-
Coronary artery disease
RFs
DM (worst), HLipid, HTN, Smoking, Age (M>45, W>55), FHx of premature CAD/MI, vHDL
-
Stable angina pectoris
Prognosis
- LV fn (EF) < 50%
- L main coronary artery (2/3 of heart)
- two or three-vessel CAD
-
Stress echocardiography
What it accomplishes
- Detects ischemia via wall motion abnormalities
- Assesses LV size/fn
- Dx valvular dz
- ID CAD in presence of preexisting abnormalities
- If (+), do cardiac catheterization
-
Stable angina pectoris
Pain does NOT change with...
- Breathing
- Body position
- No chest wall tenderness
-
Ways to rescue areas of reversible ischemia
-
PCI
- percutaneous coronary intervention
- consists of:
- coronary angioplasty via balloon
- stenting
- equally effective as CABG
- Higher freq of revasc with stent
-
Pharmacologic stress test options
- IV adenosine + dipyridamole
- generalized coronary vasodilation
- Dobutamine
- ^myocard O2 demand via ^HR, BP, contractil
- + Thallium - decreased uptake during exercise
-
Cardiac catheterization
- Info on hemodyn, pressure, CO, O2 sat, etc.
- Indic: (+) stress test; nondiagn; angina cont;
- severe sx; valv dz; surg?
-
Coronary arteriography (angiography)
- Most accurate ID presence/severity of CAD
- Std test for delineating coronary anatomy
- Determine if revascularization needed
- Stenosis >70% can produce angina
-
Stable Angina - Medical TXs
- aspirin & risk factor mod: (vMorb, MI)
- beta blockers: (atenolol, metoprolol)
- nitrates: nitrates
- CCBs: secondary
- ACEi & diuretics: if CHF
- revascularization: ^risk - PCI, CABG
-
Stable angina - TX guidelines
- All: aspirin & risk factor modifications
- Mild: (nl EF, mild ang, 1vsl) nitr, BB, ?CCB
- Mod: (nl EF, mod ang, 2vsl) ?+angiography
- Sev: (v EF, sev ang, 3 or L) CABG
-
CAD - TX
- hospital admission w/ continuous cardiac mon
- IV access, supplemental O2 (if hypoxic)
- Pain cntl w/ nitrates and morphine
- aspirin, clopidigrel, BB, LMWH, nitrates
- IIb/IIIa inhib as adjuncts (PTCA/stenting)
- Cardiac catheterization/revascularization
- Post acute: ASA/~platelet, BB, nitrates; RFs
-
Acute MI - Dx
- ECG: ^T, ST/->Q->~T, ST
- Card Enz:
- Marker / ^
- CK 6-12h 18hr 2-3d
- CK-MB 3- 6h 12-24h 12-48h
- CTn-I 3-12h 12-24h 7-10d
- CTn-T 3-12h 12-24h 10-14d
- STEMI^; NSTEMI ~ST/
-
Acute MI - tx
- Init: ASA, BB, ~thromb<12h(gIIb/IIIa,UFH), P;
- Post: ASA, BB, statins, ACEI
- Other: nitrates, O2
- Revasc: PCI (<90m); thromb (<24h); CABG
-
Variant or Prinzmetal's angina
- def: transient coronary vasospasms
- occ: episodes at rest, at night, v-dysrhythm
- hallmk: transient ST/ (angiogr IV ergonovine)
- tx: CCB ?LA NO3; NOT BBs!, RF mod
-
EKG lead associations
- Ant: V1-4
- Post: V1-2 (inv)
- Lat: I, aVL, V5, V6
- Inf: II, III, aVF
-
Acute pericarditis - causes
- Idiopathic: probably post-viral
- Infectious: V (cox, echo, adeno, EBV, flu, HIV, HAV, HBV), B (TB), F (toxo)
- Acute MI: 1st 24 hrs
- Uremia: -
- Collagen vascular dzs: SLE, sclero, RA, sarc
- Neoplasm: Hodgkin lymphoma, breast/lung CAs
- Drug-induced lupus: procainamide, hydralazine
- Post-MI: Dressler's syndr (weeks-months)
- Post surg: postpericardiotomy syndrome
- Misc: Amyloidosis, Radiation, Trauma
-
Acute pericarditis - prognosis
- Most pts recover w/in 1-3 weeks
- Complicat'ns: pericard'l effus'n, card tampon'de
-
Acute pericarditis - Sx
- CP: severe, pleuritic, w/breathing; retrosternal & L precordial rad to trapezius ridge & neck; positional ^supine, cough, swallow, deep inspir; vSitting up, leaning forward. ~P rheumatoid
- F & leukocytosis: .
