E2 Cardio Major Concepts

Prinzmetal's (Variant) Angina

Prinzmetal's (Variant) Angina

Episodic chest pain at rest due to spasm of the coronary arteries, typically seen in females with low risk factors w/o stenosis
-Treat with CCBs long-term

What differentiates between unstable angina & an NSTEMI?

Troponins

What drug CANNOT be used in the treatment of cocaine-induced MI?

Beta-blockers --> worsens vasospasm!

Killip Classification

Stratifies patients based on severity of post-MI heart failure :
1 - no signs of HF
2 - Rales/crackles in lungs, S3, inc. JVP
3 - acute pulmonary edema
4 - cardiogenic shock, systolic BP <90, dec. CO

Door-To-Balloon Time

90 minutes

Door-To-Needle Time (thrombolytics)

30 minutes

TIMI Score

Predicts the risk of death/ischemic events in MIs & whether going to PCI is warranted for NSTEMI

-Score 5-7 = high risk & go to PCI

Acute MI Treatment

THROMBINSS** or MONA BASH

Thienopyridine (ADP-blocker like Clopidogrel)

Heparin

RAAS inhibitor (ACEi)

Oxygen

Morphine

Beta blockers

Intervention (Stent)

Nitrates

Salicylates (aspirin)

Statins

What are the absolute contraindications to thrombolytic therapy?

-Any prior intracranial hemorrhage
-Known cerebral vascular lesion (like aneurysm)
-Known malignant intracranial neoplasm
-Ischemic stroke within 3 months
-Suspected aortic dissection
-Active bleeding or bleeding disorder
-Significant closed head trauma within 3 months

Preferred anti-coagulant for patients with a STEMI

heparin

preferred anti-coagulant for patients with angina & NSTEMI

Lovenox (enoxaparin) - factor Xa inhibitor

What is the treatment protocol for a patient after an acute coronary event?

-Aspirin or Clopidogrel
-Beta-blockers (mainstay)
-ACE inhibitors
-Statins
-Nitrates

Dressler's Syndrome

Post-MI pericarditis - chest pain is worse lying flat & better sitting upright, friction rub
-Tx = NSAIDs & colchicine

Normal ejection fraction

50-70%

Right-sided heart failure signs

peripheral edema, RUQ pain, JVD, hepatomegaly

Left-sided heart failure symptoms

dyspnea, orthopnea, PND, fatigue, diaphoresis, tachycardia, tachypnea, pulmonary rales, Loud P2, S3/S4

What is the best test(s) for diagnosing heart failure?

BNP & echo for EF

New York Heart Association Functional Classification (for Heart Failure)

1 - asymptomatic
2 - symptoms with moderate exertion
3 - symptoms with minimal exertion
4 - symptoms at rest

What is the pharmacologic treatment protocol for acute heart failure?

LMNOP:

Lasix (loop diuretics)

Morphine

Nitrates

Oxygen

Position pt upright

**NEVER use Beta-blockers in ACUTE

What is the pharmacologic treatment for patients with chronic heart failure?

"Fantastic Four" :

-ACE inhibitor (or ARNi)

-Beta-blocker

-Mineral-receptor antagonist (Spironolactone)

-SGLT-2 inhibitors (cenagliflozin)

What is the treatment protocol for African American patients in heart failure?

Fantastic four + Hydralazine & nitrates

Dilated Cardiomyopathy

Most common cardiomyopathy - chamber enlargement & diffuse decrease in contraction & inc. pressure (low EF)
-Tx with Fantastic Four

Hypertrophic Cardiomyopathy

-Most common abnormality in sudden death of young athletes
-Thickened ventricles that have a difficult time filling due to a decreased chamber size
-Characteristic = Inc. with Valsalva
-Tx with BBs & CCBs

Restrictive Cardiomyopathy

Rigid ventricular walls & decreased compliance due to an infiltrative process

-Diastolic issue = restricted filling

-Biopsy must be done to dx underlying disease

Takotsubo Cardiomyopathy (Broken Heart Syndrome)

Apical ballooning of the ventricular walls usually caused by increased cortisol & catecholamines, secondary to sudden stress = MINOCA (MI with nonobstructive coronary arteries)
-Usually in older women with sudden stress or pregnancy, Tx supportively

Most common cause of pericarditis & myocarditis

Coxsackie virus

Pericarditis

Inflammation of the pericardial sac typically following a URI prodrome

-Continuous, scratchy friction rub better leaning forward, pain radiates to trapezius m.

