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CARDIOLOGY

Anatomy
O The position of the heart in the mediastinum is such that 2/3 of it
extends to the left of the mediastinum
O The most anterior chamber is the right ventricle and most posterior
chamber is the left Atrium.
O The normal heart in chest x ray occupies < 50 % of transthoracic
diameter.
O The left border formed by Aortic arch, pulm trunk, left atrium and
left ventricle, on the right the right atrium joined by SVC.
Coronary circulation
+ The left main and right coronary arteries arise from the left and right
coronary sinuses just distal to the aortic valve.
+ The left coronary gives Left anterior descending artery
supplies anterior left ventricle, Apex
and the anterior septum
Circumflex artery supplies the left
atriumand left ventricle (marginal
branches)
+ The right coronary gives branches to supply the right Atrium , right
ventricle and inferior and posterior aspect of left ventricle.
Nerve supply of the heart
Sympathetic supplies Atria & Ventricles
Parasympathetic supplies Atria only (vegal escape)
Cardiac symptoms see the practical part
Cardiac examination see the practical part
ECG and X ray see the practical part
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CARDIOLOGY
Other investigations
1. Echo Ultrasonic to study blood flow, heart structures and the
movement of valve and muscle
Value
Chamber pressure and size.
Valve diseases (stenosis - Regurge).
Calcification.
Pulmonary and Aortic pressure.
Pericardial effusion.
Cardiomyopathy.
measure COP and ejection fraction = Stroke Volume = 55-75%
End diastolic volume
The function of artificial valves
Echo Doppler detects abnormal direction of blood and pressure
Gradient across valves and blood velocity.
2. ECG with effort and ambulatory ECG (Holter) see later
3. Cardiac Catheter
O Catheter from the femoral or brachial V can be advanced into the
RT. Atr RTV pulm Ar ..........
Value 1- Measure Pr Chambers pressure
Gradient across the valves
2- Measure O
2
left side O
2

right side O
2

3- Pass through anomaly e.g. VSD, ASD, PDA.


4- Inject dye to be followed with normal or abnormal
pathways e.g. ASD, VSD
4. Cardiac scan
Radioisotope is injected I.V. circulation Gamma camera detects
the radioactivity in the heart.
Value The Gamma camera detects the amount of isotope
emitting blood in the heart during cardiac cycle and also the
size of cardiac chamber
Also Gamma camera can detects Isotope (Thallium), uptake by the
myocardium to differentiate between ischaemic area
from non ischaemic area. Recently we use technetium
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CARDIOLOGY
Heart Failure
Defintion
Failure of the heart to pump sufficient cardiac output to meet
the demands of the body. With tissue hypoxia, in spite of normal venous
return and venous inflow to the heart (normal filling of the heart).
This usually occur with failure of the compensatory mechanism.
Causes
1. Lt. Sided failure Atrial
M.S, left atrial myxoma.
Ventricular
* Pr. load A.S.
systemic hypertension
Coarctation of Aorta.
* V. load M. I
A. I
V. S. D.
* muscular disease.
ischaemic heart Cardiomyopathy
heart disease
diagnosed by exclusion
to be confirmed by echo
2. Rt. Sided failure
1ry
p++
Pr. load 2ry (M.S.)
Rt.V P. S.
V. load A.S.D
T. I.
muscle disease. (Cardiomyopathy)
N.B. the most frequent cause of right heart failure is secondary to
left heart lesion.
Compensatory mechanisms
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CARDIOLOGY
Aim : To maintain normal COP
i.e When the heart is subjected to any load compensatory
mechanisms, as below to maintain sufficient COP.
1- Hypertrophy with pressure load.
thickness of muscle
fibres. late
ischaemic Heart disease
2- Dilatation with volume load.
length of
muscle fibre.
* Starling law:-
force of contraction initial length of
ms fibre within limits
N.B.
The heart withstands volume load more than pressure
load.
3- O
2
extraction
i.e. O
2
dissociation curve shifts to the right
4- Tachycardia (sympathetic drive)
'.' COP = stroke v. Ht. rate
In Ht. F. stroke V.
this lead to H.R. to maintain normal COP.
5- Release of atrial natriuretic peptide.
6- Activation of the renin angiotensin aldosterone system.
PPT. factors (Aggravating factors)
PPT. F
Example Pt.with M.V.D. decompensated heart
with compensated e.g chest infection
heart Heart failure
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Infectiove
endocarditi
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CARDIOLOGY
PPT. Fs.
Arrythmia Anemia pregnancy - pills. Exertion
e.g. A.F. stoppage Infection
- ve inotropic I.V. fluid of digitalis e.g. chest
drug pulm embolism infection
C/P of Ht. failure
A) C/P of Lt. sided Ht. failure

