Dr.

Lamia El Wakeel, PhD Lecturer of Clinical Pharmacy

Every 36 seconds 1 person dies from CVD In the US, 2,500 people die every day CVD exceeds the next four leading causes of death combined (cancer, lung disease, accidents &diabetes) A careful patient history & physical examination are extremely important in diagnosing CVD & should be done prior to any test

1. History taking 2. Physical examination 3. Prognostic & diagnostic testing

 Cornerstone of a cardiovascular workup The elements of a comprehensive history include;

Chief complaint (CC); exact complaint, duration, severity,

limitation of daily activities, character & location of complaint & what brings on the complaint.

Present problems Past medical history History of Present Illness (HPI) Review of systems (ROS) Family history (FH) Social history

Cardiovascular PE is divided into 4 categories: 1. Global examination of the patient for signs of CVD & a review of all body systems 2. Observation & assessment of physical findings (JVP) 3. Measurement of parameters of CVD function (P, B.P) 4. Auscultation, percussion &palpation of the chest & related cardiac structures. A. Heart sounds B. Peripheral circulation & arterial pulses C. Heart rate

1. Normal heart sounds a. 1st heart sound S1; closure of AV valves (tricuspid b.

& mitral); beginning of systole (loudest at apex) ; lub 2nd heart sound S2; closure of SL valves (pulmonic & aortic);. ending of systole (loudest at base); dub .

Splitting; P2 & A2 sounds

2. Abnormal heart sounds a. S3; heard at the end of the rapid filling interval of the diastole Auscultated areas; denoting volume overload apex or base of the heart (mitral sounds) b. S4; indicating an increased resistance to filling(noncompliant lower left sternal border (tricuspid sounds)
ventricle or an increased volume)

S3 is normal in children & young adults. Horse while S4 may be normal above 40 yrs
turbulent blood flow within the heart chambers or valves)

second left interspace (pulmonic sounds) gallop, second right interspace (aortic sounds) S1 & S2 heard at all

c. Murmur; auditory vibrations heard on auscultation (due to

Classified by; timing & duration (systolic, diastolic & continuous), location, intensity, pitch (frequency) & radiation. Fever, anxiety, anemia, hyperthyroidism & pregnancy exacerbate physiologic murmurs

 The JVP is used as an indirect measure of RAP measured in cms from the sternal angle best visualized with the patients head rotated to the left Report; extent of elevation & pt position JVP; cms above the manubrium, or this value +5 -7 cm to indicate the rise of the JVP above the right ventricle. Elevated in HF degree of elevation; used to assess severity & management

 Arterial pulses are evaluated & characterized bilaterally by; observation, palpation & auscultation for presence, character, pattern & rhythm. Patterns; pulsus alternans , & paradoxical pulse & others. Pts overall peripheral circulation is recorded; presence degree of edema or skin changes Capillary refill (N; < 2 seconds); depress nail bed until it blanches , release pressure & watch for color return (indicating blood flow)

Described by both rate & rhythm Arterial pulse; taken at the radius, but other arterial pulses may be used Healthy; count pulse for 15 seconds & multiply by 4 Pts with irregular rhythms, the pulse should be taken over an extended period (1-2 minutes), In patients with AF apical pulse should be counted Pts with a rapid ventricular rate (SVT, AF, VT);
extremity pulses (radial) may be slower than true rate more accurate; listen to ventricles with stethoscope (usually at the apex) or counting from an ECG.

