MTB Cardiology notes

REINFARCTION: [NEW CP episode within few days of first episode] INITIAL management?
1. EKG [see NEW ST abnl]
2. CK-MB: (see inc levels) [nl CK-MB disappears 24-48hrs 2 days after 1st MI]

AFTER INITIAL management: Monitor in ICU: Continuous rhythm monitor

 First few days: risk: VTach, VFib

ST-elevation MI: STEMI

STEMI

INITIAL tx: STENTING placement: give

Allergy to aspirin give:
ASPRIN Prasugrel or Ticagrelor
Clopidogrel (alternative to Clopidogrel)
(oral or chew)

ANGIOPLASTY (PCI)
[Decrease Mortality]
Do within 90minutes (if
avail)

Complications of ANGIOPLASTY
(PCI):
-Ruptures coronary artery on
ballon inflation
-Restenosis/thrombosis
-Hematoma @entry site (femoral)

-tx: Paclitaxel, Sirolimus

(Drug-eluting stent) = Prevents risk of Restenosis of coronary art. After PCI. [inhibits local T-cell
response] (Heparin at procedure time, but not long-term. Warfarin is not for coronary disease.
It’s for Venous: DVT, PE]

Cardiology Notes 1
Don’t use Thrombolytics if got:
-Bleed in bowel (melena) or Brain (ANY type of CNS bleeding)
-Recent surgery (w/in last 2wks)
-Severe htn (>180/110)

-IF hospital has NO cath lab → give THROMBOLYTICS now

-IF contraindications for thrombolytic use → then transfer to facility performing PCI

REMEMBER:
Which is better for SURVIVAL & MORTALITY benefit?
= ANGIOPLASTY

What to do if cannot do Angioplasty/Delayed Angioplasty-cath lab for several hours?

= Thrombolytics immediately >>> delayed angioplasty (bc lab is not near)

-Can answer “THROMBOLYTICS” in any pt w/CP & STEMI within first 12 hours of CP onset
(thrombolytics: Mortality benefits extends to 12hours from CP onset)
= pt w/CP enters ER doors → give THROMBOLYTICS within 30mins

CASES and the THERAPY to use. Benefit depends on specific circumstance.

Aspirin: Best ONLY Clpidogrel/Prsugrel/Ticagrelor BB: Oxygen, nitrates
with STEMI -Undergoing ANGIOPLASTY- -Start any time during -no clear mortality
-BEST INITIAL med PCI or Stenting admission; Not benefit
-add to aspirin dependent on time;
NO Urgency for (BB:
metoprolol use)
Angioplasty: Heparin: BEST for NON-STEMI CCB: Statins: goal:
(AFTER aspirin given!) -AFTER thrombolytics/PCI- -pt cannot use BB -<100mg LDL
-Best for Survival & angioplasty to PREVENT -cocaine induced pain
Mortality benefit restenosis -prinzmetal or
(>>thrombolytics) -INITIAL med w/ST Depression vasospasm variant
and NON-STEMI angina
(Unstable angina)
GPIIb/IIIa inhibitor Paclitaxel, Sirolimus ACE-I:
[Abciximab, (Drug-eluting stent) = Prevents -Best Benefit if has
Tirofiban, risk of Restenosis of coronary <40% EF
Eptifibatide] BEST for art. After PCI
NON-STEMI and…
-Undergoing
ANGIOPLASTY PCI or
stenting
-Not useful for acute
STEMI
-Reduce MORTALITY
in ST depression
(Unstable angina)

Cardiology Notes 2
ST-depression
-ST-depression, CP. Aspirin given. What’s next?
=Heparin (LMWH) =URGENT
[=prevents clot growing/forming more in coronary arteries. It won’t dissolve already formed clots]

-NO ST-elevation = NO benefit of thrombolytic therapy!

-NG/Morphine/Oxy = NO CLEAR reduction in mortality!
-CCB & warfarin NO CLEAR mortality benefit in ACS.

