Ite Crash Course - Cardiology 595v6x
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Cardiology
Cardiology Part 1: ACS Heart Failure Pericardial Disease
ACS • PE: new MR, S3 or S4 sings of ischemia • STEMI equivalents: • new LBB • or posterior MI (tall R and ST dep in V1-V3) • Angina equivalents (diabetic W) • DOE • Fatigue • N/V
TIMI scoreà
7 points
TIMI 0-2?
5
TIMI 0-2?
EKG Stress Test 6
TIMI of 3 or greater
7
TIMI of 3 or greater
Early Angiography 8
TIMI 0-2 stress first, otherwise cath
Don’t Be Tricked • What are non-STEMI causes of STE? – Give me 5…
Don’t Be Tricked • Non-STEMI causes of STE – Acute pericarditis – LV aneurysm – Takotsubo’s CM – Coronary vasospasm – Normal variant
When do You Choose Thrombolytics?
12
Thrombolytics • If PCI not available within X minutes
Thrombolytics • If PCI not available within 90 minutes • Bunch of contraindications, but : • ICH • recent ischemic stroke (3mo) • head trauma • active PUD • BP 180/110
15
When do you send for CABG in the presence of a STEMI? • Give me 4…
When do you send for CABG in the presence of a STEMI? • • • •
Failure of PCI or fibrinolysis Cardiogenic shock Lt main or Lt main equivalent dz 2-3 ves dz involving LAD AND reduced EF
Don’t be Tricked • If can transfer and have PCI done in <90min, choose transfer to PCI rather than thrombolytic for STEMI • No thrombolytics in NSTEMI or asx w onset of pain >24hr ago • Reperfusion arrhythmias after thrombolytics are common and do NOT require antiarrhythmic therapy • No spironolactone in acute MI
– Effectiveness not known – (eplerenon can be used for sev LV dysfunction after MI)
Signs of a Right Sided/Posterior MI • Elevated CVP with clear lungs • Hypotension • Tachycardia • Tx: IVFs • Why get a right-sided EKG?
RV Infarct: EKG • The most useful lead is V4R • place V4 electrode in the 5th right intercostal space in the midclavicular line • STE in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI.
When do you choose an intra-aortic balloon pump? • Give me 4…
When to place an intra-aortic balloon pump? • • • •
Cardiogenic shock Acute MR or VSD Intractable V tach Refractory angina
• Severe AR…AVOID IABP.
Post-MI complications: 2-7 days out • What will you see with these? • VSD & Papillary muscle rupture • LV free wall rupture
Post-MI complications: 2-7 days out • VSD & Papillary muscle rupture – Both cause: – flash pulm edema – hypotension – loud holosystolic mumur and thrill
• LV free wall rupture – Sudden hypotension or cardiac death assoc w PEA
• Dx: emergency echo
Who are ICDs indicated in? • Give me 3…
Who are ICDs indicated in? • EF< 30% & at least: • >40days since MI • >3months since PCI or CABG
What is associated w increased hospitalizations & death in post MI patients that we should screen everyone for?
What is assoc w increased hospitalizations & death in post MI pts that we should screen for?
Other causes of • Vasospasm (W w migraines)à • Cocaine ( after a party)à • Tall thin, AI murmurà
tx CCB tx CCB
dissectionà CT or TEE
• PE • Tall, thin smokerà
PTXà CXR
Test Yourself • 56 W, 3hr , BP 80/60, HR 120, RR 30 • On exam: +JVD, crackles, S3 • EKG: STE in V2-V6 • What do you want to do next?
Answer • STEMI w cardiogenic shock • Choose cardiac cath & PCI
Test Yourself • 58M , BP 80/50, HR 54 • On exam: +JVD, but clear lungs, no murmur or S3 • EKG: STE II, III, aVF
Answer • RV MI • Choose IVFs • Obtain right-sided EKG for V4R tracing
Chronic Stable Angina: RF Goals • HDL? • A1c? • BP?
Chronic Stable Angina: RF Goals • HDL: <100 • A1c: <7 • BP: <140/90
Don’t Be Tricked • No HRT, Vit E, folate or B12 as tx for CAD • Mod to high risk for CAD? • Rx ASA • if h/o GIB, take ASA w PPI
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? • Abn EKG but can exercise? • LBBB? • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? • LBBB? • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? vasodilator myocardial perfusion imaging • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? vasodilator myocardial perfusion imaging • Unable to exercise? pharm stress myocardial perfusion or dobutamine echo • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? vasodilator myocardial perfusion imaging • Unable to exercise? pharm stress myocardial perfusion or dobutamine echo • V paced?
pharm stress myocardial perfusion
High pretest probability of CAD coming in with stable angina?
• Just cath them :)
High pretest probability of CAD coming in with stable angina?
Tx stable angina • Lifestyle modification for all • Asa, statin, BB – Goal HR 55-60 so uptitrate BB
• If no response to anti-anginals?
Tx stable angina • Lifestyle modification for all • Asa, statin, BB – Goal HR 55-60 so uptitrate BB
• Ranolazine if no response to antianginals – X and X increase levels of ranolazine by 50%, must reduce ranolazine dose if on these drugs – All thru p450
Tx stable angina • Lifestyle modification for all • Asa, statin, BB – Goal HR 55-60 so uptitrate BB
• Ranolazine if no response to antianginals – Diltiazem and verapamil increase levels of ranolazine by 50%, must reduce ranolazine dose if on these drugs – All thru p450
When to add an ACEi? • Give me 4…
When to add ACEi • • • •
EF <35% h/o CAD, stroke, PVD DM 1 additional CAD RF
When is PCI or CABG helpful in chronic stable • Give me another 4 baby… angina?
When is PCI or CABG helpful in chronic stable angina?
• Angina refractory to med therapy • High risk criteria on stress • High risk coronary anatomy • like Lt main or 3ves dz • Sig CAD w red EF
What about CABG in pts w DM? 1. ? 2. ? 3. ?
What about CABG in pts w DM? 1. Sev Left main dz 2. 3 vessel dz 3. 2 ves dz if one is the LAD & there is red EF
Don’t Be Tricked • Don’t select PCI or CABG for stable angina in absence of high risk features
Test Yourself • 69M exertional , normal PE & EKG. Father died of AMI at 61 • What meds do you start? • Andy further testing?
Answer • Rx ASA, SL nitro, BB • Follow up w exercise stress test – Intermediate pretest probability bc of gender & age – no fam hx of premature CAD, no HTN, DM, smoking
Done with ACS/Angina! On To Heart Failure
59
Heart Failure • BNP>500 = HF • BNP<100 excludes HF as cause of acute dyspnea
Don’t Be Tricked • BNP can NOT differentiate systolic from diastolic HF • What things increase BNP? • Decrease?
Don’t Be Tricked • BNP can NOT differentiate systolic from diastolic HF • What things increase BNP? – kidney failure, older age, female sex • Decrease? • obesity
PM & ICDs in HF..when to place • BiV pacing for: – NYHA class X, EF<X & QRS >X – NYHA class X, EF<X & QRS >X
• ICD for: – Ischemic and nonischemic CM w EF<X%
PM & ICDs in HF • BiV pacing for: – NYHA class III-IV, EF<35%, & QRS >120msec – NYHA class II, EF<30%, & QRS >150msec
• ICD for: – Ischemic and nonischemic CM w EF<35%
Don’t Be Tricked • Don’t start BB in decompensated CHF • Generally, continue BB during decompensation if were previously stable using BB • Use metoprolol in COPD or asthma • No NSAIDs or TZDs: worsen HF • No role of CCB in systolic CHF • Avoid digoxin in CKD pts or in changing kidney function
Test Yourself • • • •
66W w stable HF, now with orthopnea on ACEi & furosemide BP 140/68, HR 102 overloaded on exam
• What should you do with her meds?
Test Yourself • • • •
66W w stable HF, now with orthopnea on ACEi & furosemide BP 140/68, HR 102 overloaded on exam
• What should you do with her meds? • increase lasix and lisinopril dosages • add BB when pt is stable
HF w preserved EF=diastolic • X medicine – Reduces hospitalizations in diastolic HF but no change in mortality
• Tx underlying causes: – HTN – tachycardia
HF w preserved EF=diastolic • Candesartan – Reduces hospitalizations in diastolic HF but no change in mortality
• Tx underlying causes: – HTN – tachycardia
Dilated CM • Dilation & reduced function of 1 or both ventricles • Get HF, arrhythmias, sudden death • 50% idiopathic • Tx: Reverse underlying cause then standard HF med
Causes of dilated CM • Give me 4…or more..
Causes of dilated CM • Myocarditisàhigh trop – Multinucleated giant cells on bx = giant cell myocarditis
• Alcohol • Drug-inducedàcocaine, amphetamines – Labetolol preferred BB
• Tachycardia-induced • Arrhythmogenic RV dysplasia • Takotsubo’s
Test Yourself • 35M drinker, heart failure on exam • Dx: alcoholic cardiomyopahty • Choose echo & alcohol cessation
Peripartum CM • Dx 1mo before or 5mo after delivery • Avoid ACEi/ARB if still pregnant, deliver early • Should they have more babies?
Peripartum CM • Dx 1mo before or 5mo after delivery • Avoid ACEi/ARB if still pregnant, deliver early • Discourage subsequent pregnancies even if EF recovers
Hypertrophic CM • 50% inherited AD • Tx: avoid strenuous exercise • BB 1st line • ACEi only if reduced EF • All need genetic counseling • When do you choose surgery or septal ablation?
