adiuvante Dei gratia doctorum factionis
CARDIOLOGY: CARDIAC
TUMORS
CARDIAC TUMORS
Primary tumors of the heart RARE (.0017 - .28%)
Often BENIGN (75%) usually myxoma
Potential for life-threatening complication if thaht goes to
the brain, stroke, to heart, MI
Curable by surgery
Most common cause of primary tumor is myxoma
Followed by rhabdomyomas infants and children
Myxoma is the most common primary tumor of the heart
Myxoma is the most common primary BENIGN tumor of the
heart
Sarcomas (angiosarcoma) - most common primary malignant
tumor of the heart and is the second most common primary
tumor of the heart after myxoma
In children infants you have rhabdomyosarcoma and malignant
teratoma to think of
SIGNS AND SYMPTOMS SIMILAR TO ALL FORM OF HEART DISEASE
2014-2015
DR. MOISES
BARTOLOME, MD
CLINICAL MANIFESTATIONS
Cardiac and non-cardiac manifestations
o When you say cardiac, murmurs, heart failure
o Non cardiac anemiaa fever etc
Location and size of tumor the major determinants of
specific signs and symptoms
o halimbawa, sa pericardium (most common area
the tumor goes into the heart) , end up problems
like pericarditis and pericardial tamponade
o If it is in SA node, end up having AV blocks
o If in intramyocardium, end up with congestive
heart failure because of inadequate contraction
and relaxation of the heart
Chest pain different hard to differentiate from other
Syncope loss of consciousness; inadequate perfusion to
the brain.
o Heart attack and then having ventricular
arrhythmia no CO inadequate perfusion to
the brain syncopal attack
o if obstruct carotid arteries inadeaute perfusion
to the brrain syncopal attack
o If tumor obstruct outflow tract (area before aorta)
syncopal attack
Heart failure
o Right sided neck vein distention, ascites,
o Left sided dyspnea, orthopnea, nocturnal
paroxysmal dyspnea
Murmurs
o Systolic aortic stenosis, pulmonic stenosis,
mitral and tricuspid regurgitation
o Diastolic aortic regurg, pulmonic regurg, mitral
and tricuspid stenosis
Arrhythmias
o Example: Ventricular arrhythmia
o Ventricular tap vs supraventricular tap in ECG
unless theres no bundle branch block you look
at QRS. QRS in supraventricular is narrow,
ventricular wide QRS
Conduction disturbance
o AV blocks
Pericardial effusion or tamponade
 Diagnosis: SIGNS AND SYMPTOMS
Essential is positive imaging for characteristic cardiac
masses and biopsy of that masses
Have to open up the patient

MYXOMA

Most common type of primary cardiac tumor (1/3 to of all

cases)
rd th
Most commonly in 3 6 decade; female > male
Sporadic vs familial
Majority sporadic; some are familial (autosomal dominant
transmission) or part of a syndrome
Carney complex spotty skin pigmentation, myxomas,
endocrine overactivity, schwannomas
NAME syndrome nevi, atrial myxoma, myxoid
neurofibroma, ephelides
LAMB syndrome lentigines, atrial myxoma, blue nevi

CLINICAL PRESENTATION

Systemic or cardiovascular findings

Pulm hypeetension R sided failure

Pulmonary emboli- difficulty of breathing, if obstruct pulm
artery -> RV sided failure
Anemia, elevated ESR, Raynauds, clubbing, elevated
Autosomal dominant investigate the whole family,
globulin you can think of SLE
diagnostic procedure to use: echo
most common primary cardiac neoplasm--an atrial Cardiovascular findings:
myxoma.
These benign masses are most often attached to the atrial 1. Atrial
wall, but can arise on a valve or in a ventricle. s/sx resemble mitral valve disease most
They can produce a "ball valve" effect by intermittently common clinical presentation
occluding the atrioventricular valve orifice. Stenosis tumor prolapse into the mitral
Embolization of fragments of tumor may also occur. orifice during diastole, mas common
Myxomas are easily diagnosed by echocardiography. stenosis kesa sa regurg
Regurgitation injury to the valve by
tumor-induced trauma, itf theres
destruction of the valves

