HISTORY. Questions: 1. What diagnosis is suggested by this history? 2. How do you explain her symptoms during pregnancy?
|
|
- Steven Gaines
- 8 years ago
- Views:
Transcription
1 HISTORY 33-year-old woman. CHIEF COMPLAINT: months duration. Dyspnea, fatigue and nocturnal wheezing of six PRESENT ILLNESS: At ages 5 and 9, she had migratory arthritis. At age 29, in the third trimester of her second pregnancy, she had paroxysmal nocturnal dyspnea and hemoptysis. Questions: 1. What diagnosis is suggested by this history? 2. How do you explain her symptoms during pregnancy? 3-1
2 Answers: 1. The history of arthritis in childhood is consistent with acute rheumatic fever. The cardinal manifestations of acute rheumatic fever include: arthritis, carditis, chorea, subcutaneous nodules and erythema marginatum. The diagnosis of rheumatic fever may be made when these occur associated with evidence of prior group A beta hemolytic streptococcal infection. Paroxysmal nocturnal dyspnea and hemoptysis in the third trimester of pregnancy, in association with her present symptoms, are highly suggestive of pulmonary venous congestion due to rheumatic mitral valve disease. 2. Cardiac decompensation is likely to occur during the third trimester of pregnancy (especially the 28th week), the period of maximal increase in cardiac output. Proceed 3-2
3 PHYSICAL SIGNS a. GENERAL APPEARANCE - Slender young woman in no distress at rest. b. VENOUS PULSE - The CVP is estimated to be 11 cm H 2 O. JUGULAR VENOUS PULSE ECG Question: How do you interpret the venous pulse? 3-3
4 Answer: The mean CVP is elevated, reflecting an increased right atrial filling pressure. There is a giant a wave (arrow) that reflects the increased force of right atrial contraction against a stenotic tricuspid valve or a poorly compliant right ventricle. c. ARTERIAL PULSE - (BP = 120/80 mm Hg) PHONO UPPER RIGHT STERNAL EDGE S1 S2 CAROTID 1.0 SECOND Question: How do you interpret the arterial pulse? 3-4
5 Answer: The arterial pulse is normal. A normal arterial pulse in a patient with suspected rheumatic valvular heart disease severe enough to cause moderate symptoms of left heart failure, suggests a mixed valvular lesion. Isolated stenosis or regurgitation of the mitral valve (the most commonly affected by rheumatic fever) may cause a change in pulse contour. In mitral stenosis the pulse may be diminished, and in mitral regurgitation it may be enhanced. Proceed 3-5
6 d. PRECORDIAL MOVEMENTS ECG LOWER LEFT STERNAL EDGE APEX Question: How do you interpret these impulses? 3-6
7 Answer: The systolic impulses at the apex and the lower left sternal edge are sustained, consistent with hypertrophy of both ventricles. Left ventricular hypertrophy is not typical of isolated mitral stenosis (MS) and, therefore, significant mitral regurgitation (MR) and/or aortic valve disease should be suspected. Right ventricular hypertrophy suggests significant pulmonary hypertension is present. e. CARDIAC AUSCULTATION ECG PHONO UPPER RIGHT STERNAL EDGE S1 S2 Question: How do you interpret these acoustic events? 3-7
8 Answer: The first heart sound (S1) at the upper right sternal edge is increased in intensity, so that it is as loud as the normal aortic second sound (A2). S1 is normally less intense than A2 in this area. In the absence of a short P-R interval or a hyperkinetic state, this finding implies the presence of MS. e. CARDIAC AUSCULTATION (continued) UPPER LEFT STERNAL EDGE ECG 2L A 2 P 2 A 2 P sec EXPIRATION INSPIRATION Question: How do you interpret these acoustic events? 3-8
9 Answer: At the upper left sternal edge, the second heart sound (S2) splits physiologically. The pulmonic sound (P2) is louder than the normal A2, compatible with some degree of pulmonary hypertension. e. CARDIAC AUSCULTATION (continued) ECG S1 S1 A2 PHONO APEX 0.1 sec Question: How do you interpret these acoustic events? 3-9
10 Answer: An opening snap (OS) (arrow) occurs.06 sec. after A2 and is followed by a long diastolic rumble with presystolic accentuation (broken arrow) ending with a loud S1. There is a high frequency holosystolic murmur. These acoustic events identify combined MS and MR. The accentuated S1 and the OS are also typically heard at the lower left sternal edge. The OS is the acoustic equivalent of mitral valve opening and may be heard in patients with MS and a pliable valve. The interval from A2 to OS is an index of severity. The more severe the MS, the higher the left atrial pressure and the earlier the mitral valve is snapped open in diastole. Hence, the more severe the MS, the shorter the A2-OS interval. An A2-OS interval <.06 sec. usually indicates at least moderately severe stenosis. While assessment of this interval is valuable, it is affected by a variety of hemodynamic factors, and must be interpreted in the total clinical context. Proceed 3-10
11 Answer (continued): The length of the diastolic rumble is also an index of severity. With more severe stenosis, the murmur is longer, as there is a persistent gradient across the valve during more of diastole. Presystolic accentuation is due to increased turbulence at the time of atrial contraction and mitral valve closure. The intensity of the holosystolic murmur is not, per se, an index of the severity of MR. Question: Would isometric handgrip help assess this patient s auscultatory findings? 3-11
12 Answer: Yes. Her response is shown below. ECG 0.2 sec PHONO LOWER LEFT STERNAL EDGE S1 S2 OS S1 S2 OS S1 PHONO APEX CONTROL HANDGRIP Question: How do you explain the changes with the handgrip? 3-12
13 Answer: With handgrip exercise, the apical systolic murmur (arrow) and diastolic murmur (broken arrow) increase in intensity. Isometric handgrip increases peripheral resistance (ventricular afterload) and heart rate. The increased resistance increases the degree of MR and the murmur. The increased heart rate shortens diastolic filling time, raising left atrial pressure, resulting in an increase in the intensity of the diastolic rumble. Question: Would amyl nitrite help assess the patient s auscultatory findings? 3-13
