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G R V d e t i n U - 9 9 r i h a t MeSdtu®d y INTERNAMLE DICINREE VIEW RE SIXTEENTH EDITION CURRICULUM G R V d Book3 of 5 e t i n U Topicisnt hivso lume: Cardiology - 9 Rheumatology 9 r i h a t RoberAt.H annamanM,D EditionrC hief Disclaimers NOTICEM:e dicianned a cceptsetda ndarodfcs a raer ec onstancthlayn ginWge. a tM edStuddyo ourb estto r evieawn di ncluidnte h ipsu blication dacicsucruastseio oftn hse s tandarodfcs a rea nd methodosfd iagnosHiosw.e vetrh,e e ditionrc hietfh,er eviewetrhses, e ctieodni totrhsep, u blis,h er anda lolt hepra rtiiensv olvweidtt hh ep reparatainodpn u blicaotfit ohniw so rkd on otg uarantee that thei nformactoinotna inheedr eiinsi ne verrye speacctc uraotrec ompletMee.d Studfyu rthdeirs claims anya nda llli abifloidrta ym ageasn dc laimtsh amta yr esuflrto mt heu seo fi nformaotriv oine wpoints presentWeed r.e commentdh ayto uc onfitrhme m ateriwailtc hu rresnotu rceosfm edicakln owledge whenevecro nsiderpirnegs entatoirto rnesa tpiantgi ents. 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Allof u sa tM edStudwyo rki ncredihbalrydt od oo urv eryb esotn yourb ehalf. Pleashee lups o utb yn otu sincgo pieosft himsa teriTahla.n ks!! Notificaotfci oopnysr iignhftr ingesmheonutlb des enitnc onfidetnoc e @ copyrigmhetdstudy.com MEDSTUDY® 1455 QuaiLla keL oop 80906 ColoraSdpor inCgosl,o rado (80804)1 -0547 www .medstudy.com 0 )> ::a c 6 r- 0 C) -< G R V d e t i n U - 9 9 r i h a t Cardiology PROCEDURESL,A BS,P HYSICAELX AM ...............5.-.1. .....P.E.R.I.P.H.E.R.A.AL.R .T.E.R.I.A.DL.I .S.E.A.S. E. .............5.-.2.6. ........................ CHEST X-RA.Y.S. ..........................5.-.1. ......C.A.U.S.E.S.O .F. P.A.D.A .N.D. I.N.T.E.R.M.TI.T.E.N.T. ...................... ECH0. .....................................................................................................5. -2 CLAUDICATIO.N. .....................5.-.2.6. ......................................... CARDIACS TRESST EST.S.. ....................................t.. ... .................5..-..2. DIAGNOSIOSF P AD. .....................5.-.2.6. ....................................... ExerciToslee ranTcees( tW ithoIumta gin.g.). ...........5.-.2. ......T.R.E.A.T.M.E.N.TO. F..P A.D. ...... ..................5.-.2.6. ..................................... Stress ImTaegs.it.ns.g . ......................5.-.3. .....V.A.S.O.S.AP.S.T.I.CD. I.S.E.A.S..E.. .......................................5..-..2..7.. ..... .................................. CardiSatcr eTsess -tsPickitnhgCe o rreTcets. t. ....,.. ........5..-..4.. ..... ..C.A ROTIDA RTERYD ISEAS.E. .................5.-.2.7. ............................... CARDIOPULMONAREYX ERCISET ESTING ..........5.-.5. ......C.A.R.O.T.I.DA. R.T.E.R.Y.A .TH.E.R OSCLEROS.I.S. .......5.-.2.7. ............... CARDIACS CANSI C ATHS. ...............,.. ..........5..-..5.. ..............I..N .T.E.R.N.A.LC. A.R.O.T.I.DA. R.T ERYD ISSECTI.O.N. .....5.-.2.8. ......... ContrCaasrtd iCaact heteri.z.a.t.i.o.n. ............5.-.5. .....C.E.R.E.B.R.A.L.E .M.B.O.L.I.CD. I.S.E.A.S..E.. ................ .......5.-.2.8. ........................... CardiCaTc. .........................,.. .......5..-..5.. ......... ..T.R.A.N.S.I.E.TN.I .S.C.H.E.M.I.AC.T T.A.C.K.. ............................5..-..2..8 . ....................... CardiMaRcJ . .............................5.-.6. .....A.O.R.T.I.CD. I.S.E.A.S..E.. ..............................................5..-..2..8.. ...................... .................................. PULMONARYA RTERYC ATHETREJZATIO.N. ..........5.-.6. ......A.O.R.T.I.C.A .N.E.U.R.Y.S.M S. ......G..............5.-.2.8. .................................... CARDIACB IOPS.Y. .........................5.-.6. ........T.h.o.r.a.cA.io.cr. t.Ai.nc.e .u.r.y.s..m..s.. ..............................5..-..2..8.. .......... ......................... PHYSICAELX AM ...........................5.-.7. .........A.b.d.o.m.i.nA.ao.lr. t.Ai.nc.e .u.r.y..s..m.. ............................5..-..2..9.. ............ ...................... Puls.e.s. ..............................5.-.7. .......C.O.A.R.C.T.A.T.I.O.NO .F. T.H.E.A .RO.R.T.A.. ............................5..-..2..9.. ..................................... ...... HearSto undasn dM urmur.s. ....................5.-.7. .....V.A.L.VU.L.A.R. H.E.A.R.T.D .I.S.E.A.S..E.. .............................. .5.-.2.9. ............................... Venous Wave.f.o.r.m.s. ....................5.-.9. .......I.N.F.E.CT.I.V.EE. N.D.O.C.A.R.D.I.T.I..S.. ..............................5..-..2..9.. ........ ........................ HYPERTENSIO.N. ...........................5.-.01. .........O.v.e.r.v.i..e..w.. ..V...............................................5..-..2..9.. .................. ........................................ CARDIACM EDICATION.S. .....................5.-.1.0. ........A.n.t.i.b.i.Po.rt.oi.pc.h .y.l..a..x..i..s.. ................................5..- .3.0. ................................... CARDIACI SCHEMI.A. ........................5.-.I.O. ......R.U.B.E.L.L.A.. .......................................................5..-.1.3. ........ ................................................ d ANTI-ANGINAL DRUGS. ......................5.-.1.2. ......R.H.E.U.M.A.T.I.CF. E.V.E..R.. .........................................5 .-.13. ....................................... EVALUATIOONF CHRONICS TABLEANGINA. .........5.-.1.2. ......S.P.E.C.I.F.IV.CA LVE LESION.S. ................5.-.I3. ................................ e Not.e. ...............................5.-.1.2. ........A.o.r.t.i.c. .S.t..e..n..o..s..i..s.. ....................................5..-.1.3. ..................................... .......................... I.H istoarnydP hysiEcxaalm D:e termPinreo babiolfCi ArDy . ..5.-.1.3 ChronAiocr tRiecg urgit.a.t.i.o.n. ...........5.-.3.2. ............................. 2.N oninvasivef oCTrhe rsotnsSi tca bAlneg ina: tAcutAeo rtRiecg urgit.a.t.i.o.n. ............5.-.3.3. ............................... DiagnoasnidRs i sSkt ratifi.c.a.t.i.o.n. ...........5.-.1.3. ...i....M.i.t.r.Sa.tl.e .n.o..s..i..s.. .................... ...........5.-.3.3. ........................................... n 3.D eterminaotfF iuornt hWeorr kuipn C hronSitca bAlneg in.a. .5.-.1.3 ChronMiict rRaelg urgit.a.t.i.o.n. ...........5.-.3.6. ............................. TREATMENTO F CHRONICS TABLEA NGINA. .........5.-.1.4. ........M.i.t.r.a.l. .V alve. .P.r.o.l.a.p.s.e. ...........5.-.3.6. ..................................... CARDIOVASCULAR DISE(ACSVED P)R EVENTION U AcutMei trRaelg urgit.a.t.i.o.n. ............5.-.3.6. ............................... INW OMEN ..............................5.-.1.4. ........T.r.i.c.u.sS.pt.ie.dn. o..s..i..s.. ......................................5..-..3..7.. .................... .............................. ACUTEC ORONARYS YNDROME. ..................5.-.1.4. ........T.r.i.c.u.sR.pe.ig.du. r.g.i.t..a..t..i..o..n.. ............ ........5.-.3.7. .................................. CLASSIFICATIOOFNA CS. .....................5.-.1.4. ........P.u.l.m.o.nS.it.ce. n.o..s..i..s.. .................................. ..5.-.3.7. ........................................ - NOTES. ............................................................5....-....1... 5... ..................P.u.l.m.o.n.Riecg urgit.a.t.i.o.n. ..............5.-.3.7. .................................. MARKERSF ORA MI. .................. ......5.-.1.5. ........E.b.s.t.eA.in.no. m.a.l..y.. ............................................5..-7..3 .. ... ........................................ TREATMENTO F ACS. ................9........5.-.1.6. ......V.A.L.VE. .S.U.R.G.E.R.Y.. .............................................5..-..3..7.. ......................................... PrehospMiatnaalg eme.n..t. .....................5.