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This book differs from most other available cardiology texts. We have designed it to provide didactic answers to specific questions, wherever possible. Some are everyday questions. Others deal with less common situations, where an answer is often not readily found. The book is suitable for all grades of doctor, cardiologist and physician alike.Responses have been kept as brief as possible and practical. A few important topics defied our editorial culling and were given more space. The aim was not to review the entire literature, but rather to present the conclusions which that author has reached from such evaluation, combined with experience. Where helpful or necessary, a few relevant references have been provided with the answer.
We hope that the text can be read in several ways to suit the reader – in one go, referred to on the wards or in clinic or dipped into for pleasure and education. The short question and answer
format should permit such an approach.
Content:-
Contributors
Introduction
1. What are the cardiovascular risks of hypertension?
2. Is 24 hour blood pressure monitoring necessary, and what do I do with the information?
3. Who should be screened for a cause of secondary hypertension? How do I screen?
4. What blood pressure should I treat, and what should I aim for when treating a 45 year old, a 60 year old, a 75 year old or an 85 year old?
5. Is one treatment for hypertension proven to be better than another in terms of survival?
6. It was once suggested that calcium channel blockers might be dangerous for treating hypertension. Is this still true?
7. How can I outline a management plan for the patient with essential hypertension?
8. How do I manage the patient with malignant hypertension?
9. Which asymptomatic hypercholesterolaemic patients benefit from lipid-lowering therapy? What cholesterol level should I aim for?
10. Which patients with coronary disease have been proven to benefit from pharmacological
intervention? What lipid levels should I aim for?
11. What drugs should I choose to treat dyslipidaemia, and how should I monitor treatment?
12. What are the side effects of lipid-lowering therapy, and how should they be monitored?
13. Is there a role for prescribing antioxidant vitamins to patients with coronary artery disease? If so, who should get them, and at what dose?
14. What is the sensitivity, specificity and positive predictive value of an abnormal exercise test?
15. What are the risks of exercise testing? What are the contraindications?
16. What are the stratification data for risk from exercise tests in patients with angina? Which patterns of response warrant referral for angiography?
17. Who should have a thallium scan? How does it compare with standard exercise tests in
determining risk?
18. What are hibernating and stunned myocardium? What echocardiographic techniques are useful for detecting them? How do these methods compare with others available?
19. Which class of antianginal agent should I prescribe in stable angina? Does it matter?
20. What is the role of troponin T in the diagnosis and risk stratification of acute coronary syndromes?
21. What are the risks of myocardial infarction and death in someone with unstable angina during hospital admission, at six months and one year?
22. What medical treatments of unstable angina are of proven benefit?
23. Under what circumstances should the patient with unstable angina undergo PTCA or CABG?
24. What new approaches are there to prevent restenosis following PTCA?
25. Which thrombolytics are currently available for treating acute myocardial infarction? Who should receive which one? What newer agents are there?
26. Is angioplasty better than thrombolysis in myocardial infarction? Which patients should receive primary or “hot” angioplasty for these conditions?
27. What are the contraindications to thrombolytic therapy for acute myocardial infarction? Is diabetic retinopathy a contraindication?
28. Exercise testing after myocardial infarction: how soon, what protocol, how should results be acted upon?
29. What are the risks of recurrent ischaemic events after myocardial infarction: prehospital, at 30 days and at 1 year?
30. What is appropriate secondary prevention after acute myocardial infarction?
31. What advice should I give patients about driving and flying after myocardial infarction?
32. What is the mortality rate for cardiogenic shock complicating myocardial infarction? How should such patients be managed to improve outcome and what are the results?
33. What is the risk of a patient dying or having a myocardial infarction around the time of surgery for coronary artery disease and for valve replacement?
34. Which patients with post-infarct septal rupture should be treated surgically, and what are the success rates?
35. What patterns of coronary disease are associated with improved short and long term survival after CABG compared with medical therapy?
36. Coronary artery bypass grafting: what is the case for total arterial revascularisation?
37. How common are neuropsychological complications after cardiopulmonary bypass (CPB)? How predictable and severe are they? Can they be prevented?
38. Are there benefits to switching from sulphonylureas to insulin after coronary artery bypass grafting?
39. How does recent myocardial infarction affect the perioperative risks of coronary artery bypass grafting?
40. How soon before cardiac surgery should aspirin be stopped?
41. When should we operate to relieve mitral regurgitation?
42. When to repair the mitral valve?
43. What is the Ross procedure? When is it indicated and what are the advantages?
44. What is the risk of stroke each year after a) tissue or b) mechanical MVR or AVR? What is the annual risk of bacterial endocarditis on these prosthetic valves?
45. When and how should a ventricular septal defect be closed in adults?
46. How should I treat atrial septal defects in adults?
47. How do I follow up a patient who has had correction of aortic coarctation? What should I look for and how should they be managed?
