This document discusses the assessment, investigation, and treatment of chronic stable angina. It defines chronic stable angina as chest pain or discomfort that is reproducibly associated with exertion or stress and relieved by rest. The document outlines how to evaluate patients presenting with chest pain through history, physical exam, risk factor assessment, and probability estimation models. It recommends initial tests like ECG, cardiac biomarkers, and stress testing. Treatment focuses on lifestyle changes, medications like aspirin, beta-blockers, calcium channel blockers, and revascularization if needed. Regular patient follow up and education are also emphasized.
This document provides information on acute myocardial infarction (AMI), commonly known as a heart attack. It defines AMI as the irreversible necrosis of heart muscle tissue due to prolonged lack of oxygen. AMI is typically caused by a blockage in one of the coronary arteries, reducing blood supply to the heart. The document discusses the epidemiology, risk factors, pathophysiology, signs and symptoms, diagnosis, management, prevention, and classification of AMI. It emphasizes the importance of rapidly restoring blood flow to limit damage to heart muscle.
Unstable angina is a form of ischemic heart disease where a person experiences chest pain or discomfort that occurs at rest or with minimal exertion. It is caused by decreased blood supply to the heart muscle due to partial blockage of the coronary arteries. Diagnosis involves taking a medical history, electrocardiogram, cardiac enzyme tests, and stress testing. Treatment consists of blood thinners, nitroglycerin, blood pressure medications, and cholesterol-lowering drugs medically or early cardiac catheterization and angioplasty or bypass surgery if high risk.
This document discusses ischemic heart disease and coronary artery disease. Coronary artery disease is caused by atherosclerosis which develops due to risk factors like smoking, high blood pressure, high cholesterol, and diabetes. Clinical presentations include stable angina, unstable angina, non-ST elevation myocardial infarction, and ST elevation myocardial infarction. Treatment involves lifestyle modifications, medications like antiplatelets, anticoagulants, and statins, as well as procedures like percutaneous coronary intervention and coronary artery bypass grafting.
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Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
Atrial fibrillation and atrial flutter are types of arrhythmia where the heart beats irregularly. Atrial fibrillation occurs when rapid, irregular electrical signals cause the heart's upper chambers (atria) to beat very fast and irregularly. Atrial flutter is similar but the heart beats fast in a regular pattern. These conditions are diagnosed through electrocardiograms which detect abnormal heart rhythms. Holter monitors and event recorders can also detect arrhythmias over longer periods of time when symptoms occur. Complications include stroke and heart failure, so treatment focuses on rate or rhythm control and preventing clots.
The document provides guidelines for the diagnosis and management of chronic stable angina, defining it as chest discomfort caused by myocardial ischemia that is typically triggered by exertion or stress. It discusses the pathophysiology, risk factors, diagnostic testing options including ECG, stress testing, and imaging, and recommendations for invasive coronary angiography. The guidelines are intended to help clinicians properly evaluate and treat patients experiencing chronic stable angina.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by disorganized atrial activity without effective contractions. It increases risk of stroke and prevalence rises with age.
2) Management involves restoring sinus rhythm through drugs, cardioversion, or ablation or controlling heart rate and preventing clots with anticoagulants. Rate control uses beta blockers, calcium channel blockers, or digoxin while restoring rhythm uses antiarrhythmics, cardioversion, or ablation.
3) Treatment depends on whether AF is paroxysmal, persistent or permanent and involves restoring rhythm if possible or controlling rate and preventing complications if not.
This document provides information on acute myocardial infarction (AMI), commonly known as a heart attack. It defines AMI as the irreversible necrosis of heart muscle tissue due to prolonged lack of oxygen. AMI is typically caused by a blockage in one of the coronary arteries, reducing blood supply to the heart. The document discusses the epidemiology, risk factors, pathophysiology, signs and symptoms, diagnosis, management, prevention, and classification of AMI. It emphasizes the importance of rapidly restoring blood flow to limit damage to heart muscle.
Unstable angina is a form of ischemic heart disease where a person experiences chest pain or discomfort that occurs at rest or with minimal exertion. It is caused by decreased blood supply to the heart muscle due to partial blockage of the coronary arteries. Diagnosis involves taking a medical history, electrocardiogram, cardiac enzyme tests, and stress testing. Treatment consists of blood thinners, nitroglycerin, blood pressure medications, and cholesterol-lowering drugs medically or early cardiac catheterization and angioplasty or bypass surgery if high risk.
This document discusses ischemic heart disease and coronary artery disease. Coronary artery disease is caused by atherosclerosis which develops due to risk factors like smoking, high blood pressure, high cholesterol, and diabetes. Clinical presentations include stable angina, unstable angina, non-ST elevation myocardial infarction, and ST elevation myocardial infarction. Treatment involves lifestyle modifications, medications like antiplatelets, anticoagulants, and statins, as well as procedures like percutaneous coronary intervention and coronary artery bypass grafting.
Kindly leave your comment if you found this helpful ;)
Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
Atrial fibrillation and atrial flutter are types of arrhythmia where the heart beats irregularly. Atrial fibrillation occurs when rapid, irregular electrical signals cause the heart's upper chambers (atria) to beat very fast and irregularly. Atrial flutter is similar but the heart beats fast in a regular pattern. These conditions are diagnosed through electrocardiograms which detect abnormal heart rhythms. Holter monitors and event recorders can also detect arrhythmias over longer periods of time when symptoms occur. Complications include stroke and heart failure, so treatment focuses on rate or rhythm control and preventing clots.
The document provides guidelines for the diagnosis and management of chronic stable angina, defining it as chest discomfort caused by myocardial ischemia that is typically triggered by exertion or stress. It discusses the pathophysiology, risk factors, diagnostic testing options including ECG, stress testing, and imaging, and recommendations for invasive coronary angiography. The guidelines are intended to help clinicians properly evaluate and treat patients experiencing chronic stable angina.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by disorganized atrial activity without effective contractions. It increases risk of stroke and prevalence rises with age.
2) Management involves restoring sinus rhythm through drugs, cardioversion, or ablation or controlling heart rate and preventing clots with anticoagulants. Rate control uses beta blockers, calcium channel blockers, or digoxin while restoring rhythm uses antiarrhythmics, cardioversion, or ablation.
3) Treatment depends on whether AF is paroxysmal, persistent or permanent and involves restoring rhythm if possible or controlling rate and preventing complications if not.
Mitral stenosis is characterized by obstruction of blood flow from the left atrium to the left ventricle due to thickening and immobility of the mitral valve leaflets. The most common cause is rheumatic heart disease. As the stenosis progresses, the left atrial pressure rises, leading to pulmonary congestion and right-sided heart failure over time. On examination, findings may include an accentuated S1, opening snap, and mid-diastolic murmur with presystolic accentuation. Chest x-ray may show an enlarged left atrium and signs of pulmonary congestion. Treatment involves rate control for atrial fibrillation, diuretics, and potentially balloon valvuloplasty or
Aortic stenosis is a narrowing of the aortic valve that obstructs blood flow from the left ventricle to the aorta. It is most commonly caused by calcification and fibrosis of the aortic valve. Symptoms include dyspnea, exertional dizziness, and exertional angina as the left ventricle has to work harder to maintain adequate cardiac output against the increased resistance. On examination, the carotid pulse is weak and delayed while auscultation reveals a crescendo-decrescendo systolic murmur best heard at the right upper sternal border that radiates to the carotid arteries. Management involves prompt aortic valve replacement for symptomatic severe aortic stenosis.
The aortic valve has three cusps that open and close to regulate blood flow from the heart to the aorta. Aortic stenosis occurs when the valve opening narrows due to calcium buildup on the cusps. In the elderly, aortic stenosis is usually caused by age-related degeneration and calcification of the valve. Symptoms include chest pain, shortness of breath, and fainting. Diagnosis involves echocardiogram, Doppler ultrasound and cardiac catheterization. Treatment options include medications, balloon valvuloplasty, open-heart surgery to replace the valve, and newer transcatheter aortic valve replacement procedures for high-risk elderly patients.
definition of heart failure, classification of heart failure, risk factors for heart failure, clinical features, general physical examination findings in heart failure
The document discusses aortic regurgitation, including its anatomy, etiology, pathophysiology, epidemiology, clinical manifestations, diagnosis, and management. Key points include:
- Aortic regurgitation occurs when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle during diastole.
