Cardiology Explained PDF

EXPLAINED SERIES Cardiology explained Cardiology One of the most time-consuming tasks in clinical medicine is s...

EXPLAINED SERIES Cardiology explained Cardiology One of the most time-consuming tasks in clinical medicine is seeking the opinion of specialist colleagues. There is a pressure not only to make referrals appropriate, but also to summarize the case in the language of the specialist. Cardiology Explained is an essential tool in this task. It explains the basic physiology and pathophysiologic mechanisms of cardiovascular disease in a straightforward and diagrammatic manner, gives guidelines as to when referral is appropriate, and, uniquely, explains what the specialist is likely to do. explained This facilitates an understanding of the specialty not available from Euan A Ashley and Josef Niebauer Euan A Ashley and Josef Niebauer standard textbooks. With wide appeal, this book is ideal for any hospital doctor, generalist, or even senior medical student who may need a cardiology opinion; or for that matter, anyone who simply wants some of cardiology – explained. Contents Cardiac arrest Cardiovascular examination Conquering the ECG Understanding the echocardiogram Coronary artery disease Hypertension Heart failure Arrhythmia Valve disease Infective endocarditis Cardiomyopathy Aneurysm and dissection of the aorta Pericardial disease Adult congenital heart disease “Cardiology Explained is for the generalist who wants a no-nonsense, jargon-explaining, up-to-date overview of the latest developments in cardiology. It is not intimidating and is well-illustrated with clear diagrams and clinical data. The 14 chapters cover the whole range of modern cardiology in a thoroughly satisfactory manner.” Professor Peter Sleight Emeritus Professor of Cardiovascular Medicine, University of Oxford, UK Cardiology explained Remedica explained series ISSN 1472-4138 Also available Anal and rectal diseases explained Interventional radiology explained Forthcoming Common spinal disorders explained Published by Remedica 32–38 Osnaburgh Street, London, NW1 3ND, UK Civic Opera Building, 20 North Wacker Drive, Suite 1642, Chicago, IL 60606, USA Email: [email protected] www.remedicabooks.com Publisher: Andrew Ward In-house editors: Tonya Berthoud, Helen James, Roisin O’Brien, & Cath Harris Design: AS&K Skylight Creative Services © 2004 Remedica While every effort is made by the publisher to see that no inaccurate or misleading data, opinions, or statements appear in this book, they wish to make it clear that the material contained in the publication represents a summary of the independent evaluations and opinions of the authors. As a consequence, the authors, publisher, and any sponsoring company accept no responsibility for the consequences of any inaccurate or misleading data or statements. Neither do they endorse the content of the publication or the use of any drug or device in a way that lies outside its current licensed application in any territory. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher. Remedica is a member of the AS&K Media Partnership. ISBN 1 901346 22 6 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. Cardiology explained Euan A Ashley and Josef Niebauer Euan A Ashley Division of Cardiovascular Medicine Stanford University School of Medicine Falk CVRC, 300 Pasteur Drive Palo Alto, California 94305 USA Josef Niebauer Privatdozent and Consultant Cardiologist Department of Internal Medicine and Cardiology University of Leipzig – Heart Center Strümpellstr. 39 04289 Leipzig Germany Foreword Cardiology is a rapidly changing field. New technologies such as drug-eluting stents, left ventricular assist devices, and novel inflammatory markers, and imaging modalities such as magnetic resonance imaging and three-dimensional echocardiography, offer us an unprecedented view of the function of the heart in health and an unparalleled scope of therapies with which to treat disease. Yet, although we cardiologists like to think that we are more innovative and pioneering than our colleagues in other specialties, it seems at least possible that there are equally exciting changes in other fields, too. All of this leaves the generalist as the patient’s primary advocate, as the integrator of all these specialist opinions, trying at once to learn enough of the new advances to communicate with both patient and specialist, but not so much as to lose the big picture in amongst the details. What the generalist needs is a concise, well written, beautifully illustrated guide to cardiology. And fortunately, if you’re reading this, you’ve already found it! The authors have recognized that generalists need help in staying up-to-date with specialist advances in a way that journals can rarely provide: a comprehensive, yet highly digestible update to cardiology that can jog the memory in a tactful but not patronizing way. Further, it is organized not in the didactic way in which many such textbooks are written, but in a way that will make sense to the practicing clinician who needs the facts quickly to hand. Clear yet detailed explanations of what cardiologists do can be found within these pages. Specific guides to understanding cardiological tests and writing good referral letters are two of the unusual, yet extremely useful places where this book differs from others you might have read. All recommendations are, of course, consistent with the latest guidelines from the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. Meanwhile, the historical nuggets remind us from where we have come and just how lucky we are to make it this far (intact!). Together, these things serve to make this book a unique and invaluable resource for generalists and other subspecialists, both in hospital and in the community. I highly commend you for picking it up! Alan Yeung Professor of Medicine (Cardiovascular), Stanford University Medical Center, USA Preface We may not be the most impartial commentators, but it seems to us that the heart is the most interesting organ in the body. It beats in a tightly regulated, finely coordinated, gracefully rhythmic fashion to distribute blood and oxygen to all the other organs. It does this more than 2 billion times in the lifetime of an average human. It can accelerate to power an Olympic athlete for 26 miles in a little over 2 hours, and it can weaken to hold your 86-year-old patient hostage in her favorite chair. Yet the heart, so central to the metaphors of our language, has not revealed its secrets readily. This may be because until relatively recently, it was believed the heart was the only organ that could not be cut (heart surgery was unthinkable from the time of Aristotle until the late 1800s). But this reflects the heart’s eternal mystique. Since the invention of the stethoscope we have used technology to reveal the innermost workings of the heart. In recent times, technological advance has been ever more rapid. Indeed, the rapidity of this technological advance is what led us to writing this book. Meanwhile, the bulk of cardiovascular disease remains the realm of the generalists. From whose perspective, knowing when to make use of specialists and knowing how to view their input in the context of the whole patient is increasingly important, yet increasingly difficult. So this is the aim of our book: to sit beside you when you wonder, “Should I refer this patient to a cardiologist”; to look over your shoulder when you receive the cardiology clinic letter; to whisper in your ear the normal left ventricular internal diameter. In short, if our book can be your partner in working with your cardiologist then it has been successful. If it can answer questions the answers to which you once knew, it has been valuable. If it can explain the answers to questions you didn’t know you wanted to ask, then it has been worth our while and worth your money. We care deeply that this book fulfils your needs and welcome any feedback on its content, explanatory style, or level of detail. Many people have made this book possible. Too many to mention in these pages. We would like to thank our wives Fiona and Dörte who have been patient and understanding during the long nights and early mornings. Many cardiologists and generalists gave advice and read chapters and we would like to thank them all here. Finally, we’d like to thank Cath Harris, Andrew Ward, and all the team at Remedica who coaxed and cajoled us, encouraged and enlivened our text, and heroically rescued our diagrams from obscurity. Euan A Ashley and Josef Niebauer To Angus Ashley, the best doctor I know EAA  “To study disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler, 1901 “As a cardiologist, I may panic when I see somebody bleed from his nose, but not when I see a heart fibrillate. This is my territory.” Lofty L Basta, 1996 Contents Chapter 1 Cardiac arrest 1 Chapter 2 Cardiovascular examination 5 Chapter 3 Conquering the ECG 15 Chapter 4 Understanding the echocardiogram 35 Chapter 5 Coronary artery disease 45 Chapter 6 Hypertension 77 Chapter 7 Heart failure 93 Chapter 8 Arrhythmia 111 Chapter 9 Valve disease 145 Chapter 10 Infective endocarditis 167 Chapter 11 Cardiomyopathy 181 Chapter 12 Aneurysm and dissection of the aorta 189 Chapter 13 Pericardial disease 197 Chapter 14 Adult congenital heart disease 203 Abbreviations 215 Index 219 Chapter 1 Cardiac arrest Adult basic life-support algorithm Check responsiveness Shake and shout Open airway Head tilt/chin lift If breathing: Check breathing Look, listen, and feel recovery position Breathe Two effective breaths Assess Signs of a circulation 10 seconds only Circulation present No circulation Continue rescue breathing Compress chest Check circulation 100 per minute every minute 15:2 ratio Send or go for help as soon as possible according to guidelines 1 Chapter 1 Advanced life-support algorithm for the management of cardiac arrest in adults (US version) Cardiac arrest Basic life-support algorithm Precordial thump Attach defibrillator/monitor Assess rhythm Check pulse +/– During CPR VF/VT Non-VF/VT Check electrodes, paddle positions, and contact Attempt to place, confirm, secure airway Attempt/verify IV access Attempt Patients with VF/VT refractory to initial shocks: defibrillation x3 – epinephrine 1 mg IV, every 3–5 minutes, or as necessary – vasopressin 40 U IV, single dose 1 time only Patients with non-VF/VT rhythms: – epinephrine 1 mg IV, every 3–5 minutes Consider: buffers, antiarrhythmics, pacing CPR CPR up to Search for and correct reversible causes 1 minute 3 minutes Consider causes that are potentially reversible Hypoxia "Tablets" (drug OD, accidents) Hypovolemia Tamponade, cardiac Hydrogen ion – acidosis Tension pneumothorax Hyper-/hypokalemia & metabolic disorders Thrombosis, coronary (ACS) Hypothermia Thrombosis, pulmonary (embolism) ACS: acute coronary syndromes; CPR: cardiopulmonary resuscitation; IV: intravenous; OD: overdose; VF: ventricular fibrillation; VT: ventricular tachycardia. 