14 Answer: Yes. This patient s response to amyl nitrite inhalation is shown below. 0.2 sec ECG PHONO LOWER LEFT STERNAL EDGE S1 S2 OS S1 S2 OS S1 PHONO APEX CONTROL AMYL NITRITE Question: How do you interpret these changes? 3-14
15 Answer: With amyl nitrite, the apical systolic murmur diminishes (arrow), while the diastolic murmur (broken arrow) intensifies. Amyl nitrite reduces peripheral resistance and, therefore, the MR. In addition, the reflex increase in heart rate shortens diastolic filling time, increasing left atrial pressure and, hence, the intensity of the mitral diastolic rumble. f. PULMONARY AUSCULTATION Question: How do you interpret the acoustic events in the pulmonary lung fields? Proceed 3-15
16 Answer: In the lower anterior and posterior lung fields, there are inspiratory crackles and expiratory wheezes bilaterally, reflecting chronic pulmonary congestion and bronchospasm. In all other lung fields, there are normal vesicular breath sounds. ELECTROCARDIOGRAM I II III avr avl avf V1 V2 V3 V4 V5 V6 NORMAL STANDARD Question: How do you interpret this electrocardiogram? 3-16
17 Answer: There is normal sinus rhythm with a vertical axis. The P-R interval is normal, with a deep negative P wave in V1, suggesting left atrial enlargement. These changes are consistent with rheumatic mitral valve disease. The clinically observed right ventricular hypertrophy may be less apparent electrocardiographically because it is masked by the greater left ventricular mass. Left ventricular hypertrophy that is associated with MR is also frequently not reflected in the electrocardiogram. Proceed 3-17
18 CHEST X RAYS PA LEFT LATERAL Question: How do you interpret these chest X rays? 3-18
19 Answer: The PA chest X ray shows prominence of the venous pattern in the upper lobes and a decrease in the lower lobes. This inversion of the usual pattern is typical of pulmonary venous hypertension. The cardiac silhouette is enlarged, with prominence of the pulmonary artery. Left atrial enlargement is reflected by straightening of the left heart border with a prominent left atrial appendage (arrow), a double density along the right heart border (broken arrows) and some superior displacement of the left stem bronchus. The left lateral chest X ray confirms left atrial enlargement (arrow) and shows obliteration of the retrosternal space consistent with right ventricular enlargement (broken arrow). Calcification in the area of the mitral valve is also seen (double arrow). Question: Based on the history, physical examination, electrocardiogram and chest X rays, what is your diagnosis and plan for further evaluation? 3-19
20 Answer: The history, physical examination, ECG and chest X rays are consistent with rheumatic mitral valve disease with moderately severe MS and MR associated with pulmonary hypertension. An echo Doppler study also confirmed the diagnosis. The patient was treated with salt restriction and diuretics. She remained moderately dyspneic with minimal activity. Because of her significant symptoms and the relative severity of her disease, cardiac catheterization was advised as a prelude to surgical correction. The patient refused further evaluation. After several days, the patient left the hospital against medical advice. She returned six months later complaining of the sudden onset of rapid irregular heart action, severe shortness of breath and marked weakness of her left arm and leg. An electrocardiogram was obtained immediately. Proceed 3-20
21 ELECTROCARDIOGRAM I II III avr avl avf V1 V2 V3 V4 V5 V6 V5-6 1/2 STANDARD Question: How do you interpret this ECG? 3-21
22 Answer: The ECG shows coarse atrial fibrillation with a ventricular response of approximately 90. The axis has shifted further to the right and the R/S ratio in V1 is greater, suggesting right ventricular hypertrophy. With increasing evidence of right ventricular hypertrophy, left ventricular voltage usually decreases. Therefore, the increase in voltage in leads reflecting the left ventricle (2, 3, F, V5-6 ½ standard), associated with ST-T changes, suggests left ventricular hypertrophy as well. Question: How do you explain the patient s symptoms? 3-22
23 Answer: Her symptoms are typical of atrial fibrillation causing pulmonary congestion. With the increase in heart rate, diastole is shortened, decreasing the time for left atrial emptying. In addition, without atrial contraction, the atrial contribution to ventricular filling and cardiac output is lost. The result is an increase in pulmonary venous pressure that produces pulmonary edema. Patients with rheumatic mitral valve disease frequently have left atrial thrombi. In this case, atrial fibrillation has precipitated a cerebral embolism from the left atrium to the right hemisphere causing a left hemiparesis. Question: How would you confirm this scenario in this patient? 3-23
24 Answer: Transesophageal Echocardiogram (TEE). TEE, because of its proximity to the heart, gives excellent resolution of both the left atrium and left atrial appendage. The patient s study is shown below. LA LAA Clot LAA LA Ao = Left Atrial Appendage = Left Atrium = Aorta Ao Question: How would you treat this patient? Transesophageal Echocardiogram 3-24
25 Answer: The patient was treated for pulmonary edema with oxygen and elevation of the head of the bed. She was given an intravenous beta-blocker to reduce the ventricular response to her atrial fibrillation. Furosemide was also given intravenously to reduce pulmonary congestion. Because of the risk of recurrent emboli, intravenous heparin was subsequently administered. Over the next several days, her ventricular response decreased to a normal level and her pulmonary congestion and left hemiparesis resolved. The patient was again advised that surgery was indicated, especially in view of the recent complications. She agreed, and preoperative cardiac catheterization was carried out. Proceed 3-25
26 mm Hg LABORATORY- CATHETERIZATION ADDITIONAL DATA: LV LA Pulmonary Artery Pressure = 63 / 37 (Mean = 50) 20 LV LA D LA = Left Atrium LV = Left Ventricle SHORT LONG Question: How do you interpret this pressure tracing? 3-26
