EKG/cardio review

angina/CAD/MI

s/s:

•Exertional chest pain

•Tight, squeezing, pressure

•Radiation (left arm? jaw?)

•Dyspnea, diaphoresis, N/V, indigestion, syncope

•PE may be Normal

•Tachycardia

•HTN

stable angina

CP lasts <30 minutes

unstable angina

CP lasts > 30 minutes or unrelieved with nitro/rest

•Troponins x 3

•CK-MB

•Risk factor screening:

•HEART Score

•Lipids

•DM status

•smoking

•family history

labs to order for suspected angina/CAD/MI

•Stable angina: normal vs. downsloping ST segment depression, reverses when ischemia disappears

•T-wave flattening or inversion

•ST-segment elevation: Check which leads are involved

•Q-wave

what findings may be seen on ECG in CAD/angina/MI

ECG

•Stress test

•Coronary angiography

•Monitors for arrythmias

•Echocardiogram

other studies to get for angina/CAD/MI

•MONA

•Heparin

•Beta-blockers

•ACE inhibitors

•Statins

•PCI/CABG

management for angina/CAD/MI

Calcium channel blockers

Tx for coronary vasospasm

•HTN

•Atherosclerosis

•Aneurysm

•Structural defects

RF for aortic dissection

type A aortic dissection

•involves arch proximal to left subclavian artery

type B aortic dissection

Involves proximal descending thoracic aorta just beyond left subclavian artery

aortic dissection

s/s:

•Sudden onset

•"Tearing" chest pain

•Radiation (to back)

•Hyper/hypotension

•Syncope

•Decreased peripheral pulses

•Aortic regurgitation murmur

•ECG: left ventricular hypertrophy

•CT scan

•Chest radiograph

•MRI

•Transesophageal echocardiogram

Dx for aortic dissection

•Reduce systolic blood pressure and pulse pressure

•Surgical intervention

Tx for aortic dissection

pericarditis

s/s:

•Chest pain – pleuritic, postural (better leaning forward, worse when taking a deep breath)

•Dyspnea

•Fever

Pericardial friction rub

•CBC

•Viral titers

•Cardiac enzymes- may be elevated

•ECG- diffuse ST elevation

•Sed rate

•ANA, RF, DS-DNA

•BUN/Creatinine

•Echocardiogram

Diagnostics to get for pericarditis

•NSAIDS/Colchicine

•Dialysis if uremic pericarditis

Tx for pericarditis

ASA

Tx for dressler syndrome

•Congenital

•Degenerative or calcific (atherosclerosis)

etiologies of aortic stenosis

aortic stenosis

s/s

•Systolic ejection murmur best heard at right upper sternal border

•Angina

•Heart failure

•Syncope

•Echocardiogram

•Cardiac catheterization

•ECG (LVH)

Dx for aortic stenosis

•Risk factor modification (ACEi, BB, diet, exercise, etc)

•Monitoring

Valve replacement

management for aortic stenosis

heart failure

s/s:

•Dyspnea

•Orthopnea

•PND

•Fatigue

•Cough

•Low cardiac output

•Pulmonary hypertension

•Increased venous pressure

•Decreased appetite

•Dependent peripheral edema

•Hepatomegaly

•Ascites

NYHA class I

Asymptomatic

NYHA class II

Mild limitation of physical activity; symptoms with ordinary activity

NYHA class III

Marked limitation of physical activity; symptoms with less than ordinary activity

NYHA class IV

Unable to perform any physical activity; Symptomatic at rest

HF stage A

No objective evidence of CV disease

HF stage B

Minimal CV disease

HF stage C

Moderate CV disease

HF stage D

Severe CV disease

•BNP

•Chest radiograph

•Echocardiogram

•ECG

•Cardiac Catheterization

Dx for heart failure

•Diuretic

•ACE inhibitor/ARB

•Neprilysin inhibitor/ARNI

•Beta-blocker – carvedilol (Coreg)

•ICD/Bi-ventricular pacing

•Daily weights

Dietary modifications

management for HF

dilated cardiomyopathy

causes: Idiopathic, alcohol, postpartum, other

s/s: LV or Bi-V Heart Failure Cardiomegaly, S3, elevated JVP, rales

echo: LV dilation and dysfunction

hypertrophic cardiomyopathy

Cause: Hereditary

s/s: Dyspnea, chest pain, syncope, Sustained PMI, S4, variable systolic murmur

Echo: LVH, asymmetric septal hypertrophy, small LV size, normal or supranormal EF

restrictive cardiomyopathy

Causes: Amyloidosis, post-radiation, post-open heart, diabetes

s/s: Dyspnea, fatigue, RV HF > LV HF, Elevated JVP, Kussmaul sign

Echo: Small or normal LV size, normal or mildly reduced EF

•Vasovagal

•Arrhythmia

•Cardiomyopathy

•Valvular heart disease

•Orthostatic

causes of syncope

vasovagal, situational, carotid sinus, atypical forms

causes of reflex-mediated syncope

primary/secondary autonomic failure, volume depletion, drug-induced

causes of orthostatic hypotension

arrhythmia- brady, tachy, drug induced, structural cardiac causes

causes of cardiac syncope

alpha 1 receptors

contraction of vascular and GU smooth muscle

beta-1 receptors

positive inotropic and chronotropic effects on the heart

hypertension urgency/emergency

180 or above/120 or above

stage 2 HTN

140 or above/90 or above

stage 1 HTN

130-139/80-89

elevated BP

120-129/<80

normal BP

<120/<80

•Headache

•Visual changes

•Chest pain

•Palpitations

•Dyspnea

•Claudication

•Sexual dysfunction

•Mental status change, n/v

•CV risk factors

symptoms to ask about in history for HTN

•thiazides, ACE/ARB, CCB

Tx for stage I HTN, non-black

•CCB, thiazides

Tx for stage I HTN, black

•2 or more drugs: ACE/ARB + Thiazide or BB

Tx for stage II HTN

•Orals/IV: Nifedipine, captopril, clonidine

•Reduce over hours

Tx for hypertensive urgency

•IV: Labetalol, nitroprusside

•Reduce BP by 25% in 1-2 hours

Tx for hypertensive emergency

arrhythmia

s/s:

•None!