Signs Symp.
Signs of COP
cop signs of P.V.C
(fine basal) PVC
C Low pulse V crepitation murmurs
C systolic of M.I
Bl. pressure
Tachycardia Pulses apex
alternans Gallop
except in (3rd ht. sound)
digitized pt = (ventricular gallop)
Murmur Murmur of the valve lesion causing Heart failure
e.g. double Aortic lesion ( org. murmur )
Heart failure may murmur as Lf
ventricular
dilation functional M. I.
B) C/P of Rt. Sided failure

signs Symp
Tachycardia CO
Gallop 3rd ht. sound. SVC
S. V. C. Tricuspid area
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CARDIOLOGY
O neck V (congested)
O enlarged tender liver Pulses paradoxicus
O LL edema murmur.
T. I. (functional) due to dilated Rt.
V.
N.B. Complication of Hr. failure :-
Uremia (prerenal) K (diuretics and aldost)
Na (diuretics) Impaired liver F (COP + SVC )
Thromboembolism Arrythmias
Investigations
1. X-ray :- cardiomegally dilated Heart
Lt sided failure P.V. C.
2. E C G :-
It records electrical activity of the heart. & not
mechanics (no specific finding of heart failure).
It can detect chamber ++ & tachycardia.
3. Echo :-
Measure C. O. P. This reflects ventricular function.
Str. V.
By measurement of ejection fraction = if < 40-45% = failure
E D V
4. Cardiac scan.
ttt of left ventricular failure
1- Rest
(renal blood flow and help diuresis)
Rest until clinical improvement.
Q. Complication D V T
Pulm. Embolism
Constipation, osteoporosis.

2- Diet
+ Salt restriction
+ Kcl, is a salt containing no sodium
+ Fluid restriction :-
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CARDIOLOGY
fluid chart
value
Avoid volume monitor kidney perfusion
load in cases of COP.
Required fluid = 500 CC + the volume of urine output
in the previous day.
+ Avoid heavy meals, avoid alcohol as it has a negative
inotropic effect
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CARDIOLOGY
3- Digitalis
* Chemistry it is 2 part a glycol (active part )
sugar (modifies solubility
& potency).
* Mechanism of action:
Na Na
depolanization
muscle fibre K or stimulation
Na influx
ATP ATPase ADP
enz +
energy
Role of digitalis Na
digit ATPase
No energy Then Na pump
* It needs energy
No Na * The source of energy is
ATPase enzyme
Pump
Na
influx
Ca influx
muscle contraction by sliding of actin on myosin.
K Inhibits the action of digitalis on ATPase
So , K digitalis toxicity.
also, we use K in ttt of digit . toxicity.
Pharm. Actions:
electrical activity mechanical actions.
the heart rate due to Contraction
A-V. block Cop
size of heart
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CARDIOLOGY
Venous pr(shift of Bl.
from venous to Ar.
side)
Coronary supply
due to heart rate.
Bl. Pr. (Normalize bl. Pr.)
Ht. failure Ht. failure
COP symp. activity
Bl. Pr. Periph. vasoconstion
since digit COP
Bl. Pr.
Bl. Pr.
. digitais corrects the COP
sympathy drive
So Bl. pr return to
normal
Uses: heart failure
A. F.
arrhythmia's A. flutter
Supraventricular tachycardia.
Dose
digoxin life 1.6 days - 85 % excreted in the urine, 15 %
through biliarly excretion.
Therapeutic level after 5 days of daily maintenance ttt.
Cumulative method: (maintenance dose)

