Cardiovascular CareCardiovascular CareKenneth H. Cohen, M.D.,F.A.C.C.Kenneth H. Cohen, M.D.,F.A.C.C.
Ronald D. D’Agostino, D.O., F.A.C.C., F.A.C.P.Ronald D. D’Agostino, D.O., F.A.C.C., F.A.C.P.
Henry Gomez, M.D., F.A.C.C.Henry Gomez, M.D., F.A.C.C.
Jeffrey M. Bernstein, M.D.Jeffrey M. Bernstein, M.D.
Internal Medicine, Cardiology and Cardiovascular DiseasesInternal Medicine, Cardiology and Cardiovascular Diseases
Diplomates American Board and Internal Medicine of Diplomates American Board and Internal Medicine of Cardiovascular DiseasesCardiovascular Diseases
““Everything you wanted Everything you wanted to know about to know about
cardiovascular care but cardiovascular care but the HMO’s were afraid the HMO’s were afraid
you’d ask.”you’d ask.”
Ronald D. D’Agostion, D.O., F.A.C.C.,F.A.C.PSpecializing in:
Cardiology
Cardio-vascular Diseases
Atherosclerosis
Angina & Myocardial Infarction
Hypertension
Renal Artery Stenosis
Valvular Heart Disease
Peripheral Vascular Disease
Cardiomyopathy & Hypertrophy
Carotid Diseases
Congestive Heart Failure
Stroke Prevention & Treatment
Arrythmias
Diabetes Management
Atherosclerosis Time LineAge 0
10
20
30
40
50
60
70
80
Birth
Fatty Streaks
Intimal Changes
Plaque
Obstruction, Symptons, Angina
Events, MI, Stroke
CHF
Risk Factor Modification
• Genetics - Change Your Parents• Diet & Exercise• Vices - Sedentary, Cigarettes, Caffiene, Stress• Prevent Disease
– Manage Lipids, HTN, Diabetes– Prevent Plaque Progression, Stabilization,
Regression, Formation
JNC VI Risk Stratification and Treatment of Hypertension
The Sixth Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NIH.
Drug TherapyLifestyle Modification (up to 6 months)
Lifestyle Modification (up to 12 months)
Stage 1140-159/ 90-99
Drug Therapy
Lifestyle Modification
Risk Group B(At Least 1 Risk Factors, Not Including
Diabetes; No TOD/CCD)
Drug TherapyDrug TherapyStage 2 & Stage 3>160/>100
Drug TherapyLifestyle ModificationHigh-normal 130-139/85-89
Risk Group C(TOD/CCD and/or Diabetes, With or
Without Other Risk Factors)
Risk Group A(No Risk Factors No TOD/CCD)
Blood Pressure Stages (mm Hg)
Lifestyle Modifications
• Stop smoking and reduce intake of saturated fat and cholesterol
• Lose weight if overweight
• Limit alcohol intake
• Increase aerobic physical activity
• Limit sodium intake
• Maintain adequate intake of K+, Ca++, and Mg++ for general health
JNC VI, 1997.
DIAGNOSTIC TESTING
Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P.Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P.
HISTORY & PHYSICALHISTORY & PHYSICAL
• Most important test
• 80% of diagnosis from history
• Testing to confirm clinical
• Testing without knowledge of patient issues
PROBABILITY
• False Positive (FP)
• False Negative (FN)
• Prevalence
• Positive Predictive Value (PPV)
• Negative Predictive Value (NPV)
• Sensitivity
• Specificity
SENSITIVITY& SPECIFICITY
Sensitivity = Sensitivity = True PositiveTrue Positive
True Positive + False NegativeTrue Positive + False Negative
Specificity = Specificity = True NegativeTrue Negative
True Negative + False PositiveTrue Negative + False Positive
PREVALENCEPREVALENCE
• Percent of population with Percent of population with diseasedisease
• Varies with the type of patient Varies with the type of patient the doctor is seeingthe doctor is seeing
PREDICTIVE VALUEPREDICTIVE VALUE
Positive Predictive Value = True PositiveTrue Positive + False Positive
Negative Predictive Value = True NegativeTrue Negative + False Positive
DIAGNOSISDIAGNOSIS
• PrevalencePrevalence
• SensitivitySensitivity
• SpecificitySpecificity
• Predictive ValuePredictive Value
• Pre Test ProbabilityPre Test Probability
• Post Test ProbabilityPost Test Probability
EXAMPLE WITH LOW PREVALENCE
• 10% prevalence• 1000 patients• 100 with disease• 900 without disease
80% sensitivity, 80% specificity80% sensitivity, 80% specificity
