Cardiology Dr Osama Mahmoud

CardiologV

.

..........................'Q~' 'I~e'iiafilyileite'iis I()·I'························

~ ClP: C/P of hypertension - C/P of the cause.

·

~

~ t1!:1!:il

~Medical

.

drugs

(as before)

•.••

.

4Surgical,

according

to the cause

as renal

artery

stenosis./

•••••

........•........................................

............

•.........

•.

~.....

•..•

.........••••

,.....-----.

Renal artery

stenosis - Cushing $

1-----

. Acromegally

• Pheochromocytoma.

-----:;-----

+ Coarctation

of aorta

C/IP~Hypertension + the

cause

IDyg§jti8'.t~Q)aSJ

* for hypertension

Hypertensive crises

IBP >

!!OO/I!!O

mmHg)

are subclassified into:

* Hypertensive

urgency:

Severely elevated blood pressure with no evidence of

ongoing

target

organ damage i.e no neurologic,

cardiovascular or renal deterioration

and

funduscopic

abnormalities.

Blood pressure

should

be controlled

within

24-48 hours.

It can includes

the term accelerated

H !?

* Hypertensive

emergency:

As above but with evidence

of ongoing target organ damage. It should be

treated immediately

with parentral

medications,

with reduction

of

the

mean blood

pressure

by 25% within

1 hour of presentation.

It includes

hypertensive

encephalopathy,

LVF

and

acute

renal

failure,

aortic

dissection,

subarachnoid

hemorrhage,

and

cerebral

infarction

or

haemorrhage.

It can includes

the term!? Malignant

H.

t. Age ---

Usually

above 40, sometimes

rHD occurs in young age due to

Obesity!

Smokingr

Stress1

Familial1

2. Sex: male>

female,

positive family history.

hyperlipidemia

Diets

deficient

in fresh fruit, vegetables and polyunsaturated

fatty acids.

Low

levels of

vitamin C. vitamin E and other antioxidants

may enhance

the production

of oxidised LDL. Low dietary folate and Vit B 12 can elevate

homocysteine

levels.

¢ High CRP

¢ Chlamydia pneumoniae.

t---

+ Bronchogenic

carcinoma

__--

....'----

+ Emphysema

l (evs

1t----

+ Hypertension!?

t---

+;~;~~~a~eart

disease

.....................:·:::::::::.::Smoking J-J- HC03

contents]

Oesophagus

l

-, of pancreatic

juice.

.r" :

i!

i

.

Carcinoma.

)

(··..It·{nc~~·~~·~·s··the·"inddence··oi·..·········\

..................................

~ crohn' s disease

and decreases

the ~

r-·R~fl~~··~·~~·~~h~~·i·~i·~······lincidence of ulcerative colitis

~

...........

~

;

l (Urinary k;/

\

l

~./

-

.

(Cancer.....................

\

(~::~'.~l~~~

"U

fWdiilt·' il·' II:

1-]

Do not sJoke

1· -Regular exercise

1Ideal bO!Y weight

No more than 30%

Fruits and vegetables

of energy intake from fat

in diet

I'Ut~¥!§;lSi!t.]; i.]II: It]

1. Asymptomatic.

2. Sudden death.

3. Angina pectoris

4. Myocardial Infarction.

S. Heart failure.

6. Arrhythmia.

Caf'diologi

I

AI\IGII\IA

PECTORI§

GlEpisodic

clinical syndrome due to transient

myocardial

ischemia

characterized mostly by chest pain with no cardiac tissue damage.

~

•••.

Quantitative

defect of

Atheroma

coronary blood flow

Coronary

spasm

Vasculitis

Qualitative

defect of

,

Thrombosis or emboli

Anemia

coronary blood flow

Hypoxia.

Increased cardiac

Left ventricular hypertrophy.

muscle demand

oChest pain:

S~-1?>trQ~~

(hcaviness.T

by exertion, -l-by rest or nitrates)

~

jaw, neck

Left shoulder

retrostemal-+-------+I

epigastrium

Left arm.

@ Risk factors

are positive (see before)

•••••••••••••••••••••••••••••••••••••••••••

s ••••••••••••••••••••••••••••

@ Anginal pain never to be:

<DLocalized.

@ Stitching or throbbing.

