Hok

Anteroseptal Wall Myocardial Infarction

Chapter 13 THE ECHOCARDIOGRAM ISCHEMIC HEART DISEASE Echocardiography in Coronary Heart Disease Although originally of greatest value in valvular heart disease and cardiomyopathy, echocardiography has now become one of the most important techniques for the detection and quantitative assessment of myocardial ischemia and infarction. Cardiac ultrasound-because it is rapid, portable, noninvasive, and inexpensive-is especially well suited to the evaluation of ischemic heart disease. Although...

Congenital Heart Disease

About one million persons in the United States have congenital cardiovascular disease, and each year an estimated 32,000 babies, about 8 per 1000 live births, are born with this disease.2,43 Of the new cases, 8 to 13 percent have atrial sepal defects, 6 to 11 percent have patent ductus arteriosus, and 20 to 25 percent have ventricular sepal defects. The prevalence of congenital heart disease at birth as determined during the infant's brief stay in the hospital is likely to be underestimated,...

Coronary Heart Disease

CHD kills and disables people in their most productive years and in 1999 was estimated to account for 53 billion in medical care costs and 47 billion in indirect economic costs.2 Each year there are more hospitalizations for CHD than for any broad diagnostic group, with the exceptions of births, all respiratory diseases, all digestive diseases, and all injuries.8 In the United States, an estimated 12 million people have CHD, about one-half of whom have acute MI and half have angina pectoris.2...

Endothelial Dysfunction And Vascular Smooth Muscle Abnormalities

In general, the normal endothelium is in an inhibitory mode-inhibiting contraction, thrombosis, white cell adhesion, and vascular smooth muscle growth (Q-hB Figs. 6-4 and 6-5). Endothelial dysfunction is one of the important concepts that has developed in vascular biology over the last decade. Implicit in the term is the recognition that the fundamental or normal functions of the endothelium are not fixed, but are mutable. Thus, the endothelium in a given area may lose its vasodilator...

Edema And Ascites

Edema is a common symptom or finding in patients with right- or left-sided heart failure. Fluid retention in heart failure results from increased venous pressure and abnormal activity of salt-retaining hormones (see Chap. 20). In an average-sized person, 5 to 10 lb of excess fluid is required for edema to become apparent a history of recent weight gain often will correlate with a deterioration in clinical status. The amount of weight loss in response to treatment for heart failure in the past...

Cardiovascular Diseases In The United States And Prevention Approaches

Kannel, Halit Silbershatz, Ralph B. D'Agostino, Sr. The large and long-term decline in mortality from the cardiovascular diseases accounted for almost 4 of the 5.6-year increase in life expectancy in the United States attained between 1965 and 1995.1 The 55 percent decline in the age-corrected death rate for total cardiovascular disease between 1950 and 1996 indicates the extent to which these leading causes of death are subject to preventive and therapeutic...

Insomnia

The most common causes of insomnia are mental conflict, emotional disturbances, and depression. Heart failure, however, also may cause insomnia. The patient with Cheyne-Stokes respirations (see above) may sleep during the apneic phase and wake during the hyperpneic phase of the condition. Occasionally, patients with pulmonary congestion due to heart failure have insomnia before they develop nocturnal Classification of Cardiac Disability Several classifications have been proposed and used for...

Cardiovascular Diseases

Coronary Artery Disease Statistics

Major Cause of Morbidity and Mortality The most common cardiovascular diseases are hypertension and heart disease, but the basis for most cardiovascular diseases is atherosclerosis, which is almost universally present in U.S. adults and is manifest clinically as coronary heart disease (CHD), cerebrovascular disease (stroke), or peripheral arterial disease. The likelihood of developing one of these diseases is high, and they affect the health of nearly 59 million Americans.2 In 1999, these...

