Circulatory system

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Circulatory_system 

Circulatory system
The human circulatory system (simplified). Red indicates oxygenated blood carried in arteries. Blue indicates deoxygenated blood carried in veins. Capillaries, which join the arteries and veins, and the lymphatic vessels are not shown.
Identifiers
MeSH	D002319
TA98	A12.0.00.000
TA2	3891
FMA	7161

The circulatory system, also called the cardiovascular system or the vascular system, is an organ system that permits blood to circulate and transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, and blood cells to and from the cells in the body to provide nourishment and help in fighting diseases, stabilize temperature and pH, and maintain homeostasis.

The circulatory system includes the lymphatic system, which circulates lymph. The passage of lymph takes much longer than that of blood. Blood is a fluid consisting of plasma, red blood cells, white blood cells, and platelets that is circulated by the heart through the vertebrate vascular system, carrying oxygen and nutrients to and waste materials away from all body tissues. Lymph is essentially recycled excess blood plasma after it has been filtered from the interstitial fluid (between cells) and returned to the lymphatic system. The cardiovascular (from Latin words meaning "heart" and "vessel") system comprises the blood, heart, and blood vessels. The lymph, lymph nodes, and lymph vessels form the lymphatic system, which returns filtered blood plasma from the interstitial fluid (between cells) as lymph.

The circulatory system of the blood has two components, a systemic circulation and a pulmonary circulation. While humans and other vertebrates have a closed cardiovascular system (which means that the blood never leaves the network of arteries, veins and capillaries), some invertebrate groups have an open cardiovascular system. The lymphatic system, in contrast, is an open system providing an accessory route for excess interstitial fluid to be returned to the blood. The more primitive, diploblastic animal phyla lack circulatory systems.

Many diseases affect the circulatory system. This includes cardiovascular disease, affecting the cardiovascular system, and lymphatic disease affecting the lymphatic system. Cardiologists are medical professionals which specialise in the heart, and cardiothoracic surgeons specialise in operating on the heart and its surrounding areas. Vascular surgeons focus on other parts of the circulatory system.

Structure

Cardiovascular system

Depiction of the heart, major veins and arteries constructed from body scans

 

Cross section of a human artery

The essential components of the human cardiovascular system are the heart, blood and blood vessels. It includes the pulmonary circulation, a "loop" through the lungs where blood is oxygenated; and the systemic circulation, a "loop" through the rest of the body to provide oxygenated blood. The systemic circulation can also be seen to function in two parts – a macrocirculation and a microcirculation. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, accounting for approximately 7% of their total body weight. Blood consists of plasma, red blood cells, white blood cells, and platelets. Also, the digestive system works with the circulatory system to provide the nutrients the system needs to keep the heart pumping.

The cardiovascular systems of humans are closed, meaning that the blood never leaves the network of blood vessels. In contrast, oxygen and nutrients diffuse across the blood vessel layers and enter interstitial fluid, which carries oxygen and nutrients to the target cells, and carbon dioxide and wastes in the opposite direction. The other component of the circulatory system, the lymphatic system, is open.

Arteries

Oxygenated blood enters the systemic circulation when leaving the left ventricle, through the aortic semilunar valve. The first part of the systemic circulation is the aorta, a massive and thick-walled artery. The aorta arches and gives branches supplying the upper part of the body after passing through the aortic opening of the diaphragm at the level of thoracic ten vertebra, it enters the abdomen. Later it descends down and supplies branches to abdomen, pelvis, perineum and the lower limbs. The walls of aorta are elastic. This elasticity helps to maintain the blood pressure throughout the body. When the aorta receives almost five litres of blood from the heart, it recoils and is responsible for pulsating blood pressure. Moreover, as aorta branches into smaller arteries, their elasticity goes on decreasing and their compliance goes on increasing.

Capillaries

Arteries branch into small passages called arterioles and then into the capillaries. The capillaries merge to bring blood into the venous system.

Veins

Capillaries merge into venules, which merge into veins. The venous system feeds into the two major veins: the superior vena cava – which mainly drains tissues above the heart – and the inferior vena cava – which mainly drains tissues below the heart. These two large veins empty into the right atrium of the heart.

Portal veins

The general rule is that arteries from the heart branch out into capillaries, which collect into veins leading back to the heart. Portal veins are a slight exception to this. In humans the only significant example is the hepatic portal vein which combines from capillaries around the gastrointestinal tract where the blood absorbs the various products of digestion; rather than leading directly back to the heart, the hepatic portal vein branches into a second capillary system in the liver.

Heart

View from the front

The heart pumps oxygenated blood to the body and deoxygenated blood to the lungs. In the human heart there is one atrium and one ventricle for each circulation, and with both a systemic and a pulmonary circulation there are four chambers in total: left atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lungs as well as the pulmonary vein which is passed into the strong left ventricle to be pumped through the aorta to the different organs of the body.

Coronary vessels

The heart itself is supplied with oxygen and nutrients through a small "loop" of the systemic circulation and derives very little from the blood contained within the four chambers. The coronary circulation system provides a blood supply to the heart muscle itself. The coronary circulation begins near the origin of the aorta by two coronary arteries: the right coronary artery and the left coronary artery. After nourishing the heart muscle, blood returns through the coronary veins into the coronary sinus and from this one into the right atrium. Back flow of blood through its opening during atrial systole is prevented by Thebesian valve. The smallest cardiac veins drain directly into the heart chambers.

Lungs

The pulmonary circulation as it passes from the heart. Showing both the pulmonary and bronchial arteries.

The circulatory system of the lungs is the portion of the cardiovascular system in which oxygen-depleted blood is pumped away from the heart, via the pulmonary artery, to the lungs and returned, oxygenated, to the heart via the pulmonary vein.

Oxygen-deprived blood from the superior and inferior vena cava enters the right atrium of the heart and flows through the tricuspid valve (right atrioventricular valve) into the right ventricle, from which it is then pumped through the pulmonary semilunar valve into the pulmonary artery to the lungs. Gas exchange occurs in the lungs, whereby CO
2 is released from the blood, and oxygen is absorbed. The pulmonary vein returns the now oxygen-rich blood to the left atrium.

