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THE CARDIOVASCULAR SYSTEM An In-depth Look MARK H. HYMAN, MD, FACP, FAADEP

THE CARDIOVASCULAR SYSTEM An In-depth Look MARK H. HYMAN, MD, FACP, FAADEP. THE CARDIOVASCULAR SYSTEM Chapter 3-Heart and Aorta Chapter 4-Systemic and Pulmonary Arteries. THE CARDIOVASCULAR SYSTEM Chapter 3-Heart and Aorta. NYHA Functional Classifications (Table 3-1, pg 26).

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THE CARDIOVASCULAR SYSTEM An In-depth Look MARK H. HYMAN, MD, FACP, FAADEP

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  1. THE CARDIOVASCULAR SYSTEMAn In-depth LookMARK H. HYMAN, MD, FACP, FAADEP

  2. THE CARDIOVASCULAR SYSTEMChapter 3-Heart and AortaChapter 4-Systemic and Pulmonary Arteries

  3. THE CARDIOVASCULAR SYSTEMChapter 3-Heart and Aorta

  4. NYHA Functional Classifications (Table 3-1, pg 26) 1 - Ordinary Activity - No Symptoms 2 - Greater than Ordinary Activity Symptoms - Fatigue, Angina 3 - Comfortable At Rest Symptoms - Ordinary Activity 4 - Symptoms At Rest and Worse with Ordinary Activity

  5. OBJECTIVEMEASUREMENTS

  6. Evaluation of CAD • Exercise - treadmill or bicycle • Thallium Exercise Study • Exercise Wall Motion - Multi-gated • Exercise Echocardiography • Magnetic Resonance Study • Positron Emission • Coronary Angiography

  7. Sensitivity and Specificity of Exercise Tests Test Sensitivity Specificity Stress ECG 68% 77% Spect Thallium-201 90 89 Tc-99 Sestamibi 89 90 Dipyridamole Thallium 85 87 Stress Echo 80 90

  8. Stress Testing • Peak Level - METs • Symptoms and Signs • Arrhythmias • ST Changes • Blood Pressure

  9. MET - Metabolic Unit • 1 MET = Energy Expenditure of Sitting at Rest • 3.5 cc/Kg/Min • Use Table 3-2 or 3-3 to convert exercise performance into METs.

  10. Tables 3-2 and 3-3

  11. 3.2-Valve Stenosis - Aortic Impairment Valve Gradient Valve Area mm Hg CM2 Aortic Valve Mild < 25 > 1.5 Moderate 25 - 50 1.0 – 1.5 Severe > 50 < 1.0

  12. 3.2-Valve Stenosis - Mitral Impairment Valve Gradient Valve Area mm Hg CM2 Mitral Valve Mild < 5 > 1.5 Moderate 5 - 10 1.0 – 1.5 Severe > 10 < 1.0

  13. 3.3 CORONARY HEART DISEASE

  14. Occupational Categories Carpentry 3.5 METs Maid 2.5 Plumbing 3.5 Farming 8.0 Forestry 17.0 Machine Tool 8.0 Shoe Repair 2.5 Typing 1.5

  15. Problem With Categories • Average energy • Peak much higher • Travel exertion • No study on CAD • Time of work

  16. Haskell Work Classification METs Activity Very Heavy > 6 Climb stairs Medium 4 - 6 50 lbs Light 2 - 4 20 lbs Sedentary < 2 Sit

  17. Impairment VO2MAX MET Impairment > 25 > 7 None 20 - 25 5 - 7 Mild to Mod. 15 - 20 2.5 - 5 Severe < 15 < 2.5 Total

  18. Cardiac Guidelines Peak METs Work Preclusion > 9 None to No Very Heavy Lifting 7 - 9 No Heavy Work 5 - 7 To Light Work 2.5 - 5 To Sedentary Work < 2.5 Total 1998 - California

  19. Sustained Work - Percent of Maximal Level Achieved Ilmarinin, 1984 30 - 50% Astrand, 1988 40 - 45% NIOSH Guide 33% NIOSH Safety Manual 40 - 50%

