Download A Cardiologist`s View - Health Professions Institute

A Cardiologist’s View
by Michael J. O’Donnell, M.D.
1989, 2007
Cardiology and cardiovascular surgery are both concerned with the diagnosis and treatment
of diseases of the heart, great vessels, and peripheral circulation. The difference between
cardiologists and cardiovascular surgeons lies in the methods used to treat these diseases.
The cardiologist is, by training, an internist who specializes in the diagnosis and medical
treatment of cardiovascular disease. The cardiac surgeon specializes in the surgical treatment of
cardiovascular disease. In no other area of medicine does an internist work so closely with a
surgeon as in the management of cardiovascular disease.
Cardiologists must rely on their cardiovascular surgeon colleagues when surgical
intervention is needed in the treatment of their patients. Similarly, cardiovascular surgeons rely
on their cardiologist colleagues for the majority of their case referrals. The cardiologist and
cardiovascular surgeon collaborate during a surgical procedure if the patient develops
hemodynamic instability or refractory cardiac arrhythmia, and also during the postoperative
period in the routine management of the cardiac surgery patient. Thus there is considerable
overlap between the two specialties.
The Cardiology Patient
Patients with myocardial ischemia (inadequate blood supply to the heart) are those most
frequently seen by both cardiologists and cardiovascular surgeons. Myocardial ischemia is
usually caused by arteriosclerosis, or hardening of the arteries. These patients are seen initially by
a cardiologist for evaluation; those who are found to have extensive disease may be referred to a
cardiovascular surgeon for a coronary artery bypass procedure.
The next largest group of patients seen by cardiologists are those who suffer from varying
degrees of congestive heart failure, where the heart’s pumping capability is impaired. This
condition may develop as a result of coronary artery disease, valvular heart disease, or other
abnormal processes, some of which may not be identifiable. These patients are generally not
surgical candidates and therefore are cared for almost exclusively by cardiologists.
The third largest group of patients seen by both the cardiologist and the cardiovascular
surgeon comprises those with valvular heart disease, either congenital or acquired. Congenital
valvular disease refers to a structural malformation of one or more cardiac valves that is present
at birth and that eventually leads to cardiac dysfunction requiring evaluation and treatment. In the
majority of patients with valvular disease, the condition is acquired; that is, the patient is born
with structurally normal heart valves but then develops valvular abnormalities as a result of
acquired disease.
Another common cardiologic condition is arrhythmia, a disturbance of the heart rhythm.
Arrhythmias are classified as either supraventricular or ventricular, depending on their site of
origin. Generally they are treated medically but in selected cases surgical intervention may be
warranted.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Numerous other conditions are treated by both cardiologists and cardiovascular surgeons, but
taken together they represent only a small portion of cardiologic or cardiovascular surgical
practice.
The proportion of cardiac surgical patients in a cardiologist’s practice depends largely on
where the cardiologist practices. A cardiologist practicing in a rural setting where there is no
cardiovascular surgeon would have no surgical patients in the practice. A cardiologist working in
a teaching hospital or large regional or metropolitan medical center, whether a private or
university hospital, might have as many as 50% surgical patients in the practice.
Cardiac patients vary widely in age. The youngest patient seen by a cardiologist or
cardiovascular surgeon might be a newborn infant with a severe heart defect requiring surgery
within the first few hours of life. At the other extreme are patients in the final years of life. As a
general rule, the older the patient, the less likely is surgical intervention to be indicated.
Cardiovascular Disease
Cardiovascular disease continues to be the most serious threat to life and health in the United
States. One in every three men in this country can expect to develop some major cardiovascular
disease before reaching the age of 60. The odds for women are approximately 1 in 10, although
these odds continue to rise as more women develop the same risk factors as men. Coronary
disease is the major cause of death after the age of 40 in men and after the age of 50 in women.
