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philippine heart center
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PHILIPPINE HEART CENTER OUTPATIENT DIVISION
ALGORITHMS OF
CARDIOVASCULAR DISEASES
CORONARY ARTERY DISEASE HEART FAILURE CONGENITAL HEART DISEASE VALVULAR HEART DISEASE VASCULAR DISEASE MISCELLANEOUS CARDIOVASCULAR DISEASE
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PHILIPPINE HEART CENTER OUTPATIENT DIVISION
ALGORITHMS OF
CARDIOVASCULAR DISEASES
1st Edition, Printed in 2011
This booklet on Algorithms of Cardiovascular Diseases aims to
provide examining physicians, internists and cardiologists
guidelines on the evaluation, management and treatment of
known cardiovascular conditions such as chronic coronary artery
disease, heart failure, congenital heart disease, arrhythmias,
valvular heart disease, vascular disease, and infections and
inflammatory heart disease.
Compiled by Outpatient Division Consultants: • Dr. Euprepes B. Donato • Dr. Antonio C. Pascual • Dr. Annette P. Borromeo
Acknowledgement is due the Clinical Cardiology Division of the
Department of Adult Cardiology for their untiring dedication and
effort to come up with Consensus Guidelines based on Philippine
setting.
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Table of Contents
Page CORONARY ARTERY DISEASE
Chronic Stable Angina 4 HEART FAILURE
Chronic Heart Failure 6 Acute Decompensated Heart Failure 10
CONGENITAL HEART DISEASE Common Congenital Acyanotic Heart Disease 12 Atrial Septal Defect 13 Ventricular Septal Defect 14 Perimembranous, Supra-infracristal, Doubly-committed 15 Patent Ductus Arteriosus 16 Coarctation of Aorta 17 Tetralogy of Fallot / Double Outlet Right Ventricle 18 Right Ventricular Outflow Tract Obstruction 19 Left Ventricular Outflow Tract Obstruction 20
VALVULAR HEART DISEASE Diagnosis of Valvular Heart Disease 21 Asymptomatic Aortic Stenosis 22 Severe Aortic Stenosis 23 Mitral Stenosis 24 Moderate to Severe Mitral Stenosis 25 Aortic Regurgitation 26 Mitral Regurgitation 27
VASCULAR DISEASE Screening for AAA in High Risk Populations 29 Symptomatic Infrarenal Abdominal Aortic Aneurysm 30 Asymptomatic Infrarenal Abdominal Aortic Aneurysm 31 Extracranial Carotid Artery Disease 32 Chronic Venous Insufficiency of the Lower Extremities 34 Peripheral Arterial Disease 46
MISCELLANEOUS CARDIOVASCULAR DISEASE Acute Rheumatic Fever 53 Infective Endocarditis 56 Pericardial Effusion 58 Atrial Fibrillation 59
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CHRONIC STABLE ANGINA
2002 ACC/AHA Guidelines for the management of patients w/ chronic stable angina.
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CHRONIC STABLE ANGINA
MEDICAL MANAGEMENT
1. Anti-anginal drug therapy 2. Patient education 3. Risk factor modification
HIGH RISK CATEGORY ON TREADMILL STRESS TEST
1. Duration of symptom-limiting exercise < 5 METS
2. Failure to ↑ BP of >120 mm Hg or sustained ↓ of >10 mm Hg 3. Downsloping ST-segment depression of >2 mm at 5 mets in
> 5 leads persisting > 5 mins into recovery 4. ST-segment elevation 5. Angina at low exercise load 6. Reproducible sustained VT of >30 secs
OPTIMAL MEDICAL THERAPY FOR CHRONIC STABLE ANGINA
Daily Aspirin 81-325 mg
Clopidogel if aspirin is contraindicated
Anti-anginal Drugs
ß-Blockers, Long-Acting Nitrates, CCB
Treat w/ optimal dose of a single class of drug to begin
Trial of combination if response to monotherapy is inadequate
Triple therapy is not always superior to treatment w/ 2 agents
ACE-Inhibitors
Smoking Cessation
Lipid Management
LDL <100mg/dl, <70mg/dl if w/ high risk profile
BP Control
<135/85 mm Hg in all patients, ≤120/80 mmHg in diabetics
Physical Activity
Minimum Goal: 30 minutes 3-4 days per week; Optimal: Daily DEFINITION OF SUCCESSFUL TREATMENT OF CSA
Complete, or nearly complete, elimination of anginal chest pain and return to normal activities and a functional capacity of CCS class I an-gina.
