Cardiology

Define Hypertension

Defined as an elevated blood pressure with systolic BP of 140mmHg or more and/or a diastolic BP of 90mmHg or more in 2 readings 4-6 hours apart, or any reading in a patient on antihypertensive medication

Classify Hypertension with values

Types of Hypertension

• Primary Hypertension

• Secondary Hypertension

Risk factors for hypertension

• Age: risk rises with age

• Sex: Higher in males because estrogen protects against high BP. Post menopausal women this have high risk

• Race: blacks

• Obesity: BMI > 30

• Sedentary lifestyle

• Smoking

• Excessive alcohol

• Environment: Urban > rural due to lifestyle

• Obstructive sleep apnea

• Genetics: higher concordance in monozygotic than dizygotic twins

• Microalbuminuria

• LBW

Causes of secondary Hypertension

Renal: Chronic glomerulonephritis, ADPKD, ARPKD, acute glomerulonephritis, obstructive uropathy, renal artery stenosis, renal vein thrombosis, renin producing tumors

Endocrine: Cushing syndrome, Conn syndrome, Hyperthyroidism, Pheochromocytoma, acromegaly, hyperparathyroidism, congenital adrenal hyperplasia

CVS: Coarctation of aorta

Drugs: NSAIDs, OCPs, Steroids, Cocaine, MAO inhibitors, TCAs, Cyclosporine

Neurogenic: Obstructive sleep apnea, Raised ICP,

Others: Pregnancy, (pre) eclampsia.

Symptoms of Hypertension

• Asymptomatic

• Vague symptoms: Headache, insomnia, palpitations

• Symptoms of underlying pathology

• Symptoms of target organ damage

1. Hypertension target organs and damage on each

• Brain

  1. Hypertensive encephalopathy

  2. Stroke (ischemic & hemorrhagic)

  3. Amyloid angiopathy

  4. Dementia

  5. Lacunar infarcts

• Heart

  1. LVH

  2. CHF

  3. IHD

  4. Arrhythmias

  5. Aortic dissection

  6. Sudden death

• Kidneys

Focal segmental glomerulosclerosis

1. AKI

2. CKD

• Eyes

  1. Hypertensive retinopathy

• Peripheral arteries

  1. Atherosclerotic disease

• Ears

  1. Tinitus

Grade hypertensive retinopathy

Grade 1-4

• Grade 1: tortuosity of retinal arteries with thick shiny walls (silver/copper wiring)

• Grade 2: 1 + arteriovenous nipping ( narrowing where arteries and veins cross)

• Grade 3: 2 + flame-shaped hemorrhages and cotton wool spots

• Grade 4: Papilledema (swelling of the optic disc)

Examination findings in hypertension

Hypertension Investigations

1. CXR

2. ECG

3. Echo

4. E/U/Cr & Ca & Albumin

5. Urinalysis

6. Renal USS

7. FBS

8. FLP

9. Thyroid function test

10. Urinary metanepheines or catecholamines

Treatment of Hypertension

• Lifestyle modifications: SAWAD

• stop Smoking

• reduce Alcohol

• Weight reduction

• increased physical Activity

• Diet:

  • Salt reduction Nacl < 6g/day, Na < 3g/day

  • DASH Diet:

    • High in K, Low in Ca, Low saturated fats, high unsaturated fats.

    • Diet rich in fruits, vegetables, and low fat diary peoducts

Pharmacological Therapy: A³BCD-R

• ACE Inhibitors e.g lisonpril, ramipril

• ARBs e.g losartan, valsartan, candesartan

• Beta blockers e.g atenolol, metoprolol, carvedilol

• Calcium channel blockers e.g amlodipine, nifedipine

• Diuretics

  • Thiazides e.g HCT

  • Aldosterone antagonist e.g sporinolactone

• Renin inhibitors e.g Aliskiren

• Alpha antagonist e g prazosin, Doxazosin

Define the following:

Hypertensive urgency

Hypertensive emergency

Malignant Hypertension

Accelerated hypertension

1. Hypertensive urgency: severely elevated BP (>180/110 mmHg) with no evidence of target organ damage

2. Hypertensive emergency: severely elevated BP (>180/110 mmHg) with evidence of target organ damage

• Accelerated and Malignant Hypertension are also hypertensive emergencies with similar outcomes and therapies

