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The central arterial pulses. This may sufficiently stretch the myocytes Frank—Starling physiology to improve the the ejection fraction of the next heart beat.
Third heart sound S3 Due to the passive filling of the ventricles on opening of the atrioventricular AV valves. It is typically palpable in the fifth intercostal space in the midclavicular line.
Pathological in cases of rapid left ventricular filling eg mitral regurgitation. HCM and left. Fourth heart sound S4 Due to the atrial contraction that fills a stiff left ventricle. Severe aortic stenosis Splitting Fixed: ASD Widely split: Electrocardiography ECG strips illustrating typical changes in common disease states are shown in Figure 1. Opening snap In mitral stenosis an opening snap OS can be present and occurs after S2 in early diastole.
It is absent in atrial fibrillation. The causes of common abnormalities are given in the box below. Axes are defined as: The closer it is to S2 the greater the severity of mitral stenosis. It is absent when the mitral cusps become immobile due to calcification.
As the overall vector is predominantly towards the bulkier left ventricle in normal situations. Recognition of positive tall R waves in V1 can be the only sign with a typical history. This lead largely faces the posterior wall of the left ventricle and the mass of the right ventricle. This balance can be reversed in the following situations: Posterior infarctions are easily missed because the rest of the ECG can be normal.
In contrast to RBBB. LBBB is always pathological. During the hyperacute and acute phases of cerebral events. Bundle-branch block and ST-segment abnormalities Complete bundle-branch block is a failure or delay of impulse conduction to one ventricle from the AV node.
These changes result from abnormal autonomic discharges due to intense sympathetic nervous activation. T inversion and peaking downsloping ST depression ST depression. T inversion ST depression. Digoxin therapy: Cardiac contusion: Mitral valve prolapse: Acute cerebral event eg subarachnoid haemorrhage: Electrolyte abnormalities ST depression.
T inversion T-wave inversion ST depression. T inversion Q waves can be permanent reflecting myocardial necrosis or transient suggesting failure of myocardial function. T inversion and peaking ST depression. At the onset of symptoms the monitor is placed to the chest and this records the ECG Wearable loop recorders: The device records the ECG constantly on a self-erasing loop.
At the time of symptoms. The patient is encouraged to keep a diary in order to correlate symptoms with ECG changes External recorders: Again the ECG data from several seconds before symptoms to several minutes after are stored. The recorder is activated by the patient or according to pre-programmed parameters. The battery life of the implantable loop recorder varies between 18—36 months.
Stress images are then acquired in the long-axis and short-axis views at moderate and peak heart rates and compared with resting images. Diagnostic uses of echocardiography Conventional echocardiography is used in the diagnosis of: Doppler measurements: The signal-to-noise ratio is improved by minimising the distance and number of acoustic structures between the transducer and the object being recorded.
This helps identify and quantify valvular regurgitation. Colour Doppler: Stress echo is used in the diagnosis of myocardial viability and ischaemia. This allows identification of anatomy and structural abnormalities. Moving structures including fluid structures reflect sound back as a function of their own velocity. Newer probes can produce three-dimensional images to better visualise defects.
Regional wall motion abnormalities such as hypokinesia. Resting images are acquired and then stress is induced. It allows calculations of left atrial LA size.
Contrast may be required for optimal myocardial definition — it appears bright. These are typically made in the parasternal long-axis view. Two-dimensional echocardiography: Velocities can be measured along the length of the Doppler beam continuous-wave Doppler.
Tissue Doppler imaging is a new technique that applies Doppler principles to analyse the velocity of myocardial motion. It is indicated in the diagnosis of aortic dissection when a CT aortogram is delayed. Transoesophageal echocardiography TOE is performed under general anaesthesia or in sedated patients with local anaesthetic applied to the oropharynx. Values will vary according to the site. Three-dimensional echocardiography has increasing clinical application in better understanding structural anatomy.
M-mode imaging is now used less in clinical practice. This is particularly useful for planning therapy to valvular heart disease. Tissue Doppler differs from conventional Doppler. It has particular usefulness in congenital heart disease.
