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CARDIOLOGY STEP 3 REVIEW By James K. Rustad, M.D. Copyright © 2009 All Rights Reserved. Outline Arrythmias and Chest Pain Pericarditis Endocarditis Rheumatic Fever Hypertension Valvular Heart Disease Congential Heart Diseases Arrhythmias Wolf Parkinson White Syndrome Accessory pathway between atria and ventricle Short PR interval (no AV nodal delay) and delta wave at onset of wide slurred QRS complex WPW (continued) If symptomatic – best initial therapy Procainamide (for VT or SVT from WPW) Long term treatment: Radiofrequency ablation Avoid digitalis, beta blocker and calcium channel blocker (may precipate arrhythmia) Atrial fibrillation Irregularly irregular heart beat EKG – no P wave, irregular RR interval Rule out Thyrotoxicosis Often patient has history of HTN, ischemia, or cardiomyopathy. If patient is unstable > Synchronized Cardioversion Rate control and anticoagulation Rate control medications including beta blockers (metoprolol, esmolol), calcium channel blockers (diltiazem), or digoxin. Once rate is controlled, anticoagulation with warfarin for INR 2-3 for all patients with atrial arrhythmia lasting beyond 48 hours. Clinical Scenario 23 year old woman comes for evaluation of “rapid heart beat.” Pulse is 130 but otherwise VSS. EKG shows Paroxysmal Supraventricular Tachycardia. The next most appropriate step in management is: A) IV heparin B) Load digoxin C) Carotid Massage D) Immediate Cardioversion Management of SVT 1) Valsalva 2) Carotid massage 3) Adenosine (if 6 mg ineffective give 6 mg more) 4) Verapamil, Diltiazem 5) If hemodynamically unstable: Synchronized Cardioversion Clinical Case: Syncope 62 yo woman comes to clinic complaining of fainting spells. Investigation with Holter Monitor shows two episodes of arrhythmia, one of sinus brady 40/min and one SVT with 200/min. The most appropriate step in management is: A) Start atenolol B) Start verapamil C) Echocardiogram D) Recommend Dual chamber pacemaker E) Refer for cardiac catheterization Tachy-Brady Syndrome (Sick Sinus) Treatment: Dual Chamber Pacemaker Initially try to D/C digitalis, calcium channel blocker, beta blocker – If still symptomatic PACEMAKER Chest Pain Risk factors for CAD Men >45, Women >55 Male gender Diabetes, HTN, Lipid abnormality (increased LDL) Smoking Physical inactivity Increased Homocysteine Differential Diagnosis Nonpleuritic CP Cardiac: MI/infarction, myocarditis Esophageal: spasm, esophagitis, ulceration, neoplasm, achalasia, diverticula, foreign body Referred pain from subdiaphragmatic GI structures Gallbladder and biliary: cholecystitis, cholelithiasis, impacted stone, neoplasm Gastric and duodenal: hiatal hernia, neoplasm, PUD Differential (continued) Chest pain associated with MVP Pulmonary: neoplasm, pneumonia, PE/infarction Mediastinal tumors: lymphoma, thymoma Pain originating from skin, breasts and musculoskeletal structures: herpes zoster, mastitis, cervical spondylosis Dissecting aortic aneurysm Pancreatic: pancreatitis, neoplasm Angina Exertional chest pain relieved by rest. Tightness, squeezing, pressure like. Short duration 3-20 minutes. EKG during chest pain: T wave inversion and ST depression. Stable angina: Aspirin and Metoprolol have benefit on mortality; nitrates helpful for pain. Unstable angina 1. History of chronic angina but recent increase in frequency, intensity. 2. New onset (less than 2 months) severe and 3 or more episodes a day. Angina at rest. Unstable Angina Management S/L NTG for chest pain (IV next option), Aspirin, Bed Rest, O2 Clopidrogrel, Heparin for 48 hours, platelet glycoprotein IIb/IIIa receptor antagonist Beta Blocker (or Ca channel blocker) Enzymes X 3 and admit to CCU Clinical Scenario 55 year old man with diabetes comes to clinic for follow-up after ED visit for L sided chest pressure 2 weeks lasting 10-20 min in duration with no radiation. Escalation of symptoms 2 days prior to ED visit, SOB on exertion, and diaphoresis on onset of pressure. Transient 1.5 mm ST elevation anterior leads, no Q waves, and negative enzymes. BP 150/80. Total cholesterol of 290 with HDL 33 and LDL 