Hypertrophic CM • 50% inherited AD • Tx: avoid strenuous exercise • BB 1st line • ACEi only if reduced EF • All need genetic counseling • When do you choose surgery or septal ablation? • Outflow gradient >50mmHg and symptoms despite max medical therapy
EKG in HOCM • LVH • LAE • Deeply inverted symmetric Ts in V3-V6 – Can mimic ischemia
Don’t Be Tricked • EP studies NOT useful in predicting risk of sudden death in HOCM • ie not the right test answer • Do NOT Rx digoxin, vasodilators or diuretics – All increase outflow obstruction
Test Yourself • 18yo basketball player collapsed at practice • Answer: HOCM – Young person collapses at athletic event
Restrictive CM • Abnormally rigid ventricular walls causes DIASTOLIC DYSFUNCTION without systolic dys • Most have normal systolic function • Right sided HF & pulm HTN from pulm venous congestion • Kussmaul signà
engorged jugular veins w inspiration
• Cathàelevated RV & LV diastolic Ps & characteristic “early ventricular diastolic dip & plateau”
Causes of Restrictive CM • Infiltrative dz – Amyloid, sarcoid, hemochromatosis
• Glycogen storage dz • Endomyocardial process – Fibrosis, hypereosinophilic synd, carcinoid, radiation, anthracycline
• Noninfiltrating dz – scleroderma
Clues in the history in pt with diastolic dysfunction • What might you see? • Amyloidà • Sarcoidà • Hemochromatosisà
Clues in the history in pt with diastolic dysfunction • Amyloidà neuropathy, proteinuria, HM, periorbital ecchymosis – low voltage EKG – Dx: abd fat pad aspiration
• Sarcoidà
hilar LAN, skin, t, eye lesions
– Usual heart block – Dx: cardiac MRI with gadolinium
• Hemochromatosisà
abn LFTs, OA, DM, ED, HF
– Dx: high ferritin and transferrin saturation
OA in hemachromatosis 2nd & 3rd M TS!!!!
87
Amyloid purura (NEJM 2007)
Don’t Be Tricked • No endomyocardial biopsy unless hemachromatosis, sarcoidosis, or amyloidosis is suspected – Can do cardiac MRI for sarcoid
BB in Restictive CM: Good or Bad?
BB in Restictive CM • Watch out! • Most have conduction abnormalities and need high HR to maintain CO
Test Yourself • 63M DOE/fatigue • PE: +JVD, prominent jugular a wave, S4, 2/6 holosys murmur at LSB, clear lungs • enlarged tender liver • petechiae over face & periorbital ecchymosis
Answer
Dx: amyloid CM Notice the noncardiac sx
94
Done with Heart Failure! Moving on to pericardial disease & restrictive CM
95
Pericardial Tamponade & Constriction • Dyspnea, fatigue, edema, HM, ascites WITH clear lungs • PE: JVD, pulsus paradoxus, tachycardia, reduced HSs, hypotension • Which patients? – – – – –
Cancer Recent cardiac sx Dissecting aneurysm Pericarditis Collagen vascular dz
Kussmaul Sign?
Kussmaul Sign • paradoxical rise in JVP on inspiration • or increase in CVP with inspiration
Tamponade
• No effusion = No tamponade
Constrictive pericarditis • Thick fibrotic pericardium that does not allow ventricular expansion during diastole so get impaired filling – Usually result of pericarditis
• Xray: calcified pericardium • Loud S3 (pericardiac knock) & friction rub
Chronic constrictive pericarditis • CO depends on high preload so careful with diuretics (usually avoid all together) • Pericardiectomy is most effective treatment BUT is unnecesary is pts w early dz (NYHA I) and unwarranted in advanced dz (NYHA IV)
Don’t Be tricked • In constrictive pericarditis, echo will show shifting of ventricular septum to-&-fro during diastole – Manifestation of Rt and Lt Ventricles competing for confined space during filling – These findings are NOT seen in restrictive CM
Restrictive CM vs. Constrictive pericarditis Must be able to differentiate
• Restrictive CM – – – –
S3 Really high BNP EKG: BBB Echo: LVH and atrial enlargement on echo
• Constrictive pericarditis
– Pericardial knock – CXR: calcified pericardium – Echo: Accentuated drop in peak LV filling during inspiration (pulsus paradoxus in tamponade) – Rt heart cath: equalized Lt & Rt diastolic ventricular pressures (within 5mmHg)
Test Yourself • 44W ovarian cancer p/w fatigue, dyspnea, edema. BP 90/50, HR 130, +20mmHg pulsus paradoxis • PE: +JVD that increase w inspiration, reduced HSs • Dx: acute pericardial tamponade likely from metastatic dz • Order echo, give fluids & vasopressors
Acute Pericarditis • Acute sharp stabbing pain worse with inspiration & lying down • Med history: – – – – – –
Cancer Trauma Arthralgia (suggest collagen vasc dz) MI Thoracic sx Hydralazine & minoxidil…WHY?
Classic PE finding • 2 or 3 component pericardial friction rub • EKG: diffuse STE (no reciprocal depressions) – PR dep in limb leads – PR elevation in aVR
• If effusion? • If pulsus paradoxus >10mmHg?
Classic PE finding • 2 or 3 component pericardial friction rub • EKG: diffuse STE (no reciprocal depressions) – PR dep in limb leads – PR elevation in aVR
• If effusion? Electrical alterans • If pulsus paradoxus >10mmHg? Tamponade
Don’t be tricked • CEs may be slightly elevated in isolated pericarditis
Tx pericarditis • 1st line: ASA (after MI), NSAIDs, colchicine • Recurrent pericarditis? – Choose colchicine + aspirin
• Pericarditis that does not respond to ASA or NSAIDs? – Choose 2-3d of steroids • Increases risk of recurrence though 9
• Tamponade or unstable? Emergent pericardiocentesis – So any question that has pulsus paradoxus >10mmHg, the answer is emergen pericardiocentesis
Test Yourself • 57M 2d worse w lying flat. 3 component friction rub • Anser: pericarditis – Look for diffuse STE and PR depr – IGNORE elevated trop tempting you to answer “acute MI”
Cardiology Part 2: Vavular Dz Murmurs
Rheumatic Fever • Give penicillin to pts with group A strep infections – Or erythromycin if penicillin allergy
• h/o of RF: longterm ppx penicillin – Bc recurrent infections are dangerous
• Rheumatic valvular dz: – Ppx for at least 10yrs after last epi of RF – Or until age 40 • Whichever is LONGER
Rheumatic Fever • Mitral valve: MS & MR • AV 2nd most common affected valve
Tx Rheumatic Fever • Abx required even if throat cx negative for GAS • ASA drug of choice – Nonresponse to salicylates makes RF unlikely
Heart Murmurs General Tips • Which increase in intensity w inspiration? • Which increase in intensity w Valsalva or standing from squatting? • Which has a click that may move closer to S1 and lengthen w Valsalva?
Heart Murmurs • Which increase in intensity w inspiration? – Right sided
• Which increase in intensity w Valsalva or standing from squatting? • Which has a click that may move closer to S1 and lengthen w Valsalva?
Heart Murmurs • Which increase in intensity w inspiration? – Right sided
• Which increase in intensity w Valsalva or standing from squatting? – HOCM
• Which has a click that may move closer to S1 and lengthen w Valsalva?
Heart Murmurs • Which increase in intensity w inspiration? – Right sided
• Which increase in intensity w Valsalva or standing from squatting? – HOCM
• Which has a click that may move closer to S1 and lengthen w Valsalva? – MVP
S2 • Normal: should only hear split S2 w inspiration
• Abn splitting of S2 helps differentiate murmurs
Abn splitting of S2 helps differentiate murmurs
Splitting during inspiration & expiration? – Things that delay RV ejection: • • • •
PS VSD w left to right shunt ASD w left to right shunt RBBB
Abn splitting of S2 helps differentiate murmurs
Reversed or splitting only w expiration? – Things that prolong LV ejection: • • • •
AS HOCM ACS w LV dysfunction LBBB
Innocent Murmurs • • • •
Midsystolic Base of heart 1-2/6 without radiation Associated w normal splitting of S2
Signs of SERIOUS disease • • • •
S4 Grade 3/6 or greater Any diastolic murmur Fixed splitting of S2
• If any of these are in the question or pt has symptoms or a continuous murmurà answer is Echo – Any diastolic murmur gets an echo
Don’t Be tricked • An increased P2, S3, early peaking systolic murmur over LUSB are NORMAL in pregnancy • Innocent heart murmurs do not require Echos
Test Yourself • 19 F, asx, murmur on sports exam. Nonradiating, 2/6 midsystolic over RUSB, normal split S2, soft S3 • Dx: innocent murmur, no further work up
Cheat Sheet for the Non-Cardiologist • Mr Ass • Ms Aid • MR & AS è Systolic murmurs • MS & AI è Diastolic murmurs
Aortic Stenosis • Calcifications or AV sclerosis most common cause • Pts w bicuspid valves should be evaluated for dilation of aortic arch • SSX: HF, angina, syncope
Findings of AS • • • •
Midsystolic RUSB Radiates to carotids Pulsus parvus et tardus
– Delayed low amplitude carotid pulse
• CXR: boot shaped heart • Echo: LAE, LVH, calcified AV • Severe AS:
– AVA <1cm2 – Mean transvalvular gradient >50mmHG
Heyde syndrome • What’s That?
Heyde syndrome • Aortic Stenosis + GI Bleed – Acquired von willebrand dz due to disruption of VWF through diseased AV
Don’t be tricked • Echo significantly underestimated the transvalvular gradient in pt with AS & low EF • If the calculated valve area increases with dobutamine stress, then diagnose pseudostenosis • Do NOT select exercise stress test for pts w symptomatic AS!
Pseudostenosisà not on test but will see with your patients • If you have low EF & mild AS, the echo can give you a falsely small AVA making the AS appear severe • This phenomenon is called “pseudostenosis” – Low force of weak LV is not strong enough to open even a weakly stenotic valve • If you give dobuatmineàincrease COàAVA will be more accurate
Work up of AS • Equivocal symptoms: exercise stress test – If hypotensive during exerciseà immediate replacement
• Cath for all pts >35 who are going for AVR – Need to make sure no CAD requiring CABG while the surgeons are in there
Serial Echos for AS?*** • Mild AS? • Moderate AS? • Asymptomatic w severe AS?
