Bøger i Developments in Cardiovascular Medicine serien

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

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

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

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

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

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

Autopsy derives from the greek word autopsia, which means act of seeing with one's own eyes. It remains the most objective and accurate method to understand human. disease. Unfortunately, the volume of autopsies in teaching hospitals has decreased dramatically over the past years. The crucial factors that account for this are the recent progress and development of new technologies, especially in diagnostic imaging, immunology, cell biology and genetics. Additionally, the perpetual fear of legal liability by physicians accounts for its further decline. Consequently, physicians and medical students are engaged in fewer autopsies and are not reaping the rich educational rewards that accompany these examinations. The purpose of the autopsy is not only to establish the cause of death, but also to determine the nature and course of the disease process. Our goal with this book is to emphasize the importance of the post-mortem exam and the correlation between pathologic material and clinical data by analyzing actual cases with problem-based methodology. The focus of this handbook is on cardiovascular disease, and when appropriate, other disease categories are included if they have an impact on cardiovascular function. The approach is more than the usual clinico-pathological correlation. Rather, we attempt to present the material from the perspective of the autopsy table. We use the clinical data as the initial framework and the autopsy findings to develop a true understanding of the disease and the associated pathophysiology of the condition.

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

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

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

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

It is the mark of an instructed mind to rest satisfied with the degree of precision which the nature of the subject admits, and not to seek exactness where only an approximation of the truth is possible. Aristotle With the development of imaging techniques, the in vivo study of human anatomy and physiology has become possible with increasing "e;approximation of the truth. "e; Advances have been made not only in data acquisition, but also in processing as well as visualization of functional and morphological data. Following the successful application of planar two-dimensional imaging approaches, more recently three-dimensional data acquisition and correspond- ing tomographic image reconstruction has become possible. With the rapid growth of computer support, advanced processing allows for user-friendly interaction with complex data sets. Classical x-ray imaging techniques have matured to excellent spatial resolution and contrast, which provide specific delineation of anatomical changes occurring in cardiovascular disease. In parallel, the use of tracer principles supported the successful introduction of nuclear medicine procedures for the functional characterization of physiology and pathophysiology. The application of such techniques were initially limited by relatively poor spatial resolution, but excelled in high sensitivity 30 years, scintigraphic imaging emerged from and specificity. In the last rectilinear scanning to planar gamma camera imaging and single-photon xvi Preface emISSIOn tomography (SPECT). Based on these advances and the experi- mental success of autoradiography, the potential of scintigraphy as a clinical and research tool has been well appreciated.