Table of contents :
Epidemiology : in 2002 62 million
Americans
(32 million females and 30 million males > 20%) - had a
cardiovascular
disease (including hypertension). The prevalence rises
progressively with
age from 5% at age 20 to 75% at age > 75 years. 8% or 22
million adults
in the US have heart disease. In the US, the prevalence rate for
those
who have angina pectoris is 17.5 per 1000 people
Cardiovascular diseases (CVD) represent the first leading cause of
death in Westernized countries, accounting for 45-50% of all
deaths: 35%
are
coronary artery diseases (CAD).
Contradicting conventional wisdom, the largest-ever worldwide
collaborative
study of heart disease has found that women are slightly more
likely to
die from CVD than men and that heart
attacks and stroke
kill twice as many women as all cancers combined. Out of the total
16.5
million CVD deaths annually, 8.6 million are of women. Although
> 80% of
the global burden of cardiovascular disease occurs in low-income
and middle-income
countries, knowledge of the importance of risk factors is largely
derived
from developed countries. Therefore, the effect of such factors on
risk
of coronary heart disease in most regions of the world is unknown.
Risk factors significantly related to acute myocardial infarction
(p<0.0001
for all risk factors and p=0.03 for alcohol) include :
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symptoms (NYHA class) | absent | I/II | III/IV |
EF% | > 60 | 50-60 | < 50 |
ESD [mm] | < 40 | 40-45 | > 45 |
factibility | absent | possible | sure |
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Atrial Fibrillation Investigators ref |
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American College of Chest Physiciansref |
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Stroke Prevention in Atrial Fibrillationref |
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effective | amiodarone | all drugs in
recommendation class I (except
ibutilide)
plus b-blockers![]() |
I | B |
flecainide | ||||
ibutilide | ||||
propafenone | ||||
propafenone + verapamil | ||||
quinidine | ||||
sotalol | ||||
uncertain/unknown | b-blockers![]() |
diltiazem![]() |
IIb | B |
disopyramide | dofetilide | |||
diltiazem![]() |
verapamil | |||
dofetilide | ||||
procainamide | ||||
verapamil |
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dosage (Dosages given in the table
may differ from those recommended
by the manufacturers.
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amiodarone | oral | inpatient: 1.2–1.8 g per day in divided dose until 10 g total, then 200–400 mg per day maintenance or 30 mg/kg as single dose | hypotension, bradycardia, QT prolongation, torsade de pointes (rare), GI upset, constipation, phlebitis (IV) |
outpatient: 600–800 mg per day divided dose until 10 g total, then 200–400 mg per day maintenance | |||
intravenous/oral | 5–7 mg/kg over 30–60 min, then 1.2–1.8 g per day continuous IV or in divided oral doses until 10 g total, then 200–400 mg per day maintenance | ||
dofetilide | oral | creatinine clearance (mL/min) =>
Dose (mcg BID)
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QT prolongation, torsade de pointes; adjust dose for renal function, body size, and age |
flecainide (insufficient data are available on which to base specific recommendations for the use of one loading regimen over another for patients with ischemic heart disease or impaired left ventricular function, and these drugs should be used cautiously or not at all in such patients) | oral | 200–300 mg | hypotension, rapidly conducting atrial flutter |
intravenous | 1.5–3.0 mg per kg over 10–20 min | ||
ibutilide | intravenous | 1 mg over 10 min; repeat 1 mg when necessary | QT prolongation, torsade de pointes |
propafenone | oral | 450–600 mg | |
intravenous | 1.5–2.0 mg per kg over 10–20 min | ||
quinidine (the use of quinidine loading to achieve pharmacological conversion of atrial fibrillation is controversial, and safer methods are available with the alternative agents listed in the table. Quinidine should be used with caution) | oral | 0.75–1.5 g in divided doses over 6–12 h, usually with a rate-slowing drug | QT prolongation, torsade de pointes, GI upset, hypotension |
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amiodarone | 100–400 mg | photosensitivity, pulmonary toxicity, polyneuropathy, GI upset, bradycardia, torsade de pointes (rare), hepatic toxicity, thyroid dysfunction |
disopyramide | 400–750 mg | torsade de pointes, HF, glaucoma, urinary retention, dry mouth |
dofetilide | 500–1000 mg (a loading dose of 600 mg per day is usually given for one month or 1000 mg per day over 1 week) | torsade de pointes |
flecainide | 200–300 mg | ventricular tachycardia, congestive HF, enhanced AV nodal conduction (conversion to atrial flutter) |
procainamide | 1000–4000 mg | torsade de pointes, lupus-like syndrome, GI symptoms |
propafenone | 450–900 mg | ventricular tachycardia, congestive HF, enhanced AV nodal conduction (conversion to atrial flutter) |
quinidine | 600–1500 mg | torsade de pointes, GI upset, enhanced AV nodal conduction |
sotalol | 240–320 mg (dose should be adjusted for renal function and QT-interval response during in-hospital initiation phase) | torsade de pointes, congestive HF, bradycardia, exacerbation of chronic obstructive or bronchospastic lung disease |
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digoxin | 0.25 mg PO each 2 h; up to 1.5 mg | 2 h | 0.125–0.375 mg daily | Digitalis toxicity, heart block, bradycardia | I |
diltiazem![]() |
NA | 2-4 h | 120–360 mg daily in divided doses; slow release available | hypotension, heart block, HF | I |
metoprolol (the table includes representative members of the type of beta-blocker drugs, but other, similar agents could be used for this indication in appropriate doses.) | NA | 4-6 h | 25–100 mg BID | hypotension, heart block, bradycardia, asthma, HF | I |
