MEDICINE 2

ELEMENTS OF A COMPLETE CARDIAC DIAGNOSIS

Manuel B. Zacarias, MD
First Shift: August 14, 2018

REMEMBER TEXTBOOK EDITOR PREVIOUS TRANS

Table of Contents
G & ! 4
I. The Elements of a Complete Cardiac Diagnosis ............... 1
A. Etiology...................................................................... 1
Notes, Messages & Disclaimers
1. Example of an Etiology ......................................... 1
a. Aging ................................................................ 1
b. Atherosclerosis ................................................. 1 I. The Elements of a Complete Cardiac Diagnosis
c. Congenital Anomaly.......................................... 1
d. Unknown .......................................................... 1
2. Question................................................................ 2
B. Anatomic Abnormality................................................ 2
1. Examples .............................................................. 2
a. Diseases of the Aorta ....................................... 2
b. Diseases of the Pulmonary Vasculature ........... 2
c. Diseases of the Coronary Arteries .................... 2
d. Diseases of the Endocardium and Valves ........ 2
e. Diseases of the Myocardium ............................ 2 • Clinical diagnosis (logical diagnosis) is based purely on history
and PE. Majority of cases you will encounter only need clinical
f. Diseases of the Pericardium.............................. 2 diagnosis. | !
g. Anomalies of Cardiac Position .......................... 2 • History + PE + Ancillary procedure = Definitive Diagnosis | !
h. Anomalies of Aorta ........................................... 2
i. Anomalies of the Pulmonary Arteries ................. 2 A. Etiology
j. Anomalies of the Coronary Arteries ................... 2 • Cause or origin of disorder | G
k. Communication between the Great Arteries ..... 2 • Any significant systemic disease can lead to heart disease | !
l. Transposition Complexes .................................. 2 • Is the disease…
o Congenital
m. Defects at the Atrial Level................................ 2
o Metabolic
n. Defects at the Ventricular Level ........................ 2 o Hypertensive
o. Congenital Malformations of the Aortic Valve ... 2 o Inflammatory
p. Congenital Malformations of the Mitral Valve.... 2 o Atherosclerotic
o Aging
q. Congenital Malformations of the Pulmonary Valve
............................................................................. 2
1. Example of an Etiology
r. Congenital Malformations of the Tricuspid Valve2
s. Anomalies of the Venous Drainage .................. 2 a. Aging
2. How to Write an Anatomic Abnormality ................. 3 § Loss of arterial compliance
§ Hypertrophy of LV
C. Physiologic Diagnosis ............................................... 3
§ Prolongation of contraction and relaxation
1. Examples .............................................................. 3 § A decline in β-adrenergic responsiveness
a. ECG Findings ................................................... 3 § A decline in pericardial compliance
b. Disorders of Myocardial Function ..................... 3 b. Atherosclerosis
c. Disorders of Intravascular Pressure .................. 3
§ ½ of all deaths worldwide
d. Abnormal Communications in Heart or Great
§ Classic anginal syndrome in the absence of other known
Vessels................................................................. 3 cause
e. Anginal Syndrome ............................................ 3 § MI in the absence of other known causes
D. Functional Capacity ................................................... 3 § Demonstration by coronary anguography, angioscopy,
IVUS, CT, or MRI of obstructive coronary disease
E. Objective Assessment ............................................... 3 § Anginal syndrome in the presence of evidence of
II. Sample Case I: Patient with AMI ...................................... 4 reversible myocardial ischemia by a noninvasive method
A. History of Present Illness ........................................... 4 like exercise stress test
B. Past History ............................................................... 4 c. Congenital Anomaly
C. Physical Exam........................................................... 4 § Clinical, ECG and imaging evidence for the specific
D. Ancillary Procedures ................................................. 4 anomaly present or presumed present at birth
E. Complete Cardiac Diagnosis ..................................... 4 d. Unknown
III. Sample Case II: Patient with RHD ................................... 4 § Either definite structural changes in the heart or abnormal
IV. End Notes ....................................................................... 4 cardiac function for which no etiology can be determined

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AW | BALISI • BATARA.• BAUTISTA, C. • BAUTISTA, F.