2  Cardiac arrest Advanced life-support algorithm for the management of cardiac arrest in adults (UK version) Cardiac arrest Precordial thump if appropriate Basic life-support algorithm if appropriate Attach defibrillator/monitor Assess rhythm Check pulse +/– VF/VT During CPR Non-VF/VT Correct reversible causes If not already Attempt Check electrodes, paddle positions, and contact defibrillation x3 Attempt/verify airway and O2 IV access as necessary Give epinephrine every 3 minutes Consider: – amiodarone – atropine/pacing CPR – buffers CPR up to 1 minute 3 minutes Consider causes that are potentially reversible Hypoxia Tamponade Hypovolemia Tension pneumothorax Hyper-/hypokalemia & metabolic disorders Toxic/therapeutic disorders Hypothermia Thromboembolic & mechanical obstruction CPR: cardiopulmonary resuscitation; IV: intravenous; VF: ventricular fibrillation; VT: ventricular tachycardia. 3 Chapter 1 The adult basic life-support algorithm (UK version) is reprinted with permission from the Resuscitation Council (UK) website and is available at: www.resus.org.uk The advanced life-support algorithm for the management of cardiac arrest in adults (US version) is reprinted with permission from the American Heart Association (Circulation 2000;102:I-143). The advanced life-support algorithm for the management of cardiac arrest in adults (UK version) is reprinted with permission from the Resuscitation Council (UK) website and is available at: www.resus.org.uk 4 Chapter 2 Cardiovascular examination Although technology has a high profile in cardiology, clinical examination remains a central tool, especially for the generalist. General inspection Many clues to the cardiac condition can be detected with a simple visual inspection. In the acutely unwell patient, cyanosis, pallor, and sweatiness can all be signs of impending danger – does the patient “look” ill? In nonacute patients, cachexia is perhaps the most important feature to note on general inspection since it is an important prognostic sign in heart failure. Palpation is essential to confirm that girth is excess fluid (pitting edema). Certain physical appearances should always prompt an awareness of cardiac abnormalities (see Table 1). Facial signs for which there is evidence of an association with cardiac conditions are shown in Table 2. Finally, it is important to document the condition of a potential cardiac patient’s teeth. Genetic disorder Associated cardiac manifestation Marfan’s syndrome Aortic regurgitation (aortic dissection) Down’s syndrome ASD, VSD Turner’s syndrome Coarctation of the aorta Spondyloarthritides, Aortic regurgitation eg, ankylosing spondylitis Table 1. Cardiac manifestations of genetic disorders. ASD: atrial septal defect; VSD: ventricular septal defect. Taking the pulse Taking the pulse is one of the simplest, oldest, and yet most informative of all clinical tests. As you pick up the patient’s hand, you should check for clubbing and any peripheral signs of endocarditis (see Table 3). Note the rate and document the rhythm of the pulse. The character and volume of the pulse can also be useful signs and traditionally it is believed that these are easier to detect in larger arteries such as the brachial and the carotid (see Table 4). 5 Chapter 2 Facial sign Description Possible cardiac association Malar flush Redness around the cheeks Mitral stenosis Xanthomata Yellowish deposits of lipid around the Hyperlipidemia eyes, palms, or tendons Corneal arcus A ring around the cornea Age, hyperlipidemia Proptosis Forward projection or displacement of Atrial fibrillation the eyeball; occurs in patients with Graves’ disease Table 2. Facial signs associated with cardiac conditions. Peripheral Description Cardiac sign association Clubbing Broadening or thickening of the tips of Infective endocarditis, the fingers (and toes) with increased cyanotic congenital lengthwise curvature of the nail and a heart disease decrease in the angle normally seen between the cuticle and the fingernail Splinter Streak hemorrhages in nailbeds Infective endocarditis hemorrhages Janeway lesions Macules on the back of the hand Infective endocarditis Osler’s nodes Tender nodules in fingertips Infective endocarditis Table 3. Peripheral signs associated with infective endocarditis. Checking both radials simultaneously is important in all cases of chest pain as a gross screening test for aortic dissection. Adding radiofemoral delay (or radiofemoral difference in volume) may alert you to coarctation as a rare cause of hypertension. Peripheral pulses should also be documented, as peripheral vascular disease is an important predictor of coronary artery disease: femoral – feel at the midinguinal point (midway between the symphysis pubis and the anterior superior iliac spine, just inferior to the inguinal ligament) popliteal – feel deep in the center of the popliteal fossa with the patient lying on their back with their knees bent posterior tibial – feel behind the medial malleolus dorsalis pedis – feel over the second metatarsal bone just lateral to the extensor hallucis tendon 6  Cardiovascular examination Type of pulse Pulse characteristics Most likely cause Regularly irregular – 2nd-degree heart block, ventricular bigeminy Irregularly irregular – Atrial fibrillation, frequent ventricular ectopics Slow rising Low gradient upstroke Aortic stenosis Waterhammer, Steep up and down stroke Aortic regurgitation, collapsing (lift arm so that wrist is patent ductus arteriosus above heart height) Bisferiens A double-peaked pulse – the Aortic regurgitation, second peak can be smaller, hypertrophic cardiomyopathy larger, or the same size as the first Pulsus paradoxus An exaggerated fall in pulse Cardiac tamponade, volume on inspiration acute asthma (>10 mm Hg on sphygmomanometry) Bounding Large volume Anemia, hepatic failure, type 2 respiratory failure (high CO2) Pulsus alternans Alternating large and small Bigeminy volume pulses Table 4. Abnormal pulses. Blood pressure This is described in Chapter 6, Hypertension. Jugular venous pressure Of all the elements of clinical examination, the jugular venous pressure (JVP) is the most mysterious. It is highly esoteric, and whilst some people wax lyrical about the steepness of the “y” descent, others will feel grateful to be convinced they see it at all. Two things are very clear: (1) the JVP is a very useful clinical marker in many situations, and (2) the exact height of the JVP is a poor guide to central venous pressure. Taken together, this suggests that noting whether the JVP is “up” or “down” is good practice in every cardiac patient. In particular, it can be very useful in diagnosing right-sided heart failure and in differentiating a cardiovascular cause of acute shortness of breath (right ventricular failure, pulmonary embolism) from an intrinsic pulmonary cause (asthma, chronic obstructive pulmonary disease). For the general physician, the waveform of the JVP (see Figure 1) is, for most purposes, only of academic significance. 7 Chapter 2 a a v c y x Diastole Ventricular Diastole systole a wave x descent v wave y descent Atrium contracting Atrium relaxing then Atrium tense, full; Atrium emptying, tricuspid valve open filling, tricuspid tricuspid closed tricuspid open closed Figure 1. Waveforms of the jugular venous pressure (including a brief explanation for each wave). The “c” wave represents right ventricular contraction “pushing” the tricuspid valve back into the right atrium. Reproduced with permission from Oxford University Press (Longmore JM et al. The Oxford Handbook of Clinical Medicine, 5th Edn, p. 79). The JVP should be assessed with the patient reclined at a 45º angle (see Figure 2). Accepted practice is that only the internal jugular vein should be used, as only this vessel joins the superior vena cava at a 180º angle. The JVP is defined as the height of the waveform in centimeters above the sternal angle (20,000 Hz). For adult cardiac imaging, ultrasound waves in the range of 4–7 MHz are used (intravascular ultrasound uses frequencies as high as 30 MHz). These are created within the ultrasound probe by striking piezo-electric crystals with an electric pulse, which stimulates the crystals to release sound waves. The central principle of ultrasound imaging is that, while most waves are absorbed by the body, those at interfaces between different tissue densities are reflected. In addition to emitting the ultrasound waves, the transducer detects the returning waves, processes the information, and displays it as characteristic images. Higher frequency ultrasound waves increase resolution, but decrease tissue penetration. Imaging modes There are three basic “modes” used to image the heart: two-dimensional (2D) imaging M-mode imaging Doppler imaging Two-dimensional imaging 2D imaging is the mainstay of echo imaging and allows structures to be viewed moving in real time in a cross-section of the heart (two dimensions). It is used for detecting abnormal anatomy or abnormal movement of structures. The most common cross-sectional views are the parasternal long axis, the parasternal short axis, and the apical view (see Figure 1). The gastric or subcostal and suprasternal views are also commonly used. 35 Chapter 4 (a) (b) (c) RV RV LV LV AV LV RV LA RA LA Figure 1. The most common two-dimensional imaging echo views. The first line illustrates the three planes (think of them as three plates of glass intersecting at 90°), the second line shows these three planes separated, and the third line shows the accompanying echo views. (a) Parasternal long axis; (b) parasternal short axis; (c) apical 4-chamber view (note, in the UK, the 4-chamber view is shown upside down). AV: aortic valve; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle. M-mode imaging The