DOCSLIB.ORG

When Should I Order an Echo?

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
When Should I Order an Echo? When Should I Order An Echo? A Primer for General Practitioners The role of echocardiography as a diag- nostic, therapeutic and management- guiding tool is becoming increasingly relevant in cardiology and general prac- tice. This article discusses the appro- priate application of this form of testing. By Richard Bon, MD; and Kenneth Gin, MD, FRCPC comprehensive history and thorough replaced in the assessment and treatment of physical examination have tradition- patients, technology has provided physicians Aally been the cornerstones upon with additional tools to aid in the pursuit of which the diagnosis and management of car- optimal patient care. Since its inception, diovascular disease are based. While these echocardiography has become an invaluable fundamentals of medicine will never be addition to the diagnostic and therapeutic About the author... About the author... Dr. Gin is clinical assistant professor of medicine Dr. Bon completed his medical school and and director of the post-graduate cardiology internal medicine residency at the University of training program, University of British Columbia; British Columbia and is currently a cardiology and associate director, coronary care unit, and fellow at McGill University, Montreal, Quebec. associate director, cardiac ultrasound, Vancouver General Hospital. Perspectives in Cardiology / February 2002 27 Echo Case Michael, a 68-year-old man, presents for his initial visit to your office for a life insurance assessment. He has no known cardiac history, however, you elicit a history of infrequent “skipped beats” and one prolonged episode of self-terminating irregular palpitations while he was vacationing in Mexico one year ago. He denies any his- tory of chest pain or dyspnea at rest, however, he has noticed a decrease in exercise tolerance over the past six months, which he attributes merely to deconditioning. He has a history of “borderline” hypertension, which cur- rently is not being treated medically. He has no known history of diabetes or hypercholesterolemia, he quit smoking 30 years ago, and has no family history of coro- nary artery disease. He currently takes no medications. On examination, Michael’s blood pressure (BP) is 145/85 mmHg and the pulse is 72 beats per minute (BPM) and regular. Auscultation of the lungs is normal. Examination of the cardiovascular system reveals a jugular venous pulsation at 4 cm above the ster- nal angle, a normal carotid upstroke, a normal apical impulse, and normal first and second heart sounds. There are no third or fourth heart sounds. A holosystolic grade II/VI murmur is heard at the apex. The remainder of the physical examination is unremarkable. The patient’s electrocardiogram (ECG) shows normal sinus rhythm at a rate of 75 bpm with bor- derline voltage criteria for left ventricular hypertrophy and left atrial enlargement. Question: At this point, what would your clinical interventions be? Discussion on page 34 28 Perspectives in Cardiology / February 2002 Cardiac Angiogenesis Echo Figure 1 Algorithm for Assessment of Cardiac Murmur with Echocardiography Presence of cardiac murmur Systolic murmur Diastolic or continuous murmur Grade 1 to 2 mid-systolic Grade 3 Holo- or late systolic Echo Asymptomatic Other signs or symptoms No associated findings of cardiac disease No further work-up Adapted from: Cheitlin M, Alpert J, Armstrong W, et al: ACC/AHA Guidelines for the Clinical Application of Echocardiography. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Circulation 1997; 95(6):1686-744. armamentarium used by physicians treating Murmurs and Valvular Heart cardiovascular disease. Disease The ability of echocardiography to provide unique, non-invasive information with mini- Heart murmurs are the audible manifestation mal discomfort or risk, without using contrast of turbulent blood flow which may signify material or radiation, coupled with its porta- stenotic or regurgitant valvular disease or bility, availability and repeatability, accounts other congenital or acquired cardiovascular for its use in virtually all categories of cardio- defects. Echocardiography can help in the vascular disease.1 Despite these advantages, assessment of murmurs by providing infor- indiscriminate use of echocardiography could mation regarding valvular morphology, thick- lead to inappropriate further testing or inter- ness, calcification, vegetations and leaflet vention and could result in needless expendi- motion; quantification of stenotic or regurgi- ture of health-care dollars. tant lesions; and cardiac chamber size and Consequently, this article will review the function. While a murmur may be the major evidence for some of the most common sce- clinical feature of a cardiac abnormality, narios in which echocardiography may be many murmurs in asymptomatic people are useful to general