(BQ) Part 1 book Tips and tricks of bedside cardiology presents the following contents: Systemic hypertension, headache and dizziness; exertional angina and fainting episodes, young hypertensive, exertional fatigue; thin and tall male and early diastolic murmur; severe chest pain, cold and blue hand;...
TIPS AND TRICKS OF BEDSIDE CARDIOLOGY TIPS AND TRICKS OF BEDSIDE CARDIOLOGY Atul Luthra MBBS MD DNB Diplomate National Board of Medicine Consultant Physician and Cardiologist New Delhi, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • St Louis (USA) • Panama City (Panama) • London (UK) • Bengaluru • Ahmedabad • Chennai • Hyderabad • Kochi • Kolkata • Lucknow • Mumbai • Nagpur Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com Offices in India • • • • • • • • • Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: ahmedabad@jaypeebrothers.com Bengaluru, Phone: Rel: +91-80-32714073, e-mail: bangalore@jaypeebrothers.com Chennai, Phone: Rel: +91-44-32972089, e-mail: chennai@jaypeebrothers.com Hyderabad, Phone: Rel:+91-40-32940929, e-mail: hyderabad@jaypeebrothers.com Kochi, Phone: +91-484-2395740, e-mail: kochi@jaypeebrothers.com Kolkata, Phone: +91-33-22276415, e-mail: kolkata@jaypeebrothers.com Lucknow, Phone: +91-522-3040554, e-mail: lucknow@jaypeebrothers.com Mumbai, Phone: Rel: +91-22-32926896, e-mail: mumbai@jaypeebrothers.com Nagpur, Phone: Rel: +91-712-3245220, e-mail: nagpur@jaypeebrothers.com Overseas Offices • North America Office, USA, Ph: 001-636-6279734, e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com • Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: cservice@jphmedical.com Website: www.jphmedical.com • Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: info@jpmedpub.com Tips and Tricks of Bedside Cardiology © 2010, Jaypee Brothers Medical Publishers (P) Ltd All rights reserved No part of this publication and CD-ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher This book has been published in good faith that the material provided by author is original Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s) In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only First Edition: 2010 ISBN 978-93-80704-99-9 Typeset at JPBMP typesetting unit Printed at To My Father Mr PP Luthra who made me & to My Mother Ms Prem Luthra whose fond memories always guide me Foreword With the widespread availability of sophisticated investigative technology, the clinical approach towards the diagnosis of heart disease has undergone a paradigm shift These days, it has become customary to diagnose a cardiac ailment solely on the basis of an electronic report generated by a CATHlab., ECHO-room or EPS-facility Nevertheless, a meticulously taken medical history and a thoroughly performed physical examination have been and will remain indispensable tools to mentally construct a plausible clinical diagnosis of heart disease The electrocardiogram (ECG), chest skiagram (X-Ray) and echocardiogram (ECHO) are simple yet informative diagnostic modalities that have withstood the test of time They elegantly complement the information gathered from medical history and physical examination and they are cost-effective investigations in resource sensitive settings Moreover, since the equipment for these tests are portable, the tests can be conveniently performed at the patient’s bedside and the results interpreted in the light of clinical data I must compliment Dr Luthra for this brilliant and unique title Tips and Tricks of Bedside Cardiology He has elegantly compiled a wide variety of real-world clinical situations encountered during the course of cardiology practice The discussion and clinical pearls after each case description are really worth appreciating Cardiology students preparing for their examinations, resident doctors and paramedical staff working in cardiaccare units as well as non-cardiologist physicians dealing with heart patients are most likely to benefit from this book I wish Atul and his excellent book all success Dr JPS Sawhney Chief of Clinical Cardiology Chairman, Department of Cardiology Sir Ganga Ram Hospital New Delhi, India www.preventivecardiology.in Preface There was a time when heart disease was diagnosed at the bedside of the patient Clinicians were like