cardiology review 6/3/2009. a 28 yom is evaluated for palpitations. he reports a 5 year history of...

Cardiology ReviewCardiology Review

6/3/20096/3/2009

A 28 yom is evaluated for palpitations. He reports a 5 year history of A 28 yom is evaluated for palpitations. He reports a 5 year history of palpitations. These episodes used to occur once or twice a year, but over the palpitations. These episodes used to occur once or twice a year, but over the past 6 months, he has been experiencing them on a monthly basis. He reports past 6 months, he has been experiencing them on a monthly basis. He reports that his heart starts racing suddenly for no reason, and the episode usually that his heart starts racing suddenly for no reason, and the episode usually terminates abruptly after he takes a few deep breaths. Episodes typically last 10 terminates abruptly after he takes a few deep breaths. Episodes typically last 10 to 15 minutes, although one episode last month lasted 30 minutes. He is to 15 minutes, although one episode last month lasted 30 minutes. He is otherwise healthy, denies other symptoms, and takes no medications. Results of otherwise healthy, denies other symptoms, and takes no medications. Results of his physical examination are within normal limits. A baseline EKG is obtained his physical examination are within normal limits. A baseline EKG is obtained and shown. The ECHO demonstrated a subtle anterior wall motion abnormality and shown. The ECHO demonstrated a subtle anterior wall motion abnormality but is otherwise WNL. A 24 hr holter demonstrates a narrow complex regular but is otherwise WNL. A 24 hr holter demonstrates a narrow complex regular tachycardia with rate of 205 during an episode of palpitations. tachycardia with rate of 205 during an episode of palpitations. What is the next step?What is the next step?RF ablationRF ablationmetoprololmetoprololstress teststress testverapamilverapamil

A 28 yom is evaluated for palpitations. He reports a 5 year history of A 28 yom is evaluated for palpitations. He reports a 5 year history of palpitations. These episodes used to occur once or twice a year, but over the palpitations. These episodes used to occur once or twice a year, but over the past 6 months, he has been experiencing them on a monthly basis. He reports past 6 months, he has been experiencing them on a monthly basis. He reports that his heart starts racing suddenly for no reason, and the episode usually that his heart starts racing suddenly for no reason, and the episode usually terminates abruptly after he takes a few deep breaths. Episodes typically last 10 terminates abruptly after he takes a few deep breaths. Episodes typically last 10 to 15 minutes, although one episode last month lasted 30 minnutes. He is to 15 minutes, although one episode last month lasted 30 minnutes. He is otherwise healthy, denies other symptoms, and takes no medications. Tesults of otherwise healthy, denies other symptoms, and takes no medications. Tesults of his physical examination are within normal limits. A baseline EKG is obtained his physical examination are within normal limits. A baseline EKG is obtained and shown. The EKG demonstrated a subtle anterior wall motion abnormality and shown. The EKG demonstrated a subtle anterior wall motion abnormality but is otherwise WNL. A 24 hr holter demonstrates a narrow complex regular but is otherwise WNL. A 24 hr holter demonstrates a narrow complex regular tachycardia with rate of 205 during an episode of palpitations. tachycardia with rate of 205 during an episode of palpitations. What is the next step?What is the next step?RF ablationRF ablationmetoprololmetoprololstress teststress testverapamilverapamil

WPWWPW

Short PRShort PR interval interval +delta wave+delta wave +h/o tachycardia = WPW +h/o tachycardia = WPW

Two circuits: Two circuits: 1.1. AV node AV node 2.2. retrograde accessory pathway retrograde accessory pathway

QRS in narrow since there is conduction via AV nodeQRS in narrow since there is conduction via AV node

The WMA is a result of abnormal depolarization via the accessory The WMA is a result of abnormal depolarization via the accessory pathway. pathway.

RF ablation is first lineRF ablation is first line

Avoid metoprolol, CCB, and adenosine; they blocks the AV node but not Avoid metoprolol, CCB, and adenosine; they blocks the AV node but not the accessory. the accessory.

Use ProcainamideUse Procainamide

WPW

A 45 yof is evaluated in the emergency department for palpitations. A 45 yof is evaluated in the emergency department for palpitations. She has no history of CV disease but does have a h/o intermittent She has no history of CV disease but does have a h/o intermittent palpitations. This is her first prolonged episode, and cough and strain palpitations. This is her first prolonged episode, and cough and strain maneuvers that she has used in the past to terminate the episodes maneuvers that she has used in the past to terminate the episodes have been ineffective this time. PE is unremarkable with the have been ineffective this time. PE is unremarkable with the exception of tachycardia. The BP is 110/70. EKG shown. exception of tachycardia. The BP is 110/70. EKG shown. What is the diagnosis: What is the diagnosis: AV nodal reentrant tachycardiaAV nodal reentrant tachycardiaAV reentrant tachycardiaAV reentrant tachycardiaectopic atrial tachycardiaectopic atrial tachycardiamultifocal atrial tachycardiamultifocal atrial tachycardiaa fluttera flutter

A 45 yof is evaluated in the emergency department for palpitations. She has A 45 yof is evaluated in the emergency department for palpitations. She has no history of CV disease but does have a h/o intermittent palpitations. This is no history of CV disease but does have a h/o intermittent palpitations. This is her first prolonged episdoe, and the cough and strain maneuvers that she has her first prolonged episdoe, and the cough and strain maneuvers that she has used in the past to terminate the episodes have been ineffective this time. PE used in the past to terminate the episodes have been ineffective this time. PE is unremarkable with the exception of tachycardia. The BP is 110/70. EKG is unremarkable with the exception of tachycardia. The BP is 110/70. EKG shown. shown. What is the diagnosis: What is the diagnosis: AV nodal reentrant tachycardiaAV nodal reentrant tachycardiaAV reentrant tachycardiaAV reentrant tachycardiaectopic atrial tachycardiaectopic atrial tachycardiamultifocal atrial tachycardiamultifocal atrial tachycardiaa fluttera flutter

Narrow complex tachycardia Narrow complex tachycardia

No P wavesNo P waves; buried in the QRS complex; buried in the QRS complex

Usual rate 160-180Usual rate 160-180

Tx with IV Tx with IV adenosineadenosine

Compare to: Compare to: AVRT- P waves are visible AVRT- P waves are visible MAT- irregular with 3 P wave morphologies.MAT- irregular with 3 P wave morphologies.

