bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of takotsubo syndrome
Authors: Madias John E.
Published: March 2018

The pathophysiology of takotsubo syndrome (TTS) is still elusive. Management is non-specific, extrapolated from established treatments for patients with acute coronary syndromes, and heart failure, or other medical or surgical conditions. The mainstay of therapy consists of the use of aspirin, beta blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), diuretics, and anticoagulation. Anticoagulation may be needed not only for evident intracardiac thrombus, but also for severe cardiac wall motion abnormalities. Severe heart failure or cardiogenic shock may necessitate the use of levosimendan, an inotropic agent and a calcium sensitizer, and the implementation of extracorporeal membrane oxygenator, or external cardiac assist devices. Inotropic catecholamines should be used sparingly, particularly in the presence of left ventricular outflow tract obstruction, although their use occasionally becomes inevitable in the presence of severe heart failure or cardiogenic shock. Pericardial tamponade and left ventricular free wall and septal perforations are managed as done routinely. Transcatheter repair has been employed successfully for ventricular septal perforation. Management of atrial fibrillation should follow established principles, and vigilance should be exercised for ventricular arrhythmias, particularly in connection with a prolonged QTc interval. Rarely, for persisting atrioventricular blocks or recurrent ventricular arrhythmias, cardiac electronic implanted devices may be necessary. There are no proven therapies to prevent recurrence of TTS; ACEIs/ARBs, but not beta blockers, have been linked to improved survival at 1-year post discharge. Since TTS is not a benign syndrome, it is hoped that specific management will emerge based on data from controlled randomized clinical trials or large international TTS registries.
Hypertrophic cardiomyopathy: diagnosis and assessment of symptoms
Authors: Hagège Albert Alain
Published: March 2018

The diagnosis of hypertrophic cardiomyopathy (HCM) in adults is based on the presence of left ventricular wall thickness greater than 15 mm using any imaging modality on at least one myocardial segment and not explained solely by abnormal cardiac loading conditions; a 13 mm threshold should be applied for familial screening in first-degree relatives. Diagnosis in children, in the elderly, in hypertensive individuals, and in elite athletes may be challenging. Initial evaluation should include a family pedigree, evaluation of signs and symptoms, electrocardiogram, and 48 h Holter electrocardiogram monitoring, exercise testing, imaging, and biochemistry. The presence of an intraventricular left ventricular obstruction, present in two-thirds of the patients at rest, during Valsalva or exercise, should be systematically evaluated using echocardiography. Cardiovascular magnetic resonance imaging with late gadolinium enhancement should always be considered, particularly to assess apical hypertrophy, left ventricular aneurysms, and fibrosis. This systematic approach is recommended to assist in the detection of HCM not caused by mutations in cardiac sarcomere protein genes (up to 10% of patients). Genetic tests should be performed and interpreted after a careful and complete clinical evaluation and genetic counselling. HCM is characterized by symptoms of dyspnoea, fatigue, chest pain, palpitations, and syncope, which are highly variable. Functional limitation may be difficult to evaluate and often necessitates cardiopulmonary exercise testing.
Myocarditis: clinical presentation
Authors: Caforio Alida L. P , Marcolongo Renzo , Iliceto Sabino
Published: March 2018

Myocarditis has no typical clinical presentation, and may mimic a variety of non-inflammatory myocardial diseases. Cardiac signs and symptoms lack specificity, depending on the degree of myocardial inflammation and ventricular dysfunction, and may be subtle; thus the disease may be unrecognized. Myocarditis may resolve spontaneously, recur, or become chronic leading to dilated cardiomyopathy, sudden or heart failure-related death, or heart transplantation. In 2013, a European Society of Cardiology (ESC) Myocarditis Task Force proposed new criteria for clinically suspected myocarditis, using the combination of a plausible clinical presentation and diagnostic criteria. Importantly, diagnosis requires exclusion of non-inflammatory disease (e.g. coronary artery disease) that could explain specific presentations. The ESC 2013 Task Force also recommended a systematic consideration of endomyocardial biopsy in clinically suspected myocarditis, provided that endomyocardial biopsy includes standard histology, immunohistochemistry, and molecular analysis for infectious agents.
Surgical therapies for pericardial disease
Authors: Krasopoulos George
Published: March 2018

Surgical treatment for pericardial disease can be both curative and provide symptomatic relief particularly in cases of pericardial collection and constrictive pericarditis. Ideally, every tertiary centre should aspire to having a multidisciplinary team for the treatment of pericardial disorders.
Prognosis and complications
Authors: Vilacosta Isidre , Olmos Carmen
Published: March 2018

Nowadays, despite improvements in diagnosis and treatment, infective endocarditis remains associated with high mortality and severe complications. When assessing the prognosis of patients with endocarditis, three different clinical periods are distinguished: prognostic assessment at admission, early risk reassessment during the first week after the beginning of antibiotics, and short- and long-term prognosis after discharge. The three cornerstones for assessing patients’ prognosis can be obtained from clinical findings, echocardiography, and blood cultures. Analytic parameters such as thrombocytopenia may also help to stratify risk.
Cardiac device-related endocarditis
Authors: Bongiorni Maria Grazia , Cori Andrea Di
Published: March 2018

