Cardiac Diseases

Dr Anil Sabharwal
MD
 Cardiac Diseases
1. Disorder of HR, Rhythm & conduction
2. IHD,MI
3. Vascular disease
4. Diseases of heart valves
5. CHD
6. Diseases of myocardium
7. Diseases of pericardium
 Heart
• Along with brain & lung it is part of tripod
of life
• Muscular organ,3layers
• Wt-300 gm
• 4 chambers
• Left side of chest
Diseases of HR, Rhythm, conduction
• Under resting conditions HR is 60-70/mt
• SA node is natural pacemaker
• SA node is controlled by autonomic NS-vagus
causes inhibition & sympathetic nerves cause↑ HR
• Sympathetic stimulation eg exercise, emotional
stress, fever, CHF →↑ HR
• In diabetes autonomic nerves are damaged so
there is little variation in HR
 Heart Rate-Bradycardia
• Bradycardia :HR<60/mt
1) Sinus bradycardia- ↓automaticity -
2) AV block-nodal or idioventricular rhythm
 Rhythm disorder-arrythmia
• Sinus arrhythmia:-normal,↑ HR during
inspiration, ↓HR during expiration
• Sinus bradycardia: asymptomatic-no
treatment, symptomatic-atropine or pace
maker
• Sinus tachycardia: anxiety, fever, anemia,
CHF, thyrotoxicosis, drugs eg
bronchodilator
 Atrial tachyarrhythmias
• Atrial ectopic beat
• Atrial tachycardia
• Atrial flutter-atrial rate appr 300/mt
• Atrial fibrillation-irregularly irregular
 Supraventricular tachycardia
• AV nodal re entry tachycardia (AVNRT)
HR-140-220/mt ,re-entry phenomenon,
lasts from few seconds to few hours
• Atrioventricular re-entry tachycardia &
WPW syndrome
 Sino atrial Disease-sick sinus
syndrome
• Sinus bradycardia
• Sinoatrial block
• PSVT
• Paroxysmal atrial fibrillation
• Atrioventricular block
 Atrio ventricular or BBB
• 1st degree
• 2nd degree-Mobitz typeI,Mobitz typeII
• 3rd degree

• RBBB
• LBBB
 Ventricular tachyarrythmia
• Ventricular ectopic
• VT
• VF
 Heart
• Heart acts as 2 separate pumps operating
side by side.
• LV Systolic pressure is 4 times>right &
wall of LV is usually 1cm thicker than right
• Coronary circulation: left & right coronary
Art. just distal to aortic valve & it’s filling
is during diastole.
 Heart
• Nerve supply-sympathetic & para
sympathetic
• At rest vagal activity predominates & HR is
slow. adrenergic stimulation is associated
with exercise, fever, stress→ ↑HR
 Atherosclerosis
• Atherosclerosis is a progressive inflammatory
disorder of arterial wall that is characterized
by focal lipid rich deposits called atheroma
• Complications of atheroma

