APPROACH TO A PATIENT

WITH
CARDIOVASCULAR DISORDER
MPPRC CONFERENCE
Group 1 2-A
A Abella - M Alivia

Health History

Aguda, Eunice Heincy H.

LMS, 73 year old male , retired mechanical engineer

Chief complaint: Chest Pain

HISTORY OF PRESENT ILLNESS:
3 months

(+) easy fatigability

(+) intermittent chest pain - midsternal, 5/10 during
activity & at rest unrelieved by ISDN
advised to undergo angioplasty at PHC

ADMISSION
3

Past Medical
AdultHistory
Illnesses

Aguda, Eunice Heincy H.

1988 - Nephrolithiasis leading to recurrent UTI

1991 - Coronary Artery Disease
1998 - Diabetes Mellitus Type II
2006 - 3 vessel CAD s/p MI
11/24/2006 - Percutaneous Transluminal Coronary
Angioplasty of the LAD and 1 left circumflex artery

Injuries: 1988 - torn ligament on the left knee

No surgery, transfusions and allergies
Immunization unrecalled, no adult immunization
4

Past Medical
Health Status: regular medical visits, blood tests
History

Aguda, Eunice Heincy H.

Medications:
Glicazide (Diamicron MR) 30mg/tab 1 tab once a day
Atorvastatin 10mg/tab 1 tab once a day
Aspirin 80mg/tab once a day
Clopidogrel 75mg/tab 1 tab once a day
Methycobal 1 cap three times a day
5

Aguda, Eunice Heincy H.

Personal and Social History

Diet: prefers pork, eats vegetables and rice

Exercise: biking - 2-3km for 1 hour every day
Sleep: 8 hours
Alcohol: alcoholic beverage drinker
Type: Brandy, beer
Amount: 1 shot
Frequency: every night for 20 years
Smoking: 47-pack years - stopped in 2005

Environmental Exposure:

none

Aguda, Eunice Heincy H.

Personal and Social History

Denies illicit drug use
Married
Lives with his wife and son
No significant life events

Aguda, Eunice Heincy H.

Family History
Father - (+) Coronary Artery Disease (CAD)
- Dissecting Aneurysm (deceased)
Son
- (+) Myocardial Infarction
(deceased - 40 y/o )

Aunt

- (+) CAD

Aguda, Eunice Heincy H.

Review of Systems
General: (-) weight loss, (-) fever, (-) fatigue, (-) chills (+) easy fatigability, no
changes in sleep patterns
Skin: (-) pruritus, (-) jaundice, no excessive sweating
Head: (-) headache, (-) dizziness, (-) loss of consciousness
Eyes: (-) excessive lacrimation, (-) blurring of vision, (-) eye pain, (-) stiffness,
(-) limitation of motion, (-) neck masses
Ears: (-) hearing loss, (-) tinnitus, (-) discharge
Nose: (-) sinusitis, (-) epistaxis, (-) nasal discharge
Throat & Mouth: (-) sore throat, (-) dysphagia, (-) gum bleeding, (-) mouth
sores, (-) voice changes
9

Aguda, Eunice Heincy H.

Review of Systems
Neck: (-) stiffness, no limitation of motion, (-) masses
Breast: (-) masses, (-) discharge, (-) trauma
Pulmonary: (-) cough, (-) difficulty of breathing, (-) cough, (-) cyanosis, (-)
wheezing,
Vascular: no phlebitis, no varicosities on both lower extremities
Gastrointestinal: no changes in appetitite, (-) intolerance of any class foods,
(-) abdominal pain, (-) heartburn (-) nausea, (-) vomiting, (-) hematemesis, (-)
constipation, (-) changes in stool color

10

Aguda, Eunice Heincy H.