Infection of cardiac implantable electronic devices is a severe disease associated with high mortality. Coagulase-negative staphylococci account for 70% of cases. Definite cardiac device-related infective endocarditis (CDRIE) diagnosis is particularly difficult and echocardiography and blood cultures are the cornerstones of diagnosis. Prognosis is poor and a definite treatment is mandatory. CDRIE must be treated by prolonged antibiotic therapy and complete device removal. Transvenous lead extraction is the gold standard, also in the presence of large vegetations. After extraction, the indication to reimplantation has to be reconsidered carefully and immediate reimplantation should be avoided.
Chronic heart failure diagnosis: biomarkers
Authors: Mueller Christian
Published: March 2018

Natriuretic peptides including B-type natriuretic peptide (BNP), N-terminal (NT)-proBNP, and midregional pro-atrial natriuretic peptide (MR-proANP) are the biomarkers of choice in the diagnosis of heart failure. Assays measuring either BNP, NT-proBNP, or MR-proANP are widely available and run on large analysers operating in the central laboratory or as point-of-care options. Natriuretic peptides are considered quantitative markers of haemodynamic cardiac stress and therefore quantitative markers of heart failure itself. The clinical introduction of natriuretic peptides constitutes the most important advance in the diagnosis of heart failure in the last decade.
Co-morbidity (HFrEF and HFpEF): hypertension
Authors: Paneni Francesco , Volpe Massimo
Published: March 2018

Hypertensive heart disease is a major cause of heart failure (HF) and mortality. Hypertension precedes HF occurrence in 75% of cases, and carries a sixfold increase in HF risk as compared to non-hypertensive individuals. Most importantly, a minority of patients survive 5 years after the onset of hypertensive HF. In hypertensive patients, the heart may present different patterns of adaptive remodelling: concentric remodelling, concentric hypertrophy, and eccentric hypertrophy. Although most hypertensive patients are at high risk of developing concentric hypertrophy, a growing proportion of subjects display a concentric-to-eccentric progression eventually leading to left ventricular dilation and systolic dysfunction. Several factors including myocardial ischaemia, ethnicity, genetic background, history of diabetes, and blood pressure pattern may significantly influence the pathway from hypertension to left ventricular dilation. Patients with a concentric hypertrophy usually develop HF with preserved ejection fraction (HFpEF), whereas those with an eccentric (dilated) phenotype develop HF with reduced ejection fraction (HFrEF). Lowering blood pressure has a striking effect in reducing the risk of HF. Although available antihypertensive drugs are all successful in lowering blood pressure, angiotensin-converting enzyme inhibitors, angiotensin receptor blocker (ARBs), and diuretics are more effective than other drug classes in preventing HF. The combination of the neprilysin inhibitor sacubitril with the ARB valsartan (LCZ696) has recently been shown to be highly effective in reducing HF-related outcomes in hypertensive subjects. An individualized treatment scheme taking into account blood pressure levels, type of HF (HFpEF or HFrEF), and relevant co-morbidities (i.e. renal disease, diabetes) is currently the best approach to improve morbidity and mortality in hypertensive patients with HF.
Co-morbidity (HFrEF and HFpEF): lung disease
Authors: Roversi Sara , Hawkins Nathaniel
Published: March 2018

Approximately one in four patients with heart failure (HF) has a clinical diagnosis of pulmonary disease, predominantly chronic obstructive pulmonary disease (COPD). A further 40–70% may have unrecognized airflow obstruction. Clinical diagnosis is challenging given the cardinal symptom of both conditions is dyspnoea. Objective documentation of airflow obstruction by pulmonary function tests is essential, performed during clinical stability to avoid obstruction associated with congestion. In patients with pulmonary disease, natriuretic peptides retain high negative predictive values for excluding heart failure. The treatment of both HF and COPD should not deviate from international guidelines. The risk of bronchoconstriction due to beta blockers, and adverse cardiovascular events attributable to bronchodilators is controversial. The balance of evidence strongly favours prescribing beta blockers irrespective of pulmonary disease, recommending caution only in very severe COPD. Similarly, bronchodilators exhibit a reassuring safety profile, particularly long-acting muscarinic antagonists. Caution is advised when commencing new bronchodilator therapy, using high-dose, short-acting compounds, or when treating patients with severe heart failure. Concurrent pulmonary disease in patients with HF further impairs symptoms, quality of life, and exercise capacity. It also increases the risk of HF hospitalization, non-cardiovascular adverse outcomes, and long-term mortality. All efforts should be made to correctly identify and treat lung disease in clinical practice.
Atrioventricular conduction abnormalities and atrioventricular blocks: ECG patterns and diagnosis
Authors: Barold S. Serge
Published: March 2018

