Your Heart: An Owner's Guide / Edition 1

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Despite great progress in prevention and treatment, heart disease remains the leading cause of death in the United States. An estimated one in six Americans will develop some kind of cardiac problem in their lifetime, and each year nearly three-quarters of a million people die from heart disease. Faced with these statistics, Americans naturally have many questions about risk factors, warning signs, treatment options, and numerous other concerns.

This comprehensive guide makes crucial, potentially life-saving information about the heart easily accessible. Based on decades of hands-on experience in treating patients, the authors — a cardiothoracic surgeon and a cardiologist, both affiliated with Yale University School of Medicine — address specific questions that they hear virtually every day from the people in their care. Simulating an office visit with heart specialists, the book uses an easy-to-follow format that allows readers to find answers quickly. Numerous professional medical drawings and actual operating-room photographs illustrate important facts and concepts.

From well-known problems such as hypertension, high cholesterol, and angina, to lesser-known conditions such as valvular heart disease, rheumatic fever, and arrhythmia, the authors provide clear, up-to-date, fact-based medical information, while avoiding confusing jargon as well as fad therapies. They also discuss tests and diagnoses; lifestyle changes to avoid or to live with heart disease; medications and therapies; and surgical procedures such as bypass grafting, valve replacement, and heart transplants, among other treatments. A special section is devoted to women and their hearts.

This superb all-in-one popular reference book on the heart will be a welcome resource for heart patients, their families, healthcare providers, and anyone concerned about a healthy lifestyle.

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Editorial Reviews

From the Publisher
"A comprehensive, accessible guide to your internal metronome. Study hard, there might be a test."

Mehmet Oz, MD,
Author of You: On a Diet and You: The Owner's Manual

"This remarkable book - this Owner's Guide - is so user-friendly that it reads like a fascinating conversation between ourselves and two of our nation's most experienced and eminent cardiac specialists. Not only will it be of immense value to everyone with an interest in heart disease, but it serves also as a model of clarity to help physicans learn how to answer their patients' questions in completely lucid and authoritative terms."

Sherwin B. Nuland, MD
Clinical Professor of Surgery, Yale University
Author of How We Die and The Art of Aging

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Product Details

  • ISBN-13: 9781591024514
  • Publisher: Prometheus Books
  • Publication date: 2/28/2007
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 415
  • Product dimensions: 5.39 (w) x 8.32 (h) x 0.87 (d)

Meet the Author

John A. Elefteriades, MD (New Haven, CT), is chief of cardiothoracic surgery and professor of surgery at Yale University School of Medicine and Yale New Haven Hospital. He is currently the president of the International College of Angiology and serves on the editorial board of the American Journal of Cardiology, the Journal of Cardiac Surgery, and Cardiology. The winner of the prestigious "Socrates Award" for the teaching of cardiac surgery, he is the author, with Lawrence S. Cohen, MD, of House Officer Guide to ICU Care.

Lawrence S. Cohen, MD (New Haven, CT), is the Ebenezer K. Hunt Professor of Medicine at the Yale University School of Medicine. He is on the editorial board of Clinical Cardiology, Heart, and the American Journal of Geriatric Cardiology.

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Read an Excerpt


An Owner's Guide

Prometheus Books

Copyright © 2007 John A. Elefteriades, and Lawrence S. Cohen, MD
All right reserved.

ISBN: 978-1-59102-451-4

Chapter One


Case 1: Trouble in the Cherry Picker.

Robert hadn't been sick a day in his life. Sure, he had put on some pounds over the years, mainly around his middle, but at fifty-five, he was still fit enough to climb utility poles every day as a repairman for the phone company. One night, he didn't feel quite right. He was tired and took several heartburn tablets from his medicine cabinet. He was able to get to sleep, and felt fine when he got up in the morning. Later, when he had a 20,000-volt line disconnected and was suspended thirty feet in the air in his cherry picker, he knew he was in trouble. He felt a pain right in the middle of his chest. He could have sworn that an elephant had sat right there on top of his sternum. He felt lightheaded. He sat back in the cherry picker and thought he would have to vomit right over the side.

Fortunately, on this day, he was out with a partner. Back in the truck cab, Marty sensed right away that something was wrong with Robert. He brought the cherry picker down, and didn't like what he saw.Robert was pale. He was sweating profusely, although it was a cool autumn day. His breathing was obviously heavy, labored. Marty had to rouse his partner to get him to focus his eyes. Marty phoned the ambulance immediately, which arrived within minutes. It looked like a heart attack, the medics told Marty. It was good he had called right away. Marty saw the medics put an oxygen mask on Robert's face. They started an IV and ran some "nitro." As the ambulance pulled away, Marty thought Robert looked better.