® < 30 sec. ,> 30 min

(except unstable

angina)

@ The anginal

pain

PPT

by:

.:.

Exertion

.:.

Cold exposure

.:. Heavy

meals

.:.

Vivid dreams

(nocturnal

angina)

.

~

~

z. Heart

sounds

~ S4 due to decreased

ventricular compliance (Apex).

3. Murmur of MI due to ischaemic papillary muscle may be present.

4. Other

manifestations

e.g xanthelasma

in hyperlipidemia, anaemia.

Cat'diotogi

~~

~J~~~

~~,A

(Thallium,

Technetium)

Thallium

IV

Uptake

by the heart.

~

reflect

coronary

perfusion. ~

Ji!5

Thallium with exercise

is more accurate.

Ji!5

The heart also can be stressed with dobutamine

in patients

unable

to do exertion.

S,.

E~~lm~~1~4iim\U~-a'ftlbvr 3!Tr'Id!dm,'hI1!l!:Ii'3!TrI'r'I;j!De).;e~lml.

=,:1

~!!a~~~-

_!2!:.I~~~

_~=a:.l~

__~!:.I_':I

__::a~

_:.I:.1_~~!:

'='~

'=' ~I!a~:a

~~ ~:r-Q)a~J-T

~....D~Q)~~4?JIIl.y (coronary catheter).

Indications:

1.

Stable angina refractory

to medical

therapy

2.

Unstable

angina

3.

Strongly positive stress test

4.

Post infarction angina

5.

Unexplained

/ significant chest pain, where the diagnosis of angina is uncertain

~~

1iJLI~

I

~..I~

~~~-ym.~

Ji!5 Normal/No

tissue damage.

8.

E.IiiD,iid!

'm1~...(f)\Pil!,e\ S~\r.J1!l!'I'rYr'1 bm\lf.'I!llm~-!''''rSftre\il~le\

~:i

=...~_:a

I!:r~- ~~

~g

~=.&

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C~lQ)

:b'~lmllr'~1sl"Il'IIlga'r.!!

~~"

~~~

~~!!!J-~-:i

¢ Aetiology:

Atherosclerosis.

¢ Risk factors:

Are usually present.

¢ Criteria of pain EShort duration (5-10 minutes)

Induced by exertion, emotional stress.

Relieved by rest and nitrates.

Some patients suffer anginal pain during the start of walking then disappear

despite

greater

effort.(start - up angina).

¢ ECG

•

S-T segment depression occur in EeG with effort

or during anginal attacke.

¢ Angiography--+

Fixed lesion /~:

""

(stable atheromatous)

"Atheroma.

plaque

./

Predictable exertional

angina.

./ Good effort tolerance .

./

Ischemia

only at high work load.

./

Good left ventricular function .

./

Single vessel or minor

two vessel disease.

Treatment of ~a

~

High risk

Low risk

+

+

Medical treatment

,. ,. ,. ,.

,. ,..•..Coronary angiography

•

B.B.

,.

•

Ca. Ch. Blockers.

•

Nitrates.

I

I

Single or two

Left main or severe

•

Antiplatelete.

I

I

vessel disease

3 vessel disease

I

If no response

II

+

treatment

+

.:. Medical

.:. CABG .

•:. PTCA .

•:. CABG.

CABG (Coronary artery bypass grafting)

PTCA (percutaneous transluminal

coronary

angioplasty)

Or

~-.

Pre infarction

angina.

~~

T

¢ Aetiology

~-

Intermediate

coronary $.

as above. (But with complicated

atheromatous plague)

i.e a complex ulcerated

or fissured atheromatous plague

± local coronary spasm.

¢ Treatment,

It is a medical emergency:

o Hospitalization:

To exclude

infarction (by enzymes), also there is high

~~.B.

risk of MI or death.

@Initialttt

e.g atenolol50-100

mg/12 hr. (verapamil is an alternative)

---

--++-

ca ch. B.

Anticoagulant

.• Nitrates

e.g Amlodipine (can be added

(Low molecular

Antiplatelete

e.g glyceryl

to BB, it may cause unwanted

weight heparin)

Aspirin 75-325

trinitrate infusion

tachycardia if used alone).

for 3-5 days.

mg/d.

0.6-1.2 mg/hr.

