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The Art and Science of Cardiac Physical Examination (With Heart Sounds, Jugular and Precordial Pulsations)
Narasimhan Ranganathan, Vahe Sivaciyan, Franklin B Saksena
CHAPTER 1:
Approach to the Physical Examination of the Cardiac Patient
REASONS FOR WHICH CARDIAC ASSESSMENT IS SOUGHT
CARDIAC SYMPTOMS AND THEIR APPRAISAL
GENERATION OF WORKING LIST OF POSSIBLE DIAGNOSES
THE APPROACH TO A FOCUSED PHYSICAL EXAMINATION
Clinical Exercise
Congenital
Acquired
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Ischemic Heart Disease
Hypertensive Heart Disease
Cardiomyopathies
Conduction System Disorders
Pericardial Diseases
Cardiac Tumors
Pulmonary Hypertension
Precipitating or Aggravating Factors
Exercise
Congenital
Acquired
Cardiac Examination Findings in Patient B
Interpretations of the Physical Findings of Patient B
Synthesis
PRACTICAL POINTS TO A FOCUSED CARDIAC PHYSICAL EXAMINATION
CHAPTER 2:
Arterial Pulse
PHYSIOLOGY OF THE ARTERIAL PULSE
Laplace's Law
The Volume Effect
Pressure in the Vessel
Reflection
Pulse Wave Contour
Factors that Affect the Magnitude of the Initial Systolic Wave
Characteristics of the Proximal Arterial System
The Left Ventricular Pump
Momentum of Ejection (mv)
Mass (Stroke Volume)
Velocity of Ejection
Contractility
Impedance to Ejection
Low Peripheral Resistance
High Peripheral Resistance
Transmission or Velocity of Propagation of the Pulse Wave
Reflection
The Effects of Wave Reflection on the Pressure and the Flow Waveforms
Intensity of Reflection
Clinical Implications of Pressure Pulse Wave Reflection
Arterial Pulse Contour in Hypertrophic Cardiomyopathy
ASSESSMENT OF THE ARTERIAL PULSE
PRACTICAL POINTS IN THE CLINICAL ASSESSMENT OF THE ARTERIAL PULSE
CHAPTER 3:
Blood Pressure and its Measurement
PHYSIOLOGY OF BLOOD FLOW AND BLOOD PRESSURE
PHYSIOLOGY OF BP MEASUREMENT
The Mechanism of Origin of the Korotkoff Sounds
POINTS TO REMEMBER WHEN MAKING THE BP MEASUREMENT
FACTORS WHICH AFFECT BLOOD PRESSURE READINGS
INTERPRETATION OF BLOOD PRESSURE MEASUREMENTS
USE OF BP MEASUREMENT IN SPECIAL CLINICAL SITUATIONS
Determination of Pulsus Paradoxus
Effects of Respiration on the BP in the Normal Subjects
Pulsus Paradoxus in Cardiac Tamponade
Conditions Other than Cardiac Tamponade with Pulsus Paradoxus
Blood Pressure Response to the Valsalva Maneuver
Blood Pressure Response to Exercise
Determination of Pulsus Alternans
Assessment of Arterial Occlusion
Assessment of Dissecting Aortic Aneurysm
Atherosclerotic Vascular Disease
Ankle Brachial Index
Coarctation of the Aorta
Assessment of Severity of Aortic Regurgitation and Left Ventricular Function in Aortic Regurgitation
A Clinical Exercise-Manual Assessment of BP
Blood Pressure in the Assessment of the Relative Intensity of the First and the Second Heart Sounds
CHAPTER 4:
Jugular Venous Pulse
NORMAL RA PRESSURE PULSE CONTOURS
JUGULAR VENOUS INFLOW VELOCITY PATTERNS AND THE RELATIONSHIP TO THE RIGHT ATRIAL PRESSURE PULSE
JUGULAR VENOUS FLOW EVENTS AND THEIR RELATIONSHIP TO JUGULAR VENOUS PULSE CONTOURS
NORMAL JUGULAR VENOUS PULSE CONTOUR AND ITS RECOGNITION AT THE BEDSIDE
INDIVIDUAL COMPONENTS OF THE RIGHT ATRIAL PRESSURE PULSE, THEIR DETERMINANTS AND THEIR RECOGNITION IN THE JUGULARS
ABNORMAL JUGULAR VENOUS PULSE CONTOURS AS RELATED TO ABNORMAL JVF VELOCITY PATTERNS
