebrovascular disease
CVP	central venous pressure
CXA	X-ray coronary angiography
CXR	chest X-ray
DAPT	dual anti-platelet therapy
DC	direct current
DCM	dilated cardiomyopathy
DH	drug history
DHP	dihydropyridine
DKA	diabetic ketoacidosis
DM	diabetes mellitus
DVLA	Driver and Vehicle Licensing Agency
DVT	deep vein thrombosis
EBV	Epstein–Barr virus
ECG	electrocardiogram
echo	echocardiogram
ED	emergency department
EDV	end-diastolic volume
EEG	electroencephalogram
EF	ejection fraction
EGDT	early goal-directed therapy
eGFR	estimated glomerular filtration rate
ELR	external loop recorder
EPS	electrophysiological study
ESC	European Society of Cardiology
ESM	ejection systolic murmur
ESR	erythrocyte sedimentation rate
ESV	end-systolic volume
EVAR	endovascular aneurysm repair
FAST	focused assessment with sonography for trauma
FBC	full blood count
FFP	fresh frozen plasma
FFR	fractional flow reserve
FH	family history
FY2	foundation year 2 doctor
G6PD	glucose-6-phosphate dehydrogenase
GCS	Glasgow coma scale
GFR	glomerular filtration rate
GI	gastrointestinal
GMP	guanosine monophosphate
GORD	gastro-oesophageal reflux disease
GP	general practitioner
GRA	glucorticoid-remediable aldosteronism
GRACE	Global Registry of Acute Coronary Events
GTN	glyceryl trinitrate
GZA	glycyrrhizic acid
HACEK	organisms associated with culture-negative infective endocarditis
Hb	haemoglobin
HbA1c	glycated haemoglobin
HBPM	home blood pressure monitoring
HCG	human chorionic gonadotrophin
HCM	hypertrophic cardiomyopathy
HDL	high density lipoprotein
HDU	high dependency unit
HF	heart failure
HF-PEF	heart failure with preserved ejection fraction
HF-REF	heart failure with reduced ejection fraction
HIT	heparin-induced thrombocytopenia
HIV	human immunodeficiency virus
HOCM	hypertrophic obstructive cardiomyopathy
HPC	history of the presenting complaint
HR	heart rate
HTN	hypertension
IABP	intra-aortic balloon pump
IC	intercostal
ICD	implantable cardioverting defibrillator
ICH	intracerebral haemorrhage
IE	infective endocarditis
IGG	immunoglobulin G
IHD	ischaemic heart disease
ILR	internal loop recorder
IM	intramuscular
INR	international normalized ratio
ISMN	isosorbide mononitrate
ITU	intensive therapy unit
IV	intravenous
IVCD	intraventricular conduction delay
IVDU	intravenous drug user
IVUS	intravascular ultrasound
JVP	jugular venous pulse/pressure
LA	left atrium
Lac	lactate
LAD	left anterior descending coronary artery
LBBB	left bundle branch block
LCx	left circumflex artery
LDH	lactate dehydrogenase
LDL cholesterol	low density lipoprotein cholesterol
LFT	liver function test
LGV	large goods vehicle
LL	left leg
LMA	laryngeal mask airway
LMCA	left main coronary artery
LMWH	low molecular weight heparin
LQTS	long QT syndrome
LV	left ventricular/left ventricle
LVEDP	left ventricular end-diastolic pressure
LVEDV	left ventricular end-diastolic volume
LVEF	left ventricular ejection fraction
LVESD	left ventricular end-systolic diameter
LVH	left ventricular hypertrophy
LVOT	left ventricular outflow tract
LVOTO	left ventricular outflow tract obstruction
MAHA	microangiopathic haemolytic anaemia
MAOI	monoamine oxidase inhibitor
MAP	mean arterial pressure
MAU	medical assessment unit
MCA	middle cerebral artery
MCV	mean corpuscular volume
MDCT	multi-detector row computed tomography
MDM	multidisciplinary meeting
MDT	multidisciplinary team
MEN	multiple endocrine neoplasia
MI	myocardial infarction
MIBG	meta-iodobenzylguanidine
MR	mitral regurgitation
MRA	mineralocorticoid receptor antagonist
MRI	magnetic resonance imaging
MS	mitral stenosis
