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 EDITION

12

HEART
B R A U N WA L D’S

DISEASE
A TEXTBOOK OF CARDIOVASCULAR MEDICINE

Edited by
PETER LIBBY, MD DEEPAK L. BHATT, MD, MPH
Mallinckrodt Professor of Medicine Executive Director of Interventional Cardiovascular Programs
Harvard Medical School Brigham and Women’s Hospital
Brigham and Women’s Hospital Senior Physician
Boston, Massachusetts Brigham and Women’s Hospital
Professor of Medicine
ROBERT O. BONOW, MD Harvard Medical School
Max and Lilly Goldberg Distinguished Professor of Cardiology Boston, Massachusetts
Department of Medicine
Northwestern University Feinberg School of Medicine SCOTT D. SOLOMON, MD
Chicago, Illinois The Edward D. Frohlich Distinguished Chair
Professor of Medicine
DOUGLAS L. MANN, MD Harvard Medical School
Lewin Distinguished Professor of Cardiovascular Disease Senior Physician
Washington University School of Medicine in St. Louis Brigham and Women’s Hospital
Saint Louis, Missouri Boston, Massachusetts

GORDON F. TOMASELLI, MD
Professor of Medicine (Cardiology) Founding Editor and Online Editor
The Marilyn and Stanley M. Katz Dean
Albert Einstein College of Medicine EUGENE BRAUNWALD, MD,
Executive Vice President and Chief Academic Officer MD(Hon), ScD(Hon), FRCP
Montefiore Medicine Distinguished Hersey Professor of Medicine
Bronx, New York Harvard Medical School
Founding Chairman, TIMI Study Group
Brigham and Women’s Hospital
Boston, Massachusetts
ELSEVIER
1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-­2899

BRAUNWALD’S HEART DISEASE: A TEXTBOOK OF TWO-­VOLUME SET ISBN: 978-­0-­323-­72219-­3

CARDIOVASCULAR MEDICINE, TWELFTH EDITION SINGLE VOLUME ISBN: 978-­0-­323-­82467-­5
Copyright © 2022 by Elsevier Inc. INTERNATIONAL EDITION ISBN: 978-­0-­323-­82468-­2

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s
Rights Department: phone: (+1) 215-­239-­3804 (US) or (+44) 1-­865-­843830 (UK); fax: (+44) 1-­865-­853333; e-­mail:
[email protected]. You may also complete your request on-­line via the Elsevier website at
http://www.elsevier.com/permissions.

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose
or formula, the method and duration of administration, and contraindications. It is the responsibility of
the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions. To the fullest extent of the law, neither the Publisher nor the Authors assume any liability
for any injury and/or damage to persons or property arising out of or related to any use of the material
contained in this book.

The Publisher

Previous editions copyrighted 2019, 2015, 2012, 2008, 2005, 2001, 1997, 1992, 1988, 1984, 1980 by Elsevier Inc.

Library of Congress Control Number: 2021936447

Executive Content Strategists: Dolores Meloni, Robin Carter

Senior Content Development Specialist: Anne Snyder
Publishing Services Manager: Catherine Jackson
Senior Project Manager: John Casey
Design Direction: Renee Duenow

About the cover:

Professor C. Michael Gibson is well known in interventional cardiology for his many contributions to clinical sci-
ence. He has had leadership positions in many pivotal clinical trials that have influenced our practice and guidelines.
He originated the TIMI myocardial perfusion grade. He currently leads the Baim Institute for Clinical Research, an
academic research organization at Boston’s Beth Isræl Hospital. Beyond his investigative prowess, Professor Gibson
is an unusually talented artist. The editor-­in-­chief was delighted that he agreed to provide art for the cover for this
12th edition of Braunwald’s Heart Disease. This addition is particularly appropriate because of Dr. Gibson’s long-­
term association with Dr. Braunwald’s research in ischemic heart disease. The editors are proud to have his artistic
rendition of the now classic Heart Disease logo grace the cover of our book.

Printed in United States of America

9 8 7 6 5 4 3 2 1
 To
Beryl, Oliver, and Brigitte
Pat, Rob, Sam, Laura, and Yoko
Benjamin Tan
Charlene, Sarah, Emily, and Matthew
Shanthala,Vinayak, Arjun, Ram, and Raj
Caren, Will and Lyz, Katie and Zach, and Dan
 Contributors

Keith D. Aaronson, MD, MS Sadeer Al-­Kindi, MD

Bertram Pitt MD Collegiate Professor of Cardiovascular Medicine Assistant Professor of Medicine
Professor of Internal Medicine Case Western Reserve University
Division of Cardiovascular Medicine Harrington Heart and Vascular Institute
University of Michigan University Hospitals Cleveland Medical Center
Ann Arbor, Michigan Cleveland, Ohio
Chapter 59. Mechanical Circulatory Support Chapter 3. Impact of the Environment on Cardiovascular Health

Michael J. Ackerman, MD, PhD Nandan S. Anavekar, MBBCh

Windland Smith Rice Cardiovascular Genomics Research Professor Professor of Medicine
Professor of Medicine, Pediatrics, and Pharmacology Department of Cardiovascular Diseases
Mayo Clinic College of Medicine and Science Department of Radiology
Department of Cardiovascular Medicine (Division of Heart Rhythm Mayo Clinic College of Medicine and Science
Services and the Windland Smith Rice Genetic Heart Rhythm Rochester, Minnesota
Clinic) Chapter 80. Infectious Endocarditis and Infections of Indwelling
Department of Molecular Pharmacology & Experimental Devices
Therapeutics (Windland Smith Rice Sudden Death Genomics
Laboratory) Zachi Attia, PhD
Department of Pediatric and Adolescent Medicine (Division of Department of Cardiovascular Medicine
Pediatric Cardiology) Mayo Clinic College of Medicine and Science
Mayo Clinic Rochester, Minnesota
Rochester, Minnesota Chapter 11. Artificial Intelligence in Cardiovascular Medicine
Chapter 63. Genetics of Cardiac Arrhythmias
Sonya V. Babu-­Narayan, MBBS, BSc, PhD, FRCP
Philip A. Ades, MD Adult Congenital Heart Disease
Endowed Professor of Medicine Royal Brompton Hospital
Division of Cardiology Reader, National Heart and Lung Institute
University of Vermont College of Medicine Imperial College London
Director, Cardiac Rehabilitation and Prevention London, United Kingdom
University of Vermont Medical Center Chapter 82. Congenital Heart Disease in the Adolescent and
Burlington,Vermont Adult
Chapter 15. Exercise Physiology and Exercise Electrocardiographic
Testing Larry M. Baddour, MD
Professor of Medicine
Christine M. Albert, MD Mayo Clinic College of Medicine and Science
Chair and Professor of Cardiology Rochester, Minnesota
Smidt Heart Institute, Cedars-­Sinai Medical Center Chapter 80. Infectious Endocarditis and Infections of Indwelling
Los Angeles, California Devices
Chapter 70. Cardiac Arrest and Sudden Cardiac Death
Aaron L. Baggish, MD
Michelle A. Albert, MD, MPH Associate Professor of Medicine
Professor of Medicine Harvard Medical School
Director, Center for the Study of Adversity and Cardiovascular Disease Director, Cardiovascular Performance Program
(NURTURE Center) Massachusetts General Hospital
University of California at San Francisco Boston, Massachusetts
San Francisco, California Chapter 32. Exercise and Sports Cardiology
Chapter 93. Heart Disease in Racially and Ethnically Diverse
Populations C. Noel Bairey Merz, MD
Women’s Guild Endowed Chair in Women’s Health
Mark J. Alberts, MD Director, Barbra Streisand Women’s Heart Center
Chief of Neurology Erika J. Glazer Women’s Heart Research Initiative Director
Hartford Hospital Director, Linda Joy Pollin Women’s Heart Health Program
Hartford, Connecticut; Barbra Streisand Women’s Heart Center
Co-­Physician-­in-­Chief Cedars-­Sinai Heart Institute
Ayer Neuroscience Institute Los Angeles, California
Hartford HealthCare Chapter 91. Cardiovascular Disease in Women
Professor of Neurology
University of Connecticut
Storrs, Connecticut
Chapter 45. Prevention and Management of Ischemic Stroke

vi
 vii
George L. Bakris, MD, MA Ron Blankstein, MD
Professor of Medicine Associate Director, Cardiovascular Imaging Program
Section of Endocrinology, Diabetes and Metabolism Director, Cardiac Computed Tomography

Contributors
Director, American Heart Association Comprehensive Hypertension Co-­Director, Cardiovascular Imaging Training Program
Center Brigham and Women’s Hospital
UChicago Medicine Professor of Medicine and Radiology
Chicago, Illinois Harvard Medical School
Chapter 26. Systemic Hypertension: Mechanisms, Diagnosis, and Boston, Massachusetts
Treatment Chapter 20. Cardiac Computed Tomography

Gary J. Balady, MD Erin A. Bohula, MD, DPhil

Professor of Medicine TIMI Study Group and Division of Cardiology
Boston University School of Medicine Brigham and Women’s Hospital
Director, Non-­Invasive Cardiovascular Laboratories Harvard Medical School
Boston Medical Center Boston, Massachusetts
Boston, Massachusetts Chapter 38. ST-­Elevation Myocardial Infarction: Management
Chapter 15. Exercise Physiology and Exercise Electrocardiographic
Testing Marc P. Bonaca, MD, MPH
Executive Director
David T. Balzer, MD CPC Clinical Research
Professor of Pediatrics Professor of Medicine
Division of Pediatric Cardiology Cardiology and Vascular Medicine
Washington University School of Medicine in St. Louis University of Colorado
Saint Louis, Missouri Aurora, Colorado
Chapter 83. Catheter-­Based Treatment of Congenital Heart Disease in Chapter 35. Approach to the Patient with Chest Pain
Adults Chapter 43. Peripheral Artery Diseases

Joshua A. Beckman, MD Robert O. Bonow, MD

Professor of Medicine Max and Lilly Goldberg Distinguished Professor of Cardiology
Division of Cardiovascular Medicine Department of Medicine
Vanderbilt University College of Medicine Northwestern University Feinberg School of Medicine
Director, Section of Vascular Medicine Chicago, Illinois
Vanderbilt University Medical Center Chapter 72. Aortic Valve Stenosis
Nashville, Tennessee Chapter 73. Aortic Regurgitation
Chapter 23. Anesthesia and Noncardiac Surgery in Patients with Heart Chapter 76. Mitral Regurgitation
Disease
Barry A. Borlaug, MD
Donald M. Bers, PhD Professor of Medicine
Distinguished Professor and Chair Mayo Medical School
Department of Pharmacology Director, Circulatory Failure Research
University of California, Davis Consultant, Cardiovascular Diseases
Davis, California Mayo Clinic College of Medicine and Science
Chapter 46. Mechanisms of Cardiac Contraction and Relaxation Rochester, Minnesota
Chapter 46. Mechanisms of Cardiac Contraction and Relaxation
Aruni Bhatnagar, PhD
Professor of Medicine Jason S. Bradfield, MD
University of Louisville Associate Professor of Medicine
Louisville, Kentucky Director, Specialized Program for Ventricular Tachycardia
Chapter 28. Cardiovascular Disease Risk of Nicotine and Tobacco UCLA Cardiac Arrhythmia Center
Products Ronald Reagan UCLA Medical Center
Los Angeles, California
Deepak L. Bhatt, MD, MPH Chapter 102. Cardiovascular Manifestations of Autonomic Disorders
Executive Director of Interventional Cardiovascular Programs
Brigham and Women’s Hospital Eugene Braunwald, MD, MD(Hon), ScD(Hon), FRCP
Senior Physician Distinguished Hersey Professor of Medicine
Brigham and Women’s Hospital Harvard Medical School
Professor of Medicine Founding Chairman, TIMI Study Group
Harvard Medical School Brigham and Women’s Hospital
Boston, Massachusetts Boston, Massachusetts
Chapter 41. Percutaneous Coronary Intervention Chapter 1. Cardiovascular Disease: Past, Present, and Future
Chapter 44. Treatment of Noncoronary Obstructive Vascular Disease Chapter 39. Non-­ST Elevation Acute Coronary Syndromes