practitioners, including the of no hemodynamic or functional signifi- assessment of: cance. •Murmurs and valvular heart disease; Murmurs can be categorized into systolic, • Chest pain; diastolic, and continuous murmurs (Figure 1). •Left ventricular (LV) function; Diastolic and continuous murmurs are always • Systemic hypertension; and pathologic and warrant echocardiographic • Atrial fibrillation. investigation. Systolic murmurs can be divid- ed into functional and pathologic murmurs. A Perspectives in Cardiology / February 2002 29 Echo murmur in an asymptomatic patient is classi- al murmurs usually can be distinguished from fied as functional if it has the following char- an organic murmur.4 However, the ability of acteristics: the cardiac examination to determine the • Systolic murmur of short duration; exact cause of the murmur, especially if more •Grade I or II intensity at the left sternal than one lesion is present, was limited and, border; therefore, echocardiography was recommend- • Systolic ejection pattern; ed for patients suspected of having significant 4 • Normal second heart sound (S2); cardiac disease. • No other abnormal sounds or murmurs; In keeping with these findings, the • No evidence of ventricular hypertrophy American College of Cardiology/American or dilation; Heart Association (ACC/AHA) Guidelines for • No thrills; the Clinical Application of Echocardiography do • Absence of an increase in intensity with not recommend echocardiography replace the Valsalva’s maneuver.1 basic cardiovascular evaluation as a screen In one study looking at the accuracy of the for VHD.1 However, in patients with car- cardiovascular physical examination for the diorespiratory symptoms or in asymptomatic diagnosis of asymptomatic valvular heart dis- patients with ambiguous clinical findings or ease (VHD) in 143 subjects, a complete phys- features indicative of at least a moderate ical examination with dynamic cardiac aus- probability that the murmur is reflective of cultation showed a sensitivity of 70% and a structural heart disease, echocardiography is specificity of 98%. It also showed a positive the test of choice (Figure 1).1 Among patients and negative predictive value of 92% for the with known VHD and changing symptoms or diagnosis of valvular heart disease, as com- signs, echocardiography is clearly the opti- pared to transesophageal echocardiography mal method of noninvasively and accurately (TEE).2 Furthermore, only two of the 10 re-evaluating the progression of valvular patients with VHD by TEE (but not by physi- lesions as well as any accompanying changes cal examination) had clinically important in chamber size or contractile function.1 VHD.2 Another retrospective study involving 169 patients with systolic murmurs aged 18 to Chest Pain 55, found older age, male gender, and mur- mur ≥ grade III were the only significant pre- Coronary artery disease (CAD) is the most dictors of positive echocardiographic results.3 common cause of cardiac chest pain. While In addition, if female patients aged ≤ 35 with echocardiography has long been used to diag- murmur grade II or less had not been referred nose other causes of chest pain (e.g., valvular for investigation, 47% of the echocardio- aortic stenosis, hypertrophic cardiomyopathy, graphic studies could have been avoided aortic dissection, acute pulmonary embolism), while retaining a sensitivity of 90%.3 the use of standard echocardiography for Finally, a recent study involving 100 chest pain related to CAD has not been as patients with a systolic murmur of unknown widespread. Unlike angiography, echocardio- cause compared the diagnostic accuracy of graphy is unable to directly image coronary echocardiography with physical examination artery occlusions or stenoses, and relies on the by a cardiologist. It was shown that function- presence of regional ventricular wall motion 30 Perspectives in Cardiology / February 2002 Echo abnormalities to detect the presence of myocardial ischemia or infarction. Standard echocardiographic studies are insensitive for the detection of CAD. In fact, patients with high- grade coronary stenosis often have completely normal ventricular function. If performed dur- ing an episode of chest pain, however, the absence of regional wall motion abnormalities identifies a subset of patients unlikely to have a myocardial infarction (MI) with a negative predic- tive accuracy of 95%.5 This may be useful when acute myocardial ischemia is suspected, but the baseline electrocardiogram (ECG) is nondiag- nostic (i.e., chronic left-bundle-branch block, ventricular pacing). Yet another indication
Load more

Recommended publications
  • Viding Diagnostic Insights Into the Pathophysiologic Mechanisms
