Key Point

Volume expansion is the primary supportive treatment for the hemodynamic

abnormalities of a right ventricular myocardial infarction.

Coronary artery bypass graft surgery is recommended for patients with

diabetes mellitus and multivessel disease.

Valvuloplasty or valve replacement is indicated once mitral stenosis becomes

symptomatic.

Peripartum cardiomyopathy is defined as heart failure with a left ventricular

ejection fraction less than 45% that is diagnosed between 3 months before and
6 months after delivery in the absence of an identifiable cause.

A biventricular pacemaker-defibrillator may provide symptomatic and

mortality benefit in patients with ejection fraction less than or equal to 35%,
QRS width greater than 120-130 msec, and New York Heart Association class
III or IV heart failure.

Characteristic features of pulmonary valve stenosis include a prominent a

wave in the jugular venous pulse contour, a parasternal impulse, an ejection
click, a systolic thrill, and an early systolic murmur that increases with
inspiration.

Cardiopulmonary symptoms in patients with less than severe valvular

regurgitation usually indicate other disease processes.

Surgical septal myectomy is the treatment of choice in patients with

hypertrophic obstructive cardiomyopathy who have New York Heart
Association functional class III or IV symptoms and are refractory to medical
therapy.

Patients with unstable angina or a nonST-elevation myocardial infarction and

a high TIMI risk score benefit from aggressive medical therapy and referral
for early coronary angiography.

Presentation of coronary artery disease in a cardiac transplant patient is

frequently atypical, and may manifest with new-onset heart failure symptoms,
decreased exercise tolerance, syncope (usually due to arrhythmias or
conduction defects), or cardiac arrest.

Implantable cardioverter-defibrillators reduce the risk of death in patients with

New York Heart Association class II or III heart failure and either ischemic or
nonischemic cardiomyopathy and an ejection fraction of 35% or less.

Angiotensin-converting enzyme inhibitor and -blocker therapy is indicated

for all patients with systolic heart failure regardless of symptoms or functional
status, including asymptomatic or very functional patients.

All available -blockers cross the placenta and are present in human
breast milk, resulting in significant levels in the fetus or newborn.
Therefore, when used during pregnancy, fetal and newborn heart rate and
blood glucose monitoring are indicated. Adverse fetal effects, such as low
birth weight, early delivery, and small size for gestational age, have been
associated with the use of atenolol, especially when initiated early in the
pregnancy. Metoprolol (pregnancy risk category C) should be considered
as an alternative

Adenosine is the treatment of choice for a hemodynamically stable

supraventricular tachycardia that occurs during pregnancy.

intravenous amiodarone can be used in patients with atrial or ventricular

arrhythmias during pregnancy that are not controlled by other
medications. Amiodarone is classified as an FDA pregnancy risk category
D drug. Amiodarone crosses the placenta, affecting fetal heart rate and
causing fetal hypothyroidism or goiter

. ..Diltiazem, Metoprolol, Digoxin are classified as a pregnancy risk category C drug

For asymptomatic abdominal aortic aneurysms 4.0 to 5.4 cm in diameter, an

ultrasound surveillance interval of 6 months has been shown to be safe.

Glycoprotein IIb/IIIa inhibitors should be added to standard anti-anginal and

antithrombotic therapy in patients with unstable angina or nonST-elevation
myocardial infarction with ongoing anginal symptoms.

Low-molecular-weight heparin is contraindicated in patients with renal

insufficiency and estimated glomerular filtration rate below 30 mL/min/1.73
m2.

Surgical removal of left atrial myxoma is curative and is the appropriate

primary treatment.

Patients presenting late with an ST-elevation myocardial infarction (>12 hours

after symptoms onset) and ongoing chest pain should be treated with primary
percutaneous coronary intervention as opposed to thrombolytic therapy.

Surgery for infective endocarditis is indicated if there is significant

hemodynamic instability or paravalvular extension and should be considered if
there is heart failure, resistant infections, or large mobile vegetations.

