Cardiology

• bronchospasm
• 2⁰ AV block
• theophylline dependent
• valvular dysfunction

• Prior symptomatic arrhythmia (particularly VT)
• Low blood pressure
• Marked HTN
• Poor echo window

Do adenosine perfusion instead, but if they have bronchospasm, 2⁰ AV block, theophylline dependent, valvular dysfunction -- then do other modes such as Holter or angiography.

• Mainly for detection of coronary calcification
• A high calcium score (> 100) indicates an increased risk of cardiac events
• Lack of coronary calcification is predictive of a very low risk of a cardiac event.

• LV function
• Tissue characterization (infiltrative cardiomyopathies)
• Myocardial masses
• Myocardial viability

<12 mm Hg

• LVH
• LV failure
• MR
• AR
• Tamponade
• Constrictive pericarditis

• 1. Mild dyspnea on exertion
• 2. DOE
• 3. Dyspnea at rest
• 4. Pulmonary edema

7 cm H₂O

0-5

13-28/3-13

3-11

110/70

RV infarction

RA pressure is high, but the PCWP is higher (extremely elevated), BP is low.

Pulmonary systolic pressure and PCWP are very high, systemic BP is normal.

PA systolic and diastolic pressures are very high, but the PCWP is normal.

Chronic multiple PE may also show something similar.

• pericardial tamponade
• asthma
• tension pneumothorax

• Aortic regurgitation
• Hypertrophic cardiomyopathy

• Bigeminal PVC
• Severe LV dysfunction
• Severe AS

• Aortic stenosis
• May not be present in the elderly in spite of severe AS

• Tension Pneumothorax
• SVC obstruction

Large "a" waves are of considerable diagnostic value (figure 203-b ). When giant "a" waves are present with each beat,the right atrium is contracting against an increased resistance. This may result from obstruction at the tricuspid valve( tricuspid stenosis or atresia,right atrial myxoma or conditions associated with increased resistance to right ventricular filling. A giant "a" wave is more likely to occur in patients with pulmonary stenosis or pulmonary hypertension in whom both the atrial and right ventricular septa are intact. Cannon "a" waves occur when the right atrium contracts while the tricuspid valve is closed during right ventricular systole. Cannon waves may occur either regularly or irregularly and are most common in the presence of arrhythmias

It is pathognomonic for constrictive pericarditis.

Tricuspid stenosis

• a wave = RA systole
• x descent = atrial relaxation and dropping of TV annulus during RV systole
• v wave = rise in RA pressure with inflow to the RA during RV systole
• y descent = RA emptying following RA systole

• Tricuspid stenosis
• Severe pulmonic stenosis
• Severe noncompliant RVH
• Mitral stenosis

Severe RV dysfunction of any sort.

• Indicate A-V dissociation
• Occur in:
• --70% of VT
• --Third degree AV block
• --Ventricular pacing in a patient with sinus rhythm and complete heart block

V-tach

ASD

• Caused by closure of the mitral valve leaflets when they are close together
• Prolonged PR interval
• AR
• Severely calcified MV

• Caused by closure of the mitral valve leaflets when they are wide open or stiffened:
• Short PR interval
• Hyperdynamic LV function
• MS

• Or "widened S₂", caused by delayed RV emptying:
• Pulmonic stenosis
• PE
• Ectopic LV rhythm
• RBBB
• Early closure of the aortic valve (as in severe MR) may also cause a wide S₂

• Caused by delayed LV emptying:
• Severe AS
• Paced rhtym in the RV
• Ectopic RV rhythm
• LBBB
• HCM

• Indicates poor LV function and therefore poor prognosis indicator.
• It is usually normal in children and in pregnant women
• Abnormal over age 40
• May be described as "early diastolic sound at the apex."

Critical AS

• Previous hemorrhagic stroke
• CVA within 1 year
• Intracranial neoplasm
• Active internal bleeding
• Suspected aortic dissection

• Mortality is decreased the earlier fibrolysis is given, particularly first hour
• In the GUSTO trial, the combination of tPA and the IV heparin had a slight mortality advantage over other agents.

