Cardio (Tsu) STUDY - IE3

Lecture 1: Ventricular Arrhytmias

• Vtach - can be regular or irregular

  • Torsades de pointes

• Vfib - irregular

  • Life-threatening

• Asystole (flat-lining)

  • CPR —> MEDS ASAP —> CPR

    
    

Causes of Ventricular Arrhythmias & Cardiac Arrest

• 5 H’s:

  • Hypovolemia

    • Bolus fluids, pressors

  • Hypoxia

    • Oxygenation

    • Ventilation

    • Advanced airway

  • Hydrogen Ion (Acidosis)

    • Sodium bicarbonate

  • Hypo/Hyperkalemia

    • CaCl2

    • Sodium bicarbonate

    • Regular Insulin/dextrose

  • Hypothermia

    • Warm fluids

• 5 T’s:

  • Toxins/Tablets

    • Specific antidotes for toxins

  • Tamponade, cardiac

    • Pericardiocentesis

  • Tension pneumothorax

    • Needle decompression

    • Insert chest tube

  • Thrombosis (pulmonary) —> REVERSIBLE

    • Fibrinolysis with t-PA

  • Thrombosis (coronary)

    • Initiation of MI protocol

ACLS Algorithms

• Cardiac Arrest

  • Vfib

  • Pulseless Vtach

  • PEA

  • Asystole

• Bradycardia

• Stable tachycardia

Cardiac Arrest Treatment

• VF/PVT

  • Epinephrine every 3-5 min

    • Augment/increase perfusion pressure

  • Amiodarone or Lidocaine

    • Raise fibrillation threshold

• Asystole/PEA

  • Epinephrine every 3-5 min

• Vasopressin?

Adjunctive Meds

• Mg

  • TdP

• Sodium Bicarb

  • Acidosis

• Thrombolytics

  • Use if concerned for MI or pulmonary embolism

Bradycardia Treatment

• Atropine

• Dopamine

• Epinephrine

(brady loves A[tr]DE)

Stable Tachycardia Treatment

• Adenosine - narrow

• Procainamide - wide QRS

• Amiodarone - wide QRS

(APA format is TACHY/tacky :p)

Targeted Temperature Management (TTM)

Post-Resuscitative Care

• 32-34C, 12-24 hrs post arrest

• Neuroprotective —> decrease cerebral metabolic rate and O2 demand

• Decrease reperfusion injury

Implantable Cardioverters Defibrillator (ICD)

Prevent sudden cardiac death from recurrent Vtach or Vfib

Lecture 2: Atrial Arrhythmias

HR

• Normal: 60-100 bpm

• Bradycardia: <60 bpm

  • AV blocks

• Tachycardia: >100 bpm

AV Blocks

• 1st Degree

  • PR > 0.2 sec

• 2nd Degree

  • Mobitz Type 1

    • No QRS

  • Mobitz Type 2

    • Constant PR + RANDOM QRS are dropped

• 3rd Degree

  • No P waves

Torsades de Pointes

Prolonged QTc

• Males > 450 msecs

• Females > 460 msecs

• High risk of TdP >  500 msecs

Atrial Fibrillation vs. Atrial Flutter

• AF: multiple reentrant loops

  • Irregularly irregular

  • No discernible P waves

• Aflutter: single, dominant reentrant wavelet

  • (butterflies are DOMINANT)

  • Single ectopic focus

  • Regularly irregular

• Causes:

  • MI

  • VHD

  • Congenital abnormalities

  • High adrenergic states- thyrotoxicosis, surgery, alcohol withdrawal, sepsis

Treatment of AF

• Stroke

  • CHADSVASC Score

• Tachyarrythmias

  • Rate control

    • Rate-control meds

      • BB

      • Non-DHP CCB

      • Digoxin

  • Rhythm control

    • 1. Cardioversion

    • 2. Antiarrhythmics

    • 3. Catheter Ablation

    • 4. Surgery

CHADS vs. CHADSVASC

• Congestive HF

• HTN

• Age > 75

• Diabetes

• Stroke/Transient Ischemic Attack/Thromboembolism = 2 pt

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• Vascular Disease

  • MI, PAD, Aortic plaque

• Age 65-74

• Sex: female

CHADSVASC Scores & Anticoag Therapy

• Men = 0, Women = 1 —> no therapy

• Men = 1, Women = 2 —> consider therapy

• Men = 2+, Women = 3+ —>

  • Recommend oral anticoag

    • 2. Warfarin (INR 2-3)

