PC2CARDIAC

Acute Myocardial Infarction (AMI)

• AMI is also known as ST elevation myocardial infarction (STEMI) and acute coronary syndrome (ACS)
• Classic presentation: Gradual onset of intense, steady chest discomfort/pain described as squeezing, tightness, crushing, or heavy pressure
• The feeling is comparable to an elephant sitting on the chest or like a band Chest pain Presentation:
• Pain/discomfort may radiate to the left side of the neck, jaw, and/or arms
• Pain/discomfort continues even at rest.
• Diaphoresis with cool, clammy skin can develop

Atypical Presentations of Myocardial Infarction

• Women and the elderly are more likely to show non-specific MI symptoms
• Symptoms include shortness of breath/dyspnea, weakness, nausea/vomiting
• Epigastric pain, fatigue, syncope, or back pain instead of anterior chest pain can also occur

Palpitations

• Palpitations are often arrhythmia-related and are the sensation of a rapid, fluttering, or pounding heartbeat
• They can be caused by a heart rhythm issue (arrhythmia), anxiety or caffeine
• Heart palpitations are subjective and can feel like the heart is beating faster/irregularly or skipping beats
• Palpitations can feel like fluttering, pounding, or racing in your chest

Arrhythmias

• Palpitations can indicate a more serious underlying condition such as arrhythmias
• Arrhythmias: are irregular heartbeats which can be too fast (tachycardia), too slow (bradycardia), or irregular in rhythm Arrhythmias that cause palpitations:
• Atrial fibrillation and ventricular tachycardia
• Premature ventricular contractions or supraventricular tachycardia also cause palpitations
• Atrial fibrillation (AFib), the most common type of arrhythmia, can cause a rapid and erratic heartbeat potentially leading to palpitations, shortness of breath, dizziness or fatigue

Other Palpitation Causes

• Anxiety, stress, panic attacks, and fear can trigger palpitations
• Excessive caffeine or alcohol consumption
• Certain medications (like those for asthma, high blood pressure, or heart problems) can cause palpitations
• Overactive thyroid, dehydration, and low blood sugar are medical conditions that cause palpitations
• Exercise, pregnancy, fever, and anemia can also trigger palpitations

When to Seek Medical Attention for Palpitations

• Seek medical attention if heart palpitations are frequent or accompanied by chest pain, shortness of breath, dizziness, or fainting
• A doctor can determine the cause and recommend the correct treatment
• Discuss new/worsening palpitations with your doctor, especially with any known heart condition

Pericarditis

• This is an inflammation of the pericardium, and can cause sharp stabbing chest pain, worsened with deep breaths or when lying down Causes:
• Viral infections (e.g., viral upper respiratory tract infections)
• Bacterial infections (e.g., tuberculosis)
• Autoimmune disorders (e.g., rheumatoid arthritis)
• Heart attack, cancer or trauma

Pericarditis Symptoms

• Symptoms include sharp, stabbing chest pain, shortness of breath, fever, cough, and fatigue
• Chest pain may radiate to the back, neck, or shoulder and worsens when taking deep breaths, lying down, or leaning forward

Diagnosing Pericarditis

• Physical exam includes listening for a "friction rub" sound when the inflamed pericardium rubs against the heart.
• Electrocardiogram (ECG) shows heart's electrical activity changes
• Chest X-rays may show fluid buildup around the heart

Pericarditis Treatment

• Treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and antibiotics if there is an infection
• Pericardial aspiration removes fluid from the pericardium if it builds up
• Surgery is rarely necessary, and is only in cases if the pericardium is severely inflamed

Pericarditis Complications and Prevention

• Cardiac tamponade is a life-threatening condition and is caused by fluid buildup in the pericardium and prevents the heart from pumping properly
• Chronic pericarditis involves recurring episodes of inflammation, and can lead to scarring and constrictive pericarditis Prevention includes:
• Avoiding contact with sick people
• Getting vaccinated against viral infections
• Managing underlying conditions that increase pericarditis risk (autoimmune disorders/heart disease)

