Cardiovascular CareCardiovascular CareKenneth H. Cohen, M.D.,F.A.C.C.Kenneth H. Cohen, M.D.,F.A.C.C.

Ronald D. D’Agostino, D.O., F.A.C.C., F.A.C.P.Ronald D. D’Agostino, D.O., F.A.C.C., F.A.C.P.

Henry Gomez, M.D., F.A.C.C.Henry Gomez, M.D., F.A.C.C.

Jeffrey M. Bernstein, M.D.Jeffrey M. Bernstein, M.D.

Internal Medicine, Cardiology and Cardiovascular DiseasesInternal Medicine, Cardiology and Cardiovascular Diseases

Diplomates American Board and Internal Medicine of Diplomates American Board and Internal Medicine of Cardiovascular DiseasesCardiovascular Diseases

““Everything you wanted Everything you wanted to know about to know about

cardiovascular care but cardiovascular care but the HMO’s were afraid the HMO’s were afraid

you’d ask.”you’d ask.”

Ronald D. D’Agostion, D.O., F.A.C.C.,F.A.C.PSpecializing in:

Cardiology

Cardio-vascular Diseases

Atherosclerosis

Angina & Myocardial Infarction

Hypertension

Renal Artery Stenosis

Valvular Heart Disease

Peripheral Vascular Disease

Cardiomyopathy & Hypertrophy

Carotid Diseases

Congestive Heart Failure

Stroke Prevention & Treatment

Arrythmias

Diabetes Management

Atherosclerosis Time LineAge 0

10

20

30

40

50

60

70

80

Birth

Fatty Streaks

Intimal Changes

Plaque

Obstruction, Symptons, Angina

Events, MI, Stroke

CHF

Risk Factor Modification

• Genetics - Change Your Parents• Diet & Exercise• Vices - Sedentary, Cigarettes, Caffiene, Stress• Prevent Disease

– Manage Lipids, HTN, Diabetes– Prevent Plaque Progression, Stabilization,

Regression, Formation

JNC VI Risk Stratification and Treatment of Hypertension

The Sixth Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NIH.

Drug TherapyLifestyle Modification (up to 6 months)

Lifestyle Modification (up to 12 months)

Stage 1140-159/ 90-99

Drug Therapy

Lifestyle Modification

Risk Group B(At Least 1 Risk Factors, Not Including

Diabetes; No TOD/CCD)

Drug TherapyDrug TherapyStage 2 & Stage 3>160/>100

Drug TherapyLifestyle ModificationHigh-normal 130-139/85-89

Risk Group C(TOD/CCD and/or Diabetes, With or

Without Other Risk Factors)

Risk Group A(No Risk Factors No TOD/CCD)

Blood Pressure Stages (mm Hg)

Lifestyle Modifications

• Stop smoking and reduce intake of saturated fat and cholesterol

• Lose weight if overweight

• Limit alcohol intake

• Increase aerobic physical activity

• Limit sodium intake

• Maintain adequate intake of K+, Ca++, and Mg++ for general health

JNC VI, 1997.

DIAGNOSTIC TESTING

Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P.Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P.

HISTORY & PHYSICALHISTORY & PHYSICAL

• Most important test

• 80% of diagnosis from history

• Testing to confirm clinical

• Testing without knowledge of patient issues

StatisticsStatistics

PROBABILITY

• False Positive (FP)

• False Negative (FN)

• Prevalence

• Positive Predictive Value (PPV)

• Negative Predictive Value (NPV)

• Sensitivity

• Specificity

SENSITIVITY& SPECIFICITY

Sensitivity = Sensitivity = True PositiveTrue Positive

True Positive + False NegativeTrue Positive + False Negative

Specificity = Specificity = True NegativeTrue Negative

True Negative + False PositiveTrue Negative + False Positive

PREVALENCEPREVALENCE

• Percent of population with Percent of population with diseasedisease

• Varies with the type of patient Varies with the type of patient the doctor is seeingthe doctor is seeing