Bernadette Biondi, MD Alan C. Braverman, MD

Professor of Internal Medicine Alumni Endowed Professor in Cardiovascular Diseases
Department of Clinical Medicine and Surgery Director, Marfan Syndrome and Aortopathy Clinic
Federico II University Washington University School of Medicine in St. Louis
Naples, Italy Director, Inpatient Cardiology Firm
Chapter 96. Endocrine Disorders and Cardiovascular Disease Barnes-­Jewish Hospital
Saint Louis, Missouri
Chapter 42. Diseases of the Aorta
 viii
John E. Brush Jr., MD Mark A. Creager, MD
Senior Medical Director Professor of Medicine and Surgery
Sentara Health Research Center Geisel School of Medicine at Dartmouth
CONTRIBUTORS

Sentara Healthcare Hanover, New Hampshire;

Professor of Medicine Director, Heart and Vascular Center
Department of Internal Medicine Heart and Vascular Center
Eastern Virginia Medical School Dartmouth-­Hitchcock Medical Center
Norfolk,Virginia Lebanon, New Hampshire
Chapter 5. Clinical Decision-­Making in Cardiology Chapter 43. Peripheral Artery Diseases

Hugh Calkins, MD Paul C. Cremer, MD

Catherine Ellen Poindexter Professor of Cardiology Assistant Professor of Medicine
Professor of Medicine Cleveland Clinic Lerner College of Medicine of Case Western Reserve
Director, Cardiac Arrhythmia Service University
The Johns Hopkins Medical Institutions Associate Director of Cardiovascular Training Program
Baltimore, Maryland Cleveland Clinic Foundation
Chapter 66. Atrial Fibrillation: Clinical Features, Mechanisms, and Cleveland Clinic
Management Cleveland, Ohio
Chapter 71. Hypotension and Syncope Chapter 86. Pericardial Diseases

John M. Canty Jr., MD Juan A. Crestanello, MD

SUNY Distinguished and Albert and Elizabeth Rekate Professor of Professor of Surgery
Medicine Mayo Clinic College of Medicine and Science
Division of Cardiovascular Medicine Rochester, Minnesota
Jacobs School of Medicine and Biomedical Sciences Chapter 80. Infectious Endocarditis and Infections of Indwelling Devices
University at Buffalo
Buffalo, New York Anne B. Curtis, MD
Chapter 36. Coronary Blood Flow and Myocardial Ischemia Charles and Mary Bauer Professor and Chair
SUNY Distinguished Professor
Robert M. Carney, PhD Department of Medicine
Professor of Psychiatry Jacobs School of Medicine and Biomedical Sciences
Washington University School of Medicine in St. Louis University at Buffalo
Saint Louis, Missouri Buffalo, New York
Chapter 99. Psychiatric and Psychosocial Aspects of Cardiovascular Chapter 61. Approach to the Patient with Cardiac Arrhythmias
Disease
George D. Dangas, MD, PhD
Y.S. Chandrashekhar, MD Professor of Medicine (Cardiology)
Professor of Medicine Zena and Michael A Wiener Cardiovascular Institute
Division of Cardiology Icahn School of Medicine at Mount Sinai
University of Minnesota New York, New York
Chief of Cardiology Chapter 21. Coronary Angiography and Intravascular Imaging
VA Medical Center
Minneapolis, Minnesota James P. Daubert, MD
Chapter 75. Mitral Stenosis Professor of Medicine
Cardiology (Electrophysiology)
Peng-­Shen Chen, MD Duke University Medical Center
Cedars-­Sinai Medical Center Durham, North Carolina
Los Angeles, California Chapter 69. Pacemakers and Implantable Cardioverter-­Defibrillators
Chapter 71. Hypotension and Syncope
James A. de Lemos, MD
Mina K. Chung, MD Professor of Medicine
Professor of Medicine Sweetheart Ball-­Kern Wildenthal MD PhD Distinguished Chair in
Cardiovascular and Metabolic Sciences Cardiology
Lerner Research Institute UT Southwestern Medical Center
Cleveland Clinic Lerner College of Medicine of Case Western Reserve Dallas, Texas
University Chapter 40. Stable Ischemic Heart Disease
Staff, Cardiovascular Medicine
Cleveland Clinic Jean-­Pierre Després, PhD
Cleveland, Ohio Professor
Chapter 69. Pacemakers and Implantable Cardioverter-­Defibrillators Kinesiology Department
Université Laval
Leslie T. Cooper Jr., MD Scientific Director
Professor of Medicine VITAM – Centre de recherche en santé durable
Chair, Department of Vascular Medicine Centre intégré universitaire de santé et de services sociaux de la
Mayo Clinic Capitale-­Nationale
Jacksonville, Florida Québec City, Québec, Canada
Chapter 55. Myocarditis Chapter 30. Obesity: Medical and Surgical Management
 ix
Stephen Devries, MD G. Michael Felker, MD, MHS
Executive Director Professor of Medicine
Gaples Institute for Integrative Cardiology Vice Chief for Clinical Research

Contributors
Deerfield, Illinois; Division of Cardiology
Division of Cardiology Duke University School of Medicine
Northwestern University Feinberg School of Medicine Director, Cardiovascular Research
Chicago, Illinois Duke Clinical Research Institute
Chapter 34. Integrative Approaches to the Management of Patients with Durham, North Carolina
Heart Disease Chapter 49. Diagnosis and Management of Acute Heart Failure

Marcelo F. Di Carli, MD Jerome L. Fleg, MD

Seltzer Family Professor of Radiology and Medicine Medical Officer
Harvard Medical School Division of Cardiovascular Sciences
Executive Director, Cardiovascular Imaging Program National Heart, Lung, and Blood Institute
Chief, Division of Nuclear Medicine and Molecular Imaging Bethesda, Maryland
Brigham and Women’s Hospital Chapter 90. Cardiovascular Disease in Older Adults
Boston, Massachusetts
Chapter 18. Nuclear Cardiology Lee A. Fleisher, MD
Professor
Sharmila Dorbala, MD, MPH Anesthesiology and Critical Care
Professor of Radiology Professor of Medicine
Harvard Medical School University of Pennsylvania Perelman School of Medicine
Director, Nuclear Cardiology Philadelphia, Pennsylvania
Division of Nuclear Medicine and Molecular Imaging Chapter 23. Anesthesia and Noncardiac Surgery in Patients with Heart
Brigham and Women’s Hospital Disease
Boston, Massachusetts
Chapter 18. Nuclear Cardiology Daniel E. Forman, MD
Professor of Medicine
Adam L. Dorfman, MD University of Pittsburgh
Professor Chair, Section of Geriatric Cardiology
Departments of Pediatrics and Radiology Divisions of Geriatrics and Cardiology
Director, Non-­Invasive Imaging, Division of Pediatric Cardiology University of Pittsburgh Medical Center
University of Michigan Medical School Director, Cardiac Rehabilitation
C. S. Mott Children’s Hospital VA Pittsburgh Healthcare System
Ann Arbor, Michigan Pittsburgh, Pennsylvania
Chapter 82. Congenital Heart Disease in the Adolescent and Adult Chapter 90. Cardiovascular Disease in Older Adults

Dirk J. Duncker, MD, PhD Kenneth E. Freedland, PhD

Professor of Experimental Cardiology Professor of Psychiatry
Department of Cardiology Washington University School of Medicine in St. Louis
Erasmus MC, University Medical Center Rotterdam Saint Louis, Missouri
Rotterdam, The Netherlands Chapter 99. Psychiatric and Psychosocial Aspects of Cardiovascular Disease
Chapter 36. Coronary Blood Flow and Myocardial Ischemia
Paul Friedman, MD
Kenneth A. Ellenbogen, MD Norman Blane & Billie Jean Harty Chair
Martha M. and Harold W. Kimmerling Professor of Cardiology Mayo Clinic Department of Cardiovascular Medicine Honoring
Director, Electrophysiology and Pacing Robert L. Frye, MD
Virginia Commonwealth University School of Medicine Professor of Medicine
Richmond,Virginia Mayo Clinic College of Medicine and Science
Chapter 64. Therapy for Cardiac Arrhythmias Rochester, Minnesota
Chapter 11. Artificial Intelligence in Cardiovascular Medicine
Thomas H. Everett IV, PhD
Associate Professor of Medicine J. Michael Gaziano, MD, MPH
The Krannert Institute of Cardiology and Division of Cardiology Professor of Medicine
Indiana University School of Medicine Harvard Medical School
Indianapolis, Indiana Chief, Division of Aging
Chapter 71. Hypotension and Syncope Brigham and Women’s Hospital
Director, Preventive Cardiology
James C. Fang, MD VA Boston Healthcare System
Professor of Medicine Boston, Massachusetts
Division of Cardiovascular Medicine Chapter 2. Global Burden of Cardiovascular Disease
University of Utah
Executive Director, Cardiovascular Service Line Thomas A. Gaziano, MD, MSc
University of Utah Health Sciences Associate Professor
Salt Lake City, Utah Harvard Medical School
Chapter 13. History and Physical Examination: An Evidence-­Based Physician
Approach Cardiovascular Medicine Division
Brigham & Women’s Hospital
Boston, Massachusetts
Chapter 2. Global Burden of Cardiovascular Disease
 x
Jacques Genest, MD William J. Groh, MD, MPH
Professor of Medicine Clinical Professor of Medicine
Faculty of Medicine Medical University of South Carolina
CONTRIBUTORS

McGill University Chief of Medicine

Research Institute of the McGill University Health Centre Ralph H. Johnson VAMC
Montreal, Quebec, Canada Charleston, South Carolina
Chapter 27. Lipoprotein Disorders and Cardiovascular Disease Chapter 100. Neuromuscular Disorders and Cardiovascular Disease

