MEDICINE Approach to Patients with Cardiovascular Problems Lecturer: Dr.

Jaime Pacifico INTRODUCTION You need to know that these cardiovascular diseases are responsible for 40% of all deaths in the United States. This is in spite of the fact that, in the last 40 years, there has been a decline of about 56%. So though it has already declined, it is still responsible for 40% of all deaths in the United States. About 20 years ago, you would often hear that infection is the most common cause of death in the Philippines. However, a lot has changed in the past decade such that cardiovascular diseases are now the most common cause of death in the Philippines as well. Why? This is because of the increasing prevalence of coronary risk factors. CORONARY RISK FACTORS It is important to understand the concept behind coronary risk factors! There are four major coronary risk factors that must be memorized because these are questions we'll be encountering for the rest of our professional lives <3 These major coronary risk factors are, again, based on a program done by a US organization. (For example: Do you smoke? Do you have a history of hypertension? History of diabetes? What is your cholesterol level?) 1. Hypertension 2. Diabetes Mellitus 3.Hypercholesterolemia Hyperlipidemia) 4. Smoking

Transcriber: Pielle Pacifico Editor: Kim Galang Number of pages: 10

You should know that 90-95% of CAD is due to atherosclerosis, and the rest are due to unusual causes such as emboli from a vegetation, secondary myocarditis, or congenital anomalies. But again, it is important for you to remember that 90-95% of coronary artery diseases is due to atherosclerosis. This is why it is important the concept of coronary risk factors: because coronary risk factors accelerate the process of atherosclerosis. You may not be aware of it, but all of us are already undergoing the process of atherosclerosis (despite the difference/s in age range). In fact, during the Korean War, they did an autopsy of the American soldiers who died (these soldiers were usually individuals in their early 20s) and they found that even those in their early 20s were already undergoing different stages of atherosclerosis. So, if you are diabetic, hypertensive and have hypercholesterolemia but you do not do anything about it, then there's a very high chance that you will die of coronary artery disease at an early age. Again, this is because the risk factors accelerate the process of atherosclerosis, and you must know that atherosclerosis is a lifelong process. It has started as early as years ago, probably about the time when you were in high school, and it is still ongoing. Hence, you must be cautious of the high cholesterol food that you eat! Question from the audience: If you do something about the risk factors, does it reverse the process of atherosclerosis or does it only slow down the process? Answer: It doesn't reverse, but it does slow down. Thus, as future physicians, you can advise your patients on modifying or eliminating the coronary risk factors. Removing or modifying the risk factors would delay the progression of atherosclerosis. CORONARY ARTERY DISEASES: OVERVIEW Coronary artery diseases refer to significant reduction of the lumen of coronary arteries due to atherosclerosis. CAD is also known as ischemic heart disease (IHD). Coronary arteries are small but even a small obstruction in the lumen can compromise oxygen supply in the myocardium; and during exertion, the heart will not be able to deliver enough oxygen to the myocardium which can cause necrosis or infarction or death of the myocardium. You've heard of individuals who just drop dead while doing other things, and these are probably due to a coronary artery disease.

(accdg

to

Robbins

Important: A few years ago, they removed Diabetes Mellitus from coronary risk factors and elevated it to a coronary disease equivalent. Elevating Diabetes Mellitus as equivalent to (a person with) coronary artery disease would mean that anybody who has Diabetes Mellitus is considered as having a coronary artery disease. However, for our purposes, we should stick to/remember the four coronary risk factors mentioned above. Again, these are: hypertension, DM, hypercholesterolemia, and smoking. What is the concept behind the coronary risk factors? These are conditions or habits, the presence of which would increase the probability of coronary artery disease. This means that if you have hypertension and diabetes, you have twice the probability of getting a CAD compared to a person who does NOT have a coronary risk factor. If you have hypertension, diabetes, and you also smoke or even have hyperlipidemia, then you have more chances of having a coronary artery disease at an early age. What do these coronary risk factors do? Remember: They enhance or accelerate the process of atherosclerosis.

