(BQ) Part 2 book Clinical examinations in cardiology presents the following contents: Basic investigations - Clinical electrocardiogram, basic investigations - Radiology of the heart and great vessels.
BASIC INVESTIGATIONS 6A CLINICAL ELECTROCARDIOGRAPHY 22 Introduction and basic concepts 459 23 The normal electrocardiogram 474 24 Abnormal P, T and U waves 490 25 Ventricular hypertrophy 500 26 Intraventricular conduction defects 516 27 Myocardial infarction and ischemia 533 28 Pericarditis and myocarditis 560 29 Drug effects and electrolyte abnormalities 568 30 Arrhythmias 580 “This page intentionally left blank" ■■■ INTRODUCTION INTRODUCTION BASIC CONCEPTS a) Electrophysiology of the Heart b) Electrocardiographic Instrument, Recording Electrodes and Lead AND 459 461 461 CHAPTER 22 BASIC CONCEPTS c) Precautions to be Taken for Recording an ECG REFERENCES 472 473 466 INTRODUCTION The electrocardiogram (ECG) is a graphic record of the electrical potentials produced during heart beat ECG of today is the product of a series of technological and physiological advances occurred over the past two centuries ● ● ● The existence of electricity in the animal (“animal electricity”) was first suggested by Edward Bancroft (1769, in torpedo fish)1 and substantiated by John Walsh (1773 in eel)2 and Luigi Galvani (1780 in dissected frog) (see Table 22.1) However; it was in 1842, when Carlo Matteucci, Professor of Physics at the University of Pisa first showed that an electric current accompanies each heart beat in a dissected frog,3 which was later confirmed by Rudolph von Koelliker and Heinrich Muller in 1856.4 First successful attempt to record an ECG in humans was made by Alexander Muirhead, a Telegraph engineer in 1869 at St Bartholomew’s hospital, London, using Thomson Siphon recorder Table 22.1 History of development of ECG Discovery/invention Scientist Animal electricity Bancroft (1769), Walsh (1773) and Galvani (1780) Matteucci (1842), Koelliker and Muller (1856) Gabriel Lippmann (1872) Willem Einthoven (1901) Alexander Muirhead (1869) Augustus D Waller (1887) Willem Einthoven (1895) Electric current accompanies each heart beat (frog) Capillary electrometer String galvanometer Attempt to record ECG in humans Recorded first human ECG Naming of deflections in ECG as “PQRST” 460 BASIC INVESTIGATIONS: CLINICAL ELECTROCARDIOGRAPHY ● ● ● ● ● ● French Physicist Gabriel Lippmann invented (1872) capillary electrometer, a glass tube with a column of mercury beneath the sulphuric acid, for which he was awarded a Nobel Prize in 1908 British Physiologists John Burden Sanderson and Frederick Page in 1878 first recorded the heart’s electric current with a capillary electrometer which consisted of two phases from the ventricle of a frog.5 But it was in 1887 when Augutus D Waller, British Physiologist, at St Mary’s Medical school, London, recorded the first human ECG with a Lippmann’s capillary electrometer and labeled the deflections as ‘V1’, ‘V2’ and the third wave which was later discovered as ‘A’.6 After witnessing the Waller’s demonstration in 1889, the Dutch Physiologist Willem Einthoven recorded ECG with an improved Lippmann’s electrometer in 1895 and named the deflections as “ABCD” and with a correction formula as “PQRST”7 as per the mathematical convention derived from the French Philosopher Descartes points on the curves (1662).8 His invention of string galvanometer later in 1901 provided a reliable and direct method for recording ECG, and by 1910 the string galvanometer emerged from the research laboratory in the clinic.9 Subsequent improvement of the instrument and better understanding of the ECG resulted in the wide use of ECG and has become an invaluable clinical tool for the detection and diagnosis of a broad range of cardiac conditions Though at present not a sine qua non for the diagnosis of the heart diseases, it continues even 100 yrs after its inception to be the most commonly used cardiologic test – For the diagnosis of the cause of chest pain – As a reliable tool for the diagnosis of acute myocardial infarction and dictates the timely administration of life saving thrombolytic therapy – For the diagnosis and the management of cardiac arrhythmias – Can help with the diagnosis of the cause of breathlessness – For the diagnosis of pericarditis and – For assessing the electrolyte disorders, drug effects and toxicity (see Table 22.2) A patient with an organic heart disorder may have a normal ECG and a perfectly normal individual may show non-specific ECG abnormalities Hence, a patient should not be given an unwarranted assurance of the absence of heart disease solely on the basis of a normal ECG Table 22.2 Utility of ECG in the current era Diagnosis Management Assessment Acute myocardial infarction Cardiac arrhythmias Electrolyte disorders Drug effects and toxicity Chest pain Acute myocardial infarction Pericarditis Cardiac arrhythmias INTRODUCTION AND BASIC CONCEPTS 461 BASIC CONCEPTS The basic concepts are described as follows: ● ● ● Electrophysiology of the heart Electrocardiographic instruments, recording electrodes and leads Precautions to be taken for recording an ECG a) Electrophysiology of the Heart 1) The Conduction System of the Heart See Part-1: Basic anatomy and physiology: chapter 2) The Contractile or Working Myocardial Cell See Part-1: Basic anatomy and physiology, chapter 7: a) b) c) d) e) Sarcolemma—see p57 Intercalated discs—see p58 Sarcotubular system—see p59 Diadic cleft—see p60 Contractile proteins—see p61 3) Electrical Activity of the Heart a) Properties of the transmembrane potentials: see Part-1: Basic anatomy and physiology, chapter b) Recording of the electrical potentials (electrogram) produced by the normal cardiac cell: (i) Resting cell: In a resting cardiac muscle cell, molecules dissociate into positively charged ions on the outer surface and negatively charged ions on the inner surface of the cell membrane, and the cell is in an electrically balanced or polarized resting state If an electrode is placed on the surface of the resting cell, no deflection is recorded by the galvanometer as entire cell surface has zero potential due to high impedance of the cell membrane (see Fig 22.1) (ii) Depolarization: When the cell is stimulated (S) by an excitatory electrical wave, the negative ions migrate to the outer surface of the cell and positively charged ions pass into the cell, this reversal of polarity is called depolarization ● ● ● If an electrode is placed so that the depolarization wave flows toward the electrode, a galvanometer will record a positive or an upward deflection When a depolarization current is directed away from an electrode, a negative or downward deflection is recorded If an electrode (E) overlies the mid portion of the cell (muscle strip), the deflection will be diphasic The initial deflection is upward due to an advancing positive charge, while the second deflection is downward due to the effect of passing negative charge (see Fig 22.2) 462 BASIC INVESTIGATIONS: CLINICAL