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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.

After hypertrophic cardiomyopathy, coronary artery anomalies of origin from the wrong sinus of Valsalva are the second most common cause of sudden death on the athletic field in the USA. Although the right coronary artery arising from the left coronary sinus (ARCA) is four times as common as the left coronary artery arising from the anterior sinus (ALCA), it is the latter that is by far the more common cause of sudden death with or shortly after vigorous physical activity. Of the four types of ALCA, the interarterial type, where the left coronary artery passes anteriorly between the aorta and the right ventricular outflow tract, is the only type that places the patient at risk of sudden death. Another feature of this syndrome is the fact that sudden death occurs associated with or shortly after vigorous exercise and is very unusual after the patient is > 35 years of age. The mechanism by which there is sudden occlusion of the interarterial coronary artery is at present unknown, although there are a number of hypotheses involving the oblique passage of the vessel as it leaves the aorta. Sudden death is probably rare considering the number of people who have these anomalies. Symptoms premonitory to a fatal event such as exertional syncope, chest pain, or palpitations are probably common in patients at risk, and surgical correction is indicated in symptomatic patients at any age. In older asymptomatic patients, surgery is not recommended, since the incidence of sudden death in this age group is extremely small. In asymptomatic young patients, a stress test, preferably with radioisotope myocardial perfusion imaging or stress echocardiogram, should be done and surgical correction performed in those with ischemia provoked in the appropriate myocardial region. Since there is evidence that in patients who have survived a potentially fatal event, it is rare to be able to provoke ischemia with equal or greater exercise than had precipitated the malignant arrhythmia, the decision to surgically correct an asymptomatic young patient, serendipitously found to have ALCA, who has a negative exercise test, is debatable. Any decision for surgery in such patients should be made only after a full discussion of the risks pro and con surgery with the patient and the patient's family.

Sildenafil citrate (Viagra; Pfizer Inc, New York, NY) relaxes vascular smooth muscle, resulting in modest reductions in blood pressure that are insufficient to stimulate a reflex increase in heart rate. These blood pressure reductions are similar for healthy men and men with coronary artery disease (CAD) or who use antihypertensive drugs. Sildenafil does not affect the force of cardiac contraction, and cardiac performance is unaffected. Sildenafil is mildly vasodilating in the coronary circulation and does not increase the risk of ventricular arrhythmia. During exercise and recovery, sildenafil does not cause clinically significant alterations in hemodynamic parameters in men with CAD, and it has no negative effects on coronary oxygen consumption, ischemia, or exercise capacity. Clinical trial data from >13,000 patients, 7 years of international postmarketing data, and observational studies of >28,000 men in the United Kingdom and 3813 men in the European Union reveal that (1) there are no special cardiovascular concerns when sildenafil is used in accordance with product labeling and (2) the risk for serious events such as myocardial infarction or death is not increased. However, because safety has not been established in patients with recent serious cardiovascular events, hypotension or uncontrolled hypertension, or retinitis pigmentosa, physicians should consult their current local prescribing information before prescribing sildenafil for these patients. Among men with erectile dysfunction treated with sildenafil, the adverse event profile is similar overall to that in men with comorbid cardiovascular disease (CVD), it is similar between those with and without CAD, and it is similar between those who take and those who do not take antihypertensive drugs (regardless of the number or class). In a controlled interaction study of sildenafil and amlodipine, the mean additional reduction in supine blood pressure was 8 mm Hg systolic and 7 mm Hg diastolic. Sildenafil should be used with caution in patients who take alpha-blockers because coadministration may lead to symptomatic hypotension in some individuals. When sildenafil is coadministered with an alpha-blocker, patients should be stable on alpha-blocker therapy before initiating sildenafil treatment and sildenafil should be initiated at the lowest dose. Also, in the absence of information specific to mixed alpha/beta blockers, such as carvedilol and labetalol, similar care should be taken as for alpha-blockers. Sildenafil potentiates the hypotensive effects of nitrates, and its administration to patients who are using organic nitrates in any form, either regularly or intermittently, is contraindicated. Before prescribing sildenafil, physicians should carefully consider whether their patients with underlying CVD could be affected adversely by resuming sexual activity. Management recommendations based on cardiovascular risk, from the Second Princeton Consensus Conference, are presented.

