Internal Medicine

0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

314 Chronic Bundle Branch Block Chronic Coronary Artery Disease (CAD)

complications and prognosis

■Progression of bifascicular block to complete heart block: slow.

■Syncope in the presence of bifascicular block: increased incidence

of sudden cardiac death.

Chronic Coronary Artery Disease (CAD)....................

JOEL S. KARLINER, MD

history & physical

History

■Risk factors: hypertension, abnormal lipids, smoking, diabetes, prior

MI, revascularization, obesity, family history

■Associations: peripheral vascular and cerebral vascular disease,

chronic renal disease, especially dialysis

■Complaint: chest discomfort with exertion, and/or at rest (mixed

angina)

■Squeezing, burning, substernal. Can radiate to throat, jaws, shoulder,

arm (usually left), back

■Emotion (anger) also a cause

■Anginal equivalent: exertional dyspnea due to LV ischemia

Signs & Symptoms

■May be normal. Hypertension common.

■Signs of valvular heart disease (e.g., aortic stenosis)

■Mitral insufficiency usually secondary

■Signs of CHF (see CHF chapter)

tests

■Basic blood tests

➣Hct, Hgb, smear (R/O anemia)

➣Lipid and renal panels

➣Glucose, Hgb A1C

■Basic test

➣resting ECG

■Specific Diagnostic Tests

➣Treadmill exercise test: alone or with imaging

➣If pt unable to walk, do pharmacologic imaging test (e.g., dobu-

tamine echocardiography, persantine-thallium study).

➣Gold standard: coronary angiography