Angina Pectoris (Unstable Angina)

• Unstable angina occurs when the heart muscle doesn't receive enough oxygen due to reduced blood flow and requires immediate attention as a medical emergency What it is:
• Unstable angina is a type of angina pectoris (chest pain) which is irregular or easily provoked, also classified as acute coronary syndrome Symptoms:
• Chest pain described as tightness, squeezing, crushing, burning, choking, or aching.
• Discomfort that occurs at rest which does not easily subside with medication
• Additional symptoms of shortness of breath, sweating, anxiety, dizziness, nausea, and vomiting may be present
• Pain may spread to the arm, jaw, or back Can be caused by:
• Coronary artery disease, atherosclerosis (plaque buildup), coronary artery spasms, plaque rupture or acute thrombosis

Unstable Angina Causes

• A reduction in blood flow to the heart causes unstable angina Immediate Medial Attention:
• Unstable angina can signify an impending heart attack, so medical attention to restore blood flow is required immediately Diagnosis:
• Diagnosis is based on symptoms, electrocardiography (ECG), and cardiac biomarker testing Treatment:
• Treatment includes medications (antiplatelets, anticoagulants, nitrates, statins, beta-blockers) and potentially coronary angiography (percutaneous intervention/coronary artery bypass surgery) Difference from Stable Angina:
• Stable angina often during exertion and is relieved by rest or medication Unstable Angina:
• Unstable angina can occur at rest or with minimal exertion and isn't relieved by rest or usual angina medications

Acute Rheumatic Fever (ARF)

• A serious inflammatory condition that can occur after an untreated streptococcal throat infection potentially leading to rheumatic heart disease if left untreated Cause:
• Autoimmune response triggered by a group A Streptococcus (Strep A) infection often manifested as pharyngitis (strep throat) Symptoms:
• Symptoms appear 1 to 5 weeks after the initial infection
• Symptoms include fever, joint pain or swelling (arthritis), chest pain, fatigue, and sometimes skin rashes or small bumps

ARF Complications and Treatment

• Carditis: Serious ARF complication involving heart tissue inflammation which can include the heart valves
• Diagnosis is based on clinical evaluation using the Jones Criteria as there's no single test for ARF Complications of ARF:
• Untreated ARF can lead to rheumatic heart disease which weakens the heart valves requiring surgeries Treatment:
• ARF is treated with medication and antibiotics to treat Strep A infection to prevent complications Prevention:
• Preventing ARF involves the diagnosis and early treatment of strep throat infections with antibiotics
• Individuals in communities with high rates of ARF or RHD are considered high-risk
• Those who already had ARF are at a higher risk of reoccurrence

Acute Endocarditis

Clinical Manifestations:

• Fever, chills, and malaise, associated with new onset of a new murmur are common
• Subungual hemorrhages (splinter hemorrhages) on the nail bed, Petechiae on the palate and Osler nodes can be observed
• Osler nodes are painful and violet-colored on the fingers/feet Janeway lesions also appear:
• Janeway lesions are nontender red spots found on the palms/soles
• Roth spots or retinal hemorrhages can be found on fundoscopic exam
• Patients require a referral to the emergency department

Antibiotic Prophylaxis

• Antibiotic prophylaxis is recommended for patients with a previous history of bacterial endocarditis
• Consider for individuals with a prosthetic heart valve, congenital heart disease and Cardiac transplant with abnormal valvular function Invasive procedures:
• It is given before dental procedures that traumatize the oral mucosa, gingiva, or the periapical area of the teeth
• Invasive procedures on the respiratory tract or existing infection present before cystoscopy

Standard Regimen

• No longer given due to MVP or with GI/GU
• One hour before the procedure, administer Amoxicillin 2 g PO x 1 dose to adults
• Antibiotic for children: 50 mg/kg PO x 1 dose
• Use Clindamycin, azithromycin, clarithromycin (Biaxin) or cephalexin (Keflex) if there is a penicillin allergy

