Presentation
Acute Coronary Syndrome
substernal pain on exertion 15-30 min/episode “dull, squeezing, pressure” S3/S4 rales (normal exam does not exclude ACS)
Tests
Hx consistent with ischemia = most important !"
exercise stress test# intermediate ris$ %/ normal E!& loo$s 'or re"ersible ischemia & cateterize anormal results eco# e*aluate %all + *al*e motion, + & normal %all motion excludes -. !"# $T depression
5S:-.
S:-.
cest pain
cest pain rales S3 B
<
Systolic ysx C7
E!4 $T ele"ation CD co :roponin .# ele*ated E5# ele*ated
!"# repeat i' symptoms cange co stress test# =62G o' max 7D to assess S: depression on !"& stress test; H re*ersile per'usion de'ect
CA/angina
Acute Fulmonary dema (C7)
Troponin . # rises 364 r a'ter pain onset, stays positi*e 061 %$s (-,# rises 164 r a'ter onset stays positi*e 061 days (est test o' rein'arction)& 'alse; %it C7 + renal 'ailure ,'o&lobin# rises at 064 r
sudden onset d'spnea , relie*ed y sitting up ;/6rales, ;/6 periperal edema S3, B tacycardia diaporesis, nausea
stress test %/ dip'ridamole or dobutamine eco !" (excludes iscemia + arrytmia) CD (excludes e''usion, cardiomegaly, congestion/*ascular 'luid o*erload) A" NP :roponin/C!6- 7N/(r4 ele"ated 89041 (pre6renal azotemia) ((4 h'ponatremia echo# determine , syst/diast dysx, *al*e 'x
Treatment
#$# (0 mg x1) -etoprolol (12 mg .) 5itroglycerin AC6iniitor Statin -orpine
catheteri%ation/an&io&raph' telemetry , heparin 2$( enoxaparin clopidogrel/prasugrel/ticagrelor ce%ale ASA (1 x 0 mg) 5:" statin (<< goal# 80== mg/d<) >6loc$er (metoprolol) AC6. morpine cat/angio despite medical inter*ention angioplasty/cat or tromolytics 'or FC. clopidogrel/prasugrel/ticagrelor 2+ NT use heparin ce%ale ASA 5:" statin (<< goal# 80== mg/d<) > 6loc$er (metoprolol) AC6. angiograpy %en IJ=G stenosis ASA ;/6 clopidogrel/prasugrel/ticargrel 2+ NT use heparin > 6loc$er (metoprolol) statin (<< goal# 80== mg/d<) AC6. (i' 832G)
?1 + ele*ate ead :urosemide 2asix .B 1= mg, doule e*ery 1=63= min till urine produced monitor ./ 5:" paste, .B, or S< morpine 164 mg .B hemodial'sis 'or re'ractory cases trans'er to .CE i' systolic 8 K= mm7g (+ NT use > -blocers in acutely ill pt) #(E-. (or AD i' coug& or alternati*e is ydralazine/nitrate i' yper$alemia) -blocer (metoprolol, car*edilol) spironolactone 'or stage .../.B C7 only (eplerenone as alternati*e) diuretics + di&oxin (no mortality ene'it)
Notes #($ = Hx o) chest pain * E!
-C ris$ 'actor# HTN %orst ris$ 'actor# +, (also smo$ing, yperlipidemia, + 'amily 7x 0st degree relati*e (822 male, 892 'emale)) (a**-channel blocers used 'or symptomatic relie' only, not mortality
no ?1 unless ypoxic don@t %ait 'or troponin or C!6- results statins can cause increased <:s + myositis
no ?1 unless ypoxic epti'iitide or acixima (glycoprotein ../...a iniitor) used i' FC. + stent Taotsubo cardiom'opath' due to o*er%elming emotions& mimics anterior %all S:-.