It can be performed using either transthoracic or transoeophageal approaches. Intravascular ultrasonography IVUS is performed by placing a small probe mounted on a catheter on an intracoronary wire during coronary angioplasty. Standard contrast echo is used in the diagnosis of right-to-left shunts. Each wall will have a unique pattern of velocities. Intracardiac ultrasonography images the heart chambers from within.
The probe is passed into the oesophagus. It is also used to diagnose LV thrombus and other specific conditions eg the congenital failure of muscle fibre alignment [known as non-compaction] and apical hypertrophy.
Often imaging is performed during the procedure to guide valve placement. It provides high-resolution imaging of coronary arteries for measurement of stenosis severity and plaque characteristics. It may also be indicated when transthoracic images are suboptimal.
Classic M-mode patterns Due to improvements in real-time image quality. Transpulmonary contrast echo is used to improve discrimination between the blood pool and the endocardium to help definition in those individuals whose characteristics lead to poor image quality. Tracer uptake is detected using tomograms and displayed in a colour scale in standard views. Lack of uptake may be: Pathological perfusion defects are categorised as fixed scar and reversible viable but ischaemic tissue.
MPI can be used to: IVUS and optical coherence tomography OCT are intracoronary tools used to visualise the stenosis severity and estimate the lumen area occupied by atherosclerotic plaque. Percutaneous coronary intervention PCI can be performed immediately after coronary angiography or at a later occasion. Coronary and ventricular angiography Direct injection of radio-opaque contrast into the coronary arteries allows high-resolution assessment of restrictive lesions and demonstrates any anomalies.
Imaging is acquired by fluoroscopy. Multiple different radiographic views are required to view each vessel. Intervention is most commonly performed for the treatment of coronary obstruction in acute coronary syndrome. Left ventriculography provides a measure of ventricular systolic function. The severity of a stenosis can be gauged visually. Angiography is typically performed via the femoral artery or radial artery through a sheath that allows insertion of specifically designed catheters that intubate the coronary vessels.
The lumen is carefully assessed for narrowings or stenoses. Complications of cardiac catheterisation. The contrast provides an image of the vessel lumen but the other parts of the vessel are poorly visualised.
Contrast can be hand injected or injected by automated pumps. It involves the treatment of stenoses using balloon inflation and stent deployment. The main contraindications to exercise testing include those conditions where fatal ischaemia or arrhythmias may be provoked. Vasovagal reactions are common. Indicators of a positive exercise test result The presence of each factor is additive in the overall positive prediction of coronary artery disease: Exercise tests also give diagnostic and prognostic information post-infarction.
Diagnostic sensitivity is improved if the test is conducted with the patient having discontinued antianginal especially rate-limiting medication. These include the following: Other complications are: CT coronary angiography has gained considerable attraction in the identification of coronary artery disease. More detailed scanning allows coronary arteries to be identified and followed in two-dimensional cross-sections.
Calcium scores can be calculated quickly. The negative predictive value is higher than the positive predictive value.
Specific areas of usefulness include the following situations: Increased speed. Exercise tests have low specificity in the following situations often as a result of resting ST-segment abnormalities: This enables identification of lesions that appear obstructive. Cervical venous hum: As such. Thirty per cent of children may have an innocent flow murmur. CT coronary angiography is typically used when patients have a low pre-test likelihood of coronary disease.
Limitations include its contraindication in patients with certain implanted devices eg pacemakers and time consequently also cost. Large arteriovenous fistula of the arm: The contrast used gadolinium. Effect of posture on murmurs: ECG or chest radiograph abnormalities.
Chief indications for cardiac MRI: Squatting and passive leg raising increase cardiac afterload and therefore decrease the murmur of HCM and mitra valve prolapse. Effect of respiration on murmurs: Treatment can be percutaneous balloon valvuloplasty or surgical limited mitral valvotomy — now rarely performed in developed nations — or open valve replacement. A normal mitral valve has a valve area of 4—6 cm2: Rarer causes include congenital disease.
The most common cause remains chronic rheumatic heart disease. Twothirds of patients presenting with this are women. Rheumatic heart disease originating in the UK is now exceptionally rare. Various techniques have revolutionised mitral valve surgery. Functional mitral regurgitation MR is a term used to describe MR that is caused by stretching of the annulus secondary to ventricular dilatation.
