CARDIOLOGY

| r. 1 . | t ss
| | ri s 1 at s, !t t | | am ar 1 Iatt | aj i ra, t 1 i It rs
K t i | | am , asst ti aIt t 1 i It r
BASIC CLINICAL CARDIOLOGY EXAM. . . . . . . . 2
| a r tIi t r a| | |assi Ii taIi t r t I | ar1 i t tasta |ar | i sa| i |i I
| ar1 i at | tam i r aIi t r
CARDIAC DIAGNOSTIC TESTS . . . . . . . . . . . . . . . 7
| | | | r It rj rt IaIi t r - | t | asi ts
1 j t rIrt j | ar 1 | | am | t r | r |ar]t m t r I
| st| t m i aI| r IartIi t r
M i stt ||ar t t a s | | | | | ar ]t s
km | a |aIt r | | | 1 t |It r M t r i It r
| t| t tar1 i t ]raj |
| tt rti st t sIs
| a1 i t r a t|i 1 t kr ]i t ]raj |
K a t|t ar | m a]i r ]
ARRHYTHMIAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
M t t| ar i sm s t I krr| I| m i as
k|It rt 1 | m j a |st | t rm aIi t r
k|It rt 1 | m j a |st | t r 1 a tIi t r
| |i r i ta| kj j rt at| It krr| I| m i as
| ra1 arr| I| m i as
at| arr| I| m i as
1 I| t r | Ii t |t ]i t | atIt rs
| rt t tti IaIi t r r 1 rt m t s
| t r 1 a tIi t r | t |as
| att m a|t r | r 1 i taIi t r s
| ati r ] t t| r i | a t s
ISCHEMIC HEART DISEASE. . . . . . . . . . . . . . . . . . 20
| at|]rt a r 1
kr ]i r a | t tIt ri s
| r sIa| |t kr ]i r a
a 1 1 t r | t aI|
kta It M t tar1 i a| | r IartIi t r
HEART FAILURE . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
| t Ii r i Ii t r
| aI| t j | si t |t ]
| Ii t |t ]
| t m j t r saIt r | t sj t r st s
sIt |i t ts. | i asIt |i t | sIa r tIi t r
|t t j -| i st r1 t rt 1 | rt aI| i r ]
1 i ]| -1 a Ij a I 1 t arI | ai |a rt
| r tt sIi ]aIi t r s
M ar a]t m t r I
kta It | ar1 i t ]t r i t | a |m t r ar | 1 t m a
| ar1 i at rar sj |ar IaIi t r
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ]
CARDIOMYOPATHIES . . . . . . . . . . . . . . . . . . . 34
| i |aIt 1 | ar1 i t m t j aI|
1 j t rIrt j | i t | ar1 i t m t j aI|
| t sIri tIi tt | ar1 i t m t j aI|
M t tar1 i Ii s
VALVULAR HEART DISEASE. . . . . . . . . . . . . 38
| r It tIi tt | r 1 t tar1 i Ii s
| | t a m aIi t | t tt r
kt rIi t It r t si s
kt rIi t | t ]a r]i IaIi t r
M i Ira| It r t si s
M i Ira| | t ]a r]i IaIi t r
M i Ira| Va|tt | rt |aj st
ri ta sj i 1 Va|tt | i st ast
| a |m t r ar Va|tt | i st ast
| rt sI| t Ii t Va|tt s
PERICARDIAL DISEASE . . . . . . . . . . . . . . . . . 48
kta It | t ri tar1 i Ii s
| t rtar1 i a| | IIa si t r
| ar1 i at am j t r a1 t
| t r sIri tIi tt | t ri tar1 i Ii s
SYNCOPE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
COMMONLY USED CARDIAC. . . . . . . . . . . . . 52
THERAPEUTICS (TABLES)
a| |t s
| a|ti a m | | ar r t | | |t t|t rs
kr Ii -krr| I| m i t | ra ]s
APPENDIX: SAMPLE ECGS. . . . . . . . . . . . . . 56
| ar1 i t |t ] I M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
BASIC CLINICAL CARDIAC EXAM
FUNCTIONAL CLASSIFICATION OF
CARDIOVASCULAR DISABILITY
Table 1. Ne w York He art As s ociat ion (NYHA) Funct ional Clas s ificat ion
Clas s Funct ion
I t r1 i r ar j | si ta| atIi ti I 1 t t s r t I t tt |t sm j It m s IaIi ]a t , j a|j i IaIi t r , 1 sj r t a, t r ar ]i r a
II s|i ]| I |i m i IaIi t r t I j | si ta| atIi ti I, tt m It rIa| |t aI rt sI,
t r1 i r ar j | si ta| atIi ti I rt sa |Is i r sm j It m s
III m ar|t 1 |i m i IaIi t r t I j | si ta| atIi ti I, |t ss I| ar t r1 i r ar j | si ta| atIi ti I rt sa |Is i r sm j It m s
IV i r a| i |i I It tarr t a I ar j | si ta| atIi ti I i I| t a I 1 i stt m It rI, sm j It m s m a | t j rt st r I aI rt sI
Table 2. Canadian Cardiovas cular Socie t y (CCS) Funct ional Clas s ificat ion
Clas s Funct ion
I t r1 i r ar j | si ta| atIi ti I 1 t t s r t I taa st ar ]i r a, ar ]i r a t r | i I| sIrt r a t a s t r j rt |t r ]t 1 atIi ti I
II s|i]| I |im iIaIit r t I j | sita| atIitiI, ar ]ir a | rt a ]| I t r aI - I | |t t|s t r |t tt | ar 1 It r | t m t Iit r a| sIrt ss
III m ar|t 1 |i m i IaIi t r t I j | si ta| atIi ti I, ar ]i r a | rt a ]| I t r aI I | |t t|s t r |t tt |
IV i r a| i |i I It tarr t a I ar j | si ta| atIi ti I i I| t a I 1 i stt m It rI, ar ]i r a m a | t j rt st r I aI rt sI
Table 3. Clinical Applicability of Clas s ification Sche me s
Scale Validit y (%) Re producibilit y (%)
NYHA ! !t
CCS !1 I1
Que s tions to as k on His tory to Clarify Dis ability
J w| aI |ir 1 t I atIitiIit s | rir ] t r sm j It m s IaIi]a t , j a|j iIaIit r s,
1 sj r t a, t r ar ]ir a !
J 1 t Iar tar t a a|| | t It rt | t tt m ir ] sm j It m aIit!
J | t |t im j atI atIitiIit s, sa t| as tt m | ir ] t a r | air t r ]t IIir ] ir It I| t
s| t t r t tt r | rir ] t r sm j It m s!
J 1 att t a t tt r t tj t rit r tt 1 sm j It m s aI rt sI!
CARDIAC EXAMINATION
Blood Pre s s ure
J s| t a |1 | t Ia|t r ir | t I| arm s, ar 1 iI| I| t j aIit r I sa j ir t ar 1 a j ri]| I
J t rI| t sIaIit | j t It r sit r j t sIa ra| 1 rt j - I1 m m 1 ] ssIt |it t r
- 1 m m 1 ] 1 iasIt |it, a sa a|| attt m j ar it 1 | Iat| tar1 ia, im j |it s
ir a1 t | a aIt tirta |aIir ] | |t t 1 tt |a m t
J j a |st j rt ssa rt j rt ssa rt 1 iIIt rt r Iia| | t It t r ssIt |it ar 1 1 iasIt |it | |
i1 t j a |st j rt ssa rt . sIiIIt r ir ] t I arIt ria| ssIt m t .]. aI| t rt st|t rt sis,
| j t rIt r sit r , ir trt ast 1 sIrt |t tt |a m t ar tit I, t tt rtist , k| , ir trt ast 1
| 1 t r 1 t trt ast 1 j t rij | t ra| rt sisIt r tt It tt r, ar t m ia, I| rt It titt sis,
tirr| t sis t I I| t |itt r
r arrt j a |st j rt ssa rt . 1 t trt ast 1 | 1 it . | 1 |, s| t t|, | j t tt |t m ia,
ata It M |, tar1 it m t j aI| , j t rij | t ra| tast tt r sIritIit r s| t t|, | j t tt |t m ia ,
ta|ta |ar 1 ist ast k , M , M | , at rIit 1 ist ast t .]. tt artIaIit r t I at rIa
J j a |sa s a|It rar s | t aI-It -| t aI a|It raIit r ir j a |st j rt ssa rt am j |iIa 1 t
i.t . tt|it 1 ij ir ssIt |it | | , 1 a t It a|It rr aIir ] |V tt r IratIi|t It rtt
1 iIIt rt r Iia| 1 ia]r t sis. st tt rt |V Ia r tIit r a| im j airm t r I, | V
J j a |sa s j ara1 t ta s 1 t trt ast ir ssIt |it arIt ria| | |t t 1 j rt ssa rt
- 1 m m 1 ] 1 a rir ] ir sj iraIit r
1 iIIt rt r Iia| 1 ia]r t sis. j t ritar1 ia| Iam j t r a1 t , tt r sIritIitt
j t ritar1 iIis, aira t | sIra tIit r , sa j t rit r tt r a tata t | sIra tIit r
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1
K t It s
BASIC CLINICAL CARDIAC EXAM . . . CONT.
The Arte rial Puls e
J rt m ar| t r
raIt , r| I| m , tt |a m t Iam j |iIa 1 t , tt r It a r
am j |iIa 1 t ar 1 tt r It a r | t sI aj j rt tiaIt 1 ir tart Ii1 arIt rit s
Pre cordial Ins pe ction
J t | st rtt It r aj t t | t aI, | t att s, |iIIs
Pre cordial Palpation
J aj t t - 1 t Iir iIit r - m t sI |aIt ra| im j a |st
J | M | - 1 t Iir iIit r - j t ir I t I m atim a| ir It r siI, a sa a|| I| t aj t t
J tt m m t r I t r |t taIit r , sitt ar 1 | a a|iI t I aj t t
iI 1 iIIita |I It j a|j aIt , Ir | | | |
J r t rm a| aj t t is I-1 tm ir 1 iam t It r ir !I| ir It rtt sIa| sj att aI m i1 t|atita |ar
|ir t , r t I - I| ar 1 tm Irt m m i1 |ir t , ar 1 a 1 a raIit r - II1 ssIt |t
J a| r t rm a| im j a |st s
|V | j t rIrt j | - sa sIair t 1 - II1 ssIt |t , | t atir ] aj t t
|V 1 i|aIaIit r - aj t t 1 isj |att 1 1 t r ar 1 t a I , t r |ar]t 1 - 1 tm
| V | j t rIrt j | - sa sIair t 1 , | t atir ] j a |saIit r aI | | |
| V 1 i|aIaIit r - |t ss-sa sIair t 1 j a |saIit r aI | | |
ar It rit r M | - im j a |st | t It t r aj t t ar 1 | | |
j a |m t r ar arIt r j a |saIit r - st tt r 1 |t II ir It rsj att
j a |m t r ar | j t rIt r sit r
1 t a | |t t r Irij |t im j a |st - 1 | M
t ta]]t raIt 1 , | rit I - k| , M | , | It | s| a r I
J j a|j aIt t tt r t at| ta|ta |ar art a It r j a|j a| |t m a rm a rs I| ri||s
IatIi|t t | a ita|t r Is t I m a rm a rs
Clinical Pe arl
J Le ft paras te rnal lift - DDX - RVH, LAE (s e condary to MR), LV ane urys m,
rare ly thoracic aortic ane urys m
Aus cultation - He art Sounds
J
tt m j t st 1 t I aa 1 i| |t m iIra| M ar 1 Irita sj i1 tt m j t r t r Is
m a | t sj |iI ir I| t r t rm a| j aIit r I
J iI is |t a 1
s| t rI | | ir It rta|
| i]| |t II aIria| j rt ssa rt t .]. t ar| m iIra| sIt r t sis
| i]| t a Ij a I sIaIt s t r Iat| tar1 ia 1 iasIt |t s| t rIt r t 1
J iI is st II
IirsI 1 t ]rt t kV | |t t|
ta|tiIit m iIra| ta|tt t .]. |aIt m iIra| sIt r t sis
| i]| |V 1 iasIt |it j rt ssa rt s t .]. | 1 |, st tt rt k|
t ttasit r a|| ir m iIra| rt ]a r]iIaIit r
J iI tarit s ir tt |a m t
kV 1 isst tiaIit r tt m j |t It kV | |t t|, V
aIria| Ii| ri||aIit r
J I
r t rm a|| | as I tt m j t r t r Is. kI ar 1 | I
r t rm a| sj |iIIir ] t I I kI - | I s| t a |1 tar iI| rt sj iraIit r
Exp. Ins p. r t rm a|
I kI | I ir trt ast 1 tt r t a s rt Ia rr It ri]| I si1 t t I | t arI iI|
ir sj iraIit r rt sa |Is ir 1 t |at 1 t|t sa rt t I
j a |m t r ar ta|tt i1 t r s sj |iI
kI | I kI | I i1 t Iitt 1 sj |iIIir ]
k |
I kI | I i1 t r t 1 sj |iIIir ] 1 t |at 1 | V t r t ar| |V t m j Iir ]
ri]| I | a r 1 |t | rar t| | |t t|
j a |m t r ar | j t rIt r sit r
m iIra| rt ]a r]iIaIit r
| I kI I j ara1 t tita| sj |iIIir ] 1 t |at 1 |V t r t ar| | V t m j Iir ]
|t II | a r 1 |t | rar t| | |t t|
at rIit sIt r t sis Ii]| I
ssIt m it | j t rIt r sit r
|V Iai|a rt
j att 1 r| I| m
Irita sj i1 rt ]a r]iIaIit r
| ar1 i t |t ] \ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
BASIC CLINICAL CARDIAC EXAM . . . CONT.
J st II I
at rIit kI t r j a |m t r ar sIt r t sis | I
J |t a 1 I
ssIt m it kI t r j a |m t r ar | j t rIt r sit r | I
J st II | t arI st a r 1 s
|t tar1 iat t a Ij a I
t | t siI
t m j | st m a
j t ritar1 ia| t IIa sit r m a II|t 1 = Iam j t r a1 t
J 1 | i]a rt
t tta rs 1 a rir ] j t rit 1 t I raj i1 tt r Irita |ar Ii||ir ]
|t Irt | a t r t - | t sI | t ar1 iI| | t || aI aj t t
taa st s
m a | t r t rm a| ir t| i|1 rt r ar 1 t a r ] a1 a |Is k]t - 11
|t II tt r Irita |ar Iai|a rt ssIt |it 1 sIa r tIit r
raj i1 tt r Irita |ar Ii||ir ], as ir m iIra| rt ]a r]iIaIit r t r | i]|
t a Ij a I sIaIt s
1 iIIt rt r Iia| 1 ia]r t sis - sj |iI I, t j t r ir ] sr aj , j t ritar1 ia| |r t t|,
Ia m t a r j |t j
J \ | i]a rt
t tta rs 1 a rir ] aIria| tt r IratIit r
| t sI | t ar1 iI| | t || aI aj t t
a|m t sI a|as j aI| t |t ]ita|
| t ar1 iI| tt r 1 iIit r s I| aI rt sa |I ir a ri]i1 , r t r -tt m j |iar I tt r Irit|t
i.t . 1 iasIt |it 1 sIa r tIit r
ist| t m ia tt r Irita |ar rt |ataIit r r t t 1 s k |
| j t rIrt j | 1 K , k , 1 | M
rt sIritIitt tar1 it m t j aI|
1 iIIt rt r Iia| 1 ia]r t sis - sj |iI , t }t tIit r t|it|s, j rt |aj st t|it|s
J t tIra st a r 1 s
J t j t r ir ] sr aj - t ar|-1 iasIt |it st t | i]a rt
m iIra| sIt r t sis kI-1 Iim t s| t rIt r s as M t rst r s
J t }t tIit r t|it|s
at rIit sIt r t sis
j a |m t r ar sIt r t sis
J r t r -t }t tIit r t|it|s
t ar|, m i1 t r |aIt ssIt |it
asst tiaIt 1 iI| m iIra| ta|tt j rt |aj st , Irita sj i1 ta|tt j rt |aj st
J j t ritar1 ia| ra | s
j t ritar1 iIis
straIt| st a r 1
a j It I| rt t tt m j t r t r Is - tt r Irita |ar ssIt |t , tt r Irita |ar 1 iasIt |t
ar 1 aIria| ssIt |t
Aus cultation - Murmurs
J asst ss |t taIit r , ra1 iaIit r , Iim ir ] rt |aIit r It ssIt |t I1 iasIt |t ,
s| aj t , j iIt| , ir It r siI ]ra1 t -t , m ar t a tt rs
J j rt st r tt t r a| st r tt t I attt m j ar ir ] I| ri||s, asst tiaIit r iI| t tIra | t arI st a r 1 s
J tt r si1 t r a st t I m ar t a tt rs It attt r Ia aIt m a rm a rs
J rt sj iraIt r m ar t a tt rs
Clinical Pe arl
J Ins piration augme nts all right-s ide d murmurs and s ounds
(Carvallo's s ign), e xce pt pulmonary e je ction click and right s ide d HCM
J Expiration augme nts AR
J j t sIa ra| m ar t a tt rs
| | | | It r M
a j ri]| I, |t ar ir ] It rar1 It r k|
J sj t tia| m ar t a tt rs
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] !
K t It s
BASIC CLINICAL CARDIAC EXAM . . . CONT.
Table 4. Mane uve rs for Aus cultation of He art Murmurs
Mane uve rs | a it I ir sj iraIit r Irar sit r I arIt ria| sIar 1 ir ] It s| a aIIir ] ta|sa|ta
sa sIair t 1 a| 1 t m ir a| t tt|a sit r a sir ] I j assitt |t ] t |t taIit r
j rt ssa rt sj | ]m t m ar t m t It rs
IisI t|t r t| ir ]
Phys iological e ffe ct 8tt r t a s rt Ia rr 8ssIt m it arIt ria| 8tt r t a s rt Ia rr 9tt r t a s rt Ia rr
rt sisIar tt 8ssIt m it arIt ria| 8ssIt m it arIt ria|
rt sisIar tt rt sisIar tt
Effe ct on 8ri]| I-si1 t 1 8|t II-si1 t 1 m a rm a rs 91 | M 9 k
inte ns ity of the m a rm a rs 8M | 9M V|
mumme r 8 | 8V |
8j a |m t r it sIt r t sis
J ssIt |it t }t tIit r m a rm a rs st t | i]a rt
1 iam t r 1 -s| aj t 1 , trt stt r 1 t -1 t trt stt r 1 t
at rIit t r j a |m t r ar sIt r t sis
| i]| t a Ij a I t r I|t m a rm a rs
ar t m ia
| j t rI| rt i1 ism
j rt ]r ar t
arIt rit tt r t a s IisIa |a
t| i|1 rt r
J j ar ssIt |it m a rm a rs st t | i]a rt
rt | a irt a sa sIair t 1 j rt ssa rt 1 iIIt rt r tt I| rt a ]| t a I ssIt |t
m iIra| rt ]a r]iIaIit r
Irita sj i1 rt ]a r]iIaIit r
V |
J | i]| -j iIt| t 1 1 iasIt |it 1 t trt stt r 1 t m a rm a rs st t | i]a rt
at rIit rt ]a r]iIaIit r
j a |m t r ar rt ]a r]iIaIit r
J |t -j iIt| t 1 1 iasIt |it m a rm a rs st t | i]a rt
m iIra| sIt r t sis
Irita sj i1 sIt r t sis
st tt rt k| m a j rt 1 a tt ka sIir | |ir I m a rm a r
J | i]| I|t m a rm a rs rt sa |I Irt m rt |aIitt sIt r t sis
M | , | | k, V | ir trt ast 1 | k Ii||ir ]
k | ir trt ast 1 | k Ii||ir ]
J tt r Iir a t a s m a rm a rs st t | i]a rt
| | k
m am m ar st a II|t - ]t t s aa iI| j rt ssa rt t r sIt I| t stt j t
tt rt r ar arIt rit tt r t a s IisIa |a
tt r t a s | a m
1 a t It | i]| | |t t 1 I|t ir I| t }a ]a |ar tt ir s
| t ar1 ir | i]| t a Ij a I sIaIt s
| ar1 i t |t ] t M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
BASIC CLINICAL CARDIAC EXAM . . . CONT.
S3 Pans ys tolic Murmur
S4 High Pitche d Dias tolic Murmur
Ope ning Snap Low Pitche d Dias tolic Murmur
Sys tolic Eje ction Murmur Continuous Murmur
Figure 1. He art Sounds and Murmurs
Jugular Ve nous Puls ations (Figure 2)
J aIIt m j I tisa a|itaIit r iI| j aIit r I aI 11-\! 1 t ]rt t s ir t|ir aIit r ar 1
a1 }a sI as r t tt ssar It st t !V| aI m i1 -r t t| |t tt |
J i1 t r IiIir ] It aIa rt s t I I| t !V|
|t taIit r - | t It t r | t a1 s t I I| t sIt rr t t|t i1 t m asIt i1 tt a rsir ]
It ar1 s ar ]|t t I }a
m a |Iij |t att It rm ir r t rm a| j aIit r I
r t r -j a|j a| |t
t | |iIt raIt 1 iI| j rt ssa rt aI | ast t I r t t|
t| ar ]t s ir |t taIit r iI| 1 t ]rt t t I ir t|ir t ar 1 ir sj iraIit r
ir trt ast s iI| a| 1 t m ir a| j rt ssa rt . I1-1! m m 1 ] 1 !|
r t rm a| rt sj t r st is a Irar sit r I rist 1 !| , st t | t |t
1 t stt r Is art t|ir ita|| m t rt j rt m ir t r I I| ar astt r Is aI I| t | t 1 si1 t
J r t rm a| att It rm s
a att = aIria| tt r IratIit r j rt tt 1 t s tart Ii1 j a |st
t 1 t stt r I = aIria| rt |ataIit r t tta rs 1 a rir ] j t a| t I tart Ii1 j a |st
t att = | a |]ir ] a j t I V 1 a rir ] | V ssIt |t m a rt I|t tI tart Ii1
j a |st ir r t t|
t j rim t 1 t stt r I = 1 t stt r I t I | ast t I | t arI 1 a rir ] tt r Irita |ar ssIt |t
t att = j assitt aIria| Ii||ir ] a]air sI t|t st 1 kV ta|tt
1 t stt r I = t ar| raj i1 aIria| t m j Iir ] It ||t ir ] t j t r ir ] t I kV
ta|tt t tta rs aIIt r tart Ii1 j a |st It |I
J j aI| t |t ]ita| att It rm s
|t ss t I a att
aIria| Ii| ri||aIit r , aIria| sIar 1 sIi||
I 1
I \
I 1
I
I
I
I 1
I
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] I
K t It s
BASIC CLINICAL CARDIAC EXAM . . . CONT.
]iar I a att s
tt r IratIit r t I aIria m a]air sI ir trt ast 1 rt sisIar tt
t .]. t r | V1 t tt r | t aI
tar r t r att s
tt r IratIit r t I aIria m a]air sI t|t st 1 V as ir kV 1 isst tiaIit r
r t I t tt r | t aI
ssIt |it tt r t a s j a |saIit r t-t att s
rt ]a r]iIaIit r t I | |t t 1 ir It tt r t a s ssIt m iI| tt r Irita |ar
tt r IratIit r as ir |
s| arj 1 t stt r I
raist 1 tt r t a s j rt ssa rt as ir tt r sIritIitt j t ritar1 iIis
J 1 !|
j t siIitt rt sj t r st tt r Irt tt rsia| - - 1 t Iir iIit r
aj ira sas sa sIair t 1 t |t taIit r - \ tm It r t r t m ir a It
1 I| t r - !kM k 11t = - 1s t |t taIit r t I - \ tm iI| a| 1 t m ir a|
tt m j rt ssit r
tt rrt |aIt s | t IIt r iI| ir trt ast 1 | | w| | -si1 t 1 Iai|a rt I| ar
| -si1 t 1 Iai|a rt
Figure 2. Jugular Ve nous Puls ations
CARDIAC DIAGNOSTIC TESTS
ECG INTERPRETATION-THE BASICS
Ke y Fe ature s (s e e ECG appe ndix)
J raIt
J r| I| m
J atis
J att s ar 1 st ]m t r Is
J | j t rIrt j | ar 1 t| am | t r t r |ar]t m t r I
J ist| t m iaIir IartIit r
J m istt ||ar t t a s
Rate
J t at| sm a|| | t t is 1.1\ st t, t at| |ar]t | t t is 1.I st t.
J iI r| I| m is rt ]a |ar, raIt is t | Iair t 1 | 1 iti1 ir ] 111 | r a m | t r t I
|ar]t s| a art s | t It t r It | att s
J iI| irrt ]a |ar r| I| m s r t It I| t att ra]t tt r Irita |ar raIt
J sir a s r| I| m = t1- 11 | j m
J | ra1 tar1 ia - t1 | j m
J Iat| tar1 ia - 11 | j m
Rhythm
J as| It a r | a t sIit r s
art I| t rt | att s j rt st r I!
art I| t | tt m j |t tt s i1 t t r r arrt !
| aI is I| t rt |aIit r s| ij | t It t r I| t | att s ar 1 | tt m j |t tt s!
is I| t r| I| m rt ]a |ar t r irrt ]a |ar!
J r t rm a| sir a s r| I| m , | as a | att j rt tt 1 ir ] t at| | tt m j |t t
J | is r t ]aIitt ir aV| ar 1 j t siIitt ir || ir r t rm a| sir a s r| I| m
a
t
t t
t

| ar1 i t |t ] M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s

K t It s
CARDIAC DIAGNOSTIC TESTS . . . CONT.
Axis
J 1 t tiaIit r - |im | |t a1 s. r t rm a| = j t siIitt | ir | ar 1 ||
atis is j t rj t r 1 ita |ar It |t a1 ir | it| | is ist t |t tIrit
st t st tIit r s t r tt r Irita |ar | j t rIrt j | ar 1 | t m i| |t t|s, | t |t
J rt IaIit r - j rt tt r1 ia| |t a1 s. ist t |t tIrit | ir V1, V\
| t arI rt IaIt s It ar1 | j t rIrt j | ar 1 aa Irt m ir IartIit r
t|t t|ist = ist t |t tIrit | ir V!, Vt
tt a r It rt|t t|ist = ist t |t tIrit | ir V , VI i.t . Ia|| | att
ir V , st t | t |t
Figure 3. Diagram of Ele ctrocardiogram Limb Le ads
Wave s and Se gme nts
J | att - aIria| 1 t j t |aritaIit r
J | | ir It rta| - r t rm a| is 1. I - 1.I1 st tt r 1 s 1-! sm a|| s| a art s
raIt 1 t j t r 1 t r I
J | tt m j |t t - tt r Irita |ar 1 t j t |aritaIit r
r t rm a| 1 a raIit r - 1. I st tt r 1 s 1 sm a|| s| a art s
J st ]m t r I
is iI a| t tt t r | t |t I| t | ast |ir t !
