Understanding Angina Pectoris, Myocardial Infarction, and Other Cardiac Conditions
Angina Pectoris (AP)
Etiology and Risk Factors
AP + Ischemia | Blood Supply to the Myocardium | Myocardial O2 Demand |
1. Myocardial O2 Demand > Oxygen Supply 2. Cellular Acidosis & Lactate Release 3. ST Depression on ECG → ST Depression in the absence of angina is called = Silent Ischemia !!! Angina = Ischemia | • Coronary Artery, Aortic Stenosis • Coronary Artery Spasm • Hypercoagulation States • Anemia • Increased Heart Rate • Myocardial Hypertrophy | • Physical/Emotional Exertion • Increased Heart Rate • Myocardial Hypertrophy |
Modifiable 1st Line Risk Factors | Unmodifiable Risk Factors | Normal Lipid Profile |
• Dyslipidemia • Hyperfibrinogenemia • Smoking • Arterial Hypertension • Diabetes Mellitus | • Familial Predisposition • Increased Age • Male Sex | Total Cholesterol: < 5.0 mmol/L LDL Cholesterol: < 3.0 mmol/L HDL Cholesterol: > 1.0 mmol/L Triglycerides: < 2.0 mmol/L |
Clinical Features (CF)
– Pain: Sensation of pressure, squeezing, burning, or numbness
– When? Physical, emotional stress, cold
– Where? Sub- or parasternal area, epigastric
– Radiation? Neck, shoulder, arm (mostly left)
– How long? 0.5 – 15 min
– Relief? 1.5 – 3 min after sublingual nitroglycerin
– Levine’s Sign: Patient shows pain with palm
– Dyspnea/Nausea/Anxiety/Cold Sweating
Classification
Class 0: Asymptomatic | Class I: Strenuous Exertion– Prolonged Exertion – Strenuous Exercise | Class II: Moderate Exertion– High but Daily Activity – More Frequent Attacks |
Class III: Mild Exertion– Moderate Physical Activity (+) AP (walking 100 m) | Class IV: At Rest– AP with Light Physical Activity or Rest |
Diagnosis (Dx)
I – Clinical Features | II – ECG | III – Echocardiography | IV – Perfusion Scintigraphy with Thallium 201 |
• Pallor • Increased Heart Rate • Increased Blood Pressure • Gallop Rhythm • Paradoxical S2 • Paradoxical Movement | – May be normal (50% of patients) at rest – Needs continuous recording – ST Depression or Elevation/T Inversion/R wave Depression | – Assesses: Cardiac Muscle Size of Cavities Systolic and Diastolic Function of LV Total Segment Function of LV | V – Interventional Studies: – Coronary Artery Angiography – Intracoronary Echography VI – Stress Test VII – 24-Hour ECG |
Treatment (Tx)
Goals– Alleviate/Prevent Anginal Pain – Increase Quality of Life – Fast Diagnosis of MI and Prevent Ischemic Death | Lifestyle Changes• Improve Nutrition • Decrease Body Weight • Increase Physical Activity • Decrease Blood Pressure • Modify Modifiable Risk Factors |
Increase Oxygen Supply• Nitrates • ACE Inhibitors • Revascularization Procedures: Percutaneous Coronary Intervention Coronary Bypass Operation | Decrease Oxygen Demand• Nitrates • β-blockers • Calcium Channel Blockers (CCB) • Ivabradine • Ranolazine |
I – Nitrates | II – β-blockers | III – Calcium Channel Blockers |
– Decrease: Systolic Blood Pressure, Myocardial Wall Tension – Increase: Cardiac Contractility (Blood from Non-Ischemic to Ischemic Zone) Sublingual Nitroglycerin – 0.5 mg II – Long-Acting Nitrates | – Block Sympathetic Stimulation of Heart – Decrease: Systolic Blood Pressure/Heart Rate/Contractility/Cardiac Output – Non-Selective (β1 + β2 Receptors): Propranolol, Timolol, Pindolol – Cardioselective (Only β1): Metoprolol, Atenolol, Betaxolol – Long-Term Treatment: Cardioselective | – Positive Hemodynamic Effects: – Increase Diastolic and Systolic Function – Decrease Hypertrophy of Left Ventricle + Blood Vessels – (Dihydropyridines/Benzodiazepines) |
