Do cardiologists have to do surgery?

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

Cardiology

Although the cardiovascular system is inextricably linked to blood, cardiology is relatively unconcerned with hematology and its diseases. Some obvious exceptions that affect the function of the heart would be blood tests (electrolyte disturbances, troponins), decreased oxygen carrying capacity (anemia, hypovolemic shock), and coagulopathies.

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

Cardiology is a specialty of internal medicine. To be a cardiologist in the United States, a three-year residency in internal medicine is followed by a three-year fellowship in cardiology. It is possible to specialize further in a sub-specialty. Recognized sub-specialties in the United States by the ACGME are cardiac electrophysiology, echocardiography, interventional cardiology, and nuclear cardiology. Recognized subspecialties in the United States by the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS) include clinical cardiac electrophysiology and interventional cardiology.

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

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

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

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

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

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

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

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

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

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

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

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

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

Tetralogy of Fallot, pulmonary atresia, double outlet right ventricle, transposition of the great arteries, persistent truncus arteriosus, and Ebsteins anomaly are various congenital cyanotic heart diseases. Congenital cyanotic heart diseases is where something is wrong with the heart of a newborn and it is not oxygenating the blood efficiently.
Tetralogy of Fallot is the most common congenital heart disease arising in 1–3 cases per 1,000 births. The cause of this defect is a ventricular septal defect (VSD) and an overriding aorta. These two defects combined causes deoxygenated blood to bypass the lungs and going right back into the circulatory system. The modified Blalock-Taussig shunt is usually used to fix the circulation. This procedure is done by placing a graft between the subclavian artery and the ipsilateral pulmonary artery to restore the correct blood flow.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hypertension, also known as "high blood pressure"", is a long term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long term high blood pressure, however, is a major risk factor for coronary artery disease, stroke, heart failure, peripheral vascular disease, vision loss, and chronic kidney disease.
Lifestyle factors can increase the risk of hypertension. These include excess salt in the diet, excess body weight, smoking, and alcohol. Hypertension can also be caused by other diseases, or as a side-effect of drugs.
Blood pressure is expressed by two measurements, the systolic and diastolic pressures, which are the maximum and minimum pressures, respectively. Normal blood pressure at rest is within the range of 100–140 millimeters mercury (mmHg) systolic and 60–90 mmHg diastolic. High blood pressure is present if the resting blood pressure is persistently at or above 140/90 mmHg for most adults. Different numbers apply to children. Ambulatory blood pressure monitoring over a 24-hour period appears more accurate than office best blood pressure measurement.
Lifestyle changes and medications can lower blood pressure and decrease the risk of health complications. Lifestyle changes include weight loss, decreased salt intake, physical exercise, and a healthy diet. If lifestyle changes are not sufficient then blood pressure medications are used. Up to three medications can control blood pressure in 90% of people. The treatment of moderately high arterial blood pressure (defined as >160/100 mmHg) with medications is associated with an improved life expectancy. The effect of treatment of blood pressure between 140/90 mmHg and 160/100 mmHg is less clear, with some reviews finding benefit and others finding a lack of evidence for benefit. High blood pressure affects between 16 and 37% of the population globally. In 2010 hypertension was believed to have been a factor in 18% (9.4 million) deaths.