222 Most appropriate next step in management? Unstable Angina A) Continue Aspirin 325 mg daily and close follow up B) Stop Aspirin and start Clopidrogrel C) Schedule him for coronary angiography D) Start therapy with Lovastatin E) Initiate therapy with Nifedipine Unstable angina (continued) The answer is D: Long term goals include LDL <100. patient should be managed conservatively by managing risk factors optimally. Coronary angiography is accepted for those who continue to report symptoms despite aggressive management, escalation of symptoms/severity, or hemodynamic instability. Stress test Poor Prognosis ST depression over 2 mm at < 6 min on BRUCE protocol ST dep. persists > 5 min post exercise ST elevation Hypotension HR < 70% predicted max Indications of CABG Left main disease Triple vessel disease with low EF Diabetes with 2 or more vessels involved MI Chest pain greater than 30 min. Diaphoresis, SOB, weakness, pain. Cardiac Enzymes: CKMB, Troponin I, Troponin T ST elevation MI Q wave, transmural ST elevation greater or = to 1 mm in two consecutive leads. O2, S/L NTG, Morphine, Aspirin or Clopidrogrel, Bblocker, IV heparin. PTCA OR Thrombolytic (less than 12 hours post MI, ST elevation, New LBBB) Non ST elevation MI Sub-endocardial, ST depression or T-wave inversion No Q wave but cardiac enzymes up Manage similar to unstable angina. With continued Chest Pain – Cardiac Cath Clinical Scenario 61 year old male with CAD and history of 2 MI’s comes to ER because of chest pain and SOB. EKG shows sinus rhythm with ST-segment elevation in leads II, III and aVF Next appropriate diagnostic step to order? A) cardiac stress test B) chest X-ray C) EKG with R-sided leads D) green dye cardiac output measurement E) Ventilation-perfusion scan Right Ventricular Infarct Check Right sided lead V4 for ST elevation! Hypotension but elevated JVD (increased right atrial pressure) Positive Kussmaul’s, clear lung field Treat with IV fluids and manage like MI Knowledge test A 58 year old man comes to the office several days after going to the ER with an episode of chest pain. He had a normal EKG and normal CK-MB and was discharged. What is most appropriate for further management? Stress testing When the case is not acute and initial EKG/enzymes do not establish diagnosis: the stress test is a way of increasing the sensitivity of detection of CAD. What if the stress test is abnormal? If the stress test shows an area of “reversible ischemia,” angiography is the next diagnostic test. “Fixed defects” – unchanged between exercise and rest – is a scar from a previous infarction. Clinical Scenario 52 year old man comes to ED unresponsive with no pulse. After assessing ABC’s, the next appropriate step is which of the following? Amiodarone load, defibrillate, intubate, push adenosine or push epinephrine? ACLS Protocol CPR until defibrillator ready. 3 shocks: 200, 300 then 360 J then intubation. 1 mg of epinephrine Shock again w/ 360 J If no stable rhythm: Amiodarone loading Aortic Dissection Type A: intimal tear at ascending aorta just distal to aortic valve. Look for new aortic regurgitation murmur. SURGICAL EMERGENCY!!!! Type B: just distal to L subclavian artery. Mostly managed medically but still call SURGERY! Symptom: sudden onset of chest pain radiates to back. Signs: Widening of mediastinum in CXR Asymmetrical pulse, BP (R 180/100 and L 130/70) Aortic dissection investigation and treatment Stable vitals: CT chest with contrast Vitals unstable: TEE Keep pulse around 60+, decrease reflex tachy and tear propagation with IV Propranolol or Labetalol Keep systolic BP around 100 with IV Nitroprusside or Verapamil Aortic dissection Actor John Ritter (1948-2003) Special topic: Diastolic Dysfunction Diastolic dysfunction refers to an abnormality in the heart's (LV) filling during diastole (phase of the cardiac cycle when the heart (ventricle) is not contracting but is actually relaxed and filling with blood that is being returned to it, either from the body (into RV) or from the lungs (into LV). DD Ventricle = balloon made thick rubber. Fills with high pressure, volume can’t expand. HTN = LV muscle