Heart Sounds Outline

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    Cardiology

    1. Cardiac Auscultation and Physical Diagnosis

    • Basic Physiology

    Key (Wiggers cycle)

    o A. Atrial systole (late ventricular  diastole)

    o B. Isovolumic contraction

    o C. Early ventricular systole

    o D. ate ventricular systole

    o E. Isovolumic rela!ation

    o ". Early diastole (ra#id #assive vent. $illing)

    o %. &id diastole (diastasis' (near) cessation o$ ventricular

    $illing due to eualiation o$ atrial and ventricular #ressures) *ugular venous +ave$orm'

    o a +ave' small rise in right atrial #ressure due to right atrial

    contractiono c +ave' small rise in right atrial #ressure as the tricus#id

    valve closes and ,ulges to+ard the right atriumo v +ave' rise in right atrial #ressure during ventricular

    systole- +hen the tricus#id valve is (su##osedly) closed

    • Physical Diagnosis

    Cardiac auscultation

    • 1 / closure o$ mitral0tricus#id valves onset o$ ventricular

    systole

    • 2 / closure o$ semilunar valves

    3ormal (4#hysiological5) s#litting o$ 2 means those 2 distinct com#onents o$ 2 can ,e heard during ins#irat

    ,ut not during e!#iration (,est heard at 6B).

    • 6

    3ormal in children and young adults

    Cause' 7ensing o$ the chordae tendineae and0or sudden limitation o$ longitudinal ventricular e!#ansion durin

    early ra#id ventricular $illing 7iming' Early (to mid) diastole

    "reuency' o+ (dull 4thud5)

    ocation' A#e! () lo+er B0!i#hoid (8)

    4Kentuc9y5

    • :

    Rarely  normal (; normal in elderly)

    Cause' Atrium vigorously contracting against a sti$$ened ventricle (results $rom reduced ventricular com#lianc

    7iming' ate diastole (4#resystolic5)

    "reuency' o+

    ocation' A#e! () lo+er B0!i#hoid (8)

    47ennessee5

    • Physiological s#litting o$ the 2nd heart sound

    During ins#iration 2 distinct com#onents o$ 2 (not during e!#iration)

    During ins#iration increase venous return to the heart- higher than usual

    #ressure causes second heart sound

    • Parado!ical s#litting o$ the 2nd heart sound

    Anything causes delayed closure o$ the aortic valve (com#ared to the

    #ulmonic valve)

     

    &ost common causes'

    o e$t ,undle ,ranch ,loc9

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    o e$t ventricular out$lo+ o,struction

    • Aortic stenosis (A)

    • ecto#ic ,eat

    Increase $orce o$ contraction (#redominant e$$ect)

    Increase #reload

    o Isometric e!ercise

    • ustained handgri# (2>6 seconds)

    • Avoid simultaneous alsalva maneuver

    • Increases'

    ystemic vascular resistance- Arterial #ressure-

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    • Cardiac murmurs

    &urmurs result $rom tur,ulent $lo+

    o &ay ,e #hysiologic or #athologic

    o &ay ,e non>valvular or valvular in origin

    %rading system

    o Based on loudness0intensity o$ murmur

    o grades ($or systolic murmurs)

    • %rade 10' ery $aint- not usually heard during the $irst $e+ seconds o$ listening

    • %rade 20' "aint- ,ut heard immediately

    • %rade 60' Easily heard

    • %rade :0' Easily heard- and associated +ith a #al#a,le thrill• %rade 0' ery loud- #al#a,le thrill- audi,le +ith only one edge o$ the stethosco#e on the chest

    • %rade 0' Way loud- #al#a,le thrill- audi,le +ith the stethosco#e removed slightly $rom contact +ith the

    chesto %rading system- diastolic mumurs

    • %rade 10:' ery $aint- not usually heard during the $irst $e+ seconds o$ listening

    • %rade 20:' "aint- ,ut heard immediately

    • %rade 60:' Easily heard

    • %rade :0:' ery loud

    ystolic

    o Begins +ith or a$ter 1 and ends at or ,e$ore 2

    Diastolic

    o Begins +ith or a$ter 2 and ends ,e$ore the ne!t1

    Continuous

    o Begins in systole and continues- +ithout

    interru#tion- through the 2 into all or #art o$

    diastole Cardiac murmur 3ote'

    o While the anatomical location +here a murmur is

    ,est heard may #rovide a clue to its cause- the

    timing and quality  o$ the murmur- as +ell as

    associated $indings- are o$ten more reliable in

    elucidating a murmurFs cause.

