Sudarat Satitthummanid, MD. CARDIOVASCULAR DISEASES CARDIOVASCULAR DISEASES Endocardium : Aortic disease : Valvular heart disease Aortic aneurysm Infective endocarditis Aortic dissection MdiMyocardium : ChdiCoronary heart disease Ischemic heart disease Congenital heart disease Myocarditis Arrhythmias Cardiomyopathy Hypertension Pericardial disease Peripheral arterial disease Periiditicarditis CCtidtarotid artery st enosi s Pericardial effusion Renal artery stenosis Extremityyy artery stenosis Miscellaneous Pulmonary artery embolism Deep vein thrombosis AIMS OF INVESTIGATIONS FOR DIAGNOSIS His tory + P. E. + ItitiInvestigations • FOR ASSESSMENT OF • DISEASE SEVERITY •DISEAS E PROG NOS IS CARDIAC INVESTIGATIONS NON-INVASIVE - Blood pressure measurement - Oxygen saturation measurement INVASIVE - Electrocardiogram (ECG) - Coronary angiography - Chest X-ray (CXR) - Left sided cardiac catheterization - Laboratoryyg testing - Right sided cardiac catheterization - 2D-3D Echocardiography - Pulmonary artery, carotid artery, renal - Transesophageal echocardiography artery, extremity artery angiography (TEE) - Endomyocardial biopsy - Exercise stress test (EST) or Exercise - Electrophysiologic (EP) study treadmill test (ETT) - Exercise stress- Echocardiographic study - Dobutamine stress echocardiographic study - Holter monitoring - Tilt table test - CtidtDCarotid artery Dopp ler s tdtudy - Ankle-brachial index (ABI) study - CT-angiography : coronary, pulmonary, aorta, renal artery, peripheral artery - Cardiac MRI: rest CMR or stress CMR - Stress cardiac nuclear study Exercise-Stress Echocardiographic Study Dobutamine-Stress Echocardiographic Study Ventriculogram LV-gram Pulmonary Embolism Intracardiac Electrogram SCOPE OF ‘MANAGEMENT’ Diagnosis Prognosis and course of disease assessment TtTreatment Prev en ti on an d ri sk f actor s m odifi cati on Primary prevention Secondary prevention LINE OF TREATMENT • Medications • Invasive procedures • Surgery • Rehabilitation MEDICATIONS CARDIAC DRUGS NON-CARDIAC • Adrenergic agonists DRUGS • Antiarrhythmic agents • Antithrombotic agents •Antippglatelet agents • NhlidNephrologic drugs • Antianginal agents • Fibrinolytic agents • Neurologic drugs • ACEI • Gastroenterologic drugs •ARB • Pulmonary drugs • Beta blockers • Endocrinologic drugs • Calcium channel blockers • Diuretics • Anti-diabetic agents • Lipid lowering agents INVASIVE PROCEDURES DIAGNOSTIC TREATMENT PROCEDURES PROCEDURES • Coronary angiography (CAG) •PCI or PTCA • Cardiac ventriculography • PTA : of renal , carotid , • Pulmonary angiography peripheral arteries • Angiographic of the aorta and • PTMC/ PBMV/PBPV peripheral arteries •RFCA • Left and right cardiac • Pacemaker, CRT, ICD catheterization implantation • Electrophysiologic study (EPS) • Endomyocardial biopsy คํายอ PCI : Percutaneous Coronary Intervention PTCA : Percutaneous Transluminal Coronary Angioplasty PTA : Percutaneous Transluminal Anggpioplast y(y (of renal , carotid, peripheral arteries) PTMC/ PBMV/PBPV : Percutaneous Transluminal Mitral CiCommissuro t/Pttomy/ Percutaneous B BllMitlalloon Mitral Valvuloplasty/ Percutaneous Balloon Pulmonic Valv ul opl astyasty RFCA: Radio Frequency Catheter Ablation Permanent pacemaker, CRT (Cardiac Resynchronization Therapy) , AICD (Automatic Implantable Cardioverter Defibrillator) implantation CRT-D (Cardiac Resynchronization Therapy – Defibrillator) implantation CARDIOVASCULAR DISEASES Endocardium : Aortic disease : valvular heart disease aortic aneurysm infective endocarditis aortic dissection MdiMyocardium : ChdiCoronary heart disease Ischemic heart disease Congenital heart disease myocarditis Arrhythmias cardiomyopathy Hypertension Pericardial disease Peripheral arterial disease periiditicarditis CCtidtarotid artery st enosi s