Comprehensive Guide to Cardiovascular Disease, ECG Interpretation, and Emergency Care

Cardiovascular Disease (CVD)

CVD mortality in both Canada and NL accounts for 30% of all causes of death.

CVD morbidity

CVD results in significant morbidity from MIs and CVAs.

CVD costs in Canada

CVD costs in Canada over $22 billion.

Hospitalizations cost

Hospitalizations inpatient 2.4 billion.

Lost productivity and disability from stroke

Lost productivity and disability from stroke 3.6 billion.

CV drugs utilization

6/10 major drugs are CVD related.

Risk factors for CVD

Hypertension, Family history, Ethnicity, Age, Stress, Lack of physical activity/sedentary behaviour, Poor nutrition, Sleep apnea, Obesity, High alcohol consumption, Smoking or vaping, Substances, e.g. cocaine, Dyslipidemia, Diabetes, Chronic kidney disease.

Sex and Gender Considerations

Risk factors for cardiovascular diseases.

Types of CVDs

CAD (IHD) decreased blood supply to the coronary vessels and muscle causes chest pain/angina.

Heart Failure

Left or right-sided decreased perfusion chronic tiredness, reduced physical activity and shortness of breath, edema.

Cardiomyopathy

Thickened or stiffness affects contractility and cardiac output.

Valvular heart disease

Heart valve dysfunction due to calcification, drugs, infection.

PAD/PVD

Decreased circulation, coolness, paresthesia and limb pain.

Renal perfusion

Decreased.

Social determinants of health (SDOH)

Social, economic, and environmental influences on health.

Health inequities

Unfair or unjust and modifiable.

Access to nutritious foods

Canadians who live in remote or northern regions do not have the same access to nutritious foods such as fruits and vegetables as other Canadians.

Increased screening for risk factors

Decreased morbidity and mortality and decreased costs and promote healthy aging.

CVD emergency care

Discuss the care of an adult patient experiencing 'chest pain' during a CVD emergency.

Professional practice guidelines

Explore professional practice guidelines for chest pain and arrhythmias.

Cardiac arrhythmias

Review cardiac arrhythmias, etiologies, signs and symptoms, and recommended treatments.

Effective communication

Communicate and collaborate effectively as a member of the health care team.

Congenital disorders

Disorders of the heart or central blood vessels present at birth that lead to heart failure, pulmonary HTN, delayed growth.

Electrical conduction dysfunction

Can lead to blood pressure issues, decreased cardiac output, and death.

ECG Interpretation

To understand the electrical conduction of the heart and to identify and interpret normal sinus rhythm and common abnormal cardiac rhythms or arrhythmias.

P wave

Atrial depolarization.

QRS complex

Ventricular depolarization.

T wave

Ventricular repolarization or the 'resting state'.

EKG Paper

Used for EKG interpretation.

8 Step Approach

A systematic approach for consistency with each strip that you interpret.

Heart rhythm

Regular or irregular; determined by the evenness of small boxes between each R wave.

Heart rate

6 second strip method: count number of QRS complexes in six seconds and multiply by 10.

Presence of P wave

P wave should be rounded and upright, indicating SA node pacing.

PR interval

Measured from the beginning of P to the start of QRS, should be 0.12-0.20 seconds.

Width of QRS complex

Should be 0.08-0.12 seconds (1½ to 3 small boxes) and less than <0.12 sec.

ST segment

Should be at the isoelectric line; deviations may indicate myocardial ischemia or infarction.

QT interval

0.34-0.42 seconds; time required for depolarization and repolarization of the ventricles.

T wave abnormalities

Peaked T waves could indicate high potassium or hyperkalemia.

Normal sinus rhythm

1. Rhythm: regular; 2. Rate: 80 (60 -100); 3. P wave: one in front of every QRS, round, consistent shape; 4. PR interval: 0.16 sec (0.12-0.20); 5. QRS: 0.04 sec (<0.12 sec); 6. ST Segment: no depression or elevation; 7. QT interval: 0.36 sec (0.34-0.42).