    • alvular cardiac murmurs' &urmurs resulting $rom valvular  dys$unction'

    o A systolic murmur may ,e the result o$ dys$unction o$ any o$ the $our cardiac valves

    o A diastolic murmur may ,e the result o$ dys$unction o$ any o$ the $our cardiac valves

    A valve that does not o#en #ro#erly +ill cause a murmur o$ stenosis during the #art o$ the cardiac cycle +hen that valve sho

    ,e o#en. A valve that does not close #ro#erly +ill cause a murmur o$ regurgitation (insu$$iciency) during the #art o$ the cardiac cycle +

    that valve should ,e closed. Determining +hich ty#e o$ valve #ro,lem can cause +hich ty#e o$ murmur sim#ly reuires a ,asic understanding o$ +hat ea

    the cardiac valves should ,e 4doing5 during systole and diastole.

    ystole Diastole

    Aortic =#en ClosedPulmonic =#en Closed

    &itral Closed =#en

    7ricus#id Closed =#en

    ystolic &urmur Diastolic &urmur

    Aortic tenosis 8egurgitation

    Pulmonic tenosis 8egurgitation

    &itral 8egurgitation tenosis

    7ricus#id 8egurgitation tenosis

    • ystolic &urmurs

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    Potential causes'

    o =ut$lo+ o,struction o$ either ventricle

    • A- P- or su#ravalvlar stenosis o$ the aortic or #ulmonic valves

    o Insu$$iciency o$ either atrioventric. valve

    • &8- 78

    o D

    o entricular e@ection through an aortic valve +ith $i,rocalci$ic thic9ening

    • Aortic sclerosis

    o entricular e@ection in 4high>$lo+5 states

    • Gouth (4innocent5 murmur)

    • Pregnancy• "ever- anemia- hy#erthyroidism- etc.

    2 ma@or categories'

    o ystolic e@ection murmurs

    • Crescendo>decrescendo

    • ometimes re$erred to as 4midsystolic5

    • A- P-

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    Aortic stenosis

    o Congenital

    • Bicus#id aortic valve

    Aortic e@ection sound (clic9) is the auscultatory

    hallmar9o Acuired

    • 8heumatic

    • enile $i,rocalci$ic

    o Crescendo>decrescendo murmur

    • =$ten heard ,est at 28B- radiating to the carotids

    • I$ murmur #ea9s early in systole- stenosis is not severeo Pulsus #arvus et tardus (diminished and delayed carotid u#stro9e)

    • &ay not  see in elderly

    o May  have'

    • Parado!ical s#litting o$ the 2nd heart sound

    • Diminished or a,sent A2 (aortic com#onent o$ the 2 nd heart sound)

    • Aortic e@ection sound (i$ valve is not heavily calci$ied) / most common in congenital A

    Di$$erentiating A $rom &8

    • ystolic e@ection murmurs

    decrescendo murmur +hich'

    • %ets louder during'

    uatting (or lying- $rom standing)

    Amyl nitrite inhalation (same as

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    Potential causes'

    o Insu$$iciency o$ either ventricular out$lo+ valve

    • A8 (AI)

    • P8 (PI)

    o tenosis o$ either atrioventricular valve

    • &

    • 7

    Aortic insu$$iciency (regurgitation)

    o Primary murmur'

    • Early diastolic

    • Decrescendo• #itched

    • 4Blo+ing5

    • Best heard +ith dia#hragm o$ stethosco#e at 6 or 8B- +ith #atient leaning $or+ard- during held- dee#-

    e!halationo Associated murmurs'

    • Patients +ith AI- in addition to the #rimary murmur- may have'

    ystolic e@ection murmur

    o Due to 4high $lo+5 across aortic valve- $rom high stro9e volume

    Austin "lint murmur

    o Diastolic rum,le- ,est heard +ith ,ell o$ stethosco#e at a#e!

    o 7hought to ,e due to 4$unctional5 mitral stenosis resulting $rom the aortic regurgitant

    $orcing the anterior mitral lea$let into a #artially closed #ositiono =ther #ro#osed mechanism'

    • Diastolic rum,le results $rom $luttering o$ the anterior mitral lea$let caused

    the aortic regurgitant @eto Associated $indings (chronic severe AI)

    • Duroie sign

    ystolic murmur over $emoral artery +hen stethosco#e is com#ressed #ro!imally- and a diasto

    murmur over $emoral artery +hen stethosco#e is com#ressed distally &ost #redictive sign o$ severe AI

    • igns associated +ith high stro9e volume'

    Wide #ulse #ressure

    ?uinc9eFs #ulse

    o Phasic ,lanching o$ the nail ,ed hammer) #ulse

    o Pal#a,le a,ru#t u#stro9e and ra#id $all o$ arterial #ulsation

    7rau,e sign

    o Pistol shot sound over $emoral artery

    &ueller sign

    o Pulsating uvula

    Pulmonic insu$$iciency (regurgitation)

    o &ay ,e due to'

    • Pulmonary hy#ertension- in the a,sence o$ #ulmonic valve de$ormity (%raham teell murmur)

    De$ormity o$ the #ulmonic valve Congenital

    Acuired

    o %raham teell murmur'

    • Early diastolic

    • Begins +ith a loud #ulmonic com#onent o$ 2

    • Decrescendo

    • #itched

    • 4Blo+ing5

    • %ets louder during ins#iration

    • Best heard +ith dia#hragm o$ stethosco#e at 2 nd to :th IC- B

    o Pulmonic insu$$iciency due to de$ormity o$ the #ulmonic valve'

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    • &id diastolic

    • Begins after  #ulmonic com#onent o$ 2

    • Crescendo>decrescendo

    • o+>#itched

    • %ets louder during ins#iration

    • Best heard +ith ,ell o$ stethosco#e at 6rd to :th IC- B

    &itral stenosis

    o  Almost always a seuela o$ rheumatic $ever

    o &urmur' 

