case base cardiology 4.17.2014 kyavar md facc. no 1
TRANSCRIPT
![Page 1: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/1.jpg)
Case Base Cardiology 4.17.2014 kyavar md facc
![Page 2: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/2.jpg)
No 1
![Page 3: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/3.jpg)
A 75 year old woman with Recent orthopnea
• Chronic dyspnea• Fatigue• Recent orthopnea• palpitation• Pedal edema
![Page 4: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/4.jpg)
![Page 5: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/5.jpg)
![Page 6: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/6.jpg)
LA
LV
AO
Diastole
![Page 7: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/7.jpg)
Mitral Stenosis: Physical Exam
First heart sound (S1) is loud and snappingOpening snap (OS)Low pitch diastolic rumble at the apexPre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S!
![Page 8: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/8.jpg)
MS
MR/TR/VSD
AS with ES
PS with ES
AR
MS with OS
PDA
S1 S2
![Page 9: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/9.jpg)
Mitral Stenosis: Investigations
• CXR• ECG• Echo
![Page 10: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/10.jpg)
![Page 11: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/11.jpg)
![Page 12: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/12.jpg)
![Page 13: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/13.jpg)
Mitral Stenosis
• Etiology• Natural history • Symptoms• Physical Exam• Severity• Timing of Surgery
![Page 14: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/14.jpg)
Mitral Stenosis: EtiologyPrimarily a result of rheumatic fever
(~ 99% of MV’s @ surgery show rheumatic damage )
Scarring & fusion of valve apparatusRarely congenitalPure or predominant MS occurs in
approximately 40% of all patients with rheumatic heart disease
Two-thirds of all patients with MS are female.
![Page 15: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/15.jpg)
Mitral Stenosis: Natural History• Progressive, lifelong disease, • Usually slow & stable in the early years.• Progressive acceleration in the later years• 20-40 year latency from rheumatic fever to
symptom onset.• Additional 10 years before disabling
symptoms
![Page 16: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/16.jpg)
Mitral Stenosis:Pathophysiology
Right Heart Failure:Hepatic Congestion
JVDTricuspid Regurgitation
RA Enlargement
Pulmonary HTNPulmonary Congestion
Atrial FibLA Thrombi
LA Enlargement LA Pressure
RV Pressure OverloadRVH
RV Failure LV Filling
![Page 17: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/17.jpg)
Jugular Veins
Add 5 cm
![Page 18: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/18.jpg)
Mitral Stenosis: Symptoms• Breathlessness• Fatigue• Oedema, ascites• Palpitation• Haemoptysis• Cough• Chest painmitral facies or malar flushSymptoms of thromboembolic complications (e.g. stroke, ischaemic limb)Worsened by conditions that cardiac output.
◦ Exertion,fever, anemia, tachycardia,, pregnancy, thyrotoxicosis
![Page 19: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/19.jpg)
Signs of Mitral Stenosis
Palpation:Small volume pulseTapping apex-palpable S1Palpable S2
• Atrial fibrillation• Signs of raised pulmonary
capillary pressure– Crepitations, pulmonary
oedema, effusions• Signs of pulmonary hypertension
– RV heave, loud P2
Auscultation:Loud S1S2 to OS interval inversely
proportional to severityDiastolic rumble: length
proportional to severityIn severe MS with low flow- S1,
OS & rumble may be inaudible
![Page 20: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/20.jpg)
What if you hear something?
• When does it occur? Is it systolic, diastolic, or both?
– What is the pattern?• Where is it loudest?• Where does it radiate?• Who goes with it?Are there other associated
findings? – S2 splitting normal, loud P2, gallop sound?