-.1.6. .......F.i..n.aP.le. a.ra.lb.so. u.Mt.u .r.m.u.r..s... .......................... ..5.-.3.8. .............................. EvaluatoifPo ant iewnittsSh y mptomSsu gg9estoifAv CeS . ....5.-.1.7. .... ARRHYTHMIAS. .........................5.-.3.8. .............................................. ACS:G ENERALM EASURES. ...................5.-.1.8. .......M.E.C.H.A.N.I.S.M.SO. F. A.R.R.H.Y.T.H.M.I.A.S.. ............... ....5.-.3.8. .................... ECG,N TG,M orphiBneet,a -BlorcAkCeErI ssA,,t rop.i.n.e. ..5.-.1.8. ......S ICKS INUSS YNDROME. ..................5.-.3.8. ................................. AnticoagIuA lnatnitp laTtheelreatip nyA CS. ...........5.-.1.8. ......H.E.A.R.T.B. L.O.C.K.. ...... .....................5.-.3.8. ............................................. i FibrinoTlhyetriacip nAy C S. ....................5.-.1.9. ......S.U.P.R.AV.E.N.T.R.I.C.U.L.A.RT.A .C.H.Y.C.A.R.D.I.A..S.. ........ ....5.-.3.9. .............. h AntiarrhyDtrhumgiiscnA CS. ...................5.-.1.9. ........A.t.r.iF.al.lu. t..t..e..r.. ................................ ......5.-.3.9. .............................................. ACS:M ANAGEMENTO F UA IN STEM-I AtriFailb rill.a.t.i.o.n. .................5.-.3.9. ......................................... a THEA CUTEI SCHEMIPAA THWAY ................5.-.1.9. .......M.A.T.. ................................ .............5.-.4.2. ....................................................... EarlIyn vasvisvC.eo nservative ..T.h.e.r.a.p.y. .....5.-.1.9. ........S.V.T.... ....................... .................5.-.4.2. ....................................................... Early Invatsivien U TAh INe SrTaEpMyI. .............5.-.1.9. ........W.P.W. ....................... ..................5.-.4.2. ..................................................... EarlCyo nservaTthievrea ipnyU A IN STEMI. ..........5.-.2.0. ......V.E.N.T.R.I.C.U.L.A.AR.R RHYTHMIAS. ..............5.-.4.3. ....................... LongT-ermA ntpil ateTlheetr aapftye UrA IN STEMI.. ......5.-.2.0. .......P.V.C s.. ............................5.-.4.3. ...................................................... Cocaianned M ethamphetaUmsienrwesi tShT Elevation .5.-.2.0. .......V.e.n tricTualcahry ca.r.d.i.a. ...............5.-.4.3. .................................. ACS:M ANAGEMENTW ITH STEMI O R NonsustaViennetdr icTuaclhayrc ar.d.i.a. ........5.-.4.4. ................... NEW LEFTB UNDLE-BRANCBHL OCK. ............5.-.2.0. ......P.A.C.E.M.A.K.E.R.S.. ........... ...................5.-.4.4. ............................................. Not.e. ...............................5.-.2.0. .......A.N.T.I.A.R.R.H.Y.T.H.M.I.TC.H .E.R.A.P.Y.. .............................5..-..4..5.. .................................. ........ ImmediaRteep erfusiTohne rap.i.e.s. ..............5.-.2.0. .......D..r.u.g..s.. ................................... ..........5.-.4.5. ..................................................... AdditiRoencaolm mendatfiroontmsh 2e0 13 ElectrophysTieoslto.ig.ni.gc. ...............5.-.4.6. ............................... ACC IA HA STEMI G uideli.n.e.s. ..............5.-.2.2. ........R.a.d.if.or. e.q.u.eA.nb.cl.y.a .t..i..o..n.. ........... .........5.-.4.6. ................................. ComplicatoifMo ynosc ardiinafla rc.t.i.o.n. .........5..-.2.2. ....S.Y.N.C.O.P.E.. ......................... ................5.-.4.7. ...................................................... Implantable Cardiovert.e.r.-.D.e.f.i.b.r.i.l.l.a.t.5o.-r.2s.3 . ....C.A.R.D.I.O.M.Y.O.P.A.T.H.I.E..S... ........ ...............5.-.4.8. ....................................... CORONARYA RTERYD ISEAS.E. ..................5.-.2.4. ......H.Y.P.E.R.T.R.O.P.H.I.CC.A .R.D.I.O.MY.O.P.A.T.H.Y.. .......... .....5.-.4.8. ................. RISKF ACTORSF ORC AD. .....................5.-.2.4. ........T.r.e.a.t.m.fe.on.Hrt.C .M. ......................................... .5.-.4.8. ...................................... SCREENIN.G. ............................5.-.2.4. ......R.E.S.T.R.I.C.T.IE.V C.A.R.D.I.O.M.Y.O.P.A.T.H..Y.. .......................5..-..4..8.. ..................... ......... REVASCULARIZATI.O.N. ....................5.-.2.4. .......D.I.L.A.T.E.DA. N.D. N.O.N.I.S.C.H.E.M.I.CC.A .R.D.I.O.M.Y.O.P.A.T.H.I.E..S.5. .- 49 CABG VS.P CI. ...........................5.-.2.4. ................................................... Sten.t.s. ..............................5.-.2.5. ............................................................ Othe.r. ...............................5.-.2.5. ............................................................. The Electrocardiogram HEART FAILUR...E... .....................................................................5 -49 THE I2-LEAEDC G .......................................................................5. -60 OVERVIEW. ...............................................................................5 -49 AXISD EVIATIONS... .................................................................... .5-60 LOW-OUTPUTH F .....................................................................5 -50 RATESA ND INTERVAL.S.. .........................................................5. -60 NYHA Claisfiscant .i...o..........................................................5 -05 INTERVAL.S... .................................................................................5 -I6 ACC IA HA Stagi..n..g... .........................................................5 -50 PRI NTERVAL... ........................................................................5. -I6 DeterinminPgr ongosiisnH F .................................................5 -51 QRS DURATION.. ......................................................................5 -I6 Mechnaisomf HF ..................................................................5. -51 QT INTERVAL.. ..........................................................................5 -I6 TreatmefnoHtrF . ........................5.-2.5 ..........W.A.V.E.F.O.R.M.S. A.N.D. .S.E.G.M.E.N.T.S.. ....................... .....5.-.I6. ............................ EmergenTcrye atmefnotSr everHee arFta ilu...r...e... ............5 -54 P WAVE .....................................................................................5.. -6I HIGH-OUTPUTH F. ...................................................................5 -54 TWAVE ....................................................................................... 5-62 RIGHTV ENTRICULARF AILUR£.... ............5.-.5.4. .........U. .W.AV.E. ................. ......................5.-6.2. ..................................................... PULMONARYE DEMA .............................................................5 -55 STS EGMENT ...........................5.-.2.6 ............................................... PERICARDIALD ISEASE.S.. .........................................................5 -55 QRS COMPLEX .........................................G................................ 5-62 NON-CONSTRICTIVPEE RICARDIT.I...S.. ...........................5 -55 VENTRICULAHR YPERTROPH.Y.. ............................................ 5-63 CONSTRCITIVEP ERICARDIT..I...S.. .....................................5 -55 LVH. ...........................................................................................5.. -63 RECURRENTP ERICARDIST. I...............................................5. -56 RVH. ..............................................R...............................................5 -63 PERICARDIAELF FUSION.. ...................................................5. -56 CONDUCTIOND ISTURABNCES. .............................................5. -64 CONGENITALH EARTD ISEASE... ............................................5. -57 AV BLOCKS. ..............................................................................5 -64 ASD. .............................................................................................5 -57 BUNDLE-BRANHC BLVOCK. ...................................................5 -64 OstiuSme cunduAmS D. ........................................................5 -57 LBBB. ..................................................................................... 