Clinical cardiology, current practice guidelines demosthenes g katritsis

Clinical Cardiology


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Clinical Cardiology
Current Practice Guidelines
Demosthenes G. Katritsis, MD, PhD, FRCP, FACC
Athens Euroclinic, Athens, Greece

Bernard J. Gersh, MB, ChB, DPhil, FRCP, FACC
Mayo Medical School, Rochester, MN, USA

A. John Camm, MD, FRCP, FACC
St George’s University of London, UK

1


3

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First Edition published in 2013
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Foreword

Over the years I have had the pleasure of writing forewords for a number of books that I considered to be timely and to
fulfill important objectives. Without hesitation, I would say that Clinical Cardiology: Current Practice Guidelines, by D.G.
Katritsis, B.J. Gersh, and A.J. Camm, is the most outstanding book for which I have had the pleasure to write a foreword.
Further, this is probably the book that better serves the cardiovascular specialist in day-to-day practice than any other
written in the last two decades. This is not just a textbook; it is an extraordinary “toolkit” in the context of an evidencebased cardiovascular practice in the midst of rapidly evolving scientific knowledge and guidelines.
Because of the need to integrate current knowledge on evidence-based cardiology, about three years ago, under the
auspices of the American Heart Association, we published a book that included the most recent guidelines by both the
ACCF/AHA and the ESC. I believe that such integration was a step forward for the practicing cardiologist; indeed, in a
“synopsis” fashion, this aspect is well served in Clinical Cardiology: Current Practice Guidelines. However, in the excellent compendium of my colleagues, three new components are incorporated, which we can describe as the “jewel” of the
book: a very succinct definition, classification, pathophysiology, diagnosis, management, and need of specific clinical investigation (including genetics and molecular biology) of the various disease entities; a regularly updated online version
on the most recent developments; and, most importantly a “user friendly, at a glance” presentation. These additional three
components, that make Clinical Cardiology: Current Practice Guidelines so unique, deserve a brief description.
1) In regard to the various disease entities, general textbooks tend to employ, from definition to management, a
rather long and descriptive format. In contrast, Clinical Cardiology: Current Practice Guidelines consolidates many
of the topics, regardless of their complexity, from definition to management, in a clear, concise and instructive way,
intermixed with the most recent guidelines. Thus, over 600 easily accessible tables dissect and summarize the key
points of all the latest ACCF/AHA and ESC guidelines.
2) Rapidly evolving scientific knowledge, including the value of new diagnostic and management approaches and
their incorporation in practicing guidelines, makes it difficult for the cardiovascular specialist to be aware of the
latest clinical evidence-base. Written by three leading authorities in the field, its biannually updated online version
provides the solution.
3) A novelty of this book is the “user-friendly, at glance” way of presentation that it makes it very useful to the practicing cardiovascular specialist. Useful because of its combination of succinctness and clarity, the book is up to date
in every aspect of the cardiovascular science, and particularly on the most recent recommendations from both
sides of the Atlantic. Thus, these recommendations are summarized in tables derived from the guideline documents and incorporated in the appropriate diagnostic or management sections of the 85 comprehensive chapters.
For example, when confronted with complicated clinical issues that appear in everyday clinical practice (such as
modern antiplatelet therapy of ACS, differential diagnosis of wide complex tachycardia, or management of stable
CAD in view of COURAGE, FREEDOM or STICH) physicians consult general textbooks or, often several journal
articles, in order to obtain this information in a rather loose form. In contrast, Clinical Cardiology: Current Practice

Guidelines consolidates such topics in a summarized, succinct, and clear way.
This book is a tribute to the skill of the three editors who also served as the only authors. This limited, but unified and
hardworking internationally known authorship is, without doubt, a great part of the success. It is with great pleasure that
I pen these words to relate my enthusiasm for their work as a remarkable addition to the cardiovascular field.
Valentin Fuster
Physician-in-Chief, Mount Sinai Medical Center
Director, Mount Sinai Heart