Review of Systems
Genitourinary: (-) dysuria, (-) flank or suprapubic pain, (-) urgency, (-)
frequency, (-) hematuria, (-) dribbling
Musculoskeletal: (+) joint pain on the left knee, no limitation of movement, (-)
bipedal edema, (-) swelling
Endocrine: No heat-cold intolerance, (-) polyphagia, (-) polydipsia, (-)
polyuria, (-) nocturia
Hematopoietic: (-) abnormal bleeding, (-) anemia, (-) bruising, (-) pallor
Neurologic: (-) syncope, (-) seizures, (-) weakness or paralysis, (-) loss of
memory
Psychiatry: (-) disorientation, (-) anxiety, (-) depression, (-) delusion,
(-) paranoia, (-) hallucination
11

PHYSICAL EXAMINATION

12

GENERAL SURVEY
ADMISSION ( Jan. 27, 2016)

GROUP PE ( Jan. 29, 2016)

awake

alert, awake, conscious. coherent

alert

lying on the bed, ambulatory

conscious and coherent

not in cardiorespiratory distress

not in cardiorespiratory distress

hyposthenic, no gross body

deformity noted

13

VITAL SIGNS AND ANTHROPOMETRIC MEASUREMENTS

ADMISSION ( Jan. 27, 2016)

GROUP PE ( Jan. 29, 2016)

BP: 120/70 mmHg

BP: 130/90 mmHg

PR: 72, regular

PR: 108, regular

RR: 18, regular

RR: 26, regular

Temp: 36.5 C

Temp: 36.1 C

Wt. 64.5 kg

Wt. 64.5 kg

Ht: 165 cm

Ht: 165 cm

BMI: 23.7

BMI: 23.7

14

SKIN
ADMISSION ( Jan. 27, 2016)
warm
wrinkled
dry skin
(-) jaundice

GROUP PE ( Jan. 29, 2016)

warm, moist to touch, good skin
turgor
hair is thinly distributed over the
extremities
(-) jaundice or any other skin
discolorations
(-) clubbing
15

HEENT
ADMISSION ( Jan. 27, 2016)
Head
Normocephalic
thinly distributed hair
Eyes
anicteric sclera
pale palpebral conjunctiva
2-3mm ERTL
intact EOM
Nose:
nasal septum at midline
(-) nasal discharge
non congested turbinates

GROUP PE ( Jan. 29, 2016)

Head
no gross lesions or deformities
Eyes
anicteric sclera, pale palpebral
conjunctiva, 2-3mm ERTL, intact
EOM
Nose:
nasal septum at midline
(-) nasal discharge, (-) sinus
tenderness, non congested
turbinates

16

HEENT
ADMISSION ( Jan. 27, 2016)
Mouth
moist
midline uvula and tongue
non hyperemic posterior
pharyngeal wall

GROUP PE ( Jan. 29, 2016)

Mouth
moist, midline uvula and tongue
upon protrusion, non hyperemic
posterior pharyngeal wall, no
exudates
(-) cyanosis and oral lesions

no exudates

17

NECK
ADMISSION ( Jan. 27, 2016)

GROUP PE ( Jan. 29, 2016)

Full ROM

Trachea is midline

Thyroid gland not enlarged, smooth

lobes, rises with deglutition, no
bruit

Thyroid gland not enlarged,moves

with deglutition, no bruit
Full ROM

18

THORAX/LUNGS
ADMISSION ( Jan. 27, 2016)

GROUP PE ( Jan. 29, 2016)

Symmetrical chest expansion

Symmetrical chest expansion

equal tactile fremiti on both sides

equal tactile fremiti on both sides

resonant

resonant

clear breath sounds

no adventitious breath sounds

19

CARDIOVASCULAR
ADMISSION ( Jan. 27, 2016)
adynamic precordium
apex beat at the 5th LICS AAL
(-) heaves
(-) thrills
(-) lifts
S1 louder at the apex
S2 louder at the base
(-) murmur

GROUP PE ( Jan. 29, 2016)

JVP 3 cm at 30 degrees
Carotid artery pulse: brisk
upstroke, gradual less abrupt
downstroke
Peripheral pulses: equal bilaterally
on upper and lower extremities
(++)
Adynamic precordium
Apex beat at the 5th LICS AAL
(-) heaves, lifts, thrills, murmur
S1 louder at the apex

20

GASTROINTESTINAL
ADMISSION ( Jan. 27, 2016)
flat
no abdominal pulsations or
peristalsis noted
normoactive bowel sounds
tympanic upon percussion
soft, no masses, no tenderness
noted

GROUP PE ( Jan. 29, 2016)

flat
no abdominal pulsations noted
soft, no masses, no tenderness noted

21

MUSCULOSKELETAL
ADMISSION ( Jan. 27, 2016)
5/5 on all extremities

GROUP PE ( Jan. 29, 2016)

