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CONTENTS
Contributors
Preface
Credits for Figures and Tables

SECTION 1 CARDIOVASCULAR DISEASE: PAST, PRESENT, AND FUTURE

CHAPTER 1 A History of the Cardiac Diseases, and the Development of Cardiovascular Medicine as a Specialty
Questions
Answers
CHAPTER 2 The Global Burden of Cardiovascular Diseases
Questions
Answers
CHAPTER 3 Assessing and Improving the Quality of Care in Cardiovascular Medicine
Questions
Answers

SECTION 2 FOUNDATIONS OF CARDIOVASCULAR MEDICINE

CHAPTER 4 Functional Anatomy of the Heart

Questions
Answers
CHAPTER 5 Normal Physiology of the Cardiovascular System
Questions
Answers
CHAPTER 6 Molecular and Cellular Biology of the Heart
Questions
Answers
CHAPTER 7 Biology of the Vessel Wall
Questions
Answers
CHAPTER 8 Molecular and Cellular Development of the Heart
Questions
Answers
CHAPTER 9 Genetic Basis of Cardiovascular Disease
Questions
Answers
CHAPTER 10 Stem Cells and the Cardiovascular System
Questions
Answers

SECTION 3 EVALUATION OF THE PATIENT

CHAPTER 11 The History, Physical Examination, and Cardiac Auscultation

Questions
Answers
CHAPTER 12 Surface Electrocardiography
Questions
Answers
CHAPTER 13 Electrocardiographic Exercise Testing
 Questions
Answers
CHAPTER 14 Cardiac Radiography
Questions
Answers
CHAPTER 15 Echocardiography
Questions
Answers
CHAPTER 16 Magnetic Resonance Imaging of the Heart
Questions
Answers
CHAPTER 17 Computed Tomography of the Heart
Questions
Answers
CHAPTER 18 Nuclear Cardiology
Questions
Answers
CHAPTER 19 Positron Emission Tomography in Heart Disease
Questions
Answers
CHAPTER 20 Cardiac Catheterization, Cardiac Angiography, and Coronary Blood Flow and Pressure Measurements
Questions
Answers
CHAPTER 21 Coronary Intravascular Imaging
Questions
Answers
CHAPTER 22 Magnetic Resonance Imaging and Computed Tomography of the Vascular System
Questions
Answers

SECTION 4 SYSTEMIC ARTERIAL HYPERTENSION

CHAPTER 23 Epidemiology of Hypertension

Questions
Answers
CHAPTER 24 Pathophysiology of Hypertension
Questions
Answers
CHAPTER 25 Diagnosis and Treatment of Hypertension
Questions
Answers

SECTION 5 METABOLIC DISORDERS AND CARDIOVASCULAR DISEASE

CHAPTER 26 The Metabolic Syndrome

Questions
Answers
CHAPTER 27 Obesity and Cardiovascular Disease
Questions
Answers
CHAPTER 28 Diabetes and Cardiovascular Disease
Questions
Answers
CHAPTER 29 Hyperlipidemia
 Questions
Answers

SECTION 6 CIGARETTE SMOKING AND CARDIOVASCULAR DISEASE

CHAPTER 30 Epidemiology of Smoking and Pathophysiology of Cardiovascular Damage

Questions
Answers
CHAPTER 31 Preventing and Mitigating Smoking-Related Heart Disease
Questions
Answers

SECTION 7 ATHEROSCLEROSIS AND CORONARY HEART DISEASE

CHAPTER 32 Atherothrombosis: Disease Burden, Activity, and Vulnerability

Questions
Answers
CHAPTER 33 Coronary Thrombosis: Local and Systemic Factors
Questions
Answers
CHAPTER 34 Coronary Blood Flow and Myocardial Ischemia
Questions
Answers
CHAPTER 35 Nonobstructive Atherosclerotic and Nonatherosclerotic Coronary Heart Disease
Questions
Answers
CHAPTER 36 Definitions of Acute Coronary Syndromes
Questions
Answers
CHAPTER 37 Pathology of Myocardial Infarction and Sudden Death
Questions
Answers
CHAPTER 38 Molecular and Cellular Mechanisms of Myocardial Ischemia/Reperfusion Injury
Questions
Answers
CHAPTER 39 Evaluation and Management of Non–ST-Segment Elevation Myocardial Infarction
Questions
Answers
CHAPTER 40 ST-Segment Elevation Myocardial Infarction
Questions
Answers
CHAPTER 41 Antiplatelet and Anticoagulant Therapy in Acute Coronary Syndromes
Questions
Answers
CHAPTER 42 Percutaneous Coronary Interventions in Acute Myocardial Infarction and Acute Coronary Syndromes
Questions
Answers
CHAPTER 43 The Evaluation and Management of Stable Ischemic Heart Disease
Questions
Answers
CHAPTER 44 Coronary Artery Bypass Grafting and Percutaneous Interventions in Stable Ischemic Heart Disease
Questions
Answers
CHAPTER 45 Rehabilitation of the Patient with Coronary Heart Disease
 Questions
Answers

SECTION 8 VALVULAR HEART DISEASE

CHAPTER 46 Acute Rheumatic Fever

Questions
Answers
CHAPTER 47 Aortic Valve Disease
Questions
Answers
CHAPTER 48 Degenerative Mitral Valve Disease
Questions
Answers
CHAPTER 49 Ischemic Mitral Regurgitation
Questions
Answers
CHAPTER 50 Mitral Stenosis
Questions
Answers
CHAPTER 51 Tricuspid and Pulmonary Valve Disease
Questions
Answers
CHAPTER 52 Prosthetic Heart Valves
Questions
Answers
CHAPTER 53 Antithrombotic Therapy for Valvular Heart Disease
Questions
Answers
CHAPTER 54 Management of Mixed Valvular Heart Disease
Questions
Answers

SECTION 9 CONGENITAL HEART DISEASE

CHAPTER 55 Mendelian Basis of Congenital and Other Cardiovascular Diseases

Questions
Answers
CHAPTER 56 Congenital Heart Disease in Adolescents and Adults
Questions
Answers

SECTION 10 MYOCARDIAL, PERICARDIAL, AND ENDOCARDIAL DISEASES

CHAPTER 57 Classification of Cardiomyopathies

Questions
Answers
CHAPTER 58 Dilated Cardiomyopathy
Questions
Answers
CHAPTER 59 Hypertrophic Cardiomyopathies
Questions
Answers
CHAPTER 60 Left Ventricular Noncompaction
Questions
 Answers
CHAPTER 61 Restrictive Heart Diseases
Questions
Answers
CHAPTER 62 Arrhythmogenic Cardiomyopathy
Questions
Answers
CHAPTER 63 Myocarditis
Questions
Answers
CHAPTER 64 The Athlete and the Cardiovascular System
Questions
Answers
CHAPTER 65 Cardiovascular Disease in the Elderly: Pathophysiology and Clinical Implications
Questions
Answers
CHAPTER 66 Pericardial Diseases
Questions
Answers
CHAPTER 67 Infective Endocarditis
Questions
Answers

SECTION 11 HEART FAILURE

CHAPTER 68 Pathophysiology of Heart Failure

Questions
Answers
CHAPTER 69 The Epidemiology of Heart Failure
Questions
Answers
CHAPTER 70 The Diagnosis and Management of Chronic Heart Failure
Questions
Answers
CHAPTER 71 Evaluation and Management of Acute Heart Failure
Questions
Answers
CHAPTER 72 Cardiac Transplantation
Questions
Answers
CHAPTER 73 Mechanically Assisted Circulation
Questions
Answers

SECTION 12 CARDIOPULMONARY DISEASE

CHAPTER 74 Pulmonary Hypertension

Questions
Answers
CHAPTER 75 Pulmonary Embolism
Questions
Answers
CHAPTER 76 Cor Pulmonale: The Heart in Parenchymal Lung Disease
Questions
 Answers
CHAPTER 77 Sleep-Disordered Breathing and Cardiac Disease
Questions
Answers

SECTION 13 RHYTHM AND CONDUCTION DISORDERS

CHAPTER 78 Electrophysiologic Anatomy

Questions
Answers
CHAPTER 79 Mechanisms of Cardiac Arrhythmias and Conduction Disturbances
Questions
Answers
CHAPTER 80 Genetics of Channelopathies and Clinical Implications
Questions
Answers
CHAPTER 81 Approach to the Patient with Cardiac Arrhythmias
Questions
Answers
CHAPTER 82 Invasive Diagnostic Electrophysiology
Questions
Answers
CHAPTER 83 Atrial Fibrillation, Atrial Flutter, and Atrial Tachycardia
Questions
Answers
CHAPTER 84 Supraventricular Tachycardia: Atrial Tachycardia, Atrioventricular Nodal Reentry, and Wolff–Parkinson–White
Syndrome
Questions
Answers
CHAPTER 85 Ventricular Arrhythmias
Questions
Answers
CHAPTER 86 Bradyarrhythmias
Questions
Answers
CHAPTER 87 Antiarrhythmic Drugs
Questions
Answers
CHAPTER 88 Catheter-Ablative Techniques
Questions
Answers
CHAPTER 89 Pacemakers and Defibrillators
Questions
Answers
CHAPTER 90 Diagnosis and Management of Syncope
Questions
Answers
CHAPTER 91 Sudden Cardiac Death
Questions
Answers
CHAPTER 92 Cardiopulmonary and Cardiocerebral Resuscitation
Questions
Answers
 SECTION 14 DISEASES OF THE GREAT VESSELS AND PERIPHERAL VESSELS

CHAPTER 93 Diseases of the Aorta

Questions
Answers
CHAPTER 94 Cerebrovascular Disease and Neurologic Manifestations of Heart Disease
Questions
Answers
CHAPTER 95 Carotid Artery Stenting
Questions
Answers
CHAPTER 96 Diagnosis and Management of Diseases of the Peripheral Arteries
Questions
Answers
CHAPTER 97 Diagnosis and Management of Diseases of the Peripheral Venous System
Questions
Answers

SECTION 15 MISCELLANEOUS CONDITIONS AND CARDIOVASCULAR DISEASE

CHAPTER 98 Perioperative Evaluation for Noncardiac Surgery

Questions
Answers
CHAPTER 99 Anesthesia and the Patient with Cardiovascular Disease
Questions
Answers
CHAPTER 100 Rheumatologic Diseases and the Cardiovascular System
Questions
Answers
CHAPTER 101 The Diagnosis and Management of Cardiovascular Disease in Patients with Cancer
Questions
Answers
CHAPTER 102 HIV/AIDS and the Cardiovascular System
Questions
Answers
CHAPTER 103 Heart Disease in Pregnancy
Questions
Answers
CHAPTER 104 Traumatic Heart Disease
Questions
Answers
CHAPTER 105 The Kidney in Heart Disease
Questions
Answers
CHAPTER 106 Exercise in Health and Cardiovascular Disease
Questions
Answers

