Difference between revisions of "Cardiology"
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=Pericardial Disease= | =Pericardial Disease= | ||
− | * [[Pericarditis]] | + | * [[Pericarditis]] improved when leaning forward, can show calcifications on CXR, pleuritic chest pain, possible history of MI |
− | * [[Cardiac Tamponade]] (Beck's triad) | + | * [[Cardiac Tamponade]] (Beck's triad), get TTE to look for pericardial effusion, urgent pericardiocentesis if present. |
=Valvular Heart Disease= | =Valvular Heart Disease= |
Revision as of 15:50, 29 December 2022
Electrocardiogram
- sinus or not sinus? (look at P waves in II and V1)
- rate is 300 / number of large boxes between R waves, or the number of complexes on a rhythm strip x 6
- QRS narrow or wide?
- axis, look for isoelectric lead
- PR interval
- QTc interval
- Signs of MI: T wave morphology? ST elevations/depressions? Pathologic Q waves? R wave progression? LBBB?
- Signs of Heart Failure: P wave morphology? LVH?
Cardiac Physical Exam
Arrhythmias
SA node -> AV node -> bundle of His -> left/right bundles -> Purkinje fibers
- Bradyarrhythmias and Conduction Abnormalities
- H&P: syncope, nausea, vomiting, blurred vision, dizziness
- DDx: sinus brady, SSS, 1st degree AV block, 2nd degree AV block (Mobitz 1), 2nd degree AV block (Mobitz 2), 3rd degree AV block
- Tx: correct electrolytes/hypothermia, atropine/dopamine, transcutaneous pacing, transvenous pacing, leadless pacing, permanent pacemaker
- Tachyarrhythmias
- H&P: palpitations, syncope
- DDx: Sinus tach, Multifocal Atrial Tachycardia, Afib, Aflutter, AVNRT, AVRT, WPW, Vtach, Vfib, Torsades de Pointes
- Tx: Stable vs. Unstable. Synchronized cardioversion vs DCCV. Vagal maneuvers (blowing into a 20 ml syringe), atropine, beta blockers, amiodarone, digoxin, diltiazem. Rate control superior to rhythm control most of the time. Calculate a CHA2DS2-VASc for Afib patients. Consider cardioablation vs. Watchman. Always get a TEE/cardioversion for chronic Afib. The most effective AC is warfarin. Best AC is usually DOAC because of once daily oral dosing. LMWH is an alternative if they can't have a DOAC. Aflutter can be 2:1, 3:1, or 4:1 with fixed rates of 150, 100, and 75 respectively. Do NOT shock sinus tach.
Congestive Heart Failure
- Systolic Dysfunction/HFrEF
- H&P: History of CAD, hypertension, valvular disease, dilated cardiomyopathy (EtOH, Chagas, Coxsackie B), or MI. Dyspnea, PND, orthopnea, cough, hemoptysis, fatigue; S3, displaced PMI, crackles, signs of right heart failure (S4, JVD, edema)
- Dx: LVEF < 40%, enlarged cardiomediastinal silhouette on CXR, elevated BNP
- Tx: ACEI/ARBs, ARNIs, β blockers, SGLT2 inhibitors, Spironolactone, and LVAD all have mortality benefit; Digoxin and diuretics don't have any mortality benefit but help with symptoms and decrease hospitalizations. For acute exacerbations use LMNOP (lasix, morphine, nitrates, oxygen, positioning).
- Non-systolic Dysfunction/HFpEF
- H&P: History of amyloidosis, sarcoidosis, hemochromatosis, or radiation leading to infiltrative or restrictive cardiomyopathy.
- Dx: LVEF > 40%
- Tx: SGLT2 inhibitors
Cardiomyopathy
- Dilated Cardiomyopathy
- Hypertrophic Cardiomyopathy
- Restrictive Cardiomyopathy
Coronary Artery Disease
- Angina Pectoris
- H&P: History of atherosclerosis, HCL, HLD, HTN, Diabetes.
- Dx: Chest pain that is brought on by exertion, relieved by rest or nitrates. Differential includes GERD, esophageal spasm, costochondritis, pericarditis, aortic dissection, PUD, pancreatitis, shingles
- Tx: sublingual nitroglycerin, GTN
- Prinzmetal Angina
- H&P: Similar to angina, but occurs mostly in young women and at rest, not with exertion, most often in the morning.