Normal Sinus Rhythm (NSR)

Interpretation of T wave

Sinus Bradycardia

Same as NSR except for RATE <60 bpm

Sinus Tachycardia

Same as NSR except for RATE >100 bpm

Atrial Arrhythmias

When the SA node does not generate an impulse, atrial tissues in various locations may initiate impulses

Atrial flutter

Caution: may cause thromboemboli

Atrial fibrillation

Caution: may cause thromboemboli

Supraventricular tachycardia

1. Rhythm: Usually regular 2. Rate: 150-250 bpm 3. P wave may be buried in the previous T wave 4. PR interval: less than < 0.12 sec 5. QRS complex: less than < 0.12 sec 6. ST segment: cannot assess 7. QT interval: unable to assess 8. T wave: difficult to assess; impulse originates at or above the AV node

Ventricular Arrhythmias

No P waves because there is no atrial activity or depolarization; SA node and the AV junctional tissues do not generate an impulse & ventricles **************** of the 'pacemaker'; QRS complex > 0.12 sec; QRS has 'bizarre shape'

Premature Ventricular Contractions

Includes Bigeminy: every second beat PVC

Ventricular Tachycardia (VT)

3 PVC's, rate >100 bpm; can have a pulse or be pulseless; if not treated patient may go into cardiopulmonary arrest; 1. Rhythm: mostly regular 2. Rate: ventricular 100-250 bpm; can't tell atrial 3. P wave: can't see, not associated with QRS wave 4. PR interval: can't measure 5. QRS > 0.12 sec, wide and abnormal shape; hard to determine P: QRS ratio, QT interval, T wave; Monomorphic or polymorphic

Ventricular Tachycardia (Polymorphic)

Torsades de pointes

Ventricular Fibrillation

No pulse or cardiac output; Cardiopulmonary arrest; 'quivering ventricles'; Rate: ventricles > 300 bpm; Rhythm: Irregular; QRS: bizarre...no shape; P wave: none; PR interval: none; Coarse or Fine

Asystole

Check Your Patient !! No QRS; check in two leads; No pulse, no respirations; Patient is clinically dead

Heart blocks

First degree block, Second degree block (type I and type II), Third degree block

Third degree heart block

No atrial impulse conducted via AV node to ventricle; Two pulses generated: one stimulates ventricle and one stimulates the atria, thus AV dissociation; No association between P waves and QRS or atria and ventricle; Rate: depends on atrial and ventricular underlying rhythm; Rhythm: PP interval and RR interval both regular but not equal so 'beating out of sync'; QRS & duration: normal or abnormal; PR interval irregular; More P waves than QRS complexes

Ventricular pacemaker rhythm

Single chamber

Atrioventricular pacemaker rhythm

Dual chamber

Chest Pain

Chest pain is one of the most common presentations to the emergency department and outpatient settings.

Acute Coronary Syndrome (ACS)

Chest pain is the most common symptom of myocardial ischemia in both men and women.

Severity Scale

Scale of 1-10.

Chest Pain Symptoms

Heaviness, tightness, pressure, fatigue.

Chest Pain Location

Varies: central, left arm, right arm, neck, jaw, shoulder, back.

Chest Pain Timing

Occurs during strenuous activity, mild activity, or at rest.

Chest Pain Duration

A few seconds, minutes, hours.

Aggravating Factors

Cold, exercise.

Alleviating Factors

Rest, medications.

Chest Pain Treatment

Immediate implementing the Chest Pain Protocol.

Chest Pain Medications

Long-acting nitrates, beta blockers, calcium channel blockers.

Chest Pain Investigations

Exercise stress test, coronary angiogram, echocardiogram, other.

ST-Elevation Myocardial Infarction (STEMI)

Ischemia 6/7 - STEMI on ECG.

STEMI Treatment

ECG monitor, oxygen, morphine IV, nitroglycerine IV, ASA orally, clopidogrel or Plavix orally, anticoagulation (enoxaparin/Lovenox s/c and/or IV), bloodwork (troponin level, CBC, Lytes, UN, Cr, arterial blood gas (ABG)).

Nitroglycerin IV Indications

ACS, MI.