- Causes include conditions like infective endocarditis, bicuspid aortic valve, hypertension, and Marfan syndrome.
- In acute severe cases, a rapid increase in left ventricular preload can cause pulmonary edema and cardiogenic shock. Chronic cases involve left ventricular dilation and hypertrophy to compensate for the increased preload over time.
- Physical exam may
Myocardial infarction, also known as a heart attack, results from a critical imbalance between oxygen supply and demand in the heart muscle. The primary cause is coronary artery occlusion due to atherosclerosis, vasospasm, or embolism. Symptoms may include chest pain, dyspnea, sweating, and anxiety. Diagnosis is made based on elevated cardiac enzyme levels and ECG changes. Initial treatment focuses on pain relief, oxygen, fluids, and aspirin while long-term prevention includes medications like beta-blockers, ACE inhibitors, antiplatelets, and statins to reduce risk of future heart attacks and heart failure.
An aortic aneurysm is a localized sac or dilation formed at a weak point in the aortic wall. They most commonly occur in the abdominal aorta and can be caused by conditions like hypertension, atherosclerosis, and smoking. Aortic aneurysms are classified as either saccular or fusiform based on their shape and size. Untreated aneurysms risk rupture, which can cause massive hemorrhage and death. Surgical treatment involves replacing the diseased aortic segment with a synthetic graft to prevent rupture.
Acute Coronary Syndrome (ACS) refers to a range of conditions caused by reduced blood flow in the coronary arteries. It includes Unstable Angina (UA), Non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). ACS is diagnosed based on electrocardiogram (ECG) findings and cardiac enzyme levels. STEMI shows ST elevations and enzyme elevations, while NSTEMI shows ST depressions/inversions and enzyme elevations without ST elevations. UA shows non-specific ECG changes and normal enzymes. Risk stratification systems like the TIMI score are used for NSTEMI/UA patients to guide management, which may
The document discusses the anatomy, causes, diagnosis, and management of aortic regurgitation (AR). It provides details on the location of the aortic valve, variants such as bicuspid aortic valve, and common causes of AR including rheumatic heart disease. Physical exam findings, echocardiography parameters, and indications for surgery to replace the aortic valve are summarized. Medical management including vasodilator therapy to reduce afterload is also reviewed.
Infective endocarditis is a microbial infection of the heart valves or endocardium. It is characterized by the formation of vegetations composed of platelets, fibrin, microorganisms, and inflammatory cells. It occurs more commonly in males and the elderly. Streptococci and Staphylococcus aureus are the most common causes. Diagnosis involves blood cultures, echocardiography, and applying the Duke criteria. Complications include embolisms, heart failure, and metastatic infections. Treatment involves prolonged antibiotic therapy targeted to the infecting organism. Surgery may be needed for complications or uncontrolled infection. Antibiotic prophylaxis is now restricted to highest risk patients undergoing highest risk procedures.
This document provides an overview of acute myocardial infarction (MI), also known as a heart attack. It discusses the definition, causes, risk factors, pathogenesis, classification, diagnosis and management of MI. The diagnosis involves taking a patient history, examining signs and symptoms, electrocardiography, serum analysis and echocardiography. Management is staged and involves pre-hospital, emergency department and post-discharge care, with a focus on reperfusing the blocked artery as quickly as possible, such as through percutaneous coronary intervention or thrombolytic therapy. The goal is to correctly identify the type of MI, treat the patient according to guidelines and manage any complications.
Myocarditis is an inflammatory disease of the heart muscle that can be caused by infectious or non-infectious triggers. It has a variable clinical presentation ranging from mild symptoms to life-threatening conditions. The diagnosis is challenging due to the heterogeneity of symptoms but can involve electrocardiogram, cardiac biomarkers, echocardiogram, cardiac MRI and endomyocardial biopsy. About half of acute cases resolve in 2-4 weeks but some develop heart failure or arrhythmias. Treatment focuses on supporting heart function and managing symptoms while the disease runs its course.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by irregular electrical activity in the atria. It increases in prevalence with age and can cause complications like heart failure, stroke, and systemic embolism.
2) Management of atrial fibrillation involves rate or rhythm control as well as long-term anticoagulation to prevent thromboembolism depending on stroke risk factors. The CHA2DS2-VASc score is used to assess this risk.
3) While antiarrhythmic drugs and cardioversion can restore normal sinus rhythm, rate control is preferred for many patients. Newer anticoagulants like dabigatran and rivar
This document defines and describes sick sinus syndrome, which is a dysfunction of the sinoatrial node that can cause abnormal heart rhythms like bradycardia, tachycardia, and alternating slow and fast rhythms. It may be caused by certain drugs, aging, or underlying heart conditions. Symptoms can include fatigue, dizziness, and fainting. Diagnosis involves an electrocardiogram showing arrhythmias. Treatment options include medications or a pacemaker if symptoms are severe. The document also briefly discusses different types of heart block.
The document discusses various pericardial diseases including acute pericarditis, constrictive pericarditis, pericardial effusion, and cardiac tamponade. It provides details on the anatomy and functions of the pericardium, pathophysiology, clinical features, diagnostic tests, and management of these conditions. Key points include that pericardial diseases can present with non-specific symptoms, clinical suspicion is important for diagnosis, and treatment depends on underlying etiology and presence of hemodynamic compromise. Differentiating constrictive pericarditis from restrictive cardiomyopathy is important as treatment approaches differ significantly.
Mitral stenosis is commonly caused by rheumatic heart disease which leads to inflammation and fusion of the mitral valve leaflets, reducing the mitral valve orifice area. Severe mitral stenosis, defined as a mitral valve area less than 1.0 cm2, can cause pulmonary hypertension, pulmonary edema, atrial fibrillation, and right heart failure as the heart tries to maintain sufficient cardiac output against the back pressure. Physical exam may reveal signs of pulmonary hypertension like a loud pulmonary component to S2, as well as a tapping apex, opening snap, and mid-diastolic rumble on cardiac auscultation. Echocardiography can determine the severity of mitral stenosis and assess
Mitral valve stenosis involves a blockage of blood flow through the mitral valve due to abnormalities of the valve leaflets. It is commonly caused by rheumatic fever or infective endocarditis. Risk factors include acute rheumatic fever or streptococcal infections. The narrowed valve orifice increases pressures in the left atrium and lungs. Symptoms include fatigue, palpitations, and dyspnea. Diagnosis involves echocardiogram, electrocardiogram, and chest x-ray. Treatment may include diuretics, anticoagulants, balloon valvuloplasty, or valve replacement surgery. Nursing care focuses on monitoring for fluid overload, promoting rest and oxygenation, and educ
Ventricular tachycardia is a fast heart rhythm originating from the ventricles with a rate over 100 bpm. It is classified based on duration (sustained vs non-sustained), morphology (monomorphic, polymorphic, sinusoidal), and symptoms. Causes include structural heart disease, electrolyte abnormalities, drugs, and prolonged QT interval. Diagnosis involves ECG criteria showing ventricular origin. Treatment depends on hemodynamic stability and may include antiarrhythmic drugs, implantable cardioverter-defibrillator, catheter ablation, or surgery. Recurrent ventricular tachycardia is managed long term with devices, drugs, and treatment of underlying causes.
This document discusses various types of cardiomyopathies:
- Dilated cardiomyopathy is caused by an unknown etiology and results in left ventricular dilatation and systolic dysfunction. It is a common cause of heart failure.
- Hypertrophic cardiomyopathy involves abnormal thickening of the heart muscle and can lead to outflow obstruction. It is a common cause of sudden death in young athletes.
- Restrictive cardiomyopathy causes stiff ventricles and impaired ventricular filling due to disorders like amyloidosis. It presents with symptoms of right and left heart failure.