1. Chest radiography 2. Electrocardiogram ECG 3. Ambulatory ECG monitoring (AECG) (Holter) 4. Exercise stress (tolerance) testing (ETT) 5. The echocardiogram (ECHO) 6. Nuclear cardiology 7. Positron emission tomography PET 8. Pharmacologic stress testing 9. Computed tomography CT 10. Catheterization

 Does not provide details of internal cardiac structures but general information about position & size of heart & surrounding anatomy. Standard chest radiographs are ; standing posteroanterior & lateral views taken at maximal inspiration (AP in Bed) Lack of inspiratory effort & obesity lead to a poor-quality chest radiograph 2 perspectives: (a)Observation (b) clinical correlation Observation; size & placement of the heart, chamber enlargement, pulmonary vasculature, airfluid levels & diaphragm. Cardiac enlargement (cardiothoracic ratio)

 ECHO; the use of US to visualize anatomic structures (valves) & describe wall motion Indications: valvular dysfunction, Global or segmental wall motion abnormalities associated with cardiomyopathy or ischemia, respectively. Segmental wall motion abnormalities are graded as; akinetic, hypokinetic, Estimated parameters: chamber wall thickness, left ventricle dyskinetic, and hyperkinetic. ejection fraction, ventricular function & abnormalities of the pericardium (effusions or thickening). ECHO in clinical practice: can be Transthoracic (TTE) or transesophageal (TEE)

 TEE ; patients in whom TTE is limited (MV, obesity), more accurate assessment of valvular structure / function or to visualize intracardiac masses (tumors or thrombi). CI of TEE; patients with esophageal abnormalities. Doppler and color-flow Doppler technology Principle; reflecting sound off a moving object (RBCs) Used with ECHO for analysis of ; valvular function (aortic regurgitation, mitral stenosis) or blood flow patterns measurement of transvalvular pressure gradients, valve area, and pressure changes on either side of the valve.

 ETT ; evaluates clinical & CVS responses to exercise (ability of HR to increase appropriately during exercise) Method: done on treadmill or bicycle ergometer while patient ECG, HR & hemodynamics are assessed Degree of stress delivered in a graded & calibrated manner Protocols customized ; an exercise time of 6 - 12 min & HR of 85% - 90% of maximum predicted (target HR= 220-age) Principle; increase myocardial oxygen demand > myocardial oxygen supply & coronary reserve provoking ischemia Ischemia; pt symptoms, ECG changes, and/or hemodynamic changes Measurements; peak heart rate, predicted max HR & HR recovery after exercise testing (N; rapid fall of HR during 1st 30 sec after exercise). AE: arrhythmias, sudden death, hypotension & MI CI: UA, CHF, untreated life threatening arrhythmias

 An alternative in pts unable to undergo ETT Agents produce stress by; hyperemic (vasodilator) response; dipyridamole & adenosine increasing myocardial oxygen demand (HR & contractility); dobutamine Evaluates; wall motion abnormalities & perfusion Can be performed using; thallium, MRI, ECHO, etc

Dobutamine
Mechanism; inc. HR & CO; inc myocardial oxygen demand (Ischemia develops in stenotic areas) Detection; Ischemia detected by ECHO or thallium . Dose of stress test; doses of 10 - 40 mcg/kg/min; dose titrated at 3-min intervals in increments of 10 mcg/kg/min Atropine may be given to augment HR response Monitoring; ECG & BP; continuously ,ECHO ;last minute of each dose level & during recovery D.C -Blocker & CCBs prior to test (interfere w HR response) D.C if ; severe CP, extensive new wall motion abnormalities, ST-segment dist (ischemia), tachyarrhythmias, & symptomatic reductions in BP CI; aortic stenosis, uncontrolled HTN & severe ventricular arrhythmias.

Dipyridamole & adenosine

Principle; Dipyridamole inhibits adenosine cellular reuptake Adenosine is a potent CA VD & increase perfusion 4-5 times > baseline Areas distal to CA obstruction show relative hypoperfusion vs normal Acutely, these areas will appear as cold spots, On redistribution scans; defects will fill, indicating viable but jeopardized myocardium. Dose; Dipyridamole IV; 0.142 mg/kg/min over 4 min. Adenosine; over 6 min at a dose of 0.140 mcg/kg/min Imaging (thallium scanning) can follow immediately to heighten the redistribution defects. ADR; dipyridamole; CP, headache, dizziness & N (give xanthines; adenosine bocker) Caffeine products and theophylline must be avoided for about 24 hrs prior to the test. CI; history of bronchospasm.