AVNRT

AV Nodal BlockAV Nodal Block

11stst degree: degree: prolonged PRprolonged PR Look for drug effect (dig, beta blocker, CCB)Look for drug effect (dig, beta blocker, CCB)

22ndnd degree: degree: Mobitz I: PR progressively lengthens, then a dropped beatMobitz I: PR progressively lengthens, then a dropped beat Mobitz II: Intermittent non-conducted beatsMobitz II: Intermittent non-conducted beats

33rdrd degree: complete dissociation degree: complete dissociation PM: asymptomatic Mobitz II and complete block.PM: asymptomatic Mobitz II and complete block.

TorsadesTorsades

Atypical VtachAtypical Vtach Look for hypoK or hypoMgLook for hypoK or hypoMg Worse prognosis than V tachWorse prognosis than V tach Management is different from other VTsManagement is different from other VTs

Avoid Class I, Ic or III antiarrhythmics (prolong QT)Avoid Class I, Ic or III antiarrhythmics (prolong QT) Give Magnesium acutelyGive Magnesium acutely

Things that cause torsades: arsenic, ciapride, Things that cause torsades: arsenic, ciapride, droperidol, Li, methadone, droperidol, Li, methadone, fluoroquinolonesfluoroquinolones

A 79 yof is seen for an annual examination. She is in good health except for osteopenia, for A 79 yof is seen for an annual examination. She is in good health except for osteopenia, for which she takes Ca and VitD supplements. She walks regularly to and from the bus stop which she takes Ca and VitD supplements. She walks regularly to and from the bus stop several times per week. It now takes her 25 min to get to the bus stop; whereas it only took several times per week. It now takes her 25 min to get to the bus stop; whereas it only took her 10 min a year ago. She describes dyspnea midway in her walk, causing her to stop and her 10 min a year ago. She describes dyspnea midway in her walk, causing her to stop and catch her breath. She denies angina, presyncope, syncope or pedal edema. PE: HR 80, BP catch her breath. She denies angina, presyncope, syncope or pedal edema. PE: HR 80, BP 165/86. Lungs CTAB, carotid upstrokes delayed. S1 nl, single S2, and S4. Grade 3/6 late 165/86. Lungs CTAB, carotid upstrokes delayed. S1 nl, single S2, and S4. Grade 3/6 late peaking systolic murmur at R 2nd intercostal, radiates to R carotid. TTE with concentric peaking systolic murmur at R 2nd intercostal, radiates to R carotid. TTE with concentric LVH. EF 69%, no WMA. Trileaflet AV with heavy calcification, aortic jet 4.8/ m/sec, peak LVH. EF 69%, no WMA. Trileaflet AV with heavy calcification, aortic jet 4.8/ m/sec, peak transaortic gradient of 92, valve area of 0.7 cm2. transaortic gradient of 92, valve area of 0.7 cm2.

What will improve her quality of life?What will improve her quality of life?Begin ACEIBegin ACEIPercutaneous aortic balloon valvuloplastyPercutaneous aortic balloon valvuloplastyAVRAVRCardiac rehabCardiac rehabStop Calcium supplementStop Calcium supplement

ASASA 79 yof is seen for an annual examination. She is in good health except for osteopenia, for A 79 yof is seen for an annual examination. She is in good health except for osteopenia, for which she takes Ca and VitD supplements. She walks regularly to and from the bus stop which she takes Ca and VitD supplements. She walks regularly to and from the bus stop several times per week. It takes her 25 mimn to get to the bus stop whereas it only took her 10 several times per week. It takes her 25 mimn to get to the bus stop whereas it only took her 10 min a year ago. She describes dyspnea midway in her walk, causing her to stop and catch her min a year ago. She describes dyspnea midway in her walk, causing her to stop and catch her breath. She denies angina, presyncope, syncope or pedal edema. PE: HR 80, BP 165/86. breath. She denies angina, presyncope, syncope or pedal edema. PE: HR 80, BP 165/86. Lungs CTAB, carotid upstrokes delayed. S1 nl, single S2, and S4. Grade 3/6 late peaking Lungs CTAB, carotid upstrokes delayed. S1 nl, single S2, and S4. Grade 3/6 late peaking systolic murmur at R 2nd intercostal, radiates to R carotid. TTE with concentric LVH. EF systolic murmur at R 2nd intercostal, radiates to R carotid. TTE with concentric LVH. EF 69%, no WMA. Trileaflet AV with heavy calcification, aortic jet 4.8/ m/sec, peak transaortic 69%, no WMA. Trileaflet AV with heavy calcification, aortic jet 4.8/ m/sec, peak transaortic gradient of 92, valve area of 0.7 cm2. gradient of 92, valve area of 0.7 cm2.

What will improve quality of life?What will improve quality of life?Begin ACEIBegin ACEIPercutaneous aortic balloon valvuloplastyPercutaneous aortic balloon valvuloplastyAVRAVRCardiac rehabCardiac rehabStop Calcium supplementStop Calcium supplement

Severe AS: valve area below 0.8Severe AS: valve area below 0.8Most common cause: progressive valvular CaMost common cause: progressive valvular CaInitial compensatory mechanism is myocardial hypertrophyInitial compensatory mechanism is myocardial hypertrophy

Indication for AVR: Indication for AVR: onset of cardiac symptomsonset of cardiac symptoms NOT prophylactically NOT prophylactically

Triad of symptomsTriad of symptoms: : AnginaAngina CHFCHF SyncopeSyncope

ACEIs contraindicated: afterload reduction may increase effective pressure ACEIs contraindicated: afterload reduction may increase effective pressure gradient across stenotic valve. gradient across stenotic valve.