    viding diagnostic insights into the pathophysiologic mechanisms under- lying the acoustic findings heard in clinical practice.162-165 Contemporary physicians should take advantage of the valuable clinical information that can be obtained by such an inexpensive instrument and expedient and reli- able tool as the stethoscope. The following section reviews the funda- mental technique of cardiac auscultation, emphasizing the diagnostic value and practical clinical applications of this time-honored (but endan- gered) art in this time of need.166 The Art and Technique of Cardiac Auscultation. Auscultation of the heart and vascular system is one of the most challenging and rewarding clinical diagnostic skills that can (and should) be learned and applied by every prac- ticing physician. Proficiency in cardiac auscultation requires experience, repeated practice, and a great deal of patience (and patients). Most impor- tantly, it requires a proper state of mind. (“we hear what we listen for”). Although the most vital component of the auscultatory apparatus lies between the earpieces, the proper use of a well-designed, efficient stetho- scope cannot be overemphasized. To ensure optimal sound transmission, the well-crafted stethoscope should be airtight, with snug but comfortably-fit- ting earpieces, properly aligned metal binaurals, and flexible, double-barrel, 1 thick-walled tubing, ⁄8 inch in internal diameter and no more than 12 to 15 inches in length. A high-quality stethoscope should be equipped with both bell and diaphragm chest pieces. The bell, when applied gently to the skin, will “bring out” low frequency sounds and murmurs (eg, faint S4 or S3 gal- lop or diastolic rumble) and the diaphragm, when pressed firmly against the skin, will accentuate high-pitched acoustic events (eg, diastolic blowing murmur of AR).
    [Show full text]
  • ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient P
    JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. - ,NO.- ,2014 ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2014.08.003 1 APPROPRIATE USE CRITERIA 55 2 56 3 57 4 ACC/AAP/AHA/ASE/HRS/ 58 5 59 6 SCAI/SCCT/SCMR/SOPE 60 7 61 8 2014 Appropriate Use Criteria for 62 9 63 10 Initial Transthoracic Echocardiography 64 11 65 12 in Outpatient Pediatric Cardiology 66 13 67 14 A Report of the American College of Cardiology Appropriate Use Criteria Task Force, 68 15 American Academy of Pediatrics, American Heart Association, American Society of 69 16 Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and 70 17 Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular 71 18 Magnetic Resonance, and Society of Pediatric Echocardiography 72 19 73 20 74 21 75 22 76 Q1 Writing Group for Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS, Wyman W. Lai, MD, MPH, FACC, FASE 23 77 Echocardiography Chair Leo Lopez, MD, FACC, FAAP, FASE 24 78 in Outpatient Ritu Sachdeva, MD, FACC, FAAP, FASE 25 79 Pediatric Pamela S. Douglas, MD, MACC, FAHA, FASE 26 80 Cardiology Benjamin W. Eidem, MD, FACC, FASE 27 81 28 82 29 83 30 Rating Panel Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS, Richard Lockwood, MD** 84 yy 31 Chair* G. Paul Matherne, MD, MBA, FACC, FAHA 85 zz 32 Pamela S. Douglas, MD, MACC, FAHA, FASE, Moderator* David Nykanen, MD, FACC 86 yy 33 Catherine L.
    [Show full text]
  • An Audio Guide to Pediatric and Adult Heart Murmurs
    Listen Up! An Audio Guide to Pediatric and Adult Heart Murmurs May 9, 2018 Dr. Michael Grattan Dr. Andrew Thain https://pollev.com/michaelgratt679 Case • You are working at an urgent care centre when a 40 year old recent immigrant from Syria presents with breathlessness. • You hear the following on cardiac auscultation: • What do you hear? • How can you describe what you hear so another practitioner will understand exactly what you mean? • What other important information will help you determine the significance of your auscultation? Objectives • In pediatric and adult patients: – To provide a general approach to cardiac auscultation – To review the most common pathologic and innocent heart murmurs • To emphasize the importance of a thorough history and physical exam (in addition to murmur description) in determining underlying etiology for heart problems Outline • A little bit of physiology and hemodynamics (we promise not too much) • Interactive pediatric and adult cases – https://pollev.com/michaelgratt679 – Get your listening ears ready! • Systolic murmurs (pathologic and innocent) • Diastolic murmurs • Continuous murmurs • Some other stuff Normal Heart Sounds Normal First & Second Sounds Splitting of 2nd heart sound Physiological : • Venous return to right is increased in inspiration – causes delayed closure of the pulmonary valve. • Simultaneously, return to left heart is reduced - premature closure of the aortic valve. • Heart sounds are unsplit when the patient holds breath at end expiration. Fixed: • No alteration in splitting with respiration. • In a patient with ASD – In expiration there is reduced pressure in the right atrium and increased pressure in the left atrium. • Blood is shunted to the right and this delays closure of the pulmonary valve in the same way as would occur in inspiration.