Later that night, Marty visited Robert in the coronary care unit-the CCU, as it is called. Sally and the kids were there. Robert was sitting up in bed, picking at his dinner. Sally expressed her thanks for Marty's concern and prompt action out in the field. She explained that the doctors had told her that Robert had had a severe angina attack. Without prompt attention, it would have progressed to a heart attack. The oxygen, the nitroglycerine, and the blood thinner heparin, as well as an aspirin tablet, had succeeded in turning things around. The heart attack had been aborted. The EKG (electrocardiogram) had returned to normal.

Robert would need a catheterization, though. The doctors were sure he had coronary artery disease-blockages in the coronary arteries, which supply blood to the heart muscle itself.

What is angina?

Most people are familiar with angina, the overt manifestation of inadequate flow of blood to the heart. Angina was first described by the British physician William Heberden more than two hundred years ago. Figure 1.1, adapted from the Netter series, a well-known collection of anatomical illustrations used to train doctors, shows the areas of pain in a typical patient with angina.

The heart is a muscle. As such, it requires blood flow and oxygen delivery in order to function. In contrast to other muscles throughout the body, which function only episodically when needed, the heart pumps "twenty-four/seven" throughout our lives. Even a period of seconds without heart function leads to unconsciousness and threat of organ damage. The diaphragm, the large muscle used for breathing, which separates the chest from the abdomen, is the other muscle in the body that operates full time, all the time. In the case of the heart, its blood flow and oxygen requirements are huge. The heart requires about one cup of blood per minute to nourish itself at rest. Under stress, it can utilize over one quart of blood per minute just to meet its own nutrient needs. This corresponds to about one-fifth of the total baseline flow of blood in the body. Even a short interruption of blood flow to the heart muscle itself will lead to oxygen deprivation of the heart cells. If this does not last more than a few minutes, no permanent damage to these cells is incurred. The transiently insufficient blood flow is felt as typical angina pain. The classic characteristics of this pain are that it is felt substernally, under the breastbone, and that it is perceived as a pressurelike pain. The classic scenario is that of a patient clutching his chest in severe discomfort. The pain is often described in terms such as the following: "I feel like an elephant is sitting on my chest." "I feel like I have a vise on my chest." The patient often uses a clenched fist over his chest to illustrate what he is feeling.

Angina is really the muscle burn that one can feel from any muscle stressed to the point of exceeding its blood flow capacity. For example, you can do sit-ups to the point of exhaustion. The intense pain you will feel in your midsection is really "angina," so to speak, of your abdominal muscles.

We grade your angina according to the level of exertion required to bring it on. This is called the Canadian Cardiovascular Society classification system. If the patient has no angina whatsoever, despite exertion, he is Class I. If angina comes on only with vigorous exertion (at the gym, for example), he is Class II. If the angina comes on with only mild exertion (as in walking on level ground), he is Class III. If the angina comes on with no exertion, during the resting state, the angina is the highest category, or Class IV. Class IV patients may feel angina while resting, watching TV, reading, or even sleeping.

Severe anginal attacks, especially those likely to eventuate in a heart attack, may be accompanied by profuse sweating. Friends or relatives may comment on an ashen color or an appearance of obvious physical distress.

Doctors used to think that all or most patients with inadequate blood flow to the heart would feel angina pain. We now know that many patients, perhaps up to 40 percent, do not feel angina pain. This may be dangerous for a number of reasons. First, these patients may escape diagnosis of their heart disease entirely. Second, even patients with known heart disease may not be aware when they are exceeding their heart's capacity. After all, symptoms of disease, in general, reflect the body's intrinsic "early warning system." Patients who do not feel angina have a defective warning system. Such a defective pain mechanism is seen especially in diabetic patients, in whom the sensory nerves are damaged by the excess ambient sugar levels in the body.

What is the cause of angina?

As explained above, angina occurs when the heart muscle's demand for oxygen is greater than the supply. Pain fibers in the muscle are stimulated, and angina occurs. The root cause of angina is blockages in the coronary arteries, which are responsible for supplying oxygen-rich blood to the heart muscle itself.

