HISTORY TAKING: ISCHEMIA AND HYPERTENSION

1. HISTORY TAKING: ISCHEMIA AND HYPERTENSION ADRIEL E. GUERRERO, MD, FPCP, FPCC Training Officer Section of Cardiology, Dept of Medicine The Medical City

2. Typical Angina • Precipitated by effort and relieved by rest and/or nitroglycerin sublingual • Fixed coronary obstruction • Atypical – coronary spasm +/- obstruction

3. Differential Diagnosis of Chest Pain according to Location

4. Pain Patterns of Myocardial Ischemia

5. Your initial questions should be broad • “Do you have any pain or discomfort in your chest?” Ask the patient to point to the pain and to describe • move on to more specific questions such as “Is the pain related to exertion?” • “What kinds of activities bring on the pain?” • “How intense is the pain, on a scale of 1 to 10?” • “Does it radiate into the neck, shoulder, back, or down your arm?” • “Are there any associated symptoms like shortness of breath, sweating, palpitations, or nausea?” • “Does it ever wake you up at night?” • “What do you do to make it better?” • Exertional chest pain with radiation to the left side of the neck and down the left arm in angina pectoris; • sharp pain radating into the back or into the neck in aortic dissection.

6. Features Differentiating Ischemic from Non-Ischemic Chest Pain FACTORS PROVOKING PAIN

7. Features Differentiating Ischemic from Non-Ischemic Chest Pain QUALITY OF PAIN

8. Features Differentiating Ischemic from Non-Ischemic Chest Pain LOCATION OF PAIN

10. Angina Pectoris AMI Pericarditis AorticDissectn Tracheobronchitis PleuriticPain

12. GERD DES Costochondritis Anxiety

13. Clinical Spectrum of Myocardial Ischemic syndromes • Stable angina • Unstable angina • Non Q wave MI/NSTEMI • ST Elevation MI/Q wave MI • Sudden death

14. HYPERTENSION • Most patients have no specific symptoms referable to their blood pressure elevation • When symptomatic, they are related to: • The elevated blood pressure itself • The hypertensive vascular disease • The underlying disease, in the case of secondary HPN

15. Symptoms from the BP itself • Headache (most popular) • More in severe HPN • Occipital, present upon waking up and subsides spontaneously after several hours OTHERS: Dizziness, palpitations, easy fatigability, impotence

16. Symptoms referable to Vascular Disease • Epistaxis, hematuria, • blurring of vision (retinal changes), • episodes of weakness or dizziness due to transient cerebral ischemia, • angina pectoris, • dyspnea due to cardiac failure, • Pain due to dissection of the aorta or a leaking aneurysm

17. Symptoms related to underlying disease in secondary HPN • Primary Aldosteronism • Polyuria, polydipsia, muscle weakness from hypokalemia • Cushing’s Syndrome • Weight gain, emotional lability • Pheochromocytoma • Episodic headaches, palpitations, diaphoresis and postural dizziness • Thyrotoxicosis • Palpitations, weight loss, heat intolerance

18. Symptoms attributable to End-organ damage of HPN • Cardiac /Vascular effects • Cardiomegaly (CHF), angina and ischemic syndromes, peripheral arterial occlusive disease (fingers/toes) • Neurologic/Ophthalmologic • Retinopathy (BOV), papilledema, • cerebral infarction/hemorrhages/Charcot-Bouchard aneurysms • Hypertensive encephalopathy (severe HPN, disordered conciousness, inc. ICP • Renal • Chronic renal failure (pallor, anemia with HPN, bipedal /facial edema

19. Thank You!!!

20. Risk Factors for Ischemic Heart Disease, Myocardial Infarction and Hypertension • Age (older than 55 for men, 65 for women) • Gender ( male > female) • Smoking history • Hyperlipidemia • Diabetes mellitus • Hypertension • Obesity • Family history of premature CAD