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

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

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

Cardiac arrhythmia
Cardiac arrhythmia, also known as "cardiac dysrhythmia" or "irregular heartbeat", is a group of conditions in which the heartbeat is irregular, too fast, or too slow. A heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia and a heart rate that is too slow – below 60 beats per minute – is called bradycardia. Many types of arrhythmia have no symptoms. When symptoms are present these may include palpitations or feeling a pause between heartbeats. More seriously there may be lightheadedness, passing out, shortness of breath, or chest pain. While most types of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in cardiac arrest.
There are four main types of arrhythmia: extra beats, supraventricular tachycardias, ventricular arrhythmias, and bradyarrhythmias. Extra beats include premature atrial contractions, premature ventricular contractions, and premature junctional contractions. Supraventricular tachycardias include atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia. Ventricular arrhythmias include ventricular fibrillation and ventricular tachycardia. Arrhythmias are due to problems with the electrical conduction system of the heart. Arrhythmias may occur in children; however, the normal range for the heart rate is different and depends on age. A number of tests can help with diagnosis including an electrocardiogram (ECG) and Holter monitor.
Most arrhythmias can be effectively treated. Treatments may include medications, medical procedures such as a pacemaker, and surgery. Medications for a fast heart rate may include beta blockers or agents that attempt to restore a normal heart rhythm such as procainamide. This later group may have more significant side effects especially if taken for a long period of time. Pacemakers are often used for slow heart rates. Those with an irregular heartbeat are often treated with blood thinners to reduce the risk of complications. Those who have severe symptoms from an arrhythmia may receive urgent treatment with a jolt of electricity in the form of cardioversion or defibrillation.
Arrhythmia affects millions of people. In Europe and North America, as of 2014, atrial fibrillation affects about 2% to 3% of the population. Atrial fibrillation and atrial flutter resulted in 112,000 deaths in 2013, up from 29,000 in 1990. Sudden cardiac death is the cause of about half of deaths due to cardiovascular disease or about 15% of all deaths globally. About 80% of sudden cardiac death is the result of ventricular arrhythmias. Arrhythmias may occur at any age but are more common among older people.

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

Risk factors include: high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol, among others. Other risks include depression. The underlying mechanism involves atherosclerosis of the arteries of the heart. A number of tests may help with diagnoses including: electrocardiogram, cardiac stress testing, coronary computed tomographic angiography, and coronary angiogram, among others.
Prevention is by eating a healthy diet, regular exercise, maintaining a healthy weight and not smoking. Sometimes medication for diabetes, high cholesterol, or high blood pressure are also used. There is limited evidence for screening people who are at low risk and do not have symptoms. Treatment involves the same measures as prevention. Additional medications such as antiplatelets including aspirin, beta blockers, or nitroglycerin may be recommended. Procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) may be used in severe disease. In those with stable CAD it is unclear if PCI or CABG in addition to the other treatments improve life expectancy or decreases heart attack risk.
In 2013 CAD was the most common cause of death globally, resulting in 8.14 million deaths (16.8%) up from 5.74 million deaths (12%) in 1990. The risk of death from CAD for a given age has decreased between 1980 and 2010 especially in developed countries. The number of cases of CAD for a given age has also decreased between 1990 and 2010. In the United States in 2010 about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45. Rates are higher among men than women of a given age.

Cardiac arrest is a sudden stop in effective blood flow due to the failure of the heart to contract effectively. Symptoms include loss of consciousness and abnormal or absent breathing. Some people may have chest pain, shortness of breath, or nausea before this occurs. If not treated within minutes, death usually occurs.
The most common cause of cardiac arrest is coronary artery disease. Less common causes include major blood loss, lack of oxygen, very low potassium, heart failure, and intense physical exercise. A number of inherited disorders may also increase the risk including long QT syndrome. The initial heart rhythm is most often ventricular fibrillation. The diagnosis is confirmed by finding no pulse. While a cardiac arrest may be caused by heart attack or heart failure these are not the same.
Prevention includes not smoking, physical activity, and maintaining a healthy weight. Treatment for cardiac arrest is immediate cardiopulmonary resuscitation (CPR) and, if a shockable rhythm is present, defibrillation. Among those who survive targeted temperature management may improve outcomes. An implantable cardiac defibrillator may be placed to reduce the chance of death from recurrence.
In the United States, cardiac arrest outside of hospital occurs in about 13 per 10,000 people per year (326,000 cases). In hospital cardiac arrest occurs in an additional 209,000 Cardiac arrest becomes more common with age. It affects males more often than females. The percentage of people who survive with treatment is about 8%. Many who survive have significant disability. Many U.S. television shows, however, have portrayed unrealistically high survival rates of 67%.