M-mode echo, which provides a 1D view, is used for fine measurements. Temporal and spatial resolutions are higher because the focus is on only one of the lines from the 2D trace (see Figure 2). Doppler imaging The concept of Doppler imaging is familiar to all those who have heard the note of a police siren change as it moves past them – as the police siren travels towards you, the frequency of the wave (pitch) appears to be higher than if it was stationary; as the siren travels away, the pitch appears to be lower. Estimates of blood-flow velocity can be made by comparing the frequency change between the transmitted and reflected sound waves. In cardiac ultrasound, Doppler is used in three ways: 36  Understanding the echocardiogram (a) (b) Figure 2. M-mode image of (a) the aorta/left atrium and (b) the mitral valve, both in a healthy heart. Figure 3. Continuous-wave Doppler signal. continuous-wave (CW) Doppler pulsed-wave (PW) Doppler color-flow mapping (CFM) Continuous-wave Doppler CW Doppler is sensitive, but, because it measures velocity along the entire length of the ultrasound beam and not at a specific depth, it does not localize velocity measurements of blood flow. It is used to estimate the severity of valve stenosis or regurgitation by assessing the shape or density of the output (see Figure 3). Pulsed-wave Doppler PW Doppler was developed because of the need to make localized velocity measurements of turbulent flow (it measures the blood-flow velocity within a small area at a specified tissue depth). It is used to assess ventricular in-flow patterns, intracardiac shunts, and to make precise measurements of blood flow at valve orifices. 37 Chapter 4 Figure 4. Color-flow mapping. Color-flow mapping CFM uses measurements of the velocity and direction of blood flow to superimpose a color pattern onto a section of a 2D image (see Figure 4). Traditionally, flow towards the transducer is red, flow away from the transducer is blue, and higher velocities are shown in lighter shades. To aid observation of turbulent flow there is a threshold velocity, above which the color changes (in some systems to green). This leads to a “mosaic” pattern at the site of turbulent flow and enables sensitive screening for regurgitant flow. Transesophageal echocardiography Transesophageal echocardiography (TEE) is usually carried out under mild sedation with midazolam. A thin probe is passed down the esophagus until it is level with the heart. This position provides especially clear views. It is particularly useful for imaging posterior cardiac structures. The key indications for TEE are: infective endocarditis – if vegetations are not seen on transthoracic echo, but suspicion is high, or with prosthetic valves to rule out an embolic source (especially in atrial fibrillation) acute dissection mitral valve (MV) disease preoperatively Contrast echocardiography Contrast echo can be useful for confirming a diagnosis of atrial septal defect (ASD). Agitating saline or synthetic contrast create microbubbles. These are very reflective, 38  Understanding the echocardiogram Normal ranges for measures of systolic and diastolic function Echocardiography Fractional shortening (%) 28–44 Doppler Systolic velocity integral (cm) 15–35 Mitral valve E (cm/s) 44–100 Mitral valve A (cm/s) 20–60 E:A ratio 0.7–3.1 Tricuspid valve E (cm/s) 20–50 Tricuspid valve A (cm/s) 12–36 E:A ratio 0.8–2.9 Time intervals Mitral E deceleration time (ms) 139–219 Mitral A deceleration time (ms) >70 Isovolumic relaxation time (ms) 54–98 Normal intracardiac dimensions (cm) Men Women Left atrium 3.0–4.5 2.7–4.0 LV diastolic diameter 4.3–5.9 4.0–5.2 LV systolic diameter 2.6–4.0 2.3–3.5 IV septum (diastole) 0.6–1.3 0.5–1.2 Posterior wall (diastole) 0.6–1.2 0.5–1.1 Table 1. The approximate normal values for various cardiac structures. IV: interventricular; LV: left ventricular. and when injected intravenously can be seen as opacification in the echo window. They are normally seen on the right side of the heart before being trapped and absorbed by the pulmonary capillaries, so have no route to the left side of the heart. The contrast created by the bubbles allows a left-to-right shunt to be seen as a jet “interrupting” the opacification of the right atrium. However, there is a theoretical risk of systemic air embolism with a right-to-left shunt. Applications Echo is the cheapest and least invasive method available for screening cardiac anatomy. Generalists most commonly request an echo to assess left ventricular (LV) dysfunction, to rule out the heart as a thromboembolic source, and to characterize murmurs. The approximate normal values for various cardiac structures are described in Table 1. 39 Chapter 4 Figures 5. E and A waves representing mitral flow in a healthy heart (E>A). Systolic dysfunction LV systolic dysfunction is assessed using the ejection fraction (the percentage of the end diastolic volume ejected during systole). In most cases, this is estimated by eye from all the available echo views. A normal ejection fraction is 50%–80%, but values as low as 5% are compatible with life (end-stage heart failure). The E/A ratio When flow across the MV is assessed with PW Doppler, two waves are characteristically seen. These represent passive filling of the ventricle (early [E] wave) and active filling with atrial systole (atrial [A] wave). Classically, the E-wave velocity is slightly greater than that of the A wave (see Figure 5). However, in conditions that limit the compliance of the LV, two abnormalities are possible: reversal – in which the A wave is greater than the E wave. This indicates slow filling caused by older age, hypertension, left ventricular hypertrophy (LVH), or diastolic dysfunction exaggeration of normal – a tall, thin E wave with a small or absent A wave. This indicates restrictive cardiomyopathy, constrictive pericarditis, or infiltrative cardiac disease (eg, amyloidosis) Diastolic dysfunction A normal LV ejection fraction in the presence of the heart failure syndrome leads to a search for diastolic dysfunction. Typical echo findings in diastolic dysfunction are normal LV cavity size, thickened ventricle, and reversed E/A ratio. Wall-motion abnormality When ischemia occurs, contractile abnormalities of segments of the myocardium can be detected by echo prior to the appearance of electrocardiogram (ECG) changes or symptoms. Therefore, echo can be a valuable tool in the diagnosis of 40  Understanding the echocardiogram Mild or no aortic stenosis Severe aortic stenosis Area of effective >1 60 drop (mm Hg) Table 2. Echo characteristics of aortic stenosis. both stable coronary artery disease (via stress echo) and acute myocardial infarction. In the former situation, it offers localization of the ischemic region where the ECG cannot; in the latter, it offers some measure of the extent of the infarct and a screen for complications, such as ventricular septal defect (VSD). Valve assessment Echo is the tool of choice for the assessment of valvular abnormalities. Aortic stenosis The etiology of aortic stenosis (AS) can be confirmed by the visualization of either a bicuspid valve or calcification. The severity of the stenosis can be estimated by measuring high-velocity flow across the valve by Doppler. This can be converted to an estimation of the pressure drop. In addition, the effective orifice area can be measured (see Table 2). Aortic regurgitation CFM is the most useful technique for detecting and quantifying the degree of regurgitation. The width of the regurgitant jet and of the slope of the decline in pressure gradient between the left ventricle and the aorta (which is reduced already compared with normal) are measured. Mitral stenosis With mitral stenosis (MS), as with AS, calcified, immobile MV leaflets can be demonstrated with 2D and M-mode echo. Anterior motion of the posterior MV leaflet in diastole (caused by commissural fusion) is characteristic in MS. Doppler demonstrates increased flow velocity and can be used to estimate the effective orifice area (see Table 3). Mitral regurgitation As with aortic regurgitation, mitral regurgitation is assessed using CFM. The severity of mitral regurgitation is commonly reported as the area of the regurgitant jet expressed as a percentage of the area of the left atrium. 41 Chapter 4 Mild mitral stenosis Severe mitral stenosis Area of effective >1.5 20 g/day), and low in fat (3 seconds, VVI(R) Yes ventricular rate 100 bpm. It is most common in sick sinus syndrome (40% of cases), but it can also occur in AF. The solution to this condition is to use a rate-adaptive pacemaker. This type of pacemaker uses one of three methods to detect the need for an increased heart rate and responds accordingly. Examples of detection methods are: mechanical accelerometers that detect movement; changes in transthoracic impedance that can be used to detect changes in ventilation or RV filling; and QT sensors that respond to the shortening of the paced QT interval by catecholamines. 136  Arrhythmia Paced Sensed Response Rate A A T R V V I D D D Table 8. Pacemaker codes. A: atrium; D: dual (ie, both chambers or both responses); I: inhibited; R: rate responsive; T: triggered; V: ventricle. Implantation Pacemaker implantation is carried out under sedation. Leads are inserted via the subclavian or cephalic vein into the RA and/or RV. Atrial leads are J-shaped and are positioned in the right atrial appendage (anteriorly and superiorly in the RA). Ventricular leads are positioned in the RV apex. Most ventricular leads are placed in position and left against the myocardial wall. In certain circumstances, eg, when these leads become easily displaced or do not provide adequate threshold values, an active fixation lead can be used. This lead has a screw “thread” on its end – usually covered by a dissolvable tip, so that it is not exposed until it is in position – that allows the lead to be fixed into the myocardium. After the leads are positioned, a series of tests are carried out to determine if the lead position is satisfactory from an electrical point of view. These would typically assess: threshold – the voltage required to cause a contraction. This increases if the lead is not well-positioned and can be a sensitive method of detecting poor placement lead impedance – this is a test of the integrity of the lead. It is essentially a measure of electrical resistance and is measured in Ohms abnormal stimulation of the phrenic nerve – a high-voltage protocol tests for a diaphragmatic twitch THE PACEMAKER’S MAKER Canadian John Hopps invented the first cardiac pacemaker. Hopps was trained as an electrical engineer at the University of Manitoba and joined the National Research Council in 1941, where he conducted research on hypothermia. While experimenting with radiofrequency heating to restore body temperature, Hopps made an unexpected discovery: if a heart stopped beating due to cooling, it could be started again by artificial stimulation using mechanical or electrical means. In 1950, this led to Hopps’ invention of the world’s first cardiac pacemaker. His device was far too large to be implanted inside the human body – it was an external pacemaker. 