J ir It rta| - s| t a |1 | t - II t I I| t | | ir It rta|
aj j rt j riaIt ir It rta| is raIt rt |aIt 1
J att - tt r Irita |ar rt j t |aritaIit r
r t rm a| = r t ]aIitt ir aV| , I|aI t r m ir im a|| r t ]aIitt ir |im |
|t a1 s, t I| t rist j t siIitt
HYPERTROPHY AND CHAMBER ENLARGEMENT
Right Ve ntricular Hype rtrophy
J | - 1. I st tt r 1 s, | I raIit - ir V , | I raIit - ir V! ar 1 Vt, | - I m m ir V
J | k| - 11
J st ]m t r I 1 t j rt ssit r ir V ar 1 VI sIrair iI asm m t Irita|| ir tt rIt 1
Le ft Ve ntricular Hype rtrophy
J ir V t r VI ir m m | ir V! t r Vt - 1! m m
J ir V t r VI t r | ir V! t r Vt - I! m m
J | ir aV| - m m
J | ir | ir ||| - I! m m
J | k| - 11 iI| s|i]| I| i1 t r t 1 |
J asm m t Irit st ]m t r I 1 t j rt ssit r ar 1 att ir tt rsit r sIrair |t a1 s |, aV| , V\-Vt
J | k|
Right Atrial Enlarge me nt (P Pulmonale )
J | att - I.! m m ir | t i]| I ir |t a1 s ||, ||| t r aV|
J | att 1 a raIit r - 1. I st tt r 1 s
Le ft Atrial Enlarge me nt (P Mitrale )
J | att 1 a raIit r - 1. s | t sI st t r ir |t a1 s |, ||, aV| , V\-Vt
J |ar]t , | ij | asit | att ir V iI| 1 t t j It rm ir a| tt m j t r t r I I| aI is
aI |t asI t r t s| a art i1 t 1.1\ st t ar 1 t r t s| a art 1 t t j m m
J r t It| t 1 | iI| ir It rj t a| ir It rta| - 1.1\ st tt r 1 s
aV|
11
| k|
11, kV|
|
1
K 1 | M k|
kX|
11
kV|
| k|
|||
||
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1
K t It s
CARDIAC DIAGNOSTIC TESTS . . . CONT.
Clinical Pe arl
Diffe re ntial Diagnos is of tall R wave in V1
J RVH, Pos te rior MI, RBBB, WPW, Hype rtrophic cardiomyopathy
(s e ptal hype rtrophy), Duche nne s Mus cular Dys trophy, counte rclockwis e rotation
ISCHEMIA/INFARCTION
Crite ria for Q wave infarct (two le ads s e rving an arte rial te rritory)
J 1 a rir ] ar kM |, I| t | | | t| ar ]t s iI| Iim t m a ir t|a 1 t
J st ]m t r I t |t taIit r I Ia|| j t a|t 1 att s | j t rata It
att s art a t I ir }a r
J att s 1 t tt |t j Irar sm a ra| ir IartIs t r |
J att s ir tt rI ist| t m ia
Q Wave
J si]r iIitar I iI - m m i1 t i.t . - 1.1\ st tt r 1 s ir 1 a raIit r t r iI - I1 I| t
am j |iIa 1 t t I |
J r t It |t a1 s | t rt att s art j rt st r I ir ||| ar 1 V is r t rm a|
ST Se gme nt
J t |t taIit r
ata It m t tar1 ia| ir IartIit r
| rir tm t Ia|s ar ]ir a tt rt r ar tast sj asm
t I| t r taa st s - ata It j t ritar1 iIis, tt r Irita |ar ar t a rsm
j t sI M |
t ar| rt j t |aritaIit r r t rm a| tariar I
J 1 t j rt ssit r
ar ]ir a ist| t m ia
sa | t r 1 t tar1 ia| ir IartIit r r t r -att M |
j t siIitt sIrt ss It sI
ata It j t sIt rit r a|| M | V ar 1 VI
|V1 sIrair , | | | |
1 i]iIa|is t IIt tI stt t j ir ] t r | t t|t sIit|
T Wave
J a1 a |Is m a | att I|aI t r s|i]| I| ir tt rIt 1 att s ir |im | |t a1 s
J r t It a| r t rm a|| ir tt rIt 1 att s t r t| ar ]t s Irt m t |1 | | | s
J | ij | aIit att s a|as j rt st r I | t It rt t| t m ia
Crite ria for Non-Q-Wave MI (Sube ndocardial Infarctions )
J r t r sj t tiIit | | | t| ar ]t s. att ir tt rsit r , st ]m t r I ir trt ast 1 ,
1 t trt ast 1 t r - -
J 1 ia]r t sis 1 t j t r 1 s t r ir trt ast 1 tar1 iat t r tm t s ir j rt st r tt t I t| t sI
j air , I a| r t rm a| | | |
Table 5. Are as of Infarction
Infarct Are a Ve s s e l Q wave s
ar It rt st j Ia| | k| V , VI
|t ta|i tt 1 ar It ri t r V1, V\
ar It rt |aIt ra| V!, Vt
t tIt r si tt ar It ri t r V - Vt
i r It ri t r | | k 1-11X | | , | | | , aV|
|aIt ra| ti rta m I|t t | , aV| , V!, Vt
j t sIt ri t r | | k attt m j ar i t s i r I. M | Vt, m i rrt r i m a]t V ar 1 VI
ti rta m I|t t i st |aIt 1 j t sI. M |
ri ]| I tt r Iri t|t | | k m t sI t IIt r | V1 ar 1 | V\ ri ]| I si 1 t 1 t| t sI |t a1 s
t IIt r r t | | | t| ar ]t s | t taa st sm a|| i r IartIs ar 1 |aIt ra| a|| i s |aIt i r I| t 1 t j t |ari taIi t r | tt m j |t t
| ar1 i t |t ] 1 M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
CARDIAC DIAGNOSTIC TESTS . . . CONT.
Figure 4. Anatomy of the Coronary Arte rie s
(right ante rior oblique proje ction)
Variations in Cardiac Vas cular Anatomy
J a| |t ! 1 t stri| t s ar aIt m t I ri]| I-1 t m ir ar I tirta |aIit r 1X
J tt m j art iI|
|t II-1 t m ir ar I tirta |aIit r !X
j t sIt rt ir It rit r |V sa j j |it 1 | | | k
| a|ar tt 1 tirta |aIit r !X
1 a a| sa j j | t I j t sIt rt ir It rit r |V | | | k ar 1 | | k
MISCELLANEOUS ECG CHANGES
Ele ctrolyte Dis turbance s
J | j t r|a|t m ia kj j t r 1 it !a
j t a|t 1 att s M t titar | aI , I|aI | att , i1 t | , |t r ] | |
ir It rta|, t |t taIt 1 st ]m t r I
a |Iim aIt | I| t | ar 1 att s m t r]t It It rm a sir t att ar 1 V| m a 1 t tt |t j
J | j t |a|t m ia
att I|aIIt r ir ], | att s, 1 t j rt ssit r , j rt |t r ]t 1 - ir It rta|
J | j t ta|tt m ia
j rt |t r ]t 1 - ir It rta|
J | j t rta|tt m ia
s| t rIt r t 1 - ir It rta|
Hypothe rmia
J j rt |t r ]t 1 ir It rta|s, sir a s | ra1 tar1 ia, s|t k|
J | t art t I m a st|t Irt m t r arIiIatI
J 1 s| t rr t t r ! att 1 t I|t tIit r
Pe ricarditis
J t ar| - 1 iIIa st st ]m t r I t |t taIit r I | | 1 t j rt ssit r
J a j ri]| I att s
J |aIt r - ist t |t tIrit st ]m t r I
J att s I|aI t r ir tt rIt 1
J Iat| tar1 ia
Low Voltage s
J 1 t Iir iIit r - It Ia| | | t i]| I ir j rt tt r1 ia| |t a1 s - 1 m m , |im | |t a1 - ! m m
J 1 iIIt rt r Iia| 1 ia]r t sis
ir aj j rt j riaIt tt |Ia]t sIar 1 ar1 itaIit r
j t ritar1 ia| t IIa sit r t .]. Iam j t r a1 t
| arrt | t| t sI | 1 | |
| j t I| rt i1 ism
| 1 |, 1 i|aIt 1 tar1 it m t j aI| , m t tar1 ia| 1 ist ast , m t tar1 iIis
t | t siI
Drugs
J | i]t tir kj j t r 1 it !|
J I| t raj t a Iit |t tt |s m a | t asst tiaIt 1 iI| | i] t IIt tI
att 1 t j rt ssit r t r ir tt rsit r
1 t r s|t j ir ] t r stt t j ir ]
|t II m air tt rt r ar arIt r
tirta m I|t t
|t II ar It rit r 1 t stt r 1 ir ]
st j Ia| j t rIt raIt r
t | Ia st m ar]ir a|
1 ia]r t r a|
j t sIt rit r
ir It rtt r Irita |ar
ata It m ar]ir a|
ri]| I tt rt r ar
arIt r
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ]
K t It s
CARDIAC DIAGNOSTIC TESTS . . . CONT.
s| t rIt r ir ]
I | att s
s|t ir ] t I tt r Irita |ar raIt ir aIria| Ii| ri||aIit r
J It tit |t tt |s asst tiaIt 1 iI|
Iat| arr| I| m ias iI| tt r 1 a tIit r | |t t|s
|k iI| | |t t| is m t sI t| aratIt risIit
| V| s, | i]t m ir
t|assit rt ]a |aritaIit r t I tt r Irita |ar raIt ir k| 1 a t It
tt m j |t It kV 1 isst tiaIit r
J a ir i1 ir t
j rt |t r ]t 1 ir It rta|, | att s
J | | t r t I| iatir t s ar 1 | ks
t| ar ]t s sim i|ar It | a ir i1 ir t
Othe r Cardiac Conditions
J 1 | M
tt r Irita |ar | j t rIrt j | , | k| , st j Ia| att s
J m t tar1 iIis
tt r 1 a tIit r | |t t|s, |t tt |Ia]t
Pulmonary Dis orde rs
J | 1 | |
|t tt |Ia]t , | k| , j t t r | att j rt ]rt ssit r
t| rt r it | t r j a |m t r a|t tar j rt 1 a tt | j a |m t r a|t ar 1 | V1
iI| sIrair
m a |IiIt ta| aIria| Iat| tar1 ia
J m assitt j a |m t r ar t m | t |a s
sir a s Iat| tar1 ia ar 1 k| art I| t m t sI tt m m t r arr| I| m ias
| V1 iI| sIrair , | | | | , , 1, 1 ir tt rIt 1
AMBULATORY ECG (HOLTER MONITOR)
J I\-\ | r | | | rt tt r1 ir ] iI| j aIit r I 1 iar t I sm j It m s It 1 t It rm ir t
tt rrt |aIit r | t It t r sm j It m s ar 1 a| r t rm a|iIit s
ir 1 itaIit r s. . 1 t It tI ir It rm iIIt r I arrI| m ias
I. rt |aIt sm j It m s It 1 sr| I| m ias
1. 1 t It tI m t tar1 ia| ist| t m ia
ECHOCARDIOGRAPHY
J t -1 im t r Iit r a| I-| t t| t = ar aIt m - | I rt I|t tIir ] Irt m Iissa t ir It rIatt s
1 t It rm ir t s.
|t II tt r Irita |ar ssIt |it t }t tIit r IratIit r
t| am | t r sitt s
a|| I| it|r t ss
ta|tt m t rj | t |t ]
j t ritar1 ia| t IIa sit r
a|| m t Iit r a| r t rm a|iIit s
tt m j |itaIit r s t I kM |
J | t j j |t r = | |t t 1 I|t - | I rt I|t tIir ] Irt m ir Iratar1 iat | | | s
1 t It rm ir t s. | |t t 1 I|t tt |t tiIit s a sir ] ]ra1 it r I = \t
I
It
t sIim aIt at rIit ar 1 m iIra| ta|tt art as
J | t |t a r I|t im a]ir ]
1 t It rm ir t s.
ta|ta |ar rt ]a r]iIaIit r
ta|ta |ar sIt r t sis
s| a r Is
J rar st st j | a]t a| | t| t
| i]| | a a|iI im a]t s | a I ir tasitt
m t rt st r siIitt It r.
j rt sI| t Iit | t arI ta|tt s
It i1 t r IiI tar1 iat st a rtt s t I ssIt m it t m | t |i, ir Iratar1 iat I| rt m | i,
Ia m t a rs, 1 t | ris iI| ir I| t at rIa ar 1 ta|ta |ar tt ]t IaIit r s, ir It tIitt t r 1 t tar1 iIis
at rIit 1 isst tIit r
EXERCISE TESTS
J ir 1 itaIit r s.
asst ssm t r I t I t| t sI j air
ris| sIraIiIitaIit r j t sI-M |
asst ssm t r I t I I| t raj
J Iar 1 ar1 | tt rtist t sI
j aIit r I t tt rtist s t r a Irt a1 m i|| t r | itt|t
| ar1 i t |t ] I M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
CARDIAC DIAGNOSTIC TESTS . . . CONT.
st r siIitiI t!-I1X, sj t tiIitiI t!-I1X
j rt It sI |i|t |i| t t 1 t I | k| is tt r im j t rIar I
j aIit r I m a sI | t a| |t It t tt rtist
a1 tar Ia]t s. asst ssm t r I t I ist| t m ia, Ia r tIit r a| t|ass, j rt ]r t sis,
atta rat It sIt 1 ir 1 iIIt rt r I j t j a |aIit r s
1 isa1 tar Ia]t s. st r siIitiI |t t r I| ar sIrt ss im a]ir ] sIa 1 it s,
sj t tiIitiI j t t r iI| m ar|t 1 - a| r t rm a|iIit s t r rt sIir ] | | | ,
1 i]t tir , | | | | , j att m a|t rs t r ir It m a|t s, 1 t t s r t I atta raIt |
|t ta|itt siIt t r t tIt r I t I m t tar1 ia| ist| t m ia
J | | arm att |t ]it ir 1 a tt 1 sIrt ss It sI iI| im a]ir ] r a t|t ar t r t t| t
st r siIitiI 1X, sj t tiIitiI !-11X
ir trt ast 1 tt rt r ar I|t . 1 ij ri1 am t |t Ij t rsar Iir t , a1 t r t sir t
ir trt ast 1 m t tar1 ia| 1 I 1 t m ar 1 . 1 t | a Iam ir t
J Irt ss | t| t
st r siIitiI 11X, sj t tiIitiI 11X
j rt ti1 t s ir It rm aIit r t r I| t j rt st r tt ar 1 t tIt r I t I tt rt r ar 1 ist ast
asst ss m a |Iij |t j aram t It rs st t I-| t t| t
RADIONUCLIDE ANGIOGRAPHY
J t |a| t ||t 1 | | | s It asst ss | |
ir 1 itaIit r s. ris|-sIraIiIitaIit r j t sI-M |
|V|
| 1 |
| | = | | V-| V
| | V
]t t 1 im a]t s ir j aIit r Is iI| | 1 | | t r t | t siI
NUCLEAR IMAGING
J st r siIitiI !X, sj t tiIitiI 11X
asst ss.
m t tar1 ia| j t rIa sit r
| |t t 1 I|t
|t ta|itt ar 1 | a ar IiI m t tar1 ia| ist| t m ia ar 1 ir IartIit r
m t tar1 ia| m t Ia| t |ism
Table 6. Imaging in Cardiac Dis orde rs
Myocardial Is che mia (re ve rs ible )
Irt ss-1 t |at 1 -rt -ir }t tIit r I| a||ia m |t a j Ia|t 1 a rir ] sIrt ss iI| tt m j |t It t r j arIia| a j Ia|t ir 1 t |at 1
t r rt -ir }t tIit r im a]t s it rt tt rsi| |t 1 t It tI
| t sI sIrt ss st sIam i| i r t rm a| a j Ia|t aI rt sI iI| 1 t trt ast 1 a j Ia|t 1 a rir ] sIrt ss
| t | a Iam ir t sIrt ss t t| t a|| m t Iit r a| r t rm a|iI iI| sIrt ss
| | 1 t trt ast I|t iI| r t rm a| t r ir trt ast 1 a j Ia|t 1 a rir ] sIrt ss
Myocardial infarct (fixe d)
Irt ss-1 t |at 1 -rt -ir }t tIit r I| a||ia m |t a j Ia|t 1 a rir ] sIrt ss ar 1 aIIt r rt -ir }t tIit r it Iitt 1 1 t It tI
| t sI-sIrt ss st sIam i| i |t a j Ia|t ir rt sI ar 1 sIrt ss im a]t s
| t | a Iam ir t sIrt ss t t| t a|| m t Iit r a| r t rm a|iI aI rt sI ar 1 iI| sIrt ss
| | 1 t trt ast 1 I|t ar 1 1 t trt ast 1 a j Ia|t aI rt sI
Hibe rnating Myocardium:
rt sI-1 t |at 1 I| a||ia m tt m j |t It t r j arIia| a j Ia|t t r 1 t It tIs aIIt r rt -ir }t tIit r
1 t | a Iam ir t sIrt ss t t| t a|| m t Iit r a| r t rm a|iIit s iI| sIrt ss, tt r IratIi|t rt st rtt
| | 1 t trt ast 1 I|t ar 1 ir trt ast 1 a j Ia|t aI rt sI
As s e s s me nt of
ve ntricular function:
t-11m | | | ]aIt 1 | |t t 1 j t t | im a]ir ] asst ssm t r I t I ]|t | a| |t II ar 1 ri]| I tt r Irita |ar Ia r tIit r aI rt sI t r 1 a rir ]
t tt rtist , atta raIt 1 t It rm ir aIit r t I t }t tIit r IratIit r
| t| t rt ]it r a| a|| m t Iit r ar 1 Ia r tIit r , t sIim aIt t I t }t tIit r IratIit r
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1
K t It s
ARRHYTHMIAS
MECHANISMS OF ARRHYTHMIAS
J a|It rt 1 im j a |st It rm aIit r
J a|It rt 1 im j a |st tt r 1 a tIit r
ALTERED IMPULSE FORMATION
J aa It m aIitiI = I| t a| i|iI t I a tt || It 1 t j t |aritt iIst |I It I| rt s| t |1
ar 1 , I| t rt It rt , ]t r t raIt ar atIit r j t It r Iia|
J tt ||s iI| I| is a| i|iI art |r t r as j att m a|t r tt ||s
k r t 1 t , j a r|ir }t tt ||s I| rt a ]| t a I aIria
| a r 1 |t t I 1 is, | a r 1 |t | rar t| t s
j a r|ir }t tt ||s ir Iastit|t s ar 1 j t rij | t ra| tt r Irita |ar tt r 1 a tIit r ssIt m
J aa It m aIitiI is ir I|a t r tt 1 |
r t a rt | t rm t r a| IatIt rs. sm j aI| t Iit ar 1 j arasm j aI| t Iit
1 ra ]s I| aI st |t tIitt | ir trt ast aa It m aIitiI t I j att m a|t rs
| it| art r t rm a|| s|t t r I| ar k r t 1 t
t .]. 1 i]t tir , | it| | as ta]a| t IIt tI t r k ar 1 kV
r t 1 t s | a I sm j aI| t Iit t IIt tI t r t I| t r j att m a|t r siIt s
|t ta| ist| t m iaIj aI| t |t ]
| |t t|a]t t I j rt tim a| j att m a|t r k r t 1 t im j a |st s | it|
a||t s m t rt 1 isIa| It ta s It tt r Irt | I| t tt r Irita |ar r| I| m
J Iri]]t rt 1 atIitiI
t sti||aIit r s t I I| t m t m | rar t j t It r Iia| aIIt r r t rm a|
1 t j t |aritaIit r |t a1 It rt ta rrt r I 1 t j t |aritaIit r
j rt |t r ]t 1 ir It rta| j rt 1 isj t st s t .]. t |t tIrt |It
1 isIa r| ar tt s, 1 ra ]s
j t sIa |aIt 1 m t t| ar ism t I t rsa1 t s 1 t | t ir It s
ALTERED IMPULSE CONDUCTION
J rt -t r Ir
j | t r t m t r t r | it| rt | a irt s j ara||t | t |t tIrita| tirta iI ir
| it| It |im | s | att 1 iIIt rt r I rt IratIt r j t rit 1 s,
t .]. k|, kVK |
J tt r 1 a tIit r | |t t|s - j arIia| t r It Ia|
J tt r Irita |ar j rt t ttiIaIit r
tt r ]t r iIa| a| r t rm a|iI ir | it| tt r Irita |ar m t tar1 ia m is
t |t tIrita|| atIitaIt 1 t ar|it r I| ar | I| t r t rm a| kV r t 1 a| im j a |st
t .]. | j ass IratI ir w| w sr 1 rt m t
OTHER ETIOLOGIC FACTORS
J sIrt It| t I m t tar1 ia| tt ||s is arr| I| m t ]t r it, | t r tt , ir trt ast 1 | k
sitt - k|
J | ra1 tar1 ia j rt 1 isj t st s tia It m j t ra| 1 isj t rsit r ir rt IratIt r
j t rit 1 s, t .]. Iat| -| ra1 sr 1 rt m t , j rt It tIit r tia j atir ] t r aIrt j ir t
J | j t tiaIati1 t sis |t t rs I| t I| rt s| t |1 It r V| , | t r tt I| t j rt It tIitt
rt |t t I 1 I | itar| t r aIt
J t |t tIrt |It 1 isIa r| ar tt s, t .].. | j t |a|t m ia, im | a|ar tt s t I | a

, M ]

J ir It tIit r , t .].. m t tar1 iIis t r ir It tIitt t r 1 t tar1 iIis taa sir ] at rIit
rt t I a| stt ss
J tar1 it m t j aI| it s, 1 t ]t r t raIitt 1 ist ast , ir Ii|IraIit r t .]. sartt i1
CLINICAL APPROACH TO ARRHYTHMIAS
k| | 1 Y 1 M | k
| | k| Yk| | Y 1 M | k - t1 | | M | 1 K | | | | 1 K | | | kY k| 1 Yk| | 1 Y 1 M | k - 11 | | M
si r a s | ra1 tar1 i a kV r t 1 a| tt r 1 a tIi t r | |t t|s | | | | | | | k|
si t| si r a s sr 1 rt m t , I, 1 k| | |
t staj t r| I| m s Iasti ta |ar | |t t| M k
}a r tIi t r a| | a r 1 |t | rar t| | |t t| k| | | tari a| |t | |t t|
tt r Iri ta |ar Irt | a t r I k| | s, V| | s
| | | | | k|
K k| | 1 w | 1 M | | | X w| | | | 1 M | | | X
a j ratt r Iri ta |ar Iat| tar1 i a V i I| a| t rrar t t r | | |
aIri a| I|a IIt r tt r Iri ta |ar
kVK |
w| w rt Irt ]ra1 t tt r 1 a tIi t r
I| rt a ]| | j ass IratI
Figure 5. Clinical Approach to Arrhythmias
| ar1 i t |t ] \ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ARRHYTHMIAS . . . CONT.
BRADYARRHYTHMIAS
SA NODE
Sinus Bradycardia (Appe ndix 1a)
J rt ]a |ar | t arI raIt |t ss I| ar t1 | j m iI| r t rm a| | att j rt tt 1 ir ]
t at| |
J t ttt ssitt ta]a| It r t . sj t r Iar t t a s tast ta]a| sr tt j t , ata It
ir It rit r M |, 1 ra ]s, tt m iIir ], | j t I| rt i1 ism , ir trt ast 1 || |
J Irt aIm t r I. iI sm j It m aIit, aIrt j ir t ar 1 It r t |t tIrita| j atir ] t| rt r it
Sinus Arrhythmia
J irrt ]a |ar r| I| m iI| r t rm a| | att ar 1 tt r sIar I, r t rm a| | | ir It rta|
J r t rm a| tariar I - ir sj iraIit r attt |t raIt s I| t 1 | , t tj iraIit r s|t s iI 1 t r
J j aI| t |t ]ita| - a r tt m m t r , tariaIit r r t I rt |aIt 1 It rt sj iraIit r
Sick Sinus Syndrome
J = ir aj j rt j riaIt sir a s | ra1 tar1 ia
J | ra1 tar1 ia m a | t j a r tIa aIt 1 | t j ist 1 t s t I V, t sj t tia|| k|
t r aIria| I|a IIt r at| -| ra1 r 1 rt m t
J a sa a|| t |1 t r|, t a r ]t r j aIit r I. iI| tar1 it m t j aI| it s
J sr tt j t
J Irt aIm t r I = j atir ] It r | ra1 , m t 1 s It r Iat|
Sinus Arre s t or Exit Block (Appe ndix 1b)
J sir a s r t 1 t sIt j s Iirir ] arrt sI t r 1 t j t |aritaIit r Iai|s It t tiI I| t
sir a s r t 1 t t tiI | |t t|
J 1 t j t r 1 ir ] t r 1 a raIit r t I ir atIitiI, t staj t | t aIs t r r| I| m m a
t tta r - r t tI atai|a| |t j att m a|t r i|| Ia|t t tt r, ir I| t It ||t ir ]
t r1 t r
aIria| t staj t raIt t1-1 . t ri]ir aIt s t a Isi1 t I| t sir a s r t 1 t
iI| ir I| t aIria r t rm a| | m t rj | t |t ] is |t sI
}a r tIit r a| t staj t raIt \1-t1 . t ri]ir aIt s r t ar I| t kV r t 1 t
as a rt sa |I, a r t rm a| | att is r t I st t r
t ttasit r a|| a rt Irt ]ra1 t | att m a | t st t r
rt j rt st r Iir ] aIria| 1 t j t |aritaIit r m t tir ] | at|ar1
Irt m I| t kV r t 1 t ir It I| t aIria
tt r Irita |ar t staj t raIt I1-\1 . t ri]ir aIt s ir tt r Irita |ar
tt r 1 a tIit r ssIt m
r t | att , i1 t , a| r t rm a| |
J Irt aIm t r I. sIt j m t 1 s | it| sa j j rt ss I| t sir a s r t 1 t
| t Ia-| |t t|t rs, | | | , 1 i]t tir , m a r t t 1 j atir ]
TACHYARRHYTHMIAS
SUPRAVENTRICULAR
J r arrt i.t ., r t rm a| | tt m j |t t t r
J i1 t | iI a| t rrar I tt r Irita |ar tt r 1 a tIit r , t r j rt -t tisIir ] | | |
J a| t rrar t = ir Iratt r Irita |ar tt r 1 a tIit r 1 t |a asst tiaIt 1 iI| a t| ar ]t ir
tt|t |t r ]I| i.t ., iI| Iat| tar1 ia , r t I r t rm a| j aIIt rr It r I| t ir 1 iti1 a a|
Sinus Tachycardia (Appe ndix 2a)
J rt ]a |ar | t arI raIt ]rt aIt r I| ar 11 | j m iI| | att j rt tt 1 ir ] |
J r t rm a| | att m t rj | t |t ]
J t tta rs iI| It tt r, | j t It r sit r , I| rt It titt sis, ar t m ia, ar tit I,
| j t tt |t m ia, | | , | 1 |, M |, s| t t|, 1 ra ]s | I1 1 , taIIt ir t , aIrt j ir t ,
taIt t| t |am ir t s
J Irt aIm t r I. Irt aI a r 1 t r|ir ] 1 ist ast , tt r si1 t r j rt j rar t |t | iI sm j It m aIit
Pre mature Be ats
J kIria| | rt m aIa rt | t aI k| |
a sir ]|t t tIt j it sa j ratt r Irita |ar | t aI I| aI t ri]ir aIt s ir I| t aIria
I| t | att tt r It a r t I I| t k| | 1 iIIt rs Irt m I| aI t I a r t rm a| sir a s | t aI
J !a r tIit r a| | rt m aIa rt | t aI
a sir ]|t t tIt j it sa j ratt r Irita |ar | t aI I| aI t ri]ir aIt s ir I| t
titir iI t I I| t kV r t 1 t
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] !
