CARDIOLOGY Congestive Heart Failure Hypertrophic Cardiomyopathy Dilated Cardiomyopathy Restrictive Cardiomyopathy Contrictive Pericarditis Pericardial Effusion Cardiac

Tamponade Myortic Stenosis Mitral Regurgitation Mitral Valve Prolapse Aortic Stenosis Aortic Insufficiency Acute Pericarditis Infectious Endocarditis EKG Intro Brady Arrythmias Tachy Arrythmias

ACRONYMS TV = Tricuspid Valve PV = Pulmonary Valve MV = Mitral Valve AV = Aortic Valve EDV = End Diastolic Volume

AI = Aortic Insufficiency MR = Mitral Regurgitation TR = Tricuspid Regurgiation PR = Pulmonary Regurgitation LHF = Left Heart Failure RHF = Right Heart Failure

Murmurs

ARF / RF = Acute Rheumatic Fever BBB = Bundle Branch Block WPW =

Lungs COPD = Chronic Obstructive Pulmonary Disease

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Mostly patients > 50 yrs DOE; Fatigue; Mental status Diabetic; Smoker; HTN; Obese; Family Hx

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Palpitations DOE; PND; Effort on respiration Urine output; Nocturia Fatigue / weakness Mental status Depression

Anorexic; Weight loss JVD S2, S3, S4; SM (axilla / sternal border) Rales at base; Rapid shallow breathing URQ Tenderness; Enlarged liver Orthopnea; Peripheral edema Dusky appearance; pale; clammy -

LABS Schwann Catheter LA Pressure (> 20 mmHg) RA Pressure X-Ray Cardiomegaly Kerley B Lines Enlarged pulmonary veins Pulmonary edema (if LA Pressure > 25 mmHg)

TREATMENT Plan Treat acute problem Treat underlying disease / causal factors Prevent future episodes Prolong life Lifestyle Rx's: Vasodilators ACE-Inhibitors Hydralazine (arterial dilator) Isosorbide Dinitrate (venous dilator) ARB's (AT II-R Blockers) Natriuretic Peptides - Nesiritide Diuretics Furosemide - Lasix; Torsemide HCl Thiazides - Metolazone K Sparing - Spironolactone (+) Inotropes Glycosides - Digoxin Agonists - Dobutamine Phosphodiesterase Inhibitors - Amrinone; Milrinone Acute Pulmonary Edema L asix M etoproline N itrates O xygen P

ETIOLOGY Contractility (70%) Ventricular filling (30%) Afterload (<1%)

LSHF Systolic Dysfunction Contractility Ischemia MI Volume Overload (MR; TR) Dilated CM Afterload Aortic stenosis HTN Diastolic Dysfunction Diastolic Relaxation Constrictive CM Hypertrophic CM LV Hypertrophy MI Obstructive MV Stenosis Tamponade Pericardial Constriction

RSHF Heart Disorder LSHF Cor Pulmonale Pulmonary Valve Stenosis R.V. Infarct Sarcoidosis Vascular Disorder Pulmonary vascular disease Acute Pulmonary Embolism COPD

Risk Factors Metabolic Demands Infection / Illness Pregnancy Anemia Hyperthyroidism Exercise / Stress Circulating Volume Na+ intake Renal Failure Afterload HTN Arteriolosclerosis Obesity Pulmonary embolism Contractility (-) Inotropes MI Alcohol

PATHOPHYSIOLOGY Etiological Stimulus A CO A Circulating volume A CNS Fatigue / weakness Mental status Depression A Kidneys A Urine output; Nocturia A GI Tract A Anorexic; Weight loss A Skin A Dusky appearance; pale; clammy A LVEDP; LA Pressure A Rales at base; Rapid shallow breathing A DOE; PND; Effort on respiration A S2, S3, S4 A RV/RA Pressure A TR A JVD A RA Dilation A Palpitations A URQ Tenderness; Enlarged liver Orthopnea; Peripheral edema Compensatory Mechanisms Frank-Starling Stroke Volume A LVEDP A Cross-bridges A Contractile potential Neurohormonal Cardiac Output A Baroreceptor Stimulation A Sympathetic Tone A NE Release A Vasotone A HR + Contractility A Renin / Ang-T II / Ald A GFR A Na+ Filtration / Excretion A JGA Detection A Renin / Ang-T II / Ald Hypertrophic Compensation Volume Overload (AI; MR) A Eccentric hypertrophy Afterload (AS; HTN) A Concentric hypertrophy

= Pxr 2h

NOTES

Chronic Heart Failure - CHF

Chronic Heart Failure - CHF

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Mid 20's ASx often; DOE; Chest discomfort; Syncope Often Normal / Athletic lifestyle