propanolol | NA | 60-90 min | 80–240 mg daily in divided doses | hypotension, heart block, bradycardia, asthma, HF | I |
verapamil | NA | 1-2 h | 120–360 mg daily in divided doses; slow release available | hypotension, heart block, HF, digoxin interaction | I |
amiodarone | 800 mg daily for 1 wk 600 mg daily for 1 wk 400 mg daily for 4–6 wk | 1-3 wk | 200 mg daily | pulmonary toxicity, skin discoloration, hypothyroidism, corneal deposits, optic neuropathy, warfarin interaction, proarrhythmia | Ib |
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diltiazem![]() |
0.25 mg/kg IV over 2 min | 2-7 mm | 5-15 mg per hour infusion | hypotension, heart block, HF | I (type IIb in congestive HF) |
esmolol (only representative members of the type of b-adrenergic antagonist drugs are included in the table, but other, similar agents could be used for this indication in appropriate doses) | 0.5 mg/kg over 1 min | 5 min | 0.05–0.2 mg·kg-1·min-1 | hypotension, heart block, bradycardia, asthma, HF | I |
metoprolol | 2.5–5 mg IV bolus over 2 min; up to 3 doses | 5 min | NA | hypotension, heart block, bradycardia, asthma, HF | I (type IIb in congestive HF) |
propanolol | 0.15 mg/kg IV | 5 min | NA | hypotension, heart block, bradycardia, asthma, HF | I (type IIb in congestive HF) |
verapamil | 0.075–0.15 mg/kg IV over 2 min | 3-5 min | NA | hypotension, heart block, HF | I (type IIb in congestive HF) |
digoxin | 0.25 mg IV each 2 h, up to 1.5 mg | 2 hr | 0.125–0.25 mg daily | Digitalis toxicity, heart block, bradycardia | IIb (type I in congestive HF) |
drug | route of administration | type of recommendation | level of evidence | |
agents with proven efficacy | dofetilide | oral | I | A |
flecainide | oral or intravenous | I | A | |
ibutilide | intravenous | I | A | |
propafenone | oral or intravenous | I | A | |
amiodarone | oral or intravenous | IIa | A | |
quinidine | oral | IIb | B | |
less effective or incompletely studied | procainamide | intravenous | IIb | C |
digoxin | oral or intravenous | III | A | |
sotalol | oral or intravenous | III | A |
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diltiazem![]() |
intravenous | I | A |
esmolol | intravenous | I | A |
verapamil | intravenous or oral | I | A |
other b-blockers![]() |
intravenous or oral | I | B |
digoxin | intravenous or oral | IIa | B |
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age < 60 years; no heart disease (lone AF) | aspirin (325 mg daily) or no therapy | I |
age < 60 years; heart disease but no risk factors (risk factors for thromboembolism include HF, LVEF < 0.35, and history of hypertension) | aspirin (325 mg daily) | I |
age >= 60 years; no risk factors (risk factors for thromboembolism include HF, LVEF < 0.35, and history of hypertension) | aspirin (325 mg daily) | I |
age >= 60 years; with diabetes
mellitus![]() |
oral anticoagulation (INR 2.0–3.0) | I |
addition of aspirin,
81–162 mg daily is optional
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IIb | |
age >= 75 years especially women | oral anticoagulation (INR 2.0) | I |
HF; LVEF <= 0.35; thyrotoxicosis; hypertension | oral anticoagulation (INR 2.0–3.0) | I |
rheumatic heart disease (mitral stenosis); prosthetic heart valves; prior thromboembolism; persistent atrial thrombus on TEE | oral anticoagulation (INR 2.5–3.5 or higher may be appropriate) | I |
ref |
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normal | < 430 | < 450 |
borderline | 430-450 | 450-470 |
pathological | > 450 | > 470 |
stage | duration (min) | total time (min) | velocity | slope (%) | workload (METS) | equivalent recreational activity |
1 | 1 | 1 | 3 km/h (1.9 mph) | 0 | 2 | walking |
2 | 3 | 4 | 3 km/h (1.9 mph) | 10 | 5 | riding |
3 | 3 | 7 | 4 km/h (2.5 mph) | 12 | 6-7 | slow running |
4 | 3 | 10 | 5.5 km/h (3.4 mph) | 14 | 8-9 | running |
5 | 3 | 13 | 7 km/h (4.4 mph) | 16 | 16 | squash |
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parietal stress | increased | no | increased :
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ejection fraction | decreased | no | very decreased |
characteristic |
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clinical | pulsus paradoxus | common | usually absent | rare | rare |
jugular vein : prominent y descent | absent | usually present | rare | rare | |
jugular vein : prominent x descent | present | usually present | present | rare | |
Kussmaul's sign | absent | present | absent | absent | |
S3
sound![]() |
absent | absent | rare | may be present | |
pericardial knock | absent | often present | absent | absent | |
EKG | low EKG voltage | may be present | may be present | may be present | absent |
electrical alternans | may be present | absent | absent | absent | |
echocardiography | thickened pericardium | absent | present | absent | absent |
pericardial calcification | absent | often present | absent | absent | |
pericardial effusion | present | absent | absent | absent | |
RV size | usually small | usually normal | usually normal | enlarged | |
myocardial thickness | normal | normal | usually increased | normal | |
right atrial collapse and right ventricular diastolic collapse | present | absent | absent | absent | |
increased early filling, increased mitral flow velocity | absent | present | present | may be present | |
exaggerated respiratory variation in flow velocity | present | present | absent | absent | |
CT![]() |
thickened/calcific pericardium | absent | present | absent | absent |
cardiac catheterization | equalization of diastolic pressures | usually present | usually present | usually absent | absent or present |
cardiac biopsy | helpful ? | no | no | sometimes | no |
Heart disease news
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