1] ‘Cresendo Angina’ is when a patient with exertional angina experiences – a decrease in ‘angina distance’ &/or increase in duration of angina.
Cresando angina is considered as a form of unstable angina wherein a major coronary event is likely in the near future. Management is aggressive.
2] Commonest causes of left heart failure are CAD & hypertension. Systolic dysfunction & failure due to chronic CAD is termed ‘ischemic cardiomyopathy’.
Is it possible to have heart failure with normal ejection fraction?
Yes. Diastolic failure is heart failure with normal EF eg. Hypertrophic cardiomyopathy.
3] Some causes of syncope picked up on history + clinical examination are Aortic stenosis, Neurocardiogenic & situational syncope, Severe bradycardia, Postural hypotension.
Some causes of syncope appearant on ECG or Holter-Bradyarrythemias like complete heart block, tachyarrythemias like VT, Acute myocardial infarct, WPW syndrome.
Some causes of syncope diagnoised on Echocardiography – Aortic stenosis, hypertrophic obstructive cardiomyopathy, pericardial temponaade, MI, Atrial myoma.
Neurocardiogenic syncope also known as vasovagal syncope, accounts for 50% of all syncope. It is experienced by normal persons during pain, fatigue, heat etc.
‘Situational syncope’ occurs after triggers like micturation (esp BPH patients), cough (COPD patients), Deglutition (Oesophageal spasm) & defecation (Constipated patients).
4] If a young female (15 to 30 years) comes with palpitations, atypical chest pain, systolic click or murmur &/or ‘minor’ ST-T changes on ECG, think of MVP.
Diagnosis of MVP is made when the Echo shows posterior displacement (into the LA) of one or both mitral leaflets late in systole.
Most patients of MVP are asymptomatic others may be given beta blockers. Infective endocarditis prophylaxis is given ONLY if there is past history of endocarditis.
5] Non HDL-C is defined as total cholesterol mimics HDL. It is an approximation of VLDL + LDL. It is a useful calculation in persons with high TG (>200)
VLDL-C is a good measure of atherogenic remnant lipproteins. Non-HDL-C includes CLDL-C. Hence its usefulness esp. when TG>200 i.e. VLDL > 40.
6] Pulsus paradoxus is identified while checking BP. It is an exaggerated inspiratory fall (>10 mm Hg) in systolic BP. Most commonly seen in severe asthma/COPD.
Low HDL (<40 mg%) is associated with or caused by the focal – High TG, obesity, physical inactivity, type 2 diabetes, smoking, drugs (e.g. beta blockers).
Treating low HDL is a challenge.
The following helps
A. Cessation of smoking
B. Alcohol consumption in moderation
C. Exercise
D. Fibrates
E. Nicotinic acid (Niacin)
A combination (coming soon) for raising HDL is ‘Tredapthine; contains Niacin 1gm & laropriprant 20mg’. The latter reduces skin side effects of niacin.
7] Retrospective data from University of Waruick, U.K. – in people who sleep < 6 hours per night, fatal heart attack incidence rises by 48% & stroke risk by 15%
8] A dobutamine stree Echo is a test for identifying ischemic territories & assessing myocardial viability. Esp. useful in patients who can’t do exercise tests.
A biphasic response, in which contractility (on Echo) initially increases with lower dose of dopamine & then decreases with higher doses, is diagnostic.
9] Beriberi occurs due to thiamine (B1) deficiency, occurring in alcoholics or people whose staple diet is polished rice. Manifests as dry or wet beriberi.
Wet beriberi is a dilated cardiomyopathy presenting as CCF with unusually severe oedema. Dry beriberi has peri neuropathy, glossitis & hyperkeratosis.
Treatment for beriberi consists of parenteral (IV or IM) thiamine 100 mg/d (e.g. Trineurosol-H) for 7 days followed by oral thiamine 10-25 mg/ d for weeks.
Oral preparations of high dose (75 mg) thiamine (e.g. Berin/Benalgis) are not available. Standard multivitamins (e.g. Becosule, Optineuron) contains 10 mg.
10] The medical council of Mumbai is considering making it compulsory for physicians to put remarks on blood reports like lipid profile, TSH & blood sugars.
This rule means that if you see a lipid report, you have to note down on the report itself whether patient is taking any lipid-lowering drug & what dose.
Sorry! No such proposed law by medical council of Mumbai (non-existant entity). I just like the ‘remark on report’ idea & would like all to adopt it.
11] Primary prevention of cardiovascular disease (CVD) refers to preventive interventions (pharmacologic or non-pharmacologic) in a person without any CVD).
12] If a patient is planning to go to native place (esp. Gujarat/Rajasthan) and if this patient has HT or IHD, warn him about high mineral content in bore-well water.
To prevent HT/edema/CCF in patient travelling to his native ask him to carry drinking water from here (local packaged water is also mineral rich)
If possible, patient should use water from R-O (Reverse osmosis) filter. If above 2 are not practical, add/increase diuretic for the duration of travel.
13] 20-30% of coronary artery disease & 10% of ischaemic cerebrovascular disease are caused by cigarette smoking. Cigars cause less CHD than cigarettes/bidis.
Smokers, who quit, reduce the excess risk of coronary event by 50% in 2 years. Risk of former smokers reaches that of newer smokers at about 15 years.
I was surprised to find from literature that lack of regular exercise is as much a cardiac risk factor as smoking! I am off to jogger’s park!
14] Indication for 24 hour ambulatory BP monitoring
– White coat HT
– Apparent drug resistance
– Hypotensive symptoms with anti-hypertensives
– Episodic/liable HT
15] As per U.S. prevention Services Task Force, if a doctor were to give proper patient education on prevention of heart disease, he would need 90 extra minutes / day.
16] Enhanced Extra Counterpulsation (EECP) involves compression of lower limbs with inflatable cuffs to raise diastolic pressure & coronary flow.
In EECP, 3 sets of balloons are wrapped around lower limbs, with precisely timed inflation in diastole & deflation in systole synchronized with ECG.
EECP involves 35 sessions of 1 hour/day costs 70,000/- 60% report benefit in angina/dyspnea. Benefit can last > 2 years. At least 6 centers in Mumbai.
17] Off-pump CABG using a fixator device (e.g. ‘Octopus’) placed in the area where a graft has to be sutured making this area relatively immobile.
On-pump CABG involves causing complete cardioplegia (using K+ containing IV solution) & channeling circulation through an oxygenator (heart-lung machine).
If you refer a patient for CABG to a relatively less experienced cardiac surgeon, do try to influence the surgeon to do an on-pump surgery! Results improve.
18] The grafts placed at CABG may after some time, get occluded, some related statistics – LIMA anastomosed to LAD artery – 10% get occluded by 10th year.
The occlusion rate of saphenous venous graft is 15% by 1st year & 50% by 10th year. Patency rates of radial artery are also not comparable to LIMA.
19] Incidence of HT, usually diastolic, is increased three fold in hypothyroid patients. Overall 1% of cases of diastolic HT are due to hypothyroidism.
If a patient is simultaneously diagnosed with hypothyroidism & HT, first treat only the former as control of hypothyroidism normalizes HT in 1/3rd of patients
