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Chest wall:
• Onset - Can be precipitated by vigorous or unaccustomed exercise (muscular or ligamentous
strain), inflammation (costochondritis), rib fracture, metastatic cancer, herpes zoster (virus)
or cervical root compression (c-spine disease).
• Duration - varies from a few seconds to several days. The pain of herpes zoster may precede
the rash by 3-5 days. In the elderly it may persist for months, long after the rash subsides.
• Location - pain can be pinpointed by the patient being somatic in nature
• Relief (?)-aggravated by cough, deep inspiration, direct palpation and movement.
• Quality - ranges from sharp to dull or aching.
Esophageal reflux
• Onset - brought on by large meal, lying down, or bending over.
• Duration -? longer than angina ?
• Location - may radiate to interscapular region. (acute cholecystits can produce substernal
nitrates relieved by nitro). PUD and pancreatitis can produce substernal chest pain also.
• Relieved by antacids
Psyche
• Onset – unrelated to exertion and unrelieved by rest
• duration – hours to days
• location – Goroll doesn’t specify
• relief - ? treat underlying anxiety?
• Quality - patients w/ anxiety or depression often describe feelings of chest tightness or
heaviness. Anxiety disorders can include a feeling of not being able to take a deep breath.
Aprilt Noble 2nd ed. p. 220
QUALITY, DURATION and RELIEF- Angina is described as a tightness, squeezing, heaviness,
pressure, burning, indigestion, or an ache. It usually a steady discomfort that lasts a few
minutes, rarely more than 10, UNLESS it becomes unstable angina or an MI. Always more than
a few seconds, which will differentiate it from a muscu/skel type discomfort. It is usually
relieved quickly with a SL (sublingual). Relief with Nitro (NTG) may be a distinguishing
feature.
LOCATION and RADIATION- angina is usually a diffuse sensation rather than at discrete spot.
If a pt. can localize with one finger ischemia is an unlikely cause. Usually most intense
retrosternal and left ant. chest but may occur anywhere from the jaw to upper abd. frequently
radiates to the shoulders, upper back, neck, or inner aspect of the arms, particularly on the left
side. When an MI is in progress it is generally more diffuse and severe.
PRECIPITANTS- Except when caused by pure vasospasm, angina is usually caused by things
that ^ myocardial demand. Provoked by exertion, climbing stairs, sex or work using the arms.
Eating large meals and activity in cold weather. The threshold for angina in usually lower in the
AM. The patients who primarily experience vasospasm usually acquire angina at rest
independent of activity.
Anonymous Noble-166
Onset and precipitating factors- gradual onset and resolution; continuous pain typically lasts 1-
10 min. The pain will have a “lag” time before onset after precipitating events, exercise, stress,
eating, cold temp, cocaine, etc.
Duration- lasts 1-10min after precipitating factors.
Location- substernal or anterior chest; May radiate to upper back, neck, teeth, shoulder or arm.
Relief- rest, Ntg. Pain that vanishes immediately on stopping activity is not likely to be angina.
Quality- heaviness, pressure or squeezing (occasionally burning) or deep dull ache;
accompanied by nausea, diaphoresis or hypotension.
Anonymous Currents p 336-337
A) Onset and Precipitating Factors: Angina occurs most commonly during activity with
exertion that involves straining the thoracic or upper extremity muscles. Rapidly walking uphill
and sexual activity also can precipitate angina due to their increased heart rate increasing oxygen
demands on the heart. The threshold for angina is often lower in the morning or after periods of
strong emotion.
B) Relief: Angina is usually relieved by rest and the diagnosis can be strongly supported if
relieved by sublingual nitroglycerin. Upright posture, time after meals, times of excitement, and
upon exposure to cold are instances where angina is less likely.
C) Duration: Angina is of short duration and subsides completely without residual discomfort.
If the attack is precipitated by exertion, and the patient promptly stops to rest the duration is
usually not longer than 3 minutes. Attacks after a meal or period of emotion may last up to 15
minutes and periods lasting longer than 30 minutes suggest unstable angina or myocardial
infarction.
D) Location: In 80-90% of cases the pain is felt behind or slightly to the left of the sternum.
When it begins to the left of the sternum or uncommonly to the right of the sternum it will
usually move to be more directly behind the mid sternum. Radiation is most commonly to the
left shoulder and upper arm, and occasionally can be felt initially in the lower jaw and back of
the neck.
E) Quality: Patients often do not describe angina as pain, rather as discomfort or a sensation of
tightness, squeezing, burning, pressing, choking, aching, bursting, or an ill characterized
discomfort. It is often characterized by the Levine Sign- clenched fist held at the sternum.
B) Unstable Angina- this term is used to denote an accelerating or "crescendo" pattern of pain
in cases where previously stable angina occurs with less exertion or at rest, last longer, and is
less responsive to medication. This carries a poorer prognosis than stable angina. Newly
diagnosed angina may be termed unstable until it is determined whether or not it will be
responsive to rest and medication. Currents p 346
6. Compare and contrast causes of chest pain which will have normal physical
examinations, against those which will demonstrate important physical
findings.
Tim Noble 164-168, 548 and 549, CMDT pgs 336-354 and 5 min. clinical consult palm
I divided these up according to non CV etiologies and CV etiologies because the books didn’t
divide things up the way the question is asking. The next 5 objectives are the best I could do
considering the vagueness and depth of what’s being asked and my inexperience with all things
CV, so if you think I missed the boat on something let me know. Thanks guys.
Positive PE: Aortic dissection, Musculoskeletal causes, Mitral Valve prolapse, pleural process,
Myocarditis, pulmonary causes and most cardiogenic disorders.
Anonymous Noble 1005-6
There is an excellent table on page 111 (Goroll) that outlines the complete differential diagnoses
for chest pain; I think it’s worth looking at in detail, but I’ll summarize it here. Basically, there
are five categories of chest pain: chest wall, cardiopulmonary, aortic, GI, and pyschogenic. All
except for the pyschogenic causes will produce important physical exam findings. Pyschogenic
causes should be considered when more serious causes have been worked-up and ruled-out.
Also, about one-third of patients with chest pain of unknown origin (CPUO), have concurrent
panic disorder.
Anonymous Noble p 163-165/ Currents p 337
Cause of Chest Pain Important Physical Findings Normal Findings
Anterior Chest Wall Sharp intercostals pain than may be
Syndrome associated with warmth, swelling,
and may be painful to touch
Intercostal Neuronitis Intercostal pain due to herpes
zoster or diabetes and again
reproducible with palpation
Cervical and Thoracic Sudden sharp pain that is
Nerve Root Disease reproducible with certain
movements of the neck or spine
GERD Normal exam with the exception of
increased discomfort upon bending
over after heavy meals
Degenerative/ Normal exam but pain may be
Inflammatory Lesions of reproduced with manipulation of
the left shoulder the left arm or shoulder
Spontaneous Decreased breath sounds on side of
Pneumothorax pneumo as well as tracheal
deviation
Pleuritis Chest pain with auscultation of
pulmonary friction rubs
Pulmonary Consolidation Decreased tactile fremitus over
lobes involved
Disection of Aorta Changes in peripheral pulses in
different extremities
Valvular Disorders Appropriate murmurs
Pericarditis Cardiac friction rubs
Anxiety/ Panic Disorder Normal Exam Findings with
the exception of mild
tachycardia and tachypnea
Hypertension Normal exam findings
although may cause
headaches
Acute Myocardial Exam may be acutely normal
Infacrtion
Angina Exam may be normal
however history will elucidate
decreased discomfort with
rest
Esophageal Spasm Exam may be normal
Functional Exam may be normal
Gastrointestinal Disease
* Isolated musculoskeletal chest pain syndromes (costosternal, posterior chest wall syndromes)
* Rheumatic diseases
* Nonrheumatic systemic diseases
Isolated musculoskeletal chest pain syndromes — There are a number of chest wall syndromes
with chest pain associated with musculoskeletal inflammation.
* Chest wall pain occurring after coronary artery bypass surgery may be a result of incisional
discomfort, of internal mammary artery grafting, or related to sternal wires.
Skin and sensory nerves — Chest pain may be the presenting symptom of herpes zoster
(shingles); it may precede the characteristic rash and, rarely, zoster may occur without a rash.
Dysesthesia is usually present in the affected dermatome. Postherpetic and postradiation
neuralgia are other unusual causes of chest pain.
Anonymous
• Costochondritis (Tietze's syndrome) - inflammatory condition that produces localized
swelling, erythema, warmth, and tenderness at costochondral or costosternal junctions.
• Rib fracture - similar to costochondritis with different location. History of antecedent
trauma or metastatic cancer.
• Herpes zoster - dermatomal distribution. Pain may precede rash by 3-5 days. In elderly pain
may persist for months, long after rash subsides.
• Cervical root compression - due to cervical spine disease or thoracic outlet syndrome nerve
injury can produce pain in the chest and upper arm. In the outlet syndrome , a cervical rib can
compress part of the brachial plexus, resulting in motor and sensory deficits in an ulnar
distribution at the same time that there is discomfort in the chest and upper arm.
Anonymous Goroll, pp 108-109
Muscular or ligament strain- hx of vigorous, unaccustomed exercise, pinpoint pain with
quality of sharp to dull/aching, occasionally c/o chest tightness.
Costochondritis- inflammatory condition causing localized swelling, erythema, warmth and
tenderness of the costochondral or chondrosternal junction.
Rib fracture- hx of antecedent trauma or metastatic CA, similar to costochondritis, but located
over rib, rather than at junction.
Herpes Zoster- characteristic dermatomal distribution, pain may precede rash by 3-5 days. May
c/o hypoesthesia, dysesthesia or hyperesthesia.
Cervical root compression or Thoracic outlet syndrome- due to cervical spine disease. May
produce pain in the chest and upper arm, superficially resembling angina. With outlet syndrome,
often accompanied by motor/sensory deficits in ulnar distribution
Anonymous Currents p 337
A) Anterior Chest Wall Syndrome- sharply localized intercostals tenderness
B) Tietze's Syndrome- inflammation of the costo-chondral junctions which may be warm,
swollen, and red of which pain is reproducible by local pressure
C) Intercostal neuronitis- due to herpes zoster or diabetes mellitus disease of these nerves
8. Summarize common tests ordered for patients with chest pain, their possible
indications, and their limitations.
Tim Noble 548-550
Laboratory findings: Blood tests to evaluate for underlying risk factors include measurement
of the serum lipids and fasting serum glucose. The hematocrit and thyroid function tests should
be measured if clinically appropriate, since anemia and hyperthyroidism can exacerbate
myocardial ischemia.
Resting ECG: Many patients with CAD have normal baseline ECGs, or may demonstrate
pathologic Q waves indicative of previous infarction. In many patients minor ST and T wave
abnormalities are present but are not specific for CAD. However, the ECG can be diagnostically
useful if recorded during an episode of chest pain, whereupon ischemia often results in transient
horizontal or downsloping ST segments or T wave inversions, which normalize following
resolution of the pain. Less often, transient ST elevation may be observed, which suggests severe
transmural ischemia or coronary artery spasm.
Exercise Stress Testing: The most useful noninvasive studies in the evaluation of angina
involve exercise testing. In patients without resting ST or T wave abnormalities the standard
treadmill (or bicycle) exercise test, without additional imaging modalities, should be the initial
procedure, since it is the most convenient and cost-effective. For patients whose presentation
strongly suggests myocardial ischemia, the exercise test has a sensitivity and specificity greater
than 85%. However, when the probability of significant coronary disease is low (e.g., a young
woman with prickly chest pains), the test is less specific, and false-positive results are more
common. Exercise testing is most commonly used (1) to confirm the diagnosis of angina, (2) to
identify IHD patients at high risk of complications, (3) to assess the response of antianginal
therapy, and (4) as a screening procedure for certain asymptomatic populations, such as
individuals with strong cardiac risk factors, older patients about to begin exercise programs, and
individuals whose well being could affect public safety (e.g., airline pilots).
Radionuclide Studies: Two types of nuclear studies are used to enhance the diagnostic value of
standard exercise tests: myocardial perfusion imaging and radionuclide ventriculography. These
tests can provide additional information regarding the location and extent of CAD, and their
interpretations are not hampered by resting ECG abnormalities. However, they are more
expensive than standard treadmill tests and should be used judiciously.
Myocardial Perfusion Scintigraphy: Myocardial perfusion scintigraphy is generally more
sensitive and specific than conventional stress testing. During this test a radionuclide (e.g., 201
T1 or 99m Tc sestamibi) is used, which after peripheral venous injection distributes to the
myocardium in proportion to coronary blood flow. The radionuclide is injected at peak exercise,
and immediate imaging is performed. Perfusion defects (cold spots) indicate regions of prior
infarction or exercise-induced ischemia. Repeat imaging at rest several hours later shows filling
in of the zones that were ischemic, differentiating them from regions of previous infarction. The
location of perfusion abnormalities correlates with coronary disease in the respective territory
(e.g., left anterior descending artery disease results in perfusion abnormalities within the anterior
wall). Multiple large perfusion defects correlate with left main or severe three-vessel disease.
Echocardiography: Imaging of the left ventricle by ultrasound can reveal segmental wall
motion abnormalities indicative of ischemia or previous infarction. In exercise
echocardiography, left ventricular function is assessed before and during vigorous exercise
(supine bicycle or treadmill); exercise-induced segmental regional wall motion abnormalities are
an indication of ischemia. Exercise echocardiography is therefore analogous to exercise
radionuclide ventriculography and has similar sensitivity and specificity for the presence of
significant coronary disease. For patients who are unable to exercise, pharmacologic stress
testing with echocardiography can be performed in one of two fashions: (1) using potent
vasodilators such as adenosine or dipyridamole (analogous to pharmacologic 201 T1
scintigraphy described above), or (2) using an adrenergic stimulating drug (e.g., dobutamine).
Either of these techniques signifies the presence of myocardial ischemia by drug-induced left
ventricular wall motion abnormalities.
Coronary Arteriography: Coronary arteriography allows selective visualization of the
coronary arteries and their major branches and is the most accurate means to detect the presence
and extent of CAD. In experienced laboratories it is performed with low mortality
(approximately 0.2%) or severe vascular complications (0.7%). However, this technique is
costly, is not risk-free, and is seldom needed to simply establish the diagnosis of significant
coronary disease. The decision to proceed with arteriography should be dictated by the patient's
clinical presentation and only when a change in therapeutic plan is under consideration. Note that
an individual with mild to moderate angina that is reasonably controlled with medical therapy
does not generally require cardiac catheterization, since the long-term prognosis and quality of
life may not be significantly affected. However, if that individual has other markers of a poor
prognosis by exercise testing or impaired left ventricular function, then catheterization should be
performed.
