Cardiac Intensive Care, 2nd. Ed.

Cardiac Intensive Care

Second Edition

Allen Jeremias, MD, MScAssistant Professor, Department of Medicine

Director, Vascular Medicine and Peripheral InterventionDivision of Cardiovascular Medicine

SUNY-Stony Brook School of MedicineHealth Sciences CenterStony Brook, New York

David L. Brown, MDProfessor, Department of Medicine

Co-Director, Stony Brook Heart CenterChief, Division of Cardiovascular Medicine

SUNY-Stony Brook School of MedicineHealth Sciences CenterStony Brook, New York

1600 John F. Kennedy Blvd.Ste 1800Philadelphia, PA 19103-2899

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.

The Publisher

CARDIAC INTENSIVE CARE ISBN: 978-1-4160-3773-6Copyright © 2010, by Saunders, an imprint of Elsevier Inc.

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Library of Congress Cataloging-in-Publication Data

Cardiac intensive care / [edited by] Allen Jeremias, David L. Brown. — 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4160-3773-6 1. Cardiac intensive care. I. Jeremias, Allen. II. Brown, David L. (David Lloyd). [DNLM: 1. Heart Diseases—therapy. 2. Intensive Care—methods. WG 166 C263 2010] RC684.C36C37 2010 616.1'2028--dc22 2010000913

Executive Publisher: Natasha AndjelkovicDevelopmental Editor: Bradley McIlwainProject Manager: Jagannathan VaradarajanDesign Direction: Steven StavePublishing Services Manager: Hemamalini Rajendrababu

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

The care of acutely ill cardiac patients has evolved over the past 40 years through a series of landmark developments and milestones. Coronary intensive care began in the 1960s with the introduction of electrocardiogram (ECG) monitoring for patients with acute myocardial infarction (MI). ECG moni-toring coupled with the introduction of antiarrhythmic inter-ventions (cardioversion, defibrillation, and lidocaine) led to a dramatic decrease in the mortality of patients with acute MI, largely through a reduction of in-hospital ventricular dysrhyth-mias. This was the first major milestone in the care of patients with acute MI. At this time, hemodynamic dysfunction and pump failure emerged as the leading causes of death in acute MI.

In the early 1970s, the introduction of bedside pulmonary artery catheterization, by Willie Ganz and Jeremy Swan at the Cedars-Sinai Medical Center, made possible accurate assessment of hemodynamic dysfunction in critically ill cardiac patients. This landmark development spawned a new era of coronary care that led to better assessment and management of pump dysfunction, stimulating the introduction of afterload-reducing therapy for heart failure. Around the same time, the concept of infarct size as a major determinant of ventricular dysfunction and prognosis began in the experimental laboratory, triggering a search for interventions to limit infarct size in experimental animals. The results of various therapies in this regard were in-consistent in the laboratory and in the clinical arena.

The next major milestone came in the late 1970s and early 1980s, when the role of coronary thrombosis as the proximate cause of acute MI became firmly established through the land-mark study of Marcus DeWood, then a trainee in cardiology. With this observation and the elegant early experimental work of many investigators, the importance of timely reperfusion as a powerful method for infarct size limitation was recognized. The focus on reperfusion, initially with intracoronary and subse-quently with intravenous thrombolysis and more recently with primary angioplasty, as a means of reducing infarct size and de-creasing mortality revolutionized contemporary care of patients with developing MI.

This advance represented another major milestone in coro-nary care. All this stepwise progress over the years has led to a substantive and steadily declining mortality for patients with acute MI. The past several years have witnessed an explosion in our knowledge of vascular biology, atherogenesis, plaque disruption and thrombosis, and the concept of acute coronary syndromes. These concepts have led to dramatic improvements in our ability to diagnose and manage patients with unstable an-gina with potent antithrombotic strategies ranging from aspirin and heparin to platelet receptor antagonists and direct thrombin inhibitors to angioplasty and stent implantation.

Throughout this progress, coronary care units evolved from specialized areas catering to patients with acute ischemic syn-dromes to a place where we now take care of the ever-increasing population of patients with other critical cardiovascular ill-nesses, such as acute and severe chronic heart failure, chronic pulmonary hypertension, life-threatening cardiac dysrhythmias, aortic dissection, and other diagnoses. A modern coronary care unit is, in reality, a cardiac intensive care unit.

This second edition of Cardiac Intensive Care, presented in a new full-color design, edited by Allen Jeremias, MD, MSc, and David L. Brown, MD, provides a state-of-the-art compendium summarizing all of the progress that has been made in the di-agnosis, assessment, and treatment of patients with critical car-diac illnesses over the past several years. The 52 chapters and 3 appendices are written by experienced authors who have made important contributions in their respective fields. Nine new chapters have been added in this new edition dealing with topics including quality assurance and improvement, physical exami-nation, mechanical treatments for acute ST segment elevation MI, non–ST segment elevation MI, and management of post–cardiac surgery patients. The convenience of full-text online ac-cess at expertconsult.com is an added bonus.

The editors have captured the essence of what is the state-of-the-art in a rapidly evolving and dynamic field. The contents of this text provide a nice blend of pathophysiology and the more pragmatic issues of actual intensive cardiac care. In addition to dealing in detail with the issues of acute cardiac problems, this text provides a broader perspective by including many useful chapters that deal with critical care issues of a more general na-ture, such as airway and ventilator management, resuscitation, dialysis, and ultrafiltration. The editors and the authors are to be commended for having produced an up-to-date and useful treatise on cardiovascular critical care.

P. K. Shah, MDShapell and Webb Chair and Director

Division of Cardiology and Oppenheimer Atherosclerosis Research Center

Cedars-Sinai Heart InstituteLos Angeles, California

Foreword

vii

Since the publication of the first edition of Cardiac Intensive Care, there have been considerable changes in the level of care and the complexity of therapies provided in the cardiac inten-sive care unit (CICU). To reflect these changes appropriately, the second edition of Cardiac Intensive Care has not only been updated, but also completely restructured with many new chap-ters. Given that most CICU admissions are still related to coro-nary artery disease and its acute manifestations, one major focus of this text remains the diagnosis and therapeutic options for patients with acute coronary syndromes. Section III, Coronary Artery Disease, is divided into Acute Myocardial Infarction, Complications of Acute Myocardial Infarction, and Complica-tions of Percutaneous Interventional Procedures. We recognize, however, the ever-increasing multifaceted disease states that are cared for in the CICU and have included sections on Noncoro-nary Diseases, Pharmacologic Agents in Cardiac Intensive Care Unit, and Advanced Diagnostic and Therapeutic Techniques.

The evidence base for practice in the CICU is expanding rapidly, placing high demands on the daily “rounders.” The field of cardiovascular medicine has expanded to subsume multiple subspecialties and a multitude of procedures, including percu-taneous coronary intervention, percutaneous valve procedures,

peripheral arterial procedures, atrial and ventricular ablations, pacemaker and defibrillator implantations, and cardiac imaging. The cardiac intensivist is required to make informed decisions about the potential benefit versus the risks of referring patients for these procedures and to interpret the data derived from these procedures adequately. In addition, adding to the dynamic environment, optimal patient care in the CICU is delivered via a multidisciplinary approach involving physicians, nurses, ethi-cists, respiratory therapists, nutritionists, physical therapists, and social workers. The goal of this second edition of Cardiac Intensive Care is to provide a comprehensive, conceptual, yet practical and evidence-based text for all specialties involved in patient care in a CICU.

The editors thank Natasha Andjelkovic from Elsevier for her tireless efforts and her ongoing encouragement throughout this endeavor. Additionally, we express our deep appreciation to all the contributing authors. Without their expertise, dedication, and time commitment, this book would not have been possible.

Allen JeremiasDavid L. Brown

Preface

ix

Index

AAbciximab. See also Antiplatelet therapy; Glycoprotein IIb/IIIa recep-

tor blockersclinical indications for, 187tfor non-ST-elevation myocardial infarction, 458–459, 458f

dosing for, 189t–191tfor unstable angina, 458–459, 458f

dosing for, 189t–191tAbdominal examination, 45–47Abdominojugular reflux, examination for, 40–41, 40fACC/AHA (American College of Cardiology/American Heart Associa-

tion) Task Force recommendationsfor β blockers in ST-elevation myocardial infarction, 155for angiotensin-converting enzyme inhibitors and other renin-

angiotensin-aldosterone system inhibitors,in ST-elevation myocardial infarction, 163–164

for anticoagulation in ST-elevation myocardial infarction, 172for aspirin in ST-elevation myocardial infarction, 150for calcium-channel blockers in ST-elevation myocardial infarction, 165for glycemic control in ST-elevation myocardial infarction, 167for lipid control in ST-elevation myocardial infarction, 167–168for magnesium in ST-elevation myocardial infarction, 165–166for morphine in ST-elevation myocardial infarction, 166for nitrates in ST-elevation myocardial infarction, 156–157for thienopyridines in ST-elevation myocardial infarction, 152–153for vitamin and dietary supplements following ST-elevation myocar-

dial infarction, 172Accelerated hypertension, 355–356Accelerated idioventricular rhythm (AIVR) in acute myocardial infarc-

tion, 245ACE. See Angiotensin-converting enzyme (ACE) inhibitorsAcebutolol for acute myocardial infarction, dosing of, 154tAcetaminophen, drug interactions of, with warfarin, 526tAcetazolamide for acute heart failure, 289tAcetylsalicylic acid (ASA). See AspirinAcidosis

hemorrhage and, 93lactic, metformin-induced, 264

ACSs. See Acute coronary syndromes (ACSs)Activated charcoal for sodium channel blocker cardiotoxicity, 436–437Activated partial thromboplastin time (aPTT) for unfractionated

heparin monitoring, 445Acute coronary syndromes (ACSs). See also Non-ST-elevation myocar-

dial infarction (NSTEMI); Unstable angina (UA)chest pain and, 25–27, 27techocardiographic evaluation of, 534–535pathophysiology of, 73–86

atherogenesis in. See Atherogenesisintegrated, 84, 84fplaque and. See Plaquethrombosis and. See Thrombosis

Acute heart failure (AHF), 275–292cardiogenic vs. noncardiogenic, differentiating, 283–284, 283t, 284fclinical presentation of, 280–282compensatory mechanisms and, 278–279decompensation of chronic heart failure as, 280–282determinants of left ventricular pump performance and, 277–278,

278f–280fdiagnosis of, 282–283evaluation and triage of patients with, 284–286

early assessment and, 284, 285tongoing patient evaluation for, 284–286, 285t

hemodynamic examples of, 279–280, 281fhypertensive, treatment of, 291with normal ejection fraction, treatment of, 291pathophysiology of, 275–280

chronic progressive fluid and water retention and, 275pulmonary edema and, 275–277, 276t

severe, 282treatment of, 286–291

for acute heart failure with normal ejection fraction, 291continued, for chronic heart failure, 290deep vein thrombosis prophylaxis and, 286in diabetes, 286for hypertensive acute heart failure, 291for infections, 286intra-aortic balloon pumping for, 291oxygenation for, 286pharmacologic, 286–290, 287f, 289t–290tsurgical, 291ultrafiltration for, 290

Acute myocardial infarction (AMI). See also Myocardial infarction (MI)

anterior, electrocardiography in, 107, 107f, 108tbiomarkers for, 98–100, 99t

adjunctive, 100creatine kinase MB as, 99t, 100lactate dehydrogenase as, 99tmyoglobin as, 99t, 100novel, 100troponin as, 98–100, 99f, 99t

chest pain and, 25–27, 27tconduction disturbances in. See Conduction disturbances, in acute

myocardial infarctiondiagnosis of, 97–105

biochemical markers and, 98–100, 99f, 99tclinical evaluation and, 101–102, 101tdefinition of myocardial infarction and, 98, 98telectrocardiography in, 102–103, 102t–103thistorical background of, 97–98imaging in, 103reinfarction and, 103

Page numbers followed by f indicate figures; t, tables.

686

Index

Acute myocardial infarction (AMI) (Continued)double jeopardy in, 146, 147fas indication for pulmonary artery catheterization, 565–566inferior, electrocardiography in, 106–107, 106f, 107tintra-aortic balloon pump counterpulsation for, 573–574, 574fleft main occlusion and, electrocardiography in, 107–108, 108fmechanical complications of, 233–240, 233t

dynamic left ventricular outflow tract obstruction as, 238free wall rupture as, 233–234mitral regurgitation as, 234–236ventricular septal rupture as, 236–238

pathogenesis of, coronary thrombosis and, 111pericardiopathies following, 381in right bundle branch block, electrocardiography in, 108right ventricle, electrocardiography in, 107ST segment elevation. See ST-elevation myocardial infarction (STEMI)sudden cardiac death and. See Sudden cardiac death (SCD)supraventricular arrhythmias in. See Supraventricular arrhythmias in

acute myocardial infarctionventricular arrhythmias in. See Ventricular arrhythmias, in acute

myocardial infarctionAcute respiratory distress syndrome (ARDS), mechanical ventilation

and, 638–639Acute respiratory failure (ARF), 388–397

clinical assessment for, 390–391, 391tdifferential diagnosis of, 391–393, 392tmanagement of, 393–395mechanical ventilation for, 395–396pathophysiology of, 389–396, 389fphysiology of gas exchange and, 388–389, 389f

Acylated plasminogen-streptokinase (APSAC) for ST-elevation myocardial infarction, 112–113, 113t

Adenosine, 495t, 501–502for acute myocardial infarction, 242tdosage and administration of, 501–502drug interactions of, 522indications for, 501interaction with antiarrhythmics, 520t–521tpharmacokinetics of, 502for pulmonary hypertension, 413side effects of, 502

Adenosine antagonists for edema in decompensated heart failure, 485Adenosine diphosphate receptor antagonists

for non-ST-elevation myocardial infarction, 455–460for ST-elevation myocardial infarction, 461–463, 462ffor unstable angina, 455–460

Admission criteria for cardiac intensive care unit. See Cardiac intensive care unit (CICU), admission criteria for

β-Adrenergic blockers, 496–497, 496ffor acute myocardial infarction, 153–155

ACC/AHA Task Force recommendations for, 155adverse effects of, 155dosing, timing, and benefits of, 153–155, 154tmode of action of, 153

administration of, 497cardiotoxicity of, 429–430

clinical manifestations of, 429management of, 429–430pathophysiology of, 429

dosage of, 497, 497tdrug interactions of, 524, 525t

pharmacodynamic, 524pharmacokinetic, 524

indications for, 497pharmacokinetics of, 497pharmacology of, 429pretransplant use of, 592

β-Adrenergic blockers (Continued)side effect of, 497for sudden cardiac death prevention, 248for unstable angina and non-ST-elevation myocardial infarction,

183, 193tfor unstable angina and non-ST-elevation myocardial infarction

(NSTEMI), for postdischarge therapy, 193Adult congestive heart failure. See Congenital heart disease, adultAdvance directives, 16–17Advanced life support, withholding/withdrawal of, 18–19Afterload

acute heart failure and, 277changes in, end-systolic pressure-volume relationship and, 63–64, 64fincreased, with left ventricular assist devices, 583reduction of, for right ventricular infarction, 230right ventricular, increased, as complication of airway management,

625Age

autonomy and, 10as selection criterion for cardiac transplantation, 588

Agonal respirations, following cardiac arrest, 658AHF. See Acute heart failure (AHF)Air embolism with percutaneous coronary intervention, 262–263

distal, 262–263treatment of, 263

Airway, difficult. See Difficult airwayAirway examination, 600–604

atlanto-occipital joint extension for, 60411-step airway exam of Benumof for, 603, 603texamination principles and, 603–604, 603t, 604frelative tongue/pharyngeal size for, 603, 604fthyromental distance or mandibular space for, 603–604in trauma patients, 604

Airway management, 598–631complications of, 623–626

aspiration of gastric contents as, 624–625decreased arterial carbon dioxide pressure as, 625–626decreased right ventricular preload and increased right ventricular

afterload as, 625direct myocardial depression and vasodilation as, 625failure to intubate or ventilate as, 623hemodynamic compromise as, 625loss of consciousness as, 625unrecognized esophageal intubation as, 623–624, 625f

difficult airway and. See Difficult airwayemergency scenarios for, 626–631

airway management for cardioversion as, 630–631asthma as, 629–630congenital heart disease as, 628, 629tcongestive heart failure as, 628full cardiopulmonary arrest as, 626–627, 627fimminent cardiopulmonary arrest as, 627respiratory failure due to gas exchange problems as, 627–628valvular heart disease as, 628–629, 630tventilatory failure due to airway compromise as, 627

laryngeal mask airway for, 605, 607fwith difficult airway, 612–613, 613f–615f, 615t

mask ventilation for, 604masks for, 604technique for, 604, 606f

oropharyngeal and nasopharyngeal airways for, 604, 606frapid sequence intubation for, 607–610, 610t

anesthesia induction drugs for, 626requirements for, 598–604, 599t

airway evaluation as, 600–603airway examination principles and, 603–604, 603t, 604ffunctioning intravenous catheter as, 600

687

Index

Airway management (Continued)inotropic drugs as, 600intubation equipment check as, 599mask ventilation capacity as, 599, 602tmonitoring as, 600oxygen as, 598–599, 600tpatient preparation and positioning and, 604, 605fpreoxygenation as, 598–599, 601fsuction as, 599vasopressors as, 600

rigid direct laryngoscopy for, 605–610, 607f–609fAirway pressure release ventilation (APRV) for acute respiratory

distress syndrome, 639AIVR (accelerated idioventricular rhythm) in acute myocardial

infarction, 245Albumin, ischemia-modified, as biomarker for acute myocardial

infarction, 100Aldosterone antagonists

for edema in decompensated heart failure, 485pretransplant use of, 592

Allopurinol, drug interactions of, with warfarin, 526tAmbrisentan for pulmonary hypertension, 412American College of Cardiology/American Heart Association Task

Force recommendations. See ACC/AHA (American College of Cardiology/American Heart Association) Task Force recommendations

AMI. See Acute myocardial infarction (AMI)Amiodarone, 495t, 497–499

for acute myocardial infarction, 242tcardiotoxicity of, clinical manifestations of, 433clinical effects of, 498dosage and administration of, 498drug interactions of, 522

with antiarrhythmics, 520t–521twith digoxin, 519twith warfarin, 526t

indications for, 498pharmacokinetics of, 498–499pharmacology of, 433side effects of, 499

Amphetamines, 438tcardiotoxicity of, 438–439

clinical manifestations of, 439management of, 439pathophysiology of, 438

pharmacology of, 438Amrinone for cardiogenic shock, 217tAnalgesia for difficult airway, 619Anesthesia

drugs for inducing, for rapid sequence intubation, 626local, for difficult airway, 619–621, 621f–622fwith pacemakers, 327

Aneurysms, left ventricular, echocardiographic evaluation of, 534, 536fAngina. See Unstable angina (UA)Angiotensin-converting enzyme (ACE) inhibitors. See also specific

drugsfor acute myocardial infarction, 157–164

ACC/AHA Task Force recommendations for, 163–164adverse effects of, 162–163dosing, timing, and benefits of, 159–162, 160t–161t, 163tmode of action of, 157–159, 158f–159f

drug interactions of, 517–518, 517tfor non-ST-elevation myocardial infarction, for postdischarge

therapy, 192pretransplant use of, 591for ST-elevation myocardial infarction, 216ffor unstable angina, for postdischarge therapy, 192