1)Impaired perfusion or obstruction

2)Ulceration→thrombus or embolization
 Atherosclerosis
• In established atherosclerotic plaque
macrophages mediate inflammation &
smooth muscle cells promote repair. If
inflammation predominates plaque becomes
unstable →ulceration & throbosis
 IHD-Risk Factors
• Family H/O CAD-due to shared genetic, environmental
&life style factors
• Male : Female 4:1
• Age: peak age M-50-60,F 60-70
• Glucose intolerance, insulin resistance
• Lipid disorder-cholesterol, triglycerides, apolipo
• Hypertension
• Cigarette smoking-tobacco use-avoidable cause
• Diet: deficient in fresh fruits ,vegetables & PUFA→high
risk
 Atherosclerosis
• Diabetes Mellitus
• Physical Inactivity- doubles the risk
• Obesity-central
• Alcohol –small amount offer some
protection,heavy→HT
• Other factors like increased homocystine or
hypo estrogenemia
 CAD
• Stable angina -fixed atheromatous stenosis
• Unstable angina –unstable plaque
• MI
• Heart failure
• Arrhythmia
• Sudden death
 Diseases of myocardium &
pericardium
• Acute myocarditis: viral, bacterial, fungal,
rickettsial,spirochetal or parasitic agent & toxins, drugs &
immunological disorders.
• Infectious myocarditis: follows URTI (coxsackie &
influenza virus- immuno compromised patients have more
chances)
• C/F: no symptoms, chest pain, severe CHF
• Enzymes ↑ ,CPK-MB, Troponin I & T
• ECG: tachycardia, arrhythmias, intra ventricular
conduction abnormalities
• ECHO: Cardiomegaly & contractile dysfunction.
• Treatment-adequate rest, specific antimicrobial
 Drug induced & toxic myocarditis
• Emetine, Doxorubicin & other cytotoxic drugs
Catecholamines (pheochromocytoma) →
inflammation & necrosis→ CHF
• Phenohiazine, lithium, chloroquine, antimony &
Arsenic compounds→ ECG changes &CHF
• Hypersensitivity:sulphonamides,penicillins
• Cocaine
• Radiation,
 Dilated Cardiomyopathy
• Causes: idiopathic, alcoholic, postpartum
• C/F:CHF,
• ECG: low voltage QRS, intraventricular
conduction defect
• X-ray chest: cardiomegaly
• ECHO:LV dilatation, global dysfunction
• Treatment-CHF beta blockers, ace
inhibitors
 Hypertrophic cardiomyopathy
• Autosomal dominant
• C/F: dyspnea, chest pain, syncope,sudden death
during vigorous exercise
• ECG:LVH,
• ECHO: asymmetric septal hypertrophy,↑
contractility, dynamic LV outflow obstruction
• Treatment: beta blocker, calcium channel blocker,
ICD (Intra cardiac defibrillator) device
• Surgery
 Restrictive cardiomyopathy
• Impaired diastolic filling because ventricles
are stiff .Contractile function are preserved
• Causes: Amyloidosis, radiation, myocardial
fibrosis, sarcoidosis,hemochromatosis
• Diagnosis-echo, CT or MRI
 ARF-treatment
• Bed rest, Aspirin 0.6-0.9 g 4 hourly,
penicillin, erythromycin
• Prevention of recurrence-till age of 30
 RHD
• RF→ rigidity & deformity of valve cusps
• Mitral valve alone is affected 50-60 %, combined
mitral & aortic 20 % times ,pure aortic valve
involvement less common, tricuspid valve affected
10 % along with mitral or aortic involvement
• Stenosis or regurgitation or combination
• Prophylaxis for SABE for dental extraction or
other surgery
 Diseases of pericardium
• Acute pericarditis-acute inflammation
• Causes: infection( viral, bacterial, tubercu
losis) autoimmune syndrome, uremia,
neoplasm, radiation, drug toxicity, post MI
• C/F: chest pain, fever, dyspnea O/E –rub
• Lab-↑ TLC, ECG-ST elevation
• X-ray-cardiomegaly
• Echo-
 Pericardial effusion
• Collection of fluid in pericardium
• Cardiac tamponade-↑ intra pericardial pressure>15 mm
Hg→ restriction of venous return & ventricular filling
→shock & death
• C/F-asymptomatic, pain, dyspnea,
• O/E-rub, edema, ascites
• X-ray ↑cardiac shadow,
• ECG-T wave changes, Low voltage QRS
• ECHO
• Treatment-Tamponade-emergency removal of fluid
 Constrictive Pericarditis
• Inflammation→ thick, fibrosed & adherent
pericardium which restrict diastolic filling
→chronic elevated venous pressures
• Causes: tuberculosis, radiation, cardiac surgery,
viral pericarditis
• C/F dyspnea, fatigue, weakness
• O/E: edema, hepatic congestion, ascites
• X-ray-cardiomegaly, calcification
• ECHO
• Treatment-diuretic, surgery
 Vascular Diseases
• Atherosclerosis-occlusive disease
1)Peripheral
2)Visceral
• Acute arterial occlusion-embolus, thrombus
• Thromboangitis obliterans
• Idiopathic arteritis-of Takayasu (pulse less disease)
• Raynaud’s Disease & Raynaud’s phenomenon
• Aneurysm
• Aortic dissection
• Venous Diseases: Varicose veins, Thrombophlebitis
 Aneurysm
• Weakening of artrial wall from loss of elastin &
collagen→ aneurysmal dilatation
• Aneurysm of abdominal aorta-cause
aorta atherosclerosis-in
25% concomitant occlusive atherosclerosis of lower limbs
• Mostly asymptomatic-detected during physical
examination or USG. Infra renal aorta is 2cm in diameter
in aneurysm it is >4 cm
• Severe abdominal or back pain indicate rupture which has
highmortality
• Treatment-1)Surgical repair,2)Prosthesis
• Aneurysm Thoracic aorta- Syphilis, vasculitis, Marfan’s
syndrome
 Aortic dissection
• H/O HT, Marfan’s syndrome
• Sudden severe chest pain with radiation to
back occasionally migrating to abdomen
• It originates at the site of intimal tear then
propagates distally
• Treatment: treat HT, Surgery
Atherosclerotic Occlusive disease
• Atherosclerosis is more at places of stress
especially at bifurcations
• Symptoms depend on site of occlusion-
 Occlusive disease of iliac arteries

