Cardiac System

Abnormal Physical Examination Findings

Finding	Conditions
Kussmaul sign	Cardiac tamponade Right heart failure Restrictive cardiomyopathy
Pulsus paradoxus	Cardiac tamponade Obstructive lung diseases
Pulsus parvus et tardus	Aortic stenosis
Pulsus alternans	LV systolic dysfunction
Differential cyanosis	Eisenmenger syndrome of PDA
Reverse differential cyanosis	Transposition of great artery (TGA)

Abnormal Heart Sounds

Extra Heart Sounds

Heart Sound	Synonym	Mechanism	Diseases
S2	Opening snap	MV & TV opening	MS & TS
S3	Ventricular gallop	Ventricular filling Volume overload	HF & DCMP & MR & TR
S4	Atrial gallop	Atrial contraction Diastolic dysfunction	HF & HCMP

Abnormal Splitting

Type	Etiology
Wide	Pulmonary stenosis RBBB
Paradoxical	Aortic stenosis LBBB
Fixed	ASD

Murmurs

Disease	Phase	↑ Preload	↑ Afterload
VSD	Systolic	↑	↑
AS	Systolic	↑	↓
AR	Diastolic	↑	↑
MS	Diastolic	↑	-
MR	Systolic	↑	↑
MVP	Systolic	↓	↓
HCMP	Systolic	↓	↓

Grading of Murmurs

Grade	Thrill	Stethoscope
1	-	Against
2	-	Against
3	-	Against
4	+	Against
5	+	Partially off
6	+	Completely off

Abnormal ECG Findings

Finding	Conditions
Diffuse ST elevation	Acute pericarditis
Electrical alternans	Pericardial effusion
Low voltage	Pericardial effusion
Widened QRS	Ventricular rhythm Hyperkalemia TCA toxicity
Bidirectional VT	Digitalis toxicity
S1Q3T3	Pulmonary embolism
Delta waves	Wolff-Parkinson-White (WPW) syndrome
U waves	Hypokalemia
Sine waves	Hyperkalemia
Osborn waves	Hypothermia

Regional Wall Motion Abnormality

Inotropes

Mechanism	Medication
Na-K pump blockers	Digitalis
β1 agonists	Norepinephrine Epinephrine Isoproterenol Dobutamine Dopamine
PDE inhibitors	Inamrinone Milrinone

Effects of Inotropes

Inotrope	Mechanism	CO	SVR	MAP	IE
Norepinephrine	α1 > β1	-	↑ (1°)	↑	100
Epinephrine	β1 > β2 > α1	↑ (1°)	↓	↑	100
Isoproterenol	β1 = β2	↑ (1°)	↓ (1°)	-	100
Dobutamine	β1 > β2	↑ (1°)	↓	↑	1
Dopamine	D > β1 > α1	↑	↓ (1°)	↓	1
Inamrinone Milrinone	-	↑ (1°)	-	↑	15

• Cardiac output (CO)
• Systemic vascular resistance (SVR)
• Mean arterial pressure (MAP)
• Inotropic equivalent (IE)

Inotropic Equivalent (IE)

Parameter	Σ(E × R)
E	Equivalent
R	Rate (µg/kg/min)

Medications Slowing Conduction {ABCD}

• Adenosine
• Amiodarone
• β antagonists
• Ca channel blockers
• Digitalis

Atrial Septal Defects (ASD)

Type	Prevalence
Secundum	70%
Primum	20%
Sinus venosus	10%
Coronary sinus	< 1%

Ventricular Septal Defects (VSD)

Cyanotic Congenital Heart Defects (CHD) {5T-HE}

Defect	Obligatory Shunt	Cyanosis
Truncus arteriosus	-	Non-differential
Transposition of great artery (TGA)	(ASD / VSD) & PDA	Reverse differential
Tricuspid atresia	ASD & (VSD / PDA)	Non-differential
Tetralogy of Fallot (TOF)	VSD & PDA	Non-differential
Total anomalous pulmonary venous return (TAPVR)	ASD / VSD / PDA	Non-differential
Hypoplastic left heart syndrome (HLHS)	ASD & PDA	Non-differential
Eisenmenger syndrome of ASD	-	Non-differential
Eisenmenger syndrome of VSD	-	Non-differential
Eisenmenger syndrome of PDA	-	Differential

PDA-dependent Cyanotic Congenital Heart Defects (CHD)

