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From the ancient Greek Olympics to the high school gymnasium, competitive sports have become an increasingly important part of human culture. At an early age, children around the world are introduced and encouraged into sports by their parents and peers. For some, playing sports becomes a regular part of life even as they enter adulthood. The medical profession has always been encouraging of physical activity. With the rising obesity epidemic, even the recent Obama administration, spearheaded by First Lady Michelle Obama, started a campaign called “Let’s Move” to promote exercise among our children. Regular physical activity has been shown to improve many markers of health and can ward off diseases fraught with high morbidity and mortality, like diabetes and obesity. However, as the intensity level of sports increases, there remains controversy as to the advantages of certain vigorous forms of exercise. In rare but dramatic circumstances, young athletes can experience sudden cardiac death on the playing field. There are some evidence-based guidelines to help the cardiologist manage the young athlete before they step foot onto the playing field, but major differences exist in different countries as to how this evidence is interpreted and how cost-effectiveness plays a role.

The following valvular disorders are considered here in the context of competitive athletes: mitral stenosis (MS), mitral regurgitation (MR), aortic stenosis (AS), aortic regurgitation (AR), tricuspid regurgitation (TR), tricuspid stenosis, and multivalvular disease. Recommendations are also

The previous guideline for the use of echocardiography was published in March 1997. Since that time, there have been significant advances in the technology of echocardiography and growth in its clinical use and in the scientific evidence leading to recommendations for its proper use. Each section has been reviewed and updated in evidence tables, and where appropriate, changes have been made in recommendations. A new section on the use of intraoperative transesophageal echocardiography (TEE) is being added to update the guidelines published by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists. There are extensive revisions, especially of the sections on ischemic heart disease; congestive heart failure, cardiomyopathy, and assessment of left ventricular (LV) function; and screening and echocardiography in the critically ill. There are new tables of evidence and extensive revisions in the ischemic heart disease evidence tables. Because of space limitations, only those sections and evidence tables with new recommendations will be printed in this summary article. Where there are minimal changes in a recommendation grouping, such as a change from Class IIa to Class I, only that change will be printed, not the entire set of recommendations. Advances for which the clinical applications are still being investigated, such as the use of myocardial contrast agents and three-dimensional echocardiography, will not be discussed. The original recommendations of the 1997 guideline are based on a Medline search of the English literature from 1990 to May 1995. The original search yielded more than 3000 references, which the committee reviewed. For this guideline update, literature searching was conducted in Medline, EMBASE, Best Evidence, and the Cochrane Library for English-language meta-analyses and systematic reviews from 1995 through September 2001. Further searching was conducted for new clinical trials on the following topics: echocardiography in adult congenital heart disease, echocardiography for evaluation …

Since the etiology of erectile dysfunction is frequently related to endothelial dysfunction, a problem in common with much vascular disease, erectile dysfunction disproportionately affects patients with cardiovascular disease. With the development of phosphodiesterase 5 inhibitors, the first of which was sildenafil (Viagra), an effective oral medication became available. The question of safety of these drugs, especially in patients with latent or overt coronary artery disease, is of concern. Sildenafil relaxes smooth muscle and therefore lowers systolic and diastolic blood pressure slightly. With organic nitrates, the drop in blood pressure is potentiated, at times dangerously, thereby making it contraindicated to take nitrates within 24 hours of using sildenafil. In double-blind, placebo-controlled trials, there was no difference between sildenafil subjects and control patients in the incidence of myocardial infarction, cardiovascular, and total deaths. Coronary disease patients with stable angina, controlled on medications, were included in the trials. Therefore, sildenafil, as a drug, is safe in such patients. With a patient with coronary artery disease suddenly engaging in the physical exercise associated with sexual intercourse, there is the danger of increased risk of precipitating myocardial infarction or death. The cardiovascular metabolic cost of sexual activity is reviewed and appears to be approximately at the level of 3-5 metabolic equivalents of exercise. Sexual activity occurs within 2 hours of the onset of an acute myocardial infarction in

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines. The customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective . Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data …

Preamble......971 I. Introduction ......972 A. Organization of Committee and Evidence Review......972 B. Purpose of These Guidelines......973 C. Overview of the Acute Coronary Syndrome......973 1. Definition of Terms......973 2. Pathogenesis of UA/NSTEMI ......974 3. Presentations of

Table of contents It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies in the management or prevention of disease states. Rigorous and expert analysis of the available data documenting relative benefits and

