Cardiology Flashcards
(114 cards)
1
Q
Acute Coronary Syndrome: Chest Pain Evaluation
- General term for conditions where the blood supplied to the heart muscle is suddenly re____ or b_____
- Chest pain caused by acute coronary syndromes may occur s_____
- Pain can be unpredictable or worsens even with rest, both hallmark symptoms of ______angina.
A
- General term for conditions where the blood supplied to the heart muscle is suddenly reduced or blocked.
- Chest pain caused by acute coronary syndromes may occur suddenly
- Pain can be unpredictable or worsens even with rest, both hallmark symptoms of unstable angina.
2
Q
ACS Incidence
- 1/__ of all deaths in the world due to heart disease
- ~ 7.5 million deaths are estimated to be due to (1) (IHD)
- More than 3 million cases per year in US
- A coronary event occurs every 26 seconds, and someone dies from one every ______ in the USA
A
- 1/3 of all deaths in the world due to heart disease
- ~ 7.5 million deaths are estimated to be due to ischemic heart disease (IHD)
- More than 3 million cases per year in US
- A coronary event occurs every 26 seconds, and someone dies from one every minute in the USA
3
Q
Cardiac Arrest
- occurs ______
- triggered by an e_______ malfunction in the heart that causes an irregular heartbeat (1).
- P______ action disrupted, the heart cannot pump blood to the br____, l____ and other organs. Seconds later, a person
- loss c______ness and ______ of pulse.
- D_____ occurs within minutes without treatment.
A
- occurs suddenly
- triggered by an electrical malfunction in the heart that causes an irregular heartbeat (arrhythmia).
- Pumping action disrupted, the heart cannot pump blood to the brain, lungs and other organs. Seconds later, a person
- loss consciousness and absence of pulse.
- Death occurs within minutes without treatment.
4
Q
Chest Pain Evaluation in outpatient setting
The signs and symptoms of acute coronary syndrome usually begin abruptly. They include:
- Chest pain (1) or discomfort, often described as a____, pr_____, t____ness or b_____
- Pain r_______ from the chest to the sh_____, a____, upper ab_____, b___, n___ or j___
- N_____ or v_____
- In_______
- Shortness of breath (1)
- Sudden, heavy sweating (1)
- ______headedness, d_____ess or f_____
- Unusual or unexplained f______
- Feeling r_____less or appr_______
A
- Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning
- Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw
- Nausea or vomiting
- Indigestion
- Shortness of breath (dyspnea)
- Sudden, heavy sweating (diaphoresis)
- Lightheadedness, dizziness or fainting
- Unusual or unexplained fatigue
- Feeling restless or apprehensive
5
Q
Causes of Chest Pain in Outpatient Setting
A
6
Q
Chest Pain Assessment Tool (mnemonics)
PQRST =
CHEST =
PAIN =
A
7
Q
Chest Pain Assessment Tool
OLDCARTS =
A
8
Q
Risk Factors for Heart Disease
- Unsafe lifestyle
- S_______
- Physical _____
- Diet high in ____
- High risk diseases
- Hy_______
- D_______
- Hy_______
- O________
A
- Unsafe lifestyle
- Cigarette smoking
- Physical activity
- Diet high in fat
- High risk diseases
- Hypertension
- Diabetes
- Hyperlipidemia
- Obesity
9
Q
Risk Factors for Heart Disease
- Non-Modifiable Factors
- A____
- ______ History of (1)
- End Organ Damage
- H____ disease
- St_____
- P______ artery disease
- Chronic k_____ disease
- E_______ failure
A
- Non-Modifiable Factors
- Age
- Family History of premature coronary artery disease (CAD)
- End Organ Damage
- Heart disease
- Stroke
- Peripheral artery disease
- Chronic kidney disease
- Eyesight failure
10
Q
Diabetes and Cardiometabolic Disease
- Approximately 68 percent of people age 65 or older with diabetes die from some form of _____ disease; and 16% die of ____.
- Adults with diabetes are __-__X more likely to die from heart disease than adults without diabetes.
- The American Heart Association considers diabetes to be one of the seven major ____trollable risk factors for cardiovascular disease.
A
- Approximately 68 percent of people age 65 or older with diabetes die from some form of heart disease; and 16% die of stroke.
- Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes.
- The American Heart Association considers diabetes to be one of the seven major controllable risk factors for cardiovascular disease.
11
Q
HTN and HLD
High blood pressure (hypertension): risk for cardiovascular disease ______ with the presence of both HTN and Diabetes (VERY COMMON COMBINATION!)
Hyperlipidemia : ____ LDL (“bad”) cholesterol, ____ HDL (“good”) cholesterol, and high tr_____.
- This triad of poor lipid counts often occurs in patients with (1).
A
High blood pressure (hypertension): risk for cardiovascular disease doubles with the presence of both HTN and Diabetes (VERY COMMON COMBINATION!)
Hyperlipidemia : high LDL (“bad”) cholesterol, low HDL (“good”) cholesterol, and high triglycerides.
- This triad of poor lipid counts often occurs in patients with premature coronary heart disease.
12
Q
Obesity and Lack of Exercise
Obesity: Major risk factor for cardiovascular disease
- strongly associated with ______ resistance.
- (1) can improve cardiovascular risk, ______ insulin concentration and _____ insulin sensitivity.
Lack of Exercise:
- _____fiable major risk factor
- Leads to insulin ______ and cardiovascular disease.
- Exercising and weight loss can prevent or delay the onset of type 2 (1), reduce blood (1) and help reduce the risk for heart (1) and (1)
A
Obesity: Major risk factor for cardiovascular disease
- strongly associated with insulin resistance.
- Weight loss can improve cardiovascular risk, decrease insulin concentration and increase insulin sensitivity.
Lack of Exercise:
- modifiable major risk factor
- Leads to insulin resistance and cardiovascular disease.
- Exercising and weight loss can prevent or delay the onset of type 2 diabetes, reduce blood pressure and help reduce the risk for heart attack and stroke.
13
Q
Smoking and Genetic Factors
Smoking:
- Damages the arterial _____, leading to ______ or build up of _____ material which leads to the ______ of the arteries
Genetic factors:
- play a role in high blood pressure, heart disease, and other related conditions.
- people with a family history of heart disease share common en_______ and other potential factors that increase their risk.
A
Smoking:
- Damages the arterial lining, leading to atheroma or build up of fatty material which leads to the narrowing of the arteries
Genetic factors:
- play a role in high blood pressure, heart disease, and other related conditions.
- people with a family history of heart disease share common environments and other potential factors that increase their risk.
14
Q
Coronary Arteries
A
Obtuse marginal is on the back off the left circumflex
15
Q
Coronary Arteries on ECG
A
16
Q
Likelihood of Coronary Artery Disease
A
17
Q
ST Elevation - NOT ALWAYS MI
ELEVATION Mnemonic =
A
18
Q
Diagnosis of Acute Coronary Syndrome (ACS)
- A complete blockage of a coronary artery means you suffered a (1)
- A partial blockage translates to a (1)
- Labs tests: (3)
- E___
- E________
A
- A complete blockage of a coronary artery means you suffered a STEMI heart attack – which stands for ST-elevation myocardial infarction.
- A partial blockage translates to an NSTEMI heart attack – a non-ST-elevation myocardial infarction.
- Labs tests: Troponin, CPK, CK-MB
- EKG
- Echocardiogram
- ** Troponin is needed every 46 hours inpatient.*
- Echo should be read by cardiology ideally not radiology*
- If high suspicion – troponin shouldn’t really be taken in primary care office – should send to ED*
- NSTEMI = partial blockage, STEMI = complete blockage*
19
Q
Chest Pain Eval
A
20
Q
What does this EKG show?
A
This EKG was from a patient who went on to develop ST elevation and V-fib arrest. If you are suspicious of hyperacute T waves, get frequent repeat EKG’s to identify ST elevation or other evolution
Beware the Hyperacute T wave in the setting of chest pain. Hyperacute T waves may not always have ST elevation. The real key is the T wave’s size in relation to the QRS complex. This EKG was from a patient who went on to develop ST elevation and V-fib arrest. If you are suspicious of hyperacute T waves, get frequent repeat EKG’s to identify ST elevation or other evolution.
21
Q
What does this EKG Show?