No. However, arrhythmias that occur after 48 hours imply a bad prognosis.

• Hypotension
• Clear lung fields
• Elevated JVP (Kussmaul's sign)

• Cardiovert VF and unstable VT
• Stable VT can be treated with:
• Amiodarone 150 mg infused over 10 minutes repeated every 10-15 minutes
• Or, 360 mg over 6 hours (1 mg/min), then 540 mg over next 18 hours (0.5 mg/min ), not to exceed 2.2 g in 24 hours.

Urgent surgery

• Large anterior MI
• Loud holosystolic murmur along the left lower sternal border
• There is an oxygen step-up (>10%) from RA to PA on right heart cath
• Mortality is 50%
• Tx is urgent surgery

• decreases mortality and decreases reinfarction rate by 50%.
• benefits of smoking cessation begin within 48 hours

Post ACS patients should be instructed to take 1 NTG for ischemic-like pain, and to call 911 if the pain is not relieved within 5 minutes.

beta-blockers, ACE-I, ARB

beta-blockers, nitrates (with hydralazine), ACE-I, ARB, Spironolactone/Eplerenone

• Brachial and ankle blood pressures before and after exercise is the best test of the degree of functional impairment
• Angiography is the best test for defining the location of the disease

• In order of importance:
• Smoking
• Diabetes
• HTN
• Hypercholesterolemia
• Hyperhomocysteinemia
• C-Reactive protein (not a risk factor but a marker for ongoing inflammation)

• Smoking cessation
• Treatment of HTN to JNC-7 goals
• Beta-blockers are not contraindicated
• Decrease LDL < 100, perhaps to 70 mg/dl (typically with a statin)
• Treat diabetes aggressively
• ASA for all patients
• Clopidogrel is an effective alternative
• Cilostazol (100 mg bid) improves symptoms and increases walking distance (contraindicated in heart failure)
• Pentoxifylline is a second-lie alternative with less effectiveness.

Nitroprusside and Beta-blocker

• Major
• Carditis
• Polyarthritis
• Chorea
• Erythema marginatum
• Subcutaneous nodules

• Minor
• Previous rheumatic fever
• Arthralgias
• Increased seed rate, WBC, C-reactive protein
• Prolonged PR interval

• Diagnosis
• 2 major criteria or
• 1 major and 2 minor criteria
• AND positive Strep test or elevated ASO titers

• Commonest congenital cardiac anomaly (1 in 50)
• By age 45, half will have significant AS
• May be associated with ascending aortic aneurysm or dissection

When orifice size is reduced to ≤ 25% (orifice area < 0.7 cm²; normal 2-4 cm²)

• 1. Decreased rise time and volume in the carotid pulses (pulsus parvus et tardus)
• 2. Systolic thrill or shudder in the carotids or the suprasternal notch
• 3. Second heart sound paradoxically split or A2 absent completely
• 4. Murmur peaks after mid systole

Pressure = 4(peak velocity)²

• 1. Symptomatic patients
• 2. Asymptomatic patients but with LVEF > 50%, LVESD > 55 mm, or LVEDD > 75 mm
• -- LVEF < 50%

• Streptococcus viridans -- 50%
• Staph aureus -- 20%

• Staphylococcus is most common (80%), particularly the tricuspid endocarditis
• Fungi (Candida)

• Early (< 2 months) Staphylococcus epidermis
• Late ( > 2months) similar to native valve

• Major criteria:
• --Positive blood cultures
• --Evidence of endocardial involvement (echo, new regurgitant murmur)

• Minor Criteria:
• -- Predisposing cardiac lesion
• -- Fever
• -- Vascular phenomena
• -- Immunological phenomena
• -- < 2 positive blood cultures
• -- mild echo abnormalities

Diagnosis is by 2 major criteria, or 1 major plus 3 minor criteria, or 5 minor criteria

• They are flat, painless lesions on the palms and soles seen on endocarditis.