This goal should be accomplished with minimal side effects of therapy.
2002 ACC/AHA Guidelines for the management of patients with chronic stable angina. Therapy for Stable Angina Pectoris: The uncomplicated patients. Circulation 2005.
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CHRONIC HEART FAILURE
Modified from Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.
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CHRONIC HEART FAILURE
INDICATIONS FOR EVALUATION OF PATIENTS AT RISK FOR HEART FAILURE Condition Hypertension
Diabetes Obesity CAD (e.g. After MI, revascularization, PAD or CVD, VHD) Family Hx of CMP in a 1
st Degree Relative
Sleep-Disordered Breathing Test Findings Sustained arrhythmias
Abnormal ECG (e.g. LVH, LBBB, pathologic Q wave) Cardiomegaly on CXR
SIGNS TO EVALUATE IN PATIENTS SUSPECTED OF HAVING HEART FAILURE Cardiac Abnormality Sign
Elevated cardiac filling Elevated JVP pressure & fluid overload S3 gallop
Rales Hepatojugular Reflux Ascites Edema
Cardiac enlargement Laterally displaced or prominent apical impulse
Murmurs suggesting valvular dysfunction
SYMPTOMS SUGGESTING THE DIAGNOSIS OF HEART FAILURE Symptoms Dyspnea at rest or on exertion
Reduction in exercise capacity Orthopnea PND or Nocturnal cough Edema Ascites or Scrotal edema
Less specific presentation of HF Early satiety, Nausea, Vomiting, Abdominal Discomfort Wheezing or cough Unexplained fatigue Confusion/delirium
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CHRONIC HEART FAILURE
DIFFERENTIAL DIAGNOSIS FOR HEART FAILURE SYMPTOMS AND SIGNS
Myocardial Ischemia
Pulmonary Disease
Pneumonia, Asthma, COPD, Pulmonary Embolus, Primary Pulmonary hypertension
Sleep-Disordered Breathing
Obesity
Deconditioning
Malnutrition
Anemia
Hepatic Failure
Renal Failure
Hypoalbuminemia
Venous Stasis
Depression
Anxiety & Hyperventilation Syndrome PHARMACOLOGICAL THERAPY OF SYMPTOMATIC HEART FAILURE
For Survival/Morbidity For Symptoms:
NYHA I:
Continue ACEI / ARB if ACEI intolerant Continue Aldosterone Antagonist if post
MI Add Beta blocker if post-MI
Reduce / stop diuretics
NYHA II:
ACEI as first-line treatment ABB if ACEI intolerant Add BB or AA of post-MI
+/- diuretic depending on fluid retention
NYHA III:
ACEI plus ARB or ARB alone if ACEI intolerant
Beta blocker Add AA
+ diuretics + digitalis if still symptomatic
NYHA IV:
Continue ACEI / ARB Beta blocker Aldosterone antagonist
+ diuretics + digitalis + consider temporary inotropic support
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CHRONIC HEART FAILURE
Modified from Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.
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ACUTE DECOMPENSATED HEART FAILURE RECOMMENDATIONS FOR HOSPITALIZATION
Evidence for severely decompensated HF including: - Hypotension - Worsening renal function - altered mentation
Dyspea at rest - resting tachypnea - Oxygen saturation <90%
Hemodynamically significant arrhythmia - including new onset rapid AF
Acute coronary syndrome HOSPITALIZATION SHOULD BE CONSIDERED
Worsened congestion
Major electrolyte disturbance
Associated comorbid conditions - pneumonia - pulmonary embolus - DKA - TIA or stroke
Repeated ICD firings
Previously undiagnosed HF with signs and symptoms of pulmonary congestion
TREATMENT GOALS FOR PATIENTS ADMITTED FOR ADHF
Improve symptoms especially congestion and low output syndrome
Optimize volume status
Identify etiology
Identify precipitating factors
Optimize chronic therapy
Minimize side effects
Identify patients who may benefit from revascularization
Educate patients concerning medications and self assessment of HF
Initiate a disease management program MONITORING RECOMMENDATIONS FOR PATIENTS ADMITTED FOR ADHF
Weight
Fluid intake and output
Vital signs
Signs : edema, ascites, rales, hepatomegaly, JVP
Syptoms : PND, orthopnea, cough, fatigue
Electrolytes
Renal function
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ACUTE DECOMPENSATED HEART FAILURE DISCHARGE CRITERIA
