The following are iterative notes that I take while studying for my general cardiology, echocardiography, and nuclear cardiology board exams. Making them public so I can access them on the go and help out anyone else looking for similar information.
Valvular Heart Disease
Aortic Insufficiency/Regurgitation (AI/AR)
Severe AI, indications for surgery
- Asymptomatic: EF ≤55%
- Asymptomatic: EF >55% + LVESD >50mm or LVESDi >25mm/m2
- Asymptomatic: EF >55% with progressive decline in EF to low-normal (55-60%) with LVEDd >65mm
- Symptomatic
- Other concurrent cardiac/aortic surgery
Aortic Stenosis
Bicuspid Aortic Valve
Surgical indications for dilated aortic root/ascending aorta
| Aorta size | Indication | Class recomendation |
|---|---|---|
| ≥ 5.5 cm | Risk factors for dissection (FH, growth rate >0.5cm/year, bicuspid AV) | I |
| > 5.0 cm | Risk factors and low surgical risk <4% (FH of dissection, growth 3-5mm/year, aortic coarctation, small stature) | IIa |
| > 5.0 cm | Low risk, experienced surgeon, expert center | IIa |
| > 4.5 cm | Bicuspid AV planning for surgical AVR for AS/AI | IIa |
*Aortic root measured at sinus of Valsalva
Mitral Regurgitation
Simplified asymptomatic severe primary MR algorithm 
Primary mitral regurgitation (MR) algorithm 
Qualitative and quantitative MR by echocardiography (TTE) 
Abnormal function of any one of the structures may result in MR 
Etiologies of chronic mitral regurgitation (MR)- acute and chronic 
Pathophysiology of acute and chronic MR 
Qualitative assessment of MR 
MR algorithm 
Mitral valve prolapse and flail
Carpentier Classification of MR
- Type 1: normal leaflet mobility (primary: endocarditis, perforation, clefts; secondary: dilated annulus)
- Type 2: excessive leaflet mobility (prolapse, flail)
- Type 3: restricted leaflet motion
- 3a: in systole and diastole (Fibrosis of subvalvular apparatus: rheumatic, radiation, drug-induced injury, inflammatory conditions)
- 3b: only in systole (Leaflet or chordal tethering: ICM, NICM causing LV dilation)
Mitral Valve Regurgitation Review Article
Chronic MR Algorithms
Qualitative and Quantitative Assessment of MR severity by echo 
Recommended Treatment of severe secondary MR 
Severe MR Algorithm 
Recommended Treatment of severe secondary MR 
Algorithm for Eligibility of Transcatheter Edge-to-Edge Repair (TEER) of severe MR 
Semiquantitative parameters in MR 
Quantitative measures for severe MR by PISA 
Pulsed Doppler Volumetric Quantification of severe MR 
Indications for exercise stress testing in MR 
Routine monitoring of MR via echo 
MR treatment algorithm
- Chronic MR, Houston Methodist Power Point
- American Society of Echocardiography: valvular regurgitation cases
Indications for TTE, TEE in MR
- Initial evaluation if suspicious for MV disease or MVP
- Initial evaluation of known ur suspected MR
- Annual evaluation in severe MR
- Reevaluation of MR with change in clinical status
- TEE to determine mechanism of MR and suitability of valve repair
- *Inappropriate: routine evaluation of MVP with (1) no or mild MR and (2) no change in clinical status
Mitral Valve Prolapse (MVP)
Arrhythmic MVP
- Non-invasive markers associated with sudden cardiac death (SCD) despite not having severe MR
- High density of PVCs, inferior TWI, spiked systolic high-velocity signal on echo (Pickelhaube sign), myocardial/papillary scar on MRI
- Pickelhaube sign: peak systolic lateral mitral annular velocity ≥16 cm/s. More likely to have malignant arrythmia in those with myxomatous bileaflet MVP (‘B’ in image below)
