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CARDIOLOGY. Cardinal Signs. 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.

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Cardinal Signs

dyspnea cardio pulmonary

CHF-Rt / Lt


Valvular Disease




Asthma/ COPD


1 Interstitial (alveolar) fibrosis/ SLE

2Other non pulmonary- Obesity/ Spine-chest deformities



DYSPNEA: ?Cardio/ ?Pulmonary
non cardio pulmonary
  • Metabolic- Acidosis
  • Hematology-Anemia
  • Psychic- Anxiety/Panic disorder
  • MSK- MS/ Musuclar Dystrophy
diagnostic tests
Diagnostic tests
  • CXR
  • ECHO
  • ECG
  • MRI
  • EBT
bioprosthesis homografts
Bioprosthesis/ Homografts
  • Life expetency -10-15 years
  • Bovine better than porcine
  • Homografts (allograft) human
mechanical valve prosthesis
Mechanical Valve Prosthesis
  • Thrombosis/embolism risk: mitral > aortic
diet changes to lower cholesterol
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
CHF Data
  • Prevalence- 5 million
  • Incidence 500,000/year
  • Older age group 65+
congestive heart failure
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
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
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
CHF-Physical findings
  • Tachycardia- increased ISA
  • Wet lungs (crackles)- LVF
  • Enlarged ventricle
  • S3-
  • Jugular vein distension- right failure
  • Edema feet
  • Ascites
case workup
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
  • Treat the cause- ?thyrotoxicosis

?valvular disease


  • Symptomatic-

improve force of contraction- digoxin

reduce arterial pressure ‘after load’-


decrease fluid volume- diuretics:

Thiazides (HCTZ) / Lasix/ Aldactone

reduce ISA- betablockers

cardiac fitness- rehab training exercise

therapy choices
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
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
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
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


Panic attacks


Exercise intolerance


Atypical chest pain



Syncope or presyncope

Neuropsychiatric symptoms




Exercise intolerance


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
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
markers for inflammation
Markers for inflammation
  • Hs-CRP
  • IL-6
  • CD-40
  • Homocysteine
preventive interventions
? Preventive Interventions
  • Stop smoking
  • Lower LDL/ Elevate HDL
  • ?Statins
  • ?Aspirin in men / not so in women
  • ?Omega-3
  • ?ACEi
ischemia angina pectoris
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
DD: ?Angina
  • Costochondritis (chest wall pain)
  • Herpes Zoster dermatomal pain
  • Cervical Spondylitis (C6-8)
  • Peptic ulcer/ Cholcecystitis/ Esophageal reflux/ Pneumothorax
angina types
Angina Types
  • Chronic stable type
  • Unstable angina- serious may progress to heart attack
  • Variant (Prinzmetal’s) angina- coronary spasm
lab workup
Lab Workup
  • Lab workup- ECG/ EBCT (CACS status) score >100 high risk

>1000 very high risk

  • Coronary angiography
angina therapy
Angina Therapy
  • Nitroglycerine sub-lingual
  • Beta blockers- propranalol (Inderal)
  • CCB- verapamil/ diltiazem
  • Aspirin/ Clopidogrel (Plavix)
  • Role for acupuncture
  • CABG
acute coronary syndrome
Acute Coronary Syndrome
  • Unstable Angina>Ischemia>Infarction
  • Check ECG/Blood markers determine heart attack or not
  • ‘Chest pain Observation Units’
  • Troponin-1
ami therapy
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
Underlying Arrhythmia of Sudden Death


de Pointes









  • 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
  • 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’

60 beats a minute

not enough oxygen-rich blood

symptoms of a slow heartbeat are:




Fainting or near fainting


above 100 beats a minute,

ventricles, do not have enough time to fill with blood

Skipping a beat

Beating out of rhythm


Rapid heart action

Shortness of breath

Chest pain



Fainting or near fainting.

Chaotic, quivering or irregular rhythm

definitions atrial
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.
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



? Anticoagulant- warfarin

Electrical cardioversion

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

Sinus arryhtmia
sinus bradycardia
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
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

drug induced toxic myocarditis
Drug-Induced & Toxic Myocarditis
  • Doxorubicin
  • cocaine cardiotoxicity
pulmonary heart disease cor pulmonale
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 pulmonale1
Pulmonary Heart Disease (Cor Pulmonale)
  • Oxygen,
  • salt and fluid restriction, and
  • diuretics
  • Once congestive signs appear, the average life expectancy is 2–5 years
cardiovascular changes during pregnancy
Cardiovascular Changes During Pregnancy
  • Maternal blood volume
  • Stroke volume
  • heart rate
  • High cardiac output
  • more horizontal position of the heart
cardiovascular complications of pregnancy
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
dilated cardiomyopathy
dilated cardiomyopathy
  • women over age 30 years
  • gestational hypertension and drugs used to stop uterine contractions
  • 60% of patients make a complete recovery.
acute pericarditis
Post heart attack


Collagen- SLE

Bacterial infection

Metastatic cancer



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

Acute Pericarditis