Take Note • They love follow-up imaging questions in cards & pulm (because there are guidelines that no one knows, so easy to test & hard to get right)
Serial Echos for AS? • Mild AS? Every 5 years • Moderate AS? Every 2 years • Asymptomatic w severe AS? Every 1 year
When to send for AVR • • • •
Any age if have symptoms Undergoing CABG for CAD LV dysfunction Hypotension during exercise stress
• Young pts with congenital AS & no AV calcificationsà can go for percutaneous valvuloplasty
Test Yourself • 71, HF sx, murmur of AS, EF 30%, calcified AV w mean gradient of 26 • Dx: Severe AS w CM despite low gradient – Bc of severe LV dysfunction
• Choose cardiac cath and probable valve replacement
Aortic Regurgitation • Classified as Chronic & Acute
Chronic AR • Seen w bicuspid AV, marfans, aortic aneurysms • Sx: angina, orthopnea, DOE
PE of AR • Soft S1, soft or absent A1, loud S3 • Diastolic murmur LUSB or RUSB • Louder when leaning forward or exhaling
PE of AR • Wide pulse pressure • • • • •
De Musset sign – bobbing head w heart beat Duroziez sign – systolic M w compression of prox fem A Traube sign – Pistol shot sounds over peripheral arteries Corrigan pulse – Water hammer pulse w abrupt distention & collapse Quincke pulse – Systolic plethora & diastolic blanching in nail beds w nail compressions
Chronic AR • EKG: LAD & LVH • CXR: CM, aortic root dilatation, calcification • Test for syphilis & get echo – “Never marry the man with the bobbing head”…unless he’s super rich…J
Serial Echos in Chronic AR*** • Echo 2-3mo after initial diagnosis to exclude rapid progression • Asx w LV dilatation? Every 6-12mo • Asx with normal LV? Every 2-3yrs
When to go for AVR in chronic AR • • • • •
Symptomatic (even if EF normal) Plan for CABG or other valvular sx Progressive LV dilatation EF<50% Declining exercise performance
Acute AR • Aortic dissection, endocarditis, traumatic rupture (rare) • Short, soft sometimes inaudible diastolic murmur • Normal heart size • Normal pulse pressure
Tx Acute AR • Schedule immediate AVR for acute AR • Bridge w nitroprusside and diuretics
Don’t be tricked • Do NOT select BB or IABP for acute ARà both may worsen AR
Test Yourself • 36, AV endocarditis transferred to ICU w abrupt onset hypotension & hypoxemia. • BP 80/30, HR 120, crackles and gallop. • No murmur • Dx: acute AR • Choose echo, IV sodium nitroprusside & dobutamine as bridge to urgent surgery
Mitral Stenosis • Most common sx: orthopnea & PND • PE: – Prominent a wave – Tapping apical impulse – Right sided HF – Opening snap & attenuated P2 – Low-pitched rumbling diastolic mumur
Give Away on Test
Mitral Stenosis= Snap
Unlike AS, percutanous valvuotomy (repair) is preferred over replacement for MS • MV repair indicated if: – No LA appendage thrombus on echo – Pt is symptomatic with MVA <1cm2 or <1.5cm2 w exercise limitations • If had MS + mild MR, can do repair, but if the MR is mod or sevà have to replace the valve L – Has been on every test I have taken in residency
Test Yourself • 28W 29wks pregnant p/w DOE. • Tachycardia, JVP, parasternal impulse • Opening snap, 2/6 rumbling diastolic murmur w presystolic accentuation • Dx: MS – Classic presentation in pregnancy bc of increased intravascular volume • Choose metoprolol to allow for greater LV diastolic filling time & to relieve pulm HTN
Don’t be tricked • All pts with MS and Afib get warfarin, doesn’t matter the CHADS2 score – CHADS2 only calculated for nonvalvular Afib
Mitral Regurgitation • Like AR, can be chronic or acute
Chronic MR Causes: • MVP • IE • HCM • Ischemia • Marfans • Ventricular dilation • Sx: orthopnea, PND, edema
Murmur of Chronic MR • • • • • • •
Holosystolic Radiates to left axilla Displaced hyperdynamic apical impulse Decreased intensity of S2 Widely split S2 S3 Increased P2
Tx chronic MR • Diuretics, BB, ACEi, +/- digoxin or spironolactone • Associated Afib requires anticoagulation!
When to repair MV? • Symptomatic
– Even if EF & LV size are normal
• Notice this is a theme in all valvular disease
• EF <55% or LV dilated to >45mm – even if no sx
• Repair preferred to replacement (avoid AC) • If from ischemiaà MR should improve after revascularization
Acute MR • Causesà papillary muscle rupture (post MI), – chordae tendineae rupture (myxomatous valve dz) – endocarditis • Sx: Abrupt onset dyspnea, flash pulm edema, cardiogenic shock • PE: right sided HF – Holosystolic murmur at apex that radiates to axilla • There may be NO murmur w acute MR bc wide open
Tx Acute MR • Sodium nitroprusside – Like in AR – but can give nitroglycerine for MR which we avoid in AR
• Another differenceà IABP should be used if unstable acute MR – Worsens AR
• Surgery for acute severe MR
Don’t be tricked • Do not select mitral valve surgery if EF <30%
Test Yourself • 63M asx found to have MR • EF 52%, LV size 51mm • Choose mitral valve replacement or repair
Mitral Valve Prolapse • Most common cause of MR (though most do not have MR) • Usually asx • Can cause , palpitations, syncope, dyspnea, emboli – If sx, tx w BB • High-pitched midystolic click followed by late systolic murmur loudest at apex
Mitral Valve Prolapse
• MVP = Click • Standing from sitting & valsalva cause the click and murmur to come earlier • Squatting does the oppositeà click and murmur are delayed and softer
Test Yourself • 28W w palpitations. Isolated click on exam, echo w mild MR, 24hr ECG w 728 isolated PVCs • What to do next?
Test Yourself • 28W w palpitations. Isolated click on exam, echo w mild MR, 24hr ECG w 728 isolated PVCs • Provide reassurance & counsel on lifestyle modification – Avoid caffeine & other stimulants
Tricuspid Regurgitation • Causes: marfans, ebstein’s, AV canal malformations, IE, carcinoid, pulm HTN, RF • PE: prominent v wave, increased JVP w inspiration, hepatic pulsations • Holosystolic murmur LLSB, increases w inspiration – Know it is either TR or PR if increases w inspiration (right sided) and must be TR if systolic as PR would be diastolic
Don’t Be Tricked • Mild or less severe TR is common, easy to identify on echo, is physiologically normal, and does NOT require treatment
Prosthetic Valves • Valve dysfunction: new cardiac sx, emboli, hemolytic anemia (schistocytes) • If valve dysfunction is suspected, TEE is procedure of choice – Do not select TTE in prosthetic valves
Don’t Be tricked • Begin long term AC for pts with mechanical heart valves – Prosthetic require short but not long term AC but are not as durable and more likely to get infected
Goal INR in mechanical valves • AVà 2-3 • AV + risk factorà 2.5-3.5 – RFs= Afib, prior emboli, hypercoagulable, low EF
• MVà 2.5-3.5 • All should be on ASA
Keep in mind when asked about anticoagulation •
No need to hold AC before cataract sx
•
For AVs, stop warfarin 4-5d before sx, let INR<1.5 and restart as soon as safe post op – Higher flow across AV so less likely to clot than mitral so bridging in low risk pts not necessary
•
If high risk for thrombosis (mitral valve, Afib), bridge with IV heparin once INR<2
•
Do NOT use Vit K to reverse, if needed urgently, use FFP – Takes several days for factors to become deplete again for AC
Atrial Septal Defect • Fixed split S2 • Pulmonic midsystolic murmur • Tricuspid diastolic flow murmur • Ostium secundum most common • EKG: RAD, RBBB • Ostium primum associated w mitral disease
When to close an ASD? • Right atrial or ventricular enlargement • Large left to right shunt • Symptoms – Dyspnea, paradoxical emboli
• Select percutaneous device closure for secundum – vs. surgical closure for primum & associated MV defects
Don’t be tricked • Closure of ASD is contraindicated if shunt reversal is present
Test Yourself • 26 W, no sx, 30wks preg, fixed split S2, 2/6 early SEM in LUSB • Dx: ASD – Like MS, often first discovered in preg bc of increased intravascular volume
Ventricular Septal Defect • Loud systolic murmur that obliterates the S2 • What suggests a hemodynamically important VSD? – Displaced apical impulse – Mitral diastolic flow rumble
When to close a VSD? • Progressive AR or TR • Progressive LV volume overload • Recurrent endocarditis • Large VSDs can cause pulm HTN and right to left shunt (Eisenmenger) – At this stage, closure is contraindicated • Similar to our ASD don’t be trickedà if shunt reversal, no surgery
Cardiology Part 3: Arrhythmias Aortic Dz PAD Preop risk assessment
Palpitations/Arrhythmia work up •
Resting EKG in all
• • •
Ambulatory 24hr ECGà only if daily symptoms Exercise ECGà only if exercise-related Event monitorà for long arrythmias >1-2min where pt’s have enough time to activate the device Loop recorderà for infrequent sx, saves the prior 30sec-2min after pt activates the recorder – Usually the test answer Implanted recorderà invasive, for long term monitoring mo-yr EP studyà for treatment not diagnosis – Rarely the test answer
•
• •
Narrow Complex Tachycardias
Atrial Fibrillation • No Ps • Narrow complex – Wide complex if there is underlying conduction delay like RBBB or accessory pathway
• Irregularly irregular • The presence of deformed Ts or STs “hiding” P waves rule out Afib
Tx Afib • Almost all require AC as the stroke risk in nonvalvular Afib with one other risk factor exceeds risk of bleed • CHADS2
AC in Afib • Because the daily risk of stroke in nonvalvular Afib is low, most do not require bridging when warfarin is interrupted for procedures
Tx Afib • No benefit to rhythm control in elderly – May be appropriate in young w persistent Afib
• Amio- 1st line in ischemic HD & LV dysfunction • For older asx pts, clinical outcomes are not improved with HR <80 compared to more lenient target of <100
Don’t be Tricked • No Digoxin as single agent for rate control • No catheter ablation of AVN before medication trial for rate control • No CCBs, BBs, or digoxin in pts with Afib & WPW – Then they just go down conduction pathway which has no inhibition
Test Yourself • 55W & SOB x12hr • BP 70/40, HR 160 • EKG: wide complex tachycardia shown
Test Yourself • Cardioversion – always the answer in Afib w hemodynamic instability
Atrial Flutter • EKG: saw tooth in inferior leads, positive deflection in V1 • Ventricular response in regular • Most 150 beats per min (2:1 block) • Tx: radiofrequency catheter ablation superior to medical therapy – Bc reentrant tachycardia – AC like you would for Afib
Other Supraventricular Tachycardias
AVNRT much more common than AVRT (85% of the time) AVNRT should be your guess & there should be no visible Ps
AVNRT much more common than AVRT (85% of the time) This is AVRT , notice the Ps are buried in the ST segments
MAT: correct underlying cardiac or pulm dz, low K/Mg. Tx: metoprolol (verapamil if bronchospasm)
Don’t be tricked • Do NOT treat irregular, wide complex tachycardia or polymorphic tachycardia with adenosine
Test Yourself • 32W, 4hr palpitations • BP 80/50, HR very rapid (they do not give a #). • EKG regular, narrow compex tachy of 180 bpm, norm QRS morphology, no Ps are seen • Dx: AVNRT • Choose valsalva, carotid sinus massage, verapamil (can cause hypotension) or IV adenosine
Wolff-Parkinson-White Syndrome • Accessory AV conduction pathway • EKG: short PR, delta wave, norm or long QRS • Afib associated w WPW is a risk factor for sudden death caused by degeneration into VF
Don’t be tricked • Asymptomatic WPW without arrhythmia does NOT require investigation or treatment • Do NOT select CCB, BB or digoxin for pts with Afib & WPW because can convert Afib to VT or Vfib
Tx WPW • ?
