myocardial ischemic disorders coronary artery disease (cad)
TRANSCRIPT
MYOCARDIAL MYOCARDIAL ISCHEMIC ISCHEMIC
DISORDERSDISORDERS
MYOCARDIAL MYOCARDIAL ISCHEMIC ISCHEMIC
DISORDERSDISORDERS
CORONARY ARTERY CORONARY ARTERY DISEASE (CAD)DISEASE (CAD)
CORONARY ARTERY CORONARY ARTERY DISEASE (CAD)DISEASE (CAD)
Coronary artery disease is the
most common form of heart
disease and the single most
important cause of premature
death in the developed world.
Coronary artery disease is the
most common form of heart
disease and the single most
important cause of premature
death in the developed world.
Disease of the coronary arteries Disease of the coronary arteries is almost always due to is almost always due to
atheroma and its complications atheroma and its complications
thrombosisthrombosis
Disease of the coronary arteries Disease of the coronary arteries is almost always due to is almost always due to
atheroma and its complications atheroma and its complications
thrombosisthrombosis
Occasionally the coronary arteries Occasionally the coronary arteries
are involved in other disorders:are involved in other disorders: congenital anomalies (anomalous origin, congenital anomalies (anomalous origin,
fistula or malformation of a major coronary fistula or malformation of a major coronary
artery)artery)
aortitisaortitis
polyarteritispolyarteritis
and other connective tissue disorders and other connective tissue disorders
Occasionally the coronary arteries Occasionally the coronary arteries
are involved in other disorders:are involved in other disorders: congenital anomalies (anomalous origin, congenital anomalies (anomalous origin,
fistula or malformation of a major coronary fistula or malformation of a major coronary
artery)artery)
aortitisaortitis
polyarteritispolyarteritis
and other connective tissue disorders and other connective tissue disorders
ATHEROMA = ATHEROMA = ARTHEROSCLEROSISARTHEROSCLEROSIS
ATHEROMA = ATHEROMA = ARTHEROSCLEROSISARTHEROSCLEROSIS
a patchy focal disease of the arterial walla patchy focal disease of the arterial wall
Some arteries such as the coronary and Some arteries such as the coronary and cerebral are at high risk, while others cerebral are at high risk, while others
(e.g. radial artery and the internal (e.g. radial artery and the internal mammary artery) are largely spared.mammary artery) are largely spared.
a patchy focal disease of the arterial walla patchy focal disease of the arterial wall
Some arteries such as the coronary and Some arteries such as the coronary and cerebral are at high risk, while others cerebral are at high risk, while others
(e.g. radial artery and the internal (e.g. radial artery and the internal mammary artery) are largely spared.mammary artery) are largely spared.
Coronary artery, cerebral and Coronary artery, cerebral and
peripheral vascular disease often peripheral vascular disease often
coexist but seldom develop at the coexist but seldom develop at the
same ratesame rate..
Coronary artery, cerebral and Coronary artery, cerebral and
peripheral vascular disease often peripheral vascular disease often
coexist but seldom develop at the coexist but seldom develop at the
same ratesame rate..
The evolution of an atheromatous plaThe evolution of an atheromatous plaqqueueThe evolution of an atheromatous plaThe evolution of an atheromatous plaqqueue
Fatty Fatty streakstreak
Transitonal Transitonal plaqueplaque
Mature Mature plaqueplaque
Ruptured Ruptured plaque with plaque with thrombus thrombus formationformation
Foam cells
Extracellular lipid
pool
Smooth muscle cells
Thrombus
Fibrous cap
Foam cells
Extracellular lipid
pool
Smooth muscle cells
Thrombus
Fibrous cap
Fatty streaks develop as circulating Fatty streaks develop as circulating
monocytes migrate into the intima, take monocytes migrate into the intima, take
up oxidisup oxidiseded low-density lipoprotein low-density lipoprotein
(LDL) from the plasma, and become (LDL) from the plasma, and become
lipid-laden foam cells.lipid-laden foam cells.
As these foam cells die and release their As these foam cells die and release their
contents, extracellular lipid pools appear.contents, extracellular lipid pools appear.
Fatty streaks develop as circulating Fatty streaks develop as circulating
monocytes migrate into the intima, take monocytes migrate into the intima, take
up oxidisup oxidiseded low-density lipoprotein low-density lipoprotein
(LDL) from the plasma, and become (LDL) from the plasma, and become
lipid-laden foam cells.lipid-laden foam cells.
As these foam cells die and release their As these foam cells die and release their
contents, extracellular lipid pools appear.contents, extracellular lipid pools appear.
Local and systemic factors will determine Local and systemic factors will determine
whether a fatty streak resolves or whether a fatty streak resolves or
progresses to an atheromatous lesion.progresses to an atheromatous lesion.
In early atheroma, smooth muscle cells In early atheroma, smooth muscle cells
migrate into and proliferate within the migrate into and proliferate within the
plaque.plaque.
As the lesion grows it encroaches into the As the lesion grows it encroaches into the
lumen of the vessel and erodes the media.lumen of the vessel and erodes the media.
Local and systemic factors will determine Local and systemic factors will determine
whether a fatty streak resolves or whether a fatty streak resolves or
progresses to an atheromatous lesion.progresses to an atheromatous lesion.
In early atheroma, smooth muscle cells In early atheroma, smooth muscle cells
migrate into and proliferate within the migrate into and proliferate within the
plaque.plaque.
As the lesion grows it encroaches into the As the lesion grows it encroaches into the
lumen of the vessel and erodes the media.lumen of the vessel and erodes the media.
A mature fibrilipid plague has a core of A mature fibrilipid plague has a core of
extracellular lipid surrounded by smooth extracellular lipid surrounded by smooth
muscle cells and is separated from the lumen muscle cells and is separated from the lumen
by a cap of collagen-rich fibrous tissue.by a cap of collagen-rich fibrous tissue.
Such plaques may rupture or fissure, allowing Such plaques may rupture or fissure, allowing
blood to enter and disrupt the arterial wall; blood to enter and disrupt the arterial wall;
this may compromise the lumen of the vessel this may compromise the lumen of the vessel
and often precipitates thrombosis and local and often precipitates thrombosis and local
vasospasm.vasospasm.
A mature fibrilipid plague has a core of A mature fibrilipid plague has a core of
extracellular lipid surrounded by smooth extracellular lipid surrounded by smooth
muscle cells and is separated from the lumen muscle cells and is separated from the lumen
by a cap of collagen-rich fibrous tissue.by a cap of collagen-rich fibrous tissue.
Such plaques may rupture or fissure, allowing Such plaques may rupture or fissure, allowing
blood to enter and disrupt the arterial wall; blood to enter and disrupt the arterial wall;
this may compromise the lumen of the vessel this may compromise the lumen of the vessel
and often precipitates thrombosis and local and often precipitates thrombosis and local
vasospasm.vasospasm.
Plaque rupture may lead to rapid Plaque rupture may lead to rapid
growth of the lesion or occlusion of growth of the lesion or occlusion of
the vessel and is thought to be the the vessel and is thought to be the
cause of most acute coronary cause of most acute coronary
syndromes.syndromes.
Plaque rupture may lead to rapid Plaque rupture may lead to rapid
growth of the lesion or occlusion of growth of the lesion or occlusion of
the vessel and is thought to be the the vessel and is thought to be the
cause of most acute coronary cause of most acute coronary
syndromes.syndromes.
The number and state of evolution of The number and state of evolution of
plaques both increase with age, but plaques both increase with age, but
the rate of progression of the rate of progression of
individual plaques, even in the individual plaques, even in the
same patient, is very variable.same patient, is very variable.
The number and state of evolution of The number and state of evolution of
plaques both increase with age, but plaques both increase with age, but
the rate of progression of the rate of progression of
individual plaques, even in the individual plaques, even in the
same patient, is very variable.same patient, is very variable.
Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations
Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations
Clinical problemClinical problem
Stable anginaStable angina
Unstable anginaUnstable angina
Clinical problemClinical problem
Stable anginaStable angina
Unstable anginaUnstable angina
PathologyPathology
Ischaemia due to fixed atheromatous Ischaemia due to fixed atheromatous stenosis of one or more coronary stenosis of one or more coronary
arteriesarteries
Ischemia caused by dynamic Ischemia caused by dynamic obstruction of a coronary artery obstruction of a coronary artery
due to plaque rupture with due to plaque rupture with superimposed thrombosis and superimposed thrombosis and
spasmspasm
PathologyPathology
Ischaemia due to fixed atheromatous Ischaemia due to fixed atheromatous stenosis of one or more coronary stenosis of one or more coronary
arteriesarteries
Ischemia caused by dynamic Ischemia caused by dynamic obstruction of a coronary artery obstruction of a coronary artery
due to plaque rupture with due to plaque rupture with superimposed thrombosis and superimposed thrombosis and
spasmspasm
Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations
Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations
Clinical problemClinical problem
MyocardialMyocardial
infarctioninfarction
Heart failureHeart failure
Clinical problemClinical problem
MyocardialMyocardial
infarctioninfarction
Heart failureHeart failure
PathologyPathology
Acute occlusion of a coronary Acute occlusion of a coronary artery due to plaque rupture artery due to plaque rupture
and thrombosis and resulting in and thrombosis and resulting in myocardial necrosismyocardial necrosis
Myocardial dysfunction due to Myocardial dysfunction due to infarction or ischemiainfarction or ischemia
PathologyPathology
Acute occlusion of a coronary Acute occlusion of a coronary artery due to plaque rupture artery due to plaque rupture
and thrombosis and resulting in and thrombosis and resulting in myocardial necrosismyocardial necrosis
Myocardial dysfunction due to Myocardial dysfunction due to infarction or ischemiainfarction or ischemia
Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations
Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations
Clinical problemClinical problem
ArrhythmiaArrhythmia
Sudden deathSudden death
Clinical problemClinical problem
ArrhythmiaArrhythmia
Sudden deathSudden death
PathologyPathology
Altered conduction due to Altered conduction due to infarction or ischemiainfarction or ischemia
Ventricular arrhythmia, asystole Ventricular arrhythmia, asystole or massive myocardial or massive myocardial
infarctioninfarction
PathologyPathology
Altered conduction due to Altered conduction due to infarction or ischemiainfarction or ischemia
Ventricular arrhythmia, asystole Ventricular arrhythmia, asystole or massive myocardial or massive myocardial
infarctioninfarction
Some important risk factors for Some important risk factors for coronary artery diseasecoronary artery disease
Some important risk factors for Some important risk factors for coronary artery diseasecoronary artery disease
FixedFixed
AgeAge
Male sexMale sex
Family historyFamily history
FixedFixed
AgeAge
Male sexMale sex
Family historyFamily history
ModifiableModifiable SmokingSmoking
HypertensionHypertension Lipid disordersLipid disorders
Diabetes mellitusDiabetes mellitus Hemostatic variablesHemostatic variables
Sedentary lifestyleSedentary lifestyle Dietary deficiencies Dietary deficiencies
ModifiableModifiable SmokingSmoking
HypertensionHypertension Lipid disordersLipid disorders
Diabetes mellitusDiabetes mellitus Hemostatic variablesHemostatic variables
Sedentary lifestyleSedentary lifestyle Dietary deficiencies Dietary deficiencies
„„New” risk factors for coronary New” risk factors for coronary artery diseaseartery disease
„„New” risk factors for coronary New” risk factors for coronary artery diseaseartery disease
HomocysteineHomocysteine
FibrinogenFibrinogen
Von Willebrand factorVon Willebrand factor
CRPCRP
Lp(a)Lp(a)
HomocysteineHomocysteine
FibrinogenFibrinogen
Von Willebrand factorVon Willebrand factor
CRPCRP
Lp(a)Lp(a)
Folic acid, Vit BFolic acid, Vit B1212, Vit B, Vit B66Folic acid, Vit BFolic acid, Vit B1212, Vit B, Vit B66
ANGINA PECTORISANGINA PECTORISANGINA PECTORISANGINA PECTORIS
A clinical syndrome due to A clinical syndrome due to
myocardial ischemia characterized myocardial ischemia characterized
by episodes of perby episodes of periicordial cordial
discomfort or pressure, typically discomfort or pressure, typically
precipitated by exertion and relived precipitated by exertion and relived
by rest or sublingual nitroglycerin.by rest or sublingual nitroglycerin.
A clinical syndrome due to A clinical syndrome due to
myocardial ischemia characterized myocardial ischemia characterized
by episodes of perby episodes of periicordial cordial
discomfort or pressure, typically discomfort or pressure, typically
precipitated by exertion and relived precipitated by exertion and relived
by rest or sublingual nitroglycerin.by rest or sublingual nitroglycerin.
ANGINA PECTORISANGINA PECTORISANGINA PECTORISANGINA PECTORIS
may occur whenever there may occur whenever there
is an imbalance between is an imbalance between
myocardial oxygen supply myocardial oxygen supply
and demand.and demand.
may occur whenever there may occur whenever there
is an imbalance between is an imbalance between
myocardial oxygen supply myocardial oxygen supply
and demand.and demand.
ANGINA PECTORISANGINA PECTORISANGINA PECTORISANGINA PECTORIS
Cause:Cause:
most common most common coronary atheromacoronary atheroma
but also:but also:
aortic valve diseaseaortic valve disease
hypertrophic cardiomyopathyhypertrophic cardiomyopathy
some other forms of heart diseasesome other forms of heart disease
Cause:Cause:
most common most common coronary atheromacoronary atheroma
but also:but also:
aortic valve diseaseaortic valve disease
hypertrophic cardiomyopathyhypertrophic cardiomyopathy
some other forms of heart diseasesome other forms of heart disease
Clinical situations precipitating Clinical situations precipitating anginaangina
Clinical situations precipitating Clinical situations precipitating anginaangina
Common:Common: Physical exertionPhysical exertion
Cold exposureCold exposure Heavy mealsHeavy meals
Intense emotionIntense emotion
Common:Common: Physical exertionPhysical exertion
Cold exposureCold exposure Heavy mealsHeavy meals
Intense emotionIntense emotion
Rare:Rare: Lying flatLying flat
decubitus anginadecubitus angina Vivid dreamsVivid dreams
nocturnal anginanocturnal angina
Rare:Rare: Lying flatLying flat
decubitus anginadecubitus angina Vivid dreamsVivid dreams
nocturnal anginanocturnal angina
Stable angina is characterised Stable angina is characterised
typically by central chest typically by central chest
pain that is precipitated by pain that is precipitated by
exertion and promptly exertion and promptly
relived by restrelived by rest
Stable angina is characterised Stable angina is characterised
typically by central chest typically by central chest
pain that is precipitated by pain that is precipitated by
exertion and promptly exertion and promptly
relived by restrelived by rest
Most patients describe a sense of Most patients describe a sense of
oppression or tightness in the oppression or tightness in the
chestchest
„„like a band round the chest”like a band round the chest”;;
„„pain” may be deniedpain” may be denied
Most patients describe a sense of Most patients describe a sense of
oppression or tightness in the oppression or tightness in the
chestchest
„„like a band round the chest”like a band round the chest”;;
„„pain” may be deniedpain” may be denied
When describing angina the victim often When describing angina the victim often
closes a hand around the throat, puts a closes a hand around the throat, puts a
hand or clenched fist on the sternum, or hand or clenched fist on the sternum, or
places both hands across the lower chest.places both hands across the lower chest.
Many patients report a „choking” Many patients report a „choking”
sensation.sensation.
Breathlessness is sometimes a prominent Breathlessness is sometimes a prominent
featurefeature..
When describing angina the victim often When describing angina the victim often
closes a hand around the throat, puts a closes a hand around the throat, puts a
hand or clenched fist on the sternum, or hand or clenched fist on the sternum, or
places both hands across the lower chest.places both hands across the lower chest.
Many patients report a „choking” Many patients report a „choking”
sensation.sensation.
Breathlessness is sometimes a prominent Breathlessness is sometimes a prominent
featurefeature..
The pain may radiate to:The pain may radiate to:
the left shoulder and down the inside of the left the left shoulder and down the inside of the left
arm, even to the fingers,arm, even to the fingers,
the necthe neckk,,
the jaw,the jaw,
the teeth,the teeth,
occasionally even down the right arm.occasionally even down the right arm.
Anginal discomfort may be felt in the upper Anginal discomfort may be felt in the upper
abdomen.abdomen.
The pain may radiate to:The pain may radiate to:
the left shoulder and down the inside of the left the left shoulder and down the inside of the left
arm, even to the fingers,arm, even to the fingers,
the necthe neckk,,
the jaw,the jaw,
the teeth,the teeth,
occasionally even down the right arm.occasionally even down the right arm.
Anginal discomfort may be felt in the upper Anginal discomfort may be felt in the upper
abdomen.abdomen.
Attacks may vary in frequency from Attacks may vary in frequency from several/day to several/day to ooccasional episodes separated ccasional episodes separated by symptom-free intervals of weeks, months, by symptom-free intervals of weeks, months,
or years.or years.
They may increase in frequency (crescendo They may increase in frequency (crescendo angina) to a fatal outcome or may gradually angina) to a fatal outcome or may gradually
decrease or disappear if an adequate decrease or disappear if an adequate collateral coronary circulation develops, if collateral coronary circulation develops, if the ischemic area becomes infarcted, or if the ischemic area becomes infarcted, or if
heart failure supervenes and limits activityheart failure supervenes and limits activity..
Attacks may vary in frequency from Attacks may vary in frequency from several/day to several/day to ooccasional episodes separated ccasional episodes separated by symptom-free intervals of weeks, months, by symptom-free intervals of weeks, months,
or years.or years.
They may increase in frequency (crescendo They may increase in frequency (crescendo angina) to a fatal outcome or may gradually angina) to a fatal outcome or may gradually
decrease or disappear if an adequate decrease or disappear if an adequate collateral coronary circulation develops, if collateral coronary circulation develops, if the ischemic area becomes infarcted, or if the ischemic area becomes infarcted, or if
heart failure supervenes and limits activityheart failure supervenes and limits activity..
Any change in the pattern of symptoms:Any change in the pattern of symptoms:Any change in the pattern of symptoms:Any change in the pattern of symptoms:
increased intensity of attacksincreased intensity of attacks decreased threshold of stimulusdecreased threshold of stimulus
longer durationlonger duration occurrence when patient is sedentary or occurrence when patient is sedentary or
awakening from sleepawakening from sleep
unstable angina pectoris = unstable angina pectoris = acute coronary insufficiency = acute coronary insufficiency =
preinfarction anginapreinfarction angina
increased intensity of attacksincreased intensity of attacks decreased threshold of stimulusdecreased threshold of stimulus
longer durationlonger duration occurrence when patient is sedentary or occurrence when patient is sedentary or
awakening from sleepawakening from sleep
unstable angina pectoris = unstable angina pectoris = acute coronary insufficiency = acute coronary insufficiency =
preinfarction anginapreinfarction angina
Stable anginaStable anginais relis relaated to a fixed ted to a fixed
obstruction and obstruction and
usually precipitated usually precipitated
by an increase in by an increase in
myocardial oxygen myocardial oxygen
demanddemand
demand-led ischaemiademand-led ischaemia
Stable anginaStable anginais relis relaated to a fixed ted to a fixed
obstruction and obstruction and
usually precipitated usually precipitated
by an increase in by an increase in
myocardial oxygen myocardial oxygen
demanddemand
demand-led ischaemiademand-led ischaemia
Unstable anginaUnstable anginais due to an abrupt is due to an abrupt
reduction in reduction in
coronary blood flow coronary blood flow
caused by thrombosis caused by thrombosis
or spasmor spasm
ssupply-led ischaemiaupply-led ischaemia
Unstable anginaUnstable anginais due to an abrupt is due to an abrupt
reduction in reduction in
coronary blood flow coronary blood flow
caused by thrombosis caused by thrombosis
or spasmor spasm
ssupply-led ischaemiaupply-led ischaemia
Unstable angina may be prodromal Unstable angina may be prodromal
to acute MI;to acute MI;
Sudden death is less commonSudden death is less common
Prospective studies suggest that ~30% of Prospective studies suggest that ~30% of
patients with unstable angina will patients with unstable angina will
suffer an MI within 3 months of onset.suffer an MI within 3 months of onset.
