Cardiology 7 Step 3

Risk factors for CAD: DM, HTN, HLD, Age, Smoking, PAD, obesity, inactivity and family hx (fem < 65, male < 55) Jugular veins in CCS are part of CVS exam and not HEENT. If the case is very clear to be ischemic pain and the exam asks to choose between EKG and (Aspirin, Nitrates, O2 and morphine) go for treatment. While in CCS do EKG, enzymes, give Rx, angio. BI test is EKG and MA is enzymes, CKMB is best for reinfarction, Myoglobin is the first to rise, LDH has no role. Stress test: do it in non acute case when it is equivocal. Never do angiography without abnormal stress. In stress test we look for ST depression. If stress test shows reversible ischemia then do angio. Persistent ischemia means scar. In case of unreadable EKG (LBBB, digoxin use, pacemaker, LVH, any baseline abnormality if ST segment) do stress echo or exercise thallium. In case of inability to exercise do dipyridamole or adenosine thallium stress test, regadenosine stress test (lexiscan) or dobutamine echo. Sestamibi nuclear stress is used in obese or those with large breasts as it has greater ability to penetrate tissues. Never stress a patient with CP and stop the test if it shows ischemia, low BP, CP, any other critical conditions like asthma, Arrhythmias. First do stress then angio then bypass if needed. Valvular dysfunction needs echo. MA test for EF is nuclear ventriculogram. Aspirin and metoprolol decrease mortality. Nitrates should be used if patient has anginal pain but has no effect on mortality. O2 is useless if patient is not hypoxic. Add clopidogrel or prasugrel to any patient getting angio and stent or to any patient with acute MI or in case of allergy to aspirin. Do PCI within 90 min of arrival and do thrombolytic within 30 minutes and choose it if PCI can't be done within time frame. Watch for CI of thrombolytic. Thrombolytic can be given to any patient with CP for less than 12 hrs with ST elevation or new LBBB. Give statin to all patients with ACS regardless of EKG or enzymes. Aspirin, Clopidogrel or prasugrel, thrombolytic, PCI, metoprolol and statins always lower mortality. ACE and ARBs will lower mortality only if there is low EF, ie: systolic dysfunction. O2, morphine, nitrates, CCB, lidocaine and amiodarone never lower mortality. Give CCB if patient can't tolerate BB, cocaine induced CP or prinzmetal angina. Do pacemaker for MI if patient develops 3rd degree HB, ,mobitz II, bifascicular block, new LBBB or symptomatic bradycardia. Use lidocaine or amiodarone for VF and VT and never for prophylaxis. Complications of MI: cardiogenic shock --> echo, swan ganz, Give ACEI and revascularize. Ruptures: all of them need echo, septal will show step up of SO2 from right atrium to right ventricle. Rx: valve: ACEI, nitroprusside, intra-aortic ballon pump as a bridg to surgery, Septal:

same meds and surgery. Free wall: pericardiocentesis and surgery. Sinus brady: EKG, atropine and pacemaker if resistant. Third degree HB: canon a wave, EKG, atropine and pacemaker even if asymptomatic, RV infarction will show on right leads and needs fluid loading and avoid nitrates. NSTEMI: use heparin (LMWH is better), Give glycoprotein IIb/IIIa inh. (eptifibatide, tirofiban, abciximab) will lower mortality especially for those who will undergo angio Stable angina: Give aspirin and metoprolol to lower mortality. Give nitrates to control pain, Give ACEI/ARB for low EF, systolic dysfunction and cardiogenic shock. Angi to know who will benefit from CABG: LAD > 70%, 3 vessels > 70%, 2 vessels in DM. Internal mammary artery graft remains open for 10 years while saphenous vein graft remains for 5 years. CAD equivalents: DM, PAD, Aortic disease, carotid disease. Goal LDL in CAD is below 100, in CAD + DM < 70. Start statins for any patient with CAD and LDL above 100. Risk factors to consider while calculating LDL goal: smoking, BP >/= 140/90 or the patient takes meds for HTN, HDL < 40, Family hx of premature CAD, age male >/= 45 and 55 for females. ED following MI is due to anxiety and less commonly due to BB, never start seldenafil while the patient takes nitrates. Clues for type of CHF: Hx of HTN --> diastolic dysfunction, IHD --> systolic dysfunction, echo will tell. Pulmonary edema: Give O2, furosemide, nitrates and morphine before doing any tests, Take care of BP. In CCS order the above + CXR, EKG, Oximeter and may be ABG, echo. All these orders and meds need to be done on first screen. Place patient in ICU. Still short of breath after 30 - 60 minutes --> inotropes (Dobutamine is the best), amrinone, milrinone Rule: in CCS with unstable ICU or emergency department patient move the clock no more than 15-30 minutes. VT with pulse, acute afib, flutter or SVT in HD unstable --> synch cardioversion. VF or pulseless VT --> unsynch cardioversion. Nesitiride is synthetic atrial natriuretic peptide that can be used to decrease the preload and give symptomatic relief but no mortality benefit. BNP is useful if thee patient presents with SOB and etiology is not clear. It is nonspecific but if found normal then CHF is exluded, Look for other causes like pneumonia, pulmonary embolism, asthma, etc. Swan ganz in pumonary edema will show: low COP, high right atrial and wedge pressures and high SVR.