    • &id diastolic (#re>systolic accentuation i$ rhythm

    is sinus) holodiastolic i$ severe• o+>#itched (rum,le)

    • Best heard +ith #atient in the le$t lateral

    recum,ent #osition- +ith the ,ell o$ the

    stethosco#e at the cardiac a#e!o Associated $indings'

      Opening snap

    #itched sound

    =ccurs a$ter 2- early  in diastole

    As severity o$ stenosis +orsens- o#ening sna# occurs closer to 2

    o$tens or disa##ears +ith calci$ication (and loss o$ mo,ility) o$ the ,ody o$ the mitral lea$lets

    • oud (accentuated) 1 (&1)

    o$tens or disa##ears +ith calci$ication (and loss o$ mo,ility) o$ the ,ody o$ the mitral lea$lets =ther reasons $or diminished or a,sent 1 in #atients +ith mitral stenosis'

    o ong P8 interval- severe dys$unction- signi$icant AI- signi$icant &8- hy#ertension

    =ther mitral stenosis>li9e murmurs

    o Austin>"lint murmur (o$ aortic regurg.) (no o#ening sna#)

    o Carey>Coom,s murmur

    • Active mitral valvulitis associated +ith acute rheumatic fever 

    o e$t atrial my!oma

    o 7ricus#id stenosis

    • ounds @ust li9e mitral stenosis excet '

    Auscultatory $indings o$ 7'

    o %et louder during ins#iration

    o Are ,est heard along the lo+er B• Is rare

    &ost common cause' rheumatic heart disease

    =ther causes' carcinoid syndrome- anorectic diet medications

    Continuous murmurs

    o &ust continue through 2 (uninterru#ted)

    o Potential causes'

    • Patent ductus arteriosus (PDA)

    • Cervical venous hum

    &ammary sou$$le•

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    o E!aggeration (greater than 1 mm

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    o Congenital heart disease

    • Hnre#aired0 #artially re#aired cyanotic de$ects

    o Previous IE

    o Intravenous drug a,use (IDA)

    • Etiology

    Bacteria> most common

    o !tah" aureus  most common overall

    o iridans stre#. ne!t (overall)

    o Prosthetic valve

    • Early ($irst days)' !tah" eidermidis

    •ate (a$ter days)' viridans stre#.

    o Intravenous drug a,use (IDA)' !tah" aureus

    "ungi> uncommon virulent

    Intravenous drug a,use IE

    o !tah" aureus  most common #athogen

    o Candida most common $ungus

    o 8ight>heart involvement most common

    • 7ricus#id valve most common (#reviously normal valve)

    • e#tic #ulmonary em,oli common

    o Classic #eri#heral stigmata usually a,sent

    • Pathogenesis

    Conditions necessary $or IE

    o

    Endocardial in@uryo Platelet>$i,rin mesh at the site o$ in@ury

    • 7hrom,us $ormation

    • A.K.A.' 3on,acterial throm,otic endocarditis (3B7E)

    o &icro,ial entry into the circulation

    o &icro,ial adherence to the in@ured sur$ace0 throm,us

    • Diagnosis

    reactive #rotein (C8P)' elevated

    • 8heumatoid $actor' elevated (in M N)

    Clinical $eatures

    o "ever is most sensitive sym#tom

    o &urmur is the most relia,le sign

    Classic #eri#heral stigmata o$ IE

    o Petechiae

    • &ost $reuently $ound on the con@unctivae- #alate- ,uccal mucosa- and u##er e!tremities

    o #linter hemorrhages

    • 1>2 mm ,ro+n strea9s under the nails (o$ greater signi$icance +hen seen in the #ro!imal nail ,ed)

    o =sler nodes

    • mall- tender nodules usually $ound on the $inger and toe #ads

    o *ane+ay lesions

    • Painless- $lat (macular)- ,lanching discolorations located on the #alms and soles

    o 8oth s#ots

    • 8etinal hemorrhages +ith #ale centers

    o Clu,,ing

    • Present in some #atients +ith longstanding disease

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    • De$initive Diagnosis

    Pathologic criteria' &icroorganisms gro+n or demonstrated in vegetation or intracardiac a,scess

    Clinical criteria'

    o 7+o &a@or- or

    o =ne &a@or and 7hree &inor criteria- or

    o "ive minor criteria

    &odi$ied Du9e Criteria

    o De$inite IE' 7+o ma@or =8 one ma@or and three minor =8 $ive minor

    o Possi,le IE' one ma@or and one minor =8 three minor

    o &a@or

    Positive ,lood culture 7y#ical microorganism $rom t+o se#arate cultures

    Persistently #os. cultures $rom cultures dra+n more than 12 hours a#art- or   all o$ three or m

    o$ $our +ith $irst and last dra+n at least one hour a#art

    • Evidence o$ endocardial involvement

    Positive echo sho+ing oscillating vegetation- or  a,scess- or   dehisced #rosthetic valve

    3e+ valvular regurg. (increase or change not su$$icient)

    o &inor

    • Predis#osition

    • "ever J1.:O " (J6.O C)

