care is taken in marking the correct side of the radiograph. ebstein's anomaly – malformation of the tricuspid valve (see above). great artery defects – there are several conditions that affect the great arteries (e.g., double aortic arch, aberrant subclavian artery) that often result in problems with the trachea and breathing. hypoplastic left heart syndrome – defect in the development of the left heart such that it is hypoplastic (under developed). patent ductus arteriosus (pda) – failure of the ductus arteriosus to close on birth. patent foramen ovale (pfo) – an atrial septal defect in that the foramen ovale fails to close at birth. persistent truncus arteriosus – defect in that the truncus arteriosus fails to divide. pulmonary valve stenosis (pvs) – narrowing of the pulmonary valve that is the key finding in noonan syndrome. tetralogy of fallot (tof) – set of four anatomical abnormalities: pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. transposition of the great vessels (tgv) – abnormal spatial arrangement of the great vessels (superior vena cava, inferior vena cava, pulmonary arteries, pulmonary veins, and aorta). uhl anomaly – partial or total loss of the right ventricular wall. ventricular septal defect (vsd) – defect in the ventricular septum that permits blood flow between ventricles. diseases of blood vessels – diseases of the blood vessels can be multidisciplinary in nature. for example, medical treatment of atherosclerosis tends to be managed by cardiologists while vascular surgery repairs aneurysms and stenotic arteries. atherosclerosis – thickening of an arterial wall due to increased cholesterol and macrophages (see above). aneurysm – balloon-like bulging of arteries (also possible of the heart: see ventricular aneurysm above). aortic aneurysm – aneurysm of the aorta, typically of the abdominal aorta (abdominal aortic aneurysm or aaa). they are associated with a smoking history and in connective tissue diseases (e.g., marfan syndrome, ehlers-danlos syndrome). current uspstf recommendations are for a single abdominal ultrasound screening for a aaa in anyone 65 or older who has smoked. surgical repair of a aaa is advised after it is larger than 5.0–5.5 cm because of concern for rupture that leads to death from internal bleeding. cerebral aneurysm – aneurysms of the arteries in the brain most commonly affect the anterior cerebral artery. rupture of the aneurysm results in a subarachnoid hemorrhage and a very severe headache. aortic dissection – dissection along the length of the aorta between the layers of the aortic wall. dissection of the ascending aorta (type a) is a surgical emergency while dissection of the descending aorta (type b) can possibly be managed medically. dissection of the ascending aorta is an emergency because dissection may interrupt coronary blood flow and blood flow to the brain, neither of which tolerate ischemia particularly well. aortic rupture – frank rupture of the aorta is often fatal from internal bleeding. rupture of the aorta can occur at the sites of aneurysm, but is also due to trauma and results in a traumatic aortic rupture. carotid artery – diseases of the carotid arteries: carotid artery stenosis / carotid artery disease – narrowing of the carotid artery, typically due to atherosclerosis. carotid artery dissection – dissection along the length of the carotid artery between the layers of the carotid wall and filled with blood. deep vein thrombosis (dvt) and pulmonary embolism (pe) – formation of a thrombus in a deep vein, commonly in the legs that may break loose, travel to the lungs, and occlude blood flow (pulmonary embolism) sufficient to interrupt oxygenation to the body. traveller's thrombosis / economy class syndrome: a dvt due to being sedentary during air travel. microangiopathy – disease of capillaries in which the walls become thick and weak, and result in bleeding and decreased blood flow. one very common cause is diabetes mellitus in which microangiopathy results in diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy. varicose veins – veins that have become enlarged and tortuous with failed valves, commonly in the legs. vericose veins have cosmetic concerns, but they may become painful. surgery and sclerotherapy are two options for treating varicose veins. vasculitis – inflammation of blood vessels (veins & arteries) with a long list of causes. aortitis – inflammation of the aorta that can be seen in giant cell arteritis, polymyalgia rheumatica, rheumatoid