Aortic Stenosis

SoundsSounds ManeuversManeuvers OtherOther

Mitral Mitral StenosisStenosis

Opening snapOpening snap following following S2 on LSB or apex. S2 on LSB or apex. Middiastolic rumbleMiddiastolic rumble. .

Loudest after exercise. Loudest after exercise. RADRAD, negative biphasic , negative biphasic P in V1P in V1

Mitral RegurgMitral Regurg Holosystolic, blowingHolosystolic, blowing, , over PMI, radiates to L over PMI, radiates to L axillaaxilla

LAD, LVH, LAD, LVH,

Aortic Aortic stenosisstenosis

Harsh, Harsh, crescendo/decrescendocrescendo/decrescendo, , at R 2at R 2ndnd intercostal intercostal

Paradoxical splitting of Paradoxical splitting of S2S2, , radiates to carotidsradiates to carotids with slow upstoke, with slow upstoke, louder with squatting or louder with squatting or expiration.expiration.

LVHLVH

Aortic regurgAortic regurg Faint, blowing between Faint, blowing between S2 and S1, S2 and S1, diastolicdiastolic, at , at LSB 3/4LSB 3/4thth intercostal intercostal

Wide pulse pressure, Wide pulse pressure, prominent carotid prominent carotid pulsespulses. .

LVHLVH

VSDVSD Holosystolic at LLSBHolosystolic at LLSB Louder with handgripLouder with handgrip

ASDASD Fixed split S2Fixed split S2 Primum: LAD, RBBBPrimum: LAD, RBBB

Secundum: RAD, RBBBSecundum: RAD, RBBB

Primum needs Abx Primum needs Abx prophyprophy

Primum may have AV Primum may have AV blockblock

Murmurs

42 yof with recent onset of exertional dyspnea and occasional palpitations. 42 yof with recent onset of exertional dyspnea and occasional palpitations. She has been told for many years that she has a heart murmur. PE: BP 129/78 She has been told for many years that she has a heart murmur. PE: BP 129/78 in both upper extremities, JVP elevated with both a and v waves. Apical pulse in both upper extremities, JVP elevated with both a and v waves. Apical pulse unremarkable. Parasternal impulse present. 2/6 midsystolic murmur noted at unremarkable. Parasternal impulse present. 2/6 midsystolic murmur noted at 2nd L intercostal and 2/6 holosystolic murmur at the apex and L sternal 2nd L intercostal and 2/6 holosystolic murmur at the apex and L sternal border. Fixes splitting of S2. border. Fixes splitting of S2. Which is the most likely cause of the symptoms?Which is the most likely cause of the symptoms?secundum atrial septal defectsecundum atrial septal defectprimum atrial septal defectprimum atrial septal defectPFOPFOsinus venosus atrial septal defectsinus venosus atrial septal defect

ASD ASD

42 yof with recent onset of exertional dyspnea and occasional palpitations. 42 yof with recent onset of exertional dyspnea and occasional palpitations. She has been told for many years that she has a heart murmur. PE: BP She has been told for many years that she has a heart murmur. PE: BP 1269/78 in both upper extremities, JVP elevated with both a and v waves. 1269/78 in both upper extremities, JVP elevated with both a and v waves. Apical pulse unremarkable. Parasternal impulse present. 2/6 midsystilic Apical pulse unremarkable. Parasternal impulse present. 2/6 midsystilic murmur noted at 2nd L intercostal and 2/6 holosystolic murmur at the apex murmur noted at 2nd L intercostal and 2/6 holosystolic murmur at the apex and L sternal border. Fixes splitting of S2. and L sternal border. Fixes splitting of S2. Which is the most likely cause of the symptoms?Which is the most likely cause of the symptoms?secundum atrial septal defectsecundum atrial septal defectprimum atrial septal defectprimum atrial septal defectPFOPFOsinus venosus atrial septal defectsinus venosus atrial septal defect

Fixed splitting of S2: hallmark of ASDFixed splitting of S2: hallmark of ASD

Exam:Exam: Parasternal impulse: R sided cardiac enlargement (also seen on CXR)Parasternal impulse: R sided cardiac enlargement (also seen on CXR) Systolic murmur at the apex: mitral regurgSystolic murmur at the apex: mitral regurg L sternal border: TVRL sternal border: TVR midsystolic murmur: flow across the pulmonary valve. midsystolic murmur: flow across the pulmonary valve.

EKG shows first degree AV vlock and LAD= primumEKG shows first degree AV vlock and LAD= primum

PE for PFO is normalPE for PFO is normal

Why does this matter: Secundum and PFO can be treated with percutaneous Why does this matter: Secundum and PFO can be treated with percutaneous

devices.devices.

ASD

69 yom is evaluated in the ED for acute onset of substernal CP radiating to the 69 yom is evaluated in the ED for acute onset of substernal CP radiating to the L arm. Former smoker and PMH of HTN. PE 210/95 R arm, 164/56 L arm, L arm. Former smoker and PMH of HTN. PE 210/95 R arm, 164/56 L arm, HR 90, RR 20, dullness half way up the R posterior thorax, 2/6 diastolic HR 90, RR 20, dullness half way up the R posterior thorax, 2/6 diastolic murmur at RUSB, EKG with NSR, 2-3 mm inferior ST segment elevation. murmur at RUSB, EKG with NSR, 2-3 mm inferior ST segment elevation.

What is the most appropriate med to administer?What is the most appropriate med to administer? ASAASAIV heparinIV heparinThrombolyticThrombolyticBeta blockerBeta blockerACEIACEI

DissectionDissection69 yom is evaluated in the ED for acute onset of substernal CP radiating to the 69 yom is evaluated in the ED for acute onset of substernal CP radiating to the L arm. Former smoker and PMH of HTN. PE 210/95 R arm, 164/56 L arm, L arm. Former smoker and PMH of HTN. PE 210/95 R arm, 164/56 L arm, HR 90, RR 20, dullness half way up the R posterior thorax, 2/6 diastolic HR 90, RR 20, dullness half way up the R posterior thorax, 2/6 diastolic murmur at RUSB, EKG with NSR, 2-3 mm inferior ST segment elevation. murmur at RUSB, EKG with NSR, 2-3 mm inferior ST segment elevation.