Unstable angina may be prodromal Unstable angina may be prodromal
to acute MI;to acute MI;
Sudden death is less commonSudden death is less common
Prospective studies suggest that ~30% of Prospective studies suggest that ~30% of
patients with unstable angina will patients with unstable angina will
suffer an MI within 3 months of onset.suffer an MI within 3 months of onset.
Physical findingsPhysical findings
Between and even during attacks, there Between and even during attacks, there
may be no signs of organic heart disease.may be no signs of organic heart disease.
However, during the attack, heart rate However, during the attack, heart rate
may increase modestly, BP is often may increase modestly, BP is often
elevated, heart sounds become more elevated, heart sounds become more
distant, and the apical impulse is more distant, and the apical impulse is more
diffuse.diffuse.
Between and even during attacks, there Between and even during attacks, there
may be no signs of organic heart disease.may be no signs of organic heart disease.
However, during the attack, heart rate However, during the attack, heart rate
may increase modestly, BP is often may increase modestly, BP is often
elevated, heart sounds become more elevated, heart sounds become more
distant, and the apical impulse is more distant, and the apical impulse is more
diffuse.diffuse.
Physical findingsPhysical findings
Palpation of the precordium may Palpation of the precordium may
reveal a localized systolic bulging or reveal a localized systolic bulging or
paradoxical movement reflecting paradoxical movement reflecting
segmental myocardial ischaemia and segmental myocardial ischaemia and
regional dyskinesia. regional dyskinesia.
Palpation of the precordium may Palpation of the precordium may
reveal a localized systolic bulging or reveal a localized systolic bulging or
paradoxical movement reflecting paradoxical movement reflecting
segmental myocardial ischaemia and segmental myocardial ischaemia and
regional dyskinesia. regional dyskinesia.
Physical findingsPhysical findings
The 2nd heart sound may become The 2nd heart sound may become
paradoxical because of more paradoxical because of more
prolonged LV ejection during the prolonged LV ejection during the
ischaemia episode.ischaemia episode.
A 4th heart sound is common. A 4th heart sound is common.
The 2nd heart sound may become The 2nd heart sound may become
paradoxical because of more paradoxical because of more
prolonged LV ejection during the prolonged LV ejection during the
ischaemia episode.ischaemia episode.
A 4th heart sound is common. A 4th heart sound is common.
Physical findingsPhysical findings
A mid- or late-systolic apical A mid- or late-systolic apical
murmur, rather shrill but not murmur, rather shrill but not
especially loud, due to localized especially loud, due to localized
papillary muscle dysfunction papillary muscle dysfunction
secondary to the ischaemia may secondary to the ischaemia may
occur. occur.
A mid- or late-systolic apical A mid- or late-systolic apical
murmur, rather shrill but not murmur, rather shrill but not
especially loud, due to localized especially loud, due to localized
papillary muscle dysfunction papillary muscle dysfunction
secondary to the ischaemia may secondary to the ischaemia may
occur. occur.
DiagnosisDiagnosisDiagnosisDiagnosis Angina pectoris is a clinical diagnosis based Angina pectoris is a clinical diagnosis based
on a characteristic complaint of chest on a characteristic complaint of chest discomfortdiscomfort brought on by exertion and brought on by exertion and
relieved by rest.relieved by rest. Confirmation may be obtained by observing Confirmation may be obtained by observing
reversible ECG changes during a reversible ECG changes during a spontaneous attack or by giving a test dose spontaneous attack or by giving a test dose
of sublingual nitroglycerin that of sublingual nitroglycerin that characteristically relives the pain within 1.5 characteristically relives the pain within 1.5
to 3 min.to 3 min.
Angina pectoris is a clinical diagnosis based Angina pectoris is a clinical diagnosis based on a characteristic complaint of chest on a characteristic complaint of chest
discomfortdiscomfort brought on by exertion and brought on by exertion and relieved by rest.relieved by rest.
Confirmation may be obtained by observing Confirmation may be obtained by observing reversible ECG changes during a reversible ECG changes during a
spontaneous attack or by giving a test dose spontaneous attack or by giving a test dose of sublingual nitroglycerin that of sublingual nitroglycerin that
characteristically relives the pain within 1.5 characteristically relives the pain within 1.5 to 3 min.to 3 min.
DiagnosisDiagnosisDiagnosisDiagnosis
An abnormal resting ECG alone does An abnormal resting ECG alone does
not establish or refute the diagnosis not establish or refute the diagnosis
of angina pectoris, which must be of angina pectoris, which must be
recognized from characteristic recognized from characteristic
symptoms.symptoms.
An abnormal resting ECG alone does An abnormal resting ECG alone does
not establish or refute the diagnosis not establish or refute the diagnosis
of angina pectoris, which must be of angina pectoris, which must be
recognized from characteristic recognized from characteristic
symptoms.symptoms.
DiagnosisDiagnosisDiagnosisDiagnosis
Several diagnostic tests are availableSeveral diagnostic tests are available
Exercise tolerance testing or radionuclide Exercise tolerance testing or radionuclide
imaging durinimaging duringg stress and after rest can stress and after rest can
establish the presence of ischaemia, but false establish the presence of ischaemia, but false
– positives and –negatives occur.– positives and –negatives occur.
Several diagnostic tests are availableSeveral diagnostic tests are available
Exercise tolerance testing or radionuclide Exercise tolerance testing or radionuclide
imaging durinimaging duringg stress and after rest can stress and after rest can
establish the presence of ischaemia, but false establish the presence of ischaemia, but false
– positives and –negatives occur.– positives and –negatives occur.
DiagnosisDiagnosisDiagnosisDiagnosis
Coronary arteriography Coronary arteriography
documents coronary documents coronary
obstruction in the epicardial obstruction in the epicardial
vessels due to CAD.vessels due to CAD.
Coronary arteriography Coronary arteriography
documents coronary documents coronary
obstruction in the epicardial obstruction in the epicardial
vessels due to CAD.vessels due to CAD.
ECGECGECGECG Typically ST segment depressionTypically ST segment depression
ST segment elevationST segment elevation decrease in R wave heightdecrease in R wave height
intrintraaventricular or bundle branch ventricular or bundle branch conduction disturbancesconduction disturbances
arrhythmia (ventricular extrasystoles)arrhythmia (ventricular extrasystoles)
Typically ST segment depressionTypically ST segment depression ST segment elevationST segment elevation
decrease in R wave heightdecrease in R wave height intrintraaventricular or bundle branch ventricular or bundle branch
conduction disturbancesconduction disturbances arrhythmia (ventricular extrasystoles)arrhythmia (ventricular extrasystoles)
ECGECGECGECG Between episodes, the ECG Between episodes, the ECG
at rest is normal in ~30% of at rest is normal in ~30% of
patients with a typical patients with a typical
history of angina pectoris, history of angina pectoris,
even in extensive 3-vessel even in extensive 3-vessel
CAD.CAD.
Between episodes, the ECG Between episodes, the ECG
at rest is normal in ~30% of at rest is normal in ~30% of
patients with a typical patients with a typical
history of angina pectoris, history of angina pectoris,
even in extensive 3-vessel even in extensive 3-vessel
CAD.CAD.
The components of an ECG complexThe components of an ECG complexThe components of an ECG complexThe components of an ECG complex
Forms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depression
Planar ST depressionPlanar ST depression
(( 1mm) 1mm)
Planar ST depressionPlanar ST depression
(( 1mm) 1mm)
Downsloping depressionDownsloping depression
(( 1mm) 1mm)
Downsloping depressionDownsloping depression
(( 1mm) 1mm)
Forms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depression
Upsloping depression Upsloping depression
(may be a normal finding!)(may be a normal finding!)
Upsloping depression Upsloping depression
(may be a normal finding!)(may be a normal finding!)
Forms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depression
A positive A positive exercise testexercise test
A positive A positive exercise testexercise test
MYOCARDIAL MYOCARDIAL
INFRACTIONINFRACTION
MYOCARDIAL MYOCARDIAL
INFRACTIONINFRACTION
MI is almost always due to the MI is almost always due to the
formation of occlusive thrombus at formation of occlusive thrombus at
the site of rupture of an the site of rupture of an
atheromatous plaque in a coronary atheromatous plaque in a coronary
artery.artery.
MI is almost always due to the MI is almost always due to the
formation of occlusive thrombus at formation of occlusive thrombus at
the site of rupture of an the site of rupture of an
atheromatous plaque in a coronary atheromatous plaque in a coronary
artery.artery.
