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REINFARCTION: [NEW CP episode within few days of first episode] INITIAL management?
1. EKG [see NEW ST abnl]
2. CK-MB: (see inc levels) [nl CK-MB disappears 24-48hrs 2 days after 1st MI]
STEMI
ANGIOPLASTY (PCI)
[Decrease Mortality]
Do within 90minutes (if
avail)
Complications of ANGIOPLASTY
(PCI):
-Ruptures coronary artery on
ballon inflation
-Restenosis/thrombosis
-Hematoma @entry site (femoral)
Cardiology Notes 1
Don’t use Thrombolytics if got:
-Bleed in bowel (melena) or Brain (ANY type of CNS bleeding)
-Recent surgery (w/in last 2wks)
-Severe htn (>180/110)
REMEMBER:
Which is better for SURVIVAL & MORTALITY benefit?
= ANGIOPLASTY
-Can answer “THROMBOLYTICS” in any pt w/CP & STEMI within first 12 hours of CP onset
(thrombolytics: Mortality benefits extends to 12hours from CP onset)
= pt w/CP enters ER doors → give THROMBOLYTICS within 30mins
Cardiology Notes 2
ST-depression
-ST-depression, CP. Aspirin given. What’s next?
=Heparin (LMWH) =URGENT
[=prevents clot growing/forming more in coronary arteries. It won’t dissolve already formed clots]
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Acute MI complication QUESTIONS
-What’s most likely diagnosis? [common Q]
-HEART RATE = key clue
BRADYCARDIA
Sinus- Bradycardia [SA node fkd] = NO Cannon A Third-degree (complete) AV block: = Bardycardia,
waves Cannon A waves.
(moa: atrial systole against closed tricuspid)
(Tricuspid closed bc 3rd degree block…Atria &
ventricles contract out of coordination with each
other)
(‘cannon = bounding jugulovenous wave back into
neck’ see: RV infract & Third-degree AV block
link!)
Symptomatic Bradycardia
Tx: ATROPINE (FIRST); then Place PACEMAKER if atropine not effective
TACHYCARDIA:
RV infarct: link New INFERIOR wall Tamponade/free wall rupture VTach/VFib:
MI (II, III, aVF) + Clear lungs auscul; [several days post-MI….wall -Sudden death; Loss Pulse.
Tachy,HoTN with NG use scars/weakens-then rupture] NEED EKG to answer Q
-“sudden pulse loss”; JVD; clear -tx:
-dx: RV4 (Right chest)*** lungs Cardioversion/defibrillation
Cardiology Notes 3
(see Check ST-elevation) emergency
[RCA supplies: RV/AV node/Inferior -dx: Echocardiogram emergency
wall -tx: Pericardiocentesis emergency
-Inferior wall MI has 40% chance on way to OR to repair it
has RV infarction ]
-Intraaortic Balloon pump is temporary BRIDGE to surgery for valve replacement for 24-to-48hrs)
Angioplasty-PCI or Bypass
surgery
Cardiology Notes 4
POST-INFARCTION take home meds:
-ASPIRIN
-BB (metoprolol)
-Statins
-ACE-I
QUESTIONS – HY
POSTINFARCT – SEX PROBLEMS
-Do not combine nitrates/NG with Sildenafil [pt taking 2 drugs…has HYPOTENSION. Likely
cause?...vasodilators]
-Erectile dysfunction postinfarction Most Commonly from: ANXIETY
-ED due to Meds? = Beta-Blockers (propranolol/metoprolol)
-Patient does not have to wait after an MI to have sex. If no symptoms, then can have sex immediately
[bc sex doesn’t last long enough to have excess inc myocardial oxy consumption]
-If Post-MI stress test nl, pt can do any form of Exercise program. Including sex
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CONGESTIVE HEART FAILURE
-sx: Dyspnea [insufficient oxy to tissues & fluid builds in lung]
-dt: MI → DILATED CM & dec EF (= systolic dysfunction; won’t pump) → Regurge → CHF
Cardiology Notes 5
WHAT’S THE MOST LIKELY DIAGNOSIS? For DYSPNEA
Sudden onset; Sudden, Slower, fever, Circumoral Pallor, gradual over
clear lungs wheezing, inc sputum, numbness/mouth; days to weeks
= Pulmonary expiratory phase unilateral caffeine use, h/o =Anemia
emboli = Asthma rales/rhonchi anxiety
=Pneumonia = Panic attack
Pulse paradoxus, Palpitations, Dull percussion Long smoking hx, Recent anesthetic use,
dec heart sounds, syncope at BASES barrel chest brown blood not
JVD =Arrhythmia of =Pleural effusion =COPD improved with
=Tamponade any kind oxygen, clear lungs
auscultate, cyanosis
=Methemoglobinemia
Burning building
or car, wood-
burning stove in
winter, suicide
attempt
=Carbon
monoxide poison
Dx: ECHO (diagnoses CHF) (distinguish systolic vs diastolic dysfunction) [NOT: EKG, CXR, BNP)
To evaluate Ejection Fraction.