K t It s
ARRHYTHMIAS . . . CONT.
I| t rt is r t | att j rt tt 1 ir ] I| t j rt m aIa rt | tt m j |t t,
| a I a rt Irt ]ra1 t | att m a It ||t I| t | iI kV r t 1 a|
tt r 1 a tIit r is ir IatI
J Irt aIm t r I. r t r t a r |t ss sm j It m aIit, | t Ia-| |t t|t rs, t r ta|tia m
t| ar r t | | |t t|t rs
Atrial Flutte r (Appe ndix 2b)
J rt ]a |ar, aIria| raIt I!1-1!1 | j m , a sa a|| 111
Clinical Pe arl
J Narrow comple x tachycardia at a rate of 150 is atrial flutte r with 2:1
block until prove n othe rwis e
J t Iit |t ]. |1 | , I| rt It titt sis, M V 1 ist ast , tar1 iat sa r]t r, | 1 | | ,
| | , j t ritar1 iIis
J I. , 1. , \. , t It... | |t t| m a | t taria| |t i.t . tt r Irita |ar raIt t r t
| a|I, t r t I| ir1 , t It... I| t aIria| raIt
J | | | . saIt t I| ir It rit r |t a1 s, r arrt | a r |t ss a| t rrar t
J tart Ii1 m assa]t t| t t| IirsI It r | ra iIs , Va|sa|ta t r a1 t r t sir t .
ir trt ast s I| t | |t t|, | rir ]s t a I I|a IIt r att s
J Irt aIm t r I
raIt tt r Irt |. | t Ia-| |t t|t r, tt raj am i|, 1 i]t tir
m t 1 ita| tar1 it tt rsit r . j rt tair am i1 t , st Ia|t |, am it 1 art r t , | a ir i1 ir t
t |t tIrita| tar1 it tt rsit r . | | s| t t| |t sr t| rt r itt 1
t r t r] |t tt |s. sIarI aI !1!
ar Iitt a]a |aIit r a sa a|| r t I r t tt ssar
Multifocal Atrial Tachycardia (MAT)
J irrt ]a |ar r| I| m , aIria| raIt 11-I11 | j m , aI |t asI 1 1 isIir tI | att
m t rj | t |t ]it s j rt st r I t r | | |
J j rt | a| | rt sa |Is Irt m ir trt ast 1 aa It m aIitiI t I st tt ra| 1 iIIt rt r I
aIria| It ti
J | t r tt tarir ] | -|, | -| , ar 1 | -| ir It rta|s, tarir ] 1 t ]rt t s t I kV | |t t|
J tt m m t r ir | 1 | | , | j t tt m ia, | j t |a|t m ia, | j t m a]r t st m ia,
st j sis, I| t t j | ||ir t t r 1 i]t tir It titiI
J iI raIt - 11 | j m , I| t r It rm t 1 a war 1 t rir ] kIria| | att m a|t r
J tart Ii1 m assa]t | as r t t IIt tI ir M k
J Irt aIm t r I. Irt aI I| t a r 1 t r|ir ] taa st , iI r t tt ssar, Ir tt raj am i|,
t r, iI r t I tt r Irair 1 itaIt 1 , m t It j rt |t |
Atrial Fibrillation (AF) (Appe ndix 2c)
J st t r ir 1X t I j t j a |aIit r t tt r I! t ars t |1
J I| t m a}t riI t I tar1 it ]t r it sIrt |t s ar 1 j t rij | t ra| I| rt m | t t m | t |it
t tt r Is t tta r ir asst tiaIit r iI| k|
J irrt ]a |ar| irrt ]a |ar tt r Irita |ar raIt , r arrt | a r |t ss a| t rrar t,
a r 1 a |aIir ] | ast |ir t , r t | att s
J aIria| raIt \11-t11 | j m , tt r Irita |ar raIt taria| |t 1 t j t r 1 ir ] t r kV
r t 1 t , art a r 1 \1- 1 | j m
J i1 t | tt m j |t tt s 1 a t It a| t rrar t m a t tta r It ||t ir ] a |t r ]
s| t rI | -| tt|t st | a t r tt ks| m ar j | t r t m t r t r
J |t st aIria| tt r Iri| a Iit r It tt r Irita |ar Ii||ir ] r t a att s st t r ir !V|
J tart Ii1 m assa]t . m a s|t tt r Irita |ar raIt
J k| rt sisIar I It tar1 it tt rsit r - | k - !1 m m , |t r ]t r 1 a raIit r t I k|
J m a}t r issa t s It | t a1 1 rt sst 1 iI| k| . | k| |
| aIt tt r Irt | tt r Irita |ar
1 i]t tir , | t Ia | |t t|t rs, tt raj am i|, 1 i|Iiatt m
m air It r ar tt t I sir a s r| I| m - st Ia|t |, am it 1 art r t t r
| |ass | iI r t rm a| |V Ia r tIit r
kr Ii-tt a]a |aIit r j rt tt r Iit r t I I| rt m | t t m | t |it j | t r t m t r t r
arIarir It r j art tsm a| t r t| rt r it k|
| a|ar tt ris| t I | |t t 1 ir ] XIt ar tt rsa s ris| t I t|t I
| ar1 it tt rsit r It sir a s r| I| m
1 | iI| t a I ar Iitt a]a |aIit r iI| ir \ | t a rs t I t r st I
iI - \ | t a rs t I t r st I M | ar Iitt a]a |aIt j rit r It
tar1 it tt rsit r aI |t asI 1 t t |s | t It rt ar 1 \ t t |s aIIt r tar1 it tt rsit r
a|It rr aIt t j Iit r is | | j rit r It t |t tIrita| tar1 it tt rsit r It ra |t t a I t|t I
| ar1 i t |t ] t M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ARRHYTHMIAS . . . CONT.
m t 1 ita| tar1 it tt rsit r - st Ia|t |, am it 1 art r t , | |ass | a]t r I
iI r t rm a| |V Ia r tIit r t .]. |V j rt tair am i1 t , j rt j aIt r t r t
t |t tIrita| tar1 it tt rsit r - sr t| rt r itt 1 | | tar1 it tt rsit r sIarI aI 111!
| Iit |t ]
| k| , ta|ta |ar 1 ist ast , j t ritar1 iIis, tar1 it m t j aI| , | | ,
| j t rIt r sit r , | 1 | | , I| rt It titt sis, Iat| -| ra1
sr 1 rt m t , | I1 1 | t |i1 a | t arI
Paroxys mal Suprave ntricular Tachycardia (PSVT) (Appe ndix 2d)
J sa 1 1 t r t r st I rt ]a |ar r| I| m , raIt !1-I!1 | j m
J a sa a|| ir iIiaIt 1 | a sa j ratt r Irita |ar t r tt r Irita |ar j rt m aIa rt | t aI
J tt m m t r m t t| ar ism s art kV r t 1 a| rt t r Ir ar 1 attt sst r IratI rt t r Ir
J kVK | attt a r Is It r t1-I1X t I a|| V s
J rt Irt ]ra1 t | att s m a | t st t r | a I art a sa a|| |t sI ir I| t | tt m j |t t
J asm j It m aIit t r j a|j iIaIit r s
J m a j rt tij iIaIt | 1 | t r | j t It r sit r iI a r 1 t r|ir ] 1 ist ast
J Irt aIm t r I
ata It . Va|sa|ta t r tart Ii1 m assa]t t| t t| IirsI It r | ra iIs ,
a1 t r t sir t t sj t tia|| iI asst tiaIt 1 iI| w| w a1 t r t sir t is
IirsI t| t itt iI a r rt sj t r sitt It ta]a| m ar t a tt rs , iI r t
rt sj t r st , Ir tt raj am i|, m t It j rt |t |, I| t r 1 i]t tir , | | s| t t|
iI si]r s t I tar1 it ]t r it s| t t|, ar ]ir a, t r | 1 |
t| rt r it. | t Ia-| |t t|t r, tt raj am i|, 1 i]t tir , ar Ii-arr| I| m it
1 ra ]s, | | taI| t It r a| |aIit r
VENTRICULAR
Pre mature Ve ntricular Contraction (PVC or VPB) (Appe ndix 2e )
J | i1 I| ]rt aIt r I| ar 1. I st tt r 1 s, r t j rt tt 1 ir ] | att
J j rt m aIa rt ir I| t tar1 iat tt|t , m a | t It ||t t 1 | a j rt |t r ]t 1 j aa st
J t ri]ir . | | | | j aIIt rr = | V siIt , | | | | j aIIt rr = |V siIt
J ra |t s t I m a|i]r ar tit s iI| | V| s st t r ir | k| , 1 K , | 1 | |
Irt | a t r I, - 1I| t a r , tt r st ta Iitt - 1 = V t r m a |IiIt rm
tarit 1 t ri]ir
| V| s Ia||ir ] t r I| t att t I I| t j rt tit a s | t aI | t r
j | t r t m t r t r ta |r t ra| |t Iim t ir tt|t iI| ris| t I V t r V|
J ir t|a 1 t ris| t I sa 1 1 t r 1 t aI| iI asst tiaIt 1 iI| | k| , 1 | M , M V| ,
ris| r t I a|It rt 1 | Irt aIm t r I t I | V| s
J Irt aIm t r I. sir tt r t t ti1 t r tt It sa ]]t sI I| aI Irt aIm t r I rt 1 a tt s
m t rIa|iI, | V| s art r t I a sa a|| Irt aIt 1
iI sm j It m aIit, a st |i1 t tair t ata It | ar 1 m a tt r si1 t r
j rt tair am i1 t , | a ir i1 ir t , | t Ia | |t t|t r t r 1 ist j ram i1 t iI t| rt r it
Acce le rate d Idiove ntricular Rhythm
J | t r i]r r| I| m - t ri]ir aIt s ir It rm ir a| | a r|ir }t ssIt m t r
tt r Irita |ar m t tar1 ia m
J rt j rt st r Is a tt r Irita |ar t staj t It ta s I| aI | as attt |t raIt 1
sa IIitit r I| It 1 ritt I| t | t arI
J st m t Iim t s st t r 1 a rir ] kM | t sj t tia|| 1 a rir ] rt j t rIa sit r t r
1 i]t tir It titiI
J rt ]a |ar r| I| m , raIt !1- 11 | j m
J rart | sa sIair t 1 ar 1 rart | rt | a irt s Irt aIm t r I
J Irt aIm t r I. iI sm j It m aIit, |i1 t tair t , aIrt j ir t
Ve ntricular Tachycardia (VT) (Appe ndix 2f)
J a ra r t I I| rt t t r m t rt tt r st ta Iitt | V| s raIt - 11 is ta||t 1 V
J rt t r Ir attt a r Is It r I| t m a}t riI
J sa sIair t 1 V is ar t m t r]t r t, j rt sIa]ir ] tar1 iat arrt sI ar 1
rt | a irir ] im m t 1 iaIt Irt aIm t r I
J m t sI tt m m t r It rm t I | t arI 1 ist ast j rt 1 isj t sir ] It V is | k| iI| M |
J raIt I1-111 | j m
J | rt a1 | , kV 1 isst tiaIit r , Ia sit r | t aIs, taj Ia rt | t aIs, |t II atis
1 t tiaIit r , m t r t j | asit t r | ij | asit | ir V iI| | | | | ,
tt r tt r1 ar tt V -Vt
J kV 1 isst tiaIit r
I| t aIria ar 1 tt r Irit|t s | t aI ir 1 t j t r 1 t r I| t I t r t ar t I| t r,
I| t rt | j rt 1 a tir ] tar r t r a att s ir I| t }a ]a |ar tt r t a s
ssIt m , | att s m art| I| rt a ]| a r rt |aIt 1 It | tt m j |t tt s
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] I
K t It s
ARRHYTHMIAS . . . CONT.
J Ia sit r | t aI
t tta rs | t r ar aIria| im j a |st m ar a]t s It s|ij I| rt a ]| I| t
kV r t 1 t aI I| t sam t Iim t I| aI ar im j a |st t I tt r Irita |ar
t ri]ir is sj rt a1 ir ] atrt ss I| t tt r Irita |ar m t tar1 ia m
I| t It im j a |st s }t ir I| 1 t j t |aritt I| t tt r Irit|t s j rt 1 a tir ]
a | | ri1 | tt m j |t t I| aI is m t rj | t |t ]ita|| j arI
sa j ratt r Irita |ar ar 1 j arI tt r Irita |ar
J taj Ia rt | t aI
t tta rs | t r ar aIria| im j a |st m ar a]t s It taj Ia rt I| t
tt r Irit|t ar 1 ]t I a r t rm a| |
J Irt aIm t r I It r ata It sa sIair t 1 V
| t m t 1 r am it tt m j rt m ist - | | tar1 it tt rsit r
r t | t m t 1 r am it tt m j rt m ist
1 isIir ]a is| Irt m V iI| a| t rrar t st t Ia| |t
| | s| t t|, |i1 t tair t , j rt tair am i1 t , | rt I|ia m , am it 1 art r t
Ve ntricular Fibrillation (VF) (Appe ndix 2g)
J m t 1 ita| t m t r]t r t, j rt -It rm ir a| t tt r I a r |t ss j rt m j I| tar1 it tt rIt 1
J m t sI Irt | a t r I| t r tt a r It rt 1 arr| I| m ia ir a1 a |Is | t t tj t rit r tt
sa 1 1 t r 1 t aI|
J m t t| ar ism . sim a |Iar t t a s j rt st r tt t I m a |Iij |t atIitaIit r
att Irt r Is iI| ir I| t tt r Irit|t
J r t Ira t | tt m j |t tt s - t| at Iit i1 t Iat| arr| I| m ia iI| t a I
tt r sisIt r I i1 t r IiIia| |t | tt m j |t t
J r t tar1 iat t a Ij a I 1 a rir ] V|
J | | | , t |t tIrita| 1 t Ii| ri||aIit r , t j ir t j | rir t , |i1 t tair t . |I V| j t rsisIs,
| rt I|ia m , M ] 1 \, j rt tair am i1 t , am it 1 art r t
J rt It r It k| | a|]t riI| m It r tt m j |t It I| t raj t a Iit ]a i1 t |ir t s
Tors ade s de Pointe s (Appe ndix 2h)
J j t |m t rj | it V - iI m t ar s IisIir ] t I I| t j t ir Is
J |t t |s |i|t V t ttt j I I| aI | tt m j |t tt s rt IaIt art a r 1 I| t
| ast |ir t t| ar ]ir ] I| t ir atis ar 1 am j |iIa 1 t
J tt r Irita |ar raIt ]rt aIt r I| ar 11, a sa a|| !1-111
J a It rm t I V st t r ir j aIit r Is iI| j rt |t r ]t 1 ir It rta|s
tt r ]t r iIa| |t r ] sr 1 rt m t s
1 ra ]s - | |ass |k | a ir i1 ir t , | |ass ||| st Ia|t | , j | t r t I| iatir t s,
Iritt|it ar Ii1 t j rt ssar Is
t |t tIrt |It 1 isIa r| ar tt s - | j t |a|t m ia, | j t m a]r t st m ia
t I| t r - r a IriIit r a| 1 t Iitit r tit s
J Irt aIm t r I. It m j t rar j atir ], |V m a]r t sia m , tt rrt tI a r 1 t r|ir ]
taa st t I j rt |t r ]t 1 , | | tar1 it tt rsit r iI | t m t 1 r am it
tt m j rt m ist j rt st r I
Diffe re ntiation of VT vs . SVT with Abe rrant
Conduction*
VT SVT
Clinical Clue s
tart Ii 1 m assa]t r t rt sj t r st m a It rm i r aIt
tar r t r a att s m a | t j rt st r I r t I st t r
r t t| j t a r 1 i r ] m a | t j rt st r I r t I st t r
ECG Clue s
kV 1 i sst ti aIi t r m a | t st t r r t I st t r
Ia si t r | t aIs m a | t st t r r t I st t r
i r i Ii a| | 1 t I|t tIi t r m a 1 i IIt r Irt m sam t as r t rm a|
r t rm a| | tt m j |t t | tt m j |t t
ati s t tIrt m t ati s 1 t ti aIi t r r t rm a| t r m i |1 1 t ti aIi t r
i I j aIi t r I - t!, j rt st r tt t I j rt ti t a s M | t r sIra tIa ra| | t arI 1 i st ast
I| t r t| ar tt t I V - 1!X
| ar1 i t |t ] M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ARRHYTHMIAS . . . CONT.
PREEXCITATION SYNDROMES
Wolff-Parkins on-White Syndrome (Appe ndix 3a)
J | j ass j aI| a ta||t 1 I| t | a r 1 |t t I | t r I tt r r t tIs I| t aIria ar 1 tt r Irit|t s
J tt r ]t r iIa| 1 t It tI, j rt st r I ir 1. 111
J triIt ria 1 t |Ia att
| | ir It rta| is |t ss I| ar 1. I st tt r 1 s
i1 t | tt m j |t t 1 a t It j rt m aIa rt atIitaIit r
rt j t |aritaIit r a| r t rm a|iIit s
1 t |Ia att st t r ir |t a1 s iI| Ia|| | att s
s|a rrt 1 ir iIia| a j sIrt |t t I | tt m j |t t
J I| t It Iat| arr| I| m ias m t sI t IIt r st t r ir w| w art | V ar 1 k|
J tart Ii1 m assa]t , ta]a| m ar t a tt rs, ar 1 a1 t r t sir t tar t r | ar tt I| t
1 t ]rt t t I j rt t ttiIaIit r | s|t ir ] kV r t 1 a| tt r 1 a tIit r
J r t It . iI i1 t tt m j |t t aIria| Ii| ri||aIit r , tt r tt rr is I| aI ar It rt ]ra1 t
tt r 1 a tIit r is t tta rrir ] 1 t r a | j ass IratI, I| t rt It rt 1 t r t I a st
a]t r Is I| aI s|t kV tt r 1 a tIit r t .]. 1 i]t tir as m a ir trt ast
tt r 1 a tIit r I| rt a ]| I| t | j ass IratI ar 1 j rt tij iIaIt V|
Lown-Ganong-Le vine Syndrome
J I| t attt sst r j aI| a !am t s Ii| rt s is ir Irar t 1 a|, | j assir ] I| t
1 t |a iI| ir I| t kV r t 1 t
J I| t | | ir It rta| is s| t rIt r t 1 It |t ss I| ar 1. I st tt r 1 s
J I| t | tt m j |t t is r arrt ar 1 I| t rt is r t 1 t |Ia att
CONDUCTION DELAYS
AV NODE
Conduction Block
J |t t | aI I| t rt |aIit r s| ij t I I| t | att s It I| t | tt m j |t tt s
J sI 1 t ]rt t - tt r sIar I j rt |t r ]t 1 | | ir It rta| - 1.I st tt r 1 s
kj j t r 1 it t
a|| | t aIs art tt r 1 a tIt 1 I| rt a ]| It I| t tt r Irit|t s
r t Irt aIm t r I rt | a irt 1 iI asm j It m aIit
J Ir 1 1 t ]rt t - r t I a|| sir a s | att s art It ||t t 1 | | , 1 isIir ]a is|
j t | Irt m j t ||
M t | iIt Ij t | wt r t|t | at| - 1 a t It kV r t 1 t | |t t|a]t kj j t r 1 it 1
j rt ]rt ssitt j rt |t r ]aIit r t I I| t | | ir It rta| a r Ii| a | is 1 rt j j t 1
Irt aIm t r I. r t r t a r |t ss sm j It m aIit, aIrt j ir t
M t | iIt Ij t || - 1 a t It 1 is-| a r|ir }t | |t t|a]t kj j t r 1 it t
a||-t r-r t r t tt r 1 a tIit r , | tt m j |t tt s art 1 rt j j t 1
aI rt ]a |ar ir It rta|s iI| t a I | | j rt |t r ]aIit r
sIa| |t | | ir It rta| r t rm a| t r j rt |t r ]t 1
ris| t I 1 t tt |t j ir ] sr tt j t t r tt m j |t It 1 |
tar | att I. t r | i]| t r | |t t|s
rt | a irt s ir st rIit r t I a j att m a|t r tt r Irita |ar t r 1 a a| t| am | t r
1r1 1 t ]rt t t r tt m j |t It 1 | kj j t r 1 it I
r t | att j rt 1 a tt s a | rt sj t r st
tt m j |t It kV 1 isst tiaIit r r t rt |aIit r s| ij | t It t r ar 1 |
tar | att r arrt }a r tIit r a| | t r i1 t tt r Irita |ar
| }a r tIit r a| ts. tt r Irita |ar t staj t r| I| m ,
1 t j t r 1 s t r | t rt t staj t tt m t s Irt m
raIt a sa a|| 11-t1 | j m
It |t s-k1 am s aIIat|s
Irt aIm t r I. j att m a|t r tt r Irita |ar t r 1 a a| t| am | t r
BUNDLE BRANCH AND FASCICULAR
J | | | | , |t II ar It rit r Iastita |a s ar 1 |t II j t sIt rit r Iastita |a s s| t a |1
t at| | t tt r si1 t rt 1 ir 1 iti1 a a||, ar 1 tt m | ir aIit r i.t ., | iIastita |ar
| |t t|s s| t a |1 a|st | t r t It 1
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1
K t It s
ARRHYTHMIAS . . . CONT.
