Introduction to cardiologyIntroduction to cardiology Dr. Judit Keller Dr. Judit Keller

Cardiovascular diseaseCardiovascular diseaseImportanceImportance

Single greatestSingle greatest cause of death and disability cause of death and disability all over the worldall over the world

Coronary heart diseaseCoronary heart disease Valvular heart diseaseValvular heart disease Diseases of the myocardiumDiseases of the myocardium Rhythm disordersRhythm disorders

CV mortalityCV mortality

Case history in cardiologyCase history in cardiology

Previous diseases,

Current symptoms

Family history and risk factors

The results of the physical examination

Technical cardiovascular examinations.

Treatment

Medical historyMedical history

• Present symptoms. • Chest pain, dyspnea, palpitations, swelling in the

legs, ankles, and feet or abdomen • Other, more general symptoms, such as fever,

weakness, fatigue, lack of appetite, and a general feeling of illness or discomfort (malaise), may suggest a heart disorder.

• Pain, numbness, or muscle cramps in a leg may suggest peripheral arterial disease, which affects the arteries of the arms, legs, and trunk (except those supplying the heart).

Chest painChest pain

Chest pain is one of the most common reasons people call for emergency medical help or go to a cardiologist

Angina - is often described as a pressure or tightness in the chest. It's usually brought on by physical or emotional stress. The pain usually goes away within minutes after stopping the stressful activity.

Heart attack - pressure, fullness or a crushing pain in the chest that lasts more than 5 minutes. The pain may radiate to the back, neck, jaw, shoulders and arms, especially to the left arm. Other signs: shortness of breath, sweating, dizziness and nausea.

AnginaActivities triggeringChest pain

Excercisetolerance

CCS-1. degree

Strenuous, rapid, or prolonged exertion

>120 W – 10 METs

CCS-2. degree

Walking rapidly or uphillEmotional stress

80–120 W – 6-8 METs

CCS-3. degree

Walking, even 1 or 2 blocks at usual pace and on level ground.  Climbing stairs, even 1 flight

20–80 W – 5-6 METs

CCS-4. degree

Any physical activity, sometimes occurring at rest

<20 W alatt< 4 METs

Angina Classification (Canadian Cardiovascular Society)

Differential diagnosisDifferential diagnosis

• Pericarditis. causes sharp, piercing and centralized

chest pain. You may also have a fever and feel sick. • Aortic dissection. In this condition, the inner layers of

the aorta separate, forcing blood between them.

Symptoms are sudden and tearing chest and back pain. • Noncardiac causes • Pulmonary embolism, Heartburn, Panic attack,Sore

muscles, GI problems

DyspneaDyspnea

• sensation of breathlessness GradeDegree of dyspnea

1 no dyspnea except with strenuous exercise 2 dyspnea when walking up an incline or

hurrying on the level 3 walks slower than most on the level, or stops

after 15 minutes of walking on the level 4 stops after a few minutes of walking on the

level 5 dyspnea with minimal activity such as getting

dressed, too dyspneic to leave the house 6 Ortopnea – severe dyspnea at rest

Differential diagnosis:

cardiac, pulmonary, mixed cardiac or pulmonary, noncardiac or nonpulmonary.

• Cardiac Congestive heart failure (right, left or biventricular) Coronary artery disease Myocardial infarction (recent or past history) Cardiomyopathy Valvular dysfunction Left ventricular hypertrophy Asymmetric septal hypertrophy Pericarditis Arrhythmias

• Pulmonary COPD Asthma Restrictive lung disorders Hereditary lung disorders Pneumothorax

• Mixed cardiac or pulmonary COPD with pulmonary hypertension and cor pulmonale Deconditioning Chronic pulmonary emboli Trauma

• Noncardiac or nonpulmonary Metabolic conditions (e.g., acidosis) Pain Neuromuscular disorders Otorhinolaryngeal disorders Functional - Anxiety - Panic disorders - Hyperventilation

• Next: previous diseases• past infections; previous exposure to chemicals;

use of drugs, alcohol, and tobacco; • home and work environments; and recreational

activity. • family history: whether family members

members have had a heart disorder or any other disorders that may affect the heart or blood vessels.

Physical examinationPhysical examination

• Weight and overall appearance • Looking for paleness (pallor), sweating, or

drowsiness, which may be subtle indicators of heart disorders.

• The person's general mood and feeling of well-being, also may be affected by heart disorders.

• Assessing skin color • pallor - anaemia• bluish-purplish coloration - cyanosis

• These findings may indicate • lung disorder, • heart failure, • various circulatory problems.

• feeling pulse:

carotids, radial arteries, a. femoralis, a. dorsalis pedis, a. tibialis posterior

are they adequate and equal on both sides of the body?

the blood pressure and body temperature are also checked

pressing the skin over the ankles and legs and sometimes over the lower back - to check for fluid accumulation (edema)

Basic cardiological „hardware”

Heart auscultationHeart auscultation

Cardiac Cycle

DiastoleSystole

Systolic murmursSystolic murmurs• Systolic murmurs occur between S1 and S2 (first and

second heart sounds), and therefore are associated with mechanical systolic and ventricular ejection.

