AF, IE, Brugada, PAD, VTE Flashcards
ECG findings in AF
Irregularly irregular rhythm
no discernable P-Waves
CHADSVAS Scoring
CHF Hypertension Age >=75 DM Stroke Vascular Disease Age 65-75 Sex - Female
1 point each except for Stroke and Age >=75 given a score of 2
1pt - 1.3 2pt - 2.2 3pt - 3.2 4pt - 4.0 5pt - 6.7 6-9pt - >9
1pt - aspirin
>=2pt - anticoagulation
AF Treatment: Pharmacologic Cardioversion
Amiodarone - if with structural heart dse
Flecainide, Ibutilide, Propafenone - if without structural heart disease
AF Treatment: Rate Control
Beta Blockers, Verapamil, Diltiazem, Digoxin, Amiodarone
AF Treatment: Electrical Cardioversion
For recent onset AF (<48h) with hemodynamic instability
AF Treatment: Anticoagulation
Warfarin - Vit K Antagonism
Dabigatran - oral direct thrombin inh.
Rivaroxaban, Apixaban - oral direct factor Xa inh.
Most Important Step in diagnosing IE
Serial Blood Cultures
Risk Factors IE
Structural Heart Disease (RHD, VHD)
IV Drug Use
Prosthetic Heart Valves
Duke’s Criteria
02/13/05
2 major or 1 major+3minors or 5 minors
MAJOR
- sustained bacteremia
- endocardial involvement documented by echocardiogram or established new valvular regurgitation
MINOR
- Predisposing condition (abnormal valve or abnormal risk of bacteremia)
- Fever
- Vascular Phenomena (septic arterial or pulmonary emboli, mycotic aneurysms, intracranial hemorrhage, janeway lesions)
- Immune Phenomena (GN, osler nodes, roth spots, Rheumatoid Factor)
- positive blood culture not meeting major criteria
- positive echocardiogram not meeting major criteria
Etiology for
- Acute IE
- Subacute IE
Acute - s. aureus
Subacute - s. viridans
Best Empiric Therapy for IE
Vancomycin + Gentamycin
- will cover most common organisms such as s. aureus, MRSA, s. viridans
Most common cause of Sudden Cardiac Death
Brugada Syndrome
Ventricular Fibrillation that is ischemic in nature (secondary to ACS)
Take note of patient profile - young, male, Asian, with family history
Brugada Syndrome pathophysiology
loss of function mutation in SCN5A gene causing decrease in sodium channel that affect the Phase 0 and Phase 1 of the cardiac action potential
ECG findings in Brugada
pseudo RBBB and persistent ST segment elevation in V1-V2
Brugada Pattern Types
Type 1: Coved
Type 2: Saddle-back
Type 3: Saddle-back (?)
Diagnosis of Brugada
ECG - Type 1 Pattern in at least one right precordial lead plus one of the ff:
- documented vfib
- polymorphic VT
- family hx of sudden cardiac death age<45
- family hx of type 1 pattern on ECG
- inducivle vtach during EP study
- unexplained syncope
- nocturnal agonal respiration
MEDICATIONS TO AVOID IN BRUGADA
Class I anti-arrhythmic drugs (ajmaline, flecainide, ranolazine)
Management: Brugada
ICD implantation or Amiodarone 200mg once daily after initial loading dose of 400mg 2-3x daily for 1-2 weeks
65/M, heavy smoker, with pain on both calves after walking a few blocks, and resolves with rest. Femoral and dorsalis pedis pulses are diminished bilaterally. Skin on legs are cool to touch and appears shiny with very little hair growth. DIAGNOSIS?
PAD
Best initial test for PAD
Ankle Brachial Index (Duplex Ultrasonography) >1 normal <0.9 PAD <0.5 Severe Ischemia
Most accurate test for PAD
Arteriography
Leading cause of PAD
Atherosclerosis
Primary site of involvement in PAD
90% Femoral and Popliteal Arteries
Most common symptom of PAD
Intermittent Claudication
6Ps of Acute Limb Ischemia (PAD)
Pain Pallor Paresthesia Paralysis Pulselessness Poikilothermia
True of False. Calcium Channel Blockers can be used in management of PAD.
FALSE.
WHY?
Management: PAD
smoking cessation, BP control, exercise
Cilostazol - first line
Pentoxifylline - second line
Antiplatelets - Aspirin
ACEi, BB, Statins
First Line Therapy for PAD
Cilostazol
Virchow’s Triad
Endothelial Injury
Venous Stasis
Hypercoagulable state
Most common symptom of Pulmonary Embolism
Sudden onset unexplained breathlessness (dyspnea) in a patient with risk factors
Rule Out test for DVT
D-Dimer
- if normal, not DVT
Most common symptom in DVT
Leg cramps or charley horse
ECG findings in VTE
Sinus tachycardia
S1Q3T3
T-wave inversion V1-V4
Ultrasound finding in DVT
Loss of vein compressibility - primary criterion for DVT
Diagnostic Test of Choice for DVT
Chest CT with Contrast
Primary Therapy for DVT
Clot dissolution
Secondary therapy for DVT
Anticoagulation
IVC filter
Compression stockings
Only NOAC with a reversing agent
Dabigatran
reversing agent: Idarucimab
Warfarin reversing agent
Prothrombin complex
Protamine reverses effect of
Heparin, Enoxaparin, Dalteparin, Fondaparinux
CPR rate
100-120 compressions per minute
CPR depth
2-2.4 inches deep
When to stop CPR
Patient is revived
You are too tired to continue
Help arrives
Wide QRS
VTach, Vfib
Narrow QRS
ST, AF, SVT, MAT
Patient in pulseless VTach or VFib, what will you do?
SCREAM
Patient in VT with pulse but unstable. What will you do?
Sedate then cardiovert starting 100j
Patient in VT with pulse and stable. What will you do?
Manage medically.
Give Amiodarone 150mg slow IV push…
Patient in SVT, unstable. What will you do?
Sedate. Cardiovert starting 50j
Patient in SVT, stable. What will you do?
Vagal maneuver
Adenosine
CCB (Verapamil)