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Cardiology
1. Cardiac Auscultation and Physical Diagnosis
• Basic Physiology
Key (Wiggers cycle)
o A. Atrial systole (late ventricular diastole)
o B. Isovolumic contraction
o C. Early ventricular systole
o D. ate ventricular systole
o E. Isovolumic rela!ation
o ". Early diastole (ra#id #assive vent. $illing)
o %. &id diastole (diastasis' (near) cessation o$ ventricular
$illing due to eualiation o$ atrial and ventricular #ressures) *ugular venous +ave$orm'
o a +ave' small rise in right atrial #ressure due to right atrial
contractiono c +ave' small rise in right atrial #ressure as the tricus#id
valve closes and ,ulges to+ard the right atriumo v +ave' rise in right atrial #ressure during ventricular
systole- +hen the tricus#id valve is (su##osedly) closed
• Physical Diagnosis
Cardiac auscultation
• 1 / closure o$ mitral0tricus#id valves onset o$ ventricular
systole
• 2 / closure o$ semilunar valves
3ormal (4#hysiological5) s#litting o$ 2 means those 2 distinct com#onents o$ 2 can ,e heard during ins#irat
,ut not during e!#iration (,est heard at 6B).
• 6
3ormal in children and young adults
Cause' 7ensing o$ the chordae tendineae and0or sudden limitation o$ longitudinal ventricular e!#ansion durin
early ra#id ventricular $illing 7iming' Early (to mid) diastole
"reuency' o+ (dull 4thud5)
ocation' A#e! () lo+er B0!i#hoid (8)
4Kentuc9y5
• :
Rarely normal (; normal in elderly)
Cause' Atrium vigorously contracting against a sti$$ened ventricle (results $rom reduced ventricular com#lianc
7iming' ate diastole (4#resystolic5)
"reuency' o+
ocation' A#e! () lo+er B0!i#hoid (8)
47ennessee5
• Physiological s#litting o$ the 2nd heart sound
During ins#iration 2 distinct com#onents o$ 2 (not during e!#iration)
During ins#iration increase venous return to the heart- higher than usual
#ressure causes second heart sound
• Parado!ical s#litting o$ the 2nd heart sound
Anything causes delayed closure o$ the aortic valve (com#ared to the
#ulmonic valve)
&ost common causes'
o e$t ,undle ,ranch ,loc9
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o e$t ventricular out$lo+ o,struction
• Aortic stenosis (A)
• ecto#ic ,eat
Increase $orce o$ contraction (#redominant e$$ect)
Increase #reload
o Isometric e!ercise
• ustained handgri# (2>6 seconds)
• Avoid simultaneous alsalva maneuver
• Increases'
ystemic vascular resistance- Arterial #ressure-
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• Cardiac murmurs
&urmurs result $rom tur,ulent $lo+
o &ay ,e #hysiologic or #athologic
o &ay ,e non>valvular or valvular in origin
%rading system
o Based on loudness0intensity o$ murmur
o grades ($or systolic murmurs)
• %rade 10' ery $aint- not usually heard during the $irst $e+ seconds o$ listening
• %rade 20' "aint- ,ut heard immediately
• %rade 60' Easily heard
• %rade :0' Easily heard- and associated +ith a #al#a,le thrill• %rade 0' ery loud- #al#a,le thrill- audi,le +ith only one edge o$ the stethosco#e on the chest
• %rade 0' Way loud- #al#a,le thrill- audi,le +ith the stethosco#e removed slightly $rom contact +ith the
chesto %rading system- diastolic mumurs
• %rade 10:' ery $aint- not usually heard during the $irst $e+ seconds o$ listening
• %rade 20:' "aint- ,ut heard immediately
• %rade 60:' Easily heard
• %rade :0:' ery loud
ystolic
o Begins +ith or a$ter 1 and ends at or ,e$ore 2
Diastolic
o Begins +ith or a$ter 2 and ends ,e$ore the ne!t1
Continuous
o Begins in systole and continues- +ithout
interru#tion- through the 2 into all or #art o$
diastole Cardiac murmur 3ote'
o While the anatomical location +here a murmur is
,est heard may #rovide a clue to its cause- the
timing and quality o$ the murmur- as +ell as
associated $indings- are o$ten more reliable in
elucidating a murmurFs cause.