27 Answer: The simultaneous left atrial and left ventricular pressure tracing shows a diastolic gradient (cross hatching) of 12 mm Hg, reflecting moderate MS. The pulmonary artery pressure is also moderately elevated. During the first short cycle, left atrial pressure exceeds left ventricular pressure throughout diastole. During the long second cycle, with more time in diastole for the left atrium to empty, left atrial and left ventricular pressures equilibrate in late diastole (D). This is the hemodynamic explanation for the variation in the mitral diastolic rumble seen in patients with MS and atrial fibrillation. A phonocardiogram demonstrating this bedside finding in this patient follows. Proceed 3-27
28 Note that during the long diastolic cycle the murmur wanes in late diastole (arrow), due to equilibration of the left atrial and left ventricular pressures. PHONO APEX S1 A2 S1 A2 ECG SHORT LONG 0.2 sec Question: What is your explanation for the lack of presystolic accentuation of the diastolic murmur (broken arrow)? 3-28
29 Answer: It is likely due to the atrial fibrillation associated with a loss of presystolic augmentation in mitral valve flow. LABORATORY (continued) ANGIOGRAMS Left Ventricular Injection - Systole LA = LEFT ATRIUM LAA = LEFT ATRIAL APPENDAGE LV = LEFT VENTRICLE PA LEFT LATERAL Question: How do you interpret these angiograms? 3-29
30 Answer: The PA film shows mitral regurgitation as dye flows from the left ventricle into an enlarged left atrium during systole. The left atrial appendage is also enlarged and straightens the left heart border, a finding that correlates with the PA chest film interpretation. Left atrial enlargement is particularly well seen on the left lateral projection. Hemodynamic study has confirmed the clinical impression of moderately severe combined mitral stenosis and regurgitation with moderate pulmonary hypertension. The patient was treated with prosthetic mitral valve replacement and was successfully cardioverted to sinus rhythm. Her postoperative course was uneventful. Proceed 3-30
31 SUMMARY Mitral stenosis is virtually always due to rheumatic heart disease. Commissural fusion and scarring of leaflet tissue often combine to produce mixed MS and MR. A prior history of rheumatic fever is found in approximately half of adult patients with rheumatic mitral valve disease. Acute rheumatic fever is the result of group A beta hemolytic streptococci reacting through an immune mechanism with certain constituents of the heart to produce inflammation. This reaction, along with subsequent scarring, fusion of the chordae and valves, and calcification results in the valvular lesions of chronic rheumatic heart disease. The mitral valve is invariably involved, with the aortic valve next in frequency. When both of these valves are affected, the tricuspid valve may also be involved. In the United States, the pulmonic valve is virtually never affected. Proceed 3-31
32 Rheumatic mitral valve disease is more frequent in women. Such patients with predominant stenosis often become symptomatic in the third trimester of pregnancy. Patients with predominant regurgitation usually become symptomatic later in life. Rheumatic mitral valve disease typically presents with insidious symptoms of fatigue and dyspnea. Subsequently, paroxysmal nocturnal dyspnea, nonproductive cough, hemoptysis and palpitations may occur. Atrial fibrillation occurs as the left atrium enlarges, and is generally associated with symptomatic deterioration, especially when there is rapid ventricular response. Thrombi commonly form in the large left atrium, and emboli to the brain, kidneys and extremities may occur. Infective endocarditis may also occur, especially if there is associated significant mitral regurgitation. Proceed 3-32
33 PATHOLOGY This specimen shows the typical chronic rheumatic lesions associated with long standing MS and MR. FIBROTIC, THICKENED ANTERIOR MITRAL LEAFLET FIBROTIC, FUSED, SHORTENED CHORDAE TENDINEAE DILATED LEFT ATRIUM FIBROTIC, THICKENED POSTERIOR MITRAL LEAFLET DILATED LEFT VENTRICLE Proceed for Case Review 3-33
34 To Review This Case of Rheumatic Heart Disease with Moderately Severe Mitral Stenosis and Regurgitation and Pulmonary Hypertension: The HISTORY is typical, with acute rheumatic fever in childhood, nocturnal dyspnea and hemoptysis during the third trimester of pregnancy, and the subsequent development of congestive failure, with atrial fibrillation precipitating pulmonary edema and a cerebral embolus. PHYSICAL EXAMINATION a. The GENERAL APPEARANCE is normal. b. The JUGULAR VENOUS PULSE mean pressure is elevated, with a giant a wave due to increased right atrial contraction into a poorly compliant, failing right ventricle. c. The CAROTID PULSE is normal as a result of the combination of MS and MR. Proceed 3-34
35 d. PRECORDIAL MOVEMENTS reveal sustained impulses at the apex and lower left sternal edge due to hypertrophy of both ventricles. e. CARDIAC AUSCULTATION at the apex reveals a loud S1, a holosystolic murmur, an OS approximately.06 sec. after A2 and a long diastolic rumble with presystolic accentuation. These findings are typical of moderately severe combined MS and MR. P2 is increased at the base, due to associated pulmonary hypertension. f. PULMONARY AUSCULTATION reveals inspiratory crackles and expiratory wheezes in the lower anterior and posterior lung fields, reflecting chronic pulmonary congestion and bronchospasm. In all other lung fields, there are normal vesicular breath sounds. The initial ELECTROCARDIOGRAM shows normal sinus rhythm, a vertical axis and left atrial enlargement. A subsequent tracing shows more advanced findings, with coarse atrial fibrillation, a shift of the axis to the right and probable right and left ventricular hypertrophy. Proceed 3-35