Angiotensin-receptor blockers (ARBs)drug interactions of, 517–518, 517tfor unstable angina and non-ST-elevation myocardial infarction, for

postdischarge therapy, 192–193Antiarrhythmics, 488–503. See also specific drugs

for acute myocardial infarction, 242tatypical, 500–502class I, 491, 491fclass IA, 494–495

drug interactions of, 519–521class IB, 495–496

drug interactions of, 521–522pharmacology of, 432toxicity of, clinical manifestations of, 432

class IC, 496cardiotoxicity of, clinical manifestations of, 433drug interactions of, 522pharmacology of, 433

class II, 491–492, 496–497, 496fclass III, 491, 492f, 497–499

cardiotoxicity of, clinical manifestations of, 433drug interactions of, 522pharmacology of, 433

class IV, 492, 499–500drug interactions of, 522–524

classification of, 490–492Vaughan-Williams classification for, 490–492, 491t

drug interactions of, 519–528, 520t–521tbefore electrical cardioversion, 668His-Purkinje action potential and, 488–489, 489f

phase 0 of, 489phase 1 of, 489phase 2 of, 489phase 3 of, 489phase 4 of, 488–489

physiology and, 488Sicilian Gambit and, 492–494, 493t

distribution and, 493–494drug absorption and, 492metabolism and elimination and, 494pharmacology of, 492–494

sinoatrial and atrioventricular node action potential and, 489–490, 490f

autonomic innervation and, 490phase 0 of, 490phase 3 of, 490phase 4 of, 490

Antibiotics, broad-spectrum, drug interactions of, with warfarin, 526t

Anticancer drugs, interaction with digoxin, 519tAnticoagulation. See also specific drugs

for acute myocardial infarction, 168–172, 168t, 169fACC/AHA Task Force recommendations for, 172dosing, timing, benefits, and adverse effects of, 169–171modes of action of, 168–169

antithrombin therapy for. See Antithrombin therapydrug interactions of, 524–525before electrical cardioversion, 667–668before electrical coagulation, 667–668

Antidepressants, cycliccardiotoxicity of, 434

pathophysiology of, 434pharmacology of, 434

Antifungals, azole, drug interactions of, with warfarin, 526tAntihistamines, cardiotoxicity of, 435Anti-HLA antibodies, surveillance, cardiac transplantation

and, 592

688

Index

Anti-ischemic therapies, unstable angina and non-ST-elevation myocardial infarction, 183–184, 184t, 193t

β blockers for, 183, 193tcalcium-channel blockers for, 184, 193tnitrates for, 183, 193t

Antioxidants for acute myocardial infarction, 172ACC/AHA Task Force recommendations for, 172

Antiplatelet therapy, 452–469. See also specific drugsbleeding complications with, 466–467for non-ST-elevation myocardial infarction, 184–188, 189t–191t,

193t, 452–455aspirin for, 184–185, 189t–191t, 193t, 453–455, 454f, 455tglycoprotein IIb/IIIa receptor inhibitors for, 185–188, 187f–188f,

187t, 189t–191tthienopyridine agents for, 184t, 185, 186f, 193t

platelets and acute coronary syndromes and, 452, 453ffor ST-elevation myocardial infarction, 460–466

adenosine diphosphate receptor antagonists for, 461–463, 462f

aspirin for, 460–461, 461fglycoprotein IIb/IIIa receptor inhibitors for, 463primary percutaneous coronary intervention and, 464–466,

465fthrombolytic therapy and, 463–464

for unstable angina, 184–188, 189t–191t, 193t, 452–460aspirin for, 184–185, 189t–191t, 193tglycoprotein IIb/IIIa receptor inhibitors for, 185–188, 187f–188f,

187t, 189t–191tthienopyridine agents for, 184t, 185, 186f, 193t

Antipsychotics, 513cardiotoxicity of, 434–435

Antisialagogues for difficult airway, 619Antithrombin therapy, 433–451. See also Direct thrombin inhibitors

(DTIs); Low molecular weight heparin (LMWH); Pentasaccha-rides; Unfractionated heparin (UFH); specific antithrombin agents

antithrombin mechanism of action and, 444–445, 444fhemostasis and coagulation cascade and, 443–444, 444f

arterial thrombosis and, 444cell-based model of coagulation and, 444

Antithrombotic therapiesdrug interactions of, 524–525for unstable angina and non-ST-elevation myocardial infarction,

188–192, 193tdirect thrombin inhibitors for, 191–192factor Xa inhibitors for, 192heparin for, 188–191low molecular weight heparin for, 191

Aortic diseases. See also specific disordersas admission criterion for cardiac intensive care unit, 31echocardiography in, 541–542, 541f

Aortic dissection, acute, 368–374classification of, 369, 369fclinical features of, 369–370diagnosis of, 370–372, 371f–373fmanagement of, 372–374, 373fpathogenesis of, 368predisposing factors for, 368–369

Aortic insufficiencyacute, 339–342

clinical presentation of, 340–341, 340tdiagnosis of, 341, 341f–342fetiology of, 339, 340tpathophysiology of, 339–340, 340ftreatment of, 341–342, 342t

auscultation in, 44t, 45emergency airway management for, 628, 630t

Aortic intramural hematoma (IMH), 376–377classification of, 376clinical features of, 376diagnosis of, 376, 376fmanagement of, 376–377pathogenesis of, 376

Aortic stenosisacute, 350–351

clinical presentation of, 350complications of, 350diagnosis of, 350etiology of, 350treatment of, 350–351

auscultation in, 44t, 45emergency airway management for, 628, 630tend-systolic pressure-volume relationship and, 65, 66f

Aortic ulcers, penetrating, 374–376clinical features of, 374–375diagnosis of, 375, 375flaboratory findings in, 375management of, 376pathogenesis of, 374, 374fpredisposing factors for, 374

Aortic valvuloplasty, complications of, 265APACHE II score, 4Apical clots, echocardiographic evaluation of, 535, 536f–537fAPRV (airway pressure release ventilation) for acute respiratory

distress syndrome, 639APSAC (acylated plasminogen-streptokinase) for ST-elevation myocar-

dial infarction, 112–113, 113taPTT (activated partial thromboplastin time) for unfractionated

heparin monitoring, 445ARBs (angiotensin-receptor blockers)

drug interactions of, 517–518, 517tfor unstable angina and non-ST-elevation myocardial infarction, for

postdischarge therapy, 192–193ARDS (acute respiratory distress syndrome), mechanical ventilation

and, 638–639ARF. See Acute respiratory failure (ARF)Arrhythmia(s). See also specific arrhythmias

as admission criterion for cardiac intensive care unit, 29, 30tin adult congestive heart failure, 419–420intra-aortic balloon pump counterpulsation for, 576posttransplant, 595, 595tas pulmonary artery catheterization complication, 563in right ventricular infarction, 228supraventricular. See Supraventricular arrhythmias in acute myocar-

dial infarctiontreatment of. See also Antiarrhythmics

for right ventricular infarction, 230ventricular. See Ventricular arrhythmias

Arrhythmia surgery for sudden cardiac death survivors, 304–305Arterial carbon dioxide pressure (PaCO2), 388

in acute respiratory failure, 389decreased, as complication of airway management, 625–626

Arterial elastance, 64Arteriovenous fistulas, following percutaneous coronary intervention, 273Arteriovenous oxygen difference, tissue oxygenation and, 61ASA (acetylsalicylic acid). See AspirinAshman phenomenon, 39Aspiration of gastric contents, as complication of airway management,

624–625Aspirin. See also Antiplatelet therapy

for acute myocardial infarction, 146–150adverse effects of, 149–150dose, timing, and benefits of, 147–149, 148t, 168tmode of action of, 147, 148f

689

Index

Aspirin (Continued)bleeding complications with, 466drug interactions of, 524–525for non-ST-elevation myocardial infarction, 184–185, 189t–191t,

193t, 453–455, 454f, 455tdosing for, 189t–191t

for ST-elevation myocardial infarction, 130, 460–461, 461fACC/AHA Task Force recommendations for, 150

for unstable angina, 184–185, 189t–191t, 193t, 453–455, 454f, 455tdosing for, 189t–191t

Assist devicesechocardiographic evaluation guidance of placement and monitoring

of, 540, 540fleft ventricular. See Left ventricular assist devices (LVADs)pretransplant use, 592right ventricular, for right ventricular infarction, 230

Assisted suicide, 21Assisted ventilations, dangers of, with cardiocerebral resuscitation, 658Asthma

cardiac, 42emergency airway management for, 629–630

Atelectasis, pneumonia vs., 392Atenolol, 497t

for acute myocardial infarction, 242tdosing of, 154t

ATGAM, posttransplant, 595tAtherogenesis, 73–79

plaque development and, 73–76fatty streak and, 73–76, 74f–75fplaque formation and, 76, 76f–78f

progression of, 76–79chronic endothelial injury and, 77–78recurrent thrombosis and, 78–79

Atherosclerosis, coronary blood flow and, 71Atlanto-occipital joint extension for airway examination, 604Atorvastatin, drug interactions of, with lipid-lowering drugs, 527tAtrial arrhythmias. See also specific arrhythmias

in acute myocardial infarction, 241–243electrical cardioversion of. See Cardioversion, electrical, of atrial

arrhythmiasAtrial fibrillation

in acute myocardial infarction, 243electrical cardioversion of. See Cardioversion, electrical, of atrial

arrhythmiasAtrial flutter

in acute myocardial infarction, 243electrical cardioversion of. See Cardioversion, electrical, of atrial

arrhythmiasAtrial septostomy for pulmonary hypertension, 413Atrial tachyarrhythmias in adult congestive heart failure, 420–421Atrioventricular block

as pacemaker indication, 311t–312tas pulmonary artery catheterization complication, 563in right ventricular infarction, 228

Atrioventricular nodal blockers, for conduction abnormalities, in acute myocardial infarction, 253

Atrioventricular nodeconduction abnormalities below, in acute myocardial infarction,

251–252, 252fconduction abnormalities in, in acute myocardial infarction,

251–253Atrioventricular node action potential, 489–490, 490f


Atypical antipsychotics, cardiotoxicity of, 434–435

Auscultation of heart, 43–44, 43tmurmurs and, 44–45, 44t

Austin Flint murmurs, 45Automatic external defibrillators for sudden cardiac death survivors,

305Autonomy, 10AutoPEEP in chronic obstructive pulmonary disease, 640Autoregulation of myocardial oxygen consumption, 69–70Axial flow pumps, 581–582, 582fAzathioprine, posttransplant, 595tAzimilide, implantable cardioverter-defibrillator function and, 333Azole antifungals, drug interactions of, with warfarin, 526t

BBarbiturates, drug interactions of, with warfarin, 526tBasic life support, withholding/withdrawal of, 17–18Basiliximab, posttransplant, 595tBeneficence, 10–11Benumof 11-step airway exam, 603Benzodiazepines, 508–510

cardiovascular effects of, 509hemodynamic effects of, 509historical background of, 508indications for, 510metabolism, 509pharmacodynamics of, 509pharmacokinetics of, 508–509, 509tside effects of, 509–510site of action and receptor physiology and, 508structure of, 508toxicity of, 510

Beta blockers. See β-Adrenergic blockersBetaxolol for acute myocardial infarction, dosing of, 154tBifascicular block, chronic, as pacemaker indication, 311t–312tBiomedical ethics, Western, 9–13Bisoprolol for acute myocardial infarction, dosing of, 154tBivalirudin. See also Anticoagulation

for acute myocardial infarction, dosing for, 168tfor unstable angina and non-ST-elevation myocardial infarction,

dosing for, 189t–191tBiventricular pacing systems, 324–325, 325fBlalock-Taussig shunt for adult congestive heart failure, 423–424,

424tBlood flow

during cardiac arrest and closed chest compression, mechanisms of, 660–661

coronary. See Coronary blood flowpulmonary

distribution of, 54–55, 54f–55ftotal, oxygen exchange and, 52, 52f–53f

Blood pressure. See also Hypertension; Hypertensive emergencies; Pulmonary hypertension

assessment of, 39–40in hypertensive emergencies, 355, 355tlow, following induction and intubation, 625

techniques to limit, 625–626monitoring of, airway management and, 600in pulmonary embolism, 398–399systemic arterial, monitoring of, 558–562, 559t

pulmonary artery occluded pressure and, 561–562right heart and pulmonary artery catheterization for, 558–561,

560t, 561fwedge pressure and, 561–562

BNP (brain natriuretic peptide) as biomarker for acute myocardial infarction, 100

Body temperature, assessment of, 36–37Bosantan for pulmonary hypertension, 412

690

Index

Bouvia v. Superior Court, 15Bowditch phenomenon, 278Brachial arterial line, 547–548, 548fBradycardia, 38Brain natriuretic peptide (BNP) as biomarker for acute myocardial

infarction, 100Bronchoscopy

fiberoptic, for difficult airway, 618–619, 620tpatient preparation and, 619

rigid, for difficult airway, 613–614, 615f–616fBrugada syndrome, sudden cardiac death and, 299, 300fBumetanide

for acute heart failure, 289tfor cardiogenic shock, 217t

Bundle branch blockin right ventricular infarction, 228thrombolysis in, 126

Butyrophenones, cardiotoxicity of, 434–435

CCABG (coronary artery bypass grafting)

for cardiogenic shock, 221emergency

for coronary occlusion, 262for coronary perforations, 260

Calcium salts, for β-adrenergic antagonist cardiotoxicity, 430Calcium-channel blockers (CCBs), 427–429, 499–500. See also specific

drugsfor acute myocardial infarction, 164–165

ACC/AHA Task Force recommendations for, 165–166adverse effects of, 165dose, timing, and benefits of, 164–165mode of action of, 164

cardiotoxicity of, 427–429clinical manifestations of, 428, 428tmanagement of, 428–429pathophysiology of, 427–428

clinical effects of, 499–500dosage and administration of, 500drug interactions of, 522–524, 523t

pharmacodynamic, 524pharmacokinetic, 522–524

indications for, 500pharmacokinetics of, 500pharmacology of, 427for pulmonary hypertension, 413

in chronic lung disease, 414side effects of, 500for unstable angina and non-ST-elevation myocardial infarction, 184,

193tCalcium-sensitizing agents, 474. See also specific drugsCandesartan for acute myocardial infarction, dosing for, 163tCaptopril

for acute myocardial infarction, dosing for, 163tfor ST-elevation myocardial infarction, 216f

Carbamazepinecardiotoxicity of, 435drug interactions of, with warfarin, 526t

Cardiac arrestcardiocerebral resuscitation for, 654–656

chest compression technique for, 656circulatory phase of untreated ventricular fibrillation and, 654new approach for, 654–655, 654f–655fout-of-hospital, survival with, 655–656, 656f

full, emergency airway management for, 626–627, 627fimminent, emergency airway management for, 627prevention of, as focus of CCU, 2–3

Cardiac arrhythmias. See Arrhythmia(s); specific arrhythmiasCardiac asthma, 42Cardiac catheterization

historical background of, 558–561in pulmonary hypertension, 409right heart, historical background of, 558–561in sudden cardiac death survivors, 304

Cardiac dysrhythmias. See Arrhythmia(s); specific arrhythmiasCardiac emergencies in adult congestive heart failure, 418, 419tCardiac glycosides. See also Digoxin

for cardiogenic shock, 216–217pharmacology of, 430for pulmonary hypertension, in chronic lung disease, 414

Cardiac intensive care unit (CICU). See also Coronary care unit (CCU)admission criteria for, 25–35, 26t

adult congenital heart disease as, 30aortic disease as, 31arrhythmias as, 29, 30tcardiac tamponade as, 31cardiogenic shock as, 30tchest pain as, 25–27, 27theart failure as, 27–29, 28thistorical background of, 25hypertensive emergency as, 31intra-aortic balloon pump indications as, 30pulmonary embolism as, 31pulmonary hypertension as, 29valvular heart disease as, 30–31

elderly patients and, 32minority populations and, 32as periprocedure and postprocedure setting, 31–32women and, 32

Cardiac outputlow, as indication for pulmonary artery catheterization, 566measurement of, 562–564

complications of, 563–564Fick method for, 562–563, 563findicator dilution method for, 562, 562f

regulation of, 61–68arteriovenous oxygen difference and, 61end-systolic pressure-volume relationship and, 63–64, 64fleft ventricular performance and, 62–63, 62f–63freflex control and, 61–62, 62t

Cardiac surgery, intra-aortic balloon pump counterpulsation for, 576Cardiac tamponade

as admission criterion for cardiac intensive care unit, 31causes of, 383, 383fdiagnosis of, 383–385, 384f–385f, 384tas indication for pulmonary artery catheterization, 565, 565flow pressure, 386in pericarditis, 382–386pulsus paradoxus and, 385–386, 385frecognition of, 383–385treatment of, 386

Cardiac transplantation, 586–597candidate selection criteria for, 586–587, 588t

age and, 588cerebrovascular disease and, 589diabetes mellitus and, 589finances and, 590hepatic impairment and, 589infection and, 589–590malignancy and, 590obesity and, 590peripheral vascular disease and, 589psychosocial issues and, 590pulmonary function and, 589

Index

Cardiac transplantation (Continued)pulmonary hypertension and, 589renal impairment and, 589

future directions for, 596intra-aortic balloon pump counterpulsation for, 576left ventricular assist devices as bridge to, 580–581

adverse events with, 580–581, 581tnumber performed annually in United States, 579, 579fas pacemaker indication, 311t–312tposttransplant patient management and, 593–596

immediate posttransplant care and, 593immunosuppression and, 593, 594fnecessitating intensive care, 594–596, 595t–596t, 596f

pretransplant patient management and, 590–593, 590timmediate pretransplant considerations and, 592–593mechanical circulatory support and, 592medical therapy in advanced cardiac failure and, 591–592surveillance anti-HLA antibodies and, 592

stage D heart failure and, identification of, 586, 587fsurvival following, 586, 586f

Cardiocerebral resuscitation (CCR), 652–671bystander responders and, 657–660

acceptance of dispatch directed chest-compression-only CPR and, 658

continuous chest compressions vs. chest-compression-only CPR and, 657

electrical vs. circulatory phase of ventricular fibrillation and, 659, 659f

emergency medical services components of cardiocerebral resus-citation and, 658–659

importance of full chest recoil following chest compressions and, 657–658

importance of minimal interruptions of chest compressions and, 659–660

teaching chest-compression-only CPR and, 657for cardiac arrest, 654–656

chest compression technique for, 656circulatory phase of untreated ventricular fibrillation and, 654new approach for, 654–655, 654f–655fout-of-hospital, survival with, 655–656, 656f

cardiopulmonary resuscitation and, 661care following, 662–663, 662fdefibrillation and, 653–654, 663–664

contraindications to, 663electrical, 653–654, 664fmechanical, 653ventricular fibrillation and, 663–664, 664f

dysfunction following, 662electrical cardioversion in. See Electrical cardioversionending, 663hemodynamics of cardiac arrest and, 660–661

mechanisms of blood flow during cardiac arrest and closed chest compression and, 660–661

mechanical devices for, 662phases of ventricular fibrillation and, 652–653, 653fresearch on resuscitation and, 661–662

Cardiogenic shock, 212–224, 212tas admission criterion for cardiac intensive care unit, 30tclinical presentation of, 214–215definition of, 212echocardiography in, 214–215electrocardiography in, 214epidemiology of, 212–213etiology of, 212–213incidence of, 213intra-aortic balloon pump counterpulsation for, 575laboratory testing in, 214

Cardiogenic shock (Continued)management of, 215–219

general measures for, 215, 216f, 217themodynamic monitoring in, 215, 217tmechanical support in, 217–219, 218fnew approaches for, 221pharmacologic support in, 215–217, 217treperfusion in, 219–221

pathology of, 213pathophysiology of, 213–214, 214fpercutaneous coronary intervention in, 115–116prognosis of, 221–222, 222fthrombolysis in, 126

Cardiomyopathydilated

as pacemaker indication, 311t–312tsudden cardiac death and, 297

hypertrophicauscultation in, 44t, 45as pacemaker indication, 311t–312tsudden cardiac death and, 296–297

restrictive, as indication for pulmonary artery catheterization, 567Cardiopulmonary arrest. See Cardiac arrestCardiopulmonary resuscitation (CPR), 661. See also Cardiocerebral

resuscitation (CCR)decision whether to use, 18–19focus on, 1–2with pacemakers, 326patient wakening during, 662

