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PHILIPPINE HEART CENTER OUTPATIENT DIVISION

ALGORITHMS OF

CARDIOVASCULAR DISEASES

CORONARY ARTERY DISEASE HEART FAILURE CONGENITAL HEART DISEASE VALVULAR HEART DISEASE VASCULAR DISEASE MISCELLANEOUS CARDIOVASCULAR DISEASE

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PHILIPPINE HEART CENTER OUTPATIENT DIVISION

ALGORITHMS OF

CARDIOVASCULAR DISEASES

1st Edition, Printed in 2011

This booklet on Algorithms of Cardiovascular Diseases aims to

provide examining physicians, internists and cardiologists

guidelines on the evaluation, management and treatment of

known cardiovascular conditions such as chronic coronary artery

disease, heart failure, congenital heart disease, arrhythmias,

valvular heart disease, vascular disease, and infections and

inflammatory heart disease.

Compiled by Outpatient Division Consultants: • Dr. Euprepes B. Donato • Dr. Antonio C. Pascual • Dr. Annette P. Borromeo

Acknowledgement is due the Clinical Cardiology Division of the

Department of Adult Cardiology for their untiring dedication and

effort to come up with Consensus Guidelines based on Philippine

setting.

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Table of Contents

Page CORONARY ARTERY DISEASE

Chronic Stable Angina 4 HEART FAILURE

Chronic Heart Failure 6 Acute Decompensated Heart Failure 10

CONGENITAL HEART DISEASE Common Congenital Acyanotic Heart Disease 12 Atrial Septal Defect 13 Ventricular Septal Defect 14 Perimembranous, Supra-infracristal, Doubly-committed 15 Patent Ductus Arteriosus 16 Coarctation of Aorta 17 Tetralogy of Fallot / Double Outlet Right Ventricle 18 Right Ventricular Outflow Tract Obstruction 19 Left Ventricular Outflow Tract Obstruction 20

VALVULAR HEART DISEASE Diagnosis of Valvular Heart Disease 21 Asymptomatic Aortic Stenosis 22 Severe Aortic Stenosis 23 Mitral Stenosis 24 Moderate to Severe Mitral Stenosis 25 Aortic Regurgitation 26 Mitral Regurgitation 27

VASCULAR DISEASE Screening for AAA in High Risk Populations 29 Symptomatic Infrarenal Abdominal Aortic Aneurysm 30 Asymptomatic Infrarenal Abdominal Aortic Aneurysm 31 Extracranial Carotid Artery Disease 32 Chronic Venous Insufficiency of the Lower Extremities 34 Peripheral Arterial Disease 46

MISCELLANEOUS CARDIOVASCULAR DISEASE Acute Rheumatic Fever 53 Infective Endocarditis 56 Pericardial Effusion 58 Atrial Fibrillation 59

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CHRONIC STABLE ANGINA

2002 ACC/AHA Guidelines for the management of patients w/ chronic stable angina.

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CHRONIC STABLE ANGINA

MEDICAL MANAGEMENT

1. Anti-anginal drug therapy 2. Patient education 3. Risk factor modification

HIGH RISK CATEGORY ON TREADMILL STRESS TEST

1. Duration of symptom-limiting exercise < 5 METS

2. Failure to ↑ BP of >120 mm Hg or sustained ↓ of >10 mm Hg 3. Downsloping ST-segment depression of >2 mm at 5 mets in

> 5 leads persisting > 5 mins into recovery 4. ST-segment elevation 5. Angina at low exercise load 6. Reproducible sustained VT of >30 secs

OPTIMAL MEDICAL THERAPY FOR CHRONIC STABLE ANGINA

Daily Aspirin 81-325 mg

Clopidogel if aspirin is contraindicated

Anti-anginal Drugs

ß-Blockers, Long-Acting Nitrates, CCB

Treat w/ optimal dose of a single class of drug to begin

Trial of combination if response to monotherapy is inadequate

Triple therapy is not always superior to treatment w/ 2 agents

ACE-Inhibitors

Smoking Cessation

Lipid Management

LDL <100mg/dl, <70mg/dl if w/ high risk profile

BP Control

<135/85 mm Hg in all patients, ≤120/80 mmHg in diabetics

Physical Activity

Minimum Goal: 30 minutes 3-4 days per week; Optimal: Daily DEFINITION OF SUCCESSFUL TREATMENT OF CSA

Complete, or nearly complete, elimination of anginal chest pain and return to normal activities and a functional capacity of CCS class I an-gina.

