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Cardiology Clinical Methods
S Ramakrishnan, V Jacob Jose
CHAPTER 1:
History Taking
DYSPNEA
Definition
Hypothetical Model (Gillette and Schwartstein)
Signals for the Sensation of Dyspnea
Orthopnea
Paroxysmal Nocturnal Dyspnea (PND)
Platypnea
Trepopnea
Orthostatic Dyspnea
Bendopnea (JACC heart failure Feb 2014)
Definition
Causes of Dyspnea (Table 1)
Severity of Dyspnea Assessment
Indicators for Heart Failure as a Cause
Dyspnea and Valvular Heart Disease
CHEST PAIN
Angina ‘Equivalents’
CCS Functional Classification for Angina
SYNCOPE
Definition
Diagnostic Approach to Syncope
Scoring Systems for Syncope
Palpitations
Character of the Palpitations (Lancet May 1993; 1254)
Role of ECG for Clue to Diagnosis (NEJM May 1998: 338: 1369)
FUNCTIONAL CLASSIFICATIONS USED IN CARDIOLOGY
CHAPTER 2:
Arterial Pulse
DEFINITION
EXAMINATION
Trisection of the Pulse
FEATURES OF ARTERIAL PULSE TO BE EXAMINED
RATE
RHYTHM
CHARACTER
Pulse in Aortic Regurgitation
Pulsus Parvus et Tardus
C. Bisferiens Pulse
Pulsus Alternans
Causes
Pulsus Bigeminus
Pulsus Paradoxus
Causes of Reversed Pulsus paradoxus
VOLUME OF PULSE
RADIOFEMORAL DELAY
Method of Examination
CONDITION OF VESSEL WALL
CHAPTER 3:
Blood Pressure
METHODS OF MEASURING ARTERIAL BLOOD PRESSURE
A. Direct Method
B. Indirect Method
KOROTKOFF SOUNDS (KS)
Five Phases
AHA RECOMMENDATIONS (TABLE 1)
FEATURES INDICATIVE OF SECONDARY CAUSES
GUIDELINES FOR MEASURING BP
Posture
Circumstances
Equipment
Technique
VALSALVA MANEUVER AND BLOOD PRESSURE
AMBULATORY BP MONITORING (ABPM)
Indications for ABPM
BP THRESHOLDS—Definition
GOALS IN HYPERTENSON—JNC 20141
CHAPTER 4:
Jugular Venous Pulse
DEFINITION
DETERMINATION OF JVP
TECHNIQUE OF EXAMINATION
Methods to Make JVP More Obvious
Differences between the venous and arterial pulsations
NORMAL WAVE PATTERN (FIG. 1)
a Wave
x Descent
c Wave
v Wave
y Descent
h Wave
TEMPORAL SEQUENCE WITH CARDIAC CYCLE
NORMAL JUGULAR VENOUS PRESSURE
ELEVATED JUGULAR VENOUS PRESSURE
CAUSES OF ELEVATED JVP
HEPATOJUGULAR REFLUX (PASTEUR RONDOT MANEUVeR)
Normal Response
HJR is Positive in
False-positive Hepatojugular Reflux
ALTERATION OF “a” WAVE
X’ DESCENT
Small x Descent
Prominent x Descent
v WAVE (Fig. 6)
Prominent v Waves
y DESCENT
Slow y Descent
Deep y Descent
x versus y Descent
KUSSMAUL's SIGN
SPECIFIC CARDIAC CONDITIONS
A. Atrial Septal Defect (Fig. 7)
B. Tricuspid Regurgitation
C. Constrictive Pericarditis (Fig. 8)
D. Eisenmenger Syndrome
CHAPTER 5:
Precordial Examination—Palpation
APEX BEAT
Definition
Mechanism
Characteristics of a normal apical impulse:
POINT OF MAXIMAL IMPULSE (PMI)
CHARACTER OF APICAL IMPULSE
SUSTAINED APICAL IMPULSE