    [Show full text]
  • Heart Murmurs in Children
    Fa c tfile 10 / 2 0 0 1 HEART MURMURS IN CHILDREN Although a heart murmur is an important presenting murmur is likely to be pathological and that prompt feature of a cardiac disorder in infancy and childhood, expert evaluation is needed: innocent murmurs are very common, occurring in up to 80% of children at some time or other. These murmurs ● Cyanosis or clubbing are frequently detected during a febrile illness and are ● Abnormal cardiac impulse ● also exacerbated by nervousness or on exercise. It is Abnormal breathing (tachypnoea, intercostal i m p o rtant to distinguish between innocent and recession) ● pathological murmurs and to arrange more detailed Thrill over precordium or suprasternal notch ● Cardiac failure evaluation of the child if there is any doubt. Children ● should be routinely screened for heart murmurs and Abnormal heart sounds ● Failure to thrive other evidence of cardiac disorder between 6 and 8 ● weeks of age and at subsequent examinations during Presence of click ● Abnormal pulses - diminished or absent femorals childhood. Serious cardiac pathology may exist ● without symptoms. Radiation of murmur to the back ● Arrhythmia ● Murmur which is purely diastolic Innocent murmurs The commonest innocent murmur in children (usually Pathological systolic murmurs heard at age 3-6 years, although also occasionally in Systolic murmurs maximal at the upper sternal borders infants) is the parasternal vibratory ejection systolic are more likely to be ejection in type due to heart m u rmur (Still's mur m u r ) which has a very outflow abnormality or increased flow - aortic valve, characteristic low-frequency 'twanging' or musical subvalve or supravalve stenosis and HOCM being quality.
    [Show full text]
  • PACES 4 (CVS).Pdf
    PACES- CVS Adel Hasanin Ahmed CVS STEPS OF EXAMINATION (1) APPROACH THE PATIENT Read the instructions carefully for clues Approach the right hand side of the patient, shake hands, introduce yourself Ask permission to examine him “I am just going to feel your pulse and listen to your heart; is that alright?” Adjust the backrest so that the patient reclines at 45° to the mattress Expose the top half completely (2) GENERAL INSPECTION STEPS POSSIBLE FINDINGS 1. Scan the patient. Nutritional status: under/average built or overweight Abnormal facies: Marfanoid (AA, AR, MR), Down’s (VSD), Turner’s (coarctation, bicuspid AV, AS), Noonan’s (PS), malar flush (MS) Dysponea (tachyponea + use of accessory muscles of respiration; the scalene and the sternocleidomastoid) Earlobe creases → increased incidence of coronary artery disease (see theoretical notes) 2. Examine the eyes. Pull down the eyelid. Anaemia (pallor) in the conjunctivae at the guttering between the eyeball and the lower lid Cornea (arcus senilis) Pupil (Argyll-Robertson pupil) → consider syphilitic aortitis 3. Examine the mouth. Ask the patient to protrude his Central cyanosis in the under-surface of the tongue tongue. Teeth must be examined in all cases (see theoretical notes for types of cyanosis) (infective endocarditis) 4. Examine the hands: tell the patient “outstretch your Clubbing (congenital heart disease, infective hands like this (dorsum facing upwards)”… then endocarditis, atrial myxoma) “like this (palms facing upwards)”… demonstrate. Cyanosis (could be peripheral or central) Capillary pulsations (AR, PDA) Splinter haemorrhage, Osler’s nodes and Janeway lesions (infective endocarditis)… see theoretical notes Palmer erythema (consider CO2 retention) Arachnodactyly (see theoretical notes) Xanthomas (dyslipidaemia) Cool peripheries (poor flow - hyperdynamic circulation) 1 PACES- CVS Adel Hasanin Ahmed (3) PULSE STEPS POSSIBLE FINDINGS 1.