061 *essel# medical Dx + possile FC. 3 *essel %/
-CC# ;. #, in hi&h salt' )luid< .scemia Arrytmia -edication (most common) .n'ection 7:5 crisis Salty 'ood luid o*erload (iatrogenic) #.(+ i' lo% despite medical terapy (lo%ers mortality) AC6. not ene'icial in diastolic d ysx
7ypertensi*e crisis
Cardiomyopaty
7ypertropic ?struction Cardiomyopaty
Arr ytmia
i*entricular pacema$er i' LDS I01= ms .> anti-h'pertensi"es # laetalol, enalaprilat, or nitroprusside (stro$e caution# do not lo%er F I 12G 0 st 'e% rs)
cest pain, dyspnea/C7, lurry *ision, con'usion, renal insu''iciency
S? %orsens on exertion, impro*es %it rest rales ;/6 periperal edema syncope,
palpitations
CD# congestion or pulmonary *ascular redistriution eco (alternati*e -E"A or le't eart cat)
-blocer , AC6., spironolactone, diuretics ('or dilated cardiomyopaty) treat underlying cause ('or restricti*e cardM)
systolic murmur at <
-blocer (metoprolol) implantale de'irillator ('or syncope)
!" (i' normal, 7olter as outpatient, telemetry 'or inpatient) exclude tyroid disease, alcool, ca''eine
N anticoa&ulation i) present ? @A hr anticoa&ulate i) ris )or stroe 2(H#+9 cardiomyopaty 7:5 age IJ2 prior Stro$e/:.A (anticoagulate) rate control 80== pm %itin 3= min metoprolol (2 mg .B e*ery 2 min 3x, ten oral 2= mg id, max 1== id), ?DN diltia%em (=M12 mg/$g, ten .B =M32 mg/$g, ten oral 3= mg qid, max 1== qid) use di&oxin i' F is lo% or orderline (digoxin doesn@t lo%er F& slo% acting)
palpitations, ;/6 cest pain ligteadedness
!"# irre&ularl' irre&ular rytmB P-wa"es absentB normal C6$ (do not measure 7D y radial pulse) eco (detects *al*e disease + clots) :roponin/C!6-
SB:
sudden onset palpitations S?, ligteadedness
E!4 narrow C6$ tach'cardia (I09=pm), F6%a*es asent no pysical 'indings echo to exclude oter patology troponin/C!6- are not use'ul
telemetry adenosine 6loc$er (metoprolol or diltiazem) cardio*ersion i' emodynamically unstale
Ool'6Far$inson Oite Syndrome
palpitations, ligteadedness, syncope
E!4 small/short P-6B delta wa"es (early *entricular depolarization), SB: alternating %/ *6tac
procainamide, amiodarone, 'lecainide, or sotalol electroph'siolo&' (F) to identi'y anormal conduction tract 'or alation
-ulti'ocal Atrial :acycardia
a/% C?F
3 F6%a*e morpologies + normal LDS
same as 'or a6'i/a6'lutter
:D- -D"5CP cest pain, con'usion, S?
E!4 wide C6$B reproducily regular, sustained B: I3= sec :roponin/C!6- eco
recent -. loss o' pulse
CFD Q de'i Q CFD Q epi Q CFD Q de'i a'ter 1 min Q CFD 6 amiodarone
lo% systolic 8 K= mm7g ligteadedness
!"# determine emodynamic staility *entricular pacema$ers gi*e %ide LDS + anormal :6
A6'i/A6'lutter
B6:ac
B6'i radycardia
saline olus i' systolic 8K= mm7g cec$ !;M -g;;, Ca;;, ?1 s'nchroni%ed cardio"ersion i' unstale amiodarone, lidocaine, procainamide, + -g;; i' stale ".B CFDR uns'nchroni%ed cardio"ersion epineprine or *asopressin i' no response amiodarone (lidocaine alternati*e) i' unstale/symptomaticN atropine (=M260M= mg .B& 3 mg max)
7:5 crisis H se*ere 7:5 %it end6organ damage
systolic dysx# diated cardioM diastolic dysx# ypertropic cardM restricti*e card# sarcoidosis, amyloidosis, emocrM, cancer, endomyocardial 'irosis E: is preser"ed diuretics, AC6., deydration, + digoxin %ill %orsen 7?Cemodynamic instaility H cest pain, S?, con'usion, ypotension (8K= mm7g systolic) C7A1 H =/0# ASA +/or clopidogrel C7A1 H 1;# %ar'arin, ri*aroxaan, or daigatran (no .5D monitoring required, not re*ersile) causes# 7:5 (-C), C7, alcool, cocaine, tyroid disease, reumatic 'e*er (immigrants), dilated atrium oter rate control meds# *erapamil, esmolo, propranolol, atenolol (ardio"ersion# a6'i rytm control -CC y anormal AB conduction *agal maneu*ers# carotid massage or *alsal*a
pre*ious !" digoxin + Ca;;6c loc$er use %orsens symptoms or arrytmia 5? -blocer (%orsens C?F) ,(( is pre"ious ,. 2ischemia , also lo% -g;;, Ca;;, or ?1, ig/lo% !;, cocaine toxicity, lo% dilated cardiomyopaty :orsade de Fointes
treat B6tac %itout pulse te same i' stale/asymptomaticN Sinus rady, 0 st degree AB loc$, or -oitz .
