Cardiovascular

AGENDA

  • Common complaints
    • Chest pain
    • Palpitations
    • Syncope
    • Acute coronary syndrome (will include Stable Angina)
    • Pericarditis
    • DVT (Deep Vein Thrombosis)
    • Abdominal aortic aneurysm

ACUTE CARDIOVASCULAR DISORDERS

Cardiovascular Complications

  • Several lifestyle changes can significantly reduce mortality risk:
    • Smoking cessation
    • Increase in physical activity
    • Approximately 80% of preventable deaths attributed to poor diet, lack of physical activity, and tobacco use.
    • Approximately 34% of individuals who experience a coronary event in any given year will die from it.

Leading Causes of Death in the US

  • The 10 leading causes of death are significantly lifestyle-related:
    1. Heart disease
    2. Cancer
    3. Accidents (unintentional injuries)
    4. Chronic lower respiratory disease (CLRD)
    5. Stroke
    6. Alzheimer’s disease
    7. Diabetes mellitus (DM)
    8. Influenza/Pneumonia (PNA)
    9. Nephritis, nephrotic syndrome, nephrosis
    10. Intentional self-harm

Cardiovascular Health in Primary Care

  • Predominantly lifestyle-related medical conditions are seen in primary care (approx. 80%):
    • Obesity
    • Metabolic syndrome
    • Hypertension (HTN)
    • Cardiovascular disease (CVD)
    • Hyperlipidemia (HLD)
    • Arthritis
    • Diabetes mellitus (DM)
    • Osteoporosis
  • Ornish Lifestyle intervention for coronary artery disease (Lifestyle Heart Trial).
  • Major causes of heart disease:
    • Food and lack of activity!
  • Consider lifestyle modifications as essential components of management and treatment—EDUCATE YOURSELF!

COMMON COMPLAINTS: CHEST PAIN

Description

  • Chest pain may have pulmonary, gastrointestinal (GI), musculoskeletal (MK), neurological, psychogenic, or idiopathic causes.
  • It is a major symptom appraisal of heart disease and can be analyzed through symptom characteristics and individual risk factors.

Common Causes of Chest Pain

  1. Chest Wall Syndrome (Costochondritis)

    • Often localized and reproducible with arm movements or palpation.
    • Exclusion of coronary artery disease history.
    • Well-localized stabbing pain.

  2. Angina Pectoris (Stable Angina)

    • Diffuse, retrosternal pain that may radiate, often described as a heavy or burning sensation.
    • Duration: More than 1 minute, but less than 10 minutes.
    • Exertional symptoms increase with exercise/stress, often accompanied by nausea.
    • Symptoms relieved by rest or nitroglycerin.
    • A change in symptom pattern can indicate alteration in vessel patency.
    • Dyspnea, diaphoresis during chest pain are concerning signs.
    • Normal PE, may have S4 gallop during episodes.

  3. Unstable Angina

    • Chest pain at rest without acute MI signs; requires rapid assessment.
    • Associated with coronary artery vasospasms.

  4. Acute Myocardial Infarction (MI)

    • Anginal-type pain lasting more than 20 minutes, potentially waxing and waning.
    • Symptoms include dyspnea, diaphoresis, nausea, shimmering pain radiating to neck, jaw, shoulder, or arm.

  5. Pericarditis

    • Sharp, centralized chest pain, worsened by supine position and alleviated by leaning forward; possible shortness of breath due to pain.
    • Since it can have a viral or bacterial origin, evaluate for recent infections or autoimmune diseases.
    • Objective findings may include fever, tachycardia, and pericardial friction rub (60-70% occurrence).
    • Diagnostics: WBC, ESR, ECG (shows diffuse ST-segment elevations), CXR.

  6. Myocarditis

    • Inflammation often due to viral infections.
    • Symptoms include chest pain, fever, dyspnea, heart murmur, friction rub, cardiomegaly on CXR.

  7. Aortic Dissection

    • Severe ripping/tearing chest pain, radiating to back, neck, or jaw.
    • Associated with hypertension (70% cases) and presents as an emergency.
    • Diagnostics include CXR (wide mediastinum), CTA with contrast, transesophageal US.
    • Immediate hospital referral due to high mortality rate.

COMMON COMPLAINTS: PALPITATIONS

Definition

  • Palpitations refer to the awareness of the heartbeat; they can be benign or pathological.

Diagnosis Considerations

  • Evaluate for possible life-threatening arrhythmias through history and physical examination (PE). Questions include:
    • History of coronary artery disease (CAD)?
    • Experiences of lightheadedness or syncope?
    • Associated symptoms like chest pain or dyspnea?
    • Family history of sudden cardiac death?
    • Recent surgical procedures?
    • Description of beat sensations (e.g., skipped beats could indicate ectopic beats).
    • Strong, regular beats after exertion might be physiological responses; more inquiry into stress and anxiety effects is critical.
    • Consider drugs (prescription or recreational); stimulants?

PE and Diagnostics for Palpitations

  • Conduct a complete physical exam covering:
    • General appearance, vitals, HEENT, JVP, extremities, cardiovascular checks, reflexes.
  • Laboratory tests may include:
    • Thyroid function, blood chemistries, complete blood count (CBC), comprehensive metabolic panel (CMP).
    • Ambulatory cardiac monitoring (Holter Monitor) to check for lethal arrhythmias.
    • Echocardiogram to assess cardiac output.

Differential Diagnosis

  • Often benign or related to excessive caffeine/alcohol/tobacco use but can sometimes indicate cardiac pathology.
    • Atrial Ectopic Beats
    • May reflect increased risk of sudden cardiac death if patient has heart disease risks.
    • Ventricular Ectopic Beats
    • In sporadic/rapid scenarios, require monitoring.
    • Supraventricular or Ventricular Tachycardia
Atrial Fibrillation
  • Most common cardiac arrhythmia leading to stroke, characterized by quivering of upper chambers (ineffective pumping).
  • Diagnosis via ECG (absence of P waves and irregular ventricular rate).
  • Major risk factors include hypertension (HTN), coronary artery disease (CAD), valvular disease, diabetes, CKD, obesity, etc.

Diagnosis and Treatment of Atrial Fibrillation

  • Evaluation for coagulopathy using CHA₂DS₂-VASc score for anticoagulation necessity; 12-lead EKG, R/O heart failure via BNP, obtain troponin levels.
  • Treatment options include:
    • Medications like beta-blockers, calcium channel blockers, digoxin, amiodarone, and anticoagulants (Warfarin, Pradaxa, Xarelto).
Important Note on INR Management
  • The INR target for atrial fibrillation is:
    • INR of 2.0 to 3.0 for general patients.
    • INR of 2.5 to 3.5 for synthetic/prosthetic valves.
Patient Education regarding Vitamin K and Warfarin
  • Patients advised on consistent dietary sources of Vitamin K to manage INR effectively.