Basic scoring, grading and classifications in cardiology

1. TIMI Score Calculation for UA/NSTEMI (1 point for each):

- Age ≥ 65

- Aspirin use in the last 7 days (patient experiences chest pain despite ASA use in past 7days)

- At least 2 angina episodes within the last 24 hrs

- ST changes of at least 0.5mm on admission EKG

- Elevated serum cardiac biomarkers

- Known Coronary Artery Disease (CAD) (coronary stenosis ≥ 50%)

- At least 3 risk factors for CAD, such as: Hypertension ≥ 140/90 or on antihypertensives, current cigarette smoker, low HDL cholesterol (< 40 mg/dL), diabetes mellitus, Family history of premature CAD (CAD in male first-degree relative or father less than 55, or female first-degree relative or mother less than 65).

Score Interpretation:

% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.

Score of 0-1 = 4.7% risk

Score of 2 = 8.3% risk

Score of 3 = 13.2% risk

Score of 4 = 19.9% risk

Score of 5 = 26.2% risk

Score of 6-7 = at least 40.9% risk

'TIMI risk estimates mortality following acute coronary syndromes.

2. TIMI Score Calculation for STEMI.

3. Killip class

Killip class I includes individuals with no clinical signs of heart failure. Killip class II includes individuals with rales or crackles in the lungs, an S3, and elevated

jugular venous pressure. Killip class III describes individuals with frank acute pulmonary edema. Killip class IV describes individuals in cardiogenic shock or hypotension (measured as

systolic blood pressure lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosis or sweating).

4. TIMI Grade Flow

TIMI 0 flow (no perfusion) refers to the absence of any antegrade flow beyond a coronary occlusion.

TIMI 1 flow (penetration without perfusion) is faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed.

TIMI 2 flow (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of the distal territory.

TIMI 3 is normal flow which fills the distal coronary bed completely.

5. Braunwald Classification of Unstable Angina (UA)

 

 

Severity

Clinical CircumstancesA B C

Develops in presence of extracardiac condition that intensifies myocardial ischemia (secondary UA)

Develops in the absence of extracardiac condition (primary UA)

Develops within 2 weeks after acute myocardial infarction (postinfarction UA)

I New onset of severe angina or accelerated angina; no rest pain

IA IB IC

II Angina at rest within past month but not within preceding 48 hr (angina at rest, subacute)

IIA IIB IIC

III Angina at rest within 48 hr (angina at rest, acute)

IIIA IIIB Troponin negative

IIIB Troponin positive

IIIC

6. NYHA Functional Classification for Congestive Heart Failure

Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.

Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.

Class III: patients with marked limitation of activity; they are comfortable only at rest.

Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.

7. Framingham Criteria for Congestive Heart Failure

Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria.

Major criteria:         Paroxysmal nocturnal dyspnea         Neck vein distention        Rales        Radiographic cardiomegaly (increasing heart size on chest radiography)        Acute pulmonary edema        S3 gallop        Increased central venous pressure (>16 cm H2O at right atrium)        Hepatojugular reflux        Weight loss >4.5 kg in 5 days in response to treatment

 Minor criteria:

        Bilateral ankle edema        Nocturnal cough        Dyspnea on ordinary exertion        Hepatomegaly        Pleural effusion        Decrease in vital capacity by one third from maximum recorded        Tachycardia (heart rate>120 beats/min.)

Minor criteria are acceptable only if they cannot be attributed to another medical condition (such as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome).

The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying persons with definite congestive heart failure.

8. Duke Criteria for Infective Endocarditis (IE)

Major criteria:A. Positive blood culture for Infective Endocarditis

1- Typical microorganism consistent with IE from 2 separate blood cultures, as noted below: viridans streptococci, Streptococcus bovis, or HACEK* group, or community-acquired Staphylococcus aureus or enterococci, in the absence of a primary

focus or2- Microorganisms consistent with IE from persistently positive blood cultures defined as: 2 positive cultures of blood samples drawn >12 hours apart, or all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1

hour apart) B. Evidence of endocardial involvement

1- Positive echocardiogram for IE defined as :        oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or         abscess, or         new partial dehiscence of prosthetic valve or2- New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Minor criteria:

Predisposition: predisposing heart condition or intravenous drug use Fever: temperature > 38.0° C (100.4° F) Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic

aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid

factor Microbiological evidence: positive blood culture but does not meet a major criterion as

noted above¹ or serological evidence of active infection with organism consistent with IE Echocardiographic findings: consistent with IE but do not meet a major criterion as noted

above

Clinical criteria for infective endocarditis requires: • Two major criteria, or• One major and three minor criteria, or• Five minor criteria

*HACEK group: Haemophilus sp, Actinobacilius actinomycetemcomitans, Cardiobacterium hominis, Eikenella rodens y Kingella sp

9. Revised Jones Criteria for Acute Rheumatic Fever (ARF)

A firm diagnosis requires that two major or one major and two minor criteria are satisfied, in addition to evidence of recent streptococcal infection.

Major Criteria

1. Carditis: All layers of cardiac tissue are affected (pericardium, epicardium, myocardium, endocardium) The patient may have a new or changing murmur, with mitral regurgitation being the most common followed by aortic insufficiency.

2. Polyarthritis: Migrating arthritis that typically affects the knees, ankles, elbows and wrists. The joints are very painful and symptoms are very responsive to anti-inflammatory medicines.

3. Chorea: Also known as Syndenham´s chorea, or "St. Vitus´ dance". There are abrupt, purposeless movements. This may be the only manifestation of ARF and is its presence is diagnostic. May also include emotional disturbances and inappropriate behavior.

4. Erythema marginatum: A non-pruritic rash that commonly affects the trunk and proximal extremities, but spares the face. The rash typically migrates from central areas to periphery, and has well-defined borders.

5. Subcutaneous nodules: Usually located over bones or tendons, these nodules are painless and firm.

Minor Criteria:

1. Fever 2. Arthralgia 3. Previous rheumatic fever or rheumatic heart disease 4. Acute phase reactants: Leukocytosis, elevated eritrosedimentation rate (ESR) and C-

reactive protein (CRP) 5. Prolonged P-R interval on electrocardiogram (ECG)

Evidence of preceding streptococcal infection: Any one of the following is considered adequate evidence of infection:

Increased antistreptolysin O or other streptococcal antibodies Positive throat culture for Group A beta-hemolytic streptococci Positive rapid direct Group A strep carbohydrate antigen test Recent scarlet fever.

10. Wells Clinical Prediction Rule for Pulmonary Embolism (PE)

Clinical feature PointsClinical symptoms of DVT 3Other diagnosis less likely than PE 3Heart rate greater than 100 beats per minute 1.5Immobilization or surgery within past 4 weeks 1.5Previous DVT or PE 1.5Hemoptysis 1Malignancy 1

Total points  

PE = pulmonary embolism; DVT = deep venous thrombosis.

Risk score interpretation (probability of PE):

>6 points: high risk (78.4%); 2 to 6 points: moderate risk (27.8%); <2 points: low risk (3.4%)

11. NYHA functional classification

NYHA Class

Symptoms

ICardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.

IIMild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

IIIMarked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).Comfortable only at rest.

IVSevere limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

12. The CCS Angina Grading Scale or the CCS Functional Classification of Angina)

Class I – Angina only during strenuous or prolonged physical activity Class II – Slight limitation, with angina only during vigorous physical activity Class III – Symptoms with everyday living activities, i.e., moderate limitation Class IV – Inability to perform any activity without angina or angina at rest, i.e., severe

limitation

Class 0: asymptomatic category.

13. Grading of aortic stenosis

  Aortic sclerosis

Mild Moderate Severe

Aortic jet velocity (m/s) ≤2.5 m/s 2.6-2.9 3.0-4.0 >4.0 Mean gradient (mmHg) - <20 (<30a) 20-40b (30-50a) >40b (>50a) AVA (cm2) - >1.5 1.0-1.5 <1 Indexed AVA (cm2/m2)   >0.85 0.60-0.85 <0.6 Velocity ratio   >0.50 0.25-0.50 <0.25

aESC Guidelines. bAHA/ACC Guidelines.