CHF clues. Best INITIAL test? Most ACCURATE test? Acute SOB with etiology of dyspnea
= transTHORACIC ECHO = MUGA (Multiple-gated is NOT Clear
acquisition scan) or Nuclear And you cannot wait for ECHO to
ventriculography be done.
-dx: BNP
[TEE: Transesophageal Echocardiogram = more accurate then both to evaluate heart VALVE function &
diameter. TEE not for CHF eval.]
“Nuclear testing” = rarely needed (for precision) (ex: Chemo w/doxorubicin – trying to give max chemo
but not cause cardiomyopathy)
Nuclear Ventriculogram = precision of WALL MOTION problems
Cardiology Notes 6
Septal defects
CBC: T4/TSH: thyroid funct. Endomyocardial biopsy Swan-Ganz right
-Anemia =Both high & low -Rarely done heart catheterization:
thyroid levels cause CHF -excludes infiltrative -Distinguish CHF from
disease: sarcoid/amyloid ARDS; not routine
-biopsy is “most accurate
test” for some infections
///////////////////////
TREAT CHF:
Systolic dysfunction (Low ejection fraction):
-ACE-I or ARBs → give TO ALL Systolic dysfunction CHF (doesn’t matter which stage) pt coughs
on ACE-I….switch to ARBs-sartans
-BB
-Spironolactone
-Diuretics
-Digoxin
SE: HyperKalemia;
gynecomastia
99% CHF pts are at home, not acutely SOB. They dies SUDDEN DEATH by: Ventricular Arrhythmias
(ischemia)
-Beta-Blockers = anti-arrhythmic & anti-ischemia….so they prevent sudden death!
Cardiology Notes 7
-Pt has h/o Dilated CM 2/2 MI. On Lisinopril, furosemide, metoprolol, aspirin, digoxin. Labs show
persistent elevated potassium. EKG unchanged. Best management?
= Switch Lisinopril to hydralazine and nitroglycerin
CHF devices:
-tx: Implantable Defibrillator: [for pt w/Ischemic Cardiomyopathy and EF <35%]
[bc Arrhythmia & SCD = MCCO death in CHF]
-tx: Biventricular Pacemaker: case of Dilated CM (Systolic dys) & <35% EF AND Wide QRS above
milliseconds [resynchronizes heart when there’s conduction defect]
-NEVER “anticoagulation with WARFARIN” …always wrong answer in absence of a clot in heart.
MUST KNOW **** Drugs that LOWER MORTALITY in CHF **** - Mortality Benefit: - memorize
1. ACEIs/ARBs
2. Beta-blockers
3. Spironolactone or Eplerenone
4. Hydralazine/Nitrates
5. Implantable DEFIBRILLATOR
/////////////////////////////
TREAT CHF:
DIASTOLIC dysfunction (Low ejection fraction):
(contraction is okay)
-tx: Beta-blockers = CLEAR benefits
[don’t confuse: Diastolic dysfunction from hypertrophic cardiomyopathy (with hypertrophic obstructive
cardiomyopathy:HOCM]. HOCM = congenital disease w/asymmetric enlarged SEPTUM…obstructs LV
outflow tract.
