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THE BEST CARDIOLOGISTS IN YELAHANKA nvestigations of possible or probable stable angina Electrocardiography A standard 12-lead ECG should be obtained in all patients. This is likely to be normal in almost half of patients with subsequently proven coronary artery disease. Nevertheless, an abnormal trace lends weight to the symptoms and favours further investigation. Chest X-ray Routine radiology is not essential but may reveal important co-morbidities. It should always be performed in those with clinical evidence of hypertension, pericarditis (p. 174), heart failure or valvular disease, if only as a baseline. It is similarly indicated for patients with suspected or known pulmonary or systemic disease such as rheumatoid arthritis, COPD or alcoholism. Routine blood tests All patients with suspected angina should have the following routine investigations at presentation (NHF grade A recommendation): n fasting lipids, including total cholesterol, LDLs, HDLs and triglycerides—risk factors n fasting blood sugar—risk factor n full blood count—anaemia exacerbates angina n serum creatinine—impaired renal function is a risk factor and can be worsened by some cardiac investigations. If indicated clinically, thyroid function
THE CARDIOLOGY CLINICS IN BANGALORE Important coronary risk factors 1 Existing vascular disease (coronary, cerebral or peripheral) 2 Age 3 Dyslipidaemia 4 Smoking 5 Family history 6 Hypertension 7 Male sex/hormonal factors 8 Diabetes 9 Renal impairment 10 Obesity 11 Inactivity 12 Thrombogenic factors 13 Other dietary factors 14 Homocystinaemia 15 Psychological factors 16 Elevated hsCRP 17 Abnormal CT calcium score/coronary angiogram 18 Left ventricular hypertrophy (hypertensive patients) 19 Abnormal
HEART SPECIALISTS IN HEBBALABANGALORE Case-based learning: cardiovascular risk assessment Mr RF is 60 years old and presents for a check-up because he is concerned he may be at risk of heart disease. Objectives for the group to understand How should this type of request be managed What can be done to assess an individual’s future cardiac risk, and what can be done to improve the prognosis for those at increased risk Epidemiology and population health The presenter should ask the group to consider the concept of risk factors for cardiovascular disease and the differences between population risk factors and those for an individual. How did the concept of risk factors arise Presenting symptoms and clinical examination What questions should be asked of Mr RF to begin the risk factor assessment 1 Is there a history of ischaemic heart disease or symptoms of heart disease 2 Has his cholesterol level been checked in the past What was itHas it been treated with diet or drugs, or both Has the level improved 3 Is he a diabetic, or has he had an abnormal blood sugar measurement 4 Is there a history of high blood pressure Has this been treated If so, how 5 Is there a history of heart disease in the familIf so, who has been affected and at what age 6 Does he smoke? How many cigarettes a day If he has ceased smoking, when did he stop 7 Does he exercise regularly 8 Have any cardiac investigations been performed before What were the results 9 Is there a history of peripheral arterial disease (claudication) or erectile dysfunction The group should appreciate that considerable information about risk can be obtained by asking simple questions. What physical examination should be performed
GOOD CARDIOLOGY CLINICS IN YELAHANKA NWE TOWN BANGALORE Summary of recommendations for CHD risk factor reduction Assess the severity and presence of all risk factors: family history blood pressure non-fasting serum cholesterol (if greater than 5.5 mmol/L, or other risk factors are present, proceed to fasting HDL, LDL, trig.) diabetesn smoking dietary history. 1• CORONARY RISK FACTORS 23 Manage risk factors by: encouraging smoking cessation undertaking dietary modification: • ensure dietary fat is less than 30% of total kJ intake and less than 30% of total saturated fat • increase intake of fish and plant oils • restrict kJ intake if patient is overweight • reduce salt and alcohol intake in hypertensive patients controlling blood pressure with lifestyle and medication maintaining diabetic control encouraging regular physical activity using prophylactic drugs in high-risk patients • aspirin • statins • beta-blockers or ACE inhibitors after AMI • ACE inhibitors in left ventricular (LV) dysfunction screening relatives of high-risk patie