hypertrophies to deal with the high pressure, and LV becomes stiff Aortic Stenosis =ventricular muscle has hypertrophied and becomes stiff, due to the increased pressure load placed on it by the stenosis. Special topic: Jugular Venous Pressure A: Atrial contraction C: Closure of Tricuspid X: Atrial RelaXation V: Venous filling Y: opening of Tricuspid JVP is Right Atrial Pressure Large right sided “a” wave is Tricuspid stenosis Large left sided “a” wave is Mitral Stensosis Rapid x and y descent is Constrictive Pericarditis (rapid x only = cardiac tamponade) Canon “a” wave = complete heart block (atria and ventricle have own rhythm, no coordination) Pericarditis Acute Pericarditis Mid sternal chest pain, non radiating. Relieved by sitting up and leaning forward. Worst with supine and inspiration. Associated hx: viral fever, breast cancer, s/p radiation therapy, renal failure, MI EKG: Diffuse ST elevation and PR depression. Confirm with Echo Treatment: Aspirin, NSAIDS. Clinical scenario 58 year old woman with metastatic lung cancer and HTN admitted for CP, SOB. s/p radiation Transthoracic echo shows constrictive pericarditis, but no pericardial effusion present. On physical, what would you expect? A) increase in JVP with inspiration. B) inspiratory stridor C) jugular venous flattening D) muffled cardiac sounds E) tracheal deviation to right Kussmaul’s sign Increase in jugular pressure with inspiration. Increased R-sided pressure exerted by noncompliant pericardium as heart moved inferiorly by descending diaphragm during inspiration. Endocarditis Endocarditis Most present with a fever for a few days. Other possible s/sx: splinter hemorrhage of finger nail (sub-ungal hemorrhage), palate/conjunctival petechia Osler Node (painful,violaceous raised lesions of fingers/toes/feet) Roth’s spot: exudative lesions in the retina Fever + New or Changed murmur Blood cultures first! If positive, do an ECHO to look for vegetations. Common organisms/treatment Common: Strep viridens Virulent: Staph aureus S/P cardiac surgery: Staph epidermis (for this or prosthetic valve give vanco + rifampin + genta) Strep: Penicillin with Gentamicin or Ceftriaxone Staph: Nafcillin + Genta Best empiric therapy (or for MRSA or Penicillin allergy): Vanco + Gent Give Ceftriaxone if c/s shows: Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella IV Drug Abuse Endocarditis typically involves R side of heart (injecting in veins) – usually staph aureus, MRSA Fever, pleuritic chest pain, cough, hemoptysis CXR: nodular density in both lung fields, cavitary lesion Endocarditis Prophylaxis Previous endocarditis. Prosthetic cardiac valve. Congenital Cyanotic cardiac disease. First 6 mos after repair with prosthetic material (or with residual effects after repair). Cardiac Valvulopathy in transplanted heart. Procedures which need prophylaxis: Dental procedures that cause bleeding (amoxicillin - or clindamycin if patient allergic to penicillin) Respiratory tract surgery or surgery of infected skin. Valve replacement surgery Anatomic defects – difficult to correct with only ABX! Valve rupture/prosthetic valve Abscess Fungal endocarditis Embolic events after starting ABX. Rheumatic Fever Acute RF usually develops after 2-4 weeks of pharyngeal infection with Group A streptococcus. Can erysipelas lead to rheumatic fever? No --- skin goes to kidneys only. Throat goes to kidneys and heart. Earliest Symptomatic manifestation Arthritis --- migratory and involves large joints mainly lower extremity. Subjective pain greater than objective inflammation. Erythema marginatum Non-pruritic Erythematous lesion with pale center, mostly on trunk, rounded margin. Early manifestation Evanescent (appear, disappear) Syndenham chorea Commonly on one side and ceases during sleep. Abrupt, purposeless, non rhythmic involuntary movement. Rheumatic Fever (continued) Carditis Early: Mitral Regurgitation Late: Mitral stenosis, secondary to scarring and calcification of damaged valve. Subcutaneous Nodule Nodule: mostly over bony surface. Firm, painless, usually disappears within a month. Diagnosis: Jones Criteria Major Carditis Polyarthritis Chorea Subcutaneous Nodule Erythema Marginatum Minor Fever Arthralgia Previous RF or Rheumatic Heart disease Rheumatic Fever treatment Acute Treatment Aspirin Oral Penicillin V for 10 days or Benzathine Penicillin G IM X 1 dose Penicillin allergic: Erythromycin X 10 days Prophylaxis Oral Penicillin V or oral sulfadiazine daily or Pen. G IM q4 weeks Until patient is approx. 