.

Figure 1. Coronary heart disease (A) and stroke (B) mortality rate in each decade of age
versus usual BP at the start of that decade.

Franco V et al. Circulation 2004;109:2953-2958

Copyright American Heart Association

2 5
30 (2
10/5 .)
SBP DBP
BP <140/90 mmHg
chronic kidney disease diabetes BP goal
<130/80 mmHg (<125/75 mmHg proteinuria >1 gm
/day)

Isolated Systolic HT (ISH) SBP >140 DBP <90 mmHg.

Isolated Office HT (white-coat HT) home BP <135/85
Masked HT ; no office HT but home BP >135/85
Orthostatic hypotension ; SBP <20 mmHg.
BP >20/10 mmHg. Refer
BP

2 2-4
( BP
>180/110 mmHg. BP >140/90 +
SCORE >5)

Category

SBP

DBP

Optimal
Normal
High normal
Grade 1 hypertension
(mild)

<120
120-129
130-139
140-159

and
and/or
and/or
and/or

<80
80-84
85-89
90-99

Grade 2 hypertension
(moderate)

160-179

and/or

100-109

Grade 3 hypertension
(severe)

>180

and/or

>110

Isolated systolic
hypertension

>140

and

<90


HT
SBP

DBP

Office or clinic

140

90

24-hour

125-130

80

Day

130-135

85

Night

120

70

Home

130-135

85

2-3 /

white-coat effect

presence progression
organ damage
(office BP values)

Awareness ( )
Treatment (/)
( )
Patient history of cardiovascular disease
Family history (HT, CVD, sudden death) 65
55
Lifestyle factors (alcohol, smoking, exercise, stress, diet)

(90 . 80
.)
Funduscopic examination

Examination of the neck, heart, lungs,
abdomen, and extremities
Neurological assessment

Fasting plasma glucose*

Hemoglobin and hematocrit
Lipid profile (Total chol, TG,
HDL) 12 *
Urine dipstick and sediment

Creatinine*
EKG
Uric acid
Potassium*


(Secondary hypertension)

<25 >55
20/10 .
( nocturia )
>180/110 mmHg
3 (resistant HT)

(sudden onset of hypertension)

Echocardiogram

Carotid ultrasound carotid bruit, amaurosis

fujax, stroke
Glucose tolerance FPG 110-125 mg/dl
test
Microalbuminuria Diabetes mellitus

 Cardiovascular Risks
Major Risk Factors: ESH
2007
Smoking
Family history of
CVD or sudden death
male <55 female <65
years
Diabetes mellitus
*Glucose tolerance test
* >
126
mg/dl
CVD or
2

2003 ESH / ESC Guidelines

FBS

+ metabolic syndrome
hr.GTT >198 mg/dl Fasting plasma glucose

 Cardiovascular Risks
Major Risk Factors:

ESH
2007

Age male >55 female >65

Total cholesterol >240
*Total cholesterol
mg/dl or LDL-chol >160 >190 ./.
mg/dl
*LDL-cholesterol
>115 ./.
HDL-chol
male
<40
*HDL-cholesterol
*
CVD
mg/dl
2003
ESH / ESC Guidelines
<

metabolic syndrom
or+female
45 mg/dl
:e<40 ./.

 Cardiovascular Risks
Major Risk Factors:
BMI >25 kg/m2 or
sedentary lifestyle

ESH
2007

* pulse pressure
()
*Triglyceride >150
./.+
* CVD
2003
ESH / :>90 .
*

ESC Guidelines
; >80 .

 Target Organ Damage

(Subclinical OD)
Target Organ
Damage
Left ventricular
hypertrophy

Nephropathy

/
CXR, EKG
Echocardiographic LVH
(LVMI >125 /2
; >110 /2)
Microalbuminuria 30-300
mg/day
albumin-creatinine

 Target Organ Damage

(Subclinical OD)
Target Organ
Damage
Retinopathy
Atherosclerotic
plaque (aorta,
carotid, coronary,
iliac, femoral
arteries)

/
Fundoscopy grade 3-4
X-ray, ultrasound
carotid wall
(IMT >0.9 .)
plaque
*Carotid-femoral pulse
wave velocity >12 ./
*Ankle/Brachial BP index