Approximately 19% of the U.S. population have heart disease or hypertension (high blood
pressure), causing limitation in activity. The most common cardiovascular diseases are
hypertension and arteriosclerosis-related diseases (which include coronary heart disease,
cerebrovascular disease, and peripheral vascular disease). Coronary disease accounts for half of
all deaths in the U.S. Of these, 70% are related to cardiovascular disease, while 16% are related
to stroke. Coronary heart disease causes approximately 800,000 new heart attacks each year and
an additional 450,000 recurrent heart attacks.
The presenting complaint for coronary disease in women is most likely to be angina pectoris,
whereas in men it is most likely to be myocardial infarction (heart attack) or sudden death.
Therefore, only 20% of heart attacks are preceded by long-standing angina pectoris.
Unrecognized myocardial infarctions are common, accounting for approximately 20% of all heart
attacks. One half of these are silent and the remaining half are atypical in that neither the patient
nor the physician considers the possibility of a myocardial infarction. Roughly two thirds of
patients who experience a myocardial infarction do not make a complete recovery. However,
88% of those patients under the age of 65 are able to return to their usual occupations. Within
approximately five years after initial myocardial infarction, 13% of the men and almost 40% of
the women develop a second myocardial infarction. The mortality rate is 30% for the initial
myocardial infarction and 50% for recurrent myocardial infarction. The 10-year survival rate is
50% for men and 30% for women.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Hypertension. Hypertension is by far the most prevalent cardiovascular disease and is one of
the most significant risk factors for cardiovascular disease and death. Hypertension is defined as
blood pressures of 140/90 mmHg or greater. The prevalence of hypertension is approximately
30% for persons between 25 and 75 years of age. The prevalence increases with age, and is
highest among blacks and the elderly. Awareness of hypertension has markedly increased.
Malignant hypertension as a cause of death is becoming a rarity. Hypertension disease mortality
is largely due to arteriosclerotic sequelae or complications, such as coronary disease, stroke, and
cardiac failure.
Stroke. The most common variety of stroke seen by a cardiologist is the atherothrombotic
brain infarction (blocking circulation to the brain), which accounts for approximately 59% of all
strokes. The next most common is cerebral embolus (blood clot to brain) (14%), followed by
subarachnoid hemorrhage (9%), and intracerebral hemorrhage (5%). The chances of having a
stroke before age 70 are approximately 1 in 20 for either sex. Unlike hypertension and other
arteriosclerosis-related disease, there is no clear-cut male predominance in stroke incidence.
Stroke remains the third most frequent cause of death, behind heart disease and cancer.
Heart failure. Heart failure is a condition that develops after the myocardium has exhausted
all its reserve and compensatory mechanisms. Once overt signs of heart failure occur, 50% of all
patients will die within five years despite aggressive medical management. The etiology (cause)
of cardiac failure may be hypertension, ischemic myocardial disease, or congenital or acquired
valvular disease. The dominant cause is hypertension, which precedes failure in approximately
75% of cases. Coronary heart disease, generally accompanied by hypertension, is responsible in
39% of cases. Despite modern intervention for cardiac failure, the prognosis remains grim.
Cardiac arrhythmia. An arrhythmia (abnormal heartbeat) results from some disturbance in
the formation or transmission of the cardiac impulse. It may be a manifestation of any of the
major forms of heart disease and is an important source of mortality. Many such deaths occur
suddenly and without warning. Cardiac arrhythmia and congestive failure are critical
developments common to the course of most types of severe heart disease.
Valvular heart disease. One cause of acquired valvular disease is rheumatic fever.
Rheumatic heart disease may cause degenerative valvular disease as well as mitral valve
prolapse. Rheumatic fever or rheumatic heart disease in the U.S. has significantly decreased in
recent years because of the use of antibiotics in the treatment of streptococcal infections.
However, the disease still occurs in disadvantaged areas such as inner cities and remote rural
areas.