Chronic Rightsided Heart Failure

Right Sided Heart Failure Patient

Chronic right-sided heart failure has a number of causes. The common ones include congenital pulmonary stenosis, Ebstein's anomaly, severe chronic obstructive pulmonary disease, and recurrent pulmonary thromboembolic disease. Diffusely decreased pulmonary vascularity with unusually lucent lungs is seen in patients with right-sided heart failure without pulmonary hypertension see Fig. 12-7Q. Centralized PBF pattern is encountered when the right-sided heart failure is secondary to precapillary...

Rix

Decreased Ejection

Chapter 10 THE HISTORY, PHYSICAL EXAMINATION, AND CARDIAC AUSCULTATION HEART MURMURS A cardiac murmur is defined as a relatively prolonged series of auditory vibrations of varying intensity loudness , frequency pitch , quality, configuration, and duration.273 Although the exact physical principles that govern the production of murmurs have been debated for years, most authorities now agree that turbulence is the prime factor responsible for most murmurs. Turbulence arises when blood velocity...

Lkd

Myogenic Response

Chapter 3 NORMAL PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM THE CORONARY CIRCULATION Anatomic and Mechanical Considerations The right and left main coronary arteries CAs arise at the root of the aorta and provide the blood supply to the myocardium. The right CA normally supplies the inferior surface of the LV, the RV and RA, whereas the left CA divides into circumflex and anterior descending branches that perfuse the rest of the LV and the LA. In about 10 percent of cases the left circumflex...

S

Periarteritis Nodosa

Chapter 10 THE HISTORY, PHYSICAL EXAMINATION, AND CARDIAC AUSCULTATION Inspection of the smaller vessels of the body is possible in only three areas the retina, the conjunctiva, and the nail beds. The ophthalmoscope has made the retina by far the easiest and most rewarding site.201 Viewing this two-dimensional vascular display is generally much easier if the pupils are dilated. Pulse and blood pressure determinations should be made prior to the instillation of rapidly acting mydriatics, since...

Heart Failure

Heart failure is the end stage of cardiac disease after the myocardium has used all its reserve and compensatory mechanisms. Once overt signs appear, half of patients die within 5 years despite medical management.32 Heart failure is most often a consequence of hypertension, CHD, valve deformity, diabetes, or cardiomyopathy. The various etiologies tend to coexist. CHD, frequently accompanied by hypertension, is responsible in more than 50 percent of cases and has been increasing in prevalence...

Functional Anatomy Of The Heart

Anatomy The Heart Has Four Chambers

Edwards, A. Jamil Tajik, James B. Seward BACKGROUND The study of the heart and great vessels has come a long way since the days of Andreas Vesalius, the great 16th-century anatomist who recognized the impact of anatomy on the practice of medicine. During the European Renaissance, the tomographic approach to the study of cardiac anatomy became popular because of its artistic-based correlations. This is vividly depicted in the drawings of Leonardo da Vinci2...

Echo Speckled Appearance

Speckled Pattern Echocardiogram Amyloid

Chapter 13 THE ECHOCARDIOGRAM THE CARDIOMYOPATHIES The evaluation of cardiomyopathy is complicated by the fact that few specific diagnostic criteria exist, and identification is often a process of exclusion. Further, many potential etiologies may be responsible for the myopathic process, and it may be possible to identify a specific etiology in only the minority of patients. Accordingly, a diagnostic strategy has evolved that initially seeks to place patients into one of three pathophysiologic...

Flail Mitral Leaflet

Flail Mitral Valve Leaflet

Figure 10-62 The apex phonocardiogram is displayed simultaneously with the cardiac cycle, as recorded by high-fidelity catheter-tipped micromanometers in the central aorta, left ventricle LV , and left atrium LA . The first high-frequency component of Mj is coincident with the downstroke of the left atrial cwave and is separated from left ventricular-left atrial pressure crossover by an interval of 30 ms. From Shaver JA, Saderni R, Reddy PS, et al. Normal and abnormal heart sounds in cardiac...