What is the most appropriate med to administer?What is the most appropriate med to administer? ASAASAIV heparinIV heparinThrombolyticThrombolyticBeta BlockerBeta BlockerACEIACEI

Disparate blood pressuresDisparate blood pressures + diastolic murmur of AR + diastolic murmur of AR= acute ascending aortic dissection (involves the AV)= acute ascending aortic dissection (involves the AV)

Dullness in R lung = hemothorax (complication of dissection) Dullness in R lung = hemothorax (complication of dissection)

RCA is the most common involvedRCA is the most common involved coronary with dissection, coronary with dissection, ischemia (STEMI). ischemia (STEMI).

Initial TreatmentInitial Treatment beta blockadebeta blockade (decrease shear stress) (decrease shear stress) Start BB before afterload reduction. Start BB before afterload reduction.

Avoid: ASA, heparin, thrombolyticsAvoid: ASA, heparin, thrombolytics Increased risk of: periaortic hemorrhage, aortic rupture, and cardiac tamponade Increased risk of: periaortic hemorrhage, aortic rupture, and cardiac tamponade

Studies: TEE, chest CT with contrast, contrasted MR. Studies: TEE, chest CT with contrast, contrasted MR.

Aortic Dissection

A 68 yom is evaluated in the ED for chest pain that has lasted 90 min. He was A 68 yom is evaluated in the ED for chest pain that has lasted 90 min. He was eating when he developed sudden onset of sharp precordial pain radiating eating when he developed sudden onset of sharp precordial pain radiating toward both shoulders and back. The pain is 9/10. PMH for HTN and toward both shoulders and back. The pain is 9/10. PMH for HTN and dyslipidemia. PE: HR 90, RR 19 BP 110/60, O2 sat 94% on RA. Lungs: dyslipidemia. PE: HR 90, RR 19 BP 110/60, O2 sat 94% on RA. Lungs: bibasilar crackles. Heart sounds distant, nl S1, S2, no S4 or S3. 3/6 diastolic bibasilar crackles. Heart sounds distant, nl S1, S2, no S4 or S3. 3/6 diastolic murmur at the RUSB, radiates across L precordium. No abdominal bruits. murmur at the RUSB, radiates across L precordium. No abdominal bruits. Trace pedal edema. P CXR with prominent thoracic aorta and widening of the Trace pedal edema. P CXR with prominent thoracic aorta and widening of the mediastinum. mediastinum. Next step?Next step?cathcathfibrinolytic therapyfibrinolytic therapyVQ scanVQ scanCT chestCT chestballoon pumpballoon pump

Aortic dissection with ARAortic dissection with ARA 68 yom is evaluated in the ED for chest pain that has lasted 90 min. He was A 68 yom is evaluated in the ED for chest pain that has lasted 90 min. He was eating when he developed sudden onset of sharp precordial pain radiating eating when he developed sudden onset of sharp precordial pain radiating toward both shoulders and back. The pain is 9/10. PMH for HTN and toward both shoulders and back. The pain is 9/10. PMH for HTN and dyslipidemia. PE: HR 90, RR 19 BP 110/60, O2 sat 94% on RA. Lungs: dyslipidemia. PE: HR 90, RR 19 BP 110/60, O2 sat 94% on RA. Lungs: bibasilar crackles. Heart sounds distant, nl S1, S2, no S4 or S3. 3/6 diastolic bibasilar crackles. Heart sounds distant, nl S1, S2, no S4 or S3. 3/6 diastolic murmur at the RUSB, radiates across L precordium. No abdominal bruits. murmur at the RUSB, radiates across L precordium. No abdominal bruits. Trace pedal edema. P CXR with prominent thoracic aorta and widening of the Trace pedal edema. P CXR with prominent thoracic aorta and widening of the mediastinum. mediastinum. Next step?Next step?cathcathfibrinolytic therapyfibrinolytic therapyVQ scanVQ scanCT chestCT chestballoon pump – balloon pump – This would exacerbate the acute ARThis would exacerbate the acute AR

Aortic Regurg: Diastolic murmurAortic Regurg: Diastolic murmur

Risk Factors: Risk Factors: age age HTN HTN bicuspid aortic valvebicuspid aortic valve CoarctationsCoarctations 33rdrd trimester pregnancy and Marfans) trimester pregnancy and Marfans)

Possible imaging include: Possible imaging include: CT chest with contrastCT chest with contrast MRI with contrastMRI with contrast TEETEE

Complications: Complications: MI from anterograde propogation, MI from anterograde propogation, TamponadeTamponade limb ischemia (if great vessels involved)limb ischemia (if great vessels involved) aortic ruptureaortic rupture

Ascending Dissection with Acute AR

Ascending vs DescendingAscending vs Descending

Ascending dissections are high risk for complications. Ascending dissections are high risk for complications. Do not pass go, instead… go directly to surgery. Do not pass go, instead… go directly to surgery.

Descending dissections treat medically (Beta Blockers Descending dissections treat medically (Beta Blockers and nitroprusside-if needed), and if pain persists, it is and nitroprusside-if needed), and if pain persists, it is due to extension of dissection, then go to surgery. due to extension of dissection, then go to surgery.