- Other rare types discussed include arrhythmogenic right ventricular dysplasia and obliterative cardiomyopathy. Diagnosis involves imaging and endomyocardial biopsy
This document discusses aortic regurgitation (AR), which occurs when the aortic valve does not close properly, allowing blood to flow backward into the left ventricle. It can be caused by damage to the aortic valve leaflets or distortion of the aorta. Common causes include rheumatic heart disease, bicuspid aortic valves, hypertension, and Marfan syndrome. Over time, the left ventricle must work harder to compensate for the backflow of blood, which can lead to enlarged and weakened heart muscles. Symptoms may include palpitations, chest pain, and shortness of breath. Diagnosis involves listening for an early diastolic murmur and confirming the diagnosis with echocardiogram
CT scans use X-rays and computers to create detailed images of the inside of the body. CT scanning was independently developed in the 1970s by Godfrey Hounsfield and Allan Cormack. A CT scan works by using an X-ray device and detector that rotate around the body, detecting differences in radiation absorption as they pass through tissues. The data is then used to construct a series of cross-sectional images of the bones, muscles, fat, and organs inside the body. CT scans allow doctors to see internal structures in great detail and find diseases that may not be visible on regular X-rays.
Radioactive isotopes emit radiation through radioactive decay as their unstable nuclei break down. There are three main types of radiation emitted: alpha particles, beta particles, and gamma rays. Radioactive isotopes are used in scientific research, analytical applications like radioimmunoassays, and medical diagnostic procedures and therapies. Some key radioactive isotopes used include iodine-131 for thyroid imaging and cancer treatment, technetium-99m for thyroid scans, and strontium-89 or samarium-153 to treat bone metastases.
Mitral stenosis is characterized by obstruction of blood flow from the left atrium to the left ventricle due to thickening and immobility of the mitral valve leaflets. The most common cause is rheumatic heart disease. As the stenosis progresses, the left atrial pressure rises, leading to pulmonary congestion and right-sided heart failure over time. On examination, findings may include an accentuated S1, opening snap, and mid-diastolic murmur with presystolic accentuation. Chest x-ray may show an enlarged left atrium and signs of pulmonary congestion. Treatment involves rate control for atrial fibrillation, diuretics, and potentially balloon valvuloplasty or
Aortic stenosis is a narrowing of the aortic valve that obstructs blood flow from the left ventricle to the aorta. It is most commonly caused by calcification and fibrosis of the aortic valve. Symptoms include dyspnea, exertional dizziness, and exertional angina as the left ventricle has to work harder to maintain adequate cardiac output against the increased resistance. On examination, the carotid pulse is weak and delayed while auscultation reveals a crescendo-decrescendo systolic murmur best heard at the right upper sternal border that radiates to the carotid arteries. Management involves prompt aortic valve replacement for symptomatic severe aortic stenosis.
The aortic valve has three cusps that open and close to regulate blood flow from the heart to the aorta. Aortic stenosis occurs when the valve opening narrows due to calcium buildup on the cusps. In the elderly, aortic stenosis is usually caused by age-related degeneration and calcification of the valve. Symptoms include chest pain, shortness of breath, and fainting. Diagnosis involves echocardiogram, Doppler ultrasound and cardiac catheterization. Treatment options include medications, balloon valvuloplasty, open-heart surgery to replace the valve, and newer transcatheter aortic valve replacement procedures for high-risk elderly patients.
definition of heart failure, classification of heart failure, risk factors for heart failure, clinical features, general physical examination findings in heart failure
The document discusses aortic regurgitation, including its anatomy, etiology, pathophysiology, epidemiology, clinical manifestations, diagnosis, and management. Key points include:
- Aortic regurgitation occurs when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle during diastole.
- Causes include conditions like infective endocarditis, bicuspid aortic valve, hypertension, and Marfan syndrome.
- In acute severe cases, a rapid increase in left ventricular preload can cause pulmonary edema and cardiogenic shock. Chronic cases involve left ventricular dilation and hypertrophy to compensate for the increased preload over time.
- Physical exam may
Myocardial infarction, also known as a heart attack, results from a critical imbalance between oxygen supply and demand in the heart muscle. The primary cause is coronary artery occlusion due to atherosclerosis, vasospasm, or embolism. Symptoms may include chest pain, dyspnea, sweating, and anxiety. Diagnosis is made based on elevated cardiac enzyme levels and ECG changes. Initial treatment focuses on pain relief, oxygen, fluids, and aspirin while long-term prevention includes medications like beta-blockers, ACE inhibitors, antiplatelets, and statins to reduce risk of future heart attacks and heart failure.
An aortic aneurysm is a localized sac or dilation formed at a weak point in the aortic wall. They most commonly occur in the abdominal aorta and can be caused by conditions like hypertension, atherosclerosis, and smoking. Aortic aneurysms are classified as either saccular or fusiform based on their shape and size. Untreated aneurysms risk rupture, which can cause massive hemorrhage and death. Surgical treatment involves replacing the diseased aortic segment with a synthetic graft to prevent rupture.
Acute Coronary Syndrome (ACS) refers to a range of conditions caused by reduced blood flow in the coronary arteries. It includes Unstable Angina (UA), Non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). ACS is diagnosed based on electrocardiogram (ECG) findings and cardiac enzyme levels. STEMI shows ST elevations and enzyme elevations, while NSTEMI shows ST depressions/inversions and enzyme elevations without ST elevations. UA shows non-specific ECG changes and normal enzymes. Risk stratification systems like the TIMI score are used for NSTEMI/UA patients to guide management, which may
The document discusses the anatomy, causes, diagnosis, and management of aortic regurgitation (AR). It provides details on the location of the aortic valve, variants such as bicuspid aortic valve, and common causes of AR including rheumatic heart disease. Physical exam findings, echocardiography parameters, and indications for surgery to replace the aortic valve are summarized. Medical management including vasodilator therapy to reduce afterload is also reviewed.
Infective endocarditis is a microbial infection of the heart valves or endocardium. It is characterized by the formation of vegetations composed of platelets, fibrin, microorganisms, and inflammatory cells. It occurs more commonly in males and the elderly. Streptococci and Staphylococcus aureus are the most common causes. Diagnosis involves blood cultures, echocardiography, and applying the Duke criteria. Complications include embolisms, heart failure, and metastatic infections. Treatment involves prolonged antibiotic therapy targeted to the infecting organism. Surgery may be needed for complications or uncontrolled infection. Antibiotic prophylaxis is now restricted to highest risk patients undergoing highest risk procedures.
This document provides an overview of acute myocardial infarction (MI), also known as a heart attack. It discusses the definition, causes, risk factors, pathogenesis, classification, diagnosis and management of MI. The diagnosis involves taking a patient history, examining signs and symptoms, electrocardiography, serum analysis and echocardiography. Management is staged and involves pre-hospital, emergency department and post-discharge care, with a focus on reperfusing the blocked artery as quickly as possible, such as through percutaneous coronary intervention or thrombolytic therapy. The goal is to correctly identify the type of MI, treat the patient according to guidelines and manage any complications.
Myocarditis is an inflammatory disease of the heart muscle that can be caused by infectious or non-infectious triggers. It has a variable clinical presentation ranging from mild symptoms to life-threatening conditions. The diagnosis is challenging due to the heterogeneity of symptoms but can involve electrocardiogram, cardiac biomarkers, echocardiogram, cardiac MRI and endomyocardial biopsy. About half of acute cases resolve in 2-4 weeks but some develop heart failure or arrhythmias. Treatment focuses on supporting heart function and managing symptoms while the disease runs its course.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by irregular electrical activity in the atria. It increases in prevalence with age and can cause complications like heart failure, stroke, and systemic embolism.
2) Management of atrial fibrillation involves rate or rhythm control as well as long-term anticoagulation to prevent thromboembolism depending on stroke risk factors. The CHA2DS2-VASc score is used to assess this risk.
3) While antiarrhythmic drugs and cardioversion can restore normal sinus rhythm, rate control is preferred for many patients. Newer anticoagulants like dabigatran and rivar
This document defines and describes sick sinus syndrome, which is a dysfunction of the sinoatrial node that can cause abnormal heart rhythms like bradycardia, tachycardia, and alternating slow and fast rhythms. It may be caused by certain drugs, aging, or underlying heart conditions. Symptoms can include fatigue, dizziness, and fainting. Diagnosis involves an electrocardiogram showing arrhythmias. Treatment options include medications or a pacemaker if symptoms are severe. The document also briefly discusses different types of heart block.