Cardiotoxic drug overdose, 427–442Cardiovascular function, 51–60

pulmonary gas exchange and, 51–56distribution of blood flow within lungs and, 54–55, 54f–55fleft ventricular dysfunction and lung fluid exchange and, 55pulmonary transit time and, 53–54, 53ftotal pulmonary blood flow and oxygen exchange and, 52, 52f–53fventricular function and lung disease and, 55–56

systemic gas exchange and, 57fCardioversion

airway management for, 630–631electrical. See Electrical cardioversionfor ventricular fibrillation, 246for ventricular tachycardia, 245–246

Carotid sinus hypersensitivity as pacemaker indication, 311t–312tCarvedilol

for acute myocardial infarction, dosing of, 154tdrug interactions of, 525t

Casuistry, 12–13Catecholamines

for cardiogenic shock, 215–216preinduction increases of, airway management and, 625

Catheter ablation for sudden cardiac death survivors, 305Cavopulmonary connections for adult congestive heart failure, 424,

424tCCBs. See Calcium-channel blockers (CCBs)CCPD (continuous cyclic peritoneal dialysis), principles and technical

aspects of, 645tCCR. See Cardiocerebral resuscitation (CCR)CCU. See Coronary care unit (CCU)Cefamandole, drug interactions of, with warfarin, 526tCellular respiration, cardiovascular function and. See Cardiovascular

functionCentral venous lines

external jugular, 553, 553ffemoral, 550, 551finternal jugular, 550–553, 552fsubclavian, 553–555, 554f

691

692

Index

Cerebrovascular diseasein adult congestive heart failure, 425as hypertensive emergency, 359t, 360as selection criterion for cardiac transplantation, 589thrombolytic agents and, 123–124, 123t–124t

Chamber stiffness, acute heart failure and, 278, 280fCharcoal, activated, for sodium channel blocker cardiotoxicity, 436–437C-HD (continuous hemodiafiltration), principles and technical aspects

of, 645tChest compression(s)

closed, mechanism of blood flow during, 660–661continuous

chest-compression-only CPR vs., 657immediately after defibrillation, 659

dispatch-directed chest-compression-only CPR and, 658assisted ventilations and, 658gasping and agonal respirations and, 658

importance of full chest wall recoil following, 657–658importance of minimal interruptions of, 659–660mechanical devices for, 662proper technique of, 656rates of, correlation with survival, 662teaching bystander chest-compression-only CPR and, 657

Chest examination, 41–42, 41tChest pain

as admission criterion for cardiac intensive care unit, 25–27, 27techocardiographic evaluation of, 534–540

in acute coronary syndromes, 534–535acute mitral regurgitation secondary to papillary muscle rupture

and, 539–540, 540fapical clot and, 535, 536f–537fexclusion of right ventricular involvement using, 536–537, 537ffree wall rupture and, 538, 539fguidance of placement and monitoring of assist devices and, 540,

540fischemic mitral regurgitation and, 537, 538fleft ventricular aneurysm and, 534, 536fleft ventricular function evaluation using, 534, 535f–536fleft ventricular outflow tract obstruction and, 537, 538f–539fwith multiple complications, 540ventricular septal rupture and, 539, 539f

in ischemic heart disease, pericardial syndromes and, 380–381Chest radiography

in acute respiratory failure, 391, 391tmonitoring during mechanical ventilation with, 637

CHF (congestive heart failure)emergency airway management for, 628left ventricular assist devices for. See Left ventricular assist devices

(LVADs)prosthetic valve dysfunction in, treatment of, 347–348thrombolysis in, 126

C-HF (continuous hemodialysis), principles and technical aspects of, 645t

Chloroquine, cardiotoxicity of, 435Chlorothiazide for acute heart failure, 289tCholestyramine

drug interactions ofwith lipid-lowering drugs, 527twith warfarin, 526t

interaction with digoxin, 519tChronic heart failure

decompensation of, 280–282hypotensive, 282normotensive, 280–282

therapy for, continued, 290Chronic obstructive pulmonary disease (COPD), mechanical ventila-

tion for, 639–640

CICU. See Cardiac intensive care unit (CICU)Cimetidine, drug interactions of, with warfarin, 526tCirculatory support for cardiogenic shock, 217–219, 218fClinical training, 5–6Clofibrate, drug interactions of, with lipid-lowering drugs, 527tClopidogrel. See also Antiplatelet therapy

for acute myocardial infarction, dosing for, 148t, 168tbleeding complications with, 466drug interactions of, 525

with warfarin, 526tfor unstable angina and non-ST-elevation myocardial infarction, dos-

ing for, 189t–191tCMV (continuous mandatory ventilation), 635Coagulation. See also Anticoagulation; Hemostasis

clinical laboratory testing of, 93initiation of, on tissue factor-bearing cells, 89–90, 90fregulation of, 92–93

by endothelial antithrombotic mechanisms, 92–93, 92fby fibrinolysis, 93by plasma protease inhibitors, 92

Coagulation cascade, 443–444, 444farterial thrombosis and, 444cell-based model of coagulation and, 444

Coagulation components, consumption of, hemorrhage and, 93Coagulation proteins, hemostasis and, 88–89, 89fCOAT platelet phenomenon, 91–92Cocaine

cardiotoxicity of, 437–438clinical manifestations of, 437–438pathophysiology of, 437

pharmacology of, 437Code blue, 2, 626Colestipol, drug interactions of

with lipid-lowering drugs, 527twith warfarin, 526t

Collateral blood vessels, coronary blood flow and, 71Communication

conflicting, 14inadequate, 14language barriers and, 14listening and, 13medical decision making and, 13–14

Compensatory mechanisms in acute heart failure, 278–279Computed tomography (CT)

monitoring during mechanical ventilation with, 637in pulmonary hypertension, 409, 412f

Conduction disturbancesin acute myocardial infarction, 251–254

anatomy and, 251atrioventricular node, 251–253below atrioventricular node, 251–252, 252fincidence of, 251inferior wall myocardial infarction vs. anterior wall myocardial

infarction and, 252–253, 252fmanagement of, 253–254, 254tmortality and, 253sinoatrial node, 251

sudden cardiac death and, 301Confidentiality, 9–10Congenital heart disease

adult, 418–426, 420tas admission criterion for cardiac intensive care unit, 30anatomic and pathophysiologic classification of, 419–422arrhythmias and, 419–420cardiac emergencies and, 418, 419tEisenmenger syndrome and, 425heart failure and, 422–425

Index

Congenital heart disease (Continued)ischemic complications of, 421–422pulmonary hemorrhage and, 425stroke and, 425

emergency airway management for, 628, 629tas pacemaker indication, 311t–312tsudden cardiac death and, 301

Congestive heart failure (CHF)emergency airway management for, 628left ventricular assist devices for. See Left ventricular assist devices

(LVADs)prosthetic valve dysfunction in, treatment of, 347–348thrombolysis in, 126

Consciousness, loss of, as complication of airway management, 625Consequentialism, 12Constrictive pericarditis as indication for pulmonary artery catheteri-

zation, 567, 568fContact factors, 88Continuous cyclic peritoneal dialysis (CCPD), principles and technical

aspects of, 645tContinuous hemodiafiltration (C-HD), principles and technical aspects

of, 645tContinuous hemodialysis (C-HF), principles and technical aspects of,

645tContinuous hemofiltration, principles and technical aspects of, 645tContinuous mandatory ventilation (CMV), 635Continuous positive airway pressure (CPAP), 635Continuous renal replacement therapy (CRRT)

intermittent hemodialysis compared with, 646–648principles and technical aspects of, 645–646, 645t

Continuous venovenous hemodiafiltration (CVVHDF), principles and technical aspects of, 645t

Continuous venovenous hemodialysis (CVVT), principles and techni-cal aspects of, 645t

Continuous venovenous hemofiltration (CVVHD), principles and technical aspects of, 645t

Contractile state, changes in, end-systolic pressure-volume relationship and, 63, 64f

Contractility, acute heart failure and, 277Contrast toxicity with percutaneous coronary intervention, 263–264,

264tanaphylactoid reaction and, 263–264nephrotoxicity and, 264

COPD (chronic obstructive pulmonary disease), mechanical ventilation for, 639–640

Coronary arterieswith anomalous origin from pulmonary artery, in adults, 421complex anatomy of, perforation and, with percutaneous coronary

intervention, 258–259epicardial, coronary blood flow and, 70left, arising from right sinus of Valsalva, in adults, 421perforation of, with percutaneous coronary intervention, 258, 259t

with complex coronary anatomy, 258–259with devices, 259with glycoprotein IIb/IIIa inhibitors, 259

right, arising from left sinus of Valsalva, in adults, 421–422Coronary artery bypass grafting (CABG)

for cardiogenic shock, 221emergency

for coronary occlusion, 262for coronary perforations, 260

Coronary artery disease, sudden cardiac death and, 295–296Coronary blood flow, 70, 70f

epicardial coronary arteries and, 70extravascular compression of coronary blood supply and, 70neural control of, 70–71pathophysiology and, 71–72

Coronary blood flow (Continued)atherosclerosis and, 71collateral blood vessels and, 71myocardial ischemia and, 71–72

reflexes and, 70–71resistance vessels and, 70

Coronary blood supply, extravascular compression of, 70Coronary care unit (CCU). See also Cardiac intensive care unit (CICU)

benefits of, validating, 3contemporary, 4, 5f–6fcontinued evolution of, 4–7critical care in, 4economic impact of, 3future of, 4–7multidisciplinary clinical integration and, 4–5, 7fnursing and clinical training for, 5–6origins of, 1–3, 2fresearch platforms for, 7, 7tsudden cardiac death prevention and, 247technology needs in, 6–7

Coronary circulation, right ventricle and, 225–226Coronary occlusion, reperfusion of myocardium and, 110–111Coronary thrombosis, acute myocardial infarction pathogenesis and, 111Corrigan pulse, 45Co-trimoxazole, drug interactions of, with warfarin, 526tCPAP (continuous positive airway pressure), 664CPR (cardiopulmonary resuscitation). See also Cardiocerebral resusci-

tation (CCR)decision whether to use, 18–19focus on, 1–2with pacemakers, 326patient wakening during, 662

Crackles, 41Cranial nerve examination, 47C-reactive protein (CRP) as biomarker for acute myocardial infarction, 100Creatine kinase-MB

as acute myocardial infarction biomarker, 99t, 100as pericarditis biomarker, 381

Cricothyroidotomyopen, for difficult airway, 616, 617fpercutaneous, for difficult airway, 614–615

CRP (C-reactive protein) as biomarker for acute myocardial infarction, 100CRRT (continuous renal replacement therapy)

intermittent hemodialysis compared with, 646–648principles and technical aspects of, 645–646, 645t

CT (computed tomography)monitoring during mechanical ventilation with, 637in pulmonary hypertension, 409, 412f

Cultural valuesethical issues and, 21–22medical decision making and, 21–22

CVVHD (continuous venovenous hemofiltration), principles and technical aspects of, 645t

CVVHDF (continuous venovenous hemodiafiltration), principles and technical aspects of, 645t

CVVT (continuous venovenous hemodialysis), principles and technical aspects of, 645t

Cyanide toxicity, sodium nitroprusside and, 363–364, 364tCyclosporine

interaction with digoxin, 519tposttransplant, 595t

DDaclizumab, posttransplant, 595tDalteparin. See also Anticoagulation

for unstable angina and non-ST-elevation myocardial infarction, dosing for, 189t–191t

693

Index

de Musset sign, 45Death. See also Sudden cardiac death (SCD)

assisted suicide and, 21conduction abnormalities and, in acute myocardial infarction, 253euthanasia and, 20–21

Decompensated heart failure, 479–487, 280–282, 479tcycle of sodium and water management in, 483, 483tedema and. See Edema, in decompensated heart failurehypotensive, 282normotensive, 280–282treatment of, ultrafiltration for, 648–649, 649f

Deep vein thrombosis, prophylaxis of, in acute heart failure, 286Defibrillation, 653–654

continuous chest compression immediately after, 659electrical, 653, 664

defibrillation energy, current, and voltage for, 664, 665fdefibrillation threshold and, 666defibrillation waveform and, 666direct current, with pacemakers, 326–327factors determining transthoracic impedance and, 665–666shock strength for, 666

mechanical, 653for ventricular fibrillation, 246for ventricular tachycardia, 245–246ventricular tachycardia or fibrillation storm and, 654

Demand ischemia, troponin elevation and, 197–198Dexmedetomidine, 512–513

cardiovascular effects of, 512complications of, 512hemodynamic effects of, 512historical background of, 512indications for, 512–513metabolism of, 512pharmacodynamics of, 512pharmacokinetics of, 512side effects of, 512site of action and receptor physiology and, 512structure of, 512toxicity of, 512

Diabetes mellitusin acute heart failure, treatment of, 286as selection criterion for cardiac transplantation, 589

Dialysishemodialysis as

for β-adrenergic antagonist cardiotoxicity, 430continuous, principles and technical aspects of, 645tslow low-efficiency, principles and technical aspects of, 645for sodium channel blocker cardiotoxicity, 437venovenous, continuous, principles and technical aspects of, 645t

peritonealcontinuous cyclic, principles and technical aspects of, 645tprinciples and technical aspects of, 645, 645t

Diastolic dysfunction, end-systolic pressure-volume relationship and, 65, 65f

Difficult airway, 610–622anatomic characteristics impairing laryngoscopy and, 603in apneic patients, 610–612ASA algorithm for, 610, 611f

awake limb of, 610blind intubation techniques for, 616–618

with light wand, 617, 619fnasal, 617, 618fretrograde wire intubation as, 617–618

definition of, 601–602, 602f–603fesophageal-tracheal combitube for, 612, 612f–613ffiberoptic bronchoscopy for, 618–619, 620tfiberoptic intubation for, 621–622

Difficult airway (Continued)awake nasal technique for, 621–622, 623foral technique for, 622, 624f

historical indicators of, 602laryngeal mask airway for, 612–613, 613f–615f, 615tpathologic causes of, 602–603patient preparation and, 619–621

for fiberoptic bronchoscopy, 619intravenous analgesia, sedation, and antisialagogue for, 619local anesthesia and vasoconstriction for, 619–621, 621f–622f

recognition of, 610–612awake limb of ASA algorithm and, 610

rigid bronchoscope for, 613–614, 615f–616fsurgical airway for, 614–616

open cricothyroidotomy and, 616, 617fpercutaneous cricothyroidotomy and, 614–615tracheostomy and, 616, 618ftranstracheal jet ventilation and, 614, 616f–617f

in unstable or uncooperative patients, 610–612Digitalis

for acute heart failure, 290for pulmonary hypertension, in chronic lung disease, 414

Digoxin, 474, 495t, 500–501for acute myocardial infarction, 242tcardiotoxicity of, 430–431

clinical manifestations of, 430management of, 430–431pathophysiology of, 430

clinical effects of, 500dosage and administration of, 500–501drug interactions of, 518, 519tindications for, 500pharmacokinetics of, 501pharmacology of, 430pretransplant use of, 592side effects of, 501

Dilated cardiomyopathyas pacemaker indication, 311t–312tsudden cardiac death and, 297

Diltiazem, 499. See also Calcium-channel blockers (CCBs)for acute myocardial infarction, 242tdrug interactions of, 523t

with warfarin, 526tDirect myocardial damage, troponin elevation and, 198–199Direct thrombin inhibitors (DTIs), 448–449. See also specific drugs

administration of, 448clinical trials of, 448–449metabolism of, 448pharmacokinetics of, 448for ST-elevation myocardial infarction, 131for unstable angina and non-ST-elevation myocardial infarction,

191–192Disopyramide

cardiotoxicity of, clinical manifestations of, 432drug interactions of, 521interaction with antiarrhythmics, 520t–521tpharmacology of, 432

Dissection with percutaneous coronary intervention, 273Diuretics

for acute heart failure, 288–289, 289tfor aortic insufficiency, 342for decompensated heart failure

cycle of sodium and water management in heart failure and, 483, 483t

diuretic-resistant edema and, 484–485electrolyte imbalance induced by, 484failure of, alternatives for, 485

694

695

Index

Diuretics (Continued)intravenous, optimizing response to, 483–484loop diuretics as, 482, 482tpotassium-sparing diuretics as, 482–483response to, 480–482thiazide diuretics as, 482–483

drug interactions of, 517t, 528with digoxin, 519t

pharmacokinetics of, 480–483potassium-sparing, drug interactions of, 517tpretransplant use of, 591resistance to, 288–289

edema and, 484–485DNR orders, 18Dobutamine, 471–472

for acute heart failure, 289for cardiac transplantation, 28for cardiogenic shock, 215, 217tdrug interactions of, 518–519for mitral regurgitation, 345for ST-elevation myocardial infarction, 216f

Dofetilide, 495tcardiotoxicity of, clinical manifestations of, 433pharmacology of, 433

Dopamine, 470–471, 470t, 471f, 472tfor acute heart failure, 289for cardiogenic shock, 215, 217tdrug interactions of, 518–519for mitral regurgitation, 345for ST-elevation myocardial infarction, 216f

Droperidol, cardiotoxicity of, 435Drug(s). See also specific drugs and drug types

adjunctive therapy using, for acute myocardial infarction, 145–182, 146f–147f. See also specific drugs

illicit, cardiotoxicity of, 437–439implantable cardioverter-defibrillator function and, 333pharmacoinvasive therapy and, for ST-elevation myocardial infarc-

tion, 115f, 119f, 127f, 129f, 131–136, 132f–136f, 137tDrug interactions, 516–531

of β-adrenergic blockers, 524, 525tof angiotensin-converting enzyme inhibitors, 517–518, 517tof angiotensin-receptor blockers, 517–518, 517tof antiarrhythmic drugs, 519–528, 520t–521tof anticoagulants, 524–525of antithrombotic drugs, 524–525of diuretics, 528of inotropes, 518–519of lipid-lowering drugs, 527, 527tof vasodilators, 516

DTIs. See Direct thrombin inhibitors (DTIs)Duroziez sign, 45Dysrhythmias. See Arrhythmia(s); specific arrhythmias

EEars, examination of, 40ECG. See Electrocardiography (ECG)Echocardiography, 553–544

in aortic diseases, 541–542, 541fin cardiogenic shock, 214–215chest pain evaluation using. See Chest pain, echocardiographic

evaluation ofin infective endocarditis, 542–543, 542f–543fin pericardial effusion, 542, 542fin pulmonary embolism, 541, 541fin right ventricular infarction, 228

Eclampsia as hypertensive emergency, 359t, 361–362EDD (extended daily dialysis), principles and technical aspects of, 645, 645t

Edemain decompensated heart failure, 479–480

adenosine antagonists for, 485aldosterone antagonists for, 485clinical conditions and, 479diuretics for, 480–483mechanisms of, 479–480, 480f–481fnatriuretic peptides for, 485positive inotropic antagonists for, 485–486refocusing therapy for, 486vasopressin antagonists for, 485

pulmonaryas indication for pulmonary artery catheterization, 565reperfusion, following thromboendarterectomy, 415

Egophony, 42Eisenmenger syndrome, 406

in adult congestive heart failure, 425Elderly patients, 32

percutaneous coronary intervention in, 136–137thrombolysis in, 125–126

Electrical cardioversion, 666–669antiarrhythmic therapy before, 668anticoagulation before, 667–668applications of, 666–667for atrial arrhythmias, 666–669of atrial arrhythmias, 666–669

antiarrhythmic therapy before, 668anticoagulation before, 667–668atrial fibrillation as, 666–667atrial flutter as, 667candidates for, 666–667electrode positions for, 667electrode type for, 668–669, 668f–669flong-term success of, prdictors of, 667rate vs. rhythm control for, 667shock strength for, 668

candidates for, 666–667direct current, with pacemakers, 326–327electrode positions for, 667electrode type and, 668–669, 668f–669fpredictors of long-term success for, 667rate control and rhythm control and, 667shock strength for, 668