ELECTROCARDIOGRAPHY ϩ Ϫ ϩ Ϫ ϩ Ϫ Ϫ ϩ Ϫ ϩ Ϫ ϩ Ϫ ϩ Ϫ ϩ Ϫ ϩ ϩ Ϫ ϩ Ϫ ϩ Ϫ Ϫ ϩ Ϫ ϩ Polarized resting state no deflection ϩ Ϫ ϩ Ϫ Fig 22.1 Electrical activity Depolarization positive redeflection | Electrical activity in resting cell and effect of depolarization Ϫ Ϫ ϩ Ϫ E Ϫ ϩ E Upward deflection S Current flow towards the electrode Downward deflection S Current flow away from the electrode Ϫ E ϩ Diphasic deflection S Electrode overlying the mid portion of a cell Fig 22.2 | Depolarization wave in a single cell E: electrode, S: stimulation ϩ Ϫ Ϫ E ϩ E S Two muscle strips of equal size Fig 22.3 ● ● | Depolarization wave in two cells of equal size E: electrode, S: stimulation If two cells (muscle strips) of approximately equal size are stimulated at a central point, a positive of equal magnitude is recorded at either end (see Fig 22.3) If two cells (muscle strips) of different sizes (e.g RV and LV) are stimulated at a central point, a large positive deflection is recorded over the large cell (muscle mass) and a small positive deflection followed by a deep negative deflection or entirely negative deflection is recorded over the smaller cell surface (muscle mass) (see Fig 22.4) INTRODUCTION AND BASIC CONCEPTS Ϫ ϩ 463 ϩ Ϫ E OR S Two muscle strips of different sizes Fig 22.4 | Depolarization wave in two cells of unequal size E: electrode, S: stimulation Ϫ ϩ E Ϫ E S Depolarization towards the electrode Fig 22.5 E Repolarization in the opposite direction | Repolarization in the opposite direction of depolarization E: electrode, S: stimulation Ϫ E ϩ ϩ E S Depolarization towards the electrode Fig 22.6 ϩ E E Ϫ E Repolarization in the same direction | Repolarization in the same direction of depolarization E: electrode, S: stimulation (iii) Repolarization: During recovery period, positively charged ions return to the outer surface and negatively charged ions move into the cell The electrical balance of the cell is restored; this process of return of the stimulated cell to the resting state is known as repolarization ● ● If the repolarization occurs in a direction opposite to that of depolarization, the deflection will be in the same direction as that produced by depolarization (see Fig 22.5) If the repolarization occurs in the same direction as that of depolarization, the deflection will be opposite to that of depolarization (see Fig 22.6) c) Intracellular and extracellular ion concentrations: see Part-1: Basic anatomy and physiology, chapter 464 BASIC INVESTIGATIONS: CLINICAL ELECTROCARDIOGRAPHY ● ● ● The transfer of the Naϩ and Kϩ ions across the cell membrane plays an important role in generating cardiac electrical activity Intracellular concentration of Kϩ is 30 times greater than extracellular Kϩ Naϩ concentration is 30 times less inside the cell as compared to outside Because of this ionic composition, membrane of the resting cardiac fiber is in an electrically balanced or polarized state d) Origin and sequence of cardiac activation: see Part-1: Basic anatomy and physiology, chapter e) Phases of cardiac action potential: see Part-1: Basic anatomy and physiology, chapter f) The modifying transmission factors: These factors affect transmission of electrical activity of the heart throughout the body and are broadly grouped into four categories: (i) Cellular factors determine the intensity of the current flow They include: ● ● Intracellular and extracellular resistance Intracellular and extracellular ions: Lower ion concentrations reduce the intensity of the current flow by reducing the movement of the ions and by lowering the extracellular potentials (ii) Cardiac factors affect the transmission of current from one cardiac cell to another These include: ● ● Anisotropy: It is the property of the cardiac tissue to propagate more rapidly along the length of the fiber than transversely Hence, the recording electrodes oriented along the long axis of a cardiac fiber register larger potentials than the electrodes oriented perpendicular to the long axis Connective tissue between the cardiac fibers: It disrupts the effective electrical coupling between adjacent fibers The waveforms recorded from fibers with little or no intervening connective tissue are narrow and smooth in contour, whereas those recorded from the fibers with abundant connective tissue (fibrosis) are prolonged and fractionated.10 (iii) Extracardiac factors include all tissues and structures that lie between the region of cardiac electrical activity and the body surface These tissues alter the electrical activity due to differences in electrical resistances of the adjacent tissues i.e electrical inhomogeneities within the torso e.g intracardiac blood has lower resistance of 162 ⍀-cm than the lungs (2150 ⍀-cm) ● ● ● ● ● ● ● Ventricular walls Intracardiac and intrathoracic blood volume Pericardium Lungs Skeletal muscles Subcutaneous fat and Skin INTRODUCTION AND BASIC CONCEPTS 465 Table 22.3 Factors modifying transmission of action potential Modifying factors Intracellular and extracellular resistance Intracellular and extracellular resistance Intracellular and extracellular ions Anisotrophy Connective tissue between the cardiac fibers Electrical in-homogeneities within the torso Distance between the heart and recording electrode Eccentric location of the heart Intracellular and extracellular ions Cellular factors Eccentric location of the heart Cardiac action potential Cardiac factors Anisotrophy Connective tissue between cardiac fibers Fig 22.7 Connective tissue between heart and recording electrode Physical factors Extacardiac factors Ventricular walls Pericardium Intracardiac and intrathoracic blood volume Subcutaneous fat Skin Lungs Skeletal muscles | Factors modifying cardiac action potential (iv) Physical factors which affect the electrical activity are: ● ● The distance between the heart and recording electrode is governed by ‘inverse square law’ i.e amplitude of the electrical potential decreases in proportion to the square of the distance All electrodes placed at a distance Ͼ15 cm from the heart may be considered to be equidistant from the heart in electrical sense as the amplitude of the electrical potentials recorded will be the same in all electrodes Eccentric location of the heart i.e the heart is located eccentrically more anteriorly so that the RV and anteroseptal portion of the LV are located closer to the anterior of the chest than other parts of the LV and atria Hence, the ECG potentials and wave forms generated by the anterior regions of the heart are higher and greater than those generated by the posterior ventricular regions and atria As a result of all these factors, body surface potentials have amplitude of only 1% of the amplitude of transmembrane potentials (see Table 22.3 and Fig 22.7) 466 BASIC INVESTIGATIONS: CLINICAL ELECTROCARDIOGRAPHY Table 22.4 Methods of ECG recording Methods Standard method ECG monitoring Ambulatory ECG Telemetry b) Electrocardiographic Instrument, Recording Electrodes and Lead 1) Electrocardiographic Instrument The two main types of