A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung.

Systemic circulation

The systemic circulation and capillary networks shown and also as separate from the pulmonary circulation

Systemic circulation is the portion of the cardiovascular system which transports oxygenated blood away from the heart through the aorta from the left ventricle where the blood has been previously deposited from pulmonary circulation, to the rest of the body, and returns oxygen-depleted blood back to the heart.

Brain

The brain has a dual blood supply that comes from arteries at its front and back. These are called the "anterior" and "posterior" circulation respectively. The anterior circulation arises from the internal carotid arteries and supplies the front of the brain. The posterior circulation arises from the vertebral arteries, and supplies the back of the brain and brainstem. The circulation from the front and the back join together (anastomise) at the Circle of Willis.

Kidneys

The renal circulation receives around 20% of the cardiac output. It branches from the abdominal aorta and returns blood to the ascending vena cava. It is the blood supply to the kidneys, and contains many specialized blood vessels.

Lymphatic system

The lymphatic system is part of the circulatory system in many complex animals such as mammals and birds. It is a network of lymphatic vessels and lymph capillaries, lymph nodes and organs, and lymphatic tissues and circulating lymph. One of its major functions is to carry the lymph, draining and returning interstitial fluid back towards the heart for return to the cardiovascular system, by emptying into the lymphatic ducts. Its other main function is in the adaptive immune system.

Development

The development of the circulatory system starts with vasculogenesis in the embryo. The human arterial and venous systems develop from different areas in the embryo. The arterial system develops mainly from the aortic arches, six pairs of arches that develop on the upper part of the embryo. The venous system arises from three bilateral veins during weeks 4 – 8 of embryogenesis. Fetal circulation begins within the 8th week of development. Fetal circulation does not include the lungs, which are bypassed via the truncus arteriosus. Before birth the fetus obtains oxygen (and nutrients) from the mother through the placenta and the umbilical cord.

Heart

Arteries

Animation of a typical human red blood cell cycle in the circulatory system. This animation occurs at a faster rate (~20 seconds of the average 60-second cycle) and shows the red blood cell deforming as it enters capillaries, as well as the bars changing color as the cell alternates in states of oxygenation along the circulatory system.

The human arterial system originates from the aortic arches and from the dorsal aortae starting from week 4 of embryonic life. The first and second aortic arches regress and form only the maxillary arteries and stapedial arteries respectively. The arterial system itself arises from aortic arches 3, 4 and 6 (aortic arch 5 completely regresses).

The dorsal aortae, present on the dorsal side of the embryo, are initially present on both sides of the embryo. They later fuse to form the basis for the aorta itself. Approximately thirty smaller arteries branch from this at the back and sides. These branches form the intercostal arteries, arteries of the arms and legs, lumbar arteries and the lateral sacral arteries. Branches to the sides of the aorta will form the definitive renal, suprarenal and gonadal arteries. Finally, branches at the front of the aorta consist of the vitelline arteries and umbilical arteries. The vitelline arteries form the celiac, superior and inferior mesenteric arteries of the gastrointestinal tract. After birth, the umbilical arteries will form the internal iliac arteries.

Veins

The human venous system develops mainly from the vitelline veins, the umbilical veins and the cardinal veins, all of which empty into the sinus venosus.

Function

Cardiovascular system

About 98.5% of the oxygen in a sample of arterial blood in a healthy human, breathing air at sea-level pressure, is chemically combined with hemoglobin molecules. About 1.5% is physically dissolved in the other blood liquids and not connected to hemoglobin. The hemoglobin molecule is the primary transporter of oxygen in mammals and many other species.

Lymphatic system

Clinical significance

Many diseases affect the circulatory system. These include a number of cardiovascular diseases, affecting the cardiovascular system, and lymphatic diseases affecting the lymphatic system. Cardiologists are medical professionals which specialise in the heart, and cardiothoracic surgeons specialise in operating on the heart and its surrounding areas. Vascular surgeons focus on other parts of the circulatory system.

Cardiovascular disease

Diseases affecting the cardiovascular system are called cardiovascular disease.

Many of these diseases are called "lifestyle diseases" because they develop over time and are related to a person's exercise habits, diet, whether they smoke, and other lifestyle choices a person makes. Atherosclerosis is the precursor to many of these diseases. It is where small atheromatous plaques build up in the walls of medium and large arteries. This may eventually grow or rupture to occlude the arteries. It is also a risk factor for acute coronary syndromes, which are diseases that are characterised by a sudden deficit of oxygenated blood to the heart tissue. Atherosclerosis is also associated with problems such as aneurysm formation or splitting ("dissection") of arteries.

Another major cardiovascular disease involves the creation of a clot, called a "thrombus". These can originate in veins or arteries. Deep venous thrombosis, which mostly occurs in the legs, is one cause of clots in the veins of the legs, particularly when a person has been stationary for a long time. These clots may embolise, meaning travel to another location in the body. The results of this may include pulmonary embolus, transient ischaemic attacks, or stroke.

Cardiovascular diseases may also be congenital in nature, such as heart defects or persistent fetal circulation, where the circulatory changes that are supposed to happen after birth do not. Not all congenital changes to the circulatory system are associated with diseases, a large number are anatomical variations.

Investigations

Magnetic resonance angiography of aberrant subclavian artery

The function and health of the circulatory system and its parts are measured in a variety of manual and automated ways. These include simple methods such as those that are part of the cardiovascular examination, including the taking of a person's pulse as an indicator of a person's heart rate, the taking of blood pressure through a sphygmomanometer or the use of a stethoscope to listen to the heart for murmurs which may indicate problems with the heart's valves. An electrocardiogram can also be used to evaluate the way in which electricity is conducted through the heart.

Other more invasive means can also be used. A cannula or catheter inserted into an artery may be used to measure pulse pressure or pulmonary wedge pressures. Angiography, which involves injecting a dye into an artery to visualise an arterial tree, can be used in the heart (coronary angiography) or brain. At the same time as the arteries are visualised, blockages or narrowings may be fixed through the insertion of stents, and active bleeds may be managed by the insertion of coils. An MRI may be used to image arteries, called an MRI angiogram. For evaluation of the blood supply to the lungs a CT pulmonary angiogram may be used.