• alvular cardiac murmurs' &urmurs resulting $rom valvular dys$unction'
o A systolic murmur may ,e the result o$ dys$unction o$ any o$ the $our cardiac valves
o A diastolic murmur may ,e the result o$ dys$unction o$ any o$ the $our cardiac valves
A valve that does not o#en #ro#erly +ill cause a murmur o$ stenosis during the #art o$ the cardiac cycle +hen that valve sho
,e o#en. A valve that does not close #ro#erly +ill cause a murmur o$ regurgitation (insu$$iciency) during the #art o$ the cardiac cycle +
that valve should ,e closed. Determining +hich ty#e o$ valve #ro,lem can cause +hich ty#e o$ murmur sim#ly reuires a ,asic understanding o$ +hat ea
the cardiac valves should ,e 4doing5 during systole and diastole.
ystole Diastole
Aortic =#en ClosedPulmonic =#en Closed
&itral Closed =#en
7ricus#id Closed =#en
ystolic &urmur Diastolic &urmur
Aortic tenosis 8egurgitation
Pulmonic tenosis 8egurgitation
&itral 8egurgitation tenosis
7ricus#id 8egurgitation tenosis
• ystolic &urmurs
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Potential causes'
o =ut$lo+ o,struction o$ either ventricle
• A- P- or su#ravalvlar stenosis o$ the aortic or #ulmonic valves
o Insu$$iciency o$ either atrioventric. valve
• &8- 78
o D
o entricular e@ection through an aortic valve +ith $i,rocalci$ic thic9ening
• Aortic sclerosis
o entricular e@ection in 4high>$lo+5 states
• Gouth (4innocent5 murmur)
• Pregnancy• "ever- anemia- hy#erthyroidism- etc.
2 ma@or categories'
o ystolic e@ection murmurs
• Crescendo>decrescendo
• ometimes re$erred to as 4midsystolic5
• A- P-
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Aortic stenosis
o Congenital
• Bicus#id aortic valve
Aortic e@ection sound (clic9) is the auscultatory
hallmar9o Acuired
• 8heumatic
• enile $i,rocalci$ic
o Crescendo>decrescendo murmur
• =$ten heard ,est at 28B- radiating to the carotids
• I$ murmur #ea9s early in systole- stenosis is not severeo Pulsus #arvus et tardus (diminished and delayed carotid u#stro9e)
• &ay not see in elderly
o May have'
• Parado!ical s#litting o$ the 2nd heart sound
• Diminished or a,sent A2 (aortic com#onent o$ the 2 nd heart sound)
• Aortic e@ection sound (i$ valve is not heavily calci$ied) / most common in congenital A
Di$$erentiating A $rom &8
• ystolic e@ection murmurs
decrescendo murmur +hich'
• %ets louder during'
uatting (or lying- $rom standing)
Amyl nitrite inhalation (same as
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Potential causes'
o Insu$$iciency o$ either ventricular out$lo+ valve
• A8 (AI)
• P8 (PI)
o tenosis o$ either atrioventricular valve
• &
• 7
Aortic insu$$iciency (regurgitation)
o Primary murmur'
• Early diastolic
• Decrescendo• #itched
• 4Blo+ing5
• Best heard +ith dia#hragm o$ stethosco#e at 6 or 8B- +ith #atient leaning $or+ard- during held- dee#-
e!halationo Associated murmurs'
• Patients +ith AI- in addition to the #rimary murmur- may have'
ystolic e@ection murmur
o Due to 4high $lo+5 across aortic valve- $rom high stro9e volume
Austin "lint murmur
o Diastolic rum,le- ,est heard +ith ,ell o$ stethosco#e at a#e!
o 7hought to ,e due to 4$unctional5 mitral stenosis resulting $rom the aortic regurgitant
$orcing the anterior mitral lea$let into a #artially closed #ositiono =ther #ro#osed mechanism'
• Diastolic rum,le results $rom $luttering o$ the anterior mitral lea$let caused
the aortic regurgitant @eto Associated $indings (chronic severe AI)
• Duroie sign
ystolic murmur over $emoral artery +hen stethosco#e is com#ressed #ro!imally- and a diasto
murmur over $emoral artery +hen stethosco#e is com#ressed distally &ost #redictive sign o$ severe AI
• igns associated +ith high stro9e volume'
Wide #ulse #ressure
?uinc9eFs #ulse
o Phasic ,lanching o$ the nail ,ed hammer) #ulse
o Pal#a,le a,ru#t u#stro9e and ra#id $all o$ arterial #ulsation
7rau,e sign
o Pistol shot sound over $emoral artery
&ueller sign
o Pulsating uvula
Pulmonic insu$$iciency (regurgitation)
o &ay ,e due to'
• Pulmonary hy#ertension- in the a,sence o$ #ulmonic valve de$ormity (%raham teell murmur)
•
