Rapid Revision Internal Medicine - Cardiology

Dr.G Bhanu Prakash Animated Medical Videos・2 minutes read

The text extensively covers various topics related to cardiology, including heart failure, cardiomyopathy, heart sounds, cardiac murmurs, valvular heart diseases, and diagnostic methods. It also delves into specific conditions such as dilated cardiomyopathy, hypertrophic cardiomyopathy, mitral stenosis, aortic stenosis, and pericardial effusion, detailing their clinical features, diagnosis, and treatments.

Insights

  • 1. The patient in the clinical scenario is a 56-year-old man with coronary artery disease and an ejection fraction of 40%, placing him in Stage B of heart failure as per ACC guidelines.
  • 2. Left heart failure is categorized by ejection fraction, with preserved EF >50% and reduced EF <40%, showcasing distinct manifestations like paroxysmal nocturnal dyspnea and orthopnea.
  • 3. Right heart failure's initial signs include a positive hepatogular reflex, followed by JVP elevation, hepatomegaly, and pedal edema, progressing to portal hypertension, ascites, and splenomegaly.
  • 4. Chain Stokes respiration, characterized by alternating rapid breathing and apnea, is a notable feature in congestive heart failure patients.
  • 5. Cardiomyopathies, encompassing dilated, hypertrophic, and restrictive forms, are crucial disorders affecting heart muscle function, with dilated cardiomyopathy linked to various factors like toxins, inflammation, and nutritional deficiencies.
  • 6. Mitral stenosis, commonly caused by rheumatic fever, presents with unique auscultation findings like loud S1 and P2 due to pulmonary hypertension, requiring treatment modalities like sodium restriction and mitral valve interventions.
  • 7. Thrombolysis is exclusively used in ST elevation MI, not for non-ST elevation MI or unstable angina, with tenecteplase being the most effective thrombolytic agent available.

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Recent questions

  • What are the main classifications of heart failure?

    Heart failure is classified into left and right heart failure. Left heart failure is further categorized based on ejection fraction, with preserved EF >50% and reduced EF <40%. Right heart failure manifests with a positive hepatogular reflex, raised JVP, tender hepatomegaly, pedal edema, portal hypertension, ascites, and splenomegaly.

  • How is left heart failure diagnosed?

    Left heart failure is diagnosed based on clinical manifestations like paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and dyspnea at rest. NYHA classification assesses symptoms, ranging from Class 1 with no limitations to Class 4 experiencing dyspnea at rest. Diagnostic methods include chest X-rays showing cardiomegaly and echocardiograms revealing reduced ejection fraction and dilated chambers.

  • What are the primary forms of cardiomyopathies?

    Cardiomyopathies encompass dilated, hypertrophic, and restrictive forms. Dilated cardiomyopathy can be caused by various factors like toxins, inflammatory conditions, autoimmune diseases, and nutritional deficiencies. Clinical features mirror those of heart failure, with diagnostic methods including chest X-rays and echocardiograms.

  • How is hypertrophic cardiomyopathy characterized?

    Hypertrophic cardiomyopathy involves an increase in the thickness of the left ventricle, particularly the septum, by more than 1.5 centimeters. It can lead to asymmetrical septal hypertrophy, obstructing the left ventricular outflow tract and causing hypertrophic obstructive cardiomyopathy. Genetic mutations in genes like beta myosin and myosin binding protein C are the main etiology.

  • What are the main treatments for mitral stenosis?

    Treatment for mitral stenosis includes sodium restriction, diuretics, and beta-blockers for symptomatic relief. Severe cases may require mitral valve intervention like percutaneous mitral valve balloon valvuloplasty or mitral valve replacement. Diagnosis involves 2D echo, ECG, and chest X-ray, with complications like left atrial enlargement leading to atrial fibrillation.

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Summary

00:00

Cardiology Quick Revision: Heart Failure Essentials

  • Topics covered in the Cardiology quick revision include congestive heart failure, cardiomyopathy, heart sounds, JVP, cardiac murmurs, arterial pulse, valvular heart diseases, and more.
  • The patient in the clinical scenario, a 56-year-old man with coronary artery disease and an ejection fraction of 40%, belongs to Stage B of heart failure according to ACC guidelines.
  • Left heart failure is classified based on ejection fraction, with preserved ejection fraction having EF >50% and reduced ejection fraction having EF <40%.
  • Manifestations of left heart failure include paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and dyspnea at rest.
  • NYHA classification assesses heart failure symptoms, with Class 1 having no limitations and Class 4 experiencing dyspnea at rest.
  • Right heart failure's earliest manifestation is a positive hepatogular reflex, followed by raised JVP, tender hepatomegaly, pedal edema, portal hypertension, ascites, and splenomegaly.
  • Chain Stokes respiration, characterized by alternating periods of increased respiratory rate and apnea, is seen in congestive heart failure patients.
  • Framingham's criteria, including major and minor criteria, are used for diagnosing heart failure, along with cardiac biomarkers and imaging like chest x-ray and ECG.
  • Chest x-ray findings in congestive heart failure progress from upper lobe vein distention to interstitial edema, curly B lines, alveolar edema, and pleural effusion.
  • NT Pro BNP is the most sensitive cardiac biomarker for heart failure, with other markers like atrial natriuretic peptide and endothelin-1 also elevated.

