CARDIOLOGYCARDIOLOGY

Cardinal SignsCardinal Signs

22

DYSPNEA: ?Cardio/ ?PulmonaryDYSPNEA: ?Cardio/ ?PulmonaryIschemiaIschemiaCHF-Rt / LtCHF-Rt / LtCADCADValvular DiseaseValvular DiseasePericarditisPericarditisArrythmiaArrythmia

Obstructive- Obstructive- Asthma/ COPDAsthma/ COPD

Restrictive- Restrictive- 1 Interstitial (alveolar) fibrosis/ SLE 1 Interstitial (alveolar) fibrosis/ SLE 2Other non pulmonary- Obesity/ 2Other non pulmonary- Obesity/ Spine-chest deformitiesSpine-chest deformitiesPneumoniaPneumoniaPneumothoraxPneumothorax

33

Non-Cardio-PulmonaryNon-Cardio-Pulmonary

Metabolic- AcidosisMetabolic- AcidosisHematology-AnemiaHematology-AnemiaPsychic- Anxiety/Panic disorderPsychic- Anxiety/Panic disorderMSK- MS/ Musuclar DystrophyMSK- MS/ Musuclar Dystrophy

44

CARDIOVASCULAR

TachycardiaTachycardia Present in many conditions, including Present in many conditions, including hypoxia, hyperthyroidism, and heart hypoxia, hyperthyroidism, and heart failurefailure

Abnormalities in rate or Abnormalities in rate or rhythmrhythm

May be due to atrial fibrillationMay be due to atrial fibrillation

Displacement of PMIDisplacement of PMI Ventricular hypertrophy or dilatationVentricular hypertrophy or dilatation

MurmursMurmurs Valvular dysfunctionValvular dysfunction

S3S3 CHFCHF

Abnormalities in peripheral Abnormalities in peripheral pulsespulses

Peripheral arterial diseasePeripheral arterial disease

55

ABDOMENABDOMEN

HepatomegalyHepatomegaly May be seen with CHFMay be seen with CHF

EXTREMITIESEXTREMITIES

EdemaEdema Right-sided heart failureRight-sided heart failure

CyanosisCyanosis Hypoxemia, poor peripheral Hypoxemia, poor peripheral perfusionperfusion

ClubbingClubbing Fibrotic lung disease (cystic Fibrotic lung disease (cystic fibrosis) or congenital heart fibrosis) or congenital heart disease resulting in chronic disease resulting in chronic cyanosiscyanosis

66

Diagnostic testsDiagnostic tests

CXRCXRECHOECHOECGECGMRIMRIEBTEBTCARDIAC CATHCARDIAC CATH

77

Bioprosthesis/ HomograftsBioprosthesis/ HomograftsLife expetency -10-15 yearsLife expetency -10-15 yearsBovine better than porcineBovine better than porcineHomografts (allograft) humanHomografts (allograft) human

88

Mechanical Valve Mechanical Valve ProsthesisProsthesis

Thrombosis/embolism risk: mitral > Thrombosis/embolism risk: mitral > aorticaortic

99

Diet Changes to lower CholesterolDiet Changes to lower CholesterolReduce intake of saturated fat Reduce intake of saturated fat

(<7% of total calories) (<7% of total calories) Reduce cholesterol intakeReduce cholesterol intake(<200 mg/day)(<200 mg/day) Include LDL lowering foods to diet- plant Include LDL lowering foods to diet- plant stanols/sterols (2 g/day) and viscous (soluble) fiber (10-stanols/sterols (2 g/day) and viscous (soluble) fiber (10-25 g/day) 25 g/day) Losing weight Losing weight Increasing exercise Increasing exercise

1010

CHF DataCHF Data

Prevalence- 5 millionPrevalence- 5 millionIncidence 500,000/yearIncidence 500,000/yearOlder age group 65+Older age group 65+

1111

Congestive Heart FailureCongestive Heart FailureInability to pump blood at normal or elevated pressure Inability to pump blood at normal or elevated pressure or meet the oxygen demandor meet the oxygen demandIts not a diagnosisIts not a diagnosisIt’s a syndrome due to several causesIt’s a syndrome due to several causesArising from- systolic dysfunctionArising from- systolic dysfunction