14. Grading of aortic regurgitation

  Mild Moderate Severe Specific signs for

AR severity

Central Jet, width < 25% of LVOTς

Vena contracta < 0.3 cmς

No or brief early diastolic flow reversal in descending aorta

Signs of AR>mild present but no criteria for severe AR

Central Jet, width ≥ 65% of LVOTς

Vena contracta > 0.6cmς

Supportive signs

Pressure half-time > 500 ms

Normal LV size∗

Intermediate values

Pressure half-time < 200 ms

Holodiastolic aortic flow reversal in descending aorta

Moderate or greater LV enlargement∗∗

Quantitative parametersψ R Vol, ml/beat

< 30 30-44 45-59 ≥ 60

RF % < 30 30-39 40-49 ≥ 50 EROA, cm2 < 0.10 0.10-0.19 0.20-0.29 ≥ 0.30

AR, Aortic regurgitation; EROA, effective regurgitant orifice area; LV, left ventricle; LVOT, left ventricular outflow tract; R Vol, regurgitant volume; RF, regurgitant fraction.

∗ LV size applied only to chronic lesions. Normal 2D measurements: LV minor-axis ≤ 2.8 cm/m2, LV end-diastolic volume ≤ 82 ml/m2 (2).

ς At a Nyquist limit of 50–60 cm/s. ∗∗ In the absence of other etiologies of LV dilatation. ψ Quantitative parameters can help sub-classify the moderate regurgitation group into

mild-to-moderate and moderate-to-severe regurgitation as shown.

15. Grading of mitral regurgitation

   Mild Moderate Severe

Specific signs of severity 

Small central jet <4 cm2 or <20% of LA areaψ

Vena contracta width <0.3 cm

No or minimal flow convergence

Signs of MR>mild present, but no criteria for severe MR

Vena contracta width ≥ 0.7cm with large central MR jet (area < 40% of LA) or with a wall-impinging jet of any size, swirling in LAψ

Large flow convergenceς

Systolic reversal in pulmonary veins

Prominent flail MV leaflet or ruptured papillary muscle

Supportive signs 

Systolic dominant flow in pulmonary veins

A-wave dominant mitral inflowΦ

Soft density, parabolic CW Doppler MR signal

Normal LV size∗

Intermediate signs/findings

Dense, triangular CW Doppler MR jet

E-wave dominant mitral inflow (E >1.2 m/s)Φ Enlarged LV and LA size∗∗, (particularly when normal LV function is present).

Quantitative parametersφ R Vol (ml/beat)

< 30 30-44 45-59 ≥ 60

RF (%) < 30 30-39 40-49 ≥ 50

EROA (cm2) < 0.20 0.20-0.29 0.30-0.39 ≥ 0.40 CW, Continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle;

MV, mitral valve; MR, mitral regurgitation; R Vol, regurgitant volume; RF, regurgitant fraction. ∗ LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis ≤ 2.8 cm/m2, LV

end-diastolic volume ≤ 82 ml/m2, maximal LA antero-posterior diameter ≤ 2.8 cm/m2, maximal LA volume ≤ 36 ml/m2 (2;33;35).

∗∗ In the absence of other etiologies of LV and LA dilatation and acute MR. ψ At a Nyquist limit of 50-60 cm/s. Φ Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral

stenosis or other causes of elevated LA pressure. ς Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and ≤ 0.9 cm for

central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; Cut-offs for eccentric jets are higher, and should be angle corrected (see text).

φ Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.

16. Grading of mitral stenosis

17. Mitral stenosis: Wilkins score

Grade

Mobility Thickening Calcification Subvalvular Thickening

1  Highly mobile valve with only leaflet tips restricted 

Leaflets near normal in thickness (4-5 mm) 

A single area of increased echo brightness 

Minimal thickening just below the mitral leaflets 

2  Leaflet mid and base portions have normal mobility 

Midleaflets normal, considerable thickening of margins (5-8 mm) 

Scattered areas of brightness confined to leaflet margins 

Thickening of chordal structures extending to one-third of the chordal length 

3  Valve continues to move forward in diastole, mainly from the base 

Thickening extending through the entire leaflet (5-8mm) 

Brightness extending into the mid-portions of the leaflets 

Thickening extended to distal third of the chords 

4  No or minimal forward movement of the leaflets in diastole 

Considerable thickening of all leaflet tissue (>8-10mm) 

Extensive brightness throughout much of the leaflet tissue 

Extensive thickening and shortening of all chordal structures extending down to the papillary muscles 

The total score is the sum of the four items and ranges between 4 and 16.

