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Cardiovascular Care

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Cardiovascular Care Kenneth H. Cohen, M.D.,F.A.C.C. Ronald D. D Agostino, D.O., F.A.C.C., F.A.C.P. Henry Gomez, M.D., F.A.C.C. Jeffrey M. Bernstein, M.D. – PowerPoint PPT presentation

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Title: Cardiovascular Care


1
Cardiovascular Care
  • Kenneth H. Cohen, M.D.,F.A.C.C.
  • Ronald D. DAgostino, D.O., F.A.C.C., F.A.C.P.
  • Henry Gomez, M.D., F.A.C.C.
  • Jeffrey M. Bernstein, M.D.
  • Internal Medicine, Cardiology and Cardiovascular
    Diseases
  • Diplomates American Board of Internal Medicine
    and Cardiovascular Diseases
  • 1129 Northern Blvd - Suite 408
  • Manhasset, NY 11030
  • 516-627-2121

2
Everything you wanted to know about
cardiovascular care but the HMOs were afraid
youd ask.
3
Ronald D. DAgostino D.O., F.A.C.C.,F.A.C.P
  • Specializing in
  • Cardiology
  • Cardio-vascular Diseases
  • Atherosclerosis
  • Angina Myocardial Infarction
  • Hypertension
  • Renal Artery Stenosis
  • Valvular Heart Disease
  • Peripheral Vascular Disease
  • Cardiomyopathy Hypertrophy
  • Carotid Diseases
  • Congestive Heart Failure
  • Stroke Prevention Treatment
  • Arrythmias
  • Diabetes Management

4
HOW IMPORTANT IS THE HEART! IT IS THERE THAT
CHARACTER IS FORMED. IT ALONE HOLDS THE SECRETS
OF TRUE SUCCESS. CHARLES SWINDOLL
5
Cardiovascular Disease Statistics
  • Claims more lives each year than the next 7
    leading causes of death combined
  • More than 2600 Americans die each day from
    cardiovascular disease (1 death every 33 seconds)
  • Since 1900, cardiovascular disease has been the
    1 cause of death each year (except 1918)
  • 1 in 5 people has some form of cardiovascular
    disease
  • 1 in 3 men can expect to develop a major
    cardiovascular disease by age 60. The odds for
    women are 1 in 10
  • American Heart Association 2000 Heart Stroke
    Statistical Update

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Hypertension
8
Approximately 50 Million Americans Have
Hypertension
Controlled27.4
Uncontrolled72.6
(13.7 million)
(36 million)
(American Heart Association. 2001 Heart and
Stroke Statistical Update. Dallas, Texas
American Heart Association. 2000)
9
Hypertension High Blood Pressure
  • Systolic - (top number) The measurement of the
    pressure placed on artery walls when the heart is
    working.
  • Diastolic - (bottom number) The measurement of
    the pressure placed on the artery walls when the
    heart is at rest.

10
Warning Signs
  • No warning signs for high blood pressure
  • Called the silent killer
  • The only way to diagnose high blood pressure is
    to have your pressure taken.
  • New guidelines (JNC-7) define high blood
    pressure and the treatment guidelines for
    healthcare providers

11
JNC-7
  • B/P lt120 systolic/lt80 diastolic
  • normal
  • B/P 120-139 systolic/80-89 diastolic
  • pre-hypertension
  • B/P 140-159 systolic/90-99 diastolic
  • stage 1 hypertension

Treatment is based on risk factors for disease.
No one drug is right for every person. Treatment
is always tailored for the individual.
12
The Cardiovascular Continuum High BP to Heart
Failure
Normal
Higher
Elevated Blood Pressure
Left Ventricular Dysfunction
Health Status/QOL
Heart Failure
Death
Lower
Time (years)
(Adapted from Dzau V, Braunwald E. Am Heart J.
1991)
13
HYPERTENSION
  • Elevated blood pressure damages the walls of the
    arteries.
  • May increase the development of atherosclerosis
  • May lead to the development of heart failure
  • Increased blood pressure may also lead to damage
    in other organs including the brain, eyes and
    kidneys