Robert Gerszten, MD Martha Gulati, MD, MS

Herman Dana Professor of Medicine Chief of Cardiology
Harvard Medical School Professor of Medicine
Chief, Division of Cardiovascular Medicine University of Arizona–Phoenix
Beth Israel Deaconess Medical Center Phoenix, Arizona
Boston, Massachusetts Chapter 91. Cardiovascular Disease in Women
Chapter 8. Proteomics and Metabolomics in Cardiovascular Medicine
Rebecca Tung Hahn, MD
Linda D. Gillam, MD, MPH Director of Interventional Echocardiography
Dorothy and Lloyd Huck Chair Center for Interventional and Vascular Therapy
Department of Cardiovascular Medicine Columbia University Medical Center
Morristown Medical Center New York, New York
Morristown, New Jersey; Chapter 76. Mitral Regurgitation
Professor of Medicine
Thomas Jefferson University Gerd Hasenfuss, MD
Philadelphia, Pennsylvania Professor of Medicine
Chapter 16. Echocardiography Chair, Department of Cardiology and Pneumology
University of Göttingen Medical Center
John R. Giudicessi, MD, PhD Göttingen, Germany
Assistant Professor of Medicine Chapter 47. Pathophysiology of Heart Failure
Department of Cardiovascular Medicine (Division of Heart Rhythm
Services and the Windland Smith Rice Genetic Heart Rhythm Howard C. Herrmann, MD
Clinic) John W. Bryfogle Jr. Professor of Cardiovascular Medicine
Mayo Clinic College of Medicine and Science Division of Cardiovascular Medicine
Rochester, Minnesota University of Pennsylvania Perelman School of Medicine
Chapter 63. Genetics of Cardiac Arrhythmias Health System Director for Interventional Cardiology
Hospital of the University of Pennsylvania
Robert P. Giugliano, MD, SM Philadelphia, Pennsylvania
Staff Physician Chapter 78. Transcatheter Therapies for Mitral and Tricuspid Valvular
Cardiovascular Medicine Heart Disease
Brigham and Women’s Hospital
Professor of Medicine Joerg Herrmann, MD
Harvard Medical School Professor of Medicine
Boston, Massachusetts Department of Cardiovascular Medicine
Chapter 39. Non-­ST Elevation Acute Coronary Syndromes Mayo Clinic
Rochester, Minnesota
Ary L. Goldberger, MD Chapter 22. Invasive Hemodynamic Diagnosis of Cardiac Disease
Professor of Medicine Chapter 57. Cardio-­Oncology: Approach to the Patient
Harvard Medical School
Department of Medicine Ray E. Hershberger, MD
Beth Israel Deaconess Medical Center Professor of Internal Medicine
Boston, Massachusetts Director, Division of Human Genetics
Chapter 14. Electrocardiography Division of Cardiovascular Medicine
Section of Heart Failure and Cardiac Transplantation
Jeffrey J. Goldberger, MD, MBA Dorothy M. Davis Heart and Lung Research Institute
Professor of Medicine Wexner Medical Center at the Ohio State University
Chief, Cardiovascular Division Columbus, Ohio
University of Miami Miller School of Medicine Chapter 52. The Dilated, Restrictive, and Infiltrative Cardiomyopathies
Miami, Florida
Chapter 70. Cardiac Arrest and Sudden Cardiac Death Carolyn Y. Ho, MD
Associate Professor of Medicine
Samuel Z. Goldhaber, MD Cardiovascular Division
Professor of Medicine Brigham and Women’s Hospital
Harvard Medical School Boston, Massachusetts
Director, Thrombosis Research Group Chapter 54. Hypertrophic Cardiomyopathy
Associate Chief and Clinical Director
Division of Cardiovascular Medicine Priscilla Y. Hsue, MD
Brigham and Women’s Hospital Professor
Boston, Massachusetts Department of Medicine
Chapter 87. Pulmonary Embolism and Deep Vein Thrombosis University of California, San Francisco
San Francisco, California
Chapter 85. Cardiovascular Abnormalities in HIV-­Infected Individuals
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 xi
W. Gregory Hundley, MD Scott Kinlay, MBBS, PhD
Professor of Medicine Chief, Cardiology (acting)
Chairman, Cardiology Division Director Cardiac Catheterization Laboratory and Vascular Medicine

Contributors
VCU School of Medicine VA Boston Healthcare System
Director, Pauley Heart Center West Roxbury, Massachusetts
Virginia Commonwealth University Health Physician, Cardiovascular Division
Richmond,Virginia Brigham and Women’s Hospital
Chapter 98. Tumors Affecting the Cardiovascular System Associate Professor in Medicine
Harvard Medical School
Silvio E. Inzucchi, MD Adjunct Associate Professor in Medicine
Professor, Internal Medicine (Endocrinology) Boston University Medical School
Yale University School of Medicine Boston, Massachusetts
Clinical Chief, Endocrinology Chapter 44. Treatment of Noncoronary Obstructive Vascular Disease
Director,Yale Diabetes Center
Yale-­New Haven Hospital Allan L. Klein, MD, FRCP(C)
New Haven, Connecticut Professor of Medicine
Chapter 31. Diabetes and the Cardiovascular System Cleveland Clinic Lerner College of Medicine of Case Western Reserve
University
Francine L. Jacobson, MD, MPH Director, Center for the Diagnosis and Treatment of Pericardial
Thoracic Radiologist Diseases
Brigham and Women’s Hospital Department of Cardiovascular Medicine
Harvard Medical School Heart,Vascular and Thoracic Institute
Boston, Massachusetts Cleveland Clinic
Chapter 17. Chest Radiography in Cardiovascular Disease Cleveland, Ohio
Chapter 86. Pericardial Diseases
James L. Januzzi Jr., MD
Physician Robert A. Kloner, MD, PhD
Cardiology Division Professor of Medicine (Clinical Scholar)
Massachusetts General Hospital Cardiovascular Division
Hutter Family Professor of Medicine Keck School of Medicine of University of Southern California
Harvard Medical School Los Angeles, California;
Boston, Massachusetts Chief Science Officer
Chapter 48. Approach to the Patient with Heart Failure Scientific Director of Cardiovascular Research Institute
Huntington Medical Research Institutes
Karen E. Joynt Maddox, MD, MPH Pasadena, California
Associate Professor of Medicine Chapter 84. Cardiomyopathies Induced by Drugs or Toxins
Cardiovascular Division
Washington University School of Medicine in St. Louis Kirk U. Knowlton, MD
Co-­Director, Center for Health Economics and Policy Director of Cardiovascular Research
Institute for Public Health at Washington University Intermountain Healthcare Heart Institute
Saint Louis, Missouri Adjunct Professor
Chapter 6. Impact of Health Care Policy on Quality, Outcomes, and Department of Medicine
Equity in Cardiovascular Disease University of Utah
Salt Lake City, Utah;
Jonathan M. Kalman, MBBS, PhD Professor Emeritus of Medicine
Director of Cardiac Electrophysiology University of California, San Diego
Department of Cardiology La Jolla, California
Royal Melbourne Hospital, Melbourne Chapter 55. Myocarditis
Professor of Medicine
University of Melbourne Eric V. Krieger, MD
Melbourne,Victoria, Australia Professor of Medicine
Chapter 65. Supraventricular Tachycardias Division of Cardiology
University of Washington School of Medicine
Suraj Kapa, MD Director, Adult Congenital Heart Service
Assistant Professor of Medicine University of Washington Medical Center
Cardiovascular Diseases Seattle Children’s Hospital
Mayo Clinic College of Medicine and Science Seattle, Washington
Rochester, Minnesota Chapter 82. Congenital Heart Disease in the Adolescent and Adult
Chapter 11. Artificial Intelligence in Cardiovascular Medicine
Harlan M. Krumholz, MD, SM
Morton J. Kern, MD Harold H. Hines, Jr. Professor of Medicine
Professor of Medicine Section of Cardiovascular Medicine
University California, Irvine Department of Medicine
Orange, California; Department of Health Policy and Management
Chief of Medicine and Cardiology School of Public Health
Veterans Administration Long Beach Healthcare System Yale School of Medicine
Long Beach, California Center for Outcomes Research and Evaluation
Chapter 22. Invasive Hemodynamic Diagnosis of Cardiac Disease Yale New Haven Hospital
New Haven, Connecticut
Chapter 5. Clinical Decision-­Making in Cardiology
 xii
Dharam J. Kumbhani, MD, SM Martin B. Leon, MD
Associate Professor of Medicine The Mallah Family Professor of Cardiology
Section Chief, Interventional Cardiology Director, Center for Interventional Vascular Therapy
CONTRIBUTORS

Department of Internal Medicine Columbia University Irving Medical Center

University of Texas Southwestern Medical Center NY Presbyterian Hospital
Dallas, Texas Founder and Chairman Emeritus
Chapter 41. Percutaneous Coronary Intervention Cardiovascular Research Foundation
New York, New York
Raymond Y. Kwong, MD, MPH Chapter 74. Transcatheter Aortic Valve Replacement
Professor of Medicine
Harvard Medical School Martin M. LeWinter, MD
Director of Cardiac Magnetic Resonance Imaging Professor Emeritus of Medicine and Molecular Physiology and
Cardiovascular Division Biophysics
Brigham and Women’s Hospital Larner College of Medicine at the University of Vermont
Boston, Massachusetts Attending Cardiologist
Chapter 19. Cardiovascular Magnetic Resonance Imaging University of Vermont Medical Center
Burlington,Vermont
Bonnie Ky, MD, MSCE Chapter 86. Pericardial Diseases
Associate Professor of Medicine and Epidemiology
Division of Cardiovascular Medicine Peter Libby, MD
Senior Scholar Mallinckrodt Professor of Medicine
Department of Biostatistics, Epidemiology and Informatics Harvard Medical School
University of Pennsylvania School of Medicine Brigham and Women’s Hospital
Philadelphia, Pennsylvania Boston, Massachusetts
Chapter 56. Cardio-­Oncology: Managing Cardiotoxic Effects of Cancer Chapter 10. Biomarkers and Use in Precision Medicine
Therapies Chapter 24. The Vascular Biology of Atherosclerosis
Chapter 25. Primary Prevention of Cardiovascular Disease
Carolyn S.P. Lam, MBBS, PhD, MRCP, MS Chapter 27. Lipoprotein Disorders and Cardiovascular Disease
Professor Chapter 37. ST-­Elevation Myocardial Infarction: Pathophysiology and
Cardiovascular Academic Clinical Program Clinical Evolution
Duke–National University of Singapore
Senior Consultant Cardiologist JoAnn Lindenfeld, MD
National Heart Centre Singapore Professor of Medicine
Singapore Samuel S Riven MD Directorship in Cardiology
Chapter 51. Heart Failure with Preserved and Mildly Reduced Ejection Vanderbilt University Medical Center
Fraction Nashville, Tennessee
Chapter 58. Devices for Monitoring and Managing Heart Failure
Eric Larose, DVM, MD, FRCPC
Professor and Head of Cardiology Division Brian R. Lindman, MD, MSc
Department of Medicine Associate Professor of Medicine
Chair of Research & Innovation in Cardiovascular Imaging Medical Director, Structural Heart and Valve Center
Université Laval Cardiovascular Division
Cardiologist, Institut universitaire de cardiologie et de pneumologie Vanderbilt University Medical Center
de Québec – Université Laval Nashville, Tennessee
Quebec City, Quebec, Canada Chapter 72. Aortic Valve Stenosis
Chapter 30. Obesity: Medical and Surgical Management
Michael J. Mack, MD
John M. Lasala, MD, PhD Chair, Cardiovascular Service Line
Professor of Medicine Baylor Scott & White Health
Director, Structural Heart Disease Program President, Baylor Scott & White Research Institute
Cardiology Division Dallas, Texas
Washington University School of Medicine in St. Louis Chapter 74. Transcatheter Aortic Valve Replacement
Saint Louis, Missouri
Chapter 83. Catheter-­Based Treatment of Congenital Heart Disease in Mohammad Madjid, MD, MS
Adults Associate Professor of Medicine
McGovern Medical School
Daniel J. Lenihan, MD University of Texas Health Science Center at Houston
President, International Cardio-Oncology Society Interventional Cardiologist
Professor of Medicine Heart and Vascular Institute
Director, Cardio-­Oncology Center of Excellence Memorial Hermann Hospital
Cardiovascular Division Houston, Texas
Washington University School of Medicine in St. Louis Chapter 94. Endemic and Pandemic Viral Illnesses and Cardiovascular
Saint Louis, Missouri Disease: Influenza and COVID-­19
Chapter 98. Tumors Affecting the Cardiovascular System
Douglas L. Mann, MD
Eric J. Lenze, MD Lewin Distinguished Professor of Cardiovascular Disease
Professor of Psychiatry Washington University School of Medicine
Washington University School of Medicine in St. Louis Saint Louis, Missouri
Saint Louis, Missouri Chapter 47. Pathophysiology of Heart Failure
Chapter 99. Psychiatric and Psychosocial Aspects of Cardiovascular Chapter 48. Approach to the Patient With Heart Failure
Disease Chapter 50. Management of Heart Failure Patients with Reduced
Ejection Fraction
 xiii
Bradley A. Maron, MD Roxana Mehran, MD
Associate Professor of Medicine Professor of Medicine (Cardiology)
Division of Cardiovascular Medicine Director of Interventional Cardiovascular Research and Clinical Trials