• Painful raised lesions on the hands and feet.
• Seen in endocarditis

• Glomerulonephritis
• Janeway lesions
• Osler nodes
• Roth spots
• (+) Rheumatoid factor

• Retinal hemorrhages with white centers seen in endocarditis

• Heart failure
• Annular involvement or abscesses
• Fungal endocarditis
• Antibiotic-resistant organism
• Vegetation > 10 cm

• 1. Prosthetic cardiac valve
• 2. Previous infective endocarditis
• 3. Congenital heart disease
• -- Unrepaired cyanotic CHD
• -- Completely repaired CHD with prothetic material or device
• 4. Cardiac transplantation recipients who develop valvular disease

Echo

• Surgery is indicated in symptomatic patients with severe AS
• Most patients who have gradients of > 50 mm Hg are symptomatic
• Almost all sudden deaths occur in symptomatic patients
• AVR is often followed by dramatic improvement in LV function and symptoms.

Heart catheterization due to the high prevalence of CAD in those with AS ( > 33% in those over 69 years old).

Beta- blockers

• Congenital deformities
• Endocarditis
• Aortic root dilation (Marfan's, HTN)
• VSD
• Giant cell arteritis, relapsing polychondritis
• Syphilis
• Trauma

• Long asymptomatic latent period
• Exercise is well tolerated ( as opposed to every other valvular disease ) because of:
• -- peripheral vasodilation
• -- increased heart rate shortens diastole

High-pitched, blowing, decrescendo murmur at the lower left sternal border best heard leaning forward at exhalation.

• Austin-Flint murmur found in Severe AR
• Caused by the AR jet hitting the anterior MV leaflet and forcing it into the posterior leaflet, causing functional mitral stenosis
• A systolic outflow murmur may occur, caused by the high velocity of blood through the aortic valve.

• Caused by: "T-E-A"
• -- Endocarditis
• -- Trauma
• -- Aortic dissection

• Tachycardia, hypotension, pulmonary edema, signs of vasoconstriction
• The murmur, if heard at all, is short, high-pitched, and decrescendo.
• The bounding pulse pressure of chronic AR is not present.

Echo, especially TEE

• Urgent Cardiothoracic surgical consult
• Temporizing measures include positive inotropic therapy (dobutamine) and peripheral vasodilation (nitroprusside)

• The CXR features of:
• 1. Pulmonary vascular congestion
• 2. Large left atrium
• 3. Normal sized ventricle

• 2/3 are females
• Often present with sudden onset of symptoms when atrial fibrillation occurs
• Hemoptysis is fairly common in MS because of the very high pulmonary pressures
• Peripheral emboli, particularly stroke, occurs in 20% of patients

• opening snap heard at the apex
• S₁ may be loud
• A low-pitched diastolic rumble is heard at the apex with the bell.

• May present with pulmonary edema at the onset of atrial fibrillation
• Digoxin probably indicated in all patients
• Warfarin is teratogenic
• Cardioversion, procainamide, and verapamil are all safe during pregnancy

• Patients with class II-IV symptoms should have percutaneous balloon valvuloplasty (PBV) or surgery ( only if PBV is not possible)
• Asymptomatic patients should have PBV if PA pressure is > 50 mmHg.

No, because these are mostly young women and chances of CAD is low.

Onset of atrial fibrillation

• Soft S₁
• Holoystolic murmur
• In severe MR, the aortic valve may close early, resulting in a widely split S₂
• An S₃ is common in severe MR

• Symptomatic
• -- LVEF > 30% and LVESD < 55 mm

• Asymptomatic patients
• -- LVEF < 60% and LVESD > 40 mm
• -- LVEF > 60% ad LVESD < 40 mm in the presence of pulmonary HTN as long as the valve can be repaired (not replaced).

• There may be a mid-systolic ( not diastolic) click, which may be followed by a murmur
• The click becomes louder and moves earlier in systole with maneuvers that decrease LV volume, such as Valsalva or standing.