• Mid-systolic murmurs typically have a crescendo-decrescendo character, that is, they start softly and become loudest near mid-systole, followed by a decrease in sound amplitude as shown in the figure.

•  This type of murmur is caused by either aortic or pulmonic valve stenosis. 

• A second type of systolic murmur is holosystolic (sometimes called pansystolic) because the amplitude is high throughout systole as shown in the figure.

• This type of murmur is caused by mitral or tricuspid regurgitation, or by a ventricular septal defect.

Diastolic murmursDiastolic murmurs

• Diastolic murmurs occur after S2 and are therefore associated with ventricular relaxation and filling. 

• They may be caused by aortic or pulmonic valve regurgitation,

• or by mitral or tricuspid valve stenosis. • They can occur early mid-diastolic, ( aortic

regurgitation),

• or late diastolic (mitral stenosis).

• The murmur of aortic stenosis is typically a mid-systolic ejection murmur, heard best over the “aortic area” : right second intercostal space, with radiation into the right neck.

• Additional heart sounds, such as an S4, may be heard secondary to hypertrophy of the left ventricle which is caused by the greatly increased work required to pump blood through the stenotic valve

• Systolic murmur of MR– Usually high-pitched, blowing– Usually best heard over the apex– Usually radiates to the left axilla or subscapular region

• Posterior leaflet dysfunction causes murmur to radiate to the sternum or aortic area

• Anterior leaflet dysfunction causes murmur to radiate to the back or top of the head

• Holosystolic– May be confined to early systole in acute MR– May be confined to late systole in MVP or papillary muscle

dysfunction• S 1 will probably be normal in these cases since initial

closure of mitral valve cusps is unimpeded.• A midsystolic click preceding murmur is suggestive of MVP.

• Intensity– Little correlation exists between intensity of murmur and severity

of MR.– Intensity may be diminished in severe MR and LV dysfunction,

acute myocardial infarction, or periprosthetic valve regurgitation. 

ImportanceImportance

• Despite decreasing of the incidence of rheumatic heart valve diseases

• The tendency of valvular diseases themselves does not decrease but increases

The most important is aortic stenosis– Below 60 mostly congenital and post IE– Above 60 mostly sclerotic – very progressive!!

The most frequent is mitral regurgitation

CHD, MPS, hypertension, annulus dilatation or calcification, papillary muscle dysfunction

Epidemiology of CHDEpidemiology of CHD

• A population-based survey, using data from the Framingham study, assessed sex-specific patterns of coronary heart disease occurring over a 26-year period of time. Among subjects ages 35 to 84 years, men have about twice the total incidence of morbidity and mortality of women. The sex gap in morbidity tends to diminish during the later years of the age range, mainly because of a surge in growth of female morbidity after age 45 years, while by that age, the growth in the male rate begins to taper off.

Risk factors Risk factors for coronary heart disease (CHD)for coronary heart disease (CHD)

• Age• Family history• Hypertension• Hypercholesterolaemia• Male gender• Smoking• Overweight and obesity• Physical inactivity• Diabetes• Stress

Multimetabolic catastrophe!Multimetabolic catastrophe!

22 22Smoking

9 22 Physical inactivity

12 28 Diabetes

23 33 Overweight

27 63 High cholesterin level

72 58 Hypertension

strokeCHDRisk factor

Ezzati M et al. Lancet 2003;362:271-80.

(%)(%)

Increasing of the incidence of CHD and stroke

?

Risk stratification - Euroscore

Effects of hypertension, smoking and hypercholesterolaemia to CHD risk

Effects of hypertension, smoking and hypercholesterolaemia to CHD risk

X1.6 x4

x3

x6

x16

X4.5 x9

hypertension

(SBP 195 Hgmm)

High TC(8.5 mmol/L, 330 mg/dl)

smoking

(Poulter et al, 1993)

hypertension

High TCdiabetes

x3

x2

x2

x5x4

x3

x8

Effects of hypertension, diabetes and hypercholesterolaemia to CHD risk

Stable angina pectoris - diagnostics Anamnesis – family history, present complaints, risk factor detection Physical examination – murmurs (aortis stenosis!!), rhythm disorders, BP Lab – lipid profile, blood glucose, uric acid, serum potassium level,

excuding anaemia, hyperthyreosis ECG – rest12 lead ECG is mandatory, though the sensitivity is less than

60 % ! Echokg – valves, cavities, wall thickness and motion, systolic and

diastolic function of the ventricles. Stress tests – treadmill or bicycle ergometry stress test, isotope and/or

stress echocardiography, cardiac MR Holter – total ischaemic burden, rhythm disorders Invasive diagnostics - coronarography

Thank you for your attention!