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CARDIOLOGY

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									CARDIOLOGY

Cardinal Signs
    DYSPNEA: ?Cardio/ ?Pulmonary
Ischemia           Obstructive-
CHF-Rt / Lt                 Asthma/ COPD
CAD                Restrictive-
Valvular Disease   1 Interstitial (alveolar) fibrosis/ SLE
Pericarditis       2Other non pulmonary- Obesity/
Arrythmia          Spine-chest deformities
                    Pneumonia
                    Pneumothorax



                                                          2
Non-Cardio-Pulmonary

Metabolic- Acidosis
Hematology-Anemia
Psychic- Anxiety/Panic disorder
MSK- MS/ Musuclar Dystrophy




                                   3
                       CARDIOVASCULAR
                              Present in many conditions, including
Tachycardia                   hypoxia, hyperthyroidism, and heart
                              failure
Abnormalities in rate or      May be due to atrial fibrillation

rhythm
                              Ventricular hypertrophy or dilatation
Displacement of PMI
                              Valvular dysfunction
Murmurs
                              CHF
S3

Abnormalities in peripheral   Peripheral arterial disease

pulses


                                                                      4
                 ABDOMEN


Hepatomegaly         May be seen with CHF

               EXTREMITIES

Edema                Right-sided heart failure



Cyanosis             Hypoxemia, poor peripheral
                     perfusion


Clubbing             Fibrotic lung disease (cystic
                     fibrosis) or congenital heart
                     disease resulting in chronic
                     cyanosis
                                                     5
Diagnostic tests


CXR
ECHO
ECG
MRI
EBT
CARDIAC CATH



                   6
 Bioprosthesis/ Homografts
Life expetency -10-15 years
Bovine better than porcine
Homografts (allograft) human




                                7
Mechanical Valve
     Prosthesis
Thrombosis/embolism risk: mitral >
aortic




                                8
 Diet Changes to lower Cholesterol
Reduce intake of saturated fat
       (<7% of total calories)
Reduce cholesterol intake
 (<200 mg/day)
Include LDL lowering foods to diet- plant
stanols/sterols (2 g/day) and viscous (soluble) fiber (10-
25 g/day)
Losing weight
Increasing exercise

                                                         9
CHF Data

Prevalence- 5 million
Incidence 500,000/year
Older age group 65+




                          10
  Congestive Heart Failure
Inability to pump blood at normal or elevated pressure
or meet the oxygen demand
Its not a diagnosis
It‟s a syndrome due to several causes
Arising from- systolic dysfunction




                                                      11
Systolic malfunction:

Myocardial infarction
Valvular disease
Hypertension
Cardiomyopathy- alcohol/ amyloid
Can also be identified as-
      Left sided failure
      Right sided failure


                                    12
 Symptoms of heart failure
Dyspnea – vascular congestion
      NYHA classification 1-4
Orthopnea –recumbency pools more blood in the
heart
Paroxysmal nocturnal dyspnea- „cardiac asthma‟
Nocturia- night diuresis
Edema- Right heart failure
Anorexia- hepatic congestion

                                                  13
CHF-Physical findings

Tachycardia- increased ISA
Wet lungs (crackles)- LVF
Enlarged ventricle
S3-
Jugular vein distension- right failure
Edema feet
Ascites


                                          14
 Case Workup
ECG
CXR
Echocardiography- ejection fraction (normal-55-76%)
Doppler echo-valves and chamber function
Cardiac cath studies
CBC/Bun and Creatinine/Na+/ K+
Serum BNP (B-type natriuretic peptide) + in CHF



                                                  15
 Therapy
Treat the cause- ?thyrotoxicosis
                                 ?valvular disease
                                    ?HTN
Symptomatic-
     improve force of contraction- digoxin
    reduce arterial pressure „after load‟-
    ACEi/ARBs
    decrease fluid volume- diuretics:
    Thiazides (HCTZ) / Lasix/ Aldactone
    reduce ISA- betablockers
    cardiac fitness- rehab training exercise


                                                     16
Therapy choices

ACEi + Diuretic
±Beta blocker/ Digoxin
Vasodilators- NTG
New drug-nesiritide (rDNA- brain natriuretic peptide)
?Pacing in sever CHF (EF<30%)
?Tx
Poor prognosis-50% in 5yrs


                                                     17
Acute LVF –Red flag

ICU- 911!
Oxygen/ IV-lasix/ Morphine/      nitorglycerine/
ventilator
Acute shock/ rapid pulse/ dropping blood pressure/
dyspnea/ frothing mouth
Causes- infarction/ mitral stensosis



                                                      18
Mitral Valve Prolapse

2-6% affected/ F:M 2:1/benign
Can lead to: mitral regurge/ sbe/ sudden death/cva
?genetics- X linked/ Marfans (90%)/ Ehlers-Danlos
syndrome
Diagnosed by mid-systolic „click‟