14
Lifestyle Modifications to Prevent and Manage HTN
  • Reduce weight
  • Moderate consumption of
  • alcohol
  • sodium
  • saturated fat
  • cholesterol
  • Maintain adequate intake of dietary
  • potassium
  • calcium
  • magnesium
  • Increase physical activity
  • Avoid tobacco

(JNC VI. Arch Intern Med. 1997)
15
Lifestyle Modifications
  • Stop smoking and reduce intake of saturated fat
    and cholesterol
  • Lose weight if overweight
  • Limit alcohol intake
  • Increase aerobic physical activity
  • Limit sodium intake
  • Maintain adequate intake of K, Ca, and Mg
    for general health

JNC VI, 1997.
16
Cardiovascular Disease
17
Cardiovascular Disease
  • HEART BLOOD VESSEL DISEASE IS THE 1 KILLER OF
    AMERICANS
  • Elevated cholesterol is a major risk factor.
  • The higher the total cholesterol, the greater the
    risk of cardiovascular disease.
  • The higher the cholesterol level, the greater the
    chances of dying from CV disease.

18
Cardiovascular Disease
  • Coronary Artery Disease
  • Angina
  • Myocardial Infarction
  • Peripheral Arterial Disease
  • Carotid Artery Disease
  • Aortic Aneurysm
  • Renal Artery Disease
  • Blockages affecting the circulation to the legs

19
UNCHANGEABLE RISK FACTORS
  • Age
  • Gender
  • Genetics - Family history
  • Diabetes

20
LIFESTYLE CHOICESChangeable Factors
  • SMOKING
  • DIET
  • INACTIVITY
  • OBESITY
  • Diabetes Control

21
RISK FACORS
  • THE MORE RISK FACTORS YOU HAVE, THE GREATER THE
    RISK OF CARDIOVASCULAR DISEASE!

22
Atherosclerosis Time Line
CV Events MI/Stroke
Obstruction Symptoms
CHF
Birth
Fatty Streak
Plaque formation
Intimal Changes
Age 0 10 20 30
40 50 60 70 80
Not everyone progresses along the continuum as
described above
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Cholesterol
25
WHAT IS CHOLESTEROL?
  • -WAXY, FAT-LIKE SUBSTANCE (LIPID)
  • ESSENTIAL TO THE BODYS CELLS
  • HELPS IN DIGESTION OF FOOD
  • INSULATION OF NERVES
  • PRODUCTION OF CERTAIN HORMONES
  • YOU CANNOT LIVE WITHOUT IT!

26
CHOLESTEROL
  • YOUR BODY MAKES CHOLESTEROL
  • THE LIVER MAKES APPROXIMATELY 80 OF THE BLOOD
    CHOLESTEROL
  • APPROXIMATELY 20 COMES FROM THE FOODS YOU EAT

27
CHOLESTEROL
  • To be carried by the blood, the body coats
    cholesterol with proteins called APOPROTEINS
  • Once coated, they form a package called
    LIPOPROTEINS
  • Lipoproteins carry both cholesterol
    Triglycerides.

28
LIPOPROTEINS
  • Some lipoproteins are called Low Density (LDL).
    They contain lots of cholesterol.
  • Some lipoproteins are called High Density (HDL).
    They contain mostly protein.
  • Other lipoproteins are called Very Low Density
    Lipoproteins (VLDL). They contain cholesterol,
    triglycerides protein.

29
LDL - BAD CHOLESTEROL
  • LDL particles (carry cholesterol), attach to cell
    surfaces are then brought into cells.
  • If there are too many LDL particles in the blood,
    if the liver cells (LDL receptors) do not receive
    LDL particles, or if there are too few LDL
    receptors in the liver the bodys cells become
    saturated with cholesterol from LDL products.

30
LDL CHOLESTEROL
  • CHOLESTEROL IS THEN DEPOSITED ON ARTERY WALLS.

31
HDL-GOOD CHOLESTEROL
  • The good role of HDL then comes in
  • These particles pick up the cholesterol
    deposited on the artery walls and bring it to the
    liver for removal.

32
LDL VERSUS HDL
  • If too much cholesterol from LDL particles
    remains on artery walls the arteries begin to
    narrow - ATHEROSCLEROSIS.
  • This is the reason why a high HDLLDL ratio is
    good. It can protect you.