The document discusses various pericardial diseases including acute pericarditis, constrictive pericarditis, pericardial effusion, and cardiac tamponade. It provides details on the anatomy and functions of the pericardium, pathophysiology, clinical features, diagnostic tests, and management of these conditions. Key points include that pericardial diseases can present with non-specific symptoms, clinical suspicion is important for diagnosis, and treatment depends on underlying etiology and presence of hemodynamic compromise. Differentiating constrictive pericarditis from restrictive cardiomyopathy is important as treatment approaches differ significantly.
Mitral stenosis is commonly caused by rheumatic heart disease which leads to inflammation and fusion of the mitral valve leaflets, reducing the mitral valve orifice area. Severe mitral stenosis, defined as a mitral valve area less than 1.0 cm2, can cause pulmonary hypertension, pulmonary edema, atrial fibrillation, and right heart failure as the heart tries to maintain sufficient cardiac output against the back pressure. Physical exam may reveal signs of pulmonary hypertension like a loud pulmonary component to S2, as well as a tapping apex, opening snap, and mid-diastolic rumble on cardiac auscultation. Echocardiography can determine the severity of mitral stenosis and assess
Mitral valve stenosis involves a blockage of blood flow through the mitral valve due to abnormalities of the valve leaflets. It is commonly caused by rheumatic fever or infective endocarditis. Risk factors include acute rheumatic fever or streptococcal infections. The narrowed valve orifice increases pressures in the left atrium and lungs. Symptoms include fatigue, palpitations, and dyspnea. Diagnosis involves echocardiogram, electrocardiogram, and chest x-ray. Treatment may include diuretics, anticoagulants, balloon valvuloplasty, or valve replacement surgery. Nursing care focuses on monitoring for fluid overload, promoting rest and oxygenation, and educ
Ventricular tachycardia is a fast heart rhythm originating from the ventricles with a rate over 100 bpm. It is classified based on duration (sustained vs non-sustained), morphology (monomorphic, polymorphic, sinusoidal), and symptoms. Causes include structural heart disease, electrolyte abnormalities, drugs, and prolonged QT interval. Diagnosis involves ECG criteria showing ventricular origin. Treatment depends on hemodynamic stability and may include antiarrhythmic drugs, implantable cardioverter-defibrillator, catheter ablation, or surgery. Recurrent ventricular tachycardia is managed long term with devices, drugs, and treatment of underlying causes.
This document discusses various types of cardiomyopathies:
- Dilated cardiomyopathy is caused by an unknown etiology and results in left ventricular dilatation and systolic dysfunction. It is a common cause of heart failure.
- Hypertrophic cardiomyopathy involves abnormal thickening of the heart muscle and can lead to outflow obstruction. It is a common cause of sudden death in young athletes.
- Restrictive cardiomyopathy causes stiff ventricles and impaired ventricular filling due to disorders like amyloidosis. It presents with symptoms of right and left heart failure.
- Other rare types discussed include arrhythmogenic right ventricular dysplasia and obliterative cardiomyopathy. Diagnosis involves imaging and endomyocardial biopsy
This document discusses aortic regurgitation (AR), which occurs when the aortic valve does not close properly, allowing blood to flow backward into the left ventricle. It can be caused by damage to the aortic valve leaflets or distortion of the aorta. Common causes include rheumatic heart disease, bicuspid aortic valves, hypertension, and Marfan syndrome. Over time, the left ventricle must work harder to compensate for the backflow of blood, which can lead to enlarged and weakened heart muscles. Symptoms may include palpitations, chest pain, and shortness of breath. Diagnosis involves listening for an early diastolic murmur and confirming the diagnosis with echocardiogram
CT scans use X-rays and computers to create detailed images of the inside of the body. CT scanning was independently developed in the 1970s by Godfrey Hounsfield and Allan Cormack. A CT scan works by using an X-ray device and detector that rotate around the body, detecting differences in radiation absorption as they pass through tissues. The data is then used to construct a series of cross-sectional images of the bones, muscles, fat, and organs inside the body. CT scans allow doctors to see internal structures in great detail and find diseases that may not be visible on regular X-rays.
Radioactive isotopes emit radiation through radioactive decay as their unstable nuclei break down. There are three main types of radiation emitted: alpha particles, beta particles, and gamma rays. Radioactive isotopes are used in scientific research, analytical applications like radioimmunoassays, and medical diagnostic procedures and therapies. Some key radioactive isotopes used include iodine-131 for thyroid imaging and cancer treatment, technetium-99m for thyroid scans, and strontium-89 or samarium-153 to treat bone metastases.
An isotope is one of two or more atoms having the same atomic number but different mass numbers.
Unstable isotopes are called Radioisotopes.
uses of radioisotopes are many which are discussed in this slide.
The history of echocardiography began in the 18th century with discoveries about echo reflection and uses of ultrasonic waves. The first application of ultrasound to examine the heart was in 1953 by Paul Edler and Hellmuth Hertz in Sweden. Edler identified structures like the mitral valve but echocardiography was advanced significantly by Harvey Feigenbaum in the 1960s. The development of real-time 2D echocardiography in the 1960s-1970s, including devices created by Bom, Griffith and Henry, further improved cardiac imaging abilities. Contrast echocardiography was also described in 1968.
SPECT involves injecting a radiopharmaceutical that emits gamma rays. Detectors rotate around the body to acquire data from multiple angles and produce 3D images. It allows visualization of organ function. A gamma camera detects gamma rays and includes a collimator, scintillation detector, photomultiplier tubes, and computer. SPECT is used for heart, brain, and tumor imaging. It has lower resolution than PET but is commonly used to detect coronary artery disease.
This document provides an overview of ophthalmic ultrasound including instrumentation, indications, principles, and techniques. It discusses B-scan, UBM, and A-scan ultrasound and how they are used to examine intraocular structures. Specific applications like detecting vitreous hemorrhage, retinal detachment, and intraocular tumors are covered. The document concludes with sample ultrasound images and multiple choice questions to test comprehension.
X-rays are a form of electromagnetic radiation that can penetrate materials and are used in medical imaging to see inside the body. Wilhelm Röntgen discovered X-rays in 1895 while experimenting with cathode ray tubes. He noticed a fluorescent screen glowing nearby even when covered, and realized the rays could pass through some materials but not others like bone. This allowed him to see the outline of bones in his hand, demonstrating their medical application. Today, X-rays are widely used in medicine, industry, and research due to their ability to penetrate soft tissue while being blocked by denser materials like bones and metals.
The document discusses x-rays, how they produce images, and their risks and benefits. It explains that x-rays are electromagnetic waves that can pass through tissues at different levels, exposing film to create internal images of the body. German physicist Wilhelm Röntgen discovered x-rays in 1895 while experimenting with vacuum tubes. Lead shields are used during x-rays to block radiation and prevent long-term exposure, as x-rays can detect health problems. The document identifies different bones and joints visible in sample x-ray images.
Computed tomography (CT scan) is a medical imaging procedure that uses computer-processed X-rays to produce tomographic images or 'slices' of specific areas of the body. These cross-sectional images are used for diagnostic and therapeutic purposes in various medical disciplines.
Anaesthetic Management of a Patient with Ischaemic Heart DiseaseZareer Tafadar
This document discusses the anaesthetic management of patients with ischemic heart disease undergoing non-cardiac surgery. It begins by defining ischemic heart disease and outlining its various manifestations including stable angina, unstable angina, and myocardial infarction. It then discusses preoperative evaluation and risk stratification of these patients, including medical history, physical exam, ECG, stress testing, and coronary angiography. Intraoperative management focuses on minimizing myocardial ischemia through beta-blockers, tight blood pressure control, and avoidance of tachycardia or hypotension.
This document discusses chronic coronary syndrome, also known as stable angina. It describes the pathophysiology as fixed atherosclerotic lesions causing an imbalance between myocardial oxygen supply and demand, leading to demand-induced ischemia. The key clinical features are chest pain or discomfort that is precipitated by exertion or stress and relieved by rest. Investigations include electrocardiograms, stress tests, echocardiography, myocardial perfusion scans, CT coronary angiography, and invasive coronary angiography to diagnose coronary artery disease and determine management.