-Diffuse ST elevations, GOLD = echo

-Tx = NSAIDs & colchicine, monitor for effusion

Pericardial Effusion

Collection of fluid in the pericardial space best identified with an echo

-Electrical Alternans on EKG, muffled heart sounds, "Oreo & Water bottle sign" on CXR

-Tx = pericardiocentesis

Cardiac Tamponade

"Malignant pericarditis" = so much fluid around the heart that it cannot pump efficiently

-Beck's Triad: JVD, hypotension, muffled heart sounds, also see Pulsus Paradoxus & Kussmaul

-Medical emergency = Tx pericardiocentesis or pericardial window

Constrictive Pericarditis

Fibrotic thickening/calcification of the pericardium that adheres to the heart secondary to chronic inflammation (radiation, cancer mets, cardiac surgery)

-Presents as R. HF & dec. cardiac output symptoms

-CXR = calcification ring, but most cases need a R. heart catheter for definitive diagnosis

-Tx = NSAIDs, colchicine +/- steroids, immune therapy, late stages = pericardectomy

Myocarditis

Inflammation of the heart muscle most commonly caused by Coxsackie virus

-most are clinically silent, some with flu-like symptoms & chest pain

-Every pt gets an echo but definitive diagnosis = endomyocardial biopsy

Pulmonary Hypertension

Mean pulmonary arterial pressure >25 mmHg - complex & progressive disease with no cure

-CXR shows pruning of peripheral pulm vessels, EKG shows RVH, but R. heart cath is most useful for dx

-S&S: DOE, chest pain, dizziness, edema, signs of R. heart failure, loud P2, S3/S4, holosystolic TR

WHO Classification of Pulmonary Hypertension

1 - Pulmonary Artery Hypertension (narrow, thick, stiffened arteries)
2 - pHTN with L. heart disease
3 - pHTN with lung disease/hypoxemia
4 - Chronic thombotic embolic pHTN (chronic PE)
5 - Miscellanous (sarcoidosis, anemia, tumors, etc.)

What is seen on chest x-ray during a pulmonary embolism?

Westermark Sign - cutoff of the pulmonary vessels distal to the site of occlusion

What are the 1st & 2nd line treatments for pulmonary hypertension?

1 = Calcium Channel Blockers
2 = Endothelin-Receptor Antagonists (Ambrisentan)

When is an AICD used?

Class 3 & 4 heart failure to decrease risk of V. Fib

Sick Sinus Syndrome

-Altering bradycardia and tachycardia with sinus arrest & blocks >3 seconds

Wolff-Parkinson-White (WPW) Treatment

-Unstable = synchronized cardioversion

W/AFib = amiodarone or procainamide (stabilize HR)

DO NOT USE BBs, CCBs, adenosine, digoxin

Atrial Fibrillation Treatment

IV Cardizem (Diltiazem) = Tx of choice

-Can also use BB, digoxin, amiodarone

-May keep pt in Afib and just stabilize HR <100 bpm

48 Hours Rule of AFib

- <48 hours of Afib = assume no atrial clot
- >48 hours = assume there is a clot
-Helps determine when/if cardioversion should be done & when to initiate anticoagulants

CHA2DS2VASc Score

Predicts the risk of stroke in atrial fibrillation:

C - Heart Failure(1)

H- Hypertension (1)

A - Age ≥75 years (2)

D - Diabetes (1)

S -Previous stroke (2)

V - Vascular disease (1)

A - Age 65-74 years (1)

Sc - Sex category: female (1)

>2 points = high risk, gets DOACs (Apixaban, Dabigatran) or Warfarin if pt has prosthetic mechanical valve

Holiday Heart Syndrome

Alcohol use in prior healthy non-frequent drinkers can cause sudden heart arrhythmias, usually Afib