0.125- 0.25 mg / Day
Tab = 0.25 mg
Response after about 5 days.
Rapid digitalization (loading method)

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CARDIOLOGY
Example: Pateint requires loading dose 1-1.5 mg
since patients needs 1-1.5 mg (average) over 24
hours
oral I. V.
e.g. 1 tab / 6 hr 0.25 mg / 6 hrs

Then 0.125 0.25 mg/D as maintenance as an example
Q. Indications of I. V. digitalization :-
Severe , left V. failure
Rapid tachycardia arrhythmia (aggravating factor)

Rapid AF Supra V. tachycardia.
This is to get the benefit of A-V block also.
N.B. Digitoxin with life 5 days, metabolized mainly in the liver only
15 % excreted in the kidney to reach steady state it
must be taken for about 3 weeks.
Quabain is very rapidly acting onset of action 5-10 minutes,
peak 60 m after I.V injection excreted from the kidney.
Contraindications of digitalis:
toxicity Partial heart block
absolute Relative
PVT. V. extra systole
Digitalis toxicity:
# Patient liable to toxicity
core pulmonal
hypo & hyper- old K Ca Rh. renal ischaemic
Thyroidism age activity failure
heart
# to avoid this:
dose (give half the dose)
drug holiday
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CARDIOLOGY
C/P vomiting - diarrhea
arrythmia ( e.g. extrasystole ) especially bigeminy,
ventricular tachycardia and heart block
blurring of vision - yellow vision .
E C G arrythmia , digitalis effect.
Diagnostic Normal serum level is 0.5 2 ng/ml, it is >
2ng/ml in
case of digitalis toxicity.

ttt Stop Stop diuretics
Give K. ttt arrythmia. (see later) v. tachycardia
heart. block
Digitalis Ab
FAB fragments of digitalis Ab.

FAB fragments digit. complex

excreted from. The kidney.


Haemopefusion adsorption of digitalis
4- Diuretics
Aim Na & water excretion .
Na retention fluid loss with venous pressure, this
reduction of heart load leads to relief of P.V.C &
S.V.C
Frusemide Acts on loop of Henle. High ceiling
Diuretics

It is a veno dilator. Bumetanide
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CARDIOLOGY
On pulm. veins. Furosemide
Ethacrynic acid
P. V. C.
tab. 40 mg ( 20 - 200 )
dose
amp. Amp 20 mg I. V., I. M.

N.B. High ceiling Diuretics i.e. their action increase with
increase of the dose.
Thiazides Act mainly on distal tubules.
dihydrocholorothiazide
25 - 50 mg / d.
chlorothalidone ( long act ). thiazides like
Indapamide (natrilix) drugs
Side effects of diuretics: Lasix.
Thaizides.
K alkalosis D.M. dehydration
Na K Hyperuricemia
& gynaecomastia Ca
in case of aldactone
(thiazides)

Q- Uses of diuretics in medicine
Hypertension, heart failure Ascites, Nephrotic $
Hyper Ca, ( Lasix ) Glaucoma (diamox)
A. D. H. Thiazides in D.I.
Brain edema. Conns aldactone
Osmotic D e.g. mannitol , urea and Isosorbide
they do not markedly influence Na ,Cl excretion,
they usually not used in Heart failure as they
cause
initial hypervolemia heart load
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CARDIOLOGY
K- sparing diuretics K sparing (so it can be combined with
Lasix). Spironolactone acts througt
aldosterone antagonist in the distal tubules.
Tab 25 mg up to 200 mg/D
Other K sparing diuretics. e.g. triamterene and amiloride they act
directly on the distal tubules, with no aldosterone antagonism.
Carbonic anhydrase inhibitors
e.g acetazolamide used in glaucoma only.
oral
Aminophylline
supp. It is only used when
I . V. bronchospasm is present
I.V Broncho- +ve inotropic V. pressure it has a
injection dilator diuretic effect
must be
very slowly to
avoid arrhythmia
5- Vasodilators
V.R