- Pericardial friction rub: (specific) scratching, hi-pitched sound (a-systole, v-systole loudest, early diastole) heard best during expiration sitting up, comes and goes over several hours
-
Acute pericarditis - Dx
- ECG shows 4 changes in sequence:
- 1: Diffuse ST elevation & PR depression
- 2: ST segment->nl (1 week)
- 3: ? T wave inverts
- 4: T wave returns to nl
- Echo if PC w/ effusion suspected (often nl)
-
Acute pericarditis - Tx
- Most cases self-limited (2-6 weeks)
- Tx underlying cause if known
- NSAIDs mainstay of tx; colchicine
-
Constrictive pericarditis - etiology
- Fibrous scarring of pericardium->rigidity/thick w/ obliteration of pericardial cavity
- Fibrotic, rigid pericardium diastolic filling
- Ventricular filling unimpeded in early diastole
- Ventricular filling abruptly stops at limit
- MC idiopathic; uremic, rad, TB, chron PC effus, tumor, connective tissue d/o, prior surg
-
Constrictive pericarditis - S/Sx
- Appears ill;
- Presents: vol overload sxs or CO
- JVD, Kussmaul's sign (JVD ~ w/inspir), pericardial knock (early diast fill sound after S2), ascites, dependent (pedal) edema, tender hepatomegaly, x pulsus paradoxus
-
Constrictive pericarditis - Dx
- ECG: (non-specif) QRS v, T flat/inv, L atr abnl, aFib (adv, <.5)
- Echo: /periph thickness (.5), sharp halt ventr fill, atrial enlargement
- CT/MRI: ? pericardial thickening/calcifications
- CXR: clear lungs, nl-slightly /<3, PC calcif'n
- Cath: /&= diastolic all chambers; vent tracing show rapid y descent (square root sign)
-
Constrictive pericarditis - Tx
- Underlying condition
- Diuretics to alleviate fluid overload sx
- Monitor/treat for any coagulopathy
- Surg strip/remove both layers of constricting PC
-
Pericardial effusion
- defn: Pericarditis->exudate (//->tamponade)
- etiol: CHF, cirrhosis, nephrotic syndr
- s/sx: muffled <3 sounds, soft PMI, dull lung base, ?pericardial friction rub
- dx: echo, CXR (>250ml, watter bottle), ECG (QRS v, T flat), CT/MRI(?), fluid analysis
- tx: depends on hemodynamic stability; pericardiocentesis iff tamponade; small - 1-2wk
-
Cardiac tamponade
- Def: Pericardial effusion that mechanically impairs diastolic filling of the heart; elevation & equalization intra-cardiac/pericardial pressures
- Rate: of accumulation (fast 200mL, slow 2L)
- Cause: penetr trauma, iatrog, pericard, post-MI w/ free wall rupture
- S/sx: /JVP, ><pulse press, pulsus paradoxus (weak inhale/strong exhale), muffled HS, cardiogenic shock (tachyp, tachyc, HoTN)
- Dx: echo, CXR, ?ECG, cath (pressure eq)
- Tx: Non-hemorrh - stable--monitor, RF-dialysis; unstable--pericardiocentesis, fluid challenge. Hemorrh - emergent surgery
-
Endocarditis - types
- Acute
- Subacute
- Native valve
- Prosthetic valve
- IV Drug
-
Acute endocarditis - cause & prognosis
- MC cause: Staph aureus on normal heart valve
- Prognosis: Death in < 6 weeks untreated
-
Subacute endocarditis - cause & prognosis
- Cause: Strep viridans, Enterococcus on damaged heart valve
- >6 weeks for death
-
Endocarditis in IV drug users
- R-sided
- Staph aureus, enterococci, strep
- Candida, Pseudomonas
-
Endocarditis diagnosis - imaging
TEE > transthoracic echocardiography
-
Endocarditis - dx criteria
- Duke Criteria (2 maj, 1 maj + 3 min, 5 min)
- Major criteria: sustained bacteremia, Endocardial involvement
- Minor criteria: predisposing cond, F>38C, vascular phenom, immune phenom, (+) blood culture, (+) echo
-
Endocarditis - tx
- Parenteral abx 4-6 weeks
- -cx but ^suspicion: Pen/Vanc + aminogycoside
- Empiric
- -native valve: PenG/Amp + Nafc/Oxac + Gent
- -IV drug user: Vanc
- -Prosthetic vlv: Vanc + Gent + Rifamp
-
Cardiomyopathy types
- Dilated MC: insult causes dysfn of L ventricle contractility
- Hypertrophic: inherit, diastolic dysfn; stiff, hypertroph ventricle
- Restrictive (rare): infiltr of myocard->V ventricular compliance
-
Dilated cardiomyopathy - causes
- 50% idioCADtoxic (EtOH, doxyrub)
- Metabol (thiam/Se defic, HoPO4, uremia)
- infect (viral, Chagas, Lyme, HIV)
- Thy dz (Ho/H)
- PeripartumColagen vasc dz (SLE, scleroderma)
- ->tachycatechol induced (pheo, cocaine)
- familial/genetic
-
Dilated cardiomyopathy - clinical
- s/sx: L&R CHF
- Ht sounds: S3, S4, mitral/tricusp insuff murmurs
- Cardiomegaly
- Arrythmia: coexistingSudden death
- Asympt: until HF
-
Cardiomyopathy - dx by type
- Dilated: ECG, CXR, Echo (CHF); fam hx DCM
- Hypertrophic: Echo; clinical/fam hx
- Restrictive: Echo (thick myocard, ^R/L atrium), ECG (vVolt, conduct abnl, arrhyth/afib, endomyocardial bx (amyloid apple)
-
Cardiomyopathy - tx by type
- Dil: ~CHF digox,diur,vasodil,xplant;ICD; anticoag
- HTroph: x exer; BB(CCB), diur, myomectomy
- Restr: tx disorder
|
|