Kate CMDT 316
ECG - indicates cardiac rhythm, reveals conduction abnormalities, and provides evidence of
ventricular hypertrophy, MI, or ischemia. Nonspecific ST segment and T wave changes may
reflect these processes but are also noted with electrolyte imbalance, drug effects, and many
other conditions. Routine x-rays and ECGs are not recommended to screen for heart disease and
have limited role in the follow-up of pts with known heart disease. However, a baseline ECG is
helpful in older pts.
Chest X-ray: provides information about heart size, pulmonary circulation (with characteristic
signs suggesting both pulmonary artery or pulmonary venous hypertension), primary pulmonary
disease and aortic abnormalities. When using X-ray, provider should already have high-suspicion
for specific diagnosis.
M-mode and 2-dimensional Echocardiography: Used in initial and serial evaluation of many
conditions. Provides measurements of left ventricular size, function and thickness. Left
ventricular segmental wall motion can be assessed, and the size of all four cardiac chambers can
be determined. The morphology of the heart valves can be examined. Hypertrophic
cardiomyopathy, pericardial effusion, mitral valve prolapse, valvular vegetations and cardiac
tumors may all be diagnosed.
Transesophageal echo: Provides information about posterior structures (especially atria and
atrioventricular valves) and prosthetic valves, and to monitor pts during surgery. It is superior to
surface echo in diagnosing left atrial thrombi, valvular vegetations and eccentric mitral
regurgitant jets (esp. with prosthetic valves). It is quite sensitive in detecting aortic dissection
and severe atherosclerosis of the ascending aorta.
Stress Echo: used to enhance the information available from ECGs and as an alternative to
nuclear medicine procedures. May be performed during/ after exercise. Transient depression of
segmental wall motion during or following stress suggests ischemia. Dobutamine infusions can
also be utilized in pts unable to exercise.
MRI: Currently available systems provide high-quality and high-resolution images of cardiac
and adjacent vascular structure, making this a preferred technique to evaluate many cardiac
conditions, including pericardial and congenital abnormalities. MRI also provides excellent
images that can be used to quantify cardiac function and structure. With the use of gadolinium
contrast agents, MRI has been used to assess myocardial perfusion and viability.
Cardiac catheterization and angiography:: These invasive procedures have been supplanted
by echocardiography for the initial and serial evaluation of many conditions, but remain
invaluable in the management of most pts with congenital, valvular and coronary disease. Risks
- pneumothorax, bleeding, arrhythmias, pulmonary artery rupture, PE, and infection. Role of this
procedure remains unsettled, evidence indicates that appropriate use of pulmonary artery
catheters to guide therapy may reduce morbidity. Right heart catheterization is convenient to
perform in the lab, bedside, or the OR. It allows measurement of right atrial, right ventricular,
pulmonary artery and pulmonary capillary wedge pressures, O2 saturation, and CO. These data
may diagnose intracardiac shunts, physiologically significant pericardial disease, and right-sided
valve lesions and can distinguish between pulmonary and cardiac disease.Menodynamic
monitoring may be very helpful in the assessment of treatment of shock, heart failure,
complicated MI, respiratory failure, and post-op hemodynamic instability. Left heart
catheterization is performed to assess the cardiac valves and left ventricular function (also
assessable by echo). The main indications for left heart cath. are for confirmation of the need for
valve surgery and for obtaining coronary angiograms. Increasingly, the catheterization lab is
used for performing coronary interventions.
Anonymous Note: this question seems like an easy one to answer – NOT!! I looked in several
books, but most of my answers came from Ravel chapter 21 and Goroll pgs 114&115 .
Chest X-ray
• Make sure it isn’t a lung problem!!
ECG
• First test to order on your chest pain patient
• Most useful direct test available in acute MI
o 50% of acute MIs show unequivocal ECG changes on first ECG
Cardiac Enzymes:
Creatine Kinase (CK)
• Useful in determining if patient had an MI
• Total CK drawbacks
o Relatively short time period after MI onset during the CK during which CK
enzyme is elevated
o False positive elevations due to skeletal muscle injuries (especially IM
injections)
CK-BB (CK-1)
• Found predominantly in brain and lung
CK MM (CK-3)
• Found predominantly in skeletal muscle
CK MB (CK-2)
• Predominantly found in cardiac muscle
• Level begins to rise 3-6 hours after onset of acute MI
• Peaks 12-24 hours
• Returns to normal in 24-48 hours (sometimes earlier)
• Rough correlation exists between size of infarct and degree of enzyme elevation
Troponin T
• Specific for myocardium
• Level begins to increase in 4-6 hours after onset of acute MI
• Peaks at approx 11 hours (10-24 hour range)
• Returns to normal in ten days or more
o Advantage over CK MB = stays elevated longer
Troponin I
• Specific for myocardium
• Elevates in 4-6 hrs after onset of acute MI
• Peaks at 11 hours
• Returns to normal in about 4 days
Radionuclide Heart Scan
• Scans for acute MI
• Agents localize in acutely damaged myocardium
• Scan not reliable less than 24 hours after onset of infarct
• Returns to normal by 6-7 days post-infarct
That was from Ravel . . . now let’s go to Goroll which is divided by probability of coronary heart
disease
Unstable Angina or PE . . . hospitalize immediately – do not stop to test them with any type of
test!!
At the ER . . .
• Resting ECG
o Look for S-T or T wave changes
If you have changes
• Proceed to coronary angiography
o More cost effective than stress testing in very high probability patients
If you have no changes
• Don’t discharge patient
• Observe X6 hours, then do a stress test
*always check cardiac enzymes too!!
Routine chest x-rays and ECG's are not recommended to screen for heard disease and have a
limited role in the follow-up of patients with known heart disease.
E) Color Doppler- shows patterns and directions of flow. Particularily useful in evaluating
congenital heart disease.
Doppler studies typically detect clinically insignificant valvular regurgitation so care should
be taken not to overinterpret these findings.
F) Transesophageal Echocardiography- this is superior to surface echocardiography in
looking at the posterior aspects of the heart. IT is often utilized during surgical procedures and is
quite sensitive at detecting aortic dissections.
H) MRI- currently this provides high resolution images of cardiac and adjacent vascular
structures, making this the preferred procedure to evaluate many cardiac conditions including
pericardial and congenital abnormalities.
I) Cardiac Catheterization & Angiography- the standard test for assessment of many
hemodynamic and anatomic abnormalities of the heart. This procedure is more invasive than the
others but remains invaluable in the management of most patients with congenital, valvular, and
coronary heart disease.
sublingual nitroglycerin: Sublingual nitro is the drug of choice; it acts in about 1-2 minutes.
Nitrates decrease arteriolar and venous tone, reduce preload and afterload, and lower the oxygen
demand of the heart. Repeated tablets may be placed every 3-5 minutes as needed. Sublingual
nitro can be taken prophylactically before activities likely to precipitate angina.
long-acting nitrates: A number of longer-acting nitrate preps are available. Depending on the
med, they are taken 2-4 times daily or as a transdermal patch to maintain nitro levels and
decrease episodes of angina. The main limitation to chronic nitro therapy is tolerance, which
occurs in most pts. Tolerance can be limited by utilizing a regimen of 8-10 hour period per day
without nitrates, usually overnight. Nitrate therapy is often limited by headache, nausea, light-
headedness andhypotension.
Aspirin: Coronary thrombosis is responsible for most episodes of myocardial infarction and
many unstable ischemic syndromes. Several studies have denonstrated the benefit of anti-
platelet drugs following unstable angina and infarction. Therefore, small doses of aspirin should
be prescribed for patients with angina.
risk factor modification: Pts with coronary disease should undergo aggressive risk factor
modification (decreasing BP, strenuous activity, cold temperature exposure and emotional
stress). This approach, with particular focus on lowering LDL cholesterol under 100mg/dL, not
only prevents future events but may markedly improve symptomatic angina.
Exercise: Information obtained from Up to Date Gradual institution of a regular aerobic exercise
program should be encouraged. Exercise can result in a lower oxygen requirement for a given
workload, thereby improving exercise tolerance and a sense of well-being, and reducing
symptoms. An exercise program is also beneficial in the management of risk factors for CHD
such as lipids, blood pressure, obesity, and diabetes mellitus.
Anonymous Goroll 195-201
• coronary angiography
o establishes degree of blockage (and location)
• coronary artery surgery
o revascularization of the heart
• angioplasty
• coronary artery bypass grafting (CABG)
• sublingual nitroglycerin
o provides short-term relief of anginal pain (up to 30 min)
o improvement of exercise tolerance when taken prophylactically
• long-acting nitrates
o more sustained nitrate activity than nitroglycerin
o better anginal prophylaxis
• beta blockers
o reduce the frequency of angina (especially exercise-induced)
o improves exercise tolerance
o prevention of sudden cardiac death
o prolongs survival post MI
• calcium channel blockers
o treatment of chronic stable angina
o reduce frequency of anginal episodes
o prolong exercise tolerance
o decrease need for nitroglycerin
• aspirin
o the only conventional platelet inhibitor proven to reduce cardiac risk
o prolongs survival in unstable angina
o reduces risk of MI in chronic stable angina
• risk factor modification
o reduction in these risk factors: hypercholesterolemia, HTN, DM, emotional stress,
and lack of exercise . . . all proven to reduce risk of heart disease
• exercise
o increase the strength of your heart!! Get in shape!!
Anonymous Goroll, pp. 196-204
coronary angiography: Dye is injected into the bloodstream or heart chamber, and x-rays are
taken of the heart and large blood vessels in the chest. (Lang. of Med., p. 370) Percutaneous
transluminal angioplasty (PTCA) is an alternative to surgical revascularization for patients who
remain unacceptable symptomatic yet do not have high-risk disease. PCTA involves passing a
balloon catheter into a stenosed vessel and inflating the balloon at the site of the narrowing to
widen the lumen. This procedure requires coronary angiography and surgical standby d/t risk of
sudden vessel occlusion and infarction.
coronary artery surgery: Surgical revascularization is the treatment of choice in persons with
high-risk disease. It not only improves symptoms and functional status but prolongs survival and
reduces risk of infarction. coronary artery bypass graft surgery (CABG) is superior to medical
therapy for prevention of infarction and prolongation of survival in stable high-risk anginal
patients, especially if accompanied by LV dysfunction. (High-risk patient: moderate to severe
angina; large amount of myocardium at risk; three-vessel, left-main, or left-main equivalent
disease; and reduced ejection fraction.) Patients at less risk who continue to be limited by their
angina despite a full medical regimen and aggressive Tx of risk factors are reasonable candidates
for revascularization. CABG is preferential Tx for diabetics and those who don’t want/can’t
tolerate repeat surgeries.
sublingual nitroglycerin: (TNG) provides short-term relief of anginal pain (30 minutes) and
improvement in exercise tolerance when taken prophylactically. Onset of action: 30 seconds – 3
minutes. TNG must be taken sublingually d/t denitrified & hepatic inactivation on first pass.
long-acting nitrates: (isosorbide dinitrate) provides sustained nitrate activity for good anginal
prophylaxis. Onset of action: 15-30 minutes. Duration of action: up to 4 hours. tid dosing with 8
hours off to minimize risk of nitrate tolerance. (isosorbide mononitrate) more convenient control
of chronic stable angina. Duration of action: 12 hours. Cost: 10x more than dinitrate. (also
ointment and patches).
beta blockers: reduce frequency of angina (especially exercise induced) and increases exercise
tolerance. Proven to prevent sudden cardiac death and prolong survival in patients surviving MI.
In patients with stable coronary dz, they reduce the frequency of silent ischemia and other
coronary events. Their benefits are attributed to their lowering of myocardial oxygen
consumption – they reduce contractility, blood pressure, and heart rate – and they raise the
ventricular fibrillatory threshold. Slowing the HR allows more time for myocardial perfusion
during diastole.
calcium channel blockers: They reduce frequency of anginal episodes, prolong exercise
tolerance, and decrease the need for nitroglycerin. They are especially useful in persons with
coronary vasospasm. Symptomatic benefits only – have not demonstrated any reduction in rates
of MI, need for revascularization, cardiac sudden death, or overall mortality. Shorter acting
preparations may increase risk of MI and cariac death especially in the setting of LV failure.
Currently, their use should be limited to patients who cannot tolerate beta-blockers, or if beta-
blockers & nitrates fail to achieve adequate control of symptoms.
aspirin: only conventional platelet inhibitor that reduces cardiac risk. ASA prolongs survival in
patients with unstable angina and reduces the risk of MI in persons with chronic stable angina.
risk factor modification: (hypercholesterolemia, HTN, smoking, DM, sedentary lifestyle, &
emotional stress) Patients with coronary Dz have 5 times the risk of coronary event. Secondary
preventive efforts can improve quality of life, reduce risk of coronary events, obviate the need
for revascularization, and prolong survival.
exercise: can significantly improve functional status and directly and indirectly improve skeletal
muscle efficiency, decrease heart rate & blood pressure, and enhances moral well-being.
Anonymous Currents p 340-350
A) Coronary Angiography- this is a definitive diagnostic procedure for coronary artery
disease. This is an invasive and expensive procedure and should not be performed solely for
diagnosis. This images the lumen of the vessel only, so it may underestimate atherosclerosis
since it is not specific for vessel wall thickening and cannot determine the amount of wall
reorganization due to atherosclerosis.
B) Coronary Artery Surgery- patients may be subject for revascularization surgery if they
have advanced angina that is not susceptible to pharmacologic therapies. These patients often
have severe enough angina that exercise is not possible due to its propensity to initiate an attack
of the angina. The degree of vessel involvement and severity are weighed prior to initiating a
revascularization procedure.
C) Sublingual Nitroglycerin- this is a fast acting agent that decrease arteriolar and venous tone
utilized in the treatment of an acute attack. This action reduces preload, afterload, and oxygen
demands of the heart. This can be used prophylactically prior to activities known to cause
angina as well.
D) Long-acting Nitrates- these deliver nitroglycerin at a predetermined rate over long periods
of time for prevention of attacks of angina in patients with more advanced CAD. This is a longer
acting nitrate and has some problems with tolerance.
F) Calcium Channel Blockers- these drugs prevent angina by reducing myocardial oxygen
demands by inducing coronary artery dilation. Myocardial oxygen demand is lessened by
reducing the blood pressure and the left ventricular stress.
G) Aspirin- this is an agent that helps many ischemic events by inhibiting platelet aggregation
making the blood less viscous. This allows the blood to flow more freely and with less
resistance through coronary arteries that are partially occluded or narrowed.