The indication to initiate cholesterol-lowering medication as well as the goal

level for treatment are dependent on the absolute level of LDL cholesterol and
the estimated 10-year risk for a coronary artery disease event.

Noninvasive stress tests for detecting coronary artery disease perform best in
patients with an intermediate pretest probability of disease.

Iron chelation therapy can be effective in the treatment of restrictive

cardiomyopathy from acquired hemochromatosis in patients who cannot
tolerate phlebotomy therapy.

Short, soft, midsystolic murmurs in the elderly are usually benign and due to
minor, age-related changes of the aortic valve (aortic sclerosis).

Postmyocardial infarction patients with reduced ejection fraction are not

candidates for implantable cardioverter-defibrillator placement until 40 days
after infarction.

Alternative therapies for patients with medically refractory angina, such as

external enhanced counterpulsation, are appropriate after medical therapy is
optimized and complete percutaneous and/or surgical coronary
revascularization has been achieved.

Radiofrequency ablation of recurrent atrial flutter is highly successful with a

low risk of complications and recurrence.

Medical management of pain, heart rate, and blood pressure is the preferred
treatment for type B (distal) acute intramural hematoma.

Contraindications to the use of a -blocker, such as shock or

atrioventricular block greater than first-degree block, would also be
contraindications to the use of verapamil. In patients with active,
uncontrolled reactive airways disease

Patients who have sustained a nonST-elevation myocardial infarction benefit

from the addition of clopidogrel to aspirin regardless of whether percutaneous
coronary intervention was performed.

In acutely decompensated patients with mitral stenosis, medical therapy

optimization should be provided initially before contemplating valvuloplasty.

Colchicine is the treatment of choice for acute bouts of recurrent pericarditis.

Vasodilator therapy is the primary treatment of cocaine-induced chest pain.

Bicuspid aortic valve occurs in more than 50% of patients with aortic
coarctation, and these patients should be monitored for aortic stenosis and
aortic valve regurgitation.

The treatment of choice for a patient with Eisenmenger syndrome with anemia
is low-dose iron therapy with reassessment of the hemoglobin and hematocrit
after 7 to 10 days.

Maximal medical therapy for chronic stable angina includes aspirin, an

angiotensin-converting enzyme inhibitor, a -blocker, a long-acting nitrate,
and a statin.

Unlike the pain of peripheral arterial disease, the pain of spinal stenosis is
aggravated by prolonged standing and is relieved with sitting or lumbar
flexion.

Placement of an implantable cardioverter-defibrillator is indicated in a patient

with left ventricular dysfunction and a hemodynamically significant
ventricular arrhythmia.

Aortic valve replacement should be recommended in any symptomatic patient

with aortic stenosis, regardless of age, owing to the improvement in long-term
survival and quality of life.

An implanted cardioverter-defibrillator giving inappropriate shocks should be

disabled pending further evaluation.

Pericardiocentesis is the appropriate immediate treatment for cardiac

tamponade.

Patients with new-onset heart failure and angina should be evaluated with
cardiac catheterization if they are possible candidates for revascularization.

Transesophageal echocardiography is the test of choice to detect a patent

foramen ovale.

Primary percutaneous coronary intervention is favored over thrombolytic

therapy for ST-elevation myocardial infarction if it is available in fewer than
90 minutes; it is also favored in patients with late presentation, shock,
contraindications to thrombolysis, or if the diagnosis is unclear.

The treatment for acute ischemic mitral regurgitation and cardiogenic shock is
mitral valve replacement.

Risk of anthracycline cardiotoxicity is related to cumulative dosage and may

occur many years after administration.

The long-term risks of radiotherapy include pericardial disease,

cardiomyopathy, peripheral arterial disease, coronary artery disease, and
valvular heart disease.

Pericardiocentesis should be performed when an idiopathic pericardial

effusion persists longer than 3 months.

MRI is contraindicated in patients with pacemakers or implantable

cardioverter-defibrillators.