3. Accelerated hypertension: sudden elevation of BP associated with fundoscopic vascular changes but without papilledema

4. Malignant Hypertension: sudden elevation of BP which can present with grade 3/4 retinopathy or hematuria and/or proteinuria

Treatment of Hypertensive urgency and hypertensive emergency

Hypertensive urgency:

• there is room for oral antihypertensives

• Aim to reduce MAP by 25% in 24 hours

Hypertensive emergency:

• IV antihypertensives is used

• Aim to reduce MAP by 25% in 1 hour

Define Heart Failure

Heart Failure is a clinical syndrome consisting of symptoms (fatigue leg swelling difficulty in breathing) and/or signs (rales, pedal edema) resulting from structural or functional abnormalities of the heart leading to inability of the heart to pump blood to meet the metabolic needs of the body or when the heart is able to do this at elevated intracardiac pressure.

Types of heart failure

• Right

• Left

• Congestive

• Systolic

• Diastolic

• HFpEF

• HFmrEF

• HFrEF

• Acute

• Chronic

• High output

• Low output

Classifications of Heart failure:

NYHA

AHA & ACC

Araoye

NYHA: CLASS I- IV

• Class I: Symptoms with more than ordinary activity

• Class II: Symptoms with ordinary activities

• Class III: Symptoms with less than ordinary activity

• Class IV: Symptoms at rest

Symptoms: Dyspnoea, fatigue, palpitations

ACC & AHA: STAGE A-D

• Stage A: normal cardiac structure & functions in presence of risk factors

• Stage B: Subclinical changes in Left ventricular structure and/or function

• Stage C: Clinical heart failure

• Stage D: Advanced heart failure

Araoye: Grade 1-3

• Grade 1: Heart failure + high BP

• Grade 2: Heart failure+ long term peripheral stigmata of Hypertension + Low BP which rises on treatment

• Grade 3: Grade 2 + BP remains low/normal on treatment

Clinical diagnosis of Heart failure

FRAMINGHAM’S CRITERIA

• MAJOR CRITERIA: PICS RANCH

  • PND or orthopnea

  • Increased venous pressure > 6 cmH2O

  • Cardiomegaly

  • Rales

  • Acute pulmonary edema

  • Neck vein distention

  • Circulatory time > 25 sec

  • Hepatojugular reflex

• MINOR CRITERIA:

  • Night cough, ankle swelling, DOE, hepatomegaly

  • Pleural effusion, tachycardia (>120)

  • Vital capacity decreased 50% from maximal capacity

  • Weight loss > 4.5kg in 5 days in response to treatment

2 MAJOR

1 MAJOR + 2 MINOR

Causes of heart failure

• Hypertensive heart disease

• Dilated cardiomyopathy

• Valvular heart disease

• IHDs

• Congenital heart diseases

• CADs

• Pericarditis

• Myocarditis

• Infective Endocarditis

• Arrhythmias

• Other Cardiomyopathies

• Cor pulmonale

• End myocardial fibrosis

• Alcohol

• Drugs

• Hyperdynamic circulation

  • Anemia

  • Thyrotoxicosis

  • Pager disease

Risk factors for heart failure

• Major

  • Age

  • Males

  • Hypertension

  • DM

  • Obesity

  • LVH on ECG

  • MI

• Minor

  • Alcohol

  • Smoking

  • Dyslipidemia

  • Renal insufficiency

  • Sedentary lifestyle

  • Low SE status

  • Salt

  • Coffee

  • Impaired pulmonary function

  • Sleep disordered breathing

  • Tachycardia

  • Mental stress/depression

Heart Failure precipitants

HEART FAILED

• Hypertension - accelerated/malignant

• Endocarditis, unaccustomed Exercise

• Anemia, Alcohol

• Renal impairment, RHD

• Thyrotoxicosis

• Failure to take meds

• Arrhythmias

• Infections, infarction, ischemia

• Lung problems ( Pulmonary embolism, pneumonia, COPD), Lifestyle

• Endocrine- Pheochromocytoma, hyperaldosteronism

• Dietary indiscretions

Others: pregnancy

Most common:

• Chest infections

• Arrhythmias

• Thyrotoxicosis

• NSAIDs

• Steroids

• Anemia

• Pregnancy

• Unaccustomed Exercise

• Indiscriminate drug use

Pathophysiology of heart failure

• Myocardial injury (e.g., ischemia, pressure overload, volume overload)