Acute Severe MR
- Rapid equalization of pressure across LA/LV may only cause a short, unimpressive murmur (may only appear as mild MR)
- *Suspect in acute heart failure with normal LV systolic function
- *Suspect in decreased LVOT VTI despite hyperdynamic LV EF (suggestive of low forward flow- consistent with severe MR)
Mitral Stenosis
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease
Invasive Hemodynamics Review
Classic Valvular Murmurs
| Lesion | Timing | Quality | Radiation | Severity |
|---|---|---|---|---|
| AS | Crescendo-decrescendo Gap between S1, murmur, and S2 | Harsh, noisy | ||
| MR | Holosystolic through S2 Starts with S1 through S2 | Blowing, high pitched | Anterior prolapse/flail: axilla, left intrascapular area Posterior: anteriorly along aortic outflow in left parasternal area (can be confused with SEM) | Weak correlation between intensity and severity S3: increase in diastolic flow across MV orifice during rapid filling phase Increased P2 intensity: pHTN Enlarged, displaced LV impulse: LV dilation |
| Post PVC | MR changes little: high gradient between LA/LV in SR and post-PVC | *AS murmur increases post-PVC as SV after PVC is greater (more flow) | ||
| MVP | Early, mid-systolic click ➡️ systolic murmur | ±High pitched, ‘whoop’ sound | Maneuvers on click and murmur: – ⬇️ LV volume/preload (Valsalva, squat to stand): murmur/click occur earlier in systole – ⬆️ LV afterload (squatting): murmur/click occur later in systole | Severe MVP: holosystolic murmur |
Prosthetic Valves
Prosthetic Aortic Valves
Pressure recovery: due to small aorta causing falsely elevated mean gradient readings and thus low AVA
Prosthetic Valve Thrombosis
Urgent-surgery-compared-with-fibrinolytic-therapy-for-the-treatment-of-left-sided-prosthetic-heart-valve-thrombosis-a-systematic-review-and-meta-analysis-of-observational-studiesDownload
Prosthetic Valve Guidelines from JASE (Journal of American Society of Echocardiography)
Heart Failure
Non-Ischemic Cardiomyopathy (NICM)
2022 AHA/ACC/HFSA Guidelines
2022-AHAACCHFSA-Guideline-for-the-Management-of-Heart-Failure-A-Report-of-the-American-College-of-CardiologyAmerican-Heart-Association-Joint-Committee-on-Clinical-Practice-Guidelines-Download
Abnormalities in Hepatic Vein Flow on Doppler
Amyloidosis
Diagnostic algorithm for diagnosis of amyloidosis
Treatment for ATTR amyloidosis
Cardiac-Amyloidosis-Evolving-Diagnosis-and-Management-A-Scientific-Statement-From-the-American-Heart-AssociationDownload
Medical therapies for amyloid
- Tafamadis: amyloidosis but not NYHA IV
- Patisiran: for ‘papa’- familial amyloid neuropathy
Pulmonary Hypertension (pHTN)
| Peak TR jet velocity (m/s) | Presence of other echo ‘PH Signs’ | TTE probability of pHTN |
|---|---|---|
| ≤2.8 or not measurable | No | Low |
| ≤2.8 or not measurable | Yes | Intermediate |
| 2.9-3.4 | No | Intermediate |
| 2.9-3.4 | Yes | High |
| >3.4 | Not required | High |
Echo Findings in Pulmonary Hypertension (pHTN)
| Ventricles | Pulmonary Artery | IVC, RA |
|---|---|---|
| RV/LV basal diameter ratio >1 | RVOT acceleration time (AT) <105ms ±midsystolic notching | IVC >21mm, <50% inspiratory collapse with sniff (or <20% with quiet inspiration) |
| IVS flattening | Early diastolic PI velocity >2.2m/s | RA size >18cm2 at end-systole |
| PA diameter >25mm |
Chagas Cardiomyopathy
Hypertrophic Cardiomyopathy (HCM)
| Surgical options and complications | Septal myectomy –> LBBB Alcohol septal ablation —> RBBB |
