·
The increased venous return of inspiration (the Müller maneuver is sucking in with the nares
held closed) increases the murmurs of the right side of the heart, and expiration
increases the murmurs of the left side of the heart.
·
Low-risk patients (score of 0, stroke
risk 0.5%/year without warfarin) can be managed with aspirin alone. High-risk patients (score ≥3,
stroke risk ≥5.2%/year without warfarin) should be managed with warfarin. Intermediate-risk patients
(score 1 or 2, stroke risk 1.5% –2.5%/year without warfarin) may be managed
with aspirin or warfarin, depending
upon the clinician's assessment of risk, the ability to monitor the intensity
of anticoagulation, the patient's risk of bleeding with anticoagulation, and
patient preference. If warfarin is used, the goal INR should be 2–3.
·
The left parasternal border at the third,
fourth, and fifth intercostal spaces should be palpated for a right ventricular
tap, which is also called a lift or heave. It is a nondiagnostic finding and
results from any etiology of right ventricular hypertrophy. A heave that
is palpable at the apex is consistent with LVH.
·
An easy mnemonic to remember systematic heart
auscultation is APT. M (Aortic
valve, Pulmonic valve, Tricuspid valve, and Mitral valve.
·
·
Prophylaxis for SABE
is not recommended in isolated secundum ASD, surgical repairs of septal
defects (both atrial and ventricular), and PDA.
·
Systolic ejection murmur with a THRILL ON THE UPPER LEFT
STERNAL BORDER: pulmonic stenosis
·
Holosystolic murmur with a THRILL ON THE LOWER LEFT
STERNAL BORDER: VSD
·
Holosystolic murmur best heard on the apex, radiating to
the AXILLA: mitral regurgitation
·
Systolic murmur along with LSB THRILL RADIATING TO THE
RIGHT SIDE OF THE NECK: aortic stenosis
·
Midsystolic click with late systolic murmur: mitral valve prolapsed
·
Opening snap, loud S1, diastolic rumble, atrial
fibrillation: mitral stenosis
·
2nd H.S.:
Fixed Split = ASD (the
only one)
Narrow/ Paradoxical: LHAIM (LBBB,
HTN, AS, IHSS, MI)
All other have wide split.
·
The uraemia
leads to exudation of fibrin onto the
epicardial and pericardial surfaces. Haemorrhagic
pericarditis is more typical of tuberculosis or
metastatic tumour. Serous
pericarditis is more typical of collagen vascular
diseases.
·
Antimicrobials with prolonged QTI:
Erythro,Quinine,Levoflox
·
Pulmonary
embolism should be considered in the differential diagnosis of patients
presenting with undifferentiated chest pain or dyspnea and an elevated cardiac
troponin level.
·
Patients with Hypertrophic
Cardiomyopathy (HCM) are at increased risk of sudden cardiac death
due to VF/VT. The five poor prognostic markers which are predictive of sudden
cardiac death are:
- Syncope
- Family History of HCM and sudden cardiac death
- Maximum Left Ventricular Wall Thickness >3cm
- BP drop during peak exercise on stress testing
- Documented runs of Non-Sustained VT on 24 hour tape.
LVOT obstruction causes
symptoms and can lead to deterioration of LV function but does not predict
sudden cardiac death. Asymmetric Septal Hypertrophy is a feature of HCM, in
order to assess the risk for sudden cardiac death a detailed echocardiogram
with measurements of the maximum left ventricular wall thickness is required.
Systolic anterior movement of the mitral valve is often seen on echocardiogram
and is thought to be the mechanism behind the left ventricular outflow tract
obstruction.
·
IWMI pt may need
temporary pacemaker if not controlled with medication.
·
systolic ejection
click- signify congenital bicuspid aortic valve then acquired AS
·
Total cholesterol
and HDL cholesterol can be calculated without FASTING. LDL
cholesterol is calculated from the fasting triglyceride level and total and HDL
cholesterol levels are calculated by the following formula:
LDL=Total-HDL+(TG/5)
·
Cigarette smoking
is a greater risk factor for cardiovascular disease than obesity.
·
Cardiologists express functional
status in terms of metabolic equivalent
(MET) levels. One MET is equal to the oxygen consumption (3.5
mL/kg/min) of a 70-kg, 40-year-old man in a resting state. With this benchmark,
functional capacity is excellent in patients who can perform at a level of >
7 METs; moderate at 4-7 METs; and poor if patients cannot meet a 4-MET demand
during most daily activities. The 4-MET cut point
is used in the ACC/AHA guideline.
·
Clues to the diagnosis of cholesterol emboli syndrome include a
predisposing procedure in a patient with extensive vascular disease; the
presence of leukocytosis, and especially eosinophilia, in the peripheral blood
film; and cholesterol crystals in tissue specimens and retinal arteries.
·
The most common cause of atrial tachycardia with
block is digitalis toxicity.
