Cardiology pearls

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CARDIOVASCULAR DISEASE

Ischemic Heart Disease

Risks: DM, HTN, high LDL, low HDL, cigarettes, men >45yo, women > 55yo, family history

Stable Angina Pectoris: O2 to heart insufficient for metabolic demand

Clinically: Less than 15 min of substernal pressure brought on by exertion and relieved with rest or NTG

Dx: Stress tests (ECG, echo, radioactive perfusion imaging). Stressor may be exercise or pharmacological. Resting tests are normal.

Any positive test, inconclusive test, or sx refractory to medical management must undergo cardiac cath and coronary angiography

Rx: risk reduction, ASA, B blockers, NTG, CCB, and revascularization (PTCA vs CABG) when stenosis > 70%

Unstable Angina Pectoris

Definition: decreased coronary perfusion from thrombus occlusion

Clinically: increase in frequency, duration, intensity of angina or sx at rest

Dx: rule out MI (enzymes not elevated), avoid stress tests until pt stable on medical management, cardiac cath with angio if refractory to medical rx

Rx: admit to unit, O2, NTG, morphine, ASA, B Blockers, LMWH, GPIIb/IIIa blockers, revascularization if 48 hrs of medical therapy fails or if indicated by stress tests. Long term therapy includes risk reduction, ASA, B Blockers, NTG

Variant (Prizmetal) angina: IV ergonovine provokes chest pain and coronary angio displays vasospasm. Rx with CCB and NTG

MI (STEMI/NSTEMI): no coronary perfusion from due to complete thrombus occlusion causing damaged tissue

Clinically: Intense substernal pressure with radiation to left jaw, shoulder, arm. Also dyspnea, diaphoresis, N/V, weakness, fatigue, etc.

Dx: ECG (ST changes, T inversion, Q waves), elevated enzymes (CK-MB, Troponin I + T). Note that Troponins have greater sensitivity and specificity but may be elevated in renal failure.

Rx: Admit to CCU, administer MONA (morphine, O2, NTG, ASA), B Blockers, ACE inhibitors, statins, LMWH, AND early revascularization with thrombolysis (tPA) or PTCA.

Complications to monitor: CHF, arrythmias, recurrent infarction, rupture of free wall, /interventricular septum, or / mitral papillary muscle, ventricular aneurysm, acute pericarditis, dressler’s pericarditis

Risk reduction for ischemic coronary events: smoking cessation, BP control, glycemic control, cholesterol reduction, exercise, diet (decrease saturated fat and cholesterol)

Locating infarction on ECG

Anterior: ST elevation (early) or Q wave (late) in V1-V4

Posterior: Large R, ST depression, large upright T in V1, V2

Lateral: Q wave in leads I and aVL (late change)

Inferior: Q waves in leads II, III, aVF (late change)

CHF

Pathophys: decreased CO  SNS and Aldosterone  vasoconstriction (increased TPR) and fluid retention (increased preload) increased afterload from vascular resistance and ventricular wall tension (law of LaPlace)  exacerbated heart failure and congestion

Causes

Systolic dysfunction (decreased contractility): post-MI, cardiomyopathy, myocarditis

Diastolic dysfunction (impaired filling): myocardial hypertrophy from HTN, aortic stenosis, mitral stenosis, aortic regurge itation. Restrictive cardiomyopathy from amyloidosis, sarcoidosis, hemochromatosis.

Clinically

LHF: dyspnea, orthopnea (your attending may want you to ask the patient how many pillows they need at night), paroxysmal nocturnal dyspnea.

RHF: JVD, dependant pitting edema, ascites

Dx

Echo is most important: check EF, heart morphology, and dynamics

TEE may be required depending on the patient’s body habitus

CXR: cardiomegaly, pleural effusion

Cardiac cath to check hemodynamics and look for signs of MI

Rx: Na restricted diet, diuretics, ACE inhibitors/ARBs, B blockers, digitalis, hydralazine + nitrate

Arrhythmias

A-fib: multiple foci in the atria fire chaotically causing irregular rapid ventricular rate

Clinically: fatigue, exertional dyspnea, palpitations, dizziness, irregularly irregular pulse, possible intramural thrombi embolizing to brain , extremities, abdomen, etc.

Dx: ECG- no identifiable p waves, irregularly irregular QRS waves

Rx: rate control most important (CCB, B blockers), then rhythm control (electrical cardioversion, procainamide, amiodarone, etc) and anticoagulation (asprin, warfarin)

Deciding whether to anticoagulate use the CHADS score: any 2 of CHF, HTN, Age>60  75, DM, Stroke – important for considering Risk of stroke vs risk of anticoagulation

CHADS-VASC recently developed: in addition to CHADS2 breaks down age (<65, 65-75, >75) and considers gender (female greater risk than male)

Paroxysmal Supraventricular Tachycardia : reentrant circuit within the AV node

ECG: narrow QRS complexes with no discernable p waves (buried in QRS)

Rx: vagal maneuvers, adenosine, verapamil, esmolol, digoxin, electrical cardioversion