arthritis, syphilis and takayasu's arteritis. behçet's disease – affects small-sized vessels that often initially presents with oral aphthous ulcers, genital ulcers and uveitis, and can be fatal from ruptured aneurysms. pericarditis is commonly seen with behçet's. eosinophilic granulomatosis with polyangiitis (egpa; formerly known as churg–strauss syndrome) – affects small- & medium-sized vessels that often affects lungs, kidneys, & heart in those with a history of airway allergic hypersensitivity and p-anca antibodies. giant-cell arteritis (gca) / temporal arteritis – affects medium- & large-sized vessels of the head, typically branches of the external carotid artery and namely the temporal artery. occlusion of the ophthalmic artery results in blindness. suspicion of gca necessitates immediate treatment with glucocorticoids and temporal artery biopsy. granulomatosis with polyangiitis (gpa) – affects small- & medium-sized vessels that often affects the lung & kidneys (rpgn) with classic saddle nose and c-anca antibodies. iga vasculitis (igav; formerly known as henoch-schönlein purpura) – affects small-sized vessels and produces palpable purpura and proteinuria from immunocomplex (iga) deposition. kawasaki disease – affects medium-sized vessels mostly seen in young children with myocarditis, & pericarditis, and is the most common cause of acquired heart disease in children (results in coronary artery aneurysms). myocardial infarction from coronary thrombosis is the most common cause of death from kawasaki disease. thromboangiitis obliterans – affects small- & medium-sized vessels that is strongly associated with tobacco products. pain, diminished pulses, gangrene and eventual amputation of affected hands and feet. procedures to counter coronary artery disease an example of a drug-eluting stent. this is the taxus express2 paclitaxel-eluting coronary stent system, which releases paclitaxel. coronary artery disease is not currently reversible and eventually requires surgical management if it progresses. coronary artery bypass surgery (cabg): grafting an artery or vein from elsewhere to bypass a stenotic coronary artery. performed by cardiothoracic surgeons, a sternotomy is performed to open the chest and then grafts are performed. cardiopulmonary bypass may be necessary. the internal mammary artery or saphenous vein can be used as grafts. the grafts are used to provide an alternate path for blood flow around a stenosis. enhanced external counterpulsation (eecp): pneumatically assisting the heart to move blood using inflatable cuffs on the legs. percutaneous coronary intervention (pci) – procedures to treat stenotic coronary arteries by accessing through a blood vessel. angioplasty in this manner is ptca (described below) but may also involve the insertion of stents to keep vessels open. percutaneous transluminal coronary angioplasty (ptca): insertion of a catheter through the skin ("percutaneous") into a blood vessel ("transluminal") to enlarging the lumen of a coronary artery by forcibly expanding it with a balloon ("angioplasty"), hence the name. it is a form of pci and generally what is implied when referring to "pci." atherectomy – enlarging the lumen of an artery by removal of atherosclerotic plaque by means of catheterization. this is in contrast to angioplasty that does not remove the plaque but merely pushes it out of the way to increase the lumen size. this method is primarily used in peripheral disease, but has been used for coronary disease as well. endarterectomy – enlarging the lumen of an artery by removal of atherosclerotic plaque by means of open surgery. this is primarily done on the carotid arteries (carotid endarterectomy or cea) but was first performed on the superficial femoral artery. while not performed on coronary arteries, it is mentioned here for completeness. stenting: enlarging the lumen of an artery by forcibly expanding it with a metal wire tube by means of catheterization. typically, the artery is expanded first through angioplasty (see ptca above). devices used in cardiology a stethoscope. stethoscope – acoustic device for hearing internal sounds including heart sounds. the stethoscope is the quintessential medical icon, regardless of specialty. modern stethoscopes can have a diaphragm and a bell, and be sized for adults or children. in cardiology, it is primarily used to listen to heart sounds it can also be used to listen for bruits (carotid & renal for renal artery stenosis), bowel sounds, and lung sounds. electronic