36 The CHEST X RAYS show pulmonary venous congestion, left atrial, pulmonary artery and right ventricular enlargement with mitral valve calcification. LABORATORY STUDIES with cardiac catheterization and angiography confirm the presence of moderately severe mitral stenosis and regurgitation associated with pulmonary hypertension. TREATMENT consists of medical therapy for congestive heart failure, and tachydysrhythmias, including rate control, cardioversion to sinus rhythm, and anticoagulants for thromboembolic disease. For severe disease, treatment consists of prosthetic mitral valve replacement. Techniques for definitive treatment of atrial fibrillation should also be considered at the time of surgery. 3-36
5. Management of rheumatic heart disease
5. Management of rheumatic heart disease The fundamental goal in the long-term management of RHD is to prevent ARF recurrences, and therefore, prevent the progression of RHD, and in many cases allow for
More informationHeart Murmurs. Outline. Basic Pathophysiology
Heart Murmurs David Leder Outline I. Basic Pathophysiology II. Describing murmurs III. Systolic murmurs IV. Diastolic murmurs V. Continuous murmurs VI. Summary Basic Pathophysiology Murmurs = Math Q =
More informationThe P Wave: Indicator of Atrial Enlargement
Marquette University e-publications@marquette Physician Assistant Studies Faculty Research and Publications Health Sciences, College of 8-12-2010 The P Wave: Indicator of Atrial Enlargement Patrick Loftis
More informationHeart Sounds & Murmurs
Cardiovascular Physiology Heart Sounds & Murmurs Dr. Abeer A. Al-Masri MBBS, MSc, PhD Associate Professor Consultant Cardiovascular Physiologist Faculty of Medicine, KSU Detected over anterior chest wall
More informationAuscultation of the Heart
Review of Clinical Signs uscultation of the Heart Series Editor: Bernard Karnath, MD Bernard Karnath, MD William Thornton, MD uscultation of the heart can provide clues to the diagnosis of many cardiac
More informationHeart Sounds and Murmurs. Objectives. Valves. Wright, 2012 1
Heart Sounds and Murmurs Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Family Nurse Practitioner Owner Wright & Associates Family Healthcare Partner Partners in Healthcare Education 1 Objectives Upon completion
More informationManagement of the Patient with Aortic Stenosis undergoing Non-cardiac Surgery
Management of the Patient with Aortic Stenosis undergoing Non-cardiac Surgery Srinivasan Rajagopal M.D. Assistant Professor Division of Cardiothoracic Anesthesia Objectives Describe the pathophysiology
More informationManaging Mitral Regurgitation: Repair, Replace, or Clip? Michael Howe, MD Traverse Heart & Vascular
Managing Mitral Regurgitation: Repair, Replace, or Clip? Michael Howe, MD Traverse Heart & Vascular Mitral Regurgitation Anatomy Mechanisms of MR Presentation Evaluation Management Repair Replace Clip
More informationDynamic Auscultation of Heart Sounds and Murmurs. Acknowledgement. Disclosures Real or Potential Conflicts of Interest
Dynamic Auscultation of Heart Sounds and Murmurs W. Lane Edwards, Jr., MSN, ARNP, ANP Hospitalist Group of Southwest Florida Affiliate Professor of Nursing, University of Alaska at Anchorage Acknowledgement
More informationRACE I Rapid Assessment by Cardiac Echo. Intensive Care Training Program Radboud University Medical Centre NIjmegen
RACE I Rapid Assessment by Cardiac Echo Intensive Care Training Program Radboud University Medical Centre NIjmegen RACE Goal-directed study with specific questions Excludes Doppler ultrasound Perform 50
More informationDERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)
DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic
More informationTreating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC
Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG
More informationHow To Understand What You Know
Heart Disorders Glossary ABG (Arterial Blood Gas) Test: A test that measures how much oxygen and carbon dioxide are in the blood. Anemia: A condition in which there are low levels of red blood cells in
More informationPotential Causes of Sudden Cardiac Arrest in Children
Potential Causes of Sudden Cardiac Arrest in Children Project S.A.V.E. When sudden death occurs in children, adolescents and younger adults, heart abnormalities are likely causes. These conditions are
More informationSection Four: Pulmonary Artery Waveform Interpretation
Section Four: Pulmonary Artery Waveform Interpretation All hemodynamic pressures and waveforms are generated by pressure changes in the heart caused by myocardial contraction (systole) and relaxation/filling
More informationAnatomy Review. Heart Murmurs. Surface Topography of the Heart 7/19/2011. The Base of the Heart and Erb s Point
James A Mathey PA C, MPA CAPA WORKSHOP 2010 Heart Murmurs Anatomy Review 4 Classic Auscultatory Areas: Aortic 2ICS R SB Pulmonic 2ICS L SB Tricuspid 4 th L Lower SB Mitral 5ICS MCL Surface Topography of
More informationNote: The left and right sides of the heart must pump exactly the same volume of blood when averaged over a period of time
page 1 HEART AS A PUMP A. Functional Anatomy of the Heart 1. Two pumps, arranged in series a. right heart: receives blood from the systemic circulation (via the great veins and vena cava) and pumps blood
More informationUW MEDICINE PATIENT EDUCATION. Aortic Stenosis. What is heart valve disease? What is aortic stenosis?
UW MEDICINE PATIENT EDUCATION Aortic Stenosis Causes, symptoms, diagnosis, and treatment This handout describes aortic stenosis, a narrowing of the aortic valve in your heart. It also explains how this
More informationRheumatic fever & acute rheumatic heart disease. Done by Dr Hussein Amrat
Rheumatic fever & acute rheumatic heart disease Done by Dr Hussein Amrat # The most common cause of acquired valvular disease in developed and underdeveloped countries is rheumatic fever(r.f.) # Now in
More informationMinimally Invasive Mitral Valve Surgery
Minimally Invasive Mitral Valve Surgery Stanford Health Care offers leading, superior options in cardiac surgery, including the latest techniques and research for Minimally Invasive Cardiac surgery. Advanced
More informationThe heart then repolarises (or refills) in time for the next stimulus and contraction.