Radiofrequency ablation of AV node for sx refractory to medical rx

WPW: Accessory conduction pathway from atria to ventricles causing PSVT

ECG: narrow QRS complex tachycardia with delta wave

Rx: radiofrequency ablation of accessory pathway NOTE do NOT treat with drugs that slow down the AV node as this may accelerate conduction through accessory pathway

Vtach: three or more PVCs in a row at a rate between 100 and 250 bpm

Originates below bundle of His (p waves unaffected)

ECG: wide and bizarre QRS complexes

Rx: amiodarone, procainamide, soltalol

DC cardioversion in hemodynamically unstable patients

ICD in pt’s with underlying heart disease (higher mortality)

VFib: firing of multiple foci in the ventricles causing chaotic quivering

Most common cause is ischemia

ECG: no identifiable waves

Rx: immediate defibrillation and CPR + epi and amiodarone protocols

Maintainance amiodarone or implantable defibrillator

AV block

1st degree: delay in AV node causes PR interval >0.2 sec, but sinus rhythm  benign

2nd degree type I: delay in AV node causes progressive prolongation of PR interval until a QRS is dropped  benign

2nd degree type II: delay in His/Purkinje system causes sudden drops of QRS complexes and may progress to full heart block  pacemaker necessary

3rd degree: complete AV heart block causing p waves to fire at rate of SA node and QRS to fire at lower rate (25-40 bpm) from ventricular pacemaker with no concordance  pacemaker necessary

Heart Muscle Disease

Dilated Cardiomyopathy

Results from insult (ischemia, infection, metabolic, toxin) causing impaired contractility

Clinically: Systolic CHF picture

Dx: S3, murmurs of mitral or tricusp insufficiency (distorted valve from ventricular dilation); make dx with echo

Rx: ACE-I, diuretics, digoxin, anticoagulation, REMOVE OFFENDING AGENT

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Usually autosomal dominant condition

Pathophys: diastolic dysfunction due to stiff ventricle causes CHF picture and obstructive outflow due to asymmetric hypertrophy of IV septum

Clinically: DOA, angina, syncope, arrhythmias, sudden death (seen in young athletes). Systolic ejection murmur that decreases with squatting/lying down (increased LV preload) and increases with valsalva/standing (decreased LV preload) best heard at lower left sternal border.

Dx: Establish dx with Echo. 

Rx: avoid strenuous exercise, B blockers, CCB, diuretics, and surgery such as myomectomy of IV septum and mitral valve replacement

Restrictive Cardiomyopathy

Pathophys: infiltration of myocardium causes inpaired diastolic filling due to decreased compliance and eventually systolic dysfunction also  CHF. Seen with amyloidosis, sarcoidosis, hemochromatosis, scleroderma, etc.

Clinically: signs of diastolic and systolic CHF

Dx: Echo will show thickened myocardium with systolic/diastolic dysfunction. Endomyocardial biopsy is diagnostic

Rx: treat underlying disorder, digoxin, diuretics, and ACE-I cautiously

Myocarditis

Causes: usually viral infection, also caused by bacteria, SLE, drugs

Clinically: fever, chest pain, pericarditis, CHF, sudden death

Dx: increased cardiac enzymes, increased ESR

Rx: supportive, underlying cause, complications

Pericardial Disease

Acute Pericarditis

Causes: usually viral infection, also post MI, uremia, collagen vascular diseases, drugs, trauma from surgery, amyloidosis, radiation

Clinically: pleuritic chest pain relieved by sitting up and leaning forward, fever, cough. Friction rub on auscultation.

Dx: EKG shows diffuse ST elevation and PR depression

Rx: NSAIDS, asprin, steroids (last resort)

Constrictive Pericarditis

Pathophys: fibrous scaring of pericardium leads to diastolic CHF

Causes: idiopathic, uremia, radiation, TB, connective tissue disease, etc

Clinically: CHF picture, JVD, Kussmaul sign (no decrease in JVD on inspiration), pericardial knock (mid-diastolic sound)

Dx: EKG often shows Afib, Echo/CT/MR show thickened pericardium, cardiac cath shows elevated and equal diastolic pressures in all chambers. Ventricular pressure tracing shows rapid y descent “square root sign”

Rx: surgical resection of pericardium

Pericardial effusion

Seen as complication of pericarditis, or fluid retaining state (CHF, cirrhosis, nephritic syndrome)

Dx: CXR water bottle appearance, Echo most sensitive and specific

Get pericardial fluid analysis to analyze (protein, glucose, gram stain, cytology, LDH, WBC with diff, etc)

Only need to therapeutically tap if sx of CHF seen (tamponade) 

Cardiac tamponade

RATE of fluid accumulation in pericardial sac is important, NOT amount

Causes diastolic filling impairment and CHF picture

Causes: trauma (usually penetrating), iatrogenic, post-MI free wall rupture, pericarditis

Clinically: Picture of CHF or possible cardiogenic shock

Dx: venous waveform shows prominent x descent with absent y descent. Pulsus paradoxicus, muffled heart sounds, electrical alternans on EKG. Diagnostic test of choice is echo.