PREDICTIVE VALUEPREDICTIVE VALUE

Positive Predictive Value = True PositiveTrue Positive + False Positive

Negative Predictive Value = True NegativeTrue Negative + False Positive

DIAGNOSISDIAGNOSIS

• PrevalencePrevalence

• SensitivitySensitivity

• SpecificitySpecificity

• Predictive ValuePredictive Value

• Pre Test ProbabilityPre Test Probability

• Post Test ProbabilityPost Test Probability

EXAMPLE WITH LOW PREVALENCE

• 10% prevalence• 1000 patients• 100 with disease• 900 without disease

80% sensitivity, 80% specificity80% sensitivity, 80% specificity

TEST TRUTH (+) (-)(+) 80 180(-) 20 720 ____ ____

100 900PREDICTIVE VALUEPREDICTIVE VALUE

PPV=80/260 =25%NPV=720/740 = 95%

EXAMPLE WITH HIGH PREVALENCE

• 90% prevalence• 1000 patients• 900 with disease• 100 without disease

80% sensitivity, 80% specificity80% sensitivity, 80% specificity

TEST TRUTH (+) (-)(+) 720 20(-) 180 80 ____ ____

900 100PREDICTIVE VALUEPREDICTIVE VALUE

PPV=720/740 =95%NPV=80/260 = 30%

DIAGNOSTIC TESTINGDIAGNOSTIC TESTING

• General ScreeningGeneral Screening

• Overall functionOverall function

• PlumbingPlumbing

• PumpPump

• ValvesValves

• WiringWiring

BLOOD WORKBLOOD WORK

• ChemistryEndocrine: Glucose, HBA1c

Renal Function

Liver Function

• CBC -Homocysteine Level, C-Reactive Protein

• Lipids -Total Cholesterol, HDL, LDL, Lipoproteins

• Coagulation

• Thyroid Function

CHEST X-RAYCHEST X-RAY

• Heart SizeHeart Size

• Chamber SizeChamber Size

• LungsLungs

• Limited InformationLimited Information

• AortaAorta

EKGEKG

• ElectrocardiogramElectrocardiogram

• Very usefulVery useful

• Old InfarctsOld Infarcts

• ConductionConduction

• Heart BlockHeart Block

• HypertrophyHypertrophy

HEMODYNAMIC PROFILE (HDP)HEMODYNAMIC PROFILE (HDP)

• Non-Invasive ScanNon-Invasive Scan

• Measures cardiovascular Measures cardiovascular pressures & efficacy of therapypressures & efficacy of therapy

• Helps direct therapyHelps direct therapy

• Very useful for treating Very useful for treating Hypertension & Heart FailureHypertension & Heart Failure

EXERCISE STRESS TESTING

• Overall FunctionOverall Function

• Coronaries, Ventricular Function, Coronaries, Ventricular Function, Valves. ConductionValves. Conduction

• Treadmill, BicycleTreadmill, Bicycle

• Cardiac MonitoringCardiac Monitoring

• Diagnosis & ProgressDiagnosis & Progress

• After Myocardial InfarctionAfter Myocardial Infarction

THALLIUM STRESS TESTINGTHALLIUM STRESS TESTING

• Coronary PerfusionCoronary Perfusion

• Thallium follows blood flowThallium follows blood flow

• Radioisotope Thallium 201 IVRadioisotope Thallium 201 IV

• CameraCamera

• Stress--RestStress--Rest

MYOVIEW or CARDIOLITE MYOVIEW or CARDIOLITE STRESS TESTINGSTRESS TESTING

• Similar to ThalliumSimilar to Thallium

• Better ImagesBetter Images

• Technetium 99, Tetrofosmin or Technetium 99, Tetrofosmin or Sestamibi IVSestamibi IV

