(BQ) Part 1 book Fundamentals of cardiology presents the following contents: Embryology of heart, anatomy, physiology, arterial pathology, venous pathology. Invite you to consult.
FUNDAMENTALS++ OF+ CARDIOLOGY+ A+CONCISE+REVIEW+BOOK+FOR+ THE+USMLE+STEP+19293+AND+GENERAL+MED+PRACTITIONERS! ! ! ! ! ! www.medrx-education.com + + + + AUTHOR+ CHIRAG!NAVADIA,!MD! ! + TABLE!OF!CONTENTS! CHAPTER!1!6!EMBRYOLOGY!OF!HEART! !10 Vascular+Development+ +12 Fetal+Circulation+ +14 Septation+of+Heart+Tube+ +15 CHAPTER!2!6!ANATOMY! .!19 Mediastinum+ .+19 Internal+Structures+ +23 External+Structures+ +23 Cardiac+Territories+ +24 Cardiac+Projection+ +25 Cardiac+Muscle+fibre+ +27 Conduction+Pathway+ .+28 Coronary+Arteries+ .+29 CHAPTER!3!6!PHYSIOLOGY! !31 Concepts+of+Preload,+Ejection+Fraction+&+Cardiac+Output+ .+31 Concepts+of++Velocity,+Area,+Resistance+and+Flow+ .+33 Auto9Regulation+of+Blood+Flow+ +35 Resistance+In+Series+And+Parallel+Circuits+ +36 Blood+Pressure+ +38 Compliance+and+Elasticity+of+Vessels+ .+42 Relationship+Between+Contractility+&+Preload+ +45 Action+Potential+ +48 Normal+ECG+ +50 Autoregulation+of+Blood+Pressure+ .+51 ! Baroreceptor+reflex+ +52 Renin9Angiotension9Aldosterone+System+ +53 Phases+of+Cardiac+Cycle+ +55 Valvular+Problems+and+Pressure9Volume+Loops+ +57 Ventricular+Pressure+Testing+ .+62 Heart+sounds+ .+64 Murmurs+ .+66 Effect+of+Posture,+Amyl+Nitrate+&+Arterioconstriction+on+Murmurs+ +73 Jugular+venous+pressure+ +74 CHAPTER!4!–!ARTERIAL!PATHOLOGY! !77 Hypertension+ +77 Hypertension+in+Pregnancy+ +86 Hypertensive+Crisis+ +87 Arteriosclerosis+ +90 Monckeberg!arteriosclerosis! !90 Arteriolosclerosis! !92 Atherosclerosis! !93 Aneurysms+ +98 Aortic+Dissection+ .+101 Coarctation+of+Aorta+ +106 Vasculitis+ +109 Raynaud+Phenomenon+ +115 Tumors+ +118 CHAPTER!5!–!VENOUS!PATHOLOGY! !120 Venous+System+of+Leg+ +120 Varicose+Veins+ +120 Deep+Venous+Thrombosis+ +123 Superficial+Thrombophlebitis+ +127 Leg+Ulcers+ +128 CHAPTER!6!6!CARDIAC!PATHOLOGY! !130 Ischemic+Heart+Disease+ .+130 Cardiac+Arrest+vs+Respiratory+Arrest+ +149 Cardiopulmonary+Resuscitation+ +150 Broken+Heart+Syndrome+ .+153 Heart+Failure+ +156 Left!Heart!Failure! !156 Right!Heart!Failure! !160 High!Output!Heart!Failure! !161 Cardiomyopathy+ +163 Dilated!Cardiomyopathy! .!163 Restrictive!Cardiomyopathy! !164 Hypertrophic!cardiomyopathy! !165 Arrhythmogenic!Right!Ventricular!Cardiomyopathy! .!168 Peripartum!Cardiomyopathy! !171 Circulatory+Shock+ +174 Myocarditis+ .+180 Pericarditis+ .+182 Constrictive+Pericarditis+ .+184 Cardiac+Tamponade+ +185 Valvular+Pathology+ +188 ! Infective!Endocarditis! !191 Aortic!stenosis! !197 Aortic!regurgitation! !200 Rheumatic!Heart!Disease! !202 Mitral!Stenosis! !205 Mitral!Regurgitation! .!208 Tricuspid!Regurgitation! .!210 Tricuspid!Stenosis! !211 Pulmonary!Stenosis!and!Regurgitation! !212 CHAPTER!7!6!CONGENITAL!HEART!DISEASE! !215 Acyanotic+condition+ .+216 Atrial!Septal!Defect! !217 Ventricular!Septal!Defects! !218 Patent!Ductus!Arteriosus! .!220 Cyanotic+conditions+ .+222 Tetralogy!of!Fallot! !222 Transposition!of!the!great!vessels! !224 Tricuspid!atresia! .!225 Valvular+Defects+ .