Non-ST Elevation Myocardial Infarction (NSTEMI)
Clinical Features
– Angina > 20 min
– Deep, Substernal Pain
– Aching Pressure
– Radiating to Back/Jaw
– Nitroglycerin Ineffective
– Pain Can Start at Night (4 AM) with Increased Severity
– NSTEMI = Subendocardial (Only Part of Ventricle)
Diagnosis
Physical Examination | I – ECG (Most Important) | II – Biomarkers |
– High Blood Pressure or Low Blood Pressure – Increased or Decreased Heart Rate – Gallop Rhythm – Systolic Murmur – Pulmonary Edema | – Within 10 Minutes of Admission – ST Changes – Left Bundle Branch Block (LBBB) | – (Myoglobin/Total CK/CK-MB/Troponin T and I) – Elevate 5x the Normal —–> Immediate Invasive Management |
III – X-ray | IV – Echocardiography |
– Pulmonary Edema – Heart Dilation | – Regional Wall Motion Defect – Assesses Left Ventricle V – Perfusion Scintigraphy (Thallium 201) |
Risk Assessment
GRACE | TIMI |
– Age – Blood Pressure, Heart Rate – Elevated Cardiac Biomarkers – Elevated Serum Creatinine – Killip Class at Presentation – Cardiac Arrest on Admission – ST Changes | – Age 65+ Years Old – > 3 Coronary Artery Disease Risk Factors – Known Coronary Artery Disease – Aspirin Use in Past 7 Days – Severe Angina (> 2 Episodes/24 Hours) – ST Changes – Positive Cardiac Markers |
Treatment
Strategies:
– Decrease Myocardial O2 Demand (Nitrates, β-blockers, ACE Inhibitors)
– Reocclusion Prophylaxis (Antiplatelets, Anticoagulants)
– Ather Plaque Stabilization (Statins)
First Aid: MONA Rule | Pharmacological Treatment Sequence | New Antiplatelet Drugs |
Morphine 3-5 mg IV Oxygen 4-8 L/min Nitrates IV Aspirin 150-300 mg | 1. β-blockers (Metoprolol 25, 50, 100 mg) 2. ACE Inhibitors (Ramipril 2.5, 5, 10 mg) 3. Nitrates (ISMN 10, 20, 40, 60 mg) 4. Statins (Atorvastatin 10, 20, 40, 80 mg) 5. Antiplatelet (Aspirin 75-150 mg, Clopidogrel 75 mg) | • Ticagrelor 90 mg 2x/day • Prasugrel 10 mg daily • Clopidogrel 75 mg daily |
Invasive Coronary Angiography Indications
Very High Risk (PCI < 2 Hours) | High Risk (PCI < 24 Hours) | Medium Risk (PCI < 72 Hours) |
• Hemodynamically Unstable • Life-Threatening Arrhythmias • Mechanical Complications | • Rise or Fall in Troponin • Dynamic ST Changes | • Diabetes Mellitus • Renal Insufficiency • Left Ventricular Ejection Fraction (LVEF) < 40% |
Long-Term Treatment
• Lifestyle Changes
• Initiate High-Intensity Statin Therapy
• Antihypertensive Therapy
• Dual Antiplatelet Therapy
• ACE Inhibitors in Left Ventricular Dysfunction, Hypertension, Diabetes
• β-blockers if LVEF < 40%
ST Elevation Myocardial Infarction (STEMI)
– Aspirin 325 mg
– Cardiac Monitoring, Oximetry
– Oxygen is Given for First Few Hours
– Morphine 5-10 mg IV
– Nitroglycerin
– Thrombolysis or PCI
Indications: Typical pain, ECG ST elevation > 1 mm, new LBBB
Contraindications: Internal bleeding, pancreatitis, stroke, trauma
Regimen: IV Streptokinase (2nd/5th Line Agent), Anistreplase, Reteplase
β-blockers | ACE Inhibitors | Antithrombotic Drugs | Subsequent Treatment |
– Antagonize Hyperadrenergic State – Decrease Heart Rate, Blood Pressure, O2 Demand – IV Metoprolol 5 mg over 2 min, Repeat 5 mg every 5 minutes until Heart Rate < 60 bpm and Blood Pressure < 100 mmHg | – Goals: Avoid Geometric Ventricle Change, Prevent Dilation of Cavities, Decrease Infarction and Mortality – Indications: Q wave in MI, Increased Ventricular Contractility – Examples: Captopril, Enalapril | – Oral: Aspirin, Clopidogrel – Heparin: Unfractionated Heparin, Low Molecular Weight Heparin (LMWH) – Glycoprotein IIb/IIIa Inhibitors: Abciximab | – Bed Rest (1 Day Recumbency, 2 Hours Sitting, 5 Minutes Walking, Discharge on Day 7-9) – Aspirin – Long-Term β-blockers – Statins (Simvastatin 40 mg) |