SECTION 16 POPULATIONS AND SOCIAL DETERMINANTS OF CARDIOVASCULAR DISEASE

CHAPTER 107 Social Determinants of Cardiovascular Disease

Questions
Answers
CHAPTER 108 Women and Ischemic Heart Disease: An Evolving Saga
 Questions
Answers
CHAPTER 109 Race, Ethnicity, and Cardiovascular Disease
Questions
Answers
CHAPTER 110 Environment and Heart Disease
Questions
Answers
CHAPTER 111 Behavioral Cardiology: Epidemiology, Pathophysiology, and Clinical Management
Questions
Answers
CHAPTER 112 Economics and Cost-Effectiveness in Cardiology
Questions
Answers

Index
CONTRIBUTORS
MARIA L. ALCARAZ, BA
Clinical Research Assistant
Division of Clinical Epidemiology
Department of Medicine
Jewish General Hospital
McGill University
Montreal, Quebec, Canada

EMMANUEL E. EGOM, MD, MSc, PHD

Clinician-Lead for Heart Health Clinic and Hearts in Motion Program
Department of Medicine
St Martha’s Regional Hospital
Antigonish, Nova Scotia, Canada

INNA ERMEICHOUK, MSc

Clinical Research Assistant
Division of Clinical Epidemiology
Department of Medicine
Jewish General Hospital
McGill University
Montreal, Quebec, Canada

CAROLINE FRANCK, MSc

Clinical Research Assistant
Division of Clinical Epidemiology
Department of Medicine
Jewish General Hospital/McGill University
Montreal, Quebec, Canada

SARAH B. WINDLE, MPH

Clinical Research Associate
Division of Clinical Epidemiology
Department of Medicine
Jewish General Hospital
McGill University
Montreal, Quebec, Canada
PREFACE
Cardiology Board Review and Self-Assessment is an all-inclusive study guide written to complement the 14th Edition of Hurst’s
The Heart. Edited by Drs. Valentin Fuster, Robert A. Harrington, Jagat Narula, and Zubin J. Eapen, the 14th Edition of Hurst’s
The Heart is an exhaustive and thorough state-of-the-art review of the entire field of cardiovascular medicine.
Cardiology Board Review contains over 1100 questions and answers presented in a multiple-choice format. Each of the 112
chapters of Hurst’s The Heart is represented in Cardiology Board Review with 10 multiple-choice questions. Detailed answers
are provided for each question including not only an explanation of why the correct answer is correct but also why incorrect
answers are incorrect. Questions and answers correspond to appropriate sections of Hurst’s The Heart and include tables,
figures, and references. The more than 1100 questions presented in Cardiology Board Review span the depth and breadth of the
fascinating field of cardiovascular medicine.
Cardiology Board Review is designed to be a study guide for individuals preparing to take the Subspecialty Examination in
Cardiovascular Disease given by the American Board of Internal Medicine. Thus, Cardiology Board Review will be of particular
interest to cardiology fellows preparing to take the board examination for the first time and for practicing cardiologists preparing
to take the board examination as part of their recertification process. Cardiology Board Review will also be of interest to medical
students, residents, fellows, practicing physicians, and other health care professionals who wish to advance their knowledge of
cardiovascular medicine.
The current generation of health care professionals increasingly obtains their knowledge from nontraditional formats. To that
end, Cardiology Board Review and Self-Assessment is available in multiple electronic formats in addition to the traditional print
format. The book will be available in print, e-book, and online on McGraw-Hill Education’s cardiology web site at
www.AccessCardiology.com.
It has been my distinct pleasure to work with four coauthors while preparing Cardiology Board Review: Drs. Jonathan
Afilalo, Jacqueline E. Joza, Ravi Karra, and Patrick R. Lawler. Each of us contributed original questions and answers
corresponding to our particular areas of expertise. We would like to thank the members of the editorial and production
departments at McGraw-Hill Education with whom we worked, including Karen Edmonson, Robert Pancotti, and Shivani
Salhotra. We would also like to acknowledge the contributions and assistance of a number of other individuals, including Maria
L. Alcaraz, Emmanuel E. Egom, Inna Ermeichouk, Caroline Franck, and Sarah B. Windle. Finally, on behalf of myself and my
coauthors, we would like to express thanks to our families and colleagues for their encouragement and forbearance during the
many months it took to prepare this study guide.
Taking care of patients with cardiovascular disease is an honor and a privilege. Many of these patients have life-threatening
conditions that require advanced knowledge and highly technical skills. It is our responsibility, as health care professionals, to
ensure that our knowledge and skills match the needs of our patients. It is our hope that you will find Cardiology Board Review
and Self-Assessment to be an essential and valuable tool in your study of the ever expanding and always fascinating field of
cardiovascular medicine.
Mark J. Eisenberg, MD, MPH
CREDITS FOR FIGURES AND TABLES
The following figures and tables have been used with permission from this McGraw-Hill Education publication:

Fuster V, Harrington RA, Narula J, Eapen ZJ, eds. Hurst’s The Heart. 14th ed. New York: McGraw-Hill Education; 2017:

Chapter 9: Figure 9-1.

Chapter 11: Figures 11-1, 11-2, and 11-3.Chapter 14: Figures 14-1, 14-2, 14-3, and 14-4.
Chapter 15: Figures 15-1, 15-2, 15-3, 15-4, 15-5, 15-6, 15-7, and 15-8.
Chapter 16: Figures 16-1, 16-2, 16-3, 16-4, and 16-5.
Chapter 17: Figures 17-1, 17-2, 17-3, 17-4, and 17-5.
Chapter 18: Figures 18-1 and 18-2.
Chapter 19: Figures 19-1, 19-2, 19-3, and 19-4.
Chapter 20: Figure 20-1.
Chapter 33: Figure 33-1.
Chapter 34: Figure 34-2.
Chapter 39: Figure 39-1 and Tables 39-1 and 39-2.
Chapter 40: Table 40-1.
Chapter 45: Table 45-1.
Chapter 55: Figure 55-2.
Chapter 59: Figure 59-1.
Chapter 61: Figure 61-1.
Chapter 63: Figure 63-1.
Chapter 66: Tables 66-1 and 66-2.
Chapter 72: Figure 72-1.
Chapter 74: Figure 74-1.
Chapter 76: Tables 76-1 and 76-2.
Chapter 78: Figure 78-1.
Chapter 80: Figure 80-1.
Chapter 82: Figure 82-1.
Chapter 86: Figure 86-1.
Chapter 89: Figure 89-1.
Chapter 94: Table 94-1.
Chapter 111: Figure 111-1.

Data from Fuster V, Alexander RW, O’Rourke RA, et al. Hurst’s The Heart. 11th ed. New York: McGraw-Hill; 2004:

Chapter 5: Figure 5-1.

SECTION 1

Cardiovascular Disease: Past, Present, and Future

CHAPTER 1
A History of the Cardiac Diseases, and the Development of
Cardiovascular Medicine as a Specialty
Mark J. Eisenberg

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

1-1. All of the following were experimental questions asked by William Harvey except:
A. What is the relationship of the motion of the auricle to the ventricle?
B. Do the arteries distend because of the propulsive force of the heart?
C. What purpose is served by the orientation of the cardiac and venous valves?
D. How much blood is present, and how long does its passage take?
E. All were questions asked by William Harvey

1-2. What were the primary component(s) of the clinical examination until the 17th century?
A. Palpating the pulse
B. Palpating the pulse and inspecting the urine
C. Palpating the pulse and percussion
D. Palpating the pulse and auscultation
E. Palpating the pulse, percussion, and auscultation

1-3. Which physician received the Nobel Prize for his work in electrophysiology?
A. Albert von Kölliker
B. Heinrich Müller
C. Augustus Waller
D. Willem Einthoven
E. Thomas Lewis

1-4. Who performed the first cardiac catheterization in a human?

A. Werner Forssmann
B. Claude Bernard
C. Dickinson Richards
D. Etienne Jules Marey
E. André Cournand

1-5. From which Latin word is the term angina appropriated?

A. Pain
B. Stress
C. Strangulation
D. Anxiety
E. Discomfort

1-6. Before the defibrillator and coronary care units, the in-hospital mortality associated with acute myocardial infarction was
approximately:
A. 10%
B. 15%
C. 20%
 D. 30%
E. 40%

1-7. Who first described audible heart murmurs?

A. James Hope
B. John Mayow
C. William Cowper
D. René Laennec
E. Raymond Vieussens

1-8. Which procedure pioneered by Helen Taussig and Alfred Blalock was a pivotal breakthrough in thinking about congenital
heart abnormalities?
A. Balloon atrial septostomy
B. Subclavian-pulmonary artery shunt
C. Closure of atrial septal defect
D. Closure of ventricular septal defect
E. Stenting of patent ductus arteriosus

1-9. Who invented the first device for measuring blood pressure?
A. Etienne Jules Marey
B. Jean Poiseuille
C. Scipione Riva-Rocci
D. Karl von Vierordt
E. Carl Ludwig

1-10. Which of the following statements about hypertension is false?

A. In 1913, Janeway showed that patients, once diagnosed with hypertensive heart disease and symptoms, lived an average
of 4 to 5 years
B. Until the latter half of the 20th century, the asymptomatic state of most patients with hypertension and a prevalent view
that lowering the blood pressure would be deleterious to the kidney and brain lulled most physicians into accepting the
condition as being normally associated with aging
C. Effective oral treatment was available before President Franklin Roosevelt’s death in 1945 from severe hypertension
D. In the 1970s, reports from the Framingham Heart Study showed hypertension to be a major contributing cause to stroke,
heart attack, and heart and kidney failure
E. Richard Bright’s 1836 discovery of the relationship of cardiac hypertrophy and dropsy to shrunken kidneys introduced the
kidneys as a cause of heart failure long before hypertension was known

ANSWERS

1-1. The answer is E. (Hurst’s the Heart, 14th Edition, Chap. 1) Starting in 1603, Harvey dissected the anatomy and observed
the motion of the cardiac chambers and the flow of blood in more than 80 species of animals. His experimental questions
“to seek unbiased truth” can be summarized in the following questions: What is the relationship of the motion of the
auricle to the ventricle? Which is the systolic and which is the diastolic motion of the heart? Do the arteries distend
because of the propulsive force of the heart? What purpose is served by the orientation of the cardiac and venous valves?
How does blood travel from the right ventricle to the left side of the heart? Which direction does the blood flow in the
veins and the arteries? How much blood is present, and how long does its passage take? After many experiments and
without knowledge of the capillary circulation of the lungs, which was not known until 1661, Harvey stated, “It must of
necessity be concluded that the blood is driven into a round by a circular motion and that it moves perpetually; and hence
does arise the action or function of the heart, which by pulsation it performs.” This was published in 1628 as Exercitatio
Anatomica de Motu Cordis et Sanguinis in Animalibus.1 This revolutionary concept eventually became accepted in
Harvey’s lifetime and remains the foundation of our understanding of the purpose of the heart.