Clinical Cardiovascular Disease

(Associated clinical conditionACC)
Diabetes mellitus

FBS >126 mg/dl

Postload plasma glucose
>200 ./.
HbA1C >6.5

Stroke and TIA,

RIND
Heart diseases
CXR, EKG
(CAD, MI,
CABG, PCI, CHF)

Clinical Cardiovascular Disease

(Associated clinical conditionACC)
Chronic kidney disease Creatinine, urine
(Cr >1.3-1.5 mg/dl in
microalbuminuria,
male or >1.2-1.4 mg/dl UA
in female, Creatinine
clearance <60 dl/min,
Cockroft-Gault
albuminuria >300
formula Ccr
mg/day or proteinuria (ml/min) =
>500 mg/day
(140-age yrs) (wt
GFR
* *Estimate
CVD

2003
ESH
ESC (
kg)
x / 0.85
creatinine clearance <60
Guidelines
)/ 72 x Scr

Clinical Cardiovascular Disease

(Associated clinical conditionACC)
Peripheral arterial
Ankle-Brachial
disease
Index <0.9
Advanced HT
retinopathy
hemorrhage
exudates, papilledema
(grade 3-4)

Quantify Prognosis
low 15- moderate 20- high 30- very
high in10 yrs.
Blood pressure (mmHg)

Other RF
OD or
Disease

High normal
SBP 130-139
or DBP 85-89

Grade 1
SBP 140-159
or DBP 90-99

Grade 2
Grade 3
SBP 160-179
SBP > 180
or DBP 100-109 or DBP > 110

No other RF

Average

Average

Low

Moderate

High

1-2 RF

Low

Low

Moderate

Moderate

Very High

> 3 RF, MS,

OD or DM

Moderate

High

High

High

Very High

Established
CV or renal
disease

Very High

Very High

Very High

Very High

Very High

Initiation of Antihypertensive
Treatment
Blood pressure (mmHg)
Grade 2:
SBP 160-179
or DBP 100-109

Other RF Normal:
OD and Dis.SBP 120-129

High normal:
SBP 130-139
or DBP 85-89

Grade 1:
SBP 140-159
or DBP 90-99

No other RF No BP
intervention

No BP
intervention

Lifestyle changes forLifestyle changes forLifestyle changes

several m.
several wks.
+ Immediate
then drug Rx if
then drug Rx if
drug Rx
BP uncontrolled
BP uncontrolled

Lifestyle
change

Lifestyle
change

Lifestyle changes forLifestyle changes forLifestyle changes

several wks.
several wks.
+ Immediate
then drug Rx if
then drug Rx if
drug Rx
BP uncontrolled
BP uncontrolled

Lifestyle
change

Lifestyle changes
and consider
drug Rx

or DBP 80-84

1-2 RF

> 3 RF, MS
or OD

DM
Lifestyle
changes

Established
CV or renal Lifestyle changes
+ Immediate
disease
drug Rx

Grade 3:
SBP > 180
or DBP > 110

Lifestyle changes
Lifestyle
changes
+ Immediate
Lifestyle change
+
drug Rx
+
drug
Rx
drug Rx
Lifestyle changes
Lifestyle change
+ Immediate
+ drug Rx
drug Rx
Lifestyle changes Lifestyle changes Lifestyle changes Lifestyle changes
+ Immediate
+ Immediate
+ Immediate
+ Immediate
drug Rx
drug Rx
drug Rx
drug Rx

SBP
BMI 18.5-24.9 kg/m2 5-20 mmHg/
Waist circumference
10 kg
<90 cm (male) <80
reduction
cm.(female)
Dietary
8-14 mmHg.
Approa

ch to

Stop HT

SBP
2-8 mmHg.

Na <2.4 gm/day or
NaCl <6 gm/day
aerobic exercise 30
4-9 mmHg.

