Cardiology 3rd Year


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Cardiology 3rd Year

  1. 1. Introduction to cardiology Dr. Judit Keller
  2. 2. Cardiovascular disease Importance <ul><li>Single greatest cause of death and disability all over the world </li></ul><ul><li>Coronary heart disease </li></ul><ul><li>Valvular heart disease </li></ul><ul><li>Diseases of the myocardium </li></ul><ul><li>Rhythm disorders </li></ul>
  3. 3. CV mortality
  4. 4. Case history in cardiology <ul><li>Previous diseases, </li></ul><ul><li>Current symptoms </li></ul><ul><li>Family history and risk factors </li></ul><ul><li>The results of the physical examination </li></ul><ul><li>Technical cardiovascular examinations. </li></ul><ul><li>Treatment </li></ul>
  5. 5. Medical history <ul><li>Present symptoms. </li></ul><ul><li>Chest pain , dyspnea, palpitations, swelling in the legs, ankles , and feet or abdomen </li></ul><ul><li>Other, more general symptoms, such as fever, weakness, fatigue, lack of appetite , and a general feeling of illness or discomfort (malaise), may suggest a heart disorder. </li></ul><ul><li>Pain, numbness, or muscle cramps in a leg may suggest peripheral arterial disease, which affects the arteries of the arms, legs, and trunk (except those supplying the heart). </li></ul>
  6. 6. Chest pain <ul><li>Chest pain is one of the most common reasons people call for emergency medical help or go to a cardiologist </li></ul><ul><li>Angina - is often described as a pressure or tightness in the chest. It's usually brought on by physical or emotional stress. The pain usually goes away within minutes after stopping the stressful activity. </li></ul><ul><li>Heart attack - pressure, fullness or a crushing pain in the chest that lasts more than 5 minutes. The pain may radiate to the back, neck, jaw, shoulders and arms, especially to the left arm. Other signs: shortness of breath, sweating, dizziness and nausea. </li></ul>
  7. 7. Angina Classification (Canadian Cardiovascular Society) < 20 W alatt < 4 METs Any physical activity, sometimes occurring at rest C C S-4. degree 20–80 W – 5-6 METs Walking, even 1 or 2 blocks at usual pace and on level ground.  Climbing stairs, even 1 flight C C S-3. degree 80–120 W – 6-8 METs Walking rapidly or uphill Emotional stress C CS -2. degree > 120 W – 10 METs Strenuous, rapid, or prolonged exertion C C S-1. degree Excercise toleranc e Activities triggering Chest pain Angina
  8. 8. Differential diagnosis <ul><li>Pericarditis. causes sharp, piercing and centralized chest pain. You may also have a fever and feel sick. </li></ul><ul><li>Aortic dissection. In this condition, the inner layers of the aorta separate, forcing blood between them. Symptoms are sudden and tearing chest and back pain . </li></ul><ul><li>Noncardiac causes </li></ul><ul><li>Pulmonary embolism, Heartburn, Panic attack,Sore muscles, GI problems </li></ul>
  9. 9. Dyspnea <ul><li>sensation of breathlessness </li></ul><ul><li>Grade Degree of dyspnea </li></ul><ul><li>1 no dyspnea except with strenuous exercise </li></ul><ul><li>2 dyspnea when walking up an incline or hurrying on the level </li></ul><ul><li>3 walks slower than most on the level, or stops after 15 minutes of walking on the level </li></ul><ul><li>4 stops after a few minutes of walking on the level </li></ul><ul><li>5 dyspnea with minimal activity such as getting dressed, too dyspneic to leave the house </li></ul><ul><li>6 Ortopnea – severe dyspnea at rest </li></ul>
  10. 10. <ul><li>Differential diagnosis: </li></ul><ul><li>cardiac, </li></ul><ul><li>pulmonary, </li></ul><ul><li>mixed cardiac or pulmonary, </li></ul><ul><li>noncardiac or nonpulmonary. </li></ul>