DIABETIC CLINICS IN DODDABALLAPUR ROAD BAMNGALORE Low-density lipoproteins Sixty to seventy per cent of total cholesterol is transported as LDL, and total cholesterol measurements usually reflect LDL levels. In both males and females, coronary heart disease risk is proportional to LDL and total cholesterol. As seen above, LDL supplies cholesterol to peripheral tissues. High concentrations of LDL in the serum accelerate atheroma by interacting with damaged endothelium. Oxidation of LDL accelerates this process. A total cholesterol of 5.5 mmol/L, or LDL of 3.5 mmol/L, is usually considered the upper limit of normal but even these levels seem to be responsible for an increased population risk of atheroma. Populations with lower average levels than these have less coronary disease. Lower levels are beneficial for patients with established coronary disease or multiple risk factors. It is not yet clear whether the lowering of total cholesterol to less than 4.0 (LDL 2.0) provides further benefit or whether a target level is indeed the correct approach. Trials of more aggressive cholesterol lowering are underway.14 Although a reduced HDL level (< 1) is associated with increased risk, there is no evidence as yet that raising HDL has beneficial effects. An elevation of triglyceride levels (> 1.7) is also considered a marker of increased risk, but there is no evidence to what level they should be reduced. Exogenous
CARDIAC CLINICS IN YELAHANKA NEWTOWN BANGALORE Thrombogenic factors Thrombosis is an important pathological process in coronary artery disease. Factors increasing the tendency to thrombosis include: smoking hypertriglyceridaemia elevated fibrinogen (possibly) oestrogen-containing contraceptive pills polycythaemia increased von Willebrand factor (a marker of endothelial dysfunction). The following factors are associated with reduced thrombotic tendency: low-dose aspirin other anti-platelet drugs (e.g. clopidogrel) fish oils and mono-unsaturated fatty acids. Alcohol intake
CARDIAC CLINICS IN YELAHANKA NEWTOWN BANGALORE Thrombogenic factors Thrombosis is an important pathological process in coronary artery disease. Factors increasing the tendency to thrombosis include: smoking hypertriglyceridaemia elevated fibrinogen (possibly) oestrogen-containing contraceptive pills polycythaemia increased von Willebrand factor (a marker of endothelial dysfunction). The following factors are associated with reduced thrombotic tendency: low-dose aspirin other anti-platelet drugs (e.g. clopidogrel) fish oils and mono-unsaturated fatty acids. Alcohol intake
DIABETIC CLINICS IN DODDABALLAPUR ROAD BAMNGALORE Low-density lipoproteins Sixty to seventy per cent of total cholesterol is transported as LDL, and total cholesterol measurements usually reflect LDL levels. In both males and females, coronary heart disease risk is proportional to LDL and total cholesterol. As seen above, LDL supplies cholesterol to peripheral tissues. High concentrations of LDL in the serum accelerate atheroma by interacting with damaged endothelium. Oxidation of LDL accelerates this process. A total cholesterol of 5.5 mmol/L, or LDL of 3.5 mmol/L, is usually considered the upper limit of normal but even these levels seem to be responsible for an increased population risk of atheroma. Populations with lower average levels than these have less coronary disease. Lower levels are beneficial for patients with established coronary disease or multiple risk factors. It is not yet clear whether the lowering of total cholesterol to less than 4.0 (LDL 2.0) provides further benefit or whether a target level is indeed the correct approach. Trials of more aggressive cholesterol lowering are underway.14 Although a reduced HDL level (< 1) is associated with increased risk, there is no evidence as yet that raising HDL has beneficial effects. An elevation of triglyceride levels (> 1.7) is also considered a marker of increased risk, but there is no evidence to what level they should be reduced. Exogenous
the best cardiac clinics in yelahanka new town bangalore Ventricular arrhythmias Ventricular ectopic beats Like SVEBs, VEBs are common and, by themselves, generally harmless. Past attempts to suppress them as harbingers of malignant arrhythmias have caused more harm than good. Nevertheless, recognition of their electrocardiographic morphology and behaviour remain important. VEBs that have a fixed coupling to the preceding beats are thought to represent a localised ventricular re-entry and are said to be extra-systolic (extra-systoles). In the top strip of they each replace a sinus beat, with a sinus P wave buried inside the ectopic QRS; their pauses are exactly (fully) compensatory. In the bottom strip, the pause cannot be quantified but, unlike the aberrant beats of Ashman’s phenomenon in , there is hint of a compensatory pause, even during AF. Also unlike aberrant beats in Figure 3.33, the VEBs do not come after the longest cycles in AF. VEBs with same morphology but variable coupling intervals usually represent a continuous discharge from an ectopic focus, like a fixed-rate electronic pacemaker. They capture the ventricles whenever the latter are not refractory and, when they occur at the right time, produce ventricular fusion beats. Fusion beats occur when impulses from two origins, in the case seen in from the sinus node and the parasystolic focus, occur at almost the same time. The resultant QRS complex has features of both types of beat. These VEBs are called parasystolic
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