5-64 OstiuPmr imuAmS D. .............................................................5 -57 RBBB. ..........d...........................................................................5 -64 SinuVsen osuAsS D. ................................................................5 -57 LAFB ......................................................................................5.- 65 PDA. .............................................................................................5 -57 LPFB.. .....................................................................................5 -65 PULMONARY STENOSI.S... ....................................................5 -57 BifasecliaBcrlu oc..k.. ...............................................................5 -65 VSD. ............................................................................................5. -58 WIDEQRS ..................................................................................5 -65 COARCTATIONO F THEAORTA. ...........................................5 -58 ARRHtYTHMIAS. ...........................................................................5 -65 ANOMALOUS CORONARYA RTERY. ..................................5 -58 EiCTOPICv s.P ACEMAKER .....................................................5 -65 SUDDEN DEATH INE XERCISINYGO UNG PEOPLE ........5 -58 nATRIALA RRHYTHMIAS.. .......................................................5 -66 OTHER. .......................................................................................5 -58 VENTRICULARE CTOPICB EATS AND HEART BLOCK .. 5-66 PULMONARYH EART DISEAS.E... .............................................5 -58 U MYOCARDIAL INFARCTI.O...N... .............................................. 5-66 COPD ANDS LEEPA PNEA ......................................................5 -58 COMMON FINDING.S... ...........................................................5 -66 EISENMENGERS YNDROME .................................................5 -58 LOCATIONO F Mlv s.E CG CHANGES. .................................5 -66 CHRONICT HROMBOEMBOLICO BSTRUCTION.. ............5 -58 NOTES.. ....................................................................................... 5-67 PULMONARYA RTERIALH YPERTENSIO..N... ...................5 -5-9 REMEMBER ................................................................................5. -67 PREGNANCY AND THEH EART..... .......................................... 5.. -59 ANALYSI.S... ................................................................................... 5-67 9 FOR FURTHERR EADING.. .........................................................5. -81 9 r i h a t G R V d e t i n U - 9 9 r i h a t 5-1 PROCEDURESL,A BS,P HYSICAELX AM uppelro bpeu lmonavreyi nKse)r,l Be yl ineasn,dp leural PROCEDURE,SL ABS,P HYSICAELX AM effusion(su suarlilgyh lte>ft ). CHESTX -RAYS An anomaloupsu lmonarvye int hadtr aiinnst toh e infervieonrac avcaa nc reaat "es cimistiagrno "n c hest Knowa ltlh ef ollowcihnegsx t- rafiyn dings! x-raTyh.i si sa curvilionpeaacri itnyt her ighlto wer Chesxt- raiysa ne ffectimveea nosf q uickdleyt ermininlgu nfige lddu et oa ssocilautnehgdy poplasia. significiannctr eaisneb so tho verahlela rsti zaen d Aortica bnormaltihtaiyteo sum ays eei nclutdoer tuosity (sometimheesa)rc th ambesri zeAs c.a rdiothorraatciioc andc alcificaAnt iaoonr.ta ince uryisssm o metimeeass ily > 50%i ndicates an caerndliasaricgl ehdo uestutge­, visiobnlt eh el atefirlamlAn. aortdiics secctainos nh ow gestienigt hcearr diomegoaral yp ericaredffuisai!o n. upa sm ediastwiindaeln ionntg h PeA p rojection. Thisi st her aticoo mparitnhgem ostr ightward and leftward boorftd heehr esa rste en ao pno steroantePreiroirc aredffiuas! ioinss uggesbtyea d w"atebro tt"l oer (PAc)h esxt- radyi,v idbeydt het ransvcehressedt i am­ a" watbearl losohna"p teot heh eart, somweittishmi egs­ 5-)3. ete(rm easurfreodm thei nsirdiemb a rgiantt hew idest nificaenntl argeomfet nhtce a rdisaicl hoGu(eItmtaeg e poinatb ovteh ec ostophraenngilcoe nst hes amex -ray). Shunvta sculya (reintlargsheadr,p ly dpeufilnmeodn ary Thirsa tiisov aliodn lfyo ra nu prignhotn,r otafitlemd vasculatiusr vei)s ibwliet hs iRgnificvaenntt ricular on fuliln spira(tdiioanp hrfauglml cyo ntracwtietdh) septdaelf e(cVtS D)a,t risaelp tdaelf e(cAtS D)o,ro ther a well-visucaalridzieoaduc t liannedw hent heriesn o left-to-srhiugnhtts . abdomincaolm pressoino nt dhiea phrasgumc,ah s t hat V Areaosfc alcificaotnic ohnessx t- ray: causebdya sciotrep sr egnancy. On thPe Afi lmt,h el eftv entriccalues tehseb ulgient he • AortiTch:i ndki ssdecitfyi oouns eea s eparation betweceanl cificaantdit ohnea ortbiocr deers,p ecially left-loswiedroe f t hec ardisahca dowt;h er ight atrium (RA) ift hem ediaestianpupme awrisd e. causes theo not uhtel irniaegn hdtt h;ea reoaf t he cardi"awca istline"-btehteaw oeretnki nco ba ndt he • Myocardtiyapli: caflrloyam n a picaanle urysm. t leftv entri(cLlVe) -ifso rmebdy t hem ainp ulmonary• Valvulcaorm:m onlayo rtic. 5-)1. i artery alnedfta ttrhi(eaL lA ) appe(nmIdaaggee • Annnul(arri ng-shmaipterda)an:ln ulcaarl cification; ifi ti sa p erfercitnt gh eanp rosthveatlivices l ikely Ont hel atevriaelwa ,n yi ncreianst eh em asso ft hel eft U(especiiafsl ulryg icclailap rsea lspor esent). ventriecxltee ntdhse c ardisahca dopwo steriaonrdl y lower-clotsote hre d iaphraAgnmy.i ncreaisnte h e • PericardTihai!nc:ko nstripcetriivcea rodri tis; masso ft her ighvetn trificllliesn t hel owepra rotf t h e thinTkB ift hec linihciaslt osruyg gessitgsn ificant anterciloersa pra cbee hinthdse ternu(mI mag5e -)2.- exposu(rIem ag5e-) 4. Coarctatoifot nh ea ort(aC OA)i si ndicabtyea db sence ofa normaalo rtaircc hI.n stelaodo,fk o rt he"9 3s"i gn, whicihs c reatbeyda prominelnetfts, u bclavairatne ry, 9 thec oarctaatnidpo ons,t stednioltaitcoi fto nh dee scend­ inga ortTah.eb ariusmw allcoawn s howa " rever3s,e"d r duet ot hei mpressoifot nhsea rtersitarlu ctounrt ehse i esophagAudsu.l atlss soh owi ntercroisnbto atlc hidnuge h toc ollatfleorwat lh routgohr tuionutse rcaorsttearli es. Heart failur(eH F)is ai ndicatbeyd c ardiomegaly, pulmonavrays curleadri stri(bwuittvihio sni tbhliyc kened t Imag5e- 1N:o rmpaols teroacnhteexsr-tir oary Image N5o-r2m:a /lactheersatl x-ray © 20M1ed4S tudy 5-2 PROCEDURES , LABS, PHYSICAL EXAM intracasrhduinatDcso .p pleecrh ocardiogmreaapshuyr es thev elocaintdyd irectoifot nh eb loofdl ow. Doppler echod etermimneeasn g radiepnetask,v elocitaineds , valvaer ea. So,D oppleirsu sefuiln d etermintihnesg e verity of valvulsatre noosrir se gurgitaastw ieolnal,s i ne valu­ atinlge ftv entricular diastloelftvi ecn tfruinccutliaorn , outfltorwa gcrta dieanntdis n,t racasrhduinatIcsti . sa lso helpfiunle stimatpiunlgm onaarryt e(rPyA )p ress.u re To estimaptree ssubryeu sinpge ak Dopvpelleorc ity measuroende choP:re ssugrrea di(emnmtH g=) 4x V2 Ima5g-3e": Wabtoetrht elaer"It m a5g-4eP: ericardia/ (measurveedl ociFtoyre) x.a mplieft, h ev elocaictryo ss calcification thet ricusvpaildvi es5 m /sect,h etnh eP A press=u re 4x 5(x 5)+ rigahttr iparle ssuGSroe,i. ft her igahttr li a Knowt haats inglleea idnt heap eoxf t her igvhetn tricle pressuirnte hiesx amplies 1 0m mHg,t hent heP A (RV)i ndicattheeps r esenocfea ne lectrvoennitcr icu­ press=u 1r1e0m mHg (whicihse xtremheilgyh ). larp acemakoerr i mplantdeedf ibrillatotrh-ew ith R defibrillelaabdte oirn lga rgaenrd w idetrh atnh aotf a pacemak2e