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 Stroke vs. Myocardial Infarction Stroke is like a myocardial infarction but it involves the brain! You'll be surprised because when you read the newspapers, a lot of reports would mistake a heart attack for stroke and stroke for heart attack. So again: Stroke is similar to a myocardial infarction in the sense that there is either an obstruction in the cerebral artery or a rupture of the cerebral artery. On the other hand, myocardial infarction refers to an obstruction in the coronary artery. So these are two different things! K? K. Analogy: Coronary risk factors and CADs If you are a reckless driver, there is a very high chance that you will meet an accident BUT it does not mean that you will indeed meet a car accident. HOWEVER, if you are a careful driver, there is a low chance that you will meet an accident on the road, though this does not guarantee that you will not get into an accident. Gets? We're talking about chances or the probability that one will have a CAD or heart disease. And of course, the more coronary risk factors you have, the higher chances of having CAD at an early age. But despite this probability, you should realize that there are also other factors that can affect the process of atherosclerosis. (Factors that certain medical science cannot or have yet to understand. However, as a doctor, since it has been proven that the more coronary risk factors your patient has, the higher the chances are of dying from cardiac death, you are responsible in advising the patients to eliminate or modify these risk factors.) EN: Risk Factors for Atherosclerosis (accdg to Robbins) o Non-Modifiable o Age (40-60) Gender (male>female) Genetics ( o

Lifestyle Metabolic Syndrome Lipoprotein A Hemostasis Factors

EN2: (accdg to Harrisons) Risk Factor for Atherosclerosis o o Cigarette smoking Hypertension (BP 140/90 mmHg or on

antihypertensive medication) o o o Low HDL cholesterola [<1.0 mmol/L (<40 mg/dL)] Diabetes mellitus Family history of premature CHD o o CHD in male first-degree relative <55 years CHD in female first-degree relative <65 years

Age (men 45 years; women 55 years) Lifestyle risk factors Obesity (BMI 30 kg/m2) Physical inactivity Atherogenic diet

Emerging risk factors Lipoprotein(a) Homocysteine Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherogenesis

Modifiable Major: Hyperlipidemia Hypercholesterolemia) Hypertension Cigarette Smoking Diabetes Mellitus (specifically

CAUSES OF CARDIAC DISEASES In general, these are the causes of cardiac diseases: 1. Coronary Artery Disease or Ischemic Heart Disease 2. Valvular Heart Disease 3. Congenital Heart Disease 4. Hypertensive Heart Disease 5. Cardiomyopathy Later on, as a 4th Year Medical Student, and you will have to make a diagnosis, your diagnosis will not be far from these as far as common causes of cardiac diseases are concerned. What is the difference between hypertension and hypertensive heart disease? Hypertensive heart diseases are those Individuals with hypertension with existing target-organ damage of the heart. The target-organ damage in the heart can be a simple hypertrophy of the left ventricle or a dilatation of the left ventricle, or symptoms pointing to coronary artery

Minor/Additional: Inflammation Hyperhomocystinemia

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disease because, as he said, hypertension can accelerate the process of atherosclerosis. EN: According to Harrisons: Hypertensive heart disease is the result of structural and functional adaptations leading to left ventricular hypertrophy, diastolic dysfunction, CHF, abnormalities of blood flow due to atherosclerotic coronary artery disease and microvascular disease, and cardiac arrhythmias.

Valvular Heart Disease As mentioned in the previous lecture, the most common in the Philippines is Rheumatic Heart Disease, while in the US, the most common is Degenerative. Again, most common: In the Philippines: Rheumatic Heart Disease In the USA: Degenerative (calcific aortic stenosis) To some extent, they do not have mitral stenosis there. In fact, they will be apprehensive if they find mitral stenosis there because they believe that they have controlled Rheumatic Fever already. Calcific aortic stenosis is the most common valvular disease that they operate on in the Western countries. EN: According to Harissons, Aortic stenosis occurs in about one-fourth of all patients with chronic heart valvular heart disease. Age-related degenerative calcific AS is the most common cause of AS in adults in North America and Western Europe. You need to understand the symptoms because you cannot diagnose a patient with cardiac diseases if you cannot recognize the symptoms. You must be able to suspect the probability of cardiac diseases based on the symptoms. CARDINAL SYMPTOMS OF CARDIOVASCULAR DISEASES 1. Chest Pain or Discomfort Narrowing of coronary arteries Not always suggestive of a cardiac disease Differentiate anginal from non-anginal chest pain o Know the etiology of the pain Cardiac origin or not It could be of pulmonary dysfunction Typical chest pain: heaviness which is pressing character o Not the chest pain commonly experience by anybody If cardiogenic shock in origin, it occurs with exertion o May suggest CHD or IHD, meaning there is decrease in oxygen supply to the heart muscle o Activities that increases oxygen demand like physical exertion, the heart compensates by making the blood circulation faster Anginal Pain