Exacerbating factors addressed
Near optimal volume status achieved
Transition from IV to oral diuretics
Patient and family education completed
At least near-optimal pharmacologic therapy achieved
FF-up clinic visit scheduled in 7-10 days ELEMENTS TO DETERMINE AT FOLLOW-UP VISITS OF HF PATIENTS
Functional capacity and activity level
Changes in body weight
Patient understanding of and compliance with dietary sodium restriction
Patient understanding of and compliance with medical regimen
History of arrhythmia, syncope, presyncope, or palpitation
Compliance and response to therapeutic interventions
The presence or absence of exacerbating factors for HF, including worsening ischemic heart disease, HPN, and new or worsening valvular disease
RECOMMENDED COMPONENTS OF CARE AND FOLLOW-UP PROGRAMS (Class of Recommendation = I, Level of Evidence = C)
Use of Multidisciplinary team approach
Vigilant follow up, first follow up within 10 days of discharge
Discharge planning
Increase access to health care
Optimizing medical therapy with guidelines
Early attention to signs and symptoms
Flexible diuretics regimen
Intensive education and counseling
In patient and OPD (home-based)
Attention to behavioural strategies
Address barriers to compliance PROPOSED PHC HEART FAILURE CLINIC
Cardiologist-supervised
Nurse-led home visits/ telephone follow up
Multidisciplinary care
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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COMMON CONGENITAL ACYANOTIC HEART DISEASE
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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ATRIAL SEPTAL DEFECT
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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VENTRICULAR SEPTAL DEFECT
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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PERIMEMBRANOUS, INFRA-SUPRACRISTAL
DOUBLY COMMITTED
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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PATENT DUCTUS ARTERIOSUS
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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COARCTATION OF THE AORTA
(a) History and PE Suggestive of Coarctation of Aorta
Upper limb hypertension
Differential arm-leg pulses (at least >10 mm Hg SBP)
Exertional dyspnea
Interscapular systolic murmur
Cresendo-decresendo systolic murmur through the chest wall
(b) To delineate the coarctation anatomy, possible aneurysm formation and
with velocity mapping.
Concensus Guidelines, Clinical Cardiology Division
Philippine Heart Center, 2008-2009.
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TETRALOGY OF FALLOT
DOUBLE OUTLET RIGHT VENTRICLE
* catheterization:
further definition of coronary artery anatomy
determine coexistent conditions that cannot be elucidated by echo
determine PVR and reactivity (in pts suspected of having increased
resistance)
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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RIGHT VENTRICULAR
OUTFLOW TRACT OBSTRUCTION
(a) History and PE Suggestive of RVOTO
Exertional fatigue, Dyspnea, Lightheadness, Chest discomfort
Ejection systolic murmur heard at the LUPSB and transmitted to the axil-
la and back, Prominent A wave, RV lift
(b) Exertional dyspnea, angina, presyncope or syncope.
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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LEFT VENTRICULAR OUTFLOW
TRACT OBSTRUCTION
(a) History and PE Suggestive of LVOTO
Exertional dyspnea
Angina
Presyncope
Syncope
(b) Schematic Approach to the Diagnostic Use of Echocardiography
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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VALVULAR HEART DISEASE
ALGORITHM FOR DIAGNOSIS OF
VALVULAR HEART DISEASE
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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ALGORITHM for ASYMPTOMATIC AORTIC STENOSIS
