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Metabolic Causes The most frequent secondary cause of dyslipoproteinemia is probably the constellation of metabolic abnormalities seen in patients with metabolic syndrome (see Chapters 45 and 50) buy red viagra 200mg visa erectile dysfunction filthy frank. Patients with poorly controlled type 1 diabetes can also have severe hypertriglyceridemia purchase genuine red viagra on line erectile dysfunction age 27. Dunnigan lipodystrophy, a genetic disorder with features of metabolic syndrome, results from mutations within the lamin A/C gene and is associated with limb-girdle fat atrophy. Patients receiving the combination of a statin plus cyclosporine merit careful dose titrations and monitoring for myopathy. Liver Disease Obstructive liver disease, especially primary biliary cirrhosis, may lead to the formation of an abnormal lipoprotein termed lipoprotein-x. Extensive xanthoma formation on the face and palmar areas can result from accumulation of lipoprotein-x. Lifestyle Factors contributing to obesity, such as an imbalance between caloric intake and energy expenditure, lack of physical activity, and a diet rich in saturated fats and refined sugars, contribute in large part to the lipid and lipoprotein lipid levels within a population (see Chapters 45 and 50). The exact composition, dosage, and frequency of use of anabolic steroids are often impossible to determine from the patient history. The use of antipsychotic medications may lead to metabolic disorders, weight gain, and lipoprotein abnormalities. In clinical practice, many dyslipoproteinemias, other than the genetic forms mentioned earlier, share an important environmental cause. Lifestyle changes (diet, exercise, reduction of abdominal obesity) should form the foundation for the treatment of most dyslipidemias. Rigorous clinical data showing that these measures improve outcomes, as well as implementing them in a sustained manner in practice, however, have proved more difficult (see Chapters 45 and 50). In addition to blocking the synthesis of cholesterol, statins also interfere with the synthesis of lipid intermediates with important biologic effects. Two of these intermediates, geranylgeranyl and farnesyl, participate in protein prenylation, the covalent attachment of a lipid moiety to a protein, thereby allowing anchoring into cell membranes and enhancing its biologic activity. Lowering low-density lipoprotein cholesterol: statins, ezetimibe, bile acid sequestrants, and combinations: comparative efficacy and safety. European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. Statin Pharmacology The currently available drugs are fluvastatin (Lescol), 20 to 80 mg/day; lovastatin (Mevacor), 20 to 80 mg/day; pravastatin (Pravachol), 20 to 40 mg/day; simvastatin (Zocor), 10 to 40 mg/day (the 80-mg dose may increase risk for rhabdomyolysis, especially within the first year of treatment); atorvastatin (Lipitor), 10 to 80 mg/day; and rosuvastatin (Crestor), 5 to 40 mg/day. Such agents include antibiotics, antifungal medications, certain antiviral drugs, grapefruit juice, cyclosporine, amiodarone, and several others. In many cases of statin-associated myositis, a neuromuscular disease is identified (inclusion body myositis and myopathies of genetic origin and spinal cord compression). This life-threatening situation is often related to predisposing factors: advanced age, frailty, renal failure, shock, concomitant use of antifungal agents, 48,49 antibiotics, the fibric acid derivative gemfibrozil, and hypothyroidism. Statins are generally well tolerated; side effects include reversible elevation of transaminases and myositis, which necessitates discontinuation of the drug in less than 1% of patients. Thereafter, clinical judgment should dictate the interval between follow-up visits. Although frequent visits are probably not useful for the detection of serious side effects, they serve to encourage compliance and adherence to diet and lifestyle changes. Imaging studies have shown that treatment with more potent statins can actually produce limited regression of atheromata. The effects on major vascular events are shown for each of the 26 studies included in the meta-analysis. Preventive strategies with aspirin, angiotensin-converting enzyme inhibitors, tight glycemic control, and statins have all shown benefit. Statins and Risk for Diabetes 52,53 The use of statins is associated with a small but significant increase in diabetes. Further analysis of the clinical study data shows that statins hasten the diagnosis almost exclusively in patients with preexisting risk factors for the development of diabetes, such as baseline elevation of plasma glucose levels. Nevertheless, statin therapy should accompany a diet and exercise program aimed at achieving a healthy diet and ideal body weight. A recent meta-analysis of statin