Contributors
Brigham and Women’s Hospital Zena and Michael A. Wiener Cardiovascular Institute
Harvard Medical School Icahn School of Medicine at Mount Sinai
Department of Cardiology New York, New York
Boston VA Healthcare System Chapter 21. Coronary Angiography and Intravascular Imaging
Boston, Massachusetts
Chapter 88. Pulmonary Hypertension John M. Miller, MD
Professor of Medicine
Nikolaus Marx, MD Indiana University School of Medicine
Professor of Medicine / Cardiology Director, Cardiac Electrophysiology Services
Head of the Department of Internal Medicine I Indiana University Health
University Hospital Aachen Indianapolis, Indiana
Aachen, Germany Chapter 64. Therapy for Cardiac Arrhythmias
Chapter 31. Diabetes and the Cardiovascular System
David M. Mirvis, MD
Justin C. Mason, PhD, FRCP Professor Emeritus
Professor of Vascular Rheumatology Preventive Medicine
Vascular Sciences and Rheumatology University of Tennessee College of Medicine
Imperial College London Memphis, Tennessee
London, United Kingdom Chapter 14. Electrocardiography
Chapter 97. Rheumatic Diseases and the Cardiovascular System
Ana Olga Mocumbi, MD, PhD
Mathew S. Maurer, MD Associate Professor
Arnold and Arlene Goldstein Professor of Cardiology Internal Medicine
Professor of Medicine Universidade Eduardo Mondlane
Columbia University College of Physicians and Surgeons Head of Division
Center for Advanced Cardiac Care Non Communicable Diseases
Columbia University Medical Center Instituto Nacional de Saúde
Director, Clinical Cardiovascular Research Laboratory for the Elderly Maputo, Mozambique
New York, New York Chapter 81. Rheumatic Fever
Chapter 53. Cardiac Amyloidosis
Samia Mora, MD
Peter A. McCullough, MD, MPH Associate Professor of Medicine
Consultant Cardiologist Harvard Medical School
Clinical Professor of Medicine Associate Physician
Department of Internal Medicine Brigham and Women’s Hospital
Texas A&M College of Medicine Boston, Massachusetts
Dallas, Texas Chapter 25. Primary Prevention of Cardiovascular Disease
Chapter 101. Interface Between Renal Disease and Cardiovascular Chapter 27. Lipoprotein Disorders and Cardiovascular Disease
Illness
Fred Morady, MD
Darren K. McGuire, MD, MHSc McKay Professor of Cardiovascular Disease
Professor, Internal Medicine Department of Medicine
Division of Cardiology University of Michigan
University of Texas Southwestern Medical Center Ann Arbor, Michigan
Dallas, Texas Chapter 66. Atrial Fibrillation: Clinical Features, Mechanisms, and
Chapter 31. Diabetes and the Cardiovascular System Management

Alanna A. Morris, MD, MSc

John McMurray, OBE BSc (Hons), MB ChB (Hons), MD,
Associate Professor of Medicine
FRCP
Director, Heart Failure Research
Professor of Medical Cardiology
Emory University School of Medicine
Deputy-­Director (Clinical), Institute of Cardiovascular and Medical
Atlanta, Georgia
Sciences
Chapter 93. Heart Disease in Racially and Ethnically Diverse Populations
BHF Cardiovascular Research Centre
University of Glasgow David A. Morrow, MD, MPH
Honorary Consultant Cardiologist Professor of Medicine
Queen Elizabeth University Hospital Harvard Medical School
Glasgow, Scotland, United Kingdom Boston, Massachusetts
Chapter 4. Clinical Trials in Cardiovascular Medicine Chapter 37. ST-­Elevation Myocardial Infarction: Pathophysiology and
Clinical Evolution
Elizabeth M. McNally, MD, PhD Chapter 38. ST-­Elevation Myocardial Infarction: Management
Director, Center for Genetic Medicine Chapter 40. Stable Ischemic Heart Disease
Northwestern University Feinberg School of Medicine
Chicago, Illinois Dariush Mozaffarian, MD, DrPH
Chapter 100. Neuromuscular Disorders and Cardiovascular Disease Dean, Friedman School of Nutrition Science & Policy
Jean Mayer Professor of Nutrition
Tufts University School of Medicine
Boston, Massachusetts
Chapter 29. Nutrition and Cardiovascular and Metabolic Diseases
 xiv
Kiran Musunuru, MD, PhD, MPH, ML Jeffrey E. Olgin, MD
Professor of Cardiovascular Medicine and Genetics Gallo-­Chatterjee Distinguished Professor
Cardiovascular Institute Chief, Division of Cardiology
CONTRIBUTORS

University of Pennsylvania Perelman School of Medicine University of California, San Francisco

Philadelphia, Pennsylvania San Francisco, California
Chapter 7. Applications of Genetics to Cardiovascular Medicine Chapter 68. Bradyarrhythmias and Atrioventricular Block

Robert J. Myerburg, MD Steve R. Ommen, MD

Professor of Medicine and Physiology Division of Cardiovascular Diseases
Department of Medicine Mayo Clinic College of Medicine and Science
University of Miami Miller School of Medicine Rochester, Minnesota
Miami, Florida Chapter 54. Hypertrophic Cardiomyopathy
Chapter 70. Cardiac Arrest and Sudden Cardiac Death
Catherine M. Otto, MD
Pradeep Natarajan, MD, MMSc Professor of Medicine
Director of Preventive Cardiology J. Ward Kennedy-­Hamilton Endowed Chair in Cardiology
Massachusetts General Hospital Division of Cardiology
Assistant Professor of Medicine University of Washington School of Medicine
Harvard Medical School Director, Heart Valve Clinic
Boston, Massachusetts; Associate Director, Echocardiography
Associate Member University of Washington Medical Center
Program in Medical and Population Genetics Seattle, Washington
Broad Institute of Harvard and MIT Chapter 72. Aortic Valve Stenosis
Cambridge, Massachusetts
Chapter 7. Applications of Genetics to Cardiovascular Medicine Francis D. Pagani, MD, PhD
Otto Gago MD Endowed Professor of Cardiac Surgery
Stanley Nattel, MDCM Department of Cardiac Surgery
Professor University of Michigan
Department of Medicine Ann Arbor, Michigan
Paul-­David Chair in Cardiovascular Electrophysiology Chapter 59. Mechanical Circulatory Support
Montreal Heart Institute
University of Montreal Kristen K. Patton, MD
Montreal, Quebec, Canada Professor of Medicine
Chapter 62. Mechanisms of Cardiac Arrhythmias Division of Cardiology
University of Washington
Rick A. Nishimura, MD Seattle, Washington
Judd and Mary Morris Leighton Professor of Cardiovascular Diseases Chapter 68. Bradyarrhythmias and Atrioventricular Block
Department of Cardiovascular Medicine
Mayo Clinic College of Medicine and Science Patricia A. Pellikka, MD
Rochester, Minnesota The Betty Knight Scripps Professor of Medicine
Chapter 73. Aortic Regurgitation Mayo Clinic College of Medicine and Science
Vice Chair, Academic Affairs and Faculty Development
Vuyisile T. Nkomo, MD, MPH Consultant, Department of Cardiovascular Medicine
Cardiologist Director, Ultrasound Research Center
Professor of Medicine Mayo Clinic
Department of Cardiovascular Medicine Rochester, Minnesota
Mayo Clinic College of Medicine and Science Chapter 77. Tricuspid, Pulmonic, and Multivalvular Disease
Rochester, Minnesota
Chapter 77. Tricuspid, Pulmonic, and Multivalvular Disease Gregory Piazza, MD, MS
Staff Physician
Peter Noseworthy, MD Cardiovascular Division
Consultant Department of Medicine
Cardiovascular Diseases Section Head,Vascular Medicine
Mayo Clinic College of Medicine and Science Brigham and Women’s Hospital
Rochester, Minnesota Boston, Massachusetts
Chapter 11. Artificial Intelligence in Cardiovascular Medicine Chapter 87. Pulmonary Embolism and Deep Vein Thrombosis

Patrick T. O’Gara, MD Philippe Pibarot, DVM, PhD

Professor of Medicine Professor
Harvard Medical School Department of Medicine
Senior Physician Québec Heart & Lung Institute
Cardiovascular Division Université Laval
Brigham and Women’s Hospital Québec City, Quebec, Canada
Boston, Massachusetts Chapter 79. Prosthetic Heart Valves
Chapter 13. History and Physical Examination: An Evidence-­Based
Approach
Chapter 79. Prosthetic Heart Valves
 xv
Paul Poirier, MD, PhD, FRCPC Paul M Ridker, MD, MPH
Chief, Cardiac Prevention/Rehabilitation Eugene Braunwald Professor of Medicine
Institut universitaire de cardiologie et de pneumologie de Québec – Harvard Medical School