Atrial Fibrillation BRIEFLY, HOW DOES THE HEART PUMP? The heart has four chambers. The upper chambers are called atria. One chamber is called an atrium, and the lower chambers are called ventricles. In
More informationAtrial Fibrillation An update on diagnosis and management
Dr Arvind Vasudeva Consultant Cardiologist Atrial Fibrillation An update on diagnosis and management Atrial fibrillation (AF) remains the commonest disturbance of cardiac rhythm seen in clinical practice.
More informationAcute heart failure may be de novo or it may be a decompensation of chronic heart failure.
Management of Acute Left Ventricular Failure Acute left ventricular failure presents as pulmonary oedema due to increased pressure in the pulmonary capillaries. It is important to realise though that left
More informationHEART HEALTH WEEK 3 SUPPLEMENT. A Beginner s Guide to Cardiovascular Disease HEART FAILURE. Relatively mild, symptoms with intense exercise
WEEK 3 SUPPLEMENT HEART HEALTH A Beginner s Guide to Cardiovascular Disease HEART FAILURE Heart failure can be defined as the failing (insufficiency) of the heart as a mechanical pump due to either acute
More information5. Diagnosis and management of rheumatic heart disease
5. Diagnosis and management of rheumatic heart disease Introduction Chronic rheumatic valvular heart disease is the long-term result of ARF. It is a disease of poverty and disadvantage. In Australia, the
More informationSAM, Student Auscultation Manikin
SAM, Student Auscultation Manikin Product: SAM, Student Auscultation Manikin Cat. No.: 718-9007 Price: (Call for latest pricing) 281-488-5901 or 1-800-364-5901 in US and Canada; Email: keith.johnson@cardionics.com
More information12-Lead EKG Interpretation. Judith M. Haluka BS, RCIS, EMT-P
12-Lead EKG Interpretation Judith M. Haluka BS, RCIS, EMT-P ECG Grid Left to Right = Time/duration Vertical measure of voltage (amplitude) Expressed in mm P-Wave Depolarization of atrial muscle Low voltage
More informationINTRODUCTORY GUIDE TO IDENTIFYING ECG IRREGULARITIES
INTRODUCTORY GUIDE TO IDENTIFYING ECG IRREGULARITIES NOTICE: This is an introductory guide for a user to understand basic ECG tracings and parameters. The guide will allow user to identify some of the
More informationNormal & Abnormal Intracardiac. Lancashire & South Cumbria Cardiac Network
Normal & Abnormal Intracardiac Pressures Lancashire & South Cumbria Cardiac Network Principle Pressures recorded from catheter tip Electrical transducer - wheatstone bridge mechanical to electrical waveform
More informationFellow TEE Review Workshop Hemodynamic Calculations 2013. Director, Intraoperative TEE Program. Johns Hopkins School of Medicine
Fellow TEE Review Workshop Hemodynamic Calculations 2013 Mary Beth Brady, MD, FASE Director, Intraoperative TEE Program Johns Hopkins School of Medicine At the conclusion of the workshop, the participants
More informationNormal Intracardiac Pressures. Lancashire & South Cumbria Cardiac Network
Normal Intracardiac Pressures Lancashire & South Cumbria Cardiac Network Principle Pressures recorded from catheter tip Electrical transducer - wheatstone bridge mechanical to electrical waveform display
More informationPractical class 3 THE HEART
Practical class 3 THE HEART OBJECTIVES By the time you have completed this assignment and any necessary further reading or study you should be able to:- 1. Describe the fibrous pericardium and serous pericardium,
More informationCardiovascular diseases. pathology
Cardiovascular diseases pathology Atherosclerosis Vascular diseases A disease that results in arterial wall thickens as a result of build- up of fatty materials such cholesterol, resulting in acute and
More informationPress conference: Rheumatic Heart Disease a forgotten but devastating disease
www.worldcardiocongress.org Chairpersons: Bongani M. Mayosi Jonathan Carapetis Press conference: Rheumatic Heart Disease a forgotten but devastating disease www.worldcardiocongress.org www.worldcardiocongress.org
More informationAtrial Fibrillation The High Risk Obese Patient
Atrial Fibrillation The High Risk Obese Patient Frederick Schaller, D.O.,F.A.C.O.I. Professor and Vice Dean Touro University Nevada A 56 year old male with a history of hypertension and chronic stable
More informationExchange solutes and water with cells of the body
Chapter 8 Heart and Blood Vessels Three Types of Blood Vessels Transport Blood Arteries Carry blood away from the heart Transport blood under high pressure Capillaries Exchange solutes and water with cells
More informationNeal S. Gaither, MD, FACC, FSCAI. The Sonographer Knows
Neal S. Gaither, MD, FACC, FSCAI The Sonographer Knows Definition of Stroke sudden death of brain cells in a localized area due to inadequate blood flow Annually, 500,000 new cases in U.S. one in three
More informationObjectives. The ECG in Pulmonary and Congenital Heart Disease. Lead II P-Wave Amplitude during COPD Exacerbation and after Treatment (50 pts.
The ECG in Pulmonary and Congenital Heart Disease Gabriel Gregoratos, MD Objectives Review the pathophysiology and ECG signs of pulmonary dysfunction Review the ECG findings in patients with: COPD (chronic
More informationHow To Treat Heart Valve Disease
The Valve Clinic at Baptist Health Madisonville The Valve Clinic at Baptist Health Madisonville Welcome to the Baptist Health Madisonville Valve Clinic at the Jack L. Hamman Heart & Vascular Center. We
More informationWhat is echo? CHAPTER 1 1.1 BASIC NOTIONS. Ultrasound production and detection
What is echo? CHAPTER 1 1.1 BASIC NOTIONS Echocardiography (echo) the use of ultrasound to examine the heart is a safe, powerful, non-invasive and painless technique. Echo is easy to understand as many
More informationDr Richard Telford. Introduction
Dr Richard Telford Valvular Heart Disease 1. You visit a patient who is due to have an orthopaedic procedure. He tells you he gets occasional chest pain and shortness of breath on exertion. You notice
More informationAtrial Fibrillation Peter Santucci, MD Revised May, 2008
Atrial Fibrillation Peter Santucci, MD Revised May, 2008 Atrial fibrillation (AF) is an irregular, disorganized rhythm characterized by a lack of organized mechanical atrial activity. The atrial rate is
More informationPreoperative Laboratory and Diagnostic Studies
Preoperative Laboratory and Diagnostic Studies Preoperative Labratorey and Diagnostic Studies The concept of standardized testing in all presurgical patients regardless of age or medical condition is no
More informationECHOCARDIOGRAPHY PROPERTY OF ELSEVIER SAMPLE CONTENT - NOT FINAL CHAPTER 6. Hisham Dokainish, MD, FACC, FASE
CHAPTER 6 ECHOCARDIOGRAPHY Hisham Dokainish, MD, FACC, FASE 1. How does echocardiography work? Echocardiography uses transthoracic and transesohageal probes that emit ultrasound directed at cardiac structures.
