00:00
So, here’s our patient, Mr. AB. He’s got
a pretty typical story for angina pectoris.
I would like to get some more information from
him though. For example, does he have risk
factors for atherosclerosis? We have talked
about this a number of times in earlier lectures.
Does the patient have high blood pressure?
Does he have high cholesterol? Does he have
diabetes mellitus? Is he a cigarette smoker?
Cigarette smoking markedly increases the risk
for coronary heart disease and for stroke.
00:33
In other words, it increases the risk for
atherosclerosis. Does the patient have high
blood lipids? Is he obese? That is, has he
got a big stomach bulging out in front? Does
he have high LDL cholesterol that, in part,
is related to a diet rich in saturated fat
and calories and lots of sugar, lots of carbohydrates?
Also, what’s his blood pressure? Is his
blood pressure elevated? And in fact, we are
going to then move, having taken a history,
we have found that Mr. AB has some risk factors.
He is a smoker, he has high blood pressure
and in a moment we are going to check his
lipids to see what they are. But first, we are
going to do an examination on him. When we
do the examination, as you can see, he does
have high blood pressure, at least at that
moment in the office. Often we will want him
to check some blood pressures at home to make
sure that this wasn’t just the excitement
of the office visit that caused that high
blood pressure. At least here, it’s 155-
165/ 90 mmHg. That’s markedly elevated. Remember,
the normal’s 120/80 mmHg. In an older person,
we might tolerate systolic blood pressure
up to... into the 140s, but for a man in middle
age like… like Mr. AB, this is high blood
pressure. But, in addition, when we listen
to him, we hear a systolic murmur. Now, what
are systolic murmurs? Systolic murmurs tell
us that there’s turbulent blood flow somewhere
in the cardiovascular system. In this case,
turbulent blood flow coming out of the heart.
The location of the murmur and the quality
of the murmur tells us, “Oh, I think this
man may have aortic stenosis.” As we are
going to hear in the valvular heart disease
lecture, atherosclerosis is a major cause
not only of narrowing in the blood vessels
in the heart, but it also contributes to hardening
and thickening and calcification in the aortic
valve. Remember? That’s the valve that leads
from the left ventricle out into the aorta.
And that this narrowing in the aortic valve
actually imposes a great extra workload on
the ventricle because it has to squeeze extra
hard to get blood out into the aorta. This
is a very easy-to-diagnose murmur with your
stethoscope and let me show you what it sounds
like. It sounds a little bit like this: “HOHM,
HOHM, HOHM,” as opposed to the normal person’s
heart, which is, “Lub-dub, lub-dub, lub-dub.”
In this patient, you will hear, “Lub-CHUH,
lub-CHUH, lub-CHUH.” So, you can see that
this sound is telling us there’s some obstruction
in the cardiovascular system. Aortic stenosis,
as you will learn in the valvular heart disease
lecture, is the commonest valvular heart disease.
03:28
It’s extremely common in elderly individuals
who, of course, also have a lot of atherosclerotic
disease. In addition, you also notice that
this patient has a little swelling in their
legs, so called “peripheral edema.” This
swelling is actually a sign that the cardiovascular
system is under stress and that it’s retaining
salt and water in excess of what should be
done by the body under normal conditions and
some of that excess fluid and water gets into
the legs. We will also talk, when we do the
lecture on heart failure, that sometimes that
excess fluid gets into the lungs and makes
people markedly short of breath.
04:08
So, now, we have put it all together and it
appears to us that this patient has atherosclerotic
coronary artery disease with narrowings in
the coronary arteries. He has risks for atherosclerosis,
he has symptoms that are suggestive and he
has findings on physical exam that suggest,
“Hey, maybe it’s not just narrowings in
the coronary arteries, but even a narrowing
in the aortic valve.” And so, we are going
to move on to do some confirmatory tests.
But, we have already got pretty good idea
that this is a patient with atherosclerosis,
probably with a fairly significant aortic
stenosis and he may well also have coronary
artery disease.
Well, let’s see. Okay. So, we are going
to do some… the simple tests first. We do
an electrocardiogram, we do a standard chest
x-ray and then we do an echocardiogram where
we actually can see the aortic valve. And
if the echo confirms that we are seeing some
aortic stenosis, we may even go on to do a
cardiac catheterization. If there were no
aortic stenosis, but the patient had the same
symptoms, we might do a stress test to confirm
that we are seeing lack of blood flow in
the heart during exercise. And of course,
we are going to be doing some blood tests.
05:34
We are going to be looking - is the kidney
function normal? Is the patient anemic, that
is do they have enough red blood cells? And
of course, we are going to be looking at
lipids. And in fact, when we do the lipids
in Mr. AB, no surprise, they are markedly
abnormal. You can see his total cholesterol
is elevated at 249… we like to… mg%
We like to see a value that’s under 200
mg%. You will see that he has an elevated
LDL cholesterol. Remember, we like to see
that number 70 or 80 or certainly under 100,
his is quite elevated. And he also has a low
HDL cholesterol. So, he has a low good cholesterol
and his triglycerides are a little bit slightly
elevated, but not significantly so. So, his
major issue - he has hyperlipidemia of the
type with a high LDL cholesterol and a low
HDL cholesterol, the pattern which is also
associated with the atherosclerotic process.
06:39
We, of course, have done… the other blood
tests are okay. The chest x-ray is all right,
doesn’t show us anything very exciting.
The cardiogram shows a little bit of thickening
of the left ventricle, perhaps because of
the aortic stenosis, but most important, the
echo shows us quite severe aortic stenosis
and his left ventricular ejection fraction,
that is the percentage of blood that the ventricle
squeezes out with each beat is actually low.