Mechanism of Abnormal JVF Patterns and Contours in Pulmonary Hypertension
Mechanism of Abnormal JVF Patterns and Jugular Pulse Contours in Postcardiac Surgery Patients
Mechanism of Abnormal JVF Patterns and Jugular Pulse Contours in Restriction to Ventricular Filling
Late Diastolic Restriction
Mid- and Late-Diastolic Restriction
Total Diastolic Restriction
ABNORMAL JUGULAR CONTOURS
Double Descents in the Jugular Venous Pulse
Differential Diagnosis of Double Descents
With Pulmonary Hypertension
Without Pulmonary Hypertension
Venous Pulse Contour in Atrial Septal Defect
Venous Pulse Contour in Constrictive Pericarditis
Venous Pulse Contour in Severe Heart Failure
Venous Pulse Contours in RV Infarction
Venous Pulse Contours in Ebstein's Anomaly
Rare Types of Double Descents
Two Descents in Diastole (Double Diastolic Descents)
Triple Descents
Flutter Waves
Single y Descent
Exaggerated Ascents of Waves
ASSESSMENT OF JUGULAR VENOUS PRESSURE
Hepatojugular Reflux
Obstruction of the Superior Vena Cava
CLINICAL ASSESSMENT OF THE JUGULAR VENOUS PULSE
POINTS TO REMEMBER
CHAPTER 5:
Precordial Pulsations
THE MECHANICS AND PHYSIOLOGY OF THE NORMAL APICAL IMPULSE
PHYSICAL PRINCIPLES GOVERNING THE FORMATION OF THE APICAL IMPULSE
NORMAL APICAL IMPULSE AND ITS DETERMINANTS
ASSESSMENT OF THE APICAL IMPULSE
Location
Area
Which Ventricle is Causing the Apical Impulse?
Character
Dynamicity
Duration
Extra Humps and Their Timing
Palpable Sounds and Murmurs in the Area of the Apical Impulse
LEFT PARASTERNAL AND STERNAL MOVEMENTS
Causes of the Outward Systolic Left Parasternal/Sternal Movement
Causes of the Left Parasternal/Sternal Systolic Retraction
RIGHT PARASTERNAL MOVEMENT
PULSATIONS OVER THE CLAVICULAR HEADS
PULSATIONS OVER THE SECOND AND/OR THIRD LEFT INTERCOSTAL SPACES
SUBXIPHOID IMPULSE
PRACTICAL POINTS IN THE CLINICAL ASSESSMENT OF THE PRECORDIAL PULSATIONS
CHAPTER 6:
Heart Sounds
PRINCIPLES OF SOUND FORMATION IN THE HEART
FIRST HEART SOUND (S1)
Atrial Component
Mitral Component
Tricuspid Component
Aortic Component
Normal S1
Intensity of S1 (Loudness)
Mitral Component Intensity (M1)
M1 in Mitral Stenosis or Obstruction Secondary to Atrial Myxoma
Mitral Component (M1) and PR Intervals
Mitral Component (M1) and Short Diastoles in Atrial Fibrillation
Mitral Component (M1) in Heart Failure
Mitral Component (M1) in Mitral Regurgitation
Lesions that Interfere with the Integrity of the Isovolumic Phase of Systole
Mitral Component (M1) in Aortic Regurgitation
Tricuspid Component Intensity (T1)
Increased RV Contractility
Higher Right Atrial Pressure at the Time of Tricuspid Valve Closure
Aortic Component Intensity (A1)
Aortic Ejection Sound and Click
Pulmonary Ejection Sound and Click
CLINICAL ASSESSMENT OF S1 AND ITS COMPONENTS
Intensity or Loudness
Variability of Intensity
Components of S1 and Its Quality
SECOND HEART SOUND
Mechanism of Formation of S2
NORMAL S2
Normal Respiratory Variations of A2-P2 Split
ABNORMAL S2
Intensity of S2
Intensity of A2
Aortic Component (A2) Intensity in Aortic Regurgitation
Intensity of P2
Abnormal Timing of A2 and P2 Components
Electrical Delay
Mechanical Delay
Delay Secondary to Effects of Impedance
Effect of Delayed Occurrence of the S2 Components on the Respiratory Variation of S2 Splitting
Delayed A2
Left Bundle Branch Block
Mechanical Delay