Update of ACC/AHA Guidelines for Valvular Heart Disease,
Bonow et al, Circulation 2008
GRADING OF AORTIC STENOSIS
Mild Moderate Severe
Valve Area > 1.5 cm² 1.0 - 1.5 cm² < 1.0 cm²
Gradient < 25 mm Hg 25 - 40 mm Hg > 40 mm Hg
Velocity < 3 m/sec 3 - 4 m/sec > 4 m/sec
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ALGORITHM for SEVERE AORTIC STENOSIS
Update of ACC/AHA Guidelines for Valvular Heart Disease,
Bonow et al, Circulation 2008
HIGH RISK ASYMPTOMATIC AORTIC STENOSIS PATIENTS
Risk of Rapid Hemodynamic Progression
1. Age >50 yrs
2. Severe valve calcification
3. Concurrent CAD
Risk of Impending Symptom Onset
1. LVH by ECG
2. Smaller valve area by Doppler
3. B-type natriuretic peptide
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ALGORITHM for MITRAL STENOSIS
Update of ACC/AHA Guidelines for Valvular Heart Disease,
Bonow et al, Circulation 2008
GRADING OF MITRAL STENOSIS
Mild Moderate Severe
Valve Area > 1.5 cm² 1.0 - 1.5 cm² < 1.0 cm²
Gradient < 5 mm Hg 5 - 10 mm Hg > 10 mm Hg
PASP < 30 mm Hg 30 - 50 mm Hg > 50 mm Hg
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ALGORITHM for MODERATE to
SEVERE MITRAL STENOSIS
Update of ACC/AHA Guidelines for Valvular Heart Disease,
Bonow et al, Circulation 2008
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ALGORITHM for AORTIC REGURGITATION
Update of ACC/AHA Guidelines for Valvular Heart Disease,
Bonow et al, Circulation 2008
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ALGORITHM for MITRAL REGURGITATION
Update of ACC/AHA Guidelines for Valvular Heart Disease,
Bonow et al, Circulation 2008
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GRADING OF AORTIC REGURGITATION
GRADING OF MITRAL REGURGITATION
Qualitative Mild Moderate Severe
Angiographic grade 1+ 2+ 3 - 4+
Doppler jet width central jet,
< 25% of LVOT
> mild,
< severe
central jet,
> 65% of LVOT
Doppler vena contracta < 0.3 cm 0.3-0.6 cm > 0.6 cm
Quantitative Mild Moderate Severe
Regurgitant volume < 30 ml/beat 30 - 59 ml/beat > 60 ml/beat
Regurgitant fraction < 30 % 30 - 49 % > 50 %
Regurgitant orifice area < 0.1 cm² 0.1 - 0.29 cm² > 0.30 cm²
Qualitative Mild Moderate Severe
Angiographic grade 1+ 2+ 3 - 4+
Doppler jet width central jet,
< 20% of LA
> mild,
< severe
central jet,
> 40% of LA
Doppler vena contracta < 0.3 cm 0.3-0.69 cm > 0.7 cm
Quantitative Mild Moderate Severe
Regurgitant volume < 30 ml/beat 30 - 59 ml/beat > 60 ml/beat
Regurgitant fraction < 30 % 30 - 49 % > 50 %
Regurgitant orifice area < 0.2 cm² 0.2 - 0.39 cm² > 0.40 cm²
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VASCULAR DISEASE
Screening for Aortic Abdominal Aneurysm
In High Risk Populations
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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MANAGEMENT ALGORITHM FOR SYMPTOMATIC
INFRARENAL ABDOMINAL AORTIC ANEURYSM
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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MANAGEMENT ALGORITHM FOR ASYMPTOMATIC
INFRARENAL ABDOMINAL AORTIC ANEURYSM
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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EXTRACRANIAL CAROTID ARTERY DISEASE
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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1
CDS can distinguish between normal and diseased ICA with sensitivity of
96-98%, specificity of 81-81%, accuracy of 88-89%. (Zwiebel’s and Strand-
ness criteria) J Vasc Surg. 20.4.Oct 1994.
2 Antithrombotic agents: ASA (1
st choice if without contraindication. Alterna-
tives: Clopidogrel, Cilostazol, ASA-Dipyridamole)
Risk factor modification: hypertension, diabetes, dyslipidemia, smoking,
physical inactivity.
3 Carotid Endarterectomy (CEA) is the 1
st choice except in high-risk patients
(cardiac valvular disease, rhythm disorders, recent MI, unstable angina,
uncontrolled BP, uncontrolled DM) or presence of local conditions that con-
traindicates CEA (postradiation therapy, restenosis, surgical inaccessibility).