5/5 on all extremities

22

EXTREMITIES
ADMISSION ( Jan. 27, 2016)

GROUP PE ( Jan. 29, 2016)

No bipedal edema

No bipedal edema

pulses full and equal

pulses full and equal

no cyanosis

no cyanosis

no clubbing

no clubbing
no varicosities or lesions

23

NEUROLOGIC
ADMISSION ( Jan. 27, 2016)
GCS 15 (E4V5M6)
CN II - pupils 2-3mm ERTL
CN III, IV, VI - primary gaze midline,
EOMs full and equal
CN V - no sensory deficit, can clench
teeth
CN VII - able to raise eyebrows, close
eyes against resistance, puff cheeks

GROUP PE ( Jan. 29, 2016)

GCS 15 (E4V5M6)
CN I - no problem in smelling
CN II - pupils 2-3mm ERTL
CN III, IV, VI - primary gaze midline,
EOMs full and equal
CN V - no sensory deficit, can clench
teeth
CN VII - able to raise eyebrows, close
eyes against resistance, puff cheeks

24

NEUROLOGIC
ADMISSION ( Jan. 27, 2016)

GROUP PE ( Jan. 29, 2016)

CN VIII - gross hearing intact

CN VIII - gross hearing intact

CN IX, X - uvula at midline

CN IX, X - uvula midline

CN XI - able to shrug shoulders with

resistance

CN XI - able to shrug shoulders with

resistance

CN XII - tongue midline upon protrusion

CN XII - tongue midline upon protrusion

Reflexes: ++ on all extremities

25

Salient Features
73yo male, retired engineer
CC: Chest Pain

Subjective

Coronary Artery Disease (since 1991)

Easy fatigability
Chest pain upon exertion and at rest
47 pack year smoker
(+) Diabetes Mellitus II
Alcoholic beverage drinker
(+) CAD - Father and Aunt
(+) MI- Son

26

Salient Features
Objective
Positive

Negative

BP: 130/90
PR: 108, regular
Neck veins not distended
JVP 3 cm at 30 degrees
Adynamic precordium
Apex beat at 5th LICS, AAL
(-) Heaves, lifts, thrills
S1 louder at the apex, S2 at the base
(-) murmurs
(-) cough, (-) difficulty of breathing, (-) cyanosis,
(-) wheezing,

27

AGRAVIO, J.N/ ALCANTARA, F.L

DIFFERENTIAL DIAGNOSIS
CHEST PAIN
CARDIOPULMONARY

NON-CARDIOPULMONARY

CARDIAC PULMONARY VASCULAR

MYOCARDIAL ISCHEMIA
PERICARDITIS

Reference: Harrisons Principle of Internal Medicine 19th Edition

28

AGRAVIO, J.N/ ALCANTARA, F.L

Reference: Harrisons Principle of Internal Medicine 19th Edition

29

RADIOLOGY

Chest X-ray
images the heart and surrounding thoracic
anatomy, shows heart size and shape and reveals
whether the heart is enlarged due to a disease

 Borders of the heart

Right ventricle - anterior

surface of the heart
Right atrium - right border
Left ventricle - left border
Left atrium - posterior border

Increased cardio thoracic ratio (>0.5)

ELECTOCARDIOGRAM
Graphic representation of electrical
activity of the heart
Recorded from electrodes at various
locations on the patients skin
Extremities
Chest wall

ECG LEADS: display instantaneous

differences in potential between
electrodes

ECG Leads
Limb leads

Lead 1 and aVL- facing the

lateral wall of the heart
Lead II, Lead III, aVF - facing
inferior of the heart
aVR - oriented to the cavity of
the heart

Precordial leads

V1, V2 - facing the septal wall

V3, V4 - facing the anterior
wall of the heart
V5, V6 - facing the lateral wall
of the heart

2D Echo

Adornado, Josemarie

Versatile imaging modality for the

management of patients with chest pain
Provides a rapid evaluation of regional
systolic function

Adornado, Josemarie

Global Wall Motion Score

1 Normal
contraction or
hyperkinesia
2 Hypokinesis,
3 Akinesia,
4 Dyskinesia, and
5 Aneurysmal
segments

Wall motion score index :