Decreased Systemic Impedance
Delayed P2
Right Bundle Branch Block
Mechanical Delay
Effects of Impedance
Early A2
Abnormal Respiratory Variations of A2-P2 Split
CLINICAL ASSESSMENT OF S2
OPENING SNAP
The Mechanism of Formation of the OS
Opening Snap in the Absence of Mitral Stenosis
Timing of the OS and the S2-OS Interval
The Intensity of OS
CLINICAL ASSESSMENT OF THE OS
THIRD HEART SOUND (S3)
Diastolic Function
Hypertrophic Cardiomyopathy with Obstruction
Post-extrasystolic Beat
Mild LV Dysfunction
Early Rapid Filling Phase
Slow Filling Phase and Atrial Contraction Phase
Mechanism of Formation of the S3
Physiologic S3
Third Heart Sound (S3) in Ventricular Volume Overload
Third Heart Sound (S3) in Ventricular Dysfunction
Third Heart Sound (S3) in Constrictive Pericarditis (Pericardial Knock)
Third Heart Sound (S3) in Atrial Myxoma (Tumor Plop Sound)
Summation Gallop
CLINICAL FEATURES OF S3
CLINICAL ASSESSMENT OF S3
Third Heart Sound Persisting on Standing
Third Heart Sound Differentiation from OS
Third Heart Sound Differentiation from Tumor Plop
Intermittent S3
FOURTH HEART SOUND (S4)
Mechanism of Formation of the S4
CLINICAL ASSESSMENT OF S4
Fourth Heart Sound (S4) Differentiation from the Split S1
Gallop Rhythm
S3 and S4 and Left Ventricular Dysfunction
CHAPTER 7:
Heart Murmurs (Part I)
PRINCIPLES GOVERNING MURMUR FORMATION
HEMODYNAMIC FACTORS AND CARDIAC MURMURS
FREQUENCIES OF MURMURS
THE GRADING OF THE MURMURS
SYSTOLIC MURMURS
EJECTION MURMURS
Normal Physiology of Ventricular Ejection
Formation of Ejection Murmurs
Characteristics of Ejection Murmurs
Anatomic Differences Between the Left and the Right Ventricular Outflow Tract
Causes of Ejection Murmurs
Rapid Circulatory States
Ejection of a Large Stroke Volume
Abnormalities of the Outflow Tract Structures or the Semilunar Valves without Stenosis
Outflow Tract Obstruction
Left Ventricular
Sub-valvular Aortic Obstruction
Proximal Septal Hypertrophy with Angulated Septum Causing Mild Outflow Obstruction
Supravalvular Stenosis
Right Ventricular
Pulmonary Valvular Stenosis
Sub-valvular Pulmonary Stenosis
Supravalvular Pulmonary Stenosis
REGURGITANT SYSTOLIC MURMURS
MITRAL REGURGITATION
Normal Mitral Valve and Function
Causes of Mitral Regurgitation
Annular Abnormalities
Leaflet and Chordal Abnormalities
Papillary Muscle and Left Ventricular Wall Pathology
Atrial Myxoma
Pathophysiology of Mitral Regurgitation
Chronic Mitral Regurgitation
Acute Mitral Regurgitation
Characteristics of Mitral Regurgitation Murmurs
Severity of Mitral Regurgitation
Specific Etiologic Types of Mitral Regurgitation
Rheumatic Mitral Regurgitation
Mitral Regurgitation Secondary to the Prolapsed Mitral Leaflets
Mitral Regurgitation Secondary to Papillary Muscle Dysfunction
Clinical Features of Papillary Muscle Dysfunction
Mitral Regurgitation Secondary to Ruptured Chordae
Clinical Features of Mitral Regurgitation Secondary to Ruptured Chordae
TRICUSPID REGURGITATION
Tricuspid Valve Anatomy and Function
Causes of Tricuspid Regurgitation
Annular Abnormalities
Leaflet and Chordal Abnormalities
Papillary Muscle and Right Ventricular Wall Pathology
Atrial Myxoma
Others
Pathophysiology of Tricuspid Regurgitation
Tricuspid Regurgitation Secondary to Pulmonary Hypertension
Tricuspid Regurgitation with Normal Pulmonary Artery Pressures