A
Cerebral T waves which can be seen in subarachnoid hemorrhage. Subarachnoid hemorrhage can cause changes on the EKG such as deep t wave inversions or ST elevation. -> not everything on an EKG is from a cardiac cause
ECG Findings of Cerebral T Waves
- Inverted, wide T waves are most notable in precordial leads (can be seen in any lead).
- QT interval prolongation.
Pearls
- These are associated with acute cerebral disease, most notably an ischemic cerebrovascular event or subarachnoid hemorrhage.
- They may be accompanied by ST segment changes, U waves, and/or any rhythm abnormality.
- Differential diagnosis includes extensive myocardial ischemia.
- Strongly suspect an intracranial etiology in a patient with altered mental status and these electrocardiographic findings. (Atlas of EM)
22
Q
What tool is used to assess someone’s CVD risk outpatient?
A
ASCVD Risk Calculator
(ALWAYS PERFORM)
23
Q
What is the Inpatient ACS Risk Calculator?
What’s the difference?
A
Duke Clinical Score
More detailed than ASCVD
24
Q
NYP STEMI Protocol
A
NYP STEMI Protocol
- Do NOT give beta blocker if hypotensive
- TNK (we never really give tenecteplase unless neuro thinks they’re having an acute event)
- Stat meds can be given all at once
Long term maintenance
- Plavix common but slowly moving towards ticagrelor-Should not be on nitrate, P2y12, and warfarin at once, will wean off nitrate and be on the other two-LIFETIME beta blocker!
25
NSTEMI Protocol
What is the main difference?
Guidelines pretty much the same
If not acute can go to cath lab within 24 hrs (not as urgent as STEMI)
26
Common Complications from Myocardial Infarction
*BB to prevent afib post MI*
27
Management of Acute coronary syndrome
Main Procedures
1. **(3)**
* Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cut off.
* _Often combined with implantation_ of a stent to help open blocked arteries.
2. **(1)** Similar to angioplasty except that the catheter has a laser tip that opens the blocked artery. Pulsating beams of light vaporize the plaque buildup.
3. **(1)** needed when 3 or more diseased arteries/blockages
1. **Angioplasty [Percutaneous Coronary Interventions [PCI], Balloon Angioplasty and Coronary Artery Balloon Dilation.**
* Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cut off.
* _Often combined with implantation_ of a stent to help open blocked arteries.
2. **Angioplasty, Laser:** Similar to angioplasty except that the catheter has a laser tip that opens the blocked artery. Pulsating beams of light vaporize the plaque buildup.
3. **CABG- Coronary artery bypass surgery** needed when 3 or more diseased arteries/blockages
28
Dual Antiplatelet Therapy post PCI
=
**Aspirin + Second Agent**
Second Agents include
* Clopidogrel (Plavix®)
* Prasugrel (Effient)
* Ticagrelor (Brilinta)
* Dipyridamole
29
(1)
* Decreases (2), which lowers blood pressure and makes the heartbeat more slowly and with less force.
* Used to treat cardiac arrhythmias and in treating chest pain (angina).
* Used in patients with some degree of heart failure post myocardial infarction.
**Beta Blockers**
* Decreases **heart rate and cardiac output**, which lowers blood pressure and makes the heartbeat more slowly and with less force.
* Used to treat cardiac arrhythmias and in treating chest pain (angina).
* Used in patients with some degree of heart failure post myocardial infarction.
30
Cholesterol Lowering Medication Classes
(4)
Statins
Nicotinic Acids
Cholesterol Absorption Inhibitors
PCSK9 Inhibitors
31
Statins
Which 2 do we like post MI?
\_\_\_\_\_\_\_ (Lipitor)
\_\_\_\_\_\_\_\_ (Lescol)
\_\_\_\_\_\_\_ (Altoprev)
\_\_\_\_\_\_\_ (Livalo)
\_\_\_\_\_\_\_ (Pravachol)
\_\_\_\_\_\_\_\_ (Crestor)
\_\_\_\_\_\_\_\_ (Zocor)
**Atorvastatin 80mg or Rosuvastatin 40mg** with goal LDL _\<_70 preferred post MI
## Footnote
**Atorvastatin (Lipitor)**
Fluvastatin (Lescol)
Lovastatin (Altoprev)
Pitavastatin (Livalo)
Pravastatin (Pravachol)
**Rosuvastatin calcium (Crestor)**
Simvastatin (Zocor)
32
Nicotinic Acids
(1) Rx
(2) Indications
**Niacin**
Treats high cholesterol and triglyceride levels, Treates niacin (B3) deficiency
33
Cholesterol Absorption Inhibitors
Rx (1)
Ezetimibe/Simvastatin (Vytorin)
34
**PCSK9 Inhibitors**
**(2) Rx**
**MOA**
Route, Frequency
When is this medication used?
Mainly used in what adults?
**Alirocumab (Praluent) and Evolocumab (Repatha)**
They block a protein called PCSK9 to make it easier for the body to remove LDL from the blood.
Biweekly Injection
Used in patients who are unable to manage their cholesterol through lifestyle and statin treatments.
They are mainly used in adults who inherit a genetic condition called “heterozygous familial hypercholesterolemia”
35
Vasodilators
Indication (1)
Commonly prescribed include:
* Isosorbide \_\_nitrate (Isordil)
* Isosorbide \_\_\_\_nitrate (Imdur)
* Hy\_\_\_\_\_\_ (Apresoline)
* Nit\_\_\_\_\_ ( SL, topical, )
*For pts who continue to complaint of angina symptoms post stenting*
* Isosorbide dinitrate (Isordil)
* Isosorbide mononitrate (Imdur
* Hydralazine (Apresoline)
* Nitrates ( SL, topical, )
36
**Diuretics**
Commonly prescribed include:
* Am\_\_\_\_\_ (Midamor)
* \_\_\_etanide (Bumex)
* Chl\_\_\_\_\_\_ (Diuril)
* Chl\_\_\_\_\_\_ (Hygroton)
* F\_\_\_\_\_\_ (Lasix)
* Hy\_\_\_\_\_\_ (Esidrix, Hydrodiuril)
* \_\_\_\_pamide (Lozol)
* S\_\_\_\_\_\_\_ (Aldactone)
* Amiloride (Midamor)
* Bumetanide (Bumex)
* Chlorothiazide (Diuril)
* Chlorthalidone (Hygroton)
* Furosemide (Lasix)
* Hydro-chlorothiazide (Esidrix, Hydrodiuril)
* Indapamide (Lozol)
* Spironolactone (Aldactone)
37
Heart Disease Risk Evaluation in Women - Summary Algorithm
Main point is Do risk assessment for women! Often overlooked
38
Case Study 1
## Footnote
Patient A was a woman, 88 years of age, who lived in an assisted living retirement home. She had been a widow for 20 years, after losing her husband to long-term complications associated with diabetes. Until approximately seven years ago, Patient A had been in relatively good health with no major health problems, but she suffered a mild stroke at 81 years of age. At that time, she decided to quit her 50- to 60-year smoking habit. Other than her smoking history, she did not have any other significant cardiovascular risk factors.
After recuperating from her stroke, Patient A decided to leave her apartment and move into the assisted living facility where she would not only have some companionship but also receive assistance with meals and transportation to doctor's appointments and other activities. About six years after suffering the cerebrovascular accident, she had a bout of heart failure. She was admitted to the local hospital and received oxygen per nasal cannula, IV furosemide, and digoxin. After two weeks in the hospital, the patient was discharged home in apparently better condition. However, two days after returning home Patient A suffered a sudden cardiac death event at the breakfast table. Efforts at resuscitation were unsuccessful.
1. What coronary risk factors are present? What risk factors are negative?
2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?
Smoking, stroke, age. Negative risk factors no DM, HTN.
not typical for a women, sudden cardiac death more common for men
- her MI was probably missed/ had it before the heart failure
39
Case Study 2
## Footnote
**Patient S** is caucasian woman, 43 years of age, and mother of three small children. She has a long-standing history of significant obesity with little success in dieting over the years. At 5'3", she is obese, weighing 220 pounds. Her fat distribution is "apple-shaped" and consequently, her waist-hip ratio is more than the 0.8 normal range. In addition, Patient S lives a fairly sedentary lifestyle and does not have a regular exercise program. Her dietary habits do not take into account basic recommendations for cardiac nutrition.