33
TRIGLYCERIDES
  • Form of fat
  • Most of the bodys fat is in the form of
    Triglycerides stored in fat tissue a small
    portion is found in the bloodstream.
  • Normally, used by the body for energy.
  • Body produces Triglycerides.
  • Found in the diet meats, cheese, fish, nuts
    vegetable oils.

34
ELEVATED TRIGLYCERIDES
  • EXCESSIVE ALCOHOL INTAKE
  • OBESITY
  • HIGH CARBOHYDRATE DIET
  • DIABETES (POORLY CONTROLLED)

35
GENETICS
  • Genes can give you cells that do not remove LDL
    from blood, or a liver that makes too much
    cholesterol or too little HDL.

36
SMOKING
  • Damages the walls of blood vessels making them
    more prone to fatty deposits.
  • Nicotine constricts blood vessels
  • Decreases HDL (good cholesterol) by 15
  • If you stop smoking, HDL may improve

37
OBESITY
  • INCREASED WEIGHT - INCREASED TRIGLYCERIDES
  • INCREASED WEIGHT - DECREASED HDL INCREASED
    VLDL
  • DECREASED EXERCISE - DECREASED HDL

38
DIABETES
  • ELEVATED TRIGLYCERIDES
  • DECREASED HDL

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Inflammation and CRP
44
Inflammatory Pathways in Atherogenesis
Pro-inflammatory Risk Factors
Primary Pro-Inflammatory Cytokines (eg, IL-1,
TNF-a)
IL-6 Messenger Cytokine
ICAM-1 Selectins, HSPs, etc.
CRP SAA
Endothelium and other cells
Liver
Circulation
Adapted from Libby P et al. Circulation.
199910011481150.
45
Atherosclerosis An Inflammatory Disorder
Adherence andentry of leukocytes
VSMCmigration
Adherence andaggregation of platelets
T-cellactivation
Foam-cellformation
VSMC, vascular smooth muscle cell migration.
46
Chest Pain
47
Heart Attack/MI
  • Caused by a blockage of one of the hearts
    arteries
  • The area of blockage then causes the heart muscle
    to infarct or die.
  • The area that dies does not return to life.
  • The key is to limit the extent of the damage, or
    to prevent damage from happening in the first
    place

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Warning Signs
  • Sudden onset of chest pressure or tightness
  • May be described as squeezing or like an
    elephant sitting on the chest
  • May be associated with shortness of breath, a
    feeling of indigestion, sweating
  • Pain may travel to back, jaw, arm, elbow or
    shoulder

50
Prevention
  • Decrease Risk Factors
  • Pay attention to the symptoms you may be having
  • Chest pain or pressure with exercise/relieved
    with rest
  • Shortness of breath with exercise/relieved with
    rest
  • Any change in your ability to walk or exercise
    due to pressure, pain or shortness of breath

51
DIAGNOSTIC TESTING
52
HISTORY PHYSICAL
  • Most important test -
  • The reason we want to see you and not diagnose
    over the phone
  • 80 of diagnosis comes from history
  • Clinical testing done to confirm clinical
    findings or suspicion

53
DIAGNOSTIC TESTING
  • General Screening
  • Overall function
  • Plumbing
  • Pump
  • Valves
  • Wiring

54
BLOOD WORK
  • Chemistry
  • Endocrine Glucose, HgB A1c, Thyroid function
  • Kidney Function BUN/Creatinine
  • Liver Function
  • Electrolytes (Sodium, Potassium, Magnesium,
    Calcium
  • CBC
  • Lipids
  • Total Cholesterol, HDL, LDL,Triglycerides,
    Lipoproteins
  • Coagulation
  • Urine
  • Miscellaneous
  • C-Reactive Protein, Homocysteine

55
CHEST X-RAY
  • Heart Size
  • Chamber Size
  • Lungs
  • Limited Information
  • Aorta

56
EKG
  • Useful Information about
  • Heart Rate Rhythm
  • Old Infarcts
  • Ischemia (lack of blood flow
  • Electrical Conduction Problems
  • Heart chamber enlargement
  • Cannot predict future events

