循环系统诊断常见症征课件

SignsandsymptomsofsomecommonheartdiseasesWeiMengShanghaisixthpeople’shospitalShanghaijiaotonguniversitySignsandsymptomsofsomecom1ContentsMitralstenosis(MS)Mitralregurgitation(MR)Aorticstenosis(AS)Aorticregurgitation(AR)PericardialeffusionHeartfailure(HF)ContentsMitralstenosis(MS)2MitralstenosisConditionscausingleftventricularinflowobstructionCongenitalAcquiredValvularmitralstenosisValvularmitralstenosisCortriatriatumAtrialmyxomaSubvalvularringThrombusPulmonaryveinstenosisNeoplasmInfectivevegetationProstheticvalvedisfunctionMitralstenosisConditionscaus3MitralstenosisCauseofMSrequiringintervention(n=1050)CauseNumberpercentageRheumaticfever56253.5Rheumaticequivalent13913.2Scarletfever11110.6Infectiveendocarditis353.3Degenerative282.7Congenital131.2Others16215.5MitralstenosisCauseofMSreq4PathophysiologyofMitralstenosisLVinflowobstructionLeftatrialpressureLungcongestionO2supplyshortagepulmonaryA&Vhypertension(RHF

hemoptysisleftatrialenlargementAtrialfibrillationthrombosis&embolismhoarsenessPathophysiologyofMitralsten5CommonSymptomsofMitralstenosisAsymptomaticsExertionaldyspnea,paroxysmalnocturnaldyspnea,orthopneaPalpitationduetoarhythmiaMiscellaneousHemoptysis,blood-tingesputum,pinkfrothysputum,chestpain,mitralfacies,Cough,hoarseness,dysphagiaCommonSymptomsofMitralsten6RelationbetweendyspneaandMVA

