CARDIOLOGY Cardinal Signs Ch 10-14 = cardio and blood. Refer to that. CMDT 2010 (preferably)

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

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

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

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

Diagnostic tests CXR ECHO ECG MRI EBT CARDIAC CATH

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

Mechanical Valve Prosthesis Thrombosis/embolism risk: mitral > aortic

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

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

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

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

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

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

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

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

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

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

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’

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)

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)

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

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

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  

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

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

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

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

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

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

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

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

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

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

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

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

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

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’

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

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.

Heart Blocks

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

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

Ventricular fibrillation Life threatening Needs defibrillation!

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

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.

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

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.

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.

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

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.

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!

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.

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.

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.