This document contains notes from a cardiologist on various topics: 1. The most common causes of congestive heart failure and signs on a chest x-ray. 2. Major risk factors for dilated cardiomyopathy and the triad seen in acute pericarditis. 3. The classic presentation of cardiac tamponade and differential diagnosis of an abnormal early diastolic sound. 4. How murmur intensity is affected by position changes in hypertrophic cardiomyopathy and the mechanism of pulsus paradoxus. 5. Causes of an increased QT interval and features of Wolff-Parkinson-White syndrome on an electrocardiogram.

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2. Medical notes in Cardiology

3. CARDIOLOGY NOTES
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4. • Most common causes of congestive heart failure:
1. Coronary artery disease (60- 70 % ) .
2. HTN .
3. Idiopathic (dilated cardiomyopathy ) .
4. Valvular ( AS , AR , MR ) .
5. Alcoholic ( dilated cardiomyopathy ).
• Features of heart failure on chest xray :
1. heart enlargement ( cardiothoracic ratio > 50 % ) .
2. Pleural effusion .
3. redistribution (alveolar edema ) .
4. Kerly B lines .
5. Brochiolar - alveolar cuffing .
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5. • Major risk factors for dilated cardiomyopathy ⇒ Alcohol , cocaine , family history .
• Acute pericarditis triad :
1. Chest pain .
2. Friction rub .
3. ECG changes .
• Classic presentation of tamponade ⇒
1. Hypotension .
2. Increased JVP .
3. Pulsus paradoxus .
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6. • What is the differential diagnosis of an abnormal early diastolic
sound heard at the apex and lower left sternal border?
1. Loud P2 .
2. S3 gallop .
3. OS (opening snap) .
4. Pericardial knock .
5. Tumor plop (atrial myxoma)
6. An early diastolic sound may be due to wide splitting of S2, with
or without a loud pulmonary closure sound. An ASD causes wide
and fixed splitting of S2.
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7. • How do standing, squatting, and leg-raising affect the intensity and
duration of the systolic murmur heard on dynamic auscultation in a
patient with hypertrophic cardiomyopathy ?
• Standing increases the murmur intensity, and leg-raising and
squatting decrease the murmur intensity. In HCM, a decrease in
the size of the LV increases the dynamic LV outflow obstruction,
leading to an increased intensity of the murmur. A decrease in LV
volume occurs on standing. In contrast, leg-raising and squatting
increase venous return and thereby increase LV volume,
decreasing the dynamic LV obstruction and the murmur intensity.
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8. • Describe the mechanism of a pulsus paradoxus.
• Pulsus paradoxus can occur when the fall in intrathoracic
pressure during inspiration is rapidly transmitted through a
pericardial effusion, resulting in an exaggerated increase in
venous return to the right side of the heart. The increased
venous return causes bulging of the interventricular septum
toward the LV, resulting in a smaller LV volume and a smaller LV
stroke volume. The decreased LV stroke volume results in a
lower cardiac output and lower systolic BP during inspiration. A
drop in systolic BP is a normal physiologic finding as long as this
drop does not exceed 10 mm Hg. In contrast, an exaggerated
drop in systolic BP > 10 mm Hg is a pathologic finding
characteristic of cardiac tamponade.
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9. • What do you know about cardiac tamponade?
• The sudden accumulation of fluid within the pericardial
sac under pressure. When the clinical triad of cardiac
tamponade was first described by Claude Beck in 1935,
he noted hypotension, elevated systemic venous
pressure, and a small, quiet heart. The condition was
commonly due to penetrating cardiac injuries, aortic
dissection, or intrapericardial rupture of an aortic or
cardiac aneurysm. Today, the most common causes are
neoplastic disease, idiopathic pericarditis, acute MI, and
uremia.
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10. Q-T INTERVAL
This represents the duration of ventricular depolarization and
repolarization .
• Causes of increased Q.T (>450 msec for males and >460 msec for females):
risk for Torsades de Pointes (a lethal tachyarrhythmia)
1. genetic Long QT Syndrome (often a channelopathy) .
2. drugs: antibiotics, SSRIs, antipsychotics, antiarrhythmics .
3. electrolytes: low Ca2+, low Mg2+, low K+ .
4. others: hypothyroidism, hypothermia, cardiomyopathy .
• Decreased in : electrolytes: high Ca++ ,drugs: digoxin , others:
hyperthyroidism
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11. WOLFF-PARKINSON-WHITE SYNDROME
• congenital defect present in 1.5-2/1,000 of the general population .
• An accessory conduction tract (Bundle of Kent; can be in right or left atrium)
abnormally allows early electrical activation of part of one ventricle .
• Impulses travel at a greater conduction velocity across the Bundle of Kent
thereby effectively ‘bypassing’ AV node .
• Since the ventricles are activated earlier, the ECG shows early ventricular
depolarization in the form of initial slurring of the QRS complex – the so-
called “delta wave” .
• Atrial impulses that conduct to the ventricles through both the
Bundle of Kent and the normal AV node/His-Purkinje system
generate a broad “fusion complex” .
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12. WOLFF-PARKINSON-WHITE SYNDROME
• ECG featurs in WPW :
1. PR interval < 120 msec .
2. Widening of the QRS complex due to premature activation .
3. delta wave: slurred upstroke of the QRS (the leads with the
delta wave vary with site of bypass)
4. secondary ST segment and T wave changes .
5. tachyarrhythmias may occur .
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