Heaviness, compressing in character, tightness o May suggest ongoing CHD or IHD o Occurs with exertion Other factors o Age o Presence of coronary risk factor Hypercholesterolemia Smoking DM Hypertension If the patient can point at the location of the pain chances are its not cardiac in nature (EN. Ex. if the patient points that the pain is from the left part of the chest it is malingering lang. The heart is located near the mid sternal line. Its just that the hearts frame points to the left. Another example are teenage girls who complains of heartache secondary to love lost) Of course, if we're talking about coronary artery disease, we're talking of chest pain or discomfort. It should be clear to you that the chest pain being talked about is chest pain that is ANGINAL. ANGINAL means heaviness or compression-like or pressure-like sensation on the chest. If you are to pretend that you have a cardiac disease, don't say that it's the left side of your chest that is painful. Because if a patient experiences anginal pain, he will feel it in the middle of the chest-- the pain is substernal. (Think Levine's sign.) A lot of your decision-making will be based on the character of the chest pain. If the patient tells you (and this is usually common) that the pain is pricking in character and would last for a few seconds, there is a 95% chance that this is NOT angina. Thus, It is very important for you to extract the character of the patient's chest pain.

EN: The following symptoms (dyspnea, orthopnea 2. Dyspnea, Orthopnea, PND, Wheezing these symptoms may suggest heart failure especially left ventricular heart failure. Dyspnea Dyspnea is the most common symptom of heart failure. Dyspnea, orthopnea, PND, and wheezing are all symptoms of heart failure. It is caused by an increase in pulmonary venous pressure due to LV failure or valvular diseases. Dyspnea is an unusual awareness of one's breathing. Normally, you're not aware of your breathing. But when you're climbing from the first floor to the fourth, you become aware of your breathing by the time you reach the fourth floor. In patients with heart failure, however, they experience dyspnea even with minimal exertion. Going back to the earlier example, we are normal because we can climb the four floors with just a slight difficulty of breathing. This is normal because this is just our heart compensating for the slight increase in physical activity. However, in patients with heart failure, their heart cannot compensate for increased physical activity; hence,

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even walking just a few meters will be too much effort and the patient experiences dyspnea even with minimal exertion. Simply put, dyspnea in heart failure really is a manifestation of just how minimal a person can do before experiencing shortness of breath. Dyspnea is one of the earliest symptoms found in patients with heart failure. In the early stages of HF, dyspnea is observed only during exertion. In HF, diastolic dysfunction or LV filling is delayed due reduced LV compliance. An increase in heart rate shortens diastolic filling time causing increase in LV filling pressure. Elevated LV end-diastolic filling pressures result in increases in pulmonary capillary pressures, which can contribute to the dyspnea experienced by patients with diastolic dysfunction. Orthopnea Defined as dyspnea on recumbent position or in supine position (cuddling with este lying with your pillow na spongebob and patrick). If you will recall from PD lab, why does the patient have to be in a supine position in taking the JVP? The answer is because you want to increase the venous return so that the pulsation will be more prominent. So in orthopnea, what happens is a patient in heart failure lies down and more blood returns to the right side of the heart. So more blood is returning to the heart and this can increase the pulmonary venous pressure and the pulmonary capillary pressure. So this patient, after lying down for a few hours will eventually experience shortness of breath because the left ventricular filling pressure would have increased after just a few hours of lying down. This is all because of increased blood volume when a patient lies down (redistribution of volume). So the compensation of these patients is to use pillows so that they would not experience shortness of breath Orthopnea is usally a later manifestation of HF than is exertional dyspnea. Orthopnea may be relieved by sitting upright or by sleeping with additional pillows. Paroxysmal Nocturnal Dyspnea This term refers to acute episodes of severe shortness of breath and coughing that generally occur at night and awaken the patient from sleep, usually 1-3 hours after the patient retires. (according to Harrison PND may be manifest by coughing or wheezing, possibly because of increased pressure in the bronchial arteries leading to airway compression, along with interstitial pulmonary edema leading to increased airway resistance). Whereas orthopnea may be relieved by sitting upright at the side of the bed with the legs in a dependent position, patients with PND often have persistent coughing and wheezing even after they have assumed the upright position. (accdg to recording, there is a decrease in adrenergic stimulation of the heart at night, which decreases myocardial contraction and therefore, also results to a decrease in cardiac output and contributes to an elevation in the left ventricular filling pressure.) Left ventricular filling pressure! Take note! REMEMBER: A patient in heart failure has two components by definition: 1. Increased cardiac output 2. Elevation of the filling pressure

