Elias B. Hanna, MD, is Associate Professor of Medicine (Cardiovascular Medicine and Interventional Cardiology) at the University of Iowa. He has authored multiple cardiology books and has extensive fellowship teaching experience.

Preface xx

Abbreviations xxi

About the Companion Website xxiv

Part 1. Coronary Artery Disease 1

1. Non- ST- Segment Elevation Acute Coronary Syndrome 1

I. Definition types of myocardial infarction and pitfalls 1

II. Clinical features ECG cardiac biomarkers and echocardiography in ACS 6

III. Initial approach to acute chest pain presentations and the use of conventional and high- sensitivity troponins 8

IV. Management of NSTEMI 10

V. General procedural management after coronary angiography: PCI CABG or medical therapy only 14

VI. Discharge medications in NSTEMI 14

VII. Prognosis 17

Appendix 1. Complex angiographic disease- Moderate disease progression 17

Appendix 2. Women and ACS elderly patients and ACS CKD 18

Appendix 3. Bleeding transfusion patients on chronic warfarin or NOAC gastrointestinal bleed 19

Appendix 4. Antiplatelet and anticoagulant therapy 20

Appendix 5. Difference between plaque rupture and plaque erosion 23

Appendix 6. Spontaneous coronary artery dissection 23

Appendix 7. Harmful effects of NSAIDs and cyclooxygenase- 2 inhibitors in CAD 25

Appendix 8. Additional ideas on the physiology of hs- troponin- Role of hs- troponin in primary prevention 25

Questions and answers 25

2. ST- Segment Elevation Myocardial Infarction 38

1. Definition reperfusion and general management 39

I. Definition 39

II. Timing of reperfusion 39

III. ECG phases of STEMI 40

2. Stemi Complications 50

I. Cardiogenic shock 50

II. Mechanical complications 53

III. Recurrent infarction and ischemia 55

Appendix 1. Out- of- hospital cardiac arrest: role of early coronary angiography and therapeutic hypothermia 60

Questions and answers 62

3. Stable Ischemic Heart Disease and Approach to Chronic Chest Pain 74

I. Causes of angina and pathophysiology of coronary flow 74

II. Diagnostic approach 75

III. Silent myocardial ischemia. Is there a role for screening asymptomatic patients and post- PCI patients? 78

Appendix 1. Notes on various surgical grafts 86

Appendix 2. Coronary vasospasm (variant angina Prinzmetal angina) 88

Appendix 3. Microvascular endothelial dysfunction 90

Appendix 4. Women with chest pain and normal coronary arteries 90

Appendix 5. Diagnostic strategy for ischemia with non- obstructed coronary arteries (INOCA) 91

Appendix 6. Myocardial bridging 91

Appendix 7. Coronary collaterals chronic total occlusion 92

Appendix 8. Hibernation stunning ischemic preconditioning 92

Questions and answers 93

Part 2. Heart Failure (Chronic and Acute Heart Failure Specific Cardiomyopathies and Pathophysiology) 103