A congenital heart defect, also known as a "congenital heart anomaly" or "congenital heart disease", is a problem in the structure of the heart that is present at birth. Signs and symptoms depend on the specific type of problem. Symptoms can vary from none to life-threatening. When present they may include rapid breathing, bluish skin, poor weight gain, and feeling tired. It does not cause chest pain. Most congenital heart problems do not occur with other diseases. Complications that can result from heart defects include heart failure.
The cause of a congenital heart defect is often unknown. Certain cases may be due to infections during pregnancy such as rubella, use of certain medications or drugs such as alcohol or tobacco, parents being closely related, or poor nutritional status or obesity in the mother. Having a parent with a congenital heart defect is also a risk factor. A number of genetic conditions are associated with heart defects including Down syndrome, Turner syndrome, and Marfan syndrome. Congenital heart defects are divided into two main groups: cyanotic heart defects and non-cyanotic heart defects, depending on whether the child has the potential to turn bluish in color. The problems may involve the interior walls of the heart, the heart valves, or the large blood vessels that lead to and from the heart.
Congenital heart defects are partly preventable through rubella vaccination, the adding of iodine to salt, and the adding of folic acid to certain food products. Some defects do not need treatment. Other may be effectively treated with catheter based procedures or heart surgery. Occasionally a number of operations may be needed. Occasionally heart transplantation is required. With appropriate treatment outcomes, even with complex problems, are generally good.
Heart defects are the most common birth defect. In 2013 they were present in 34.3 million people globally. They affect between 4 and 75 per 1,000 live births depending upon how they are diagnosed. About 6 to 19 per 1,000 cause a moderate to severe degree of problems. Congenital heart defects are the leading cause of birth defect-related deaths. In 2013 they resulted in 323,000 deaths down from 366,000 deaths in 1990.

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

Cardiology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


What is the circumference of the Earth?

Earth's circumference is the distance around the Earth, either around the equator () or around the poles ().

Earth's circumference

Measurement of Earth's circumference has been important to navigation since ancient times. It was first calculated by Eratosthenes, which he did by comparing altitudes of the mid-day sun at two places a known North-South distance apart. In the Middle Ages, Al Biruni calculated a more accurate version, becoming the first person to perform the calculation based on data from a single location.

In modern times it has been used to define fundamental units of measurement of length – the nautical mile in the seventeenth century and the metre in the eighteenth. Earth's polar circumference is almost exactly 40,000 km because the metre was originally calibrated on this measurement (1/10-millionth of the distance between the poles and the equator), which is almost exactly 21,600 nautical miles (being defined as one minute of a degree – i.e. 360 multiplied by 60).

It has been described as "the single most important measurement" of the Earth, assuming the Earth to be a sphere (the Earth is an technically an ellipsoid, albeit with just 0.3% flattening).

Earth's circumference lines are the foundation of the coordinate system of latitude and longitude, introduced in the mid-second century BC by Hipparchus.

Longditude lines, also known as meridian lines, follow the polar circumference, and are all exactly the same length.

Latitude lines, known as circles of latitude are parallel to each other; the equatorial circumference is the largest circle of latitude, and the Earth’s longest circumference distance. Other circles of latitude have smaller circumference; for example, the 60th parallel north or south is approximately half as long as the Equator.

According to Cleomedes' "On the Circular Motions of the Celestial Bodies", around 240 BC, Eratosthenes, the librarian of the Library of Alexandria, calculated the circumference of the Earth in Ptolemaic Egypt. Using a scaphe, he knew that at local noon on the summer solstice in Syene (modern Aswan, Egypt), the Sun was directly overhead. (Syene is at latitude 24°05′ North, near to the Tropic of Cancer, which was 23°42′ North in 100 BC) He knew this because the shadow of someone looking down a deep well at that time in Syene blocked the reflection of the Sun on the water. He then measured the Sun's angle of elevation at noon in Alexandria by using a vertical rod, known as a gnomon, and measuring the length of its shadow on the ground. Using the length of the rod, and the length of the shadow, as the legs of a triangle, he calculated the angle of the sun's rays. This angle was about 7°, or 1/50th the circumference of a circle; taking the Earth as perfectly spherical, he concluded that the Earth's circumference was 50 times the known distance from Alexandra to Syene (5,000 stadia, a figure that was checked yearly), i.e. 250,000 stadia. Depending on whether he used the "Olympic stade" (176.4m) or the Italian stade (184.8m), this would imply a circumference of 44,100 km (an error of 10%) or 46,100 km, an error of 15%. In 2012, Anthony Abreu Mora repeated Eratosthenes's calculation with more accurate data; the result was 40,074 km, which is 66 km different (0.16%) from the currently accepted polar circumference.