/
3-5 /

male <2 drink/day (ethanol 2-4 mmHg.

alcohol 30 gm, Beer 720 ml, Wine

Total chol <190

mg/dl LDL-chol <115 mg/dl
CVD
Total chol <175 mg/dl
LDL-chol <100 mg/dl

Fasting plasma glucose >126 mg/dl

Random plasma glucose >200 mg/dl

108 mg/dl (6.0

mmol/l)

2-4 HbA1C 3-6

 Metabolic
Syndrome
>130/85 mmHg
>90 . >80 . (asia)
fasting blood glucose >100 mg/dl (AHA)
>110 mg/dl (IDF)
triglyceride >150 mg/dl
HDL <40 mg/dl <46 mg/dl
3/5

C ontraindication
Class

Favoring use

Thiazide CHF, Elderly,

ISH
L oop
Renal
diuretic insufficiency,
CHF

C ompelli Possible
ng
Gout
Pregnanc
y

Class

Favoring use C ompelli Possible

ng
BetaCAD, post MI, 2nd-3rd PAD,
blocker
CHF,
AV
glucose
tachyarrhyth block,
intolera
mias,
asthma, nce,
pregnancy
COPD
athletic
s
Dihydropy Elderly, ISH,
Tachyarrh
ridine
CAD, PAD,
ythmias

Class

Favoring use Compelling Possibl

e
Verapami CAD, carotid
2nd-3rd AV
l,
atherosclerosi block,
diltiaze s, PSVT
CHF
m CC B
ACEI
CHF, post MI, Pregnancy,
LV
bilateral
dysfunction,
renal
non-DM
artery

Class
ARB

Favoring use

C ompelling Possibl
e
Type II DM
Pregnancy,
nephropathy,
bilateral
DM
renal
microalbumin artery
uria,
stenosis,
proteinuria,
hyperK
LVH, ACEI
cough

C lass
Alpha
agonist
Reserpi
ne

Favoring C ompell
use
ing

Possible
Hepatotoxic
,
Withdrawal
syndrome
Depression,
active
peptic ulcer

guidelines
isolated systolic HT (ISH)
diuretic Calcium antagonist

<140/90 .

, TOD, CVD

postural
hypotension
80
cardiovascular morbidity CHF

ACEI ARB

RAS
drug combination
monotherapy

orthostatic
hypotension

Microalbuminuria (MAU) 24 .
30 to 300mg/L
high normal
Albumin/creatinine ratio (ACR)
microalbuminuria ACR 2.5 mg/mmol () 3.5
mg/mmol ()

statin

/ (stroke)

stroke TIA
stroke
<130/80 .
high normal BP
combination
ACEI ARB
BP acute stroke
stroke

(MI) BB,
ACEI ARB MI

BP <130/80 .

thiazide
loop diuretic BB, ACEI,
ARB aldosterone
CA

diastolic heart failure

Atrial fibrillation (AF)

AF AF
CVD 2-5 embolic
stroke
anticoagulant
anticoagulant SBP >140
.

2
1.) BP <130/80
. <120/75 proteinuria >1 /
proteinuria ARB ACEI 2

statin
CVD

ACEI ARB
teratogenic effect
estrogen
, stroke
MI
progestogen

(Hormone
replacement therapy - HRT)
HRT
,
, stroke,
thromboembolism, ,
HRT

SBP 140-149 .
DBP 90-95 . gestational hypertension (
proteinuria) BP
>140/90 . SBP >170 . DBP
>110 .


methyldopa, CA BB
drug of choice aspirin pre-ecla
mpsia

Metabolic syndrome (MS)

MS
subclinical organ damage
ambulatory BP home BP

RAS CA

()

,
cocaine, glucocorticosteroid, NSAID
Obstructive sleep apnea
Secondary hypertension
Irreversible organ damage
Volume overload ,
, Na ,
hyperaldosteronism

()

Isolated office (white coat) hypertension

cuff
Pseudohypertension (
)

Carotid bruit
Headache, sweating, and
palpitations
Cushingoid body habitus
Persistent or severe
elevation

Carotid stenosis
pheochromocytoma
Cushing's disease
Consider medications,
illicit drug use, and
excessive alcohol
use

Abnormal creatinine
or severe
hypertension
Hypokalemia
Thyroid abnormality
Upper but not lower
extremity
hypertension

renovascular disease,
chronic kidney disease
primary aldosteronism
hyperthyroidism
coarctation of aorta

Conditions Provoking or Exacerbating Ischemia

Increased Oxygen Demand
Non-Cardiac

Decreased Oxygen Supply

Hyperthermia

Non-Cardiac
Anemia

Hyperthyroidism

Hypoxemia

Sympathomimetic toxicity (cocaine use)