PHYSICAL EXAM Vital Signs: BP: N HR: N RR: N Wt: N Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Arrhythmia / palpitations -

Healthy; Athletic Carotid pulse surge & quick decline S4; SM (aorta + axilla) + Valsalva; Arrhythmia -

LABS EKG LV Hypertrophy Prominent Q Waves in inferior and lateral leads Atrial arrhythmias Ventricular arrhythmias Echo LV Hypertrophy Assymetric wall thickness LV outflow obstruction Abnormal MV movement on stystole Partial aortic valve closure on systole (mild) Doppler MR

TREATMENT Plan O2 Demand LV Outflow & Force Diastolic filling Ectopic beats LV Stiffness Pulmonary congestion Control arrhythmias Blockers Metoprolol (1) Propranolol (1, 2) A HR, Contractility A O2 Demand & Stress A Filling time A LV EDV Ca2+ Channel Blockers Verapamil Diltiazam A LV Stiffness A HR Stress Anti-arrhythmics Amiodarone Dysopyramide Antibiotics

ETIOLOGY Genetic / Familial (50%) = Autosomal Dominant -Myosin chain Troponin-T Myosin-binding Protein C Risk Factors Most common cardiac abnormality among athletes (+) Inotropes can induce Diuretics can induce Venous dilators can induce

PATHOPHYSIOLOGY Etiological Stimulus A Fibroblastic scattering Disarray of myocardial fibers A Conduction abnormalities A Arrythmias A Eccentric hypertrophy of ventricular septum (compensatory) A Stiffening of Ventricles A S4 A Diastolic filling A Distance b/w MV and enlarged septum A Mitral valve suck on systole A Outflow tract obstruction A Surging systolic murmur A MR on diastole

NOTES

Hypertrophic Cardiomyopathy - HCM

Hypertrophic Cardiomyopathy - HCM

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Fatigue; weakness; light-headedness

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

DOE; PND; Orthopnea Fatigue / weakness Light-headedness -

JVD Arrhythmias; Diffuse apical impulse; S3; MR Rales Ascites; Hepatomegaly Cool; Peripheral edema -

LABS EKG Atrial + Ventricular enlargement Arrhythmias Pathcy fibrosis BBB (majority of cases) ST & T wave abnormalities X-Ray Large heart silhouette Pulmonary vascular redistribution I.S. & Alveolar edema Pleural effusions Echo Enlarged heart Leftward displacement Contractile dysfunction 4 chamber enlargement RV + LV systolic function MR +/- TR Catheter R + L Diastolic Pressures CO

TREATMENT Plan Treat underlying cause Prevent dilation progress Pulmonary + systemic congestion C.O. Prevent arrhythmias Prevent thromboembolism Transplant? Rx's: Vasodilators - ACE-I's; Hydralazine + Isosorbide dinitrate Blockers Inotropes - Digitalis Diuretics - K+ Sparing (Spironolactone); Arrhythmias Anti-coagulants - Warfarin Anti-arrhythmics - Amiodarone Tx's Prognosis

ETIOLOGY Idiopathic (majority of cases) Ventricular dilation Genetic - Troponin T, Myosin, Actin Inflammatory - Infections (Coxsackie V.); Non-infectious (CM, Sarcoidosis) Toxic - Alcohol, chemotherapy (doxorubicin) Metabolic - Hyperthyroidism, Hypocalcemia Neruomuscular - MS

PATHOPHYSIOLOGY Compensation Etiological Stimulus Frank-Starling A Fibrosis A Stretch + crossbridges A Myocyte injury A Contractility Neurohormonal A Enlargement of all 4 chambers Cardiac Output A Arrhythmias; Diffuse apical impulse; S3; MR A Contractile function (hallmark) A Baroreceptor Stimulation A Stroke volume A Sympathetic Tone A LVEDP A NE Release A Pulmonary congestion: DOE; PND; Orthopnea; Rales A Vasotone A Systemic congestion: JVD; Peripheral edema; Ascites; Hepatomegaly A HR + Contractility A Forward C.O. A Renin / Ang-T II / Ald A Fatigue / weakness; Light-headedness A GFR A Na+ Filtration / Excretion A JGA Detection A Renin / Ang-T II / Ald

NOTES

Dilated Cardiomyopathy - DCM

Dilated Cardiomyopathy - DCM

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Fatigue / Weakness

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Palpitations DOE Fatigue / Weakness -

Weakness JVD / Kussmaul's Sign Atrial fibrillations DOE; Rales URQ Tenderness; Enlarged liver; Ascites Peripheral edema -

LABS EKG Nonspecific ST & T Abnormalities X-Ray Normal Echo Normal systole Speckled appearance Biopsy - Transvenous endomyocardial biopsy Amyloid Fe2+