rl,e adisn dicaant aet rioventr(iAcV)u laCrA RDIACS TRESST ESTS V sequent(idaula l-champbaecre)m akearn,d 3 leads Overview indicaa btiev entripcaucleamra kIefrt .h eriesn oa trial d leatdh,pe atielnikte hlaysc hronaitcr ifailb rillationT.h ei ncreadseemda ndf orm yocardoixaylg ewni th exerciisst eh ek eyf actionrt heu seo fe xerctiesset ing e asa diagnotsotoifclo rc oronaarryt edriys ea(s[eC AD]; ECHO a.k.cao.r onahreyad rits eaSster)e.ts ess htasv aen i ntegral t Echocardiogirsaa pnh uyl trasomuondda liutsye dt o rolien b otthh ed etectoifoC nA D (diagnotsotoilac)n d i imagteh eh earItt.u tiliMz-emso de2,D ,a nd3 D for nins tratifiofcr aits(pikro ong nosttoioclT )o. appropriately structiumraagli anngd D opplfeorar s sessbilnogofl do w utilsitzree tsess tas p,a tiepnrte'tspe rsotb abiolfCi AtDy rataen dd irection. U mustb et akeinn taoc cou(nAtp .o sittievsietn a low-risk patiiesnm to rel iketloby e a f alpsoes itainvdea ,n egative Besuts eo fe chios f otrh fe ollowsicnegn arios: tesitna h igh-rpiastki iesnm to rel iketloby e a f alnseeg ­a • Leftv entricsutlraurc taunrdse y stofluincc tion tiveD.i)a gnostteisct iinsmg o stv aluabwlhee np retest - • Righvte ntricsutlraurc taunrdse y stofluincc tion probabifloiCrtA yD isi nterme.d iate • Valvuhleaarrd ti sease 9 Theraer 2e genertaylp eosfc ardisatcr etsess dtosn e: • Congenihteaalrd ti sease • Myocardiinafla rc(tiinocnl 9updoisntg- MI I)E xercitsoel eratnecse(t [ ETT]; tbraesaidcm oirl l stationary bicycle itmeasgtiinngg) without complications) • Cardiomyop(abtohtlyho r sosfe jectfiroanc tion 2)S treismsa gitnegs t-in"sgtr"e isssi nducweidt h: andh ypertroofpm hyyio cardium) • exerc(itr seea d1m1io rb icycolre ), h • Peircarddiias!e ase • pharmacolsotrgeis(cse itdhoebru tamionrae • Cardimaacs sae(st umotrh,r ombaunsd,v egetation) vasodilator) • Diseasoefts h ea ortaan dp ulmonaarryt ery Thea ssociiamtaegdi insgd onew ith: • Estimattoifpo unl monaprrye ssure • Echocardiog(raa.pk"h.syatr .e escsh o") • Diastofluincc tion • Myocardpiearlf usion (iMmPaIg)i ng • Cardisaocu rcoefes m boli ExercTioslee raTnecs(etW ithIomuatg ing) Transesopheacgheoacla rdio(TgrEaE)m i sa n echo performweidt ha n esophageparlo beI.t offers Exercitsoel eratnecs(etE TT)u,s inegi thae trr eadmill higher-resoilmuatgieocsno mparetdo tratnhsoraciocr s tatiobniacryyc ilset ,h ec ornerstoofnd ei agnostic imagianngd i se speciuaslelfuyfl o erv aluating: testifnogri schemainad fu nctioncaalp aciatyn df or determipnrionggn o(siinsc lupdoisntg- MI). • Valvusltarru ctaunrdfe u nction • Lefta tri(uimn cluldeiftan tgr iaaplp endage) Despiatneo verallolws ensitainvdis tpye cific(imetny: sensit=i 6v8i%t,ys pecif=i 7c7i%t;yw omens:e nsitivity • Cardimaacs ses • Intracasrhduinatcs = 61%,s pecif=i c7i0ty%) ,t hes ensitiavnids tpye cific­ itiyn crewaistehh i ghperre tpersotb abiolfCi AtDy. E TT • Endocarditis hasa n umbeorf a dvantages, itnhceal buidlitinottg ye: s t • Aortdiics section functiocnaapla cistayf,e twyi,d espraevaadi labainldi ty, A bubblset ud(yp erforbmyei dn jecthianngd -agitarteelda tilvoewcl oys t. salianneda iirn ttoh vee noussy steimsu) s etdo e valuate © 201M4e dStu-dyPieasRee porCto pyriIgnhftr ingemteocn otpsy [email protected] PROCEDURES ,L ABS, PHYSICAL EXAM 5-3 Tehcnicdailffi culitnmi oensi toErCiGn/gB P • Q� uiz • Patireenqtu etsost tso p Serioaursr hyt(hem.isgau. s,t aviennetdr icular • tachycardia) • On a latevriaelwC XRe,x tensiooftn h eh eart Achievtianrgg heeta rrta tael oniesn ota reastoon bordepro steriaonrdli yn feriionrdliyc ates disconttihneEu TeT ,a ndt hei ndivisdhuoaullb de enlargemoefnw th icvhe ntricle? encouratgoge oda sl onags t oleruantteridel q uired to • On a latevriale wC XRe,x tensiooftn h e stofpo sro mree ason (e.gf.a,t idgeyuxsehp,an uesat,i on, cardisahca doowf t hel owepra rotf t hea nterior oro neo ft haeb soliuntdei caftoitroe nrsm ination). cleasrp acbee hintdh es ternuimn dicates enlargemoefnw th icvhe ntricle? Excelleexnetr ctioslee r(a>nIc0 eM ETS)i sa ssociated witah g oodp rognoisnidse penodfet nhted egroefe • Whatc onditiiosan TsE Eu seffuoler v aluating? coronaarrtyed riys ease. • Whata rea bsoluitned icatfiootrne sr minating Absolcuotnet raindtiocE aTtTi:o nsG anE TT? • AcutMeI w ith2id na ys • Whena res treismsa gisntgu dideosn ei nstead R Unstaabnlgei nnoapt r eviosutsalbyi lbiyz ed ofa nE TT? • medictahle rapy Uncontraorlrlheydt hcVmaiuassis nygm ptoomrs Thep atietnytp iceaxlelryc iosnea s t readmuisliln g • hemodynacmoimcp romise standeaxredr cpirsoet ocsoulcashs, t hBer ucper otocol (seTeab le5 -o6n p ag5e- 1)2.Th e leovfme alx imal • Symptomsaetviedcar oer tsitce nosis exercaicshei eovnet dh EeT Ti sm easurienmd e taboli• cU ncontrolled shyemapfrtatoi mlautriec e equiva(lMeEnTtS)s. • Acutpeu lmoneamrbyo louris n farction ETTs hounlodbt e p erforimn2e g dr oups: • Acutmeyt ocardoirpt eirsi carditis Acutaeo rtdiics section • i I)P atieunntasbt loee x ercsiusffiec ie(nmtulsaytc hieve n 85%o fa ge-predmiacxtiemduh me arratt e) StreIsmsa giTnegs ts 2)P atiewnittsbh a selEiCnGea bnormaltihtacitae ns U Overview interwfietirhne t erproeftt ahsteti roetnse (sse t. lge.ft, ventrihcyuplearrt r[oLpYhHy]l ,e fbtu ndle-braTnhcehs treismsa gisntgu diaerset hes treescsh oa nd bloc[kL BBB]W,o lff-Park-Wihniseto [nWPW], myocardpiearlfu siiomna gi(nMgP I).T hec hoiocfe - ventripcauclianargn ,dr estSiTnd ge pressoiro nw)h,i cohn et ou sei so ften obanos peedr aetxopre rience takidnigg oxin att hfea cility. 9 Knowt hfeo llowiinnfgo rmarteiloatnto Ee TdT :s Streismsa gisntgu daireuess eads t hien itdiiaalg nostic 9 methowdh enap atiiesnn otat c andidfaotre EdTuTet o Definiotfia o pno sitEiTvT:e f laotr d own-sloping inabitloei xteyr caidseeq uaotrew lhye n theErCeG are ST-segmednetp res>s iIo mnm arnd8 0m s aftetrh e changaetrs e stth acta ni nterwfietrihen terpretoaft ion J-poiin3n ct o nsecubteiavtes . i thEeT T.T heayl saor per efeirnrp eadt iewnittpshr ior h UnliSkTee levatSiTod ne,p resdsoieonsno tc orrelarteev ascularization. witthh ea natomliocc atoifom ny ocardiisaclh emia. a Streismsa gisntgu diheasv eg reatseern sitainvdi ty IsolaStTe dde pressiini onnf erlieoardi ssf arl ess specifitchiattnyh er eguElTaTr. T heya reus ewdh en specitfihcaSn T d epresisnli aotne lreaal(d Vs-4 V6). t measuremoefn te jectiforna ctioorn m yocardial ST elevatdiuorni anngE TT in3 contiguloeuasd sv iabiilsdi etsyi rienad d dittiooi nd enticfyoirnogn ary withoQu wta veosfp riMoIri sa nu nusufianld itnhga t artedriys ease. iss uggesotfmi avrek eids che(mciaabn es eeanl so with coronaarrtyes rpya sm). StrestshiHene ga rt Ifmoarg iSntgu dies Absoliuntdei caftoitroe nrsm inoafta inEo TnT : The" strepsosr"t oifot nh etsees ctasbn e p erforwmietdh STe leva>tI im omn i nl eawdist hoQu wta vefsr om exercoirps hea rmacoalgoegn.it cs • priMoIra nde xcludaiVnRga, Y La,n dV I Witeh xerciimsaeg,i sntgu daireesd onjeu slti kaen • Decreianss yes toBlP>i Ic m0m Hgw hen ETTa ndr equtihrseea mea biltiotm ye e8t5 %o fa ge­ accompabnyia endyo theevri deonfc e predicmtaexdi muhme arrta tEex.e rciissp er eferable ischeomrhi yap operfusion becauistpe r oviaddedsi tifounnaclt iaonndpa rlo gnostic • Moderate-taon-gsienvae re informaEtxieornc.ii sns oeut s eidnp atiewnittpsha ce­ • CNSs ympto(mast adxiizaz,i nneesassry, n cope) makerosrl eftb undle-branc(LhB BbB)l boeccka use Sigonfsp oopre rfu(sciyoann osis/pallor) itc anc ausfea lse-polseiftvt einvter iacnutlearro septal • • Sustai2nnoedrd3 rdde grAeVe b lock perfusdieofne cTthsep. h armacoalgoegniutcss e fdo r cardiimaacg isntgu dairedeso butamoirvn aes odilators. © 2014M edStudy

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Internal Medicine Review Core Curriculum, Book 3: Cardiology, Rheumatology PDF

167 Pages·2014·28.225 MB·English
by  Robert A. Hannaman (ed.)
