1. Lesson 1
Cardiovascular testing
Tsegaye Melaku (BPharm, MSc)
[Assistant Professor of Clinical Pharmacy]
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.et +251913765609December, 2019
Pharmacotherapy of Cardiovascular Disorders
2. Session Tips
Differentiate types of cardiovascular testing
Type of murmur (systolic/diastolic) Vs specific valvular abnormalities.
How echo, EC(K)G used for CVD dx, Rx, prognosis
Clinical importance of cardiac biomarkers
Other investigation modalities
When to order these CV testing
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3. Estimate average heart rate of the following mammals (beats/min)
Estimated size of your heart?
3
Human Whale
Camel Lion
Cat Mouse
Elephant Neonates (human)
9
40
376
70
28
200
30 150
4. Height? Width ?
Beats per day?
Beats 2.5 billion times in an average 70 yrs. Lifetime
Pumps about of blood each day
Pumps blood through miles of vessels
Suffers 7.2 mil. CAD deaths worldwide each year
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4.8 inches tall 3.35 inches wide 12 x 9 cm
~100,000 times
2000 galloons/7600 liters
62,000
5. CO (ml/min) = HR (75 beats/min) x SV (70 ml/beat)
– CO = 5250 ml/min (5.25 L/min)
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6. Components
Heart: hollow muscular organ
Blood
Vessels
– Arteries: Away from heart
– Veins: toward heart
– Capillaries: Link arterioles to veins
» sites of o2, nutrients & waste exchange
• Pinocytosis/diffusion
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8. Heart :
– Provides the driving force for the cardiovascular system
– Organ at the center of the circulatory system.
– It pumps blood around the body
– ~ the size of your fist
– Weight ~ 250-300g
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14. CVD afflicts an estimated 80 million people (i.e.~1 in 3 adults)
– Accounts for 35% of all deaths: US data
Total cost of CVD (HTN, CHD, HF, and stroke)~ $475.3 billion.
Atherosclerosis: cause of most CVD events.
– Typically present for decades before symptoms appear
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17. Thorough history,
Comprehensive P/E
Appropriate testing,
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– Identify sub-clinical CVD
– Assess symptomatic CVD for the risk of an adverse event
– Help in appropriate management
18. Elements of a comprehensive history:
– Chief complaint,
– Current symptoms, …HPI
– Past medical history,
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– Family history,
– Social history…..
– Review of systems
Diet/physical activity/tobacco/alcohol/illicit drug
Duration/quality/frequency/severity/progression/precipitating &
relieving factors, associated symptoms, & impact on daily activities
19. Chest pain: frequent symptom
– Angina/infarction, non-cardiac conditions (esophageal,
pulmonary, or musculoskeletal disorders)
– Quality/location/duration;
– Provoking or relieving factors (ascertain etiology)
– Example:
Sensation of heaviness/pressure in the retrosternal area
Radiate to the jaw, left shoulder, back, or left arm
Typically lasts only a few minutes
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20. Angina pain
– Precipitated by exertion, emotional stress, eating, cigarette
smoking, or exposure to cold,
– Relieved with rest or SL NTG
– Unstable angina pain is ↑ in severity, longer in duration, or
occurring at rest;
» Need prompt medical attention expeditiously.
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21. CHF & pulmonary vascular congestion
– Complain of SOB (dyspnea) with exertion or even at rest
– Orthopnea, PND, and nocturia
CHF & peripheral venous congestion
– Abdominal swelling (from hepatic congestion or ascites),
– Nausea, vomiting, lower extremity edema, fatigue, & dyspnea
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27. A. JVP:
Indirect assessment of right atrial pressure
– Normal: 1 to 2 cm above the sternal angle
– Extent of elevation: assess the severity congestion,
– Diminution: assess the response to therapy
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29. B. Carotid arterial pulse
Diminished pulsations (indicate):
– In ↓ SV, atherosclerotic narrowing of carotid artery,
– Obstruction to LV outflow, AS or HCM.
