CLINICAL DISCUSSION

Ischemic Cardiomyopathy

What is Ischemic Cardiomyopathy?

Ischemic cardiomyopathy is a term used to describe patients whose heart can no longer pump enough blood to the rest of their body due to coronary artery disease. Coronary artery disease is a narrowing of the small blood vessels that supply blood and oxygen to the heart. These patients often have heart failure.

Causes
Ischemic cardiomyopathy is caused by coronary heart disease -- the buildup of a hard substance called plaque in the arteries to the heart. This may also be called hardening of the arteries. When the arteries that bring blood and oxygen to the heart are blocked or very narrowed, over time, the heart muscle does not work as well. It becomes harder for the heart to fill and pump blood to the body. Patients with this condition usually have a history of heart attacks or angina (chest pain). Ischemic cardiomyopathy is a common cause of heart failure. It is the most common type of cardiomyopathy in the United States. It most often affects middle-aged and elderly people.

Symptoms
Patients with this condition often have had symptoms of angina or a heart attack. Sometimes, patients do not notice any symptoms. Symptoms of heart failure usually develop slowly over time. Common symptoms include:
Cough Fatigue, weakness, faintness Irregular or fast pulse, or a sensation of feeling the heart beat (palpitations) Loss of appetite Shortness of breath, especially with activity Shortness of breath that occurs after lying down Swelling of feet and ankles (in adults) Swelling of the abdomen (in adults) Waking up from sleep after a couple of hours due to shortness of breath

Exams
The physical exam may be normal, or there may be signs that fluid is building up in the body: "Crackles" in the lungs (heard with a stethoscope) Enlarged liver Extra heart sounds Leg swelling Raised pressure in the neck vein

Diagnostics
Echocardiogram Gated SPECT MRI of heart Ventriculogram or cardiac blood pooling imaging Biopsy of the heart is needed in rare cases to rule out other conditions.

Cardiopulmonary Arrest

What is Cardiopulmonary Arrest?

A cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole. A cardiac arrest is different from (but may be caused by) a heart attack (myocardial infarction), where blood flow to the still-beating heart is interrupted (as in cardiogenic shock). Arrested blood circulation prevents delivery of oxygen to ''all'' parts of the body. Cerebral hypoxia, or lack of oxygen supply to the brain, causes victims to lose consciousness and to stop normal breathing, although agonal breathing may still occur. Brain injury is likely if cardiac arrest is untreated for more than five minutes, although new treatments such as induced hypothermia have begun to extend this time. To improve survival and neurological recovery immediate response is paramount.

Causes
Hypovolemia - A lack of circulating body fluids, principally blood volume. Hypoxia - A lack of oxygen delivery to the heart, brain and other vital organs. Hydrogen ions (Acidosis) - An abnormal pH in the body as a result of lactic acidosis which occurs in prolonged hypoxia and in severe infection, diabetic ketoacidosis, renal failure causing uremia, or ingestion of toxic agents or overdose of pharmacological agents, such as aspirin and other salicylates, ethanol, ethylene glycol and other alcohols, tricyclic antidepressants, isoniazid, or iron sulfate.

 Hyperkalemia or Hypokalemia - Both excess and inadequate potassium can be life-threatening. Hypothermia - A low core body temperature, defined clinically as a temperature of less than 35 degrees Celsius (95 degrees Fahrenheit). Hypoglycemia or Hyperglycemia - Low blood glucose from overdose of oral hypoglycemics such as sulfonylureas, or overdose of insulin. Rare endocrine disorders can also cause unexpected hypoglycemia.

Treatment
Tablets or Toxins - Tricyclic antidepressants, phenothiazines, beta blockers, calcium channel blockers, cocaine, digoxin, aspirin, acetominophen. Cardiac Tamponade - Blood or other fluids building up in the pericardium can put pressure on the heart so that it is not able to beat. Tension pneumothorax - The build-up of air into one of the pleural cavities, which causes a mediastinal shift. When this happens, the great vessels (particularly the superior vena cava) become kinked, which limits blood return to the heart. Thrombosis (Myocardial infarction) - If the patient can be successfully resuscitated, there is a chance that the myocardial infarction can be treated, either with thrombolytic therapy or percutaneous coronary intervention. Thromboembolism (Pulmonary embolism) hemodynamically significant pulmonary emboli are generally massive and typically fatal.

CVA Hemorrhagic Infarction

 Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue.
Alternative names: Brain bleeding; Brain hemorrhage; Stroke - hemorrhagic; Hemorrhagic cerebrovascular disease

CAUSES
Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very sensitive to bleeding and damage can occur very rapidly. Bleeding irritates the brain tissue, causing swelling. Bleeding collects into a mass called a hematoma. Bleeding also increases pressure on the brain and presses it against the skull. Hemorrhagic strokes are grouped according to location of the blood vessel: Intracerebral hemorrhage: Bleeding in the brain Subarachnoid hemorrhage: Bleeding in the area between the brain and the thin tissues that cover the brain Hemorrhagic stroke is most often due to high blood pressure, which stresses the artery walls until they break. Other causes of hemorrhagic stroke include:

 Aneurysms, which create a weak spot in an artery wall, which can eventually burst Abnormal connections between arteries and veins, such as anarteriovenous malformation (AVM) Cancer, particularly cancer that spreads to the brain from distant organs such as the breast, skin, and thyroid Cerebral amyloid angiopathy, a build up of amyloid protein within the artery walls in the brain, which makes bleeding more likely Conditions or medications (such as aspirin or Warfarin) that can make you bleed excessively Illicit drugs, such as cocaine

SYMPTOMS
The symptoms vary depending on the location of the bleed and the amount of brain tissue affected. Symptoms usually develop suddenly, without warning, and often during activity. They may come and go (be episodic) or slowly get worse over time. Symptoms may include: Change in alertness (level of consciousness)
Apathetic Coma Lethargy Sleepiness Stupor Unconsciousness Withdrawn

Difficulty speaking or understanding others Difficulty swallowing Difficulty writing or reading Headache
Occurs when lying flat Wakes you up from sleep Gets worse when you change positions or when you bend, strain, or cough Starts suddenly

 Loss of coordination Loss of balance Movement changes, usually

Nausea or vomiting Seizure Sensation changes, usually on only one side of the body
Decreased sensation Numbness or tingling

Weakness of any body part Vision changes

Decreased vision Loss of all or part of vision