Indirect Methods

The invention of the pneumatic cuff manometer Riva-Rocci, 1896 and the subsequent discovery and use of the arterial sounds Korotkoff, 1905 permitted indirect measurement of the arterial pressure. The mercury manometer is the gold standard, and the more fragile aneroid manometer should be calibrated against the mercury manometer at least every 6 months. Semiautomatic electronic devices, if used, should be validated according to Association for the Advancement of Medical Instrumentation AAMI...

Enlarged Aortic Root Left Atrial Enlargement Sigmoid Septum

Pectinate Muscles And Crista Terminalis

Figure 2-35 Various locations of left ventricular false tendons. A. Two false tendons arrows from posteromedial mitral papillary muscle PM to ventricular septum VS , representing the most common location. . . Complex branching false tendon arrows with origin from the left ventricular free wall FW and insertions into the ventricular septum VS and base of posteromedial mitral papillary muscle PM . Prominent left ventricular trabeculations26 are another common anatomic normal variant that may be...

Abnormal Splitting

All conditions in which abnormal splitting of S2 exists can be identified at the bedside by the presence of audible expiratory splitting gt 30 ms -i.e., the ability to hear two distinct sounds during expiration246 see -H Fig. 10-71 . This finding must be present when the patient is auscultated in both the supine and upright positions. There are three causes of audible expiratory splitting 1 wide physiologic splitting primarily due to delayed P2, 2 reversed splitting primarily due to delayed A2,...

Mitral Valve Endocarditis

Marantic Endocarditis Tee

Chapter 13 THE ECHOCARDIOGRAM INFECTIVE ENDOCARDITIS Infective endocarditis remains an all too common illness, with a significant risk of morbidity and mortality see also Chap. 78 . Traditionally, the diagnosis has been based on either the cumulative results of blood cultures, physical examination, and laboratory findings or on pathologic proof of infected valvular vegetations at surgery or autopsy. Echocardiography may play an important role in infective endocarditis in regard to diagnosis,...

Lfl

Pericarditis Constrictive Roentgen

Figure 12-4 Patient with situs ambiguous, interruption of the inferior vena cava, ventricular septal defect, and polysplenia. A. Posteroanterior view shows that the aortic arch and the heart are left-sided and the stomach lower arrows is right-sided. The azygos vein upper arrow is markedly enlarged. The heart is mildly enlarged, and there is a moderate increase in pulmonary vascularity. B. Lateral view shows an absent image of the inferior vena cava. The azygos arch arrow is markedly dilated....

Info

Left Posterolateral Accessory Pathway

Source Used with permission from Castellanos and Myerburg.15 Table 11-3 Criteria for Diagnosis of Pure Left Anterior Fascicular Block 1. Abnormal left-axis deviation usually between -45 and -60 2. rS complexes in leads II, III, and aVp and qR complexes in leads I and aVp 3. Delayed intrinsicoid deflection in leads I and aVp 4. Peak of r wave in lead III occurring earlier than peak of r wave in lead II 5. Peak of R wave in lead aVp occurring earlier than peak of R wave in aVR Source From...

Left Ventricular Pseudotendon

Hyperdominant Lad

Collage of anatomic sections obtained by bread slicing the heart in its short-axis plane, corresponding to the tomographic sections obtained by echocardiography and SPECT imaging, viewed from the apex toward the base of the heart. B. Comparable sestamibi SPECT images of the left ventricle showing normal myocardial perfusion at rest and with exercise. SA, short axis. Figure 2-58 Schematic diagram of the three levels of short-axis tomographic views used in...

The Fourth Heart Sound

Heart Sound Separation Ecg

Precordial vibrations resulting from atrial contraction are normally neither palpable nor audible. Under pathologic conditions, forceful atrial contraction generates a low-frequency sound S4 just prior to Si also termed the atrial diastolic gallop or the presystolic gallop . Atrial contraction must be present for production of an S4. It is absent in atrial fibrillation and in other rhythms in which atrial contraction does not precede ventricular contraction. The S4 follows the onset of the P...