Even with repair mortality is 26%, without 55%Even with repair mortality is 26%, without 55%

AAAAAA

Screen all men with smoking hx after Screen all men with smoking hx after age 65 (medicare pays for this)age 65 (medicare pays for this)

AAA, DM are both CAD equivalentsAAA, DM are both CAD equivalents Surgery Surgery

Men >5 cmMen >5 cm Women >4.5Women >4.5 Marfans >4.5 Marfans >4.5 expands more than 0.5/yearexpands more than 0.5/year

64 yof presents 6 hrs after onset of severe crushing chest pain associated with 64 yof presents 6 hrs after onset of severe crushing chest pain associated with diaphoresis, n/v. She has a h/o mild hyperlipidemia, meds include atorvastatin diaphoresis, n/v. She has a h/o mild hyperlipidemia, meds include atorvastatin and ASA. BP 140/88, HR 88, lungs clear, no murmurs, abd and extremities and ASA. BP 140/88, HR 88, lungs clear, no murmurs, abd and extremities normal. EKG 3 mm ST elevation in leads II, III, and aVF, occasional PVCs. normal. EKG 3 mm ST elevation in leads II, III, and aVF, occasional PVCs. No cath lab facilities are present, fibrinolytics are given and transferred to No cath lab facilities are present, fibrinolytics are given and transferred to ICU. CP resolves. 2 episodes of 6-10 beats of Vtach noted with stable ICU. CP resolves. 2 episodes of 6-10 beats of Vtach noted with stable hemodynamics. EKG now shows <0.5 mV ST segment elevation. hemodynamics. EKG now shows <0.5 mV ST segment elevation.

In addition to heparin ans ASA, which is the next appropriate step?In addition to heparin ans ASA, which is the next appropriate step? CathCathPlavixPlavixBeta blockerBeta blockeramiodaroneamiodaroneDSEDSE

64 yow presents 6 hrs after onset of severe crushing chest pain associated with 64 yow presents 6 hrs after onset of severe crushing chest pain associated with diaphoresis, n/v. She has a h/o mild hyperlipidemia, meds in clude diaphoresis, n/v. She has a h/o mild hyperlipidemia, meds in clude atorvastatin and ASA. BP 140/88, HR 88, lungs clear, no murmurs, abd and atorvastatin and ASA. BP 140/88, HR 88, lungs clear, no murmurs, abd and extremities normal. EKG 3 mm ST elevation in leads II, III, and aVF, extremities normal. EKG 3 mm ST elevation in leads II, III, and aVF, occasional PVCs. No cath lab facilities are present, fibrinolytics are given and occasional PVCs. No cath lab facilities are present, fibrinolytics are given and transferred to ICU. CP resolves. 2 episodes of 6-10 beats of Vtaqch noted transferred to ICU. CP resolves. 2 episodes of 6-10 beats of Vtaqch noted with stable hemodynamics. EKG now shows <0.5 mV ST segment elevation. with stable hemodynamics. EKG now shows <0.5 mV ST segment elevation.

In addition to heparin ans ASA, which is the next appropriate step?In addition to heparin ans ASA, which is the next appropriate step? CathCathPlavixPlavixBeta blockerBeta blockeramiodaroneamiodaroneDSEDSE

Medical management After MI: Medical management After MI: ASAASA beta blockersbeta blockers ACEIACEI StatinStatin

Reperfusion arrhythmias usu do not require additional Reperfusion arrhythmias usu do not require additional antiarrhythmic therapy. antiarrhythmic therapy.

Immediate cath after STEMI for:Immediate cath after STEMI for: recurrent ischemiarecurrent ischemia persistent ST elevationpersistent ST elevation hemodynamic instabilityhemodynamic instability CHFCHF

Inferior STEMI

ACS Treatment for the ACS Treatment for the BoardsBoards

ASAASA Plavix (with, or prior to, PCI- CURE trial), Plavix (with, or prior to, PCI- CURE trial), Lovenox (more effective than heparin)Lovenox (more effective than heparin) beta blockerbeta blocker ACEIACEI IIbIIIa for PCI but NOT without PCIIIbIIIa for PCI but NOT without PCI StatinStatin smoking cessation. smoking cessation.

78 yom brought to the ED for malaise, fatigue and mild dyspnea on exertion. 78 yom brought to the ED for malaise, fatigue and mild dyspnea on exertion. Intermittent CP for 5 days, with the most severe episode 2 days ago. Pain free Intermittent CP for 5 days, with the most severe episode 2 days ago. Pain free since then. PMH: HTN, DM type 2, meds: ACEI and metformin. BP 112/82, since then. PMH: HTN, DM type 2, meds: ACEI and metformin. BP 112/82, HR 92, JVP is 5 mmHg, no carotid bruits, lungs clear. CV nl S1/S2, 2/6 HR 92, JVP is 5 mmHg, no carotid bruits, lungs clear. CV nl S1/S2, 2/6 holosystoloic murmur at apex to axilla, diminished leg pulses, no edema. holosystoloic murmur at apex to axilla, diminished leg pulses, no edema. EKG with sinus tach, Q waves in V1-4. Renal fn and Hct are normal. CK EKG with sinus tach, Q waves in V1-4. Renal fn and Hct are normal. CK 120, Troponin 6.8. CXR with mild pulmonary edema. Pt is started on 120, Troponin 6.8. CXR with mild pulmonary edema. Pt is started on lovenox and ASA. lovenox and ASA. Next appropriate therapeutic approach is?Next appropriate therapeutic approach is?plavixplavixglycoprotein receptor blockerglycoprotein receptor blockerfibrinolysisfibrinolysisurgent cathurgent cathbeta blockerbeta blocker