20 years old (approx. 10 years from attack) Hypertension Management of Blood Pressure Blood Pressure Systolic Diastolic Management Recheck Stage I 140-159 90-99 Thiazide unless other indication Within 2 months Stage II Greater than or equal to 160 > Or = to 100 2 Drug Combo If greater than 180/110 treat right away, otherwise recheck within one month Thiazide diuretics They work by inhibiting reabsorption of Na+ and Cl− ions from the distal convoluted tubules by blocking the thiazidesensitive Na+-Cl− symporter. Thiazides also cause loss of potassium and an increase in serum uric acid. Hypokalemia, Hyponatremia and Hyperuricemia Recommended starting dose: Hydrochlorothiazide 25 mg once daily K+ sparing diuretics (think SAT) Spironolactone inhibits the effect of aldosterone by competing for intracellular Ald. receptor in the distal tubule cells (it actually works on Ald. receptors in the collecting duct). This increases the secretion of water and sodium, while decreasing the excretion of potassium. Amiloride works by directly blocking the epithelial sodium channel (ENaC) thereby inhibiting sodium reabsorption in the distal convoluted tubules and collecting ducts in the kidneys. Triamterene with similar Mechanism to Amiloride. Loop Diuretics Loop diuretics act on the Na+- K+ - 2Clcotransporter in the thick ascending limb of the loop of Henle inhibit sodium and chloride reabsorption. Loop (of Henle) diuretics Loop diuretics prevent the urine from becoming concentrated and disrupt generation of hypertonic renal medulla. Water has less of an osmotic driving force to leave the collecting duct system, ultimately resulting in increased urine production. Furosemide, Bumetanide, Ethacrynic acid, Torsemide Beta Blockers Cardioselective (Beta 1) Atenolol 50-100 mg/day Metoprolol 25-100 mg/day Non-selective: Propranolol 40-80 mg PO BID Alpha and Beta blocker: Labetolol (The recommended initial dosage is 100 mg twice daily - usual maintenance dosage of labetalol HCl is between 200 and 400 mg twice daily). ACE inhibitors Lisinopril: recommended initial dose is 10 mg qdaily. Usual dosage range is 20 to 40 mg per day administered in a single daily dose. Side effects: Dry cough, hyperkalemia, angioedema. ACE inhibitors (continued) Angiotensin II receptor blockers Losartan Irbesartan Valsartan Candesartan Calcium Channel Blockers Non-Dihydropyridine (bradycardia) Diltiazem Verapamil (constipation) Dihydropyridine (cause Tachycardia) Amlodipine 5-10 mg/day Felodipine Nifedipine 30-60 mg/day Calcium channel blockers: Ankle Edema Valvular Heart Disease Presents with Shortness of breath ---“worse with exertion or exercise.” Physical findings: Murmur, Rales on lung exam. Possibly peripheral edema, carotid pulse findings, gallops. Heart Sounds S1: Closing of the mitral valve. S2: Aortic valve closes first, followed by pulmonic. Right sided murmurs increase on inspiration because the lung expands and intrathoracic pressure goes down > blood to the heart increases. Wide splitting of S2 Aortic valve closes earlier Pulmonic valve closes later MR, VSD, Pulmonary Stenosis, Pulmonary Artery Hypertension, RBBB Mitral Regurgitation MR Holosystolic murmur best heard at apex radiates to the axilla. Blood travels from Left Ventricle to Left atrium. There is less blood for LV to pump out and the Aortic Valve closes earlier. MR Test of choice: Transthoracic Echocardiogram Acute MR caused by rupture of chordae tendinae during MI or Endocarditis. Tx: Emergency Surgery. Chronic MR should be referred for surgery when symptomatic or asymptomatic with EF < 55% or LV end systolic dimension greater than 45 mm. Ventricular Septal Defect Holosystolic murmur, Lower left sternal border Most common acyanotic congenital cardiac anomaly. Blood goes from