1) PUBLIC HEALTH



1) MANIFESTATIONS OF CARDIOVASCULAR DISEASES:

A) CHEST PAINS:

• There are many causes of chest pain that are not all attributable to the heart itself. Moreover the pains may be midline or to the side of the chest.

|CAUSE OF PAIN |PRESENTATION & DIFF. DIAGNOSIS |LOCATION (MIDLINE/PERIPHERAL) |

|1. HEART | | |

|• Anginal Pain |• Angina is due to the ( of blood supply (ischemia) which ( oxygen & leads to anaerobic glycolysis. This |• Angina (Midline) |

| |( Lactic acid & stimulates nerve endings to then present as pain | |

| |( Pain ( with exertion & ( with rest (transient ischemia) & is worse after a heavy meal | |

| |( Sublingual Nitrate held under tongue for 15 seconds should relieve pain due to vasodilation. (side | |

| |effect | |

| |is headache due to pulsating temporal arteries) | |

| |( The pain is Retrosternal & characterized by: Choking, Squeezing, Constricting, crushing pains that may | |

| |radiate to jaw & arm (especially left arm) [THE PAIN IS NEVER STABBING/TEARING] | |

|( Myocardial Infarct | |( Myocardial Infarct (Midline) |

| |( Myocardial infarct may be diagnosed by EKG changes & blood test reveals ( cardiac enzymes | |

| |( Pain is greater than in Angina & does not decrease with rest, change in posture or Sublingual Nitrate | |

| |( Respiration does not change the pain | |

|( Pericarditis | |( Pericarditis (midline) |

| |( Pericarditis presents with the same pain as for Angina but is diagnosed in the following way | |

| |( Pain varies in intensity with respiration & coughing ( patient catches breath. Pain is also worse lying| |

| | | |

|( Mitral Valve prolapse |down or leaning forward. |( Mitral Valve Prolapse |

| | | |

| |( Mitral valve prolapse is Atypical chest pain | |

| |( It has no pattern. Pain comes & goes & doesn’t radiate. | |

|2. LUNGS | | |

|3. ESOPHAGUS |• Acid reflux pain relieved by antacids & generally food related. Worse for lying down |• Midline pain |

|4. TRACHEA (tracheatis) |• Generally associated with a cough |• Midline |

|5. RIBS |• Associated with injury |• Lateral |

|6. COSTOCHONDRITIS |• Inflammation of the Chostochondral joints near the sternum. Pain associated with breathing |• Mostly midline pain |

|7. DISSECTING AORTIC ANEURYSM |• Extremely painful & has sudden drop in Blood pressure |• Midline pain |

|8. I.V.D. PROLAPSE |• Nerve involvement | |

|9. HERPES ZOSTER (reactivated |• Unilateral rash that does not cross the midline of the body |- Peripheral & Does not cross |

|chickenpox virus) | |midline |

|10. PSYCHOGENIC | | |

1) MANIFESTATIONS OF CARDIOVASCULAR DISEASES:

B) CARDIOVASCULAR DISEASE MANIFESTATIONS:

• Cardiovascular disease manifestations include more than simply pain symptoms as above. It may include:

a) Dyspnea: difficulty breathing due to restricted blood flow through left atrium therefore ( fluid in lungs

b) Shock: ( perfusion of blood leading to hypotension

c) Edema: This is fluid in the intracellular space due to right side heart failure (may also have hepatomegaly & congested/nutmeg liver). Moreover, ascites & pedile edema may be present

d) Palpitations: Patient feels there heart beats

e) Syncope: This is loss of consciousness (transient) of the patient due to ( cerebral blood supply

C) CARDIOVASCULAR DISEASE EVALUATION:

• May include any of the following:

a) Physical exam: Pulses (radial, veinous/arterial etc., Apex beat, Auscultation for sounds & murmurs

b) EKG: Will reveal hypertrophy, ischemia, infarction & pericardial lesions

c) Exercise: Stress EKG can help provoke an ischemia

d) Holter monitoring: Ekg worn for 24 hours to see if any problems are present

e) Echocardiography: Non-invasive way to see blood flow, heart structure, heart valve movement & cardiac muscle. 3 types Doppler (most common), M-Mode, Two dimensional

f) Chest X rays: See what grossly what heart & great vessels look like

g) N/invasive tomography: MRI used often for wide variety of cardiac anomalies.

CT Scan has 90% accuracy for verifying coronary artery bypass patency.

