Contents

The Big Heart Disease Lie

Cardiovascular Disease Causes and Possible Treatments

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Preface vii

Acknowledgment x

Companion CD xv

Color Plates xvii

Chapter 1

Approach to the Physical Examination of the Cardiac Patient 1

Reasons for Which Cardiac Assessment Is Sought 2

Cardiac Symptoms and Their Appraisal 2

Generation of Working List of Possible Diagnoses 4

Focused Physical Examination: Clinical Exercise 6

Focused Physical Examination: Practical Points 14

Chapter 2

Arterial Pulse 15

Physiology of the Arterial Pulse 15

Assessment of the Arterial Pulse 34

Practical Points in the Clinical Assessment of the Arterial Pulse 44

References 46

Chapter 3

Blood Pressure and Its Measurement 49

Physiology of Blood Flow and Blood Pressure 49

Physiology of Blood Pressure Measurement 50

Points to Remember When Measuring Blood Pressure 52

Factors That Affect Blood Pressure Readings 53

Interpretation of Blood Pressure Measurements 54

Use of Blood Pressure Measurement in Special Clinical Situations 56

References 64

Chapter 4

Jugular Venous Pulse 67

Normal Right Atrial Pressure Pulse Contours 68

Jugular Venous Inflow Velocity Patterns and the Relationship to the Right Atrial Pressure Pulse 70

Jugular Venous Flow Events and Their Relationship to Jugular Venous Pulse Contours 74

Normal Jugular Venous Pulse Contour and Its Recognition at the Bedside 81

Individual Components of the Right Atrial Pressure Pulse, Their Determinants, and Their Recognition in the Jugulars 82

Abnormal Jugular Venous Pulse Contours as Related to Abnormal Jugular Venous Flow Velocity Patterns 92

Abnormal Jugular Contours 96

Assessment of Jugular Venous Pressure 105

Clinical Assessment of the Jugular Venous Pulse 107

References 110

Chapter 5

Precordial Pulsations 113

Mechanics and Physiology of the Normal Apical Impulse 113

Physical Principles Governing the Formation of the Apical Impulse 115

Normal Apical Impulse and Its Determinants 118

Assessment of the Apical Impulse 120

Left Parasternal and Sternal Movements 133

Right Parasternal Movement 134

Pulsations Over the Clavicular Heads 134

Pulsations Over the Second and/or Third Left Intercostal Spaces 135

Subxiphoid Impulse 135

Practical Points in the Clinical Assessment of Precordial Pulsations 136

References 138

Chapter 6

Heart Sounds 141

Principles of Sound Formation in the Heart 141

First Heart Sound (S1) 142

Clinical Assessment of S1 and Components 156

Second Heart Sound (S2) 158

Normal S2 159

Abnormal S2 162

Clinical Assessment of S2 174

Opening Snap (OS) 179

Third Heart Sound (S3) 185

Clinical Assessment of S3 198

Fourth Heart Sound (S4) 200

Clinical Assessment of S4 204

References 206

Chapter 7

Heart Murmurs: Part 1 211

Principles Governing Murmur Formation 211

Hemodynamic Factors and Cardiac Murmurs 214

Frequencies of Murmurs 214

Grading of Murmurs 216

Systolic Murmurs 216

Ejection Murmurs 217

Regurgitant Systolic Murmurs 232

Mitral Regurgitation 233

Tricuspid Regurgitation 253

Ventricular Septal Defect (VSD) 258

Clinical Assessment of Systolic Murmurs 265

References 269

Chapter 8

Heart Murmurs: Part II 275

Diastolic Murmurs 275

Diastolic Murmurs of Mitral Origin 275

Diastolic Murmurs of Tricuspid Origin 282

Semilunar Valve Regurgitation 283

Aortic Regurgitation 283

Pulmonary Regurgitation 290

Clinical Assessment of Diastolic Murmurs 292

Continuous Murmurs 294

Persistent Ductus Arteriosus 296

Aorto-Pulmonary Window 298

Sinus of Valsalva Aneurysm 298

Coronary Arteriovenous Fistulae 299

Venous Hum 300

Mammary Souffle 300

Clinical Assessment of Continuous Murmurs 300

Pericardial Friction Rub 302

Innocent Murmurs 303

References 304

Chapter 9

Elements of Auscultation 309

The Stethoscope 309

Auscultation Method 310

References 318

Chapter 10

Pathophysiological Basis of Symptoms and Signs in Cardiac Disease 321

Pathophysiology of Mitral Regurgitation 321

Pathophysiology of Aortic Regurgitation 325

Pathophysiology of Mitral Stenosis 329

Pathophysiology of Aortic Stenosis 331

Pathophysiology of Myocardial Ischemia/Infarction 334

Pathophysiology of Hypertensive Heart Disease 336

Pathophysiology of Dilated Cardiomyopathy 338

Pathophysiology of Hypertrophic Obstructive Cardiomyopathy 340

Pathophysiology of Atrial Septal Defect 342

Pathophysiology of Diastolic Dysfunction 345

Pathophysiology of Constrictive Pericarditis 347

Pathophysiology of Cardiac Tamponade 348

Appendix 351

References 356

Chapter 11

Local and Systemic Manifestations of Cardiovascular Disease 361

General Observations 361

Congenital Syndromes/Diseases 364

Vascular Diseases 369

Valvular Heart Disease 372

Endocrine and Metabolic Diseases 373

Inflammatory Diseases 377

Diseases of Connective Tissue and Joints 377

Pharmacological Agents 381

Musculoskeletal Diseases 384

Tumors 386

Synopsis 386

Acknowledgment 390

References 390

Index 397

About the Authors 413

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