detectives who would skillfully gather vital diagnostic clues from a thoughtfully taken medical history and a meticulously performed clinical examination Present-day cardiology is replete with a wide variety of high-tech diagnostic tools that seem to have eclipsed the art of making a clinical diagnosis In this scenario, it would be worthwhile to amalgamate the conventional with the contemporary as in several other aspects of life in general and the field of clinical medicine in particular It gives me immense pleasure to present Tips and Tricks of Bedside Cardiology, a harmonious blend of the time-honored clinical approach with the modern technical approach, towards the diagnosis of heart disease The book is formatted as clinical cases, giving the reader an opportunity to mentally construct a plausible diagnosis from symptoms and signs Illustrations of electrocardiograms, chest radiographs and echocardiograms that follow, aid in clinching the diagnosis Each case description is followed by a discussion which incorporates the differential diagnosis in that particular patient The clinical pearls given at the end provide the key ‘take-home’ messages It has been my endeavor to incorporate most cardiac diseases encountered in heart-clinics and ward-rounds but there may be some omissions While avoiding case duplication to the extent possible, some clinically important facts may have been emphasized repeatedly I sincerely hope that the wealth of clinical material presented in a concise, readable and assimilable form will rekindle the romance between the clinician and clinical cardiology These tips and tricks should benefit students undergoing training in cardiology and preparing for examinations as much as they would interest clinicians involved in the care of heart patients Atul Luthra www.atulluthra.in atulluthra@sify.com 102 Tips and Tricks of Bedside Cardiology X-RAY Findings: • Enlarged cardiac silhouette (money- bag appearance) • Narrow basal vascular pedicle • Normal pulmonary vasculature An ECHO was also performed ECHO Finding: • Echo- free space around the heart anteriorly as well as posteriorly Low BP, Raised JVP & Silent Precordium 103 Diagnosis PERICARDIAL EFFUSION Discussion • Pericardial effusion creates an echo-free space between the left ventricular posterior wall and pericardium posteriorly and between the right ventricular free wall and chest wall anteriorly Posterior accumulation of fluid precedes collection of fluid anteriorly The quantity of pericardial fluid can be gauged from the width of the echo-free space on M-mode scan Amount Small Moderate Large Estimating quantity of pericardial effusion from the width of echo-free space Volume Posterior space Anterior space < 100 ml 100-300 ml > 300 ml < cm 1-2 cm > cm — < cm > cm • The causes of a pericardial effusion are: – Infection viral, bacterial, tubercular – Malignancy metastasis, hematogenous – Trauma accidental, surgical – Auto-immune rheumatoid arthritis, SLE – Metabolic uremia, myxedema – Toxic drug-induced, irradiation – Infarction post-MI syndrome (Dressler’s syndrome) • Echo features of cardiac tamponade are: – Large volume of pericardial effusion – Diastolic collapse of right atrium and ventricle The right ventricular free wall merges with the interventricular septum obliterating the right ventricular cavity – Swinging heart during most of the cardiac cycle The heart swings due to undulation of chambers by displacement of fluid within the confines of a stretched pericardial sac 104 Tips and Tricks of Bedside Cardiology Clinical Pearls • Cardiac tamponade is a serious clinical situation in which cardiac function is impaired due to external pressure exerted on the heart by a pericardial effusion Tamponade results from a large volume of effusion or the rapid formation of a small effusion A large effusion can accumulate gradually without causing tamponade if the pericardial sac gets adequate time to stretch • The combination of low BP, raised JVP and muffled heart sounds is known as the Beck’s triad It is characteristic of cardiac tamponade • An appreciable decrease in pulse volume and pulse pressure during inspiration is known as pulsus paradoxus Increased venous return to the right ventricle shifts the IV septum towards the