The end result of rheumatic valvular disease is disruption of normal valvular tissue and
subsequent calcification (calcium deposits) and stenosis (narrowing). The mitral valve is nearly
always involved, and in many instances the aortic valve is affected as well. Once the stenosis
becomes critical, the patient will need either surgical replacement of the valve or nonsurgical
treatment by balloon valvuloplasty.
Other forms of acquired valvular disease can also lead to valvular stenosis. Degeneration of a
valve can result in valvular insufficiency rather than stenosis. The most common presentation
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
for patients with either stenosis or insufficiency is progressive dyspnea (difficulty breathing) on
exertion with easy fatigability. The patient may also begin to experience chest discomfort
unrelated to any coexisting coronary artery disease and myocardial ischemia.
Congenital heart disease. Congenital heart disease is generally seen by pediatric rather than
adult cardiologists or cardiovascular surgeons. The types and presentations of congenital heart
disease can be somewhat complex and their diagnosis and surgical management can be equally
complex. Therefore, it remains a subspecialty area within the field of cardiology and
cardiovascular surgery.
Structural abnormalities of the heart or intrathoracic great vessels seem to affect 8-10 of
every 1000 newborns in the U.S. Approximately one of these 1,000 live newborns has a
congenital cardiac defect that cannot be managed medically or surgically. The incidence of most
congenital heart diseases has remained stable for many years. Rubella vaccine has reduced
rubella-caused congenital heart disease, and congenital heart defects associated with Down
syndrome are less common because older women are having fewer babies. There still remains a
lack of knowledge of the cause of most congenital heart disease, although it has been shown that
alcohol and some prescription drugs can cause cardiac defects. The majority of congenital heart
defects, however, probably result from complex genetic-environmental causes not presently
understood.
Pulmonary thromboembolism. A final disease entity seen by both the cardiologist and the
cardiovascular surgeon is pulmonary thromboembolism. This occurs when an embolus (usually a
clot from the deep veins in the pelvic cavity or lower extremities) dislodges and travels along
with the normal blood return to the right heart. As the right heart supplies blood to the pulmonary
vasculature, the embolus lodges within the lung circulation.
Pulmonary thromboembolism is the most common lethal pulmonary disease. If it is left
untreated, recurrent episodes are likely, and more than 25% of these will be fatal. Most fatalities
occur within one hour of the onset of symptoms, and sudden death due to pulmonary embolism
can be confused with sudden coronary death. Predisposing factors include chronic pulmonary
disease, malignancy, estrogen therapy, orthopedic trauma, immobilization, recent operative
procedures, obesity, pregnancy, and blood disorders.
Diagnostic Studies, Invasive and Noninvasive
Highly specialized radiologic and other diagnostic technologies probably find more
application in the practice of cardiology than in any other subspecialty of medicine.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Electrocardiography. The standard evaluative tool of the cardiologist is the
electrocardiogram (EKG), which measures the electrical impulses generated by the heart. With
the standard 12-lead EKG it is possible to diagnose myocardial infarction (past or present),
ischemic heart disease, left ventricular hypertrophy (enlargement), hypertensive heart disease,
cardiac dysrhythmias, and other cardiac maladies. Advanced techniques based on the EKG
include 24-hour Holter monitoring, stress electrocardiography, and signal-averaged
electrocardiography.
Vectorcardiography. Vectorcardiography assesses the direction of the heart’s electrical
activity, either in sum or at a particular instant. With each cardiac cycle the electrical activity
travels through the heart in a loop, a configuration that may be altered in predictable fashion by
various kinds of heart disease.
Electrophysiologic studies. All of the electrical studies mentioned above are noninvasive;
that is, no catheters are inserted into the heart. One technique that does require invasive technique
is the electrophysiologic study. This is a procedure in which a sensing and stimulating electrode
is placed via catheter in various positions within the heart, particularly the right chambers. In this
way the electrical activity of the heart can be measured from an internal rather than an external
observation point.