14:27

Cardiomyopathy: Diagnosis, Treatment, and Risk Factors

  • Post myocardial infarction, if a patient still exhibits NYHA Class 2 or 3 symptoms after a year or 40 days, they are eligible for an implantable cardioverter defibrillator due to the heightened risk of sudden cardiac death.
  • For CRT, individuals with an ejection fraction below 35%, Class 2 to 4 symptoms, and a QRS complex of 150 milliseconds or more with left bundle branch block necessitate cardiac resynchronization therapy.
  • If a patient remains refractory to treatment, reaching NYHA Class B or 4 despite CRT, they may require cardiac transplantation or a left ventricular assist device (LVAD).
  • Cardiomyopathies encompass disorders within the cardiac muscle, with dilated, hypertrophic, and restrictive cardiomyopathies being the primary forms.
  • Dilated cardiomyopathy can be caused by various factors, including toxins like alcohol and chemotherapeutic drugs, inflammatory conditions, autoimmune diseases, nutritional deficiencies, endocrine issues, hematological disorders, and neuromuscular conditions.
  • Clinical features of dilated cardiomyopathy mirror those of heart failure, with diagnostic methods including chest X-rays showing cardiomegaly and echocardiograms revealing reduced ejection fraction and dilated chambers.
  • Treatment for dilated cardiomyopathy involves medications like beta-blockers, diuretics, ACE inhibitors, and aldosterone antagonists, with caution against calcium channel blockers due to reduced ejection fraction.
  • Frederick's ataxia is a neurological condition linked to dilated cardiomyopathy, characterized by ataxia, Romberg sign, dysmetria, and a dilated heart.
  • Peripartum cardiomyopathy occurs in pregnant or postpartum women without pre-existing cardiac issues, with risk factors including pre-eclampsia and multiparity, requiring beta-blockers, diuretics, hydralazine, nitrates, and bromocriptine.
  • Takotsubo cardiomyopathy, also known as stress cardiomyopathy or broken heart syndrome, involves ballooning of the heart apex due to severe stress, necessitating modified Mayo criteria for diagnosis and treatment akin to acute MI, with intra-aortic balloon pump use in cardiogenic shock and avoidance of certain drugs like dopamine and norepinephrine.

28:14

Hypertrophic Cardiomyopathy: Causes, Symptoms, and Treatment

  • Hypertrophic cardiomyopathy is characterized by an increase in the thickness of the left ventricle, specifically the septum, by more than 1.5 centimeters.
  • This condition can lead to asymmetrical septal hypertrophy, obstructing the left ventricular outflow tract, and causing hypertrophic obstructive cardiomyopathy.
  • Hypertrophy can also occur at the apex, resulting in apical hypertrophy, leading to different shapes of the left ventricle - banana-shaped for obstructive cardiomyopathy and Ace of Spades shape for apical hypertrophy.
  • The main etiology of hypertrophic cardiomyopathy is genetic, with mutations in genes like beta myosin, myosin binding protein C, and troponin T.
  • Clinical presentation includes asymptomatic patients who may present with sudden cardiac death or symptoms like dyspnea, giddiness, palpitations, syncopal attacks, and angina.
  • Examination findings in hypertrophic cardiomyopathy include characteristic pulses, double carotid upstroke, double apical impulse, and a harsh systolic diamond-shaped murmur.
  • Murmur intensity increases with conditions that decrease left ventricular volume or increase obstruction, while it decreases with conditions that increase volume or decrease obstruction.
  • Diagnostic investigations like 2D Echo show preserved ejection fraction and systolic anterior motion of the mitral valve leaflet, while ECG may reveal deep dagger-shaped Q waves and LV strain pattern.
  • Treatment involves propranolol as the drug of choice, avoidance of strenuous physical activity, and surgical options like alcohol septal ablation or myomectomy if medical management fails.
  • In restrictive cardiomyopathy, abnormal material accumulation in the myocardium leads to stiffness, diastolic dysfunction, and heart failure with preserved ejection fraction, commonly caused by amyloidosis or storage disorders like Fabry's disease.

