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CARDIOLOGY
SECRETS
To Lydia, who inspires me to try to be a better husband, friend, and person.
 SIXTH EDITION

CARDIOLOGY
SECRETS

GLENN N. LEVINE, MD, FACC, FAHA

Professor of Medicine, Baylor College of Medicine
Chief, Cardiology Section
Michael E. DeBakey VA Medical Center
Houston, Texas, USA
Elsevier
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CARDIOLOGY SECRETS, SIXTH EDITION ISBN: 978-0-323-82675-4

Copyright © 2023 by Elsevier, Inc. All rights reserved.

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 CONTRIBUTORS

Suhny Abbara, MD Neal Barshes, MD, MPH

Chief, Cardiothoracic Imaging Associate Professor of Surgery
Department of Radiology Michael E. DeBakey Department of Surgery
Professor, Department of Radiology Baylor College of Medicine
UT Southwestern Medical Center Houston, Texas, USA
Dallas, Texas, USA
Luc M. Beauchesne, MD, FRCPC, FACC
Richa Agarwal, MD Cardiologist, Adult Congenital Heart Disease Program
Associate Professor of Medicine University of Ottawa Heart Institute
Division of Cardiology Ottawa, Ontario, Canada
Duke University School of Medicine
Durham, North Carolina, USA Jeffrey S. Berman, MD
Cardiology Fellow
Ali M. Agha, MD Department of Medicine, Division of Cardiology
Department of Cardiology Baylor College of Medicine
Baylor College of Medicine Houston, Texas, USA
Houston, Texas, USA
Sheilah Bernard, MD
David Aguilar, MD, MSc Associate Professor of Medicine
Professor of Medicine Section of Cardiology, Department of Medicine
Division of Cardiovascular Medicine Boston Medical Center
University of Kentucky College of Medicine Boston, Massachusetts, USA
Lexington, Kentucky, USA
Gilad Birnbaum, MD
Rami Akhrass, MD Department of Medicine
Regional Director Section of Cardiology
Department of Thoracic and Cardiovascular Surgery Baylor College of Medicine
Cleveland Clinic Houston, Texas, USA
Cleveland, Ohio, USA
Yochai Birnbaum, MD
Mahmoud Al Rifai, MD, MPH Professor
Cardiology Fellow Department of Medicine
Department of Medicine-Cardiology Section of Cardiology
Baylor College of Medicine Baylor College of Medicine
Houston, Texas, USA Houston, Texas, USA
Eric Awtry, MD Fernando Boccalandro, MD, FACC, FSCAI
Associate Professor of Medicine Pro-Care/Odessa Heart Institute
Section of Cardiology Director, Cardiovascular Laboratory
Boston University School of Medicine; Medical Center Hospital
Associate Chief for Clinical Affairs Department of Cardiology
Section of Cardiology Associated Clinical Professor
Boston Medical Center Texas Tech University Health Science Center
Boston, Massachusetts, USA Department of Internal Medicine
Faisal G. Bakaeen, MD Odessa, Texas
Professor Michael Boone, DO
Department of Thoracic and Cardiovascular Surgery Resident, Department of Family Medicine
Cleveland Clinic Waco Family Health Center
Cleveland, Ohio, USA Waco, Texas, USA
Gary J. Balady, MD Stephen Boone, MD, FACEP
Director, Non Invasive Cardiovascular Laboratories Assistant Professor
Section of Cardiology Department of Emergency Medicine
Boston Medical Center Assistant Professor
Professor of Medicine Department of Internal Medicine
Boston University School of Medicine Baylor College of Medicine
Boston, Massachusetts, USA Houston, Texas, USA

vi
 CONTRIBUTORS vii

Sanket Borgaonkar, MD Kim A. Eagle, MD

Chief Fellow, PGY-VII Albion Walter Hewlett Professor of Internal Medicine
Department of Cardiology Department of Internal Medicine
Baylor College of Medicine University of Michigan
Houston, Texas, USA Ann Arbor, Michigan, USA
Biykem Bozkurt Lothar Faber, MD, FESC, FACC
Professor Professor
Mary and Gordon Cain Chair and Professor of Home Office
Medicine Schuerhornweg 36
Director, Winters Center for Heart Failure Bielefeld, Germany
Research at Baylor College of Medicine Savitri Fedson, MA, MD
Medical Care Line Executive Professor
DeBakey VA Medical Center Center for Medical Ethics and Health Policy
Houston, Texas, USA Baylor College of Medicine;
Arzu Canan, MD Professor
Assistant Professor Department of Medicine
Department of Radiology, Cardiothoracic Imaging Michael E. DeBakey VA Medical Center
UT Southwestern Medical Center Houston, Texas, USA
Dallas, Texas, USA Matthew J. Feinstein, MD, MSc
Kelly N. Casteel, MD Assistant Professor of Medicine
Assistant Professor Division of Cardiology, Department of Medicine
Department of Benign Hematology Northwestern University Feinberg School of Medicine
MD Anderson Cancer Center Chicago, Illinois, USA
Houston, Texas, USA G. Michael Felker, MD, MHS
Professor of Medicine
Tiffany Chen, MD
Division of Cardiology
Assistant Professor of Clinical Medicine
Duke University School of Medicine
Division of Cardiovascular Medicine
Durham, North Carolina, USA
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania, USA James J. Fenton, MD
Clinical Associate Professor
Leslie T. Cooper Jr., MD Pulmonary Medicine
Elizabeth C. Lane, Ph.D. and M. Nadine Zimmerman, National Jewish Health
Ph.D. Professor of Internal Medicine Denver, Colorado, USA
Chair, Cardiovascular Department
Jacksonville, Florida, USA Michael E. Field, MD
Professor of Medicine
Edmond M. Cronin, MB BCh BAO Department of Medicine
Associate Professor Medical University of South Carolina
Department of Medicine Charleston, South Carolina, USA
Temple University
Philadelphia, Pennsylvania, USA Scott D. Flamm, MD, MBA
Professor of Radiology
George D. Dangas, MD, Department of Radiology
Professor of Medicine and Surgery Cleveland Clinic
Director, Cardiovascular Innovation Cleveland, Ohio, USA
Mount Sinai Hospital
Icahn School of Medicine at Mount Sinai Lee A. Fleisher, MD
New York, USA Professor
Department of Anesthesiology and Critical Care
Amish S. Dave, MD, PhD, FACC Perelman School of Medicine at the University
Assistant Professor of Medicine of Pennsylvania
Department of Cardiology Philadelphia, Pennsylvania, USA
Houston Methodist Hospital
Laura Flink
Houston, Texas, USA
The permanente medical group
Ali E. Denktas, MD California, USA
Professor of Medicine Marat Fudim, MD
Department of Cardiology Assistant Professor of Medicine
Baylor College of Medicine Division of Cardiology
Houston, Texas, USA Duke University School of Medicine
Durham, North Carolina, USA
 viii CONTRIBUTORS