    • ascular #henomena (em,oli- con@. hemorrhage)

    • Immunological #henomena(%3- Q8"- =sler nodes)

    Echo (consistent ,ut not meeting ma@or criteria)• &icro,iologic evidence (cultures not meeting ma@or criteria)

    • Com#lications

    2N si!>month mortality (even +ith a##ro#riate thera#y)

    1N mortality i$ not recognied and treated #ro#erly

    • 7reatment

    I anti,iotics

    o 8euired in all  cases

    o &ost reuire :> +ee9s o$ thera#y

    o ome may reuire only 2 +ee9s o$ thera#y

    o Consult in$ectious disease (ID) s#ecialist

    urgery (valve re#lacement) is needed $or some

    urgical indications'

    o

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    Anti,iotic endocarditis #ro#hyla!is only recommended $or individuals +ith'

    o Prosthetic valves

    o Previous IE

    o Congenital heart disease

    • Hnre#aired cyanotic lesions

    • 8e#aired congenital heart disease +ith residual de$ects

    • Com#letely re#aired de$ects- $or the $irst si! months

    o Cardiac trans#lant #atients +ith valvulo#athy

    6. Aortic tenosis

    • ocaliation

    =,struction to le$t ventricular out$lo+ may occur at various levels'

    o Aortic valve

    o u#ravalvular

    o

    u,valvular•

    &ost common level o$ o,struction

    • Etiology

    Congenital (:'1 male'$emale)

    o Hnicus#id aortic valve

    • Causes severe o,struction to le$t ventricular out$lo+ in in$ancy

    • &ost common cause o$ $atal valvular aortic stenosis in in$ancy

    o Bicus#id aortic valve

    • &ost common congenital cardiac de$ect (1 > 2 N o$ the #o#ulation)

    • :'1 male>to>$emale

    • =$ten not detected until adulthood

    Hsually does not cause signi$icant o,struction during childhood

    =,struction develo#s after   childhood due to trauma induced ,y tur,ulent $lo+ (causes $i,rosis andcalci$ication o$ aortic cus#s)

    • &ay also cause #rogressive aortic regurgitation

    • 2 N are associated +ith other a,normalities'

    Coarctation o$ the aorta- PDA- dilated aortic root

    o 7ricus#id aortic valve

    Acuired

    o Degenerative (senile) calci$ic

    • 8is9 $actors

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    End>stage renal disease

    o 8heumatic (#ost>in$lammatory)

    Age related variation in etiology

    o years'

    • &ost are congenital

    ast ma@ority are ,icus#id aortic valve

    • &inority are acuired

    Degenerative

    8heumatic

    o J years'

    &inority are congenital• &ost are acuired

    &ost are degenerative

    "e+ rheumatic

    • Diagnosis

    ym#toms

    o Angina- synco#e- heart $ailure sym#toms

    Physical $indings

    o &ost common $inding is a systolic e@ection murmur (E&) that radiates to the nec9

    o =thers'

    • Pulsus #arvus et tardus

    • :

    ystolic e@ection sound (clic9) (i$ ,icus#id A)• Diminished or a,sent A2 (single 2)

    • Parado!ical s#litting o$ 2 Diagnostic studies

    o EK% >

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    • Adding &8 to A8 nearly dou,les o#erative ris9

    Percutaneous

    o Balloon aortic valvulo#lasty (BA)

    • 7em#orary relie$ o$ severe heart $ailure sym#toms

    ym#tom return

    o 6 N at months

    o S N at 2 years

    8estenosis rate

    o N at months

    o 3early 1 N at 2 years

    Procedural com#lication rate J 1 N Death

    CA

    igni$icant aortic insu$$iciency

    ascular com#lications

    • Indications

    Bridge to A8

    Emergency non>cardiac surgery

    Palliation in non>surgical candidates

    • ummary

    Diagnosis is made ,y #hysical e!amination- su##orted ,y a##ro#riate diagnostic studies.

    A8 is the only de$initive treatment.

    7iming o$ surgery is ,ased on sym#tom onset or decline in $unction. BA is only a tem#orary treatment o#tion that is only used in very rare clinical circumstances.

    BE #ro#hyla!is no longer indicated.

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    :. Aortic Insu$$iciency (regurgitation)• Etiology

    alvular

    o tructural valve #ro,lem

    o Congenital

    • Bicus#id aortic valve

    AI may ,e the result o$'

    o tructural valve #ro,lem itsel$

    o Associated aortic aneurysm

    • D

    tructural aortic valve disease is sometimes associated +ith D

    o Acuired

    • In$ective (Endocarditis)