Posidonius calculated the Earth's circumference by reference to the position of the star Canopus. As explained by Cleomedes, Posidonius observed Canopus on but never above the horizon at Rhodes, while at Alexandria he saw it ascend as far as degrees above the horizon (the meridian arc between the latitude of the two locales is actually 5 degrees 14 minutes). Since he thought Rhodes was 5,000 stadia due north of Alexandria, and the difference in the star's elevation indicated the distance between the two locales was 1/48 of the circle, he multiplied 5,000 by 48 to arrive at a figure of 240,000 stadia for the circumference of the earth. It is generally thought that the stadion used by Posidonius was almost exactly 1/10 of a modern statute mile. Thus Posidonius's measure of 240,000 stadia translates to, not much short of the actual circumference of. Strabo noted that the distance between Rhodes and Alexandria is 3,750 stadia, and reported Posidonius's estimate of the Earth's circumference to be 180,000 stadia or. Pliny the Elder mentions Posidonius among his sources and without naming him reported his method for estimating the Earth's circumference. He noted, however, that Hipparchus had added some 26,000 stadia to Eratosthenes's estimate. The smaller value offered by Strabo and the different lengths of Greek and Roman stadia have created a persistent confusion around Posidonius's result. Ptolemy used Posidonius's lower value of 180,000 stades (about 33% too low) for the earth's circumference in his "Geography". This was the number used by Christopher Columbus in order to underestimate the distance to India as 70,000 stades.
A more accurate estimate was provided in Al-Biruni's "Codex Masudicus" (1037). In contrast to his predecessors, who measured the Earth's circumference by sighting the Sun simultaneously from two different locations, al-Biruni developed a new method of using trigonometric calculations, based on the angle between a plain and mountain top, which yielded more accurate measurements of the Earth's circumference, and made it possible for it to be measured by a single person from a single location.

1,700 years after Eratosthenes's death, while Christopher Columbus studied what Eratosthenes had written about the size of the Earth, he chose to believe, based on a map by Toscanelli, that the Earth's circumference was one-third smaller. Had Columbus set sail knowing that Eratosthenes's larger circumference value was more accurate, he would have known that the place that he made landfall was not Asia, but rather the New World.

Both the metre and the nautical mile were originally defined as a subdivision of the Earth's circumference; today the circumference around the poles is almost exactly 40,000 km and 360 × 60 nautical miles long.

In 1617 the Dutch scientist Willebrord Snellius assessed the circumference of the Earth at 24,630 Roman miles (24,024 statute miles). Around that time British mathematician Edmund Gunter improved navigational tools including a new quadrant to determine latitude at sea. He reasoned that the lines of latitude could be used as the basis for a unit of measurement for distance and proposed the nautical mile as one minute or one-sixtieth () of one degree of latitude. As one degree is of a circle, one minute of arc is of a circle – such that the polar circumference of the Earth would be exactly 21,600 miles. Gunter used Snell's circumference to define a nautical mile as 6,080 feet, the length of one minute of arc at 48 degrees latitude.

In 1791, the French Academy of Sciences selected the circumference definition over the alternative pendular definition because the force of gravity varies slightly over the surface of the Earth, which affects the period of a pendulum. To establish a universally accepted foundation for the definition of the metre, more accurate measurements of this meridian were needed. The French Academy of Sciences commissioned an expedition led by Jean Baptiste Joseph Delambre and Pierre Méchain, lasting from 1792 to 1799, which attempted to accurately measure the distance between a belfry in Dunkerque and Montjuïc castle in Barcelona to estimate the length of the meridian arc through Dunkerque. This portion of the meridian, assumed to be the same length as the Paris meridian, was to serve as the basis for the length of the half meridian connecting the North Pole with the Equator. The problem with this approach is that the exact shape of the Earth is not a simple mathematical shape, such as a sphere or oblate spheroid, at the level of precision required for defining a standard of length. The irregular and particular shape of the Earth smoothed to sea level is represented by a mathematical model called a geoid, which literally means "Earth-shaped". Despite these issues, in 1793 France adopted this definition of the metre as its official unit of length based on provisional results from this expedition. However, it was later determined that the first prototype metre bar was short by about 200 micrometres because of miscalculation of the flattening of the Earth, making the prototype about 0.02% shorter than the original proposed definition of the metre. Regardless, this length became the French standard and was progressively adopted by other countries in Europe.