·
Three ECG findings are virtually pathognomonic
of VT: AV dissociation, capture beats, and fusion beats
·
The normal range for the PR interval is 0.12-0.20 sec. It is not
significantly related to age, sex, or heart rate.
The normal range
for the QT interval also is unrelated
to age, but it does vary with heart rate. As the heart rate increases, the QT
interval shortens. To help evaluate a QT interval independent of heart rate,
the corrected QT interval (QTc) can be calculated:
QTc (in msec) = measured QT (in
msec)/square root of the R-R interval (in sec)
The normal range for the QTc is 0.36-0.44 sec. A prolonged QTc is defined as QTc > 0.44 sec.
·
Diagnostic
criteria for left anterior fascicular block: QRS axis -60° to -90°,
Small q-wave in lead I, Small r-wave in lead III
·
Prolongation
of the QT interval is associated in certain patients with a definite increase
in risk of VF and death.
·
Some patients exhibit ECG changes similar to
those of MI but do not have any other definitive evidence of an MI. Such
patients are said to have ECG evidence of "pseudoinfarction."
Causes include:
o LV or RV hypertrophy
o LBBB
o Wolff-Parkinson-White syndrome
o Hypertrophic cardiomyopathy
o Hyperkalemia
o Early repolarization
o Cardiac sarcoid or amyloid
o
Intracranial hemorrhage
·
The primary
angioplasty in myocardial infarction (PAMI) trial is the first
published clinical trial designed specifically to compare balloon angioplasty
with t-PA as the primary reperfusion therapy in patients with acute
ST-elevation MI. Survival rates (at 30 days and at 2 years) after primary
angioplasty were similar to those with t-PA in acute MI, but angioplasty
conferred greater freedom from recurrent ischemia, reinfarction, and need for
readmission to the hospital. Another important advantage of balloon angioplasty
over thrombolytic drug therapy is freedom from intracranial hemorrhage, a
dreadful complication of thrombolysis, particularly in elderly patients.
·
Acute coronary
syndrome is a clinical syndrome characterized by ischemic cardiac
chest pains associated with ST or T-wave changes, but, unlike classic acute MI,
there is no acute ST segment elevation. Thus, it is called the non-ST elevation acute coronary syndrome.
This includes two diseases: unstable angina
and non-Q-wave MI, which are differentiated based on the presence or
absence of an elevation of the creatinine kinase MB fraction (MB CK) or
troponin I or T levels.
·
Digoxin
is successful in decreasing
hospitalization for heart failure—an important clinical end point—but did not decrease mortality. It has no role in
preventing maladaptive ventricular remodeling.
·
A presystolic, or S4,
gallop indicates reduced compliance of the left ventricle but
not a failing left ventricle per se. Pulsus alternans, characterized by
alternating weaker and stronger pulsations in the peripheral arteries,
indicates a diseased left ventricle with poor systolic function. Pulsus
alternans will usually be accompanied by an S3
gallop.
·
In patients with severe
and chronic systemic venous congestion, the prothrombin time
can be prolonged. Thus, an abnormal international normalized ratio does not
automatically indicate liver disease. Similarly, chronic congestion may produce
mild elevations in bilirubin and alkaline phosphatase levels. An
elevation of transaminase levels is more likely to be associated with acute
liver congestion with hypoxia and hepatocellular damage. Splanchnic
congestion in right heart failure can lead to nausea, diarrhea, and
malabsorption.
·
The oral bioavailability
of furosemide varies widely (10% to 100%), but absorption of torsemide and
bumetanide is nearly complete, ranging from 80% to 100%.
·
ABPM is
the best method to establish the presence of isolated
clinic hypertension (socalled white-coat hypertension), which is
defined as an elevation in BP that occurs only in the clinic setting, with
normal BP in all other settings, in the absence of evidence of target-organ
injury.
·
The JNC VII report suggests initiation of
therapy with two drugs rather than a single
agent if the systolic blood pressure is higher than 20 mm Hg above
the treatment goal or if the diastolic blood pressure is higher than 10 mm Hg
above the goal. Generally, a two-drug regimen should include a diuretic
appropriate for the level of renal function.
·
Establishment and
maintenance of sinus rhythm is not superior to ventricular rate control in
patients with AF.
·
Although success rates are high with DC
cardioversion in AF, a number of risk factors for
cardioversion failure have been identified. These include longer duration of AF (notably, longer than 1 year), older
age, left atrial enlargement, cardiomegaly, rheumatic heart disease, and
transthoracic impedance. Pretreatment with amiodarone, ibutilide,
sotalol, flecainide, propafenone, disopyramide, and quinidine have been shown
to increase DC cardioversion success rates.
·
The most feared arrhythmia in the WPW syndrome involves atrial
fibrillation with dominant conduction over an accessory pathway that has
rapid conduction properties. These patients may experience extraordinarily
rapid ventricular rates and are at risk for sudden cardiac death from
ventricular fibrillation.
·
It is not uncommon for trained athletes to have type I second-degree AV block and be
asymptomatic. Pacemaker therapy is not indicated.
