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Cardiovascular Care

Cardiovascular Care

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Cardiovascular Care

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  1. Cardiovascular Care Kenneth H. Cohen, M.D.,F.A.C.C. Ronald D. D’Agostino, D.O., F.A.C.C., F.A.C.P. Henry Gomez, M.D., F.A.C.C. Jeffrey M. Bernstein, M.D. Internal Medicine, Cardiology and Cardiovascular Diseases Diplomates American Board and Internal Medicine of Cardiovascular Diseases

  2. “Everything you wanted to know about cardiovascular care but the HMO’s were afraid you’d ask.”

  3. Ronald D. D’Agostion, D.O., F.A.C.C.,F.A.C.P Specializing in: Cardiology Cardio-vascular Diseases Atherosclerosis Angina & Myocardial Infarction Hypertension Renal Artery Stenosis Valvular Heart Disease Peripheral Vascular Disease Cardiomyopathy & Hypertrophy Carotid Diseases Congestive Heart Failure Stroke Prevention & Treatment Arrythmias Diabetes Management

  4. Atherosclerosis Time Line Birth Fatty Streaks Intimal Changes Plaque Obstruction, Symptons, Angina Events, MI, Stroke CHF Age 0 10 20 30 40 50 60 70 80

  5. Risk Factor Modification • Genetics - Change Your Parents • Diet & Exercise • Vices - Sedentary, Cigarettes, Caffiene, Stress • Prevent Disease • Manage Lipids, HTN, Diabetes • Prevent Plaque Progression, Stabilization, Regression, Formation

  6. Blood Pressure Stages (mm Hg) Risk Group A(No Risk Factors No TOD/CCD) Risk Group B(At Least 1 Risk Factors, Not Including Diabetes; No TOD/CCD) Risk Group C(TOD/CCD and/or Diabetes, With or Without Other Risk Factors) High-normal 130-139/85-89 Lifestyle Modification Lifestyle Modification Drug Therapy Stage 1140-159/ 90-99 Lifestyle Modification (up to 12 months) Lifestyle Modification (up to 6 months) Drug Therapy Stage 2 & Stage 3 >160/>100 Drug Therapy Drug Therapy Drug Therapy JNC VI Risk Stratification and Treatment of Hypertension The Sixth Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NIH.

  7. Lifestyle Modifications • Stop smoking and reduce intake of saturated fat and cholesterol • Lose weight if overweight • Limit alcohol intake • Increase aerobic physical activity • Limit sodium intake • Maintain adequate intake of K+, Ca++, and Mg++ for general health JNC VI, 1997.

  8. DIAGNOSTIC TESTING Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P.

  9. HISTORY & PHYSICAL • Most important test • 80% of diagnosis from history • Testing to confirm clinical • Testing without knowledge of patient issues

  10. Statistics

  11. PROBABILITY • False Positive (FP) • False Negative (FN) • Prevalence • Positive Predictive Value (PPV) • Negative Predictive Value (NPV) • Sensitivity • Specificity

  12. SENSITIVITY& SPECIFICITY Sensitivity = True Positive True Positive + False Negative Specificity = True Negative True Negative + False Positive

  13. PREVALENCE • Percent of population with disease • Varies with the type of patient the doctor is seeing

  14. PREDICTIVE VALUE Positive Predictive Value = True Positive True Positive + False Positive Negative Predictive Value = True Negative True Negative + False Positive

  15. DIAGNOSIS • Prevalence • Sensitivity • Specificity • Predictive Value • Pre Test Probability • Post Test Probability

  16. 10% prevalence 1000 patients 100 with disease 900 without disease 80% sensitivity, 80% specificity TEST TRUTH (+) (-) (+) 80 180 (-) 20 720 ____ ____ 100 900 PREDICTIVE VALUE PPV=80/260 =25% NPV=720/740 = 95% EXAMPLE WITH LOW PREVALENCE

  17. 90% prevalence 1000 patients 900 with disease 100 without disease 80% sensitivity, 80% specificity TEST TRUTH (+) (-) (+) 720 20 (-) 180 80 ____ ____ 900 100 PREDICTIVE VALUE PPV=720/740 =95% NPV=80/260 = 30% EXAMPLE WITH HIGH PREVALENCE

  18. DIAGNOSTIC TESTING • General Screening • Overall function • Plumbing • Pump • Valves • Wiring

  19. BLOOD WORK • Chemistry Endocrine: Glucose, HBA1c Renal Function Liver Function • CBC -Homocysteine Level, C-Reactive Protein • Lipids -Total Cholesterol, HDL, LDL, Lipoproteins • Coagulation • Thyroid Function

  20. CHEST X-RAY • Heart Size • Chamber Size • Lungs • Limited Information • Aorta

  21. EKG • Electrocardiogram • Very useful • Old Infarcts • Conduction • Heart Block • Hypertrophy

  22. HEMODYNAMIC PROFILE (HDP) • Non-Invasive Scan • Measures cardiovascular pressures & efficacy of therapy • Helps direct therapy • Very useful for treating Hypertension & Heart Failure

  23. EXERCISE STRESS TESTING • Overall Function • Coronaries, Ventricular Function, Valves. Conduction • Treadmill, Bicycle • Cardiac Monitoring • Diagnosis & Progress • After Myocardial Infarction

