PAINE #PANCE Pearl – Cardiovascular



Question

 

64yo male, with a history of HTN, DMII, and hyperlipidemia, is brought in by EMS to the ED with a 2 hour history of lightheadedness and palpitations.  He states both these symptoms seem to fluctuate and nothing seems to make them better or worse when they occur.  He has never had anything like this before.  He denies syncope, chest pain, dyspnea, nausea, vomiting, diaphoresis, or vision changes.

 

Medications

Lisinopril 10mg

Metformin 1000mg

Simvastatin 20mg

 

Physical Exam

General – NAD, A&Ox3

HEENT – no diaphoresis, no gaze deviation, no facial palsies

CV – irregular, no M/G/R

Pulm – CTA bilaterally

MSK – 5/5 strength throughout

Neuro – CN II-XII grossly intact, MAE

 

While getting set up for a formal 12 lead EKG, the paramedic hands you the rhythm strips from transport:

 

What is the diagnosis????

 



Image result for sick heart yeti

 

Answer – Sick Sinus Syndrome

 

Definition

SSS is characterized by chronic sinoatrial node dysfunction with chronotropic incompetence and inappropriate heart rate responses to physiologic demands.  Classically, patients have bouts of bradycardia, tachyarrythmias, and sinus pauses or arrests.

 

Signs and Symptoms

  • fatigue
  • lightheadedness
  • palpitations
  • pre-syncopy and/or syncope

 


References

  1. Jensen PN, Gronroos NN, Chen LY. Incidence of and risk factors for sick sinus syndrome in the general population. Journal of the American College of Cardiology. 2014; 64(6):531-8. [pubmed]

Ep-PAINE-nym



Mobitz, Wenckebach, and Hay AV Blocks

 

Other Known AliasesSecond degree AV blocks

 

DefinitionSecond degree AV block refers to the inability of the P-wave to initiate a QRS complex.  In Type I (Wenckebach), there is progressive elongation of the PR interval until a beat is dropped.

Image result for mobitz type I

In Type II (Hay), there is no progressive elongation, but there are dropped beats.

Image result for mobitz type II

 

Clinical SignificanceMobitz Type I is generally considered a benign entity due to absence of structural changes on histology.  Mobitz Type II is concerning because it can progress to a complete heart block with sudden cardiac arrest.

 

History – Named after Woldemar Mobitz (1889-1951), who was a Russian-German physician and earned his doctorate of medicine in 1914 from the Universities of Freiburg and Munich.  He researched heart block extensively in the early 1900’s which culminated in his landmark paper in 1924, where he classified the two distinct types of second degree heart block. 

Woldemar Mobitz The Apical View The Journey Continues To the end of the

Woldemar Mobitz

 

Interestingly, these two types were already described by:

1) Karel Frederik Wenckebach (1864-1940), who was a Dutch physician and anatomist in Hague and recieved his medical doctorate from the University of Groningen.  He published his findings of a irregular pulses due to partial blockage of the AV conduction system causing progressive lengthening of conduction time in cardiac tissue in 1899.

Wenckebach1.jpg

2) John Hay (1873-1959), who was an English physician and received his medical doctorate from Victoria University of Manchester in 1901.  He first described what would become Type II AV block in 1905 in a 65yo man with a 2.5 year history of dyspnea on exertion.  Interestingly, he did this without the benefit of elctrocardiography.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Silverman ME, Upshaw CB, Lange HW. Woldemar Mobitz and His 1924 classification of second-degree atrioventricular block. Circulation. 2004; 110(9):1162-7. [pubmed]
  6. Mobitz W. Über die unvollständige Störung der Erregungsüberleitung zwischen Vorhof und Kammer des menschlichen Herzens. Zeitschrift für die Gesamte Experimentelle Medizin, Berlin 1924, 41: 180–23.
  7. Wenckebach KF. De Analyse van den onregelmatigen Pols. II. Over eenige Vormen van Allorhythmie en Bradycardie. Nederl Tijdschr Geneesk 1899;35:665.
  8. Hay J. Bradycardia and cardiac arrhythmia produced by depression of certain of the functions of the heart. The Lancet 1906, 1: 139–143
  9. Upshaw CB, Silverman ME.  John Hay: Discoverer of Type II Atrioventricular Block.  Clin Cardiol.  2000;23:869-871

#38 – Cardiac Murmurs



***LISTEN TO THE PODCAST HERE***

 



Aortic Stenosis

 

Causes

  • Congenitally abnormal valve (bicuspid)
  • Calcific disease –> most common in US
  • Rheumatic valve disease –> most common world wide