ClassMVA(cm2)manifestationminimal>2.5noneMild1.4~2.5MinimaldyspneawithmarkedexertionModerate1.0-1.4Dyspnea,orthopnea,paroxysmalnocturnaldyspnea,pulmonaryedemaSevere<1.0RestingdyspneaRelationbetweendyspneaandM7SignsofMitralstenosisInspectionMitralfacies,increasedimpulseatprecardialarea&/orwithlocalelevationofthethoraciccavity,thoseduetorightheartfailurePalpationApicalimpulseisnormalordecreasedRightventricularheaveispresentifwithpulmonaryhypertensionApicaldiastolicthrillmaybepresentSignsofMitralstenosisInspec8SymptomsofMitralstenosisPercussionDullnessareaoftheheartshiftstowardtheleftatwaistoftheheartaswellastowardtherightifmarkedenlargementofrightheartAuscultationLouds1OpeningsnapDiastolicrumble,nearapexLoudP2withorwithoutsplitGrahamsteelmurmurMurmurofTRIrregularrhythmSymptomsofMitralstenosisPer9SymptomsofMitralstenosisSymptomsduetochronicHFEdema,Effusion,Hepatomegaly,Jaundice,WetRalesCachexiaSymptomsofMitralstenosisSym10MitralregurgitationEtiologyofMR(1)OrganicMRRheumaticheartdiseaseMyxomatouschanges(mitralvalveprolapse)InfectiousendocarditisChordalraptureordysfunctionofpapillarymusclesCollagenvasculardiseaseTrauma:pentratingornonpeneratingMitralregurgitationEtiologyo11MitralregurgitationEtiologyofMR(2)FunctionalMRCoronaryheartdiseaseHypertrophiccardiomyopathyDilatedcardiomyopathyLeftatrialdilatationMitralregurgitationEtiologyo12PathophysiologyofMRPreloadincreasecausedbybloodreturntotheleftventriclefromLAIncreasedleftatrialvolume&pressureDiastolicvolumeaugmentationVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)PathophysiologyofMRPreloadi13SymptomsofMRAsymptomaticDyspneaonexertion,cough,progressingparoxysmalnocturnaldyspnea,orthopneaultimately,evenacutepulmonaryedema(lessthanMS)FatiguePalpitationduetoarhythmiaAtypicalchestpain,inappropriatesympatheticnervesystemactivation,panicattack(ofteninvalveprolaps)SymptomsofMRAsymptomatic14SignsofMR(1)InspectionSomehavingincreasedimpulseoftheapexPalpationEnhancedapicalimpulseistotheleftlowerPercussionDullnessareaoftheheartshiftstowardtheleftlowerSignsofMR(1)Inspection15SymptomsofMR(2)Auscultation(1)NormalormuffledS1,P2ifpulmonarypressurehighS3iscommon,notalwaysindicatingHFHolosytolicmurmurisclassicalattheapex,radiatingtotheaxillaeventheback,thebaseoftheheart.MurmuratlatesystoliccanbeheardatthevalveprolapseoratmildMRSymptomsofMR(2)Auscultation(16SymptomsofMR(3)Auscultation(2)Music-likemurmurcanbeheardatsevereMR,atthevalveprolapseMidsystolicclickwithorwithoutmurmurpresentsatthevalveprolapseOccasionallydiastolicrumblingcanbeheardatsevereMRbecauseofrelativeMSNomurmurcanbeheardatmildevenmoderateMRsometimeSymptomsofMR(3)Auscultation(17AorticstenosisEtiologyCongenitalBicuspidvalve(verycommon)Fusionofthevalveleaflet(rare)DegenerationRheumaticfeverOthersSLE,ochronosis,severefamilialhyper-cholesterolemiaAorticstenosisEtiology18PathophysiologyofASAfterloadofleftventricleincreasedLVhypertrophy,ischemiaCompliance,LAlarge&pressurehighLowcardiacoutputInsufficientbloodsupplytoheart,brain,kidney,etcPathophysiologyofASAfterload19SymptomsofAS(1)AsymptomaticAnginawithorwithoutcoronaryarterystenosisTypicalchestpainlikeeffortanginaAtypicalchestpainSyncope,usuallyoneffortHeartfailure,diastoliccommon,ComplaintrelatedtoLow(output)BPSymptomsofAS(1)Asymptomatic20signsofAS(1)InspectionPale,carotidpulsationweakenApicalimpulseincreasedOccasionalimpulsecausedbyS4canbeseenPalpationCarotidupstrokelowinvolumeanddelayedForcefulandsustainedapexbeatOccasionaloscillationcausedbyS4ThrillintheaorticareaPercussiondullnessareaoftheheartshiftingleftlowersignsofAS(1)Inspection21SymptomsofAS(2)AuscultationReducedandeveninaudibleA2,paradoxicsplittingP2increasedinpulmonaryhypertensionEjectionmurmurradiatingtothecarotidarterieswithorwithoutthrillintheaorticareaS4causedbyatrialkickagainstthestiffventricleS3inadvancedstageSymptomsofAS(2)Auscultation22DifferentiationofsystolicmurmurFlowTRASMR/VSDMVPHOCMinspiration-or____Stand___Squat___ValsalvaHandgrip__postpvcDifferentiationofsystolicmu23EtiologyofAR(1)AorticcupsabnormalitiesRheumaticfeverInfectiousendocarditisNon-specificinflammation:SLE,rheumatoidarthritis,Behcet’ssyndromeDegenerative:myxomatouschange,calcificationOthers:trauma,postaorticvalvularplasty,dietdrugvalvulopthyEtiologyofAR(1)Aorticcupsa24EtiologyofAR(2)AorticrootabnormalitiesTherootdilatationMarfan’s,syndrome,syphilis,ankylosingspondylitis,relapsingpolychondritis,idiopathicaortitis,annuloaorticectasia,cysticmedialnecrosis,Ehlers-danlossyndromeLossofcommissuralsupportAorticdissection,trauma,ventricularseptaldefectEtiologyofAR(2)Aorticroota25EtiologyofAR(3)IncreasedafterloadHypertensionSupravalvularaorticstenosiEtiologyofAR(3)Increasedaf26PathophysiologyofARPreloadincreasecausedbybloodreturntoLVfromAOIncreasedLVvolume&pressureVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)PathophysiologyofARPreloadi27SymptomesofARAsymptomaticPalpitationduetoforcefulbeatingorarhythmiaChestpain,typicaloratypicalDyspneaonexertion,cough,orthopnea,paroxysmalnocturnaldyspneaSymptomesofARAsymptomatic28SignsofAR(1)InspectionVisiblecardiacimpulseenhancedtowardleftlowerPalpationTheapicalimpulseisincreasedanddisplacedcaudallyandlaterallyAuscultation(1)A2maybedecreased,S4isoftenpresent,S3isaudiblewhenHFoccursSignsofAR(1)Inspection29SignsofAR(2)Auscultation(2)Soft,high-pitchedidastolicdecrescendomurmurisheardbestat3rdintercostalspacealongtheleftsternalborderatendexpirationwiththepatientsittingandleaningforward,maybebestattherightofthesternalinthepresenceofaorticarootdilatationMurmurradiatingtotheleftlowersternumandtheapexSignsofAR(2)Auscultation(2)30SignsofAR(3)Auscultation(3)AsystolicejectionmurmurmaybepresentattheaorticareaAdiastolicmurmurmaybeheardattheapex(Austinflintmurmur)PeripheralsingsPulsepressureisincreased,othersignsSignsofAR(3)Auscultation(3)31OtherperipheralsignsofARCrrigan’spulse(locomotivepulse)RapidandforcefuldistensionofarterialpulsewithquickcollapseDe-Msset’ssignToandfroheadbobingMuller’ssignVisiblepulsationofuvulaQuincke’ssignCapilarypulsationseenonlightcompressionofnailbedTraube’ssignSystolicanddiastolicsounds(pistolshots)overthefemoralarteryDurosier’ssignBruitsheardoverthefemoralarteryonlightcompressionbystethoscopeHill’ssignPoplitealcuffpressureexeedingbrachialpressureby60mmHgorgreaterOtherperipheralsignsofARC32PericardialeffusionEtiology(1)Infection:virus,bacterium,tuberculosis,AIDSMalignancyIatrogeniccauseSurgeryrelatedsyndromeTraumaRadiation