Syncope

• Syncope is a temporary loss of consciousness accompanied by fainting and loss of muscle tone
• Take a detailed history including symptoms before and after the event Note:
• Position changes, prolonged standing, or exposure to a warm environment are associated with syncope What to Assess for:
• Recent food and water intake, lightheadedness, diaphoresis, nausea, and visual changes before the event
• Confusion/drowsiness after the event, length of loss of consciousness, seizure activity, height of fall, and any injuries Associated cardiac/neuro symptoms:
• Chest pain, diaphoresis, palpitations, headache, diplopia, aphasia, unilateral motor weakness, paresthesia
• Incontinence of bowel or bladder Medications:
• Recent use of vasodilators, beta-blockers, diuretics, or anticholinergics
• Assess past medical history: cardiac, neurologic, seizures, and family history; interview a family member/witness
• Physical exam should include vital signs, including orthostatic hypotension
• Do a cardiovascular exam checking for arrhythmia, murmurs, displaced PMI, bruits, and differences in BP in the arms including orthostatic pressures
• Do a neurologic exam for focal deficits

Syncope Causes

• Cardiac-related syncope is associated with a high rate of mortality
• Most commonly vasovagal or cardioneurogenic syncope: Common cardiac cause is due to arrhythmia
• Sick-sinus syndrome: heart's natural pacemaker doesn't create a heart rate appropriate for the body and causes arrhythmias
• Sick sinus syndrome has multiple manifestations on electrocardiogram; sinus bradycardia, sinus arrest, or sinoatrial block can be seen
• Alternating patterns of bradycardia and tachycardia can occur (bradycardia-tachycardia syndrome) Tachycardia:
• Tachycardia is a fast heart rate of more than 100 beats per minute Ventricular vs. Supraventricular tachycardia:
• Ventricular tachycardia will occur if the tachycardia begins in the ventricles
• Supraventricular tachycardia will occur if the tachycardia begins above the ventricles
• SVT is a broad term for tachyarrhythmias that originate above the ventricular electrical conduction system
• Classic Paroxysmal SVT has a narrow QRS complex/regular rhythm: Inverted P waves are sometimes seen after QRS complex and are known as retrograde p waves Heart blocks:
• Heart block is an abnormal heart rhythm where the heart beats too slowly This will result in electrical signals being partially/totally blocked between the upper chambers (atria) and lower chambers (ventricles) Bradycardia:
• Bradycardia is a slower than normal heart rate, and is commonly exhibited by adults at rest
• The heart usually beats between 60 and 100 times a minute, so less than 60 bpm is considered bradycardia

Arrhythmias

• Arrhythmias are irregular heartbeats and can encompass atrial fibrillation (AFib), ventricular tachycardia (V-tach), and ventricular fibrillation (V-fib) Can be classified as supraventricular or ventricular depending on whether it affects the upper or lower chambers Types of Arrhythmias:
• Atrial Fibrillation (AFib): The heart's upper chambers beat chaotically/rapidly potentially leading to blood clots/stroke
• Atrial Flutter: A rapid but more regular beating of the atria potentially leading to blood clots/stroke
• Supraventricular Tachycardia (SVT): Rapid heartbeat originating in the upper chambers often triggered by an extra pathway/electrical signal
• Ventricular Tachycardia (V-tach): Fast/regular heartbeat originating from ventricles and can be dangerous requiring immediate medical attention
• Ventricular Fibrillation (V-fib): Life-threatening arrhythmia where the ventricles quiver instead of pumping blood effectively can be triggered by a heart attack
• Bradycardia: A slow heart rate below 60 beats per minute
• Tachycardia: A fast heart rate, above 100 beats per minute

Arrhythmias Causes

• Conditions like coronary artery disease, heart failure, and cardiomyopathy
• Aging: The risk of arrhythmias increases with age
• Other medical conditions: high blood pressure, diabetes, and obesity
• Lifestyle factors: smoking, excessive alcohol use, and lack of exercise
• Genetic components