Acute Tricuspid Regurgitation
Characteristics of Tricuspid Regurgitation Murmurs
VENTRICULAR SEPTAL DEFECT (VSD)
Congenital Ventricular Septal Defects
Septal Rupture Secondary to Myocardial Infarction
General Characteristics of the VSD Murmur
Variations in Clinical and Auscultatory Features in Ventricular Septal Defects
Sub-pulmonic VSD
Large VSD
Small Muscular VSD
VSD Murmurs and Vasoactive Agents
Ventricular Septal Defect Eisenmenger
Ventricular Septal Defect with Pulmonary Stenosis
Large VSD with Severe Pulmonary Stenosis
Large VSD with Mild Pulmonary Stenosis
Small VSD with Severe Pulmonary Stenosis
Small VSD with Mild Pulmonary Stenosis
Total Absence of Ventricular Septum
Post-Myocardial Infarction Septal Rupture
CLINICAL ASSESSMENT OF SYSTOLIC MURMURS
CHAPTER 8:
Heart Murmurs (Part II)
DIASTOLIC MURMURS
DIASTOLIC MURMURS OF MITRAL ORIGIN
DIASTOLIC MURMURS OF TRICUSPID ORIGIN
SEMILUNAR VALVE REGURGITATION
AORTIC REGURGITATION
Causes of Aortic Regurgitation
Valvular Causes
Aortic Root Disease
Pathophysiology of Chronic Aortic Regurgitation
Pathophysiology of Acute Severe Aortic Regurgitation
Auscultatory Features in Aortic Regurgitation
PULMONARY REGURGITATION
CLINICAL ASSESSMENT OF DIASTOLIC MURMURS
Evaluation of Symptoms
Clues from the Arterial Pulse, the Pre-cordial Pulsations and the Venous Pulse
The Auscultatory Assessment of Diastolic Murmurs
CONTINUOUS MURMURS
Communications Between a High Pressure Vessel and a Low Pressure Vessel or Chamber
Increased Velocity of Blood Flow
Arterial Obstruction
PERSISTENT DUCTUS ARTERIOSUS
AORTOPULMONARY WINDOW
Sinus of Valsalva Aneurysm
Auscultatory Features
Coronary Av Fistulae
Venous Hum
Mammary Souffle
CLINICAL ASSESSMENT OF CONTINUOUS MURMURS
PERICARDIAL FRICTION RUB
INNOCENT MURMURS
Systolic Murmurs
Continuous Murmurs
Mid-Diastolic Murmurs
CHAPTER 9:
Elements of Auscultation
THE STETHOSCOPE
THE METHODICAL WAY OF AUSCULTATION
Listening for One Thing at a Time and One Thing at a Time Only
Listening for Specific Things with Predetermined Mental Filter
Application of Principles Based on Sound Transmission Related to the Site of Origin
Recognition of Location of Maximal Loudness of Sound and/or Murmur
Effect of Gradient versus Effect of Flow on Frequency and Character of Murmurs
Logical Application of Behavior of Timing of Sounds Based on Proper Understanding of Physiologic Alterations
Application of the Concepts of Mechanisms
The Use of Bedside Maneuvers and Vasoactive Agents
Bedside Maneuvers
Vasoactive Agents
CHAPTER 10:
Pathophysiologic Basis of Symptoms and Signs in Cardiac Disease
INTRODUCTION
PATHOPHYSIOLOGY OF MITRAL REGURGITATION
Chronic Mitral Regurgitation
Acute Mitral Regurgitation
Clinical Symptoms and Signs in Mitral Regurgitation
PATHOPHYSIOLOGY OF AORTIC REGURGITATION
Chronic Aortic Regurgitation
Acute Severe Aortic Regurgitation
Clinical Symptoms and Signs in Aortic Regurgitation
PATHOPHYSIOLOGY OF MITRAL STENOSIS
Clinical Symptoms and Signs in Mitral Stenosis
PATHOPHYSIOLOGY OF AORTIC STENOSIS
Clinical Symptoms and Signs in Aortic Stenosis
PATHOPHYSIOLOGY OF MYOCARDIAL ISCHEMIA/INFARCTION
Clinical Symptoms and Signs in Myocardial Ischemia/Infarction
PATHOPHYSIOLOGY OF HYPERTENSIVE HEART DISEASE
Clinical Symptoms and Signs in Hypertensive Heart Disease
Heart Failure with Preserved Ejection Fraction
