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The Cardiovascular System

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The Cardiovascular System THE CARDIOVASCULAR SYSTEM. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) HISTORY Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) PRESENTING COMPLAINTS. • Chest pain. • Fatigue. • Dyspnea. • Palpitations. • Presyncope/syncope. • Lower limb swelling. • Abdominal distension. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) History of chronic diseases. • Thyroid disease, connective tissue diseases, neoplastic diseases, TB. • RHD and HTN – valvular disease. • DM, dyslipidaemias and smoking – ACS. • Alcohol, drugs – arrhythmias, cardiomyopathies. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Family history. • ACS. • HTN. • Cardiomyopathies. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Chest pain. • ACS • Pericarditis. • Aortic dissection. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Myocardial ischaemia(angina) Typical patient • Middle-aged or elderly man or woman often with a family history of coronary heart disease and one or more of the major reversible risk factors (smoking, hypertension, hypercholesterolaemia) Major symptoms • Exertional chest pain and shortness of breath. Pain often described as 'heaviness' or 'tightness', and may radiate into arms, neck or jaw Major signs • None, although hypertension and signs of hyperlipidaemia (xanthelasmata, xanthomas) may be present • Peripheral vascular disease, evidenced by absent pulses or arterial bruits, is commonly associated with coronary heart disease Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) M.I • Diagnosis - Typical history is most important diagnostic tool - ECG: often normal; may show Q waves in patients with previous myocardial infarction - Stress test: exertional ST depression - Isotope perfusion scan: exertional perfusion defects - Coronary arteriogram: confirms coronary artery disease Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) M.I • Ischaemia of the heart results from an imbalance between myocardial oxygen supply and demand, producing pain called angina. • Angina is usually a symptom of atherosclerotic coronary artery disease, which impedes myocardial oxygen supply. • The patient describes retrosternal pain which may radiate into the arms, the throat or the jaw. It has a constricting character, is provoked by exertion and relieved rapidly by rest. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) M.I • Additional investigations • Blood sugar and lipids to rule out diabetes and dyslipidaemia • Comments • A careful history is the single most important means of diagnosing angina Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) MYOCARDIAL INFARCTION, UNSTABLE ANGINA • Life-threatening cardiac emergencies. • The pain is similar in location and character to angina but is usually more severe, more prolonged, and unrelieved by rest. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Myocardial infarction. Typical patient • Middle-aged (male) or elderly (either sex), often with a family history of coronary heart disease and one or more of the major reversible risk factors (smoking, hypertension, hypercholesterolaemia) • In many patients there is no preceding history of angina Major symptoms • Chest pain and shortness of breath. • Pain usually prolonged and often described as 'heaviness' or 'tightness', with radiation into arms, neck or jaw. Alternative descriptions include 'congestion' or 'burning', which may be confused with indigestion Major signs • Ischaemic myocardial damage, fourth heart sound, dyskinetic precordial impulse • Autonomic disturbance, tachycardia (anterior MI), bradycardia (inferior MI), sweating, vomiting, syncope Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Myocardial infarction. Diagnosis • Markers of injury: raised CKMB and troponins • ECG: may be normal or show ST depression or T-wave change (non-ST elevation myocardial infarction). ST elevation myocardial infarction denotes higher risk Additional investigations • Biochemistry: blood sugar and lipids to rule out diabetes and dyslipidaemia • Risk stratification: echocardiogram (LV function) and stress testing (reversible ischaemia) Comments • History and troponin testing most useful diagnostic tools Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Causes of angina. Impaired myocardial oxygen supply • Coronary artery disease – atherosclerosis – arteritis in connective tissue disorders – diabetes mellitus • Coronary artery spasm • Congenital coronary artery disease – arteriovenous fistula – anomalous origin from pulmonary artery • Severe anaemia Increased myocardial oxygen demand • Left ventricular hypertrophy – hypertension – aortic valve disease – hypertrophic cardiomyopathy • Tachyarrhythmias Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Pericarditis. • This also causes central chest pain, which is sharp in character and aggravated by deep inspiration, cough or postural changes. • It is usually idiopathic or caused by Coxsackie B infection. • Other causes are rare. • It may also occur as a complication of myocardial infarction. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Causes of acute pericarditis. • Idiopathic • Infective – viral (Coxsackie B, influenza, herpes simplex) – bacterial (Staphylococcus aureus, Mycobacterium tuberculosis) • Connective tissue disease – systemic lupus erythematosus – rheumatoid arthritis – polyarteritis nodosa • Uraemia • Malignancy (e.g. breast, lung, lymphoma, leukaemia) • Radiation therapy • Acute myocardial infarction • Post myocardial infarction/cardiotomy (Dressler's syndrome Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Aortic dissection. Typical patient • Middle-aged or elderly patient with a history of hypertension or arteriosclerotic disease • Occasionally younger patient with aortic root disease (e.g. Marfan's syndrome) Major symptoms • Chest pain Major signs • Often none • Sometimes regional arterial insufficiency (e.g. occlusions of coronary artery causing myocardial infarction, carotid or verterbral artery causing stroke, spinal artery causing hemi- or quadriplegia); subclavian artery occlusion may cause differential blood pressure in either arm; aortic regurgitation; cardiac tamponade; sudden death Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Aortic dissection. • Diagnosis • CXR: widened mediastinum, occasionally with left pleural effusion • Transoesophageal echocardiogram: confirms dissection • CT scan: confirms dissection • MRI scan: confirms dissection Comments • Having established the diagnosis, emergency surgery is usually necessary, particularly if the dissection involves the ascending thoracic aorta Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Dyspnea. • Dyspnea is an abnormal awareness of breathing occurring either at rest or at an unexpectedly low level of exertion. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Exertional dyspnea. • DIB occurring with exercise/activity. • Exercise causes a sharp increase in left atrial pressure and this contributes to the pathogenesis of dyspnoea by causing pulmonary congestion. • As left heart failure worsens, exercise tolerance deteriorates. • In advanced disease the patient is dyspnoeic at rest. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) NYHA, exertional Dyspnea. • NYHA 1 – has heart disease but asymptomatic. • NYHA 2 – Dyspnea on more than ordinary exertion. • NYHA 3 – Dyspnea on ordinary exertion. • NYHA 4 – Dyspnea at rest or has had valvular Sx. • Once grade 4, always grade 4. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Orthopnea. • In patients with heart failure lying flat causes a steep rise in left atrial pressure, resulting in pulmonary congestion and severe dyspnoea. • To obtain uninterrupted sleep extra pillows are required, and in advanced disease the patient may choose to sleep sitting in a chair Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) PND • Frank pulmonary oedema on lying flat wakes the patient from sleep with distressing dyspnoea and fear of imminent death. • The symptoms are corrected by standing upright, which allows gravitational pooling of blood to lower the left atrial pressure, the patient often feeling the need to obtain air at an open window. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Fatigue. • It is caused partly by deconditioning and muscular atrophy but also by inadequate oxygen delivery to exercising muscle, reflecting impaired cardiac output. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Causes of heart failure. Ventricular pathophysiology. Clinical examples. • Restricted filling • Mitral stenosis • Hypertrophic cardiomyopathy. • Pressure loading • HTN • COA • Aortic
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