Sanjay Ganapathi, MD, DM Brian D. Hoit, MD

Professor Professor of Medicine and Physiology and Biophysics
Department of Cardiology Department of Medicine
Sree Chitra Tirunal Institute for Medical Sciences and Case Western Reserve University;
Technology Director of Echocardiography
Trivandrum, India University Hospitals Cleveland Medical Center
Cleveland, Ohio, USA
Kathryn A. Gayle, MD
Fellow Geoffrey D. Huntley, MD
Department of Cardiovascular Medicine Fellow
Vanderbilt University Medical Center Department of Cardiovascular Medicine
Nashville, Tennessee, USA Mayo Clinic
Rochester, Minnesota, USA
Marie Gerhard-Herman, MD
Associate Professor Aliza Hussain, MD
Department of Medicine Fellow Physician
Mass General Brigham Department of Medicine, Section of Cardiology
Boston, Massachusetts, USA Baylor College of Medicine
Houston, Texas, USA
Casey Graziani, MD
Fellow Scott E. Janus, MD
Departments of Pulmonary and Critical Care Medicine Physician
Baylor College of Medicine Department of Cardiology
Houston, Texas, USA University Hospitals of Cleveland
Cleveland, Ohio, USA
Cindy Grines, MD
Chief Scientific Officer Xiaoming Jia, MD
Cardiovascular Institute Fellow, Department of Medicine
Northside Hospital Baylor College of Medicine
Atlanta, Georgia, USA Houston, Texas, USA

Aakriti Gupta, MD Hani Jneid, MD, FACC, FAHA, FSCAI

Cardiologist Associate Professor of Medicine
Department of Cardiology Department of Cardiology
Columbia University Irving Medical Center Baylor College of Medicine
New York, New York, USA Houston, Texas, USA

Gabriel B. Habib Sr., MD, FACC, FCCP, FAHA Jose A. Joglar, MD

Professor of Medicine Professor of Internal Medicine
Department of Medicine Department of Internal Medicine
Baylor College of Medicine UT Southwestern Medical Center
Houston, Texas, USA Dallas, Texas, USA

Ihab Hamzeh, MD Thomas A. Kent, MD

Associate Professor of Medicine Robert Welch Chair Professor
Department of Medicine Center for Genomic and Precision Medicine
Baylor College of Medicine Institute of Biosciences and Technology
Houston, Texas, USA Texas A&M Health Science Center-Houston
Adjunct Professor
Sivadasanpillai Harikrishnan, MD, DM, DNB Stanley H. Appel Department of Neurology
Professor Houston Methodist Hospital
Department of Cardiology Houston, Texas, USA
Sree Chitra Tirunal Institute for Medical Sciences and
Umair Khalid, MD, FACC
Technology
Assistant Professor of Medicine – Cardiology
Trivandrum, India
Baylor College of Medicine
Gustavo A. Heresi, MD, MS Houston, Texas, USA
Director, Pulmonary Vascular and CTEPH Program
Sarah Kohnstamm, MD
Department of Pulmonary and Critical Care Medicine
Clinical Assistant Professor
Cleveland Clinic
Department of Cardiovascular Medicine
Cleveland, Ohio, USA
Michigan Medicine
Tomoya T. Hinohara, MD Ann Arbor, Michigan, USA
Fellow, Department of Cardiology Nitin Kondamudi, MD
Houston Methodist Hospital House Staff
Houston, Texas, USA Division of Cardiology, Department of Internal Medicine
University of Texas Southwestern Medical Center
Dallas, Texas, USA
 CONTRIBUTORS ix

