Cardiomyopathy, HF, PE, AFIB/Aflutter Flashcards
1
Q
What is a disease of the heart muscle?
A
Cardiomyopathy
2
Q
Cardiomyopathies manifest with what?
A
Various structural and functional abnormalities
3
Q
What are the classifications of cardiomyopathy?
A
- Dilated cardiomyopathy (DCM)
- Restrictive cardiomyopathy (RCM)
- Hypertrophic cardiomyopathy (HCM)
- Hypertrophic obstructive cardiomyopathy (HOCM) - Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)
4
Q
Dilated cardiomyopathy
A
LV cavitary dilation, normal or decreased wall thickness, LA enlargement, possibly right ventricular enlargement (all 4 chambers may be dilated)
5
Q
Dilation and impaired contraction of one or both ventricles
A
Dilated cardiomyopathy
6
Q
What happens to the systolic function in dilated cardiomyopathy?
A
Its impaired, the ejection fraction is <40%
7
Q
What are the common causes of dilated cardiomyopathy?
A
- Idiopathic (most common-often genetic)
- Infections (viral myocarditis, Chagas dx)
- Toxins (drugs, meds, alcohol)
- Tachycardia induced CMP
- Stress (takotsubo)- sometimes considered “unclassified”
8
Q
Infectious cardiomyopathy
A
Begins as an infectious myocarditis
9
Q
What type of infectious cardiomyopathy is most common?
A
Viral
10
Q
What type of bacteria can cause infectious cardiomyopathy?
A
Lyme, Mycoplasma
11
Q
Chagas Disease
A
Protozoan infectious cardiomyopathy
12
Q
Clinical manifestations of dilated cardiomyopathy from infections
A
Fever, myalgia, muscle tenderness, heart palpitations/arrhythmias, heart block, chest pain, pre-syncope, syncope, HF, clinical syndrome ranges from subclinical to fulminant
13
Q
What is performed in pts who do not improve from dilated cardiomyopathy?
A
Endomyocardial biopsy
14
Q
Dilated CMP; Infectious CMP; Chagas Disease
A
Protozoan infection (Trypanosoma Cruzi) Causes acute myocarditis, cardiac enlargement, nonspecific EKG changes, LV apical aneurysms
15
Q
What can cause left ventricular apical aneurysms?
A
Dilated CMP; Infectious CMP; Chagas Dx
16
Q
Clinical manifestation of Chagas’ disease
A
HF, Arrhythmias and heart block, thromboembolism, chest pain
17
Q
What types of thromboembolism can be seen in Chagas Dx
A
Pulmonary embolism, cerebrovascular accident CVA = stroke
18
Q
How do you diagnose Chagas Dx?
A
Serologic test that detects IgG antibodies to T. Cruzi
CXR with cardiomegaly
EKG with RBBB or LBBB and ST-T changes
Echocardiography-cardiac structure and fxn abnormalities
Cardiac MRI-detects myocardial fibrosis
19
Q
Treatment of Chagas Disease
A
Antitrypanosomal drugs for acute dx and indeterminate dx (not useful in chronic condition)
Standard treatment of HF
Implantable cardiac pacer +/- defibrillator
20
Q
What are the causes of toxic cardiomyopathy?
A
Alcohol, cocaine, medications
21
Q
Alcohol induced cardiomyopathy
A
Correlated to amount and duration of daily drinking
Abstinence can lead to improved cardiac fxn if diagnosed early
22
Q
Dilated cardiomyopathy; Tachycardia induced cardiomyopathy
A
AFIB with RVR, AVNRT, preexcitation syndromes, reduced myocardial contractility, abnormalities in myocardial architecture, decrease in calcium responsiveness
23
Q
How do you treat tachycardia induced cardiomyopathy?
A
Treatment of arrhythmia results in reversal of myocardial dysfunction
24
Q
What is takotsubo?
A
Stress-induced dilated cardiomyopathy
25
Precipitated by intense psychological stress, also called “broken heart syndrome”
Takotsubo
26
Stress-induced cardiomyopathy patho
Post-menopausal women, LV apical ballooning, ST elevation without CAD
27
What happens in restrictive cardiomyopathy?
Hypertrophy is typically absent, rigid ventricular walls result in diastolic dysfunction, systolic function usually remains normal, there is also biatrial enlargement
28
What are the causes of restrictive cardiomyopathy?