Additionally, the heart may be stimulated through these catheters in order to assess whether
the patient is susceptible to ventricular tachycardia or other ventricular or atrial arrhythmias. If
susceptibility to these rhythm disturbances is found, then various antiarrhythmic drugs may be
tried and repeat stimulations used to assess the efficacy of the drug regimen.
Ultrasound. Nonelectrical techniques for diagnosis of cardiac disease include ultrasound,
radioisotopes (radioactive substances), and x-rays. Cardiac ultrasound is better known as
echocardiography and cardiac Doppler evaluation. In these techniques, ultrasound waves directed
at the cardiac chambers and valves are reflected into the receiving portion of the transducer,
amplified, and projected onto a screen. This allows for real-time evaluation of cardiac function.
Doppler study is a procedure in which the ultrasound waves are reflected by moving red blood
cells, so that velocities can be measured through the cardiac valves and chambers. This is an
extremely useful tool for measuring and assessing valvular stenosis, insufficiency, and structural
defects such as atrial septal or ventricular septal defects.
Nuclear cardiology. Nuclear cardiology is a fast-growing field in which radioisotopes are
employed in various ways, including thallium scans, multi-gated blood pool analysis (MUGA),
and positron emission scanning. In all of these radionuclear techniques, radioisotopes given
intravenously are picked up and quantified by scanning the chest cavity, with particular attention
to the heart. These tests can provide data on the perfusion, function, and physiologic demands of
the myocardium.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Radiology. The use of diagnostic x-rays in cardiology includes routine chest x-ray,
fluoroscopy, and CT scanning. The most recent advance in this field is ultrafast CT scanning,
which is being developed largely at the University of Illinois Medical Center. The ultrafast CT
scan provides estimates of blood flow through cardiac chambers and coronary arteries or
coronary artery bypass grafts. This useful tool, though still in its infancy, may make it possible to
estimate the degree of severity of coronary artery disease without invasive measures.
Another recent advance in the field of cardiac radiology is magnetic resonance imaging
(MRI). The advantage of MRI is its ability to visualize with great clarity the soft tissues of the
body. This technique makes possible a structural assessment of cardiac chambers and valves as
well as estimation of blood flow. This is another noninvasive procedure that holds great promise
for accurate evaluation of coronary artery disease and other cardiac pathology.
Cardiac catheterization. This is an invasive technique that requires the introduction of a
diagnostic catheter through a peripheral vessel, under fluoroscopic guidance, into the various
cardiac chambers. By this means, pressure readings can be taken directly from a variety of sites.
Placement of the catheter in the coronary ostium (opening) and injection of contrast medium
permits radiographic visualization and recording of the coronary blood flow on motion picture
film (coronary cineangiography).
The purpose of all of these cardiac diagnostic studies is to strive to treat the patient
medically. In about half of the patients, however, an invasive therapy will be indicated. This may
include coronary artery angioplasty, balloon valvuloplasty, or cardiac surgery either with
coronary artery bypass grafting or repair or replacement of a valve.
Cardiovascular Surgery
The simplest cardiovascular surgical procedure is carotid endarterectomy. This involves
opening up a segment of the internal carotid artery that has become obstructed by atherosclerotic
disease, causing intermittent neurologic problems. In this procedure, the diseased portion of the
artery is exposed via a surgical incision in the lateral aspect of the neck. Once the carotid artery is
exposed, it is clamped above and below the obstruction. Then an incision is made into the vessel
and the atherosclerotic material is peeled away. The incision in the vessel is sutured, the clamps
are removed, and the skin is sewn closed. During this procedure, the patient is under general
anesthesia but does not require the use of a heartlung bypass machine.
The most difficult kind of cardiac surgery is repair of congenital heart defects in the infant.