Tx WPW • Procainamide • Cardioversion is preferred for any unstable WPW pt • Board Question: pre-op intervention in asx WPW pt?
Test Yourself • 28W, 4hr palpitations • BP 130/80, irregularly irregular HR of 140 • EKG shows Afib w ventricular rate of 180-270. QRS is broad and bizarre • Dx: WPW • Begin IV procainamide
Heart Blocks • Choose IV atropin +/- transcutaneous or transvenous pacing for symptoms of hemodynamic compromise
May precede to 3rd deg block
When to put in a permanent PM? • • • •
Persistent, advanced mobitz type 2 Transient 2nd degree block w BBB 3rd deg block Symptomatic block at any level
Ventricular Tachycardia QRS >120msec & AV dissocation Nonsustained <30sec 1. Vtach
Monomorphic (no variation in QRS complexes) Polymorphic
2. Torsades de pointesà specific form of polymorphic VT associated w long QT 3. Vfib
VT vs. SVT w aberrancy • Which is more common?
VT vs SVT w aberrancy • VT much more common, so any wide complex tachycardia should be considered VT til proven otherwise (so no adenosine) – If prior MI or structural heart dz, chance of it being VT even higher
Don’t Be tricked • In pts w structural heart disease, therapy to suppress PVCs does NOT affect outcomes
Tx PVCs • BB only for: – Disabling symptoms – Nonsustained VT with symptoms • Acute sustained VT – Hemodynamically stable w impaired EFà IV lidocaine or amio – Unstableà immediate electrical cardioversion • ICDs reduce sudden cardiac death in VF or sustained VT associated w hemodynamic compromise
Test Yourself • 65W chronic stable angina, prior MI, p/w lightheadedness & palpitations. • Vitals stable. • EKG w wide complex tachycardia & RBBB. • No prior EKGs for comparison • Dx: likely sustained VT • Acute tx: IV lidocaine or amio
Sudden Cardiac Death • Risk greatest when QTc >500 • Select echo for survivors of sudden cardiac death • Brugada syndrome?
Brugada syndrome • Inherited, structurally normal heart but abnormal conduction system associated w sudden death – Incomplete RBBB w STE in V1-V2
Who gets an ICD? • Survivors of cardiac arrest 2/2 VF or VT not explained by reversible cause • After sustained VT in presence of structural HD • EF <35% • Brugada syndrome • Inherited long QT synd not responding to BB • After MI w EF <30% 3mo later • High risk HOCM pts – Familial sudden death, multiple repetitive nonsustainedVT, extreme LVH, exercise hypotension
Test Yourself • 55M 4mo after large MI, asx, Ef 28% • Answer: pt at high risk for sudden cardiac death and should be considered for ICD
Aortic Atheroemboli*** • Clinical findings: livido reticularis, gangrene of digits, transient vision loss • A golden or brightly refractile cholesterol body within a retinal A (Hollenhorst plaque) is pathognomonic • Common presentation: stroke or AKI after cardiac or aortic sx or cath • Dx by biopsy of muscle, skin, kidney or other organs • Tx: control CV risk factors
Test Yourself • • • •
67 M w AKI 10d after cath BP 170/100 bruits over abd and femoral A legs are lacy & purple
• Look for cholesterol emboli to skin and kidneys • Choose skin biopsy & control all CV risk factors
Coarctation of the Aorta • • • •
HTN Diminished femoral pulses Radial-to-femoral delay Murmur of AS w continuous murmur audible over the back
• CXR: classic “figure 3” • MRA confirms the diagnosis • Tx: balloon dilatation
Test Yourself • 35 immigrant female w cold feet and leg cramping w walking. • BP 160/90. • Systolic murmur at RUSB • Dx: coarctation w bicuspid AV • Be alert for congenital HD in questions about “immigrant” patients
Thoracic Aortic Aneurysm & Dissection • Yearly echo until root 4.5cm, then every 6mo • Repair when 5-5.5cm • Counsel against pregnancy if root >4cm
Symptoms & Signs • Compressionà
– hoarseness, dysphagia, recurrent PNA, SVC syndrome
• Chest, flank, abd, back pain
• New AR murmur • HF • BP differential between arms • CXR: wide mediastinum • Dx: TEE, CT w contrast, MRA
Type A=Surgery • Type A dissections involve the ascending aorta, all other class B • Emergent surgery is required for Type A dissections. Uncomplicated type B dissections can by treated w medical therapy alone – BB
When to do prophylactic surgery • • • •
Sxs of hoarseness, dysphagia, back pain Ascending aorta diameter of >50-60mm Descending aorta diameter of >60-70mm Rapid growth of >10mm/year
Don’t be tricked • Which anti-HTN do you not use for acute aortic dissection bc it increases shear stress?
Don’t be tricked • Do NOT use hydralazine for acute aortic dissection bc it increases shear stress • Schedule surgery for type B dissection if major vessel like a renal artery is involved
Test Yourself • 73M, 1hr severe tearing • BP 90/60 on right and 130/70 on left • CXR w widened mediastinum • Dx: dissection of the aortic arch • Choose BB, sodium nitroprusside and emergent imaging
Abdominal Aortic Aneurysm • Screening: one time U/S indicated for asx AAA in any male who has EVERY smoked between 65-75yo • Pulsatile abd mass • Tx: CV risk factors, BB preferred
Don’t be tricked • U/S is NOT accurate for diagnosing ruptured AAA – New abd, flank or back pain with shock/syncope – CT or MRA
When to repair an asx AAA? • >5.5cm in diameter • Growth of >0.5cm/yr • Symptomatic • Follow up for unrepaired AAA – If >4cm every 6mo – If <4cm every 2-3yrs
Peripheral Arterial Disease • RF: age, smoking, DM, HLD • Intermittent claudication is the classic sign • Ddx spinal stenosis (pain when standing that resolves with sitting, lying or leaning forward)
5 Ps • • • • •
Pain Paresthesias Pallor Paralysis Pulselessness
ABI • Highest systolic arm BP compared to highest systolic ankle BP (ankle/arm) • <0.9 =PAD • <0.4 ischemic rest pain • False normal in diabetics w calcified noncompressible arteries (ABI >1.4)
Don’t be tricked • ABI >1.4, then a toe-brachial index will be a better assessment
Tx PAD • PAD= CAD risk equivalent – Same BP & lipid goals
• All with symptomatic PAD should begin a supervised exercise training program • Meds: ASA, statin (LDL<100) – cilostazol for sx PAD – ramipril (reduces MI, stoke or vascular death in PAD)
Acute arterial ischemia • Antiplat, heparin and urgent surgery • If chronic but rest pain or poorly healing ulcersà schedule angioplasty or surgery – All others get medical therapy
Don’t be tricked • Do not use cilostazol in pts with low EF or h/o HF • BB are NOT contraindicated in pts w PAD
Test Yourself • 60M, 6mo claudication thighs & calves. • ABI 0.66 & 0.55 • Symptomatic despite lifestyle management program • Choose to begin cilostazol
Preop Cardiac Risk Assessment • Should delay elective surgery for the following active cardiac conditions: – ACS (MI<30d ago, unstable or severe angina) – Decompensated HF – Sig arrhythmia – Severe valvular dz
Who can go for elective surgery without further cardiac w/u? • Low risk sx – endoscopy, breast, cataract, outpt sx
• >=4METs – can climb a flight of stairs, walk up a hill, walk at 4mi/hr without sx
RCRI used to risk stratify the other ppl
*0= no further tests *3 or more RFs if undergoing a vascular sx & further workup will change their management? may get additional cardiac work up; consider BB
Who does not need preop assessment? Patients at low risk who: • Having minor surgery under local anesthesia (cataracts) w no comorbidities • <55yo, no murmurs, no illnesses • Recent normal cath (past 6m-1y) & no new sx • Require emergent surgery • Isolated BP <180/100 does not increase risk of complications
On every test I’ve taken • Postpone elective surgery in someone who has received a bare metal stent for at least 46wks & 1yr if received drug-eluting stent
Post Surgical MIs • Most within 24-48hrs after surgery • 50% have , the other 50% may have new onset HF, hypotension or SVT • Asx pts at high cardiac risk should be monitored w EKGs and CEs for up to 1wk postop
Test Yourself • 82M evaluated for preop eval for AAA • HTN on ACEi, no h/o MI, stroke, angina, arrhythmia, kid dz, DM. BP 130/80, exam normal, Cr 1.2, EKG w LVH – (RCRI 0)
• Choose proceed to surgery without additional preop testing
BREAK TIME
Cardiology Part 1: ACS Heart Failure Pericardial Disease
ACS • PE: new MR, S3 or S4 sings of ischemia • STEMI equivalents: • new LBB • or posterior MI (tall R and ST dep in V1-V3) • Angina equivalents (diabetic W) • DOE • Fatigue • N/V
TIMI scoreà
7 points
TIMI 0-2?