HYPERDYNAMIC APICAL IMPULSE
HYPOKINETIC IMPULSE
ECTOPIC IMPULSE
PARASTERNAL LIFT
Causes of Parasternal Lift
Dressler's Grading of Parasternal lift
EPIGASTRIC IMPULSE
PA Impulse
AORTIC Impulse
THRILLS
PALPABLE SOUNDS
CHAPTER 6:
First Heart Sound
FIRST HEART SOUND
COMPONENTS OF FIRST HEART SOUND
THEORIES OF GENERATION OF FIRST HEART SOUND
INTENSITY OF S1
LOUD FIRST HEART SOUND
Causes of Loud S1
Mitral Stenosis
SOFT FIRST HEART SOUND
Causes of Soft S1
SPLIT S1
Reverse splitting of S1
Hemodynamic Correlation of S1
CHAPTER 7:
Second Heart Sound
THEORIES OF GENERATION OF SECOND HEART SOUND
HANG OUT INTERVAL
ABNORMALITIES OF S2 INTENSITY
Increased Intensity of P2
Soft P2
SPLITTING OF S2
Mechanism of Splitting
Types of S2 Splitting
Wide Split S2 (Also Called As Persistent Split)
Other Causes
FIXED SPLITTING
REVERSED OR PARADOXICAL SPLITTING
Type I Paradoxical Splitting (The Most Common)
Type II Paradoxical Splitting
Type III Paradoxical Splitting
Pseudoparadoxical Splitting
Narrow Physiologic Splitting
SINGLE S2
II. Fusion of A2 and P2
III. Apparently Single S2 (Due to Inaudibility of P2)
CHAPTER 8:
Third Heart Sound
MECHANISM OF PRODUCTION OF THIRD HEART SOUND
Impact Theory (Most Accepted)
Ventricular Theory by Leatham
Valvular Theory
CLINICAL
CAUSES OF LV S3
CAUSES OF RV S3
DIFFERENTIATION OF S3 AND OPENING SNAP
CHAPTER 9:
Fourth Heart Sound
DEFINITION
MECHANISM OF PRODUCTION
Left Ventricular S4
Right Ventricular S4
Temporal Sequence
FOURTH HEART SOUND IN DISEASE CONDITIONS
1. Atrioventricular Block
2. Coronary Artery Disease
3. Cardiomyopathy
4. Systemic Hypertension
5. Aortic Valve Disease
6. Age
7. Pulmonary Hypertension
8. Pulmonary Stenosis
9. Bernheim Phenomenon
10. Other Conditions
DIFFERENTIATION OF M1–T1 FROM S4–S1
SUMMATION GALLOP
CHAPTER 10:
Systolic and Diastolic Sounds
EJECTION CLICKS
Early Systolic Sounds
Mechanism of Production
Ejection Sounds and Phases of Respiration
Aortic Ejection Sound
Pulmonary Ejection Click
Pulmonary ES in Valvular PS
Pulmonary ES in PH or IDPA
NON-EJCTION CLICKS
Mitral Valve Prolapse
OPENING SNAP
S2 - OS Interval
S2-OS Interval and Its Relationship to the Severity of Mitral Stenosis
Causes of Soft OS in Mitral Stenosis
Differentiation Of S3 and Opening Snap
PERICARDIAL KNOCK
PROSTHETIC VALVE SOUNDS
CHAPTER 11:
Diastolic Murmurs
DEFINITION
CLASSIFICATION
MECHANISM
EARLY DIASTOLIC MURMURS
Aortic Regurgitation
Severity of Aortic Regurgitation
Musical Diastolic Murmur
Sinus of Valsalva Aneurysms
Pulmonary Regurgitation
Dock's Murmur
MID-DIASTOLIC MURMUR (MDM)
Mitral Stenosis
Severity of Mitral Stenosis
Tricuspid Stenosis
Rytand Murmur
Carey Coombs Murmur
Flow Murmur
Pulmonary Regurgitation
