Bøger i Developments in Cardiovascular Medicine serien

The most salient feature of the infor- last four chapters of the book evaluate the mation provided by nuclear medicine is its information from an analytical and pathophysiological and functional charac- statistical point of view. This approach is ter. For adequate experimental or clinical required for correct decision-making. interpretation, such information should This book is therefore the result of necessarily be interpreted alongside the accumulated experience in nuclear cardiology views of the clinical cardiologist, who is with the invaluable cooperation of medical able to apply it to the individual patient. statisticians. It is directed to physicians This approach, which is routine in every- with an interest in nuclear cardiology, to day clinical practice, reaches its plenitude nuclear medicine specialists wishing to when the whole process is completed and learn the uses and limitations of these an intimate cooperation is established procedures in everyday clinical cardiology, between the nuclear medicine specialist and to cardiologists who feel the need to and the clinical cardiologist. In such understand the rationale and methodology instances, each one of these professionals of the studies which benefit their patients. understands the needs, limits and possi- We understand that the ultimate reason bilities of the other. for any scientific book is the transmission The present book is the fruit of such of knowledge, and we are fully conscious cooperation. In our hospital, an efficient of the enthusiasm of the authors of the nuclear cardiology team has been made up present text to achieve that aim.

The molecular basis for atrial fibrillation continues to be largely unknown, and therapy remains unchanged, aimed at controlling the heart rate and preventing systemic emboli with anticoagulation. Familial atrial fibrillation is more common than previously suspected. While atrial fibrillation is commonly associated with acquired heart disease, a significant proportion of individuals have early onset without other forms of heart disease, referred to as "e;lone"e; atrial fibrillators. It is also well recognized that atrial fibrillation occurs on a reversible or functional basis, without associated structural heart disease, such as with hyperthyroidism or of atrial fibrillation following surgery. It remains to be determined what percentage in these individuals is familial or due to a genetic predisposition. Mapping the locus for familial atrial fibrillation is the first step towards the identification of the gene. Isolation of the gene and subsequent identification of the responsible molecular genetic defect should provide a point of entry into the mechanism responsible for the familial form and the common acquired forms of the disease and eventually provide more effective therapy. We know that the ionic currents responsible for the action potential of the atrium is due to multiple channel proteins as is electrical conduction throughout the atria. Analogous to the ongoing genetic studies in patients with familial long QT syndrome, it is highly likely that defects in each of these channel proteins will be manifested in familial atrial fibrillation.

By the time a man gets well into his seventies, his continued existence is a mere miracle. -Robert Louis Stevenson It hardly seems possible that a second edition is needed after the first has been in print for only three years. However, when I reflect on what has happened in geriatric cardiology during that short period, it becomes obvious why. First, cardiologists all over the globe have begun to realize that geriatric cardiology has evolved into a science and a clinical discipline of its own. Although some of us may consider such subspecialization unfortunate, it has become clear that a variety of cardiac disorders present with different symptoms and signs, require a different diagnostic and therapeutic approach, and have a different prognostic outlook in the elderly when compared to middle-aged patients. Since the aging segment of the population has increased dramatically over the past few decades, and continues to do so, specific age-related disorders are more frequently encountered by the practicing physician, be it by the general practitioner, by the internist, or by a cardiologist. Cardiovascular Disease in the Elderly provides an up-to-date guide to help the physician deal with these problems, leading the way in what turns out to be an increasingly complex area. Second, I have been heartened by the warm reception of the first edition and by the excellent reviews that it got in the most prestigious medical journals.

Most of the progress in cardiac energetics in recent years has been spurred by the pressure-volume area concept, the natural extension into energetics of earlier pioneering work delineating the time-varying elastance framework for ventricular contraction. The book draws together a broad spectrum of researchers - basic, applied and clinical - having a shared interest in the energetics of cardiac muscle and ventricle, providing an overview of the current state of the art.

Teleologically, the hemostatic mechanism is among The of Coronary Thrombosis and the most fundamental yet complex physiologic pro- in essence, represents a heartfelt gift of cesses in humans. Early scientists and physicians were knowledge from a dedicated group of scientists and fascinated by the blood's ability to remain in a liquid clinicians, who collectively have set out on a mission state only to clot in response to vascular injury. The to minimize the societal impact of"e;hemostasis in the cellular and noncellular components of normal wrong place. "e; The book is divided into four distinct hemostasis took centuries to discover, and the intrica- sections: Part 1, Scientific Principles, lays down the cies of their delicate interactions are still being unrav- supporting foundation; Part 2, Clinical Application eled today. As is so often the case, an in-depth of Scientific Principles, places the knowledge base in appreciation of physiologic hemostasis, representing a a working perspective, directly applying science to basic life-sustaining sequence of events, paved the patient care; Part 3, New Dimensions, provides a way for understanding abnormal hemostasis or glimpse of tomorrow. Steering the field clear of se- pathologic thrombosis. Aristotle, Malpighi, and proclaimed victory and the dangers of complacency as Osier, representing but a few of the founding fathers we move into the 21st century, Part 4, Evolution of in the field, would undoubtedly be honored to see Thrombocardiology, focuses on laboratory standards, their observations form the template for lifesaving clinical trials, and drugs in development.