Chayakrit Krittanawong, MD Sharyl R. Martini

House Staff Medical Director
Section of Cardiology VA National Telestroke Program
Baylor College of Medicine Department of Veterans Affairs
Houston, Texas, USA Assistant Professor
Department of Neurology
Michael H. Kroll, MD Baylor College of Medicine
Professor Houston, Texas, USA
Department of Benign Hematology
UT MD Anderson Cancer Center Jim McCord, MD
Houston, Texas, USA Professor of Medicine, Wayne State Medical School
Heart and Vascular Institute
Richard A. Lange, MD, MBA Cardiology Director Observation Unit
President Henry Ford Hospital
Texas Tech University Health Sciences Center El Paso Detroit, Michigan, USA
Dean, Paul L. Foster School of Medicine
El Paso, Texas, USA Roxana Mehran, MD, FACC, FAHA, MSCAI
Mount Sinai Professor in Cardiovascular Clinical
Glenn N. Levine, MD, FACC, FAHA Research and Outcomes
Professor of Medicine Professor of Medicine (Cardiology), and Population
Baylor College of Medicine Health Science and Policy
Chief, Cardiology Section Director, the Center for Interventional Cardiovascular
Michael E. DeBakey VA Medical Center Research and Outcomes
Houston, Texas, USA Icahn School of Medicine at Mount Sinai
Paul Litvak, MD New York, New York, USA
Assistant Professor Lisa A. Mendes, MD
Department of Neurology Professor of Medicine
Baylor College of Medicine Department of Cardiovascular Medicine
Houston, Texas, USA Vanderbilt University Medical Center
Jing Liu, MD Nashville, Tennessee, USA
Cardiology Fellow Geno J. Merli, MD, MACP, FHM, FSVM
Department of Internal Medicine-Cardiology Professor of Medicine and Surgery
Baylor College of Medicine Department of Surgery
Houston, Texas, USA Sydney Kimmel Medical College at Thomas Jefferson
Melissa A. Lyle, MD University
Assistant Professor of Medicine Co-Director
Cardiologist, Department of Cardiovascular Medicine Jefferson Vascular Center
Mayo Clinic Thomas Jefferson University
Jacksonville, Florida, USA Senior Vice President & Associate CMO
Thomas Jefferson University Hospital
Thomas Maddox, MD, MSc Philadelphia, Pennsylvania, USA
Professor
Division of Cardiology Hassan Mir, MD, FRCPC
Washington University School of Medicine Cardiologist and Clinician Investigator
St. Louis, Missouri, USA Cardiology
University of Ottawa Heart Institute;
Jamal H. Mahar, MD, MEd Assistant Professor
Cardiology Fellow Department of Medicine
Department of Cardiology University of Ottawa
Baylor College of Medicine Ottawa, Ontario, Canada
Houston, Texas, USA
Arunima Misra, MD
Salvatore Mangione, MD Associate Professor
Associate Professor of Medicine Department of Internal Medicine
SKMC of Thomas Jefferson University Baylor College of Medicine
Philadelphia, Pennsylvania, USA Houston, Texas, USA
Rita Marr, BS, MD Ajith Nair, MD
Staff Cardiologist Assistant Professor of Medicine
Department of Cardiology Department of Medicine
Michael E. DeBakey VA Medical Center Baylor College of Medicine
Houston, Texas, USA Houston, Texas, USA
 x CONTRIBUTORS

Vijay Nambi, MD, PhD Lawrence Phillips, MD

Staff Cardiologist Director, Nuclear Cardiology
Department of Medicine Division of Cardiology, Department of Medicine
Michael E DeBakey Veterans Affairs Hospital; NYU Langone Health
Associate Professor New York, New York, USA
Division of Atherosclerosis and Vascular Medicine, June K. Pickett, MD
Section of Cardiovascular Research Fellow
Department of Medicine Department of Cardiology/Internal Medicine
Baylor College of Medicine Baylor College of Medicine
Houston, Texas, USA
Houston, Texas, USA
G. Titus Ngeno, MBCHB, MSc Andrew Pipe, BA, MD, LLD(Hon), DSc(Hon), FRCPSC(Hon)
Assistant Professor Professor
Department of Medicine Faculty of Medicine, University of Ottawa;
Duke University Division of Cardiac Prevention and Rehabilitation
Durham, North Carolina, USA University of Ottawa Heart Institute
Vuyisile T. Nkomo, MD, MPH Ottawa, Ontario, Canada
Professor of Medicine Stuart B. Prenner, MD
Director, Valvular Heart Disease Clinic Assistant Professor of Clinical Medicine
Department of Cardiovascular Medicine Section of Advanced Heart Failure and Cardiac Transplant
Mayo Clinic University of Pennsylvania
Rochester, Minnesota, USA Philadelphia, Pennsylvania, USA
E. Magnus Ohman, MD, FRCPI, FESC, FACC Prabhakar Rajiah, MBBS, MD,FRCR
Professor Professor of Radiology
Department of Medicine Department of Radiology, Mayo Clinic
Duke University School of Medicine Rochester, Minnesota, USA
Durham, North Carolina, USA
Pattara Rattanawong, MD
Nicolas L. Palaskas, MD Fellow in Cardiovascular Medicine
Assistant Professor Assistant Professor of Medicine
Department of Cardiology Department of Cardiovascular Diseases
UT MD Anderson Cancer Center Mayo Clinic
Houston, Texas, USA Phoenix, Arizona, USA
Ambarish Pandey, MD, MSCS Heidi Reich, MD
Assistant Professor Cardiothoracic Surgeon
Division of Cardiology, Department of Medicine Department of Surgery
University of Texas Southwestern Medical Center Central California Heart and Lung Surgery
Dallas, Texas, USA Fresno, California, USA
Shivda Pandey, MBBS Eric E. Roselli, MD, FACS
Assistant Professor of Medicine Chief, Adult Cardiac Surgery
Section of Cardiology Surgical Director, Aorta Center
Boston University School of Medicine Department of Thoracic and Cardiovascular Surgery
Boston, Massachusetts, USA Heart Vascular and Thoracic Institute, Cleveland Clinic
Cleveland, Ohio, USA
Lavannya M. Pandit, MD, MS
Associate Professor of Medicine Smita Scholtz
Department of Pulmonary, Critical Care, and Sleep Clinic for General and Interventional Cardiology/Angiology
Medicine Herz- und Diabeteszentrum NRW, Ruhr University Bochum
Baylor College of Medicine/Michael E. DeBakey Bad Oeynhausen, Germany
VA Medical Center Paul Schurmann, MD
Houston, Texas, USA Associate Professor
Maria A. Parekh, MD Department of Cardiology
Chief Resident Houston Methodist Hospital
Department of Neurology Houston, Texas, USA
Baylor College of Medicine Nagendra Boopathy Senguttuvan, MD, DM, FACC, FSCAI
Houston, Texas, USA Associate Professor of Cardiology & Senior Consultant
W. Frank Peacock, MD, FACEP, FACC Interventional Cardiologist
Vice Chair for Research Sri Ramachandra Institute of Higher Education
Department of Emergency Medicine and Research
Baylor College of Medicine Adjunct Faculty, Indian Institute of Technology-Madras
Houston, Texas, USA Chennai, Tamil Nadu, India
 CONTRIBUTORS xi