The diagnosis of first-degree and third-degree atrioventricular (AV) block is straightforward but that of second-degree AV block is more involved. Type I block and type II second-degree AV block are electrocardiographic patterns that refer to the behaviour of the PR intervals (in sinus rhythm) in sequences (with at least two consecutive conducted PR intervals) where a single P wave fails to conduct to the ventricles. Type I second-degree AV block describes visible, differing, and generally decremental AV conduction. Type II second-degree AV block describes what appears to be an all-or-none conduction without visible changes in the AV conduction time before and after the blocked impulse. The diagnosis of type II block requires a stable sinus rate, an important criterion because a vagal surge (generally benign) can cause simultaneous sinus slowing and AV nodal block, which can resemble type II block. The diagnosis of type II block cannot be established if the first post-block P wave is followed by a shortened PR interval or by an undiscernible P wave. A narrow QRS type I block is almost always AV nodal, whereas a type I block with bundle branch block barring acute myocardial infarction is infranodal in 60–70% of cases. All correctly defined type II blocks are infranodal. A 2:1 AV block cannot be classified in terms of type I or type II block, but it can be AV nodal or infranodal. Concealed His bundle or ventricular extrasystoles may mimic both type I or type II block (pseudo-AV block), or both
Pacing for bradycardia: device features and algorithms and clinical impact
Authors: Nielsen Jens Cosedis , Kristensen Jens
Published: March 2018

Cardiac pacing is the treatment of choice for patients with bradycardia. Several existing algorithms and features facilitate individualization and optimization of device programming on an individual patient basis. Individually based optimal choice of device and pacing mode should be the rule. Correct programming of available pacemaker algorithms and features is a prerequisite for optimal patient treatment.
Pacemakers in children and adolescents
Authors: Sperzel Johannes
Published: March 2018

Children have been the beneficiaries of pacing therapies since the pioneering days of the technology. Yet, despite the fact that paediatric pacemaker implants represent around 1% of all pacemaker implantations, there are no guidelines at present dedicated to pacing in this population. This chapter discusses the challenges and needs specific to pacing therapy in children, such as the small stature and the continual somatic growth of paediatric patients; the prevalence of intracardiac shunting; and the often complex anatomical heart structures in children with an indication for pacing. Such differences from adult pacemaker recipients are reflected in the decisions on, for example, implantation route (epicardial versus endocardial), on choice of single-chamber versus dual-chamber devices, selection of pacing sites, or programming. The chapter also highlights questions about lead removal, which is particularly important given the sheer number of replacements expected in paediatric patients, and provides an outlook towards the future of pacing in children and the role of leadless devices and future therapeutic advances.
Electromagnetic interference in pacemaker patients
Authors: Steffel Jan
Published: March 2018

In spite of the development of specific shielding of electronic devices as well as the current-day preference for bipolar sensing, electromagnetic interference (EMI) may still occur with certain pacemakers in certain settings, which in turn may lead to false inhibition of ventricular stimulation with potentially fatal consequences. The most important sources of clinically relevant EMI include medical diagnostics and therapy (e.g. magnetic resonance imaging, radiofrequency ablation, cardioversion/defibrillation, and electrocautery), the working environment (including high-power lines, combustion/degaussing/welding equipment, and others), as well as sources from daily life (such as wireless mobile phones, metal detectors, household appliances such as induction furnaces, electronic article surveillance devices, and others). To what extent, and whether or not at all, any given source of interference leads to EMI depends on several factors including the duration of interference, the field strength, and the frequency spectrum of the source. In addition, lead properties and device programming are important determinants. Awareness, recognition, and avoidance of EMI sources is of paramount importance, particularly in high-risk pacemaker-dependent individuals. The importance of proper education of patients as well as healthcare providers cannot be overemphasized.
Definition, epidemiology, classification, and pathophysiology
Authors: van Dijk J. Gert , Thijs Roland D.
Published: March 2018

Syncope can closely resemble other disorders with which it shares an apparent short-lived transient loss of consciousness. Together, these disorders are labelled as ‘transient loss of consciousness (T-LOC)’. Syncope is the form of T-LOC caused by cerebral hypoperfusion; the other main T-LOC forms are several types of epileptic seizures and the psychogenic conditions that resemble either syncope or epileptic seizures. The main forms of syncope are reflex syncope, syncope due to orthostatic hypotension, and cardiac syncope, also comprising cardiopulmonary causes and disorders of the great vessels. All forms of syncope share cerebral hypoperfusion and arterial hypotension as a final common pathway. They differ in the mechanism of hypotension: cardiac syncope is largely due to a low cardiac output, but both low peripheral resistance and low cardiac output contribute to syncope due to orthostatic hypotension and reflex syncope. The clinical expression of the main forms is tightly linked to their pathophysiology, which is therefore important for differential diagnosis.
Orthostatic intolerance: orthostatic hypotension and postural orthostatic tachycardia syndrome
Authors: Fedorowski Artur
Published: March 2018