The pharmaceutical preparation sildenafil citrate (Viagra) is being widely prescribed as a treatment for male erectile dysfunction, a common problem that in the United States affects between 10 and 30 million men. The introduction of sildenafil has been a valuable contribution to the treatment of erectile dysfunction, which is a relatively common occurrence in patients with cardiovascular disease. This article is written to appropriately caution and not to unduly alarm physicians in their use of sildenafil in patients with heart disease. Reported cardiovascular side effects in the normal healthy population are typically minor and associated with vasodilatation (ie, headache, flushing, and small decreases in systolic and diastolic blood pressures). However, although their incidence is small, serious cardiovascular events, including significant hypotension, can occur in certain populations at risk. Most at risk are individuals who are concurrently taking organic nitrates. Organic nitrate preparations are commonly prescribed to manage the symptoms of angina pectoris. The coadministration of nitrates and Viagra significantly increases the risk of potentially life-threatening hypotension. Therefore, Viagra should not be prescribed to patients receiving any form of nitrate therapy. Although definitive evidence is currently lacking, it is possible that a precipitous reduction in blood pressure with nitrate use may occur over the initial 24 hours after a dose of Viagra. Thus, for patients who experience an acute cardiac ischemic event and who have taken Viagra within the past 24 hours, administration of nitrates should be avoided. In the event that nitrates are given, especially within this critical time interval, it is essential to have the capability to support the patient with fluid resuscitation and α-adrenergic agonists if needed. In patients with recurring angina after Viagra use, other nonnitrate antianginal agents, such as β-blockers, should be considered. Other patients in whom the use of Viagra is potentially hazardous include those …

The article in this issue of the Journal by Brothers et al. ([1][1]) is the first study to show convincingly that the anomalous aortic origin of a coronary artery, that is, the left main coronary artery arising from the right sinus of Valsalva (ALCA) or the right coronary artery arising from the

This executive summary and recommendations appears in the November 3, 1998, issue of Circulation . The guidelines in their entirety, including the ACC/AHA Class I, II, and III recommendations, are published in the November 1, 1998, issue of the Journal of the American College of Cardiology . Reprints of both the full text and the executive summary and recommendations are available from both organizations. During the past 2 decades, major advances have occurred in diagnostic techniques, the understanding of natural history, and interventional cardiological and surgical procedures for patients with valvular heart disease. The information base from which to make clinical management decisions has greatly expanded in recent years, yet in many situations, management issues remain controversial or uncertain. Unlike many other forms of cardiovascular disease, there is a scarcity of large-scale multicenter trials addressing the diagnosis and treatment of valvular disease from which to derive definitive conclusions, and the literature represents primarily the experiences reported by single institutions in relatively small numbers of patients. The Committee on Management of Patients With Valvular Disease was given the task of reviewing and compiling this information base and making recommendations for diagnostic testing, treatment, and physical activity. These guidelines follow the format established in previous American College of Cardiology/American Heart Association (ACC/AHA) guidelines for classifying indications for diagnostic and therapeutic procedures: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment IIa. Weight of evidence/opinion is in favor of usefulness/efficacy IIb. Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases …

The publication of major studies dealing with the natural history of bradyarrhythmias and tachyarrhythmias and major advances in the technology of pacemakers and implantable cardioverter-defibrillators (ICDs) has mandated this revision of the 1991 ACC/AHA Guidelines for Implantation of Pacemakers and Antiarrhythmia Devices. This executive summary appears in the April 7, 1998 issue of Circulation. The full text of the guidelines, including the ACC/AHA Class I, II, and III recommendations, is published in the April 1998 issue of the Journal of the American College of Cardiology. Reprints of both the executive summary and the full text are available from both organizations. Following extensive review of the medical literature and related documents previously published by the American College of Cardiology, the American Heart Association, and the North American Society for Pacing and Electrophysiology, the writing committee developed recommendations that are evidence based whenever possible. Evidence supporting current recommendations is ranked as level A if the data were derived from multiple randomized clinical trials involving a large number of individuals. Evidence was ranked as level B when data were derived from a limited number of trials involving comparatively small numbers of patients or from well-designed data analysis of nonrandomized studies or observational data registries. Evidence was ranked as level C when consensus of expert opinion was the primary source of recommendation. The committee emphasizes that for certain conditions for which no other therapies are available, the indications for device therapies are based on years of clinical experience as well as expert consensus and are thus well supported, even though the evidence was ranked as level C. These guidelines include expanded sections on selection of pacemakers and ICDs, optimization of technology, cost, and follow-up of implanted devices. The follow-up sections are relatively brief because in many instances the type and frequency of follow-up examinations …

