Inflammation of the inner lining of the heart. Damage to the heart valves from infection (bacterial endocarditis) produces lesions called vegetations (resembling cauliflower) that break off into the bloodstream as emboli (material that travels through the blood). The emboli can lodge in other vessels, leading to a transient ischemic attack (TIA), or stroke, or in small vessels of the skin, where multiple pinpoint hemorrhages known as petechiae (from the Italian petechio, a flea bite) form. Antibiotics can cure bacterial endocarditis.
hypertensive heart disease
High blood pressure affecting the heart. This condition results from narrowing of arterioles, which leads to increased pressure in arteries. The heart is affected (left ventricular hypertrophy) because it pumps more vigorously to overcome the increased resistance in the arteries.
mitral valve prolapse (MVP)
Improper closure of the mitral valve. This condition occurs because the mitral valve enlarges and prolapses into the left atrium during systole. The physician hears a midsystolic click on auscultation (listening with a stethoscope). Most people with MVP live normal lives, but prolapsed valves can on rare occasion become infected.
Extra heart sound, heard between normal beats. Murmurs are heard with the aid of a stethoscope and usually are caused by a valvular defect or disease that disrupts the smooth flow of blood in the heart. They also are heard in cases of interseptal defects, in which blood flows abnormally between chambers through holes in the septa. Functional murmurs are not caused by valve or septal defects and do not seriously endanger a person’s health.A bruit (brū-Ē) is an abnormal sound or murmur heard on auscultation. A thrill, which is a vibration felt on palpation of the chest, often accompanies a murmur.
Inflammation of the membrane (pericardium) surrounding the heart. In most instances, pericarditis results from disease elsewhere in the body (such as pulmonary infection). Bacteria and viruses cause the condition, or the etiology may be idiopathic. Malaise, fever, and chest pain occur, and auscultation with a stethoscope often reveals a pericardial friction rub (heard as a scraping or grating sound). Compression of the heart caused by collection of fluid in the pericardial cavity is cardiac tamponade (tăm-pō-NŎD). Treatment includes anti-inflammatory drugs and other agents to manage pain. If the pericarditis is infective, antibiotics or antifungals are prescribed, depending on the microorganisms detected in specimens obtained by pericardiocentesis.
rheumatic heart disease
Heart disease caused by rheumatic fever. Rheumatic fever is a childhood disease that follows a streptococcal infection. The heart valves can be damaged by inflammation and scarred (with vegetations), so that they do not open and close normally (Figure 11-19A). Mitral stenosis, atrial fibrillation, and congestive heart failure, caused by weakening of the myocardium, also can result from rheumatic heart disease. Treatment consists of reduced activity, drugs to control arrhythmia, surgery to repair a damaged valve, and anticoagulant therapy to prevent emboli from forming. Artificial and porcine (pig) valve implants can replace deteriorated heart valves
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Local widening (dilation) of an arterial wall. An aneurysm (Greek, aneurysma, widening) usually is caused by atherosclerosis and hypertension or a congenital weakness in the vessel wall. Aneurysms are common in the aorta but may occur in peripheral vessels as well. The danger of an aneurysm is rupture and hemorrhage. Treatment depends on the vessel involved, the site, and the health of the patient. In aneurysms of small vessels in the brain (berry aneurysms), treatment is occlusion of the vessel with small clips. For larger arteries, such as the aorta, the aneurysm is resected and a synthetic graft is sewn within the affected vessel. Figure 11-20A shows an abdominal aortic aneurysm, and Figure 11-20B illustrates a synthetic graft in place. Stent grafts also may be placed less invasively as an alternative to surgery in some patients.
deep vein thrombosis (DVT)
Blood clot (thrombus) forms in a large vein, usually in a lower limb. This condition may result in a pulmonary embolism (clot travels to the lung) if not treated effectively. Anticoagulants (blood-thinning drugs) such as heparin are used to prevent pulmonary emboli.
Abnormally swollen and twisted veins, usually occurring in the legs. This condition is caused by damaged valves that fail to prevent the backflow of blood (Figure 11-21A to C). The blood then collects in the veins, which distend to many times their normal size. Because of the slow flow of blood in the varicose veins and frequent injury to the vein, thrombosis may occur as well. Hemorrhoids (piles) are varicose veins near the anus.Physicians now treat varicose veins with sclerotherapy (injections with sclerosing solution) or laser and pulsed-light treatments to seal off veins. Surgical interventions such as vein stripping and ligation are used less frequently.
acute coronary syndromes (ACSs)
Unstable angina and myocardial infarction (heart attack), which are consequences of plaque rupture in coronary arteries.