This goal should be accomplished with minimal side effects of therapy.

2002 ACC/AHA Guidelines for the management of patients with chronic stable angina. Therapy for Stable Angina Pectoris: The uncomplicated patients. Circulation 2005.

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CHRONIC HEART FAILURE

Modified from Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.

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INDICATIONS FOR EVALUATION OF PATIENTS AT RISK FOR HEART FAILURE Condition Hypertension

Diabetes Obesity CAD (e.g. After MI, revascularization, PAD or CVD, VHD) Family Hx of CMP in a 1

st Degree Relative

Sleep-Disordered Breathing Test Findings Sustained arrhythmias

Abnormal ECG (e.g. LVH, LBBB, pathologic Q wave) Cardiomegaly on CXR

SIGNS TO EVALUATE IN PATIENTS SUSPECTED OF HAVING HEART FAILURE Cardiac Abnormality Sign

Elevated cardiac filling Elevated JVP pressure & fluid overload S3 gallop

Rales Hepatojugular Reflux Ascites Edema

Cardiac enlargement Laterally displaced or prominent apical impulse

Murmurs suggesting valvular dysfunction

SYMPTOMS SUGGESTING THE DIAGNOSIS OF HEART FAILURE Symptoms Dyspnea at rest or on exertion

Reduction in exercise capacity Orthopnea PND or Nocturnal cough Edema Ascites or Scrotal edema

Less specific presentation of HF Early satiety, Nausea, Vomiting, Abdominal Discomfort Wheezing or cough Unexplained fatigue Confusion/delirium

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DIFFERENTIAL DIAGNOSIS FOR HEART FAILURE SYMPTOMS AND SIGNS

Myocardial Ischemia

Pulmonary Disease

Pneumonia, Asthma, COPD, Pulmonary Embolus, Primary Pulmonary hypertension

Sleep-Disordered Breathing

Obesity

Deconditioning

Malnutrition

Anemia

Hepatic Failure

Renal Failure

Hypoalbuminemia

Venous Stasis

Depression

Anxiety & Hyperventilation Syndrome PHARMACOLOGICAL THERAPY OF SYMPTOMATIC HEART FAILURE

For Survival/Morbidity For Symptoms:

NYHA I:

Continue ACEI / ARB if ACEI intolerant Continue Aldosterone Antagonist if post

MI Add Beta blocker if post-MI

Reduce / stop diuretics

NYHA II:

ACEI as first-line treatment ABB if ACEI intolerant Add BB or AA of post-MI

+/- diuretic depending on fluid retention

NYHA III:

ACEI plus ARB or ARB alone if ACEI intolerant

Beta blocker Add AA

+ diuretics + digitalis if still symptomatic

NYHA IV:

Continue ACEI / ARB Beta blocker Aldosterone antagonist

+ diuretics + digitalis + consider temporary inotropic support

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Modified from Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.

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ACUTE DECOMPENSATED HEART FAILURE RECOMMENDATIONS FOR HOSPITALIZATION

Evidence for severely decompensated HF including: - Hypotension - Worsening renal function - altered mentation

Dyspea at rest - resting tachypnea - Oxygen saturation <90%

Hemodynamically significant arrhythmia - including new onset rapid AF

Acute coronary syndrome HOSPITALIZATION SHOULD BE CONSIDERED

Worsened congestion

Major electrolyte disturbance

Associated comorbid conditions - pneumonia - pulmonary embolus - DKA - TIA or stroke

Repeated ICD firings

Previously undiagnosed HF with signs and symptoms of pulmonary congestion

TREATMENT GOALS FOR PATIENTS ADMITTED FOR ADHF

Improve symptoms especially congestion and low output syndrome

Optimize volume status

Identify etiology

Identify precipitating factors

Optimize chronic therapy

Minimize side effects

Identify patients who may benefit from revascularization

Educate patients concerning medications and self assessment of HF

Initiate a disease management program MONITORING RECOMMENDATIONS FOR PATIENTS ADMITTED FOR ADHF

