Cardiac Flashcards
Most common complications of endocarditis
CHF
CNS disorder
Peripheral embolization
Cutaneous embolic phenomena of endocarditis
- Splinter or subungual hemorrhages of finger/toenails
- Osler nodes - (small, tender subcutaneous nodules on the pads of the fingers or toes)
- Janeway lesions - (small hemorrhagic painless plaques on the palms or soles)
Admitting for endocarditis
- Febrile injection drug users
2. Admit all patients with a cardiac prosthetic valve and fever (or persistent malaise, vasculitis, or new murmur)
Abx for endocarditis
- Uncomplicated hx - Ceftriaxone, Oxcacillin, or Vancomycin PLUS Gentamicin or Tobramycin
- Injection drug users: Nafcillin + Gentamicin + Vancomycin
- Prosthetic heart valve: Rifampin + Gentamicin + Vancomycin
Iatrogenic causes of acute heart failure
Recent addition of negative inotropic drugs (e.g., calcium channel blocker, β-blocker)
Initiation of salt-retaining drugs (e.g., NSAID, steroids, thiazolidinediones- glitazones)
Inappropriate therapy reduction
New antiarrhythmic agents
Acute heart failure with hypotension, tx:
Ionotropic therapy:
norepinephrine, dopamine, or dobutamine
Hypertensive acute heart failure, tx:
- O2
- Nitroglycerin (venous and arterial dilator). Sublingual then IV if needed
- IV loops diuretics - Furosemide of Bumetanide for volume overload
- Admite or discharge after obs
Diuretics without vasodilators in acute hypertensive HF?
NO - vasodilators first
Diuretics (furosemide most commonly used) administered alone without vasodilators for hypertensive heart failure may increase mortality44 and worsen renal dysfunction.
successful management of blood pressure and cardiac filling pressure creates marked improvement in respiratory status long before any diuresis.
Contraindications to using vasodilators in acute HF
Signs of hypoperfusion or hypotension
Flow-limiting, preload-dependent states such as right ventricular infarction, aortic stenosis, hypertrophic obstructive cardiomyopathy, or volume depletion increase the risk of vasodilator-associated hypotension
Flow-limiting, preload-dependent states
Right ventricular infarction
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Volume depletion
Normotensive HF tx:
Diuresis first
Loop diuretic electrolyte complications
Hypokalemia - keep an eye out for increasing QT interval
also hypocalcemia, hypomagnesemia
Drugs to avoid in Heart Failure
Calcium Channel Blockers (verapamil, diltiazem, amlodipine,
NSAIDs
High-risk physiologic markers in ED patients with acute heart failure associated with morbidity and mortality
Renal dysfunction
Low BP
Low sodium
Elevated BNP or Troponin
Diagnosis of STEMI vs NSTEMI
STEMI = ECG changes in presence of suggestive sx
NSTEMI = depends on cardiac biomarkers, but may include ECG changes
Inferior wall AMIs on ECG
ST-segment elevations in II, III, and aVF
get V4 on right side to check for ST elevation there too!
ST-segment elevations in II, III, and aVF + V4 (right side)
Suggestive of right ventricular infarction = NO NITRO
Reciprocal ST-segment changes—those in leads away from or opposite the elevation area—
– are from subendocardial ischemia and denote a larger area of injury risk, an increased severity of underlying CAD, more severe pump failure, a higher likelihood of cardiovascular complications, and increased mortality.
In general, the more elevated the ST segments and the more ST segments that are elevated, the more extensive is the injury.