**Patient J** is 55 years of age and teaches high school English. Her coronary risk factor profile includes a 30-pack-year history of cigarette smoking and altered lipid levels. Her HDL is only 35 mg/dL and her LDL is 145 mg/dL. Patient J has tried with little success to control her cholesterol with diet. Recently, she began taking gemfibrozil as prescribed by her family physician, but has not followed his recommendation to quit smoking and enroll in a smoking cessation program at a local hospital. Rather, she continues to smoke one pack of cigarettes per day.
**Patient V** is a woman, 47 years of age, who has a family history of heart disease. Although she denies ever experiencing cardiac symptoms, her brother suffered a nonfatal MI at 46 years of age and her father had an MI at 53 years of age. Both of these cardiac events were medically managed. However, her father's disease did progress to the point that he underwent CABG surgery five years ago. He had three coronary artery lesions bypassed. In addition to her family history, Patient V is approximately 30 pounds overweight and does not exercise on a regular basis. She drinks approximately two to three glasses of red wine per day and has never smoked.
**Patient D** is 67 years of age and lives in an assisted living retirement community. An insulin-dependent diabetic since adolescence, Patient D is unable to care for herself due to the effects of the diabetes on her eyesight, as well as the development of peripheral neuropathies. In addition to the diabetes, Patient D continues to smoke. By now, she has a 40-pack-year history of smoking.
**Patient F** is an African American woman, 36 years of age, with a history of mild hypertension. Her blood pressure has been fairly well controlled on an ACE inhibitor over the past two years. Patient F eats a well-balanced, nutritious diet, exercises three to five times a week, and does not have a history of smoking or alcohol use. However, she does exhibit many of the characteristics of the Type A behavior pattern, such as excessive competitiveness, being harried, and rushing to complete more and more tasks in an ever-shrinking period of time. In addition to these characteristics, she exhibits a somewhat cynical or negative outlook with occasional expression of hostile or angry thoughts and feelings.
**1.****Which of these women is at greatest risk for heart disease?**
**2.****Who is at least risk?**
**3.****What recommendations would you make in counseling each patient regarding her cardiovascular health?**
**1.****Which of these women is at greatest risk for heart disease?****V**
**2.****Who is at least risk?****F**
**3.****What recommendations would you make in counseling each patient regarding her cardiovascular health?**
* **Smoking also decreases HDLs…recommend cessation.**
* **Stress increases likelihood of CV event**
* **Genetic hx increases likelihood of CV event**
40
Carotid Artery Stenosis
* These arteries carry blood to the h\_\_\_\_, f\_\_\_\_, and b\_\_\_\_.
* Carotid artery stenosis can be caused by **(1)** build-up in the blood vessels (ath\_\_\_\_\_\_).
* Thromboses in coronary and cerebral arteries are complications of ath\_\_\_\_\_\_\_.
* Condition is present for a long time before _______ appear.
* St\_\_\_\_\_ or T\_\_\_s may occur.
* Carotid artery stenosis, accounts for approximately 18%–25% of (1)
* These arteries carry blood to the head, face, and brain.
* Carotid artery stenosis can be caused by cholesterol build-up in the blood vessels (atherosclerosis).
* Thromboses in coronary and cerebral arteries are complications of atherosclerosis.
* Condition is present for a long time before symptoms appear.
* Stroke or TIAs may occur.
* Carotid artery stenosis, accounts for approximately 18%–25% of ischemic stroke
*Same risk factors as CAD - so treat the modifiable risk factors*
41
CAS Detection
1. **(1)** uses sound waves to create real-teim pictures of the arteries and locate blockages. Doppler is a special ultrasound technique that can detect areas of restriced blood flow in the artery.
2. **_(_1)** uses a CT scanner to produce detailed views of the arteries in the neck. The test is particularly useful for patients with pacemakers or stents.
3. **(1)** noninvasive test gives information similar to CTA without using ionizing radiation.
4. **(1)** minimally invasive test in which a catheter is guided through an artery in the groin to the area of interest in the brain. Contrast material is injected through the tube and images are captured with x-rays.
1. **_Carotid ultrasound:_** uses sound waves to create real-teim pictures of the arteries and locate blockages. Doppler is a special ultrasound technique that can detect areas of restriced blood flow in the artery.
2. **_Computed Tomography Angiography (CTA):_** uses a CT scanner to produce detailed views of the arteries in the neck. The test is particularly useful for patients with pacemakers or stents.
3. [**_Magnetic resonance angiography_**](https://www.radiologyinfo.org/en/info/angiomr) (MRA): This noninvasive test gives information similar to CTA without using ionizing radiation.
4. [**_Cerebral angiography**_](https://www.radiologyinfo.org/en/info/angiocerebral)_**:_**cerebral angiography is a minimally invasive test in which a catheter is guided through an artery in the groin to the area of interest in the brain. Contrast material is injected through the tube and images are captured with x-rays.
42
Carotid Artery Stenosis Disease Management
1. Selection of treatment depends on?
2. Medical Tx to reduce stroke from CAS (4)
3. Current Tx of CAS **(3), + (1) right before procedure?**
4. How to treat symptomatic Bilateral CAS? Which side do you treat first?
5. How to treat asymptomatic Bilateral CAS? Which side do you treat first?
1. Tx depends on symptomatic status, severity of stenosis, individual risk factors, efficacy and risk of complications
2. **Aspirin, statin, antiplatelets and tight BP contro**l
3. Current treatment of carotid artery stenosis includes
* **optimal medical therapy**
* **carotid endarterectomy (CEA)**
* **carotid artery stenting (CAS).**
* Dual platelet therapy has been recommend during the peri-procedural period and for at least 1 month after CAS.
4. Bilateral carotid stenosis is not rare in patients with atherosclerotic disease - If surgery is indicated, then the **symptomatic side** first.
5. For bilateral asymptomatic stenosis, the **more** **severe stenosis** **first**. If the degree of stenosis is similar on both sides, then the artery supplying the **dominant hemisphere** first.
43
CAS Management Notes
***(1)** Risk factor control: important risk factor for ECAD*
* *\_\_\_\_\_/\_\_\_\_\_ = Goal BP in non-diabetic patients with asymptomatic carotid stenosis*
* _\<_ _____ diastolic BP goal if pt has concomitant diabetes
***Hypertension*** *Risk factor control: important risk factor for ECAD*
* *140/90 = Goal BP in non-diabetic patients with asymptomatic carotid stenosis*
* *_\<_ 85 diastolic BP goal if pt has concomitant diabetes*
44
What do these pictures show?
Left =
Right =
Carotid Artery Stenting (CAS)
Carotid Endarterectomy (CEA)
45
Case Study 3
## Footnote
A 67-year-old man comes to your office for a regularly scheduled visit. He has type 2 diabetes mellitus and a 40-pack-year smoking history, but he quit smoking two years ago. He takes lisinopril and atorvastatin (Lipitor); his blood pressure today is normal. His A1C and lipid panel at his last visit were within normal limits. He says that he feels well and has no neurologic complaints or any other symptoms. His father had a stroke at 68 years of age and was told it was caused by a blocked artery in his neck. The patient asks whether he should be screened for the same kind of blockage.
*If asymptomatic do not order - overtesting may result in complications/AE, symptoms including dizziness, syncope, memory loss*
46
Hypertensive Urgency vs. Emergency
Hypertensive crises are acute, severe elevations in blood pressure that may or may not be associated with target-organ dysfunction
* **Hypertensive Urgency =**
* **Hypertensive Emergency =**
* often \>\_\_\_/\_\_\_ (typically with SBP \>\_\_\_\_and/or DBP \>\_\_\_)
* **Hypertensive Urgency =**is a marked elevation in blood pressure **without evidence of target organ damage**, such as pulmonary edema, cardiac ischemia, neurologic deficits, or acute renal failure
* **Hypertensive Emergency =** Acute, severe elevation in blood pressure with **presence or impending target-organ dysfunction**
* **often \>180/110 (typically with SBP \>200 and/or DBP \>120)**
*Note: Difference btw urgency and emergency is S/S of EOD - visual disturbances, dizziness, SOB, chest pain, HA*
47
Risk factors for the development of hypertensive crises
* #1 cause =
* Th\_\_\_\_\_ dysfunction
* Gender =
* Higher grades of o\_\_\_\_\_
* Presence of hypertensive or co\_\_\_\_\_ heart disease
* An\_\_\_\_\_ and P\_\_\_\_ may cause acute elevations in blood pressure and require a different treatment strategy
* Presence of m\_\_\_\_\_ illness
* #1 cause = **Noncompliance with antihypertensive therapy**
* Thyroid dysfunction
* Female gender
* Higher grades of obesity
* Presence of hypertensive or coronary heart disease
* Anxiety and Pain may cause acute elevations in blood pressure and require a different treatment strategy
* Presence of mental illness
48
Risk factors for the development of hypertensive crises cont.