42:23

Heart Sounds and Cardiomyopathy Treatment Insights

  • In restrictive cardiomyopathy, ECG shows less than 10 mm in chest leads and less than 5 mm in limb leads, leading to heart failure with preserved ejection fraction.
  • Amyloidosis presents with a speckled pattern in echocardiogram, along with atrial distention, functional MR, and TR.
  • Treatment for restrictive cardiomyopathy involves diuretics to prevent heart failure and pulmonary edema.
  • Anticoagulants are necessary to prevent thromboembolic events caused by atrial distention in restrictive cardiomyopathy.
  • Digoxin should be avoided in restrictive cardiomyopathy to prevent arrhythmias.
  • Heart sounds include S1 in isovolumetric contraction, S2 in proto-diastole, S3 in first rapid filling, and S4 in second rapid filling.
  • S1 and S2 are high-pitched sounds, while S3 and S4 are low-pitched sounds, heard with a diaphragm and bell, respectively.
  • Conditions affecting heart sounds include hyperkinetic states for loud S1, obesity for soft S1, and conditions like mitral stenosis for soft S1.
  • Split S2 has A2 and P2 components, with wide split seen in conditions like ASD and VSD, and wide fixed split in conditions like ASD and pulmonary stenosis.
  • Additional heart sounds include ejection click in aortic stenosis, opening snap in mitral stenosis, pericardial knock in constrictive pericarditis, and tumor plop in myxoma.

56:53

Cardiac Pulse Abnormalities and Mitral Stenosis

  • Kussmaul sign is an increase in jugular venous distension during inspiration, commonly seen in diabetic ketoacidosis.
  • Arterial pulse abnormalities include paradoxical pulses in cardiac tamponade, alternating strong and weak pulses in severe left ventricular failure, and pulsus bisferiens in aortic stenosis.
  • Water hammer pulse, also known as collapsing pulse, is observed in aortic regurgitation, while dichrotic pulse is seen in dilated cardiomyopathy.
  • Mid-systolic click with late systolic murmur characterizes mitral valve prolapse.
  • Mitral stenosis is classified based on valve area, with very severe stenosis having an area less than or equal to 1 cm², severe stenosis less than or equal to 1.5 cm², and progressive stenosis more than 1.5 cm².
  • Mitral stenosis is commonly caused by rheumatic fever, connective tissue disorders, and storage disorders like Hurler syndrome.
  • Auscultation in mitral stenosis reveals a loud S1, variable S1 in calcified MS, and loud P2 due to pulmonary hypertension.
  • Complications of mitral stenosis include left atrial enlargement leading to atrial fibrillation, dysphagia, and hoarseness of voice (Ortner syndrome).
  • Diagnosis of mitral stenosis involves 2D echo, ECG showing a characteristic M-shaped P wave, and chest x-ray showing straightening of the left heart border and double density sign.
  • Treatment of mitral stenosis includes sodium restriction, diuretics, and beta-blockers for symptomatic relief, with severe cases requiring mitral valve intervention like percutaneous mitral valve balloon valvuloplasty or mitral valve replacement.

01:10:59

Cardiac Conditions: Mitral Regurgitation and Aortic Stenosis

  • Hypertrophic cardiac conditions can lead to secondary mitral regurgitation, particularly affecting the inferior and anterior walls of the heart.
  • Mitral valve prolapse is diagnosed when the mitral valve prolapses more than 2 mm into the left atrium, leading to a mid-systolic click and late systolic murmur.
  • Clinical features of mitral regurgitation include left ventricular failure, resulting in dyspnea, atrial enlargement, palpitations, atrial fibrillation, and subsequent right ventricular failure.
  • Signs of mitral regurgitation include irregularly irregular pulse with atrial fibrillation, hyperdynamic apical impulse, soft S1 heart sound, pan systolic murmur, and the possibility of S3 heart sound.
  • Dynamic auscultation in mitral valve prolapse involves maneuvers affecting venous return, altering the timing of the click and murmur.
  • Diagnosis of mitral regurgitation is primarily done through 2D echocardiography, with treatment involving diuretics, digoxin for atrial fibrillation, and beta-blockers if necessary.
  • Surgical intervention for mitral regurgitation is required when ejection fraction drops below 50% with symptoms, necessitating mitral valve replacement.
  • Aortic stenosis occurs when the aortic valve area reduces to less than 2 cm², commonly caused by calcified degenerative valves in adults.
  • Symptoms of aortic stenosis include syncope, angina, and dyspnea, with examination findings of narrow pulse pressure and a heaving apical impulse.
  • Treatment for aortic stenosis involves surgical correction when symptomatic or when ejection fraction drops below 55% or left ventricular end-systolic diameter exceeds 55 mm.