Heart Hypertrophy and Failure brings together leading basic scientists and clinicians, presenting improved knowledge of the pathophysiology and treatment of the condition. The result is a synthesis of state-of-the-art information on molecular biology, cellular physiology and structure-function relationships in the cardiovascular system in health and disease. The papers presented describe fundamental mechanisms underlying changes in the cellular machinery during the development of cardiac hypertrophy and heart failure. Audience: Students, scientists, clinical and experimental cardiologists who seek to understand and manage the perplexing problems of hypertrophy and heart failure.

Sir Dominic Corrigan's classic monograph "e;On Permanent Patency of the Mouth of the Aorta, or Inadequacy of the Aortic Valves"e; was published in 1832. Descriptions of aortic regurgitation had previously been published by others, but Corrigan's contribution was so comprehensive that his name is still closely associated with this disorder. He described the physical findings and the underlying gross pathologic anatomy of aortic regurgitation. He recognized that sudden death was not characteristic of aortic regurgitation, as it was in aortic stenosis, and his therapeutic approach was based on firm physiologic principles. In the past 150 years we have expanded Corrigan's work, and we have developed a detailed appreciation of the natural history, pathophysiology, diagnostic methods, and treatment of chronic aortic regurgitation. Fifteen years ago, cardiac catheterization and angiography had already achieved widespread application in the evaluation of aortic regurgitation, but cardiac ultrasound, especially Doppler echocardiography, was in its infancy, and the utility of radionuclide ventriculography was not widely appreciated.

Some 25 years ago, the coronary care unit concentrated high technology and the acutely ill patients who might benefit from it in a single, recognizable space. Since then, that space and its technical equipment have changed, as has part of its population. Acute ischemia, silent and manifest, occurs within and outside of the coronary care unit as pain, arrhythmia, or pump failure. Its detection and treatment require the utilization of many diagnostic techniques and skills, not the least of which is two-dimensional Doppler echocardio- graphy, which is gaining importance. Future developments, in tandem with computer technology, may add to this importance by enabling tissue identification, spatial representation, and Doppler flow mapping. This book describes the state of the art for the practicing clinician using Doppler echocardi?graphy at the bedside of patients with acute ischemic manifestations of coronary heart disease. The first requirement is to move from the echo laboratory to the coronary care unit, emergency department, operating room, or catheterization laboratory, using equipment suited for that purpose. The second, more trying imperative is to secure good cooper- Ition between those treating the acutely ill patient and the investigator who interferes with his probes. If successful ceeding in both, rewarding results can be obtained, since echocardiography is a very sensitive and specific tool for recognizing and quantifying early ischemia.

The field of electrocardiography is at a cross- roads. We have reached an era in cardiovascular about the electrical state of the heart not likely to be available in any other imaging techniques. medicine where it is claimed that "e;imaging"e; is king. The innovative and useful ultrasound And, in the body surface potential map, we have an imaging technique that goes beyond struc- techniques continue to develop, and, in the wings lie magnetic resonance, position emission, ture-the only other being, perhaps, magnetic resonance, which has the potential for metabolic and, perhaps, other modalities. Consequently, there are those who state that, other than the imaging. Clinical electrocardiography is impor- problems related to cardiac rhythm, electro- tant not only as a diagnostic tool for it can truly cardiography as a discipline is passe. In addi- give insight into the effect of the disease in question on the heart muscle itself. tion, although there is continued superb work in the basic science related to arrhythmias, only Therefore, it seemed now to be appropriate to a handful of scientists are interested in the bring together leaders in the various fields of myocardial source per se. And few scientists are electrocardiography with the only constraint interested in what happens to that myocardial being a concentration on newer concepts and electrical source on its trip from the endo- ideas.

It has been known or suspected for centuries that there is an association between mind and emotions and the occurrence of heart disease apd sudden death. During the past fifty years this relationship has become identified with the concept of Stress, a notion developed and popularized by Hans Selye. In recent years there has been an upward surge of interest in stress by scientists in several disciplines and by the general public. Although, books, journal articles, seminars and media programs devoted to stress now abound, the definition, manifestations, mechanisms, and management of stress remain uncertain and controversial. In an attempt to clarify the situation an International Symposium on Stress and Heart Disease was held in Winnipeg, Canada, June 26-29, 1984, and the proceedings form the basis of this book and its companion volume "e;Patho- genesis of Stress-Induced Heart Disease"e;. Although most species which have ever existed are now extinct through countless millenia, the human species has successfully adapted to changing conditions ("e;stressors"e;) such as ice ages, predators and parasites, wars, famine and plague, and now it is coping with rapidly changing social, economic and political circumstances. Such adaptation occurs at all levels of life- at the molecular level within the cell, at the level of the whole cell, in the groups of cells as organs, in the entire organism or individual, and in some cases, in the society in which the individual lives.