·
The three basic functions of a pacemaker—pacing, sensing,
and action—are determined by basic pacemaker programming. Five-position
code currently in use. The first position denotes the chamber or
chambers paced; the second denotes the
chamber or chambers sensed; the third
denotes the action or actions performed; the fourth
denotes rate response; and the fifth
denotes multiple site pacing. The simplest mode
of pacing is VVI, otherwise known as
ventricular demand pacing or ventricular inhibited pacing. The most commonly
used mode in dual-chamber pacing is DDD.
The most basic timing cycle is the lower rate, which reflects how long the
pacemaker will wait after a paced or sensed beat before initiating pacing.
·
Exercise ECG
is the diagnostic test of choice for the average patient with an intermediate pretest probability of IHD and a normal
resting ECG. Exercise-induced falls in blood pressure or the development of an
exercise-induced S3 heart sound are strongly suggestive of ischemic left
ventricular dysfunction. Specific exercise-induced ECG changes include changes
≥ 1 mm horizontal or downward-sloping ST segment depression or elevation
during or after exercise. Exercise-induced changes in lead V5 are most reliable for the diagnosis of IHD.
·
Calcium channel
blockers are contraindicated in the presence of decompensated congestive heart
failure, although the vasoselective dihydropyridine agents amlodipine and felodipine are tolerated in
patients with clinically stable left ventricular dysfunction.
·
Exercise testing
is most useful for diagnosing coronary artery disease in patients with an intermediate pretest probability (e.g., 20% to 80%).
·
Approximately 35% to 50%
of patients with unstable angina will not have chest pain
as their presenting symptom. 51.7% of patients with unstable angina had the
following atypical symptoms: dyspnea (69.4%), nausea
(37.7%), diaphoresis (25.2%), syncope (10.6%), arm pain (11.5%), epigastric
pain (8.1%), shoulder pain (7.4%), and neck pain (5.9%).
·
Type B dissection
is frequently accompanied by hypertension,
whereas type A dissection more often
occurs in the presence of normal or low blood pressure.
Emergency surgery is crucial for patients with type A aortic dissections. Type B dissection cases are managed medically by
means of aggressive blood pressure control with beta
blockers.
·
Depression of the
PR segment, which reflects superficial injury of the atrial
myocardium, is as frequent and specific as ST segment elevation and is often
the earliest electrocardiographic manifestation of Acute
Pericarditis. The diffuse distribution
and the absence of reciprocal ST segment depression distinguish the
characteristic pattern of acute pericarditis from acute myocardial infarction.
A finding of diffuse ST segment elevations without
reciprocal changes or PR depressions would confirm the diagnosis of viral
pericarditis.
·
The constitutional symptoms may be caused by
production of interleukin-6 by the myxoma.
·
The most
important complication of myocardial contusion is cardiac arrhythmia.
Hypotension, intracardiac thrombus, congestive heart failure, and cardiac
tamponade occur occasionally.
·
Left axis deviation is
present in the majority of patients with AVSD; in contrast, right axis
deviation is found in patients with ostium secundum ASD.
·
All
patients with bicuspid aortic valves—even
those with no significant stenosis or regurgitation—should be given
instructions regarding endocarditis prophylaxis.
·
Patients with Down
syndrome have roughly a 40% chance of congenital cardiac anomalies.
The most common are the endocardial cushion defects
(especially ostium primum defects). They are also at risk for AR, tetralogy of Fallot, and pulmonary hypertension. Tetralogy
of Fallot is much less common than the endocardial cushion defects.
Interestingly, these patients are also at increased risk for mitral valve prolapse.
·
The exceptions, in which IE prophylaxis is not recommended, include
isolated secundum ASD, surgical repairs of septal
defects (both atrial and ventricular), and PDA.
·
LMWH is
more effective than standard low-dose heparin in general surgical patients,
patients undergoing elective hip surgery, and patients
with stroke or spinal injury. For those undergoing
genitourinary, neurologic, or ocular surgery, intermittent pneumatic compression, with or
without graduated compression stockings, is effective prophylaxis against
venous thrombosis and does not increase the risk of bleeding.
·
The ALLHAT trial
is the largest multicenter, double-blind, controlled clinical trial designed to
evaluate the effects of four different classes of antihypertensive drugs (e.g.,
thiazide diuretics, ACE inhibitors, alpha blockers, and calcium blockers) on
CHD and stroke risk. It showed no superiority of ACE inhibitors, calcium
blockers, or alpha blockers over diuretics in preventing CHD events.
·
Mitral valve prolapse (MVP) in the absence of
other systemic manifestations of Marfan's syndrome has been called Marfan syndrome-forme fruste, in view of the
similar pathologic appearance of the myxomatous mitral valve in both disorders.
Isolated mitral valve prolapse is more common than Marfan syndrome.
·
The most common
site of origin of atrial myxomas is the fossa ovalis. To prevent
recurrence of myxoma, a wide resection of the fossa ovalis area of the
interatrial septum is performed during surgical excision.
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