Cardiology

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?

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
  • 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: > 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