Anterior STEMIAnterior STEMI

78 yom brought to the ED for malaise, fatigue and mild dyspnea on exertion. 78 yom brought to the ED for malaise, fatigue and mild dyspnea on exertion. Intermittent Cp for 5 days, most severe episode 2 days ago. Pain free since Intermittent Cp for 5 days, most severe episode 2 days ago. Pain free since then. PMH: HTN, DM type 2, meds: ACEI and metformin. BP 112/82, HR then. PMH: HTN, DM type 2, meds: ACEI and metformin. BP 112/82, HR 92, JVP is 5 mmHg, no carotid bruits, lungs clear. CV nl S1/S2, 2/6 92, JVP is 5 mmHg, no carotid bruits, lungs clear. CV nl S1/S2, 2/6 holosystoloic murmur at apex to axilla, diminished leg pulses, no edema. holosystoloic murmur at apex to axilla, diminished leg pulses, no edema. EKG with sinus tach, Q waves in V1-4. Renal fn and Hct are normal. CK EKG with sinus tach, Q waves in V1-4. Renal fn and Hct are normal. CK 120, Troponin 6.8. CXR with mild pulmonary edema. Pt is started on 120, Troponin 6.8. CXR with mild pulmonary edema. Pt is started on lovenox and ASA. lovenox and ASA. Next appropriate therapeutic approach is?Next appropriate therapeutic approach is?plavixplavixglycoprotein receptor blockerglycoprotein receptor blockerfibrinolysisfibrinolysisurgent cathurgent cathbeta blockerbeta blocker

Beta Blockers are always a good answer.Beta Blockers are always a good answer.Unless signs of persistent ischemia, cath is not urgently indicated.Unless signs of persistent ischemia, cath is not urgently indicated.Late fibrinolysis not beneficialLate fibrinolysis not beneficial, and increases risk of hemorrhage in the , and increases risk of hemorrhage in the infarcted zone. infarcted zone. No benefit of plavix added to ASA if there are no plans on PCINo benefit of plavix added to ASA if there are no plans on PCI

IIbIIIaIIbIIIa is indicated for patients who are is indicated for patients who are going to cath/PCIgoing to cath/PCI, if there are high , if there are high risk factors such as: risk factors such as: TIMI>3TIMI>3 elevated troponinelevated troponin ongoing ischemiaongoing ischemia new ST changesnew ST changes CHF or DMCHF or DM hemodynamic instabilityhemodynamic instability PCI within the past 6 monthsPCI within the past 6 months

Anterior STEMI

42 yom evaluated in Halifax Regional for L shoulder chest pain that radiates to 42 yom evaluated in Halifax Regional for L shoulder chest pain that radiates to the jaw, associated with diaphoresis and mild dyspnea. No PMH, no meds. the jaw, associated with diaphoresis and mild dyspnea. No PMH, no meds. FH of CAD in first degree relatives. ED administered IV heparin, atenolol, FH of CAD in first degree relatives. ED administered IV heparin, atenolol, ASA. BP 100/79, HR 61, no JVD, no carotid bruits, lungs clear, nl S1/S2, no ASA. BP 100/79, HR 61, no JVD, no carotid bruits, lungs clear, nl S1/S2, no murmurs. Abd and extremities wnl. No cath lab at the OSH, UNC is 62 miles murmurs. Abd and extremities wnl. No cath lab at the OSH, UNC is 62 miles away, and will take 2 hours. away, and will take 2 hours. Before transfer you should give…..Before transfer you should give…..2b3a receptor blocker2b3a receptor blockerplavixplavixesmololesmololfibrinolytic therapyfibrinolytic therapyNTGNTG

STEMI with no Cath LabSTEMI with no Cath Lab

42 yom evaluated in rural ED for L shoulder chest pain that radiates to the 42 yom evaluated in rural ED for L shoulder chest pain that radiates to the jaw, associated with diaphoresis and mild dyspnea. No PMH, no meds. FH of jaw, associated with diaphoresis and mild dyspnea. No PMH, no meds. FH of CAD in first degree relatives. ED administered IV heparin, atenolol, ASA. CAD in first degree relatives. ED administered IV heparin, atenolol, ASA. BP 100/79, HR 61, no JVD, no carotid bruits, lungs clear, nl S1/S2, no BP 100/79, HR 61, no JVD, no carotid bruits, lungs clear, nl S1/S2, no murmurs. Abd and extremities wnl. No cath lab at the OSH, UNC is 62 miles murmurs. Abd and extremities wnl. No cath lab at the OSH, UNC is 62 miles away, and will take 2 hours. away, and will take 2 hours. Before transfer you should give…..Before transfer you should give…..2b3a receptor blocker2b3a receptor blockerplavixplavixesmololesmololfibrinolytic therapyfibrinolytic therapyNTGNTG

The best answer is always CATHThe best answer is always CATHSecond best is FIBRINOLYSISSecond best is FIBRINOLYSIS

FibrinolysisFibrinolysis Given within 30 minutes of arrival to EDGiven within 30 minutes of arrival to ED DO NOT give if >12 hours after onset of symptoms and asymptomatic (this DO NOT give if >12 hours after onset of symptoms and asymptomatic (this

pt is less than 12 hours)pt is less than 12 hours)

Contraindications: Contraindications: recent surgeryrecent surgery CVACVA BleedingBleeding uncontrolled HTNuncontrolled HTN PUDPUD cardiogenic shock cardiogenic shock

STEMI and Fibrinolytics

68 yom seen 14 hrs after onset of substernal CP that lasted for 2 hrs. 6 hrs 68 yom seen 14 hrs after onset of substernal CP that lasted for 2 hrs. 6 hrs prior to presentation he experienced 2 additional shorter episodes of CP, each prior to presentation he experienced 2 additional shorter episodes of CP, each 10 min in duration. CP associated with diaphoresis, no dyspnea, palpitations, 10 min in duration. CP associated with diaphoresis, no dyspnea, palpitations, or dizziness. H/o HTN, DM, active smoker 40 pack year hx. Home meds: or dizziness. H/o HTN, DM, active smoker 40 pack year hx. Home meds: ASA, norvasc, metoprolol and glyburide. PE: normotensive, NAD, enlarged ASA, norvasc, metoprolol and glyburide. PE: normotensive, NAD, enlarged PMI. CK and troponins elevated, EKG with small R waves in V1-3, PMI. CK and troponins elevated, EKG with small R waves in V1-3, unchanged by day 3 of hospitalization. ECHO with severe hypokinetic LV unchanged by day 3 of hospitalization. ECHO with severe hypokinetic LV anterior wall, moderate hypokinesis of the inferior wall and LVEF 38%. anterior wall, moderate hypokinesis of the inferior wall and LVEF 38%. Current meds: metoprolol, asa, NTG, plavix, lipitor, lisinopril, heparin. What Current meds: metoprolol, asa, NTG, plavix, lipitor, lisinopril, heparin. What is the most appropriate evaluation prior to discharge?is the most appropriate evaluation prior to discharge? 24 hr EKG24 hr EKGlow level treadmill stress testlow level treadmill stress testdobutamine viability studydobutamine viability studycathcath