The impairment of adaptive mechanisms during orthostatic challenge may evoke orthostatic intolerance, a heterogeneous condition, in which the standing position elicits a fall in blood pressure and/or excessive tachycardia, accompanied by a wide spectrum of subjective symptoms such as dizziness, discomfort, nausea, and palpitations. Apart from chronic and potentially debilitating symptoms, orthostatic intolerance may occasionally lead to sudden loss of consciousness and fall injuries. Consequently, orthostatic intolerance should be considered as a possible cause of unexplained syncope. Two main forms of orthostatic intolerance are orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS). Clinical variants of OH include initial, classical, and delayed forms. The prevalence of OH increases with age, ranging from less than 5% under 40 years to about 20% above 70 years of age, and is higher in chronic diseases, such as hypertension and diabetes, reaching above 35% in Parkinson’s disease and advanced kidney failure. The presence of OH is associated with a higher mortality and an increased incidence of cardiovascular disease, with the majority of patients being asymptomatic in normal conditions. In contrast, POTS affects predominantly young women (70–80%) within an age range of 15–40 years and is usually accompanied by non-specific symptoms: deconditioning, headache, cognitive impairment, and gastrointestinal dysfunction. Management of orthostatic intolerance includes both non-pharmacological and pharmacological methods with limited efficacy in the severe cases. Empirical treatment with vasoactive and volume expanding drugs for OH and POTS, and rhythm controlling therapy for POTS are recommended. Future studies on syndromes of orthostatic intolerance should focus on mechanisms leading to OH and POTS, novel diagnostic methods, and more effective therapeutic options.
Sinus node-related tachycardias: physiological sinus tachycardia, inappropriate sinus tachycardia, sinus node reentrant tachycardia, and postural orthostatic tachycardia syndrome
Authors: Olshansky Brian
Published: March 2018

This chapter describes the different types of sinus tachycardias and an approach to evaluate and treat these sinus tachycardias based on the clinical presentation and on recent guidelines and consensus documents.
Atrioventricular nodal reentrant tachycardia
Authors: Katritsis Demosthenes G.
Published: March 2018

The definition, classification, electrophysiological diagnosis, and ablation of atrioventricular nodal reentrant tachycardia are discussed in this chapter
Accessory pathways-related tachycardias: Wolff–Parkinson–White syndrome and atrioventricular reentrant tachycardias
Authors: Chrispin Jonathan , Calkins Hugh
Published: March 2018

Wolff–Parkinson–White syndrome is an uncommon clinical condition defined as manifest pre-excitation on electrocardiogram and symptoms of arrhythmias related to the abnormal conduction between the atria and ventricle. Years of invasive electrophysiological, along with histological and epidemiological studies has grown our understanding of the accessory atrioventricular pathway responsible for Wolff–Parkinson–White syndrome. The overall prognosis for those with accessory pathways is excellent; however, a minority will experience symptomatic arrhythmias and rarely, sudden cardiac death. Fortunately, for those who are at high risk for sudden death, or for those who are highly symptomatic, catheter ablation has developed to become a curative therapy. This chapter details the anatomy, electrical properties, and assorted arrhythmias related to atrioventricular accessory pathways.
Thromboprophylaxis in atrial fibrillation: device therapy and surgical techniques
Authors: Lewalter Thorsten , Jilek Clemens , Sick Peter
Published: March 2018

The concept of left atrial appendage (LAA) occlusion is to mainly prevent stroke by excluding the most relevant source of embolism from the blood circulation. The LAA can be occluded by a number of interventional or surgical approaches. Following a successful LAA occlusion implant procedure or surgical LAA exclusion, oral anticoagulation is typically terminated, followed by antiplatelet therapy, which is routinely used in the post-implant phase for 3–6 months. The need for chronic antiplatelet therapy is still unclear. Most patients are maintained on a single antiplatelet medication, but patients with a particularly high bleeding risk receive no chronic drug therapy. Currently, the main indication for LAA occluder implantation or LAA exclusion is stroke prevention in patients at high stroke risk, with contraindications for long-term oral anticoagulation due to a bleeding history or an otherwise elevated risk for major bleeding.
Atrial fibrillation after cardiopulmonary surgery
Authors: Wijesurendra Rohan S. , Casadei Barbara
Published: March 2018

Postoperative atrial fibrillation (POAF) is a frequently noted complication following cardiopulmonary surgery, with a reported incidence of between 10% and 60%. Most studies have defined POAF as atrial fibrillation (or other atrial arrhythmia, such as atrial flutter) occurring between the procedure and hospital discharge; this definition is also adopted in this chapter, while recognizing that cardiopulmonary surgery is also associated with an increased incidence of atrial fibrillation in the longer term. POAF is an important condition, as it is associated with a prolonged hospital stay and consequent increase in medical costs, significant morbidity, including an increased risk of stroke, and has also been linked to an increased risk of premature death. Much recent work has focused on an improved understanding of the underlying mechanisms, and on trialling prophylactic therapies designed to reduce the incidence of POAF. Nevertheless, this condition remains a significant clinical challenge following cardiopulmonary surgery, particularly valvular intervention, coronary artery bypass grafting, and combined valvular/coronary cases.
Atrial fibrillation and hyperthyroidism
Authors: Biondi Bernadette
Published: March 2018