Vascular ultrasonography include for example:

• Intravascular ultrasound
• Ultrasonography of deep venous thrombosis
• Ultrasonography of chronic venous insufficiency of the legs

Surgery

There are a number of surgical procedures performed on the circulatory system:

• Coronary artery bypass surgery
• Coronary stent used in angioplasty
• Vascular surgery
• Vein stripping
• Cosmetic procedures

Cardiovascular procedures are more likely to be performed in an inpatient setting than in an ambulatory care setting; in the United States, only 28% of cardiovascular surgeries were performed in the ambulatory care setting.^[13]

Society and culture

In Ancient Greece, the heart was thought to be the source of innate heat for the body. The circulatory system as we know it was discovered by William Harvey.

Other animals

The open circulatory system of the grasshopper – made up of a heart, vessels and hemolymph. The hemolymph is pumped through the heart, into the aorta, dispersed into the head and throughout the hemocoel, then back through the ostia in the heart and the process repeated.

While humans, as well as other vertebrates, have a closed blood circulatory system (meaning that the blood never leaves the network of arteries, veins and capillaries), some invertebrate groups have an open circulatory system containing a heart but limited blood vessels. The most primitive, diploblastic animal phyla lack circulatory systems.

An additional transport system, the lymphatic system, which is only found in animals with a closed blood circulation, is an open system providing an accessory route for excess interstitial fluid to be returned to the blood.

The blood vascular system first appeared probably in an ancestor of the triploblasts over 600 million years ago, overcoming the time-distance constraints of diffusion, while endothelium evolved in an ancestral vertebrate some 540–510 million years ago.

Open circulatory system

See also: Hemolymph

In arthropods, the open circulatory system is a system in which a fluid in a cavity called the hemocoel bathes the organs directly with oxygen and nutrients, with there being no distinction between blood and interstitial fluid; this combined fluid is called hemolymph or haemolymph. Muscular movements by the animal during locomotion can facilitate hemolymph movement, but diverting flow from one area to another is limited. When the heart relaxes, blood is drawn back toward the heart through open-ended pores (ostia).

Hemolymph fills all of the interior hemocoel of the body and surrounds all cells. Hemolymph is composed of water, inorganic salts (mostly sodium, chloride, potassium, magnesium, and calcium), and organic compounds (mostly carbohydrates, proteins, and lipids). The primary oxygen transporter molecule is hemocyanin.

There are free-floating cells, the hemocytes, within the hemolymph. They play a role in the arthropod immune system.

Flatworms, such as this Pseudoceros bifurcus, lack specialized circulatory organs.

Closed circulatory system

Two-chambered heart of a fish

The circulatory systems of all vertebrates, as well as of annelids (for example, earthworms) and cephalopods (squids, octopuses and relatives) always keep their circulating blood enclosed within heart chambers or blood vessels and are classified as closed, just as in humans. Still, the systems of fish, amphibians, reptiles, and birds show various stages of the evolution of the circulatory system. Closed systems permit blood to be directed to the organs that require it.

In fish, the system has only one circuit, with the blood being pumped through the capillaries of the gills and on to the capillaries of the body tissues. This is known as single cycle circulation. The heart of fish is, therefore, only a single pump (consisting of two chambers).

In amphibians and most reptiles, a double circulatory system is used, but the heart is not always completely separated into two pumps. Amphibians have a three-chambered heart.

In reptiles, the ventricular septum of the heart is incomplete and the pulmonary artery is equipped with a sphincter muscle. This allows a second possible route of blood flow. Instead of blood flowing through the pulmonary artery to the lungs, the sphincter may be contracted to divert this blood flow through the incomplete ventricular septum into the left ventricle and out through the aorta. This means the blood flows from the capillaries to the heart and back to the capillaries instead of to the lungs. This process is useful to ectothermic (cold-blooded) animals in the regulation of their body temperature.

Birds, mammals, and crocodilians show complete separation of the heart into two pumps, for a total of four heart chambers; it is thought that the four-chambered heart of birds and crocodilians evolved independently from that of mammals. Double circulatory systems permit blood to be repressurized after returning from the lungs, speeding up delivery of oxygen to tissues.

No circulatory system

Circulatory systems are absent in some animals, including flatworms. Their body cavity has no lining or enclosed fluid. Instead, a muscular pharynx leads to an extensively branched digestive system that facilitates direct diffusion of nutrients to all cells. The flatworm's dorso-ventrally flattened body shape also restricts the distance of any cell from the digestive system or the exterior of the organism. Oxygen can diffuse from the surrounding water into the cells, and carbon dioxide can diffuse out. Consequently, every cell is able to obtain nutrients, water and oxygen without the need of a transport system.

Some animals, such as jellyfish, have more extensive branching from their gastrovascular cavity (which functions as both a place of digestion and a form of circulation), this branching allows for bodily fluids to reach the outer layers, since the digestion begins in the inner layers.

History

Human anatomical chart of blood vessels, with heart, lungs, liver and kidneys included. Other organs are numbered and arranged around it. Before cutting out the figures on this page, Vesalius suggests that readers glue the page onto parchment and gives instructions on how to assemble the pieces and paste the multilayered figure onto a base "muscle man" illustration. "Epitome", fol.14a. HMD Collection, WZ 240 V575dhZ 1543.

The earliest known writings on the circulatory system are found in the Ebers Papyrus (16th century BCE), an ancient Egyptian medical papyrus containing over 700 prescriptions and remedies, both physical and spiritual. In the papyrus, it acknowledges the connection of the heart to the arteries. The Egyptians thought air came in through the mouth and into the lungs and heart. From the heart, the air travelled to every member through the arteries. Although this concept of the circulatory system is only partially correct, it represents one of the earliest accounts of scientific thought.

In the 6th century BCE, the knowledge of circulation of vital fluids through the body was known to the Ayurvedic physician Sushruta in ancient India. He also seems to have possessed knowledge of the arteries, described as 'channels' by Dwivedi & Dwivedi (2007). The valves of the heart were discovered by a physician of the Hippocratean school around the 4th century BCE. However, their function was not properly understood then. Because blood pools in the veins after death, arteries look empty. Ancient anatomists assumed they were filled with air and that they were for the transport of air.