* In\_\_\_\_\_\_\_ (e.g., cocaine, amphetamines, phencyclidine hydrochloride, stimulant diet supplements)
* With\_\_\_\_\_ syndromes (e.g, clonidine or B-antagonists)
* Drug-drug/drug food _______ (e.g, monoamine oxidase inhibitors and tricyclic antidepressants, antihistamines, or tyramine)
* Sp\_\_\_\_ cord disorders
* Pheo\_\_\_\_\_\_\_
* Pr\_\_\_\_\_\_\_
* C\_\_\_\_\_\_ vascular disease (e.g, SLE)
* Intoxications (e.g., cocaine, amphetamines, phencyclidine hydrochloride, stimulant diet supplements)
* Withdrawal syndromes (e.g, clonidine or B-antagonists)
* Drug-drug/drug food interactions(e.g, monoamine oxidase inhibitors and tricyclic antidepressants, antihistamines, or tyramine),
* Spinal cord disorders
* Pheochromocytoma
* Pregnancy
* Collagen vascular disease (e.g, SLE)
49
HTN History and Physical
* History and physical exam for **signs of t\_\_\_\_\_ o\_\_\_\_\_ damage**
* Symptoms warranting further evaluation include a **H\_\_\_\_\_\_, D\_\_\_\_\_\_, S\_\_\_\_\_ of breath, C\_\_\_\_ pain, V\_\_\_\_\_\_, or changes in V\_\_\_\_\_**
* **Obtain acc\_\_\_\_\_ blood pressure reading****,** with a properly-s\_\_\_\_\_ cuff placed on a bare _____ arm
* Patient should be carefully evaluated for → **Signs of (1) such as elevated jugular venous distension, rales on lung auscultation, or a gallop on heart auscultation indicate that the patient may be actively experiencing a hypertensive emergency rather than urgency**
* **A detailed (1)** **exam** including c\_\_\_\_\_\_ testing is also important to rule out central nervous system impairment
* **(1)** showing **(1)** **(optic disc swelling that is secondary to elevated intracranial pressure)** may be a significant finding mandating more aggressive therapy
* History and physical exam for **signs of target organ damage**
* Symptoms warranting further evaluation include a headache, dizziness, shortness of breath, chest pain, vomiting, or changes in vision
* **Obtain accurate blood pressure reading****,** with a properly-sized cuff placed on a bare upper arm
* Patient should be carefully evaluated for → **Signs of heart failure such as elevated jugular venous distension, rales on lung auscultation, or a gallop on heart auscultation indicate that the patient may be actively experiencing a hypertensive emergency rather than urgency**
* **A detailed neurologic** **exam** including cerebellar testing is also important to rule out central nervous system impairment
* **Fundoscopy** showing papilledema **(optic disc swelling that is secondary to elevated intracranial pressure)** may be a significant finding mandating more aggressive therapy
50
**Laboratory and Diagnostic Evaluations**
* Blood pressure measurement in b\_\_\_\_ arms
* ______ toxicology screen
* \_\_\_\_\_scopic examination
* Serum gl\_\_\_\_, cr\_\_\_\_\_, el\_\_\_\_\_, C\_ *, \_\_\_\_\_\_* function tests
* Urinalysis (in search of p\_\_\_\_uria and h\_\_\_turia)
* Chest \_\_\_\_\_\_
* E\_ *,* \_\_\_\_cardiography
* Urine or serum pr\_\_\_\_\_\_\_ screening
* Head or chest C\_\_
* Blood pressure measurement in both arms
* Urine toxicology screen
* Fundoscopic examination
* Serum glucose, creatinine, electrolytes, CBC, liver function tests
* Urinalysis (in search of proteinuria and hematuria)
* Chest radiography
* ECG, echocardiography
* Urine or serum pregnancy screening
* Head or chest CT
51
Hypertensive Urgency
For the general treatment of hypertensive crisis, patients should be classified as having hypertensive emergency or hypertensive urgency
**Treatment =**
**Requires ICU or hospital admission?**
**Why do we not want to over aggressively correct the BP?**
Initiating, reinitiating, modifying, or titrating oral therapy to gradually reduce BP over 24-48hrs
Usually does not require ICU or hospital admission
May potentially cause harm due to too rapid a decrease in blood pressure bc their end organs have adapted to chronically elevated blood pressures, setting a new physiologic “norm” of autoregulation. This new “norm” leads to optimal organ perfusion at a higher baseline blood pressure
52
Hypertensive Emergency
Treatment Goal =
Why do we not want more aggressive therapy? What should you do if you do see signs of neuro deterioration?
After the first hour?
**Reduce mean arterial pressure (MAP) by 25% over the first hour of therapy.**
**\> 25% reduction associated with cerebral ischemia**. DC therapy if signs of neuro deterioration
After the first hour; a more gradual blood pressure reduction is recommended
53
Exceptions to the general treatment goals
(3) conditions (has unique treatment goals)
Aortic Dissection
Acute Stroke (Ischemic and Hemorrhagic)
Preeclampsia/Eclampsia/HTN emergency in pregnancy
54
Preeclampsia
* Pregnant patients with elevated blood pressure also require extra caution
* In the absence of preexisting hypertension, preeclampsia can ensue at blood pressure levels much _____ than commonly seen in hypertensive emergencies
* Moreso, if the patient complains of potentially worrisome symptoms such as a h\_\_\_\_\_, v\_\_\_\_ changes, or ab\_\_\_\_\_ pain, lab testing should be obtained (3)\*
* *Preeclampsia requires (1) dt risk of seizures*
* Pregnant patients with elevated blood pressure also require extra caution
* In the absence of preexisting hypertension, preeclampsia can ensue at blood pressure levels much lower than commonly seen in hypertensive emergencies
* Moreso, if the patient complains of potentially worrisome symptoms such as a headache, vision changes, or abdominal pain, lab testing should be obtained, including complete blood count, hepatic function panel, and lactic dehydrogenase
* *Preeclampsia requires hospitalization dt risk of seizures*
55
Specific Treatment for Malignant Hypertension
Treatment goal =
Rx (2)
MAP -20-25%
Labetolol, Nicardipine
56
Specific Treatment for Stroke/Encephalopathy
1. **Acute Ischemic Stroke**
1. Treatment Goal =
2. Rx (2)
2. **Acute Hemorrhagic Stroke**
1. Treatment Goal =
2. Rx (2)
3. **Hypertensive Encephalopathy**
1. Treatment Goal =
2. Rx (2)
1. **Acute Ischemic Stroke**
1. MAP -15% in 1h
2. Labetolol, Nicardipine
2. **Acute Hemorrhagic Stroke**
1. SBP \>130 but \<180
2. Labetolol, Nicardipine
3. **Hypertensive Encephalopathy**
1. MAP -20-25% Immediately
2. Labetolol, Nicardipine
57
Specific Treatment for ACS, Cardiogenic Pulmonary Edema
1. **Acute coronary event**
1. Treatment goal
2. Rx (2)
2. **Acute cardiogenic pulmonary edema**
1. Treatment goal
2. Rx (2)
1. **Acute coronary event**
1. SBP \<140 Immediately
2. Labetolol, Nitroglycerin
2. **Acute cardiogenic pulmonary edema**
1. SBP \<140 Immediately
2. Nitroglycerin, Nitroprusside
58
Specific Treatment for Acute Aortic Disease
Treatment Goal =
Rx (4)
SBP \<120, HR \<60 Immediately
Nicardipine, Nitroglycerine, Nitroprusside, Esmolol
59
Specific Treatment for Eclampsia/Severe Preeclampsia/HELLP
Treatment Goal =
Rx (3)
SBP \<160 and DBP \<105 Immediately
Labetolol, Nicardipine, Magnesium Sulfate
60
Hypertensive Emergency Algorithm
61
Patient Care Scenario
**Classify this patient’s hypertensive crisis and decide on the appropriate treatment goals.**
* A 52-year-old man with a medical history of hypertension, sarcoidosis, and asthma presents to the ED with new severe, sharp headache.