137 Chapter 8 Once all the required tests are completed, the pacemaker pocket (in the fascia overlying the pectoral muscle) is created by blunt dissection and the wound sutured. Complications Acute complications will generally occur in hospital. These may include pneumothorax, RV perforation and cardiac tamponade, and hematoma. Chronic complications are more likely to present to the generalist. Lead infection is fortunately rare, but can present a very difficult management problem. Skin commensals are the most common culprits in right-sided endocarditis. If you suspect this, you should immediately refer the patient for an echo and blood cultures. Treatment is initially with antibiotics, but the lead system should be quickly replaced if this is unsuccessful. Lead displacement can occur as a result of concurrent right-sided pathology, eg, RV dilatation or valve abnormalities, and can be detected by changes in threshold. Changes in impedance can point to deterioration of old wires or loss of insulation properties. Subclavian vein or superior vena cava occlusion is more common with multiple lead systems. Classic signs include unilateral superficial vein engorgement around the upper thorax, neck, and face. Erosion occasionally occurs if the pacemaker box becomes gradually more superficial. Unless it causes chronic pain, or erodes completely, it does not demand referral. Some patients move their own box back and forward under the skin (Twiddler’s syndrome). This can cause hemorrhage or lead breaks. Infection of the implantation site can be problematic and should be taken seriously. In the early stage, superficial redness of the skin or swelling around the box will be noticed. For this, standard treatment is indicated, eg, a skin swab, cloxacillin (flucloxacillin) (oral dosage, 500 mg four times daily). If the infection does not respond, or if you suspect deep infection for another reason, eg, marked constitutional symptoms, refer immediately. Infections resistant to antibiotic therapy demand box and lead extraction – a procedure not without difficulty or complications. Pacemaker syndrome occurs in some patients with a VVI pacemaker who are in SR. It is thought to relate to the fact that although sometimes the atria contract “in time” and cardiac output is normal, at other times they contract against closed AV valves, which causes elevated venous pressure and a fall in cardiac output. The patient will experience dizziness, and the solution is to upgrade the patient to a DDD pacemaker. Finally, atrial-sensing pacemakers, eg, DDD, respond to atrial arrhythmia with tachycardic pacing. If this happens, it is possible to alter the program (to DDI or set 138  Arrhythmia an upper rate limit) or use antiarrhythmic drugs. This problem can be avoided by using a mode-switching pacemaker that detects atrial arrhythmia and switches to VVI. Pacemaker ECGs ECGs are harder to interpret in a patient with a pacemaker as there are more variables; although the pacing spikes are usually straightforward to recognize. It is important to remember that the paced QRS complex will be in an LBBB pattern because the wave of depolarization begins where the lead is placed in the RV. Doctor, I have a pacemaker, what should I avoid? This is a common question that patients ask. In general, patients should live life as normal. They should avoid magnetic resonance imaging studies, and care should be taken with the following: electrocautery during surgery – this can cause sensing problems therapeutic radiation cardioversion/defibrillation – this should be carried out using the lowest effective energy with the paddles in the anterior–posterior positions on the body of the patient mobile phones – these should not be placed in a shirt pocket next to the pacemaker car batteries – batteries can produce large magnetic fields. Again, this is only a problem if the person is leaning over and the pacemaker comes close to the battery high-voltage cables Most manufacturers supply each pacemaker recipient with a wallet-sized emergency card for identification as the bearer of an implanted device. This card should include important information about current pacing parameters, names and numbers of the pulse generator (including leads), indication for pacing, and underlying structural heart disease. Patient follow-up Application of a magnet to many pacemaker generators reveals the current battery status by pacing with a fixed pacing rate or “magnet rate”. The pacemaker rate decreases in most models with declining battery charge. When a decrease indicates exhaustion of one battery capacity, the pulse generator should be replaced. Implantable cardioverter defibrillators The natural evolution of pacemaker technology led, in the late 1960s, to the development of the AICD. Early versions were implanted abdominally under 139 Chapter 8 general anesthesia. These boxes, now barely bigger than a VVI pacemaker, are implanted under heavy sedation/light general anesthesia, and have revolutionized the treatment of ventricular arrhythmias. Indications for use of the device are expanding as the evidence base grows, but at present these include VF or VT cardiac arrest without a reversible cause; spontaneous sustained VT; syncope of undetermined origin with hemodynamically significant sustained VT; and nonsustained VT with prior MI or LV dysfunction. A recent study suggested that all post-MI patients with an EF 1.5 cm2 moderate if the area is 1–1.5 cm2 severe if the area is 50 mm Hg in the presence of normal transvalvular flow (ie, normal LV function). However, abnormally low pressure gradients are found in conditions of LV dysfunction, so the gradient alone is not a clear guide. The natural history of AS is one of slow progression. Studies suggest that some patients exhibit a decrease in valve area of 0.1–0.3 cm2/year, although no progression is discernible in many patients. However, regardless of the individual variability, symptoms of angina, syncope, or heart failure generally develop after a latent period. At this point, the outlook changes dramatically. After the onset of symptoms, the average survival is less than 3 years. Thus, development of symptoms is the critical point in the natural history of AS and thereafter the benefits of surgery outweigh the risk. Consequently, asymptomatic AS patients should be monitored closely. Although there is no clear consensus, most cardiologists follow-up mild AS annually (together with 5-yearly echos); moderate AS every 6 months (together with 2-yearly echos); and severe AS more frequently (together with annual echos). If a patient with AS presents with a change in symptoms, their next appointment at the cardiology clinic should be expedited. If a patient with severe AS is undergoing open chest bypass grafting for coexisting coronary artery disease (CAD), the opportunity should be taken to carry out aortic valve replacement (AVR) – regardless of whether or not AS symptoms are evident. The merit of carrying out a concomitant AVR is less clear for those with mild or moderate AS. 148  Valve disease Cardiac catheterization is only indicated in AS for two reasons: (1) to perform coronary angiography before AVR in patients with risk factors for CAD; (2) to assess the severity of AS in symptomatic patients when AVR is planned or when noninvasive tests are inconclusive (catheterization allows accurate quantification of the orifice because it can account for transvalvular flow). Contrary to popular belief, exercise testing is not contraindicated for mild to moderate AS patients and can give useful information with respect to exercise capacity, heart rate recovery, and exercise-induced rise in blood pressure. Balloon valvotomy Percutaneous balloon aortic valvotomy (stretching a stenotic valve by balloon inflation) has an important role to play in the treatment of young adults with AS, but a very limited role in older patients. This is because the postoperative valve area is rarely >1 cm2 and because complications are frequent (10%) and serious. This procedure can act as a “bridge” to reduce the requirement for surgery (with its inherent risk) in adult patients with refractory pulmonary edema or cardiogenic shock. Aortic valve replacement in the elderly Due to the limitations of medical therapy and balloon valvotomy, AVR should be considered for all elderly patients with symptomatic AS. However, the decision as to whether to carry out AVR is rarely straightforward and must take into account the risks as viewed by both the surgeon and the patient. Comorbidity in the form of LVH or CAD greatly increases the risk associated with surgery. In addition, specific valve problems, such as heavy calcification and narrow LV outflow tract or annulus, make the procedure more complex. The decision is highly individual. Aortic regurgitation AR is associated with classic clinical signs (see Table 2): waterhammer (collapsing) pulse – detected by comparing the character of the radial pulse at the level of the heart with its character on elevation of the arm (use several fingers). Elevation accentuates the steep rise-and-fall character of this pulse, which seems to slap faster and harder against the fingers Corrigan’s sign – visible arterial pulsation in the neck de Musset’s sign – nodding of the head in time with the heartbeat Duroziez’s sign – caused by retrograde diastolic flow in the femoral artery. Place the stethoscope on the femoral pulse and occlude the artery distally. The turbulent flow will be picked up as a “to-and-fro” murmur 149 Chapter 9 Quincke’s sign – capillary pulsation in