• How does it respond? Maneuvers
![Page 21: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/21.jpg)
A 75 year old woman with loud first heart sound and mid-diastolic murmer
![Page 22: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/22.jpg)
![Page 23: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/23.jpg)
No 2
![Page 24: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/24.jpg)
70 years old man with PND
•Syncope•Chest pain
![Page 25: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/25.jpg)
![Page 26: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/26.jpg)
LA
LV
AO
Systole
RV
![Page 27: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/27.jpg)
![Page 28: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/28.jpg)
Valve StenosesTwo Catheter Technique
![Page 29: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/29.jpg)
![Page 30: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/30.jpg)
Ejection Murmur
• Mixed frequencies and is moderate-to-marked crescendo-decrescendo
• Caused by forward flow across the left or right outflow
• Aortic stenosis & pulmonic stenosis
![Page 31: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/31.jpg)
![Page 32: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/32.jpg)
![Page 33: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/33.jpg)
No 3
![Page 34: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/34.jpg)
Patient with Purplish lips, hands and feet
• History: 6 week old male with 2 days of clear, nasal
congestion, no fever
Gets bluish after feeding or crying
Previously well, full-term baby
The family history was negative
![Page 35: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/35.jpg)
Tetralogy of Fallot- Clinical Findings squatting
“Tet spells” – due to pulmonary outflow tract spasm
Severe cases ---at birth---severe PS
Mild cases ---- much later---mild PS
Cyanosis usually
ECG reveals right ventricular hypertrophy
![Page 36: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/36.jpg)
![Page 37: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/37.jpg)
Physical Examination Central Cyanosis vs. Peripheral cyanosis
Vital signs
Lung and CNS examination to rule these out
Cardiac Examination Heaves, thrills, abnormal or increased precordial activity Absent or diminished femoral pulses Abnormal first or second heart sound (abnormal splitting) Extra heart sounds (gallop, ejection click, opening snap) Murmurs that are loud, harsh, blowing
![Page 38: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/38.jpg)
Case Presentation cont’d Purplish lips, hands and feet
Grade III/VI systolic murmur loudest at lower left sternal border
Liver was 1.5 cm below right costal margin and a normal spleen
Peripheral pulses equal in upper/lower extremities, 1.5 sec cap refill
![Page 39: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/39.jpg)
![Page 40: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/40.jpg)
Lab/Imaging Studies CBC/Sepsis evaluation
Chest x-ray
Oxygen Saturation (Arterial blood gas, pulse oximetry)
Hyperoxia test
Electrocardiogram
Echocardiography
![Page 41: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/41.jpg)
![Page 42: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/42.jpg)
Hyperoxia test- Cardiac or Pulmonary?
50-150mm Hg Truncus Arteriosus ( No restricted pulmonary blood flow)
<50 mm Hg Tetralogy of Fallot, Tricuspid Atresia ( Reduced pulmonary flow)
<150 mm HgCardiac disease or PPHN (SHUNT)
>150mm HgPulmonary disease (V/Q mismatch)
On 100% oxygenpaO2
![Page 43: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/43.jpg)
TOF - ECG
![Page 44: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/44.jpg)
Brickner, M. E. et al. N Engl J Med 2000;342:334-342
Tetralogy of Fallot
• 5/10k births• Ventricular septal
defect• Narrowing of the
pulmonary outflow tract
• Over riding aorta • right ventricular
hypertrophy
![Page 45: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/45.jpg)
Hypoxemia Differential Right-to-Left Shunt
INTRACARDIAC, Great Vessels, pulmonary AV malformation
V/Q Mismatch Pneumonia, atelectasis, aspiration, pulmonary hypoplasia
Hypoventilation CNS depression, Neuromuscular disease, Airway obstruction
Diffusion Impairment Pulmonary edema, pulmonary fibrosis
Hemoglobinopathy
![Page 46: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/46.jpg)
No4
![Page 47: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/47.jpg)
A 41-year-old man was initially evaluated 6 years previously by his family physician, found to be hypertensive, and managed with pharmacologic agents. Over the next several years, control of his BP became increasingly difficult, requiring multiple agents. He was referred to a cardiologist for further evaluation. Throughout the entire period, he has remained asymptomatic.
![Page 48: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/48.jpg)
Physical examination disclosed a BP of 160/94 mm Hg and a heart rate of 75 beats/min. Precordial pulsations were normal. Auscultation disclosed a late-peaking systolic murmur heard well at the apex; however, it was also heard over the entire thoracic cage and upper back (Fig 1 ). No diastolic murmurs were audible. Simultaneous palpation of the radial and femoral pulses disclosed a significant delay of the latter. The systolic pressure in the lower extremities was 130 mm Hg, determined with a Doppler probe over the pedal vessels, yielding an ankle/brachial index of 0.85. The remainder of the examination was normal.
![Page 49: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/49.jpg)
Graphic recording of murmurs as heard at two locations over the chest.