Endothelial dysfunction underlies both atherosclerosis and erectile dysfunction (ED). Therefore, the incidence of coronary artery disease (CAD) is inevitably increased in patients with ED. Patients with ED, who are typically unable to develop or maintain an erection, are able to engage in sexual activity when treated with phosphodiesterase 5 inhibitors. Acute coronary syndromes and cardiac sudden death are precipitated by either vulnerable plaque erosion or rupture, or by the development of sudden myocardial ischemia. The physical activity of sexual intercourse is associated with increased myocardial oxygen demand (MVo(2)) and increased sympathetic nervous system activation, both of which can result in myocardial ischemia in the presence of CAD. The effect of sexual activity on total body oxygen consumption (Vo(2)) and MVo(2) has been studied in the past, but not extensively. Available research shows that sexual intercourse increases Vo(2) to a modest extent. As studied, Vo(2) is increased modestly to 3 to 5 metabolic equivalents. Further, this increase in Vo(2) lasts only for a brief period. The small increase in the incidence of myocardial infarction that accompanies sexual activity within 2 hours of onset is likely related to sympathetic activation and to an increase in MVo(2). The evidence for this hypothesis is reviewed in this article.

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

Cardiovascular disease and erectile dysfunction (ED) are frequently comorbid. Therefore, it is important to consider the risk of renewed sexual activity after successful treatment of ED in men with cardiovascular disease. This article reviews the limited existing knowledge of the metabolic and cardiovascular demands of sexual activity. Evidence suggests that there is a small increase in cardiovascular risk related to sexual activity. Overall, however, the metabolic and cardiovascular demands of sexual activity are modest, and regular physical activity can almost eliminate the increase in risk occurring during sex. In addition, it is unlikely that any direct effect of a phosphodiesterase 5 inhibitor increases cardiovascular risk in patients with cardiovascular disease, absent the coadministration of organic nitrates.

Robert A. Kloner, MD, PhD (Los Angeles, California, USA): In his editorial comment on an article by Morales et al, in 1998, Dr. Francesco Montorsi was referring to sildenafil when it arrived on the market, but his point is still relevant. Many clinicians—specialists and generalists alike—will have to become familiar with a new class of agents generally termed phosphodiesterase 5 (PDE5) inhibitors. Accordingly, we convened a group of clinicians representing several specialties to discuss the implications of these agents. This roundtable includes the views of 3 cardiologists (Drs. Brindis, Cheitlin, and myself), 2 primary care physicians (Drs. Kuritzky and Miller), 1 urologist (Dr. Padma-Nathan), and 1 psychologist (Dr. Rosen).

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 …

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

Aortic stenosis in the elderly is related to calcification of either a bicuspid valve or a morphologically normal tricuspid valve. There is increasing evidence that factors relating to atherosclerosis are involved in valvular calcification and that it is an actively regulated process rather than a degenerative one. With severe aortic stenosis left ventricular hypertrophy occurs, decreasing wall stress and supporting the left ventricular ejection fraction. However, with pathologic hypertrophy there is a dropout of myocardial cells, subendocardial ischemia, and fibrosis. Eventually, symptoms of angina, non-Q wave myocardial infarction, exertional syncope, and heart failure occur. Once symptoms begin, the prognosis is poor, with sudden death occurring in about one third of patients who die. In the elderly, symptoms can be recognized very late in the course of the disease since they can be attributed to other problems and since the elderly patient may have reduced physical activity to a minimum. The more comorbidities that exist, the greater the risk of valve replacement. Symptomatic patients with severe aortic stenosis even over age 80 can be operated upon with a relatively low mortality and morbidity. In patients over age 80, prolongation of life for any meaningful length of time is not as important as relief of symptoms and improvement in the quality of life. Thus, it is unlikely that any truly asymptomatic patient over age 80, even with severe aortic stenosis, should be sent to surgery.