Weight

Fluid intake and output

Vital signs

Signs : edema, ascites, rales, hepatomegaly, JVP

Syptoms : PND, orthopnea, cough, fatigue

Electrolytes

Renal function

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ACUTE DECOMPENSATED HEART FAILURE DISCHARGE CRITERIA

Exacerbating factors addressed

Near optimal volume status achieved

Transition from IV to oral diuretics

Patient and family education completed

At least near-optimal pharmacologic therapy achieved

FF-up clinic visit scheduled in 7-10 days ELEMENTS TO DETERMINE AT FOLLOW-UP VISITS OF HF PATIENTS

Functional capacity and activity level

Changes in body weight

Patient understanding of and compliance with dietary sodium restriction

Patient understanding of and compliance with medical regimen

History of arrhythmia, syncope, presyncope, or palpitation

Compliance and response to therapeutic interventions

The presence or absence of exacerbating factors for HF, including worsening ischemic heart disease, HPN, and new or worsening valvular disease

RECOMMENDED COMPONENTS OF CARE AND FOLLOW-UP PROGRAMS (Class of Recommendation = I, Level of Evidence = C)

Use of Multidisciplinary team approach

Vigilant follow up, first follow up within 10 days of discharge

Discharge planning

Increase access to health care

Optimizing medical therapy with guidelines

Early attention to signs and symptoms

Flexible diuretics regimen

Intensive education and counseling

In patient and OPD (home-based)

Attention to behavioural strategies

Address barriers to compliance PROPOSED PHC HEART FAILURE CLINIC

Cardiologist-supervised

Nurse-led home visits/ telephone follow up

Multidisciplinary care

Concensus Guidelines, Clinical Cardiology Division Philippine Heart Center, 2008-2009.

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COMMON CONGENITAL ACYANOTIC HEART DISEASE


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ATRIAL SEPTAL DEFECT


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VENTRICULAR SEPTAL DEFECT


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PERIMEMBRANOUS, INFRA-SUPRACRISTAL

DOUBLY COMMITTED


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PATENT DUCTUS ARTERIOSUS


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COARCTATION OF THE AORTA

(a) History and PE Suggestive of Coarctation of Aorta

Upper limb hypertension

Differential arm-leg pulses (at least >10 mm Hg SBP)

Exertional dyspnea

Interscapular systolic murmur

Cresendo-decresendo systolic murmur through the chest wall

(b) To delineate the coarctation anatomy, possible aneurysm formation and

with velocity mapping.

Concensus Guidelines, Clinical Cardiology Division

Philippine Heart Center, 2008-2009.

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TETRALOGY OF FALLOT

DOUBLE OUTLET RIGHT VENTRICLE

* catheterization:

further definition of coronary artery anatomy

determine coexistent conditions that cannot be elucidated by echo

determine PVR and reactivity (in pts suspected of having increased

resistance)


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RIGHT VENTRICULAR

OUTFLOW TRACT OBSTRUCTION

(a) History and PE Suggestive of RVOTO

Exertional fatigue, Dyspnea, Lightheadness, Chest discomfort

Ejection systolic murmur heard at the LUPSB and transmitted to the axil-

la and back, Prominent A wave, RV lift

(b) Exertional dyspnea, angina, presyncope or syncope.


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LEFT VENTRICULAR OUTFLOW

TRACT OBSTRUCTION

(a) History and PE Suggestive of LVOTO

Exertional dyspnea

Angina

Presyncope

Syncope

(b) Schematic Approach to the Diagnostic Use of Echocardiography


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VALVULAR HEART DISEASE

ALGORITHM FOR DIAGNOSIS OF

VALVULAR HEART DISEASE


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ALGORITHM for ASYMPTOMATIC AORTIC STENOSIS

Update of ACC/AHA Guidelines for Valvular Heart Disease,

Bonow et al, Circulation 2008

GRADING OF AORTIC STENOSIS

Mild Moderate Severe

Valve Area > 1.5 cm² 1.0 - 1.5 cm² < 1.0 cm²

Gradient < 25 mm Hg 25 - 40 mm Hg > 40 mm Hg

Velocity < 3 m/sec 3 - 4 m/sec > 4 m/sec

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ALGORITHM for SEVERE AORTIC STENOSIS



HIGH RISK ASYMPTOMATIC AORTIC STENOSIS PATIENTS

Risk of Rapid Hemodynamic Progression

1. Age >50 yrs

2. Severe valve calcification

3. Concurrent CAD

Risk of Impending Symptom Onset

1. LVH by ECG

2. Smaller valve area by Doppler

3. B-type natriuretic peptide

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ALGORITHM for MITRAL STENOSIS