+226 Coronary!Artery!Abnormalities! !227 Other!Congenital!Cardiac!Pathology! !228 CHAPTER!8!6!ARRHYTHMIAS! .!230 Narrow+QRS+Complex+ +230 Wide+QRS+Complex+ +236 Torsade9de9Pointes+ +240 Sinus+Tachycardia+ +241 Wolf+Parkinson+White+Syndrome+ +242 Focal+Junctional+Tachycardia+ +243 Multifocal+Atrial+Tachycardia+ +243 Premature+Atrial+Contractions+ +244 Heart+Blocks+ .+247 First!Degree!AV!Block! !247 Second!Degree!AV!Block!(Mobitz!Type!1)! !248 Second!Degree!AV!Block!(Mobitz!Type!2)! !249 3rd!Degree!AV!Block! .!250 SA!BLOCK! !251 Right!&!Left!Bundle!Branch!Blocks! !251 Brugada!syndrome! !254 CHAPTER!9!–!CARDIAC!TUMORS! !256 Benign+tumors+ +256 Malignant+Tumors+ +257 CHAPTER!10!6!CARDIAC!PHARMACOLOGY! !258 Antiarrhythmic+drugs+ +258 Antihypertensive+drugs+ .+263 Antihyperlipidemic+drugs+ +267 Anticoagulants+ +269 Non+Pharmacological+Treatments+ +271 ! ! INTRODUCTION! Hello+friends,++ This+is+your+boy+Dr.+Navadia+and+I+am+very+happy+to+present+this+comprehensive+clinical+ review+book+of+“Cardiology”+for+the+USMLE+and+all+general+med+practitioners.+ This+book+mainly+focuses+on+fundamental+clinical+concepts+of+“USMLE+step+19293”+and+“ABIM”+ exam,+that+will+serve+as+a+base+for+your+future+clinical+practice.++ Book+begins+with+basic+“USMLE+Step+1”+concepts+of+anatomy+and+physiology+that+will+be+ helpful+to+any+new+learner.+After+reviewing+preclinical+topics,+there+is+a+brief+description+of+ “cardiovascular+medicine”+that+systematically+describes+cause,+mechanism,+clinical+association,+ investigation!of!choice!and!primary!managements!that+will+play+a+vital+role+for+your+Step+29 3,+IM/FM+board+exam+prep+or+day9to9day+practice.+ Most+of+the+investigation+and+managements+are+referred+from+reputed+cardiology+resources+ like+AHA,+AMA,+Medscape,+JACC,+NCBI,+Pubmed+and+so+on.+As+this+book+is+not+for+cardiologist,+ all+contents+are+selected+accordingly+to+make+this+book+an+easy+learning+guide+for+med+ students,+interns,+nurse+practitioners,+physician+assistants+and+even+general+physicians.+ “THUNDERNOTES”+is+a+new+concept+that+we+adapted+for+this+book.+‘Thundernotes’+are+side+ notes+that+connect+you+with+other+relevant+topic+of+different+subject.+At+the+end,+there+is+a+brief+ summary+of+“Step+1”+cardiac+pharmacology+that+describes+each+drug+with+its+mechanism+and+ common+side+effects.++ I+want+you+to+end+this+book+with+smiling+face+!.+In+case,+if+you+don’t+like+this+book+or+the+ content+you+wanted+to+review+is+not+covered+in+this+book,+I+am+ready+to+refund+your+full+ purchase+price+as+a+part+of+149day+full+money+back+guarantee.+If+you+can+give+me+your+two+ minutes,+please+leave+495+stars+rating+on+amazon.++ + Best+wishes+for+your+brilliant+future+ + Sincerely,! CHIRAG!NAVADIA,!MD! IMPORTANT!NOTICE! ++++All+printed+and/or+digital+content+is+for+educational+and/or+learning+use+only.+MEDRX+is+not+ responsible+for+the+use+of+any+knowledge,+information+or+facts+gained+from+the+printed+and/or+ digital+content+in+the+practice+of+medicine,+medical+research+or+any+related+medical+or+science+ applications.