INTERNAL MEDICINE: CVS Stage 3 T wave inversion

Stage 4 Normal
PERICARDIAL DISEASES
PERICARDITIS VS MI
PERICARDITIS CONCAVE ST ELEVATION
MI CONVEX ELEVATION

CARDIAC TAMPONADE
🚩FLUID IN THE PERICARDIAL SPACE
BECK’S TRIAD 🚩SIGNS
1. Hypotension
2. Muffled Heart Sounds
3. JVP distention

ABSENCE OF PERICARDIUM is still compatible with LIFE PARADOXICAL PULSE (>10 mmHg
RARELY!!: Parietal defects causes herniation & cardiac death decline in inspiratory systolic arterial
CARDIOMEGALY pressure)
European Society of Cardiology
can be seen
Acute 6 weeks Incessant 4 – 6 weeks but Soft or absent muffled sound
<3 months JV distention +
without prominent x descent
remission absent y descent
Subacut 6 weeks – 6 Recurrent symptom free
e months interval of 4 - 6
weeks EWART SIGN Patch of dullness & increase fremitus on
Chronic > 6 months Chronic lasting > 3 left scapula
months CXR WATER BOTTLE SIGN
PLEURAL FLUID ANALYSIS FAT PAD SIGN
BLOODY TB ; Malignancy Echo IDEAL DIAGNOSTIC TEST
TRANSUDATIVE HF SWINGING HEART on Echo EARLY SIGN OF TAMPONADE
CHYLOUS Traumatic or Surgical Injury SIGN
GOLD PAINT Hypothyroidism Etiology same as pericarditis
CHOLESTEROL RICH Management DEFINITIVE: PERICARDIECTOMY
GREEN Bacterial
CHRONIC PERICARDITIS
End stage of an inflammatory process
ACUTE PERICARDITIS RIGHT SIDED HEART FAILURE
Congestive Hepatomegaly -> impair hepatic function -> ASCITES
2 out of 4  Chest pain Etiology Idiopathic, TB, Neoplastic, Uremia
Criteria  Friction rub M or W- shaped JVP
 ECG CHANGES (STE, DEPRESSED PR) Prominent x & y (most prominent)
 Effusion
Etiology INFECTIOUS: PH: TB, World wide: Bacterial: SQUARE ROOT SIGN: Deep & Plateau
Streptococcal, Pediatric: Viral Kussmauls Sign Venous pressure FAILS to decrease
during inspiration.
paradoxical increase in JVP that occurs
NON-INFECIOUS: Uremia, Hypothyroidism,
during inspiration.
trauma, radiation, malignancy, CTD
Broadbent Sign Reduced Apical pulse & may retract at
UREMIA (MC cause in PH)
SYSTOLE
Management Bedrest Aspirin
PERICARDIAL KNOCK EARLY DIASTOLE SOUND heard at LSB
Depends on etiology
(early abrupt cessation of ventricular
 Bacterial : Antibiotics
filling)
 Fungal: Ampho B
CXR Normal or with pericardial
ECG CHANGES
CALCIFICATION
MRI & CT SCAN DIAGNOSTIC PROCEDURE OF CHOICE
Show pericardial thickening &
calcification
Management 🚩PERICARDIECTOMY
NSAIDS, Colchicine, Steroids
Diuretics & Salt Restriction
Stage 1 CONCAVE ST elevation
PR interval depression
PERICARDIAL preventing recurrences when underlying
Stage 2 ST returns to baseline WINDOW cause of the effusion continuous to be
 more present

POST CARDIAC INJURY SYNDROME

Autoimmune reaction after cardiac injury / cardiac surgery
Pleuritis & Pneumonitis -> Pleural Effusion
2 of the Following Fever w/o cause
Pleuritic chest pain
Pleural rubs
Pericardial effusion
Pleural effusion Elevated hsCRP
1 – 4 weeks after surgery
Management Aspirin, Analgesics, NSAID, Colchicine

EARLY POST MI PERICARDITIS & DRESSLERS YNDROME

Early PMI occurs 1 -3 days after MI not more than a week
Dressler’s LATE pericarditis
as early as one week – few months
Etiology “postpericardiotomy syndrome” after cardiac sx TREATMENT
(autoimmune reaction)
Management Self limiting,
Aspirin, Colchicine
AVOID: NON ASA NSAIDS & Corticosteroids