ΠΑΝΤΕΣ ΑΝΘΡΩΠΟΙ ΤΟΥ ΕΙΔΕΝΑΙ ΟΡΕΓΟΝΤΑΙ ΦΥΣΕΙ
All humans by nature desire to know

Aristotle
The Metaphysics


Prologue

The entire field of cardiovascular medicine has witnessed an era of rapid scientific progress, accompanied by continuous technological and applied innovation. This occurs against a backdrop of increasing emphasis on the importance of
evidence-based practice, and rapid development of guidelines by major professional societies. The resultant expansion of
our body of knowledge by evidence-based recommendations interjects a new set of challenges for the practicing clinician
with ever-extensive clinical responsibilities.
In order to practice evidence-based medicine, information must be easily accessible and, more importantly, easily
retrievable when the need arises; this may not always be easy with the current pace of dissemination of knowledge. The
rationale for writing this book reflects exactly this need, both ours and that of our potential readers: to organize our
continually evolving knowledge on often diverse cardiology issues, in our environment of networked and facilitated communication. In other words, to provide a clinical tool that can be used in everyday clinical practice as a concise guide to
what we know and, more importantly, what we do not know, and what we think we know. To quote Mark Twain, “what
gets us into trouble is not what we don’t know, it is what we know for sure that just ain’t so.”
The prerequisites of informed clinical practice are: a satisfactory background of basic knowledge of disease entities,
remaining up-to-date on important clinical trials and emerging scientific evidence that shape current diagnosis and

therapy, and acquaintance with current practice guidelines from established professional societies such as the American
College of Cardiology Foundation/American Heart Association (ACCF/AHA) and the European Society of Cardiology
(ESC), among many others.
Each chapter of this book has therefore been structured around the following parts:
1. A clear definition and modern classification of disease entities, followed by updated, focused information on
recent developments on the epidemiology and pathophysiology of each condition. Recent original articles and
reviews from leading journals were consulted and a summary of the most relevant information is included. Special
care was taken not to omit the most recent information on medical genetics, an expanding and promising aspect.
2. A description of the clinical presentation of the disease, with instructions on necessary clinical investigations.
Clinical investigations are presented in the context of recent evidence that dictates their current value or obsolescence. An effort has been made to include the very latest published knowledge on the clinical value of existing and
evolving tests, based on recent randomized clinical trials and guidelines by both ACCF/AHA and ESC.
3. Recommendations on management as derived from the most recent evidence available to the authors. Because
of the comprehensive nature of guidelines offered by learned societies, it was decided to provide the most recent
recommendations in a summarized, tabulated format. These are not readily accessible since overlapping guidelines
may appear on the same condition from different working groups, and updated documents are continually appearing. Thus, all guideline documents and their updates published in the US and Europe were scrutinized and classified according to year of publication. The most recent recommendations were defined, extracted and tabulated. The
resulting tables provided in the book offer the most recent recommendations on each disease entity by both ACCF/
AHA and ESC. Where appropriate, new evidence that questions the validity of specific recommendations, as well
as the opinions of established experts, and other data, such as FDA alerts are included.
4. Practical advice on “what and why to do”. Therapies, drug doses and selection of procedures are presented in a
clear and user-friendly way.
5. Carefully chosen references. Major randomized clinical trials and seminal scientific studies that define evidencebased practice are included for further reference. In addition, recent, scholarly reviews are provided, which together with the contents of the book should allow in-depth study of specific entities that may interest the individual
reader.
6. Presentation of all recent guidelines. Guidelines are referenced and presented separately in order to guide the
reader to the most recent publications by ACCF/AHA and ESC.
An inherent disadvantage of a medical textbook is inability to keep up-to-date with recent developments. To overcome
the problem, the online version of this book will be updated, initially on a 6-monthly basis.


This book would have never been possible without the wholehearted support and commitment of Helen Liepman, our
Senior Editor at Oxford University Press. We are grateful for her acceptance of our view of a “next generation textbook”.

We also thank Imogen Lowe, Mark Knowles, and Richard Martin of Oxford University Press. Their professionalism and
assistance throughout the production process is much appreciated.
Demosthenes G. Katritsis
Bernard J. Gersh
A. John Camm


Contents

List of abbreviations

xxv

Part 1 Grown-up congenital heart disease
1 Grown-up congenital heart disease: general principles

Definition 3
Epidemiology 3
Aetiology 3
Clinical problems in GUCH 3
Imaging techniques and investigations 4
Principles of management 5
2 Ventricular septal defects

