Cardiovascular Diseases: Diagnosis and Treatment

Posted on Oct 17, 2024 in Medicine & Health

Dilated Cardiomyopathy

Diagnosis

Enlargement of ventricles
Left systolic dysfunction
Dyspnea
Pulmonary edema
Leg edema
Hepatomegaly
Ascites
Angina pectoris
Fatigue, dizziness
Thromboembolic complications

ECG Findings

Sinus tachycardia
ST changes
Left bundle branch block

Echocardiogram Findings

Increased chamber dimensions
Decreased left ventricular ejection fraction (LVEF)
Valvular abnormalities
Increased left ventricular end-diastolic pressure

Other Diagnostic Tests

Coronary angiography
Endomyocardial biopsy

X-ray Findings

Cardiomegaly
Pulmonary blood congestion
Interstitial pulmonary edema

Treatment

Heart Failure Treatment

Beta-blockers
Diuretics
ACE inhibitors/Angiotensin receptor blockers (ARBs)
Digitalis

Anticoagulation

Vitamin K antagonists

Biventricular Pacing Indications

Symptomatic heart failure (NYHA Class III/IV)
Left ventricular end-diastolic diameter >55mm
LVEF

Surgical Interventions

Valve correction/replacement
Coronary artery bypass grafting (CABG)
Pericardial disease treatment
Implantable defibrillator

Ultimate Ratio

Heart transplant

Hypertrophic Cardiomyopathy

Diagnosis

Diagnostic Criteria

Left ventricular wall thickness >15mm in one or more segments

Symptoms

Angina pectoris
Dyspnea
Palpitations
Arrhythmias
Syncope
Dizziness

Physical Exam

Systolic ejection murmur over Erb’s point

ECG Findings

Left ventricular hypertrophy
Pathological Q waves
Paroxysmal supraventricular tachycardia (PSVT)

Echocardiogram Findings

Increased LVEF
Left ventricular diastolic dysfunction
Increased left ventricular filling pressures
Papillary muscle abnormalities

Other Diagnostic Tests

Exercise test
Genetic testing for hypertrophic cardiomyopathy mutations
Cardiac MRI (for assessment of anatomy, thrombi, papillary muscles, myocardial fibrosis)

Treatment

General Management

Avoid strenuous physical activity

Left Ventricular Outflow Tract Obstruction

Beta-blockers
Non-dihydropyridine calcium channel blockers
Septal ablation

Atrial Tachyarrhythmias

Beta-blockers, calcium channel blockers
Elective DC cardioversion
Lifelong anticoagulation therapy

Surgical Options

Myotomy-myectomy
Papillary muscle resection
Mitral valve replacement

Pericarditis

Definition

Inflammation of the pericardium (the tissue surrounding the heart).

Etiology

Causes of pericarditis can include:

Infectious: Viral, bacterial, fungal, protozoal
Autoimmune: Rheumatic fever, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Dressler syndrome, hypersensitivity reactions
Inflammatory/Non-infectious: Sarcoidosis, amyloidosis
Concomitant: Myocardial infarction, myocarditis, aortic aneurysm
Metabolic: Uremia, myxedema
Trauma: Penetrating injury
Neoplasia: Lymphoma, leukemia, metastasis, post-chemotherapy

Diagnosis

Diagnostic Criteria

At least two of the following:

Pericardial chest pain
Pericardial friction rub on auscultation
ST elevation, PR depression on ECG
Pericardial effusion

X-ray Findings

Enlarged heart silhouette (with effusion)

Echocardiogram Findings

Pericardial effusion
Atrioventricular collapse
Decreased chamber size

ECG Findings

Sinus tachycardia
Low voltage QRS complexes
ST elevation
PR depression

Clinical Features and Treatment (No Effusion)