18. Grading of tricuspid regurgitation

Parameter Mild Moderate Severe Tricuspid valve  Usually normal  Normal or abnormal  Abnormal/Flail leaflet/Poor 

coaptation RV/RA/IVC size  Normal∗  Normal or dilated  Usually dilated∗∗ Jet area-central jets (cm2)§ 

< 5  5-10  > 10 

VC width (cm)Φ  Not defined  Not defined, but < 0.7  > 0.7 PISA radius (cm)ψ  ≤ 0.5  0.6-0.9  > 0.9 Jet density and  Soft and parabolic  Dense, variable  Dense, triangular with early 

contour–CW  contour  peaking Hepatic vein flow†  Systolic dominance  Systolic blunting  Systolic reversal 

CW, Continuous wave Doppler; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; VC, vena contracta width.

∗ Unless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical 4-chamber view: RV medio-lateral end-diastolic dimension ≤ 4.3 cm, RV end-diastolic area ≤ 35.5 cm2, maximal RA medio-lateral and supero-inferior dimensions ≤ 4.6 cm and 4.9 cm respectively, maximal RA volume ≤ 33 ml/m2(35;89).

∗∗ Exception: acute TR. § At a Nyquist limit of 50-60 cm/s. Not valid in eccentric jets. Jet area is not recommended as the 

sole parameter of TR severity due to its dependence on hemodynamic and technical factors. Φ At a Nyquist limit of 50-60 cm/s. ψ Baseline shift with Nyquist limit of 28 cm/s. † Other conditions may cause systolic blunting (eg. atrial fibrillation, elevated RA pressure).

19. Grading of pulmonary regurgitation

Specific findings Mean pressure gradient  ≥5 mmHg Inflow time-velocity integral  >60 cm T1/2  ≥190 ms Valve area by continuity equationa  ≤1 cm2 Supportive findings Enlarged right atrium ≥moderate DHated inferior vena cava 

aStroke volume derived from left or right ventricular outflow. In the presence of more than mild TR, the derived valve area will be underestimated. Nevertheless, a value ≤1 cm2 implies a significant haemodynamic burden imposed by the combined lesion. 

20. Grading of tricuspid stenosis

Parameter Mild Moderate Severe Pulmonic valve Normal Normal or

abnormal Abnormal

RV size Normal∗ Normal or dilated Dilated Jet size by color Doppler§ Thin (usually < 10 mm in

length) with a narrow Intermediate Usually large, with a wide

origin; May be brief in

origin duration Jet density and deceleration rate –CW†

Soft; Slow deceleration Dense; variable deceleration

Dense; steep deceleration, early termination of diastolic flow

Pulmonic systolic flow compared to systemic flow –PWφ

Slightly increased Intermediate Greatly increased

CW, Continuous wave Doppler; PR, pulmonic regurgitation; PW, pulsed wave Doppler; RA, right atrium; RF, regurgitant fraction; RV, right ventricle.

∗ Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical 4-chamber view; RV medio-lateral end-diastolic dimension ≤ 4.3 cm, RV end-diastolic area ≤ 35.5 cm2(89).

∗∗ Exception: acute PR § At a Nyquist limit of 50-60 cm/s. φ Cut-off values for regurgitant volume and fraction are not well validated. † Steep deceleration is not specific for severe PR.

21. Grading of pulmonary stenosis

Mild Moderate Severe Peak velocity (m/s)  <3  3-4  >4 Peak gradient (mmHg)  <36  36-64  >64 

22. Levine grading scale

1. The murmur is only audible on listening carefully for some time.2. The murmur is faint but immediately audible on placing the stethoscope on the chest.3. A loud murmur readily audible but with no palpable thrill.4. A loud murmur with a palpable thrill.5. A loud murmur with a palpable thrill. The murmur is so loud that it is audible with only the rim 

of the stethoscope touching the chest.