Nitroglycerin IV Dosage

Available in: 25mg/250 mL, 50mg/250 mL, 100 mg/250 mL bottle, 5mg/mL injectable solution.

Nitroglycerin IV Administration

5-200 mcg/min starting at 5 mcg/min, titrate to effect, keep BP >90mmHg.

Sinus Bradycardia Symptoms

Dizziness, chest pain, shortness of breath, exercise intolerance, cool, clammy skin.

Sinus Bradycardia Treatment

Prevent vagal response, hold medications e.g., beta blockers, atropine, epinephrine, dopamine.

Pacemaker

Treat the underlying cause

Hypoglycemia

Consider cardiac history

Hypothermia

Medications

Hypothyroidism

Electrolyte imbalance

Atropine IV

Epinephrine IV

Indications: Bradycardia, 2-10 mcg/min IV infusion

Dopamine IV

Indications: Low dose - renal perfusion, Increase cardiac output, Bradycardia, Vasoconstriction to raise BP. Available in: 400 mg/250 mL, 800 mg/250 mL, 800 mg/500 mL. Dose: 2-5 mcg/kg/min up to 20 mcg/kg/min

Sinus tachycardia S & S

Dizziness, SOB, Heart palpitations, Fast pulse, Chest pain

Sinus tachycardia Treatment

Treat symptoms & underlying cause: Adenosine, Diltiazem, Beta blockers, Ablation of SA node

Atrial flutter S & S

Palpitations, SOB, Anxiety, Weakness, Chest pain, Hypotension

Atrial Flutter Causes

> 60 years of age, Heart disease (Valve dysfunction), Ischemia, Cardiomyopathy, COPD, Emphysema, Post CV surgery, Hyperthyroidism

Atrial Flutter Treatment

Anticoagulation therapy usually required, Cardioversion: If symptomatic & onset <48 hours, Meds to slow rate (beta blockers, calcium channel blockers), Ablation

Atrial Fibrillation Symptoms

Palpitations 'racing heart', Irregular pulse, Chest pain, Dizziness, Fainting, Decrease LOC, Fatigue, SOB

Atrial Fibrillation Causes

Hypoxia, Hypertension, Stimulants, Heart failure, CAD/Valve dysfunction, SA node problem, Rheumatic heart disease, Pericarditis, Hyperthyroidism, Post CV surgery

Atrial Fibrillation Treatment

If hemodynamically stable: anticoagulant therapy (heparin, lovenox, xarelto, warfarin) and may consider other treatments to stop fibrillation. If hemodynamically unstable: cardioversion (Electrical, Pharmacological (beta blockers, amiodarone, digoxin)). If onset >48 hours: need anticoagulant therapy or risk of thrombus formation and emboli. Pacemaker or Ablation

Amiodarone IV

Indications: atrial fibrillation. Dose: 150-300 mg IV push, then 150 mg IV q 3-5 min. Dose dependent on severity of symptoms. IV infusion.

Metoprolol IV

Indications: Atrial fibrillation, Narrow complex tachycardia. Dose: 5 mg over 1-2 min, and repeat q5 min to a max dose of 15 mg.

Digoxin IV

Used for atrial fibrillation, atrial flutter and heart failure. Dose: 8-12 mcg/kg total loading dose, give 50% of dose first then q6-8h after give remaining loading dose in 2 separate doses.

Adenosine IV

Used for: SVT. Dose: 6mg rapid IV push over 1-3 seconds followed by NS flush and then if rhythm persists, 6 mg rapid IV push followed by NS flush.

Bigeminy

every second beat PVC

Premature Ventricular Contractions Causes

Exercise, Stress, Stimulants, Heart disease, Electrolyte imbalances, Hypoxia, Tricyclic antidepressants, Digitalis toxicity

Premature Ventricular Contractions Symptoms

Palpitations, Weakness/Dizziness, Hypotension, SOB

Treatment for Premature Ventricular Contractions

depends on frequency or if multifocal; Amiodarone, Lidocaine

Ventricular Tachycardia (Monomorphic) Treatment

Amiodarone IV

Ventricular Tachycardia (Monomorphic) Indications

ventricular tachycardia, ventricular fibrillation