So again, there is an increase in cardiac output and a concomitant increase in the left ventricular filling pressure. This increase in left ventricular filling pressure is responsible for the dyspnea in patients with heart failure. Wheezing Not so common and may occur in patients with severe heart failure. Mechanism may be due to Increase in pulmonary capillary pressure. 3. Palpitations, Dizziness, Syncope may be due to heart or breathing Palpitations vary in definition, but generally, palpitation is a subjective sensation of regular or abnormal heartbeat. There are 2 reasons for this: Palpitations are not just due to a fast heart rate but also of irregular heart beat. Take note: A fast heart rate (tachycardia) and arrhythmia are the two major causes of palpitations. This is important because: If you have a very fast heart rate, there might not be enough time for left ventricular filling and there would be an increase in the blood pressure. Hence, a lot of patients with palpitations will present with dizziness and syncope when they stand up to some form of physical activity. Again, the shortened filling time is responsible for the hypotension in patients with tachyarrhythmia. (fast heart rate with irregular heart beating) Palpitations, dizziness and syncope are symptoms suggestive of the probability of arrhythmia. Either a tachyarrhythmia, or a very fast and irregular heart rate and rhythm. Remember that you need time for ventricular filling. But if you have a very fast heart rate, you shorten your ventricular filling time. This may result to hypotension, and soon after can also cause syncope due to the reduced cardiac output and decreased blood pressure.

Lightheadedness or Syncope Can be caused by any condition that decreases cardiac output. Even diarrhea can cause syncope due to the decrease in blood volume. 4. Cough and Stenosis You might be surprised, but patients with mitral stenosis can present with hemoptysis due to the increased left atrial pressure, which can cause rupture of the pulmonary vein. Note that hemoptysis is not purely a symptom of patients with pulmonary diseases! Because,

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again, patients with mitral stenosis can present with hemoptysis. Cough and Hemoptysis are manifestations not specific for lung disease. 5. Fatigue and Weakness Remember: These are symptoms of decreased cardiac output! Fatigue and weakness are symptoms of decreased oxygen perfusion (i.e. a decrease in cardiac output). 6. Pain in extremities with exertion (Claudication) Please remember the concept of claudication. Claudication is defined as pain in skeletal muscle or in walking. The analogy is this: if angina is to the heart, claudication is to the peripheral blood vessels. The pathophysiology is also the same. In angina, you have decreased oxygen perfusion to the myocardium that's why there is pain; whereas in claudication, you have decreased oxygen perfusion to the skeletal muscles, hence the pain. The mechanism is also the same: Decreased oxygen perfusion, meaning there is an obstruction in the peripheral arteries, causing decreased oxygen perfusion in the skeletal muscles. Again: Angina: Heart; Claudication: Peripheral arteries.

to the neck= Aortic stenosis Auscultatory area is on the right because that is where you can best hear the murmur based on the flow of blood towards the right too. CAUSES OF CHEST PAIN 1. Cardiovascular Causes a. Angina o Pain cannot be localized to a specific area o Heavy compressing occur with exertion o Located substernally o Radiates to left shoulder but never above the jaw and under umbilicus area o Crescendo to decrescendo in character (decrease in intensity) o Kaya nga pag napipinpoint nila ang location of the chest pain, its not a cardiac problem b. Rest or Unstable Angina o Longer duration (30 mins) and occurs even at rest c. Myocardial Infarction o Chest pain at rest d. Pericarditis o Associated with fever; leaning forward while seating relieves pain e. Aortic Dissection o Radiates toward to the back o Usually in elderly males with chronic hypertension f. Pulmonary Embolism (chest pain often not present) g. Pulmonary Hypertension (common to females) 2. Non-cardiac causes a. Pneumonia with pleurisy b. Spontaneous pneumothorax c. Musculoskeletal disorders d. Herpes Zoster e. Esophageal Reflux: causes from GI tract f. Peptic Ulcer g. Gall Bladder disease h. Anxiety states: hard to diagnose ***Muscuskeletal disorders and anxiety states are the most common cause of chest pain encountered in the clinic 3. Dyspnea Cardinal symptom of heart failure Left sided HF increase in pulmonary venous pressure pain 4. Orthopnea Dyspnea at recumbent position 5. PND 6. Palpitations 7. Lightheadedness or Syncope SYMPTOMS ACCORDING TO CARDIAC DISEASES: 1. MI Indicator: Chest Pain (angina) 2. CHF Indicators: o Easy fatigability/Weakness o Dyspnea, Orthopnea o PND, Wheezing 3. Abnormal Cardiac Rhthym or Rate Indicators:

Just to reiterate, here are some things that you must take note (part of cardiac auscultation): 1. Intensity 2. Timing 3. Quality of the sound 4. Location 5. Pitch Again: Describe the murmur in terms of its intensity (Grading; 1/6, 2/6...) Timing: systolic or diastolic? Quality of the sound: blowing, harsh, machinery-like? Location: 2nd ICS left, 2nd ICS right, tricuspid, fourth ICS left parasternal border; does it radiate towards the back or the neck?

Commercial! Q: What is the earliest grade when you may experience a thrill? A: Grade 4/6. A grade 3/6 will not have a thrill but a grade 4/6 may or may not have a thrill. When/where do you find a diamond shaped murmur? Ascending aortic stenosis! Sample Case 1 A patient who presents with a grade 4/6 systolic crescendo-decrescendo murmur of the right parasternal border. Crescendo: ascending; decrescendo: descending; radiating

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o o o o

Cyanosis Syncope Palpitations Dizziness

Cardiac Arrhythmias o Tachy and brady can cause symptoms of syncope o Big interval between each cardiac cycle

COMMON CAUSES OF HEART DISEASES IN RELATION TO SYMPTOMS Myocardial Ischemia o Atherosclerosis = most common cause (95%) o Presence of risk factors is need for diagnosis Smoking, DM, HPN, Hyperlipidemia o The classification here is more in terms of pathophysiology. For example, if a patient presents with chest pain and decreased cardiac output, then the mechanism is myocardial ischemia. Ventricular Impairment (Contraction/Relaxation) o Systolic Dysfunction o Diastolic Dysfunction If a patient comes to you because of decreased cardiac output, then it can also be due to abnormalities in contraction and relaxation. So as early as now, you should understand systolic and diastolic heart failure. Diastole is the relaxation of the left ventricle when you have ventricular filling. But as early as now, you must be aware that there is such a thing as pure diastolic heart failure that occurs in patients with very thickened or hypertrophied left ventricle. Again: Pure Diastolic Heart Failure: occurs in patients with very thickened or hypertrophied left ventricle Obstruction to Blood Flow/Forward Flow o There is hypertrophic cardiomyopathy (HCM) diastolic problem decreased CO Cardiomyopathy refers to primary diseases of the myocardium. There is no known cause or etiology but the patient usually presents with heart diseases. What happens in hypertrophic cardiomyopathy is a diastolic problem: You have a very small left ventricular cavity due to the thickened myocardium. Thus, during diastole, it can hardly relax. Therefore, what happens is there is decreased cardiac output due to decreased venous return. There is decreased stroke volume, and decreased blood pressure. Again: Hypertrophic cardiomyopathy: Diastolic Dysfunction

Abnormal breathing or syncope Manifestations of persons with abnormal breathing or weight. So, in terms of pathophysiology, most of the patients with cardiac diseases can be classified under these 4 classifications. But if you are asked to diagnose, you will not put these but rather you will put coronary heart disease, congenital heart disease, valvular heart disease, or cardiomyopathy. ELEMENTS OF A COMPLETE CARDIAC DIAGNOSIS (must memorize) When you make a diagnosis, you must include the following information: 1. Etiology 2. Anatomic Abnormalities 3. Physiologic Disturbances 4. Functional classification. - Etiology (Ex. RHD) Concerned with the type; Congenital: ASD, VSD, PDA (LV dilatation) Infectious: infective endocarditis (valvular/Congenital heart disease), myocarditis Hypertensive: very prevalent condition that can affect the heart, brain and kidneys Ischemic: Hypertension Cardiomyopathy (elicit from History and PE) - Anatomic Abnormalities (eg. Dilated RV) If the diagnosis would suggest the presence of a dilated left ventricle or hypertrophied left ventricle, or dilated left atrium, then include that in the diagnosis. Valvular involvement? LV hypertrophied or dilated? LA dilated? Specificity with a particular chamber of the heart that is enlarged o Most common is the mitral followed by aortic; o Least affected is tricuspid and pulmonic o Right sided enlargement: Pulmonary HPN (this italicized part taken from past tranx) - Physiologic Disturbances Is there arrhythmia? Is there sinus rhythm? Note that the opposite of arrhythmia is sinus rhythm. Arrhythmia listen for 1 full minute to hear 1 or 2 skip beats/min Thyrotoxicosis Anemia Regularly irregular every 4th beat is premature Irregulary irregular no pattern, sometimes fast or slow SAMPLE QUESTION 1. 50 year old with chest pain, consulting in the ER due to