Coronary artery thrombosisCoronary artery thrombosisCoronary artery thrombosisCoronary artery thrombosis
lipid poollipid poolintraintimal
thrombosis
intraintimal
thrombosis
intraluminal
thrombosis
intraluminal
thrombosispropagating
thrombosis
propagating
thrombosis
The thrombus is often undergoes The thrombus is often undergoes
spontaneous lysis over the course spontaneous lysis over the course
of the next few days, although by of the next few days, although by
this time irreversible myocardial this time irreversible myocardial
damage has occurred.damage has occurred.
The thrombus is often undergoes The thrombus is often undergoes
spontaneous lysis over the course spontaneous lysis over the course
of the next few days, although by of the next few days, although by
this time irreversible myocardial this time irreversible myocardial
damage has occurred.damage has occurred.
The time course of myocardial infarctionThe time course of myocardial infarctionThe time course of myocardial infarctionThe time course of myocardial infarction
The relative proportion of ischaemic, infarcting and The relative proportion of ischaemic, infarcting and infarcted tissue slowly changes over a period of infarcted tissue slowly changes over a period of 8 – 8 –
12 hours. In the early stages of myocardial infarction 12 hours. In the early stages of myocardial infarction a significant proportion of the myocardium in a significant proportion of the myocardium in
jeopardy is potentially salvageablejeopardy is potentially salvageable..
The relative proportion of ischaemic, infarcting and The relative proportion of ischaemic, infarcting and infarcted tissue slowly changes over a period of infarcted tissue slowly changes over a period of 8 – 8 –
12 hours. In the early stages of myocardial infarction 12 hours. In the early stages of myocardial infarction a significant proportion of the myocardium in a significant proportion of the myocardium in
jeopardy is potentially salvageablejeopardy is potentially salvageable..
Myocardial infarction-Myocardial infarction-clinical featuresclinical features
Myocardial infarction-Myocardial infarction-clinical featuresclinical features
Some 2/3 of patients experience Some 2/3 of patients experience
prodromal symptoms days to prodromal symptoms days to
weeks before the event, weeks before the event,
characterized by crescendo characterized by crescendo
angina, shortness of breath, or angina, shortness of breath, or
fatigue.fatigue.
Some 2/3 of patients experience Some 2/3 of patients experience
prodromal symptoms days to prodromal symptoms days to
weeks before the event, weeks before the event,
characterized by crescendo characterized by crescendo
angina, shortness of breath, or angina, shortness of breath, or
fatigue.fatigue.
Clinical featuresClinical features
Cardinal symptom:Cardinal symptom:
painpain
breathlessnessbreathlessness vomitingvomiting collapse or collapse or
syncopesyncope
Cardinal symptom:Cardinal symptom:
painpain
breathlessnessbreathlessness vomitingvomiting collapse or collapse or
syncopesyncope
common
symptoms
common
symptoms
The pain occurs in the same sites as angina The pain occurs in the same sites as angina
but is usually more severe and lasts but is usually more severe and lasts
longer; it is often described as a tightness, longer; it is often described as a tightness,
heaviness or constriction in the chest.heaviness or constriction in the chest.
At its worst the pain is one of the most At its worst the pain is one of the most
severe which can be experienced and the severe which can be experienced and the
patient’s expression and pallor may patient’s expression and pallor may
vividly convey the seriousness of the vividly convey the seriousness of the
situationsituation..
The pain occurs in the same sites as angina The pain occurs in the same sites as angina
but is usually more severe and lasts but is usually more severe and lasts
longer; it is often described as a tightness, longer; it is often described as a tightness,
heaviness or constriction in the chest.heaviness or constriction in the chest.
At its worst the pain is one of the most At its worst the pain is one of the most
severe which can be experienced and the severe which can be experienced and the
patient’s expression and pallor may patient’s expression and pallor may
vividly convey the seriousness of the vividly convey the seriousness of the
situationsituation..
Deep, substernal, visceral, long lasting Deep, substernal, visceral, long lasting
pain described as aching or pressure, pain described as aching or pressure,
with radiation to the back, jaw, or with radiation to the back, jaw, or
left armleft arm
MIMI
Deep, substernal, visceral, long lasting Deep, substernal, visceral, long lasting
pain described as aching or pressure, pain described as aching or pressure,
with radiation to the back, jaw, or with radiation to the back, jaw, or
left armleft arm
MIMI
Most patients are breathless and in some Most patients are breathless and in some
this is the only symptom.this is the only symptom.
If syncope occurs it is usually due to an If syncope occurs it is usually due to an
arrhythmia or profound hypotension.arrhythmia or profound hypotension.
Vomiting and sinus bradycardia are often Vomiting and sinus bradycardia are often
due to vagal stimulation and are due to vagal stimulation and are
particularly common in patients with particularly common in patients with
inferior myocardial infraction.inferior myocardial infraction.
Most patients are breathless and in some Most patients are breathless and in some
this is the only symptom.this is the only symptom.
If syncope occurs it is usually due to an If syncope occurs it is usually due to an
arrhythmia or profound hypotension.arrhythmia or profound hypotension.
Vomiting and sinus bradycardia are often Vomiting and sinus bradycardia are often
due to vagal stimulation and are due to vagal stimulation and are
particularly common in patients with particularly common in patients with
inferior myocardial infraction.inferior myocardial infraction.
Symptoms of LV failure, Symptoms of LV failure,
pulmonary pulmonary ooedema, shock, or edema, shock, or
significant arrhythmia may significant arrhythmia may
develop and dominant the develop and dominant the
clinical picture. clinical picture.
Symptoms of LV failure, Symptoms of LV failure,
pulmonary pulmonary ooedema, shock, or edema, shock, or
significant arrhythmia may significant arrhythmia may
develop and dominant the develop and dominant the
clinical picture. clinical picture.
However, discomfort may be However, discomfort may be
very mild, and a significant very mild, and a significant
percentage (~20%) of acute percentage (~20%) of acute
MIs are silent or unrecognized MIs are silent or unrecognized
as illness by the patient.as illness by the patient.
However, discomfort may be However, discomfort may be
very mild, and a significant very mild, and a significant
percentage (~20%) of acute percentage (~20%) of acute
MIs are silent or unrecognized MIs are silent or unrecognized
as illness by the patient.as illness by the patient.
On examination:On examination:On examination:On examination:
The patient is usually:The patient is usually: restlessrestless
apprehensiveapprehensive palepale
diaphoreticdiaphoretic and in severe painand in severe pain
The patient is usually:The patient is usually: restlessrestless
apprehensiveapprehensive palepale
diaphoreticdiaphoretic and in severe painand in severe pain
On examination:On examination:On examination:On examination:
the skin is usually coldthe skin is usually cold
peripheral or central peripheral or central
cyanosis may be cyanosis may be
appappaarentrent
the skin is usually coldthe skin is usually cold
peripheral or central peripheral or central
cyanosis may be cyanosis may be
appappaarentrent
On examination:On examination:On examination:On examination:
the pulse may be threadythe pulse may be thready
the BP is variably, although the BP is variably, although
many patients initially manifest many patients initially manifest
some degree of hypertension some degree of hypertension
unless cardiogenic shock is unless cardiogenic shock is
developingdeveloping
the pulse may be threadythe pulse may be thready
the BP is variably, although the BP is variably, although
many patients initially manifest many patients initially manifest
some degree of hypertension some degree of hypertension
unless cardiogenic shock is unless cardiogenic shock is
developingdeveloping
On examination:On examination:On examination:On examination:
Arrhythmia is common:Arrhythmia is common:
bradycardiabradycardia
extrasystolesextrasystoles
ventricular fibrillationventricular fibrillation
Arrhythmia is common:Arrhythmia is common:
bradycardiabradycardia
extrasystolesextrasystoles
ventricular fibrillationventricular fibrillation
On examination:On examination:On examination:On examination:
The heart sounds are usually The heart sounds are usually
somewhat distantsomewhat distant
the presence of 4th heart the presence of 4th heart
sound is almost universalsound is almost universal
The heart sounds are usually The heart sounds are usually
somewhat distantsomewhat distant
the presence of 4th heart the presence of 4th heart
sound is almost universalsound is almost universal
On examination:On examination:On examination:On examination:
There may be a soft systolic blowing apical There may be a soft systolic blowing apical
murmur (a reflection of papillary muscle murmur (a reflection of papillary muscle
dysfunction)dysfunction)
At initial evaluation, the presence of a At initial evaluation, the presence of a
friction rub or more striking murmurs friction rub or more striking murmurs
suggests the possibility of preexisting heart suggests the possibility of preexisting heart
disease or another diagnosisdisease or another diagnosis
There may be a soft systolic blowing apical There may be a soft systolic blowing apical
murmur (a reflection of papillary muscle murmur (a reflection of papillary muscle
dysfunction)dysfunction)
At initial evaluation, the presence of a At initial evaluation, the presence of a
friction rub or more striking murmurs friction rub or more striking murmurs
suggests the possibility of preexisting heart suggests the possibility of preexisting heart
disease or another diagnosisdisease or another diagnosis
Detection of friction rub within a few hours Detection of friction rub within a few hours
after the onset of symptoms of acute MI after the onset of symptoms of acute MI
is distinctly unusual and might suggest is distinctly unusual and might suggest
a diagnosis of acute pericarditis rather a diagnosis of acute pericarditis rather
than MI.than MI.
Friction rubs, usually evanescent, are Friction rubs, usually evanescent, are
common on days 2 and 3 post infarction common on days 2 and 3 post infarction
with transmural infarctswith transmural infarcts
Detection of friction rub within a few hours Detection of friction rub within a few hours
after the onset of symptoms of acute MI after the onset of symptoms of acute MI
is distinctly unusual and might suggest is distinctly unusual and might suggest
a diagnosis of acute pericarditis rather a diagnosis of acute pericarditis rather
than MI.than MI.