Electrical storm, implantable cardioverter-defibrillators and, 331–332

Electrocardiography (ECG)in acute myocardial infarction, 106–109

anterior, 107, 107f, 108tinferior, 106–107, 106f, 107twith left main occlusion, 107–108, 108fin right bundle branch block, 108right ventricle, 107

acute myocardial infarction diagnosis and, 102–103, 102tairway management and, 600in cardiogenic shock, 214in pericarditis, acute, 381–382, 382fin sudden cardiac death survivors, 303

Electrocauteryendoscopic, with pacemakers, 327with pacemakers, 327

Electrolyte imbalances, diuretic-induced, 484Electromagnetic interference (EMT), pacemaker oversensing and,

322Electrophysiological studies (EPSs) in sudden cardiac death survivors,

304Electrotherapy with pacemakers, 32711-step airway exam of Benumof, 603, 603t

Index

Embolectomy, pulmonary, 402percutaneous, 402surgical, 402

Embolismair, with percutaneous coronary intervention, 262–263

distal, 262–263treatment of, 263

as pacemaker implantation complication, 314–315pulmonary. See Pulmonary embolismsystemic

as pacemaker implantation complication, 315with valvular interventions, 265

Emergency medical services, cardiocerebral resuscitation and, 658–659Emotional support, pretransplant, 592EMT (electromagnetic interference), pacemaker oversensing and, 322Enalapril for acute myocardial infarction, dosing for, 163tEnalaprilat, 477

for hypertensive emergencies, 363t, 365Encainide

drug interactions of, 522interaction with antiarrhythmics, 520t–521t

Encephalopathy, hypertensive, as hypertensive emergency, 359–360, 359f, 359t

Endocarditisinfective

echocardiography in, 542–543, 542f–543fmitral regurgitation and, treatment of, 345

as pacemaker implantation complication, 313prosthetic valve, treatment of, 348

Endothelial antithrombotic mechanisms, coagulation regulation by, 92–93, 92f

Endothelial injury, chronic, atherogenesis progression and, 77–78Endotracheal tubes (ETTs), 599. See also Intubation

radiographic monitoring of, with mechanical ventilation, 637End-stage renal disease

renal replacement therapy for patients with, 648troponin elevation and, 199–200

End-systolic pressure-volume relationship (ESPVR)dilated cardiomyopathy and, 66, 67ftissue oxygenation and, 63–64

acute systolic dysfunction and, 65, 65faortic stenosis and, 65, 66fchanges in afterload and, 63–64, 64fchanges in contractile state and, 63, 64fdiastolic dysfunction and, 65, 65fdilated cardiomyopathy and, 66, 67flimitation of pressure-volume approach and, 67mitral stenosis and, 66, 66fvalvular regurgitation and, 66, 66f

Enoxaparin. See also Anticoagulationfor unstable angina and non-ST-elevation myocardial infarction,

dosing for, 189t–191tEpinephrine, 472Eplerenone for acute myocardial infarction, dosing for, 163tEpoprostenol for pulmonary hypertension, 412–413EPSs (electrophysiological studies) in sudden cardiac death survivors,

304Eptifibatide. See also Antiplatelet therapy; Glycoprotein IIb/IIIa

receptor blockersclinical indications for, 187tfor non-ST-elevation myocardial infarction, 459

dosing for, 189t–191tfor unstable angina, 459

dosing for, 189t–191tErythromycin, interaction with digoxin, 519tEsmolol, 497t

for acute myocardial infarction, 242t

Esmolol (Continued)dosing of, 154t

for hypertensive emergencies, 363t, 365Esophageal intubation, unrecognized, 623–624, 625fEsophageal-tracheal combitube for difficult airway, 612, 612f–613fESPVR. See End-systolic pressure-volume relationship (ESPVR)Ethical issues, 9–24

casuistry and, 12–13consequentialism and, 12cross-cultural conflict and, 21–22decision making guidelines for, 13–15

authority for medical decision making and, 13communication and, 13–14determining patients' values and preferences and, 14–15patient partnership as, 13

principlism and, 10–12autonomy and, 10beneficence and, 10–11justice and, 11–12nonmaleficence and, 11

Western biomedical ethics and, 9–13withholding and withdrawing of life support and. See Withholding/

withdrawing life supportEtomidate for anesthesia induction, for rapid sequence intubation, 626ETTs (endotracheal tubes), 599. See also Intubation

radiographic monitoring of, with mechanical ventilation, 637Euthanasia, 20–21Exercise stress testing in sudden cardiac death survivors, 304Extended daily dialysis (EDD), principles and technical aspects of, 645,

645tExternal jugular central venous line, 553, 553fExtracorporeal shock-wave lithotripsy with pacemakers, 327Extravascular tissues, hemostasis and, 87Eyes, examination of, 40

FFab for digoxin toxicity, 430Factor IIa, 88–89

amplification of procoagulant signal by, 90, 91fgeneration in platelet surface, propagation of, 90–92, 91fgeneration of, 89–90, 90f

Factor V, 88Factor VIII, 88Factor Xa inhibitors for unstable angina and non-ST-elevation myocar-

dial infarction, 192Failure to capture with pacemakers, 315–319, 315f–318f, 316tFar-field oversensing, 321Felodipine, drug interactions of, 523tFemoral arterial line, 548–550, 549fFemoral central venous line, 550, 551fFemoral vein for vascular access, 560tFenofibrate, drug interactions of, with warfarin, 526tFenoldopam for hypertensive emergencies, 363t, 366Fentanyl, 507–508

cardiovascular effects of, 508complications with, 508hemodynamic effects of, 508historical background of, 507–508indications for, 508metabolism of, 507–508pharmacodynamics of, 507–508pharmacokinetics of, 507–508side effects of, 508structure of, 507toxicity of, 508

Fiberoptic bronchoscopy for difficult airway, 618–619, 620tpatient preparation and, 619

696

Index

Fiberoptic intubation for difficult airway, 621–622awake nasal technique for, 621–622, 623foral technique for, 622, 624f

Fibrinogen, 88Fibrinolysis

coagulation regulation by, 93excessive, hemorrhage and, 93

Fibrinolytic therapy for cardiogenic shock, 219Fick method for cardiac output measurement, 562–563, 563fFinances as selection criterion for cardiac transplantation, 590Fixed splitting, 43Flecainide

drug interactions of, 522interaction with antiarrhythmics, 520t–521t

Fluid loading for pulmonary embolism, 399–400Fluid retention, chronic, acute heart failure and, 275Fluvoxamine, drug interactions of, with warfarin, 526tFondaparinux. See also Anticoagulation; Pentasaccharides, synthetic

for acute myocardial infarction, dosing for, 168tfor unstable angina and non-ST-elevation myocardial infarction,

dosing for, 189t–191tFontan procedures for adult congestive heart failure, 424, 424tFosinopril for acute myocardial infarction, dosing for, 163tFree radical scavengers for acute myocardial infarction, 166Free wall rupture, 233–234

clinical features of, 233–234diagnosis of, 234echocardiographic evaluation of, 538, 539fmanagement of, 234pathophysiology of, 233

Furosemidefor acute heart failure, 289tfor cardiogenic shock, 217tfor ST-elevation myocardial infarction, 216f

Futilityrationing vs., 11–12withholding/withdrawal of life support and, 17

GGas exchange

cardiovascular function and. See Cardiovascular functionphysiology of, 388–389, 389fproblems with, respiratory failure due to, emergency airway

management for, 627–628Gasping respirations following cardiac arrest, 658Gastric contents, aspiration of, as complication of airway management,

624–625Gemfibrozil, drug interactions of


Glenn procedures for adult congestive heart failure, 424, 424tGlucagon for β-adrenergic antagonist cardiotoxicity, 429–430Glycemic control in ST-elevation myocardial infarction, 166–167

ACC/AHA Task Force recommendations for, 167Glycoprotein IIb/IIIa receptor blockers

bleeding complications with, 466–467coronary perforation and, 259

with percutaneous coronary intervention, 259for non-ST-elevation myocardial infarction, 185–188, 187f–188f,

187t, 189t–191t, 457–458for ST-elevation myocardial infarction, 130–131, 463

percutaneous coronary intervention and, 464–466, 465fthrombolytic therapy and, 463–464

for unstable angina, 185–188, 187f–188f, 187t, 189t–191t, 457–458

Graham-Steele murmur, 45Grapefruit juice, interaction with calcium-channel blockers, 523

Griseofulvin, drug interactions of, with warfarin, 526tGroin hematoma with percutaneous coronary intervention, 271GUSTO-I, patency and reocclusion of infarct-occluded artery and, 117tGut decontamination for sodium channel blocker cardiotoxicity, 436

HHaldane effect, 388Haloperidol, 513

cardiotoxicity of, 435Handgrip maneuver, 44tHCM (hypertrophic cardiomyopathy)

auscultation in, 44t, 45as pacemaker indication, 311t–312tsudden cardiac death and, 296–297

Head examination, 40Health care resources, fair allocation of, 11–12Heart. See also Cardiac entries; Cardiopulmonary entries

auscultation of, 43–44murmurs and, 44–45, 44t

examination of, 42–45auscultation of heart in, 43–44, 43theart murmurs in, 44–45, 44t

Heart failureacute. See Acute heart failure (AHF)as admission criterion for cardiac intensive care unit, 27–29, 28tin adult congenital heart disease, 422–425

diastolic function abnormalities and, 423etiologies of pump failure and, 422–423failed palliative procedures in, 423–425, 424tmanagement of, 423valve function abnormalities and, 423

chronic. See Chronic heart failurecongestive. See Congestive heart failure (CHF)decompensated. See Decompensated heart failuremultiorgan dysfunction in, 29severe, as indication for pulmonary artery catheterization, 565systolic, with pacemakers, 329troponin elevation and, 199

Heart murmurs, auscultation of, 44–45, 44tHeart rate, 38–39

acute heart failure and, 277–278Heart sounds, 43–44, 43tHematomas

groin, with percutaneous coronary intervention, 271intramural, aortic, 376–377

classification of, 376clinical features of, 376diagnosis of, 376, 376fmanagement of, 376–377pathogenesis of, 376

retroperitoneal, with percutaneous coronary intervention, 271–272Hemocynamids in acute heart failure, 279–280, 281fHemodiafiltration

continuous, principles and technical aspects of, 645tvenovenous, continuous, principles and technical aspects of, 645t

Hemodialysisfor β-adrenergic antagonist cardiotoxicity, 430continuous, principles and technical aspects of, 645tslow low-efficiency, principles and technical aspects of, 645for sodium channel blocker cardiotoxicity, 437venovenous, continuous, principles and technical aspects of, 645t

Hemodynamic compromise as complication of airway management, 625

Hemodynamic factors as plaque rupture triggers, 81Hemodynamic monitoring

in cardiogenic shock, 215, 217tinvasive, 558–569

697

698

Index

Hemodynamic monitoring (Continued)of cardiac output and mixed venous O2 consumption, 562–564,

562f–563fpulmonary artery catheterization for. See Pulmonary artery cath-

eterization (PAC)of systemic arterial blood pressure, 558–562, 559t–560t, 561f

in right ventricular infarction, 230Hemodynamics of cardiac arrest, 660–661Hemofiltration

continuous, principles and technical aspects of, 645tvenovenous, continuous, principles and technical aspects of, 645t

Hemoperfusion for sodium channel blocker cardiotoxicity, 437Hemopericardium with valvular interventions, 265Hemorrhage, 93

acidosis and, 93coagulation component consumption and, 93excessive fibrinolysis and, 93hypothermia and, 93with percutaneous coronary intervention, 271–273

dissection as, 273groin hematoma as, 271pseudoaneurysm as, 272, 272f–273fretroperitoneal hematoma as, 271–272vascular perforation as, 272–273, 273f

with thrombolysis, treatment of, 126, 127fHemostasis, 87–95, 443–444, 444f. See also Coagulation

arterial thrombosis and, 444cell-based model of coagulation and, 444coagulation proteins and, 88–89, 89fdefinition of, 87extravascular tissues and, 87platelets and, 87–88process of, 89–92, 90f–91fvascular bed and, 87wound healing following, 94

Hemostatic disorders, 93–94. See also Hemorrhage; ThrombosisHeparin

broad-spectrum, 527for unstable angina and non-ST-elevation myocardial infarction,

188–191Hepatic impairment as selection criterion for cardiac transplantation,

589High frequency oscillators (HFOs) for acute respiratory distress syn-

drome, 639Hill sign, 45Hirudin for ST-elevation myocardial infarction, 122His-Purkinje action potential

phase 2 of, 489phase 3 of, 489

HMG-CoA (hydroxymethylglutaryl-coenzyme A) reductase inhibitors

drug interactions of, with lipid-lowering drugs, 527tfor ST-elevation myocardial infarction, 167–168

ACC/AHA Task Force recommendations for lipid management and, 167–168

Holosystolic murmurs, 44Holter monitoring in sudden cardiac death survivors, 303Hydralazine, 476–477

for hypertensive emergencies, 363t, 365–366Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase

inhibitorsdrug interactions of, with lipid-lowering drugs, 527tfor ST-elevation myocardial infarction, 167–168


Hyperadrenergic states as hypertensive emergency, 359t, 362–363Hypercapnia, respiratory failure and, 393

Hypertensionaccelerated, 355–356malignant, 355–356postoperative, as hypertensive emergency, 359t, 362pulmonary. See Pulmonary hypertension

Hypertensive emergencies, 355–367as admission criterion for cardiac intensive care unit, 31definition of, 355, 355tdiagnosis of, 356–358, 356t–358teclampsia as, 359t, 361–362etiology of, 356, 357fhyperadrenergic states as, 359t, 362–363hypertensive encephalopathy as, 359–360, 359f, 359tincidence of, 355intracerebral hemorrhage as, 359t, 360, 361fmyocardial infarction as, 359t, 360myocardial ischemia as, 359t, 360pathogenesis of, 356, 356tpostoperative hypertension as, 359t, 362preeclampsia as, 358t–359t, 361–362, 362f, 362tprevalence of, 355prognosis of, 358–359renal insufficiency as, 359t, 360–361stroke as, 359t, 360subarachnoid hemorrhage as, 359t, 360treatment of, 358, 359t, 363–366

enalaprilat in, 363t, 365esmolol in, 363t, 365fenoldopam in, 363t, 366hydralazine in, 363t, 365–366labetalol in, 363t, 365nicardipine in, 363t, 365nitroglycerin in, 363t, 364–365phentolamine in, 363t, 365sodium nitroprusside in, 363–364, 363f, 363t

Hypertensive encephalopathy as hypertensive emergency, 359–360, 359f, 359t

Hypertrophic cardiomyopathy (HCM)auscultation in, 44t, 45as pacemaker indication, 311t–312tsudden cardiac death and, 296–297

Hypokalemia, diuretic-induced, 484Hypomagnesemia, diuretic-induced, 484Hypotension following induction and intubation, 625

techniques to limit, 625–626Hypothermia, hemorrhage and, 93Hypothermia therapy, post resuscitation, 663Hypoventilation in acute respiratory failure, 389Hypoxemia, causes of, 600tHypoxia, 598

IIABP. See Intra-aortic balloon pump (IABP) counterpulsationIbutilide, 495t, 499

cardiotoxicity of, clinical manifestations of, 433clinical effects of, 499indications for, 499pharmacokinetics of, 499pharmacology of, 433side effects of, 499

ICDs. See Implantable cardioverter-defibrillators (ICDs)ICH (intracranial hemorrhage), thrombolytic agents and, 123–124,

123t–124tIdraparinux. See also Pentasaccharides, synthetic

clinical trials of, 448IHD (intermittent hemodialysis), principles and technical aspects of,

645, 645t

699

Index

Illicit drugs, cardiotoxicity of, 437–439Iloprost for pulmonary hypertension, 412Imaging. See also specific modalities

acute myocardial infarction diagnosis and, 103IMH. See Aortic intramural hematoma (IMH)Immunosuppression, posttransplant, 593, 594fImplantable cardioverter-defibrillators (ICDs), 329–330, 329f

drug effects on function of, 333electrical storm and, 331–332implantation guidelines for, 330, 330tinappropriate ICD shock and, 330–331, 330t, 331f–332fineffective therapy using, 333–334interaction with pacemakers, 333pretransplant use of, 592for sudden cardiac death prevention, 248for sudden cardiac death survivors, 305–307, 306f

IMV (intermittent mandatory ventilation), 635Inamrinone, 474Indicator dilution method for cardiac output measurement, 562, 562fInfection(s)

in acute heart failure, treatment of, 286as pacemaker implantation complication, 313–314following percutaneous coronary intervention, 274posttransplant, 596as pulmonary artery catheterization complication, 564as selection criterion for cardiac transplantation, 589–590

Infective endocarditisechocardiography in, 542–543, 542f–543fmitral regurgitation and, treatment of, 345

Infiltrative disease, sudden cardiac death and, 302Inflammation, plaque rupture and, 79–80Inflammatory disease, sudden cardiac death and, 302Inotropes, 470, 470t. See also specific drugs and drug types

for acute heart failure, 289–290, 290tfor airway management, 600for aortic insufficiency, 342for cardiac transplantation, 28for cardiogenic shock, 215drug interactions of, 518–519

affecting absorption and bioavailability, 518affecting elimination, 518–519pharmacodynamic, 519

pretransplant use of, 591for pulmonary embolism, 400for pulmonary hypertension, 413for right ventricular infarction, 229–230

Insulin in ST-elevation myocardial infarction, 166–167Integumental examination, 48–49Intermittent hemodialysis (IHD), principles and technical aspects of,

645, 645tIntermittent mandatory ventilation (IMV), 635Internal jugular central venous line, 550–553, 552fInternal jugular vein for vascular access, 560tIntra-aortic balloon pump (IABP) counterpulsation, 570–578

for acute heart failure, 291for β-adrenergic antagonist cardiotoxicity, 430for arrhythmias, 576cardiac surgery and, 576for cardiogenic shock, 575clinical efficacy and indications for, 573–575, 573t

acute myocardial infarction and, 573–574, 574funstable angina and, 573

complications of, 573contraindications to, 572, 572tfor heart transplantation, 576for high-risk percutaneous coronary intervention, 575–576indications for, as admission criterion for cardiac intensive care unit, 30

Intra-aortic balloon pump (IABP) counterpulsation (Continued)monitoring of, 571–572, 571fphysiologic principles of, 570–571, 570tpump placement for, 572–573pump removal and, 573

Intracerebral hemorrhage as hypertensive emergency, 359t, 360, 361fIntracranial hemorrhage (ICH), thrombolytic agents and, 123–124,

123t–124tIntramural hematomas, aortic, 376–377

classification of, 376clinical features of, 376diagnosis of, 376, 376fmanagement of, 376–377pathogenesis of, 376

Intravenous catheters for airway management, 600Intubation

awake technique for, 604blind, for difficult airway, 616–618

with light wand, 617, 619fnasal, 617, 618fretrograde wire intubation as, 617–618

cardiocerebral resuscitation and, 660equipment check for, 599esophageal, unrecognized, 623–624, 625ffailure of, 623fiberoptic, for difficult airway, 621–622

awake nasal technique for, 621–622, 623foral technique for, 622, 624f

rapid sequence, 607–610, 610tanesthesia induction drugs for, 626modified technique for, 608–610, 610t"sniffing" position for, 604technique for, 607–608

Ischemia. See also Anti-ischemic therapies; Myocardial ischemiademand, troponin elevation and, 197–198recurrent. See Recurrent ischemia after reperfusion therapy

Ischemic mitral regurgitation, echocardiographic evaluation of, 537, 538f

Isoproterenol, 472Itraconazole, interaction with digoxin, 519t

JJet ventilation, transtracheal, for difficult airway, 614, 616f–617fJugular venous pulse, assessment of, 40–41, 40fJustice, 11–12

KKaren Ann Quinlan case, 15Ketamine for anesthesia induction for rapid sequence intubation, 626Kevorkian, Jack, 20Kidneys. See Renal entries

LLabetalol, 497t

for acute myocardial infarction, dosing of, 154tfor hypertensive emergencies, 363t, 365