LATE DIASTOLIC OR PRESYSTOLIC MURMURS
Mitral Stenosis
Tricuspid Stenosis
Complete Heart Block
Austin Flint Murmur
Dynamic Auscultation
Right-Sided Austin Flint Murmur
Bioprosthetic Valve
CHAPTER 12:
Continuous Murmurs
DEFINITION
MECHANISMS OF CONTINUOUS MURMURS [Myer's Classification (1975)]
PATENT DUCTUS ARTERIOSUS (MACHINERY MURMUR OR GIBSONS MURMUR)
AORTOPULMONARY WINDOW
CONGENITAL CORONARY ARTERIAL FISTULA
General Principles
RUPTURE OF SINUS VALSALVA ANEURYSM
RSOV into RA
RSOV into RV
ANOMALOUS ORIGIN OF LEFT CORONARY ARTERY FROM THE PULMONARY ARTERY (BLAND WHITE GARLAND SYNDROME)
CONGENITAL PULMONARY AV FISTULA
ACQUIRED ARTERIOVENOUS FISTULA
LUTEMBACHER SYNDROME
MURMURS OCCURRING IN CONSTRICTED ARTERIES
CONTINUOUS MURMUR ARISING FROM COLLATERALS BETWEEN SYSTEMIC AND PULMONARY ARTERIES
VENOUS HUM
Two Mechanisms Proposed for Venous Hum
Total Anomalous Pulmonary Venous Connection
Hepatic Venous Hum
CONTINUOUS MURMUR WITH CYANOSIS
CHAPTER 13:
Rheumatic Fever
GROUP A BETA HEMOLYTIC STREPTOCOCCI - GABHS
Prevalence of Rheumatic Heart Disease in India
Age of RF
CRITERIA FOR DIAGNOSIS
Exceptions to Jones Criteria
ARTHRITIS
Jaccoud's Arthritis
CARDITIS
Valve Involvement in Acute Rheumatic Fever
Valve Combinations in Indian Data for Chronic RHD (IHJ 2014: 320- 326)
Carditis—Role of Echo
CHOREA
Signs
Duration
Sequelae
PRECEDING STREPTOCOCCAL INFECTION WITHIN LAST 45 DAYS—MANDATORY CRITERIA
Clinical Course
TREATMENT
Rheumatic Fever Recurrence Rates using Drugs
Treatment of Chorea
CONCLUSION
CHAPTER 14:
Aortic Stenosis
HEMODYNAMICS
ETIOLOGY OF VALVAR AS
Progression
HISTORY
Reasons for Angina
PHYSICAL FINDINGS
Chest X-ray
ECG
Echo Assessment of AS (Table 3)
Coronary Angiography
NATURAL HISTORY
SURGERY
Indications for Surgery ACC/AHA 201410
Bicuspid Valve and Aortic Root Surgery (JACC Dec 4, 2015)
STATINS AND AORTICS STENOSIS PROGRESSION
LOW FLOW LOW GRADIENT AS
Low Dose Dobutamine Echo Test
AORTIC STENOSIS WITH REGURGITATION
TRANSCATHETER AORTIC VALVE REPLACEMENT – TAVI 12
Indications for Transcatheter AVR – 2014 AHA/ACC Guidelines
CHAPTER 15:
Aortic Regurgitation
ETIOLOGY
PATHOPHYSIOLOGY
LV Remodeling
Signals for Remodeling
Coronary Flow
CLINICAL
Arterial Pulse
Peripheral Signs
Head and Neck
Upper Limb
Lower Limb
Abdomen
Precordial Examination
Auscultation
Mechanism
CHEST X-RAY
ECG
NATURAL HISTORY
TREATMENT
Vasodilators
Indications for Surgery in Severe AR (ACC/AHA June 2014)6
Recommendations for Angiogram in severe AR:
CHAPTER 16:
Mitral Stenosis
ETIOLOGY
HEMODYNAMICS
Valve Area and Gradients
Features of LA Pressure Tracing
Pulmonary Hypertension
ATRIAL FIBRILLATION2
History
AUSCULTATION
Loud First Heart Sound
S1 is Loud for the following Reasons