H) Risk Factor Modification- this has an aggressive approach at lowering LDL cholesterol
below 100. Patients have been shown to have fewer subsequent ischemic events with this lipid
lowering therapy. This is accomplished with medication as well as diet modification.
I) Exercise- this conditions the heart and cardiovascular system as well as increasing muscle
tone which increases the venous return to the heart inadvertently reducing the venous pooling
and back pressure that increased the force required of the heart to move blood through the
vasculature.
Pleuritic chest pain = pain due to acute pleural inflammation is caused by irritation of the
parietal pleura. Pain is localized, sharp and fleeting and is made worse by cough, sneezing, deep
breathing or movement.
Uncommon:
Tension Pneumothorax Herpes Zoster
Cardiac Tamponade Cervical/ thoracic radicular pain
Esophageal Rupture
Anonymous Goroll, 109
Cardiac
○ CAD presenting as angina pectoris
○ MI
○ Variant or atypical angina
○ Mitral valve prolapse (presents as “atypical chest pain”)
○ Pericarditis (can also present as pleuritic)
Aortic
o Dissecting aortic aneurysm
Esophagus
o Acid reflux
o Motor dysphagia
Other GI sources
○ Cholecystitis
○ Pancreatitis
○ Peptic ulcer disease
Psyche
○ Anxiety, depression, etc.
Noncardiac chest pain of unknown etiology . . . when all else fails!!
Anonymous Noble pg
Angina Pectoris—caused by impaired myocardial blood supply from coronary artery Dz
including aortic stenosis.
Hallmarks sudden onset with exertion, emotional stress or eating a large meal and its relief in
minutes by rest or nitro Pain described as squeezing, heaviness or pressure, it may be burning or
sharp. Radiation to the neck back, jaw shoulder abdomen or arm are common and may present
in the absence of chest symptoms. The arm is reported to feel numb or tingling. Also
diaphoresis and nausea, and dyspnea.
Aortic dissection—a must not miss cause of severe chest pain or interscapular pain, maximal
from the start and tearing or ripping in quality. It begins in the chest and may radiate to the
interscapular region, neck, jaw, lower back, or even down into the legs. Symptoms include
neurological deficits from cutoff of blood supply to the brain, spinal cord, or limb. Loss or
diminution of a major peripheral pulse is a key finding, also new onset of aortic insufficiency
and pericardial tamponade due to dissection into the aortic root.
Esophageal pain—mimickes anginal chest pain. Persists as a dull sensation for several hours
after an acute attack and may occur with swallowing. Sometimes radiates to the interscapular
region. Pain can occur spontaneously or in the context of meals or acid reflux. Some report
dysphagia.
Other GI tract Sources—acute cholecystitis may resemble angina by producing substernal
chest pain that responds to nitrates which reduce cystic duct spasm. Pancreatitis or peptic ulcer
disease as well as gaseous distention of the bowel in the area of the splenic flexure can cause
precordial discomfort.
Psyche—people with anxiety or depression often describe feelings of chest heaviness or
tightness that can last for hours to days with unrelated exertion and unrelieved by rest. They may
complain of the inability to take a deep breath. Hyperventilation causes hypocapnia resulting in
light-headedness and tingling extremities. Cardiac neurosis—may lead to reports of chest pain
mimicking angina. Also lookout for personality disorder and malingering.
Anonymous Goroll p 111
A) Musculoskeletal Disorders- muscle strain
B) Skeletal Disorders- rib fracture
C) Neurologic Disorders- herpes zoster/ nerve root compression
D) Pericarditis
E) Myocardial Ischemia
F) Prolapsed Mitral Valve
G) Disecting Aortic Aneurysm
H) Esophageal Disorders- reflux or spasm
I) Other GI Disorders- PUD, Pancreatitis, Functional Motility Disorders, Cholecystitis
J) Psychogenic- anxiety/panic disorders, depression
11. Differentiate between patient presentation and common important causes of
acute pleuritic chest pain.
Zen Seeker
PLEURITIC CHEST PAIN -
implies that the pain varies with the respiratory cycle and is frequently exacerbated during
inspiration and coughing. Pleuritic chest pain is typically sharp and unilateral
Pleural Effusion
-transudates- increased capillary fluid production due to increased hydrostatic or
decreased oncotic pressure.
-exudates- increased fluid production due to abnormal capillary permeability.
Decreased lymphatic clearance of fluid from the pleural space.
-emphyema- infection in the pleural space.
-hemothorax- bleeding into pleural space.
-pleuritic pain worsened by turning, but relieved by sitting up and leaning forward is
indicative of pericarditis.
1. Explain the role and limitations of the following enzymes in making the
diagnosis of acute myocardial infarction, including recognition of their initial
and peak elevation times.
LDH Dropped 2004
CK and CK-MB
Troponin-I & T
Megan Mosby 308
LDH: This intracellular enzyme (lactose dehydrogenase) is found in the cells of many body
tissues, especially the heart, liver, RBC’s, kidneys, skeletal muscle and lungs. Because it is
widely distributed the total LDH is not a specific indicator of any one disease or indicative of
injury to any one organ. Five separate fractions, isoenzymes, make up the total LDH. Each
tissue contains a predominance of one or more LDH enzymes. In general isoenzyme LDH-1
comes mainly from the heart. Isolated elevation of LDH-1 above LDH-2 indicates myocardial
injury. With myocardial injury the serum LDH level rises within 24-48 hours after MI, peaks in
2-3 days and returns to normal in approximately 5-10 days. This makes the serum LDH level
especially useful for a delayed diagnosis of MI. (e.g. When a patient complains of having chest
pain 4 days earlier) LDH-1 may become obscured if the patient has other existing problems, e.g.
pulmonary infarction or CHF.
Because of their high specificity for myocardial cell injury, cardiac troponins are very useful in
the evaluation of patients with chest pain, their use is similar to CPK-MB, except that troponins
are more specific. They become elevated sooner and remain elevated longer than CPK-MB.
Cardiac troponins become elevated as early as 3 hrs after MI, and troponin T may remain n
elevated for 7-10 days after MI, and troponin I may remain elevated 10-14 days. However, if
reinfarction is considered, troponins are not helpful because they could be elevated from the first
ischemic event.
CK & CK-MB: Creatine kinase (CK) is found in heart muscle, skeletal muscle, and brain. It is
elevated at some time in about 90%-93% (literature range, 65%-100%) of patients with acute MI.
In acute MI, CK behaves similarly to AST. In addition, elevations have also been reported in
myocarditis and also in some patients with tachyarrhythmias (mostly ventricular) for unknown
reasons. Acute liver cell damage, which frequently causes an abnormal AST value, has no effect
on CK. This is an advantage, since the situation often arises in which an elevated AST (or LDH)
level might be due to severe hepatic passive congestion from heart failure rather than from acute
MI. . A considerable number of conditions associated with acute muscle injury or severe muscle
exertion affect CK values. Thus, CK values are usually elevated in muscle trauma, myositis,
muscular dystrophy, after surgery, postpartum, after moderately severe exercise (e.g., long-
distance running), and in delirium tremens or convulsions. Increased serum values have been
reported in about 80% of patients with hypothyroidism (literature range, 20%-100%) and in
patients with severe hypokalemia, due to changes induced in skeletal muscle. CK elevation can
be due to effects of alcohol on muscle. For example, one study found that CK levels became
abnormal after 24-48 hours in the majority of persons following heavy drinking episodes as well
as in most patients with delirium tremens. Levels of CK are said to be normal in chronic
alcoholics without heavy intake. The major drawbacks of total CK are (1) the relatively short
time period after onset of infarction during which the CK value is elevated and (2) false positive
elevations due to skeletal muscle injury (especially intramuscular injections).
CK-MB (CK-2), found predominantly in cardiac muscle – The CK-MB level begins to rise
3-6 hours after onset of acute MI, reaches a peak in 12-24 hours, and returns to normal in 24-
48 hours (sometimes earlier). There is a rough correlation between the size of the infarct and the
degree of elevation. Since small infarcts may not elevate the MB fraction dramatically, it is
important to time the collection of specimens so as not to miss the peak values. Some
recommend five specimens: one immediately, then at 6, 12, 18, and 24 hours afterward. Others
use 4 specimens: one immediately, then at 8, 16, and 24 hours or at 6, 12, and 18 hours. Some
use 3 specimens: immediately, 12 hours, and 24 hours. Some laboratories do not perform CK-
MB assay unless the total CK value is elevated. However, reports indicate that about 10% of
acute MI patients (literature range 0%-16%) demonstrate elevated CK-MB levels with the total
CK value remaining within reference range limits.
Troponin I & T (also refer to the “Improved Laboratory Diagnosis” article in your syllabus)
Troponin-I is a regulatory protein in the troponin cardiac muscle complex. This protein, like
troponin-T, is specific for myocardium. The troponin-I level becomes elevated after onset of
acute MI in about 4-6 hours (range, 3-19 hours), peaks at about 11 hours (range, 10-24
hours), and returns to reference range in about 4 days (range, 3.5-6 days). Therefore, troponin-
I behaves much like troponin-T, except that return to reference range is faster. Response to acute
MI is also somewhat similar to CK-MB. However, troponin-I may become elevated a little
sooner than CK-MB in the first 4 hours after onset of acute MI (in one study, troponin-I was
elevated at or before the fourth hour in 44% of MI patients, whereas when using CK-MB only
17% had elevated levels). Troponin-T is a regulatory protein located in skeletal and cardiac
muscle fibers. Skeletal muscle and myocardium have different forms of this protein, so that the
antibody that detects cardiac troponin-T in serum is a specific test for myocardial fiber injury.
After onset of acute MI, the troponin-T level begins to increase in about 4-6 hours, peaks at
about 11 hours (range, 10-24 hours), and returns to reference range in 10 days or more.
Therefore, Troponin-T behaves like CK-MB but remains elevated much longer.
Anonymous
Role Limitations Initial
Onset/Peak
Times
LDH elevated in 92-95% -found in many organs 24hrs / 3 days
(total) of acute MIs -elevated under many conditions;
-affected by hemolysis
CK (total) elevated in 90-93% -affected by trauma or hypoxia of 4-6hrs / 24hrs
of acute Mis skeletal muscle;
B) Creatine Phosphokinase (CPK)- this is an enzyme found in the heart muscle, skeletal
muscle and the brain. Serum levels of this enzyme become elevated when there is injury to these
cells. Levels can rise within 6 hours after damage and levels peak at about 18 hours after injury
and will return to normal levels within 2-3 days.
1. CPK-MB- this is an isozyme of this family specific for myocardial cells. The levels
rise within 3-6 hours after infarction and if there is no continuing damage occurring, the level
will peak within 12-24 hours and will return to normal 12-48 hours after infarction. This is
useful in quantifying the degree of myocardial infarction and timing of the onset of infarction.
Pagana p 190-191
C) Troponins- these are proteins that exist in skeletal and cardiac muscle that regulate the
calcium-dependant interaction of myosin with actin for the muscle contractile apparatus. There
are two cardiac specific troponins; Troponin T and Troponin I. Cardiac troponins are more
specific to myocardial muscle infarction than is CPK-MB, and they will always be normal in
noncardiac muscle disorders.
1. Troponin T- May become elevated within 3 hours after infarction and may remain
elevated for 7-10 days
2. Troponin I- May become elevated within 3 hours after infarction and may remain
elevated for 10-14 days
Pagana p 465
2. Describe the basic pathologic mechanisms which may result in heart failure
and list one or two common examples of each.
Jennyb Noble 581
Ventricular dilatation occurs with chronic volume overload, and ventricular hypertrophy occurs
with chronic pressure overload
Anonymous Noble, 584, table 65-3
Contractile dysfunction
• ischemic heart disease
• dilated cardiomyopathy
pressure overload
• HTN
• Aortic stenosis
• Aortic coarctation
Volume overload
• Aortic regurgitation
• Mitral regurgitation
Impaired Filling
• Valvular dysfunction
○ Mitral stenosis
○ Tricuspid stenosis
• Diastolic dysfunction
○ Hypertrophic cardiomyopathy
○ Amyloidosis
○ Constrictive pericarditis
Increased demand
• Anemia
• Thyrotoxicosis
• Thiamine deficiency
• Paget’s disease
Anonymous Gorroll, pg 182-183
The “congestive” manifestations of CHF—leg edema, orthopnea, paroxysmal nocturnal dyspnea
(PND), rales, jugular venous distention—represent elevations in right or left ventricular filling
pressures. Traditionally, filling pressure elevations have been viewed as a consequence of
systolic dysfunction producing a backup of blood into the pulmonary and systemic venous
systems. The hallmark of systolic dysfunction is a reduced ejection fraction.
However, 40% of patients presenting with CHF appear to have reasonably well-preserved
systolic function but suffer from diastolic dysfunction, manifested by increased resistance to
diastolic ventricular filling—i.e. valvular heart disease, hypertrophic, ischemic and
cardiomyopathic diseases.
An initial fall in CO in a CHF patient activates renin-angiotensin production and sympathetic
discharge, which temporarily help preserve CO, but at the cost of an increase in preload and
afterload. Eventually, the resultant venous htn and increased left ventricular work affect the
failing heart, which cannot tolerate such increases in work, and CO drops. Normal hearts
respond to increased venous return via the Frank-Starling mechanism to increase cardiac output,
but not the failing heart. The result is increased pulmonary and systemic htn and no
improvement in CO.
Right-sided heart failure is easier to document than left-sided. It is defined as a right atrial
pressure greater than 6cm H2O, manifested as a vertical distance from the level of the right
atrium to the top of the jugular venous column that is greater than 6cm. Ankle edema and JVD
may (but not necessarily) indicate CHF. A hx of orthopnea and PND are suggestive of left-sided
heart failure, as are basilar rales on pulmonary exam. The finding of an S3 is among the more
specific of signs for systolic dysfunction, but is hard to appreciate. Other findings: CXR—
prominent interstitial markings, upper zone redistribution, cardiomegaly, perihilar haziness,
Kerley “B” lines. Left atrial enlargement by ECG criteria in conjunction wth cardiomegaly by
CXR also have diagnostic value. Echo to determine LV function.
Anonymous Currents p 380
A) Systolic function of the heart is governed by four major determinants; the contractile state of
the myocardium, the preload of the ventricle, the afterload of the ventricle, and the heart rate.
Dysfunction in any of these four areas can result in heart failure.
1. Contractility- contractility can be decreased as a result of loss of functional muscle
due to infarction or by any process that diffusely affects the myocardial muscle.
2. Preload- if the preload is excessively elevated the heart will stretch too far and not be
able to contract adequately as the muscle fibers lose association. This can result from valvular
regurgitation.