1-2. The answer is B. (Hurst’s the Heart, 14th Edition, Chap. 1) Until the 17th century, the clinical examination consisted of
palpating the pulse and inspecting the urine to reveal disease and predict prognosis. Percussion was first suggested in
1761 by Leopold Auenbrugger, a Viennese physician, who published a book proposing “percussion of the human thorax,
whereby, according to the character of the particular sounds thence elicited, an opinion is formed of the internal state of
that cavity.”2 It was reintroduced by Jean-Nicolas Corvisart in early 19th-century France and became an essential addition
to the chest examination until it was mostly supplanted by the chest x-ray. While auscultation of the chest was first
practiced by Hippocrates (460-370 BC), who applied his ear directly to the chest, it was not until the mid-19th century that
the stethoscope (first invented by René Laennec in Paris in 1816) moved auscultation to the forefront of the clinical
 examination.3,4

1-3. The answer is D. (Hurst’s the Heart, 14th Edition, Chap. 1) In 1856, von Kölliker and Müller demonstrated that the heart
also produced electricity. Augustus Waller, with a capillary electrometer device (1887), detected cardiac electricity from
the limbs, a crude recording that he called an “electrogram.” Willem Einthoven, a physiologist in Utrecht, devised a more
sensitive string galvanometer (1902), for which he received the Nobel Prize, and the modern electrocardiogram was born.
Initially weighing 600 lb and requiring five people to operate, the three-lead electrocardiograph would eventually become
portable, 12 leads, routine, and capable of providing both static and continuous recordings of cardiac rhythm.5 With the
electrocardiogram, the activation and sequence of stimulation of the human heart could now be measured, and the
anatomic basis for the conduction system confirmed. Thomas Lewis in London was the first to realize its great potential,
beginning in 1909, and his books on disorders of the heartbeat became essential for aspiring electrocardiographers.2,6

1-4. The answer is A. (Hurst’s the Heart, 14th Edition, Chap. 1) Claude Bernard in 1844 was the first to insert a catheter into
the hearts of animals to measure temperature and pressure.2 In the early 1860s, Auguste Chauveau, a veterinary
physiologist, and Etienne Jules Marey, inventor of the sphygmograph, collaborated to develop a system of devices called
sounds, forerunners of the modern cardiac catheter, which they used to catheterize the right heart and left ventricle of the
horse.7 Cardiac catheterization in humans was thought an inconceivable risk until Werner Forssmann, a 29-year-old
surgical resident in Germany, performed a self-catheterization in 1929.8,9 Interested in discovering a method of injecting
adrenaline to treat cardiac arrest, Forssmann passed a ureteral catheter into his antecubital vein and confirmed its right
atrial position using x-ray. The next year he tried to image his heart using an iodide injection. However, he was
reprimanded by superiors and did not experiment further. Catheterization began in earnest in the early 1940s in New York
and London. André Cournand and Dickinson Richards at Bellevue, interested in respiratory physiology, developed and
demonstrated the safety of complete right heart catheterization, for which they shared the Nobel Prize with Forssmann in
1956.7,10

1-5. The answer is C. (Hurst’s the Heart, 14th Edition, Chap. 1) On July 21, 1768, William Heberden presented “Some
Account of a Disorder of the Breast” to the Royal College of Physicians, London: “But there is a disorder of the breast
marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare.
The seat of it, and sense of strangling and anxiety with which it is attended, may make it not improperly be called angina
pectoris.”2,11 Heberden appropriated the term angina from the Latin word for strangling. His classic account marks the
beginning of our appreciation of coronary artery disease and myocardial ischemia. Edward Jenner and Caleb Parry were
the first to suspect a coronary etiology, which Parry published in 1799. Allan Burns, in Scotland, likened the pain of
angina pectoris to the discomfort brought about by walking with a tight ligature placed on a limb (1809), a prescient
concept that remains relevant today.

1-6. The answer is D. (Hurst’s the Heart, 14th Edition, Chap. 1) Before the defibrillator and coronary care units, the in-
hospital mortality associated with acute myocardial infarction was approximately 30%. With the development of the
defibrillator by William Kouwenhoven, Claude Beck and Paul Zoll were able to prove that rescue of cardiac arrest victims
was possible. Beck’s concept that “the heart is too good to die” instilled optimism into the care of coronary patients and
aggressiveness into their providers. Myocardial infarction was no longer a disease to be watched but rather one that might
benefit from aggressive therapeutic interventions. Zoll reported closed chest defibrillation in 1956 and cardioversion of
ventricular tachycardia in 1960. The monitoring of patients in close proximity to skilled nursing personnel who could
perform cardiopulmonary resuscitation was a logical next step suggested by Desmond Julian in 1961.

1-7. The answer is D. (Hurst’s the Heart, 14th Edition, Chap. 1) Valvular pathology was described in the 17th and 18th
centuries; however, Laennec was the first to describe audible heart murmurs, calling them “blowing, sawing, filing, and
rasping.”3 Originally, he attributed the noises to actual valvular disease, but he later decided that they were caused by
spasm or contraction of a cardiac chamber. James Hope in England was the first to classify valvular murmurs in A
Treatise on the Diseases of the Heart and Great Vessels (1832).12 He interpreted physical findings in early physiologic
terms and provided detailed pathologic correlations.13 Constriction of the mitral valve was recorded by John Mayow
(1668) and Raymond Vieussens (1715); the latter also recognized that this condition could cause pulmonary congestion.14
The presystolic murmur of mitral stenosis was described by Bertin (1824), timed as both early diastolic and presystolic by
Williams (1835), and placed on firmer grounds by Fauvel (1843) and Gairdner (1861). Aortic stenosis was first described
pathologically by Rivière (1663), and Laennec pointed out that the aortic valve was subject to ossification (1819).15
Corvisart showed an astute grasp of the natural history of aortic stenosis (1809). Early descriptions of aortic regurgitation
were by William Cowper (1706) and Raymond Vieussens (1715),16 whereas Giovanni Morgagni recognized the
hemodynamic consequences of aortic regurgitation (1761). In 1832, Corrigan provided his classic description of the
arterial pulse and murmur of aortic regurgitation. Flint added that the presystolic murmur was sometimes heard with
severe aortic regurgitation (1862).4

1-8. The answer is B. (Hurst’s the Heart, 14th Edition, Chap. 1) The pivotal breakthrough in thinking about congenital
abnormalities came from Helen Taussig and Alfred Blalock at Johns Hopkins Hospital with their “blue baby operation.”
Taussig had observed that patients with cyanotic heart disease worsened when their ductus arteriosus closed. She
suggested creating an artificial ductus to improve oxygenation.17 Blalock, assisted by Vivian Thomas, successfully
created a shunt from the subclavian to the pulmonary artery in November 1944. This innovative operation, in which a blue
 baby was dramatically changed to a pink one—the Blalock-Taussig shunt—was highly publicized, and other operations
soon followed. These include closure of atrial septal defects (1950s), closure of ventricular septal defects (1954), and
tetralogy of Fallot repair (1954). In 1966, Rashkind introduced the balloon septostomy, a novel catheter therapeutic
technique that bought time for severely cyanotic infants with transposition of the great arteries.7 In the 1980s, catheters
were adapted to dilate stenotic aortic and pulmonic valves as well as aortic coarctation. Today, transcatheter closure of
patent ductus arteriosus (1971), atrial septal defects (1976), and ventricular septal defects (1987) has become routine.
Indomethacin therapy to enable closure of a patent ductus in the premature infant (1976) and prostaglandin infusion to
maintain ductal patency (1981) profoundly changed the medical management of fragile newborns. Stents now help keep
the ductus open as well as alleviate right ventricular obstruction in tetralogy of Fallot.

1-9. The answer is B. (Hurst’s the Heart, 14th Edition, Chap. 1) Stephen Hales, an English country parson, reported in his
Statical Essays (1733) that the arterial blood pressure of the cannulated artery of a recumbent horse rose more than eight
feet above the heart—the first true measurement of arterial pressure and the beginning of sphygmometry.2,18,19 His
pioneering efforts stood alone until 1828 when Jean Poiseuille introduced a mercury manometer device to measure blood
pressure.20,21 Over the next 60 years, various sphygmomanometric methods were developed—notably by Ludwig (1847),
Vierordt (1855), and Marey (1863)—to refine the measurement of the arterial pressure. An inflatable arm cuff coupled to
the sphygmograph, a device small enough to allow measurement outside the laboratory, was invented by Riva-Rocci
(1896), who also noted the “white-coat effect” on blood pressure.22 Nicolai Korotkoff, a Russian military surgeon, first
auscultated brachial arterial sounds (1905), a discovery that marked the advent of modern blood pressure recording. This
auscultatory approach eventually ensured its widespread use by the 1920s. In 1939, blood pressure recordings were
standardized by committees of the American Heart Association (AHA) and the Cardiac Society of Great Britain and
Ireland.

1-10. The answer is C. (Hurst’s the Heart, 14th Edition, Chap. 1) President Franklin Roosevelt’s death in 1945 from severe
hypertension and stroke called international attention to the consequences of hypertension and its inadequate treatment—
he had been managed with diet, digitalis, and phenobarbital. Effective oral treatment became possible in 1949, first with
reserpine and then with hydrochlorothiazide.23 Lumbar sympathectomy and adrenalectomy (1925), the last resort, was
abandoned. Subsequently, β-adrenergic blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blocking
agents, and direct renin inhibitors have brought antihypertensive relief to many. Severe salt restriction, as practiced earlier
with the Kempner rice diet, has taken a lesser role, whereas the Dietary Approaches to Stop Hypertension (DASH) diet,
exercise, and alcohol restriction are encouraged. Since 1973, recommendations published by the Joint National Committee
(JNC) on Detection, Evaluation, and Treatment of High Blood Pressure have been very helpful.