trials using data on patients older than 75 showed a 22% relative reduction in all-cause mortality. This analysis supports continued use of statins in older patients if clinically indicated. Physicians must nevertheless exercise caution in implementing preventive strategies in older patients already taking multiple medications. Starting statins in an otherwise healthy elderly patient requires clinical judgment and shared decision making. Women Most clinical trials are not statistically powered to show an effect in women as a subgroup. Advanced Heart Failure Recent studies have addressed the issue of statin treatment of patients with advanced heart failure (left ventricular ejection fraction <30%). Patients 45 with end-stage renal failure do not appear to benefit from statin therapy. Taken together, the heart failure trials and the renal failure trials suggest that lipid management strategies in patients with end-stage disease produce limited improvement in outcomes. Clinical judgment must carefully weigh the benefits of such preventive measures in these patients. Second, because of its importance in cellular functions, most (if not all) cell types have the cellular machinery to make cholesterol endogenously. After a mean follow-up of 20 months, there was no evidence of cognitive events in patients treated with evolocumab compared with placebo. Cholesterol Absorption Inhibitors The development of selective inhibitors of intestinal sterol absorption has added to the treatment of lipoprotein disorders. Because ezetimibe also prevents the intestinal absorption of sitosterol, it might be the drug of choice in patients with sitosterolemia. Fibric Acid Derivatives (Fibrates) Two derivatives of fibric acid are currently available in the United States. In other countries, ciprofibrate (Lypanthyl, Lipanor), clofibrate (Atromid), and bezafibrate (Bezalip) are available. Fibrates, especially gemfibrozil, can inhibit the glucuronidation of statins and thus impair their elimination. For this reason, gemfibrozil combined with statins may increase the risk for myotoxicity, and therefore such a combination is contraindicated. Subgroup analyses suggest a benefit of some fibrates in individuals with baseline high triglyceride levels, but no large endpoint study has tested this conjecture rigorously. Gemfibrozil was used in these older studies but has little relevance to current therapy because of a drug-drug interaction that renders concomitant administration with statins contraindicated. Another consideration with the use of fibrates is the theoretical prevention of pancreatitis in patients with severe hypertriglyceridemia (>11 mmol/L; 1000 mg/dL). Lifestyle changes, including a marked reduction in fats (especially saturated fats), tight control of glycemia in diabetic patients, avoidance of alcohol, frequent small meals during the acute phase of a severe episode of hypertriglyceridemia, fish oil consumption, and avoidance of estrogens in women, remain the fundamentals of prevention of pancreatitis in hypertriglyceridemic individuals. Niacin requires doses in the range of 2000 to 3000 mg/day in three separate doses to maximize effects on lipid levels. An escalating dose schedule to reach the full dose in 2 to 3 weeks rather than starting with the full dose can help manage the adverse effects of this agent.

Hypercortisolism is associated with increased coronary arterial atherosclerosis: Analysis of noninvasive coronary angiography using multidetector computerized tomography discount red viagra 200 mg on line erectile dysfunction drugs research. Primary aldosteronism in 2011: Towards a better understanding of causation and consequences cheap red viagra 200mg without a prescription erectile dysfunction pills non prescription. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline. Screening for primary aldosteronism in hypertensive subjects: results from two German epidemiological studies. Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society Clinical Practice Guideline. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. Genetics and clinical characteristics of hereditary pheochromocytomas and paragangliomas. Is the excess cardiovascular morbidity in pheochromocytoma related to blood pressure or to catecholamines? Cardiac structure and function before and after parathyroidectomy in patients with asymptomatic primary hyperparathyroidism. Effect of surgery on cardiovascular risk factors in mild primary hyperparathyroidism. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. Endocrine Society: Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. Mechanisms of thyroid hormone receptor–specific nuclear and extra nuclear actions. Changes in thyroid hormone metabolism and gene expression in the failing heart: Therapeutic implications. Subclinical thyroid dysfunction and the risk of heart failure events: An individual participant data analysis from 6 prospective cohorts. Membrane receptor for thyroid hormone: Physiologic and pharmacologic implications. American Thyroid Association guide to investigating thyroid hormone economy and action in rodent and cell models : report of the American Thyroid Association Task Force on Approaches and Strategies to Investigate Thyroid Hormone Economy and Action in rodent and cell models. Recombinant human thyrotropin improves endothelial coronary flow reserve in thyroidectomized patients with differentiated thyroid cancer. Pulmonary hypertension is frequent in hyperthyroidism and normalizes after therapy. Hyperthyroidism and risk of atrial fibrillation or flutter: a population-based study. The 2015 European Thyroid Association guidelines on diagnosis and treatment of endogenous subclinical hyperthyroidism. How could we improve the increased cardiovascular mortality in patients with overt and subclinical hyperthyroidism? Ablation of atrial fibrillation: patient selection, periprocedural anticoagulation, techniques, and preventive measures after ablation. Comparison of mortality in hyperthyroidism during periods of treatment with thionamides and after radioiodine. Aggressive case finding: a clinical strategy for the documentation of thyroid dysfunction. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Benefits of thyrotropin suppression versus the risks of adverse effects in differentiated thyroid cancer. Levothyroxine treatment of subclinical hypothyroidism, fatal and nonfatal cardiovascular events, and mortality. Amiodarone-induced thyrotoxicosis is associated with a nearly threefold increased risk for major adverse cardiovascular events that must be identified and treated. Total thyroidectomy in patients with amiodarone- induced thyrotoxicosis and severe left ventricular systolic dysfunction. Association of serum triiodothyronine with B-type natriuretic peptide and severe left ventricular diastolic dysfunction in heart failure with preserved ejection fraction. The role of thyroid hormone in the pathophysiology of heart failure: clinical evidence. Usefulness of serum triiodothyronine (T ) to3 predict outcomes in patients hospitalized with acute heart failure. Thyroid hormone and heart failure: from myocardial protection to systemic regulation. Usefulness of triiodothyronine (T ) treatment after3 surgery for complex congenital heart disease in infants and children. Preservation of blood fluidity depends on an intact vascular endothelium and a complex series of regulatory pathways that maintain platelets in a quiescent state and keep the coagulation system in check. In contrast, arrest of bleeding requires rapid formation of hemostatic plugs at sites of vascular injury to prevent exsanguination. Perturbation of hemostasis can lead to thrombosis, which can occur in arteries or veins and causes considerable morbidity and mortality. Arterial thrombosis is the most common cause of acute coronary syndrome, ischemic stroke, and limb gangrene, whereas thrombosis in the deep veins of the leg leads to postthrombotic syndrome and pulmonary embolism (see also Chapter 84). Most arterial thrombi form on top of disrupted atherosclerotic plaques because plaque rupture exposes thrombogenic material in the core to blood (see also Chapter 44). This material then triggers platelet aggregation and fibrin formation, which results in the generation of a platelet-rich thrombus that 1 temporarily or permanently occludes blood flow. The consequent reduction in blood flow can cause acute coronary syndrome, transient ischemic attack, or ischemic stroke. Although venous thrombi can develop after surgical trauma to veins or arise due to indwelling venous catheters, they usually originate in valve cusps of the deep veins of the calf or in muscular sinuses, which can cause stasis. Sluggish blood flow in these veins reduces oxygen supply to the avascular valve cusps. Hypoxemia induces endothelial cells lining the valve cusps to express adhesion molecules, which tether tissue factor–bearing leukocytes and microparticles onto their surface. Tissue factor–bearing leukocytes 3 and microparticles adhere to these activated cells and induce coagulation. Impaired blood flow exacerbates local thrombus formation by reducing clearance of activated clotting factors. Thrombi that extend into the proximal veins of the leg can dislodge and travel to the lungs to produce pulmonary embolism. Arterial and venous thrombi contain platelets and fibrin, but the proportions differ. Arterial thrombi are 1 rich in platelets because of high shear in the injured arteries. In contrast, venous thrombi, which form under low-shear conditions, contain relatively few platelets and consist mostly of fibrin and trapped red 3 cells. Because of the predominance of platelets, arterial thrombi appear white, whereas venous thrombi appear red because of the trapped red cells.