Bundle Branch Blocks
J | tt m j |t t - 1. I st tt r 1 s
J | | | | kj j t r 1 it \a
| | ir V ar 1 VI ra| | iI t ars , iI| st ]m t r I 1 t j rt ssit r
ar 1 att ir tt rsit r
j rt st r tt t I i1 t s|a rrt 1 att ir |, Vt
i1 t | sj |iI I t r aa sta |IaIit r
J | | | | kj j t r 1 it \|
| rt a1 t r r t It| t 1 m t r t j | asit | att iI| j rt |t r ]t 1
a j sIrt |t ar 1 a| st r tt t I ir iIia| att ir |t a1 s Vt, | ar 1
aV| , iI| st ]m t r I 1 t j rt ssit r ar 1 att ir tt rsit r
|ar]t t r ir V
j ara1 t tita|| sj |iI I t r aa sta |IaIit r
J r t It
iI| | | | I| t triIt ria It r tt r Irita |ar | j t rIrt j | | t tt m t a r rt |ia| |t
iI| | | | | , ir IartIit r is 1 iIIita |I It 1 t It rm ir t
He miblock
J | |t t| t I ar It rit r t r j t sIt rit r Iastit|t t I | | |
J ar It rit r | t m i| |t t|
r t rm a| | 1 a raIit r , r t st ]m t r I t r att t| ar ]t s
|t II atis 1 t tiaIit r - \! 1 t ]rt t s , iI| r t t I| t r taa st j rt st r I
sm a|| | ir | ar 1 aV| , sm a|| r ir ||, |||, aV|
J j t sIt rit r | t m i| |t t|
r t rm a| | 1 a raIit r , r t st ]m t r I t r att t| ar ]t s
ri]| I atis 1 t tiaIit r - 1 1 t ]rt t s , iI| r t t I| t r taa st
sm a|| r ir | ar 1 aV| , sm a|| | ir ||, ||| ar 1 aV|
PACEMAKER INDICATIONS
J sir a s r t 1 t 1 sIa r tIit r
sm j It m aIit | ra1 tar1 ia
J kV r t 1 a| | |t t|
sm j It m aIit M t | iIt |
| iIastita |ar | |t t|
J ir Irar t 1 a| | |t t|
M t | iIt ||
tt m j |t It 1 |
J sm j It m aIit tart Ii1 | j t rst r siIitiI
PACING TECHNIQUES
J It m j t rar. Irar stt r t a s }a ]a |ar, sa | t|atiar , It m t ra| t r t tIt rr a| j atir ]
J j t rm ar t r I. Irar stt r t a s ir It | aIria m , aj t t t I | V t r | t I| , j t t r
st a rtt im j |ar It 1 a r 1 t r t|atit|t
tar st r st ar 1 j att aIria m , tt r Irit|t t r | t I|
r t ]t r t raIit r = raIt rt sj t r sitt , a| |t It rt sj t r 1 It j | sit |t ]it 1 t m ar 1
J r t m t r t|aIa rt t .]. V V |
V - t| am | t r j att 1 . tt r Irit|t
V - t| am | t r st r st 1 . tt r Irit|t
| - atIit r . ir | i| iI
| ar1 i t |t ] I1 M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ISCHEMIC HEART DISEASE
BACKGROUND
Epide miology
J tt m m t r t sI taa st t I tar1 it tasta |ar m t r| i1 iI ar 1 m t rIa|iI
J m a|t . It m a|t raIit
= I. iI| a|| a]t ]rt a j s ir t|a 1 t 1 | ram ir ]| am sIa 1
= . | t It rt a]t \1
= . aIIt r a]t I1
1 isj ariI 1 a t It j rt It tIitt t IIt tI t I t sIrt ]t r
J j t a| ir ti1 t r tt t I sm j It m aIit ist| t m it | t arI 1 ist ast is
Irt m a]t s !1 It t1 ir m t r ar 1 a]t s t1 It I1 ir t m t r
J sj t tIra m t I ist| t m it | t arI 1 ist ast I| k| rar ]t s ar | t rt Irt m
asm j It m aIit It sa 1 1 t r 1 t aI|
Pathophys iology of Myocardial Is che mia
1 I 1 I
| t m ar 1 a j j |
1 t arI | aIt | t r ]I| t I | iasIt |t
| t r IratIi|iI | t rt r ar | iam t It r
wa|| t r sit r |V wa|| t r sit r
1 t m t ]|t | ir
a1 I
Figure 6. Phys iological Principle s
Athe ros cle ros is and Is che mic He art Dis e as e
J aI| t rt st|t rt sis ar 1 I| rt m | t sis art | Iar I| t m t sI im j t rIar I
j aI| t ]t r t Iit m t t| ar ism s ir ist| t m it | t arI 1 ist ast
Major Ris k Factors For Athe ros cle rotic He art Dis e as e
J sm t |ir ]
ris| tar | t | a|tt 1 | tt ssaIit r t I sm t |ir ]
J 1 ia| t It s
m itrt ar 1 m atrt tasta |ar tt m j |itaIit r s
J | j t rIt r sit r
1 t j t r 1 s t r 1 t ]rt t ar 1 1 a raIit r
J Iam i| | isIt r
IirsI 1 t ]rt t m a|t rt |aIitt - !! t r IirsI 1 t ]rt t It m a|t rt |aIitt - t1
J | j t r|ij i1 t m ia
Minor Ris k Factors
J t | t siI
- 11X a| t tt i1 t a| t i]| I
J st 1 t r Iar |iIt sI|t
J m a}t r 1 t j rt ssit r ir trt ast s I| t ris| It r IaIa| ar 1 r t r -IaIa| |1 |
ar 1 I1 t I ata It j t sI-M | j aIit r Is art 1 t j rt sst 1
J | j t r| t m t tsIt ir t m ia
Pre ve ntative Me as ure s
J sm t |ir ] tt ssaIit r
J Ii]| I ]|tt m it tt r Irt | ir 1 ia| t Iits
J | | tt r Irt |
m a}t r rt ast r It r I| t rt tt r I 1 t t|ir t ir |1 |
J Iam i| strt t r ir ] | i]| ris| ]rt a j s
J |ij i1 -m t 1 iIir ] I| t raj
J 1 it Iar m t asa rt s t .]. m i|1 a|tt | t | tt r sa m j Iit r
J t i]| I |t ss
J t tt rtist im j rt tt s t i]| I, | j t rIt r sit r , t| t |t sIt rt | ar 1 ]|tt m it tt r Irt |
ANGINA PECTORIS
De finition
J sm j It m tt m j |t t rt sa |Iir ] Irt m ar im | a|ar tt | t It t r
t t]t r sa j j | ar 1 1 t m ar 1 ir I| t m t tar1 ia m
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] I
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Etiology
J rt 1 a tt 1 m t tar1 ia| t t]t r sa j j |
aI| t rt st|t rt Iit | t arI 1 ist ast tasI m a}t riI
tt rt r ar tast sj asm tariar I ar ]ir a
st tt rt at rIit sIt r t sis t r ir sa IIitit r t
I| rt m | t t m | t |ism
st tt rt ar t m ia
arIt riIis
1 isst tIit r
tt r ]t r iIa| ar t m a|it s
J ir trt ast 1 m t tar1 ia| t t]t r 1 t m ar 1
m t tar1 ia| | j t rIrt j |
st tt rt Iat| tar1 ia
st tt rt | j t rI| rt i1 ism
st tt rt ar t m ia
Diffe re ntial Diagnos is
J M | 1 ist ast
ri| IratIa rt
ir It rtt sIa| m a st|t It r 1 t rr t ss
tt sIt t| t r 1 riIis
ir It rtt sIa| r t a riIis s| ir ]|t s
r t rtt rt t I 1 ist ast tt rtita| ra1 ita |Iis
J | | 1 ist ast
| | |
rt I|a t t st j | a]iIis
t st j | a]t a| sj asm ar 1 m t Ii|iI 1 ist r1 t r m a | t im j rt tt 1 | r iIrt
J j a |m t r ar 1 ist ast
| |
j r t a m t I| t rat
j r t a m t r ia
J | V 1 ist ast
at rIit 1 isst tIit r assm t Irita| | | ar 1 j a |st s, r t k| m a rm a r
j t ritar1 iIis
J r t It
tart Ia | | isIt r ar 1 j | sita| rt | a irt 1
tt r si1 t r ris| IatIt rs It r t at| t r IiI
| t art tar1 iat ar 1 r t r -tar1 iat 1 ist ast m a tt t tisI
Diagnos is of Angina Pe ctoris
J | isIt r
t|assita|| j rt tt r1 ia| t| t sI j air , Ii]| Ir t ss
t r 1 istt m It rI ra1 iaIir ] It |t II s| t a |1 t rIarm I}a
1 sj r t a t r IaIi]a t m a j rt st r I as t| t sI j air t | a ita|t r Is
asst tiaIt 1 iI| 1 iaj | t rt sis t r r aa st a
j rt 1 itIa| | j rt tij iIaIt 1 | I| t 1 | s t tt rIit r , t m t Iit r ar 1 t aIir ]
| rit I 1 a raIit r , |asIir ] - 1- ! m ir a It s ar 1 Ij ita|| rt |it tt 1 | rt sI
J sIrt ss It sIir ] st t | ar1 iat | ia]r t sIit t sIs t tIit r
|t |i|t |i| t t 1 ir It rm t 1 iaIt |i|t |i| t t 1 | i]| |i|t |i| t t 1
r t r -r a t|t ar t I| t rist | t a|I| tt r t |1 t r
tt m j |itaIir ] 1 ist ast
r a t|t ar sIrt ss It sIir ] r a t|t ar sIrt ss It sIir ]
m t 1 ita| It ||t -a j taI| m t 1 ita| It ||t -a j
|t ris| | i]| ris|
m t 1 ita| m ar a]t m t r I | | k, | k| |
Figure 7. Diagnos tic Strate gie s in the Manage me nt of IHD

| ar1 i t |t ] II M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s

K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Variant Angina
J tast sj asm t I tt rt r ar arIt rit s rt sa |Is ir m t tar1 ia| ist| t m ia
m a t tta r ir r t rm a| t r aI| t rt st|t rt Iit tt sst |s
J Ij ita|| t tta rs | t It t r m i1 r i]| I ar 1 am
J a r rt |aIt 1 It t tt rtist
J Ij ita|| t |t taIit r t r | | | m a | t tt r Ia st 1 iI| ata It ir IartIit r
J 1 ia]r t st | j rt tt taIitt It sIir ] iI| t r]t I tast tt r sIritIt rs rart | 1 t r t
Me dical Tre atme nt
J | t Ia-| |t t|t rs IirsI |ir t I| t raj
rt 1 a tt t tt ra|| m t rIa|iI
rt 1 a tt | t arI raIt , tt r IratIi|iI, ar 1 It a
|t sst r 1 t ]rt t , | |t t 1 j rt ssa rt aIIt r|t a1
a|st ir trt ast tt rt r ar j t rIa sit r
att i1 a]t r Is iI| ir Irir sit sm j aI| t m im t Iit
atIitiI | k a r |t ss j aIit r I is | ra1 tar1 it
J ta|tia m t| ar r t | | |t t|t rs st tt r 1 |ir t I| t raj
tt r Ira|| atIir ]. taria| | 1 t trt ast aIIt r|t a1 ar 1 tt r IratIi|iI ar 1
j rt 1 a tt tt rt r ar 1 i|aIaIit r
J r iIraIt s
a st 1 It r sm j It m aIit tt r Irt |
r t t|t ar im j atI t r sa rtita|
rt 1 a tt m t tar1 ia| t r| ar 1 , I| t rt It rt , t t]t r rt | a irt m t r Is
I| rt a ]| tt r t a s 1 i|aIaIit r 1 t trt ast 1 j rt |t a1 ar 1 arIt rit |ar
1 i|aIaIit r 1 t trt ast 1 aIIt r|t a1
a|st 1 i|aIt tt rt r ar arIt rit s
m air Iair 1 ai| r iIraIt -Irt t ir It rta|s It Ir It j rt tt r I It |t rar tt
1 ra ] | t |i1 a
J | | k k
a|| j aIit r Is
1 t trt ast j |aIt |t I a]]rt ]aIit r
J |ij i1 |t t rir ]
CAD-Lipid The rapy
Trial Drug Dos e CHD Eve nt Re duction
j rim ar w1 | 1 | j ratasIaIir \1 1 X
j rt tt r Iit r k| | k| |t tasIaIir I1-\1 I\X
st tt r 1 ar | || || j ratasIaIir \1 I1X
j rt tt r Iit r \ sim tasIaIir I1-\1 1\X
| k| | j ratasIaIir \1 I\X
CAD-NCEP Guide line s
Die t Drug Goal
Primary Pre ve ntion
- I ris| IatIt rs - I= \. - I= \.1 - \.
I ris| IatIt rs - I= 1.\ - I\. - 1.\
Se condary Pre ve ntion
| ast 1 t r | | | -| |t tt |s - I - I= 1.\ - I= I.t
J Irt aIm t r I sIraIt ]
s| t rI atIir ] r iIraIt s t r j rr | asis It rt |it tt ata It aIIat|s
ar 1 j rr j rit r It t tt rIit r
]t t 1 j rt j | |atIit tt m | ir aIit r rt ]im t r s ir t|a 1 t .
| t Ia-| |t t|t r ar 1 |t r ]-atIir ] r iIraIt
| t Ia-| |t t|t r ar 1 ta|tia m t| ar r t | | |t t|t r |t r ] atIir ] t r
j t rij | t ra|| atIir ] -st tt r 1 ]t r t raIit r 1 i| 1 rt j ri1 ir t ]rt a j
| t tart Ia | | t r tt m | ir ir ] | t Ia-| |t t|t rs ar 1 tt raj am i|I1 i|Iiatt m
| t I| 1 t j rt ss tt r 1 a tIit r ar 1 tt r IratIi|iI ar 1
m a rt sa |I ir sir a s | ra1 tar1 ia t r kV | |t t|
tart Ia || tt r si1 t r r t r -tar1 iat a1 tt rst t IIt tIs
a st r iIraIt s ar 1 ta|tia m t| ar r t | | |t t|t rs It r tariar I ar ]ir a
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] I1
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Indications for Angiography
J sIrt r ]| j t siIitt t tt rtist It sI
J si]r iIitar I, rt tt rsi| |t 1 t It tIs t r I| a||ia m star
J rt IratIt r It m t 1 ita| I| t raj t r j aIit r I a r a| |t It It |t raIt m t 1 ita| I| t raj
J a r sIa| |t ar ]ir a
Pe rcutane ous Trans luminal Coronary Angioplas ty (PTCA)
J a st s a | a||t t r ir I|aIt 1 a r 1 t r | i]| j rt ssa rt It ra j Ia rt aI| t rt m aIt a s j |a| a t s
J m a | t a st 1 as j rim ar I| t raj ir ar ]ir a, ata It M |, j t sI M | ar ]ir a t r ir
j aIit r Is j rt st r Iir ] iI| | j ass ]raII sIt r t sis
J t j Iim a|| a st 1 It r j rt tim a| |t sit r s Irt t t I I| rt m | a s ar 1
1 isIar tt 1 Irt m I| t t ri]ir s t I |ar]t tt sst | | rar t| t s
J j rim ar sa ttt ss raIt is - 1X
J rt sIt r t sis t tta rs ir aj j rt tim aIt | 11-!1X t I 1 i|aIt 1 tt sst |s
iI| ir I| t IirsI t m t r I| s 1 t j t r 1 t r I a j t r |t taIit r
J a st t I ir Iratt rt r ar sIt r I is asst tiaIt 1 iI| a |t t r rt sIt r t sis raIt
ar 1 rt 1 a tt s r t t 1 It r a r]t r I | k| | ir j aIit r Is iI| I| rt aIt r t 1
tt sst | t|t sa rt aI Iim t t I | | k
J tt m j |itaIit r s t tt ra|| 1-!X
m t rIa|iI - X
M | 1-!X
ir Iim a| 1 isst tIit r tt sst | t tt|a sit r rt | a irir ] a r]t r I | k| | ir 1-!X
Surgical Tre atme nt- Coronary Arte ry Bypas s Grafting (CABG)
J ir 1 itaIit r s - It r sa rtita| | t r t IiI, t r sm j It m aIit rt |it I t I ar ]ir a
sIa| |t ar ]ir a sa rtita| | t r t IiI It r | k| | s| t r
|t II m air tt rt r ar 1 ist ast t r t | a ita|t r I
I| rt t -tt sst | 1 ist ast iI| 1 t j rt sst 1 |V Ia r tIit r
m a |Ii-tt sst | 1 ist ast iI| si]r iIitar I j rt tim a| | k| sIt r t sis
a r sIa| |t ar ]ir a
tt r Iir a ir ] ar ]ir a 1 t sj iIt a]]rt ssitt m t 1 ita| I| t raj a r sIa| |t ar ]ir a
t tt |tir ] m t tar1 ia| ir IartIit r j t sI ir IartI ar ]ir a
tt m j |itaIit r sIIai|t 1 | | k
J tt m j arist r t I | k| | iI| | | k
sIa 1 it s. | |k, | k| |, | k| |, | k , | | k| |, | k| | |
| i]| | st |t tI j aIit r I j t j a |aIit r - r t |t II m air 1 ist ast ar 1 m ir im a| |V 1 sIa r tIit r
t tt ra|| r t 1 iIIt rt r tt ir sa rtita| t r M | aI 1 t ars, | a I m t rt
rt tasta |aritaIit r ar 1 rt ta rrt r I ist| t m ia ir | | k ]rt a j
| k| |, sa | st I ar a|sis - | k| | sa j t rit r ir j aIit r Is iI|
1 ia| t It s m t ||iIa s ar 1 m a |Ii-tt sst | |1 |
J j rt 1 itIt rs t I j t t r t a Itt m t
j t t r |V Ia r tIit r | | - \1X , | isIt r t I | 1 |, K Y1 k ||| t r |V
j rt tit a s tar1 iat sa r]t r
a r]t r IIt m t r]t r I tast , j rt t j t raIitt |k| |
]t r 1 t r rt |aIitt ris| It r | .M = .t.
a1 tar tt 1 a]t - I1 , | M , tt m t r| i1 1 ist ast
J | k| | t j t raIitt m t rIa|iI
t |t tIitt tast - X
t |t tIitt tast , j t t r |V Ia r tIit r -1X
a r]t r I tast -!X
t tt ra|| 11- 111 I.IX
J t IIitat. - 11X sm j It m aIit im j rt tt m t r I ir ar ]ir a
J tt r 1 a iIs ar 1 j aIt r t
ir It rr a| m am m ar I| t ratit arIt r 11X j aIt r t aI 1 t ars
saj | t r t a s tt ir ]raII !1X j aIt r t aI 1 t ars
ra1 ia|I]asIrt t j ij |t itIir It rit r !X j aIt r t aI ! t ars
t j i]asIrit arIt rit s im j rt tir ] iI| t tj t rit r tt
UNSTABLE ANGINA
De finition
J attt |t raIir ] j aIIt rr t I j air
ir trt ast 1 Irt | a t r t
|t r ]t r 1 a raIit r
t tta rir ] iI| |t ss t tt rIit r
|t ss rt sj t r sitt It Irt aIm t r I
J ar ]ir a aI rt sI
J r t t r st I ar ]ir a
J ar ]ir a j t sI-M |
J j t sI-ar ]it ]raj |
J j t sI-| k| |
J r t It I| aI a r sIa| |t ar ]ir a is a | t It rt ]t r t a s ]rt a j ar 1 tar
| t 1 iti1 t 1 ir It a | i]| t r ar 1 |t t r ris| ]rt a j s
| ar1 i t |t ] I\ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Significance
J I| t a ]| I It rt j rt st r I j |a| a t ra j Ia rt ar 1 ata It I| rt m | t sis iI|
ir tt m j |t It tt sst | t tt|a sit r
J 1- !X i|| j rt ]rt ss It M |
J !- 1X t r t t ar m t rIa|iI
Diagnos is
J | isIt r
J | | | t| ar ]t s
1 t j rt ssit r t r t |t taIit r
att ir tt rsit r
J r t t |t taIit r t I tar1 iat t r tm t s
Manage me nt
J t t]t r
J | t 1 rt sI
J | t sj iIa|itaIit r Im t r iIt rir ]
J ar Ii-ar ]ir a| m t 1 itaIit r s
sa | |ir ]a a| t r |V r iIrt ]|tt rir t
| t Ia-| |t t|t rs art IirsI |ir t I| t raj
aim It r rt sIir ] | t arI raIt t I !1-t1
ta|tia m t| ar r t | | |t t|t rs art st tt r 1 |ir t I| t raj
t ti1 t r tt sa ]]t sIs I| aI I| t 1 t r t I j rt tt r I M | t r rt 1 a tt m t rIa|iI
| t taa Iit a s a sir ] tt raj am i|I1 i|Iiatt m iI| | t Ia-| |t t|t rs
m a a st am |t 1 ij ir t t r |t r ] atIir ] r iIt 1 ij ir t
iI tt r tt m iIar I | t Ia | |t t|a1 t
J asj irir
t1-1I! m ]I1 a, a|I| t a ]| |t t r 1 t st s | att j rt tt r | t r t Iitia|
J |V | t j arir
J ar ]it ]raj | iI| tit It j t It r Iia| | | k t r | k| |
J iI a]]rt ssitt m t 1 ita| m ar a]t m t r I is a r sa ttt ssIa |
m a a st ir Ira-at rIit | a||t t r j a m j It sIa| i|itt | t It rt j rt tt t 1 ir ] iI| rt tasta |aritaIit r
j rt tt t 1 It t m t r]t r t ar ]it ]raj | ar 1 | | k t r | k| |
SUDDEN DEATH
De finition
J a r ar Iitij aIt 1 , r t r -Iraa m aIit 1 t aI| ir a t|ir ita|| sIa| |t j aIit r I,
iI| ir | t a r t I sm j It m t r st I
J im m t 1 iaIt taa st t I 1 t aI| is
tt r Irita |ar Ii| ri||aIit r m t sI tt m m t r
tt r Irita |ar assIt |t
Significance
J attt a r Is It r aj j rt tim aIt | !1X t I | k| m t rIa|iIit s
J ir iIia| t|ir ita| j rt st r IaIit r ir a j It I1X t I j aIit r Is iI| | k|
Etiology
J j rim ar tar1 iat j aI| t |t ]
ist| t m iaIM |
|t II tt r Irita |ar 1 sIa r tIit r
st tt rt tt r Irita |ar | j t rIrt j |
| j t rIrt j | it | M
k
j rt |t r ]aIit r sr 1 rt m t
tt r ]t r iIa| | t arI 1 ist ast
J | i]| ris| j aIit r Is m a | att ir tt m m t r
m a |Ii-tt sst | 1 ist ast
tt r Irita |ar t |t tIrita| ir sIa| i|iI i.t . V| | s
rt j t |aritaIit r a| r t rm a|iIit s t r si]r a|-att ra]t 1 | | |
|V 1 sIa r tIit r
J ar It tt 1 t r I r| I| m s It V|
V tIX
| ra1 arr| I| m ias tX
It rsa1 t 1 t j t ir It s IX
j rim ar V| X
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] I!
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Manage me nt
Acute
J rt sa stiIaIt iI| j rt m j I | | | ar 1 1 t Ii| ri||aIit r
Long Te rm Survivors
J i1 t r IiI ar 1 Irt aI a r 1 t r|ir ] j rt 1 isj t sir ] IatIt rs
J ist| t m it | t arI 1 ist ast
tar1 iat taI| t It ritaIit r It t ta|a aIt tar1 iat ar aIt m , |V Ia r tIit r
ar 1 r t t 1 It r rt tasta |aritaIit r
J 1 t |It r m t r iIt rir ]
J t |t tIrt j | sit |t ]it sIa 1 it s
Tre atme nt
J ar Iiarr| I| m it 1 ra ] I| t raj
am it 1 art r t , | t Ia-| |t t|t rs
J sa r]t r
rt tasta |aritaIit r It Irt aI ist| t m ia
m aj -]a i1 t 1 sa | t r 1 t tar1 ia| rt st tIit r
trt a| |aIit r , ra1 it Irt | a t r t a| |aIit r
J im j |ar Ia| |t tar1 it tt rIt r-1 t Ii| ri||aIt r
Prognos is
J t ar m t rIa|iI j t sI-rt sa stiIaIit r I1-11X
J j rt 1 itIt rs t I rt ta rrt r I tar1 iat arrt sI ir I| t sa rtitt r t I sa 1 1 t r
tar1 iat 1 t aI|
rt m t It M |
| 1 |
|V 1 sIa r tIit r
t tIt r sitt | k|
tt m j |t t tt r Irita |ar t tIt j
a| r t rm a| si]r a|-att ra]t 1 | | |
ACUTE MYOCARDIAL INFARCTION
De finition
J sr 1 rt m t t I ata It tt rt r ar ir sa IIitit r t rt sa |Iir ] ir 1 t aI| t I
m t tar1 ia m
Diagnos is
(Dx infarction bas e d on 2 of 3 his tory, ECG, cardiac e nzyme s )
J | isIt r
sa 1 1 t r t r st I t I t| aratIt risIit t| t sI j air It r - 11 m ir a It s 1 a raIit r
m a | t attt m j ar it 1 | sm j It m s t I | t arI Iai|a rt
J | | | t| ar ]t s
| j t rata It att s
st ]m t r I t |t taIit r
att ir tt rsit r
si]r iIitar I att
J tar1 iat t r tm t s
It ||t | | -M | | | t 1, rt j t r ir | | t 1
J tar1 iat Irt j t r ir | ar 1 It r |t tt |s j rt ti1 t a st Ia | 1 ia]r t sIit,
j rt ]r t sIit ir It rm aIit r ar 1 j t rm iI t ar| i1 t r IiIitaIit r t I ar
ir trt ast 1 ris| t I m t rIa|iI ir j aIit r Is iI| ata It tt rt r ar sr 1 rt m t s
Irt j t r ir | ar 1 rt m air t |t taIt 1 It r ! It I 1 as
J | t art
a j It 11X art a r rt tt ]r itt 1 t r si|t r I 1 a t It aIj ita| sm j It m s
1 ia| t Iits
t |1 t r|
j aIit r Is iI| | j t rIt r sit r
J 1 ra st ra m |ij i1 s iI| ir I\-\ | t a rs | t taa st I| t st ra m ta|a t s art
a r rt |ia| |t aIIt r \ | t a rs, | a I | t tt m t rt |ia| |t a]air t t |s j t sI M |
| ar1 i t |t ] It M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
| aIi t r I | ta|a aIi t r
a r sIa| |t ar ]i r a
| i sIt r j | si ta| t tam | | | t r tm t s
t |t taIi t r r t r t |t taIi t r
j rt sa m t 1 ata It M | sam j |t t r tm t s
asst ss It r j t si Ii tt t r tm t s r t ]aIi tt t r tm t s
I| rt m | t |si s ata It M |
a r sIa| |t ar ]i r a r t r tar1 i at t| t sI j ai r
Figure 8. Diagnos tic algorithm in acute IHD
Etiology
J tt rt r ar aI| t rt st|t rt sis sa j t rim j t st 1 I| rt m | a s t r ra j Ia rt 1
j |a| a t tasI m a}t riI
ta |r t ra| |t st II j |a| a t s m t rt I| rt m | t ]t r it
J tt rt r ar I| rt m | t t m | t |ism
ir It tIitt t r 1 t tar1 iIis
r| t a m aIit | t arI 1 ist ast
ir IratatiI I| rt m | a s
t| t |t sIt rt | t m | t |i
J st tt rt tt rt r ar tast sj asm
J arIt riIis
J tt rt r ar 1 isst tIit r
J tt r si1 t r j t ssi| |t t tatt r| aIir ] IatIt rs
st t kr ]ir a | t tIt ris st tIit r
| kY | 1 -M |
Figure 9. Cardiac Enzyme Profile in Acute MI
Clas s ification of MIs
J att
asst tiaIt 1 iI| Irar sm a ra| ir IartIit r s,
ir tt |tir ] Ia || I| it|r t ss t I m t tar1 ia m
J r t r - att
asst tiaIt 1 iI| r t r -Irar sm a ra| sa | t r 1 t tar1 ia| ir IartIit r s,
ir tt |tir ] t r t I| ir1 It t r t | a|I t I m t tar1 ia| I| it|r t ss
ir -| t sj iIa| m t rIa|iI Irt m r t r - att ir IartIit r is |t
- !X | a I t ar m t rIa|iI aj j rt at| t s I| aI t I att
ir IartIit r
Manage me nt
J ]t a| is It m ir im itt I| t am t a r I t I ir IartIt 1 m t tar1 ia m ar 1
j rt tt r I tt m j |itaIit r s
CK-MB
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] II
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
J t m t r]t r t rt t m m t asa rt s
asj irir 1I! m ] t| t t 1 sIaI
t t]t r
sa | |ir ]a a| r iIrt ]|tt rir t t 1 It rIt ar ]ir a
m t rj | ir t It r j air rt |it I ar 1 st 1 aIit r
| t Ia-| |t t|t rs It rt 1 a tt | t arI raIt iI r t I tt r Irair 1 itaIt 1
J I| rt m | t |Iit I| t raj st t a| |t I
| t r t IiIs t I I| rt m | t |sis s| t r It | t irrt sj t tIitt t I a]t ,
st t, | |, | t arI raIt , t r | isIt r t I M | t r 1 ia| t It s
sIrt r ]| rt tt m m t r 1 t 1 I| aI j aIit r Is iI| I| t
It ||t ir ] s| t a |1 rt tt itt I| rt m | t |Iit I| t raj
k. aI |t asI 1.! | t a rs t I ist| t m it tar1 iat j air ar 1
| . ar t I I| t It ||t ir ] | | | t| ar ]t s I| t a ]| I It | t t I ata It t r st I
aI |t asI m m t I t |t taIit r ir aI |t asI It |im | |t a1 s
aI |t asI m m t I t |t taIit r ir aI |t asI It a1 }att r I
j rt tt r1 ia| |t a1 s t r
r t t r st I tt m j |t It | | | |
| . j rt st r IaIit r iI| ir I | t a rs t I sm j It m t r st I
t| t itt t I I| rt m | t |Iit a]t r Is ir t|a 1 t sIrt j It |ir ast ar 1 rI-|k
j aIit r Is | atir ] j rt tit a s| rt tt itt 1 sIrt j It |ir ast m a sI
rt tt itt a|It rr aIt a]t r I 1 a t It 1 t tt |t j m t r I t I im m a r iI
J | | k, | k| |
J | t r ]-It rm m t asa rt s
ar Iij |aIt |t IIar Iitt a]a |aIit r I| t raj
| | k k 1I! m ] 1 ai|
| t j arir
It r a|| j aIit r Is, t sj t tia|| iI | i]| ris| t I ssIt m it t r tt r t a s
I| rt m | t t m | t |ism ar It rit r M |, aIria| Ii| ri||aIit r , tt r Irita |ar
ar t a rsm
r iIraIt s
a||t tiaIt ist| t m ia | a I m a r t I im j rt tt t a Itt m t
| t Ia | |t t|t rs IirsI |ir t I| t raj
sIarI im m t 1 iaIt | ar 1 tt r Iir a t ir 1 t Iir iIt | iI r t tt r Irair 1 itaIit r s
rt 1 a tt m t rIa|iI
ta|tia m t| ar r t | | |t t|t rs
K 1 rt tt m m t r 1 t 1 ir -att M |
1 i|Iiatt m t I | a t sIit r a| |t | t r t IiI ir r t r -
att M | iI r t |V 1 sIa r Iit r
k| | -ir | i| iIt rs
a|| j aIit r Is s| t a |1 | t tt r si1 t rt 1 It r k| | |
rt 1 a tt m t rIa|iI
sIrt r ]| rt tt m m t r 1 t 1 It r.
sm j It m aIit | 1 |
rt 1 a tt 1 |V| | - \1X sIarIir ] 1 a 1 It t j t sI M | kV| Iria|
ar It rit r M |
|ij i1 |t t rir ] a]t r I 1 M | -| 1k rt 1 a tIast ir | i| iIt rs t r r iatir
iI It Ia| t| t |t sIt rt | - !.! t r | | | - I.t
tt a m a1 ir It r 1 m t r I| s
It r |ar]t ar It rit r M |, t sj t tia|| iI |V
I| rt m | a s st t r t r I| t t| t
J st t | i]a rt 1 It r j t sI-| | | sIraIt ]
Table 7. Contraindications to Thrombolytic The rapy in AMI
Abs olut e Re lat ive
atIi tt | |t t 1 i r ] | | , | | | t m t rr| a]t t r sIrt |t i I| i r j asI t m t r I| s
at rIi t 1 i sst tIi t r m a}t r sa r]t r t r Iraa m a i I| i r j asI I-\ t t |s
ata It j t ri tar1 i Ii s st tt rt a r tt r Irt ||t 1 | j t rIt r si t r
tt rt | ra| | t m t rr| a]t | |t t 1 i r ] 1 i aI| t si s t r i r Iratrar i a| r t t j |asm
j rt ti t a s t r ta rrt r I j a r tIa rt t I a r t r tt m j rt ssi | |t tt sst |
si ]r i Ii tar I t| t sI Iraa m a Irt m | | |
| ar1 i t |t ] I M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Table 8. Complicat ions of Myocardial Infarct ion
Complicat ion Et iology Pre s e nt at ion The rapy
arrhyt hmia
a Iat| si r a s, k|, V, V| t ar|I|aIt st t krr| I| m i a st tIi t r
| | ra1 si r a s, kV | |t t| t ar|
myocardial
rupt ure
a |V Irt t a|| Irar sm a ra| i r IartIi t r -I 1 as j t ri tar1 i t tt r It si s t r sa r]t r
| j aj m a st|t i r It ri t r i r IartIi t r -I 1 as sa r]t r
M | ar It ri t r i r IartIi t r
t tt r I st j Ia m st j Ia| i r IartIi t r -I 1 as sa r]t r
V |
s hock/CHF |VI| V i r IartIi t r i I| i r \ | t a rs I|a i 1 s, i r t Irt j t s, | k| |
ar t a rsm
pos t infarct angina j t rsi sIt r I tt rt r ar sIt r t si s ar Ii m t a]]rt ssi tt m t 1 i ta| I| t raj
m a |Ii tt sst | 1 i st ast | | k t r | k| |
re curre nt MI rt t tt|a si t r ar Ii m t st t a| t tt
t hromboe mbolis m m a ra| I| rt m | a s i r att I 1 1 as, | t j ari r , arIari r
i r IartIi t r a j It t m t r I| s
pe ricardit is j t sI-M | -I 1 as K k| | s
(Dre s s le r's ) aa It i m m a r t | rt ss|t rs I- t t |s K k| | s, sIt rt i 1 s
Figure 10. Acute MI and Pre dis charge Ris k Stratification
Acute MI Ris k Stratification
| ar1 it ]t r it | t t| | |t taIit r t r | | | | K t | |t taIit r
!X - 1X ar 1 | rt st r IaIit r I | t a rs ar 1 | rt st r IaIit r - I | t a rs
I!X - \!X !1X - I1X
| rt m | t |sis
! | t sta t | | k, | k|
K t | t j t rIa sit r | t j t rIa sit r
1X - \!X !!X - X
Non-Acute Ris k Stratification
1 i]| -| is| 11X - 1!X |r It rm t 1 iaIt I| t -| is|
j rit r M | t!X - I1X
| 1 |
| t ta rrt r I |st| t m ia
1 i]| -| is| krr| I| m ia K t r -ir tasitt Irt ss t sIir ]
| ar1 iat | aI| t It ritaIit r
|st| t m ia t r K t rm a| | t sa |Is
| t t r | a r tIit r a| IaIa s
| ar1 iat | aI| t It ritaIit r K t Ia rI| t r It sIir ] aI I| is Iim t
| |t ast r t It I| aI | t| t tar1 it ]raj | is 1 t r t rt a Iir t | j t sI-M |.
|I is tt r Irt tt rsia| | t I| t r ar | | - \1X is | iIst |I ar ir 1 itaIit r It r tt rt r ar ar ]it ]raj | .
k
t
a
I
t

|
|
a
s
t
|
|
|

|
|
a
s
t
|
r
-
1
t
s
j
i
I
a
|

|
|
a
s
t
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] I1
K t It s
ISCHEMIC HEART DISEASE . . . CONT.