| Dysopyramide | QT-prolongation |
| Physical exam maneuvers | Louder murmur with Valsalva (decreased preload)Softer murmur with hand grip |
| High risk features for SCD | 1. First degree relative SCD 2. IVSd ≥30mm (IIa indication: ICD for primary prevention) 3. Unexplained syncope in past 6 months 4. LV apical aneurysm 5. EF <50% 6. NSVT: children (IIa), adults (IIb) 7. Extensive LGE on CMR (IIb) 8. Exercise induced NSVT or abnormal BP response to (drop ≥20mmHg) + high risk features (IIa- it is IIb if no high risk features) |
Echo following septal myectomy for HCM with edge-to-edge (Alfieri) repair of the mitral valve
- Anterior and posterior leaflets are sutured together in the mid portion giving the typical appearance of a double-orifice mitral valve
- The color jet that can be seen on the septal wall represents flow from a coronary-LV fistula, a common benign finding after septal myectomy procedures
- May lead to functional mitral stenosis (MS) requiring surgical interventions following edge-to-edge repair
Coronary Artery Disease
Guidelines/Review Articles
CABG (coronary artery bypass graft) Guidelines
UA/NSTEMI
- TIMI risk score for UA/NSTEMI: predicts all-cause mortality, new/recurrent MI, severe recurrent ischemia requiring urgent revascularization through 14 days
- GRACE score for UA/NSTEMI: predicts in-hospital mortality and death or MI
- Risk stratification into ischemia guided, immediate invasive
NSTEMI: Early invasive strategy (within 24 hours) if:
- Elevated troponin
- Dynamic ST-changes
- Recurrent angina
- EF <40%
- Recent PCI
- Prior CABG
- DM
- Intermediate/high risk score (GRACE >140)
2014-AHAACC-Guideline-for-the-Management-of-Patients-With-Non–ST-Elevation-Acute-Coronary-SyndromesDownload
ACS Medications and Anti-Platelet Agents
NTg and PDE5i interaction
- NTg contraindicated 24 hours of last use of sildenafil (Viagra, Revatio)
- NTg cointraindicated 48 hours of last use of tadalafil (Cialis)
Coronary Microvascular Dysfunction
- Coronary flow reserve (CFR) <2.5 indicative of microvascular disease in the absence of obstructive epicardial CAD
- Treatment: ± beta blockers, CCB but not definitive guideline
Coronary Flow Reserve
- iFR ≤0.89 or FFR <0.8
STEMI
- RCA vs. LCX: STE III >II indicates RCA
Spontaneous Coronary Artery Dissection
- Risk factors: fibromuscular dysplasia (FMD), postpartum status, multiparity, connective tissue disorders, systemic inflammatory conditions, and hormonal therapy
- FMD screening: screen for extracoronary disease from brain to pelvis with CTA or contrast-enhanced MRA for aneurysms, dissections, and other areas of FMD
- Renal aneurysms: treat when >2cm
- Renal stenosis: balloon angioplasty > stenting. Stent reserved for procedural complications (i.e. dissection)
General Cardiology
Guideline Indications
| Treatment | Indication |
| Entresto | HFrEF (≤40%) and NYHA II, III |
| Ivabridine | HFrEF (≤35%) at max tolerated dose of bb in SR with HR ≥70bpm |
| IV iron sucrose or ferric carboxymaltose | NYHA II, III and at least 1 of the following: 1. Ferritin <100 ng/mL2. Ferritin 100-299 ng/mL but iron sat <20% |
| Patisiran | Familial amyloid neuropathy |
| ICD, primary prevention | 1. EF ≤35%, NYHA II, III due to N/ICM 2. EF ≤30%, NYHA I, II, III |
| CRT indications | 1. LBBB with QRS ≥150 msec 2. EF ≤35% 3. NYHA II, III or ambulatory type IV 4. Already on GDMT (LOE A for NYHA class III, IV and LOE B for NYHA class II) |
ICD Indications
| EF | NYHA | Etiology | Class Indication |