Chest pain resulting from myocardial ischemia. Stable angina occurs predictably with exertion; unstable angina is chest pain that occurs more often and with less exertion.
angiotensin-converting enzyme (ACE) inhibitor
Antihypertensive drug that blocks the conversion of angiotensin I to angiotensin II, causing blood vessels to dilate. It prevents heart attacks, CHF, stroke, and death. See Table 21-6 on page 886 for names of ACE inhibitors and other cardiovascular drugs.
Listening for sounds in blood vessels or other body structures, typically using a stethoscope.
Drug used to treat angina, hypertension, and arrhythmias. It blocks the action of epinephrine (adrenaline) at receptor sites on cells, slowing the heartbeat and reducing the workload on the heart.
Device enabling ventricles to beat together (in synchrony) so that more blood is pumped out of the heart.
Abnormal blowing or swishing sound heard during auscultation of an artery or organ.
calcium channel blocker
Drug used to treat angina and hypertension. It dilates blood vessels by blocking the influx of calcium into muscle cells lining vessels.
Sudden, unexpected stoppage of heart action; sudden cardiac death.
Pressure on the heart caused by fluid in the pericardial space.
Pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest.
Drug that treats arrhythmias and strengthens the heartbeat.
embolus ( plural: emboli)
Clot or other substance that travels to a distant location and suddenly blocks a blood vessel.
Area of dead tissue.
Drugs used in the treatment of angina. They dilate blood vessels, increasing blood flow and oxygen to myocardial tissue.
Nitrate drug used in the treatment of angina.
Closure of a blood vessel due to blockage.
Uncomfortable sensations in the chest related to cardiac arrhythmias, such as premature ventricular contractions (PVCs).
pericardial friction rub
Scraping or grating noise heard on auscultation of the heart; suggestive of pericarditis.
Small, pinpoint hemorrhages.
Drugs used to lower cholesterol in the bloodstream.
Vibration felt over an area of turmoil in blood flow (as a blocked artery).
Clumps of platelets, clotting proteins, microorganisms, and red blood cells on diseased heart valves.
Measurement of BNP (brain natriuretic peptide) in blood. BNP is elevated in patients with heart failure, and it is useful in the diagnosis of CHF in patients with dyspnea who come to the emergency department. Its presence also identifies patients at risk for complications when presenting with acute coronary syndromes (e.g., myocardial infarction and unstable angina). It is secreted when the heart becomes overloaded, and it acts as a diuretic to help heart function return to normal.The reference to brain in this substance originates from its initial identification from the brain of a pig.
Chemicals are measured in the blood as evidence of a heart attack. Damaged heart muscle releases chemicals into the bloodstream. The substances tested for are troponin-I (cTnI) and troponin-T (cTnT). Troponin is a heart muscle protein released into circulation after myocardial injury.
lipid tests (lipid profile)
Measurement of cholesterol and triglycerides (fats) in a blood sample. High levels of lipids are associated with atherosclerosis. The National Guideline for total cholesterol in the blood is less than 200 mg/dL. Saturated fats (animal origin, such as milk, butter, and meats) increase cholesterol in the blood, whereas polyunsaturated fats (of vegetable origin, such as corn and safflower oil) decrease blood cholesterol.Treatment of hyperlipidemia includes proper diet (low-fat, high-fiber intake) and exercise. Niacin (a vitamin) also helps reduce lipids. Drug therapy includes statins, which reduce the risk of heart attack, stroke, and cardiovascular death. Statins lower cholesterol by reducing its production in the liver. Examples are simvastatin (Zocor), atorvastatin (Lipitor), and pravastatin (Pravachol).
Lipoproteins (combinations of fat and protein) are physically separated and measured in a blood sample. Examples of lipoproteins are low-density lipoprotein (LDL) and high-density lipoprotein (HDL). High levels of LDL are associated with atherosclerosis. The National Guideline for LDL is less than 130 mg/dL in normal persons and less than 70 mg/dL in patients with CAD, PAD, and diabetes mellitus. High levels of HDL protect adults from atherosclerosis. Factors that increase HDL are estrogen, exercise, and alcohol in moderation.
X-ray imaging of blood vessels after injection of contrast material. Arteriography is x-ray imaging of arteries after injection of contrast via a catheter into the aorta or an artery.
computed tomography angiography (CTA)
Three-dimensional x-ray images of the heart and coronary arteries using computed tomography (CT) (64-slice CT scanner). This newer technique takes hundreds of images of the heart per second. Cross-sectional images are assembled by computer into a three-dimensional picture. It is less invasive than angiography (contrast material is injected into a small peripheral vein with a small needle) and provides excellent views of the coronary arteries for diagnosis of coronary artery disease (Figure 11-22A). (A, Courtesy Massachusetts General Hospital, Boston; B, from Crawford MH, DiMarco JP, Paulus WJ: Cardiology, 2nd ed., St. Louis, Mosby, 2004, p. 224.)
digital subtraction angiography (DSA)
Video equipment and a computer produce x-ray images of blood vessels. After taking an initial x-ray picture and storing it in a computer, physicians inject contrast material and take a second image of that area. The computer compares the two images and subtracts digital data for the first from the second, leaving an image of vessels with contrast.
electron beam computed tomography (EBCT or EBT)
Electron beams and CT identify calcium deposits in and around coronary arteries to diagnose early CAD. A coronary artery calcium score is derived to indicate future risk of heart attack and stroke. This new test is faster (called ultrafast CT) than a standard CT scan and takes a clear picture of coronary arteries while the heart is beating (Figure 11-22B).