* He states that it started about 3 hours ago and is getting worse.
* The patient’s vital signs include blood pressure 192/102 mm Hg, heart rate 78 beats/minute, respiratory rate 20 breaths/minute, and pain 9/10, while afebrile.
* Laboratory test results show SCr 0.8 mg/dL (baseline 0.7 mg/dL), AST 32 U/L, total bilirubin 0.7 mg/dL, and lipase 40 units/L.
* A head CT reveals a small acute ICH with no mass effect or edema.
First, determine whether the patient has signs or symptoms of target-organ damage. In general, the patient’s physical examination and presenting symptoms will lead toward which diagnostic tests and laboratory assays to use.
Laboratory values do not always indicate specific target-organ damage.
Diagnostic head CT evaluation reveals target organ damage to the brain, specifically the development of an ICH. Because of this finding, the patient qualifies for a hypertensive emergency warranting intravenous therapy and ICU admission.
* With his acute ICH, this patient would qualify as an exception to the general treatment principles for hypertensive emergency. In addition, with ICH, further delineation is required. Although rapid, aggressive blood pressure lowering has been shown to be safe, these large studies excluded patients with large ICH volumes, ICP elevations, and/or severe elevations in blood pressure (SBP greater than 220 mm Hg).
* Because G.A. does not meet any of these exclusion criteria, the blood pressure goal would be SBP less than 160 mm Hg within the first few hours, being mindful of overaggressive correction.
*Ans: hypertensive emergency, tx goal of reducing BP by no more than 25% in first hour, ICU admission*
62
**Heart Failure and Cardiomyopathies**
**_Congestive Heart Failure_**
* About 5.8 million people in the US suffer from heart failure
* ~670,000 new cases are diagnosed each year. Heart failure usually develops gradually
* In _____ **heart failure** there is stretching of heart chambers resulting in impaired systolic function, decreased cardiac output, and impaired ability to meet metabolic oxygen demands
* _____ heart failure results in decreased pulmonary flow, and ultimately less systemic flow. Backup to liver can cause hepatic changes c/w NAFLD.
* Heart failure can affect both left and right side, referred to as \_\_\_**Ventricular failure.**
* Mortality rate after first admission of CHF at 5 years \_\_\_\_%
* E\_\_\_\_\_ treatment can extend survival BB, CCB
* About 5.8 million people in the US suffer from heart failure
* ~670,000 new cases are diagnosed each year. Heart failure usually develops gradually
* In **systolic heart failure** there is stretching of heart chambers resulting in impaired systolic function, decreased cardiac output, and impaired ability to meet metabolic oxygen demands
* Right heart failure results in decreased pulmonary flow, and ultimately less systemic flow. Backup to liver can cause hepatic changes c/w NAFLD.
* Heart failure can affect both left and right side, referred to as **BiVentricular failure.**
* Mortality rate after first admission of CHF at 5 years 67.8%
* Early treatment can extend survival BB, CCB
63
Measurement, expressed as a percentage, of how much blood the left ventricle pumps out with each contraction =
Average ~\_\_%
This indication of how well your heart is pumping out blood can help to diagnose and track **_heart failure_**
Ejection Fraction
Ejection fraction of 60% of the total amount of blood in the left ventricle is pushed out with each heartbeat.
This indication of how well your heart is pumping out blood can help to diagnose and track **_heart failure_**
64
Ejection Fraction
Normal value =
Borderline Ejection Fraction =
Reduced Ejection Fraction =
* Can you have heart failure if you have a normal ejection fraction?
* Why is this?
50-70%
41-49%
_\<_40%
* You can have a normal ejection fraction measurement and still have heart failure (called HFpEF heart failure with preserved ejection fraction)
* Someone with heart failure might seem like they're still pumping out a normal percentage of the blood that enters it but there is smaller volume of blood bc the heart is so thick and stiff, so in reality, total amount of blood pumped still not enough to meet your body's needs
65
Systolic “reduced ejection fraction”
* D\_\_\_\_\_\_ Cardiomyopathy
* Is\_\_\_\_\_\_\_ heart failure
* “B\_\_\_\_\_” valvular and congenital cardiomyopathy
* G\_\_\_\_\_ and unclassified cardiomyopathy
* Dilated Cardiomyopathy
* Ischemic heart failure
* “Burnout” valvular and congenital cardiomyopathy
* Genetic and unclassified cardiomyopathy
66
**Diastolic “preserved ejection fraction”**
* Hyper\_\_\_\_\_, val\_\_\_\_\_, and con\_\_\_\_ related cardiomyopathy
* Hypertr\_\_\_\_\_
* Res\_\_\_\_\_ cardiomyopathy
* ARVC =
* Other g\_\_\_\_\_ and unclassified cardiomyopathy
* Hypertensive, valvular, and congenital related cardiomyopathy
* Hypertrophic
* Restrictive cardiomyopathy
* Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC)
* Other genetic and unclassified cardiomyopathy
67
Cardiomyopathy Etiology
* **In\_\_\_\_\_\_**
* **To\_\_\_\_ and Dr\_\_\_\_\_**
* **M\_\_\_\_\_\_\_**
* **G\_\_\_\_\_\_**
* **H\_\_\_\_/Onc\_\_\_\_\_\_**
* **Dep\_\_\_\_\_**
* **Heredity N\_\_\_\_\_\_/N\_\_\_\_\_\_ diseases**
* **Endom\_\_\_\_\_\_ diseases**
* **Inf\_\_\_\_\_\_\_\_**
* **Infectious**
* **Toxins and Drugs**
* **Metabolic**
* **Genetic**
* **Hematologic/Oncologic**
* **Deposits**
* **Heredity Neurologic/Neuromuscular diseases**
* **Endomyocardial diseases**
* **Inflammatory**
68
Primary vs. Secondary Cardiomyopathy
* **Primary Cardiomyopathy**
* G\_\_\_\_\_: Hypertrophic CM, ARVC
* M\_\_\_\_\_: Dilated CM and Restrictive CM
* Ac\_\_\_\_\_\_: myocarditis, stress-induced (takotsubo), peripartum, tachycardia-induced
* **Secondary Cardiomyopathy**
* Associated with (1)
* **Primary Cardiomyopathy**
* Genetic: Hypertrophic CM, ARVC
* Mixed: Dilated CM and Restrictive CM
* Acquired: myocarditis, stress-induced (takotsubo), peripartum, tachycardia-induced
* **Secondary Cardiomyopathy**
* Associated with other organ system involvement
69
What type of Cardiomyopathy does this describe? Does is cause systolic or diastolic HF?
* Cardiac muscle is weakened due to inadequate coronary perfusion from CAD or MI
* Muscle damage can cause wall motion abnormality from scarring and altered electrical activity leading to ventricular enlargement, dilatation, and decreased ejection fraction
**“Ischemic Cardiomyopathy” Systolic Heart Failure**
70
Dilated Cardiomyopathy (DCM)
* Most commonly related to (1) (“ischemic cardiomyopathy”) and “\_\_\_\_\_\_\_" hypertension
* “\_\_\_\_\_\_” valvular and congenital heart disease
* Bacterial/viral myo\_\_\_\_\_, en\_\_\_\_\_/met\_\_\_\_\_, in\_\_\_\_\_\_, t\_\_\_\_
* G\_\_\_\_\_\_\_/Idiopathic
* Can be seen in the first year of life with n\_\_\_\_\_\_ diseases, ie Du\_\_\_\_\_\_ and other muscular dystrophies; N\_\_\_\_\_ syndrome; and B\_\_\_\_\_ syndrome (X-linked genetic disorder consisting of dilated cardiomyopathy, skeletal myopathy, and neutropenia)
* Most commonly related to CAD (“ischemic cardiomyopathy”) and “burnout” hypertension
* “Burnout” valvular and congenital heart disease
* Bacterial/viral myocarditis, endocrine/metabolic, inflammatory, toxic
* Genetic/Idiopathic
* Can be seen in the first year of life with neuromuscular diseases, ie Duchenne and other muscular dystrophies; Noonan’s syndrome; and Barth syndrome (X-linked genetic disorder consisting of dilated cardiomyopathy, skeletal myopathy, and neutropenia)
71
Hypertrophic Cardiomyopathy
Definition
* 50% of cases are caused by?