• Transposition of great artery (TGA)
• Tetralogy of Fallot (TOF)
• Hypoplastic left heart syndrome (HLHS)
• Critical pulmonary stenosis
• Critical aortic stenosis
• Critical coarctation of the aorta (CoA)

Conditions Associated with Heart Defects

Defect	Conditions
Endocardial cushion defects	Down syndrome
Atrial septal defect (ASD)	Down syndrome Fetal alcohol syndrome
Ventricular septal defect (VSD)	Down syndrome Fetal alcohol syndrome VACTERL association Apert syndrome
Patent ductus arteriosus (PDA)	Congenital rubella
Tetralogy of Fallot (TOF)	DiGeorge syndrome Velocardiofacial syndrome
Mitral valve prolapse (MVP)	Ehlers-Danlos syndrome (EDS) Marfan syndrome Fragile X syndrome Rheumatic fever ADPKD
Supravalvular aortic stenosis	Williams syndrome
Bicuspid aortic value Coarctation of the aorta (CoA)	Turner syndrome
Ebstein anomaly	Lithium
Libman-Sacks endocarditis	Systemic lupus erythematosus (SLE)
Coronary artery aneurysms	Kawasaki disease
Aortic dissection	Ehlers-Danlos syndrome (EDS) Marfan syndrome Tertiary syphilis

Presentation of Tetralogy of Fallot (TOF) {PROV}

• Pulmonary stenosis
• RV hypertrophy
• Overriding aorta
• Ventricular septal defect

Classification of Heart Failure (HF)

	HFrEF	HFpEF
LVEDV	↑	↓
LVESV	↑	↓
SV	↓	↓
LVEF	↓	-
Dysfunction	Systolic	Diastolic
Etiology	ACS & DCMP	HCMP & RCMP

Staging of Heart Failure (HF)

NYHA

ACC/AHA

Management of Heart Failure (HF)

Decompensated {LMNOP}

• Diuretics :: Lasix
• Venodilators
  • Morphine
  • Nitrates
• Oxygen
• Position

Compensated {ABVD}

• ACEI & ARB
• β₁ antagonists
  • Carvedilol
  • Bisoprolol
  • Metoprolol
• Vasodilators :: Nitrates
• Diuretics :: Spironolactone
• Digitalis
• SGLT-2 inhibitors
• Cardiac resynchronization therapy (CRT)

Indications for CRT in Heart Failure (HF)

• NYHA class II / III / IV
• LV ejection fraction < 35%
• Left bundle branch block (LBBB) w/ QRS complex > 150 ms

Cardiomyopathy

• Dilated cardiomyopathy (DCMP)
• Hypertrophic cardiomyopathy (HCMP)
• Restrictive cardiomyopathy (RCMP)

Etiology of Dilated Cardiomyopathy (DCMP) {ABCD}

• Alcohol
• Beriberi & Vitamin B₁ deficiency
• Coxsackie B virus myocarditis
• Cocaine
• Chagas disease
• Doxorubicin
• Duchenne muscular dystrophy (DMD)

Etiology of Arrhythmia {HIS-BEDS}

• Hypoxia
• Ischemia
• Irritability
• Sympathetic tone
• Bradycardia
• Electrolyte disturbances
• Drugs
• Stretch

Pathogenesis of Arrhythmias

• Automaticity
• Triggered activity
  • Early after-depolarization (EAD)
  • Delayed after-depolarization (DAD)
• Reentry
• Conduction delay

Classification of Arrhythmias

Sinus Arrhythmias

• Sinus bradycardia
• Sinus tachycardia

Supraventricular Arrhythmias :: Atrial

• Atrial tachycardia (AT)
  • Focal atrial tachycardia (FAT)
  • Multifocal atrial tachycardia (MAT)
• Atrial flutter
• Atrial fibrillation (AF)

Supraventricular Arrhythmias :: Junctional

• Junctional escape [Idiojunctional] rhythm
• Junctional tachycardia (JT)
• AV nodal reentrant tachycardia (AVNRT)
• AV reentrant/reciprocating tachycardia (AVRT)

Ventricular Arrhythmias

• Ventricular escape [Idioventricular] rhythm
• Ventricular tachycardia (VT)
• Ventricular fibrillation (VF)

Types of Pre-excitation

• Wolff-Parkinson-White (WPW) syndrome
• Lown-Ganong-Levine syndrome (LGL) syndrome

