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CARDIOLOGY

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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  1. CARDIOLOGY Cardinal Signs

  2. 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

  3. Non-Cardio-Pulmonary • Metabolic- Acidosis • Hematology-Anemia • Psychic- Anxiety/Panic disorder • MSK- MS/ Musuclar Dystrophy

  4. Diagnostic tests • CXR • ECHO • ECG • MRI • EBT • CARDIAC CATH

  5. Bioprosthesis/ Homografts • Life expetency -10-15 years • Bovine better than porcine • Homografts (allograft) human

  6. Mechanical Valve Prosthesis • Thrombosis/embolism risk: mitral > aortic

  7. 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

  8. CHF Data • Prevalence- 5 million • Incidence 500,000/year • Older age group 65+

  9. 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

  10. Systolic malfunction: • Myocardial infarction • Valvular disease • Hypertension • Cardiomyopathy- alcohol/ amyloid • Can also be identified as- Left sided failure Right sided failure

  11. 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

  12. CHF-Physical findings • Tachycardia- increased ISA • Wet lungs (crackles)- LVF • Enlarged ventricle • S3- • Jugular vein distension- right failure • Edema feet • Ascites

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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’

  18. 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)

  19. 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

  20. Lab Workup: Echcocardiography • Therapy: Repeat echo every 3-5 yrs • ? Beta blockers • Stay away from- caffeine/ alcohol/ nicotine ?Valve repair/ ?Warfarin

  21. 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

  22. Markers for inflammation • Hs-CRP • IL-6 • CD-40 • Homocysteine

  23. ? Preventive Interventions • Stop smoking • Lower LDL/ Elevate HDL • ?Statins • ?Aspirin in men / not so in women • ?Omega-3 • ?ACEi

  24. 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

  25. DD: ?Angina • Costochondritis (chest wall pain) • Herpes Zoster dermatomal pain • Cervical Spondylitis (C6-8) • Peptic ulcer/ Cholcecystitis/ Esophageal reflux/ Pneumothorax

  26. Angina Types • Chronic stable type • Unstable angina- serious may progress to heart attack • Variant (Prinzmetal’s) angina- coronary spasm

  27. Lab Workup • Lab workup- ECG/ EBCT (CACS status) score >100 high risk >1000 very high risk • Coronary angiography

  28. Angina Therapy • Nitroglycerine sub-lingual • Beta blockers- propranalol (Inderal) • CCB- verapamil/ diltiazem • Aspirin/ Clopidogrel (Plavix) • Role for acupuncture • CABG

  29. Acute Coronary Syndrome • Unstable Angina>Ischemia>Infarction • Check ECG/Blood markers determine heart attack or not • ‘Chest pain Observation Units’ • Troponin-1

  30. 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

  31. 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

  32. Underlying Arrhythmia of Sudden Death Torsades de Pointes 13% Primary VF 8% VT 62% Bradycardia 17%

  33. 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

  34. Abnormal Heart Rhythms

  35. CAUSES • electrolyte abnormalities, • hormonal imbalances (thyrotoxicosis, hyper adrenaline (catecholaminergic) states), • hypoxia, • drug effects • myocardial ischemia

  36. 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’

  37. 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

  38. 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.

  39. Heart Blocks

  40. 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

  41. Ventricular tachycardia • Leads to ventricular fibrillation- causing sudden cardiac death (300,000/yr) • Diagnosis by ECG • Defib and Amiodarone • Implanted cardiac defibrillator

  42. Ventricular fibrillation Life threatening Needs defibrillation!

  43. 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

  44. 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

  45. 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

  46. 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

  47. Drug-Induced & Toxic Myocarditis • Doxorubicin • cocaine cardiotoxicity

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