Familial, infiltrative (amyloidosis, sarcoidosis), storage diseases (rare inherited disorders), scleroderma and endomyocardial fibrosis
29
Hypertrophic cardiomyopathy (HCM)
Genetically determined heart muscle disease
Interventricular septum typically more prominently involved than LV free wall
LV volume is normal or reduced, diastolic dysfunction is usually present
30
Hypertrophic obstructive cardiomyopathy (HOCM)
Hypertrophy of the ventricular septum, significant left ventricular outflow tract (LVOT) obstruction
31
What type of murmur can be heard with HOCM?
Harsh crescendo-decrescendo systolic murmur that increases intensity with Valsalva maneuver, decreases intensity with squatting
32
What are the common symptoms of HOCM?
Fatigue, dyspnea, chest pain, palpitations, presyncope or syncope
33
Clinical manifestations of HCM
LV outflow obstruction (HOCM), diastolic dysfunction, myocardial ischemia, mitral regurg, systolic dysfunction (end-stage), HF, supraventricular and ventricular arrhythmias, sudden death
34
How can you manage hypertrophic cardiomyopathy?
Stay hydrated! Restricted intense physical exertion, medical therapy to treat chest pain and dyspnea, medical therapy for arrhythmias, invasive procedures to improve LV outflow tract
35
What procedure is used to improve LVOT?
Alcohol septal ablation or septal myectomy
36
What is a C/I for alcohol septal ablation
C/I under 21 years old, increased risk or ventricular arrhythmias under age 40 too
37
ARVC
Arrhythmogenic right ventricular cardiomyopathy
38
ARVC
Myocardium of RV is replaced by fibrous and/or fibro-fatty tissue
39
Patho of ARVC
Ventricular arrhythmias (VTACH), RV fxn is abnormal with regional akinesis or dyskinesis, global RV dilation and dysfunction
40
What can cause sudden cardiac death in young adults?
ARVC
41
Symptoms of ARVC
May be silent, palpitations, syncope, atypical chest pain, dyspnea
42
Diagnosing ARVC
Echocardiogram, *Cardiac MRI* genetic testing, endomyocardial biopsy
43
Treatment of ARVC
ICD Implantable cardiac defibrillator, antiarrhythmic drugs, no competitive sports, cardiac transplant if progressive and debilitating after optimal use of other treatments
44
Cardiac output = what
HR x SV
45
Stroke volume
How much blood is ejected with each beat
46
Cardiac output
How much blood is ejected in one minute
47
Preload
Loading condition of the heart at the end of diastole, right before systole (maximum diastolic stretch for that contraction)
48
What is preload determined by?
Mainly by venous return to the heart
49
Afterload
The force that the contracting heart must generate to eject blood from the filled heart
50
What is afterload determined by?
Ventricular wall tension, peripheral vascular resistance (PVR)
51
Cardiac contractility
The ability of the heart to contract
52
Ionotropic influence is what?
Increases the cardiac contractility
53
What is a positive inotropic action?
Digitalis, sympathetic stimulation
54
What is a negative inotropic action?
Akinesis secondary to myocardial infarction
55
What is LVEF?
Left ventricular ejection fraction, the % of blood leaving the heart each time it contracts
56
What is a normal EF? Or LVEF?
55-65%
57
What is the clinical diagnosis of HF based on?
Careful hx, PE and objective data
58
Impairment of ventricular filling or ventricular ejection
Heart Failure
59
What is low output HF?
Pumping or filling ability of the heart is impaired (most common type)
60
Right sided heart failure
Blood backs up into the systemic venous system (legs, hepatic veins, GI tract)
61
What are the causes of right-sided heart failure?
Left-sided HF (most common cause), severe or chronic pulmonary dx, pulmonic valve stenosis
62
Left-sided HF
Blood backs up into lungs (pulmonary edema), and into right heart and systemic venous system
Can be both systolic or diastolic dysfunction
63
Causes of left-sided HF
Acute myocardial infarction, chronic CAD/multiple infractions, CMPs, LV hypertrophy
64
Systolic dysfunction
Impaired ejection of blood from the heart during systole (HF with reduced EF/HFrEF)
65
What type of dysfunction is there HF with reduced ejection fraction?
Systolic
66
Diastolic dysfunction
Impaired filling of the ventricles during diastole (HF with preserved EF/HFpEF)
67
Which type of dysfunction has preserved EF?