#Biology #Ecology
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Preview Internal Medicine Review Core Curriculum, Book 3: Cardiology, Rheumatology

G R V d e t i n U - 9 9 r i h a t MeSdtu®d y INTERNAMLE DICINREE VIEW RE SIXTEENTH EDITION CURRICULUM G R V d Book3 of 5 e t i n U Topicisnt hivso lume: Cardiology - 9 Rheumatology 9 r i h a t RoberAt.H annamanM,D EditionrC hief Disclaimers NOTICEM:e dicianned a cceptsetda ndarodfcs a raer ec onstancthlayn ginWge. a tM edStuddyo ourb estto r evieawn di ncluidnte h ipsu blication dacicsucruastseio oftn hse s tandarodfcs a rea nd methodosfd iagnosHiosw.e vetrh,e e ditionrc hietfh,er eviewetrhses, e ctieodni totrhsep, u blis,h er anda lolt hepra rtiiensv olvweidtt hh ep reparatainodpn u blicaotfit ohniw so rkd on otg uarantee that thei nformactoinotna inheedr eiinsi ne verrye speacctc uraotrec ompletMee.d Studfyu rthdeirs claims anya nda llli abifloidrta ym ageasn dc laimtsh amta yr esuflrto mt heu seo fi nformaotriv oine wpoints presentWeed r.e commentdh ayto uc onfitrhme m ateriwailtc hu rresnotu rceosfm edicakln owledge whenevecro nsiderpirnegs entatoirto rnesa tpiantgi ents. G ABIMF:o ro ve2r0 y earMse,d Studhya se xcelliendd e terminainndtg e achiwnhga ta cliniccaolmlpye tent R InterMneadli cipnhey sicsihaonu lkdn owT.h eA mericBaona rodf I nterMneadli ci(nAeB IMt)e sttsh is exacsta mep ooolf k nowledge. MedStudy'sd emeoxnpsetrrtaibtsyeet d,h es uperpba ssr atoef t hose whou sei itn t hesitru diiessi ,nt hea ctu"atle achionftg h"i ksn owledignea clVealre,a rner-friendly manner tharte sulitnas s trongkenro wledbgaes ei,m provceldi nisckailla lnsd,b ettBeora rrde sulAtlst.h ouwghha t we teacihsi ns yncw itwhh att heB oartde stMse,d Studhya sn oa ffidliwaittithoh neA BIMa,n do ura uthors, editoarnsd,r eviewhearvse n oa ccestsoA BIMe xamc ontenOtu.rm ateriiasd le velopaesdo rigiwnoarlk byM edStudpyh ysicaiuatnh orwsi,ta hd ditiionnpaulft r ome xperceto ntribubtaosresdo,n t heeixrt ensive backgrouinndp sr ofessimoendailc eadlu catiTohni.cs o nteinsdt e signteodi nclusdueb jemcatt ter t typictaelsltyie ndc ertifiacnadtr ieocne rtifiecxaatmisao sno utliinnet dh eA BIM's pubalviacillyaeb xlaem i blueprbinuttms a kesn ou seo fa,n dd ivulgneods e taniolfAs,B IM'psr oprieetxaarmyc ontent. 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Allof u sa tM edStudwyo rki ncredihbalrydt od oo urv eryb esotn yourb ehalf. Pleashee lups o utb yn otu sincgo pieosft himsa teriTahla.n ks!! Notificaotfci oopnysr iignhftr ingesmheonutlb des enitnc onfidetnoc e @ copyrigmhetdstudy.com MEDSTUDY® 1455 QuaiLla keL oop 80906 ColoraSdpor inCgosl,o rado (80804)1 -0547 www .medstudy.com 0 )> ::a c 6 r- 0 C) -< G R V d e t i n U - 9 9 r i h a t Cardiology PROCEDURESL,A BS,P HYSICAELX AM ...............5.-.1. .....P.E.R.I.P.H.E.R.A.AL.R .T.E.R.I.A.DL.I .S.E.A.S. E. .............5.-.2.6. ........................ CHEST X-RA.Y.S. ..........................5.-.1. ......C.A.U.S.E.S.O .F. P.A.D.A .N.D. I.N.T.E.R.M.TI.T.E.N.T. ...................... ECH0. .....................................................................................................5. -2 CLAUDICATIO.N. .....................5.-.2.6. ......................................... CARDIACS TRESST EST.S.. ....................................t.. ... .................5..-..2. DIAGNOSIOSF P AD. .....................5.-.2.6. ....................................... ExerciToslee ranTcees( tW ithoIumta gin.g.). ...........5.-.2. ......T.R.E.A.T.M.E.N.TO. F..P A.D. ...... ..................5.-.2.6. ..................................... Stress ImTaegs.it.ns.g . ......................5.-.3. .....V.A.S.O.S.AP.S.T.I.CD. I.S.E.A.S..E.. .......................................5..-..2..7.. ..... .................................. CardiSatcr eTsess -tsPickitnhgCe o rreTcets. t. ....,.. ........5..-..4.. ..... ..C.A ROTIDA RTERYD ISEAS.E. .................5.-.2.7. ............................... CARDIOPULMONAREYX ERCISET ESTING ..........5.-.5. ......C.A.R.O.T.I.DA. R.T.E.R.Y.A .TH.E.R OSCLEROS.I.S. .......5.-.2.7. ............... CARDIACS CANSI C ATHS. ...............,.. ..........5..-..5.. ..............I..N .T.E.R.N.A.LC. A.R.O.T.I.DA. R.T ERYD ISSECTI.O.N. .....5.-.2.8. ......... ContrCaasrtd iCaact heteri.z.a.t.i.o.n. ............5.-.5. .....C.E.R.E.B.R.A.L.E .M.B.O.L.I.CD. I.S.E.A.S..E.. ................ .......5.-.2.8. ........................... CardiCaTc. .........................,.. .......5..-..5.. ......... ..T.R.A.N.S.I.E.TN.I .S.C.H.E.M.I.AC.T T.A.C.K.. ............................5..-..2..8 . ....................... CardiMaRcJ . .............................5.-.6. .....A.O.R.T.I.CD. I.S.E.A.S..E.. ..............................................5..-..2..8.. ...................... .................................. PULMONARYA RTERYC ATHETREJZATIO.N. ..........5.-.6. ......A.O.R.T.I.C.A .N.E.U.R.Y.S.M S. ......G..............5.-.2.8. .................................... CARDIACB IOPS.Y. .........................5.-.6. ........T.h.o.r.a.cA.io.cr. t.Ai.nc.e .u.r.y.s..m..s.. ..............................5..-..2..8.. .......... ......................... PHYSICAELX AM ...........................5.-.7. .........A.b.d.o.m.i.nA.ao.lr. t.Ai.nc.e .u.r.y..s..m.. ............................5..-..2..9.. ............ ...................... Puls.e.s. ..............................5.-.7. .......C.O.A.R.C.T.A.T.I.O.NO .F. T.H.E.A .RO.R.T.A.. ............................5..-..2..9.. ..................................... ...... HearSto undasn dM urmur.s. ....................5.-.7. .....V.A.L.VU.L.A.R. H.E.A.R.T.D .I.S.E.A.S..E.. .............................. .5.-.2.9. ............................... Venous Wave.f.o.r.m.s. ....................5.-.9. .......I.N.F.E.CT.I.V.EE. N.D.O.C.A.R.D.I.T.I..S.. ..............................5..-..2..9.. ........ ........................ HYPERTENSIO.N. ...........................5.-.01. .........O.v.e.r.v.i..e..w.. ..V...............................................5..-..2..9.. .................. ........................................ CARDIACM EDICATION.S. .....................5.-.1.0. ........A.n.t.i.b.i.Po.rt.oi.pc.h .y.l..a..x..i..s.. ................................5..- .3.0. ................................... CARDIACI SCHEMI.A. ........................5.-.I.O. ......R.U.B.E.L.L.A.. .......................................................5..-.1.3. ........ ................................................ d ANTI-ANGINAL DRUGS. ......................5.-.1.2. ......R.H.E.U.M.A.T.I.CF. E.V.E..R.. .........................................5 .-.13. ....................................... EVALUATIOONF CHRONICS TABLEANGINA. .........5.-.1.2. ......S.P.E.C.I.F.IV.CA LVE LESION.S. ................5.-.I3. ................................ e Not.e. ...............................5.-.1.2. ........A.o.r.t.i.c. .S.t..e..n..o..s..i..s.. ....................................5..-.1.3. ..................................... .......................... I.H istoarnydP hysiEcxaalm D:e termPinreo babiolfCi ArDy . ..5.-.1.3 ChronAiocr tRiecg urgit.a.t.i.o.n. ...........5.-.3.2. ............................. 2.N oninvasivef oCTrhe rsotnsSi tca bAlneg ina: tAcutAeo rtRiecg urgit.a.t.i.o.n. ............5.-.3.3. ............................... DiagnoasnidRs i sSkt ratifi.c.a.t.i.o.n. ...........5.-.1.3. ...i....M.i.t.r.Sa.tl.e .n.o..s..i..s.. .................... ...........5.-.3.3. ........................................... n 3.D eterminaotfF iuornt hWeorr kuipn C hronSitca bAlneg in.a. .5.-.1.3 ChronMiict rRaelg urgit.a.t.i.o.n. ...........5.-.3.6. ............................. TREATMENTO F CHRONICS TABLEA NGINA. .........5.-.1.4. ........M.i.t.r.a.l. .V alve. .P.r.o.l.a.p.s.e. ...........5.-.3.6. ..................................... CARDIOVASCULAR DISE(ACSVED P)R EVENTION U AcutMei trRaelg urgit.a.t.i.o.n. ............5.-.3.6. ............................... INW OMEN ..............................5.-.1.4. ........T.r.i.c.u.sS.pt.ie.dn. o..s..i..s.. ......................................5..