Atrial fibrillation develops in about 10–25% of patients with hyperthyroidism with a higher risk in patients with toxic multinodular goitre compared to those with Graves disease. Advanced age, history of cardiac failure, and presence of associated cardiovascular risk factors represent independent predictors for the development of atrial fibrillation. Spontaneous reversion to sinus rhythm frequently occurs in successfully treated hyperthyroid patients under 50 years of age with newly diagnosed atrial fibrillation, without underlying heart disease and lower systolic blood pressure. In contrast, atrial fibrillation persisting for 4 months or more after the control of hyperthyroidism rarely reverts to sinus rhythm in mainly elderly patients and in those with heart disease.
Atrial fibrillation and sleep apnoea and chronic obstructive pulmonary disease
Authors: Miller Jared D. , Calkins Hugh G.
Published: March 2018

Rate control, rhythm control, and anticoagulation are well entrenched as the three central pillars of atrial fibrillation (AF) management. Risk factor modification of other associated co-morbidities is now emerging as a critical fourth pillar in the prevention and management of AF. Obstructive sleep apnoea and chronic obstructive pulmonary disease, in particular, have important implications in the development of AF and appropriate selection of therapy. This chapter reviews the pathophysiology and clinical evidence linking these conditions with AF. In addition, it discusses important considerations in the management of concurrent AF and obstructive sleep apnoea or chronic obstructive pulmonary disease.
Electrical storm
Authors: Ganz Leonard
Published: March 2018

Electrical storm is a condition in which there are recurrent episodes of ventricular fibrillation or sustained and/or poorly tolerated ventricular tachycardia that occurs within a short period and requires aggressive intervention to prevent imminent mortality and other adverse outcomes. The condition may be related to precipitating factors, such as ischaemia or electrolyte disturbances, or may be part of an underlying cardiac disorder (e.g. cardiomyopathy, ischaemic heart disease, and channelopathies) that, often for uncertain reasons, culminates in recurrent episodes of life-threatening ventricular arrhythmias. Frequently, sympathetic activation plays a role in precipitating episodes. Here, electrical storm is characterized and an approach to management is discussed.
Primary prevention of sudden death in idiopathic dilated cardiomyopathy
Authors: Cappato Riccardo
Published: March 2018

Idiopathic dilated cardiomyopathy is characterized by early ventricular enlargement and systolic contractile dysfunction with congestive heart failure not secondary to recognizable causes. Symptoms of congestive heart failure develop at a later stage, usually between 18 and 50 years of age, although they may occasionally occur earlier as a first manifestation of the underlying disease. Mechanisms of life-threatening arrhythmias are facilitated by subendocardial scarring, electrolyte unbalance, stretch-induced electrophysiological changes, autonomic impairment, conduction delay, or proarrhythmic effects of drug therapy. Sudden death may occur as a consequence of ventricular fibrillation, but electromechanical dissociation or bradycardia may also be a possible underlying cause. Most of the clinical characterization of idiopathic dilated cardiomyopathy is drawn from studies also enrolling patients with cardiomyopathies secondary to variable underlying conditions. Secular trends have improved the ability of early diagnosis, and the therapeutic strategies used to prevent sudden death. Among them are angiotensin-converting enzyme inhibitors, beta blockers, and mineralocorticoids/aldosterone receptor antagonists. The role of implantable cardioverter defibrillator (ICD) therapy for the primary prevention of all-cause mortality is controversial with some studies showing and others questioning the benefit of ICD in this population. Survivors of near-fatal arrhythmias have a high risk of recurrence, which may often be fatal. Idiopathic dilated cardiomyopathy contributes to less than 15% of all such patients. Previous randomized studies conducted in large heterogeneous populations showed that ICD therapy is beneficial and improves survival by about 30%. This therapy is currently recommended for all survivors of a near-fatal arrhythmia regardless of the underlying substrate.
Epidemiology and pathophysiology of hypertension
Authors: Taddei Stefano , Bruno Rosa Maria , Masi Stefano , Solini Anna
Published: March 2018

Hypertension remains the leading cause of morbidity and mortality worldwide and significantly impacts the risk of all major cardiovascular events, including stroke, sudden cardiac death, coronary heart disease, heart failure, abdominal aortic aneurysm, and peripheral vascular disease. Important advances in our understanding of its pathophysiology contributed to clarifying the complex origins of the disease, involving dysregulation of multiple homeostatic systems influencing not only blood pressure but also the progression of end-organ damage related to hypertension. Growing evidence suggests that the pathophysiology of hypertension results from complex interactions between environmental and genetic factors, resulting in different risks and age of onset of the disease within the general population. This chapter reviews the recent statistics of hypertension with a specific emphasis on its prevalence and temporal trends in Europe. Also, it provides a comprehensive overview of the mechanisms involved in the aetiopathogenesis of hypertension, highlighting their relative importance in different forms of hypertension.
Blood pressure measurement in hypertension: definition and classification of blood pressure levels
Authors: Parati Gianfranco , Ochoa Juan E.
Published: March 2018