Dr. Rikesh Tamrakar's document discusses two types of chest pain conditions: Prinzmetal angina and microvascular angina. Prinzmetal angina, also known as variant angina, is caused by transient spasms of the coronary arteries and presents with chest pain at rest, often between midnight and dawn. Microvascular angina presents with chest pain on exertion despite no blockages in the coronary arteries, and may be caused by endothelial dysfunction or small vessel disease. Both conditions can cause ischemia and be diagnosed through ECG changes and stress testing, and are generally treated with calcium channel blockers, nitrates, and lifestyle modifications.
This document provides an overview of acute coronary syndrome (ACS). It defines ACS and describes the epidemiology in Malaysia. The pathophysiology, classification, clinical presentation and investigations are discussed for unstable angina/NSTEMI and STEMI. Management is outlined for both conditions, including medications, fibrinolytic therapy, percutaneous coronary intervention and complications. A clinical case of STEMI is then presented demonstrating diagnosis and management. The document concludes with references to Malaysian clinical practice guidelines for ACS.
This document discusses the evaluation and management of patients presenting with chest pain. It outlines the various potential causes of chest pain, both cardiac and non-cardiac. When evaluating patients, clinicians must choose the optimal diagnostic test based on factors like the patient's history, symptoms, and ability to exercise. Functional tests like exercise ECG, stress echocardiography, and nuclear imaging can detect ischemia but have limitations. Anatomic tests like coronary CT angiography provide high sensitivity but expose patients to radiation. The document provides guidance on selecting the most appropriate initial diagnostic evaluation based on individual patient characteristics and test attributes.
- Chest pain is a common complaint accounting for 5% of emergency department visits. It can be caused by conditions affecting the heart, lungs, esophagus or other structures in the chest.
- The document outlines the epidemiology, characteristics, diagnostic workup and differential diagnosis for various potential causes of chest pain. These include acute coronary syndromes, pulmonary embolism, aortic dissection, pneumothorax and esophageal rupture.
- Key aspects of the history, physical exam and initial testing are discussed to help guide diagnosis and emergency management of life-threatening conditions causing chest pain.
CORONARY ARTERY DISEASE in medicine and nurses.pptxfmwansagalizye
This document discusses coronary artery disease (CAD) and angina pectoris. It defines CAD and describes the different types of angina. Risk factors for angina include atherosclerosis, smoking, diabetes, hypertension, high cholesterol, obesity, and sedentary lifestyle. Signs and symptoms include chest pain and shortness of breath. Diagnosis involves ECG, echocardiogram, angiogram, and stress testing. Nursing management focuses on reducing anxiety, preventing pain by balancing activity and rest, and teaching self-care and management of modifiable risk factors.
1) Acute myocardial infarction is irreversible necrosis of heart muscle caused by prolonged ischemia and can present as unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI).
2) UA/NSTEMI is diagnosed based on symptoms of chest pain or discomfort and elevated cardiac biomarkers showing myocardial necrosis.
3) Treatment involves reducing myocardial oxygen demands, improving supply, and risk stratification to determine need for aggressive versus conservative management. High risk patients may receive early invasive procedures while low risk patients can be managed medically.
Diagnosis and Management of acute coronary syndromes-latest guidelines (1).pptxAbhinay Reddy
This document provides guidelines for the diagnosis and management of acute coronary syndromes. It discusses how to evaluate patients presenting with chest pain or discomfort, including obtaining an ECG, measuring cardiac biomarkers, and appropriate use of imaging tests. Based on the ECG, biomarker levels, and clinical presentation, patients should be stratified as high, intermediate, or low risk and managed accordingly, which may include stress testing, invasive coronary angiography, or medical management and follow-up for stable patients. The guidelines emphasize the importance of a rapid initial evaluation and provide algorithms outlining recommended diagnostic pathways and timing of tests.
Clinical tips in cardiovascular emergencies copyAhmed Mohsen
This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves vital signs, ECG, CXR, labs including cardiac enzymes and D-dimer, and potentially CT imaging. Prompt diagnosis and treatment are essential given the high mortality associated with cardiovascular emergencies like out-of-hospital cardiac arrest.
Clinical tips in cardiovascular emergenciesAhmed Mohsen
This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves obtaining vital signs, performing a physical exam, 12-lead ECG, chest x-ray, and cardiac biomarker tests. Emergent conditions require urgent diagnostic testing and treatment to reduce mortality. Timely diagnosis and management is critical for improving outcomes in cardiovascular emergencies.
This document summarizes a presentation on anesthesia for noncardiac surgery in patients with ischemic heart disease. It discusses the overview and risk factors for ischemic heart disease. It also outlines recommendations for screening, evaluation, preoperative preparation and optimization of patients, including medication management, anesthesia induction techniques to minimize hemodynamic changes, and goals for intraoperative management. The objective is to reduce perioperative cardiovascular risks for these high-risk patients undergoing noncardiac surgery.
Pericardial diseases can present as pericarditis, pericardial effusion, tamponade, constrictive pericarditis, or effusive-constrictive pericarditis. The document discusses the anatomy and functions of the pericardium, pericarditis including its classification, presentations, investigations, and management. It also covers pericardial effusion and tamponade discussing their pathophysiology, clinical features, diagnostic workup including echocardiography, and management focusing on pericardiocentesis for tamponade cases. Recurrent pericarditis and its treatment strategies are also summarized.
1) The document discusses pericardial diseases, beginning with the anatomy and functions of the pericardium.
2) It then covers pericarditis, including classifications, presentations, and management. Empirical anti-inflammatory therapy including NSAIDs and colchicine is recommended for acute idiopathic pericarditis.
3) Recurrent pericarditis is identified as the most common complication, occurring in 15-30% of cases, and requiring prolonged anti-inflammatory treatment.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
Acute Coronary Syndrome (ACS) encompasses a spectrum of conditions caused by reduced blood flow in the coronary arteries, including unstable angina and myocardial infarction (MI). It is typically diagnosed through a patient's symptoms, electrocardiogram (ECG) findings, and cardiac biomarker levels. For ACS patients presenting within 12 hours of symptoms, guidelines recommend obtaining an ECG within 10 minutes and starting reperfusion therapies like thrombolysis within 30 minutes to minimize heart muscle damage. Diagnosis is based on criteria including typical chest pain, ECG changes, and elevated troponin levels. Outcomes are generally worse in elderly patients and those with atypical presentations and longer treatment delays.
Natural history and treatment of aortic stenosisKunal Mahajan
This document discusses the natural history and treatment of aortic stenosis. It defines the severity classifications based on aortic jet velocity, mean gradient, and valve area. Symptoms rarely occur with severe aortic stenosis if left ventricular function is normal. The document reviews progression rates in asymptomatic patients and risk factors for more rapid progression. Exercise testing may help identify higher risk asymptomatic patients but is not routinely recommended. Biomarkers like BNP levels can also predict outcomes. The prognosis is poor once patients become symptomatic, so surgical intervention is recommended for symptomatic severe aortic stenosis.
This document provides information on ischemic heart disease (IHD), also known as coronary artery disease (CAD). IHD is caused by atherosclerosis of the coronary arteries leading to inadequate blood flow and oxygen supply to the heart. It presents as stable angina, unstable angina, myocardial infarction, heart failure or arrhythmias. Risk factors include age, male sex, family history, smoking, hypertension, diabetes, and hypercholesterolemia. Diagnosis involves history, examination, electrocardiogram, stress testing and angiography. Treatment focuses on risk factor modification, anti-anginal medications like nitrates and beta-blockers, and revascularization if needed.
Similar to Chronic Stable Angina- Diagnosis & management (20)
1. The document describes how to properly hold and use a stethoscope to listen to heart sounds and murmurs. It discusses positioning the ear tips, chest piece, and avoiding touching the tubing to reduce extra noises.
2. Key aspects of cardiac murmurs are defined, including their timing within the cardiac cycle, causes, pitch, quality, location, and how they change with maneuvers. Common murmurs from conditions like aortic stenosis, mitral regurgitation, and ventricular septal defects are detailed.