Anxiety

pneumonia, asthma, COPD,

pulmonary hypertension,
interstitial pulmonary fibrosis,
obstructive sleep apnea

Arteriovenous fistula

Sickle-cell disease

Cardiac

Sympathomimetic toxicity (cocaine use)

Hypertension

Hypertrophic cardiomyopathy
Aortic stenosis
Dilated cardiomyopathy
Tachycardia
ventricular
supraventricular

Hyperviscosity
polycythemia, leukemia,
thrombocytosis, hypergammaglobulinemia
Cardiac
Aortic stenosis
Hypertrophic cardiomyopathy

Angina Pectoris
History: chest discomfort

Quality - "squeezing," "griplike," "pressurelike," "suffocating" and

"heavy; or a "discomfort" but not "pain." Angina is almost never

sharp or stabbing, and usually does not change with position or
respiration
Duration - anginal episode is typically minutes in duration. Fleeting
discomfort or a dull ache lasting for hours is rarely angina
Location - usually substernal, but radiation to the neck, jaw,
epigastrium, or arms can occur. Pain above the mandible, below
the epigastrium, or localized to a small area over the left lateral
chest is rarely anginal.
Provocation - angina is generally precipitated by exertion or
emotional stress and commonly relieved by rest. Sublingual
nitroglycerin also relieves angina, usually within 30 seconds to
several minutes.

Non-ischemic Chest Pain

Chest wall pain

GERD
Pleuritic chest pain
Disecting aortic aneurysm
Pericardial pain
Mitral valve prolapse syndrome

Canadian Cardiovascular Society Classification

for Angina Pectoris
I.

III.

I.
Ordinary physical activity does not cause angina, such as
walking and climbing stairs. Angina with strenuous or rapid or
prolonged exertion at work or recreation.
II.
Slight limitation of ordinary activity. Walking or climbing
stairs rapidly, or uphill, walking or stair climbing after meals, or in cold,
or under emotional stress. Walking more than 2 blocks on the level
and climbing more than one flight of ordinary stairs at a normal pace
and in normal conditions.

III. Marked limitation of ordinary physical activity. Walking one to two

blocks on the level and climbing one flight of stairs in normal
conditions and at normal pace.

IV. Inability to carry on any physical activity without discomfort -- anginal

syndrome may be present at rest.

Circulation 1976; 54:522-523

Diagnostic test for CAD

EKG
Exercise Stress Test (Treadmill)
Dobutamin Stress Echo
Myocardial Perfusion Scan (MIBI)
Cardiac MRI (Stress CMR)
CT angiogram (CTA)
Coronary Angiography (CAG)

Spectrum of Coronary
Disease

Stable angina pectoris

Unstable angina pectoris: new onset 2
mons., crescendo angina, angina at
rest >15 min.
Clinical UA: primary, secondary,
postinfarct UA (2 weeks post AMI)
Non-ST elevation MI, STEMI.

A 55 year old man with 4 hours of "crushing" chest pain

Acute inferior myocardial infarction

ST elevation in the inferior leads II, III and aVF
reciprocal ST depression in the anterior leads

A 63 year old woman with 10 hours of chest pain and sweating

Acute anterior myocardial infarction

ST elevation in the anterior leads V1 - 6, I and aVL
reciprocal ST depression in the inferior leads

A 60 year old woman with 3 hours of chest pain

Acute posterior myocardial infarction

(hyperacute) the mirror image of acute injury in leads V1 - 3
(fully evolved) tall R wave, tall upright T wave in leads V1 -3
usually associated with inferior and/or lateral wall MI

Use of Cardiac Markers in ACS

URL = 99th %tile of Reference Control Group

50
Multiples of the URL

20

Cardiac troponin after

classical AMI

10

CK-MB after AMI

Cardiac troponin after

microinfarction

2
Upper reference limit

1
0

2
3
4
5
6
Days After
Onset of AMI
Modified from:

ESC/ACC Comm MI redefined JACC 36: 959,2000

Wu AH et al. Clin Chem 1999;45:1104.