Imprecise blood pressure (BP) measurement may be responsible for inappropriate diagnosis and classification of hypertension, resulting in either excessive or insufficient use of antihypertensive drugs. On the background of the enormous impact of hypertension in terms of global disease burden, an accurate measurement and classification of BP levels becomes a fundamental step for the appropriate management of hypertensive patients. This chapter will provide an overview of the different methodologies currently available for BP measurement in the medical office, such as conventional office blood pressure (OBP) readings and unattended automated office blood pressure measurements (AOBP). It will also address techniques for BP measurement out of the doctor’s office such as 24 h ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), giving also practical recommendations for their implementation in clinical practice, based on current hypertension Guidelines. The chapter will also review the current definitions and classification of BP levels based on different BP measurement techniques, the abnormalities in 24 h BP patterns that can be identified through ABPM, and the different BP phenotypes that result from the discrepancies between office and out- of- office BP measurement techniques when used in combination (i.e. white coat hypertension and masked hypertension).
Drug treatment of hypertension
Authors: Burnier Michel , Kjeldsen Sverre , Heagerty Anthony , Williams Bryan
Published: March 2018

The prescription of antihypertensive drugs to achieve the recommended target blood pressures remains the main step of the management of hypertensive patients. Today, there is strong evidence from randomized controlled trials that antihypertensive drug classes proposed to treat hypertension are superior to placebo in reducing cardiovascular mortality and morbidity. In terms of cardiovascular protection, differences between drug classes exist but they are relatively modest. Indeed, the reduction of blood pressure per se remains the prominent mechanism whereby antihypertensive drugs provide cerebral, cardiac, renal, and vascular benefits. According to more recent guidelines, three drug classes are recommended as first-line therapy: blockers of the renin–angiotensin system, diuretics, and calcium antagonists. The use of beta blockers has been restricted to the treatment of hypertension associated with cardiac co-morbidities such as post-myocardial infarction or coronary heart disease. Many studies have demonstrated that drug classes can be combined successfully and nowadays, it is strongly recommended to use single pill combinations containing two or three antihypertensive drugs. This simplifies the treatment regimen, increases the efficacy, and promotes the long-term adherence and persistence, this latter being the major challenge of drug therapy for hypertension.
Hypertension in specific conditions/co-morbidities
Authors: Rosei Enrico Agabiti , Muiesan Maria Lorenza , Salvetti Massimo
Published: March 2018

The optimal management of hypertensive patients requires accurate evaluation of cardiovascular risk factors and co-morbidities. The therapeutic approach to hypertension may, in fact, be significantly different according to associated conditions. Among them, the presence of coronary heart disease, heart failure, cerebrovascular disease, chronic kidney disease, and specific age groups deserve special attention. In this chapter, the initial diagnostic work-up, the thresholds and targets for treatment, and the preferred drugs in specific conditions/co-morbidities will be briefly discussed.
Referral centres and patient education
Authors: Simon J. , Gibbs R.
Published: March 2018

The need to engender high-quality clinical outcomes for a rare and lethal disease is best served by specialist referral centres with a high patient volume, although the volume–outcome relationship has not been shown specifically for pulmonary hypertension. The link between access to information and successful pulmonary arterial hypertension management is well established. Healthcare professionals report that patients who receive comprehensive guidance at the beginning of treatment have better outcomes. Information is understood to motivate patients to participate in their own care, thereby improving outcomes.
Acute aortic syndrome: aortic dissection—ascending aortic dissection
Authors: Starck Christoph T. , Hammerschmidt Robert , Falk Volkmar
Published: March 2018

Aortic dissection, intramural haematoma, and penetrating aortic ulcer can each present as an acute aortic syndrome. If left untreated, acute aortic syndrome carries a high mortality. Therefore, rapid diagnostic work-up and appropriate surgical therapy are of utmost importance. Chest computed tomography is the imaging method of first choice.
Acute aortic syndrome: aortic dissection—descending aortic dissection
Authors: Clough Rachel E. , Yuan Xun , Nienaber Christoph A.
Published: March 2018

The concept of an acute aortic syndrome (AAS) facilitates early identification of patients with chest pain due to an aortic cause, and expedites implementation of definitive treatment. Important differentials are acute coronary syndromes and pulmonary embolism. Patients with AAS should be evaluated using a combination of blood tests, electrocardiography, and imaging, such as computed tomography, echocardiography, and magnetic resonance imaging. Aortic dissection is the most common form of AAS. Risk factors include congenital factors such as connective tissue disease and bicuspid aortic valve, and acquired disease such as hypertension. Patients with evidence of aortic rupture or end-organ ischaemia require urgent intervention, which in cases of type A dissection is typically open surgery and in type B dissection, endovascular stent graft placement. The optimal treatment of patients with AAS is challenging and requires a multidisciplinary team approach. Further studies are required to fully characterize conditions within the AAS spectrum and to design individualized, patient-centred treatment.
Long-term follow-up in patients with aortic diseases
Authors: Sechtem Udo , Gaemperli Oliver
Published: March 2018

Patients with aortic disease usually require life-long surveillance, regardless of the initial treatment strategy. This surveillance consists of clinical evaluation, reassessment of a patient’s medical therapies and treatment goals, and imaging of the aorta. This chapter addresses the chronic phase of aortic dissection, including patients discharged after aortic interventions. It also deals with the follow-up of patients in whom chronic aortic dissection or aneurysm is diagnosed incidentally and in whom there was no need for immediate surgery.
Preoperative evaluation: surgical risk for cardiac events and functional capacity risk indices
Authors: Juanatey José R. González
Published: March 2018