Preamble It is clearly important that the medical profession plays a significant role in critically evaluation of the use of diagnostic procedures and therapies in the management or prevention of disease. Rigorous and expert analysis of the available data documenting relative benefits and risks of those procedures and therapies can produce helpful guidelines that …

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), premier organizations in cardiovascular medicine, are considered trusted sources of consensus about matters related to cardiovascular health. It is important to make clear when one is or is not representing one of these organizations. Members of the ACCF or the AHA have a variety of roles aside from their professional relationships with these organizations. Delineation of these varying roles may not always be entirely clear. A member's particular expertise in research or as a care provider naturally provides the impetus for his or her official contributions to the organization's programs, written position statements, and guidelines. Individuals may also serve each organization in a variety of official capacities, including as officers, board members, committee chairs, and members. It is the responsibility of the individual member not to misrepresent or imply an opinion as being that of the ACCF or the AHA unless the person is functioning as an officially designated representative of either organization. This may require a formal statement by the individual to exclude any possibility that his or her personal opinion could be reasonably interpreted as being that of the organization (as may be the case if one's organizational service or contributions are highlighted as part of one's qualifications as an expert), unless organizational affiliation is absent from the stated qualifications. This is particularly important if the expert is an officer, board member, or committee chair of the ACCF or the AHA. An individual's qualifications as an expert are often based on recognized clinical expertise, which is at times difficult to quantify, or on one's contributions to medical knowledge based on research productivity as reflected in peer-review publications. Both ACCF and AHA volunteers (and staff) file annual conflict of interest declarations. Spokespersons for specific topic areas …

Of all valve lesions, mitral stenosis has the most options for intervention and in many ways is the valve lesion where it is easiest to make a decision that intervention is necessary. This was the first acquired valve lesion where patient symptoms and ultimate prognosis could be improved surgically

"Guidelines for Clinical lntracardiac Electrophysiological and Catheter Ablation Procedures" was approved by the American Heart Association SAC/Steering Committee in May 1995 and the American College of Cardiology Board of Trustees in March 1995 and was endorsed by the North American Society of Pacing and Eleetrophysiology Board of Directors in May 1995. This statement is being published simultaneously in Circulation, the Journal of the American College of Cardiology, and the Journal of Cardiovascular Electrophysiology. Address for renrints: Educational Services, American College of Cardiology, l i l t ()ld Georgetown Road, Bethesda, Maryland 208141699. cardiology. Such analysis, carefully conducted, could potentially impact the cost of medical care without diminishing the effectiveness of that care. To this end, the American College of Cardiology and the American Heart Association in 1980 established a Task Force on the Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (now the ACC/AHA Task Force on Practice Guidelines) with the following charge: The task force of the American College of Cardiology and the American Heart Association shall develop guidelines relative to the role of new therapeutic approaches and specific noninvasive and invasive procedures in the diagnosis and management of cardiovascular disease. The task force shall address, when appropriate, the contribution, uniqueness, sensitivity, specificity, indications, contraindications and cost-effectiveness of such diagnostic procedures and therapeutic modalities. The task force shall emphasize the role and value of the developed guidelines as an educational resource. The task force shall include a chair and six members, three representatives from the American Heart Association

Objectives. This study attempted to evaluate the long-term effcacy of enalapril versus hydralazine therapy on left ventricular volume, mass and function as well as on the renin-angiotensin system in chronic asymptomatic aortic regurgitation.Background. We tested the hypothesis that early administration of a vasodilator drag might be able to reduce left ventricular dilution and mass expansion. Because the renin-angiotensin system may be activated in chronic aortic regurgitation, early enalapril therapy might be beneficial.Methods. Between 1990 and 1993, 76 asymptomatic nonrheumatic patients with mild to severe chronic aortic regurgitation were enrolled in a randomized, double-blind trial comparing enalapril with hydralazine. All patients underwent serial noninvasive studies. Seventy patients completed the 12-month follow-up.Results. At 1 year, patients receiving enalapril had a significant reduction in left ventricular end-diastolic and end-systolic volume indexes (124 ± 15 vs. 108 ± 17 ml/m2, p < 0.01; 50 ± 12 vs. 40 ± 14 ml/m2, p < 0.01, respectively) and mass index (131 ± 16 vs. 113 ± 19 g/m2, p < 0.01), wheress hydralazine therapy showed no significant changes. Both regimens not only had a significant reduction in left ventricular mean wall stress but also had a mild increase in exercise duration. Only enalapril therapy achieved a significant inhibition of the renin-angiotensin system, in contrast to hydralazine therapy. Moreover, the multiple r2value from the analysis for end-diastolic volume index using the two variables of age and treatment drugs was 72.1% (p < 0.01).Conclusions. Both regimens decrease left ventricular mean wall stress. Enalapril therapy achieves significant left ventricular mass regression, left ventricular end-diastolic and end-systolic volume index reduction and renin-angiotensin system suppression. These findings suggest that early unloading enalapril therapy has the potential to favorably influence the natural history of chronic aortic regurgitation.