1)Intermittent claudication-pain & weakness of lower limbs

C/F
on walking & relieved after taking rest 2) rest pain means
serious disease 3) Impotence
O/E: absent peripheral pulses, bruit may be heard over aorta,
Systolic BP normally higher in leg is higher in brachial artery
& difference is more during exercise
Investigation: 1)Doppler,2)aortography,3)MRI
Treatment:1)stop smoking 2)Grafting
3)Thromboendarterectomy
 Occlusive Cerebrovascular disease

• TIA-sudden onset of neurological deficit

which resolves completely in 24 hours
• Stroke-neurological deficit beyond 24 hours
• C/F contra lateral weakness or sensory
changes, speech alteration or visual changes
 Aneurysm-Thoracic aorta
• Causes:
 Valvular Heart Disease
• Mitral Stenosis
• Mitral valve size-4-6 cm2, <1cm-critical MS
• Mitral Stenosis- cause RHD
• C/F-dyspnea, orthopnea, PND-symptoms ↑by any
stress like fever, pregnancy
• O/E-S1-↑,Opening snap, diastolic murmur
• ECG-LA abnormality, AF
• ECHO confirms diagnosis & assess severity
• Treatment-
 Mitral Regurgitation
• Causes: RHD,MVP,SABE,PMD,AMI
• C/F-DOE & Fatigue, MVP-chest pain,
palpitation
• O/E-S1↓,Pan systolic murmur, LV
enlargement
 Aortic stenosis
• Causes: Congenital, Bicuspid aortic valve, RHD
• Usually no symptom till 50,DOE,Angina, syncope
• O/E Harsh systolic murmur
• ECG-LVH
• X-ray calcific valve
• Echo
 Aortic Regurgitation
• Causes: Bicuspid, RHD, SABE, trauma
• C/F-Palpitation, dyspnea, angina
• O/E collapsing pulse, bounding pulses,early
diastolic murmur
• ECG-LVH,T↓,
• Chest X-ray-cardiomegaly,
• ECHO:
 Congenital Heart Disease
• CHD-child is born with heart disease .It may
or may not manifest at birth. E.g ASD,
bicuspid aortic valve
• congenital heart disease complicates
approximately 1% of all live births. It occurs
in about 4% of offspring of women with
congenital heart disease. .
 Fetal Circulation
• In fetus oxygenated blood comes through umblical vein to
IVC (Through ductus venosus)→ RA→LA( through foramen
ovale), LV →Aorta
• Venous blood from SVC ,partially mixed with oxygenated
blood in RA→RV→ Pulm A → descending aorta through
ductus arteriosus
• Aortic isthmus is a constriction in aorta which lies in the
aortic arch before the junction with the ductus arteriosus &
limits the flow of oxygen rich blood to descending aorta.
This means that less oxygen rich blood is supplied to organs
which take up function after birth ie GIT, Kidney
 Changes at birth
• Lungs expand with air pulm vascular
resistance ↓ & pulmonary flow starts LA
pressure becomes >LA pr,so foramen ovale
closes. Umblical A & veins close .In nnext
few days ductus arteriosus closes under
influence of prostaglandins & aortic
isthmus closes
 Incidence CHD
VSD 20%
ASD 10%
PDA 10%
PS 7%
Co Aorta 7%
AS 6%
TOF 6%
TGA 4%
Others 20%
 CHD-Causes
• Maternal infection, drugs, toxins
• Rubella→ PDA, PS, AS, ASD
Alcohol→ VSD
Dilantin→ PS, AS,Coarctation of Aorta, PDA
Lithium→Ebstein anomaly, Tricuspid atresia
Genetic & Chromosomal factors
Down’s syndrome (Trisomy 21) ASD
 Clinical Features
• Birth & Neonatal period
• Cyanosis
• Heart failure
• Infancy & Childhood
• Cyanosis
• CHF
• Arrhythmia
• Murmur
• Failure to Thrive
 Clinical Features
• Adolescence & adulthood
• CHF
• Murmur
• Arrhythmia
• Cyanosis-shunt reversal
• Hypertension (Co arctation)
• Central Cyanosis-of cardiac origin occurs when
de saturated blood enters the systemic circulation
without passing through lungs (R→L shunt).
• In neonate cause-TGA,
• In older children VSD with severe PS(TOF)
or with pulm vascular disease (Eisenmenger
syndrome)
• Clubbing-prolonged cyanosis→clubbing
• Early diagnosis important because treatment
is available or many CHD
 Congenital Heart Disease

