Washington manual of cardiology 3rd ed subspeciality consult

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Third Edition
© 2014 by Department of Medicine, Washington University School of Medicine
Second Edition, © 2009 by Department of Medicine, Washington University School of Medicine
First Edition, © 2004 by Department of Medicine, Washington University School of Medicine
Printed in China
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in
any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any
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987654321
Library of Congress Cataloging-in-Publication Data
The Washington manual cardiology subspecialty consult / editors, Phillip S. Cuculich, Andrew M. Kates, Thomas
M. De Fer. — Third edition.
p. ; cm. — (Washington manual subspecialty consult series)
Cardiology subspecialty consult
Includes bibliographical references and index.
ISBN 978-1-4511-1422-5
I. Cuculich, Phillip S., editor of compilation. II. Kates, Andrew M., editor of compilation. III. De Fer, Thomas
M., editor of compilation. IV. Title: Cardiology subspecialty consult. V. Series:
Washington manual subspecialty consult series.
[DNLM: 1. Cardiovascular Diseases—Handbooks. 2. Cardiology—methods—Handbooks. WG 39]
RC667
616.1'2—dc23
2014003539
The Washington Manual™ is an intent-to-use mark belonging to Washington University in St. Louis to which
international legal protection applies. The mark is used in this publication by LWW under license from Washington
University.
Care has been taken to confirm the accuracy of the information present and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied, with

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respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner; the clinical

treatments described and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth
in this text are in accordance with current recommendations and practice at the time of publication. However, in
view of ongoing research, changes in government regulations, and the constant flow of information relating to drug
therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in
indications and dosage and for added warnings and precautions. This is particularly important when the
recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of health care providers to ascertain
the FDA status of each drug or device planned for use in their clinical practice.

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We dedicate this book to the many people who influence us: our wives, children,
teachers, students, and patients. We thank you for inspiring us, teaching us and
keeping us humble.
—PSC & AMK

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Ratin g Scheme fo r the Stren gth o f the Reco mmen datio n s
Class I: Conditions for which there is evidence and/or general agreement that a
given procedure or treatment is beneficial, useful, and effective.
Class II: Conditions for which there is conflicting evidence and/or a divergence of
opinion about the usefulness/efficacy of a procedure or treatment.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Conditions for which there is evidence and/or general agreement that a

procedure/treatment is not useful/effective and in some cases may be harmful.
Ratin g Scheme fo r the Stren gth o f the Eviden ce
Level of Evidence A: Data derived from multiple randomized clinical trials or
meta-analyses.
Level of Evidence B: Data derived from a single randomized trial or
nonrandomized studies.
Level of Evidence C: Only consensus opinion of experts, case studies, or standardof-care.

Gibbons RJ, Smith S, Antman E. American College of Cardiology/American Heart Association clinical practice
guidelines: Part I: where do they come from? Circulation 2003;107:2979-2986.

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Su zan n e V. Arn o l d
AdjunctAssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Rich ard G. B ach
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Al o k B ach u w ar
Clinical Fello w

Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Su desh n a B an erjee
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Preben B jerregaard
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine

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St. Louis, Misso uri
El isa A. B radl ey
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri

Al an C . B raverman
Alumni Endo wed Pro fesso r o f Cardio vascular Diseases in Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
An gel a L. B ro w n
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ari M. C edars
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mu ral i M. C h akin al a
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Pulmo nary Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Jan e C h en
Asso ciate Pro fesso r o f Medicine

Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri

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Risa M. C o h en
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
D an iel H. C o o per
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ph il l ip S. C u cu l ich
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri

Jeremiah P. D epta
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Grego ry A. Ew al d
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mitch el l N. Faddis
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
D errick R. Fan sl er

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Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n

Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
C o rey G. Fo ster
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Marye J. Gl eva
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
C h irayu Go r
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ro bert J. Gro pl er
Pro fesso r o f Radio lo gy
Departmento f Radio lo gy
Nuclear Medicine Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mo h ammed Hadi

Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
I
l ia G. Hal atch ev
Clinical Fello w

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Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
C h risto ph er L. Ho l l ey
I
nstructo r in Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Su dh ir K. Jain
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine

Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Su san M. Joseph
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
An drew M. Kates
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mo h ammad Al i Kizil bash
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
An drew J. Krain ik
Clinical Fello w
Departmento f I
nternal Medicine

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Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ro n al d J. Kro n e
J
o hn E. Simo n Scho lar in Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Th o mas K. Ku rian
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ho w ard I
. Ku rz
Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Sh an e J. LaRu e
I

nstructo r in Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Joh n M. Lasal a
Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Jeffrey M.C . Lau
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n

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Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ko ry J. Lavin e
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine

St. Louis, Misso uri
Jefferso n Lee
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
C . Hu ie Lin
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
B rian R. Lin dman
AssistantPro fesso r Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Jose A. Madrazo
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Majesh Makan

Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine

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St. Louis, Misso uri
Keith Man ko w itz
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Sara C . Martin ez
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
W il l iam J. Nien aber
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine

St. Louis, Misso uri
Sco tt M. No rdl ich t
Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Jiafu O u
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ravi Rasal in gam
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri

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Ash w in Ravich an dran
Clinical Fello w
Departmento f I
nternal Medicine

Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
C raig K. Reiss
Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mich ael W . Rich
Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mo h ammed Sagh ir
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Joel D . Sch il l in g
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine

St. Louis, Misso uri
D avid B . Sch w artz
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Kristen Sco tt-Til l ery

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Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Lyn n e M. Seaco rd
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Jay Sh ah
Clinical Fello w
Departmento f I
nternal Medicine

Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Sh imo l i Sh ah
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Sh ivak Sh arma
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Jasvin dar Sin gh
Asso ciate Pro fesso r o f Medicine
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Timo th y W . Smith
Asso ciate Pro fesso r o f Medicine

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Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Pabl o F. So to
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Ju stin M. Vader
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Joh n Verbsky
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Al an N. W eiss
Pro fesso r o r Medicine
Departmento f I
nternal Medicine

Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Mich ael Y eu n g
Clinical Fello w
Departmento f I
nternal Medicine
Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri
Al an Zajarias
AssistantPro fesso r o f Medicine
Departmento f I
nternal Medicine

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Cardio vascular Divisio n
Washingto n University Scho o l o f Medicine
St. Louis, Misso uri

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t is a pleasure to present the new edition of The Washington Manual ™
Subspecialty Consult Series: Cardiology Subspecialty Consult. This pocketsize book continues to be a primary reference for medical students, interns,
residents, and other practitioners who need ready access to practical clinical
information to diagnose and treat patients with a wide variety of disorders. Medical
knowledge continues to increase at an astounding rate, which creates a challenge for

physicians to keep up with the biomedical discoveries, genetic and genomic
information, and novel therapeutics that can positively impact patient outcomes. The
Washington Manual ™ Subspecialty Consult Series addresses this challenge by
concisely and practically providing current scientific information for clinicians to
aid them in the diagnosis, investigation, and treatment of common medical
conditions.
I want to personally thank the authors, which include house officers, fellows, and
attendings at Washington University School of Medicine and Barnes-Jewish
Hospital. Their commitment to patient care and education are unsurpassed, and their
efforts and skill in compiling this manual are evident in the quality of the final
product. In particular, I would like to acknowledge our editors, Drs. Phillip S.
Cuculich and Andrew M. Kates, and the series editor, Dr. Tom De Fer, who have
worked tirelessly to produce another outstanding edition of this manual. I would also
like to thank Dr. Melvin Blanchard, Chief of the Division of Medical Education in
the Department of Medicine at Washington University School of Medicine, for his
advice and guidance. I believe this Manual will meet its desired goal of providing
practical knowledge that can be directly applied at the bedside and in outpatient
settings to improve patient care.
Victoria J. Fraser, MD
Adolphus Busch Professor of Medicine
Chairman, Department of Medicine
Washington University School of Medicine
St. Louis, Missouri
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dvances in cardiovascular medicine are currently proceeding at a
breathtaking pace. As the knowledge base in cardiovascular medicine
expands, it becomes increasingly important to condense this new information
into a format that honors the traditional approaches to teaching clinical medicine, but