In skilled surgical hands the repair is tailored to the precise anatomical abnormality. The presence of symptoms and increasing left ventricular dilatation are indicators for surgery in the chronic setting. Often there is myxomatous degeneration and redundant valve tissue due to deposition of acid mucopolysaccharide material. Several conditions are associated with mitral valve prolapse see below. Squatting increases the click and standing increases the murmur. Sequelae of mitral valve prolapse: The patients are usually female and may present with chest pains.
Mitral valve prolapse is usually eminently suitable for mitral valve repair. Either can occur acutely or chronically. Acute causes. There are many echocardiographic criteria used to assess the severity of AR and none is ideal. Chronic causes allow time for the left ventricle to accommodate. At 10 years. In cases of biscuspid disease aortic regurgitation is more common. This abnormal valve has early onset degeneration with aortic stenosis presenting many years sooner than typical 40—50s versus 60—70s.
Bicuspid valves are also associated with an aortopathy and aortic root dilatation. The vulnerability to ventricular tachycardia is due to LVH Complete heart block: The pressure gradient is dependent not only on the severity of the stenosis. This can also occur post-operatively after valve replacement due to trauma Calcified emboli: Concomitant CABG should be considered at the time of valve replacement.
This means that the pressure gradient can be reduced when LV function is impaired. In these cases. Mechanical valves There are many different types of mechanical valves. A modern variant includes the Medtronic Hall valve Bileaflet valves: A variation designed in the s was prone to strut fracture with catastrophic embolisation and is now no longer manufactured. Patients have cyanosis and there is an association with pulmonary atresia or ASD and. All valve replacements have a residual transvalvular gradient across them.
Common ones are: Bjork—Shiley was the first. No need for long-term anticoagulation if patient is in sinus rhythm Homografts: These are the original mechanical valves. Other signs may be more prominent with an elevated JVP and giant c-V waves. Now the most commonly used valve type with many different manufacturers.
Mechanical valves are more durable but tissue valves do not require full lifelong anticoagulation. Causes of severe TR include the following: This risk is dose dependent and abnormalities include chondrodysplasia.
Heart failure secondary to valvular regurgitation or heart block may also occur. Signs of infective endocarditis As well as cardiac murmurs detected at auscultation. There is no agreed consensus on the ideal strategy: The risk of spontaneous abortion may be increased. See also Section 1. Earlier operations are undertaken only if clinically necessary as outcomes are poorer. Patients should be made aware of non-medical riskprone activities eg intravenous drug use.
ASDs are the most common congenital defects found in adulthood. The size of shunting and reduction in oxygenation will depend upon the size of the defect.
There may be a left parasternal heave and a pulmonary ESM due to increased blood flow. Investigations forASDs Right atrial and right ventricular dilatation may be seen on any imaging technique. Surgical closure is recommended with pulmonary: Closure of secundum defects may be performed via cardiac catheterisation. Other characteristic features are: There are three main subtypes: Fixed splitting of the second heart sound is the hallmark of an uncorrected ASD. Holt—Oram syndrome triphalangeal thumb with ASD: It is associated with absence or reduction anomalies of the upper arm.
There may be a history of headaches. Debate continues about the value of closing PFOs. Indications for closure: Upon birth. During fetal development and while the placenta provides oxygenation. Defects can occur in either. In a quarter of adults. Patent foramen ovale A PFO is a channel within the interatrial septum. Most defects are small. Stroke may occur in young patients.
PFOs are visualised on echocardiography using bubble contrast. Spontaneous closure is more common in muscular defects but either can be closed by a percutaneous or surgical approach. The apex beat is typically hyperdynamic. The connection occurs between the pulmonary trunk and the descending aorta. Surgery should occur earlier to avoid this situation. PDA often occurs with other abnormalities. The murmur may be ejection systolic in very small or very large defects.
With large defects the aortic component of the second sound is obscured. Balloon dilatation of the coarctation is typically focused on recurrent coarctation after surgery. Pulses distal to the obstruction are diminished and delayed with lower blood pressure in the legs.