Prognos is
J I1X t I j aIit r Is iI| ata It M | 1 it | t It rt rt at| ir ] | t sj iIa|
J !- !X t I | t sj iIa|itt 1 j aIit r Is i|| 1 it
ris| IatIt rs
ir IartI sitt Ist tt riI
a]t
tt m t r| i1 tt r 1 iIit r s
1 t tt |t j m t r I t I | t arI Iai|a rt t r | j t It r sit r
J j t sI-1 ist| ar]t m t rIa|iI raIt s
t-X iI| ir IirsI t ar, | a|I t I I| t st iI| ir IirsI 1 m t r I| s
\X j t r t ar It ||t ir ] IirsI t ar
ris| IatIt rs
|V 1 sIa r tIit r
rt si1 a a| m t tar1 ia| ist| t m ia
tt r Irita |ar arr| I| m ias
| isIt r t I j rit r M |
rt sIir ] |V t }t tIit r IratIit r is m t sI a st Ia | j rt ]r t sIit IatIt r
HEART FAILURE
J I| t t tt ra|| j rt ]r t sis t I j aIit r Is iI| | 1 | rt m air s !1X m t rIa|iI aI Iitt t ars
DEFINITION
J ir a| i|iI t I | t arI It m air Iair a1 t | a aIt tar1 iat t a Ij a I It m t t I
I| t 1 t m ar 1 s t I | t |t -| t 1 m t Ia| t |ism ar 1 It r It | t a| |t It 1 t st
t r | Irt m ar t |t taIt 1 Ii||ir ] j rt ssa rt It rar1 | t arI Iai|a rt
J ir a| i|iI t I | t arI It t|t ar tt r t a s rt Ia rr rt sa |Iir ] ir tasta |ar
tt r ]t sIit r | at|ar1 | t arI Iai|a rt
J r t I a 1 ist ast t r IiI ir ar 1 t I iIst |I | a I raI| t r a sr 1 rt m t ir tt |tir ]
tt m j t r t r Is Irt m I| t It rar1 ar 1 | at|ar1 | t arI Iai|a rt I| t t rit s
PATHOPHYSIOLOGY
J It tt m j t r t r Is
j rim ar ir sa |Is ir iIiaIir ] I| t 1 ist ast j rt tt ss
tt m j t r saIt r rt sj t r st s | it| t tatt r| aIt ar 1
j t rj t Ia aIt I| t 1 ist ast j rt tt ss ir t| rt r it | t arI Iai|a rt
| ri m ar 1 am a]t
m t tIt |t ss
t tt r|t a1
K t trt si s, aj t j It si s Irt It|
| a m j 1 sIa r tIi t r
| | |
K t a rt | a m t ra| atIi taIi t r Vt r Iri ta |ar rt m t 1 t |i r ]
k| | | 1 i |aIaIi t r
| j t rIrt j |
k| | | | 1 t m a, Iat| tar1 i a
-| |t t|t rs tast tt r sIri tIi t r , tt r ]t sIi t r
| i a rt Ii ts
| 1 |
Figure 11. Pathoge ne s is of CHF
ETIOLOGY OF PRIMARY INSULTS
J tt r si1 t r j rt 1 isj t sir ], j rt tij iIaIir ] ar 1 j t rj t Ia aIir ] IatIt rs
| ar1 i t |t ] 11 M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
HEART FAILURE . . . CONT.
Clinical Pe arl
J What are the five commone s t caus e s of CHF?
coronary arte ry dis e as e (60-70%)
idiopathic (20%) ofte n in the form of dilate d cardiomyopathy
valvular (e .g. AS, AR and MR)
hype rte ns ion ( may produce hype rtrophic cardiomyopathy)
alcohol (may caus e dilate d cardiomyopathy)
J I| t |t ss tt m m t r taa st s t I | 1 |
It tit t .]. a1 riam tir , 1 t tt ra | itir , ra1 iaIit r , a rt m ia, taIt t| t |am ir t s
ir It tIit a s t .]. | | a]as tt r tt m m t r taa st t r|1 i1 t , tt tsat|it , 1 |V
t r 1 t trir t t .]. | j t rI| rt i1 ism , 1 ia| t It s, atrt m t ]a|
ir Ii|IraIitt t .]. sartt i1 t sis, am |t i1 t sis, | t m t t| rt m aIt sis, r t t j |asia
]t r t Iit t .]. | t rt 1 iIar | j t rIrt j | it tar1 it m t j aI|
m t Ia| t |it t .]. I| iam ir t 1 t Iit r t, st |t r ia m 1 t Iitit r t
j t rij arIa m
tt r ]t r iIa|
J j rt tij iIar Is
|at| t I tt m j |iar tt iI| 1 it I ar 1 m t 1 itaIit r s, ir a1 t | a aIt I| t raj
a r tt r Irt ||t 1 | j t rIt r sit r
arr| I| m ias t .]. aIria| Ii| ri||aIit r
rt ta rrt r I ist| t m ia
1 ist ast j rt ]rt ssit r
t r tirt r m t r Ia| t .]. | t aI att
ir It rta rrt r I ir It tIit r , It tt r
j a |m t r ar t m | t |ism
I| rt It titt sis
J iI is im j t rIar I It 1 iIIt rt r IiaIt ar t tatt r| aIit r 1 a t It a rt tt rsi| |t taa st
Irt m j rt ]rt ssit r t I I| t j rim ar 1 ist ast It r Irt aIm t r I ar 1 j rt ]r t sis
COMPENSATORY RESPONSES IN HEART FAILURE
J tar1 iat rt sj t r st It m t tar1 ia| sIrt ss
j rt ssa rt t tt r|t a1 rt sa |Is ir | j t rIrt j | t .]. | j t rIt r sit r
tt |a m t t tt r|t a1 rt sa |Is ir tar1 iat 1 i|aIaIit r t .]. k|
J ssIt m it rt sj t r st It ir t IIt tIitt tirta |aIir ] tt |a m t
atIitaIit r t I sm j aI| t Iit r t rtt a s ar 1 rt r ir -ar ]it It r sir
ssIt m s rt sa |I ir
sa|I ar 1 1 I1 rt It r Iit r iI| ir Iratasta |ar t tj ar sit r
ir trt ast 1 | t arI raIt ar 1 m t tar1 ia| tt r IratIi|iI
ir trt ast 1 aIIt r|t a1
J tt m j t r saIt 1 | t arI Iai|a rt | t tt m t s 1 t tt m j t r saIt 1 as
tar1 iat ar 1 ssIt m it rt sj t r st s t tt rs| t t I
J Irt aIm t r Is art 1 irt tIt 1 aI I| t st tt m j t r saIt r t tt rs| t t Is
Table 9. Ove rs hooting of Compe ns atory Re s pons e s
in He art Failure
Compe ns at ory Re s pons e Re s ult of Exce s s
| j t rIrt j | i r trt ast 1 1 I tt r sa m j Ii t r
1 i asIt |i t 1 sIa r tIi t r
1 i |aIaIi t r i m j ai rt 1 m t tar1 i a| Ia r tIi t r
sa|I ar 1 1 I1 rt It r Ii t r tt r t a s tt r ]t sIi t r
i r trt ast 1 | t arI raIt i r trt ast 1 1 I tt r sa m j Ii t r
ar 1 tt r IratIi |i I
i r trt ast 1 ssIt m i t 1 t trt ast 1 tar1 i at t a Ij a I
tasta |ar rt si sIar tt
SYSTOLIC vs . DIASTOLIC DYSFUNCTION
Sys tolic Dys function (de fe ct in the e je ction of blood from the he art)
J im j airt 1 m t tar1 ia| tt r IratIi|t Ia r tIit r
J | a||m ar| is im j airt 1 sIrt |t tt |a m t ar 1 It r t }t tIit r IratIit r
J sm j It m s j rt 1 t m ir ar I| 1 a t It 1 t trt ast 1 tar1 iat t a Ij a I
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1
K t It s
HEART FAILURE . . . CONT.
J ssIt |it 1 sIa r tIit r m a |t a1 It 1 iasIt |it 1 sIa r tIit r | t r
tt m j t r saIt r rt sj t r st s t I | j t rIrt j | I1 i|aIaIit r rt sa |I ir
ir trt ast 1 t r 1 -1 iasIt |it j rt ssa rt
J t tam j |t s
M |
m t tar1 iIis
1 i|aIt 1 tar1 it m t j aI|
Dias tolic Dys function (de fe ct in ve ntricular filling)
J I1 t I a|| j aIit r Is t ta|a aIt 1 It r t|ir ita| 1 ia]r t sis t I | t arI Iai|a rt
| att r t rm a| ssIt |it Ia r tIit r t }t tIit r IratIit r
J a| i|iI t I |t II tt r Irit|t It attt j I | |t t 1 is im j airt 1 1 a t It a |at| t I
tt m j |iar tt
Irar sit r I| | ist| t m ia
j t rm ar t r I| | st tt rt | j t rIrt j | 1 K , k , ir Ii|IraIitt
1 ist ast , M | 1 a t It starrir ] t r 1 | M
J ist| t m ia taa st s sIiIIr t ss t I |V | t taa st rt |ataIit r t I m t tar1 ia m is
atIitt ar 1 rt | a irt s t r t r]Ik |
ir trt ast 1 |V Ii||ir ] j rt ssa rt s j rt 1 a tt tt r t a s tt r ]t sIit r a j sIrt am
it . j a |m t r it ar 1 ssIt m it tt r t a s tt r ]t sIit r
J 1 iasIt |it 1 sIa r tIit r m a |t a1 It ssIt |it 1 sIa r tIit r | t r
tt m j t r saIt r rt sj t r st s t I 1 i|aIaIit r I| j t rIrt j | |t a1 It
1 t trt ast 1 | |
t|a t s It 1 ia]r t sis. \, 1 K , |V1 t r | | | I| | 1 1 , r t rm a| | |
Irt aIm t r I. | t Ia | |t t|t rs, tt raj am i| t r 1 i|Iiatt m
Table 10. Signs and Symptoms of L vs . R He art Failure
Le ft Failure Right Failure
low cardiac out put IaIi ]a t 1 sj r t a
(forward) sr tt j t Iri ta sj i 1 rt ]a r]i IaIi t r
ssIt m i t | j t It r si t r 1
tt t | t tIrt m i Ii t s
s|t taj i ||ar rt Ii ||
j t ri j | t ra| tar t si s
m i Ira| rt ]a r]i IaIi t r
| | t r t - It |t s | rt aI| i r ]
j a |sa s a|It rr ar s
1
ve nous conge s t ion 1 sj r t a j t ri j | t ra| t 1 t m a
(backward) t rI| t j r t a | t j aIt m t ]a|
| K | | t j aIi t It r 1 t rr t ss
| asa| trat||t s j a |saIi |t |i tt r
tt a ]| t |t taIt 1 !V|
| t m t j Isi s j t si Ii tt 1 !|
\ | a ssm aa | s si ]r
\
SLEEP-DISORDERED BREATHING
J \!-!!X t I j aIit r Is iI| | 1 | ssIt |it ar 1 1 iasIt |it | t arI Iai|a rt
| att s|t t j 1 isIa r| ar tt s, | it| ir t|a 1 t | | t r t - It |t s | rt aI| ir ],
tt r Ira| ar 1 t | sIra tIitt s|t t j aj r t a
J asst tiaIt 1 iI| a t rst j rt ]r t sis ar 1 ]rt aIt r |V 1 sIa r tIit r
J r asa| tt r Iir a t a s j t siIitt aira j rt ssa rt | |k| is t IIt tIitt ir
Irt aIir ] | | t r t - It |t s rt sj iraIit r Is|t t j aj r t a iI| im j rt tt m t r I ir
tar1 iat Ia r tIit r ar 1 sm j It m s
HIGH-OUTPUT HEART FAILURE
J a tarit I t I IatIt rs m a trt aIt a siIa aIit r t I rt |aIitt | t arI Iai|a rt |
1 t m ar 1 ir ] a ]rt aIt r I| ar r t rm a| tar1 iat t a Ij a I It r a tarit I t I rt ast r s
J rart | taa st s | t arI Iai|a rt ir iIst |I | a I t IIt r t tatt r| aIt s t tisIir ] | t arI
Iai|a rt t r j a Is a j aIit r I iI| t I| t r tar1 iat j aI| t |t ] t tt r I| t t 1 ]t
J 1 iIIt rt r Iia| 1 ia]r t sis ir t|a 1 t s ar t m ia, I| iam ir t 1 t Iitit r t,
| j t rI| rt i1 ism , k-V IisIa |a, | a]t Is 1 ist ast
| ar1 i t |t ] 1I M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
HEART FAILURE . . . CONT.
INVESTIGATIONS
J t r| a j ir tt |tt s asst ssm t r I It r j rt tij iIaIir ] IatIt rs ar 1 Irt aIa| |t
taa st s t I | 1 |
J | |t t 1 t r|
| | |
|It s
1 i|a Iit r a| | j t r aIrt m ia ir 1 itaIt s t r 1 -sIa]t | 1 |
si]r t I r t a rt | t rm t r a| atIitaIit r ar 1 j t t rt r j rt ]r t sis
| j t |a|t m ia st tt r 1 ar It | i]| rt r ir sIaIt
| | K , | r
m a | t t |t taIt 1 1 a t It j rt rt r a| ir sa |I
| t ar t I k K iI| 1 ia rt Iit I| t raj
J | | |
t| am | t r t r |ar]t m t r I
a| r t rm a| r| I| m s
ist| t m iaIir IartIit r
J t| t sI t-ra
si]r s t I j a |m t r ar tt r ]t sIit r
j t ri| rt r t| it |ar ta IIir ]
tasta |ar rt 1 isIri| a Iit r
| t r|t | | ir t s
ir It rsIiIia| j aIIt rr
a|tt t |ar Ii||ir ] iI ]rt ss j a |m t r ar t 1 t m a
a|st |t t | It r
tar1 it m t ]a| | I - 1.!
aIria| t r |ar]t m t r I
j t ritar1 ia| t IIa sit r
j |t a ra| t IIa sit r
J t t| t tar1 it ]raj | is I| t j rim ar 1 ia]r t sIit m t I| t 1 It 1 t It rm ir t
t }t tIit r IratIit r |V | ra1 t | | | t1X , || \1-!1X , ||| I -11X , |V I1X
aIria| t r tt r Irita |ar 1 im t r sit r s
a|| m t Iit r a| r t rm a|iIit s
ta|ta |ar sIt r t sis t r rt ]a r]iIaIit r
j t ritar1 ia| t IIa sit r
J ra1 it r a t|i1 t ar ]it ]raj | M | | k j rt ti1 t s m t rt atta raIt t }t tIit r
IratIit r m t asa rt m t r Is I| ar t t| t tar1 it ]raj | , | t t tt r, iI j rt ti1 t s
|iII|t ir It rm aIit r t r ta|ta |ar a| r t rm a|iIit s
J m t tar1 ia| j t rIa sit r stir Ii]raj | | a||ia m t r t sIam i| i | | |
1 t It rm ir t s art as t I Ii| rt sisIir IartI t r tia| i|iI
J ar ]it ]ram ir st |t tIt 1 j aIit r Is
MANAGEMENT
J s| t rI It rm ]t a|s t I I| t raj art It rt |it tt sm j It m s ar 1
im j rt tt I| t | a a|iI t I |iIt
J |t r ] It rm ]t a| is It j rt |t r ] |iIt | s|t ir ], | a|Iir ],
t r rt tt rsir ] I| t j rt ]rt ssitt |V 1 sIa r tIit r
J Irt aI I| t taa st Ia]]rataIir ] IatIt rs
J sm j It m aIit m t asa rt s
t t]t r , | t 1 rt sI
J tt r Irt | t I st 1 ia m ar 1 I|a i1 rt It r Iit r
st 1 ia m rt sIritIit r I ]m , rt | a irt s j aIit r I t 1 a taIit r
I|a i1 rt sIritIit r ar 1 m t r iIt r 1 ai| t i]| Is
1 ia rt Iits r t t IIt tI t r m t rIa|iI ar 1 j a rt | sm j It m aIit
t ttt j I sj irr t |atIt r t | a|t s sIa 1
I| iati1 t s It r m i|1 | t arI Iai|a rt
Ia rt st m i1 t It r j t It r I 1 ia rt sis
m t Ia|t tt r t m a | t a st 1 iI| Ia rt st m i1 t It ir trt ast 1 ia rt sis
J tast 1 i|aIt rs
]t a| is It arIt rit 1 i|aIt 1 t trt ast aIIt r|t a1 ar 1
tt r t 1 i|aIt 1 t trt ast j rt |t a1 , I| t rt | im j rt tir ]
ssIt |it Ia r tIit r ar 1 tt r t a s tt r ]t sIit r
ir | t sj iIa|, m t r iIt r rt sj t r st It I| t raj iI|
1 ai| t i]| Is ar 1 m t asa rt m t r I t I I|a i1 | a|ar tt ar 1
It ||t rt r a| Ia r tIit r
k| | ir | i| iIt rs. sIar 1 ar1 t I tart im j rt tt s sa rtita|
sIrt r ]| rt tt m m t r 1 t 1 It r
a|| sm j It m aIit j aIit r Is
a|| asm j It m aIit j aIit r Is iI| |V| | - 1!X
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 11
K t It s
HEART FAILURE . . . CONT.
j t sI-M | st IIir ] iI
sm j It m aIit | t arI Iai|a rt
asm j It m aIit |V| | - \1X
ar It rit r M |
t|t ar| s| t r It 1 t trt ast m t rIa|iI ar 1
s|t j rt ]rt ssit r ir I| t st st IIir ]s
| 1 ra|atir t ar 1 r iIraIt s
st tt r 1 |ir t It k| | ir | i| iIt rs
1 t trt ast ir m t rIa|iI r t I as ]rt aI as iI| k| | ir | i| iIt rs
am |t 1 ij ir t
m a | t t I | t r t IiI ir 1 i|aIt 1 tar1 it m t j aI|
ar ]it It r sir || rt tt j It r | |t t|t rs t .]. |t sarIar
j rt |im ir ar t ti1 t r tt sa ]]t sIs | t r t IiI
J ir t Irt j it sa j j t rI
1 i]iIa|is
im j rt tt s sm j It m s ar 1 1 t trt ast s
| t sj iIa|itaIit r s | || Iria|
r t im j atI t r sa rtita|
t ttt ||t r I t| t itt ir st IIir ] | 1 | iI| aIria|
Ii| ri||aIit r
sm j aI| t m im t Iits
j t It r I a]t r Is a st 1 ir || | I| | | st IIir ]s
1 t j am ir t
|t -1 t st taa st s st |t tIitt
rt r a| tast 1 i|aIit r
m t 1 ia m -1 t st j rt ti1 t s ir t Irt j it sa j j t rI
| i]| -1 t st ir trt ast s ssIt m it tasta |ar
rt sisIar tt , | it| ir m t sI tast s is a r 1 t sira| |t
1 t | a Iam ir t
st |t tIitt ir t Irt j it a]t r I
a|st j rt 1 a tt s arIt ria| tast 1 i|aIit r
j | t sj | t 1 it sIt rast ir | i| iIt rs
t IIt tIs sim i|ar It 1 t | a Iam ir t
a1 tt rst t IIt tI t r sa rtita| | t r a st 1 as t ra|
a]t r I | | 1 M | | sIa 1
J t I| t r a]t r Is
| t Ia-| |t t|t rs - rt tt m m t r 1 t 1 It r | | ||-||| j aIit r Is
s| t a |1 | t a st 1 taa Iit a s|, IiIraIt s|t |
| t taa st m a ir iIia|| t rst r | 1 |
j t sIa |aIt 1 I| aI I| t st a]t r Is ir It rIt rt iI|
r t a rt | t rm t r a| atIitaIit r
tartt 1 i|t | tt r It rs sa rtita| | t r t IiI ir Ia r tIit r a|
t|ass ||-||| | 1 |
m t It j rt |t | | as | t t r s| t r It 1 t |a Iim t It
Irar sj |ar I, rt 1 a tt | t sj iIa|itaIit r s ir 1 i|aIt 1
tar1 it m t j aI| ar 1 It 1 t trt ast m t rIa|iI M | | | sIa 1
ta|tia m t| ar r t | | |t t|t rs | att t | a itt ta| t IIt tI t r sa rtita|
ar Iiarr| I| m it, iI rt | a irt 1 I| t r am it 1 art r t is 1 ra ] t I t| t itt
t|ass | ar Ii-arr| I| m its asst tiaIt 1 iI|
ir trt ast 1 m t rIa|iI ir | 1 |
ACUTE CARDIOGENIC PULMONARY EDEMA
De finition
J st tt rt j a |m t r ar tt r ]t sIit r |t a1 ir ] It t tIratasaIit r t I taj i||ar
I|a i1 ir It a|tt t |ar sj att
Clinical Manife s tations
J Iat| tar1 ia, Iat| j r t a, 1 iaj | t rt sis
J st tt rt |t II-si1 t 1 tt r t a s tt r ]t sIit r
Manage me nt, us e mne monic "LMNOP"
J m a|t sa rt It Irt aI ar ata It j rt tij iIaIir ] IatIt rs t .]. ist| t m ia, arr| I| m ias
J siI j aIit r I a j iI| |t ]s | ar ]ir ] 1 t r iI | |t t 1 j rt ssa rt is a1 t | a aIt
J | asit - Ia rt st m i1 t \1 m ] |V, 1 t a | |t 1 t st | | as r t tt ssar
J M t rj | ir t I-\ m ] |V | !- 1 m ir a It s
1 t trt ast s ar tit I
tast 1 i|aIit r
| ar1 i t |t ] 1\ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
HEART FAILURE . . . CONT.
J K iIrt ]|tt rir t It j ita| I ir t| t s | I| t r |V r iIrt ]|tt rir t
J 1 t]t r
J | t siIitt aira j rt ssa rt
| |k| t r | i|k| 1 t trt ast r t t 1 It r tt r Ii|aIit r
J t I| t r tast 1 i|aIt rs as r t tt ssar ir || | st IIir ]
r iIrt j ra ssi1 t |V
| 1 ra|atir t | 1
J ir t Irt j it sa j j t rI
J tt r si1 t r |k |ir t It m t r iIt r taj i||ar t 1 ]t j rt ssa rt
J tt r si1 t r m t t| ar ita| tt r Ii|aIit r iI r t t 1 t 1
J rart | a st 1 | a I j t It r Iia|| |iIt -satir ] m t asa rt s
rt IaIir ] It a rr i| a t Is
j | |t | t It m
CARDIAC TRANSPLANTATION
J ir 1 itaIit r s - t r 1 sIa]t tar1 iat 1 ist ast | k| , | | M , t It...
Iai|a rt t I m atim a| m t 1 ita|Isa r]ita| I| t raj
j t t r t m t r I| j rt ]r t sis
a| st r tt t I tt r Irair 1 itaIit r s
a| i|iI It tt m j rt | t r 1 ar 1 tt m j | iI| I| t raj
J t ar sa rtita| !X, ! t ar sa rtita| I1X
J tt m j |itaIit r s. rt }t tIit r , ir It tIit r , ]raII tasta |ar 1 ist ast , m a|i]r ar t
CARDIOMYOPATHIES
De finition
J 1 ist ast t I I| t m t tar1 ia m r t I st tt r 1 ar It tt rt r ar arIt r 1 ist ast ,
ta|ta |ar | t arI 1 ist ast , tt r ]t r iIa| | t arI 1 ist ast , | j t rIt r sit r t r
j t ritar1 ia| 1 ist ast
J 1 ia]r t sis t I ar t I I| t It ||t ir ] tt r 1 iIit r s m ar 1 aIt s t tt|a sit r t I
I| t a| t tt tt r 1 iIit r s
J 1 i|aIt 1 tar1 it m t j aI|
J | j t rIrt j | it tar1 it m t j aI|
J rt sIritIitt tar1 it m t j aI|
J m t tar1 iIis
DILATED CARDIOMYOPATHY
Etiology
J i1 it j aI| it
J j t ri-j arIa m
J ir I|am m aIt r
J ir It tIit a s
j t sI-tira| | t tsat|it , | | a]as, t It...