De$ormity o$ the #ulmonic valve Congenital
Acuired
o %raham teell murmur'
• Early diastolic
• Begins +ith a loud #ulmonic com#onent o$ 2
• Decrescendo
• #itched
• 4Blo+ing5
• %ets louder during ins#iration
• Best heard +ith dia#hragm o$ stethosco#e at 2 nd to :th IC- B
o Pulmonic insu$$iciency due to de$ormity o$ the #ulmonic valve'
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• &id diastolic
• Begins after #ulmonic com#onent o$ 2
• Crescendo>decrescendo
• o+>#itched
• %ets louder during ins#iration
• Best heard +ith ,ell o$ stethosco#e at 6rd to :th IC- B
&itral stenosis
o Almost always a seuela o$ rheumatic $ever
o &urmur'
• &id diastolic (#re>systolic accentuation i$ rhythm
is sinus) holodiastolic i$ severe• o+>#itched (rum,le)
• Best heard +ith #atient in the le$t lateral
recum,ent #osition- +ith the ,ell o$ the
stethosco#e at the cardiac a#e!o Associated $indings'
Opening snap
#itched sound
=ccurs a$ter 2- early in diastole
As severity o$ stenosis +orsens- o#ening sna# occurs closer to 2
o$tens or disa##ears +ith calci$ication (and loss o$ mo,ility) o$ the ,ody o$ the mitral lea$lets
• oud (accentuated) 1 (&1)
o$tens or disa##ears +ith calci$ication (and loss o$ mo,ility) o$ the ,ody o$ the mitral lea$lets =ther reasons $or diminished or a,sent 1 in #atients +ith mitral stenosis'
o ong P8 interval- severe dys$unction- signi$icant AI- signi$icant &8- hy#ertension
=ther mitral stenosis>li9e murmurs
o Austin>"lint murmur (o$ aortic regurg.) (no o#ening sna#)
o Carey>Coom,s murmur
• Active mitral valvulitis associated +ith acute rheumatic fever
o e$t atrial my!oma
o 7ricus#id stenosis
• ounds @ust li9e mitral stenosis excet '
Auscultatory $indings o$ 7'
o %et louder during ins#iration
o Are ,est heard along the lo+er B• Is rare
&ost common cause' rheumatic heart disease
=ther causes' carcinoid syndrome- anorectic diet medications
Continuous murmurs
o &ust continue through 2 (uninterru#ted)
o Potential causes'
• Patent ductus arteriosus (PDA)
• Cervical venous hum
•
&ammary sou$$le•
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o E!aggeration (greater than 1 mm
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o Congenital heart disease
• Hnre#aired0 #artially re#aired cyanotic de$ects
o Previous IE
o Intravenous drug a,use (IDA)
• Etiology
Bacteria> most common
o !tah" aureus most common overall
o iridans stre#. ne!t (overall)
o Prosthetic valve
• Early ($irst days)' !tah" eidermidis
•ate (a$ter days)' viridans stre#.
o Intravenous drug a,use (IDA)' !tah" aureus
"ungi> uncommon virulent
Intravenous drug a,use IE
o !tah" aureus most common #athogen
o Candida most common $ungus
o 8ight>heart involvement most common
• 7ricus#id valve most common (#reviously normal valve)
• e#tic #ulmonary em,oli common
o Classic #eri#heral stigmata usually a,sent
• Pathogenesis
Conditions necessary $or IE
o
Endocardial in@uryo Platelet>$i,rin mesh at the site o$ in@ury
• 7hrom,us $ormation
• A.K.A.' 3on,acterial throm,otic endocarditis (3B7E)
o &icro,ial entry into the circulation
o &icro,ial adherence to the in@ured sur$ace0 throm,us
• Diagnosis
reactive #rotein (C8P)' elevated
• 8heumatoid $actor' elevated (in M N)
Clinical $eatures
o "ever is most sensitive sym#tom
o &urmur is the most relia,le sign
Classic #eri#heral stigmata o$ IE
o Petechiae
• &ost $reuently $ound on the con@unctivae- #alate- ,uccal mucosa- and u##er e!tremities
o #linter hemorrhages
• 1>2 mm ,ro+n strea9s under the nails (o$ greater signi$icance +hen seen in the #ro!imal nail ,ed)
o =sler nodes
• mall- tender nodules usually $ound on the $inger and toe #ads
o *ane+ay lesions
• Painless- $lat (macular)- ,lanching discolorations located on the #alms and soles
o 8oth s#ots
• 8etinal hemorrhages +ith #ale centers
o Clu,,ing
• Present in some #atients +ith longstanding disease
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• De$initive Diagnosis
Pathologic criteria' &icroorganisms gro+n or demonstrated in vegetation or intracardiac a,scess
Clinical criteria'
o 7+o &a@or- or
o =ne &a@or and 7hree &inor criteria- or
