1. CARDIOLOGY Cardinal Signs
Ch = cardio and blood. Refer to that. CMDT 2010 (preferably)

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

3. Non-Cardio-Pulmonary
Metabolic- Acidosis
Hematology-Anemia
Psychic- Anxiety/Panic disorder
MSK- MS/ Musuclar Dystrophy

4. Abnormalities in rate or rhythm Displacement of PMI Murmurs S3
CARDIOVASCULAR
Tachycardia
Present in many conditions, including hypoxia, hyperthyroidism, and heart failure
Abnormalities in rate or rhythm
May be due to atrial fibrillation
Displacement of PMI
Ventricular hypertrophy or dilatation
Murmurs
Valvular dysfunction S3
CHF
Abnormalities in peripheral pulses
Peripheral arterial disease

5. Right-sided heart failure
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

6. Diagnostic tests
CXR
ECHO
ECG
MRI
EBT
CARDIAC CATH

7. Bioprosthesis/ Homografts
Life expetency years
Bovine better than porcine
Homografts (allograft) human

8. Mechanical Valve Prosthesis
Thrombosis/embolism risk: mitral > aortic

9. 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

10. CHF Data Prevalence- 5 million Incidence 500,000/year
Older age group 65+

11. 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

12. Systolic malfunction:
Myocardial infarction
Valvular disease
Hypertension
Cardiomyopathy- alcohol/ amyloid
Can also be identified as-
Left sided failure
Right sided failure

13. 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

14. CHF-Physical findings
Tachycardia- increased ISA
Wet lungs (crackles)- LVF
Enlarged ventricle
S3-
Jugular vein distension- right failure
Edema feet
Ascites

15. 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

16. 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

17. 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

18. 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

19. 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’

20. 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)

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

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

23. Coronary Heart Disease (CHD)
Number one killer – one death/ minute (700,000/yr 1 in 5)
16 million affected
F: 10 times the breast cancer deaths
2004 data

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

25. Markers for inflammation
Hs-CRP
IL-6
CD-40
Homocysteine

26. ? Preventive Interventions
Stop smoking
Lower LDL/ Elevate HDL
?Statins
?Aspirin in men / not so in women
?Omega-3
?ACEi

27. 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

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

29. Angina Types Chronic stable type
Unstable angina- serious may progress to heart attack
Variant (Prinzmetal’s) angina- coronary spasm

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

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

32. Acute Coronary Syndrome
Unstable Angina>Ischemia>Infarction
Check ECG/Blood markers determine heart attack or not
‘Chest pain Observation Units’
Troponin-1

33. 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

34. Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis.
6% PSVT
18% Unspecified
6% PVCs
4% Atrial Flutter
9% SSS
34% Atrial Fibrillation
8% Conduction Disease
10% VT
3% SCD
2% VF

35. Underlying Arrhythmia of Sudden Death
Torsades
de Pointes
13%
Primary VF 8% VT
62%
Bradycardia
17%

36. 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

37. Abnormal Heart Rhythms
Arrhythmia
BPM
tachycardia
bradycardia
<60
atrial flutter
atrial fibrillation
>350
prem. atrial cont.
variable
prem. vent. cont.
vent.fibrillation

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

39. 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’

40. Tachycardias
above 100 beats a minute,
ventricles, do not have enough time to fill with blood
Skipping a beat
Beating out of rhythm
Palpitations
Rapid heart action
Shortness of breath
Chest pain
Dizziness
Lightheadedness
Fainting or near fainting.
Chaotic, quivering or irregular rhythm
Bradycardias
60 beats a minute
not enough oxygen-rich blood
symptoms of a slow heartbeat are:
Fatigue
Dizziness
Lightheadedness
Fainting or near fainting

41. Definitions: Atrial Sinus bradycardia - <60 beats/min.
Sinus tachycardia
Sick sinus syndrome – (cycles of bradycardia and tachycardia).
Atrial flutter
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.

42. Heart Blocks

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

44. Ventricular tachycardia
Leads to ventricular fibrillation- causing sudden cardiac death (300,000/yr)
Diagnosis by ECG
Defib and Amiodarone
Implanted cardiac defibrillator

45. Ventricular fibrillation
Life threatening
Needs defibrillation!

46. 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

47. Sinus arryhtmia
cyclic increase in 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
This is normal. The breath affects the movement of the heart. That’s what you’re seeing here.

48. 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

49. Sinus tachycardia rate infrequently exceeds 160 beats/min
heart rate faster than 100 beats/min
Causes-
fever,
exercise,
emotion,
pain,
anemia,
heart failure,
shock,
thyrotoxicosis, or
in response to many drugs
Alcohol and alcohol withdrawal
rate infrequently exceeds 160 beats/min
Every 10 beats above 90 bpm = increase in body temp by 1 degree.

50. Drug-Induced & Toxic Myocarditis
Doxorubicin
cocaine cardiotoxicity
Doxorubicin is an anticancer drug. Can cause myocardial inflammation as can coke. Even a small amount can affect the heart….even years down the road.

51. 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

52. Pulmonary Heart Disease (Cor Pulmonale)
Oxygen,
salt and fluid restriction, and
diuretics
Once congestive signs appear, the average life expectancy is 2–5 years
Look at the blacker areas in the right side of the pic.

53. Cardiovascular Changes During Pregnancy
Maternal blood volume
Stroke volume
heart rate
High cardiac output
more horizontal position of the heart
Blood Volume up 33% in 2nd and 3rd trimesters. Pulse will be bounding. Growing fetus also pushes on the heart so it sits more horizontal. Heart will always be a little different after preggers than before! Huh!

54. 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
Bout 20% of preggers end up with eclampsia/preeclampsia. Sudden weight gain – like 15 lbs in a month, increase in blood proteins, fat in the face. 130/85 is the maximum.
Small % end up in cardiomyopathy.

55. dilated cardiomyopathy
women over age 30 years
gestational hypertension and drugs used to stop uterine contractions
60% of patients make a complete recovery.
1st pregs and over age of 30.

56. Acute Pericarditis Post heart attack Viral Collagen- SLE
Bacterial infection
Metastatic cancer
Uremia
Radiation
Left sided chest pain on inspiration
Feels better on sitting up and leaning forward
Auscultation- pericardial friction rub
Lab work up: ECG/ Echo
Therapy- NSAIDs/ Steroids
These are posible causes on the left, sx on right, dx on lab workup bullet and then therapy.