References
1. Harvey W. Anatomical Studies on the Motion of the Heart and Blood. Leake CD, trans. Springfield, IL: Charles C Thomas;
1970.
2. Acierno LJ. The History of Cardiology. London, UK: Parthenon; 1994.
3. Duffin JM. The cardiology of RTH Laënnec. Med Hist. 1989;33:42-71.
4. Hanna IR, Silverman ME. A history of cardiac auscultation and some of its contributors. Am J Cardiol. 2002;90:259-267.
5. Burch GE, DePasquale NP. A History of Electrocardiography. Chicago, IL: Year Book; 1964.
6. Fleming P. A Short History of Cardiology. Amsterdam, Netherlands: Rodopi; 1997.
7. Bing RJ. Cardiology: The Evolution of the Science and the Art. Basel, Switzerland: Harwood; 1992.
8. Forssmann-Falck R. Werner Forssmann: a pioneer of cardiology. Am J Cardiol. 1997;79: 651-660.
9. Mueller RL, Sanborn TA. The history of interventional cardiology: cardiac catheterization, angioplasty, and related
interventions. Am Heart J. 1995;129:146-172.
10. Fishman AP, Dickinson WR. Circulation of the Blood: Men and Ideas. Bethesda, MD: American Physiological Society;
1982.
11. Leibowitz JO. The History of Coronary Heart Disease. Berkeley, CA: University of California Press; 1970.
12. Flaxman N. The hope of cardiology: James Hope (1801–1841). Bull Hist Med. 1938;6:1-21.
13. Vander Veer JB. Mitral insufficiency: historical and clinical aspects. Am J Cardiol. 1958;2:5-10.
14. Rolleston H. The history of mitral stenosis. Br Heart J. 1941;3:1-12.
15. Vaslef SN, Roberts WC. Early descriptions of aortic valve stenosis. Am Heart J. 1993;125:1465-1474.
16. Vaslef SN, Roberts WC. Early descriptions of aortic regurgitation. Am Heart J. 1993;125:1475-1483.
17. Engle MA. Growth and development of state of the art care for people with congenital heart disease. J Am Coll Cardiol.
1989;13:1453-1457.
18. Willius FA, Dry TJ. A History of the Heart and the Circulation. Philadelphia, PA: Saunders; 1948.
19. Naqvi NH, Blaufox MD. Blood Pressure Measurement: An Illustrated History. New York, NY: Parthenon; 1998.
20. Dustan HP. History of clinical hypertension: from 1827 to 1970. In: Oparil S, Weber MA, eds. Hypertension: A Companion
 to Brenner and Rector’s The Kidney. Philadelphia, PA: Saunders; 2000:1-4.
21. Ruskin A. Classics in Arterial Hypertension. Springfield, IL: Charles C Thomas; 1956.
22. Posten–Vinay N. A Century of Arterial Hypertension: 1896-1996. Chichester, UK: Wiley; 1996.
23. Piepho RW, Beal J. An overview of antihypertensive therapy in the 20th century. J Clin Pharmacol. 2000;40:967-977.
CHAPTER 2
The Global Burden of Cardiovascular Diseases
Mark J. Eisenberg

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

2-1. How many deaths worldwide are caused each year by cardiovascular disease (CVD)?
A. 10 million
B. 15 million
C. 17 million
D. 20 million
E. 23 million

2-2. Which of the following statements about global cardiovascular disease (CVD) is false?
A. There has been a steady decrease in the age-specific death rate for CVD in both sexes over the past 20 years
B. Women represent 50% of CVD deaths worldwide
C. The total number of deaths from CVD increased more than 40% between 1990 and 2013
D. Increases in gross domestic product are well correlated with reductions in cardiovascular disease mortality
E. A continued increase in the number of CVD deaths is expected as a result of demographic changes worldwide

2-3. What proportion of ischemic heart disease (IHD) patients from low-income world regions are taking none of the standard
secondary prevention medications?
A. 20%
B. 30%
C. 40%
D. 60%
E. 80%

2-4. Which noncommunicable disease (NCD) is the second most common cause of all disability globally?
A. Stroke
B. Ischemic heart disease
C. Chronic obstructive pulmonary disease
D. Lower back and neck pain
E. Depression

2-5. Which of the following cardiovascular diseases are more commonly diagnosed in men than in women worldwide?
A. Abdominal aortic aneurysm
B. Peripheral arterial disease
C. Atrial fibrillation
D. Both A and B
E. Both A and C

2-6. What is the most common complication of infective endocarditis?

A. Stroke
B. Embolization other than stroke
C. Heart failure
D. Intracardiac abscess
E. Intracardiac fistula
2-7. Which of the following statements about Chagas disease is false?
A. Chagas disease is primarily transmitted through the bites of the Triatoma infestans insect
B. No rapid diagnostic tests are available to detect the causative parasite
C. The acute phase immediately following infection is often asymptomatic, but it produces fever and malaise in up to 5% of
people
D. More than 50% of those infected will not progress to chronic Chagas disease
E. Approximately 30% of those infected will develop chronic cardiovascular Chagas disease

2-8. What percentage of patients with acute rheumatic fever will develop rheumatic heart disease (RHD)?
A. 50%
B. 60%
C. 70%
D. 80%
E. 90%

2-9. Which modifiable cardiovascular risk factor is responsible for the most morbidity and mortality worldwide?
A. Low fruit intake
B. High body mass index
C. High sodium
D. High blood pressure
E. Smoking

2-10. In 2013, the WHO and all member states (194 countries) agreed to a Global Non-Communicable Disease (NCD) Action
Plan, which aims to reduce the number of premature deaths from NCDs by 25% by 2025 through nine voluntary global
targets. Which of the following is not one of the nine voluntary targets?
A. A 20% relative reduction in daily exposure to outdoor and indoor air pollution
B. A 30% relative reduction in the prevalence of current tobacco use in persons aged 15 years and over
C. A 25% relative reduction in the prevalence of raised blood pressure or else containing the prevalence of raised blood
pressure, according to national circumstances
D. A halt in the rise of diabetes and obesity
E. At least 50% of eligible people receiving drug therapy and counseling (including glycemic control) to prevent heart
attacks and strokes

ANSWERS

2-1. The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 2) In 2013, more than 17 million people died from CVDs, with
an estimated US $863 billion in direct health care costs and productivity losses worldwide.1 As a result of the large
populations in many low- and middle-income countries (LMICs), nearly 70% of CVD deaths occurred in LMICs. CVDs
account for 50% of all NCD deaths in the world each year and represent a significant threat to human welfare and
sustainable development. CVDs are the leading cause of death in every region of the world, with the exceptions of sub-
Saharan Africa—where infectious diseases are still the leading cause of death—and South Korea and Japan, where
cancers cause more deaths. The leading cause of CVD-related death was IHD, accounting for more than eight million
deaths, followed by ischemic and hemorrhagic strokes, with more than three million deaths each. Rheumatic heart
disease, although not the leading cause of death, was a significant contributor to the global burden and a leading cause of
highly preventable death, with approximately 275,000 deaths in 2013.

2-2. The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 2) Despite the steady decrease in death rate for both sexes over
the past 20 years, the total number of deaths is increasing as a result of population growth and aging, which
disproportionately affects low- and middle-income countries (LMICs). Globally, the total number of CVD deaths
increased from 12.3 to 17.3 million, a 41% increase between 1990 and 2013.2 Women represent 50% of these deaths.
Although most countries have seen an increased national income per capita over this time, the decrease in the number of
CVD deaths cannot be entirely explained by economic growth. The decline in age-specific CVD mortality does not
correlate well with increases in country income, except weakly in upper-middle income countries. Therefore, it appears
unlikely that economic growth alone will improve a country’s burden of CVD. Despite an overall decrease in the global
age-specific CVD death rate, a continued increase in the number of CVD deaths is expected as a result of demographic
changes. The United Nations estimated that the global population in 2015 was 7.3 billion and will increase to a total of 8.5
billion by 2025 and 9.7 billion by 2050. When population growth slows down as a result of a reduction in fertility, the
population ages, and the proportion of older persons aged 60 or older increases over time. In 2015, about 10% of the
population was aged 60 or older, and the number of adults in this age group is projected to more than double by 2050 and
more than triple by 2100, with more than two-thirds of these older adults residing in LMICs.
2-3. The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 2) Ischemic heart disease is the leading cause of death
worldwide, encompassing myocardial infarction and all other acute coronary syndromes as well as long-term sequelae of
coronary heart disease, including angina pectoris and ischemic cardiomyopathy. Since the 1990s, the high-income
regions, specifically Australasia, Western Europe, and North America, have seen dramatic declines in the age-
standardized IHD mortality.3 However, IHD mortality has increased in other regions, including Central Asia, South Asia,
and East Asia. Although IHD burden falls largely on those aged older than 70 years in high-income regions, the age of
IHD deaths is much lower in other regions, with a mean age of onset of IHD events before age 50 years in more than 29%
of males and 24% of females in North Africa/Middle East and South Asia.3,4 As more patients with IHD survive their
initial event, the IHD death rate and case fatality will no longer be the sole public health benchmark for success; improved
symptom control and overall quality of life and access to adequate treatment will be important secondary outcomes.3 The
mainstays of treatment include standard, low-cost medications that are insufficiently used in low- and middle-income
countries (LMICs). The Prospective Urban Rural Epidemiological (PURE) study found that only 11% of patients from
high-income countries were not taking standard secondary prevention medications, whereas 80% of low-income-region
patients were taking none of the recommended medications.5,6

2-4. The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 2) Stroke was the second largest contributor to disability
globally and in developing countries, whereas it was the third largest contributor to disability in developed countries (after
IHD and lower back and neck pain).7 Globally, the proportional contribution of stroke-related disability-adjusted life
years (DALYs) as a proportion of all diseases increased from 3.5% in 1990 to 4.6% in 2013. The deaths caused by stroke
also increased from 9.7% in 1990 to 11.8% in 2013. In order to reduce the rising burden of stroke worldwide, urgent
prevention and management strategies are needed. Prevention of risk factors remains key to reversing the stroke
pandemic, and universal access to organized stroke services must remain a priority, especially in LMICs.8 In 2013, the top
five noncommunicable causes of disability globally (from most to least) were: IHD, stroke, lower back and neck pain,
chronic obstructive pulmonary disorder, and depression.9

2-5. The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 2) Abdominal aortic aneurysm (AAA) and atrial fibrillation
(AF) are more commonly diagnosed in men than in women worldwide, while peripheral arterial disease (PAD) is equally
common among men and women in developed countries, and it is more often diagnosed in women than in men in
developing countries. AAA is a focal dilation of the abdominal aorta of at least 1.5 times the normal diameter or an
absolute value of 3 cm or greater. Risk factors include male sex, smoking, hypertension, atherosclerosis, and history of
AAA in a first-degree relative. In 2010, the age-specific prevalence rate per 100,000 ranged from 7.9 to 2274. Prevalence
was higher in developed versus developing nations. The age-specific annual incidence rate per 100,000 ranged between
0.83 and 164.6.10 AF and atrial flutter are irregular heart rhythms that often cause a rapid heart rate and can increase the
risk of stroke, heart failure, and other heart-related complications. In 2010, the estimated age-standardized DALYs
resulting from AF was 65 per 100,000 population in males and 46 in females, which was an increase of 18.8% and 19%
for males and females since 1990, respectively.11 Higher burden in men compared with women may reflect actual disease
rates or poorer access to medical care among women in resource-poor settings. PAD is a circulatory problem in which
narrowed arteries reduce blood flow to the limbs and cause symptoms of leg pain with walking (claudication). PAD is
defined as an ankle brachial index lower than or equal to 0.90. In developed countries, among adults aged 45–49 years,
the prevalence is similar for males and females and is around 5%. The prevalence increases to around 18% for males and
females in those aged 85 to 89 years.12 In developing countries, for the same age groups, the prevalence is around 6% for
females and 3% for males and increases to 15% in females and 14% in males.12