Diastolic dysfunction
68
What are some common causes of systolic dysfunction?
*Ischemic Heart disease* idiopathic dilated cardiomyopathy, HTN, valvular disease
69
How does HTN cause systolic dysfunction?
Chronic pressure overload causes remodeling
70
What are the causes of diastolic dysfunction?
Longstanding HTN (stiff ventricles), restrictive CMPs, valvular disorders (mitral vale stenosis)
71
NY Heart Association functional classification of HF
Class 1-4
72
Class 1 HF
Symptoms onyl with significant activity
73
Class 2 HF
Symptoms with ordinary activity of daily living
74
Class 3 HF
Symptoms with only minimal exertion
75
Class 4 HF
Symptoms at rest
76
What are the common symptoms of HF?
SOB especially with exertion (DOE), orthopedist, PND paroxysmal nocturnal dyspnea, weight gain, swelling-ankle edema, increased abd girth
77
What other symptoms can be seen with HF?
Chest pain or pressure, fatigue, weakness, heart palpitation if associate arrhythmia
78
What are triggers for a new diagnosis of HF?
Acute MI, recent MI, AFIB with RVR or other tachyarrythmias
79
What are triggers for pts with known HF (triggers for decompensation)
Change it diet- increased salt, increased fluid
| Change in medication- reduction in diuretic doses missed doses, non-compliance
80
PE findings of HF
Weight gain, hypoxia, elevated jugular venous pressure (JVD) + hepatojugular reflux, S3 gallop, pulmonary rales (crackles) & decreased breath sounds at bases, pitting edema of lower extremities
81
What can be seen on an EKG for someone with HF?
Arrhythmias (AFIB), acute or prior MI, acute ischemia, LVH
82
What lab studies are done for someone with HF?
BNP, troponin, creatinine kinase, CK-MB, CBC, CMP, kidney fxn, liver fxn
83
What radiographic studies can be used for HF?
CXR and echocardiogram for new diagnoses
84
CXR findings in HF
Blunting of costrophrenic angles, pulmonary vein engorgement, cephalization, Kerley B lines, caridomegaly
85
What does pulmonary vein engorgement look like on a CXR for HF?
Increased interstitial markings
86
What are Kerley B Lines?
Thickened horizontal linear opacities in the subpleural region, which meet the pleura at right angles (HF)
87
What are the goals of therapy for HF?
Clinical improvement of symptoms, reduction of mortality and morbidity risk, reduction in rate of hospitalization
88
What are some ways to manage HF?
Determine underlying etiology, severity of syndrome, correct systemic factors, lifestyle mods, remove excess fluid, ultrafiltration, implantable devices
89
What is the treatment for HTN in HF?
ACE inhibitor, ARB, or ARNI (angiotensin receptor neprilysin inhibitor)
BB C/I during acute decompensated CHF
90
Why are BB C/I in heart failure?
Due to bradycardia, can worsen CHF
91
What is used to treat ischemic heart disease in HF?
Aspirin, BB, statin and revascularization
92
What is used to treat valvular disease in HF?
Surgical correction
93
What is the step-wise pharmacological management of HF?
Reduce fluid and improve symptoms, reduce afterload and improve CO, improve remodeling (less scar tissue), improve outcomes in African Americans, reduce hospitalization
94
How do you reduce fluid and improve symptoms for HF?
Diuretics
95
How do you reduce afterload and improve CO for HF?
ACE inhibitor, ARB, or ARNI
96
How do you improve remodeling for HF?
Beta-blockers
97
How do you improve outcomes in African Americans with HF?
Hydralazine and Bidil (Isosorbide Dinitrate)
98
How do you reduce hospitalizations for HF?
Digoxin
99
Which diuretics are used to reduce fluid levels in HF pts?
Furosemide (Lasix) with Spironolactone
| Budesonide and Torsemide (stronger than lasix)
100
Which ACE inhibitors are used to reduce afterload and improve CO?
Lisinopril, Captopril
101
Which ARBs are used to reduce afterload and improve CO?
Irbesartan, Losartan, Valsartan (used if pt cant tolerate ACE-I)
102
What beta-blockers are used to improve remodeling and lessen scar tissue?
Carvedilol and Metoprolol
103
What is the treatment for acute decompensated HF?
```
IV Loop diuretics (furosemide) q12 to q6
Rate control (CCB or BB)
ACE-I for systolic dysfunction (or ARB)
Monitor electrolytes
Monitor kidney fxn
```
104
What else needs to be monitored in a pt with acute decompensated HF?