apparatus used are: ● ● String galvanometer Radio amplifier String galvanometer records on the photographic paper which has to be developed It requires experience to operate so as not to damage the valuable string Radio amplifier is compact, light, easy to operate and has a direct writer Many modern machines record multiple leads simultaneously Other methods utilized clinically are (see Table 22.4): ● ● ● ● Oscilloscopic viewing of the ECG i.e ECG monitoring in coronary and intensive care units This produces a constant ECG on a fluorescent screen with a facility to obtain the ECG tracing Ambulatory ECG recording: A small ECG tape recorder is attached to the patient for continuous recordings for 24 hrs while the patient is ambulatory which can be reviewed later by the attending physician for arrhythmias or myocardial ischemia Telemetry ECG: ECGs can be transmitted via telephone lines, for constant or temporary monitoring and interpretation by a physician many miles away from the patient Computer facilities are available not only for ECG interpretation but also for the recognition and quantitation of arrhythmias 2) Recording Electrodes and Leads These are as follows: ● ● ● ● ● ● ● ● Bipolar standard or limb leads Bipolar chest leads Unipolar augmented limb leads Unipolar precordial or chest leads Monitor leads Unipolar esophageal leads The Mason-Liker modified standard leads Unipolar intracardiac leads The standard clinical ECG consists of 12 leads: bipolar limb leads (I, II, III), augmented limb leads (aVR, aVL, aVF) and unipolar precordial leads (V1–V6) The bipolar EVALUATION OF EXTRACARDIAC STRUCTURES Right 703 Left AK AAo Descending aorta PT DAo Apex Apex S Fig 34.6 Stomach L with situs inversus—DAo: | Dextrocardia descending aorta, PT: pulmonary trunk, Fig 34.7 Liver with situs | Dextrocardia inversus (Diagrammatic) L: liver, S: fundus of the stomach, AK: aortic knuckle, AAo: ascending aorta Fig 34.8 | Vanishing tumor (arrow) in congestive heart failure Congestive heart failure may be associated with a ‘pseudo-tumor’ or ‘vanishing tumor’ due to interlobar collection of pleural fluid (see Fig 34.8) As CHF improves, the tumor disappears Bones and Joints Notching of the ribs is the erosion of lower borders of the ribs, which can occur due to enlarged intercostal arteries, veins or nerves i) Commonest cause of notching of ribs is coarctation of aorta, in which case it is known as Dock’s sign.2 It is due to dynamic dilatation and tortuosity of the posterior intercostal arteries ● Notching is bilateral between 3rd and 8th posterior ribs, when coarctation is located distal to the left subclavian artery (usual position) (see Figs 34.9 and 34.10) 704 Fig 34.9 BASIC INVESTIGATION: RADIOLOGY OF THE HEART AND GREAT VESSELS of the inferior margins of posterior | Notching ribs (arrows)—PA view in coarctation of aorta Fig 34.10 of the ribs (arrows, | Notching magnified view) Table 34.1 Evaluation of extracardiac structures Features Structures to be examined or etiology Situs Pleural effusion Fundus of the stomach, left main bronchus Right sided: in left heart failure Bilateral: in severe congestive heart failure (CHF) CHF Coarctation of aorta, superior vena caval syndrome, intercostal neurofibromatosis Vanishing tumor Notching of the ribs ● ● ● Unilateral rib notching is present only on the right side when coarctation narrows the orifice of the left subclavian artery and collaterals fail to develop on the left side The rib notching in anomalous origin of right subclavian artery distal to coarctation is unilateral (only on the left side) as collaterals fail to develop on the right side If rib notching occurs, in abdominal coarctation of aorta, it is confined to lower ribs only ii) Superior vena caval syndrome also causes rib notching of venous origin iii) Neurofibromatosis can also produce rib notching by the intercostal neurofibromas Soft Tissues Over the Chest Severe edema in the soft tissue over the chest occurs as a part of anasarca in patients with renal failure (see Table 34.1) EVALUATION OF CHEST X-RAY IN OTHER VIEWS Structures of the heart which cannot be evaluated in frontal view of chest X-ray can be evaluated in the left lateral, RAO and LAO views EVALUATION OF EXTRACARDIAC STRUCTURES 705 Aorta Ao PA Pulmonary artery Left atrium LA RV LV Fig 34.11 X-ray lateral view in a normal individual| Chest black arrow: retrosternal space, white arrow: Left ventricle Right ventricle Posteroinferior cardiophrenic recess Fig 34.12 posteroinferior cardiophrenic recess X-ray lateral view | Chest (Normal and diagrammatic) Chest X-ray in Left Lateral Projection i) The Anterior Border ● ● ● The anterior border is formed by right ventricle in the subxiphoid region extending superiorly to a point about 1/3rd of the distance between the diaphragm and the suprasternal notch The enlarged right ventricle may obliterate the retrosternal space (see Figs 34.11 and 34.12) The normal right atrium is not border forming in this projection Anterior margin of main pulmonary artery and ascending aorta lie above the right ventricle; but due to abundant mediastinal fat, these structures are not clearly visualized in a normal person In patients with severe emphysema, main pulmonary artery and ascending aorta may be well outlined ii) The Arch of Aorta ● ● ● ● It is clearly outlined superiorly Inferior margin of the posterior aortic arch is often visible posteriorly Also, the superior margin of left pulmonary artery is visualized in the semilunar lucency of the aorticopulmonary window The descending aorta is not usually visible clearly as it lies adjacent to the spine and in the posterior mediastinal fat However, descending aorta may be better visualized in the patients with tortuous or calcified aorta iii) Posterior Border ● ● The upper posterior border is formed by the left atrium, which appears as a shallow convex bulge and is anterior to the pulmonary venous confluence The posteroinferior heart border just above the diaphragm is formed by the left ventricle, which appears as a long convex bulge 706 BASIC INVESTIGATION: RADIOLOGY OF THE HEART AND GREAT VESSELS Aorta Superior vena cava Pulmonary artery Left atrium Right atrium Right ventricle Left ventricle Fig 34.13 | Chest X-ray RAO view Fig 34.14 X-ray RAO view (Normal and dia| Chest grammatic) iv) Lateral Projection ● It is also useful for the identification of valvular calcification Barium filled esophagus can be used for the visualization of enlarged left atrium and left ventricle Chest X-ray in RAO View Chest X-ray in RAO view is performed with the patient in a 45° oblique relationship to the film cassette, i.e right shoulder towards the film cassette (see Figs 34.13 and 34.14) i) The Anterior Border of the Heart ● It is formed by the sinus portion of the right ventricle inferiorly, and RVOT and main pulmonary superiorly.3 ii) The Posterior Border ● It is formed by right atrium superiorly and left atrium inferiorly RAO view is usually used for the evaluation of left atrial enlargement iii) This View