To our knowledge, this is the first book dealing exclusively with myocardial contrast two-dimensional echocardiography (MC-2DE), a new and exciting diagnostic methodology for assessment of myocardial perfusion, which has seen rapid development and has now entered the clinical stage. The experi- mental research and human applications have been described in technical papers published in a variety of journals, but our objective is to provide the reader with a comprehensive and concentrated overview of the field and of the current state of the art. To facilitate appreciation of the significant ad- vances made and issues yet to be resolved, we are pleased to have several well known specialists contribute their own assessment of specific aspects of MC- 20E and illustrate the method's principles as well as applications. We were faced with inevitable overlaps and some repetitions in the discussion of quan- titative potentials or limilations of the methodology. Rather than strictly 'streamlining' the text, we decided to accept some redundancy in the interest of presenting a diversity of points of views, reflecting the current evolutionary state of MC-20E. Following a brief reference to the established clinical contrast echocardiog- raphy, recent developments and validations of the specialized MC-2DE tech- nique are reviewed, bearing in mind that the field is in a flux and some of the ongoing activities have not as yet been formally reported. Mechanisms of the echo contrast and several new agents are decribed next, and an additional chapter illustrates current thoughts-on optimizing the echo contrast medium.

This volume constitutes the proceedings of a satellite symposium of the XXXth congress of the International Union of Physiological Sciences. The symposium has been held In Banff, Alberta Canada July 9-11 1986. The program was organized to provide a selective overview of current developments in cardiac biophysics, biochemistry, and physiology. In order to highlight areas of develop- ing ideas and to stimulate the participants' inquisitiveness into the nature and complexity of the integrated cardiovascular system, lectures and discussions were presented that emphasized evolving and sometimes provocative concepts in the field. With the same goal in mind we have, for the readers of this volume, briefly summarized the general discussions. We would like to thank several individuals whose dedication made this sym- posium and publication of the proceedings possible. Mrs. Lois Kokoski and Mrs. Madeleine Aldridge of the Conference Office of the University of Calgary seemingly effortlessly handled the details of the symposium. Peter de Tombe, Dr. Peter Backx and Dr. Jeroen Bucx transcribed the general discussions. Finally, we appreciate the extra effort of our secretaries, Lenore Doell and Gregory Douglas, and the work of Anna Tyberg who prepared the final manuscripts for publication. Henk E.D.J. ter Keurs, M.D. Ph.D. John V. Tyberg, M.D. Ph.D.

Cardiac output has always been a subject of interest to both clinicians and researchers in different branches of medicine and surgery. In the last decade more attention has also been paid to its application in pediatrics, neonatology, fetal medicine and pregnancy. Better understanding of the peripheral circulation has provided more insight into the patholophysiology of different diseases. Many cardiac and non-cardiac disorders affect cardiac outputs. Monitoring of the changes in cardiac output is also important in the acutely ill patient. There are several methods to measure cardiac output, each with advantages and pitfalls. This book deals with all relevant aspects of cardiac output in eight parts: part one describes the methods of measuring cardiac output and a comparison between the catheterisation based and the noninvasive techniques, while part two describes the changes in cardiac output due to physiological causes. Part three describes cardiac output in cardiac diseases and systemic hypertension. Cardiac output in acutely ill patients is discussed in part four. Effect of cardiac medications, temporary atrial pacing, permanent pacing, pharmacologic stress testing and anesthesia are covered in detail in part six, while changes in cardiac output in noncardiac diseases are described in part seven. Finally great attention has been paid in part eight to the regional circulation including cerebral, coronary, skeletal and splanchnic circulations. A separate chapter discusses in detail the dynamics of blood flow. This book will be useful both to the cardiologists as well as to physicians in other fields of surgery and medicine and to their trainees. Readers will find this book an interesting and a useful reference on the topic of cardiac output.

Non-Invasive Imaging of Atherosclerosis is a primer, reference and review of some of the key features of current activities in the field of atherosclerosis. The Editors' goal is to provide material and stimulating ideas to basic scientists and clinical researchers in order to extend the application of vascular imaging and to further develop methods suitable for investigation of the arterial wall. The first section presents current knowledge about pathology, vascular mechanics and compensatory mechanisms active during atherogenesis. It explores the early lesion, complications of plaques and early detection of plaques. Section II reviews several key methodological issues of B-mode ultrasound imaging and some of the most current data. Quantitative B-mode ultrasound is an established non-invasive tool widely used in large epidemiologic studies and interventional clinical trials of atherosclerosis. The last section addresses the most promising areas of development in vascular imaging. This involves new techniques to evaluate the atherosclerotic bed, to follow atheroma progression/regression and to evaluate vascular mechanics in atherosclerotic arteries. The last chapter places the application of non-invasive imaging in perspective.