TREATMENT Plan No Tx for RCM Sinus rhythm maintenance Rx's: Anticoagulants Tx's Fe2+ chelation therapy A Hemochromatosis Prognosis RCM = Very poor

ETIOLOGY Fibrosis / Scarring of endomyocardium Amyloid Infiltration / Sarcoidosis

Differential Diagnosis CT / MRI Thick pericardium Biopsy

Contrictive Pericarditis Restrictive CM

PATHOPHYSIOLOGY Etiological Stimulus A Wall compliance A CO A Fatigue / Weakness A LA Pressure A Pulmonary venous pressure A DOE; Rales A Atrial fibrillations; palpitations A RA Pressure A Atrial fibrillations; palpitations A JVD / Kussmaul's Sign A URQ Tenderness; Enlarged liver; Ascites A Peripheral edema

NOTES Less common than other CM's

Restrictive Cardiomyopathy - RCM

Restrictive Cardiomyopathy - RCM

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Fatigue; Tender abdomen; Palpitations

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: N Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Hypotensive; Systemic venous pressure

Palpitations Tender abdomen Fatigue / Weakness (chronic) -

JVD; Kussmaul's sign; No pulsus paradoxus Early Diastolic knock > S2; Arrhythmias Dyspnea Hepatomegaly; Ascites Peripheral edema -

LABS EKG Non-specific ST & T Abnormalities Atrial arrhythmia (common) X-Ray Mildly enlarged silhouette Calcification of pericardium (50% of Px's) Echo Mild constriction Thickened pericardium Ventricular filling ends in early diastole MRI Pericardial thickening > 2mm Catheter Equalization of cardiac chambers in diastole Dip and plateau (LV Pressure) INSERT DIAGRAM OF C.P.

TREATMENT Plan Relieve contrictive components Rx's: Tx's Pericardial stripping Prognosis

ETIOLOGY TB (major cause) Idiopathic

PATHOPHYSIOLOGY Fluid organization A Fibrous scar formation A Stiffening of pericardium A Diastolic dysfunction A Early Diastolic knock > S2 Arrhythmias A LV Filling A CO A BP A Fatigue / Weakness (chronic) A Systemic venous pressure A Hepatomegaly; Ascites Peripheral edema JVD; Kussmaul's sign; No pulsus paradoxus Early Diastolic knock > S2 Signature pericardial knock Due to sudden cessation of LV filling from restriction of sac No pulsus paradoxus

NOTES

Constrictive Pericarditis

Constrictive Pericarditis

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Dull constant ache in left side of chest

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Dyspnea; hoarseness; chronic hickups Difficulty swallowing -

Ewart's: Dull percussion over scapular angle -

LABS EKG QRS complex variation X-Ray Normal Small PC effusion Cardiac silhouette (symmetric) Echo PC Effusion > 20mL

TREATMENT Plan Treat underlying disease Pericardiosentesis + fluid test Tx's Pericardiosentesis + fluid test A Relief A Analysis of fluid Prognosis

ETIOLOGY Capillary permeability - Hypothyroidism Capillary hydrostatic pressure - CHF Plasma oncotic pressure - Cirrhosis Lymphatic obstruction - Chylous effusion Trauma / rupture

PATHOPHYSIOLOGY Etiological Stimulus A Pericardial effusion A Intracardial pressure Compliance A Ewart's: Dull percussion over scapular angle A Heart movement in fluid A QRS variations A Heart impingement on neighboring structures A Difficulty swallowing A Dyspnea; hoarseness; chronic hickups

Compliance =

V P

NOTES Normal pericardial fluid = 15-50 mL Plasma ultrafiltrate by mesothelial cells of serosal layer

Pericardial Effusion

Pericardial Effusion

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Fatigue; Dyspnea; Palpitations

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: N Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Hypotensive; BP on inspiration (P. Paradoxus) Sinus tachycardia

Tachycardia Dyspnea Fatigue / Weakness (chronic) -

JVD; Pulsus paradoxus Tachycardia; Quiet heart Dyspnea Hepatomegaly; Ascites Peripheral edema -

LABS Echo Fluid in pericardium Diastolic dysfunction Compression of RV & RA in diastole Catheter Blunted y descent Diastolic pressure equalization

TREATMENT Plan Give fluids Inotropic support Pericardiocentesis + fluid tests Bacteria, fungi, malignancy Cell counts Protein + lactate dehydrogenase Adenosine deaminase (TB) Rx's: Tx's x v y Prognosis

ETIOLOGY MI Neoplasm Postural Uremic pericarditis Disecting aortic aneurism complication

