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 - 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