The Greek physician, Herophilus, distinguished veins from arteries but thought that the pulse was a property of arteries themselves. Greek anatomist Erasistratus observed that arteries that were cut during life bleed. He ascribed the fact to the phenomenon that air escaping from an artery is replaced with blood that entered by very small vessels between veins and arteries. Thus he apparently postulated capillaries but with reversed flow of blood.

In 2nd-century AD Rome, the Greek physician Galen knew that blood vessels carried blood and identified venous (dark red) and arterial (brighter and thinner) blood, each with distinct and separate functions. Growth and energy were derived from venous blood created in the liver from chyle, while arterial blood gave vitality by containing pneuma (air) and originated in the heart. Blood flowed from both creating organs to all parts of the body where it was consumed and there was no return of blood to the heart or liver. The heart did not pump blood around, the heart's motion sucked blood in during diastole and the blood moved by the pulsation of the arteries themselves.

Galen believed that the arterial blood was created by venous blood passing from the left ventricle to the right by passing through 'pores' in the interventricular septum, air passed from the lungs via the pulmonary artery to the left side of the heart. As the arterial blood was created 'sooty' vapors were created and passed to the lungs also via the pulmonary artery to be exhaled.

In 1025, The Canon of Medicine by the Persian physician, Avicenna, "erroneously accepted the Greek notion regarding the existence of a hole in the ventricular septum by which the blood traveled between the ventricles." Despite this, Avicenna "correctly wrote on the cardiac cycles and valvular function", and "had a vision of blood circulation" in his Treatise on Pulse. While also refining Galen's erroneous theory of the pulse, Avicenna provided the first correct explanation of pulsation: "Every beat of the pulse comprises two movements and two pauses. Thus, expansion : pause : contraction : pause. [...] The pulse is a movement in the heart and arteries ... which takes the form of alternate expansion and contraction."

In 1242, the Arabian physician, Ibn al-Nafis, became the first person to accurately describe the process of pulmonary circulation, for which he is sometimes considered the father of circulatory physiology. Ibn al-Nafis stated in his Commentary on Anatomy in Avicenna's Canon:

"...the blood from the right chamber of the heart must arrive at the left chamber but there is no direct pathway between them. The thick septum of the heart is not perforated and does not have visible pores as some people thought or invisible pores as Galen thought. The blood from the right chamber must flow through the vena arteriosa (pulmonary artery) to the lungs, spread through its substances, be mingled there with air, pass through the arteria venosa (pulmonary vein) to reach the left chamber of the heart and there form the vital spirit..."

In addition, Ibn al-Nafis had an insight into what would become a larger theory of the capillary circulation. He stated that "there must be small communications or pores (manafidh in Arabic) between the pulmonary artery and vein," a prediction that preceded the discovery of the capillary system by more than 400 years. Ibn al-Nafis' theory, however, was confined to blood transit in the lungs and did not extend to the entire body.

Michael Servetus was the first European to describe the function of pulmonary circulation, although his achievement was not widely recognized at the time, for a few reasons. He firstly described it in the "Manuscript of Paris" (near 1546), but this work was never published. And later he published this description, but in a theological treatise, Christianismi Restitutio, not in a book on medicine. Only three copies of the book survived but these remained hidden for decades, the rest were burned shortly after its publication in 1553 because of persecution of Servetus by religious authorities.

Better known discovery of pulmonary circulation was by Vesalius's successor at Padua, Realdo Colombo, in 1559.

Image of veins from William Harvey's Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, 1628

Finally, the English physician William Harvey, a pupil of Hieronymus Fabricius (who had earlier described the valves of the veins without recognizing their function), performed a sequence of experiments and published his Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus in 1628, which "demonstrated that there had to be a direct connection between the venous and arterial systems throughout the body, and not just the lungs. Most importantly, he argued that the beat of the heart produced a continuous circulation of blood through minute connections at the extremities of the body. This is a conceptual leap that was quite different from Ibn al-Nafis' refinement of the anatomy and bloodflow in the heart and lungs." This work, with its essentially correct exposition, slowly convinced the medical world. However, Harvey was not able to identify the capillary system connecting arteries and veins; these were later discovered by Marcello Malpighi in 1661.

In 1956, André Frédéric Cournand, Werner Forssmann and Dickinson W. Richards were awarded the Nobel Prize in Medicine "for their discoveries concerning heart catheterization and pathological changes in the circulatory system." In his Nobel lecture, Forssmann credits Harvey as birthing cardiology with the publication of his book in 1628.

In the 1970s, Diana McSherry developed computer-based systems to create images of the circulatory system and heart without the need for surgery.

Cardiology

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Cardiology 

Cardiology

Blood flow diagram of the human heart. Blue components indicate de-oxygenated blood pathways and red components indicate oxygenated blood pathways.
System	Cardiovascular
Subdivisions	Interventional, Nuclear
Significant diseases	Heart disease, Cardiovascular disease, Atherosclerosis, Cardiomyopathy, Hypertension (High Blood Pressure)
Significant tests	Blood tests, electrophysiology study, cardiac imaging, ECG, echocardiograms, stress test
Specialist	Cardiologist
Glossary	Glossary of medicine

Cardiologist

Occupation
Names	Physician Surgeon
Occupation type	Specialty
Activity sectors	Medicine, Surgery
Description
Education required	Doctor of Medicine (M.D.) Doctor of Osteopathic medicine (D.O.) Bachelor of Medicine, Bachelor of Surgery (M.B.B.S.) Bachelor of Medicine, Bachelor of Surgery (MBChB)
Fields of employment	Hospitals, Clinics

Cardiology (from Greek καρδίᾱ kardiā, "heart" and -λογία -logia, "study") is a branch of medicine that deals with the disorders of the heart as well as some parts of the circulatory system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

Specializations

All cardiologists study the disorders of the heart, but the study of adult and child heart disorders are through different training pathways. Therefore, an adult cardiologist (often simply called "cardiologist") is inadequately trained to take care of children, and pediatric cardiologists are not trained to take care of adult heart disease. The surgical aspects are not included in cardiology and are in the domain of cardiothoracic surgery. For example, coronary artery bypass surgery (CABG), cardiopulmonary bypass and valve replacement are surgical procedures performed by surgeons, not cardiologists. However, the insertion of stents and pacemakers is performed by cardiologists.