Medication
Antiplatelet Agents | Antithrombotic Agents |
– Oral: Aspirin, Clopidogrel – Intravenous Antiplatelet: Glycoprotein IIb/IIIa Inhibitors | – Unfractionated Heparin – Low Molecular Weight Heparin (LMWH) |
Coronary Artery Bypass Graft (CABG)
CABG |
– Percutaneous Coronary Intervention (Balloon Angioplasty, Stent Placement, Atherectomy, Radiation) |
Principles
– Track Symptoms of Angina Pectoris
– Increase Long-Term Survival
– Decrease Non-Fatal Events, Congestive Heart Failure, Ventricular Arrhythmia
– Unstable Angina
– Surgical Revascularization Done in Cases > 50% Stenosis of the Left Coronary Artery Stem, > 70% Stenosis of Proximal Segments of 2-3 Coronary Arteries, Drug-Resistant AP, and in Cases of Increased Left Ventricular Function
Hypertension (HPB)
Classification
Category | Systolic (mmHg) | Diastolic (mmHg) |
| Optimal | < 120 | < 80 |
| Normal | 120-129 | 80-84 |
| High Normal | 130-139 | 85-89 |
| Hypertension 1 | 140-159 | 90-99 |
| Hypertension 2 | 160-179 | 100-109 |
| Hypertension 3 | ≥ 180 | ≥ 110 |
| Isolated Systolic Hypertension | ≥ 140 | < 90 |
Risk Factors
– Hereditary – Excessive Sodium Intake – Alcohol Abuse – Age 35+ – Smoking – Physical Inactivity – Increased BMI – Increased Blood Cholesterol | – Chronic Stress – Drug Intake: Adrenomimetics Oral Contraceptives NSAIDs Glucocorticoids Tricyclic Antidepressants Amphetamines |
→ Probability to Develop Cardiac or Cerebral Complications of Hypertension
Normal < 10% Slightly Increased 15-20% Moderately Increased 20-30% (Very) High > 30%
Treatment
General Measures– Diet → Decrease Weight – Sufficient Exercise – Stop Smoking and Drinking – Decrease Stress |
Pharmacological Treatment– Never Use a Combination of Drugs that Act on the Same Site. – Diuretics → Decrease Blood Volume – α-blockers, β-blockers → Decrease Renin Secretion – ACE Inhibitors, Angiotensin II Receptor Blockers (ARB) → Decrease Vascular Tone – Calcium Channel Blockers (CCB) → Smooth Muscle Cell Relaxation – Centrally Acting Antihypertensives (Clonidine) – Vasodilators (Hydralazine) |
Rheumatic Fever
Criteria (Jones Criteria)
– Evidence of Preceding Group A Streptococcal (GAS) Infection (Increased Antistreptolysin O Antibodies, Positive Throat Culture)
Major Criteria
– Carditis
– Chorea
– Erythema Marginatum
– Polyarthritis
– Subcutaneous Nodules
Minor Criteria
– Arthralgia
– Increased ESR/CRP
– Fever
– Increased ASO
– Prolonged PR Interval
– Streptococcal A Infection
Diagnosis
– Increased Antistreptococcal Antibodies + Positive Throat Culture + (2 Major Criteria) or (1 Major + 2 Minor Criteria)
Treatment and Prevention
Acute Phase | Late Phase |
– Bed Rest for 2-6 Weeks – Penicillin G for 10 Days – Allergy: Cephalosporin/Erythromycin – NSAIDs for Arthralgia (Aspirin) – Prednisone in Heart Failure Until CRP is Normal – Diazepam for Chorea | – Aortic/Mitral Valve Surgery – Bioprosthesis if No Anticoagulation – Biventricular Pacing in Heart Failure |
Prevention
Primary Prevention | Secondary Prevention |