This Quick Reference Guide for Clinicians contains recommendations on the care of patients with unstable angina based on a combination of evidence obtained through extensive literature reviews and consensus among members of an expert panel. Principal conclusions include the following. (1) Many patients suspected of having unstable angina can be discharged home after adequate initial evaluation. (2) Further outpatient evaluation may be scheduled for up to 72 hours after initial presentation for patients with clinical symptoms of unstable angina judged at initial evaluation to be at low risk for complications. (3) Patients with acute ischemic heart disease judged to be at intermediate or high risk of complications should be hospitalized for careful monitoring of their clinical course. (4) Intravenous thrombolytic therapy should not be administered to patients without evidence of ST segment elevation and acute myocardial infarction. (5) Assessment of prognosis by noninvasive testing often aids selection of appropriate therapy. (6) Coronary angiography is appropriate for patients judged to be at high risk for cardiac complications or death based on their clinical course or results of noninvasive testing. (7) Coronary artery bypass surgery should be recommended for almost all patients with left main disease and many patients with three-vessel disease, especially those with left ventricular dysfunction. (8) The discharge care plan should include continued monitoring of symptoms; appropriate drug therapy, including aspirin; risk-factor modification; and counseling.

Although calcium antagonists form a mainstay of therapy in patients with angina pectoris, the currently available agents have significant limitations. Nifedipine, diltiazem, and verapamil are all high-clearance agents with significant hepatic extraction and rapid clearance, leading to limited and short-lived bioavailability necessitating frequent daily administration. In contrast, amlodipine, a dihydropyridine calcium antagonist, has a long half-life of 35-50 h (compared with 3 to 4 h elimination half-life of diltiazem, verapamil, and nifedipine). After oral doses, the relative bioavailability of amlodipine is high (64%) and absorption is smooth, with peak plasma levels being achieved 6-12 h postdose. Bioavailability is not affected by the consumption of food. In common with other dihydropyridine calcium antagonists, amlodipine is eliminated mainly by metabolism. None of the metabolites of amlodipine has significant calcium antagonist effects in humans. In contrast to verapamil or diltiazem, amlodipine has no effect on sinus or atrioventricular node and little or no effect on the resting heart rate. Amlodipine does not have any appreciable negative inotropic effect with the relevant clinical dose. Other clinical studies have shown amlodipine to be effective when used once-daily in chronic stable angina and vasospastic angina. Comparative studies indicate that the antianginal efficacy of amlodipine is comparable to the beta blocker nadolol and the benzothiazepine calcium antagonist diltiazem. Amlodipine has also been found to provide improved antianginal effects when combined to treatment with beta blockers and/or long-acting nitrates. Treatment with amlodipine either as monotherapy or combined with other antianginal therapy for up to 26 weeks shows that efficacy is maintained, with no evidence of tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives . The purpose of this study was to evaluate the ability of velocity-encoded nuclear magnetic resonance (NMR) imaging to quantify left to right intracardiac shunts in patients with an atrlal septal defect. Background . Quantification of intracardiac shunts is clinically important in planning therapy. Methods . Velocity-encoded NMR imaging was used to quantify stroke flow in the aorta and in the main pulmonary artery in a group of patients who were known to have an increased pulmonary to systemic flow ratio (QpQs). The velocity.encoded NMR flow data were used to calculate QpQs, and these values were compared with measurements of QpQs obtained with oximetric data derived from cardiac catheterization and from stroke volume measurements of the two ventricles by using volumetric data from biphasic spin echo and cine NMR images obtained at end-diastole and end-systole, Results . Two independent observers measured QpQs by using velocity-encoded NMR imaging in 11 patients and found QpQ ranging from 1.4:1 to 3.9:1. These measurements correlated well with both oximetric data (r = 0.91, SEE = 0.35) and ventricular volumetric data (r = 0.94, SEE = 0.30). Interobserver reproducibility for QpQs by velocity-encoded NMR imaging was good (r = 0.97, SEE = 0.20). Conclusions . Velocity-encoded NMR Imaging is an accurate and reproducible method for measuring QpQs, In left to right shunts. Because it is completely noninvasive, it can be used to monitor shunt volume over time.