5
TIMI 0-2?
EKG Stress Test 6
TIMI of 3 or greater
7
TIMI of 3 or greater
Early Angiography 8
TIMI 0-2 stress first, otherwise cath
Don’t Be Tricked • What are non-STEMI causes of STE? – Give me 5…
Don’t Be Tricked • Non-STEMI causes of STE – Acute pericarditis – LV aneurysm – Takotsubo’s CM – Coronary vasospasm – Normal variant
When do You Choose Thrombolytics?
12
Thrombolytics • If PCI not available within X minutes
Thrombolytics • If PCI not available within 90 minutes • Bunch of contraindications, but : • ICH • recent ischemic stroke (3mo) • head trauma • active PUD • BP 180/110
15
When do you send for CABG in the presence of a STEMI? • Give me 4…
When do you send for CABG in the presence of a STEMI? • • • •
Failure of PCI or fibrinolysis Cardiogenic shock Lt main or Lt main equivalent dz 2-3 ves dz involving LAD AND reduced EF
Don’t be Tricked • If can transfer and have PCI done in <90min, choose transfer to PCI rather than thrombolytic for STEMI • No thrombolytics in NSTEMI or asx w onset of pain >24hr ago • Reperfusion arrhythmias after thrombolytics are common and do NOT require antiarrhythmic therapy • No spironolactone in acute MI
– Effectiveness not known – (eplerenon can be used for sev LV dysfunction after MI)
Signs of a Right Sided/Posterior MI • Elevated CVP with clear lungs • Hypotension • Tachycardia • Tx: IVFs • Why get a right-sided EKG?
RV Infarct: EKG • The most useful lead is V4R • place V4 electrode in the 5th right intercostal space in the midclavicular line • STE in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI.
When do you choose an intra-aortic balloon pump? • Give me 4…
When to place an intra-aortic balloon pump? • • • •
Cardiogenic shock Acute MR or VSD Intractable V tach Refractory angina
• Severe AR…AVOID IABP.
Post-MI complications: 2-7 days out • What will you see with these? • VSD & Papillary muscle rupture • LV free wall rupture
Post-MI complications: 2-7 days out • VSD & Papillary muscle rupture – Both cause: – flash pulm edema – hypotension – loud holosystolic mumur and thrill
• LV free wall rupture – Sudden hypotension or cardiac death assoc w PEA
• Dx: emergency echo
Who are ICDs indicated in? • Give me 3…
Who are ICDs indicated in? • EF< 30% & at least: • >40days since MI • >3months since PCI or CABG
What is associated w increased hospitalizations & death in post MI patients that we should screen everyone for?
What is assoc w increased hospitalizations & death in post MI pts that we should screen for?
Other causes of • Vasospasm (W w migraines)à • Cocaine ( after a party)à • Tall thin, AI murmurà
tx CCB tx CCB
dissectionà CT or TEE
• PE • Tall, thin smokerà
PTXà CXR
Test Yourself • 56 W, 3hr , BP 80/60, HR 120, RR 30 • On exam: +JVD, crackles, S3 • EKG: STE in V2-V6 • What do you want to do next?
Answer • STEMI w cardiogenic shock • Choose cardiac cath & PCI
Test Yourself • 58M , BP 80/50, HR 54 • On exam: +JVD, but clear lungs, no murmur or S3 • EKG: STE II, III, aVF
Answer • RV MI • Choose IVFs • Obtain right-sided EKG for V4R tracing
Chronic Stable Angina: RF Goals • HDL? • A1c? • BP?
Chronic Stable Angina: RF Goals • HDL: <100 • A1c: <7 • BP: <140/90
Don’t Be Tricked • No HRT, Vit E, folate or B12 as tx for CAD • Mod to high risk for CAD? • Rx ASA • if h/o GIB, take ASA w PPI
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? • Abn EKG but can exercise? • LBBB? • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? • LBBB? • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? vasodilator myocardial perfusion imaging • Unable to exercise? • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? vasodilator myocardial perfusion imaging • Unable to exercise? pharm stress myocardial perfusion or dobutamine echo • V paced?
Choose proper test for those w intermediate probability of CAD • Can exercise & norm EKG? exercise EKG • Abn EKG but can exercise? exercise echo or exercise EKG w myocardial perfusion imaging • LBBB? vasodilator myocardial perfusion imaging • Unable to exercise? pharm stress myocardial perfusion or dobutamine echo • V paced?
pharm stress myocardial perfusion
High pretest probability of CAD coming in with stable angina?
• Just cath them :)
High pretest probability of CAD coming in with stable angina?
Tx stable angina • Lifestyle modification for all • Asa, statin, BB – Goal HR 55-60 so uptitrate BB
• If no response to anti-anginals?
Tx stable angina • Lifestyle modification for all • Asa, statin, BB – Goal HR 55-60 so uptitrate BB
• Ranolazine if no response to antianginals – X and X increase levels of ranolazine by 50%, must reduce ranolazine dose if on these drugs – All thru p450
Tx stable angina • Lifestyle modification for all • Asa, statin, BB – Goal HR 55-60 so uptitrate BB
• Ranolazine if no response to antianginals – Diltiazem and verapamil increase levels of ranolazine by 50%, must reduce ranolazine dose if on these drugs – All thru p450
When to add an ACEi? • Give me 4…
When to add ACEi • • • •
EF <35% h/o CAD, stroke, PVD DM 1 additional CAD RF
When is PCI or CABG helpful in chronic stable • Give me another 4 baby… angina?
When is PCI or CABG helpful in chronic stable angina?
• Angina refractory to med therapy • High risk criteria on stress • High risk coronary anatomy • like Lt main or 3ves dz • Sig CAD w red EF
What about CABG in pts w DM? 1. ? 2. ? 3. ?
What about CABG in pts w DM? 1. Sev Left main dz 2. 3 vessel dz 3. 2 ves dz if one is the LAD & there is red EF
Don’t Be Tricked • Don’t select PCI or CABG for stable angina in absence of high risk features
Test Yourself • 69M exertional , normal PE & EKG. Father died of AMI at 61 • What meds do you start? • Andy further testing?
Answer • Rx ASA, SL nitro, BB • Follow up w exercise stress test – Intermediate pretest probability bc of gender & age – no fam hx of premature CAD, no HTN, DM, smoking
Done with ACS/Angina! On To Heart Failure
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Heart Failure • BNP>500 = HF • BNP<100 excludes HF as cause of acute dyspnea
Don’t Be Tricked • BNP can NOT differentiate systolic from diastolic HF • What things increase BNP? • Decrease?
Don’t Be Tricked • BNP can NOT differentiate systolic from diastolic HF • What things increase BNP? – kidney failure, older age, female sex • Decrease? • obesity
PM & ICDs in HF..when to place • BiV pacing for: – NYHA class X, EF<X & QRS >X – NYHA class X, EF<X & QRS >X
• ICD for: – Ischemic and nonischemic CM w EF<X%
PM & ICDs in HF • BiV pacing for: – NYHA class III-IV, EF<35%, & QRS >120msec – NYHA class II, EF<30%, & QRS >150msec
• ICD for: – Ischemic and nonischemic CM w EF<35%
Don’t Be Tricked • Don’t start BB in decompensated CHF • Generally, continue BB during decompensation if were previously stable using BB • Use metoprolol in COPD or asthma • No NSAIDs or TZDs: worsen HF • No role of CCB in systolic CHF • Avoid digoxin in CKD pts or in changing kidney function
Test Yourself • • • •
66W w stable HF, now with orthopnea on ACEi & furosemide BP 140/68, HR 102 overloaded on exam
• What should you do with her meds?
Test Yourself • • • •
66W w stable HF, now with orthopnea on ACEi & furosemide BP 140/68, HR 102 overloaded on exam
• What should you do with her meds? • increase lasix and lisinopril dosages • add BB when pt is stable
HF w preserved EF=diastolic • X medicine – Reduces hospitalizations in diastolic HF but no change in mortality
• Tx underlying causes: – HTN – tachycardia
HF w preserved EF=diastolic • Candesartan – Reduces hospitalizations in diastolic HF but no change in mortality
• Tx underlying causes: – HTN – tachycardia
Dilated CM • Dilation & reduced function of 1 or both ventricles • Get HF, arrhythmias, sudden death • 50% idiopathic • Tx: Reverse underlying cause then standard HF med
Causes of dilated CM • Give me 4…or more..
Causes of dilated CM • Myocarditisàhigh trop – Multinucleated giant cells on bx = giant cell myocarditis
• Alcohol • Drug-inducedàcocaine, amphetamines – Labetolol preferred BB
• Tachycardia-induced • Arrhythmogenic RV dysplasia • Takotsubo’s
Test Yourself • 35M drinker, heart failure on exam • Dx: alcoholic cardiomyopahty • Choose echo & alcohol cessation
Peripartum CM • Dx 1mo before or 5mo after delivery • Avoid ACEi/ARB if still pregnant, deliver early • Should they have more babies?
Peripartum CM • Dx 1mo before or 5mo after delivery • Avoid ACEi/ARB if still pregnant, deliver early • Discourage subsequent pregnancies even if EF recovers
Hypertrophic CM • 50% inherited AD • Tx: avoid strenuous exercise • BB 1st line • ACEi only if reduced EF • All need genetic counseling • When do you choose surgery or septal ablation?
