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CARDIOLOGY
Cardinal Signs
DYSPNEA: ?Cardio/ ?Pulmonary
Ischemia
CHF-Rt / Lt
CAD
Valvular Disease
Pericarditis
Arrythmia
ObstructiveAsthma/ COPD
Restrictive1 Interstitial (alveolar) fibrosis/ SLE
2Other non pulmonary- Obesity/
Spine-chest deformities
Pneumonia
Pneumothorax
2
Non-Cardio-Pulmonary
Metabolic- Acidosis
Hematology-Anemia
Psychic- Anxiety/Panic disorder
MSK- MS/ Musuclar Dystrophy
3
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
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 (1025 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 asLeft 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
Symptomatic-
?valvular disease
?HTN
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
Anxiety
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)
21
Lab Workup: Echcocardiography
Therapy: Repeat echo every 3-5 yrs
? Beta blockers
Stay away fromcaffeine/ alcohol/ nicotine
?Valve repair/ ?Warfarin
22
Coronary Heart Disease (CHD)
Number one killer – one death/ minute
(700,000/yr 1 in 5)
Coronary Heart
Disease
Stroke
7
6
4
14
HF*
High Blood Pressure
17
52
16 million affected
F: 10 times the breast cancer deaths
2004 data
Diseases of the
Arteries
Other
23
Modifiable CAD Risk
Factors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
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 painC8-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
patient discharges
with arrhythmia as
principal diagnosis.
4%
Atrial
Flutter
6%
PSVT
6%
PVCs
18%
Unspecified
9%
SSS
34%
Atrial
Fibrillation
8%
Conduction
Disease
10% VT
3% SCD
2% VF
34
Underlying Arrhythmia of Sudden
Death
Primary
VF
8%
VT
62%
Bradycardia
17%
Torsades
de Pointes
13%
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
Bradycardias
60 beats a minute
not enough oxygen-rich blood
symptoms of a slow heartbeat are:
Fatigue
Dizziness
Lightheadedness
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
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
Atrial
Fibrillation
2.2 million affected
Causes 15-25% of all Strokes
Etiology-IHD/ Diabetes/ HTN/
 TherapyDigoxin
? Anticoagulant- warfarin
Electrical cardioversion
Valve disease/ thyrotoxicosis
Irregularly irregular pulse
ECG absence of P waves
43
Ventricular
tachycardia
Leads to ventricular
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
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
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
Alcohol and alcohol withdrawal
rate infrequently
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
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
56