– Accurate Diagnosis – Treatment for Streptococcal Infection Duration of Secondary Prophylaxis: Rheumatic Fever + Carditis & Residual Valve Disease → 10 Years Until Age 40 Rheumatic Fever + Carditis & No Valve Disease → 10 Years Until Age 21 Rheumatic Fever & No Carditis → 5 Years Until Age 21 | – Prevent Recurrence – Continuous Prophylaxis: 1. Penicillin G IM 2. Sulfadiazine 3. Macrolide – Streptococcal Vaccine – Treatment of Inflammatory Foci |
Mitral Regurgitation (MR)
Etiology
Primary (Valvular): Acute (Infective Endocarditis, Acute MI, Chordal/Papillary Rupture), Chronic (Degenerative Changes)
Secondary (Functional): Dilated Cardiomyopathy, Left Ventricular and Annulus Dilation
Pathophysiology
1. Systolic Reversal of Blood Flow from Left Ventricle to Left Atrium
2. Left Atrial Overload → Left Atrial Dilation and Hypertrophy
3. Increased Left Ventricular Preload → Increased Left Ventricular Pressure and Volume → Left Ventricular Dilation and Hypertrophy
4. Pulmonary Venous Congestion → Pulmonary Artery Hypertension
5. Increased Right Ventricular Afterload → Right Ventricular Hypertrophy
Diagnosis and Treatment
Symptoms
– Slow Exertional Dyspnea
– Weakness and Fatigue
– Palpitations
Signs
– Fatigue
– Exertional Dyspnea
– Atypical Angina Pectoris
– Palpitations
ECG (Non-Specific)
– P Mitrale
– Atrial Fibrillation
X-ray
– Left Atrial and Left Ventricular Enlargement
– Pulmonary Venous Congestion
Echocardiography (Gold Standard)
– Quantification
– Chamber Dimensions
– Ejection Fraction
CT
– Thoracic Aorta Evaluation
MRI
– If Echocardiography is Insufficient
Treatment
– Asymptomatic and No Left Ventricular Hypertrophy: No Treatment
– Symptomatic and Ejection Fraction < 60%
– Pulmonary Congestion: Diuretics
– Symptoms: Decrease Afterload → ACE Inhibitors + Angiotensin II Receptor Blockers
– Rhythm Control: Calcium Channel Blockers, β-blockers, Digoxin
Indications for Surgery
– Symptomatic Patients
– Asymptomatic Patients with Ejection Fraction < 60%, Pulmonary Hypertension, Atrial Fibrillation
– Acute/Chronic Ischemic Mitral Regurgitation
– Rupture of Papillary Muscle
– Significant Coronary Stenosis
Mitral Valve Reconstruction
– Decreased Perioperative Mortality
– Increased Prognosis
Mitral Valve Replacement: Ultima Ratio!
Mitral Stenosis (MS)
Definition
– Narrowing of Mitral Valve Opening Blocking Blood Flow from Left Atrium to Left Ventricle
Etiology
– Rheumatic Fever (95%)
– Congenital
– Annulus Calcification
– Systemic Lupus Erythematosus (SLE)
– Myxoma
– Rheumatoid Arthritis (RA)
Pathophysiology
1. Mitral Valve Gets Smaller (From 4-6 cm2 to 2 cm2)
2. Less Blood Flow from Left Atrium to Left Ventricle
3. Increased Atrioventricular Pressure Gradient
4. Left Atrial Pressure Overload → Left Atrial Dilation and Hypertrophy
5. Increased Pulmonary Venous Pressure → Pulmonary Blood Congestion
6. Pulmonary Artery Hypertension → Increased Right Ventricular Afterload → Right Ventricular Dilation and Hypertrophy
7. Systemic Blood Congestion
Diagnosis and Treatment
Symptoms
– Exertional Dyspnea
– Hemoptysis
– Chest Pain
– Chronic Bronchitis
– Facies Mitralis
Auscultation
– S1 Increased
– S2 Split and Increased
– Diastolic Murmur Decreased
– Presystolic Thrill at Apex
ECG
– P Mitrale
– Atrial Fibrillation
– Right Ventricular Hypertrophy
X-ray
– Mitral Configuration of Heart
– Left Atrial Enlargement
– Enlargement of Pulmonary Artery, Right Ventricle, Right Atrium
Echocardiography (Gold Standard)
– Mitral Valve Calcification → Decreased Mitral Valve Area
– Left Atrial Enlargement
– Right Ventricular Enlargement
