Cardiovascular diseases not only have a wide variety of types, but also have the characteristics of high disability rate and high mortality rate. Clinicians should understand the characteristics of various cardiovascular diseases and identify them in the process of diagnosis and treatment.
01
heart failure
1. According to the patient’s conscious activity ability, cardiac function is divided into four grades, and the severity of cardiac disease is assessed according to objective auxiliary examination, which is divided into four grades A, B, C, and D; the basic cause of heart failure is primary myocardial damage Heart failure and heart overload, infection, arrhythmia, increased blood volume, fatigue or excitement, improper treatment, aggravation of the original heart disease or complicated by other diseases can induce heart failure; left heart failure is pulmonary circulation congestion, right heart failure is systemic circulation congestion ; Heart failure patients should distinguish between systolic and diastolic heart failure; Ventricular remodeling is of great significance in the process of heart failure in patients with heart disease.
2. There are three main manifestations of left heart failure in chronic heart failure: dyspnea, cough and hemoptysis, and blisters at the bottom of the lung. Cardiogenic asthma is the most serious manifestation of left heart failure dyspnea. Pay attention to the difference between it and bronchial asthma. Cardiac asthma is diagnosed if the patient coughs up pink foamy sputum.
There are three main manifestations of right heart failure: jugular vein distention, hepatomegaly, and edema; edema and ascites caused by right heart failure should be differentiated from renal edema, pericardial diseases such as constrictive pericarditis, liver cirrhosis, and endocrine diseases. Important measures for the treatment of heart failure include removing or limiting the underlying cause, eliminating incentives; increasing cardiac output and reducing cardiac load. With ACEI and beta-blockers, the only option for patients with irreversible heart failure is heart transplantation.
3. Acute heart failure mostly refers to left heart failure, manifested as orthopnea, cough, cough pink foamy sputum, and dry rales in both lungs. First aid measures: semi-recumbent position, sagging legs, oxygen inhalation, diuresis, etc. Morphine is prohibited when there are respiratory diseases.
02
Arrhythmia
1. Pay attention to sick sinus syndrome in sinus arrhythmia.
2. Premature atrial beats generally do not require treatment; rapid atrial fibrillation can be treated with digitalis, beta-blockers and calcium ion antagonists, chronic atrial fibrillation can be divided into three categories: paroxysmal, persistent and permanent; paroxysmal supraventricular The quick termination method can be used to stimulate the vagus nerve, and the best way to cure it is radiofrequency ablation.
3. Lidocaine is the first choice for termination of ventricular tachycardia, and verapamil can treat idiopathic ventricular tachycardia; the early appearance of wide malformed QRS complex is the main manifestation of premature ventricular contractions, and propafenone, mexiletine and amiodarone are used for treatment. .
4. Atrioventricular block is divided into three degrees. The PR interval of the first degree atrioventricular block is greater than 0.20 s. There is no special treatment for the first degree and the second degree. Atropine can be given for the third degree slow heart rate, and pacing can be installed for those with obvious symptoms. device.
03
Cardiac Arrest and Sudden Cardiac Death
Sudden cardiac death must be sudden cardiac arrest. Incomplete cardiac arrest is sudden cardiac death. Most of sudden cardiac death is caused by coronary heart disease and its complications. Electrical defibrillation is an effective means of cardioversion. Master CAB for sudden death emergency.
04
hypertension
1. Diagnostic criteria for hypertension: blood pressure ≥ 140/90 mmHg, three grades of hypertension, six categories of antihypertensive drugs, attention to the choice of antihypertensive drugs, and the blood pressure target below 140/90 mmHg.
2. Pay attention to the clinical features of malignant hypertension.
3. Hypertensive encephalopathy is characterized by severe headache, nausea, vomiting, convulsions, and coma due to elevated blood pressure. Pathologically, it is characterized by fibrous necrosis of renal arterioles.
05
coronary atherosclerotic heart disease
1. Among the risk factors for coronary heart disease, hyperlipidemia, hypertension, and hyperglycemia are important risk factors.
2. Ischemic heart disease includes structural and functional changes of coronary artery. Coronary angiography is the gold standard for diagnosing coronary heart disease.
3. Insufficient coronary blood flow, causing acute and temporary ischemia and hypoxia in the myocardium, resulting in angina pectoris. The nature of chest pain is often compressive or constricting, lasting 3 to 5 minutes, and can be relieved by nitroglycerin. Angina pectoris is divided into four types. class. Electrocardiography is a common method for diagnosing angina pectoris, but its diagnosis depends on medical history and other auxiliary examinations, and needs to be differentiated from cardiac neurosis and acute myocardial infarction.
4. Unstable angina pectoris is all angina pectoris except stable and exertional angina pectoris, and its treatment includes nitrates, beta-blockers, calcium channel blockers, aspirin and low molecular weight heparin.
