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  • Image not available. A careful history and physical examination are extremely important in diagnosing cardiovascular disease; they should be performed before any testing.
  • Image not available. Elevated jugular venous pressure is an important sign of heart failure and may be used to assess its severity and the response to therapy.
  • Image not available. Heart sounds and heart murmurs are important in identifying heart valve abnormalities and other structural cardiac defects.
  • Image not available. Electrocardiography is useful for determining rhythm disturbances (tachyarrhythmias or bradyarrhythmias).
  • Image not available. Exercise stress testing provides important information concerning the presence and severity of coronary artery disease; changes in heart rate, blood pressure, and the electrocardiogram are used to assess the response to exercise.
  • Image not available. Echocardiography is used to assess valve structure and function as well as ventricular wall motion; transesophageal echocardiography is more sensitive than transthoracic echocardiography for detecting thrombus and vegetations.
  • Image not available. Radionuclides, such as technetium-99m and thallium-201, are used to assess wall motion and myocardial viability in patients with coronary artery disease and heart failure.
  • Image not available. When patients cannot exercise, pharmacologic stress testing is used to assess the likelihood of coronary artery disease.
  • Image not available. Cardiac catheterization and angiography are used to assess coronary anatomy and ventricular performance.

On completion of the chapter, the reader will be able to:

  1. Identify the elements of a cardiovascular history.

  2. Describe the symptoms associated with angina and congestive heart failure.

  3. Apply the New York Heart Association grading system.

  4. Classify heart murmurs.

  5. Differentiate biomarkers of myonecrosis, inflammation, and hemodynamic stress.

  6. Identify the P wave, QRS complex, and QT interval on the electrocardiogram, and describe their origin.

  7. Determine which test(s) is(are) most appropriate for the person with a dsyrhythmia.

  8. Describe the influence of pretest probability on stress test results.

  9. Choose the most appropriate test to evaluate valvular function.

  10. Differentiate exercise stress testing from pharmacologic stress testing.

  11. Differentiate vasodilator stress testing from dobutamine stress testing.

  12. Discuss the role of coronary calcium scoring.

  13. Describe the indications for cardiac catheterization.

  14. List the complications of cardiac catheterization.

  15. Identify the methods to measure cardiac output.

  16. Compare coronary angiography and intravascular ultrasound.

In the United States, cardiovascular disease (CVD) afflicts an estimated 83 million people (i.e., approximately one in three adults) and accounts for 33% of all deaths. One of every six hospital stays results from CVD. In 2008, the estimated direct and indirect cost of CVD—which includes hypertension, coronary heart disease, heart failure, and stroke—was $297.7 billion.1

Atherosclerosis, the cause of most CVD events, is typically present for decades before symptoms appear. With a thorough history, comprehensive physical examination, and appropriate testing, the individual with subclinical CVD usually can be identified, and the subject with symptomatic CVD can be assessed for the risk of an adverse event and can be managed appropriately.

The elements of a comprehensive history include the chief complaint, current symptoms, past medical history, family history, social history, and review of systems.

The chief complaint is a brief statement describing the reason the patient is seeking medical attention. The ...

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