Cardiology

C H E S

History Any symptom can be categorized exhaustively according to the following 4 logical categories, each of which has 2 convenient subdivisions:

WHEN <—F.O.P.P.'. First occurred (when + what were you doing then?) Onset (rapid / slowly?) Persistent (until present, or has now gone?) Pattern (continuous / episodic?)

Ever had before? (first time or recurrent?)

- WHERE^— Location ^ Radiation

- XTER ^ — Type: e.g. pleuritic (sharp, localized, worse on inspiration); pressing; ache-burning (character) ^ Severity

I — XTRA ^ — Aggravating / relieving factors ^ Associated symptoms

OTHER HISTORY: PMH e.g. arteriopathy (angina); immunodeficiency (pneumonia); SLE (PE) DH: Thyroxine (angina), NSAIDs (gastritis). PH: smoking (angina) FH: Angina. SH: Travel abroad (pneumonia)

JVP: t - M I / P E

GENERAL: e.g. xanthelasma, fever, shingles, anxiety

ABP: i) I - M l ii) Differential arm

pressures - dissection

PULSE: i) Weak - Ml ii) Bounding -

pneumonia

i) Aortic stenotic murmur ii) S 4 - M I

CHEST: Palpation: Costochondral tenderness /

shoulder immobility Percussion: Pn.thorax / consolidation Auscultation: Creps. / wheeze / rub

ABDO: Palpation Organomegaly

Blood: WCC (pneumonia, Ml, cholecystitis); CK, troponin I (Ml); LFTs (cholecystitis)

Urine: Glucose (diabetes - angina); blood (SBE) Micro: Blood, sputum cultures, inc. for AFB ECG: Angina / Ml / pericarditis Radiology: CXR: pneumothorax / consolidation I dissection / pericardial effusion

V/Q scan or pulmonary angiography / liver USS / chest CT Special: i) Exercise tolerance test / MIBI scan / stress ECHO

ii) Upper Gl endoscopy / oesophageal manometry / Bernstein's acid perfusion test (reproduces oesophageal pain)

4. Neck a) Carotid Pulse: (both, separately) b) JVP: level + character c) Other:

Goitre; SVC0 (distended veins)

3. Face-General a) Eyes:

• Conjunctivae: pallor, petechiae • Sclera: jaundice (CCF) • Cholesterol: xanthelasma, arcus

b) Mouth: • Central cyanosis, dental caries

c) Cheeks: • Flush (polycythaemia, SVCO, MS) • Wasted (CCF) • Plump (RSH failure)

d) Congenital syndromes: • Chromosomal (Down's, Turner's' • Connective tissue (Marfan's etc. • Myopathy (e.g. DMD, myotonia;

2. Pulse, ABP, RR a) Pulse: both radials; femorals; pedal x 4 b) ABP • Lying + Standing

• R + LArm • Pulsus Paradoxus:

> 10mmHg i on inspiration (cardiac tamponade)

c) RR: t with CCF

1. Hands a) Nails:

• clubbing (SBE, CCHD) • splinter haemorrhages (SBE, vasculitis, trauma) • Quincke's sign (AR)

b) Fingers: • capillary refill • digital infarcts, Osier's nodes (SBE) • arachnodactyly

c) Palms: • temperature (CCF - cold) • erythema (Janeway lesions, polycythaemia, AR)

5. Precordium a) Inspection:

i) Scars (CABG, PPM, mitral valvotomy) ii) Chest Wall:

• Ankylosing spondylitis (AR), • Pectus excavatum (ESM, R BBB) • Shield chest, wide nipples (Turner's) Pulsation:

Apex = LV L parasternal = RV

b) Palpation c Auscultation

6. Other Systems Lung auscultation: • Pulmonary oedema • Pulmonary fibrosis

(ankylosing spondylitis, pulmonary hypertension)

Abdomen: • Ascites, liver edge (RSH failure) • Pulsatile liver (TR) • Abdominal aortic aneurysm • Renal bruits Feet: (peripheral oedema) +

