Cardiology 2

Front 1

Main predisposition factors for ischemic heart disease

Back 1

arterial hypertension, hyperlipidemia and atherosclerosis, diabetes, hypothyroidism, gout, obesity, stress, smoking, inactivity, family predisposition

Front 2

Classification of Ischemic heart disease

Back 2

stable angina, unstable angina, myocardial infarction (unstable angina, ST elevation myocardial infarction and non ST elevation myocardial infarction are classified as acute coronary syndrome), disorders of rhythm and conduction, ischemic cardiomyopathy, sudden death, asymptomatic.

Front 3

Specific characteristics of stable angina

Back 3

retrosternal, precordial or epigastrial pain, tightness or discomfort in the chest on LARGE AREA;duration – usually 5-15 minutes;provoking factors - physical exercise, emotions or stress, high blood pressure, tachycardia (tachyarrhythmia) or extreme bradycardia, hypoglycemia, cold weather and is usually relieved at rest and by nitroglycerin, or when the blood pressure, the hearts rate or the blood sugar are normalized

Front 4

Path of unstable angina

Back 4

ulceration and thrombosis of atherosclerotic plaque in the coronary wall or/and coronary spasm;

Front 5

Symptoms of unstable angina

Back 5

pain in the chest, which appears at rest and is not relieved (or only partially) by nitroglycerin with duration usually between 15 and 30 min. chest pain which appears for first time or with accelerated frequency (crescendo angina) is also considered as unstable angina

Front 6

Specific symptoms of Myocardial Infarction

Back 6

chest pain more than 30 minutes not relieved at rest or by nitroglycerin, vegetative symptoms as sweating, nausea, vomiting; anxiousness, fear possibly disorders of rhythm and conduction or acute left side heart failure – cardiac asthma, pulmonary edema, cardiac shock;

Front 7

Main symptoms of Ischemic cardiomyopathy

Back 7

left side or total heart failure;possibly disorders of rhythm and conduction and chest pain;

Front 8

Ordinary lab tests for ischemic

Back 8

high total cholesterol and LDL, triglycerides and VLDL, low HDL, possibly increased blood sugar and uric acid

Front 9

Specific lab tests for acute myocardial infarction

Back 9

increased troponin, CK-MB (creatine kinase with high MB fraction), relatively specific; ASAT (aspartate transaminase) LDH (lactate dehydrogenase); unspecific: WBC, sedimentation rate, CRP, blood sugar

Front 10

Diagnosis of stable angina

Back 10

no ECG changes at rest; the diagnosis is proven by veloergometry or other cardiac stress tests including scintigraphy; Holter ECG, can show signs of ischemia (negative T waves and/or ST depression); CT or coronary angiography are crucial for the diagnosis;

Front 11

Diagnosis of unstable angina

Back 11

ECG with persisting ischemic changes (negative T wave or/and ST depression), coronary angiography; echocardiography – hypokinesia of the ischemic zone. Veloergometry or other stress tests are contraindicated in such cases

Front 12

Diagnosis of Myocardial infarction

Back 12

ECG most important change is the elevation of the ST segment, which shows the lesions zones and can persists if an aneurism is formed; appearance of Q deeper than 2 mm shows necrosis, however it is not available in small infarctions and often persists after the acute stage as a sign of a scar (fibrosis); the negative T waves represent the ischemic area; echocardiography – akinesia of the scar zone

Front 13

Draw an ECG of MI

Back 13

Front 14

Complications of MI

Back 14

acute - disorders r and c. Lshf- pulm edema/cardiac shock Rupture papillary muscle/ chorda tendinea, causing acute lshf w/ loud systolic murmur due to mitral valve insufficiency.Rupture of the myocardial wall w/ hemopericardium followed by cardiac tamponade and cardiac shock

subacute or chronic:Cardiac aneurism maybe w/ thrombosis, which can cause v. Extrasystoles/fib, also lshf or thromboembolism in arterial circulation. Dressler’s syndrome is an autoimmune reaction following a mi, which appears usually 2 weeks to 2-3 months after the incident. main symptoms are fever and chest pain, caused by pericarditis and sometimes pleurisy. Pericardial friction rub or enlargement of the area of absolute dullness and decreased heart sounds are found during the physical examination.

