Cardiology Flashcards
Acute Coronary Syndrome: Chest Pain Evaluation
- General term for conditions where the blood supplied to the heart muscle is suddenly re____ or b_____
- Chest pain caused by acute coronary syndromes may occur s_____
- Pain can be unpredictable or worsens even with rest, both hallmark symptoms of ______angina.
- General term for conditions where the blood supplied to the heart muscle is suddenly reduced or blocked.
- Chest pain caused by acute coronary syndromes may occur suddenly
- Pain can be unpredictable or worsens even with rest, both hallmark symptoms of unstable angina.
ACS Incidence
- 1/__ of all deaths in the world due to heart disease
- ~ 7.5 million deaths are estimated to be due to (1) (IHD)
- More than 3 million cases per year in US
- A coronary event occurs every 26 seconds, and someone dies from one every ______ in the USA
- 1/3 of all deaths in the world due to heart disease
- ~ 7.5 million deaths are estimated to be due to ischemic heart disease (IHD)
- More than 3 million cases per year in US
- A coronary event occurs every 26 seconds, and someone dies from one every minute in the USA
Cardiac Arrest
- occurs ______
- triggered by an e_______ malfunction in the heart that causes an irregular heartbeat (1).
- P______ action disrupted, the heart cannot pump blood to the br____, l____ and other organs. Seconds later, a person
- loss c______ness and ______ of pulse.
- D_____ occurs within minutes without treatment.
- occurs suddenly
- triggered by an electrical malfunction in the heart that causes an irregular heartbeat (arrhythmia).
- Pumping action disrupted, the heart cannot pump blood to the brain, lungs and other organs. Seconds later, a person
- loss consciousness and absence of pulse.
- Death occurs within minutes without treatment.
Chest Pain Evaluation in outpatient setting
The signs and symptoms of acute coronary syndrome usually begin abruptly. They include:
- Chest pain (1) or discomfort, often described as a____, pr_____, t____ness or b_____
- Pain r_______ from the chest to the sh_____, a____, upper ab_____, b___, n___ or j___
- N_____ or v_____
- In_______
- Shortness of breath (1)
- Sudden, heavy sweating (1)
- ______headedness, d_____ess or f_____
- Unusual or unexplained f______
- Feeling r_____less or appr_______
- Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning
- Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw
- Nausea or vomiting
- Indigestion
- Shortness of breath (dyspnea)
- Sudden, heavy sweating (diaphoresis)
- Lightheadedness, dizziness or fainting
- Unusual or unexplained fatigue
- Feeling restless or apprehensive
Causes of Chest Pain in Outpatient Setting
Chest Pain Assessment Tool (mnemonics)
PQRST =
CHEST =
PAIN =
Chest Pain Assessment Tool
OLDCARTS =
Risk Factors for Heart Disease
- Unsafe lifestyle
- S_______
- Physical _____
- Diet high in ____
- High risk diseases
- Hy_______
- D_______
- Hy_______
- O________
- Unsafe lifestyle
- Cigarette smoking
- Physical activity
- Diet high in fat
- High risk diseases
- Hypertension
- Diabetes
- Hyperlipidemia
- Obesity
Risk Factors for Heart Disease
- Non-Modifiable Factors
- A____
- ______ History of (1)
- End Organ Damage
- H____ disease
- St_____
- P______ artery disease
- Chronic k_____ disease
- E_______ failure
- Non-Modifiable Factors
- Age
- Family History of premature coronary artery disease (CAD)
- End Organ Damage
- Heart disease
- Stroke
- Peripheral artery disease
- Chronic kidney disease
- Eyesight failure
Diabetes and Cardiometabolic Disease
- Approximately 68 percent of people age 65 or older with diabetes die from some form of _____ disease; and 16% die of ____.
- Adults with diabetes are __-__X more likely to die from heart disease than adults without diabetes.
- The American Heart Association considers diabetes to be one of the seven major ____trollable risk factors for cardiovascular disease.
- Approximately 68 percent of people age 65 or older with diabetes die from some form of heart disease; and 16% die of stroke.
- Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes.
- The American Heart Association considers diabetes to be one of the seven major controllable risk factors for cardiovascular disease.