Fundi: (DM, HT, Roth spots)

7. AND FINALLY... a) Temperature chart b) Urine dipstick c) BM stick (diabetes, SBE)

C A R D I O L O G Y EXAMINAT

" Rate: Tachycardia (> 100); Bradycardia (< 60) Rhythm:

i) Regular ii) Reg. irregular: Mobitz II Heart Block, ectopics iii) Irreg. irregular: AF, frequent ectopics

Volume (felt at brachial or carotid): i) t Bounding: hyperdynamic circulatn, AR, PDA

Wide pulse pressure: arteriosclerosis ii) i Thready: hypovol. shock, LVF, AS, MS, MR iii) Differential volume of R vs L brachial:

dissection, atheroma Character:

i) Slow-rising: AS p

ii) Collapsing: AR, PDA, bradycardia iii) Double:

Bisferiens * Mixed AR+AS Bigeminy = Regular VE's Jerky = H0CM Dicrotic = Hyperdynamic circulation

iv) Variable: Paradoxus (1 es a lot on inspiration) = Cardiac tamponade

Alternans = LVF - Delay: R vs. L; Radio vs. Femoral = Coarctation

JVP • Level: Normal: < 3 cm above sternal notch

Causes of raised JVP, may be classified according to the response to inspiration: 1. 4 es on inspiration (normal response):

i) RSH failure / fluid overload ii) Bradycardia iii) Cardiac tamponade

2. t (Kussmaul's sign): i) Constrictive pericarditis ii) Restrictive cardiomyopathy iii) Tricupsid stenosis

3. None: SVCO Character:

1. CANNON WAVES: big a wave + big x descent = Atrial systole against closed TV

Complete heart block Atrial flutter Nodal / ventricular rhythm (inc. pacemaker)

2. BIG A WAVES: = RV filling 4 • pulmo. hypertension, tricuspid stenosis

3. CV (single) WAVES: = Tricuspid regurgitation

Apex Beat Position: Normal = Midclavic. line Displaced: i) RV or LV enlargement

ii) Mediastinal shift iii) Pectus excavatum, absent pericardium

Apex Beat Character: i) Heaving: Pressure overload = LVH, inc. AS, HT

Thrusting: Volume overload = AR, MR, VSD ii) Knocking: MS (palpable S1) iii) Dyskinetic, rocking: LV aneurysm iv) Double or triple ripple: H0CM v) Impalpable: fat, fluid (effusion), air (CGAD);

CCF; dextrocardia • Heave: at either sternal edge =

RVH or severe LA dilatation, e.g. MS - Thrill: palpable murmur in location

of murmur radiation

' Heart Sounds M1 T1 A2P2 $3 T I I

S1: Loud (MS); Soft (MR, heart block); Wide Split (normal at apex, heart block, VT)

S2: Loud (HT, PHT); Soft (aortic sclerosis, PS); Wide Split (ASD - fixed; VSD, MR - variable)

S3: Volume Overload: AR, MR, acute Ml S4: Pressure Overload: AS, HT, H0CM; heart block

- A d d e d E P L 0 P K

Early Sys: VSD, Ebstein's anomaly (TR) MidSys(ESM): AS, PS, H0CM, coarctatn, ASD (flow) Pan Sys: MR; Late Sys: MVP with regurgitation Early Dias: AR, PR, GrahaM Steel (PR 2° to MS) MidDias: MS, Austin Flint (Aortic Incomp.), MR (flow) Late Dias: MS (pre-systolic accentuation)

JVP: Small 'a' wave

Pulse: 1. Small-volume 2. Slow-rising

Signs of Severity: I Pulse pressure j I A B P \ 2. Apex beat: volume overload 3 Murmur: loud (thrill) or soft (CCF) 4. S2 becomes silent or single

Auscultation: 1. Ejection systolic murmur:

• aortic area —+ carotids • on sitting forward, on expiration • harsh

2. Ejection click: if pliable valves, e.g. bicuspid 3. S2: • single or reversed splitting S2

(due to delayed AV closure) • silent A2: if calcified valve

S4

Palpation: 1. APB (apex beat):

Heaving, sustained, non-displaced = pressure-overload

2. Systolic thrill at aortic area, • on leaning forward, on expiration

2. Collapsing pulse or carotid shudder

Auscultation: 1. Early diastolic murmur:

• LSE 3rd-4th ICS —Tricuspid area (or RSE with dilated aortic root)

• on sitting forward, on expiration • blowing = chronic; musical = perforation

2. Other murmurs: Aortic Incompetence • Middiastolic murmur: 'Austin Flint'

• Forward-flow systolic murmur 3. SI: soft

S2: soft, single (cf. Pulmo. Regurg. = S2 + loud P2) S3: t LVEDP

Palpation: 1. APB: Thrusting, non-sustained, displaced

= volume-overload 2. Diastolic thrill at LSE = Acute AR

Signs of Severity: 1. Pulse pressure t (but I es with coincident L VF or HT) 2. Apex beat displacement t es 3. Murmur: length t es (but I es with acute AR or CCF, due to

L VEDP rising towards aortic pressure) 4. Pulmonary or peripheral oedema

M U R

Mitral Stenosis General:

1. Malar flush / cachectic 2. CVA or PVD 2° to AF 3. Mitral valvotomy scar

JVP: Prominent 'a' (pulmo. hypertension

Pulse: 1. AF 2. Small volume

Auscultation: 1. Mid-diastolic murmur

• apex • lean to left, on expiratn., after exercise • rumble

2. Other murmurs: Mitral Stenosis • Early diastolic murmur: 'GrahaM-Steel'

= Pulmo. regurgitation loudest on inspiration • Pre-systolic accentuation: if sinus rhythm

3. Opening snap: if pliable valves 4. S1: if pliable valves

S3: always absent Palpation:

1. APB: Tapping S1, undisplaced 2. Parasternal heave (LAD / PHT)

Signs of Severity: 7. Pulse = AF, or systemic emboli 2. Opening Snap: Severity inversely prop, to time between S2 and OSf\ LAP IL VP) 3. Murmur - length tes (except in CCF) 4. Pulmonary oedema, or Pulmonary hypertension (RSH failure)

JVP: Prominent 'a' (pulmo. hypertension

Pulse: 1. AF 2. Short, sharp

jerky

Auscultation: 1. Pan-systolic murmur:

• blowing • apex —> axilla (may be aortic area or spine) • lean to left, on expiration

2. Other murmurs: Forward-flow diastolic murmur 3. Mitral valve prolapse:

4. S2: wide splitting SI: soft, S3: (T LADP)

Palpation: 1. APB: Volume-overload 2. Parasternal heave:

= L atrial dilatation or Pulmo. hypertension 3. Apical thrill

Signs of Severity: 7. Pulse = AF 2. Apex beat displacement ^es 3. Murmur: becomes softer 4. S3 + Soft SI; S2-Widely split 5. Pulmonary oedema, or Pulmonary hypertension (RSH failure)

N.B. Other Murmurs: 1. Pulmonary Hypertension (p. 98); 2. Congenital Heart Disease (p. 48)

Congenital: Presents in childhood; M:F =4:1

~ Valvar: 3, 2, or 1 Cusp *~ Subvalvar: Congenital ring or H0CM — Supravalvular: William's syn. = AS, Ca 2 + t , elfin-like Face 4IQ

Rheumatic fever esp. females ('tight-lipped' females) Rheumatoid arthritis: (rare) due to nodular thickening

Atherosclerosis esp. FH homozygotes

Bicuspid AV calcification (40-60): EPI: Commonest congenital anomaly (1%) PATH: progressive mechanical stress leads to premature calcification PC: Stenosis (1/3) + Mixed (1/3) + Asymptomatic (1/3) ASSOC: i) Dissection; ii) Coarctation; iii) Turner's