Friction rubs, usually evanescent, are Friction rubs, usually evanescent, are
common on days 2 and 3 post infarction common on days 2 and 3 post infarction
with transmural infarctswith transmural infarcts
MI MI physical signs physical signs MI MI physical signs physical signs
Signs of sympathetic Signs of sympathetic activation:activation: pallorpallor
sweatingsweating tachycardiatachycardia
Signs of vagal Signs of vagal activation:activation:
vomitingvomiting bradycardiabradycardia
Signs of sympathetic Signs of sympathetic activation:activation: pallorpallor
sweatingsweating tachycardiatachycardia
Signs of vagal Signs of vagal activation:activation:
vomitingvomiting bradycardiabradycardia
Signs of tissue Signs of tissue
damage:damage:
feverfever
Signs of Signs of
complicationscomplications
mitral regurgitationmitral regurgitation
pericarditispericarditis
Signs of tissue Signs of tissue
damage:damage:
feverfever
Signs of Signs of
complicationscomplications
mitral regurgitationmitral regurgitation
pericarditispericarditis
MI MI physical signs physical signs MI MI physical signs physical signs
hypotension,hypotension, oliguria, oliguria,
cold peripheriescold peripheries narrow pulse narrow pulse
pressurepressure raised JPVraised JPV
hypotension,hypotension, oliguria, oliguria,
cold peripheriescold peripheries narrow pulse narrow pulse
pressurepressure raised JPVraised JPV
third heart soundthird heart sound
quiet first heart quiet first heart
soundsound
diffuse apical diffuse apical
impulseimpulse
lung crepitationslung crepitations
third heart soundthird heart sound
quiet first heart quiet first heart
soundsound
diffuse apical diffuse apical
impulseimpulse
lung crepitationslung crepitations
Signs of impaired myocardial function:Signs of impaired myocardial function:
Sudden death, from ventricular Sudden death, from ventricular
fibrillation or asystole, may occur fibrillation or asystole, may occur
immediately, and many deaths occur immediately, and many deaths occur
within the first hour.within the first hour.
The development of cardiac failure The development of cardiac failure
reflects the extent of myocardial damage reflects the extent of myocardial damage
and is the major cause of death in those and is the major cause of death in those
who survive the first few hours of MIwho survive the first few hours of MI..
Sudden death, from ventricular Sudden death, from ventricular
fibrillation or asystole, may occur fibrillation or asystole, may occur
immediately, and many deaths occur immediately, and many deaths occur
within the first hour.within the first hour.
The development of cardiac failure The development of cardiac failure
reflects the extent of myocardial damage reflects the extent of myocardial damage
and is the major cause of death in those and is the major cause of death in those
who survive the first few hours of MIwho survive the first few hours of MI..
LABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGS
The most important The most important
laboratory procedure in laboratory procedure in
the patient with suspected the patient with suspected
acute MI is analysis of the acute MI is analysis of the
ECG.ECG.
The most important The most important
laboratory procedure in laboratory procedure in
the patient with suspected the patient with suspected
acute MI is analysis of the acute MI is analysis of the
ECG.ECG.
LABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGS
The ECG is usually a sensitive and specific The ECG is usually a sensitive and specific
way to confirming the diagnosis; however, it way to confirming the diagnosis; however, it
may be difficult to interpret if there is bundle may be difficult to interpret if there is bundle
branch block or evidence of previous branch block or evidence of previous
myocardial infarction.myocardial infarction.
Occasionally the initial ECG is normal and Occasionally the initial ECG is normal and
diagnostic changes appear a few hours later.diagnostic changes appear a few hours later.
The ECG is usually a sensitive and specific The ECG is usually a sensitive and specific
way to confirming the diagnosis; however, it way to confirming the diagnosis; however, it
may be difficult to interpret if there is bundle may be difficult to interpret if there is bundle
branch block or evidence of previous branch block or evidence of previous
myocardial infarction.myocardial infarction.
Occasionally the initial ECG is normal and Occasionally the initial ECG is normal and
diagnostic changes appear a few hours later.diagnostic changes appear a few hours later.
The serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MI
B:B: Acute ST elevation („the Acute ST elevation („the current of injury”)current of injury”)
C:C: Progressive loss of the R Progressive loss of the R wave, developing Q wave, wave, developing Q wave, resolution of the ST elevation resolution of the ST elevation and terminal T wave and terminal T wave inversioninversion
D:D: Deep Q wave and T wave Deep Q wave and T wave inversioninversion
E:E: Old or established infarct Old or established infarct pattern – the Q wave tends pattern – the Q wave tends to persist but the T wave to persist but the T wave changes become less markedchanges become less marked
B:B: Acute ST elevation („the Acute ST elevation („the current of injury”)current of injury”)
C:C: Progressive loss of the R Progressive loss of the R wave, developing Q wave, wave, developing Q wave, resolution of the ST elevation resolution of the ST elevation and terminal T wave and terminal T wave inversioninversion
D:D: Deep Q wave and T wave Deep Q wave and T wave inversioninversion
E:E: Old or established infarct Old or established infarct pattern – the Q wave tends pattern – the Q wave tends to persist but the T wave to persist but the T wave changes become less markedchanges become less marked
A: Normal ECG complexA: Normal ECG complex
The serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MI
B:B: stage B appears within stage B appears within
minutesminutes
C:C: within hours within hours
D:D: within days within days
E:E: after several weeks or after several weeks or
monthsmonths
B:B: stage B appears within stage B appears within
minutesminutes
C:C: within hours within hours
D:D: within days within days
E:E: after several weeks or after several weeks or
monthsmonths
The rate of evolution is
very variable; in general:
The rate of evolution is
very variable; in general:
In contrast to transmural lesion, In contrast to transmural lesion,
subendocardial infarction causes ST/T subendocardial infarction causes ST/T
wave changes without Q waves or wave changes without Q waves or
prominent ST elevation; this is often prominent ST elevation; this is often
accompanied by some loss of the R waves accompanied by some loss of the R waves
in the lein the leaads facing the infarct.ds facing the infarct.
In contrast to transmural lesion, In contrast to transmural lesion,
subendocardial infarction causes ST/T subendocardial infarction causes ST/T
wave changes without Q waves or wave changes without Q waves or
prominent ST elevation; this is often prominent ST elevation; this is often
accompanied by some loss of the R waves accompanied by some loss of the R waves
in the lein the leaads facing the infarct.ds facing the infarct.
Recent anterior Recent anterior
subendocardial subendocardial
(partial thickness) (partial thickness)
infarctioninfarction
Recent anterior Recent anterior
subendocardial subendocardial
(partial thickness) (partial thickness)
infarctioninfarction
There is deep There is deep
symmetrical T wave symmetrical T wave
inversion together inversion together
with a reduction in with a reduction in
the height of the R the height of the R
wave in leads Vwave in leads V11, V, V22, ,
VV33 and V and V44..
There is deep There is deep
symmetrical T wave symmetrical T wave
inversion together inversion together
with a reduction in with a reduction in
the height of the R the height of the R
wave in leads Vwave in leads V11, V, V22, ,
VV33 and V and V44..
The ECG changes are best seen in the leads which The ECG changes are best seen in the leads which „face” the infarcted area.„face” the infarcted area.
The ECG changes are best seen in the leads which The ECG changes are best seen in the leads which „face” the infarcted area.„face” the infarcted area.