Aspirin is preferred over NSAIDs to treat acute pericarditis that is caused by

acute myocardial infarction.

Guidelines for prevention of infective endocarditis now recommend antibiotic

prophylaxis only for persons with prosthetic valves, prior endocarditis, cardiac
transplant recipients with valvulopathy, and complex congenital heart disease.

Adenosine and dipyridamole stress testing are contraindicated in patients with

severe bronchospastic disease.

For patients intolerant of angiotensin-converting enzyme inhibitors due to

hyperkalemia or renal insufficiency, the combination of hydralazine and a
nitrate is a suitable alternative.

Unlike sudden cardiac death occurring in other settings, cardiac arrest

occurring within the first 48 hours of an acute, transmural myocardial
infarction does not require secondary prevention therapy other than standard
postmyocardial infarction care.

Implantable cardioverter-defibrillator placement is indicated for patients with

ischemic or nonischemic cardiomyopathy and an ejection fraction less than or
equal to 35% for mortality reduction, regardless of symptoms or functional
status.

Pulmonary balloon valvuloplasty is the treatment of choice for patients with

isolated congenital pulmonary valve stenosis. Intervention is
recommended when the gradient is greater than 50 mm Hg or when
right ventricular hypertrophy is present

Chronic inflammatory conditions, such as systemic lupus erythematosus, may

be associated with cardiac complications, including premature atherosclerotic
coronary artery disease.

In the setting of an inferior wall ST-elevation myocardial infarction, the

clinical triad of hypotension, clear lung fields, and jugular venous distention
suggests a right ventricular infarction. This diagnosis should be
considered in patients with the clinical triad of hypotension, clear
lung fields, and jugular venous distention. Sublingual nitroglycerin
further limits filling of the right ventricle and therefore worsens
hypotension.

Continuous-loop monitoring is more effective in diagnosis of tachycardia than

ambulatory monitoring.

Heart failure following treatment of an ST-elevation myocardial infarction

includes afterload reduction with an angiotensin-converting enzyme inhibitor
and preload reduction with nitroglycerin and diuretics.

Prophylactic aortic valve replacement is not performed in asymptomatic

patients with aortic stenosis.

Suppression of premature ventricular complexes is only indicated in patients

with severe and disabling symptoms; in these patients, -blockers are the
safest initial choice.

In patients with atrial fibrillation, it is important to correlate symptoms with

episodes of arrhythmia and assess rate control to determine whether symptoms
are caused by rapid heart rate or by the atrial fibrillation itself.

When aortic dissection is suspected, transesophageal echocardiography can be

performed quickly to assess the aorta, pericardium, aortic valve, and left
ventricular function.

Transesophageal echocardiography (TEE), contrast-enhanced CT, and MRI

(without contrast) have similar sensitivity and diagnostic accuracy for the
detection of acute aortic dissection. TEE has the benefit of being a
portable test that can be performed at bedside, and it yields additional
information regarding ventricular and valvular function. Contrastenhanced chest CT would normally be an acceptable test for further
investigation of a suspected acute aortic syndrome. However, the
patients abnormal renal function makes this choice less attractive
because of the risks of dye-induced nephropathy. Contrast is not
necessary with MRI for definition of an acute aortic dissection, but it may
be useful in the evaluation of chronic dissection for defining flow in the
false lumen. However, gadolinium contrast should be avoided in this
patient because of the risk of nephrogenic fibrosing dermopathy.

An atrial septal defect should be closed if there is evidence of a left-to-right

shunt with a pulmonary flow to systemic flow ratio that is greater than or
equal to 1.5:1.0, volume overload of right-sided cardiac chambers, or
symptoms related to the defect.

Prophylaxis is now limited to cardiac conditions with the highest risk of

adverse outcome from infective endocarditis, including prosthetic heart
valves; prior history of infective endocarditis; unrepaired cyanotic
congenital heart disease; repaired congenital heart defects with prosthetic
material or device, whether placed by surgery or by catheter intervention
(for 6 months after the procedure); repaired congenital heart disease with
residual defects; and cardiac valvulopathy in a transplanted heart

For patients with low or moderate (<20%) 10-year risk of a coronary artery
disease event, lifestyle modifications are recommended initially, with followup in 3 to 6 months.