Continuous Murmurs

A continuous murmur is defined as one that begins in systole and extends through S2 into part or all of diastole. It need not occupy the entire cardiac cycle therefore, a systolic murmur that extends into diastole without stopping at S2 is considered to be continuous even if it fades completely before the subsequent Sj. A physiologic classification of continuous murmurs as described by Myers320 is detailed in Table 10-13. Table 10-13 Physiologic Classification of Continuous Murmurs Continuous...

Eud

Abnormal Mons Pubis

View Contents in a Separate Window Chapter 11 THE RESTING ELECTROCARDIOGRAM NONSPECIFIC ST-SEGMENT-T-WAVE CHANGES While it seems more appropriate to discuss ST-segment and T-wave changes separately, they will be dealt with together because of their often coexistence. While nonspecific or rather, nondiagnostic ST-segment-T-wave changes are the most commonly diagnosed ECG abnormalities, they have not been categorized adequately and represent different findings for various interpreters.45 In the...

Endothelial Influences On Vascular Smooth Muscle Contractility

Although the importance of the endothelium as a nonthrombogenic surface has been known for some time, its role in modulating arterial tone was unrecognized until the early 1980s, when Furchgott and Zawadski187 observed that this cell type was obligatory for the relaxation response to acetylcholine. Although cholinergic vasodilation in vivo had been recognized, its mechanism was difficult to study because the event rarely could be reproduced in vitro. In their landmark paper, Furchgott and...

Examination Of The Arterial Pulse

All major arterial pulses should be examined bilaterally for both patency and waveform characteristics. The thickness and hardness of the arterial walls often can be assessed by rolling the vessel against underlying tissue. A pulse in the foot should not be considered absent unless examined with the foot in a dependent position. Otherwise, the arterial pulses usually are examined with the patient supine and with the trunk of the body slightly elevated. The examiner uses tactile receptors in the...

Diastolic Regurgitant Murmurs

Holodiastolic Aortic Regurgitant Murmurs The early diastolic murmur of aortic regurgitation is blowing and high-pitched in character and is often more difficult to record than to hear because of its high-frequency content. Since isovolumic relaxation of the left ventricle is very rapid, a large gradient quickly develops between the aortic and LV diastolic pressures, and the murmur builds up to maximum intensity almost immediately after A2. As diastole progresses, the gradient between the two...

Molecular Development Of The Heart Tube

Molecular Formation Heart

Morphogenesis of the heart begins with the initial patterning of the embryo that determines the three axes of the embryo anterior-posterior, dorsal-ventral, and left-right. These axes are imprinted onto the cellular program as cell populations expand to form the embryo and extraembryonic tissues. Specific genes have been identified that alter axis determination in a range of species, including the mouse. 2, 3 After determination of the embryo axes, subpopulations of cells are programmed in a...

Table 1011 Fourth Heart Sound S4 Atrial Diastolic Gallop and Presystolic Gallop

Physiologic-recordable rarely audible Left or right ventricular outflow obstruction Excessively rapid late diastolic filling secondary to Acute atrioventricular valve incompetence An audible S4 with a palpable presystolic impulse is common in patients with ischemic heart disease during an acute episode of angina and in the early phases of transmural MI. Its prevalence is also increased with prior MI however, audible fourth heart sounds in patients with ischemic heart disease without prior...

Elevated Venous Pressure

Ecg Waveform For Tricuspid Atresia

The most common cause of an elevated jugular venous pressure is an increased RV pressure such as occurs in patients with pulmonic stenosis, pulmonary hypertension, or RV failure secondary to left-sided heart failure or RV infarction. The venous pressure also is elevated when obstruction to RV inflow occurs, as with tricuspid stenosis or RA myxoma, or when constrictive pericardial disease impedes RV inflow. It also may result from vena cava obstruction and, at times, an increased blood volume....