Hospitalize! Monitor strict ins and outs (fluid in/urine out), daily weights, 2gm daily sodium restriction, 1.5L daily fluid restriction
105
What is the daily sodium restriction for someone with acute decompensated HF?
2gm/Day
106
What is the daily fluid restriction for someone with acute decompensated HF?
1.5L daily
107
Which electrolytes need to be monitored for someone with acute decompensated HF?
Potassium and Magnesium
108
What is the treatment for someone in severe hemodynamic compromise?
Intubation, CCU admission, inotropic agents, vasoconstrictors, mechanical/surgical interventions
109
What inotropic agents are given to pts who have severe hemodynamic compromise?
Dobutamine or Milrinone
110
What vasoconstrictors are used for someone who has severe hemodynamic compromise?
Dopamine, Epinephrine, Phenylephrine, Vasopressin
111
What mechanical and surgical interventions are necessary for someone who has severe hemodynamic compromise?
Intra-aortic balloon counter pulsation, percutaneous and surgically implanted LV assist devices and cardiac trans plantations
112
What is a common cause of systolic CHF?
Ischemic heart disease
113
What is a common cause of diastolic CHF?
Longstanding HTN
114
What is the pericardium?
Sac of visceral and parietal layers
115
What stabilizes the heart in anatomic position?
Pericardium
116
Pericardium functions
Reduces contact between the heart and surrounding structures
117
The pericardial cavity has how much fluid?
15-50ml of plasma
118
What is an effusion?
The presence of abnormal amount of fluid
119
Pericardial effusion
Many etiologies, there is acute, subacute and chronic
| A complication: Cardiac tamponade
120
What does a cardiac tamponade result in?
Compression of the heart
121
Pericardial effusion etiologies
Acute pericarditis, autoimmune dx, post MI or s/p cardiac surgery, sharp or blunt chest trauma, malignancy, renal failure, myxedema, aortic dissection, meds
122
Symptoms of PE and cardiac tamponade
Chest pain/pressure, chest discomfort, lightheaded, palpitations, SOB, cough
123
Si/PE of pericardial effusion
Pericardial friction rub
124
Si/PE or Cardiac Tamponade
Tachycardia, tachypnea, hepatojugular reflex, pulsus paradoxus, beck’s triad
125
What is Pulsus Paradoxus?
Si of cardiac tamponade, decrease in BP by 10mmHg during inspiration
126
What is Beck’s Triad?
1. Hypotension
2. Muffled heart sounds
3. JVD
127
What is Beck’s triad found in?
Cardiac tamponade
128
PE and cardiac tamponade diagnostics
1. *Echocardiogram*
2. Electrocardiograph EKG
3. CXR
4. +/- CT or MRI
129
What can be seen on an EKG for PE and cardiac tamponade?
Low voltage, tachycardia, and electrical alternans
130
What is electrical alternans?
Get a change in amplitude depending on which lead you are at
131
What will a CXR show for PE and cardiac tamponade?
Varies depending on etiology and size of effusion, can see cardiomegaly for pts with chronic PE
132
What is required to establish a diagnosis of PE and cardiac tamponade?
Echocardiography
133
What types of echcardiographies are there?
TTE transthoracic and TEE transesophageal
134
Treatment options for PE and cardiac tamponade
Directed at underlying cause- percutaneous pericardiocentesis, surgical pericardectomy with drainage
135
When is a procedure indicated for PE or cardiac tamponade?
If emergent hemodynamic instability/cardiac tamponade
| Sampling of effusion for diagnostic purposes with unclear etiology
136
What is pericarditis?
Inflammation of the pericardial sac
| Can be acute, recurrent and chronic
137
Pericarditis epidemiology
Most common disorder involving pericardium
138
Etiology of pericarditis
Idiopathic/Infectious: viral (most common), bacterial, fungal, Lyme
Neoplasticism, Iatrogenic, Drugs, Metabolic disorder
139
What types of neoplasms cause pericarditis?
Malignancies of lung/breast, Hodgkin’s
140
Iatrogenic causes of pericarditis
Post MI (Dressler Syndrome), radiation therapy, metabolic disorders, Rheymatologic dx
141
What drugs can cause pericarditis?
Isoniazid, Hydralazine
142
What are some complications of pericarditis?