HTN and HLD
High blood pressure (hypertension): risk for cardiovascular disease ______ with the presence of both HTN and Diabetes (VERY COMMON COMBINATION!)
Hyperlipidemia : ____ LDL (“bad”) cholesterol, ____ HDL (“good”) cholesterol, and high tr_____.
- This triad of poor lipid counts often occurs in patients with (1).
High blood pressure (hypertension): risk for cardiovascular disease doubles with the presence of both HTN and Diabetes (VERY COMMON COMBINATION!)
Hyperlipidemia : high LDL (“bad”) cholesterol, low HDL (“good”) cholesterol, and high triglycerides.
- This triad of poor lipid counts often occurs in patients with premature coronary heart disease.
Obesity and Lack of Exercise
Obesity: Major risk factor for cardiovascular disease
- strongly associated with ______ resistance.
- (1) can improve cardiovascular risk, ______ insulin concentration and _____ insulin sensitivity.
Lack of Exercise:
- _____fiable major risk factor
- Leads to insulin ______ and cardiovascular disease.
- Exercising and weight loss can prevent or delay the onset of type 2 (1), reduce blood (1) and help reduce the risk for heart (1) and (1)
Obesity: Major risk factor for cardiovascular disease
- strongly associated with insulin resistance.
- Weight loss can improve cardiovascular risk, decrease insulin concentration and increase insulin sensitivity.
Lack of Exercise:
- modifiable major risk factor
- Leads to insulin resistance and cardiovascular disease.
- Exercising and weight loss can prevent or delay the onset of type 2 diabetes, reduce blood pressure and help reduce the risk for heart attack and stroke.
Smoking and Genetic Factors
Smoking:
- Damages the arterial _____, leading to ______ or build up of _____ material which leads to the ______ of the arteries
Genetic factors:
- play a role in high blood pressure, heart disease, and other related conditions.
- people with a family history of heart disease share common en_______ and other potential factors that increase their risk.
Smoking:
- Damages the arterial lining, leading to atheroma or build up of fatty material which leads to the narrowing of the arteries
Genetic factors:
- play a role in high blood pressure, heart disease, and other related conditions.
- people with a family history of heart disease share common environments and other potential factors that increase their risk.
Coronary Arteries
Obtuse marginal is on the back off the left circumflex
Coronary Arteries on ECG
Likelihood of Coronary Artery Disease
ST Elevation - NOT ALWAYS MI
ELEVATION Mnemonic =
Diagnosis of Acute Coronary Syndrome (ACS)
- A complete blockage of a coronary artery means you suffered a (1)
- A partial blockage translates to a (1)
- Labs tests: (3)
- E___
- E________
- A complete blockage of a coronary artery means you suffered a STEMI heart attack – which stands for ST-elevation myocardial infarction.
- A partial blockage translates to an NSTEMI heart attack – a non-ST-elevation myocardial infarction.
- Labs tests: Troponin, CPK, CK-MB
- EKG
- Echocardiogram
- ** Troponin is needed every 46 hours inpatient.*
- Echo should be read by cardiology ideally not radiology*
- If high suspicion – troponin shouldn’t really be taken in primary care office – should send to ED*
- NSTEMI = partial blockage, STEMI = complete blockage*
Chest Pain Eval
What does this EKG show?
This EKG was from a patient who went on to develop ST elevation and V-fib arrest. If you are suspicious of hyperacute T waves, get frequent repeat EKG’s to identify ST elevation or other evolution
Beware the Hyperacute T wave in the setting of chest pain. Hyperacute T waves may not always have ST elevation. The real key is the T wave’s size in relation to the QRS complex. This EKG was from a patient who went on to develop ST elevation and V-fib arrest. If you are suspicious of hyperacute T waves, get frequent repeat EKG’s to identify ST elevation or other evolution.
What does this EKG Show?
Cerebral T waves which can be seen in subarachnoid hemorrhage. Subarachnoid hemorrhage can cause changes on the EKG such as deep t wave inversions or ST elevation. -> not everything on an EKG is from a cardiac cause
ECG Findings of Cerebral T Waves
- Inverted, wide T waves are most notable in precordial leads (can be seen in any lead).
