@matthewcommet on GrepMed

Combination of diagnostic criteria used to assess the severity of tricuspid regurgitation (TR). This figure lists the 4 proposed combination criteria described by Grant et al.60 In this algorithm, severe TR was present in the presence of a suggestive color Doppler jet and if any ≥1 of the combinations shown were present. ASD indicates atrial septal defect; CW, continuous wave; IVC, inferior vena cava; and RA, right atrial. #Diagnosis #Cardiology #Tricuspid #Regurgitation #Criteria #Severe

RA/CVP Waveform Interpretation Central venous pressure (CVP) or right atrial pressure (RAP) waveform tracings can often times provide useful insight about a patient’s right ventricle (RV), tricuspid valve (TV), and overall cardiopulmonary status. The waveform morphology is easier to identify at slower heart rates and consists of three waves and two descents: - ‘a’ wave (RA contraction at end diastole): lost in atrial fibrillation/flutter due to disorganized atrial activity. ↑ in pathologies that impede forward flow like tricuspid/pulmonic stenosis and pHTN. Classic “cannon waves” caused by RA contraction against a closed TV causing reflection wave back into RA (junctional rhythm, V-tach, third degree block) - ‘c’ wave (TV cusps bulge into RA during early systole): c-v wave fusion and blunting of ‘x’ descent with TR - ‘x’ descent (RA relaxation in mid systole): ↑ in constrictive pericarditis (CP), ↓ with TR (jet ↑ RAP) and RV dysfunction due to ↓ downward movement of RV - ‘v’ wave (rapid filling of RA in late systole). ↑ in TR from regurgitant jet ↑ RAP. Similar tracings obtained for LEFT atrial pressures (↑ ‘v’ wave with mitral regurgitation). Success of mitral valve repair (ie, MitraClip) can be partly gauged by ↓ in ‘v’ wave. - ‘y’ descent (rapid RV filling in early diastole) Steep ↑ with constrictive pericarditis and ↓ with tamponade (↓ RV filling from ↓ caval inflow). Rishi Kumar, MD @rishimd #CVP #Waveform #Interpretation #Diagnosis #Cardiology #Venous

Differentiating PAH from PVH - Echocardiography Pulmonary Artery Hypertension (PAH): • RV size - Enlarged • LA size - Small • RA/LA size ratio - Increased • Interatrial septum - Bows from right to left • RVOT notching - Common • ElA ratio << 1 • Lateral e' Normal • Lateral E/e' <8 • Aortic pressure - Normal/Low • PCWP < 15 mmHg • PADP-PCWP > 7 mmHg Pulmonary Venous Hypertension (PVH): • RV size - May be enlarged • LA size - Large • RA/LA size ratio - Normal (LA > RA size) • Interatrial septum - Bows from left to right • RVOT notching - Rare • ElA ratio > 1 • Lateral e' Decreased • Lateral E/e' > 10 • Aortic pressure - Normal/High • PCWP > 15 mmHg • PADP-PCWP < 5 mmHg Dr. Sanjiv Shah @HFpEF #Differentiating #PAH #PVH #Echocardiogram #comparison #diagnosis #cardiology #pulmonary #arterial #venous #hypertension

$Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management Source:$

Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management Source: https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.1029 Graphic representation of echocardiographic parameters in the assessment of right ventricular dysfunction. Ao, aorta; DTI, Doppler tissue imaging; EF, ejection fraction; ET, ejection time; FAC, fractional area change; IVC, inferior vena cava; IVCT, isovolumic contraction time; IVRT, isovolumic relaxation time; LA, left atrium; LV, left ventricle; LVEDD, left ventricular end‐diastolic diameter; RA, right atrium; RIMP, right ventricular index of myocardial performance; RV, right ventricle; RVEDD, right ventricular end‐diastolic diameter; TAPSE, tricuspid annular plane systolic excursion; TR, tricuspid regurgitation. Reproduced from Harjola et al.99 with permission of the authors. #Diagnosis #Cardiology #Echocardiogram #RightSided #CongestiveHeartFailure #RVFailure #Criteria #Assessment #RVDysfunction #RightVentricular

Periprosthetic Aortic Valve Regurgitation Grading • Vena Contracta Area • Circumference • Jet Length Mild - Moderate - Severe Mild: 1) 0.1 cm2 VC Area, 8% Circumference Moderate: 2) 0.2 cm2 VC Area, 10% Circumference 3) 0.2 cm2 VC Area, 16% Circumference 4) 0.26 cm2 VC Area, 18% Circumference Severe: 5) 0.7 cm2 VC Area, 30% Circumference #AorticValve #Regurgitation #Periprosthetic #Grading #Classification #Criteria #Diagnosis #cardiology #echocardiography