Permits The optimal visualization of a calcified mitral or tricuspid valve The aortic arch is foreshortened in this projection, so the aortic arch and proximal descending aorta are often superimposed and not visualized Chest X-ray in LAO View Chest X-ray in LAO view is performed with the patient in a 60Њ oblique relationship to the film cassette, i.e left shoulder towards the film cassette i) The Anterior Border of the Heart ● ● It is formed by right atrium above and right ventricle below This view is superior for detecting right ventricular enlargement, which is characterized by an increase in the convexity of the anterior border of the cardiac silhouette EVALUATION OF EXTRACARDIAC STRUCTURES 707 Aortic triangle Aorta Aortic window Pulmonary artery Right atrium Left atrium Left ventricle Right ventricle Fig 34.15 | Chest X-ray LAO view Fig 34.16 ● | Chest X-ray LAO view (Normal and diagrammatic) An enlarged right atrium may cause bulging of the right upper anterior border of the cardiac shadow and may produce a typical shelf-like configuration ii) The Posterior Border ● ● ● It is formed by left atrium superiorly and left ventricle inferiorly This view is useful for diagnosing the presence of left ventricular enlargement The enlarged left ventricle overlaps the spine, and posteroinferior cardiophrenic recess may be obliterated iii) Visualization of Other Structures in LAO View ● ● ● ● The aortic and pulmonary valves are in profile in this view, so that aortic and pulmonary valve calcifications can be visualized (see Figs 34.15 and 34.16) The aorta and pulmonary artery are seen as two arches one above the other separated by a lucent subaortic window, in which trachea and left bronchus can be outlined The aortic arch is also in profile in this projection, so that the abnormalities of the arch, including dissection, aneurysm and coarctation can be detected especially with angiography The ventricular septum is also in profile in this LAO view, hence septal defects and right and left ventricular functions can be evaluated with angiography REFERENCES Elliott LP, Jue KL, Amplatz K A roentgen classification of cardiac malpositions Invest Radiol 1966; 1(1):17–28 Dock W Erosion of ribs in coarctation of aorta A note into the history of a pathognomic sign BHJ 1948;10:148 Murphy ML, Blue LR, Ferris EF, et al Sensitivity and specificity of chest roentgenogram criteria for right ventricular hypertrophy Invest Radiol 1988;23(11):853–856 I NDEX A Arrhythmias 580, see also individual arrhythmias Arterial pulse 225, f226 absent or delayed femoral pulse 245, f246 character 233, t235 anacrotic pulse 236, f236 bisferiens pulse 236, f237 dicrotic pulse 238, f238 pulsus alternans 239, f239 compound 239 partial 239 total 239 pulsus bigeminus 238, f239 Brokenbrough sign 239 pulsus paradoxus 240, t241 mechanism 241, f242, f243 reversed 244, t244 total 244, t244 pulsus tardus 233, f234 water hammer pulse 234, f234, f235 condition of the vessel wall 245 definition 225 examination 228 brachial 228, f229 carotid 228, f229 dorsalis pedis 229, f230 femoral 229, f229 popliteal 229, f230 posterior tibial 229, f230 radial 228, f228 genesis 225 peripheral signs of aortic regurgitation 246 abdomen 248 BP 247 eyes 247 head and neck 247 lower limb 248 pulse 246 upper limb 247 rate 231 bradyarrhythmias 232 bradycardia 231 pulse deficit 232 tachyarrhythmias 231 tachycardia 231 Note: f indicates figures and t indicates tables rhythm 232, t232 irregularly irregular 233 regularly irregular 232 radial pulse synchronicity 245 volume 244, t244 hyperkinetic pulse 245 pulsus magnus 245 pulsus parvus 244, t244 wave pattern 226, t227 in ascending aorta 226, f227 in peripheral artery 226, f227 Arterial supply of the heart 34, f35, t34 divergent coronary anatomy 38 LCA 34 coronary angiogram f36, f36 LAD 35 LCx 35 measurements 39, t39 RCA 37 AV nodal branch 34 conus artery 34 coronary angiogram f36 PDA 34 PLV 34 RA branch 37 RV branch 37 SA nodal branch 34 Atrial arrhythmias 586, f598 Atrial fibrillation 593 classification 591, f593, t593 chronic or permanent 597 coarse 596, f597 discernible 596 fine 596, f597 paroxysmal 596 persistent 596 ECG 595 Ashman’s phenomenon 595, f596 lone atrial fibrillation 596 rule of bigeminy 524 etiology 594, t596 incidence 593 mechanism 594, f595 Atrial flutter 589, f590, t591 etiology 591 incidence 591 types 591, t593, f593 chronic 592 CTI dependent 591 non CTI dependent 592 paroxysmal 592 persistent 592 type I 592 type II 592 Atrial infarction 544, f545 diagnostic criteria 544 Atrial tachycardia 587, t588 focal 587, f588, t588 MAT 589, f589, t589 premature atrial contractions 586, f587, t588 Auscultation 354 characteristics of cardiac sounds 355 factors affecting 355 frequency 355, t356 human acoustic acuity 354, t355 dynamic auscultation 361, see also dynamic auscultation examination 358 identification of systole and diastole 359 methods 359 Levine and Harvey’s inching 359 selective listening 359 posture of the patient 360, f360, f361 principles 354, 355 stethoscope 356, f357 bell 356, f357 binaural 358 diaphragm 357, f357 tubing 357, f357 technique 354 topographical sites 358, f359 AV junctional area 47, 50 AV junctional arrhythmias 598, f599, f600 AV junctional escape beats 598, f599, t601 ECG 599 mechanism 598 AV junctional premature beats 600, f601, t601 AV junctional rhythm 599, f600 AV junctional tachycardia 601, t603 focal 601, f602 non paroxysmal 602, f603 INDEX AV nodal reciprocating tachycardia (AVNRT) 603, t605 atypical 605 common features 605, f606 etiology and characteristics t605 pathophysiology 603, f604 types and mechanism f606 typical 604, f604 AV node 50 AN region 50 N region 50 NH region 50 B Basic electrophysiological principles 66 action potentials 67 extracardiac ion concentration t66 in Purkinje fibers 69 in SA node 69 intracardiac ion concentration t66 mechanism of automaticity 70 origin and sequence of cardiac activation 71 atrial depolarization 71 atrial repolarization 71 decremental conduction 71 ventricular depolariztion 71 ventricular repolarization 71 phases 67, f68, t68 transmembrane potentials t67 Biventricular hypertrophy 513, f514 features of LVH 513 LA abnormality 513 Blood pressure (arterial) 249 component 249, t249 definition 249 determinants 250 measurements 250 ambulatory BP monitoring 261, t262 continuous non invasive BP monitoring 260, f261 direct 250 flush method 260 indirect 251 auscultatory 252, f252 in special circumstances 256 lower limb 256, f257 palpatory 251 upper limb 247, f256 variable BP recordings 257, t257 self monitoring 261 ultrasound Doppler method 260 Build and stature 162 build 166 BMI 162 Cushing syndrome t164 indices 162 Laurence Moon Biedle syndrome t169 obese 166 over weight 168 Pickwickian syndrome t169 Under weight 169 waist circumference 163 short stature 165 causes 166, t166 Ellis van Creveld syndrome t166, f167 Noonan syndrome t166 tall stature 163 homocystinuria 163, t164 Klinefelter’s syndrome 163, f163, t164 Marfan syndrome 163, f163, t193 Turner syndrome f191, t191 