Contributors
Université Laval Director, Center for Cardiovascular Disease Prevention
Professor Brigham and Women’s Hospital
Faculty of Pharmacy Boston, Massachusetts
Université Laval Chapter 10. Biomarkers and Use in Precision Medicine
Quebec City, Quebec, Canada Chapter 25. Primary Prevention of Cardiovascular Disease
Chapter 30. Obesity: Medical and Surgical Management
Dan M. Roden, MD
Dorairaj Prabhakaran, MD, DM (Cardiology), MSc, FRCP Professor of Medicine, Pharmacology, and Biomedical Informatics
Vice President, Research and Policy Senior Vice President for Personalized Medicine
Public Health Foundation of India Vanderbilt University School of Medicine
Executive Director, Centre for Chronic Disease Control Nashville, Tennessee
Gurgaon, Haryana, India; Chapter 9. Principles of Drug Therapeutics, Pharmacogenomics, and
Professor Biologics
Department of Epidemiology
London School of Hygiene and Tropical Medicine Frederick L. Ruberg, MD
London, United Kingdom Associate Professor of Medicine
Chapter 2. Global Burden of Cardiovascular Disease Section of Cardiovascular Medicine
Department of Medicine and Amyloidosis Center
Sanjay Rajagopalan, MD Boston Medical Center
Professor of Medicine Boston University School of Medicine
Director, Case Cardiovascular Research Institute Boston, Massachusetts
Case Western Reserve University Chapter 53. Cardiac Amyloidosis
Chief, Division of Cardiovascular Medicine
Harrington Heart and Vascular Institute Marc S. Sabatine, MD, MPH
University Hospitals Cleveland Medical Center Chair, TIMI Study Group
Cleveland, Ohio Lewis Dexter MD Distinguished Chair in Cardiovascular Medicine
Chapter 3. Impact of the Environment on Cardiovascular Health Brigham and Women’s Hospital
Professor of Medicine
Michael J. Reardon, MD Harvard Medical School
Professor of Cardiothoracic Surgery Boston, Massachusetts
Department of Cardiovascular Surgery Chapter 35. Approach to the Patient with Chest Pain
Houston Methodist Hospital
Houston, Texas Prashanthan Sanders, MBBS, PhD
Chapter 78. Transcatheter Therapies for Mitral and Tricuspid Valvular Director, Centre for Heart Rhythm Disorders
Heart Disease School of Medicine
Chapter 98. Tumors Affecting the Cardiovascular System University of Adelaide
Director, Cardiac Electrophysiology and Pacing
Susan Redline, MD, MPH Department of Cardiology
Peter C. Farrell Professor of Sleep Medicine Royal Adelaide Hospital
Harvard Medical School Director, Heart Rhythm Group
Senior Physician Heart Health
Division of Sleep and Circadian Disorders South Australian Health and Medical Research Institute
Departments of Medicine and Neurology Adelaide, Australia
Brigham and Women’s Hospital Chapter 65. Supraventricular Tachycardias
Boston, Massachusetts
Chapter 89. Sleep-­Disordered Breathing and Cardiac Disease Marc Schermerhorn, MD
George H. A. Clowes Jr. Professor of Surgery
Shereif Rezkalla, MD Harvard Medical School
Adjunct Professor of Medicine Chief, Division of Vascular and Endovascular Surgery
University of Wisconsin Beth Israel Deaconess Medical Center
Madison, Wisconsin; Boston, Massachusetts
Department of Cardiology and Cardiovascular Research Chapter 42. Diseases of the Aorta
Marshfield Clinic Health System
Marshfield, Wisconsin Benjamin M. Scirica, MD, MPH
Chapter 84. Cardiomyopathies Induced by Drugs or Toxins Associate Professor of Medicine
Harvard Medical School
Michael W. Rich, MD Senior Investigator, TIMI Study Group
Professor of Medicine Associate Physician, Cardiovascular Division
Division of Cardiology Brigham and Women’s Hospital
Washington University School of Medicine in St. Louis Boston, Massachusetts
Saint Louis, Missouri Chapter 37. ST-­Elevation Myocardial Infarction: Pathophysiology and
Chapter 90. Cardiovascular Disease in Older Adults Clinical Evolution
Chapter 99. Psychiatric and Psychosocial Aspects of Cardiovascular
Disease
 xvi
Arnold H. Seto, MD, MPA Randall C. Starling, MD, MPH
Associate Clinical Professor Professor of Medicine
University of California, Irvine Kaufman Center for Heart Failure
CONTRIBUTORS

Cardiologist Heart, Thoracic and Vascular Institute

Veterans Administration Long Beach Healthcare System Cleveland Clinic
Long Beach, California Cleveland, Ohio
Chapter 22. Invasive Hemodynamic Diagnosis of Cardiac Disease Chapter 60. Cardiac Transplantation

Sanjiv J. Shah, MD William G. Stevenson, MD

Neil Stone MD Professor of Medicine Professor of Medicine
Division of Cardiology Division of Cardiology
Northwestern University Feinberg School of Medicine Vanderbilt University Medical Center
Chicago, Illinois Nashville, Tennessee
Chapter 51. Heart Failure with Preserved and Mildly Reduced Ejection Chapter 67.Ventricular Arrhythmias
Fraction
John R. Teerlink, MD, FRCP(UK)
Shabana Shahanavaz, MBBS Professor of Medicine
Associate Professor of Pediatrics University of California School of Medicine, San Francisco,
Director, Cardiac Catheterization Laboratory Director, Heart Failure
The Heart Institute Director, Echocardiography
Cincinnati Children’s Hospital Section of Cardiology
Cincinnati, Ohio San Francisco Veteran Affairs Medical Center
Chapter 83. Catheter-­Based Treatment of Congenital Heart Disease in San Francisco, California
Adults Chapter 49. Diagnosis and Management of Acute Heart Failure

Kalyanam Shivkumar, MD, PhD David J. Tester, BS

Professor of Medicine (Cardiology), Radiology, and Bioengineering Associate Professor of Medicine
Director, UCLA Cardiac Arrhythmia Center and Electrophysiology Mayo Clinic College of Medicine and Science
Programs Department of Molecular Pharmacology & Experimental
Director, Adult Cardiac Catheterization Laboratories Therapeutics (Windland Smith Rice Sudden Death Genomics
Ronald Reagan UCLA Medical Center Laboratory)
Los Angeles, California Mayo Clinic
Chapter 102. Cardiovascular Manifestations of Autonomic Disorders Rochester, Minnesota
Chapter 63. Genetics of Cardiac Arrhythmias
Candice K. Silversides, SM, MD
Professor of Medicine Randal Jay Thomas, MD, MS
University of Toronto Pregnancy and Heart Disease Program Professor of Medicine
Toronto, Ontario, Canada Mayo Clinic Alix School of Medicine
Chapter 92. Pregnancy and Heart Disease Medical Director, Cardiac Rehabilitation Program
Division of Preventive Cardiology
Samuel C. Siu, MD, SM, MBA Department of Cardiovascular Medicine
Professor of Medicine Mayo Clinic
Division of Cardiology Rochester, Minnesota
Schulich School of Medicine and Dentistry Chapter 33. Comprehensive Cardiac Rehabilitation
Western University
London, Ontario, Canada Paul D. Thompson, MD
Chapter 92. Pregnancy and Heart Disease Chief of Cardiology, Emeritus
Hartford Hospital
Scott D. Solomon, MD Hartford, Connecticut
The Edward D. Frohlich Distinguished Chair Chapter 32. Exercise and Sports Cardiology
Professor of Medicine
Harvard Medical School Gordon F. Tomaselli, MD
Senior Physician Professor of Medicine (Cardiology)
Brigham and Women’s Hospital The Marilyn and Stanley M. Katz Dean
Boston, Massachusetts Albert Einstein College of Medicine
Chapter 4. Clinical Trials in Cardiovascular Medicine Executive Vice President and Chief Academic Officer
Chapter 16. Echocardiography Montefiore Medicine
Chapter 51. Heart Failure with Preserved and Mildly Reduced Ejection Bronx, New York
Fraction Chapter 61. Approach to the Patient with Cardiac Arrhythmias
Chapter 94. Endemic and Pandemic Viral Illnesses and Cardiovascular Chapter 62. Mechanisms of Cardiac Arrhythmias
Disease: Influenza and COVID-­19 Chapter 66. Atrial Fibrillation: Clinical Features, Mechanisms, and
Management
Matthew J. Sorrentino, MD Chapter 100. Neuromuscular Disorders and Cardiovascular Disease
Professor of Medicine
Section of Cardiology
UChicago Medicine
Chicago, Illinois
Chapter 26. Systemic Hypertension: Mechanisms, Diagnosis, and
Treatment
 xvii
Mintu P. Turakhia, MD, MAS Nanette Kass Wenger, MD
Associate Professor of Medicine (Cardiovascular Medicine) Professor of Medicine (Cardiology) Emeritus
Executive Director, Center for Digital Health Emory University School of Medicine

Contributors
Stanford University Consultant, Emory Heart and Vascular Center
Stanford, California; Atlanta, Georgia
Chief, Cardiac Electrophysiology Chapter 90. Cardiovascular Disease in Older Adults
VA Palo Alto Health Care System
Palo Alto, California Walter R. Wilson, MD
Chapter 12. Wearable Devices in Cardiovascular Medicine Professor of Medicine
Mayo Clinic College of Medicine and Science
Anne Marie Valente, MD Rochester, Minnesota
Associate Professor Chapter 80. Infectious Endocarditis and Infections of Indwelling Devices
Pediatrics and Internal Medicine
Harvard Medical School Justina C. Wu, MD, PhD
Director, Boston Adult Congenital Heart Program Assistant Professor of Medicine
Children’s Hospital Boston Harvard Medical School
Brigham and Women’s Hospital Director of Echocardiography
Boston, Massachusetts Brigham and Women’s Hospital
Chapter 82. Congenital Heart Disease in the Adolescent and Adult Boston, Massachusetts
Chapter 16. Echocardiography
Orly Vardeny, PharmD, MS
Associate Professor of Medicine Katja Zeppenfeld, MD, PhD
Center for Care Delivery and Outcomes Research Professor of Cardiology
Minneapolis VA Health Care System and University of Minnesota Leiden University Medical Centre
Minneapolis, Minnesota Leiden, The Netherlands
Chapter 94. Endemic and Pandemic Viral Illnesses and Cardiovascular Chapter 67.Ventricular Arrhythmias
Disease: Influenza and COVID-­19
Michael R. Zile, MD
David D. Waters, MD Charles Ezra Daniels Professor of Medicine
Professor Emeritus Division of Cardiology
Department of Medicine Medical University of South Carolina
University of California, San Francisco Charleston, South Carolina
San Francisco, California Chapter 58. Devices for Monitoring and Managing Heart Failure
Chapter 85. Cardiovascular Abnormalities in HIV-­Infected Individuals

Jeffrey I. Weitz, MD, FRCP(C)

Professor of Medicine and Biochemistry
McMaster University
Executive Director
Thrombosis and Atherosclerosis Research Institute
Hamilton, Ontario, Canada
Chapter 95. Hemostasis, Thrombosis, Fibrinolysis, and Cardiovascular
Disease
 Preface