Very forceful/hyperdynamic/"bounding“ pulsations:
– In ↑ stroke volume, Chronic AR,
– High CO [hyperthyroidism, marked anemia]
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30. C. Peripheral arterial pulses (Legs & arms)
– Diminished: in ↓ stroke volume, PAD
D. Chest
– Percussion of the posterior chest: pleural effusion
– Auscultation of anterior & posterior lung fields:
» Pneumonia/airway obstruction/pleural effusion/ pulmonary edema.
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31. E. Heart Sounds
– Typical "lub-dub" sound of the normal heart
– S1:precedes ventricular contraction
» Due to closure of the mitral & tricuspid valves
– S2: follows ventricular contraction
» Due to closure of the aortic & pulmonic valves
– Others [S3/S4/Murmur/gallop]:presence of underlying heart
disease
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32. S3 sounds
– Aka ventricular gallop,
– Low-pitched sound heard at the cardiac apex
– Occur in early diastole (i.e. immediately after S2).
– Caused by vibrations that occur when blood rapidly rushes
from a "tense" atrium stiff, noncompliant ventricle.
– Associated with decompensated HF or intravascular volume
overload.
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33. S4 sound
– Dull, low-pitched sound
– Caused by the vibrations that occur when atrial contraction
forces blood into a stiff, noncompliant ventricle.
– Audible at the cardiac apex just before ventricular contraction
(i.e., just before S1)
– Occur with AS/arterial hypertension/HCM/CAD
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35. Murmurs
– Auditory vibrations [turbulent blood flow] within the heart
chambers or across the valves.
– Based on timing & duration within cardiac cycle (systolic,
diastolic, or continuous), intensity (grade 1 to 6, from softest to
loudest), pitch (high or low frequency),
– May be some are “Innocent" or "physiologic"
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38. Systolic murmurs
– Occur during ventricular contraction
– Begin with or after S1 and end at or before S2
– Can be mid-systolic or holosystolic (pansystolic)
Mid-systolic murmurs: PS/AS/hypertrophic obstructive cardiomyopathy
Holosystolic murmurs: when blood flows from a chamber of higher
pressure to one of lower pressure throughout systole
– In case of TR, MR, VSD
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39. Diastolic murmurs
– Occur during ventricular filling
– Begin with or after S2
– High pitched: in AR & PR
– Low Pitched: in MS & TS stenosis
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NB: If murmur detected confirm the cause by Echo/MRI/Angiography
41. Troponin [I & T]
– Contractile proteins found only in cardiac myocytes
– Most sensitive, tissue-specific
– Detectable in the blood 2 to 4 hrs of onset of sxs
– Remains detectable for 5 to 10 days
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44. Provides supplemental information to the physical examination
About position & size of the heart & its chambers /adjacent structures
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45. Graphic recording of the electrical potentials generated by the heart
Signals are detected by using electrodes attached to the extremities and
chest wall
Used to detect:
– Arrhythmias, conduction disturbances,
– MI, metabolic disturbances (e.g., hyperkalemia),
– Increased susceptibility to sudden cardiac death (e.g., prolonged
QT interval)
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56. P-wave:
– Depolarization of the atria
– Duration: ~0.12 seconds
PR segment:
– Passage of impulse through AV node bundle of His
its branches
– Duration: 0.12 to 0.20 seconds.
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57. QRS complex
– Electrical depolarization of the ventricles
– -Ve deflection (Q wave) +Ve deflection (R wave) -ve
deflection(S wave)
– Duration: <0.12 second
V1, V2: right ventricle: -Ve
V5, v6: left ventricle: +Ve
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58. 58
ST segment
– Plateau phase
– Duration: 0.005- 0.15 sec
T wave
– Repolarization of the ventricle
– Duration: 0.1 - 0.25 sec
QT interval
– From QRS complex to end of the T wave
– Time required for ventricular depolarization & repolarization
– Duration: <0.44 second.
– Prolonged: electrolyte disturbances(hypoK+,hypoCa2+,hypoMg2+