Tamponad Constrictive Effusive Restrictive RVMI

e Pericarditis Constrictive Cardiomyopa
Pericarditis thy
Pulsus +++ + +++ + +
Paradoxus
y ++ + +
Sildenafil – contraindicated in giving nitrates
x +++ ++ +++ +++ +
Streptokinase – contraindicated in Hx of bleeding ??
Kussmaul’s +++ ++ + +++

3rd heart + + +
sound
Pericardial +
knock

ISCHEMIC HEART

AGINA SYMPTOMS: Jaw pain, neck pain, arms, back, or even teeth
ANGINAL “EQIVALENTS”: Dyspnea, Nausea, Fatigue, Faintness
  Detect for ischemia & arrythmia & determination of
functional capacity

B-adrenergic : Mainstay for Unstable Angina

Nitrates & Calcium Channel Antagonist: Prinzmetal Angina

ACUTE MYOCARDIAL INFARCTION

Anterior Infarction SYMPATHETIC

Inferior Infarction PARASYMPATHETIC

MYOCARDITIS

ST DEPRESSION: MI of Anterolateral Wall

LABORATORY EVALUATION
Troponin I Mildly Elevated
A – ST ELEVEATION in leads I Creatinine may be elevated
kinase
Coronary rule out ischemia
Angiography
Endomyocardial DALLAS CRITERIA
biopsy - Lymphocytic infiltration with evidence
of myocyte necrosis present in only 10 –
20%

Inflammation of the heart can result from multiple causes

Most attributed to INFECTIVE AGENTS that can injure
o Direct invasion
o Cardiotoxic substances
LV: major pumping chamber o Chronic inflammation
Formation of Blood Clot:
 Most common – viral infection (including covid),
 Most common cause of Coronary Artery Blockage
o T. Cruzi in South America (CHAGAS: Reduviid bug)
DIASTOLE
 Majority of blood flows to coronary arteries o Endomyocardial Fibrosis: Equitorial Africa
Ischemia manifests as ANGINA
 ECG: ST SEGEMENT DEVIATION INFECTIVE
Coronary Atherosclerosis: o VIRAL : HIV, hepa C, picoRNA
 FOCAL PROCESS -> NON-UNIFROM ISCHEMIA  Presents as HEART FAILURE
o PARASITIC
Transient T wave Non transmural intramyocardial  CHAGAS: Myocyte lysis, has a silent stage that
inversion ischemia progress slowly in 10 – 30 year period with cardiac
Transient ST segment Patchy subendocardial ischemia or GI manifestations Chagas disease
depression
(Reduviid kissing bug: T. Cruzi)
ST segment deviation more severe transmural ischemia
 TRICHINELLOSIS: Trichinella spiralis larvae ingested,
Most die due to ischemia induced ventricular tachyarrhythmias
eosinophil inflammatory response produces clinical
heart failure
ANGINA PECTORIS
 Crescendo-Decrescendo in nature  TOXOPLASMOSIS
 Occur 2 – 5 minutes  AFRICAN TRYPANOSOMIASIS: RAPID
 Radiate to either shoulder or both arms PROGRESSION THROUGH PERIVASCULAR
 DO NOT RADIATE TO TRAPEZIUS MUSCLE INFILTRATION TO MYOCARDITIS: African Tse-Tse
o Radiation to trapezius muscle is more Fly: T. brucei
typical of PERICARDITIS o Bacterial – TB (MC in PH), clostridial, diphtheria
LABORATORY EXAM  CLOSTRIDIAL: GAS BUBBLES
HIGH CRP (elevated Independent Risk Factor for IH  STREPTOCOCCAL: ARHF
level (0 – 3mg / dL)  TB
 WHIPPLE’S DISEASE
STRESS TEST
NON-INFECTIVE (without preceding infection)
o GRANULOMATOUS MYOCARDITIS – MC
o Cardiac transplant rejection
o Sarcoidosis
 HALLMARK: CARDIAC GRANULOMATA
 Dermatologic Skin Manifestations
 Typical in African American Young Adults
 Rapid onset of HF, Ventricular Arrythmias, Cardiac
Block, Chest Pain Syndromes
o Giant Cell myocarditis 🚩PHYSICAL EXAMINATION
o Eosinophilic myocarditis Precordium Heaves L or R Ventricular Enlargement
Thrills Valvular heart Diseases
VIRAL MYOCARDITIS PRESENTATION Heart Sounds S1: soft Dilated
o Acute – young to middle aged adult within few day/weeks S1: loud Hypertrophic
after viral infection (with fever & myalgia) S3 & S4 DIASTOLIC DYSFUNCTION
o Anginal-type chest pain, positional chest pain due to
Murmurs Valvular & Congenital
pericarditis, chest pain suggestive of MI
JVP Elevation R sided HF
o Fulminant myocarditis – rapid progression from severe
Auscultation Rales Pulmonary Congestion
febrile respiratory syndrome to cardiogenic shock ( Drop
in BP & tacycardia & possible congestion)
o Renal failure, hepatic failure, coagulopathy
o Typically affects young adults
o Cardiac test abnormalities: elevated troponin, asx
arrhythmia, abnormalities on imaging
o Myocardial injury (elev. Troponin) common:
 Myocarditis
 Stress myopathy
 MI