Varma C et al. Chest 2003;123:1749-1752
©2003 by American College of Chest Physicians
![Page 50: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/50.jpg)
Rib notching
![Page 51: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/51.jpg)
![Page 52: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/52.jpg)
Coarctation of the Aorta
• Grade II or III murmur• Heard posteriorly & over base of the heart• Hypertension in the arms, but not in the legs• Decreased or absent femoral arterial pulsation
![Page 53: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/53.jpg)
![Page 54: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/54.jpg)
Coarctation of Aorta
• Narrowing in proximal descending aorta
• May be long/tubular but most commonly discrete ridge
• Natural hx: poor prognosis if unrepaired– Aortic Aneurysm/dissection– CHF– Premature CADz
![Page 55: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/55.jpg)
![Page 56: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/56.jpg)
Coarctation Repair
Edmunds’ Cardiac Surgery in the Adult, Ch 47
• Surgical correction1) Patch aortoplasty with removal of segment and end to end anastomosis or subclavian flap repair 2) bypass tube grafting around segment
![Page 57: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/57.jpg)
Coarctation of Aorta
• Residual or recoarctation may be seen in 3% to 41% of patients and can occur with any surgical technique or after angioplasty (seen in 8% to 11% of patients undergoing angioplasty for native coarctation)
![Page 58: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/58.jpg)
No5
![Page 59: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/59.jpg)
Dyspnea & Chest Pain
• The patient was a 33 year old housewife who had acute cardiac failure on the sixteenth day after the onset of the disease
![Page 60: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/60.jpg)
• Physical examination revealed a pale thin female with tachycardia (107 beats/minute), tachypnea (22 breaths/minute), hypotension (blood pressure 86/50 mmHg), jugular venous distension with rapid “×” descent, and distant heart sounds. While the patient was being evaluated in the emergency room, she suddenly had a cardiopulmonary arrest
![Page 61: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/61.jpg)
Myocarditis• Myocarditis is an inflammation of the myocardium, the thick
muscular layer making up the major portion of your heart. • Often follows URI• May present with chest pain (either pleuritic or non-specific) or signs
of heart failure• ECG may show sinus tachycardia, nonspecific repolarization
abnormalities, and intraventricular conduction abnormalities• Echocardiography documents cardiomegaly & contractile
dysfunction• Myocardial biopsy, although not sensitive, may reveal characteristic
inflammatory pattern (ex. Giant Cell)
![Page 62: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/62.jpg)
![Page 63: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/63.jpg)
Myocarditis basics
• Wide spectrum of clinical consequences– Mild & self-limited with few symptoms or severe
with progression to CHF & dilated CM– Very localized or diffuse– Clinical involvement can be limited to the heart or
be part of widespread systemic disorder
![Page 64: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/64.jpg)
Electrocardiogram showing PQ-segment depression and diffusely elevated ST-T-segments at presentation (A)
and evolution after 1 day (B).
![Page 65: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/65.jpg)
ECG & CXR
• ECG - nonspecific ST-T changes and conduction delays are common– Ventricular ectopy may be only clinical finding
• CXR - cardiomegaly is frequent, may have evidence for pulmonary venous hypertension & pulmonary edema
![Page 66: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/66.jpg)
Diagnostics
• Wbc’s often elevated• ESR increased• Troponins elevated in 1/3• CK-MB elevated in 10%• Echocardiogram helps evaluate cardiac
function & exclude other causes• Cardiac MRI improving in ability to see
abnormalities in myocardium
![Page 67: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/67.jpg)
Endomyocardial Bx
• Pathologic exam may reveal lymphocytic inflammatory response with necrosis, but this is not sensitive b/c of the patchy areas of distribution.
• “Dallas” criteria for histopathologic dx• May see “Giant cells”
![Page 68: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/68.jpg)
No6
![Page 69: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/69.jpg)
65 years man with sever chest pain
•History• DM • Hyperlipidemia• smoking
![Page 70: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/70.jpg)
![Page 71: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/71.jpg)
![Page 72: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/72.jpg)
![Page 73: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/73.jpg)
![Page 74: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/74.jpg)
![Page 75: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/75.jpg)
![Page 76: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/76.jpg)
![Page 77: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/77.jpg)
![Page 78: Case Base Cardiology 4.17.2014 kyavar md facc. No 1](https://reader035.vdocuments.us/reader035/viewer/2022062407/56649ccd5503460f9499870b/html5/thumbnails/78.jpg)