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CARDIOLOGY Cardinal Signs. 2 DYSPNEA: ?Cardio/ ?Pulmonary Ischemia Ischemia CHF-Rt / Lt CHF-Rt / Lt CAD CAD Valvular Disease Valvular Disease Pericarditis.

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Presentation on theme: "CARDIOLOGY Cardinal Signs. 2 DYSPNEA: ?Cardio/ ?Pulmonary Ischemia Ischemia CHF-Rt / Lt CHF-Rt / Lt CAD CAD Valvular Disease Valvular Disease Pericarditis."— Presentation transcript:

1 CARDIOLOGY Cardinal Signs

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

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

4 4 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 S3CHF Abnormalities in peripheral pulses Peripheral arterial disease

5 5 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 6 Diagnostic tests CXR CXR ECHO ECHO ECG ECG MRI MRI EBT EBT CARDIAC CATH CARDIAC CATH

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

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

9 9 Diet Changes to lower Cholesterol Reduce intake of saturated fat Reduce intake of saturated fat (<7% of total calories) Reduce cholesterol intake Reduce cholesterol intake (<200 mg/day) Include LDL lowering foods to diet- plant stanols/sterols (2 g/day) and viscous (soluble) fiber ( g/day) Include LDL lowering foods to diet- plant stanols/sterols (2 g/day) and viscous (soluble) fiber ( g/day) Losing weight Losing weight Increasing exercise Increasing exercise

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

11 11 Congestive Heart Failure Inability to pump blood at normal or elevated pressure or meet the oxygen demand Inability to pump blood at normal or elevated pressure or meet the oxygen demand Its not a diagnosis Its not a diagnosis Its a syndrome due to several causes Its a syndrome due to several causes Arising from- systolic dysfunction Arising from- systolic dysfunction

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

13 13 Symptoms of heart failure Dyspnea – vascular congestion Dyspnea – vascular congestion NYHA classification 1-4 Orthopnea –recumbency pools more blood in the heart Orthopnea –recumbency pools more blood in the heart Paroxysmal nocturnal dyspnea- cardiac asthma Paroxysmal nocturnal dyspnea- cardiac asthma Nocturia- night diuresis Nocturia- night diuresis Edema- Right heart failure Edema- Right heart failure Anorexia- hepatic congestion Anorexia- hepatic congestion

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

15 15 Case Workup ECG ECG CXR CXR Echocardiography- ejection fraction (normal-55-76%) Echocardiography- ejection fraction (normal-55-76%) Doppler echo-valves and chamber function Doppler echo-valves and chamber function Cardiac cath studies Cardiac cath studies CBC/Bun and Creatinine/Na+/ K+ CBC/Bun and Creatinine/Na+/ K+ Serum BNP (B-type natriuretic peptide) + in CHF Serum BNP (B-type natriuretic peptide) + in CHF

16 16 Therapy Treat the cause- ?thyrotoxicosis Treat the cause- ?thyrotoxicosis ?valvular disease ?HTN Symptomatic- Symptomatic- improve force of contraction- digoxin 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 17 Therapy choices ACEi + Diuretic ACEi + Diuretic ±Beta blocker/ Digoxin ±Beta blocker/ Digoxin Vasodilators- NTG Vasodilators- NTG New drug-nesiritide (rDNA- brain natriuretic peptide) New drug-nesiritide (rDNA- brain natriuretic peptide) ?Pacing in sever CHF (EF<30%) ?Pacing in sever CHF (EF<30%) ?Tx ?Tx Poor prognosis-50% in 5yrs Poor prognosis-50% in 5yrs

18 18 Acute LVF –Red flag ICU- 911! ICU- 911! Oxygen/ IV-lasix/ Morphine/ nitorglycerine/ ventilator Oxygen/ IV-lasix/ Morphine/ nitorglycerine/ ventilator Acute shock/ rapid pulse/ dropping blood pressure/ dyspnea/ frothing mouth Acute shock/ rapid pulse/ dropping blood pressure/ dyspnea/ frothing mouth Causes- infarction/ mitral stensosis Causes- infarction/ mitral stensosis

19 19 Mitral Valve Prolapse 2-6% affected/ F:M 2:1/benign 2-6% affected/ F:M 2:1/benign Can lead to: mitral regurge/ sbe/ sudden death/cva Can lead to: mitral regurge/ sbe/ sudden death/cva ?genetics- X linked/ Marfans (90%)/ Ehlers-Danlos syndrome ?genetics- X linked/ Marfans (90%)/ Ehlers-Danlos syndrome Diagnosed by mid-systolic click Diagnosed by mid-systolic click

20 20 MVP: Body features Asthenic body habitus Asthenic body habitus Low body weight or body mass index (BMI) Low body weight or body mass index (BMI) Straight-back syndrome Straight-back syndrome Scoliosis or kyphosis Scoliosis or kyphosis Pectus excavatum Pectus excavatum Hypermobility of the joints Hypermobility of the joints Arm span greater than height (which may be indicative of Marfan syndrome) Arm span greater than height (which may be indicative of Marfan syndrome)

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

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

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

24 24 Modifiable CAD Risk Factors 1.Cigarette smoking 2.Obesity 3.Hypertension 140/90 4.Physical inactivity 5.Kidney disease 6.Diabetes mellitus 7.Alcohol consumption 8.Stress 9.Elevated LDL 10.Reduced HDL Non-modifiable CAD Risk Factors 1 Males > 45 years 2 Females > 55 years 3 Family history of coronary artery disease

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

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

27 27 Ischemia= Angina Pectoris Brought on by exertion/ relieved by rest Brought on by exertion/ relieved by rest ?due to vasospasm ?due to vasospasm tightness/ tightness/ squeeze/ squeeze/ burning/ burning/ pressing/ gas or indigestion – pressing/ gas or indigestion – precordial region Radiation of pain- Radiation of pain- C8-T4 dermatome area