Anteroseptal infarctionAnteroseptal infarction
Anterolateral infarctionAnterolateral infarction
Inferior infarctionInferior infarction
Posterior infarctionPosterior infarction
Anteroseptal infarctionAnteroseptal infarction
Anterolateral infarctionAnterolateral infarction
Inferior infarctionInferior infarction
Posterior infarctionPosterior infarction
one or more leads from Vone or more leads from V11 to V to V44
from Vfrom V44 to V to V66; AVL, and lead I; AVL, and lead I
leads II, III, AVF; and the anterior leads II, III, AVF; and the anterior chest leads chest leads →”reciprocal” →”reciprocal” changes of ST depressionchanges of ST depression
In leads VIn leads V11-V-V44 → reciprocal changes → reciprocal changes
of ST depression and a tall R of ST depression and a tall R wavewave
one or more leads from Vone or more leads from V11 to V to V44
from Vfrom V44 to V to V66; AVL, and lead I; AVL, and lead I
leads II, III, AVF; and the anterior leads II, III, AVF; and the anterior chest leads chest leads →”reciprocal” →”reciprocal” changes of ST depressionchanges of ST depression
In leads VIn leads V11-V-V44 → reciprocal changes → reciprocal changes
of ST depression and a tall R of ST depression and a tall R wavewave
Abnormalities in:Abnormalities in:
Acute full thickness Acute full thickness anterior MIanterior MI
Acute full thickness Acute full thickness anterior MIanterior MI
ST elevation in ST elevation in leads I, AVL, Vleads I, AVL, V22 – –
VV66
Q waves in leads Q waves in leads VV33 – V – V55
ST elevation in ST elevation in leads I, AVL, Vleads I, AVL, V22 – –
VV66
Q waves in leads Q waves in leads VV33 – V – V55
Anterior infarctAnterior infarctwith prominent changes in:with prominent changes in:
Anterior infarctAnterior infarctwith prominent changes in:with prominent changes in:
leads Vleads V22, V, V33, V, V44leads Vleads V22, V, V33, V, V44 leads Vleads V44, V, V55, V, V66leads Vleads V44, V, V55, V, V66
anteroseptal infarct
anteroseptal infarct
anterolateral infarct
anterolateral infarct
Acute full thickness Acute full thickness inferolateral MIinferolateral MI
Acute full thickness Acute full thickness inferolateral MIinferolateral MI
ST elevation in ST elevation in inferior leads II, inferior leads II,
III, AVF III, AVF ST elevation in ST elevation in lateral leads Vlateral leads V44 – V – V66
„„reciprocal” ST reciprocal” ST depression in leads depression in leads
AVL and VAVL and V22
ST elevation in ST elevation in inferior leads II, inferior leads II,
III, AVF III, AVF ST elevation in ST elevation in lateral leads Vlateral leads V44 – V – V66
„„reciprocal” ST reciprocal” ST depression in leads depression in leads
AVL and VAVL and V22
Established full Established full thickness anterior thickness anterior and inferior MIand inferior MI
Established full Established full thickness anterior thickness anterior and inferior MIand inferior MI
Q waves in inferior Q waves in inferior leads II, III, AVF leads II, III, AVF
Q waves with some Q waves with some residual ST residual ST
elevation in the elevation in the anterior leads I and anterior leads I and
VV22 – V – V66
Q waves in inferior Q waves in inferior leads II, III, AVF leads II, III, AVF
Q waves with some Q waves with some residual ST residual ST
elevation in the elevation in the anterior leads I and anterior leads I and
VV22 – V – V66
Plasma enzymesPlasma enzymesPlasma enzymesPlasma enzymesMI causes a detectable rise in the plasma MI causes a detectable rise in the plasma
concentration of enzymes which are concentration of enzymes which are normally concentrated within cardiac normally concentrated within cardiac
cellscells
most widely usedmost widely used →→ ccreatine kinase (CK)reatine kinase (CK) cardiospecific:cardiospecific:
CK-MBCK-MB troponin Ttroponin T troponin Itroponin I
MI causes a detectable rise in the plasma MI causes a detectable rise in the plasma concentration of enzymes which are concentration of enzymes which are
normally concentrated within cardiac normally concentrated within cardiac cellscells
most widely usedmost widely used →→ ccreatine kinase (CK)reatine kinase (CK) cardiospecific:cardiospecific:
CK-MBCK-MB troponin Ttroponin T troponin Itroponin I
Changes in plasma enzyme concentrations Changes in plasma enzyme concentrations after MIafter MI
Changes in plasma enzyme concentrations Changes in plasma enzyme concentrations after MIafter MI
HEART FAILUREHEART FAILURE
Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)
A clinical syndrome with many different A clinical syndrome with many different
etiologies that reflects a fundamental etiologies that reflects a fundamental
abnormality in effectiveabnormality in effective mechanical mechanical
performance of the heart, resulting in performance of the heart, resulting in
cardiac output inadequate to meet the cardiac output inadequate to meet the
body’s needs.body’s needs.
A clinical syndrome with many different A clinical syndrome with many different
etiologies that reflects a fundamental etiologies that reflects a fundamental
abnormality in effectiveabnormality in effective mechanical mechanical
performance of the heart, resulting in performance of the heart, resulting in
cardiac output inadequate to meet the cardiac output inadequate to meet the
body’s needs.body’s needs.
Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)
Impaired cardiac function may be Impaired cardiac function may be
manifested initially only during exertion, manifested initially only during exertion,
but with progression of disease, the but with progression of disease, the
contractile performance of the heart contractile performance of the heart
deteriorates, and symptoms and signs of deteriorates, and symptoms and signs of
congestion and fatigue are associated congestion and fatigue are associated
with a low cardiac output, even at rest..with a low cardiac output, even at rest..
Impaired cardiac function may be Impaired cardiac function may be
manifested initially only during exertion, manifested initially only during exertion,
but with progression of disease, the but with progression of disease, the
contractile performance of the heart contractile performance of the heart
deteriorates, and symptoms and signs of deteriorates, and symptoms and signs of
congestion and fatigue are associated congestion and fatigue are associated
with a low cardiac output, even at rest..with a low cardiac output, even at rest..
Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)
In practice, heart failure may be In practice, heart failure may be
diagnosed whenever a patient with diagnosed whenever a patient with
significant heart disease develops the significant heart disease develops the
signs or symptoms of low cardiac signs or symptoms of low cardiac
output, pulmonary congestion or output, pulmonary congestion or
systemic venosus congestion. systemic venosus congestion.
In practice, heart failure may be In practice, heart failure may be
diagnosed whenever a patient with diagnosed whenever a patient with
significant heart disease develops the significant heart disease develops the
signs or symptoms of low cardiac signs or symptoms of low cardiac
output, pulmonary congestion or output, pulmonary congestion or
systemic venosus congestion. systemic venosus congestion.
The cardiac output is a function of:The cardiac output is a function of:
the preloadthe preload
the afterloadthe afterload
myocardial contractilitymyocardial contractility
The cardiac output is a function of:The cardiac output is a function of:
the preloadthe preload
the afterloadthe afterload
myocardial contractilitymyocardial contractility
the volume and pressure of blood in the ventricle at
the end of diastole
the volume and pressure of blood in the ventricle at
the end of diastole
the arterial resistancethe arterial resistance
The renin-angiotensin-aldosterone system in HFThe renin-angiotensin-aldosterone system in HFThe renin-angiotensin-aldosterone system in HFThe renin-angiotensin-aldosterone system in HF
AngiotensinogenAngiotensinogen
Angiotensin IAngiotensin I
Angiotensin IIAngiotensin II
AldosteroneAldosterone
Salt and water
retention
Salt and water
retention
Potassium lossPotassium loss
AfterloadAfterload
PreloadPreload
ContractilityContractility
Direct
vasoconstriction
Direct
vasoconstriction
Activation of sympathetic nervous
system
Activation of sympathetic nervous
system
Release of antidiuretic hormnoe
Release of antidiuretic hormnoe
renin
Angiotensin-converting enzyme
Types of heart failureTypes of heart failureTypes of heart failureTypes of heart failure
Heart failure can be Heart failure can be
described or described or
classified in several classified in several
ways.ways.
Heart failure can be Heart failure can be
described or described or
classified in several classified in several
ways.ways.
Types of heart failureTypes of heart failureTypes of heart failureTypes of heart failure
Acute heart Acute heart
failurefailure
develop suddenly, develop suddenly,
as in myocardial as in myocardial
infarction infarction
Acute heart Acute heart
failurefailure
develop suddenly, develop suddenly,
as in myocardial as in myocardial
infarction infarction
Chronic heart Chronic heart
failurefailure
develop gradually as develop gradually as
in progressive in progressive
valvular heart valvular heart
diseasedisease
Chronic heart Chronic heart
failurefailure
develop gradually as develop gradually as
in progressive in progressive
valvular heart valvular heart
diseasedisease
When there is gradual impairment of When there is gradual impairment of
cardiac function, a variety of cardiac function, a variety of
compensatory changes may take place.compensatory changes may take place.
Although initially these changes may Although initially these changes may
improve overall cardiac function, as the improve overall cardiac function, as the
disease progresses they often become disease progresses they often become
counterproductivecounterproductive
When there is gradual impairment of When there is gradual impairment of
cardiac function, a variety of cardiac function, a variety of
compensatory changes may take place.compensatory changes may take place.