Bundle branches 51, f52 blood supply 51, t52 LBB 51 RBB 51 Bundle of His 51 distal 51 middle 51 proximal 51 C Cardiac cycle 77, t77 atrial diastole 81 atrial systole 81 correlations f78, f80 ECG changes 82 ventricular diastole 79 ventricular systole 78 Cardiac imaging 661 fluoroscopy 663 introduction 661 technical facts 662 technologies t661 usefulness of X ray chest t661 Cardiac tamponade 126, f126, 564, f564 Cardinal symptoms 85, t86 importance of history taking 85 Cardiovascular pulsations 306 Inspection 306, f307 aortic area 310, t310 apical 306, t307 absent 308, t308 displacement 308, t309 double 308 extent 309 lateral retraction 308 normal 307, t307 ectopic areas 313 beneath the left clavicle 314 LA 314 LV 314 RA 314 epigastric 312, t313, f313 aortic 313 cardiac 313 hepatic 313 left parasternal 311, f311, t312 pulmonary area 310, t310 709 sternoclavicular area 310, t311 palpation 316, f317 aortic area 326, f327 sounds 326 thrills 327, f327, t328 apex f317, 318 absent 318 character 318, t307 heaving t318, f319, 320, 331 hyperdynamic t318, 319, f319, 331 OS 321, t321 pericardial knock 320 pericardial rub 322 S1 321 S3 320, t320 S4 320, t320 site and extent 318 sounds 316, t321 thrills 316, t328 tumor plop 321 ectopic areas 328 in PDA 329 LA 329 LV 328 RA 329 epigastrium 328, f329 left parasternal area 322 grading 323, f324, t324 in MR 324, f325 lift 322, f324 sounds 326 lower left sternal area 326 sounds 326 thrills 326, t328 pulmonary area 326, f327 sounds 327 thrills 327, t328 sternoclavicular areas 328 Chest 299, f301 Inspection 299, f301 abnormalities 300, t301, f301, f302 breast abnormalities 303, t303, f304 cutaneous lesions 303 distended vessels 304, f304 shape 300, f301 palpation 315 distended vessels 316 shape 316 Chest pain 87 aggravating and relieving factors 98 associated symptoms 100, t101 causes 87, f87 character and mode of onset 93 definitive typical anginal pain 101 differential diagnosis t88 duration 89, f89 functional classification 98 linked angina 99 location 90, f91 noncardiac chest pain 101 710 INDEX Chest pain (contd.) patient gestures 100, f100 radiation 90 Chest roentgenogram 662, see X-ray chest Conduction system of heart 47, f48, t48 Conjunctiva 177 conjunctivitis 178 pallor 200 petechiae 177, f178 suffusion 177 Constrictive pericarditis 387, f388, 565, f565 Continuous murmur 441, f444, t444 causes 442 ALCAPA 445 AV fistula 446 bronchial collaterals 445 coronary cameral fistula 446 left-to-right shunt with MV obstruction 446 localized arterial obstruction 443 mammary soufflé 449, f449, t449 PDA 444, f444, t444, t445 RSOV 445 venous hum 448, f448, t449 venous shunts 442 portosystemic shunts 446, f447 TAPVC 446 Cornea 178 arcus juvenalis 178, f179 arcus senilis 179, f179 clouding 179 Cyanosis 147, t152 central 148 associations 149, f149 differentiation from pulmonary causes 153, t154 etiology 149, f150 O2 saturation 149 pathogenesis 150, f151 site 149 types t152, 148 definition 147 evaluation 156, f156 age of appearance 156 aggravating factors 157 associations 157 distribution 157 relieving factors 157 squatting 158 squatting equivalents 158, f158 methemoglobinemia 153 diagnosis 155 etiology 154, t155 normal physiology 153 presentation 154 treatment 155 mixed 153 peripheral 148 etiology 148 D Diastolic murmur 431, t431, f433 classification 432 EDM 432, f432 AR 433 causes 433 functional PR 434 late or presystolic 440 causes 440, f441 complete heart block 441 MS 440 TS 441 MDM 435, f435 Austin flint murmur 439 causes 436, t436 increased flow across AV valves 438 MS 440, f441, t442 organic PR 440, f441 TS 441 pandiastolic or holodiastolc 435 Digits 200, t203 arachnodactyly 200, f201 brachydactyly 202 broad thumbs and toes 202, f203, t203 clench hand 203 clindactyly 201, f201 fingerized thumbs 202, f202 phocomelia 203, f204 polydactyly 201, f201 Raynaud’s phenomenon 204 sclerodactyly 204, f204 single thumb like digit 202, t202 syndactyly 201, f201 Digitalis 568, f569 effects 568 mechanism 572 therapeutic 568, f570, f571 toxic 569, f571, f572, t572 unequivocal toxic effects 571, f571, f572 Dynamic auscultation 361, t411 changes in cardiac cycle length 418 effects on heart sounds 419 effects on murmurs 419, f419 isometric exercise 417 effects on heart sounds 418 effects on murmurs 418 methods 417, f418 physiological response 418 Muller maneuver 415 effects on heart sounds 415 effects on murmurs 415 methoxamine and phenylephrine 421 effects on heart sounds 421 effects on murmurs 421 methods 421 physiological response 421 normal respiration 412 effects on heart sounds 412 effects on murmurs 413 pharmacological effects 420 amyl nitrate inhalation 420 effects on heart sounds 420 effects on murmurs 420 postural changes 415 knee elbow position 417 left lateral recumbent position 417 effects on heart sounds 417 effects on murmurs 417 sitting up and leaning forward 417 effects on heart sounds 417 effects on murmurs 417 squatting 416, f416 effects on heart sounds 416 effects on murmurs 416 sudden lying down 415 effects on heart sounds 415 effects on murmurs 415 sudden standing 416 types of bed side maneuver 412 Valsalva maneuver 413, f414 effects on heart sounds 414 effects on murmurs 414 phases 414 E Ears 185, t186 cauliflower ears 186, f186 deafness 187 ear lobe crease 185, f186 low set ears 186, f187, t186 Electrocardiogram 474 effect of heart position 484, t485 clockwise rotation 486, f486, t485 counter clockwise rotation 486, f486, t485 horizontal heart 485 intermediate heart 485 vertical heart 485 electrical axis 485 hexaxial reference system 481, f481 method of determination 482 classical 483, f483 equiphasic 482, f482 simplified 484 normal 484 intervals 479, f480, t481 LAD 484 PP 479 PR 479 QRS 479 QT 479 QU 479 RAD 484 RR 479 VAT 480, f481 normal 486 normal variants 487, f487 anxiety 489 INDEX children 486, f487, t487 deep respiration 489 early repolarization 487, f488, t488 hyperventilation 489 infants 486, t487 juvenile pattern 487 postprandial 489 P 474, t475 abnormal P 490, f491 biatrial 494, f495, t495 dextrocardia 491, f491 left atrial abnormality 491, f492, t492, f493 right atrial abnormality 493, f493, t492 waves 474 Q 476, t476 R 476 S 477 segments 480 PR 480 ST 481 T 477, t478 abnormal T 495, t495 flat 496 inversion with ST changes 496 inversion without ST changes 497 tall T 495, f495 U 478, t478 abnormal U 497, t497 inverted 497, f498 prominent 497, f498 Electrocardiography 459 Electrophysiology of the heart 461 see also basic electrophysiology of heart action potentials 464, f465 cardiac activation 464 origin 464 sequence 464 electrical activity 461 depolarization 461, f462 repolariztion 463, f463 resting cell 461, f462 electrocardiographic grid 472 extracellular ion concentration 463 history 459, t459 intracellular ion concentration 463 instrument 466 radio ampliflier 466 string galvanometer 466 introduction 459 methods of recording t466 precautions 472, t473 recording electrodes and leads 466 bipolar chest 467 bipolar limb 467, f467 monitor leads 470, f471 relationship between