48. How should I investigate a patient with hypertrophic cardiomyopathy (HCM)?
49. What is the medical therapy for patients with hypertrophic cardiomyopathy, and what surgical options are of use?
50. What is the role of permanent pacing in hypertrophic cardiomyopathy?
51. How do I investigate the relative of a patient with hypertrophic cardiomyopathy? How should they be followed up?
52. What investigation protocol should a patient with dilated cardiomyopathy undergo?
53. Which patients with impaired ventricles should receive an ACE inhibitor? What are the survival advantages? Do AT1-receptor antagonists confer the same advantages?
54. What is the role of vasodilators in chronic heart failure? Who should receive them?
55. Should I give digoxin to patients with heart failure if they are in sinus rhythm? If so, to whom? Are there dangers to stopping it once started?
56. Which patients with heart failure should have a beta blocker? How do I start it and how should I monitor therapy?
57. What is mean and model life expectancy in NYHA I-IV heart failure?
58. What are LVADs and BIVADS, and who should have them?
59. Who is eligible for a heart or heart-lung transplant? How do I assess suitability for transplantation?
60. What are the survival figures for heart and heart-lung transplantation?
61. What drugs do post-transplant patients require, and what are their side effects? How should I follow up such patients?
62. Can a cardiac transplant patient get angina? How is this investigated?
63. What drugs should be used to maintain someone in sinus rhythm who has paroxysmal atrial
fibrillation? Is there a role for digoxin?
64. Which patients with paroxysmal or chronic atrial fibrillation should I treat with aspirin, warfarin or neither?
65. Which patients with SVT should be referred for an intracardiac electrophysiological study (EP study)? What are the success rates and risks of radiofrequency (RF) ablation?
66. What drugs should I use for chemically cardioverting atrial fibrillation and when is DC
cardioversion preferable?
67 How long should someone with atrial fibrillation be anticoagulated before DC cardioversion, and how long should this be continued afterwards?
68. What factors determine the chances of successful elective cardioversion from atrial fibrillation?
69. What are the risks of elective DC cardioversion from atrial fibrillation?
70. Are patients with atrial flutter at risk of embolisation when cardioverted? Do they need
anticoagulation to cover the procedure?
71. How do I assess the risk of CVA or TIA in a patient with chronic atrial fibrillation and in a patient with paroxysmal atrial fibrillation?
72. How sensitive are transthoracic and transoesophageal echocardiography for the
detection of thrombus in the left atrium?
73. What are the roles of transthoracic and transoesophageal echocardiography in patients with a TIA or stroke?
74. Which patient with a patent foramen ovale should be referred for closure?
75. How should I investigate the patient with collapse? Who should have a tilt test, and what do I do if it is positive?
76. What are the chances of a 24 hour tape detecting the causes for collapse in a patient? What other alternative monitoring devices are now available?
77. Should the patient with trifascicular disease be routinely paced? If not, why not?
78. Who should have VVI pacemakers and who should have dual chamber pacemakers? What are the risks of pacemaker insertion?
79. Can a patient with a pacemaker touch an electric fence? …have an MRI scan? …go through airport metal detectors? …use a mobile phone?
80. What do I do if a patient has a pacemaker and needs cardioversion?
81. What do I do about non-sustained ventricular tachycardia on a 24 hour tape?
82. How do I treat torsades de pointes at a cardiac arrest?
83. How do I assess the patient with long QT? Should I screen relatives, and how? How do I treat them?
84. How do I investigate the relatives of a patient with sudden cardiac death?
85. What percentage of patients will suffer the complications of amiodarone therapy, and how
reversible are the eye, lung, and liver changes? How do I assess thyroid function in someone on amiodarone therapy?
86. Who should have a VT stimulation study? What are the risks and benefits?
87. What are the indications for implantable cardioverter defibrillator (ICD) implantation and
what are the survival benefits?
88. How do I manage the patient with an ICD?
89. How do I follow up the patient with the implantable
cardioverter defibrillator?
90. What do I do if an ICD keeps discharging?
91. How do I manage the pregnant woman with dilated cardiomyopathy?
92. How do I manage the pregnant woman with valve disease?
93. Which cardiac patients should never get pregnant? Which cardiac patients should undergo elective Caesarean section?
94. A patient is on life-long warfarin and wishes to become pregnant. How should she be managed?
95. How should the anticoagulation of a patient with a mechanical heart valve be managed for elective surgery?
96. What are the indications for surgical management of endocarditis?
97. What is the morbidity and mortality of endocarditis with modern day management (and how many relapse)?
98. What percentage of blood cultures will be positive in endocarditis?
99. Which patients should receive antibiotic prophylaxis for endocarditis, and which procedures should be covered in this way?
100. Which patients should undergo preoperative non-invasive investigations or coronary
angiography?
101. Which factors predict cardiac risk from general surgery and what is the magnitude of the risks associated with each factor?
Index
Author Details
"Diana Holdright"
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