the nail beds that is visible on applying gentle pressure to induce a degree of whitening Traube’s sign – a “pistol-shot” sound heard over the femoral pulse Müller’s sign – pulsation of the uvula An early diastolic murmur is heard at the left lower sternal edge when the patient is sitting forward and holding his or her breath in expiration. There could also be a coexistent aortic systolic flow murmur, caused by the large stroke volume (rather than reflecting organic AS). There may be a mid diastolic murmur at the apex (Austin Flint murmur) caused by the regurgitant aortic jet vibrating the anterior mitral valve (MV) leaflet. Acute aortic regurgitation Acute AR is one hallmark of aortic dissection and is a medical emergency in its own right. A large regurgitant volume is suddenly imposed on an LV of normal size that has not had time to accommodate to the volume overload. The result is a reduction in stroke volume, compensatory tachycardia, pulmonary edema, and cardiogenic shock. Characteristic clinical findings are absent and an echo is essential to document the severity of the lesion. This is done by assessing the speed of equilibration of aortic and LV pressures in diastole. Useful echo measures are short regurgitant wave half time, short mitral deceleration time, and premature closure of the MV. Mortality is high in acute severe AR and early surgical intervention is essential. Nitroprusside can be helpful in reducing preload and afterload, possibly in combination with dobutamine or dopamine. Intra-aortic balloon pumping is absolutely contraindicated (it increases aortic diastolic pressure and worsens the regurgitation), while b-blockers, often used in the management of dissection, should be used with caution in associated acute severe AR as they dampen the compensatory tachycardia. Chronic aortic regurgitation An early diastolic murmur is always justification for referral to a cardiologist for assessment and echo. Causes Rheumatic involvement of the aortic valve, resulting in thickening of the cusps and fusion of the commissures – the valve neither opens nor closes completely. Dilatation of the aortic root resulting from aneurysm of the ascending aorta – this is commonly seen in Marfan’s syndrome. 150  Valve disease Dilatation of the aortic annulus can also result from connective tissue disease, such as ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, relapsing polychondritis, or systemic lupus erythematosus. Dissecting aneurysm involving the aortic root. Syphilitic aortitis causing aortic aneurysm and dilatation of the valve ring that may involve the coronary ostia. Table 2 outlines the causes of aortic regurgitation. Natural history and therapeutic options Chronic AR represents a condition of combined volume and pressure overload on the LV. The ejection fraction (EF) – the percentage of the end diastolic volume ejected during systole – is maintained by compensatory LVH and the majority of patients remain in this compensated phase for decades. However, in time, the EF drops. Although initially this is fully reversible, soon, due to progressive dilatation and remodeling, full recovery with AVR is out of reach. A large number of studies have identified LV systolic dysfunction and end systolic dimension as the key determinants of survival in patients undergoing AVR for AR. Thus, in contrast to AS, the critical point when the benefit of AVR outweighs the risk is determined not by symptoms, but by echo-determined LV function. More specifically, AVR is indicated in: patients with New York Heart Association (NYHA) class III or IV symptoms (see Chapter 7, Heart failure) and preserved LV systolic function – defined as normal EF (350% at rest) patients with NYHA class II symptoms and preserved LV systolic function at rest, but with progressive LV dilatation, declining rest EF, or declining effort tolerance (the trend is more important than the absolute level) patients with angina on walking or climbing stairs rapidly asymptomatic or symptomatic patients with mild to moderate LV dysfunction at rest (EF 25%–49%) patients undergoing open chest surgery for another reason (eg, bypass grafting) Exercise testing can be useful in AR if the patient is sedentary or has equivocal symptoms. It assesses functional capacity and the hemodynamic effects of exercise. Radionuclide ventriculography should be used if the echo window is poor. Cardiac catheterization is only required in patients at risk of CAD prior to AVR or where other tests are equivocal. 151 Chapter 9 Asymptomatic patients with no LV dysfunction should be encouraged to participate in all forms of normal daily activity, including exercise (although lifting weights should be avoided). Vasodilator therapy can, in theory, retard the natural history of chronic AR by reducing the regurgitant volume. However, very few studies have actually examined the effect of this treatment on the long-term outcome. Indications for vasodilator therapy (generally using long-acting nifedipine) are: long-term therapy in patients with severe regurgitation who have symptoms and/or LV dysfunction, when surgery is not recommended long-term therapy in asymptomatic patients with severe regurgitation who have LV dilatation, but normal systolic function long-term therapy in asymptomatic patients with hypertension and any degree of regurgitation long-term therapy in patients with persistent LV systolic dysfunction after AVR (angiotensin-converting enzyme inhibitor) short-term therapy to improve the hemodynamic profile of patients with severe heart failure symptoms and severe LV dysfunction before proceeding with AVR Asymptomatic patients with mild AR and normal LV systolic function should be seen by a cardiologist annually and undergo echo every 2–3 years. Asymptomatic patients with normal systolic function, but severe AR and significant LV dilatation (end diastolic diameter >6 cm), require more frequent evaluation. These patients should be seen by a cardiologist every 6 months and undergo echo every 6–12 months. Mitral stenosis The MV apparatus consists of three components: two leaflets, the fibrous annulus, and the chordae tendineae, which connect the leaflets to the papillary muscles (see Figure 1). The anterior leaflet is larger than the posterior leaflet (see Figure 2). The normal area of the MV orifice is 4–5 cm2. Symptoms of mitral stenosis (MS) develop when the orifice is 80%), but low for those with symptoms (0%–15%). Asymptomatic patients with mild MS (MV area >1.5 cm2) require no further evaluation and do not need to be followed up more than annually. Percutaneous and surgical therapy Decisions on therapy are made by joint consideration of symptoms and MV morphology (including hemodynamics and pulmonary artery pressure). Therapeutic options include MV repair (open/closed commissurotomy), MV replacement, and percutaneous valvotomy. 155 Chapter 9 Current recommendations for surgical therapy Percutaneous NYHA class II–IV symptoms, MVA 50 mm Hg), and no LA thrombus or MR NYHA class III–IV symptoms, MVA ≤1.5 cm2, and at high surgical risk MV repair NYHA class III–IV symptoms, MVA ≤1.5 cm2, and one of the following: percutaneous valvotomy is not available LA thrombus is resistant to anticoagulation an intraoperative decision on repair versus replacement will be made MV replacement NYHA class I–II symptoms, MVA ≤1 cm2, and severe pulmonary hypertension (>60 mm Hg) NYHA class III–IV symptoms, MVA ≤1.5 cm2, and not suitable for repair or valvotomy (calcification, fibrosis, subvalvular fusion) Table 5. Current recommendations for surgical therapy. LA: left atrium; MR: mitral regurgitation; MV: mitral valve; MVA: mitral valve area; NYHA: New York Heart Association. Both repair and percutaneous valvotomy acutely result in a doubling of the valve area and a 60% reduction in transmitral gradient. However, open commissurotomy and percutaneous valvotomy produce better long-term hemodynamic results. The current recommendations for percutaneous and surgical therapy are outlined in Table 5. Medical therapy Prophylaxis against rheumatic fever and endocarditis should be considered for all patients with MS. Agents with negative chronotropic properties, such as b-blockers or calcium-channel blockers, may benefit those in sinus rhythm with symptoms relating to exertional tachycardia. Atrial fibrillation AF develops in 40% of patients with symptomatic MS and should be treated according to standard protocols (see Chapter 8, Arrhythmia). The value of anticoagulation therapy for those with AF and those with a prior embolic event with or without AF is clear. However, there is no evidence that oral anticoagulation is beneficial in those with MS who have neither AF nor a prior embolic event. The frequency of embolic events does not seem to be related to the severity of MS, the size of the LA, or the presence of symptoms. There is some controversy over 156  Valve disease (a) (b) Figure 5. (a) Transesophageal echocardiography showing a tear in the papillary muscle (the most common cause of acute mitral regurgitation). (b) The same scene with a color jet from the left ventricle into the left atrium, demonstrating “blood flow” in the wrong direction. whether percutaneous mitral valvotomy should be performed in patients with new- onset AF and moderate or severe MS who are otherwise asymptomatic. Mitral regurgitation Acute mitral regurgitation In acute severe mitral regurgitation (MR), the hemodynamic changes are not tolerated and the result is generally acute decompensation. Without time for compensatory LV and LA dilatation, the increase in ventricular preload leads to a decreased stroke volume and pulmonary congestion. However, examination findings may not be typical: there may be no hyperdynamic apex beat the systolic murmur may be short there may be a fourth heart sound The most common cause of acute MR is papillary muscle rupture secondary to myocardial infarction (MI) (see Figure 5). In this situation, the principal differential diagnosis is ventricular septal defect and an echo is required to differentiate between the two. Ventricular septal defect is more likely with: right-sided radiation of murmur raised jugular venous pressure (JVP) anterior MI (inferior MI is more likely to cause acute MR) The goal of medical therapy in acute severe MR is to diminish regurgitation, increase stroke volume, and reduce pulmonary congestion. As such, nitroprusside alone or in combination with dobutamine (if blood pressure is low) can be 157 Chapter 9 Figure 6. Echocardiogram showing a vegetation on the mitral valve (arrow). Clinical signs of chronic mitral regurgitation Prominent and sustained apex beat Systolic thrill at the apex Left parasternal heave – resulting from left atrium expansion, rather than right ventricular hypertrophy Soft first heart sound Pansystolic murmur at the apex that radiates into the axilla Third heart sound that is high pitched due to high early diastolic filling velocities Table 6. The clinical signs of chronic mitral regurgitation. effective. Intra-aortic balloon pumping can also help to achieve these goals. In many cases, emergency surgery is warranted. If so, prior transesophageal echo helps to characterize the anatomy and severity of the lesion. Cardiac catheterization should be performed if the patient is at high risk for CAD. Chronic mitral regurgitation Causes Degenerative MV disease is common in the elderly. The valve leaflets are thickened, redundant, increased in area, and they prolapse into the LA in systole. The chordae may become elongated, thinned, and tortuous – predisposing to rupture. 