Objectives. The aim of the study was to determine the mechanism of the Austin Flint murmur. Background. More than 100 years after the initial description of the Austin Flint murmur, the etiology of the murmur remains unclear.Methods. M-mode and two-dimensional echocardiography, conventional and color flow Doppler study, and cine nuclear magnetic resonance (cine NMR) imaging were performed in 24 patients with clinically moderate or severe aortic regurgitation. Mitral valve area was determined by planimetry and pressure half-time measurement. Overlap of the aortic regurgitation and mitral inflow jets was graded 0 (no overlap) to 4 (marked overlap) by Doppler study and cine NMR imaging. The volume of signal loss resulting from turbulent blood flow secondary to the aortic regurgitation jet was determined on cine NMR images, and the extent of contact with the left ventricular endocardium was graded 0 (no contact) to 4 (extensive contact).Results. The presence of an Austin Flint murmur did not correlate with mitral valve area (2.7 ± 0.8 cm2with the murmur vs. 2.5 ± 0.7 cm2without), overlap of the aortic regurgitation and mitral inflow jets (3 ± 1 vs. 2.3 ± 1.2), diastolic mitral regurgitation (50% vs. 71%) or fluttering of the anterior mitral valve leaflet (70% vs. 50%). The presence of an Austin Flint murmur correlated best with the volume of signal loss associated with the aortic regurgitation jet on cine NMR imaging (65 ± 16 ml with the murmur, vs. 38 ± 11 ml without, p < 0.001) and the extent of contact of this signal loss with the left ventricular endocardium (2.9 ± 0.5 vs. 1.5 ± 0.4, p < 0.0001).Conclusions. The Austin Flint murmur is caused by the aortic regurgitation jet abutting the left ventricular endocardium, resulting in the generation of a low-pitched diastolic rumbling.

1. 1. The American College of Cardiology acknowledges the continuum of changing societal, medical and economic perspectives affecting traditional medical ethics. Primacy of patient responsibility remains paramount to the cardiovascular specialist who at the same time should participate in the development of broader societal programs. 2. 2. Medical decisions should be freely and jointly formulated by the patient and the cardiovascular specialist with appropriate sensitivity to such matters as mental competence, pertinent medical information and standards of care, sufficient time for contemplation, informed consent, patient right of refusal, physician right to refuse to provide inappropriate care and the right of patient, physician or third party payer to seek consultation or additional opinions. 3. 3. The cardiovascular specialist should make a special effort to clarify and document patient preferences regarding end-of-life treatment through some form of advance directive. 4. 4. The cardiovascular specialist bears a moral obligation to provide medical care to any patient who is HIV positive or has AIDS. 5. 5. A conflict of interest occurs when a cardiovascular specialist places personal or financial interest ahead of the welfare and health of a patient. Professional accountability should be established through local or regional peer review. 6. 6. The American College of Cardiology encourages and supports a renewed dedication to the principles of medical ethics, particularly in the field of cardiovascular disease. Cardiovascular specialists are encouraged to participate in the promulgation of medical ethics by teaching and by example, individually and with others.

From the very beginning of the epidemic of human immunodeficiency virus (HIV) infection, which surfaced in the late 1970s, involvement of the heart was described in autopsies of patients who had died of the acquired immune deficiency syndrome (AIDS). The early reports described Kaposi’s sarcoma involving the myocardium and pericardium,1,2 often as incidental findings at autopsy. Large series of patients with AIDS described nonbacterial thrombotic endocarditis, a possibly nonspecific finding resulting from the severe cachexia and wasting frequently seen with this disease.3,4 Later, larger autopsy series showed frequent evidence of focal pockets of inflammatory cells in the myocardium, at times with incidental findings of fungal or parasitic involvement of the myocardium, but clinical manifestations of this myocardial involvement were unusual. Rarely, severe myocarditis due to toxoplasmosis was seen as a cause of death.