    [Show full text]
  • Cardiac Auscultation: Rediscovering the Lost Art Michael A
    Cardiac Auscultation: Rediscovering the Lost Art Michael A. Chizner, MD Abstract: Cardiac auscultation, long considered the center- piece of the cardiac clinical examination, is rapidly becoming a lost art. Inadequate emphasis on the essentials of cardiac auscultation has resulted from the widespread availability of more elaborate and expensive “high-tech” diagnostic and therapeutic methods, particularly Doppler echocardiogra- phy. However, sophisticated high technology is not a substi- tute for a solid foundation in clinical cardiology including cardiac auscultation. When used properly, the stethoscope remains a valuable and cost-effective clinical tool that often enables many well-trained and experienced cardiac auscul- tators to make a rapid and accurate cardiac diagnosis with fewer, if any, additional studies. Not every patient needs every test. Accordingly, this monograph reviews the fundamental principles of the art of cardiac auscultation. Emphasis is placed on the proper use of the stethoscope and the diagnos- tic and prognostic significance of the myriad heart sounds and murmurs present in patients with and without symp- tomatic heart disease. A practical clinical overview of the common auscultatory findings encountered in a variety of cardiac disease states and conditions will also be discussed. This monograph will inspire many practitioners to pick up their stethoscope, practice their cardiac examination, perfect their auscultatory skills, and reap the rewards of rediscov- ering this time-honored method of evaluating the cardiovas- cular system. (Curr Probl Cardiol 2008;33:326-408.) espite its long and rich tradition in clinical medicine, the time- honored art of cardiac auscultation is rapidly becoming a lost art. D Most of today’s physicians have a difficult time identifying normal The author has no conflicts of interest to disclose.
    [Show full text]
  • A Holistic, Naturopathic and Homeopathic Education in Cardiology by Professor of Medicine Desiré Dubounet
    INTERNATIONAL MEDICAL UNIVERSITY A Holistic, Naturopathic and Homeopathic Education in CARDIOLOGY BY PROFESSOR OF MEDICINE DESIRÉ DUBOUNET IMUNE 1989 A Holistic, Naturopathic and Homeopathic Education in Cardiology edited by Professor Emeritus Desire’ Dubounet, IMUNE ISBN 978-615-5169-07-6 1 Table of Contents I. Introduction 4 II. Cardiology Risk Factors and Risk Signs 7 1. Class 1 8 2. Class 2 8 3. Discussion 10 4. Vitamin Deficiency 10 5. Angina 12 6. Shortness of Breath 17 7. Some Possible Causes of Dyspnoea 18 8. Possible Causes of Edema 18 9. Fatigue 20 10. Cyanosis 21 11. Hemoptysis 28 12. Recurrent Bronchitis 29 13. Insomnia 29 14. Systemic Embolism 30 a. Cerebral Embolism 30 b. Visceral Embolism 30 c. Peripheral Embolism 31 d. Other Symptoms 32 III. Physical Signs 32 1. General Inspection 32 2. The Arterial Pulse 33 a. Depth 34 b. Pace 34 c. Length 34 d. Strenght 35 e. Quality 35 f. Pulsus Parvis 35 g. Bounding Pulse 36 h. Anacrotic Pulse 36 i. Pulsus Bisferiens 36 j. Dicrotic Pulse 36 k. Water Hammer Pulse 36 l. Pulsus Alternans 37 m. Pulsus Paradoxes 37 n. Pulsus Bigeminies 38 o. The Pulse in other Arteries 38 3. Examination of the Heart 38 a. Inspection 39 b. Palpation 40 c. Percussion 44 d. Auscultation 44 e. Valve Areas 45 f. The Heart Sounds 46 g. Murmurs 52 4. Examinations of other Systems 59 2 5. Circulatory Disorders 64 6. Arrhythmia 67 a. Sistolic 67 b. Diastolic 68 c. Continuous 69 7. Reference Charts 69 a. Differentiation of Precordial Pain 69 b.