GRADING OF MITRAL STENOSIS

Mild Moderate Severe

Valve Area > 1.5 cm² 1.0 - 1.5 cm² < 1.0 cm²

Gradient < 5 mm Hg 5 - 10 mm Hg > 10 mm Hg

PASP < 30 mm Hg 30 - 50 mm Hg > 50 mm Hg

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ALGORITHM for MODERATE to

SEVERE MITRAL STENOSIS



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ALGORITHM for AORTIC REGURGITATION



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ALGORITHM for MITRAL REGURGITATION



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GRADING OF AORTIC REGURGITATION

GRADING OF MITRAL REGURGITATION

Qualitative Mild Moderate Severe

Angiographic grade 1+ 2+ 3 - 4+

Doppler jet width central jet,

< 25% of LVOT

> mild,

< severe

central jet,

> 65% of LVOT

Doppler vena contracta < 0.3 cm 0.3-0.6 cm > 0.6 cm

Quantitative Mild Moderate Severe

Regurgitant volume < 30 ml/beat 30 - 59 ml/beat > 60 ml/beat

Regurgitant fraction < 30 % 30 - 49 % > 50 %

Regurgitant orifice area < 0.1 cm² 0.1 - 0.29 cm² > 0.30 cm²

Qualitative Mild Moderate Severe

Angiographic grade 1+ 2+ 3 - 4+

Doppler jet width central jet,

< 20% of LA

> mild,

< severe

central jet,

> 40% of LA

Doppler vena contracta < 0.3 cm 0.3-0.69 cm > 0.7 cm

Quantitative Mild Moderate Severe

Regurgitant volume < 30 ml/beat 30 - 59 ml/beat > 60 ml/beat

Regurgitant fraction < 30 % 30 - 49 % > 50 %

Regurgitant orifice area < 0.2 cm² 0.2 - 0.39 cm² > 0.40 cm²

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VASCULAR DISEASE

Screening for Aortic Abdominal Aneurysm

In High Risk Populations


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MANAGEMENT ALGORITHM FOR SYMPTOMATIC

INFRARENAL ABDOMINAL AORTIC ANEURYSM


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MANAGEMENT ALGORITHM FOR ASYMPTOMATIC

INFRARENAL ABDOMINAL AORTIC ANEURYSM


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EXTRACRANIAL CAROTID ARTERY DISEASE


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1

CDS can distinguish between normal and diseased ICA with sensitivity of

96-98%, specificity of 81-81%, accuracy of 88-89%. (Zwiebel’s and Strand-

ness criteria) J Vasc Surg. 20.4.Oct 1994.

2 Antithrombotic agents: ASA (1

st choice if without contraindication. Alterna-

tives: Clopidogrel, Cilostazol, ASA-Dipyridamole)

Risk factor modification: hypertension, diabetes, dyslipidemia, smoking,

physical inactivity.

3 Carotid Endarterectomy (CEA) is the 1

st choice except in high-risk patients

(cardiac valvular disease, rhythm disorders, recent MI, unstable angina,

uncontrolled BP, uncontrolled DM) or presence of local conditions that con-

traindicates CEA (postradiation therapy, restenosis, surgical inaccessibility).


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ALGORITHM FOR CHRONIC VENOUS INSUFFICIENCY

OF THE LOWER EXTREMITIES

Eberhardt, et.al., Circulation, May 2005

World Congress of Microcirculation 1997

(1) History and PE typical of CVI

Leg swelling or discomfort associated with dependent position of legs,

relieved by leg elevation; stasis skin changes

Predisposing factors ie occupation, family hx previous pregnancy, use

of OCP, obesity

(2) Other Causes

DVT

Lymphedema

Cellulitis

Lipidema

Systemic causes of edema

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(3) Classification of Chronic Lower Extremity Venous Disease

C Clinical Signs: (grade 0-6)

Supplemented by: (A) for asymptomatic

(S) for symptomatic

E Etiologic Classification

(Congenital, Primary, Secondary)

A Anatomic Distribution

(Superficial, Deep, or Perforator, alone or in combination)

P Pathophysiologic Dysfunction

(Reflux or Obstruction, alone or in combination)