PATHOPHYSIOLOGY OF DILATED CARDIOMYOPATHY
Clinical Symptoms and Signs in Dilated Cardiomyopathy
PATHOPHYSIOLOGY OF HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
Clinical Symptoms and Signs in Hypertrophic Obstructive Cardiomyopathy
PATHOPHYSIOLOGY OF ATRIAL SEPTAL DEFECT
Clinical Symptoms and Signs in Atrial Septal Defect
PATHOPHYSIOLOGY OF DIASTOLIC DYSFUNCTION
PATHOPHYSIOLOGY OF CONSTRICTIVE PERICARDITIS
Clinical Symptoms and Signs in Constrictive Pericarditis
PATHOPHYSIOLOGY OF CARDIAC TAMPONADE
Clinical Symptoms and Signs in Cardiac Tamponade
APPENDIX
Laplace's Law
Symptoms of High Left Atrial Pressure
Clinical Signs of High left Atrial Pressure
Symptoms of Pulmonary Hypertension
Signs of Pulmonary Hypertension
Signs of Wide Pulse Pressure with Decreased Peripheral Resistance
Splitting of the Second Heart Sound
Right Bundle Branch Block
Left Bundle Branch Block
Aortic Stenosis
Atrial Septal Defect
Chronic Pulmonary Hypertension
Acute Pulmonary Hypertension
CHAPTER 11:
Local and Systemic Manifestation of Cardiovascular Disease
GENERAL OBSERVATIONS
Height
Weight
Degree of Alertness
Skin
Nails
Gait
CONGENITAL SYNDROMES/DISEASES
Down's Syndrome
LEOPARD Syndrome
Noonan's Syndrome
Tuberous Sclerosis
William's Syndrome
Osler-Weber-Rendu Syndrome
Holt-Oram Syndrome
Cyanotic Heart Disease
VASCULAR DISEASES
Coronary Artery Disease (CAD)
Hypercholesterolemia
Hypertriglyceridemia
Dysbetalipoproteinemia (Type III)
Unilateral Internal Carotid Artery Disease
Temporal Arteritis
Cholesterol Emboli to the Lower Extremities
Buerger's Disease (Thromboangiitis Obliterans)
Raynaud's Phenomenon
Superior Vena Caval Syndrome
Sub-clavian Vein Thrombosis
Inferior Vena Caval Syndrome
VALVULAR HEART DISEASE
Tricuspid Regurgitation
Mitral Stenosis
Aortic Regurgitation
ENDOCRINE AND METABOLIC DISEASES
Acromegaly
Hyperthyroidism
Myxedema
Cushing's Disease
Amyloidosis
Hemochromatosis
Gout
Alkaptonuria (Ochronosis)
INFLAMMATORY DISEASES
Infective Endocarditis (IE)
Syphilis
Sarcoidosis
DISEASES OF CONNECTIVE TISSUE AND JOINTS
Ehlers–Danlos Syndrome
Osteogenesis Imperfecta
Systemic Lupus Erythematosus
Scleroderma
Dermatomyositis
Polyarteritis Nodosa
Rheumatic Fever
Ankylosing Spondylitis
Reiter's Syndrome
PHARMACOLOGICAL DRUGS
Nifedipine
Angiotensin Converting Enzyme Inhibitors
Anticoagulants (Heparin and Coumadin)
Amiodarone
Procaine Amide
Hydralazine
Alpha Methyl Dopa
Digitalis, Spironolactone, Estrogens
Recreational Drugs
MUSCULOSKELETAL DISEASES
Muscular Dystrophies
Friedreich's Ataxia
Osteogenesis Imperfecta
Thoracic Cage Deformities
Paget's Disease of Bone
TUMORS
SYNOPSIS
ACKNOWLEDGMENT
CHAPTER 12:
12-Lead Electrocardiogram Interpretation
SECTION I BASIC PRINCIPLES AND THE ELECTROCARDIOGRAM (ECG) OF THE NORMAL PATIENTS
Anatomic Considerations of the Conduction System of the Heart
The Sinoatrial (SA) Node and the Atrioventricular (AV) Node
His Bundle, Bundle Branches, Divisions of the Left Bundle and the Purkinje System
The Arterial Supply of the Conduction System
The Function of the Conduction System
Basic Principles of ECG
Action Potential
The Electric Dipole Concept in Electrocardiography
The Lead System Used in Electrocardiography
The Limb Leads and the Hex-axial System in the Frontal Plane
Deducing the Direction of the Electrical Force from the Frontal Plane Leads
The Precordial (Unipolar) Leads in the Horizontal Plane