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

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

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

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

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

33 33 AMI: Therapy MONA- Morphine/ Oxygen/ NTG/ Aspirin MONA- Morphine/ Oxygen/ NTG/ Aspirin Clot busters- thrombolytics- tPa- tissue plasminogen activator: Clot busters- thrombolytics- tPa- tissue plasminogen activator: alteplase/ retiplase/ tenecteplase Post-infarction- aspirin/ warfarin/ betablockers/ ace-i/ ccb Post-infarction- aspirin/ warfarin/ betablockers/ ace-i/ ccb Cardiac-rehab-8-12 weeks Cardiac-rehab-8-12 weeks

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

35 Underlying Arrhythmia of Sudden Death VT62% Bradycardia17% Torsades de Pointes 13% PrimaryVF8%

36 36 ARRHYTHMIAS can be lethal (sudden cardiac death), symptomatic (syncope, near syncope, dizziness, fatigue, or palpitations), or asymptomatic can be lethal (sudden cardiac death), symptomatic (syncope, near syncope, dizziness, fatigue, or palpitations), or asymptomatic reduce cardiac output, reduce cardiac output, perfusion of the brain or myocardium is impaired perfusion of the brain or myocardium is impaired

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

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

39 39 14 million people in the USA have arrhythmias (5% of the population) 14 million people in the USA have arrhythmias (5% of the population) Related to age and the presence of underlying heart disease Related to age and the presence of underlying heart disease Most common disorders: atrial fibrillation and flutter Most common disorders: atrial fibrillation and flutter Missed beat / Racing heart Missed beat / Racing heart

40 40 Bradycardias Bradycardias 60 beats a minute 60 beats a minute not enough oxygen-rich blood not enough oxygen-rich blood symptoms of a slow heartbeat are: symptoms of a slow heartbeat are: Fatigue Fatigue Dizziness Dizziness Lightheadedness Lightheadedness Fainting or near fainting Fainting or near fainting 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

41 41 Definitions: Atrial Sinus bradycardia - <60 beats/min. Sinus bradycardia - <60 beats/min. Sinus tachycardia Sinus tachycardia Sick sinus syndrome – (cycles of bradycardia and tachycardia). Sick sinus syndrome – (cycles of bradycardia and tachycardia). Atrial flutter Atrial flutter Atrial fibrillation - uncoordinated atrial depolarizations. 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. 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 42 Heart Blocks

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

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

45 45 Ventricular fibrillation Life threatening Needs defibrillation!

46 46 DRUG THERAPY Class I agents block membrane sodium channels – Class I agents block membrane sodium channels – quinidine, procainamide, disopyramide, lidocaine quinidine, procainamide, disopyramide, lidocaine Class II agents are the β -blockers Class II agents are the β -blockers Class III agents block potassium channels - amiodarone, Class III agents block potassium channels - amiodarone, Class IV agents- are the Class IV agents- are the calcium channel blockers – verapamil, diltiazem

47 47 Sinus arryhtmia cyclic increase in normal heart rate with inspiration and decrease with expiration 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 has no clinical significance. It is common in both the young and the elderly results from reflex changes in vagal influence results from reflex changes in vagal influence

48 48 Sinus bradycardia heart rate slower than 50 beats/min heart rate slower than 50 beats/min a normal finding in persons with excellent physical condition a normal finding in persons with excellent physical condition sinus node pathology especially in elderly patients and individuals with heart disease. sinus node pathology especially in elderly patients and individuals with heart disease. weakness, confusion, or syncope weakness, confusion, or syncope Pacing may be required Pacing may be required

49 49 Sinus tachycardia heart rate faster than 100 beats/min heart rate faster than 100 beats/min Causes- Causes- fever, fever, exercise, exercise, emotion, emotion, pain, pain, anemia, anemia, heart failure, heart failure, shock, shock, thyrotoxicosis, or thyrotoxicosis, or in response to many drugs in response to many drugs Alcohol and alcohol withdrawal Alcohol and alcohol withdrawal rate infrequently exceeds 160 beats/min

50 50 Drug-Induced & Toxic Myocarditis Doxorubicin Doxorubicin cocaine cardiotoxicity cocaine cardiotoxicity

51 51 Pulmonary Heart Disease (Cor Pulmonale) Chronic productive cough, Chronic productive cough, Exertional dyspnea, Exertional dyspnea, wheezing respirations, wheezing respirations, easy fatigability, and weakness easy fatigability, and weakness Dependent edema and right upper quadrant pain Dependent edema and right upper quadrant pain Cyanosis, clubbing Cyanosis, clubbing

52 52 Pulmonary Heart Disease (Cor Pulmonale) Oxygen, Oxygen, salt and fluid restriction, and salt and fluid restriction, and diuretics diuretics Once congestive signs appear, the average life expectancy is 2–5 years Once congestive signs appear, the average life expectancy is 2–5 years

53 53 Cardiovascular Changes During Pregnancy Maternal blood volume Maternal blood volume Stroke volume Stroke volume heart rate heart rate High cardiac output High cardiac output more horizontal position of the heart more horizontal position of the heart

54 54 Cardiovascular Complications of Pregnancy eclampsia and preeclampsia eclampsia and preeclampsia Cardiomyopathy of Pregnancy (Peripartum Cardiomyopathy) 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 one of 4000–15,000 patients, dilated cardiomyopathy develops in the final month of pregnancy or within 6 months after delivery

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

56 56 Acute Pericarditis Post heart attack Post heart attack Viral Viral Collagen- SLE Collagen- SLE Bacterial infection Bacterial infection Metastatic cancer Metastatic cancer Uremia Uremia Radiation 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


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