TEST TRUTH (+) (-)(+) 80 180(-) 20 720 ____ ____
100 900PREDICTIVE VALUEPREDICTIVE VALUE
PPV=80/260 =25%NPV=720/740 = 95%
EXAMPLE WITH HIGH PREVALENCE
• 90% prevalence• 1000 patients• 900 with disease• 100 without disease
80% sensitivity, 80% specificity80% sensitivity, 80% specificity
TEST TRUTH (+) (-)(+) 720 20(-) 180 80 ____ ____
900 100PREDICTIVE VALUEPREDICTIVE VALUE
PPV=720/740 =95%NPV=80/260 = 30%
DIAGNOSTIC TESTINGDIAGNOSTIC TESTING
• General ScreeningGeneral Screening
• Overall functionOverall function
• PlumbingPlumbing
• PumpPump
• ValvesValves
• WiringWiring
BLOOD WORKBLOOD WORK
• ChemistryEndocrine: Glucose, HBA1c
Renal Function
Liver Function
• CBC -Homocysteine Level, C-Reactive Protein
• Lipids -Total Cholesterol, HDL, LDL, Lipoproteins
• Coagulation
• Thyroid Function
CHEST X-RAYCHEST X-RAY
• Heart SizeHeart Size
• Chamber SizeChamber Size
• LungsLungs
• Limited InformationLimited Information
• AortaAorta
EKGEKG
• ElectrocardiogramElectrocardiogram
• Very usefulVery useful
• Old InfarctsOld Infarcts
• ConductionConduction
• Heart BlockHeart Block
• HypertrophyHypertrophy
HEMODYNAMIC PROFILE (HDP)HEMODYNAMIC PROFILE (HDP)
• Non-Invasive ScanNon-Invasive Scan
• Measures cardiovascular Measures cardiovascular pressures & efficacy of therapypressures & efficacy of therapy
• Helps direct therapyHelps direct therapy
• Very useful for treating Very useful for treating Hypertension & Heart FailureHypertension & Heart Failure
EXERCISE STRESS TESTING
• Overall FunctionOverall Function
• Coronaries, Ventricular Function, Coronaries, Ventricular Function, Valves. ConductionValves. Conduction
• Treadmill, BicycleTreadmill, Bicycle
• Cardiac MonitoringCardiac Monitoring
• Diagnosis & ProgressDiagnosis & Progress
• After Myocardial InfarctionAfter Myocardial Infarction
THALLIUM STRESS TESTINGTHALLIUM STRESS TESTING
• Coronary PerfusionCoronary Perfusion
• Thallium follows blood flowThallium follows blood flow
• Radioisotope Thallium 201 IVRadioisotope Thallium 201 IV
• CameraCamera
• Stress--RestStress--Rest
MYOVIEW or CARDIOLITE MYOVIEW or CARDIOLITE STRESS TESTINGSTRESS TESTING
• Similar to ThalliumSimilar to Thallium
• Better ImagesBetter Images
• Technetium 99, Tetrofosmin or Technetium 99, Tetrofosmin or Sestamibi IVSestamibi IV
• Rest--Stress or Stress--RestRest--Stress or Stress--Rest
PERSANTINE STRESS TESTINGPERSANTINE STRESS TESTING
• Can’t ExerciseCan’t Exercise• Peripheral Vascular DiseasePeripheral Vascular Disease• Orthopedic DifficultyOrthopedic Difficulty• ElderlyElderly• Vasodilator IVVasodilator IV• Stress--RestStress--Rest• Thallium or Myoview Cardiolite IVThallium or Myoview Cardiolite IV
MUTIGATED ACQUISITION MUTIGATED ACQUISITION WALL MOTION SCANWALL MOTION SCAN
• Technetium IVTechnetium IV
• CameraCamera
• Pump FunctionPump Function
• Ejection FractionEjection Fraction
• Wall MotionWall Motion
• Diagnosis and PrognosisDiagnosis and Prognosis
FIRST PASSFIRST PASS
• Same information as MUGA & Same information as MUGA & Right Ventricular FunctionRight Ventricular Function
• Rapid IV injection of Rapid IV injection of technetiumtechnetium
• Rapid ImagingRapid Imaging• May be combined with Myoview May be combined with Myoview
or Cardiolite studyor Cardiolite study
SPECTSPECT
• Single Photon Emission Computed Single Photon Emission Computed TomographyTomography
• Multiple ImagesMultiple Images
• 3 Planes: Short Axis, Horizontal 3 Planes: Short Axis, Horizontal Long Axis, Vertical Long AxisLong Axis, Vertical Long Axis
• Has replaced planar imagingHas replaced planar imaging
• Camera and computerCamera and computer
GRATED SPECTGRATED SPECT
• Wall motion study and Wall motion study and perfusion study in oneperfusion study in one
• Coronary and Ventricular Coronary and Ventricular functionfunction
• Specialized camera and Specialized camera and computercomputer