Clinical Classification of Chronic Lower Extremity Venous Disease

Class 0 No visible or palpable signs of venous disease

Class 1 Telangiectasia, reticular veins, malleolar flare

Class 2 Varicose veins

Class 3 Edema without skin changes

Class 4 Skin changes ascribed to venous disease

(e.g. pigmentation, venous eczema, lipodermatosclerosis)

Class 5 Skin changes as defined above with healed ulceration

Class 6 Skin changes as defined above with active ulceration

Etiologic classification of Chronic Lower Extremity Venous Disease

Congenital (EC) The cause of the chronic venous disease has been

present since birth

Primary (EP) Chronic venous disease of undetermined cause

Secondary (Es) Chronic venous disease with an associated known

cause (postthrombotic, posttraumatic, others)

Eberhardt, et.al., Circulation, May 2005

World Congress of Microcirculation 1997

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TREATMENT OF CHRONIC VENOUS INSUFFICIENCY

General measures

Leg elevation

Control of body weight

Exercise of calf muscles

Avoid heat

Avoid standing for long periods

Cold showers to delay progression of disease

Limitation of long periods spent standing or sitting

Periodic flexion of ankles, transfer of weight to toes

Daily rest with legs raised (15-20 cm) and also at night

Antistasis exercise

Lying flat on the healthy side in the presence of unilateral varicose veins

Conservative management

To reduce symptoms and help prevent the development of secondary

complications and the progression of disease.

Behavioral measures such as elevating the legs to minimize edema and

reducing intraabdominal pressure should be advocated.

CHRONIC VENOUS INSUFFICIENCY

CLINICAL CLASSIFICATION

Symptoms Signs

Grade I: - mild swelling - ankle edema < 1 cm

- heaviness - dilated superficial veins

- vein dilatation - normal skin and subcutaneous

tissue

Grade II: - mod-severe swelling - ankle edema > 1 cm

- heaviness - multiple dilated veins

- varicosities - incompetent perforating veins (mild)

-skin changes - pigmentation (mild)

Grade III: - severe swelling - edema > 2 cm

- calf pain - multiple dilated veins

+/- claudication - incompetent perforating veins

- multiple varicosities

- marked pigmentation

- ulcer

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ALGORITHM FOR

TREATMENT OF CHRONIC VENOUS INSUFFICIENCY


Conservative Management

To reduce symptoms and help prevent the development of secondary

complications and the progression of disease.

Behavioral measures such as elevating the legs to minimize edema and

reducing intraabdominal pressure should be advocated.

Wound Skin Care

Progressive CVI may lead to compromised skin integrity, it is important

to keep the affected area well moisturized to reduce the risk of skin

breakdown and possibility of infection.

Development of stasis dermatitis needs to be treated with a topical ster-

oid.

With venous ulcers, bacterial overgrowth control and aggressive wound

care are required to minimize infectious complications.

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Pharmacologic Therapy

Four groups of drugs evaluated for CVI:

Coumarins (alpha-benzopyrones)

Flavonoids (gamma-benzopyrones) DAFLON

Saponosides (horse chestnut extracts)

Other plant extracts ie rutosides VENORUTON

• With venoactive properties, widely used in Europe but not approved for use

in the USA.

• Principle for use of venoactive drugs: improve venous tone and capillary per-

meability.

Compression Therapy - compression stockings

Compression stockings

Compression Stockings

Initiate mild compression, then move to higher compression to achieve therapeutic effect

Must be worn after morning shower and removed last thing at night

Poorly tolerated in warm weather so better use during the first few hours of the day than not at all

COMPRESSION USE

Mild compression Prevent DVT in mobile patients

18 - 25 mm Hg

Intermediate compression Mild CVI

Post-sclerosing therapy

6 - 34 mm Hg

Strong compression

More advance CVI

Increased tendency to edema

37 - 49 mm Hg

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CONTROLLING VEIN PROBLEMS

Raise your feet above heart level.

Elevate your feet at work to prevent worsening of leg edema.

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Anti-stasis exercises

Exercises to improve venous circulation

Exercises to improve venous circulation

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Other basic measures

Elastic stockings

They should be worn daily

Put other socks over them if

you’re concerned about their

appearance.

Tips for Wear & Care

Once your stockings are on, make

sure the top of the stockings is

about two fingers’ width below the

crease of the knee or the groin. If a

stocking is too high, it will cut off

blood flow.