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anginal pain. This is how we should diagnose: Etiology: Myocardial Ischemia Anatomic abnormalities: Coronary atherosclerosis (because we said that 90-95% of coronary artery diseases are due to atherosclerosis) Physiologic: You cannot rule out the probability that the patient may have anemia or thyrotoxicosis. Sinus rhythm Always the last in the diagnosis is the New York Heart Association (NYHA) Functional Classification. NYHA Functional Classification: Gives us an idea of the severity of the heart failure. Class Class I (Mild) Patient Symptoms No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. Class III (Moderate ) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea (causes symptoms). Asymptomatic at rest Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

position other than sitting upright. Lying down would aggravate the elevation of left ventricular filling pressure and aggravate the symptom of heart failure. Example: If a patient can text before without any discomfort but now experiences shortness of breath while texting, which class does this fall under? Class III Of course, this is an exaggeration. But this is more less the idea behind Class III.

ESSENTIALS IN CARDIAC DIAGNOSIS Despite the laboratories now, a good history and thorough physical exam is still necessary to come up with a good and proper diagnosis. 1. History and Physical Examination 2. ECG recording of electrical activity of the heart, most common indication is chest pain Common uses: 1. Find out if there is an ongoing ischemic or coronary artery disease (most common use) 2. Chest Pain 3. Find out the kind of arrhythmia that the patient has. 3. Chamber enlargement ECG is very useful in documenting myocardial infarction, especially if youre considering an old M.I. Old M.I. = Pathologic Q Wave Acute/Ongoing M.I. = ST Elevation 3. Chest X Ray For cardiac enlargement/chamber enlargement Most useful in diagnosing if there is pulmonary congestion Vascular Diseases CHD Edema Pleural Effusion (see enlarged cardiac shadow) 4. Non-invasive examination Echocardiogram: Ultrasound for the heart o Said to be gold standard o To know presence of: Wall motion abnormality LV dysfunction Valvular heart diseases For valvular heart diseases, echocardiography is the diagnostic procedure of choice (from past tranx) Treadmill Exercise Test o Done if a patient is symptomatic but shows a normal ECG (and the age of patient is around 50 60 years) o Provoke the occurrence of ischemia where there is imbalance of oxygen supply and

Class II: Ordinary activity will cause symptoms. The situation is usually something like this: The patient will go to work and will have to run to ride a bus. If before, the patient can do that without symptom, now the patient can no longer do that. The patient now experiences shortness of breath just by walking fast or climbing up a few flights of stairs. This falls under Class II. Class III: Less than ordinary activity causes the symptoms. This means there is marked limitation of physical activity. The usual example is if a patient experiences shortness of breath just by taking a bath or brushing his/her teeth (basically normal/regular things we do for hygiene). Class IV: There is inability to carry out any physical activity without discomfort. Patients in Class IV also cannot tolerate any

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demand Halter Monitoring o 24 hour ECG monitoring o If you watch HIMYM, si Barney Stinson nag-ganto. True story. haha.