Loudness and Calcification
Opening Snap
Differentiating A2–P2 from 2 OS
Mid Diastolic Murmur
Differential Diagnosis of Mid-Diastolic Murmur
Presystolic Murmur (PSM)
CHEST X-RAY
ECG
NATURAL HISTORY
MANAGEMENT
PTMC/BMV Indications (ACC/AHA - JACC June 2014)
Absolute Contraindications for PTMC
Relative Contraindications for PTMC
Results of PTMC from India
Restenosis after PTMC
Effect of PTMC and Atrial Fibrillation9
20 year Results of PTMC (Circulation 2012; 125: 2119 – 2127)
JUVENILE MS
ECHO Approach to Mitral Stenosis
Left Atrial Clot
CHAPTER 17:
Mitral Regurgitation
ETIOLOGY
TYPES OF MR
CLINICAL EXAMINATION
Precordial Examination
Heart Sounds
MR Murmur
Murmur of Rheumatic MR
Maneuvers
Thrill
ECHO GRADING OF SEVERITY - ESC 2013 guidelines2
NATURAL HISTORY
SURGERY
MITRAL VALVE REPAIR
Predictors of Recurrent Functional MR after Annuloplasty
MEDICAL TREATMENT FOR PRIMARY MR
CHAPTER 18:
Prosthetic Valve
CASE SCENARIO
TYPES OF VALVES
Mechanical
Tissue
AUSCULTATION
ANTICOAGULATION
Mechanical Valves
Tissue Valves
Risk of Bleeding with Warfarin
MECHANICAL OR TISSUE VALVE – ACC/AHA JUNE 2014
Randomized Studies on Mechanical Versus Tissue Valves
AORTIC HOMOGRAFT
INVESTIGATIONS
COMPLICATIONS
2. Embolism
3. Endocarditis (PVE)
4. Valve Dysfunction
Porcine versus Pericardial Valve
5. Hemolysis
EXCESSIVE ANTICOAGULATION – ACC/AHA guidelines 2014
BRIDGING THERAPY6 (TABLE 3)
CORONARY ANGIOGRAM BEFORE VALVE SURGERY
HEART FAILURE AFTER VALVE REPLACEMENT
AFIB ABLATION DURING MITRAL VALVE REPLACEMENT
TRANS CATHETER AORTIC VALVE REPLACEMENT8 (TAVI OR TAVR)
Contraindications
Complications9
Limitations between Medtronic and Edwards Sapien Valves (Circulation 2014;130:2321–2331)
CHAPTER 19:
Hypertrophic Cardiomyopathy
DEFINITION
PREVALENCE
PATHOGENESIS
Myocardial Fibrosis
Types of Asymmetric Hypertrophy
Causes of Myocardial Ischemia
Mitral Regurgitation in HCM
GENES ASSOCIATED WITH HCM
FAMILY SCREENING BY ECHO OR CMR 4 (JACC JULY 2012)
CLINICAL FEATURES—Obstructive Cardiomyopathy (FIG. 2)
Mid-Ventricular Obstruction
Valsalva and HCM
Effect of Valsalva in HCM Murmur
Identification of the Phases of the Valsalva
Alcohol and Obstructive HCM5
Yamaguchi's Apical HCM
ECG FEATURES OF HCM
ECHO
ELECTROPHYSIOLOGIC STUDIES
HEMODYNAMICS
NATURAL HISTORY
SUDDEN DEATH
SCD Risk Modifiers
Gene Mutations and Survival
SCD Risk Calculation Formula (ESC Aug 2014 Guidelines)13 (Figure 3)
ESC Guidelines for ICD Implantation - 2014
TMT Testing in HCM
TREATMENT
DRUG THERAPY
SURGERY—MYECTOMY/MORROW PROCEDURE
ALCOHOL SEPTAL ABLATION (PTSMA)18
Effects of PTSMA on the Conduction System
Predictors for Complete Heart Block
Complications of PTSMA
PTSMA Concerns
Indications
Technique