Patient did not get revascularization or thrombolytics. By ECHO pt has Patient did not get revascularization or thrombolytics. By ECHO pt has decreased EF and 2 areas of WMA with TIMI 5decreased EF and 2 areas of WMA with TIMI 5

High risk factors for complications after MI:High risk factors for complications after MI: Multivessel CADMultivessel CAD anterior MIanterior MI EF <40%EF <40% CHFCHF recurrent ischemiarecurrent ischemia

Never subject a high risk pt to stress testing even if submaximal stress.Never subject a high risk pt to stress testing even if submaximal stress.

>12 Hours out from an Anterior MI

Post-MI complicationsPost-MI complications1. Recurrent ischemia: 1/3 of patients, and more common in NSTEMI

rather than STEMI. 2. Arrhythmias: bradycardia, SVT/atrial fibrillation, ventricular

arrhythmias (mostly in the first few hours), AV block, 3. CHF4. Myocardial rupture: rupture of the LV, 1% of pts, 2-7 days

(pseudoaneurysm- rupture sealed by pericardium)5. LV aneursym: from scar, predisposed to CHF, thrombus, and

arrhythmias6. Papillary muscle rupture: posteromedial papillary muscle is more

common b/c single blood supply from RCA. Classic case: inferior MI, later becomes hypotensive, large V waves in PA wedge tracing, new holosytolic murmur at the apex.

7. Mural thrombi (in anterior and apical STEMI)8. pericarditis

45 yom brought by EMS for severe CP. Pain similar to prior episode when he 45 yom brought by EMS for severe CP. Pain similar to prior episode when he underwent angioplasty 8 m ago. H/O HTN, on beta blocker, also takes ASA underwent angioplasty 8 m ago. H/O HTN, on beta blocker, also takes ASA 81 mg q day. Nl serum CH and no h/o DM, DOE or claudication. PE: BP 81 mg q day. Nl serum CH and no h/o DM, DOE or claudication. PE: BP 90/60, HR 59, no JVD, no bruits, lungs clear, Nl S1, S2. S4 present with 1/6 90/60, HR 59, no JVD, no bruits, lungs clear, Nl S1, S2. S4 present with 1/6 SEM at LSB, nonradiating. Abd and extremities nl. EKG with ST depression SEM at LSB, nonradiating. Abd and extremities nl. EKG with ST depression in II, III, and aVF. Admitted and placed on plavix, nitrates, and lovenox. in II, III, and aVF. Admitted and placed on plavix, nitrates, and lovenox. Troponin 0.8 (nl <0.5). Troponin 0.8 (nl <0.5).

What is the next appropriate step?What is the next appropriate step? HeparinHeparinesmololesmololabciximababciximabNTGNTG

USAUSA45 yom brought by EMS for severe CP. Pain similar to prior episode when he 45 yom brought by EMS for severe CP. Pain similar to prior episode when he underwent angioplasty 8 m ago. H/O HTN, on beta blocker, also takes ASA underwent angioplasty 8 m ago. H/O HTN, on beta blocker, also takes ASA 81 mg q day. Nl serum CH and no h/o DM, DOE or claudication. PE: BP 81 mg q day. Nl serum CH and no h/o DM, DOE or claudication. PE: BP 90/60, HR 59, no JVD, no bruits, lungs clear, Nl S1, S2. S4 present with 1/6 90/60, HR 59, no JVD, no bruits, lungs clear, Nl S1, S2. S4 present with 1/6 SEM at LSB, nonradiating. Abd and extremities nl. EKG with ST depression SEM at LSB, nonradiating. Abd and extremities nl. EKG with ST depression in II, III, and aVF. Admitted and placed on plavix, nitrates, and lovenox. in II, III, and aVF. Admitted and placed on plavix, nitrates, and lovenox. Troponin 0.8 (nl <0.5). Troponin 0.8 (nl <0.5).

What is the next appropriate step?What is the next appropriate step? HeparinHeparinesmololesmololabciximababciximabNTGNTG

IIbIIIa:IIbIIIa: beneficial with pts going to PCIbeneficial with pts going to PCI associated with increased mortality for those not going to PCIassociated with increased mortality for those not going to PCI

Who should get it:Who should get it: TIMI >3TIMI >3 recurrent anginarecurrent angina elevated troponinelevated troponin new ST depressionsnew ST depressions prior CABGprior CABG percutaneous intervention within 6 monthspercutaneous intervention within 6 months VTachVTach hemodynamic instabilityhemodynamic instability

Plavix is also indicated, but usually held if going to cath in case CABG Plavix is also indicated, but usually held if going to cath in case CABG needed. needed.

USA and NSTEMI

49 yom presents to the ED with mild chest discomfort, with nausea and 49 yom presents to the ED with mild chest discomfort, with nausea and dyspnea for 2 hours. No relief with antacids. No PMH, no meds. Older dyspnea for 2 hours. No relief with antacids. No PMH, no meds. Older brother with an MI 9 months earlier, father with CABG 12 years ago. BP brother with an MI 9 months earlier, father with CABG 12 years ago. BP 109/78, HR 88, no jvd, no carotid bruits, nl S1/S2, no m/r/g, lungs, abd, 109/78, HR 88, no jvd, no carotid bruits, nl S1/S2, no m/r/g, lungs, abd, extremities wnl. Troponin of 6. EKG with 1mV ST elevation in II, III and extremities wnl. Troponin of 6. EKG with 1mV ST elevation in II, III and aVF. Started on lovenox, asa, metoprolol, and IIbIIIa, and sent to cath. DES aVF. Started on lovenox, asa, metoprolol, and IIbIIIa, and sent to cath. DES placed in subtotally occluded RCA. ECHO on d#2 shows nl LV, no MR, no placed in subtotally occluded RCA. ECHO on d#2 shows nl LV, no MR, no effusion. D#4 no complications, and plan on d/c. effusion. D#4 no complications, and plan on d/c.