+ In+addition,+while+materials+available+in+this+book+may+be+useful+for+medical+coursework+ examinations+and+qualifying+examinations+such+as+the+NCLEX™,+USMLE™+and+ABIM™,+you+ understand+that+MEDRX+is+not+affiliated+with+any+other+third+party+and+does+not+(directly+or+by+ implication)+make+any+guarantees+that+the+materials+provided+by+us+will+be+tested+on+these+ examinations.++ 95%+of+the+investigations+and+management+mentioned+in+this+book+are+from+year+201092014,+ however+you+realize+that+errors+can+occur+and+thus+managements+mentioned+in+this+book+ should+not+be+directly+use+in+clinical+practice+without+any+guidance.+We+are+not+responsible+for+ any+harm+done+to+anybody+by+the+managements+mentioned+in+this+book.++ Finally,+we+want+to+hear+what+you+would+like+to+improve+in+our+book?+This+will+help+us+to+ create+even+better+subsequent+editions.+If+you+can+give+your+2+minutes,+please+leave+us+495+star+ feedback+on+amazon.+If+you+even+think+about+193+stars,+please+contact+us+through+our+website++ &+we+will+consider+to+refund+you+your+full+purchase+price+(book+must+be+purchased+from+our+ website+or+amazon.com+official+store+(not+valid+on+purchases+from+amazon+private+sellers+or+ other+places).+ TO+THE+PUBLISHERS++9+Certain+images+were+freely+available+on+internet+and+we+had+adapted+ some+of+them+with+full+credits.+Most+of+the+images+are+taken+with+permission,+however+we+ were+unable+to+reach+at+all+places+or+don’t+know+the+real+owner+in+few+cases.+If+anybody+have+ any+objection+for+the+image+use+in+this+book,+feel+free+to+contact+us+through+our+website+and+ that+particular+image+will+be+removed+immediately.++ + ! + SPEACIAL!THANKS! ! To#my,## Family#–!for!being!with!me!all!the!time! Friends#(Zafar,#Talli,#Zatu,#SG,#Ira,#Pasha#and#others)#–#for!not!allowing!me!to!get!into! depression! College#professors#–#for!being!so!strict!with!me!!!that!encouraged!me!to!study!hard! Dr.#Satani#and#Dr.#Reiyani##–!for!giving!me!wonderful!guidance!and!motivation!for!my!board! exams! Dr.#Patel#and#Dr.#Prajapati#–!for!giving!me!wonderful!clinical!experience! Tutors#of#Kaplan#Medical,#First#Aid#Team,#Dr.#Fischer,#and#Dr.#Goljan#–!for!being!an! extraordinary!tutors!in!my!journey!of!medicine.! + ! # # Printed#in#the#United#States#of#America# Print#number:#0#9#8#7#6#5#4#3#2#1# MSRP:#$40.00# # + All!Rights!Reserved!©!2015!Chirag!Navadia! Certain!images!were!freely!available!on!Internet!&!belong!to!their!owner.!No!part!of!this! book!may!be!reproduced!in!any!form!by!photography,!microfilms,!xerography!or!any!other! mean,!or!incorporated!into!any!information!retrieval!system,!electronic!or!mechanical,! without!the!written!permission!of!Chirag!Navadia.! ! CHAPTER!1!6!EMBRYOLOGY!OF!HEART ! • The!heart+develops+from+splanchnic!mesoderm+in+later+half+of+3rd!week+and+starts+ beating+by+4th!week.!! • Neural+crest+cell+migration+play+an+important+role+in+heart+development.+ • Single+heart+tube+is+formed+by+the+fusion+of+primordial+heart+tubes+that+are+in+turn+ developed+from+cardiogenic!cells.+Heart+tube+will+then+undergo+dextral!looping+ (bend+to+right)+and!rotation.+! • Heart+tube+will+undergo+further+morphological+changes+and+will+give+rise+to+various+ embryological+dilations+like+truncus+arteriosus,+bulbus+cordis,+primitive+ventricle,+ primitive+atrium+and+sinus+venosus.