Cardiac Findings in Sarcoidosis Most Commonly Affected Sites: - LV free wall (esp. basal posterior wall) - Interventricular septum. (esp. basal) LV Myocardial Involvement: - LV wall thickening - LV wall thinning - Focal hypokinesis or RWMA - LV Aneurysm - Global systolic dysfunction (+LVEF) - Reduced myocardial strain - Diastolic dysfunction - Papillary muscle involvement Valvular Abnormalities: - Mitral regurgitation due to primary thickening of leaflets - Mitral or tricuspid regurgitation secondary to ventricular dysfunction or pulmonary hypertension Pericardial involvement: - Effusion ECG Abnormalities: - Advanced atrioventricular block - Ventricular arrythmias (V. tachycardia, multifocal) - Right bundle branch block - Axis deviation - Abnormal a-wave #Cardiac #Findings #Sarcoidosis #Cardiology #Involvement #diagnosis

Stroke Volume & Cardiac Output Measurement on POCUS Accurately measure LVOT diameter: 1. Obtain PLAX 2. Zoom to LVOT 3. Measure at mid systole, 1cm from aortic valve apparatus Calculate VTI: 1. Obtain A5c view 2. Place PW doppler into LVOT 3. Run PWD trace 4. Trace around PWD trace CO = HR x LVOT VTI x π (LVOT Diam/2) 2 SV = LVOT VTI x π (LVOT Diam/2) 2 - Dr. Jonny Wilkinson @Wilkinsonjonny #Stroke #Volume #Cardiac #Output #Measurement #POCUS #cardiology

LVOT measurement 1. PLX view zoom mode 2. Measure within 5 mm to 10 mm from aortic annulus (solid yellow line) 3. Mid-systole #LVOT #measurements #outflowtract #diagnosis #cardiology #Echocardiography

EKG Interpretation Cheat Sheet 1) Rate - Regular - Count-Off - Irregular - Count number of QRS in 10s x 6 2) Rhythm 3) Axis 4) Alphabet - Width? Height? Shape? (Up/Down, Contour) P Waves: • Inverted P Waves (in inferior leads)? • PR interval < 120 ms = AV junction origin (e.g. accelerated junctional rhythm) • PR interval ≥ 120 ms, origin within the atria (e.g. ectopic atrial rhythm) • Variable P-Wave Morphology = multifocal atrial rhythm • No P Waves/Fibrillary = afib • Saw-Tooth = Atrial Flutter PR Interval: • 1° Block - PR >200ms • 2° Block Type I - PR ↑ incrementally before loss of P • 2° Block Type II - Suddenly Lose P • 3° Complete Block (nothing getting through) QRS Complex: • Pathological Q waves: > 40 ms (1 mm) wide > 2 mm deep or > 25% of depth of QRS complex Seen in leads V1-3 (Right sided leads) • R wave abnormalities: Dominant R wave in V1 Dominant R wave in aVR Poor R wave progression ST Segment: • Septal (V1-2) • Anterior (V3-4) • Lateral (I + aVL, V5-6) • Inferior (II, III, aVF) • Right ventricular (V1, V4R) • Posterior (V7-9) T Waves: • Normal: Upright in all leads except aVR and V1 (Invert III normal variant), Amplitude < 5mm in limb leads, < 15mm in precordial leads • Hyperacute T waves Inverted T waves, Biphasic T waves, ‘Camel Hump’ T waves, Flattened T waves QT/QTC Interval: • QT interval is inversely proportional to heart rate • Bazett formula: QTC = QT / √ RR - Note: there are multiple QTc correction formulas • Prolonged QTc > 440ms in men, > 460ms in women • QTc > 500 is associated with increased risk of torsades de pointes • Short QTc < 350ms • Rule of thumb: a normal QT is less than half the preceding RR interval Other: • U waves = severe hypokalaemia or bradycardia • J /Osborn wave (between QRS and ST) = hypothermia • Delta Wave (before QRS) = WolffParkinson-White syndrome • Epsilon Wave (blip QRS) = Arrhythmogenic right ventricular dysplasia (ARVD) - Amy Chung, MD, MSc @AmyChung #EKG #Interpretation #ECG #Electrocardiogram #cardiology #diagnosis #system #cheatsheet

EKG in Acute Pulmonary Embolism The sensitivity and specificity for EKG findings in acute PE are low. EKG is helpful in evaluating for other causes of cardio-pulmonary symptoms + supporting evidence of PE Increased Adrenergic Drive: • Sinus Tachycardia (most common finding) • Atrial Arrhythmia* (e.g., A-Fib also a result of atrial stretch) RA/RV Dilation: • Incomplete or Complete RBBB (RBB prone to stretch especially early in its course) • Right Axis Deviation • Dominant R Wave in V1 • Shift of Precordial Transition Point to V5 (as RV "rotates" with dilation in relation to ECG leads) RV Ischemia or Strain: • S1-Q3-T3 (not a sensitive finding) • TWI in Right Precordial Leads (VI-V3) +/- Inferior Leads • Non-specific ST-T Changes • STE in aVR +/- Right Precordial Leads - Karan Desai MD @karanpdesai via CardioNerds @cardionerds #EKG #EKG #Pulmonary #Embolism #AcutePE #diagnosis #cardiology #electrocardiogram