A framework for clinical reasoning in adult cardiology

Figures & data

Table 1 Clinical features of the six basic cardiac responses

Cardiac responses	Physical signs	ECG	Chest X-ray
Left ventricular hypertrophy	Sustained ventricular impulse, S4	LVH or LBBB	Prominent LV (PA projection X-ray)
Right ventricular hypertrophy	Impulse not felt in adults Right S4	RVH/RBBB Right axis deviation	Prominent RV (lateral projection X-ray)
Left ventricular dilatation	Displaced LV impulse S3, M Reg murmur?	LVH, old infarct pattern, LBBB	Prominent LV (PA projection X-ray)
RV dilatation	Impulse not felt Right S3 TR Reg murmur?	RVH/RBBB	Prominent RV (lateral projection X-ray)
Atrial dilatation	None	Prominent P-waves or AF	Prominent atria
Aortic valve dysfunction	AoSt: Syst murmur, anacrotic pulse AoReg: Diast murmur, brisk pulse	LVH/LBBB	Prominent LV and ascending aorta
Mitral valve dysfunction	M Reg: Syst murmur MSten: Diast murmur, opening snap	LVH (M Reg) FA (MSten)	M Reg: prominent LV MSten: prominent LA
Tricuspid valve dysfunction	TR Reg: JVP: V-wave, Syst murmur (> inspiration) TR Sten: JVP: A-wave	Prominent P-waves or AF	Prominent RA
Pulmonary	Loud P2, JVP >3 cm TR Reg	RVH, RBBB	Prominent RV, RA,
Hypertension	(> inspiration) S4, S3 (> inspiration)		and main pulmonary arteries
Myocardial ischemia	S4, S3, M Reg murmur	Abnormal ST–T, Q-waves, and VT	None specific
Arrhythmias	Certain arterial pulse abnormalities	Specific patterns	None

Notes: > is increased and ? is possible.

Abbreviations: AF, atrial fibrilation; AoReg, aortic regurgitation; AoSt, aortic stenosis; Diast, diastolic; JVP, jugular venous pulse; LA, left atrium; LBBB, left bundle branch block; LV, left ventricle; LVH, left ventricular hypertrophy; M Reg, mitral regurgitation; MSten, mitral stenosis; P2, second heart sound; PA, pulmonary artery; RA, right atrium; RBBB, right bundle branch block; RV, right ventricle; RVH, right ventricular hypertrophy; S3, third heart sound; S4, fourth heart sound; Syst, systolic; TR, tricuspide; VT, ventricular tachycardia.

Table 2 Construction of heart diseases with the basic cardiac responses and type of probable heart failure

	VENT HYPER	VENT DILAT	VALVE DYSFUN	PULM HYPERT	ARRHYTHM	MYOCAR ISCHEM	HF
Hypertrophic cardiomyopathy	Yes +++ S4	No	Syst Mur if obstructive	No	Syncope VT/AF	Possible angina	Yes (HFpEF)
Dilated cardiomyopathy	No	Yes S3 +++	Mitral Reg	Possible ++	VT/AF	Possible angina	Yes (HFrEF)
Restrictive cardiomyopathy	+/− S3− S4	No	Mitral/Tr Reg	Possible ++	AF/VT	Possible angina	Yes (HRpEF)
Arterial hypertension	Yes ++ S4	Possible +	No	No	AF/VT	Possible angina	Yes (HFpEF)
Aortic stenosis	Yes +++ S4	Possible +	Syst Mur Anacrotic pulse	Possible ++	AF/VT	Possible angina	Yes (HFpEF)
Aortic regurgitation	Yes +	Yes +++ S3	Diast Mur Brisk pulse	Possible +	No	No	Yes (HFrEF)
Mitral regurgitation	Yes ++	Yes +++ S3	Syst Mur	Possible ++	AF/VT	No	Yes (HFrEF)
Mitral stenosis	No	No, Atrial Dilat	Loud S1 Diast Mur Op snap	Possible ++++	AF embolism	No	Yes (HFpEF)
Tricuspid regurgitation	RVH +	Yes +++ S3	Syst Mur >inspiration	No	AF	No	>JVP (V-wave)
Coronary disease without infarction	No	No	No S4	No	VT?	Angina	No
Coronary disease with infarction	No	Yes +++	Mitral Reg? S4–S3	Possible ++	VT	Yes angina	No/yes (HFrEF)
Lone atrial fibrillation	No	No	No	No	Embolism AF	Possible angina	No/yes (HFpEF)
Supraventricular tachycardia	No	No	No	No	SVT syncope	Possible angina	No
Bradyarrhythmia AV block	No	Possible	No	No	Syncope	No	No
Acute pericarditis	No	No	No, rub	No	No	Pericardial pain	No
Constriction tamponade	No	No	No, knock, rub	No	No	No	>JVP, right HF
PULM HYPERT	RVH +	RVD ++	Tricuspid Reg	Yes P2 ++	Syncope VT SVT	Angina?	>JVP, right HF

Notes: > is increased; ? is possible; − is absence; and + is presence (the number of + indicates the severity).

Abbreviations: AF, atrial fibrillation; ARRHYTHM, arrhythmias; Diast, diastolic; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; JVP, jugular venous pulse; Mur, murmur; MYOCAR ISCHEM, myocardial ischemia; Op, opening snap; PULM HYPERT, pulmonary hypertension; Reg, regurgitation; RVD, right ventricular dilatation; RVH, right ventricular hypertrophy; S1, first heart sound; S3, third heart sound; S4, fourth heart sound; SVT, supraventricular tachycardia; Syst, systolic; Tr, tricuspide; VALVE DYSFUN, valve dysfunction; VENT DILAT, ventricular dilatation; VENT HYPER, ventricular hypertrophy; VT, ventricular tachycardia.

Figure 1 Diagnostic construction of left heart diseases.

Note: ? is possible.
Abbreviations: AF, atrial fibrillation; AR, aortic regurgitation; AS, aortic stenosis; EF, ejection fraction; Ej Mur, ejection murmur; HBP, high blood pressure; HCM, hypertrophic cardiomyopathy; IDCM, ischemic dilated cardiomyopathy; LBBB, left bundle branch block; LV, left ventricle; LVH, left ventricular hypertrophy; Mod CAD, moderate coronary artery diseases (without infarction or small); MR, mitral regurgitation; MS, mitral stenosis; Mur, murmur; NIDCM, nonischemic dilated cardiomyopathy; S3, ventricular gallop; S4, atrial gallop; SVT, supraventricular tachycardia.

Figure 2 Diagnostic construction of right heart diseases.

Notes: > is increased; ? is possible; and + is presence (the number of + indicates the severity).
Abbreviations: ASD, atrial septal defect; Ej Mur, ejection murmur; Hyper/dilat, hypertrophic/dilated; JVP, jugular venous pulse; P2, pulmonary second heart sound; Pericard Cons/Tamp, pericardial constriction/tamponade; PHT, pulmonary hypertension; PS, pulmonary stenosis; RBBB, right bundle branch block; RV, right ventricle; RVCM, right ventricular cardiomyopathy; RVH, right ventricular hypertrophy; S3, ventricular gallop; S4, atrial gallop; TR, tricuspid regurgitation; TS, tricuspid stenosis.