158  Valve disease Optimal sarcomere length Actin Actin Frank–Starling Stroke volume curve Normal resting length Sarcomere length LV dysfunction Ventricular end-diastolic volume Figure 7. Frank–Starling curve showing left ventricular (LV) dysfunction. Infective endocarditis is a major cause of chronic MR. Vegetations developing on the cusp vary from small nodules along the line of apposition to large friable masses of up to 10 mm or more (see Figure 6). “Jet” lesions on the anterior cusp of the MV can also occur in association with aortic valve endocarditis. Ischemia. Clinical signs The clinical signs of chronic MR are outlined in Table 6. With severe MR, the regurgitant murmur is usually short and stops at the same time as aortic valve closure. Occasionally, the murmur can hardly be heard due to early equalization of atrioventricular pressures. The signs and causes of MR are outlined in Table 3. Natural history In chronic MR, the increased preload and decreased afterload of the LV (caused by ejection of some of the stroke volume into the LA) are compensated for by LV and LA dilatation, and the total stroke volume is increased (the EF is also maintained). This compensated phase of chronic MR may last for years. Eventually, however, the volume overload causes sufficient dilatation to push the LV onto the downward portion of the Frank–Starling curve and dysfunction results (see Figure 7). Importantly, the loading conditions mean that this dysfunction might not be reflected in an abnormal EF (the EF in a patient with MR and normal LV function is >60%). Asymptomatic patients with mild MR and no evidence of LV dilatation or dysfunction can be followed on a yearly basis and undergo echo less frequently than that. Asymptomatic patients with moderate MR should have an echo annually. Asymptomatic patients with severe MR should be followed up every 159 Chapter 9 6–12 months and undergo echo to detect silent LV dysfunction. Exercise testing is useful to document changes in exercise tolerance. The timing of surgery is determined by the EF, LV end systolic dimension (LVESD), the presence of AF, and symptoms. It is indicated for those with: class II–IV symptoms, EF >60%, LVESD 50 mm Hg) asymptomatic patients with EF 50%–60% and LVESD 60% and LVESD 45–55 mm patients with EF 55 mm in whom the chordae tendineae are likely to be intact (ie, no previous MI in that territory) The operation of choice is MV repair. In many patients, however, replacement of the valve together with removal of part or all of the MV apparatus (chordae) is required. The repair procedure leads to better postoperative LV function and survival. There is no generally accepted medical therapy for chronic MR. Although vasodilators might seem a sensible choice, in fact, in compensated chronic MR the afterload is decreased (since the LV has two routes of ejection); as such, drugs that reduce the afterload further are unlikely to be beneficial. Chronic MR can also occur due to a primary ischemic cause, relating either to LV dysfunction or to chordal ischemia – revascularization or stenting can eliminate the episodes. Functional mitral regurgitation The normal function of the MV depends on the cusps, ring, and subvalvular apparatus, including papillary muscle fibers and the circumferential muscle layer supporting the mitral ring. Each of these components plays a significant role in maintaining the competence of the valve. With papillary muscle dysfunction due to ischemia or other causes of ventricular disease, cusp closure is not complete, leading to some degree of regurgitation. This can even occur, for example, in athletic hypertrophy. This is usually mild, but can be significant in rare cases. In such conditions, the heart rate is usually fast and the duration of MR long enough to compromise filling time and hence cardiac output. Although functional in origin, it can be hemodynamically significant. 160  Valve disease ALFRED DE MUSSET “La bouche garde le silence, Pour écouter parler le coeur.”a Alfred de Musset (1810–1857), La Nuit de Mai The French romantic poet and playwright, Alfred de Musset (1810–1857), was famous for both his creative brain and his pathological heart. His most inspiring work was prompted by the ending of a love affair he had with George Sand (a French romantic writer who later had a 10-year relationship with Chopin). During a visit to Venice in 1834, both Sand and he became very unwell. Such was the quality of care and attention lavished on them by their physician that Sand fell in love with this man and de Musset returned to France alone (where he penned some of his best work). He spent the last 2 years of his life housebound, his heart broken by the combined effects of lost love, aortic regurgitation, and alcohol-related cardiomyopathy. The nodding of his head in time with his heartbeat, the classic eponymous sign of aortic regurgitation, was described by his brother in a biography. When told of it, de Musset apparently placed his thumb and forefinger on his neck and his head stopped bobbing. a The mouth keeps silent to hear the heart speak. Mitral valve prolapse MV prolapse (MVP) is the single most common valvular abnormality. It affects 2%–6% of the population and is defined as a backward movement of one or both leaflets of the MV (usually the anterior) into the LA during (ventricular) systole. In most cases it is associated with trivial MR. However, as a result of its prevalence, it is also the most common single cause of significant MR. Although MVP does not alter life expectancy, all of the above complications of MR can occur. Sudden death, often reported as an association with MVP, is rare (75% of systemic EF 50 mm Hg, LV function likely to be normal) should be advised to delay conception until treatment is obtained. Aortic regurgitation AR can usually be managed medically with a combination of diuretics and vasodilator therapy. As with MR, surgery should be contemplated during pregnancy for the control of class III–IV symptoms. Anticoagulation in pregnancy Warfarin crosses the placenta and has been associated with an increased incidence of spontaneous abortion, fetal deformity, prematurity, and stillbirth. The incidence is probably around 5%–10%. In contrast, heparin does not cross the placenta and is generally safer. However, it is associated with a higher degree of thromboembolic complications. The evidence base for decision making is not good, and the decision should be made in partnership with the patient after explaining the risks involved. Most change from warfarin to heparin at week 36 in anticipation of labor. 164  Valve disease Further reading Guidelines for the management of patients with valvular heart disease. Executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). Circulation 1998;98:1949–84. Phoon CK. Estimation of pressure gradients by auscultations: an innovative and accurate physical examination technique. Am Heart J 2001;141:500–6. Shry EA, Smithers MA, Mascette AM. Auscultation versus echocardiography in a healthy population with precordial murmur. Am J Cardiol 2001;87:1428–30. 165 166 Chapter 10 Infective endocarditis Background Endocarditis was first described by William Osler in 1885. It is an inflammatory process that affects the endocardium and may have an infective or noninfective (eg, systemic lupus erythematosus) origin. It is uncommon in the western world (22 cases per million), but more prevalent in developing countries. Diagnosis Symptoms Endocarditis is rarely an obvious diagnosis for a generalist. It may present with a wide variety of clinical signs, some subtle; the diagnosis may be difficult or the signs misleading, and there is a wide differential diagnosis to consider. However, there is a wealth of clinical signs to look for. Constitutional symptoms Endocarditis should be considered in patients with vague or generalized constitutional symptoms such as fever, rigors, night sweats, anorexia, weight loss, or arthralgia. Cardiac signs The presence of a new murmur is very significant, as is a change in the nature of an existing murmur (a regurgitant murmur may disappear on worsening). Myocardial involvement or valvular dysfunction may both contribute to left ventricular failure. Skin lesions Endocarditis is indicated by: Osler’s nodes – tender lesions found on finger pulps and thenar/hypothenar eminences (see Figure 1) Janeway lesions – transient, nontender macular papules on palms or soles splinter hemorrhages petechiae (embolic or vasculitic) clubbing – in long-standing disease 167 Chapter 10 Figure 1. Osler’s nodes on a finger and foot. Eyes Roth spots (boat-shaped hemorrhages with pale centers, in retina) and conjunctival splinter hemorrhages may be found. Splenomegaly Splenic infarction may occur as a result of emboli. In this case, splenic palpation may be painful and tender, and a rub may be heard. Neurological An acute confusional state is common in patients with infective endocarditis (IE). Cerebral emboli, which usually affect the middle cerebral artery, result in hemiplegia and sensory dysfunction. Mycotic aneurysms also affect the middle cerebral artery, where rupture may cause a subarachnoid hematoma. Mycotic aneurysms can occur several years after endocarditis has been treated. Renal Infarction causes loin pain and hematuria. Immune complex deposition may result in glomerulonephritis. OSLER’S NODES William Osler, 1909, on the eponymous Osler’s nodes: “One of the most interesting features of [endocarditis] and one to which very little attention has been paid is the occurrence of ephemeral spots of a painful nodular erythema, chiefly in the skin of the hands and feet, the nodosités cutanées éphémerès of the French… The commonest situation is near the tip of the finger, which may be slightly swollen.” 