The knowledge relevant to the practice of cardiology continues of cardio-­oncology has expanded coverage in the 12th edition, with
to grow by leaps and bounds. Scientific and clinical advances have two chapters devoted to different aspects of this topic. Expanded cov-
occurred at such a rapid pace that clinicians often suffer information erage of valvular heart disease includes a new chapter on interven-
overload. Communications about advances in cardiovascular med- tions for mitral and tricuspid valvulopathies, which complements an
icine inundate practitioners on a seemingly minute-­to-­minute basis updated chapter on percutaneous interventions for the aortic valve.
through journals, mailings, text messages, newsletters, social media, These additions acknowledge the growing role of structural heart dis-
webinars, advertisements, and other electronic and print media. How ease interventions in tackling these conditions.
can a practitioner or trainee sift through this cacophony to discern The period of planning and preparation of this 12th edition coin-
reliable, durable, and important information critical for practice? cided with the pandemic caused by SARS-­CoV-­2. We would be remiss
This textbook of cardiovascular medicine offers a solution to this not to include an expanded discussion of viral heart diseases in a
quandary. The 12th edition of Braunwald’s Heart Disease provides a new chapter, as our specialty needs to prepare for likely future viral
comprehensive, carefully curated, balanced, and unbiased distilla- pandemics, as well as deal with the potentially long-­term cardiovas-
tion not only of the tried and true, but especially the latest advances cular consequences of COVID-­19. Of course, each and every chapter
in our field. This volume should serve the novice and experienced in the book has undergone extensive updating and revision to reflect
practitioner alike. Trainees and those preparing for certification or advances since the last edition. To this end, a number of chapters are
recertification examinations can use this text for an overall review of completely written de novo by new authors. Indeed, the 12th edition
contemporary cardiovascular medicine. Practitioners confronting a boasts almost 80 new authors, reflecting our commitment to continu-
particular clinical problem can consult the appropriate section of the ous refreshment and review of the content.
book on an as-­needed basis to answer the clinical question at hand Our field can take considerable pride in the rapid advances in both
to aid on-­the-­spot clinical decision making. While not a basic science basic and clinical investigation that this book highlights.Yet, we face a
textbook, this volume builds on Dr. Braunwald’s founding vision and disconnect between these advances and their application to practice.
reviews fundamental pathophysiologic mechanisms to furnish a foun- To this end we include a new chapter, “Impact of Health Care Policy
dation for informed practice where appropriate. on Quality and Outcomes of Cardiovascular Disease,” that focuses on
Cardiovascular medicine has expanded so enormously that few if practical societal approaches to ensure that our patients can benefit
any individuals can maintain mastery of the entire scope of practice. from the clinical and basic scientific advances in our field. Moreover,
Sub-­specialization and even sub-­ sub-­
specialization have increased. closing gaps in offering progress in cardiovascular medicine to racially,
Yet, each of us encounters issues within these super-­specialized areas ethnically, geographically diverse, or underserved populations presents
when we care for and counsel our own patients.The palette of patients’ a global challenge. We focus on cardiovascular conditions in partic-
problems often overlaps the fine divisions our specialty has developed. ular segments of the population—women, people with diabetes, and
This book aims to provide a ready reference so that we can update our those with HIV/AIDS—that may require specialized approaches; each
knowledge with recent and authoritative information in areas of car- of these and others have been accorded a separate chapter.The global
diovascular medicine afield from our own primary areas of expertise. pandemic has placed disparities and inequities in health care in stark
The online content of this textbook contains additional new figures relief, locally and globally. To address this problem, a new chapter,
and tables, as well as over 200 videos that add to the printed version. “Heart Disease in Racially and Ethnically Diverse Populations,” deals
Furthermore, through twice monthly online updates by Dr. Braunwald with cardiovascular conditions that confront disadvantaged segments
and through Elsevier’s ClinicalKey, this textbook undergoes constant of our population.
updating. Indeed, with the addition of companion volumes, the Heart Finally, the Editors were fortunate to enlist Professor Eugene Braun-
Disease family has become a living learning system and comprehen- wald, the founder of this textbook, to contribute an opening chapter,
sive reference. “Cardiovascular Disease: Past, Present, and Future,” which shares his
As necessitated by evolution and progress in cardiovascular medi- vision from his uniquely broad perspective. We have striven to uphold
cine, in planning this 12th edition the editors have carefully reviewed the standards that he set for this textbook from the first five editions
the content to reflect current knowledge. This edition has 14 totally that he edited solo. We have aimed to emulate his editorial prowess
new chapters. For example, we have added chapters on artificial intel- and example of refreshing every page of this textbook in each edition
ligence in cardiology and on the use of wearables in cardiovascular to maximize its utility for all who care for patients with or at risk of
medicine. These two topics will doubtless change our practices pro- developing cardiovascular disease.
foundly. We expect that future editions will continue to build on these
and other novel areas that will provide us with innovative tools to con- Peter Libby
front our patients’ problems. Robert O. Bonow
We have added a new chapter,“Impact of the Environment on Cardio- Douglas L. Mann
vascular Health,” as we recognize increasingly the clinical importance Gordon F. Tomaselli
of this critical interface. Another new chapter, “Cardiovascular Disease Deepak L. Bhatt
Risk of Nicotine and Tobacco Products,” highlights the concerning Scott D. Solomon
increase in smokeless tobacco use among youth. The burgeoning field

xviii
 Preface to the First Edition

Cardiovascular disease is the greatest scourge affecting the industri- disease by medical and surgical means. Indeed, in the United States, a
alized nations. As with previous scourges — bubonic plague, yellow steady reduction in mortality from cardiovascular disease during the
fever, and small pox — cardiovascular disease not only strikes down a past decade suggests that the effective application of this increased
significant fraction of the population without warning but also causes knowledge is beginning to prolong human life span, the most valued
prolonged suffering and disability in an even larger number. In the resource on earth.
United States alone, despite recent encouraging declines, cardiovascu- To provide a comprehensive, authoritative text in a field that has
lar disease is still responsible for almost 1 million fatalities each year become as broad and deep as cardiovascular medicine, I enlisted
and more than half of all deaths; almost 5 million persons afflicted with the aid of a number of able colleagues. However, I hoped that my
cardiovascular disease are hospitalized each year. The cost of these personal involvement in the writing of about half of the book would
diseases in terms of human suffering and material resources is almost make it possible to minimize the fragmentation, gaps, inconsisten-
incalculable. cies, organizational difficulties, and impersonal tone that sometimes
Fortunately, research focusing on the prevention, causes, diagno- plague multiauthored texts. Although Heart Disease: A Textbook of
sis, and treatment of heart disease is moving ahead rapidly. Since Cardiovascular Medicine is primarily a clinical treatise and not a
the early part of the twentieth century, clinical cardiology has had textbook of fundamental cardiovascular science, an effort has been
a particularly strong foundation in the basic sciences of physiol- made to explain, in some detail, the scientific bases of cardiovascular
ogy and pharmacology. More recently, the disciplines of molecular diseases.
biology, genetics, developmental biology, biophysics, biochemistry, To the extent that this book proves useful to those who wish to
experimental pathology and bioengineering have also begun to broaden their knowledge of cardiovascular medicine and thereby aids
provide critically important information about cardiac function in the care of patients afflicted with heart disease, credit must be given
and malfunction. to the many talented and dedicated persons involved in its prepara-
In the past 25 years, in particular, we have witnessed an explosive tion. I offer my deepest appreciation to my fellow contributors for their
expansion of our understanding of the structure and function of the professional expertise, knowledge, and devoted scholarship, which has
cardiovascular system—both normal and abnormal—and of our abil- so enriched this book. I am deeply indebted to them for their coopera-
ity to evaluate these parameters in the living patient, sometimes by tion and willingness to deal with a demanding editor.
means of techniques that require penetration of the skin but also with
increasing accuracy, by noninvasive methods. Simultaneously, remark- Eugene Braunwald
able progress has been made in preventing and treating cardiovascular 1980

xix
 Acknowledgments

The conception and creation of this textbook of over 100 chapters and almost 2000 pages required
the expertise, assistance, and skills of many dedicated individuals. We thank the contributors who have
authored the chapters that comprise this textbook. We recognize the leadership of Ms. Dolores Meloni,
executive content strategist at Elsevier, for her guidance and assistance at all stages of the planning and
preparation of this volume. Ms. Anne Snyder, senior content development specialist, provided invaluable
and detailed assistance on a daily basis. The editors owe her a great debt of gratitude. Mr. John Casey,
senior project manager, cheerfully worked with the authors and the editors in executing the composition
and proofing of this tome and accommodating last-­minute additions and alterations to make the print
edition as accurate and up to date as possible. The editors would not have been able to produce this
book and ensure its quality without all of these contributions.
We also thank colleagues the world over who provided suggestions on how to improve Braunwald’s
Heart Disease and identified points that could use clarification. We welcome such input that will enable
us to improve this edition in subsequent printings and plan future editions to meet our readers’ needs
even better.

xx
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now to explore a diverse
collection of ebooks available
in formats like PDF, EPUB, and
MOBI, compatible with all
devices. Don’t miss the chance
to enjoy exciting offers and
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point from which it could be sent to destination.
Mr. Small, manager of the Highland Hotel, ten miles away, kept
on his farm there eight strong horses which had been accustomed to
work on the beaches and sands. The contract provided that he
should use whatever lumber was needed for the construction of a
suitable shed or stable in which his horses could be kept near the
wreck. The horses were, with grain and hay, removed to the beach
and three men left there to watch and care for them. This stable was
necessary because of the distance from the hotel which barred going
back and forth every day.
Rapid progress was made in recovering the cargo. Then the
stripping from the vessel of all material of any value began. Rigging,
sails, anchors and material of various kinds were brought ashore at
every favorable opportunity.
 WHAT THE SEAS DO AT RACE POINT, CAPE COD

In the meantime the vessel was being pounded to pieces. The

next storm tore away the mainmast and the hull became more and
more battered until finally the foremast toppled into the sea and only
the smashed up hulk lay scattered on the storm-swept shore.
Mr. Small’s contract also provided that he should have the
lumber with which the temporary stable was built; then it was carted
to the Highlands in North Truro and went into the construction of a
fine cottage which bears the name of “Mayflower.”
This was begun in January, 1927, and completed in June.
Fortunately no lives were lost in this disaster, but it caused many
hours of suffering for those men who comprised the crew of the
wreck.
 WAS IT MURDER?
Tragedy stalks abroad on the great sea and land always, not only
on the wide stretches of the great ocean but all along the bordering
coasts and inlets.
A big ship sails away into the mists and fogs of the pulsing deep
and never comes back, a fisherman pulls out in his little boat to
draw his nets and drops as completely out of sight as though he had
never been.
This little book tells of shipwrecks and disasters and in the same
line we may note the passing of human life on the sea wherever it
may be.
Mystery goes hand and hand with passing events on the ever
restless waters.
The following little story is but one of many like it.
Mr. Eugene W. Haines was a much respected, active citizen of
the town of Sandwich, Cape Cod. He had held many important
offices in the town and was a member of the Board of Selectmen
and engaged in several lines of business.
During the summer season he set a string of lobster pots in the
bay. He owned a small power boat which he used in going to and
from his lobster traps.
On the 19th of November, 1927, an hour or more before
daylight, as was his custom, he sailed away in his boat to draw his
lobster pots, and from that hour he was never seen again by those
on shore who awaited his return.
For many days the waters of the bay were unruffled by any
strong wind and the waters were smooth. When he did not return by
mid-afternoon searching parties started out from many points and
men patrolled the coast beaches from Provincetown to Plymouth,
and boats dragged the nearby waters of the bay for many hours.
Every foot of the coast beaches were covered but not a single trace
was found of the missing man or his boat.
There was but one possible clue to this strange situation. A gang
of rum runners had been operating in and about the bay for some
time and some of them had been caught, and Mr. Haines had been
instrumental in bringing some of them to trial and punishment.
The theory has been advanced and quite generally accepted that
these law-breakers, holding a feeling of enmity against Haines,
watched his daily going out in his boat until there came a time in
which to get him.
It is generally believed that they overtook his boat, made him a
prisoner, and took the boat in tow and then proceeded out in the sea
miles from land, where they murdered their victim, weighted his
body and dropped it to the bottom of the sea, then weighted and
sank the boat and left no trace.
During the last week in November a man patrolling the shore
came upon two oars and a few things such as are carried in fishing
boats which were identified as having belonged to Haines’ boat. But
this does not clear up the mystery of the lost fishing boat, and the
how and where of the tragedy will ever remain, like many others,
unsolved.
On the 20th of December portions of Haines power dory drifted
ashore at Sandwich.
 STRANDING OF THE BARGES
On the afternoon of April 3rd, 1915, the steam tug Mars,
belonging to the Reading Railroad Company, left the harbor of
Bangor, Maine, with three light barges bound to Philadelphia. The
barges were the Tunnel Ridge, Coleraine and Manheim.
 DECK HOUSE OF BARGE COLERAINE
Wrecked on Cape Cod. Now Highland Golf Club House