J r t r -ir It tIit a s
tt ||a]t r tasta |ar 1 ist ast
J r t a rt m a sta |ar 1 ist ast - t .]. | a t| t r r t
J It tit - a|tt | t |it, a1 riam tir , tt tair t , | t rt ir , t r]ar it st |tt r Is, ]|a t sr iIIt rs | t arI
J m t Ia| t |it
J r a IriIit r a|
I| iam ir t 1 t Iitit r t, st |t r ia m 1 t Iitit r t, tarr iIir t 1 t Iitit r t
J t r 1 t trir t - t .]. I| rt It titt sis, | M
J Iam i|ia|
J ra1 iaIit r
Pathophys iology
J im j airt 1 tt r IratIi|t Ia r tIit r t I I| t m t tar1 ia m - j rt ]rt ssitt
tar1 iat 1 i|aIaIit r ar 1 t tt r Ia a||, 1 t trt ast 1 t }t tIit r IratIit r
J t|ir ita| m ar iIt sIaIit r s
| 1 |
ssIt m it t r j a |m t r ar t m | t |i
arr| I| m ias
sa 1 1 t r 1 t aI|
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1!
K t It s
CARDIOMYOPATHIES . . . CONT.
Inve s tigations
J I |t a1 | | |
- att a| r t rm a|iIit s
tt r 1 a tIit r 1 t It tIs
arr| I| m ias
J t| t sI t-ra
]|t | a| tar1 it m t ]a|
si]r s t I | t arI Iai|a rt
J t t| t tar1 it ]raj |
\-t| am | t r t r |ar]t m t r I
1 t j rt sst 1 t }t tIit r IratIit r
m iIra| ar 1 Irita sj i1 rt ]a r]iIaIit r st tt r 1 ar It tar1 iat 1 i|aIaIit r
J t r 1 t m t tar1 ia| | it j s. r t I rt a Iir t , m a | t |j 1 ia]r t st ir Ii|IraIitt
1 ist ast t r m t tar1 iIis
J ar ]it ]raj | . st |t tIt 1 j aIit r Is - iI tar1 iat ris| IatIt rs It rIt | k|
Natural His tory
J j rt ]r t sis
1 t j t r 1 s t r t Iit |t ]
]t r t ra|| ir t tt ra| |t j rt ]rt ssit r
t tt ra|| t r tt | 1 | - !1X ! t ar sa rtita|
taa st t I 1 t aI| a sa a|| | 1 | t r sa 1 1 t r 1 t aI|
ssIt m it t m | t |i art si]r iIitar I st a rtt t I m t r| i1 iI
Manage me nt
J Irt aI a r 1 t r|ir ] 1 ist ast - t .]. a| sIir t r tt Irt m | I1 1
J Irt aI | 1 | st t 1 t arI | ai|a rt t tIit r
J ar Iitt a]a |aIit r It j rt tt r I I| rt m | t t m | t |ism
a| st |a It - k|, | isIt r t I I| rt m | t t m | t |ism t r 1 t ta m t r It 1 I| rt m | a s
t|ir ita| j ratIitt is It ar Iitt a]a |aIt iI | | - I1X
J Irt aI sm j It m aIit t r st rit a s arr| I| m ias
J im m a r itt a]air sI ir I|a t r ta ar 1 j r t a m t tt tta s
J sa r]ita| I| t raj
tar1 iat Irar sj |ar I - t sIa| |is| t 1 I| t raj
tt |a m t rt 1 a tIit r sa r]t r rt |t rt m air s a r t|t ar
tar1 it m t j |asI |aIissim a s 1 t rsi raj
|Vk|
HYPERTROPHIC CARDIOMYOPATHY
J a|st |r t r as | j t rIrt j | it t | sIra tIitt tar1 it m t j aI| 1 1 | M ar 1
i1 it j aI| it | j t rIrt j | it sa | at rIit sIt r t sis |1
J issa t s art t | sIra tIit r , arr| I| m ia, 1 iasIt |it 1 sIa r tIit r
Pathophys iology
J sm m t Irita| t r asm m t Irita| | j t rIrt j | t I I| t m t tar1 ia m t iI| t r.
J r t r -t | sIra tIitt
sm j It m s st tt r 1 ar It 1 t trt ast 1 tt m j |iar tt ar 1 im j airt 1 1 iasIt |it Ii||ir ]
J t | sIra tIitt |aIt r I | rt a ]| I t r | j rt tt taIitt It sIir ] t r rt sIir ]
sm j It m s st tt r 1 ar It 1 r am it tt r Irita |ar t a II|t t | sIra tIit r
1 im ir is| ir ] tar1 iat t a Ij a I
J t|ir ita| m ar iIt sIaIit r s
asm j It m aIit
1 sj r t a 11X - st tt r 1 ar It 1 iasIt |it 1 sIa r tIit r
tar1 iat ist| t m ia
j rt sr tt j t , sr tt j t - t | sIra tIit r t r arr| I| m it
| 1 |
arr| I| m ias
sa 1 1 t r 1 t aI| m a | t IirsI m ar iIt sIaIit r
Hallmark Signs of HCM
J j a |st s
raj i1 a j sIrt |t j a |st
| iIi1 t r | isIt rit r s j a |st
J j rt tt r1 ia| j a|j aIit r
|t ta|itt 1 , sa sIair t 1 , 1 t a | |t IIrij |t im j a |st aj t t | t aI
| ar1 i t |t ] 1t M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
CARDIOMYOPATHIES . . . CONT.
J j rt tt r1 ia| aa sta |IaIit r
r t rm a| t r j ara1 t tita| I iI st tt rt t | sIra tIit r
\
| ars| , ssIt |it, 1 iam t r 1 -s| aj t 1 m a rm a r aI | | | t r aj t t
J I m a rm a r t I M |
m ar t a tt rs st t Ia| |t | t |t
Factors Influe ncing Obs truction
J I| t st ir t|a 1 t ar IatIt rs I| aI
ir trt ast tt r Irita |ar tt r IratIi|iI
1 t trt ast j rt |t a1
1 t trt ast aIIt r|t a1
Table 11. Factors Influe ncing Obs truction in Hype rtrophic
Cardiomyopathy
Incre as e d Obs t ruct ion De cre as e d Obs t ruct ion
(incre as e murmur) (de cre as e murmur)
i r t Irt j t s, tast 1 i |aIt rs, 1 i a rt Ii ts r t ]aIi tt i r t Irt j t s
| j t tt |t m i a tast tt r sIri tIt rs
Iat| tar1 i a tt |a m t t tj ar si t r
sIar 1 i r ] | ra1 tar1 i a
ta|sa|ta m ar t a trt s| a aIIi r ]
sa sIai r t 1 | ar 1 ]ri j
Inve s tigations
J I |t a1 | | |
|V1
att s ir ar It rt |aIt ra| ar 1 ir It rit r |t a1 s
J t t| t tar1 it ]raj |
|V1 - tt r tt r Irit t r asm m t Irit st j Ia| | j t rIrt j |
ssIt |it ar It rit r m t Iit r t I ar It rit r M V |t aI|t I kM
rt sIir ] t r 1 r am it tt r Irita |ar t a II|t IratI t | sIra tIit r
1 iasIt |it 1 sIa r tIit r
I M |
| k|
J tar1 iat taI| t It ritaIit r
ir trt ast 1 |t II tt r Irita |ar t r 1 -1 iasIt |it j rt ssa rt
taria| |t ssIt |it ]ra1 it r I atrt ss |V t a II|t IratI
Natural His tory
J taria| |t , st m t im j rt tt ar 1 sIa| i|itt t tt r Iim t | i|t t I| t rs sa IIt r
Irt m st m t t I I| t tt m j |itaIit r s
J k|, || - 1X , |V Iai|a rt 1- !X , sa 1 1 t r 1 t aI| taa st t I !1X t I a||
m t rIa|iI Irt m 1 | M
J ris| IatIt rs It r sa 1 1 t r 1 t aI|
m t sI rt |ia| |t
t a r ] a]t - 11 aI 1 ia]r t sis
Iam i| | isIt r
]t r t Iit a| r t rm a|iIit s asst tiaIt 1 iI| ar ir trt ast 1 ris|
|t ss t|t ar
sr tt j t t m ir t a s ir t| i|1 rt r , |t ss st ir a1 a |Is
tt r Irita |ar Iat| tar1 ia t r am | a |aIt r m t r iIt rir ]
m ar|t 1 tt r Irita |ar | j t rIrt j |
j rt tt r Iit r t I sa 1 1 t r 1 t aI| ir | i]| ris| j aIit r Is
= am it 1 art r t t r || |
Manage me nt
J sa j j t rIitt tart
J att i1 IatIt rs | it| ir trt ast t | sIra tIit r
J att i1 sIrt r a t a s t tt rtist ]a i1 t |ir t s t tisI
J Irt aI arr| I| m ias
J || j rt j | |atis
J t | sIra tIit r
| t Ia-| |t t|t rs, tt raj am i|, t r 1 i|Iiatt m taa Iit r iI |ar]t t a II|t
]ra1 it r I t r tt r | i]| j a |m t r ar j rt ssa rt K 1 | . I| t st
I| t raj it s 1 t K 1 aj j t ar It aIIt tI sa 1 1 t r 1 t aI|
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 1I
K t It s
CARDIOMYOPATHIES . . . CONT.
J tt r si1 t r sa r]ita| t j Iit r s m t It m - m t tIt m , M V rt j |att m t r I
J 1 a a| t| am | t r j atir ] - It 1 t trt ast t | sIra tIit r
J arr| I| m ias - am it 1 art r t I || |
RESTRICTIVE CARDIOMYOPATHY
Etiology
J ir Ii|IraIitt
am |t i1 t sisIsartt i1 t sis
J r t r -ir Ii|IraIitt
st|t rt 1 t rm a, i1 it j aI| it m t tar1 ia| Ii| rt sis
J It ra]t 1 ist ast s
| t m t t| rt m aIt sis, | a| rs 1 ist ast
J t r 1 t m t tar1 ia|
t r 1 t m t tar1 ia| Ii| rt sis
J | t t II|t rs t r 1 t tar1 iIis t r t t sir t j | i|it t r 1 t m t tar1 ia| 1 ist ast
J ra1 iaIit r | t arI 1 ist ast
Pathophys iology
J ir Ii|IraIit r t I I| t m t tar1 ia m - 1 t trt ast 1 tt r Irita |ar tt m j |iar tt
- 1 iasIt |it 1 sIa r tIit r
J t|ir ita| m ar iIt sIaIit r s
| 1 | - 1 iasIt |it 1 sIa r tIit r j rt 1 t m ir aIt s
arr| I| m ias
ssIt m it ar 1 j a |m t r ar t m | t |ism
Inve s tigations
J I |t a1 | | |
|t tt |Ia]t
r t r -sj t tiIit - att t| ar ]t s
J t| t sI t-ra
m i|1 tar1 iat t r |ar]t m t r I
J t t| t tar1 it ]raj |
r t rm a| t r t r | s|i]| I| 1 t trt ast 1 ssIt |it Ia r tIit r , 1 iasIt |it 1 sIa r tIit r
J tar1 iat taI| t It ritaIit r
t |t taIt 1 t r 1 -1 iasIt |it tt r Irita |ar j rt ssa rt s
Natural His tory
J 1 t j t r 1 s t r t Iit |t ]
J ]t r t ra|| j t t r j rt ]r t sis. m t sI 1 it iI| ir a It t ars, a sa a|| 1 a t It
st tt rt | 1 |
Manage me nt
J t tt|a 1 t tt r sIritIitt j t ritar1 iIis
J Irt aI a r 1 t r|ir ] 1 ist ast
J sa j j t rIitt tart
J Irt aI | 1 |
J Irt aI arr| I| m ias
J ar Iitt a]a |aIit r
J tt r si1 t r tar1 iat Irar sj |ar IaIit r - 1 t j t r 1 ir ] t r t Iit |t ]
MYOCARDITIS
J ir I|am m aIt r j rt tt ss ir tt |tir ] I| t m t tar1 ia m ar im j t rIar I taa st
t I 1 i|aIt 1 tar1 it m t j aI|
Etiology
J i1 it j aI| it
J ir It tIit a s
tira|. | t tsat|it tira s | , t t| t tira s, j t |it tira s, 1 |V, m a m j s
| atIt ria|. . aureus, C. perfringens, C. diphtheriae, M tt j |asm a
Ia r ]i
sj irt t| t Ia|
|m t tar1 iIis
| | a]as 1 ist ast , It tt j |asm t sis
J ata It r| t a m aIit It tt r
J 1 ra ]-ir 1 a tt 1 . t m t Iir t , 1 t tt ra | itir
J tt ||a]t r tasta |ar 1 ist ast
J sartt i1 t sis
| ar1 i t |t ] 1 M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
CARDIOMYOPATHIES . . . CONT.
Clinical Manife s tations
J tt r sIiIa Iit r a| i||r t ss
J ata It | 1 |
J t| t sI j air - asst tiaIt 1 j t ritar1 iIis t r tar1 iat ist| t m ia
J arr| I| m ias
J ssIt m it t r j a |m t r ar t m | t |i
J sa 1 1 t r 1 t aI|
Inve s tigations
J I |t a1 | | |
r t r -sj t tiIit - t| ar ]t s I tt r 1 a tIit r 1 t It tIs
J | |t t 1 t r|
ir trt ast 1 | | , | | 1 , ar 1 k iI| ata It m t tar1 ia| r t trt sis
I ir trt ast 1 w| | , | |
J j t rIt rm | |t t 1 ta |Ia rt , tira| IiIrt s ar 1 tt |1 a]]|a Iir ir s It r m tt j |asm a
J t| t sI t-ra
t r |ar]t 1 tar1 iat si|| t a t IIt
J t t| t tar1 it ]raj |
1 i|aIt 1 , | j t |ir t Iit t| am | t rs
st ]m t r Ia| a|| m t Iit r a| r t rm a|iIit s
Natural His tory
J a sa a|| st |I-|im iIt 1 ar 1 t IIt r a r rt tt ]r itt 1
J m t sI rt tt tt r
J m a | t Ia |m ir ar I iI| 1 t aI| ir I\-\ | t a rs
J sa 1 1 t r 1 t aI| ir t a r ] a1 a |Is
J m a j rt ]rt ss It 1 i|aIt 1 tar1 it m t j aI|
J It m a | att rt ta rrt r I t r t| rt r it m t tar1 iIis
Manage me nt
J sa j j t rIitt tart
J rt sIritI j | sita| atIitiI
J Irt aI | 1 |
J Irt aI arr| I| m ias
J ar Iitt a]a |aIit r
J Irt aI a r 1 t r|ir ] taa st iI j t ssi| |t
VALVULAR HEART DISEASE
INFECTIVE ENDOCARDITIS
Etiology
J Streptococcusviridans tt m m t r t sI
J Enterococcus
J . aureus |V 1 ra ] a| a st rs, taI| t It r-asst tiaIt 1 st j sis
J Staphylococcusepidermidis j rt sI| t Iit ta|tt
J Strepbovis
a r 1 t r|ir ] | | m a|i]r ar t
J t I| t rs. ]ram -r t ]aIitt | atIt ria, | ar 1 i1 a, 1 att | t r]ar ism s
J Irt | a t r t t I ta|tt ir tt |tt m t r I. M V - - kt V - V - | V
J ris| t I || ir tarit a s tar1 iat |t sit r s JAMA 1997;227:1794)
| i]| ris|. j rt sI| t Iit | t arI ta|tt s, j rt tit a s || , tt m j |t t
tar t Iit tt r ]t r iIa| | t arI 1 ist ast , sa r]ita|| tt r sIra tIt 1
ssIt m it It j a |m t r ar s| a r Is t r tt r 1 a iIs
m t 1 t raIt ris|. m t sI t I| t r tt r ]t r iIa| tar1 iat m a|It rm aIit r s,
at| a irt 1 ta|ta |ar 1 sIa r tIit r , 1 | M , M V| iI| M | ar 1 It r
I| it|t r t 1 |t aI|t Is
Pathoge ne s is and Symptomatology
J a sa a|| rt | a irt s st a rtt t I ir It tIit r , a r 1 t r|ir ] ta|tt |t sit r , I
ssIt m it 1 ist ast Iim m a r t tt m j rt m ist
J j t rIa| t I t r Ir. t rt j | arr t, s|ir , | | , 1 ra ] a| a st , r t st tt m ia|
ir It tIit r - | atIt rt m ia - 1 ist ast 1 ta|tt I| i]| I|t atrt ss ta|tt
- Ia r| a |t r tt t I | |t t 1 atrt ss ta|tt - 1 t j t siIit r t I | atIt ria t r
t r 1 t tar1 ia| sa rIatt t I ta|tt - t r 1 t tar1 iIis
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] 11
K t It s
VALVULAR HEART DISEASE . . . CONT.
J sm j It m s
It tt r, t| i||s, ri]t rs
r i]| I st aIs
I|a -|i|t i||r t ss, m a|aist , 1 Ik, m a|]ia, arI| ra|]ia
1 sj r t a, t| t sI j air
Signs
J t|assit Iria1 = It tt r, m a rm a r r t t r t| ar ]ir ] , ar t m ia
J si]r s t I 1 |
J j t It t| iat , rt Iir a| | t I| sj t Is, 1 s|t rs r t 1 t s t a t| | raist 1 , j air Ia |,
1- ! m m , st |t sIj a|m s , !ar t a |t sit r s j air aa| I|aI, j air |t ss,
aj j rt t. -I tm , t r st |t sIj |ar Iar sa rIatt s t I It t sIj a|m sIIir ]t rs ,
sj |ir It r | t m t rr| a]t s a|st st t r iI| |t ta| Iraa m a
J It ta| r t a rt |t ]ita| si]r s | K t m | t |i
J arI| riIis
J t|a | | ir ] sa | ata It
J sj |t r t m t ]a| sa | ata It
J m itrt stt j it | t m aIa ria rt r a| t m | t |i t r ]|t m t ra |t r t j | riIis
J t i]| I |t ss
Inve s tigations
J | |t t 1 t r| - ar t m ia, ir trt ast 1 | | , j t siIitt r| t a m aIt i1 IatIt r
J st ria| | |t t 1 ta |Ia rt s 1 t Iir iIitt 1 ia]r t sis
J t t| t tar1 it ]raj | Irar st st j | a]t a| - st r siIitiI I| ar Irar sI| t ratit
tt ]t IaIit r s, ta|tt |t aI|t I ra j Ia rt , t| t r1 a| ra j Ia rt , a| stt ss
st ria| | | 1 1 m a | t |j ir asst ssir ] tar1 iat Ia r tIit r
j t rsisIt r tt t r 1 isaj j t arar tt t I tt ]t IaIit r s is r t I a rt |ia| |t
ir 1 itaIit r t I sa ttt ss t r Iai|a rt
Natural His tory
J a1 tt rst j rt ]r t sIit IatIt rs
| 1 |, | ram t r Ia r ]a| ir It tIit r , j rt sI| t Iit ta|tt ir It tIit r ,
a| stt ss ir ta|tt rir ] t r m t tar1 ia m , t |1 t r|, rt r a| Iai|a rt ,
ta |Ia rt r t ]aIitt ||
J m t rIa|iI a j It 11X
J rt |aj st s m a t tta r - It ||t -a j is m ar 1 aIt r
J j t rm ar t r I ris| t I rt -ir It tIit r aIIt r ta rt 1 a t It rt si1 a a| ta|tt starrir ]
Complications
J | 1 | a sa a|| 1 a t It ta|ta |ar ir sa IIitit r t
J ssIt m it t m | t |i
J m tt Iit ar t a rsm It rm aIit r
J ir Iratar1 iat a| stt ss It rm aIit r |t a1 ir ] It | t arI | |t t|
J rt r a| Iai|a rt . ]|t m t ra |t r t j | riIis 1 a t It im m a r t tt m j |t t 1 t j t siIit r , It titiI t I ar Ii| it Iits
Manage me nt
J m t 1 ita|
ar Ii| it Iit I| t raj Iai|t rt 1 It ta |Ia rt s j t r iti||ir , ]t r Iam itir ,
tar tt m tir , t|t tati||ir m ir im a m t I \ t t |s Irt aIm t r I
j rt j | |atis !kM k 11I,III. I1\
1 t r Ia|It ra|Irt sj iraIt rIt st j | a]t a| j rt tt 1 a rt s
am t titi||ir I ] | t a r j rit r
| | I| | t tt|a 1 ir ] t st j | a]t a| j rt tt 1 a rt s
| i]| ris|. am j iti||ir ]t r Iam itir
m t 1 t raIt ris|. am t titi||ir , am j iti||ir , t r tar tt m tir
J sa r]ita|
ir 1 itaIit r s. rt IratIt r | 1 |, ta|tt rir ] a| stt ss, ta|ta |ar
t | sIra tIit r , a r sIa| |t j rt sI| t sis, m a |Iij |t m a}t r t m | t |i,
ar Iim itrt | ia| Iai|a rt , sj |t r it a| stt ss, m tt Iit ar t a rsm
RHEUMATIC FEVER
J !t r t s triIt ria It r 1 ia]r t sis. I m a}t r, t r m a}t r I m ir t r
m a}t r triIt ria
tar1 iIis
j t |arI| riIis
1 t r | am s t| t rt a
t rI| t m a m ar]ir aIa m
sa | ta Iar t t a s r t 1 a |t s
| ar1 i t |t ] \1 M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
VALVULAR HEART DISEASE . . . CONT.
m ir t r triIt ria
j rt tit a s | isIt r t I r| t a m aIit It tt r t r r| t a m aIit | t arI 1 ist ast
j t |arI| ra|]ia
ir trt ast 1 | | t r | | |
ir trt ast 1 | | ir It rta|
It tt r
tt r Iirm aIit r t I sIrt j It tt tta| ir It tIit r . | isIt r t I star|t I It tt r,
]rt a j k sIrt j It tt tta| j | arr ]iIis ta |Ia rt , 8 ar Ii-sIrt j It |sir 1 iIt rs
J m ar a]t m t r I. | t 1 rt sI, k k, | t r taI| ir t j t r iti||ir | .I M | |M
J j rt j | |atis a]t - \1 . | t r taI| ir t j t r iti||ir | .I M | |M m t r I| |
AORTIC STENOSIS
Etiology
J tt r ]t r iIa| | ita sj i1 - a r ita sj i1 - ta|tiIit 1 t ]t r t raIit r t r tt r ]t r iIa| k
J at| a irt 1
1 t ]t r t raIitt ta|tiIit k m t sI tt m m t r - t ar ar 1 It ar
r| t a m aIit 1 ist ast
Pathophys iology and Symptomatology
J k = r arrt t 1 ta|tt t riIitt at rIit ta|tt art a. r t rm a| = 1-\ tm
I
, st tt rt k
a sa a|| sm j It m aIit = - .1 tm
I
, triIita| k = - 1.I! tm
I
t r
j rt ssa rt ]ra1 it r I - !1 m m 1 ]
J sm a|| t riIitt - t a II|t t | sIra tIit r - Iitt 1 t a Ij a I - It rar1 Iai|a rt
sm j It m s
sr tt j t t sj t tia|| iI| | t at t tt rIit r
IaIi]a t
J sm a|| t riIitt - j rt ssa rt t tt r|t a1 - tt r tt r Irit |V1 Ii| t rs ir
j ara||t | - 8 |V| | |
sm j It m s
1 sj r t a ir iIia|| t tt rIit r a|
| K | It rI| t j r t a
j t rij | t ra| t 1 t m a | 1 | 1X 1 t tt |t j | V Iai|a rt
J 8|V| | | - 9 sa | t r 1 t tar1 ia| I|t ar 1 8 m t tar1 ia| 1 I 1 t m ar 1
sm j It m s
ar ]ir a
j a|j iIaIit r s
J | |k| . sr tt j t , | 1 |, ar ]ir a
Signs of AS
J j a |st s
aj ita|-tart Ii1 1 t |a
j a |sa s j arta s t I Iar1 a s s|t a j sIrt |t ar 1 |aIt j t a|ir ]
| rat| it -ra1 ia| 1 t |a
I| ri|| t tt r tart Ii1 ar 1 sa j rasIt rr a| r t It|
J j rt tt r1 ia| j a|j aIit r
sa sIair t 1 I 1 iIIa st aj t t | t aI
I j a|j a| |t \
ssIt |it I| ri|| ir Ir 1 | || I a|t r ] | | |
J j rt tt r1 ia| aa sta |IaIit r
| M - 1 iam t r 1 s| aj t 1 trt stt r 1 t -1 t trt stt r 1 t , j t a|s
j rt ]rt ssitt | |aIt r ir ssIt |t iI| t rst r ir ] k , ir It r siI r t I
rt |aIt 1 It st tt riI, ra1 iaIt s It r t t|, m a sita|
| a a|iI t I m a rm a r aI aj t t | a||atar1 ir t IIt tI
I 1 iasIt |it m a rm a r t I asst tiaIt 1 m i|1 k|
I - j ara1 t tita| sj |iIIir ] st tt rt k , t r sir ]|t kI a| st r I
t }t tIit r t|it| m t rt tt m m t r ir m i|1 k , a| st r I iI st tt rt
1 - |aIt ir 1 ist ast iI |V 1 i|aIaIit r j rt st r I
\ - t ar| ir 1 ist ast 1 t trt ast 1 |V tt m j |iar tt
Inve s tigations
J I |t a1 | | |
|V1 ar 1 sIrair I | | | | , | k| Ik|
J t| t sI t-ra
j t sI-sIt r t Iit at rIit rt t I 1 i|aIaIit r , ta|tiIit 1 ta|tt , |V1 | k| ,
| 1 | 1 t tt |t j s |aIt r
J t t| t tar1 it ]raj |
]t |1 sIar 1 ar1 It r 1 ia]r t sis
ta|ta |ar art a ar 1 j rt ssa rt ]ra1 it r I asst ss st tt riI t I k
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] \
K t It s
VALVULAR HEART DISEASE . . . CONT.