- QT interval prolongation.
Pearls
- These are associated with acute cerebral disease, most notably an ischemic cerebrovascular event or subarachnoid hemorrhage.
- They may be accompanied by ST segment changes, U waves, and/or any rhythm abnormality.
- Differential diagnosis includes extensive myocardial ischemia.
- Strongly suspect an intracranial etiology in a patient with altered mental status and these electrocardiographic findings. (Atlas of EM)
What tool is used to assess someone’s CVD risk outpatient?
ASCVD Risk Calculator
(ALWAYS PERFORM)
What is the Inpatient ACS Risk Calculator?
What’s the difference?
Duke Clinical Score
More detailed than ASCVD
NYP STEMI Protocol
NYP STEMI Protocol
- Do NOT give beta blocker if hypotensive
- TNK (we never really give tenecteplase unless neuro thinks they’re having an acute event)
- Stat meds can be given all at once
Long term maintenance
- Plavix common but slowly moving towards ticagrelor-Should not be on nitrate, P2y12, and warfarin at once, will wean off nitrate and be on the other two-LIFETIME beta blocker!
NSTEMI Protocol
What is the main difference?
Guidelines pretty much the same
If not acute can go to cath lab within 24 hrs (not as urgent as STEMI)
Common Complications from Myocardial Infarction
BB to prevent afib post MI
Management of Acute coronary syndrome
Main Procedures
-
(3)
- Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cut off.
- Often combined with implantation of a stent to help open blocked arteries.
- (1) Similar to angioplasty except that the catheter has a laser tip that opens the blocked artery. Pulsating beams of light vaporize the plaque buildup.
- (1) needed when 3 or more diseased arteries/blockages
-
Angioplasty [Percutaneous Coronary Interventions [PCI], Balloon Angioplasty and Coronary Artery Balloon Dilation.
- Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cut off.
- Often combined with implantation of a stent to help open blocked arteries.
- Angioplasty, Laser: Similar to angioplasty except that the catheter has a laser tip that opens the blocked artery. Pulsating beams of light vaporize the plaque buildup.
- CABG- Coronary artery bypass surgery needed when 3 or more diseased arteries/blockages
Dual Antiplatelet Therapy post PCI
=
Aspirin + Second Agent
Second Agents include
- Clopidogrel (Plavix®)
- Prasugrel (Effient)
- Ticagrelor (Brilinta)
- Dipyridamole
(1)
- Decreases (2), which lowers blood pressure and makes the heartbeat more slowly and with less force.
- Used to treat cardiac arrhythmias and in treating chest pain (angina).
- Used in patients with some degree of heart failure post myocardial infarction.
Beta Blockers
- Decreases heart rate and cardiac output, which lowers blood pressure and makes the heartbeat more slowly and with less force.
- Used to treat cardiac arrhythmias and in treating chest pain (angina).
- Used in patients with some degree of heart failure post myocardial infarction.
Cholesterol Lowering Medication Classes
(4)
Statins
Nicotinic Acids
Cholesterol Absorption Inhibitors
PCSK9 Inhibitors
Statins
Which 2 do we like post MI?
_______ (Lipitor)
________ (Lescol)
_______ (Altoprev)
_______ (Livalo)
_______ (Pravachol)
________ (Crestor)
________ (Zocor)
Atorvastatin 80mg or Rosuvastatin 40mg with goal LDL _<_70 preferred post MI
Atorvastatin (Lipitor)
Fluvastatin (Lescol)
Lovastatin (Altoprev)
Pitavastatin (Livalo)
Pravastatin (Pravachol)
Rosuvastatin calcium (Crestor)
Simvastatin (Zocor)
Nicotinic Acids
(1) Rx
(2) Indications
Niacin
Treats high cholesterol and triglyceride levels, Treates niacin (B3) deficiency
Cholesterol Absorption Inhibitors
Rx (1)
Ezetimibe/Simvastatin (Vytorin)
PCSK9 Inhibitors
(2) Rx
MOA
Route, Frequency
When is this medication used?
Mainly used in what adults?
Alirocumab (Praluent) and Evolocumab (Repatha)
They block a protein called PCSK9 to make it easier for the body to remove LDL from the blood.