bipolar and unipolar limb leads 468, f469 unipolar esophageal leads 470, f471 unipolar intracardiac leads 471 unipolar limb leads 468, f469 transmission factors 464, t465 cardiac 464 cellular 464 extra cardiac 464 physical 465 Extracardiac sounds 402 mediastinal crunch 404 pacemaker sounds 403 pericardial rub 403, f404 causes 403 clinical recognition 403, f404 components 403, f404 mechanism of production 403 Extremities 200 Eyes 176 enophthalmos 177 exophthalmos 176, f175 hypertelorism 176, f187, t177 nystagmus 177 Eye lids 177 lid lag 177 ptosis 177, f178 Kearn-sayre syndrome 177, t178, f177 Klippel Feil syndrome 177, t177 xanthelasma 177, f178 F Facial appearance 172, t172 ape like 174 butterfly rash 173, f174 dull expressionless face 173, f173 elfin facies 175 expression of fright and anxiety 174, f175 facial dysmorphism 172, f172 facial edema 172 facial flushing 174 grotesque facial features 175 malar rash 173, f174 mid facial growth deficiency 176 mongoloid facies 175, f172 moon face 174, f175 Fascicular blocks 523, f524, 525 bifascicular 528 RBBB with LAFB 528, f528 RBBB with LPFB 529, f529 LAFB 524, f525, t525 Warner criteria 526 LPFB 526, f526, t527 WHO/ISFC criteria 527 multifascicular 527 trifascicular 530, f530 Fatigue 119, f119 Feet 210 bow legs 210, f211 711 genu valgum 211, f212 pes cavus 210, f210 rocker bottom foot 210, f211 Fibrous skeleton of heart 16, f16, t16 components and attachments 16 fibrous rings 16 left fibrous trigone 17 right fibrous trigone 17 extensions 17 Frank Starling Law of heart 75 G Gestures and signs 170, f171, t171 Gower’s sign 170, f171 Levine’s sign 170, f171 Gums 189 cyanosis 189 hypertrophy 189, f190 H Heart gross anatomy external features 4, f5, f6 borders chambers see also individual chambers crux sulci surfaces location size weight in females weight in males Heart blocks 644 1st degree AV block 645, f649 2nd degree AV block 647, t649 type I 647, f649 type II 650, f651 complete AV block 652, t652 acquired 652, f653 congenital 652, f653 ECG recognition 652 types and characteristics f655 Heart murmurs 404 see also individual murmurs characteristics 406 configuration 410 intensity 409 length 406 location 407 pitch 410 timing 406 transmission 411 definition 404 factors for production 406 functional with thrill 409, t410 mechanism of production 404, f405, t405 classification 406 continuous 441 712 INDEX Heart murmurs (contd.) diastolic 431 systolic 422 Heart sounds 361, f362 S1 362 characteristics 363, t363 determinants 364, t364 evaluation 366, f367 decreased intensity 368, t369 increased intensity 366, t369 split 369 variable 368, t369 S2 369 abnormal splitting 369, f369 narrow 373, f373 persistent 373 reversed 375, f376, f377, t378 types 375 wide 374, f375 wide and fixed 375, f375, t372 characteristics 370, t370 hang out interval 371 normal split 371, f372 mechanism 371 intensity 379 determinants 379 diminished A2 380, t379 diminished P2 380, t379 loud A2 379, t379 loud P2 380, t379 evaluation 381, f381 AR 381 AS 381 ASD 381 biscuspid aortic valve 382 cyanotic CHD 383 MR 381 MS 381 PDA 382 PS 382 single S2 377, t378 VSD 381 S3 383, f383 causes 385, t385 characteristics 383, t383 pathological 384 physiological 384 clinical recognition 387 mechanism of production 384 prerequisites 384 theories 384 S4 388, f382, f388 causes 389, t391 characteristics 388 clinical recognition 390 mechanism of production 388 prerequisites 389 theories 389 Hemoptysis 144, f145 etiology 144 evaluation 144 Hoarseness 146 causes 146, t147 Hypercalcemia 576, f576 Hyperkalemia 572, f573, f574, t574 modifications by other electrolytes 573 Hypermagnesemia 578, f578 Hypertension 262 causes 262, t263 classification t263 complications 267 definition 262 mechanism 265, f266, t265 Hypocalcemia 577, f577, t578 Hypokalemia 574, f575, t576 modifications by other electrolytes 575 Hypomagnesemia 578 I Iris 179 Brush field’s spots 179, f180 CHARGE syndrome t180 coloboma 180, f180 J Joints 212 arthritis 213 Jaccord’s arthritis 213 gouty arthritis 215, f215 migrating polyarthritis 213 polychondritis 213 rheumatoid arthritis 213, f213 lax joints 212, f213 Jugular venous pressure 283 measurement 283, 284, f284 elevated 285, f285, t285 normal 284, f284 Jugular venous pulse 271 analysis 275, t276, f275 a wave 275 abnormal a 277, t278 absent 278, f279 giant 278, f279 prominent 277, f278 c wave 276 h wave 277 v wave 276 abnormal v 279, t280 diminished 280 prominent 279, f280 prominent v and a 280, f280 x descent 276 abnormal x descent 279, t279 absent 279 prominent 279, f279 y descent 277 abnormal y descent 281 rapid 281, f281 slow 281, f281 examination 272 position of the patient 274, f275 which JVP? 272, f273, t273 Vs carotid pulsations 273, t273 history 271, t272 introduction 271 diseased conditions 288 acyanotic CHD 291 ASD 291 VSD 292, f292 arrhythmias 288 conduction defects 288 cardiomyopathy 294 dilated t294 EMF t294 restrictive t294 cyanotic CHD 292 Eisenmenger syndrome 292, f292 PS with intact IVS and right-to-left shunt 293 TAPVC 293 TGA 293, f293 TOF 292, f293 TOF like physiology 292 tricuspid atresia 293 pericardial disease t294, 295 cardiac tamponade t294, f295 constrictive pericarditis f294, t294, 295 valvular lesions 289 AR 290, f291 AS 290, f290 MR 289, f290 MS 289, f289 PS 291 TR 290 TS 289 K Kinetic cardiogram 330 apical impulse 330 cardiomyopathy 331 constrictive pericarditis 332 double 331, f332 hyperdynamic 331, f331 normal 330, f330 RV hyperkinetic 331 RV sustained 331 sustained 331, f332 L Left atrium 12, t12 development t12 external features 13 shape 13 site 13 internal features 13 fossa lunata 13 muscular pectinati 13 pulmonary veins 13 LBBB 520, f521 INDEX incomplete 523 WHO/ISFC criteria 522, f522 Left ventricle 13 development t14 external features 13 shape 13 site 13 internal features 13, f14 apical portion 16 free wall 14 inflow tract 14 outflow tract 14 ventricular septum 14 development t14 Left ventricular hypertrophy 500 diastolic overload 501, f503 diagnostic ECG criteria 502, f503 Cornell product 505 Cornell voltage 505 Glassglow scoring system 504 Hernandez Padial 505 Koito and Spodick 506 natural history series 505 Novacode 505 Romhilt Estes point score system 504 Seigel’s 505 Sokolow-Lyon 503 Sokolow-Lyon grading 504 Talbot 506 ECG changes 500, f501 axis 501 others 501 QRS complex 501 ST-T 501 in LAFB 507, f507 in LBBB 506, f508 in RBBB 507, f508 systolic overload 501, f502 Lens 181 premature cataracts 181, f181 subluxation 181, f182 Lips 187 absent philtrum 187, f188 capillary pulsations 187 cyanosis 187 pallor 187 rhagades 187, f188 thick 187 Lymphatic system of heart 28, f29 left coronary channel 28 main supracardiac channel 29 right lymphatic duct 30 right coronary channel 28 cuspal 21 commissural 21 types 23 closure 21 phases 21 leaflets 20 AML 20 commissures 26 PML 20 surfaces 20 papillary muscles 21 anterolateral 21 posteromedial 21 Molecular basis of muscle contraction 73 muscular contraction 73, f74 muscular relaxation 74, f75 sliding filament theory 74 Myocardial calcification 