                                                      19
 MVP: Body features
Asthenic body habitus
Low body weight or body mass index (BMI)
Straight-back syndrome
Scoliosis or kyphosis
Pectus excavatum
Hypermobility of the joints
Arm span greater than height (which may be indicative
of Marfan syndrome)



                                                    20
   MVP-Symptoms
ANS disturbance             CHF:
Anxiety                     Fatigue
Panic attacks               Dyspnea
Arrhythmias                 Exercise intolerance
Exercise intolerance        Orthopnea
Palpitations                Paroxysmal nocturnal dyspnea (PND)
Atypical chest pain         Progressive signs of congestive heart
Fatigue                     failure (CHF)
Orthostasis
Syncope or presyncope
Neuropsychiatric symptoms



                                                                      21
Lab Workup: Echcocardiography
Therapy: Repeat echo every 3-5 yrs
? Beta blockers
Stay away from-
      caffeine/ alcohol/ nicotine
?Valve repair/ ?Warfarin




                                      22
Coronary Heart Disease (CHD)
 Number one killer – one death/ minute     Coronary Heart
        (700,000/yr 1 in 5)                 Disease
                                            Stroke
                  6     4         14
           7
                                            HF*

   17                                       High Blood Pressure

                                       52   Diseases of the
 16 million affected                       Arteries
 F: 10 times the breast cancer deaths      Other
 2004 data


                                                                  23
        Modifiable CAD Risk
                Factors       Non-modifiable CAD
1.    Cigarette smoking       Risk Factors
2.    Obesity                 1 Males > 45 years
3.    Hypertension 140/90     2 Females > 55 years
4.    Physical inactivity
                              3 Family history of coronary
5.    Kidney disease
                              artery disease
6.    Diabetes mellitus
7.    Alcohol consumption
8.    Stress
9.    Elevated LDL
10.   Reduced HDL


                                                             24
Markers for inflammation

Hs-CRP
IL-6
CD-40
Homocysteine




                           25
? Preventive Interventions

Stop smoking
Lower LDL/ Elevate HDL
?Statins
?Aspirin in men / not so in women
?Omega-3
?ACEi



                                     26
   Ischemia= Angina Pectoris
Brought on by exertion/       relieved
by rest
?due to vasospasm
tightness/
squeeze/
burning/
pressing/ „gas‟ or   „indigestion‟ –
    precordial region
Radiation of pain-
    C8-T4 dermatome area


                                          27
 DD: ?Angina
Costochondritis (chest wall pain)
Herpes Zoster dermatomal pain
Cervical Spondylitis (C6-8)
Peptic ulcer/ Cholcecystitis/     Esophageal reflux/
Pneumothorax




                                                        28
Angina Types

Chronic stable type
Unstable angina- serious may progress to heart
attack
Variant (Prinzmetal‟s) angina- coronary spasm




                                                  29
Lab Workup

Lab workup- ECG/ EBCT (CACS status) score >100
high risk
                   >1000 very high risk
Coronary angiography




                                              30
Angina Therapy

Nitroglycerine sub-lingual
Beta blockers- propranalol (Inderal)
CCB- verapamil/ diltiazem
Aspirin/ Clopidogrel (Plavix)
Role for acupuncture
CABG



                                        31
    Acute Coronary Syndrome
Unstable Angina>Ischemia>Infarction
Check ECG/Blood markers determine heart attack or not
„Chest pain Observation Units‟
Troponin-1




                                                     32
AMI: Therapy
“MONA”- Morphine/ Oxygen/ NTG/ Aspirin
Clot busters- thrombolytics- tPa- tissue plasminogen activator:
        alteplase/ retiplase/ tenecteplase
Post-infarction- aspirin/ warfarin/ betablockers/ ace-i/ ccb
Cardiac-rehab-8-12 weeks




                                                                33
Atrial fibrillation
accounts for 1/3 of all      6%
patient discharges          PSVT
with arrhythmia as
principal diagnosis.                      18%
                            6%         Unspecified
                 4%        PVCs
                 Atrial
                Flutter

                            9%                     34%
                            SSS                    Atrial
                                                Fibrillation

                8%
             Conduction
              Disease
                                   10% VT
                          3% SCD

                                            2% VF
                                                               34
Underlying Arrhythmia of Sudden
Death
                                    Torsades
                Primary            de Pointes
                  VF                  13%
                  8%


           VT
          62%        Bradycardia
                        17%
ARRHYTHMIAS
can be lethal (sudden cardiac death), symptomatic
(syncope, near syncope, dizziness, fatigue, or
palpitations), or asymptomatic
reduce cardiac output,
perfusion of the brain or myocardium is impaired




                                                     36
Abnormal Heart Rhythms
      Arrhythmia             BPM
      tachycardia           150-250
      bradycardia             <60
      atrial flutter        200-350
      atrial fibrillation    >350
      prem. atrial cont.    variable
      prem. vent. cont.     variable
      vent.fibrillation     variable