Biweekly Injection
Used in patients who are unable to manage their cholesterol through lifestyle and statin treatments.
They are mainly used in adults who inherit a genetic condition called “heterozygous familial hypercholesterolemia”
Vasodilators
Indication (1)
Commonly prescribed include:
- Isosorbide __nitrate (Isordil)
- Isosorbide ____nitrate (Imdur)
- Hy______ (Apresoline)
- Nit_____ ( SL, topical, )
For pts who continue to complaint of angina symptoms post stenting
- Isosorbide dinitrate (Isordil)
- Isosorbide mononitrate (Imdur
- Hydralazine (Apresoline)
- Nitrates ( SL, topical, )
Diuretics
Commonly prescribed include:
- Am_____ (Midamor)
- ___etanide (Bumex)
- Chl______ (Diuril)
- Chl______ (Hygroton)
- F______ (Lasix)
- Hy______ (Esidrix, Hydrodiuril)
- ____pamide (Lozol)
- S_______ (Aldactone)
- Amiloride (Midamor)
- Bumetanide (Bumex)
- Chlorothiazide (Diuril)
- Chlorthalidone (Hygroton)
- Furosemide (Lasix)
- Hydro-chlorothiazide (Esidrix, Hydrodiuril)
- Indapamide (Lozol)
- Spironolactone (Aldactone)
Heart Disease Risk Evaluation in Women - Summary Algorithm
Main point is Do risk assessment for women! Often overlooked
Case Study 1
Patient A was a woman, 88 years of age, who lived in an assisted living retirement home. She had been a widow for 20 years, after losing her husband to long-term complications associated with diabetes. Until approximately seven years ago, Patient A had been in relatively good health with no major health problems, but she suffered a mild stroke at 81 years of age. At that time, she decided to quit her 50- to 60-year smoking habit. Other than her smoking history, she did not have any other significant cardiovascular risk factors.
After recuperating from her stroke, Patient A decided to leave her apartment and move into the assisted living facility where she would not only have some companionship but also receive assistance with meals and transportation to doctor’s appointments and other activities. About six years after suffering the cerebrovascular accident, she had a bout of heart failure. She was admitted to the local hospital and received oxygen per nasal cannula, IV furosemide, and digoxin. After two weeks in the hospital, the patient was discharged home in apparently better condition. However, two days after returning home Patient A suffered a sudden cardiac death event at the breakfast table. Efforts at resuscitation were unsuccessful.
- What coronary risk factors are present? What risk factors are negative?
- Is the patient’s chest pain syndrome typical or atypical for women? Why or why not?
Smoking, stroke, age. Negative risk factors no DM, HTN.
not typical for a women, sudden cardiac death more common for men
- her MI was probably missed/ had it before the heart failure
Case Study 2
Patient S is caucasian woman, 43 years of age, and mother of three small children. She has a long-standing history of significant obesity with little success in dieting over the years. At 5’3”, she is obese, weighing 220 pounds. Her fat distribution is “apple-shaped” and consequently, her waist-hip ratio is more than the 0.8 normal range. In addition, Patient S lives a fairly sedentary lifestyle and does not have a regular exercise program. Her dietary habits do not take into account basic recommendations for cardiac nutrition.
Patient J is 55 years of age and teaches high school English. Her coronary risk factor profile includes a 30-pack-year history of cigarette smoking and altered lipid levels. Her HDL is only 35 mg/dL and her LDL is 145 mg/dL. Patient J has tried with little success to control her cholesterol with diet. Recently, she began taking gemfibrozil as prescribed by her family physician, but has not followed his recommendation to quit smoking and enroll in a smoking cessation program at a local hospital. Rather, she continues to smoke one pack of cigarettes per day.
Patient V is a woman, 47 years of age, who has a family history of heart disease. Although she denies ever experiencing cardiac symptoms, her brother suffered a nonfatal MI at 46 years of age and her father had an MI at 53 years of age. Both of these cardiac events were medically managed. However, her father’s disease did progress to the point that he underwent CABG surgery five years ago. He had three coronary artery lesions bypassed. In addition to her family history, Patient V is approximately 30 pounds overweight and does not exercise on a regular basis. She drinks approximately two to three glasses of red wine per day and has never smoked.