2-6. The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 2) Infective endocarditis (IE) is an infection caused by
bacteria, or other infectious pathogens, that enter the bloodstream and cause inflammation in the heart tissues, often on a
valve. Because of the lack of direct blood supply, the heart valves are particularly susceptible to bacterial colonization and
are neither protected by the typical immune response nor easily reached by antibiotics. IE is a serious illness, with up to
22% in-hospital and 40% five-year mortality rates.13 A global collaboration was formed to assess the current
characteristics of patients with IE via a large, prospective multicenter registry, called the International Collaboration on
Endocarditis (ICE). ICE found that contemporary infective endocarditis is most often an acute disease with a high rate of
infection with Staphylococcus aureus and involving the mitral (41.1%) and aortic (37.6%) valves. Common complications
included stroke (16.9%), embolization other than stroke (22.6%), heart failure (32.3%), and intracardiac abscess (14.4%);
these often required surgical intervention (48.2%). In-hospital mortality was high (17.7%).14 Unfortunately, there were
few sites in Asia and Africa included in the registry, which limits the ability to assess geographic differences in patient
and microbiologic characteristics in these areas. IE is estimated to have resulted in 65,000 deaths and 1.9 million DALYs
in 2013. More complete knowledge and improved surveillance are needed in all world regions.15

2-7. The answer is B. (Hurst’s The Heart, 14th Edition, Chap. 2) Chagas disease is a disease of poverty and is localized to
Latin America because it is primarily transmitted through bites from the nocturnal “kissing bug,” Triatoma infestans,
which is endemic to this region. The infection can be asymptomatic, but it can eventually lead to premature morbidity and
mortality, especially in young women of childbearing age. There are rapid diagnostic tests that can detect the causative
parasite, Trypanosoma cruzi, in serum and can diagnose chronic infections. Pesticides have been developed for vector
control programs, but much is still unknown about this disease. In any case, prevention and elimination of the vector
remain the keys to Chagas control. The disease has three phases: acute, indeterminate, and chronic. The acute phase
immediately follows infection and is often asymptomatic, but it produces fever and malaise in up to 5% of people. The
 indeterminate phase is asymptomatic, with more than 50% of those infected remaining in this phase for life without any
long-term sequelae. After a decade or more, approximately 30% of people will experience chronic cardiovascular Chagas
disease, with symptoms including heart failure, arrhythmias, and thromboembolism.16 Deaths are rare in the acute phase,
and most deaths attributable to Chagas disease result from downstream cardiovascular sequelae. In addition,
approximately 15%–20% of people will experience chronic gastrointestinal disease sequelae, including megaesophagus
and megacolon. Between 5 and 18 million people are currently infected, and the infection is estimated to cause more than
10,000 deaths annually.17

2-8. The answer is B. (Hurst’s The Heart, 14th Edition, Chap. 2) Rheumatic heart disease is an endemic disease that is
common in settings of poverty. It is caused by group A streptococcus infection and leads to mitral stenosis and premature
mortality, particularly in young, predominantly female, poorer individuals living in Oceania, South Asia, Central Asia,
Africa, and the Middle East. Approximately 60% of all acute rheumatic fever cases will develop RHD, based on data from
Aboriginal Australian populations, and 1.5% of patients with RHD will die each year.18 Globally in 2010, RHD affected
more than 34 million people, causing more than 345,000 deaths, almost all in LMICs.19 The disease can progress to cause
moderate to severe multivalvular disease, leading to congestive heart failure, pulmonary hypertension, or AF. RHD also
contributes (3%–7.5%) to an estimated 144,000–360,000 incident strokes each year.

2-9. The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 2) Elevated blood pressure is estimated to be the single largest
contributor to the global burden of disease and global mortality. There are gaps in the awareness, treatment, and control of
hypertension globally. High blood pressure in populations appears to occur in tandem with economic development, but
notably in the highest income countries, individuals with lower socioeconomic status are the group most likely to be
untreated.20,21 In Africa, hypertension is thought to be the leading cause of heart failure, whereas at global levels,
hypertension is linked to the development of atherosclerotic vascular disease. In high-income countries, it is estimated to
be responsible for 25% of deaths from stroke, 20% of deaths from IHD, and more than 17% of all global deaths.22 The
number of people with uncontrolled hypertension was 978 million in 2008, a substantial increase from 605 million in
1980, largely because of population growth and aging.23 Other modifiable cardiovascular risk factors are: high body mass
index, low fruit intake, smoking, high sodium, and high total cholesterol.24

2-10. The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 2) While a reduction in exposure to outdoor and indoor air
pollution is not one of the nine targets, such pollution ranks as the largest single environmental health risk factor, with
more than 2.9 million deaths attributed to outdoor air pollution and a similar number attributed to indoor air pollution.25
Air pollution has been shown to increase preclinical cardiovascular risk factors such as atherosclerosis, endothelial
dysfunction, and hypertension. The estimated excess risk of cardiovascular mortality rises 11% per 10 μg/m3 rise in levels
of particulate matter, with no threshold level below which long-term exposure to urban air pollution has no ill effect on
cardiovascular health.26 Answers B through E: Modeling studies have shown that significant reductions in premature
CVD are possible by 2025 if multiple risk factor targets are achieved. Globally, the risk factor change that would lead to
the largest reduction in premature mortality would be the decreased prevalence of hypertension, followed by tobacco
smoking prevalence for men and obesity for women.

References
1. Bloom DE, Cafiero E, Jané-Llopis E, et al. The global economic burden of noncommunicable diseases. Program on the
Global Demography of Aging, World Economic Forum, 2011.
2. Roth GA, Huffman MD, Moran AE, et al. Global and regional patterns in cardiovascular mortality from 1990 to 2013.
Circulation. 2015;132:1667-1678.
3. Moran AE, Forouzanfar MH, Roth GA, et al. The global burden of ischemic heart disease in 1990 and 2010: the Global
Burden of Disease 2010 study. Circulation. 2014;129:1493-1501.
4. Moran AE, Tzong KY, Forouzanfar MH, et al. Variations in ischemic heart disease burden by age, country, and income:
The Global Burden of Diseases, Injuries, and Risk Factors 2010 study. Glob Heart. 2014;9:91-99.
5. Yusuf S, Islam S, Chow CK, et al. Use of secondary prevention drugs for cardiovascular disease in the community in high-
income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey. Lancet.
2011;378:1231-1243.
6. Khatib R, McKee M, Shannon H, et al. Availability and affordability of cardiovascular disease medicines and their effect on
use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet. 2016;387:61-
69.
7. Barker-Collo S, Bennett DA, Krishnamurthi RV, et al. Sex differences in stroke incidence, prevalence, mortality and
disability-adjusted life years: results from the Global Burden of Disease study 2013. Neuroepidemiology. 2015;45:203-214.
8. Feigin VL, Krishnamurthi R, Bhattacharjee R, et al. New strategy to reduce the global burden of stroke. Stroke. 2015
Jun;46(6):1740-1747.
9. Murray CJL, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306
diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological
 transition. Lancet. 2015;386:2145-2191.
10. Sampson UK, Norman PE, Fowkes FG, et al. Estimation of global and regional incidence and prevalence of abdominal
aortic aneurysms 1990 to 2010. Glob Heart. 2014;9:159-170.
11. Chugh SS, Roth GA, Gillum RF, Mensah GA. Global burden of atrial fibrillation in developed and developing nations. Glob
Heart. 2014;9:113-119.
12. Fowkes FGR, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery
disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382:1329-1340.
13. Bannay A, Hoen B, Duval X, et al. The impact of valve surgery on short- and long-term mortality in left-sided infective
endocarditis: do differences in methodological approaches explain previous conflicting results? Eur Heart J. 2011;32:2003-
2015.
14. Murdoch DR. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International
Collaboration on Endocarditis–Prospective Cohort Study. Arch Intern Med. 2009;169:463.
15. Chu VH, Park LP, Athan E, et al. Association between surgical indications, operative risk, and clinical outcome in infective
endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation. 2015;131:131-140.
16. Nunes MC, Dones W, Morillo CA, Encina JJ, Ribeiro AL. Chagas disease: an overview of clinical and epidemiological
aspects. J Am Coll Cardiol. 2013;62:767-776.
17. Stanaway JD, Roth G. The burden of Chagas disease. Glob Heart. 2015;10:139-144.
18. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis.
2005;5:685-694.
19. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a
systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117-171.
20. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.
21. Colhoun HM, Hemingway H, Poulter NR. Socio-economic status and blood pressure: an overview analysis. J Hum
Hypertens. 1998;12:91-110.
22. Forouzanfar MH, Alexander L, Anderson HR, et al. Global, regional, and national comparative risk assessment of 79
behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a
systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287-2323.
23. Danaei G, Finucane MM, Lin JK, et al. National, regional, and global trends in systolic blood pressure since 1980:
Systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million
participants. Lancet. 2011;377:568-577.
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2015;12:627-642.
CHAPTER 3
Assessing and Improving the Quality of Care in
Cardiovascular Medicine
Mark J. Eisenberg

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

3-1. Which of the following statements concerning health care expenditures in the United States is false?
A. Health care expenditures accounted for nearly 17.5% of the gross domestic product in 2014
B. The United States invested an estimated $3.0 trillion in health care in 2014
C. Expenditures related to cardiovascular disease were estimated to be $656 billion in 2015
D. The United States health system ranked lowest among 11 similar countries with respect to access, equity, quality,
efficiency, and healthy lives, despite spending the most on health care
E. Increasing the use of expensive medical care is associated with better quality of care and patient outcomes

3-2. Which of the following factors influences the variability and appropriateness of health care delivery?
A. Patients’ clinical status
B. Sociodemographic factors
C. Providers and facilities
D. Geographic location
E. All of the above

3-3. How many years, on average, does it take for guidelines to be incorporated into clinical practice?
A. 4 years
B. 10 years
C. 13 years
D. 17 years
E. 21 years

3-4. Which of the following is not generally considered a part of defining quality of care?
A. Cost of care
B. Evidence-based care
C. Improving outcomes
D. Patient satisfaction
E. All of the above are important for defining quality of care

3-5. Which constitute the primary domains of the Donabedian framework for quality assurance?
A. Structure, process, and outcome
B. Process, outcome, and evaluation
C. Research, guidelines, and implementation
D. Research, structure, and outcome
E. Research, outcome, and cost

3-6. Which of the following is not a principal thematic dimension in the Institute of Medicine (IOM)’s landmark report on
quality improvement initiatives, Crossing the Quality Chasm: A New Health System for the 21st Century?
A. Safety
B. Cost
 C. Timeliness
D. Efficiency
E. Equity

3-7. What is the specific function of clinical data standards?