1.11.9 -small infarct size
>2.0 predict the occurrence of
complications

Adornado, Josemarie

Coronary Angiography

X-ray image of blood vessels after

they are filled with a contrast material.
Gold standard" for the evaluation of
coronary artery disease (CAD)
A coronary angiogram can be used to
identify the exact location and
severity of CAD

Adornado, Josemarie

Coronary Angiography
Catheter is put into a blood
vessel
The tube is threaded into your
coronary arteries
Dye is released into your
bloodstream.
Special x rays are taken
Doctor examines the flow of
blood

Cardiac Markers

Adornado, Josemarie

Diagnosis for patients with chest pain

and suspected acute coronary
syndrome (ACS)
Measurement help diagnose Acute coronary
syndrome and cardiac ischemia, conditions
associated with insufficient blood flow to the
heart

Cardiac Markers

Adornado, Josemarie

Cardiac
Marker

Normal
Value

Rise

Peak

Return to
Normal

CK-MB

10-13
units/L

3-4 hrs

10-24 hrs

2-4 days

2-4 hrs

10-24 hrs

5-14 days

Troponin T < 0.1 ng/ml

Troponin
(I or
is the most
ordered
most days
specific
Troponin
I T)this
< 1.5 ng/ml
2-4commonly
hrs
10-24
hrs and 5-10
of the cardiac markers
CK-MB help detect a second heart attack that occurs shortly after the
first
LDH-1 LDH activity from MI is characterized by a predominance of the
LDH-1 band.

MRI
evaluating the anatomy of the heart chambers,
valves, size and blood flow through major vessels,
and surrounding structures
uses a large magnet and radiofrequency waves to
produce high quality images
does not use ionizing radiation

Questions and
Clarifications

46

PATHOGENESIS
47

Agron, Rey Mark G.

CHEST PAIN
CHEST DISCOMFORT
unpleasant sensation
in the anterior wall of
the thorax

48

Agron, Rey Mark G.

Patterns of Angina
Stable (reversible)

Unstable (progressive)

When the heart is

stressed (as in exercise
or in sympathetic
response)
In a crescendodecrescendo pattern
For short periods of time
(2-10 minutes)

At random
In no particular
pattern
For longer periods of
time and with
increasing frequency
Is unalleviated by rest
49

Agron, Rey Mark G.

ATHEROSCLEROSIS
VS
CORONARY ARTERY DISEASE

50

Agron, Rey Mark G.

ATHEROSCLEROSIS
Characterized by intimal lesion called
atheromas that protrude into the
vessel lumen
Results in mechanical obstruction of
blood flow and/or catastrophic vessel
thrombosis
Harrisons Principles of Internal Medicine 17th Ed

51

Agron, Rey Mark G.

ATHEROSCLEROSIS
ESTABLISHED RISK FACTORS FOR ATHEROSCLEROSIS
MODIFIABLE

UNMODIFIABLE

Cigarette smoking
Dyslipidemia
Hypertension
Diabetes Mellitus
Obesity
Sedentary Lifestyle

Family history of premature

coronary heart disease
Age (men45 years and
women55 years)
Gender
Harrisons Principles of Internal Medicine 17th Ed

52

Agron, Rey Mark G.

ATHEROSCLEROSIS

53

Agron, Rey Mark G.

PATHOGENESIS OF
ATHEROSCLEROSIS

Robbins & Cotran

Pathologic Basis of 54
Disease 9th edition

Agron, Rey Mark G.

PATHOGENESIS OF
ATHEROSCLEROSIS

Robbins & Cotran

Pathologic Basis of 55
Disease 9th edition

Agron, Rey Mark G.

PATHOGENESIS OF
ATHEROSCLEROSIS

Robbins & Cotran

Pathologic Basis of 56
Disease 9th edition

Agron, Rey Mark G.

ATHEROSCLEROSIS

57
Robbins & Cotran Pathologic Basis of Disease 9 th edition

Agron, Rey Mark G.

Coronary Artery Disease

Result of atheromatous plaque buildup
in the coronary arteries Blockages
Arteries become narrow and rigid
blood flow to heart
blood flow insufficient delivery of
oxygen to the heart myocardial
oxygen requirements > myocardial
oxygen supply myocardial
ischemia
58

Agron, Rey Mark G.