Hirak Shah, MD John M. Suffredini, DO

Department of Cardiology Cardiology Fellow
Duke University Section of Cardiology
Durham, North Carolina, USA Baylor College of Medicine
Houston, Texas, USA
Nishant R. Shah, MD, MPH
Assistant Professor Luis A. Tamara, MD
Department of Medicine, Division of Cardiology Chief of Nuclear Medicine/PET-CT
Alpert Medical School of Brown University Department of Nuclear Medicine
Providence, Rhode Island, USA MEDVAMC
Houston, Texas, USA
Sanjiv J. Shah, MD
Stone Professor of Medicine Jeremy J. Thaden, MD
Department of Medicine/Cardiology Assistant Professor
Northwestern University Department of Cardiovascular Medicine
Chicago, Illinois, USA Mayo Clinic
Rochester, Minnesota, USA
Tina Shah, MD
Staff Cardiologist Paaladinesh Thavendiranathan, MD, MSc
Kaiser Permanente Cardiologist, Associate Professor of Medicine
Seattle, Washington, USA Division of Cardiology and Joint Division of Medical Imaging
Peter Munk Cardiac Center,
Fidaa Shaib, MD TGH, UHN, University of Toronto
Associate Professor Toronto, Ontario, Canada
Departments of Pulmonary, Critical Care, and Sleep Medicine
Baylor College of Medicine Kara A. Thompson, MD, FACC
Houston, Texas, USA Associate Professor, Department of Cardiology
MD Anderson
Win K. Shen, MD Houston, Texas, USA
Professor and Consultant
Department of Cardiovascular Diseases Miguel Valderrábano, MD
Mayo Clinic Arizona Lois and Carl Davis Centennial Chair, Methodist DeBakey
Phoenix, Arizona, USA Heart and Vascular Center
Associate Professor of Medicine, Weill College of Medicine,
Katherine Shreyder, MD, PhD Cornell University
Cardiology Fellow Director, Division of Cardiac Electrophysiology
Department of Cardiovascular Medicine Department of Cardiology
Lahey Hospital and Medical Center Houston Methodist Hospital
Tufts University School of Medicine
Burlington, Massachusetts, USA Patrick R. Vargo, MD
Associate Staff
Mohita Singh, MD Department of Thoracic and Cardiovascular Surgery
Cardiology Fellow Cleveland Clinic
Department of Internal Medicine Cleveland, Ohio, USA
UT Southwestern
Dallas, Texas, USA Mahesh K. Vidula, MD
Fellow in Cardiovascular Medicine
Gulmohar Singh-Kucukarslan, MD, MS Department of Medicine, Division of Cardiovascular Medicine
Department of Internal Medicine University of Pennsylvania
Henry Ford Hospital Philadelphia, Pennsylvania, USA
Detroit, Michigan, USA
Shilpa Vijayakumar, MD
Audrey E. Spelde, MD Cardiology Fellow
Clinical Instructor Department of Medicine, Division of Cardiology
Department of Anesthesiology and Critical Care Alpert Medical School of Brown University
The University of Pennsylvania Providence, Rhode Island, USA
Philadelphia, Pennsylvania, USA
Salim S. Virani, MD, PhD
Sarah A. Spinler, BS Pharm, PharmD Professor
Professor and Chair Sections of Cardiovascular Research, Department of Medicine
Department of Pharmacy Practice Baylor College of Medicine
Binghamton University School of Pharmacy Houston, Texas, USA
and Pharmaceutical Sciences
Johnson City, New York, USA Birgit Vogel, MD
Cardiovascular Imaging Fellow
Deepthi Sudhakar, MD, MS Mount Sinai Morningside Hospital
Fellow Icahn School of Medicine at Mount Sinai
Department of Cardiology
New York, New York, USA
Baylor College of Medicine
Houston, Texas, USA
 PREFACE