5. The main pathogenesis of acute myocardial infarction is atherosclerotic plaque rupture, complete occlusion by thrombosis or continuous coronary spasm, the most important symptom is pain, and gastrointestinal symptoms, arrhythmia, heart failure and Shock, signs of increased heart rate, galloping rhythm and papillary muscle insufficiency are common; the characteristic changes of myocardial infarction with Q waves are ST segment elevation, arched dorsally upward, and fusion with T waves to form unidirectional curves and pathological Q waves; no Q waves Wave myocardial infarction is the general depression of ST segment; CK-MB and LDH1 have the highest specificity in myocardial enzymes; three elements for the diagnosis of myocardial infarction; pain, ECG and enzyme changes, pay attention to angina pectoris, acute abdomen, acute pulmonary embolism and aorta Dissection tumor phase identification; acute myocardial infarction complicated by papillary muscle insufficiency is the most common, long-term ST segment does not fall back should pay attention to ventricular aneurysm.
6. The treatment measures for acute myocardial infarction include monitoring and general treatment; papaverine, morphine and pethidine are commonly used to relieve symptoms; indicators for successful thrombolysis; the most active and effective method in emergency coronary angioplasty room; elimination of ventricular arrhythmia Use more lidocaine; use digitalis with caution in the treatment of heart failure and advocate the use of beta-blockers and ACEI preparations.
7. The Killip classification of pump failure caused by acute myocardial infarction, grade I has no obvious heart failure; grade II has left heart failure; grade III has acute pulmonary edema; grade IV cardiogenic shock and other hemodynamic changes.
06
heart valve disease
1. Mitral valve stenosis is manifested by dyspnea, cough, hemoptysis and hoarseness; important signs are diastolic rumbling murmur and valve opening sound; X-ray shows left atrium enlargement, electrocardiogram shows mitral valve P wave, ultrasound Cardiac is the most valuable test for diagnosing mitral stenosis; the most common complication of this disease is atrial fibrillation, followed by acute pulmonary edema, thromboembolism, right heart failure, infective endocarditis and pulmonary infection; Pay attention to the management of complications, intervention and surgery are effective methods for the treatment of mitral valve stenosis, and prosthetic valve replacement is the best method.
2. The etiology of mitral regurgitation is divided into two categories: acute and chronic. The clinical manifestations are not typical, and the signs include left ventricular enlargement, apex movement to the left and the most important systolic murmur; echocardiography is a mitral murmur. Significant examinations for valve insufficiency; complications include heart failure and infective endocarditis; no treatment is required in the period of cardiac function compensation, and valve replacement surgery is the best treatment.
3. There are many causes of aortic valve stenosis, but rheumatic heart disease, congenital heart disease and senile degeneration are more common. The main clinical manifestations are dyspnea, angina pectoris and syncope; important signs are systolic jet-like murmur, often accompanied by tremor; ultrasound Cardiography is an important method for diagnosing and determining the degree of stenosis; complications include arrhythmia, sudden cardiac death, infective endocarditis, systemic embolism, heart failure and gastrointestinal bleeding; medical treatment is limited to complications and symptomatic treatment, Interventional surgery is an effective method.
4. Rheumatic heart disease is the first cause of aortic valve insufficiency, and the most important sign is a sigh-like murmur during diastole, followed by increased pulse pressure and peripheral vascular signs; echocardiography provides reliable signs for it; complications include Infective endocarditis and ventricular arrhythmias are common; prosthetic valve replacement is an effective treatment.
07
infective endocarditis
1. Common pathogenic microorganisms in infective endocarditis, acute cases are mainly Staphylococcus aureus; subacute cases are mainly Viridian Streptococcus; the underlying heart disease of the disease is mitral valve and aortic valve insufficiency, ventricular defect , Patent Ductus Arteriosus and Tetralogy of Fallot.
2. The incidence of subacute endocarditis is related to hemodynamic factors, nonbacterial thrombotic endocarditis, transient bacteremia and bacterial infectious vegetation; clinical symptoms are fever, and signs are heart murmur, Anemia, splenomegaly, and peripheral signs (petechiae, subnail hemorrhages, Roth spots, Osler nodules, Janeway lesions).
3. Complications are found in the heart, arterial embolism, bacterial aneurysm, metastatic abscess, nervous system, and kidney.
4. Blood culture is the most important method for diagnosing endocarditis, but the positive rate is very low. Echocardiography is of great significance for the diagnosis of endocarditis. Pay attention to the diagnostic criteria.
5. Treatment principles: early medication, large dose, long course of treatment, and intravenous administration.
6. Clinical attention should be paid to the prevention of infective endocarditis.
08
Cardiomyopathy
1. Pay attention to the definition and classification of cardiomyopathy. Dilated cardiomyopathy is more common, followed by hypertrophic cardiomyopathy.
