Table Of ContentCOMMONSENSE
CARDIOLOGY
COMMONSENSE
CARDIOLOGY
Dr George Strube
Dr Gillian Strube
General Practitioners,
Crawley, Sussex
KLUWER ACADEMIC PUBLISHERS
DORDRECHT/BOSTON/LONDON
Distributors
for the United States and Canada: Kluwer Academic Publishers, PO Box 358, Accord Station,
Hingham, MA 0201!W358, USA
for all other countries: Kluwer Academic Publishers Group, Distribution Center, PO Box 322,
3300 AH Dordrecht, The Netherlands
British Library Cataloguing in Publication Data
Strube, George
Commonsense cardiology.
1. Medicine. Cardiology
I. Title II. Strube, Gillian
616.1 '2
ISB~-13:978-94-010-7055-3
Library of Congress Cataloging in Publication Data
Strube, George.
Commonsense cardiology / George Strube, Gillian Strube.
p. cm.
Includes index.
ISB~ -13: 978-94-010-7055-3 e-ISBN-13 :978-94-009-1251-9
DOl: 10.1007/978-94-009-1251-9
1. Cardiology. 2. Heart -Diseases. I. Strube, Gillian.
II. Title.
[DNLM: 1. Cardiology. 2. Heart-Diseases. WG 100 S927c]
RC681.s894 1988
616.1 '2-dc19
DNLMfDLC
for Library of Congress 88-13304
elP
Copyright
© 1989 by Kluwer Academic Publishers
Softcover reprint of the hardcover 1st edition 1989
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without prior permission from the publishers, Kluwer Academic Publishers BV,
PO Box 17, 3300 AA Dordrecht, The Netherlands.
Published in the United Kingdom by Kluwer Academic Publishers, PO Box 55, Lancaster, UK.
Kluwer Academic Publishers BV incorporates the publishing programmes of D. Reidel,
Martinus Nijhoff, Dr W. Junk and MTP Press.
Contents
Preface
Vll
Part 1: THE BASICS 1
1.1 Introduction 2
1.2 Basic anatomy 4
1.3 Physiological models 8
1.4 Electrophysiology 31
Part 2: CARDIAC DRUGS 37
2.1 Introduction 38
2.2 Hazards, safety and effectiveness 39
2.3 Sorting out the drugs 46
Part 3: THE DIAGNOSTIC PROCESS 83
3.1 Introduction 84
3.2 Clinical history 86
3.3 Sorting out the symptoms 90
3.4 Examination 102
3.5 Electrocardiology 113
3.6 Pathological tests and chest X-rays 136
v
CONTENTS
Part 4: CARDIAC DISEASE 141
4.1 Introduction 142
4.2 Ischaemic heart disease 143
4.3 Heart failure 200
4.4 Essential hypertension 221
4.5 Arrhythmias 238
4.6 Valvular disease 256
4.7 Congenital heart disease 274
4.8 Bacterial endocarditis 278
4.9 Cardiomyopathies 282
4.10 Pulmonary embolism 285
4.11 Pregnancy 287
4.12 Care of the patient dying of heart disease 289
Part 5: THE ROLE OF GENERAL PRACTICE 295
5.1 Introduction 296
5.2 Risk factors and prevention 297
5.3 The role of the Primary Health Care Team 308
Further reading 328
Index 329
VI
Preface
Cardiology embraces a number of different conditions and disease processes.
Cardiovascular disease is now responsible for most of the deaths of adults,
especially premature deaths, in the developed world.
The development of effective preventive measures, new drugs and
surgical techniques makes it increasingly important to recognise those at risk,
to diagnose accurately those suffering from disease and to prescribe, monitor
and refer appropriately.
This book is intended to focus attention on the opportunities which family'
practice provides for this and to look at the need for a change in emphasis in
approaching the problems.
The book is in five parts. Part 1 is a reminder of some of the basic
principles, which are essential if sensible cardiology is to be practised. Part 2
is about cardiac drugs, their use, effectiveness and risks. Part 3 looks at the
diagnostic process; it comprises the history, examination, investigation and
referral of patients, who might have cardiac disease and also the drugs which
are most likely to be used. Part 4 is devoted to specific conditions. In Part 5,
we look at the need for prevention and consider how it may be tackled in
general practice.
This is not a comprehensive textbook of cardiology. It is not intended for
students. It is hoped that it may be useful to experienced doctors, struggling
to provide a sound, sensible service in an environment of ever expanding
technology.
Acknowledgement
We would like to thank Dr Richard Vincent, Consultant Cardiologist at the
Royal Sussex County Hospital, Brighton, for his help, advice and limitless
patience, particularly in choosing and providing the ECGs. He has given us
much support and encouragement and contributed greatly to any merit the
book may have. He is in no way responsible for its deficiencies.
vii
PART 1:
THE BASICS
1
1.1
Introduction
This is a review of some of the basic principles of the physiology of the heart
and circulation; not as an end in itself but as a means of providing the tools
needed to practise commonsense cardiology in general practice.
JJ7Jy basics?
Knowledge about the cardiovascular system, the disease processes which
affect it and their treatment, has increased so much during recent years that
there now exists an enormous mass of information, which is apparently
essential to everyday practice and yet which it is beyond most of us to retain
for more than a few minutes at a time.
We believe that the key to this dilemma lies in an understanding of the
physiology, pathophysiology and pharmacology which underlie both the
disease processes themselves and the use of drugs and other treatments in
their management. They form a common thread, a logical link, which allows
us to keep to a reasonable minimum the quantity of facts we have to
remember. Using this approach, makes it easier:
(1) to make accurate and consistent diagnoses;
(2) to understand and use, safely and effectively, the vast panoply of
powerful and potentially dangerous drugs now available;
(3) to make logical and appropriate use of investigations and the services
of specialists;
(4) to understand and apply new technology, including drugs, as it is
developed.
It could be said that we need to know more about less: to deepen our
understanding and not add to the facts we struggle to remember. This is the
stuff of commonsense.
This part of Commonsense Cardiology contains nothing new to anyone
who was even half awake as a medical student. It is simply revision. We make
no apologies for this: it has always been important. It is now indispensible
because of the extent of modern developments.
2
INTRODUCTION
Part 1 contains the following chapters:
Chapter 1.2: Basic Anatomy - illustrated by diagrams;
Chapter 1.3: Physiological Models - these are models of the cardiovascular
system, with explanations;
Chapter 1.4: Electrophysiology.
Throughout the book we will return to these to see how they are disturbed by
disease processes and influenced by treatment.
3
1.2
Basic Anatomy
This short chapter is a simple presentation of the basic anatomy of the
cardiovascular system. Figure 1.2A shows the circulation. Figure 1.2B shows
the distribution of the blood in different vessels. Figure 1.2C shows the heart,
Figure 1.2D shows the position of the heart in the chest and Figure 1.2E
shows the coronary arteries.
This outline may seem over-simplified but it serves to remind 'us that the
cardiovascular system is made up of a two-chambered pump with lengths of
piping and perfusion networks between the chambers.
It also serves as a framework for the discussion of cardiac physiology
which follows in the next chapter.
4