This is now the sixth edition of Cardiology Secrets and the fourth edition I have edited. Among the 16 books I have
authored or edited, this series of books is the most satisfying and rewarding; from the feedback that we receive, it is
clear that we, to at least some extent, achieve our objectives of trying to educate readers and disseminate knowledge
on the optimal evaluation and management of patients of cardiovascular disease, and do so in a concise, digestible,
and entertaining manner. As always, we have updated all chapters to bring readers the most up-to-date information
and recommendations to the extent that a format such as this allows.
I am again deeply indebted to the hundreds of national and international experts and thought leaders in cardio-
vascular disease who over the years have taken time from their many academic and clinical responsibilities, as well
as family time, to contribute to the Cardiology Secrets series of books. I am similarly appreciative to the many persons
at Elsevier who I have worked with to bring this book in both hardcopy and electronic format to fruition.
It is my hope that you find this edition of the book both educational and enjoyable and that it in some small
way serves to improve the care of the patients that entrust their health and wellbeing to us. As always, I welcome
comments and suggestions from readers; my email is glevine@bcm.tmc.edu.
Glenn N. Levine, MD, FACC, FAHA

xii
CONTENTS

Top 100 Secrets xvii

Glenn N. Levine

I  Diagnostic Examinations and Procedures

CHAPTER 1 CARDIOVASCULAR PHYSICAL EXAMINATION 3
Glenn N. Levine, Salvatore Mangione

CHAPTER 2 HEART MURMURS AND SOUNDS 10

Glenn N. Levine, Salvatore Mangione

CHAPTER 3 ELECTROCARDIOGRAPHY 19
Gilad Birnbaum, Glenn N. Levine, Yochai Birnbaum

CHAPTER 4 CHEST X-RAY 27

James J. Fenton, Glenn N. Levine

CHAPTER 5 EXERCISE STRESS TESTING 35

Fernando Boccalandro, Katherine Shreyder

CHAPTER 6 AMBULATORY ECG MONITORS 42

Chayakrit Krittanawong, Glenn N. Levine

CHAPTER 7 ECHOCARDIOGRAPHY 49
Xiaoming Jia, Arunima Misra

CHAPTER 8 NUCLEAR CARDIOLOGY 63

Laura Flink, Lawrence Phillips

CHAPTER 9 CARDIAC POSITRON EMISSION TOMOGRAPHY 71

Luis A. Tamara

CHAPTER 10 CARDIAC MAGNETIC RESONANCE IMAGING 77

Paaladinesh Thavendiranathan, Scott D. Flamm

CHAPTER 11 CARDIAC COMPUTED TOMOGRAPHY 85

Arzu Canan, Prabhakar Rajiah, Suhny Abbara

CHAPTER 12 BEDSIDE HEMODYNAMIC MONITORING 97

Ajith Nair

CHAPTER 13 CARDIAC CATHETERIZATION: CORONARY ANGIOGRAM, INTRACORONARY IMAGING,

AND PHYSIOLOGY 105
Umair Khalid

II Chest Pains, Coronary Artery Disease,

and Acute Coronary Syndromes
CHAPTER 14 CHEST PAINS AND ANGINA 117
Glenn N. Levine

CHAPTER 15 CHRONIC STABLE ANGINA 126

Mahmoud Al Rifai, Glenn N. Levine, Richard A. Lange

CHAPTER 16 NON–ST-ELEVATION ACUTE CORONARY SYNDROME 133

John M. Suffredini, Glenn N. Levine

xiii
 xiv contents

CHAPTER 17 ST-ELEVATION MYOCARDIAL INFARCTION 141

Jing Liu, Glenn N. Levine

CHAPTER 18 CARDIOGENIC SHOCK 151

Deepthi Sudhakar, Sanket Borgaonkar, Hani Jneid

CHAPTER 19 PERCUTANEOUS CORONARY INTERVENTION 158

Ali E. Denktas, Cindy Grines

CHAPTER 20 CORONARY ARTERY BYPASS SURGERY 168

Rami Akhrass, Faisal G. Bakaeen

III Heart Failure and Cardiomyopathies

CHAPTER 21 MYOCARDITIS 177
Melissa A. Lyle, Leslie T. Cooper Jr

CHAPTER 22 LV DYSFUNCTION AND DILATED CARDIOMYOPATHY: ETIOLOGIES AND EVALUATION 186

Hirak Shah, Richa Agarwal

CHAPTER 23 HEART FAILURE WITH PRESERVED EJECTION FRACTION 193

Nitin Kondamudi, Ambarish Pandey

CHAPTER 24 HYPERTROPHIC CARDIOMYOPATHY 199

Lothar Faber, Smita Scholtz

CHAPTER 25 RESTRICTIVE CARDIOMYOPATHY 208

Stuart B. Prenner, Sanjiv J. Shah

CHAPTER 26 ACUTE DECOMPENSATED HEART FAILURE 217

G. Michael Felker, Marat Fudim

CHAPTER 27 HEART FAILURE: LONG-TERM MANAGEMENT 224

Savitri Fedson, Glenn N. Levine, Biykem Bozkurt

CHAPTER 28 HEART TRANSPLANTATION 235

Savitri Fedson

IV Valvular Heart Disease

CHAPTER 29 AORTIC STENOSIS 249
Geoffrey D. Huntley, Jeremy J. Thaden, Vuyisile T. Nkomo