-..3..7.. .................... .............................. ACUTEC ORONARYS YNDROME. ..................5.-.1.4. ........T.r.i.c.u.sR.pe.ig.du. r.g.i.t..a..t..i..o..n.. ............ ........5.-.3.7. .................................. CLASSIFICATIOOFNA CS. .....................5.-.1.4. ........P.u.l.m.o.nS.it.ce. n.o..s..i..s.. .................................. ..5.-.3.7. ........................................ - NOTES. ............................................................5....-....1... 5... ..................P.u.l.m.o.n.Riecg urgit.a.t.i.o.n. ..............5.-.3.7. .................................. MARKERSF ORA MI. .................. ......5.-.1.5. ........E.b.s.t.eA.in.no. m.a.l..y.. ............................................5..-7..3 .. ... ........................................ TREATMENTO F ACS. ................9........5.-.1.6. ......V.A.L.VE. .S.U.R.G.E.R.Y.. .............................................5..-..3..7.. ......................................... PrehospMiatnaalg eme.n..t. .....................5.-.1.6. .......F.i..n.aP.le. a.ra.lb.so. u.Mt.u .r.m.u.r..s... .......................... ..5.-.3.8. .............................. EvaluatoifPo ant iewnittsSh y mptomSsu gg9estoifAv CeS . ....5.-.1.7. .... ARRHYTHMIAS. .........................5.-.3.8. .............................................. ACS:G ENERALM EASURES. ...................5.-.1.8. .......M.E.C.H.A.N.I.S.M.SO. F. A.R.R.H.Y.T.H.M.I.A.S.. ............... ....5.-.3.8. .................... ECG,N TG,M orphiBneet,a -BlorcAkCeErI ssA,,t rop.i.n.e. ..5.-.1.8. ......S ICKS INUSS YNDROME. ..................5.-.3.8. ................................. AnticoagIuA lnatnitp laTtheelreatip nyA CS. ...........5.-.1.8. ......H.E.A.R.T.B. L.O.C.K.. ...... .....................5.-.3.8. ............................................. i FibrinoTlhyetriacip nAy C S. ....................5.-.1.9. ......S.U.P.R.AV.E.N.T.R.I.C.U.L.A.RT.A .C.H.Y.C.A.R.D.I.A..S.. ........ ....5.-.3.9. .............. h AntiarrhyDtrhumgiiscnA CS. ...................5.-.1.9. ........A.t.r.iF.al.lu. t..t..e..r.. ................................ ......5.-.3.9. .............................................. ACS:M ANAGEMENTO F UA IN STEM-I AtriFailb rill.a.t.i.o.n. .................5.-.3.9. ......................................... a THEA CUTEI SCHEMIPAA THWAY ................5.-.1.9. .......M.A.T.. ................................ .............5.-.4.2. ....................................................... EarlIyn vasvisvC.eo nservative ..T.h.e.r.a.p.y. .....5.-.1.9. ........S.V.T.... ....................... .................5.-.4.2. ....................................................... Early Invatsivien U TAh INe SrTaEpMyI. .............5.-.1.9. ........W.P.W. ....................... ..................5.-.4.2. ..................................................... EarlCyo nservaTthievrea ipnyU A IN STEMI. ..........5.-.2.0. ......V.E.N.T.R.I.C.U.L.A.AR.R RHYTHMIAS. ..............5.-.4.3. ....................... LongT-ermA ntpil ateTlheetr aapftye UrA IN STEMI.. ......5.-.2.0. .......P.V.C s.. ............................5.-.4.3. ...................................................... Cocaianned M ethamphetaUmsienrwesi tShT Elevation .5.-.2.0. .......V.e.n tricTualcahry ca.r.d.i.a. ...............5.-.4.3. .................................. ACS:M ANAGEMENTW ITH STEMI O R NonsustaViennetdr icTuaclhayrc ar.d.i.a. ........5.-.4.4. ................... NEW LEFTB UNDLE-BRANCBHL OCK. ............5.-.2.0. ......P.A.C.E.M.A.K.E.R.S.. ........... ...................5.-.4.4. ............................................. Not.e. ...............................5.-.2.0. .......A.N.T.I.A.R.R.H.Y.T.H.M.I.TC.H .E.R.A.P.Y.. .............................5..-..4..5.. .................................. ........ ImmediaRteep erfusiTohne rap.i.e.s. ..............5.-.2.0. .......D..r.u.g..s.. ................................... ..........5.-.4.5. ..................................................... AdditiRoencaolm mendatfiroontmsh 2e0 13 ElectrophysTieoslto.ig.ni.gc. ...............5.-.4.6. ............................... ACC IA HA STEMI G uideli.n.e.s. ..............5.-.2.2. ........R.a.d.if.or. e.q.u.eA.nb.cl.y.a .t..i..o..n.. ........... .........5.-.4.6. ................................. ComplicatoifMo ynosc ardiinafla rc.t.i.o.n. .........5..-.2.2. ....S.Y.N.C.O.P.E.. ......................... ................5.-.4.7. ...................................................... Implantable Cardiovert.e.r.-.D.e.f.i.b.r.i.l.l.a.t.5o.-r.2s.3 . ....C.A.R.D.I.O.M.Y.O.P.A.T.H.I.E..S... ........ ...............5.-.4.8. ....................................... CORONARYA RTERYD ISEAS.E. ..................5.-.2.4. ......H.Y.P.E.R.T.R.O.P.H.I.CC.A .R.D.I.O.MY.O.P.A.T.H.Y.. .......... .....5.-.4.8. ................. RISKF ACTORSF ORC AD. .....................5.-.2.4. ........T.r.e.a.t.m.fe.on.Hrt.C .M. ......................................... .5.-.4.8. ...................................... SCREENIN.G. ............................5.-.2.4. ......R.E.S.T.R.I.C.T.IE.V C.A.R.D.I.O.M.Y.O.P.A.T.H..Y.. .......................5..-..4..8.. ..................... ......... REVASCULARIZATI.O.N. ....................5.-.2.4. .......D.I.L.A.T.E.DA. N.D. N.O.N.I.S.C.H.E.M.I.CC.A .R.D.I.O.M.Y.O.P.A.T.H.I.E..S.5. .- 49 CABG VS.P CI. ...........................5.-.2.4. ................................................... Sten.t.s. ..............................5.-.2.5. ............................................................ Othe.r. ...............................5.-.2.5. ............................................................. The Electrocardiogram HEART FAILUR...E... .....................................................................5 -49 THE I2-LEAEDC G .......................................................................5. -60 OVERVIEW. ...............................................................................5 -49 AXISD EVIATIONS... .................................................................... .5-60 LOW-OUTPUTH F .....................................................................5 -50 RATESA ND INTERVAL.S.. .........................................................5. -60 NYHA Claisfiscant .i...o..........................................................5 -05 INTERVAL.S... .................................................................................5 -I6 ACC IA HA Stagi..n..g... .........................................................5 -50 PRI NTERVAL... ........................................................................5. -I6 DeterinminPgr ongosiisnH F .................................................5 -51 QRS DURATION.. ......................................................................5 -I6 Mechnaisomf HF ..................................................................5. -51 QT INTERVAL.. ..........................................................................5 -I6 TreatmefnoHtrF . ........................5.-2.5 ..........W.A.V.E.F.O.R.M.S. A.N.D. .S.E.G.M.E.N.T.S.. ....................... .....5.-.I6. ............................ EmergenTcrye atmefnotSr everHee arFta ilu...r...e... ............5 -54 P WAVE .....................................................................................5.. -6I HIGH-OUTPUTH F. ...................................................................5 -54 TWAVE ....................................................................................... 5-62 RIGHTV ENTRICULARF AILUR£.... ............5.-.5.4. .........U. .W.AV.E. ................. ......................5.-6.2. ..................................................... PULMONARYE DEMA .............................................................5 -55 STS EGMENT ...........................5.-.2.6 ............................................... PERICARDIALD ISEASE.S.. .........................................................5 -55 QRS COMPLEX .........................................G................................ 5-62 NON-CONSTRICTIVPEE RICARDIT.I...S.. ...........................5 -55 VENTRICULAHR YPERTROPH.Y.. ............................................ 