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Essentials of Cardiovascular Examination
Sumesh Raj, Rajan GV
SECTION A: APPROACH TO THE PATIENT
CHAPTER 1:
The Cardiac History
Chief Complaints
Symptoms of Cardiovascular Disease
Dyspnea
New York Heart Association
Causes
Orthopnea
Mechanism
Causes
Paroxysmal Nocturnal Dyspnea (PND)
Causes
Pnd is the Earliest Symptom of Left Heart Failure
Trepopnea
Platypnea
Bendopnea
Angina Pectoris
Characteristics of Anginal Pain
Anginal Equivalent
Prinzmetal angina
Nocturnal angina
Unstable angina
Angina decubitus
Palpitation
Causes
Syncope
Causes
Cardiac
Vasovagal syncope
Orthostatic hypotension
Post-tussive (cough) syncope
Micturition syncope
Hemoptysis
Past History
Family History
Personal History
Treatment History
CHAPTER 2:
General Examination in Relation to Cardiovascular System (CVS)
Head to Foot Examination
Marfanoid Features
Signs of Infective Endocarditis
Embolic complications of infective endocarditis
Markers of Coronary Heart Disease
CHAPTER 3:
Examination Proforma
General Examination
Head to Foot Examination
Examination of the Cardiovascular System
Examination of the Arterial Pulse
Examination of the right radial artery
Examination of Blood Pressure
Blood pressure in atrial fibrillation
Examination of Jugular Venous Pressure, Jugular Venous Pulse and Hepatojugular Reflux
Inspection
Palpation
Percussion
Auscultation
CHAPTER 4:
Anatomy of Heart and Coronary Circulation
Embryology of the Heart
Anatomy of the Heart
Coronary Circulation
Coronary Artery Dominance
Venous Drainage of the Heart
Lymphatic Drainage of the Heart
Nerve Supply of the Heart
Sympathetic Nervous System
Parasympathetic Nervous System
SECTION B: CARDIOVASCULAR SYSTEM
CHAPTER 5:
Arterial Pulse
Definition
Importance
Method of Palpation of the Right Radial Artery
Position of the Patient
Assessment of Arterial Pulse
Pulse Rate
Causes of Sinus Bradycardia
Physiological
Pathological
Causes of Sinus Tachycardia
Physiological
Pathological
Pulse Deficit
How to look for
Causes
Rhythm
Sinus Arrhythmia
Regularly Irregular Rhythm
Irregularly Irregular Rhythm
Pulse Volume
Pulse Character
Anacrotic Pulse
Dicrotic Pulse (Fig. 5.2)
Causes
Hypokinetic Pulse (Fig. 5.3)
Causes
Hyperkinetic Pulse (Fig. 5.4)
Collapsing Pulse (Fig. 5.5)
Causes
How to look for
Mechanism
Thready Pulse
Jerky Pulse
Pseudocollapsing Pulse
Pulsus Bisferiens (Fig. 5.6)
Pulsus Alternans (Fig. 5.7)
Causes
How to Look for
Pulsus Bigemini (Fig. 5.8)
Pulsus Trigemini
Pulsus Paradoxus
Causes
How to Look for
Reverse Pulsus Paradoxus
Causes
Intermittent Pulse
Tension of the Pulse
Condition of Vessel Wall
How to Look for
Examination of Peripheral Pulses
Method of Palpation
Radiofemoral Delay
Grading of the Arterial Pulsation
CHAPTER 6:
Blood Pressure
Examination of Blood Pressure
All Clothing should be Removed from the Arm
Pulsus Paradoxus
Pulsus Alternans
Orthostatic Hypotension
Blood Pressure in Atrial Fibrillation
CHAPTER 7:
Jugular Venous Pulse and Jugular Venous Pressure
Jugular Venous Pressure (Fig. 7.1)
Prerequisites in examination of JVP
JVP as Indicator of Mean Right Atrial Pressure
Causes of Elevated JVP
