Cardiology (Atherosclerosis,Angina,Heart failure)

Cardiology

1. CARDIOLOGYCARDIOLOGY
CARDIOLOGYCARDIOLOGY
Dr. Waleed FareedDr. Waleed Fareed
MD Internal MedicineMD Internal Medicine
UMST
Faculty of Dentistry

2. Atherosclerosis
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Athero- refers to soft or “porridge-like”, and -
sclerosis refers to hardening.
Atherosclerosis is a combination of
atheromas (fatty deposits in the artery
walls) and sclerosis (hardening or stiffening
of the blood vessel walls).
the deposition of lipids in the artery wall is
followed by the development of fibrous
atheromatous plaques

3. Atherosclerosis
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These plaques result in:
Stiffening
Stenosis
Plaque rupture

Stiffening of the artery walls leads to hypertension
and strain on the heart as it tries to pump blood
against extra resistance.
Stenosis leads to reduced blood flow (e.g. in angina).
Plaque rupture creates a thrombus that can block a
distal vessel and cause ischemia. An example is
acute coronary syndrome, where a coronary artery
becomes blocked.

4. Atherosclerosis

5. Risk Factors
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Non-modifiable risk factors:
Older age
Family history
Male

Modifiable risk factors:
hypercholesterolemia
Smoking
Alcohol
Poor diet
Lack of exercise
Obesity
Diabetes
Hypertension
Chronic kidney disease (CKD)

6. End Results of Atherosclerosis
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Angina
Myocardial infarction
Transient ischemic
attacks
Strokes
Peripheral arterial
disease

7. Prevention of Cardiovascular
Disease
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Optimize the modifiable risk factors:
Address diet, exercise and obesity
Stop smoking
Reducing alcohol consumption
Optimize treatment of co-morbidities (such as
diabetes, HTN)
Statins reduce cholesterol production in the liver

8. Angina
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Angina is caused by atherosclerosis affecting the
coronary arteries, narrowing the lumen and reducing
blood flow to the myocardium (heart muscle). During
times of high demand, such as exercise, there is an
insufficient supply of blood to meet the demand. This
causes the symptoms of angina, typically constricting
chest pain, with or without radiation to the jaw or arms. 
Angina is “stable” when symptoms only come on with
exertion and are always relieved by rest or glyceryl
trinitrate (GTN). 
It is “unstable” when the symptoms appear randomly
whilst at rest. Unstable angina is a type of acute
coronary syndrome ( ACS) and requires immediate
management.

11. Presentation
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Typical chest pain:
Central, retrosternal,
constricting/gripping/heavyness
Pain radiating to the jaw or arms
Aggravated by exertion and relieved by rest

12. Investigations
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Physical examination (e.g., heart sounds,
signs of heart failure, blood pressure)
ECG (a normal ECG does not exclude stable
angina)
Serum troponin
CBC (anemia)
RFT
Lipid profile
HbA1C and blood glucose
Echocardiogram

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Troponin is a protein in cardiac muscle
(myocardium) and skeletal muscle. The
specific type of troponin.
A rise in troponin is consistent with
myocardial ischemia (STEMI & NSTEMI)
as they are released from the ischemic
muscle tissue.

14. ECG Changes in Acute Coronary
Syndrome
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STEMI:
ST-segment elevation
New left bundle branch block
 
NSTEMI:
ST segment depression 
T wave inversion

15. Management of ACS
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Emergency !
Urgent ECG
Aspirin 300mg
Intravenous morphine for pain if required
(with an antiemetic, e.g., metoclopramide)
N – Nitrate (GTN)

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Percutaneous coronary intervention ( PCI)
(if available within 2 hours of presenting)
Thrombolysis (if PCI is not available within
2 hours)

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Medications for secondary prevention:
Aspirin 75mg once daily
Atorvastatin 80mg once daily
ACE inhibitor (if diabetes, hypertension, CKD
or heart failure are also present)
beta blocker for symptomatic relief

18. •Coronary artery bypass graft ( CABG) a
Surgical procedure which is generally
offered to patients with more severe
disease and where medical treatments do
not control symptoms.

21. CABG Scar

22. Great Saphenous Vein Scar Mark
for CABG

23. Heart Failure
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refers to the clinical features of impaired
heart function, specifically the function of
the left ventricle to pump blood out of the
heart and around the body.
The ejection fraction is the percentage of
blood in the left ventricle squeezed out
with each ventricular contraction. An
ejection fraction above 50% is considered
normal.