CHAPTER 30 AORTIC REGURGITATION 260

Kathryn A. Gayle, Lisa A. Mendes

CHAPTER 31 MITRAL REGURGITATION 267

Mahesh K. Vidula, Tiffany Chen

CHAPTER 32 MITRAL STENOSIS 279

Sivadasanpillai Harikrishnan, Sanjay Ganapathi

CHAPTER 33 TRANSCATHETER AORTIC VALVE REPLACEMENT 285

Nagendra Boopathy Senguttuvan, George D. Dangas

CHAPTER 34 ENDOCARDITIS AND ENDOCARDITIS PROPHYLAXIS 296

June K. Pickett, Tina Shah, Rita Marr

V Arrhythmias
CHAPTER 35 ATRIAL FIBRILLATION 307
Michael E. Field

CHAPTER 36 SUPRAVENTRICULAR TACHYCARDIA 313

Mohita Singh, Jose A. Joglar
 contents xv

CHAPTER 37 VENTRICULAR ARRHYTHMIAS 319

Edmond M. Cronin

CHAPTER 38 CARDIAC PACING FOR BRADYCARDIA, CONDUCTION ABNORMALITIES, AND HEART

FAILURE 327
Paul Schurmann, Miguel Valderrábano

CHAPTER 39 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS 336

Paul Schurmann, Amish S. Dave

CHAPTER 40 CARDIAC ARREST AND RESUSCITATION 345

Jeffrey S. Berman, Glenn N. Levine

VI Primary and Secondary Prevention

CHAPTER 41 HYPERTENSION 353
Gabriel B. Habib Sr

CHAPTER 42 HYPERLIPIDEMIA 362

Aliza Hussain, Salim S. Virani, Vijay Nambi

CHAPTER 43 DIABETES AND CARDIOVASCULAR DISEASE 371

David Aguilar

CHAPTER 44 SMOKING CESSATION 377

Hassan Mir, Andrew Pipe

CHAPTER 45 PHYSICAL ACTIVITY, EXERCISE, AND THE HEART 382

Shivda Pandey, Eric Awtry, Gary J. Balady

VII  The Heart in Specific Populations and Conditions

CHAPTER 46 CARDIAC MANIFESTATIONS OF HIV 391
Matthew J. Feinstein

CHAPTER 47 CARDIAC MANIFESTATIONS OF RHEUMATOLOGIC DISORDERS 397

Shilpa Vijayakumar, Nishant R. Shah

CHAPTER 48 CARDIO-ONCOLOGY 402

Kara A. Thompson

CHAPTER 49 COCAINE AND THE HEART 409

Gulmohar Singh-Kucukarslan, Jim McCord

CHAPTER 50 CARDIOVASCULAR SEQUELAE OF COVID-19 415

Aakriti Gupta, Thomas Maddox

CHAPTER 51 HEART DISEASE IN THE ELDERLY 420

G. Titus Ngeno, Tomoya T. Hinohara, E. Magnus Ohman

CHAPTER 52 HEART DISEASE IN PREGNANCY 430

Sheilah Bernard

CHAPTER 53 HEART DISEASE IN WOMEN 438

Birgit Vogel, Roxana Mehran

CHAPTER 54 SLEEP APNEA AND THE HEART 444

Ihab Hamzeh, Fidaa Shaib

VIII Peripheral Vascular and Cerebrovascular Disease

CHAPTER 55 PERIPHERAL ARTERIAL DISEASE 451
Marie Gerhard-Herman

CHAPTER 56 AORTIC ANEURYSMS 459

Heidi Reich, Patrick R. Vargo, Faisal G. Bakaeen, Eric E. Roselli
 xvi contents

CHAPTER 57 AORTIC DISSECTION 468

Sarah Kohnstamm, Kim A. Eagle

CHAPTER 58 CAROTID ARTERY DISEASE 475

Ali M. Agha, Vijay Nambi, Neal Barshes

CHAPTER 59 ISCHEMIC STROKE 482

Maria A. Parekh, Paul Litvak, Sharyl R. Martini, Thomas A. Kent

CHAPTER 60 HEMORRHAGIC STROKE AND CEREBRAL VENOUS SINUS THROMBOSIS 493

Maria A. Parekh, Paul Litvak, Sharyl R. Martini, Thomas A. Kent

IX Venous Thromboembolic Disease

CHAPTER 61 DEEP VEIN THROMBOSIS 499
Geno J. Merli

CHAPTER 62 PULMONARY EMBOLISM 508

Jamal H. Mahar, Gustavo A. Heresi

CHAPTER 63 HYPERCOAGULABLE STATES 520

Kelly N. Casteel, Michael H. Kroll

X Additional Topics in Cardiology

CHAPTER 64 ADULT CONGENITAL HEART DISEASE 529
Luc M. Beauchesne

CHAPTER 65 CARDIAC TUMORS 537

Nicolas L. Palaskas, Glenn N. Levine

CHAPTER 66 HYPERTENSIVE CRISIS 542

Stephen Boone, Michael Boone, W. Frank Peacock

CHAPTER 67 ORAL ANTICOAGULATION THERAPY 548

Sarah A. Spinler

CHAPTER 68 PERICARDITIS, PERICARDIAL CONSTRICTION, AND PERICARDIAL TAMPONADE 563

Scott E. Janus, Brian D. Hoit

CHAPTER 69 PREOPERATIVE CARDIAC EVALUATION 569

Audrey E. Spelde, Lee A. Fleisher

CHAPTER 70 PULMONARY HYPERTENSION 577

Casey Graziani, Lavannya M. Pandit

CHAPTER 71 SYNCOPE 586

Pattara Rattanawong, Glenn N. Levine, Win K. Shen

CHAPTER 72 TRAUMATIC HEART DISEASE 597

Fernando Boccalandro, Katherine Shreyder

INDEX 604
TOP 100 SECRETS

1. The four conditions identified as having the highest risk of adverse outcome from endocarditis for which
prophylaxis with dental procedures is still recommended by the American Heart Association are prosthetic cardiac
valve, previous infective endocarditis, certain cases of congenital heart disease, and cardiac transplantation
recipients who develop cardiac valvulopathy.
2. Causes of ST-segment elevation include acute myocardial infarction (MI) as a result of thrombotic occlusion of a
coronary artery, Prinzmetal’s angina, cocaine-induced myocardial infarction, pericarditis, left ventricular aneurysm,
left bundle branch block (LBBB), left ventricular hypertrophy with repolarization abnormalities, J point elevation,
and severe hyperkalemia.
3. During pregnancy, maternal heart rate (HR) increases throughout the 40 weeks, mediated partially by increased