PATHOPHYSIOLOGY Etiological stimulus A Weakened cardiac wall A Wall rupture A Diastolic equalization of all chambers A Systemic & Pulmonary venous pressures A JVD; Pulsus paradoxus Hepatomegaly; Ascites Peripheral edema A CO A Tachycardia; Quiet heart Dyspnea

NOTES

Cardiac Tamponade

Cardiac Tamponade

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: All ages Fatigue, Exercise tolerance; Dyspnea Hx of Acute Rheumatic Fever

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: N Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Hoarseness Dyspnea; DOE Fatigue / Weakness Depression

Fever or Hx of fever Hoarseness JVD (in severe cases) S1; S2; SM (axilla); OS + DM (apex); PR; A-Fib Peripheral Edema -

LABS EKG LA Enlargement RV Hypertrophy X-Ray LA Enlargement + straightened left border Pulmonary vascular redistribution Kerley-B Lines IS Edema Echo Thick MV leaflets Fussion of MV commissures Restricted MV movement in diastole LA mural thrombosis MV x-sectional area

TREATMENT Plan Diastolic filling Turbulent flow and blood stasis Prevent coagulation + infection Rx's: Diuretics A Vascular congestion Blockers A HR A Diastolic filling time (+) Inotropes Digoxin (if LHF or A-Fib) Anticoagulants Antibiotics Prevents endocarditis Tx's Valvuloplasty Prognosis 7 yr survival without Tx 10 yr survival with Tx but without surgery No 60% 20% 4% Worsen Die 25% 15% 20% 60% 10% 85%

ASx Mild AS Severe AS

ETIOLOGY Rheumatic Fever (50% of Px's have history of ARF) MV Ca2+ or endocardial vegetations (< 1% of Px's) Risk Factors Infection Hyperthyroidism Pregnancy Exercise Stress Anything that increases metabolic demands Severity of stenosis is proportional to severity of LA Pressure

PATHOPHYSIOLOGY Etiological Stimulus INSERT GRAPH OF VALVE PRESSURES A Acute & Recurrent inflammation SEE MV STENOSIS SHEET A Fever A Fibrous thickening & Ca2+ deposits on MV A Fussion of commissures A Valve thickening A S1 (bulky valve closure); SM (axilla); OS + DM (apex) A Pressure gradient b/w LV & LA A LV Filling A CO A Depression; Fatigue; Weakness A LA Dilation A A-Fib; Hoarseness (vagus pinch) A Mural thrombosis (blood stasis) A Pulmonary HTN - Passive (backup of blood) A Dyspnea; DOE A PR; S2 A Pulmonary HTN - Reactive (medial hypertrophy of pulmonary arteries) A Pressure on pulmonary capillaries (compensatory) A Pulmonary congestion A RV + RA Pressure A JVD A Peripheral Edema

NOTES

Mitral Stenosis - MS

Mitral Stenosis - MS

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Fatigue; Dyspnea; PND

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Palpitations; Atrial Fibrillation Dyspnea Fatigue / Weakness (chronic) -

Fatigue / Weakness (chronic) HoloSM (apex + axilla); Clenched fists; S3 (chr) Dysnpea; Pulmonary edema Peripheral edema (chronic) -

Differential Dx Clenched Fists No SM

AS MR

LABS EKG Chronic = LA + LV Enlargement X-Ray Acute = Normal Chronic = LA + LV Enlargement; Ca2+ MV Annulus Echo Bidirectional flow b/w LV + LA Catheter LA Pressure v wave

TREATMENT Plan CO Pulmonary congestion Regurgitation Rx's: (+) Inotropes ? Digoxin ? BOOK DOES NOT SAY, BUT WHY NOT? Diuretics Lasix A Relieves pulmonary congestion Vasodilators Nitroprusside (mixed vasodilator) A PVR to promote forward flow A Venous pressure to relieve pulmonary congestion Mixed Venous CO Pulm congestion Pulm congestion Hydralazine ACE-Inhibitors Nitrates Minoxidil Nitroprusside Ca2+ Ch. Blockers 1 Blockers Verapamil; Diltiazam Central agonists 2 CO Tx's MV Surgery / replacement / repair Prognosis Arteriolar

ETIOLOGY Structural Myxomatous degeneration Ca2+ Deposits Abnormalities of annulus, leaflets, chordae tendonae or papillary muscles IHD LV Dilation HCM

