YL7
Cardiology Module [Internal Medicine]
29 June 2011
REVIEW OF BASIC BIOLOGY AND APPROACH TO CARDIOVASCULAR DISEASES
Dr. Erric Cinco
OUTLINE
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
INTRODUCTION
NORMAL CARDIOVASCULAR ANATOMY AND PHYSIOLOGY
CONGENITAL HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DI SEASE
INFECTIVE ENDOCARDITIS
HYPERTENSION
PROLAPSED MITRAL VALVE
ISCHEMIC HEART DISEASE
AORTIC DISSECTION
PERICARDITIS
CONGESTIVE HEART FAILURE
I. Introduction
1.
Health Statistics
Figure:
1.
The Cardiac Cycle

Five phases

Phases overlap slightly as one flows into another
a) Atrial Systole
II. Normal Cardiovascular Anatomy and Physiology
b)
Group 01
Almajar, Alog, Buemio, Delos Arcos, Manuel, Rabanal

designated beginning of cycle

atrial contraction

mitral & tricuspid valves open

ejection of blood into ventricles

often called 'atrial kick'
Isovolumetric Contraction
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
atrial systole
The phases of the cardiac cycle:
1. atrial systole
2. isovolumetric ventricular contraction
3. ventricular ejection
4. isovolumetric ventricular relaxation
5. ventricular filling
c)

rapid increase in ventricular pressure

ventricular blood volume unchanged

coronaries heavily constricted

majority of myocardial consumption

onset of systole
Ventricular Ejection

d)
1st - initial slow ejection of blood volume as
aortic & pulmonic valves open

2nd - rapid ejection of approx. 75% of blood
volume

3rd - final slow ejection of remaining blood
volume
Isovolumetric Relaxation




e)
all 4 valves close
rapid decrease in ventricular pressure
little or no change in blood volume
beginning of coronary filling as myocardium
relaxes

onset of diastole
Ventricular Filling
2.
During Diastole:
o Tricuspid and mitral valves are open
o Blood leaves atria and fills ventricles
o Pressured between the atria and ventricles equalize
3.
During Systole:
o Pulmonic and aortic valves are open
o Blood is rapidly ejected from ventricle into aorta or
pulmonary artery
o Systolic pressures between the ventricle and artery
equalize
COMMON CARDIOVASCULAR DISEASES

Group 01
passive flow of blood from atria into ventricles
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
III. Congenital Heart Disease

Cyanotic VS. Acyanotic

Aspects of a Symptom
o P – Precipitating or Provoking
o Q - Quality
o R – Region and Radiation
o R - Relieving
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Review of Basic Biology and Approach to Cardiovascular Diseases
o
o
S - Severity
T - Timing
A. Cyanotic
1. Tetralogy of Fallot

BB, 18/F, complaining of shortness of breath
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?

Born blue

Bluish lips and fingertips

Frequent cough and colds as a child

Gets tired easily

Squats to relieve shortness of breath

Physical Exam: Murmur at 4th ICS LPSB
INTERNAL MEDICINE
Figure:
Figure:
2.
Ventricular Septal Defect

Maladie de Roger
o Small VSD produces a very loud murmur
Figure:
B. Acyanotic
1. Atrial Septal Defect (ASD)

Fixed split s2

Palpable P2 if with pulmo htn

RVH

Tricuspid regurgitation murmur
Figure:
3.
Patent Ductus Arteriosus

Continuous machinery like murmur

Continuous because Ao pressure is greater than PA
pressure in both systole and diastole
Figure:
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
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IV. Rheumatic Fever
 RF, 18/F, complaining of fever and rash
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?
Figure:
Figure: First Degree AV Valve
1992 Revised Jones Criteria for Rheumatic Fever: Two major or one
major and two minor manifestations plus evidence of preceding
group A streptococcal infection
MAJOR
MINOR

Carditis

Clinical: fever,
polyarthralgia

Polyarthritis

Laboratory: elevated

Chorea
erythrocyte sedimentation

Erythema marginatum
rate or leukocyte count

Subcutaneous nodules

Electrocardiogram:
prolonged P-R interval
Supporting evidence of a preceding streptococcal infection within
the last 45 days

Elevated or rising anti-streptolysin O or other streptococcal
antibody, or

A positive throat culture, or

Rapid antigen test for group A streptococcus, or

Recent scarlet fever
V. Valvular Heart Disease
 RH 30/F complaining of shortness of breath
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?
 History of Rheumatic Fever
 Poor compliance with advise to get injections
 No other co-morbidities
1.
Mitral Stenosis