A. To measure and improve access to evidence-based care
B. To enable the reproducible collection of data across hospitals and settings
C. To measure physician performance
D. To measure the quality of clinical trial data
E. To enable the assessment of standards of care

3-8. The ACC/AHA guidelines indicate that percutaneous aortic balloon dilation may be considered a bridge to surgical aortic
valve replacement or transcatheter aortic valve replacement for symptomatic patients with severe aortic stenosis (Class IIb,
level C).23 A Class IIb level C recommendation could indicate that the intervention is:
A. Probably indicated, based on data from multiple randomized trials
B. Probably indicated, based on expert opinion
C. Probably indicated, based on case studies
D. Possibly indicated, based on expert opinion
E. Possibly indicated, based on a single randomized trial

3-9. Which of the following tools for improving the quality of cardiovascular care involves quantifying a range of health care
processes and outcomes, identifying multiple points in the continuum of care for which clinical inertia (the failure to
implement or titrate recommended therapies) can occur, and then selecting those with the strongest evidence and highest
correlation with clinically meaningful outcomes?
A. Clinical practice guidelines
B. Clinical data standards
C. Performance measures
D. Appropriate use criteria
E. Procedural registries

3-10. Some of the most exciting opportunities to improve care come from the combination of registries and national coalitions
to target significant gaps in care. A dramatic example of this is the Door-to-Balloon (D2B) initiative. Which of the following
was not a performance recommendation in the D2B initiative?
A. Prompt data feedback to the emergency department and cath lab staff
B. Expectations of having the cath lab team assembled within 30 minutes
C. Targeted times to first ECG acquisition for chest pain patients within 15 minutes
D. Emergency medicine physician activates cath lab
E. Single-call activation of the cath lab

ANSWERS

3-1. The answer is E. (Hurst’s the Heart, 14th Edition, Chap. 3) In the United States, health care expenditures accounted for
nearly 17.5% of the gross domestic product in 2014 (an estimated $3 trillion) and are expected to reach 19.6% by 2024.1
Cardiovascular disease (CVD) remains the leading cause of death and disability,2 with an estimated annual total cost of
$656 billion in 2015.3 In a recent report, the US health system ranked lowest among 11 countries with respect to access,
equity, quality, efficiency, and healthy lives,4 despite spending the most on health care.5 It is often thought that high-
quality health care is dependent on the continued discovery and delivery of novel diagnostic and therapeutic interventions.
However, studies suggest that greater use of expensive medical care is actually associated with lower quality and worse
outcomes.6,7 Woolf and Johnson8 have extended this concept to mathematically quantify the trade-off between the
development of new interventions and the more consistent delivery of known therapies. They argue that despite
tremendous scientific and technologic advancements, the failure to consistently deliver proven therapies dilutes and
reduces the overall quality of a health care system. Thus, money spent on improving this actual delivery of care may be
equally or even more critical than money spent on improving technology to result in improved quality of both routine and
specialized health care.

3-2. The answer is E. (Hurst’s the Heart, 14th Edition, Chap. 3) A critical goal of efforts to disseminate high-quality care is
to ensure rational and efficient use of effective treatment to those who derive the most benefit.9 Yet surveys evaluating
processes of care have shown that, on an average, only one in two US adults receives recommended care when receiving
health care services.10 Several studies have suggested that there are marked variations in the use of evidence-based
 treatments of cardiovascular disease (CVD) based on gender, age, race, education, income, and insurance status.10,11,12,13
A study examining differences in the treatment of myocardial infarction showed that although blacks lived closer than
whites to hospitals with revascularization capability that were considered high-quality, they were less likely than whites to
be admitted to revascularization-capable and high-quality hospitals.14 Further emphasizing the need to monitor the quality
of care has been the observation of marked variations in the processes of care by geographic region. Pioneering work from
the Dartmouth Atlas series, a comprehensive evaluation of health care services provided to Medicare beneficiaries, has
documented broad variation in the use of both diagnostic and treatment modalities in CVD as a function of the site of
care.15 Beyond concerns about overall disparities in care, there is emerging evidence that among the patients eligible for
treatments, those with the least potential to benefit are preferentially treated, whereas those with the most to gain are
systematically undertreated. This finding is referred to as the risk-treatment paradox. Many investigators have shown that
high-risk patients—who would be expected to benefit more than lower-risk patients—are treated less aggressively,
whereas lower-risk patients are treated more aggressively.16,17

3-3. The answer is D. (Hurst’s the Heart, 14th Edition, Chap. 3) It is estimated that, on average, it takes about 17 years for
guidelines to be incorporated into clinical practice,9 even with an intervention as simple as aspirin use at the time of
myocardial infarction (> 20 years for full adoption). There can be several levels of barriers to the effective implementation
of clinical evidence and guidelines in routine practice. These exist at policy, societal, system/organizational, provider, and
patient levels. These can be addressed through the use of frameworks for quality metrics and tools to improve quality of
care in cardiovascular disease.

3-4. The answer is E. (Hurst’s the Heart, 14th Edition, Chap. 3) Lohr and Schroeder broadly define quality of care as “the
degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge.”18 The US Agency for Healthcare Research and Quality has proposed a
similar definition: “Quality healthcare means doing the right thing at the right time in the right way for the right person
and having the best results possible.”19 The Institute for Healthcare Improvement recommends that to improve the United
States’ health care system requires simultaneous pursuit of three aims, called the “Triple Aim”—improving the patient
experience of care (including satisfaction), improving outcomes (of individuals and populations), and reducing the per
capita cost of health care.20 Achieving the best quality of care as marked by highest quality patient outcome and
experience with the lowest possible cost is what a health care system usually strives to achieve. Although the concept of
quality health care is intuitive and relatively easy to understand, to actually measure, monitor, and improve quality
requires the use of a clear conceptual framework that encompasses important, relevant aspects of health care.

3-5. The answer is A. (Hurst’s the Heart, 14th Edition, Chap. 3) One of the earliest approaches to conceptualizing the
components of quality assurance was proposed by Donabedian.21 This framework considers quality to comprise three
main domains: structure, process, and outcome. Structure refers to the attributes of settings where care is delivered and
includes aspects that exist independently of the patient. Examples of structural attributes include provider training and
experience, the availability of specialized treatments, nurse-to-patient ratios, and treatment and discharge plans. Process
refers to whether or not good medical practices are followed, and it incorporates concepts such as the medications given
and the timing of their administration, the use of diagnostic and therapeutic procedures, and patient counseling. Outcome
refers to tangible measures that capture the consequences of care and range from manifestations of disease progression
(eg, mortality and hospitalizations) to patient-centered outcomes of health status and treatment satisfaction. As noted by
Donabedian, these three components of quality are interdependent and are built on a framework that focuses mainly on
linking the delivery of care to outcomes.

3-6. The answer is B. (Hurst’s the Heart, 14th Edition, Chap. 3) The current driving force and roadmap for quality
improvement initiatives in American health care is the Institute of Medicine (IOM)’s landmark report, Crossing the
Quality Chasm: A New Health System for the 21st Century.9 The IOM recognized the following principal thematic
dimensions needed to guide QI in health care:
• Safety—avoiding injuries to patients from the care that is intended to help them
• Effectiveness—providing services based on scientific knowledge to those who could benefit while refraining from
providing services to those not likely to benefit
• Patient-centeredness—providing care that is respectful of and responsive to individual patient preferences, needs, and
values, and ensuring that patient values guide all clinical decisions
• Timeliness—reducing waits and sometimes harmful delays in care
• Efficiency—avoiding waste, including waste of equipment, supplies, ideas, and energy
• Equity—providing care that does not vary in quality because of personal characteristics such as sex, ethnicity,
geographic location, and socioeconomic status
Cost is not one of the principal themes of the IOM report, but it is considered among the outcomes in the Donabedian
framework for quality assurance.

3-7. The answer is B. (Hurst’s the Heart, 14th Edition, Chap. 3) To measure and improve care, one first needs to know both
how and what to measure. It is critical to have standardized data definitions that enable the reproducible collection of data
across different hospitals and settings. To create the foundation for clear, explicit data capture, the ACC/AHA Clinical
Data Standards were developed to serve as a foundation for implementing and evaluating the other ACC/AHA quality
 tools.22 These data standards are a set of standardized definitions of particular conditions and treatments that can and
should be applied in both QA/QI activities and, importantly, clinical trials. Inclusion in clinical trials is especially
important to support both comparability across studies and their incorporation into guidelines, performance measures, and
clinical care. In particular, standardized definitions support the consistent definition of symptoms, comorbidities, and
outcomes in many areas of CVD (eg, acute coronary syndromes, congestive heart failure, PCI).22 The more these data
standards are used in clinical trials, observational registries, and QA/QI efforts, the greater the ability will be to translate
the emerging knowledge from clinical research to clinical care.

3-8. The answer is D. (Hurst’s the Heart, 14th Edition, Chap. 3) To distill the rapidly expanding body of cardiovascular
literature, professional agencies, such as the AHA and ACC, have commissioned expert committees to synthesize the
available evidence into clinical practice guidelines.24-25 The creation of guidelines requires writing committees to
systematically review the medical literature and to assess the strength of evidence for particular treatment strategies. This
necessitates ranking the types of research from which knowledge is generated. Randomized controlled trials are given the
highest weight. When these are not available, other study designs, including preintervention and postintervention studies,
observational registries, and clinical experience are used. To transparently communicate the strength of a recommendation
and the evidence on which it is generated, a class recommendation (Class I = strongly indicated, Class IIa = probably
indicated, Class IIb = possibly indicated, or Class III = not indicated) and strength of the evidence (level A evidence [data
derived from multiple randomized trials] through level C [data derived from expert opinion, case studies, or standard of
care]) are provided.25 An intervention that is probably indicated, based on data from multiple randomized trials (option A)
is a Class IIa level A recommendation. An intervention that is probably indicated, based on expert opinion (option B) or
probably indicated, based on case studies (option C) are both Class IIa level C recommendations. An intervention that is
possibly indicated, based on a single randomized trial (option E), is a Class IIb level B recommendation.

3-9. The answer is C. (Hurst’s the Heart, 14th Edition, Chap. 3) At times, the evidence supporting (or for avoiding) a
particular diagnostic or therapeutic action is so strong that failure to perform such actions jeopardizes patients’ outcomes.
Performance measures represent that subset of the clinical practice guidelines (option A) for which the strongest evidence
exists and for which their routine use (or avoidance) is felt to be an important advance to elevating quality.26,27,28
Performance measures are often constructed as a set of measures that quantify a range of health care processes and
outcomes; they are designed to identify multiple points in the continuum of care for which clinical inertia—the failure to
implement or titrate recommended therapies—can occur.28,29 Once the relevant domains are identified, then those
guideline recommendations with the strongest evidence and highest correlation with clinically meaningful outcomes are
selected for performance measure creation. Clinical data standards (option B) are a set of standardized definitions of
particular conditions and treatments that can be applied in both quality assurance/improvement activities and clinical
trials. Appropriate use criteria (option D) help identify what specific tests and procedures to perform and when and how
often, based on estimates of the relative benefits and harms of a procedure or a test for a specific indication. Procedural
registries (option E) support the prospective collection of data for assessing performance and guideline compliance within
hospitals.

3-10. The answer is C. (Hurst’s the Heart, 14th Edition, Chap. 3) First ECG acquisition for chest pain patients was
recommended within 10 minutes. Launched in 2006, the Door-to-Balloon (D2B) initiative sought to increase the
proportion of ST-segment elevation myocardial infarction patients receiving primary PCI within 90 minutes of hospital
presentation from approximately 50% to more than 75%.30 This program supplemented data collected through the NCDR
CathPCI registry with explicit recommendations about how to improve performance,31 including (1) activation of the
catheterization laboratory (cath lab) by emergency department physicians, (2) single-call activation of the cath lab, (3)
expectations of having the cath lab team assembled within 30 minutes, (4) prompt data feedback to the emergency
department and cath lab staff, and (5) activation of the cath lab based on prehospital ECGs and targeted times to first ECG
acquisition for chest pain patients within 10 minutes. Between January 2005 and September 2010, this effort led to a
decline in median D2B time, from 96 minutes in December 2005 to 64 minutes in September 2010.32 There were
corresponding increases in the proportion of patients undergoing primary PCI within 90 minutes (from 44.2% to 91.4%),
and within 75 minutes (from 27.3% to 70.4%). The declines in median times were greatest among groups that had the
highest median times during the first period.32

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 102. Instead of και δικης, I read και μετα δικης.