3. Afterload- If the afterload is excessive, again the ventricles stretch too far as they are
filled and the muscle fibers lose association reducing the contraction. This can result from
valvular stenosis or severe systemic hypertension.
4. Heart Rate- pump function can be affected if the heart rate is too slow or too fast.
The normal heart can tolerate wide variations in preload, afterload, and heart rate but the
diseased heart lacks the reserves for such alterations.
B) Afterload- This refers to the ventricular wall stress during systole or the force that the
ventricle must overcome to eject its contents. According to Laplace's Law, systolic wall stress is
directly proportional to ventricular pressure and chamber radius and inversely proportional to
ventricular wall thickness. When left ventricular afterload is increased due to aortic vavlular
stenosis or systemic hypertension the ventricle cannot keep up and upon failing as a pump the
systemic circulation becomes more static and peripheral edema results.
D) Ejection fraction- This is the fraction of the end-diastolic volume that is ejected into
circulation with a ventricular contraction. If the pump begins to fail the ejection fraction will
decline.
E) Cardiac output- This is termed the amount of blood the heart is able to pump each minute
and is equal to the stroke volume multiplied by the heart rate. As the heart begins to fail the
amount of blood being pumped each minute begins to decline.
F) Stroke Volume- This is the volume of blood that is pumped out by the heart with each beat.
If the stroke volume of either ventricle is reduced the volume and pressure within that ventricle
will increase or the afterload will increase. This results in a stretched ventricle and a more
vigorous contraction according to Starling's Law. If this situation is chronic ventricular dilation
will occur to restore the resting cardiac output however the chronic elevation of diastolic
pressures will be transmitted to the atria, pulmonary and systemic venous systems ultimately
increasing their pressure and resulting in pulmonary and systemic edema.
5. Distinguish between the following forms of heart failure, and give examples
of each.
acute vs. chronic heart failure
left-sided vs. right-sided heart failure
low-output vs. high-output heart failure
Jennyb Noble 583
Acute heart failure is due to sudden reduction in cardiac output with poor organ perfusion and/or
marked pulmonary congestion. i.e. acute MI. Chronic is caused by a reduction in cardiac output
that occurs gradually and compensatory mechanisms take place. i.e. CHF and the renin
angiotensin system,
Left heart failure causes pulmonary congestion which increases pulmonary pressures which leads
to pulmonary hypertension and subsequent right heart failure. Right heart failure is often
associated with generalized fluid accumulation.
Low output heart failure results when the heart is at rest or mildly exercised. ( the heart is taxed
with minimal effort) this is the most common type of failure (CHF)
High output results when the heart is unable to meet high metabolic demands of the body this is
less common and examples are anemia or Paget’s disease.
Anonymous Table 65-2, p. 583 Noble
Acute vs. Chronic:
2. Feature 3. Acute heart failure 4. Chronic heart failure
Symptom severity Marked Mild to moderate
Pulmonary edema Frequent Infrequent
Peripheral edema Rare Frequent
Total body fluid No change or mild increase Increased
Cardiomegaly Uncommon Common
Sympathetic activation Marked Mild to marked
Repairable lesion Common Occasional
• In Acute Heart Failure, symptoms are due to the sudden reduction in cardiac output
with poor organ perfusion and/or marked pulmonary congestion. Examples include
acute myocardial infarction, sustained tacky arrhythmia, and valve rupture due to
infective endocarditis.
• In Chronic Heart Failure-the clinical manifestations of heart failure depend on the rate
at which the syndrome develops, and specifically on whether enough time has elapsed for
compensatory mechanisms to become operative and interstitial fluid to accumulate.
• When the reduction in cardiac output occurs gradually (e.g. due to chronic valvular
regurgitation or remodeling post myocardial infarction), compensatory mechanisms
become operative and allow the patient to tolerate hemodynamic abnormalities with few
or no signs and symptoms. However, an intercurrent event such as infection, myocardial
ischemia, or medication noncompliance may precipitate manifestations of acute heart
failure.
Physician-Related Factors
Use of medications that cause salt and water retention (e.g., nonsteroidal antiinflammatory
agents)
Use of negative inotropic agents (e.g., calcium channel blockers)
Physical Examination
The physical signs of left-sided heart failure relate to pulmonary venous
congestion, whereas signs of right-sided heart failure relate to systemic venous
congestion. In the discussion that follows, physical signs are presented in the order in
which they are typically assessed. Rigorous criteria for identifying heart failure based on
both the clinical history and physical findings were developed for the Framingham Study
( Box 65-4 ). However, heart failure may not be recognized in up to 40% of patients due
to the limited reliability of these findings.[14]
General Appearance.
Patients with compensated chronic heart failure often appear well nourished and
comfortable at rest. Even patients with moderate heart failure may appear to be in no
distress after resting for several minutes, but become dyspneic during or immediately
after activity. By contrast, patients with decompensated heart failure may appear anxious,
dusky, and diaphoretic, and are often dyspneic at rest or on lying down. Other findings
suggestive of severe heart failure include cool extremities and peripheral cyanosis
resulting from low cardiac output and systemic vasoconstriction. As noted, chronic
biventricular failure can result in cardiac cachexia. In severe right heart failure, hepatic
congestion can cause scleral icterus and jaundice. Patients with recent onset of heart
failure often appear acutely ill but are usually well nourished.
Vital Signs.
Resting sinus tachycardia is common, and is due to increased adrenergic tone. In
mild heart failure, the heart rate at rest may be normal, but increases excessively with
exercise and is slow to normalize with rest. The pulse may be irregular if atrial fibrillation
is present or in the presence of frequent premature ventricular complexes. In severe LV
failure, the peripheral pulse may be alternatingly strong and weak and is referred to as
pulsus alternans. Pulsus alternans is attributed to reduced LV contraction in every other
cardiac cycle due to incomplete recovery causing alternation in the LV stroke volume.
Rarely, weaker beats may fail to open the aortic valve, resulting in an apparent halving of
the pulse rate, a condition termed total alternans.
Tachypnea may be present in patients with severe LV failure and dyspnea at rest,
or secondary to pleural effusions or ascites in patients with right heart failure. The
respiratory rate may be normal in the sitting position, but increase in the patient with
pulmonary venous congestion on lying down. Advanced heart failure may be associated
with Cheyne-Stokes respiration, also called periodic breathing. Cheyne-Stokes respiration
consists of periods of hyperpnea alternating with apnea, and is probably caused by
prolonged circulation time from the heart to the brain, which affects the normal
regulation of breathing. In addition, there is diminished sensitivity of the respiratory
center to the arterial carbon dioxide pressure, which waxes and wanes during periods of
hyperpnea and apnea. The fall in oxygen pressure and rise in carbon dioxide pressure
during the apneic phase stimulate the respiratory center and result in hyperpnea, and the
cycle continues. Cheyne-Stokes respiration is common among elderly patients with LV
failure in whom the presence of cerebral arteriosclerosis and use of hypnotics may be
contributory. The patient is usually unaware of the altered breathing pattern, but other
family members may notice it and become alarmed. Cheyne-Stokes respiration may
contribute to daytime somnolence in patients who are awakened frequently during
periods of hyperpnea.
The systolic blood pressure may be elevated in diastolic heart failure due to
chronic hypertension, normal in compensated systolic heart failure, or low in advanced
heart failure. Diastolic blood pressure may be slightly elevated due to increased
adrenergic activity. A significant reduction in cardiac output is reflected by a narrow
pulse pressure, which is defined as the difference between the systolic and diastolic blood
pressures. For example, when the pulse pressure is less than 25% of the systolic pressure,
the cardiac index is generally less than 2.2 L/min/m2 . When the volume status is unclear
in a patient with dyspnea, a bedside Valsalva's maneuver may be used to detect elevated
left ventricular filling pressures.
A low-grade fever resulting from cutaneous vasoconstriction may occur in severe
heart failure, and subside when compensation is restored. Temperatures greater than
101°F should suggest infection.
Jugular Venous Pulse.
Elevation of the jugular venous pressure is a hallmark of elevated systemic
venous pressure. The upper limit of normal is approximately 4 cm above the sternal angle
when the patient is examined at a 45-degree angle, corresponding to a right atrial pressure
of less than 10 cm of water. Higher levels of venous pressure, approaching the angle of
the jaw, are common in right sided failure. When tricuspid regurgitation is present, the
descending limb of the a wave is attenuated, and the height of the v wave increases with a
rapid y descent. Rarely, venous pressure is so high that veins under the tongue or on the
dorsum of the hand are dilated. Kussmaul's sign is present when jugular venous pressure
increases with inspiration.
In patients with mild right heart failure, jugular venous pressure may be normal at
rest but increase with compression of the right upper quadrant. Hepatojugular reflux may
be elicited by gently applying firm, continuous pressure over the liver for up to 1 minute
while observing the neck veins. The patient must breathe normally and not strain during
this maneuver. Normally, abdominal or hepatic compression leads to a transient increase
in jugular venous pressure. In heart failure, the abnormal right ventricle is unable to
accept an increase in venous return and jugular venous pressure remains elevated. In
biventricular failure, elevated jugular venous pressure at rest or after hepatic or
abdominal compression is a moderately sensitive and highly specific marker of increased
pulmonary capillary wedge pressure.
Examination of the Heart
Precordial Palpation.
Chronic heart failure is accompanied by cardiac enlargement. Commonly, the
apical impulse is displaced downward and to the left, and may be either diffuse (in dilated
cardiomyopathy) or sustained (in pressure-overloaded states such as aortic stenosis). In
biventricular heart failure or severe right-sided heart failure, a right ventricular impulse
may be palpated along the lower sternal edge. A palpable third heart sound may also be
present. In acute heart failure or heart failure secondary to constrictive pericarditis or
restrictive cardiomyopathy, cardiac enlargement is usually not present.
Auscultation.
Although the presence of a third heart sound is common in healthy children and
young adults, in adults over age 40, an S3 gallop generally implies ventricular
dysfunction. In patients with mitral or tricuspid regurgitation or left-to-right shunts,
excessive flow into the ventricles can also cause a third heart sound without ventricular
dysfunction. In heart failure, the presence of a third heart sound is probably related to a
sudden deceleration of ventricular inflow that takes place after the early filling phase.
Abnormal compliance or diastolic dysfunction may also contribute to a gallop rhythm.
Ventricular remodeling in heart failure may lead to incompetence of the
atrioventricular (AV) valves. Thus holosystolic murmurs of mitral or tricuspid
regurgitation may be present in the absence of structural valvular abnormalities,
especially in advanced heart failure. These murmurs typically decrease in intensity or
disappear after successful treatment of decompensation. In biventricular failure or
isolated right heart failure, pulmonary hypertension is reflected in a loud pulmonary
component of the second heart sound.
Examination of the Lungs.
Rales result from the transudation of fluid into the alveoli and airways. In general,
rales are heard at the lung bases; but in severe heart failure, they may be heard throughout
the lung fields. Wheezing and rhonchi can occur with congestion of the bronchial
mucosa, and can lead to the misdiagnosis of reactive airways disease. In biventricular
failure, bilateral pleural effusions can occur, and are recognized as dullness to percussion
and decreased breath sounds at the bases. When rales or pleural effusion is limited to one
side, the right side of the chest is typically involved. Importantly, the absence of
pulmonary rales does not exclude significant elevation of the pulmonary capillary wedge
pressure in patients with chronic LV systolic failure.
Examination of the Abdomen and Extremities.
Hepatomegaly is an early sign of systemic venous congestion. In the early stages
of right heart failure, the liver may be tender due to stretching of its capsule, but with
progression of disease, tenderness may disappear. In patients with tricuspid regurgitation,
the liver may be pulsatile due to transmission of the v wave. Longstanding hepatic
congestion may lead to cardiac cirrhosis with portal hypertension and congestive
splenomegaly. Ascites results from increased pressure in the hepatic veins and the veins
draining the peritoneum. In most patients with heart failure, ascites is minimal. With
massive ascites, the physician should suspect constrictive pericarditis or primary liver
failure.
Dependent lower extremity edema is common in biventricular or isolated right
heart failure, and is typically symmetrical and pitting. In chronic heart failure, the amount
of edema does not correlate well with systemic venous pressure; in acute heart failure,
edema may be absent despite marked systemic venous hypertension. With advanced heart
failure, edema may become massive and generalized (anasarca). Chronic edema of the
distal lower extremities may cause reddening and induration of the skin.
Major Criteria
Paroxysmal nocturnal dyspnea
Neck vein distention
Rales
Radiographic cardiomegaly
Acute pulmonary edema
S3 gallop
Increased central venous pressure
Circulation time >25 sec
Hepatojugular reflux
Visceral congestion or cardiomegaly at autopsy
Weight loss >4.5 kg in 5 days in response to treatment
Minor Criteria
Bilateral ankle edema
Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Decrease in vital capacity by 1/3 from maximum value recorded
Tachycardia (rate >120/min)
Anonymous Goroll pg 216, Nobel pg 586.
Regardless of etiology, the clinical manifestations of CHF or quite stereotype and reflect the
magnitude of the fall in cardiac output and the rise in pulmonary and systemic venous pressures.
Initially and in mild cases, the patient may complain of fatigue, dyspnea on exertion, or
unexplained weight gain. There may be few overt physical signs of failure, and chest x-ray often
shows redistribution of pulmonary venous flow to upper lung fields and/or cardiomegaly.
Fatigue becomes increasingly prominent as cardiac output falls. As pulmonary congestion
increases, dyspnea worsens, orthopnea is noted, and paroxysmal nocturnal dyspnea may be
reported. At this stage, rales become evident on auscultation of the lungs, but their absence does
not well the presence of CHF. Sometimes failure-induced bronchospasm dominates the
pulmonary examination. In severe cases, chest film will show interstitial pulmonary edema. In
chronic CHF, right-sided or bilateral pleural effusions are common. Ankle edema, jugular
venous distention, and hepatojugular reflex are indicative of elevated systemic venous pressure;
if CHF is predominantly left-sided, these findings may not be present. An S3 gallop is among the
most specific physical signs of failure, but is often difficult to hear. If left ventricular dilation
becomes very marked, the mitral regurgitation murmur may become evident. Pedal edema is one
of the lease specific signs of CHF; in the elderly, isolated to you edema is more likely to be result
of venous insufficiency.
8. Review, discuss and explain the role of each of the following laboratory
studies and diagnostic procedures in CHF.