Survival—Long Term Results for PTSMA
Radiofrequency Septal Ablation for HCM
PTSMA versus Surgical Myectomy
PTSMA versus Myectomy—Survival Differences
DIFFERENTIAL DIAGNOSIS of HCM
HCM and Pregnancy
CHAPTER 20:
Constrictive Pericorditis
CONSTRICTIVE PERICARDITIS
Syndromes of Constrictive Pericarditis
Pathoanatomical Forms (ESC guidelines 2004;24:587-610)
Etiology
Pathophysiology
Clinical Signs of Constrictive Pericarditis
ECG Changes
Chest X-ray
Echo Signs (Circulation Imaging May 2014)
HEMODYNAMIC CRITERIA
Role of Cardiac MRI (JACC Oct 3rd, 2009)
Pericardectomy
CHAPTER 21:
Aortoarteritis
DEFINITION
HISTORICAL PERSPECTIVE
ETIOPATHOGENESIS
CLASSIFICATION
I. Proposed by Ueno et al. and Later Modified by Lupi Herrera
II. Takayasu Conference 1994
CLINICAL FEATURES
CRITERIA FOR DIAGNOSIS
NATURAL HISTORY
Complications
UYAMA AND ASAYAMA CLASSIFICATION OF RETINOPATHY
ASSESSMENT OF DISEASE ACTIVITY
INVESTIGATIONS
TREATMENT
Medical Treatment
Indications for Revascularization
Prognosis
Predictors of an Acute Event
Results of Intervention – DR George Joseph's series from CMC Vellore (Ref: 16th International Vasculitis and ANCA workshop 2013 proceedings)
COARCTATION OF AORTA
PHYSICAL APPEARANCE
Turner's syndrome
Signs
Chest X-Ray
Rib Notching
Unilateral Rib Notching on Chest X-ray
Natural History
Treatment
CHAPTER 22:
Approach to Congenital Heart Disease
GENETIC ASPECTS OF CONGENITAL HEART DISEASE1
Consanguinity
FOLIC ACID AND CONGENITAL TREAT DISEASE (EUR HEART J 2009;DEC)
Clinical Features of CHD
Left to Right Shunts
Obstructive Lesions
Cyanotic Lesions
Role of Hyperoxia Test
Teratogens
BEDSIDE APPROACH TO CYANOTIC CONGENITAL HEART DISEASE5
KEY POINTS ON GENETIC ASPECTS
CHAPTER 23:
Eisenmenger Syndrome
DEFINITION1
ES Starts at Infancy in2
Age at Presentation of ES
Size of the Defect and ES
Ventricle Overload in ES
Prevalence of PH with CHD
Clinical Classification of Congenital Heart Disease (JACC Dec 2013)
SYMPTOMS
SIGNS
ECG
DIFFERENCES BETWEEN THE GROUPS
Morphometric Grading
Alveloar Arterial Ratio
Simple Methods to Decide on Operability6
TREATMENT
Survival12
Survival of Treatment Naïve Patients with ES14
Suggested Treatment Algorithm for ES (Heart 2014;100:1322-1328)
CHAPTER 24:
Tetralogy of Fallot or Ventricular Septal Defect Plus Pulmonary Stenosis
ANATOMY
Spectrum of TOF Anatomy (% for Children's Hospital, Boston)
Embryology
Prevalence
Environmental Factors
Association with Genetic Disorders
Role of Karyotyping
Facial Features2
Types of VSD
Morphologic Categories of RVOT Obstruction
Haffman's Variant
Papillary Muscles of RV
Coronary Anomalies
Major Associated Cardiac Defects
Minor Associated Anomalies
CLINICAL FEATURES
Pink Tets/TET
