2012年11月19日 星期一

CV DAY 6

Q1.Thallium scan radiation dose?

Table 1

Doses in cardiology
ExaminationEffective dose (mSv)Equivalent n. of chest x-rays
CONVENTIONAL RADIOLOGY
 ♣ Chest x ray (single postero-anterior)0.021
NUCLEAR MEDICINE
 ♣ Tc-99 m tetrafosmin cardiac rest-stress (10 mCi+30 mCi)*10.6530
 ♣ Tc-99 m sestamibi cardiac 1-day rest-stress (10 mCi+30 mCi)*12600
 ♣ Tc-99 m sestamibi cardiac 2-day stress-rest (30 mCi+30 mCi)*17.5775
 ♣ Tl-201 cardiac stress and reinjection (3.0 mCi+1.0 mCi)*251500
 ♣ Dual isotope cardiac (3.0 mCi Tl201 + 30 mCi Tc-99 m)*271600
64-Slice CARDIAC COMPUTED TOMOGRAPHY
 ♣ ECG pulsing, no aorta**9450
 ♣ No ECG pulsing, yes aorta**291450
INTERVENTIONAL RADIOLOGY
 ♣ Conventional rhythm device***1.470
 ♣ Cardiac resynchronization device***5.5275
 ♣ Cerebral angiography ***1.6–10.680–530
 ♣ Coronary angiography ***3.1–10.6155–555
 ♣ Abdomen angiography ***6–23300–1150
 ♣ Peripheral angiography***2.7–14135–700
 ♣ Coronary angioplasty ***6.8–28.9340–1445
 ♣ Peripheral angioplasty***10–12500–600
 ♣ Radiofrequency ablation***17–25850–1250
 ♣ Valvuloplasty***291450
  • Seattle to Portland: 3 mrem per 100 block hours
  • New York to Chicago: 39 mrem per 100 block hours
  • Los Angeles to Honolulu: 26 mrem per 100 block hours
  • London to New York: 51 mrem per 100 block hours
  • Athens to New York: 63 mrem per 100 block hours
  • Tokyo to New York: 55 mrem per 100 block hours

2012年11月14日 星期三

CV Day 3

Q1.心臟手術後或是經歷過Acute coronary syndrome的病人，其能不能進行sexual activities?

首先要了解心臟復健的原理
Scottish Intercollegiate Guidelines Network
http://www.sign.ac.uk/guidelines/fulltext/57/index.html

然後定義activities的強度

Compendium  of Physical Activities: an update  of activity codes  and MET  intensities

http://juststand.org/portals/3/literature/compendium-of-physical-activities.pdf

裡頭寫到METS = 1 METS 每小時每公斤體重消耗一千卡

下午 12:51
METS

Sexual activities
1.5
Active, vigorous effort
Sexual activities
1.3
General, moderate effort
Sexual activities
1.0
Passive, light effort, kissing hug
不過這篇德國的文章有對其中性行為的體位跟強度，及男方或女方做更詳細的分析

[Sex, erectile dysfunction, and the heart: a growing problem].

Görge G, Flüchter S, Kirstein M, Kunz T.
Cardiac and metabolic expenditures during sexual intercourse will vary depending on the type of sexual activity. When oxygen uptake was measured in men, an average metabolic expenditure during stimulation and orgasm of 2.5 metabolic equivalents (METs) was found for woman-on-top coitus, and of 3.3 METs for man-on-top coitus (range 2.0-5.4 METs). However, coital death is rare, encompassing only 0.6% of all sudden death cases. A retrospective case-crossover study has shown that although sexual activity can trigger the onset of myocardial infarction, the relative risk in the 2 h after sexual activity was low (2.5; 95% confidence interval [CI] 1.7-3.7).


但心臟疾病急性爆發後，能不能再度進行，關鍵是在於性行為對mood的影響，而非其運動強度。所以會要求心臟復健能做到5-6METS後才能進行
Sexual dysfunction after a myocardial infarction is a common problem said to occur in 50% to 75% of all patients. Sexual dysfunction often antedates the myocardial event. The advice given by current textbooks is too often based on anecdotal reports that lack scientific accuracy. Studies of the cardiovascular response during sexual intercourse are few, but those that exist consistently show that there are wide individual variations in heart rate, blood pressure, and oxygen consumption. Recent reports have also identified potentially dangerous arrhythmias during intercourse. Patients who reach 5 to 6 metabolic equivalents (METS) on stress-testing without ischemia or arrhythmias can in all likelihood resume their normal sexual activities without any risk. All other cases have to be considered individually according to the current physiologic knowledge.
Tardif GS.Sexual activity after a myocardial infarction. 1989 Oct;70(10):763-6.