|---|---|---|---|
| ≤35% | II-III | N/ICM | I |
| ≤35% | I | NICM | IIb |
| ≤30% | I | ICM | I |
| ≤40% | Inducible VT/VF on EPS | ICM | I |
| >55% | Inducible VT/VF on EPS with extensive scarring on PET/MRI | Brugada | IIb |
| >55% | Inducible VT/VF on EPS with extensive scarring on PET/MRI | Sarcoid | IIa |
Hypertension (HTN)
| Type | Definition |
|---|---|
| Resistent HTN | ≥130/80 on 3 meds for ≥ 1 month |
| Refractory HTN | Not adequately controlled on 5 meds |
| Pseudoresistent | White coat HTN |
| Masked | Normal in office, high at home |
Genetics
| Mutation | Associated Disease |
|---|---|
| Lamin A/C | Skeletal muscle dystrophies |
| Notch 1 | Bicuspid AV, early AV calcification |
| T-box 5 | Holt-Oram syndrome (abnormal thumbs, ASD, VSD, HCM, conduction disease) |
| FBN1 | Fibrillin-1. 90% AD for Marfan syndrome |
| COL3A1 | Collagen- Ehlers-Danlos syndrome |
Long QT-Syndromes
| Syndrome | Gene | Functional Effect | Association | Inheritance |
|---|---|---|---|---|
| LQTS 1 | KCNQ1 | ⬇️ IKS | Swimming | AD; AR, ~30-35% |
| LQTS 2 | KCNH2 | ⬇️ IKR | Startle | AD, ~25-30% |
| LQTS 3 | SCN5A | ⬆️ INA | Sleep | AD, ~5-10% |
| JLNS 1, 2 | KCNQ1, KCNE1 | ⬇️ IKR | Deafness | AR, very rare |
Genetic Screening
- Start with index family member with unknown or uncertain patterns (athletes with LVH or apical hypertrophy)
- Idiopathic dilated cardiomyopathy without known mutation in family: first degree relatives TTE q3-5 years
Physical Exam
| Murmur | Lesion | Location Best Heard |
|---|---|---|
| Fixed split S2 | ASD | |
| Single 2nd heart sound | TOF | |
| Absent A2 | AS | |
| Absent P2 | Pulmonary stenosis | |
| Loud P2 | pHTN | |
| Worsens with Valsalva | HOCM (decreased preload) | |
| Diastolic murmur? | Subaortic membrane | |
| Early systolic click | Bicuspid AV (stiff but mobile) | Left 2nd IC space, apex |
| Mid-systolic click | MVP | Left lower sternal border |
| Diastolic opening snap | MS (and diastolic rumble) | Left lower sternal border in LLD position |
JVD Physical Exam Findings
| Diagnosis | JVD Finding |
|---|---|
| Constrictive pericarditis | Prominent Y descent, ±prominent X descent |
| Tamponade | Prominent X descent, absent Y descent |
| RV infarction | Absent X and Y descent |
| VT, CHB | Variable size A-waves (‘cannon A-wave’) |
Vascular Diseases
Abdominal Aortic Aneurysm (AAA)
Society for Vascular Surgery recommendations, surveillance intervals for asymptomatic AAA:
- >2.5 cm but <3.0 cm, rescreen after 10 years
- 3.0-3.9, repeat imaging every 3 years
- 4.0-4.9, repeat imaging in 12 months
- 5.0-5.4, repeat imaging in 6 months
Indications for elective repair of an asymptomatic AAA include:
- >2.5 cm but ≤5.5 cm
- rapid expansion
- AAA associated with peripheral arterial aneurysms or peripheral artery disease.
May-Thurner Syndrome
| Pathophysiology | Anatomical variant: right common iliac artery overlies and compresses the left common iliac vein against lumbar spine |
| Risk factors | Left lower DVT Scoliosis Female sex OCP use or recent pregnancy Left lower extremity swelling in absence of DVT |
| Clinical presentation | Young adult woman with left leg swelling and DVT |
| Diagnostic test | Magnetic resonance venography of the pelvis |
1. Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proc (Bayl Univ Med Cent) 2012;25:231-3.
2. Baglin T, Gray E, Greaves M, et al.; British Committee for Standards in Haematology. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol 2010;149:209-20.