Lactic acidosis, metformin-induced, 264Language barriers, 14Laryngeal mask airway (LMA), 605, 607f

for difficult airway, 612–613, 613f–615f, 615twith difficult airway, 612–613, 613f–615f, 615t

Laryngoscopy, direct, rigid, 605–610, 607f–609fLBBB (left bundle branch block), acute myocardial infarction diagnosis

and, 103, 103tLeft bundle branch block (LBBB), acute myocardial infarction diagnosis

and, 103, 103tLeft ventricular aneurysm, echocardiographic evaluation of, 534, 536f

700

Index

Left ventricular assist devices (LVADs), 579–585axial flow pumps as, 581–582, 582fas bridge to recovery, 583–584, 584fas bridge to transplantation, 580–581

adverse events with, 580–581, 581tcomplications of, 583, 583f, 583tas destination therapy, 581, 581ffuture directions for, 582–583historical background of, 579, 580f

Left ventricular dysfunction, lung fluid exchange and, 55Left ventricular end-diastolic pressure (LVEDP) in aortic insufficiency,

339–341, 340fLeft ventricular function

echocardiographic evaluation of, 534, 535f–536fevaluation of, in sudden cardiac death survivors, 303thrombolytic therapy and, 116–118, 118ttissue oxygenation and, 62–63

pressure-volume loop and, 62–63, 62f–63fLeft ventricular outflow tract obstruction

dynamic, complicating acute myocardial infarction, 238echocardiographic evaluation of, 537, 538f–539f

Left ventricular pressure-volume relationships, acute heart failure and, 278, 278f–279f

Left ventricular pump performance, determinants of, acute heart failure and, 277–278

Left-to-right shunting, residual, with valvular interventions, 265Levosimendan, 474Lidocaine, 495–496, 495t

for acute myocardial infarction, 166, 242tcardiotoxicity of, clinical manifestations of, 432–433clinical effects of, 495dosage and administration of, 496drug interactions of, 521–522

with antiarrhythmics, 520t–521tindications for, 495–496pharmacokinetics of, 496pharmacology of, 432–433side effects of, 496

Life support, withholding/withdrawing. See Withholding/withdrawing life support

Lipid-lowering drugs, drug interactions of, 527, 527tLisinopril for acute myocardial infarction, dosing for, 163tListening, communication and, 13Lithium, drug interactions of, 517tLithotripsy

extracorporeal shock-wave, with pacemakers, 327with pacemakers, 327

Living wills, 16LMA (laryngeal mask airway), 605, 607f

for difficult airway, 612–613, 613f–615f, 615twith difficult airway, 612–613, 613f–615f, 615t

LMWH. See Low molecular weight heparin (LMWH)Long QT syndrome, sudden cardiac death and, 297–299, 298f–299f,

298tLoss of consciousness as complication of airway management, 625Lovastatin, drug interactions of


Low molecular weight heparin (LMWH), 446for acute myocardial infarction, dosing for, 168tadministration of, 446broad-spectrum, 527clinical trials of, 446metabolism of, 446pharmacokinetics of, 446for ST-elevation myocardial infarction, 131for unstable angina and non-ST-elevation myocardial infarction, 191

Lung(s). See also Pulmonary entries; Respiratory entriesexamination of, 41–42, 41t

Lung biopsy in pulmonary hypertension, 411Lung transplantation

for chronic thromboembolic pulmonary hypertension, 415for pulmonary hypertension, 413

in chronic lung disease, 414LVADs. See Left ventricular assist devices (LVADs)LVEDP (left ventricular end-diastolic pressure) in aortic insufficiency,

339–341, 340f

MMacrolides, drug interactions of, with warfarin, 526tMagnesium for acute myocardial infarction, 166, 242tMagnetic resonance imaging (MRI)

with pacemakers, 328, 328tin right ventricular infarction, 228

Malignancy as selection criterion for cardiac transplantation, 590Malignant hypertension, 355–356Mandibular space for airway examination, 603–604Mask ventilation, 604

masks for, 604technique for, 604, 606f

Mask ventilation capacity, 599, 602tMatrix metalloproteinases (MMPs), plaque rupture and, 79–80Mechanical circulatory support. See Assist devices; Left ventricular

assist devices (LVADs)Mechanical ventilation, 632–643

for acute respiratory distress syndrome, 638–639for acute respiratory failure, 395–396assessment for, 633complications of, 637–638discontinuing, 637–638impact of positive pleural pressure on hemodynamics and,

638–639indications for, 632–633mandatory breaths and, 634

demand-flow volume control and, 635pressure control and, 636volume control and, 636

monitoring of patients on, 636obstructive physiology and, 638–639spontaneous breaths and, 635–636

initial ventilator settings and, 636pressure support and, 636unsupported, 635–636

ventilator alarms and, 636ventilator options and, 633–634

mode and, 633–634waveform analysis and, 636work of breathing and, 636–637

Medical decision makingauthority for, 13minors and, 10patients' right to participate in, 13regarding withholding/withdrawal of life support

patients lacking decision-making capacity and, 15–16patients with decision-making capacity and, 15

surrogate decision makers and, 14–15Medical powers of attorney, 16

Medications. See Drug(s). See also specific drugs and drug types; specific conditions

Metabolic abnormalities with pacemakers, 328–329Metabolic regulation of myocardial oxygen consumption, 69Metformin, lactic acidosis caused by, 264Methylprednisolone, posttransplant, 595tMetoclopramide, interaction with digoxin, 519t

701

Index

Metoprolol, 497tfor acute myocardial infarction, 242t

dosing of, 154tdrug interactions of, 525t

Metronidazole, drug interactions of, with warfarin, 526tMexiletine, 495

cardiotoxicity of, clinical manifestations of, 433drug interactions of, 522interaction with antiarrhythmics, 520t–521tpharmacology of, 433

MI. See Myocardial infarction (MI)Microatelectasis, acute respiratory failure vs., 393Milrinone, 473–474

for acute heart failure, 290for cardiac transplantation, 28for cardiogenic shock, 217t

Minor(s), medical decision making and, 10Minority populations, 32Minute ventilation, 637Mitral balloon valvuloplasty, complications of, 264–265Mitral regurgitation, 234–236

acute, 342–346clinical presentation of, 343, 344tdiagnosis of, 343–345, 344f–345f, 345t, 349fischemic, 346pathophysiology of, 343secondary to papillary muscle rupture, echocardiographic

evaluation of, 539–540, 540ftreatment of, 345

auscultation in, 44–45, 44tclinical features of, 235diagnosis of, 235–236, 235f–236fdue to papillary muscle rupture, as indication for pulmonary artery

catheterization, 566, 566femergency airway management for, 629, 630tmanagement of, 236, 236tpathophysiology of, 234–235

Mitral stenosisacute, 351–352

clinical presentation of, 351, 351tdiagnosis of, 351etiology of, 351treatment of, 351–352

auscultation in, 45emergency airway management for, 629, 630tend-systolic pressure-volume relationship and, 66, 66f

MMPs (matrix metalloproteinases), plaque rupture and, 79–80Morphine, 504–507

for acute heart failure, 286for acute myocardial infarction, 166

ACC/AHA Task Force recommendations for, 166adverse effects of, 166dosage and benefits of, 166mode of action of, 166

cardiovascular effects of, 505–506complications with, 507hemodynamic effects of, 505–506historical background of, 504indications for, 507metabolism of, 505pharmacodynamics of, 505pharmacokinetics of, 505, 506f, 506tside effects of, 506–507, 507fsite of action and receptor physiology and, 504–505, 505tfor ST-elevation myocardial infarction, 216fstructure of, 504toxicity of, 507

Motor nerve examination, 48Moxalactam, drug interactions of, with warfarin, 526tMRI (magnetic resonance imaging)

with pacemakers, 328, 328tin right ventricular infarction, 228

Mueller maneuver, 44tMüller sign, 45Multiorgan dysfunction in heart failure, 29Musculoskeletal examination, 48–49Mycophenolate mofetil, posttransplant, 595tMycophenolic acid, posttransplant, 595tMyocardial depression, direct, as complication of airway management,

625Myocardial dysfunction following resuscitation, 662Myocardial infarction (MI). See also Acute myocardial infarction (AMI)

anterior wall, conduction abnormalities in, 252–253, 252fas hypertensive emergency, 359t, 360inferior wall, conduction abnormalities in, 252–253, 252fas pacemaker indication, 311t–312twith pacemakers, 325–326

Myocardial ischemiain adult congestive heart failure, 421–422coronary blood flow and, 71–72with dynamic coronary artery obstruction, troponin elevation and, 198as hypertensive emergency, 359t, 360

Myocardial oxygen consumption, determinants of, 69–70, 69fautoregulation and, 69–70metabolic, 69

Myoglobin as biomarker for acute myocardial infarction, 99t, 100Myopotential oversensing, 321–322

NNadolol for acute myocardial infarction, dosing of, 154tNafcillin, drug interactions of, with warfarin, 526tNasopharyngeal airways, 604, 606fNASPE/BPEG (North American Society of Pacing and Electrophysiol-

ogy/British Pacing and Electrophysiology Group) generic (NBG) pacemaker code, 310, 313t–314t

Natriuretic peptides for edema in decompensated heart failure, 485Natural supplements for acute myocardial infarction, 172

ACC/AHA Task Force recommendations for, 172Nesiritide, 476

for acute heart failure, 288Neural control of coronary blood flow, 70–71Neurologic dysfunction following resuscitation, 662Neurologic examination, 47–48Neuromuscular weakness, respiratory failure and, 393Nicardipine for hypertensive emergencies, 363t, 365Nitrates. See also specific drugs

for acute myocardial infarction, 155–157ACC/AHA Task Force recommendations for, 156–157adverse effects of, 157dosing, timing, and benefits of, 156–157mode of action of, 156

drug interactions of, 516for unstable angina and non-ST-elevation myocardial infarction, 183,

193tNitrendipine, drug interactions of, 523tNitroglycerin, 476

for acute heart failure, 286–287for cardiogenic shock, 217tfor hypertensive emergencies, 363t, 364–365for ST-elevation myocardial infarction, 216f

Nitroprusside, 474–476, 475ffor acute heart failure, 287–288for aortic insufficiency, 342for cardiogenic shock, 217t

Index

Nitroprusside (Continued)cyanide toxicity and, 363–364, 364tfor hypertensive emergencies, 363–364, 363f, 363tfor mitral regurgitation, 345thiocyanate toxicity and, 364

Nonmaleficence, 11Non-ST-elevation myocardial infarction (NSTEMI). See also Acute

coronary syndromes (ACSs).anti-ischemic therapies for, 183–184, 184t, 193t

β blockers for, 183, 193tcalcium-channel blockers for, 184, 193tnitrates for, 183, 193t

antiplatelet therapy for, 184–188, 189t–191t, 193tabciximab in, 458–459, 458fadenosine diphosphate receptor antagonists in, 455–460aspirin for, 184–185, 189t–191t, 193taspirin in, 453–455, 454f, 455teptifibatide in, 459glycoprotein IIb/IIIa receptor antagonists in, 457–458glycoprotein IIb/IIIa receptor inhibitors for, 185–188, 187f–188f,

187t, 189t–191tthienopyridine agents for, 184t, 185, 186f, 193ttirofiban in, 459–460

antithrombotic therapies for, 188–192, 193tdirect thrombin inhibitors for, 191–192factor Xa inhibitors for, 192heparin for, 188–191low molecular weight heparin for, 191

postdischarge therapy for, 192–193β blockers for, 193angiotensin-converting enzyme inhibitors for, 192angiotensin-receptor blockers for, 192–193

statin therapy for, 192Nonsteroidal anti-inflammatory drugs (NSAIDs). See also Aspirin.

drug interactions of, 517twith warfarin, 526t

Norepinephrine, 472for cardiogenic shock, 215, 217tfor ST-elevation myocardial infarction, 216f

North American Society of Pacing and Electrophysiology/British Pac-ing and Electrophysiology Group (NASPE/BPEG) generic (NBG) pacemaker code, 310, 313t–314t

Nose, examination of, 40NSAIDs (nonsteroidal anti-inflammatory drugs). See also Aspirin.

drug interactions of, 517twith warfarin, 526t

NSTEMI. See Non-ST-elevation myocardial infarction (NSTEMI).Nursing, training for, 5–6Nutritional support, pretransplant, 592

OObesity as selection criterion for cardiac transplantation, 590OKT3, posttransplant, 595tOlanzapine, 513Omeprazole, drug interactions of, with warfarin, 526tOpioid analgesics, 504–513. See also specific drugs.Oropharyngeal airways, 604, 606fOversensing with pacemakers, 320–322Oxygen

for airway management, 598–599, 600tfor ST-elevation myocardial infarction, 216f

Oxygen consumption, myocardial, determinants of, 69–70, 69f

autoregulation and, 69–70metabolic, 69

Oxygen exchange, total pulmonary blood flow and, 52, 52f–53f

Oxygen supplementation, 598–599, 600tfor acute respiratory failure, 393–395for pulmonary embolism, 399for pulmonary hypertension, in chronic lung disease, 414

Oxygen therapy, risks associated with, 394Oxygenation. See also Tissue oxygenation.

for acute heart failure, 286mechanical ventilation and, 636–637

PPAC. See Pulmonary artery catheterization (PAC).PAC(s) (premature atrial contractions) in acute myocardial infarction,

243Pacemaker(s), 310

anesthesia with, 327with biventricular pacing systems, 324–325, 325fcardiopulmonary resuscitation and, 326direct current cardioversion and defibrillation and, 326–327electrocautery and, 327electrotherapy and, 327endoscopic electrocautery with, 327failure of output and, 319failure to capture and, 315–319, 315f–318f, 316timplantable cardioverter-defibrillator interactions with, 333implantation complications with, 313–315

infection as, 313–314thromboembolism as, 314–315thrombosis as, 314–315

lithotripsy with, 327magnetic resonance imaging with, 328, 328tmetabolic abnormalities and, 328–329myocardial infarction and, 325–326NASPE/BPEG generic (NBG) pacemaker code and, 310, 313t–314toversensing and, 320–322pacing problems and, 315permanent

for conduction abnormalities, in acute myocardial infarction, 253–254, 254t

indications for, 310, 311t–312tradiation therapy with, 328rapid paced ventricular rates and, 322–324, 323f–324fsensing problems and, 318f–320f, 319–320, 320t–321tsystolic heart failure with, 329temporary

for conduction abnormalities, in acute myocardial infarction, 253indications for, 310, 313t

undersensing and, 322, 323tPacemaker potential, 490Pacemaker-mediated tachycardia (PMT), 322, 324fPacing for right ventricular infarction, 230Pacing simulation artifact (PSA), 333PaCO2 (arterial carbon dioxide pressure), 388

in acute respiratory failure, 389decreased, as complication of airway management, 625–626

PAOP (pulmonary artery occluded pressure), 561–562Papillary muscle rupture, mitral regurgitation due to, as indication for

pulmonary artery catheterization, 566, 566fParadoxical splitting, 43Paroxysmal supraventricular tachycardia in acute myocardial infarc-

tion, 243Patient partnership, medical decision making and, 13Patient Self-Determination Act (PSDA), 16–17Patients' values and preferences, medical decision making and, 14–15PCI. See Percutaneous coronary intervention (PCI)PD (peritoneal dialysis)

continuous cyclic, principles and technical aspects of, 645tprinciples and technical aspects of, 645, 645t

702

703

Index

PEEP (positive end-expiratory pressure), 633–634in acute respiratory distress syndrome, 639

Pentasaccharidesfor ST-elevation myocardial infarction, 131synthetic, 447–448. See also Fondaparinux; Idraparinux.

administration of, 447clinical trials of, 447–448metabolism of, 447pharmacokinetics of, 447

Percutaneous coronary intervention (PCI), 270–274arterial access and sheath removal techniques for, 270–271arteriovenous fistula following, 273for cardiogenic shock, 219–221, 220fcomplications of, 255–269

abrupt vessel closure as, 260–261air embolism as, 262–263characteristics predictive of high risk for, 257t–258t, 261–262classification of, 257–258complex coronary anatomy and, 258–259contrast toxicities as, 263–264, 264tdeices and, 259management of, 259–260mechanistic categories of, 257–258, 259tmetformin and, 264outcome categories of, 257perforation as, 258, 259tstent infection as, 263

consolidation, 134, 136fearly, feasibility of, 127–128evolution of, 127–128facilitated, 134–136, 137themorrhagic complications of, 271–273

dissection as, 273groin hematoma as, 271pseudoaneurysm as, 272, 272f–273fretroperitoneal hematoma as, 271–272vascular perforation as, 272–273, 273f

high-risk, intra-aortic balloon pump counterpulsation for, 575–576

infection following, 274primary, for ST-elevation myocardial infarction, with glycoprotein

IIb/IIIa receptor antagonists, 464–466, 465frescue, 132–134, 135frisks associated with, 255, 256tfor ST-elevation myocardial infarction, 128–129, 129f

ancillary therapy for, 130–131in cardiogenic shock, 137in elderly patients, 136–137intravenous agents as ancillary therapy for, 130–131limitations of, efforts to overcome, 129–130orally active antiplatelet agents as ancillary therapy for, 130pharmacoinvasive therapy and, 131–136, 132f–136f, 137t

thrombosis following, 273–274valvular, complications of, 264–265

Pericardial disease, 380–387. See also Cardiac tamponade; Pericardial effusion; Pericarditis.

in ischemic heart disease, 380–382chest pain and, 380–381

simulating ischemic syndromes, 380, 380tPericardial effusion

echocardiography in, 542, 542fin ischemic heart disease, 382

Pericardiocentesis for pericardial tamponade, 386Pericarditis

acutebiomarkers for, 381–382, 382fin ischemic heart disease, 381

Pericarditis (Continued)constrictive, 386

as indication for pulmonary artery catheterization, 567, 568fPerindopril for acute myocardial infarction, dosing for, 163tPeripheral intravenous line, 545–546, 546fPeripheral vascular disease as selection criterion for cardiac transplan-

tation, 589Peritoneal dialysis (PD)

continuous cyclic, principles and technical aspects of, 645tprinciples and technical aspects of, 645, 645t

Pharmacoinvasive therapy for ST-elevation myocardial infarction, 115f, 119f, 127f, 129f, 131–136, 132f–136f, 137t

Pharmacologic therapy. See Drug(s). See also specific drugs and drug types; specific conditions.