24. Heart Failure - Causes

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Ischemic heart disease
Valvular heart disease (commonly aortic
stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
Cardiomyopathy

25. Presentation
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The key symptoms of chronic heart failure
are:
Breathlessness, worsened by exertion
Cough, which may produce frothy white/pink
sputum
Orthopnea, which is breathlessness when lying
flat, relieved by sitting or standing (ask how many
pillows they use)
Paroxysmal nocturnal dyspnea
Peripheral edema
Fatigue

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Signs on examination include:
Tachycardia (raised heart rate)
Tachypnea (raised respiratory rate)
Hypertension
Murmurs on auscultation indicating valvular heart
disease
Bilateral basal crackles on auscultation of the
lungs, indicating pulmonary edema
Raised jugular venous pressure ( JVP), caused by
a backlog on the right side of the heart, leading to
an engorged internal jugular vein in the neck
Peripheral edema of the ankles, legs and sacrum

27. Heart Failure - Medical Treatment
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Loop diuretics (e.g. furosemide)
ACE inhibitor (e.g., ramipril) or angiotensin
receptor blocker (ARB) (e.g. candesartan)
Beta blocker (e.g., bisoprolol)
Aldosterone antagonist when symptoms
are not controlled with A and B (e.g.,
spironolactone)

28. Hypertension
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high blood pressure > 140/90
Causes:
Essential hypertension accounts for 90% of
hypertension. This is also known as primary
hypertension. It means a high blood pressure has
developed on its own and does not have a secondary
cause. 
Secondary causes:
Renal disease: the most common cause
Obesity
Pregnancy-induced hypertension or pre-eclampsia
Endocrine
Drugs (e.g., alcohol, steroids, NSAIDs, oestrogen)

29. Complications
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Ischemic heart disease (angina and acute
coronary syndrome)
Cerebrovascular accident (stroke or
intracranial hemorrhage)
Vascular disease (peripheral arterial disease,
aortic dissection and aortic aneurysms)
Hypertensive retinopathy
Hypertensive nephropathy
Vascular dementia
Left ventricular hypertrophy
Heart failure

30. Diagnosis of HTN
•Two or more high readings on two
different occasions

31. Management
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Lifestyle advice includes a healthy diet, wt
reduction, stopping smoking, alcohol, reduce
caffeine and salt intake and regular exercise.
Medications used in management are:
A – ACE inhibitor (e.g., ramipril)
B – Beta blocker (e.g., Atenolol, bisoprolol)
C – Calcium channel blocker (e.g., amlodipine)
D –diuretic (e.g., Hydrochlorothiazide, indapamide,
Spironolactone)
ARB – Angiotensin II receptor blocker (e.g.,
Losartan, candesartan)

33. Hypertensive Crisis

35. Infective Endocarditis
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infection of the endothelium (the inner
surface) of the heart. Most commonly, it
affects the heart valves.
Causes
The most common cause is Staphylococcus
aureus. 
Other causes include:
Streptococcus viridans
Enterococcus (e.g., Enterococcus fecalis)

36. Presentation
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The presenting symptoms are non-
specific for an infection:
Fever
Fatigue
Night sweats
Muscle aches
Anorexia (loss of appetite)

Fever + new murmur = Infective Endocarditis
until proven otherwise

37. Investigations

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Blood cultures are essential before
starting antibiotics. Three blood culture
samples are recommended, usually
separated by at least 6 hours and taken
from different sites.  
Echocardiography is the usual imaging
investigation.Vegetations (an abnormal
mass or collection) may be seen on the
valves. 

38. Management
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Patients require admission
Intravenous broad-spectrum antibiotics for 4-6
weeks
Surgery may be required for:
Heart failure relating to valve pathology
Large vegetations or abscesses
Infections not responding to antibiotics

Prophylaxis Antibiotics are not routinely recommended
for dental and non-dental procedures as prophylaxis of
infective endocarditis. However, it is still considered on a
case-by-case basis in those at particularly high risk.

39. Rheumatic Heart Disease (RHD)
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Rheumatic heart disease starts as a sore
throat from a bacterium called Streptococcus
pyogenes (group A streptococcus)
repeated strep infections cause the immune
system to react against the tissues of the
body including inflaming and scarring the
heart valves. This is what is referred to as
rheumatic fever. Rheumatic heart disease
results then from the inflammation and
scarring of heart valves caused by rheumatic
fever.