End-to-end anastomosis is the preferred surgical technique but re-stenosis can occur. Heart failure. Echocardiography may be sufficient but MRI is definitive. The PDA may also be closed thoracoscopically or percutaneously. Berry aneurysms and bicuspid aortic valves should be sought as there are strong associations with coarctation. Treatment can be surgical or percutaneous. If severe. Barium swallows may demonstrate oesophageal compression from the post-stenotic dilatation of the aorta.
PGE1 can keep the ductus arteriosus patent to allow right-to-left shunting to the descending aorta while awaiting surgery. Collateral development can be significant and audible posteriorly.
Milder coarctation may present beyond infancy with hypertension. This causes shunts to reverse. Signs of development include: Long-standing left-to-right shunts eg in large VSDs. Catecholamines and hypoxaemia trigger spasm of the infundibulum. High-grade obstruction increases right-sided pressures. Typical presentation is with small for dates. The murmur lessens or disappears as the right ventricular outflow gradient increases During cyanotic episodes.
The infant becomes inconsolable and cyanosis and tachypnoea ensues Cyanotic attacks worsen with catecholamines. Parents should hold the infant against their shoulder. Infants may be stabilised on prostaglandins to maintain the patency of the ductus arteriosus and enable more elective surgery A Blalock-Taussigh shunt operation results in weaker pulses in the arm from which the subclavian artery is diverted to the pulmonary artery.
Single ventricular circulation Individuals born with only one functional ventricle are treated by redirecting the vena cavae directly into the pulmonary arteries total cavopulmonary correction and now do very well. Emergency treatment is necessary. Early versions of this operation the classic Fontan used the right atrium between the vena cavae. Effectively this is a complete correction.
In older children. Before the development of the arterial switch procedure. Common congenital circulations Common congenital circulations are summarised in Table 1. Modern practice favours total correction before 12 months.
These arrhythmias assume particular significance because of the stroke risk associated with them. Antiarrhythmic drugs or catheter ablation may be useful adjuncts to treatment or. Atrial flutter frequently coexists with AF and. High-grade AV block Mobitz 2 or complete is associated with sudden death and patients should be paced urgently even if asymptomatic.
Permanent pacing is very effective in reducing symptoms in most bradyarrhythmias. A bradyarrhythmia is a pathological bradycardia. Ventricular tachycardia and ventricular fibrillation are life-threatening conditions. Bradyarrhythmias are considered according to their prognostic significance and symptomatic impact. Thyroid function and electrolytes should be checked on presentation and corrected before considering pacemaker therapy.
Sinus node disease Sinus bradycardia and sinus pauses can cause syncope. If associated with syncope. Various drugs have been tried as treatment. Pacing is indicated only in significantly symptomatic cases as there is no prognostic benefit of pacing in sinus node disease.
It may be. In patients with a predominant cardioinhibitory component. Pacing is indicated on prognostic grounds even in asymptomatic individuals. If it occurs when the patient is awake and is associated with symptoms in older people.
Tachyarrhythmias Tachyarrhythmias are caused by re-entry. Associations with WPW include: Atrial tachycardias. This may lead to ventricular fibrillation. More seriously. Accessory pathways An accessory pathway that connects the atrium and ventricle mediates the tachycardia by enabling retrograde conduction from ventricle to atrium. This generates characteristic sawtoothed flutter waves. Atypical flutters tend to occur in congenital heart disease or after surgery or prior ablation.
Atrial flutter is described as typical when associated with a sawtooth atrial pattern in the inferior leads and positive flutter waves in V1. With AF. Atrial fibrillation This arrhythmia is due to multiple wavelet propagation in different directions. AF may be paroxysmal. TOE may exclude atrial appendage thrombus but cannot predict the development of a thrombus in the early stages post-cardioversion. Catheter ablation is indicated in symptomatic individuals who are resistant to.
The source of the arrhythmia may be myocardial tissue in the openings of the four pulmonary veins. Treatment is aimed at ventricular rate control. Online calculators can estimate the bleeding risk. After the exclusion of reversible causes such patients may need implantable defibrillators and antiarrhythmic therapy.