Cardiac
Pulmonary
Abdominal
Iatrogenic—Excess IV Fluids
Causes of Fall in JVP
Jugular Venous Pulse
Abnormalities of JVP
Cannon Waves (Giant ‘a’ Waves Seen)
Causes of Kussmaul's Sign
Hepatojugular Reflux
CHAPTER 8:
Inspection of Precordium
CHAPTER 9:
Palpation
Apical Impulse
Abnormalities of Apical Impulse
Absent apical impulse
Tapping apical impulse
Hypodynamic apical impulse (felt with decreased thrust)
Hyperdynamic apical impulse
Heaving apical impulse
Diffuse apical impulse
Double apical impulse
Triple or quadruple apical impulse
Retractile apical impulse
Heaving apical impulse
Hyperdynamic apical impulse
Left parasternal impulse
Grading of parasternal impulse
Causes of Right Ventricular Enlargement
Left Atrial Enlargement
Shocks
Thrills
CHAPTER 10:
Percussion of the Heart
CHAPTER 11:
Auscultation
CHAPTER 12:
First Heart Sound (S1)
CHAPTER 13:
Second Heart Sound (S2)
Loud S2
Causes of Loud A2
Causes of Loud P2
Soft S2 may be Due to Soft A2 or Soft P2
Soft A2
Soft P2
Causes of delayed A2
Causes of early P2
Single S2
i. Absent A2
ii. Absent P2
Splitting of S2
Mechanism of Physiological Split of S2
Normal Intervals
Wide Split S2
Early A2
Types of Split S2 (Fig. 13.1)
Wide Fixed Split
Reverse Splitting of S2
CHAPTER 14:
Third Heart Sound (S3)
Introduction
Causes of Physiological S3
Causes of Pathological S3
CHAPTER 15:
Fourth Heart Sound (S4)
S4—Atrial Contraction Sound
Site
Causes of Pathological S4
Gallops
Triple rhythm with tachycardia
Quadruple rhythm
Summation gallop
CHAPTER 16:
Ejection Clicks
Introduction
Valvular Clicks
Midsystolic Clicks
Vascular Clicks
Vascular click is heard over the aortic area in—
Vascular click is heard over the pulmonary area in—
CHAPTER 17:
Heart Murmurs
Introduction
Levine and Freeman's Grading of Murmurs
Systolic murmur
Diastolic murmur
Systolic Murmurs
Ejection Systolic Murmurs
Causes
Late Systolic Murmurs
Causes
Pansystolic Murmurs
Causes
Diastolic Murmurs
Early Diaslolic Murmurs (EDM)
Causes
Mid-diastolic Murmurs (MDM)
Uncommon causes
Late Diastolic Murmur (Presystolic Murmurs)
Causes
Continuous Murmur
Classification of Continuous Murmur
High pressure to low pressure shunts
Increased flow through normal vessels
Approach to Continuous Murmurs
Acyanotic Heart Diseases with
Cyanotic Heart Disease with
Continuous Murmur with Systolic Accentuation
Bronchopulmonary anastomosis
To and Fro Murmur (Biphasic murmur)
Systolic–Diastolic Murmur
Innocent Murmurs
Innocent murmurs may be heard
Functional Murmurs
Systolic murmurs
Pansystolic Murmur (PSM)
Changing murmurs
SECTION C: CARDIOVASCULAR SYSTEM AND RELATED DISEASES
CHAPTER 18:
Acute Rheumatic Fever (ARF)
Introduction
Epidemiology
Pathogenesis
Clinical Features
Heart Involvement
The characteristic manifestation of carditis is mitral regurgitation
Joint Involvement
Chorea
Skin Manifestations
Erythema marginatum (Fig. 18.1)
Subcutaneous Nodules (Fig. 18.2)
Other Features
Confirming the Diagnosis
1992 revised Jones criteria
Antibiotics
Salicylates
Glucocorticoids
Bed rest
Chorea
Prevention
CHAPTER 19:
Infective Endocarditis
Introduction
Acute Endocarditis
Subacute Endocarditis
Etiology