Clinical Features

Fever
Myalgia
Pericardial chest pain
Shoulder discomfort
Nausea

Treatment

Bacterial: Antibiotics
Tuberculosis: Anti-tuberculosis therapy
Rheumatic fever: Treat underlying disease
Autoimmune: Steroids
Viral: Nonsteroidal anti-inflammatory drugs (NSAIDs)
Uremic: Dialysis
Surgical: Pericardiostomy, pericardial window, pericardial resection

Clinical Features and Treatment (With Effusion)

Clinical Features

Dysphagia
Cough
Hoarseness
Hiccups
Abdominal fullness
Nausea
Jugular venous distention
Paradoxical pulse

Treatment

NSAIDs
Diuretics
Pericardiocentesis
Surgical: Pericardiostomy, pericardial window, pericardial resection

Myocarditis

Etiology

Similar to pericarditis, causes can include:

Infectious: Viral, bacterial, fungal, protozoal, parasitic
Non-infectious: Rheumatic arthritis, SLE, sarcoidosis, collagen vascular diseases, post-radiation therapy, eosinophilic myocarditis

Clinical Features

Symptoms of heart failure (dyspnea, palpitations, arrhythmias, syncope, leg edema)
Asymptomatic presentation is common
Acute (days to 3 months)
Chronic (>3 months)

Diagnosis

Laboratory Tests

Elevated cardiac troponins
Elevated creatine kinase
Leukocytosis
Elevated C-reactive protein (CRP)
Viral and bacterial serology

Echocardiogram

Chamber dimensions
Pericardial effusion
Intracavitary thrombi

ECG

ST changes
Rhythm/conduction abnormalities
Prolonged QT interval
Increased QRS duration

Other Diagnostic Tests

Scintigraphy (highly sensitive for myocarditis)
Endomyocardial biopsy

Treatment

Causative Treatment

Immunoglobulin therapy
Immunosuppressants
Antivirals
Antibiotics

Heart Failure Treatment

ACE inhibitors
Diuretics
Beta-blockers
Extracorporeal membrane oxygenation (ECMO) for severe left ventricular systolic dysfunction

AV Tachycardia

Types

Orthodromic AV Tachycardia

Anterograde conduction via AV node
Retrograde conduction via accessory pathway
ECG: Heart rate 200-300 bpm, narrow QRS complex (

Antidromic AV Tachycardia

Anterograde conduction via accessory pathway
Retrograde conduction via AV node
ECG: Heart rate 200-300 bpm, wide QRS complex (>120ms)

Treatment

Acute

Valsalva maneuver
Ajmaline (slow IV infusion under ECG monitoring, reserve propafenone)
Electrical cardioversion (for hemodynamically unstable patients)

Long-Term

Catheter ablation of accessory pathway (for recurring episodes)
Class Ia, Ic, III antiarrhythmic drugs

Wolff-Parkinson-White (WPW) Syndrome

WPW syndrome involves an extra electrical connection between the atria and ventricles, causing early ventricular contractions.

Clinical Features

Three groups of patients:

Asymptomatic, never experience increased heart rate
Symptomatic, sometimes experience increased heart rate (150-220 bpm)
Symptomatic, frequent episodes of increased heart rate

Symptoms:

Palpitations
Signs of shock

Diagnosis

ECG Findings

Short PR interval (
Delta wave before QRS complex
Wide QRS complex (>120ms)

Long-term ECG monitoring is useful for capturing prolonged episodes of increased heart rate.

Paroxysmal Ventricular Tachycardia (VT)

Clinical Features

Dyspnea
Dizziness
Syncope
Angina pectoris
Palpitations
Decreased blood pressure

Causes:

Heart disease (coronary heart disease, myocardial infarction)
Drug overdose (digitalis, antiarrhythmics)
Long QT syndrome (e.g., Torsades de Pointes)

Diagnosis (ECG)

Common Findings

Heart rate >100 bpm
Wide QRS complex (>120ms)
AV dissociation

Types

Nonsustained VT (>3 beats, but
Sustained VT (>30 seconds)
Monomorphic VT (fast and regular rhythm)
Polymorphic VT (fast and irregular rhythm)

