what is the difference between NSTEMI and unstable angina?
NSTEMI has elevations of cardiac biomarkers whereas unstable angina does not
pt presents with angina at rest or new onset / increased angina
unstable angina or NSTEMI
chronic stable angina
chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved by rest or nitroglycerin
sharp, pleuritic chest pain worsened in the supine position and radiates to top of shoulder
acute pericarditis
dx. criteria for acute pericarditis (3)
- pleuritic chest pain
- friction rub
- diffuse ST elevation on ecg, w/ PR depression
pt presents with abrupt onset, severe pain in thorax; there may be a pulse deficit on P/E, murmur of aortic regurgitation and widening of mediastinum of CXR - dx?
aortic dissection
ST elevation in II, III and aVF
inferior wall MI
preferred tx. for pts with STEMI
PCI with stent placement
- most effective if done w/in 12 hrs of onset of pain
C/I to thrombolytic therapy
prior intracerebral hemorrhage
ischemic stroke w/in 3 months
suspected aortic dissection
active bleeding
next diagnostic step in suspected aortic dissection
chest CT
when is echocardiogram useful in emergency setting?
pts presenting with chest pain and non-diagnostic ECG
classic triad of RV MI
hypotension
clear lung fields
elevated estimated CVP
most predictive findings of RV-MI
ST-segment elevation on right-sided electrocardiogram lead V4R
what test should all patients with inferior wall MI have done?
right sided ECG
primary supportive tx. in RV MI
volume expansion with normal saline
pts with RV-MI whose hypotension is not corrected after 1 L of saline should get what drug?
IV dobutamine (inotropic)
what two drugs are impaired in RV-MI?
b-blockers }bradycardia
nitrates } makes hypotension worse, inhibiting right heart filling
Tx of pt with GERD-related chest pain
rule out cardiac ischemia (i.e. exercise stress test) and then tx. empirically with PPI
prolongation of PR interval > 0.2 sec; not assoc with alterations in HR
first degree AV block
progressive prolongation of PR interval until there is a dropped beat
Mobitz Type I - Wenkebach
dropped beat without progressive prolongation of PR interval
Mobitz Type II block
- usually assoc. with BBB and progresses to third degree block
complete absence of conduction of atrial impulses with ventricular bradycardia (30-50 bpm)
third degree heart block
pt presents with recurrent, unexpected episodes of palpitations, sweating, dyspnea, chest pain, nausea, dizziness and numbness; sx. peak w/in 10 min and last 15-60 minutes - dx?
consider panic attacks
Tx. of panic acttacks
CBT
SSRI- paroxetine
pt presents with sudden severe headache, diaphoresis and palpitations; he is very pale
pheochromocytoma - episodic or sustained HTN
AV block characterizes by regularly dropped beat (nonconducted P wave every 2nd or 3rd beat)
Mobitz Type II block
causes of Mobitz Type I block
absence of heart disease - athletes, elderly
underlying heart disease - ischemia
drugs - CCBs, beta blockers, digoxin
Tx of mobitz type II block
pacemaker
anti-anginal therapy for chronic stable angina
B-blockers
CCBs
nitrates
vascular protective therapy for chronic stable angina
aspirin
statin
ACE inhibitor
Ranolazine
novel antianginal agent approved for tx. of chronic stable angina
- should only be used in addition to baseline therapy of BB, CCB and long-acting nitrate
when is coronary angiography useful in assessment of chronic stable angina?
when pt still has symptoms despite max medical therapy
pt complains of chest pain and dyspnea with asymmetric leg edema, elevated CVP, tachypnea and tachycardia - dx? what test should you do?
suspect PE
- do a CT pulmonary angiography
normal wall motion on echocardiography during chest pain excludes…
coronary ischemia or infarction
adenosine nuclear perfusion stress test is C/I in what patients?
those with asthma or sig. bronchospastic dz
primary approach to diagnosis of CAD in pts who can exercise and have normal resting ECG
exercise ECG testing
multiple P waves in a sawtooth pattern with 2:1 ventricular conduction
atrial flutter
absence of discernable P waves which are replaced by fibrillatory waves that vary in amplitude, shape and frequency; ventricular rate is irregular
atrial fibrillation
symptomatic sinus bradycardia with alternating atrial tachyarrhythmias (A.fib)
sick sinus syndrome
wide QRS morphology (QRS > 0.12 sec) and HR > 100/min
ventricular tachycardia
when do you add a CCB to a pt with chronic stable angina?
if pt is unable to tolerate BB or they can be added to BB for difficult to control sx
should you give clopidogrel to a pt with stable angina?
no - increased risk of bleeding
LDL cholesterol target range for CAD
< 100 mg/dL (2.6 mmol/L)
what studies should at the very minimum be done in dx. Atrial Fibrillation? 2
transthoracic echo - exclude occult valve or structural heart disease
TSH to exclude hyperthyroidism
who is coronary angiography reserved for?
