Clinical Examination of Cardiovascular System For Medical Students
Discussion on blood pressure is not included here as a separate topic is dedicated to it.
Though the most commonly examined pulse is the radial, to check some of the characteristics, a more proximal pulse like the brachial or carotid needs to be examined. Following parameters of the pulse are routinely documented: 1. The rate: Normal rate in adult is 60-100 per minute. It is higher in children. Younger the child, higher the pulse rate.
Rhythm: Regular and irregular rhythms are possible. Mild variation with respiration is called respiratory sinus arrhythmia, with higher rate in inspiration. Respiratory sinus arrhythmia may...
Source: Cardiophile MD - May 30, 2023 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
What is Mitochondrial Cardiomyopathy?
Mitochondria have two genomes – mitochondrial and nuclear. Mitochondrial disease could be due to mutations of nuclear or mitochondrial DNA. Mitochondrial DNA is inherited maternally while nuclear DNA has Mendelian inheritance, which could be dominant or recessive [1]. It may be noted in about one in 5000 live births. Cardiac involvement in mitochondrial disease seldom occurs in isolation and is often part of multiorgan dysfunction [2]. Mitochondria being part of the cellular respiratory chain, tissues with high energy requirements like heart, muscle, kidneys and endocrine system are often involved in mitochondrial d...
Source: Cardiophile MD - May 9, 2023 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
A man in his 40s with epigastric pain and ST Elevation
Case submitted by Magnus Nossen MD, written by Pendell MeyersA previously healthy man in his 40s presented to the ED with epigastric abdominal pain off and on for several days. Vitals were within normal limits.It is unclear whether he had active pain at the time of the first ECG:What do you think?Here is PM Cardio ' s Queen of Hearts interpretation (AI ECG interpretation trained by Meyers, Smith, and PM Cardio team using thousands of cases and their outcomes):The output number ranges from 0 to 1, with numbers closer to zero meaning likely NOT OMI, and numbers closer to 1 meaning OMI. This result of 0.0002 is obviousl...
Source: Dr. Smith's ECG Blog - February 23, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Syncope, hypotension, vomiting and diaphoresis in a 60-something male with Diabetes and Hypertension
I was texted this ECG by one of my partners, with the following history: A 60-something male with diabetes and HTN presented with syncope. Per EMS report, the patient had a syncopal episode at work. On medics arrival, patient noted to be pale and diaphoretic, SBPs 60-80s, complaining of nausea and had one episode of emesis en route, possible hematemesis. There was no chest discomfort, though the patient was non-English speaking and reportedly " stoic " .What do you think?This was my response, in quotes: " I have a sneaking suspicion that this is a mimic. Tough one! &n...
Source: Dr. Smith's ECG Blog - December 6, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 20s with syncope
Written by Destiny Folk MD, with edits by Meyers, peer reviewed by Smith and GrauerA woman in her late 20s with a past medical history of cervical cancer status post chemotherapy and radiation therapy presented to the emergency department for shortness of breath, chest tightness, and two episodes of syncope.Her initial vital signs revealed a temp of 97.7F, HR 125, RR 20, BP 115/90, and an oxygen saturation of 95% on room air. Upon arrival, she did not appear in acute distress. She was noted to be tachycardic and her heart sounds were distant on physical exam. She had a normal respiratory effort, and her lungs were clear to...
Source: Dr. Smith's ECG Blog - November 28, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
What is the role of Disopyramide in HCM?
Disopyramide is a class Ia antiarrhythmic agent which can be used in hypertrophic obstructive cardiomyopathy when beta blockers alone are ineffective. Disopyramide has a negative inotropic action and is useful in reducing left ventricular outflow tract gradients in hypertrophic obstructive cardiomyopathy and does not increase the risk of sudden cardiac death. Dose reduction is recommended when QTc exceeds 480 ms. It should be avoided in those with glaucoma and men with prostatic symptoms in view of its anticholinergic action. Anticholinergic action is responsible for increase in ventricular rate with atrial fibrillation. ...
Source: Cardiophile MD - November 24, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Abnormal exercise blood pressure response in HOCM
Abnormal exercise blood pressure response in hypertrophic obstructive cardiomyopathy has been defined as failure to rise at least 20 mm Hg or fall of at least 20 mm Hg from peak level. Please note that exercise testing in HOCM could be risky and needs due precautions.
Abnormal exercise blood pressure response in hypertrophic obstructive cardiomyopathy has been associated with increased risk of sudden cardiac death in younger individuals below the age of 40 years. Progressive increase in blood pressure upto peak exercise is the normal physiological response to exercise.
Reference
1. Elliott PM, Anastasakis A, Borger M...
Source: Cardiophile MD - November 24, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Which type of beta blocker is not ideal for HOCM?
Vasodilating beta blockers are not an ideal choice for the treatment of hypertrophic obstructive cardiomyopathy.