6. A loud murmur with a palpable thrill. The murmur is audible with the stethoscope not touching the chest but lifted just off it.

23. Vaughan William’s classification

Class Basic Mechanism Comments

Isodium-channel blockade

Reduce phase 0 slope and peak of action potential.

IA    - moderate Moderate reduction in phase 0 slope; increase APD; increase ERP.

IB    - weak Small reduction in phase 0 slope; reduce APD; decrease ERP.

IC    - strong Pronounced reduction in phase 0 slope; no effect on APD or ERP.

II beta-blockade Block sympathetic activity; reduce rate and conduction.

IIIpotassium-channel blockade

Delay repolarization (phase 3) and thereby increase action potential duration and effective refractory period.

IVcalcium-channel blockade

Block L-type calcium-channels; most effective at SA and AV nodes; reduce rate and conduction.

APD, action potential duration; ERP, effective refractory period; SA, sinoatrial node; AV, atrioventricular node.

24. Scale for assessing pulse

4 Bounding3 Increased2 Normal1 Weak0 Absent or nonpalpable

24. Phases of Korotkoff sounds

PHASE 1 - CLEAR TAPPING SOUND   (SBP) PHASE II - ONSET OF SWISHING SOUND OR SOFT MURMUR PHASE III- LOUD SLAPPING SOUND PHASE IV - SUDDEN MUFFLING OF SOUND PHASE V - DISAPPEARANCE OF SOUND / PHASE OF SILENCE (DBP)

25. Blood Pressure Classification

SBP DBPNormal <120 and <80Prehypertension 120–139 or 80–89Stage 1 Hypertension 140–159 or 90–99Stage 2 Hypertension >160or >100

26. Staging of PVD: Fontaine Classification

1. Stage I – Asymptomatic. Of note: Fontaine stage I does in fact describe patients who are for the most part asymptomatic. Careful history may actually reveal subtle and non-specific symptoms such as paresthesias. Physical examination may reveal cold extremities and other signs of “subclinical” peripheral artery disease. More examples include bruits over blood vessels and lack of normal pulses.

2. Stage II – Intermittent claudication. This stage takes into account the fact that patients usually have a very constant distance at which they have pain:

o Stage IIa – Intermittent claudication after more than 200 meters of pain free walking.

o Stage IIb – Intermittent claudication after less than 200 meters of walking3. Stage III – Rest pain. Rest pain is especially troubling for patients during the night. The

reason for this is twofold: First, the legs are usually raised up on to a bed at night, thus diminishing the positive effect gravity may have had during the day when the legs were dependent. Second, during the night the lack of sensory stimuli allow patients to focus on their legs.

4. Stave IV – Ischemic ulcers or gangrene (which may be dry or humid).

27. Rutherford classification

1. Stage 0 – Asymptomatic2. Stage 1 – Mild claudication3. Stage 2 – Moderate claudication – The distance that delineates mild, moderate and severe

claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

4. Stage 3 – Severe claudication5. Stage 4 – Rest pain6. Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot7. Stage 6 – Severe ischemic ulcers or frank gangrene

28. Romhilt Estes Criteria Points

Voltage Criteria (any of): 

1. R or S in limb leads ≥20 mm 2. S in V1 or V2 ≥30 mm 3. R in V5 or V6 ≥30 mm 

3 

ST-T Abnormalities: 

ST-T vector opposite to QRS without digitalis  ST-T vector opposite to QRS with digitalis 

31

Negative terminal P mode in V1 1 mm in depth and 0.04 sec in duration (indicates left atrial enlargement) 

3 

Left axis deviation (QRS of -30° or more)  2 

QRS duration ≥0.09 sec  1 

Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec)  1 

29. Sokolow-Lyon index

S in V1 + R in V5 or V6 (whichever is larger) ≥ 35 mm (≥ 7 large squares) R in aVL ≥ 11 mm

30. Cornell voltage criteria The Cornell criteria for LVH are:

S in V3 + R in aVL > 28 mm (men) S in V3 + R in aVL > 20 mm (women)