Cardiology

Cardiovascular diseases are a common cause of mortality and morbidity worldwide. Co-incidentally킠cardiology is also one of the most exciting branches of medicine. 킠It is also rapidly changing specialty with new imaging modalities and therapeutic advances through the advent of interventional techniques such as angiography, stenting, pacing and electrophysiology techniques.

There are a huge number of systemic disease processes that can affect the heart muscles, blood supply and pericardium ranging from malignancy to infection. In the Western world, atherosclerosis causing ischaemic heart disease is the most common problem, but this is becoming an increasing problem in developing countries. 킠Infective problems such as endocarditis and severe valvular dysfunction continue to be common in the developing world. Universally, heart disease is a very common cause of morbidity and mortality and is an important topic for any generalist.

Clinical evaluation of a patient with cardiovascular disease

A good thorough cardiovascular examination can reveal lots of important information about the underlying pathology. Whilst examination is undoubtedly best taught at the bedside with real patients, technology is making it possible for some of techniques and skills to be learned using online resources – including videos and audio files.

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    Less than 10 mins

    Cardiovascular examination videos

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    Here are a selection of sites with cardiovascular exam illustrated by video - generally pretty good and score 3-5 stars: 1. University of Bristol, UK킠Aiming at the exam scenario. 킠Series of short videos with interspersed questions to answer. Nice. 2. Geeky medics, UK.킠By medical students for medical students. 8 minute video as ... read more
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    Level ALevel B

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    10-30 mins

    Cardiovascular examination – text and photos

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    Level ALevel B

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    30-60 mins

    Cardiovascular examination – “virtual stethoscopes”

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    Several sites have audio of heart sounds and murmurs so you can practice diagnosing heart problems online - generally very good and score 4-5 stars. The auscultation assistant킠 Dr Chris Cable, UCLA. 킠Simple and easy to use. Audio files of common cardiac murmurs and respiratory pathology are explained briefly in text. Heart sounds an... read more

Understanding the electrocardiogram

An electrocardiogram (ECG or EKG) is a non-invasive recording of the electrical activity of the heart over a period of time. It is a useful tool for the diagnosis of almost all cardiac disorders and despite modern imaging techniques remains at the forefront of acute cardiology. Interpretation of ECG is a skill that needs to be learned by all young doctors and there are many good online resources here to help.

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    Level ALevel B

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    30-60 mins

    The ECG: explained in text

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    We've collected some resources readily found on the net which are equivalent to those found in books. 킠Generally as these are descriptive texts they are suitable for beginners but score only 3 stars as there are no learning activities/interactive elements. 킠They are, however, useful to read before using the other resources listed or as re... read more
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    Level ALevel BLevel C

    Duration
    Less than 10 mins

    ECG library

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    This resource provides good examples of almost every possible ECG you would expect to come across in clinical practice. The key points of each ECG are also highlighted below in order to help with interpretation. Some background history of the ECG is also included for those that are interested.  
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    30-60 mins

    Analysis and interpretation of the electrocardiogram

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    This is a very useful online tutorial from Queení¢’‚¬’„¢s University on the interpretation of the 12 lead ECG. Included within the tutorial is a logical system to approaching the ECG, which can prove invaluable when it comes to interpreting more complicated cases. There are also examples of the common ECGs that practising clinicians should know along with interactive cases.
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    Level ALevel BLevel CLevel C Plus

    Duration
    10-30 mins

    ECGpedia

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    A fantastic wiki based tutorial and textbook to which anyone can contribute. Designed for almost all healthcare professionals from medical and nursing students all the way to consultant physicians. ECGpedia provides interpretation tutorials, an online ECG textbook along with interesting cases and examples.
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    Level BLevel C

    Duration
    Less than 10 mins

    ECG Wave-Maven: Self-assessment program for students and clinicians

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    Developed by Harvard Medical School, this web based tutorial links in to more than 400 ECGs linked to clinical scenarios with multiple choice question and answer facilites. A fantastic teaching tool.
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    Level BLevel C