left ventricle thereby reducing the stroke volume It is observed in cardiac tamponade, constrictive pericarditis, pulmonary embolism and status asthmaticus • A beat-to-beat variability in the pulse volume is called pulsus alternans Its ECG counterpart is known as electrical alternans Total electrical alternans involves the P wave, QRS complex as well as the T wave Besides cardiac tamponade, pulsus alternans is observed in severe left ventricular dysfunction • The area of bronchial breathing noted at the left lung base, below the angle of the left scapula, constitutes the Ewart’s sign 27 Case Raised JVP, Edema & Distended Abdomen Patient Profile Age: 48 Sex: Male Built: Lean Chief Complaints • Increasing abdominal girth and ankle edema • Worsening dyspnea and fatigue on exertion Relevant History • Patient complained of vague ill-health for the past months with low grade fever, malaise and loss of appetite • There was no history of cough with expectoration, hemoptysis, chest pain or paroxysmal nocturnal dyspnea • He also denied any past history of heavy alcohol intake, prolonged jaundice, hematemesis or alteration of bowel habits • He did not suffer from diabetes mellitus, hypertension, bronchial asthma or tuberculosis and had no past history of heart disease Physical Examination • • • • • • • • • Ill-looking, slightly tachypneic, no distress Pinched face, thin limbs, protuberant abdomen Anemia +, jaundice +, ankle edema ++ Pulse: 90 BP: 110/ 70 Temp.: 98.8 Resp.: 20 Pulse: rapid and regular, average in volume appreciable fall in volume on inspiration JVP: cm above angle of Louis, deep x and y descent; further rise of JVP during inspiration CVS: Silent precordium; apex beat difficult to locate S1 and S2 normal; high-pitched extrasound (S3) in diastole Chest: clear on auscultation, no crepts audible Abdo : liver edge palpable cm below costal margin; shifting dullness over flanks in lateral position An X-RAY was ordered 106 Tips and Tricks of Bedside Cardiology X-RAY Finding: • Linear pericardial calcification Differences between constrictive pericarditis and restrictive cardiomyopathy Pericardium Myocardium Ventricles Atria LV function MV and TV Constrictive pericarditis Restrictive cardiomyopathy Thick Normal Normal Normal Normal Normal Normal Thick Obliterated Dilated Mildly impaired Regurgitation Raised JVP, Edema & Distended Abdomen 107 Diagnosis CONSTRICTIVE PERICARDITIS Discussion • In pericardial constriction, the pericardium becomes thick, rigid and often calcific Constrictive pericarditis limits the expansion of the ventricles and thus impairs diastolic filling On M-mode, the thickened pericardium appears as dark thick multiple parallel lines Calcification of the pericardium casts a bright reflection • There is abrupt anterior motion of interventricular septum (IVS) in diastole with paradoxical systolic motion Rapid early diastolic descent of left ventricular posterior wall (LVPW) with flat motion in mid and late diastole is also observed • It is difficult to distinguish constrictive pericarditis from restrictive cardiomyopathy by echocardiography Echo features peculiar to restrictive cardiomyopathy are myocardial thickening, small ventricles, large atria, mitral and tricuspid regurgitation and an elevated left ventricular end-diastolic pressure • Constrictive pericarditis is a masquerader of several clinical diseases Signs and symptoms are similar to those of congestive heart failure but right-sided failure is more prominent Hepatomegaly, ascites and edema may be misdiagnosed as cirrhosis of liver if the neck veins are not observed carefully Finally, if a patient is in atrial fibrillation, the diastolic knock may be misinterpreted as an opening snap and the diagnosis of mitral stenosis may be entertained 108 Tips and Tricks of Bedside Cardiology Clinical Pearls • An appreciable decrease in pulse volume during quiet respiration is known as pulsus paradoxus Besides constrictive pericarditis, pulsus paradoxus is observed in cardiac tamponade, chronic obstructive lung disease and status asthmaticus • A raised JVP that paradoxically rises even further during inspiration is known as Kussmaul’s sign Besides constrictive pericarditis, the Kussmaul’s sign is observed in restrictive cardiomyopathy