o "ive minor criteria
&odi$ied Du9e Criteria
o De$inite IE' 7+o ma@or =8 one ma@or and three minor =8 $ive minor
o Possi,le IE' one ma@or and one minor =8 three minor
o &a@or
•
Positive ,lood culture 7y#ical microorganism $rom t+o se#arate cultures
Persistently #os. cultures $rom cultures dra+n more than 12 hours a#art- or all o$ three or m
o$ $our +ith $irst and last dra+n at least one hour a#art
• Evidence o$ endocardial involvement
Positive echo sho+ing oscillating vegetation- or a,scess- or dehisced #rosthetic valve
3e+ valvular regurg. (increase or change not su$$icient)
o &inor
• Predis#osition
• "ever J1.:O " (J6.O C)
• ascular #henomena (em,oli- con@. hemorrhage)
• Immunological #henomena(%3- Q8"- =sler nodes)
•
Echo (consistent ,ut not meeting ma@or criteria)• &icro,iologic evidence (cultures not meeting ma@or criteria)
• Com#lications
2N si!>month mortality (even +ith a##ro#riate thera#y)
1N mortality i$ not recognied and treated #ro#erly
• 7reatment
I anti,iotics
o 8euired in all cases
o &ost reuire :> +ee9s o$ thera#y
o ome may reuire only 2 +ee9s o$ thera#y
o Consult in$ectious disease (ID) s#ecialist
urgery (valve re#lacement) is needed $or some
urgical indications'
o
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Anti,iotic endocarditis #ro#hyla!is only recommended $or individuals +ith'
o Prosthetic valves
o Previous IE
o Congenital heart disease
• Hnre#aired cyanotic lesions
• 8e#aired congenital heart disease +ith residual de$ects
• Com#letely re#aired de$ects- $or the $irst si! months
o Cardiac trans#lant #atients +ith valvulo#athy
6. Aortic tenosis
• ocaliation
=,struction to le$t ventricular out$lo+ may occur at various levels'
o Aortic valve
o u#ravalvular
o
u,valvular•
&ost common level o$ o,struction
• Etiology
Congenital (:'1 male'$emale)
o Hnicus#id aortic valve
• Causes severe o,struction to le$t ventricular out$lo+ in in$ancy
• &ost common cause o$ $atal valvular aortic stenosis in in$ancy
o Bicus#id aortic valve
• &ost common congenital cardiac de$ect (1 > 2 N o$ the #o#ulation)
• :'1 male>to>$emale
• =$ten not detected until adulthood
Hsually does not cause signi$icant o,struction during childhood
•
=,struction develo#s after childhood due to trauma induced ,y tur,ulent $lo+ (causes $i,rosis andcalci$ication o$ aortic cus#s)
• &ay also cause #rogressive aortic regurgitation
• 2 N are associated +ith other a,normalities'
Coarctation o$ the aorta- PDA- dilated aortic root
o 7ricus#id aortic valve
Acuired
o Degenerative (senile) calci$ic
• 8is9 $actors
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End>stage renal disease
o 8heumatic (#ost>in$lammatory)
Age related variation in etiology
o years'
• &ost are congenital
ast ma@ority are ,icus#id aortic valve
• &inority are acuired
Degenerative
8heumatic
o J years'
•
&inority are congenital• &ost are acuired
&ost are degenerative
"e+ rheumatic
• Diagnosis
ym#toms
o Angina- synco#e- heart $ailure sym#toms
Physical $indings
o &ost common $inding is a systolic e@ection murmur (E&) that radiates to the nec9
o =thers'
• Pulsus #arvus et tardus
• :
•
ystolic e@ection sound (clic9) (i$ ,icus#id A)• Diminished or a,sent A2 (single 2)
• Parado!ical s#litting o$ 2 Diagnostic studies
o EK% >
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• Adding &8 to A8 nearly dou,les o#erative ris9
Percutaneous
o Balloon aortic valvulo#lasty (BA)
• 7em#orary relie$ o$ severe heart $ailure sym#toms
ym#tom return
o 6 N at months
o S N at 2 years
8estenosis rate
o N at months
o 3early 1 N at 2 years
•
Procedural com#lication rate J 1 N Death
CA
igni$icant aortic insu$$iciency
ascular com#lications
• Indications
Bridge to A8
Emergency non>cardiac surgery
Palliation in non>surgical candidates
• ummary
Diagnosis is made ,y #hysical e!amination- su##orted ,y a##ro#riate diagnostic studies.
A8 is the only de$initive treatment.
7iming o$ surgery is ,ased on sym#tom onset or decline in $unction. BA is only a tem#orary treatment o#tion that is only used in very rare clinical circumstances.
BE #ro#hyla!is no longer indicated.