P - R
= Bl. pr.
pre load. = after load
Venodilators
Value :- venous pr., this will relieve
S.V.C and P.V.C
pr
V Transudation
V. R.
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(positive (inodilator) It is
inotropic) givenI.V in
acute heart failure
CARDIOLOGY
pre load S. V. C. P. V. C.
Arterial vasodilators
P - R
After load.
improve myocardial efficiency
So CO P
N.B. after load cop
pre load PVC, SVC
Mixed drug ( V & Ar. Vasodilator)
ACE inhibitors are the best vasodilators in case of heart failure. Captoprile,
ramipril or enlapril can be used as a vasodilator dose, so to get the benefit of
these vasodilator, keep the systolic blood pressure within normal range.
6- Potent inotropic (Infusion)
Dopamine Beta agonists Dobutamine
Phosphodiesterase
small dose renal blood flow inhibitors
dose moderate dose B1 in heart more specific e.g
Amrinone
large dose. bl. pressure act on It is inotropic
B1 only and vasodilator
7- ttt of ppt factor, surgery e.g. valvotomy,
ultrafiltration and intraortic balloon.
Q.
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CARDIOLOGY
Rest - diet
O2 and ttt of ppt.F
Non pharmacological ttt ultrafiltration
venesection &
rotating tourniquet
cardiac transplantation
Aorta intra Aortic balloon
Lt.V. Balloon inflated during diastole
balloon diast. pr. in Ascending Aorta
in coronary filling
Descending
Aorta. Computerized
inflation and
deflation
ttt of acute cardiogenic Pulm. edema
or ttt of cardiac Asthma
i.e. impending Pulm. edema
Hospitalization & rest in bed in sitting position O2 therapy.
Morphia 10 mg I. V. V. pr. & sedation.
I. V. Lasix huge dose up to 500 mg vasodilation and diuresis.
I. V. digitalization if needed e.g. with rapid A.F.
Venous vasodilators e.g glyceryl trinitrate.
Aminophylline, 5mg/kg I.V infusion over 10 minutes.
ttt of ppt factor & the cause.
Vasodilator The best is I. V. Na nitroprusside.
+ve inotropic dopamine or dobutamine.
Tracheobronchial aspiration.
Ultrafiltration - intra Aortic balloon as before.
Different classification of heart failure
1- systolic failure as before.
2- Diastolic dysfunction :
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CARDIOLOGY
i.e. the ventricular compliance with ventricular
filling blood accumulate in the atrium, this
is common in hypertension and I.Hr.D
PVC.
ttt (Ca ch. B - BB) Improve V
compliance
1- COP failure as before.
2- COP failure as in thyrotoxicosis and beri beri where there is
COP with
inadequate perfusion of tissue due to the hypermetabolic state, It
is
treated by ttt of the cause with no role for digitalis
A- Lf sided failure.
B- Rt sided failure.
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CARDIOLOGY
Systemic Hypertension

Definition
Persistent Bl. Pr. above normal value on three different.
occasions under mental & physical rest.
Bl .Pr > 140/90 diagnosed as hypertension
About 15% of population can be regarded as hypertensive.
Systolic Hypertension
It means systolic Bl. pr > 160 mm Hg., with diastolic pressure
below 90 mmHg
- Causes A.I.
complete heart block.
Coarctation of Aorta.
Atherosclerosis
- ttt Treatment of the cause.
If the systolic pressure is very high we can give
antihypertensive.
Diastolic Hypertension
Diastolic hypertension = diastolic blood pressure > 90 mm.
Hg.
mild ( 90 104 )
- Grades moderate ( 105 114 )
severe ( >115 )
- Causes of diastolic hypertension
age 35 - 55
1ry No apparent causes
F. H. +ve
= Essential S. progressive with remote complications
So it is benign H. in most cases.
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CARDIOLOGY
- Theories
1. Renal ischaemia renin
2. Adrenal gland activity + + aldosterone
3. activity of V.M.C. symp. discharge Bl. pr.
4. Multifactorial
stress V. M. C. vasospasm
renal ischaemia
then return to normal Bl. pr. renin

long time
( persistent H.)
5. Barro receptors resetting
6. Impaired pr naturesis
7. COP - P-R
8. Genetic factor
9. Insulin resistance

age < 35 yr.
> 55 yr.
Secondary Cause +ve e.g. renal
hypertension F. H. - ve
Rapidly progr. early complic.
malig. in renal hypertension
- Causes
Renal. Artery stenosis.
1. Renal G. N.
Acute renal failure
Chronic renal failure.
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CARDIOLOGY
acromegaly