• Congenital myxomatous degeneration of the chordae and mitral valve leaflets
• Some degree of chronic MR virtually certain
• Risk of acute MR from chordal rupture

• T-E-A-R
• Trauma
• Endocarditis
• Acute ischemia of the papillary muscle
• Rupture of a myxomatous chord

Patients present with shock similar to acute AR

• Tachycardia, hypotension, pulmonary edema, signs of peripheral vasoconstriction
• The murmur, if heard at all, is short, early systolic, and decrescendo

• Urgent cardiothoracic surgical consult
• Temporizing measures include inotropic therapy (dobutamine) and peripheral vasodilation (nitroprusside)

• Usually overshadowed by findings of MS
• A diastolic rumble is heard along the LLSB, which increases with inspiration
• All right-sided murmurs and sounds increase with inspiration, except the pulmonic ejection sound (heard in PS)
• The neck veins show a large a wave and a slow y descent
• There is systemic venous congestion

• Rheumatic heart disease
• Congenital
• Carcinoid causes TS/TR and any other right-sided valvular lesions

Valvuloplasty

• Large v waves in the neck
• Pulsatile liver
• Holosystolic murmur at the LLSB that increases with inspiration
• Other signs of pulmonary HTN are frequently present

• Virtually always congenital
• Does not progress
• Usually not seen with other congenital defects except Noonan syndrome
• May be seen in adults

• There may be a faint systolic murmur heard at the upper left sternal border
• Usually, there is a pulmonic ejection sound
• Prominent a wave in the JVP

• Echo shows a redundant tricuspid septal leaflet arising lower in the ventricle than normally
• The RA, therefore, appears to be huge
• A TR murmur and a "sail" sound may be heard
• ECG shows signs of right atrial enlargement or tall and broad 'Himalayan' P waves, 1st degree block
• Frequently associated with PSVT or the WPW syndrome
• Associated with other cardiac abnormalities such as an ASD or PFO

AS, HOCM

HOCM

MR

HOCM

AS, MR

AS, MR

• Increase in Post-PVC, valsalva, and standing.
• Decrease in Mueller, Handgrip, Squatting

• Increase in Post-PVC, mueller, squatting
• Decreae in Valsalva, handgrip, standing

Increased in Mueller, handgrip, and squatting

• After a forced expiration, an attempt at inspiration is made with closed mouth and nose, whereby the negative pressure in the chest and lungs is
• made very subatmospheric; the reverse of Valsalva manoeuvre

Mitral stenosis -- because of the extraordinary valvular pressures

AS

• AR
• This is the Austin-Flint murmur

AS

Tricuspid stenosis

AS

• 1. Decreased rise time and volume in the carotid pulse
• 2. Systolic thrill or shudder in the suprasternal notch or on the carotids
• 3. Late-peaking systolic ejection murmur in the 2nd right intercostal space
• 4. Paradoxically split S₂ or absence of A₂ altogether

AR

• LVEF
• Exercise tolerance does not predict outcome

• Poor LVEF
• Low serum sodium
• High BUN
• Low Potassium
• High or low magnesium
• High catecholamine levels

• Occurs from the beginning of the third trimester to 6-months postpartum
• Predilection for older women and African-Americans
• About 2/3 resolve spontaneously
• Increased risk of recurrence with subsequent pregnancies

• About 2% of patients form mural thrombi and can have arterial embolization
• Pulmonary emboli can arise from the RV
• Anticoagulation is indicated even if no mural thrombi can be detected

• Caused by infiltrative diseases, such as amyloid and sarcoidosis
• Presents with signs of left and right heart failure, initially from diastolic dysfunction, but later from systolic failure

Restrictive cardiomyopathy

• Ischemic cardiomyopathy
• -- the ventricles are infiltrated so can't dilate, but have huge ventricular pressures which dilate the upper chambers resulting in "Mickey Mouse" heart on echo.