Prosthetic Valve Endocarditis (PVE)
Endocarditis Occurring Among Injection Drug Users
Pathogenesis
Clinical Manifestations
Clinical Features (Fig. 19.1)
Cardiac Manifestations
Renal manifestation
Diagnosis
Documentation
CHAPTER 20:
Mitral Stenosis (MS)
Juvenile Mitral Stenosis
Pulmonary Hypertension
Symptoms
Palpitation
Hemoptysis
Causes
Atrial Fibrillation (AF)
Pulmonary Edema
Chest Pain
Pressure Symptoms
Physical Findings
Auscultation
Cause
Associated Lesions
ECG (Fig. 20.1)
Echocardiogram (Fig. 20.2)
Chest X-ray (Fig. 20.3)
Differential Diagnosis
Atrial Myxoma
Cardiac Catheterization
Treatment
Medical treatment
Penicillin prophylaxis for secondary prevention of rheumatic fever
Mitral valvotomy
Percutaneous balloon valvuloplasty
Mitral valve replacement (MVR)
Mechanical Prosthesis
Bioprosthesis
CHAPTER 21:
Mitral Regurgitation (MR)
Mitral Regurgitation (Fig. 21.1)
Causes
Causes of Acute MR
Symptoms
Signs
Pulse
Seagull Murmur or Cooing Dove Murmur
Signs of AF
Severity
Complications
ECG
Chest X-ray
Echocardiogram
Cardiac Catheterization
Management
Medical
Surgical
Surgery for acute MR
CHAPTER 22:
Aortic Stenosis (AS)
Introduction
Common Causes
Bicuspid Aortic Valve Disease
Symptoms
Signs
Apex
Severity
Silent AS
Complications
Investigations
ECG
Chest X-ray
Echocardiogram (Fig. 22.1)
Cardiac catheterization
Coronary angiogram
Prognosis
Management
Medical
Surgical
CHAPTER 23:
Aortic Regurgitation (AR)
Aortic Valve Involvement
Primary Aortic Root Disease
Causes of acute AR
Symptoms
Peripheral Signs of AR—Signs of Wide Pulse Pressure
Other signs
Murmur
Severity
ECG
Chest X-ray
Echocardiogram (Fig. 23.1)
Cardiac Catheterization
Causes of Combined AS and AR
Management
Medical
Acute AR
Chronic AR
Surgical
CHAPTER 24:
Tricuspid Stenosis (TS) and Tricuspid Regurgitation (TR)
Tricuspid Stenosis (TS)
When to Entertain the Diagnosis of TS
Symptoms
Signs
ECG
Chest X-ray
Echocardiogram
Treatment
Tricuspid Regurgitation (TR)
Causes
Primary
Secondary
Symptoms and Signs
Severity
ECG
Chest X-ray
Echocardiogram
Management
CHAPTER 25:
Pulmonary Stenosis (PS) and Pulmonary Regurgitation (PR)
Pulmonary Stenosis (PS)
Causes
Pulmonary Stenosis May Occur at Various Levels
Pulmonary Stenosis Associated Syndromes
Clinical Features
ECG
Chest X-ray
Complications
Treatment
Pulmonary Regurgitation (PR)
Causes
Signs
CHAPTER 26:
Pulmonary Hypertension
CHAPTER 27:
Mitral Valve Prolapse (MVP)
Synonyms
Causes
Clinical Features
Auscultation
Laboratory Examination
Treatment
CHAPTER 28:
Atrial Septal Defect (ASD)
CHAPTER 29:
Ventricular Septal Defect (VSD)
Ventricular Septal Defect (VSD) (Fig. 29.1)
Classification
Perimembranous or paramembranous type
Muscular type
Syndromes with VSD
Mechanism of Closure of Defect
Clinical features
Maladie-de-Roger Syndrome
ECG
Chest X-ray
Echocardiogram
Treatment
CHAPTER 30:
Patent Ductus Arteriosus (PDA)
CHAPTER 31:
Tetralogy of Fallot (TOF)
CHAPTER 32:
Eisenmenger's Syndrome
Introduction
Clinical Features
Death is Caused by
Differential Diagnosis
CHAPTER 33:
Coarctation of the Aorta
Investigations
ECG
Chest Radiograph
Doppler Echocardiography
Complications
Treatment
Treatment of Choice
CHAPTER 34:
Other Congenital Heart Diseases
Malpositions of the Heart
Dextrocardia
Dextrocardia with situs inversus (situs inversus totalis) (Fig. 34.1)
The ECG Shows Negative P-wave in Standard Lead I (Fig. 34.2)
Isolated Dextrocardia
Anomalous Pulmonary Venous Connection
Total Anomalous Pulmonary Venous Connection (TAPVC)
Partial Anomalous Pulmonary Venous Connection (PAPVC)
Ebstein's Anomaly (Fig. 34.3)
Complete Transposition of the Great Vessels (D-transposition)
Congenitally Corrected Transposition of the Great Vessels
Truncus Arteriosus
Tricuspid Atresia
Coronary Arteriovenous Fistula
Cor Triatriatum (or Triatrial Heart)
Ellis Van Creveld Syndrome
CHAPTER 35:
Heart Failure (HF)
Classification of Cardiac Failure
High Output Failure
Low Output Failure
Right and Left-sided Heart Failure and Congestive Cardiac Failure
Right-sided Heart Failure
Left-sided Heart Failure
Congestive Cardiac Failure
Forward and Backward Heart Failure
Forward Heart Failure
Backward Heart Failure
Systolic and Diastolic Failure
Systolic Failure
Diastolic Failure
Left Ventricular Remodeling
Clinical Manifestations
Symptoms
Orthopnea
Paroxysmal Nocturnal Dyspnea (PND)
Cheyne-Stokes Respiration
Other Symptoms
Cardiac Examination
Abdomen and Extremities
Cardiac Cachexia
Framingham Criteria for Diagnosis of Congestive Cardiac Failure (CCF)
Major criteria
Minor criteria
Major/minor criteria
Investigations
Routine laboratory testing
Electrocardiogram (ECG)
Chest X-ray
Two-dimensional (2-D) echocardiogram/doppler
Biomarkers
Management of Acute Heart Failure (Acute Pulmonary Edema)
Nonpharmacologic Measures
Physical rest
Diet
Drugs for Heart Failure
Diuretics
Angiotensin Converting Enzyme (ACE) Inhibitors
Angiotensin II Receptor Blockers (ARBs)
Adrenergic Receptor Blockers
Aldosterone Antagonists
Digoxin
Anticoagulation and Antiplatelet Therapy
Management of Cardiac Arrhythmias
Cardiac Transplantation
CHAPTER 36:
Pulmonary Thromboembolism (Acute Cor Pulmonale)
Risk Factors for Deep Vein Thrombosis
Clinical Features
Investigations
ECG (Fig. 36.1)
Chest X-ray
Blood Gas Analysis
Management
CHAPTER 37:
Cor Pulmonale (Pulmonary Heart Disease)
Definition
Etiology of Chronic Cor Pulmonale (Table 37.1)
Clinical Manifestations
Symptoms
Signs
Diagnosis
ECG
Chest X-ray
Spirometry
Arterial blood gases
High-resolution computed tomography (HRCT) scans of the chest
Ventilation-perfusion lung scanning
Echocardiography
Treatment
General principles of treatment
CHAPTER 38:
Systemic Hypertension
Hypertensive Crises
Etiology
Primary or essential hypertension
Secondary hypertension
Clinical Presentation (Table 38.1)
Symptoms
Physical Examination
Examination of Blood Vessels
Apical impulse
Examination of the Heart
Palpable Kidneys
Complications
Cerebrovascular
Investigations
Treatment (Table 38.3)
Pharmacological Treatment
Medication Selection Based on Joint National Committee 8 (JNC8) (Table 38.5)
CHAPTER 39:
Ischemic Heart Disease
Definition
Stable Angina Pectoris
Anginal “Equivalents”
Physical Examination
Laboratory Examination
Chest X-ray
Electrocardiogram
Stress Testing
Echocardiography
Coronary arteriography
Treatment