-LMWH >>> unfractionated heparin [for MORTALITY Benefit]

NON-STEMI: after all meds given - HEPARIN and pt is NOT BETTER:

= do Angiogram & maybe Angioplasty-PCI
-Persistent pain
-S3 gallop or CHF developing
-Worse EKG or VTach
-Trops rise

///////////////////////////////////////////////////////////////////////////
Acute MI complication QUESTIONS
-What’s most likely diagnosis? [common Q]
-HEART RATE = key clue

BRADYCARDIA
Sinus- Bradycardia [SA node fkd] = NO Cannon A Third-degree (complete) AV block: = Bardycardia,
waves Cannon A waves.
(moa: atrial systole against closed tricuspid)
(Tricuspid closed bc 3rd degree block…Atria &
ventricles contract out of coordination with each
other)
(‘cannon = bounding jugulovenous wave back into
neck’ see: RV infract & Third-degree AV block
link!)

Symptomatic Bradycardia
Tx: ATROPINE (FIRST); then Place PACEMAKER if atropine not effective

TACHYCARDIA:
RV infarct: link New INFERIOR wall Tamponade/free wall rupture VTach/VFib:
MI (II, III, aVF) + Clear lungs auscul; [several days post-MI….wall -Sudden death; Loss Pulse.
Tachy,HoTN with NG use scars/weakens-then rupture] NEED EKG to answer Q
-“sudden pulse loss”; JVD; clear -tx:
-dx: RV4 (Right chest)*** lungs Cardioversion/defibrillation

Cardiology Notes 3
(see Check ST-elevation) emergency
[RCA supplies: RV/AV node/Inferior -dx: Echocardiogram emergency
wall -tx: Pericardiocentesis emergency
-Inferior wall MI has 40% chance on way to OR to repair it
has RV infarction ]

-tx: High-volume Fluid replacement

(Treat RV infarct); AVOID NG-
worsens filling

Valve or Septum rupture: REINFARCTION/Extension of Aneurysm/Mural thrombus

-NEW murmur & Pulmonary infarction -dx: ECHO
congestion-Rales CLUE to 2nd MI different area of
heart: Aneurysm:
-MR: hear @Apex radiate to axilla -Recurrence of pain -No therapy needed
-New rales on exam
-Ventr. Septal rupture: hear @L -New Bump up in CK-MBs inc Mural Thrombi
lower sternal border; see Oxy sat -Sudden Pulm edema -tx: Heparin then warfarin
inc from RA to RV “ex: 72% SaO2 RA
to 85%SaO2 on RV” (step-up) -dx: EKG repeat
-tx: Angioplasty and sometimes
-dx: ECHO [best test] thrombolytics in addition to usual
(ASPIRIN, Metoprolol, Nitrates, ACE-
I, Satins)

-Intraaortic Balloon pump is temporary BRIDGE to surgery for valve replacement for 24-to-48hrs)

Detect Persistent Ischemia EVERYONE gets Stress test before discharge

Stress Test prior to discharge to

see if Angiogram needed

Angiogram: to see if need

Revascularization (Angioplasty-
PCI or Bypass Surgery)

Angioplasty-PCI or Bypass
surgery

-NO Stress test if pt clearly has symptoms…. – go Straight to ANGIOGRAM

-NO Angiogram if got reversible signs of myocardial ischemia is ABSENT (no point to vascularize
dead/infarcted myocardium)

Cardiology Notes 4
POST-INFARCTION take home meds:
-ASPIRIN
-BB (metoprolol)
-Statins
-ACE-I

-ACE-I = Best for ANTERIOR wall infract V2 –V4

-Clopidogrel or Prasugrel or Ticagrelor: for pt intolerance of aspirin or Post-stenting

-NEVER Dipyridamole for CAD: coronary artery dz

PROPHYLACTIC ANTIARRHYTHMIC MEDS:

-NO Amiodarone/flecainide; or ANY rhythm-controlling med to PREVENT VTach or VFib!
-Don’t get tricked by “Frequent PVCs and ectopy”…..
=Prophylactic Antiarrhythmic INCREASES mortality!!