Patient D is 67 years of age and lives in an assisted living retirement community. An insulin-dependent diabetic since adolescence, Patient D is unable to care for herself due to the effects of the diabetes on her eyesight, as well as the development of peripheral neuropathies. In addition to the diabetes, Patient D continues to smoke. By now, she has a 40-pack-year history of smoking.
Patient F is an African American woman, 36 years of age, with a history of mild hypertension. Her blood pressure has been fairly well controlled on an ACE inhibitor over the past two years. Patient F eats a well-balanced, nutritious diet, exercises three to five times a week, and does not have a history of smoking or alcohol use. However, she does exhibit many of the characteristics of the Type A behavior pattern, such as excessive competitiveness, being harried, and rushing to complete more and more tasks in an ever-shrinking period of time. In addition to these characteristics, she exhibits a somewhat cynical or negative outlook with occasional expression of hostile or angry thoughts and feelings.
1.Which of these women is at greatest risk for heart disease?
2.Who is at least risk?
3.What recommendations would you make in counseling each patient regarding her cardiovascular health?
1.Which of these women is at greatest risk for heart disease?V
2.Who is at least risk?F
3.What recommendations would you make in counseling each patient regarding her cardiovascular health?
- Smoking also decreases HDLs…recommend cessation.
- Stress increases likelihood of CV event
- Genetic hx increases likelihood of CV event
Carotid Artery Stenosis
- These arteries carry blood to the h____, f____, and b____.
- Carotid artery stenosis can be caused by (1) build-up in the blood vessels (ath______).
- Thromboses in coronary and cerebral arteries are complications of ath_______.
- Condition is present for a long time before _______ appear.
- St_____ or T___s may occur.
- Carotid artery stenosis, accounts for approximately 18%–25% of (1)
- These arteries carry blood to the head, face, and brain.
- Carotid artery stenosis can be caused by cholesterol build-up in the blood vessels (atherosclerosis).
- Thromboses in coronary and cerebral arteries are complications of atherosclerosis.
- Condition is present for a long time before symptoms appear.
- Stroke or TIAs may occur.
- Carotid artery stenosis, accounts for approximately 18%–25% of ischemic stroke
Same risk factors as CAD - so treat the modifiable risk factors
CAS Detection
- (1) uses sound waves to create real-teim pictures of the arteries and locate blockages. Doppler is a special ultrasound technique that can detect areas of restriced blood flow in the artery.
- _(_1) uses a CT scanner to produce detailed views of the arteries in the neck. The test is particularly useful for patients with pacemakers or stents.
- (1) noninvasive test gives information similar to CTA without using ionizing radiation.
- (1) minimally invasive test in which a catheter is guided through an artery in the groin to the area of interest in the brain. Contrast material is injected through the tube and images are captured with x-rays.
- Carotid ultrasound: uses sound waves to create real-teim pictures of the arteries and locate blockages. Doppler is a special ultrasound technique that can detect areas of restriced blood flow in the artery.
- Computed Tomography Angiography (CTA): uses a CT scanner to produce detailed views of the arteries in the neck. The test is particularly useful for patients with pacemakers or stents.
- Magnetic resonance angiography (MRA): This noninvasive test gives information similar to CTA without using ionizing radiation.
- [Cerebral angiography**](https://www.radiologyinfo.org/en/info/angiocerebral)**:cerebral angiography is a minimally invasive test in which a catheter is guided through an artery in the groin to the area of interest in the brain. Contrast material is injected through the tube and images are captured with x-rays.
Carotid Artery Stenosis Disease Management
- Selection of treatment depends on?
- Medical Tx to reduce stroke from CAS (4)
- Current Tx of CAS (3), + (1) right before procedure?
- How to treat symptomatic Bilateral CAS? Which side do you treat first?
- How to treat asymptomatic Bilateral CAS? Which side do you treat first?
- Tx depends on symptomatic status, severity of stenosis, individual risk factors, efficacy and risk of complications
- Aspirin, statin, antiplatelets and tight BP control
- Current treatment of carotid artery stenosis includes
- optimal medical therapy
- carotid endarterectomy (CEA)
- carotid artery stenting (CAS).