Risk of Stroke from Atrial Fibrillation

CHADS₂ Score

• Congestive heart failure (CHF)
• Hypertension
• Age ≥ 75 years
• Diabetes mellitus
• Stroke / CVA history

CHA₂DS₂-VASc Score

• Congestive heart failure (CHF)
• Hypertension
• Age ≥ 75 years
• Diabetes mellitus
• Stroke / CVA history
• Vascular diseases
• Age 65 ~ 75 years
• Sex :: female

Treatment of Atrial Fibrillation

• Cardioversion
  • Hemodynamic instability
  • Persistence
    • Duration < 48 hours
    • Anticoagulated
    • No atrial thrombus on TEE
• Anticoagulants
  • Duration > 48 hours
  • CHA₂DS₂-VASc ≥ 2
• Antiarrhythmics
  • Rate control :: Class 2 & 4 & Digitalis
  • Rhythm control :: Class 1C & 3

Rules of Malignancy for PVC

• Frequent PVC
• Consecutive PVC
• R-on-T phenomenon
• Acute myocardial infraction
• Multiform PVC

Etiology of QT Prolongation

• Drugs {ABCDE}
• Electrolyte disturbances
  • Hypokalemia
  • Hypocalcemia
  • Hypomagnesemia
• Congenital long QT syndrome

Antiarrhythmics

Class	Mechanism	Medication
1	Na channel blockers	Class 1A: Quinidine Procainamide Disopyramide
		Class 1B: Lidocaine Mexiletine
		Class 1C: Flecainide Propafenone
2	β antagonists	-
3	K channel blockers	Amiodarone Ibutilide Dofetilide Sotalol
4	Ca channel blockers	Verapamil Diltiazem
-	-	Adenosine Digitalis Magnesium

Effects of Antiarrhythmics on ECG

ECG	Heart	Phase	Ion Channel	Antiarrhythmics
Heart rate	SA node	4	Na & K	Class 2
PR interval	AV node	0	Ca	Class 2 & 4
QRS complex	Ventricle	0	Na	Class 1
QT interval	Ventricle	2 & 3	K	Class 1 & 3

Contraindications to Amiodarone

• Sinus bradycardia :: < 40/min
• Sick sinus syndrome
• AV blocks
  • 2nd degree Mobitz II
  • 3rd degree
• Pre-excitation syndrome
• QT prolongation

Indications for Defibrillation

Condition	Energy (J)
VF	120 ~ 200
Pulseless VT	120 ~ 200
Unstable polymorphic VT	120 ~ 200

Indications for Synchronized Cardioversion

Condition	Energy (J)
Unstable narrow-QRS tachycardia	50 ~ 100
Unstable atrial flutter	50 ~ 100
Unstable atrial fibrillation	120 ~ 200
Unstable monomorphic VT	> 100

Indications for Implantable Cardioverter Defibrillator (ICD)

• History of cardiac arrest due to ventricular arrhythmia w/o reversible cause
• Reduced ejection fraction
  • LV ejection fraction < 35% & NYHA class II / III
  • LV ejection fraction < 30% & History of MI

Indications for Permanent Pacemaker

• Symptomatic sinus bradycardia :: < 40/min
• Symptomatic sick sinus syndrome
• AV blocks
  • 2nd degree Mobitz II
  • 3rd degree

Etiology of ST Segment Elevation

• Acute myocardial infarction
• Acute myocarditis
• Acute pericarditis
• Apical ballooning syndrome
• Brugada syndrome
• Hyperkalemia
• Hypothermia
• J point elevation
• Pulmonary embolism
• Variant angina

Coronay Artery Disease (CAD)

Type	Pathogenesis	T Wave	ST Segment	Q Wave	Triggers	Cardiac Enzymes
Variant [Prinzmetal] angina	Coronary artery spasm	HTW	STE	-	Drugs	-
Stable angina	Coronary artery thrombosis	-	STD	-	Exertion	-
Unstable angina	Coronary artery thrombosis	TWI	STD	-	Anytime	-
NSTEMI	Subendocardial infarction	TWI	STD	-	Anytime	↑
STEMI	Transmural infarction	HTW	STE	PQW	Anytime	↑

Risk Factors for Coronay Artery Disease (CAD)