• Disordered myocytes in the region of the hypertrophy, especially in the upper ventricular septum
• Other areas than the septum can be affected; Asians frequently have an apical form
• Occasionally presents as concentric LVH
• Symptoms include dyspnea, chest pain, or exercise-induced syncope
• Echo is diagnostic
• The severity of the LV outflow gradient is not related to the risk of sudden death
• Associated with sudden cardiac death (VT/VF), especially in exercising young people
• An ambulatory ECG that shows VT indicates a high risk for sudden death
• Atrial fibrillation is common because of high LVEDP

• Harsh nonradiating midsystolic aortic murmur
• Murmur is louder with maneuvers which decrease LV volume. e.g. Valsalva
• Carotid pulse has a rapid upstroke and is bifid in 2/3 of patients (as opposed to AS)
• Apical pulse ay be double or triple

• If patients have septal hypertrophy, there may be inferolateral Q waves because of the thick septum
• The precordial lead voltage is usually high in the area of the hypertrophy

• Beta-blockers, verapamil
• Resynchronization therapy (biventricular pacing)
• Septal myomectomy
• Antiarrhythime therapy (amiodarone) for symptomatic VT or atrial fib
• No drugs prolong survival
• Decreasing ventricular volume (diuretics, nitrates, dehydration) is potentially dangerous
• Implantable defibrillators have been shown to reduce the incidence of sudden death
• No ultimate cure except for heart transplant

• AICD
• Heart transplant

• Patients at risk for heart failure but without structural heart disease, including:
• HTN
• Atherosclerotic disease
• Diabetes
• Metabolic syndrome
• Using cardiotoxins
• Family history of cardiomyopathy

ACE inhibitors or ARBs

• Patients with structural heart disease but without symptoms or signs of heart failure:
• Previous MI
• LV remodeling including LVH and low LVEF
• Asymptomatic valvular heart disease

• ACE inhibitors or ARBs
• Implantable defibrillators

• Pts with structural heart disease with prior or current symptoms of heart failure.
• Known structural heart disease and dyspnea fatigue, and decreased exercise tolerance

• Inappropriate reduction of therapy
• Dietary indiscretion
• Ischemia or infarction
• Arrhythmias
• Systemic infection
• PE
• Physical, environmental, or emotional stress
• High output states (anemia)
• Poorly controlled HTN
• A new, unrelated illness
• Administration of a cardiac depressant drug
• Acquiring a second form of heart disease
• Surgical procedure

• ACE-I
• ARB
• Hydralazine/Nitrates
• Beta-blockers
• Spironolactone or eplerenone (for all patients with increased preload and create < 2.5

• EF < 30%
• Wide QRS > 120 msec

• Procainamide
• Hydralazine

• Present with severe, usually pleuritic, chest pain, relieved by sitting forward
• fever and tachycardia are common
• If present, a friction rub is diagnostic
• ECG usually shows diffuse ST elevation and PR segment depression, particularly in lead II

An echo would show a segmental wall motion abnormality in acute MI

• 50% of cases in the US are idiopathic, presumably post viral
• TB is the most common cause in developing countries
• Other causes include cardiothoracic surgery, radiotherapy, and coccidiomycosis
• -- > 4,000 rads increase the risk of pericarditis

• Inspiratory rise in the jugular venous pulse (Kussmaul sign)
• Rapid x and y descents in the JVP
• Pericardial knock in early diastole
• Calcification of the pericardium on CXR (particularly if TB is the cause)
• Thickened pericardium on CT or MR

• Echo shows pericardial effusion, diastolic collapse of the RA and perhaps the RV
• Physical exam shows pulsus paradoxes and JVD with a single rapid x descent

• 70% of ASDs
• Second most common adult congenital heart disease (after bicuspid aortic valve)
• Atrial fibrillation is common
• Does not require antibiotic prophylaxis

• Systolic ejection murmur at the left sternal border due to increased pulmonary flow
• A diastolic murmur is possible due to increased tricuspid blood flow
• Fixed splitting of the second heart sound.
• ECG shows right axis deviation and/or RBBB