1212

Systolic malfunction:Systolic malfunction:

Myocardial infarctionMyocardial infarctionValvular diseaseValvular diseaseHypertensionHypertensionCardiomyopathy- alcohol/ amyloidCardiomyopathy- alcohol/ amyloidCan also be identified as- Can also be identified as-

Left sided failureLeft sided failureRight sided failureRight sided failure

1313

Symptoms of heart failureSymptoms of heart failureDyspnea – vascular congestionDyspnea – vascular congestion

NYHA classification 1-4NYHA classification 1-4Orthopnea –recumbency pools Orthopnea –recumbency pools more blood in the more blood in the heartheartParoxysmal nocturnal dyspnea- ‘cardiac asthma’Paroxysmal nocturnal dyspnea- ‘cardiac asthma’Nocturia- night diuresisNocturia- night diuresisEdema- Right heart failureEdema- Right heart failureAnorexia- hepatic congestionAnorexia- hepatic congestion

1414

CHF-Physical findingsCHF-Physical findings

Tachycardia- increased ISATachycardia- increased ISAWet lungs (crackles)- LVFWet lungs (crackles)- LVFEnlarged ventricleEnlarged ventricleS3- S3- Jugular vein distension- right failureJugular vein distension- right failureEdema feetEdema feetAscitesAscites

1515

Case WorkupCase WorkupECGECGCXRCXREchocardiography- ejection fraction Echocardiography- ejection fraction (normal-55-76%)(normal-55-76%)Doppler echo-valves and chamber Doppler echo-valves and chamber functionfunctionCardiac cath studiesCardiac cath studiesCBC/Bun and Creatinine/Na+/ K+CBC/Bun and Creatinine/Na+/ K+Serum BNP Serum BNP (B-type natriuretic peptide)(B-type natriuretic peptide) + in + in CHF CHF

1616

TherapyTherapyTreat the cause- ?thyrotoxicosisTreat the cause- ?thyrotoxicosis

?valvular disease?valvular disease?HTN?HTN

Symptomatic- Symptomatic- improve force of contraction- digoxinimprove force of contraction- digoxinreduce arterial pressure ‘after load’-reduce arterial pressure ‘after load’-ACEi/ARBsACEi/ARBsdecrease fluid volume- diuretics:decrease fluid volume- diuretics:Thiazides (HCTZ) / Lasix/ AldactoneThiazides (HCTZ) / Lasix/ Aldactonereduce ISA- betablockersreduce ISA- betablockerscardiac fitness- rehab training exercisecardiac fitness- rehab training exercise

1717

Therapy choicesTherapy choices

ACEi + Diuretic ACEi + Diuretic ±Beta blocker/ Digoxin±Beta blocker/ DigoxinVasodilators- NTGVasodilators- NTGNew drug-nesiritide (rDNA- brain natriuretic peptide)New drug-nesiritide (rDNA- brain natriuretic peptide)?Pacing in sever CHF (EF<30%)?Pacing in sever CHF (EF<30%)?Tx?TxPoor prognosis-50% in 5yrsPoor prognosis-50% in 5yrs

1818

Acute LVF –Red flagAcute LVF –Red flag

ICU- 911!ICU- 911!Oxygen/ IV-lasix/ Morphine/ Oxygen/ IV-lasix/ Morphine/ nitorglycerine/ nitorglycerine/ ventilatorventilatorAcute shock/ rapid pulse/ dropping blood pressure/ Acute shock/ rapid pulse/ dropping blood pressure/ dyspnea/ frothing mouthdyspnea/ frothing mouthCauses- infarction/ mitral stensosisCauses- infarction/ mitral stensosis

1919

Mitral Valve ProlapseMitral Valve Prolapse

2-6% affected/ F:M 2:1/benign2-6% affected/ F:M 2:1/benignCan lead to: mitral regurge/ sbe/ sudden death/cvaCan lead to: mitral regurge/ sbe/ sudden death/cva?genetics- X linked/ Marfans (90%)/ Ehlers-Danlos ?genetics- X linked/ Marfans (90%)/ Ehlers-Danlos syndromesyndromeDiagnosed by mid-systolic ‘click’Diagnosed by mid-systolic ‘click’