CBC
electrolyte levels
BUN and creatinine levels
liver function tests Dropped 2004
arterial blood gases
EKG
chest X-ray
echocardiography
radionuclide angiography
cardiac catheterization
Zen Seeker Noble 587- http://home.mdconsult.com/das/book/body/0/959/445.html#top
CBC
Anemia is not diagnostic of heart failure, but when present may exacerbate underlying ischemic
heart disease and should be corrected. Rarely, severe anemia may cause high-output failure. The
erythrocyte sedimentation rate often decreases in heart failure because of impaired fibrinogen
synthesis and decreased fibrinogen concentration. A marked increase in sedimentation rate may
suggest infective endocarditis.
electrolyte levels
Dilutional hyponatremia is common in severe heart failure and is the result of prolonged sodium
restriction, diuretic therapy, and expansion of extracellular volume. Increased vasopressin levels
may also contribute to hyponatremia. Hyponatremia is a negative prognostic indicator at the time
of hospital admission for heart failure, and predicts decreased long-term survival.
Hypokalemia is most often due to thiazide or loop diuretics given without oral potassium
supplementation, but may also result from increased aldosterone levels due to activation of the
renin-angiotensin system. If uncorrected, hypokalemia may lead to ventricular arrhythmias,
especially in the presence of digoxin. Hyperkalemia may result from marked reductions in
glomerular filtration rate and inadequate delivery of sodium to the distal renal tubule. Excess
total body potassium may be exacerbated by the use of potassium-sparing diuretics or
angiotensin-converting enzyme inhibitors, and in particular, their concurrent use. During
hospitalization for heart failure, hyperkalemia is a common cause of iatrogenic morbidity, and
even mortality. Other electrolyte abnormalities seen in heart failure include hypophosphatemia
and hypomagnesemia, both of which are commonly associated with chronic alcohol use.
EKG
No specific electrocardiographic pattern is diagnostic of heart failure. However, the ECG may
provide important information regarding the nature of the underlying cardiac disease. For
example, LVH and left atrial enlargement suggest left heart failure resulting from antecedent
hypertension or aortic stenosis. Pathologic Q waves in ischemic heart disease indicate the
presence and location of myocardial infarction, while nonpathologic Q waves (pseudoinfarction)
may be seen with restrictive or dilated cardiomyopathy. Abnormal cardiac rhythms such as atrial
fibrillation may be secondary to heart failure or may represent inadequacy of therapy if the
ventricular response is uncontrolled. If present, ventricular ectopic activity may indicate
increased risk of sudden cardiac death, or reflect digoxin toxicity or electrolyte imbalance (e.g.,
hypokalemia).
chest X-ray
The size and shape of the cardiac silhouette provide important information regarding the nature
of the underlying heart disease. A cardiothoracic ratio greater than 0.5, for example, is a good
indicator of increased LV volume. The other major radiographic abnormality associated with left
heart failure is pulmonary venous congestion. The degree of pulmonary venous congestion often
parallels increases in the pulmonary capillary wedge pressure. Early radiologic signs of
pulmonary venous hypertension and interstitial edema include distention of the pulmonary veins
extending upward from the hila, haziness of hilar shadows, and thickening of interlobular septa
(Kerley's B lines). When the pulmonary capillary wedge pressure is moderate to severely
elevated, often greater than 25 mm Hg, alveolar edema is present as diffuse haziness extending
downward toward the lower portions of the lung fields (so-called butterfly pattern). In patients
with chronic LV failure, higher pressures can be accommodated with fewer radiologic signs due
to enhanced lymphatic drainage. Pleural effusions of varying size and distribution are common in
biventricular failure.
echocardiography
Echocardiography is commonly performed in the evaluation and management of heart failure.
Two-dimensional echocardiographic imaging provides an accurate and rapid determination of
ventricular size and function, and valvular morphology and function, and can detect intracavitary
thrombi and pericardial effusions. Important hemodynamic data including cardiac output,
pulmonary artery pressures, and valve areas can be obtained using Doppler echocardiographic
techniques. Diastolic function is more difficult to assess, although newer techniques may provide
accurate, load-independent measures of LV relaxation. The advent of transesophageal
echocardiography has made it possible to obtain reliable information when transthoracic
'windows' are inadequate.
radionuclide angiography
Two other noninvasive techniques commonly used in the assessment of cardiac function are
radionuclide ventriculography (RVG) and cardiac magnetic resonance imaging (MRI). RVG
provides a reliable quantification of right and left ventricular ejection fraction, and can
characterize wall motion abnormalities in ischemic heart disease. Recently, cardiac MRI has
emerged as a highly accurate and quantitative tool for the evaluation of ventricular function and
myocardial mass. Serial MRI studies can assess ventricular remodeling in response to therapy.
cardiac catheterization
In the intensive care setting, assessment of volume status and/or cardiac output may be necessary
to differentiate cardiogenic from noncardiogenic pulmonary edema, and manage hemodynamic
instability. The gold standard for evaluating cardiac hemodynamics is right heart (or Swan-
Ganz) catheterization using a balloon-tipped flotation catheter. This procedure may be
performed safely at the bedside, and is used primarily to determine response to parenteral
inotropic and/or vasodilator therapy in severe heart failure. Simultaneous measurement of right
and left heart filling pressures in the cardiac catheterization laboratory can be used to distinguish
restrictive cardiomyopathy from constrictive pericarditis.
Anonymous Nobel pgs 587-588
• CBC-detects anemia. Anemia is not diagnostic of heart failure, but when present may
exacerbate underlying ischemic heart disease and should be corrected. Rarely, severe
anemia may cause high-output failure. The erythrocyte sedimentation rate is often
decreased in heart failure because of impaired fibrinogen and synthesis and decreased to
fibrinogen concentration a. A marked increase in SED rate may suggest infective
endocarditis.
• Serum electrolytes-dilutional hyponatremia is common in severe heart failure and is a
result of prolonged sodium restricting, diuretic therapy, and expansion of extracellular
volume. Increased vasopressin levels may also contribute to hyponatremia. Hyponatremia
is a negative indicator at the time of hospital admission for heart failure, and predicts
decreased long-term survival. Hypokalemia is most often due to thiazide or loop
diuretics given without oral potassium supplementation, but may also result from
increased aldosterone levels due to activation of the renin-angiotensin system. If
uncorrected hypokalemia may lead to ventricular arrhythmias, especially in the presence
of digoxin. Hyperkalemia may result from marked reductions in glomerular filtration rate
and inadequate delivery of sodium to the distal renal tubule. Excess total body potassium
may be exacerbated by the use of potassium sparing diuretics or ACE inhibitors, and their
concurrent use. Other abnormalities seen in heart failure include hypophosphatemia &
hypomagnesiumia, both of which are commonly associated with chronic ETOH abuse.
• BUN and Creatinine levels-allow you to assess renal hepatic function. These levels are
often moderately elevated in severe heart failure because the reduction in renal blood
flow and glomerular filtration rate. Proteinuria may also be present, especially in the
setting of long-standing hypertension or diabetes. BUN & creatinine are essential to
avoid excess volume depletion and severe prerenal azotemia.
• Liver function tests-serum aminotransferase, lactic dehydrogenase, and alkaline
phosphatase levels or elevated, typically 2 to 3 times normal. Marked elevation in
transaminases suggesting "shock liver” can be associated with severe low output states.
Hyperbilirubinemia is common in heart failure, and in severe cases of acute heart failure
jaundice may occur. In patients with cardiac cirrhosis, hypoalbuminemia may exacerbate
fluid accumulation. Chronic right-sided heart failure with congestive hepatomegaly leads
to abnormal liver function.
• Arterial blood gases-ABGs are essential to monitor hypoexmia states. It checks the
ventilation and perfusion to the tissues (basically shows how well the heart and lungs are
working). It can tell you the workload on the heart and lungs. It lets you see if your
diuretics are working by dumping excess fluid off lungs by improving ABG results.
• EKG-no EKG pattern is specific for diagnostic of heart failure. However, the EKG and
may provide import information regarding the nature of the underlying cardiac disease.
For example LVH and left atrial enlargement suggests left heart failure resulting from
antecedent hypertension or aortic stenosis. Pathologic Q waves in ischemic heart disease
indicate the presence of and location of myocardial infarction, while nonpathologic Q
waves (psuedoinfarction) may be seen with restrictive or dilated cardiomyopathy.
Abnormal cardiac rhythms such as atrial fibrillation may be secondary to heart failure or
may represent inadequacy of therapy if the ventricular responses uncontrolled. If present,
ventricular ectopic activity may indicate increased risk of sudden cardiac death or reflect
digoxin toxicity or electrolyte imbalance.
• Chest x-ray-the size and shape of the cardiac silhouette provide import information
regarding the nature of the underlying heart disease. A cardiothoracic ratio > 0.5 for
example, is a good indicator of increased LV volume. The other major radiographic
abnormality associated with left heart failure is pulmonary venous congestion. The
degree of pulmonary venous congestion often parol's increases in the pulmonary capillary
wedge pressure. Early radiologic signs of pulmonary venous hypertension and interstitial
edema include distention of the pulmonary veins extending upward from the hila,
haziness of hilar shadows, and thickening of interlobular septa (Kerley’s B lines). When
the pulmonary capillary wedge pressure is moderate to severely elevated, off then >
25mmhg, alveolar edema is present as diffuse haziness extending downward toward the
lower portions of the lung fields (so-called butterfly pattern). In patients with chronic LV
failure, higher pressures can be accommodated with fewer radiologic signs due to
enhancedlymphatic drainage. Pleural effusions of varying size and distribution are
common in biventricular failure.
• Echocardiography-is commonly performed in the evaluation and management of heart
failure. Two-dimensional echocardiographic imaging provides an accurate and rapid
determination of ventricular size and function, and alveolar morphology and function,
and can detect intracavitary thrombi and pericardial effusions. Important hemodynamic
data including cardiac output, pulmonary artery pressures, and velvet areas can be
obtained using Doppler echocardiographic techniques. Diastolic function is more difficult
to assess, although the newer techniques may provide accurate, load independent
measures of LV relaxation. The advent of transesophageal echocardiography has made it
possible to obtain reliable information when transthoracic "windows " are inadequate.
• Radionuclide angiography-a noninvasive technique commonly used in the assessment
of cardiac function. (RVG) provides a reliable quantification of right and left ventricular
ejection fraction, and can characterize wall motion abnormalities in ischemic heart
disease.
• Cardiac catheterization-(invasive study) in the intensive care setting, assessment or
volume status and/or cardiac output may be necessary to differentiate cardiogenic from
noncardiogenic pulmonary edema, and manage hemodynamic instability. The gold
standard for evaluating cardiac hemodynamics is right heart(or Swan-Ganz)
catheterization using a balloon tipped flotation catheter. This procedure may be
performed safely at the bedside, and is used primarily to determine response to parental
inotropic and/or vasodialtor therapy in severe heart failure. Simultaneous measurement
of right and left heart filling pressures in the cardiac catheterization laboratory can be
used to distinguish restrictive cardiomyopathy from constrictive pericarditis.
Anonymous Noble pg 587-588
CBC Anemia is not diagnostic of heart failure. When present may exacerbate underlying
ischemic heart disease and should be corrected. Severe anemia may cause high output period.
ESR rate decreases in heart failure.
Electrolyte levels Dilutional hyponatremia is common in severe heart failure due to prolonged
sodium restriction, diuretic therapy, and expansion of extracellular volume. Hyponatremia is a
negative prognostic indicator at the time of hospital admission and predicts decreased long term
survival. Hypokalemia is due to thiazide or loop diuretics given without oral K
supplementation. It may lead to ventricular arrhythmias especially in the presence of Digoxin.
Hyperkalemia may result from reductions in glomerular filtration rate and inadequate delivery of
Na to the distal renal tubule. It is a common cause of iatrogenic morbidity and mortality. Other
abnormalities include hypophosphatemia and hypomagnesemia. Both are commonly associated
with chronic alcohol use.
BUN and creatinine levels These are moderately elevated in severe heart failure because of a
reduction in renal blood flow and GFR. Proteinuria may also be present.
Liver function tests Serum aminotransferase, lactic dehydrogenase, and alkaline phosphatase
levels are elevated, typically 2-3 times normal. Marked elevation in transaminases suggesting
“shock liver” can be associated with severe low output states. Hyperbilirubinemia is common
and jaundice may occur. Hypoalbuminemia may exacerbate fluid accumulation.
Arterial blood gases Reduced peripheral perfusion results in anaerobic metabolism and the
production of lactic acid, causing metabolic acidosis. ABG’s reveal a lowered bicarbonate as the
body attempts to buffer the excess H ions to maintain pH. If the pH falls the patient
hyperventilates. Hyperventilation compensates for the increased acidity by lowering arterial
CO2 tensions, causing a mild respiratory alkalosis, which helps to normalize pH. (Cardiac
Nursing Underhill pg 382).
EKG No specific EKG pattern is diagnostic of heart failure, but it may provide important
information regarding the underlying disease. LVH and Lt atrial enlargement suggest Lt heart
failure resulting from HTN or aortic stenosis. Pathologic Q waves in ischemia indicate the
presence and location of MI, while nonpathologic Q waves may be seen with restrictive or
dilated cardiomyopathy. A fib may be secondary to heart failure or inadequacy of therapy.
Ventricular ectopy may indicate increased risk of sudden death or reflect digoxin toxicity or
electrolyte imbalance.
Chest X-ray Size and shape of the cardiac silhouette provide important information regarding
the nature of the underlying heart disease. Cardiothoracic ratio greater than .5 is a good indicator
of increased LV volume. Pulmonary venous congestion parallels increases in the pulmonary
capillary wedge pressure. Early radiologic signs of pulmonary venous hypertension and
interstitial edema include distention of the pulmonary veins extending upward from the hila,
haziness of hilar shadows, and thickening of intralobular septa (Kerley’s B lines). Alveolar
edema is present as diffuse haziness extending downward toward the lower portions of the lung
fields (butterfly pattern).
Echocardiography These 2 dimensional images provide an accurate and rapid determination
of ventricular size and function, and valvular morphology and function, and can detect
intracavitary thrombi and pericardial effusions. Important hemodynamic data including cardiac
output, pulmonary artery pressures, and valve areas can be obtained using Doppler
echocardiographic techniques.
Radionuclide angiography Radionuclide ventriculography provides a reliable quantification of
right and left ventricular ejection, and can characterize wall motion abnormalities in ischemic
heart disease.
Cardiac catheterization Right heart catheterization (Swan Ganz) is used to determine response
to parenteral inotropic and/or vasodilator therapy in severe heart failure. Simultaneous
measurement of right and left heart filling pressures in the cath lab can be used to distinguish
restrictive cardiomyopathy from constrictive pericarditis.
Anonymous Currents p 382-383/ Noble p 587-588
A) CBC- this may reveal anemia which is a cause of high-output failure and an exacerbating
factor in other forms of heart failure.