    • 1. DOAC or NOAC (dabigatran, rivaroxaban, apixaban, edoxaban)

      • Preferred over warfarin except in mitral stenosis or mechanical heart valve

Anticoag Therapy - Stroke, CHADSVASC

• Warfarin

• DOACs - PREFERRED

  • Dabigatran (Pradaxa)

    • 150 mg PO BID

  • Rivaroxaban (Xarelto)

    • 20 mg PO QD

  • Apixaban (Eliquis)

    • 5 mg PO BID

  • Edoxaban (Savaysa)

    • 60 mg PO QD

Rate Control

Palpitations, chest pain, shortness of breath, syncope

• Goal: <100-110 bpm

• Medications

  • BB

  • Non-DHP CCBs

  • Digoxin

  • Amiodarone?????????

Rhythm Control

• Goal: restore/maintain normal sinus rhythm (NSR)

1. Cardioversion

   1. Electrical Cardioversion

   2. Pharmacological Cardioversion

      1. Amiodarone

      2. Dofetilide - xxxxx

      3. Ibutilide (IV) ***

      4. Flecainide

      5. Propafenone

2. Anti-arrhythmics —> maintain NSR

   1. Amiodarone

   2. Sotalol ***

   3. Dofetilide

   4. Dronedarone ***

   5. Flecainide

   6. Propafenone

3. Catheter Ablation → 1st line for YOUNGER pt

   1. Last line, generally, if pharm cardioversion and AAD ineffective/CI/not tolerated

4. Surgery

Lecture 3: VHD & Shock

Stenosis

Narrowing

Regurgitation

Insufficiency or leaking

Valvular Disorders

• Mitral Valve Stenosis

• Mitral Valve Regurgitation

• Aortic Valve Stenosis

• Aortic Valve Regurgitation

Surgery

• Balloon valvuloplasty

• Valve repair

• Valve replacement

  • Bioprosthetic

    • Risk factor for bleeding

    • Anticoagulation risk

  • Mechanical

    • Young pt

Antithrombotic Therapy

• Bioprosthetic

  • Aortic:

    • Aspirin 50-100 mg/day

  • Mitral:

    • Aspirin 50-100 mg/day

    • Warfarin: INR 2-3 for 3 mo

• Mechanical —> CI: pregnancy (warfarin)

  • Aortic:

    • Aspirin 50-100 mg/day (if additional TE risks)

    • Warfarin INR 2-3

  • Mitral:

    • Aspirin 50-100 mg/day (if additional TE risks)

    • Warfarin 2.5-3.5

Shock Types

• Cardiogenic: fail to pump out blood

• Obstructive: outflow is obstructed

• Hypovolemic: not enough blood volume to pump

• Distributive: peripheral vasodilation

Shock Meds - Vasopressors

• Epinephrine - emergencies

  • a1, b1, b2

• Norepinephrine (Levophed)

  • 1st line SEPSIS

  • a1, b1

• Dopamine

  • Cardiogenic shock

  • a1, b1, D

• Phenylephrine (Neo-Synephrine)

  • Alt to norepi or dopamine

  • a1

• Vasopressin

  • OK for acidosis

  • Adjunct to norepinephrine (sepsis)

Lecture 4: IHD

Chronic Stable Angina vs. Coronary Artery Disease

• CSA: with activity or stress

• CAD: artherosclerosis- narrows coronary arteries

Cardiac Testing and Monitoring

• EKG

• Echocardiogram: structure and function of heart

  • Trans-thoracic echo (TTE)

  • Trans-esophageal echo (TEE) - invasive

• Coronary Artery Calcium Score

• Stress Test - nuclear perfusion imaging

  • Excercise

  • Pharmacological

• Cardiac Catheterization

Chronic Stable Angina —> IHD Treatment

• Aspirin 81 mg - indefinitely

• 1. Nitroglycerin SL (Nitrostat): 0.4 mg, 2×, 5 min apart

  • Do not take within 24-48 hr of erectile dysf med

  • Take 5-10 min before excercise to prevent chest pain

• 2. BB

  • Cardioselective BB

• 3. CCB or Isosorbide Nitrate (Imdur)

  • Non-DHP CCB if high HR

  • DHP CCB if low HR

• 4. Ranolazine (Ranexa)

Myocardial Oxygen Deman (MVO2)

1. HR

2. Contractility

3. Intramyocardial wall tension - systole

4. DP = HR x SBP