+ + Image+Courtesy+9+http://embryology.med.unsw.edu.au+ + Various+adult+structures+are+derived+from+these+dilations,+which+are+as+follow+9+ EMBRYONIC!STRUCTURE! ADULT!DERIVATIVE! Truncus!arteriosus! Ascending+aorta,+Pulmonary+trunk,+Semilunar+ valves+ Bulbus!cordis! Smooth+part+of+left+ventricle+(aortic+vestibule)+ &+right+ventricles+(conus+arteriosus)+ Primitive!atria! Trabeculated+part+of+atria++ Primitive!ventricles! Trabeculated+part+of+ventricles+ COARCTATION OF AORTA + COA+is+narrowing+of+aortic+segment.+ Generally,+patients+with+COA+presents+early!in!life!with!CHF+or+later!in!life!with! hypertension+ CLASSIFICATION! • Congenital+form+9+Narrowing+is+prior+to+ligamentum+arteriosus+(pre6ductal)+ • Adult+form+–+Narrowing+is+distal+to+ligamentum+arteriosus+(post6ductal).!Usually+ associated+with+bicuspid+aortic+valve,+turner+syndrome,+patent+ductus+arteriosus.+ + PATHOGENESIS!AND!SYMPTOMS! Neonates! • COA+is+due+to+medial+wall+thickening+in+segment+of+aorta.+In+infants+it+can+develop+into+ congestive+heart+failure.+ • In+severe+COA,+sudden+closure+of+ductus+arteriosus+will+result+in+sudden+rise+in+left+ heart+pressure,+this+will+result+in!opening!of!foramen!ovale+&+thus+left+to+right+shunt+ –+Right+ventricular+dilation.+ • If!foramen!ovale!does!not!open+than+blood+backs+up+in+pulmonary+circulation+&+will+ develop+right+ventricular+failure.++Cardiomegaly+&+Right+sided+hypertrophy+can+be+ seen+on+ECG+or+Echo.++ • Young+patients+may+present+in+the+first+few+weeks+of+life+with+poor+feeding,+tachypnea,+ and+lethargy+and+progress+to+overt+CHF+and+shock.+ • These+patients+may+have+appeared+well+prior+to+hospital+discharge+and+deterioration+ coincides+with+closure+of+the+patent+ductus+arteriosus.+ Adults! • Blood+flow+in+the+branches+prior+to+narrowing+increases+and+decrease+distally+ resulting+in+high+blood+pressure+in+upper+extremity+while+low+blood+pressure+(+>+ 10mmHg)+in+the+lower+extremities.++ ! • Other+symptoms+include+claudication!in!lower!extremities+(Pain+in+calf+and+ buttocks)+with+prolonged+continous+walking.++ • Further+increase+in+blood+pressure+will+occur+chronically+due+to+activation+of+RAAS+ system+(low+renal+perfusion)+(In+some+cases+–+Renin+level+will+be+normal)+ • Due+to+high+pressure+in+upper+body,+collateral+vessels+can+form+between+the+internal+ thoracic+subclavian+artery+&+aorta.+Thus+some+blood+will+flow+from+Ascending+aorta+–>+ Internal+thoracic+artery+–>+Intercoastal+arteries+–>+Descending+aorta.+ • Other+presenting+symptoms+may+include+headaches,+chest+pain,+fatigue,+or+even+life9 threatening+intracranial+haemorrhage+(due+to+rupture+of+berry+aneurysm)+ • Chest+X+ray+will+show+rib+notching+below+the+ribs+due+to+continuous+high9pressure+ pulsation+in+intercostal+arteries.++ • Can+complicated+into+Aneurysm+prior+to+coarctation+(in+aorta+or+circle+of+Willis+–+ Berry+aneurysm)+or+aortic+dissection+due+to+high+pressure+ + INVESTIGATIONS! • Laboratory+studies+in+neonatal+patients+who+present+in+shock+include+blood,+urine,+and+ cerebral+spinal+fluid+(CSF)+cultures,+electrolyte+levels,+BUN,+creatinine,+and+glucose+ concentrations.