Asymptomatic (Silent) Ischemia
CHAPTER 40:
ST-segment Elevation Myocardial Infarction (STEMI)
Introduction
Pathophysiology
Clinical Presentation
Physical Findings
Laboratory Findings
Electrocardiogram
Serum Cardiac Biomarkers
Troponin
Creatine kinase
Chest X-ray
Cardiac Imaging
Initial Management
Aspirin
Oxygen
Control of discomfort
Management Strategies
Limitation of Infarct Size
Percutaneous coronary intervention (PCI) (Fig. 40.2)
Fibrinolysis
Thrombolysis in Myocardial Infarction (Timi) Grading
Activity
Sedation
Pharmacotherapy
Antithrombotic agents
β-Adrenoceptor Blockers
ACE inhibitors
Angiotensin Receptor Blockers (Arbs)
Complications and their Management
Ventricular dysfunction
Killip classification
Cardiogenic Shock
Right Ventricular Infarction
Arrhythmias
Ventricular arrhythmias
Supraventricular Arrhythmias
Sinus Bradycardia
Atrioventricular and Intraventricular Conduction Disturbances
Other Complications
Cardiac catheterization with coronary angiography is indicated in
Secondary Prevention
CHAPTER 41:
Unstable Angina and Non-ST-segment Elevation Myocardial Infarction
Definition
NSTEMI
Clinical Presentation
Electrocardiogram
Cardiac Biomarkers
Medical Treatment
Anti-ischemic treatment
Morphine
Nondihydropyridine calcium channel blockers
Antithrombotic Therapy
Aspirin
Clopidogrel
Anticoagulant therapy
Invasive Strategy
Conservative strategy
Long-term Management
Prinzmetal's Variant Angina
CHAPTER 42:
Arrhythmias
Tachyarrhythmias
Analysis of ECG for Arrhythmia
Paroxysmal Supraventricular Tachycardia (Fig. 42.1)
Short R-P tachycardia
Long R-P tachycardia
WPW syndrome (Fig. 42.2)
Multifocal atrial tachycardia
Paroxysmal atrial tachycardia with complete heart block
Atrial Flutter (Fig. 42.3)
Atrial Fibrillation (Fig. 42.4)
Common causes
ECG
Symptoms of AF (due to rapid ventricular rate)
Management of Narrow Complex Tachycardia
In the presence of adverse signs like
Chronic therapy of SVT (Use Either One of the Drugs)
Radiofrequency Ablation after Electrophysiological Study
Atrial fibrillation: Management
Acute AF (< 72 hours)
AF with High Risk Factors
AF with Moderate Risk Factors
Atrial Flutter
Atrial Extrasystoles
AV Node
AV nodal extrasystole
Paroxysmal AV nodal tachycardia
Ventricular Arrythmias
Ventricular extrasystole
Types of Ventricular Extrasystole
Ventricular bigeminy (Fig. 42.5)
Multifocal ventricular extrasystoles
Ventricular trigeminy
Broad complex tachycardia—Ventricular tachycardia (VT)
Ventricular flutter (Fig. 42.6)
Torsades de pointes
Ventricular Fibrillation (VF) (Fig. 42.7)
Management of Broad Complex Tachycardia
Hemodynamically stable VT
Resistant VT/ VF
Torsades de pointes (Tdp) is Associated With Long QT Syndrome
Prevention of Recurrent VT
Indications for Implantable Cardioverter Defibrillators (ICDs)
Bradyarrhythmias
Sick sinus Syndrome (Tachy-Brady Syndrome)
Heart Block
First degree heart block
Second degree heart block
Complete or third degree heart block (Fig. 42.11)
Indications for Permanent Pacemakers
Exercise (Stress) ECG
Predicted Heart Rate
Holter Monitoring or Ambulatory ECG
Stress Echocardiography
CHAPTER 43:
Conduction Disorders of the Heart