VT remains the most common cause of a broad-complex tachycardia. Pro-arrhythmic channelopathies Abnormally prolonged QT intervals may be familial or acquired. Causes and associations are shown below. QT prolongation can be genetic see below or acquired — and can be of any cause to trigger torsades de pointes: Antiarrhythmic agents particularly class III.
Mortality in the untreated symptomatic patient with a congenital abnormality is high but some patients may reach the age of 50—60 years despite repeated attacks. Ventricular tachycardia polymorphic — torsades de pointes This is a particular type of VT in which the QRS complexes are of different amplitudes.
DDD is now increasingly used. Jervell—Lange—Nielsen syndrome is autosomal recessive and associated with congenital deafness. These capabilities. If the pacing lead has perforated the septum.
Pacing post-cardiac surgery employs epicardial pacing wires. Complications include: Crossing the tricuspid valve during insertion. Temporary pacing for emergencies such as heart block is typically ventricular only. Long QT syndromes: Ninety per cent are familial.
The naming convention reflects the chamber paced. Cardiac causes of electromechanical dissociation When faced with a cardiac arrest situation it is important to appreciate the list of causes of electromechanical dissociation EMD: The aim is to optimise AV delay and reduce inter.
Patients may be dizzy. A recent randomised study in which dyssynchrony markers were used to select patients for CRT instead of the traditional parameters showed no benefit and significant harm.
This therapy is known to reduce mortality. Pacing in heart failure There are several synonymous terms for pacing in patients with cardiac failure.
Pacemaker syndrome is a constellation of symptoms related to even subtle impairment of cardiac output or change in peripheral resistance caused by suboptimal pacemaker settings. This allows sophisticated programming to optimise the device for the patient. They are implanted in a similar manner to permanent pacemakers. Studies have not shown benefit in heart failure patients with narrow QRS duration.
The atria and right ventricle are paced in the usual fashion and in addition to this a pacing electrode is placed in a tributary of the coronary sinus on the lateral aspect of the left ventricle. Implantable cardioverter defibrillators Implantable cardioverter defibrillators ICDs are devices that are able to detect life-threatening tachyarrhythmias and terminate them by overdrive pacing or a counter-shock. Optimisation of pacemaker settings for the individual patient is now a routine clinical activity during pacemaker checks.
In heart failure pacing is indicated when all of the following are present: Radiofrequency ablation Radiofrequency ablation is resistive. For example.
The two ventricles are paced simultaneously or near simultaneously with a short AV delay. They reduce rates of pacemaker syndrome and act more physiologically for active patients. Current evidence supports their use in both secondary prevention of cardiac arrest and targeted primary prevention eg for individuals with LV impairment and those with familial syndromes such as arrhythmogenic right ventricular dysplasia.
Complete heart block and pericardial effusions are rare complications of radiofrequency ablation. Excellent results are obtained in the treatment of accessory pathways and atrial flutter. Using cardiac catheterisation with electrodes in right. Ventricular tachycardia is technically more difficult to treat ventricular myocardium is much thicker than atrial myocardium.
Indications to refer to an electrophysiologist Indications for referral to an electrophysiologist are given in Table 1. Isolation of the pulmonary veins by ablation therapy is now an established technique to treat AF.
Smoking and its relationship to cardiovascular disease Smokers have an increased incidence of the following cardiovascular complications: STEMI has the highest risk of inhospital mortality. It can be intermittent or persistent. The diagnosis for all three requires ECG changes and an appropriate history with typical corresponding features. These accessory symptoms are rare in stable angina. Myocardial infarction Conservative estimates suggest there are MIs per year in the UK with significant prehospital mortality.
The chest pain is typically retrosternal or heaviness. The chest pain characteristic of an ACS is: Class III. This overlapping constellation of conditions helps identify patients at risk and needing further treatment. It may be associated with sweating. Patients are typically in pain. Biochemical markers of myocardial necrosis may have normalised. Diagnosis of MI Acute. Development of new pathological Q waves on serial ECGs.
Although patients can appear well. In general clinical practice. Patients may be medically managed but those with higher risk characteristics may undergo invasive assessment. Upcoming SlideShare. Like this presentation? Why not share! An annual anal Embed Size px. Start on. Show related SlideShares at end.
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