* 5-10% of cases are caused by?
*Hypertrophic cardiomyopathy (HCM) is defined by the presence of increased left ventricular (LV) wall thickness \>1.5 cm that is not solely explained by abnormal loading conditions*
* 50% Familial Genetic Autosomal Dominant\*\*\* Family Planning
* 5-10% of adult cases are caused by other genetic disorders including inherited metabolic and neuromuscular diseases, chromosome abnormalities and genetic syndromes
72
Hypertrophic Cardiomyopathy (HCM)
Heart muscle c\_\_\_\_ enlarge and ventricular walls th\_\_\_\_\_\_ (usually the left ventricle)
* Generally causes _______ heart failure
* The left ventricular outflow tract can become o\_\_\_\_\_\_ (LVOTO) resulting in **(1)** (HOCM). Incidence 1:500
* Ventricular and atrial a\_\_\_\_\_\_
* Chest \_\_\_\_\_/syncope: from myocardial ischemia due to microvascular dysfunction, increased LV wall stress and LVOTO
* HOCM: #1 cause of **(1)\* especially in (1)**
Heart muscle cells enlarge and ventricular walls thicken (usually the left ventricle)
* Generally causes diastolic heart failure
* The left ventricular outflow tract can become obstructed (LVOTO) resulting in hypertrophic obstructive cardiomyopathy (HOCM). Incidence 1:500
* Ventricular and atrial arrhythmia
* Chest pain/syncope: from myocardial ischemia due to microvascular dysfunction, increased LV wall stress and LVOTO
* HOCM: #**1 cause of sudden cardiac death in young people, esp. Young athletes**
73
Causes of Restrictive Cardiomyopathy
* **(1)** = autoimmune inflammatory results in scarring
* **(1)** = amyloid deposits results in scarring
* **(1)** disorders = eg: Scleroderma - results in scarring
* **(1)** = heme deposits results in scarring
* **(1)** treatments = such as chemo and RT = tissue destruction results in scarring
* **C\_\_\_\_** and **hyper\_\_\_\_\_\_\_**
* **Sarcoidosis** = autoimmune inflammatory results in scarring
* **Amyloidosis** = amyloid deposits results in scarring
* **Connective tissue disorders =** eg: Scleroderma - results in scarring
* **Hemochromatosis** = heme deposits results in scarring
* **Cancer treatments**, such as chemo and RT = tissue destruction results in scarring
* **CAD** and **hypertension**
74
Pathophysiology of Restrictive Cardiomyopathy
* In\_\_\_\_\_\_\_ of the cardiac tissue with material which causes st\_\_\_\_\_\_ of the left ventricular chamber (doesn’t str\_\_\_ well)
* Like a new \_\_\_\_\_\_, it takes higher pressures to fill
* Pressure backs up into the lungs, causes _____ of breath
* Infiltration of the cardiac tissue with material which causes stiffening of the left ventricular chamber (doesn’t stretch well)
* Like a new balloon, it takes higher pressures to fill
* Pressure backs up into the lungs, causes shortness of breath
75
Rare form of cardiomyopathy resulting from a genetic disorder (50% autosomal dominant) characterized by fibrofatty replacement of the right ventricular myocardium with scar tissue.
Causes 2)
**Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)**
* Arrhythmia: palpitations and syncope after physical activity, risk of sudden death
* Heart failure
76
Heart failure symptoms
* Weight g\_\_\_\_
* F\_\_\_\_\_/Malaise/Ex\_\_\_\_\_\_ intolerance
* An\_\_\_\_\_
* Pal\_\_\_\_\_\_
* S\_\_\_\_\_\_\_ of breath
* C\_\_\_\_\_ (pulmonary edema/pleural effusions)
* Or\_\_\_\_\_\_\_
* D\_\_\_\_\_ness, l\_\_\_\_theadedness, or syn\_\_\_\_\_ episodes
* Ed\_\_\_\_\_\_ in legs and/or abdomen
* Weight gain
* Fatigue/Malaise/Exercise intolerance
* Angina
* Palpitations
* Shortness of breath
* Cough (pulmonary edema/pleural effusions)
* Orthopnea
* Dizziness, lightheadedness, or syncopal episodes
* Edema in legs and/or abdomen
77
Cardiomyopathy Diagnostic Workup
1. Patient and family \_\_\_\_\_\_
2. _______ exam: BP and HR/rhythm, icterus, color, JVD, heart sounds, breath sounds, organo\_\_\_\_\_\_, pulses, edema
3. E\_\_\_, E\_\_\_\_\_ (EF and LVOTO? or RVOTO?)
4. Imaging (3)
5. St\_\_\_\_\_ test
6. Cardiac c\_\_\_\_\_\_\_: angiogram, hemodynamics, pulmonary HTN
7. Labs: Lipid panel, HgbA1c, thy\_\_\_ function, renal, hepatic, b-type natriuretic peptide, in\_\_\_\_\_\_ screen with hepatitis and HIV, toxins, v\_\_\_\_\_deficiencies, auto\_\_\_\_\_\_ inflammatory disease
8. G\_\_\_\_\_\_ testing or screening
9. Myocardial b\_\_\_\_\_
1. Patient and family history
2. Physical examination: BP and HR/rhythm, icterus, color, JVD, heart sounds, breath sounds, organomegaly, pulses, edema
3. EKG, Transthoracic Echocardiogram (EF and LVOTO? or RVOTO?)
4. Imaging: X-ray, CT scan, or MRI with contrast
5. Stress test
6. Cardiac catheterization: angiogram, hemodynamics, pulmonary HTN
7. Laboratory testing: Lipid panel, HgbA1c, thyroid function, renal, hepatic, b-type natriuretic peptide, infectious screen with hepatitis and HIV, toxins, vitamin deficiencies, autoimmune inflammatory disease
8. Genetic testing or screening
9. Myocardial biopsy
78
ACC/AHA Heart Failure Stages
Match each description with each stage A-D
* Structural heart disease with prior or current heart failure symptoms
* At risk for heart failure but without structural heart disease or symptoms
* Structural heart disease but without heart failure
* Refractor heart failure requiring specialized interventions
Stage A = At risk for heart failure but without structural heart disease or symptoms
Stage B = Structural heart disease but without heart failure
Stage C = Structural heart disease with prior or current heart failure symptoms
Stage D = Refractory heart failure requiring specialized interventions
79
NYHA Functional Class of HF
Match each description with Stages I-IV
* Symptomatic with minimal exertion
* Symptomatic at rest
* Asymptomatic
* Symptomatic with moderate exertion
Stage I = Asymptomatic
Stage II = Symptomatic with moderate exertion
Stage III = Symptomatic with minimal exertion
Stage IV = Symptomatic at rest
80
**Medication that blocks the channel responsible for the cardiac pacemaker current, I(f), which regulates heart rate. This results in prolonged diastolic time and reduced heart rate.**
Ivabradine
Ivabradine reduces heart rate but does not affect myocardial contraction, relaxation, or ventricular repolarization
* Rapid resting heart rate can lead to detrimental effects on left ventricular function and has been associated with negative outcomes in patients with cardiovascular disease.
* Reducing resting heart rate to reduce cardiovascular morbidity and mortality is a therapeutic target among drug manufacturers.
81
**Medication that is a combination of two medications, together known as an angiotension receptor-neprilysin inhibitor (ARNI).**
Entresto (Sacubitril/Valsartan)
82
Sacubitril
Drug Class =
MOA =
Neprilysin Inhibitors
Blocks neprilysin protein from breaking down natriuretic peptides to relax your blood vessels and lower blood pressure
83
Valsartan
Drug Class
MOA
Angiotensin Receptor Blocker (ARB)
Blocks angiotensin II from causing vasoconstriction of blood vessels to help lower BP and allow more blood to get to your heart and organs (helps heart not work as hard and helps kidneys remove extra salt and water from body)
84
SGLT-2 Inhibitor
(Sodium glucose co-transport 2 inhibitors have a dramatic beneficial cardiovascular outcomes)
**MOA**
**Reduced CV death and HF in (2) chronic illnesses**
SGLT-2 are proteins found in the proximal convoluted tubules that help reabsorb filtered glucose, SGLT-2 inhibitors reduce the reabsorption of filtered glucose to promote urinary glucose and sodium excretion (there is an increase in distal tubular sodium load)
Treats Diabetes and Heart Failure
85
HFrEF Stage C Treatment
86
Starting and Target Doses of Novel Therapies for HF
87
Cardiac Resynchronization Therapy (CRT) Device
(2) two types of CRT devices.
