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APPROACH TO THE PATIENT

WITH CARDIOVASCULAR
DISEASE
JULIANA G. TAMAYO M. D.
THE MAGNITUDE OF THE
PROBLEM
CVD COMPRISE THE MOST PREVALENT SERIOUS
DISORDER
IN 2002
- 62M AMERICANS ( 1.e MORE THAN 1
IN 5 PERSONS) HAS CVD
- RISES PROGRESSIVELY WITH AGE: 5% AT AGE
20 TO 75% AT AGE > 75 YEARS
IT HAS BEEN PROJECTED THAT BY 2020 CVD
WILL BE THE LEADING CAUSE OF DEATH
WORLDWIDE

CARDIAC SYMPTOMS
CAUSES OF CARDIAC SYMPTOMS
MYOCARDIAL ISCHEMIA
DISTURBANCE OF THE CONTRACTION AND/OR
RELAXATION OF THE MYOCARDIUM.
OBSTRUCTION TO BLOOD FLOW
ABNORMAL CARDIAC RHYTHM OR RATE

ISCHEMIA > CHEST DISCOMFORT
REDUCTION IN PUMPING ACTION >
FATIGABILITY
SHORTNESS OF BREATH
CYANOSIS
HYPOTENSION
SYNCOPE
ELEVATED INTRAVASCULAR PRESSURE BEHIND
A FAILING VENTRICLE > ABNORMAL FLUID
ACCUMULATION > DYSPNEA, ORTHOPNEA
AND SYSTEMIC OR PULMONARY EDEMA
OBSTRUCTION TO BLOOD FLOW ( AS IN
VALVULAR STENOSIS ) > CAN CAUSE
SYMPTOMS RESEMBLING CHF
CARDIAC ARRHYTHMIAS:
PALPITATIONS
DYSPNEA
HYPOTENSION
PRESYNCOPE
SYNCOPE
ISCHEMIC HEART DISEASE- THE MOST
COMMON FORM OF HEART DISEASE IN ADULTS
MAY PRESENT:
CHEST DISCOMFORT
HEART FAILURE
TACHYARRHYTHMIAS
SUDDEN CARDIAC DEATH


















MYOCARDIAL OR CORONARY FUNCTION THAT
MAYBE ADEQUATE AT REST MAYBE
INADEQUATE DURING EXERTION.

CHEST DISCOMFORT OR DYSPNEA THAT APPEAR
ONLY DURING ACTIVITY ARE CHARACTERISTIC
OF HEART DISEASE WHILE THE OPPOSITE
PATTERN 1.e THE APPEARANCE OF THESE
SYMPTOMS AT REST AND THEIR REMISSION
DURING EXERTION IS RARELY OBSERVED IN
PATIENTS WITH ORGANIC HEART DISEASE.
PATIENTS WHO ARE ASYMPTOMATIC BOTH AT
REST AND DURING EXERTION- BUT MAY
PRESENT:
- ABNORMAL PHYSICAL FINDINGS
HEART MURMUR
ELEVATED ARTERIAL PRESSURE
- ABNORMALITY OF THE ECG
- ABNORMALITY OF THE CARDIAC
SILHOUETTE ON THE CHEST
ROENTGENOGRAM
- (+) STRESS TEST




DYSPNEA- ONE OF THE CARDIAC
MANIFESTATIONS OF HEART
FAILURE IS NOT LIMITED TO HEART
DISEASE BUT IS ALSO OBSERVED IN:
PULMONARY DISEASE
MARKED OBESITY
ANXIETY

CARDIOVASCULAR DISEASE
DIAGNOSIS CAN BE MADE BY:
1. THOROUGH HISTORY AND COMPLETE
PHYSICAL EXAMINATION
2. REST AND EXERCISE ECG
3. CHEST X-RAY
4. MYOCARDIAL IMAGING
ECHOCARDIOGRAM
THALLIUM
C.T. ANGIOGRAM
5. SPECIALIZED INVASIVE EXAMS
CATHETERIZATION
ANGIOGRAM






ELEMENTS OF A COMPLETE
CARDIAC DIAGNOSIS
1. UNDERLYING ETIOLOGY
CONGENITAL
INFECTIONS
HYPERTENSIVE
ISCHEMIC
2. ANATOMIC ABNORMALITIES
CHAMBER INVOLVED
- HYPERTROPHIED
- DILATED
VALVES AFFECTED
- REGURGITANT
- STENOTIC
PERICARDIAL INVOLVEMENT







3. PHYSIOGIC DISTURBANCE
ARRHYTHMIA
CONGESTIVE HEART FAILURE
MYOCARDIAL ISCHEMIA
4. FUNCTIONAL DISABILITY.
5. THERAPEUTIC RECOMMENDATION


TABLE 208-1 NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION
CLASS I NO LIMITATION OF PHYSICAL ACTIVITY
NO SYMPTOMS WITH ORDINARY EXERTION
CLASS II
SLIGHT LIMITATION OF PHYSICAL ACTIVITY
ORDINARY ACTIVITY CAUSES SYMPTOMS
CLASS III
MARKED LIMITATION OF PHYSICAL ACTIVITY
LESS THAN ORDINARY ACTIVITY CAUSES SYMPTOMS
ASYMPTOMATIC AT REST
CLASS IV
INABILITY TO CARRY OUT ANY PHYSICAL ACTIVITY
WITHOUT DISCOMFORT
SYMPTOMS AT REST


SYSTOLIC MURMUR
PRESENCE OF CARDIAC MURMUR

GRADE I+II and
MIDSYSTOLIC
ASSYPMTOMATIC and
NO ASSOCIATED
FINDINGS
NORMAL ECG and
CHEST X-RAY
NO FURTHER
WORKUP
GRADE III or >
HOLOSYSTOLIS,
or LATE
SYSTOLIC
DIASTOLIC OR
CONTINUOUS MURMUR
OTHER SIGNS
OR SYMPTOMS
OF CARDIAC
DISEASE
ABNORMAL ECG
AND CHEST
X-RAY
ECHOCARDIOGRAPHY
CARDIAC
CONSULT IF
APPROPRIATE
PITFALLS IN CARDIO VASCULAR
MEDICINE:
1. FAILURE BY THE NON CARDIOLOGIST TO
RECOGNIZE CARDIAC MANIFESTATIONS OF
SYSTEMIC ILLNESSES.
EXAMPLE:
- DOWN SYNDROME ASSOCIATED WITH
ENDOCARDIAL CUSHION DEFECT
- HYPOTHYROIDISM
(PERICARDIAL EFFUSION, CAD)
- SLE ( VALVULITIS, MYOCARDITIS,
PERICARDITIS)


2. FAILURE BY THE CARDIOLOGIST TO
RECOGNIZE AN UNDERLYINGSYSTEMIC
ILLNESS AMONG CARDIAC PATIENTS