Signs and Symptoms

  • Dyspnea on exertion
  • Exertional dizziness or syncope
  • Angina

Description

  • High-pitched, crescendo-decrescendo (diamond shaped), midsystolic murmur
  • Soft S2
  • S4 may be present

Best Auscultation Position

  • Right 2nd intercostal space

Special Notes

  • Radiate to carotid arteries

Aortic Regurgitation

 

Causes

  • Aortic root dilation
  • Congenital bicuspid valve
  • Calcific disease
  • Rheumatic heart disease –> most common world wide

Signs and Symptoms

  • Exertional angina and yspnea
  • Symptoms of heart failure
    • PND, orthopnea, pulmonary edema, lower extremity edema
  • Laterally and inferiorly displaced PMI with a thrill

Description

  • Soft, high-pitched, early diastolic, decrescendo murmur
  • Soft S1 with soft/absent A2
  • S3 may be present

Best auscultation position

  • Left 3rd intercostal space near sternal border (Erb’s point)

Special Notes

  • Accentuated by patient sitting up and leaning forward at end expiration

Mitral Stenosis

 

Causes

  • Rheumatic heart disease is most common causes
  • Mitral annular calcification
  • Radiation associated-valve disease (Hodgkin’s lymphoma)

Signs and Symptoms

  • Exertional dyspnea
  • Decreased exercise tolerance
  • Hemoptysis (increased pulmonary pressure)
  • Angina
  • Fatigue
  • Atrial fibrillation (elevated left atrial pressure)
  • Hoarseness

Description

  • Opening snap with low-pitched, diastolic murmur
  • Decrescendo after S2
  • Late, diastolic, crescendo before S1
  • Loud S1

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Patient in left lateral decubitus in held expiration
  • Using the bell

Mitral Regurgitation

 

Causes

  • Primary
    • Degenerative mitral valve disease à most common in US
      • Mitral valve prolapse
    • Rheumatic heart disease
    • Infective endocarditis
    • Trauma
    • Congenital valve cleft
    • Mitral annular calcification
  • Secondary
    • Coronary artery disease (regional wall motion abnormality)
    • Dilated cardiomyopathy
    • Hypertrophic cardiomyopathy

Signs and Symptoms

  • Exertional dyspnea
  • Fatigue
  • Atrial fibrillation
  • Heart failure

Description

  • High-pitched “blowing”, holosystolic murmur
  • Diminished S1

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Radiates to axilla
  • No variability in respiration
  • Decreases in intensity with valsalva

Mitral Valve Prolapse

 

Causes

  • Primary
    • Sporadic (myxomatous degeneration)]\
    • Familial (autosomal dominant with incomplete penetration)
      • 30-50% in 1st degree relatives
  • Secondary
    • Connective tissue disorders
    • 23CVInfective endocarditis
    • Coronary artery disease

Signs and Symptoms

  • Palpitations
  • Dyspnea
  • Exercise intolerance
  • Dizziness or syncope
  • Panic and anxiety disorders
  • Numbness or tinging

Description

  • Midsystolic click followed by a uniform, high-pitched, late systolic murmur

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Responds to dynamic auscultation
    • Increased in sudden standing
    • Decreased in sudden squatting

Tricupsid Stenosis

 

Causes

  • Rheumatic heart disease
  • Atrial myxoma
  • Carcinoid syndrome

Signs and Symptoms

  • Abdominal discomfort
    • Hepatic congestion and heptomegaly
  • Fluttering sensation in neck caused by jugular venous pulse
  • JVD, ascites, peripheral edema

Description

  • Soft, high-pitched, mid-diastolic

Best auscultation position

  • 4th intercostal space on the sternal border

Special Notes

  • Increased during inspiration, squatting, or leg raise

Tricuspid Regurgitation

 

Causes

  • Functional
    • Dilation of right atrium and ventricle with dilation of tricuspid annular leaflet
      • Pulmonary hypertension, left-sided heart failure, left-to-right shunt
  • Valvular
    • Valve damage from pacemaker or ICD
    • Infective endocarditis
    • Rheumatic heart disease
    • Ischemic heart disease

Signs and Symptoms

  • Majority are symptomatic
  • Right-sided heart failure
    • Hepatomegaly, hepatic congestion, ascites, hepatic venous hum, JVD, edema

Description

  • High-pitched, holosystolic murmur

Best auscultation position

  • 4th intercostal space on the sternal border

Special Notes

  • Radiates to right sternal border
  • Increases with inspiration, leg raises, or squatting

Pulmonic Stenosis

 