PATHOPHYSIOLOGY Structural Myxomatous degeneration A MV Prolapse Ca2+ Deposits A MV stiffening A MR / Holosystolic murmur (apex + axilla) IHD A Scar A Papillary muscle dysfunction A Cordae Tendonae rupture A MR / Holosystolic murmur (apex + axilla) LV Dilation A Stretches MV leaflets apart A MR / Holosystolic murmur (apex + axilla) HCM A Abnormal systolic function A MV Suck A MR / Holosystolic murmur (apex + axilla) MR / Holosystolic murmur (apex + axilla) A CO A Fatigue / Weakness (chronic) A LA Pressure / Volume A LA Dilation A Palpitations; Atrial Fibrillation A Subsequent stroke volumes A Pulmonary congestion A Dysnpea; Pulmonary edema A RV + RA Pressure A Peripheral edema (chronic)

NOTES

Mitral Regurgitation - MR

Mitral Regurgitation - MR

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Common among young thin women Chest discomfort; Palpitations

PHYSICAL EXAM Vital Signs: BP: HR: N RR: N Wt: N/Thin Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Palpitations; Chest discomfort -

Mid systolic click; late SM (apex) -

LABS EKG Normal LA Enlargement Echo MV leaflet displacement into LA in systole

TREATMENT Plan Prevent infection / endocarditis Rx's: Antibiotics Prognosis Most often benign

ETIOLOGY ???

PATHOPHYSIOLOGY Etiological Stimulus A Dysfunction of MV A Mid systolic click A Prolapse of one or more MV leaflets into LA A MR A LA Enlargement (chronic) A Palpitations

NOTES

Mitral Valve Prolapse - MVP

Mitral Valve Prolapse - MVP

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric:

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: N Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Angina; palpitations Syncope -

Pulsus parvus et tardus (carotids) Late SM (aorta); S4; soft S2; Atrial fibrillation -

LABS

TREATMENT Plan Endocarditis prophylaxis Rx's: Antibiotics Vasodilators Diuretics Tx's Surgical aortic valve replacement Prognosis Untreated = Poor Mild AS = 20% 10yr survival AVR = 75% 10yr survival Mean survival Years ngina 5 yncope 3 eart failure 2 Fib <1

EKG LV Hypertrophy X-Ray LV Hypertrophy Echo Thick LV muscle Concentric hypertrophy Catheter LA Pressure (late in distole when contracting into LV Pressure) OK mean LA + Pulmonary pressure Aortic pressure Insert graphs

A S H A

ETIOLOGY Age-related Ca2+ accumulation in valve Congenital deformation - Bicuspid valve (2% of US Population) Chronic rheumatoid valve disease Turbulent blood flow

PATHOPHYSIOLOGY Age-related Ca2+ accumulation in valve A Stiffening of aortic valve A AS Congenital deformation A Bicuspid valve A Insufficient valve clossure A AS Chronic rheumatoid valve disease A Fibrotic organization A Stiffening of aortic valve A AS Turbulent flow across valve A Collagen matrix formation A Stiffening of aortic valve A AS AS A Systole: Obstruction of blood flow A Late SM (aorta); soft S2 A Pulsus parvus et tardus (carotids) A LV Pressure (180/80) A Concentric Hypertrophy A Stiffening of ventricle wall A S4 = Pxr A P/h = Net Coronary perfusion 2h O2 demand ? ? A Angina A LA Dilation A Palpitations; Atrial Fibrillation A Diastole: Late closure of stenotic valve A Soft S2

NOTES

Aortic Stenosis - AS

Aortic Stenosis - AS

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Fatigue; Dyspnea; Chest discomfort

PHYSICAL EXAM Vital Signs: BP: Wide HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Wide pulse pressures; Pulse pressure

Weakness / Fatigue Bounding pulses Forceful beat; DM (sternum + apex) - A. Flint -

LABS EKG X-Ray Pulmonary congestion (acute) Large LV Silhouette (chronic) Echo LV enlargement Catheter Wide aorta pressure range INSERT CATH DIAGRAM

TREATMENT Plan Regular checkups & LV evaluation with echo Prevent infection Rx's for ASx Px's: Antibiotics - endocarditis prophylaxis Rx's for Sx Px's: Diuretics Ca2+ Channel Blockers A Enlargement Stiffness Ejection fraction Vasodilators Prognosis 60% of Px's remain without Sx's for 10yrs Severity depends on Size of hole Pressure gradient Duration of diastole

ETIOLOGY Disease AV leaflets Rheumatic fever Endocarditis Congenital Bicuspid Valve Dilation of aortic root Aortic aneurism Annulo-aortic ectasia Marfan syndrome Syphilis

PATHOPHYSIOLOGY Acute AI A AI + Regurgitation of blood into LV A DM (sternum + apex) - A. Flint A Aortic diastolic pressure A Diastolic pressure A LV Pressure + LV stretch A LA Pressure A Pulmonary Pressure A Pulmonary congestion A Surgical emergency A Chronic AI A LV Dilation (volume overload) A Aortic diastolic pressure A LA Pressure A Pulmonary Pressure A LV stroke volume A Bounding pulses Forceful beat Systolic pressure A Wide pulse pressures; Pulse pressure