21. Atherosclerosis • Leading cause of death and disability in developed countries • Heart – AMI • Nervous system – strokes • Peripheral circulation – gangrene & limb ischemia • Splanchnic circulation – mesenteric ischemia

22. Risk Factors for Ischemic Heart Disease, Myocardial Infarction and Hypertension • Age (older than 55 in men, older than 65 in women) • Gender • Excess coronary risks in men vs premenopausal women • Relatively higher HDL levels in premenopausal women • Smoking History • # of years X pack of cigarette/day • Hyperlipidemia • LDL – increased atherogenicity

23. Dyslipidemia • Total Cholesterol > 5.0 mmol/l (190 mg/dl) or • LDL-C • >3.0 mmol/L (115 mg/dl) or • HDL-C • Male < 1.0 mmol/L (40 mg/dl) • Female <1.2 mmol/L (46 mg/dl) • Triglyceride • > 1.7 mmol/L (150 mg/dl)

24. Cigarette smoking • Accelerates coronary atherosclerosis in both sexes, • At all ages…increases thrombosis, plaque instability, MI and death • Increases myocardial oxygen needs and reduces O2 supply – aggravates angina

25. Diabetes • CHD risk equivalent • Abnormal lipoprotein profile + insulin resistance • Hypertension • Tx thereof reduce stroke and heart failure risk • Obesity • (>102 cm [M]; >88 cm [W]) • Family History of premature CAD • (men under age of 55 or women below 65)

26. Diabetes Insulin resistance Hyperinsulinemia increases BP - produces renal sodium retention and inc. sympathetic activity - produces vascular smooth mucle hypertrophy (mitogenic action of insulin) - modifies ion transport across cell membrane (inc. cytosolic calcium)

27. Hypertension • One of the most common complex genetic disorders • Genetic heritability =30%

28. Emerging risk factors • Lipoprotein (a) • Modulates fibrinolysis • Elevated = increased CHD risk • Homocysteine • Atherosclerosis at a young age • Prothrombotic factors • Plasminogen activator inhibitor (PAI) • Proinflammatory factors • High-sensitivity CRP – on going inflammation to predict risk of MI • Impaired fasting glucose • Subclinical atherogenesis

29. METABOLIC SYNDROME

32. HISTORY TAKING AND PHYSICAL EXAM OF VALVULAR HEART DISEASE ADRIEL E. GUERRERO, MD, FPCP, FPCC Training Officer Section of Cardiology, Dept of Medicine The Medical City

33. Inspection and Palpation - Pulsations and PMI are transmitted by the great arteries and cardiac chambers - Can appreciate dilatation and hyper- trophy of cardiac structures - Percussion may aid in determining visceral situs

40. Palpation • Thrill • PMI • Lift • Heave

42. Use of the stethoscope • BELL • Placed lightly on the chest wall • Detects low pitched sounds and murmurs • E.g S3, S4 and mitral stenosis rumble • DIAPHRAGM • Press firmly on the chest wall • Detects high pitched sounds and murmurs • E.g. S1, S2, clicks (mitral valve prolapse), opening snaps (mitral stenosis), ejection sounds (aortic stenosis)

43. Cardiac Auscultation - the character of the heart sounds should be assessed and include: a) S1 and S2 ( S3 and S4 ) b) systolic and diastolic heart sounds c) murmurs and their timing, intensity, duration and location

44. Grading of Murmurs • GRADE 1 • Faintest under optimal conditions (quiet room) • GRADE 2 • Soft, but readily audible • GRADE 3 • Prominent. Loudest murmur without a thrill • Should always provoke investigation • GRADE 4 • Loud with a palpable thrill • GRADE 5 • Audible with a portion of the diaphragm off the chest • GRADE 6 • Audible with the stet held off the chest wall

50. Symptoms of Common Valvular Heart diseases Mitral Stenosis exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, hemoptysis Mitral Regurgitation easy fatigue, then exertional dyspnea Aortic Stenosis chest pain, effort syncope, easy fatigue Aortic Regurgitation Easy fatigue then exertional dyspnea