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Systemic Conditions Chest muscle pain can be caused by localized infam- Key Questions mation of the muscles in collagen diseases red viagra 200 mg sale impotence due to diabetic peripheral neuropathy, such as l In the past 6 months purchase red viagra without a prescription erectile dysfunction recovery stories, have you had a spell or an attack polymyositis, bromyalgia, or systemic lupus ery- in which you suddenly felt frightened, anxious, or thematosus. Pericarditis can be began to race, you felt faint, or you could not catch accompanied by fever, rapid and shallow respirations, your breath? Panic Disorder In heart failure, decreased stroke volume reduces A response of “yes” to the above key questions can be the systolic blood pressure, and compensatory vaso- a highly sensitive screen for a psychogenic component constriction maintains a constant diastolic pressure. Patients with anxiety or depression often describe Pneumothorax is manifested by tachypnea and un- feelings of chest heaviness or tightness that can last equal chest wall excursion. In children, chest pain with tachycardia and hypoten- sion is generally caused by hypovolemia, secondary to a hemothorax, hemopneumothorax, or vascular injury. Observe for grimacing, area of chest pain for signs of the vesicular rash of diaphoresis, pallor, cyanosis, tachypnea, use of ac- herpes zoster. Petechial rash on the face and shoulders cessory muscles for breathing, splinting of chest can be a sign of protracted coughing as a result of wall, and unequal chest wall excursion. Tracheal shift can occur with pneumothorax and in People with fractured ribs or signifcant chest wall children with atelectasis, involving a signifcant por- contusions splint their chest wall, and take shallow tion of one lung. To assess the trachea for lateral dis- breaths to avoid aggravating pain with respiratory placement, position your index fnger frst on the right expansion. Abnormal trachea has shifted to the side, you will feel the wall on fndings for age can indicate chronic disease. In a pneumo- thorax, the trachea is deviated to the opposite side Measure Vital Signs and Note Respiratory Patterns during exhalation and toward the side of the pneu- Vital signs for people experiencing angina can be mothorax during inspiration. Hypotension can indicate cardiogenic Palpate the entire chest wall for tenderness, depres- shock. Fractured ribs and contusions will Chapter 8 • Chest Pain 87 result in tenderness to palpation and possible defor- Auscultate for Adventitious Sounds mity. Palpate each costochondral and chondrosternal Adventitious lung sounds are superimposed on normal junction. Costochondritis will be manifested by pain sounds and can be auscultated over any area of the lung with palpation over the cartilage between the sternum feld during inspiration or expiration. Palpation and range of joint motion can of abnormal lung sounds should include the type elicit arthritic pain in the shoulder or cervical spine. Rib pain on that increases peripheral airway resistance, obstructs the palpation in children without a reported history of peripheral airway, or causes a loss of elastic recoil will trauma can indicate child abuse. These indicate the presence of fuid, To check the chest wall for symmetry, frst test for mucus, or pus in the smaller airways. Fine crackles are diaphragmatic expansion of both the anterior and the soft and high pitched. Medium crackles are louder and posterior thorax between the eighth and tenth ribs. Each Wheezing is frequently described as a whistling thumb should move the same distance from the spine sound, and can be heard during inspiration, expira- or costal margins. Wheezing indicates that there is fuid in the large airways, such as in severe heart failure; more often it Percuss the Chest is associated with bronchospasm, as seen in asthma. Percussion in the area of pneumothorax will result in a Wheezing occurs on exhalation because that is when hyperresonant sound of an air-flled cavity. During inhalation, the nega- infltration, as in pneumonia, will produce a dull or fat tive pressure in the chest tends to hold open the air- sound. However, during exhalation, positive pressure in the alveoli is conducted from the outside of the Auscultate Breath Sounds small airways and tends to collapse them. The sound Instruct the patient to breathe through the mouth is usually polyphonic; this means that multiple, slowly and deeply. Auscultate systematically from the slightly different, high-pitched sounds are heard at lung apexes to the lower lobes anteriorly, posteriorly, the same time. If breath sounds are diminished over suggests a single area of blockage, such as with all lung felds, suspect chronic obstructive pulmonary a foreign body. Obese patients can have breath respiration is produced by intrathoracic airway sounds that are diffcult to auscultate. Breath sounds obstruction associated with lower respiratory tract will be inaudible in areas of pneumothorax. Palpate the abdomen for erated by turbulent air passing through secretions in tenderness and masses. Rhonchi can be present when the patient can occur with pancreatitis, esophagitis, or peptic ulcer has pneumonia. Cholelithiasis or