2. Question
o The most logical etiologic diagnosis of a 20 year-old patient
who was diagnosed to have heart disease when she was
about 2 years old, a grade 4/6 mid-systolic crescendo-
decrescendo murmur at the 2nd LICS and S2 is widely-split
and relatively fixed in relation to respiration.
A. Aging
B. Atherosclerosis
C. Congenital Anomaly
D. Hypertension
*Answer is Congenital Anomaly. | !
B. Anatomic Abnormality
• Structural alteration | G
• Anatomic abnormalities are structual changes brought about
by a particular etiology | !
• Anything in the heart can become abnormal as a result of the
disorder, including valves and coronary arteries | !
• Questions asked:
o Which chambers are involved?
o Are they hypertrophied, dilated, or both?
o Which valves are affected?
o Are they regurgitant and/or stenotic?
o Is there pericardial involvement?
o Has there been a myocardial infarction?
o Which coronary arteries are implicated?
o Are they atherosclerotic and/or stenotic?
AW | BALISI • BATARA.• BAUTISTA, C. • BAUTISTA, F.
ELEMENTS OF A COMPLETE CARDIAC DIAGNOSIS
1. Examples
a. Diseases of the Aorta
b. Diseases of the Pulmonary Vasculature
c. Diseases of the Coronary Arteries
§ Arteritis
§ Atherosclerosis
§ Embolism to a coronary artery
§ Stenosis of a coronary orifice
d. Diseases of the Endocardium and Valves
§ Calcification of the mitral annulus
§ Endocardial fibroelastosis
§ Endocardial fibrosis
§ Endocarditis
§ Fibromyxomatous degeneration of a valve
§ Intracardiac thrombosis
§ Neoplasm of the endocardium
§ Rupture of the chordae tendinae
§ Valvular deformity
* Aortic valve deformity causing stenosis
* Aortic valve deformity causing regurgitation
* Mitral valve deformity causing stenosis
* Mitral valve deformity causing regurgitation
* Tricuspid valve deformity causing stenosis
* Tricuspid valve deformity causing regurgitation
* Pulmonary valve deformity causing stenosis
* Pulmonary valve deformity causing regurgitation
e. Diseases of the Myocardium
§ Cardiomyopathy
§ Enlargement of the heart
§ Myocardial fibrosis
§ Myocardial infarction
§ Myocarditis
§ Neoplasm
§ Rupture of the myocardium
§ Ventricular aneurysm
f. Diseases of the Pericardium
g. Anomalies of Cardiac Position
h. Anomalies of Aorta
i. Anomalies of the Pulmonary Arteries
j. Anomalies of the Coronary Arteries
k. Communication between the Great Arteries
l. Transposition Complexes
m. Defects at the Atrial Level
n. Defects at the Ventricular Level
o. Congenital Malformations of the Aortic Valve
p. Congenital Malformations of the Mitral Valve
q. Congenital Malformations of the Pulmonary Valve
r. Congenital Malformations of the Tricuspid Valve
s. Anomalies of the Venous Drainage
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 ELEMENTS OF A COMPLETE CARDIAC DIAGNOSIS

2. How to Write an Anatomic Abnormality c. Disorders of Intravascular Pressure

§ Pulmonary Arterial Hypertension
§ Pulmonary Venous Hypertension
§ Systemic Arterial Hypertension
§ Pulmonary / Systemic Circulatory Congestion
d. Abnormal Communications in Heart or Great Vessels

e. Anginal Syndrome
o Talk about the specific part that is affected and what is the § Pain in the chest, neck, shoulder, or left arm that is usually
change | ! caused by effort and relieved by rest or nitrates
o If you include valve deformity, you should state “valve § Anginal syndrome is considered physiologic while
deformity causing ______”, because if it’s just aortic stenosis, myocardial infarction is anatomic | G
then it is just a physiologic diagnosis. | G !
o Place the part that is affected and the change brought about
by the etiologic cause. | ! D. Functional Capacity
• How strenuous is the physical activity required to elicit the
C. Physiologic Diagnosis symptoms.
• Based entirely on subjective symptoms | G
• Activity dysfunction | G
• Physiologic disturbance is the dysfunction that is brought Table 1| NYHA Class for Functional Capacity
about by the structural change caused by the etiology. | !
• Normal sinus rhythm is a physiologic diagnosis. | ! Class I Class III
• Include findings of ECG in physiologic diagnosis. | ! • No physical activity • Marked physical activity
* Disorders of myocardial dysfunction, intravascular limitation limitation
function, etc is also considered physiologic. | • No symptoms present with • Symptoms present with
ordinary activity minimal activity
• Questions asked
o Is an arrhythmia present? Class II Class IV
o Is there evidence of CHF? • Slight physical activity
o Is there evidence of myocardial ischemia? • Can’t engage in physical
limitation
activity without discomfort
• Symptoms present with
1. Examples • Symptoms present at rest
ordinary activity

a. ECG Findings
§ Normal and Ectopic Impulse Formation E. Objective Assessment
§ Atrial Rhythms • Based on and emphasizes the special importance of objective
§ Atrioventricular Junctional measures of cardiac structure and function to evaluate overall
§ Paroxysmal Supraventricular Tachycardia cardiac status
§ Ventricular Rhythms • The most controversial among the elements because it is
§ Electronic Pacemaker Rhythms purely judgmental
§ Normal and Abnormal Impulse Transmission
• It is an unbiased and factual category. You need information.
§ Atrioventricular Dissociation
o A patient with cardiac disease who has not had specific
§ Intraventricular Block
tests of cardiac structure or function would be classified:
§ Disorders of the Supravalvular, Valvular, or Subvalvular
Undetermined | !
obstruction
• No precise definition of what is minimal, moderate, severe
* Aortic stenosis
* Aortic regurgitation
Table 2| Objective Assessment
* Mitral stenosis
* Mitral regurgitation A C
* Tricuspid stenosis • No objective evidence of • Objective evidence of
* Tricuspid regurgitation CVD moderately severe CVD
* Pulmonary stenosis
B D
* Pulmonary regurgitation
• Objective evidence of • Objective evidence of
* Note: Physiologic = no need to put “valve deformities” minimal CVD severe CVD
Anatomic = put “valve deformities” | G !