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Other basic measures

Prevention: Basic Measures

Limitation of long periods spent standing or sitting

Periodic flexion of ankles, transfer of weight to toes

Daily rest with legs raised (15-20 cm) and also at night

Antistasis exercise

Lying flat on the healthy side in the presence of unilateral varicose veins

Conservative management

The use of compressive stockings is the mainstay of conservative treat-

ment.

Prescription for elastic stockings includes information about the tension

and length. The tension is based on the clinical severity:

20-30mmHg for CEAP 2-3

30-40mmHg for CEAP 4-6

40-50mmHg for recurrent ulcers

DO: AVOID:

Wash in cold water after a shower Saunas

Regular deep breathing exercises Restrictive clothing, girdles

Appropriate sports: walking, swimming, cycling, running on

soft ground

Weight-lifting, skiing, tennis, mara-thons, immobile sunbathing

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DIAGNOSTIC APPROACH IN

PATIENTS WITH SUSPECTED FIRST DVT

Approach to A Patient Suspected Of

Acute Proximal Deep Vein Thrombosis of the Lower Extremities

1

Based from the Well’s Clinical Criteria. If the clinical probability is high,

treatment may be started while waiting for Duplex scan result. 2

Using either SimpliRED D-dimer, Vidas D-dimer, MDA d-dimer, or Tiniquant

D-dimer. The sensitivity of D-dimer ELISA for acute PE was 96.4%, and the

negative predictive value was 99.6% (a similar strategy works for excluding

DVT) Braunwald’s Heart des. 7th ed. p.1794. 3

Includes compression, color and pulsed Doppler ultrasonography.

(available at PVL). For patients who have low to intermediate clinical proba-

bility, the sensitivity and specificity of compression ultrasonography are low-

er. In experienced hands, sensitivity and specificity of >95% for proximal

vein thrombosis. ( Periph vasc dse. J Olin.2nd ed). 4

See Treatment Guidelines of ACCP 2004 for DVT/VTE (Chest, Sept 2004).

ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Dis-ease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.

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A Clinical prediction rule for predicting pretest probability of deep vein

thrombosis

Lancet 1997; 350: 1795-8

N Engl J Med 2003; 349: 1227-35

TOTAL:

The more symptomatic leg is used in patients with symptoms in both legs.

Pretest probability calculated as the total score:

HIGH > 3

MODERATE 1 or 2

LOW < 0

* Adapted from Wells et al. Lancet 1997; 350:1795-1798

Clinical Features Score

Active cancer (ongoing treatment or within last 6 months, or palli- 1

Paralysis, paresis or recent plaster immobilization of lower ex- 1

Recently bedridden for >3 days and/or major surgery within 4 1

Localized tenderness along the distribution of the deep venous 1

Thigh and calf swollen 1

Calf swelling >3 cm compared with asymptomatic leg

(measured 10 cm below tibial tuberosity) 1

Pitting edema (greater in the symptomatic leg) 1

Non-varicose collateral superficial veins 1

Alternative diagnosis as or more likely than DVT - 2

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2

D-dimer Using

SimpliRED D-dimer

Vidas D-dimer

MDA d-dimer

Tiniquant D-dimer

• If Vidas, MDA, or Tiniquant D-dimer assays are used, patients with

moderate clinical probability can be managed similarly to patients with

a low clinical probability of DVT.

• The sensitivity of D-dimer ELISA for acute PE was 96.4%, and the

negative predictive value was 99.6% (a similar strategy works for

excluding DVT)

Braunwald’s Heart des. 7th ed. p.1794

4 The evidence for the need of anticoagulation in patients with DVT is

based on studies performed >40 years ago.

• This trial showed a high mortality rate in untreated patients. PE

detected at autopsy was the cause of death in the majority of patients.

• Subsequent uncontrolled studies confirmed that mortality was

reduced when Heparin was used to treat VTE, and reported a high

mortality when patients did not receive anticoagulant therapy.

• Patients with DVT should be treated with anticoagulants as soon as

the diagnosis is confirmed by objective testing.

(Chest 126/3/Sept 2004 Suppl)

B Consider venography if patient is unable to return for serial ultrasound

or clinical probability is high.

• Serial ultrasound can be done 48 to 72 hours after the initial study

then 1 week after.

