PAINE #PANCE Pearl – Cardiovascular



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




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.


  1. Facts about Atrial Septal Defect.  Centers for Disease Control. 2016.
  2. Krasuski RA. Congenital Heart Disease in the Adult. Cleveland Clinic. 2010.
  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]


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)

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Starr (suit, middle)

scanned image of page 726


  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
  4. Whonamedit – dictionary of medical eponyms.
  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.


Levine’s Sign


Other Known AliasesPalm Sign, Cossio’s Sign, Cossio-Levine’s Sign

DefinitionClenched fist held over the sternum while a patient is describing their chest pain and classically is the right hand, as cardiac pain can refer to the left arm.

Image result for levine sign

Clinical SignificanceThere is very little significance to this sign and has been studied to only have a 14% sensitivity for cardiac chest pain, but is a classic physical exam finding and frequent pimp fodder.

History – Named after Samuel Albert Levine (1891-1966), who was an American cardiologist and attending physician at The Brigham Hospital in Boston, MA, and assistant professor of medicine at Harvard University.  He graduated Harvard at the age of 20 and was the first physician to diagnose President Franklin Roosevelt with poliomyelitis.  He was a pioneer in coronary thrombosis research and was the second physician to ever diagnose the condition, which he described it in his classic book Clinical Heart Disease in 1936. 

Samuel-Albert-Levine-1964.jpgImage result for samuel a levine

Image result for levine clinical heart disease

He is also the namesake of The Levine Scale, a 1 to 6 grading system to characterize the intensity  of heart murmurs, and Lown-Ganong-Levine syndrome, which is a pre-excitation syndrome causing a shortened PR interval with normal QRS complexes in tachycardia.

Image result for levine scale

The Levine Scale

Image result for lown ganong levine syndrome

Lown-Ganong-Levine Syndrome



  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
  4. Whonamedit – dictionary of medical eponyms.
  5. Edmondstone WM. Cardiac chest pain: does body language help the diagnosis? BMJ. 1995;311(7021):1660-1. [pubmed]
  6. Levine HJ.  Profiles in Cardiology: Samuel A. Levine (1891-1966).  Clin Cardiol.  1992;15:473-476
  7. Bedford DE. Samuel Albert Levine (1891-1966). British heart journal. 1966; 28(6):853-4. [pubmed]
  8. Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. The American journal of cardiology. 2008; 102(8):1107-10. [pubmed]
  9. Lown B, Ganong WF, Levine SA. The syndrome of short P-R interval, normal QRS complex and paroxysmal rapid heart action. Circulation. 1952; 5(5):693-706. [pubmed]

PAINE #PANCE Pearl – Emergency Medicine



What are the 5 main life-threatening causes of chest pain?



The 5 main life-threatening causes of chest pain you should ALWAYS think of are:

  1. Acute Myocardial Infarction
  2. Pulmonary Thromboembolism
  3. Pneumothorax (risk of tension)
  4. Pericarditis (risk of tamponade)
  5. Aortic Dissection

There are a few others that should also cross your mind:

  1. Esophageal Rupture (Boerhaave’s Syndrome)
  2. Acute Chest Syndrome in Sickle Cell patients
  3. Unstable angina



  1. The Five Deadly Causes of Chest Pain Other than Myocardial Infarction. JEMS. 2017
  2. Chest Pain.  Life in The Fastlane.
  3. Woods WA, Young JS, Just JS. Emergency Medicine Recall.  2000.


PAINE #PANCE Pearl – Cardiovascular

82-year-old male, with a history of HTN, HLD, and CAD, presents to your clinic with a six-month history of dyspnea on exertion.  He states he is unable to walk as far as he used when exercising, and when he over exerts himself, he reports having some mild chest pain and feeling lightheaded.  This resolves with rest and he denies any syncope with these events.



Metoprolol 50mg daily

Lisinopril 10mg daily

Simvastatin 30mg daily


Vital Signs

BP – 158/97

HR – 62

RR – 13

O2% – 100%


Physical exam

General – WN/WD male in NAD

Pulmonary – CTA without adventitial breath sounds

CV – Soft S2 with murmur over right 2nd intercostal space

PV – carotid pulse is weak and has a slow rise, murmur is appreciated

Neuro – No focal deficits





This patient has aortic stenosis.  The suggestive parts of the H&P are:

  • History
    • The classic triad of aortic stenosis is chest pain, dyspnea, and syncope.
  • Aortic stenosis increases in prevalence with age
  • Cardiac Auscultation
    • Soft, single S2 since A2, which is due to aortic valve closure, is delayed and occurs with P2
    • Murmur
      • Systolic ejection murmur best heard over the right 2nd intercostal space
      • medicosnotes_heart-sounds-and-murmur-in-aortic-stenosis
      • Begins on S1 and ends before S2
      • May radiate to the carotids
      • 634464_xlarge
  • Peripheral Vascular
    • Carotid Palpation
    • Pulsus Parvus et Tardus (weak and late)
    • pulse-jvp-12-638
  • EKG
    • Shows LVH and strain pattern in precordial leads

  1. What is the next step in the management of this patient?
    1. Transthoracic echocardiography
  2. After the next step, what important variables must you specifically assess?
    1. Valvular anatomy and size
      1. Aortic valve surface area
    2. Valve hemodynamics
      1. Transvavular aortic velocity
      2. Mean transvalvular pressure
    3. LV size and ejection fraction
    4. Pulmonary artery pressure
    5. Other concomitant conditions


These variables will help with staging the severity of the stenosis, as well as determine need for operative intervention.