b. Disorders of Myocardial Function

§ Ventricular Failure and CHF
* Left Ventricular Failure
* Right Ventricular Failure
§ Diastolic Dysfunction
§ Ventricular Asynergy
§ Pericardial Constriction
§ Myocardial Restriction
§ Cardiogenic Shock

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AW | BALISI • BATARA.• BAUTISTA, C. • BAUTISTA, F.
 ELEMENTS OF A COMPLETE CARDIAC DIAGNOSIS

II. Sample Case I: Patient with AMI E. Complete Cardiac Diagnosis

• A.B.C., 55 year-old male, carpenter Table 3| Complete Cardiac Diagnosis for Case I
• Chief Complaint: chest pain Cardiac Diagnosis
Etiology Atherosclerosis
A. History of Present Illness • Classic angina and MI in the absence of other
known causes | G
• Two months ago, he had pressing precordial discomfort on • Demonstration by coronary angiography,
climbing two flights of stairs, lifting heavy objects and when he angioscopy, IVUS, CT scan, or MRI of
gets mad. Consulted and prescribed ASA 80 mg OD, Atenolol obstructive coronary disease
50 mg OD, ISMN 30 mg OD, Rosuvastatin 10 mg OD, • Anginal syndrome in the presence of
Metformin 00 mg TID. Slight relief but still unable to work evidence of reversible myocardial ischemia by
comfortably. a non-invasive method
Anatomic Total occlusion of proximal LAD
• One month ago, he consulted again after he was fired from
Abnormality Myocardial fibrosis
work because of his “inability to do his job well.” Atenolol was
increased to 100 mg OD, ISMN was increased to 60 mg OD, • ECG: pathologic Q waves
• Echo: akinetic septum
ASA, Rosuvastatin, and Metformin were continued at similar
• MPS: non-viable IVS
doses. Symptoms persisted.
Physiologic Sinus bradycardia
• One week ago, he was brought by his wife for consultation Disturbance Systolic LV dysfunction
because of the above symptoms and “depression.”
Anginal Syndrome
Functional NYHA Class II
B. Past History Capacity
• Five years ago – told to have “Diabetes” Objective Class D
Classification
o Metformin 500 mg TID
• Three months ago
o AMI, coronary angiography – total occlusion proximal LAD
III. Sample Case II: Patient with RHD
• Two and a half months ago
o Thallium MPI – nonviable IVS Table 4| Complete Cardiac Diagnosis for Case II
Cardiac Diagnosis on Cardiac Diagnosis on
C. Physical Exam Admission Discharge
• Rheumatic fever: • Rheumatic fever:
• BMI: 20 Etiology
inactive inactive
• BP: 100/70 Anatomic • LA enlargment • LA enlargment
• PR 50/min Abnormality • LV enlargement • LV enlargement
• RR: 18/min • RA enlargement • RA enlargement
• JVP: 4 cm at 45˚ • RV enlargement • RV enlargement
• CAP: rapid upstroke, gradual downstroke • PA enlargement • PA enlargement
Physiologic • A. Fib with rapid • A. fib. with average
• Adynamic precordium
Disturbance ventricular response ventricular response
• AB at 5th LICS MCL • Mitral stenosis • Mitral stenosis
• Soft S1, with S3 and S4, no murmurs • Mitral regurgitation • Mitral regurgitation
• Pulmonary HTN • Pulmonary HTN
D. Ancillary Procedures • CHF • HF
Functional
• ECG • NYHA Class IV • NYHA Class II
Capacity
o Sinus bradycardia: Anterior wall MI, old Objective
o Pathologic Q waves – gives you an idea of a dead myocyte | • Class D • Class C
Classification
G !
• Chest X-ray Explanation:
o Atherosclerotic aorta
• Look at for discharge. | !
• 2D-Echocardiography o Etiologic diagnosis does not change.
o Ejection fraction (EF) = 52% o Anatomic diagnosis does not change either because it is
o Normal ejection fraction is 55 | G ! brought about by the etiology.
o Hypokinesia or akinesia may be due to ischemia or dead o Physiologic change – rapid to average ventricular response,
myocytes. no more congestion
• Exercise Thallium Myocardial Perfusion Scintigraphy o Functional class and objective class improved.
o Blue areas represent nonviable parts of the myocardium | G
IV. End Notes

• Management is based solely on the diagnosis. | G

• When someone falls in front of you, you should make a quick
assessment, call for help, then manage accordingly.

- END -

REFERENCES
• Harrison’s 19th Edition
• Lecture of Dr. Zacarias

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AW | BALISI • BATARA.• BAUTISTA, C. • BAUTISTA, F.