PET some times

h) Catheterization:

I) Coronary angiography:

2) CONGENITAL HEART DISEASE (CHD):

• Etiology: Multifactorial that includes the following:

- chromosomal (trisomi 21 autosomal or Turner’s is sex linked)

- Viral from Rubella (( pregnant & infected in 1st trimester)

- Chemicals such as alcohol, smoking during pregnancy

• Presentation: 3 broad categories

- Left to Right Atrial shunt (atrial septal, ventricular septal & persistent ductus arteriosus)

- Right to Left shunt (Tetrology of Fallot)

- No shunts (Coarctation of aorta & aortic stenosis)

|CONGENITAL DEFECT |DESCRIPTION & SYMPTOMATOLOGY |

|LEFT TO RIGHT SHUNTS |General info: |

| |- We have Right Ventricular Overload, Right Ventricular Hypertrophy & |

| |Pulmonary Hypertension (PHT) |

| |- Initially the patients are acyanotic due to ( volume of blood to lungs. However with prolonged Pulmonary Hypertension shunt |

| |reversal occurs & Cyanosis occurs. This reversal is called “Late cyanotic congenital heart disease or Eisenmenger’s Syndrome |

| | |

|1 Atrial Septal Defect (ASD) |1. Common in females & if ASD is small there are no symptoms. If ASD large then symptoms ensue |

| |( Clinically children have repeated pulm. infections & slow weight gain & symptoms only appear in 3rd decade |

| |( Palpitations (due arrhythemia), fatigue, dyspnea on exertion & Right Ventricular Heart failure |

| |( We find a displaced Apex beat (to left if LVF & upwards if RVF). Normally found at midclavicular line & 5th intercostal space |

| |( On auscultation S2 is split in both (fixed) Inspiration & Exhalation (normal individual S2 splits on Inspiration only) & there |

| |is a |

| |systolic Ejection murmur |

|2 Ventricular Septal Defect (VSD) |( X-rays reveal RV hypertrophy, Pulmonary plethora (due enlarged b.v.) . EKG reveals a Right Bundle Branch Block (RBBB) |

| |2. This is the most common form of Congenital Heart Disease (CHD) & we find 1 in 500 children. Typically the membranous part if |

| |Interventricular septum is affected 90% of times & the muscular part 10% of times. If defect is < .5cm no symptoms. |

| |( If septum is large with PHT present: L(R shunt reverses to R(L shunt (Eisenmenger’s syndrome) |

| |( If septum is large w/out Pht present: L(R shunt, growth failure, repeated LRI infection & CHF |

| |( Patient is dyspnoeic, with stunted growth, chest pains & cyanosis |

| |( Auscultation reveals a harsh Pansystolic murmur with tearing sounds between S1 & S2 |

| |( X rays show Right & Left Ventricular Hypertrophy with Pulmonary Plethora |

|3. Patent(Persistent)Ductus Arteriosus |( Complications include infective endocarditis |

|(PDA) |3. More common in females & most common etiology is Rubella. Infant may be premature ( 20-25% of LV. If 40% of tissue involved we have cardiogenic |

| |shock which is most common cause of death due to AMI), Myocardium rupture may occur between 2-10 days post infarct, Thromboembolism (due to bed |

| |rest), Fibrinous pericarditis (Dressler’s syndrome is triad of fever, pericarditis & pericardial effusion 2wks to 2 mths after infarct), Ventricular aneurysm & |

|Sudden Cardiac Death |possibly Shoulder Hand syndrome (pain/immobility left hand for weeks after MI) |

| |• This is unexpected death from cardiac causes within 1 hr of MI & has no symptoms. It is really a complication of IHD & may be due to Congenital aortic |

| |stenosis, abnormalities of conduction system (90% of time ventricular fibrillation) & Hypertrophic cardiomyopathy |

| |( We have at least 2 cardiac arteries involved with marked atherosclerosis & sever stenosis |

| |( There is sudden & complete loss of cardiac function with no pulse, no consciousness, no respiration & pupils begin to dilate. |

| |( EKG shows chaotic, bizarre irregular waves |

|Chronic IHD with CHF |( Ventricular fibrillation is most common cause & most easily treated cause |

| |• Gradual problem w/out sypmtomatology then sudden heart failure |

4) SYSTEMIC HYPERTENSION

General Info:

• This is the sustained elevation of diastolic pressure greater than 90mmHg and/or systolic greater than 140mmHg (normal should be 120/80)

• Etiologically may be classifed as Primary (Essential) or Secondary Hypertension

• Clinically may be classified as benign or malignant.

(In all cases of HT mortality rate is 10% with systolic BP of 160 mmHg or diastolic 100 mmHg & greater over 20 years w/out treatment. The increase in mortality is due to stroke (4 fold increase risk if untreated), coronary artery disease (CAD) [diastolic of 95 mmHg have 2 fold increase over normotensive person] & congestive Heart failure (CHF) [pressure of 160/95 mmHg have 4 fold increase risk of CHF]

( Mostly asymptomatic with occasional pounding headaches, worse in the morning & better towards night time.

( No cause except for arteriosclerosis

The table below outlines the types of HT

|TYPE OF HYPERTENSION |DESCRIPTION & DIAGNOSIS |

|Essential Hypertension |• Seen mostly in adult males (blacks moreso) with age predilection >35yrs |

| |• Associated risk factors are cigarette smoking, obesity, stress & alcohol consumption & family history |

|Secondary Hypertension | |

| |• Generally occurs in patients 7.4 Alkalosis |

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