cholecystitis can be mani- Pleural friction rub is a grating or squeaking sound fested by pain on palpation in the right upper quadrant. If abnormal lung sounds are detected, additional Examine the Extremities auscultation for bronchophony, egophony, and whis- Clubbing of the fngers can be an indication of chronic pered pectoriloquy are indicated (see Chapter 14). Peripheral cyanosis indicates hypoxia if accom- Auscultate Heart Sounds panied by central cyanosis. Consider exposure to a Auscultate for normal heart sounds in all positions, iden- cold environment, or anxiety, if peripheral cyanosis is tifying S , S , rate, and rhythm. Lower extremity edema is a sign of heart dial ischemia cannot be reliably performed by physical failure or venous stasis. Abnormal sounds, such as paradoxical S during2 sclerotic vessel disease or dissecting aortic aneurysm. A transient S (ventricular gallop) or mitral regur-3 gitation murmur at the apex can occur occasionally with Diagnostic tests are indicated when cardiovascular, myocardial ischemia or congestive heart failure. A summation gallop is the result of an S , S ,3 4 and rapid rate; this can also occur with heart failure. In children, ment elevation or depression indicates the presence of a loud murmur, best audible at the upper right sternal injured myocardium. T wave inversion demonstrates border, or upper left sternal border with a thrill, can the presence of ischemia. In aortic valve stenosis, a harsh ejection balance can also cause these variations from normal. Q systolic murmur, with radiation to the neck, is heard on waves are indicative of myocardial muscle loss but are auscultation. Midsystolic click/late systolic murmur (honk) is Evidence of ischemia is not always obvious on an heard with mitral valve prolapse. Observe the Spine for Evidence of Scoliosis People with scoliosis are at increased risk for pulmo- Stress Testing nary problems because of structural variations that can People experiencing intermittent chest pain who have cause compression of intrathoracic contents. Treadmill exercise testing uses a standard- movement or lack of movement of air in the lungs. An one of three categories: normal, high probability, and important objective of stress testing is to identify nondiagnostic. Radiographic contrast Exercise Myocardial Perfusion Imaging medium is injected into the pulmonary arteries, and the This imaging has greater accuracy than the standard vasculature is visualized. Radiography Pneumothorax and pneumonia can be identifed by Echocardiography chest radiography. Pneumothorax reveals evidence of An echocardiogram is a noninvasive cardiac ultra- pleural air, whereas pneumonia is seen on radiographs sound examining the heart that provides information as a parenchymal infltrate.

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Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina discount red viagra uk erectile dysfunction free samples. Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity buy red viagra on line amex erectile dysfunction vitamin deficiency. Non-invasive assessment of low risk acute chest pain in the emergency department: a comparative meta-analysis of prospective studies. Meta-analysis of coronary computed tomography angiography versus standard of care strategy for the evaluation of low risk chest pain: are randomized controlled trials and cohort studies showing the same evidence? Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry: a randomized trial. Economic outcomes with anatomical versus functional diagnostic testing for coronary artery disease. Changes in medical therapy and lifestyle after anatomical or functional testing for coronary artery disease. Use of coronary computed tomographic angiography to guide management of patients with coronary disease. Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. A novel noninvasive technology for treatment planning using virtual coronary stenting and computed tomography-derived computed fractional flow reserve. Meta-analysis of global left ventricular function comparing multidetector computed tomography with cardiac magnetic resonance imaging. Quantification of aortic regurgitant fraction and volume with multi-detector computed tomography comparison with echocardiography. Multimodality imaging in the context of transcatheter mitral valve replacement: establishing consensus among modalities and disciplines. Computed tomographic imaging of transcatheter aortic valve replacement for prediction and prevention of procedural complications. Diagnostic accuracy of 320-row computed tomography as compared with invasive coronary angiography in unselected, consecutive patients with suspected coronary artery disease. Diagnostic accuracy of second-generation dual-source computed tomography coronary angiography with iterative reconstructions: a real-world experience. Performance and efficacy of 320-row computed tomography coronary angiography in patients presenting with acute chest pain: results from a clinical registry. Diagnostic accuracy of noninvasive coronary angiography with 320-detector row computed tomography. Diagnostic accuracy of 320-row multidetector computed tomography coronary angiography in the non-invasive evaluation of significant coronary artery disease. Comparison