The primary treatment for acute myocarditis is supportive care and standard
treatment for systolic heart failure, including therapy with angiotensinconverting enzyme inhibitors and -blockers.

Clopidogrel should be continued for at least 1 year following placement of a

drug-eluting stent and for at least 1 month following placement of a bare metal
stent.

In patients with unstable angina who have contraindications to -blockers,

calcium channel blockers should be used.

An echocardiogram should be obtained in all patients with newly diagnosed or

suspected heart failure.

Normal wall motion on echocardiography during chest pain excludes coronary

ischemia or infarction.

Unrepaired patent ductus arteriosus can cause left heart volume overload and
symptoms of heart failure owing to a long-standing left-to-right shunt at the
pulmonary level.

Mild hemolysis is commonly seen in patients with a normally functioning

mechanical valve, particularly in the presence of paravalvular regurgitation.

Symptomatic hemolytic anemia can usually be treated with oral iron and
folate replacement, although more severe cases may warrant blood
transfusion or recombinant human erythropoietin. Rarely, patients will
require valve reoperation if hemolysis is due to significant valve
dysfunction or progressive paravalvular regurgitation

High-sensitivity C-reactive protein levels may be used to direct further therapy

of patients with an intermediate (10%-20%) 10-year risk of a coronary artery
disease event.but not for low risk

Clinical differences in triggers of arrhythmic events may suggest the

underlying gene defect of congenital long QT syndrome; this has implications
for outcome and drug management.
Events during swimming may be specific for LQT1 mutations. type 1
Cardiac events in LQTS type 2 are usually precipitated by emotional
arousal, exercise, or loud or sudden noises.
The Brugada syndrome is characterized by a pseudo right bundle
branch block pattern with ST-segment elevation

Endomyocardial biopsy is recommended in patients with new-onset heart

failure (>2 weeks) and hemodynamic compromise. and in those with newonset heart failure of 2 weeks to 3 months duration associated
with a dilated left ventricle and new ventricular arrhythmias, Mobitz
type II second- or third-degree atrioventricular heart block, or failure
to respond to usual care within 1 to 2 weeks

Valve replacement surgery is recommended for asymptomatic patients with a

bicuspid aortic valve and severe aortic regurgitation when the left ventricular
end-systolic diameter reaches 55 mm or the left ventricular ejection fraction is
less than 60%.

Coronary angiography is indicated in patients with chronic stable angina who

experience lifestyle-limiting angina despite optimal medical therapy.

Coarctation of the aorta should be suspected in a young patient presenting with

systemic hypertension.

Pulmonary hypertension may lead to right ventricular enlargement, tricuspid

valve annular dilation, and regurgitation in an otherwise normal tricuspid
valve.

When high clinical suspicion for peripheral arterial disease persists despite
normal resting ankle-brachial index, exercise ankle-brachial index is a
reasonable secondary test.

Severe pulmonary arterial hypertension is a contraindication to pregnancy and

carries an estimated maternal mortality rate of 30% to 50%.

Elevated high-sensitivity C-reactive protein levels are an independent

predictor of cardiovascular risk.

Treatment of complex aortic atheroma should consist of antithrombotic or

antiplatelet monotherapy.

Warfarin use throughout pregnancy until near term provides the lowest risk for
maternal complications and death in women with mechanical heart valves.

B-type natriuretic peptide levels are generally lower in obese persons, even
those with acute heart failure.

The risk of a cardiovascular event is reduced rapidly (within 5 years) of

smoking cessation in women.

The most appropriate management for patients with cardiac sarcoidosis who
are at high risk for sudden death is placement of an implantable cardioverterdefibrillator.

Lyme carditis is manifested by acute-onset, high-grade atrioventricular

conduction defects that may occasionally be associated with myocarditis.