• Surgery is indicated if there is more than a 2:1 left-to-right shunt, even in asymptomatic patients n (this is figured by echo).
• If the pulmonary resistance is > 15 U/m², surgery cannot be performed

If the pulmonary resistance is > 15 U/m2, surgery cannot be performed

• A defect low in the interatrial septum which may affect the mitral and tricuspid valves
• Systolic murmurs because of MR or TR
• ECG shows left axis deviation and RBBB
• Treatment is the same as for secundum ASD

• Defect is high in the intertribal septum
• Associated with anomalous pulmonary venous return

• More common in females
• May have differential cyanosis, with the hands affected but not the feet
• Usually has a continuous murmur
• Surgical or percutanous closure should be done in symptomatic patients of any age

• Most common congenital defect in children
• 80% os small defects close spontaneously
• Large VSDs require surgical closure

• Accompanied by a bicuspid aortic valve 70% of the time
• Other left-sided defects are common
• Delay in the femoral pulses
• Upper extremity HTN
• Rib notching on CXR
• Turner syndrome is associated with coarctation and a bicuspid aortic valve

• A large intracardiac shunt eventually causes pulmonary vascular resistance to exceed systemic resistance
• The shunt becomes right-to-left and causes cyanosis
• All of the intracardiac shunts can cause this except secundum ASD
• Treatment is heart-lung transplant
• CXR shows dilated pulmonary a. and prominent RA

• Secundum ASD

• Primary pulmonary HTN
• Multiple pulmonary emboli
• Mitral stenosis

They usually has mitral stenosis or a secundum ASD

• Anything that stretches myocardium such as:
• LV systolic and diastolic dysfunction
• Acute PE
• Cor pulmonale

• No cause is the most common finding
• Second most common is anomalous coronary artery

• Delayed intrensicoid deflection time n V₁
• rSR' in V1
• wide S-wave in Lead I and V₆

• QRS delay more than 120 sec in Leads I and V₆
• Monophasic R-wave in lead I and V₆
• rS or Q in Lead V₁

An intra-aortic balloon pump is absolutely contraindicated in patients with severe aortic regurgitation because diastolic inflation of the balloon would exacerbate aortic regurgitation.

• Patient is symptomatic
• EF < 50%
• Patient needs other cardiothoracic surgery

• If pt symptomatic or
• Abnormal hemodynamic response to exercise (PAP increases by 25 mm Hg)

Percutaneous valvotomy if anatomy amenable and if less than moderate mitral regurgitation and no left atrial appendage clot by TEEa; otherwise, mitral valve replacement

• Patient symptomatic, or
• Ejection fraction <50%, or
• End-systolic dimension >55 mm or end-diastolic dimension > 70 mm, or
• Abnormal hemodynamic response to exercise (PAP increases by 25 mm Hg)

• Patient symptomatic, or
• Ejection fraction <60%, or
• End-systolic dimension >40 mm, or
• (Consider if) pulmonary hypertension or atrial fibrillation

manifested by acute onset, high-grade av conduction defects that may occasionally be associated with myocarditis

ostium primum ASD

• NYHA class III or IV heart failure
• an ejection fraction less than or equal to 35%
• QRS width greater than 120 msec.