• Rest--Stress or Stress--RestRest--Stress or Stress--Rest

PERSANTINE STRESS TESTINGPERSANTINE STRESS TESTING

• Can’t ExerciseCan’t Exercise• Peripheral Vascular DiseasePeripheral Vascular Disease• Orthopedic DifficultyOrthopedic Difficulty• ElderlyElderly• Vasodilator IVVasodilator IV• Stress--RestStress--Rest• Thallium or Myoview Cardiolite IVThallium or Myoview Cardiolite IV

MUTIGATED ACQUISITION MUTIGATED ACQUISITION WALL MOTION SCANWALL MOTION SCAN

• Technetium IVTechnetium IV

• CameraCamera

• Pump FunctionPump Function

• Ejection FractionEjection Fraction

• Wall MotionWall Motion

• Diagnosis and PrognosisDiagnosis and Prognosis

FIRST PASSFIRST PASS

• Same information as MUGA & Same information as MUGA & Right Ventricular FunctionRight Ventricular Function

• Rapid IV injection of Rapid IV injection of technetiumtechnetium

• Rapid ImagingRapid Imaging• May be combined with Myoview May be combined with Myoview

or Cardiolite studyor Cardiolite study

SPECTSPECT

• Single Photon Emission Computed Single Photon Emission Computed TomographyTomography

• Multiple ImagesMultiple Images

• 3 Planes: Short Axis, Horizontal 3 Planes: Short Axis, Horizontal Long Axis, Vertical Long AxisLong Axis, Vertical Long Axis

• Has replaced planar imagingHas replaced planar imaging

• Camera and computerCamera and computer

GRATED SPECTGRATED SPECT

• Wall motion study and Wall motion study and perfusion study in oneperfusion study in one

• Coronary and Ventricular Coronary and Ventricular functionfunction

• Specialized camera and Specialized camera and computercomputer

ECHO DOPPLERECHO DOPPLER

• Most informationMost information

• Non-InvasiveNon-Invasive

• Easy on patientEasy on patient

• Pump and Valve functionPump and Valve function

• Essential TestEssential Test

• After Myocardial Infarction (Heart After Myocardial Infarction (Heart Attack)Attack)

TEETEE

• Transesophageal EchocardiogramTransesophageal Echocardiogram• Swallow probeSwallow probe• Sedation, local anestheticSedation, local anesthetic• Some discomfortSome discomfort• Closer look at the heartCloser look at the heart• Clot in heart, valve function, Clot in heart, valve function,

endocarditisendocarditis• Stroke RiskStroke Risk

NON-INVASIVE VASCULAR NON-INVASIVE VASCULAR TESTINGTESTING

• Renal Duplex to Assess for Renal Duplex to Assess for HypertensionHypertension

• Aortic Duplex to Assess for Aortic Duplex to Assess for AneurysmAneurysm

• Peripheral Duplex - Arterial Peripheral Duplex - Arterial CirculationCirculation

• Carotid Duplex - Stroke RiskCarotid Duplex - Stroke Risk

NON-INVASIVE VASCULAR NON-INVASIVE VASCULAR TESTING Cont...TESTING Cont...

• Pulse Volume Recording with Pulse Volume Recording with Segmented Blood Pressures - Segmented Blood Pressures - Arterial CirculationArterial Circulation

• Venous Duplex - Venous Venous Duplex - Venous CirculationCirculation

CAROTID DOPPLERCAROTID DOPPLER

• Internal and external carotid arteriesInternal and external carotid arteries• Vertebral arteriesVertebral arteries• Plaquing of arteries - Intimal ThicknessPlaquing of arteries - Intimal Thickness• ObstructionObstruction• TIA, CVA, SXTIA, CVA, SX• Unequal blood pressuresUnequal blood pressures• Identify patients at risk for StrokeIdentify patients at risk for Stroke• Identify patients who may benefit from Identify patients who may benefit from