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
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ALGORITHM FOR CHRONIC VENOUS INSUFFICIENCY
OF THE LOWER EXTREMITIES
Eberhardt, et.al., Circulation, May 2005
World Congress of Microcirculation 1997
(1) History and PE typical of CVI
Leg swelling or discomfort associated with dependent position of legs,
relieved by leg elevation; stasis skin changes
Predisposing factors ie occupation, family hx previous pregnancy, use
of OCP, obesity
(2) Other Causes
DVT
Lymphedema
Cellulitis
Lipidema
Systemic causes of edema
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(3) Classification of Chronic Lower Extremity Venous Disease
C Clinical Signs: (grade 0-6)
Supplemented by: (A) for asymptomatic
(S) for symptomatic
E Etiologic Classification
(Congenital, Primary, Secondary)
A Anatomic Distribution
(Superficial, Deep, or Perforator, alone or in combination)
P Pathophysiologic Dysfunction
(Reflux or Obstruction, alone or in combination)
Clinical Classification of Chronic Lower Extremity Venous Disease
Class 0 No visible or palpable signs of venous disease
Class 1 Telangiectasia, reticular veins, malleolar flare
Class 2 Varicose veins
Class 3 Edema without skin changes
Class 4 Skin changes ascribed to venous disease
(e.g. pigmentation, venous eczema, lipodermatosclerosis)
Class 5 Skin changes as defined above with healed ulceration
Class 6 Skin changes as defined above with active ulceration
Etiologic classification of Chronic Lower Extremity Venous Disease
Congenital (EC) The cause of the chronic venous disease has been
present since birth
Primary (EP) Chronic venous disease of undetermined cause
Secondary (Es) Chronic venous disease with an associated known
cause (postthrombotic, posttraumatic, others)
Eberhardt, et.al., Circulation, May 2005
World Congress of Microcirculation 1997
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TREATMENT OF CHRONIC VENOUS INSUFFICIENCY
General measures
Leg elevation
Control of body weight
Exercise of calf muscles
Avoid heat
Avoid standing for long periods
Cold showers to delay progression of disease
Limitation of long periods spent standing or sitting
Periodic flexion of ankles, transfer of weight to toes
Daily rest with legs raised (15-20 cm) and also at night
Antistasis exercise
Lying flat on the healthy side in the presence of unilateral varicose veins
Conservative management
To reduce symptoms and help prevent the development of secondary
complications and the progression of disease.
Behavioral measures such as elevating the legs to minimize edema and
reducing intraabdominal pressure should be advocated.
CHRONIC VENOUS INSUFFICIENCY
CLINICAL CLASSIFICATION
Symptoms Signs
Grade I: - mild swelling - ankle edema < 1 cm
- heaviness - dilated superficial veins
- vein dilatation - normal skin and subcutaneous
tissue
Grade II: - mod-severe swelling - ankle edema > 1 cm
- heaviness - multiple dilated veins
- varicosities - incompetent perforating veins (mild)
-skin changes - pigmentation (mild)
Grade III: - severe swelling - edema > 2 cm
- calf pain - multiple dilated veins
+/- claudication - incompetent perforating veins
- multiple varicosities
- marked pigmentation
- ulcer
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ALGORITHM FOR
TREATMENT OF CHRONIC VENOUS INSUFFICIENCY
Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.
Conservative Management
To reduce symptoms and help prevent the development of secondary
complications and the progression of disease.
Behavioral measures such as elevating the legs to minimize edema and
reducing intraabdominal pressure should be advocated.
Wound Skin Care
Progressive CVI may lead to compromised skin integrity, it is important
to keep the affected area well moisturized to reduce the risk of skin
breakdown and possibility of infection.
Development of stasis dermatitis needs to be treated with a topical ster-
oid.
With venous ulcers, bacterial overgrowth control and aggressive wound
care are required to minimize infectious complications.
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Pharmacologic Therapy
Four groups of drugs evaluated for CVI:
Coumarins (alpha-benzopyrones)
Flavonoids (gamma-benzopyrones) DAFLON
Saponosides (horse chestnut extracts)
Other plant extracts ie rutosides VENORUTON
• With venoactive properties, widely used in Europe but not approved for use
in the USA.
• Principle for use of venoactive drugs: improve venous tone and capillary per-
meability.
Compression Therapy - compression stockings
Compression stockings
Compression Stockings
Initiate mild compression, then move to higher compression to achieve therapeutic effect
Must be worn after morning shower and removed last thing at night
Poorly tolerated in warm weather so better use during the first few hours of the day than not at all
COMPRESSION USE
Mild compression Prevent DVT in mobile patients
18 - 25 mm Hg
Intermediate compression Mild CVI
Post-sclerosing therapy
6 - 34 mm Hg
Strong compression
More advance CVI
Increased tendency to edema
37 - 49 mm Hg
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CONTROLLING VEIN PROBLEMS
Raise your feet above heart level.
Elevate your feet at work to prevent worsening of leg edema.
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Anti-stasis exercises
Exercises to improve venous circulation
Exercises to improve venous circulation
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Other basic measures
Elastic stockings
They should be worn daily
Put other socks over them if
you’re concerned about their
appearance.
Tips for Wear & Care
Once your stockings are on, make
sure the top of the stockings is
about two fingers’ width below the
crease of the knee or the groin. If a
stocking is too high, it will cut off
blood flow.
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Other basic measures
Prevention: Basic Measures
Limitation of long periods spent standing or sitting
Periodic flexion of ankles, transfer of weight to toes
Daily rest with legs raised (15-20 cm) and also at night
Antistasis exercise
Lying flat on the healthy side in the presence of unilateral varicose veins
Conservative management
The use of compressive stockings is the mainstay of conservative treat-
ment.