Typically, anginal pain comes on with exertion. The reason for this is that in the resting state, even with blockages in the arteries that deliver blood flow to the heart, the delivery of blood and oxygen is adequate to meet the heart's needs. As exertion proceeds, the heart needs more and more oxygen, and the blocked arteries cannot deliver the required levels. Patients often first notice heart pain, or angina, during bursts of severe exertion, such as running for a bus or hurrying between terminals at the airport.

Other states that can trigger angina, by increasing oxygen demands in the heart above the available delivery, include stress and anxiety. A patient may feel anginal discomfort during an intense marital dispute or during a stressful meeting at work.

Common activities may increase the demand for oxygen and cause angina. Jogging, walking briskly up the stairs, or getting overheated while watching an exciting sporting event may be the precipitant. Any activity that causes the heart to beat more rapidly or causes the blood pressure to rise may trigger angina. Oxygen demand may also exceed supply after a big meal, when blood and oxygen are diverted from the heart to the intestinal tract. An easy way to remember the major causes of angina is to think of the three E's: exercise, emotion, and eating.

These are classic descriptions of typical angina. As all experienced physicians know, the manifestations of angina can vary greatly. Angina is not always felt in the typical substernal, or mid-chest, location. It may be felt in the left arm or shoulder. It may be felt in the jaw. Rarely, it may be felt in the back or in the teeth or neck. On occasion, it may be felt as a heartburn-type discomfort, easily confused with symptoms of dyspepsia originating in the nearly ubiquitous acid reflux that most adults experience at some times. Especially in women, anginal symptoms may be atypical (see Chapter 14).

Characteristically, anginal pain disappears when the exertion ends, as the demands of the heart for blood and oxygen come down within the limits that can be provided by the diseased arteries. Typically, angina goes away within a minute or two of sitting down and resting.

My doctor says I have "angina at rest." What does that mean?

Usually anginal attacks are brought on by specific activities above the particular patient's threshold for exertion. Often patients know that, on their daily walk, for example, pain will come on precisely two-thirds of the way up a certain hill. Sometimes, instead of physical exertion, the cause for a specific bout of angina may be emotion or a heavy meal, both of which can tax the heart. When pain comes on without any exertion or other provocation, we call that angina at rest. This is an important sign because angina at rest may predict that a heart attack is imminent.

If you are getting chest pains when you are resting, seated comfortably, perhaps while reading or watching TV, you may have angina at rest. This is a potentially serious pattern, which you should promptly call to the attention of your doctor.

How many coronary arteries do I have?

The coronary arteries originate directly above the aortic valve. There, two coronary arteries arise from the aorta and course over the heart like a crown or corona. This is why they are called coronary arteries. See figure 1.2 below.

The left coronary artery divides into two branches shortly after its beginning, becoming the left anterior descending artery and the left circumflex coronary artery. The left anterior descending coronary artery runs over the front surface of the heart, and the left circumflex coronary artery distributes itself over the lateral surface of the heart. The left anterior descending coronary artery (or LAD) is by far the most important artery of the heart, supplying by itself over 40 percent of the total blood flow to the heart.

The other major coronary artery is the right coronary artery. In general, it supplies blood to the back surface of the heart.

What is coronary artery disease?

Coronary artery disease refers to the buildup of fatty deposits in the wall of one of the arteries that supplies blood to the heart. This buildup narrows the central channel of the artery, decreasing the amount of blood and oxygen that can be carried to the heart muscle. The process of coronary arteriosclerosis, hardening of the arteries of the heart from fatty deposits, takes decades to develop. Coronary arteriosclerosis is defined as the development of narrowings in the coronary arteries due to buildup of fatty plaques. Coronary artery plaques are composed of cholesterol fats, circulating cells from the bloodstream, and tissue cells reacting to the presence of all of these elements.

What causes a heart attack?

The process of arteriosclerosis usually occurs gradually, resulting in a pattern of regular angina. In some cases, a sudden adverse event occurs, triggering a heart attack. This sudden adverse event occurs as follows.

If a plaque ruptures into the lumen, or central channel, of a coronary artery, this material gets exposed to the bloodstream. The nature of this material causes clotting of blood that streams past it. As the blood clot, or thrombus, grows, it starts to block or occlude the coronary artery at the site of the plaque rupture. The expanding clot does not allow blood to flow by it, thereby depriving part of the heart muscle of blood and oxygen.