Adult cardiology

Cardiology is a specialty of internal medicine. To be a cardiologist in the United States, a three-year residency in internal medicine is followed by a three-year fellowship in cardiology. It is possible to specialize further in a sub-specialty. Recognized sub-specialties in the United States by the ACGME are cardiac electrophysiology, echocardiography, interventional cardiology, and nuclear cardiology. Recognized subspecialties in the United States by the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS) include clinical cardiac electrophysiology and interventional cardiology. While in India, a person needs to undergo three years of residency in General Medicine or Pediatrics after M.B.B.S and then three years of residency in Cardiology to be a D.M/Diplomate of National Board (DNB) in Cardiology.

Per Doximity, adult cardiologists make an average of $436,849 in the United States.

Cardiac electrophysiology

Cardiac electrophysiology is the science of elucidating, diagnosing, and treating the electrical activities of the heart. The term is usually used to describe studies of such phenomena by invasive (intracardiac) catheter recording of spontaneous activity as well as of cardiac responses to programmed electrical stimulation (PES). These studies are performed to assess complex arrhythmias, elucidate symptoms, evaluate abnormal electrocardiograms, assess risk of developing arrhythmias in the future, and design treatment. These procedures increasingly include therapeutic methods (typically radiofrequency ablation, or cryoablation) in addition to diagnostic and prognostic procedures. Other therapeutic modalities employed in this field include antiarrhythmic drug therapy and implantation of pacemakers and automatic implantable cardioverter-defibrillators (AICD).

The cardiac electrophysiology study (EPS) typically measures the response of the injured or cardiomyopathic myocardium to PES on specific pharmacological regimens in order to assess the likelihood that the regimen will successfully prevent potentially fatal sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) in the future. Sometimes a series of EPS drug trials must be conducted to enable the cardiologist to select the one regimen for long-term treatment that best prevents or slows the development of VT or VF following PES. Such studies may also be conducted in the presence of a newly implanted or newly replaced cardiac pacemaker or AICD.

Clinical cardiac electrophysiology

Clinical cardiac electrophysiology is a branch of the medical specialty of cardiology and is concerned with the study and treatment of rhythm disorders of the heart. Cardiologists with expertise in this area are usually referred to as electrophysiologists. Electrophysiologists are trained in the mechanism, function, and performance of the electrical activities of the heart. Electrophysiologists work closely with other cardiologists and cardiac surgeons to assist or guide therapy for heart rhythm disturbances (arrhythmias). They are trained to perform interventional and surgical procedures to treat cardiac arrhythmia.

The training required to become an electrophysiologist is long and requires 7 to 8 years after medical school (within the U.S.). Three years of internal medicine residency, three years of Clinical Cardiology fellowship, and one to two (in most instances) years of clinical cardiac electrophysiology.

Cardiogeriatrics

Cardiogeriatrics, or geriatric cardiology, is the branch of cardiology and geriatric medicine that deals with the cardiovascular disorders in elderly people.

Cardiac disorders such as coronary heart disease, including myocardial infarction, heart failure, cardiomyopathy, and arrhythmias such as atrial fibrillation, are common and are a major cause of mortality in elderly people. Vascular disorders such as atherosclerosis and peripheral arterial disease cause significant morbidity and mortality in aged people.

Echocardiography

Echocardiography uses standard two-dimensional, three-dimensional, and Doppler ultrasound to create images of the heart.

Echocardiography has become routinely used in the diagnosis, management, and follow-up of patients with any suspected or known heart diseases. It is one of the most widely used diagnostic tests in cardiology. It can provide a wealth of helpful information, including the size and shape of the heart (internal chamber size quantification), pumping capacity, and the location and extent of any tissue damage. An echocardiogram can also give physicians other estimates of heart function, such as a calculation of the cardiac output, ejection fraction, and diastolic function (how well the heart relaxes).

Echocardiography can help detect cardiomyopathies, such as hypertrophic cardiomyopathy, dilated cardiomyopathy, and many others. The use of stress echocardiography may also help determine whether any chest pain or associated symptoms are related to heart disease. The biggest advantage to echocardiography is that it is not invasive (does not involve breaking the skin or entering body cavities) and has no known risks or side effects.

Interventional cardiology

Interventional cardiology is a branch of cardiology that deals specifically with the catheter based treatment of structural heart diseases. A large number of procedures can be performed on the heart by catheterization. This most commonly involves the insertion of a sheath into the femoral artery (but, in practice, any large peripheral artery or vein) and cannulating the heart under X-ray visualization (most commonly Fluoroscopy).

The main advantages of using the interventional cardiology or radiology approach are the avoidance of the scars and pain, and long post-operative recovery. Additionally, interventional cardiology procedure of primary angioplasty is now the gold standard of care for an acute Myocardial infarction. This procedure can also be done proactively, when areas of the vascular system become occluded from Atherosclerosis. The Cardiologist will thread this sheath through the vascular system to access the heart. This sheath has a balloon and a tiny wire mesh tube wrapped around it, and if the cardiologist finds a blockage or Stenosis, they can inflate the balloon at the occlusion site in the vascular system to flatten or compress the plaque against the vascular wall. Once that is complete a Stent is placed as a type of scaffold to hold the vasculature open permanently.

Preventive cardiology and cardiac rehabilitation

In recent times, the focus is gradually shifting to Preventive cardiology due to increased Cardiovascular Disease burden at an early age. As per WHO, 37% of all premature deaths are due to cardiovascular diseases and out of this, 82% are in low and middle income countries. Clinical cardiology is the sub specialty of Cardiology which looks after preventive cardiology and cardiac rehabilitation. Preventive cardiology also deals with routine preventive checkup though non invasive tests specifically Electrocardiography, Stress Tests, Lipid Profile and General Physical examination to detect any cardiovascular diseases at an early age while cardiac rehabilitation is the upcoming branch of cardiology which helps a person regain his overall strength and live a normal life after a cardiovascular event. A subspecialty of preventive cardiology is sports cardiology.