Functional capacity assessment and key clinical elements included in risk indices are cornerstones for preoperative evaluation of cardiac patients submitted for non-cardiac surgery. Poor functional capacity and high-risk surgeries identify a subgroup of patients where is it necessary to carry out a more intensive cardiac evaluation prior to surgery.
Epidemiology and socioeconomic consequences of venous thromboembolism
Authors: Cohen Alexander T. , Brekelmans Marjolein P. A. , Martinez Carlos
Published: March 2018

Venous thromboembolism (VTE) is a common disease with numerous well-characterized risk factors and many different clinical manifestations. There is great variation in the epidemiology and socioeconomic impact depending on the disease associations and the site of the thrombosis. The regional rates vary and in Western countries the incidence rate for first events is in the order of 100–250 per 100,000 person-years, attack rates (new and recurrent events) are about 250 per 100,000 person-years. The annual prevalence (a cross-sectional view) is about 400 per 100,000 population. Following hospitalization for medical or surgical conditions, the rates are higher and these events contribute to around half the population attributable risk. During periods of active cancer the incidence rates are very high. Post-thrombotic syndrome complicates 20–50% of deep vein thrombosis cases and is severe in 5–10%. Chronic thromboembolic pulmonary hypertension contributes significantly to the burden of VTE. Around 0.4–4% of patients with pulmonary embolism will eventually develop chronic thromboembolic pulmonary hypertension. Incidence rates for first episodes and attack rates have been widely studied, but incidence rates of recurrent events, post-thrombotic syndrome, and chronic thromboembolic pulmonary hypertension have not and generally only the cumulative incidence has been characterized. VTE mortality is significant particularly in the first 3 months, following that it is strongly related to the underlying diseases. The socioeconomic consequences of VTE are significant with respect to disability and costs.
Diagnosis of acute pulmonary embolism and evolving imaging modalities
Authors: Robert-Ebadi Helia , Le Gal Grégoire , Righini Marc
Published: March 2018

Modern non-invasive diagnostic strategies for pulmonary embolism rely on the sequential use of clinical probability assessment, D-dimer measurement, and thoracic imaging tests. Planar ventilation/perfusion scintigraphy was the cornerstone test for the diagnosis of pulmonary embolism for more than two decades and has now been replaced by computed tomographic pulmonary angiography (CTPA). Diagnostic strategies using CTPA are very safe to rule out pulmonary embolism and have been well validated in large prospective management outcome studies. Venous compression ultrasonography is the cornerstone test to diagnose deep vein thrombosis but is not mandatory for the diagnosis of pulmonary embolism when using multidetector CTPA.
Varicose veins
Authors: Bootun Roshan , Lane Tristan , Davies Alun H.
Published: March 2018

Varicose veins affect a third of the general population and are found in the superficial fascia of the lower limbs. There is controversy as to their actual cause with the debate still ongoing as to whether it is primarily an ascending or descending condition. Several potential risk factors have been identified and the most likely risks are increasing age, family history, and pregnancy. They cause a variety of physical symptoms, the most severe of which is ulceration, and also have an adverse effect on the quality of life of patients. Treatment of varicose veins, in turn, has been shown to improve patients’ quality of life.
Traditional cardiovascular disease risk factors
Authors: Schenck-Gustafsson Karin
Published: March 2018

The American Heart Association and American Stroke Association have published special guidelines for the prevention of cardiovascular disease in women. The European Union project ‘A Road Map for Gender Medicine in Europe’ pointed out the lack of female aspects in the guidelines from the European Society of Cardiology. So far, about 200 risk factors or non-healthy lifestyle factors have been identified in women The INTERHEART study highlighted nine risk factors that are responsible for 90% of cardiovascular disease in both genders. The nine risk factors are important for both men and women but differ in impact. For women, diabetes and hypertension appear to be the strongest. The Framingham Risk Score has been criticized because it underestimates the risk in asymptomatic postmenopausal women. The SCORE system ranges between 45 and 65 years only, it estimates fatal but not total risk, it is limited to the major determinants of risk, and not adapted to different ethnic or sex difference. Because the same risk factors for both sexes have been used in risk calculations for the last 40 years, the Reynolds score system for women was introduced, adding age, systolic blood pressure, haemoglobin A1c, current smoking, total high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, and family history. Only a further 5% risk is added in the medium-risk group and taken away from the low-risk group. Traditional risk factors include the major ones of diabetes, hypertension, dyslipidaemia, smoking, and family history of premature heart disease, as well as the non-independent risk variables of physical inactivity and body weight and composition.
Aortic diseases
Authors: Iung Bernard
Published: March 2018