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:. Aortic Insu$$iciency (regurgitation)• Etiology
alvular
o tructural valve #ro,lem
o Congenital
• Bicus#id aortic valve
AI may ,e the result o$'
o tructural valve #ro,lem itsel$
o Associated aortic aneurysm
• D
tructural aortic valve disease is sometimes associated +ith D
o Acuired
• In$ective (Endocarditis)
• 8heumatic
Consider co>e!isting mitral valve disease
• Degenerative
Aortic
o Dilated aorta
o Dissection
• 7rauma
• Cystic medial necrosis
o Dilatation
• ystemic hy#ertension
• Advanced age
•
Cystic medial necrosiso
Com,ined
o &ar$an syndrome
o An9ylosing s#ondylitis
o =steogenesis im#er$ecta
o Ehlers>Danlos syndrome
o BehcetFs syndrome
o 8eiterFs syndrome
o y#hilis
o 8heumatoid arthritis
o Psoriatic arthritis
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o 7a9ayasuFs arteritis
o %iant cell arteritis
o Polyarteritis nodosa
o 8ela#sing #olychondritis
o *accoudFs arthro#athy
o ystemic lu#us erythematosis (E)
o Hlcerative colitis
o Whi##leFs disease
o CrohnFs disease
• Chronic Aortic Insu$$iciency
Diagnosiso ym#toms
• May ,e asym#tomatic
• E!ertional dys#nea
• 8educed e!ercise tolerance
• "atigue
• Hncom$orta,le 4$orce$ul5 heart,eat
o Physical "indings
• Primary murmur'
Early diastolic
Decrescendo
#itched
4Blo+ing5 Best heard +ith dia#hragm o$ stethosco#e at 6 or 8B- +ith #atient leaning $or+ard- during h
dee#- end>e!halation
• Associated murmurs'
Patients +ith AI- in addition to the #rimary murmur- may have'
o ystolic e@ection murmur
• Due to 4high $lo+5 across aortic valve- $rom high stro9e volume
o Austin "lint murmur
• Diastolic rum,le- ,est heard +ith ,ell o$ stethosco#e at a#e!
• 7hought to ,e due to 4$unctional5 mitral stenosis resulting $rom the aortic
regurgitant @et $orcing the anterior mitral lea$let into a #artially closed #ositi
• =ther #ro#osed mechanism'
Diastolic rum,le results $rom $luttering o$ the anterior mitral lea$lecaused ,y the aortic regurgitant @et
• Associated $indings
Duroie sign
o ystolic murmur over $emoral artery +hen stethosco#e is com#ressed #ro!imally- an
diastolic murmur over $emoral artery +hen stethosco#e is com#ressed distallyo &ost #redictive sign o$ severe AI
igns associated +ith high stro9e volume +ith ra#id diastolic run>o$$'
o Wide #ulse #ressure
o ?uinc9eFs #ulse
• Phasic ,lanching o$ the nail ,ed
o
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o Diagnostic studies
• EK% / < is common
• CR8 / enlargement- ascending aorta may ,e dilated
• Echocardiogram
ery use$ul
Allo+s evaluation o$'
o tructure o$ aortic valve
o Condition o$ aortic root
o everity o$ AI
o systolic $unction and sie
E!cellent modality $or long>term $ollo+>u# and timing o$ surgery• Cardiac catheteriation
De$ines coronary anatomy #rior to surgery
Provides con$irmation o$ severity o$ AI
De$ines structure o$ the aortic root
3atural history
o De#ends on'
• sie and $unction
• Presence or a,sence o$ sym#toms
o N o$ #atients +ith asym#tomatic chronic AI and normal systolic $unction +ill remain asym#tomatic at 1 year
o Prognosis +orsens signi$icantly +hen'
• systolic dys$unction develo#s
E" N• igni$icant dilatation develo#s
end>systolic dimension J mm
end>diastolic dimension J T mm
• ym#toms develo#
7reatment
o &edical
• 3i$edi#ine
May delay the need $or A8 surgery in asym#tomatic #atients +ith severe AI and normal
systolic $unction
• =ther vasodilators (controversial)
ACE inhi,itors
A8BFs
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Pulse #ressure not +idened
Diastolic murmur so$t and short
o Diagnostic studies
• EK% / sinus tachycardia (usually)- < may ,e a,sent
• CR8
Pulmonary edema (usually)
sie is usually normal
Ascending aorta may ,e dilated (de#ending on the cause o$ the AI)
• Echocardiogram
Diagnostic test o$ choice
Allo+s evaluation o$'o tructure o$ aortic valve
o Condition o$ aortic root
o everity o$ AI
o systolic $unction and sie
• Cardiac catheteriation
&ay or may not ,e #ossi,le- de#ending on the sta,ility o$ the #atient
De$ines coronary anatomy #rior to surgery
Provides con$irmation o$ severity o$ AI
De$ines structure o$ the aortic root
7reatment
o Prom#t surgical intervention $or hemodynamically unsta,le #atients
•
&edical treatment +hile a+aiting surgery may include' Intravenous #ositive inotro#ic agents
Intravenous vasodilators
• Beta>,loc9ers and IABP are contraindicated
o u# is necessary.
o All #atients +ith severe AI should ,e re>evaluated clinically and echocardiogra#hically every > 12 months.
A8 surgery may ,e necessary before the develo#ment o$ sym#toms.
o systolic $unction and sie may +orsen signi$icantly ,e$ore sym#toms develo#.