Hypertrophic CM • 50% inherited AD • Tx: avoid strenuous exercise • BB 1st line • ACEi only if reduced EF • All need genetic counseling • When do you choose surgery or septal ablation? • Outflow gradient >50mmHg and symptoms despite max medical therapy
EKG in HOCM • LVH • LAE • Deeply inverted symmetric Ts in V3-V6 – Can mimic ischemia
Don’t Be Tricked • EP studies NOT useful in predicting risk of sudden death in HOCM • ie not the right test answer • Do NOT Rx digoxin, vasodilators or diuretics – All increase outflow obstruction
Test Yourself • 18yo basketball player collapsed at practice • Answer: HOCM – Young person collapses at athletic event
Restrictive CM • Abnormally rigid ventricular walls causes DIASTOLIC DYSFUNCTION without systolic dys • Most have normal systolic function • Right sided HF & pulm HTN from pulm venous congestion • Kussmaul signà
engorged jugular veins w inspiration
• Cathàelevated RV & LV diastolic Ps & characteristic “early ventricular diastolic dip & plateau”
Causes of Restrictive CM • Infiltrative dz – Amyloid, sarcoid, hemochromatosis
• Glycogen storage dz • Endomyocardial process – Fibrosis, hypereosinophilic synd, carcinoid, radiation, anthracycline
• Noninfiltrating dz – scleroderma
Clues in the history in pt with diastolic dysfunction • What might you see? • Amyloidà • Sarcoidà • Hemochromatosisà
Clues in the history in pt with diastolic dysfunction • Amyloidà neuropathy, proteinuria, HM, periorbital ecchymosis – low voltage EKG – Dx: abd fat pad aspiration
• Sarcoidà
hilar LAN, skin, t, eye lesions
– Usual heart block – Dx: cardiac MRI with gadolinium
• Hemochromatosisà
abn LFTs, OA, DM, ED, HF
– Dx: high ferritin and transferrin saturation
OA in hemachromatosis 2nd & 3rd M TS!!!!
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Amyloid purura (NEJM 2007)
Don’t Be Tricked • No endomyocardial biopsy unless hemachromatosis, sarcoidosis, or amyloidosis is suspected – Can do cardiac MRI for sarcoid
BB in Restictive CM: Good or Bad?
BB in Restictive CM • Watch out! • Most have conduction abnormalities and need high HR to maintain CO
Test Yourself • 63M DOE/fatigue • PE: +JVD, prominent jugular a wave, S4, 2/6 holosys murmur at LSB, clear lungs • enlarged tender liver • petechiae over face & periorbital ecchymosis
Answer
Dx: amyloid CM Notice the noncardiac sx
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Done with Heart Failure! Moving on to pericardial disease & restrictive CM
95
Pericardial Tamponade & Constriction • Dyspnea, fatigue, edema, HM, ascites WITH clear lungs • PE: JVD, pulsus paradoxus, tachycardia, reduced HSs, hypotension • Which patients? – – – – –
Cancer Recent cardiac sx Dissecting aneurysm Pericarditis Collagen vascular dz
Kussmaul Sign?
Kussmaul Sign • paradoxical rise in JVP on inspiration • or increase in CVP with inspiration
Tamponade
• No effusion = No tamponade
Constrictive pericarditis • Thick fibrotic pericardium that does not allow ventricular expansion during diastole so get impaired filling – Usually result of pericarditis
• Xray: calcified pericardium • Loud S3 (pericardiac knock) & friction rub
Chronic constrictive pericarditis • CO depends on high preload so careful with diuretics (usually avoid all together) • Pericardiectomy is most effective treatment BUT is unnecesary is pts w early dz (NYHA I) and unwarranted in advanced dz (NYHA IV)
Don’t Be tricked • In constrictive pericarditis, echo will show shifting of ventricular septum to-&-fro during diastole – Manifestation of Rt and Lt Ventricles competing for confined space during filling – These findings are NOT seen in restrictive CM
Restrictive CM vs. Constrictive pericarditis Must be able to differentiate
• Restrictive CM – – – –
S3 Really high BNP EKG: BBB Echo: LVH and atrial enlargement on echo
• Constrictive pericarditis
– Pericardial knock – CXR: calcified pericardium – Echo: Accentuated drop in peak LV filling during inspiration (pulsus paradoxus in tamponade) – Rt heart cath: equalized Lt & Rt diastolic ventricular pressures (within 5mmHg)
Test Yourself • 44W ovarian cancer p/w fatigue, dyspnea, edema. BP 90/50, HR 130, +20mmHg pulsus paradoxis • PE: +JVD that increase w inspiration, reduced HSs • Dx: acute pericardial tamponade likely from metastatic dz • Order echo, give fluids & vasopressors
Acute Pericarditis • Acute sharp stabbing pain worse with inspiration & lying down • Med history: – – – – – –
Cancer Trauma Arthralgia (suggest collagen vasc dz) MI Thoracic sx Hydralazine & minoxidil…WHY?
Classic PE finding • 2 or 3 component pericardial friction rub • EKG: diffuse STE (no reciprocal depressions) – PR dep in limb leads – PR elevation in aVR
• If effusion? • If pulsus paradoxus >10mmHg?
Classic PE finding • 2 or 3 component pericardial friction rub • EKG: diffuse STE (no reciprocal depressions) – PR dep in limb leads – PR elevation in aVR
• If effusion? Electrical alterans • If pulsus paradoxus >10mmHg? Tamponade
Don’t be tricked • CEs may be slightly elevated in isolated pericarditis
Tx pericarditis • 1st line: ASA (after MI), NSAIDs, colchicine • Recurrent pericarditis? – Choose colchicine + aspirin
• Pericarditis that does not respond to ASA or NSAIDs? – Choose 2-3d of steroids • Increases risk of recurrence though 9
• Tamponade or unstable? Emergent pericardiocentesis – So any question that has pulsus paradoxus >10mmHg, the answer is emergen pericardiocentesis
Test Yourself • 57M 2d worse w lying flat. 3 component friction rub • Anser: pericarditis – Look for diffuse STE and PR depr – IGNORE elevated trop tempting you to answer “acute MI”
Cardiology Part 2: Vavular Dz Murmurs
Rheumatic Fever • Give penicillin to pts with group A strep infections – Or erythromycin if penicillin allergy
• h/o of RF: longterm ppx penicillin – Bc recurrent infections are dangerous
• Rheumatic valvular dz: – Ppx for at least 10yrs after last epi of RF – Or until age 40 • Whichever is LONGER
Rheumatic Fever • Mitral valve: MS & MR • AV 2nd most common affected valve
Tx Rheumatic Fever • Abx required even if throat cx negative for GAS • ASA drug of choice – Nonresponse to salicylates makes RF unlikely
Heart Murmurs General Tips • Which increase in intensity w inspiration? • Which increase in intensity w Valsalva or standing from squatting? • Which has a click that may move closer to S1 and lengthen w Valsalva?
Heart Murmurs • Which increase in intensity w inspiration? – Right sided
• Which increase in intensity w Valsalva or standing from squatting? • Which has a click that may move closer to S1 and lengthen w Valsalva?
Heart Murmurs • Which increase in intensity w inspiration? – Right sided
• Which increase in intensity w Valsalva or standing from squatting? – HOCM
• Which has a click that may move closer to S1 and lengthen w Valsalva?
Heart Murmurs • Which increase in intensity w inspiration? – Right sided
• Which increase in intensity w Valsalva or standing from squatting? – HOCM
• Which has a click that may move closer to S1 and lengthen w Valsalva? – MVP
S2 • Normal: should only hear split S2 w inspiration
• Abn splitting of S2 helps differentiate murmurs
Abn splitting of S2 helps differentiate murmurs
Splitting during inspiration & expiration? – Things that delay RV ejection: • • • •
PS VSD w left to right shunt ASD w left to right shunt RBBB
Abn splitting of S2 helps differentiate murmurs
Reversed or splitting only w expiration? – Things that prolong LV ejection: • • • •
AS HOCM ACS w LV dysfunction LBBB
Innocent Murmurs • • • •
Midsystolic Base of heart 1-2/6 without radiation Associated w normal splitting of S2
Signs of SERIOUS disease • • • •
S4 Grade 3/6 or greater Any diastolic murmur Fixed splitting of S2
• If any of these are in the question or pt has symptoms or a continuous murmurà answer is Echo – Any diastolic murmur gets an echo
Don’t Be tricked • An increased P2, S3, early peaking systolic murmur over LUSB are NORMAL in pregnancy • Innocent heart murmurs do not require Echos
Test Yourself • 19 F, asx, murmur on sports exam. Nonradiating, 2/6 midsystolic over RUSB, normal split S2, soft S3 • Dx: innocent murmur, no further work up
Cheat Sheet for the Non-Cardiologist • Mr Ass • Ms Aid • MR & AS è Systolic murmurs • MS & AI è Diastolic murmurs
Aortic Stenosis • Calcifications or AV sclerosis most common cause • Pts w bicuspid valves should be evaluated for dilation of aortic arch • SSX: HF, angina, syncope
Findings of AS • • • •
Midsystolic RUSB Radiates to carotids Pulsus parvus et tardus
– Delayed low amplitude carotid pulse
• CXR: boot shaped heart • Echo: LAE, LVH, calcified AV • Severe AS:
– AVA <1cm2 – Mean transvalvular gradient >50mmHG
Heyde syndrome • What’s That?
Heyde syndrome • Aortic Stenosis + GI Bleed – Acquired von willebrand dz due to disruption of VWF through diseased AV
Don’t be tricked • Echo significantly underestimated the transvalvular gradient in pt with AS & low EF • If the calculated valve area increases with dobutamine stress, then diagnose pseudostenosis • Do NOT select exercise stress test for pts w symptomatic AS!
Pseudostenosisà not on test but will see with your patients • If you have low EF & mild AS, the echo can give you a falsely small AVA making the AS appear severe • This phenomenon is called “pseudostenosis” – Low force of weak LV is not strong enough to open even a weakly stenotic valve • If you give dobuatmineàincrease COàAVA will be more accurate
Work up of AS • Equivocal symptoms: exercise stress test – If hypotensive during exerciseà immediate replacement
• Cath for all pts >35 who are going for AVR – Need to make sure no CAD requiring CABG while the surgeons are in there
Serial Echos for AS?*** • Mild AS? • Moderate AS? • Asymptomatic w severe AS?