Lancet 1997; 350: 1795-8

N Engl J Med 2003; 349: 1227-35

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PERIPHERAL ARTERIAL DISEASES

ABI Classification System:

>1.30 - incompressible

1.00 - 1.30 - normal

0.90 - 0.99 - equivocal/borderline

0.51 - 0.89 - mild to moderarte

0.41 - 0.50 - moderate to severe

<0.40 - severe

Steps Toward the Diagnosis of Peripheral Arterial Disease (PAD)

ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.

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DIAGNOSIS AND TREATMENT OF

ASYMPTOMATIC PAD AND ATYPICAL LEG PAIN


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DIAGNOSIS OF CLAUDICATION

AND SYSTEMIC RISK TREATMENT


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TREATMENT OF CLAUDICATION

Pharmacologic Therapy for Claudication

Class I A

1. Cilostazol (100 mg orally 2 times per day)

Therapeutic trial of Cilostazol should be considered in all patients with

lifestyle-limiting caludication (in the absence of heart failure)

Class IIb A

1. Pentoxyfylline (400 mg 3 times per day) may be considered as a second

line alternative therapy to cilostazol

With published trials showing benefit

• Beraprost/ Ilioprost

Drugs with on-going trials

• Sulodexide

Naftidofuryl

ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Dis-ease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic), 2006.

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DIAGNOSIS OF ACUTE LIMB ISCHEMIA


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TREATMENT OF ACUTE LIMB ISCHEMIA


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MANAGEMENT ALGORITHM FOR

PATIENTS WITH CRITICAL LIMB ISCHEMIA


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DIAGNOSIS OF ACUTE RHEUMATIC FEVER

Algorithm for diagnosis of acute rheumatic fever (RF), incorporating the 1992 revision of the Jones criteria and the World Health Organization (WHO) expert consultation report (2002-2003). The WHO modifications incorporated in the flowchart are more sensitive

and less specific than those incorporated in the American Heart Association criteria. GABHS = group A beta-hemolytic streptococci; RHD = rheumatic heart disease

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ALGORITHM FOR MANAGEMENT OF RHEUMATIC FEVER (RF) AND ITS PRIMARY MANIFESTATIONS

Modified from Thatai D, Turi ZG: Current guidelines for the treatment of patients

with rheumatic fever. Drug 57:545, 1999

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ANTIBIOTIC THERAPY FOR ACUTE RHEUMATIC

FEVER (RF) AND LONG-TERM PROPHYLAXIS

Rheumatic fever and rheumatic heart disease. World Health Organ Tech Rep Ser 923:1, 2004.

Initial Treatment of Group A Beta-Hemolytic Streptococcal Pharyngitis (Adult Dosages)

Antibiotic Dose Frequency Duration Comments

Benzathine penicillin G 1.2 million units IM One time Acutely only ↓ Compliance issues

↑ Pain

Penicillin V 500 mg Po b.i.d. 10 days

Amoxicillin 500 mg Po t.i.d. 10 days

Cephalosporin or Varies by Drug Varies by 10 days Erythromycin if

Erythromycin Drug Penicillin Allergic [*]

Secondary Prophylaxis Regimen for Patients with Documented RF (Adult Dosages) [†]

Antibiotic Dose Frequency Comments

Penicillin V 500 mg Po b.i.d.

Erythromycin 500 mg Po b.i.d. Alternative for Penicillin-Allergic [*]

Sulfonamides 1 gm Po Daily Alternative for Penicillin-Allergic [*]

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INFECTIVE ENDOCARDITIS

Schematic approach to the diagnostic use of echocardiography

Reproduced from Bayer AS, Bolger AF, Taubert KA, et al: Diagnosis and management of infective endocarditis and its complications. Circulation 98:2936-48, 1998.

High-risk echocardiographic features: • Large vegetations • Valve insufficiency • Suggestion of perivalvular extension • Ventricular dysfunction

High initial risk: • Prosthetic heart valves • Complex congenital heart disease • Prior IE • New murmur • Heart failure

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Regimens for Prophylaxis Against Endocarditis: Use with

Dental, Oral, and Upper Respiratory Tract Procedures

Adapted from Wilson W, Taubert KA, Gewitz M, et al: Prevention of in-fective endocarditis: Recommendations of the American Heart Associa-tion. Circulation, 2007. * Dosages for adults. Initial pediatric dosages are as follows: Ampicillin

or amoxicillin, 50 mg/kg; clindamycin, 20 mg/kg; azithromycin or clar-ithromycin, 15 mg/kg.