BE #ro#hyla!is no longer indicated
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. &itral and 7ricus#id alve Disease
• &itral tenosis
Etiology
o 8heumatic $ever (JSSN)
o =ther (1N)
• E!tensive mitral annular calci$ication (in elderly)
• Congenital &
• Endocarditis +ith very large vegetations
ym#toms
o Dys#nea
• E!ertional- rest- ortho#nea- #aro!ysmal nocturnal dys#nea
o
"atigueo 8ight>heart $ailure (+ith severe &)
• Peri#heral edema- @ugular venous distention- ascites- he#atomegaly
o #itched (rum,le)
o Associated $indings
• =#ening sna#
As severity o$ stenosis +orsens- o#ening sna# occurs closer to 2 o$tens or disa##ears +ith calci$ication
o oud 1 (&1)
• o$tens or disa##ears +ith calci$ication
Diagnosis
o EK%
• e$t atrial a,normality
• 8ight ventricular hy#ertro#hy (i$ #ulmonary
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• Diuretics ($or sym#toms o$ vascular congestion)
• Beta>,loc9ers- nondihydro#yridine calcium channel ,loc9ers- or digo!in $or ventricular rate control i$ A. $i
develo#s
• Anticoagulation (+ar$arin or he#arin) i$ A. $i,. develo#s
o Percutaneous
• Balloon mitral valvulo#lasty (B&)
E!clusions' e!tensive valve calci$ication- signi$icant &8- atrial throm,us
o urgery
• "or severe sym#tomatic & in non>candidates $or B&
• =#en mitral commissurotomy
• &itral valve re#lacement• &itral 8egurgitation
Etiology
o tructural or $unctional a,normalities o$'
• &itral annulus
Calci$ication (in elderly)
Dilatation (assoc. +ith le$t ventricular dilatation)
• alve lea$lets
&y!omatous degeneration (&P)
8heumatic $ever
Endocarditis
heart $ailure sym#toms'
o Dys#nea
o =rtho#nea
o Paro!ysmal nocturnal dys#nea
8ight>heart $ailure sym#toms'
o Peri#heral edemao A,dominal $ullness0 discom$ort
Physical $indings
o Acute &8
• Early systolic (crescendo) decrescendo murmur
o Chronic &8
• Pansystolic murmur that does not get louder during ins#iration
(=$ten) ,est heard at a#e!
ometimes radiates to the le$t a!illa
• 6 Diagnosis
o Acute &8
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• EK%
inus tachycardia(;)
• CR8
Pulmonary edema
• Echocardiogram
Diagnostic
• Cardiac catheteriation
Evaluate coronary arteries (#a#illary muscle ru#ture as a com#lication o$ &I;)
o Chronic &8
• EK%
e$t atrial a,normality
e$t ventricular hy#ertro#hy
• CR8
e$t ventricular enlargement
e$t atrial enlargement
• Echocardiogram
Diagnostic
• Cardiac catheteriation
Evaluate coronary arteries (#a#illary muscle ischemia;)
3atural Danlos syndrome
ym#toms
o &ay ,e asym#tomatic
o Chest discom$ort
o Pal#itations
Physical "indings
o &id>systolic clic9 and late systolic murmur
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o Dynamic auscultation'
• uatting ma9es clic9 later- and murmur shorter (and o$ten so$ter).
• tanding (or alsalva maneuver) ma9es clic9 earlier- and murmur longer (and o$ten louder).
Diagnosis
o EK%
• 3ormal unless chronic &8 has caused le$t atrial enlargement and0or le$t ventricular hy#ertro#hy
o CR8
• 3ormal unless chronic &8 has caused le$t ventricular and0or atrial enlargement
o Echocardiogram
• Diagnostic
o Cardiac catheteriation• Hsually not necessary
3atural history
o Hsually ,enign
o ome develo# gradually #rogressive &8
o 8arely- my!omatous chordae tendineae may ru#ture- causing acute severe &8 and #ulmonary edema
&anagement
o 8eassurance
o &edical
• Beta>,loc9ers o$ten #rovide sym#tomatic relie$ $or chest discom$ort and0or #al#itations
o urgery
• &itral valve re#air or re#lacement $or the rare #atient +ho develo#s severe &8 +ith sym#toms or sys
dys$unction• 7ricus#id 8egurgitation
Etiology
o Hsually $unctional
• 8esults $rom right ventricular enlargement
o =ther causes
• 8heumatic $ever
• Carcinoid syndrome
ym#toms
o 8ight>heart $ailure sym#toms
• Peri#heral edema
• A,dominal $ullness0 discom$ort
•
"atigue0 +ea9ness Physical $indings
o &urmur
• Pansystolic murmur that gets louder during ins#iration (CarvalloFs sign)
• =$ten ,est heard along lo+er le$t sternal ,order
o Classic triad o$ severe 78
• CarvalloFs sign
• Pulsatile @ugular venous distention (*D)
• Pulsatile liver
Com#lete triad rarely seen
Diagnosis
o EK%
•
&ay sho+ changes characteristic o$ the #rocess res#onsi,le $or the right ventricular enlargemento CR8
• 8ight atrial enlargement
• 8ight ventricular enlargement
o Echocardiogram
• Diagnostic
o Cardiac catheteriation
• arge v +aves in the right atrial #ressure +ave$orm
3atural tolerated
&anagement
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o "or $unctional 78- thera#y is directed at the underlying cause o$ the increased right ventricular sie or #ressure.
o &edical
• Diuretics ($or right>heart $ailure sym#toms)
o urgery
• 7ricus#id valve re#air or re#lacement only $or severe cases re$ractory to the a,ove measures
• ummary
&itral stenosis is almost al+ays a seuela rheumatic $ever.