    • 8heumatic

    Consider co>e!isting mitral valve disease

    • Degenerative

    Aortic

    o Dilated aorta

    o Dissection

    • 7rauma

    • Cystic medial necrosis

    o Dilatation

    • ystemic hy#ertension

    • Advanced age

    Cystic medial necrosiso

    Com,ined

    o &ar$an syndrome

    o An9ylosing s#ondylitis

    o =steogenesis im#er$ecta

    o Ehlers>Danlos syndrome

    o BehcetFs syndrome

    o 8eiterFs syndrome

    o y#hilis

    o 8heumatoid arthritis

    o Psoriatic arthritis

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    o 7a9ayasuFs arteritis

    o %iant cell arteritis

    o Polyarteritis nodosa

    o 8ela#sing #olychondritis

    o *accoudFs arthro#athy

    o ystemic lu#us erythematosis (E)

    o Hlcerative colitis

    o Whi##leFs disease

    o CrohnFs disease

    • Chronic Aortic Insu$$iciency

    Diagnosiso ym#toms

    • May  ,e asym#tomatic

    • E!ertional dys#nea

    • 8educed e!ercise tolerance

    • "atigue

    • Hncom$orta,le 4$orce$ul5 heart,eat

    o Physical "indings

    • Primary murmur'

    Early diastolic

    Decrescendo

    #itched

    4Blo+ing5 Best heard +ith dia#hragm o$ stethosco#e at 6 or 8B- +ith #atient leaning $or+ard- during h

    dee#- end>e!halation

    • Associated murmurs'

    Patients +ith AI- in addition to the #rimary murmur- may have'

    o ystolic e@ection murmur

    • Due to 4high $lo+5 across aortic valve- $rom high stro9e volume

    o Austin "lint murmur

    • Diastolic rum,le- ,est heard +ith ,ell o$ stethosco#e at a#e!

    • 7hought to ,e due to 4$unctional5 mitral stenosis resulting $rom the aortic

    regurgitant @et $orcing the anterior mitral lea$let into a #artially closed #ositi

    • =ther #ro#osed mechanism'

    Diastolic rum,le results $rom $luttering o$ the anterior mitral lea$lecaused ,y the aortic regurgitant @et

    • Associated $indings

    Duroie sign

    o ystolic murmur over $emoral artery +hen stethosco#e is com#ressed #ro!imally- an

    diastolic murmur over $emoral artery +hen stethosco#e is com#ressed distallyo &ost #redictive sign o$ severe AI

    igns associated +ith high stro9e volume +ith ra#id diastolic run>o$$'

    o Wide #ulse #ressure

    o ?uinc9eFs #ulse

    • Phasic ,lanching o$ the nail ,ed

    o

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    o Diagnostic studies

    • EK% / < is common

    • CR8 / enlargement- ascending aorta may ,e dilated

    • Echocardiogram

    ery use$ul

    Allo+s evaluation o$'

    o tructure o$ aortic valve

    o Condition o$ aortic root

    o everity o$ AI

    o systolic $unction and sie

    E!cellent modality $or long>term $ollo+>u# and timing o$ surgery• Cardiac catheteriation

    De$ines coronary anatomy #rior to surgery

    Provides con$irmation o$ severity o$ AI

    De$ines structure o$ the aortic root

    3atural history

    o De#ends on'

    • sie and $unction

    • Presence or a,sence o$ sym#toms

    o N o$ #atients +ith asym#tomatic chronic AI and normal systolic $unction +ill remain asym#tomatic at 1 year

    o Prognosis +orsens signi$icantly +hen'

    • systolic dys$unction develo#s

    E" N• igni$icant dilatation develo#s

    end>systolic dimension J mm

    end>diastolic dimension J T mm

    • ym#toms develo#

    7reatment

    o &edical

    • 3i$edi#ine

    May   delay the need $or A8 surgery in asym#tomatic #atients +ith severe AI and normal

    systolic $unction

    • =ther vasodilators (controversial)

    ACE inhi,itors

    A8BFs

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    Pulse #ressure not +idened

    Diastolic murmur so$t and short

    o Diagnostic studies

    • EK% / sinus tachycardia (usually)- < may ,e a,sent

    • CR8

    Pulmonary edema (usually)

    sie is usually normal

    Ascending aorta may  ,e dilated (de#ending on the cause o$ the AI)

    • Echocardiogram

    Diagnostic test o$ choice

    Allo+s evaluation o$'o tructure o$ aortic valve

    o Condition o$ aortic root

    o everity o$ AI

    o systolic $unction and sie

    • Cardiac catheteriation

    &ay or may not ,e #ossi,le- de#ending on the sta,ility o$ the #atient

    De$ines coronary anatomy #rior to surgery

    Provides con$irmation o$ severity o$ AI

    De$ines structure o$ the aortic root

    7reatment

    o Prom#t surgical intervention $or hemodynamically unsta,le #atients

    &edical treatment +hile a+aiting surgery may include' Intravenous #ositive inotro#ic agents

    Intravenous vasodilators

    • Beta>,loc9ers and IABP are contraindicated

    o u# is necessary.

    o All #atients +ith severe AI should ,e re>evaluated clinically and echocardiogra#hically every > 12 months.

    A8 surgery may ,e necessary before the develo#ment o$ sym#toms.

    o systolic $unction and sie may +orsen signi$icantly ,e$ore sym#toms develo#.