3. Dynamic auscultation, or how murmurs change with respiration, body position, and other stresses, is an important part of diagnosis. Variations
Rosuvastatin is an effective treatment for cardiovascular disease (CVD) prevention and risk reduction. It provides significant reductions in LDL cholesterol levels with doses as low as 10 mg per day and can reduce LDL by over 50% at higher doses. Multiple studies have shown that rosuvastatin lowers rates of major adverse cardiac events compared to placebo in both primary and secondary prevention populations. Rosuvastatin has also demonstrated plaque regression in coronary arteries and slowed progression of atherosclerosis. It is considered a first-line agent by guidelines for lowering cholesterol and reducing CVD risk.
1) Heart failure treatment has evolved from an initial "Fantastic 4" drugs to a current "Fantastic 4 plus vericiguat and intravenous iron", providing more options to reduce hospitalizations and mortality.
2) A recent large trial showed that the new drug vericiguat reduced the composite of cardiovascular death and heart failure hospitalization when added to existing heart failure treatments.
3) New guidelines now recommend initiating quadruple heart failure therapy including an ARNI, beta-blocker, MRA, and SGLT2 inhibitor rapidly and titrating doses aggressively, as well as considering vericiguat for high-risk patients and administering intravenous iron for patients with iron deficiency.
CT coronary angiography (CTA) is indicated for evaluating stable chest pain when CAD is unknown or known, and after nonconclusive functional tests. It can assess plaque characteristics like vulnerability features. CTA guides treatment by identifying obstructive CAD needing revascularization versus non-obstructive CAD managed medically. Interpretation considers stenosis severity per CAD-RADS, and plaque features like low attenuation or positive remodeling indicate high risk. Motion artifacts must be distinguished from noncalcified plaque. CTA accurately rules out flow-limiting CAD and guides appropriate medical versus invasive management.
CTA is an accurate, noninvasive alternative to invasive coronary angiography (ICA) for initial CAD evaluation in patients with stable chest pain and intermediate pretest probability for obstructive CAD. Evidence from trials such as PROMISE and SCOT-HEART show that an initial CTA strategy results in similar cardiovascular outcomes as functional testing and is associated with a lower incidence of major adverse cardiovascular events compared to usual care. CTA has excellent sensitivity for identifying flow-limiting disease and high negative predictive value, making it well-suited for initially ruling out CAD. However, factors such as a history of prior stenting, obesity, arrhythmias, or breathing issues may favor ICA over CTA for initial evaluation.
1. Cardiovascular disease is a leading cause of mortality in India, with ischemic heart disease and stroke responsible for over 80% of CVD deaths. Recurrent ischemic events remain challenging to manage in patients with acute coronary syndromes.
2. Diagnostic tools for ACS include ECG, biomarkers like high-sensitivity cardiac troponin, and transthoracic echocardiogram. Management involves oxygen, nitrates, beta-blockers, and selecting an invasive reperfusion strategy like primary PCI or fibrinolysis if PCI cannot be done within 120 minutes.
3. Pharmacological treatments aim to lower lipids, control blood pressure, prevent clotting, and manage diabetes; vaccinations and ensuring adherence to lifestyle
This document discusses heart sounds and murmurs. It describes the characteristics of normal heart sounds S1 and S2, as well as abnormal sounds including S3, S4, opening snaps, and pericardial knocks. It discusses the causes, locations, and clinical recognition of these various sounds. Key points include that S1 is produced by mitral and tricuspid valve closure, S2 by aortic and pulmonary valve closure, S3 indicates rapid ventricular filling, and S4 occurs during atrial contraction. Abnormal sounds can indicate conditions like ventricular dysfunction, valvular incompetence, or constrictive pericarditis.
This document provides information on auscultating heart murmurs, including how to properly hold a stethoscope and define heart murmurs. It describes the timing, location, quality, and changes with maneuvers of common murmurs like aortic stenosis, mitral regurgitation, ventricular septal defect, and innocent murmurs. Dynamic auscultation is emphasized as murmurs may vary with respiration, body position, exercise, and other factors. The physiology of murmur production and distinguishing characteristics of various murmurs, clicks, and gallops are thoroughly outlined.
This document discusses rheumatic fever, including its etiology as a delayed complication of streptococcal sore throat, epidemiology showing higher rates in developing countries, pathogenesis involving autoimmune cross-reactivity, and clinical manifestations most commonly involving the heart valves. It provides details on the evolution of the Jones criteria for diagnosis and highlights carditis as the most frequent major manifestation, usually affecting the mitral valve and presenting as mitral regurgitation.
The document discusses evaluation of myocardial and coronary blood flow and its role in coronary intervention. It covers fundamental concepts of coronary physiology used in clinical practice today. Physiologic lesion assessment using indices like fractional flow reserve (FFR) and coronary flow reserve (CFR) have become routine before percutaneous coronary intervention (PCI) to determine hemodynamic significance, as angiography alone cannot accurately reflect ischemia potential. Several studies demonstrated using FFR to guide PCI decision-making resulted in fewer stents, less contrast, lower costs and better long-term outcomes than angiography-guided PCI. While FFR remains the gold standard, indices like instantaneous wave-free ratio (IFR) may provide more accurate assessment, especially in complex
Mechanical circulatory support devices such as left ventricular assist devices (LVADs) are increasingly being used as an alternative to cardiac transplantation for patients with advanced heart failure. LVADs are mechanical pumps that are implanted to support the left ventricle and improve cardiac output. They can be used as a bridge to transplantation, destination therapy for those ineligible for transplant, or potentially as a bridge to recovery in some cases. Common LVAD devices are continuous flow pumps that are more pulsatile than earlier generation pulsatile pumps. LVADs have been shown to improve symptoms, quality of life and survival for advanced heart failure patients.
This document provides an overview of pacemaker basics and timing cycles. It discusses the components of a pacemaker circuit including the implantable pulse generator containing a battery and circuitry. It describes pacemaker leads which deliver electrical impulses from the pulse generator to the heart. The document outlines characteristics of pacemaker leads including fixation mechanisms, insulation materials, and polarity. It also discusses concepts such as stimulation threshold, polarization, impedance, and how these factors interact based on Ohm's law relationships.
This document provides information on performing and interpreting cardiac auscultation. It describes:
1. How to properly hold a stethoscope and the parts of the stethoscope.
2. The definition of a heart murmur as an auditory vibration caused by increased turbulence in blood flow.
3. Guidelines for describing a murmur, including timing in the cardiac cycle, location, intensity, pitch, quality, and how it changes with maneuvers.
4. Characteristics of common murmurs from conditions like aortic stenosis, mitral regurgitation, ventricular septal defect, and more. It provides details on identifying murmurs and distinguishing between similar murmurs.
Vitamin D is an important prohormone for optimal intestinal calcium absorption for mineralization of bone. Because the vitamin D receptor is present in multiple tissues, there has been interest in evaluating other potential functions of vitamin D, particularly, in cardiovascular diseases (CVD). Cross-sectional studies have reported that vitamin D deficiency is associated with increased risk of CVD, including hypertension, heart failure, and ischemic heart disease. Initial prospective studies have also demonstrated that vitamin D deficiency increases the risk of developing incident hypertension or sudden cardiac death in individuals with preexisting CVD. Very few prospective clinical studies have been conducted to examine the effect of vitamin D supplementation on cardiovascular outcomes. The mechanism for how vitamin D may improve CVD outcomes remains obscure; however, potential hypotheses include the downregulation of the renin-angiotensin-aldosterone system, direct effects on the heart, and vasculature or improvement of glycemic control. This review will examine the epidemiologic and clinical evidence for vitamin D deficiency as a cardiovascular risk factor and explore potential mechanisms for the cardioprotective effect of vitamin D.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
Hypertension is a common medical and social problem leading to cardiovascular diseases worldwide. Antihypertensive drugs are clinically applied to decrease the morbidity and mortality induced by hypertension itself and its complications. The 2014 hypertension guideline of the Eighth Joint National Committee (JNC8) for hypertension therapy in the United States has made several significant changes with respect to the clinical management of hypertension and the initiative medications, as compared with the previous guidelines. In addition to the instructions that pharmacologic treatment should be initiated when blood pressure (BP) is 150/90 mmHg or higher in adults over 60 years, 140/90 mmHg in adults younger than 60 years, or 140/90 mmHg or higher (regardless of age) in patients with hypertension and diabetes, a thiazide-type diuretic, calcium (Ca2+) channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) should be considered to start an initial antihypertensive medication in non-black population. In black population with or without diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Thus, CCB has become one of the most important initial agents for antihypertensive monotherapy. Furthermore, since CCBs have been proved not to increase the risk of coronary events and stroke,CCBs appear to be a favorable choice for monotherapy as well as for combination with other agent classes in the treatment of hypertension and may provide specific benefits beyond BP lowering.Nowadays, dihydropyridine (DHP) CCBs are one group of most frequently prescribed antihypertensive medications in China and other Eastern Asian countries.