Right Bundle Branch Block (RBBB) (Fig. 43.1)
Complete RBBB
Incomplete RBBB
Significance
Left Bundle Branch Block (LBBB) (Fig. 43.2)
Complete LBBB
Significance
Hemiblocks (Fascicular Blocks)
Left Anterior Hemiblock (LAHB) (Fig. 43.3)
Causes
ECG features
Left Posterior Hemiblock (LPHB) (Fig. 43.4)
ECG features
Bifascicular Block
Trifascicular Block
CHAPTER 44:
Pericardial Diseases
Pericarditis
Acute < 6 weeks
Subacute 6 weeks–6 months
Chronic > 6 months
Etiologic Classification
Infectious pericarditis
Noninfectious pericarditis
Pericarditis Related to Hypersensitivity or Autoimmunity
There are four principal diagnostic features
Management
Cardiac Tamponade
Causes
Clinical Features
Management
Chronic Constrictive Pericarditis
Causes
Pathology
Clinical and Laboratory Findings
Differential Diagnosis
Treatment of Chronic Constrictive pericarditis
CHAPTER 45:
Myocarditis
Definition
Causes
Infective
Hypersensitivity
Physical agents
Chemicals
Drugs
Clinical features
On Examination
ECG
Diagnosis
Management
CHAPTER 46:
Cardiomyopathy
Types of Cardiomyopathy
Dilated Cardiomyopathy
Clinical features
ECG
Chest X-ray
Echocardiography
Cardiac Catheterization
Management
Restrictive (Obliterative) Cardiomyopathy
Causes
Chest X-ray
ECG
Doppler echocardiography
CT and MRI
Endomyocardial biopsy
Hypertrophic Obstructive Cardiomyopathy (HCM) (Fig. 46.2)
Symptoms
Signs
ECG
Chest X-ray
Echocardiography
Cardiac Catheterization
Management
CHAPTER 47:
Diseases of the Aorta
Aortic Aneurysm
Classification Aneurysms
According to their Gross Appearance
According to location (Fig. 47.1)
Etiology (Table 47.1)
Thoracic Aortic Aneurysms
Chest X-ray
Transesophageal Echocardiography
Treatment
Abdominal Aortic Aneurysms
Treatment
Aortic dissection
Aortitis
Takayasu's Arteritis
Giant Cell Arteritis
Rheumatic Aortitis
Idiopathic Aortitis
Infective Aortitis
CHAPTER 48:
Cardiac Manifestations of Systemic Disease
CHAPTER 49:
Neoplastic Diseases of the Heart
Primary Tumors
Clinical Presentation
Myxoma
The Familial Variety
Treatment
Other Benign Tumors
Tumors Metastatic to The Heart
SECTION D: INVESTIGATIONS IN CARDIOVASCULAR SYSTEM (CVS)
CHAPTER 50:
The Electrocardiogram
ECG Waveforms and Intervals (Fig. 50.1)
ECG Leads
Electrical Axis
Abnormalities
Acute Cor Pulmonale Due to Pulmonary Embolism
Bundle Branch Blocks
Wolff-Parkinson-White (WPW) syndrome
Myocardial Ischemia and Infarction
Brugada pattern (Fig. 50.3)
Hyperkalemia (Fig. 50.4)
Hypokalemia (Fig. 50.5)
Electrical Alternans (Fig. 50.7)
CHAPTER 51:
Noninvasive Cardiac Imaging
Echocardiography
2D Echocardiography
Doppler Echocardiography
Ejection fraction (EF)
Stress Echocardiography
Transesophageal Echocardiography
Radionuclide Imaging
MRI/CT Imaging
CHAPTER 52:
Stress Tests
Definition
Contraindications for Stress Testing
Treadmill Protocol
Interpretation of Test Findings
CHAPTER 53:
Cardiac Catheterization
Cardiac Catheterization
Indications (Table 53.1)
Vascular Access
Right Heart Catheterization
Left Heart Catheterization
Ventriculography and Aortography
Coronary Angiography (Fig. 53.1)
Fractional Flow Reserve
INDEX
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