  11. 11. <ul><li>Cardiac Congestive heart failure (right, left or biventricular) Coronary artery disease Myocardial infarction (recent or past history) Cardiomyopathy Valvular dysfunction Left ventricular hypertrophy Asymmetric septal hypertrophy Pericarditis Arrhythmias </li></ul><ul><li>Pulmonary COPD Asthma Restrictive lung disorders Hereditary lung disorders Pneumothorax </li></ul><ul><li>Mixed cardiac or pulmonary COPD with pulmonary hypertension and cor pulmonale Deconditioning Chronic pulmonary emboli Trauma </li></ul><ul><li>Noncardiac or nonpulmonary Metabolic conditions (e.g., acidosis) Pain Neuromuscular disorders Otorhinolaryngeal disorders Functional - Anxiety - Panic disorders - Hyperventilation </li></ul>
  12. 12. <ul><li>Next: previous diseases </li></ul><ul><li>past infections; previous exposure to chemicals; use of drugs, alcohol, and tobacco; </li></ul><ul><li>home and work environments; and recreational activity. </li></ul><ul><li>family history: whether family members members have had a heart disorder or any other disorders that may affect the heart or blood vessels. </li></ul>
  13. 13. Physical examination <ul><li>Weight and overall appearance </li></ul><ul><li>Looking for paleness (pallor), sweating, or drowsiness, which may be subtle indicators of heart disorders. </li></ul><ul><li>The person's general mood and feeling of well-being, also may be affected by heart disorders. </li></ul>
  14. 14. <ul><li>Assessing skin color </li></ul><ul><li>pallor - anaemia </li></ul><ul><li>bluish-purplish coloration - cyanosis </li></ul><ul><li>These findings may indicate </li></ul><ul><li>lung disorder, </li></ul><ul><li>heart failure, </li></ul><ul><li>various circulatory problems. </li></ul>
  15. 15. <ul><li>feeling pulse: </li></ul><ul><li>carotids, radial arteries, a. femoralis, a. dorsalis pedis, a. tibialis posterior </li></ul><ul><li>are they adequate and equal on both sides of the body? </li></ul><ul><li>the blood pressure and body temperature are also checked </li></ul><ul><li>pressing the skin over the ankles and legs and sometimes over the lower back - to check for fluid accumulation (edema) </li></ul>
  16. 16. Basic cardiological „hardware”
  17. 17. Heart auscultation
  18. 18. Cardiac Cycle Diastole Systole
  19. 19. Systolic murmurs <ul><li>Systolic murmurs occur between S1 and S2 (first and second heart sounds ), and therefore are associated with mechanical systolic and ventricular ejection. </li></ul><ul><li>Mid-systolic murmurs typically have a crescendo-decrescendo character, that is, they start softly and become loudest near mid-systole, followed by a decrease in sound amplitude as shown in the figure. </li></ul><ul><li>  This type of murmur is caused by either aortic or pulmonic valve stenosis .  </li></ul><ul><li>A second type of systolic murmur is holosystolic (sometimes called pansystolic) because the amplitude is high throughout systole as shown in the figure. </li></ul><ul><li>This type of murmur is caused by mitral or tricuspid regurgitation , or by a ventricular septal defect . </li></ul>
  20. 20. Diastolic murmurs <ul><li>Diastolic murmurs occur after S2 and are therefore associated with ventricular relaxation and filling.  </li></ul><ul><li>They may be caused by aortic or pulmonic valve regurgitation , </li></ul><ul><li>or by mitral or tricuspid valve stenosis .  </li></ul><ul><li>They can occur early mid-diastolic, ( aortic regurgitation), </li></ul><ul><li>or late diastolic (mitral stenosis). </li></ul>
  21. 21. <ul><li>The murmur of aortic stenosis is typically a mid-systolic ejection murmur, heard best over the “aortic area” : right second intercostal space, with radiation into the right neck. </li></ul><ul><li>Additional heart sounds, such as an S4 , may be heard secondary to hypertrophy of the left ventricle which is caused by the greatly increased work required to pump blood through the stenotic valve </li></ul>