INSERT DIAGRAM OF AI

NOTES

Aortic Insufficiency - AI

Aortic Insufficiency - AI

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: All ages Acute, stabbing chest pain (radiates to back)

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Sharp pain in chest; positional pain Dysnpea; Sharp pain on inhalation -

Friction rub; On exhalation and leaning forward -

Pain is aleviated when leaning forward or sitting upright

LABS EKG (abnormal in 90% of Px's) Diffuse ST Elevations on all but AVr and V1 leads Echo Reveals hemodynamic significance of effusions Serologic Tests Ab's to Rheumatoid Factor PPD TB is a major cause Malignancy of neighboring structure Breast Lung

TREATMENT Plan Relieve pain Rest Allow self-resolution Usually self-limiting disease (if idiopathic or viral) A 1-3 weeks to resolve Lifestyle Lots of rest; no exertion Rx's: Pain relief (aspirin) Anti-inflammatories Antibiotics Tx's Catheter drainage (Prurulent PC) Chemotherapy / Radiation (if Cancer) Prognosis Very good, if not cancerous

ETIOLOGY Infectious (ICH - E) Inluenza Virus Coxsackie Virus HBV Echovirus Non-infectious Uremia - CRF; Nitrogenous waste CT Diseases - Rheumatoid arthritis; SLE Post MI - Few days post MI; Dressler's autoimmune Drugs - Hydralazine; Procainamide Neoplastic - Metastatic / inflammatory response

PATHOPHYSIOLOGY Etiological Stimulus A Vasodilation A Transudate (Serous PC) A Permeability A Fluid + Protein leak A Exudate (Serofibrinous PC) A Leukocyte infiltration (PMN's + Mono's) A Suppurative (Prurulent) PC A Severe vascular damage A Hemorrhagic PC

Serous Serofibrinous

Suppurative Hemorrhagic

Fluid Fluid only Fluid Proteins Fibrinogen Inflammation Bloody

Cause Vasodilation

Appearance Dense scar

Notes Most common

Bacterial Erythematous TB Malignancy

Bloody

NOTES

Acute Pericarditis

Acute Pericarditis

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Explosive illness; shaking chills; fatigue Hx of surgery, dental work, IVDA? Night sweats; Anorexia Hematuria; Flank pain Fatigue / Weakness -

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

Roth spots (retinal emboli) Possible murmur Splenomegaly Janeway lesions (palms) Rash (possible); Discorioration -

LABS EKG Heart block Arrhythmias Echo Vegetations Valvular dysfunction Valvular abscesses DUKE CRITERIA IVDA Fever Immune Phenomena (+) Blood culture Strep Viridans Staph Aureas Endocardial Involvement Abscesses Masses

TREATMENT Plan Treat infection Restore normal function of heart and valves Rx's: Prolonged, high-dose antibiotics (IV) Tx's Valve replacement Prognosis 10-30% mortality rate with Tx 100% mortality without Tx

Major

Minor

ETIOLOGY Acute Bacterial Endocarditis 20% Staph. Areus A Valves Subacute Bacterial Endocarditis 70% Strep Viridans A Valves w/ pre-existing problems Native/prosthetic valves (NVE = 60-80%) IVDA - Staph Areus Non-Bacterial Thrombotic Endocarditis Turbulent Blood Flow Gram (+) = 90% b/c of resistance to circulating complement Libman-Sacks Endocarditis

PATHOPHYSIOLOGY Etiological Stimulus - ABE, SBE, NVE, IVDA A Thrombus formation A Bacterial entry into circulation A Bacterial attachment to site Turbulent Blood Flow A Endothelial injury A Endocarditis Non-Bacterial Thrombotic Endocarditis A Endothelial injury A Sterile thrombus (vegetation) A Bacterial attachment to site A Fibrin/platelet deposits protect bacteria

NOTES

Infectious Endocarditis

Infectious Endocarditis

EKG CYCLE

Atrial Depolarization AV node conduction Axis: 0-90 No electrical activity (+) Deflection (I, aVF) PR = Flat

Septum DepolarizationLV/RV Depolarization Wall Depolarization Ventricle Repolarization Axis: 180-270 Axis: 0-90 Axis: 180-270 (-) Deflection (I, aVF) (+) Deflection (I, aVF) (-) deflection (I , aVF) (+) Deflectionin (I, aVF) R. Septum LV > RV Anteriorly LV Placement To Right Posteriorly To Left A Up-Right depol A QRS Complex