Senile calcific degeneration (60 + ) PATH: i) Initially, Aortic sclerosis: = Haemodynamically insignificant ring calcification

0/E: ESM only, no radiation ii) Later: Cusp calcification, renders them immobile

PC 1. ANGINA

PROG: Survival = 2-3 yrs AET: due to 0 2 demand t

but 0 supply i

2. ARRHYTHMIAS: • Stokes-Adams • Sudden death (8%)

EMBOLI, from calcified valve - TIA / CVA

1. Concentric LVH 2. LVF/RVF: Prognosis = 1-2 yrs

Ix 1. ECG:

2. CXR:

Pressure-overload LVH: lateral strain, P mitrale Heart block: due to septal calcification

LAD

n

Calcified AV Post-stenotic dilatation LV prominence / LVF

ECHO: M-Mode: thickened cusps; LVH 2D: Valve area

iij Doppler: peak jet velocity + pressure 4. CATHETER:

i) Pressure gradient ii) Angiography

ient

Rx 1. Medical: Vasodilators contraindicated:

• Nitrates • Ca antagonists • ACE inhibitors

2. SBE prophylaxis 3. Surgical:

a) Valvuloplasty / valvotomy: IND = children; elderly

b) Valve replacement: IND = • Symptomatic, esp. syncope • ECG: deteriorating • Valve area < 0.5 cm2 • Systolic gradient > 55 mmHg

N.B. Good pre-op nutrition / SBE prox. c) Myomectomy: Tunnel stenosis

A O R T I C VALVE D I S

Causes — Ring dilatation

L - Poor fitting

1. ARRHYTHMIAS: i) Sinus tachycardia

ii) Extrasystoles / AF iii Sudden death

Aortic Regurgitation a) Pressure: hypertension, aortic dissection, trauma b) Weak connective tissue:

• Hereditary: Marfan's, osteogenesis imperfecta, Ehlers-Danlos syn. • Infection: Syphilis: cor bovinum

a) Infection: • Infective endocarditis • Rheum, fever (esp. males: like to regurgitate on Saturday night!)

b) Autoimmune: • Seronegative arthropathies, e.g. ank. spondylitis, Reiter's • SLE (Libman. Sacks endocarditis) / RA

c) Toxins - cabergoline, pergolide

a) Bicuspid aortic valve disease b) Supracristal VSD

1. Eccentric LVH 2. LVF, due to TLVEDP 3. RVF

lx ECG: Volume-overload LVH:

Q waves anterolat / R6 + S1 > 35 mm CXR:

Proximal aorta dilatation LV — LA dilatation LVF

ECHO: i) M-Mode: dilated LV; flutter of anterior MV ii) 2D: Ejection fraction

End-systolic volume iii) Doppler: Pressure half-time CATHETER:

Site + severity of AR n) LV function

Angiography

Rx 1. MEDICAL:

Nifedipine recommended, but avoid in heart failure ACE inhibitors

2. SBE prophylaxis 3. SURGICAL:

Valve replacement: IND:

i) Symptoms of heart failure ii) Pulse pressure > 100, or DBP < 40 iii) Heart Size on CXR > 17 cm iv) ECG: lateral T inv: ST depression v) LV End-sys.volume > 5.5 cm

Ejection fraction <50% CONTRAIND:

Dilated heart, as irreversible, and

3. PULMONARY OEDEMA/ RECURRENT RTI

4. PULMONARY HYPERTENSION/ RSH FAILURE; ISCHAEMIA /CACHEXIA

2. EMBOLI Causes: • Mural thrombus forms on 'McCallum's patch' above posterior MV cusp, or

• Calcification of cusps Effects:

TIA; CVA; PVD; Ischaemic colitis

1. LEFT ATRIAL ENLARGEMENT a) AF b) Hoarseness (Ortner's Syn.=

L Recurrent Laryngeal N Palsy) c) Dysphagia d) L Bronchiectasis

Ix 1. ECG:

i) P mitrale (with sinus rhythm) / AF ii) RHS strain (with RV hypertrophy)

