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procedures in cardiology
Common symptoms
Dyspnea. Paroxysmal nocturnal dyspnea: Relieved by sitting up standing. It is more specific
cardiac disease
Chest pain. Characteristics of myocardial ischemia: dull, aching, sensation of pressure or
tightness, commonly accompanied by anxiety or uneasiness. Protracted episodes suggest
myocardial infarction Location: retrosternal or precordial. (The pain nearly always involves
the sternal region.) Radiation: throat, lower jaw, shoulders, inner arms, upper abdomen or
back Precipitation: exertion, cold temperature, meals, stress, or combinations of these
factors, usually relieved by rest.
Palpitation, dizziness, syncope

General examination of a patient with suspected heart disease

Vital signs: respiratory rate, pulse, blood pressure
Skin color (e.g., cyanosis, pallor), clubbing, edema
Evidence of decreased perfusion (cool and sweaty skin)
Hypertensive changes in optic fundi
Abdomen for evidence of hepatomegaly, ascites, or abdominal aortic aneurysm
An ankle-brachial index (systolic bp at ankle divided by arm systolic bp) <0.9 indicates lower
extremity arterial obstructive disease.

Physical examination

Peripheral pulse
Radial, carotid, etc. pulse

Pulsus parvus: Weak upstroke due to decreased stroke volume (hypovolemia, LV failure,
aortic or mitral stenosis).
Pulsus tardus (plateau pulse): Delayed upstroke (aortic stenosis).
Bounding (hyperkinetic) pulse: Hyperkinetic circulation, aortic regurgitation, patent ductus
arteriosus, marked vasodilatation.
Pulsus bisferiens: Double systolic pulsation in aortic regurgitation, hypertrophic
Pulsus alternans: Regular alteration in pulse pressure amplitude (severe LV dysfunction).
Pulsus paradoxus: Exaggerated inspiratory fall (>10 mmHg) in systolic bp (pericardial
tamponade, severe COPD).
Pulsus bigeminus (coupled rhythm): The intervals between members of the couplet are
shorter than the time between the pairs.
Inequality of contralateral pulses: aneurysm, partial obstruction
Pulse deficit: Difference between rates counted over the heart and peripheral arteries (atrial

Jugular venous pulsation

Precordial palpation
Parasternal lift, left ventricular apical impulse

Vital signs: heart rate, blood pressure, tachypnea, periodic breathing

Pulmonary examination
Rales heard at lung bases congestive heart failure localized pulmonary disease
Wheezing and rhonchi: COPD, left heart failure
Pleural effusion: bibasilar percussion dullness, reduced breath sounds, congestive heart

Heart sounds
S1, S2, S3, S4

Heart mumurs
Systolic murmurs
Ejection type: aortic outflow tract, aortic valve stenosis. hypertrophic obstructive
cardiomyopathy, aortic flow murmur, pulmonary outflow tract, pulmonic valve stenosis,
pulmonic flow murmur
Holosystolic: mitral regurgitation, tricuspid regurgitation, ventricular septal defect
Late-systolic: mitral or tricuspid valve prolapse

Diastolic murmurs
Early diastolic: aortic or valve regurgitation, pulmonic valve regurgitation
Mid-to-late diastolic: mitral or tricuspid stenosis, flow murmur across mitral or tricuspid
Continuous: patent ductus arteriosus, coronary AV fistula, ruptured sinus of Valsalva

Auscultatory findings
Mitral stenosis

1. Accentuated S1
2. Opening snap
3. Early-mid diastolic murmur, maximally heard on the apex, radiates towards the left axilla,
intensified when th patients is on his left side, with knees bent
4. This murmur accentuates presystolically (not when atrial fibrillation is present)

Mitral regurgitation
Holosystolic, ribbon-like murmur, maximally heard on the apex, radiates towards the left
axilla, intensified when th patients is on his left side, with knees bent

Aortic stenosis

Crescendo-decrescendo (diamond-shaped) systolic murmur, maximally heard over the aorta,

radiates towards the neck
Pulsus tartus et parvus

Aortic regurgitation

Early diastolic, decrescendo murmur, maximally heard over the aorta, radiates towards the
apex. Intensified in vertical position
Pulsus celer et altus
RR(syst) increases, RR(diast) decreases: e.g., 200/60 mmHg

Systolic, diastolic


Opening (OS): mitral, tricuspid

Conventional: coronary disease, disturbances of rate and rhythm, conduction defects,
electrolyte imbalance, drug effects
Ergometry: Sensitivity:60-80%, specificity: 80-90%
24 hour monitoring (Holter): detects ischemia, arrhythmia or conduction defect
Electrophysiologic testing
Trans-teelphonic ECG

Ambulatory blood pressure monitoring (ABPM)

Chest radiography
Heart size pulmonary circulation (with characteristic signs: pulmonary artery or pulmonary venous
hypertension), primary pulmonary disease, aortic abnormalities

Chamber size, motion, hypertrophy, pericardial effusions, valvular abnormalities (defects,
vegetations, congenital abnormalities, thormbus, tumor

transthoracic (TTE)
transoesophageal (TEE)

Color Doppler to detect flow velocity

The main application: evaluation of pericardial disease

No radiation exposure. Excellent anatomic definition, assessment of pericardial disease, neoplastic
disease of the heart, myocardial thickness, chamber size, congenital heart defects

Cardiac catheterization and angiography

Coronary angiography, intravascular stent
Intracardiac shunts, valvular lesions

Nuclear imaging
Scintigraphy following dipyridamole or adenosine-induced vasodilatation

Reversible perfusion defect signifies myocardial ischemia

Positron emission tomography (PET)

Qualitative and quantitative information concerning myocardial metabolism and blood flow

Myocarditis, amyloidosis

Examination of the peripheral vessels

pulse palpation
ankle/arm index

Special tests for the evaluation of peripheral vessels disease

Doppler echography
Color doppler echography
CT contrast material
MRI contrast material