CARDIAC CYCLE I Post --> Ant AC Sup --> Inf Post --> R. Ant A SC Inf --> Sup A VC Sup --> Inf Ant --> L. Post A WC Inf --> Sup Post --> Ant A VR Sup --> Inf (+) (-) (+) (-) (-) aVF V1 (+) (-) (+) (-) (-) (+) r (-) q V6 II III

(+) ~(+) (-) ~(-)

(+) ~(+) (-) S (+) R (-) ~(-)

(+) ~(+)

NORMAL Northwest axis (no man's land) Emphysema Hyperkalaemia Lead transposition Artificial cardiac pacing Ventricular tachycardia Right axis deviation Right ventricular hypertrophy Left posterior hemiblock Normal finding in children b/c RV > LV from birth Chronic lung disease even without pulmonary hypertension Anterolateral myocardial infarction Pulmonary embolus Wolff-Parkinson-White syndrome - left sided accessory pathway Atrial septal defect Ventricular septal defect

ACUTE INFERIOR MI Absence of Electrical Activity Body is uniformly (+) No electrical gradient EKG is isoelectric along baseline Action Potential Generates electrical gradients 12 Leads 6 = Frontal plane (limb leads) Bipolar (I, II, III) + Unipolar (aVR, aVL, aVF) 6 = Transverse (horizontal) plane (precordial leads) Six points along chest wall Depolarization (-) ---> (+) along each axis (Upward deflection) e-'s are moving to (+)!

Left axis deviation LV Hypertrophy Left anterior hemiblock Q waves of inferior myocardial infarction Artificial cardiac pacing Emphysema Hyperkalaemia Wolff-Parkinson-White syndrome - right sided accessory pathway Tricuspid atresia Ostium primum ASD Injection of contrast into left coronary artery

EKG ABNORMALITIES Long QT interval Sinus Rhythm ( R-R Interval) MI, Myocarditis, Diffuse myocardial Dz; CHF Rate <60 = sinus bradycardia Hypocalcaemia, hypothyrodism Rate >100 = sinus tachycardia CVA Variation >10% = sinus arrhythmia Drugs (e.g. sotalol, amiodarone) P Wave Abnormalities Hereditary; Varies with age and sex of Px RA Hypertrophy, LA Hypertrophy Romano Ward syndrome (autosomal dominant) Atrial premature beat Jervill + Lange Nielson syndrome Hyperkalaemia Autosomal Recessive PR Segment Abnormalities Associated with sensorineural deafness Short PR ST Segment Abnormalities Wolff-Parkinson-White syndrome ST Elevation Lown-Ganong-Levine syndrome Acute MI (e.g. anterior, inferior), LBBB, Acute pericarditis, Normal variants Duchenne muscular dystrophy ST Depression Type II glycogen storage disease (Pompe's) MI, Digoxin effect, LV Hypertrophy, Acute posterior MI HOCM Pulmonary embolus, LBBB Long PR T Wave Abnormalities 1st degree heart block Tall T waves Trifasicular block MI; Ischemia; CVA's QRS Complex Abnormalities Hyperkalaemia Wide QRS LBBB RBBB; LBBB Small, flattened or inverted T waves Ventricular rhythm, Hyperkalaemia, etc. MI; Ischaemia No pathological Q waves LVH, Drugs (e.g. digoxin), Pericarditis, PE No QRS evidence of left or right ventricular hypertrophy BBB and electrolyte disturbance Normal variants NOTES

EKG

EKG

NORMAL Sinus Rhythm Each P wave is followed by a QRS P wave rate 60 - 100 bpm with <10% variation Rounded in contour Upright in I, II, aVF, and V4-V6 QRS Axis P Waves Height < 2.5 mm in lead II Width < 0.11 s in lead II PR Interval 0.12 to 0.20 s (3 - 5 small squares) QRS Complex < 0.12 s duration (3 small squares) QT Interval Corrected QT interval (QTc) = QT / R-R^(1/2) ST Segment (LV/RV already depolarized) Isoelectric T Wave (LV/RV Repolarization) Upright in leads with (+)QRS Complexes (except V1, V2) ACUTE INFERIOR MI Sinus Rhythm QRS Axis P Waves PR Interval QRS Complex QT Interval ST Segment T Wave Elevation (Inf II, III and aVF) Reciprocal depression (Ant's)

ACUTE ANTERIOR MI Sinus Rhythm QRS Axis P Waves PR Interval QRS Complex QT Interval ST Segment T Wave Elevation (Ant. V1-6; aVL) Reciprocal depression (Inf. leads)

