Symptoms
There are many symptoms of
heart disease. It could be due to age, genetics, lifestyle, exertion, fainting,
shortness of breath while working or sitting, chest pain and palpitations are
just some of the symptoms. Sometimes indigestion is confused with heart disease.
Symptoms as mentioned are good examples of why it is important to see your physician
about your concerns.
How many times have you
heard stories on the tv news, read in newspapers, or listened to testimonials
about how people described certain symptoms before their hear attack. Be aware
and seek help from your physician when you experience any of these symptoms.
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AF and STROKE
Atrial Fibrillation (AF) can increase the risk of Stroke.
Atrial Fibrillation or AF
in some people is something that happens in your heart . Stroke is something
that happens in your brain. The connection is unclear. AF, the two small upper
chambers of the
heart (called the atria) quiver instead of beating effectively. When AF happens,
blood in these
quivering chambers can collect and clot. If the blood clot travels to an artery
in the brain and
becomes lodged, it may cause a Stroke. Knowing this, it's clear that to help
reduce the risk of stroke
in people with AF, treatment is needed to help prevent the clots from forming
initially.
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Aortic Dissection - Rapid Assessment and Treatment
| Aortic dissection occurs in approximately 1 in 2000 patients. It commonly presents as acute onset of chest or back pain in the emergency department or acute care setting. Clinical acumen and an efficient workup can lead to an early diagnosis and prompt intervention, which are critical to reducing the early mortality associated with this disease. | |
Two Major Theories On Etiology
Of An Aoritc Dissection
1. The
first postulates that the intimal layer of the aorta has been damaged, exposing
the medial layer to high blood pressure forces. A jet of blood dissects this
layer, causing the medial and intimal layers to separate. A dissection flap
forms at the site, creating a false lumen channel.
2. The second etiology of aortic dissection stems from a spontaneous rupture of the vasa vasorum in the medial layer of the aorta. This creates a localized hematoma that is contained within the medial layer. No dissection flap forms, and the false lumen does not communicate with the true lumen.
Patient Characteristics
The peak incidence of aortic dissection occurs
in the sixth and seventh decades of life. It is more common in males by 2 to
1. About 80% of patients have pre-existing hypertension.
Risk
Factors For Aortic Dissection
~ hypertension
~ bicuspid aortic valve
~ prior aortic valve replacement
~ cocaine use*
~ Marfan syndrome
~ Ehlers-Danlos, Noonan's, and Turner's syndromes
~ other fibrillin gene mutations
~ pregnancy and the postpartum period (questionable)
*Cocaine has been cited as a cause of dissection, especially in young men without other risk factors. Patients who have undergone cardiac surgery, especially aortic valve replacement, have an increased risk of dissection.
Signs
And Symptoms
The patient with aortic dissection typically presents with pain, most often
described as "tearing" in quality. It is usually of sudden onset and
cannot be relieved with a change in position. Radiation or migration of the
pain may occur in up to 20% of patients. Dissections involving the ascending
aorta may produce anterior chest pain with radiation to the neck, throat, or
jaw. Descending aortic dissection may cause interscapular back pain with radiation
to the lower back or abdomen. Nausea, vomiting, and diaphoresis frequently accompany
the pain.
Initial
Workup
~In addition to a complete history and physical
examination, laboratory evaluation is useful in diagnosing aortic dissection.
~An ECG may be useful in evaluating the patient for complications of dissection.
~About 1 in 10 patients with aortic dissection have a normal chest X-ray.
~Magnetic resonance imaging (MRI) is considered the current gold standard for
detecting aortic dissection.
~Echocardiography can discern true and false lumens, with visualization of the
intimal flap. A suspected dissection should be seen in several views.
~Transthoracic echocardiography, due to its low sensitivity, is not sufficient
for the diagnosis of aortic dissection.
~Transesophageal echocardiography has 95% to 99% sensitivity and specificity
for aortic dissection.
If the patient's blood pressure does not adequately respond to fluids, norepinephrine or phenylephrine can be used. Dopamine should only be used in low doses because it increases the shear stress on the vessel wall.
Medication
Administration
In patients who present with hypertension, medications that quickly lower the
dP/dt (change in pressure over time) of the aortic wall should be used.
Urgent
Surgical Evaluation
With proximal dissection, urgent surgical evaluation is indicated. Mortality
in the first 48 hours of an unrepaired acute proximal aortic dissection is about
40%.