C) BUN and Creatinine Levels- these are often moderately elevated in CHF due to reduced
renal blood flow and glomerular filtration rate.
D) Liver Function Tests- these may become elevated due to right sided failure and hepatic
congestion
E) Arterial Blood Gases- the arterial blood gases detect decreases in oxygenated hemoglobin as
in cases of pulmonary edema. It can also detect metabolic acidosis or alkalosis as in cases of
excessive salt retainment.
G) Chest X-ray- these provide information about the size and shape of the cardiac silhouette. It
will also show pulmonary venous dilation and haziness will elucidate perivascular edema and
alveolar fluid.
H) Echocardiography- this test will reveal the size and function of both ventricles and both
atria. It will also show pericardial effusion, valvular abnormalities, intracardiac shunts, and
segmental wall motion abnormalities indicative of old myocardial infarction.
I) Radionuclide Angiography- this measures specific left ventricular ejection fraction and
regional wall motion indicative again of old myocardial infarction.
J) Cardiac Catheterization- This is much more invasive but useful in determining significant
valvular disease and the presence and extend of coronary artery disease. Coronary artery disease
is extremely important because left ventricular revascularization often will reverse left ventricle
ischemia leading to CHF.
9. Compare and contrast in general terms the role of each of the following in
the treatment of CHF:
rest
diet
diuretics
digitalis
vasodilators(especially ACE inhibitors)
Zen Seeker Noble 589- http://home.mdconsult.com/das/book/body/0/959/446.html#top
Rest
Appropriate restriction of physical activity is essential in the treatment of patients with
heart failure. Physical rest reduces metabolic demands and thus the overall work of the failing
heart. Bed rest in the hospital is usually necessary in the management of acute heart failure and
other forms of severe cardiac decompensation. Progressive mobilization is initiated when the
patient's condition permits and is encouraged as further clinical improvement results. Explicit
instructions regarding physical activity are discussed before discharge. Patients who work full-
time may need to reduce their hours or stop working altogether, depending on the physical and
mental demands of the job. It may be beneficial to avoid emotional stress and use relaxation
techniques.
Exercise is not contraindicated in patients with heart failure. Supervised cardiac
rehabilitation in selected patients may increase exercise tolerance, reduce symptoms, and
improve quality of life. Reduction in morbidity and mortality has been reported. These clinical
benefits are associated with important physiologic changes including improved vascular
endothelial function and skeletal muscle metabolism and decreased sympathetic tone. Thus a
program of regular, aerobic exercise for patients with heart failure is recommended.
Diet
Expanded extracellular volume, due in part to avid sodium retention by the kidney, may
be treated in most patients with diuretics (see below) and reduction in the dietary intake of
sodium. The average American diet without salt restriction contains as much as 10 gm/day of
salt. Prohibiting the addition of salt to cooked food and eliminating some salty foods (e.g., potato
chips) often reduce salt intake to about 4 to 5 gm/day ( Table 65-5 ). A salt substitute or herbs
and spices may be used to flavor food. Removal of salt from cooking altogether reduces intake to
about 2 gm of salt per day but often results in unpalatable food and poor compliance. This degree
of salt restriction is often unnecessary unless edema persists after vigorous diuretic therapy.
Further reduction of salt intake requires elimination of most processed foods and when possible,
substitution with low-sodium foods (e.g., fresh vegetables, low-sodium milk, cheese, and bread).
In obese patients with heart failure, supervised weight reduction is of critical
importance in reducing the workload of the heart. Specific advice regarding caloric restriction is
given, and the therapeutic goal of weight loss is reinforced during follow-up.
Diuretics
Diuretic therapy is an important element in the treatment of edema associated with heart failure.
By reducing the reabsorption of sodium and water by the renal tubule, diuretics improve
symptoms related to excess volume and may prevent ventricular remodeling by reducing cardiac
filling pressures. Current recommendations are to reserve diuretic therapy for patients with signs
and symptoms of fluid retention on an ACE inhibitor (or other vasodilator) and moderate salt
restriction, with or without digoxin. Commonly used diuretics in heart failure are thiazides, loop
diuretics, and potassium-sparing diuretics ( Table 65-6 ).
Digitalis
Although digoxin and related compounds have been used for over 200 years to treat heart
failure, debate continues regarding their safety and efficacy. Multicenter trials have shown that
digoxin increases ejection fraction and exercise tolerance, and decreases symptoms in patients
with systolic heart failure, and withdrawal of digoxin leads to increased symptoms and
hospitalizations ( Table 65-9 ). The recently completed DIG trial showed no difference in
survival with digoxin compared with placebo when given with an ACE inhibitor and diuretic.[5]
In the digoxin-treated group, fewer deaths attributable to the progression of heart failure were
offset by an increase in deaths due to other causes.
Digoxin increases cardiac contractility by inhibiting sacrolemmal Na-K-ATPase, thereby
increasing the amount of intracellular calcium available to the contractile apparatus. Cardiac
output increases and diuresis ensues. Digoxin also increases baroreceptor sensitivity, attenuates
neurohormonal activation, slows heart rate, and decreases systemic vasoconstriction. Finally,
digoxin decreases AV nodal conduction velocity, which makes it a useful agent for treating heart
failure in patients with atrial fibrillation or flutter with rapid ventricular response.
Digoxin is given to outpatients as a maintenance oral dose of 0.125 to 0.25 mg per day. In
the presence of normal renal function, full digitalization occurs within 5 to 7 days. If rapid
digitalization is required (e.g., in a hospitalized patient with rapid atrial fibrillation), an initial
dose of 0.25 to 0.5 mg is given intravenously, followed by 0.125 to 0.25 mg every 2 to 4 hours
up to a total of 1 mg. The peak effect is usually achieved between 1.5 and 6 hours.
Electrocardiographic monitoring should be used to monitor for proarrhythmia, with the
knowledge that some changes (e.g., shortening of the QT interval, flattening or inversion of the T
wave) reflect drug effect rather than drug toxicity.
Digoxin has a low toxic to therapeutic ratio. However, there is little evidence to support
using serum levels to guide dose selection. Hypokalemia, renal insufficiency, and hypoxia
commonly predispose patients to the toxic effects of digoxin. Digoxin should also be used with
caution in older patients with slower renal excretion; in patients with acute myocardial infarction,
myocarditis, or hypothyroidism; and in patients treated with drugs such as quinidine, verapamil,
and amiodarone that increase serum digoxin levels. Digoxin is contraindicated in patients with
second-or third-degree AV block unless a temporary pacemaker has been inserted.
Toxic manifestations of digoxin include gastrointestinal upset, visual disturbances, and a
wide range of cardiac arrhythmias. The new occurrence, or increased frequency, of ventricular
premature beats is the most common rhythm disturbance related to excess digoxin. Other cardiac
arrhythmias include second-degree AV block, paroxysmal atrial tachycardia with block, and life-
threatening ventricular tachycardia and fibrillation. Digoxin toxicity is usually reversed by
simply withdrawing the drug. Hypokalemia, if present, should be corrected. High-grade AV
block may require temporary pacing, while significant ventricular arrhythmias are treated with
lidocaine, phenytoin, and propranolol. Severe digoxin toxicity associated with recurrent
ventricular arrhythmias (e.g., following massive overdose) can be treated with purified Fab
fragments of digoxin-specific antibodies. The digoxin antibody complex is excreted in the urine.
B) Diet- moderate salt restriction will help with the fluid retention. Extreme salt restriction
should not be done because many of the diuretics are not sodium sparing so the patient will
develop hyponatremia if they limit salt intake to extremely.
C) Diuretics- this is the most effective means of providing symptomatic relief to patients with
CHF. The increased diuresis helps to reduce excess fluid volume however, excessive diuresis
can lead to electrolyte imbalance. Most of these agents block sodium resorption in the terminal
segment of the loop on henle.
D) Digitalis- these drugs are positive inotropic agents that increase cytosolic calcium which
enhances contractile protein cross bridge formation and force generation.
E) Vasodilators (especially ACE inhibitors)- agents that dilate arteriolar smooth muscle and
lower peripheral vascular resistance reduce left ventricular afterload. ACE inhibitors have
shown to be the most effective at improving prognosis due to their nonselective ability to reduce
preload of both ventricles.
C) Resistant Hypertension- Almost all patients with hypertension can achieve good blood
pressure control with minimal side effects, although a few patients may persistently have
unacceptably high diastolic pressures regardless of treatment. Noble p 523
D) Isolated Systolic Hypertension- this is a type of hypertension in which only the systolic
blood pressure is elevated. This condition, which usually affects the elderly, increases the risk of
stroke or heart attack.
E) Hypertensive Urgencies- situations in which blood pressure must be reduced within a few
hours. Many of these cases are asymptomatic or have target organ symptomology. Currents p
432
F) Hypertensive Emergencies- these are cases that require substantial reduction of blood
pressure within 1 hour to avoid the risk of serious morbidity or death. Currents p 432
Anonymous
Essential (Primary) HTN
95% of HTN cases
No cause identified. Currents p 409
Secondary HTN
5% of patients w/HTN
Specific identifiable causes. Currents p 411
Resistant HTN
Some pts have persistently unacceptably ^ diastolic pressures regardless of Tx. Noble p 523
HTN Urgencies
BP must be reduced within a few hours.
Many cases are asymptomatic or have target organ symptomology.
Currents p 432
HTN Emergencies
Require substantial reduction of BP w/i 1 hour
to avoid risk of serious morbidity or death. Currents p 432
Brain
HTN = Main Predisposing cause of Stroke
especially intercerebral hemorrhage, but also ischemic cerebral infarction.
These are more closely related to Systolic BP.
W/o Tx cognitive decline eminent
W/Tx risks decline.
Kidneys
Chronic HTN leads to Nephrosclerosis
This in turn limits Kidney's effectiveness at filtering & maintaining
fluid & electrolyte balances.
HTN accelerates other forms of Renal Dz such as Diabetic Nephropathy.
Retina
HTN leads to Atherosclerosis of Retinal Arteries
giving them a characteristic copper or silver wire appearance.
Arterial diameter Narrows to < 50% venous diameter leading to Exudates
Hemorrhages
Papilledema.
¨ Cushing's syndrome- nearly 80% of patients have elevated blood pressure because the high
levels of cortisol have mineralocorticoid activity. The initial diagnostic test is a morning
plasma cortisol after suppression with 1 mg of dexamethasone at bedtime the night before. A
cortisol level less than 5 mg/dl excludes Cushing's syndrome with 98% certainty.
¨ Primary aldosteronism- induces HTN and potassium wasting, although hypokalemia is not
always present. The most useful screening test for primary hyperaldosteronism is measuring
the plasma aldosterone/plasma renin activity ratio. A ratio of greater than 20:1 with an
absolute aldosterone concentration of greater than 15 ng/dl suggests primary
hyperaldosteronism.
¨ Coarctation of the aorta-is suggested by delayed or absent femoral pulses and decreased lower
extremity blood pressure. A chest x-ray may show the E sign, formed by the abnormal
contour of the aortic knob and the uppermost portion of the descending aorta. Notching of
the rib may be noted. An aortagram confirms the diagnosis.
Anonymous Noble p. 511 –513
Secondary hypertension – by definition, has an identifiable underlying cause, which can be
curable.
Most common cause: is Renal parenchymal disease: e.g. glomerulonephritis, chronic nephritis,
diabetic nephropathy, hydronephrosis, connective tissue disease, polycystic disease - which is
responsible for 2% to 3% of all Hypertension.
Labs: The Dx is based on finding elevated Blood urea nitrogen (BUN) and creatinine, decreased
creatinine clearance, and an abnormal urinalysis.
-Renal Vascular Disease: (RVD), Abrupt onset of severe difficult to control HTN. Patient <30
or >50 yr old. Abdominal or flank bruit. End-organ damage. Etiologies are fibromuscular
dysplasia and atherosclerosis.
Labs: Captopril renogram or duplex Doppler study of renal arteries.
-Acute stress: e.g. alcohol withdrawal, surgery, and acute illness –
-Exogenous Drugs: e.g. nonsteroidal antiinflammatory drugs [NSAIDs], estrogen, appetite
suppressants, corticosteroids, thyroid supplements, and sympathomimetics, caffeine, cocaine,
amphetamines and antidepressants.
-Primary aldosteronism: Muscle weakness, Periodic paralysis, Muscle cramps, decrease [K],
increase [Na].
Labs: measuring the plasma aldosterone / plasma rennin activity ratio.
-Pheochromocytoma: Paroxysmal HTN, Headache, diaphoresis, Palpitations, Wt loss,
tachycardia.
Labs: Spot urine metanephrines level; 24 hr urine collection for VMA (vanillylmandelic acid),
metanephrines, catecholamines, and creatinine, consider clonidine suppression.
Cushing’s syndrome: Obesity, acne, Muscle weakness, easy brushing, edema, glucose
intolerance, and striae.
Labs: Overnight 1 mg dexamethasone suppression tests 24 hr urine free cortisol, low dose
dexamethasone suppression.
Coarctation of aorta: Murmur, pulse delay, femoral pulse delay or absent.
Labs: A CXR may show the “E” sign, formed by the abnormal contour of the aortic knob. An
aortogram confirms the Dx, but CT scan or MRI can demonstrate the coarctation
Anonymous Currents p 411-412/ Noble p 511-513
A) Estrogen Use- This may cause no symptoms but blood pressure is checked in all women on
oral contractptives. These are more likely to cause hypertension if on over five years, if over 35
years of age, and less likely to cause hypertension if postmenopausal.
B) Renal Disease- Renal parenchymal disease is the most common cause of secondary
hypertension. This is commonly associated with spilling of protein in the urine, elevated BUN
and createnine, decreased createnine clearance, but may have no other symptoms. Diabetic
nephropathy leads to the same kidney problem and hypertension.
C) Renal Vascular Hypertension- This is the cause of 1-2% of secondary hypertensives most
common in women under 50 years old as a result of fibromuscular hyperplasia. Renal arteries
become stenotic and do not allow free flow of renal blood supply. The kidneys in turn respond
by activating the rennin-angiotensis system which increases volume further in attempts to get
more blood to the kidney. There is no diagnostic test, but if suspicion is high renal arteriography
is the definitive test.
F) Coarctation of Aorta- This may cause hypertension and is characterized by a tearing chest
pain usually detected by delayed or absent femoral pulses and decreased lower extremity blood
pressure. Chest x-ray reveals a "E" sign formed by the abnormal contour of the aortic knob and
uppermost portion of the descending aorta.
Renal Dz
Renal Parenchymal Dz - Most common cause of 2 O HTN.