Pediatric cardiology

Helen B. Taussig is known as the founder of pediatric cardiology. She became famous through her work with Tetralogy of Fallot, a congenital heart defect in which oxygenated and deoxygenated blood enters the circulatory system resulting from a ventricular septal defect (VSD) right beneath the aorta. This condition causes newborns to have a bluish-tint, cyanosis, and have a deficiency of oxygen to their tissues, hypoxemia. She worked with Alfred Blalock and Vivien Thomas at the Johns Hopkins Hospital where they experimented with dogs to look at how they would attempt to surgically cure these "blue babies." They eventually figured out how to do just that by the anastomosis of the systemic artery to the pulmonary artery and called this the Blalock-Taussig Shunt.

Tetralogy of Fallot, pulmonary atresia, double outlet right ventricle, transposition of the great arteries, persistent truncus arteriosus, and Ebstein's anomaly are various congenital cyanotic heart diseases, in which the blood of the newborn is not oxygenated efficiently, due to the heart defect.

Tetralogy of Fallot

Tetralogy of Fallot

Tetralogy of Fallot is the most common congenital heart disease arising in 1–3 cases per 1,000 births. The cause of this defect is a ventricular septal defect (VSD) and an overriding aorta. These two defects combined causes deoxygenated blood to bypass the lungs and going right back into the circulatory system. The modified Blalock-Taussig shunt is usually used to fix the circulation. This procedure is done by placing a graft between the subclavian artery and the ipsilateral pulmonary artery to restore the correct blood flow.

Pulmonary atresia

Pulmonary atresia happens in 7–8 per 100,000 births and is characterized by the aorta branching out of the right ventricle. This causes the deoxygenated blood to bypass the lungs and enter the circulatory system. Surgeries can fix this by redirecting the aorta and fixing the right ventricle and pulmonary artery connection.

There are two types of pulmonary atresia, classified by whether or not the baby also has a ventricular septal defect.

• Pulmonary atresia with an intact ventricular septum: This type of pulmonary atresia is associated with complete and intact septum between the ventricles.
• Pulmonary atresia with a ventricular septal defect: This type of pulmonary atresia happens when a ventricular septal defect allows blood to flow into and out of the right ventricle.

Double outlet right ventricle

Double outlet right ventricle (DORV) is when both great arteries, the pulmonary artery and the aorta, are connected to the right ventricle. There is usually a VSD in different particular places depending on the variations of DORV, typically 50% are subaortic and 30%. The surgeries that can be done to fix this defect can vary due to the different physiology and blood flow in the defected heart. One way it can be cured is by a VSD closure and placing conduits to restart the blood flow between the left ventricle and the aorta and between the right ventricle and the pulmonary artery. Another way is systemic-to-pulmonary artery shunt in cases associated with pulmonary stenosis. Also, a balloon atrial septostomy can be done to fix DORV with the Taussig-Bing anomaly.

Transposition of great arteries

Dextro-transposition of the Great Arteries

There are two different types of transposition of the great arteries, Dextro-transposition of the great arteries and Levo-transposition of the great arteries, depending on where the chambers and vessels connect. Dextro-transposition happens in about 1 in 4,000 newborns and is when the right ventricle pumps blood into the aorta and deoxygenated blood enters the bloodstream. The temporary procedure is to create an atrial septal defect (ASD). A permanent fix is more complicated and involves redirecting the pulmonary return to the right atrium and the systemic return to the left atrium, which is known as the Senning procedure. The Rastelli procedure can also be done by rerouting the left ventricular outflow, dividing the pulmonary trunk, and placing a conduit in between the right ventricle and pulmonary trunk. Levo-transposition happens in about 1 in 13,000 newborns and is characterized by the left ventricle pumping blood into the lungs and the right ventricle pumping the blood into the aorta. This may not produce problems at the beginning, but will eventually due to the different pressures each ventricle uses to pump blood. Switching the left ventricle to be the systemic ventricle and the right ventricle to pump blood into the pulmonary artery can repair levo-transposition.

Persistent truncus arteriosus

Persistent truncus arteriosus is when the truncus arteriosus fails to split into the aorta and pulmonary trunk. This occurs in about 1 in 11,000 live births and allows both oxygenated and deoxygenated blood into the body. The repair consists of a VSD closure and the Rastelli procedure.

Ebstein anomaly

Ebstein's anomaly is characterized by a right atrium that is significantly enlarged and a heart that is shaped like a box. This is very rare and happens in less than 1% of congenital heart disease cases. The surgical repair varies depending on the severity of the disease.

Pediatric cardiology is a sub-specialty of pediatrics. To become a pediatric cardiologist in the United States, one must complete a three-year residency in pediatrics, followed by a three-year fellowship in pediatric cardiology. Per doximity, pediatric cardiologists make an average of $303,917 in the United States.

The heart

Blood flow through the valves

As the center focus of cardiology, the heart has numerous anatomical features (e.g., atria, ventricles, heart valves) and numerous physiological features (e.g., systole, heart sounds, afterload) that have been encyclopedically documented for many centuries.

Disorders of the heart lead to heart disease and cardiovascular disease and can lead to a significant number of deaths: cardiovascular disease is the leading cause of death in the United States and caused 24.95% of total deaths in 2008.

The primary responsibility of the heart is to pump blood throughout the body. It pumps blood from the body — called the systemic circulation — through the lungs — called the pulmonary circulation — and then back out to the body. This means that the heart is connected to and affects the entirety of the body. Simplified, the heart is a circuit of the Circulation. While plenty is known about the healthy heart, the bulk of study in cardiology is in disorders of the heart and restoration, and where possible, of function.

The heart is a muscle that squeezes blood and functions like a pump. Each part of the heart is susceptible to failure or dysfunction and the heart can be divided into the mechanical and the electrical parts.

