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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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CARDIOLOGY

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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

DYSPNEA: ?Cardio/ ?Pulmonary


Non-Cardio-Pulmonary

  • Metabolic- Acidosis

  • Hematology-Anemia

  • Psychic- Anxiety/Panic disorder

  • MSK- MS/ Musuclar Dystrophy


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)


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)

MVP-Symptoms


  • 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


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


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’


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


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


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

Atrial Fibrillation


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


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

  • 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

  • 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

  • Doxorubicin

  • cocaine cardiotoxicity


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


Cardiovascular Changes During Pregnancy

  • Maternal blood volume

  • Stroke volume

  • heart rate

  • High cardiac output

  • more horizontal position of the heart


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

  • women over age 30 years

  • gestational hypertension and drugs used to stop uterine contractions

  • 60% of patients make a complete recovery.


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

Acute Pericarditis


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