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Investigations in cardiovascular diseases by dr. rkdhaugoda

Investigations in cardiovascular diseases by dr. rkdhaugoda

DrRajkumar
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Investigations in cardiovascular diseases by dr. rkdhaugoda

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  1. Investigations in cardiovascular diseases.NEW CONCEPT AND UNDERSTANDING CTGU- dr. RKDHAUGODA 12th MAY -2014

  2. COMMON PRESENTING PROBLEMS-IN CVS • Chest pain/chest tightness • palpitation • Dizziness/ syncope/LIMB WEAKNESS • Dyspnea-PND, on exertion,orthopnea • Oedema • Fatigue- low cardiac output. • Cough/hemoptysis-MS • FEVER/JOINT PAIN- rheumatic fever/ carditis

  3. Common Diseases of CVS • Hypertension • hypotension • Atherosclerosis • Coronary artery disease ( ACS) • Heart failure • Pericardial effusion/ cardiac tamponade • Peri/myo/endo-carditis • Rheumatic heart diseases/VALVULAR HEART DISEASES • Dilated/hypertrophic cardiomyopathies. • Arrhythmias • Congenital heart diseases • DVT • BUERGER’S DISEASE • DISEASES OF AORTA • Various forms of vasculitis/auto-immune diseases

  4. Common comorbidities • hypertension • Diabetes mellitus • Renal diseases • Connective tissues disorders-SLE,RA • Hypothyroidism • Hypothyroidism • Blood disorders • MORBID OBESITY • CHRONIC LUNG DISEASES • DRUGS- • Physiological stresses • Electrolyte- imbalances • Psychological- stress • Life style/ food habits/ drug abuse

  5. COMMON DRUGS USED IN CVS • Anti-hypertensives- diuretics,CCB,B-blokers,ACE/AR- inhibitors • Anti-plateletes- aspirine,clopidogrel • Thrombolytic-streptokinase,alteplase,reteplase • Vasodilators- GTN,sildenafil,isosorbidedinitrate • Antiboitics- penicillin, cefalosporine • Anti-coagulants- warfarine, heparin, • Antilipid- atorvastatine • Anti-hypotensives- adrenaline,atropine, dopamine,dobutamin, noradrenaline. • Anti-arrythmics-verapamil, b-blockers,digoxin,amiodarone, MgSO4,lidocaine. • Anxiolytics- alprazolam, diazepam • studies reveal the presence of the NMDA receptor in the kidney and the cardiovascular system. • NMDA-receptor modulator - may be the new class of drugs.

  6. Important CLINICAL examination of CVS • JALCCOD • PULSE- • BLOOD PRESSURE • JVP • SPO2 • R/R • AUSCULTATION- LUNG/HEART-heart sounds/ murmur • THYROID GLAND

  7. Current problems in cardiology • Philosophical problem-unscientific WHO HEALTH definition. unable to define disease and immunity officially by WHO. • Immerging Global problem-being number one cases of death world wide with long term morbidity and high cost. • Diagnostic problem-difficulty to subclinical level of disorder/disease, lack of discovery of proper early cardiac disease marker. As sudden cardiac death is being high.

  8. Current problems in cardiology • Disease understanding problem- lack of understanding of final pathway of disease pathogenesis. • Unable to identify the key influencing factor of immunity. • Management problem- preventive and curative • Problem of over and under nutrition. • Problem of modernization- smoking ,drinking, drug abuse, infections and more incidence of co-morbidity like, DM, HTN, CKD,COPD,VIRAL DISEASES,OBESITY.