Commonly associated w/Spilling of protein in Urine
Elevated BUN & Createnine
Decreased Createnine Clearance
May have No other Symptoms.
Pheochromocytoma
Tumor of Adrenal Medulla or Sympathetic Paraganglia
Excessive secretion of Epinephrine & Norepinephrine
Causing persistent or intermittent HTN.
Typical signs include Headache
Palpitations
Sweating
Nervousness.
One symptom may be Orthostatic Hypotension & Glucose Intolerances.
Spot urine screen for Metanephrine is screening test.
Coarctation of Aorta
May cause HTN
Characterized by a Tearing Chest Pain
Usually detected by Delayed or Absent Femoral Pulses &
Decreased Lower Extremity BP.
Chest X-Ray reveals an "E" Sign
Formed by Abnormal Contour of Aortic Knob &
Uppermost Portion of Descending Aorta.
Pregnancy
Physiologic Hypervolemia during Pregnancy
^ BP usually more towards End of pregnancy.
IF becomes elevated too high = eclampsia as protein begins to spill into the urine & edema
develops.
Medications
NSAIDs
Nasal decongestants (containing sympathomimetics)
Corticosteroids
Diet pills
Caffeine
Cyclosporine
Erythropoietin
Antidepressant
Amphetamines
Cocaine
5. Specify the items that should be covered in taking the medical history of a
patient with newly discovered hypertension.
Pam Current, p410-416
Family history of HTN; PMH of renal disease, dyslipidemia, neurological disease, heart
conditions, cerebrovascular disease, peripheral arterial disease, diabetes mellitus,
prior MI, retinopathy, prior coronary revascularization, other medical conditions;
Medications and Allergies; Lifestyle modification: Smoking; Exercise
Anonymous Noble 508 .
Hypertension is usually asymptomatic, and is often detected only during routine screening.
Patients with elevated pressures should be questioned about symptoms of cardiovascular,
cerebrovascular, and renal disease. Questions about a family history of high blood pressure,
cardiovascular disease, or diabetes. If HTN has already been diagnosed, the patient should be
asked about the duration and the levels of BP. The history should also identify other
cardiovascular risk factors such as, smoking, hyperlipidemia, inactivity, obesity, and DM. Other
important factors to ask about include drug use, dietary intake of salt, intake of cholesterol, and
saturated fats. A quick review of systems may help determine whether a secondary cause may
be present.
Anonymous Goroll p. 105 – 4th ed
(The syllabus mentions The 6th Report of Joint commission but I cannot find it in Goroll and it
has not been presented in our Pt. Management class yet).
Pts should be asked date of onset, any medications ( OTC and herbal as well), family history of
HTN. The pt. should be asked about hx renal disease, alcohol intake,salt intake and recent weight
gain. They should also be asked about any use of recreational drugs. Their cardio-vascular
history should also be asked. They should also be asked the date of their most recent blood
pressure reading and the results.SMOKING history or current use should be asked.
Anonymous Noble p 509
A) Patients should be questioned about symptoms of cardiovascular, cerebrovascular, and renal
disease
B) Patients should be questioned about family history of high blood pressure, cardiovascular
disease, or diabetes
C) Ask about any complications of the hypertension the patient has experienced
D) Identification of any hypertension risk factors including:
1. Tobacco use
2. hyperlipidemia
3. Inactivity
4. Obesity
5. Diabetes Mellitus
E) Questions about drug use should be asked
F) Dietary questions about daily intake of salt, cholesterol, and saturated fats.
G) A quick review of systems may reveal causes of secondary hypertension.
Anonymous Noble p 509
Symptoms of Cardiovascular - Cerebrovascular - Renal Dz
FMHx HTN
Cardiovascular Dz
Diabetes
Complications of HTN Pt has experienced
Serum K+
Seeking Mineralcorticoid Excess
Lipid Panel
R/O Atherosclerosis
CBC
R/O Anemia of Chronic Dz
Non-Pharmacologic Tx options:
1. Lifestyle Interventions:
Wt reduction
Reduced salt intake
Regular Aerobic Exercise
Decreased Alcohol Consumption.
2. Exercise
Aerobic Exercise @ least 3 times a wk for 30-45 mins lowers BP pressure and assists in Wt
Control.
Pts should begin @ five minutes & work gradually up to the Optimum 30-45 minute work outs.
3. Diet
Reduce Saturated Fat Intake.
Diets high in Potassium and Magnesium
consisting of fruits, vegetables, & low fat dairy products can reduce BP
4. Weight Loss
Wt loss of 3-9% can effectively reduce BP
6. Salt Restrictions
Salt restrictions trying to remain under 1 gram daily shown to reduce BP
7. Dietary Supplementation
No direct evidence of effect of dietary supplementation on mortality or morbidity in people
w/HTN.
Few randomized trials shown Potassium supplementation to Lower BP
Studies considered inconclusive.
9. Smoking Cessation
Tobacco known to raise BP lead to Arteriosclerosis
B) Aortic Regurgitation- This is most likely due to a congenital bicuspid aortic valve however
endocarditis, connective tissue disorders (Marfan Syndrome), aortic aneurysm, rheumatic fever,
syphilis, and aortic involvement of rheumatoid arthritis can also be implicated. Most often these
are asymptomatic at the time of diagnosis. The heart can compensate for a long time, however
eventually the left ventricle weakens and signs of CHF or angina appear. The physical exam
reveals bounding peripheral pulses with a widened pulse pressure and a high-pitched blowing
diastolic murmur is usually heard along the left sternal border.
C) Mitral Stenosis- Classicaly mitral stenosis was due to rheumatic fever, however in the last 2
decades the prevalence of this has declined and now most commonly the causes are elderly or
patients who have previously undergone surgical or percutaneous palliation. The symptoms
often are not evident for years of mitral stenosis but become evident in situations of stress on the
heart such as pregnancy, anemia, and febrile conditions. Atrial fibrillation often develops as the
first sign in patients that have had undiagnosed, asymptomatic mitral stenosis for years.
Emblematic of mitral stenosis is accentuation of S1 or the opening snap due to the opening of the
stenotic valve best heard over the apex impulse.
D) Mitral Regurgitation- Competence of the mitral valve relies on valve leaflets, chordae
tendinae, papillary muscles, and mitral annulus. Mitral regurgitation may be caused by
dysfunction of any one of these commonly as a result of rheumatic fever, ruptured chordae
tendinae, papillary muscle ischemia or infarction, tissue erosion due to late endocarditis, and
calcification of the mitral annulus. The ventricle can compensate for some time but upon reserve
failures congestive symptoms develop of which pulmonary congestion may become rapidly fatal
if untreated. The apical impulse is enlarged, displaced downward to the left and is rapidly
retracted. An attenuated S1 coincides with the onset of a high-pitched holosystolic murmur
which may radiate to the axilla and extend beyond A2.
E) Mitral Valve Prolapse- Primary mitral valve prolapse is due to myxomatous degeneration
that disrupts the normal connective tissue architecture of the valve leaflets, chordae, or annulus.
Secondary mitral valve prolapse can be a result of many things such as rheumatic fever,
Marfan's, coronary artery disease, etc. This valvular abnormality is also associated with thoracic
cage abnormalities such as pectus excavatum and straight back. Most individuals are
asymptomatic but the most common complaints are chest pain and palpitations. The hallmark of
mitral valve prolapse is the mid to late systolic click which is the only detectible manifestation in
more than half the cases.
In Noble, Post-phlebitic syndrome (syn, thrombophlebitis) and Varicose Veins are addressed
together. Both arise from incompetent venous valves. Varicose Veins or Dz (incl. Raynauds)
can lead to venous stasis that sometimes lead to the thrombophlebitis.
Varicose Veins (VV)
D: enlarged, twisted, superficial veins most common in LE or esophagus
C: high venous pressure due to incompetent venous valves from congenital (primary)
or acquired (secondary) conditions
PP:
RF: pregnancy, obesity, portal HTN (esophageal), prolonged standing (occupational)
SS: pain, swelling, skin ulcers, bleeding 2° to trauma
Dx: Ultrasound (US), Physical Exam (PE)
Tx: Preventive: rest, elevation, external support (stockings)
Surgical: ligation and excision
Raynauds dz, reversible, idiopathic. (idiopathic (eg idiot, we don't know the cause) dx in
pts with suggestive sx persisting over 3 yr w/o evidence of associated dz, as per
Current).
Raynaud's phenomenon(if associated with a trigger).
Prognosis, dz vs phenom: Distinction implicates prognosis. The phenomenon can
progress to atrophy, gangrene. Dz incident in females 15-45. Hard to distinguish
between dz and phenom.
D: episodic vasospastic disorder characterized by digital pallor, cyanosis and rubor(upon
rewarming) in response to cold or environmental stress
C: precipitating factors: Regional: automimmune dz, myeloproliferative disorder,
multiple myeloma, cryoglobulinemia, myxedema (hypothyroidism), arterial
occlusive dz. Incidence 10% (80% female). Abn. Sympathetic nervous stystem
suspected etiology.
DDx: scleroderma, SLE, RA, Carpal tunnel, hx of frostbite, chemotherapy, etc.
SS: pain, paresthesia, numbness, trace edema. Fingers normal between attacks. Can
involve toes.
Tx: preventive: warmth, protective (ie Gloves!), moisture, avoid vasocontrictors (ie
nicotine, smoking cessation), stress mngmt,. d/c drugs assoc. with exacerbation of
symptoms, eg oral contraceptives, betablocker, and ergotamines (?).
Pharmacotherapy: aspirin, to decrease thrombotic complications. Vasodilators:
nifedipine, diltiazem, SSRIs.
Surgery in severe cases of arterial occlusive dz.
Prognosis: that of associated dz
Anonymous
Varicose Veins
• The superficial veins of the lower extremities lie in the subcutaneous tissue and lack the
support afforded by muscle and fascial compartments. It is unclear whether the primary
problem is a congenital incompetence of valves or a weakness of the venous wall itself,
which causes dilation of the vein lumen and subsequent valve inadequacy. In any event,
a self-perpetuating cycle ensues of venous reflux leading to further vein dilation and
valve failure. In time, the poorly supported veins widen, elongate, and become tortuous.
Factors that raise intraluminal vein pressure such as repeated pregnancies, obesity, or
wearing of tight garments that constrict the thigh may be of importance. The final
common pathway remains valvular incompetence.
• Clinical presentation usually involve local aching or burning pain most commonly
involving the veins of the greater saphenous system and its tributaries occurring in the
medial and anterior thigh, calf, and ankle region. “Tiredness”, “heaviness”, or a
“bursting” sensation are commonly reported particularly after being on your feet all day.
Itching due to a stasis dermatitis may occur in the region of a severe or chronic varix.
• Diagnostic studies include demonstrating the incompetent valves of varicose veins by
applying a tourniquet on an elevated extremity so that the superficial veins are empty.
The patient then stands; release of the tourniquet allows the vein distally to enlarge
quickly if incompetent valves are present.
• Treatment includes using heavy gauge elastic stockings. This prevents symptoms,
edema, and further enlargement of the veins. Panty girdles or garters are never worn.
Obese patients are encouraged to lose weight and prolonged standing should be avoided.
Ligation and stripping of veins have decreased in popularity since the veins may be
needed in the future for arterial bypass. Goroll 242-43, Noble 632-33
B) Heparin Induced Thrombocytopenia (HIT)- this is the most common cause of drug-
induced thrombocytopenia usually occurring after 6-8 days of intravenous heparin therapy,
although it may occur sooner.
C) Idiopathic (immune) Thrombocytopenia Purpura (ITP)- this is the most common corm
of immumologic thrombocytopenia. It occurs in acute (often in children) and chronic (often in
adults) forms resulting in an immune mediated destruction of platelets. In 90% of cases these
have an acute onset often preceeded by a viral illness and resolve on their own over the course of
1-3 months.
D) Qualitative Platelet Disorders- Functional platelet defects produce a long bleeding time in
the presence of a normal platelet count and may predispose to bleeding. Inherited disorders are
uncommon with von Willebrand's Disease being one, acquired platelet disorders are much more
common.
1. von Willebrand's Disease- a disease characterized by a defect in von Willebrand's
factor which is a component of clotting Factor VIII necessary for normal platelet adhesion.
2. Acquired Aspirin Induced- aspirin impair platelet prostaglandin production
irreversibly
3. Acquired NSAID Induced- other NSAIDs impair prostaglandin production
reversible
4. Uremia- produces a qualitative defect sometimes improved by dialysis
5. Myeloproliferative Disorders- can be associated with a platelet defect resulting from
an abnormal stem cell.
B) Platelet Dysfunction: I don't know what they want here. The question is pretty vague and
all these prior are platelet dysfunctions. I guess pay attention in class. Books do not really have
anything that jumps out at me,
3. Describe typical signs or symptoms and general approach for each of the
following bleeding disorders:
a. Factor VIII deficiency
b. Vitamin K deficiency
c. Liver disease
d. DIC
Brent CMDT 512-16
a. Factor VIII deficiency (Hemophilia A)- Most common severe bleeding disorder and 2nd only
to von Willbrand’s disease as the most common congenital disorder. Bleeding may occur
anywhere. The most common sites of bleeding are into joints, muscles, and from the GI tract.
Spontaneous hemarthroses are virtually diagnostic of thisdisorder. Treatment Is the infusion of
factor VIII concentrates.
b. Vit K deficiency- No specific clinical features and bleeding may occur at any site. Treatment
includes a single dose of 15mg SQ Vit K. Labs will normalize within12-24hrs.
c. Liver disease- bleeding at any site. Excessive fibrinolysis may lead to oozing at venipuncture
sites. Most liver disease is clinically obvious. Fresh frozen plasma is
the treatment of choice.
d. Disseminated Intravascular Coagulation (DIC)- bleeding and thrombosis with bleeding the
more common. Bleeding at any site. Thrombosis causing digital ischemia and gangrene but
renal cortical necrosis and hemorrhagic adrenal infection. DIC may also secondarily produce
microangiopathic hemolytic anemia. Treatment is focused on the underlying cause of DIC.
Although controversial, when DIC is producing serious clinical consequences and the underlying
cause is not rapidly reversible. Heparin in combination with replacement therapy (platelets) can
be used.
jam, CMDT 512-514, Noble on-line 1048
a. Factor VIII deficiency CMDT 512-514
• Hereditary form is hemophilia A. Common sites of bleeding are into joints, muscles, and
from GI tract. Patients with mild hemophilia bleed only after major trauma or surgery;
severe disease bleeds spontaneously. PTT will be prolonged; PT, bleeding time, and
fibrinogen level will be normal. Standard treatment is infusion of factor VIII
concentrates.