The surgery is technically difficult, as extensive cardiac remodeling must often be done to correct
these complex abnormalities. The best example of an involved procedure in regular use would be
the Mustard operation to correct tetralogy of Fallot (pulmonary stenosis, ventricular septal defect,
dextroposition of the aorta, and right ventricular hypertrophy). In addition, the smallness of the
patient contributes to the difficulty encountered in performing the surgery.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Cardiopulmonary bypass. The purpose of the heart-lung bypass machine is to take over the
patient’s cardiac and pulmonary function while surgery is being performed on the heart. The
machine includes a pumping mechanism to maintain blood pressure and circulation to vital
organs. In addition, the machine functions as an oxygenator since the lungs are bypassed once the
patient’s heart is placed in cardiac arrest. Oxygen taken from the hospital’s oxygen supply lines
diffuses across a bubble oxygenator which comes in contact with the patient’s blood as it passes
through the cardiopulmonary bypass machine. During this time, the patient’s red blood cells
derive adequate oxygen from the machine even though the lungs are not functioning. Thus the
surgeon can perform an intricate procedure on a nonbeating heart without jeopardizing the
patient’s vital organs.
Cardiac Rehabilitation
Cardiac rehabilitation is an integral part of the field of cardiology. A patient who has
sustained a myocardial infarction, developed congestive failure, or undergone cardiac surgery is
generally placed in a cardiac rehabilitation program to provide for a controlled increase in heart
function and tone. Such a program generally consists of three phases.
Phase 1 is performed in the hospital after the patient is released from the intensive care unit.
This initially involves bedside exercises and then progresses to walking for gradually increasing
distances and periods. After discharge, cardiac surgery patients are usually given 1-2 weeks to
continue their recuperation and phase 1 cardiac exercises at home. They are then seen in the
office by a cardiologist and an evaluation is made regarding advance to phase 2 cardiac
rehabilitation.
Phase 2 consists of an 8- to 12-week course in which the patient reports to a cardiac
rehabilitation center on a twice-weekly basis. The patient performs progressive cardiac exercises
that are primarily aerobic, such as bicycle, treadmill, and arm wheel exercises. During these
sessions, the patient’s heart rate and blood pressure are continually monitored. The patient also is
educated on lifestyle changes that are required for improvement in cardiopulmonary status, such
as diet, stress management, and behavior modification in those patients who must stop smoking
or discontinue other high-risk behavior.
Finally, phase 3 cardiac rehabilitation is given to those patients who wish to continue on a
more strenuous program following successful completion of the phase 2 program.
Other Cardiac Diseases
Other cardiac patients include those with anomalous (abnormal) coronary arteries that do not
originate from their usual positions in the aortic root. These are always a joy to find during a
cardiac catheterization, and test a cardiologist’s memory as to the innumerable types and
purposes of catheters that are available. Even more unusual cases are those involving
unsuspected congenital defects, such as coarctation of the aorta or supravalvular or subvalvular
aortic stenosis.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
I distinctly remember one such case in which a young woman with Down syndrome was
brought into the hospital by her aunt for evaluation. After completing my history-taking from the
aunt and briefly questioning the patient, I proceeded to examine her and found that she was
deathly afraid of me and my stethoscope. I did my best to console her and assure her that nothing
I was going to do would hurt her. She quickly became a trusting friend and returned to the happy
state typical of Down syndrome patients. The examination confirmed the diagnosis of Williams
syndrome and supravalvular aortic stenosis. Williams syndrome, transmitted generally as an
autosomal dominant trait, is characterized by the triad of mental retardation, elfin facies, and
supravalvular aortic stenosis.
To document the severity of her supravalvular aortic stenosis, cardiac catheterization was
performed. Prior to the catheterization, my new-found friend had many innocent questions as to
what exactly the procedure involved. Although I am sure she had little technical understanding of
what she was about to undergo, she looked at me with complete trust and said that as long as she
knew that I would not hurt her she would proceed with the test—only after giving me a hug and a
kiss prior to going to the cardiac catheterization laboratory.
At the time of her catheterization, she was found to have severe supravalvular aortic stenosis.