168  Infective endocarditis If any of these signs occur together with a fever, the patient should be urgently referred to a cardiologist for blood cultures and echocardiography – the level of risk will determine whether this is transesophageal echo (TEE) or transthoracic echo. Blind treatment with antibiotics should not be undertaken since it will delay diagnosis and identification of the causal organism. Antibiotics should not be initiated before three sets of blood cultures have been taken. Formal diagnosis The Duke diagnostic classification for IE divides signs and symptoms into major and minor criteria (see Table 1). IE is diagnosed if patients have: two major criteria; or one major and three minor criteria; or five minor criteria These criteria are associated with a 99% specificity for diagnosis in follow-up studies. It has been proposed that the minor criteria be extended to include erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), splenomegaly, microscopic hematuria, and newly diagnosed clubbing. This adjustment increases diagnostic sensitivity by 10%. Intravenous drug abuse Right-sided endocarditis is common in intravenous drug abusers (IVDAs) because of nonsterile injection into the venous system. The presentation tends to differ from that of classic IE, in that these patients are more likely to develop pneumonia or septic pulmonary emboli than the characteristic signs mentioned above (which result from left-sided embolization). In addition, predominant right-sided failure is more common (look for significantly raised jugular venous pressure and gross peripheral edema). The tricuspid valve is most commonly affected (50%), whereas involvement of the mitral and aortic valves is less common (20% each). The involvement of multiple valves is common. Pulmonary valve endocarditis is rare. Etiology IE has a large number of causative organisms. Streptococci These account for 50%–80% of IE cases. Streptococcus viridans (eg, S. anguis, S. milleri, S. mutans, S. mitior) make up the normal bacterial flora of the pharynx and upper respiratory tract. Tonsillectomy, dental extraction, and dental cleaning can result in bacteremia and lead to infection. 169 Chapter 10 The Duke criteria for the diagnosis of IE Major criteria 1. Positive blood culture for IE A. Typical micro-organism consistent with IE from two separate blood cultures, as noted below: viridans streptococci, Streptococcus bovisa, or HACEK group; or community-acquired Staphylococcus aureus or enterococci, in the absence of a primary focus; or B. Micro-organisms consistent with IE from persistently positive blood cultures defined as: two or more positive cultures of blood samples drawn >12 hours apart all of three or a majority of four or more separate cultures of blood (with first and last sample drawn ≥1 hour apart) 2. Evidence of endocardial involvement A. Positive echocardiogram for IE defined as: oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or abscess; or new partial dehiscence of prosthetic valve; or B. New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient) Minor criteria 1. Predisposition: predisposing heart condition or intravenous drug use 2. Fever: temperature ≥ 38.0ºC 3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions 4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth spots, and rheumatoid factor 5. Microbiological evidence: positive blood culture, but does not meet a major criterion as noted aboveb or serological evidence of active infection with an organism consistent with IE 6. Echocardiography findings: consistent with IE, but do not meet a major criterion as noted above Table 1. Definitions of terms used in the Duke criteria for the diagnosis of infective endocarditis (IE). HACEK: Haemophilus parainfluenza, Haemophilus aphrophilus, Actinobacillus (Haemophilus) actinomycetemcomitans, Cardiobacterium hominis, Eikenella species, and Kingella species. aIncludes nutritionally variant strains (Abiotrophia species); bexcludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis. Reproduced with permission from Excerpta Medica (Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994;96:200–9). ©1994 Excerpta Medica. 170  Infective endocarditis WILLIAM OSLER, 1919: “Observe, record, tabulate, communicate. Use your five senses.” Sir William Osler (1849–1919) is one of the most admired and honored physicians in the history of medicine. He exerted a truly global influence through professorships (McGill, Johns Hopkins, and Oxford), his textbook The Principles and Practice of Medicine, and other clinical and philosophical writings. This influence is apparent not least in the sheer number of conditions that bear his name: Osler–Weber–Rendu syndrome (hereditary hemorrhagic telangiectasia), Osler’s nodes, Osler–Libman disease (subacute bacterial endocarditis), and Osler–Libman–Sacks syndrome (systemic lupus erythematosus with endocarditis) are simply a few. But it was perhaps his overwhelming humanism and his dedication to patient-centered learning that marked him out as truly great (he once ran after an alcoholic beggar to whom he’d just given coins and added his own overcoat to the donation, saying: “You may drink yourself to death, and undoubtedly will, but I cannot let you freeze to death”). The combination of profound caring, a prolific output of creative writing and ideas, and a lifelong penchant for elaborate practical jokes has made him one of the most memorable physicians of the 20th century. Staphylococci Staphylococcus aureus and Staphylococcus epidermidis account for 20%–30% of subacute cases of IE and 50% of the acute forms. The presence of central venous catheters (feeding lines or temporary pacing lines) increases susceptibility. Acute S. aureus infection of previously normal valves has a mortality rate of 3%. This is the most common situation in IVDAs. Coagulase-negative staphylococci cause 30%–50% of prosthetic valve endocarditis. Enterococci Enterococci account for 5%–15% of IE cases. Enterococcal organisms, which include Streptococcus faecalis, have low infectivity. HACEK organisms The HACEK group of organisms – Haemophilus parainfluenza, Haemophilus aphrophilus, Actinobacillus (Haemophilus) actinomycetemcomitans, Cardiobacterium hominis, the Eikenella species, and the Kingella species – also commonly cause IE and can be difficult to diagnose. Their identification may require samples to be taken in special media. IE is also caused by other, less common organisms. Candida, Aspergillus, Histoplasma, and Brucella infections are rare, but are found, in particular, in IVDAs, alcoholics, and patients with prosthetic heart valves. Coxiella burnetii (the causative agent of Q fever) can also cause a subacute infection. 171 Chapter 10 Figure 2. Mitral valve vegetation. Pathogenesis Endocarditis infection occurs along the edges of the heart valves. The lesions, called vegetations, are masses composed of fibrin, platelets, and infecting organisms, held together by agglutinating antibodies produced by the bacteria. As inflammation continues, ulceration may result in erosion or perforation of the valve cusps, leading to valvular incompetence, damage to the conduction pathway (if in the septal area), or rupture of a sinus of Valsalva (if in the aortic area). Although endocarditis can affect native and prosthetic valves, infection seldom affects a previously normal heart – the majority (60%) of IE patients have a predisposing cardiac condition. Vegetations usually affect the left side of the heart, with the most common underlying lesions being mitral valve prolapse and degenerative mitral and aortic regurgitation (see Figure 2). Rheumatic disease is a risk factor for the development of endocarditis. Other predisposing cardiac lesions include hypertrophic cardiomyopathy with associated mitral reflux, subaortic stenosis, and ventricular aneurysm. There are also congenital lesions that predispose adults to endocarditis: these include ventricular septal defect (VSD), bicuspid aortic valve, and coarctation of the aorta. Vegetations occur when a high-pressure jet enters a low-pressure cavity through a narrow orifice. This explains why endocarditis complicates a small VSD, but is not associated with a large VSD, mitral stenosis, or an atrial septal defect. In the presence of a VSD, vegetations can be found on the right ventricular side of the VSD, on the tricuspid valve, or where the jet impinges on the right ventricular wall. Vegetations found in coarctation usually occur distal to the obstruction. 