CRT-P (Cardiac resynchronization therapy - pacemaker) ("biventricular pacemaker")
CRT-D (same device but built in implantable cardiac defibrillator)
88
Systolic Heart Failure Treatment
GDMT = (1) can help to reduce mortality, often medication alone is not enough.
For HF patients with electrical dyssynchrony, (1) in + GDMT is the only therapy clinically proven to help:
* Improve ______ of life
* S\_\_\_\_\_ HF disease progression
* Decrease mor\_\_\_\_\_
* Reduce HF hos\_\_\_\_\_\_\_
Guideline-directed medication therapy (GDMT) can help to reduce mortality, often medication alone is not enough
For HF patients with electrical dyssynchrony, **cardiac resynchronization therapy (CRT) + GDMT** — is the only therapy clinically proven to help:
* Improve quality of life
* Slow HF disease progression
* Decrease mortality
* Reduce HF hospitalizations
89
HOCM Procedures
(1) Long-term survival after this procedure is 97% at 5 and 91% at 10 years, which did not differ from the age- and gender-matched general U.S. population, 4% risk of complete heart block
(1) A small portion of the thickened heart muscle is destroyed by injecting alcohol through a catheter into the artery supplying blood that leads to the enlarged septum. This leads to immediate controlled cell death at the targeted location. 7-20% risk of complete heart block. High risk of arrhythmia during procedure, risk of developing ventricular septal defect
Septal Myectomy
Septal Ablation
90
Case 4
## Footnote
A 54-year-old woman presented to the telemetry floor with shortness of breath (SOB) for 4 months that progressed to an extent that she was unable to perform daily activities. She also used 3 pillows to sleep and often woke up from sleep due to difficulty catching her breath. Her medical history included hypertension, dyslipidemia, diabetes mellitus, and history of triple bypass surgery 4 years ago. Her current home medications included aspirin, atorvastatin, amlodipine, and metformin. No significant social or family history was noted. Her vital signs were stable. Physical examination showed bilateral diffuse crackles in lungs, elevated jugular venous pressure, and 2+ pitting lower extremity edema. ECG showed normal sinus rhythm with left ventricular hypertrophy. Chest x-ray showed vascular congestion. Laboratory results showed a pro-B-type natriuretic peptide (pro-BNP) level of 874 pg/mL and troponin level of 0.22 ng/mL. Thyroid panel was normal. An echocardiogram demonstrated systolic dysfunction, mild mitral regurgitation, a dilated left atrium, and an ejection fraction (EF) of 33%. How would you manage this case?
*Start diuretic + send to ER (probably start on ARB/ACE, BB)*
91
Cardiac non-invasive imaging
(6)
**Ambulatory electrocardiography**
**Exercise Stress Test**
**Nuclear Heart Scan/Thallium Stress Test**
**Cardiac Magnetic Resonance Imaging**
**CT coronary angiogram & Calcium Scoring**
**Echocardiogram**
92
Type of non invasive cardiac imaging that utilizes electrodes and electrical leads similar to an EKG – it is a continuous test to record the heart's rate and rhythm for 24 hours – 48hours.
Ambulatory electrocardiography
93
Type of non-invasive imaging commonly used for the detection of CAD in patients with chest pain or dyspnea on exertion who are at intermediate risk of acute coronary syndrome
Reduces costs of hospitalization without worsening outcomes in patients presenting to the emergency department with **chest pain and negative cardiac enzymes.**
Exercise stress test
94
Indications for Exercise Stress Test
* Prediction of cardiovascular ev\_\_\_\_\_
* Evaluation of e\_\_\_\_\_\_\_-induced symptoms
* Evaluation of unexplained s\_\_\_\_\_\_\_ in patients at intermediate to high risk of CAD
* Prediction of cardiovascular events
* Evaluation of exercise-induced symptoms
* Evaluation of unexplained syncope in patients at intermediate to high risk of CAD
95
Exercise Stress Test CONTRAINDICATIONS
(5)
1. Inappropriate for detection of ischemia in asymptomatic patients with no history of revascularization
2. MI in the previous 2 days
3. Ongoing stable angina
4. Uncontrolled cardiac arrhythmia with hemodynamic compromise
5. Symptomatic severe aortic stenosis
*1/10,000 exercise stress tests results in sudden cardiac death or hospitalization*
96
Best Practices in Cardiology
1. DO NOT PERFORM stress test or ambulatory ECG on initial eval with **no cardiac _____ unless high risk _____ present**
2. DO NOT PERFORM cardiac imaging for patients at **\_\_\_ risk**
3. AVOID stress echo for **a\_\_\_\_\_\_ patients** who meet **\_\_\_ risk scoring criteria for coronary disease**
4. Patients who have **no cardiac h\_\_\_\_\_ and good f\_\_\_\_\_ status** DO NOT REQUIRE pre\_\_\_ stress testing before noncardiac thoracic surgery
5. DO NOT OBTAIN baseline diagnostic cardiac testing or cardiac stress testing in **a\_\_\_\_\_ stable patients with known cardiac disease** (CAD, valvular disease) undergoing **\_\_\_-\_\_\_\_ risk noncardiac surgery**
6. DO NOT PERFORM **routine ann\_\_\_\_\_ stress testing after coronary artery re\_\_\_\_\_\_\_\_**
1. DO NOT PERFORM stress test or ambulatory ECG on initial eval with **no cardiac symptoms unless high risk markers present**
2. DO NOT PERFORM cardiac imaging for patients at **low risk**
3. AVOID stress echo for **asymptomatic patients** who meet low **risk scoring criteria for coronary disease**
4. Patients who have **no cardiac history and good functional status** DO NOT REQUIRE preop stress testing before noncardiac thoracic surgery
5. DO NOT OBTAIN baseline diagnostic cardiac testing or cardiac stress testing in **asymptomatic stable patients with known cardiac disease** (CAD, valvular disease) undergoing **low-moderate risk noncardiac surgery**
6. DO NOT PERFORM **routine annual stress testing after coronary artery revascularization**
97
**Type of non-invasive cardiac imaging that uses** **radioactive dye and an imaging machine to create pictures showing the blood flow to the heart (poor blood flow shows cardiac damage) Measures blood flow at rest and on exertion. Can be performed alone or in combination with another test (ie echo)**
Nuclear Heart Scan/Thallium Stress Test
98
Cardiac Magnetic Resonance Imaging
Provides detailed info on the t\_\_\_\_ and s\_\_\_\_\_ of heart disease
Can detect:
* C\_\_\_\_\_\_heart disease
* Cardiac t\_\_\_\_\_
* Problem in \_\_\_\_\_- the heart’s main artery- such as a tear, aneurysm (bulge), or narrowing
* Disease of the ______ (outer lining of the heart muscle) eg. constrictive pericarditis
* Heart m\_\_\_\_ disease (eg. heart failure/ enlargement of the heart)
* Heart _____ disorders (eg.s regurgitation)
* Con\_\_\_\_\_\_ heart problems and the success of surgical repair
Provide detailed information on the type and severity of heart disease
Can detect:
* Coronary heart disease
* Cardiac tumors
* Problem in aorta- the heart’s main artery- such as a tear, aneurysm (bulge), or narrowing
* Disease of the pericardium (outer lining of the heart muscle) eg. constrictive pericarditis
* Heart muscle disease (eg. heart failure/ enlargement of the heart)
* Heart valve disorders (eg.s regurgitation)
* Congenital heart problems and the success of surgical repair
99
Coronary Calcium Scoring
What is the significance of calcium deposits? Calcium deposits increase with (1) and increases risk of?
* Does this study need contrast?
* How is this study done?