con'usion, syncope, S? Sic$ Sinus Syndrome
Bal*ular 7eart isease
Aortic/-itral Degurgitation
sudden reco*ery o' consciousness# cardiac gradual reco*ery# seizures, glucose, ?1, drug ?/
dyspnea C7 edema murmurs congenital/reumatic 'e*er
dyspnea, rales, edema
an&ina a/% CA syncope C7 (%orse prognosis)
-itral Stenosis
'oun& immi&rant a6'i, dyspagia, oarseness, early onset stro$e
-itral Bal*e Frolapse
Fericarditis
Fericardial :amponade
Constricti*e Fericarditis
!" :roponin/C!6- eco measure ?1, glucose, 5a;, Ca;; -D. 'or rainstem causes ead C: + eco %/o murmur 'indings are useless
eco (est initial assessment) cateterization (most accurate test)
echo (est test) !"# AD %ill so%
AD# diastolic decrescendo murmur <
Aortic Stenosis
palpitations atypical cest pain incidental 'inding chest pain# relie*ed y sitting up, %orse on inspiration
S?, ligteadedness dyspnea, ypotension, B tach'cardia sudden loss o' pulse edema, B, !ussmaul@s sign enlarged li*er + spleen
H no treatment -oitz .. or 3 rd degree AB loc$ H pacemaer
transcutaneous pacema$er pacema$er i' slo% (I3 sec pause) 6loc$er i' 'ast
a$a tach'-brad' s'ndrome sudden
Syncope
%a*es
echo (est test) stress test D an&io&raph' (due to CA)
!"# biphasic P-wa"es in >1 D >9 CD# “doule ule”, < mainstem roncus pusing up, straigtened < eart order : + < eart cateterization is est test echo 2 est test) mid6systolic clic$ %/ late systolic murmur !" + CD %ill e normal 'riction ru on auscultation !"# S: ele*ation in all leads except ABD, FD segment depression pulsus paradoxus (I0= mm7g %it inspiration) CD# enlarged eart sado% C:# pericardial e''usion eco# e''usion pressing on rigt eart# DA + DB diastolic collapse is te 'irst sign !"# lo% *oltage, LDS electrical alternans $3 ;pericardial noc< CD# 'irosis, tic$ening, calci'ication Cest C:/-D. so%s more detail
exclude cardiac + neurologic causes -. • *entricular arrytmia • aortic stenosis • 7?C• seizure • rainstem stro$e increased *enous return (squatting or legs • raised) increases all murmur intensities (except -BF + 7?C-) decreased *enous return (sudden standing or • *alsal*a) decreases le't6sided murmur (except -BF) andgrip increases a'terload& %orsens • regurgitations, impro*es 7?C•
*aso*agal episode telemetry
endocarditis FFx i' *al*e %as replaced
AC6./ADs decreased a'terload no A FFx e'ore dental procedures unless *al*e %as replaced surgery# AD 82=G or
'luids pre*ent/re*erse tamponade toracocentesis pericardial %indo% placement cardiac cateterization# pressure equalization o' all camers in diastole surgical remo*al is est diuretics + salt restriction pre*ents uild6up
due to any cause o' dilated cardiomyopaty louder %it squatting + leg raised so'ter %it *alsal*a + standing %orsens %it and grip ( a'terload)
? 5?: use AC6. or AD (%orsens) -S can cause
,((4 "iral in)ection
also 'e*er, recent lung in'ection renal 'ailure cest %all trauma S<, DA, Oegner@s recent -., cancer o' cest organs
ascities
Feriperal Artery isease
;an&ina o) the cal"es< pain in legs relie*ed y rest decreased periperal pulses smoot, siny s$in (se*ere)
Adominal Aortic Aneurysm
7$$4 all men a&e 85 who ha"e e"er smoed
:oracic Aortic Aneurysm
cest pain radiates to te ac$
7eart isease + Fregnancy
peripartum cardiomyopaty %/
Fneumonia
Fulmonary molus Aortic dissection Costocndrtis "D 7ypotension
systolic 8 K= mm7g
eydration Sepsis
anle/brachial index 2#. # an$le pressure I0=G lo%er tan racial (A. 8=MK) H ostruction lo%er extremity oppler angiograpy
e*er
?rtostasis
CD# %ide mediastinum C: angiogram, -DA, : (K=6K2G sensit/speci') angiogram %it cateter is most accurate isenmenger@s leads to pulmonary 7:5 (lood *olume increases y 2=G in pregnancy) CD oximeter A" sputum culture
S:?F S-?!.5"R ASA (or clopidogrel) Cilostazol AC6. 'or F Statin (<< goal# 80== mg/d<) tigt glucose control in diaetics AAA I2M= cm H surgical repair AAA 82M= cm H ESS in 9 monts 6loc$er (laetalol) decreases pulse pressure nitroprusside surgical repair -itral stenosis Aortic stenosis A propylaxis
(T pulmonar' an&io&ram CD, oximeter, A"
CD# %ide mediastinum none repeat F manually
C: angiogram, -DA, : impro*es %it antacids position 'eet up/ead do%n .B 12=62== m< 5S olus o*er 0263= min
7N4 (r ratio 815-9041 lo% urine 5a; (81=) ig urine ?sm (I2==) CC# leu$ocytosis lood cultures F normalizes lying 'lat :ilt6tale test
Fremature Bentricular Contractions (FBCs)
incidental 'inding
!"# alternating normal LDS %it %ide, premature FBCs
no speci'ic treatment
3= eart loc$
recent -.
!"# radycardia, canon # wa"es
atropine 'or symptoms pacema$er 'or all pt
DB in'arct
recent -.
!"# in'erior %all -. ri&ht-sided E!4 >@ $TE,.
Bal*e Dupture Septal Dupture
recent -., ne% murmur rales/congestion recent -., ne% murmur increased ?1 sat in DB
Hx o) tobacco smoin& 7x o' 7:5, -, yperlipidemia pain %it exertion, spinal stenosis %orse %al$ing downhill, ut not upill
alloon pump in some pt alloon pump in some pt
Tx )irstB +x later M
