Cardiology

Acute coronary Sx



STEMI

"MONA F HABS"

Troponin levels may also be elevated in:

CHF
cardiomyopathy
cardiac contusion
myocarditis
pericarditis
renal insufficiency
PE
severe infections
shock
certain chronic inflammatory conditions of muscles and skin.

Morphine

Morphine sulfate 2-4 mg IV
with increments of 2-8 mg IV repeated at 5-15 min intervals.

Oxygen

Supplemental O2 during 1st 6 hrs.

If SaO2 < 90% or overt pulmonary congestion → O2 continued beyond 1st 6 hrs.

Nitrates

If ongoing ischemic discomfort → NTG 0.4 mg SL q 5 mins x 3

If persistent ischemia, CHF, or Htn → NTG IV.

If recurrent angina or persistent CHF > 48 hrs after STEMI → NTG IV, PO, or topical.

In view of their marginal treatment benefits, nitrates should not be used if hypotension limits the administration of beta-blockers, which have more powerful salutary effects.

Contraindications:

systolic <90 mm Hg
systolic > 30 mm Hg below baseline
severe bradycardia (<50 bpm)
tachycardia (>100 bpm)
suspected RV infarction
phosphodiesterase inhibitor within 24 hrs (48 hrs for tadalafil)

ASA


ASA 162-325 mg PO chewed

Fibrinolysis

Fibrinolytic therapy should be administered if:
symptom onset w/n 12-24 hrs who have continuing ischemic symptoms and
ST elevation > 0.1 mV in
≥ 2 contiguous precordial leads or
≥ 2 adjacent limb leads

or with new (or presumably new) LBBB
Absolute contraindications:

● Asymptomatic patients whose initial symptoms began > 24 hrs earlier
● only ST-segment depression (except if a true posterior MI is suspected)
● Any prior ICH
● Known structural cerebral vascular lesion (e.g. AVM)
● Known malignant intracranial neoplasm (primary or metastatic)
● Ischemic stroke < 3 mos EXCEPT acute ischemic stroke within 3 hrs
● Suspected aortic dissection
● Active bleeding or bleeding diathesis (excluding menses)
● Significant closed head or facial trauma < 3 mos


Relative contraindications:


● H/o chronic, severe, poorly controlled Htn
● sBP > 180 or dBP > 110
● H/o prior ischemic stroke > 3 mos, dementia, or known intracranial pathology not covered in absolute contraindications
● Traumatic or > 10 mins CPR
● Major surgery < 3 wks
● Within 2-4 wks internal bleeding
● Noncompressible vascular punctures
● For streptokinase/anistreplase: prior exposure > 5 days ago or prior allergic reaction
● Pregnancy
● Active peptic ulcer
● Current use of anticoagulants


Unfractionated heparin


UFH 60 U/kg (maximum 4000 U) bolus
followed by an initial infusion of 12 U/kg/hr (max 1000 U/hr)
adjusted to maintain aPTT 1.5-2.0 x control (approx 50-70 s).

LMWH


LMWH might be considered an acceptable alternative to UFH if:
< 75 y/o & Cr > 2.5 mg/dL in men or 2.0 mg/dL in women

Enoxaparin 30 mg IV bolus
followed by 1.0 mg/kg sc q12h until hospital discharge used in combination with full-dose tenecteplase

DVT prophylaxis with sc LMWH or with sc UFH 7,500-12,500 U BID until completely ambulatory, may be useful.

Warfarin

Target INR 2-3 for >3 months if:
Persistent atrial fibrillation
Extensive wall motion abnormalities
Severe LV systolic dysfunction
LV thrombus
Previous systemic or pulmonary embolism


β-blockers


Immediate β-blocker therapy appears to reduce the magnitude of infarction, the risk of reinfarction, and the risk of life-threatening ventricular tachyarrhythmias.

Contraindications:

β-blockers or calcium channel blockers should not be administered acutely to STEMI patients with frank cardiac failure evidenced by pulmonary congestion or signs of a low-output state.

β-blockers should be initiated before discharge for secondary prevention. For those who remain in heart failure throughout the hospitalization, low doses should be initiated, with gradual titration on an outpatient basis.

ACE inhibitor

ACEI PO within 1st 24 hrs of STEMI to patients with anterior infarction, pulmonary congestion, or LVEF < 40%
if no hypotension (systolic < 100 or > 30 below baseline).

IV ACE inhibitor should not be given b/c risk of hypotension.

E.g. captopril 1.0 - 6.25 mg PO TID

Valsartan (target: 160 mg BID) should be administered to STEMI patients who are intolerant of ACEI.

Other drugs

Diuretic


Low- to intermediate-dose furosemide if pulmonary congestion with associated volume overload. Caution is advised for patients who have not received volume expansion.