103. i. e. Should be perfectly impartial.

104. Instead of διπλοτατοις μοναδος as in the original, which is nonsense, it is

necessary to read, as in the above translation, απλοτητι της μοναδος.

105. For 2 + 4 + 6 + 8 = 20; and 1 + 3 + 6 + 7 = 16; and 20 + 16 = 36.

106. The cock was sacred to Apollo, and therefore its heart was believed to be
the instrument of divination in sacrifices. The chemic Olympiodorus says, “that the
cock obscurely signifies the essence of the sun and moon.” See, in the additional
notes, what is said by Proclus concerning the cock, in his treatise On Magic.

107. It is well observed by Ficinus, in lib. i. Eunead. ii. Plotin. “that the fire
which is enkindled by us is more similar to the heavens than other terrestrial
substances. Hence it participates of light, which is something incorporeal, is the
most powerful of all things, is as it were vital, is perpetually moved, divides all
things, without being itself divided, absorbs all things in itself, and avoids any
foreign mixture: and lastly, when the fuel of it is consumed, it suddenly flies back
again to the celestial fire, which is every where latent.”

108. For this vehicle is luciform, and consists of pure, immaterial, unburning,
and vivific fire. See the fifth book of my translation of Proclus on the Timæus.

109. Proclus in Tim. lib. v. observes concerning the telestic art, or the art
which operates through mystic ceremonies, “that, as the oracles teach, it
obliterates through divine fire all the stains produced by generation.” Η τελεστικη
δια του θειου πυρος αφανιζει τας εκ της γενεσεως απασας κηλιδας, ως τα λογια
διδασκει. Hence another Chaldean oracle says, τῳ πυρι γαρ βροτος εμπελασας
θεοθεν φαος εξει. i. e. “The mortal who approaches to fire will have a light from
divinity.” Hercules, as we also learn from Proclus, was an example of this telestic
purification. For he says, Ηρακλης δια τελεστικης καθῃραμενος, και των αχραντων
καρπων μετασχων, τελειας ετυχε εις τους θεους αποκαταστασεως, in Plat. Polit. p.
382. i. e. “Hercules being purified through the telestic art, and participating of
undefiled fruits, obtained a perfect restoration to the Gods.”

110. In the original, λεγω δε της θειας ψυχης τε και φυσεως, αλλ’ ουχι της
περικοσμιου τε και γενεσιουργου. But it appears to me that we should here read,
conformably to the above translation, λεγω δε της θειας, ψυχης τε και ψυσεως,
αλλ’ ουχι μονου της περικοσμιου τε και γενεσιουργου.

111. These media consist of the order of Gods denominated αρχαι, or rulers,
and of those called απολυτοι, or liberated; the former of which also are
denominated supermundane, and the latter supercelestial, in consequence of
existing immediately above the celestial Gods. See, concerning these media, the
sixth book of my translation of Proclus on the Theology of Plato.

112. Proclus on the First Alcibiades observes, “that about every God there is an
innumerable multitude of dæmons, who have the same appellations with their
leaders. And that these are delighted when they are called by the names of Apollo
or Jupiter, because they express in themselves the characteristic peculiarity of their
leading Gods.” In the same admirable commentary, also, he says, “that in the most
holy of the mysteries [i. e. in the Eleusinian mysteries], prior to the appearance of
divinity, the incursions of certain terrestrial dæmons present themselves to the
view, alluring the souls of the spectators from undefiled good to matter.”

113. It is beautifully observed by Simplicius on Epictetus, “that as if you take

away letters from a sentence, or change them, the form of the sentence no longer
remains, thus also in divine works or words, if any thing is deficient, or is changed,
or is confused, divine illumination does not take place, but the indolence of him
who does this dissolves the power of what is effected.” Ωσπερ γαρ εαν στοιχεια του
λογου αφελῃς, ἢ υπαλλαξης, ουκ επιγινεται το του λογου ειδος, ουτω και των θειων
εργων ἢ λογων ει ελλειπει τι, ἢ υπηλλακται, ἢ συγκεχυται, ουκ επιγινεται η του
θειου ελλαμψις, αλλα και εξυδαροι την των γινομενων δυναμιν η του ποιουντος
ραθυμια.

114. Conformably to this, Servius, in his Annotations on the words

Diique, deæque omnes—

in the sixth book of the Æneid observes, “more pontificum, per quos ritu veteri
in omnibus sacris post speciales Deos, quos ad ipsum sacrum, quod fiebat necesse
erat invocari, generaliter omnia numina invocabantur.” i. e. “This is spoken after
the manner of the pontiffs, by whom, according to ancient rites, in all sacrifices,
after the appropriate Gods whom it was necessary to invoke to the sacrifice, all the
divinities were invoked in general.” And in his Annotations on the seventh of the
Æneid he informs us, “that king Œneus offered a sacrifice of first fruits to all the
divinities but Diana, who being enraged sent a boar [as a punishment for the
neglect].” With respect to this anger, however, of Diana, it is necessary to observe
with Proclus, “that the anger of the Gods does not refer any passion to them, but
indicates our inaptitude to participate of them.” Ο γαρ των θεων χολος, ουκ εις
εκεινας αναπεμπει τι παθος, αλλα την ημων δεικνυσι ανεπιτηδειοτητα της εκεινων
μεθεξεως.

115. Plotinus was a man of this description, to whom, most probably,

Iamblichus alludes in what he now says.

116. In the original θυμον τινος: but it is doubtless requisite to read with Gale,
θεσμον τινος. This I have translated a certain divine legislation, because we are
informed by Proclus, in Platon. Theol. lib. iv. p. 206, “that θεσμος is connected
with deity, and pertains more to intelligibles; but that νομος, which unfolds
intellectual distribution, is adapted to the intellectual fathers.” Ο γαρ θεσμος
συμπλεκεται τῳ θεῳ, και προσηκει μαλλον τοις νοητοις ο δε νομος την νοεραν
εμφαινων διανομην, οικειος εσι τοις νοεροις πατρασι.

117. “Perhaps,” says Proclus, in MS. Comment, in Parmenid. “it is necessary

that, as in souls, natures, and bodies, fabrication does not begin from the
imperfect; so likewise in matter, prior to that which is formless, and which has an
evanescent being, there is that which is in a certain respect form, and which is
beheld in one boundary and permanency.” This, therefore, will be the pure and
divine matter of which Iamblichus is now speaking. Damascius also says, that
matter is from the same order whence form is derived.

118. This particular respecting the apples of gold is added from the version of
Scutellius, who appears to have translated this work from a more perfect
manuscript than that which was used by Gale.

119. The conjecture of Gale, that for ἢ το εν Αβυδῳ in this place, we should
read ἢ το εν αδυτῳ, is, I have no doubt, right. For the highest order of intelligibles
is denominated by Orpheus the adytum, as we are informed by Proclus in Tim. By
the arcanum in the adytum, therefore, is meant the deity who subsists at the
extremity of the intelligible order (i. e. Phanes); and of whom it is said in the
Chaldean Oracles, “that he remains in the paternal profundity, and in the adytum,
near to the god-nourished silence.”

120. For εις το φαινομενον και ορφμενον σωμα, I read εις το φερομενον κ. τ.
λ.

121. Here too for Αβυδῳ I read αδυτῳ.

122. Conformably to this, Martianus Capella also, in lib. ii. De Nuptiis Philol.
&c. speaking of the sun, says, “Ibi quandam navim, totius naturæ cursus diversa
cupiditate moderantem, cunctaque flammarum congestione plenissimam, et beatis
circumactam mercibus conspicatur. Cui nautæ septem, germani tamen, suique
similes præsidebant in prora. Præsidebat in prora felis forma depicta, leonis in
arbore, crocodili in extimo.” For these animals, the cat, the lion, and the crocodile
were peculiarly sacred to the sun. Martianus adds, “In eadem vero rate, fons
quidem lucis æthereæ, arcanisque fluoribus manans, in totius mundi lumina
fundebatur.” i. e. “In the same ship there was a fountain of etherial light flowing
with arcane streams, which were poured into all the luminaries of the world.”
Porphyry, likewise, in his treatise De Antro Nymph. says, “that the Egyptians
placed the sun and all dæmons not connected with any thing solid or stable, but
raised on a sailing vessel.”
 123. In the original παν ζωδιον, which Gale erroneously translates animalia
omnia.

124. Of this kind are the following names in Alexand. Trallian. lib. ii. Μευ,
Θρευ, Μορ, Φορ, Τευξ, Ζα, Ζων, Θε, Λου, Χρι, Γε, Ζε, Ων, i.e. Meu, Threu, Mor,
Phor, Teux, Za, Zōn, The, Lou, Chri, Ge, Ze, Ōn. By these names Alexander
Trallianus says, the sun becomes fixed in the heavens. He adds, “Again behold the
great name Ιαξ, (lege Ιαω), Αζυφ, Ζυων, Θρευξ, Βαϊν, Χωωκ, i. e. Iaō, Azuph, Zuōn,
Threux, Baïn, Chōōk.” Among the Latins, also, Cato, Varro, and Marcellus de
Medicamentis Empiricis, there are examples of these names; the power and
efficacy of which, as Gale observes, are testified by history, though it is not easy to
explain the reason of their operation.

125. Proclus, in commenting on the following words of Plato in the Timæus,

(see vol. i. p. 228, of my translation of his Commentary), viz. “Let, therefore, this
universe be denominated by us all heaven, or the world, or whatever other
appellation it may be especially adapted to receive,” beautifully thus observes
concerning the divine name of the world. “As of statues established by the telestic
art, some things pertaining to them are manifest, but others are inwardly
concealed, being symbolical of the presence of the Gods, and which are only known
to the mystic artists themselves; after the same manner, the world being a statue of
the intelligible, and perfected by the father, has indeed some things which are
visible indications of its divinity; but others, which are the invisible impressions of
the participation of being received by it from the father, who gave it perfection, in
order that through these it may be eternally rooted in real being. Heaven, indeed,
and the world are names significant of the powers in the universe; the latter, so far
as it proceeds from the intelligible; but the former, so far as it is converted to it. It
is, however, necessary to know that the divine name of its abiding power, and
which is a symbol of the impression of the Demiurgus, according to which it does
not proceed out of being, is ineffable and arcane, and known only to the Gods
themselves. For there are names adapted to every order of things; those, indeed,
that are adapted to divine natures being divine, to the objects of dianoia being
dianoetic, and to the objects of opinion doxastic. This also Plato says in the
Cratylus, where he embraces what is asserted by Homer on this subject, who
admits that names of the same things are with the Gods different from those that
subsist in the opinions of men,

Xanthus by God, by men Scamander call’d

Iliad xx. v. 74.