therapyConnectivetissuedisordersPericardialeffusionEtiology(133PericardialeffusionEtiology(2)MyocardialinfarctionAcutephasein1stweekDressler’ssyndrome(postmyocardialinfarctionsyndrome)1-6weeklaterUremiaHypothyroidismDrug-relatedProcainamide,hydralazine,methydopa,etcPericardialeffusionEtiology(234Pathophysiology

ofpericardialeffusionPericardialpressureincreasedObstructionofvenousflowreturnFillingvolumeofLVinsufficientCardiacoutputdecreasedPathophysiology

ofpericardia35PericardialeffusionClassificationAcutepericardialeffusion(pericarditis)ChronicpericardialeffusionCardiacpamponadeConstrictivepericarditisEffusive-constrictivepericarditisPericardialeffusionClassifica36PericardialeffusionSymptomedependsontheeffusivevolumeandtherapidityofaccumulationCommonseenAsymptomaticChestdiscomfort,dyspnea,cough,dysphagia,hoarseness,hiccup,nausea,abdominalfullness,evencardiactamponadeSignsofprimarydiseasesPericardialeffusionSymptome37PericardialeffusionSigns(1)InspectionWeakenpulsationofapex,PalpationApexbeatweakenornotpalpable,ifpalpableithasadistancetothedullnessborderPericardialeffusionSigns(1)38PericardialeffusionSigns(2)PercussionDullnessareaoftheheartisenlargedtobothsidesandtheshapechangeswithbodypositionAuscultationTachycardia,muffuledheartsound,pericardialrubandpericardialknockareinfrequentPericardialeffusionSigns(2)39PericardialeffusionOthermanifestationsPulsepressurenarrowingwithorwithoutBPPulseparadoxus:Pulseweakenordisappearsatinspiratoryphase.inspiratoryfallofsystolicBP>10mmHg.Ewartsignleftlowerlobelungbecomenullnessengorgementofjugularvein,positivesignofhepatojugularrefluxPericardialeffusionOthermani40PericardialtaponadeCirculationcollapseorshockcausedbyrapidorlargevolumefluidaccumulationHR,BPdecreased,pulsusparadoxus,jugularveinpressureExtremitiesarecoldandwetDyspnea,restlessness,diminishedresponse,unconsciousnessPulsepressurediminishedPericardialtaponadeCirculatio41HeartfailureAcomplexclinicalsyndromeinwhichtheheartisincapableofmaintainingacardiacoutputadequatetoaccommodatemetabolicrequirementsandthevenousreturn.HeartfailureAcomplexclinica42EtiologyofHeartFailureWhatcausesheartfailure?Thelossofacriticalquantityoffunctioningmyocardialcellsafterinjurytotheheartdueto:IschemicHeartDiseaseHypertensionIdiopathicCardiomyopathyInfections(e.g.,viralmyocarditis,Chagas’disease)Toxins(e.g.,alcoholorcytotoxicdrugs)ValvularDiseaseProlongedArrhythmiasEtiologyofHeartFailureWhat43VolumeOverloadPressureOverloadLossofMyocardiumImpairedContractilityLVDysfunctionEF<40%Cardiac