Swan ganz in hypovolemic shock: Low COP, right atrial and wedge pressures and high SVR. Swan ganz in PHTN: low COP, low wedge pressure, high right atrial pressure and SVR. Swan ganz in septic shock: high COP and low SVR, Low right trail and wedge pressures. Only shock with high COP and low SVR is septic shock. All others show low COP and high SVR. After the patient is stabilized further management is required: Systolic dysfunction or DCM: Metoprolol or carvedilol (only BB that lower mortality in CHF), ACEI/ARB (lower mortality), Spironolactone (lowers morrtality in advanced dz and should be sued with any patient who had pulmonary edema, diuretics, digoxin. Diastolic dysfunction: Metoprolol or carvedilol, diuretics. ACEI/ARBs are not of clear benefit. MCC of death is arrhythmia so if there is persistant EF < 35 % implant defebrilator. If patient is short of breath and has QRS > 120 msec then do biventricular pacemaker. No role for warfarin except with clots or afib. Symptomatic bradycardia is the only absolute CI to BB. Valvular disease: cluse: MVP --> young female of general population or palpiations and atypical CP not related to exertion, HOCM: healthy young athlete, MS --> pregnant immigrant, bicusped aortic valve --> turner's syndrome, coarctation of aorta. With any valvular caseselect CVS, chest and extremities exam. Systolic murmers: AS/PS, MR/TR, MVP, HOCM, VSD. Diastolic: AR/PR and MS/TS. All right sided murmers will increase with inspiration and all left sides will increase with expiration. Squatting, leg raising will increase blood flow to heart. Valsalva and standing will decrease venous return. All murmurs will be louder with increased flow (squatting, leg raising) except MVP and HOCM. All murmurs will be softer with low blood flow (standing or valsalva) (diuretic) except MVP and HOCM where they become louder. Hand grip increases afterload: worsens MR, AR and VSD. It soften HOCM and MVP murmurs due to fuller heart. Also will soften AS murmur due to decreasing pressure gradient across the valve. Amyl nitrate softens MR, AR and VSD murmuurs and will worsen HOCM, MVP and AS. MS is negligibly affected by these maneuvers. Amyl nitrate is similar to ACE. Location of murmur will help identifying it. AS at 2nd right Intercostal and radiates to carotids (crescendo decrescendo), PS/PR at 2nd left space. AR/TR/TS/VSD at lower left sternal border. MR at apex and radiates to axilla. MS where?? Intensity is 6 grades: I needs maneuvers to be heard, II and III are heard with no maneuvers. IV will feel thrill. V heared with stethoscope partially off chest. VI heared without stethoscope. BI test is echo, most accurate is left heart catheter. In CCS order EKG and CXR. In CCS order transthoracic echo and if not diagnostic order TEE.