QUESTIONS – HY
POSTINFARCT – SEX PROBLEMS
-Do not combine nitrates/NG with Sildenafil [pt taking 2 drugs…has HYPOTENSION. Likely
cause?...vasodilators]
-Erectile dysfunction postinfarction Most Commonly from: ANXIETY
-ED due to Meds? = Beta-Blockers (propranolol/metoprolol)

-Patient does not have to wait after an MI to have sex. If no symptoms, then can have sex immediately
[bc sex doesn’t last long enough to have excess inc myocardial oxy consumption]
-If Post-MI stress test nl, pt can do any form of Exercise program. Including sex
/////////////////////////////////////////////////////////////////////////////////////
CONGESTIVE HEART FAILURE
-sx: Dyspnea [insufficient oxy to tissues & fluid builds in lung]

-Systolic dysfunction: LOW EF & Dilated heart

-Diastolic dysfunction: Heart cannot “Relax/dilate” to receive blood; EF preserved or above normal
(contraction is ok)

-dt: HYPERTENSION → heart dilates overtime systolic dysfunction & low EF

-dt: MI → DILATED CM & dec EF (= systolic dysfunction; won’t pump) → Regurge → CHF

Main Clue: DYSPNEA; Dyspnea on exertion

Other additional clues:
-Orthopnea [worse when lying flat, relieved when sit up or standing; many pillows)
-limb edema
-Rales
-JVD
-PND (Paroxysmal Nocturnal Dyspnea: sudden worsening at night, during sleep)
-S3 gallop (Identify sound on STEP 2: “ken-tuc-KY”

Cardiology Notes 5
WHAT’S THE MOST LIKELY DIAGNOSIS? For DYSPNEA
Sudden onset; Sudden, Slower, fever, Circumoral Pallor, gradual over
clear lungs wheezing, inc sputum, numbness/mouth; days to weeks
= Pulmonary expiratory phase unilateral caffeine use, h/o =Anemia
emboli = Asthma rales/rhonchi anxiety
=Pneumonia = Panic attack
Pulse paradoxus, Palpitations, Dull percussion Long smoking hx, Recent anesthetic use,
dec heart sounds, syncope at BASES barrel chest brown blood not
JVD =Arrhythmia of =Pleural effusion =COPD improved with
=Tamponade any kind oxygen, clear lungs
auscultate, cyanosis
=Methemoglobinemia
Burning building
or car, wood-
burning stove in
winter, suicide
attempt
=Carbon
monoxide poison

ALL OF THESE WILL LACK:

-Orthopnea/PND [cannot lay down – SOB; Wakes up at night gasp for air]
-S3 gallop
= CHF

Dx: ECHO (diagnoses CHF) (distinguish systolic vs diastolic dysfunction) [NOT: EKG, CXR, BNP)
To evaluate Ejection Fraction.

CHF clues. Best INITIAL test? Most ACCURATE test? Acute SOB with etiology of dyspnea
= transTHORACIC ECHO = MUGA (Multiple-gated is NOT Clear
acquisition scan) or Nuclear And you cannot wait for ECHO to
ventriculography be done.
-dx: BNP

BNP excludes CHF as cause of SOB

[TEE: Transesophageal Echocardiogram = more accurate then both to evaluate heart VALVE function &
diameter. TEE not for CHF eval.]

“Nuclear testing” = rarely needed (for precision) (ex: Chemo w/doxorubicin – trying to give max chemo
but not cause cardiomyopathy)
Nuclear Ventriculogram = precision of WALL MOTION problems

TESTS to determine/diagnose the Etiology/CAUSE of CHF

EKG: CXR: Holter monitor: Cardiac
-MI, Heart block -Dilated CM -Paroxysmal arrhythmias Catheterization:
-Valve diameters,

Cardiology Notes 6
 Septal defects
CBC: T4/TSH: thyroid funct. Endomyocardial biopsy Swan-Ganz right
-Anemia =Both high & low -Rarely done heart catheterization:
thyroid levels cause CHF -excludes infiltrative -Distinguish CHF from
disease: sarcoid/amyloid ARDS; not routine
-biopsy is “most accurate
test” for some infections

///////////////////////
TREAT CHF:
Systolic dysfunction (Low ejection fraction):
-ACE-I or ARBs → give TO ALL Systolic dysfunction CHF (doesn’t matter which stage) pt coughs
on ACE-I….switch to ARBs-sartans
-BB
-Spironolactone
-Diuretics
-Digoxin

ACE-I/ARBs: give to ALL SYSTOLIC Beta Blockers: CLEAR evidence Spironolactone:

Dysfunction CHF of benefit ONLY for: [inhibits aldo effects]
- -Metoprolol/Bisoprolol (beta-1 -Proven effective ONLY in
antagonist) Advanced/serious stages of
-Carvedilol: (NS BB; also has CHF [“Dyspnea at rest or with
alpha-1 blocking) minimal exertion”]

SE: HyperKalemia;
gynecomastia

EPLERENONE: switch from

Spironolactone to
Eplerenone…. inhibits aldo
-MORTALITY benefit (proven)
-No antiandrogen side effect
ACE-I/ARBs + Digoxin:
LOOP:Furosemide/torsemide/ -never proven to lower
bumetanide = INITIAL treatment mortality** TESTED USMLE.
CHF w/ LOW EF -Digoxin control SYMPTOMS of
dyspnea…lessens
-Diuretics control SYMPTOMS hospitalizations
-does NOT LOWER Mortality

99% CHF pts are at home, not acutely SOB. They dies SUDDEN DEATH by: Ventricular Arrhythmias
(ischemia)
-Beta-Blockers = anti-arrhythmic & anti-ischemia….so they prevent sudden death!

-NO beta blockers for ACUTE CHF exacerbation!!

Cardiology Notes 7
-Pt has h/o Dilated CM 2/2 MI. On Lisinopril, furosemide, metoprolol, aspirin, digoxin. Labs show
persistent elevated potassium. EKG unchanged. Best management?
= Switch Lisinopril to hydralazine and nitroglycerin

-Hydralazine: (direct-acting arteriolar vasodilator) – Survival [hydralazine +Nitrates in systolic dysfunc]

-Candesartan is SE: Hyperkalemia
-Dialysis for hyperkalemia, only if has Renal Failure as cause.

CHF devices:
-tx: Implantable Defibrillator: [for pt w/Ischemic Cardiomyopathy and EF <35%]
[bc Arrhythmia & SCD = MCCO death in CHF]

-tx: Biventricular Pacemaker: case of Dilated CM (Systolic dys) & <35% EF AND Wide QRS above
milliseconds [resynchronizes heart when there’s conduction defect]

-NEVER “anticoagulation with WARFARIN” …always wrong answer in absence of a clot in heart.

MUST KNOW **** Drugs that LOWER MORTALITY in CHF **** - Mortality Benefit: - memorize
1. ACEIs/ARBs
2. Beta-blockers
3. Spironolactone or Eplerenone
4. Hydralazine/Nitrates
5. Implantable DEFIBRILLATOR

[CCB = NO clear benefit in systolic dysfunction…..risk increased mortality!!]

/////////////////////////////
TREAT CHF:
DIASTOLIC dysfunction (Low ejection fraction):
(contraction is okay)
-tx: Beta-blockers = CLEAR benefits

-digoxin; spironolactone = has NO BENEFIT; NEVER USE in diastolic dysfunction!!

-Uncertain/unclear benefit: ACEIs, ARBs, Hydralazine

-Diuretics = to CONTROL symptoms of fluid overload of CHF

[don’t confuse: Diastolic dysfunction from hypertrophic cardiomyopathy (with hypertrophic obstructive
cardiomyopathy:HOCM]. HOCM = congenital disease w/asymmetric enlarged SEPTUM…obstructs LV
outflow tract.
Diuretics = BAD for HOCM bc will INCREASE OBSTRUCITON

Cardiology Notes 8
//////////////////////////////////////////////////////////////////////////////////////////////////////
ACUTE PULMONARY EDEMA
Pulmonary edema = worse/most severe form of CHF
-RAPID onset fluid buildup in lungs → Acute SOB
-Rales
-JVD
-S3 gallop
-Edema
-Orthopnea

-(maybe ascites & enlarged liver…if chronic congestion)

-dx: EKG = most important test to do ACUTELY [bc can lead to change in immediate therapy]
IF Afib/Aflutter/VTach is cause of Pulmonary edema →
then: Rapid, Synchronized Cardioversion [to restore systole) = fast way to fix it!

