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'infusion exercise echocardiography'
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HEART SPEACIALISTS IN BANGALORE Stress echocardiography Ischaemic areas of myocardium are known to have reduced contraction compared with normal areas. This can be demonstrated by high-quality echocardiograms. A number of standard views of the heart are obtained and the wall is divided into regions that are assessed for reduced motion. The echo equipment must be designed to store rest images and to present them next to stress images on a split screen so that direct comparison can be made. The stress can be provided by exercise or dobutamine infusion. Exercise echocardiography is difficult to perform because of movement problems and there is quite high inter-reporter variability, but both techniques can approach the accuracy of sestamibi testing in experienced hands. It is not possible to obtain images of adequate quality in all patients.
CARDIOLOGIST IN DODDABOMMASANDRA, BANGALORE Cardiac rehabilitation Although rehabilitation has been a part of the management of patients following a myocardial infarction since the beginning of the last century, ideas have changed radically about the form this should take. In the early 1900s Sir Thomas Lewis insisted his patients remain in bed and be ‘guarded by day and night nursing and helped in every way to avoid voluntary movement or effort’. These severe restrictions were continued for at least six to eight weeks. The thinking was that complete rest would reduce the risk of aneurysm formation and avoid hypoxia that might cause arrhythmias. Even after discharge mild exertion was discouraged for up to a year and return to work was most unusual. In the 1970s periods of bed rest of between one and four weeks were enforced and patients remained in hospital for up to four weeks. It is now clear that this de-conditioning has many adverse physical and psychological effects. Patients with uncomplicated infarcts are now mobilised in hospital within a day or so of admission and are often discharged on the third day if successful primary angioplasty has been performed. Many hospitals provide a supervised rehabilitation program for patients who have had an infarct or episode of unstable angina. The program begins in hospital as soon as possible after admission. It includes a graded exercise regimen and advice about risk factor control. Such programs have many benefits for patients to help them to return quickly to normal life, including work and sexual activity. The supervised exercise regimen helps restore the patient’s confidence. There is clear evidence of the benefits of exercise for patients with ischaemic heart disease.54 Rehabilitation programs have been shown to be cost-effective. Well-conducted programs are tailored to individual patients’ needs and are very popular with many patients.55 There are often long-term exercise groups available for people who have completed the formal classes. Non-cardiac causes of chest pain Pulmonary embolism
Average reductions in coronary events (benefits are greatest in patients with highest total risk) 1 Smoking cessation: 50% reduction in coronary events6 2 Low-dose aspirin in high-risk patients: 25% reduction in coronary events7 3 20% reduction in total cholesterol with statin treatment: 30% reduction in coronary events8 4 Treatment with pravastatin after acute coronary events: 22% reduction in mortality9 5 5–6 mmHg reduction in blood pressure: 15% reduction in coronary events (40% risk reduction for stroke)10 6 30 minutes of moderate exercise a day: 18% reduction in coronary events11 CARDIAC SPEACIALIST IN HEBBALA
CARDIOLOGIST IN YELAHANKA SECOND DEGREE AV BLICK There are two basic types of second-degree AV block: AV nodal Möbitz type I (Wenckebach) heart block, and the more distal and more sinister Möbitz type II heart block. Möbitz type I heart block is much more common. In Möbitz type I block the PR interval lengthens progressively with each cardiac cycle, until an atrial wave is not conducted. There is recovery of conduction and the next a wave is conducted with a shorter interval and the cycle begins again. The QRS complex is narrow (Fig 3.10) (unless associated with pre-existing BBB). The increment is largest between the first and second conducted P wave, and the PR interval continues to increase by less and less until a P wave is dropped. Möbitz type II heart block is almost always associated with a BBB (Fig 3.11), since its origin is intraventricular (below the AV node), and it tends to lapse suddenly into extreme bradycardia or asystole. It tends to be over-diagnosed, especially in the setting of 2:1 AV block (Fig 3.12). There is no lengthening of the PR interval before an atrial wave is not conducted. At times, atropine or exercise can demonstrate the site of the block, by increasing the block from 2:1 to a higher grade when the underlying mechanism is Möbitz II. Conversely, Wenckebach conduction may improve to 3:2 or better. For a distinction to be made between Möbitz type I and Möbitz type II, at least two consecutively conducted P waves have to be evaluated. This is impossible in 2:1 conduction (block) and can only be reported as 2:1 AV block (Fig 3.12). Yet this is very commonly reported as
POPULAR CARDIOLOGISTS IN SAHAKARANAGAR Left ventricular hypertrophy Although the ECG is reasonably specific, it is not as sensitive as echocardiography in detecting LVH. The LVH voltage alone may be a normal finding in younger subjects, but in adults over 35 years it usually connotes true LVH, especially if corroboratory findings are present Unfortunately, LVH with ST/T changes may be impossible to separate from LVH voltage complicated by ST/T changes of different, especially ischaemic, origin . Right ventricular hypertrophy The main criteria fSAor detecting RVH are RAD over +110° and a dominant R wave in V1 (in the absence of its other causes and in the presence of normal-duration QRS) In congenital heart disease conduction defects often come to obscure the hypertrophy patterns.
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