ECHO DOPPLERECHO DOPPLER
• Most informationMost information
• Non-InvasiveNon-Invasive
• Easy on patientEasy on patient
• Pump and Valve functionPump and Valve function
• Essential TestEssential Test
• After Myocardial Infarction (Heart After Myocardial Infarction (Heart Attack)Attack)
TEETEE
• Transesophageal EchocardiogramTransesophageal Echocardiogram• Swallow probeSwallow probe• Sedation, local anestheticSedation, local anesthetic• Some discomfortSome discomfort• Closer look at the heartCloser look at the heart• Clot in heart, valve function, Clot in heart, valve function,
endocarditisendocarditis• Stroke RiskStroke Risk
NON-INVASIVE VASCULAR NON-INVASIVE VASCULAR TESTINGTESTING
• Renal Duplex to Assess for Renal Duplex to Assess for HypertensionHypertension
• Aortic Duplex to Assess for Aortic Duplex to Assess for AneurysmAneurysm
• Peripheral Duplex - Arterial Peripheral Duplex - Arterial CirculationCirculation
• Carotid Duplex - Stroke RiskCarotid Duplex - Stroke Risk
NON-INVASIVE VASCULAR NON-INVASIVE VASCULAR TESTING Cont...TESTING Cont...
• Pulse Volume Recording with Pulse Volume Recording with Segmented Blood Pressures - Segmented Blood Pressures - Arterial CirculationArterial Circulation
• Venous Duplex - Venous Venous Duplex - Venous CirculationCirculation
CAROTID DOPPLERCAROTID DOPPLER
• Internal and external carotid arteriesInternal and external carotid arteries• Vertebral arteriesVertebral arteries• Plaquing of arteries - Intimal ThicknessPlaquing of arteries - Intimal Thickness• ObstructionObstruction• TIA, CVA, SXTIA, CVA, SX• Unequal blood pressuresUnequal blood pressures• Identify patients at risk for StrokeIdentify patients at risk for Stroke• Identify patients who may benefit from Identify patients who may benefit from
Carotid Endarterectomy or StentCarotid Endarterectomy or Stent
HOLTERHOLTER
• Electrical SystemElectrical System• Slow, FastSlow, Fast• Heart BlockHeart Block• Ventricular TachycardiaVentricular Tachycardia• Correlate with symptomsCorrelate with symptoms• Palpitations, DizzinessPalpitations, Dizziness• After Myocardial InfarctionAfter Myocardial Infarction• Sudden Death RiskSudden Death Risk
SIGNAL AVERAGE ECGSIGNAL AVERAGE ECG
• Prognosis with Ventricular Prognosis with Ventricular TachycardiaTachycardia
• Dizziness, PalpitationsDizziness, Palpitations
• After Myocardial InfarctionAfter Myocardial Infarction
• Use in Consideration with Holter Use in Consideration with Holter and studies of Ventricular Functionand studies of Ventricular Function
• Sudden Death RiskSudden Death Risk
HRVHRV
• Heart Rate VariabilityHeart Rate Variability
• Prognosis after Myocardial Prognosis after Myocardial InfarctionInfarction
• Sudden Death RiskSudden Death Risk
• Acquired with HolterAcquired with Holter
• High Variability Good PrognosisHigh Variability Good Prognosis
T WAVE ALTERNANST WAVE ALTERNANS
• Subtle changes in T Wave Subtle changes in T Wave amplitudeamplitude
• Mild exercise Heart Rate to 110Mild exercise Heart Rate to 110
• May predict patients at May predict patients at increased risk for Sudden increased risk for Sudden DeathDeath
TRANSTELEPHONIC TRANSTELEPHONIC MONITORINGMONITORING
• After HolterAfter Holter
• Loop RecordersLoop Recorders
• Useful for intermittent Useful for intermittent symptomssymptoms
• Home telemetryHome telemetry
• Palpitations, DizzinessPalpitations, Dizziness
PACEMAKER TESTINGPACEMAKER TESTING
• To monitor functionTo monitor function• Test battery lifeTest battery life• Test thresholds for proper Test thresholds for proper
sensing of native conduction sensing of native conduction and captureand capture
• DDDR rate adaptive DDDR rate adaptive pacemakerspacemakers
AMBULATORY BLOOD PRESSURE AMBULATORY BLOOD PRESSURE AND HEART RATEAND HEART RATE