|V1 ar 1 |V Ia r tIit r
s| t s |t aI|t I a| r t rm a|iIit s ar 1 }t I I|t atrt ss ta|tt
J tar1 iat taI| t It ritaIit r
rIt | k| i.t . t sj t tia|| | t It rt sa r]t r ir I| t st iI| ar ]ir a
ta|ta |ar art a ar 1 j rt ssa rt ]ra1 it r I It r ir tt r t|a sitt | | 1 1
|V| | | ar 1 | 1 r t rm a| a r |t ss asst tiaIt 1 |V 1 sIa r tIit r
Natural His tory
J asm j It m aIit j aIit r Is | att t ttt ||t r I sa rtita| r t ar r t rm a|
J t r tt sm j It m aIit, a r Irt aIt 1 j aIit r Is | att a | i]| m t ar m t rIa|iI
! t ars aIIt r t r st I t I sr tt j t , 1 t ars aIIt r t r st I t I ar ]ir a,
ar 1 - I t ars aIIt r t r st I t I | 1 | I1 sj r t a
J I| t m t sI tt m m t r IaIa| ta|ta |ar |t sit r t ar| m t rIa|iIIsa 1 1 t r 1 t aI|
tt r Irita |ar 1 sr| I| m ias |i|t |it sI taa st t I sa 1 1 t r 1 t aI|
sa 1 1 t r t r st I |V Iai|a rt
J t I| t r tt m j |itaIit r s. || , tt m j |t It | t arI | |t t|
Manage me nt
J asm j It m aIit j aIit r Is - It ||t It r 1 t tt |t j m t r I t I sm j It m s
st ria| t t| t tar1 it ]ram s
sa j j t rIitt Im t 1 ita|
att i1 | t at t tt rIit r
|| j rt j | |atis
att i1 r iIraIt sItast 1 i|aIt rs ir st tt rt k
Irt aI | 1 | st t | 1 | t tIit r
J ir 1 itaIit r s It r sa r]t r
t r st I t I sm j It m s. ar ]ir a, sr tt j t , t r | 1 |
j rt ]rt ssit r t I |V 1 sIa r tIit r
kt V art a - 1. tm
I
asst tiaIt 1 iI| sm j It m s
m t 1 t raIt k iI t I| t r tar1 iat sa r]t r i.t . | k| | rt | a irt 1
J sa r]ita| t j Iit r s
t j t r t r | a||t t r ta|ta |t j |asI
t| i|1 rt r , rt j air j t ssi| |t iI m ir im a| 1 ist ast
a1 a |Is rart . j rt ]r ar t, j a||iaIitt ir j aIit r Is iI|
tt m t r| i1 iI, t r It sIa| i|itt j aIit r I aaiIir ] kV
rt j |att m t r I - !1X rt ta rrt r tt t I k ir t m t r I| s
at rIit ta|tt rt j |att m t r I
t ttt ||t r I |t r ]-It rm rt sa |Is, j rt tt 1 a rt t I t| t itt
tt m j |itaIit r s. |t | 1 , | |t t 1 ir ], tt r 1 a tIit r | |t t|, sIrt |t
AORTIC REGURGITATION
Etiology
J sa j rata|ta |ar at rIit rt t I 1 ist ast iI| 1 i|aIaIit r t I astt r 1 ir ] at rIa
aI| t rt st|t rt Iit 1 i|aIaIit r ar 1 ar t a rsm , tsIit m t 1 ia| r t trt sis
M arIar s sr 1 rt m t , 1 isst tIir ] at rIit ar t a rsm , ssIt m it
| j t rIt r sit r , sj | i|is, tt r r t tIitt Iissa t 1 ist ast s ar ||t sir ]
sj t r 1 |iIis, j st riaIit arI| riIis, | t iIt rs sr 1 rt m t , r| t a m aIt i1
at rIiIis, t It
J ta|ta |ar
tt r ]t r iIa| a| r t rm a|iIit s | ita sj i1 kt V, |ar]t V | , tt r r t tIitt Iissa t
1 ist ast s |a j a s, ar ||t sir ] sj t r 1 |iIis, r| t a m aIt i1 arI| riIis, t It ,
r| t a m aIit It tt r I asst tiaIt 1 k , || , m tt m aIt a s 1 t ]t r t raIit r ,
1 t It rit raIit r t I j rt sI| t Iit ta|tt
J ata It k|
||
at rIit 1 isst tIit r
ata It r| t a m aIit It tt r
Iai|t 1 j rt sI| t Iit ta|tt
Pathophys iology and Symptomatology
J k| = | |t t 1 I|t Irt m at rIa ir It |V 1 iasIt |it ra r -t II
J tt |a m t t tt r|t a1 - |V 1 i|aIaIit r - 8 V ar 1 m t rt 1 iasIt |it
ra r -t II - | i]| | | ar 1 |t | | | i1 t j a |st j rt ssa rt
J |V 1 i|aIaIit r tt m | ir t 1 iI| 8 | | - 8 a|| It r sit r = j rt ssa rt t tt r|t a1 - |V1
sm j It m s
1 sj r t aIt rI| t j r t aI| K |
IaIi]a t ar 1 j a|j iIaIit r s arr| I| m ias t r | j t r1 r am it tirta |aIit r
| ar1 i t |t ] \I M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
VALVULAR HEART DISEASE . . . CONT.
J 9| | | - 9 tt rt r ar j t rIa sit r , |V1 - 8 m t tar1 ia| 1 I 1 t m ar 1
sm j It m s
sr tt j t , ar ]ir a t r | iI st tt rt k|
J a sa a|| sm j It m aIit t r | aIIt r t r st I t I |V Iai|a rt
Signs of chronic AR
J j a |st s
ir trt ast 1 tt |a m t | t a r 1 ir ]Itt ||aj sir ]
1 t M a sst Is si]r - | t a1 | t | | ir ] 1 a t It 8| |
j isIt |-s| t I st a r 1 s t tt r It m t ra| arIt r iI| t a I tt m j rt ssit r
| a rt tit t s m a rm a r - It -ar 1 -Irt m a rm a r t tt r It m t ra| arIt r
iI| |i]| I tt m j rt ssit r
raa | t s si]r - 1 t a | |t st a r 1 | t ar1 iI| I| t sIt I| t stt j t
|i]| I| aj j |it 1 t tt r I| t arIt r
a ir t|t s si]r - j a |saIi|t | |a s| ir ] t I r ai| | t 1 s r t r sj t tiIit
aIt r-| am m t r j a |st - sIrt r ] | a I raj i1 | tt ||aj sir ] j a |st
| t rri]ar s j a |st - tisi| |t tart Ii1 j a |st
1 i||s si]r - It m t ra|-| rat| ia| | | 1 iIIt rt r tt - I1 ]rt aIt r
1 iIIt rt r tt s tt rrt |aIt iI| m t rt st tt rt k|
| isIt rit r s j a |st - Iitt | t aIir ] ir ssIt |t , t sj t tia|| iI k a|st
j rt st r I
t I| t r - j a |saIir ] a ta |a M a ||t r , |itt r | t st r | at| , j a j i|
| ar 1 t |Ii , t r sj |t t r | t r| ar1 I
J j rt tt r1 ia| j a|j aIit r
| j t r1 r am it, 1 isj |att 1 aj t t tt |a m t t tt r|t a1
J j rt tt r1 ia| aa sta |IaIit r
- st II ir st tt rt k| t ar| t|t sa rt t I M V
I - |t a 1 , t r st II st tt rt k| t r iI| ta|tiIitaIit r t I ta|tt
1 ir st tt rt k| t ar| |V 1 t tt m j t r saIit r
1 iasIt |it 1 t trt stt r 1 t m a rm a r - | i]| -j iIt| t 1 , aI | | | ta sj
1 ist ast t r | | | at rIit rt t I 1 ist ast , |t r ]I| tt rrt |aIt s iI|
st tt riI, | t sI | t ar1 iI| j aIit r I |t ar ir ] It rar1
| M - ir at rIit art a, st tt r 1 ar It ir trt ast 1 I|t
ka sIir | |ir I m a rm a r - 1 iasIt |it ra m | |t aI aj t t, st tt r 1 ar It
rt ]a r]iIar I }t I t r ar It rit r M V |t aI|t I
J ata It k| - m t sI t I I| t st si]r s art a| st r I V r t I t I ir trt ast 1
j aIit r I a sa a|| j rt st r Is ir | 1 |, Iat| tar1 ia, st II , st II I,
s| t rI t ar| 1 iasIt |it m a rm a r
Inve s tigations
J I |t a1 | | |
|V1 , | k| j -m iIra|t
J t| t sI t-ra
|V t r |ar]t m t r I, | k| , at rIit rt t I 1 i|aIaIit r
J t t| t tar1 it ]raj |
]t |1 sIar 1 ar1 It r 1 ia]r t sis ar 1 asst ssm t r I t I st tt riI t I k|
rt ]a r]iIar I }t I Irt m at rIa ir It |V, 1 i|aIt 1 |V, at rIit t a I|t I, ar 1 | k
|V tt |a m t t tt r|t a1
I|a IIt rir ] t I ar It rit r M V |t aI|t I
| t j j |t r m t sI st r siIitt
J ra1 it r a t|i1 t im a]ir ]
st ria| rt sIir ] ar 1 t tt rtist | | r t rm a| 8 iI| t tt rtist - !X
st r siIitt si]r t I 9 |V Ia r tIit r . Iai|a rt It 8 | |
iI| t tt rtist
J tar1 iat taI| t It ritaIit r
tt rt r ar ar ]it ]raj | ir 1 itaIt 1 iI a]t - \1
8 |V tt |a m t , | 1 r t rm a| t r 1 t j rt sst 1
|V 1 sIa r tIit r , 8 |V| | |
Natural His tory
J m i|1 It m t 1 t raIt k| - It sm j It m s
J t| rt r it j rt ]rt ssit r It st tt rt k| m a | t asm j It m aIit a j It 1 t ars
J t r tt sm j It m aIit, j rt ]r t sis is m a t| t rst
m t ar m t rIa|iI \ t ars aIIt r t r st I t I ar ]ir a, I t ars aIIt r | 1 |
J st tt rt ata It k| - t r | 1-11X |itt m t rt I| ar t ar aIIt r 1 ia]r t sis
J |aIt tt m j |itaIit r s. arr| I| m ias, | 1 |, ||
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] \1
K t It s
VALVULAR HEART DISEASE . . . CONT.
Manage me nt
J asm j It m aIit
It ||t iI| st ria| | | 1 1 asst ss |V sitt ar 1 Ia r tIit r
I aIIt r|t a1 rt 1 a tIit r . r iIt 1 ij ir t 1 t |as r t t 1 It r sa r]t r
|| j rt j | |atis
J m t 1 ita|
rt sIritIit r t I atIitiIit s
Irt aI | 1 | r t r -j | arm att |t ]it, aIIt r|t a1 rt 1 a tIit r , 1 i]t tir , ar 1 1 ia rt Iits
ata It k| . m a sIa| i|itt iI| |V tast 1 i|aIt rs | t It rt sa r]t r
J sa r]ita|
ata It k| |t a1 ir ] It |V Iai|a rt - | t sI Irt aIt 1 sa r]ita||
t| rt r it st tt rt k| - ir 1 itaIit r s It r sa r]t r ]t r t ra|| t j t raIt
j rit r It t r st I t I irrt tt rsi| |t |V 1 sIa r tIit r
sm j It m aIit j aIit r Is iI| t| rt r it st tt rt k|
j rt ]rt ssit r t I |V 1 i|aIaIit r , t tt r iI asm j It m aIit
tt r si1 t r iI j t t r |V| | - !!X aI rt sI, t r Iai|a rt It ir trt ast | | iI|
t tt rtist iI| st ria| M | | k asst ssm t r I
J sa r]ita| t j Iit r s
ta|tt rt j air rart ir k|
sa | tt m m issa ra| ar r a |t j |asI It r ar r a |ar 1 i|aIaIit r
at rIit ta|tt rt j |att m t r I
| t It rt ]raII, | t m t ]raII, t r st m t Iim t s j a |m t r ar
aa It ]raII | t ss j rt tt 1 a rt ta|tt m a | t a st 1
MITRAL STENOSIS
Etiology
J tt r ]t r iIa| rart
J at| a irt 1
| 1 | m t sI tt m m t r t sj t tia|| 1 t tt |t j ir ] r aIit r s, | - M
t I| t r. aIria| m tt m a, aIria| t r ta|ta |ar I| rt m | a s, t It
Pathophys iology and Symptomatology
J r t rm a| M V art a = \-t tm
I
J M = |V ir |t I t | sIra tIit r - | k| - 8 | k j rt ssa rt - 8 | V|
- 8 ri]| I-si1 t 1 j rt ssa rt - | V1 ar 1 I | - ri]| I-si1 t 1 | 1 |
sm j It m s
1 sj r t a t tt rIit r a|, 8 1 | - 9 1 iasIt |it Ii||ir ] Iim t -
8 | k j rt ssa rt ar 1 j a |m t r ar tt r ]t sIit r
t rI| t j r t aI| K | 8 tt r t a s rt Ia rr - 8 | k j rt ssa rt ar 1
1 iasIt |it |k| j a |m t r ar tt r ]t sIit r
tt a ]| , | t arst r t ss, | t m t j Isis
j a|j iIaIit r s k| I It | k|
J |V ir |t I t | sIra tIit r - Iitt 1 | 1
sm j It m s
IaIi]a t
|t t tt rtist It |t rar tt
J aIria| |it| tra tia| - | 1 m a 9 iI| k| |t ss t I aIria| |it| , j rt ]r ar t, t r
Iat| tar1 ia s| t rIt r t 1 1 iasIt |it Ii||ir ] j t rit 1
Signs of MS
J ]t r t ra| t tam ir aIit r
m iIra| Iatit s, j t rij | t ra| tt |1 r t ss ar 1 tar t sis
| t j aIit t r |ar]t m t r IIj a |saIit r , astiIt s, j t rij | t ra| t 1 t m a a||
I It | ar 1 | V Iai|a rt
J j a |st
I irrt ]a |ar| irrt ]a |ar k| , m a | t sm a|| tt |a m t
J !V|
I |t ss t I a att s k| , t |t taIt 1 | V Iai|a rt , t r |ar]t t
att s |
J j rt tt r1 ia| j a|j aIit r
aj t t - ir tt r sj ita t a s |V
j a|j a| |t
j a|j a| |t | I ir st tt rt M
|t II j arasIt rr a| |iII | V
J j rt tt r1 ia| aa sta |IaIit r
|t a 1 |t sI iI | t ati| ta|tiIit 1 ar 1 r t I j |ia| |t
t j t r ir ] sr aj |t sI iI | t ati| ta|tiIit 1 ar 1 r t I j |ia| |t
| ar1 i t |t ] \\ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
VALVULAR HEART DISEASE . . . CONT.
m i1 -1 iasIt |it ra m | |t - aI aj t t, | t ar1 | t IIt r ir | | | | j t siIit r
ar 1 j t sI-t tt rtist , a |t r ]t r m a rm a r ar 1 a s| t rIt r kI-1
1 a raIit r tt rrt |aIt iI| t rst M ir trt ast 1 | k|
j rt ssIt |it attt r Ia aIit r |t sI iI| k|
iI j a |m t r ar | j t rIt r sit r j rt st r I - |t a 1 | I, j a |m t r ar
rt ]a r]iIaIit r | ra| am It t || m a rm a r
J t| t sI t tam ir aIit r
trat||t s j a |m t r ar tt r ]t sIit r
Inve s tigations
J I |t a1 | | |
r t rm a| sir a s r| I| m Ik|, | k| , | V1
J t| t sI t-ra
| k t r |ar]t m t r I | k aj j t r 1 a]t , 1 t a | |t tt r It a r, sj |air ] t I
tarir a , j a |m t r ar tt r ]t sIit r , M V ta|tiIitaIit r
J t t| t tar1 it ]raj |
]t |1 sIar 1 ar1
I| it|t r t 1 ta|tiIit 1 ta|tt , Ia sit r t I |t aI|t Is, | k|
| t j j |t r tar t sIim aIt ta|ta |ar art a
1 t ta t I ]ra1 it r I It asst ss st tt riI
J tar1 iat taI| t It ritaIit r
tt r ta rrt r I | k| ir j aIit r Is iI a]t - 1!
Natural His tory
J sm j It m s arist - !-I1 t ars aIIt r ir iIia| r| t a m aIit ir tt |tt m t r I t I
I| t ta|tt , It ||t t 1 | st tt rt ir taj atiIaIit r i.t . t|ass |V K Y1 k
sm j It m s a| t a I 1 t ars |aIt r
J tt m j |itaIit r s t I k| . ata It rt sj iraIt r 1 t tt m j t r saIit r , ssIt m it
ar 1 tt rt | ra| t m | t |itaIit r t IIt r r t t ti1 t r tt t I rt si1 a a| aIria|
I| rt m | a s
J t I| t r tt m j |itaIit r s. || , j a |m t r ar | t m t rr| a]t , tar1 iat tat| t tia
Manage me nt
J att i1 IatIt rs I| aI ir trt ast | k j rt ssa rt Iat| tar1 ia, It tt r, ti]t rt a s
t tt rtist , t It...
J m t 1 ita|
Irt aI k| raIt tt r Irt |, tar1 it tt rsit r
ar Iitt a]a |aIit r - iI k|, j rt tit a s t m | t |a s, t r | k| - !1 m m
|| j rt j | |atis
1 ia rt Iits ar 1 raIt tt r Irt | - iI m i|1 sm j It m s, ar 1 | i]| ris|
sa r]ita| tar 1 i1 aIt
J ir 1 itaIit r s It r sa r]t r
M V art a - .1 tm
I
iI| sm j It m s
K Y1 k t|ass ||| t r |V
t r st I t I k|
t rst r ir ] j a |m t r ar | j t rIt r sit r
||
ssIt m it t m | t |itaIit r
a r attt j Ia| |t |iIt sI|t |im iIaIit r s 1 a t It sm j It m s
J sa r]ita| t j Iit r s
t|t st 1 tt m m isa rt It m
rart | j t rIt rm t 1 ir K t rI| km t rita
| a||t t r ta|ta |t j |asI
iI | i]| ris| j aIit r I, Ia st 1 tt m m isa rt s, ar 1
r t r -ta|tiIit 1 ta|tt iI| ir IatI t| t r1 at , m ir im a| M |
t j t r tt m m isa rt It m
| t sI j rt tt 1 a rt iI ta|tt am t r a| |t It rt j air
a|| I| t a| t tt Ia rr I| t t|t t| | at| - rt -sIt r t sis i|| 1 t tt |t j
m iIra| ta|tt rt j |att m t r I
iI im m t | i|t |t aI|t IsI| t at ta|tiIitaIit r , st tt rt
sa | ta|ta |ar 1 ist ast , M |
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] \!
K t It s
VALVULAR HEART DISEASE . . . CONT.
MITRAL REGURGITATION
Etiology
J ar r a |a s
1 i|aIaIit r | 1 |, | | M , m t tar1 iIis , m iIra| ar r a |ar ta|tiIitaIit r ,
|| a| stt ss
J |t aI|t Is
tt r ]t r iIa| t .]. t|t IIs , m tt m aIt a s 1 t ]t r t raIit r M V|,
M arIar s , || , r| t a m aIit | t arI 1 ist ast , tt ||a]t r tasta |ar 1 ist ast
J t| t r1 at
Iraa m a, m tt m aIt a s 1 t ]t r t raIit r , || , ata It M |
J j aj i||ar m a st|t s ar 1 |V a||
ist| t m iaIir IartIit r , ar t a rsm , 1 | M
Pathophys iology and Symptomatology
J t| rt r it M | = ]ra1 a a|| ir trt asir ] I|t atrt ss M V 1 a rir ] ssIt |t
- j rt ]rt ssitt | k| - 9 IratIit r t I V I|t s It rar1 -
|V 1 i|aIaIit r It m air Iair | 1 - 8 |V a|| It r sit r - |V1 -
| 1 | 9 | 1 , j a |m t r ar t 1 t m a
sm j It m s
It sm j It m s ir iIia|| | k| ]t r t ra|| tar j rt tt r I ar
ir trt ast ir |k| ar 1 I| t sa | st | a t r I j a |m t r ar t 1 t m a
|aIt r. 1 sj r t a, | K | It rI| t j r t a, IaIi]a t ar 1 |t I| ar]
j a|j iIaIit r s |V1
| t taa st t I |V 1 i|aIaIit r , M | | t ]t Is M | as tt ir t 1
J ata It M | = sa 1 1 t r t r st I t I M V ir tt m j t It r tt - 8 | k j rt ssa rt
- 8 |k| - j a |m t r ar t 1 t m a - | V Iai|a rt ata It t r st I | 1 |
Signs of MR
J j a |st
| a it| ar 1 ti]t rt a s a r |t ss |V Iai|a rt
J j rt tt r1 ia| j a|j aIit r
aj t t - 1 isj |att 1 , | j t r1 r am it, t r |ar]t 1
I |t II j arasIt rr a| |iII | k t tj ar 1 s iI| M | , aj ita| I| ri||
J j rt tt r1 ia| aa sta |IaIit r
r t rm a|, st II, t r | a rit 1 ir m a rm a r
1 a sa a|| j rt st r I
| t |t ssIt |it m a rm a r - aI aj t t, a sa a|| ra1 iaIt s It ati||a,
st m t Iim t s It | ast t r | at| j t sIt rit r| 1 irt tIt 1 }t I
M | m a rm a r I It M V| - a sa a|| m i1 -ssIt |it
j aj i||ar m a st|t 1 sIa r tIit r - Ij ita|| a |aIt ssIt |it
| t t j t r | t r |
m i1 -1 iasIt |it ra m | |t - ir trt ast 1 I|t atrt ss ta|tt t IIt r r t M
st tt riI - ]aa ]t | |V 1 i|aIaIit r , 1, 1 iasIt |it I|t ra m | |t
t j t r ir ] sr aj = asst tiaIt 1 M , | a I 1 t t s r t I j rt t|a 1 t j rt 1 t m ir ar I M |
J k|, | 1 |, j a |m t r ar | j t rIt r sit r 1 t tt |t j |aIt
J ata It M | - | 1 |, 1 ar 1 \ j rt st r I, a sa a|| ar 1 I r t rm a| iI|
st II t r a| st r I m a rm a r t ar| ir ssIt |t , t IIt r a 1 iasIt |it I|t m a rm a r
Inve s tigations
J I |t a1 | | |
| k| , |t II aIria| 1 t |a | iIi1 | att s , |V1 !1X t I j aIit r Is
J t| t sI t-ra
|V1 , | k| , j a |m t r ar tt r t a s | j t rIt r sit r
J t t| t tar1 it ]raj |
t Iit |t ] - I|ai| |t aI|t Is, tt ]t IaIit r s, t It
st tt riI rt ]a r]iIar I tt |a m t IIratIit r It riIitt art a
|V Ia r tIit r - ir trt ast 1 |VI| k sitt , |V| | tt |a m t , | |
tt |t a r I|t m aj j ir ] s| t s a| r t rm a| }t I Irt m |V It | k
J tar1 iat taI| t It ritaIit r
asst ss tt rt r ar arIt rit s
tt r Irita |t ]raj | - tt r IrasI Ii||s | k
j rt m ir t r I |t II aIria| t att t r ar -| ar t
Manage me nt
J m t 1 ita|
asm j It m aIit - st ria| t t| t tar1 it ]ram s
| ar1 i t |t ] \t M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
VALVULAR HEART DISEASE . . . CONT.
|| j rt j | |atis
sm j It m aIit - 9 j rt |t a1 1 ia rt sis ar 1 9 aIIt r|t a1 k| | | It r
st tt rt |V 1 sIa r tIit r ar 1 M | ir j t t r sa r]ita| tar 1 i1 aIt
J sa r]ita|
ata It M | - ]t r t ra|| | t sI m ar a]t 1 sa r]ita||
t| rt r it M | - ir 1 itaIit r s It r sa r]t r
j t rsisIt r I sm j It m s K Y1 k t|ass || 1 t sj iIt t j Iim a| m t 1 ita| I| t raj
t r st I t I |t II tt r Irita |ar 1 sIa r tIit r t r ir trt ast 1 |V tt |a m t t r
sitt , t tt r iI asm j It m aIit
J sa r]ita| t j Iit r s
ta|tt rt j air
j rt It rrt 1 |t m t rIa|iI , t IIt r It t| r ita|| 1 iIIita |I
m iIra| ta|tt rt j |att m t r I
iI a r a| |t It rt j air M V
sIrai]| I It rar1 It t| r i| a t , aIIt m j I It tt r st rtt
t| t r1 a| sIra tIa rt sItt r r t tIit r s, tt m j |t It tt rrt tIit r t I
M | at| it tt 1 , ]t t 1 j rt ]r t sis a r |t ss a]t - I!
MITRAL VALVE PROLAPSE
(Barlow's Syndrome )
Etiology
J m tt m aIt a s 1 t ]t r t raIit r t I t| t r1 at ar 1 |t aI|t Is | it| art
I| it|t r t 1 , tt |a m ir t a s ar 1 rt 1 a r 1 ar I It t | i] It r I| t t riIitt
J |t aI|t Is 1 isj |att 1 ir It | k 1 a rir ] ssIt |t
J 1-!X t I j t j a |aIit r | - M
J a|t r t , t r iI| tt r r t tIitt Iissa t 1 ist ast s t .]. M arIar s
J asst tiaIt 1 iI| |t t i]| I ar 1 | |, ar 1 j t tIa s t ttataIa m
Symptoms
J t|it|-m a rm a r sr 1 rt m t
J aIj ita| t| t sI j air j rt |t r ]t 1 , r t r -t tt rIit r a|, sIa| | ir ]
J 1 sj r t a, | j t rtt r Ii|aIit r , ar tit I, j ar it, j a|j iIaIit r s, j rt sr tt j t ,
IaIi]a t - r t taa sa| rt |aIit r s t r m t t| ar ism s It a r 1
J I sm j It m s t I M |
Signs of MVP
J m i1 -ssIt |it t|it| It r sir ] t I rt 1 a r 1 ar I ta|tt Iissa t
J m i1 It |aIt ssIt |it m a rm a r t r j ar ssIt |it m a rm a r rt ]a r]iIaIit r
aIIt r j rt |aj st
J m ar t a tt rs It t| ar ]t |V tt |a m t s| a aI It sIar 1 , t r Va|sa|ta -
1 t trt ast 1 tt r Irita |ar Ii||ir ] - t ar|it r t|it| ar 1 |t a 1 t rI|t r ]t r m a rm a r
Inve s tigations
J I |t a1 | | |
r t r sj t tiIit - att t| ar ]t s, | V, tt r Irita |ar t tIt j
J t t| t tar1 it ]raj |
j t sIt rit r ssIt |it j rt |aj st t I M V |t aI|t Is
asst ss st tt riI t I M |
Natural His tory
J t ttt ||t r I j rt ]r t sis a sa a|| | t r i]r
J ris| t I tt m j |itaIit r s is m t sI 1 t j t r 1 t r I t r 1 t ]rt t t I M |
j rt ]rt ssitt M | , st tt rt M | | t art t I ra j Ia rt 1 t| t r1 at , || ,
arr| I| m ias, I| rt m | t t m | t |ism , sa 1 1 t r 1 t aI|
Manage me nt
J asm j It m aIit iI| t a I M | - t ttt ||t r I j rt ]r t sis tasI m a}t riI
It ||t -a j | 1-! t ars
J | t Ia-| |t t|t rs - It r j a|j iIaIit r s, j air , ar tit I
J ar Iitt a]a |aIit r - iI ssIt m it t m | t |ism
J It r M | - || j rt j | |atis, tt r si1 t r t ar| M V rt j air It r st tt rt M | ,
sIar 1 ar1 ir 1 itaIit r s It r M V rt j |att m t r I
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] \I
K t It s
VALVULAR HEART DISEASE . . . CONT.