Aortic diseases encountered in young women are mainly associated with syndromic diseases, which are often heritable, or bicuspid aortic valve. The most frequent syndromic disease is Marfan syndrome. In Marfan syndrome, the risk of aortic dissection is low during pregnancy when the maximum diameter of the ascending aorta is less than 45 mm. Dissection may affect the thoracic ascending or descending aorta. The risk of aortic dissection is low in bicuspid aortic valve when the aortic diameter is less than 50 mm. Beta blockers are recommended throughout pregnancy in Marfan syndrome and are often used in other causes of aortic aneurysms. Close echocardiographic follow-up is needed during pregnancy and after delivery.
Cardiomyopathies and heart failure
Authors: Regitz-Zagrosek Vera
Published: March 2018

Treatment of heart failure in pregnancy is based on the respective guidelines for the treatment of heart failure with some pregnancy-specific limitations. Cardiomyopathies are a rare but serious cause of heart failure and currently the most frequent cause of maternal mortality in pregnancy. All forms of cardiomyopathies may occur in pregnancy but peripartum cardiomyopathy is a specific and dangerous manifestation. Some new treatment options are arising based on its specific pathophysiology. Dilated cardiomyopathy has a high risk of deterioration in pregnancy. In contrast, hypertrophic cardiomyopathy is frequently tolerated well. Delivery should be well planned and some limitations on breastfeeding should be considered.
Venous thromboembolism in the peripartum period
Authors: Sliwa Karen , Johnson Mark R.
Published: March 2018

Maternal hypercoagulability reduces the risk of postpartum haemorrhage, one of the most important causes of maternal mortality, but results in a five times greater risk of venous thromboembolism in pregnancy and a greater than 20-fold increase in the peripartum period. The diagnosis of venous thromboembolism is often overlooked since dyspnoea, leg swelling, and tachycardia are common symptoms of pregnancy. A high index of suspicion is needed to make an early diagnosis.
Ethnicity and cardiovascular risk factors
Authors: Sarrafzadegan Nizal , Masoudkabir Farzad
Published: March 2018

Significant variation is evident among different ethnicities regarding the prevalence, awareness, severity, treatment, and complications of major cardiovascular disease (CVD) risk factors. Relative to white Europeans, stroke mortality is almost doubled in South Asians and Afro-Caribbeans; however, when coronary artery disease mortality is considered, it is high in South Asians and low in Afro-Caribbeans. Hypertension is more common, severe, and is associated with higher rates of morbidity and mortality in black people than white people. Diabetes is more prevalent and less controlled in South Asians which leads to a nearly fourfold higher cardiovascular mortality in South Asians than other ethnic groups. Furthermore, South Asians suffer from a highly atherogenic lipid profile. In contrast, black people are generally known for their higher high-density lipoprotein and lower triglyceride levels than white people which seem to play a major role in protecting them from coronary artery disease. For a given waist circumference, Asian, black, and Caucasian people show different levels of intra-abdominal adiposity and CVD risk. Hence, the joint definition from five major organizations in 2009 of the metabolic syndrome set ethnic-specific values of waist circumference to define central obesity. Black Caribbean men have the highest rates of current smoking among all ethnic groups in the United Kingdom while nearly all South Asian and black African women are never-smokers. Varied genetic and lifestyle-related risk factors and their interactions seem to be responsible for the ethnic differences in CVD risk factors. There is a clear need for ethnic-specific guidelines for diagnosis and treatment of major CVD risk factors to maximize the outcomes of preventive strategies.
Clinical assessment of the athlete’s heart: normal and abnormal ECGs in athletes
Authors: Zorzi Alessandro , Corrado Domenico
Published: March 2018

The electrocardiogram (ECG) of trained athletes may show changes that represent the consequence of the heart’s adaptation to physical exercise (‘athlete’s heart’) such as enlarged cardiac chamber size and increased vagal tone. Physiological ECG changes must be differentiated from the ECG abnormalities secondary to an underlying cardiovascular disease that may be responsible for sudden cardiac death during exercise. The ECG changes of athletes are classified according to their prevalence, relation to exercise training, association with an increased risk of cardiovascular disease, and the need for further investigations: common ECG changes should be considered as a benign sign of physiological adaptation to exercise and do not require additional evaluation; on the other hand, in case of uncommon and training-unrelated abnormalities, which may be associated with an underlying cardiovascular disease, further work-up should be performed. This chapter reviews the abnormalities that may be found in an athlete’s ECG and proposes criteria for interpretation of such changes as normal or abnormal findings.
Imaging testing for differential diagnosis of the athlete’s heart from structural cardiac diseases
Authors: Pelliccia Antonio
Published: March 2018

Long-term athletic conditioning is responsible for morphological cardiac changes that are collectively described as the ‘athlete’s heart’. Morphological changes are usually mild, but in a not trivial proportion of athletes may be more marked, by mimicking changes usually observed in certain cardiomyopathies, raising the question of differential diagnosis between physiological remodelling and structural cardiac diseases. In this chapter, the morphological features of the physiological left and right ventricular remodelling are described in comparison with the mimicking changes occurring, respectively, in hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, and arrhythmogenic right ventricular cardiomyopathy. Differential diagnosis using imaging techniques (i.e. echocardiography and cardiac magnetic resonance) is discussed, and the most efficient and clinically useful criteria for diagnosis in each of the pathological conditions considered are provided.