Prescription for elastic stockings includes information about the tension
and length. The tension is based on the clinical severity:
20-30mmHg for CEAP 2-3
30-40mmHg for CEAP 4-6
40-50mmHg for recurrent ulcers
DO: AVOID:
Wash in cold water after a shower Saunas
Regular deep breathing exercises Restrictive clothing, girdles
Appropriate sports: walking, swimming, cycling, running on
soft ground
Weight-lifting, skiing, tennis, mara-thons, immobile sunbathing
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DIAGNOSTIC APPROACH IN
PATIENTS WITH SUSPECTED FIRST DVT
Approach to A Patient Suspected Of
Acute Proximal Deep Vein Thrombosis of the Lower Extremities
1
Based from the Well’s Clinical Criteria. If the clinical probability is high,
treatment may be started while waiting for Duplex scan result. 2
Using either SimpliRED D-dimer, Vidas D-dimer, MDA d-dimer, or Tiniquant
D-dimer. The sensitivity of D-dimer ELISA for acute PE was 96.4%, and the
negative predictive value was 99.6% (a similar strategy works for excluding
DVT) Braunwald’s Heart des. 7th ed. p.1794. 3
Includes compression, color and pulsed Doppler ultrasonography.
(available at PVL). For patients who have low to intermediate clinical proba-
bility, the sensitivity and specificity of compression ultrasonography are low-
er. In experienced hands, sensitivity and specificity of >95% for proximal
vein thrombosis. ( Periph vasc dse. J Olin.2nd ed). 4
See Treatment Guidelines of ACCP 2004 for DVT/VTE (Chest, Sept 2004).
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Dis-ease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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DIAGNOSTIC APPROACH IN
PATIENTS WITH SUSPECTED FIRST DVT
A Clinical prediction rule for predicting pretest probability of deep vein
thrombosis
Lancet 1997; 350: 1795-8
N Engl J Med 2003; 349: 1227-35
TOTAL:
The more symptomatic leg is used in patients with symptoms in both legs.
Pretest probability calculated as the total score:
HIGH > 3
MODERATE 1 or 2
LOW < 0
* Adapted from Wells et al. Lancet 1997; 350:1795-1798
Clinical Features Score
Active cancer (ongoing treatment or within last 6 months, or palli- 1
Paralysis, paresis or recent plaster immobilization of lower ex- 1
Recently bedridden for >3 days and/or major surgery within 4 1
Localized tenderness along the distribution of the deep venous 1
Thigh and calf swollen 1
Calf swelling >3 cm compared with asymptomatic leg
(measured 10 cm below tibial tuberosity) 1
Pitting edema (greater in the symptomatic leg) 1
Non-varicose collateral superficial veins 1
Alternative diagnosis as or more likely than DVT - 2
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DIAGNOSTIC APPROACH IN
PATIENTS WITH SUSPECTED FIRST DVT
2
D-dimer Using
SimpliRED D-dimer
Vidas D-dimer
MDA d-dimer
Tiniquant D-dimer
• If Vidas, MDA, or Tiniquant D-dimer assays are used, patients with
moderate clinical probability can be managed similarly to patients with
a low clinical probability of DVT.
• The sensitivity of D-dimer ELISA for acute PE was 96.4%, and the
negative predictive value was 99.6% (a similar strategy works for
excluding DVT)
Braunwald’s Heart des. 7th ed. p.1794
4 The evidence for the need of anticoagulation in patients with DVT is
based on studies performed >40 years ago.
• This trial showed a high mortality rate in untreated patients. PE
detected at autopsy was the cause of death in the majority of patients.
• Subsequent uncontrolled studies confirmed that mortality was
reduced when Heparin was used to treat VTE, and reported a high
mortality when patients did not receive anticoagulant therapy.
• Patients with DVT should be treated with anticoagulants as soon as
the diagnosis is confirmed by objective testing.
(Chest 126/3/Sept 2004 Suppl)
B Consider venography if patient is unable to return for serial ultrasound
or clinical probability is high.
• Serial ultrasound can be done 48 to 72 hours after the initial study
then 1 week after.