Non vasodilating betablockers are recommended for the treatment of hypertrophic obstructive cardiomyopathy (Class I, Level of Evidence B, as per European Society of Cardiology Recommendations 2014). Other class I drug recommendation when beta blockers are not tolerated is verapamil. Disopyramide has a class I recommendation in combination with betablocker or verapamil.
Reference
1. Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna W...
Source: Cardiophile MD - November 24, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
What is Morrow procedure?
Ventricular septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM) is otherwise known as Morrow procedure.
In Morrow procedure, a rectangular trough is created in the basal left ventricular septum from below the aortic valve to a point beyond the point of contact of the anterior mitral leaflet to the septum (point of SAM septal contact). It is the procedure of choice for symptomatic drug refractory HOCM, provided it is done in centers with adequate experience with the procedure.
Reference
1. Morrow AG, Reitz BA, Epstein SE, Henry WL, Conkle DM, Itscoitz SB, Redwood DR. Operative treatment in hypertrophic subao...
Source: Cardiophile MD - November 23, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Can digoxin be given in hypertrophic cardiomyopathy?
Low dose digoxin can be used to control ventricular rate in those with left ventricular ejection fraction less than 50%, having NYHA class II-IV symptoms and permanent atrial fibrillation (Class IIb, level of evidence C, 2014 European Society of Cardiology Guidelines)
Being an inotropic agent digoxin can enhance the left ventricular outflow tract obstruction. Even in those without LVOT obstruction, digoxin is not recommended, except in the specific subset mentioned above, that too only as a Class IIb recommendation.
Reference
1. Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, L...
Source: Cardiophile MD - November 23, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
What is the commonest sustained arrhythmia in HCM?
Commonest sustained arrhythmia in hypertrophic cardiomyopathy is atrial fibrillation. Atrial fibrillation (AF) can occur in about 1/5th of cases of hypertrophic cardiomyopathy (HCM). Factors predisposing to AF in HCM are left atrial pressure and size due to left ventricular diastolic dysfunction, left ventricular outflow tract obstruction and mitral regurgitation. About one fourth of them may develop embolic episodes and stroke. It has been suggested that those with left atrial diameter of 45 mm or more should undergo 48 hour Holter once or twice a year to look for AF. Anticoagulation is recommended in those with AF ...
Source: Cardiophile MD - November 23, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Role of beta blockers in hypertrophic obstructive cardiomyopathy (HOCM)
Beta blockers are the mainstay of medical treatment in hypertrophic cardiomyopathy with or without obstruction. They reduce the dynamic left ventricular outflow obstruction, angina, exertional dyspnea and the risk of ventricular arrhythmias [1]. Reduction in left ventricular outflow obstruction is mostly due to the negative inotropic effect of beta blockers [2].
Reduction in heart rate by beta blockers increases diastolic filling time. Sympatholytic effect of beta blockade can also reduce ventricular stiffness. Non-vasodilating beta blockers titrated to maximum tolerated dose is considered for those with symptomatic left ...
Source: Cardiophile MD - November 18, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
In which condition is a hyperkinetic pulse associated with a normal pulse volume?
Hyperkinetic pulse usually has a high pulse volume but in hypertrophic obstructive cardiomyopathy, is it associated with a normal pulse volume. A hyperkinetic pulse in HOCM is due to rapid initial rate of development of left ventricular pressure. Volume is not high because left ventricular outflow obstruction sets in soon. A hyperkinetic pulse with normal pulse volume may also be noted in mitral regurgitation. Here again the dilated left ventricle empties rapidly, but volume is not high because part of the blood goes back into the left atrium and not the aorta. In all other conditions with hyperkinetic puls...
Source: Cardiophile MD - November 3, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
What is myocardial contrast echocardiography?
Myocardial contrast echocardiography (MCE) is used for the assessment of myocardial microcirculation and endocardial demarcation. MCE uses gas-filled microbubbles that are inert and remain wholly within the vascular space. These microbubbles have an intravascular rheology similar to that of red blood cells [1]. A continuous intravenous infusion of microbubbles is given to achieve a steady state. These microbubbles are destroyed by high energy ultrasound. The rate of microbubble replenishment within the ultrasound beam is measured and represents the mean red blood cell velocity [2].
Normally, the ultrasound beam fills with...
Source: Cardiophile MD - November 1, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Heart disease in pregnancy? Cardiology Basics
Changes in blood circulation during pregnancy and labour can adversely affect many of the significant heart diseases. Increase in blood volume and heart rate are the important factors during pregnancy. Increase in blood volume is needed to give enough nutrients and oxygen to the growing baby. Nutrients and oxygen are transferred to the baby through the placenta during pregnancy, though there is no actual mixing of the blood of the baby and mother. In general, obstructive lesions and complex cyanotic congenital heart diseases have high risk in pregnancy.
Obstructive lesions like severe aortic stenosis and mitral stenosis a...
Source: Cardiophile MD - October 21, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