Among patients with or at high risk of CVD, use of an FDC strategy for blood pressure, cholesterol, and platelet control vs usual care resulted in significantly improved medication adherence.Polypill therapy significantly improved adherence, SBP and LDL-cholesterol in high risk patients compared with usual care, especially among those who were under-treated at baseline.
A transesophageal echocardiogram (TEE) uses echocardiography to assess the structure and function of the heart. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves. When the transducer is placed at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves bounce or "echo" off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer displays the echoes as images of the heart walls and valves.
A traditional echocardiogram is done by putting the transducer on the surface of the chest. This is called a transthoracic echocardiogram. A transesophageal echocardiogram is done by inserting a probe with a transducer down the esophagus. This provides a clearer image of the heart because the sound waves do not have to pass through skin, muscle, or bone tissue. The TEE probe is much closer to the heart since the esophagus and heart are right next to each other.
This document summarizes recent advances in the treatment of pulmonary arterial hypertension (PAH). It discusses new drugs such as macitentan and riociguat that have been shown to improve outcomes in clinical trials. It also describes an experimental treatment called pulmonary artery denervation that aims to reduce pulmonary artery pressure by ablating nerve endings around the pulmonary arteries. The document reviews the clinical evidence from trials of these new treatments and identifies limitations and areas needing further study to improve outcomes for patients with PAH.
This document provides an overview of pulmonary hypertension (PH), including:
- Definitions and classifications of PH
- Genetics and pathophysiology involving genes like BMPR2
- Causes like pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease
- Presentation with symptoms linked to right ventricular dysfunction
- Diagnostic workup including right heart catheterization as the gold standard
- Treatment options for different PH types including medications, surgery, transplantation.
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3. Chest Pain
• One of the most common complaints of patients
being seen in the Emergency Department.
• 5 million patients/year seen with this symptom.
• Need to distinguish patients with life threatening
illness from those with less serious illness.
• Missed MI is most frequent malpractice issue in ED
medicine.
4. Patients with chest pain
• 15% will have myocardial infarction
• 30-35% will have (angina )
• 45-50% will have non-cardiac pain
6. Definition of Angina
A pain or discomfort in the chest or adjacent areas
caused by insufficient blood flow to the heart
muscle.
7. Types
• Angina is consisted of three types:
Stable - Due to obstruction of coronaries by
atheroma.
Unstable- Due to spasm and partial obstruction of
coronaries.
Variant (Prinzmetal's Angina) - Due to Spasm of
coronaries.
10. ANGINA
• Chronic Stable Angina is characterized as a deep, poorly
localized chest or arm discomfort that is reproducibly
associated with physical exertion or emotional stress and is
relieved promptly (i.e., <5 min) with rest and/or the use of
sublingual nitroglycerin (NTG).
• Patients with Unstable Angina may have discomfort that
has all of the qualities of typical angina except that the
episodes are more severe and prolonged, may occur at rest,
or may be precipitated by less exertion than previously.
11. History: chest discomfort
• Quality - "squeezing," "griplike," "pressurelike," "suffocating" and
"heavy”; or a "discomfort" but not "pain." Angina is almost never sharp or
stabbing, and usually does not change with position or respiration.
• Duration - anginal episode is typically minutes in duration. Fleeting
discomfort or a dull ache lasting for hours is rarely angina
• Location - usually substernal, but radiation to the neck, jaw,
epigastrium, or arms is not uncommon. Pain above the mandible, below
the epigastrium, or localized to a small area over the left lateral chest
wall is rarely anginal.
• Provocation - angina is generally precipitated by exertion or emotional
stress and commonly relieved by rest. Sublingual nitroglycerin also
relieves angina, usually within 30 seconds to several minutes.
12.
13. • Some patients may have no chest discomfort
but present solely with jaw, neck, ear, arm, or
epigastric discomfort. If these symptoms
have a clear relationship to exertion or stress
or are relieved promptly with NTG, they
should be considered equivalent to angina.
14. ANGINAL VARIANT
• Indigestion or heartburn; nausea and/or vomiting
associated with chest discomfort
• Persistent shortness of breath
• Weakness, dizziness, lightheadedness, loss of
consciousness
• Nausea and vomiting, diaphoresis, and unexplained
fatigue
18. Evaluation and Diagnosis
• In patients presenting with chest pain
– detailed symptom history
– focused physical examination
– directed risk-factor assessment
• Estimate the probability of significant CAD
(i.e., low, intermediate, high)
19. History: Risk Factors for CAD
Increases the likelihood that CAD will be present
– Cigarette smoking
– Hyperlipidemia
– Diabetes
– Hypertension
– Family history of premature CAD
– Past history of CVA or PVD
20. Estimate the probability of significant CAD
Bayesian Analysis - "Is it the heart?"
• Low probability of CAD (5%) - the positive predictive
value of an abnormal test result is only 21%.
• Intermediate probability of CAD (50%), a positive test
result increases the likelihood of disease to 83% and a
negative test result decreases the likelihood to 36%.
• High probability of CAD (90%) - a positive test result
raises the probability of disease to 98% and a negative
test result lowers probability to 83%.
21. Probability Estimate
the Diamond and Forrester approach
The simple clinical observations of pain type,
age, and gender were powerful predictors of
the likelihood of CAD
– a 64-year-old man with typical angina has a %
likelihood of having significant CAD
– a 32-year-old woman with nonanginal chest pain
has a % chance of CAD
N Engl J Med 1979;300:1350-8
94
1
22. Probability Estimate
the Duke and Stanford models
• Age, gender and pain type were the most powerful
predictors
• other predictors
– Smoking (defined as a history of smoking half a pack or more of
cigarettes per day within five years of the study or at least 25 pack-
years)
– Q wave or ST-T-wave changes
– Hyperlipidemia (defined as a cholesterol level >250 mg/dL)
– Diabetes (glucose >140). Of these risk factors, diabetes had the
greatest influence on increasing risk.
Am J Med 1983;75:771-80 ; Am J Med 1990;89:7-14
Ann Intern Med 1993;118:81-90
27. Risk stratification: Chest X-Ray
• Often normal in patient with stable angina pectoris
• Usefulness as a routine test is not well established
• Findings associated with poorer long-term
prognosis
– Cardiomegaly
– LV aneurysm
– Pulmonary venous congestion
– Left atrial enlargement
– Calcium in the coronary arteries
28. 12 Lead Resting ECG
• Should be recorded in all patients with
symptoms suggestive of angina pectoris
• Normal in ≥ 50% of patients
• A normal ECG does not exclude severe
CAD; however, it does imply normal LV
function with favorable prognosis
31. Comparison of Stress Tests
• Meta-analysis on 44 articles (published between 1990 and 1997)
Sensitivity Specificity
ECG 52% 71%
Echocardiography 85% 77%
Scintigraphy 87% 64%
JAMA 1998;280:913-20
32. Comparative Advantages of
Stress Echocardiography and Stress Radionuclide
Perfusion Imaging in Diagnosis of CAD
• Advantages of Stress Echocardiography
1. Higher specificity
2. Versatility - more extensive evaluation of cardiac anatomy and function
3. Greater convenience / efficacy / availability
4. Lower cost
• Advantages of Stress Perfusion Imaging
1. Higher technical success rate
2. Higher sensitivity - especially for single vessel coronary disease involving the left
circumflex
3. Better accuracy in evaluating possible ischemia when multiple resting LV wall motion
abnormalities are present
4. More extensive published data base - especially in evaluation of prognosis
33. “ Whenever possible, treadmill or bicycle
exercise should be used as the most
appropriate form of stress because it
provides the most information concerning
patient symptoms, cardiovascular function
and hemodynamic response during usual
forms of activity ”
34. Stress Perfusion Studies for Risk Stratification
Normal poststress thallium scan
• Highly predictive of a benign prognosis even in patients with known CAD
• A rate of cardiac death and MI of 0.9% per year, nearly as low as that of
the general population
• In a recent prospective study of 5,183 consecutive patients, mean follow-
up 642 ± 226 days, normal scans were at associated with low risk
(<0.5% per year) for cardiac death and MI
• The single exception would appear to be patients with high-risk treadmill
scores and normal images
Circulation 1998;97:533-43
35. Stress Perfusion Studies for Risk Stratification
Stress Imaging Studies
Recognition of high-risk patients
• The number, size, and location of perfusion abnormalities
– the magnitude of the perfusion abnormality was the single
most prognostic indicator
• The amount of lung uptake of 201
Tl on poststress images
• The presence or absence of poststress ischemic LV dilation
38. Assessment of Global LV Function
• Most patients with angina need an echocardiogram
• In patients with prior MI
– LVF may be important in choosing appropriate medical or surgical
therapy and making recommendations about activity level,
rehabilitation and work status
• In patients with heart failure
– may be helpful in establishing pathophysiologic mechanisms and
guiding therapy. For example: systolic vs. diastolic dysfunction, mitral
or aortic valve disease, and pulmonary artery pressure
• A rest ejection fraction of <35% is associated with an annual mortality
rate >3% per year.