Front 15

Etio arterial hypertension

Back 15

1°, renal, endocrine - Cushing disease, 1°hyperaldosteronism – Cohn disease, hyperthyroidism, hyperparathyroidism, acromegalia);cardiac-aortic valve insufficiency, coarctation of aorta, disorders of conduction w/ significant bradycardia;neurological - increased intracranial pressure due to intracranial bleeding, or tumors;nephropathia gravidarum – late toxicosis of the pregnancy caused by immune incompatibility between the mother and the fetus;obstructive sleep apnea syndrome

Front 16

Predisposition factors for arterial hypertension

Back 16

family predisposition, atherosclerosis, hyperlipidaemia (hereditary or symptomatic – diabetes, hypothyroidism), obesity, stress, sedentary lifestyle, age, smoking, increased intake of salt, hyperactivity of the sympathetic nervous system;

Front 17

Symptoms of arterial hypertension

Back 17

pain or tightness at the back of the head, easy tiredness, fatigue, vertigo, drowsiness, nausea; There are also asymptomatic cases of arterial hypertension;

Front 18

Grades of arterial hypertension

Back 18

Normal 90–119 60–79Prehypertension 120–139 80–89grade 1 140–159 90–99grade 2 160-179 100-119grade 3 over 179 over 119Isolated systolic hypertension: systolic pressure over 140 and diastolic under 90;

Front 19

Stages of arterial hypertension

Back 19

I – usually intermittent arterial hypertension with no effect on the targeted organs (heart, brain, eyes, kidneys); II – stable arterial hypertension, which had already affected the targeted organs – hypertrophy of the left ventricle, hypertonic retinal angiopathy with spasm of the arterioles and increased vascular reflexes, possible sclerotic changes; possible mild proteinuria and incipient nephrosclerosis, early symptoms of hypertonic encephalopathy; III – arterial hypertension, which have already caused severe damages to the targeted organs – myocardial or brain infarction, hemorrhage in the retina, nephrosclerosis with chronic renal failure;

Front 20

Definitions and symptoms of hypertonic crisis

Back 20

sudden elevation of bp (oft over 200/120 mmHg) which endangers seriously life health of patient;Symptoms: stable angina, cardiac asthma or even pulmonary edema; tachyarrhythmia, severe headache with nausea and vomiting, transitory impairment of brain circulation w/ disturbances in speech/reversible hemiparesis; epistaxis, hemorrhage inretina, rare cases acute renal failure;

Front 21

Most common PF of hypertonic crisis

Back 21

stress; extreme physical exercise; over dosage of drugs causing hypoglycemia, thyroid hormones or corticosteroids; effect of catecholamines, in patients with pheochromocytoma, or by sudden interruption of antihypertensive treatmen

Front 22

Lab and instrumental tests for diagnosis of arterial hypertension

Back 22

lab tests: chol, triglycerides, blood sugar, urine, creatinine, uric acid, electrolytes (K, Na, in some cases Ca and P); hormones in patients with supposed endocrine hypertension,instrumental tests - ECG – hypertrophy lv; echo - hypertrophy and poss enlargement of lv; abd ultrasound, CT, MRI or selective angiography of the renal arteries in patients w/renovascular and endocrine hypertension; ophtalmoscopy is gen required in all patients w/ arterial hypertension; in some patients is recommended 24 h. Holter-RR test to establish the dynamics of the blood pressure

Front 23

Most common etio for pericarditis

Back 23

infections (most often coxsackie virus); idiopathic – with unknown etiology; immune (in connective tissue diseases most common systemic lupus erythematosus and rheumatic fever, also Dressler’s syndrome; uremic – in patients with end stage chronic renal failure; hypothyroidism

Front 24

Main symptoms of dry pericarditis

Back 24

sharp pain in the chest (retrosternal or left precordial, fixed or propagating toward the back, epigastrium or shoulders) which is often accelerating in inhaling or changing the position of the body; but not by physical exercise; with duration of several hours and sometimes even few days