Executive summary Most randomized, controlled trials evaluating the effectiveness of pharmaceutical, surgical, and device interventions for the prevention and treatment of cardiovascular disease have excluded patients over 75 years of age. Consequently, the use of these therapies in the older population is based on extrapolation of safety and effectiveness data obtained from younger patients. However, there are many registries and observational databases that contain large amounts of data on patients 75 years of age and older, as well as on younger patients. Although conclusions from such data are limited, it is possible to define the characteristics of patients who did well and those who did poorly. The goal of this conference was to convene the principal investigators of these databases, and others in the field of geriatric cardiology, to address questions relating to the safety and effectiveness of treatment interventions for several cardiovascular conditions in the elderly. Seven committees discussed the following topics: I. Risk Factor Modification in the Elderly II. Chronic Heart Failure III. Chronic Coronary Artery Disease: Role of Revacularization IV. Acute Myocardial Infarction V. Valve Surgery in the Elderly VI. Electrophysiology, Pacemaker, and Automatic Internal Cardioverter Defibrillators Databases VII. VII. Carotid Endarterectomy in the Elderly The chairs of these committees were asked to invite principal investigators of key databases in each of these areas to discuss and prepare a written statement concerning the available safety and efficacy data regarding interventions for these conditions and to identify and prioritize areas for future study. The ultimate goal is to stimulate further collaborative outcomes research in the elderly so as to place the treatment of cardiovascular disease on a more scientific basis.

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 incidence and severity of coronary artery disease increase with age. Because the mortality and morbidity of patients over the age of 70 are higher than those for younger patients, many earlier studies comparing the effectiveness of bypass surgery to medical management deliberately excluded patients over the age of 65. Presently, however, there are many reports on the morbidity and mortality of patients having coronary bypass sugery who are over the age of 65 and 70 and even in some reports, over the age of 80. Compared with younger patients, the elderly have more severe disease, frequent comorbidity, and a slightly higher perioperative mortality and morbidity. In properly selected patients, that is patients in whom the major problem is the coronary artery disease and not multisystem failure, the benefit from coronary artery bypass surgery as far as relief of angina and improvement of physical activity is concerned is equal to the benefit that younger patients experience. Unlike younger patients, in patients over 75 years of age, the goal of surgery is not necessarily to prolong life, although in the appropriate patients this probably occurs, but to decrease or eliminate angina and return the patient to more normal activity and a better quality of life.

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

To investigate whether serial incremental continuous positive airway pressure (CPAP) has any short-term or long-term advantages over face-mask oxygen therapy by way of intrapulmonary shunt reduction, 100 patients admitted to the coronary care unit for the treatment of acute cardiogenic pulmonary edema were studied. All patients received Swan-Ganz catheterization. Hemodynamic and pulmonary function parameters were recorded over the next 6 h, and the patients were followed until hospital discharge. All survivors received regular follow-up at 1-month intervals in the outpatient clinic. During the first-stage investigation period (3 h) PaO 2 in the CPAP group showed a significant increase, whereas the intrapulmonary shunt and alveolar-arterial oxygen tension gradient (P[A-a]O 2 ) was significantly reduced (p

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.