OutputHypoperfusionEndSystolicVolumeEndDiastolicVolumePulmonaryCongestion

LeftVentricularDysfunctionVolumePressureLossofImpair4430%70%DiastolicDysfunctionSystolicDysfunction(EF<40%)(EF>40%)LeftVentricularDysfunctionSystolic:Impairedcontractility/ejectionApproximatelytwo-thirdsofheartfailurepatientshavesystolicdysfunction1Diastolic:Impairedfilling/relaxation1Lilly,L.PathophysiologyofHeartDisease.SecondEditionp20030%70%DiastolicDysfunctionSys45HemodynamicBasisfor

HeartFailureSymptomsLVEDPLeftAtrialPressurePulmonaryCapillaryPressurePulmonaryCongestionHemodynamicBasisfor

HeartFa46LeftVentricularDysfunction

SystolicandDiastolicSymptomsDyspneaonExertionParoxysmalNocturnalDyspneaTachycardiaCoughHemoptysisPhysicalSignsBasilarRalesPulmonaryEdemaS3GallopPleuralEffusionCheyne-StokesRespirationLeftVentricularDysfunction

S47RightVentricularFailure

SystolicandDiastolicSymptomsAbdominalPainAnorexiaNauseaBloatingSwellingPhysicalSignsPeripheralEdemaJugularVenousDistentionAbdominal-JugularRefluxHepatomegalyRightVentricularFailure

Syst48

NewYorkHeartAssociation

FunctionalClassificationClassI:

NosymptomswithordinaryactivityClassII:

Slightlimitationofphysicalactivity.Comfortableatrest,

butordinaryphysicalactivityresultsinfatigue,

palpitation,dyspnea,oranginaClassIII:

Markedlimitationofphysicalactivity.Comfortableat

rest,butlessthanordinaryphysicalactivityresultsin

fatigue,palpitation,dyspnea,oranginalpainClassIV:

Unabletocarryoutanyphysicalactivitywithout

discomfort.Symptomsofcardiacinsufficiencymaybe

presentevenatrest

NewYorkHeartAssociation

F49HFClassification:Evolutionand

DiseaseProgressionFourStagesofHF(ACC/AHAGuidelines):StageA:PatientathighriskfordevelopingHFwithnostructuraldisorderoftheheartStageB:PatientwithstructuraldisorderwithoutsymptomsofHFStageC:PatientwithpastorcurrentsymptomsofHFassociatedwithunderlyingstructuralheartdiseaseStageD:Patientwithend-stagediseasewhorequiresspecializedtreatmentstrategiesHunt,SA,etalACC/AHAGuidelinesfortheEvaluationandManagementofChronicHeartFailureintheAdult,2019HFClassification:Evolution50ThanksThanks51谢谢谢谢52SignsandsymptomsofsomecommonheartdiseasesWeiMengShanghaisixthpeople’shospitalShanghaijiaotonguniversitySignsandsymptomsofsomecom53ContentsMitralstenosis(MS)Mitralregurgitation(MR)Aorticstenosis(AS)Aorticregurgitation(AR)PericardialeffusionHeartfailure(HF)ContentsMitralstenosis(MS)54MitralstenosisConditionscausingleftventricularinflowobstructionCongenitalAcquiredValvularmitralstenosisValvularmitralstenosisCortriatriatumAtrialmyxomaSubvalvularringThrombusPulmonaryveinstenosisNeoplasmInfectivevegetationProstheticvalvedisfunctionMitralstenosisConditionscaus55MitralstenosisCauseofMSrequiringintervention(n=1050)CauseNumberpercentageRheumaticfever56253.5Rheumaticequivalent13913.2Scarletfever11110.6Infectiveendocarditis353.3Degenerative282.7Congenital131.2Others16215.5MitralstenosisCauseofMSreq56PathophysiologyofMitralstenosisLVinflowobstructionLeftatrialpressureLungcongestionO2supplyshortagepulmonaryA&Vhypertension(RHF