Causes

  • Congenital (10% of children with congenital heart disease)
    • Tetralogy of Fallot
    • Noonan Syndrome
  • Bicuspid valves
  • Calcification

Signs and Symptoms

  • Exertional dyspnea
  • Right heart failure

Description

  • Midsystolic, high-pitched, crescendo-decrescendo
  • Pulmonary ejection click
  • Extends through the A2
  • Splitting of S2

Best auscultation position

  • Left 2nd intercostal space

Special Notes

  • Increased during inspiration

Pulmonic Regurgitation

 

Causes

  • Primary
    • Iatrogenic, infectious, rheumatic, congenital
  • Secondary
    • Pulmonary artery hypertension and/or dilation
  • Physiologic (incidental)

Signs and Symptoms

  • Asymptomatic until right ventricular dysfunction occurs
    • Exertional dyspnea, fatigue
    • Tachyarrythmias

Description

  • Soft, high-pitched, early diastolic decrescendo
  • Graham-Steele murmur (pulmonary HTN)
    • High-pitched, blowing with accentuated P2

Best auscultation position

  • Left 2nd intercostal space

Special Notes

  • Increased with inspiration

S3 (ventricular gallop)

 

Causes

  • Large amount of blood hitting a very compliant left ventricle
    • Systolic heart failure

Description

  • Low-pitched, early diastolic sound
  • Occurs after S2

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Present with bell and absent with diaphragm

S4 (atrial gallop)

 

Causes

  • Blood striking a non-compliant left ventricle
    • Diastolic heart failure, LVH

Description

  • Low-pitched, late-diastolic murmur

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Present with bell and absent with diaphragm



Cottage Physician

 



References

  1. Eveborn GW, Schirmer H, Heggelund G, Lunde P, Rasmussen K. The evolving epidemiology of valvular aortic stenosis. the Tromsø study. Heart (British Cardiac Society). 2013; 99(6):396-400. [pubmed]
  2. Enriquez-Sarano M, Tajik AJ. Clinical practice. Aortic regurgitation. NEJM. 2004; 351(15):1539-46. [pubmed]
  3. Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aetiology and natural history of acquired mitral valve stenosis. European heart journal. 1991; 12 Suppl B:55-60. [pubmed]
  4. Hull MC, Morris CG, Pepine CJ, Mendenhall NP. Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of hodgkin lymphoma treated with radiation therapy. JAMA. 2003; 290(21):2831-7. [pubmed]
  5. Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet (London, England). 2009; 374(9697):1271-83. [pubmed]
  6. Freed LA, Benjamin EJ, Levy D. Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study. Journal of the American College of Cardiology. 2002; 40(7):1298-304. [pubmed]
  7. Strahan NV, Murphy EA, Fortuin NJ, Come PC, Humphries JO. Inheritance of the mitral valve prolapse syndrome. Discussion of a three-dimensional penetrance model. The American journal of medicine. 1983; 74(6):967-72. [pubmed]
  8. Sagie A, Schwammenthal E, Padial LR, Vazquez de Prada JA, Weyman AE, Levine RA. Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients. Journal of the American College of Cardiology. 1994; 24(2):446-53. [pubmed]
  9. Snellen HA, Hartman H, Buis-Liem TN, Kole EH, Rohmer J. Pulmonic stenosis. Circulation. 1968; 38(1 Suppl):93-101. [pubmed]
  10. Nishimura RA, Otto CM, Bonow RO. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014; 63(22):e57-185. [pubmed]
  11. Ozawa Y, Smith D, Craige E. Origin of the third heart sound. II. Studies in human subjects. Circulation. 1983; 67(2):399-404. [pubmed]
  12. Abrams J. Current concepts of the genesis of heart sounds. II. Third and fourth sounds. JAMA. 1978; 239(19):2029-30. [pubmed]
  13. Learn The Heart. https://www.healio.com/cardiology/learn-the-heart

PAINE #PANCE Pearl – Cardiovascular



Question

 

64yo male, with a history of HTN, DMII, and hyperlipidemia, is brought in by EMS to the ED with a 2 hour history of lightheadedness and palpitations.  He states both these symptoms seem to fluctuate and nothing seems to make them better or worse when they occur.  He has never had anything like this before.  He denies syncope, chest pain, dyspnea, nausea, vomiting, diaphoresis, or vision changes.