Arrhythmia Symptoms

• Palpitations, shortness of breath, and dizziness/lightheadedness
• Fainting, chest pain/discomfort, and fatigue Diagnosis and and Treatment:
• Electrocardiogram (ECG or EKG) measures the heart's electrical activity
• Holter monitor: A portable ECG which records heart rhythm for 24+ hours
• Electrophysiology study: This test maps the heart's electrical pathways
• Medications: Antiarrhythmic drugs that can help regulate heart rhythm
• Pacemaker: A device that helps regulate heart rhythm

Deep Vein Thrombosis and Superficial Thrombophlebitis:

Superficial Thrombophlebitis:

• This condition exhibits acute inflammation and clot formation of a superficial vein due to local trauma Risk Factors:
• Intravenous drug use, secondary bacterial infection, IV therapy, or trauma Assessment:
• Note isolated indurated cord-like vein, warmth, redness, and tenderness along the vein with no significant extremity swelling Treatment:
• Bed rest with elevated extremity, NSAIDs, and antibiotics is needed in the event of bacterial infection
• Sepsis requires a referral to ED Deep Vein Thrombosis (DVT): Thrombi, acute blood clot, forming inside the deep lower extremity or pelvic veins are potentially secondary to stasis DVT causes stasis:
• Stasis is caused by prolonged travel (plane or car), immobilization due to surgery, or prolonged bed rest
• Trauma to vessel walls, vascular wall injury, and venous incompetence
• Congestive heart failure due to chronic inflammatory state or lifestyle
• Inherited coagulation disorders, factor C deficiency/Leiden External factors:
• Oral contraceptive use, pregnancy, long bone fractures, trauma, recent surgery, malignancy

DVT Risk Factors and Prevention

Risk Factors:

• Obesity, orthopedic surgery, immobility, trauma, oral contraceptive use
• Malignancy, coagulation deficits, venous catheters
• High altitude elevations, polycythemia vera, rheumatoid disease, or lupus Prevention:
• Limit period of immobility: prophylactic anticoagulation for associated risk factors
• Avoidance of estrogen-containing oral contraceptives or use low dose
• Use postsurgical mechanical leg compression

Classic Presentation

• Gradual onset of swelling in the lower leg if someone has recently traveled for more than 3 hours Symptoms:
• Complains of a painful and swollen lower extremity that is red and warm- Assessment:
• Examine for a positive Homan's sign: Lower leg pain on dorsiflexion of the foot
• Do an ultrasound of extremity during the assessment

DVT Treatment

Treatment:

• Hospital admission for heparin IV then warfarin (Coumadin) PO can be administered
• CBC, platelets, PT/PTT/INR to monitor clotting time, D-dimer, chest x-ray, and EKG
• Treat single-episode DVT for 3 months, but longer for recurrent episodes

Aortic Dissection

• Involves a dissecting Abdominal Aortic Aneurysm (AAA)
• Patient will complain of severe, sharp, and excruciating pain located in the abdomen, flank, and/or back can be described as gnawing, deep, and tearing pain
• Patient can also have a distended/pulsating abdomen as well as abnormal vital signs of hypotension Risk factors:
• Aortic Dissection is higher in smokers and those with hypertension

Acute Coronary Syndrome (ACS)

• ACS is a medical emergency and is characterized by a sudden reduction in blood flow to the heart
• This encompasses conditions like unstable angina and heart attack requiring immediate medical attention Definition:
• ACS refers to a group of conditions that involve a sudden decrease in blood flow to the heart muscle, potentially leading to damage or even death of heart tissue Underlying Cause:
• Rupture/erosion of plaque within the coronary arteries leading to blood clot (thrombus) which then blocks blood flow Types of ACS:
• Unstable Angina: Chest pain that occurs at rest or with minimal exertion, & is more severe and longer-lasting than stable angina
• Heart Attack (Myocardial Infarction): Occurs when a significant portion of heart muscle is deprived of oxygen for a prolonged period, leading to tissue damage or death
• ST-elevation myocardial infarction (STEMI): ECG shows ST-segment elevation, indicating more severe/potentially wider area of heart damage
• Non-ST-elevation myocardial infarction (NSTEMI): ECG doesn't have ST-segment elevation, but there are still heart damage markers

ACS as a Medical Emergency

Why is it a medical emergency?