• Reduced cardiac contractility (systolic dysfunction)

• Impaired ventricular relaxation (diastolic dysfunction)

• DECREASED cardiac output

• Activation of sympathetic nervous system

• INCREASED heart rate and peripheral vasoconstriction

• Activation of renin–angiotensin–aldosterone system (RAAS)

• INCREASED sodium and water retention

• INCREASED preload

• INCREASED afterload

• Ventricular remodeling (hypertrophy and dilation)

• INCREASED wall stress → release of ANP, BNP and C-type peptide

• Neurohormonal activation (e.g., ADH release)

• Fluid accumulation → pulmonary congestion and peripheral edema

• DECREASED tissue perfusion

• Progressive worsening of cardiac function

Symptoms of heart failure

Signs of heart failure

LHF SYMPTOMS

• DOE

• Orthopnea

• PND

• Cough productive of pink frothy sputum

• Tachycardia

SIGNS

• Basilar rales

• Pulmonary edema

• S3 Gallop

• Pleural effusion

• Cheyne-stokes respiration

RHF SYMPTOMS

• Abdominal pain

• Anorexia - due to gastric edema

• Nausea

• Bloating

• Leg/body swelling

SIGNS

• Peripheral edema

• Jugular venous distention

• Tender hepatomegaly

Other signs and symptoms depending on etiology

Investigations done in heart failure

1. Chest X-ray: ABCDE

2. Echocardiography

3. ECG

4. Cardiac biomarkers assay

5. FBC

6. E/U/Cr

7. LFT

8. TFT

9. C-reactive protein

Non pharmacological management of heart failure

1. Bed rest

2. Cardiac position

3. Low salt diet (Na <2.4g/day)

4. Weight reduction

5. Stop alcohol

6. Stop smoking

7. Stress reduction

8. Avoid constipation

Principles of Management of heart failure

1. Resuscitate

2. Reduce preload- furosemide

3. Reduce afterload- ACE Inhibitors, ARBs

4. Increase contractility of heart- digoxin

5. Reduce morbidity or mortality

6. Identify & treat etiology

7. Identify & treat precipitants

8. Treat complications

Goals of Management of heart failure

Complications of heart failure

1. Cardiogenic shock

2. Arrhythmias

3. Stroke

4. DVT

5. Pulmonary embolism

6. Intracardiac clots

7. Cardiac cirrhosis

8. Electrolyte derangements

9. AKI

10. CKD

11. Congestive hepatopathy

12. Weight loss - cardiac cachexia

13. Death

Causes of weight loss in heart failure

1. Early satiety

2. Anorexia

3. Vomiting

4. Cardiac cachexia

5. Hypoxia- cellular death

Poor Prognostic factors for heart failure

Clinical

• Age

• Men

• Blacks

• NYHA 4

• Regular hospitalization

• Cardiac cachexia

• Syncope

• S3

• Arrhythmias

Biochemical

• Hypokalemia

• Hyponatremia

• Hypernatremia

• BNP >400 nanograms

• proBNP > 1200 nanograms

• Elevated creatinine

• Elevated urea

• Low GFR

Imaging

• Reduced LVEF

• Positive X ray features

• RV dysfunction on echo

• Pulmonary Hypertension

Functional

• Frailty

• 6 minute walk distance - worse if patient CAN tolerate this

• Low peak VO2 (<14ml/kg/min)

Contraindications to cardiac transplantation

• Active infection

• Active malignancy

• Poor adherence to medical therapy

• Active substance abuse (alcohol, drugs)

• Severe irreversible pulmonary hypertension

• Advanced irreversible renal failure

• Advanced irreversible liver disease

• Severe chronic lung disease

• Uncontrolled diabetes mellitus with end-organ damage

• Significant peripheral vascular disease

• Severe psychiatric illness

• Systemic disease with poor prognosis

• HIV with uncontrolled disease

• Morbid obesity

• Advanced age (relative)

