By Glenn N. Levine

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3. In addition to aortic regurgitaiton, which other processes cause rapid upstroke and widened pulse pressure? The most common are the hyperkinetic heart syndromes (high output states). These include anemia, fever, exercise, thyrotoxicosis, pregnancy, cirrhosis, beriberi, Paget’s disease, arteriovenous fistulas, patent ductus arteriosus, aortic regurgitation, and anxiety—all typically associated with rapid ventricular contraction and low peripheral vascular resistance. 4. What is pulsus paradoxus?

Figure 3-3. Hyperkalemia. Peaked T waves are seen in many of the precordial leads. (Adapted with permission from Levine GN, Podrid PJ: The ECG workbook: a review and discussion of ECG findings and abnormalities, New York, Futura Publishing Company, 1995. p. 405) Figure 3-4. Severe hyperkalemia. The rhythm strip demonstrates the preterminal rhythm sinusoidal wave seen in cases of severe hyperkalemia. (Adapted with permission from Levine GN, Podrid PJ: The ECG workbook: a review and discussion of ECG findings and abnormalities, New York, Futura Publishing Company, 1995.

The latter may become so prominent as to be misinterpreted as a separate apical ‘‘cooing’’ of MR. 12. Where is the murmur of hypertrophic cardiomyopathy (HCM) best heard? It depends. When septal hypertrophy obstructs not only left but also right ventricular outflow, the murmur may be louder at the left lower sternal border. More commonly, however, the HCM murmur is louder at the apex. This may often cause a differential diagnosis dilemma with the murmur of MR. 13. What are the characteristics of a ventricular septal defect (VSD) murmur?

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