Treatment

Acute

Oxygen
Antiarrhythmics (ajmaline if no heart failure, amiodarone if heart failure present)
Electrical cardioversion (for patients at risk of cardiogenic shock or pulmonary edema)
Magnesium sulfate IV (for Torsades de Pointes)

Underlying Disease

Treat underlying disease
Long-term antiarrhythmic therapy
Beta-blockers (post-myocardial infarction)
Implantable cardioverter-defibrillator (ICD)
Catheter ablation

Anticoagulation

Risk Assessment (CHA₂DS₂-VASc Score)

Used to assess stroke risk in atrial fibrillation:

Congestive heart failure: 1 point
Hypertension: 1 point
Age >75 years: 2 points
Diabetes mellitus: 1 point
Previous stroke/transient ischemic attack: 2 points

Higher scores indicate a higher risk of stroke.

Anticoagulation Management:

Warfarin 3 weeks before elective cardioversion (target INR 2.0-3.0)
Warfarin 4 weeks if atrial fibrillation >48 hours
Permanent anticoagulation for recurrent atrial fibrillation

Atrial Flutter

Treatment

Acute

Thromboembolism prevention: Heparin
Transesophageal echocardiogram (TEE) to exclude thrombi
Electrical cardioversion

Long-Term

Combination of beta-blockers, digitalis, or verapamil
Curative: Electrical cardioversion, pacemaker implantation

AV Block

Types

First-Degree AV Block

1:1 P wave to QRS complex conduction
PR interval >200ms

Second-Degree AV Block (Mobitz Type I)

Some P waves not followed by QRS complexes
Grouped QRS complexes
Progressively lengthening PR intervals until a QRS complex is dropped
Shortening R-R intervals
Cluster pattern

Second-Degree AV Block (Mobitz Type II)

Some P waves not followed by QRS complexes
Normal PR intervals
Sudden dropped QRS complexes
No cluster pattern

Third-Degree AV Block

No AV conduction
P waves and QRS complexes are independent
QRS complexes generated by ventricular or junctional escape rhythm
Severely decreased heart rate

Cardiac Pacing

Pacing Codes

The five-letter pacing code describes the pacemaker’s function:

Letter 1: Chamber paced (A=atrium, V=ventricle, D=dual)
Letter 2: Chamber sensed (A, V, D)
Letter 3: Response to sensing (I=inhibited, T=triggered, D=dual)
Letter 4: Rate modulation (R=rate modulation, 0=no rate modulation)
Letter 5: Multisite pacing (A, V, D)

Pacemaker Types and Indications

Single-Chamber Pacemakers

VVI: For decreased heart rate in atrial fibrillation
AAI: For sinus node dysfunction with decreased heart rate or sinus arrest

Dual-Chamber Pacemakers

DDD: For AV block with or without sinus node dysfunction
VDD: For AV block

Congestive Heart Failure (CHF)

Definition

A structural or functional cardiac disorder that impairs the ventricles’ ability to fill or eject blood adequately.

Etiology

Reduced Ejection Fraction (Systolic Failure)

Direct myocardial damage (ischemia, infarction, myocarditis, dilated cardiomyopathy)
Chronic pressure overload (valvular stenosis, pulmonary hypertension, systemic arterial hypertension)
Impaired left ventricular filling (mitral stenosis, constrictive pericarditis, restrictive cardiomyopathy, hypertrophic cardiomyopathy)
Disorders of rate and rhythm

Preserved Ejection Fraction (Diastolic Failure)

Pathological hypertrophy (cardiomyopathy, hypertension)
Restrictive cardiomyopathy
Myocardial fibrosis
Aging

Increased Ejection Fraction (High-Output Failure)

Metabolic disorders (thyrotoxicosis)
Nutritional disorders (beriberi)
Excessive blood flow

Classification

New York Heart Association (NYHA) Functional Classification

No limitation of physical activity
Slight limitation of physical activity
Marked limitation of physical activity
Symptoms at rest