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    Less than 10 mins

    EKG World Encyclopedia

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    McGill University (in conjunction with the online journal of cardiology) have developed this resource which contains a huge number of ECGs and clincial case scenarios divided by clinical area or shown in a quiz format. 킠Test yourself and compare your interpretation of the ECGs with their answers. 킠Not the slickest site to use, and not all... read more
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    Level ALevel B

    Duration
    30-60 mins

    Introduction to ECG interpretation (UW-Madison)

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    This 'course' on ECG interpretation goes through basic concepts through to clinical case examples and guidelines. There are also links to powerpoint slides with accompanying audio (podcasts) on ECG interpretation (about 20 minutes in length) if you like to learn this way.    
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    Level ALevel B

    Duration
    30-60 mins

    ECG learning center

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    A nicely produced site, with an ECG outline, self test quiz and links structured according to American College of Cardiology/American Heart Association (ACC/AHA) clinical competencies in ECG diagnoses.  
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    Level ALevel B

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    Less than 10 mins

    The 6 second ECG (SkillStatLearning)

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    27 of the most common cardiac rhythms in lead 2 for you to identify under time pressure!  
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    Level ALevel B

    Duration
    30-60 mins

    Mauvila ECG tutorial

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    An easy to follow, no nonsense approach to ECG. All concepts are described in a straightforward manner which can help, especially when learning about them for the first time. Along with interpretation of the ECG, both the mechanical and electrical components of the heart are described in detail.
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    Level A

    Duration
    10-30 mins

    ECG quiz

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    A 20 question multiple choice test which tests basic knowledge of the ECG. 킠A hyperlink at the top of the page links to ECG articles which explain the ECG simply in short note form. The answers to the quiz are explained and once completed your score is calculated.

Cardiac imaging

Cardiac imaging is one of the fastest growing areas of clinical cardiology. Whilst the Echocardiogram is currently the mainstay for assessment of cardiac structure and function, MRI and nuclear imaging look set to have a major role in the future.

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    Level BLevel CLevel C Plus

    Duration
    10-30 mins

    The Edinburgh Cardiology Imaging Website

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    This site provides information on a range of cardiac imaging modalities such as echocardiography, CT, angiography and MRI. There are also interesting case studies submitted by clinicians which aim to illustrate some of the ways in which these different imaging techniques may be applied in a clinical setting.
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    Level ALevel B

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    10-30 mins

    Atlas of Human Cardiac Anatomy

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    This site, developed by the University of Minnesota, provides flash based tutorials on both echocardiography and cardiac MRI. Text based versions of the tutorials are also available for quick reference. The site details most of the major anatomical structures of the heart and displays their location clearly on a 3D cardiac model.
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    Level BLevel C

    Duration
    10-30 mins

    Introduction to Cardiothoracic Imaging (Yale University)

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    This site provides a good overview of the core forms of cardiac imaging, while also detailing some of the less common types. There are several examples of interesting pathology which can be observed via the various imaging techniques, with important features clearly highlighted.
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    Level ALevel B

    Duration
    10-30 mins

    Echocardiogram (Medline Plus)

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    A brief and easy to read summary of transthoracic echocardiograms (TTE). Included in this is a basic description of the process involved in producing the echocardiogram along with the possible indications. This resource allows you to obtain a rudimentary understanding of TTE at a glance.
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    Level CLevel C Plus

    Duration
    30-60 mins

    Cardiac CT (Radiographics)

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    A detailed guide to the interpretation of cardiac CT. High-quality CT images of the heart and coronary arteries along with 3D reconstructions are available to aid learning. A comprehensive resource for someone with a particular interest in cardiac CT.