hemoptysisleftatrialenlargementAtrialfibrillationthrombosis&embolismhoarsenessPathophysiologyofMitralsten57CommonSymptomsofMitralstenosisAsymptomaticsExertionaldyspnea,paroxysmalnocturnaldyspnea,orthopneaPalpitationduetoarhythmiaMiscellaneousHemoptysis,blood-tingesputum,pinkfrothysputum,chestpain,mitralfacies,Cough,hoarseness,dysphagiaCommonSymptomsofMitralsten58RelationbetweendyspneaandMVA

ClassMVA(cm2)manifestationminimal>2.5noneMild1.4~2.5MinimaldyspneawithmarkedexertionModerate1.0-1.4Dyspnea,orthopnea,paroxysmalnocturnaldyspnea,pulmonaryedemaSevere<1.0RestingdyspneaRelationbetweendyspneaandM59SignsofMitralstenosisInspectionMitralfacies,increasedimpulseatprecardialarea&/orwithlocalelevationofthethoraciccavity,thoseduetorightheartfailurePalpationApicalimpulseisnormalordecreasedRightventricularheaveispresentifwithpulmonaryhypertensionApicaldiastolicthrillmaybepresentSignsofMitralstenosisInspec60SymptomsofMitralstenosisPercussionDullnessareaoftheheartshiftstowardtheleftatwaistoftheheartaswellastowardtherightifmarkedenlargementofrightheartAuscultationLouds1OpeningsnapDiastolicrumble,nearapexLoudP2withorwithoutsplitGrahamsteelmurmurMurmurofTRIrregularrhythmSymptomsofMitralstenosisPer61SymptomsofMitralstenosisSymptomsduetochronicHFEdema,Effusion,Hepatomegaly,Jaundice,WetRalesCachexiaSymptomsofMitralstenosisSym62MitralregurgitationEtiologyofMR(1)OrganicMRRheumaticheartdiseaseMyxomatouschanges(mitralvalveprolapse)InfectiousendocarditisChordalraptureordysfunctionofpapillarymusclesCollagenvasculardiseaseTrauma:pentratingornonpeneratingMitralregurgitationEtiologyo63MitralregurgitationEtiologyofMR(2)FunctionalMRCoronaryheartdiseaseHypertrophiccardiomyopathyDilatedcardiomyopathyLeftatrialdilatationMitralregurgitationEtiologyo64PathophysiologyofMRPreloadincreasecausedbybloodreturntotheleftventriclefromLAIncreasedleftatrialvolume&pressureDiastolicvolumeaugmentationVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)PathophysiologyofMRPreloadi65SymptomsofMRAsymptomaticDyspneaonexertion,cough,progressingparoxysmalnocturnaldyspnea,orthopneaultimately,evenacutepulmonaryedema(lessthanMS)FatiguePalpitationduetoarhythmiaAtypicalchestpain,inappropriatesympatheticnervesystemactivation,panicattack(ofteninvalveprolaps)SymptomsofMRAsymptomatic66SignsofMR(1)InspectionSomehavingincreasedimpulseoftheapexPalpationEnhancedapicalimpulseistotheleftlowerPercussionDullnessareaoftheheartshiftstowardtheleftlowerSignsofMR(1)Inspection67SymptomsofMR(2)Auscultation(1)NormalormuffledS1,P2ifpulmonarypressurehighS3iscommon,notalwaysindicatingHFHolosytolicmurmurisclassicalattheapex,radiatingtotheaxillaeventheback,thebaseoftheheart.MurmuratlatesystoliccanbeheardatthevalveprolapseoratmildMRSymptomsofMR(2)Auscultation(68SymptomsofMR(3)Auscultation(2)Music-likemurmurcanbeheardatsevereMR,atthevalveprolapseMidsystolicclickwithorwithoutmurmurpresentsatthevalveprolapseOccasionallydiastolicrumblingcanbeheardatsevereMRbecauseofrelativeMSNomurmurcanbeheardatmildevenmoderateMRsometimeSymptomsofMR(3)Auscultation(69AorticstenosisEtiologyCongenitalBicuspidvalve(verycommon)Fusionofthevalveleaflet(rare)DegenerationRheumaticfeverOthersSLE,ochronosis,severefamilialhyper-cholesterolemiaAorticstenosisEtiology70PathophysiologyofASAfterloadofleftventricleincreasedLVhypertrophy,ischemiaCompliance,LAlarge&pressurehighLowcardiacoutputInsufficientbloodsupplytoheart,brain,kidney,etcPathophysiologyofASAfterload71SymptomsofAS(1)AsymptomaticAnginawithorwithoutcoronaryarterystenosisTypicalchestpainlikeeffortanginaAtypicalchestpainSyncope,usuallyoneffortHeartfailure,diastoliccommon,ComplaintrelatedtoLow(output)BPSymptomsofAS(1)Asymptomatic72signsofAS(1)InspectionPale,carotidpulsationweakenApicalimpulseincreasedOccasionalimpulsecausedbyS4canbeseenPalpationCarotidupstrokelowinvolumeanddelayedForcefulandsustainedapexbeatOccasionaloscillationcausedbyS4ThrillintheaorticareaPercussiondullnessareaoftheheartshiftingleftlowersignsofAS(1)Inspection73SymptomsofAS(2)AuscultationReducedandeveninaudibleA2,paradoxicsplittingP2increasedinpulmonaryhypertensionEjectionmurmurradiatingtothecarotidarterieswithorwithoutthrillintheaorticareaS4causedbyatrialkickagainstthestiffventricleS3inadvancedstageSymptomsofAS(2)Auscultation74DifferentiationofsystolicmurmurFlowTRASMR/VSDMVPHOCMinspiration-or____Stand___Squat___ValsalvaHandgrip__postpvcDifferentiationofsystolicmu75EtiologyofAR(1)AorticcupsabnormalitiesRheumaticfeverInfectiousendocarditisNon-specificinflammation:SLE,rheumatoidarthritis,Behcet’ssyndromeDegenerative:myxomatouschange,calcificationOthers:trauma,postaorticvalvularplasty,dietdrugvalvulopthyEtiologyofAR(1)Aorticcupsa76EtiologyofAR(2)AorticrootabnormalitiesTherootdilatationMarfan’s,syndrome,syphilis,ankylosingspondylitis,relapsingpolychondritis,idiopathicaortitis,annuloaorticectasia,cysticmedialnecrosis,Ehlers-danlossyndromeLossofcommissuralsupportAorticdissection,trauma,ventricularseptaldefectEtiologyofAR(2)Aorticroota77EtiologyofAR(3)IncreasedafterloadHypertensionSupravalvularaorticstenosiEtiologyofAR(3)Increasedaf78PathophysiologyofARPreloadincreasecausedbybloodreturntoLVfromAOIncreasedLVvolume&pressureVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)PathophysiologyofARPreloadi79SymptomesofARAsymptomaticPalpitationduetoforcefulbeatingorarhythmiaChestpain,typicaloratypicalDyspneaonexertion,cough,orthopnea,paroxysmalnocturnaldyspneaSymptomesofARAsymptomatic80SignsofAR(1)InspectionVisiblecardiacimpulseenhancedtowardleftlowerPalpationTheapicalimpulseisincreasedanddisplacedcaudallyandlaterallyAuscultation(1)A2maybedecreased,S4isoftenpresent,S3isaudiblewhenHFoccursSignsofAR(1)Inspection81SignsofAR(2)Auscultation(2)Soft,high-pitchedidastolicdecrescendomurmurisheardbestat3rdintercostalspacealongtheleftsternalborderatendexpirationwiththepatientsittingandleaningforward,maybebestattherightofthesternalinthepresenceofaorticarootdilatationMurmurradiatingtotheleftlowersternumandtheapexSignsofAR(2)Auscultation(2)82SignsofAR(3)Auscultation(3)AsystolicejectionmurmurmaybepresentattheaorticareaAdiastolicmurmurmaybeheardattheapex(Austinflintmurmur)PeripheralsingsPulsepressureisincreased,othersignsSignsofAR(3)Auscultation(3)83OtherperipheralsignsofARCrrigan’spulse(locomotivepulse)RapidandforcefuldistensionofarterialpulsewithquickcollapseDe-Msset’ssignToandfroheadbobingMuller’ssignVisiblepulsationofuvulaQuincke’ssignCapilarypulsationseenonlightcompressionofnailbedTraube’ssignSystolicanddiastolicsounds(pistolshots)overthefemoralarteryDurosier’ssignBruitsheardoverthefemoralarteryonlightcompressionbystethoscopeHill’ssignPoplitealcuffpressureexeedingbrachialpressureby60mmHgorgreaterOtherperipheralsignsofARC84PericardialeffusionEtiology(1)Infection:virus,bacterium,tuberculosis,AIDSMalignancyIatrogeniccauseSurgeryrelatedsyndromeTraumaRadiation