2. Ventricular outflow obstruction syncope

DIAGNOSIS

1. Two-dimensional transthoracic or trans-

esophageal echocardiography

Determine site of tumor attachment

and tumor size

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 st
Screening of 1 degree relatives for Benign connective tissue tumor
familial or syndrome myxoma
Associated with calcification
2. CT scan and MRI
Occur in the ventricle and IVS
Tumor size, shape, composition, and
surface characteristics s/sx secondary to mechanical interference with cardiac
flow, ventricular contraction abnormalities, conduction
3. Cardiac catheterization disturbance

Done if theres Risk of tumor emboli; for PAPILLARY FIBROELASTOMA

suspected CAD

RHABDOMYOMAS
Common findings on cardiac valves or the adjacent
endothelium at post-mortem
Most common in infants and children (75% < 1 y/o)
Seldom result in clinical manifestations
Most common in ventricles s/sx due to mechanical
obstruction mimic valvular stenosis, CHF, restrictive or Growth may cause mechanical interference with valve
hypertrophic cardiomyopathy, & pericardial constriction function -> regurg problems

Multiple in 90% of cases Found in elderly population (mean age 60 y/o)

May be associated with tuberous sclerosis, adenoma HEMANGIOMAS AND MESOTHELIOMA

sebaceum, benign kidney tumors

CARDIAC LIPOMAS
Generally small tumors

nd
2 most common benign tumor Most often intra-myocardial in location

Usually incidental post mortem findings May cause atrioventricular (AV) conduction disturbances
and sudden death due to predilection for region of AV node
Usually solitary; grow as large as 15 cm -- AV blocks

Clinical: SARCOMA

Symptoms due to mechanical interference with

cardiac function
nd
Most common malignant tumor; 2 most common primary
Arrhythmias tumor of heart

Conduction disturbances Common in male (3:1)

Abnormality of cardiac silhouette on CXR Characterized by rapidly downhill course leading to

patients death weeks to months from time of presentation
If subepicardial due to:

Compression of the heart 1. Hemodynamic compromise

Pericardial effusion 2. Local invasion

If subendocardial 3. Distant metastases

With intracavitary extension, may produce Histologic types:

symptoms characteristic of their location
1. Angiosarcomas most common
Most common chambers affected: LV, RA, Interatrial
septum 2. Rhabdomyosarcoma

FIBROMAS 3. Fibrosarcoma

4. Osteosarcoma
nd
2 most common in pediatric age group
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 5. Characterized by rapid growth 2. Signs of pericarditis (triad of pericarditis)

At presentation, often spread extensively for surgical a) Chest pain aggravated by coughing, inspiration or
excision recumbency

Commonly involve RA & pericardium right-sided failure, b) Pericardial friction rub on auscultation
pericardial disease, vena cava obstruction
c) Characteristic ECG changes
May occur in left side mistaken for myxoma
3. Cardiac tamponade
TREATMENT AND PROGNOSIS
a) Increased JVP

Surgery not effective to establish diagnosis b) Pulsus paradoxus

Occurrence of distant metastases Look for the pulse, palpate it, if nawala
in neck vein engorgement
Poor prognosis
c) To confirm: Echo evidence of RA and RV collapse
CARDIAC METASTASIS (metastatic to the heart)
CARDIOVASCULAR MANIFESTATIONS OF SYSTEMIC DISEASES