All regurgitaions need ACEI/ARBs/nifidipine, if worse do surgery. MS needs balloon, AS needs replacement. All lesions except HOCM and MVP will soften with standing and valsalva so need diuretics. Finally Regurgitaions need diuretics and dilators, stenosis needs diuretics. AS: CP, syncope, CHF. Usually old hypertensive patient and may be CAD. Survival is highest with CAD and lowest with CHF. Do Echo (TTE and then TEE if needed) and most accurate is left heart cath. Normal gradient is 70 mmHg. Don't forget to do EKG and CXR that will show LVH. Do replacement with bioprosthetic valve which will not need anticoagulation but needs replacement every 10 years in average or use mechanical valve which will need anicoagulation at INR 2-3. Do ballooning if patient can't tolerate the surgery. AR: diastolic decrescendo murmur at left sternal border. Caused by HTN, rheumatic heart dz, endocarditis, cystic medial dz, Marfan's syndrome, ankylosing spondylitis, syphilis, and reactive arthritis which is called reiter's syndrome (inflammation of large joints, eyes "conjunctivitis and uveitis" and urethritis) Quincke pulse: pulsations of fingernails. Corrigan's pulse: water hummer pulse. Musset's sign: head bobbing up and down with each pulsation. Durozies's sign: Murmur over femoral artery. Hill sign: BP is much higher in LL. CXR will show LVH. Give ACE/ARB/nifidipine + loop diuretic. IF EF < 55 or LV systolic diameter > 55 mm --> surgery even if asymptomatic. MS: MCC is RF so look for immigrant patient and also pregnant as large increase of plasma volume will aggravate it. May show dysphagia (esophageal compression), hoarsness (recurrent laryngeal nerve compression) or afib. Murmur is diastolic rumble after and opening snap (extra diastolic sound), loud S1, As MS worsens the opening snap will become closer to S2. CXR will show left atrial hypertrophy + straight left heart border and elevation of mainstem bronchus and may be double density of cardiac silhouette. Give diuretics and balloon the valve even if pregnant. MR: caused by HTN, IHD or any cause of heart dilation. Most common complaint is dyspnea on exertion. S3 is often heard. Holosystolic murmur that obscures S1 and S2, heard best at apex and radiates to axilla. BI Rx: ACE/ARB/nifidipine can decrease progression of dz. In CCS add loop diuretic. Do surgery if EF 40 mm even if asymptomatic. VSD: asymptomatic with holosystolic murmur at left sternal border. If large will cause SOB. Worse with exhalation, squatting and leg raising.. If mild leave as is. Severe do surgery. ASD: If small will be asymptomatic, If large: SOB or signs of right heart failure as SOB, parasternal heave, Fixed splitting. Rx: percutaneous or catheter devices are best therapy, repair is needed if shunt ratio > 1.5:1 Wide S2: P2 is delayed: RBBB, PS, PHTN, RVH. Paradoxical S2: A2 Delayed: LBBB, AS, HTN, LVH. Fixed splitting: No change with respiration: ASD. Normal S2 is A2-P2. Cardiomyopathy: DCM is caused by ischemmia, alcohol, adriamycin, radiation or chagas's dz. Rx is exactly as systolic CHF. Detect EF with echo but MUGA scan is the most accurate. HCM: Will present with SOB and S4 gallop. Rx is as diastolic HF. RCM: caused by sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial fibrosis and

glycogen storage dz. SOB, Kussmaul's sign (increased JVP on inhalation). EKG will show low voltage, echo is diagnostic, catheter will show rapid x and y descent. Bx is the most accurate to diagnose the etiology. Give diuretics and correct the cause. Pericarditis: mostly viral but hx of trauma, surgery or collagen vascular dz can be present. Also any infectious agen can cause it. Exam will only show friction rub and the patient will have sharp bried positional pain.. EKG: ST elevation everywhere with PR depression sometimes. Give NSAID as indomethacin, naprooxen, ibuprofen or aspirin and advance 1-2 days, If not better give prednisone and and advance 1-2 days, if not better add colchicine. Pericardial tamponade: SOB, shock, JVD. In CCS lung exam will be clear. Pulsus paradoxus: BP decreases > 10 mmHg on inspiration. EKG: electrical alternans + low voltage. Echo is most accurate test: diastolic collapse of right atrium and ventricle (earliest finding), note that 50 ml of pericardial fluid cann be normal. Right heart catheter: equalization of diastolic pressures of heart (wedge pressure = right atrial pressure = pulmonary artery pressure). Rx: BI is pericardiocentesis, Most effective long term: pericardial window, Most dangerous: diuretics. Constrictive pericarditis: SOB + signs of chronic CHF: edema, JVD, hepatosplenomegaly, asccitis + Kussmaul's sign and percardial knock which is an extra diastolic sound as the heart hits the calcified myocardium. CXR: calcification, EKG: low voltage, CT/MRI: thick pericardium.. Rx: BI is diuretics, Most effectivve is removal of pericarium (stripping) Dissection of thoracic aorta: In CCS if the case describes severe CP radiating to back with HTN order BB in first screen with EKG and CXR. No matter what the EKG will show move the clock forward and order either: CT angiography, TEE or MRA as they are all equally accurate. After starting BB order nitroprusside to control BP. Place the patient in ICU and do surgical consultation (most effective therapy is consultation). PAD: Claudication, shiny skin with no hair and loss of pulsations of LL. BI test is ABI (normally >/= 0.9) as BP in legs should be greater than arms. If less than 0.9 do angiography. Rx: BI is: aspirin, control BP with ACEI, exercise as tolerated, Cilostazole, statin for target LDL < 100. PEntoxifylline is marginally effective. CCB are useless. BB are not CI in PAD. In CCS move clock several weaks. If intial therapy fails or there is signs of ischemia as gangrene or pain at rest then do surgical bypass. Pain + pallor + pulseless = arterial occlusion. Afib and AS are commonly in the hx. Afib and flutter: is suspcted and initial EKG is not diagnostic do holter for outpatient or telemetry for inpatient. In CCS order echo "clots, valves, left atrial size", T4/TSH, Electrolyts (K, Ca, Mg), Troponin and CKMB may be appropriate. Unstable (SBP < 90, CP, confusion, CHF) do cardioversion on first screen. Stable: slow HR if > 100-110 with BB (metoprolol, esmolol) (metoprolol is prefered with IHD, migraines, graves dz, pheochromocytoma), CCB (diltiazem prefered in asthma or migraine) or digoxin (prefered in borderline hypotension). In acute setting as in ER give them IV. Anticagulate with warfarin or Dabigatran (No INR monitoring) or rivaroxaban if beyond 2 days or duration unknown and if CHADS2 score 2 or more. If score is 0 or 1 then give aspirin. CHADS2: CHF, HTN, Age > 75, DM, stroke or TIA are 2 points. MAT is tachycardia assocaited with COPD/emphysema. Don't use BB.

SVT is regular with rate of 160-180. If EKG is not diagnostic do holter or telemetry. Any arrhythmia in CCS needs echo TTE) after initial set of orders. Rx: unstable cardivert, stable: BI is vagal maneuvers (carotid massage, ice immersion of face, valsalva), next step is IV adenosine, Best long term management is radiofrequency ablation. WPW: presents as SVT that alternates with VT or worsening SVT after using CCB or digoxin. EKG shows delta wave. MA test is electrophysiologic study. RX: BI is procainamide, Best long term is radiofrequency ablation. VT: If EKG is not diagnnostic do telemetry. Can present with palpitaions, CP, syncope or sudden death. Most accurate test is electrophysiologic study. Rx: stable: amiodarone, lidocaine, procainamide, magnesium. Unstable: DC. VF: presents with sudden death. Can't diagnose without EKG. Do unsynch DC. Do not intubate first Sudden LOC: cardiac (rhythm or structural dz), seizures (neurologic). Gradual: metabolic: toxic, hypoglycemia, anemia, hypoxia. Sudden regaining of consciousness: cardiac, gradual: neurologic. Cardiac exam normal then it is arrhythmia, Abnormal then it is structural (AS, HOCM, MS, MVP a rare cause of syncope) In CCS: cardiac and neuro exam, EKG, chemistry for glucose, oximeter, CBC, CKMB and troponin Carotid doppler has nothing to do with syncope. Then according to circumstances: murmur --> echo, focal deficit or head trauma due to syncope --> head CT, Headache --> head CT, Seizures are suspected --> head CT and EEG. On further management if diagnosis is not clear after clock is moved to obtain results of initial tests order: holter/telemetry, repeat CKMB and troponin 4 hours later, urine and blood toxicology. On further management if etiology is not clear do tilt table test to diagnose vasovagal and electrophysiologic testing. Holter is routine for any syncope that requires admission. Most important thing to do is to exclude arrhythmia as 80% of mortalities from syncope involves cardiac cause. If ventricular arrhythmia is diagnosed then implant difibrilator.