– Left Ventricle Normal
– Leaflet Excursion Decreased
ECG Stress Test
– Worsening Symptoms
– Decreased Physical Capacity
Coronary Angiography
– Preoperative
Treatment
– Pulmonary Congestion: Diuretics
– Rhythm Control: Digoxin, β-blockers, Calcium Channel Blockers
– Anticoagulation: Vitamin K Antagonists (Warfarin)
Indications for Surgery
– Symptomatic Patients with Medical Therapy
Open Surgery
– Mitral Valve Replacement
– Open Commissurotomy
Percutaneous Mitral Balloon Valvuloplasty
– Young Patients
Percutaneous Mitral Commissurotomy
– Contraindications: Left Atrial Thrombus, Severe Calcification
Pressure Gradient | Mitral Valve Area | |
| Normal | < 5 mmHg | 4.0-6.0 cm2 |
| Mild | 5-8 mmHg | 1.5-2.0 cm2 |
| Moderate | 8-15 mmHg | 1.0-1.5 cm2 |
| Severe | > 15 mmHg | < 1.0 cm2 |
Aortic Regurgitation (AR)
Definition
– Incompetency of Aortic Valve
– Permanent Diastolic Blood Reflux from Aorta into the Left Ventricle
Etiology
Primary | Secondary |
– Congenital Bicuspid (Unicuspid) – Rheumatic Fever – Infective Endocarditis – Degenerative Changes | – Arterial Hypertension – Aortic Aneurysm – Ankylosing Spondylitis (Morbus Bechterew) – Marfan Syndrome – Aortoannular Ectasia – Syphilis |
Pathophysiology
1. During Systole, Aorta Dilates; During Diastole, it Contracts
2. Diastolic Reversal of Blood Flow from Aorta to Left Ventricle
3. Left Ventricular Volume and Pressure Overload → Left Ventricular Eccentric Hypertrophy
4. Increased Left Ventricular End-Diastolic Pressure
5. Coronary Artery Hypoperfusion
6. Relative Mitral Valve Dysfunction → Increased Left Ventricular Filling
7. Increased Pulmonary Venous Pressure → Pulmonary Blood Congestion
Treatment
Pharmacological Treatment
– Vasodilators (ACE Inhibitors, Calcium Channel Blockers) → Decrease Afterload
– β-blockers → Prevent Aortic Rupture
– Avoid Bradycardia → No β-blockers in Severe Aortic Regurgitation
– Infective Endocarditis Prophylaxis in High-Risk Patients
Indications for Surgery
– Symptomatic Patients
– Asymptomatic Patients with Ejection Fraction < 50%, > 5% Ejection Fraction Decrease on ECG Stress Test, Left Ventricular End-Diastolic Diameter > 75 mm, or Left Ventricular End-Systolic Diameter > 55 mm
Aortic Valve Replacement
– Frequently Aortic Root Resection Required
Aortic Stenosis (AS)
Definition
– Narrowing of Aortic Valve Producing Obstruction of Blood Flow from Left Ventricle to Ascending Aorta During Systole
Etiology
Congenital | Acquired |
– Bicuspid – Unicuspid – Quadricuspid | – Calcification (Age 65+ Years) – Rheumatic (Age 40-60 Years) – Disturbances of Calcium Metabolism – Rheumatoid Arthritis – Renal Failure – Fabry Disease |
Pathophysiology
1. Increased Left Ventricular Systolic and Diastolic Pressure → Prolonged Ejection Time
2. Left Ventricular Pressure Overload → Left Ventricular Concentric Hypertrophy
3. Increased Myocardial O2 Consumption → Decreased Relative Myocardial Perfusion
4. Left Ventricular Myocardial Ischemia → Left Ventricular Myocardial Fibrosis
5. Increased Left Ventricular Filling Pressure → Increased Pulmonary Venous Pressure → Pulmonary Blood Congestion
Diagnosis and Treatment