3. Society for Vascular Medicine. Five Things Physicians and Patients Should Question (Choosing Wisely website). 2015. Available at: http://www.choosingwisely.org/wp-content/uploads/2015/02/SVM-Choosing-Wisely-List.pdf. Accessed 03/22/2019.
Electrophysiology (EP)
CRT Indications
Antiarrhythmic Medications
| Syndrome | Gene | Miscellaneous | |
|---|---|---|---|
| ARVC | PKP-2 | Plakophillin-2 | Intracellular calcium signaling abnormality |
| ARVC | DSP | Desmoglein-2 | Intracellular calcium signaling abnormality |
| ARVC | DSC2 | Desmocollin-2 | Intracellular calcium signaling abnormality |
| ARVC | JUP | Plakoglobin | Intracellular calcium signaling abnormality |
| Marfan | FBN1 | Fibrillin-1 | Associated with aortic aneurysm, dissection |
| Ehlers-Danlos | COL3A1 | Collagen type 3, a1 | Associated with aortic aneurysm, dissection |
| Loeys-Dietz | TGFB1, 2 | Transforming growth factor | Associated with aortic aneurysm, dissection |
| CPVT1 | RYR-2 | Ryanodine receptor | AD (>70% of cases, intracellular Ca-signaling) |
| CPVT2 | CASQ2 | Calsequestrin | AR inheritence |
| LQTS1 | KCNQ1 | K current IKs | bb (nadalol > propanalol) ***Associated with SCD while swimming |
| LQTS2 | KCNH2 | K current IKr | K-supplementation (IIb rec) |
| LQTS3 | SCN5A | alpha-unit of INa | ±Mexilitine (IIb rec) GAIN of function mutation |
| Brugada | SCN5A | LOSS of function mutation | |
| Hereditary PAH | BMPR-2 | Bone morphogenic protein receptor | Associated with >70% of inherited pulmonary arterial HTN |
| DCM | Lamin A/C | ± skeletal muscle dystrophy | |
| T-box5 | Holt-Oram (hand heart, ASD) | ||
| Notch 1 | Bicuspid AV, premature AV calcification |
Supraventricular Tachycardia (SVT)
Early Afterdepolarization (EAD) and Delayed Afterdepolarization (DAD)
Localizing VT Origin: LVOT vs. RVOT
- Step 1: V1
- LBBB: anterior to posterior- RVOT
- RBBB: posterior to anterior- LVOT
- Step 2: concordance
- Positive: originates near base
- Negative: originates near apex
- RVOT: later R-wave transition (≥V3)
- LVOT: earlier R-wave transition, LBBB, inferior axis
Bidirectional Ventricular Tachycardia (aka CPVT or catecholaminergic polymorphic VT)
- Also known as Familial polymorphic VT
- Inheritance: RyR2 gene mutation is AD, CASQ2 gene mutation is AR
- Treatment: Nadolol (non-selective β1 and β2 agonist)
- Dose: 0.8 mg/kg of nadolol ~ 1 mg/kg of metoprolol SR
- Flecainide also used (ask EP)
2:1 AV Block
| AV node | HPS | |
|---|---|---|
| Type of Block | Mobitz I >> Mobitz II | Mobitz II > Mobitz I |
| Conducted QRS | Narrow (unless preexisting BBB) | Wide (except intra-His block) |
| Escape rhythm | Reliable (narrow QRS) | Unreliable (wide QRS) |
| PR on conducted beats | Long | Normal |
| *Carotid sinus pressure | Block worsens | Blok improves |
| *Exercise/atropine | Improves block | Block worsens |
Stroke (CVA) Management
Blood Pressure
- If tPA used: BP should be lowered <180/110 prior to tPA administration
- After tPA: <180/105 for at least 24 hours post-tPA
- No tPA: only treat if >220/120
- Can treat if no tPA plus other reason to treat (Aortic dissection, pre/eclampsia, unstable CAD, acute HF)
CHA2DS2-VASc
- 2 points: age ≥ 75 years and history of stroke/TIA/thromboembolism
Contraindications (CI) to tPA
| Absolute | Relative |
|---|---|
| History of hemorrhagic stroke or stroke unknown origin | TIA in prior 6 months |
| CVA within previous 6 months | Oral anticoagulation |