40x more common than primary tumors

DIABETES MELLITUS
Occurs in 1-20% of all tumor types

Malignant melanoma highest predilection for cardiac 1. Increased incidence of CAD most common cause of death
metastasis (50-65%) can go to heart and cause problems, in adults with DM
kala niyo ganun ganun lang yung melanoma.
o CAD is the most common cause of death in adult
Most common from breast (if female) and lung CA (if male) DM patients
o Equivalent ang survival rate with DM patient vs
Almost always occur in the setting of widespread primary patient with MI
disease
Two types of vascular disease
May be the initial presentation of tumor elsewhere
a) Macrovascular
Reach the heart via bloodstream, lymphatics or direct
invasion Atherosclerosis &
arteriosclerosis - CAD
Usually present as small, firm nodules in the pericardium (
most common kasi) Cerebral circulation TIA,
stroke
LOCATION
>50% of DM have CAD; >50%
of DM ending up with stroke
Pericardium most common
Lower limb circulation
Pericardial tamponade claudication, ulceration,
gangrene
Myocardium
b) Microvascular
Rarely, endocardium and cardiac valves
Retinopathy (number 1 cause
CLINICAL PRESENTATION of blindness) , nephropathy
(number 1 cause of dialysis),
neuropathy, small artery
Depends on location and size of tumor occlusions of the heart

Signs & symptoms occur only in 10%; non-specific MI more frequent but also tend to be larger in
size and more likely to result in complications
Usually occurs in the setting of recognized neoplasm such as heart failure, shock, and death
(stage 4 carcinomas)

1. Dyspnea most common

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 Abnormal or absent pain response to myocardial MALNUTRITION AND VITAMIN DEFICIENCY
ischemia due to generalized autonomic nervous
system dysfunction up to 90% silent ischemias
KWASHIORKOR OR MARASMUS OR BOTH
When you have DM, threshold to test
for ischemia is low.
ECG, stress test Heart becomes thin, pale, and flabby with
Angina equivalent no chest pain, but myofibrillar atrophy and interstitial edema
come to you with dyspnea, and sa ECG
may infarction na Low systolic pressure and cardiac output

Presentation of ischemia may be: Narrow pulse pressure

a) Exertional or episodic dyspnea Generalized edema due to:

b) Flash pulmonary edema Reduced serum oncotic pressure

c) Arrhythmias ventricular arrhythmia Myocardial dysfunction

request for stress test. If may block,
check for CAD. Effects of starvation on the heart:

d) Heart block Decreased contractile force

decreased cardiac output
e) Syncope
Diminished diastolic compliance
RESTRICTIVE CARDIOMYOPATHY
Clinical:
Myocardial dysfunction in the absence of large-
Bradycardia
vessel CAD

Abnormal relaxation of myocardium elevated Hypotension

left ventricular filling pressure
ECG: NSSTTWC, ectopic rhythm
Diastolic heart failure
MVP
AUTONOMIC NEUROPATHY
Decreased exercise capacity

Secondary to autonomic denervation Heart failure, worsened or precipitated

by feeding
Manifested as fixed tachycardia (>90 bpm
usually)with subsequent parasympathetic damage Heart becomes thin, pale, and flabby with
decreased heart rate (give beta blockers) myofibrillar atrophy and interstitial edema

Complete autonomic denervation HR no longer Low systolic pressure and cardiac output
responsive to physiologic stimuli
Narrow pulse pressure
All DM patients should receive statin therapy
unless contraindicated Generalized edema due to:

All receive anti thrombotic unless contraindicated Reduced serum oncotic pressure

Target BP: below 135/85 Myocardial dysfunction

Best drug for DM patients: ACEI or ARB Effects of starvation on the heart:

Cholesterol: <80 Decreased contractile force

decreased cardiac output

Diminished diastolic compliance

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young, but set an examples to the believers in speech, in life, in love, in faith and in
purity 1 Timothy 4:12
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 Clinical: The acute administration of thiamine to these patients
increases the left ventricular ejection fraction and the
a) Bradycardia excretion of salt and water.

b) Hypotension Characteristic cardiovascular syndrome:

Heart failure with increased cardiac output high output
c) ECG: NSSTTWC, ectopic rhythm
due to vasomotor depression leading to reduced systemic
d) MVP vascular resistance
Tachycardia
e) Decreased exercise capacity Elevated filling pressures in the left and right sides of the
heart
f) Heart failure, worsened or precipitated
by feeding
DIAGNOSTIC CRITERIA
Decreased intake also seen in:
Clinical features
a) Chronic disease AIDS, PTB
Dependent edema
b) Semi-starvation anorexia nervosa Low peripheral vascular resistance, decreased minimum BP,
increased pulse pressure
c) Severe CHF GI hypoperfusion and
venous congestion anorexia and Hyperkinetic circulatory state (mid-systolic murmur and S3)
malabsorption Enlarged heart
T-wave changes on ECG: inverted, diphasic, depressed
Treatment should be gradual rapid expansion Peripheral neuritis
leads to stress to heart heart failure Dietary deficiency for at least 3 months or chronic
alcoholism
THIAMINE DEFICIENCY (BERIBERI)

May occur in the presence of adequate intake of calories and
protein if polished rice is used
Deficiency common among alcoholics
Dont forget there is such a thing as thiamine deficiency or
beriberi heart disease.
This is common in alcoholic patients
Probably those who are nagaavoid ng four legged animals.
May ituturo ako sa inyo, you know, best food for patients
with increased cholesterol, you should avoid 4 legged
animals. Baka, baboy, lahat ng 4 legged animals, mataas ang
cholesterol. Sarap sarap ng baboy ano? Advise them to eat
2 legged animals. Pag 2 legged animals, kita mo, mababa
ang cholesterol mo. Turkey, chicken
Clinical:
Generalized malnutrition
Peripheral neuropathy
Glossitis
Anemia
Dont forget in Beriberi heart disease there is generalized
malnutrition, peripheral neuropathy, glossitis, anemia.
What is glossitis? Tama din yung mga Chinese, tinitingnan
yung dila, may sakit ka, di ba? Tapos pulang pula. So that is
your P.E.
When thiamine stores are measured using the thiamine-
pyrophosphate effect (TPPE), thiamine deficiency has been
found in 2090% of patients with chronic heartfailure.
This deficiency appears to result from both reduced dietary
intake and a diuretic-induced increase in the urinary
excretion of thiamine.
Dont let anyone look down on you because you are
Presence of thiamine deficiency
Decreased blood thiamine concentration
Decreased ESR
Improvement after adequate thiamine therapy
The major cause of the high-output state is vasomotor
depression leading to reduced systemic vascular resistance, the
precise mechanism of which is not understood.
The cardiac examination reveals a wide pulse pressure,
tachycardia,a third heart sound, and, frequently, an apical
systolic murmur.
The electrocardiogram (ECG) may reveal decreased voltage, a
prolonged QT interval, and T-wave abnormalities. The chest x-
ray generally reveals cardiomegaly and signs of congestive heart
failure (CHF).
The response to thiamine is often dramatic, with an increase in
systemic vascular resistance, a decrease in cardiac output,
clearing of pulmonary congestion, and a reduction in heart size
often occurring in 1248 h
OBESITY
Increased CV mortality and morbidity
Increased prevalence of
Hypertension
Glucose intolerance
Atherosclerotic coronary artery disease
Obesity can have problems, alam niyo naman yun pag
obese, increased cardiovascular mortality and
morbidity because they have more likely to have
hypertension, more likely to have diabetes,
atherosclerosis.