• Sudden blockage of blood flow can lead to heart failure, abnormal heart rhythms, or death Symptoms of ACS:
• Chest pain/pressure: often described as crushing/squeezing and may radiate to the left arm, jaw, or back-
• Shortness of breath, excessive sweating, nausea/vomiting, and dizziness/lightheadedness may be present
• Pain/discomfort in the back, neck, jaw, or upper belly can be signs of ACS (especially with other symptoms)
• Note that some patients may not have chest pain, especially with those who have diabetes or are elderly

ACS Diagnosis and Treatment

Diagnosis:

• ACS is diagnosed based on symptoms, physical exam/ECG, and blood tests such as troponin levels Treatment:
• Aims to restore blood flow to heart muscle ASAP
• Medications can be used to relieve pain, prevent clots, and improve heart function
• Procedures such as angioplasty (opening blocked arteries with balloon/stent) or coronary artery bypass surgery (CABG) can be used
• ACS is a medical emergency, so prompt treatment can significantly improve outcomes Prevention:
• Manage risk factors by controlling high blood pressure, high cholesterol, treating diabetes, and stopping smoking
• Healthy lifestyle involves a heart-healthy diet, getting regular physical, and maintaining a healthy weight

Congestive Heart Failure (CHF) Exacerbation

• CHF exacerbation is an intensification of symptoms triggered by factors like high salt intake or infections marked by the onset of shortness of breath, swelling, and fatigue What is CHF Exacerbation?
• CHF/heart failure involves the heart not pumping blood effectively leading to fluid buildup in the lungs/legs
• Exacerbation describes a period where symptoms get worse indicating a temporary worsening of the underlying heart condition Causes of Exacerbation:
• Medication non-compliance of stopping/reducing prescribed for heart failure.
• Excessive salt/water intake leading to fluid retention & worsening fluid overload.
• Infections such as pneumonia/other respiratory illnesses
• Heart rhythm problems (arrhythmia): Irregular heartbeats can strain the heart
• Coronary artery disease: Reduced blood flow to the heart muscle
• Heart valve disease: Valves not working can cause blood to back up the heart
• Cardiomyopathy: A disease of the heart muscle
• Advanced kidney disease: Kidneys help aid in fluid balance

CHF Exacerbation Treatment

Symptoms:

• Shortness of breath that worsens when lying down or when exerting oneself
• Swelling in the legs/ankles/feet/abdomen along with fatigue and weakness Other symptoms:
• Rapid or irregular heartbeat, a cough that doesn't go away/brings up white or pink mucus with blood spots, rapid weight gain due to fluid retention
• Chest pain/pressure/discomfort, feeling dizzy/weak, fainting/feeling like you might faint, and mental confusion
• Treatment will involve relieving symptoms, diuretics to help body eliminate excess fluid, and oxygen therapy in order to improve circulation/breathing
• Medication Adjustments: Doctors can modify the treatment plan from its original state Addressing Underlying Causes:
• Treating infections if there's a lung infection
• Managing other heart-related conditions if exacerbation is related to another heart problem
• Seek immediate medical help with symptoms; chest pain, severe shortness of breath, or loss of consciousness Prevention:
• Monitor weight/fluid intake, adhere to low-salt intake, stay active
• Following doctor's recommendations for treatment; prescription medications and follow-up appointments

Pulmonary Embolism (PE)