40. Rheumatic Heart Disease (RHD)
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Signs & Symptoms
fever
Arthritis & Arthralgia
fatigue
jerky uncontrollable body movements called ‘chorea’
painless subcutaneous nodules.
heart murmur
Symptoms of heart valve damage that is associated
with rheumatic heart disease may include:
chest pain or discomfort
shortness of breath
Atrial fibrillation

41. Rheumatic Heart Disease (RHD)
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Complications
Valvular damage mostly mitral stenosis
Heart Failure
Infective Endocarditis
Stroke

42. Arrhythmias
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abnormal heart rhythms.
They result from an interruption to the
normal electrical signals that coordinate
the contraction of the heart muscle. There
are several types of arrhythmia, each with
different causes and management options

43. Arrhythmias
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Heart Block:
First-degree heart block occurs where there is
delayed conduction through the
atrioventricular node
Second-degree heart block is where some
atrial impulses do not make it through the
atrioventricular node to the ventricles.
Third-degree heart block is also called
complete heart block. There is no observable
relationship between the P waves and QRS
complexes (needs urgent pacemaker)

44. Arrhythmias
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Atrial Fibrillation:
electrical activity in the atria of the heart
becomes disorganized, leading to fibrillation
(random muscle twitching) of the atria and an
irregularly irregular pulse.
The overall effects of atrial fibrillation are:
Irregularly irregular ventricular contractions 
Tachycardia (fast heart rate)
Heart failure due to impaired filling of the
ventricles during diastole
Increased risk of stroke & thromboembolisation
(prevention by anticoagulation)

45. Atrial Fibrillation
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Common Causes
Sepsis
Mitral valve pathology (stenosis or
regurgitation)
Ischemic heart disease
Thyrotoxicosis
Hypertension

46. Atrial Fibrillation
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Presentation
Patients are often asymptomatic, and atrial
fibrillation is an incidental finding. It may be
diagnosed after a stroke. 
Patients may present with:
Palpitations
Shortness of breath
Dizziness or syncope (loss of consciousness)

47. Atrial Fibrillation
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Medications used in treatment of atrial
fibrillation include:
Beta blockers. ...
Calcium channel blockers. ...
Digoxin. ...
Anti-arrhythmic medications. ...
anticoagulation

48. Supraventricular Tachycardia (SVT)
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SVT refers to when abnormal electrical
signals from above (supra-) the ventricles
cause a fast heart rate ( tachycardia). 
Fast & regular heart beats.
Presentation: Most SVTs are unpleasant rather than life-
threatening:
palpitations
Weakness /fatigue
Chest pain/tightness
Shortness of breath
Lightheadedness or dizziness
Fainting (syncope) or near fainting

49. Supraventricular Tachycardia (SVT)
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Acute Management
Step 1: Vagal manoeuvres
Step 2: Medical ttt
Step 3: Synchronised DC cardioversion
Vagal manoeuvres stimulate the vagus nerve, increasing
the activity in the parasympathetic nervous system. This
can slow the conduction of electrical activity in the heart,
terminating an episode of supraventricular tachycardia.
Valsalva manoeuvres involve increasing the intrathoracic
pressure. This can be achieved by having the patient blow
hard against resistance, for example, blowing into a 10ml
syringe for 10-15 seconds.
Carotid sinus massage involves stimulating the
baroreceptors in the carotid sinus by massaging that area
on one side of the neck (not both sides at the same time).

50. Valvular heart disease
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any cardiovascular disease process
involving one or more of the four valves of
the heart (the aortic and mitral valves on
the left side of heart and the pulmonic and
tricuspid valves on the right side of heart).
Common causes:
Congenital (inborn) abnormalities
Aging
IHD (MI)
Rheumatic heart disease
Infective Endocarditis

53. Signs and symptoms
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heart failure symptoms, such as dyspnea
on exertion, orthopnea and paroxysmal
nocturnal dyspnea,.
angina pectoris.

54. Valvular heart disease
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Echocardiography is the diagnostic gold
standard.
Treatment:
Medical:
antithrombotic medications such as aspirin,
anticoagulants
Symptomatic ttt: diuretics, beta blockers…
Surgical:
valve repair
Valve replacement (mechanical/metalic or
tissue/biological)