| CNS neoplasm | Pregnancy or first post-partum week |
| Major trauma, surgery, or head injury in past 3 weeks | Non-compressible puncture site |
| Bleeding diathesis | Traumatic resuscitation |
| Active bleeding | Refractory HTN (sBP > 180) |
| Advanced liver disease | |
| Infective endocarditis | |
| Active peptic ulcer |
Pulmonary Embolism
Cardiac Oncology
- Dexrazoxane: prevent anthracycline-induced cardiotoxocity
- Anthracycline cardiotoxicity: risk if >250mg/m2
Congenital Heart Disease (CHD)
D-Loop Transposition of the Great Arteries (D-TGA)
- Atrio-ventricular concordance and ventricular arterial discordance
- 2nd most common cyanotic congenital lesion (#1 is ToF)
- Associated defects: VSD (~40%), pulmonic stenosis (PS), coronary artery anomalies
Complications Following D-TGA Surgical Correction: Arterial Switch (Mustard/Senning Procedure)
- Arrhythmia: sinus node dysfunction, frequent SVT
- Systemic RV: 25% develop heart failure in their 30’s
- Tricuspid regurgitation (TR): functional due to annular dilation
Complications Following D-TGA Surgical Correction: Atrial Switch
- Supravalvular AS, pulmonic stenosis (AS), PPS (pulmonary artery stenosis)
- Coronary stenosis at re-implantation site
- Branch pulmonary artery stenosis
- Neo-aortic dilation and AI
L-TDA (or congenitally corrected-TGA)
- Double-discordance (RA to LV to PA, LA to RV to aortia)
- Non-cyanotic
- Treat severe TR like severe MR in normal patients
- Complications: TR, RV dysfunction, CHB (complete heart block)
Biostats
| Term | Definition | Example |
|---|---|---|
| Relative risk reduction (RRR) | Rate in treatment/rate in placebo | 10%/20%=0.5 |
| Absolute risk reduction (ARR) | (Rate in placebo)-(rate in treatment) | 20%-10%=10% or 0.1 |
| Number needed to treat (NNT) | 1/(ARR) | 1/(0.1)=10 so treat 10 patients over 2 years to prevent 1 event |
Echocardiography
Physics
Speed of sound propagation through tissue: 1540 m/s
Mitral Valve Leaflets on TEE
Stress Testing
Duke Treadmill Score= minutes of exercise – (5 x mm of ST-depression) – (4 x anginal index)
- Anginal index: 0 for no angina, 1 for non-limiting angina, 2 for having to stop exercise due to angina
- Positive score is good. Possible to get a negative score
- Score ≤ -11 is high risk (79% survival at 5 years), -10 to +4 is medium risk (95% survival at 5 years) ≥5 is low risk (99% 5 year survival)
- Consider LHC for high risk patients (≤ -11)
Nuclear Cardiology
Interpretation of SPECT/ CT Myocardial Perfusion Images: Common Artifacts and Quality Control TechniquesDownload
Occupational Dose Limits
1 Rem = 0.01 Sv (international standard unit)
| Location | Rem | Sv |
|---|---|---|
| Whole body (organs) | 5 Rem | 0.05 Sv |
| Skin | 50 Rem | 0.5 Sv |
| Lens of eye | 15 Rem | 0.15 Sv |
| Pregnant workers (Over gestation period) | 500 mRem | 5 mSv |
| Fetus (non-occupational worker) | 500 mRem | 5 mSv |
| General public | 100 mRem | 1 mSv |
Shielding
Alpha particles
| Particle type | Shield requirement |
|---|---|
| Alpha particles | Sheet of paper |
| Beta particles | Plastic/clothing |
| Gamma rays | Inches/feet of concrete or lead |
Common artifacts
- LBBB: anterior septum (occurs least frequently with NM stress)
Abnormal TID (~1.36, exercise ≥1.29) with normal perfusion: special considerations
- HTN with LVH
- Difference in HR between rest and stress
- Technical difficulties in image acquisition