CV day 2

"Life is just all about  problem based learning"

Today's learning issue:
Q1.5 years survival rate of heart failure=what kind of cancer 5 year survival rate?

-
Male
Female
Median survival rate
1.7 year
3.2 year
5-year survival rate
25%
38%
1-year survival rate
57%
64%

Kannel WB. Incidence and epidemiology of heart failure. 2000 Jun;5(2):167-73.

Source

Figure 1.1: Five year age standardised relative survival (%), adults diagnosed 1996-1999, England and Wales by sex and site

Women Pancreas 2% 　
Lung 6% 　
Oesophagus 8% 　
Stomach 13% 　
Brain 15% 　
Multiple myeloma 22% 　
Ovary 34% 　
Leukaemia 36% 　
Kidney 43% 　
Colon 45% 　
Rectum  48% 　
NHL 52% 　
Bladder 61% 　
Cervix  68% 　
Uterus 76% 　
Breast 79% 　
Hodgkin's lymphoma 83% 　
Melanoma 90% 　
Men Pancreas 3% 　
Lung 6% 　
Oesophagus 7% 　
Stomach 12% 　
Brain 13% 　
Multiple myeloma 24% 　
Leukaemia 38% 　
Kidney 45% 　
Rectum 45% 　
Colon 46% 　
NHL 51% 　
Prostate 61% 　
Larynx 67% 　
Bladder 71% 　
Melanoma 78% 　
Hodgkin's lymphoma 84% 　
Testis 95% 　
Male:
 Heart failure 5-year-survival rate:25%=Multiple myeloma 5-year-survival rate:24%
Female:
Heart failure 5-year-survival rate:38%=Leukaemia 5-year-survival rate: 36%
                                                           Ovary  5-year-survival rate: 34%

Q2:Cheyne-Stokes respiration in congestive heart failure.

It is likely that one or more of the following factors are likely to contribute to hyperventilation in congestive heart failure.

Hypoxaemia

Hypoxaemia may contribute to hyperventilation and Cheyne-Stokes respiration in congestive heart failure through peripheral chemoreceptor stimulation. However, in contrast to high altitude periodic breathing where hypobaric hypoxia stimulation of the peripheral chemoreceptors is likely to be responsible for the periodic breathing,24 hypoxia is thought not to be solely responsible for the development of Cheyne-Stokes respiration in patients with congestive heart failure for the following reasons. Hyperventilation, in the absence of hypoxaemia, has been shown to trigger central apnoeas during non-REM sleep induced by either mechanical hyperventilation in normal subjects31 or by arousal induced hyperventilation in Cheyne-Stokes respiration3 and idiopathic non-hypercapnic central sleep apnoea.32 Furthermore, supplemental oxygen has been shown to attenuate rather than abolish Cheyne-Stokes respiration in patients with congestive heart failure.33-36

Increased pulmonary vagal afferent traffic

Increased pulmonary vagal afferent nerve traffic related to pulmonary venous congestion and pulmonary C fibre stimulation has been shown to induce rapid shallow breathing and hyperventilation in animal studies.37-40 In humans with congestive heart failure, those with Cheyne-Stokes respiration have a significantly greater pulmonary artery pressure (mean 34 mm Hg) than those without Cheyne-Stokes respiration (mean 21 mm Hg).6 Moreover, there is a significant inverse correlation between awake pulmonary capillary wedge pressure (PCWP) and awake PaCO 2.6 Finally, there is a tendency for the analogous condition high altitude periodic breathing to occur in patients with associated high altitude pulmonary oedema,41 so Cheyne-Stokes respiration with congestive heart failure is associated with increased pulmonary artery pressures, but whether this is a cause and effect relationship remains to be seen.