Coronary

~

Bypass

~~::======~--------------~

Artery

Coronary

angioplasty:

'"\

Grafting

(CABG):

By balloon catheter

Using saphenous vein

(percutaneous

transluminal

or internal mammary

artery

,

.

coronary angioplasty) = PTCA.

The main acute complications

are

occlusion of the target vessel by thrombus

'- or.dissection

(2%), mortality

(l %).

¢ Pathology

Coronary spasm.

¢ Age

Young age.

¢ Risk factors

are negative

¢ Not related

to exertion.

¢ Diagnosis

Hospitalization

•

Coronary care unit (CCU)

* Give~Ca

Ch. Blockers.

"<,

Or

Q Decubitus

Angina:

Is that occurring

on lying down.

It usually occurs

with association impaired

left ventricular function.

Q Nocturnal

Angina:

Is that occurring

at night and may wake up the patient from sleep.

It may be provoked by vivid dreams.

Q Cardiac syndrome X:

Refers

to patients

with a good history

of angina,

positive exercise test with

normal angiography.

This is due to abnormalities

of the coronary

microcirculation.

Q Angina with normal

coronary

arteries

i.e. (normal angiography)

1.

Coronary spasm.( < 1% of all cases of angina)

2.

Cardiac syndrome X.

~ In between the aitaeks:

I.

l3i~

.t fat,

t CHO,

.t salt.

II.

Stop

smoking,

moderation

of life,

aspirin 75-150 mg/d.

III.

Treatment

of risk

factors:

DM -

Hypertension

- Hyperlipid~mla.

IV.

Drug therapy.

I~ID!!!!!!!!ru!!!!!!!!g!!!!!!!!t~he!!!!!!!!r

a!!!!!!!!p!!!!!!!!y!!!!!!!!!!lll

"I- Nitrates:

(converted

to nitric

oxide

vasodilatation.)

'* Action:---+

I@' Venodilators

----+ .tVR

~

.t preload

"'" coro!ary

vasodilatation?!

,dilate

tt ventricufar

wall

tension,

the larger conductance

arteries.

'*Other

uses:

CD Oes

spasm

and

achalasia.

(?)

Reliefe

of pulmonary

venous

congestion

G) Myocardial

infarction.

@ Biliary

colic

and hypertensive

encephalopathy.

'*Side

effects: Headache

-

Hypotension

,*Routes:

tlhe

1. Sublingual

tablets

300 or

500

ug

(glycerly

trmrm-ate). It call relieve

anginal

attack

within

3 minutes,

the

dose

GaB be

repeated,

subling\!lal

spray can be used (glyceryl

trinitrate

400

ug/puff).

2. Oral

isosorbide

dinitrate

10 - 20

mg/8

hrs

(Dinitra)

3. Amyl

nitrate ampule for

inhalation.

4.

Ointment

(2%

nitroglycerin

ointment)

at night.

5. IV used

in myocardial

infarction

and

unstable

angina.

6.

Transdermal

patches

~

long

acting

transdermal

nitroglycerin (it

can

be

applied

in the morning

and removed

at bed time).

¢ Chronic

use

of nitrate

produces

tolerance.

¢ Long

acting

nitrates

(Isosorbide

mononitrate)

are

preferred,

20-60

mg

once

or twice/d

e.g effox

tablets

20 mg.

¢ Sildenafil

(Viagra)

should

not

be given

to patients

taking nitrates.

Cardiotogi "

11-B.B.:

*Action:

-J< tt 02 consumption.

L

Negative

inotropic

2.

Negative

chronotropic

II the time of coronary filling.

*Types:

3. Third generation

with

additional vasodilatation effect

E.g. Carvidilol

(Dilatrend 25 mg/d)

Lipophilic

B.B (lipid soluble):

They are well absorbed

but undergoes extensive hepatic metabolism,

this leads to short half life. They cross BBB e.g.: Propranolol.

Hydrophilic

B.B (water

soluble):

They are less absorbed

and slowly eliminated, this leads to sustained

Concentration.

They can't pass BBB e.g.: Atenolol.Nadolol.

• Bradycardia.

•

Heart

block.

• Heart failure.

•

Night

mares.

• Depression.

•

Sudden withdrawal ~angina.

• Fatigue.

•

Impotence.

• Bronchospasm

(with non selective BB).