DiagnosisSymptoms– Angina Pectoris – Syncope – Exertional Dyspnea Physical Examination– Small, Weak, Late-Peaking Carotid Pulse – Systolic Thrill Auscultation– Systolic Thrill in Aortic Area – Decreased S2, S4 in Severe Cases – Crescendo-Decrescendo Systolic Murmur ECG– Left Ventricular Hypertrophy + Pressure Overload – Left Bundle Branch Block X-ray– Aortic Configuration – Aortic Arch Calcification – Post-Stenotic Dilation – Pulmonary Congestion Echocardiography (Gold Standard)– Increased Flow Velocity Through Aortic Valve > 2.5 m/s – Quantification of Aortic Stenosis – Concentric Left Ventricular Hypertrophy Palpation– Pulsus Parvus et Tardus Coronary Angiography– Coronary Heart Disease Risk Assessment | TreatmentGeneral Approach– Correct Coronary Artery Disease Risk Factors – Decrease Physical Activity in Severe Aortic Stenosis Pharmacological TreatmentSequence: | New Antiplatelet Drugs: |
Morphine 3 – 5 mg i/v Oxygen 4 – 8 L/min Nitrates i/v Aspirin 150 – 300 mg | 1. β-blockers (metoprolol 25, 50, 100 mg) 2. ACE-I (ramipril 2.5, 5, 10 mg) 3. Nitrates (ISMN 10, 20, 40, 60 mg) 4. Statins (atorvastatin 10, 20, 40, 80 mg) 5. Antiplatelet (aspirin 75 – 150 mg, clopidogrel 75) | • Ticagrelor 90 mg 2x/day • Prasugrel 10 mg daily • Clopidogrel 75 mg daily |
Invasive coronary Angiography ind:
| VHigh Risk PCI | H RiskPCI | M riskPCI |
| • Hemodynamically unstable • Life-threatening arrhythmias • Mechanical complications | • Rise of fall in troponin • Dynamic ST changes | • Diabetes mellitus • Renal insufficiency • LVEF |
^^Long Term:
• Initiate high-intensity statin therapy
• Antihypertensive therapy
• Dual antiplatelet therapy
• ACE-I in LV dysfunction, hypertension, diabetes
• β-blockers if LVEF
***MI^^Troponin T and I :
| – highly-specific to myocardialtissue. -essential biomarkers to diagnose MI. • (S) 80% after 3 hours • (S) 100% after 5 hours • Max after 12 hours | Causes of ↑ Troponin: •MI • M-tis • Hypertensive crisis •A stenosis • Kidney(-) • ↑ ↑ physical activity |
^^Complication :
| Early Complications: | Late Complications: > 48 hours |
• aRR Ventricular extrasystoles Ventricular fibrillation /flutter Atrial fibrillation Bradyarrythmias • LV insufficiency & cardiogenic shock if > 20% of LV MI • RV insufficiency | Cardiac aneurysm • Arterial embolisms • Pericarditis • Dressler syndrome • Arrhythmias • Heart failure |
***STEMI-Aspirin 325 mg-Cardiac monitory , Oxumtery-O2 is given for first few hours-Morphine 5-10 mg IV-Nitrglycerin-Thrombolysis or PCIInd : typical pain . ECG ST elevation >1mm , new LBBB)(Contra ind :internal bleeding /pacreatitic/ stroke/ trauma)(Regiment: IV streptroinase (2/5 firline agent)(Anistreprase )(Reteplase)
| -B-Blockers: | -ACE (-): | -Antithromboptic Drugs | ^^ subsequent Tx: |
| (antagonist hyperadneric State),( ↓ HR, BP, O2 demand)(IV metaprolol 5mg over 2 min ,repeat 5 mins 15mg till hR | (GOALS: AVild geometric ventricle change / (-) dialation of cavivties/ ↓ infaction& mortality)(Ind : Q wave in MI / ↑ the VC)(X :Captropril/enalpril) | (OP : aspirin/ Clopidogei) (Heparin : unfractionEnocparin ) (GP IIB, IIIa(-) : Ableximab) | -Bed rest(1 recumbecy ,2 sitting 2 hours 5 WC walking 7-9 discharge)-Aspirin)-Long term B blocker)-Statins( simvastin 40 m |
^^ Medication :
| I-Antiplatelet | II- antithrombotic Agnent: |
| (OP Aspirin/ clopodrogen)(IV antiplatlent : glycoprotien IIb/IIIa) | ( Undefraction heparin(LMWH) |
^^CABG
^^CABG ^^Percutanous coronary intervation |
| (Ballooon Angioplasty)(Stent placement)(Atherectomy)(Radiation) |
^^ Principle:-Track Sx of angina pectoris-↑ Long term suribal– ↓ nonfaal events , Congestive HF , Ventricular arrythmia-unstable angina-The surgical revascularization done in cases > 50% stenosis of the left coronary artery stem,