• It is a same manifestation and treatment as DVT, yet requires emergent referral
• The Mortality rate exceeds 20% Classic presentation:
• Abrupt onset of chest pain or sudden onset of dyspnea
• Other symptoms include dizziness, syncope, a cough, and hemoptysis Assessment:
• Check for tachycardia or tachypnea, accentuated S2, pleural friction rub, rales, or pleuritic chest pain
• Pulmonary CT is highly sensitive, so get a pulmonary CT done right away
• Note any ECG which causes right heart strain Treatment:
• Administer therapeutic Coumadin (Warfarin)
• Maintenance therapy is started in the hospital and overlaps with heparin/Lovenox
• Adjust the dose to maintain an INR of 2 to 3
• This condition is teratogenic and should not be used in pregnant patients, but is safe while breastfeeding.
• Vitamin K is the anecdote to reversing the Coumadin effect in case of a reaction

Cardiac Tamponade

• Cardiac tamponade occurs when fluid accumulates in the pericardium compressing the heart preventing effective pumping Causes:
• Pericarditis (inflammation of the pericardium)
• Trauma (e.g., car accidents, stab wounds)
• Heart surgery, cancer, and certain medications such as vasodilators Symptoms:
• Chest pain/discomfort, Shortness of breath and dizziness/lightheadedness
• Rapid heart rate, low blood pressure, along with swelling in the neck and arms Diagnosis:
• Physical exam
• Perform an Electrocardiogram (ECG) and Echocardiogram (if the patient has the room and stability for it) Treatment:
• Remove the fluid from the pericardium using a needle
• Perform a Pericardiectomy by removing part of the pericardium Complications:
• Heart failure, shock, and death can occur Prevention:
• Treat underlying conditions that can cause cardiac tamponade
• Avoid certain medications that may increase the risk of tamponade
• Conduct heart surgery with the utmost caution

Hypertensive Crisis

• This is a severe and life-threatening condition characterized by extreme blood pressure It is caused by the blood rising rapidly and significantly above normal levels Definition:
• Systolic blood pressure should be 180 mmHg or higher Diastolic blood pressure:
• Diastolic blood pressure should be 120 mmHg or higher Causes:
• Untreated/poorly controlled hypertension
• Sudden withdrawal from blood pressure medications, Cocaine/stimulant use, or Aortic dissection/Pheochromocytoma Symptoms:
• Severe headache, chest pain, and shortness of breath Also:
• Nausea and vomiting, confusion and seizures, nosebleeds, and stroke-like symptoms (numbness, weakness, difficulty speaking) Complications:
• Stroke, heart attack, kidney failure, and aortic dissection Treatment:
• Hypertensive crisis is an emergency so call 911 May include:
• Oxygen therapy, along with IV medications and surgery

Kawasaki Disease

• Also known as Kawasaki Syndrome and Mucocutaneous Lymph Node Syndrome
• The average age of those affected is 2 years old
• Leading cause of acquired heart disease in children: Acute immune-mediated disease characterized by vasculitis and coronary artery aneurysms
• Note that boys are 1.5 times more likely than girls to get KD, but only 75% are younger than 5.
• Diagnosis: Runs a fever of 101°F – 104°F for five+ days; can be diagnosed and treated with aspirin: Moderate does is used in the acute phase
• Additional symptoms include a rash over the torso, especially in the groin area -Light peeling of the skin on the fingers and toes occurs in the second and third weeks of the illness and an extreme case of bloodshot eyes
• Swollen lymph glands in the neck.
• “Strawberry” tongue: tongue is bumpy, red, enlarged taste buds
• Moderate doses of aspirin are used in the acute phase to help control fever; afterwards it's given in lower doses to prevent blood clots
• Check the child's coronary dimensions for an adequate amount of time- between 4 to 6 weeks Multisystem Inflammatory Syndrome:
• A new syndrome named and coined from the wake of the COVID-19 pandemic
• Symptoms include fever, abdominal pain, and some features of Kawasaki: red eyes, red tongue, swollen hands/feet, and a skin rash
• Watch for aortic dissection, coronary aneurysms, blood clots, heart valve problems, myocarditis, and dysrhythmias Care must be followed up:
• Children with this syndrome must see a pediatric cardiologist for many years to come out if not dealt with in a manner that is not adequate