More informationAdministrative. Patient name Date compare with previous Position markers R-L, upright, supine Technical quality
CHEST X-RAY Administrative Patient name Date compare with previous Position markers R-L, upright, supine Technical quality AP or PA ( with x-ray beam entering from back of patient, taken at 6 feet) Good
More informationCardiology Fact Sheet. ACVIM Fact Sheet: Myxomatous Mitral Valve Degeneration
Cardiology Fact Sheet ACVIM Fact Sheet: Myxomatous Mitral Valve Degeneration Overview Myxomatous mitral valve degeneration (MMVD) is the most common acquired type of heart disease and new murmurs in older
More informationCardiac Masses and Tumors
Cardiac Masses and Tumors Question: What is the diagnosis? A. Aortic valve myxoma B. Papillary fibroelastoma C. Vegetation from Infective endocarditis D. Thrombus in transit E. None of the above Answer:
More informationDoc, I Am Fine, But I Have A Cardiac Condition
Doc, I Am Fine, But I Have A Cardiac Condition Nevine Mahmoud, MD John Ludtke, MD Maj, USAFR, MC, FS RAM Class 2014 Wright State University Boonshoft School of Medicine Division of Aerospace Medicine Dayton,
More informationHeart Failure EXERCISES. Ⅰ. True or false questions (mark for true question, mark for false question. If it is false, correct it.
Heart Failure EXERCISES Ⅰ. True or false questions (mark for true question, mark for false question. If it is false, correct it. ) 1. Heart rate increase is a kind of economic compensation, which should
More informationCongestive heart failure (CHF) is a. Diastolic Heart Failure. By Michel D Astous, MD, FRCPC
Diastolic Heart Failure The evaluation of both systolic and diastolic functions is of great importance among patients presenting with signs of CHF, as the treatment may be quite different depending on
More informationMarilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL
Marilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL www.goldcopd.com GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT
More informationHeart valve repair and replacement
16 Heart valve repair and replacement 222 Valvular heart disease can be treated in a variety of ways: valve replacement, in which an artificial (prosthetic) heart valve is implanted surgically to replace
More information1 Congestive Heart Failure & its Pharmacological Management
Harvard-MIT Division of Health Sciences and Technology HST.151: Principles of Pharmocology Instructor: Prof. Keith Baker 1 Congestive Heart Failure & its Pharmacological Management Keith Baker, M.D., Ph.D.
More informationPulmonary Artery Hypertension
Pulmonary Artery Hypertension Janet M. Pinson, RN, MSN, ACNP Maureen P. Flattery, RN, MS, ANP Virginia Commonwealth University Health System Richmond, VA Pulmonary artery hypertension (PAH) is defined
More information2/20/2015. Cardiac Evaluation of Potential Solid Organ Transplant Recipients. Issues Specific to Transplantation. Kidney Transplantation.
DISCLOSURES I have no relevant financial relationships to disclose. Cardiac Evaluation of Potential Solid Organ Transplant Recipients Michele Hamilton, MD Director, Heart Failure Program Cedars Sinai Heart
More informationHYPERTROPHIC CARDIOMYOPATHY
HYPERTROPHIC CARDIOMYOPATHY Most often diagnosed during infancy or adolescence, hypertrophic cardiomyopathy (HCM) is the second most common form of heart muscle disease, is usually genetically transmitted,
More informationEquine Cardiovascular Disease
Equine Cardiovascular Disease 3 rd most common cause of poor performance in athletic horses (after musculoskeletal and respiratory) Cardiac abnormalities are rare Clinical Signs: Poor performance/exercise
More informationScott Hubbell, MHSc, RRT-NPS, C-NPT, CCT Clinical Education Coordinator/Flight RRT EagleMed
Scott Hubbell, MHSc, RRT-NPS, C-NPT, CCT Clinical Education Coordinator/Flight RRT EagleMed Identify the 12-Lead Views Explain the vessels of occlusion Describe the three I s Basic Interpretation of 12-Lead
More informationAtrial Fibrillation (AF) Explained
James Paget University Hospitals NHS Foundation Trust Atrial Fibrillation (AF) Explained Patient Information Contents What are the symptoms of atrial fibrillation (AF)? 3 Normal heartbeat 4 How common
More informationTABLE 1 Clinical Classification of AF. New onset AF (first detected) Paroxysmal (<7 days, mostly < 24 hours)
Clinical Practice Guidelines for the Management of Patients With Atrial Fibrillation Deborah Ritchie RN, MN, Robert S Sheldon MD, PhD Cardiovascular Research Group, University of Calgary, Alberta Partly