Supraventricular Tachycardia (SVT) treatment

1st line - do vagal maneuver to slow the heart & identify the rhythm

2nd line = adenosine

Torsades de Pointes Treatment

IV Magnesium Sulfate

V. Tach Treatment

Stable = Amiodarone or Procainamide
Unstable = Synchronized Cardioversion

AV Blocks Treatment

Atropine and/or subcutaneous pacing

Anti-Arrhythmic Drug Categories

1 - Sodium channel blockers
2 - Beta blockers
3 - Potassium channel blockers
4 - Calcium Channel blockers
5 - Nodal Blockade

Class 1A antiarrhythmic drugs

Quinidine, Procainamide Disopyramide

-Used for PVCs, PACs, AFIB, WPW

-Toxicites = prolong QT (Torsades)

-Procainamide = Lupus-like syndrome

Class 1B antiarrhythmic drugs

Lidocaine, Tocainide, Mexiletine, Diphenylhydantoin

-Used primarily to prevent recurrent VTach

Class 1C antiarrhythmics

Flecainide & Propafenone

-Rarely used anymore due to toxicity, do not prescribe (Inc. mortality)

Class 2 antiarrhythmics

Beta blockers - decrease sympathetic activity

-Used for AFIB, A. flutter, PVCs, SVT, etc.

Class 3 antiarrhythmics

Amiodarone, Ibutilide, Dofetilide, Sotalol

-Cause prolonged QT, pulmonary toxicity, thyroid issues, blue/gray hyperpigmentation of skin

Class 4 antiarrhythmics

Verapamil & Diltiazem (CCBs) -

-Primarily used for reentrant PSVTs

-DO NOT USE in: wide complex tachys, A-Fib w/WPW, Sick Sinus Syndrome, AV Blocks

Class 5 antiarrhythmics

Adenosine & Digoxin

-Good for rapid termination of PSVT

What is the most common area for an Aortic Aneurysm?

abdominal aorta (& in males)

What is the most common area for an Aortic Dissection?

Ascending thoracic area

What is the gold standard test for Aortic Anuerysm?

CTA

Aortic Aneurysms

Bulging in the aorta: fusiform & saccular types (saccular & >5.5 cm = most likely to rupture)

-Risk factors = CAD, HTN, tobacco, high cholesterol

-S&S: chest pain, tearing/severe back pain, bruit

-Cardarelli's Sign: Abnormal pulsation of the trachea in an aneurysm of the aortic arch

What are the screening guidelines for Aortic Aneurysms?

All male smokers > 65 get a screening ultrasound annually

When is an aortic aneurysm operated on?

>5.5 cm in males
>5 cm in females

Aortic Dissection

An intimal tear that causes blood to flow between the layers of the aorta = "tearing" pain

-Gold standard dx = CTA noninvasive

-IV beta-blockers 1st line tx until surgery

-Debakey & Stanford Classifications

Claudication Site & Corresponding Location of Ischemia

Buttock/Hip = Aortoiliac a.
Thigh = common femoral a.
Upper calf = superficial femoral a.
Lower calf = popliteal a.
Foot = Tibial/Peroneal a.

**Affected artery most proximal to site of pain

Ankle-Brachial Index (ABI) Values

For Peripheral Artery Disease

Normal = 1.0-1.4

0.5 - 0.8 = moderate disease

<0.5 = severe disease

PAD Management

Supervised exercise program to increase collateral circulation & control risk factors
-Sx after this = phosphodiesterase inhibitor Cilostazol, bypass surgery

6 P's of acute ischemia

Pain, pallor, pulselessness, paresthesias, poikiloderma, paralysis

Thromboangitis Obliterans (Buerger's Disease)

Non-atheromatous inflammatory & occlusive condition of the extremities exclusively seen in smokers (young)

-Tender phlebitis --> cold sensitivity, instep claudication

-Signs: triphasic color scheme: white, blue, red, decreased/absent foot & radial pulses

-Tx = stop smoking

What is the treatment for cold-sensitivity/Reynaud's?

Calcium-channel blockers to relax & open small blood vessels

Stages of Vein Diseases

1 = spider veins
2 = varicose veins
3 = leg edema
4 = skin changes
5 = leg ulcers

Ulcers of Arterial Insufficiency

Painful, punched-out, triphasic color scheme & on dorsum of foot or lateral malleolus