2020

MVP: Body featuresMVP: Body featuresAsthenic body habitus Asthenic body habitus Low body weight or body mass index (BMI) Low body weight or body mass index (BMI) Straight-back syndrome Straight-back syndrome Scoliosis or kyphosis Scoliosis or kyphosis Pectus excavatum Pectus excavatum Hypermobility of the joints Hypermobility of the joints Arm span greater than height (which may be indicative Arm span greater than height (which may be indicative of Marfan syndrome)of Marfan syndrome)

2121

MVP-SymptomsMVP-SymptomsANS disturbanceANS disturbanceAnxiety Anxiety Panic attacks Panic attacks Arrhythmias Arrhythmias Exercise intolerance Exercise intolerance Palpitations Palpitations Atypical chest pain Atypical chest pain Fatigue Fatigue Orthostasis Orthostasis Syncope or presyncope Syncope or presyncope Neuropsychiatric symptomsNeuropsychiatric symptoms

CHF: CHF: Fatigue Fatigue Dyspnea Dyspnea Exercise intolerance Exercise intolerance Orthopnea Orthopnea Paroxysmal nocturnal dyspnea (PND) Paroxysmal nocturnal dyspnea (PND) Progressive signs of congestive heart Progressive signs of congestive heart failure (CHF)failure (CHF)

2222

Lab Workup: EchcocardiographyLab Workup: EchcocardiographyTherapy: Repeat echo every 3-5 yrsTherapy: Repeat echo every 3-5 yrs? Beta blockers? Beta blockersStay away from-Stay away from-

caffeine/ alcohol/ nicotinecaffeine/ alcohol/ nicotine?Valve repair/ ?Warfarin?Valve repair/ ?Warfarin

2323

52

17

76 4 14

Coronary HeartDisease

Stroke

HF*

High Blood Pressure

Diseases of theArteries

Other

52

17

76 4 14

Coronary HeartDisease

Stroke

HF*

High Blood Pressure

Diseases of theArteries

Other

Coronary Heart Disease (CHD)Coronary Heart Disease (CHD)Number one killer – one death/ minute Number one killer – one death/ minute (700,000/yr 1 in 5)(700,000/yr 1 in 5)

16 million affected16 million affectedF: 10 times the breast cancer deathsF: 10 times the breast cancer deaths2004 data2004 data

2424

Modifiable CAD Risk Modifiable CAD Risk FactorsFactors

1.1. Cigarette smokingCigarette smoking2.2. ObesityObesity3.3. Hypertension 140/90Hypertension 140/904.4. Physical inactivityPhysical inactivity5.5. Kidney diseaseKidney disease6.6. Diabetes mellitusDiabetes mellitus7.7. Alcohol consumptionAlcohol consumption8.8. StressStress9.9. Elevated LDLElevated LDL10.10. Reduced HDLReduced HDL

Non-modifiable CAD Non-modifiable CAD Risk FactorsRisk Factors1 Males > 45 years1 Males > 45 years2 Females > 55 years2 Females > 55 years

33 Family history of coronary Family history of coronary artery diseaseartery disease

2525

Markers for inflammationMarkers for inflammation

Hs-CRPHs-CRPIL-6IL-6CD-40CD-40HomocysteineHomocysteine

2626

? Preventive Interventions? Preventive Interventions

Stop smokingStop smokingLower LDL/ Elevate HDLLower LDL/ Elevate HDL?Statins?Statins?Aspirin in men / not so in women?Aspirin in men / not so in women?Omega-3 ?Omega-3 ?ACEi?ACEi