Doppler ultrasound studies
Sound waves measure blood flow within blood vessels. An instrument focuses sound waves on blood vessels, and echoes bounce off red blood cells. The examiner can hear various alterations in blood flow caused by vessel obstruction. Duplex ultrasound combines Doppler and conventional ultrasound to allow physicians to image the structure of blood vessels and measure the speed of blood flow. Carotid artery occlusion, aneurysms, varicose veins, and other vessel disorders can be diagnosed with Duplex ultrasound.
Echoes generated by high-frequency sound waves produce images of the heart ( Figure 11-23A ). ECHOs show the structure and movement of the heart. In transesophageal echocardiography (TEE), a transducer placed in the esophagus provides ultrasound and Doppler information (Figure 11-23B). This technique detects cardiac masses, prosthetic valve function, aneurysms, and pericardial fluid.
positron emission tomography (PET) scan
Images show blood flow and myocardial function following uptake of radioactive glucose. PET scanning can detect CAD, myocardial function, and differences between ischemic heart disease and cardiomyopathy.
technetium Tc 99m sestamibi scan
Technetium Tc 99m sestamibi injected intravenously is taken up in cardiac tissue, where it is detected by scanning. This scan is used in persons who have had an MI, to assess the amount of damaged heart muscle. It also is used with an exercise tolerance test (ETT-MIBI). Sestamibi is a radioactive tracer compound used to define areas of poor blood flow in heart muscle.
thallium 201 scan
Concentration of radioactive thallium is measured to give information about blood supply to the heart muscle. Thallium studies show the viability of heart muscle. Infarcted or scarred myocardium shows up as “cold spots.”
Images of the heart are produced using radiowave energy in a magnetic field. These images in multiple planes give information about aneurysms, cardiac output, and patency of peripheral and coronary arteries. The magnetic waves emitted during MRI could interfere with implanted pacemakers because of their metal content, so it is currently contraindicated for a patient with a pacemaker to undergo cardiac MRI. Magnetic resonance angiography (MRA) is a type of MRI that gives highly detailed images of blood vessels. Physicians use MRA to view arteries and blockage inside arteries.
An ECG device is worn during a 24-hour period to detect cardiac arrhythmias. Rhythm changes are correlated with symptoms recorded in a diary.
Exercise tolerance test (ETT) determines the heart’s response to physical exertion (stress). A common protocol uses 3-minute stages at set speeds and elevations of a treadmill. Continual monitoring of vital signs and ECG rhythms is important in the diagnosis of CAD and left ventricular function.
Brief delivery of radiofrequency or cryosurgery to destroy areas of heart tissue that may be causing arrhythmias A catheter is guided through a vein in the leg to the vena cava and into the heart. The abnormal electrical pathway is located and ablated (destroyed) via energy emitted from the catheter.
coronary artery bypass grafting (CABG)
Arteries and veins are anastomosed to coronary arteries to detour around blockages. Internal mammary (breast) and radial (arm) arteries and saphenous (leg) vein grafts are used to keep the myocardium supplied with oxygenated blood (Figure 11-26). Cardiac surgeons perform minimally invasive CABG surgery with smaller incisions instead of the traditional sternotomy to open the chest. Vein and artery grafts are removed endoscopically with small incisions as well. Although most operations are performed with a heart-lung machine (“on-pump”), an increasing number are performed “off-pump” with a beating heart.
Brief discharges of electricity are applied across the chest to stop dysrhythmias (ventricular fibrillation). For patients at high risk for sudden cardiac death from ventricular dysrhythmias, an implantable cardioverter-defibrillator (ICD) or automatic implantable cardioverter-defibrillator (AICD) is placed in the upper chest.Cardioversion is another technique using lower energy to treat atrial fibrillation, atrial flutter, and supraventricular tachycardia.
Surgical removal of plaque from the inner layer of an artery. Fatty deposits (atheromas) and thromboses are removed to open clogged arteries. Carotid endarterectomy is a procedure to remove plaque buildup in the carotid artery to reduce risk of stroke.