  9. Current problems in cardiology • Generalized correlation problem with other diseases and alternative treatment system • Lack of other advanced newer knowledge and skills- • Post CABG- RE-ATHEROSCLEROSIS PROBLEM • INCRESEAD INCIDENCE OF OVER TREATMENT INDUCED INJURIES • REVEALING OF VIRAL DISEASES AND ITS DIFFICULT management

  10. Current problems in cardiology • Difficult management of underlying causes like diabetes and hypertension. • Management difficulties on mental stresses and lifestyle and food habits cultures of people. • Lack of time for practicing useful medical advice – like exercise in busy lifestyle • DIFFICULTY ON ACCESS WITH LOW COST

  11. AREAS OF INVESTIGATION IN CVS • Ix for proper cardio-vascular system-initial symptoms( screening , initial diagnostic, final diagnostic, staging/ quantification) • Ix for complications of symptoms or disease • Ix for concomitant associated diseases • Ix for screening of organ functions • Ix for evaluation of prognosis and treatment response • Ix for searching of iatrogenic effects of drugs and procedures.

  12. Basic CVS- investigation- theirinterpretations and D/D • ECG • CHEST X-RAY • CBC- TC,DC,HB, PLATELETS • CARDIAC ENZYMES • ASO-TITRE • ELECTROLYTES, UREA, CEATININE, ACETONE, RBS • LIPID PROFILE • CRP • BLOOD CULTURE • URINE R/E • COAGULATION PROFILE • ECHO-CARDIO-GRAPHY. • FUNDOSCOPY. • TFT

  13. ADVANCE INVESTIGATIONS • 24-HOUR ECG MONITORING • TREAD MILL • CT/ MRI • CARDIAC CATHETERIZATION • ANGIOGRAPHY • CT- ANGIOGRAPY • CAROTID DOPPLER

  14. Ix for complication of symptoms • Repeated ECG- Continuous cardiac monitoring • Repeated- cardiac enzymes • Repeat – chest x-ray • Repeat electrolytes/ ABG • REPEAT- ECHO-CT-MRI- • Blood c/s • LFT/ TFT/ RFT. Coagulation profile • RBS/ ACETONE

  15. Ix FOR COMORBITITYDM,THYOID DYSODERS, BLOOD DISOREDERS,SEPSIS,CONNECTIVE TISSUE DISODERS, LUND DISEASES, CKD, • Usg ABD • DM-BLOOD SUGAR- fasting /pp/Urine acetone • HTN- lipid profile, Doppler study of renal artery, 24 hour VMA • LUNG DISEASE- PFT/ ABG/ CT/MRI/ BIOPSY • For- connective tissue disoders- RA factor, ds DNA, ANA • D-DIMER • TFT- to rule out- thyroid disoders.

  16. Screening for OTHER-organ functions • RFT-Na, K,Mg ,Ca, urea creatinine • LFT- • LIPID –profile • Echo- • Chest- x-ray • CBC, RBS, URINE R/E • TFT ( GIVES- STATUS- OF BEFORE AND AFTER TREATMENT)- REFERENCE.

  17. Ix for searching of iatrogenic effects of drugs and procedures • ECG-cardiac enzymes, • RFT-Na, K, urea creatinine • LFT- • LIPID –profile • Echo- • Chest- x-ray • CBC, RBS, URINE R/E • TFT • Blood c/s , CT/ MRI, ANGIOGRAPHY, ABG

  18. ECG • Graphical representation of electrical activity of cardiac muscle ( heart) • Normal- ECG- • Physiological deviation- heavy exercise, athletics, high altitudes, pregnancy. • Abnormal- structural- heart diseases • Abnormal- chemical/ drug/ hormone induced

  19. NORMAL ECG

  20. interpretation • Rate • Rhythm • Axis • P-wave • PR-interval • QRS-complex • Q-wave • ST-segment • T-wave • U- wave

  21. Normal 12 lead ECG

  22. Characters of normal ECG • RATE- 60-100 beat/ m • Regular rhythm- equal distances between -R-R intervals. • Normal P- wave-best seen lead-II, INVERTED in aVR • Normal PR- interval= 3-5 small squars • Nomal-QRS-complex- duration less than 3 small squars, normal axis= 30-90 degree, steady progression from V1-V6.V1 predominantly down wards. • Normal axis. If both QRS complex is upward in lead I and III or aVF • Q-wave- non pathologic ,less than 40 ( 1 small square ) • ST-segment isoelectric • T – wave- normal hight. • U- wave- can be normal- usually not seen.