Long-term aldosterone blockade

If LVEF < 40% and either symptomatic CHF or DM
& already receiving therapeutic doses of ACEI →
L-T aldosterone blockade
if Cr > 2.5 mg/dL in men & > 2.0 mg/dL in women &
K+ < 5.0

Non-DHP CCB


If ongoing ischemia or atrial fibrillation or flutter with rapid ventricular response →
may give verapamil or diltiazem when β-blockers are ineffective or contraindicated
contraindications: CHF, LV dysfunction, AV block.

Anxiolytics

It is reasonable to use anxiolytics to alleviate short-term anxiety or altered behavior related to hospitalization.

Cautions
DHP CCBs
Nifedipine (immediate-release form) is contraindicated b/c risk of hypotension → reflex tachycardia.

Estrogen plus progestin


should not be given de novo to postmenopausal women after STEMI for secondary prevention of coronary events.

Postmenopausal women who are already taking estrogen plus progestin at the time of a STEMI should not continue hormone therapy.

Thiazolidinediones


should not be used in patients recovering from STEMI who have NYHA class III or IV CHF.

Acivity

Patients with STEMI who are free of recurrent ischemic discomfort, symptoms of heart failure, or serious disturbances of heart rhythm should not be on bed rest for more than 12-24 hours.

After 12-24 hours, it is reasonable to allow patients with hemodynamic instability or continued ischemia to have bedside commode privileges.

Coronary angiography
Diagnostic coronary angiography should be performed in candidates:
for PCI
with cardiogenic shock who are candidates for revascularization
for surgical repair of ventricular septal rupture or severe mitral regurgitation
with persistent hemodynamic and/or electrical instability
with failed reperfusion (eg, recurrence of chest pain and persistence of ECG findings indicating infarction)
mechanical complications (eg, sudden onset of heart failure or presence of a new murmur)


Cardiogenic shock
Pulmonary edema + hypotension = Dx: cardiogenic shock

A preshock state of hypoperfusion with normal blood pressure may develop before circulatory collapse and is manifested by cold extremities, cyanosis, oliguria, or decreased mentation.
→ If BP permits, afterload-reducing agents → ↓ cardiac work & pulmonary congestion
→ dobutamine infusion
→ IABP → improved coronary perfusion & ↓ afterload → ↓ cardiac work
→ PCI or CABG (Early revascularization is reasonable for selected patients who develop shock w/n 36 hrs) of MI


Pulmonary congestion
1. Oxygen supplementation to SaO2 >90%
2. Morphine
3. Titration of short-acting ACEI
4. Possible insertion of IABP for the management of refractory pulmonary congestion

The immediate management goals include adequate oxygenation and preload reduction to relieve pulmonary congestion. Because of sympathetic stimulation, the blood pressure should be elevated in the presence of pulmonary edema. Patients with this appropriate response can typically tolerate the required medications, all of which lower blood pressure.

Inferior STEMI and hemodynamic compromise:


should be assessed with a V4R lead & echocardiogram to screen for RV infarction.

Inf STEMI → RV dysfunction → ↓ CO

Mgt: flds → ↑ RV preload → ↑ CO

Treatment of RV ischemia/infarction includes early maintenance of RV preload, reduction of RV afterload, inotropic support of the dysfunctional RV, early reperfusion, and maintenance of AV synchrony.

Patients with pulmonary congestion or hypotension often need inotropic and vasopressor agents and/or IABP.

IABP (intra-aortic balloon pump) counterpulsation
If:

STEMI & hypotension (systolic <90 mm Hg or 30 mm Hg below baseline mean arterial pressure) who do not respond to other interventions.


Rehabilitation
On the basis of assessment of risk, ideally with an exercise test to guide the prescription, all patients recovering from STEMI should be encouraged to exercise for a minimum of 30 minutes, preferably daily but at least 3 or 4 times per week (walking, jogging, cycling, or other aerobic activity), supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, and household work).

Cardiac rehabilitation/secondary prevention programs are recommended particularly for those with modifiable risk factors.

Treatment with cognitive-behavioral therapy and selective serotonin reuptake inhibitors can be useful for depression that occurs in the year after hospital discharge.

The patient?s list of current medications should be reevaluated in a follow-up visit, and appropriate titration of ACE inhibitors, beta-blockers, and statins should be undertaken.

The predischarge risk assessment and planned workup should be reviewed and continued. This should include a check of LV function and possibly Holter monitoring for those whose early post-STEMI ejection fraction was 30-40% or lower, in consideration of possible ICD use.

The psychosocial status of the patient should be evaluated in follow-up, including inquiries regarding symptoms of depression, anxiety, or sleep disorders and the social support environment.

If symptoms recur, patients should be advised to call 911 after 5 minutes despite possible feelings of uncertainty and fear of embarrassment.

NSTEMI

Diagnostic evaluation of suspected UA/NSTEMI


Patients with a low likelihood of ischemia are observed in a monitored bed over a period of 6 h, and 12-lead EKGs are performed if the patient has recurrent chest discomfort. A panel of cardiac markers (e.g., troponin and CK-MB) is drawn at baseline and 6 h later.