2. CXR: i) LA enlargement:

- Loss of aorto-pulmonary concavity - Double R wall shadow - Splayed carina

ii) Pulmo. oedema => RV enlargement iii) Calcified MV

3. 2D-ECH0: i) Valve area: < 1 cm = severe ii) Rate of LV filling / regurgitatn (Doppler) iii) LA dilatation ± thrombus iv) RVH

4. CATHETER: i) Pressure gradient: > 20 mmHg = severe ii) Pulmonary vase, resistance:

> 8 Wood Units = High op. risk (Normal = 1)

iii) LV Function / angiography

Rx ANTI-COAGULATE:

IND: Moderate - severe MS, with LA dilatation Sx of systemic emboli AF, even if paroxysmal

2. SBE PROPHYLAXIS Given to established MS, or Post-rheumatic fever < 25 yrs

3. SURGICAL i) Closed valvotomy:

- Intercostal - Percutaneous transluminal catheter

balloon dilatation ii) Open valvotomy

- Median sternotomy - Allows ring insertion

iii) Valve replacement - Indicated if partial mitral regurgitatn

M I T R A L VALVE D I S E A S E 11

Ring dilatation 1. LV Dilatation:

a) Volume overload: AR b) Pressure overload: AS, HT

2. Cardiomyopathy: HOCM, dilated, restrictive

3. Trauma / Mechanical valve leak

Cusp contraction 1. Infection:

i) Rhematic fever ii) SBE

2. Autoimmune: i) RA, SLE

II) Ank. Spond. 3. ASD, primum 4. Senile calcific degeneration

Mitral Valve Prolapse: M.V.P. SIN. Def: Myxomatous degeneration of chordae tendinae ASSOC: Marfan's +01, ED, PXE

PC 2. PULMONARY OEDEMA/

RECURRENT RTI

3. PULMONARY HYPERTENSION/ RSH FAILURE

1. AF

PC: 1. Chest pain - atypical 2. Palpitations / syncope

(due to assoc. SVT, VT) 3. SOB, fatigue

COMPS: 1. Regurgitation (cord rupture) 2. Endocarditis / emboli 3. Death, sudden (VT)

Ix 1. ECG:

P mitrale (with sinus rhythm) / AF LHS strain (with RV hypertrophy) MVP: Inferior T wave inversion

CXR: i) LA and LV enlargement ii) Pulmonary oedema

2D-ECH0: i) Cause: thickened / flail valves / MVP / ASD ii) Volume overload of LV + LA

CATHETER: i) Distinguishes MR from LV muscle pump failure ii) LV function / angiography

Rx 1. ANTI-COAGULATE, if in AF

2. SBE PROPHYLAXIS, inc. for MVP

3. SURGICAL: Valve replacement IND: Deteriorating LV function (not asymptomatic pts, as the condition pogresses slowly)

ECG Interpretation -1 The ECG may be read either by instant pattern recognition (e.g. 'this shows fast atrial fibrillation; left bundle branch block; anterior infarction...'), or by adopting a systematic approach that includes all the sources of information an ECG trace carries. Novices to the ECG will have no choice but to use the systematic approach, but even when a learnt pattern 'jumps out' of a particular ECG, it is important to go over the ECG again, so as not to miss the smaller details. ECG Interpretation - 2 (p. 4) takes the reader through a comprehensive ECG analysis in a logical order. A guide to the use of this double page is outlined below:

1. Details 2. Rate 3. Axis

P Wave

PR Interval

R Wave

QRS Width

QT interval

ST segment

| - Sinus Q Wave QRS Height T Wave

L-Non-Sinus I U Wave PQRST COMPLEX

Tachycardias and Bradycardias (pp. 14-23) provides an overview of most ectopics and dysrhythmias. Ectopics are beats that are interspersed randomly within a background rhythm. When frequent, ectopics may degenerate into an abnormal rhythm of their own.