Take Note • They love follow-up imaging questions in cards & pulm (because there are guidelines that no one knows, so easy to test & hard to get right)
Serial Echos for AS? • Mild AS? Every 5 years • Moderate AS? Every 2 years • Asymptomatic w severe AS? Every 1 year
When to send for AVR • • • •
Any age if have symptoms Undergoing CABG for CAD LV dysfunction Hypotension during exercise stress
• Young pts with congenital AS & no AV calcificationsà can go for percutaneous valvuloplasty
Test Yourself • 71, HF sx, murmur of AS, EF 30%, calcified AV w mean gradient of 26 • Dx: Severe AS w CM despite low gradient – Bc of severe LV dysfunction
• Choose cardiac cath and probable valve replacement
Aortic Regurgitation • Classified as Chronic & Acute
Chronic AR • Seen w bicuspid AV, marfans, aortic aneurysms • Sx: angina, orthopnea, DOE
PE of AR • Soft S1, soft or absent A1, loud S3 • Diastolic murmur LUSB or RUSB • Louder when leaning forward or exhaling
PE of AR • Wide pulse pressure • • • • •
De Musset sign – bobbing head w heart beat Duroziez sign – systolic M w compression of prox fem A Traube sign – Pistol shot sounds over peripheral arteries Corrigan pulse – Water hammer pulse w abrupt distention & collapse Quincke pulse – Systolic plethora & diastolic blanching in nail beds w nail compressions
Chronic AR • EKG: LAD & LVH • CXR: CM, aortic root dilatation, calcification • Test for syphilis & get echo – “Never marry the man with the bobbing head”…unless he’s super rich…J
Serial Echos in Chronic AR*** • Echo 2-3mo after initial diagnosis to exclude rapid progression • Asx w LV dilatation? Every 6-12mo • Asx with normal LV? Every 2-3yrs
When to go for AVR in chronic AR • • • • •
Symptomatic (even if EF normal) Plan for CABG or other valvular sx Progressive LV dilatation EF<50% Declining exercise performance
Acute AR • Aortic dissection, endocarditis, traumatic rupture (rare) • Short, soft sometimes inaudible diastolic murmur • Normal heart size • Normal pulse pressure
Tx Acute AR • Schedule immediate AVR for acute AR • Bridge w nitroprusside and diuretics
Don’t be tricked • Do NOT select BB or IABP for acute ARà both may worsen AR
Test Yourself • 36, AV endocarditis transferred to ICU w abrupt onset hypotension & hypoxemia. • BP 80/30, HR 120, crackles and gallop. • No murmur • Dx: acute AR • Choose echo, IV sodium nitroprusside & dobutamine as bridge to urgent surgery
Mitral Stenosis • Most common sx: orthopnea & PND • PE: – Prominent a wave – Tapping apical impulse – Right sided HF – Opening snap & attenuated P2 – Low-pitched rumbling diastolic mumur
Give Away on Test
Mitral Stenosis= Snap
Unlike AS, percutanous valvuotomy (repair) is preferred over replacement for MS • MV repair indicated if: – No LA appendage thrombus on echo – Pt is symptomatic with MVA <1cm2 or <1.5cm2 w exercise limitations • If had MS + mild MR, can do repair, but if the MR is mod or sevà have to replace the valve L – Has been on every test I have taken in residency
Test Yourself • 28W 29wks pregnant p/w DOE. • Tachycardia, JVP, parasternal impulse • Opening snap, 2/6 rumbling diastolic murmur w presystolic accentuation • Dx: MS – Classic presentation in pregnancy bc of increased intravascular volume • Choose metoprolol to allow for greater LV diastolic filling time & to relieve pulm HTN
Don’t be tricked • All pts with MS and Afib get warfarin, doesn’t matter the CHADS2 score – CHADS2 only calculated for nonvalvular Afib
Mitral Regurgitation • Like AR, can be chronic or acute
Chronic MR Causes: • MVP • IE • HCM • Ischemia • Marfans • Ventricular dilation • Sx: orthopnea, PND, edema
Murmur of Chronic MR • • • • • • •
Holosystolic Radiates to left axilla Displaced hyperdynamic apical impulse Decreased intensity of S2 Widely split S2 S3 Increased P2
Tx chronic MR • Diuretics, BB, ACEi, +/- digoxin or spironolactone • Associated Afib requires anticoagulation!
When to repair MV? • Symptomatic
– Even if EF & LV size are normal
• Notice this is a theme in all valvular disease
• EF <55% or LV dilated to >45mm – even if no sx
• Repair preferred to replacement (avoid AC) • If from ischemiaà MR should improve after revascularization
Acute MR • Causesà papillary muscle rupture (post MI), – chordae tendineae rupture (myxomatous valve dz) – endocarditis • Sx: Abrupt onset dyspnea, flash pulm edema, cardiogenic shock • PE: right sided HF – Holosystolic murmur at apex that radiates to axilla • There may be NO murmur w acute MR bc wide open
Tx Acute MR • Sodium nitroprusside – Like in AR – but can give nitroglycerine for MR which we avoid in AR
• Another differenceà IABP should be used if unstable acute MR – Worsens AR
• Surgery for acute severe MR
Don’t be tricked • Do not select mitral valve surgery if EF <30%
Test Yourself • 63M asx found to have MR • EF 52%, LV size 51mm • Choose mitral valve replacement or repair
Mitral Valve Prolapse • Most common cause of MR (though most do not have MR) • Usually asx • Can cause , palpitations, syncope, dyspnea, emboli – If sx, tx w BB • High-pitched midystolic click followed by late systolic murmur loudest at apex
Mitral Valve Prolapse
• MVP = Click • Standing from sitting & valsalva cause the click and murmur to come earlier • Squatting does the oppositeà click and murmur are delayed and softer
Test Yourself • 28W w palpitations. Isolated click on exam, echo w mild MR, 24hr ECG w 728 isolated PVCs • What to do next?
Test Yourself • 28W w palpitations. Isolated click on exam, echo w mild MR, 24hr ECG w 728 isolated PVCs • Provide reassurance & counsel on lifestyle modification – Avoid caffeine & other stimulants
Tricuspid Regurgitation • Causes: marfans, ebstein’s, AV canal malformations, IE, carcinoid, pulm HTN, RF • PE: prominent v wave, increased JVP w inspiration, hepatic pulsations • Holosystolic murmur LLSB, increases w inspiration – Know it is either TR or PR if increases w inspiration (right sided) and must be TR if systolic as PR would be diastolic
Don’t Be Tricked • Mild or less severe TR is common, easy to identify on echo, is physiologically normal, and does NOT require treatment
Prosthetic Valves • Valve dysfunction: new cardiac sx, emboli, hemolytic anemia (schistocytes) • If valve dysfunction is suspected, TEE is procedure of choice – Do not select TTE in prosthetic valves
Don’t Be tricked • Begin long term AC for pts with mechanical heart valves – Prosthetic require short but not long term AC but are not as durable and more likely to get infected
Goal INR in mechanical valves • AVà 2-3 • AV + risk factorà 2.5-3.5 – RFs= Afib, prior emboli, hypercoagulable, low EF
• MVà 2.5-3.5 • All should be on ASA
Keep in mind when asked about anticoagulation •
No need to hold AC before cataract sx
•
For AVs, stop warfarin 4-5d before sx, let INR<1.5 and restart as soon as safe post op – Higher flow across AV so less likely to clot than mitral so bridging in low risk pts not necessary
•
If high risk for thrombosis (mitral valve, Afib), bridge with IV heparin once INR<2
•
Do NOT use Vit K to reverse, if needed urgently, use FFP – Takes several days for factors to become deplete again for AC
Atrial Septal Defect • Fixed split S2 • Pulmonic midsystolic murmur • Tricuspid diastolic flow murmur • Ostium secundum most common • EKG: RAD, RBBB • Ostium primum associated w mitral disease
When to close an ASD? • Right atrial or ventricular enlargement • Large left to right shunt • Symptoms – Dyspnea, paradoxical emboli
• Select percutaneous device closure for secundum – vs. surgical closure for primum & associated MV defects
Don’t be tricked • Closure of ASD is contraindicated if shunt reversal is present
Test Yourself • 26 W, no sx, 30wks preg, fixed split S2, 2/6 early SEM in LUSB • Dx: ASD – Like MS, often first discovered in preg bc of increased intravascular volume
Ventricular Septal Defect • Loud systolic murmur that obliterates the S2 • What suggests a hemodynamically important VSD? – Displaced apical impulse – Mitral diastolic flow rumble
When to close a VSD? • Progressive AR or TR • Progressive LV volume overload • Recurrent endocarditis • Large VSDs can cause pulm HTN and right to left shunt (Eisenmenger) – At this stage, closure is contraindicated • Similar to our ASD don’t be trickedà if shunt reversal, no surgery
Cardiology Part 3: Arrhythmias Aortic Dz PAD Preop risk assessment
Palpitations/Arrhythmia work up •
Resting EKG in all
• • •
Ambulatory 24hr ECGà only if daily symptoms Exercise ECGà only if exercise-related Event monitorà for long arrythmias >1-2min where pt’s have enough time to activate the device Loop recorderà for infrequent sx, saves the prior 30sec-2min after pt activates the recorder – Usually the test answer Implanted recorderà invasive, for long term monitoring mo-yr EP studyà for treatment not diagnosis – Rarely the test answer
•
• •
Narrow Complex Tachycardias
Atrial Fibrillation • No Ps • Narrow complex – Wide complex if there is underlying conduction delay like RBBB or accessory pathway
• Irregularly irregular • The presence of deformed Ts or STs “hiding” P waves rule out Afib
Tx Afib • Almost all require AC as the stroke risk in nonvalvular Afib with one other risk factor exceeds risk of bleed • CHADS2
AC in Afib • Because the daily risk of stroke in nonvalvular Afib is low, most do not require bridging when warfarin is interrupted for procedures
Tx Afib • No benefit to rhythm control in elderly – May be appropriate in young w persistent Afib
• Amio- 1st line in ischemic HD & LV dysfunction • For older asx pts, clinical outcomes are not improved with HR <80 compared to more lenient target of <100
Don’t be Tricked • No Digoxin as single agent for rate control • No catheter ablation of AVN before medication trial for rate control • No CCBs, BBs, or digoxin in pts with Afib & WPW – Then they just go down conduction pathway which has no inhibition
Test Yourself • 55W & SOB x12hr • BP 70/40, HR 160 • EKG: wide complex tachycardia shown
Test Yourself • Cardioversion – always the answer in Afib w hemodynamic instability
Atrial Flutter • EKG: saw tooth in inferior leads, positive deflection in V1 • Ventricular response in regular • Most 150 beats per min (2:1 block) • Tx: radiofrequency catheter ablation superior to medical therapy – Bc reentrant tachycardia – AC like you would for Afib
Other Supraventricular Tachycardias
AVNRT much more common than AVRT (85% of the time) AVNRT should be your guess & there should be no visible Ps
AVNRT much more common than AVRT (85% of the time) This is AVRT , notice the Ps are buried in the ST segments
MAT: correct underlying cardiac or pulm dz, low K/Mg. Tx: metoprolol (verapamil if bronchospasm)
Don’t be tricked • Do NOT treat irregular, wide complex tachycardia or polymorphic tachycardia with adenosine
Test Yourself • 32W, 4hr palpitations • BP 80/50, HR very rapid (they do not give a #). • EKG regular, narrow compex tachy of 180 bpm, norm QRS morphology, no Ps are seen • Dx: AVNRT • Choose valsalva, carotid sinus massage, verapamil (can cause hypotension) or IV adenosine
Wolff-Parkinson-White Syndrome • Accessory AV conduction pathway • EKG: short PR, delta wave, norm or long QRS • Afib associated w WPW is a risk factor for sudden death caused by degeneration into VF
Don’t be tricked • Asymptomatic WPW without arrhythmia does NOT require investigation or treatment • Do NOT select CCB, BB or digoxin for pts with Afib & WPW because can convert Afib to VT or Vfib
Tx WPW • ?