    BE #ro#hyla!is no longer indicated

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    . &itral and 7ricus#id alve Disease

    • &itral tenosis

    Etiology

    o 8heumatic $ever (JSSN)

    o =ther (1N)

    • E!tensive mitral annular calci$ication (in elderly)

    • Congenital &

    • Endocarditis +ith very large vegetations

    ym#toms

    o Dys#nea

    • E!ertional- rest- ortho#nea- #aro!ysmal nocturnal dys#nea

    o

    "atigueo 8ight>heart $ailure (+ith severe &)

    • Peri#heral edema- @ugular venous distention- ascites- he#atomegaly

    o #itched (rum,le)

    o Associated $indings

    • =#ening sna#

    As severity o$ stenosis +orsens- o#ening sna# occurs closer to 2 o$tens or disa##ears +ith calci$ication

    o oud 1 (&1)

    • o$tens or disa##ears +ith calci$ication

    Diagnosis

    o EK%

    • e$t atrial a,normality

    • 8ight ventricular hy#ertro#hy (i$ #ulmonary

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    • Diuretics ($or sym#toms o$ vascular congestion)

    • Beta>,loc9ers- nondihydro#yridine calcium channel ,loc9ers- or digo!in $or ventricular rate control i$ A. $i

    develo#s

    • Anticoagulation (+ar$arin or he#arin) i$ A. $i,. develo#s

    o Percutaneous

    • Balloon mitral valvulo#lasty (B&)

    E!clusions' e!tensive valve calci$ication- signi$icant &8- atrial throm,us

    o urgery

    • "or severe sym#tomatic & in non>candidates $or B&

    • =#en mitral commissurotomy

    • &itral valve re#lacement• &itral 8egurgitation

    Etiology

    o tructural or $unctional a,normalities o$'

    • &itral annulus

    Calci$ication (in elderly)

    Dilatation (assoc. +ith le$t ventricular dilatation)

    • alve lea$lets

    &y!omatous degeneration (&P)

    8heumatic $ever

    Endocarditis

    heart $ailure sym#toms'

    o Dys#nea

    o =rtho#nea

    o Paro!ysmal nocturnal dys#nea

    8ight>heart $ailure sym#toms'

    o Peri#heral edemao A,dominal $ullness0 discom$ort

    Physical $indings

    o Acute &8

    • Early systolic (crescendo) decrescendo murmur

    o Chronic &8

    • Pansystolic murmur that does not get louder during ins#iration

    (=$ten) ,est heard at a#e!

    ometimes radiates to the le$t a!illa

    • 6 Diagnosis

    o Acute &8

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    • EK%

    inus tachycardia(;)

    • CR8

    Pulmonary edema

    • Echocardiogram

    Diagnostic

    • Cardiac catheteriation

    Evaluate coronary arteries (#a#illary muscle ru#ture as a com#lication o$ &I;)

    o Chronic &8

    • EK%

    e$t atrial a,normality

    e$t ventricular hy#ertro#hy

    • CR8

    e$t ventricular enlargement

    e$t atrial enlargement

    • Echocardiogram

    Diagnostic

    • Cardiac catheteriation

    Evaluate coronary arteries (#a#illary muscle ischemia;)

    3atural Danlos syndrome

    ym#toms

    o &ay ,e asym#tomatic

    o Chest discom$ort

    o Pal#itations

    Physical "indings

    o &id>systolic clic9 and late systolic murmur

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    o Dynamic auscultation'

    • uatting ma9es clic9 later- and murmur shorter (and o$ten so$ter).

    • tanding (or alsalva maneuver) ma9es clic9 earlier- and murmur longer (and o$ten louder).

    Diagnosis

    o EK%

    • 3ormal unless chronic &8 has caused le$t atrial enlargement and0or le$t ventricular hy#ertro#hy

    o CR8

    • 3ormal unless chronic &8 has caused le$t ventricular and0or atrial enlargement

    o Echocardiogram

    • Diagnostic

    o Cardiac catheteriation• Hsually not necessary

    3atural history

    o Hsually ,enign

    o ome develo# gradually #rogressive &8

    o 8arely- my!omatous chordae tendineae may ru#ture- causing acute severe &8 and #ulmonary edema

    &anagement

    o 8eassurance

    o &edical

    • Beta>,loc9ers o$ten #rovide sym#tomatic relie$ $or chest discom$ort and0or #al#itations

    o urgery

    • &itral valve re#air or re#lacement $or the rare #atient +ho develo#s severe &8 +ith sym#toms or sys

    dys$unction• 7ricus#id 8egurgitation

    Etiology

    o Hsually $unctional

    • 8esults $rom right ventricular enlargement

    o =ther causes

    • 8heumatic $ever

    • Carcinoid syndrome

    ym#toms

    o 8ight>heart $ailure sym#toms

    • Peri#heral edema

    • A,dominal $ullness0 discom$ort

    "atigue0 +ea9ness Physical $indings

    o &urmur

    • Pansystolic murmur that gets louder during ins#iration (CarvalloFs sign)

    • =$ten ,est heard along lo+er le$t sternal ,order

    o Classic triad o$ severe 78

    • CarvalloFs sign

    • Pulsatile  @ugular venous distention (*D)

    • Pulsatile liver

    Com#lete triad rarely seen

    Diagnosis

    o EK%

    &ay sho+ changes characteristic o$ the #rocess res#onsi,le $or the right ventricular enlargemento CR8

    • 8ight atrial enlargement

    • 8ight ventricular enlargement

    o Echocardiogram

    • Diagnostic

    o Cardiac catheteriation

    • arge v +aves in the right atrial #ressure +ave$orm

    3atural tolerated

    &anagement

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    o "or $unctional 78- thera#y is directed at the underlying cause o$ the increased right ventricular sie or #ressure.

    o &edical

    • Diuretics ($or right>heart $ailure sym#toms)

    o urgery

    • 7ricus#id valve re#air or re#lacement only $or severe cases re$ractory to the a,ove measures

    • ummary

    &itral stenosis is almost al+ays a seuela rheumatic $ever.