ACUTE POSTERIOR MI Sinus Rhythm QRS Axis P Waves PR Interval QRS Complex QT Interval ST Segment T Wave Tall R; Tall upright T (V1 -3) Tall R; Tall upright T (V1 -3)

Usually associated with inferior / lateral wall MI

ACUTE MI + LBBB Sinus Rhythm QRS Axis P Waves PR Interval QRS Complex QT Interval ST Segment T Wave ST in the same direction as the QRS ST elevation more than LBBB alone Q waves in two consecutive lateral leads Indicating anteroseptal MI

LEFT VENTRICAL HYPERTROPHY Sinus Rhythm QRS Axis P Waves PR Interval QRS Complex QT Interval ST Segment T Wave S V1-3 > 25 mm, S V1 or V2 + R aVL > 11mm, R V4-6 > 25mm R V5 or V6 > 35 mm, R I + S III > 25 mm M shaped P wave in lead II terminal negative component to P (V1)

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Healthy normal person Fatigue; light-headedness; syncope

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

HR < 60

Fatigue Light-headedness; syncope -

Sinus brady-tachycardia; escape rhythms -

LABS EKG QRS w/o P Inverted P / post-QRS P Escape rhythms Wide QRS 1st degree AV block Mobitz II (wide QRS) Mobitz I (PR --> Skip QRS) INSERT EKG's

TREATMENT Plan Restore normal sinus rhythm Rx's: Anticholinergics - Atropine Adrenergics - Isoproteronol Tx's Prognosis

ETIOLOGY Impaired impulse information Impaired impulse conduction Intrinsic Aging - Degeneration of conduction pathways) Cardiomyopathies Physiologic Extrinsic Medications - Blocker; Ca2+ Channel Blockers Metabolic cuases - Hyperthyroidism 1st Degree A-V Block Vagal tone Ischemia Drugs Aging Benign 2nd Degree A-V Block P's not always followed QRS complex Mobitz I / Wenckebach A P-R interval until skipped QRS complex A-V node conduction (children; athletes) A Anti-muscarinics 3rd Degree A-V Block "Complete heart block" No atria-->ventricle conduction MI Drug Toxicity Chronic degeneration P & QRS completely independent Distal escape rhythm AV Dissociation

PATHOPHYSIOLOGY

NOTES

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric: Palpitations

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: N Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

> 100; Arrhythmias

LABS EKG Wide QRS BBB Ventricular tachycardia (mostly) QRS in all leads same direction PSVT? Sudden onset Atrial rates 140-250 Narrow / Normal QRS AVNRT - AV Node Re-entry Tachycardia W-P-W delta wave Wide QRS

TREATMENT Plan Ventricular rate control Restore sinus rhythm Prevent coagulation Rx's: 1 2 3 4 5

Blockers; Ca2+ Channel Blockers Ia; Ic; III (chronic) Anticoagulants Digitalis (AV Node) Procainimide

Tx's Pacemaker Prognosis > 2 or 3 premature beats = mortality risk

Sinus Re-entrant Ectopic Atria 100-180140-250 130-250 P-wave Normal Variable Variable Carotid May May Reversion Massage Slow Correct AVB may Location SN SVT (AV) AV block Cardiovert Pacemaker Treatment

Atrial Flutter A Fib 180-350 > 350-600 Saw Tooth No P AVB may

Cardiovert Pacemaker 1, 2, 3

Cardiovert Pacemaker 1, 3

ETIOLOGY Enhanced automaticity Triggered activity Unidirectional Block & Re-entry Supra & Ventricular QRS width Morphology & rate of P wave Relationship P-QRS Response to vagal stimulation PSVT RE-entry via anterior pathway WPW Ectopic Automaticity of atrial focus Digitalis toxicity Vagal Ventricular Arrhythmias Premature beats Wide QRS (ectopic site) > 2 or 3 premature beats = mortality risk Ventricular Tachycardia > 3 premature beats Torsade de Point Early afterpolarization QT E'lyte disturbances - K+, Mg+

PATHOPHYSIOLOGY

INSERT GRAPHS OF ALL EKG's

NOTES

Tachyarrhythmias

Tachyarrhythmias

SYMPTOMS & HISTORY Profile Chief Complaint: Med / Soc History: Review of Systems: HEENT: Cardiac: Heme/Lymphatic: Respiratory: GI: Genitourinary: Endocrine: Musculoskeletal: Neurological: Psychiatric:

PHYSICAL EXAM Vital Signs: BP: HR: RR: Wt: Systems Exam: General: HEENT: Neck: Cardiac: Lungs: Abdomen: Rectal: Extremities: Skin Neurological:

LABS

TREATMENT Plan Lifestyle Rx's: Tx's Prognosis

ETIOLOGY

PATHOPHYSIOLOGY

NOTES