Palpable P2

RV heave

Loud s1

Opening snap

Diastolic rumble

Usually with associated tricuspid regurgitation
Figure:
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
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Figure:
Figure:
Figure: AR: biggest heart
4.
Aortic Stenosis
5.
Summary
Figure: 2D Echo
Figure: Left Atrial Enlargement
2.
3.
Mitral regurgitation
Aortic Regurgitation
o Giant hearts
o Lottsa eponyms
NORMAL VALVE Operation
Valve closes after left ventricle
pumps blood into aorta
Group 01
Leakage of valve (Aortic)
Valve does not close completely,
leaking blood into the heart
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
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Figure: Osler’s nodes: tender, papulopustules located on the pulp of
the finger in a patient with endocarditis caused by Staphylococcus
aureus
*SEE APPENDIX B*
VI. Infective Endocarditis
 IE, 35/F, complaining of fever
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?
 History of Rheumatic Heart Disease
 Had recent dental procedure
 No other co-morbidities
Figure: Splinter hemorrhages: linear reddish brown lesions, seen in
the nail bed of this patient with bacterial endocarditis due to group B
streptococcus.
Figure: Janeway lesion (arrow) occurred on the palm in this patient
with bacterial endocarditis sue to Streptococcus bovis. These lesions
are macular, blanching, and nonpainful, and are located on the palms
and soles.
Figure: Subconjunctival petechiae: prominent in this case of bacterial
endocarditis caused by Staphylococcus aureus.
The Duke Criteria for the Clinical Diagnosis of Infective Endocarditis
Major Criteria
1. Positive blood culture

Typical microorganism for infective endocarditis from two
separate blood cultures
o Viridans streptococci, Streptococcus bovis, HACEK
group, Staphylococcus aureus

Community-acquired enterococci in the absence of a primary
focus or
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
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

Persistently positive blood culture, defined as recovery of a
microorganism consistent with infective endocarditis
from: Blood cultures drawn >12 h apart; or
All of three or a majority of four or more separate blood
cultures, with first and last drawn at least 1 h apart Single
positive blood culture for Coxiella burnetii or phase I IgG
antibody titer of >1:800
2. Evidence of endocardial involvement

Positive echocardiograma

Oscillating intracardiac mass on valve or supporting structures
or in the path of regurgitant jets or in implanted material, in the
absence of an alternative anatomic explanation, or

Abscess, or

New partial dehiscence of prosthetic valve, or

New valvular regurgitation (increase or change in preexisting
murmur not sufficient)
Minor Criteria
1. Predisposition: predisposing heart condition or injection drug use
2. Fever 38.0°C (100.4°F)
3. Vascular phenomena: major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival
hemorrhages, Janeway lesions
4. Immunologic phenomena: glomerulonephritis, Osler's nodes,
Roth's spots, rheumatoid factor
5. Microbiologic evidence: positive blood culture but not meeting
major criterion as noted previouslyb or serologic evidence of active
infection with organism consistent with infective endocarditis
VII. Hypertension
 BB, 40/M, complaining of nape pain
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?
o How will you treat this patient?
 Smoker
 Likes fatty food
 Sedentary lifestyle
 Family history of hypertension
 Physical Exam: BP 180/100
1. Relationships Between Blood Flow, Pressure and Resistance
•
The relationship of flow, pressure, and resistance is
analogous to the relationship of current (I), voltage (ΔV),
and resistance (R) in electrical circuits, as expressed by
Ohm's law (Ohm's law states that ΔV = I × R or I = ΔV/R).
•
Blood flow is analogous to current flow, the pressure
difference or driving force is analogous to the voltage
difference, and hydrodynamic resistance is analogous to
electrical resistance.
•
The equation for blood flow is expressed as follows:
Q = ΔP/R
o Q = Flow (mL/min)
o ΔP = Pressure difference (mm Hg)
o R = Resistance (mm Hg/mL/min)

The equation for blood pressure and resistance:
BP = CO x TPR
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
o
o
INTERNAL MEDICINE
Given CO = SV x HR
BP = SV x HR x TPR
VIII. Prolapsed Mitral Valve
 MP, 20/F, complaining of chest pain
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?
 Palpitations
 No co-morbidities
IX. Ischemic Heart Disease

AP, 50/M, complaining of chest pain
o What questions will you ask?
o What physical exam findings will you look for?
o What laboratory tests will you order?
o What is your diagnosis?
o How will you treat this patient?

Smoker

Likes fatty food

Sedentary lifestyle

Polyuria, Polydipsia, Polyphagia

Hypertensive

Diabetic
Figure:
Figure:


Cardiac Enzymes
o CK-MB
o Troponin
Heart Disease can progress very slowly, often without
symptoms.
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Review of Basic Biology and Approach to Cardiovascular Diseases



Often the first sign that something may be wrong can be
angina or even a heart attack.
It is important to look out for risk factors often seen in
patients with CAD.
Poiseuille Equation: Resistance to Blood Flow
o The factors that determine the resistance of a blood
vessel to blood flow are expressed by the Poiseuille
2.
INTERNAL MEDICINE
Anterolateral Wall MI
equation:
R = Resistance
η = Viscosity of blood
l = Length of blood vessel
r4 = Radius of blood vessel raised to the fourth power
Figure: Coronary Angiographic Findings of a Patient with
Anterolateral MI
3. Inferior Wall MI
Figure:
Figure: ST-elevation – changes associated with ischemia
1.
Anterior Wall MI
*SEE APPENDIX C*
X. Aortic Dissection
•
Pain radiates to the back
•
May have unequal pulses
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
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Review of Basic Biology and Approach to Cardiovascular Diseases
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Figure: X-Ray demonstrating widened mediastinum in a patient with
aortic dissection.
Figure:
Figure: @D Echo showing aortic dissection
Figure:
Figure: CT Scan showing aortic dissection
*Two most widely used classifications of aortic dissection SEE
APPENDIX D*
XI. Pericarditis
•
Maybe preceded or accompanied by fever
•
Pain is aggravated by lying down, relieved with sitting up
•
Pericardial friction rub
•
Dressler’s Syndrome - Post-MI pericarditis
Figure:
XII. Congestive Heart Failure

Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
BB, 50/F, complaining of shortness of breath
o What questions will you ask?
o What physical exam findings will you look for?
Page 9 of 13
Review of Basic Biology and Approach to Cardiovascular Diseases

o What laboratory tests will you order?
o What is your diagnosis?
Prior MI











Paroxysmal nocturnal
dyspnea
Neck vein distention
Rales
Radiographic cardiomegaly
Acute pulmonary edema
S3 gallop
Central venous pressure
greater than 16 cm water
Circulation time of 25
seconds
Hepatojugular reflux
Pulmonary edema, visceral
congestion, or cardiomegaly
at autopsy
Weight loss of 4.5 kg in 5
days in response to
treatment
INTERNAL MEDICINE







Bilateral ankle edema
Nocturnal cough
Dyspnea on ordinary
exertion
Hepatomegaly
Pleural effusion
A decrease in vital capacity
by one third the maximal
value recorded
Tachycardia (rate of 120
bpm)

Figure:



















SYMPTOMS IN HEART FAILURE
MAJOR
MINOR
Dyspnea

Weight loss
Orthopnea

Cough
Paroxysmal

Nocturia
Nocturnal Dypnea

Palpitations
Ankle edema

Peripheral cyanosis
Pulmonary edema

Depression
Fatigue
Exercise intolerance
Cachexia
Figure:

The Law of Laplace
o Wall tension (T) in a hollow viscus is equal to the
product of the transmural pressure (Pr) and the radius
(r) divided by the thickness of the wall (w):
PHYSICAL FINDINGS IN HEART FAILURE
MAJOR
MINOR
Tachycardia

Mitral regurgitation
Elevated venous pressure

Cardiomegaly
Positive hepatojugular

Splenomegaly
reflux

Hypotension
Pulmonary rales

Pulsus alternans
Tachypnea

Extrasystoles
Third heart sound

Atrial fibrillation
Hepatomegaly

Weight loss
Ankle edema
Ascites
Pleural effusion
FRAMINGHAM CRITERIA FOR CHF: 2 MAJOR; OR 1 MAJOR AND 2
MINOR
MAJOR
MINOR
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
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Review of Basic Biology and Approach to Cardiovascular Diseases
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APPENDICES
A.
TERMS
1. Corrigan's pulse - rapidly rising "water-hammer" pulse, which collapses suddenly as arterial pressure falls rapidly during late
systole and diastole
2. Quincke's pulse - capillary pulsations, an alternate flushing and paling of the skin at the root of the nail while pressure is applied
to the tip of the nail
3. Traube's sign - A booming "pistol-shot" sound can be heard over the femoral arteries
4. Duroziez's sign - to-and-fro murmur audible if the femoral artery is lightly compressed with a stethoscope.
5. Austin Flint murmur - Low-pitched, rough, rumbling murmur that begins in mid-diastole and terminates at the end of diastole
6. Hill sign - Increase in manually measured blood pressure of the lower extremity compared with the upper extremity
7. de Musset sign - Anteroposterior bobbing of the head
8. Mayne sign - More than a 15 mm Hg decrease in diastolic blood pressure with arm elevation from the value obtained with the
arm in the standard position
9. Rosenbach sign - Pulsatile liver
10. Mueller sign - Pulsatile uvula
11. Becker sign - Accentuated retinal artery pulsations
12. Gerhardt sign - Pulsatile spleen
B.
PRINCIPAL CAUSES OF HEART MURMURS
Group 01
Alog, Almajar, Buemio, Delos Arcos, Manuel, Rabanal
Page 11 of 13
YL7
C.
Cardiology Module [Internal Medicine]
29 June 2011
REVIEW OF BASIC BIOLOGY AND APPROACH TO CARDIOVASCULAR DISEASES
Dr. Erric Cinco
DIFFERENTIALS FOR CHEST PAIN
Group 01
Almajar, Alog, Buemio, Delos Arcos, Manuel, Rabanal
Page 12 of 13
YL7
D.
Group 01
Cardiology Module [Internal Medicine]
REVIEW OF BASIC BIOLOGY AND APPROACH TO CARDIOVASCULAR DISEASES
29 June 2011
Dr. Erric Cinco
Two Most Widely Used Classification of Aortic Dissection
Almajar, Alog, Buemio, Delos Arcos, Manuel, Rabanal
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