A72-YEAR-OLD MAN WITH SYSTOLIC HEART failure (left ventricular ejection fraction, 20%) and hypertension was admitted to the hospital with 2 weeks of dyspnea at rest and a 20-lb weight gain. He reported good compliance with his outpatient regimen of lisinopril, carvedilol, spironolactone, and furosemide. Findingsfromphysicalexaminationwerenotableforablood pressure of 95/40 mm Hg and heart rate of 105 beats/ min, elevated jugular venous pressure, diffuse crackles in the lung fields, an S3 gallop, and warm extremities. The patient was admitted to the cardiac intensive care unitandadministeredintravenousfurosemide,withanet diuresis of 2 L overnight. Thenexthospitalday,thepatient’screatininelevelhad increasedfrom0.8to1.4mg/dL,buthisdyspneahadimproved. He had persistent crackles bilaterally and an S3 galloponauscultation.Concernforworseningrenalfunction prompted right heart catheterization for continuoushemodynamicmonitoring.Apulmonaryarterycatheterwasplacedintheintensivecareunitusingultrasound guidancethroughtherightinternaljugularvein.Theprocedure was uncomplicated and confirmed elevated left and right heart filling pressures. Diuresis was continued; isosorbide and hydralazine therapies were added to decrease his systemic vascular resistance.

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)

In brief Athletes who have heart symptoms need the same type of evaluation as nonathletes who have such symptoms, except that the evaluation generally should include testing during exercise. In history taking, be aware that an athlete may try to minimize heart symptoms in an effort to avoid restrictions on participation. Syncope and related symptoms are Important in that they may reflect an arrhythmia caused by a potentially fatal condition. Syncope or near syncope also may be caused by cat- echolamine-dependent tachycardia, which usually responds to treatment with β-blockers.

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.

In a world that is faster-paced, the frequency with which the physician sees cardiac trauma has increased. This article discusses the mechanisms of injury and classification, immediate evaluation and treatment, diagnosis and therapy for specific injuries, great vessel trauma, and other types of injury.

Electrocardiographic abnormalities develop in patients with chronic aortic regurgitation (AR). Although vasodilator drugs may reduce left ventricular (LV) volume overload, the effects of such therapy on electrocardiographic abnormalities have not been previously evaluated. Accordingly, electrocardiograms were analyzed before and after double-blind, randomized administration of either hydralazine or placebo in 54 patients with chronic AR. These patients were without limiting symptoms and had preserved ejection fraction on entry in the study. The magnitude of ST-segment depression and Romhilt-Estes point score for LV hypertrophy were assessed. Baseline ST depression and LV hypertrophy scores in the placebo and hydralazine groups were not significantly different. At follow-up, after a mean of 19 ± 6 months, there was a significant reduction in ST depression in patients taking hydralazine (n = 28) compared with patients given placebo (n = 26): −0.023 ± 0.044 vs 0.029 ± 0.055 mV, respectively (p = 0.0001); and in the LV hypertrophy score (−1.1 ± 2.2 vs 0.9 ± 2.3 points, respectively; p = 0.002). Hydralazine-treated patients also had significant decreases in LV end-diastolic and end-systolic volume indexes, and a significant increase in ejection fraction. These results suggest that such vasodilator therapy may be beneficial in patients with chronic AR.

Potassium-sparing diuretics have been reported to decrease the positive inotropic effect of digoxin. We studied the hemodynamic effects of amiloride in patients taking digoxin for chronic heart failure. Eleven men with a history of congestive heart failure were studied in a double blind, cross-over, placebo controlled trial with the patients on digoxin alternating placebo with amiloride. After 7 days on the trial drug, a Swan-Ganz catheter was placed in the pulmonary artery and measurements made at rest and with increasing degrees of supine bicycle exercise. Right-sided and pulmonary artery wedge pressures and systemic arterial pressures, as well as cardiac outputs, were measured. After a 7 day washout period, placebo (P) and Amiloride (A) were switched and after 7 days on the therapy, a second hemodynamic study at rest and varying degrees of supine bicycle exercise was repeated. At rest there were no significant differences in the right-sided, pulmonary arterial wedge pressure or cardiac outputs between the patients on Amiloride (A) versus placebo (P). During exercise there were significant differences between (P) and (A) at the 50 watt-second stage of exercise.(ABSTRACT TRUNCATED AT 250 WORDS)