Carotid Endarterectomy or StentCarotid Endarterectomy or Stent

HOLTERHOLTER

• Electrical SystemElectrical System• Slow, FastSlow, Fast• Heart BlockHeart Block• Ventricular TachycardiaVentricular Tachycardia• Correlate with symptomsCorrelate with symptoms• Palpitations, DizzinessPalpitations, Dizziness• After Myocardial InfarctionAfter Myocardial Infarction• Sudden Death RiskSudden Death Risk

SIGNAL AVERAGE ECGSIGNAL AVERAGE ECG

• Prognosis with Ventricular Prognosis with Ventricular TachycardiaTachycardia

• Dizziness, PalpitationsDizziness, Palpitations

• After Myocardial InfarctionAfter Myocardial Infarction

• Use in Consideration with Holter Use in Consideration with Holter and studies of Ventricular Functionand studies of Ventricular Function

• Sudden Death RiskSudden Death Risk

HRVHRV

• Heart Rate VariabilityHeart Rate Variability

• Prognosis after Myocardial Prognosis after Myocardial InfarctionInfarction

• Sudden Death RiskSudden Death Risk

• Acquired with HolterAcquired with Holter

• High Variability Good PrognosisHigh Variability Good Prognosis

T WAVE ALTERNANST WAVE ALTERNANS

• Subtle changes in T Wave Subtle changes in T Wave amplitudeamplitude

• Mild exercise Heart Rate to 110Mild exercise Heart Rate to 110

• May predict patients at May predict patients at increased risk for Sudden increased risk for Sudden DeathDeath

TRANSTELEPHONIC TRANSTELEPHONIC MONITORINGMONITORING

• After HolterAfter Holter

• Loop RecordersLoop Recorders

• Useful for intermittent Useful for intermittent symptomssymptoms

• Home telemetryHome telemetry

• Palpitations, DizzinessPalpitations, Dizziness

PACEMAKER TESTINGPACEMAKER TESTING

• To monitor functionTo monitor function• Test battery lifeTest battery life• Test thresholds for proper Test thresholds for proper

sensing of native conduction sensing of native conduction and captureand capture

• DDDR rate adaptive DDDR rate adaptive pacemakerspacemakers

AMBULATORY BLOOD PRESSURE AMBULATORY BLOOD PRESSURE AND HEART RATEAND HEART RATE

• To monitor Blood Pressure and Pulse To monitor Blood Pressure and Pulse at homeat home

• 24 hr. Recording vs. Intermittent use by 24 hr. Recording vs. Intermittent use by patient periodically and as per patient periodically and as per symptomsymptom

• White Coat HypertensionWhite Coat Hypertension• Extremely useful to diagnose Extremely useful to diagnose

hypertension and assess efficacy of hypertension and assess efficacy of therapytherapy

EPSEPS

• Electrophysiology StudyElectrophysiology Study• InvasiveInvasive• HospitalizationHospitalization• Electrical Stimulation of HeartElectrical Stimulation of Heart• Measure Conduction System: Measure Conduction System:

Bradyarrythmias, Heart BlockBradyarrythmias, Heart Block• Essential with Severe Symptoms or High Essential with Severe Symptoms or High

Risk patientsRisk patients• SyncopeSyncope• Ventricular TachycardiaVentricular Tachycardia

ABLATIONABLATION

• WPW: Wolff-Parkinson-WhiteWPW: Wolff-Parkinson-White

• Supraventricular Tachycardia (SVT)Supraventricular Tachycardia (SVT)

• Bypass TractsBypass Tracts

• High Radio FrequencyHigh Radio Frequency

• May be useful for VT or Atrial May be useful for VT or Atrial FibrillationFibrillation

• AV Nodal AblationAV Nodal Ablation

PACEMAKERSPACEMAKERS

• For Bradyarrythmias & Heart BlockFor Bradyarrythmias & Heart Block

• To enable use of some To enable use of some medications which may be helpful medications which may be helpful i.e, Beta Blockers, Amiodoronei.e, Beta Blockers, Amiodorone