The decision to recommend operative intervention to the patient with valve disease is the most difficult when the valve disease is severe chronic aortic regurgitation and the patient is asymptomatic or minimally symptomatic. Because aortic valve replacement is almost always necessary and because the biological and mechanical valves still have problems resulting in significant mortality and morbidity, the decision to recommend surgery in an asymptomatic patient must wait until there are indications that changes are occurring that will predict an increased risk of death or congestive heart failure even after valve replacement. The goals of operative intervention in valve disease are to (1) decrease or diminish symptomatology and thus to improve the quality of life for the patient; (2) prevent “catastrophes” or problems that are irreversible, such as myocardial infarction, left ventricular (LV) fibrosis, decreasing myocardial contractility, thromboemboli, and sudden death; and (3) prolong life. There is little doubt that the first goal is achievable, that of decreasing symptomatology. Every study reported of aortic valve replacement succeeds in that goal. If the patient survives, the chances of improvement in symptoms and functional classification are excellent. Success of the third goal, that of prolonging life, is difficult to prove. The problem is that the mortality rate in patients with aortic regurgitation, especially those who are asymptomatic or only mildly symptomatic, is very low, and it would take large numbers of patients followed for a long period of time to randomize for study. This is not likely to be done. To randomize patients who are symptomatic would be unethical because surgery would improve the quality of life, even if it did not prolong survival. Consequently, the most difficult task for the cardiologist who is following an asymptomatic or minimally symptomatic patient with moderate to severe aortic regurgitation is to choose which parameters …

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Remarkable advances in surgical and catheter management of congenital heart disease (CHD) over the last half century have allowed greater than 85% of children with CHD to survive to adulthood ([1][1]). It is estimated that there are now over 1 million adult survivors with CHD in North America alone

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of unstable angina and non–ST-segment elevation myocardial infarction (UA/NSTEMI) were published in September 2000.1 Since then, a number of clinical trials and observational studies have been published or presented that, when taken together, alter significantly the recommendations made in that document. Therefore, the ACC/AHA Committee on the Management of Patients With Unstable Angina, with the concurrence of the ACC/AHA Task Force on Practice Guidelines, revised these guidelines. These revisions were prepared in December 2001, reviewed and approved, and then published on the ACC World Wide Web site (www.acc.org) and AHA World Wide Web site (www.americanheart.org) on March 15, 2002. The present article describes these revisions and provides further updates in this rapidly moving field. Minor clarifications in the wording of three recommendations that now appear differently from those that were previously published on the ACC and AHA Web sites are noted in footnotes. The ACC/AHA classifications I, II, and III are used to summarize indications as follows: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of …

Reprinted with permission. Cheitlin MD, Gerstenblith G, and colleagues. Do Existing Databases Answer Clinical Questions about …

A. Organization of Committee and Evidence Review The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Ischemic heart disease is the single leading cause of death in the United States. The most common manifestation of this disease is chronic stable angina. Recognizing the importance of the management of this common entity and the absence of national clinical practice guidelines in this area, the task force formed the Committee on Management of Patients With Chronic Stable Angina to develop guidelines for the management of stable angina. Because this problem is frequently encountered in the practice of internal medicine, the task force invited the American College of Physicians–American Society of Internal Medicine (ACP–ASIM) to serve as a partner in this effort by identifying 3 general internists to serve on the committee. The guidelines are arbitrarily divided into 4 sections: diagnosis, risk stratification, treatment, and patient follow-up. Experienced clinicians will quickly recognize that the distinctions between these sections may be arbitrary and unrealistic for individual patients. However, for most clinical decision making, these divisions are helpful and facilitate the presentation and analysis of the available evidence. Detailed evidence was developed whenever possible. The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials involving large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials involving small numbers of patients or careful analyses of nonrandomized studies or observational regis-tries. A low rank (C) was given when expert consensus was the primary basis for the recommendation. The customary ACC/AHA classifications I, II, and III are used in tables that summarize both the evidence and expert opinion and provide final recommendations for both patient …

This document revises and updates the original “Guidelines for Coronary Angiography,” published in 1987. This executive summary and recommendations appears in the May 4, 1999, issue of Circulation . The guidelines in their entirety, including the American College of Cardiology/American Heart Association (ACC/AHA) class I, II, and III recommendations, are published in the May 1999 issue of the Journal of the American College of Cardiology . Reprints of both the full text and executive summary and recommendations are available from both organizations. The frequent and still growing use of coronary angiography, its relatively high costs, its inherent risks, and the ongoing evolution of its indications provide the reasons for this revision. The committee appointed to develop this document included private practitioners and academicians who were selected to represent both experts in coronary angiography and senior clinician consultants. Representatives from the family practice and internal medicine professions were also included on the committee. In addition to reviewing the original document, the committee conducted a search of the literature for the 10 years preceding development of these guidelines. Evidence was compiled and ranked by the committee. Whereas randomized trials are often available for reference in the development of treatment guidelines, randomized trials regarding the use of diagnostic procedures such as coronary angiography are rarely available. This document uses the ACC/AHA classifications of class I, II, and III. These classes summarize the indications for coronary angiography as follows: Class I: Conditions for which there is evidence and/or general agreement that this procedure is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure. Class IIa: Weight of evidence/opinion is in favor of usefulness/ efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there …