Front 25

Main symptoms of exudative pericarditis

Back 25

dull pain or heaviness in the precordial region; in pretamponade there are symptoms of total heart failure with shortness of breath, edema, tachycardia, even cardiac asthma; the tamponade causes cardiac shock and death of the patient; There are also asymptomatic cases of exudative pericarditis

Front 26

Main symptoms of constrictive pericarditis

Back 26

chronic right-side heart failure with easy tiredness, fatigue, hepatomegalia, swollen legs, in severe cases dropsy

Front 27

PE dry pericarditis

Back 27

pericardial friction rub, both in systole and diastole, which is not related to the breathing but is better heard during exhaling in the area of absolute dullness

Front 28

PE Exudative Pericarditis

Back 28

Enlarged areas abs dullness and almost covers rel dullness; often impossible to palpate apex beat, usually tachycardia, dull sounds; of hard to be heard; patients w/ large effusions low bp; severe cases of tamponade (usually when effusion is excessively large (over 700-1000 ml and rapidly cumulated, severely restricts diastolic filling of the vs) the patients could be in cardiac shock, or orthopnoeic, or bowing on elbows and knees; peripheral cyanosis, high neck veins, enlarged and painful liver, swollen legs; tachycardia w/ pulsus paradoxus (when decreases during inhale and also the systolic bp decreases w/ more than 10 mmHg during inhale) are typical symptoms for the large effusions and tamponade

Front 29

Lab and instrumental tests for diagnosis pericarditis

Back 29

lab- est. etio (microbio immuno, hormonal tests); ECG specific for exudative peri is low-voltage QRS complexes w/ ST elevation in precordial leads and negative T wave, simulating mi or aneurism; in exudative peri– heart w/ triangular shape on X-ray; echo - dry peri – thickening of pericardium;Exudative – fluid pericardial cavity can be measured approx; severe cases decreased end-diastole vol and increased pressure in pulmonary a, decreased ejection fraction; constrictive peri – decreased end-diastole volume but normal pressure in pulmonary a; pericardiocentesis - specific procedure used for diagnosis and treatment of exudative peri; the fluid could be used for microbiological, immunological and cytological tests

Front 30

Etio and PF Endocarditis

Back 30

bacterial infection (strep) affecting previously damaged valves as rheumatic or congenital valve disease, prolapse mitral valve/ valve prosthesis. Infection source- tonsillitis, sinusitis, inflamed bronchiectasis, pneumonia, abscess, tooth extraction, septic abortion etc. complication of iv of narcotics, intravenous catheters, heart operation, implanting of pacemaker or catheterization. Non-infective - rheumatism, lupus erythematosus

Front 31

Main symptoms of infective endocarditis

Back 31

fever (septic in acute endocarditis, lower, even subfebrile in patients with endocarditis lenta), fatigue, easy tiredness, shortness of breath, night sweating, lack of appetite, loss of weight, anemia, septic thromboembolism with infarctions and abscesses in the brain, kidneys (pain in the lumbar area and hematuria), spleen (pain in the left hypochondrium, sometimes perisplenal friction rub), lungs and other organs, hemorrhagic rush on the palms and the soles, sometimes in the conjunctiva;

Front 32

Specific changes PE of patient with endocarditis

Back 32

pale-brown skin, hemorrhagic spots on palms/soles, sometimes conjunctivas/retinas (Roth spots – pale area surrounded by hemorrhage), nodes of Osler (painful lesions on the distal phalanxes fingers), sometimes even necrotic changes due to embolism/clubbing; fever; heart – usually tachycardia/arrhythmia, new/ increased murmur characteristic depends on afflicted valve; usually low bp; enlargement spleen, often liver

Front 33

Specific lab and instrumental of endocarditis

Back 33

increased WBC with neutrophilia, increased sedimentation rate and CRP, decreased levels of HB, HTC and RBC (anemia); hemocultures – crucial for the diagnosis; echocardiography – vegetations on the afflicted valve, which is crucial for the diagnosis, usually insufficiency of the afflicted valve, new partial dehiscence of the prosthesis valve, often decreased ejection fraction; abdominal ultrasound – enlargement of the spleen and often of the liver