Lancet 1997; 350: 1795-8
N Engl J Med 2003; 349: 1227-35
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PERIPHERAL ARTERIAL DISEASES
ABI Classification System:
>1.30 - incompressible
1.00 - 1.30 - normal
0.90 - 0.99 - equivocal/borderline
0.51 - 0.89 - mild to moderarte
0.41 - 0.50 - moderate to severe
<0.40 - severe
Steps Toward the Diagnosis of Peripheral Arterial Disease (PAD)
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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DIAGNOSIS AND TREATMENT OF
ASYMPTOMATIC PAD AND ATYPICAL LEG PAIN
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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DIAGNOSIS OF CLAUDICATION
AND SYSTEMIC RISK TREATMENT
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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TREATMENT OF CLAUDICATION
Pharmacologic Therapy for Claudication
Class I A
1. Cilostazol (100 mg orally 2 times per day)
Therapeutic trial of Cilostazol should be considered in all patients with
lifestyle-limiting caludication (in the absence of heart failure)
Class IIb A
1. Pentoxyfylline (400 mg 3 times per day) may be considered as a second
line alternative therapy to cilostazol
With published trials showing benefit
• Beraprost/ Ilioprost
Drugs with on-going trials
• Sulodexide
Naftidofuryl
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Dis-ease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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DIAGNOSIS OF ACUTE LIMB ISCHEMIA
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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TREATMENT OF ACUTE LIMB ISCHEMIA
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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MANAGEMENT ALGORITHM FOR
PATIENTS WITH CRITICAL LIMB ISCHEMIA
ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.
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DIAGNOSIS OF ACUTE RHEUMATIC FEVER
Algorithm for diagnosis of acute rheumatic fever (RF), incorporating the 1992 revision of the Jones criteria and the World Health Organization (WHO) expert consultation report (2002-2003). The WHO modifications incorporated in the flowchart are more sensitive
and less specific than those incorporated in the American Heart Association criteria. GABHS = group A beta-hemolytic streptococci; RHD = rheumatic heart disease
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ALGORITHM FOR MANAGEMENT OF RHEUMATIC FEVER (RF) AND ITS PRIMARY MANIFESTATIONS
Modified from Thatai D, Turi ZG: Current guidelines for the treatment of patients
with rheumatic fever. Drug 57:545, 1999
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ANTIBIOTIC THERAPY FOR ACUTE RHEUMATIC
FEVER (RF) AND LONG-TERM PROPHYLAXIS
Rheumatic fever and rheumatic heart disease. World Health Organ Tech Rep Ser 923:1, 2004.
Initial Treatment of Group A Beta-Hemolytic Streptococcal Pharyngitis (Adult Dosages)
Antibiotic Dose Frequency Duration Comments
Benzathine penicillin G 1.2 million units IM One time Acutely only ↓ Compliance issues
↑ Pain
Penicillin V 500 mg Po b.i.d. 10 days
Amoxicillin 500 mg Po t.i.d. 10 days
Cephalosporin or Varies by Drug Varies by 10 days Erythromycin if
Erythromycin Drug Penicillin Allergic [*]
Secondary Prophylaxis Regimen for Patients with Documented RF (Adult Dosages) [†]
Antibiotic Dose Frequency Comments
Penicillin V 500 mg Po b.i.d.
Erythromycin 500 mg Po b.i.d. Alternative for Penicillin-Allergic [*]
Sulfonamides 1 gm Po Daily Alternative for Penicillin-Allergic [*]
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INFECTIVE ENDOCARDITIS
Schematic approach to the diagnostic use of echocardiography
Reproduced from Bayer AS, Bolger AF, Taubert KA, et al: Diagnosis and management of infective endocarditis and its complications. Circulation 98:2936-48, 1998.
High-risk echocardiographic features: • Large vegetations • Valve insufficiency • Suggestion of perivalvular extension • Ventricular dysfunction
High initial risk: • Prosthetic heart valves • Complex congenital heart disease • Prior IE • New murmur • Heart failure
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Regimens for Prophylaxis Against Endocarditis: Use with
Dental, Oral, and Upper Respiratory Tract Procedures
Adapted from Wilson W, Taubert KA, Gewitz M, et al: Prevention of in-fective endocarditis: Recommendations of the American Heart Associa-tion. Circulation, 2007. * Dosages for adults. Initial pediatric dosages are as follows: Ampicillin
or amoxicillin, 50 mg/kg; clindamycin, 20 mg/kg; azithromycin or clar-ithromycin, 15 mg/kg.
† Cephalosporins are not used in patients with history of anaphylaxis,
angioedema, or urticaria associated with penicillin, ampicillin, or ceph-alosporins.
