Electrocardiogram
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, Afib, Aflutter, Vtach, Vfib, Vflutter, AVNRT, AVRT, WPW
- Tx: Stable vs. Unstable. Synchronized cardioversion vs DCCV. Vagal maneuvers, atropine, beta blockers, amiodarone, digoxin, diltiazem. Rate control superior to rhythm control most of the time. Calculate a CHAD2S2VASc 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
- Non-systolic Dysfunction/HFpEF
Cardiomyopathy
- Dilated Cardiomyopathy
- Hypertrophic Cardiomyopathy
- Restrictive Cardiomyopathy
Coronary Artery Disease
- Angina Pectoris
- Prinzmetal Angina
- Carotid Artery Stenosis
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:
- > 7.5% give high dose statin
- 5-7.5% give moderate dose statin
- < 5% no statin
|
| 40+ w/ LDL 70-189 w/ diabetes |
Calculate 10-yr ASCVD risk:
- > 7.5% give high dose statin
- < 7.5% give moderate dose statin
|
Hypertension
- Primary/Essential Hypertension
- Dx: Rule out secondary causes, BP > 130/90 on two separate occasions.
- DDx: Secondary HTN--RAS, Hypo/Hyper(para)thyroidism, Conn syndrome, Cushing's syndrome, Pheochromocytoma
- Tx: Can start with 1 or 2 agents depending on severity. First line: ACEI/ARB (good for kidney protection), (Non)Dihydropyridine CCB, Beta Blockers (cardiac selective, non-selective), Thiazide/Non-Thiazide Type Diuretics (second line)
- Hypertensive Urgency BP > 180
- Hypertensive Emergency BP > 180 + symptoms
Pericardial Disease
- Pericarditis
- Cardiac Tamponade (Beck's triad)
Valvular Heart Disease
Cardiac Murmur Descriptions and Maneuvers
| 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: Different types of repair (open vs endovascular), when to intervene (> 5.5 cm or rapidly enlarging), one time screening abd US in ever smokers at age 50
- Aortic Dissection: Stanford classification: type B (post arch and descending aorta) is medically managed; type A (ascending or arch) is surgical emergency.
- Deep Venous Thrombosis: Virchow's triad
- Peripheral Arterial Disease: ABI
- Lymphedema
Syncope
- Ddx includes cardiac arrhythmias, vasovagal, seizures, orthostatic hypotension, vertigo, symptomatic anemia