  24. THALLIUM STRESS TESTING • Coronary Perfusion • Thallium follows blood flow • Radioisotope Thallium 201 IV • Camera • Stress--Rest

  25. MYOVIEW or CARDIOLITE STRESS TESTING • Similar to Thallium • Better Images • Technetium 99, Tetrofosmin or Sestamibi IV • Rest--Stress or Stress--Rest

  26. PERSANTINE STRESS TESTING • Can’t Exercise • Peripheral Vascular Disease • Orthopedic Difficulty • Elderly • Vasodilator IV • Stress--Rest • Thallium or Myoview Cardiolite IV

  27. MUTIGATED ACQUISITION WALL MOTION SCAN • Technetium IV • Camera • Pump Function • Ejection Fraction • Wall Motion • Diagnosis and Prognosis

  28. FIRST PASS • Same information as MUGA & Right Ventricular Function • Rapid IV injection of technetium • Rapid Imaging • May be combined with Myoview or Cardiolite study

  29. SPECT • Single Photon Emission Computed Tomography • Multiple Images • 3 Planes: Short Axis, Horizontal Long Axis, Vertical Long Axis • Has replaced planar imaging • Camera and computer

  30. GRATED SPECT • Wall motion study and perfusion study in one • Coronary and Ventricular function • Specialized camera and computer

  31. ECHO DOPPLER • Most information • Non-Invasive • Easy on patient • Pump and Valve function • Essential Test • After Myocardial Infarction (Heart Attack)

  32. TEE • Transesophageal Echocardiogram • Swallow probe • Sedation, local anesthetic • Some discomfort • Closer look at the heart • Clot in heart, valve function, endocarditis • Stroke Risk

  33. NON-INVASIVE VASCULAR TESTING • Renal Duplex to Assess for Hypertension • Aortic Duplex to Assess for Aneurysm • Peripheral Duplex - Arterial Circulation • Carotid Duplex - Stroke Risk

  34. NON-INVASIVE VASCULAR TESTING Cont... • Pulse Volume Recording with Segmented Blood Pressures - Arterial Circulation • Venous Duplex - Venous Circulation

  35. CAROTID DOPPLER • Internal and external carotid arteries • Vertebral arteries • Plaquing of arteries - Intimal Thickness • Obstruction • TIA, CVA, SX • Unequal blood pressures • Identify patients at risk for Stroke • Identify patients who may benefit from Carotid Endarterectomy or Stent

  36. HOLTER • Electrical System • Slow, Fast • Heart Block • Ventricular Tachycardia • Correlate with symptoms • Palpitations, Dizziness • After Myocardial Infarction • Sudden Death Risk

  37. SIGNAL AVERAGE ECG • Prognosis with Ventricular Tachycardia • Dizziness, Palpitations • After Myocardial Infarction • Use in Consideration with Holter and studies of Ventricular Function • Sudden Death Risk

  38. HRV • Heart Rate Variability • Prognosis after Myocardial Infarction • Sudden Death Risk • Acquired with Holter • High Variability Good Prognosis

  39. T WAVE ALTERNANS • Subtle changes in T Wave amplitude • Mild exercise Heart Rate to 110 • May predict patients at increased risk for Sudden Death

  40. TRANSTELEPHONIC MONITORING • After Holter • Loop Recorders • Useful for intermittent symptoms • Home telemetry • Palpitations, Dizziness

  41. PACEMAKER TESTING • To monitor function • Test battery life • Test thresholds for proper sensing of native conduction and capture • DDDR rate adaptive pacemakers

  42. AMBULATORY BLOOD PRESSURE AND HEART RATE • To monitor Blood Pressure and Pulse at home • 24 hr. Recording vs. Intermittent use by patient periodically and as per symptom • White Coat Hypertension • Extremely useful to diagnose hypertension and assess efficacy of therapy

  43. EPS • Electrophysiology Study • Invasive • Hospitalization • Electrical Stimulation of Heart • Measure Conduction System: Bradyarrythmias, Heart Block • Essential with Severe Symptoms or High Risk patients • Syncope • Ventricular Tachycardia

  44. ABLATION • WPW: Wolff-Parkinson-White • Supraventricular Tachycardia (SVT) • Bypass Tracts • High Radio Frequency • May be useful for VT or Atrial Fibrillation • AV Nodal Ablation

  45. PACEMAKERS • For Bradyarrythmias & Heart Block • To enable use of some medications which may be helpful i.e, Beta Blockers, Amiodorone • To treat Heart Failure - Biventricular Pacemakers

  46. ICD’S • Implantable Cardiovertors Defibrillators • Saves Lives • For High Risk patients • Like living with an EMS Technician

  47. AED’S • Automatic External Defibrillators • Public Areas • Airports, Restaurants, Health Clinics • Saves Lives

  48. CARDIAC CATHETERIZATION • Definitive Test • Essential with Prognosis or Unstable symptoms • Hospital Procedure • Invasive • Some Risk • Coronary, Ventricular and Valves • Via Radial Artery

  49. PTCA • Requires Transluminal Coronary Angioplasty • Requires Cath-Angiography • Balloon, Atherectomy, Stent, Laser • Generally Successful • Restenosis

  50. STENTS • Standard Use • Smaller risk of Restenosis • Can be placed almost anywhere • Coronary, Carotid, Renal, Peripheral • Coated Stents