Long-Term
Follow-Up
With all aortic dissections, patients who survive the initial phase and are
discharged from the hospital have a five-year survival rate of up to 80% and
a ten-year survival rate of about 50%. Patients with known aortic dissection
or a history of aortic dissection should maintain a systolic blood pressure
below 130 mm Hg. Beta blockers are preferred for long-term treatment. Successful
blood pressure control can reduce the risk of dissection recurrence by up to
one-third. Aggressive surveillance can facilitate early diagnosis of complications
from dissection and new one occurring. There is also an approximately 25% risk
of a saccular aneurysm developing at the site of an unrepaired distal aortic
dissection. Follow-up checkups are important.
Reference:
Above information is excerpts from "Rapid Assessment and Treatment of Aortic
Dissection" by David B. Stultz, MD, and Satyendra C. Gupta, MD is a cardiology
fellow at Good Samaritan/Veterans Affairs Medical Center and Wright State University
School of Medicine in Dayton, Ohio. Dr. Gupta is chief of cardiology at the
medical center and professor of medicine at the school of medicine. 2005
[http://www.mdchoice.com/emed/main.asp?template=0&page=detail&type=8&id=1105]
or go to mdchoice.com and do a search on Aortic Dissection.
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CHF (congestive heart failure)
CHF is defined as "an imbalance in pump function in which the heart fails to maintain the circulation of blood adequately." (Grossman & Brown, 2002). According to the U.S. National Heart, Blood, and Lung Institute (NHBLI, 1997), CHF causes at least 39,000 deaths per year. The prevalence of CHF in the U.S. is two to three million people, with approximately 400,000 cases diagnosed each year
CHF is classified as systolic CHF or diastolic CHF.
Systolic CHF is
caused by coronary artery disease, hypertension, alcoholism, diabetes mellitus,
or certain viruses. These conditions cause dilation of the left ventricle and
weak ventricular contractions.
Diastolic CHF is caused by hypertrophic cardiomyopathy, ventricular
hypertrophy, or amyloid infiltration in the heart muscle. In diastolic CHF,
the heart muscle does not relax, so it cannot fill with blood from the venous
system.
Diagnosis of CHF - Patients
with congestive heart failure will report fatigue, dyspnea on exertion, orthopnea,
and paroxysmal nocturnal dyspnea (Farmer & Torre, 2002). On physical examination,
you will find peripheral edema, a S3 gallup, jugular vein distension, and pulmonary
rales. Physicians usually diagnose CHF based on signs and symptoms. They may
also do an echocardiograph (ECHO) or radionuclide ventriculogram (MUGA), to
examine the health of the ventricles.
A relatively new test, the B-type natriuretic peptide test (BNP), is now available to diagnosis CHF and determine prognosis (Lu, 2001). Natriuretic peptides are hormones that vasodilate peripheral vessels in response to hemodynamic overload. The serum level of BNP increases in proportion to the hemodynamic overload of the heart. Thus, the presence of BNP indicates CHF. An increasing BNP indicates a deteriorating heart. See the medical C.E. program on natriuretic peptides by Alan Wu at MLO Online for more information: (mlo-online.com/ce/pdfs/oct01.pdf).
Treatment of CHF
CHF is treated with loop diuretics, such as furosemide (Lasix); a dietary sodium restriction; ACE inhibitors (which dilate vessels); digitoxin; and/or vasodilators. The underlying cause of heart failure is also treated.
Patient Tips
- lifestyle changes to prevent and treat CHF or complications from its treatment:
~Restrict salt intake to 2
grams of sodium or less per day.
~Restrict fluids to 1.5 to
2 liters of fluids per day when experiencing edema.
~Eat a well balanced diet
to counteract poor appetite caused by medications.
~Lose weight if overweight.
~Avoid drinking alcohol and smoking cigarettes.
~Engage in at least mild exercise at least three times a week (consult your
doctor first).
~Take potassium supplements or eat foods with ample potassium (bananas, orange
juice) if on loop diuretics.
~Monitor and keep track of your blood pressure regularly.
~Keep in touch with your primary care provider for monitoring.
~Suggest the following consumer websites for more information about CHF:
---American Heart Association Congestive Heart Failure page
.......( americanheart.org/presenter.jhtml?identifier=4585)
---Facts About Heart Failure from the National Heart, Lung, and
Blood Institute, National Institutes for Health
.......(nhlbi.nih.gov/health/public/heart/other/hrtfail.htm)
---HeartCenterOnline - Complete patient education guides on common heart problems
.......(heartcenteronline.com/ )
References: Farmer, J. & Torre, G. (2002). Approach to
the patient with congestive heart failure. Retrieved August 12, 2002. http://merck.micromedex.com/bpm/bpm.asp?page=BPM01CA06.
