Cardiology Lecture Notes Week 11 PDF

**[Cardiology Notes Week 11]** **[Coronary Artery Disease (CAD) ]** - CAD = pathologic process impacting coronary arteries - AKA CHD - CHD/CAD = includes angina pectoris, MI, Silent MI, and CHD mortality resulting from CAD - CVD = Pathologic process (usually atherosclerosis) imp...

**[Cardiology Notes Week 11]** **[Coronary Artery Disease (CAD) ]** - CAD = pathologic process impacting coronary arteries - AKA CHD - CHD/CAD = includes angina pectoris, MI, Silent MI, and CHD mortality resulting from CAD - CVD = Pathologic process (usually atherosclerosis) impacting entire arterial circulation, not just coronary arteries - Includes stroke, TIA, angina, MI, claudication, and critical limb ischemia - Stable CAD -- referring to reversible supply/demand mismatch related to ischemia - Considered stable if asymptomatic - Patho - Process of atherosclerosis begins when endothelium is damaged by different pathways or diseases (htn, hld, trauma, toxins, genetics, etc) - Atherosclerotic plaque forms along inner vessel wall, hindering blood flow and dilation of coronary arteries - Artery becomes stiff, obstructed and incapable of vasodilation - Coronary insufficiency = ischemia - Inflammation of endothelium can have a vasoconstrictive effect - Risk Factors for CAD - Non Modifiable - Age - Gender - Family History - Modifiable - Smoking - Dyslipidemia - Statin therapy per ACC/AHA - Clinical atherosclerosis present - LDL 190 mg/dL or greater - DM in pt 40-75 yo - Estimated 10 yr atherosclerotic risk of 7.5% or higher - Diabetes - A1C goal \60 yo 150/90, \ 100.4 - Subacute course over days/weeks - Evidence suggestive of tamponade - Moderate ot large pericardial effusion - Immunosuppressed patients - Acute trauma - Failure to show clinical improvement following 7 days of NSAID/Colchicine therapy - Elevated troponin **[Myocarditis ]** - Inflammation of cardiac muscle - Classifications - Acute = new onset - Subacute = develop over several days - Chronic = lasts longer than 3 months - Etiology - Infectious or non infectious causes - Infectious = bacterial, fungal, parasitic or protozoal - Non-infectious = toxins (anthrax, cocaine), immunological, diabetes, IBS - Inflammatory cardiomyopathy is defined as myocarditis accompanied by cardiac dysfunction - Dx can be a challenge - Risk factors - Most frequent in young adults - Myocarditis of unknown origin is more common in children and neonates - Men generally have worse prognosis than women - Genetic association with dilated cardiomyopathy or myocarditis - Clinical presentation - Mild sympt = fever, CP, fatigue, palpitations - Severe sympt = cardiogenic shock, arrythmias, sudden death - Heart failure - Chest pain - Sudden cardiac death - Arrhythmias - Diagnostic testing for myocarditis - 12 lead EKG - Chest Xray - ECHO - CRP - CBC - Cardiac biomarkers - BNP - Diagnostic criteria for myocarditis - Elevated troponin - EKG/holter stress test abnormalities - Prior clinical suspected or dx myocarditis - Functional structural abnormalities on ECHO - Fever\>100.4 at presentation or during/preceding 30 days with or without associated symptoms - Exposure to toxic agents - Treatment of myocarditis - Heart failure therapy - Weight management, lipid lowering, reduction of cardiac demand with cardiac medications (ACEI, ARM, Diuretics, beta blockers) - May require anticoagulation - AVOID NSAIDS, strenuous exercise - Refer to cardiology for initial management **[Arrythmias ]** - Cardiac arrythmias -- related to abnormal electrical conduction system of heart - Atrial - Atrial fibrillation (afib) - Premature Atrial contractions (PAC) - Atrial tachycardia - Atrial Flutter (Aflutter) - Ventricular - Supraventricular tachycardia - Premature ventricular contractions (PVC) - Ventricular tachycardia - Heart block - Cardiac Electrical Pathway Review - SA node -- impulse generating note/pacemaker of heart - Contraction spreads through the atrial wall to the AV node - AV bundle passes from AV node and divides into the R/L bundle branches on either side of the intraventricular septum - R bundle travels inferiorly to the anterior wall of R ventricle through perkinjie fibers - L bundle travels inferior to the L side of the intraventricular septum to the L ventricle - Tachyarrhythmias (Fast rhythms) - Sinus Tachycardia - Afib - Supraventricular tachycardia (SVT - Clinical presentation - May be entirely asymptomatic or cause symptoms impacting ADL - If Symptomatic -- occurs due to - Ventricular rate - Extent of underlying heart disease - Ventricular function - Associated precipitating factors - Palpitations most common symptom - Dizziness/syncope - Sinus Tachycardia (ST) - HR \> 100 BPM - Caused by rapid impulse formation from SA Node - Normal physiologic response to exercise or conditions when catecholamine release is increased - Rarely will exceed 160 BPM - Onset and termination is gradual - Occasionally pt will have inappropriate sinus tachycardia where increased HR not in line with physiological demands - Treat underlying cause -- physiologic, psychologic, pharmacologic - Phys = exercise - Psych = stress - Pharm = stimulants - Atrial Fibrillation - Most common tachyarrhythmia in clinic - Triggers - Excess sympathetic stimulation - Atrial stretch caused by ventricular overload - Atrial infarction and pericarditis - Electrolyte abnormalities - Hypoxia - Underlying lung disease - Rule out secondary causes - PE, MI, COPD exacerbation, HF - Stroke risk evaluation - All pt with AFib should be evaluated for risk of stroke and need for anticoagulation therapy - CHA2DSVASC scoring tool - With score of \>2 oral anticoagulation is recommended - Supraventricular Tachycardia (SVT) - Rapid regular tachycardia commonly seen in young adults - Abrupt onset and offset - Narrow QRS duration (\200 msec w/ atrial impulses conducted - Second degree (intermittent blocked beats - Mobitz type I (Wenckebach) -- AV conduction time (PR interval) progressively lengthens and then beat is blocked - Mobitz II -- intermittently non conducted beats - Third degree -- complete heart block - No atrial impulses are conducted to the ventricles - AV block treatment - Asymptomatic with first or second degree (type 1) = no therapy - Consider medications that may be cause that may need dose adjust - Beta blockers, CCB, digoxin - Symptomatic pt with any heart block should be treated with atropine and pacing - Usually second degree type II and complete (third degree) - Considered emergent and needs transfer to higher level of care (ER) - Bundle Branch Blocks - Right - Associated conditions - Right ventricular hypertrophy - Ischemic heart disease - Pulmonary embolus - Atrial septal defect - Rheumatic heart disease - Myocarditis - Cardiomyopathy - Bragada syndrome - Genetic disorder in which electrical activity within the heart is abnormal - Left - New LBBB = suspicious for cardiac event - Associated conditions - Ischemia - MI - Aortic Stenosis - Dilated cardiomyopathy - Lyme disease **[Palpitations ]** - What are they - Unpleasant awareness of forceful, irregular beating of heart - Primary sympt for 16% of pt presenting to outpatient clinic - Need detailed description of sensation - Cardiac causes - Afib/Flutter - PVC/PAC - Cardiomyopathy - Long QT syndrome - Sick Sinus Syndrome - SVT - Valvular heart disease - Non-Cardiac Causes - Alcohol/drugs - Anemia - Anxiety/stress - Caffeine - Exercise - Fever - Medications - Nicotine - Thyroid Disease - Hypovolemia - Hypoglycemia - Pheochromocytoma - Patient history for palpitations - Underlying heart disease or previous rhythm disturbance and treatment - Family history - Evaluation of coronary risk factors - Use of alcohol, tobacco, caffeine - Triggers (standing, bending, laying in bed) - Syncope - Use of sympathomimetics - Commonly found over the counter in cold meds or diet aids - Prescription medication use - Theophylline or thyroid supplements - Use of street drugs - Known stimulants - Cocaine, amphetamines, synthetic cannabis, synthetic cathinone (bath salts) - Physical Exam - Initial exam - Eval BP, pulse, temp - Mental status - Diaphoresis? - Resp effort - Manifestation of anxiety - Orthostatic VS may be useful - Can exclude orthostatic hypotension as cause of syncope, dehydration or hypovolemia - Assessment of hydration status -- skin turgor, status of mucus membranes - Should include thorough evaluation of neck, chest, abdomen - Dx for palpitations - 12 lead EKG - Lab testing - CBC, CMP, Mg, TSH, Digoxin level, toxicology, cardiac enzymes, CK, CKMB) - Holter monitor 24-48 hours - Echo - CXR - Stress Testing **[Peripheral Vascular Disease ]** - PVD or peripheral arterial disease - PAD -- encompasses the various diseases that affect the noncardiac, non-intracranial arteries - Condition resulting from insufficient blood flow to the extremities (likely the lower) - Risk Groups - Age 70 or older - Age 50-69 years with hx of DM or smoking - Age 40-49 with hx of DM or one other risk factor for atherosclerosis - Exertional symptoms suggestive of claudication or ischemic rest/pain - Abnormal lower extremity pulses - Known CAD, carotid, renal artery disease - Complications associated with PVD - Number one cause of PVD is atherosclerosis - Smoking is most important risk factor - Vascular disease also common with DM - Less common causes - Vasculitis, dysplastic syndrome, degenerative conditions, thrombosis, thromboemboli - Clinical manifestations of PVD - Increased leg pain with ambulation (claudication) - Weak pulse - Pallor - Paresthesia - Coolness of lower extremity - Muscle atrophy - Diminished hair growth - Discolored, hardened toenails on affected extremity - Physical exam for PVD - Blood pressure - Palpation for pulse quality, amplitude - All pulses - Cervical, radial, brachial, popliteal, dorsalis pedis, posterior tibial - Use grading system 0= absent, 3= bounding - Abd aortic pulsation assessment - Auscultation for bruits - Full foot exam - Lower extremity skin assessment -- hair growth, ulcers, nail features - 6 P's of peripheral Vascular disease - Pain - Pallor - Pulselessness - Paresthesia - Paralysis - Poikilothermy (coolness) - Diagnostics - Doppler exam - ABI - Ankle brachial index - Used for dx of lower extremity PAD - Blood pressure measurements are obtained using systolic readings from the upper extremity (brachial) as well as those obtained at the ankle (dorsalis pedis and posterior tibial) - Results obtained by dividing the ankle systolic pressure by the brachial systolic pressure - 0.9 or greater = normal - 0.6-0.9 = moderate level of disease - 0.5 or less = severe disease - High ABI greater or equal to 1.4 also abnormal, may indicate possible calcified vessels that lack compressibility, associated with CV risk of the following characteristics - When to complete ABI - Pt with 1 or more of the following characteristics - Exertional leg symptoms - Non Healing wounds - Greater or equal to 65 yo - Greater or equal to 50 yo with hx of DM or smoking - CT Angio - Peripheral Vascular disease treatment - Smoking cessation - Exercise - Lifestyle modifications (DM management/weight management) - Statin therapy - Goal LDL \< 100 - \