PDX 1

• visceral in nature (V for Vague!!)
• hard to localize
• hard to describe

• easier to localize
• NOT made worse by palpation
• made worse by lying supine
• made better by sitting up/leaning forward

can imitate chest wall pain

• 1. age (men 45+, women 55+)
• 2. gender (more in men)
• 3. premature CHD
• 4. family history (male relative <55, female relative <65)

true!

HIGH arterial wall stress

from risk factors causing endothelial activation

increase in endothelial permeability

sustained risks lead to decreased arterial stress causing the endothelium to favor vasoconstrictina nd platelet aggregation

bifurcations!

• hypertension
• smoking/tabacco
• diabetes mellitus (#1!!)
• sedentary lifestyle
• body weight/obesity
• left ventricular hypertrophy
• cholesterol
• hypertriglyceridemia

sig: the relationship is continuous and graded. no clear cut-off. can be partially reversed.

residual: damage to the arterial endothemium. left ventrical hypertrophy.

sig: the risk is proportional to the # of cigs smoked and how deeply they're inhaled

sig: at risk even when blood glucose levels are under control

residual: increased vascular permeability

sig: effect of hypertension

residual: change to ventricular myocardium

• very high risk: prior heart attack/stroke
• low risk: 0 or 1 traditional risks

• very high risk: target <70
• high risk: target <100
• moderate risk: target < 130
• low risk: target <160

• poorly controlled diabetes
• obesity
• excessive alcohol consumption

• fatty liver disease
• pancreatitis

embolim or thrombi

a mass traveling in the blood stream

an embolus that lodges to obstruct a blood vessel

ischemic heart disease from arterial fibrillation

• 50-80% in aortic bifurcation/legs
• 20% in carotid arteries

a blood clot that remains attached at its origin

the site of plaque

• inflammation of arterial wall
• chronic mechanical irritation

• has a limited ability to increase oxygen extraction
• (in healthy people, the maximun is 4-6x resting flow)

-> increase in demand-> increase blood flow-> no problems

-> increase demand-> significant reduction in flow-> typical angina and Levines sign

-> no increase in demand-> no CFR to increase flow-> angina at rest

typical!

coronary artery plaque fron decreased CFR

• reproducable pattern (same level of exercise to reproduce)
• attacks start abruptly and seize the patient
• retrosternal pain (poorly localized, visceral in nature, strangling)
• attacks last 1-5 minutes
• pain relieve by rest!

• emotion
• exposure to cold
• heavy metals
• (these triggers decrease the amount of exertion needed to cause the angina)

no, it is always the same, severity does not change

the patient holds a clenched fist of the sternum when describing/experiencing the discomfort.

• pain radiates to the left shoulder/arm (typically!)
• location can vary greatly for each individual but a persons angina is always in the same place/predictable

pain anywhere from umbilicus to eyebrows that is provoked by exercise and relieved by rest

coronary or intramyocardial arteries (they have very low flow reserve since surrounded by heart muscle)

Prinzmetal angina/coronary vasospasm-> angina at rest

normal coronary As--> good blood flow--> no problems

increased resistance-> less exertion needed-> angina at rest

• shortness of breath
• nausea
• diaphoresis (sweating)
• discomfort NOT in the chest

• older/female patients
• diabetic patients
• patients with hypertension
• patients with collagen vascular disease

to recieve rapid/aggressive treatment. once hospitalized there is no difference in mortality rates

unstable cardiac symptoms that are happening in real time

• atypical angina
• MI
• death

• abrupt onset
• 14% with pleuritic pain
• 33% without chest pain
• non-pain angina equivalents (nausea, shotrness of breath, fatigue)
• symp. activity (diaphoresis, pallor, pilomotor activity)

the exam might be normal!

• older
• women
• diabetics

C for comfortable!!

• standard cardiovascular risks
• history of previous MI
• heart valve abnormalities

• 1. catecholamines (symp. nervous system)
• 2. retention of Na and H2O
• 3. Cardiac remodeling

• 1. dialated cardiomiopathy
• 2. hypertrophic cardiomiopathy
• 3. hypertrophic obstructive cardiomiopathy

• D for dying :(
• inadequate cardiac output even at rest!= not comfortable

• causes reduced contractability and systolic heart failure
• most common form of heart failure

• abnormal apical impulse
• cardiac heave (from prolonged contraction)
• radiographic evidence of cariomegally

causes muscle to be inelastic and non-compliant and diastolic heart failure

• right jugular vein distension
• radiographic evidence of pulmonary venous hypertension

• breathlessness
• dysphnea on exertion (may be absent in sedentary patients, not specific)
• orthopnea (early warning sign)
• paroxysmal nocturial dyspnea (patient is asleep, more specific to heart disease)
• fatigue and weakness
• nocturia
• oliguria
• cerebral symptoms

• occurs when patient is awake
• develops/resolves rapidly
• measured by the # of pillows needed to make the patient comfortable

• patient is asleep
• takes hours to develop
• 30+ minutes for relief
• "cardiac asthma" from pulmonary edema

• left sided CHF
• Cor pulmonale (lungs)

• peripheral edema
• ascites
• hepatomegaly
• anasarca

• obvious physical findings are ominous in nature
• symptomatic arrhythmias
• symptomatic cardiac murmurs

• A PET Monkey
• 1. Aortic valve: 2nd right ICS
• 2. Pulmonic valve: 2nd left ICS
• (3. Erbs point: 3rd left ICS)
• 4. Tricuspid valve: 5th left ICS
• 5. Mitral valve: 4th/5th left ICS