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Dizzy
- Do you get dizzy when you stand up after sitting?
It's called
orthostatic hypotension.
Instructions
for patients with orthostatic hypotension
Orthostatic hypotension means that when you are standing ("static")
upright ("ortho"), your blood pressure ("tension") falls
("hypo"), and causes you to become dizzy or even pass out.
There are several causes for this, including:
~ not taking
enough fluids and salts,
~ some medications (for example, the tricyclic antidepressants and the anti-hypertensives,
of course),
~ some hormonal problems.
However, much of the time, the problem is due to the fact that the nerves are
not telling the vessels to close down when you stand up. You may not realize
this, but whenever you stand, the blood vessels in the rest of the body must
close down, so that blood can continue flowing to the brain. The nerves (specifically,
the autonomic nerves) are responsible for this. If they are not working, as
sometimes happens in diabetes or in Parkinson's disease, the vessels do not
close properly, and result in orthostatic hypotension.
First,
a diagnosis must be obtained, to understand the origin and severity of the problem.
This will usually include autonomic testing, including blood pressure testing,
perhaps some bloodwork, and sometimes some imaging of the brain.
Second, some basic simple measures will
help greatly:
1. Elevate the head of your bed with 2 bricks under the legs on the head end (pillows don't work). This causes more fluid to remain in your body overnight, so that you are not so dizzy in the morning.
2. Begin water jogging. This means walking in the water 3 times a week with the water level up to your neck. The water exerts pressure on your legs and stomach, causing blood to return more efficiently to the brain. This in turn allows you to do much more exercise without feeling exhausted, and without danger to your brain, toning your muscles, and increasing the efficiency of your vessels in closing down.
3. If you feel dizzy, sit down or lie down immediately, until the feeling passes.
4. Eat frequent small meals, perhaps 6 per day, rather than large meals 2-3 times per day. When you eat, blood goes to the gut, and the amount of blood diverted depends on the size of the meal. If you have trouble getting blood to the brain in the first place, the gut is not where you want more to go. In addition, insulin is released with the meal, and makes the blood pressure lower.
5. Take salt tablets if prescribed: 500 mg tablets each am, to increase the fluid in your body.
6. Wear Jobst stockings, mmHg pressure, thigh high. This sheet consitutes a prescription, because it is signed at the bottom, and you may take it to the store to have this filled. In addition, you should wear an abdominal corset, to keep blood flowing from there back to the brain.
7. Buy an automated blood pressure cuff, and record your blood pressure and pulse when you are lying down, and when you are standing. This should be done at the same time of day every day, particularly when you are changing treatment, to see what effect it has. You should also record your blood pressure lying and standing whenever you have a spell. Finally the "standing time", the time you are able to stand still without developing symptoms should be recorded every morning at the same time, if it is less than 10 minutes. A special sheet will be provided for you to record all of this information.
8. Medications: many are available. By the time you have done all of the measures above, the problem may be resolved, and you may not need medication. However, here are some of the common medications: a) fludrocortisone (Florinef ®) improves vessel response at low dose, and causes fluid retention at high doses. b) midodrine (Proamatine ®) available since 12/95, directly causes the vessels to close down by acting just like the chemical that the nerves would have used to close down the vessels, had they been functionning properly. c) beta-blockers such as propranolol (Inderal ®), prevent the veins from opening excessively, and may also trigger increased standing blood pressure through other unknown mechanisms.
When you are starting a new medication, you can fax us your blood pressure readings and how you are feeling every week or every 2 weeks, and we will either call you or respond by fax as well, if changes are needed.
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KIDNEYS
There are many things that can happen to the kidneys. This is ONE of the common problems with the kidneys that is worth discussing with viewers of this web site:
Renal Cell Carsanoma (which is a common type of kidney cancer)
Some or all these symptoms:
~Back pain
~Kidney stones
~Blood in urine
~Pain in and around kidney area
~Uncontrollable blood pressure
Note: In this example, one Kidney had swollen to about the size of a football (not typical). The cancer was enveloping the Left Kidney like an Octopus with tentacles. The only problems in this example was that the person had noticed some blood in the urine and had a history of back pain. Immediately after spotting the blood in the urine, a doctor was contacted. The doctor used ultrasound to examine the kidneys and a large mass was found around the left kidney. This problem can be found with these type exams: Ultrasound, CAT Scan (CT) and MRI. This particular kidney problem was found by an Ultrasound. See graphic below:
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A
study was done recently on low income males and the findings showed that strokes
seem to occur more often on Mondays and less often on Sundays. This may give
a renewed meaning to "a day of rest."