technetium-99m (99mTc); t ; 6 hrs (multiple dosing); gamma ray emission Evaluation of bld pool & myocardial perfusion (EF, cardiac shunts, volumes & wall motion) 99mTc-PYP; for presence & extent of damaged myocardium after MI Uptake into infarcted tissue depends on; regional blood flow, myocardial calcium concentration, degree of irreversible myocardial injury & time after infarction Attaches to calcium deposited in the infarcted area; hot-spot scanning False hot spots; necrotic myocardial tissue (detected after 4 hrs of coronary occlusion) Scans prior 4hrs are ve, +ve 12 hrs after 99mTc-PYP is a useful late marker of infarction

Thallium-201 (201Tl); t ; 73 hrs; energy emitted x-ray Thallium is a potassium analog taken up into normal myocardium by passive diffusion & active transport via Na+-K+ATPase pump. Uptake depends on regional blood flow; high uptake occurs in perfused myocardium & vise versa A repeat scan 4 -6 hrs after initial scan may show a redistribution; these defects are referred to as partial defects (areas hypoperfused during stress but viable myocardium at rest) Areas of nil distribution are called cold spots or fixed defects (MI) For postop evaluation of angioplasty procedures & in conjunction with ETT (inject at ETT peak & exercise continues for another 30-60 sec

Priniciple; CT uses series of X-rays taken from different directions & info presented as cross sections of organ viewed giving 3 dimensional images (w or w out I2 dye) Uses; determination of chamber volume, size & myocardial wall thickness, localized areas of infarction, abnormal perfusion Most sensitive to; differentiate types of pericarditis, estimate pericardial fluid volume, evaluate cardiac masses Calculate; EF, LVV, SV

Principle; PET measures emissions from radioactively labeled metabolically active chemicals, data computer processed; 2-3 dimensional images of distribution in organs. Types of studies; Myocardial perfusion study; (82Rb), ([13N]H3) & 15O2labeled H2O. Uptake of 82 Rb via Na+ K+ ATPase pump (viable cells) Myocardial substrate metabolism; [11C]palmitate, [11C]acetate, and [18F]2-deoxyglucose (FDG) Fasting & PP cell metabolism (ischemic & N) Hibernating vs infarcted (decision for angioplasty) Uses; measure regional myocardial uptake of exogenous (glu & FA) quantitate FFA metabolism define perfused myocardium energy source(s) Adv; non invasive, repeat scans over short time (t ; <10min) Disadv; expensive

Priniciple; for vascular access to CA, percutaneous through brachial or femoral artery till site then dye injected Types of procedures; 1. Lt sided catheterization; access to aorta, LV & LA For coronary angiography & ventriculography 2. Rt sided catheterization; coronary sinus, pulm arteries, Determination of cardiac performance

Prior to Procedure; fasting, D.C warfarin, heparin (6hrs prior to procedure), ACS; UFH, LMWH, sedatives (pt aware) During procedure; HD, BP, HR & ECG continuous monitoring After procedure; pt remains still 6-8 hrs, discharged same day or w in 24 hrs, CPK troponin elevated Complications; Thrombotic (depend on) Bleeding Heart perforation Vagal reflex w hypotension, brady cardia (atropine) MI (risk; DM, UA)

1. 2. 3.

Cardiac catheterization is the GOLD standard for diagnosis & assesment of CAD Used w PTCA & or drug therapy in management of ACS assessment of valvular function & computation of cardiac performance parameters; CO, SV, SVR, bld flow Drug administration for; Thrombolytics to assess CA patency VD for CP Diagnosis; ergonovine for coronary spasm

Angiographic study
Radiographic visualization of coronary vessels after injection of radio opaque contrast media Angiography determines morphology of a stenotic lesion & degree of luminal obstruction Collateral circulation Dynamic; vasospasm Extent of disease depends on; no of vessels 75% or more; seen on angiography 50 % or >; significant marrowing 40-60% ; are CA lesions prone rupture or form thrombus Lesions are simple or complicated