Setting Regimen Administered 30-60 Min before Procedure
Standard regimen[†] Amoxicillin 2.0 gm PO
Amoxicillin/penicillin-allergic patients
Cephalixin 2 gm PO[†] or Azithromycin or clarithromycin 500 mg PO or Clindamycin 600 mg PO
Patients unable to take oral medications
Ampicillin 2.0 gm IM or IV Or Cefazolin or ceftriaxone 1 gm IV[†]
Ampicillin/amoxicillin/penicillin-allergic patients una-ble to take oral medi-cations
Clindamycin 300 mg IV 30 min before procedure, then 150 mg 6 hr after initial dose
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DIAGNOSTIC AND TREATMENT ALGORITHM FOR
PERICARDIAL EFFUSION
Concensus Guidelines, Clinical Cardiology Division
Philippine Heart Center, 2008-2009.
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ATRIAL FIBRILLATION
Patterns of Atrial Fibrillation
1, episodes that generally last less than or equal to 7 days (most less
than 24 h); 2, usually more than 7 days; 3, cardioversion failed or not
attempted; and 4, either paroxysmal or persistent AF may be recur-
rent.3
Fuster and Ryde´n, et al. ACC/AHA/ESC Executive Summary
JACC Vol. 38, No. 4, 2001. October 2001:1231–65
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Minimum and Additional Clinical Evaluation of Patients With Atrial Fibrillation
Minimum evaluation 1. History and physical examination, to define
• The presence and nature of symptoms associated with AF • The clinical type of AF (first episode, paroxysmal, persistent, or permanent) • The onset of the first symptomatic attack or date of discovery of AF • The frequency, duration, precipitating factors, and modes of termination of AF • The response to any pharmacological agents that have been administered • The presence of any underlying heart disease or other reversible conditions (eg,
hyperthyroidism or alcohol consumption) 2. Electrocardiogram, to identify
• Rhythm (verify AF) • LV hypertrophy • P-wave duration and morphology or fibrillatory waves • Preexcitation • Bundle-branch block • Prior MI • Other atrial arrhythmias • To measure and follow the RR, QRS, and QT intervals in conjunction with anti-
arrhythmic drug therapy 3. Chest radiograph, to evaluate
• The lung parenchyma, when clinical findings suggest an abnormality • The pulmonary vasculature, when clinical findings suggest an abnormality
4. Echocardiogram, to identify • Valvular heart disease • Left and right atrial size • LV size and function • Peak RV pressure (pulmonary hypertension) • LV hypertrophy • LA thrombus (low sensitivity) • Pericardial disease
5. Blood tests of thyroid function • For a first episode of AF, when the ventricular rate is difficult to control, or when AF
recurs unexpectedly after cardioversion Additional testing
• One or several tests may be necessary 1. Exercise testing
• If the adequacy of rate control is in question (permanent AF) • To reproduce exercise-induced AF • To exclude ischemia before treatment of selected patients with a type IC anti-
arrhythmic drug 2. Holter monitoring or event recording
• If diagnosis of the type of arrhythmia is in question • As a means of evaluating rate control
3. Transesophageal echocardiography • To identify LA thrombus (in the LA appendage) • To guide cardioversion
4. Electrophysiological study • To clarify the mechanism of wide-QRS-complex tachycardia • To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supra-
ventricular tachycardia • Seeking sites for curative ablation or AV conduction block/modification
Fuster and Ryde´n, et al. ACC/AHA/ESC Executive Summary
JACC Vol. 38, No. 4, 2001. October 2001:1231–65
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Pharmacological management of patients with newly discovered AF
Pharmacological management of patients with newly discovered AF. AF indicates atrial fibrillation; HF, heart failure.
Fuster and Ryde´n, et al. ACC/AHA/ESC Executive Summary
JACC Vol. 38, No. 4, 2001. October 2001:1231–65
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Pharmacological Management of Patients with Recurrent Paroxysmal AF.
Pharmacological Management of Patients with Recurrent Persistent or Permanent AF
Fuster and Ryde´n, et al. ACC/AHA/ESC Executive Summary
JACC Vol. 38, No. 4, 2001. October 2001:1231–65
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Antiarrhythmic Drug Therapy to Maintain Sinus Rhythm in Patients With Recurrent Paroxysmal
or Persistent Atrial Fibrillation
Drugs are listed alphabetically and not in order of suggested use. *For adrenergic atrial fibrillation, beta-blockers or sotalol are the initial drugs of choice. †Consider nonpharmacological options to maintain sinus rhythm if drug failure occurs. HF indicates heart failure; CAD, coronary artery disease; and LVH, left ventricular hypertrophy.
Fuster and Ryde´n, et al. ACC/AHA/ESC Executive Summary
JACC Vol. 38, No. 4, 2001. October 2001:1231–65
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