4. Heart Failure 103

Definition Types Causes and Diagnosis of Heart Failure 104

1. Definition and types of heart failure 104

I. Heart failure is diagnosed clinically not by echocardiography 104

II. After HF is defined clinically echocardiography is used to differentiate the three major types of HF 105

III. Two additional types of HF 107

2. Causes of heart failure 107

I. Systolic HF or HF with reduced EF (HFrEF) 107

II. HF with preserved EF (HFpEF) 108

III. Right HF 110

3. Diagnostic tests 110

I. Echocardiography 110

II. BNP 111

III. ECG 112

IV. Coronary angiography and other ischemic tests 112

Chronic Treatment of Heart Failure 113

1. Treatment of systolic heart failure 113

I. Treat the underlying etiology: target BP and CAD 113

II. Value of revascularization in ischemic cardiomyopathy: STICH trial 113

2. Treatment of HFpEF 124

Acute Heart Failure and Acutely Decompensated Heart Failure 126

I. Triggers of acute decompensation 126

II. Profiles of acute HF: congestion without low cardiac output congestion with low cardiac output 127

Appendix 1. Management of isolated or predominant RV failure 135

Questions and answers 138

5. Additional Heart Failure Topics 156

1. Specific cardiomyopathies 156

I. Arrhythmia- induced cardiomyopathy 156

II. Viral myocarditis 157

2. Advanced heart failure: heart transplant and ventricular assist devices 163

I. Stages of HF 163

II. Cardiac transplantation 163

3. Pathophysiology of heart failure and hemodynamic aspects 166

I. LV diastolic pressure in normal conditions and in HF (whether systolic or diastolic) 166

II. Definition of afterload 167

Questions and answers 173

Part 3. Valvular Disorders 181

6. Valvular Disorders 181

1. Mitral regurgitation 182

I. Mechanisms of mitral regurgitation 182

II. Specifics of various causes of mitral regurgitation 182

2. Mitral stenosis 192

I. Etiology and natural history 192

II. Diagnosis 193

III. Treatment 197

3. Aortic insufficiency 199

I. Etiology 199

II. Pathophysiology and hemodynamics 200

III. Diagnosis 200

4. Aortic stenosis 203

I. Etiology 203

II. Echo and catheterization diagnosis pitfalls and hemodynamics 204

5. Tricuspid regurgitation and stenosis 213

I. Etiology of tricuspid regurgitation 213

II. Natural history of TR 215

6. Pulmonic stenosis and regurgitation 216

I. Pulmonic stenosis 216

II. Pulmonic regurgitation 216

7. Mixed valvular disease; radiation heart disease 217

I. Mixed single- valve disease 217

II. Multiple valvular involvement (combined stenosis or regurgitation of two different valves) 217

III. Radiation heart disease 217

8. Prosthetic valves 218

I. Bioprosthesis versus mechanical prosthesis 218

II. Determinants of valve degeneration and valve thrombosis; anticoagulation guidelines 218

III. Particular cases: women who wish to become pregnant and dialysis patients 220

IV. Echocardiographic follow- up of prosthetic valves 221

V. Complications 221

9. Auscultation and summary ideas 223

I. Auscultation and other physical findings 223

II. General ideas and workup 226

Questions and answers 227

Part 4. Hypertrophic Cardiomyopathy 243

7. Hypertrophic Cardiomyopathy 243

I. Definition and features of HCM 243

II. Natural history and mortality 245

III. Symptoms and ECG 246

Questions and answers 253

Part 5. Arrhythmias and Electrophysiology 257

8. Approach to Narrow and Wide QRS Complex Tachyarrhythmias 257

I. The unstable patient 257

II. Initial approach to any tachycardia 257

9. Ventricular Arrhythmias: Types and Management Sudden Cardiac Death 274

I. Premature ventricular complexes 274

II. Ventricular tachycardia 276

III. Polymorphic ventricular tachycardia 278

Questions and answers 288

10. Atrial Fibrillation 294

I. Predisposing factors 294

II. Types of AF 295

III. General therapy of AF 295

X. AF burden as a correlate and a driver of HF progression 303

Appendix 1. Optimal heart rate and AF rate for optimal cardiac output 303

Appendix 2. Antiarrhythmic drug therapy 303

Appendix 3. Catheter ablation of atrial fibrillation surgical ablation AV nodal ablation 305

Appendix 4. INR follow- up in patients receiving warfarin- Non- vitamin K oral anticoagulants 306

Appendix 5. Bridging anticoagulation in patients undergoing procedures 308

Appendix 6. Management of elevated INR values 309

Appendix 7. Left atrial appendage surgical and percutaneous closure 309

Appendix 8. A common situation: AF and symptomatic pauses or bradycardia 309

Appendix 9. DC cardioversion in patients with a slow ventricular response 310

Appendix 10. AF occurring post- cardiac surgery and AF related to acute transient triggers 310

Appendix 11. Brief asymptomatic runs of AF on device interrogation and association with stroke. Role of rhythm monitoring after cryptogenic stroke 310

Questions and answers 311

11. Atrial Flutter and Atrial Tachycardia 319

I. Atrial flutter 319

II. Focal atrial tachycardia 322

III. Multifocal atrial tachycardia (MAT) (or chaotic atrial tachycardia) 325

Questions and answers 326

12. Atrioventricular Nodal Reentrant Tachycardia Atrioventricular Reciprocating Tachycardia Wolff-Parkinson- White Syndrome and Junctional Rhythms 329

I. Inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) 329

II. Atrioventricular nodal reentrant tachycardia (AVNRT) 329

III. Atrioventricular reciprocating tachycardia (AVRT) and Wolff-Parkinson-White (WPW) syndrome 332

Questions and answers 342

13. Bradyarrhythmias 345

I. AV block 345

II. Sinus node dysfunction 354

Questions and answers 359

14. Permanent Pacemaker and Implantable Cardioverter Defibrillator 363

I. Indications for permanent pacemaker implantation 363

II. Types of cardiac rhythm devices 363

Appendix. Cases of PM troubleshooting 381

Questions and answers 386

15. Basic Electrophysiologic Study 390

I. General concepts; intracardiac electrograms 390

II. AV conduction abnormalities 390

16. Action Potential Features and Propagation: Mechanisms of Arrhythmias Antiarrhythmic Drugs 403

I. Action potential 403