9
Definition and classification 9
Epidemiology 9
Aetiology 9
Pathophysiology 9
Presentation 10

Physical examination 10
Investigations 10
Therapy 10
Pregnancy 11

3 Atrioventricular septal defects

12
Definitions and classification of AVSDs
Ostium primum ASD 12

4 Atrial septal defects

15
Ostium secundum ASD 15
Sinus venosus defect 17
Patent foramen ovale 17

5 Patent ductus arteriosus

19

Definition 19
Epidemiology 19
Aetiology 19
Pathophysiology and natural history 20
Presentation 20
Physical examination 20
Investigations 20
Therapy 20

12

3


x

CONTENTS

6 Right ventricular outflow tract obstruction

22
Definitions and classification of RVOT obstruction 22
Valvular pulmonary stenosis 22
Subvalvular pulmonary stenosis 22
Supravalvar pulmonary stenosis 23
Branch pulmonary artery stenosis 23

7 Left ventricular outflow tract obstruction

25
Definitions and classification of LVOT obstruction 25
Valvular aortic stenosis (bicuspid aortic valve) 25
Subvalvular aortic stenosis 27
Supravalvular aortic stenosis 28

8 Coarctation of the aorta

29

Definitions 29
Epidemiology 29
Pathophysiology and natural history 29
Presentation 30
Physical examination 30
Investigations 30
Therapy 30
Pregnancy 31
9 Tetralogy of Fallot

31

Definition 31
Epidemiology 31
Aetiology 32
Pathophysiology 32
Presentation 32
Physical examination 32
Investigations 32
Therapy 32
Indications for intervention after repair
Participation in exercise 33
Pregnancy 33

33

10 Transposition of great arteries

34

Definitions and classification of TGA 34
Complete TGA (d-TGA) 35
Congenitally corrected transposition (l-TGA)

11 Ebstein’s anomaly

40

Definition 40
Epidemiology 40
Presentation 40
Physical examination

41

38


CONTENTS

Investigations 41
Therapy 41
Pregnancy 42
12 Anomalous PV connections, AV malformations, coronary

and LV abnormalities 43
Total anomalous pulmonary venous connection (TAPVC) 43
Partial anomalous pulmonary venous connection (PAPVC) 43
Pulmonary arteriovenous malformations 43
Congenital coronary anomalies 43

Coronary fistulas 43
Left ventricular protrusions 44
13 The Fontan patient

45

Definition 45
Pathophysiology 45
Clinical problems 45
Therapy 45
14 Eisenmenger syndrome

47

Definition 47
Pathophysiology 47
Clinical problems 48
Physical examination 48
Investigations 49
Therapy 49

Part 2 Valve disease
15 General principles

53

Epidemiology 53
Cardiac auscultation 53
Coronary angiography 54
Endocarditis prophylaxis 54

Pregnancy 54
16 Mitral stenosis

56
Epidemiology 56
Aetiology 56
Pathophysiology and natural history 56
Presentation 57
Physical examination 57
Investigations 57
Therapy 57
Non-cardiac surgery 63
Pregnancy 64

xi


xii

CONTENTS

17 Mitral regurgitation

66

Classification 66
Epidemiology 66
Aetiology 66
Pathophysiology and natural history 66
Presentation 67

Physical examination 67
Investigations 67
Therapy 68
Non-cardiac surgery 74
Pregnancy 74
18 Aortic stenosis

75
Epidemiology 75
Aetiology 76
Pathophysiology and natural history 76
Presentation 76
Physical examination 76
Investigations 77
Therapy 79
Non-cardiac surgery 85
Pregnancy 86

19 Aortic regurgitation

88

Epidemiology 88
Aetiology 88
Pathophysiology and natural history 88
Presentation 89
Physical examination 89
Investigations 89
Therapy 90
Non-cardiac surgery 92

Pregnancy 94
20 Tricuspid valve disease

94
Tricuspid regurgitation 94
Tricuspid stenosis 97

21 Pulmonary valve disease

98
Pulmonary valve regurgitation 98
Pulmonary valve stenosis 98

22 Prosthetic heart valves

99
Risk stratification for surgery 99
Mechanical valves 99
Tissue valves (bioprostheses) 99


CONTENTS

Anticoagulation 100
MRI 102
Thrombosis of prosthetic valves 102
Haemolysis 103
Paravalvular leaks 103
Pregnancy 103

Part 3 Systemic hypertension
23 Classification and pathophysiology of hypertension

111

Definition 111
Epidemiology 111
Pathophysiology 111
Subtypes of hypertension 113
Blood pressure measurement 114
24 Primary (essential) hypertension