Pharyngeal size, airway examination and, 604fPhenothiazines, cardiotoxicity of, 434–435Phentolamine for hypertensive emergencies, 363t, 365Phenylbutazone, drug interactions of, with warfarin, 526tPhenytoin

drug interactions of, with warfarin, 526tpharmacology of, 433toxicity of, clinical manifestations of, 433

Pheochromocytoma, hypertensive emergency and, 362–363Phosphodiesterase inhibitors, 473–474, 473f, 473t. See also specific

drugs.for β-adrenergic antagonist cardiotoxicity, 430

Physical examination, 36–50abdominal, 45–47for acute myocardial infarction diagnosis, 101–102of chest and lungs, 41–42, 41tgeneral assessment in, 36of head, eyes, ears, nose, and throat, 40jugular venous pulse and abdominojugular reflux in,

40–41, 40fmusculoskeletal and integumental, 48–49neurologic, 47–48of thorax and heart, 42–45

auscultation of heart in, 43–44, 43theart murmurs in, 44–45, 44t

vascular, 48vital signs in, 36–40, 37t–38t

Physical therapy, pretransplant, 592Pindolol for acute myocardial infarction, dosing of, 154tPlaque, development of, 73–76

fatty streak and, 73–76, 74f–75fplaque formation and, 76, 76f–78f

Plaque rupture, 79–81triggers for, 80–81

cap and plaque compression as, 80–81cap tension as, 80, 80fcircumferential bending as, 81hemodynamic factors as, 81longitudinal flexion as, 81

vulnerability to, 79–80cap thickness and content and, 79core size and content and, 79inflammation and, 79–80

Plasma protease inhibitors, coagulation regulation by, 92Platelet(s)

hemostasis and, 87–88thrombin generation on surface of, propagation of, 90–92, 91f

Platelet activation, thrombosis and, 82, 82fPlatelet adenosine diphosphate receptor inhibitors for ST-elevation

myocardial infarction, 114, 130Platelet adherence, thrombosis and, 81, 81fPlatelet aggregation, thrombosis and, 82, 82fPMT (pacemaker-mediated tachycardia), 322, 324f

704

Index

Pneumoniaacute respiratory failure vs., 391atelectasis vs., 392monitoring for, with mechanical ventilation, 637

Pneumothorax, monitoring for, with mechanical ventilation, 637Positive airway pressure for acute respiratory failure, 394–395Positive end-expiratory pressure (PEEP), 633–634

in acute respiratory distress syndrome, 639Positive inotropic antagonists for edema in decompensated heart

failure, 485–486Positive pressure ventilations, cardiocerebral resuscitation and,

659–660Postoperative hypertension as hypertensive emergency, 359t, 362Potassium supplements, drug interactions of, 517tPotts procedure for adult congestive heart failure, 423–424, 424tPrasugrel for acute myocardial infarction, dosing for, 148tPrecordial thump, 653Prednisone, posttransplant, 595tPreeclampsia as hypertensive emergency, 358t–359t, 361–362, 362f, 362tPreferences of patient, 14–15Preload

acute heart failure and, 277decreased, with left ventricular assist devices, 583pressure-volume loop and, 63, 63freduction of, for right ventricular infarction, 230right ventricular, decreased, as complication of airway management,

625Premature atrial contractions (PACs) in acute myocardial infarction,

243Preoxygenation for airway management, 598–599, 601fPressure-volume loop, left ventricular function, tissue oxygenation and,

62–63, 62f–63fPrinciple of double effect, 21Principlism, 10–12

autonomy and, 10beneficence and, 10–11justice and, 11–12nonmaleficence and, 11

Probucol, drug interactions of, with lipid-lowering drugs, 527tProcainamide, 494–495, 495t

for acute myocardial infarction, 242tcardiotoxicity of, clinical manifestations of, 432clinical effects of, 494dosage and administration of, 494drug interactions of, 521indications for, 494interaction with antiarrhythmics, 520t–521tpharmacokinetics of, 494pharmacology of, 432side effects of, 494–495

Propafenone, drug interactions of, 522with antiarrhythmics, 520t–521twith digoxin, 519twith warfarin, 526t

Propofol, 510–512for anesthesia induction, for rapid sequence intubation, 626cardiovascular effects of, 510–511complications of, 511hemodynamic effects of, 510–511historical background of, 510indications for, 511–512metabolism of, 510pharmacodynamics of, 510pharmacokinetics of, 510side effects of, 511structure of, 510toxicity of, 511

Proportionate treatment, 15–16Propoxyphene, cardiotoxicity of, 435Propranolol, 495t, 497t

for acute myocardial infarction, 242tdosing of, 154t

drug interactions of, 525tProstanoids for pulmonary hypertension, 412Prosthetic material failure in adult congestive heart failure,

424–425Prosthetic valve dysfunction

acute, 346–348clinical presentation of, 347congestive heart failure and, 347–348diagnosis of, 347endocarditis and, 348etiology of, 346–347, 346tthrombotic, 348treatment of, 347–348

in adult congestive heart failure, 424–425Prosthetic valve endocarditis (PVE), treatment of, 348Prosthetic valve thrombosis (PVT), treatment of, 348Protein C, 88Protein S, 88PSA (pacing simulation artifact), 333PSDA (Patient Self-Determination Act), 16–17Pseudoaneurysms with percutaneous coronary intervention, 272,

272f–273fPsychosocial issues as selection criterion for cardiac transplantation,

590Pulmonary angiography in pulmonary hypertension, 409, 411fPulmonary artery catheterization (PAC)

in acute heart failure, 285–286catheter for, 559catheter insertion and, 555–556, 556f, 560–561, 560t, 561fcomplications of, 563–564

arrhythmias and atrioventricular block as, 563infection as, 564pulmonary vascular damage as, 563–564thrombosis as, 564

controversies about, 567–568, 568tequipment and signal calibration for, 560, 560thistorical background of, 558–561indications for, 564–568, 564t

acute myocardial infarction as, 565–566constrictive pericarditis as, 567, 568flow cardiac output as, 566mitral regurgitation due to papillary muscle rupture as, 566,

566fpericardial tamponade as, 565, 565fpulmonary edema as, 565restrictive cardiomyopathy as, 567right ventricular infarction as, 567, 567fsevere heart failure as, 565shock as, 566ventricular septal defect as, 566–567

Pulmonary artery occluded pressure (PAOP), 561–562Pulmonary blood flow

distribution of, 54–55, 54f–55ftotal, oxygen exchange and, 52f–53f

Pulmonary disease. See also specific disorders.troponin elevation and, 199

Pulmonary edemaas indication for pulmonary artery catheterization, 565reperfusion, following thromboendarterectomy, 415

Pulmonary embolectomy, 402percutaneous, 402surgical, 402

Index

705

Pulmonary embolismacute heart failure and, 275–277, 276tas admission criterion for cardiac intensive care unit, 31cardiogenic, noncardiogenic pulmonary embolism differentiated

from, 283–284, 283t, 284fechocardiography in, 541, 541fmassive, 398–404

definition of, 398–399diagnosis of, 399, 399ffluid loading for, 399–400inotropic support for, 400oxygen supplementation for, 399pulmonary embolectomy for, 402thrombolytic therapy for, 400–402, 400t–402t

noncardiogenic, cardiogenic pulmonary embolism differentiated from, 283–284, 283t, 284f

as pacemaker implantation complication, 314–315severe, acute heart failure with, 282submassive, thrombolytic therapy for, 401–402

Pulmonary function as selection criterion for cardiac transplantation, 589

Pulmonary gas exchange, cardiovascular function and. See Cardiovas-cular function, pulmonary gas exchange and.

Pulmonary hemorrhage in adult congestive heart failure, 425Pulmonary hypertension, 405–417

as admission criterion for cardiac intensive care unit, 29classification of, 406–414, 406tclinical presentation of, 407, 407tdiagnostic evaluation of, 407–411, 408f–412fpostoperative, 414pulmonary vascular anatomy and physiology and, 405–406as selection criterion for cardiac transplantation, 589thromboembolic, chronic, 414–415, 415ftreatment of, 411–414

in chronic lung disease, 413–414for idiopathic pulmonary arterial hypertension, 411–413

Pulmonary regurgitation, auscultation in, 45Pulmonary stenosis, auscultation in, 44tPulmonary transit time, 53–54, 53fPulmonary vascular damage as pulmonary artery catheterization

complication, 563–564Pulmonary vasodilators for right ventricular infarction, 230Pulse, assessment of, 38–39, 38tPulse oximetry, airway management and, 600PVE (prosthetic valve endocarditis), treatment of, 348PVT (prosthetic valve thrombosis), treatment of, 348

QQ waves in right ventricular infarction, 228Quinapril for acute myocardial infarction, dosing for, 163tQuincke sign, 45Quinidine

cardiotoxicity of, clinical manifestations of, 431–432drug interactions of, 519–521

with antiarrhythmics, 520t–521twith digoxin, 519twith warfarin, 526t

pharmacology of, 431–432Quinine, interaction with digoxin, 519tQuinlan, Karen Ann case, 15Quinolones, drug interactions of, with warfarin, 526t

RRadial arterial line, 546–547, 547fRadiation therapy with pacemakers, 328Rales, 41Ramipril for acute myocardial infarction, dosing for, 163t

Ranitidine, drug interactions of, with warfarin, 526tRapid paced ventricular rates with pacemakers, 322–324, 323f–324fRapid sequence intubation (RSI), 607–610, 610t

anesthesia induction drugs for, 626"sniffing" position for, 604technique for, 607–608

modified, 608–610, 610tRationing, futility vs., 11–12Recurrent ischemia after reperfusion therapy, 203–211

consequences of, 204–205, 205tincidence of, 203–204predictors of, 203, 203fprevention of, 205–206recognition of, 206–207treatment of, 207–208

Reflexes, coronary blood flow and, 70–71Refusal of treatment, patient's right to, 10Reinfarction, diagnosis of, 103Relative tongue/pharyngeal size for airway examination, 603, 604fRenal disease, end-stage

renal replacement therapy for patients with, 648troponin elevation and, 199–200

Renal impairment as selection criterion for cardiac transplantation, 589Renal insufficiency

chronic, troponin elevation and, 199–200as hypertensive emergency, 359t, 360–361

Renal replacement therapy (RRT), 644–651continuous cyclic peritoneal dialysis for, 645tcontinuous hemodiafiltration for, 645tcontinuous hemodialysis for, 645tcontinuous hemofiltration for, 645tcontinuous renal replacement therapy for, 645–646, 645tcontinuous venovenous hemodiafiltration for, 645tcontinuous venovenous hemodialysis for, 645tcontinuous venovenous hemofiltration for, 645tfor end-stage renal disease patients, 648goals of, 647–648hemodialysis for

for β-adrenergic antagonist cardiotoxicity, 430continuous, 645tcontinuous venovenous, 645tfor sodium channel blocker cardiotoxicity, 437

indications for, 644initiation of, optimal time for, 646–647intermittent hemodialysis for, 645, 645tmonitoring parameters for, 647–648optimal does of, 647peritoneal dialysis for, 645, 645tprinciples and technical aspects of, 644–646, 644t–645tslow continuous ultrafiltration for, 645tslow intermittent ultrafiltration for, 645tslow low-efficiency dialysis/extended daily dialysis for, 645,

645tRenin-angiotensin-aldosterone system inhibitors, for acute myocardial

infarction, 157–164ACC/AHA Task Force recommendations for, 163–164adverse effects of, 162–163dosing, timing, and benefits of, 159–162, 160t–161t, 163tmode of action of, 157–159, 158f–159f

Reperfusion therapy. See also Coronary artery bypass grafting (CABG); Percutaneous coronary intervention (PCI); Thrombo-lytic therapy.

for cardiogenic shock, 219–221recurrent ischemia after, 203–211

consequences of, 204–205, 205tincidence of, 203–204predictors of, 203, 203f

Index

Reperfusion therapy (Continued)prevention of, 205–206recognition of, 206–207treatment of, 207–208

for right ventricular infarction, 229Research platforms, 7, 7tResistance vessels, coronary blood flow and, 70Respiration, assessment of, 37–38, 37tRespiratory distress, acute, mechanical ventilation and,

638–639Respiratory failure

acute. See Acute respiratory failure (ARF).due to gas exchange problems, emergency airway management for,

627–628Respiratory rate, mechanical ventilation and, 637Restrictive cardiomyopathy as indication for pulmonary artery

catheterization, 567Resuscitation. See Cardiocerebral resuscitation (CCR);

Cardiopulmonary resuscitation (CPR).Retroperitoneal hematomas with percutaneous coronary intervention,

271–272Revascularization for sudden cardiac death survivors, 304–305Rhonchi, 42Rifampin

drug interactions of, with warfarin, 526tinteraction with digoxin, 519t

Right heart catheterization, historical background of, 558–561Right ventricular afterload, increased, as complication of airway

management, 625Right ventricular assist devices for right ventricular infarction, 230Right ventricular dysfunction, echocardiographic exclusion of,

536–537, 537fRight ventricular dysplasia, arrhythmogenic, sudden cardiac death and,

300–301, 302fRight ventricular infarction, 225–232

clinical presentation of, 226–227complications of, 230–231, 230tcoronary circulation and, 225–226diagnosis of, 227–228

electrocardiographic, 227–228, 227fmagnetic resonance imaging in, 228

historical background of, 225as indication for pulmonary artery catheterization, 567, 567fprognosis of, 228, 231treatment of, 229–230, 229f

hemodynamic monitoring and, 230inotropic support for, 229–230pacing and, 230preload and afterload reduction for, 230pulmonary vasodilator therapy for, 230reperfusion therapy for, 229right ventricular assist devices for, 230volume infusion for, 229

ventricular independence and, 226, 226f, 226tRight ventricular preload, decreased, as complication of airway

management, 625Right-to-left shunt

in acute respiratory failure, 390acute respiratory failure vs., 393

Rigid bronchoscope for difficult airway, 613–614, 615f–616fRigid direct laryngoscopy, 605–610, 607f–609fRRT. See Renal replacement therapy (RRT)RSI (rapid sequence intubation), 607–610, 610t

anesthesia induction drugs for, 626"sniffing" position for, 604technique for, 607–608

modified, 608–610, 610t

SSAECG (signal-averaged echocardiography) in sudden cardiac death

survivors, 303SCD. See Sudden cardiac death (SCD).SCUF (slow continuous ultrafiltration), principles and technical aspects

of, 645tSedation for difficult airway, 619Selective serotonin reuptake inhibitors (SSRIs), drug interactions of,

with warfarin, 526tSensing problems with pacemakers, 318f–320f, 319–320, 320t–321tSensory nerve examination, 48Sertraline, drug interactions of, with warfarin, 526tShock

cardiogenic. See Cardiogenic shock.as indication for pulmonary artery catheterization, 566

Short QT syndrome, sudden cardiac death and, 299, 301fShunting

left-to-right, residual, with valvular interventions, 265right-to-left, in acute respiratory failure, 390

Sicilian Gambit, 492–494, 493tdistribution and, 493–494drug absorption and, 492metabolism and elimination and, 494pharmacology of, 492–494

Signal-averaged echocardiography (SAECG) in sudden cardiac death survivors, 303

Sildenafil for pulmonary hypertension, 412Simvastatin, drug interactions of, with lipid-lowering drugs, 527tSinoatrial block, in acute myocardial infarction, 251Sinoatrial node action potential, 489–490, 490f


Sinus arrest in acute myocardial infarction, 251Sinus bradycardia in acute myocardial infarction, 251Sinus node dysfunction as pacemaker indication, 311t–312tSinus tachycardia in acute myocardial infarction, 241, 242tSirolimus, posttransplant, 595tSIUF (slow intermittent ultrafiltration), principles and technical aspects

of, 645tSK (streptokinase) for ST-elevation myocardial infarction, 112–114,

113tSLED (slow low-efficiency dialysis), principles and technical aspects of,

645, 645tSlow continuous ultrafiltration (SCUF), principles and technical

aspects of, 645tSlow intermittent ultrafiltration (SIUF), principles and technical

aspects of, 645tSlow low-efficiency dialysis (SLED), principles and technical aspects of,

645, 645tSodium, management of, in decompensated heart failure, 483tSodium bicarbonate for sodium channel blocker cardiotoxicity, 436Sodium channel blocking agents, 431t. See also Antiarrhythmics.

cardiotoxicity of, 431–433clinical manifestations of, 431–433management of, 435–437, 436tpathophysiology of, 431

pharmacology of, 431–433Sodium management in decompensated heart failure, 483Sodium nitroprusside. See Nitroprusside.Sotalol

drug interactions of, 522implantable cardioverter-defibrillator function and, 333

Spironolactonefor acute myocardial infarction, dosing for, 163tinteraction with digoxin, 519t

706

Index

Splitting of S2, 43Squatting, 44tST segment. See also ST-elevation myocardial infarction (STEMI).

in right ventricular infarction, 227–228, 227fStaphylokinase for ST-elevation myocardial infarction, 113t, 114Statins

for non-ST-elevation myocardial infarction, 192for ST-elevation myocardial infarction, 167–168


for unstable angina, 192ST-elevation myocardial infarction (STEMI)

ACC/AHA Task Force recommendations for. See ACC/AHA Task Force.

antiplatelet therapy for, 460–466emergency management of, 216fglycemic control in, 166–167insulin in, 166–167reperfusion therapies for, 110–144

conjunctive therapy and, 121–122fundamental concepts underlying, 110–111historical background of, 110percutaneous coronary intervention as, 127–128. See also

Percutaneous coronary intervention (PCI).pharmacoinvasive, 131–136, 132f–136f, 137tpharmacologic, 111–114, 112f. See also Thrombolytic therapy.

Stenosis, degree of, thrombus formation and, 83Stents

for coronary perforations, 260infection of, with percutaneous coronary intervention, 263

Streptokinase (SK) for ST-elevation myocardial infarction, 112–114, 113t

Strokein adult congestive heart failure, 425as hypertensive emergency, 359t, 360as selection criterion for cardiac transplantation, 589thrombolytic agents and, 123–124, 123t–124t

Subarachnoid hemorrhage as hypertensive emergency, 359t, 360Subclavian central venous line, 553–555, 554fSubclavian vein for vascular access, 560tSubstituted judgment standard, 16Sucralfate, interaction with digoxin, 519tSuction for airway management, 599Sudden cardiac death (SCD), 293–309

clinical presentation of, 302, 303fdefinition of, 293epidemiology of, 293, 294fpathophysiology of, 293–302

arrhythmogenic right ventricular dysplasia and, 300–301, 302fBrugada syndrome and, 299, 300fcatecholinergic polymorphic ventricular tachycardia and, 299–300clinical substrate and, 295, 295f–296fconduction system abnormalities and, 301congenital heart disease and, 301coronary artery disease and, 295–296dilated cardiomyopathy and, 297functional modulators and, 295hypertrophic cardiomyopathy and, 296–297inflammatory and infiltrative disease and, 302long QT syndrome and, 297–299, 298f–299f, 298tpathological substrates and, 293–294short QT syndrome and, 299, 301fvalvular heart disease and, 301–302Wolff-Parkinson-White syndrome and, 301

prevention of, 247–248β-adrenoreceptor antagonists for, 248coronary care unit for, 247

Sudden cardiac death (SCD) (Continued)implantable cardioverter-defibrillators for, 248thrombolytic therapy for, 247–248

survivors of. See Sudden cardiac death survivors.Sudden cardiac death survivors

evaluation of, 302–304therapy for, 304–307

automatic external defibrillator for, 305catheter ablation for, 305implantable cardioverter defibrillator for, 305–307, 306fmyocardial revascularization and arrhythmia surgery for, 304–305pharmacologic, 304wearable automatic defibrillator for, 307, 307f

Suicide, assisted, 21Sulfinpyrazone, drug interactions of, with warfarin, 526tSulfonylureas, drug interactions of, 517tSupraventricular arrhythmias in acute myocardial infarction, 241–243,

241tatrial arrhythmias as, 241–243atrial fibrillation and flutter as, 243paroxysmal supraventricular tachycardia as, 243premature atrial contractions as, 243sinus tachycardia as, 241, 242t

Surgery. See also specific procedures.cardiac, intra-aortic balloon pump counterpulsation for, 576postoperative hypertension and, 359t, 362postoperative pulmonary hypertension and, 414pulmonary hypertension following, 414

Surgical airway, 614–616open cricothyroidotomy and, 616, 617fpercutaneous cricothyroidotomy and, 614–615tracheostomy and, 616, 618ftranstracheal jet ventilation and, 614, 616f–617f

Surrogate decision makers, 14–15Sympathomimetics, 470–472, 470t. See also specific drugsSystemic arterial blood pressure, monitoring of, 558–562, 559t

pulmonary artery occluded pressure and, 561–562right heart and pulmonary artery catheterization for, 558–561, 560t,

561fwedge pressure and, 561–562

Systemic gas exchange, cardiovascular function and, 57fSystemic-pulmonary arterial shunts, for adult congestive heart failure,

423–424, 424tSystolic dysfunction, acute, end-systolic pressure-volume relationship

and, 65, 65fSystolic heart failure with pacemakers, 329

TT wave alternans in sudden cardiac death survivors, 304T wave oversensing, 321Tachycardia, 38

prevention of, as pacemaker indication, 311t–312tTacrolimus, posttransplant, 595tTamponade. See Cardiac tamponadeTechnology, CCU needs for, 6–7TF (tissue factor), 88Thienopyridines. See also specific drugs.

for acute myocardial infarction, 150–153ACC/AHA Task Force recommendations for, 152–153adverse effects of, 152dosing, timing, and benefits of, 148t, 151–152mode of action of, 150–151, 151f

drug interactions of, 525–526for ST-elevation myocardial infarction, ACC/AHA Task Force

recommendations for, 152–153for unstable angina and non-ST-elevation myocardial infarction, 185,

186f, 193t

707

Index

Thiocyanate toxicity, sodium nitroprusside and, 364Thiopental for anesthesia induction, for rapid sequence intubation, 626Thorax, examination of, 42–45Throat, examination of, 40Thrombin, 88–89

amplification of procoagulant signal by, 90, 91fgeneration in platelet surface, propagation of, 90–92, 91fgeneration of, 89–90, 90finhibitors of. See Antithrombin therapy; Direct thrombin inhibitors

(DTIs); Low molecular weight heparin (LMWH); Pentasac-charides; Unfractionated heparin (UFH); specific antithrombin agents; specific drugs.

