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CARDIOVASCULAR SYSTEM

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CARDIOVASCULAR SYSTEM – PowerPoint PPT presentation

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Title: CARDIOVASCULAR SYSTEM


1
CARDIOVASCULAR SYSTEM
2
  • General approach
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

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  • Heart murmurs
  • Abnormal heart sounds produced as a result of
    turbulent blood flow sufficient to produce
    audible noise.
  • Characteristics
  • timing , shape, location, radiation , intensity,
    pitch and quality.

5
  • Timing
  • 1 systolic murmurs
  • a- Mid-systolic ejection murmurs
  • b- late systolic murmurs
  • c- holosystolic murmurs

6
  • 2 Diastolic murmurs
  • a- early diastolic murmurs
  • b- mid-diastolic murmurs
  • c- late diastolic murmurs
  • 3 continuous murmurs
  • 4- interventions that change murmur sounds

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  • Location
  • 5 places on the anterior sternum
  • Radiation
  • Refers where the sound radiates
  • Regle of thumb sound radiates in the direction
    of the blood flow

9
  • Intensity
  • Grade 1 Very faint,heard only after listener
    has tuned in,may not be heard in all positions
  • Grade 2 Quiet ,but heard immediately after
    placing the stethoscope on the chest
  • Grade 3 Moderately loud

10
  • Grade 5 Very loud, with thrill .May he heard
    when stethoscope is partly off the chest
  • Grade 6 Very loud ,with thrill .May be
    heard with stethoscope entirely off the chest

11
  • Pitch
  • is determined by whether it can be auscultated
    best with the bell or diaphragm of a
    stethoscope.
  • Quality
  • Blowing
  • Harsh
  • Rumbling and musical

12
  • Heart murmurs
  • Aortic stenosis crescendo-decrescendo systolic
    murmur
  • Aortic regurgitation high-pitched blowing
    diastolic murmur
  • Mitral stenosis rumbling late diastolic
    murmurs, opening snap
  • Mitral regurgitation high pitched
    holosystolic murmur

13
  • Mitral prolapse systolic murmur with midsystolic
    click, most frequent valvular lesion in young
    women
  • VSD holosystolic murmur
  • PDA continuous machine-like murmur

14
  • Respiration
  • Right-sided murmurs typically increase with
    inspiration, while left-sided murmurs generally
    are louder during expiration. Valsalva maneuver
    Most murmurs decrease in length and intensity
    during the Valsalva maneuver. Two exceptions are
    the systolic murmur of hypertrophic
    cardiomyopathy (HCM), which usually becomes much
    louder, and the systolic murmur of mitral valve
    prolapse (MVP), which becomes longer and often
    louder. Following release of the Valsalva,
    right-sided murmurs tend to return to baseline
    intensity earlier than left-sided murmurs

15
  • Exercise Murmurs caused by blood flow across
    normal or obstructed valves (eg, mitral or
    pulmonic stenosis) become louder with both
    isotonic and submaximal isometric (handgrip)
    exercise. Murmurs of mitral (MR) and aortic
    regurgitation (AR) and ventricular septal defect
    (VSD) also increase with handgrip exercise.

16
  • Positional changes
  • Most murmurs diminish with standing due to
    reduced preload. However, the murmur of HCM
    becomes louder, and the murmur of MVP lengthens
    and often is intensified. Similarly, most murmurs
    become louder with prompt squatting (or usually
    passive leg raising), while the murmurs of HCM
    and MVP typically soften and may disappear

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  • Sounds
  • S1 mitral and tricuspid valve closure
  • S2 aortic and pulmonary valve closure
  • S3 end of rapid ventricular filling
  • S4 high atrial pressure/stiff ventricle

21
  • Different types of dyspnea
  • Tachypnea
  • Orthopnea
  • Trepopnea
  • Platypnea
  • Paroxysmal nocturnal dyspnea

22
Coronary artery disease
  • ANGINA
  • Refer to substernal chest pain that originates
    from myocardial ischemia( increased oxyxen demand
    or decreased oxygen suppy).Pain described as a
    substernal pressure,heaviness radiating to the
    jaw,shoulder and arm.

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  • 3 types of Angina stable , unstable and variant
    (Prinzmetals ).
  • Stable angina
  • Most common type
  • Brought on by exertion or emotion
  • Pain increases over several minutes
  • Relieved by rest or medication
  • Follows a pattern

25
  • Unstable Angina
  • It is new
  • It is accelerating
  • Lasts longer
  • Less responsive to medication
  • Occurs at rest

26
  • Prinzmetals angina
  • Due to coronary vasospasm
  • Not linked to exertion
  • Chronic, intermittent nature
  • Occurs at a specific hour early in the morning
  • Coronary vessels angiographically normal

27
  • Typical scenario
  • A 62 year old smoker presents complaining of
    three episodes of severe heavy chest pain this
    morning .Each episode lasted 3 or 5 minutes , but
    he has no pain now. He has never had this type of
    pain

28
  • Scenario II
  • A 43 y/o woman presents with frequent episodes of
    dull chest chest pain on and off for 8 months .He
    says the pain wakes him from sleep.