• Tetralogy of Fallot repair involves placement of a transannular pulmonary outflow tract patch. This causes severe pulmonary valve regurgitation, which is confirmed by the presence of a diastolic murmur that increases with inspiration, a parasternal impulse (right ventricular enlargement), and elevated central venous pressure. The holosystolic murmur at the left lower sternal border that increases with inspiration is characteristic of tricuspid regurgitation. Long-standing pulmonary valve regurgitation causes right ventricular enlargement and tricuspid annular dilatation with resultant regurgitation. The tricuspid regurgitation causes right atrial enlargement and increases the risk of atrial arrhythmias.
• Aortic valve regurgitation may occur in patients with repaired conotruncal abnormalities, such as tetralogy of Fallot. These patients may demonstrate progressive enlargement of the aorta and, eventually, aortic valve regurgitation may occur.
• The murmur of aortic regurgitation does not vary with respiration and is best heard in the second left intercostal space and down the left sternal border and would not cause right ventricular enlargement with a parasternal impulse.
• In a patient with aortic regurgitation, a wide pulse pressure would be expected.
• Residual or recurrent ventricular septal defect also occurs in patients with prior tetralogy of Fallot repair. A ventricular septal defect causes a loud systolic murmur that obliterates the S2 and is often associated with a palpable thrill. A displaced apical left ventricular impulse and mitral diastolic flow rumble would suggest a hemodynamically important ventricular septal defect causing volume overload.
• Right ventricular outflow tract obstruction occurs commonly after repair of tetralogy of Fallot. However, the primary features include right ventricular hypertrophy rather than right heart enlargement.
• The murmur of pulmonary stenosis is an early systolic murmur that increases with inspiration and is heard best at the second left intercostal space. It is associated with a loud P2 heart sound that is sometimes palpable.

Exercise stress testing is not recommended for the estimation of cardiovascular risk in an asymptomatic patient. In patients with diabetes mellitus who are beginning an exercise program, exercise testing has been recommended.

• Significant left main coronary artery stenosis
• Left main coronary artery equivalent disease: ≥70% stenosis of proximal LAD and proximal left circumflex artery
• Three-vessel disease
• Two-vessel disease with significant proximal LAD stenosis and either ejection fraction <50% or demonstrable ischemia on noninvasive testing

• One- or two-vessel disease without significant proximal LAD stenosis but with a large area of viable myocardium and high-risk criteria on noninvasive testing
• Developed disabling angina despite maximal noninvasive therapy, when surgery can be performed with acceptable risk (if angina is not typical, objective evidence of ischemia should be obtained)

• wide pulse pressure
• rapidly collapsing pulse
• pulsating nailbeds
• brief systolic and long diastolic murmur
• features of left ventricular enlargement

• Patients with coarctation of the aorta are prone to aneurysm formation.
• Hoarseness due to left vagus or left recurrent laryngeal nerve compression
• Dysphagia due to esophageal compression
• Recurrent pneumonia due to bronchial compression
• Superior vena cava syndrome

Warfarin use throughout pregnancy until near term provides the lowest risk for maternal complications and death in women with mechanical heart valves.

Medical treatment with cilostazol, a phosphodiesterase inhibitor, is effective in increasing pain-free and overall walking distance and is recommended for patients with lifestyle-limiting claudication. However, cilostazol is contraindicated in patients with heart failure or left ventricular systolic dysfunction. Chronic use of oral phosphodiesterase inhibitors (not specifically cilostazol) for inotropic therapy in patients with heart failure has been associated with increased mortality.

BNP levels are generally lower in obese pts, even those with acute heart failure.

• The Brugada syndrome is characterized by a pseudo right bundle branch block pattern with ST-segment elevation on the electrocardiogram and ventricular arrhythmias.
• It is genetic, with ventricular fibrillation as the cause of death

• Another inherited arrhythmic disorder is the short QT syndrome, which carries a high risk of sudden cardiac death. The syndrome is characterized by an autosomal dominant pattern of inheritance, a short QT interval (<300 msec), atrial fibrillation occurring at a young age, and an increased risk of death due to ventricular fibrillation.
• Other clinical presentations include polymorphic VT or VF, unexplained syncope

• It is suggested by recurrent syncope triggered by activity, a prolonged QT interval > 580 msec, and a family history of early sudden death.
• Pts can be misdiagnosed with a seizure disorder.
• Cardiac events in LQTS patients include syncope and cardiac arrest due to torsade de pointes.
• Corrected QT intervals are considered abnormal if greater than 440 msec in men and 450 to 460 msec in women, but there is substantial overlap among normal patients and abnormal LQT gene carriers.