Rx: pericardial tap and surgical repair (if hemorrhagic) in hemodynamically unstable patients 

Valvular Heart Disease

Mitral Stenosis

MCC is rheumatic heart disease

Clincially: PND, orthopnea, exertional dyspnea, hemoptysis

Murmur: opening snap followed by low pitch diastolic rumble best heard at apex

Rx: anticoagulation (often Afib), endocarditis prophy, diuretics, surgery

Aortic stenosis

Causes: senile calcification, bicusp valve, rheumatic fever

Clinically: angina, syncope, CHF due to LV outflow obstruction

Murmur: crescendo/decrescendo systolic murmur radiating to carotids best heard at right parasternal 2nd intercostals space

Rx: valve replacement indicated in symptomatic patients, no medical rx

Aortic Regurgitation

Causes: aortic dissection, endocarditis, connective tissue diseases

Clinically: CHF, wide pulse pressure, head bobbing (De Musset sign)

Murmur: diastolic decrescendo murmur at right parasternal 2nd intercostals space +/- mitral stenosis murmur (Austin flint murmur)

Rx: treat like CHF pts if stable, if unstable or if post-MI replace valve

Mitral Regurgitation

Causes: endocarditis, post MI, connective tissue disease

Clinically: CHF picture, often Afib

Murmur: holosystolic murmur best heard at apex

Rx: treat CHF, anticoagulation, valve replacement before LVHF becomes too severe

Tricupsid Regurgitation

Causes: RV dilation, endocarditis (IV drug users), ebstein’s anomaly 

Clinically: picture of RVHF, rapid y descent

Murmur: holosystolic blowing murmur that increases with inspiration best heard at left parasternal border 5th intercostals space

Rx: treat CHF, treat endocarditis, surgery if severe

Mitral valve prolapse

Causes: any connective tissue disorder

Clinical: usually asymptomatic, chest pain, TIA

Murmur: midsystolic click with late systolic murmur at apex that increases with decreased preload and also with sustained hand grip

Rx: endocarditis prophy, no surgery

Rheumatic Heart Disease: complication of GABHS infection

Major Criteria: Migratory polyarthritis, erythema marginatum, heart disease, chorea, subcutaneous nodules

Dx: two of above criteria, or 1 of above with 2 minor criteria (ESR, fever, polyarthralgias, prior RF, prolonged PR interval, previous GABHS infection)

Rx: penicillin/erythromycin to rx GABHS and prevent RF, otherwise NSAIDS to treat ARF and Abx later for endocarditis prophylaxis

Bacterial Endocarditis

Acute: usually S. aureus on normal heart valve esp IV drug users

Subacute: usually S. viridans or enterococcus on damaged heard valve

S. epidermitis for prosthetic heart valve

Dx: Duke’s Criteria  2 major, 1 major + 3 minor, or 5 minor

Major: sustained bacteremia, endocardial involvement seen on echo or via new heart murmur

Minor: predisposing condition, fever, janeway lesions, osler’s nodes, roth spots, positive blood cultures or echo

Complications: heart failure, myocardial abscess, organ damage from septic emboli (eg glomerulonephritis)

Rx: parenteral antibiotics depending on cultures and sensitivities OR empirically with pen/vanc + aminoglycoside before cultures are back

Vascular Disease

Aortic Dissection

Cause: most commonly HTN, other causes are connective tissue disease, coarctation, trauma

Clinically: sudden tearing chest pain radiating to back, sweating, pulse asymmetry between limbs, possible aortic regurgitation

Dx: TEE and CT scan are preferred tests

Type A include the ascending portion are ascending and Type B are descending only

Rx: B Blockers and nitroprusside to decrease HTN; Surgery if type A

Abdominal Aortic Aneurysm

Causes: HTN, smoking, atherosclerosis

Clinically: usually asymptomatic besides feeling of fullness

Warning signs: sudden onset sever lower abdominal and back pain, grey-turner (flank ecchymosis) and turners (umbilical ecchymosis) signs  also seen in hemorrhagic pancreatitis

Ruptured AAA: pain, hypotension, pulsatile umbilical mass, syncope

Dx: Ultrasound is test of choice

Rx: emergency repair in ruptured AAA and if AAA > 5 cm

Peripheral Vascular Disease (Chronic Arterial Insufficiency)

Occlusive atherosclerotic disease of lower extremities

Clinically: intermittent claudication, rest pain if severe

Dx: Ankle Brachial Index <0.7, Angiography is gold standard

Rx: stop smoking, atherosclerosis risk reduction, surgery only if severe enough to significantly interfere with life

Deep Vein Thrombosis

Cause: Virchow’s triad – endothelial injury, venous stasis, hypercoagulability

Clinical: Lower extremity pain and swelling, fever, skin atrophy and ulcers if chronic venous insufficiency develops

Dx: D-Dimer (non-specific), Doppler ultrasound, venography

Rx: heparin, warfarin, tPA if PE occurs