2727

Ischemia= Angina PectorisIschemia= Angina PectorisBrought on by exertion/ Brought on by exertion/ relieved relieved by restby rest?due to vasospasm?due to vasospasmtightness/ tightness/ squeeze/ squeeze/ burning/ burning/ pressing/ ‘gas’ or pressing/ ‘gas’ or ‘indigestion’ – ‘indigestion’ –

precordial regionprecordial regionRadiation of pain-Radiation of pain-

C8-T4 dermatome areaC8-T4 dermatome area

2828

DD: ?AnginaDD: ?AnginaCostochondritis (chest wall pain)Costochondritis (chest wall pain)Herpes Zoster dermatomal painHerpes Zoster dermatomal painCervical Spondylitis (C6-8)Cervical Spondylitis (C6-8)Peptic ulcer/ Cholcecystitis/ Peptic ulcer/ Cholcecystitis/ Esophageal reflux/ Esophageal reflux/ PneumothoraxPneumothorax

2929

Angina TypesAngina Types

Chronic stable typeChronic stable typeUnstable angina- serious may progress to heart Unstable angina- serious may progress to heart attackattackVariant (Prinzmetal’s) angina- coronary spasmVariant (Prinzmetal’s) angina- coronary spasm

3030

Lab WorkupLab Workup

Lab workup- ECG/ EBCT (CACS Lab workup- ECG/ EBCT (CACS status) score >100 status) score >100 high riskhigh risk

>1000 very high risk>1000 very high riskCoronary angiographyCoronary angiography

3131

Angina TherapyAngina Therapy

Nitroglycerine sub-lingualNitroglycerine sub-lingualBeta blockers- propranalol (Inderal)Beta blockers- propranalol (Inderal)CCB- verapamil/ diltiazemCCB- verapamil/ diltiazemAspirin/ Clopidogrel (Plavix)Aspirin/ Clopidogrel (Plavix)Role for acupunctureRole for acupunctureCABGCABG

3232

Acute Coronary SyndromeAcute Coronary SyndromeUnstable Angina>Ischemia>InfarctionUnstable Angina>Ischemia>InfarctionCheck ECG/Blood markers determine heart attack or notCheck ECG/Blood markers determine heart attack or not‘‘Chest pain Observation Units’Chest pain Observation Units’Troponin-1Troponin-1

3333

AMI: TherapyAMI: Therapy

““MONA”- Morphine/ Oxygen/ NTG/ AspirinMONA”- Morphine/ Oxygen/ NTG/ AspirinClot busters- thrombolytics- tPa- tissue plasminogen activator: Clot busters- thrombolytics- tPa- tissue plasminogen activator:

alteplase/ retiplase/ tenecteplasealteplase/ retiplase/ tenecteplasePost-infarction- aspirin/ warfarin/ betablockers/ ace-i/ ccbPost-infarction- aspirin/ warfarin/ betablockers/ ace-i/ ccbCardiac-rehab-8-12 weeksCardiac-rehab-8-12 weeks

3434

Atrial fibrillation Atrial fibrillation accounts for 1/3 of all accounts for 1/3 of all patient discharges patient discharges with arrhythmia as with arrhythmia as principal diagnosis.principal diagnosis.

2% VF2% VF

34% Atrial

Fibrillation

18% Unspecified

6% PSVT

6% PVCs4%

Atrial Flutter

9% SSS

8% Conduction

Disease

3% SCD10% VT

Underlying Arrhythmia of Sudden Underlying Arrhythmia of Sudden DeathDeath

VTVT62%62% BradycardiaBradycardia

17%17%

Torsadesde Pointes

13%

PrimaryPrimaryVFVF8%8%

3636

ARRHYTHMIASARRHYTHMIAS

can be lethal (sudden cardiac death), symptomatic can be lethal (sudden cardiac death), symptomatic (syncope, near syncope, dizziness, fatigue, or (syncope, near syncope, dizziness, fatigue, or palpitations), or asymptomatic palpitations), or asymptomatic reduce cardiac output, reduce cardiac output, perfusion of the brain or myocardium is impaired perfusion of the brain or myocardium is impaired

3737

Abnormal Heart RhythmsAbnormal Heart Rhythms

ArrhythmiaArrhythmia BPMBPM

tachycardiatachycardia 150-250150-250

bradycardiabradycardia <60<60

atrial flutteratrial flutter 200-350200-350

atrial fibrillationatrial fibrillation >350>350

prem. atrial cont.prem. atrial cont. variablevariable

prem. vent. cont.prem. vent. cont. variable variable

vent.fibrillationvent.fibrillation variablevariable

3838

CAUSESCAUSESelectrolyte abnormalities,electrolyte abnormalities, hormonal imbalances (thyrotoxicosis, hyper adrenaline hormonal imbalances (thyrotoxicosis, hyper adrenaline (catecholaminergic) states),(catecholaminergic) states), hypoxia, hypoxia, drug effects drug effects myocardial ischemia myocardial ischemia