117

Risk stratification 117
Physical examination 117
Investigations 119
Therapy 119
Resistant hypertension 131
Hypertensive crisis 132
Hypertension in pregnancy 133
25 Secondary hypertension

137

Introduction 137
Renal parenchymal disease 137
Renovascular hypertension 137
Primary aldosteronism 138
Phaeochromocytoma 140

Adrenal ‘incidentaloma’ 140
Other causes of hypertension 140

Part 4 Coronary artery disease
26 Epidemiology and pathophysiology of coronary artery disease

145

Definitions and classification 145
Epidemiology 145
Aetiology 145
Pathophysiology 146
27 Unstable angina and non-ST elevation myocardial infarction

Definition 149
Presentation 150

149

xiii


xiv

CONTENTS

Diagnosis 150
Therapy 150
Invasive vs conservative management 166
Specific patient groups 168

Complications 170
Risk stratification before discharge 173
Post-hospital discharge care 173
28 Acute myocardial infarction

177

Definition 177
Presentation 177
Physical examination 177
Diagnosis 178
Initial therapy and medication 182
Reperfusion therapy 187
Complications of MI 196
Discharge 204
Chronic therapy 204
Stem cell transplantation 208
29 Stable coronary artery disease

212

Definition 212
Presentation 212
Physical examination 212
Investigations 212
Differential diagnosis 221
Risk stratification 222
Therapy 223
Evaluation and risk assessment before non-cardiac surgery 251

Part 5 Heart failure
30 Classification, epidemiology, and pathophysiology of heart failure

Definitions and classification 267
Epidemiology 267
Pathophysiology 267
Aetiology 268
31 Chronic heart failure

Presentation 270
Physical examination
Investigations 272
Prognosis 278
Therapy 278
Pregnancy 302

270
270

267


CONTENTS

32 Heart failure with preserved LVEF

306

Definition 306
Aetiology and pathophysiology 306

Epidemiology 306
Clinical presentation 306
Diagnosis 307
Therapy 307
33 Acute heart failure and cardiogenic shock

Acute heart failure 308
Cardiogenic shock 314

Part 6 Cardiomyopathies
34 Classification of cardiomyopathies

319

Introduction 319
American Heart Association (2006) 319
European Society of Cardiology (2008) 319
35 Dilated cardiomyopathy

324

Definition 324
Epidemiology 324
Aetiology and pathophysiology 324
Presentation 327
Physical examination 327
Investigations 327
Risk stratification 327
Therapy 328
Prognosis 329

Pregnancy 329
36 Hypertrophic cardiomyopathy

331

Definition 331
Epidemiology 331
Aetiology 331
Pathophysiology 331
Presentation and natural history 333
Physical examination 335
Investigations 335
Differential diagnosis 336
Therapy 336
Physical activity and sports 343
Family counselling and genetic testing 343
Pregnancy 346

308

xv


xvi

CONTENTS

37 Restrictive cardiomyopathy

348

Definition 348
Pathophysiology 348
Aetiology 348
Presentation 349
Physical examination 350
Investigations 350
Differential diagnosis 351
Therapy 352
38 Arrhythmogenic right ventricular cardiomyopathy/dysplasia

Definition 353
Epidemiology 353
Aetiology 353
Pathophysiology 354
Presentation 355
Investigations 355
Differential diagnosis 357
Risk stratification 357
Therapy 357
Genetic testing 359
Pregnancy 360
39 Peripartum cardiomyopathy

Definition 361
Epidemiology 361
Aetiology 362
Presentation 362
Investigations 362
Therapy 362

Delivery 363
Prognosis 363
40 Tachycardiomyopathy

364

Definition 364
Epidemiology 364
Aetiology 364
Pathophysiology 364
Presentation 364
Diagnosis 364
Therapy 364
41 Stress cardiomyopathy

Definition 365
Pathophysiology 365

365

361

353


CONTENTS

Diagnosis 365
Therapy 365
42 Iron overload cardiomyopathies

367

Definition 367
Aetiology 367
Pathophysiology 367
Presentation 367
Diagnosis 367
Therapy 367
43 Left ventricular non-compaction

369

Definition 369
Epidemiology 369
Aetiology 369
Presentation 369
Diagnosis 369
Therapy 370