The electrical part of the heart is centered on the periodic contraction (squeezing) of the muscle cells that is caused by the cardiac pacemaker located in the sinoatrial node. The study of the electrical aspects is a sub-field of electrophysiology called cardiac electrophysiology and is epitomized with the electrocardiogram (ECG/EKG). The action potentials generated in the pacemaker propagate throughout the heart in a specific pattern. The system that carries this potential is called the electrical conduction system. Dysfunction of the electrical system manifests in many ways and may include Wolff–Parkinson–White syndrome, ventricular fibrillation, and heart block.

The mechanical part of the heart is centered on the fluidic movement of blood and the functionality of the heart as a pump. The mechanical part is ultimately the purpose of the heart and many of the disorders of the heart disrupt the ability to move blood. Failure to move sufficient blood can result in failure in other organs and may result in death if severe. Heart failure is one condition in which the mechanical properties of the heart have failed or are failing, which means insufficient blood is being circulated.

Coronary circulation

Coronary circulation is the circulation of blood in the blood vessels of the heart muscle (myocardium). The vessels that deliver oxygen-rich blood to the myocardium are known as coronary arteries. The vessels that remove the deoxygenated blood from the heart muscle are known as cardiac veins. These include the great cardiac vein, the middle cardiac vein, the small cardiac vein and the anterior cardiac veins.

As the left and right coronary arteries run on the surface of the heart, they can be called epicardial coronary arteries. These arteries, when healthy, are capable of autoregulation to maintain coronary blood flow at levels appropriate to the needs of the heart muscle. These relatively narrow vessels are commonly affected by atherosclerosis and can become blocked, causing angina or a heart attack. The coronary arteries that run deep within the myocardium are referred to as subendocardial.

The coronary arteries are classified as "end circulation", since they represent the only source of blood supply to the myocardium; there is very little redundant blood supply, which is why blockage of these vessels can be so critical.

Cardiac examination

The cardiac examination (also called the "precordial exam"), is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination.

Like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation and auscultation.

Heart disorders

Cardiology is concerned with the normal functionality of the heart and the deviation from a healthy heart. Many disorders involve the heart itself but some are outside of the heart and in the vascular system. Collectively, the two together are termed the cardiovascular system and diseases of one part tend to affect the other.

Hypertension

Hypertension, also known as "high blood pressure"", is a long term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long term high blood pressure, however, is a major risk factor for coronary artery disease, stroke, heart failure, peripheral vascular disease, vision loss, and chronic kidney disease.

Lifestyle factors can increase the risk of hypertension. These include excess salt in the diet, excess body weight, smoking, and alcohol. Hypertension can also be caused by other diseases, or as a side-effect of drugs.

Blood pressure is expressed by two measurements, the systolic and diastolic pressures, which are the maximum and minimum pressures, respectively. Normal blood pressure at rest is within the range of 100–140 millimeters mercury (mmHg) systolic and 60–90 mmHg diastolic. High blood pressure is present if the resting blood pressure is persistently at or above 140/90 mmHg for most adults. Different numbers apply to children. Ambulatory blood pressure monitoring over a 24-hour period appears more accurate than office best blood pressure measurement.

Lifestyle changes and medications can lower blood pressure and decrease the risk of health complications. Lifestyle changes include weight loss, decreased salt intake, physical exercise, and a healthy diet. If lifestyle changes are not sufficient then blood pressure medications are used. Up to three medications can control blood pressure in 90% of people. The treatment of moderate to severe high arterial blood pressure (defined as >160/100 mmHg) with medications is associated with an improved life expectancy and reduced morbidity. The effect of treatment of blood pressure between 140/90 mmHg and 160/100 mmHg is less clear, with some reviews finding benefit and others finding a lack of evidence for benefit. High blood pressure affects between 16 and 37% of the population globally. In 2010 hypertension was believed to have been a factor in 18% (9.4 million) deaths.

Essential vs Secondary hypertension

Essential hypertension is the form of hypertension that by definition has no identifiable cause. It is the most common type of hypertension, affecting 95% of hypertensive patients, it tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. Prevalence of essential hypertension increases with age, and individuals with relatively high blood pressure at younger ages are at increased risk for the subsequent development of hypertension. Hypertension can increase the risk of cerebral, cardiac, and renal events.

Secondary hypertension is a type of hypertension which is caused by an identifiable underlying secondary cause. It is much less common than essential hypertension, affecting only 5% of hypertensive patients. It has many different causes including endocrine diseases, kidney diseases, and tumors. It also can be a side effect of many medications.

Complications of hypertension

Main complications of persistent high blood pressure

Complications of hypertension are clinical outcomes that result from persistent elevation of blood pressure. Hypertension is a risk factor for all clinical manifestations of atherosclerosis since it is a risk factor for atherosclerosis itself. It is an independent predisposing factor for heart failure, coronary artery disease, stroke, renal disease, and peripheral arterial disease. It is the most important risk factor for cardiovascular morbidity and mortality, in industrialized countries.

Cardiac arrhythmia

Cardiac arrhythmia, also known as "cardiac dysrhythmia" or "irregular heartbeat", is a group of conditions in which the heartbeat is irregular, too fast, or too slow. A heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia and a heart rate that is too slow – below 60 beats per minute – is called bradycardia. Many types of arrhythmia have no symptoms. When symptoms are present these may include palpitations or feeling a pause between heartbeats. More seriously there may be lightheadedness, passing out, shortness of breath, or chest pain. While most types of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in cardiac arrest.

There are four main types of arrhythmia: extra beats, supraventricular tachycardias, ventricular arrhythmias, and bradyarrhythmias. Extra beats include premature atrial contractions, premature ventricular contractions, and premature junctional contractions. Supraventricular tachycardias include atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia. Ventricular arrhythmias include ventricular fibrillation and ventricular tachycardia. Arrhythmias are due to problems with the electrical conduction system of the heart. Arrhythmias may occur in children; however, the normal range for the heart rate is different and depends on age. A number of tests can help with diagnosis including an electrocardiogram (ECG) and Holter monitor.