and in right ventricular infarction • The deep x and y descent on the JVP represents the rapid phase of early diastolic ventricular filling This is known as the dip and plateau pattern or the “square- root” sign • A silent precordium with a ‘lost’ apex-beat is a feature of pericardial effusion or constriction, morbid obesity and pulmonary emphysema • The third heart sound in constrictive pericarditis is the pericardial knock It is a sharp and high-pitched sound when compared to the classical S3 The pericardial knock marks the termination of early-diastolic rapid ventricular filling • Due to pericardial constriction, the inferior vena cava is dilated and there is congestive hepatomegaly The spleen is also enlarged and ascites is present These findings are picked up on clinical examination as well as by ultrasonography 28 Case Productive Cough, Dyspnea & Wheeze Patient Profile Age: 58 Sex: Male Built: Heavy Chief Complaints • Increasing dyspnea, cough with purulent sputum, wheezing and fever for the past one week Relevant History • Patient had history of long-standing dyspnea, cough and wheeze He noticed a recent increase in these symptoms along with fever • There was no history of chills or rigors, chest pain, hemoptysis or significant weight loss • Patient admitted to have smoked two packs of cigarettes daily for the last about 25 years Physical Examination • • • • • • • Obviously dyspnic; accessory muscles of respiration working Mild cyanosis of fingers; clubbing of nails; Face puffy and hyperemic; ankle edema++ Pulse: 110 BP: 136/ 84 Temp.: 101 Resp.: 28 Pulse: rapid, regular, good volume, no special character JVP: raised, Trachea: central, Lymph nodes: nil CVS: Apex beat not visible; quiet precordium S1 and S2 difficult to appreciate; P2 louder than A2 Gr III/VI pansystolic murmur in the parasternal area • Chest: increased antero-posterior diameter of the chest; bilateral expiratory rhonchi with scattered crepts • Abdo.: liver edge cm below costal margin, pulsatile; no shifting dullness An ECG was obtained 110 Tips and Tricks of Bedside Cardiology ECG Finding: • Nonprogression of R wave in precordial leads Lab Investigations • Blood counts : Hb 16.8, TLC 14800, N81L17, ESR 42 • Biochemistry : Glucose 88, Creatinine 1.1, Cholesterol 167 Bilirubin 1.2, SGOT 34, SGPT 68 • Bacteriology : Sputum: Gram +ve cocci in pairs; no AFB or fungal hyphae Productive Cough, Dyspnea & Wheeze 111 Diagnosis CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Discussion • Chronic obstructive pulmonary disease (COPD) is the most frequent reason for long-standing productive cough, wheezing and breathlessness on exertion Degree and duration of smoking is related to the onset and severity of COPD • On chest X- ray, features of COPD are: – prominent bronchovascular markings – bilateral hyperlucent lung fields – dilated main pulmonary artery – flattened domes of diaphragm • Nonprogression of the R wave in precordial leads is a feature of COPD Due to clockwise rotation of the heart, the right ventricle underlies most of the precordium giving a rS pattern in all precordial leads • The long-term prognosis of patients with chronic lung disease (obstructive or interstitial) depends upon right ventricular (RV) function RV dilatation and dysfunction, pulmonary hypertension and cor pulmonale all carry a poor prognosis 112 Tips and Tricks of Bedside Cardiology Clinical Pearls • Facial hyperemia and elevated hemoglobin level are indicative of polycythemia as a consequence of chronic hypoxia Central cyanosis is a marker of cardiorespiratory disease with hemoglobin deoxygenation while clubbing of finger-nails is indicative of a chronic lung suppuration • An appreciable decrease in pulse volume during inspiration is known as pulsus paradoxus Besides COPD, other causes of pulsus paradoxus are status asthmaticus, cardiac tamponade and constrictive pericarditis • A raised JVP, enlarged liver and ankle edema are all indicative of right heart failure Heart disease secondary to a chronic lung disorder is cor pulmonale Hyperinflated lung fields are a feature of pulmonary emphysema • Apex beat is not visible or palpable due to hyperinflated lungs Other reasons for apex beat being difficult to locate are morbid obesity and pericardial