lifestyle limiting angina despite tx
positive results on stress testing
successful resuscitation from sudden cardiac death
ventricular tachycardia
coronary calcium testing - who gets this test?
asx. pts with a 10-20% 10 yr risk category
young pts with strong family history of premature CVD
how do you diagnose pre-excitation?
short PR interval
presence of delta wave
- if tachycardia - dx. is WPW syndrome
wide QRS complex and HR between 60-100/min
idioventricular or slow ventricular tachycardia
three or more p-wave configurations on ECG w/ assoc. tachycardia; commonly seen in chronic lung disease patients
multifocal atrial tachycardia
what test is indicated in a pt with chronic stable angina who is experiencing lifestyle limiting angina despite optimal medical therapy?
coronary angiography
coronary revascularization is beneficial in stable angina pts who meet the following conditions:
- refractory to medical tx
- large area of ischemic myocardium and high risk criteria on stress testing
- high risk coronary anatomy (Left main or 3-vessel dz)
what 3 conditions are “cannon waves” present in?
3rd degree heart block
pulmonary HTN
ventricular tachycardia
a wide QRS tachycarida, in the presence of known structural heart disease (esp prior MI) is almost certainly…
ventricular tachycardia
what is important drug to initiate in NSTEMI?
BB - reduces infarct size, decreases frequency of recurrent MI and improves short/long term survival
indications for intra-aortic balloon pump
cardiogenic shock unresponsive to med. tx
acute mitral regurg. secondary to papillary mm. dysfunction
ventricular septal rupture
refractory angina
how does an intra-aortic balloon pump work?
reduces afterload during systole and increases coronary perfusion during diastole
what type of infarct predisposes to papillary muscle rupture and acute mitral regurg?
inferior wall infarcts
signs of ventricular aneurysm
intractable ventricular tachyarrrhythmia
systemic emboli
heart failure
how does ventricular free wall rupture manifest?
pericardial tamponade, cardiovascular collapse or pulseless electrical activity
new systolic murmur with palpable thrill 2-7 days following STEMI
ventricular septal defect or ischemic mitral regurgitation
- next steps: echo and surgery
pt presents with severe, sharp, tearing chest pain; pain radiates widely and is assoc. with syncope, systemic ischemia or heart failure
aortic dissection
physical findings assoc. with aortic dissection
acute aortic regurg (diastolic murmur at base)
myocardial ischemia
cardiac tamponade/hemopericardium
hemothorax/exsanguination
sick sinus syndrome consists of…
sinus bradycardia
sinus arrest
sinus exit block
tachycardia-bradycardia syndrome
rapid ventricular conduction during episodes of atrial fibrillation with resting bradycardia between episodes
symptomatic sinus dysfunction is an indication for what?
pacemaker implantation
effects of Donepezil on heart
Achesterase inhibitor - causes increased vagal tone, bradycardia and AV block
cardiac effects of Trazodone
palpitations and ventricular ectopy
next best step in pt with cardiac arrhythmia who is unstable
electrical cardioversion
what test should you order in pt with sinus tachycardia?
TSH level to test for hyperthyroidism
what is adenosine used for?
- terminates AV nodal re-entrant tachycardia
2. can reveal flutter waves during adenosine-induced AV block
elevated resting sinus rate in the absence of recognized cause and an exaggerated rate response to exercise
inappropriate sinus tachycardia
Tx. inappropriate sinus tachycardia
CCB or BB
- refractory cases - sinoatrial node ablation
CHA2DS2 ASc risk score
CHF HTN age > 75- 2 pts Diabetes Stroke or TIA - 2 points Vascular disease (prior MI, PAD, Aortic plaque) Age 65-74 Sex (F)
what do you do with a 25 yo patient with PVCs and structurally normal heart
no additional investigation or tx. needed
first-line therapy for PVCs
beta blocker - metoprolol OR CCB - verapamil
medical therapy of sustained ventricular tachycardia
amiodarone, procainamide, flecainide
- does not improve survival in pts with VT or structural disease
primary eligibility criterion for ICD implantation
EF < 35%, regardless of presence or absence of coronary disease or arrhythmias
ICD implantation is not indicated for whom?
pts who experience ventricular arrhythmias less than 48 hours after acute STEMI - these should be managed medically
indications for pacemaker placement
symptomatic sinoatrial node dysfunction
symptomatic bradycardia due to 2nd or 3rd degree block
pt presents with recurrent syncope as well as a family history of syncope triggered by activity or sudden death/cardiac arrest due to torsades - dx?
long QT syndrome - most likely congenital
acquired long QT syndrome
female sex hypokalemia, hypomagnesemia structural heart disease previous QT interval prolongation history of drug-induced arrhythmia
when is digoxin used in HF treatment?
added to other therapy in pts with NYHA class III/IV heart failure - strictly for symptom control (no survival benefit)
HF with EF < 45% diagnosed between 3 months before and 6 months after delivery (usually first month post-partum)
peripartum cardiomyopathy
what do you suspect in pt with elevated CVP, pulmonary crackles, S3 and S4 heard, any cardiac murmus and LE edema
heart failure
next best step in pt with new-onset heart failure
cardiac angiography
what is radionuclide ventriculogram useful for?
confirming the EF if clarification is needed
what test should be ordered in all patients with newly suspected heart failure?
echocardiography
BNP > 500 suggests what?
acute heart failure
what drugs are recommended for all NYHA class 1 and 2 patients, regardless of symptoms or functional status?