sympathetic tone and heat production. Hormonal changes cause an increase in both plasma volume (from water
and sodium retention) and red blood cell volume (from erythrocytosis) during a normal pregnancy. Stroke volume
subsequently continues to increase until the third trimester, when inferior vena cava (IVC) return may be
compromised by the gravid uterus. Maternal cardiac output (CO) increases by 30% to 50% during a normal
pregnancy. Systolic blood pressure drops during the first half of pregnancy and returns to normal levels by
delivery.
4. The major risk factors for coronary artery disease (CAD) are family history of premature coronary artery disease
(father, mother, brother, or sister who first developed clinical CAD at age younger than 45–55 for males and at age
younger than 55–60 for females), hypercholesterolemia, hypertension, cigarette smoking, and diabetes mellitus.
5. Coronary flow reserve (the increase in coronary blood flow in response to agents that lead to microvascular
dilation) begins to decrease when a coronary artery stenosis is 50% or more luminal diameter. However, basal
coronary flow does not begin to decrease until the lesion is 80% to 90% luminal diameter.
6. Important causes of chest pain not related to atherosclerotic coronary artery disease include aortic dissection,
pneumothorax, pulmonary embolism, pneumonia, hypertensive crisis, Prinzmetal’s angina, cardiac syndrome X,
anomalous origin of the coronary artery, pericarditis, esophageal spasm or esophageal rupture (Boerhaave’s
syndrome), and shingles.
7. Sinus node dysfunction, commonly referred to as sick sinus syndrome, refers to a broad array of abnormalities of
the sinus node ranging from atrial impulse formation through propagation of the depolarization impulse. Sick
sinus syndrome can manifest as sinus bradycardia, paroxysmal sinus arrest, sinus node exit block or chronotropic
insufficiency. Tachycardia-bradycardia (“tachy-brady”) syndrome is a common appearance of sick sinus syndrome
in patients with an atrial fibrillation or atrial flutter.
8. Other causes of elevated cardiac troponin besides acute coronary syndrome and myocardial infarction that should
be considered in patients with chest pains include pulmonary embolism, aortic dissection, myopericarditis, severe
aortic stenosis, and severe chronic kidney disease.
9. Causes of pericarditis include infectious (viral, bacterial, fungal, mycobacterial, human immunodeficiency virus
[HIV] associated), neoplastic (usually metastatic from lung or breast; melanoma, lymphoma, or acute leukemia),
myocardial infarction, injury (postpericardiotomy, traumatic), radiation, metabolic (myxedema, uremia), and
connective tissue disease. In the developed world, the most common cause remains viral etiologies, whereas
tuberculosis is the most frequent cause in developing countries.
10. Prinzmetal’s angina, also called variant angina, is an unusual cause of angina caused by coronary vasospasm.
Patients with Prinzmetal’s angina are typically younger and often female. Treatment is based primarily on the use
of calcium channel blockers and nitrates.
11. Microvascular angina appears to play a major role in the underlying mechanisms of ischemia with nonobstructive
coronary arteries (INOCA) and is defined as the occurrence of chest pain based on abnormal coronary flow
reserve due to coronary microvascular dysfunction in the absence of obstructive coronary artery disease. This
condition was prior referred to as “syndrome X.” Microvascular angina is more common in women and likely
underdiagnosed. Abnormal coronary flow reserve is diagnosed as a coronary flow reserve of less than 2.5, which
requires measurement using invasive (flow wire) or noninvasive (positron emission tomography, echo Doppler, or
cardiac magnetic resonance imaging) techniques. Standardized criteria for diagnosis of microvascular angina
have been proposed. However, many uncertainties about the underlying pathophysiological mechanisms of
microvascular angina persist, and further studies are needed to develop the evidence base for diagnosis and
especially for the treatment of this condition. For now, potential therapies include beta-blockers, short-acting
nitrates, calcium antagonists, and angiotensin-converting enzyme inhibitors for symptom relief.
12. The three main types of ASDs are secundum (80%), primum (15%), and sinus venosus (5%). The secundum ASD
is a defect involving the floor of the fossa ovalis of the atrial septum. It usually presents as an isolated anomaly.
xvii
 xviii TOP 100 SECRETS