Soon after clearing the outer roadstead at Bangor, the weather,

which had been fine, became overcast and threatening, but the
wind, though strong, was fair, so that sail was made on the barges
and the tow made good progress. The captain of the tug hoped to
pick up the Highland Light in a short time, but on the morning of the
4th snow began falling, the wind swung out to the northeast and
soon increased to a gale, and the tow was soon wallowing in a
rapidly rising sea. At six o’clock on the afternoon of the 4th suddenly,
right under the bow of the tug, came great rolling waves, breaking
white capped over the sand bars, only a hundred yards from the tug.
The captain immediately realized that unless his boat could get away
from this danger the tug would be smashed to pieces on the sands
of the bar. The only safe thing to do was to cut away from the
barges. This was done; then by all the power in the tug’s engines he
was able to pull away, round Race Point and anchor in Provincetown
Harbor. Hardly had this been accomplished when the propeller of the
tug dropped off. Had this happened when the tug was attached to
the barges or was battling the sea outside of Cape Cod, it is quite
probable the tug would have foundered and her entire crew lost.
The barges left to the fury of the storm drove rapidly towards
the sand bars and on towards the beach. In this encounter with the
sea the Tunnel Ridge and the Coleraine were so badly smashed that
they were not worth any attempt to float them, and it was only by
the prompt action of the Highland Coast Guard crew that those on
the barges were brought safely to shore.
Capt. George Israel of the Manheim, a man of many experiences
in shipwrecks, believing he could save his vessel, dropped both
anchors off the bow of the barge. This only checked for a short time
the onward drive of the barge. Capt. Israel had mistaken the force of
the sea on the outside of Cape Cod in a storm, and his barge
dragging her anchors was forced nearer and nearer the shore, until
he and his crew of four men had to be brought ashore in the
breeches buoy by the Coast Guard men.
The fury of the gale and the high and rising tide soon forced the
barges well up on the beach, so that on the following morning one
might walk dry footed entirely around them. The Manheim escaped
serious injury. Then began an effort to float her. Soon it was found
that the action of the sea and tide was building up a great
breakwater of sand around the Tunnel Ridge and Coleraine which
were stranded one on each side of the Manheim. There could be no
hope of floating the latter until these hulks were removed. Kerosene
was liberally poured over them and on a dark night a torch was
applied, and the burning hulls lit up the sea and shore for many
miles around. When it was decided to burn the barges, Capt. Israel
told E. Hayes Small if he would send a gang of men on board and
remove the deckhouses from the Coleraine he could have them; he
did so, and a few days work landed the houses on the sands of the
beach, where they were cut into three pieces. Some planks were laid
on the slope of the 100 feet high cliff, and with four horses the three
parts were skidded to the top of the cliffs; then on trucks the parts
were drawn to a point on the south side of the town road leading to
Highland Light, there put together and converted to a three-room
cottage. Later on, with a small addition on the south side, made the
club house of the Highland House golf links.
Capt. Israel, with two of his men, lived on the Manheim all
winter, and on the 4th day of April, 1916, just a year to a day from
the time the Manheim stranded, she was floated off and entered the
coal transportation business again.
 THE JOHN TRACY MYSTERY
On the 9th day of January, 1927, the big 2000 ton freighter John
Tracy of the M. & J. Tracy Transportation Line, with some 2500 tons
of coal for Boston, steamed out of the harbor of Philadelphia, but
she never reached her destination, and from that day to this no
word has come to land to tell what befell her. Every effort by search
in every port on the coast, by telephone, by wireless, and the hunt
through every possible avenue for information, failed to obtain the
slightest clue to the missing boat. Another tragedy of the sea had
been added to the long and ever increasing list of sea tragedies of
lost ships that have dropped beneath the sea.
Knowing the usual speed with which these ships move along the
coast and knowing the conditions which prevailed, it is estimated
that this ship would have been in the immediate vicinity of Highland
Light on the night of January 11th, when conditions on the sea were
dark and stormy, with a gale-driven fog over all the sea.
In the early morning of the 10th, the three masted schooner
Charles Whittemore, with a high deck load of piling (logs), bound
from Portland to New York, encountered a strong gale and rough sea
when a few miles east of Highland Light and her entire deck load of
these big logs was swept from her decks. It has been quite generally
believed that the Tracy, steaming up the coast in the darkness and
storm, ran directly into this mass of floating logs, and the fury of the
sea drove one of them through the steamer’s side and sent her to
the bottom in a very few minutes.
On the ship were thirty-one officers and men. No man or
message ever came back to tell how, why and where it happened.
No wreckage came to the surface or the shore, but this is readily
explained because of the fact that this was an iron ship, with very
little material that could be washed from her decks, so the ship
carried everything with her when she went to the bottom of the sea.
 WRECK OF THE ROGER DICKY
On the first day of January, 1927, one of those fierce easterly
gales which frequently sweep the North Atlantic coast and the
outside of Cape Cod from Chatham to Boston Light, caught the
fishing schooner Roger Dicky in a dense fog and drove her hard and
fast on the outside beach a short distance beyond the Cahoon’s
Hollow Coast Guard Station, within the boundaries of Wellfleet.

ROGER DICKY
Wrecked on Cape Cod, January 1st, 1927
 She was coming in from the fishing grounds bound to Boston
with 20,000 pounds of cod and haddock. The Coast Guardsmen from
Cahoon’s Hollow Station were promptly on hand and brought the
entire ship’s crew of fifteen men safely to shore.
The Dicky was a staunch craft, only a year old, but the terrific
seas soon made a complete wreck of her. She was a very modern
boat and quite up to date in equipment of electric lights, hot and
cold water, and the most valuable piece of her expensive furnishings
was a $12,000 electric engine.
When it was seen that the vessel must speedily break up,
preparations were made to strip from the hull everything of value
that could be moved.
This craft stranded directly in front of a hundred feet high cliff,
and the nearest place at which teams could approach the wreck was
more than two miles at Pamet River Coast Guard Station.
The rigging and sails were quickly taken off, but the great
problem which confronted them was how to land that engine.
At that time Mr. Hayes Small, of the Highland House Hotel,
owned eight powerful horses, and Capt. Pine, of Boston, who had
been sent down by the owners of the craft to take charge, made a
contract with Mr. Small to truck the engine along the beach up
through the Pamet River valley and on to Provincetown.
By lively work on the part of a gang of men the engine was
removed from the vessel to the waiting trucks and four horses pulled
it quickly up the beach and on to destination.
Three days later the Roger Dicky was only a mass of broken
timbers and twisted chains.
Fortunately no lives were lost in this disaster.
 THE GETTYSBURG TOW
On the 21st day of June, 1927, the ocean-going tug Gettysburg,
of the Reading Coal Company, towing four empty barges from
Portland for Port Reading, Pennsylvania, was proceeding down the
coast outside of Cape Cod. When the tow had reached a point east
of Race Point Light, the wind, which had been strong from the
northwest, began shifting to the northeast and increasing in
violence, but as it was fair and favorable for running down the coast,
the tow kept on instead of pulling up for Provincetown.
Every moment the wind increased in force, and when the tow
was four miles east of Highland Light the wind had increased to a
strong gale and the sea had become very rough. Suddenly at noon
the hawser holding the tug to the first barge snapped and the four
empty barges comprising the tow were adrift in the raging sea.
Then the tug made strenuous efforts to recover the barges, but
the gale and the sea made this impossible.
All the while the storm and the sea were driving the helpless
barges nearer and nearer to the sea-swept sand bars where they
might be torn to pieces if their keels once touched the bottom. The
crews on the barges, realizing that there was no hope of the tug
being able to recover them, dropped all the anchors with which they
were equipped. This held them, but it was by no means certain that
they would be able to do so if the sea and gale further increased.
Capt. Andrews, of the Highland Coast Guard Station, assembled
his entire crew and they took their life-saving apparatus up to a
point directly opposite the Signal Station of the Weather Bureau on
the Highland Cliffs. The tide was running high and sweeping the
entire foot of the cliffs and it might be a question whether it would
be possible to use the gun and shot line from the shore. So Capt.
Andrews placed part of his crew on the cliffs and the others on the
beach, and there from this point they watched the situation through
the night.
Fortunately the gale did not further increase and by mid-
forenoon of the following day the storm had so far moderated that it
became possible for the tug to return to pick up her barges and
proceed to destination.
The moderating of the gale made it possible to avert what might
have been another death-dealing disaster.