And,

Which the Gods Chalcis, men Cymindis call.

Iliad xiv. v. 291.
 And in a similar manner in many other names. For as the knowledge of the
Gods is different from that of partial souls, thus also the names of the one are
different from those of the other; since divine names unfold the whole essence of
the things named, but those of men only partially come into contact with them.
Plato, therefore, knowing that this preexisted in the world, omits the divine and
ineffable name itself, which is different from the apparent name, and with the
greatest caution introduces it as a symbol of the divine impression which the world
contains. For the words, “or whatever other appellation” and “it may receive” are
a latent hymn of the mundane name, as ineffable, and as allotted a divine essence,
in order that it may be coordinate to what is signified by it. Hence, also, divine
mundane names are delivered by Theurgists; some of which are called by them
ineffable, but others effable; and some being significant of the invisible powers in
the world, but others of the visible elements from which it derives its completion.
Through these causes, therefore, as hypotheses, the mundane form, the demiurgic
cause and paradigm, and the apparent and unapparent name of the world are
delivered. And the former name, indeed, is dyadic, but the latter monadic. For the
words “whatever other” are significant of oneness. You may also consider the
ineffable name of the universe as significant of its abiding in the father; but the
name world, as indicative of its progression; and heaven of its conversion. But
through the three, you have the final cause, on account of which it is full of good;
abiding ineffably, proceeding perfectly, and converting itself to the good as the
antecedent object of desire.”

126. See the additional notes at the end of vol. v. of my translation of Plato,
where many of these names are beautifully unfolded from the MS. Scholia of
Proclus on the Cratylus.

127. See the additional notes at the end of vol. v. of my translation of Plato,
and also the notes to my translation of Aristotle de Interpretatione, in which the
reader will find a treasury of recondite information concerning names, from
Proclus and Ammonius.

128. Most historians give the palm of antiquity to the Egyptians. And Lucian,
in lib. De Syria Dea, says, “that the Egyptians are said to be the first among men
that had a conception of the Gods, and a knowledge of sacred concerns.——They
were also the first that had a knowledge of sacred names.” Αιγυπτιοι πρωτοι
ανθρωπων λεγονται θεων τε εννοιην λαβειν και ιρα εισασθαι——πρωτοι δε και
ονοματα ιρα εγνωσαν. Conformably to this, also, an oracle of Apollo, quoted by
Eusebius, says that the Egyptians were the first that disclosed by infinite actions
the path that leads to the Gods. This oracle is as follows:

Αιπεινη γαρ οδος, μακαρων, τρηχειατε πολλον,

Χαλκοδετοις τα πρωτα διοιγομενη πυλεωσιν.
Ατραπιτοι δε εασσιν αθεσφατοι εγγεγαυιαι
Ας πρωτοι μεροπων επ’ απειρονα πρηξιν εφηναν,
 Οι το καλον πινοντες υδωρ Νειλωτιδος αιης·
Πολλας και Φοινικες οδους μακαρων εδαησαν,
Ασσυριοι, Λυδοιτε, και Εβραιων (lege Χαλδαιων) γενος ανδρων.

i.e. “The path by which to deity we climb,

Is arduous, rough, ineffable, sublime;
And the strong massy gates, through which we pass
In our first course, are bound with chains of brass.
Those men the first who of Egyptian birth
Drank the fair water of Nilotic earth,
Disclosed by actions infinite this road,
And many paths to God Phœnicians show’d.
This road th’ Assyrians pointed out to view,
And this the Lydians and Chaldeans knew.”

For Εβραιων in this oracle I read Χαλδαιων, because I have no doubt that
either Aristobulus the Jew, well known for interpolating the writings of the
Heathens, or the wicked Eusebius as he is called by the Emperor Julian, have
fraudulently substituted the former word for the latter.

129. Prayers of this kind are such as those of which Proclus speaks in Tim. p.
65, when he says, “The cathartic prayer is that which is offered for the purpose of
averting diseases originating from pestilence, and other contagious distempers,
such as we have written in our temples.” Καθαρτικαι δε (ευχαἰ, επι αποτροπαις
λοιμικων νοσημοτων, ἢ παντοιων μολυσμων’ οιας δε και εν τοις ιεροις εχομεν
αναγεγραμμενας.

130. Porphyry, in lib. ii. De Abstinentia, mentions Seleucus the theologist, and
Suidas says that Seleucus the Alexandrian wrote 100 books concerning the Gods.

131. These books (βιβλοι) were most probably nothing more than short
discourses, such as the treatises now are which are circulated as written by
Hermes, and which, as Iamblichus informs us, contain Hermaic doctrines.

132. A great priest, a scribe of the Adyta in Egypt, by birth a Sebanite, and an
inhabitant of Heliopolis, as he relates of himself.

133. In the original, πρωτος και του πρωτου θεου και βασιλεως, which Gale
translates, prior etiam primo Deo, et rege [sole]. But the addition of sole in his
translation is obviously most unappropriate and false: for Iamblichus is evidently
speaking of a deity much superior to the sun.

134. For Ημηφ here, Gale conjectures that we should read Κνηφ Kneph: for
Plutarch says that the unbegotten Kneph was celebrated with an extraordinary
degree of veneration by the Egyptian Thebans.
 135. Hence the moon is said by Proclus to be αυτοπτον της φυσεως αγαλμα,
the self-visible statue or image of nature.

136. Proclus in Tim. p. 117, cites what is here said as the doctrine of the
Egyptians, and also cites for it the authority of Iamblichus. But his words are, και
μην και η των Αιγυπτιων παραδοσις τα αυτα περι αυτης (της υλης) φησιν. ο γε τοι
θειος Ιαμβλιχος ιστορησεν οτι και Ερμης εκ της ουσιοτητος την υλοτητα
παραγεσθαι βουλεται., i. e. “Moreover the doctrine of the Egyptians asserts the
same things concerning matter. For the divine Iamblichus relates that Hermes also
produces matter from essentiality.”

137. This is most probably the Chæremon who is said by Porphyry, in lib. iv.
De Abstinentia, “to be a lover of truth, an accurate writer, and very conversant with
the Stoic philosophy.” Τοιαυτα μεν τα κατ’ Αιγυπτιους υπ’ ανδρος φιλαληθους τε
και ακριβους, εντε τοις Στωϊκοις πραγματικωτατα φιλοσοφησαντος
μεμαρτυρημενα.

138. This was the ninth king in the twenty-sixth dynasty of the Saitan kings.

139. This city is mentioned by Plato in the Timæus, who represents Critias as
saying “that there is a certain region of Egypt, called Delta, about the summit of
which the streams of the Nile are divided, and in which there is a province called
Saitical.” He adds, “of this province the greatest city is Saïs, from which also King
Amasis derived his origin. The city has a presiding divinity, whose name is, in the
Egyptian tongue, Neith, but in the Greek Athena, or Minerva.” It is singular that
Gale, who is not deficient in philology, though but a smatterer in philosophy,
should have omitted to remark in his notes this passage of Plato.

140. Proclus, in MS. Comment, in Alcibiad. cites one of the Chaldean oracles,
which says,

——πορθμιον ουνομα το δ’ εν απειροις

Κοσμοις ενθρωσκον.

i. e. “There is a transmitting name which leaps into the infinite worlds.” And in
his MS. Scholia in Cratyl. he quotes another of these oracles, viz.

Αλλα εστιν ουνομα σεμνον ακοιμητῳ στροφαλιγγι,

Κοσμοις ενθρωσκον, κραιπνην δια πατρος ενιπην.

i. e. “There is a venerable name with a sleepless revolution, leaping into the

worlds through the rapid reproofs of the father.”

141. For εχεται in this place, I read περιεχεται.

 142. Gale, in his translation of this part, has entirely mistaken the meaning of
Iamblichus, which he frequently does in other places. For the words of Iamblichus
are, οταν γαρ δη τα βελτιονα των εν ημιν ενεργῃ, και προς τα κρειττονα αναγεται
αυτης η ψυχη; and the version of Gale is “quando enim pars nostri melior operari
incipiat, et ad sui portionem meliorem recolligatur anima.” For τα κρειττονα is not
the better part of the soul; but when the better parts of the soul energize, the soul is
then intimately converted to itself, and through this conversion is elevated to
superior natures.

143. Viz. The science of calculating nativities.

144. i. e. The joint risings and settings.

145. i. e. Through a period of 300,000 years; and Procl. in Tim. lib. iv. p. 277,
informs us that the Chaldeans had observations of the stars which embraced whole
mundane periods. What Proclus likewise asserts of the Chaldeans is confirmed by
Cicero in his first book on Divination, who says that they had records of the stars
for the space of 370,000 years; and by Diodorus Siculus, Bibl. lib. xi. p. 118, who
says that their observations comprehended the space of 473,000 years.

146. “We say,” says Hephestion, “that a star is the lord of the geniture, which
has five conditions of the lord of the nativity in the horoscope; viz. if that star
receives the luminaries in their proper boundaries, in their proper house, in their
proper altitude, and in the proper triangle.” He also adds, “and if besides it has
contact, effluxion, and configuration.” See likewise Porphyry in Ptolemæum, p. 191.

147. According to the Egyptians every one received his proper dæmon at the
hour of his birth; nor did they ascend any higher, in order to obtain a knowledge of
it. For they alone considered the horoscope. See Porphyry apud Stobæum, p. 201,
and Hermes in Revolut. cap. iv.

148. In the original ενταυθα δε ουν και η της αληθειας παρεστι θεα, και η της
νοερας επιστημης. But instead of η της νοερας απιστημης, which appears to me to
be defective, I read η κτησις της νοερας επιστημης.

149. For θεωτος here, I read θεωτερος.

150. In the original, by a strange mistake, των θνητων is inserted here instead
of των νοητων, which is obviously the true reading. The version of Gale also has
intelligibilium.

151. i. e. Man, considered as a rational soul, connected with the irrational life;
for this man has dominion in the realms of generation.

152. See the second edition of this work in Nos. XV. and XVI. of the
Pamphleteer.
 153. i. e. Of natures which are not connected with body.

154. For in these, all are in each, but not all in all.

155. By an unaccountable mistake here του σωματος is inserted instead of της

ψυχης; but the mistake is not noticed by the German editor of these Scholia.

156. And in consequence of this mistake, for αυτο in this place, we must read
αυτα.

157. Odyss. xi. 612.

158. Iliad xv. 605.

159. For μουσικης here, it is necessary to read μαντικης.

160. And for μαντικην read μαντικη.

161. For υπο here, it is necessary to read υπερ.

162. The German editor of these Scholia, instead of πρακτικῃ which is the true
reading in this place, and which he found in the manuscript, absurdly substitutes
for it πυκτικῃ, as if Hercules was a pugilist. See my translation of the Dissertation
at Maximus Tyrius, on the Practic and Theoretic Life.

163. Vid. Olympiodor. in Aristot. Meteor.

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