The Scale or the Grid on the ECG Output Paper
The Language of the ECG
The Normal Activation Sequence and the Direction of the Normal Electrical Forces
Atrial Activation
Ventricular Activation
Repolarization of the Atria
Repolarization of the Ventricles
QRS-T Angle
The Ventricular Gradient
The Duration of Repolarization and the QT interval
The ECG of Normal Patients
The Effect of Age and Body Habitus on the Normal ECG
Review Exercise
SECTION II: AXIS DEVIATIONS AND INTRA-VENTRICULAR CONDUCTION DEFECTS
Determination of Mean Axes and Direction of Normal Axes
Axis Deviations of the QRS
Left Axis Deviation
Left Axis Deviation Associated with Congenital Heart Lesions
Clinical Significance of LAFB
Right Axis Deviation
Diagnosis of Fascicular Blocks in the Presence of an Infarct
Blocks in the Conduction System
First Degree Block
Second Degree Block
Type I, 2° block (Wenckebach conduction)
Type II, 2° block
Third degree block
Bundle Branch Blocks
Normal Intra-ventricular Conduction
Right Bundle Branch Block (RBBB)
Left Bundle Branch Block (LBBB)
Secondary ST-T Wave Changes in BBB
Axis Determination in the Presence of RBBB and Bifascicular Blocks
Clinical Significance of RBBB
Clinical Significance of LBBB
Trifascicular Disease
SECTION III: CHAMBER ENLARGEMENT, HYPERTROPHY, OVERLOADS
Atrial Enlargement/Hypertrophy (Overloads)
Right Atrial Overload/Abnormalities
Left Atrial Overload/Abnormalities
Pathophysiology of P Wave Abnormalities in Atrial Overloads
Ventricular Hypertrophy (Enlargement)
Left Ventricular Hypertrophy
The Voltage Criteria
The Combination Voltage Criteria (Cornell)
The secondary criteria
Diagnosis of LVH in the Presence of Bundle Branch Blocks
Left Ventricular Hypertrophy (LVH) in Hypertrophic Cardiomyopathy (HCM)
Systolic (Pressure) and Diastolic (Volume) Overload of the Left Ventricle
Right Ventricular Hypertrophy
Right Ventricular Systolic and Diastolic Overload
Specific Clinical Conditions
Combined Ventricular Overload/Hypertrophy
SECTION IV: MYOCARDIAL INFARCTION
Definition and Diagnostic Criteria
Symptoms of Ischemia
Clinical Types of Myocardial Infarction
ECG Changes of Myocardial Infarction
Temporal Sequence of Changes
Changes in the ST Segment Vector of Infarction—Current of Injury
Correlation of ST Segment Elevation and Depression to the Anatomic Region of the Heart and the Coronary Artery Involved
Evaluation of ST Segment Elevation in the Setting of Intra-ventricular Conduction Defect
Changes in the T Waves Direction Due to Infarction
Changes in the Initial QRS Force Due to Infarction
Correlation of Q Waves to the Site of Infarction
Anterior Infarct
Posterior and postero-lateral infarct
Inferior Infarct
Right Ventricular Infarction
Reliability of the Q Waves
Changes in the Mid and Late QRS Forces Caused by Infarction
Ventricular Aneurysm
Ventricular Rupture
Recognition of myocardial infarction in the Presence of Intra-ventricular Conduction Defect
Infarct Recognition in the Presence of Fascicular Block, RBBB and/orBifascicular block
Infarct Recognition in the Presence of LBBB
ECG Changes Simulating Infarction
Terminology of Left Ventricular Walls and Location of Myocardial Infarcts
SECTION V: VENTRICULAR PRE-EXCITATION/PERICARDITIS
Initial QRS Abnormalities of Ventricular Pre-excitation
Definition and Diagnostic Criteria