 

Medications

Lisinopril 10mg

Metformin 1000mg

Simvastatin 20mg

 

Physical Exam

General – NAD, A&Ox3

HEENT – no diaphoresis, no gaze deviation, no facial palsies

CV – irregular, no M/G/R

Pulm – CTA bilaterally

MSK – 5/5 strength throughout

Neuro – CN II-XII grossly intact, MAE

 

While getting set up for a formal 12 lead EKG, the paramedic hands you the rhythm strips from transport:

 

What is the most likely diagnosis?

 

Ep-PAINE-nym



Corrigan’s Pulse

 

Other Known AliasesWatson’s water hammer pulse

DefinitionRefers to a pulse that is bounding and forceful, but also rapidly collapsing, resembling a Victorian water hammer toy.

Clinical SignificanceThis abnormality is due to increased stroke volume of the left ventricle and decrease in the peripheral resistance seen with aortic regurgitation.  Corrigan’s pulse classically refers to bounding carotid arteries and Watson’s water hammer pulse refers to radial arteries.

History – The two namesake’s for these findings are:

Sir Dominic John Corrigan (1802-1880), who was an Irish physician, received his medical doctorate from University of Edinburgh in 1825.  He was best known for his work ethic and experiments to further the knowledge of the symptomatology of heart disease.  He was also the first 5 time president of the Irish College of Physicians.  He published his findings of this pulse in 1832.

Dominic John Corrigan2crop.jpg

 

Sir Thomas Watson (1792-1882), was a British physician, received his medical doctorate from Cambridge University in 1825 and was inducted into the Royal College of Physicians in 1826.  He served as president from 1862-1866.  He studied and followed Corrigan’s work on the carotid artery findings in aortic regurgitation and studied the peripheral manifestations, which he published in 1844.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Suvarna JC. Watson’s water hammer pulse. Journal of postgraduate medicine. 2008;54(2):163-5. [pubmed]
  6. Corrigan DJ. On permanent patency of the mouth of the aorta, or inadequacy of the aortic valves. The Edinburgh Medical and Surgical Journal. 1832;37: 225-245

PAINE #PANCE Pearl – Cardiovascular



Question

 

What is the most common congenital heart defect seen in adults?

  • Ventricular Septal Defect (VSD)
  • Atrial Septal Defect (ASD)
  • Coarctation of the Aorta
  • Tetralogy of Fallot

 


Answer

 

Atrial septal defect (ASD) is the most common congenital heart defect that will be first diagnosed in adulthood with an incidence around 13% of all congenital heart defects.  Most are asymptomatic and are found during routine physical exams, by a presence of a murmur, or incidentally due to increased use of echocardiography in the clinical setting.


References

  1. Facts about Atrial Septal Defect.  Centers for Disease Control. 2016. https://www.cdc.gov/ncbddd/heartdefects/atrialseptaldefect.html
  2. Krasuski RA. Congenital Heart Disease in the Adult. Cleveland Clinic. 2010.  http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/congenital-heart-disease-in-the-adult/
  3. van der Linde D, Konings EE, Slager MA. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. Journal of the American College of Cardiology. 2011; 58(21):2241-7. [pubmed]

Ep-PAINE-nym



Starr-Edwards Valve

 

Other Known Aliasescaged-ball artificial heart valve

DefinitionOne of the first types of artificial heart valves produced.  When the pressure in the ventricle of the heart exceeds the pressure outside the ventricle, the ball is pushed against the cage and blood flows in.  After contraction, the pressure inside the ventricle drops below the outside of the ventricle and the ball moves back against the base, forming the seal.

Clinical SignificanceThis type of valve was one of the first to have long-term survival and you may still encounter these valves today because they were just discontinued in 2007.  Due to the make-up of the valve, patients needed to have INR levels from 2.5-3.5 to prevent thrombosis.

History – Named after Albert Starr (1926-) and Lowell Edwards (1898-1982), who were both noted American cardiovascular surgeons.  It was an interesting partnership as Starr was 30 years junior to Edwards at their initial meeting, but both had a passion for valvular research and worked well together.  The 1st valve was placed in August of 1960 and they went on to replace mitral valves in 8 patients that year and published their results in 1961.  This paper was voted one of the top 100 manuscripts of the 20th century and revolutionized valve surgery.

Related image

Edwards (Left) and Starr (Right)

Image result for albert starr

Starr (suit, middle)

scanned image of page 726


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Matthews AM.  The development of the Starr-Edwards heart valve.  Tex Heart Int J.  1998;25(4):282-293
  6. Starr-Edwards Heart Valve.  The National Museum of American History
  7. Starr A, Edwards ML. Mitral Replacement: Clinical Experience with a Ball-Valve Prosthesis. Starr A, Edwards ML. Ann Surg 1961; 154: 726-740.