therapyConnectivetissuedisordersPericardialeffusionEtiology(185PericardialeffusionEtiology(2)MyocardialinfarctionAcutephasein1stweekDressler’ssyndrome(postmyocardialinfarctionsyndrome)1-6weeklaterUremiaHypothyroidismDrug-relatedProcainamide,hydralazine,methydopa,etcPericardialeffusionEtiology(286Pathophysiology

ofpericardialeffusionPericardialpressureincreasedObstructionofvenousflowreturnFillingvolumeofLVinsufficientCardiacoutputdecreasedPathophysiology

ofpericardia87PericardialeffusionClassificationAcutepericardialeffusion(pericarditis)ChronicpericardialeffusionCardiacpamponadeConstrictivepericarditisEffusive-constrictivepericarditisPericardialeffusionClassifica88PericardialeffusionSymptomedependsontheeffusivevolumeandtherapidityofaccumulationCommonseenAsymptomaticChestdiscomfort,dyspnea,cough,dysphagia,hoarseness,hiccup,nausea,abdominalfullness,evencardiactamponadeSignsofprimarydiseasesPericardialeffusionSymptome89PericardialeffusionSigns(1)InspectionWeakenpulsationofapex,PalpationApexbeatweakenornotpalpable,ifpalpableithasadistancetothedullnessborderPericardialeffusionSigns(1)90PericardialeffusionSigns(2)PercussionDullnessareaoftheheartisenlargedtobothsidesandtheshapechangeswithbodypositionAuscultationTachycardia,muffuledheartsound,pericardialrubandpericardialknockareinfrequentPericardialeffusionSigns(2)91PericardialeffusionOthermanifestationsPulsepressurenarrowingwithorwithoutBPPulseparadoxus:Pulseweakenordisappearsatinspiratoryphase.inspiratoryfallofsystolicBP>10mmHg.Ewartsignleftlowerlobelungbecomenullnessengorgementofjugularvein,positivesignofhepatojugularrefluxPericardialeffusionOthermani92PericardialtaponadeCirculationcollapseorshockcausedbyrapidorlargevolumefluidaccumulationHR,BPdecreased,pulsusparadoxus,jugularveinpressureExtremitiesarecoldandwetDyspnea,restlessness,diminishedresponse,unconsciousnessPulsepressurediminishedPericardialtaponadeCirculatio93HeartfailureAcomplexclinicalsyndromeinwhichtheheartisincapableofmaintainingacardiacoutputadequatetoaccommodatemetabolicrequirementsandthevenousreturn.HeartfailureAcomplexclinica94EtiologyofHeartFailureWhatcausesheartfailure?Th