Disorders of heart rhythm

Coronary heart disease

Coronary heart disease (CHD) is caused by a build up in atheroma in the cells lining the wall of the coronary arteries. This causes a narrowing in the blood vessel limiting the blood (and oxygen) supply to the heart muscle. If a severe blockage occurs킠 quickly (often as a result of a superimposed blood clot) then a heart attack can occur. A more gradual narrowing results in the clinical syndrome of angina.

In the Western world , cardiovascular disease is the leading cause of death among both sexes, and coronary artery disease is the commonest cause of cardiovascular disease. A number of preventable risk factors lead to coronary heart disease namely high blood pressure (hypertension), high cholesterol, diabetes, a sedentary lifestyle and smoking. The rising epidemic of obesity and associated metabolic syndrome (hypertension, insulin resistance and hypercholesterolaemia) is increasing the incidence of heart disease.

Treatments to tackle coronary heart disease are aimed at prevention, symptom control and revascularisation either using drugs, newer interventional techniques such as angioplasty and stenting or surgery (coronary artery bypass grafting).

Heart failure and cardiomyopathy

Heart Failure occurs when the pumping action of the heart is unable to meet the bodies demands resulting in reduced blood and oxygen deliver to peripheral organs and tissues. Fatigue and breathlessnes are common and fluid accumulation in the lungs (pulmonary oedema) and legs (peripheral oedema) are characteristic signs of heart failure. Heart failure can occur as a result of any of the conditions discussed above (ischaemic heart disease, valvular heart disease, cardiomyopathies, pericardial disease etc.). The mainstay of treatment is medication (aimed at diuresing and lowering peripheral resistance), although pacing devices and heart transplant may be considered in some cases.

Cardiomyopathy is a collective term for diseases affecting the muscle of the heart. The common intrinsic cardiomyopathies include hypertrophic (HOCM), restrictive and dilated. Other recognised types include arrhythmogenic right ventricular cardiomyopathy (ARVC) and noncompaction cardiomyopathy. Cardiomyopathies may be congenital, occur as a result of systemic diseases such as amyloidosis, or secondary to toxins including alcohol. Treatment is challenging and may include medication, pacemakers, ventricular assist devices or ablation. The goal of treatment is symptom relief and some patients may ultimately requires a heart transplant.

Adult congenital heart disease

Congenital heart disease consists of any cardiac abnormality that is present from birth. This may range form an abnormality in the hearts rhythm such as long QT syndrome through to more major defects of the heart chambers and major blood vessels. Heart defects are the most common cause of birth defects (approx 9 in 1000 people are born with congenital heart problem). Most of these are due to sporadic genetic changes although some are due to environmental factors such as infections (e.g. Rubella), toxins such as alcohol, prescription drugs and diseases such as diabetes and SLE.

Valvular heart disease

The heart has 4 valves (two of the right side of the heart (the Tricuspid and Pulmonary) and two on the Left Side of the heart (Mitral and Aortic). Valve abnormalities may be congenital (occur during development) or acquired later in life due to processes such as rheumatic fever and infection. It is possible to replace heart valves surgically in selected patients.

Pericardial disease

The pericardium is a double walled sac surrounding the heart and the great vessels which can be affected by a number of disease processes. Fluid or blood accumulation in the pericardial space can lead to effusions which may impact on cardiac function. Malignancy, renal failure, viruses and systemic diseases such as amyloidosis can lead to pericardial inflammation or scarring.

Cardiology interventions and therapeutics

This sections covers therapeutics from pharmacological therapies to interventional techniques. This is a rapidly growing area of cardiology. Many of the new and novel procedures are discusses below.

Clinical case scenarios and self assessment

Here is a collection of resources containing virtual patients and clinical case scenarios. These are excellent for problem based learning and for improving clinical insight. There are also self-assessment materials, useful for exam practice.

Section editors

Dr Nikhil Joshi, Clinical Research Fellow in Cardiology, University of Edinburgh

Dr Alka Joshi, Core Medical Trainee, Royal Infirmary of Edinburgh

Dr Adam Melville, Foundation Doctor, Victoria Hospital, Kirkcaldy

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