Part 7 Myocarditis
44 Acute myocarditis

373
Definition and classification 373
Epidemiology 373
Aetiology 373
Pathophysiology 373
Presentation 373
Physical examination 374

Investigations 374
Therapy 374
Prognosis 375

Part 8 Pericardial disease
45 Pericardial anatomy and congenital pericardial defects

Pericardial anatomy 379
Congenital pericardial defects

379

46 Acute and relapsing pericarditis

379

Acute pericarditis 379
Relapsing pericarditis 382
47 Pericardial effusion and cardiac tamponade

Pericardial effusion 383
Cardiac tamponade 385

383

379

xvii

xviii

CONTENTS

48 Constrictive pericarditis

388

Definition 388
Aetiology 388
Pathophysiology 388
Presentation 388
Physical examination 388
Investigations 388
Differential diagnosis 390
Therapy 390

Part 9 Tachyarrhythmias
49 Classification of tachyarrhythmias, mechanisms of arrhythmogenesis,

and acute management 393
Definitions and classification 393
Electrophysiological mechanisms of arrhythmogenesis 393
Acute management of tachyarrhythmias 399
50 Classification, epidemiology, and presentation of supraventricular tachycardias

Definitions and classification 403
Epidemiology of SVT 403
Presentation of SVT 403
SVT in congenital heart disease 403

SVT in pregnancy 405
Therapy of SVT 405
51 Atrial tachycardias

406
Atrial and junctional premature beats 406
Physiological sinus tachycardia 407
Inappropriate sinus tachycardia 407
Sinus reentrant tachycardia 408
Focal atrial tachycardia 408
Multifocal atrial tachycardia 409
Macro-reentrant atrial tachycardias (atrial flutters)

52 Atrial fibrillation

413
Definitions and classification 413
Epidemiology 413
Aetiology 414
Pathophysiology 414
Diagnosis 415
Investigations 416
Risk stratification 417
Therapy 417

410

403

CONTENTS

AF in specific conditions
AF in pregnancy 447

444

53 Atrioventricular junctional tachycardias

456
Atrioventricular nodal reentrant tachycardia 456
Non-reentrant junctional tachycardias 462

54 Atrioventricular reentrant tachycardias

464

Definitions 464
Epidemiology 464
Pathophysiology 464
Aetiology 465
Presentation 465
Diagnosis 465
Risk stratification in WPW syndrome 467
Therapy 467
55 Ventricular arrhythmias

470
Definitions and classification 470
Pathophysiology 470

Presentation 473
Differential diagnosis of wide QRS tachycardia 473
Acute therapy of ventricular arrhythmias 474
Risk stratification 477
Long-term therapy 483
Clinical forms of ventricular arrhythmias 484

Part 10 Genetic channelopathies
56 Definitions of inherited arrhythmias

Definitions 507
Glossary of terms and acronyms 507
57 Long QT syndrome

512

Definition 512
Epidemiology 512
Pathophysiology and genetics 512
Presentation 513
Diagnosis 513
Genetic testing 515
Specific LQTS types 515
Therapy 516
58 Short QT syndrome

Definition 518
Aetiology 518

518

507

xix


xx

CONTENTS

Presentation 518
Diagnosis 518
Therapy 519
59 Brugada syndrome

521

Definition 521
Epidemiology 521
Genetics and pathophysiology 521
Presentation 522
Diagnosis 522
Risk stratification 524
Therapy 524
60 Catecholaminergic polymorphic ventricular tachycardia

Definition 528
Epidemiology 528
Genetics and pathophysiology 528
Presentation 528

Diagnosis 528
Therapy 528
61 Early repolarization syndromes

530

Definition 530
Genetics and pathophysiology 530
Clinical significance 531
Therapy 533

Part 11 Bradyarrhythmias
62 The cardiac conduction system

537

Overview 537
63 Sinus nodal disease

539
Sinus bradycardia 539
Sick sinus syndrome 539

64 Atrioventricular and intraventricular block

Atrioventricular block 543
Atrioventricular dissociation
Intraventricular block 548

543

548

65 Conduction disease in specific conditions

Recent myocardial infarction 553
Congenital AV block 553
Sleep apnoea 554
Cardiac transplantation 554
Pacing in pregnancy 554
Other pacing indications 556

553

528


CONTENTS

Part 12 Syncope and sudden cardiac death
66 Syncope

561
Definition 561
Epidemiology 561
Classification 561
Pathophysiology 561
Presentation 561
Aetiologic diagnosis 561
Investigations 562