Front 34

Common complications of endocarditis

Back 34

Multiple infective infractions in different organs

Front 35

Common etio of myocarditis

Back 35

virus infection (coxsackievirus, parvovirus, grippe, rubella, etc). bacterial (Corynebacterium diphtheriae etc), protozoa (Toxoplasma, etc), parasites (Trichinella); non infective - rheumatic fever or autoimmune diseases as lupus erythematosus and systemic sclerosis;

Front 36

Specific symptoms of myocarditis

Back 36

left or total heart failure: (easy tiredness, fatigue, shortness of breath, sometimes swollen legs); palpitations or premature beats; possibly fever and chest pain;

Front 37

PE myocarditis/dilated cardiomyopathy

Back 37

tachycardia, extrasystoles or tachyarrhythmia, decreased heart sounds, often third sound and gallop rhythm; systolic murmur due to relative mitral (and possibly tricuspid) insufficiency; usually low blood pressure, other signs of left side or total heart failure;

Front 38

Specific lab and instrumental tests for myocarditis

Back 38

increased CRP, rbc sr, WBC; ckMB and troponine.Special microbio or immune test as AST, antib to est etiol; ECG tachycardia w/ v. extrasystoles, diffuse repolarization changes (neg T waves depression ST seg), of prolonged PQ interval. echo – enlargement cavities w/ diffuse hyperkinesia, relative mitral (poss tricuspid) insufficiency, impaired systolic diastolic function w/ decreased ejection fraction, radio: enlargement heart oft w/ lung congestion

Front 39

Common complications myocarditis

Back 39

Dilative cardiomyopathy

Front 40

Classification cardiomyopathy

Back 40

Dilative, restrictive, hypertrophic

Front 41

Etio dilative cardiomyopathy

Back 41

ischemic cardiomyopathy due to atherosclerosis of the coronary arteries; infections - cardiomyopathy as a complication of myocarditis; toxic agents - alcoholic cardiomyopathy due to alcohol abuse; drug abuse; cobalt intoxication; chemotherapy, etc; hyperthyroidism; idiopathic dilative cardiomyopathy;

Front 42

Symptoms dilative cardiomyopathy

Back 42

total heart failure (shortness of breath, easy tiredness, fatigue, edema); palpitations, tachyarrhythmia, premature beats; possible sudden death due to ventricular fibrillation;

Front 43

Most common etio and path of restrictive cardiomyopathy

Back 43

amyloidosis, hemochromatosis, sarcoidosis, autoimmune diseases (as sclerodermia and polyarteriitis nodosa); pathogenesis - rigidity of the myocardium, which restricts the diastolic loading of the ventricles, resulting reduced cardiac output and total heart failure.

Front 44

Specific tests restrictive cardiomyopathy

Back 44

cardiomyopathy - echocardiography - decreased end-diastolic size and volume of both ventricles, reduced ejection fraction, impaired kinetics of the myocardium;

Front 45

Etio and path hypertrophic cardiomyopathy

Back 45

(non-obstructive or obstructive - idiopathic hypertrophic subaortic stenosis) - idiopathic or genetic disease causing partial hypertrophy of the myocardium of the left ventricle. This thickening can obstruct the pumping out of blood from the left ventricle, causing significant peripheral hypoperfusion.

Front 46

Symptoms hypertrophic cardiomyopathy

Back 46

chest pain during physical exercise, rhythm disorders, signs of left side heart failure, light-headedness, vertigo or syncope during physical exercise or tachycardia typical for the obstructive form

Front 47

PE hypertrophic cardiomyopathy

Back 47

often tachycardia and disorders of the rhythm; in obstructive forms – systolic murmur best heard on Erb point in contrast with the aortic stenosis (II intercostal space next to the sternum); low blood pressure

Front 48

Instrumental tests hypertrophic cardiomyopathy

Back 48

ECG – often tachycardia and rhythm disorders, hypertrophy of the left ventricle including left bundle branch block, repolarization changes; echocardiography (crucial for the diagnosis) – symmetric or asymmetric hypertrophy of the left ventricle, measurement of the gradient