- Dual platelet therapy has been recommend during the peri-procedural period and for at least 1 month after CAS.
- Bilateral carotid stenosis is not rare in patients with atherosclerotic disease - If surgery is indicated, then the symptomatic side first.
- For bilateral asymptomatic stenosis, the more severe stenosis first. If the degree of stenosis is similar on both sides, then the artery supplying the dominant hemisphere first.
CAS Management Notes
(1) Risk factor control: important risk factor for ECAD
- _____/_____ = Goal BP in non-diabetic patients with asymptomatic carotid stenosis
- < _____ diastolic BP goal if pt has concomitant diabetes
Hypertension Risk factor control: important risk factor for ECAD
- 140/90 = Goal BP in non-diabetic patients with asymptomatic carotid stenosis
- < 85 diastolic BP goal if pt has concomitant diabetes
What do these pictures show?
Left =
Right =
Carotid Artery Stenting (CAS)
Carotid Endarterectomy (CEA)
Case Study 3
A 67-year-old man comes to your office for a regularly scheduled visit. He has type 2 diabetes mellitus and a 40-pack-year smoking history, but he quit smoking two years ago. He takes lisinopril and atorvastatin (Lipitor); his blood pressure today is normal. His A1C and lipid panel at his last visit were within normal limits. He says that he feels well and has no neurologic complaints or any other symptoms. His father had a stroke at 68 years of age and was told it was caused by a blocked artery in his neck. The patient asks whether he should be screened for the same kind of blockage.
If asymptomatic do not order - overtesting may result in complications/AE, symptoms including dizziness, syncope, memory loss
Specific Treatment for Malignant Hypertension
Treatment goal =
Rx (2)
MAP -20-25%
Labetolol, Nicardipine
Specific Treatment for Stroke/Encephalopathy
-
Acute Ischemic Stroke
- Treatment Goal =
- Rx (2)
-
Acute Hemorrhagic Stroke
- Treatment Goal =
- Rx (2)
-
Hypertensive Encephalopathy
- Treatment Goal =
- Rx (2)
-
Acute Ischemic Stroke
- MAP -15% in 1h
- Labetolol, Nicardipine
-
Acute Hemorrhagic Stroke
- SBP >130 but <180
- Labetolol, Nicardipine
-
Hypertensive Encephalopathy
- MAP -20-25% Immediately
- Labetolol, Nicardipine
Specific Treatment for ACS, Cardiogenic Pulmonary Edema
-
Acute coronary event
- Treatment goal
- Rx (2)
-
Acute cardiogenic pulmonary edema
- Treatment goal
- Rx (2)
-
Acute coronary event
- SBP <140 Immediately
- Labetolol, Nitroglycerin
-
Acute cardiogenic pulmonary edema
- SBP <140 Immediately
- Nitroglycerin, Nitroprusside
Specific Treatment for Acute Aortic Disease
Treatment Goal =
Rx (4)
SBP <120, HR <60 Immediately
Nicardipine, Nitroglycerine, Nitroprusside, Esmolol
Specific Treatment for Eclampsia/Severe Preeclampsia/HELLP
Treatment Goal =
Rx (3)
SBP <160 and DBP <105 Immediately
Labetolol, Nicardipine, Magnesium Sulfate
Hypertensive Emergency Algorithm
Ejection Fraction
Normal value =
Borderline Ejection Fraction =
Reduced Ejection Fraction =
- Can you have heart failure if you have a normal ejection fraction?
- Why is this?
50-70%
41-49%
_<_40%
- You can have a normal ejection fraction measurement and still have heart failure (called HFpEF heart failure with preserved ejection fraction)
- Someone with heart failure might seem like they’re still pumping out a normal percentage of the blood that enters it but there is smaller volume of blood bc the heart is so thick and stiff, so in reality, total amount of blood pumped still not enough to meet your body’s needs
Cardiomyopathy Etiology
- In______
- To____ and Dr_____
- M_______
- G______
- H____/Onc______
- Dep_____
- Heredity N______/N______ diseases
- Endom______ diseases
- Inf________
- Infectious
- Toxins and Drugs
- Metabolic
- Genetic
- Hematologic/Oncologic
- Deposits
- Heredity Neurologic/Neuromuscular diseases
- Endomyocardial diseases
- Inflammatory
Hypertrophic Cardiomyopathy
Definition
- 50% of cases are caused by?