5-63 CONSTRCITIVEP ERICARDIT..I...S.. .....................................5 -55 LVH. ...........................................................................................5.. -63 RECURRENTP ERICARDIST. I...............................................5. -56 RVH. ..............................................R...............................................5 -63 PERICARDIAELF FUSION.. ...................................................5. -56 CONDUCTIOND ISTURABNCES. .............................................5. -64 CONGENITALH EARTD ISEASE... ............................................5. -57 AV BLOCKS. ..............................................................................5 -64 ASD. .............................................................................................5 -57 BUNDLE-BRANHC BLVOCK. ...................................................5 -64 OstiuSme cunduAmS D. ........................................................5 -57 LBBB. ..................................................................................... 5-64 OstiuPmr imuAmS D. .............................................................5 -57 RBBB. ..........d...........................................................................5 -64 SinuVsen osuAsS D. ................................................................5 -57 LAFB ......................................................................................5.- 65 PDA. .............................................................................................5 -57 LPFB.. .....................................................................................5 -65 PULMONARY STENOSI.S... ....................................................5 -57 BifasecliaBcrlu oc..k.. ...............................................................5 -65 VSD. ............................................................................................5. -58 WIDEQRS ..................................................................................5 -65 COARCTATIONO F THEAORTA. ...........................................5 -58 ARRHtYTHMIAS. ...........................................................................5 -65 ANOMALOUS CORONARYA RTERY. ..................................5 -58 EiCTOPICv s.P ACEMAKER .....................................................5 -65 SUDDEN DEATH INE XERCISINYGO UNG PEOPLE ........5 -58 nATRIALA RRHYTHMIAS.. .......................................................5 -66 OTHER. .......................................................................................5 -58 VENTRICULARE CTOPICB EATS AND HEART BLOCK .. 5-66 PULMONARYH EART DISEAS.E... .............................................5 -58 U MYOCARDIAL INFARCTI.O...N... .............................................. 5-66 COPD ANDS LEEPA PNEA ......................................................5 -58 COMMON FINDING.S... ...........................................................5 -66 EISENMENGERS YNDROME .................................................5 -58 LOCATIONO F Mlv s.E CG CHANGES. .................................5 -66 CHRONICT HROMBOEMBOLICO BSTRUCTION.. ............5 -58 NOTES.. ....................................................................................... 5-67 PULMONARYA RTERIALH YPERTENSIO..N... ...................5 -5-9 REMEMBER ................................................................................5. -67 PREGNANCY AND THEH EART..... .......................................... 5.. -59 ANALYSI.S... ................................................................................... 5-67 9 FOR FURTHERR EADING.. .........................................................5. -81 9 r i h a t G R V d e t i n U - 9 9 r i h a t 5-1 PROCEDURESL,A BS,P HYSICAELX AM uppelro bpeu lmonavreyi nKse)r,l Be yl ineasn,dp leural PROCEDURE,SL ABS,P HYSICAELX AM effusion(su suarlilgyh lte>ft ). CHESTX -RAYS An anomaloupsu lmonarvye int hadtr aiinnst toh e infervieonrac avcaa nc reaat "es cimistiagrno "n c hest Knowa ltlh ef ollowcihnegsx t- rafiyn dings! x-raTyh.i si sa curvilionpeaacri itnyt her ighlto wer Chesxt- raiysa ne ffectimveea nosf q uickdleyt ermininlgu nfige lddu et oa ssocilautnehgdy poplasia. significiannctr eaisneb so tho verahlela rsti zaen d Aortica bnormaltihtaiyteo sum ays eei nclutdoer tuosity (sometimheesa)rc th ambesri zeAs c.a rdiothorraatciioc andc alcificaAnt iaoonr.ta ince uryisssm o metimeeass ily > 50%i ndicates an caerndliasaricgl ehdo uestutge­, visiobnlt eh el atefirlamlAn. aortdiics secctainos nh ow gestienigt hcearr diomegoaral yp ericaredffuisai!o n. upa sm ediastwiindaeln ionntg h PeA p rojection. Thisi st her aticoo mparitnhgem ostr ightward and leftward boorftd heehr esa rste en ao pno steroantePreiroirc aredffiuas! ioinss uggesbtyea d w"atebro tt"l oer (PAc)h esxt- radyi,v idbeydt het ransvcehressedt i am­ a" watbearl losohna"p teot heh eart, somweittishmi egs­ 5-)3. ete(rm easurfreodm thei nsirdiemb a rgiantt hew idest nificaenntl argeomfet nhtce a rdisaicl hoGu(eItmtaeg e poinatb ovteh ec ostophraenngilcoe nst hes amex -ray). Shunvta sculya (reintlargsheadr,p ly dpeufilnmeodn ary Thirsa tiisov aliodn lfyo ra nu prignhotn,r otafitlemd vasculatiusr vei)s ibwliet hs iRgnificvaenntt ricular on fuliln spira(tdiioanp hrfauglml cyo ntracwtietdh) septdaelf e(cVtS D)a,t risaelp tdaelf e(cAtS D)o,ro ther a well-visucaalridzieoaduc t liannedw hent heriesn o left-to-srhiugnhtts . abdomincaolm pressoino nt dhiea phrasgumc,ah s t hat V Areaosfc alcificaotnic ohnessx t- ray: causebdya sciotrep sr egnancy. On thPe Afi lmt,h el eftv entriccalues tehseb ulgient he • AortiTch:i ndki ssdecitfyi oouns eea s eparation betweceanl cificaantdit ohnea ortbiocr deers,p ecially left-loswiedroe f t hec ardisahca dowt;h er ight atrium (RA) ift hem ediaestianpupme awrisd e. causes theo not uhtel irniaegn hdtt h;ea reoaf t he cardi"awca istline"-btehteaw oeretnki nco ba ndt he • Myocardtiyapli: caflrloyam n a picaanle urysm. t leftv entri(cLlVe) -ifso rmebdy t hem ainp ulmonary• Valvulcaorm:m onlayo rtic. 5-)1. i artery alnedfta ttrhi(eaL lA ) appe(nmIdaaggee • Annnul(arri ng-shmaipterda)an:ln ulcaarl cification; ifi ti sa p erfercitnt gh eanp rosthveatlivices l ikely Ont hel atevriaelwa ,n yi ncreianst eh em asso ft hel eft U(especiiafsl ulryg icclailap rsea lspor esent). ventriecxltee ntdhse c ardisahca dopwo steriaonrdl y lower-clotsote hre d iaphraAgnmy.i ncreaisnte h e • PericardTihai!nc:ko nstripcetriivcea rodri tis; masso ft her ighvetn trificllliesn t hel owepra rotf t h e thinTkB ift hec linihciaslt osruyg gessitgsn ificant anterciloersa pra cbee hinthdse ternu(mI mag5e -)2.- exposu(rIem ag5e-) 4. Coarctatoifot nh ea ort(aC OA)i si ndicabtyea db sence ofa normaalo rtaircc hI.n stelaodo,fk o rt he"9 3s"i gn, whicihs c reatbeyda prominelnetfts, u bclavairatne ry, 9 thec oarctaatnidpo ons,t stednioltaitcoi fto nh dee scend­ inga ortTah.eb ariusmw allcoawn s howa " rever3s,e"d r duet ot hei mpressoifot nhsea rtersitarlu ctounrt ehse i esophagAudsu.l atlss soh owi ntercroisnbto atlc hidnuge h toc ollatfleorwat lh routgohr tuionutse rcaorsttearli es. Heart failur(eH F)is ai ndicatbeyd c ardiomegaly, pulmonavrays curleadri stri(bwuittvihio sni tbhliyc kened t Imag5e- 1N:o rmpaols teroacnhteexsr-tir oary Image N5o-r2m:a /lactheersatl x-ray © 20M1ed4S tudy 5-2 PROCEDURES , LABS, PHYSICAL EXAM intracasrhduinatDcso .p pleecrh ocardiogmreaapshuyr es thev elocaintdyd irectoifot nh eb loofdl ow. Doppler echod etermimneeasn g radiepnetask,v elocitaineds , valvaer ea. So,D oppleirsu sefuiln d etermintihnesg e verity of valvulsatre noosrir se gurgitaastw ieolnal,s i ne valu­ atinlge ftv entricular diastloelftvi ecn tfruinccutliaorn , outfltorwa gcrta dieanntdis n,t racasrhduinatIcsti . sa lso helpfiunle stimatpiunlgm onaarryt e(rPyA )p ress.u re To estimaptree ssubryeu sinpge ak Dopvpelleorc ity measuroende choP:re ssugrrea di(emnmtH g=) 4x V2 Ima5g-3e": Wabtoetrht elaer"It m a5g-4eP: ericardia/ (measurveedl ociFtoyre) x.a mplieft, h ev elocaictryo ss calcification thet ricusvpaildvi