    [Show full text]
  • CHAPTER E13 Approach to the Patient with a Heart Murmur
    S1 S2 CHAPTER e13 A Approach to the Patient With a Heart Murmur B Patrick T. O’Gara C Joseph Loscalzo CHAPTER e13 A2 P2 D Ⅵ INTRODUCTION The differential diagnosis of a heart murmur begins with a careful assessment of its major attributes and response to bedside maneu- vers. The history, clinical context, and associated physical examina- E tion findings provide additional clues by which the significance of a heart murmur is established. Accurate bedside identification of a OS Approach to the Patient With a Heart Murmur heart murmur can inform decisions regarding the indications for F noninvasive testing and the need for referral to a cardiovascular specialist. Preliminary discussions can be held with the patient regarding antibiotic or rheumatic fever prophylaxis, the need to S3 restrict various forms of physical activity, and the potential role for G family screening. Heart murmurs are caused by audible vibrations that are due to increased turbulence from accelerated blood flow through normal or abnormal orifices, flow through a narrowed or irregular orifice H into a dilated vessel or chamber, or backward flow through an incompetent valve, ventricular septal defect, or patent ductus arte- Figure e13-1 Diagram depicting principal heart murmurs. riosus. They traditionally are defined in terms of their timing within A. Presystolic murmur of mitral or tricuspid stenosis. B. Holosystolic (pansystolic) the cardiac cycle ( Fig. e13-1 ) . Systolic murmurs begin with or after murmur of mitral or tricuspid regurgitation or of ventricular septal defect. the first heart sound (S1 ) and terminate at or before the component C. Aortic ejection murmur beginning with an ejection click and fading (A2 or P2 ) of the second heart sound (S2 ) that corresponds to their before the second heart sound.
    [Show full text]
  • TRP 2021 Written Answers
    TRP Written Exam 2021 Booklet 1 - Answers Q1a. PH 1. PAH: 1.1 idiopathic; 1.2 heritable; 1.3 drug/toxin- induced; associated with 1.4.2. HIV or 1.4.3. portal hypertension 2. Left Heart Disease: 2.1 DCM, 2.2 restrictive CM; 2.3 severe AI or MR 3. Lung Disease or Hypoxia: 3.2 interstitial lung disease 4. Obstruction: 4.1 CTEPH; 4.2.5 Parasites 5. Unclear or Multifactorial Mechanisms: 5.1 sickle cell disease; 5.2 sarcoidosis Q1b. PVR PVR = mean PAP - mean PCWP Cardiac Output = Wood units (or x 80 dynes-sec-cm-5) Normal < 1.25 units or < 100 dynes-sec-cm-5 Q1c. PAH Treatments 1. Prostanoids (IV, inhaled, oral) 2. Prostacyclin agonists (e.g. selexipag) 3. Endothelin receptor antagonists 4. PDE5 inhibitors 5. DHP CCB in patients who have positive vasodilator testing 6. Soluble guanylate cyclase stimulator (e.g. riociguat) Q2. Aspirin: irreversible inhibition of platelet cyclo- oxygenase activity leading to decreased thromboxane A2 production Carvedilol: B1, B2 and a1 antagonist with anti- inflammatory properties Fondaparinux: activation of ATIII to (indirectly) and selectively inhibit Factor Xa Q2. Clopidogrel and ticagrelor are both P2Y12 adenosine receptor antagonists. Clopidogrel is a pro-drug that requires metabolism to active drug via cyp2C19; ticagrelor is active drug. Clopidogrel is irreversible; ticagrelor is reversible. Q3. Mechanical MVR Warfarin for an INR target of 3.0. ASA 75-100 mg daily only if antiplatelet therapy is indicated (vascular dz). Change in 2020 guideline In patients with mechanical valves and appropriately anticoagulated with warfarin define the approximate annual risk of a) Thromboembolism 1-4% b) Major bleeding 1-2% Q3.