CARDIOMYOPATHY
Dilated vs Hypertrophic: LEFT ventricular wall thickness & cavity
dimension
🚩RIGHT SIDED HEART FAILURE: Dyspnea, Peripheral Edema CLEAR
Dilated SYSTOLIC DYSFUNCTION BREATH SOUNDS, elevated JVP
Cardiomyopathy Most Common
Enlarged Left Ventricle
Mitral Regurgitation DILATED CARDIOMYOPATHY
1. Peripartum Cardiomyopathy
Hypertrophic DIASTOLIC DYSFUNCTION  Develops during the LAST trimester or within 1st 6
Thickened Ventricular Wall months of pregnancy
mostly INTERVENTRICULAR SEPTUM
ASYMMETRIC SEPTAL HYPERTROPHY 2. Toxic Cardiomyopathy
LV Hypertrophy in ABSENCE of causative  CHEMOTHERAPEUTIC AGENTS: most common
hemodynamic factors implicated drugs in toxic cardiomyopathy
LV OUTFLOW OBSTRUCTION Anthracyclines Vacuolar Degeneration
SEM enhances by Valsalva & squatting Doxorubicin Myofibrillar Loss
position 5 FU & Cisplatin Coronary Spasm
Risk of Sudden Death in young athletes IFN a Hypotension & Arrythmias
Hydroxychloroquine QT prolongation
Restrictive DIASTOLIC DYSFUNCTION Chloroquine
Rigid Ventricular Wall Emetine
Least Common Type Antiretroviral
Both Atria Enlarged Therapy
More Right Sided Symptoms
 Alcohol ( 5 -6 drinks daily for 5 – 10 years)
Atrial fibrillation occurs commonly (holiday Heart)
 Cocaine & Amphetamines. Microinfarcts consistent
with small vessel ischemia
3. Endocrine Disorders
4. Hemochromatosis
5. Familial
 Most common: mutations in TNN
  Dystrophies (Duchenne’s, Becker’s)
 Arrhythmogenic Right Ventricular HYPERTROPHIC CARDIOMYOPATHY
Cardiomyopathy  ASSYMETRIC SEPTAL HYPERTROPHY
6. Takotsubo Cardiomyopathy  LVH in absence of causative hemodynamic factor
 Disease of older women precipitated by extreme  Left Ventricular Outflow obstruction
emotions
 Pulmonary Edema, Chest Pain
7. Idiopathic

Fabry’s Disease Alpha galactosidase Def

X linked
Glycogen Storage Lysosomal enzyme Def -> gag accumulation
Diseases in skeleton
X linked or Autosomal Recessive
Carnitine causes intracellular lipid inclusions
Deficiency Autosomal Recessive
SLC22A5 GENE
INTERVRENTRICULAR SEPTUM
 Typical location of maximal hypertrophy

RESTRICTIVE CARDIOMYOPATHY
 Abnormal DIASTOLIC DYSFUNCTION
 Both ATRIA are enlarged
 More Right Sided Symptoms
 AMYOLYDOSIS: major cause of restrictive cardiomyopathy