- 5-10% of cases are caused by?
Hypertrophic cardiomyopathy (HCM) is defined by the presence of increased left ventricular (LV) wall thickness >1.5 cm that is not solely explained by abnormal loading conditions
- 50% Familial Genetic Autosomal Dominant*** Family Planning
- 5-10% of adult cases are caused by other genetic disorders including inherited metabolic and neuromuscular diseases, chromosome abnormalities and genetic syndromes
Heart failure symptoms
- Weight g____
- F_____/Malaise/Ex______ intolerance
- An_____
- Pal______
- S_______ of breath
- C_____ (pulmonary edema/pleural effusions)
- Or_______
- D_____ness, l____theadedness, or syn_____ episodes
- Ed______ in legs and/or abdomen
- Weight gain
- Fatigue/Malaise/Exercise intolerance
- Angina
- Palpitations
- Shortness of breath
- Cough (pulmonary edema/pleural effusions)
- Orthopnea
- Dizziness, lightheadedness, or syncopal episodes
- Edema in legs and/or abdomen
NYHA Functional Class of HF
Match each description with Stages I-IV
- Symptomatic with minimal exertion
- Symptomatic at rest
- Asymptomatic
- Symptomatic with moderate exertion
Stage I = Asymptomatic
Stage II = Symptomatic with moderate exertion
Stage III = Symptomatic with minimal exertion
Stage IV = Symptomatic at rest
Medication that blocks the channel responsible for the cardiac pacemaker current, I(f), which regulates heart rate. This results in prolonged diastolic time and reduced heart rate.
Ivabradine
Ivabradine reduces heart rate but does not affect myocardial contraction, relaxation, or ventricular repolarization
- Rapid resting heart rate can lead to detrimental effects on left ventricular function and has been associated with negative outcomes in patients with cardiovascular disease.
- Reducing resting heart rate to reduce cardiovascular morbidity and mortality is a therapeutic target among drug manufacturers.
HFrEF Stage C Treatment
Starting and Target Doses of Novel Therapies for HF
Cardiac Resynchronization Therapy (CRT) Device
(2) two types of CRT devices.
CRT-P (Cardiac resynchronization therapy - pacemaker) (“biventricular pacemaker”)
CRT-D (same device but built in implantable cardiac defibrillator)
Systolic Heart Failure Treatment
GDMT = (1) can help to reduce mortality, often medication alone is not enough.
For HF patients with electrical dyssynchrony, (1) in + GDMT is the only therapy clinically proven to help:
- Improve ______ of life
- S_____ HF disease progression
- Decrease mor_____
- Reduce HF hos_______
Guideline-directed medication therapy (GDMT) can help to reduce mortality, often medication alone is not enough
For HF patients with electrical dyssynchrony, cardiac resynchronization therapy (CRT) + GDMT — is the only therapy clinically proven to help:
- Improve quality of life
- Slow HF disease progression
- Decrease mortality
- Reduce HF hospitalizations
HOCM Procedures
(1) Long-term survival after this procedure is 97% at 5 and 91% at 10 years, which did not differ from the age- and gender-matched general U.S. population, 4% risk of complete heart block
(1) A small portion of the thickened heart muscle is destroyed by injecting alcohol through a catheter into the artery supplying blood that leads to the enlarged septum. This leads to immediate controlled cell death at the targeted location. 7-20% risk of complete heart block. High risk of arrhythmia during procedure, risk of developing ventricular septal defect
Septal Myectomy
Septal Ablation
Type of non-invasive cardiac imaging that uses radioactive dye and an imaging machine to create pictures showing the blood flow to the heart (poor blood flow shows cardiac damage) Measures blood flow at rest and on exertion. Can be performed alone or in combination with another test (ie echo)
Nuclear Heart Scan/Thallium Stress Test
Pulmonary Venous Thromboembolism Management
When should you not treat outpatient?