39. Risk Stratification
long-term survival with CAD
• The patient's risk is usually a function of 4 types of
patient characteristic:
– LV functioning - ejection fraction
– Anatomic extent and severity of atherosclerotic
involvement of the coronary tree
– Evidence of a recent coronary plaque rupture - indicator
of short-term risk for cardiac death or nonfatal MI
– General health and noncoronary comorbidity
40. Noninvasive Risk Stratification
High-Risk (>3% annual mortality rate)
1. Severe resting LV dysfunction (LVEF < 35%)
2. High-risk treadmill score (score ≤ -11)
3. Severe exercise LV dysfunction (LVEF < 35%)
4. Stress-induced large perfusion defect
(particularly if anterior)
5. Stress-induced multiple perfusion defects of
moderate size
6. Large, fixed perfusion defect with LV dilation or
increased lung uptake (thallium-201)
7. Stress-induced moderate perfusion defect with
LV dilation or increased lung uptake (thallium-
201)
8. Echocardiographic wall motion abnormality
(involving > 2 segments) developing at low
dose of dobutamine (≤ 10 mg/kg/min) or at low
heart rate (< 120 beats/min)
9. Stress echocardiographic evidence of
extensive ischemia
Intermediate-Risk (< 3% annual mortality
rate)
1. Mild-moderate resting LV dysfunction (LVEF -
35% to 49%)
2. Intermediate-risk treadmill score (-11≤ score
≤5)
3. Stress-induced moderate perfusion defect
without LV dilatation or increased lung uptake
(thallium-201)
4. Limited stress echocardiographic ischemia with
a wall motion abnormality only at higher doses
of dobutamine involving ≤ two segments
Low-Risk (< 1% annual mortality rate)
1. Lowest treadmill score (score ≤ 5).
2. Normal or small myocardial perfusion defect at
rest or with stress
3. Normal stress echocardiographic wall motion
or no change of limited resting wall motion
abnormality during stress .
41. Cost-effective Use of Noninvasive Tests
• When appropriately used, noninvasive tests are less costly
than coronary angiography and have an acceptable
predictive value for adverse events This is most true when
the pretest probability of severe CAD is low
• When the pretest probability of severe CAD is high, direct
referral for coronary angiography without noninvasive testing
has been shown to be most cost-effective as the total
number of tests is reduced
Circulation 1995;91:54-65
44. Direct Referral For
Diagnostic Coronary Angiography
• When Noninvasive Testing Is Contraindicated Or Unlikely To
Be Adequate Due To Illness, Disability Or Physical
Characteristics. For Example:
– coexisting chronic obstructive pulmonary disease
– noninvasive testing is abnormal but not clearly diagnostic
– patient's occupation or activity could constitute a risk to themselves
or others
– a high clinical probability of severe CAD
– diabetics with paucity of symptoms of myocardial ischemia due to
autonomic and sensory neuropathy
45. Risk Stratification With Coronary Angiography
• The extent and severity of coronary disease and LV dysfunction are the
most powerful clinical predictors of long-term outcome
– proximal coronary stenoses
– severe left main coronary artery stenosis
• CASS registry of medically treated patients, the 12-year survival rate
Coronary arteries Ejection fraction
normal coronary arteries 91% 50% to 100% 73%
one-vessel disease 74% 35% to 49% 54%
two-vessel disease 59% <35% 21%
three-vessel disease 40%
Circulation 1994;90:2645-57
47. Chronic Stable Angina
Treatment Objectives
• To reduce the risk of mortality and morbid
events
• Reduce symptoms - anginal chest pain or
exertional dyspnea; palpitations or syncope;
fatigue, edema or orthopnea
48. Initial Treatment
• A = Aspirin and Antianginal therapy
• B = Beta-blocker and Blood pressure
• C = Cigarette smoking and Cholesterol
• D = Diet and Diabetes
• E = Education and Exercise
49.
50. Beta-Blockers in Clinical Use
Drugs Selectivity Partial Usual Dose
Agonist for Angina
Propranolol None No 20-80 mg bid
Metoprolole β1 No 50-200 mg bid
Atenolol β1 No 50-200 mg /day
Nadolol None No 40-80 mg / day
Timolol None No 10 mg bid
Acebutolol β1 Yes 200-600 mg bid
Betaxolol β1 No 10-20 mg / day
Bisoprolol β1 No 10 mg / day
Esmolol (iv) β1 No 50-300 ug/kg/min
Labetalol None Yes 200-600 mg bid
Pindolol None Yes 2.5-7.5 mg tid
51. Calcium Antagonists in Clinical Use
Drugs Usual Dose Duration Side Effects
of Action
Dihydropyridines
Nifedipine Immediate release: Short Hypotension, dizziness,
30-90 mg daily orally flushing, nausea,
constipation, edema
Slow release:
30-180 mg orally
Amlodipine 5-10 mg qd Long Headache, edema
Felodipine 5-20 mg qd Long Headache, edema
Isradipine 2.5-10 mg bid Medium Headache, fatigue
Nicardipine 20-40 mg tid Short Headache, dizziness,
flushing, edema
Nisoldipine 20-40 mg qd Short Similar to Nifedipine
Nitrendipine 20 mg qd or bid Medium Similar to Nifedipine
Miscellaneous
Diltiazem Immediate release: Short Hypotension, dizziness,
30-80 mg qid flushing, bradycardia, edema
Slow release: Long
120-320 mg qd
Verapamil Immediate release: Short Hypotension, myocardial
80-160 mg tid depression, heart failure,
edema, bradycardia
Slow release: Long
120-480 mg qd
52. • Elimination of anginal chest pain
• Return to normal activities
• Functional capacity of CCS class I angina
• Good patient compliance - minimal side effects of
therapy, cost-effective
• Goal must be modified in light of the clinical
characteristics and preferences of each patient
Chronic Stable Angina
Definition of Successful Therapy
61. Patient Education
• Patient education is often overlooked, counseling about
physical activity and diet occurred during only 19% and 23%,
respectively, of general medical visits
• Effective education is critical
– enlist patients' full and meaningful participation
– allay patient concerns and anxieties
– improve patient satisfaction and compliance
MMWR Morb Mortal Wkly Rep 1998;47:91-5
62. Take Home Message:
Patient education,knowledge,awareness and rationality on the part
of the physician are essential for management of chronic stable
angina.
Risk stratification is essential with either non invasive stress
testing or imaging studies to formulate management plan.
OMT forms a cornerstone of therapy.
OMT refractory stable angina warrants evaluation by invasive
angiography and formulation of revascularization plans.
Revascularization procedures have their own set of pros and cons.
Pragmatic selection of procedure is the key to succsfull treatment