DOCSLIB.ORG

ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient P

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read 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. Webb, MD, FACC, FAHA, FASE 87 y 34 Louis I. Bezold, MD, FACC, FAAP, FASE Robert Wiskind, MD, FAAP* 88 35 William B. Blanchard, MD, FACC, FAHA, FAAP* 89 36 Jeffrey R. Boris, MD, FACC* 90 z *American College of Cardiology representative. yAmerican Academy of 37 Bryan Cannon, MD Pediatrics representative. zHeart Rhythm Society representative. 91 Gregory J. Ensing, MD, FACC, FASEx 38 xAmerican Society of Echocardiography representative. jjSociety of 92 jj 39 Craig E. Fleishman, MD, FACC, FASE Pediatric Echocardiography representative. {Society for Cardiovascular 93 { Magnetic Resonance representative. #Society of Cardiovascular Computed 40 Mark A. Fogel, MD, FACC, FAHA, FAAP 94 yy B. Kelly Han, MD, FACC# Tomography representative. **Health Plan representative. American 41 Heart Association representative. zzSociety for Cardiovascular 95 42 Shabnam Jain, MD, MPH, FAAP* Angiography and Interventions representative. 96 jj 43 Mark B. Lewin, MD 97 44 98 45 99 This document was approved by the American College of Cardiology Board of Trustees in June 2014. 46 The American College of Cardiology requests that this document be cited as follows: 100 47 Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria 101 48 for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria 102 Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for 49 Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and 103 50 Society of Pediatric Echocardiography. J Am Coll Cardiol 2014;XX:xxx-xx. 104 51 This document is copublished in the Journal of the American Society of Echocardiography. 105 52 Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, 106 please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected]. 53 Permissions: Modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the 107 54 American College of Cardiology. 108 PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce 2 Campbell et al. JACC VOL. - ,NO.- ,2014 AUC for Pediatric Echocardiography - ,2014:- – - 109 Appropriate Manesh R. Patel, MD, FACC, Chair Pamela S. Douglas, MD, MACC, FAHA, FASE 163 110 Use Criteria Christopher M. Kramer, MD, FACC, FAHA, Co-Chair Robert C. Hendel, MD, FACC, FAHA, FASNC 164 111 Task Force Bruce D. Lindsay, MD, FACC 165 112 Steven R. Bailey, MD, FACC, FAHA, FSCAI Leslee J. Shaw, PhD, FACC, FASNC, FAHA 166 113 Alan S. Brown, MD, FACC L. Samuel Wann, MD, MACC 167 114 John U. Doherty, MD, FACC, FAHA Joseph M. Allen, MA 168 115 169 116 170 117 TABLE OF CONTENTS 171 118 172 119 173 ABSTRACT ..................................... XX Figure 5. Palpitaions and Arrhythmias .............xx 120 174 121 Figure 6. Murmur ..............................xx 175 PREFACE ...................................... XX 122 176 9. DISCUSSION ................................ XX 123 177 1. INTRODUCTION ............................. XX 124 Assumptions and Definitions ....................xx 178 125 Indications and Ratings .........................xx 179 2. METHODS .................................. XX 126 180 Comparison with the Adult Cardiology AUC ........xx 127 Figure 1. AUC Development Process ...............xx 181 128 Limitations ...................................xx 182 129 3. GENERAL ASSUMPTIONS ..................... XX 183 Use of AUC to Improve Care .....................xx 130 184 Figure 2. Factors Influencing Outcomes 131 ............................ 185 of an Imaging Study xx 10. CONCLUSIONS .............................. XX 132 186 133 187 4. DEFINITIONS ............................... XX APPENDIX A 134 188 Appropriate Use Criteria for Initial Transthoracic 135 5. ABBREVIATIONS ............................ XX 189 Echocardiography in Outpatient Pediatric Cardiology: 136 190 Participants ...................................xx 137 6. RESULTS ................................... XX 191 138 192 APPENDIX B 139 7. TRANSTHORACIC ECHOCARDIOGRAPHY IN 193 140 OUTPATIENT PEDIATRIC CARDIOLOGY: Relationships With Industry (RWI) and 194 Other Entities .................................xx 141 APPROPRIATE USE CRITERIA (BY INDICATION) ..... XX 195 142 196 Table 1. Palpitations and Arrhythmias .............xx 143 ABSTRACT 197 144 Table 2. Syncope ..............................xx 198 145 The American College of Cardiology (ACC) participated in 199 Table 3. Chest Pain .............................xx 146 a joint project with the American Society of Echocardi- 200 .............................. 147 Table 4. Murmur xx ography, the Society of Pediatric Echocardiography, and 201 148 Table 5. Other Symptoms and Signs ...............xx several other subspecialty societies and organizations to 202 149 establish and evaluate Appropriate Use Criteria (AUC) for 203 Table 6. Prior Test Results .......................xx 150 the initial use of outpatient pediatric echocardiography. 204 151 Table 7. Systemic Disorders ......................xx Assumptions for the AUC were identified, including the 205 152 fi 206 Table 8. Family History of Cardiovascular Disease in fact that all indications assumed a rst-time transthoracic 153 Patients Without Signs or Symptoms and Without echocardiographic study in an outpatient setting for pa- 207 154 Confirmed Cardiac Diagnosis .....................xx tients without previously known heart disease. The defi- 208 155 nitions for frequently used terminology in outpatient 209 Table 9. Outpatient Neonates Without Post-Natal 156 Cardiology Evaluation ..........................xx pediatric cardiology were established using published 210 157 guidelines and standards and expert opinion. These AUC 211 158 8. FLOW DIAGRAMS FOR COMMON serve as a guide to help clinicians in the care of children 212 fi 159 PATIENT SYMPTOMS ......................... XX with possible heart disease, speci cally in terms of when 213 160 a transthoracic echocardiogram is warranted as an initial 214 Figure 3. Chest Pain ............................xx 161 diagnostic modality in the outpatient setting. They are 215 162 Figure 4. Syncope .............................xx alsoausefultoolforeducationandprovidethe 216 PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce JACC VOL. - ,NO.- ,2014 Campbell et al. 3 - ,2014:- – - AUC for Pediatric Echocardiography 217 infrastructure for future quality improvement initiatives increase in the utilization of such technologies. As these 271 218 as well as research in healthcare delivery, outcomes, and imaging technologies and clinical applications continue to 272 219 resource utilization. advance, the healthcare community needs to understand 273 220 To complete the AUC process, the writing group iden- how best to incorporate these options into daily clinical 274 221 tified 113 indications based on common clinical scenarios care and how to choose between new and long-standing, 275 222 and/or published clinical practice guidelines, and each established imaging technologies. In an effort to res- 276 223 indication was classified into 1 of 9 categories of common pond to this need and to ensure the effective use of 277 224 clinical presentations, including palpitations, syncope, advanced diagnostic imaging tools and procedures, the 278 225 chest pain, and murmur. A separate, independent rating AUC project was initiated. The AUC in this document have 279 226 panel evaluated each indication using a scoring scale of 1 been developed in order to promote effective patient 280 227 to 9, thereby designating each indication as “Appropriate” care, better clinical outcomes, and improved resource 281 228 (median score 7 to 9), “May Be Appropriate” (median utilization. This set of AUC should be
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]
  • 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]
  • 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.
    [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]