Earth's circumference

Earth's circumference

Aryabhatiya also estimates the circumference of Earth, with an error of less than 1%. He gave the circumference of the earth as 4 967 yojanas and its diameter as 1 5811/24 yojanas. Since 1 yojana = 5 miles this gives the circumference as 24 835 miles, which is an excellent approximation to the currently accepted value of 24 902 miles. Aryabhata gives the radii of the orbits of the planets in terms of the Earth-Sun distance as essentially their periods of rotation around the Sun. He also gave the correct explanation of lunar and solar eclipses and that the Moon shines by reflecting sunlight.

History of geodesy

Geodesy (/dʒiːˈɒdɨsi/), also named geodetics, is the scientific discipline that deals with the measurement and representation of the Earth. The history of geodesy began in pre-scientific antiquity and blossomed during the Age of Enlightenment.

Early ideas about the figure of the Earth held the Earth to be flat (see flat Earth), and the heavens a physical dome spanning over it. Two early arguments for a spherical Earth were that lunar eclipses were seen as circular shadows which could only be caused by a spherical Earth, and that Polaris is seen lower in the sky as one travels South.

The early Greeks, in their speculation and theorizing, ranged from the flat disc advocated by Homer to the spherical body postulated by Pythagoras. Pythagoras's idea was supported later by Aristotle. Pythagoras was a mathematician and to him the most perfect figure was a sphere. He reasoned that the gods would create a perfect figure and therefore the Earth was created to be spherical in shape. Anaximenes, an early Greek philosopher, believed strongly that the Earth was rectangular in shape.

Since the spherical shape was the most widely supported during the Greek Era, efforts to determine its size followed. Aristotle reported that mathematicians had calculated the circumference of the Earth (which is slightly over 40,000 km) to be 400,000 stadia (between 62,800 and 74,000 km or 46,250 and 39,250 mi) while Archimedes stated an upper bound of 3,000,000 stadia (483,000 km or 300,000 mi) using the Hellenic stadion which scholars generally take to be 185 meters or of a geographical mile.

In Egypt, a Greek scholar and philosopher, Eratosthenes (276 BCE – 195 BCE), devised a method for a more explicit measurement of the earth's size. Reports from the ancient city of Swenett, later known as Syene, stated that on the day of the summer solstice, the midday sun shone to the bottom of a well. He observed in Alexandria, that the sun was not directly overhead. Instead, it cast a shadow with the vertical equal to 1/50th of a circle (7° 12'). To these observations, Hellenistic Astronomy and knowledge of the local geography had already established that; (1) on the day of the summer solstice, the midday sun was directly over the Tropic of Cancer; (2) Syene was on this tropic; (3) Alexandria and Syene lay on a direct north-south line; (4) The sun was a relatively long way away (which would later be known as the astronomical unit). He determined that distance between Alexandria and Syene was 5000 stadia, (possibly by having hired someone to walk and measure the distance, but more likely using reports of travelers of the distance) or at the usual Hellenic 185 m per stadion, about 925 km.

From these observations, measurements, and/or "known" facts, Eratosthenes concluded that since the angular deviation of the sun from the vertical direction at Alexandria was also the angle of the subtended arc (see illustration), the linear distance between Alexandria and Syene was 1/50 of the circumference of the Earth which thus must be 50×5000 = 250,000 stadia or probably 25,000 geographical miles. The circumference of the Earth is 24,902 mi (40,075.16 km). Over the poles it is more precisely 40,008 km or 24,860 mi. The actual unit of measure used by Eratosthenes was the stadion. No one knows for sure what his stadion equals in modern units, possibly it was the Hellenic 185 m stadion.