Acute and chronic mitral regurgitation 4,ehave5 very di$$erently.
&itral valve #rola#se is a common- usually ,enign entity that o$ten only reuires little more than reassurance.
7ricus#id regurgitation is usually $unctional- thera#y o$ +hich is directed at the underlying cause o$ the increased right ventric
sie or #ressure.
. ynco#e
• De$inition' 7em#orary loss o$ consciousness and #ostural tone due to transient cere,ral hy#o#er$usion- $ollo+ed ,y s#ontaneous recov
• Incidence
Children and adolescents
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o 1 to 2N +ill e!#erience synco#e ,e$ore adulthood
Adults
o 6 to N
o Elderly
• 2 to N annual incidence
• Im#act
6N o$ emergency room visits
1N o$ hos#ital admissions
Estimated annual cost (eval. and t!)' U--
• Etiology
7he s#eci$ic cause o$ synco#e can ,e identi$ied in a##ro!imately TN o$ #atients. Cardiovascular (>N)
o Cardiac
• Electrical
Bradyarrhythmia
o inus node dys$unction
o A nodal ,loc9
o Arti$icial #acema9er mal$unction
7achyarrhythmia
o u#raventricular
o entricular
In general- in normal individuals- heart rates ,et+een 6 and 1 ,#m do not result in signi$ica
reduction in cere,ral ,lood $lo+ (es#. in the su#ine #osition). Circumstances in +hich e!tremes o$ heart rate are #oorly tolerated'
o evere systolic dys$unction
o igni$icant diastolic dys$unction
o igni$icant mitral stenosis (es#. A" +ith 88)
o igni$icant coronary artery disease
• &echanical
Aortic stenosis
valve throm,us
Prosthetic valve mal$unction
Pulmonic stenosis
7etralogy o$ "allot
Pulmonary em,olism
evere #ulmonary hy#ertension
&yocardial ischemia or in$arction
o Presenting sym#tom in TN o$ elderly +ith &I
Coronary s#asm
Pericardial tam#onade
Aortic dissection
o ascular (most common)
• 8e$le!>mediated
7rigger (a$$erent lim,)
o 7rigger> varies +ith each s#eci$ic ty#e o$ re$le!>mediated synco#e
8es#onse (e$$erent lim,)o 8es#onse (e$$erent) lim,> essentially the same $or all ty#es o$ re$le!>mediated synco
• Increased vagal tone
• Withdra+al o$ sym#athetic tone
E!am#les
o 3eurocardiogenic (a.9.a.' vasode#ressor- vasovagal- neurally mediated- common $a
• Potential triggers'
Prolonged standing
Warm environment
Pain
ight o$ ,lood
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Emotional distress
• Beold / *arisch re$le!
J 6 second #ause
asode#ressor > Jmm J6 sec #ause and J mm
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Psychiatric
o Psychiatric (estimated that u# to 2N o$ une!#lained synco#al e#isodes may ,e #sychogenic)
o old girl e!#eriences a 4,lac9out5 +hen her ,oy$riend ,rea9s u# +ith her. Physical e!amination- including orthosta
,lood #ressures- is normal.o EK% sho+s ?7 #rolongation
• Could lead to torsades de #ointe
A >year>old man +ith 11 #revious e#isodes o$ synco#e over T years remained undiagnosed $ollo+ing tilt testing- am,ulato
cardiac monitoring +ith an e!ternal loo# recorder- and electro#hysiological testing.o T months later- he e!#erienced another synco#al e#isodeV
o Asystole
• 7reatment
7hera#y must ,e tailored to the s#eci$ic cause'
o Avoidance
o Correction
o Interru#t re$le! lim,s (modulate the A3)
o Pacema9er and 0 or ICD im#lantation
8ecommendations $or driving
o Consider'
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• Potential $or recurrence
• Presence and duration o$ +arning sym#toms
• Does synco#e only occur +hile standing;
• "reuency and ca#acity in +hich the #atient drives
• A##lica,le state la+s
• Prognosis
Hnderlying etiology determines #rognosis
o Cardiac synco#e carries the +orst #rognosis'
• 8ecurrent- une!#lained synco#e in individuals +ith structural heart disease is associated +ith a 2>year
mortality o$ :N.