696, f696, t697 LA 696 LV 696 Myocardial infarction 533 diagnosis in BBB 552, f552 LBBB 553, f553, f554, t554 RBBB 552, f552 diagnosis during RV pacing 554, f555 anterior MI 554 inferior MI 554 ECG changes 533 abnormal Q 534 abnormal R 534 QT dispersion 540 ST changes 535 T changes 538 U changes 540 evolution of ECG changes 540 localization 542 anterior MI 535, f536s anterolateral MI 535, f537 anteroseptal MI 535, f537 inferior MI 536, f538 posterior MI 538, f539 posteroinferior MI f539 prognostic value of ECG 555 prediction of coronary artery occlusion 545 ECG correlation 546 LAD occlusion 546, 547, f549 LCx occlusion 546, f547 RCA occlusion 546, 547, f547 sensitivity of ECG 555 Myocardial ischemia 541, f542 ECG changes 541 non specific ST-T changes 542 Myocarditis 565, f566 M Mitral valve 18, f18, t19, f19 annulus 18 development 18, t19 chordae tendinae 21 N Nails 205 capillary pulsations 206 clubbing 206, 207, 208 causes 208 713 grades 206 profile sign 207, f208 Schamroth window test 207, f208 unidigital 210 unilateral 209 cyanosis 205 dysplastic 205, f206 koilonychias 205, 206 plummers nail 205 splinter hemorrhages 206, f207 square 205, f206 strips 205 tuft erythema 205, f206 Narrow QRS tachycardia 622 differential diagnosis t623, f625 effects of vagal stimulation f626 irregular 622 P wave morphology f624 regular 622 response to IV adenosine f625 Neck 190, t191 low hair line 191, t191 lymphadenopathy 192 parotid enlargement 192, f192 short neck 190 thyromegaly 192, f192 webbed neck 191, f191 Nerve supply of heart 40, t40, f42 baroreceptors 43, t44, f45 arterial 45 carotid 44 cardiac plexus 40, f41 deep 41 superficial 40 chemoreceptors 43 aortic bodies 46 carotid bodies 46 parasympathetic fibers 43 peculiarities t41 sympathetic fibers 43 vasomotor center 45, f44 Nose 185, t186 broad 185, f185 thin beaked 185, t186 O Opening snap 321, 392, f394 A2-OS interval 393, f394 factors affecting 393 absent 395 causes 393, f394 characteristics 392, t392 clinical recognition 395 mechanism of production 393 prerequisites 393 theory 393 Oral cavity 187 mucous membrane 188 petechiae 177, f178 telangectasia 188 714 INDEX P Palate 189 cleft 189, f190 high arched 190 Palpitation 112 associated symptoms 118, t118 character 116 definition 112 duration and frequency 114 etiology 112 cardiac causes 112 non cardiac causes 113 evaluation 114 mode of onset 115 non persistent 114 persistent 114 relieving factors 118 Percussion 333 methods 334 auscultatory 334, f335 direct 334 indirect 334, f334 scheme 334 aortic area 336, f336 left border 336 LA appendage 337 lower part of sternum 337 manubrium sternum 337 pulmonary area 326, f327 right border 335, f335 Rotch’s sign 337 situs 337, f338 Pericardial calcification 699, f699, t700 causes t700 pathogenesis t700 Pericardial diseases 562, f566 Pericardial effusion 563, f563 Pericardial knock 388, f388 Pericarditis 560, f566 ECG changes 560 ECG variants 562 atypical 563 typical 563 evolution 561, t561 stages 561 Peripheral edema 215 causes 217 characteristics 221 pathogenesis 216, f217, t216 Starling forces 217 types 218 anasarca 219 leg edema 219 bilateral 219, f220 unilateral 220, f221 localized 218 Phonocardiography 361 Physical examination 162 importance 162 Posture or attitude 169, f170, t160 Precordial findings 338 AR 342, f343, t342 AS 341, f342, t341 ASD 343, f344, t343 cardiomyopathy 351, t352 DCM 352 HCM 352 restrictive 352 cyanotic CHD 350 decreased PBF 349, f350, t349 increased PBF 350, f350, t350 MR 340, f341, t340 MS 338, f339, t338 PDA 346, f347, t346 PS 347, f348, t348 TOF 351, t351 VSD 345, f345, t345 Precordium 299 Inspection 299 precordial prominence 305 ossification of ribs 306 ossification of sternum 306 Palpation 315 tenderness 316, t316 Preexcitation syndromes 606, 609 accessory pathways 607, f607 concealed 608 James 607, f608 Kent 607, f608 location 607 Mahaim 607, f608 antidromic AVRT 617, f618 etiology and characteristics t619 characteristics f626 classification f626 Lown-Ganong-Levine syndrome 621, f621 Mahaim tachycardia 620, f620 orthodromic AVRT 615, f615 ECG 615, f615 localization of AP pathways 616, f617 permanent form of AV junctional reciprocating tachycardia (PJRT) 621, f621 Wolff Parkinson White syndrome 609, f610, f611, f612, f613, f614 ECG 609 localization of AP pathways 612, f613, f614, f615 with atrial fibrillation and atrial flutter 617, f619 Prosthetic valve sounds 400, t401 bileaflet valves 402, f402 bioprosthetic valves 402, f402 ball-in-cage valves 400, f401 closing sounds 400 opening sounds 400 tilting disc valves 401, f401 Pupils 181 Argyll Robertson pupil 181 Pulmonary vasculature 684 abnormal 685, t687, t690 centralization 688, f688 cephalization 689, f689 collateralization 689, f610 decreased PBF 687, f687 increased PBF 686, f686 lateralization 688, f689 measurements 684, f685 normal 684, f685 pulmonary alveolar edema 690, f691 cardiac 691 non cardiac 691 pulmonary interstitial edema 690, f691 Kerley B lines 690, f691 Purkinje fibers 51, f52 R RBBB 516, t517, f518 arrhythmogenic RV dysplasia 519, f520 Brugada syndrome 519, f520 incomplete 518, f518 WHO/ISFC criteria 519 WHO/ISFC criteria 517 Retina 181 angiod streaks 180, t182 arteriosclerotic retinopathy 182, t182 corkscrew retinal arteries 183, t182, f184 fundus examination 181, t182 hypertensive retinopathy 182, f183, t182, t183 large retinal veins 184 embolic retinal occlusion 184, f185 papilledema 182, t182, f185 Roth spots 182, t182, f184 wreath like AV anastamosis 182, t182 Right atrium 7, t10 development external features internal features 7, f8 atrium proper Eustachian valve nodes of the heart t9 openings septal wall 7, t8 sinus venarum tendon of Todaro Thebesian valve torus aorticus triangle of Koch Right ventricle 10 development 12, t8 external features 10 shape 10, t10 site 10, t10 internal features 11, f11, t10 INDEX body 11 inflow tract 12 infundibulum 12 supraventricular crest 12 Right ventricular hypertrophy 507 diagnostic ECG criteria 510, f511, t511 Butler Legger 510 Milner modified Sokolow-Lyon 510 natural history series 510 other 510 diastolic overload 512, f513, f514 ECG changes 508, 509 axis 509 others 509 QRS complex 508 ST-T 509 in LBBB 511 in RBBB 510 systolic overload 512, f513 types 511 Right ventricular infarct 543, f544 diagnostic criteria 543 incidence 543, t543 S SA node 47 anterior internodal bundle 49 middle internodal bundle 49 posterior internodal bundle 49 Sclera 178 blue 178, f180 jaundice 178 Semilunar valves t24 annulus 24 commissures 26 development t19, 24 leaflets 25 sinus of Valsalva 26 valve closure 26 Shortness of breath (SOB) 101 angina equivalents 93 associated symptoms 100, t101 at rest 108 definition 101 etiology 104 cardiovascular causes 104, f104 non cardiovascular causes 104 evaluation 105 aggravating factors 106 duration 105 mode of onset 105 severity 106 functional classification 106 for congenital heart diseases 108 NYHA 106 specific activity scale 107 pathogenesis 101, t102 quantifying the severity t108 relieving factors 111 variants 109, t109 