Hence, she underwent ECG = normal Q waves; then doctor examines the patient carefully, and finds a mid-diastolic murmur at the apex. A mid-diastolic murmur is suggestive of mitral stenosis. 5. 16 year old female complaining of dyspnea and easy fatigability, and increased blood pressure and a displaced apex beat. A displaced apex beat would signify cardiomegaly or more specifically, a dilated left ventricle. (Displaced laterally and inferiorly.) An apex beat lower than 5th ICS or more lateral than the mid-clavicular line strongly suggests a dilated left ventricle. (Dilated, NOT hypertrophic) 6. 30-year old female with shortness of breath and murmur(?), and a grade 2/6 systolic murmur at the 2nd ICS right parasternal border Grade 1 or 2/6 systolic murmur can be physiologic. Heart failure on X-Ray: Find an enlarged cardiac shadow, redistribution of the pulmonary veins towards the apex. Cephalization: earliest finding in the chest x-ray of a patient with hear failure. In a normal individual, the blood flow is more prominent in the base; hence, when a chest xray is performed, the mid-lung up to the apex is clear. But in a patient with heart failure, there would be a redistribution of the pulmonary blood flow such that you will find prominent pulmonary veins from the mid-lung up to the apex. PITFALLS IN CARDIAC DIAGNOSIS A. Failure by the non-cardiologist to recognize important cardiac manifestations of systemic illnesses Example: 1. Stroke in the Young The neurologist might fail to recognize that this stroke in the young can be due to mitral stenosis o Mitral stenosis predisposes one to stroke due to the dilated left atrium The dilated left atrium is prone to thrombus formation, and once the thrombus moves out of the LA to the LV, it can go to the peripheral circulation and block the cerebral artery. 2. Hyperthyroidism (as the cause of heart failure) 3. Marfans Syndrome (aortic dilatation or aneurysm) These individuals commonly have aortic dilatation or aneurysm 4. Hypothyroidism (pericardial effusion) 5. Rheumatoid Arthritis (pericarditis) 6. SLE (pericarditis) b. Failure by the cardiologist to recognize underlying systemic disorder in patients with a cardiac disease Example: 1. Atrial Fibrillation (Hyperthyroidism) The most common arrhythmia that you would encounter in the clinics Can be due to underlying hyperthyroidism

5. Invasive Examination (very costly) Cardiac Catheterization o Check severity of coronary artery disease Coronary Angiography o Done before performing bypass procedures o Said to be gold standard for IHD o Very expensive! ***In patients with at least Grade 3 systolic murmur, do an echocardiogram. This is because Grade 1 or Grade 2/6 murmurs may be physiologic (i.e. murmurs that occur if the individual is young and there is a hyperactive circulation causing a Grade 1 or 2/6 murmur). Remember: A diastolic murmur is ALWAYS pathologic. And a continuous murmur is also always pathologic. IMPLICATIONS OF PATIENTS AGE There are what we call minor risk factors or non-major risk factors: 1. Male (aged 45 and above; females 55 and above) 2. Age Males: 45 years and above Females: 55 years and above SAMPLE PROBLEMS 1. 60 year old male, hypertensive, smoker Risk factors present: HPN, smoking This patient has two major risk factors and two non-major coronary risk factors. The point is that, when the patient comes to the ER and complains of chest pain, the first thing to do is to characterize the chest pain! If anginal, then ideally, do an ECG. If ECG is normal, do a Treadmill Exercise Test. If the chest pain is non-anginal, you will not do anything. (Of course, this does not really happen in reality due to legal matters, but ideally, once youre able to characterize the type of chest pain, you should be able to decide if an ECG is necessary or not). 2. 24 year old female, non-smoker, complaining of chest pain Well, in the first place, there is a low chance that a 24-year old female will have an anginal chest pain. Hence it is probably non-anginal. Again, in a perfect world or setting, it is okay to not do anything (i.e. cardio tests) since youve concluded that the patients chest pain is non-anginal. 3. A 20-year old female, non-smoker, complaining of chest pain and other symptoms Other symptoms: youll learn later that Mitral Valve Prolapse not only has chest pain but also comes with anxiety symptoms (i.e. palpitations, etc). Anxiety is a broad syndrome; feeling of something bad is going to happen, etc. 4. A 45-year old female, asymptomatic, needing medical clearance for employment abroad.

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2. Pericarditis (SLE) 3. Pericardial Effusion (Hypothyroidism) c. Over-reliance on and over-utilization of lab tests, particularly invasive techniques DISEASE PREVENTION AND TREATMENT This is mostly for coronary artery diseases. - Assessment of the patient - Recognizing and eliminating risk factors Drugs Lifestyle modification Lose weight Stop smoking Moderation of alcohol intake - Aggressive treatment of all the risk factors --------------------------------------------------------------------End. Hi. Sorry maraming words. Sources: Lecture, old transcription (batch 2012), Harrison, Robbins, Doogle.

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