Diuretics = BAD for HOCM bc will INCREASE OBSTRUCITON
Cardiology Notes 8
//////////////////////////////////////////////////////////////////////////////////////////////////////
ACUTE PULMONARY EDEMA
Pulmonary edema = worse/most severe form of CHF
-RAPID onset fluid buildup in lungs → Acute SOB
-Rales
-JVD
-S3 gallop
-Edema
-Orthopnea
-dx: EKG = most important test to do ACUTELY [bc can lead to change in immediate therapy]
IF Afib/Aflutter/VTach is cause of Pulmonary edema →
then: Rapid, Synchronized Cardioversion [to restore systole) = fast way to fix it!
-dx: ECHOCARDIOGRAM = done in ALL patients. (to see if Systolic or Diastolic dysfunction)
-dx: BNP Brain Natriuretic Peptide (used if Diagnosis of etiology of Short of Breath unclear)
Nl BNP excludes Pulmonary Edema
-CXR: see Vascular Congestion with filling of blood vessels toward head (Engorged Pulmonary Veins –
near trachea]
CASE: Acute SOB, RR 38, RALES, S3 Gallop, JVD. Best INITIAL step?
-tx: Intravenous Furosemide
[partial correct ans bc they all can be used in CHF management at some point…: Oximeter, Echo, ACEIs,
BB, Nesiritide]……but
WRONG:
Oximetry: Echocardiogram: ACEi or ARBs
-should be done, but doesn’t -should be done….but NOT -used if SYSTOLIC Dysfunction
alter ACUTE management bc URGENT w/LOW EF…..but doesn’t make a
must give oxygen anyways difference in an ACUTE
UNSTABLE pt.
Cardiology Notes 9
ACUTE PULMONARY EDEMA INITIAL therapy
Tx: Oxygen; LOOP: FUROSEMIDE/BUMETINIDE; Morphine, Nitrates
= Preload reduction (remove 1-2L FLUID from vascular space & lungs acutely…to dec sx)
-DIGOXIN sucks for acute setting (takes several weeks before effects kick in; positive
inotrope/contractility]
-HEPARIN = always WRONG in acute pulmonary edema in absence of clot
-ACEi/ARBs = Afterload Reduction…….use for DISCHARGE for long-term use in SYSTOLIC Dysfunction &
LOW EF.
/////////////////////////////////////////////////////////////////////////////
VALVULAR HEART DISEASE
-Rheumatic Fever can cause any valve disease….MITRAL STENOSIS is MC
-Elderly = Aortic Stenosis
-tx: DIURETICS [why: all forms of valve disease assoc. with FLUID OVERLOAD in lungs-SOB] – sx relief
Mitral Stenosis:
-tx: Balloon dilation
Aortic Stenosis
-tx: Surgery removal
REGURGES
-tx: Vasodilators: ACEi/ARBs, Nifedipine CCB, Hydralazine
-Surgery REPLACEMENT (before heart dilates too much)
Cardiology Notes 10
-Uncommon in USA…but can be Young Adult - IMMIGRANT or PREGNANT…. “What’s the most likely
diagnosis?”
-Don’t treat if asymptomatic
-Pregnancy: increases plasma volume pass through narrow valve (also uterus contraction “squeeze”
extra blood like 500mL into central circulation…gets pregnancy-related cardiomyopathy)
SYMPTOM:
-SOB & CHF signs (as in all valve diseases); unique clues:
-Dysphagia from enlarged LA compresses esophagus
-Hoarseness (LA presses on Laryngeal nerve)
- Hemoptysis
-AFib & stroke from large LA
PE:
-Diastole murmur after Open SNAP
-Squat & Leg raise → inc intensity from Venous Return to heart
-dx: TTE [Best INITIAL test: transTHORACIC Echo) [TEE is more accurate, but catheterization is MOST
accurate test)
-NO NEED FOR Endocarditis Prophylaxis for ANY valve disease unless valve has been Replaced or
Previous Endocarditis
Cardiology Notes 11