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The investigation of patients with cardiovascular disease should provide information on both the anatomy and the physiology of the heart and vessels, including the three-dimensional anatomy of the heart and its surrounding structures, global and regional pump function, blood supply and regional viability. The three main modalities currently used in cardiology (echocardiography, cardiac catheterization...
Cardiac catheterization involves insertion of a catheter into the heart, through a cannula in a peripheral artery or vein. It is performed under fluoroscopic guidance in a dedicated cardiac catheter laboratory or a shared multipurpose angiography suite. The most common access sites are the right femoral artery and vein. Left heart catheterization involves injection of contrast into the left ventricle...
Exercise ECG in the diagnosis of angina was first reported in 1932, and has since become central to the management of patients with suspected or proven coronary artery disease. This contribution focuses on performing the test and its interpretation. ECG is the most commonly used (and least expensive) method of identifying myocardial ischaemia during exercise; the sensitivity is about 70% and the specificity...
The echocardiography machine is a powerful computer that images the heart using ultrasound. It reveals cardiac anatomy and physiology, allowing diagnosis of diseases of the myocardium, valves, pericardium and aorta. The functional significance of coronary disease can be determined using stress echocardiography (see page 35) and myocardial perfusion imaging.
This contribution concentrates on the appearance of the adult chest radiograph in diseases of the heart and great vessels. It should be read in conjunction with MEDICINE 27:8, 7, which discusses the chest radiograph in respiratory disorders. The ideal radiograph for assessing the heart and great vessels is the straight, erect, postero-anterior (PA) chest radiograph taken at full inspiration. PA radiographs...
Nuclear cardiology techniques (most commonly myocardial perfusion imaging, MPI) and stress echocardiography provide functional information in coronary artery disease, in contrast to the anatomical information provided by coronary angiography. The methods involve two components: • stress (exercise or drugs), to provoke relative hypoperfusion of myocardium supplied by stenosed coronary arteries...
Despite the large range of investigations that are now available for the diagnosis of cardiovascular disease, a good clinical history remains the clinician's most valuable diagnostic tool. In many cases, the diagnosis may be made from the history alone, and examination and investigations are confirmatory. In other cases, a useful differential diagnosis list can be made and used to direct investigations...
More than 100 years since the first ECG recording, the resting 12-lead ECG remains an essential part of any cardiovascular assessment. It has been estimated that more than 100,000,000 12-lead ECGs are recorded annually worldwide.
Atherosclerosis is a disease of the arterial wall that underlies many of the very common causes of cardiovascular mortality, including myocardial infarction (MI), peripheral vascular disease and cerebrovascular disease. Early pathological descriptions viewed atherosclerosis as an end-stage degenerative disease that inevitably resulted in a generalized narrowing of the arterial lumen. However, recent...
The term ‘percutaneous coronary intervention’ (PCI) is used to describe various procedures that can be used to mechanically improve myocardial perfusion without resorting to surgery. The most common procedure is percutaneous transluminal coronary angioplasty (PTCA), usually with implantation of an intracoronary stent. Other methods may be appropriate in small subsets of patients. More than 1 million...
The normally functioning heart provides sufficient oxygenated blood containing nutrients, metabolites and hormones to meet moment-by-moment metabolic needs and to preserve a constant internal milieu. Its two essential characteristics are contractility and rhythmicity. In the regulation of these, the nervous system and neurohumoral effects modulate relationships between venous return, outflow resistance,...
Following myocardial infarction (MI), mortality and the incidence of recurrent non-fatal MI is highest in the first 4-6 weeks (Figure 1). Subsequently, 5-10% of those aged 50-70 years die each year (compared with an average 1% of the general population) and 3-4% suffer a further non-fatal MI. Survival is worse with increasing age, greater left ventricular (LV) dysfunction and recurrent MI. MI can...
The heart is a midline, valvular, muscular pump that is cone-shaped and the size of a fist. It weighs 300 g in adults and lies in the middle mediastinum of the thorax. The inferior (diaphragmatic) surface sits on the central tendon of the diaphragm, and the base faces posteriorly and lies immediately anterior to the oesophagus and descending aorta. The base comprises mainly the left atrium, with a...
This contribution discusses the use of statins (HMG-CoA reductase inhibitors), aspirin and antihypertensive drugs in secondary and primary prevention of coronary heart disease (CHD), focusing on the rationale for and practical aspects of CHD risk assessment in targeting these treatments.
The synchronous contraction of cardiac myocytes during ventricular systole generates the power required to pump blood out of the heart. Conversely, myocyte relaxation and the passive properties of the ventricles during diastole (dependent largely on the properties of the extracellular matrix) determine the filling of the heart between beats. Several interacting regulatory processes operate to ensure...
Angina is a common symptom associated with considerable morbidity and mortality; with proper management, both can be reduced. All patients (with the possible exception of the very elderly with mild symptoms) should be referred to a cardiologist for assessment. The cornerstones of management include establishing the diagnosis, treating the symptoms, determining the risk of future adverse events and...
Acute myocardial infarction (AMI) is a common, potentially fatal condition, and the long-term outcome in survivors may be poor as a result of myocardial damage and associated heart failure. Primary prevention may reduce the likelihood of coronary atheroma, but in many patients the first clinical presentation of ischaemic heart disease (IHD) is acute coronary occlusion. Thus, individuals who develop...
Coronary artery bypass grafting (CABG) is entering a new era as minimally invasive techniques, off-pump surgery and total arterial revascularization have found roles in the surgical treatment of patients with coronary artery disease. The continued development of the techniques of percutaneous coronary intervention (PCI) is also having an impact on the type of patient referred for CABG.
Valvular aortic stenosis, defined as obstruction to left ventricular (LV) outflow, is most commonly caused by calcific degeneration of a trileaflet or congenitally bicuspid valve. It is present in 1-2% of adults over the age of 65 years. Rheumatic aortic stenosis is common in developing countries but less common in Europe and the USA and invariably associated with mitral disease. Almost 30,000 aortic...
Cardiomyopathies are defined as diseases of the myocardium associated with cardiac dysfunction. In 1996, the WHO recommended that the cardiomyopathies be categorized into two groups – specific cardiomyopathy and primary cardiomyopathy. • Specific cardiomyopathies include cardiomyopathy caused by valvular heart disease, ischaemic heart disease, hypertension, inflammation, and general systemic...
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