B-blocker (carvedilol)
ACE-i (lisinopil)
- improve mortality
when do you initiate spironolactone and digoxin in HF?
NYHA III-IV patients
what can you give a patient with HF who is intolerant of an ACEi (hyperkalemia, renal insufficiency)?
hydralazine + nitrate
- also improve survival but not as much as ACEi
eplerenone - indications
HTN
LV dysfunction after MI
instead of spironolactone in CHF
contraindications to spironolactone
serum creatinine > 2.5 md/dL
K+ > 5 mmol/L
what two CCBs can be used in HF patients if symptoms are not adequately controlled by BB or ACEIs?
amlodipine
felodipine
failure of a bioprosthetic aortic valve leads to …
aortic insufficiency
widened pulse pressure, bounding peripheral/carotid pulses, holodiastolic murmur on left upper sternal border best heard when pt is leaning forward
aortic regurgitation
fixed splitting of S2 and ventricular heave
ASD
what do you do with murmurs that are grade 2/6 sysolic murmur or less
if asymptomatic, these are considered benign and require no further testing
indications for transthoracic echocardiography (murmurs)
- grade 3/6 or louder systolic murmus
- any diastolic or continuous murmur
- new murmur diagnosed
accentuated P2, opening snap and low-pitched, diastolic rumble
mitral stenosis - usually due to Rheumatic disease
systolic murmur best heard at left lower sternal border that increases with intensity during inspiration
tricuspid regurgitation
what maneuvres increase the murmur of hypertrophic cardiomyopathy
valsalva manuevre
squat-to-stand
rapid upstrokes of carotid arteries with a systolic murmur?
hypertrophic cardiomyopathy
Acute A-fib Rx in unstable patient
Immediate electrical cardioversion to sinus rythym
Acute A-fib Rx in stable patient (3)
- Rate control (DOC: B-blockers; CCB’s, in LVSD- digoxin, amiodarone)
- Cardioversion E>Pharm (ibutilide, procainamide, flecainide, sotalol, amiodarone)
- Anticoagulation
Atrial flutter rx
similar to A-fib
multifocal atrial tachycardia dx
vagal maneuvers or adenosine to show av block w/out disrupting the atrial tachycardia
multifocal atrial tachycardia Rx
improving oxygenation and ventilation
LV function ok: CCBs, B-Blockers, Digoxin, amiodarone, IV flecainide and IV propafenone
LV not preserved: Digoxin, diltiazem or amiodarone
Paroxysmal Supraventricular Tachycardia Rx maneuvers (4)
Stimulate the vagus delay AV conduction and thus re-entry mechanism: Valsalva, carotid sinus massage, breath holding, head immersion in cold water
Paroxysmal Supraventricular Tachycardia Acute Rx
DOC: adenosine 6 mg rapid IV push
Iv Verapamil or IV esmolol or Digoxin
Cardioversion if unaffective
Paroxysmal Supraventricular Tachycardia prevention
DOC: Digoxin
Verapamil or B-blocker
Ablation of AV node
Rx W-P-W
Ablation
Consider amiodarone 150 mg IV over 10 min.
Pharm(esp if patient goes into a-fib): procainamide or quinidine
Avoid drugs active on AV-node in W-P-W
Digoxin, B-Blocker, CCB, Adenosine
may accelerate conduction
Rx: Sustained VT with hemodynamically stable patients
ACLS guidelines: IV amiodarone 150 mg IV over 10 min; IV procainamide or
IV sotalol > IV lidocaine or IV bretylium
Rx: Sustained VT with hemodynamically unstable patients
Immediate synchronous DC cardioversion
Follow with Amiodarone to maintain sinus rhythm
Rx: Nonsustained VT
No underlying heart condition: NO treatment
Underlying heart disease: order electrophysio study
- if inducible S-VT give amiodarone
V-fib Rx
Immediate Defibrillation and CPR indicated
continues after shock EPI (1 mg bolus initially)
Pulseless electrical Activity causes
5H’s and 5T’s (due cpr)
Hypovolemia, hypoxia, H+ (acidosis), hypo/hyperkalemia, hypothermia
Tension Pneumo, Tamponade, Toxins (Narcs, BZ), Thrombosis (Pulm/cardiac), Trauma
