4 Abnormalities in rate or rhythm Displacement of PMI Murmurs S3 CARDIOVASCULARTachycardiaPresent in many conditions, including hypoxia, hyperthyroidism, and heart failureAbnormalities in rate or rhythmMay be due to atrial fibrillationDisplacement of PMIVentricular hypertrophy or dilatationMurmursValvular dysfunctionS3CHFAbnormalities in peripheral pulsesPeripheral arterial disease
5 Right-sided heart failure ABDOMENHepatomegalyMay be seen with CHFEXTREMITIESEdemaRight-sided heart failureCyanosisHypoxemia, poor peripheral perfusionClubbingFibrotic lung disease (cystic fibrosis) or congenital heart disease resulting in chronic cyanosis
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 weightIncreasing 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 demandIts not a diagnosisIt’s a syndrome due to several causesArising from- systolic dysfunction
12 Systolic malfunction: Myocardial infarctionValvular diseaseHypertensionCardiomyopathy- alcohol/ amyloidCan also be identified as-Left sided failureRight sided failure
13 Symptoms of heart failure Dyspnea – vascular congestionNYHA classification 1-4Orthopnea –recumbency pools more blood in the heartParoxysmal nocturnal dyspnea- ‘cardiac asthma’Nocturia- night diuresisEdema- Right heart failureAnorexia- hepatic congestion
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 syndromeDiagnosed by mid-systolic ‘click’
20 MVP: Body features Asthenic body habitus Low body weight or body mass index (BMI)Straight-back syndromeScoliosis or kyphosisPectus excavatumHypermobility of the jointsArm span greater than height (which may be indicative of Marfan syndrome)
21 MVP-Symptoms ANS disturbance CHF: Anxiety Fatigue Panic attacks ArrhythmiasExercise intolerancePalpitationsAtypical chest painFatigueOrthostasisSyncope or presyncopeNeuropsychiatric symptomsCHF:FatigueDyspneaExercise intoleranceOrthopneaParoxysmal nocturnal dyspnea (PND)Progressive signs of congestive heart failure (CHF)
23 Coronary Heart Disease (CHD) Number one killer – one death/ minute (700,000/yr 1 in 5)16 million affectedF: 10 times the breast cancer deaths2004 data
24 Modifiable CAD Risk Factors Cigarette smokingObesityHypertension 140/90Physical inactivityKidney diseaseDiabetes mellitusAlcohol consumptionStressElevated LDLReduced HDLNon-modifiable CAD Risk Factors1 Males > 45 years 2 Females > 55 years3 Family history of coronary artery disease
25 Markers for inflammation Hs-CRPIL-6CD-40Homocysteine
26 ? Preventive Interventions Stop smokingLower 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 vasospasmtightness/squeeze/burning/pressing/ ‘gas’ or ‘indigestion’ –precordial regionRadiation of pain-C8-T4 dermatome area
34 Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis.6% PSVT18% Unspecified6% PVCs4% Atrial Flutter9% SSS34% Atrial Fibrillation8% Conduction Disease10% VT3% SCD2% VF
35 Underlying Arrhythmia of Sudden Death Torsadesde Pointes13%PrimaryVF8%VT62%Bradycardia17%
36 ARRHYTHMIAScan be lethal (sudden cardiac death), symptomatic (syncope, near syncope, dizziness, fatigue, or palpitations), or asymptomaticreduce cardiac output,perfusion of the brain or myocardium is impaired
39 14 million people in the USA have arrhythmias (5% of the population) Related to age and the presence of underlying heart diseaseMost common disorders: atrial fibrillation and flutter‘Missed beat’ / ‘Racing heart’
40 Tachycardiasabove 100 beats a minute,ventricles, do not have enough time to fill with bloodSkipping a beatBeating out of rhythmPalpitationsRapid heart actionShortness of breathChest painDizzinessLightheadednessFainting or near fainting.Chaotic, quivering or irregular rhythmBradycardias60 beats a minutenot enough oxygen-rich bloodsymptoms of a slow heartbeat are:FatigueDizzinessLightheadednessFainting or near fainting
41 Definitions: Atrial Sinus bradycardia - <60 beats/min. Sinus tachycardiaSick sinus syndrome – (cycles of bradycardia and tachycardia).Atrial flutterAtrial 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.
43 Atrial Fibrillation 2.2 million affected Causes 15-25% of all Strokes Etiology-IHD/ Diabetes/ HTN/ Valve disease/ thyrotoxicosisIrregularly irregular pulseECG absence of P wavesTherapy-Digoxin? Anticoagulant- warfarinElectrical cardioversion
44 Ventricular tachycardia Leads to ventricular fibrillation- causing sudden cardiac death (300,000/yr)Diagnosis by ECGDefib and AmiodaroneImplanted cardiac defibrillator
45 Ventricular fibrillation Life threateningNeeds defibrillation!
46 DRUG THERAPY Class I agents block membrane sodium channels – quinidine, procainamide, disopyramide, lidocaineClass II agents are the β-blockersClass III agents block potassium channels - amiodarone,Class IV agents- are thecalcium channel blockers –verapamil, diltiazem
47 Sinus arryhtmiacyclic increase in normal heart rate with inspiration and decrease with expirationhas no clinical significance. It is common in both the young and the elderlyresults from reflex changes in vagal influenceThis is normal. The breath affects the movement of the heart. That’s what you’re seeing here.
48 Sinus bradycardiaheart rate slower than 50 beats/mina normal finding in persons with excellent physical conditionsinus node pathology especially in elderly patients and individuals with heart disease.weakness, confusion, or syncopePacing may be required
49 Sinus tachycardia rate infrequently exceeds 160 beats/min heart rate faster than 100 beats/minCauses-fever,exercise,emotion,pain,anemia,heart failure,shock,thyrotoxicosis, orin response to many drugsAlcohol and alcohol withdrawalrate infrequently exceeds 160 beats/minEvery 10 beats above 90 bpm = increase in body temp by 1 degree.
50 Drug-Induced & Toxic Myocarditis Doxorubicincocaine cardiotoxicityDoxorubicin 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 weaknessDependent edema and right upper quadrant painCyanosis, clubbing
52 Pulmonary Heart Disease (Cor Pulmonale) Oxygen,salt and fluid restriction, anddiureticsOnce congestive signs appear, the average life expectancy is 2–5 yearsLook at the blacker areas in the right side of the pic.
53 Cardiovascular Changes During Pregnancy Maternal blood volumeStroke volumeheart rateHigh cardiac outputmore horizontal position of the heartBlood 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 preeclampsiaCardiomyopathy of Pregnancy (Peripartum Cardiomyopathy)one of 4000–15,000 patients, dilated cardiomyopathy develops in the final month of pregnancy or within 6 months after deliveryBout 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 yearsgestational hypertension and drugs used to stop uterine contractions60% of patients make a complete recovery.1st pregs and over age of 30.
56 Acute Pericarditis Post heart attack Viral Collagen- SLE Bacterial infectionMetastatic cancerUremiaRadiationLeft sided chest pain on inspirationFeels better on sitting up and leaning forwardAuscultation- pericardial friction rubLab work up: ECG/ EchoTherapy- NSAIDs/ SteroidsThese are posible causes on the left, sx on right, dx on lab workup bullet and then therapy.