• ummary
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Etiology
o In$ectious
• iral (o$ten deemed 4idio#athic5 due to lac9 o$ serologic con$irmation)
• 7u,erculosis
• Pyogenic ,acteria
• &ost common cause o$ acute #ericarditis
o 3onin$ectious
• Postmyocardial in$arction
Early
o "irst $e+ days a$ter &I
DresslerFs syndrome
o Wee9s to months a$ter &I
• Hremia
• 3eo#lastic disease
• 8adiation>induced
• Connective tissue diseases
• Drug>induced
Assoc. +ith drug>induced lu#us syndrome
o Procainamide
o
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• erum cardiac mar9ers
I$ elevated- consider concomitant myocarditis or &I
o Chest radiogra#h
• Hsually normal (in idio#athic0viral #ericarditis)
o Echocardiogram
• Hsually normal (in idio#athic0 viral #ericarditis)
• hould ,e ordered to evaluate $or #ossi,le coe!isting large #ericardial e$$usion
7reatment ($or viral0idio#athic)
o 8est- 3AIDs- oral corticosteroids0oral colchicine (only used $or #ain re$ractory to 3AIDs and narcotic analgesia)
analgesia
7reatment (other than viral0ido#athic)o =ther than viral0 idio#athic
• 7u,erculous
Prolonged antitu,erculous thera#y
• Purulent
Catheter drainage anti,iotic thera#y
• Hremic
Dialysis
• Associated +ith &I
Avoid corticosteroids and 3AIDFs other than AA
Com#lications
o Com#lications
•Pericardial e$$usion
• Pericardial (cardiac) tam#onade
• Constrictive #ericarditis
• Pericardial E$$usion
De$inition' Accumulation o$ an a,normally large amount o$ $luid in the #ericardial s#ace
o 3ote' 7he #ericardial s#ace normally contains 1 / cc o$ $luid
• 7his $luid (#lasma ultra$iltrate) serves to reduce $riction
Etiology
o &alignancy
o Post cardiac surgery
o Post #ercutaneous cardiac #rocedure
o Com#lication o$ #ericarditis
o
7horacic aortic dissectiono Chest trauma
Diagnosis
o Clinical history and #hysical $indings
• ym#toms
Asym#tomatic
Chest discom$ort
Dys#nea
"atigue
Presence and severity o$ sym#toms de#end on the rate o$ accumulation o$ #ericardial $luid
• 6 determinants o$ sym#tom onset0 #rogression
8ate o$ accumulation o$ #ericardial $luid
olume o$ #ericardial $luid
Com#liance o$ the #ericardium
• Physical $indings
3one (small or moderate e$$usion)
In large e$$usions- one may $ind'
o &u$$led heart sounds
o E+artFs sign'
• Dullness to #ercussion over the angle o$ the le$t sca#ula due to com#ressi
the le$t lung ,y the enlarged #ericardial saco EK%
• &ay ,e normal in small to moderate e$$usions
• arge e$$usions'
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o+ voltage
o !ometimes seen in large #ericardial e$$usions
o &any other causes (not s#eci$ic)
Electrical alternans
o !ometimes seen in large #ericardial e$$usions (s#eci$ic- ,ut not sensitive- $or large
#ericardial e$$usion)o Chest radiogra#h
• 3ormal- i$ e$$usion is small
• %lo,ular- symmetric enlargement o$ cardiac silhouette in moderate to large e$$usions
*+ater bottle, heart
o Echocardiogram• &ost use$ul test $or #ericardial e$$usion
• 4%old standard5 test $or detection- localiation- and uanti$ication o$ #ericardial e$$usion
7reatment
o 7reat underlying cause (i$ 9no+n)
o =,servation
• I$ cause is 9no+n and #atient is asym#tomatic
o Pericardiocentesis
• I$ cause is un9no+n (sam#le o$ $luid may ,e sent $or analysis' 4diagnostic #ericardiocentesis5)
• I$ #atient is sym#tomatic or i$ there is evidence o$ #ericardial tam#onade (4thera#eutic #ericardiocentesis
• Pericardial 7am#onade
De$inition' Cardiac cham,er com#ression caused ,y #ericardial e$$usion
o A.K.A.' Cardiac tam#onade entricular Interde#endence
o -ormal #hysiology
• Increase in 8 volume during ins#iration causes a slight shi$t o$ the interventricular se#tum to the le$t.
• 7his le$t+ard shi$t o$ the interventricular se#tum only occurs to a mild degree- as the com#liant #ericardiu
allo+s out+ard e!#ansion o$ the right ventricle to accommodate most o$ the increased venous return dur
ins#iration.
• 7his results in a slight reduction in le$t ventricular stro9e volume during ins#iration (causing the normal #
#arado!us. ). .-ormal #ulsus #arado!us 1 mmin$late BP cu$$ to a,out 2 mmthird o$ #atients)
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Dys#nea (later)
• Physical $indings