of diagnostic value of a novel noninvasive coronary computed tomography angiography method versus standard coronary angiography for assessing fractional flow reserve. Assessment of left ventricular volumes, ejection fraction and regional wall motion with retrospective electrocardiogram triggered 320-detector computed tomography: a comparison with 2D-echocardiography. Quantification of left ventricular volumes using three- dimensional echocardiography: comparison with 64-slice multidetector computed tomography. Left ventricular ejection fraction: real-world comparison between cardiac computed tomography and echocardiography in a large population. Multidetector computed tomography vs multiplane transesophageal echocardiography in detecting atrial thrombi in patients candidate to radiofrequency ablation of atrial fibrillation. Detection of left atrial thrombus during routine diagnostic work-up prior to pulmonary vein isolation for atrial fibrillation: role of transesophageal echocardiography and multidetector computed tomography. Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings. Can contrast-enhanced multi-detector computed tomography replace transesophageal echocardiography for the detection of thrombogenic milieu and thrombi in the left atrial appendage: a prospective study with 124 patients. In clinical practice, a distinction is often made between coronary angiography (see Chapter 20) and hemodynamic (right ± left) heart catheterization, given the different aspects of these procedures. This chapter focuses on cardiac catheterization in general and hemodynamic catheterization in particular. The first cardiac catheterization has been accredited to Reverend Stephen Hales, who used brass pipes 1 inserted into the venous and arterial systems of a horse to perform a biventricular catheterization in 1711. In 1929, however, German surgery resident Werner Forssmann, aiming to find better approaches for delivering drugs directly into the heart, advanced a well-oiled 4 French (4F) ureteral catheter via the left cubital vein for a total length of 65 cm into his own heart, walked the stairs to the radiology department, and documented a 2 right atrial catheter position by a chest x-ray film. This allowed for a safer procedure, longer indwell times, and easy, repeated collection of true mixed venous blood and thus the calculation of cardiac output by the use of the direct Fick principle for 1 the first time in humans. All three physicians were awarded the Nobel Prize in Physiology and Medicine in 1956. Cardiac catheterization has continued to evolve in many aspects, and currently more than 80% of 3 all U. Cardiac catheterization is not to be understood in isolation but rather as part of the continuum of the evaluation of patients with various cardiac conditions. It is to be pursued with the knowledge of noninvasive test results, and appropriately so, when these do not suffice to direct management decisions. The invasive examination therefore is to provide definitive guidance and needs to be adapted to the presentation and disease processes of the individual patient. Performing the right procedure on the right patient for the right reason in the right way for the right outcome is becoming increasingly important, especially in a changing health care environment. This chapter reviews cardiac catheterization within the framework of operational aspects (pre-, intra-, and postprocedural assessment), technical aspects and procedural performance, and clinical aspects and integration into patient care. The Cardiac Catheterization Laboratory There are four basic types of catheterization laboratories: hospital-based laboratories with full support services including cardiovascular surgery, hospital-based laboratories without cardiovascular surgical capability, freestanding laboratories, and mobile laboratories. Even though cardiovascular surgery is the critical differentiating service, the catheterization laboratory requires all the listed services to provide catheterization services to the full spectrum of case complexities. Approximately one fourth to one third of catheterization laboratories do not have cardiovascular 3 surgery backup. One may argue that almost all diagnostic procedures that do not involve additional risks could be performed safely without any surgical backup. Even among non–high-risk patients, complications may arise that require surgical intervention. Moreover, some advanced diagnostic procedures should be performed only by experienced operators who are capable of managing any possible complications. Freestanding and mobile cardiac catheterization facilities fall into this category as well. For obvious reasons, this service is only for properly selected low-risk patients. Thus, these rooms are typically larger than usual and are operated by a team trained in and comfortable with both aspects. Cardiac Catheterization Equipment The key elements of the cardiac catheterization laboratory are the control room, the anesthesia cart and vital signs monitoring system, the imaging system, the data-processing/archiving system, and the data review and report station. The standard high-resolution x-ray imaging system operates in two modes: fluoroscopy and cine mode (cinefluorographic system).