is also up to date and readily accessible to busy health care providers. The third
edition of The Washington Manual™ Cardiology Subspecialty Consult was written
with the challenges of the busy practitioner in mind. Each chapter in the third edition
was written by a cardiovascular fellow who was paired with an attending physician
with considerable clinical expertise. This team approach to writing allowed each
chapter to be suffused with real-world approaches to real-world problems that are
not only evidence based, but also based on the expertise of seasoned clinicians who
have devoted their careers to training the next generation of health care providers.
The new edition, which was masterfully edited and organized by Drs. Andy Kates
and Phillip Cuculich, has new chapters on the physical exam, heart failure with
preserved ejection fraction, and cardiovascular diseases in elderly populations and
in women. As with the previous editions, the chapters contain simple easy-to-read
figures and flow diagrams coupled with bullet-point lists and countless bold-faced
clinical pearls. I believe the third edition of The Washington Manual ™ Cardiology
Subspecialty Consult will be enormously useful as an extremely “readable”
resource for health care providers who must provide care for the growing numbers
of patients with cardiovascular disease. I am proud to endorse this book, which will
ultimately benefit the millions of patients with cardiovascular disease.
Douglas L. Mann, MD
Lewin Chair and Chief, Cardiovascular Division
Professor of Medicine, Cell Biology and Physiology
Cardiologist-in-Chief, Barnes-Jewish Hospital
St. Louis, Missouri

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e, the editors of the third edition of The Washington Manual ™ Cardiology
Subspecialty Consult, wish to thank you for choosing our book as worthy of
your time to learn about cardiovascular diseases. There are many excellent

resources available to learners, but we hope that as you navigate through these
pages, you discover the passion that our authors have harnessed to create this up-todate and clinically impactful portable text.
We specifically wish to thank the editor of the first edition, Dr. Peter Crawford,
who planted the seeds of high-level intellect and compassionate tutelage from which
this edition grows. We are most indebted to the marvelous effort of those who
contributed to the current edition: house staff, fellows, and attending physicians
alike. While we expected excellence from our authors, we were overwhelmed by the
high quality of information and clear passion for teaching found in each chapter.
Every chapter of the third edition has been written by a pair of authors: one
cardiovascular fellow and one cardiovascular or pulmonary clinician-educator. This
pairing embodies the overriding theme of this edition: front-line, middle-of-the-night
synthesis and application of up-to-date guidelines, seasoned with expert clinical
experience. As with previous editions, we deliberately stress the most useful
information as it relates to the patient’s diagnosis and treatment with mnemonics,
bullet-point lists, bold-faced clinical pearls, and easy-to-read figures. To keep the
text thin enough to be portable, guidelines from the American Heart Association and
American College of Cardiology are emphasized with journal and online references
at the end of each chapter. We strongly encourage reading these current practice
recommendations as well as peer-reviewed journals, review articles, and primary
textbooks to supplement the material in this handbook.
We are particularly proud of the depth of the specialties in this edition. For
example, in an effort to restore the lost art of the cardiovascular physical exam, we
asked one of our most gifted master clinicians to author a dedicated chapter on this
topic. Additionally, the clinical impact of heart failure with preserved ejection
fraction, or diastolic heart failure, has inspired a new chapter for this edition. The
continued importance of individualization of medicine inspired dedicated chapters
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on cardiovascular diseases in elderly populations and in women specifically. These

new chapters are coupled with a simplified reorganization of the book, grouping
chapters together in the most logical ways.
Now more than ever, it is a thrilling time to be interested in cardiovascular
disease. Discovery is happening at a rapid pace, and translating these new
discoveries to the patient’s bedside happens quickly. More so than decades past,
there is a strong interest in providing cost-effective evidence-based cardiology. This
process requires a continuous synthesis and evaluation of the most recent clinical
trials into daily practice while maintaining diagnostic skills that are at the center of
cardiovascular disease management. It is our hope that both the information and the
enthusiasm contained in the chapters that follow provide you with the means to meet
these challenges and with it become a better teacher, a better learner, and a better
physician.
—PSC & AMK

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