More informationCardiovascular System & Its Diseases. Lecture #4 Heart Failure & Cardiac Arrhythmias
Cardiovascular System & Its Diseases Lecture #4 Heart Failure & Cardiac Arrhythmias Dr. Derek Bowie, Department of Pharmacology & Therapeutics, Room 1317, McIntyre Bldg, McGill University derek.bowie@mcgill.ca
More informationVtial sign #1: PULSE. Vital Signs: Assessment and Interpretation. Factors that influence pulse rate: Importance of Vital Signs
Vital Signs: Assessment and Interpretation Elma I. LeDoux, MD, FACP, FACC Associate Professor of Medicine Vtial sign #1: PULSE Reflects heart rate (resting 60-90/min) Should be strong and regular Use 2
More informationHEART MURMURS THROUGHOUT CHILDHOOD
HEART MURMURS THROUGHOUT CHILDHOOD Frances R. Zappalla, D.O. Nemours Cardiac Center A.I. du Pont Hospital for Children Wilmington, DE Definition: HEART MURMURS An extra abnormal heart sound usually detected
More informationTHE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT
THE INTERNET STROKE CENTER PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT Stroke Prevention in Atrial Fibrillation Gregory Albers, M.D. Director Stanford Stroke Center Professor of Neurology and Neurological
More informationUniversitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1
Test Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1 Heart Failure - Definition European Heart Journal (2008) 29, 2388 2442 Akute Herzinsuffizienz Diagnostik und
More informationDiagnosis Code Crosswalk : ICD-9-CM to ICD-10-CM Cardiac Rhythm and Heart Failure Diagnoses
Diagnosis Code Crosswalk : to 402.01 Hypertensive heart disease, malignant, with heart failure 402.11 Hypertensive heart disease, benign, with heart failure 402.91 Hypertensive heart disease, unspecified,
More informationAtrial fibrillation. Quick reference guide. Issue date: June 2006. The management of atrial fibrillation
Quick reference guide Issue date: June 2006 Atrial fibrillation The management of atrial fibrillation Developed by the National Collaborating Centre for Chronic Conditions Contents Contents Patient-centred
More informationNAME OF THE HOSPITAL: 1. Coronary Balloon Angioplasty: M7F1.1/ Angioplasty with Stent(PTCA with Stent): M7F1.3
1. Coronary Balloon Angioplasty: M7F1.1/ Angioplasty with Stent(PTCA with Stent): M7F1.3 1. Name of the Procedure: Coronary Balloon Angioplasty 2. Select the Indication from the drop down of various indications
More informationPatient Possible differentials Recommended diagnostics Puppy or kitten with a soft systolic murmur
Cardiac Auscultation 101 Terri DeFrancesco, DVM, DACVIM (Cardiology), DACVECC Associate Professor in Cardiology and Critical Care NC State University College of Veterinary Medicine Email: teresa_defrancesco@ncsu.edu
More informationDiagnostic and Therapeutic Procedures
Diagnostic and Therapeutic Procedures Diagnostic and therapeutic cardiovascular s are central to the evaluation and management of patients with cardiovascular disease. Consistent with the other sections,
More informationHTEC 91. Topic for Today: Atrial Rhythms. NSR with PAC. Nonconducted PAC. Nonconducted PAC. Premature Atrial Contractions (PACs)
HTEC 91 Medical Office Diagnostic Tests Week 4 Topic for Today: Atrial Rhythms PACs: Premature Atrial Contractions PAT: Paroxysmal Atrial Tachycardia AF: Atrial Fibrillation Atrial Flutter Premature Atrial
More informationCardiology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Cardiology
Cardiology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Cardiology Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) The diabetes mellitus codes are combination codes
More information17 Endocarditis. Infective endocarditis
17 Endocarditis 234 Endocarditis refers to inflammation of the endocardium, the inner layer of the heart (including the heart valves). Endocarditis can be: infective (e.g. bacterial, fungal) non-infective
More informationGUIDE TO ATRIAL FIBRILLATION
PATIENT INFORMATION GUIDE TO ATRIAL FIBRILLATION Atrial Fibrillation (AF) Atrial Flutter (AFL) Rate and Rhythm Control Stroke Prevention This document is endorsed by: A Comprehensive Resource from the
More informationPATIENT INFORMATION GUIDE TO ATRIAL FIBRILLATION
PATIENT INFORMATION GUIDE TO ATRIAL FIBRILLATION A Comprehensive Resource from the Heart Rhythm Society AF 360 provides a single, trusted resource for the most comprehensive and relevant information and
More informationHEART FAILURE ROBERT SOUFER, M.D.