Tx WPW • Procainamide • Cardioversion is preferred for any unstable WPW pt • Board Question: pre-op intervention in asx WPW pt?
Test Yourself • 28W, 4hr palpitations • BP 130/80, irregularly irregular HR of 140 • EKG shows Afib w ventricular rate of 180-270. QRS is broad and bizarre • Dx: WPW • Begin IV procainamide
Heart Blocks • Choose IV atropin +/- transcutaneous or transvenous pacing for symptoms of hemodynamic compromise
May precede to 3rd deg block
When to put in a permanent PM? • • • •
Persistent, advanced mobitz type 2 Transient 2nd degree block w BBB 3rd deg block Symptomatic block at any level
Ventricular Tachycardia QRS >120msec & AV dissocation Nonsustained <30sec 1. Vtach
Monomorphic (no variation in QRS complexes) Polymorphic
2. Torsades de pointesà specific form of polymorphic VT associated w long QT 3. Vfib
VT vs. SVT w aberrancy • Which is more common?
VT vs SVT w aberrancy • VT much more common, so any wide complex tachycardia should be considered VT til proven otherwise (so no adenosine) – If prior MI or structural heart dz, chance of it being VT even higher
Don’t Be tricked • In pts w structural heart disease, therapy to suppress PVCs does NOT affect outcomes
Tx PVCs • BB only for: – Disabling symptoms – Nonsustained VT with symptoms • Acute sustained VT – Hemodynamically stable w impaired EFà IV lidocaine or amio – Unstableà immediate electrical cardioversion • ICDs reduce sudden cardiac death in VF or sustained VT associated w hemodynamic compromise
Test Yourself • 65W chronic stable angina, prior MI, p/w lightheadedness & palpitations. • Vitals stable. • EKG w wide complex tachycardia & RBBB. • No prior EKGs for comparison • Dx: likely sustained VT • Acute tx: IV lidocaine or amio
Sudden Cardiac Death • Risk greatest when QTc >500 • Select echo for survivors of sudden cardiac death • Brugada syndrome?
Brugada syndrome • Inherited, structurally normal heart but abnormal conduction system associated w sudden death – Incomplete RBBB w STE in V1-V2
Who gets an ICD? • Survivors of cardiac arrest 2/2 VF or VT not explained by reversible cause • After sustained VT in presence of structural HD • EF <35% • Brugada syndrome • Inherited long QT synd not responding to BB • After MI w EF <30% 3mo later • High risk HOCM pts – Familial sudden death, multiple repetitive nonsustainedVT, extreme LVH, exercise hypotension
Test Yourself • 55M 4mo after large MI, asx, Ef 28% • Answer: pt at high risk for sudden cardiac death and should be considered for ICD
Aortic Atheroemboli*** • Clinical findings: livido reticularis, gangrene of digits, transient vision loss • A golden or brightly refractile cholesterol body within a retinal A (Hollenhorst plaque) is pathognomonic • Common presentation: stroke or AKI after cardiac or aortic sx or cath • Dx by biopsy of muscle, skin, kidney or other organs • Tx: control CV risk factors
Test Yourself • • • •
67 M w AKI 10d after cath BP 170/100 bruits over abd and femoral A legs are lacy & purple
• Look for cholesterol emboli to skin and kidneys • Choose skin biopsy & control all CV risk factors
Coarctation of the Aorta • • • •
HTN Diminished femoral pulses Radial-to-femoral delay Murmur of AS w continuous murmur audible over the back
• CXR: classic “figure 3” • MRA confirms the diagnosis • Tx: balloon dilatation
Test Yourself • 35 immigrant female w cold feet and leg cramping w walking. • BP 160/90. • Systolic murmur at RUSB • Dx: coarctation w bicuspid AV • Be alert for congenital HD in questions about “immigrant” patients
Thoracic Aortic Aneurysm & Dissection • Yearly echo until root 4.5cm, then every 6mo • Repair when 5-5.5cm • Counsel against pregnancy if root >4cm
Symptoms & Signs • Compressionà
– hoarseness, dysphagia, recurrent PNA, SVC syndrome
• Chest, flank, abd, back pain
• New AR murmur • HF • BP differential between arms • CXR: wide mediastinum • Dx: TEE, CT w contrast, MRA
Type A=Surgery • Type A dissections involve the ascending aorta, all other class B • Emergent surgery is required for Type A dissections. Uncomplicated type B dissections can by treated w medical therapy alone – BB
When to do prophylactic surgery • • • •
Sxs of hoarseness, dysphagia, back pain Ascending aorta diameter of >50-60mm Descending aorta diameter of >60-70mm Rapid growth of >10mm/year
Don’t be tricked • Which anti-HTN do you not use for acute aortic dissection bc it increases shear stress?
Don’t be tricked • Do NOT use hydralazine for acute aortic dissection bc it increases shear stress • Schedule surgery for type B dissection if major vessel like a renal artery is involved
Test Yourself • 73M, 1hr severe tearing • BP 90/60 on right and 130/70 on left • CXR w widened mediastinum • Dx: dissection of the aortic arch • Choose BB, sodium nitroprusside and emergent imaging
Abdominal Aortic Aneurysm • Screening: one time U/S indicated for asx AAA in any male who has EVERY smoked between 65-75yo • Pulsatile abd mass • Tx: CV risk factors, BB preferred
Don’t be tricked • U/S is NOT accurate for diagnosing ruptured AAA – New abd, flank or back pain with shock/syncope – CT or MRA
When to repair an asx AAA? • >5.5cm in diameter • Growth of >0.5cm/yr • Symptomatic • Follow up for unrepaired AAA – If >4cm every 6mo – If <4cm every 2-3yrs
Peripheral Arterial Disease • RF: age, smoking, DM, HLD • Intermittent claudication is the classic sign • Ddx spinal stenosis (pain when standing that resolves with sitting, lying or leaning forward)
5 Ps • • • • •
Pain Paresthesias Pallor Paralysis Pulselessness
ABI • Highest systolic arm BP compared to highest systolic ankle BP (ankle/arm) • <0.9 =PAD • <0.4 ischemic rest pain • False normal in diabetics w calcified noncompressible arteries (ABI >1.4)
Don’t be tricked • ABI >1.4, then a toe-brachial index will be a better assessment
Tx PAD • PAD= CAD risk equivalent – Same BP & lipid goals
• All with symptomatic PAD should begin a supervised exercise training program • Meds: ASA, statin (LDL<100) – cilostazol for sx PAD – ramipril (reduces MI, stoke or vascular death in PAD)
Acute arterial ischemia • Antiplat, heparin and urgent surgery • If chronic but rest pain or poorly healing ulcersà schedule angioplasty or surgery – All others get medical therapy
Don’t be tricked • Do not use cilostazol in pts with low EF or h/o HF • BB are NOT contraindicated in pts w PAD
Test Yourself • 60M, 6mo claudication thighs & calves. • ABI 0.66 & 0.55 • Symptomatic despite lifestyle management program • Choose to begin cilostazol
Preop Cardiac Risk Assessment • Should delay elective surgery for the following active cardiac conditions: – ACS (MI<30d ago, unstable or severe angina) – Decompensated HF – Sig arrhythmia – Severe valvular dz
Who can go for elective surgery without further cardiac w/u? • Low risk sx – endoscopy, breast, cataract, outpt sx
• >=4METs – can climb a flight of stairs, walk up a hill, walk at 4mi/hr without sx
RCRI used to risk stratify the other ppl
*0= no further tests *3 or more RFs if undergoing a vascular sx & further workup will change their management? may get additional cardiac work up; consider BB
Who does not need preop assessment? Patients at low risk who: • Having minor surgery under local anesthesia (cataracts) w no comorbidities • <55yo, no murmurs, no illnesses • Recent normal cath (past 6m-1y) & no new sx • Require emergent surgery • Isolated BP <180/100 does not increase risk of complications
On every test I’ve taken • Postpone elective surgery in someone who has received a bare metal stent for at least 46wks & 1yr if received drug-eluting stent
Post Surgical MIs • Most within 24-48hrs after surgery • 50% have , the other 50% may have new onset HF, hypotension or SVT • Asx pts at high cardiac risk should be monitored w EKGs and CEs for up to 1wk postop
Test Yourself • 82M evaluated for preop eval for AAA • HTN on ACEi, no h/o MI, stroke, angina, arrhythmia, kid dz, DM. BP 130/80, exam normal, Cr 1.2, EKG w LVH – (RCRI 0)
• Choose proceed to surgery without additional preop testing
BREAK TIME
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