• Elderly
  • Age ≥ 45 years in males
  • Age ≥ 55 years in females
• Family history
• Diabetes
• Hypertension
• HDL < 40 mg/dL
• Cigarette smoking

Diagnosis of STEMI

• ST elevation
  • In all leads except V2 and V3: > 1 mm
  • In V2 and V3
    • In females: > 1.5 mm
    • In males age ≥ 40 years: > 2 mm
    • In males age < 40 years: > 2.5 mm
• Left bundle branch block (LBBB)

TIMI Risk Score (TRS) for Unstable Angina and NSTEMI {ACS}

• Age > 65 years
• Aspirin use
• Angina ≥ 2 in 24 hours
• CAD history
• CAD risk factors ≥ 3
• Cardiac enzymes
• ST changes > 0.5 mm

Score	Risk	Management
< 3	Low	Cardiac stress test
≥ 3	High	Coronary angiography

Management of Acute Coronary Syndrome (ACS)

Acute {MONAB}

• Oxygen
• Venodilators
  • Morphine
  • Nitrates
• Antiplatelets
  • Aspirin
  • ADP antagonists
  • Gp2b/3a inhibitors
• Anticoagulants :: Heparin
• β₁ antagonists
• Revascularization
  • Thrombolysis if duration < 12 ~ 24 hours
  • Percutaneous intervention (PCI)
  • Coronary artery bypass grafting (CABG)

Long-Term

• ACEI & ARB
• Antiplatelets
• β₁ antagonists
• Statins

Ideal Door-to-Reperfusion Time for ACS

• Door-to-needle < 30 minutes
• Door-to-bolloon < 90 minutes

Indications for Coronary Artery Bypass Grafting (CABG)

• LCA > 50% stenosis
• Proximal LAD > 50% stenosis
• 2-vessel disease: 2 vessels > 50% stenosis & EF < 50%
• 3-vessel disease: 3 vessels > 50% stenosis

Types of Grafts for Coronary Artery Bypass Grafting (CABG)

• Saphenous vein
• Internal mammary artery (IMA)
  • Left internal mammary artery (LIMA)
  • Right internal mammary artery (RIMA)
• Radial artery

Complications of Myocardial Infarction

Time (days)	Histology	Complications
< 1	Coagulative necrosis Contraction bank Wavy fiber	Cardiogenic shock Arrhythmia Heaert failure
1 ~ 3	Neutrophilic infiltrate	Fibrinous pericarditis
3 ~ 14	Granulation tissue	Pseudo-aneurysm Free wall rupture Papillary muscle rupture
> 14	Contracted scar	Aneurysm Mural thrombus Dressler syndrome

Comparison Between Biosprosthetic and Mechanical Heart Valves

Endpoint	Outcome
Mortality	Biosprosthetic > Mechanical
Durability	Biosprosthetic < Mechanical
Bleeding	Biosprosthetic < Mechanical
Thromboembolism	Biosprosthetic < Mechanical

Beck Triad of Cardiac Tamponade

• Hypotension & Pulsus paradoxus
• Jugular vein distension (JVD) & Kussmaul sign
• Distant heart sound

Pathogens of Infective Endocarditis

• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus viridans
• Enterococcus
• Pseudomonas aeruginosa
• Candida

Pathogens of Culture-Negative Infective Endocarditis {HACEK}

• Haemophilus parainfluenzae
• Actinobacillus
• Cardiobacterium
• Eikenella
• Kingella

Presentation of Infective Endocarditis {FROM-JANE}

• Fever
• Roth spots
• Osler nodes
• Murmur
• Janeway lesions
• Anemia
• Nail-bed hemorrhage
• Emboli

Duke Criteria for Infective Endocarditis

Major

• Microbiological evidence
• Endocardial involvement

Minor

• Fever
• Vascular phenomena
• Immunologic phenomena
• Microbiological evidence
• Risk factors

Empirical Antibiotics for Infective Endocarditis

• Anti-MRSA
• Anti-pseudomonal β-lactams
• ± Aminoglycosides

Management of Pericarditis

Etiology	Management
Bacterial	Antibiotics
Viral	NSAIDs Colchicine
Fibrinous	Aspirin
Uremic	Corticosteroids

Radiation Heart Disease

• Coronay artery disease (CAD)
• Valvular heart disease
  • Aortic regurgitation (AR)
  • Aortic stenosis (AS)
• Restrictive cardiomyopathy (RCMP)
• Constrictive pericarditis