Autoregulatory mechanisms ensure relatively small fluctuations of blood pressure with postural changes in healthy people. Although orthostatic hypotension is well recognized and commonly encountered, there are only a few reports of orthostatic hypertension. Most of the reported cases of orthostatic hypertension were related to excessive venous pooling, with an initial drop in cardiac output followed by overcompensation with an excessive release of catecholamines, or to nephroptosis with orthostatic activation of the renin-angiotensin system. We describe a 44-year-old woman with normal supine blood pressure and severe orthostatic hypertension who did not demonstrate an initial decrease in cardiac output and had normal plasma and urinary catecholamines and renin release. Pharmacological tests of autonomic nervous system function showed an increased pressor sensitivity to norepinephrine (11 to 14 times normal), normal sensitivity to isoproterenol, diminished baroreceptor reflex sensitivity, and exquisite sensitivity to α-adrenergic blockers. This unusual case of orthostatic hypertension appears to be secondary to vascular adrenergic hypersensitivity.

Background Although pericardial effusion is known to be common among patients infected with HIV, the incidence of pericardial effusion and its relation to survival have never been described. Methods and Results To evaluate the incidence of pericardial effusion and its relation to mortality in HIV-positive subjects, 601 echocardiograms were performed on 231 subjects recruited over a 5-year period (inception cohort: 59 subjects with asymptomatic HIV, 62 subjects with AIDS-related complex, and 74 subjects with AIDS; 21 HIV-negative healthy gay men; and 15 subjects with non-HIV end-stage medical illness). Echocardiograms were performed every 3 to 6 months (82% had follow-up studies). Sixteen subjects were diagnosed with effusions (prevalence of effusion for AIDS subjects entering the study was 5%). Thirteen subjects developed effusions during follow-up; 12 of these were subjects with AIDS (incidence, 11%/y). The majority of effusions (80%) were small and asymptomatic. The survival of AIDS subjects with effusions was significantly shorter (36% at 6 months) than survival for AIDS subjects without effusions (93% at 6 months). This shortened survival remained significant (relative risk, 2.2, P =.01) after adjustment for lead time bias and was independent of CD4 count and albumin level. Conclusions There is a high incidence of pericardial effusion in patients with AIDS, and the presence of an effusion is associated with shortened survival. The development of an effusion in the setting of HIV infection suggests end-stage HIV disease (AIDS).

Objectives. This study sought to determine the impact of acute aortic regurgitation on coronary blood flow reserve and phasic epicardial coronary blood flow in closed-chest dogs. Background. Hemodynamic changes in acute aortic regurgitation are known to precipitate myocardial ischemia. Coronary blood flow reserve has not been studied in closed-chest experimental preparations with acute aortic regurgitation. Methods. Graded temporary acute aortic regurgitation was produced in 11 mongrel dogs. Phasic coronary blood How velocities were measured using a Doppler guide wire. Coronary flow reserve was defined as the ratio of the time average of spectral peak velocity after administration of papaverine to that of the baseline state. Results. Under control conditions (mean [±SEM]diastolic blood pressure 82.2 ± 4.5 mm Hg), coronary flow reserve was 3.51 ± 0.27 with predominantly diastolic epicardial coronary blood flow. With mild acute aortic regurgitation (diastolic blood pressure 61.8 ± 3.0 mm Hg), coronary flow reserve decreased to 2.38 ± 0.27, with an increase in phasic systolic epicardial coronary blood flow. At the onset of moderate acute aortic regurgitation (diastolic blood pressure 42.1 ± 0.9 mm Hg), coronary flow reserve declined further to 1.46 ± 0.12, and the phasic systolic epicardial coronary blood flow became more prominent. With severe aortic regurgitation (diastolic blood pressure 29.2 ± 2.2 mm Hg), coronary flow reserve reached 1.20 ± 0.05, and the phasic epicardial coronary blood flow pattern was found to be predominantly systolic with retrograde diastolic flow. The ratio of diastolic to systolic pressure-time indexes with severe aortic regurgitation suggested subendocardial underperfusion. Conclusions. This study demonstrates a marked decline in coronary blood flow reserve and documents a progressive change in the phasic epicardial blood flow to a predominantly systolic pattern with increasing degrees of acute aortic regurgitation.