Acute Coronary Syndrome

High risk UA: ongoing rest pain >20 min, sign

of LV dysfunction (pul edema, hypotension,
S3), ST depression at least 1 mm
admit.
Intermediate risk UA:
Low risk UA: age <65, normal ECG, no rest
pain, new onset 2 weeks to 2 months.
Troponin-T or I (routine), CK-MB, CRP

STEMI
Impact of Modern Critical Care on Mortality
40
30

Short-Term Mortality (%)

30

20

15

10
0

Defibrillation
Hemodynamic
Monitoring
-Blockers

Pre-CCU
Era

CCU
Era

Aspirin
Thrombolysis
PTCA

6.5
Reperfusion
Era

Adapted from Antman, Braunwald In:Braunwald ed. Heart Disease p 1184.

Complications of Acute MI
Extension / Ischemia

Expansion / Aneurysm

Mechanical

Arrhythmia
Pericarditis

Acute MI

Heart Failure

RV Infarct

Mural Thrombus

Acute MI - Risk Stratification

Hemodynamic Subgroups - Killip Class

Killip
Class

Definition

GISSI-1 (%)
Incidence Control
Mortality

Lytic
Mortality

No CHF

71

7.3

5.9

II

S3 gallop or
basilar rales

23

19.9

16.1

III

Pulmonary edema
(rales >1/2 up)

39.0

33.0

IV

Cardiogenic shock

70.1

69.9

Treatment of ACS

Thrombolytic: SK, r-TPA

ASA 325 mg/day in acute, 81 mg/day in
chronic treatment
Heparin:
Antiangina: betablocker, NTG, Ca-blocker
Intervention: after refractory angina >24 hrs.

Preparation for Discharge

Education

Antiplatelet Rx : ASA 75 - 325 mg/day

: Clopidogrel 75 mg/day if ASA intolerant

LDL

BP
: target 135/85 (JNC VI)
Diabetics
: Hb A1c < 7.0% (ADA)
ACEI
: especially if DM, HF, EF < 40%,HTN

: Symptom, Exercise, Diet, Smoking

: < 70 mg/dL

Anti-Angina

Beta blockers
Nitrates
Calcium blockers
Dihydropyridines
Non-DHP (verapamil diltiazem)

Revascularization Therapy

Percutaneous Coronary Intervention (PCI)

Coronary Artery Bypass Graft (CABG)

Heart failure

Boston Criteria for Diagnosing

Heart Failure

Category I: history
Rest dyspnea
4
Orthopnea
4
Paroxysmal nocturnal dyspnea
3
Dyspnea while walking on level area 2
Dyspnea while climbing
1

Boston Criteria for Diagnosing

Heart Failure
Category II: physical examination
Heart rate abnormality
(1 point if 91 to 110 beats per minute; 2 points if more than 110 beats per
minute)
1 or 2

Jugular venous elevation (2 points if greater than 6 cm H2O; 3

points if greater than 6 cm H2O plus hepatomegaly or edema)
2 or 3
Lung crackles (1 point if basilar; 2 points if more than basilar)1 or 2
Wheezing 3
Third heart sound 3

Boston Criteria for Diagnosing

Heart Failure

Category III: chest radiography

Alveolar pulmonary edema

4
Interstitial pulmonary edema
3
Bilateral pleural effusion
3
Cardiothoracic ratio greater than 0.50 3
Upper zone flow redistribution
2

Marantz PR, The relationship between left ventricular systolic function

and congestive heart failure diagnosed by clinical criteria. Circulation
1988;77:607-12.

Boston Criteria for Diagnosing

Heart Failure

No more than 4 points are allowed from each of three

categories; hence the composite score (the sum of
the subtotal from each category) has a possible
maximum of 12 points.

The diagnosis of heart failure is classified as

- "definite" at a score of
8 to 12 points
- "possible" at a score of 5 to 7 points
- "unlikely" at a score of 4 points or less

Precipitating causes of CHF

Investigation for CHF

CXR
ECG
Pro-BNP
Pulmonary capillary
wedge pressure (PCWP)
TnT or CK-MB
Echocardiography

Heart Failure

Right and left side failure, congestive

and forward failure, systolic and
diastolic failure, mechanical and
myocardial failure.
Underlying disease: valve, myocardial,
etc.

Treatment of CHF

Decrease preload: diuretic, nitrate

Decrease afterload: ACEI, ARB, hydralazine
Inotropic agents: digoxin, dobutamine
Control heart rate: digoxin, Ca blocker, betablocker
Betablocker, spironolactone
Others: morphine, oxygen, etc.
Cardiac Rehabilitation

Thank you