CHAPTER 14 HEART FAILURE ROBERT SOUFER, M.D. The heart s primary function is to pump blood to all parts of the body, bringing nutrients and oxygen to the tissues and removing waste products. When the body
More informationINTRODUCTION TO EECP THERAPY
INTRODUCTION TO EECP THERAPY is an FDA cleared, Medicare approved, non-invasive medical therapy for the treatment of stable and unstable angina, congestive heart failure, acute myocardial infarction, and
More informationAtrial Fibrillation The Basics
Atrial Fibrillation The Basics Family Practice Symposium Tim McAveney, M.D. 10/23/09 Objectives Review the fundamentals of managing afib Discuss the risks for stroke and the indications for anticoagulation
More informationChapter 2 Cardiac Interpretation of Pediatric Chest X-Ray
Chapter 2 Cardiac Interpretation of Pediatric Chest X-Ray Ra-id Abdulla and Douglas M. Luxenberg Key Facts The cardiac silhouette occupies 50 55% of the chest width on an anterior posterior chest X-ray
More informationAdult Cardiac Surgery ICD9 to ICD10 Crosswalks
164.1 Malignant neoplasm of heart C38.0 Malignant neoplasm of heart 164.1 Malignant neoplasm of heart C45.2 Mesothelioma of pericardium 198.89 Secondary malignant neoplasm of other specified sites C79.89
More informationHow To Teach An Integrated Ultrasound
University of South Carolina School of Medicine Integrated Ultrasound Curriculum iusc Richard Hoppmann The Integrated Ultrasound Curriculum Initiated 2006 First (M1) and Second (M2) Year Medical Students
More informationAtrial Fibrillation. Information for you, and your family, whänau and friends. Published by the New Zealand Guidelines Group
Atrial Fibrillation Information for you, and your family, whänau and friends Published by the New Zealand Guidelines Group CONTENTS Introduction 1 The heart 2 What is atrial fibrillation? 3 How common
More informationThe new Heart Failure pathway
The new Heart Failure pathway An integrated and seamless Strategy Dr Sunil Balani Definition of Heart Failure The inability of the heart to pump blood at a rate commensurate with the requirements of metabolising
More informationRight-sided infective endocarditis:tunisian experience
Right-sided infective endocarditis:tunisian experience L. Ammari, A. Ghoubontini, A. Berriche, R. Abdelmalek, S.Aissa, F.Kanoun, B.Kilani, H.Tiouiri Benaissa, T.Ben chaabane Department of Infectious diseases,
More informationProvider Checklist-Outpatient Imaging. Checklist: Nuclear Stress Test, Thallium/Technetium/Sestamibi (CPT Code 78451-78454 78469)
Provider Checklist-Outpatient Imaging Checklist: Nuclear Stress Test, Thallium/Technetium/Sestamibi (CPT Code 78451-78454 78469) Medical Review Note: Per InterQual, if any of the following are present,
More informationTreatments to Restore Normal Rhythm
Treatments to Restore Normal Rhythm In many instances when AF causes significant symptoms or is negatively impacting a patient's health, the major goal of treatment is to restore normal rhythm and prevent
More informationCTA OF THE EXTRACORONARY HEART
CTA OF THE EXTRACORONARY HEART Charles White MD Director of Thoracic Imaging Department of Radiology University of Maryland NO DISCLOSURES CWHITE@UMM.EDU CARDIAC CASE DISTRIBUTION Coronary CTA 30% ED chest
More informationAnaesthesia and Heart Failure
Anaesthesia and Heart Failure Andrew Baldock, Specialist Registrar, Southampton University Hospitals NHS Trust E mail: ajbaldock@doctors.org.uk Self-assessment The following true/false questions may be
More informationLow-gradient severe aortic stenosis with normal LVEF: A disturbing clinical entity
Low-gradient severe aortic stenosis with normal LVEF: A disturbing clinical entity Jean-Luc MONIN, MD, PhD Henri Mondor University Hospital Créteil, FRANCE Disclosures : None 77-year-old woman, mild dyspnea
More informationThe Emerging Atrial Fibrillation Epidemic: Treat It, Leave It or Burn It?
The Emerging Atrial Fibrillation Epidemic: Treat It, Leave It or Burn It? Indiana Chapter-ACC 17 th Annual Meeting Indianapolis, Indiana October 19, 2013 Deepak Bhakta MD FACC FACP FAHA FHRS CCDS Associate
More informationEVALUATION OF MEDICAL RECORDS COMPLETENESS IN THE ADULT CARDIOLOGY CLINIC AT NORK MARASH MEDICAL CENTER
American University of Armenia Center for Health Services Research and Development Nork Marash Medical Center EVALUATION OF MEDICAL RECORDS COMPLETENESS IN THE ADULT CARDIOLOGY CLINIC AT NORK MARASH MEDICAL
More informationHEART DISEASE IN THE ELDERLY
CHAPTER 21 HEART DISEASE IN THE ELDERLY LAWRENCE H. YOUNG, M.D. INTRODUCTION The elderly represent the fastest-growing segment of the American population. By the year 2000, it is estimated that people
More information81 First Responder Respiratory
81 First Responder Medical Scenarios Asthma Scenario: You are called to a local house for a woman with trouble breathing. You arrive to find a 67-year-old woman sitting upright in a chair. She states she
More information5 MILLION AMERICANS 1. Atrial Fibrillation (AFib) AFib affects an estimated
A Patient s Guide To with Atrial Fibrillation (AFib) CAUSES RISK FACTORS SYMPTOMS DIAGNOSIS TREATMENTS INSIDE The Healthy Heart... 2 Your Heart In AFib... 4 How Do You Get It?... 6 How Do You Know If You
More informationGERIATRYCZNE PROBLEMY KLINICZNE/GERIATRICS MEDICAL PROBLEMS
65 G E R I A T R I A 2011; 5: 65-69 GERIATRYCZNE PROBLEMY KLINICZNE/GERIATRICS MEDICAL PROBLEMS Otrzymano/Submitted: 24.02.2011 Poprawiono/Corrected: 01.03.2011 Zaakceptowano/Accepted: 06.03.2011 Akademia
More informationAtrial Fibrillation and Ablation Therapy: A Patient s Guide
Atrial Fibrillation and Ablation Therapy: A Patient s Guide ATRIAL FIBRILLATION CENTER AT UNIVERSITY OF ROCHESTER MEDICAL CENTER www.heart.urmc.edu 585-275-4775 INTRODUCTION Our goal at the Atrial Fibrillation
More informationWhat Can I Do about Atrial Fibrillation (AF)?
Additional Device Information 9529 Reveal XT Insertable Cardiac Monitor The Reveal XT Insertable Cardiac Monitor is an implantable patientactivated and automatically activated monitoring system that records
More informationPalpitations & AF. Richard Grocott Mason Consultant Cardiologist THH NHS Foundation Trust & Royal Brompton & Harefield NHS Foundation Trust
Palpitations & AF Richard Grocott Mason Consultant Cardiologist THH NHS Foundation Trust & Royal Brompton & Harefield NHS Foundation Trust Palpitations Frequent symptom Less than 50% associated with arrhythmia
More informationPAH. Salman Bin AbdulAziz University College Of Pharmacy 22/01/35
Salman Bin AbdulAziz University College Of Pharmacy PAH Therapeutics II PHCL 430 Ahmed A AlAmer PharmD R.W. is a 38-year-old obese woman who presents with increasing symptoms of fatigue and shortness of
More informationHow To Treat Aortic Stenosis
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Developed in Collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, Society
More information