Had the experiment been carried out as described, it would not be remarkable if it agreed with actuality. What is remarkable is that the result was probably only about 0.4% too high. His measurements were subject to several inaccuracies: (1) though at the summer solstice the noon sun is overhead at the Tropic of Cancer, Syene was not exactly on the tropic (which was at 23° 43' latitude in that day) but about 22 geographical miles to the north; (2) the difference of latitude between Alexandria (31.2 degrees north latitude) and Syene (24.1 degrees) is really 7.1 degrees rather than the perhaps rounded (1/50 of a circle) value of 7° 12' that Eratosthenes used; (3) the actual solstice zenith distance of the noon sun at Alexandria was 31° 12' − 23° 43' = 7° 29' or about 1/48 of a circle not 1/50 = 7° 12', an error closely consistent with use of a vertical gnomon which fixes not the sun's center but the solar upper limb 16' higher; (4) the most importantly flawed element, whether he measured or adopted it, was the latitudinal distance from Alexandria to Syene (or the true Tropic somewhat further south) which appears to have caused the overestimate that relates to most of the error in his resulting circumference of the earth.

A parallel later ancient measurement of the size of the Earth was made by another Greek scholar, Posidonius. He noted that the star Canopus was hidden from view in most parts of Greece but that it just grazed the horizon at Rhodes. Posidonius is supposed to have measured the angular elevation of Canopus at Alexandria and determined that the angle was 1/48 of circle. He used a distance from Alexandria to Rhodes, 5000 stadia, and so he computed the Earth's circumference in stadia as 48 times 5000 = 240,000. Some scholars see these results as luckily semi-accurate due to cancellation of errors. But since the Canopus observations are both mistaken by over a degree, the "experiment" may be not much more than a recycling of Eratosthenes's numbers, while altering 1/50 to the correct 1/48 of a circle. Later, either he or a follower appears to have altered the base distance to agree with Eratosthenes's Alexandria-to-Rhodes figure of 3750 stadia since Posidonius's final circumference was 180,000 stadia, which equals 48×3750 stadia. The 180,000 stadia circumference of Posidonius is suspiciously close to that which results from another method of measuring the earth, by timing ocean sunsets from different heights, a method which is inaccurate due to horizontal atmospheric refraction.

The abovementioned larger and smaller sizes of the Earth were those used by Claudius Ptolemy at different times, 252,000 stadia in his "Almagest" and 180,000 stadia in his later "Geography". His midcareer conversion resulted in the latter work's systematic exaggeration of degree longitudes in the Mediterranean by a factor close to the ratio of the two seriously differing sizes discussed here, which indicates that the conventional size of the earth was what changed, not the stadion.

The Indian mathematician Aryabhata (AD 476–550) was a pioneer of mathematical astronomy. He describes the earth as being spherical and that it rotates on its axis, among other things in his work Āryabhaṭīya. Aryabhatiya is divided into four sections. Gitika, Ganitha (mathematics), Kalakriya (reckoning of time) and Gola (celestial sphere). The discovery that the earth rotates on its own axis from west to east is described in Aryabhatiya (Gitika 3,6; Kalakriya 5; Gola 9,10;). For example, he explained the apparent motion of heavenly bodies is only an illusion (Gola 9), with the following simile;

The Muslim scholars, who held to the spherical Earth theory, used it to calculate the distance and direction from any given point on the earth to Mecca. This determined the Qibla, or Muslim direction of prayer. Muslim mathematicians developed spherical trigonometry which was used in these calculations.

Around AD 830 Caliph al-Ma'mun commissioned a group of astronomers led by Al-Khwarizmi to measure the distance from Tadmur (Palmyra) to Raqqa, in modern Syria. They found the cities to be separated by one degree of latitude and the distance between them to be 66 miles and thus calculated the Earth's circumference to be 24,000 miles. Another estimate given was 56 Arabic miles per degree, which corresponds to 111.8 km per degree and a circumference of 40,248 km, very close to the currently modern values of 111.3 km per degree and 40,068 km circumference, respectively.