Left Ventricle to Right Ventricle. Less blood in LV available to pump out and aortic valve closes earlier. Echo for diagnosis, but catheterization can determine degree of L > R shunting most accurately. Pulmonary Stenosis Pulmonic valve closes later (Stenotic valves take longer to close). Pulmonary Hypertension The pressure is high in the vessel and it is hard to pump blood. The Right Ventricle has to pump blood into pulmonary artery against high pressure. Pulmonary valve closes later. Right bundle branch block Right ventricle contracts slowly and pulmonic valve closes later. Narrow splitting (paradoxical) Aortic valve closes later Pulmonic valve earlier. Sometimes paradoxical splitting where pulmonic valve closes before aortic valve. Aortic stenosis, HOCM, LBBB Aortic Stenosis Stenotic valves close later. Midsystolic, upper right sternal border. Aortic Stenosis “Crescendodecrescendo” murmur Upper right sternal border and radiates to carotids. Aortic Stenosis Syncope Angina Dyspnea Aortic Stenosis LVH on EKG Treatment of choice is valve replacement. Clinical scenario 52 year old woman comes to ED complaining of SOB. History notable for heart murmur and HTN. Loud ejection murmur at cardiac apex and rales bilaterally in both lung fields. ECG shows LVH. Most appropriate next diagnostic step? A) cardiac stress test B) Chest CT C) Transesophageal Echocardiogram D) Transthoracic Echocardiogram E) Ventilation-perfusion scan HOCM Outflow tract obstruction --- Aortic valve closes later. Left Bundle Branch Block Left ventricle closes slowly and Aortic valve closes later. Blood return Squatting and Leg Raise Increases Blood Return (increase venous return to heart). Standing/Valsalva Decreased Blood Return. All murmurs decrease with standing and valsalva except for….. HOCM and MVP Hypertrophic Obstructive Cardiomyopathy Mitral Valve Prolapse (mid systolic click followed by late systolic murmur) Hand grip Increases afterload. Improves or lessens the murmurs of MVP and HOCM as the left ventricular chamber is more full. Mitral Valve Prolapse Young thin female with occasional palpitation and mild chest pain. Treatment: Beta Blocker Mitral Stenosis Middiastolic at apex best heard with bell. Diastolic rumble after opening snap. Rheumatic fever most common cause. Pregnant patient (large increase in plasma volume). Mitral Stenosis Symptoms Dyspnea (due to pulmonary edema) Hemoptysis (due to increased pressure in pulmonary vessels) Hoarseness due to compression of recurrent laryngeal nerve from enlarged LA – “Ortner’s syndrome” Treatment of Mitral Stenosis Diuretics are best initial therapy, but do not alter progression. MS without MR: Percutaneous Mitral Balloon valvuloplasty. Aortic regurgitation Causes: Rheumatic fever, aortic root diseases (Marfan’s, anklosing spondylitis, Reiter’s), congenital bicuspid valve, HTN Murmur: Diastolic decresendo murmur best heard at L sternal border. AR: “rapid rise and fall” of pulse Elevated systolic and low diastolic pressure Wide arterial pulse pressure Aortic regurgitation factoids Hill sign: blood pressure gradient higher in lower extremities. Corrigan’s pulse: High bounding pulses (“water-hammer”) Quinke pulse: Arterial or capillary pulsations in fingernails. Musset’s sign: Head bobbing up and down with each pulse. Duroziez’s sign: murmur heard over femoral artery Chronic AR treatment Medical: reduce afterload with ACE inhibitor, Nifedipine, Hydralazine. Beta Blocker Surgical indication: symptoms or LVEF less than 55% or LV end systolic dimension > 50 mm More Congential Heart Diseases Patent Ductus Arteriosus Connects descending aorta and pulmonary artery. Maternal Rubella infection in early pregnancy. In premature infant: close with Indomethacin. More common in girls. Upper left sternal border continuous machinery murmur. Tetralogy of Fallot Most common congential cyanotic cardiac anomaly. Child while playing may develop SOB, cyanosis. Coarctation of Aorta 98% occur at origin of left subclavian artery BP higher in arms than legs Give PGE1 to maintain patent ductus Surgical repair after stabilization Turner’s syndrome Thank you for your attention!