Increased sympathetic activity

Heistad et al reported a 20% increase in minute ventilation 10 minutes after a six minute venous infusion of noradrenaline, an effect that could be blocked by prior treatment with propranolol.13 As increased circulating noradrenaline levels and hyperventilation occur in congestive heart failure,11 12 particularly in those with Cheyne-Stokes respiration, it is possible that peripheral chemoreceptors bathed in noradrenaline, or possibly central sympathetic activation related to spontaneous arousals, precipitates Cheyne-Stokes respiration. Upper airway collapse towards the end of the central apnoea, known to occur in Cheyne-Stokes respiration,42 may also cause arousal from sleep and thereby hyperventilation.3 32
Q3:
Resistent Hypertension
-經過同時使用三種不同機轉的藥物治療，且達適當劑量還無法控制。
Refractory Hypertension
-BP remain 140/90(160/90 for >60 y)
-not secondary HTN
-maximal dose for 2 Different mechanism drugs
Urgent Hypertension
-severe elevation of BP
-without targeted organ dtsfunction
Emergency Hypertension
-severe elevation of BP(>180/120)
-evidence of targeted organ damage
Pseudo-resistent Hypertension
-lack of BPcontrol with appropriate treatment


2012年11月11日 星期日

CV Day 1 Learning Isuue

1.AV BLOCK
2. Comadin

AV Block
主要有三級，其中第三級是心臟急症，第一級則不需治療
AV Block
First degree
診斷:
PR>0.2 S
severe first degree heart block
基本上沒有全部阻斷，只是造成delay，正常情況下不需治療。
在正常心臟中也會發現，可能是傳導系統退化性表現，或是心肌炎及藥物中毒的狀態。
Second degree
Wenckebach block
Mobitz IMobitz I
診斷:1. 各個PR inntervel持續加長，直到block
通常是4:3或是3:2
Mobitz Type 2 block
3:1 heart block3:1 heart block
診斷:PR區間不會持續性增加，全有全無
Third degree
診斷:1.complete AV block
會有心室解離的現象，危急症，且心室心跳速率較慢
third degree heart block

Coumadin(Warfarin)

其代謝可以參考以下圖式::


故warfarin的使用藥檢測病人的
1. VFORC1 gene
2. CYP2C9
在調整藥物

1. Warfarin跟水果的交互作用:(只要是富含Vit k 的水果跟warfarin都會有所交互作用)
       
Kale
蔬菜湯
Spinach
波菜
Turnip greens
蕪菁
Collard green
羽衣甘藍(高麗菜的一種)
Brussel sprouts
球芽甘藍
lettuce
萵苣
broccoli
球花甘藍
Tonka beans
薰草豆
       









The Utility of Gestures in Patients with Chest Discomfort

準備CV前隨意看到的，似乎可以用來幫忙Differential diagnosis用
The Levine Sign has a poor sensitivity for chest pain related to myocardial ischemia or infarction.
•
A patient pointing to a specific point on the chest likely does not have discomfort due to cardiac ischemia or myocardial infarction.
•
Larger areas of chest discomfort correlate with a greater likelihood of cardiac ischemia or myocardial infarction.
Full-size image (109 K)
  1. The “Levine Sign” was defined as a clenched fist of either hand brought to the chest wall with the thumb aspect of the fist positioned towards the chest or superiorly . 
  2. The “Palm Sign” was defined as an extended palm of either hand touching the chest.
  3. The “Arm Sign” was defined as deliberately touching the left arm with the right hand.
  4. the “Pointing Sign” was defined as pointing to a single specific point with 1 or 2 fingers.
  5. The Levine, Palm, and Arm Signs were each prospectively specified as indicative of chest pain or discomfort due to cardiac ischemia. The Pointing Sign was prospectively specified as indicative of nonischemic chest pain.
不過這篇論文最後的結論是:
"Contrary to traditional clinical teaching, direct examination of these gestures fails to demonstrate clinical utility." However, the clinical value of the gestures may be related to a communication of the size of the chest discomfort, with larger diameters more indicative of cardiac ischemia

文章來源:
Gregory M. Marcus, Joshua Cohen, Paul D. Varosy, Joshua Vessey, Emily Rose, Barry M. Massie, Kanu Chatterjee, David Waters, The Utility of Gestures in Patients with Chest Discomfort, The American Journal of Medicine, Volume 120, Issue 1, January 2007, Pages 83-89, ISSN 0002-9343