- Anticoagulants (2)
- Oral Medications (W_____ + DOACS (4))
- Thrombolytic Therapy (1)
- Surgical procedures (1)
SHOULD NOT treat outpatient if massive symptomatic DVT, high risk for bleeding, or hemodynamically unstable dt concurrent symptomatic PE
- Anticoagulants = Heparin, Low molecular weight heparin
- Oral Medications = (Warfarin, Apixaban, Dabigatran, Rivaroxaban, Edoxaban)
- Thrombolytic Therapy = Tissue Plasminogen Activator (tPA)
- Surgical procedures = Thrombectomy
- TPA Can be given IV or inserting catheters directly into the blood clot in the vein or lungs
- Thrombectomy done by placing a filter in the body’s largest vein, the inferior vena cava to prevent blood clots from traveling to the lungs
WHO Group 1: Pulmonary Arterial Hypertension (PAH)
Pulmonary arteries become n____, th____, st___
____ side of the heart must work h_____ to push blood through these narrowed arteries
- Idiopathic
- Her____
- Dr___ & Toxin related
- Hep___ Disease
- Auto____ and c_____e tissue disease
- H_ _
- Con_____ heart disease
Pulmonary arteries become narrowed, thickened, stiff
Right side of the heart must work harder to push blood through these narrowed arteries
- Idiopathic
- Heritable
- Drug & Toxin related
- Hepatic Disease
- Autoimmune and connective tissue disease
- HIV
- Congenital heart disease
WHO Group 2: Pulmonary Hypertension d/t left heart disease
Left sided v____ or pump dysfunction causing (1)
- Congenital or Acquired
- Congenital defects (3)
- Eis_____ Syndrome
- Congenital cardiom_______
- Congenital defects (3)
Left sided valvular or pump dysfunction causing back-up to lungs
- Congenital or acquired
- Congenital: Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosus causing left-to-right shunt
- Eisenmenger’s Syndrome
- Congenital cardiomyopathies
WHO Group 3: Pulmonary Hypertension d/t lung disease
PH due to chronic lung diseases and/or hypoxia (low oxygen levels)
(2) lung diseases
- Inter____ lung disease/ pulmonary f_____
- Sl____ apnea
- Chronic high al______ exposure
- Con____ lung disease
Pulmonary HTN with hypoxemia may be due to associated ____-to-___ pulmonary shunt d/t v______/ p_______ mismatch
Pulmonary HTN with hypoxemia may be related to intracardiac right-to-left shunt via a (1) (PFO)
PH due to chronic lung diseases and/or hypoxia (low oxygen levels)
Eg. obstructive/ restrictive lung disease
- Interstitial lung disease/ pulmonary fibrosis
- Sleep apnea
- Chronic high altitude exposure
- Congenital lung disease
Pulmonary HTN with hypoxemia may be due to associated right-to-left pulmonary shunt d/t ventilation/ perfusion mismatch
Pulmonary HTN with hypoxemia may be related to intracardiac right-to-left shunt via a patent foramen ovale (PFO)
WHO Group 4: Pulmonary Hypertension d/t chronic blood clots in the lungs
CTEPH =
- Occur when body is not able to re_____ a blood clot in the lungs
- Leads to sc___ tissue in the blood vessels of the lungs
- Which bl___ normal blood flow and makes the ____ side of the heart work harder
- Can potentially be cured through (1) (PTE) surgery to remove blood clots
CTEPH = Chronic thromboembolic pulmonary hypertension
- Occur when body is not able to reabsorb a bloo dclot in the lungs
- Leads to scar tissue in the blood vessels of the lungs
- Which blocks normal blood flow and makes the right side of the heart work harder
- Can potentially be cured through pulmonary thoromboendarterectomy (PTE) surgery to remove blood clots
WHO Group 5: Pulmonary Hypertension d/t unknown cause
When PH is secondary to other ______ in ways that are not well understood
Associated conditions are: s____osis, s____ cell anemia, chronic hemo____ anemia, sp___ectomy, certain metabolic disorders
When PH is secondary to other diseases in ways that are not well understood
Associated conditions are: sarcoidosis, sickle cell anemia, chronic hemolytic anemia, splenectomy, certain metabolic disorders
Treatment Algorithm for PH