Muslim astronomers and geographers were aware of magnetic declination by the 15th century, when the Egyptian astronomer 'Abd al-'Aziz al-Wafa'i (d. 1469/1471) measured it as 7 degrees from Cairo.

Revising the figures attributed to Posidonius, another Greek philosopher determined 18,000 miles as the Earth's circumference. This last figure was promulgated by Ptolemy through his world maps. The maps of Ptolemy strongly influenced the cartographers of the Middle Ages. It is probable that Christopher Columbus, using such maps, was led to believe that Asia was only 3 or 4 thousand miles west of Europe.

Ptolemy's view was not universal, however, and chapter 20 of "Mandeville's Travels" (c. 1357) supports Eratosthenes' calculation.

It was not until the 16th century that his concept of the Earth's size was revised. During that period the Flemish cartographer, Mercator, made successive reductions in the size of the Mediterranean Sea and all of Europe which had the effect of increasing the size of the earth.

The invention of the telescope and the theodolite and the development of logarithm tables allowed exact triangulation and grade measurement.

In 1505 the cosmographer and explorer Duarte Pacheco Pereira calculated the value of the degree of the meridian arc with a margin of error of only 4%, when the current error at the time varied between 7 and 15%.

Jean Picard performed the first modern meridian arc measurement in 1669–1670. He measured a baseline using wooden rods, a telescope (for his angular measurements), and logarithms (for computation). Jacques Cassini later continued Picard's arc (Paris meridian arc) northward to Dunkirk and southward to the Spanish border. Cassini divided the measured arc into two parts, one northward from Paris, another southward. When he computed the length of a degree from both chains, he found that the length of one degree of latitude in the northern part of the chain was shorter than that in the southern part (see illustration).

This result, if correct, meant that the earth was not a sphere, but a prolate spheroid (taller than wide). However, this contradicted computations by Isaac Newton and Christiaan Huygens. In 1659, Christiaan Huygens was the first to derive the now standard formula for the centripetal force in his work "De vi centrifuga". The formula played a central role in classical mechanics and became known as the second of Newton's laws of motion. Newton's theory of gravitation combined with the rotation of the Earth predicted the Earth to be an oblate spheroid (wider than tall), with a flattening of 1:230.

The issue could be settled by measuring, for a number of points on earth, the relationship between their distance (in north-south direction) and the angles between their zeniths. On an oblate Earth, the meridional distance corresponding to one degree of latitude will grow toward the poles, as can be demonstrated mathematically.

The French Academy of Sciences dispatched two expeditions. One expedition (1736–37) under Pierre Louis Maupertuis was sent to Torne Valley (near the Earth's northern pole). The second mission (1735–44) under Pierre Bouguer was sent to what is modern-day Ecuador, near the equator. Their measurements demonstrated an oblate Earth, with a flattening of 1:210. This approximation to the true shape of the Earth became the new reference ellipsoid.

In 1787 the first precise trigonometric survey to be undertaken within Britain was the Anglo-French Survey. Its purpose was to link the Greenwich and Paris' observatories. The survey is very significant as the forerunner of the work of the Ordnance Survey which was founded in 1791, one year after William Roy's death.

Between 1792 and 1798 Pierre Méchain and Jean-Baptiste Delambre surveyed the Paris meridian arc between Dunkirk and Barcelona. They extrapolated from this measurement the distance from the North Pole to the Equator which was 5 130 740 toises. As the metre had to be equal to one ten-million of this distance, it was defined as 0,513074 toises or 443,296 lignes of the Toise of Peru (see below).

In South America Bouguer noticed, as did George Everest in the 19th century Great Trigonometric Survey of India, that the astronomical vertical tended to be pulled in the direction of large mountain ranges, due to the gravitational attraction of these huge piles of rock. As this vertical is everywhere perpendicular to the idealized surface of mean sea level, or the geoid, this means that the figure of the Earth is even more irregular than an ellipsoid of revolution. Thus the study of the "undulation of the geoid" became the next great undertaking in the science of studying the figure of the Earth.