Ventriculographic study
Injection of radioopaque contrast media into the ventricles & determines; contour of the heart regional wall motion filling defects Presence of mural thrombi

Left coronary artery

Right coronary Artery

Diastole Systole

 Measurement of electrical activity in the heart; by Willem Einthoven

Procedure of 1st choice for evaluation of; chest pain, dizziness, or syncope Used for; rhythm abnormalities, evaluate ischemia, monitor responses to antiarrhythmic agents or pts receiving drugs with potential cardiac effects. ECG characterizes; rhythms & conduction abnormalities by inference; info about; anatomy & structures of heart, HD of CVS ECG abnormalities are earliest sign of ADE, ischemia & electrolyte abnormalities ECG findings shd be correlated w clinical & pathologic states Prior & /or serial ECGs in; pts with cardiac disease or on meds that alter ECG

Transmembrane potential; Na+, K+, Ca++, ClNa+; conc & electrical gradient K+; conc gradient

Cardiac Cycle

Principle ECG utilizes 12 leads which are composed of 6 limb leads & 6 precordial leads

1. Limb leads are: I, II, III, aVR, aVL, and aVF

Right Arm

Lead I

+
Left Arm

Lead II

I +
Lead III

(0 degrees)

III

+Left Foot +

II

+ (60 degrees)

(120 degrees)

Principle ECG utilizes 12 leads which are composed of 6 limb leads & 6 precordial leads

1. Limb leads are: I, II, III, aVR, aVL, and aVF

For a heart with a normal ECG and a mean electrical axis of +60, the standard limb leads will appear as follows:

Principle

1. Limb leads are: I, II, III, aVR, aVL, and aVF

augmented leads use one of the electrodes as positive (lt foot, r arm, or lt arm) & other 2 electrodes as negative; Leads aVL aVR aVF Sensor used as Positive Left Arm Right Arm Left Foot Sensors used as Negative L. Foot and R. Arm L. Foot and L. Arm L. Arm and R. Arm

The resulting vectors appear as follows:

Principle

1. Limb leads are: I, II, III, aVR, aVL, and aVF augmented leads use one of the electrodes as positive (Lt foot, Rt arm, or Lt arm) &
other 2 electrodes as negative.

aVR

aVL

aVF

Principle

1. Limb leads are: I, II, III, aVR, aVL, and aVF

Principle

2. Chest leads are: V1, V2, V3, V4, V5, V6

Transitional Zone

Analyzing the ECG

Rate Rhythm Regularity Axis Intervals o P wave o PR o QRS o QT Morphology o P wave o QRS

1. Rate

2. Rhythm & Regularity

The part of the heart controlling the activation sequence
Regular P followed by QRS

2. Rhythm & Regularity

Irregular No P wave Regular

2. Rhythm & Regularity

Tachycard ia Wide QRS If P is seen: after the QRS, inverted, or dissociated

2. Rhythm & Regularity

Normal Sinus Rhythm

Sinus arrhythmia

Sinus Tachycardia

4. Axis

4. Axis

5. Intervals

5. Intervals

6. Morphology

6. Morohology
RBBB

LBBB

 AECG (Holter monitoring); detect & document ECG abnormalities over

extended periods of time detects random abnormal cardiac electrical activity during daily activity & relates to pt symptomatology Types; Noninvasive; pt activated, duration; (hrs- days) Invasive; implanted & removed later, duration; yrs uses; screening for asyptomatic ischemia limitation; analysis of xxs day to day stimulation is hard Three types of monitors are available: (a)continuous monitors; record ECG strip over test duration (b)event or intermittent recorders; continuously monitor ECG but only record preprogrammed abnormal ECG events or are pt activated based on symptoms (pt diary); occurrence, duration & severity of symptoms + activities/ interventions (c)real-time analytical recorders; record throughout the monitoring period & analyze each beat as it occurs