+ • Measure+arterial+blood+gas+and+serum+lactate+level+(because+sepsis+and+CHF+will+have+ similar+presentation)+ • Echocardiography+is+most+specific+test+(in+95%+case)+for+all+congenital+heart+disease+ in+neonates.! • • • Laboratory+studies+in+older+patients+who+present+with+hypertension+include+ urinalysis,+electrolyte+levels,+BUN,+creatinine,+and+glucose+concentrations.+ + Chest+X+Ray,+ECG+and+Echocardiography+for+COA.+ + MRI+and+CT+are+useful+in+older+or+postoperative+patients+to+assess+residual+arch+ obstruction,+arch+hypoplasia,+or+formation+of+aneurysms++ + + + + Rib+notching+(lateral+292+arrows/red+arrows),+Aortic+knob+(upper+ arrow/yellow),+Coarctation+(middle/blue+arrow),+Post+aortic+ MRI,+www.medglobus.ru+ dilation+(Lower/green+arrow),+www.radiographia.ru+ + MANAGEMENT! • First+stabilize+the+patient+(Diuretics,+Prostaglandin+E2+(to+open+ductus+arteriosus+–+in+ neonates)+&+then+do+surgery+(best+therapy).+ • In+adults,+if+narrowing+is+mild,+surgery+is+usually+not+required.+ • Treat+with+antihypertensive+therapy+like+B9Blockers+&+diuretics+(best+initial+therapy).+ • ACEi/ARBs+may+have+adverse+effect+because+it+will+result+in+severe+hypotension+in+ lower+extremity.+ • Inotropes+can+be+added+if+left+ventricular+dysfunction+had+developed.+ + ! VASCULITIS+ Vasuclitis+is+basically+and+inflammation+of+the+blood+vessel+wall+that+is+usually+due+to+ autoimmune+phenomenon.+ CLASSIFICATION! • Large!vessel!vasculitis!–+Involes+the+aorta+and+its+major+branches+–+Giant+cell+ arteritis,+Takayasu+arteritis+(Giant!Takayasu)! • Medium!vessel!vasculitis!–+Involves+muscular+arteries+–+Polyarteritis+nodosa,+ Kawasaki+disease,+Buergers+disease+(thromboangitis+obliterans)+(Nodosa+goes+to+ Burger+king+on+his+Kawasaki!bike)+ • Small!vessel!vasculitis!–+Involves+arterioles+&+capillaries+–+Wegner’s+granulomatosis,+ Microscopic+polyangitis,+Churg9Strauss+syndrome.+(Microscopic+Chucky+infects+ Wegner)+ + VASCULITIS! Temporal!giant! cell!arteritis! PATHOGENESIS! SYMPTOMS! FEATURES! Segmental+ granulomatous+ inflammation+ Headache+ (temporal+a.),+ Visual+disturbances+ Associated+with+polymyalgia+ rheumatica+(normal+ creatinine+kinase),+elevated+ involving+ branches+of+ (opthalmic+a.,+ usually+unilateral),+ ESR!>!60+(first+test+to+do+on+ suspect+because+100%+ carotid+artery+ Jaw+claudication,+ fever,+myalgia+ sensitive).+If+ESR++50+years+ Multinucleated+giant+cells+and+ intimal+fibrosis+on+biopsy+ with+new+onset+ headache+and+jaw+ (taken+from+multiple+ segments),+fragmentation+of+ pain+when+ chewing]+ internal+elastic+lamina+ common,++>+50+ years+ Rx+is+immediate+ corticosteroids+(even+before+ biopsy)+to+prevent+ irreversible+blindness+ Takayasu! Same+like+giant+ Visual+disturbances,+ Elevated+ESR,+Blood+pressure+ pulseless! arteritis! cell+arteritis+ Neurological+ symptoms+due+to+ in+legs+is+>+10+mmHg+ compared+to+upper+ Involves+aortic+ diminished+blood+ flow,+fever.+ Arthritis,+Myalgia.+ extremities+(In+contrast+to+ coarctation+of+aorta+where+ upper+extremity+pressure+is+ arch+at+branch+ point+ Young+Asian+ females,+