    Acute and chronic mitral regurgitation 4,ehave5 very di$$erently.

    &itral valve #rola#se is a common- usually ,enign entity that o$ten only reuires little more than reassurance.

    7ricus#id regurgitation is usually $unctional- thera#y o$ +hich is directed at the underlying cause o$ the increased right ventric

    sie or #ressure.

    . ynco#e

    • De$inition' 7em#orary loss o$ consciousness and #ostural tone due to transient cere,ral hy#o#er$usion- $ollo+ed ,y s#ontaneous recov

    • Incidence

    Children and adolescents

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    o 1 to 2N +ill e!#erience synco#e ,e$ore adulthood

    Adults

    o 6 to N

    o Elderly

    • 2 to N annual incidence

    • Im#act

    6N o$ emergency room visits

    1N o$ hos#ital admissions

    Estimated annual cost (eval. and t!)' U--

    • Etiology

    7he s#eci$ic cause o$ synco#e can ,e identi$ied in a##ro!imately TN o$ #atients. Cardiovascular (>N)

    o Cardiac

    • Electrical

    Bradyarrhythmia

    o inus node dys$unction

    o A nodal ,loc9

    o Arti$icial #acema9er mal$unction

    7achyarrhythmia

    o u#raventricular

    o entricular

    In general- in normal individuals- heart rates ,et+een 6 and 1 ,#m do not  result in signi$ica

    reduction in cere,ral ,lood $lo+ (es#. in the su#ine #osition). Circumstances in +hich e!tremes o$ heart rate are #oorly tolerated'

    o evere systolic dys$unction

    o igni$icant diastolic dys$unction

    o igni$icant mitral stenosis (es#. A" +ith 88)

    o igni$icant coronary artery disease

    • &echanical

    Aortic stenosis

    valve throm,us

    Prosthetic valve mal$unction

    Pulmonic stenosis

    7etralogy o$ "allot

    Pulmonary em,olism

    evere #ulmonary hy#ertension

    &yocardial ischemia or in$arction

    o Presenting sym#tom in TN o$ elderly +ith &I

    Coronary s#asm

    Pericardial tam#onade

    Aortic dissection

    o ascular (most common)

    • 8e$le!>mediated

    7rigger (a$$erent lim,)

    o 7rigger> varies +ith each s#eci$ic ty#e o$ re$le!>mediated synco#e

    8es#onse (e$$erent lim,)o 8es#onse (e$$erent) lim,> essentially the same $or all ty#es o$ re$le!>mediated synco

    • Increased vagal tone

    • Withdra+al o$ sym#athetic tone

    E!am#les

    o 3eurocardiogenic (a.9.a.' vasode#ressor- vasovagal- neurally mediated- common $a

    • Potential triggers'

    Prolonged standing

    Warm environment

    Pain

    ight o$ ,lood

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    Emotional distress

    • Beold / *arisch re$le!

    J 6 second #ause

    asode#ressor > Jmm J6 sec #ause and J mm

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    Psychiatric

    o Psychiatric (estimated that u# to 2N o$ une!#lained synco#al e#isodes may ,e #sychogenic)

    o old girl e!#eriences a 4,lac9out5 +hen her ,oy$riend ,rea9s u# +ith her. Physical e!amination- including orthosta

    ,lood #ressures- is normal.o EK% sho+s ?7 #rolongation

    • Could lead to torsades de #ointe

    A >year>old man +ith 11 #revious e#isodes o$ synco#e over T years remained undiagnosed $ollo+ing tilt testing- am,ulato

    cardiac monitoring +ith an e!ternal loo# recorder- and electro#hysiological testing.o T months later- he e!#erienced another synco#al e#isodeV

    o Asystole

    • 7reatment

    7hera#y must ,e tailored to the s#eci$ic cause'

    o Avoidance

    o Correction

    o Interru#t re$le! lim,s (modulate the A3)

    o Pacema9er and 0 or ICD im#lantation

    8ecommendations $or driving

    o Consider'

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    • Potential $or recurrence

    • Presence and duration o$ +arning sym#toms

    • Does synco#e only occur +hile standing;

    • "reuency and ca#acity in +hich the #atient drives

    • A##lica,le state la+s

    • Prognosis

    Hnderlying etiology determines #rognosis

    o Cardiac synco#e carries the +orst #rognosis'

    • 8ecurrent- une!#lained synco#e in individuals +ith structural heart disease is associated +ith a 2>year

    mortality o$ :N.