Clinical Significance Of Transverse Pericardial

Intervalvular Fibrosa Abscess

Chapter 2 FUNCTIONAL ANATOMY OF THE HEART CORRELATIVE ANATOMY This section in this chapter is an illustrated review of applied cardiac anatomy. The clinical significance of the anatomy described is highlighted in italics. The fibrous parietal pericardium is a resilient sac that envelops the heart and attaches onto the great vessels. 5 Almost the entire ascending aorta and main pulmonary artery and portions of both venae cavae and all four pulmonary veins are intrapericardial Fig. 2-19 . These...

The Ventricle As A Muscle

Muscle Tension Starling

For convenience, it is useful to consider contraction systolic performance as distinct from relaxation and filling diastolic performance . This distinction is arbitrary, however. The two aspects of function overlap and interact. Systolic performance of the ventricle traditionally is characterized in terms of loading conditions preload, afterload and contractility.112 Although contractility is a term that is employed frequently and often perfectly reasonably, it is difficult to define. We use it...

Peripheral Resistance And Its Determinants

Blood Flow And Blood Pressure

Pressure, flow, and resistance are related most often through Poiseuille's equation, which was first formulated in 1842. Based on a series of careful observations of water flowing through rigid tubes, Poiseuille demonstrated that the resistance to flow R through a tube is proportional to tube length L and fluid viscosity h and inversely proportional to the tube radius to the fourth power r4 . These variables can be related to each other in the following way Poiseuille's equation applies to the...

Eustachian Valve

Bullets Myocardium

View Contents in a Separate Window Chapter 13 THE ECHOCARDIOGRAM CARDIAC MASSES, THROMBI, AND TUMORS Normal Variants and Masses of Uncertain Significance When an abnormally localized accumulation of dense reflectances appears on the echocardiogram, it is said to represent a mass. Echocardiographic masses may be caused by technical artifacts or anomalous structures, but they are of greatest significance in representing true lesions of the heart such as tumors, thrombi, and vegetations....

Xjh

Figure 12-1 Practical application of four-view cardiac series. A. Posteroanterior view in a patient with coarctation of the aorta showing areas of rib notching bilaterally and left ventricular enlargement in the inferior and leftward direction. B. Magnified view of the left upper thorax of the same patient showing multiple areas of rib notching arrows . The sclerotic margin of each represents a reparative process by which new bone is laid down in the defect. C. Posteroanterior view of another...

Inspection And Palpation Of The Precordium

Aortic Stenosis Palpation

Inspection and palpation of the cardiac pulsations of the anterior chest have been practiced by physicians since ancient times and have a solid scientific basis. The results of precordial inspection and palpation have been correlated with noninvasive studies, hemodynamic data, and surgical and autopsy studies202,203 and remain an important part of the cardiovascular examination. Their usefulness depends on an understanding of cardiovascular physiology, the proficiency of the examiner, and his...

Hyperkinetic Arterial Pulse

Large, bounding arterial pulses usually indicate the rapid ejection of an increased volume of blood from the left ventricle see Fig. 10-42 4 . Commonly, the arterial pulse pressure is increased, and the peripheral arterial resistance diminished. The hyperdynamic arterial pulse is sometimes referred to in terms that describe a particular component of the pulse wave. Thus the water-hammer pulse, named after a Victorian toy, refers to an extremely rapid, forceful ascending limb of the arterial...

Edwards Wd. Applied Anatomy Of The Heart. In Giuliani Er Fuster V Gersh Bj Et Al Eds. Cardiology Fundamentals And

Chapter 2 FUNCTIONAL ANATOMY OF THE HEART References 1 Callahan JA, Key JD. Foundations of cardiology. In Giuliani ER, Fuster V, Gersh BJ, et al, eds. Cardiology Fundamentals and Practice, 2d ed Vol 1. St Louis Mosby-Year Book 1991 3-25. 2 O'Malley CD, Saunders JB. Leonardo da Vinci on the Human Body. New York Greenwich House 1982 223. 3 Ackermann DM, Edwards WD. Anatomic basis for tomographic analysis of the pediatric heart at autopsy. Perspect Pediatr Pathol 1988 12 44-68. PMID 3050875 4...