Manual of Outpatient Cardiology John D. Bisognano G. Ronald Beck (cid:129) Ryan W. Connell (Editors) Manual of Outpatient Cardiology Editors Dr. John D. Bisognano, M.D., Ph.D Ryan W. Connell, M.D Department of Internal Medicine Department of Internal Medicine Division of Cardiology Division of Cardiology University of Rochester University of Rochester Medical Center Medical Center Rochester, New York Rochester, New York USA USA G. Ronald Beck, M.S Department of Internal Medicine Division of Cardiology University of Rochester Medical Center Rochester, New York USA ISBN 978-0-85729-943-7 e-ISBN 978-0-85729-944-4 DOI 10.1007/978-0-85729-944-4 Springer London Dordrecht Heidelberg New York British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2011941507 © Springer-Verlag London Limited 2012 Whilst we have made considerable efforts to contact all holders of copyright mate- rial contained in this book, we may have failed to locate some of them. Should holders wish to contact the Publisher, we will be happy to come to some arrange- ment with them. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of repro- graphic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharma- ceutical literature. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword All health care providers need to know how to diagnose and treat common cardiovascular diseases for one simple reason: cardiovascular diseases are common and deadly. The preva- lence of cardiovascular diseases is enormous: 8% of adult Americans have diabetes, 23% of men and 19% of women smoke, 33% have hypertension, and 33% are obese [1]. In the United States, cardiovascular diseases cause over 780,000 heart attacks and 400,000 deaths each year [1]. Cardiovascular diseases are the biggest cause of death and disability across the globe [2]. However, it is challenging to keep up with the latest advancements in cardiovascular diagnostics and therapies. The pace of medical research is accelerating, with the spread of genetic testing, the explosion of clinical trials, and the pro- liferation of treatment guidelines. The Manual of Outpatient Cardiology provides a concise and authoritative guide for a variety of health care providers who do not necessarily specialize in cardiology: primary care physicians, physician assistants, nurse practitioners, residents, and students. We have divided the book into three parts: car- diovascular diagnostics, cardiac diseases, and cardiac symp- toms. We have included the most recent guidelines of both the American College of Cardiology and the American Heart Association to make this manual the most authoritative and reliable outpatient guide available. The section on Cardiac Diagnostics is a guide to health care providers who are confronted with patients with common cardiovascular diseases, and who must choose the best and most cost-efficient set of tests. This section discusses when to v vi Foreword use specific tests, such as stress tests and cardiac ultrasound, while weighing the risks and benefits. The chapters on Common Cardiac Diseases emphasize conditions seen every day in the clinics of general medical doctors and specialists, including common diseases such as hypertension and dyslipi- demia. The final section, Approach to the Patient, summarizes the most up to date strategy to evaluate and treat common symptoms, including chest pain, dizziness, and palpitations. We hope this Manual of Outpatient Cardiology will be use- ful to a wide range of readers who want to learn more about cardiovascular diseases encountered every day in the clinic. We thank our contributors and members of the Cardiology Division of University of Rochester Medical Center for their knowledge and expertise in preparing this book. Rochester, NY, USA Charles J. Lowenstein References 1. Roger VL et al. Heart disease and stroke statistics 2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–209. 2. World Health Organization: Global health observatory data reposi- tory, causes of death summary tables 2008: h ttp://apps.who.int/ ghodata/?vid = 10012. June 16, 2011. Contents Part I Cardiac Diagnostics 1 History and Physical. . . . . . . . . . . . . . . . . . . . . . . . . . 