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 + +
Increase synthesis of myosin, Na ,K - ATPase
Distinct CVS abnormalities Increase density of myocardial -adrenergic receptors
Increased total and central blood volumes
Increased cardiac output and LV filling pressure HYPERTHYROIDISM
Pag walang mantika ang pagkain hindi masarap dib a? That
is your lifestyle now. You dont have exercise anymore. Yun
Essentials of Diagnosis:
ang problem sa pasyente niyo ngayon. So, laging lifestyle
modification ang sinasabi. Dont forget the obesity; you Low TSH levels
should able to control that. Later, you have to master how
to advise them regarding diet therapy, and dont forget that Increased T3, T4, iodine uptake
patient with obesity, there will be increased total and
central blood volumes, increased cardiac output and LV So how do you diagnose hyperthyroidism? Examination
filling pressure and laboratory test. The most essential is to request for T3,
T4, and TSH
Hypertension
o Eccentric LVH General Considerations:
o Pickwickian syndrome cor pulmonale,
apnea, hypoxemia Increased levels of thyroid hormone hyperdynamic CVS
What is Pickwickian syndrome? Basically the
Increased cardiac output, contractility;
development of cor pulmonale in obese patient, there
tachycardia
can be primary pulmonary problem because of being
obese, nagkakaroon ng obstructive sleep apnea that Decreased SVR
end result to cor pulmonale. Sila yung mga obese
patients, matataba tapos nangingitim ngitim pa yan.

o Heart failure (+) crackles, inc. JVP, S3, S4 SIGNS AND SYMPTOMS
o Edema
o Exercise intolerance

TREATMENT
Systemic s/sx
Weight loss
Weight reduction most effective Increased appetite
Resting tremors of the hand
The most important effective way of preventing Nervousness, anxiety, insomnia, mood swings,
complications in obesity is lifestyle modification irritability
Heat intolerance & sweaty skin
Digitalis
Proximal muscle weakness & wasting
Sodium restriction Increased bowel movement or diarrhea
Diplopia
Diuretics Periodic paralysis
And when you say periodic paralysis, bigla
So how do you prefer to treat a patient with hypertensive nanghihina ang extremities mo. Kaya kailangan
obesity? so what will be your drug of choice probably? kumain kayo ng saging. Sa mga low
You have to give diuretic therapy. Sisikat ka pa. Bakit socioeconomic status, ang ulam ngayon, high
kamo? Aba, kapag umihi ang pasyente mo, bagsak ang carbo and high sodium intake. Pag nag high
timbang niya. Bumaba na yung blood pressure mo, carbo ka, bakit di bumababa potassium mo?
bumaba pa timbang mo. Because of insulin secretion. Kung alam mo
yung pinapakain mo sa pasyente mo.
THYROID DISEASE

Cardiovascular s/sx
Physiologic effects of thyroid hormone: Palpitations
Increased total body metabolism and oxygen consumption Dyspnea with or without LV failure
Increase workload on the heart Atypical chest pain
Direct inotropic, chronotropic, and dromotropic effects Cardiac arrhythmias AF, PACs
Tachycardia, increased cardiac output
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King and Cookie

young, but set an examples to the believers in speech, in life, in love, in faith and in
purity 1 Timothy 4:12
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 The most common dysrhytmia or rhythm
disturbance in patient with hyperthyroidism is
sinus tachycardia PLEASE TAKE NOTE OF THAT!
Common cardiovascular manifestations of
hyperthyroidism include palpitations, systolic
hypertension, and fatigue.
Sinus tachycardia is present in ~40% of
hyperthyroid patients, and atrial fibrillation in
~15%.
Apathetic hyperthyroidism
Elderly patient
o Present only with CV manifestations of
thyrotoxicosis such as AF (resistant to
therapy until hyper-thyroidism is
controlled)
Apathetic hyperthyroidism is very common in elderly
patients, these are patients with weight loss and atrial
fibrillation, isolated systolic hypertension
Elderly patients with hyperthyroidism may present with
only cardiovascular manifestations of thyrotoxicosis such as
sinus tachycardia, atrial fibrillation, and hypertension, all of
which maybe resistant to therapy until the hyperthyroidism
is controlled.
Thyroid function test T3, T4, TSH, RAIU
Initial Diagnosis:
Atrial arrhythmias
Cardiac enlargement
Ventricular failure
s/sx of hyperthyroidism
You label your patient with thyrotoxicosis that is
hyperthyroidism that is what we called now
thyrotoxic heart disease. If your patient has atrial
arrhythmias, cardiac enlargement, ventricular
failure, s/sx of hyperthyroidism with biochemical
evidence of hyperthyroidism and there is also
reversal of findings after treatment, you called it
thyrotoxic heart disease.
Definite Diagnosis:
o (+) signs and symptoms
o Biochemical evidence of hyperthyroidism
o Reversal of findings after treatment
TREATMENT