  22. 22. <ul><li>Systolic murmur of MR </li></ul><ul><ul><li>Usually high-pitched, blowing </li></ul></ul><ul><ul><li>Usually best heard over the apex </li></ul></ul><ul><ul><li>Usually radiates to the left axilla or subscapular region </li></ul></ul><ul><ul><ul><li>Posterior leaflet dysfunction causes murmur to radiate to the sternum or aortic area </li></ul></ul></ul><ul><ul><ul><li>Anterior leaflet dysfunction causes murmur to radiate to the back or top of the head </li></ul></ul></ul><ul><li>Holosystolic </li></ul><ul><ul><li>May be confined to early systole in acute MR </li></ul></ul><ul><ul><li>May be confined to late systole in MVP or papillary muscle dysfunction </li></ul></ul><ul><ul><ul><li>S 1 will probably be normal in these cases since initial closure of mitral valve cusps is unimpeded. </li></ul></ul></ul><ul><ul><ul><li>A midsystolic click preceding murmur is suggestive of MVP . </li></ul></ul></ul><ul><li>Intensity </li></ul><ul><ul><li>Little correlation exists between intensity of murmur and severity of MR. </li></ul></ul><ul><ul><li>Intensity may be diminished in severe MR and LV dysfunction, acute myocardial infarction, or periprosthetic valve regurgitation.  </li></ul></ul>
  23. 23. Importance <ul><li>Despite decreasing of the incidence of rheumatic heart valve diseases </li></ul><ul><li>The tendency of valvular diseases themselves does not decrease but increases </li></ul><ul><li>The most important is aortic stenosis </li></ul><ul><ul><li>Below 60 mostly congenital and post IE </li></ul></ul><ul><ul><li>Above 60 mostly sclerotic – very progressive!! </li></ul></ul><ul><ul><li>The most frequent is mitral regurgitation </li></ul></ul><ul><ul><li>CHD, MPS, hypertension, annulus dilatation or calcification, papillary muscle dysfunction </li></ul></ul>
  24. 24. Epidemiology of CHD <ul><li>A population-based survey, using data from the Framingham study , assessed sex-specific patterns of coronary heart disease occurring over a 26-year period of time. Among subjects ages 35 to 84 years, men have about twice the total incidence of morbidity and mortality of women. The sex gap in morbidity tends to diminish during the later years of the age range, mainly because of a surge in growth of female morbidity after age 45 years, while by that age, the growth in the male rate begins to taper off. </li></ul>
  25. 25. Risk factors for coronary heart disease (CHD) <ul><li>Age </li></ul><ul><li>Family history </li></ul><ul><li>Hypertension </li></ul><ul><li>Hypercholesterolaemia </li></ul><ul><li>Male gender </li></ul><ul><li>Smoking </li></ul><ul><li>Overweight and obesity </li></ul><ul><li>Physical inactivity </li></ul><ul><li>Diabetes </li></ul><ul><li>Stress </li></ul>
  26. 26. Multimetabolic catastrophe!
  27. 27. 22 22 Smoking 9 22 Physical inactivity 12 28 Diabetes 23 33 Overweight 27 63 High cholesterin level 72 58 Hypertension stroke CHD Risk factor Ezzati M et al. Lancet 2003;362:271-80. (%) Increasing of the incidence of CHD and stroke
  28. 29. ?
  29. 30. Risk stratification - Euroscore
  30. 31. Effects of hypertension, smoking and hypercholester ol aemia to CHD ri sk X1.6 x4 x3 x6 x16 X4.5 x9 hypertension (SBP 195 Hgmm) High TC (8.5 mmol/L, 330 mg/dl) smoking (Poulter et al, 1993)
  31. 32. hypertension High TC diabetes x3 x2 x2 x5 x4 x3 x8 Effects of hypertension, diabetes and hypercholester ol aemia to CHD ri sk
  32. 33. Stable angina pectoris - diagnostics <ul><li>Anamnesis – family history, present complaints, risk factor detection </li></ul><ul><li>Physical examination – murmurs (aortis stenosis!!), rhythm disorders, BP </li></ul><ul><li>Lab – lipid profile, blood glucose , uric acid, serum potassium level, excuding anaemia, hyperthyreosis </li></ul><ul><li>ECG – rest12 lead ECG is mandatory, though the sensitivity is less than 60 % ! </li></ul><ul><li>Echokg – valves, cavities, wall thickness and motion, systolic and diastolic function of the ventricles. </li></ul><ul><li>Stress tests – treadmill or bicycle ergometry stress test, isotope and/or stress echocardiography, cardiac MR </li></ul><ul><li>Holter – total ischaemic burden, rhythm disorders </li></ul><ul><li>Invasive diagnostics - coronarography </li></ul>
  33. 34. Thank you for your attention!