Thromboembolic pulmonary hypertension, chronic, 414–415, 415fThromboembolism as pacemaker implantation complication, 314–315Thromboendarterectomy for chronic thromboembolic pulmonary

hypertension, 414, 415fThrombolytic therapy

agents for, 111–114, 112f, 113tnon-fibrin-selective (first generation), 112–114, 113trelatively fibrin-selective (second generation), 113t, 114third-generation, 114

clinical trials of, 114–121direct comparison, mortality in, 119–120, 119f, 120tearly, 114–115, 115fimportance of early treatment and, 120–121left ventricular function and, 116–118, 118tpatency trials and, 115–116, 116t–117tpivotal, 118–119

complications of, 124–126conjunctive therapy with, 121–122

alternatives to unfractionated heparin for, 122platelet-targeted, 121thrombin-targeted, 121

fundamental concepts underlying, 110–111hemodynamic effects of, 400intracranial hemorrhage and stroke associated with, 123–124, 123t–124tpathogenesis of acute myocardial infarction and, 111, 111fpatient selection for, 124–126, 125tfor pulmonary embolism, 400–402

contraindications to, 402, 402teffects on recurrent pulmonary embolism, major bleeding, and

mortality, 400–402, 400t–401tmassive, 401reduction of pulmonary vascular obstruction by, 400regimens for, 402submassive, 401–402

specific patient groups and, 124–126for ST-elevation myocardial infarction, with glycoprotein IIb/IIIa

receptor antagonists, 463–464for sudden cardiac death prevention, 247–248value of, 111–114, 112f

Thrombosis, 81–84, 94arterial, 94, 444coagulation cascade and, 82–83, 82ffactors affecting thrombus formation and, 83–84

local, 83systemic, 83–84

fibrinolysis and, 83as pacemaker implantation complication, 314–315following percutaneous coronary intervention, 273–274platelet activation and aggregation and, 82, 82fplatelet adherence and, 81, 81fprosthetic valve, treatment of, 348as pulmonary artery catheterization complication, 564recurrent, atherogenesis progression and, 78–79residual, thrombus formation and, 83venous, 94

Thymoglobulin, posttransplant, 595tThyromental distance for airway examination, 603–604Ticlopidine. See also Antiplatelet therapy.

for acute myocardial infarction, dosing for, 148t, 168tdrug interactions of, 525for unstable angina and non-ST-elevation myocardial infarction, dos-

ing for, 189t–191tTidal volume, 637Timolol for acute myocardial infarction, dosing of, 154tTirofiban. See also Antiplatelet therapy; Glycoprotein IIb/IIIa receptor

blockers.clinical indications for, 187tfor non-ST-elevation myocardial infarction, 459–460

dosing for, 189t–191tfor unstable angina, 459–460

dosing for, 189t–191tTissue factor (TF), 88Tissue oxygenation

cardiac output regulation and, 61–68arteriovenous oxygen difference and, 61end-systolic pressure-volume relationship and, 63–64, 64fleft ventricular performance and, 62–63, 62f–63freflex control and, 61–62, 62t

end-systolic pressure-volume relationship and. See End-systolic pressure-volume relationship (ESPVR), tissue oxygenation and.

Tissue-type plasminogen activator (tPA) for ST-elevation myocardial infarction, 113t, 114

Tissue-type plasminogen activator mutants for ST-elevation myocar-dial infarction, 114

Tocainidecardiotoxicity of, clinical manifestations of, 433pharmacology of, 433

Tongue/pharyngeal size, relative, for airway examination, 603, 604fTorsades de pointes, suppression of, 247Total pulmonary blood flow, oxygen exchange and, 52, 52f–53ftPA (tissue-type plasminogen activator) for ST-elevation myocardial

infarction, 113t, 114Tracheostomy for difficult airway, 616, 618fTrandolapril for acute myocardial infarction, dosing for, 163tTranstracheal jet ventilation for difficult airway, 614, 616f–617fTraube sign, 45Trauma patients, airway examination in, 604Treppe effect, 278Treprostenol for pulmonary hypertension, 412Triage, justice and, 11Tricuspid regurgitation

acute, 348–350clinical presentation of, 349diagnosis of, 349, 349fetiology of, 348–349treatment of, 349–350

auscultation in, 44, 44tTricuspid stenosis, auscultation in, 45Trifascicular block, chronic, as pacemaker indication, 311t–312tTroponins, 196–202

assays of, 197biochemistry of, 196–197, 197fas biomarker for acute myocardial infarction, 98–100, 99t

diagnosis and, 98–99, 99fprognosis and, 99–100risk stratification and, 100

elevation in thrombotic and nonthrombotic mechanisms, prognostic significance of, 200

elevation of, nonthrombotic mechanisms of, 197–200, 198tchronic renal insufficiency and end-stage renal disease as, 199–200demand ischemia as, 197–198direct myocardial damage as, 198–199

708

709

Index

Troponins (Continued)heart failure as, 199myocardial ischemia with dynamic coronary artery obstruction

as, 198pulmonary disease as, 199

myocardial damage and, 197

UUA. See Unstable angina (UA).UFH. See Unfractionated heparin (UFH).UK (urokinase) for ST-elevation myocardial infarction, 113, 113tUlcers, aortic, penetrating, 374–376

clinical features of, 374–375diagnosis of, 375, 375flaboratory findings in, 375management of, 376pathogenesis of, 374, 374fpredisposing factors for, 374

Ultrafiltrationfor heart failure

acute, 290–291decompensated, 648–649, 649f

slow continuous, principles and technical aspects of, 645tslow intermittent, principles and technical aspects of, 645t

Undersensing with pacemakers, 322, 323tUnfractionated heparin (UFH), 445. See also Anticoagulation.

for acute myocardial infarction, dosing for, 168tadministration of, 445clinical trials of, 445dosing and monitoring of, 445metabolism of, 445pharmacokinetics of, 445side effects of, 445for ST-elevation myocardial infarction, 121, 131for unstable angina and non-ST-elevation myocardial infarction,

dosing for, 189t–191tUnstable angina (UA). See also Acute coronary syndromes (ACSs).

anti-ischemic therapies for, 183–184, 184t, 193tβ blockers for, 183, 193tcalcium-channel blockers for, 184, 193tnitrates for, 183, 193t

antiplatelet therapy for, 184–188, 189t–191t, 193tabciximab in, 458–459, 458fadenosine diphosphate receptor antagonists in, 455–460aspirin for, 184–185, 189t–191t, 193taspirin in, 453–455, 454f, 455teptifibatide in, 459glycoprotein IIb/IIIa receptor antagonists in, 457–458glycoprotein IIb/IIIa receptor inhibitors for, 185–188, 187f–188f,

187t, 189t–191tthienopyridine agents for, 184t, 185, 186f, 193ttirofiban in, 459–460

antithrombotic therapies for, 188–192, 193tdirect thrombin inhibitors for, 191–192factor Xa inhibitors for, 192heparin for, 188–191low molecular weight heparin for, 191

intra-aortic balloon pump counterpulsation for, 573postdischarge therapy for, 192–193

β blockers for, 193angiotensin-converting enzyme inhibitors for, 192angiotensin-receptor blockers for, 192–193

statin therapy for, 192Urokinase (UK) for ST-elevation myocardial infarction, 113, 113tUrokinase-type plasminogen activator for ST-elevation myocardial

infarction, 113t

VValsalva maneuver, 38, 44tValsartan for acute myocardial infarction, dosing for, 163tValues

culturalethical issues and, 21–22medical decision making and, 21–22

of patient, medical decision making and, 14–15Valve replacement for aortic insufficiency, 342, 342tValvular heart disease. See also specific disorders.

acute, 339–354as admission criterion for cardiac intensive care unit, 30–31emergency airway management for, 628–629, 630tsudden cardiac death and, 301–302

Valvular regurgitation. See also specific valves.end-systolic pressure-volume relationship and, 66, 66f

Vascular access, 545–557brachial arterial line for, 547–548, 548fexternal jugular central venous line for, 553, 553ffemoral arterial line for, 548–550, 549ffemoral central venous line for, 550, 551ffemoral vein for, 560tinternal jugular central venous line for, 550–553, 552finternal jugular vein for, 560tperipheral intravenous line for, 545–546, 546fpulmonary artery catheter placement for, 555–556, 556fradial arterial line for, 546–547, 547fsubclavian central venous line for, 553–555, 554fsubclavian vein for, 560t

Vascular bed, hemostasis and, 87Vascular examination, 48Vascular perforation, with percutaneous coronary intervention, 258,

259t, 272–273, 273fwith complex coronary anatomy, 258–259with devices, 259with glycoprotein IIb/IIIa inhibitors, 259

Vasoactive agents, 470, 470t. See also specific drugs and drug types.Vasoconstriction for difficult airway, 619–621, 621f–622fVasodilation as complication of airway management, 625Vasodilators, 474–477. See also specific drugs.

for acute heart failure, 286–288, 287ffor aortic insufficiency, 342drug interactions of, 516for mitral regurgitation, 345pretransplant use of, 591pulmonary, for right ventricular infarction, 230for pulmonary hypertension, in chronic lung disease, 414

Vasopressin antagonists for edema in decompensated heart failure, 485

Vasopressorsfor acute heart failure, 290for airway management, 600for cardiogenic shock, 215for pulmonary hypertension, 413

Vasospasm, plaque rupture and, 80–81Vaughan-Williams classification system for antiarrhythmics, 490–492,

491tVentilation, failure of, 623Ventilation/perfusion (V/Q) ratio, 388

mismatching and, in acute respiratory failure, 389–390, 389fVentilation/perfusion (V/Q) scanning in pulmonary hypertension, 409,

410fVentilator alarms, 636Ventilatory failure due to airway compromise, emergency airway man-

agement for, 627Ventricular arrhythmias. See also specific arrhythmias.

in acute myocardial infarction, 241t, 243–247

Index

Ventricular arrhythmias (Continued)accelerated idioventricular rhythm as, 245cardioversion for, 245–246defibrillation for, 245–246suppression of, 247therapy for, 245torsades de pointes as, 247ventricular fibrillation as, 245–247ventricular premature beats as, 244, 247ventricular tachycardia as, 244–247, 244t

etiology of, 652Ventricular dysfunction, posttransplant, 594, 596tVentricular fibrillation (VF)

in acute myocardial infarction, 245cardioversion for, 246circulatory phase of, defibrillation and, 654defibrillation for, 246, 663–664, 664felectrical vs. circulatory phase of, cardiocerebral resuscitation and,

659, 659fphases of, 652–653, 653fsuppression of, 247

Ventricular fibrillation storm, 654Ventricular function, lung disease and, pulmonary gas exchange and,

55–56Ventricular function-mortality paradox, 117Ventricular independence, right ventricular infarction and, 226, 226f,

226tVentricular infarction, right, as indication for pulmonary artery

catheterization, 567, 567fVentricular premature beats (VPBs)

in acute myocardial infarction, 244suppression of, 247

Ventricular rates, rapid paced, with pacemakers, 322–324, 323f–324fVentricular septal defect (VSD)

auscultation in, 44tas indication for pulmonary artery catheterization, 566–567

Ventricular septal rupture, 236–238clinical features of, 237diagnosis of, 237, 237f–238fechocardiographic evaluation of, 539, 539fmanagement of, 237–238, 238tpathophysiology of, 236–237

Ventricular tachyarrhythmias in adult congestive heart failure, 421Ventricular tachycardia (VT)

in acute myocardial infarction, 244–245, 244tcardioversion for, 245–246defibrillation for, 245–246polymorphic, catecholinergic, sudden cardiac death and, 299–300recurrent, 654suppression of, 247

Verapamil, 495t, 499. See also Calcium-channel blockers (CCBs).for acute myocardial infarction, 242tdrug interactions of, 523tinteraction with digoxin, 519t

Vessel occlusion, with percutaneous coronary intervention, 260–261diagnosis and management of, 261–262mechanisms, timing, and risk factors associated with, 260–261prevention of, 261, 261t

Vessel rupture with percutaneous coronary intervention, 258, 259tVessel wall injury, degree of, thrombus formation and, 83VF. See Ventricular fibrillation (VF).Vital signs, assessment of, 36–40, 37t–38tVitamins

for acute myocardial infarction, 172ACC/AHA Task Force recommendations for, 172

interaction of vitamin K with warfarin and, 526tVolume infusion for right ventricular infarction, 229VPBs (ventricular premature beats)

in acute myocardial infarction, 244suppression of, 247

V/Q (ventilation/perfusion) ratio, 388mismatching and, in acute respiratory failure, 389–390, 389f

V/Q (ventilation/perfusion) scanning in pulmonary hypertension, 409,410f

VSD (ventricular septal defect), auscultation in, 44tVT. See Ventricular tachycardia (VT).

WWarfarin

for acute myocardial infarction, dosing for, 168tdrug interactions of, 525–526, 526t

pharmacodynamic, 526pharmacokinetic, 525–526

Water retention, chronic, acute heart failure and, 275Water-hammer pulse, 45Waterston procedure for adult congestive heart failure, 423–424, 424tWearable automatic defibrillator for sudden cardiac death survivors,

307, 307fWedge pressure, 561–562Weight, assessment of, 40Western biomedical ethics, 9–13Wheezing, 42Wide splitting, 43Withholding/withdrawing life support, 15–21

advance directives and, 16–17living wills and, 16medical powers of attorney and, 16Patient Self-Determination Act and, 16–17

assisted suicide and, 21decision to withhold or withdraw life support and, 17–20

advanced life support and, 18–19basic life support and, 17–18

euthanasia and, 20–21legal precedents for, 15–16

for patients lacking decision-making capacity, 15–16for patients with decision-making capacity, 15

Wolff-Parkinson-White syndrome, sudden cardiac death and, 301Women, 32

thrombolysis in, 126Work of breathing, 636–637Wound healing, 94

710

SECTION

CHAPTER

Evolution of the Coronary Care Unit: Past, Present, and Future

Jason N. Katz, Richard C. Becker

Introduction I1

Origins of the Coronary Care Unit

Validating the Benefits of the Coronary Care Unit

Economic Impact of the Coronary Care Unit

Critical Care in the Coronary Care Unit

Describing the Contemporary Coronary Care Unit—the Duke Experience

Future Trends and Continued Evolution in the Coronary Care Unit

Conclusion

Originating during a time of great technical and investigative dis-covery, the coronary care unit (CCU) has emerged as one of the most important advances in the care of patients with acute coronary syndromes. Despite the notion that the CCU has revolutionized the management of myocardial infarction (MI), however, widespread proliferation and acceptance of the CCU as “standard of care” has not been met with universal support. Complicating matters further, the CCU has changed consider-ably over the past several decades, bringing to light unresolved issues of patient triage, medical ethics, physician and nurse training, cost, and resource use. This chapter reviews the evolu-tionary history of the CCU, from its inception in the early 1960s to its contemporary role in the care of often critically ill patients with cardiovascular disease (Fig. 1-1). Future trends in cardiac care also are addressed, with particular attention given to ways in which the CCU may remain a viable entity within a continu-ously changing health care system.

Origins of the Coronary Care UnitSeveral seminal reviews of acute MI—a highly fatal disease at the time—served to highlight the critical need for improved methods of health care delivery.1,2 Outside of morphine and comfort care measures, there was little available in the clinician's armamentarium to spare patients with acute MI from death or prolonged convalescence. Treatment of MI at the time has been described as “benign neglect,”3 and even minimal forms of patient exertion were discouraged.

Focus on ResuscitationThe first reasonable therapy to combat complications of myo-cardial ischemia finally became available after the success-ful implementation of open-chest4,5 and, later, closed-chest

defibrillation.6,7 After reporting on the effective open-chest defi-brillation of a patient who developed life-threatening ventricular arrhythmia in the setting of MI, Beck and colleagues5 propheti-cally reported that “this one experience indicates that resusci-tation from a fatal heart attack is not impossible and might be applied to those who die in hospital … and perhaps to those who die outside the hospital.” Following closely on the heels of these discoveries and the demonstrated efficacy of closed-chest mas-sage,8 the concept of the CCU as a vehicle for successful resusci-tation began to take shape.

Julian, the senior medical registrar of the Royal Infirmary of Edinburgh, first articulated the idea of the CCU. In his origi-nal presentation to the British Thoracic Society in 1961,9 Julian described five cases of cardiac massage used in resuscitation attempts for patients with acute MI. He concluded that “many cases of cardiac arrest associated with acute myocardial isch-aemia could be treated successfully if all medical, nursing, and auxiliary staff were trained in closed-chest massage, and if the cardiac rhythm of patients … were monitored by an electrocar-diographic linked to an alarm system.” His vision for the CCU was founded on four basic principles, as follows: 1. Continuous electrocardiogram monitoring with arrhythmia

alarms 2. Cardiopulmonary resuscitation with external defibrillator

capabilities 3. Admission of patients with acute MI to a single unit of the

hospital where trained personnel, cardiac medications, and specialized equipment were immediately available

4. The ability of trained nurses to initiate resuscitation attempts in the absence of immediate physician presence

At roughly the same time, several clinician investigators in North America developed specialized units devoted exclusively to the treatment of patients with suspected MI. In Philadelphia,

Introduction

1920s

1923First case

series of 19patients with

acute MIpublished

1928100 patient

case series ofpatients

presentingwith AMI

1956Successful

externaldirect currentdefibrillation

1962First CCUsestablished

in NorthAmerica

1967Killip andKimball

report onexperience

with 250 CCUpatients;

mortality ratedecreased

from 26% to 7%in CCU

1970Development

and implementationof Swan-Ganz

catheter

1947Open chestdefibrillationperformed

1968IABP used totreat AMI and

its complications

1960Efficacyof CPR

established

1961First concept of CCUarticulated to British

Thoracic Society

1930s 1940s 1950s 1960s 1970s

Figure 1-1. Timeline of landmark events in the evolution of the coronary care unit (CCU). AMI, acute myocardial infarction; CPR, cardiopul-monary resuscitation; IABP, intra-aortic balloon pump.

Meltzer10 created a two-room research unit with an aperture in the wall through which defibrillator paddles could be passed from one patient to the other. In Toronto, Ontario, Brown and associates11 erected a four-bed unit with an adjacent nursing station for the care of MI patients. Arrhythmia surveillance was provided using a converted electroencephalogram unit with electrocardiogram amplifiers. Although Brown's initial obser-vations suggested no immediate decline in mortality associated with more attentive coronary care,11 these preliminary findings did little to temper the growing enthusiasm for these specialized units.

Day,12 a contemporary of Meltzer, Brown, and Julian, began building mobile crash carts in the attempt to resuscitate acute MI patients being monitored on the general medical floors. Similar to his colleagues, Day astutely recognized that delays in arrhythmia detection on these general wards significantly limited the success of resuscitation attempts. As a result of his observations, an 11-bed unit was established at Bethany Hospi-tal in New York staffed by “specially-trained nurses who could give the patient with coronary disease expert bedside atten-tion, interpret signs of impending disaster, and quickly institute CPR.”12 Day is largely credited with introducing the term code blue to describe resuscitation efforts for cyanotic patients with cardiac arrest and, perhaps more importantly, the term coronary care unit.

