Cardiac Flashcards
(54 cards)
Most common complications of endocarditis
CHF
CNS disorder
Peripheral embolization
Cutaneous embolic phenomena of endocarditis
- Splinter or subungual hemorrhages of finger/toenails
- Osler nodes - (small, tender subcutaneous nodules on the pads of the fingers or toes)
- Janeway lesions - (small hemorrhagic painless plaques on the palms or soles)
Admitting for endocarditis
- Febrile injection drug users
2. Admit all patients with a cardiac prosthetic valve and fever (or persistent malaise, vasculitis, or new murmur)
Abx for endocarditis
- Uncomplicated hx - Ceftriaxone, Oxcacillin, or Vancomycin PLUS Gentamicin or Tobramycin
- Injection drug users: Nafcillin + Gentamicin + Vancomycin
- Prosthetic heart valve: Rifampin + Gentamicin + Vancomycin
Iatrogenic causes of acute heart failure
Recent addition of negative inotropic drugs (e.g., calcium channel blocker, β-blocker)
Initiation of salt-retaining drugs (e.g., NSAID, steroids, thiazolidinediones- glitazones)
Inappropriate therapy reduction
New antiarrhythmic agents
Acute heart failure with hypotension, tx:
Ionotropic therapy:
norepinephrine, dopamine, or dobutamine
Hypertensive acute heart failure, tx:
- O2
- Nitroglycerin (venous and arterial dilator). Sublingual then IV if needed
- IV loops diuretics - Furosemide of Bumetanide for volume overload
- Admite or discharge after obs
Diuretics without vasodilators in acute hypertensive HF?
NO - vasodilators first
Diuretics (furosemide most commonly used) administered alone without vasodilators for hypertensive heart failure may increase mortality44 and worsen renal dysfunction.
successful management of blood pressure and cardiac filling pressure creates marked improvement in respiratory status long before any diuresis.
Contraindications to using vasodilators in acute HF
Signs of hypoperfusion or hypotension
Flow-limiting, preload-dependent states such as right ventricular infarction, aortic stenosis, hypertrophic obstructive cardiomyopathy, or volume depletion increase the risk of vasodilator-associated hypotension
Flow-limiting, preload-dependent states
Right ventricular infarction
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Volume depletion
Normotensive HF tx:
Diuresis first
Loop diuretic electrolyte complications
Hypokalemia - keep an eye out for increasing QT interval
also hypocalcemia, hypomagnesemia
Drugs to avoid in Heart Failure
Calcium Channel Blockers (verapamil, diltiazem, amlodipine,
NSAIDs
High-risk physiologic markers in ED patients with acute heart failure associated with morbidity and mortality
Renal dysfunction
Low BP
Low sodium
Elevated BNP or Troponin
Diagnosis of STEMI vs NSTEMI
STEMI = ECG changes in presence of suggestive sx
NSTEMI = depends on cardiac biomarkers, but may include ECG changes
Inferior wall AMIs on ECG
ST-segment elevations in II, III, and aVF
get V4 on right side to check for ST elevation there too!
ST-segment elevations in II, III, and aVF + V4 (right side)
Suggestive of right ventricular infarction = NO NITRO
Reciprocal ST-segment changes—those in leads away from or opposite the elevation area—
– are from subendocardial ischemia and denote a larger area of injury risk, an increased severity of underlying CAD, more severe pump failure, a higher likelihood of cardiovascular complications, and increased mortality.
In general, the more elevated the ST segments and the more ST segments that are elevated, the more extensive is the injury.
In the setting of an inferior wall AMI (II, III, aVF), ST-segment elevation in at least one lateral lead (V5, V6, or aVL) with an isoelectric or elevated ST segment in lead I is strongly suggestive of lesion i which artery
Left circumflex
The presence of ST-segment elevation in lead III greater than that in lead II predicts
a right coronary artery occlusion
ST seg elevation in lead III greater than lead II, accompanied by ST-segment elevation in V1 or a V4R, it predicts
a proximal right coronary artery lesion with accompanying right ventricular infarction
pattern of abnormal T waves in the precordial leads V2and V3 associated with critical stenosis of the left anterior descending artery
Wellen’s sign (deeply inverted T waves or biphasic)
V2, V3 especially
Present in 18% of unstable angina
STEMI/NSTEMI/unstable angina initial tx:
- Aspirin
- Clopidogrel, Ticagrelor, Prasugrel
- Nitroglycerine
- Beta blockers
- Antithrombin > Enoxaparin, unfract heparin, or fondaparinux
Antithrombin options for STEMI/NSTEMI tx
Enoxaparin (Lovenox, LMWH)
Unfractionated heparin
Fondaparinux
all bind antithrombin III, inhibit Xa and thrombin