Patients with ostium primum atrial septal defect with a mitral valve cleft that
is not closed at the time of initial repair often present with symptoms of severe
mitral regurgitation and require late mitral valve repair or replacement.

B-type natriuretic peptide levels are elevated in the setting of renal

insufficiency.

A supervised exercise program can provide substantial symptomatic benefit to

selected patients with claudication.

Patients with fever and a prosthetic valve should be treated presumptively for
endocarditis unless a clear alternative source of infection is present.

Absolute and relative contraindications to thrombolytic therapy should be

reviewed in all patients being considered for thrombolytic therapy.

Spironolactone, angiotensin-converting enzyme inhibitors, and -blockers are

indicated for treatment of New York Heart Association class III and IV heart
failure.

Positive inotropic agents such as dobutamine or milrinone can be used to

correct low cardiac output and improve perfusion in patients with cardiogenic
shock.

In patients with acute limb ischemia with mild to moderate weakness and
sensory loss that extends beyond the toes (class IIb ischemia), limb salvage is
only possible with immediate revascularization.

Symptomatic sinus node dysfunction is an indication for pacemaker

placement, even if the bradycardia occurs as a consequence of drug therapy, if
there is no acceptable alternative.

The angiotensin receptor blocker candesartan has been shown to reduce heart
failurerelated hospitalizations but not mortality in patients with diastolic
heart failure.

Multiple imaging tests can confirm or exclude the diagnosis of aortic

dissection, including contrast-enhanced CT, transesophageal
echocardiography, and thoracic magnetic resonance angiography.

Maneuvers that increase preload (stand-to-squat and passive leg lift) decrease
the murmurs of hypertrophic cardiomyopathy and mitral valve prolapse. The
murmur associated with mitral valve prolapse and regurgitation is a
holosystolic to late systolic murmur that is apically located and
associated with a midsystolic click. In a patient with mitral valve
prolapse, the Valsalva maneuver moves the click murmur complex
earlier in systole and may increase the intensity of the murmur.
Similarly, decreased preload (smaller left ventricular chamber size)
increases systolic buckling of the valve leaflets, and the murmur
lengthens or intensifies. The carotid upstroke is normal in mitral
valve prolapse.

In patients with tetralogy of Fallot and 22q11.2 microdeletion, the chance of

an offspring being born with congenital heart disease is approximately 50%.

Abdominal pain, back pain, and syncope often herald an abdominal aortic
aneurysm rupture.

A ventricular septal defect following an ST-elevation myocardial infarction

results in a new systolic murmur and a step-up in oxygen saturation from the
right atrium to the right ventricle.

Atrioventricular nodal (junctional) ablation with pacemaker placement is a

safe and effective nonpharmacologic rate control option in patients with
rapidly conducted atrial fibrillation.

Procedural options for rate control include ablation of the atrioventricular

node and His bundle, with permanent pacemaker placement. This is the
most common nonpharmacologic approach for rate control, and has been
shown to be safe and effective in many studies. Demonstrated outcomes
in patients after atrioventricular nodal ablation include improved quality of
life, ventricular function, and exercise capacity, as well as decreased heart
failure episodes, hospital admissions, and use of antiarrhythmic drugs.

Pulmonary valve regurgitation is the most common residua after repair of

tetralogy of Fallot.

-Blockers should not be initiated when a patient with heart failure is acutely
decompensated or volume overloaded.

Clinical markers that should prompt surgical intervention in asymptomatic

patients with severe mitral regurgitation include left ventricular enlargement or
dysfunction, atrial fibrillation, pulmonary pressures over 50 mm Hg, or an
exercise-associated increase in pulmonary pressures.

In patients with acute decompensated heart failure, administration of an

inotropic agent such as dobutamine can improve cardiac output and therefore
systemic perfusion.

Low-risk patients with mechanical valves (aortic prosthesis and no history of

prior thromboembolism) undergoing noncardiac surgery can have warfarin
discontinued without a heparin bridge 5 days prior to surgery.