TRICUSPID VALVE DISEASE
Etiology
J . r| t a m aIit, tt r ]t r iIa|, tartir t i1 sr 1 rt m t , | k Ia m t a rs, Ii| rt t |asIt sis
J | . | V 1 i|aIaIit r tt m m t r t sI taa st , || |V 1 ra ] a st rs , r| t a m aIit,
| | sIt ir s ar t m a|, kV ta s| it r 1 t It tIs, tartir t i1 , Irita sj i1 j rt |j ast , Iraa m a
Symptoms
J ri]| I | t arI Iai|a rt
IaIi]a t
j t 1 a| t 1 t m a, a| 1 t m ir a| j air |itt r tt r ]t sIit r , astiIt s
1 sj r t a m a rt I|t tI ri]| I | t arI It rar1 Iai|a rt
Signs
J tart Ii1 j a |st . irrt ]a |ar iI k| ar 1 |t tt |a m t
J !V|
t |t taIt 1 j rt ssa rt
j rt m ir t r I a att s ir
|ar]t t att s ir | | V att s
j t siIitt | t j aIt }a ]a |ar rt I|a t ar 1 | a ssm aa |s si]r
J j rt tt r1 ia| j a|j aIit r It r |t II j arasIt rr a| |iII | V ir |
J j rt tt r1 ia| aa sta |IaIit r
r t It . a|| ri]| I si1 t 1 st a r 1 s art |t a 1 t r iI| ir sj iraIit r
| arta||t s si]r , t ttt j I a j a |m t r ar t }t tIit r t|it|
. 1 iasIt |it ra m | |t ir \I| | ||
| . | t |t ssIt |it m a rm a r a|t r ] | | | I| ri|| | arta||t s
m a rm a r , m a | t | att |i|t ar t }t tIit r m a rm a r
| V 1 a|t r ] | | | iI| ir sj iraIit r
J a| 1 t m ir a| t tam ir aIit r
| t j aIt m t ]a| tt r ]t sIit r iI| ssIt |it j a |saIit r s Irt m |
t 1 t m a, astiIt s. st tt r 1 ar It I|a i1 rt It r Iit r
Inve s tigations
J I |t a1 | | |
. | k|
| . | k| , | V1 , k|
J t| t sI t-ra
. 1 i|aIaIit r t I | k iI| t a I j a |m t r ar arIt r t r |ar]t m t r I
| . | k | V t r |ar]t m t r I
J t t| t tar1 it ]raj |
1 ia]r t sIit
Manage me nt
J . a sa a|| 1 t It rm ir t 1 | I| t m t rt st tt rt | sIt r t Iit M V
J | . ir Irt aIir ] | V Iai|a rt , a|st Irt aI |V Iai|a rt , M , t r M |
r t It . tt m m t r t sI taa st t I | V Iai|a rt is |V Iai|a rt
PULMONARY VALVE DISEASE
J tt r rart | t I t|ir ita| im j t rIar tt
Etiology
J | . a sa a|| tt r ]t r iIa|, r| t a m aIit a r tt m m t r , tartir t i1
J | | . st tt r 1 ar It 1 i|aIaIit r t I ta|tt rir ]
j a |m t r ar | j t rIt r sit r M m t sI tt m m t r , t| rt r it |a r ]
1 ist ast , rt ta rrt r I | |
ir I|am m aIt r r| t a m aIit, || , Ia | t rta |t sis
Symptoms
J t| t sI j air , sr tt j t , 1 sj r t a, st ||ir ] | V Iai|a rt ar 1 | 1 |
Signs
J |
ssIt |it m a rm a r - m atim a m aI Ir 1 | ||
j a |m t r ar t }t tIit r t|it|, r t rm a|I|t a 1 Ist II | I, ri]| I si1 t 1 \
J | | . asst tiaIt 1 iI| j a |m t r ar | j t rIt r sit r
t ar| 1 iasIt |it m a rm a r aI | ast - k| a r Ii| j rt tt r t I| t rist
| ra| am It t || 1 iasIt |it m a rm a r aI Ir 1 ar 1 1r1 | || iI| t a I j t rij | t ra| si]r s t I k|
| ar1 i t |t ] \ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
VALVULAR HEART DISEASE . . . CONT.
Inve s tigations
J I |t a1 | | |
| V1
J t| t sI t-ra
j rt m ir t r I j a |m t r ar arIt rit s iI j a |m t r ar | j t rIt r sit r
t r |ar]t 1 | V
J t t| t tar1 it ]raj |
1 ia]r t sIit | V1 , | V 1 i|aIaIit r , | t r | | | | t j j |t r
Manage me nt
J || j rt j | |atis
J | |
rart | rt | a irt s Irt aIm t r I t || It |t raIt 1 iI | V| is r t rm a|
ta|tt rt j |att m t r I m a | t rt | a irt 1
J |
| a||t t r ta|ta |t j |asI, 1 t j t r 1 ir ] t r st tt riI
PROSTHETIC VALVES
J | it j rt sI| t Iit ta|tt s
j t rtir t | t It rt ]raII, | t tir t j t ritar1 ia|, | a m ar | t m t ]raII
|t ir ti1 t r tt t I I| rt m | t t m | t |ism , ar Iitt a]a |aIit r t IIt r r t I
rt | a irt 1 a st k k t r | , i1 t a| It r I| t st iI| tt r Irair 1 itaIit r s
It ar Iitt a]a |aIit r j rt ]r ar t
1 t ]t r t raIit r t I ta|tt aIIt r 1 t ars t r att ra]t
| i]| t r Iai|a rt raIt ir I| t m iIra| j t siIit r
tt r Irair 1 itaIt 1 ir t| i|1 rt r 1 a t It raj i1 ta|tiIitaIit r
J m t t| ar ita| ta|tt s
| t IIt r j rt 1 itIa| i|iI t I j t rIt rm ar tt ar 1 1 a ra| i|iI
a st 1 j rt It rt r Iia|| iI ris| t I rt t j t raIit r is | i]|
a|as rt | a irt s ar Iitt a]a |aIit r It j rt tt r I I| rt m | t t m | t |ism
tt r Irair 1 itaIit r s. | |t t 1 ir ] It r 1 t r t t .]. j t j Iit a |tt r
1 ist ast , j rt ]r ar t | t a m a1 ir is It raIt ]t r it
Iar]t I |K | = I.!-1.!
J j t sI-t j tt m j |itaIit r s
ta|tt Iai|a rt
ta|tt I| rt m | t sis - XIt ar
ta|tt 1 t ]t r t raIit r
|| t IIt r - t ar aIIt r sa r]t r, Iaj | . t j i1 t rm i1 is
| |t t 1 ir ] j rt | |t m s 1 a t It ar Iitt a]a |aIit r m a}t r. XIt ar
I| rt m | t t m | t |ism I-!X j t r j aIit r I-t ar 1 t sj iIt a1 t | a aIt ar Iitt a]a |aIit r
tt r 1 a tIit r a| r t rm a|iIit s
PERICARDIAL DISEASE
ACUTE PERICARDITIS
Etiology
J ir It tIit a s
tira|. | t tsat|it tira s k, | m t sI tt m m t r
| atIt ria|. t r 1 t tar1 iIis, st j Iitt m ia
|
Ia r ]a|. | isIt j |asm t sis, | |asIt m tt sis
j rt It tt a|
J m t tar1 ia| ir IartIit r . ata It -I 1 as ,
j t sI M | | rt ss|t rs sr 1 rt m t I- t t |s
J j t sI-j t ritar1 it It m t .]. | k| |
J tt ||a]t r tasta |ar 1 ist ast . | | , j t riarIt riIis, | k, st|t rt 1 t rm a
J m t Ia| t |it. a rt m ia, | j t I| rt i1 ism
J tasta |ar. 1 isst tIir ] ar t a rsm
J r t t j |asm . 1 t 1 ]|ir s, | rt asI, |a r ], rt r a| tt || tartir t m a, m t |ar t m a
J ir Ii|IraIitt 1 ist ast , 1 ra ]s t .]. | 1 ra|atir t , Iraa m a, ra1 iaIit r
J i1 it j aI| it ! tira|
Pre s e ntation
J 1 ia]r t sIit Iria1 . t| t sI j air , IritIit r ra | , ar 1 | | | t| ar ]t s
J t| t sI j air - a||t tiaIt 1 | siIIir ] a j ar 1 |t ar ir ] It rar1 , j |t a riIit,
t rst iI| 1 t t j | rt aI| ir ] ar 1 sa j ir t j t siIit r
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] \1
K t It s
PERICARDIAL DISEASE . . . CONT.
J j t ritar1 ia| IritIit r ra | - m a | t a r i-, | i- t r Irij | asit
J I It tt r, m a|aist
Inve s tigations
J I |t a1 | | | . ir iIia|| t |t taIt 1 ir ar It rit r, |aIt ra| ar 1 ir It rit r
|t a1 s I 1 t j rt sst 1 | | st ]m t r I, I| t t |t taIit r ir I| t st ]m t r I is
tt r tatt a j ar1 s - I-! 1 as |aIt r ist t |t tIrit iI| att
I|aIIt r ir ] ar 1 ir tt rsit r
J t| t sI t-ra. r t rm a| | t arI sitt , j a |m t r ar ir Ii|IraIt s
J t t| t tar1 it ]raj | . asst ss j t ritar1 ia| t IIa sit r
Complications
J rt ta rrt r tt s, aIria| arr| I| m ias, j t ritar1 ia| t IIa sit r s, Iam j t r a1 t ,
rt si1 a a| tt r sIritIitt j t ritar1 iIis
Manage me nt
J Irt aI I| t a r 1 t r|ir ] 1 ist ast
J ar Ii-ir I|am m aIt r a]t r Is K k|| s, sIt rt i1 s iI st tt rt , ar a|]t sits
PERICARDIAL EFFUSION
Etiology
J It Ij t s t I t IIa sit r s.
Irar sa 1 aIitt st rt a s
| 1 |, | j t a|| a m ir t m iaI| j t j rt It ir t m ia
t ta 1 aIitt st rt sar ]a ir t a s t r | |t t 1
taa st s sim i|ar It I| t taa st s t I ata It j t ritar1 iIis
J j | sit |t ]ita| tt r st | a t r tt s 1 t j t r 1 t r Ij t ar 1 tt |a m t t I t IIa sit r ,
raIt t I t IIa sit r 1 t tt |t j m t r I, ar 1 a r 1 t r|ir ] tar1 iat 1 ist ast
Symptoms
J r i| t r sim i|ar It ata It j t ritar1 iIis
J 1 sj r t a, tt a ]|
J t tIra-tar1 iat t st j | a]t a|Irt ta rrt r I |arr ]t a| r t rtt I
Irat| t t -| rt r t| ia|Ij | rt r it r t rtt irriIaIit r
Signs
J !V| . t |t taIt 1 iI| 1 t m ir ar I t 1 t stt r I
J arIt ria| j a |st . r t rm a| It 9 tt |a m t , 9 | |
J j a |sa s j ara1 t ta s 1 rt j t I | | - 1 m m 1 ] t r ir sj iraIit r
J aj t t r t rm a| t r a| st r I
J aa sta |IaIit r . 1 isIar I | t arI st a r 1 s I ra |
Inve s tigations
J I |t a1 | | | . |t tt |Ia]t , I|aI att s
J t| t sI t-ra. tar1 it m t ]a|, rt a r 1 t 1 tar1 iat tt r It a r
J t t| t tar1 it ]raj | j rt tt 1 a rt t I t| t itt . I|a i1 ir j t ritar1 ia| sat
J j t ritar1 it tt r It sis. t sIa| |is| t s 1 ia]r t sis
Manage me nt
J m i|1 . Irt | a t r I t | st rtaIit r iI| st ria| | | 1 1 , ar Ii-ir I|am m aIt r
a]t r Is It r ir I|am m aIit r
J st tt rt . m a 1 t tt |t j tar1 iat Iam j t r a1 t
J iI | t m t 1 r am it tt m j rt m ist , j t ritar1 it tt r It sis t r t j t r 1 rair a]t
J m t 1 ita|. Irt aI I| t taa st , I| t raj t a Iit j t ritar1 it tt r It sis
J sa r]ita|. j t ritar1 ia| ir 1 t , j t ritar1 it tIt m
CARDIAC TAMPONADE
J m a}t r tt m j |itaIit r t I j t ritar1 ia| t IIa sit r
Pathophys iology and Symptomatology
J | i]| ir Ira-j t ritar1 ia| j rt ssa rt - 1 t trt ast 1 tt r t a s rt Ia rr -
1 t trt ast 1 1 iasIt |it tt r Irita |ar Ii||ir ] - 1 t trt ast 1 | 1 -
| j t It r sit r tt r t a s tt r ]t sIit r
sm j It m s
Iat| j r t a, 1 sj r t a, s| t t|
| ar1 i t |t ] !1 M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
PERICARDIAL DISEASE . . . CONT.
Signs
J t-1 t stt r I t r |, a| st r I -1 t stt r I
J | t j aIit tt r ]t sIit r
Clinical Pe arl
J | |assit | a arIt I. | j t It r sit r , ir trt ast 1 !V|, Iat| tar1 ia, j a |sa s j ara1 t ta s
J | t t| s Iria1 . | j t It r sit r , ir trt ast 1 !V|, m a II|t 1 | t arI st a r 1 s
Inve s tigations
J I |t a1 | | | . t |t tIrita| a|It rr ar s j aI| t ]r t m t r it
J t t| t tar1 it ]raj | . j t ritar1 ia| t IIa sit r , 1 iasIt |it tt m j rt ssit r t I
tar1 iat t| am | t rs | k ar 1 | V
J tar1 iat taI| t It ritaIit r . m t ar | k, | k, |V ar 1 | V 1 iasIt |it j rt ssa rt s
a|| | i]| ar 1 t | a a|
Manage me nt
J j t ritar1 it tt r It sis | | 1 1 -, I|a t rt stt j it- t r | | | -]a i1 t 1
J j t ritar1 it It m
J att i1 1 ia rt Iits ar 1 tast 1 i|aIt rs I| t st 9 tt r t a s rt Ia rr It
a|rt a1 a r 1 t r-Ii||t 1 | V - 9 |V j rt |t a1 - 9 | 1
J I|a i1 a1 m ir isIraIit r m a It m j t rari| 8 | 1
J Irt aI a r 1 t r|ir ] taa st
CONSTRICTIVE PERICARDITIS
Etiology
J ar taa st t I ata It j t ritar1 iIis m a rt sa |I ir t| rt r it j t ritar1 iIis
Symptoms
J 1 sj r t a, IaIi]a t , j a|j iIaIit r s
J a| 1 t m ir a| j air
Signs
J ]t r t ra| t tam ir aIit r - m im its | 1 | t sj t tia|| ri]| I-si1 t 1 1 |
astiIt s, | t j aIt sj |t r t m t ]a|, t 1 t m a
J j a |st s. 8 !V|, | a ssm aa |s si]r j ara1 t tita| 8 ir !V|
iI| ir sj iraIit r , | rit 1 rit| s si]r j rt m ir t r I 1 t stt r I - t 1 t stt r I
J j rt ssa rt s. | | r t rm a| It 1 t trt ast 1 , I j a |sa s j ara1 t ta s
J j rt tt r1 ia| t tam ir aIit r . I j t ritar1 ia| |r t t| t ar| 1 iasIt |it st a r 1
Inve s tigations
J I |t a1 | | | . |t tt |Ia]t , I|aI att , I k|
J t| t sI t-ra. j t ritar1 ia| ta|tiIitaIit r , t IIa sit r s
J | t r M | |. j t ritar1 ia| I| it|t r ir ]
J tar1 iat taI| t It ritaIit r . t | a a|itaIit r t I | V ar 1 |V 1 iasIt |it j rt ssa rt s,
| V| | | - I1 t I | V ssIt |it j rt ssa rt
Manage me nt
J m t 1 ita|. 1 ia rt Iits, sa|I rt sIritIit r
J sa r]ita|. j t ritar1 it tIt m
Table 12. Diffe re ntiation of Cons trictive Pe ricarditis vs . Cardiac Tamponade
Characte ris tic Cons trictive Pe ricarditis Tamponade
!V| - t t -
| a ssm aa | s si]r j rt st r I a| st r I !V| It t | i]| It st t t| ar ]t
j a |sa s j ara1 t ta s I1 t I tast s a|as
j t ritar1 ia| |r t t| j rt st r I a| st r I
| j t It r sit r m i|1 -m t 1 t raIt st tt rt
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] !
K t It s
SYNCOPE
De finition
J sa 1 1 t r , Irar sit r I 1 isra j Iit r t I tt r stit a sr t ss ar 1 |t ss t I j t sIa ra|
It r t iI| sj t r Iar t t a s rt tt tt r
J a sa a|| taa st 1 | ]t r t ra|itt 1 tt rt | ra| | j t j t rIa sit r
Etiology
J !1X t I tast s art r t tt r 1 ia]r t st 1
J tar1 iat
t |t tIrita|
Iat| tar1 ia. V, t rsa1 t s 1 t j t ir It s, V
| ra1 tar1 ia. , I t r 1 kV | |t t|
j att m a|t r Iai|a rt
m t t| ar ita|
t a II|t t | sIra tIit r . |V k , 1 1 | M , M , | k m tt m a ,
| V | , | | , j a |m t r ar | j t rIt r sit r
m t tar1 ia|. | k| IM |, |V 1 sIa r tIit r
t I| t r. Iam j t r a1 t
J t tIra-tar1 iat
r t a ra|| m t 1 iaIt 1 tast m t It r
tast ta]a| - I| t tt m m t r Iair I !1X
siIa aIit r a|Itistt ra|. m itIa riIit r I1 t It taIit r sr tt j t ,
tt a ]| sr tt j t , Va|sa|ta, t ta |ar j rt ssa rt , t It
tart Ii1 sir a s sr tt j t
j st| iaIrit. st m aIitaIit r , j ar it, ar tit I
t I| t r. t tt rtist , | i]| a|IiIa 1 t , 1 ra ]-ir 1 a tt 1
t rI| t sIaIit | j t It r sit r . 1 ra ]-ir 1 a tt 1 t .]. ar Ii| j t rIt r sitt s ,
tt r t a s j t t |ir ] j t sIa ra|, j rt ]r ar t , aa It r t m it r t a rt j aI|
. | -| ra]t r, I. | M , | j t tt |t m ia | |t t 1 |t ss,
1 ia rt sis j | t t t| rt m t tIt m a
r t a rt |t ]ita|. tt rIt | rt | asi|ar |kIsIrt |t , k1 ,
tt rtita| sj t r 1 |t sis, st ita rt , sa | t|atiar sIt a|
m t Ia| t |it. | j t tia, | j t ]|tt m ia, | j t taj r ia
Clinical Manife s tations
J | isIt r ar 1 j | sita| t tam ir aIit r art triIita| - rt I|t tI a r 1 t r|ir ]
j aI| t |t ] ir \1-!1X aIIt r Iit r It tar1 iat ar 1 r t a rt |t ]ita| t tam s
Table 13. Diffe re ntiation of Se izure vs . Syncope
Characte ris tic Syncope Se izure
Iatia| tt |t r j a|t tar t Iit
|aIt ra| It r ]a t | iIir ] rart tt m m t r
aa ra r t st m t Iim t s
r aa st a, 1 iaj | t rt sis tt m m t r | t It rt a r tt m m t r
| 1 | | rit I m a | t |t r ]t r
rt t rit r Iit r iI| ir st tt r 1 s iI| ir m ir a It s
t 1 1 s j ara|sis r t st m t Iim t s
st IIir ] rart | t r rt ta m | t r I ar Iim t
aIIat|s ir Irt | a t r I rt j t aIt 1
a]t taria| |t t a r ]t r - \!
| | r t rm a| ir trt ast 1
j t siIitt | | | r t st m t Iim t s
Inve s tigations
J 1 irt tIt 1 | rt sa |Is t I | isIt r ar 1 j | sita| t tam ir aIit r
J | |t t 1 t r|. | | | , st ra m t |t tIrt |It s, M ], | a, | | K , trt aIir ir t , ]|a tt st , k| | , | | -M |
J | | |
J | | 1 1
J tart Ii1 | t j j |t r |
J 1 t |It r m t r iIt r, |t t j 1 t |It r
J Ii|I-Ia| |t It sIir ]
J | |
Manage me nt
J Irt aIm t r I t I a r 1 t r|ir ] taa st
| ar1 i t |t ] !I M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
K t It s
COMMONLY USED CARDIAC
THERAPEUTICS
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K t It s
| ar1 i t |t ] !\ M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
COMMONLY USED CARDIAC
THERAPEUTICS . . . CONT.
Table 15. Be ta-Blocke r Actions
Clinical Effe ct s Propranolol At e nolol Ace but olol Labe t alol
-Act ivit y r t r -st |t tIi tt r t r -st |t tIi tt
-Act ivit y K K K
ISA K K
brochocons t rict ion
ort hos t at ic hypot e ns ion
lipid adve rs e e ffe ct s
CNS adve rs e e ffe ct s
Carve dilol (1-and non-s e le ct ive -blockade )
J a st Ia | i r Ia r tIi t r a| t|ass | | -| | | | 1 | t!X rt 1 a tIi t r i r m t rIa|i I
J ar Ii t ti 1 ar I
CALCIUM CHANNEL BLOCKERS
J m a}t r sa | Ij t s art rt j rt st r It 1 | 1 i |Ii att m | t r tt I| ai tt j i r t ,
tt raj am i | j | t r |a|||am i r t ar 1 r i It 1 i j i r t 1 i | 1 rt j ri 1 i r t
J 1 i |Ii att m ar 1 tt raj am i | art sIrt r ] tar1 i t 1 t j rt ssar Is, | t rt as
I| t 1 i | 1 rt j ri 1 i r t s art sIrt r ] tast 1 i |aIt rs
Table 16. Calcium Channe l Blocke r Act ions
Clinical Effe ct s Dilt iaze m Ve rapamil Nife dipine
coronary vas odilat or
pe riphe ral vas odilat or
cont ract ilit y - - 1 t tr - -
s inus rat e 1 t tr 1 t tr i r tr
AV conduct ion 1 t tr 1 t tr - -
ANTI-ARRHYTHMIC DRUGS
Figure 12. Re pre s e ntative Action Pote ntial
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M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] !!
K t It s
COMMONLY USED CARDIAC
THERAPEUTICS . . . CONT.
Table 17. Antiarrhythmic drugs
Clas s Age nt Indicat ions Side Effe ct s Me chanis m of Act ion
| a a i r i 1 i r t V, V t rsa1 t s 1 t | t i r It s a|| | a m t 1 t raIt K a t| ar r t |
| rt tai r am i 1 t 1 i arr| t a | |t t|a1 t
| i st j ram i 1 t |a j a s-|i |t sr 1 rt m t s|t s j | ast 1 a j sIrt |t
ar Ii -t| t |i r t r]i t t IIt tIs j rt |t r ]s rt j t |ari taIi t r
ar 1 I| a s s|t s tt r 1 a tIi t r
| | | i 1 t tai r t V tt r Ia si t r , sIa j t r, st i ta rt s m i |1 K a t| ar r t |
M t ti |t Ii r t | | a j st I, Irt m t r | |t t|a1 t
s| t rIt r s j | ast 1
rt j t |ari taIi t r
| t | rt j aIt r t r t V, V

t tatt r| aIi t r t I V a|| | t m ar|t 1 K a t| ar r t |

| |t tai r i 1 t k|
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a|| | t a j sIrt |t
| | | rt j rar t |t | V, k|

| rt r t| t sj asm , r t ]aIi tt | t Ia-| |t t|t rs

M t It j rt |t | t It... i r t Irt j | , | ra1 tar1 i a, kV | |t t|, 1 t trt ast s j | ast \
i m j t It r tt , IaIi ]a t 1 t j t |ari taIi t r
| | | km i t 1 art r t V, V j | t It st r si Ii ti I, | |t t|s | t| ar r t |
m a |Ii j |t t|ass k|
I
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t IIt tIs | t j aIt It ti ti I, rt j t |ari taIi t r ar 1 st
| j t rI| j t I| rt i 1 i sm j rt |t r ]s I| t t IIt tIi tt
rt IratIt r j t ri t 1
t Ia|t | V, V , k|
,I
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| rt I|i a m | V V | t i r It s, | j t It r si t r
| V Vt raj am i | V | ra1 tar1 i a, kV | |t t| | a t| ar r t | | |t t|t r
| i |Ii att m k|
I
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sj t r Iar t t a s
1 t j t |ari taIi t r ar 1 st
s|t s tt r 1 a tIi t r i r
art as sa t| as kV r t 1 t
raIt tt r Irt | t I aIri a| Ii | ri ||aIi t r t r |
Itar1 i t tt rsi t r | t I aIri a| Ii | ri ||aIi t r t r |
J k|| ar Ii -arr| I| m i ts | att j t It r Ii a| It | t j rt -arr| I| m i t
J | r I| t |ar 1 m ar| | k Iri a|, It t|ass | t a]t r Is t r tai r i 1 t , I|t tai r i 1 t
j rt tt r It 1 V| | s j t sI M | | a I si ]r i Ii tar I| i r trt ast 1 m t rIa|i I
K t It s
| ar1 i t |t ] !t M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
APPENDIX: SAMPLE ECGS
a ir a s | ra1 tar1 ia
a ir a s krrt sI | ir a s krrt sI
a ir a s krrt sI t kV | |t t|
a ir a s krrt sI 1 I kV | |t t| j t | t r wt r |t | at|
a ir a s krrt sI t I kV | |t t| j t ||
a ir a s krrt sI I 1 kV | |t t|
a ir a s krrt sI Ia ir a s at| tar1 ia
a ir a s krrt sI I| kIria| | |a IIt r iI| I. kV | |t t|
M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s | ar1 i t |t ] !I
K t It s
APPENDIX: SAMPLE ECGS . . . CONT.
a ir a s krrt sI It kIria| | i| ri||aIit r
a ir a s krrt sI I1 | art tsm a| a j ratt r Irita |ar at| tar1 ia
a ir a s krrt sI It | rt m aIa rt Vt r Irita |ar | t r IratIit r
a ir a s krrt sI II Vt r Irita |ar at| tar1 ia
a ir a s krrt sI I] Vt r Irita |ar | i| ri||aIit r
a ir a s krrt sI I| t rsa1 t s 1 t | t ir It s
a ir a s krrt sI 1a wt |II-| ar|ir st r -w| iIt r 1 rt m t ir It rm iIIt r I
K t It s APPENDIX: SAMPLE ECGS . . . CONT.
| ar1 i t |t ] ! M | | | I111 | t ti t K t It s ar 1 | t tIa rt t ri t s
a ir a s krrt sI \a | i]| I | a r 1 |t | rar t| | |t t|
a ir a s krrt sI \| | t II | a r 1 |t | rar t| | |t t|
a ir a s krrt sI !a 1 j t r|a|t m ia ir t|a 1 ir ] j t a|t 1 , i1 t | ar 1 sir t att
a ir a s krrt sI !| | i]iIa|is | IIt tI ir t|a 1 ir ] kV | |t t|, stt t j t 1