29
Risk factors for CAD
  • Modifiables
  • Smokings
  • Hypercholesterol
  • Hypertension
  • Obesity
  • Diabetes mellitus
  • Physical inactivity
  • Nonmodifiables
  • Age
  • Male
  • Family history

30
  • Differential
  • Tension pneumothorax
  • Aortic dissection
  • Pulmonary embolism
  • Unstable angina
  • Costochondritis
  • Intercostal neuritis
  • Pericarditis
  • pneumonia

31
  • Work-up
  • Resting ECG is normal in half of patient with
    angina pectoris
  • ECG may show ST-segment depression or T-wave
    flattening
  • Obtain cardiac enzymes every 8 hrs for 24 hrs to
    r/o MI
  • Exercise stress test can confirm suspected
    diagnosis of CAD

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34
Treatment
  • Stable angina
  • Nitrates
  • Cause systemic venodilation which relieves
    cardiac workload.
  • Cause coronary arterial dilation
  • Increase myocardial blood flow
  • Used in sublingual form for relief of acute
    ischemia
  • Side effects hypotension, lightheadedness and
    headache

35
  • 2-Aspirin
  • Limits platelet aggregation
  • 3-Beta-adrenergic blocking agents
  • Reduce myocardial workload by limiting
    adrenergic increases in heart rate and
    contractility
  • Side effects fatigue, impotence, bradycardia and
    worsening of heart failure

36
  • Risk factors modification
  • Smoking cessation
  • Treatment of hyperlipidemia
  • Treatment of hypertension
  • Control diabetes
  • Weight loss
  • Reduction of physical and emotional stress
  • Improvement in physical improvement

37
  • Prinzmetal s angina
  • Calcium channel blockers
  • are coronary vasodilators
  • Variable peripheral vasodilators
  • Negative inotropic activity
  • Negative chronotropic activity

38
Acute myocardial infarction
  • Epidemiology
  • Common manifestation of CAD
  • Each year 1 million suffer an AMI in USA
  • Of these about 10 to 15 will die within within
    several days and another 10 to 15 will die
    within 1 year

39
  • Etiology /pathogenesis
  • Most MI occur in the setting of underlying CAD.
  • Rupture of an atherosclerotic with thrombus
    formation is reponsible for most AMIs .
  • Other mechanisms can cause AMI
  • Coronary artery dissection
  • Coronary vasospasm( cocaine)
  • Vasculitis ( kawasakis disease)

40
  • Early death from AMI can be due to a number of
    complications
  • Arrhythmia( ventricular fibrillation/tachycardia
  • Cardiogenic shock
  • Ventricular rupture (incidence 3 to 5 days
  • Sudden arrhythmia
  • Mitral papillary rupture

41
  • Clinical manifestations
  • Retrosternal chest pain, prolonged and persistent
  • Radiate to the shoulder, jaw and left arm
  • Nitrates provide some reliefs but resolution of
    the pain
  • Associated symptoms include
  • Diaphoresis
  • Anxiety
  • Dyspnea
  • Vomiting
  • nausea

42
  • Diagnostic Evaluation
  • ECG is important in the evaluation of possible AMI

43
  • Serum Markers for MI
  • Myoglobin elevated within 1 hr but nonspecific
  • CK MB specific marker for myocardial tissue
    damage
  • Troponin T or I very specific and sensitive
    markers for cardiac muscle injury.Elevated
    within 3 hrs and can stay elevated for more gt a
    week.

44
  • Treatment
  • Relief of pain
  • Reduction of myocardial oxygen demand
  • Improvement /restoration of myocardial perfusion
  • Recognition and treatment of complications
  • Thrombolytic therapy with tissue plasminogen
    activator if pain persists after the
    administration O2, aspirin, nitrates,opiates and
    beta-blockers

45
  • Absolute contraindications to thrombolytic
    therapy
  • Uncontrolled hypertension on iv vasodilators(
    systolicgt180
  • Recent stroke
  • Recent major surgery
  • Active GI bleeding
  • Concurrent trauma
  • Intracranial mass

46
Heart Failure
  • Heart Failure defined as the inability of the
    heart to pump blood at a rate that meets
    metabolic demands. Heart failure can be
    classified according to
  • The hemodynamic state of the cardiovascular
    system (congestive versus high output)
  • The predominance of the ventricle affected(left
    vs right)
  • The predominant form of myocardial dysfunction(
    systolic or diastolic
  • The time course (acute or chronic)

47
  • Major Risk Factiors
  • Coronary artery disease
  • Hypertension
  • Valvular heart disease
  • Pericardial disease
  • cardiomyopathy

48
  • Left Heart failure
  • Right Heart failure
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Rales
  • Dyspnea on exertion
  • Cough
  • Nocturia
  • S3 gallop
  • Diaphoresis
  • tachycardia
  • RuQ pain due to hepatic congestion
  • Hepatomegaly
  • Hepatojugular reflex
  • Ascites
  • Cyanosis
  • Peripheral edema

49
  • Diagnosis
  • Chest film enlargement of cardiac silhouette,
    pulmonary vascular congestion with redistribution
    to upper lobe.
  • Echocardiogram Assess left ventricular function
    (LVF)
  • Basic natriuretic peptide(BNP)elevates in CHF

50
  • Treatment
  • ACE inhibitor ( decrease sx and mortality)
  • Diuretics
  • Beta blockers(decrease sx and improve survival
  • Digoxin ( for symtomatic relief only does not
    improve survival)
  • Spironalactone ( decrease mortality by 34

51
Pericardial tamponade
  • Definition
  • Tamponade is the physiologic result of rapid
    accumulation of fluid in the in-elastic
    pericardial sac .Pericardial tamponade impairs
    cardiac filling and reduces cardiac .
  • Etiology
  • Pericarditis
  • Trauma
  • Aortic dissection

52
  • Signs and Symptoms
  • Becks Triad
  • Hypotension
  • Muffled heart sounds
  • Jugular vein distention
  • Other symptoms/signs
  • Dyspnea
  • Tachycardia
  • Pulsus paradoxus decrease by gt10 sBP with
    inspiration

53
  • DIAGNOSIS
  • Auscultation may demonstrate distant heart sounds
  • ECG may show low voltage or electrical alternans
  • CXR may show enlarged cardial silhouette
  • Echocardiogram will show large pericardial
    effusion

54
  • Treatment
  • Immediate pericardiocentesis
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