Calcium deposits are very specific sign of coronary artery disease, cholesterol and scar tissue buildup in the arteries
Calcium deposits increase with age and pts who have significantly elevated amounts of calcium deposits are at increased risk of having a heart attack/complications
* Non contrast study
* Pictures taken of heart to look for calcium deposits in coronary arteries
100
Cardiac CT Angiography
* Small amount (~3oz) of x-ray _____ is injected through a vein in the arm
* As the contrast is circulated through the heart, the __ scanner takes high-resolution images of the heart and heart ar\_\_\_
* \_\_D imaging of the heart ch\_\_\_\_, c\_\_\_\_\_\_ arteries, p\_\_\_\_\_ veins
* Small amount (~3oz) of x-ray contrast is injected through a vein in the arm
* As the contrast is circulated through the heart, the CT scanner takes high-resolution images of the heart and heart arteries
* 3D imaging of the heart chambers, coronary arteries, pulmonary veins
101
Echocardiogram Types
## Footnote
(1) Type of echocardiogram that takes “moving pictures” of the heart with sound waves
(1) Type of echocardiogram that uses a probe is passed down the esophagus so that it is closer to the heart and better pictures can be taken
**Trans Thoracic Echocardiography (TTE):** Type of echocardiogram that takes “moving pictures” of the heart with sound waves
**Transesophageal Echocardiography (TEE):** Type of echocardiogram that uses a probe is passed down the esophagus so that it is closer to the heart and better pictures can be taken
102
What can an Echo reveal?
* S\_\_\_\_ and sh\_\_\_\_\_ of the heart
* Overall heart f\_\_\_\_\_\_
* If a wall or section of heart muscle is w\_\_\_\_and not working correctly
* Problems with heart’s v\_\_\_\_
* If you have blood ____ within the heart
* Size and shape of the heart
* Overall heart function
* If a wall or section of heart muscle is weak and not working correctly
* Problems with heart’s valve
* If you have blood clot within the heart
103
VTE (Venous Thromboembolism)
(2)
**Pulmonary Embolism**
**Deep Vein Thrombosis**
104
Pulmonary Venous Thromboembolism Management
When should you not treat outpatient?
1. **Anticoagulants (2)**
2. **Oral Medications (W\_\_\_\_\_ + DOACS (4))**
3. **Thrombolytic Therapy (1)**
4. **Surgical procedures (1)**
SHOULD NOT treat outpatient if massive symptomatic DVT, high risk for bleeding, or hemodynamically unstable dt concurrent symptomatic PE
1. **Anticoagulants = Heparin, Low molecular weight heparin**
2. **Oral Medications = (Warfarin, Apixaban, Dabigatran, Rivaroxaban, Edoxaban)**
3. **Thrombolytic Therapy = Tissue Plasminogen Activator (tPA)**
4. **Surgical procedures = Thrombectomy**
* TPA Can be given IV or inserting catheters directly into the blood clot in the vein or lungs
* Thrombectomy done by placing a filter in the body’s largest vein, the inferior vena cava to prevent blood clots from traveling to the lungs
105
Oral Medications Warfarin + DOACs
* Used for how long?
* If VTE occurred after provoking factors such as surgery, trauma, pregnancy, hospital stay, or with use of hormone treatments, this is usually given for _____ number of months
* For patient without provoking factors treatment can be recommended for l\_\_\_\_\_\_ durations
* Used for number of months
* If VTE occurred after provoking factors such as surgery, trauma, pregnancy, hospital stay, or with use of hormone treatments, this is usually given for fixed number of months
* For patient without provoking factors treatment can be recommended for longer durations
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**Pulmonary Hypertension**
**=**
**WHO Groups 1-5**
**Which group is the most common form of PH?**
**General term used to describe high blood pressure in the lungs from any cause.**
**WHO Group 1 = Pulmonary Arterial Hypertension (PAH)**
**WHO Group 2 = Pulmonary Hypertension d/t left heart disease**
**Who Group 3 = Pulmonary Hypertension d/t lung disease**
**Who Group 4 = Pulmonary Hypertension d/t unknown cause**
**WHO Group 2 most common form of PH**
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WHO Group 1: Pulmonary Arterial Hypertension (PAH)
**Pulmonary arteries become n\_\_\_\_, th\_\_\_\_, st\_\_\_**
\_\_\_\_ side of the heart must work h\_\_\_\_\_ to push blood through these narrowed arteries
* Idiopathic
* Her\_\_\_\_
* Dr\_\_\_ & Toxin related
* Hep\_\_\_ Disease
* Auto\_\_\_\_ and c\_\_\_\_\_e tissue disease
* H\_ \_
* Con\_\_\_\_\_ heart disease
**Pulmonary arteries become narrowed, thickened, stiff**
Right side of the heart must work harder to push blood through these narrowed arteries
* Idiopathic
* Heritable
* Drug & Toxin related
* Hepatic Disease
* Autoimmune and connective tissue disease
* HIV
* Congenital heart disease
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WHO Group 2: Pulmonary Hypertension d/t left heart disease
**Left sided v\_\_\_\_ or pump dysfunction causing (1)**
* Congenital or Acquired
* Congenital defects (3)
* Eis\_\_\_\_\_ Syndrome
* Congenital cardiom\_\_\_\_\_\_\_
**Left sided valvular or pump dysfunction causing back-up to lungs**
* Congenital or acquired
* Congenital: Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosus causing left-to-right shunt
* Eisenmenger’s Syndrome
* Congenital cardiomyopathies
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WHO Group 3: Pulmonary Hypertension d/t lung disease
**PH due to chronic lung diseases and/or hypoxia (low oxygen levels)**
(2) lung diseases
* Inter\_\_\_\_ lung disease/ pulmonary f\_\_\_\_\_
* Sl\_\_\_\_ apnea
* Chronic high al\_\_\_\_\_\_ exposure
* Con\_\_\_\_ lung disease
Pulmonary HTN with hypoxemia may be due to associated \_\_\_\_-to-\_\_\_ pulmonary shunt d/t v\_\_\_\_\_\_/ p\_\_\_\_\_\_\_ mismatch
Pulmonary HTN with hypoxemia may be related to intracardiac right-to-left shunt via a (1) (PFO)
**PH due to chronic lung diseases and/or hypoxia (low oxygen levels)**
Eg. obstructive/ restrictive lung disease
* Interstitial lung disease/ pulmonary fibrosis
* Sleep apnea
* Chronic high altitude exposure
* Congenital lung disease
Pulmonary HTN with hypoxemia may be due to associated right-to-left pulmonary shunt d/t ventilation/ perfusion mismatch
Pulmonary HTN with hypoxemia may be related to intracardiac right-to-left shunt via a patent foramen ovale (PFO)
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WHO Group 4: Pulmonary Hypertension d/t chronic blood clots in the lungs
**CTEPH =**
* Occur when body is not able to re\_\_\_\_\_ a blood clot in the lungs
* Leads to sc\_\_\_ tissue in the blood vessels of the lungs
* Which bl\_\_\_ normal blood flow and makes the ____ side of the heart work harder
* Can potentially be cured through (1) (PTE) surgery to remove blood clots
**CTEPH = Chronic thromboembolic pulmonary hypertension**
* Occur when body is not able to reabsorb a bloo dclot in the lungs
* Leads to scar tissue in the blood vessels of the lungs
* Which blocks normal blood flow and makes the right side of the heart work harder
* Can potentially be cured through pulmonary thoromboendarterectomy (PTE) surgery to remove blood clots
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WHO Group 5: Pulmonary Hypertension d/t unknown cause
When PH is secondary to other ______ in ways that are not well understood
Associated conditions are: s\_\_\_\_osis, s\_\_\_\_ cell anemia, chronic hemo\_\_\_\_ anemia, sp\_\_\_ectomy, certain metabolic disorders
When PH is secondary to other diseases in ways that are not well understood
Associated conditions are: sarcoidosis, sickle cell anemia, chronic hemolytic anemia, splenectomy, certain metabolic disorders
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Early symptoms of Pulmonary Hypertension
* Dyspnea on e\_\_\_\_\_
* F\_\_\_\_\_
* Chest \_\_\_\_
* Pal\_\_\_\_\_
* _____ upper quadrant pain
* Decreased app\_\_\_\_\_
* Dyspnea on exertion
* Fatigue
* Chest pain
* Palpitations
* Right upper quadrant pain
* Decreased appetite
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Later Symptoms of Pulmonary Hypertension
* D\_\_\_\_ness
* Syn\_\_\_\_/ sudden d\_\_\_\_ (ventricular arrhythmia)
* Lower extremity s\_\_\_\_\_
* Cy\_\_\_\_\_, d\_\_\_\_\_ extremities
* H\_\_\_\_tysis
* Dizziness
* Syncope/ sudden death (ventricular arrhythmia)
* Lower extremity swelling
* Cyanosis, dusky extremities
* Hemoptysis
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Treatment Algorithm for PH