  23. HEAR -RATE calculationabnormal-less than 60/m and more than 100/m For NORMAL RHYTHM - in-fast HR ,1500 Divided by numbers of small squares between two consecutive R waves • In slow HR, 300 Divided by numbers of large squares between two consecutive R waves For irregular rhythm - Needs long ECG strip- of lead –II, count the total numbers of QRS complex within 15 large sqaures , then multiply by 20.

  24. Causes of Abnormal heart-rhythm ratesa ) sinus arrhythmia HR increases with inspiration and decreases in expiration, and holding of respiration. Causes of sinus Bradycardia Causes of sinus tachycardia Exercise Emotions/excitement Anxiety/fear CCF, severe anemia Thyrotoxicosis Shock- Pyrexia Pain. Myocarditis Pregnancy Hemorrhage Drugs- atropine, adrenaline , dopamine, B- agonists. • Athletes • Sleep • Myxodema • Obstructive jaundice • Increased –ICP . • VASO-VEGAL -ATTACK • Hypothermia • Drugs- digoxin, B-blockers • Breath holding

  25. Other causes of abnormal rate and rhythm • Supraventricular premature beats (SVPB)- or atrialecxra systoles- • SVT-supraventricular tachycardia • Atrial fibrillation • Atrial flutter • Flutter-fibrillation • VPC-premature ventricular contractions • VT-ventricular tachycardia • VF- VENTRICULAR FIBRILLATION

  26. Supraventricular premature beats (SVPB)- or atrialecxra systoles- CAUAES • Overtaking of tea, coffee, alcohol, cigarettes • Anxiety • Dyspepsia • Rheumatic-ischemic-hypertensive -diseases • Thyrotoxicosis- cardiomyopathies • Drugs-adrenaline digitalis A

  27. The most common type of arrhythmiaVentricular rate=100-150No-P wave- irregular baselineIrregularly-irregular ventricular rhythmoften associated with palpitations, fainting, chest pain, or congestive heart failure AF – causes and Rx AF Causes • MS,MR,IHD,HTN,Cardiomyopathies • Hyperthyroidism ,myocarditis, pericarditis • ASD, WPW syndrome, cor-pulmonale • Drugs-adrenaline, emetine Treatment • Rate control-Beta blockersmetoprolol, atenolol, bisoprolol, nebivolol • calcium channel-blockers (e.g., diltiazem or verapamil) • Cardiac glycosides (e.g., digoxin) – have limited use, • Anti-platelete- Apirin • Anti-coagulation- warfarin. Heparin,apixaban, edoxaban • Cardioversion- DC shock, drugs- amiodarone, flecainide • Ablation-

  28. AF and normal ECG

  29. Atrial flutter is similar to atrial fibrillation in regards to symptoms and thromboembolic risk (including stroke), CAUS AND TREATMENT – MOTLY SAME AS AF SAW TOOTHED APPERANCE USUALLY REGULAR VENTRICULAR RATE

  30. VENTRICULAR PREMATUR CONTRACTION (VPC) vpc • Ectopic beats – • Bizarre ,wide ,tall , QRS-complex • Significant- if present 5 times /m • Causes same as SVT/AF • RX- B-blockers, verapamil, MAG-SULPHATE, Ablation thrapy.

