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Manual of Cardiology

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MANUAL OF CARDIOLOGY MANUAL OF CARDIOLOGY V Jacob Jose MD DM card, MS Univ of Penn, FCCP, FACC, FIAE Professor of Cardiology Department of Cardiology Christian Medical College Hospital Vellore, Chennai JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd 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: 32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected], Visit our website: www.jaypeebrothers.com Branches 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015, Phones: +91-079-26926233, Rel: +91-079-32988717, Fax: +91-079-26927094, e-mail: [email protected] 202 Batavia Chambers, 8 Kumara Krupa Road Kumara Park East, Bangalore 560 001 Phones: +91-80-22285971, +91-80-22382956, Rel: +91-80-32714073, Fax: +91-80-22281761, e-mail: [email protected] 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza Pantheon Road, Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089, Fax: +91-44-28193231, e-mail: [email protected] 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498, Rel:+91-40-32940929, Fax:+91-40-24758499, e-mail: [email protected] No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road Kochi 682 018, Kerala, Phones: 0484-4036109, +91-0484-2395739, +91-0484-2395740, e-mail: [email protected] 1-A Indian Mirror Street, Wellington Square Kolkata 700 013, Phones: +91-33-22451926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926, Fax: +91-33-22456075, e-mail: [email protected] 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel, Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896, Fax: +91-22-24160828, e-mail: [email protected] “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 (MS), Phones: Rel: 3245220, Fax: 0712-2704275 e-mail: [email protected] Manual of Cardiology © 2007, V Jacob Jose All rights reserved. No part of this publication 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: 2007 ISBN 81-8061-924-9 Typeset at JPBMP typesetting unit Printed at Gopsons Papers Ltd, Sector 60, Noida To My daughters Riya Jose and Nisha Jose PREFACE There are excellent monographs in cardiology for cardiologists, but there exists none for the undergraduates in Medicine. I felt this problem when I was taking classes for our undergraduates. Hence I decided that some of the notes that I distribute to medical students during their classes be made into a book. The idea was to keep it as simple as possible but at the same time to give them a full understanding of the subject. Since this is a small book, over simplification was unavoidable. I am sure students will find this as a basic text and will use the regular reference books to expand their knowledge. I am deeply indebted to our Director, Dr. George Chandy for giving me the permission to publish this book. I would also like to express my due thanks to my colleagues in the department who have critically looked at the text of this book. I wish to express my thanks to Dr. Noah Chelliah, who was kind enough to give some of the teaching slides he has been using in USA. These slides have been incorporated in the section of arrhythmias. I also would like to express my sincere thanks to my secretary Ms. Deepa Dayalan for typing and proof reading. I would welcome your critical comments or suggestions regarding this book, so that we will incorporate the same in our next edition. V Jacob Jose CONTENTS SECTION I: CLINICAL EXAMINATION 1. History ........................................................................... 3 2. General Examination .................................................... 9 3. Arterial Pulse ............................................................... 14 4. Jugular Venous Pulse .................................................. 21 5. Precardial Palpation .................................................... 25 6. Heart Sounds............................................................... 33 SECTION II: VALVULAR HEART DISEASE 7. Acute Rheumatic Fever ............................................... 43 8. Mitral Stenosis ............................................................. 54 9. Mitral Regurgitation ..................................................... 64 10. Aortic Stenosis ............................................................. 70 11. Aortic Regurgitation .................................................... 76 12. Infective Endocarditis .................................................. 84 SECTION III: ISCHEMIC HEART DISEASE 13. Angina ......................................................................... 96 14. Acute Myocardial Infarction ...................................... 110 SECTION IV: HEART FAILURE 15. Heart Failure .............................................................. 127 SECTION V: CARDIOMYOPATHY 16. Dilated Cardiomyopathy ........................................... 139 17. Hypertrophic Cardiomyopathy ................................. 141 18. Restrictive Cardiomyopathy ...................................... 148 x Manual of Cardiology SECTION VI: PERICARDIUM AND AORTA 19. Acute Pericarditis ....................................................... 153 20. Pericardial Effusion.................................................... 156 21. Constrictive Pericarditis ............................................. 160 22. Dissection of Aorta .................................................... 162 SECTION VII: CONGENITAL HEART DISEASE 23. Atrial Septal Defect.................................................... 170 24. Ventricular Septal Defect ........................................... 179 25. Patent Ductus Arteriosus ........................................... 186 26. Tetralogy of Fallot ...................................................... 191 27. Coarctation of Aorta.................................................. 203 SECTION VIII: ARRHYTHMIAS 28. Atrial Fibrillation ........................................................ 207 29. Atrial Flutter ............................................................... 214 30. Narrow QRS Tachycardia.......................................... 216 31. Ventricular Tachycardia ............................................. 220 32. Heart Block................................................................ 223 33. Cardiac Arrest and Sudden Death ............................ 226 SECTION IX: HYPERTENSION 34. Hypertension ............................................................. 235 SECTION X: PULMONARY VASCULAR DISORDERS 35. Pulmonary Arterial Hypertension ............................. 243 36. Pulmonary Embolism ................................................ 247 SECTION XI: INVESTIGATIONS 37. Chest X-ray ................................................................ 253 38. ECG ........................................................................... 259 Index .......................................................................... 265 Section I CLINICAL EXAMINATION HISTORY 1 DYSPNEA Abnormally uncomfortable awareness of breathing. New York Heart Association (NYHA)—Functional Classification All patients with dyspnea should be assessed in relation to their functional ability and this is usually graded as per the above classification. This classification is also used for fatigue, palpitation and chest pain TABLE 1.1: NYHA classification Class Functional classification I Ordinary physical activity does not cause dyspnea II Ordinary physical activity results in dyspnea III Less than ordinary physical activity causes dyspnea IV Inability to carry on any physical activity without discomfort Limitations 1. Subjective in nature 2. Not easily reproducible 3. Class 0 is not there. Hence many people are now using American Thoracic Society scale of dyspnea which has grade 0 as well and also has quantification in terms of length of distance walked. 4 Manual of Cardiology Etiology of Dyspnea Cardiac Causes 1. Left ventricular failure of any cause 2. Mitral stenosis. Lung Causes 1. Asthma 2. COPD 3. Interstitial lung disease 4. Large pleural effusion. Chest Wall Causes 1. Kyphoscoliosis. Metabolic Causes 1. Ketoacidiosis 2. Aspirin poisoning. Other Causes 1. Anemia 2. Obesity. Acute Dyspnea 1. Acute asthma 2. Acute pulmonary edema 3. Pulmonary thromboembolism 4. Pneumothorax 5. Foreign body in the airway. Paroxysmal nocturnal dyspnea (PND): In this form of dyspnea, the patient develops breathing difficulty 2-5 hours after going to sleep and the patient is forced to get up and seek fresh air. History 5 Mechanism 1. Decreased sympathetic drive of the heart during night 2. Nocturnal depression of respiratory center. Orthopnea This can be defined as dyspnea in the recumbent position which is relieved by elevation of the head. Many patients use several pillows at night to elevate
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