• Acquired factor VIII antibodies produce a severe bleeding disorder. PTT is prolonged;
fibrinogen, PT, and plt count are normal. Treatment is with cyclophosphamide, usually
combined with prednisone. In the interim, aggressive factor VIII replacement may be
necessary.
b. Vitamin K deficiency - Noble 1048 Vitamin K deficiency is most often seen in seriously ill
patients, especially in the postoperative state when patients are poorly nourished and receiving
antibiotics. Poor nutrition removes vitamin K from the diet, and antibiotics suppress gut bacteria
that produce vitamin K. Vitamin K deficiency produces an initial rise in the prothrombin time
because of the rapid decline of factor VII activity, the vitamin K-dependent factor with the
shortest metabolic half-life. An elevation of the activated partial thromboplastin time follows as
other vitamin K-dependent factors decline (factors IX, X, and II). This condition, which often
leads to serious bleeding, is easily reversed by parenteral vitamin K1 therapy (5 to 10 mg
subcutaneous).
c. Liver disease - Noble 1048 Hemostatic failure in liver disease involves both the platelet and
coagulation phases of clotting. Mild thrombocytopenia is frequently encountered because of
hypersplenism that accompanies portal hypertension. Qualitative defects in platelet function are
probably not a major factor.
Coagulation is impaired primarily because of decreased factor synthesis, but abnormal factors
may be produced, excessive consumption can occur, and fibrinolysis may be enhanced as
contributing causes of hemostatic failure. A low fibrinogen, one of the last factors to be reduced,
is a poor prognostic sign.
Treatment depends on the severity of the coagulopathy and the presence of bleeding and usually
includes FFP. Treatment simply for the purpose of correcting an abnormal PT and aPTT,
however, is not recommended, since it takes a large volume of plasma to correct the abnormality,
the correction is short lived, and the protein load contained in the plasma may be enough to
induce hepatic encephalopathy in a patient who is so predisposed. Platelet transfusions can be
given in the face of clinically important bleeding with a very low platelet count, but generally
they are not indicated in hypersplenism.
d. DIC – Noble 1048 DIC often occurs in critically ill patients and is common in the intensive
care setting. However, DIC can also occur in relatively well patients, a result of certain
underlying diseases such as malignancy. Its onset can be fulminant and rapidly fatal or can be
more subtle and gradual. Although its name implies a disorder of intravascular clotting, its
clinical expression is often one of a diffuse hemorrhagic disorder.
DIC involves the pathologic activation of coagulation by an underlying disease process that leads
to fibrin clot formation and secondary fibrinolysis, which then cause further consumption of
coagulation factors, platelets, and red cells. In the fulminant syndrome bleeding results from
factor deficiency (primarily factors I, II, V, VIII, and XIII), thrombocytopenia, excessive
fibrinolysis, and high levels of FDP superimposed on a vascular system already damaged by
diffuse microvascular thrombi. Bleeding is typically manifested by diffuse superficial
hemorrhage in the form of ecchymoses and petechiae as well as oozing from the gingiva, the oral
mucosa, or the gastrointestinal and urinary tracts. Most hemorrhage tends to be from the
microvasculature, although major vascular hemorrhage and central nervous system bleeding can
occur.
The most important component in the treatment of DIC is correction of the underlying disease.
Supportive measures include FFP and platelet transfusions. Recent studies suggest a benefit to
infusions of antithrombin concentrates, but it is too premature to recommend their use. In rare
cases low doses of intravenous or subcutaneous heparin may be useful to interrupt the process of
consumption by neutralizing activated coagulation factors. This may be most helpful in well-
characterized conditions such as acute promyelocytic leukemia associated with a high incidence
of DIC. Efficacy of therapy can be monitored by looking for a decrease in FDP, or D-dimer, an
increase in fibrinogen, or the normalization of the PT and aPTT.
Anonymous
• Factor VIII deficiency: It is otherwise known as hemophilia A which is a sex-linked
recessive trait. It exists as varying degrees of deficiency that roughly correlate with
clinical severity. Severe (classic) hemophiliacs have 1% or less of normal factor VIII:C
activity levels on assay, moderate hemophiliacs have 2-5%, and mild hemophiliacs have
5-25% of normal levels. Hemophilia with levels between 25-50% of normal is
sometimes called subhemophilia. Most carrier females have about 50% of normal factor
VIII:C activity. The major symptom of hemophilia is excessive bleeding. Most bleeding
episodes follow trauma. In classic cases, the trauma may be very slight. In mild cases,
the trauma must usually be more significant such as a surgical operation or dental
extraction. Bleeding into joints (hemarthrosis) is a characteristic finding in classic and
moderate factor VIII:C activity deficiency. Bleeding from the mouth, urinary tract, and
GI tract and intracranial hemorrhage are also relatively common in severe cases. Blood
product transfusion is the treatment. The biologic half-life of factor VIII:C activity is
approximately 8-12 hours. Factor VIII:C activity is unstable, and in freshly drawn and
anticoagulated blood stored in the refrigerator the activity decreases to 40% by 24 hours.
The current therapeutic sources of factor VIII:C include fresh frozen plasma, factor
VIII:C concentrate, and cryoprecipitate. As a rule of thumb, one factor VIII unit in
therapeutic material per kilogram of body weight should increase factor VIII activity
levels by 2% of normal with a half-life of 12 hours. Ravel 93
• Vitamin K deficiency: The major clotting factors of the extrinsic pathway (II, VII, X)
depend for their synthesis and modification on a healthy liver and an adequate dietary
intake of vitamin K. Some vitamin K also derives from bacterial production by gut
flora. Hereditary deficiencies of extrinsic pathway factors are rare. Most bleeding traced
to the extrinsic pathway is the consequence of impaired vitamin K production or liver
disease. Causes include hepatocellular insufficiency, cholestasis (which impairs
absorption of lipids-soluble vitamin K), poor dietary intake, and use of broad-spectrum
antibiotics that kill normal gut flora. The characteristic lab findings is a prolongation of
the PT. Prolongation of the PT also occurs with warfarin anticoagulant therapy.
Warfarin inhibits the vitamin K-dependent postsynthetic modification of factors II, VII,
IX, and X; this prevents them from being able to bind calcium and achieve biologic
activity. Serious bleeding problems can result due to vitamin K deficiency.
Administration of fresh-frozen plasma provides rapid correction of the INR.
Administration of vitamin K is also effective but somewhat slower taking 12-48 hours to
reduce the INR to a safe level. IV, SQ, and oral preparations are available. High dose
IV vitamin K (1-10 mg) is the most potent and most rapidly acting of the various
formulations. Goroll 525, 538
• Liver Disease: Impairment of the synthetic capacity of the liver is one of the most
common causes for an acquired hemostatic defect. Hemostatic failure usually reflects
the degree of liver failure and is usually subtle in acute liver failure unless the destruction
of parenchymal tissue is fulminant. Hemostatic failure in liver disease involves both the
platelet and coagulation phases of clotting. Mild thrombocytopenia is frequently
encountered because of hypersplenism that accompanies portal hypertension.
Coagulation is impaired primarily because of decreased factor synthesis, but abnormal
factors may be produced, excessive consumption can occur, and fibrinolysis may be
enhanced as contributing causes of hemostatic failure. Treatment depends on the
severity of the coagulopathy and the presence of bleeding and usually includes fresh
frozen plasma. Treatment simply for the purpose of correcting an abnormal PT and
aPTT, however, in not recommended, since it takes a large volume of plasma to correct
the abnormality, the correction is short lived, and the protein load contained in the
plasma may be enough to induce hepatic encephalopathy in a patient who is
predisposed. Platelet transfusions can be given in the face of clinically important
bleeding with a very low platelet count, but generally they are not indicated in
hypersplenism. Noble 1048
Disseminated Intravascular Coagulation: DIC occurs is critically ill patients and is common
in the intensive care setting. It involves the pathologic activation of coagulation by an
underlying disease process that leads to fibrin clot formation and secondary fibrinolysis, which
then can cause further consumption of coagulation factors, platelets, and red cells. In the
fulminant syndrome bleeding results from factor deficiency (primarily factors I, II, V, VIII, and
XIII), thrombocytopenia, excessive fibrinolysis, and high levels of FDP superimposed on a
vascular system already damaged by diffuse microvascular thrombi. Bleeding is typically
manifested by diffuse superficial hemorrhage in the form of ecchymoses and petechiae as well as
oozing from the gingival,
• the oral mucosa, or the GI and urinary tracts. Most hemorrhage tends to be from the
microvasculature, although major vascular hemorrhage and CNS bleeding can occur.
The most important component in the treatment of DIC is correction of the underlying
disease. Supportive measures include fresh frozen plasma and platelet transfusions.
Efficacy of therapy can be monitored by looking for a decrease in FDP, or D-dimer, in
increase in fibrinogen, or the normalization of the PT and a PTT. Noble 1048
Anonymous Goroll, pp 529-530. Noble pp 1030, 1048-1052
Disease Signs/Symptoms Labs General Approach
Factor Cardinal sign of a platelet Detection difficult if factor Administration of
VIII defect is presence of levels >25%, as PTT will be Factor VIII concentrate
Deficiency petechiae. Coalesced normal. Chorionic villi is the mainstay of
petechiae are referred to as analysis in utero can detect. therapy. Basic
purpura. Ecchymoses is management includes
usually indicative of a specifying guidelines
coagulation disorder. for permissible
Platelet-related bleeding physical activity and
also tends to occur in the teaching proper first
oral mucosa or GI tract aid. If the degree of
and bleeding tends to be bleeding has been only
immediate in onset since mild to moderate, then
platelets are responsible one can encourage
for the primary hemostatic participation in
plug. Can also present as noncontact sports and
delayed-onset bleeding other activities that
and bleeding into entail little risk of
intramuscular tissues and injury. Goal is to allow
joints, as well as skin and as much normal
GI tract. activity as possible.
First aid treatment of
an acute hemarthrosis
should be learned by
the family. Immobilize
the joint and apply ice
packs to reduce pain
and swelling. Splinting
and elastic bandages
can help ensure that a
position of good joint
function is maintained.
Pain control is
important.
ASA/NSAIDS must be
avoided. Tylenol and
codeine work well
when given in
adequate doses for
short periods of time.
Genetic counseling is
also an important
component of care.
Vitamin K Same as above, but in the Rapid initial rise in PT. Easily reversed with
Deficiency presence of a concurrent Elevated aPTT follows as parenteral vitamin K1
serious illness other vitamin K-dependent therapy (5-10mg SQ)
factors decline.
Liver Same as above, but in the PT is prognostically helpful. Tx depends on severity
Disease presence of liver of coagulopathy and
dysfunction the presence of
bleeding and usually
includes FFP. Tx
simply to correct
abnormal PT and aPTT
not recommended.
Platelet transfusing
indicated in face of
clinically important
bleeding with a very
low platelet count, but
generally not indicated
for hypersplenism.
DIC Generally occurs in the Blood smear +/- in low- The most important
presence of serious illness, grade, + in fulminant. component of
but can occur in relatively Platelets low normal to low treatment is correction
well patients w/ certain in low-grade, very low in of underlying disease.
underlying diseases such fulminant. PT, PTT normal Supportive Tx include
as malignancy. In the in low-grade, long in FFP and platelet
fulminant syndrome, fulminant. TT transfusions. Efficacy
bleeding results from normal/short/long in low- of Tx can be monitored
factor deficiency, grade, long in fulminant. by looking for decrease
thrombocytopenia, Fibrinogen in FDP, or D-dimer an
excessive fibrinolysis and elevated/normal/low normal increase in fibrinogen
high levels of FDP in low-grade, low in or the normalization of
superimposed on a fulminant. Fibrin monomers the PT and aPTT
vascular system already +/- in low-grade, + in
damaged by diffuse fulminant. D-dimer mildly
microvascular thrombi. elevated in low-grade, high
Bleeding is typically in fulminant.
manifested by diffuse
superficial hemorrhage in
the form of ecchymoses
and petechiae as well as
oozing from the gingiva,
oral mucosa or GI/Urinary
tracts. Most hemorrhage
tends to be from the
microvasculature,
although major vascular
hemorrhage and central
nervous system bleeding
can occur.
Anonymous Noble p 1047-1048
A) Factor VIII Deficiency- von Willebrand's can cause a factor VIII deficiency. Von
Willebrand's factor has a platelet function of helping platelets to adhere to the subendothelium of
vessels, however it also has a protective job of binding to Factor VIII and protecting it from
degradation. Factor VIII protein is coded for by a gene on the X chromosome and is the protein
deficient in classic hemophilia.
B) Vitamin K Deficiency- This is most commonly seen in seriously ill patients, especially in
the postoperative state where patients are poorly nourished and receiving antibiotics. Poor
nutrition removes vitamin K from the body and antibiotics kill gut bacteria that produce vitamin
K. Vitamin K is necessary for the production of Factor VII and a decline in this is evidenced by
an elevation in the prothrombin time.
C) Liver Disease- Impairement of the synthetic capacity of the liver is one of the most common
causes for an acquired hemostatic defect. Liver disease involves both the platelet and
coagulation phases of clotting. Coagulation is a problem mainly due to decreased factor
production and thrombocytopenia is a problem due to hypersplenism and portal hypertension that
increase destruction of platelets.
B) Low molecular weight heparin (LMWHs)- These are advantageous compared with
standard heparin in their greater ability to neutralize factor Xa compared with thrombin. They
have less binding to heparin-binding proteins and platelets, have a longer half-life, are more
uniformly absorbed from subcutaneous depots, and cause less heparin-induced
thrombocytopenia.
C) Warfarin- This is the most common oral anticoagulant used in patients requiring long term
anticoagulation. Warfarin exerts its anticoagulant effect through competitive interference with
vitamin K, which is essential for the normal synthesis of factors II, VII, IX, and X as well as the
antithrombotic factors protein S and protein C.
D) Fibrinolytics- Major ones used are streptokinase, urokinase, t-PA, and anisoylated
plasminogen-streptokinase. These agents are recommended in fulminant pulmonary embolism
and in some cases of deep vein thrombosis but they have a large risk profile and are entirely
contraindicated in any situation where bleeding is a concern. These are used for the clearance of
thrombi that obstruct indwelling catheters such as those used in cancer patients.
E) Antiplatelet Agents- Aspirin and most other NSAIDs inhibit platelet aggregation by
interfering with cyclooxygenase, an enzyme important in the generation of prostaglandins.
Aspirin irreversibly inhibits cyclooxygenase whereas other NSAIDs reversible inhibit it. Only
small amounts of Aspirin are needed to affect the majority of platelets in the system and this
effect lasts for the duration of the platelets life cycle of approximately 10 days.