Causes of mitral stenosis

1. Rheumatic fever

2. Degenerative valvular disease

3. Chemotherapy

4. Radiotherapy e.g breast Ca

5. SLE

6. Rheumatoid arthritis

7. Malignant carcinoid disease

8. Cor triatriatun

9. Left atrial myxoma

10. Congenital

Degenerative valvular disease

Chemotherapy

Radiotherapy

Connective tissue disease

Congenital heart diseases

Normal area of mitral valve orifice

4-6 cm²

Pathophysiology of mitral stenosis

Mitral valve narrowing →obstructed LV filling (LVH) → ELEVATED LA pressure & enlargement →pulmonary venous congestion →pulmonary Hypertension →right ventricular enlargement →right heart failure →tricuspid & pulmonary regurgitation

Symptoms of mitral stenosis

• Dyspnoea

• Cough- PH

• Hemoptysis - PH

• Easy fatiguability

• Chest pain

• Palpitations ( left atrial enlargement → arrhythmias AF)

• Systemic emboli

• Hoarseness ( enlarged LA compression on recurrent laryngeal nerve)

• Dysphagia ( enlarged LA compression on esophagus)

Signs of mitral stenosis

Inspection & palpation:

• Malar flush

• Small volume pulse

• Raised JVP

• Tapping apex beat

Auscultation

• Loud S1

• Loud P2

• Opening Snap

• Mid diastolic murmur

• Graham Steell murmur ( an end diastolic murmur due to pulmonary regurgitation)

Mitral stenosis investigations

Echo: Diagnostic shows fusion of mitral valve commisures. Also shows diastolic and systolic dysfunction

ECG: P-mitrale/bifid p wave (LA enlargement), right axis deviation (RVH), Atrial fibrillation

CXR: Mitralization, double heart shadow, ABCDE of HF

Angiography

MRI

FBC

E/U/Cr

Mitral stenosis treatment

• Recurrent rheumatic fever prophylaxis: Oral penicillin

• Treat atrial fibrillation: beta blockers, verapamil etc

• Low salt diet

• Heart failure: Low dose diuretics

• Surgery:

1. Open surgery mitral Valvulotomy

2. PMBV

3. Commisurotomy

4. Mitral Valve replacement

   • Metallic- for life, need anticoagulants use for life

   • Bioprosthetic- 10 years

Mitral regurgitation causes and types

Acute MR:

IHD, Infective endocarditis, rupture of chordae tendinae

Chronic MR:

RHD, MV prolapse, calcification of MV annulus

Degenerative valvular disease

Chemotherapy

Radiotherapy

Connective tissue disease

Congenital heart diseases

Mitral regurgitation pathophysiology

Acute MR: No time for LA dilation, so large regurgitant volume is delivered into a LA with normal compliance leading to markedly increased pulmonary pressure and pulmonary edema

Chronic MR: There's sufficient time for LA dilation and accommodates regurgitant volume, so LA pressure is normal/slightly elevated however chronic atrial dilation leads to Atrial fibrillation.

Mitral regurgitation symptoms

• Dyspnoea

• Fatigue

• Symptoms of HF

• Symptoms of atrial fibrillation

Mitral regurgitation signs

• Soft S1

• Wide splitting of S2

• Prominent S3

• Loud P2

• Laterally displaced apex beat with systolic thrill

• Grade 3/4 pansystolic murmur radiating to axilla

Mitral regurgitation investigations

• Echo

• ECG

• CXR

• Angiography

• MRI

• FBC

• E/U/Cr

Barlow syndrome

Barlow’s syndrome:

Associated conditions

Symptoms

Signs

Complications

Treatment

Aortic stenosis etiology

Aortic stenosis pathophysiology

Aortic stenosis symptoms

Aortic stenosis signs

Aortic stenosis investigations

Aortic stenosis treatment

Aortic regurgitation types and etiology

Aortic regurgitation symptoms

Aortic regurgitation signs

Aortic regurgitation investigations

Aortic regurgitation treatment

Define infective Endocarditis

Risk factors for infective Endocarditis

Etiology (organisms) of infective Endocarditis

Most common organism causing infective Endocarditis in:

Native valve Endocarditis

Prosthetic valve Endocarditis

IV drug associated endocarditis

Signs and symptoms of infective Endocarditis - systematically

Describe the pathology of infective Endocarditis

Diagnostic criteria for infective endocarditis

Investigations done in infective endocarditis

Treatment of infective endocarditis

Indications for surgery in infective endocarditis

Complications of infective endocarditis