Heart-lung machine diverts blood from the heart and lungs while the heart is repaired. Blood leaves the body, enters the heart-lung machine, where it is oxygenated, and then returns to a blood vessel (artery) to circulate through the bloodstream. The machine uses the technique of extracorporeal membrane oxygenation (ECMO).
A donor heart is transferred to a recipient. While waiting for a transplant, a patient may need a left ventricular assist device (LVAD), which is a booster pump implanted in the abdomen with a cannula (flexible tube) to the left ventricle.
percutaneous coronary intervention (PCI)
Balloon-tipped catheter is inserted into a coronary artery to open the artery; stents are put in place. An interventional cardiologist places the catheter in the femoral or radial artery and then threads it up the aorta into the coronary artery. Stents (expandable slotted tubes that serve as permanent scaffolding devices) create wide lumens and make restenosis less likely. Newer drug-eluting stents (DESs) are coated with polymers that elute (release) antiproliferative drugs to prevent scar tissue formation leading to restenosis (Figure 11-27). Stents are also placed in carotid, renal, and other peripheral arteries.PCI techniques include percutaneous transluminal coronary angioplasty (PTCA), stent placement, laser angioplasty (a small laser on the tip of a catheter vaporizes plaque), and atherectomy.
Drugs to dissolve clots are injected into the bloodstream of patients with coronary thrombosis. Tissue plasminogen activator (tPA) and streptokinase restore blood flow to the heart and limit irreversible damage to heart muscle. The drugs are given within 12 hours after the onset of a heart attack. Thrombolytic agents reduce the mortality rate in patients with myocardial infarction by 25%.
abdominal aortic aneurysm
angiotensin-converting enzyme inhibitor
advanced cardiac life support; CPR plus drugs and defibrillation
acute coronary syndrome
adenosine diphosphate; ADP blockers are used to prevent cardiovascular-related death, heart attack, and strokes and after all stent procedures
automatic external defibrillator
automatic implantable cardioverter-defibrillator
acute myocardial infarction
arrhythmogenic right ventricular dysplasia
atrial septal defect
aortic valve replacement
bundle branch block
brain natriuretic peptide; elevated in congestive heart failure
coronary artery bypass grafting
coronary artery disease
coronary care unit
congestive heart failure
creatine kinase; released into the bloodstream after injury to heart or skeletal muscles
coarctation of the aorta
cardiac resynchronization therapy; biventricular pacing
CTNI or cTnI; CTNT or cTnT
cardiac troponin-I and cardiac troponin-T; troponin is a protein released into the bloodstream after myocardial injury
digital subtraction angiography
deep vein thrombosis
extracorporeal membrane oxygenation
ECG; also seen as EKG
ejection fraction; measure of the amount of blood that pumps out of the heart with each beat
electrophysiology study; electrode catheters are inserted into veins and threaded into the heart and electrical conduction is measured (tachycardias are provoked and analyzed)
exercise tolerance test
exercise tolerance test combined with a radioactive tracer (sestamibi) scan
high-density lipoprotein; high blood levels are associated with lower incidence of coronary artery disease
hypertension (high blood pressure)
intra-aortic balloon pump; used to support patients in cardiogenic shock
left anterior descending (coronary artery)
left ventricular assist device
left ventricular hypertrophy
multiple-gated acquisition scan; a radioactive test of heart function
mitral valve prolapse
normal sinus rhythm
non-ST elevation myocardial infarction
premature atrial contraction
peripheral arterial disease
percutaneous coronary intervention
patent ductus arteriosus; posterior descending artery
premature ventricular contraction
SA, S-A node
sudden cardiac death
shortness of breath
single photon emission computed tomography; used for myocardial imaging with sestamibi scans
substernal chest pain
ST elevation myocardial infarction
supraventricular tachycardia; rapid heartbeats arising from the atria and causing palpitations, SOB, and dizziness
transposition of the great arteries
tissue-type plasminogen activator; a drug used to prevent thrombosis
unstable angina; chest pain at rest or of increasing frequency
ventricular septal defect
Wolff-Parkinson-White syndrome; an abnormal ECG pattern often associated with paroxysmal tachycardia
Thin, flexible tube is guided into the heart via a vein or an artery. This procedure detects pressures and patterns of blood flow in the heart. Contrast may be injected and x-ray images taken of the heart and blood vessels (Figure 11-24). This procedure may be used in diagnosis and treatment of heart conditions (see under percutaneous coronary intervention [PCI] on page 431).
Recording of electricity flowing through the heart. Continuous monitoring of a patient’s heart rhythm in hospitals is performed via telemetry (electronic transmission of data—tele/o means distant). Normal sinus rhythm begins in the SA node and is between 60 to 100 beats per minute. Figure 11-25 shows ECG strips for normal sinus rhythm and several types of dysrhythmias (abnormal rhythms).
External Cardioverter Defibrilator
use to shock the patient