As this process extends into many minutes or hours, some of the heart muscle, deprived of oxygen, begins to die. Death of heart muscle is the definition of a heart attack. (Angina alone does not do this.) If blood flow is not fairly promptly restored, the dead muscle is forever lost and forms a scar. We usually use the standard of four hours-if blood flow is not restored within this window of time, at least some of the affected muscle will die. This process is depicted in the accompanying figure.

What are the symptoms of a heart attack?

The classic symptom of a heart attack is severe chest pain, which may be localized to the breastbone area or, in some patients, may radiate to the arms, shoulders, back, jaw, or upper abdomen. Pain in the left arm is very common. Generally, there is a feeling of significant generalized weakness and a foreboding of doom. Sweating is common. Although the pain is often quite severe, the level of pain may vary. In women, the pain may be minor or absent, with nausea predominating, as we will discuss in chapter 14. The pain may be intermittent, as the culprit clot may also undergo variable degrees of dissolution by the body's own reparative mechanisms.

Can gall bladder problems simulate heart disease?

It is not always simple to localize the site of pain. Although gall bladder symptoms typically occur on the right side of the upper abdomen, under the rib cage, the discomfort can at times occur in the chest. Usually, the relation of gall bladder symptoms to meals, especially fatty ones, helps to lead to the correct diagnosis of an abdominal, rather than a cardiac, problem.

In some cases, the symptoms of the two organs, gall bladder and heart, can even mimic each other. Certain characteristics can help to distinguish the two diseases. The person who develops gall bladder disease often has a distinctive profile. It is said that the typical candidate is "female, fifty, fertile, overweight, and fair-complexioned." Although exceptions obviously occur, the index of suspicion rises the more closely the patient with symptoms approaches the classic description. In any case, a simple ultrasound exam will show conclusively whether or not you have gallstones.

How can I tell if it is an anginal episode or if I am suffering a heart attack?

There are some distinguishing characteristics between an anginal episode and a heart attack (also known as a coronary thrombosis).

First and foremost is the duration of symptoms. An anginal episode usually subsides within a few minutes. Pain that lasts beyond twenty minutes is considered to be a heart attack in evolution.

Another distinguishing characteristic is the relation of the pain to exertion. An anginal episode goes away when the exertion stops. Not so a heart attack. The pain of a heart attack continues even after the exertion has stopped.

Another characteristic has to do with the response to a nitroglycerine tablet. An anginal episode will subside promptly with the first or second nitro. The pain from a heart attack, however, continues despite nitroglycerine. The pain usually does not go away until morphine is administered in the hospital.

The pain of a heart attack usually comes on suddenly, reflecting the sudden occlusion of a coronary artery. Anginal pain, on the other hand, is more gradual in onset, as exertion increases the oxygen demand of the heart muscle above what the coronary arteries can supply.

A patient having a heart attack may sense what we call a feeling of impending doom, an intuitive sense that his or her life is in severe danger. This does not usually characterize an anginal episode.

A heart attack is often accompanied by other symptoms, such as nausea, vomiting, and severe sweating. Friends, family, or coworkers may note an ashen color. These additional symptoms and signs are less common with an uncomplicated anginal attack.

The following table indicates some of these differentiating features.

If in any doubt at all, you should dial 911 and be taken immediately to the hospital's emergency room. The EKG will usually make it immediately clear if you are experiencing a heart attack.


Excerpted from YOUR HEART by JOHN A. ELEFTERIADES LAWRENCE S. COHEN Copyright © 2007 by John A. Elefteriades, and Lawrence S. Cohen, MD. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Acknowledgments     9
Foreword     11
Preface     13
Introduction to the Heart     17
Coronary Artery Disease     25
Heart Failure     41
Arrhythmias     55
Valvular Heart Disease     75
Hypertension, High Cholesterol, and Arteriosclerosis     89
Heart Attacks     121
Tests and Diagnoses     131
Living with Heart Disease: Lifestyle Changes That Protect Your Heart     151
Treatment: Medications, Therapies, and Procedures     161
Rheumatic Fever, Aneurysms, and Cardiac Tumors     201
So You Need Heart Surgery     221
Surgical Procedures     267
After Surgery     333
Heart Disease in Women     355
Afterword     373
Glossary     375
List of Case Vignettes     383
Lists of Illustrations and Tables     385
Notes     391
Index     395
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  • Anonymous

    Posted February 23, 2009

    Your Heart

    I bought this book before undergoing mitral valve repair surgery. The book was full of helpful information, and it was presented in a manner that was neither too technical nor too simplistic.

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