es5 m /sect,h etnh eP A press=u re 4x 5(x 5)+ rigahttr iparle ssuGSroe,i. ft her igahttr li a Knowt haats inglleea idnt heap eoxf t her igvhetn tricle pressuirnte hiesx amplies 1 0m mHg,t hent heP A (RV)i ndicattheeps r esenocfea ne lectrvoennitcr icu­ press=u 1r1e0m mHg (whicihse xtremheilgyh ). larp acemakoerr i mplantdeedf ibrillatotrh-ew ith R defibrillelaabdte oirn lga rgaenrd w idetrh atnh aotf a pacemak2e rl,e adisn dicaant aet rioventr(iAcV)u laCrA RDIACS TRESST ESTS V sequent(idaula l-champbaecre)m akearn,d 3 leads Overview indicaa btiev entripcaucleamra kIefrt .h eriesn oa trial d leatdh,pe atielnikte hlaysc hronaitcr ifailb rillationT.h ei ncreadseemda ndf orm yocardoixaylg ewni th exerciisst eh ek eyf actionrt heu seo fe xerctiesset ing e asa diagnotsotoifclo rc oronaarryt edriys ea(s[eC AD]; ECHO a.k.cao.r onahreyad rits eaSster)e.ts ess htasv aen i ntegral t Echocardiogirsaa pnh uyl trasomuondda liutsye dt o rolien b otthh ed etectoifoC nA D (diagnotsotoilac)n d i imagteh eh earItt.u tiliMz-emso de2,D ,a nd3 D for nins tratifiofcr aits(pikro ong nosttoioclT )o. appropriately structiumraagli anngd D opplfeorar s sessbilnogofl do w utilsitzree tsess tas p,a tiepnrte'tspe rsotb abiolfCi AtDy rataen dd irection. U mustb et akeinn taoc cou(nAtp .o sittievsietn a low-risk patiiesnm to rel iketloby e a f alpsoes itainvdea ,n egative Besuts eo fe chios f otrh fe ollowsicnegn arios: tesitna h igh-rpiastki iesnm to rel iketloby e a f alnseeg ­a • Leftv entricsutlraurc taunrdse y stofluincc tion tiveD.i)a gnostteisct iinsmg o stv aluabwlhee np retest - • Righvte ntricsutlraurc taunrdse y stofluincc tion probabifloiCrtA yD isi nterme.d iate • Valvuhleaarrd ti sease 9 Theraer 2e genertaylp eosfc ardisatcr etsess dtosn e: • Congenihteaalrd ti sease • Myocardiinafla rc(tiinocnl 9updoisntg- MI I)E xercitsoel eratnecse(t [ ETT]; tbraesaidcm oirl l stationary bicycle itmeasgtiinngg) without complications) • Cardiomyop(abtohtlyho r sosfe jectfiroanc tion 2)S treismsa gitnegs t-in"sgtr"e isssi nducweidt h: andh ypertroofpm hyyio cardium) • exerc(itr seea d1m1io rb icycolre ), h • Peircarddiias!e ase • pharmacolsotrgeis(cse itdhoebru tamionrae • Cardimaacs sae(st umotrh,r ombaunsd,v egetation) vasodilator) • Diseasoefts h ea ortaan dp ulmonaarryt ery Thea ssociiamtaegdi insgd onew ith: • Estimattoifpo unl monaprrye ssure • Echocardiog(raa.pk"h.syatr .e escsh o") • Diastofluincc tion • Myocardpiearlf usion (iMmPaIg)i ng • Cardisaocu rcoefes m boli ExercTioslee raTnecs(etW ithIomuatg ing) Transesopheacgheoacla rdio(TgrEaE)m i sa n echo performweidt ha n esophageparlo beI.t offers Exercitsoel eratnecs(etE TT)u,s inegi thae trr eadmill higher-resoilmuatgieocsno mparetdo tratnhsoraciocr s tatiobniacryyc ilset ,h ec ornerstoofnd ei agnostic imagianngd i se speciuaslelfuyfl o erv aluating: testifnogri schemainad fu nctioncaalp aciatyn df or determipnrionggn o(siinsc lupdoisntg- MI). • Valvusltarru ctaunrdfe u nction • Lefta tri(uimn cluldeiftan tgr iaaplp endage) Despiatneo verallolws ensitainvdis tpye cific(imetny: sensit=i 6v8i%t,ys pecif=i 7c7i%t;yw omens:e nsitivity • Cardimaacs ses • Intracasrhduinatcs = 61%,s pecif=i c7i0ty%) ,t hes ensitiavnids tpye cific­ itiyn crewaistehh i ghperre tpersotb abiolfCi AtDy. E TT • Endocarditis hasa n umbeorf a dvantages, itnhceal buidlitinottg ye: s t • Aortdiics section functiocnaapla cistayf,e twyi,d espraevaadi labainldi ty, A bubblset ud(yp erforbmyei dn jecthianngd -agitarteelda tilvoewcl oys t. salianneda iirn ttoh vee noussy steimsu) s etdo e valuate © 201M4e dStu-dyPieasRee porCto pyriIgnhftr ingemteocn otpsy [email protected] PROCEDURES ,L ABS, PHYSICAL EXAM 5-3 Tehcnicdailffi culitnmi oensi toErCiGn/gB P • Q� uiz • Patireenqtu etsost tso p Serioaursr hyt(hem.isgau. s,t aviennetdr icular • tachycardia) • On a latevriaelwC XRe,x tensiooftn h eh eart Achievtianrgg heeta rrta tael oniesn ota reastoon bordepro steriaonrdli yn feriionrdliyc ates disconttihneEu TeT ,a ndt hei ndivisdhuoaullb de enlargemoefnw th icvhe ntricle? encouratgoge oda sl onags t oleruantteridel q uired to • On a latevriale wC XRe,x tensiooftn h e stofpo sro mree ason (e.gf.a,t idgeyuxsehp,an uesat,i on, cardisahca doowf t hel owepra rotf t hea nterior oro neo ft haeb soliuntdei caftoitroe nrsm ination). cleasrp acbee hintdh es ternuimn dicates enlargemoefnw th icvhe ntricle? Excelleexnetr ctioslee r(a>nIc0 eM ETS)i sa ssociated witah g oodp rognoisnidse penodfet nhted egroefe • Whatc onditiiosan TsE Eu seffuoler v aluating? coronaarrtyed riys ease. • Whata rea bsoluitned icatfiootrne sr minating Absolcuotnet raindtiocE aTtTi:o nsG anE TT? • AcutMeI w ith2id na ys • Whena res treismsa gisntgu dideosn ei nstead R Unstaabnlgei nnoapt r eviosutsalbyi lbiyz ed ofa nE TT? • medictahle rapy Uncontraorlrlheydt hcVmaiuassis nygm ptoomrs Thep atietnytp iceaxlelryc iosnea s t readmuisliln g • hemodynacmoimcp romise standeaxredr cpirsoet ocsoulcashs, t hBer ucper otocol (seTeab le5 -o6n p ag5e- 1)2.Th e leovfme alx imal • Symptomsaetviedcar oer tsitce nosis exercaicshei eovnet dh EeT Ti sm easurienmd e taboli• cU ncontrolled shyemapfrtatoi mlautriec e equiva(lMeEnTtS)s. • Acutpeu lmoneamrbyo louris n farction ETTs hounlodbt e p erforimn2e g dr oups: • Acutmeyt ocardoirpt eirsi carditis Acutaeo rtdiics section • i I)P atieunntasbt loee x ercsiusffiec ie(nmtulsaytc hieve n 85%o fa ge-predmiacxtiemduh me arratt e) StreIsmsa giTnegs ts 2)P atiewnittsbh a selEiCnGea bnormaltihtacitae ns U Overview interwfietirhne t erproeftt ahsteti roetnse (sse t. lge.ft, ventrihcyuplearrt r[oLpYhHy]l ,e fbtu ndle-braTnhcehs treismsa gisntgu diaerset hes treescsh oa nd bloc[kL BBB]W,o lff-Park-Wihniseto [nWPW], myocardpiearlfu siiomna gi(nMgP I).T hec hoiocfe - ventripcauclianargn ,dr estSiTnd ge pressoiro nw)h,i cohn et ou sei so ften obanos peedr aetxopre rience takidnigg oxin att hfea cility. 9 Knowt hfeo llowiinnfgo rmarteiloatnto Ee TdT :s Streismsa gisntgu daireuess eads t hien itdiiaalg nostic 9 methowdh enap atiiesnn otat c andidfaotre EdTuTet o Definiotfia o pno sitEiTvT:e f laotr d own-sloping inabitloei xteyr caidseeq uaotrew lhye n theErCeG are ST-segmednetp res>s iIo mnm arnd8 0m s aftetrh e changaetrs e stth acta ni nterwfietrihen terpretoaft ion J-poiin3n ct o nsecubteiavtes . i thEeT T.T heayl saor per efeirnrp eadt iewnittpshr ior h UnliSkTee levatSiTod ne,p resdsoieonsno tc orrelarteev ascularization. witthh ea natomliocc atoifom ny ocardiisaclh emia. a Streismsa gisntgu diheasv eg reatseern sitainvdi ty IsolaStTe dde pressiini onnf erlieoardi ssf arl ess specifitchiattnyh er eguElTaTr. T heya reus ewdh en specitfihcaSn T d epresisnli aotne lreaal(d Vs-4 V6). t measuremoefn te jectiforna ctioorn m yocardial ST elevatdiuorni anngE TT in3 contiguloeuasd sv iabiilsdi etsyi rienad d dittiooi nd enticfyoirnogn ary withoQu wta veosfp riMoIri sa nu nusufianld itnhga t artedriys ease. iss uggesotfmi avrek eids che(mciaabn es eeanl so with coronaarrtyes rpya sm). StrestshiHene ga rt Ifmoarg iSntgu dies Absoliuntdei caftoitroe nrsm inoafta inEo TnT : The" strepsosr"t oifot nh etsees ctasbn e p erforwmietdh STe leva>tI im omn i nl eawdist hoQu wta vefsr om exercoirps hea rmacoalgoegn.it cs • priMoIra nde xcludaiVnRga, Y La,n dV I Witeh xerciimsaeg,i sntgu daireesd onjeu slti kaen • Decreianss yes toBlP>i Ic m0m Hgw hen ETTa ndr equtihrseea mea biltiotm ye e8t5 %o fa ge­ accompabnyia endyo theevri deonfc e predicmtaexdi muhme arrta tEex.e rciissp er eferable ischeomrhi yap operfusion becauistpe r oviaddedsi tifounnaclt iaonndpa rlo gnostic • Moderate-taon-gsienvae re informaEtxieornc.ii sns oeut s eidnp atiewnittpsha ce­ • CNSs ympto(mast adxiizaz,i nneesassry, n cope) makerosrl eftb undle-branc(LhB BbB)l boeccka use Sigonfsp oopre rfu(sciyoann osis/pallor) itc anc ausfea lse-polseiftvt einvter iacnutlearro septal • • Sustai2nnoedrd3 rdde grAeVe b lock perfusdieofne cTthsep. h armacoalgoegniutcss e fdo r cardiimaacg isntgu dairedeso butamoirvn aes odilators. © 2014M edStudy

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