Thyrotoxicosis systolic hypertension.
2. Endocrinal Cushing syndrome and Conns disease
Pheochromocytoma.
3. Neurological I. C. T. reflex in
Bl. pressure
4. C. V. S Coarctation of Aorta.
5. Pregnancy preeclampsia.
6. Blood polythecymia hyperviscocity blood
pressure
7. Drugs. Cortisone
Pills salt & H
2
O
NSAID retention
Ephedrine, Erythropiotin and Cyclosporine.
C/P of hypertension
asymptomatic
headache
Symptoms blurring of vision
easy. fatigue
symptoms of complication.
symptoms of the cause (2ry H.).
elevated blood pressure
Signs signs of the cause (2ry)
Apex Lt. V. ++ (hypertrophy)
sustained.
Auscultation
S
1
S
2
S
3
S
4
mus. component Aortic component
due to Lt. V. ++ splitting apex
(reversed in with Lt. V. F. apex
severe cases) due to Lf.V
compliance
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CARDIOLOGY
Murmur Aortic dilatation
ejection syst. murmur.
ejection syst. click. Lt V.
N.B. Malig. H * Rapidly prog. & early complications.
(fibroid necrosis
of vascular wall)
cerebral hge R.F. ht. F.
* Diastolic pr > 130
* Papillaedema
C/P as above ttt
Pallor vasospasm
microangiopathic H.A.
Fundus ex macular star + papilloedema
Complications
1. Heart heart failure
ischaemic heart disease.
Diastolic dysfunction
2. Neuro stroke (cerebral hge) Lacunar infarction
3. Kidney Renal failure
4. Eye retinopathy
5. Side effects of drugs.
Investigations
1. ECG & X-ray Lt. V. ++
= old standing hypert.
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Chronic renal failure in
benign essential
hypertension
Acute or rapidly progressive
renal failure in malignant
hypertension.
CARDIOLOGY
2. Fundus ex. if +ve 1- silver wiring of Ar
= long standing hypert. 2- Ar-V nipping
+1
(essential) 3- Hge - exudate +2
4- papilloedema + 3
3. Cause Kid function, renal Angio.
Cortisone (cushing $)
Thyroxin
V. M. A. - plasma renin (in 10% of cases 25%
renin)
Na -K (Hypokalemic
hypertension)
Treatment
+ Rest during exacerbation rest in bed
cold cases moderation of life
sleep (8 - 10 hrs)
avoid stress
avoid straining
+ Diet Salt restrictionwith high potassium diet.
Fatty diet (to cholesterol)
CHO
+ Weight reduction in overweight patients leads to a true fall
in
blood pressure.
+ Drug therapy
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drugs
CARDIOLOGY
- Stepped care approach:- (old approach)
Methods Start with diuretics (thiazides)
or (BB) for 6 wk.
if good response if no response
give diuretics
continue + BB for
6 wk.
If good response if no response
Add vasodilators
Ca channel
blocker
continue centrally acting.