CLIFF WHERE THE COAST GUARD WATCHED THE DRIFTING BARGES

 LOSS OF THE ELSIA G. SILVA
The fishing schooner Elsia G. Silva of Gloucester, coming in from
a fishing trip to the South Shoals, off Nantucket, on the afternoon of
February 14th, 1927, encountered a strong wind with fog when
nearing Chatham Bars. This condition grew constantly worse and the
storm increased until it reached gale force, driving a high sea over
the outlying bars, and the thick mist obscured the shore of the entire
coast. The dense fog enveloped everything except the wildly rushing
sea, and before daylight the following morning the little schooner
was borne high upon the crest of the great white-capped waves,
only the next moment to be dashed into the deep hollows of the
gale-swept sea as it rushed onward towards the beach.
Her crew of sixteen men, with much difficulty and danger, clung
to the rigging of the tossing vessel.
The Coast Guardsmen from Cahoons Hollow Station promptly
reached the vicinity of the wave-swept boat, which soon stranded on
the beach one mile north of the station. They could render no help
to the crew of the Silva by means of boats or gear, and could only
stand by to pull the men from the surf as they were washed from
her decks. One by one the fishermen’s crew were pulled from the
surf until the entire sixteen were safely brought out of the surf that
tore across the doomed craft’s deck.
Soon the fury of the sea tore the vessel to pieces, carrying away
her deckhouses and all movable things from her deck. Soon the
masts fell with a crash into the sea, and sails, rigging and spars
mixed in a jumble of wreckage, and then was scattered along the
sands of the beach. The boat was carrying a fair catch of fish, all of
which was mixed with the wreckage and scattered in the sea.
 Soon the men from the village came to the beach and gathered
up such material as had not already been swept far down the coast,
and a few days later only a protruding bit of broken spar or a bit of
rope dangling from some buried anchor marked the spot where the
Elsia stranded.
This again was another fortunate escape of the crew from the
deck of a wrecked vessel; only a little difference in the conditions
might have sent sixteen men to untimely deaths.
 A TERRIBLE DISASTER
For several years the Pacific Mail Steamship Company has been
operating a fleet of several large ocean liners, each bearing the
name of a President of the United States. These ships had been
making around the world trips, and in 1927 one of these ships, the
Presidente Wilson, was under charter to the Cosulich Line, an Italian
company.
In the autumn of 1927, the Presidente Wilson was returning
from an all around the world trip, with a large passenger list and
tons of freight from Europe and the Far East, to Boston. She had left
Seattle quite a number of days before, passed through the Panama
Canal, touched at New York and on to Boston, which would end the
trip.
The weather held good until she had reached the vicinity of
Nantucket Shoals, where she ran into a dense fog, making it
necessary to slow down and pick her way through the fog that
enveloped her and covered all the coast.
She left New York on the morning of October 28th, and on the
morning of the 29th, at four o’clock in the morning, she had reached
a point four miles directly east of Highland Light. Out of the thick
mist not a hundred yards away, directly in the ship’s path, loomed
the masts and faint outlines of a fishing schooner, which later proved
to be the Avalon, a vessel of about a hundred tons, with home port
at Gloucester, bound on a fishing trip to the banks. She had left
Boston the afternoon before and was jogging along under short sail
waiting for the fog to lift. She was under such small amount of sail
that she could not have moved had she made the attempt.
 The oncoming great ship, towering many feet above her, had no
chance to swing clear of the fishing craft and amid the clanging of
bells, the blast of steam whistles, and the shouts and screams of
those both on the big ship and on the fishing boat, they came
together with a crash. The momentum of the huge craft carried her
right on over the Avalon and sent her, broken and wrecked, to the
bottom of the sea, carrying with her nearly all of her crew, who were
imprisoned in her cabin. From the time of the crash until she had
disappeared beneath the sea, there had been no time for the crew
to escape.
The Avalon had a crew of sixteen men and only three of them
escaped with their lives, these three being the deck watch at the
time. The other thirteen were in their bunks and had no chance to
get to the surface before death overtook them.
Boats from the ship were promptly put over and with those of
other vessels which happened to be nearby cruised about the waters
for several hours, but no other man of the fishing boat crew was
recovered.
An hour after the disaster, the fog which had been responsible
for this tragedy cleared all away, the sun shone brightly and the blue
waters of the sea rolled smoothly on. The big liner steamed away on
her course and thirteen unfortunate sailors lay dead on the bottom
of the sea.
Those who go down to the sea in ships do not know what may
be in store for them.
 TERRIBLE SUBMARINE DISASTER
A certain section of the waters in and around Provincetown
Harbor have for several years been used as the testing ground for
new or reconditioned submarines of the U. S. Navy.
Early in December of 1927, the submarine S-4 was at this testing
ground, standardizing her engines following some changes which
had been completed at the Charlestown Navy Yard. Her complement
of forty officers and men were on board, and two civilian visitors.
In the early afternoon of December 17th this submarine went
under to test some part of her machinery and a little workout, and
steamed submerged out of the harbor; when about half a mile south
of the Wood End Lighthouse, and directly in the channel for vessels
leaving or entering the harbor, started to come to the surface. Just
at this moment, coming in from a patrol cruise along the coast,
came the Coast Guard cutter Paulding, steaming for an anchorage in
the harbor at a sixteen miles an hour speed, and crashed with great
force into the side of the submarine, just breaking the surface water.
The sharp iron stem of the Paulding tore a great ragged hole in the
side of the S-4, just forward of the conning tower, and passed
completely over her. The torrent of water which poured through this
hole sent the under-sea boat to the bottom of the sea in five
minutes, with her crew of forty-two imprisoned in her iron hull, with
walls that barred their escape from certain death. Caught like rats in
a trap without the possibility or hope of escape, they were sealed up
in their coffin more than one hundred feet beneath the sea.
When this disaster became known, and it was within five
minutes of the crash, radio and wireless messages sent it to every
section of the country. It sent a thrill of horror to every point the
news had reached; the awful tidings were broadcast to the whole
country and even to points in Europe.
Every available means of possible rescue were hurried to the
scene. A dozen deep sea divers were rushed by train and auto from
New London. Provincetown was the nearest point of approach to the
location of the disaster. Big ships and tugs carrying chains and
appliances were rushed forward by every available means, hoping to
accomplish something towards raising the sunken boat before all her
officers and men had perished by drowning or suffocation.
There was hope that at least some of the men might have been
able to close the watertight compartments before they were
overcome by the inrushing current.
Many kinds of appliances were hurried to the locality by fast
ships; many tugs and steamers gathered over the place where the
S-4 lay at the bottom of the sea off Long Point. Over the sunken
boat white-capped waves were breaking, forced over the surging
waters of the bay by a thirty-mile northwest gale.
As soon as the divers reached the locality a man was sent down
and succeeded in placing a chain over the bow of the submarine;
they had hoped to raise the bow enough to tip the bow towards the
surface, but failed to offer any help.
Again a man was sent down with a hammer, and instructed to
pound along the iron sides of the sunken boat; if he got any
response from the inside it would indicate that there was life there.
The diver when a short distance forward of the locality of the
conning tower and the great hole which had been torn open by the
Paulding when she overwhelmed the under-sea boat, heard a
responsive tapping from the inside. Then the diver tapped out in the
telegraph code, “Are you alive.” The answer quickly came back, “Yes,
six of us are alive here.” Again the diver tapped, “Everything possible
is being done to help you.” Again from the inside, “The air is very
bad in here, please hurry.” This was Sunday afternoon, twenty-four
hours after the disaster.
 When it was found that six men were still alive renewed and
strenuous efforts were made to reach the men. All day Sunday and
all Sunday night a hundred men with such appliances as it was
possible to get, labored to bring the bow of the boat to the surface.
Late in the afternoon of Sunday a diver went down and in
response to his tapping found that the six men were still alive, but
they signalled, “We are still alive but growing weaker. We cannot
stand it much longer. Please hurry.”
The diver’s tapping along all other parts of the ship obtained no
other response.
The other men on the boat had been imprisoned either in the
engine room or the after compartments and were all probably
drowned when the ship went to the bottom.
Monday morning brought no change or any hope of relief. The
northwest gale had become bitterly cold, and it was more and more
certain that not a man on the boat was alive, as these men had
been entombed more than forty-eight hours, so the probability or
even possibility of any man being alive down there a hundred feet
under the sea was remote indeed.
What still further added to the horror of the situation, the
increasing cold and freezing winds drove the rescuers from their
work, because it was impossible to send divers down. By this time
the imprisoned men had been so long in their iron coffin, it was not
possible that human life could endure for that time or withstand the
terrible conditions.
Sunday night two monstrous pontoons were brought to the
scene, hoping by their use the bow of the boat might be brought to
the surface. These pontoons were brought from New London by four
powerful tugs, through the Cape Cod Canal, but this was
unavoidably slow on account of the unwieldy shape of the tow and
there was no hope that these pontoons could reach the spot until it
was too late.
 Eight skilled divers were already on the scene. Diver Thomas
Eadie went over the side earlier in the day and it was he who was
able to communicate with the entombed men by means of the
hammer tapping signals.
The last signals tapped from the inside of the ship were, “How
long will you be now, hurry.”
Late Sunday P. M. diver Michaels heard from the dying men, “We
cannot live beyond six o’clock.”
In some way this diver’s life line became entangled in a part of
the ragged hole in the hull, and though he struggled frantically to
clear himself, after he had been down more than half an hour it
became evident that something was wrong. Then diver Eadie, with a
hack saw, went down and found Michaels badly tangled in projecting
bits of broken iron of the hull, and it required another half hour for
Eadie to saw off the piece of iron that held Michaels. He had been
held there more than two and a half hours and another half hour
would have resulted in his death. He was hurried to a hospital in
Boston and was ill for some time.
Up to this time every effort to raise the boat or rescue any one
of her crew had utterly failed and some of the boats and gear
departed for other duties.
The attempts to rescue these imprisoned men encountered
awfully adverse conditions.
This disaster happened on Sunday, on that afternoon, and on
Monday, the next day, had there been adequate saving appliances at
hand it is believed some of the men might have been saved, but it
required so much time to get them on the ground that all attempts
were futile.
Another case where men have gone down in the deep sea in a
vessel that was the meanest type of craft ever conceived by man.
Forty good men sent to untimely graves because someone failed
to observe proper care.
 “Theirs not to reason why,
Theirs but to do or die,
Somebody blundered.”

What a miscarriage of justice this building of this type of vessel

is. If these vessels are built for fighting purposes, it is an uncivilized
method of warfare and every nation on the earth should be barred
from building another submarine. Already we have sent the
battleships to the scrapheap. By all means send the submarine to
join them.
In regard to the wretched lack of proper appliances for handling
such a terrible disaster, we see one more tragedy. Men familiar with
submarines, their building and handling, declare that it was a case of
criminal carelessness on the part of the Government and the Navy
Department in particular.
Secretary Wilbur, of the United States Navy, visited the locality of
the disaster and ordered that the work of salvaging the submarine
and bringing out the bodies must proceed until every one is brought
to shore.
On the 4th day of January three bodies were recovered from the
engine room of the under-sea boat and in time the others in the
after compartments will be brought to the surface.
Representative Gifford came on from Washington to learn from
personal observation if everything possible had been done to save
the men from their coffin.
Among the crew of the S-4 when she went down was a seaman
by the name of Walter Bishop. He had previously been on a
submarine when an accident happened, and among his effects, left
with relatives, was found a poem of thirteen verses, in which he
described the situation and conditions on these ships in full detail.
We have room for only the first verse, which certainly hits the mark.
 “IN THE CANKEROUS MIND OF THE DEVIL,
THERE FESTERED A FIENDISH SCHEME,
HE CALLED HIS COHORTS TOGETHER,
AND THEY DESIGNED THE SUBMARINE.”

The time having long passed when it was possible for any
human being to be alive, the only thing to do was to some day raise
the boat to the surface.
Submarines have figured in some of the most awful tragedies of
modern times. Only a partial record is available, but a recent
statement of the story discloses that no less than 295 human beings
have gone to death in submarines in the last decade.
In 1923 a Japanese boat carried down to death eighty-five
persons. In 1925 the No. 51 with thirty-three men, and now the S-4
with forty.
THE MUTE REMAINS OF A TRAGEDY OF THE SEA
 STRANDING OF THE ROBERT E.
LEE
On the afternoon of March 9th, 1928, a northeast wind pushed
in from the sea and by five P. M. it had developed into a howling
gale with blinding snow. Out from her home dock at India Wharf in
Boston the big passenger and freight boat Robert E. Lee pulled out
for her trip to New York, via the Cape Cod Canal. The storm instead
of diminishing grew constantly worse, but she ploughed her way
through the wildly rushing sea, and though only two miles from the
beach along the Manomet and Sandwich shores not a glimpse could
be had of the land through the snow filled air, and navigation
became a matter of dead reckoning and a hope to pick up the
lighthouse at the Cape Cod Bay entrance of the Canal.
When the ship had reached a point about two miles from the
Canal entrance she crashed with terrific force upon the rocks of a
projecting ledge and was there held fast on the “Mary Ann Rocks,” a
short distance south of the Manomet Coast Guard station. This found
the Robert Lee in a most dangerous position, where the great seas
driving straight across Cape Cod Bay swept the ship from stem to
stern. The ship carried 150 passengers and a crew of 110.
S. O. S. calls were quickly sent out and Coast Guard and Naval
boats hurried to the scene.
The Coast Guard boats from Gurnet, Manomet, Sandwich and
Provincetown were promptly brought into service, but as the
conditions of wind and sea were so dangerous it was not deemed
advisable to attempt the transfer of the passengers from the
stranded ship just then.
 Towards morning the fury of the gale having subsided the work
of taking off the passengers began, and was successfully
accomplished a few hours later with no serious mishap to the
passengers and the ship’s crew remained on board. But the affair
was not to escape without the tragedy of the loss of human lives.
The Coast Guard boat of the Manomet Station in trying to make
connection with the stranded steamer, was caught under the bow by
a huge sea that swept fiercely around the counter of the Lee, turned
the boat completely over and sent her crew of eight men helplessly
into the sea, four of them clung desperately to the overturned boat,
the other four struck out in an attempt to reach the shore, but those
clinging to the boat and those fighting for the shore were finally
rescued. But those from the overturned boat were so thoroughly
chilled and exhausted that they were immediately hurried to Chelsea
Hospital where three of them died.
If there are people who think that the men who man the
stations along our storm swept coasts have a sinecure, would they
like to have been in the Manomet surf boat that day?
Many names of heroes are emblazoned upon the scroll of human
endeavor the world over but there are deeds equally as deserving of
record that pass unnoticed and unsung.
The recent disaster on the rocks at Manomet brought
prominently before us several instances of unselfish heroism, not on
bloody fields of battle, but in the freezing waters of the cruel sea.
Not detracting in the least from the brave efforts of the Coast
Guardsmen, three of whom gave up their lives in the struggle, or the
men and boy who pushed out in small and leaking boats to help,
there was one case of glorious heroism that stands out preeminently,
and whose name should stand high up on the roll of honor, and that
is Ernest Douglas, a man unskilled in the use of boats, but he
stripped from his clothing his money and watch, handed them to a
friend, and as he sprang into the surf boat to take the place of an
absent member of the Surf Boat crew, called back to his friend on
shore, “If I do not come back give them to my wife.”
We are glad to record that he did come back safely.
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