                                       37
   CAUSES
electrolyte abnormalities,
 hormonal imbalances (thyrotoxicosis, hyper adrenaline
(catecholaminergic) states),
 hypoxia,
drug effects
myocardial ischemia



                                                38
14 million people in the USA have arrhythmias (5% of
the population)
Related to age and the presence of underlying heart
disease
Most common disorders: atrial fibrillation and flutter
„Missed beat‟ / „Racing heart‟




                                                          39
                                     Tachycardias
Bradycardias                        above 100 beats a minute,
60 beats a minute                   ventricles, do not have enough time to
                                     fill with blood
not enough oxygen-rich blood
                                     Skipping a beat
symptoms of a slow heartbeat are:
                                     Beating out of rhythm
Fatigue                             Palpitations
Dizziness                           Rapid heart action
Lightheadedness                     Shortness of breath
Fainting or near fainting           Chest pain
                                     Dizziness
                                     Lightheadedness
                                     Fainting or near fainting.
                                     Chaotic, quivering or irregular rhythm
                                                                          40
 Definitions: Atrial
Sinus bradycardia - <60 beats/min.
Sinus tachycardia - 100-180
Sick sinus syndrome – (cycles of bradycardia and tachycardia).
Atrial flutter - 250-350
Atrial fibrillation - uncoordinated atrial depolarizations.
AV nodal blocks - a conduction block within the AV node (or
occasionally in the bundle of His) that impairs impulse conduction
from the atria to the ventricles.




                                                               41
Heart Blocks




               42
                                          Fibrillation
                             Atrial affected
                             2.2 million
                             Causes 15-25% of all Strokes
                             Etiology-IHD/ Diabetes/ HTN/
                             Valve disease/ thyrotoxicosis
                             Irregularly irregular pulse
 Therapy-                   ECG absence of P waves
Digoxin
? Anticoagulant- warfarin
Electrical cardioversion



                                                             43
             tachycardia
Ventricularventricular
   Leads to
   fibrillation- causing sudden
   cardiac death (300,000/yr)
   Diagnosis by ECG
   Defib and Amiodarone
   Implanted cardiac
   defibrillator




                                  44
 Ventricular fibrillation




Life threatening
Needs defibrillation!




                            45
    DRUG THERAPY
Class I agents block membrane sodium channels –
quinidine, procainamide, disopyramide, lidocaine
Class II agents are the β-blockers
Class III agents block potassium channels - amiodarone,
Class IV agents- are the
          calcium channel blockers –
       verapamil, diltiazem




                                                           46
  Sinus inarryhtmia
cyclic increase normal
heart rate with inspiration
and decrease with
expiration
has no clinical
significance. It is common
in both the young and the
elderly
results from reflex
changes in vagal influence




                              47
 Sinus bradycardia
heart rate slower than 50 beats/min
a normal finding in persons with excellent physical
condition
sinus node pathology especially in elderly
patients and individuals with heart disease.
weakness, confusion, or syncope
Pacing may be required



                                                       48
   Sinus tachycardia
heart rate faster than 100
beats/min
Causes-
fever,
exercise,
emotion,
pain,
anemia,
heart failure,
shock,
thyrotoxicosis, or
in response to many drugs
                                  rate infrequently
Alcohol and alcohol withdrawal
                                  exceeds 160 beats/min




                                                          49
Drug-Induced & Toxic Myocarditis

Doxorubicin
cocaine cardiotoxicity




                               50
   Pulmonary Heart Disease
   (Cor Pulmonale)
Chronic productive cough,
 Exertional dyspnea,
wheezing respirations,
easy fatigability, and weakness
Dependent edema and right upper quadrant pain
Cyanosis, clubbing



                                                 51
         Pulmonary Heart Disease
         (Cor Pulmonale)
Oxygen,
salt and fluid restriction, and
 diuretics
Once congestive signs
appear, the average life
expectancy is 2–5 years




                                   52
    Cardiovascular Changes
    During Pregnancy

Maternal blood volume
Stroke volume
heart rate
High cardiac output
more horizontal position of the heart




                                         53
Cardiovascular Complications of
Pregnancy

eclampsia and preeclampsia
Cardiomyopathy of Pregnancy (Peripartum
Cardiomyopathy)
one of 4000–15,000 patients, dilated cardiomyopathy
develops in the final month of pregnancy or within 6
months after delivery




                                                  54
dilated cardiomyopathy
women over age 30 years
gestational hypertension and drugs used to stop
uterine contractions
60% of patients make a complete recovery.




                                                   55
Acute Pericarditis
Post heart attack     Left sided chest pain on
Viral                 inspiration
Collagen- SLE         Feels better on sitting up and
Bacterial infection   leaning forward
Metastatic cancer     Auscultation- pericardial
                       friction rub
Uremia
                       Lab work up: ECG/ Echo
Radiation
                       Therapy- NSAIDs/ Steroids



                                                     56

								
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