If the patient develops recurrent pain, has ST-segment or T-wave changes, or has positive cardiac markers → admit to hospital and treat for UA/NSTEMI.

If the patient has negative markers and no recurrence of pain, he/she is sent for exercise treadmill testing, with imaging (e.g. MIBI, stress echo) reserved for patients with abnormal baseline electrocardiograms (e.g. LBBB or LVH).

If low risk of embolization → low dose ASA long term + clopidogrel x 8-12 months.

Risk-stratification

TIMI risk score for STEMI

TIMI risk score for NSTEMI

Killip classification


Killip class	Criteria	Mortality w/n 30 days
I	no clinical signs of heart failure	6%
II	lung crackles, S3, elevated JVP	17%
III	frank acute pulmonary edema	38%
IV	cardiogenic shock or hypotension (sBP <90 mmHg), peripheral vasoconstriction (oliguria, cyanosis, or sweating)	81%




Unstable angina

Atherosclerosis

Risk factors


Major	Constitutional	Minor
DM	age	sedentary
Htn	sex	obesity
dyslipidemia	FHx	stress
smoking

Canadian Cardiovascular Society (CCS) Angina Grading Scale


Class	Criteria
I	Angina only during strenuous or prolonged physical activity
II	Slight limitation, with angina only during vigorous physical activity
III	Symptoms with everyday living activities, i.e. moderate limitation
IV	Inability to perform any activity without angina or angina at rest, i.e. severe limitation

Atrial fibrillation

CHAD2
(C for CHF, H for Htn, A for age, D for diabetes, and 2 for CVA/TIA which gets two points)


CHF	1
systolic > 160	1
≥ 75 y/o	1
DM	1
Prior cerebral ischemia	2




If score = 1 → ASA
If score ≥ 2 → warfarin → INR 2-3

CHF

New York Heart Association (NYHA) Functional Classification of Heart Failure


NYHA Class	Symptoms
I	No symptoms and no limitation in ordinary physical activity
II	Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
III	Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest.
IV	Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

CCS Summary



Valsartan (Diovan) 40 mg BID → target: 160 mg BID

Metoprolol 12.5 mg PO BID → ↑ by 50-100% q 2-4 wks to target of 100 mg PO BID

Furosemide 20-40 mg qd or BID (max 600 mg/d)

Framingham Cardiovascular Risk Calculator
U.K. Cardiovascular Risk Calculator

Risk reduction targets


Risk group	10-yr risk CVD	Target LDL	Target TC/HDL
High	>20%	<2.0	<4.0
Moderate	10-20%	<3.5	<5.0
Low	<10%	<5.0	<6.0

High risk automatically includes coronary artery disease, peripheral artery disease, cerebrovascular disease, and most patients with diabetes.

EKG.pdf

Hypertension

If average BP ≥ 140/90 on three occasions, Dx of Htn confirmed.

If diastolic BP > 130 or BP > 180/110 with signs/symptoms (papilloedema, retinal hemorrhage), then urgent treatment.

If average BP ≥ 160/100 or BP < 160/100 with DM, CKD, LVH or vascular dementia or CHD risk ≥ 20% over 10 years, then pharmacologic treatment with lifestyle management.

If not, then lifestyle management and reassess regularly. If lifestyle management insufficient (BP ≥ 140/90), then pharmacologic treatment.


INVESTIGATIONS:

Urinalysis
microalbuminuria (albumin/creatinine ratio)
blood chemistry (potassium, sodium, creatinine/eGFR)
FBG
lipids
ECG
Framingham risk assessment (10-year CHD risk) or UKPDS risk assessment if DM2
Mgt
Diastolic +/- systolic Htn:
ACEI, ARB, BB, CCB, thiazide,

Isolated systolic Htn:

ARB, LA DHP-CCB, thiazide

DM (esp. if ↑ACR):

ACEI, ARB, furosemide (prn if Cr>150)

Angina:

ACEI, ARB

MI:

ACEI, ARB

Heart failure (NYHA III or IV):

ACEI, ARB

LVH:

ACEI, ARB, LA DHP-CCB, thiazide

Non-acute CVA or TIA:

ACEI + thiazide combination

Non-diabetic CKD:

ACEI, ARB

PALS

Syncope

Syncope DDx.ppt

Cardiovascular


bradydysrhythmias
tachydysrhythmias
AS
IHSS
MI
HF
massive PE
subclavian steal Sx

Reflex mechanisms


vasovagal
micturition
deglutition
cough
carotid sinus hypersensitivity

Orthostatic hypotension


hypovolemia
drugs (e.g. antidepressants, antihypertensives)
dysautonomias


Psychogenic


hysterical
panic disorder
anxiety disorder


Unknown (18%)