In addition to ASA, plavix, and metoprolol what should be given?In addition to ASA, plavix, and metoprolol what should be given?LipitorLipitorlisinoprillisinoprilwarfarinwarfarinniacinniacin

Statins are given regardless of cholesterol level after Statins are given regardless of cholesterol level after MI because they reduce late CV events. MI because they reduce late CV events.

PROVE-IT TIMI 22: showed high dose atorvastatin PROVE-IT TIMI 22: showed high dose atorvastatin 80 was superior to pravastatin 40 with80 was superior to pravastatin 40 with a a 16% 16% reduction of a composite endpoint.reduction of a composite endpoint.

DyslipidemiaDyslipidemia

Develop more side Develop more side effects on statins effects on statins when you are when you are concurrently on concurrently on fibrates or niacin. fibrates or niacin.

Goals: ATP III-R 2005Goals: ATP III-R 2005 RF: tobacco, HTN, RF: tobacco, HTN,

Family history, AGE Family history, AGE (men>45, women (men>45, women >55)>55)

LDL LDL goalgoal

NonHDNonHDL goalL goal

CAD or CAD or equivelequivelent ent (DM)(DM)

<70<70 <130<130

2+ RF2+ RF <100<100 <160<160

0-1 RF0-1 RF <130<130 <190<190

23 yof is brought to the ED after a witnessed syncopal event. The patient reports having been at church where she DFO, after standing for 45 minutes. She noted feeling sweaty and lightheaded and seeing spots. She was aware of the sensation of her heart beating and then developed LOC. After the fall, witnessed said she had a thready pulse and urinary incontinence. She regained consciousness within 3 minutes.

Which of the following aspects of the hx is not consistent with neurocardiogenic syncope?Urinary incontinenceProdrome of seeing spots, diaphoresis and lightheadednessThready pulseNone of the above

Neurocardiogenic syncopeNeurocardiogenic syncope vasovagalvasovagal and and vasodepressorvasodepressor: :

Lose of sympathetic tone with vasodilation. Lose of sympathetic tone with vasodilation. with vasovagal there is bradycardia (due to increased vagal tone)with vasovagal there is bradycardia (due to increased vagal tone)

Look for Look for situational stressorssituational stressors: hot, crowded spaces, stressful : hot, crowded spaces, stressful environment, long period of standing, hunger, pain.environment, long period of standing, hunger, pain.

ProdromeProdrome: : light-headednesslight-headedness DiaphoresisDiaphoresis NauseaNausea WeaknessWeakness visual changesvisual changes pallorpallor

Incontinence suggests seizureIncontinence suggests seizure

Cardiogenic syncopeCardiogenic syncope

Arrhythmia: Bradyarrhythmia, ventricular Arrhythmia: Bradyarrhythmia, ventricular arrhythmia or V fib, AV node blockarrhythmia or V fib, AV node block

Mechanical: Aortic valve (AS) or HOCMMechanical: Aortic valve (AS) or HOCM Absence of premonitory symptoms, Absence of premonitory symptoms,

usually usually exertionalexertional Quick recoveryQuick recovery

Orthostatic syncopeOrthostatic syncope

11stst- Dehydration- Dehydration 22ndnd- polypharmacy- polypharmacy

AV nodal blockade (BB, CCB)AV nodal blockade (BB, CCB) Anticholinergics Anticholinergics

33rdrd- autonomic insufficiency- DM- autonomic insufficiency- DM

HTN-JNC7HTN-JNC7

Treatment of HTN benefits are greater in the Treatment of HTN benefits are greater in the older patients compared to young patients. older patients compared to young patients. Reduces CVA, CHF and CV events, Reduces CVA, CHF and CV events, but not but not overall mortalityoverall mortality

Isolated systolic HTN is still high risk, even in the Isolated systolic HTN is still high risk, even in the elderly, and should be treated.elderly, and should be treated.

Wide pulse pressure is a risk factor for CHF.Wide pulse pressure is a risk factor for CHF. All patients: All patients:

weight lossweight loss stop EtOH,stop EtOH, limit Na,limit Na, exerciseexercise

HTN-JNC 7HTN-JNC 7

Stage 1: 140-159/90-99Stage 1: 140-159/90-99 Stage II: >160/100Stage II: >160/100 Goal: treat to < 140/90 or <130/80 if DMGoal: treat to < 140/90 or <130/80 if DM Always start with a thiazideAlways start with a thiazide unless Post MI or CKD unless Post MI or CKD

The number one reason for failure to control hypertension despite The number one reason for failure to control hypertension despite multiple agents is the failure to use a thiazide diuretic.multiple agents is the failure to use a thiazide diuretic.

1.1. CHF: thiazide, BB, ACEI, ARB, spironolactoneCHF: thiazide, BB, ACEI, ARB, spironolactone2.2. POST MI: BB, ACEI, spironolactonePOST MI: BB, ACEI, spironolactone3.3. DM: thiazide, BB< ACEI, ARB, CCBDM: thiazide, BB< ACEI, ARB, CCB4.4. CKD: ACEI, ARBCKD: ACEI, ARB5.5. Recurrent CVA: thiazide, ACEIRecurrent CVA: thiazide, ACEI6.6. High CVD risk: thiazide, BB, ACEI, CCBHigh CVD risk: thiazide, BB, ACEI, CCB

cardiology review 6/3/2009. a 28 yom is evaluated for palpitations. he reports a 5 year history of...

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