Shift in Paradigms—Prevention of Cardiac ArrestUntil this point, the benefit of specialized care in the CCU was predominantly related to recognition of peri-infarction arrhyth-mias that were incompatible with life, and the successful termi-nation of such events. It seemed clear to physicians of the time

that the development of malignant arrhythmias posed the great-est threat to patients sustaining acute cardiac injury, and perhaps the early recognition and prompt therapy for early prodromata of cardiac arrest might have a significant impact on patient sur-vival. The focus of the CCU moved from one of resuscitation to a more preventive role. Julian13 described this transformation as the “second phase” in the evolution of the CCU.

In the late 1960s, Killip and Kimball14 published their experi-ence with 250 acute MI patients treated in a four-bed CCU at New York Hospital–Cornell Medical Center. Credited largely with the MI classification scheme that now bears their name, in which the presence or absence of heart failure or shock had significant prognostic implications, these two investigators also showed that aggressive medical therapy in the CCU seemed to reduce in-hospital mortality from 26% to 7%. This led Killip and Kimball to proclaim in their landmark report that “the devel-opment of the coronary care unit represents one of the most significant advances in the hospital practice of medicine.”14 Not only did it seem that patients with acute MI had improved sur-vival if treated in a CCU, but also all in-hospital cardiac arrest patients seemed more likely to survive if geographically located in the CCU.

“Although frequently sudden, and hence often ‘unexpected,’ the cessation of adequate circulatory function is usually pre-ceded by warning signals.”14 With these words, Killip and Kim-ball, collectively, with the influential findings of Day, Meltzer, Brown, and others, ushered in the rapid proliferation of CCUs throughout the world, with a categorical focus on the preven-tion of cardiac arrest.

Truly at the forefront of this new paradigm in coronary care were Lown and colleagues,15 who elaborately detailed the key

2

1Evolution of the Coronary Care Unit: Past, Present, and Future

components of the CCU at the Peter Bent Brigham Hospi-tal. “From the opening of the unit,” they reported, “the focus has been the prevention of cardiac arrest.” The foundation of their CCU revolved around employment of a “vigilant group of nurses properly indoctrinated in electrocardiographic pattern recognition and qualified to intervene skillfully with a prere-hearsed and well-disciplined repertoire of activities in the event of a cardiac arrest.”15 With a CCU mortality of 11.5% and an in-hospital mortality of 16.9%, these investigators concluded that an aggressive protocol emphasizing arrhythmia suppression after MI could virtually eradicate sudden and unexpected fatali-ties. Although more contemporary data refuting the notion of preventive antiarrhythmic therapy in MI fail to support the early premise of Lown and others,16 their debatable yet com-pelling results allowed the concept of the CCU to continue to flourish.

Several other developments in the late 1960s through the mid-1980s, including the use of intra-aortic balloon counterpul-sation,17 the implementation of flow-directed catheters capable of invasive hemodynamic monitoring,18 and the use of sys-temic thrombolysis for the treatment of coronary thrombosis,19 helped to advance the frontiers of the CCU. Along with these dramatic changes in the care of patients with acute MI came a remarkable transformation in the face and philosophy of the CCU. At the same time, questions and controversies began to emerge regarding the benefits and proper use of these special-ized and costly units.

Validating the Benefits of the Coronary Care UnitAlthough use of a CCU for the management of patients with acute MI became more commonplace, many still questioned their true impact. These critics pointed to the dubious nature of the early comparisons between CCUs and the general medical wards, most of which were purely observational and experien-tial reports, and all of which unquestionably lacked the scrupu-lous scientific and analytic techniques of contemporary clinical research. Adding further fuel to the controversy was a study by Hill and associates20 in the late 1970s comparing outcomes of patients with suspected MI managed at home with outcomes of patients managed in the hospital setting. These investigators found no significant differences in mortality for the two groups, although skeptics cite design flaws, power limitations, and dynamic advances in hospital-based care as major confound-ers to this study. Nonetheless, results such as these led many, including Cochrane,21 to exclaim, “… the battle for coronary care is just beginning.”

Much of the data in support of the CCU was largely observa-tional. As previously described, Killip and Kimball14 attributed a nearly 20% decline in mortality to the successful implemen-tation of their CCU. Other nonrandomized data from a Vet-erans Administration population22 and several Scandinavian studies23,24 corroborated the early uncontrolled observations of Killip, Kimball, Day, and others. These trials all showed lower mortality rates and greater resuscitation success in acute MI patients when treated in a CCU setting.

Goldman and Cook25 attempted to ascribe the epidemio-logic decline in mortality rates from ischemic heart disease in the United States to the presence of CCUs. From 1968-1976,

estimates suggested a decline in mortality of approximately 21%. Using complex statistical analyses and mathematical modeling, the authors surmised that nearly 40% of the decline could be directly attributable to specific medical interventions, with the CCU being one of the premier contributors. They suggested that approximately 85,000 more people would be alive at the end of 8 years because of the presence of CCUs than would have other-wise been alive; in other terms, the CCU may have accounted for approximately 13.5% of the decline in coronary disease–related mortality.25 Epidemiologic estimates from other investigators seemed to corroborate these findings.26

On an even broader scale, Julian13 and Reader27 contemplated that the steady decline in mortality among people 35 to 64 years old in the United States, Australia, and New Zealand since 1967 (the advent of CCUs) may have been a direct effect of the spe-cialized care received in the CCU. More contemporary data, in patients treated during the “thrombolytic era,” have suggested that one highly significant independent predictor of 30-day mortality among acute MI patients was treatment isolated to an internal medicine ward.28 Despite the retrospective nature of this analysis, the findings seemed to underscore the importance of treating acute MI in the setting of an intensive CCU.

Although there are significant limitations to the available data, a plethora of nonrandomized studies seems to support the beneficial role of the CCU in the management of patients with acute cardiac ischemia. A truly randomized, prospective study evaluating the role of the CCU is likely impossible, given the current (albeit arguable) burden of proof in support of these units. Key opinion leaders in the field of cardiovascular medi-cine have nearly unanimously endowed the CCU as “the single most important advance in the treatment of acute MI.”29,30

Economic Impact of the Coronary Care UnitEvaluation of the economic impact of the CCU poses a signifi-cant challenge, and no single study has directly addressed this issue. Not only is it difficult to measure true costs in a dynamic health care system, but also evolutionary changes in the CCU (with concomitant changes in resource use, therapeutic proce-dures, and medication administration) makes fiscal assessments quite unwieldy.

If one were to draw correlates with other contemporary criti-cal care units, perhaps cost could be put into some perspective. Because they are places of high resource use and high expendi-ture, intensive care units (ICUs) contribute significantly to the economic burden of health care facilities and, on a broader scale, to the economic burden of societal health care. Although ICUs constitute less than 10% of hospital beds in the United States, estimates suggest that ICUs consume more than 20% of total hospital costs and nearly 1% of the U.S. gross domestic prod-uct.31,32 It has been suggested that ICU costs have increased by nearly 200% in the years 1985-2000.33

The argument over whether or not CCUs are comparable to ICUs, or, perhaps more importantly, whether or not they should be, is addressed later in this chapter. Data exist to support simi-larities in resource use, morbidity and mortality, and in- hospital length of stay34,35—all of which have significant economic impact and need to be addressed in more rigorous scientific analyses of CCU populations.

3

Introduction

Critical Care in the Coronary Care UnitThe landscape of the CCU has evolved over the last several decades. As a result of more sensitive diagnostic tools, advanced pharmacotherapeutics, and novel interventional techniques, car-diologists now have the ability to alter the natural history of MI significantly. Consequently, the mortality rates for acute MI in several contemporary acute coronary syndrome databases have steadily declined.36-38 At the same time, however, the presence of other cardiovascular diseases and noncardiac critical illness seems to be increasing in today's CCU. An aging U.S. population, acute and chronic sequelae of nonfatal MI, comorbid medical conditions, and complications of implantable devices all result in increased susceptibility to critical illness in high-risk patients. Many, if not all, of these patients are likely to be admitted to the CCU. What were previously purely resuscitative and preventive units for patients with MI have now arguably transformed into critical care units for patients with cardiovascular disease. Some authors have suggested that perhaps even the name “coronary care unit” has become a misnomer in today's health care envi-ronment; Julian13 has advocated more recently that the CCU could instead be more appropriately called the cardiac care unit. Others have suggested that the distinction between contem-porary CCUs and ICUs has become blurred—largely resulting from an increased cardiac critical care burden.39

In a single-day descriptive analysis of U.S. critical care units, Groeger and colleagues34 highlighted mortality statistics, resource use data, and patient characteristics of modern CCUs; results which were remarkably comparable to composite data from contemporary medical ICUs.34,35 Another more recent investigation concluded that severity of illness, quantified by a classic physiologic measure of critical illness (the APACHE [Acute Physiology, Age, and Chronic Health Evaluation] II score), was the greatest independent predictor of in-hospital mortality in a CCU cohort of patients—suggesting that risk stratification in the CCU could be conducted in a manner similar to other ICUs, where the APACHE II score has been well established.40

Although limited observational data suggest that current CCU patients have become more complex from a critical care perspective, there are no large contemporary analyses that corroborate these findings on a broader scale. If the CCU has indeed evolved into an ICU for cardiac patients, re-examination of the role of the CCU, and the role of the cardiologists staffing these units, is warranted. Whether the CCU is a beneficial tool in its current stage of evolution is unknown. In a retrospective study of patients admitted to a CCU in Lazio, Italy, investigators found no significant differences in in-hospital mortality between CCU and non-CCU admissions for patients with cardiac diag-noses other than acute MI or arrhythmia.41 Additionally, a growing body of evidence now exists to support the benefits of critical care specialists to improve the care of ICU patients,42-44 and there has been some suggestion that the CCU may benefit from similarly requisite critical care physician training.39

Describing the Contemporary Coronary Care Unit—the Duke ExperienceSeveral contemporary databases have been used to describe operational and demographic features of ICUs in the United States.34,45-47 These rich datasets have been used to help

establish practice guidelines, to generate hypotheses for novel clinical research efforts, and to accelerate quality improvement initiatives in critical care medicine. The datasets contain very limited information on CCUs, however, and there have been no concerted efforts to illustrate or define, through similar regis-tries, the role of the modern CCU.

In an effort to better understand the current practice model of a CCU in today's academic health care system, the authors of this chapter have created a single-center database containing 2 decades’ worth of diagnostic, procedural, demographic, and outcome-related variables from the Duke University Medical Center CCU. Unadjusted, descriptive results are illustrated in Figures 1-2 and 1-3. These graphs highlight the growing criti-cal care burden and increased implementation of critical care resources in the CCU at Duke, and it is our hope that this data-base will result in numerous novel hypothesis-generating analy-ses, and stimulate collaborative multicenter investigations to better understand the continued evolution of the CCU.

Future Trends and Continued Evolution in the Coronary Care UnitMultiple nonrandomized studies seem to support the beneficial role of the CCU in the management of patients with acute MI. As a result, there has been a rapid proliferation of these special-ized units in the United States and worldwide since their intro-duction into the medical vernacular more than 4 decades ago. At the same time, data support significant evolutionary changes within contemporary CCUs. Observational studies suggest that although the mortality for acute MI has steadily declined, there is a greater burden of noncoronary cardiovascular disease and critical illness. For these particular patients, the role and impact of CCU care are uncertain. This uncertainty has numer-ous implications related to patient outcomes, resource use, and costs of care. As we continue to work toward better defining the changing landscape of the CCU and its place within the current health care system, there are several key topics that need to be addressed.

Multidisciplinary Clinical Integration and the Coronary Care Unit ModelBecause of the multiplicity and complexity of critical care deliv-ery, and the advancing critical care burden in the contempo-rary CCU, the development of practice models for efficient and effective patient care will be an important part of the continued evolution of the CCU. At the same time, landmark documents from the Institute of Medicine have attacked several “dysfunc-tional” processes of past and current health care systems, with particular attention focused on the elimination of “isolationist decision-making and ineffective team dynamics” that may put patient care at risk.48,49 A careful appraisal of the role of multi-disciplinary care in the CCU will therefore be a vital component of future study.

Currently, several models of health care delivery are employed in ICUs—the open model, the closed model, and hybrid models. All of these critical care platforms have distinct advantages and disadvantages from patient-care and systems-based perspec-tives. In a closed ICU model, all patients admitted to an ICU are cared for by an intensivist-led team that is primarily respon-sible for making clinical decisions. In a contemporary CCU, this

4


0

Pre

vale

nce

(%)

1992–19961987–1991 1997–2001 2002–2006

2

4

6

8

10

12

14

16

18

20

Acute respiratory failure

Acute renal failure

Acute liver failure

Sepsis/septic shock

Cardiogenic shock

Pneumonia/pneumonitis

Figure 1-2. Unadjusted trends in selected critical illness in the Duke University Medical Center coronary care unit (unpublished data, 1987-2006).

leader might be a general cardiologist, a cardiologist with criti-cal care expertise, or an intensivist adept in the care of patients with complex cardiovascular illness. In an open ICU model, the patient's primary physician determines the need for ICU admis-sion and discharge and makes all management decisions. As its name suggests, a hybrid or transitional ICU model is a blend of the two more traditional critical care delivery models. The bur-den of evidence seems to support a closed or hybrid ICU format for delivering high-quality, cost-effective care compared with the open model,50,51 and descriptive studies of current practice patterns show greater implementation of these health care deliv-ery systems in the United States.45

Governing bodies for the major critical care medicine orga-nizations universally espouse the benefits of multidisciplinary critical care.52,53 It is believed that shared responsibility for ICU team leadership is a fundamental component for providing opti-mal medical care for critically ill patients. A multidisciplinary approach to CCU management, in light of the growing patient complexity, seems equally reasonable. Potential members of

CCU teams, all of whom would be intimately connected in the day-to-day care of patients, might include a cardiologist, inten-sivist, pharmacist, respiratory therapist, critical care nurse, and social worker or case manager (Fig. 1-4). The goal of this inte-grated approach would be to provide the highest quality care, while limiting adverse events, curbing ineffective resource use practices, and providing an efficient patient transition out of the intensive care setting.

Nursing and Clinician Training RequirementsIn today's CCU, in contrast to the CCU of the 1960s, hav-ing nurses trained in the vigilant detection of life-threatening arrhythmias and educated in the implementation of cardiopul-monary resuscitation and defibrillation is no longer sufficient. Most CCUs employ nurses with the most rigorous critical care backgrounds. With growing numbers of patients who have car-diovascular disease, many of whom will require admission to the CCU during their lifetimes, there is a significant need for train-ing more nurses skilled in cardiovascular and critical care. At the

5

Introduction

Prolonged mechanical ventilation

Central venous catheter

Hemodialysis

Bronchoscopy

Swan-Ganz catheter

Endotracheal intubation

01987-1991 1992-1996 1997-2001 2002-2006

Pre

vale

nce

(%)

5

10

15

20

25

Figure 1-3. Unadjusted trends in selected critical care procedures in the Duke University Medical Center coronary care unit (unpublished data, 1987-2006).

same time, the burden of nursing shortages54 raises a difficult proposition for the continued viability and growth of CCUs in the United States. It is imperative that these issues be funda-mentally addressed because the CCU nurse is arguably the most influential component of the multidisciplinary team from an operational perspective.

As alluded to previously, the diversity of critical illness in today's CCU poses many challenges to the general cardiolo-gists that most commonly staff these units. Whether we pro-vide these clinicians with requisite skills in critical care delivery (in the form of continuing medical education), or we train car-diologists with advanced specialization in critical care medi-cine, or we demand obligatory intensivist input in the care of all critically ill CCU patients, there are many unresolved issues that have direct implications to the future role of CCU clini-cians. There is a significant amount of pressure for all critical care units to be staffed by appropriately trained intensivists,55 largely the result of numerous nonrandomized studies point-ing to the benefits that these clinicians have on the care

of patients with critical illness.43,44 CCUs may be targeted for such reform in the future.

Technology Needs in Today's Coronary Care UnitBeyond the continuous telemetry monitoring and defibrillator capabilities advocated by Julian, Brown, and others, contem-porary CCUs have considerably more technologic require-ments, including the ability to provide noninvasive and invasive hemodynamic monitoring, mechanical ventilation, fluoroscopic guidance for bedside procedures, continuous renal replace-ment therapy, methods for circulatory support (e.g., intra- aortic balloon counterpulsation, percutaneous and implantable ventricular-assist devices, extracorporeal life support), and portable echocardiography. Additionally, the development of clinical information systems for standardization of care, for monitoring outcomes metrics, and for quality assurance pur-poses has become widely supported. These clinical information systems often include electronic clinician order entry and real-time nursing data entry as well.

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Finally, there has been a growing enthusiasm for telemedi-cine, especially for more rural health care facilities with limited resources for critical care. This technology has also been advo-cated as a way to navigate the impending crisis of insufficient critical care specialists to meet the growing demands for their skills,56 and has a potentially viable role in the operation of many U.S. CCUs.

Platforms for Coronary Care Unit–Based Critical Care ResearchThe evolution of the CCU also provides a fertile environment from which to conduct novel research. Existing platforms for CCU-based critical care investigation have included the ongo-ing development and implementation of mechanical circula-tory support devices, the creation of models for the study of sepsis-associated myocardial dysfunction, and the execution of clinical analyses to study the impact of bleeding and transfu-sion on patient outcomes. The potential for future platforms in basic, translational, genomic, and clinical study is seemingly limitless, and the generation of knowledge culminating from such research will inevitably lead to improvements in patient care—the result of more efficient CCU operational models, standardization of cardiac critical care delivery, creation of phy-sician decision-support tools, and advanced personnel train-ing. Key components for developing a successful, translatable, and reproducible platform of CCU-based critical care research include the creation of uniform computerized databases for efficient data abstraction, the organization of dedicated cardiac critical care research teams, and the establishment of focused multicenter and international research networks with the necessary tools for implementing novel research constructs.

Additionally, contributions from academic organizations, government agencies, philanthropic groups, and industry to provide funding and other resources for project support and investigator career development in the field of cardiovascular critical care will be crucial. Table 1-1 lists potential research areas for future study.

ConclusionAlthough the future role of the CCU is uncertain, the potential viability of these units is quite remarkable. Much as the CCU seems to have revolutionized the care of patients with acute MI, the CCU now has the potential to improve the care of a wide range of cardiovascular patients for decades to come. As the premier setting for the recruitment of patients who popu-lated some of the landmark clinical trials in acute coronary syndromes, the CCU also represents a fertile environment for untapped research opportunities in cardiac critical care. The evolution of the CCU has been a remarkable journey of discov-ery, and it will be no less intriguing to see what the future holds for these truly specialized units.

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AmJMedSci1923;165:250-276. 2. Parkinson J, Bedford DE: Cardiac infarction and coronary thrombosis.

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Socialworker

IntensivistCardiologist

Pharmacist

Patient

Housestaff

Criticalcarenurse

Casemanager

CORONARY CARE UNIT

Figure 1-4. Proposed components of a multidisciplinary coronary care unit (CCU) team. Future training models may develop clinicians who have expertise in critical care and cardiovascular medicine—characteristics of an ideal CCU team leader.

Table 1-1. Potential Platforms for Coronary Care Unit (CCU)–based Critical Care Research

Systems-of-care studies and analyses of organizational models in the CCU

Novel biologic markers for noncoronary cardiovascular critical illness

Device development (e.g., minimally invasive hemodynamic monitoring)

Risk stratification, creation of expanded physiologic scores, and appropriate triage practices

Economic analyses of CCU-based critical care delivery

Practice patterns for pharmacotherapy in the CCU and drug development for cardiovascular critical illness

Genomic studies of critical illness susceptibility in CCU patients

Optimal mechanical ventilation strategies for cardiac patients, and effective weaning protocols

Role of telemedicine, medical informatics, and other electronic innovations in the CCU

Development and implementation of novel training models to improve cardiac critical care delivery

Effectiveness of multidisciplinary clinical integration in the CCU

End-of-life issues in CCU populations

Application of current critical care quality metrics for CCU quality-of-care initiatives

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