• To monitor Blood Pressure and Pulse To monitor Blood Pressure and Pulse at homeat home
• 24 hr. Recording vs. Intermittent use by 24 hr. Recording vs. Intermittent use by patient periodically and as per patient periodically and as per symptomsymptom
• White Coat HypertensionWhite Coat Hypertension• Extremely useful to diagnose Extremely useful to diagnose
hypertension and assess efficacy of hypertension and assess efficacy of therapytherapy
EPSEPS
• Electrophysiology StudyElectrophysiology Study• InvasiveInvasive• HospitalizationHospitalization• Electrical Stimulation of HeartElectrical Stimulation of Heart• Measure Conduction System: Measure Conduction System:
Bradyarrythmias, Heart BlockBradyarrythmias, Heart Block• Essential with Severe Symptoms or High Essential with Severe Symptoms or High
Risk patientsRisk patients• SyncopeSyncope• Ventricular TachycardiaVentricular Tachycardia
ABLATIONABLATION
• WPW: Wolff-Parkinson-WhiteWPW: Wolff-Parkinson-White
• Supraventricular Tachycardia (SVT)Supraventricular Tachycardia (SVT)
• Bypass TractsBypass Tracts
• High Radio FrequencyHigh Radio Frequency
• May be useful for VT or Atrial May be useful for VT or Atrial FibrillationFibrillation
• AV Nodal AblationAV Nodal Ablation
PACEMAKERSPACEMAKERS
• For Bradyarrythmias & Heart BlockFor Bradyarrythmias & Heart Block
• To enable use of some To enable use of some medications which may be helpful medications which may be helpful i.e, Beta Blockers, Amiodoronei.e, Beta Blockers, Amiodorone
• To treat Heart Failure - To treat Heart Failure - Biventricular PacemakersBiventricular Pacemakers
ICD’SICD’S
• Implantable Cardiovertors Implantable Cardiovertors DefibrillatorsDefibrillators
• Saves LivesSaves Lives
• For High Risk patientsFor High Risk patients
• Like living with an EMS Like living with an EMS TechnicianTechnician
AED’SAED’S
• Automatic External Automatic External DefibrillatorsDefibrillators
• Public AreasPublic Areas
• Airports, Restaurants, Health Airports, Restaurants, Health ClinicsClinics
• Saves LivesSaves Lives
CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION
• Definitive TestDefinitive Test• Essential with Prognosis or Unstable Essential with Prognosis or Unstable
symptomssymptoms• Hospital ProcedureHospital Procedure• InvasiveInvasive• Some RiskSome Risk• Coronary, Ventricular and ValvesCoronary, Ventricular and Valves• Via Radial ArteryVia Radial Artery
PTCAPTCA
• Requires Transluminal Coronary Requires Transluminal Coronary AngioplastyAngioplasty
• Requires Cath-AngiographyRequires Cath-Angiography
• Balloon, Atherectomy, Stent, LaserBalloon, Atherectomy, Stent, Laser
• Generally SuccessfulGenerally Successful
• RestenosisRestenosis
STENTSSTENTS
• Standard UseStandard Use• Smaller risk of RestenosisSmaller risk of Restenosis• Can be placed almost anywhereCan be placed almost anywhere• Coronary, Carotid, Renal, Coronary, Carotid, Renal,
PeripheralPeripheral• Coated StentsCoated Stents
HEART SURGERYHEART SURGERY
• Bypass - CABGBypass - CABG
• Valvular SurgeryValvular Surgery
• Valve Replacement vs. RepairValve Replacement vs. Repair
• Heart Failure SurgeryHeart Failure Surgery
• CardiomyoplastyCardiomyoplasty
• AnnuloplastyAnnuloplasty
HEART SURGERY cont.HEART SURGERY cont.
• Off - PUMPOff - PUMP
• Minimally InvasiveMinimally Invasive
• Heart PortHeart Port
• Arterial ConduitsArterial Conduits
MEDICAL TREATMENTSMEDICAL TREATMENTS
• VitaminsVitamins
• AntioxidantsAntioxidants
• Folic AcidFolic Acid
• B VitaminsB Vitamins
• AspirinAspirin
• PlavixPlavix• Ace InhibitorsAce Inhibitors• ARB’sARB’s• Beta BlockersBeta Blockers• StatinsStatins• Lipid, Lipid,
Hypertension, Hypertension, Diabetes Diabetes ManagementManagement
CHEST PAINCHEST PAIN
• Get to ERGet to ER
• Ideally tertiary case centerIdeally tertiary case center
• Direct Angioplasty - StentDirect Angioplasty - Stent
• ThromboluticsThrombolutics