It was a technical challenge to cannulate her coronary arteries because the supravalvular aortic
stenosis, consisting of a ridge of fibrous tissue that lies just distal to the level of the coronary
ostia, overlapped the ostium of the left main coronary artery. This was causing her myocardial
ischemia. She underwent successful surgical repair. In my daily visits to her after surgery, I
would always see a trusting and happy face and would be rewarded with a hug and a kiss that
sent me on the rest of my rounds, ready to face the challenges of another day.
Cardiology and Related Disciplines
The relationship between the cardiologist and other kinds of specialists is one of daily
interaction. A great many patients with cardiovascular disease have other medical illnesses as
well, which require evaluation and treatment by other medical specialists. In particular,
subspecialists in pulmonary disease, nephrology, and gastroenterology are commonly consulted
to aid in the treatment of cardiac patients.
Pulmonology. Many patients have developed cardiac disease because of a heavy smoking
history. A large proportion of them go on to develop chronic obstructive lung disease. Many of
these patients have difficulty in being weaned from the ventilator in the postoperative period. The
assistance of a pulmonologist in these circumstances can be invaluable.
Nephrology. The atherosclerotic process that results in coronary artery disease may also
result in other vascular diseases, including peripheral vascular and renal vascular disease. Hence
many cardiac patients have renal insufficiency (kidney failure), on either an acute or chronic
basis. The medical support of a nephrologist in the treatment of such renal disorders can be
crucial.
Gastroenterology. Many cardiology patients are found to be anemic, and the etiology of the
anemia frequently turns out to be chronic GI blood loss. Thus many patients are seen in
consultation by a gastroenterologist to find the source for their anemia.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
New Developments in Cardiology
Cardiology is by far the fastest growing medical field in terms of technical developments.
Cardiac drugs. The various new classes of drugs for control of angina pectoris, and
treatment of patients with congestive failure and arrhythmias, are too numerous to list here. It
would be a conservative estimate that, on the average, 15-25 new cardiac drugs are brought out
each year. New classes of cardiac drugs are becoming more and more specific in their therapeutic
effects and more and more free of unwanted side effects.
Heart transplant. Developments in the area of cardiac transplantation are currently centered
on the production of new immunosuppressive drugs. The most common medical problem
encountered in the treatment of cardiac transplant patients is rejection of the transplanted heart.
Therefore, most investigative efforts are focused on development of newer classes of
immunosuppressive agents that are specific for preventing rejection of the newly transplanted
heart but do not suppress the patient’s host defenses against life-threatening infections.
Pacemakers. New developments are occurring almost daily in the refinement of cardiac
pacemakers. Pacemakers that can respond to the patient’s metabolic work demands, as a normal
heart would, are currently being evaluated. These ingenious devices are able to maintain variable
heart rates depending on the body’s demands in skeletal muscle activity, changes in core
temperature, and changes in overall blood flow.
Defibrillators. Patients who have ventricular arrhythmias that do not respond to medical
treatment are now given new hope with the development of automatic implantable cardiac
defibrillators. These devices have electric pads that are secured to the surface of the heart and
sense its electrical activity. When a sustained ventricular arrhythmia is detected, the device
delivers a low-voltage shock directly to the heart to restore a normal rhythm. Although the
patient is able to sense this small electrical discharge, this is a small price to pay, in view of the
fact that the odds are against surviving a cardiac arrest occurring outside the hospital.
Catheters. In the treatment of intracardiac arterial disease, there has been rapid development
in the technology of catheters, balloons, and guide wires. Research has been primarily directed
towards newer materials to provide increased strength, decreased bulk, and smoother tracking
over the guide wire. These changes allow more complex coronary angioplasty to be undertaken
with a decreased risk of complications and restenosis.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Stents. A stent is a permanent intravascular device that can be inserted at the time of
coronary angioplasty when acute closure of a vessel occurs. Introduced into the occluded area
and then expanded, the stent provides a supporting framework to support and keep the vessel
open. Stents may also be employed in patients who have had what is termed a chronic restenosis.