2. The clinical manifestations of dilated cardiomyopathy include heart enlargement, heart failure, arrhythmia and embolism; X-ray heart shadow is significantly enlarged, cardiothoracic ratio is greater than 50%, and pulmonary congestion; echocardiographic manifestations are “one large, two thin, and three weak”. “, four small”, the above conditions can be diagnosed; the differential diagnosis should be differentiated from infective endocarditis, ischemic cardiomyopathy and some heart valve diseases; there is no special treatment for this disease, only symptomatic and complications. Treatment, the number of patients receiving heart transplants is increasing.
3. Hypertrophic cardiomyopathy is mainly manifested as dizziness, chest pain and systolic murmur. The cardiac murmur of hypertrophic cardiomyopathy changes with the application of certain drugs, such as the use of beta-blockers or the reduction of squatting murmurs, on the contrary , such as taking nitroglycerin or physical exercise, the murmur is enhanced; echocardiography provides a reliable basis for diagnosis, for patients with clinical or ECG similar to coronary heart disease, such as the patient is young, the basis for diagnosis of coronary heart disease is insufficient and other heart disease cannot be used. To explain, the possibility of this disease should be considered, combined with auxiliary examination and positive family history, it is more helpful for diagnosis, when it is differentiated from high heart disease, coronary heart disease, congenital heart disease and aortic valve stenosis; choose β-blockers , calcium channel blocker therapy.
4. The most common type of myocarditis is viral myocarditis, which is histologically characterized by the dissolution of myocardial cells, interstitial edema, and inflammatory cell infiltration; about half of the patients have prodromal symptoms of viral infection 1 to 3 weeks before the onset “-like symptoms or digestive system symptoms such as nausea and vomiting, followed by palpitations, chest pain, dyspnea, edema, and even Adams-Stokes syndrome. Heart sounds or murmurs and signs of heart failure, and cardiogenic shock may occur in severe cases. In conclusion, the diagnosis is made based on a combination of history, clinical manifestations, and laboratory tests.
09
pericardial disease
1. The causes of acute pericarditis include rheumatic fever, tuberculosis, bacterial infection, viral infection, tumor and myocardial infarction.
2. Fibrinopericarditis is mainly manifested as chest pain and pericardial friction; exudative pericarditis is mainly manifested as cardiac border enlargement and cardiac tamponade.
3. Cardiac tamponade manifests as jugular vein distention, blood pressure drop, paradoxical pulse, and a large number of pericardial effusion signs; deal with pericardiocentesis and symptomatic treatment.
4. The indications for pericardiocentesis are cardiac tamponade and exudative pericarditis for which the etiology cannot be identified; precautions: strictly grasp the indications; cardiac ultrasonography is required before surgery to determine the size and location of the liquid level; It should not exceed 200 ml at a time, and then increase to 300-500 ml each time; the changes in respiration, blood pressure and pulse should be closely observed during and after surgery.
10
shock
1. The concept of shock and effective circulating blood volume.
2. The pathological changes of shock are mainly microcirculation contraction period, microcirculation expansion period and microcirculation exhaustion period.
3. Shock is characterized by a sharp decrease in effective circulating blood volume, which depends on three factors: blood volume, cardiac output and peripheral vascular tension.
4. General monitoring of shock: ① mental state; ② limb temperature and color; ③ blood pressure; ④ pulse; ⑤ urine output.
5. Urine volume is a simple and effective index to observe changes in shock. Adult urine volume is required to be >30ml/h and children >20ml/h.
6. Special monitoring indicators for shock: ① central venous pressure; ② pulmonary artery wedge pressure; ③ cardiac output and cardiac index; ④ arterial blood gas analysis; ⑤ arterial blood lactate value; ⑥ DIC laboratory index.
7. Determination of central venous pressure (CVP) to understand the pressure of the right atrium and the superior and inferior vena cava in the thoracic cavity, which is normally 0.49 to 0.98 kPa. CVP < 0.49 kPa (5 cmH2O), blood pressure decreased, suggesting hypovolemia. CVP>1.47kPa (15 cmH2O), and low blood pressure, suggesting cardiac insufficiency.
8. Posture of shock patients: supine position or the upper body and lower limbs should be properly elevated by about 20°.
9. The use of vasoactive drugs in shock patients must supplement the blood volume, and try not to use vasoconstrictors.
10. Pay attention to the characteristics of vasoconstrictors and vasodilators.
11. Hypovolemic shock includes hemorrhagic shock and traumatic shock, both of which are caused by a sharp decrease in blood volume.
12. Common causes and treatment principles of septic shock.
13. The role of hormones in septic shock and other more severe shocks.
Source: Good Medical Heart College