Risk stratification 566
Therapy 568
Driving 571

67 Sudden cardiac death

573

Definition 573
Epidemiology 573
Aetiology 574
Pathophysiology 575
Investigations in survivors 575
Management of cardiac arrest 577

Part 13 Implantable devices
68 Technical issues

581
Permanent pacemakers 581
Biventricular pacing 582
Implantable cardioverter-defibrillators 582

69 Complications of implantable devices

586

Implantation-related complications 586
Device-related infections 587
Device implantation in the anticoagulated patient 587

Reimplantation 587
Perioperative management of patients with devices 590
Magnetic resonance imaging 594
Driving and sexual activity 594

Part 14 Diseases of the aorta
70 Acute aortic syndromes

599
Definitions and classification 599
Epidemiology 600
Pathophysiology 600
Aetiology 600
Presentation 600

xxi


xxii

CONTENTS

Physical findings 601
Diagnosis 601
Therapy 603
Follow-up 608
71 Thoracic aortic aneurysms and other conditions

609

Thoracic aortic aneurysms 609
Aortic arch and thoracic aortic atheroma and atheroembolic disease 612
Cardiovascular conditions associated with thoracic aortic disease 612
72 Genetic syndromes associated with thoracic aneurysm and dissection

614

Marfan’s syndrome 614
Other heritable syndromes and genetic defects associated with thoracic aortic disease 617
73 Inflammatory diseases associated with thoracic aortic disease

Introduction 618
Takayasu’s arteritis 619
Giant cell (temporal) arteritis

618

620

Part 15 Venous thromboembolism
74 Pulmonary embolism

623

Definitions 623
Epidemiology 623
Pathophysiology 623
Aetiology 623
Presentation 624
Diagnosis 624

Risk stratification 626
Acute therapy 626
Long-term therapy 630
Special conditions 631
75 Deep vein thrombosis

634

Overview 634
Thromboembolism in pregnancy

634

Part 16 Pulmonary hypertension
76 Definitions and classification of pulmonary hypertension

641

Definition and classification 641
77 Pulmonary arterial hypertension and hypertension associated with pulmonary

venous abnormalities 642
Pulmonary arterial hypertension

642


CONTENTS

Pulmonary hypertension associated with pulmonary venous capillary

abnormalities 653
78 Pulmonary hypertension associated with left heart disease and lung disease, and

chronic thromboembolic pulmonary hypertension 654
Pulmonary hypertension associated with left heart disease 654
Pulmonary hypertension associated with lung disease 655
Chronic thromboembolic pulmonary hypertension 655

Part 17 Infective endocarditis
79 Infective endocarditis

661

Definition 661
Epidemiology 661
Aetiology 661
Pathophysiology 661
Presentation 661
Clinical features 664
Diagnosis 664
Therapy 665
Complications 666
Prognosis 670
Pregnancy 670
Prophylaxis 670

Part 18 Rheumatic fever
80 Rheumatic fever

677

Definition 677
Epidemiology 677
Aetiology 677
Pathophysiology 677
Presentation 677
Clinical forms 677
Diagnosis 678
Therapy 679
Prophylaxis 679

Part 19 Athlete’s heart
81 Athlete’s heart

683
Exercise-induced cardiac remodelling 683
Interpretation of the ECG in athletes 683

xxiii


xxiv

CONTENTS

Arrhythmias in athletes 687
Classification of sports 687

Part 20 Cardiac tumours and pseudoaneurysms
82 Cardiac tumours

691
Primary cardiac tumours 691
Cardiac metastases 691

83 Pseudoaneurysms of the heart

692

Introduction 692
Aetiology 692
Diagnosis 692
Treatment 692

Part 21 Cardiovascular disease in pregnancy
84 Cardiovascular disease in pregnancy

695

Overview 695

Part 22 Cardiovascular drugs
85 Cardiovascular drugs

701
Antiarrhythmic drugs 701
Antiplatelet agents 701
Anticoagulants 701
Beta blockers, diuretics, ACEIs, ARBs, CCBs
Statins, fibrates 701

Drugs for erectile dysfunction 701

701

Appendix 1: Recommendation classes and levels of evidence
used in guidelines 703
Appendix 2: Therapy of endocarditis 705
Appendix 3: ESC 2011 on pregnancy 713
Index 717