3 Norman Gray and J. Franklin Richeson 2 Evaluation of Heart Rhythms . . . . . . . . . . . . . . . . . . 15 James Gallagher and Christine Tompkins 3 Cardiac Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Harry E. McCrea and Michael W. Fong 4 Cardiovascular Stress Testing . . . . . . . . . . . . . . . . . . 79 Mohan Rao, Nicholas A. Paivanas, and James Eichelberger 5 Coronary Artery Evaluation . . . . . . . . . . . . . . . . . . . 105 Michael Katz, Blake Gardner, and John P. Gassler Part II Common Cardiac Diseases 6 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Melissa Gunasekera, John D. Bisognano, and G. Ronald Beck 7 Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Kevin J. Woolf and Robert C. Block 8 Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . 179 Benjamin G. Plank, M. James Doling, and Peter A. Knight vii viii Contents 9 Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . 217 Ryan J. Hoefen and Eugene Storozynsky 10 Ambulatory Arrhythmias . . . . . . . . . . . . . . . . . . . . . 237 Andrew J. Brenyo and Mehmet K. Aktas 11 Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . 281 Susan F. Lien and Jeffrey D. Alexis 12 Vascular Diseases – Peripheral/Aorta . . . . . . . . . . . 325 Craig R. Narins, Jason D. Pacos, and Theodore I. Hirokawa Part III Approach to the Patient 13 Approach to the Patient with Chest Pain . . . . . . . . 349 Benjamin R. McClintic and Robert L. Rosenblatt 14 Syncope, Work Up and Management . . . . . . . . . . . . 373 Menachem Wakslak and David T. Huang 15 Palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391 Matthew Jonovich and Burr Hall 16 New Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Angelo J. Pedulla and Bryan Henry 17 Approach to the Patient with Dyspnea . . . . . . . . . . 427 Christopher D. Lang and Imran N. Chaudhary 18 Preoperative Cardiovascular Risk Assessment for Non-cardiac Surgery. . . . . . . . . . . . . . . . . . . . . . . 445 John E. Reuter and John C. Teeters 19 Approach to the Patient with Cardiovascular Disease and Activity Limitations . . . . . . . . . . . . . . . 465 Ryan W. Connell and Duncan D. Wormer Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489 List of Contributors Mehmet K. Aktas , M.D. Division of Cardiology – Electrophysiology , University of Rochester Medical Center , Rochester , NY , USA Jeffrey D. Alexis , M.D. Division of Cardiology, Department of Internal Medicine , University of Rochester Medical Center , Rochester , NY , USA G. Ronald Beck , M.S. Department of Internal Medicine Division of Cardiology , University of Rochester Medical Center , Rochester , NY , USA John D. Bisognano , M.D., Ph.D. Division of Cardiology, Department of Internal Medicine , University of Rochester Medical Center , Rochester , NY , USA Robert C. Block , M.D., MPH Department of Community and Preventive Medicine , The University of Rochester School of Medicine and Dentistry , Rochester , NY , USA Andrew J. Brenyo , M.D. Division of Cardiology , University of Rochester Medical Center , Rochester , NY , USA Imran N. Chaudhary , MB, BS Division of Cardiology , University of Rochester Medical Center , Rochester , NY , USA ix x List of Contributors Ryan W. Connell , M .D. Division of Cardiology, Department of Internal Medicine, University of Rochester Medical Center , Rochester , NY , USA M. James Doling , M.D. Division of Cardiology , University of Rochester Medical Center , Rochester , NY , USA James Eichelberger , M.D. Division of Cardiology, Department of Medicine , University of Rochester , Rochester , NY , USA Michael W. Fong , M.D. Division of Cardiology , University of Southern California , Los Angeles , CA , USA James Gallagher , M.D. Division of Cardiology, Department of Medicine , University of Rochester Medical Center , Rochester , NY , USA Blake Gardner , M.D. Division of Cardiology, Department of Medicine , University of Rochester Medical Center , Rochester , NY , USA John P. Gassler , M.D. Division of Cardiology, Department of Medicine , University of Rochester Medical Center , Rochester , NY , USA Norman Gray Jr, M.D. Division of Cardiology , University of Rochester Medical Center , Rochester , NY , USA Melissa Gunasekera , M.D. Department of Medicine , University of Rochester Medical Center , Rochester , NY , USA