Although initially these changes may Although initially these changes may
improve overall cardiac function, as the improve overall cardiac function, as the
disease progresses they often become disease progresses they often become
counterproductivecounterproductive
The term compensated heart failure The term compensated heart failure
is sometimes used to describe a is sometimes used to describe a
patient with impaired cardiac patient with impaired cardiac
function in whom adaptive changes function in whom adaptive changes
have prevented the development of have prevented the development of
overt heart failure overt heart failure
The term compensated heart failure The term compensated heart failure
is sometimes used to describe a is sometimes used to describe a
patient with impaired cardiac patient with impaired cardiac
function in whom adaptive changes function in whom adaptive changes
have prevented the development of have prevented the development of
overt heart failure overt heart failure
Compensatory changes in heart failureCompensatory changes in heart failureCompensatory changes in heart failureCompensatory changes in heart failure
Local changesLocal changes Chamber Chamber enlargementenlargement
Myocardial Myocardial hypertrophyhypertrophy
Increased heart rateIncreased heart rate
Local changesLocal changes Chamber Chamber enlargementenlargement
Myocardial Myocardial hypertrophyhypertrophy
Increased heart rateIncreased heart rate
Systemic changesSystemic changes Activation of sympathetic Activation of sympathetic
nervous systemnervous system Activation of the renin-Activation of the renin-
angiotensin-aldosterone angiotensin-aldosterone systemsystem
Release of antidiuretic Release of antidiuretic hormonehormone
Release of natiureic Release of natiureic peptidespeptides
Systemic changesSystemic changes Activation of sympathetic Activation of sympathetic
nervous systemnervous system Activation of the renin-Activation of the renin-
angiotensin-aldosterone angiotensin-aldosterone systemsystem
Release of antidiuretic Release of antidiuretic hormonehormone
Release of natiureic Release of natiureic peptidespeptides
Factors that may precipitate or aggravate Factors that may precipitate or aggravate heart failureheart failure
Factors that may precipitate or aggravate Factors that may precipitate or aggravate heart failureheart failure
Myocardial ischaemia Myocardial ischaemia or infarctionor infarction
Intercurrent illness (e.g. Intercurrent illness (e.g. infection)infection)
ArrhytArrhythhmiamia Inappropriate reduction Inappropriate reduction
of therapyof therapy Pulmonary embolismPulmonary embolism
Intravenous fluid Intravenous fluid overload (e.g. post-overload (e.g. post-
operative i.v. infusion)operative i.v. infusion)
Myocardial ischaemia Myocardial ischaemia or infarctionor infarction
Intercurrent illness (e.g. Intercurrent illness (e.g. infection)infection)
ArrhytArrhythhmiamia Inappropriate reduction Inappropriate reduction
of therapyof therapy Pulmonary embolismPulmonary embolism
Intravenous fluid Intravenous fluid overload (e.g. post-overload (e.g. post-
operative i.v. infusion)operative i.v. infusion)
Administration of drug Administration of drug with negative inotropic with negative inotropic
(e.g. (e.g. ββ-adrenoceptor -adrenoceptor antagonist) or fluid-antagonist) or fluid-
retaining properties (e.g. retaining properties (e.g. non-steroidal anti-non-steroidal anti-
inflammatory drugs, inflammatory drugs, corticosteroids)corticosteroids)
Conditions associated Conditions associated with increased metabolic with increased metabolic demand (e.g. pregnancy, demand (e.g. pregnancy, thyrotoxicosis, anaemia)thyrotoxicosis, anaemia)
Administration of drug Administration of drug with negative inotropic with negative inotropic
(e.g. (e.g. ββ-adrenoceptor -adrenoceptor antagonist) or fluid-antagonist) or fluid-
retaining properties (e.g. retaining properties (e.g. non-steroidal anti-non-steroidal anti-
inflammatory drugs, inflammatory drugs, corticosteroids)corticosteroids)
Conditions associated Conditions associated with increased metabolic with increased metabolic demand (e.g. pregnancy, demand (e.g. pregnancy, thyrotoxicosis, anaemia)thyrotoxicosis, anaemia)
Types of heart failureTypes of heart failureTypes of heart failureTypes of heart failure
Left-sidedLeft-sided heart failure heart failure
Left-sidedLeft-sided heart failure heart failure
Right-sidedRight-sided heart heart
failurefailure
Right-sidedRight-sided heart heart
failurefailure
BiventricularBiventricular heart heart
failurefailure
BiventricularBiventricular heart heart
failurefailure
The left side of heartThe left side of heartThe left side of heartThe left side of heart
Left atriumLeft atrium
Mitral valveMitral valve
Left ventricleLeft ventricle
Aortic valveAortic valve
Left atriumLeft atrium
Mitral valveMitral valve
Left ventricleLeft ventricle
Aortic valveAortic valve
The right side of heartThe right side of heartThe right side of heartThe right side of heart
Right atrium Right atrium
Tricuspid valve Tricuspid valve
Right ventricle Right ventricle
Pulmonary valve Pulmonary valve
Right atrium Right atrium
Tricuspid valve Tricuspid valve
Right ventricle Right ventricle
Pulmonary valve Pulmonary valve
Left-side heart failureLeft-side heart failure
reduction in the left ventricular outputreduction in the left ventricular output
and/orand/or
increase in the left atrial or pulmonary increase in the left atrial or pulmonary
pressurepressure
reduction in the left ventricular outputreduction in the left ventricular output
and/orand/or
increase in the left atrial or pulmonary increase in the left atrial or pulmonary
pressurepressure
Left-side heart failureLeft-side heart failure An acute increase in left atrial pressure may An acute increase in left atrial pressure may
cause pulmonary congestion or pulmonary cause pulmonary congestion or pulmonary
oedemaoedema
A more gradual increase in the left atrial A more gradual increase in the left atrial
pressure may lead to reflex pulmonary pressure may lead to reflex pulmonary
vasoconstriction, which protects the patient vasoconstriction, which protects the patient
from pulmonary oedema at the cost of from pulmonary oedema at the cost of
increasing pulmonary hypertension.increasing pulmonary hypertension.
An acute increase in left atrial pressure may An acute increase in left atrial pressure may
cause pulmonary congestion or pulmonary cause pulmonary congestion or pulmonary
oedemaoedema
A more gradual increase in the left atrial A more gradual increase in the left atrial
pressure may lead to reflex pulmonary pressure may lead to reflex pulmonary
vasoconstriction, which protects the patient vasoconstriction, which protects the patient
from pulmonary oedema at the cost of from pulmonary oedema at the cost of
increasing pulmonary hypertension.increasing pulmonary hypertension.
Right-side heart failureRight-side heart failure
reduction in the right ventricular outputreduction in the right ventricular output
for any given right atrial pressurefor any given right atrial pressure
Causes of isolated right heart failure include Causes of isolated right heart failure include
chronic lung disease (cor pulmonare), multiple chronic lung disease (cor pulmonare), multiple
pulmonary emboli, and pulmonary valvular pulmonary emboli, and pulmonary valvular
stenosisstenosis
reduction in the right ventricular outputreduction in the right ventricular output
for any given right atrial pressurefor any given right atrial pressure
Causes of isolated right heart failure include Causes of isolated right heart failure include
chronic lung disease (cor pulmonare), multiple chronic lung disease (cor pulmonare), multiple
pulmonary emboli, and pulmonary valvular pulmonary emboli, and pulmonary valvular
stenosisstenosis
Biventricular heart failureBiventricular heart failure
It may develop because:It may develop because:
the disease process (e.g. dilated cardiomyopathy the disease process (e.g. dilated cardiomyopathy
or ischemic heart disease) affects both ventriclesor ischemic heart disease) affects both ventricles
oror
disease of the left heart leads to chronic elevation disease of the left heart leads to chronic elevation
of the left atrial pressure, pulmonary of the left atrial pressure, pulmonary
hypertension and subsequent right heart failurehypertension and subsequent right heart failure
It may develop because:It may develop because:
the disease process (e.g. dilated cardiomyopathy the disease process (e.g. dilated cardiomyopathy
or ischemic heart disease) affects both ventriclesor ischemic heart disease) affects both ventricles
oror
disease of the left heart leads to chronic elevation disease of the left heart leads to chronic elevation
of the left atrial pressure, pulmonary of the left atrial pressure, pulmonary
hypertension and subsequent right heart failurehypertension and subsequent right heart failure
Forward and backward heart Forward and backward heart failurefailure
Forward and backward heart Forward and backward heart failurefailure
The predominant The predominant problem:problem:
an inadequate cardiac an inadequate cardiac
outputoutput
Forward heart failureForward heart failure
The predominant The predominant problem:problem:
an inadequate cardiac an inadequate cardiac
outputoutput
Forward heart failureForward heart failure
Normal or near-normal Normal or near-normal cardiac output with cardiac output with
marked salt and water marked salt and water retentionretention
pulmonary and systemic pulmonary and systemic
venosus congestionvenosus congestion
Backward failureBackward failure
Normal or near-normal Normal or near-normal cardiac output with cardiac output with
marked salt and water marked salt and water retentionretention
pulmonary and systemic pulmonary and systemic
venosus congestionvenosus congestion
Backward failureBackward failure
Diastolic and systolic dysfunctionDiastolic and systolic dysfunctionDiastolic and systolic dysfunctionDiastolic and systolic dysfunction
Impaired myocardial Impaired myocardial contractioncontraction
systolic dysfunctionsystolic dysfunction
Impaired myocardial Impaired myocardial contractioncontraction
systolic dysfunctionsystolic dysfunction
Abnormal ventricular Abnormal ventricular relaxationrelaxation
poor ventricular fillingpoor ventricular filling
high filling pressurehigh filling pressure
Diastolic dysfunctionDiastolic dysfunction
Abnormal ventricular Abnormal ventricular relaxationrelaxation
poor ventricular fillingpoor ventricular filling
high filling pressurehigh filling pressure
Diastolic dysfunctionDiastolic dysfunction
Systolic and diastolic dysfunction often coexist, particularly in patients with CAD
Systolic and diastolic dysfunction often coexist, particularly in patients with CAD
High output failureHigh output failureHigh output failureHigh output failure
Condition that are associated with a very Condition that are associated with a very
high cardiac output high cardiac output
(e.g. large AV shut, beri-beri, severe (e.g. large AV shut, beri-beri, severe
anaemia or thyrotoxicosis) can anaemia or thyrotoxicosis) can
ooccasionally cause heart failure. ccasionally cause heart failure.
In such cases additional causes of heart are In such cases additional causes of heart are
often present.often present.
Condition that are associated with a very Condition that are associated with a very
high cardiac output high cardiac output
(e.g. large AV shut, beri-beri, severe (e.g. large AV shut, beri-beri, severe
anaemia or thyrotoxicosis) can anaemia or thyrotoxicosis) can
ooccasionally cause heart failure. ccasionally cause heart failure.
In such cases additional causes of heart are In such cases additional causes of heart are
often present.often present.
Heart failure – clinical featuresHeart failure – clinical featuresHeart failure – clinical featuresHeart failure – clinical features
The clinical picture depends on the The clinical picture depends on the
nature of underlying heart disease, nature of underlying heart disease,
the type of heart failure that it has the type of heart failure that it has
evoked and neutral and endocrine evoked and neutral and endocrine
changes that have developed.changes that have developed.
The clinical picture depends on the The clinical picture depends on the
nature of underlying heart disease, nature of underlying heart disease,
the type of heart failure that it has the type of heart failure that it has
evoked and neutral and endocrine evoked and neutral and endocrine
changes that have developed.changes that have developed.