***HPB :^^^ Classification:
| * And/or | S | DS |
| optimal | ||
| N | 120-128 | 80-84 |
| High N | 130-139 | 85-89 |
| Hypertonia 1 | 140-159 | 90-99 |
| Hypertonia 2 | 150-179 | 100-109 |
| Hypertonia 3 | >180 | >110 |
| Isolated( S) | >140 |
^^^RISK :
| Hereditary • Excessive Na+ intake • OH abuse • Age 35 (+) • Smoking • Physical inactivity • ↑ BMI • ↑ Blood cholesterol | Chronic stress • Drug intake: Adrenomimetics Oral contraceptives NSAIDs Glucocorticoids Tricyclic antidepressants Amphetamines |
Normal 30%
| ^^Gx: Diet → ↓ weight • Sufficient exercise • Stop smoking and drinking • ↓ stress |
| ^^X: Never use a combination of drugs that act on the same site. • Diuretics → ↓BV • α-blockers, β-blockers → ↓ renin secretion • ACE-I, AGT2RI → ↓ vascular tone • CCBs → SMC relaxation • Centrally acting antihypertensives (clonidin) • Vasodilators (hydralazine) |
***Rh Fever^^^Criteria:”Jones Criteria”:-Evidence of Preceding GAS infection (GAS= Group A streptococcal Infection )( ↑ Antistrepto Ab) ,+ Throat culture )
-Caridtis-Chorea-erythmea marginatum-polyarthritis-Subcutanous nodules
^^Minor
-arthralgia ↑ ESR/ CRPFever↑ ASO
Prolonger PR intervalStrep A infection
| Acute Phase | Late Phase |
| Bed 2-6W-Pen G 10 days-Allergy (cephalosprin /erythromycin)-NSAID forarthalgia(aspirin)-Prednisone in HFuntil CPR is N-Diazepan for Chorea | -AV /MV surgery -Bioprothesis if no anC-Biventricular pacing in HF |
| Primary | Secondary |
| -Accurate Dx-Tx for Strepto infDuration of 2nd Ax prevention:RF+ Cariditis& Residual valve disease—>10 until40 YORF+carditis and no valvedisease—>10 till 21 YORF with No carditis—>5 Years until 21 YO | -Prevent reoccurenace-Continuos X:1-Pen G/V2-Sulfadiazine3-Macrolide-Strepto vaccine-Tx of inflamm Foci |
| Duration of 2nd Ax prevention:RF+ Cariditis& Residual valve disease—>10 until40 YORF+carditis and no valvedisease—>10 till 21 YORF with No carditis—>5 Years until 21 YO***MR:^^Etiology : |
-Sx :↓ Afterload—>ACEI+AG2-1-Rhythm Control:(CCB,B blocker, Digoxin)^^Ind for Surgery:-SX patient-Asx with EFPul HBP ,A Fib-Acute / Chronic ischmia MR-Rupture & papilla muscle-Significant coronary stenosis^^MV reconstruction:↓ perioperative mortality
↑ prognosis
^^Mitral Valve Replacement: Ultima Ratio!
4- LA pressure overload → LA dilatation & H-trophy
5- ↑ pulmonary venous pressure → pul blood congestion
6- Pul artery HBP → ↑ RV afterload → RV dilatation and hypertrophy
7- Systemic blood congestion
Dx:
Tx:
^^Sx:-excertional dyspnea-hemotpysis-Chest pain-C bronchitis-Facies Mitralis^^Ausculation:-S1 ↑S2 split & ↑DS murmor ↓-ProtoDS thrillat apex^^ ECG:-P mitrale-A Fib-RVH^^Xray:-mitral Configuration ofheart-LA ↑– ↑ of Pul artery ,RV,RA^^Echo:(GOLDEN)MV calcification–>↓ MVLA ↑RV ↑LV N Leaflet excurcion ↓^^ECG stress test:-Worse Sx-↓ physical capacity^^Coronary Angiography:Preoperative
^^X:-Pul Congestion:(Diuretics)-Rhythm Control:(Digoxin / B Blocker/ CCD)-anC:(Vit K , Anatagonist,warfarin)^^ Ind for surgery:-Sx Patient with Meds^^Open Surgery;MV replacemet-Open commissurotomy^^Percutanous Mitral Baloon valvuplasty:Young patient^^Percutanous Mitral COmmussurotomy:CI : LA thrombus ,severe calcification
Pressure GradientMVN4.0-6.0Mild5-81.5-2.0Mod8-151-1.5Severe>15
***AR^^Def:-Incompetnecy of Aortic Vavle ,– Permanent DS Blood reflux from Aorta into the LV^^Etiology :
– β-blockers → prevent aortic rupture
– Avoid bradycardia → No β-blockers in severe AR
– IE prophylaxis in high risk patients