    • ummary

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    Etiology

    o In$ectious

    • iral (o$ten deemed 4idio#athic5 due to lac9 o$ serologic con$irmation)

    • 7u,erculosis

    • Pyogenic ,acteria

    • &ost common cause o$ acute #ericarditis

    o 3onin$ectious

    • Postmyocardial in$arction

    Early

    o "irst $e+ days a$ter &I

    DresslerFs syndrome

    o Wee9s to months a$ter &I

    • Hremia

    • 3eo#lastic disease

    • 8adiation>induced

    • Connective tissue diseases

    • Drug>induced

    Assoc. +ith drug>induced lu#us syndrome

    o Procainamide

    o

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    • erum cardiac mar9ers

    I$ elevated- consider concomitant myocarditis or &I

    o Chest radiogra#h

    • Hsually normal (in idio#athic0viral #ericarditis)

    o Echocardiogram

    • Hsually normal (in idio#athic0 viral #ericarditis)

    • hould ,e ordered to evaluate $or #ossi,le coe!isting large #ericardial e$$usion

    7reatment ($or viral0idio#athic)

    o 8est- 3AIDs- oral corticosteroids0oral colchicine (only used $or #ain re$ractory to 3AIDs and narcotic analgesia)

    analgesia

    7reatment (other than viral0ido#athic)o =ther than viral0 idio#athic

    • 7u,erculous

    Prolonged antitu,erculous thera#y

    • Purulent

    Catheter drainage anti,iotic thera#y

    • Hremic

    Dialysis

    • Associated +ith &I

     Avoid  corticosteroids and 3AIDFs other than AA

    Com#lications

    o Com#lications

    •Pericardial e$$usion

    • Pericardial (cardiac) tam#onade

    • Constrictive #ericarditis

    • Pericardial E$$usion

    De$inition' Accumulation o$ an a,normally large amount o$ $luid in the #ericardial s#ace

    o 3ote' 7he #ericardial s#ace normally contains 1 / cc o$ $luid

    • 7his $luid (#lasma ultra$iltrate) serves to reduce $riction

    Etiology

    o &alignancy

    o Post cardiac surgery

    o Post #ercutaneous cardiac #rocedure

    o Com#lication o$ #ericarditis

    o

    7horacic aortic dissectiono Chest trauma

    Diagnosis

    o Clinical history and #hysical $indings

    • ym#toms

    Asym#tomatic

    Chest discom$ort

    Dys#nea

    "atigue

    Presence and severity o$ sym#toms de#end on the rate o$ accumulation o$ #ericardial $luid

    • 6 determinants o$ sym#tom onset0 #rogression

    8ate o$ accumulation o$ #ericardial $luid

    olume o$ #ericardial $luid

    Com#liance o$ the #ericardium

    • Physical $indings

    3one (small or moderate e$$usion)

    In large e$$usions- one may  $ind'

    o &u$$led heart sounds

    o E+artFs sign'

    • Dullness to #ercussion over the angle o$ the le$t sca#ula due to com#ressi

    the le$t lung ,y the enlarged #ericardial saco EK%

    • &ay ,e normal in small to moderate e$$usions

    • arge e$$usions'

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    o+ voltage

    o !ometimes seen in large #ericardial e$$usions

    o &any other causes (not s#eci$ic)

    Electrical alternans

    o !ometimes seen in large #ericardial e$$usions (s#eci$ic- ,ut not sensitive- $or large

    #ericardial e$$usion)o Chest radiogra#h

    • 3ormal- i$ e$$usion is small

    • %lo,ular- symmetric enlargement o$ cardiac silhouette in moderate to large e$$usions

    *+ater bottle,  heart

    o Echocardiogram• &ost use$ul test $or #ericardial e$$usion

    • 4%old standard5 test $or detection- localiation- and uanti$ication o$ #ericardial e$$usion

    7reatment

    o 7reat underlying cause (i$ 9no+n)

    o =,servation

    • I$ cause is 9no+n and #atient is asym#tomatic

    o Pericardiocentesis

    • I$ cause is un9no+n (sam#le o$ $luid may ,e sent $or analysis' 4diagnostic #ericardiocentesis5)

    • I$ #atient is sym#tomatic or i$ there is evidence o$ #ericardial tam#onade (4thera#eutic #ericardiocentesis

    • Pericardial 7am#onade

    De$inition' Cardiac cham,er com#ression caused ,y #ericardial e$$usion

    o A.K.A.' Cardiac tam#onade entricular Interde#endence

    o -ormal  #hysiology

    • Increase in 8 volume during ins#iration causes a slight  shi$t o$ the interventricular se#tum to the le$t.

    • 7his le$t+ard shi$t o$ the interventricular se#tum only occurs to a mild degree- as the com#liant #ericardiu

    allo+s out+ard e!#ansion o$ the right ventricle to accommodate most o$ the increased venous return dur

    ins#iration.

    • 7his results in a slight reduction in le$t ventricular stro9e volume during ins#iration (causing the normal  #

    #arado!us. ). .-ormal #ulsus #arado!us 1 mmin$late BP cu$$ to a,out 2 mmthird o$ #atients)

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    Dys#nea (later)

    • Physical $indings