Heart Rate
Myocardial Contractility
Myocardial Wall Tension

O2 levels
Coronary Blood Flow

Myocardial Oxygen
Demand

Myocardial Oxygen
Supply

59

Agron, Rey Mark G.

/N
/N

Heart Rate
Myocardial Contractility
Myocardial Wall Tension

n
e
g
y
x
lO
a
i
d
r
a
c
Myo
d
n
a
m
e
D

O2 levels
Coronary Blood Flow

n
e
g
y
x
O
l
a
i
d
r
a
Myoc
Supply

60

Agron, Rey Mark G.

61

Agron, Rey Mark G.

Robbins & Cotran

Pathologic Basis of
Disease 9th edition

62

Agron, Rey Mark G.

Coronary Artery Disease

Reduction of lumen of the coronary
arteries
Increase in oxygen demand
Myocardial Ischemia
Chest Pain
63

Agron, Rey Mark G.

PATHOLOGY

64

Agron, Rey Mark G.

NORMAL VESSEL

65
Robbins & Cotran Pathologic Basis of Disease 9 th edition

Agron, Rey Mark G.

Plaque
Stable

Vulnerable

66

Agron, Rey Mark G.

Plaque
Vulnerable

Stable

67
. Journal of the American Society of Cardiology, 61, 1041-1051

Agron, Rey Mark G.

Coronary Artery
Gross

Microscopic

Robbins & Cotran Pathologic Basis of Disease 9 th edition

68

Agron, Rey Mark G.

Coronary Artery
Gross

Microscopic

Robbins & Cotran Pathologic Basis of Disease 9 th edition 69

Questions and
Clarifications

70

PHARMACOLOGY

71

Advincula, WDC

Objectives
To reduce the symptoms of the patient to
restore quality of life
To prevent complications and recurrence of
CAD
To control the modifiable risk factors associated
with CAD

72

Advincula, WDC

Anti-Coagulants
Aspirin
o MOA: Inhibition of prostaglandin pathway

Clopidogrel
o MOA: Inhibition of ADP-induced platelet activation

Tirofiban
o MOA: glycoprotein IIb/IIIa inhibitor

73

Anti-Coagulants
Efficacy

Safety

Suitability

Cost

++

++

++++

++++

CLOPIDOG
REL

+++

+++

++++

++

TIROFIBAN

++++

++++

ASPIRIN

Advincula, WDC

74

Beta-blockers

Advincula, WDC

MOA: blockage of beta (B1 = heart) adrenergic

receptor in the heart
Contraindications: Asthma, Severe bradycardia, AV
blockade

75

Advincula, WDC

Beta-blockers
Efficacy

Safety

Suitability

Cost

PROPRANOLOL

+++

++

CARVEDIL
OL

+++

+++

++++

+++

ATENOLOL

++++

+++

+++

++

76

MOA:

ACE-Inhibitors

Advincula, WDC

77

Advincula, WDC

ACE-Inhibitors
Efficacy

Safety

Suitability

Cost

CAPTOPRIL

+++

++

++++

ENALAPRIL

++++

+++

++++

+++

LISINOPRIL

++++

+++

++

78

Advincula, WDC

Lipid-controlling medications
Reductase Inhibitors
o MOA: partial inhibition of the HMG-COA reductase
ex. rosuvastatin, atorvastatin

Niacin (vitamin B3)

o MOA: decreases VLDL and LDL but increases HDL

Bile Acid Binding resins

o MOA: binds to bile acid to prevent reabsorption
ex. colestipol, colesevelam

Fibric Acid derivatives

o MOA: acts as a ligand that activates PPAR-a

ex. gemfibrozil, fenofibrate

79

Advincula, WDC

Lipid-controlling medications
Efficacy

Safety

Suitability

Cost

ATORVASTATIN

++++

++

++++

++++

NIACIN

+++

+++

++

+++

GEMFIBROZIL

++

+++

COLESTIPOL

++

+++

++

80

Advincula, WDC

Non-pharmacologic Treatment

#1 Lifestyle Changes!
Controlling major risk factors
CABG
Percutaneous Coronary Intervention (PCI)

81

Advincula, WDC

Coronary Artery Bypass Graft (CABG)

82

Advincula, WDC

Percutaneous Coronary Intervention (PCI)

83

Questions and
Clarifications

84

85