01:24:55

Pericardial Knock and Hypertension Management Insights

  • Pericardial knock is a diastolic sound caused by the thickened pericardium hitting the myocardium during relaxation.
  • ECG changes in constrictive pericarditis include low voltage complexes with amplitudes less than 10 mm in chest leads and less than 500 in limb leads.
  • Chest X-ray in constrictive pericarditis reveals a calcified pericardium, best seen in later views.
  • 2D Echo shows septal bounce, where the interventricular septum moves left during inspiration and right during expiration.
  • CT scan displays pericardial thickening exceeding 4 mm, while MRI can also demonstrate septal bounce.
  • Treatment for pericardial disorders involves diuretics, fluid restriction, and pericardiectomy if refractory to medical management.
  • Hypertension diagnosis in a 44-year-old woman with symptoms like headache and rapid pulse involves measuring urinary methanephrine levels over 24 hours.
  • Primary hypertension is essential, while secondary hypertension has identifiable underlying causes like renal parenchymal diseases.
  • Lifestyle modifications like weight reduction, DASH diet, sodium reduction, and physical activity are crucial in hypertension management.
  • First-line antihypertensives are calcium channel blockers or diuretics, with resistant hypertension requiring three drugs of different classes at maximum doses.

01:39:26

Treatment and Diagnosis of Pericardial Effusion

  • Empirical treatment for infected endocarditis involves starting Ceftriaxone and Vancomycin initially, adjusting based on culture and sensitivity results.
  • Fungal endocarditis carries a poor prognosis, requiring lifelong antifungal drugs like amphotericin B.
  • Surgical treatment is often recommended for infected endocarditis cases.
  • Pericardial effusion is diagnosed when more than 50 mL of fluid accumulates in the pericardial space.
  • Pericardial effusion differs from cardiac tamponade based on the rapidity of fluid accumulation.
  • Dyspnea is a common presentation in individuals with pericardial effusion due to diastolic dysfunction.
  • Diagnostic methods for pericardial effusion include 2D Echo, chest x-ray, and ECG.
  • Pericardial effusion may show a "water bottle" appearance on chest x-ray and low voltage complexes on ECG.
  • Pericardiocentesis is necessary for treating pericardial effusion, especially in cases of massive effusion or cardiac tamponade.
  • Cardiac tamponade results from elevated intrapericardial pressure, causing diastolic collapse of the ventricles and restricting venous return.

01:52:57

Angina: Diagnosis, Treatment, and Imaging Modalities

  • Beta blockers are the drug of choice for chronic stable angina as they reduce heart rate and myocardial oxygen demand, slowing disease progression.
  • Nitrates are used for pain relief in chronic angina, along with antiplatelets and statins; ranolazine is also utilized.
  • Imaging methods like thallium 201 or technetium 99 aid in detecting hibernating myocardium, while PET scans with rubidium 82 assess myocardial metabolism.
  • Electron beam CT scans evaluate coronary artery calcification, and gadolinium-enhanced MRI detects and quantifies infarction extent.
  • Prinzmetal angina, or vasospastic angina, involves coronary artery spasms, commonly affecting the right coronary artery, with ST segment elevation during spasms.
  • Nitrates are the primary treatment for relieving vasospasms in Prinzmetal angina, with calcium channel blockers and fasudil as alternatives.
  • Unstable angina presents with rest-induced chest pain, accelerating in intensity, and may indicate new-onset angina or a valence syndrome ECG manifestation.
  • Non-ST elevation MI is characterized by angina at rest, fluctuating cardiac biomarkers, and ST segment depression on ECG, differing from ST elevation MI.
  • ST elevation MI involves transmural myocardial infarction, with various types based on causes like plaque rupture or coronary artery dissection.
  • Treatment for MI includes aspirin as first-line, morphine or nitrates for pain control, and antiplatelets like clopidogrel or ticagrelor, with PCI as the preferred revascularization method.

02:07:24

Management of Acute Myocardial Infarction and Complications

  • Thrombolysis is only done in ST elevation MI, not in non-ST elevation MI or unstable angina.
  • Streptokinase, alteplase, and tenecteplase are thrombolytic agents, with tenecteplase being the most effective for revascularization.
  • Coronary artery bypass graft (CABG) is preferred for triple vessel disease or severe proximal left main coronary artery stenosis.
  • Electrical complications in MI can lead to tachyarrhythmias or bradyarrhythmias, with Mobitz type 2 AV block being common.
  • Mechanical complications in MI include ventricular septal defect and mitral regurgitation, often seen in anterior or inferior wall MI.
  • Late complications like Dressler syndrome, post-MI pericarditis, can be treated with colchicine, high-dose aspirin, or corticosteroids.
  • Differentiate between stunned myocardium and hibernating myocardium using thallium 201 or technetium 99 for hibernating and Rubidium 82 for stunned.
  • Rheumatic fever is an inflammatory, not infectious, condition caused by an immune response to group A streptococcal cell wall components.
  • Jones criteria classify rheumatic fever manifestations, with arthritis being non-erosive and treated with aspirin, switching to naproxen if Reye syndrome develops.
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