American College of Cardiology (ACC)/American Heart Association (AHA) Stages

Stage A: High risk without structural heart disease
Stage B: Heart disease with asymptomatic left ventricular dysfunction
Stage C: Prior or current symptoms of heart failure
Stage D: Advanced heart failure with severe symptoms

Clinical Features

Course: Acute or chronic

Cardiac output: Low or high

Location: Left, right, or biventricular

Impaired function: Systolic or diastolic

Left Heart Failure Symptoms

Exertional dyspnea
Paroxysmal nocturnal dyspnea
Orthopnea
Acute pulmonary edema
Cough
Fatigue
Nocturia

Left Heart Failure Signs

Left ventricular enlargement
Gallop rhythm
Systolic murmur at the apex
Dry or moist rales
Peripheral cyanosis

Right Heart Failure Symptoms

Gastrointestinal symptoms
Renal symptoms
Hepatic pain
Dyspnea

Right Heart Failure Signs

Hepatojugular reflux
Hepatomegaly
Peripheral edema
Ascites

Diagnosis

Echocardiogram

Chamber size
Mural thickness
Contractility
Heart valve evaluation

X-ray

Heart shape and size
Pulmonary vasculature evaluation
Pleural effusion
Kerley B lines

Other Diagnostic Tests

Coronary angiography
ECG (for ischemia, dilated cardiomyopathy, AV block, left bundle branch block, pseudoinfarction, left ventricular hypertrophy)
Endomyocardial biopsy
Cardiac MRI
6-minute walk test (
Laboratory tests (complete blood count, serum electrolytes, serum creatinine, fasting blood glucose, troponin, brain natriuretic peptide (BNP))

Treatment

General Measures

Correct systemic factors
Lifestyle changes (fluid restriction, sodium restriction)
Treat underlying causes of heart failure
Adjust physical activity

Medications

Loop diuretics (furosemide)
ACE inhibitors (captopril) or ARBs (if ACE inhibitor intolerant)
Beta-blockers (metoprolol)
Aldosterone receptor antagonists (spironolactone)
Digoxin
Positive inotropic agents
Antithrombotic agents
Statins

Surgical Approaches

Coronary artery revascularization
Mitral valve repair/replacement
Aortic valve replacement
Left ventricular assist device (LVAD) (Stage D)
Heart transplant (Stage D)

Implantable Defibrillator

Cardiomyopathy
NYHA Class II/III
LVEF

Heart Transplant

Indications:

Severe heart failure
High risk of death despite maximal medical therapy
No alternative surgical interventions available

Contraindications:

Age >65 years
Severe liver or kidney disease
Severe vascular disease
Active infection
Incurable cancer
Poor patient compliance

Acute Heart Failure (AHF)

Etiology

De novo AHF:

Acute decompensation of chronic heart failure (75%)
Acute myocardial dysfunction
Acute valve insufficiency
Pericardial tamponade
Exacerbation of chronic obstructive pulmonary disease (COPD)
Pulmonary embolism
Perioperative complications
Cerebrovascular insult
Aortic dissection

Precipitating factors:

Infection
Uncontrolled hypertension
Rhythm disturbances

Clinical Features

Symptoms of Hypoperfusion

Cold, sweaty extremities
Oliguria
Mental confusion
Dizziness
Narrow pulse pressure

Symptoms of Right Congestion

Jugular venous distention
Peripheral edema
Congested hepatomegaly
Hepatojugular reflux
Ascites
Symptoms of gut congestion

Symptoms of Left Congestion

Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary rales
Peripheral edema

Killip Classification

No clinical signs
Rales and gallop rhythm
Acute pulmonary edema
Cardiogenic shock

Diagnosis

Physical Exam

Decreased blood pressure
Increased/decreased heart rate
Decreased oxygen saturation
Hypoxemia (
Hypercapnia (>45 mmHg)
Acidosis (pH
Elevated lactate (>2 mmol/L)
Oliguria (