† Cephalosporins are not used in patients with history of anaphylaxis,

angioedema, or urticaria associated with penicillin, ampicillin, or ceph-alosporins.

Setting Regimen Administered 30-60 Min before Procedure

Standard regimen[†] Amoxicillin 2.0 gm PO

Amoxicillin/penicillin-allergic patients

Cephalixin 2 gm PO[†] or Azithromycin or clarithromycin 500 mg PO or Clindamycin 600 mg PO

Patients unable to take oral medications

Ampicillin 2.0 gm IM or IV Or Cefazolin or ceftriaxone 1 gm IV[†]

Ampicillin/amoxicillin/penicillin-allergic patients una-ble to take oral medi-cations

Clindamycin 300 mg IV 30 min before procedure, then 150 mg 6 hr after initial dose

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DIAGNOSTIC AND TREATMENT ALGORITHM FOR

PERICARDIAL EFFUSION

Concensus Guidelines, Clinical Cardiology Division

Philippine Heart Center, 2008-2009.

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ATRIAL FIBRILLATION

Patterns of Atrial Fibrillation

1, episodes that generally last less than or equal to 7 days (most less

than 24 h); 2, usually more than 7 days; 3, cardioversion failed or not

attempted; and 4, either paroxysmal or persistent AF may be recur-

rent.3

Fuster and Ryde´n, et al. ACC/AHA/ESC Executive Summary

JACC Vol. 38, No. 4, 2001. October 2001:1231–65

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Minimum and Additional Clinical Evaluation of Patients With Atrial Fibrillation

Minimum evaluation 1. History and physical examination, to define

• The presence and nature of symptoms associated with AF • The clinical type of AF (first episode, paroxysmal, persistent, or permanent) • The onset of the first symptomatic attack or date of discovery of AF • The frequency, duration, precipitating factors, and modes of termination of AF • The response to any pharmacological agents that have been administered • The presence of any underlying heart disease or other reversible conditions (eg,

hyperthyroidism or alcohol consumption) 2. Electrocardiogram, to identify

• Rhythm (verify AF) • LV hypertrophy • P-wave duration and morphology or fibrillatory waves • Preexcitation • Bundle-branch block • Prior MI • Other atrial arrhythmias • To measure and follow the RR, QRS, and QT intervals in conjunction with anti-

arrhythmic drug therapy 3. Chest radiograph, to evaluate

• The lung parenchyma, when clinical findings suggest an abnormality • The pulmonary vasculature, when clinical findings suggest an abnormality

4. Echocardiogram, to identify • Valvular heart disease • Left and right atrial size • LV size and function • Peak RV pressure (pulmonary hypertension) • LV hypertrophy • LA thrombus (low sensitivity) • Pericardial disease

5. Blood tests of thyroid function • For a first episode of AF, when the ventricular rate is difficult to control, or when AF

recurs unexpectedly after cardioversion Additional testing

• One or several tests may be necessary 1. Exercise testing

• If the adequacy of rate control is in question (permanent AF) • To reproduce exercise-induced AF • To exclude ischemia before treatment of selected patients with a type IC anti-

arrhythmic drug 2. Holter monitoring or event recording

• If diagnosis of the type of arrhythmia is in question • As a means of evaluating rate control

3. Transesophageal echocardiography • To identify LA thrombus (in the LA appendage) • To guide cardioversion

4. Electrophysiological study • To clarify the mechanism of wide-QRS-complex tachycardia • To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supra-

ventricular tachycardia • Seeking sites for curative ablation or AV conduction block/modification



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Pharmacological management of patients with newly discovered AF

Pharmacological management of patients with newly discovered AF. AF indicates atrial fibrillation; HF, heart failure.



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Pharmacological Management of Patients with Recurrent Paroxysmal AF.

Pharmacological Management of Patients with Recurrent Persistent or Permanent AF



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Antiarrhythmic Drug Therapy to Maintain Sinus Rhythm in Patients With Recurrent Paroxysmal

or Persistent Atrial Fibrillation

Drugs are listed alphabetically and not in order of suggested use. *For adrenergic atrial fibrillation, beta-blockers or sotalol are the initial drugs of choice. †Consider nonpharmacological options to maintain sinus rhythm if drug failure occurs. HF indicates heart failure; CAD, coronary artery disease; and LVH, left ventricular hypertrophy.



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