Cyanosis3
Squatting
Squatting Equivalents
Spell/Hypoxic Spell
Presentation of Spell
Precipitating Factor for Spell4
Murmur during Spell
Complications of Spell
Mechanism of Spell
Recurrent Respiratory Tract Infections
Clubbing
Jugular Venous Pulse
Precordial Palpation
Auscultation
Ejection Systolic Murmur
Second Heart Sound
FEATURES OF ADULT TOF6
Chest X-Ray
ECG
ECG Axis
Oxymetry
Angiogram
COMPLICATIONS OF TOF7
Infective Endocarditis
DIFFERENTIAL DIAGNOSIS
Within the VSD + PS Physiology
Differences between VSD + PS versus PS with ASD
TREATMENT OF A SPELL
CATHETER INTERVENTIONS IN TOF
SURGERY
Primary Repair versus Palliation
Annular Patch
Assessment of the Adequacy of PA Size
McGoon Ratio
Nakata Index
Naito Index
Black Stone Formula
Types of Shunts
BT Shunt History
Central Shunt
Watterson Shunt
Glenn Shunt
Repaired TOF
Long-term Complications Following Surgery
Survival After Surgery9
Survival without Surgery
Causes of Death
Sudden Death10
Pulmonary Valve Replacement
Summary Indications for PVR
Results of PVR
Methods Used for PVR
CHAPTER 25:
Pulmonary Atresia with VSD
INCIDENCE
MORPHOLOGY
ENVIRONMENTAL AND GENETIC FACTORS
EMBRYOLOGY
PATHOLOGY
Collateral Anatomy in PA VSD2
Collateral Artery Supply Differences
Differences between Ductus and MAPCA
CLASSIFICATION
Congenital Heart Surgery and Database Project Based on PA Anatomy
Somerville Classification
CLINICAL
Chest X-Ray
MULTIDETECTOR COMPUTED TOMOGRAPHY
DIFFERENTIAL DIAGNOSIS
NATURAL HISTORY
MANAGEMENT
Palliative Surgery
Intracardiac Repair
Treatment Based on Pulmonary Circulation6
PA-VSD Type A
PA-VSD Type B
PA-VSD Type C
Results of Surgery
CHAPTER 26:
Chest X-Ray
ASSESSING HEART SIZE
LEFT ATRIUM ENLARGEMENT
Causes of Double Density
Causes of Elevation of Left Main Bronchus
Causes of Enlargement of Left Atrial Appendage (LAA)
RIGHT ATRIUM
LEFT VENTRICLE
PA View
Lateral View
RIGHT VENTRICLE
Lateral View
PA View
PULMONARY BLOOD FLOW
Increased Pulmonary Vascularity
Pulmonary Artery Hypertension
Pulmonary Artery Stenosis
Decreased Pulmonary Blood Flow
Congestive Cardiac Failure
Grading of Pulmonary Venous Hypertension3
Grading of PVH and PCW
Pleural Effusion in Heart Failure
CHAPTER 27:
ECG Criterias
LEFT ATRIAL ENLARGEMENT1
RIGHT ATRIAL ENLARGEMENT
BIATRIAL ENLARGEMENT
RIGHT VENTRICULAR HYPERTROPHY
Buttler and Legget Criteria for RVH
LEFT VENTRICULAR HYPERTROPHY: Voltage Criteria3
Left Ventricular Hypertrophy—Romhilt-Estes Point Score System
Paediatric Criteria for Left Ventricular Hypertrophy (Age- Related)
Paediatric Criteria for Right Ventricular Hypertrophy (Age- Related)
STEPWISE CRITERIA FAVORING VENTRICULAR TACHYCARDIA
INDEX
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