pericardial effusion Renal artery stenosis Extremityyy artery stenosis Miscellaneous Pulmonary artery embolism Deep vein thrombosis Endocardium : valvular heart disease infective endocarditis • ECG Myocardium : •LAB Ischemic heart disease • CXR myocarditis • 2D-ECHO cardiomyopathy Pericardial disease • (CMRI) pericarditis pericardial effusion Aortic disease : •CXR aortic aneurysm •TEE • CTA aortic dissection •MRA • ECG •CXR • 2D-ECHO Coronary heart disease • EST • EST-ECHO •DOBUTAMIN-ECHO • CORONARY CTA •STRESS CMR •CAG • ECG •CXR Congenital heart disease • 2D-ECHO •CMR • CARDIAC CATH. • ECG •CXR Arrhythmias • 2D-ECHO • HOLTER MONITOR • EPS • CAG Peripheral arterial disease • Carotid artery stenosis •CAROTID DOPPLER • RENAL ARTERY DOPPLER Renal artery stenosis • ABI Extremity artery stenosis •CTA •MRA • Miscellaneous • ECG •CXR • Pulmonary artery embolism • 2D-ECHO • CTA • Deep vein thrombosis • VENOUS DOPPLER DISEASES MANAGEMENT Endocardium : MEDICATIONS Antibiotics valvular heart disease Diuretics infective endocarditis ACEI/ARB Myocardium : BB/CCB Nitrates Ischemic heart disease Digoxin myocarditis NSAIDs cardiomyopathy Surgery Valve repair, valvuloplasty Pericardial disease Pericardiectomy, pericarditis pericardiotomy, pericardial window pericardial effusion Special treatment CRT, CRT-D implantation EECP (Enhanced External CounterPulsation) DISEASES MANAGEMENT Aortic disease : • CtitttConservative treatment aortic aneurysm • Cardiac risk factors modification aortic dissection • Medications • Anti-hypertensive drugs • EVAR (EndoVAscular RiRepair, aort ic stent gra f)ft) • Surgery • AtithAneurysmectomy with graft, aortic repair, etc. • Rehabilitation DISEASES MANAGEMENT • Cardiac risk factors modification • Coronary heart disease/ • Medications coronary artery disease • Antiplatelets • Chronic CAD • Anticoagulant/antithrombotic • Acute coronary •Nitrates syndrome (ACS) • ACEI/ ARB • Ischemic • BB/CCB cardiomyopathy • Others •PTCA • Surgery • CABG (Coronary Artery Bypass Grafting) • EECP • Rehabilitation Chronic Coronaryyy Artery Disease Chronic stable angina • Medications • Antiplatelet • Nitrate • Statin • Beta blocker or Calcium channel blocker •Etc. • Non-invasive investigations: stress tests • Invasive investigation: CAG • Invasive treatment: PCI or CABG ACUTE CORONARY SYNDROME (ACS) STEMI NSTEMI / UA • Medications • Antiplatelets • MditiMedications • Thrombolytic therapy • Antiplatelets ± antithrombotic agent • Antithrombotic agent • Other CAD drugs • Other CAD drugs • Medications + Procedure • Medications + Procedure • Antiplatelets • Antiplatelets • Antithrombotic agent • Antithrombotic agent • Primary PCI or • Other CAD drugs rescue PCI or CABG •CAG ± PCI or CABG • Other CAD drugs DISEASES MANAGEMENT Congenital heart disease Medications Percutaneous PdProcedures ASD closure device VSD c losure dev ice PDA closure device, coil embolization Coil embolization Surgery Palliative surgery CtiCorrective surgery DISEASES MANAGEMENT Arrhythmias • Medications •BB Bradyarrhythmia • CCB Tachyarrhythmia • Anti-arrhythmic agents • EPS + RFCA • Procedures • Temporary pacemaker insertion • Permanent pacemaker implantation • AICD imp lan ta tion • CRT-D implantation DISEASES MANAGEMENT Peripheral arterial • CdiikfCardiac risk factors mo difiidification disease • Medications CtidtCarotid artery s tenos is • Antiplatelet • Anti-hypertensive drugs Renal artery stenosis • Cilostazol EtExtremit y art ery • PTA with or without stent (carotid, stenosis renal, peripheral arteries) • Surgery • Carotid bypass •Perippypheral arterial bypass • Peripheral arterial embolectomy Miscellaneous • Medications Pulmonary artery • Anticoagulant emblibolism • Thrombolytic drugs Deep vein thrombosis • Surgery • Pulmonary embolectomy • RhbilittiRehabilitation .