Reduced ventricular contractilityReduced ventricular contractilityReduced ventricular contractilityReduced ventricular contractility
Progressive ventricular dilatationProgressive ventricular dilatation
In coronary artery disease „akinetic” or In coronary artery disease „akinetic” or „dyskinetic” segments contract poorly and „dyskinetic” segments contract poorly and
may impede the function of the normal may impede the function of the normal segments by distorting their contraction and segments by distorting their contraction and
relaxation patternsrelaxation patterns
Progressive ventricular dilatationProgressive ventricular dilatation
In coronary artery disease „akinetic” or In coronary artery disease „akinetic” or „dyskinetic” segments contract poorly and „dyskinetic” segments contract poorly and
may impede the function of the normal may impede the function of the normal segments by distorting their contraction and segments by distorting their contraction and
relaxation patternsrelaxation patterns
Causes:
•myocarditis/cardiomyopathy (global dysfunction)
•Myocardial infarction (segmental dysfunction)
Causes:
•myocarditis/cardiomyopathy (global dysfunction)
•Myocardial infarction (segmental dysfunction)
Ventricular outflow obstructionVentricular outflow obstructionVentricular outflow obstructionVentricular outflow obstruction
Initially concentric ventricular hypertrophy Initially concentric ventricular hypertrophy allows the ventricle to maintain a normal allows the ventricle to maintain a normal
output by generating a high systolic pressure. output by generating a high systolic pressure. However, secondary changes in the However, secondary changes in the
myocardium and increasing obstruction myocardium and increasing obstruction eventually lead to failure with ventricular eventually lead to failure with ventricular dilatation and rapid clinical deteriorationdilatation and rapid clinical deterioration..
Initially concentric ventricular hypertrophy Initially concentric ventricular hypertrophy
allows the ventricle to maintain a normal allows the ventricle to maintain a normal output by generating a high systolic pressure. output by generating a high systolic pressure.
However, secondary changes in the However, secondary changes in the myocardium and increasing obstruction myocardium and increasing obstruction
eventually lead to failure with ventricular eventually lead to failure with ventricular dilatation and rapid clinical deteriorationdilatation and rapid clinical deterioration..
Causes:
•Hypertension, aortic stenosis (left heart failure)
•Pulmonary hypertension, pulmonary valve stenosis (right
heart failure)
Causes:
•Hypertension, aortic stenosis (left heart failure)
•Pulmonary hypertension, pulmonary valve stenosis (right
heart failure)
Ventricular inflow obstructionVentricular inflow obstructionVentricular inflow obstructionVentricular inflow obstruction
Small vigorous ventricleSmall vigorous ventricle
Dilated hypertrophied atriumDilated hypertrophied atrium
Atrial fibrillation is common and often causes Atrial fibrillation is common and often causes marked deterioration because ventricular filling marked deterioration because ventricular filling
depends heavily on atrial contraction.depends heavily on atrial contraction.
Small vigorous ventricleSmall vigorous ventricle
Dilated hypertrophied atriumDilated hypertrophied atrium
Atrial fibrillation is common and often causes Atrial fibrillation is common and often causes marked deterioration because ventricular filling marked deterioration because ventricular filling
depends heavily on atrial contraction.depends heavily on atrial contraction.Causes:
•Mitral stenosis; tricuspid stenosis
•Endomyocardial fibrosis
•Constructive pericarditis
Causes:
•Mitral stenosis; tricuspid stenosis
•Endomyocardial fibrosis
•Constructive pericarditis
Ventricular volume overloadVentricular volume overloadVentricular volume overloadVentricular volume overload
Dilatation and hypertrophy allow the ventricle to Dilatation and hypertrophy allow the ventricle to generate a high stroke volume and help to generate a high stroke volume and help to
maintain a normal cardiac output. However, maintain a normal cardiac output. However, secondary changes in the myocardium eventually secondary changes in the myocardium eventually
lead to impaired contractility and worsening lead to impaired contractility and worsening heart failure.heart failure.
Dilatation and hypertrophy allow the ventricle to Dilatation and hypertrophy allow the ventricle to generate a high stroke volume and help to generate a high stroke volume and help to
maintain a normal cardiac output. However, maintain a normal cardiac output. However, secondary changes in the myocardium eventually secondary changes in the myocardium eventually
lead to impaired contractility and worsening lead to impaired contractility and worsening heart failure.heart failure.
Causes:
•Mitral regurgitation (LV) Atrial septal defect (RV)
•Aortic regurgitation
•Ventricular septal defect
Causes:
•Mitral regurgitation (LV) Atrial septal defect (RV)
•Aortic regurgitation
•Ventricular septal defect
Clinical featuresClinical featuresClinical featuresClinical features A low cardiac output causes:A low cardiac output causes:
ffatigueatigue llistlessnessistlessness
ppoor effort toleranceoor effort tolerance The peripheries are coldThe peripheries are cold
Blood pressure is lowBlood pressure is low Poor renal perfusion may lead to oliguria Poor renal perfusion may lead to oliguria
and uraemia.and uraemia.
A low cardiac output causes:A low cardiac output causes: ffatigueatigue
llistlessnessistlessness ppoor effort toleranceoor effort tolerance
The peripheries are coldThe peripheries are cold Blood pressure is lowBlood pressure is low
Poor renal perfusion may lead to oliguria Poor renal perfusion may lead to oliguria and uraemia.and uraemia.
Clinical featuresClinical featuresClinical featuresClinical features Pulmonary oedema due to left Pulmonary oedema due to left
heart failure may present with:heart failure may present with:
breathlessness,breathlessness,
orthopnoea,orthopnoea,
paroxysmal nocturnal paroxysmal nocturnal
dyspnoeadyspnoea
respiratory crepitations over respiratory crepitations over
the lung bases.the lung bases.
Pulmonary oedema due to left Pulmonary oedema due to left
heart failure may present with:heart failure may present with:
breathlessness,breathlessness,
orthopnoea,orthopnoea,
paroxysmal nocturnal paroxysmal nocturnal
dyspnoeadyspnoea
respiratory crepitations over respiratory crepitations over
the lung bases.the lung bases.
The appearance of the chest radiograph in heart failureThe appearance of the chest radiograph in heart failureThe appearance of the chest radiograph in heart failureThe appearance of the chest radiograph in heart failure„ground glass” appearance of
alveolar oedema
„ground glass” appearance of
alveolar oedema
Prominence of upper lobe blood
vessels
Prominence of upper lobe blood
vessels
„ground glass” appearance of
alveolar oedema
„ground glass” appearance of
alveolar oedema
Pleural effusion (usually bilateral)Pleural effusion
(usually bilateral)
Enlarged cardiac
silhouette
Enlarged cardiac
silhouette
Septal or „Kerley B” lines
Septal or „Kerley B” lines
Chest radiograph Chest radiograph
demonstrating demonstrating
pulmonary oedema in pulmonary oedema in
patient with a prosthetic patient with a prosthetic
mitral valve mitral valve
(bottom arrow).(bottom arrow).
This was due to fracture This was due to fracture
of one of the valve of one of the valve
struts; the disc had struts; the disc had
fallen out of the valve fallen out of the valve
and lodged in the aortic and lodged in the aortic
arch arch
(top arrow)(top arrow)
Chest radiograph Chest radiograph
demonstrating demonstrating
pulmonary oedema in pulmonary oedema in
patient with a prosthetic patient with a prosthetic
mitral valve mitral valve
(bottom arrow).(bottom arrow).
This was due to fracture This was due to fracture
of one of the valve of one of the valve
struts; the disc had struts; the disc had
fallen out of the valve fallen out of the valve
and lodged in the aortic and lodged in the aortic
arch arch
(top arrow)(top arrow)
Clinical featuresClinical featuresClinical featuresClinical features
Right heart failure produces a high jugular Right heart failure produces a high jugular
venous pressure, with hepatic congestion and venous pressure, with hepatic congestion and
dependent peripheral oedema:dependent peripheral oedema:
in ambulant patients in bed-bound patientsin ambulant patients in bed-bound patients
the ankles, the thighs and sacrumthe ankles, the thighs and sacrum
Right heart failure produces a high jugular Right heart failure produces a high jugular
venous pressure, with hepatic congestion and venous pressure, with hepatic congestion and
dependent peripheral oedema:dependent peripheral oedema:
in ambulant patients in bed-bound patientsin ambulant patients in bed-bound patients
the ankles, the thighs and sacrumthe ankles, the thighs and sacrum
Clinical featuresClinical featuresClinical featuresClinical features
Massive acMassive acccumulation of umulation of
fluid may cause ascites fluid may cause ascites
or pleural effusionor pleural effusion..
Massive acMassive acccumulation of umulation of
fluid may cause ascites fluid may cause ascites
or pleural effusionor pleural effusion..
Clinical featuresClinical featuresClinical featuresClinical features
Chronic heart failure is sometimes associated Chronic heart failure is sometimes associated
with marked weight losswith marked weight loss
(cardiac cachexia)(cardiac cachexia)
ccaused by a combination of anorexia and aused by a combination of anorexia and
impaired absorption due to gastrointestinal impaired absorption due to gastrointestinal
congestion, poor tissue perfusion due to a congestion, poor tissue perfusion due to a
low cardiac output, and skeletal muscle low cardiac output, and skeletal muscle
atrophy due to immobility. atrophy due to immobility.
Chronic heart failure is sometimes associated Chronic heart failure is sometimes associated
with marked weight losswith marked weight loss
(cardiac cachexia)(cardiac cachexia)
ccaused by a combination of anorexia and aused by a combination of anorexia and
impaired absorption due to gastrointestinal impaired absorption due to gastrointestinal
congestion, poor tissue perfusion due to a congestion, poor tissue perfusion due to a
low cardiac output, and skeletal muscle low cardiac output, and skeletal muscle
atrophy due to immobility. atrophy due to immobility.
ComplicationsComplications
uraemiauraemia
hypokalaemiahypokalaemia
hyponatraemiahyponatraemia
impaired liver function impaired liver function
thromboembolismthromboembolism
arrhythmiasarrhythmias
uraemiauraemia
hypokalaemiahypokalaemia
hyponatraemiahyponatraemia
impaired liver function impaired liver function
thromboembolismthromboembolism
arrhythmiasarrhythmias