II-ind for surgery:-Sx Patient-Asx Patient(EF(>5%EF ↓)
ECG-stress-test, LV end-diastolic diameter > 75
mm, OR LV end-systolic diameter > 55 mmEF ^^Aortic Valve Replacement:
• Frequently aortic root esection requirred
***AS^^Def: Narrowing of Aortic Valve Producing Obstruction of BF from LV to ascending aorta during Systole^^Etiology :
| Congenital | Acquired |
| • Bicuspid • Unicuspid • Quadricuspid | Calcification , 65 years(+) • Rheumatic (40 – 60 years) • Disturbances of Ca2+ metabolism • Rh arthritis • Renal (-) • Fabry disease |
^^Px:1. ↑ LV (S) & (DS) pressure → Prolonged ejection time
2. LV pressure overload → LV concentric hypertrophy
3. ↑ myo O2 consumption → ↓ relative myol perfusion
4. LV myocardial ischemia → LV myo fibrosis
5. ↑ LV filling pressure → ↑ pul venous pressure → Pulmonary blood congestion
***Tx
| ^^Dx: | Tx: |
| ^^Sx:-AP-Sncope-Exertional dyspnea^^ PE:-small weak late peaking carotid Pulse-(S) throll^^Ausculation :-(S) Thrill aortic Areas-↓S2 ,S4 in severe cases-Crescendo -decreasendo Systolic Murmour^^ ECG:-LVH+ pressure overload-LBBB^^ Xray:-Aortic Configuration-Aortic arch Calcinosis-Postentonitc dilation-Pul congestion^^Echocardiography:(Golden)-↑ Flow velocity through AV>2.5m/s-Quantification of AS-concentric LVH^^palpation:pulsus parvus et tardus^^Coronary angiigraphy:CHD at risk | ^^General Approach:-Correct CAD Risk Factors-↓Physical activity in severe AS^^X:-No effective Tx-Low Dose Diuretics(↓afterload)-Low Dose B blocker^^Indication for Surgery:-Sx patients with moderate/severe AS-Asx with moderate severe AS + Heart surgery-Asx patient+ severeAS+EF^^Balloon vavloplasty:-temperal effect-Dialation of Aortic Orfice-Restenosis 6-12 Month^^Aortic Valve Replacement:-Open surgery-patient with low risk^^Transcatheter aortic valveimplantation(TAVI):-patient with moderate or high operative risk |
^^^Px:
| Classifciatin: | |
• Ostium primum 20% • Ostium secundum 70% • Sinus venosus • Coronary sinus • Open Foramen ovale | • Right heart dilatation and failure • Atrial arrhythmias • Pulmonary hypertension → Dyspnea • Stroke • Recurrent respiratory infection |
^^^DX:
I-Sx: > 5 mm: • Palpitations • Exertional dyspnea • Fatigue • Late: peripheral cyanosis | III-ECG:-Right Axis Deviation-RVH-P-Pulmonale-RBBB -Right Axis Deviation-RVH-P-Pulmonale-RBBB | V-XRAY:-Right heart ↑-Pul Congestion |
II-Ascultation: -(S) ejection murmor overpul area-Wide Split S2 | IV-Echo: Evaluation of size and type • Associated abnormalities • Direction of shunt • Size of RA and RV • Qp/Qs ratio • TEE |
^^^TX:I-Percutanous Defect Closure:-Ind : Qp/Qs >1.5+RV overload-Contra : irreverible Pul HBP-HEart& Lung Transplant: Eisenmenger-Follow-up valve suegery-Vit K Antagonist***IE :^^^CRITERIA
| Major Criteria: | Minor: |
| I-(+) Blood Culture , Common ednocarditis1- (+)microganism from 2 BC typical of endocaridits2-(+) BC drawn >12 H apart typical of endocarditis3-Coxiella burnettri serological involvmentII-(+) Echocardiogram or new murmor:1- oscillating intracardiac mass on heart valve2-cardiac abscess3-Vavular regugitation | -predisposing heart disoder-IV X useFever>38-Vascular phemino:1-Atrial thrombi2-infarction-Immunological phenome:1-Gnphtiis2-Rh fact-Microbiological evidance |
-2 Major-1 Major+3 Minor-5Minor^^^^Tx:
^^STrepto:
^^Staphylocii:
^^Enterococci:
Ampicilin+oxacillin+gentamycin
-Pen+genta-Amoxicillin-Ceftriaxone
-Oxacillin-clndamycin-Vanco
-Amoxillin-Ampiccilin+gentacum
Ax therapy 4-6W