-dx: ECHOCARDIOGRAM = done in ALL patients. (to see if Systolic or Diastolic dysfunction)
-dx: BNP Brain Natriuretic Peptide (used if Diagnosis of etiology of Short of Breath unclear)
Nl BNP excludes Pulmonary Edema

-CXR: see Vascular Congestion with filling of blood vessels toward head (Engorged Pulmonary Veins –
near trachea]

-ABG: -Hypoxia; Respiratory ALKalosis (hyperventilation…CO2 leaves easily)

CASE: Acute SOB, RR 38, RALES, S3 Gallop, JVD. Best INITIAL step?
-tx: Intravenous Furosemide

[partial correct ans bc they all can be used in CHF management at some point…: Oximeter, Echo, ACEIs,
BB, Nesiritide]……but

BEST INITIAL medicine for ACUTE Pulmonary Edema

= LOOP [removes large volume of fluid from Vascular space]

WRONG:
Oximetry: Echocardiogram: ACEi or ARBs
-should be done, but doesn’t -should be done….but NOT -used if SYSTOLIC Dysfunction
alter ACUTE management bc URGENT w/LOW EF…..but doesn’t make a
must give oxygen anyways difference in an ACUTE
UNSTABLE pt.

Same with Beta-Blocker

Nesiritide: [IV form of ANP
-functions like NITRATES
-a weak diuretic
-NO PROVEN Mortality benefit!

Cardiology Notes 9
ACUTE PULMONARY EDEMA INITIAL therapy
Tx: Oxygen; LOOP: FUROSEMIDE/BUMETINIDE; Morphine, Nitrates

= Preload reduction (remove 1-2L FLUID from vascular space & lungs acutely…to dec sx)

ICU acute setting when SOB didn’t respond to meds/preload reduction

-tx: Dobutamine
Or Amrinone/Milrinone [phosphodiesterase inhibitors does same role] = Inc contractility & dec
afterload

-DIGOXIN sucks for acute setting (takes several weeks before effects kick in; positive
inotrope/contractility]
-HEPARIN = always WRONG in acute pulmonary edema in absence of clot

-ACEi/ARBs = Afterload Reduction…….use for DISCHARGE for long-term use in SYSTOLIC Dysfunction &
LOW EF.

-Acute Setting: Nitroprusside & IV Hydralazine can be used.

/////////////////////////////////////////////////////////////////////////////
VALVULAR HEART DISEASE
-Rheumatic Fever can cause any valve disease….MITRAL STENOSIS is MC
-Elderly = Aortic Stenosis

-[REGURGE = dt HTN & Ischemic heart disease…. MI → Regurge → Dilation]

-All valve problems have SOB and many sx of CHF.

-dx: ECHOCARDIOGRAM (best INITIAL test for all valve problems)

TransESOPHAGEAL echo [more sensitive & more specific than transthoracic echo]
[Chest xray: is NOT most accurate or best initial test]

-Most ACCURATE TEST: catheterization

[precise measures Valve diameter & pressure gradient across valve]

-tx: DIURETICS [why: all forms of valve disease assoc. with FLUID OVERLOAD in lungs-SOB] – sx relief

Mitral Stenosis:
-tx: Balloon dilation

Aortic Stenosis
-tx: Surgery removal

REGURGES
-tx: Vasodilators: ACEi/ARBs, Nifedipine CCB, Hydralazine
-Surgery REPLACEMENT (before heart dilates too much)

Mitral Stenosis: link Rheumatic Fever

Cardiology Notes 10
-Uncommon in USA…but can be Young Adult - IMMIGRANT or PREGNANT…. “What’s the most likely
diagnosis?”
-Don’t treat if asymptomatic
-Pregnancy: increases plasma volume pass through narrow valve (also uterus contraction “squeeze”
extra blood like 500mL into central circulation…gets pregnancy-related cardiomyopathy)

SYMPTOM:
-SOB & CHF signs (as in all valve diseases); unique clues:
-Dysphagia from enlarged LA compresses esophagus
-Hoarseness (LA presses on Laryngeal nerve)
- Hemoptysis
-AFib & stroke from large LA

PE:
-Diastole murmur after Open SNAP
-Squat & Leg raise → inc intensity from Venous Return to heart

-dx: TTE [Best INITIAL test: transTHORACIC Echo) [TEE is more accurate, but catheterization is MOST
accurate test)

-NO NEED FOR Endocarditis Prophylaxis for ANY valve disease unless valve has been Replaced or
Previous Endocarditis

Cardiology Notes 11