cardiology - CatsTCMNotes.com
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CARDIOLOGY
Cardinal Signs
DYSPNEA: ?Cardio/ ?Pulmonary
Ischemia
CHF-Rt / Lt
CAD
Valvular Disease
Pericarditis
Arrythmia
ObstructiveAsthma/ COPD
Restrictive1 Interstitial (alveolar) fibrosis/ SLE
2Other non pulmonary- Obesity/
Spine-chest deformities
Pneumonia
Pneumothorax
2
Non-Cardio-Pulmonary
Metabolic- Acidosis
Hematology-Anemia
Psychic- Anxiety/Panic disorder
MSK- MS/ Musuclar Dystrophy
3
CARDIOVASCULAR
Tachycardia
Present in many conditions, including
hypoxia, hyperthyroidism, and heart
failure
Abnormalities in rate or
rhythm
May be due to atrial fibrillation
Displacement of PMI
Ventricular hypertrophy or dilatation
Murmurs
Valvular dysfunction
S3
CHF
Abnormalities in peripheral
pulses
Peripheral arterial disease
4
ABDOMEN
Hepatomegaly
May be seen with CHF
EXTREMITIES
Edema
Right-sided heart failure
Cyanosis
Hypoxemia, poor peripheral
perfusion
Clubbing
Fibrotic lung disease (cystic
fibrosis) or congenital heart
disease resulting in chronic
cyanosis
5
Diagnostic tests
CXR
ECHO
ECG
MRI
EBT
CARDIAC CATH
6
Bioprosthesis/ Homografts
Life expetency -10-15 years
Bovine better than porcine
Homografts (allograft) human
7
Mechanical Valve
Prosthesis
Thrombosis/embolism risk: mitral >
aortic
8
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 (1025 g/day)
Losing weight
Increasing exercise
9
CHF Data
Prevalence- 5 million
Incidence 500,000/year
Older age group 65+
10
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
11
Systolic malfunction:
Myocardial infarction
Valvular disease
Hypertension
Cardiomyopathy- alcohol/ amyloid
Can also be identified asLeft sided failure
Right sided failure
12
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
13
CHF-Physical findings
Tachycardia- increased ISA
Wet lungs (crackles)- LVF
Enlarged ventricle
S3Jugular vein distension- right failure
Edema feet
Ascites
14
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
15
Therapy
Treat the cause- ?thyrotoxicosis
Symptomatic-
?valvular disease
?HTN
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
16
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
17
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
18
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’
19
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)
20
MVP-Symptoms
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)
21
Lab Workup: Echcocardiography
Therapy: Repeat echo every 3-5 yrs
? Beta blockers
Stay away fromcaffeine/ alcohol/ nicotine
?Valve repair/ ?Warfarin
22
Coronary Heart Disease (CHD)
Number one killer – one death/ minute
(700,000/yr 1 in 5)
Coronary Heart
Disease
Stroke
7
6
4
14
HF*
High Blood Pressure
17
52
16 million affected
F: 10 times the breast cancer deaths
2004 data
Diseases of the
Arteries
Other
23
Modifiable CAD Risk
Factors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Cigarette smoking
Obesity
Hypertension 140/90
Physical inactivity
Kidney disease
Diabetes mellitus
Alcohol consumption
Stress
Elevated LDL
Reduced HDL
Non-modifiable CAD
Risk Factors
1 Males > 45 years
2 Females > 55 years
3 Family history of coronary
artery disease
24
Markers for inflammation
Hs-CRP
IL-6
CD-40
Homocysteine
25
? Preventive Interventions
Stop smoking
Lower LDL/ Elevate HDL
?Statins
?Aspirin in men / not so in women
?Omega-3
?ACEi
26
Ischemia= Angina Pectoris
Brought on by exertion/
relieved
by rest
?due to vasospasm
tightness/
squeeze/
burning/
pressing/ ‘gas’ or
‘indigestion’ –
precordial region
Radiation of painC8-T4 dermatome area
27
DD: ?Angina
Costochondritis (chest wall pain)
Herpes Zoster dermatomal pain
Cervical Spondylitis (C6-8)
Peptic ulcer/ Cholcecystitis/
Esophageal reflux/
Pneumothorax
28
Angina Types
Chronic stable type
Unstable angina- serious may progress to heart
attack
Variant (Prinzmetal’s) angina- coronary spasm
29
Lab Workup
Lab workup- ECG/ EBCT (CACS status) score >100
high risk
>1000 very high risk
Coronary angiography
30
Angina Therapy
Nitroglycerine sub-lingual
Beta blockers- propranalol (Inderal)
CCB- verapamil/ diltiazem
Aspirin/ Clopidogrel (Plavix)
Role for acupuncture
CABG
31
Acute Coronary Syndrome
Unstable Angina>Ischemia>Infarction
Check ECG/Blood markers determine heart attack or not
‘Chest pain Observation Units’
Troponin-1
32
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
33
Atrial fibrillation
accounts for 1/3 of all
patient discharges
with arrhythmia as
principal diagnosis.
4%
Atrial
Flutter
6%
PSVT
6%
PVCs
18%
Unspecified
9%
SSS
34%
Atrial
Fibrillation
8%
Conduction
Disease
10% VT
3% SCD
2% VF
34
Underlying Arrhythmia of Sudden
Death
Primary
VF
8%
VT
62%
Bradycardia
17%
Torsades
de Pointes
13%
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
36
Abnormal Heart Rhythms
Arrhythmia
BPM
tachycardia
150-250
bradycardia
<60
atrial flutter
200-350
atrial fibrillation
>350
prem. atrial cont.
variable
prem. vent. cont.
variable
vent.fibrillation
variable
37
CAUSES
electrolyte abnormalities,
hormonal imbalances (thyrotoxicosis, hyper adrenaline
(catecholaminergic) states),
hypoxia,
drug effects
myocardial ischemia
38
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’
39
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
40
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.
41
Heart Blocks
42
Atrial
Fibrillation
2.2 million affected
Causes 15-25% of all Strokes
Etiology-IHD/ Diabetes/ HTN/
TherapyDigoxin
? Anticoagulant- warfarin
Electrical cardioversion
Valve disease/ thyrotoxicosis
Irregularly irregular pulse
ECG absence of P waves
43
Ventricular
tachycardia
Leads to ventricular
fibrillation- causing sudden
cardiac death (300,000/yr)
Diagnosis by ECG
Defib and Amiodarone
Implanted cardiac
defibrillator
44
Ventricular fibrillation
Life threatening
Needs defibrillation!
45
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
46
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
47
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
48
Sinus tachycardia
heart rate faster than 100
beats/min
Causesfever,
exercise,
emotion,
pain,
anemia,
heart failure,
shock,
thyrotoxicosis, or
in response to many drugs
Alcohol and alcohol withdrawal
rate infrequently
exceeds 160 beats/min
49
Drug-Induced & Toxic Myocarditis
Doxorubicin
cocaine cardiotoxicity
50
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
51
Pulmonary Heart Disease
(Cor Pulmonale)
Oxygen,
salt and fluid restriction, and
diuretics
Once congestive signs
appear, the average life
expectancy is 2–5 years
52
Cardiovascular Changes
During Pregnancy
Maternal blood volume
Stroke volume
heart rate
High cardiac output
more horizontal position of the heart
53
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
54
dilated cardiomyopathy
women over age 30 years
gestational hypertension and drugs used to stop
uterine contractions
60% of patients make a complete recovery.
55
Acute Pericarditis
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
56