Learning Cardiology

Frank sign-  Diagonal ear lobe crease (DELC) sign The Frank's sign is a diagonal crease in the earlobe that runs backward from the tragus at a 45-degree angle across the lobule to the rear edge of the auricle and may be a predictor of coronary artery disease. Frank sign is indicative of coronary artery disease (CAD). Frank's sign is thought to indicate premature aging and loss of dermal and vascular elastic fibers.  Although it has limited sensitivity, the sign is more useful diagnostically in persons younger than 60 years of age than in older persons. Sensitivity of 43% and specificity of 70% Pathophysiology: Microvascular disease of ear lobe which is end artery territory Grading system for severity of CAD                • Unilateral incomplete – least severe                • Unilateral complete                • Bilateral complete – most severe                Other classifications systems exist, but without the association with                       

NORMAL CARDIAC ANATOMY The anterior mitral leaflet is in fibrous continuity with the aortic valve and fibrous skeleton. The posterior leaflet is attached to the pliant endocardium instead of rigid fibrous skeleton. For this reason, annular dilatation, a cause of MR, has a greater effect on posterior leaflet function than on anterior leaflet function Figure 1: Dark chambers in the image are RA and RV, Bright chambers are LA and LV,  Black arrow is left ventricular outflow tract. Figure shows continuity between anterior mitral leaflet ( white arrow ) and left ventricular outflow tract leading to aorta SUBMITRAL LEFT VENTRICULAR ANEURYSM   1. Congenital origin or predisposition 2. Junctional defect between cardiac muscle  and fibrous structure of heart 3. Can extend behind LA, LV 4. Aneurysmal growth causes mitral apparatus distortion and can lead to MR and cardiac failure 5. Should be suspected with embolism and ventricular arrhythmias and absence of

The reported incidence of femoral artery pseudoaneurysms varies widely in the literature, with some society guidelines expecting an acceptable rate of less than 0.2%.  Management:  Size less than 3 cm - Follow up with serial duplex till spontaneous thrombosis Size more than 3 cm or more than 1 cm with expected poor compliance, pain or growth during follow up - DGTI ( duplex guided thrombin injection ) Size less than 1 cm which fails to resolve at 6 weeks or associated with arteriovenous fistula - DGC ( duplex guided compression )

SEGMENTAL ARTERIAL MEDIOLYSIS - Rare, non arteriosclerotic, non inflammatory vascular disease of unknown origin - Involves visceral arteries of abdomen - Any vessel may be involved with skip pattern - No predilection for bifurcation - Dilatations, saccular aneurysms, dissecting aneurysms, stenosis, thrombosis/occlusion

FIBROMUSCULAR DYSPLASIA  - Idiopathic, segmentary, non inflammatory, non atherosclerotic - All layers of small and medium sized arteries involved - 4-6% prevalence in renal arteries and 0.3-3% in cervico-encephalic arteries - In more than half the cases, lesions are bilateral - Branch or bifurcation involvement also seen -Multifocal string of beads lesions seen in 84% of the cases -Almost any artery can be involved including mesenteric, brachial and iliac

MYCOTIC ANEURYSMS -Term coined by Osler to describe aneurysms associated with bacterial endocarditis -Emboli occludes vasa vasorum or vessel lumen causing vascular wall infection -Embolism occurs in 25-50% of patients but only 1-5% develop symptomatic mycotic aneurysms -Most commonly seen in the intracranial arteries , followed by visceral arteries and upper or lower  extremely -Typically involve bifurcation

vEDS: - Group of clinically and genetically heterogeneous disorders - Also known as Type IV EDS - Prevalence 1 in 250000 - Autosomal dominant - Mutation in COL3A1 - type III collagen alpha chain 1 - Characterised by aneurysm, dissection or rupture of medium-sized abdominal arteries and abdominal aorta - No predisposition for aortic root involvement - most patients will have one complication by the age of 40 years

Pulmonary hypertension Pulmonary arterial hypertension is restricted to those with a hemodynamic profile in which high pulmonary pressure is a  result of elevated precapillary pulmonary resistance and normal pulmonary venous pressure which is measured as a pulmonary wedge pressure of 15 mmHg or less. Definition: Resting mean pulmonary artery pressure of 25 mm Hg or more at catheterization of right heart. This is the hemodynamic feature which is shared by all types of pulmonary hypertension in Dana point classification system. CLASSIFICATION OF PULMONARY HYPERTENSION Pulmonary hypertension resulting from heart disease (group 2) implies an increase in pulmonary arterial pressure due to backward transmission of pressure elevation. Precapillary pulmonary hypertension such as that resulting from lung disease is group 3. Chronic thromboembolic pulmonary hypertension is group 4. Disease resulting from multifactorial mechanisms is group 5. Important point to no

Shone complex -Shone complex is a rare combination of subvalvular aortic stenosis, supravalvular mitral membrane, parachute mitral valve, and coarctation of aorta. -A parachute mitral valve occurs when all the chordae arise from a single, fused papillary muscle. -This abnormality is associated with mitral stenosis of various degrees and with Shone syndrome.

DEEP VEIN THROMBOSIS   (DVT)- Definitions Unprovoked deep vein thrombosis implies that no identifiable provoking environmental event for DVT is evident. Proximal DVT is one that is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins). TREATMENT -  (1) MEDICAL Anticoagulation is the mainstay of therapy. Acute symptomatic proximal DVT - anticoagulation (Grade 1B), provided the risk of bleeding is not high. Asymptomatic proximal DVT - anticoagulation Symptomatic isolated distal DVT - anticoagulation For select patients with isolated distal DVT (eg, those at high risk of bleeding, negative D-dimer level, asymptomatic or minor symptoms, without risk factors for extension, and/or minor thrombosis of the muscular veins), surveillance with serial ultrasound over a two-week period rather than anticoagulat

There are three possible arrangements: Solitus (normal) Inversus (mirror image of normal), and Ambiguous (not clearly solitus or inversus ). Here the thoracic and abdominal organs cannot be lateralized and have neither the normal nor mirror image arrangement. CARDIAC ORIENTATION- Relationship or axis of the base to the apex of the heart Levocardia is defined as a normal cardiac position with the cardiac base-to-apex axis pointing from upper right to lower left. Dextrocardia refers to a heart with the base-to-apex axis pointing from the upper left to the lower right. Mesocardia refers to a heart that is usually in the midline with the base-to-apex axis directly from superior to inferior. So, the normal arrangement is Situs Solitus with Levocardia And the mirror image of it is called Situs Inversus with Dextrocardia LAST 3 POINTS ( most important ones actually ) 1) The normal arrangement is Situs Solitus with Levocardia And the mirror image

ISOMERISM - The term “isomerism” has been used to describe the combination of atrial situs ambiguity (heterotaxy) and visceral heterotaxy.

It refers to an extra mogul or bump along the upper left cardiac silhouette just below the left main bronchus in CXR. CAUSES in order of importance:- 1-enlargement of LA Appendage 2-Partial pericardial defect 3-Right ventricular outflow tract dilatation as in Ebstein, EMF, Post TOF repair 4-Asymmetric septal hypertrophy 5-Pericardial hydatid 6-LV aneurysm (mycotic which usually involves the free wall) 7-Coronary artery aneurysm

MINOCA -Myocardial Infarction With Non Obstructive Coronary Arteries MINOCA is clinically defined by the presence of 1-Acute MI criteria 2-Absence of obstructive coronary artery disease (less than 50 percent stenosis, if any, of the epicardial coronary arteries) 3-No other cause for the clinical presentation at the time of angiography e.g. takotsubo cardiomyopathy