Directed at improving s/sx, reducing the demands to the

PHYSICAL EXAMINATION heart
Anti-thyroid drugs
o Stare, lid retraction, exophthalmos Thyroid ablation
o Skin soft and velvety Steroids hydrocortisone 50-100 mg q 6-8 hours
o Goiter audible bruit Beta blockers if without CHF Propanolol 20-30
o Precordium mg 4x/day
Inspection hyperdynamic precordium Digitalis
Auscultation loud S1, systolic ejection Anti-coagulation
murmur you should have beta blockers for them, digitalis especially
Palpation rapid & bounding pulse those with atrial fibrillation
o Proximal muscle weakness
Hyperreflexic DTRs HYPOTHYROIDISM

Physical examination may reveal a hyperdynamic Essentials of Diagnosis:

precordium, a widened pulse pressure, increases in the Increased TSH
intensity of the first heart sound and the pulmonic Low T3, T4, FTI
component of the second heart sound, and a third heart
sound General Considerations:
An increased incidence of mitral valve prolapse has been Given to any form of TH deficiency
described in hyperthyroid patients,in which case a Myxedema TH deficiency with profound
midsystolic murmur may be heard at the left sternalborder hypothermia, hypoventilation, hypotension, CNS
with or without a midsystolic click. A systolic signs (coma)
pleuropericardial friction rub (Means-Lerman scratch) may Associated with accelerated athero-sclerosis
be heard at the left second intercostal space during Angina uncommon due to decreased metabolic
expiration and is thought to resultfrom the hyperdynamic demand
cardiac motion.
You have high TSH levels, associated with accelerated
atherosclerosis, most of these patients with signs and
DIAGNOSTIC STUDIES symptoms of pleural effusion