The primum ASD is a defect at the base of the atrial septum adjacent to the atrioventricular valves. It is invariably
part of an atrioventricular septal defect (endocardial cushion defect), and a cleft mitral valve is almost always
present. The sinus venosus ASD is a defect of the posterior part of the septum, usually located in the superior
part. In the majority of cases, a sinus venosus ASD is associated with anomalous connections or drainage of the
right-sided pulmonary veins
13. Numerous cardiovascular medications are associated with drug-induced lupus erythematosus. Those with a
definitive causative relationship include procainamide, hydralazine, diltiazem, quinidine, and methyldopa. Those
with a probable causative relationship include beta-blockers, captopril, hydrochlorothiazide, amiodarone, and
ticlopidine.
14. Subarachnoid hemorrhage due to aneurysm rupture classically presents with the worst headache of one’s life;
loss of consciousness, nausea/vomiting, nuchal rigidity, and focal neurologic signs are also common. Although
large amounts of subarachnoid blood are readily apparent on CT, even small amounts of subarachnoid blood can
provoke symptoms. Detection of these small “sentinel bleeds” is vital, as they herald aneurysm rupture.
15. Findings that suggest a heart murmur is pathologic and requires further evaluation include the presence of
symptoms, extra heart sounds, thrills, abnormal ECG or chest radiography, diminished or absent S2, holosystolic
(or late systolic) murmur, any diastolic murmur, and all continuous murmurs.
16. In the early- and pre-ART eras (early 2000s and prior), common CVD manifestations of HIV/AIDS included
pericardial effusion/tamponade, dilated cardiomyopathy and severe systolic dysfunction, myocarditis, marantic
(thrombotic) or infectious endocarditis, cardiac tumors (Kaposi’s sarcoma, lymphoma), pulmonary arterial
hypertension, and sudden cardiac death. These complications may still occur in the present era, especially in the
setting of poor HIV control, although now common CVD complications tend to be more subacute and chronic,
including coronary artery disease and MI, heart failure with preserved and reduced ejection fraction, and sudden
cardiac death
17. The major categories of ischemic stroke are large vessel atherosclerosis (including embolization from carotid to
cerebral arteries), small vessel vasculopathy or lacunar type, and cardioembolic. Hemorrhagic strokes are
classified by their location: subcortical (associated with uncontrolled hypertension in 60% of cases) versus cortical
(more concerning for underlying mass, arteriovenous malformation, or amyloidosis).
18. Acute MI remains the leading cause of cardiogenic shock in the United States. In fact, despite the decline in its
incidence with progressive use of timely primary PCI, cardiogenic shock still occurs in 5% to 8% of hospitalized
patients with ST-segment elevation myocardial infarction (STEMI). Unlike what is commonly believed, cardiogenic
shock may also occur in up to 2% to 3% of patients with non–ST-segment-elevation myocardial infarction
(NSTEMI). Overall, 40,000 to 50,000 cases of cardiogenic shock occur annually in the United States. Chronic
congestive heart failure may decompensate into cardiogenic shock and is the second most common etiology for
cardiogenic shock after acute MI. Ventricular septal rupture and papillary muscle rupture, both usually occurring
within days of a transmural MI, are less common causes.
19. Cardiomyopathy in COVID-19 may occur as a result of direct viral damage, myocarditis, microvasculature
dysfunction secondary to endothelial cell damage or systemic inflammatory response syndrome in response to
SARS-CoV-2 infection. Other potential etiologies include thrombotic myocardial infarction or severe myocardial
ischemia in patients with preexisting coronary artery disease, stress-mediated myocardial dysfunction,
tachycardia-induced cardiomyopathy, and myocardial stunning after resuscitation or prolonged hypotension. The
mainstay of management of COVID-19–related cardiomyopathy is supportive care.
20. Findings that should raise the suspicion for endocarditis include bacteremia/sepsis of unknown cause, fever,
constitutional symptoms, hematuria/glomerulonephritis/suspected renal infarction, embolic event of unknown
origin, new heart murmurs, unexplained new atrioventricular (AV) nodal conduction abnormality, multifocal or rapid
changing pulmonic infiltrates, peripheral abscesses, certain cutaneous lesions (Osler’s nodes, Janeway’s lesions),
and specific ophthalmic manifestations (Roth’s spots).
21. Common radiographic signs of congestive heart failure include enlarged cardiac silhouette, left atrial enlargement,
hilar fullness, vascular redistribution, linear interstitial opacities (Kerley’s lines), bilateral alveolar infiltrates, and
pleural effusions (right . left).
22. Classic ECG criteria for the diagnosis of ST-segment elevation myocardial infarction (STEMI), warranting
thrombolytic therapy, are ST-segment elevation greater than 0.1 mV in at least two contiguous leads (e.g., leads III
and aVF or leads V2 and V3) or new or presumably new left bundle branch block (LBBB).
23. Perioperative cardiac morbidity occurs most commonly during the first 3 postoperative days and includes
perioperative myocardial infarction (PMI), unstable angina, congestive heart failure, cardiac death, and nonfatal
cardiac arrests. Studies suggest a peak incidence of PMI within the first 48 hours or earlier. Among patients with
known ischemic heart disease, incidence of PMI is approximately 5%, with incidence decreasing to 2% to 4%
among patients with risk factors but no history of ischemic heart disease and decreasing still among patients with
no risk factors. Additionally, mortality from PMI has decreased from previous rates of 30% to 50% to
approximately 12%. A more recently described but separate syndrome from PMI is myocardial injury after
noncardiac surgery (MINS). MINS is defined by elevated troponin in the perioperative period due to cardiac
ischemia that does not meet criteria for MI set by the Fourth Universal Definition of Myocardial Infarction. While
seemingly more benign, MINS is independently associated with risk of death and cardiovascular complications in
the year following surgery.
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