Most arrhythmias can be effectively treated. Treatments may include medications, medical procedures such as a pacemaker, and surgery. Medications for a fast heart rate may include beta blockers or agents that attempt to restore a normal heart rhythm such as procainamide. This later group may have more significant side effects especially if taken for a long period of time. Pacemakers are often used for slow heart rates. Those with an irregular heartbeat are often treated with blood thinners to reduce the risk of complications. Those who have severe symptoms from an arrhythmia may receive urgent treatment with a jolt of electricity in the form of cardioversion or defibrillation.

Arrhythmia affects millions of people. In Europe and North America, as of 2014, atrial fibrillation affects about 2% to 3% of the population. Atrial fibrillation and atrial flutter resulted in 112,000 deaths in 2013, up from 29,000 in 1990. Sudden cardiac death is the cause of about half of deaths due to cardiovascular disease or about 15% of all deaths globally. About 80% of sudden cardiac death is the result of ventricular arrhythmias. Arrhythmias may occur at any age but are more common among older people.

Coronary artery disease

Coronary artery disease, also known as "ischemic heart disease", is a group of diseases that includes: stable angina, unstable angina, myocardial infarction, and is one of the causes of sudden cardiac death. It is within the group of cardiovascular diseases of which it is the most common type. A common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. Occasionally it may feel like heartburn. Usually symptoms occur with exercise or emotional stress, last less than a few minutes, and get better with rest. Shortness of breath may also occur and sometimes no symptoms are present. The first sign is occasionally a heart attack. Other complications include heart failure or an irregular heartbeat.

Risk factors include: high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol, among others. Other risks include depression. The underlying mechanism involves atherosclerosis of the arteries of the heart. A number of tests may help with diagnoses including: electrocardiogram, cardiac stress testing, coronary computed tomographic angiography, and coronary angiogram, among others.

Prevention is by eating a healthy diet, regular exercise, maintaining a healthy weight and not smoking. Sometimes medication for diabetes, high cholesterol, or high blood pressure are also used. There is limited evidence for screening people who are at low risk and do not have symptoms. Treatment involves the same measures as prevention. Additional medications such as antiplatelets including aspirin, beta blockers, or nitroglycerin may be recommended. Procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) may be used in severe disease. In those with stable CAD it is unclear if PCI or CABG in addition to the other treatments improve life expectancy or decreases heart attack risk.

In 2013 CAD was the most common cause of death globally, resulting in 8.14 million deaths (16.8%) up from 5.74 million deaths (12%) in 1990. The risk of death from CAD for a given age has decreased between 1980 and 2010 especially in developed countries. The number of cases of CAD for a given age has also decreased between 1990 and 2010. In the United States in 2010 about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45. Rates are higher among men than women of a given age.

Cardiac arrest

Cardiac arrest is a sudden stop in effective blood flow due to the failure of the heart to contract effectively. Symptoms include loss of consciousness and abnormal or absent breathing. Some people may have chest pain, shortness of breath, or nausea before this occurs. If not treated within minutes, death usually occurs.

The most common cause of cardiac arrest is coronary artery disease. Less common causes include major blood loss, lack of oxygen, very low potassium, heart failure, and intense physical exercise. A number of inherited disorders may also increase the risk including long QT syndrome. The initial heart rhythm is most often ventricular fibrillation. The diagnosis is confirmed by finding no pulse. While a cardiac arrest may be caused by heart attack or heart failure these are not the same.

Prevention includes not smoking, physical activity, and maintaining a healthy weight. Treatment for cardiac arrest is immediate cardiopulmonary resuscitation (CPR) and, if a shockable rhythm is present, defibrillation. Among those who survive targeted temperature management may improve outcomes. An implantable cardiac defibrillator may be placed to reduce the chance of death from recurrence.

In the United States, cardiac arrest outside of hospital occurs in about 13 per 10,000 people per year (326,000 cases). In hospital cardiac arrest occurs in an additional 209,000 Cardiac arrest becomes more common with age. It affects males more often than females. The percentage of people who survive with treatment is about 8%. Many who survive have significant disability. Many U.S. television shows, however, have portrayed unrealistically high survival rates of 67%.

Congenital heart defects

A congenital heart defect, also known as a "congenital heart anomaly" or "congenital heart disease", is a problem in the structure of the heart that is present at birth. Signs and symptoms depend on the specific type of problem. Symptoms can vary from none to life-threatening. When present they may include rapid breathing, bluish skin, poor weight gain, and feeling tired. It does not cause chest pain. Most congenital heart problems do not occur with other diseases. Complications that can result from heart defects include heart failure.

The cause of a congenital heart defect is often unknown. Certain cases may be due to infections during pregnancy such as rubella, use of certain medications or drugs such as alcohol or tobacco, parents being closely related, or poor nutritional status or obesity in the mother. Having a parent with a congenital heart defect is also a risk factor. A number of genetic conditions are associated with heart defects including Down syndrome, Turner syndrome, and Marfan syndrome. Congenital heart defects are divided into two main groups: cyanotic heart defects and non-cyanotic heart defects, depending on whether the child has the potential to turn bluish in color. The problems may involve the interior walls of the heart, the heart valves, or the large blood vessels that lead to and from the heart.

Congenital heart defects are partly preventable through rubella vaccination, the adding of iodine to salt, and the adding of folic acid to certain food products. Some defects do not need treatment. Other may be effectively treated with catheter based procedures or heart surgery. Occasionally a number of operations may be needed. Occasionally heart transplantation is required. With appropriate treatment outcomes, even with complex problems, are generally good.

Heart defects are the most common birth defect. In 2013 they were present in 34.3 million people globally. They affect between 4 and 75 per 1,000 live births depending upon how they are diagnosed. About 6 to 19 per 1,000 cause a moderate to severe degree of problems. Congenital heart defects are the leading cause of birth defect-related deaths. In 2013 they resulted in 323,000 deaths down from 366,000 deaths in 1990.

Diagnostic tests in cardiology

Diagnostic tests in cardiology are the methods of identifying heart conditions associated with healthy vs. unhealthy, pathologic heart function. The starting point is obtaining a medical history, followed by Auscultation. Then blood tests, electrophysiological procedures, and cardiac imaging can be ordered for further analysis. Electrophysiological procedures include electrocardiogram, cardiac monitoring, cardiac stress testing, and the electrophysiology study.