CLINICAL FINDINGS
ECG sinus tachycardia, AF
Echocardiography hypercontractility, increased
LV mass & hypertrophy Systemic signs and symptoms
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 o Weight gain, weakness, lethargy, fatigue,
depression
o Constipation, cold intolerance, dry skin, coarse
hair
o Menstrual disorders, impotence or decreased
libido
Cardiovascular signs and symptoms
o Decreased CO, SV, HR
o Loss of inotropism and chronotropism
o Heart failure rare decreased CO match
metabolic demands
Cardiac manifestations of hypothyroidism include
a reduction in cardiac output, stroke volume,
heart rate, blood pressure, and pulse pressure.
Pericardial effusions are present in about one-
third of patients, rarely progress to tamponade,
and probably result from increased capillary
permeability.
Other clinical signs include cardiomegaly,
bradycardia, weak arterial pulses, distant heart
sounds, and pleural effusions.
Although the signs and symptoms of myxedema
may mimic those of CHF, in the absence of other
cardiac disease, myocardial failure is uncommon.
DIAGNOSTIC STUDIES
ECG
sinus bradycardia
prolonged PR & QT interval
low voltage complexes
flattened or inverted T waves
Atrial, ventricular or interventricular delay
The ECG generally reveals sinus bradycardia and low voltage
and may show prolongation of the QT interval, decreased P-
wave voltage, prolonged AV conduction time,
intraventricular conduction disturbances, and nonspecific
ST-T-wave abnormalities.
Chest x-ray may show cardiomegaly, often with a water
bottle configuration; pleural effusions; and, in some cases,
evidence of CHF.
Echocardiography pericardial effusion, ASH
Laboratory findings
Low T3, T4; high TSH levels
Increased cholesterol & triglyceride
Hyponatremia
Increased CK-MM but not CK-MB
anemia
Pathologically, the heart is pale and dilated and
often demonstrates myofibrillar swelling, loss of
striations, and interstitial fibrosis.
Patients with hypothyroidism frequently have
elevations of cholesterol and triglycerides,
resulting in premature atherosclerotic CAD.
Dont let anyone look down on you because you are
young, but set an examples to the believers in speech, in life, in love, in faith and in
purity 1 Timothy 4:12
Page 9 of
Initial Diagnosis:
Pericardial effusion or decreased contractile
performance
Clinical suspicion of hypothyroidism
Definite Diagnosis:
o Clinical findings
o Biochemical evidence of hypothyroidism
o Reversal of abnormalities after treatment with
thyroid hormone
TREATMENT
Thyroid hormone replacement
If > 50 y/o judicious & slow replacement
To prevent exacerbation of angina or
precipitation of AMI
of the usual replacement dose (25
mg/day)
So when you start giving supplementation for thyroid
hormone in a pt. more than 50 years old, you should give
judiciously and slowly. Bakit kamo? Siyempre hindi na
normal takbo ng puso ng pasyente niyo kasi hypothyroid na
dib a? Mabagal. Pag binigyan mo ng thyroid hormone,
mghyperactive yung systole nila. Di ba sinabi natin usually
they are associated with accelerated atherosclerosis so may
probability na may significant coronary artery disease
obstruction, pag binigyan mo, bibilis, may bara. Kaya dapat
dahan dahan.
Before treatment with thyroid hormone, patients with
hypothyroidism frequently do not have angina pectoris,
presumably because of the low metabolic demands caused
by their condition.
However, angina and myocardial infarction may be
precipitated during initiation of thyroid hormone
replacement, especially in elderly patients with underlying
heart disease. Therefore, replacement should be done with
care, starting with low doses that are increased gradually.
MALIGNANT CARCINOID
Associated with right sided murmur especially tricuspid
regurgitation
Tumors that elaborate vasoactive amines (eg serotonin),
kinins, indoles responsible for diarrhea, flushing, labile
BP
Gastrointestinal carcinoids
Almost exclusively in the right side
Occur only with hepatic metastases substance
responsible for the cardiac lesions inactivated by
passage through liver and lungs
Left-sided lesions occur when
1. there exists a right-to-left shunt, or
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12
 2. tumor is located in the lungs pressure. It is very important how you define hypertension.
3. Lesion: fibrous plaques on the endothelium of Alam niyo ba yung hypertension, pwede mawalan ng
cardiac chambers, valves, and great vessels tarbaho ang isang pasyente. Pag sinabi ninyo na high blood,
result in distortion of the cardiac valves there are some companies that when you have
hypertension, they do not hire you.

CLINICAL SYNDROME SIGNS AND SYMPTOMS

o Tricuspid regurgitation, pulmonic Systemic signs and symptoms:

stenosis or both Attacks of headache
o High-output cardiac state may occur Palpitations
due to decrease in systemic vascular resistance Tachycardia
o Coronary artery spasm due to a
Sweating
circulating vasoactive substance
Irritability

CVS signs and symptoms:

Inc. HR, contractility, conduction velocity
Orthostatic hypotension
Hypertension (85%) sustained or paroxysmal
LVH
LV failure due to focal myocardial necrosis
Pulmonary edema

ACROMEGALY

Excessive growth hormone (problem)