3939

14 million people in the USA have arrhythmias (5% of 14 million people in the USA have arrhythmias (5% of the population) the population) Related to age and the presence of underlying heart Related to age and the presence of underlying heart disease disease Most common disorders: atrial fibrillation and flutter Most common disorders: atrial fibrillation and flutter ‘‘Missed beat’ / ‘Racing heart’Missed beat’ / ‘Racing heart’

4040

BradycardiasBradycardias60 beats a minute60 beats a minute not enough oxygen-rich blood not enough oxygen-rich blood symptoms of a slow heartbeat are:symptoms of a slow heartbeat are:Fatigue Fatigue Dizziness Dizziness Lightheadedness Lightheadedness Fainting or near fainting Fainting or near fainting

TachycardiasTachycardiasabove 100 beats a minute, above 100 beats a minute, ventricles, do not have enough time to ventricles, do not have enough time to fill with bloodfill with bloodSkipping a beat Skipping a beat Beating out of rhythm Beating out of rhythm Palpitations Palpitations Rapid heart action Rapid heart action Shortness of breath Shortness of breath Chest pain Chest pain Dizziness Dizziness Lightheadedness Lightheadedness Fainting or near fainting. Fainting or near fainting. Chaotic, quivering or irregular rhythm Chaotic, quivering or irregular rhythm

4141

Definitions: AtrialDefinitions: AtrialSinus bradycardia - <60 beats/min. Sinus bradycardia - <60 beats/min. Sinus tachycardia - 100-180 Sinus tachycardia - 100-180 Sick sinus syndrome – (cycles of bradycardia and tachycardia). Sick sinus syndrome – (cycles of bradycardia and tachycardia). Atrial flutter - 250-350Atrial flutter - 250-350Atrial fibrillation - uncoordinated atrial depolarizations. Atrial fibrillation - uncoordinated atrial depolarizations. AV nodal blocks - a conduction block within the AV node (or AV nodal blocks - a conduction block within the AV node (or occasionally in the bundle of His) that impairs impulse conduction occasionally in the bundle of His) that impairs impulse conduction from the atria to the ventricles. from the atria to the ventricles.

4242

Heart BlocksHeart Blocks

4343

Atrial FibrillationAtrial Fibrillation2.2 million affected2.2 million affectedCauses 15-25% of all Strokes Causes 15-25% of all Strokes Etiology-IHD/ Diabetes/ HTN/ Etiology-IHD/ Diabetes/ HTN/ Valve disease/ thyrotoxicosisValve disease/ thyrotoxicosisIrregularly irregular pulseIrregularly irregular pulseECG absence of P wavesECG absence of P waves Therapy- Therapy-

DigoxinDigoxin? Anticoagulant- warfarin? Anticoagulant- warfarinElectrical cardioversionElectrical cardioversion

4444

Ventricular tachycardiaVentricular tachycardiaLeads to ventricular Leads to ventricular fibrillation- causing sudden fibrillation- causing sudden cardiac death (300,000/yr)cardiac death (300,000/yr)Diagnosis by ECGDiagnosis by ECGDefib and AmiodaroneDefib and AmiodaroneImplanted cardiac Implanted cardiac defibrillatordefibrillator

4545

Ventricular fibrillationVentricular fibrillation

Life threateningLife threatening

Needs defibrillation!Needs defibrillation!