In the setting of an inferior wall AMI (II, III, aVF), ST-segment elevation in at least one lateral lead (V5, V6, or aVL) with an isoelectric or elevated ST segment in lead I is strongly suggestive of lesion i which artery
Left circumflex
The presence of ST-segment elevation in lead III greater than that in lead II predicts
a right coronary artery occlusion
ST seg elevation in lead III greater than lead II, accompanied by ST-segment elevation in V1 or a V4R, it predicts
a proximal right coronary artery lesion with accompanying right ventricular infarction
pattern of abnormal T waves in the precordial leads V2and V3 associated with critical stenosis of the left anterior descending artery
Wellen’s sign (deeply inverted T waves or biphasic)
V2, V3 especially
Present in 18% of unstable angina
STEMI/NSTEMI/unstable angina initial tx:
- Aspirin
- Clopidogrel, Ticagrelor, Prasugrel
- Nitroglycerine
- Beta blockers
- Antithrombin > Enoxaparin, unfract heparin, or fondaparinux
Antithrombin options for STEMI/NSTEMI tx
Enoxaparin (Lovenox, LMWH)
Unfractionated heparin
Fondaparinux
all bind antithrombin III, inhibit Xa and thrombin
Anti-platelet options for STEMI/NSTEMI/unstabe angina
Aspirin +
Clopidogrel
Ticagrelor
Prasugrel
Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if
time to treatment is <6 to 12 hours from symptom onset and the ECG has at least 1 mm of ST-segment elevation in two or more contiguous leads
Evidence of bundle branch block on EKG
- Widened QRS (> 120ms)
Normal V1, V6
V1, little positive then big negative QRS
V6, little negative then big positive QRS
LBBB V1, V6
V1, one big negative, “W”
V6, notched big positive, “M”
RBBB V1, V6
V1 “terminal R”/peaked R wave, complex looks “M’
V6, “slurred S”, looks kinda “W’
R BBB, L BBB pneumonic
WLM MRW
WILLIAM MARROW
200-300 BPM
doesnt last long
can be SOB, dizzy, syncope, palpitations
Supraventricular tachycardia (AVRT, AVNRT) Ex. Wolf Parkinson White syndrome
Supraventricular tachycardia on EKG
Buried p waves
Common causes fo syncope
- Vasovagal
- Cardiac
- Orthostatic
- Medication related
- Neurologic
- Unknown
Classic sypmtom constellation in aortic stenosis
Chest Pain
Dyspnea on exertion
Syncope
stiff noncompliant left ventricle, diastolic dysfunction, and outflow tract obstruction
hypertrophic cardiomyopathy
Hypomagnesemia on EKG
torsades de pointes
1st degree AV block
PR interval > 200 ms
2 types of 2nd degree AV block
Mobitz 1 (Wenchebach) : PR interval going, going, QRS dropped
Mobitz 2 - PR interval > 200ms, constant, doesn’t get longer - then QRS dropped
Longer longer longer drop
that is a wenchebach
Mobitz 1, 2nd degree AV block
PR interval is > 200ms, gets longer, longer, then QRS dropped
3rd degree AV block
Atria and ventricle conduct independently
Constant P-P intervals
Constant Q-Q intervals
Symptoms of A blocks
bradycardia
dizziness
syncope
patient is unstable, has a bradycardic dysrhythmia - most likely
3rd degree AV block
followed ( much less likely) by 2nd degree
Indications for treating bradydysrhythmias
HR < 50 bpm + hypotension/perfusion
Pharm tx for brady-dysrhythmia due to sinus and AV nodal diseas
Atropine
Effective in terminating narrow QRS complex reentrant tachydysrhythmias involving the AV node
Adenosine
Effective in terminating narrow QRS complex reentrant tachydysrhythmias involving the AV node
AND reducing ventricular rate in atrial fibrillation or flutter
Adenosine Verapamil Diltiazem Metropolol Propanolol
Tachycardias are categorized as
Supraventricular - “narrow complex tachycardia”
Ventricular - “wide complex tachycardia”
Ventricular tachycardia tx
Amiodarone
Cardioversion
Supraventricular tachycardia with aberrency tx
Adenosine
Afib + WolffPrkWht tx
Amiodarone or procainamide
Torsades de pointes tx
Magnesium sulfate 2g IV
Polymorphic ventricular tachycardia tx
Cardioversion
Tx for symptomatic SA node arrest
Atropine
cardiac pacing for recurrence