effusion • A loud pulmonary component (P2) of the second heart sound (S2) is due to pulmonary hypertension A parasternal pansystolic murmur, a raised JVP with rapid y descent and an enlarged pulsatile liver all indicate tricuspid regurgitation secondary to pulmonary hypertension 29 Case Chest Pain & Dyspnea after Air Travel Patient Profile Age: 56 Sex: Male Built: Obese Chief Complaints • Sudden onset of right-sided chest pain with shortness of breath and profuse sweating, followed by a fall on the airport floor Relevant History • Patient undertook a long-haul nonstop flight from New Delhi, India to Toronto, Canada days back • He had undergone a left knee replacement for severe osteoarthritis, months before his journey • He was a known case of hypertension on medication but denied any past history of heart and lung disease or diabetes mellitus • There was no past history of dyspnea or angina on exertion and he never experienced palpitation, dizziness or syncopal episodes Physical Examination • • • • • • • Dyspneic, anxious, pale and diaphoretic Mild anemia and cyanosis, no jaundice or edema Pulse: 120 BP: 90/ 60 Temp.: 99.6 Resp.: 32 Pulse: rapid, regular, feeble and constant in volume JVP: distended neck veins above angle of Louis Limbs: no calf tenderness, Homan’s sign negative CVS: Normal apex beat, visible parasternal heave S1 loud, P2 prominent, no S3 heard No murmur or pericardial rub audible • Chest: decreased chest expansion; reduced air-entry over the base of right lung An ECG was obtained 114 Tips and Tricks of Bedside Cardiology ECG Findings: • Variable R-R interval • Narrow QRS complex • No discrete P waves • Fibrillatory f waves Chest Pain & Dyspnea after Air Travel 115 Diagnosis PULMONARY EMBOLISM Discussion • The long air journey history of a recent surgical procedure, acute chest pain, dyspnea with circulatory collapse and atrial fibrillation favor the diagnosis of pulmonary embolism • Most acute pulmonary emboli not produce the classic findings depicted in this case description They are usually small and they produce little more than slight tachycardia and mild dyspnea • When an embolus is large enough to occlude more than 50% of the pulmonary vasculature, only then acute pulmonary hypertension with right ventricular strain develop • X-ray chest in case of pulmonary embolism may show areas of hypoperfusion, basal atelectasis, elevated dome of diaphragm and a small pleural effusion • The classical ECG findings in pulmonary embolism are: – Sinus tachycardia (Invariable) – Atrial fibrillation (Occasional) – Tall P wave (P pulmonale) – Right bundle branch block – T wave inversion V1 to V3 – An S1Q3T3 pattern 116 Tips and Tricks of Bedside Cardiology Clinical Pearls • Causes of sudden onset of chest pain with dyspnea are: – Myocardial infarction – Aortic dissection – Pulmonary embolism • If the symptoms are preceded by chest trauma or strenuous exercise, other possibilities are: – Spontaneous pneumothorax – Ruptured sinus of Valsalva aneurysm • Pulmonary embolism usually occurs with a background of factors that predispose to deep vein thrombosis (DVT) These factors include prolonged immobility, surgical procedure, lower limb venous disease, congestive heart failure and hypercoaguable state • Low-grade fever, tachypnea, tachycardia and hypotension occur due to loss of pulmonary vasculature and resultant hypoxia If pulmonary infarction also occurs, there are signs of pleuritis and basal atelectasis • Elevation of JVP, presence of left parasternal heave and loudness of the pulmonary component (P2)of second heart sound (S2)all indicate the presence of right ventricular strain ... Daryaganj, New Delhi - 11 0 002, India Phones: + 91- 11- 2327 214 3, + 91- 11- 23272703, + 91- 11- 232820 21 + 91- 11- 23245672, Rel: + 91- 11- 32558559, Fax: + 91- 11- 23276490, + 91- 11- 23245683 e-mail: jaypee@jaypeebrothers.com,... Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 11 0002, India, Phone: + 91- 11- 43574357, Fax: + 91- 11- 43574 314 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 11 0... of aorta are: – VSD and PDA – Bicuspid aortic valve 12 – – Tips and Tricks of Bedside Cardiology Aneurysm of sinus of Valsalva Berry aneurysm, circle of Willis Clinical Pearls • Coarctation of