4646

DRUG THERAPYDRUG THERAPYClass I agents block membrane sodium channels –Class I agents block membrane sodium channels –quinidine, procainamide, disopyramide, lidocainequinidine, procainamide, disopyramide, lidocaine

Class II agents are the Class II agents are the ββ-blockers -blockers Class III agents block potassium channels - amiodarone,Class III agents block potassium channels - amiodarone,

Class IV agents- are the Class IV agents- are the calcium channel blockers –calcium channel blockers –verapamil, diltiazemverapamil, diltiazem

4747

Sinus arryhtmiaSinus arryhtmiacyclic increase in normal cyclic increase in normal heart rate with inspiration heart rate with inspiration and decrease with and decrease with expiration expiration has no clinical has no clinical significance. It is common significance. It is common in both the young and the in both the young and the elderly elderly results from reflex results from reflex changes in vagal influence changes in vagal influence

4848

Sinus bradycardiaSinus bradycardia

heart rate slower than 50 beats/min heart rate slower than 50 beats/min a normal finding in persons with excellent physical a normal finding in persons with excellent physical condition condition sinus nodesinus node pathology especially in elderly pathology especially in elderly patients and individuals with heart disease. patients and individuals with heart disease. weakness, confusion, or syncopeweakness, confusion, or syncopePacing may be required Pacing may be required

4949

Sinus tachycardiaSinus tachycardia heart rate faster than 100 heart rate faster than 100 beats/min beats/min Causes- Causes- fever, fever, exercise, exercise, emotion, emotion, pain, pain, anemia, anemia, heart failure, heart failure, shock, shock, thyrotoxicosis, or thyrotoxicosis, or in response to many drugs in response to many drugs Alcohol and alcohol withdrawalAlcohol and alcohol withdrawal

rate infrequently exceeds 160 beats/min

5050

Drug-Induced & Toxic Myocarditis Drug-Induced & Toxic Myocarditis

Doxorubicin Doxorubicin cocaine cardiotoxicitycocaine cardiotoxicity

5151

Pulmonary Heart Disease Pulmonary Heart Disease (Cor Pulmonale)(Cor Pulmonale)

Chronic productive cough,Chronic productive cough, Exertional dyspnea, Exertional dyspnea, wheezing respirations, wheezing respirations, easy fatigability, and weakness easy fatigability, and weakness Dependent edema and right upper quadrant pain Dependent edema and right upper quadrant pain Cyanosis, clubbing Cyanosis, clubbing

5252

Pulmonary Heart Disease Pulmonary Heart Disease (Cor Pulmonale)(Cor Pulmonale)

Oxygen, Oxygen, salt and fluid restriction, andsalt and fluid restriction, and diuretics diuretics Once congestive signs Once congestive signs appear, the average life appear, the average life expectancy is 2–5 years expectancy is 2–5 years

5353

Cardiovascular Changes Cardiovascular Changes During PregnancyDuring Pregnancy

Maternal blood volume Maternal blood volume Stroke volume Stroke volume heart rate heart rate High cardiac output High cardiac output more horizontal position of the heart more horizontal position of the heart

5454

Cardiovascular Complications of Cardiovascular Complications of PregnancyPregnancy

eclampsia and preeclampsia eclampsia and preeclampsia Cardiomyopathy of Pregnancy (Peripartum Cardiomyopathy of Pregnancy (Peripartum Cardiomyopathy) Cardiomyopathy) one of 4000–15,000 patients, dilated cardiomyopathy one of 4000–15,000 patients, dilated cardiomyopathy develops in the final month of pregnancy or within 6 develops in the final month of pregnancy or within 6 months after delivery months after delivery

5555

dilated cardiomyopathydilated cardiomyopathy

women over age 30 years women over age 30 years gestational hypertension and drugs used to stop gestational hypertension and drugs used to stop uterine contractions uterine contractions 60% of patients make a complete recovery. 60% of patients make a complete recovery.

5656

Acute PericarditisAcute Pericarditis

Post heart attackPost heart attackViralViralCollagen- SLECollagen- SLEBacterial infectionBacterial infectionMetastatic cancerMetastatic cancerUremiaUremiaRadiationRadiation

Left sided chest pain on Left sided chest pain on inspirationinspirationFeels better on sitting up and Feels better on sitting up and leaning forwardleaning forwardAuscultation- pericardial Auscultation- pericardial friction rubfriction rubLab work up: ECG/ EchoLab work up: ECG/ EchoTherapy- NSAIDs/ SteroidsTherapy- NSAIDs/ Steroids