57
HEMODYNAMIC PROFILE (HDP)
  • Non-Invasive Scan
  • Measures cardiovascular pressures effect of
    therapy
  • Helps direct therapy
  • Very useful for treating Hypertension Heart
    Failure

58
EXERCISE STRESS TESTING
  • Overall Function
  • Coronaries, Ventricular Function,
    Valves,Conduction
  • Treadmill, Bicycle
  • Cardiac Monitoring
  • Diagnosis Progress
  • After Myocardial Infarction

59
NUCLEAR STRESS TESTING
  • Compares blood flow to heart during rest and
    activity
  • Rest images - Stress Test - Repeat images
  • Identifies territories of potential blockage to
    the heart arteries

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Example of an Anterior Reversible Defect
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Example of an Anterior Reversible Defect
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Example of an Anterior Reversible Defect
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ECHOCARDIOGRAM
  • Non-Invasive
  • Easy Test to Perform
  • No preparation
  • Looks at heart pump and valve function
  • Yields very important information

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NON-INVASIVE VASCULAR TESTING
  • Renal Duplex
  • Assess for Hypertension
  • Aortic Duplex
  • Assess for Aneurysm
  • Peripheral Duplex
  • Arterial Circulation
  • Carotid Duplex -
  • Stroke Risk

69
NON-INVASIVE VASCULAR TESTING Cont...
  • Pulse Volume Recording
  • Arterial Circulation
  • Venous Duplex -
  • Venous Circulation

70
CAROTID DOPPLER
  • Internal and external carotid arteries
  • Vertebral arteries
  • Plaquing of arteries - Intimal Thickness
  • Obstruction
  • TIA, CVA, SX
  • Unequal blood pressures
  • Identify patients at risk for Stroke
  • Identify patients who may benefit from Carotid
    Endarterectomy or Stent

71
HOLTER MONITOR
  • 24 Hour non-invasive monitor
  • Monitors Electrical System of Heart
  • Helps to correlate with symptoms
  • Evaluation of Palpitations, Dizziness, Skipped
    Beats
  • After Myocardial Infarction
  • Evaluates Potential Sudden Death Risk

72
AMBULATORY BLOOD PRESSURE AND HEART RATE
  • To monitor Blood Pressure and Pulse at home
  • 24 hr. Recording vs. Intermittent use by patient
    periodically and as per symptom
  • White Coat Hypertension
  • Extremely useful to diagnose hypertension and
    assess effectiveness of therapy

73
CARDIAC CATHETERIZATION
  • Definitive Test - Gold Standard
  • Essential to absolutely diagnose or disprove
    coronary artery disease
  • Hospital Procedure - Not office procedure
  • Invasive - performed via artery
  • Some Risk
  • Looks at Coronary circulation, Ventricular
    function and Valve function

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MEDICAL TREATMENTS
  • Vitamins
  • B-Vitamins
  • Folic Acid
  • Antioxidants
  • Aspirin
  • Coumadin
  • Antiplatelet drugs
  • Plavix
  • Diabetes Drugs
  • Anti-Hypertensives
  • Ace Inhibitors
  • ARBs
  • Beta Blockers
  • Calcium Channel Blockers
  • Cholesterol-Lowering Drugs

78
ICDS
  • Implantable Cardiovertors Defibrillators
  • Saves Lives
  • For High Risk patients
  • Like living with an EMS Technician

79
AEDS
  • Automatic External Defibrillators
  • Public Areas
  • Airports, Restaurants, Health Clinics
  • Saves Lives

80
And nowfor some parting words of wisdom
81
NEVER GO TO A DOCTOR WHOSE OFFICE PLANTS HAVE
DIED ERMA BOMBECK
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M-mode Echocardiograph
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Continuous Wave Doppler
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Transmitral Pulsed Wave Doppler
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Code M-mode Methodology
90
M-mode Echo Aortic Valve and Left Atrium
91
M-mode Echo Mitral Valve Level
92
M-mode Echo Left Ventricalar Level
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Display for SPECT Images
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Example of an Anterior Reversible Defect
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Example of an Anterior Reversible Defect
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Example of an Anterior Reversible Defect
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