I. Diuretics
Value Na excretion reactivity of Bl. Vs
to catecholamines .
Thiazides
Tolerated for long time
value Vasodilators.
Release P.GV. D.
Na depletion from wall of Bl. Vs.
Example Moduretic one tab/d at the
morning
Dihydrochlorothiazide Amiloride
50 mg 5 mg
K K. retaining.
Frusemide
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CARDIOLOGY
indications:- emergency e.g. H. encephalopathy.
salt & H
2
O retention e.g. nephritic
GFR < 25 ml / m.
Spironolactone (aldosterone. antagonist).
used in Conns.
dose :- 400 mg
N.B
Amiloride or spironolactone are not effective when used alone, with
the exception of spironolactone in 1ry hyperaldosteronism.
II. B.B
Mech - ve inotropic
- ve chronotropic Cop Bl. Pressure
Renine release
Types NON selective B
1
& B
2
Inderal 80 mg - 120 mg at least.
Selective B
1
Atenolol.
Tenormin
Tab. 100 mg ( - 2 tab/d)
III. - Blockers
Prazocin (minipress )
Ar. & V. vasodilator.
Uses Heart Failure.
Hypertension
Peripheral vasodilator.
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Dose
1 6 mg/D
CARDIOLOGY
Side effect
1st dose phenomenon.
1st dose marked vasodilator in splanchnic area
blood pooled to the abdomen V. R.
Cop syncope
N.B
Labetalol is an agent that has combined and B blocking properties
but not commonly used except in hypertension with pregnancy
IV. Centrally acting drugs

2
agonist sympath discharge Bl. Pr.
Aldomet ( - methyl Dopa)
Uses hypertension
hypertension with pregnancy (no effect on placental
bl. flow)
Side effects depression
extra
autoimm.
H. An chronic active hepatitis
Dose 250 - 1000 mg / d.
Clonidine as aldomet (the same mechanism)
(difference) V. potent.
Side effect salt & H
2
o retention
so, give diuretics.
N.B
Reserpine (it has no role in recent medicine)
It depletes C.A stores in the P.N.S so leads
to sympathy Nr discharge.
e.g. Serpasil
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CARDIOLOGY
Brinerdine
depression
Side effect extra
Nasal congestion
V. Vasodilators
Arterial vasodilators
Hydrazine Very potent
Used in pregnancy
Reflex H. R. coronary filling
Dose is up to 100 mg/day.
Side effects S. L. E like
Tachycardia.
Nefidipine Ca. Ch. B.
see angina
Minoxidil (not used now) it leads to
excessive hypertrichosis
Diazoxide (Ar. vasodilator).
insulin release I. V. 300 mg V. potent
used in during H.
insulinoma. encephalopathy
Venodilators nitrates see angina (they can be used by
infusion
in case of hypertension encephalopathy
Mixed (Ar & V) vasodilators
1. Na nitroprusside (Nipride)
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CARDIOLOGY
very potent
used in emergency . H. encephalopathy.
cardiogenic pulm. edema.
Dose - 50 mg vial + 500 cc glucose 5%
I. V. drip very slowly.
Side effects - Hypotension.
2. - blocker (see before)
3. Angiotensin converting enzyme inhibitors (ACE inhibitors)
inhibitors)
Action angiotensin I
converting
enz. in the lung
angiotensin II
Vasospasm Aldosterone release
Uses hypertension
heart failure
Diabetic nephropathy
Renal hypertension
Captopril 3 according to the
Dose Tab 25 mg 1 3 grades of
hypertension
2 3
Side effects K
Nephrotic (membranous G.N)
Chronic cough due to accumulation of
Bradykinin

N.B. ACE inhibitor contraindicated in bilat. Renal artery
stenosis.
Other ACE inhibitors :
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CARDIOLOGY
Lisinopril long acting 10-20 mg/D
Enalapril can be given I.V, 10-20 mg/D oral
Trandopril 1-4mg/D
Schematic approach to the treatment of hypertension
in patients with no need for specific therapy
instead of the old stepped care approach
1- Start with low dose, ACE inhibitor (25 mg captopril) or Cach. B
120mg diltiazem or 25 mg atenolol/day
2- If no response double the dose.
3- If no response add low dose thiazides.
4- If no response full dose of the initial drug + thiazides.
5- If no response search for 2 ry cause.
6- If no cause add. Clonidine, hydralazine. methyl dopa
N.B Angiotensin II receptor antagonists
This group share many of the action of the ACE inhibitors, but they
do not cause cough. So, they are used for patients who can not
tolerate ACE inhibitors. They include losatran 50-100 mg/D and
valsartan 80-160 mg/D
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