It is becoming more apparent each day that despite a strong national commitment to excellence in health care, the resources and personnel are finite. It is therefore appropriate that the medical profession examine the impact of developing technology and new therapeutic modalities on the practice of cardiology. Such analysis, carefully conducted, could potentially affect the cost of medical care without diminishing the effectiveness of that care. To this end, the American College of Cardiology and the American Heart Association in 1980 established a Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures with the following charge: The Task Force of the American College of Cardiology and the American Heart Association shall develop guidelines relative to the role of new therapeutic approaches and of specific noninvasive and invasive procedures in the diagnosis and management of cardiovascular disease. The Task Force shall address, when appropriate, the contribution, uniqueness, sensitivity, specificity, indications, contra-indications and cost-effectiveness of such diagnostic procedures and therapeutic modalities. The Task Force shall emphasize the role and values of the developed guidelines as an educational resource. The Task Force shall include a Chairman and six members, three representatives from the American Heart Association and three representatives from the American College of Cardiology. The Task Force may select ad hoc members as needed upon the approval of the Presidents of both organizations. Recommendations of the Task Force are forwarded to the President of each organization.

Aortic distensibility decreases with increasing age. Patients with chronic aortic regurgitation eject a large stroke volume into the proximal aorta. A decrease in distensibility of the aorta may impose a higher afterload on the left ventricule and may contribute to deterioration of left ventricular function over time. Accordingly, aortic distensibility was measured in 33 patients aged 13 to 73 years who had chronic isolated aortic regurgitation with minimal or no symptoms. Ascending aortic diameter was measured 4 cm above the aortic valve by two-dimensional echocardiography and pulse pressure was measured simultaneously by sphygmomanometry. Aortic distensibility was calculated as (Change in aortic diameter between systole and diastole/End-diastolic diameter)/Pulse pressure. Left ventricular systolic wall stress and mass were derived from standard M-mode echocardiographic measurements. Left ventricular volumes and ejection fraction were measured by radionuclide ventriculography. Aortic distensibility decreased logarithmically with increasing age (r = -0.62, p less than 0.001) and also correlated inversely with systolic wall stress, left ventricular mass and end-diastolic volume. Patients who eventually underwent aortic valve replacement for symptoms of left ventricular dysfunction had significantly lower aortic distensibility than did those who did not yet require valve replacement: 0.09 +/- 0.08 vs. 0.22 +/- 0.19 x 1/100 (1/mm Hg) (p less than 0.05). Thus, the reduced aortic distensibility that occurs with increasing age may contribute to the gradual left ventricular dilation and dysfunction seen in patients with chronic aortic regurgitation.

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended. (c) 2005 Elsevier Inc. All rights reserved.

To assess the prognostic importance of resting left ventricular function in survivors of acute myocardial infarction with pulmonary edema, we retrospectively identified 39 consecutive patients who presented with acute pulmonary edema and myocardial infarction. Sixteen patients had radionuclide ejection fractions 10 +/- 2 days postinfarction of greater than 0.45 (group A, mean 0.55 +/- 0.06), and 23 patients had ejection fractions less than or equal to 0.45 (group B, 0.32 +/- 0.06). There were no significant differences between the two groups for age or sex, but group A patients had a significantly greater incidence of first myocardial infarction predominantly inferior in location. The calculated stroke work index during the acute event was significantly greater in group A than in group B (33.4 +/- 2.4 vs 23.4 +/- 2.0) (p less than 0.05). During a follow-up of 9 +/- 3 months, mortality was not significantly different between the two groups: Four (25%) died in group A and seven (30%) died in group B. In addition, eight patients (50%) in group A were hospitalized for recurrent angina, new myocardial infarction or recurrent pulmonary edema, compared with 11 (48%) in group B (NS). Three deaths in group A were preceded by infarction of the anterior wall of the left ventricle, confirmed at autopsy, and two nonfatal infarctions were anterior by electrocardiography. Four patients in group A had coronary arteriography performed during the follow-up period because of unstable angina, and all had significant (greater than or equal to 70% stenosis) three-vessel disease and two had left main coronary artery disease. Therefore, the predischarge ejection fraction did not predict prognosis for this group of patients. Patients with acute pulmonary edema in the course of myocardial infarction form a high-risk group despite good resting left ventricular function at discharge. They have a significant incidence of recurrent myocardial infarction and death and, because they have good residual left ventricular function, are excellent candidates for surgical intervention.