•Palpitations

•Lightheaded/dizzy

•Pre-syncope/syncope

•Fatigue

•Dyspnea

•Altered level of consciousness

•Chest pain

•Tachycardia or bradycardia

•Irregular rhythm

•Hypotension

•ECG

•Holter monitor

•Event recorder- External loop recorder,, Internal loop recorder, Post-Event, MCOT

•Echocardiogram

•Stress test

Cardiac catheterization

general workup for arrhythmia

P wave

•Atrial depolarization

•<2mm high, <0.12sec wide

•Upright in leads I, II, V4-6, and AVF

•Inverted in AVR

•Variable in III, AVL and V1-3

ectopic atrial rhythm

Abnormal P wave inversion or morphology

Right Atrial hypertrophy

increased P wave height in V1

Left atrial hypertrophy

increased P wave width in V1

PR interval

•AV conduction time

•Measure from start of P to start of QRS

•Normal width: 0.12 – 0.20 sec

•Varies with heart rate

•Segment is isoelectric

•Long: possibly normal, 1st degree AV block, hyperthyroidism

•Short: Possibly normal, low atrial rhythm, WPW, HTN, Pheochromocytoma

QRS complex

•Ventricular depolarization

•Measured from beginning of QRS to end of S wave

•Width (duration): 0.05-0.10 sec

•Height: 5-30mm

Q wave

normal <0.04 sec and < 1/3 of the amplitude of the following R wave

ST segment

•Initial phase of ventricular repolarization

•Measured from end of QRS to beginning of the T wave

•Usually isoelectric

T wave

•Rapid phase of ventricular repolarization

•Normally upright in leads I, II, V3 and 5-6

•Normally inverted in lead AVR

•Variable in leads III, AVL, V 1-2

inversion can indicate ischemia

hyperkalemia

Peaked T waves, or height > 5mm in limb leads or 10mm in precordial leads indicates

QT interval

•Total duration of ventricular systole

•Measured from onset of QRS to end of the T wave

•Varies with heart rate and gender

•Long: Prolonged ventricular repolarization time (idiopathic, hypokalemia, meds , CAD, CHF, CVA)- Predisposes to arrhythmia

•Short: Digoxin, hypercalcemia, hyperkalemia

QTc

•Corrected Qt interval for heart rate

In general <0.45 seconds (roughly ½ the R-R)

R-R interval

•Measured from one R wave to the next

•Used to calculate rate

60-100 bpm

SA node rate

< 60 bpm

sinus bradycardia

>100 bpm

sinus tachycardia

automaticity focus

a potential pacemaker

atrial focus

60-80bpm

AV (junctional) focus

40-60bpm

ventricular focus

20-40bpm

paroxysmal tachycardia

•150-250bpm

flutter

•250-350bpm

fibrillation

350-400bpm

•one or more active automaticity sites

irregular rhythms are usually caused by:

premature atrial contraction

•Premature stimulus that orriginates from an irritable atrial focus

•Atrial beat earlier than expected

premature atrial contraction

wandering atrial pacemaker

Irregular rhythms produced by nearby atrial automaticity sites

Rate is still <100bpm

Different p wave morphologies

wandering atrial pacemaker

multifocal atrial pacemaker

oRate is >100bpm

oAt least three different p wave morphologies

oCommonly seen in COPD

multifocal atrial pacemaker

atrial tachycardia

•Sudden, rapid firing of one irritable atrial focus

oFlutter

oFibrillation

atrial flutter

•Rapid succession of identical, back-to-back atrial depolarization waves “flutter waves”

•Typically every 3rd or 4th wave depolarizes to ventricles

•“Saw tooth” pattern

atrial flutter

atrial fibrillation

•Many irritable atrial foci firing at same time

•Irregularly, irregular rhythm, no identifiable P waves

•Only small portion of atrium depolarized

atrial fibrillation

premature junctional contraction

•Premature stimulus that originates from an irritable junctional focus

•QRS slightly wider

•P wave inverted or short

premature junctional contraction

junctional tachycardia

oSudden rapid firing of irritable junctional focus

oP waves absent or possibly inverted

supraventricular tachycardia

•Tachycardic rhythm originating from above the ventricle

•Atrial or junctional

•Regular, narrow complex QRS, P waves not visible

SVT

premature ventricular contraction

•Premature stimulus that originates from an irritable ventricular focus

•Wide QRS, increased amplitude

•Unifocal or multifocal

PVC

ventricular tachycardia

•Sudden rapid firing of an irritable ventricular focus

•AV dissociation

ventricular tachycardia

torsades de pointes

oPolymorphic VT

oCaused by hypokalemia, long QT syndrome