• To treat Heart Failure - To treat Heart Failure - Biventricular PacemakersBiventricular Pacemakers

ICD’SICD’S

• Implantable Cardiovertors Implantable Cardiovertors DefibrillatorsDefibrillators

• Saves LivesSaves Lives

• For High Risk patientsFor High Risk patients

• Like living with an EMS Like living with an EMS TechnicianTechnician

AED’SAED’S

• Automatic External Automatic External DefibrillatorsDefibrillators

• Public AreasPublic Areas

• Airports, Restaurants, Health Airports, Restaurants, Health ClinicsClinics

• Saves LivesSaves Lives

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION

• Definitive TestDefinitive Test• Essential with Prognosis or Unstable Essential with Prognosis or Unstable

symptomssymptoms• Hospital ProcedureHospital Procedure• InvasiveInvasive• Some RiskSome Risk• Coronary, Ventricular and ValvesCoronary, Ventricular and Valves• Via Radial ArteryVia Radial Artery

PTCAPTCA

• Requires Transluminal Coronary Requires Transluminal Coronary AngioplastyAngioplasty

• Requires Cath-AngiographyRequires Cath-Angiography

• Balloon, Atherectomy, Stent, LaserBalloon, Atherectomy, Stent, Laser

• Generally SuccessfulGenerally Successful

• RestenosisRestenosis

STENTSSTENTS

• Standard UseStandard Use• Smaller risk of RestenosisSmaller risk of Restenosis• Can be placed almost anywhereCan be placed almost anywhere• Coronary, Carotid, Renal, Coronary, Carotid, Renal,

PeripheralPeripheral• Coated StentsCoated Stents

HEART SURGERYHEART SURGERY

• Bypass - CABGBypass - CABG

• Valvular SurgeryValvular Surgery

• Valve Replacement vs. RepairValve Replacement vs. Repair

• Heart Failure SurgeryHeart Failure Surgery

• CardiomyoplastyCardiomyoplasty

• AnnuloplastyAnnuloplasty

HEART SURGERY cont.HEART SURGERY cont.

• Off - PUMPOff - PUMP

• Minimally InvasiveMinimally Invasive

• Heart PortHeart Port

• Arterial ConduitsArterial Conduits

MEDICAL TREATMENTSMEDICAL TREATMENTS

• VitaminsVitamins

• AntioxidantsAntioxidants

• Folic AcidFolic Acid

• B VitaminsB Vitamins

• AspirinAspirin

• PlavixPlavix• Ace InhibitorsAce Inhibitors• ARB’sARB’s• Beta BlockersBeta Blockers• StatinsStatins• Lipid, Lipid,

Hypertension, Hypertension, Diabetes Diabetes ManagementManagement

CHEST PAINCHEST PAIN

• Get to ERGet to ER

• Ideally tertiary case centerIdeally tertiary case center

• Direct Angioplasty - StentDirect Angioplasty - Stent

• ThromboluticsThrombolutics

M-mode Echocardiograph

Continuous Wave Doppler

Transmitral Pulsed Wave Doppler

Code M-mode Methodology

M-mode Echo: Aortic Valve and Left Atrium

M-mode Echo: Mitral Valve Level

M-mode Echo: Left Ventricalar Level

Parasternal Long-Imaging

Right Ventricular Inflow Tract View

Right Ventricular Outflow Tract View

Parasternal Short-Axis(Aortic Valve Level)

Short-Axis View of the Mitral Valve

Short-Axis View, Mid-Ventricular Level

4-Chamber View

Apical 5-Chamber View

Apical 2-Chamber View

Apical Long-Axis View

Subcostal 4-Chamber View

Subcostal Short-Axis View

Subcostal Long-Axis View

Aortic Arch (Suprasternal Notch View)

Mild MR (Apical 4-Chamber View)

Posterior Leaflet Flail

Display for SPECT Images

Example of an Anterior Reversible Defect

Example of an Anterior Reversible Defect

Example of an Anterior Reversible Defect