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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
Fatigue
Cyanosis
Pallor
Diaphoresis
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
cardiomyopathy.
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
fibrillation)
Precordial palpation
Parasternal lift, left ventricular apical impulse
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
failure
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
valves
Continuous: patent ductus arteriosus, coronary AV fistula, ruptured sinus of Valsalva
aneurysm
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
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
Clicks
Systolic, diastolic
Knocks
Pericardial
Snaps
Opening (OS): mitral, tricuspid
Electrocardiography
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
Chest radiography
Heart size pulmonary circulation (with characteristic signs: pulmonary artery or pulmonary venous
hypertension), primary pulmonary disease, aortic abnormalities
Echocardiography
Chamber size, motion, hypertrophy, pericardial effusions, valvular abnormalities (defects,
vegetations, congenital abnormalities, thormbus, tumor
transthoracic (TTE)
transoesophageal (TEE)
CT
The main application: evaluation of pericardial disease
MR
No radiation exposure. Excellent anatomic definition, assessment of pericardial disease, neoplastic
disease of the heart, myocardial thickness, chamber size, congenital heart defects
Nuclear imaging
Thallium-201
Technetium-99
Scintigraphy following dipyridamole or adenosine-induced vasodilatation
Biopsy
Myocarditis, amyloidosis