orthopnea 109, f110 PND 109 platypnea 110, f111 tachypnea 110 trepopnea 110 Sinus nodal arrhythmias 580, f581 sick sinus syndrome 584, f585, t585 sinoatrial exit block 583, t584 1st degree 583 2nd degree type I 583, f584 2nd degree type II 583, f584 3rd degree 583 sinus arrhythmia 581, f582, t582 non phasic 582 phasic 582 sinus bradycardia 581, f582, t582 sinus node reentry tachycardia 585, f585 sinus pause or arrest 582, f583 sinus tachycardia 580, f581, t582 inappropriate 581 POTS 581 wandering pacemaker 583, f584 Skin 193, t194 cyanosis 200 icterus 200 nodules 198, t198 Osler nodes 199, f200 peripheral emboli 200 subcutaneous nodules 198, f199 subtle small nodule 198 pallor 200 pigmentation 194, f195 angiofibromas 194, f195 bronze 194 café au luit spots 194 erythema marginatum 194, f195 Janeway lesions 195 multiple lentigines 194 symmetrical vitiligo 195 texture 195 coarse 195 grooved plucked chicken 196, f196 hyperextensible 195, f196 moist 196 xanthomas 196, t197 eruptive 197, f198 tuberous 196 xanthoma striatum palmare 196, f196 xanthoma tendinosum 197, f197 Spine 192, t193, f193 functional scoliosis 193 kyphoscoliosis 192 straight back syndrome 303 Stair case phenomenon 75 reverse stair case phenomenon 75 Syncope 119 cardiac 120, 121, f122 AS 122 aortic dissection 120, 126 arrhythmias 120, 126 atrial myxomas 124, f124 CAD 120, 125 complete heart block 128 HCM 123 MS 123 nitrate syncope 128 pacemaker related 128 RVOTO 124 etiopathogenesis 119, t120 evaluation 137, f137 BP measurement 139 cardiac catheterization 142 carotid massage 139 clinical history 137, t138 CT scan 141 ECG 141 echocardiogram 142 EEG 141 electrophysiological studies 141 HUTT 139 routine blood tests 142 stress testing 142 non cardiac syncope 129, f129 exercised induced 136 metabolic 121, 136 hypoglycemia related 136 hypoxia related 136 neurological 135, 136 cerebrovascular 135 migraine related 135 neuralgias 121, 135 seizure disorders 135 psychogenic 121, 136 vascular 121, 129 carotid sinus hypersensitivity 133 orthostatic 121 situational 130 vasovagal 130, f130 undetermined 121 Systolic murmurs 422, t422, f432 classification 422, f422 early systolic 422 causes 422 holo or pansystolic 428, f429 AP window 431 causes 433 differential diagnosis t429 MR 428 PDA with PH 428 TR 429 VSD 430 late systolic 431 mid sytolic 423, f424 causes 424 functional 427 innocent 428 715 716 INDEX Systolic murmurs (contd.) MR 428 ventricular outflow tract 423, f424, t425 Systolic sounds 362, 396 clicks 399 causes 399 characteristics 399 clinical recognition 399, f400 mechanism of production 399 ejection sounds 396, f397 causes 397 characteristics 397, t396 clinical recognition 397 aortic 397, t396 pulmonary t396, 398 mechanism of production 396 T Teeth 188 delayed dentition 188 malformed teeth 188, t186 peg shaped teeth 188, t186, f189 premature dentition 188 widely spaced teeth, 188, f189 Tongue 189 color 189 glossoptosis 189 macroglossia 189, f190 Tracheal tug 329, f330 Tricuspid valve 22, f22, t22 annulus t22, 23 chordae tendinae 23 types 23 development t19, 22 leaflets 23 papillary muscles 23 Tumor calcification 700 Tumor plop 395, t395 characteristics 395, t395 U Ultrastructure of myocardium 54, t54, f55 cells 54 amoeboid 55, t54 contractile t54, 56, t56 P 48 Purkinje 55 contractile proteins t56, 61 A band 61, f55 H zone 55, f61 I band 61, f55 M line 62, f55 actin 63, f62 myosin 62, f62 myosin isoforms f64, 64 titin t56, 63 tropomyosin-troponin complex 63, f63 Z band f55, 59 diadic cleft t56, 60, f60 intercalated discs 56, 58 desmosome 58, f58 fascia adherens 58 gap junctions f58, 59 sarcolemma 57, f55, t56 sarcotubular system 59, f59 longitudinal sarcoplasmic reticulum 60, t56, f59 T system 59 V Valves of the heart 17, f18 see also individual valves development t19 general description 17 Valvular calcification 693, t696 radiological identification 693, f694 Aortic valve 694, 695, f694, f695 mitral valve 694, 695, f694, f695 pulmonary valve 695 tricuspid valve 695 Vascular calcification 697, t698 aorta 697 coronary arteries 698, f698 LAD 698 LMCA 698 pulmonary artery 697 Venous drainages of heart 31, f31, f32, t32 anterior cardic veins 33 coronary sinus 31 great cardiac vein 33 middle cardiac vein 33 oblique vein of LA 33 posterior vein of LV 33 small cardiac vein 33 Thebesian veins 33 Venous pressure 283 abdominal jugular reflux 286, f286, t287 estimation 283 Gartner’s method 287 May’s sign 287, f288 Ventricular arrhythmias 622 idioventricular rhythm 640 accelerated 640, f640 slow 640, f640 premature ventricular contractions (PVC) 622, f624 common causes t627 differential diagnosis from SVT with aberrent ventricular conduction 630, f631 ECG recognition 623, t627 estimation of risk 629, f630 rule of bigeminy 624, f627 types 627, f629 Ventricular flutter and fibrillation 641, t641 ECG recognition 642, f642 Ventricular tachycardia 630, t633, f631 ECG recognition 631, f632 genesis 631, f631 localizing the site 638 types 633, f634 bidirectional 636 fascicular 637 monomorphic 633, f634, t637 nonsustained 633 narrow QRS tachycardia 637 polymorphic 635 sustained 633 Torsades de pointes 635, f638 W Wide QRS tachycardia 642, f642, f643 differential diagnosis from SVT t645, f646, f647 irregular 643, f644 regular 642, f643 X X-ray chest 661 cardiac borders and chambers 669, f671, t670, t671 aorticopulmonary window 675 arch of aorta 675 ascending aorta 671, f672 azygous vein 671 coarctation of aorta 675, f676 LA appendage 679, f679 LA enlargement 679, f679, f680, f681, t681 left heart border 678 left subclavian artery 682 left superior intercostal vein 675, f675 LV border 680, f680, f681, t681 MPA 676, f677, t677 persistent left SVC 682 RA enlargement 670, t671, f671 right aortic arch 675, f675 right heart border 669 RV 673 RV enlargement 673, f673, t674 unfolding of aorta 675, f668 cardiac contour 666, t669 boot shaped 666, f667 egg shaped 667, f667 flask like 668, f669 globular 667, f667 mitralization 667, f667 shelf like 668 snow man 668, f668 cardiac size 663, t667 INDEX cardiothoracic (CT) ratio 664, f664 transverse diameter 664, f664 volume 665, f666 extracardiac structures 701 bones and joints 703 notching of ribs 703, f704 bronchi and sinuses 701, f702 pleura 701 vanishing tumor 704, f703 situs 701, f704 dextrocardia with situs inversus f703 717 dextrocardia with situs solitus f702 soft tissues 704 in other views 704 LAO 706, f707 left lateral 705, f705 RAO 706, f706 ... BASIC INVESTIGATIONS: CLINICAL ELECTROCARDIOGRAPHY Table 23 .6 ECG intervals Features Findings Ͼ0. 12 0 .20 s Ͻ0. 12 s Յ0. 42 s in men, Յ0.43 s in women Ͻ0.03 s in V1–V2 Ͻ0.05 s in V5–V6 PR interval... axillary line Midaxillary line Horizontal plane of V4–6 V1 V2 V3V4 V5V6 V7 V8 V9 V9R V8R V7R V6RV5RV4RV3R V2R V1R Fig 22 .11 | Location of unipolar precordial leads E20 E30 E50 Fig 22 . 12 | Monitoring... potentials (see Table 22 .3 and Fig 22 .7) 466 BASIC INVESTIGATIONS: CLINICAL ELECTROCARDIOGRAPHY Table 22 .4 Methods of ECG recording Methods Standard method ECG monitoring Ambulatory ECG Telemetry