07:06
What’s a normal value? Somewhere between
50 and 55 percent. He’s slightly reduced
at 45%. This is not uncommon in patients with
aortic stenosis. Why? Because the ventricle
is working harder against the resistance of
the stenotic aortic valve. He also has some
hypertrophy that is some thickening of the
heart muscle. So, this confirms our initial
thinking from the office visit.
Now, of course, what are we going to do about
this? Well, we know as cardiologists that
aortic stenosis, and particularly, if there’s
aortic stenosis complicated by coronary disease,
can be a fatal condition. In fact, if untreated,
eventually, this will be fatal, and in fact,
the patient has symptoms that suggest that
he’s in a beginning of a dangerous phase
of aortic stenosis, that is he’s having angina.
08:06
He’s having lack of blood flow in the heart.
So, what do we do about it? Well, first we
would do an angiogram to look at the blood
vessels to see, do they need to be fixed at
the time of surgery? We are also going to
talk to the cardiac surgeons about replacing
his aortic valve. These days, very elderly
patients can be treated with a catheter replacement
with the valve alongside of some coronary
arteries stenting with balloon catheters.
08:37
But, most younger patients like this, will
get a surgical procedure where we can get
the maximum size cardiac valve into him and
bypass any narrowed blood vessels at the same
time.
And here you just see a little diagram showing
you where the aortic valve is - between the
left ventricle and the aorta. This is going
to be the valve that we think is diseased
and we are going to have now a conversation
with the patient in which we tell him about
the risk of aortic stenosis, that it can be
associated with sudden death, it can be associated
with gradually worsening heart failure so
that the patient is completely disabled. It
is definitely something that needs to be fixed
at this point in Mr. AB’s life before it
progresses to some terrible, catastrophic
event or severe heart failure, which may,
to some degree, be irreversible.
09:33
Here’s an autopsy specimen from a patient
who died of severe aortic stenosis. It’s
easy to see how narrow the valve is. It’s
all atherosclerotic and filled with calcium
and all you see is what we call a little “fish
mouth” - a little, tiny opening. That’s
what the left ventricle has to contend to
every time it tries to squeeze blood flow
through that narrowed valve. You can see that,
that kind of obstruction is going to be very,
very challenging to the left ventricle.
So, we then talk to Mr. AB about all of this.
10:11
We explain the procedure, you know, the angiogram.
It does show that there’s a narrowing in
the right coronary artery as well as severe
aortic stenosis. We have him talk with the
cardiac surgeons and he is sent for aortic
valve replacement and a coronary bypass in
which a vein is taken out of the leg and bypassed
around the area of narrowing in the right
coronary artery. So, at the end of the operation,
Mr. AB is going to have a well-functioning
artificial valve - a prosthetic valve, and he’s
also going to have good blood flow going down
his right coronary artery through the vein
bypass.
10:48
Just to show you a couple of pictures, here’s
a prosthetic aortic valve sewn into the aorta.
10:54
This is a typical prosthetic valve. By the
way, patients have to take warfarin - a blood
thinner, so that they don’t form clots on
those little metal struts; clots that can
embolize, for example, to the brain. And we have
already talked about the dangers of embolism
in patients with atrial fibrillation.
In addition, here’s a little diagram and
you can see a graft going onto one of the
coronary arteries. The little yellow graft
coming off of the… off of one of the branches
of the aorta and into the heart around an
area of narrowing in a coronary artery.
11:30
Well, so, our typical patient has his operation,
he gets his bypass, he gets his valve. He
does extremely well. In a healthy patient
like this, the risk of him dying with the
surgery is generally way down 1-2%. So, 98-99%
chance that he’s going to do extremely well,
get out of the hospital and return to a very
normal lifestyle. However, we are going to
make some changes in his lifestyle because
we want to decrease the chance that the atherosclerotic
process is going to continue. So, we refer
him, of course, to cardiac rehab. And cardiac
rehab, there he is given the idea that he
needs to be exercising regularly, doing aerobic
exercise, walking, treadmilling, bicycling,
swimming, doing something most days that he’s
feeling… he’s not sick with a cold or
something. We are going to talk to him about
a heart-healthy diet, which is one reduced
in saturated fats and reduced in simple carbohydrates.
For example, sugar and flour products. We are
going to talk to him about the medicines he
has to take. He has to take warfarin in order
to prevent blood clots on the valve and he’s
going to be taking some other drugs to help
control his blood pressure and his lipids
- Statin drugs, remember, from the last lecture?
So, and the cardiac rehab nurses are experts
at reinforcing all of these, both healthy
and medical interventions which will help
to prevent him from having further problems
with atherosclerosis. He’s going to need
regular blood tests to check on his lipids.
13:13
He’s going to need an occasional electrocardiogram,
particularly if he complains of irregular
heartbeats. He may need a rare chest x-ray,
an echocardiogram once in a while to make
sure that the valve is functioning okay. But
most important, what he’s going to need
is careful follow-up in which he talks to
his doctor about how he’s doing, where we
measure his blood pressure, we measure his
weight, we measure his lipids and we make
sure that he’s going to be continuing to
do well.
13:40
So, then in summary, you will notice after
the office visit, we went through some blood
tests, we went through a cardiogram and a
chest x-ray, an echocardiogram, a cardiac
catheterization. They enabled us to make the
correct diagnosis and this patient then got
the correct treatment.
Thank you very much. I look forward to speaking
with you with the next lecture.