Acute Coronary Syndromes
- Unstable Angina/NSTEMI
- STEMI
Dyslipidemia
Group | Intervention |
---|---|
21+ w/ ASCVD or LDL > 190 | High dose statin |
40+ w/ LDL 70-189 w/o diabetes | Calculate 10-yr ASCVD risk:
|
40+ w/ LDL 70-189 w/ diabetes | Calculate 10-yr ASCVD risk:
|
Essential Hypertension
- Primary/Essential Hypertension (95% of cases)
- Dx: Rule out secondary causes, BP > 130/90 on three separate occasions.
- DDx: Secondary HTN (5% of cases; suspect if patient very young, very old, very high BP, or refractory to treatment)
- Endocrine: Conn syndrome (most common), Cushing's syndrome, Pheochromocytoma, Hyperthyroidism, Hyperparathyroidism
- Renal: bilateral RAS, PKD, CKD
- Other: Cocaine, OSA, OCPs, Coarctation
- Tx: For SBP 121-130, start with 8-12 weeks lifestyle modifications and reassess. If SBP 131-139 or DBP 81-89, risk stratify based on 10-yr ASCVD risk, if > 10%, start medication, if < 10%, can do trial of lifestyle modifications. When starting medication, start with 1 or 2 agents depending on severity, reassess efficacy every month and up the dose or add another agent as needed. ACEI/ARB (good for kidney protection, don't do both), Dihydropyridine CCB (better for HTN) > non-dihydropyridine CCB (better for rate control), Beta Blockers (cardiac selective (MAN BABES) > non-selective), Thiazide-Like Diuretics > Thiazide-Type Diuretics. For most patients, the combination of ACEI/ARB + CCB is the best, so start with one of these two classes so that the second can be added later for synergy. Special population considerations: CHF (avoid CCBs, use beta blockers, ACEI/ARBs, spironolactone), CKD (use ACEI/ARB), Pregnancy (hydralazine, labetalol, nicardipine, methyldopa), post-MI (use beta blockers + ACEI/ARB), Blacks (CCB + thiazide-like diuretic), Cocaine (don't give beta blockers due to unopposed alpha).
- Hypertensive Urgency BP > 180 + mild symptoms
- Hypertensive Emergency BP > 180 + ominous symptoms
Pericardial Disease
- Pericarditis improved when leaning forward, can show calcifications on CXR, pleuritic chest pain, possible history of MI
- Cardiac Tamponade (Beck's triad), get TTE to look for pericardial effusion, urgent pericardiocentesis if present.
Valvular Heart Disease
Murmur | Description | Location | Provocative Maneuvers |
---|---|---|---|
AR | Diastolic | Mitral | Example |
AS | Systolic | Aortic | Example |
MR | Systolic | Aortic | Example |
MS | Diastolic, Blowing | Mitral | Example |
MP | Systolic, Click | Aortic | Example |
TR | Systolic | Tricuspid | Example |
PDA | Continuous, Machine-like | ? | Example |
- Maneuvers increase afterload (hand grip, standing), preload (passive leg raise, lying down), or both (vagal).
- Endocarditis: Janeway lesions, Osler nodes, Splinter hemorrhages
Vascular Diseases
- Aortic Aneurism: Most are abdominal, most are below the renal arteries. Different types of repair (open vs endovascular), when to intervene (> 5.5 cm, rapidly enlarging, or causing organ damage), one time screening abdominal US recommended in ever smokers ages 65-75.
- Aortic Dissection: Stanford classification: type B (post left subclavian and descending aorta) is medically managed; type A (ascending aorta to the left subclavian or beyond) is a surgical emergency.
- Deep Venous Thrombosis: Virchow's triad, mostly occur in the legs, DVTs leading to PEs are usually in the femoral veins. Hofman's sign is neither sensitive or specific. Risk stratify based on Well's score, then get D-dimer (sensitive, not specific) if pre-test probability is low to rule out DVT. Can give therapeutic dose heparin if pre-test probability is high.
- Peripheral Arterial Disease: ABI
- Lymphedema
- In developed countries, is usually secondary to lymph node resection (e.g. radical mastectomy)
- Can also be congenital or secondary to infection (developing countries)
- Does not respond to diuretics
- Use compression stockings or arm bands
Syncope
- Ddx includes cardiac arrhythmias, vasovagal, seizures, orthostatic hypotension, SAH, vertigo, symptomatic anemia