stethoscopes can amplify and record sounds. ekg calipers – a type of divider caliper that can be used to measure intervals and compare intervals on ekgs. special rulers can be used to measure the intervals as well. devices used to maintain normal electrical rhythm: pacemaker – an implanted electrical device that replaces the heart's natural pacemaker. defibrillator – electrical devices to alter the heart's rhythm with electrical energy. as the name implies, a defibrillator is used to stop fibrillation of the heart. it can be used to cardiovert atrial fibrillation if certain conditions are met, but is mainly used to cardiovert ventricular fibrillation which is life-threatening. contrary to popular media's use, a defibrillator cannot and should not be used for asystole (a "flatline") as it has been shown to be ineffective in restoring a rhythm. if a person is in a rhythm not convertible by a defibrillator, then cardiopulmonary resuscitation (cpr) or more advanced care should be started. automated external defibrillator (aed) – an external defibrillator that is commonly found outside of health care settings and is often designed for anyone to use through verbal instructions. aed's have increased in popularity and dispersal so that people with cardiac arrest in public can be cardioverted to a safer rhythm before help can arrive. implantable cardioverter-defibrillator (icd): an implanted device to prevent life-threatening conditions (e.g., ventricular tachycardia, ventricular fibrillation) in people predisposed to these rhythms. devices used to maintain blood pressure: artificial heart – an internal pump that wholly replaces the pumping action of the heart. cardiopulmonary bypass (cpb) / heart-lung machine: external pump to take over the function of both the heart and lungs. commonly used in cardiothoracic surgery when the heart is being operated on for such surgeries like open valve replacement or cabg on the posterior side of the heart. the bypass machine is responsible for oxygenation of blood, removal of carbon dioxide, heating the blood (heat is lost from being outside the body) to maintain core body temperature or cooling blood for controlled hypothermia, and providing volatile anesthetics (e.g., isoflurane) if the lungs are not ventilated during bypass (the movement can be problematic while performing surgery). a cardioplegic solution is used to stop the heart from beating and combination with hypothermia reduces oxygen demand of the heart significantly (>97%) such that surgery is possible without causing damage. intra-aortic balloon pump (iabp): a balloon placed in the thoracic aorta to supplement cardiac output from the heart. it pulsates opposite to the heart such that it inflates during diastole and relaxes during systole. deflation during systole decreases afterload (vacuum effect), thus decreasing myocardial oxygen demand, and inflates during diastole to increase diastolic pressure which increases coronary artery perfusion of the endocardium (the heart perfuses itself during diastole, not systole). ventricular assist device (vad) – internal pump to supplement or replace the pumping action of a ventricle. can be referred to rvad or lvad depending on if it's attached to the right or left ventricle. diagnostic tests and procedures cardiologists use diagrams like this: a heart with an ecg indicator various cardiology diagnostic tests and procedures. blood tests elevated levels of ldl cholesterol in the blood are associated with an increased risk of developing atherosclerosis and coronary artery disease. creatine kinase – when skeletal muscle injury is absent, ck-mb is fairly specific to myocardium injury. troponin – the troponin complex is present in skeletal and cardiac muscle, but cardiac-specific forms of troponin i and troponin t are used as sensitive & specific indicators of heart damage if acute coronary syndrome is suspected. the presence of troponins are not exclusive to myocardial infarction, and so other conditions should be considered (e.g., heart failure, cardiomyopathies, trauma, defibrillation, cardioversion, asd closure, radiofrequency ablation, toxicity from chemotherapy, snake venom, cyanide poisoning, ascending aortic dissection, stroke, seizure). echocardiography ("echo"): ultrasonography of the heart to inspect chambers, valves, and blood flow. often utilizes the doppler effect to determine blood flow through valves (stenosis & regurgitation) and through the septum (asd & vsd). agitated saline can be used as contrast