    [Show full text]
  • Cardiac Physical Diagnosis: a Proctor Harvey Approach
    Cardiac Physical Diagnosis • The great majority of diagnosis of Cardiac Physical Diagnosis: cardiovascular disease can be made at the office or the bedside. A Proctor Harvey Approach • Usually you do not need sophisticated, elegant laboratory equipment. By Keith A. McLean, M.D. Cardiac Physical Diagnosis Cardiac Physical Diagnosis • The complete cardiovascular examination • Pulsus alternans: A pulse that alternates consists of the 5 finger method: amplitude with each beat. (i.e. STRONG, •history weak, STRONG, weak) • physical exam • You may miss it if you palpate with very •ECG firm pressure; use light pressure like a • chest x-ray blow of breath on our fingers. • simple laboratory tests. • History is generally the most important. Cardiac Physical Diagnosis • The Harvey method is: • 1. Inspection, take time to look closely • 2. Start at the left lower sternal border for an overview. Listen to the first sound, then the second sound, then sounds in systole, murmurs in systole, and sounds in diastole and murmurs in diastole. 1 Cardiac Physical Diagnosis • S3 gallop is heard better and louder with the patient: • in the left lateral decubitus position • after palpating the PMI, keeping your finger on the location of the PMI and placing the bell of the stethoscope over the PMI • The gallop may alternate in intensity with every other beat and pressure on the scope can eliminate the gallop. Cardiac Physical Diagnosis • PEARL: S3 or S4 may be missed in an emphysematous chest with an increase in AP diameter secondary to COPD, if you listen at the usual space, LLSB or apex. • If you listen over the xyphoid or epigastric area, it may easily detected.
    [Show full text]
  • Classification of Heart Sound Signal Using Multiple Features
    applied sciences Article Classification of Heart Sound Signal Using Multiple Features Yaseen, Gui-Young Son and Soonil Kwon * Department of Digital Contents, Sejong University, Seoul 05006, Korea; [email protected] (Y.); [email protected] (G.-Y.S.) * Correspondence: [email protected]; Tel.: +82-2-3408-3847 Received: 10 October 2018; Accepted: 20 November 2018; Published: 22 November 2018 Abstract: Cardiac disorders are critical and must be diagnosed in the early stage using routine auscultation examination with high precision. Cardiac auscultation is a technique to analyze and listen to heart sound using electronic stethoscope, an electronic stethoscope is a device which provides the digital recording of the heart sound called phonocardiogram (PCG). This PCG signal carries useful information about the functionality and status of the heart and hence several signal processing and machine learning technique can be applied to study and diagnose heart disorders. Based on PCG signal, the heart sound signal can be classified to two main categories i.e., normal and abnormal categories. We have created database of 5 categories of heart sound signal (PCG signals) from various sources which contains one normal and 4 are abnormal categories. This study proposes an improved, automatic classification algorithm for cardiac disorder by heart sound signal. We extract features from phonocardiogram signal and then process those features using machine learning techniques for classification. In features extraction, we have used Mel Frequency Cepstral Coefficient (MFCCs) and Discrete Wavelets Transform (DWT) features from the heart sound signal, and for learning and classification we have used support vector machine (SVM), deep neural network (DNN) and centroid displacement based k nearest neighbor.
    [Show full text]
  • Pediatric Heart Murmurs
    PEDIATRIC HEART MURMURS Manish Bansal, MD Clinical Assistant Professor Division of Pediatric Cardiology University of Iowa Murmur murmur. (n.d.). Dictionary.com Unabridged. Retrieved March 9, 2018 from Dictionary.com website http://www.dictionary.com/browse/murmur Murmur • Sound or noises made by blood • Caused by abnormal flow patterns – Abnormalities of the heart valves – Holes within the heart – Abnormal communications between blood vessels or between blood vessels and the heart. • Often innocent and result from the normal patterns of blood flow through the heart and vessels Incidence and prevalence • Revealed in over 50% of children and adolescents, with a peak incidence between 8 to 12 years • CHD - 50-100/1000 live births • CHD may occur in presence of absence of heart murmur • 6 cases per 1000 were moderate or severe • Pediatr Cardiol. 1994 Nov-Dec; 15(6):282-7 History History • Feeding difficulties – appr 1/3 with CHD • Acute heart Failure – Dyspnea (74%) – Nausea and vomiting (60%) – Fatigue (56%) – Cough (40%) • Exercise intolerance – age appropriate history – Ability to play and the duration and vigor of feeding – Ability to participate in team sports with that of peers History • Chest pain is rarely a symptom of cardiac disease in children • Chest pain or syncope prompted consultation in approximately 10 percent of children; only 11 percent of those with chest pain and 5 percent of those with syncope had cardiac disease. • Pediatrics. 2004;114(4):e409-e417 History Physical Examination • Vitals compared with age appropriate norms. http://www.cc.nih.gov/ccc/pedweb/pedsstaff/age.html • Focused examination of respiratory, cardiovascular and GI system.
    [Show full text]