These patients have undergone repeated angioplasty procedures for the same coronary artery
lesion, which continues to reappear despite multiple dilatations. The stent may be inserted
immediately after balloon dilatation to form a supporting framework that will not allow the
vessel to restenose.
Lasers. There is continuing research in the area of laser ablation (eradication and removal
with a laser) of coronary artery lesions. Various kinds of laser systems are under development.
These include laser catheters that have a metal cap tip in which laser energy is used to heat the
cap to extremely high temperatures so that it can melt through atheromatous lesions.
Other catheter systems have what is termed direct laser energy emerging from the catheter tip
to cut a channel through the atheromatous lesion. These catheters are currently able to reestablish
only a small channel through an otherwise totally or subtotally occluded atheromatous lesion.
After this procedure, a balloon catheter is advanced through the new channel and balloon
angioplasty is performed to make a larger channel for blood flow.
Another type of laser system that is currently under development is a laser balloon, which is
essentially an angioplasty dilatation catheter with the capability of diffusing laser energy through
the internal balloon surface outward to the endothelium of the coronary artery in contact with the
balloon.
Other devices. Mechanical ablation devices consist of either drill bits or coring tools that are
placed into an artery with an atheromatous lesion. The drill, spinning at rates as high as 200,000
rpm, pulverizes the atheromatous lesion. The other device cores or shaves the lesion with a blade.
These devices are expected to prove more effective than balloon angioplasty in the treatment of
atheromatous lesions, since they remove the lesion instead of just splitting or breaking it apart as
in balloon angioplasty.
All of these investigational devices are still under development, and research is in progress to
determine which of them will live up to expectations.
The Future of Cardiology
Over the past 10 years, rapid developments in cardiology have made it so broad and complex
a field that it is difficult for one person to keep current and retain a sufficient level of skill in all
areas. Therefore, various divisions within the subspecialty of cardiology are emerging.
Nuclear cardiology, for example, with advances in radioisotopes and computer-assisted
imaging equipment, has expanded to the point where additional training must be obtained to
achieve full competence. The rapid development of technology in the treatment of atheromatous
lesions has probably outpaced all other areas in the field of medicine. Fellowships in
interventional cardiology have therefore been developed to concentrate careers in this area.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
Other highly specialized areas include echocardiography and Doppler evaluation of the heart.
Nontechnical areas include those of preventive cardiology, hypertension, and treatment of lipid
disorders. In all these areas, new developments have emerged that demand specialized study and
narrowing of the scope of practice. As the years pass we will see more and more subdivision
within the specialty of cardiology.
Being a cardiologist is very rewarding. Patients who are chronically or acutely ill come to us
for help, and after assessing and evaluating, we are usually able to help them. Whatever their
illness, they usually notice a significant improvement after treatment and are able to enjoy life to
a fuller extent. I cannot tell you what a pleasant experience it is to see patients in the office after
they have had a recent hospitalization for a cardiac illness, and to have them tell me how much
better they feel and what a change it has made in their life.
Positive results cannot be expected in every patient treated, as some do have terminal illness.
However, those who respond to treatment make up for the long work hours both during the day
and during the night. The rewards of being a cardiologist or a cardiac surgeon are particularly
great when we achieve the occasional dramatic result.
The best example of a dramatic recovery would be a patient who presents to the emergency
room with an acute myocardial infarction complicated by cardiogenic shock. The mortality rate
for such patients is exceedingly high; however, with rapid intervention and today’s technology,
many of these patients can be saved. I can tell you of no greater reward than to see these patients
walk out of the hospital 7-10 days after their initial event, to go home and return to a normal life
with no significant limitations of lifestyle.
Cardiology is an exciting, rapidly expanding field, and one of which I am proud to be a part.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com