  20. Sustained Work During 8 Hour Day With Breaks Is 40% of Maximum MET Level

  21. Maximum Short Term Work • Less than 15 minutes • Once to twice a day • 80% of maximal MET level achieved OR • 1-3 minutes maximum MET level achieved

  22. AMA Impairment Classification for CHD Class Impairment Class I 0 - 9% Class II 10 - 29% Class III 30 - 49% Class IV 50 - 100%

  23. CAD - Class 1: 0-9% • Equivocal History • < 50% Blockage • EB Scan Positive

  24. CAD - Class 2: 10-29% • Functional Class I • On Treatment • Treadmill Neg > 7 METs • Post-CABG, Angioplasty and > 7 METs

  25. CAD - Class 3: 30-49% • Symptoms of CAD • > 50% Blockage • 5 - 7 METs

  26. CAD - Class 4: 50-100% • Functional Class 3 - 4 • < 5 METs

  27. Table 3-6a

  28. 3.4 Congenital Heart Disease • Uses NYHA Functional Class Table 3-1 • Classification by degree of valve abnormality, heart failure, severity of pulmonary –systemic flow abnormality, degree of shunting

  29. Congenital Heart Disease Common Examples • ASD/VSD • Ebsteins Anomaly • Tetrology of Fallot • Transposition of Great Vessels • Eisenmengers Complex

  30. Congenital Heart Disease Rating

  31. 3.5 Cardiomyopathy • Table 3-9 Uses NYHA Functional Class and Treatment. Mets Not Used • However, it would be better if you use more objective criteria of EF and METS. See e.g. past California guidelines or SSA Guides.

  32. Weber Classification of Functional Impairment in CHF

  33. 3.6 Pericardial Heart Disease • Make sure at MMI as these can relapse and recur • If recurrent, demonstrate abnormality (echo, CT) • Table 3-10 Uses NYHA Functional Class and Treatment. Mets Not Used • However, again, it would be better if you use more objective criteria of EF and METS.

  34. 3.7 Arrhythmia • Impairment from arrhythmia must be combined with impairment of underlying heart disease if present

  35. Arrhythmia Impairment AMA Guides I - Asymptomatic, Documented Arrhythmia Not Malignant, No Organic Heart Disease II - Asymptomatic, Documented Arrhythmia, Need Dietary Adjustment, Medication, Organic Heart Disease is Present III - Symptoms With Treatment, Infrequent, Active Life IV - Constant Symptoms; NYHA Class 3-4

  36. REST STOP

  37. THE CARDIOVASCULAR SYSTEMChapter 4 – Systemic and Pulmonary Arteries

  38. 4.1 Hypertensive Cardiovascular Disease • This is primarily a numbers game

  39. Classification of Hypertension Arch Int Med, 1997 (JNC 6)

  40. Hypertension - Class 1: 0-9% • Asymptomatic Stage 1 or 2 Without Medicationor • Normal BP with Medication and • No End-Organ Damage

  41. Hypertension - Class 2: 10-29% • Abnormal Urine • But No Renal Impairment • Retinal Change • No Symptoms; Stage1 or 2 with meds

  42. Hypertension - Class 3: 30-49% • Asymptomatic; Stage 3 with Meds • Renal Insufficiency or • LVH • No CHF

  43. Hypertension – Class 4 50-100% • Stage 1-3 with Medication and • Renal Disease or • Hypertensive Cerebrovascular Damage or • LVH, CHF

  44. Pulmonary Hypertension • Findings of Right Heart Failure • Pulmonary Artery Pressure • Class 1 40-50 mm Hg • Class 2 51-75 mmHg • Class 3 >75 mm Hg • Class 4 >76 mm Hg or functional class 3-4

  45. 4.2 Diseases of the Aorta • Functional Classification for Aortic Symptoms such as dyspnea, wheezing, cough • At risk or had surgery

  46. 4.4 Peripheral Vascular Disease- Upper Extremity • Claudication • Physical findings especially of edema or ulcerations • Finger-brachial indices • Amputation

  47. 4.4 Peripheral Vascular Disease- Lower Extremity • Claudication (distance) Do Claudication Treadmill Study • Physical findings especially of edema or ulcerations • Ankle-brachial indices are not mentioned but should be done • Amputation

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