Accessory Pathways
Delta Wave
Tachyarrhythmias
Localization of the Accessory Pathway
ECG Changes of Pericarditis
ST Segment and T Wave Changes
PR Segment Changes
ECG Changes with Pericardial Effusion
Arrhythmias Associated With Pericarditis
SECTION VI: ABNORMALITIES OF ST-T WAVES/QT INTERVALS/ST SEGMENT DEVIATIONS/T WAVES
ST-T Abnormalities
Basic Physiology—Correlates
U Wave
Non-specific ST-T Abnormalities
Primary and Secondary ST-T Changes
Duration of the Action Potential (QT Interval)
Inherited Long QT Syndromes (LQTS)
Short QT interval
Inherited Short QT Syndrome (SQTS)
ST Segment
ST Segment Elevation
ST Segment Elevation-Normal Variant/Early Repolarization
The Classical ECG Features
Concept of Benign Versus Malignant ST Segment Morphology in ER
Clinical Perspective
J Wave
Congenital ST Elevation and Large J Wave (Brugada Syndrome)
Evaluation of a Suspected Patient
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/ARVC)
Acquired Large J wave (Osborn Wave of Hypothermia)
ST Segment Depression
ST Segment Changes of Digitalis
The T Wave
Inverted and Low T Waves
Tall T Waves
Certain Specific Causes of T Wave Abnormalities
ECG Changes of Hypokalemia
ECG Changes of Hyperkalemia
ECG Changes of Hypo and Hypercalcemia
APPENDIX
CHAPTER 13:
Integration of ECG into Cardiac Diagnosis
INTRODUCTION
DIAGNOSTIC ECG FEATURES AND ASSOCIATED CONDITIONS
ACUTE CLINICAL STATES
SUDDEN DEATH, CARDIAC ARREST/ SYNCOPE/VENTRICULAR TACHYARRHYTHMIAS
VALVULAR DISEASE
MYOCARDIAL DISEASES
CONGENITAL HEART DEFECTS
Shunt Lesions
Atrial Septal Defect Secundum
Atrial Septal Defect Primum
Ventricular Septal Defect
Persistent Ductus Arteriosus (PDA)
Obstructive Lesions
Pulmonary Stenosis
Aortic Stenosis
Coarctation of Aorta
Ebstein's Anomaly, Congenitally Corrected Transposition
Ebstein's Anomaly
Congenitally Corrected Transposition
Cardiac Malpositions, Coronary Anomalies, Single Ventricle
Cardiac Malpositions
Coronary Anomalies
Single Ventricle
Surgically Corrected Congenital Heart Defects with Residual Issues
Surgically Corrected Tetralogy of Fallot
Complete TGA and Intra-atrial Baffle
Post-Fontan Operation
CARDIAC INVOLVEMENT IN SYSTEMIC DISORDERS
Inflammatory
Metabolic and Endocrine
Infiltrative Processes
Neuromuscular Disorders
OTHER MISCELLANEOUS CONDITIONS
CHAPTER 14:
Self-Assessment
PATIENT 1
Clinical History
Physical Findings
PATIENT 2
Clinical History
Physical Findings
PATIENT 3
Clinical History
Physical Findings
PATIENT 4
Clinical History
Physical Findings
PATIENT 5
Clinical History
Physical Findings
PATIENT 6
Clinical History
Physical Findings
PATIENT 7
Clinical History
Physical Findings
Follow-up Clinical History
PATIENT 8
Clinical History
Physical Findings
Follow-up Clinical History
PATIENT 9
Clinical History
Physical Findings
PATIENT 10
Clinical History
Physical Findings
PATIENT 11
Clinical History
Physical Findings
PATIENT 12
Clinical History
Physical Findings
PATIENT 13
Clinical History
Physical Findings
PATIENT 14
Clinical History
Physical Findings
PATIENT 15
Clinical History
Physical Findings
PATIENT 16
Clinical History
Physical Findings
PATIENT 17
Clinical History
Physical Findings
PATIENT 18
Clinical History
Physical Findings
PATIENT 19
Clinical History
Physical Findings
PATIENT 20
Clinical History
Physical Findings
INDEX
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