Laboratory Tests

Natriuretic peptides
Cardiac troponin
Blood urea
Electrolytes
Liver enzymes
Thyroid-stimulating hormone (TSH)
Glucose
Complete blood count

Other Diagnostic Tests

ECG (for acute myocardial ischemia)
Echocardiogram (for hemodynamic instability, acute structural and functional abnormalities)
Chest X-ray (for pulmonary congestion, pleural effusion, interstitial edema)

Treatment

Identify and Treat the Cause

Acute coronary syndrome (ACS): ACS + AHF = high-risk group, immediate invasive strategy
Hypertensive emergency: Pulmonary edema, aggressively lower blood pressure with vasodilators
Arrhythmias: Pharmacological therapy, electrical cardioversion, temporary pacing
Acute mechanical cause: Echocardiogram and surgical/percutaneous intervention
Acute pulmonary embolism: Primary reperfusion with thrombolysis or catheter-based approach

Criteria for ICU Admission

Need for intubation
Hypoperfusion
Oxygen saturation
Tachypnea
Tachycardia/bradycardia
Blood pressure

Treatment Modalities

Oxygen therapy/ventilation (for hypoxemic patients, monitor arterial blood gas and oxygen saturation/blood pressure, in case of respiratory failure)
Diuretics (loop diuretics, furosemide) (indicated for fluid overload and congestion, contraindicated in hypoperfusion)
Vasodilators (indicated for hypertensive AHF, contraindicated in hypotensive AHF, decrease arterial and venous tone, reduce preload and afterload)
Digoxin (indicated for AHF with increased heart rate)
Vasopressors (indicated for hypotensive AHF, contraindicated in hypertensive AHF)
Inotropes (indicated for hypotensive AHF with impaired perfusion, contraindicated in hypovolemic shock, beta-blockers)

Tricuspid Valve Regurgitation

Etiology

Primary (Valvular)

Infective endocarditis
Rheumatic fever
Myxomatous degeneration
Congenital (ventricular septal defect, Ebstein’s anomaly)
Trauma
Carcinoid syndrome

Secondary (Functional)

Pulmonary hypertension
Pulmonary stenosis
Right ventricular myocardial infarction
Left heart dysfunction

Pathophysiology

Systolic reversal of blood flow from the right ventricle to the right atrium
Increased right atrial pressure and volume overload, leading to right atrial and right ventricular dilation and hypertrophy
Right ventricular dysfunction, leading to systemic congestion and decreased cardiac output

Diagnosis

Symptoms

Fatigue
Weight loss
Cachexia
Jaundice
Jugular venous distention
Ascites
Edema

Auscultation

Decreased S1, increased S2 and S3
Holosystolic murmur

Palpation

Hepatomegaly with systolic pulsations
Epigastric pulsations

X-ray

Cardiomegaly
Superior vena cava dilation
Pleural effusion

Echocardiogram (Gold Standard)

Quantification of regurgitation
IVC diameter decrease >50% on inspiration
Tricuspid annulus measurement

Treatment

Pulmonary congestion: Diuretics
Decreased afterload: ACE inhibitors
Rhythm control: Digoxin
Pulmonary hypertension: Vitamin K antagonists, low molecular weight heparin (LMWH)

Indications for Surgery

Symptomatic patients
Mildly symptomatic patients with progressive right ventricular dysfunction
Tricuspid annulus >40mm

Surgical Procedures

Tricuspid valve annuloplasty (often concomitant with mitral valve surgery)
Aortic valve reconstruction (if primary origin and no pulmonary hypertension)

Revascularization

Medications

Antiplatelet Agents

Oral: Aspirin, clopidogrel
Intravenous: Glycoprotein IIb/IIIa inhibitors

Antithrombotic Agents

Unfractionated heparin
LMWH

Surgical Revascularization

done in cases > 50% stenosis of the left coronary artery stem,-> 70% stenosis of proximal segments of 2 – 3 coronary arteries, drug-resistantAP, & in cases of ↑ LVF