MVP	mitral valve prolapse
NAC	N-acetylcysteine
NBM	nil by mouth
NICE	National Institute for Health and Care Excellence
NOAC	novel oral anticoagulant
NPA	nasopharyngeal mask airway
NSAID	non-steroidal anti-inflammatory drug
NSTE ACS	non-ST-elevation acute coronary syndrome
NSTEMI	non-ST-elevation myocardial infarction
NYHA	New York Heart Association
OCT	optical coherence tomography
OD	once a day
OMB	obtuse marginal artery
OMT	optimal medical therapy
OR	odds ratio
OSCE	objective structured clinical examination
P2	pulmonary valve constituent of the second heart sound
PAD	peripheral arterial disease
P_aO₂	partial pressure of arterial oxygen
PCA	patient-controlled analgesia
PCC	prothrombin complex concentrate
PCI	percutaneous coronary intervention
PCR	protein:creatinine ratio
PCV	passenger-carrying vehicle
PDA	patent ductus arteriosus
PDE-5	phosphodiesterase-5
PE	pulmonary embolism
PEF	peak expiratory flow
PET	positron emission tomography
PFO	patent foramen ovale
PG	prostaglandin
PICC	peripherally inserted central catheter
PLV	posterior left ventricular branch
PMC	percutaneous mitral commisurotomy
PMH	past medical history
PND	paroxysmal nocturnal dyspnoea
PO	per os - taken orally
PP	pulse pressure
PPI	proton-pump inhibitor
PR	per rectum
PRN	pro re nata – as needed
PT	prothrombin time
PUO	pyrexia of unknown origin
PVI	pulmonary vein isolation
QDS	four times a day
QTc	corrected QT interval
RA	right atrium
RAA	renin–angiotensin–aldosterone
RBBB	right bundle branch block
RCA	right coronary artery
RCM	restrictive cardiomyopathy
RCT	randomized controlled trial
RF	risk factor
ROSC	return of spontaneous circulation
RR	respiratory rate
RRR	relative risk reduction
RV	right ventricular
RVOT	right ventricular outflow tract
RVST	right ventricular systolic pressure
S1	heart sound 1
S2	heart sound 2
S3	heart sound 3
S4	heart sound 4
SAN	sinoatrial node
S_aO₂	saturation of arterial oxygen
SAVR	surgical aortic valve replacement
SBAR	situation/background/assessment/recommendation
SC	subcutaneously
SG	specific gravity
SHO	senior house officer
SIRS	systemic inflammatory response syndrome
SLE	systemic lupus erythematosus
SOB	shortness of breath
SOBOE	shortness of breath on exertion
SPECT	single-photon emission computed tomography
SpO₂	oxygen saturation
SpR	specialist registrar
SSRI	selective serotonin reuptake inhibitor
STE ACS	ST-elevation acute coronary syndrome
STEMI	ST-elevation myocardial infarction
SV	stroke volume
SVC	superior vena cava
SVR	systemic vascular resistance
SVT	supraventricular tachycardia
T-LOC	transient loss of consciousness
TA	transapical
TAVI	transaortic valve implantation
TB	tuberculosis
TDS	three times a day
TF	transfemoral
TFT	thyroid function test
TGA	transposition of the great arteries
TIA	transient ischaemic attack
TIMI	Thrombolysis In Myocardial Infarction (study)
TOE	transoesophageal echocardiogram
TR	tricuspid regurgitation
TSH	thyroid-stimulating hormone
TTE	trans-thoracic echocardiogram
TXA2	thomboxane A2
U&E	urea and electrolytes
UA	unstable angina
UFH	unfractionated heparin
USS	ultrasound scan
UTI	urinary tract infection
VBG	venous blood gas
VF	ventricular fibrillation
VKA	vitamin K antagonist
VSD	ventricular septal defect
VT	ventricular tachycardia
VTE	venous thromboembolism
WCC	white cell count
WHO	World Health Organization
WPW	Wolff–Parkinson–White syndrome

The Clinical Guides Series

Clinical Guide to Cardiology

Contributors

Acronyms and Abbreviations

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PART 1
Examination Techniques