• ETIOLOGY AND PREVENTION

• Congenital cardiovascular malformations are

generally the result of aberrant embryonic
development of a normal structure, fetal
development. Malformations are due to complex
multifactorial genetic and environmental causes.
• Pulmonary Hypertension . Increases in pulmonary arterial
pressure result from elevation of pulmonary blood flow and/or
resistance, the latter due sometimes to an increase in vascular
tone but usually the result of obstructive, obliterative
structural changes within the pulmonary vascular bed.
• Eisenmenger syndrome is applied to patients with a large
communication between the two circulations at the
aortopulmonary, ventricular, or atrial levels and bidirectional
or predominantly right-to-left shunts because of high-
resistance and obstructive pulmonary hypertension.
PATHOPHYSIOLOGY
• Functionally normal, congenitally bicuspid aortic valve
may thicken and calcify with time, resulting in
significant aortic stenosis;
• A well-tolerated left-to-right shunt of an atrial septal
defect may not result in cardiac decompensation,fourth
or fifth decade.
 Persistent Ductus Arteriosus
• If ductus fails to close after birth→PDA
• Aortic pressure >pulmonary pressure→
continuous flow of blood →(arterovenous
shunt)continuous or machinery murmur
• 50 % of CO recirculates thro lungs→↑work load
on heart
• CHF,dyspnea,palpitation,tachycardia
• Treatment: 1) PG inhibitor-indomethacin,
ibuprofen may induce closure2)device closure
 Coarctation of aorta
• C/F-Important cause of CHF in newborn
• Headache due to HT
• Cramps in legs-due to ↓circulation in legs
• Radio femoral delay
• Systolic murmur due to associated bicuspid valve
• Complications: LVF, Dissection of aorta, cerebral
hemorrhage
• X-ray chest notching of ribs, 3 sign
• Treatment: Surgical
ASD
Erythrocytosis The chronic hypoxemia in
cyanotic congenital heart disease results in
erythrocytosis due to increased
erythropoietin production
• INFECTIVE ENDOCARDITIS
• Routine antimicrobial prophylaxis is recommended for
most patients with congenital heart disease It is
recommended for all dental procedures, gastrointestinal
and genitourinary surgery, and diagnostic procedures
such as proctosigmoidoscopy and cystoscopy.
Prophylaxis includes both chemotherapeutic
(antimicrobial) and nonchemotherapeutic (hygienic)
measures. Meticulous dental and skin care is required.
Teratogenic factors
 ACYANOTIC CONGENITAL
HEART DISEASE
ASD F>M
• The sinus venosus
• Ostium primum
• Ostium secundum –most common
• Flow:LA→RA→RV→pulm. Circulation
• C/F :asymptomatic, Recurrent URTI, often detected on routine
examination
• Wide fixed splitting of 2nd heart sound ,systolic murmur over pulm
valve
• Chest x-ray-cardiomegaly
• ECG –RBB,rSR pattern
• ECHO
• Treatment 1)Device closure,2)Surgical
• Patients with atrial septal defect are usually
asymptomatic in early life,
• Beyond the fourth decade, a significant number of
patients develop atrial arrhythmias, pulmonary
arterial hypertension, bidirectional and then right-
to-left shunting of blood, and cardiac failure.
• Electrocardiogram shows right axis deviation and an rSr¢ pattern in the
right precordial leads Varying degrees of RV and RA hypertrophy may occur
with each type of defect, depending on the height of the pulmonary artery
pressure.
• Chest roentgenograms reveal enlargement of the RA and RV, dilatation of the
pulmonary artery and its branches, and increased pulmonary vascular
marking.
 VSD
Ventricular septum has –membranous &
muscular portion
Most VSD are peri membranous
C/F-flow LV→RV→ pan systolic murmur
Small defect loud murmur, large defect soft
murmur
CHF
Treatment:surgical closure
 TOF
• PS
• Overriding of aorta
• VSD
• RVH
• C/F-cyanosis ,clubbing, polycythemia, systolic murmur
• Fallot’s spell -↑cyanosis after crying→ attack or
feeding→ apnoea & unconsciousness
• ECG-RVH,X ray-boot shape
• Treatment-surgical correction
 Other causes of cyanoticCHD
• Tricuspid atresia- absent tricuspid
orifice,VSD
• Pulmonary atresia
• TGA
• Ebstein anamoly –TV is dysplastic &
displaced into RV