In some cases a high cardiac output state may occur,
presumably as a result of a decrease systemic vascular
resistance resulting from vasoactive substances released by
the tumor.
Treatment with somatostatin analogues (e.g., octreotide) or
interferon improves symptoms and survival in patients
with carcinoid heart disease but does not appear to
improve valvular abnormalities.
In some severely symptomatic patients, valve replacement
is indicated.
Coronary artery spasm, presumably due to a circulating
vasoactive substance, may occur in patients with carcinoid
syndrome.
PHEOCHROMOCYTOMA
High circulating levels of catecholamines labile or
sustained hypertension LVH
May cause direct myocardial injury
Focal myocardial necrosis and inflammatory cell
infiltration (50% of patients) contribute to
significant LV failure and pulmonary edema
LV function and CHF may resolve after removal of
tumor
o CHF due to high cardiac output
o Diastolic dysfunction due to ventricular
hypertrophy increased LV chamber size or wall
thickness
o Global systolic dysfunction
o Suppression of renin-aldosterone axis
increased total body sodium and plasma volume
hypertension
Hypertension occurs in up to one-third of patients with
acromegaly and is characterized by suppression of the
reninangiotensin- aldosterone axis and increases in total-
body sodium and plasma volume.
Some form of cardiac disease occurs in about one-third of
patients with acromegaly and is associated with a doubling
of the risk of cardiac death.
RHEUMATOID ARTHRITIS
Inflammation of any or all anatomical parts of the heart
usually pancarditis
Pericarditis
Most common cause of clinically apparent disease
Found by echocardiography in 10-50% of patients,
particularly those with sub-cutaneous nodules
Usually benign course but may progress to cardiac
tamponade or constrictive pericarditis

Sympathetic tumor so clinical manifestation of your patient Coronary arteritis

with hypersympathetic activity 20% of cases; rarely results in angina or MI
It is secondary cause of hyoertension, usually it is
paroxysmal hypertension. Cardiac valves
Paano ninyo idedefine yung hbypertension? How do you Mitral or aortic regurgitation
make a diagnosis of hypertension? Yes, we check the blood Inflammation and granuloma formation
Dont let anyone look down on you because you are

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young, but set an examples to the believers in speech, in life, in love, in faith and in
purity 1 Timothy 4:12
Page 10 of 12
 SLE with elevated antibody to cardiolipin high
Myocarditis incidence of valvular disease
Rarely result in cardiac dysfunction Younger patients with active disease, 5 yrs.

Pericardial fluid Libman-Sacks lesion

Exudate, dec. conc. complements, dec. Glucose, Characteristic endocardial lesion
elevated cholesterol Wart-like lesions most often located at
The high circulating levels of catecholamines resulting from angle of the valves or ventricular surface
a pheochromocytoma may cause direct myocardial injury. of MV
Focal myocardial necrosis and inflammatory cell infiltration
are present in ~50% of patients who die with Hemodynamically important valcular lesions rare
pheochromocytoma and may contribute to clinically
significant left ventricular failure and pulmonary edema. Coronary Artery Disease
In addition, associated hypertension results in left Secondary to arteritis of large coronary arteries,
ventricular hypertrophy. Left ventricular dysfunction and embolism
CHF may resolve after removal of the tumor. Also due to atherosclerosis related to
hypertension or glucocorticoid therapy

Thrombotic Disease
Deep venous thrombosis
Pulmonary, peripheral or cerebral thrombosis
Associated with anti-phospholipid antibodies
produce endothelial dysfunction

Two-dimensional color and spectral Doppler echocardiographic

studies of patients with rheumatic heart disease show moderate to
severe aortic valve insufficiency with no stenosis (A, arrow) and
bowing of the anterior mitral leaflet with severe insufficiency and no
stenosis (B, arrow).

TREATMENT

Treat underlying RA
Glucocorticoids
Pericardiectomy

SYSTEMIC LUPUS ERYTHEMATOSUS

It is also pancarditis pericardial involvement, myocardial

involvement

Pericarditis
2/3 of patients
Benign course
Rarely tamponade or constriction

Myocarditis
Seen in autopsy in up to 80%
Only 20% clinically detected
Parallels the activity of the disease
Seldom results to clinical heart failure, unless
associated with hypertension

Valvular Heart Disease

Clinically most important and frequent SLE-
associated CV manifestation

Dont let anyone look down on you because you are

King and Cookie

young, but set an examples to the believers in speech, in life, in love, in faith and in
purity 1 Timothy 4:12
Page 11 of 12
Dont let anyone look down on you because you are

King and Cookie

young, but set an examples to the believers in speech, in life, in love, in faith and in
purity 1 Timothy 4:12
Page 12 of 12