  31. VT- This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation, asystole, and sudden death. Causes-IHD, DRUGS, CARDIOMYOPATHY ELECTROLYTE-IMBALANCE ECG- ventricular tachycardia No-T and P wave- TREATMENT • Defribrillation • Antiarrhythmic drug therapy • Drugs such as amiodarone or procainamide may be used in addition to defibrillation to terminate VT while the underlying cause of the VT can be determined. As hypomagnesia is a common cause of VT, stat dose magnesium sulphate can be given for torsades or if hypomagnesemia is found/suspected. • Long-term anti-arrhythmic therapy may be indicated to prevent recurrence of VT. Beta-blockers • Catheter ablation is a key therapeutic modality for patients with recurrent VT

  32. VF -Ventricular fibrillation is a sudden lethal arrhythmia responsible for cardiac arrest and sudden cardiac death SYMTOPMS ,CAUSES AND TREATMENT VF-uncoordinated fast contraction of ventricles • PULSE LESS, ABSENT CAROTID PULSE, SYNCOPE/UNCONCIOUSNESS CAUSES • most common- IHD,(ACS ,AMI) • Digitalis, quinidine toxicity- severe hypokalemia • Electrical shock • Severe hypoxia • Severe hypothermia, myocarditis • ELECTRILYTE DISBALANCE TREATMENT • Defribrillation- AED, ICD, dc-shock • Drugs- amiodarone, lidocaine, American Heart Association recommends the use of magnesium in hypomagnesemia, torsades de pointes, digitalis toxicity, and as a last resort when other antiarrhythmic drugs, such as lidocaine and bretylium, fail to control the fibrillation

  33. abnormal axis RIGHT AXIS DEVIATION INVERTED QRS COMPLEX IN LEAD -I LEFT AXIS DEVIATION INVERTED QRS COPLEX IN LEAD-III Seen in LVH, left anterior fascicular block, inferior wall MI • Seen in RVH ,left posterior fascicular block, lateral wall MI

  34. P- WAVE-ABNORMALITY P-pulmonale and p-mitrale • P-pulmonale- tall p wave-seen in core-pulmonale • P-mitrale- wide /m shaped p- wave- seen in mitral stenosis

  35. PR-interval abnormality(atrio-ventricular conduction defects) 1st , 2nd (mobitz type-I, and II )and 3rd degree heart block • PR- interval more than 5 small squares. Every P is followed by a QRS complex • 2ND-DEGREE-heart block mobitz type-1-PR Interval-not fixed progressive increased of PR interval and ends by non- conducting beat- absence of subsequent QRS complex • Mobitz type-II-PR interval is fixed. Wide QRS complex, misses one beat • 3RD DEGREE heart block-.absence of SA node impulse.nosynchrinization between atrial and ventricular beats. HR= 36-40 /M • Rx- pacemaker implantation

  36. ECG-changes in myocardial ischemia IHD •  Exercise ECG is widely used for the diagnosis of ischemic heart disease. • The most common ECG sign of myocardial ischemia is flat or down-sloping ST-segment depression of 1.0 mm or greater • St-elevation • T-inversion • ST depression and T-inversion- other causes= LVH, HYPOKALEMIA

  37. ECG-changes in AMI Deep and wide Q-wave, ST-elevation, T-inversion

  38. Cardiac enzyme changes-in- AMI • TROPININ-I/T- starts to rise-4-6 hours- peak at 12 hours Differential diagnosis of troponin elevation includes acute infarction, severe pulmonary embolism causing acute right heart overload, heart failure, myocarditis • CK-MB- 10-24 hours –peak- other causes of high level-  cancer, meningitis, encephalitis, or HIV.( less than 6% of total creatinine kinase) • LDH- PEAK after- 72 hours.(208-460 IU= normal value) • Total creatinine kinase- m 55-170/ f 30-135 • ------------------------------------------------------------------------- • Micro-RNA- decreased expression. • CRP- increased. • D-dimer-increased • Intracellular magnesium- decreased

  39. D-Dimer and fibrinogen levels were significantly higher in patients with acute ischemic events • D-Dimer, an expression of ongoing thrombus formation and lysis, is a marker of substantial incremental value for the early diagnosis of acute coronary syndromes presenting with chest pain. • It adds independent information to the traditional assessment for myocardial infarction. • D-Dimer can be incorporated into clinical decision models in the ED.

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