In the late 19th century the Mitteleuropäische Gradmessung (Central European Arc Measurement) was established by several central European countries and a Central Bureau was set up at the expense of Prussia, within the Geodetic Institute at Berlin. One of its most important goals was the derivation of an international ellipsoid and a gravity formula which should be optimal not only for Europe but also for the whole world. The Mitteleuropäische Gradmessung was an early predecessor of the International Association of Geodesy (IAG) one of the constituent sections of the International Union of Geodesy and Geophysics (IUGG) which was founded in 1919.

In 1811 Ferdinand Rudolph Hassler was selected to direct the U. S. coast survey, and sent on a mission to France and England to procure instruments and standards of measurement. The unit of length to which all distances measured in the U. S. coast survey were referred is the French "metre," of which Ferdinand Rudolph Hassler had brougth a copy in the United States in 1805"."

In the early 19th century, the Paris meridian's arc was recalculated with greater precision between Shetland and the Balearic Islands by the French astronomers François Arago and Jean-Baptiste Biot. In 1821 they published their work as a fourth volume following the three volumes of ""Bases du système métrique décimal ou mesure de l'arc méridien compris entre les parallèles de Dunkerque et Barcelone"" (Basis for the decimal metric system or measurement of the meridian arc comprised between Dunkirk and Barcelona) by Delambre and Méchain.

In 1860, the Russian Government at the instance of Otto Sturves invited the Governments of Belgium, France, Prussia and England to connect their triangulations in order to measure the length of an arc of parallel in latitude 52° and to test the accuracy of the figure and dimensions of the Earth, as derived from the measurements of arc of meridian. In order to combine the measurements, it was necessary to compare the geodetic standards of length used in the different countries. The British Government invited those of France, Belgium, Prussia, Russia, India, Australia, Austria, Spain, United States and Cape of Good Hope to send their standards to the Ordnance Survey office in Southampton. Notably the standards of France, Spain and United States were based on the metric system, whereas those of Prussia, Belgium and Russia where calibrated against the toise, of which the oldest physical representative was the Toise of Peru. The Toise of Peru had been constructed in 1735 for Bouguer and De La Condamine as their standard of reference in the French Geodesic Mission, conducted in actual Ecuador from 1735 to 1744 in collaboration with the Spanish officers Jorge Juan and Antonio de Ulloa.

Alexander Ross Clarke and Henry James published the first results of the standards' comparisons in 1867. The same year Russia, Spain and Portugal joined the "Europäische Gradmessung" and the General Conference of the association proposed the metre as a uniform length standard for the Arc Measurement and recommended the establishment of an International Bureau of Weights and Measures.

The Europäische Gradmessung decided the creation of an international geodetic standard at the General Conference held in Paris in 1875. The Metre Convention was signed in 1875 in Paris and the International Bureau of Weights and Measures was created under the supervision of the International Committee for Weights and Measures. The first president of the International Committee for Weights and Measures was the Spanish geodesist Carlos Ibáñez e Ibáñez de Ibero. He also was the president of the Permanent Commission of the "Europäische Gradmessung" from 1874 to 1886. In 1886 the association changed name for the International Geodetic Association and Carlos Ibáñez e Ibáñez de Ibero was reelected as president. He remained in this position until his death in 1891. During this period the International Geodetic Association gained worldwide importance with the joining of United States, Mexico, Chile, Argentina and Japan. In 1883 the General Conference of the "Europäische Gradmessung" proposed to select the Greenwich meridian as the prime meridian in the hope that Great Britain would accede to the Metre Convention.

Most of the relevant theories were derived by the German geodesist Friedrich Robert Helmert in his famous books "Die mathematischen und physikalischen Theorieen der höheren Geodäsie", Einleitung und 1. Teil (1880) and 2. Teil] (1884); English translation: "Mathematical and Physical Theories of Higher Geodesy," Vol. 1 and 2. Helmert also derived the first global ellipsoid in 1906 with an accuracy of 100 meters (0.002 percent of the Earth's radii). The US geodesist Hayford derived a global ellipsoid in ~1910, based on intercontinental isostasy and an accuracy of 200 m. It was adopted by the IUGG as "international ellipsoid 1924".