172  Infective endocarditis Finally, in children, cyanotic heart disease is still the most common cause of endocarditis, and the risk does not diminish after surgical repair as prostheses carry their own risk. Prosthetic valve endocarditis A special subset of endocarditis is that affecting prosthetic valves. This is traditionally divided into early onset (within 60 days of surgery) or late onset. Early onset usually results from perioperative valve contamination with staphylococci, whereas the etiology of late prosthetic valve endocarditis resembles native valve infection, usually due to streptococci. Refer with confidence As mentioned above, IE can be a difficult diagnosis to make, and the key for the generalist is to always be aware of it as a differential. Fever and arthralgia are very common complaints, but if there is any suggestion that they are not due to a simple viral illness (eg, by the presence of a particularly high temperature or other clinical signs [see above]) then the patient should be referred for blood cultures and an echo. If fever and a changing murmur coexist then urgent referral is warranted, although, even here, it can be useful to take blood cultures and a bottle for serology (for the diagnosis of culture-negative endocarditis) yourself. Specialist management Investigations Blood cultures Blood cultures are the primary investigation in the diagnosis of IE and yield the causative micro-organism in up to 95% of cases. A failure to do so can be due to prior antibiotic treatment, the presence of fastidious organisms (eg, belonging to the HACEK group), or unusual organisms such as Candida, Chlamydia, or Brucella. Most importantly, blood has to be drawn before antibiotic treatment is initiated, at three different time points over a minimum of 1 hour. At each time point, blood should be taken from a different site of the patient’s body – but not from central lines – and each sample is placed into a pair of blood culture bottles that cultivate aerobic and anaerobic bacteria separately. If immediate antibiotic treatment is warranted, this can be initiated right after completion of blood culturing, once microbiology tests have identified a specific organism and the antibiotic therapy has been modified accordingly. Antibiotic therapy can have an enormous impact on the patient’s prognosis; therefore, all efforts have to be made to collect and culture specimens as carefully as possible. This ensures the correct identification of the causative micro-organisms, and ultimately the correct use of antibiotics. 173 Chapter 10 Figure 3. Transesophageal echo for 1 mm lesions. Echocardiography This is the key investigation as it can assess underlying cardiac function as well as demonstrate vegetations. Chamber size, pre-existing rheumatic disease, and valve apparatus can be examined and the degree of valve incompetence assessed. Transthoracic two-dimensional echo can detect vegetations above 2 mm in diameter, whereas TEE has greater precision in detection of lesions (1–1.5 mm), with a sensitivity and specificity of over 90% (see Figure 3). Detection of prosthetic endocarditis is more sensitive with TEE. Other investigations Other investigations include the following: blood count – normochromic normocytic anemia is usual, while neutrophil leucocytosis is common ESR – this may be raised renal and liver function test – levels of creatinine may be raised; levels of liver enzymes may be raised in a hepatocellular (nonobstructive) pattern CRP – increases acutely in bacterial infection urine microscopy – microscopic hematuria is common in early disease culture – culture any skin lesion, drip site, or other focus of infection electrocardiography (ECG) – ECG regularly (daily if aortic or septal root abscess is suspected) Treatment Antibiotics If, following blood cultures, the diagnosis is secure, high-dose IV antibiotics should be started immediately. It is becoming increasingly common to insert a 174  Infective endocarditis tunneled central line to facilitate several weeks of IV treatment without the need for repeated cannulation – with the pain and attendant risk of secondary infection that this incurs. Native valve endocarditis with a subacute onset is most likely to be caused by S. viridans or an enterococcal species. Treatment involves IV penicillin (2.4 g, 4 hourly) for up to 4 weeks, with gentamicin (1 mg/kg, 12 hourly) for 2 weeks. If the onset is acute, staphylococci need to be covered and treatment should include IV cloxacillin (flucloxacillin) (3 g, 6 hourly, in place of penicillin) with oral fusidic acid. If the patient is allergic to penicillin, other possibilities are vancomycin (1 g twice daily) or teicoplanin (400 mg twice daily for 3 days, then 400 mg daily). Plasma levels of gentamicin and vancomycin need to be monitored every 48–72 hours. Empirical treatment of endocarditis affecting prosthetic valves should cover streptococci, enterococci, staphylococci (including methicillin-resistant S. aureus), and Gram-negative organisms. Vancomycin or teicoplanin with gentamicin have good synergistic cover. In drug abusers, treatment for endocarditis should include cover for S. aureus and Gram-negative bacilli (eg, cloxacillin and pipercillin). In the treatment of rarer causes of endocarditis, Coxiella may require doxycycline with cotrimoxazole or rifampicin. Candida and Aspergillus may respond to medical therapy (5-fluorouracil and amphotericin B, respectively), but, generally, all three of these infections respond poorly to medical therapy alone and require surgical intervention. In the treatment of IE, from any source, fever may still be present 2 weeks after starting the appropriate treatment, even with drug-sensitive organisms. This could be due to the presence of an underlying large vegetation or abscess. If fever persists, the sensitivity of the infecting organism should be checked and drug levels monitored. Repeat echo should be performed to exclude increasing vegetation size or abscess formation. If, despite these measures, the fever remains, the possibility of antibiotic resistance should be considered and a further synergistic antimicrobial treatment may be required. A second site for fever should always be excluded. Surgical intervention Surgical intervention may be required in patients with persistent fever that is resistant to medical therapy. Surgery is also indicated in the following conditions: 175 Chapter 10 valve obstruction prosthetic-valve endocarditis caused by S. aureus or resistant organisms aortic or mitral regurgitation not responding to medical therapy paravalvular abscess development of an aneurysm of a sinus of Valsalva fungal endocarditis multiple embolic episodes progressive heart failure secondary to severe valve destruction oscillating vegetation of >1 cm Surgery may involve not only valve replacement, but also aortic root replacement for aortic root abscesses. After the relevant surgical procedure, a full course of antibiotic eradication therapy should be administered. Prognosis With effective treatment, patients with IE have a 70% survival rate. The prognosis is worse if there is no identifiable organism or if there is a resistant organism. Fungal infections are associated with increased mortality, as is prosthetic valve endocarditis. Overall death rates are 20% for native valve endocarditis, 30% for staphylococcal infections, and 20%–30% for late prosthetic valve infection, despite full medical and surgical treatment. The most common cause of death is intractable heart failure. Prophylaxis All patients at risk for IE should receive antibiotic cover for invasive procedures (see Tables 2 and 3, overleaf). Spontaneous bacteremia is also common as a result of poor dental hygiene, and susceptible patients need to be made aware of this. 176  Infective endocarditis Situation Agenta Regimen Standard general Amoxicillin Adults: 2 g; children: 50 mg/kg prophylaxis orally 1 hour before procedure Unable to take Ampicillin Adults: 2 g IM or IV; children: oral medication 50 mg/kg IM or IV within 30 minutes before procedure Allergic to Clindamycin Adults: 600 mg; children: 20 mg/kg penicillin orally 1 hour before procedure Cephalexinb, Adults: 2 g; children; 50 mg/kg cefadroxilb orally 1 hour before procedure Azithromycin, Adults: 500 mg; children: 15 mg/kg clarithromycin orally 1 hour before procedure Allergic to penicillin Clindamycin Adults: 600 mg; children: and unable to take 20 mg/kg IV within oral medications 30 minutes before procedure Cefazolinb Adults: 1 g; children: 25 mg/kg IM or IV within 30 minutes before procedure Table 2. Prophylactic regimens for dental, oral, respiratory tract, or esophageal procedures. IM: intramuscularly; IV: intravenously. aTotal children’s dose should not exceed adult dose; bcephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins. Reproduced with permission from Lippincott Williams & Wilkins (Dajani AS, Taubert KA, Wilson W et al. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation 1997;96:358–66). 177 Chapter 10 Situation Agentsa Regimenb High-risk Ampicillin + Adults: ampicillin 2 g IM or IV plus patients gentamicin gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 minutes of starting the procedure; 6 hours later, ampicillin 1 g IM/IV or amoxicillin 1 g orally Children: ampicillin 50 mg/kg IM or IV (not to exceed 2 g) + gentamicin 1.5 mg/kg within 30 minutes of starting the procedure; 6 hours later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally High-risk patients Vancomycin + Adults: vancomycin 1 g IV over allergic to ampicillin/ gentamicin 1–2 hours + gentamicin 1.5 mg/kg amoxicillin IV/IM (not to exceed 120 mg); complete injection/infusion within 30 minutes of starting the procedure Children: vancomycin 20 mg/kg IV over 1–2 hours + gentamicin 1.5 mg/kg IV/IM; complete injection/infusion within 30 minutes of starting the procedure Moderate-risk Amoxicillin or Adults: amoxicillin 2 g orally 1 hour patients ampicillin before procedure, or ampicillin 2 g IM/IV within 30 minutes of starting the procedure Children: amoxicillin 50 mg/kg orally 1 hour before procedure, or ampicillin 50 mg/kg IM/IV within 30 minutes of starting the procedure Moderate-risk Vancomycin Adults: vancomycin 1 g IV over patients allergic to 1–2 hours; complete infusion within ampicillin/amoxicillin 30 minutes of starting the procedure Children: vancomycin 20 mg/kg IV over 1–2 hours; complete infusion within 30 minutes of starting the procedure Table 3. Prophylactic regimens for genitourinary/gastrointestinal (excluding esophageal) procedures. IM: intramuscularly; IV: intravenously. aTotal children’s dose should not exceed adult dose; bno second dose of vancomycin or gentamicin is recommended. Reproduced with permission from Lippincott Williams & Wilkins (Dajani AS, Taubert KA, Wilson W et al. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation 1997;96:358–66). 178  Infective endocarditis Further reading Bayer AS, Bolger AF, Taubert KA et al. Diagnosis and management of IE and its complications. AHA Scientific Statement. Circulation 1998;98:2936–48. Dajani AS, Taubert KA, Wilson W et al. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation 1997;96:358–66. Golden RL. William Osler at 150. JAMA 1999;282:2252–8. 179 180 Chapter 11 Cardiomyopathy Hypertrophic cardiomyopathy With a prevalence of only 0.2%, hypertrophic cardiomyopathy (HCM) is rarely encountered by generalists. Most cases are identified by screening family members of known sufferers – 50% of cases are familial. Background HCM is a primary, usually familial disorder of cardiac muscle with complex pathophysiology, significant heterogenei