Large pericardial effusion, cardiac tamponade
143
What diagnostics are used to evaluate for pericarditis?
EKG, CBC, cardiac biomarkers, inflammatory markers, +/-CXR, echo
144
Symptoms of pericarditis
Chest pain (pleuritic) that is sharp and worse with inspiration, +/- viral URI type complaints
145
Signs/PE of pericarditis
Classic picture: Patient sitting up and leaning forward, pericardial friction rub
146
Pericarditis diagnostic aids
ECG* most useful, WBC, ESR, CRP for inflammation, Troponin, +/- CXR, +/- echocardiogram
147
You need 2 or more of the following to diagnose pericarditis:
1. Pericardial Chest pain
2. Pericardial friction rub
3. Changes on EKG
4. New or worsening pericardial effusion
148
How do you manage pericarditis if caused by idiopathic or viral?
NSAIDs or Aspirin + Colchicine + Proton Pump Inhibitor
149
How do you manage pericarditis if caused by Dressler Syndrome?
Colchicine 3 mos+ Aspirin for 2 weeks
150
What are the indications for glucocorticoid therapy (pericarditis)
Refractory pericarditis, immune mediated causes
151
When should a pt be hospitalized for pericarditis?
Fever >100.4, evidence of suggesting tamponade, large PE, acute trauma, Warfarin/antiplatelet therapy, failure to respond to NSAID therapy, elevated troponin
152
Inflammation of the endocardium, usually heart valves
Endocarditis
153
3/4 of patient’s with endocarditis (IE) have what?
Pre-existing structural cardiac abnormality
| Acute (Short Incubation) and Subacute (Long Incubation)
154
Risk factors for endocarditis
>60YO, males, IVDA, poor dentition/dental infection requiring invasive dental procedure, structural heart disease, congenital HD, prosthetic valve, chronic hemodialysis, intravascular devices
155
What structural heart diseases make you at risk for endocarditis?
Valvular disease
156
What congenital heart disease make you at risk for endocarditis?
ASD, VSD, TOF
157
Endocarditis etiology
*Staph* strep, enterococci, strep bovis, HACEK organisms
158
What are the HACEK organisms?
Haeomophius aphrophilus, actinobacillis acntinomycetemcomitans, cardiobaterium hominis, eikenella corrodens, kingella species
159
What organisms are required to meet Duke’s criteria for diagnosis?
HACEK
160
Endocarditis symptoms
Non-specific like cough, SOB, arthralgias, fever
161
Signs/PE of endocarditis
Embolism events, inflammatory lesions, splinter hemorrhage’s, fever, new heart murmur
162
What embolic events can happen in endocarditis?
Petechiae and Janeway lesions: on palms and soles of feet
163
What inflammatory lesions can happen in endocarditis?
Osler nodes: Painful raised lesions of fingers, toes, and feet
Roth spot: exudative lesions of the retina
164
What symptoms can be seen with endocarditis?
Non specific like cough SOB, arthralgias, fever
165
Si/PE for endocarditis
Fever, new heart murmur, splinter hemorrhages, embolic events (digits, lung, kidney) petechiae, Janeway lesions, inflammatory lesions: Osler nodes and Roth spot
166
How do you diagnose endocarditis?
Blood culture x3, echocardiogram, +/- CRX, CBC, urinalysis, rheumatoid factor
167
Which echocardiogram is better for endocarditis?
Transesophageal TEE is better than TTE
168
What is Duke’s criteria?
Criteria to diagnose endocarditis
169
What are the major criteria listed in Duke’s criteria?
>2 Blood cultures with typical microorganisms consistent with IE, evidence of endo cardinal involvement documented by echocardiogram, evidence of new regurgitation murmur on exam
170
What is the minor criteria for Duke’s criteria?
Predisposing conditions (heart conditions or IVDA), Fever >38.0C, vascular phenomena like petechiae, systemic emboli, Janeway lesions, immunological phenomena like Osler nodes, Roth spots, glomerulonephritis, rheumatoid factor, <1 positive blood culture
171
What is the diagnosis requirement for Duke’s criteria of endocarditis
2 major OR 1 major and 3 minor OR 5 minor
172
What is the empiric therapy treatment for endocarditis?
Vancomycin 15-20mg/kg/dose BID-TID + Ceftriaxone 2gr every 24h
173
If endocarditis caused by MSSA, drug to use
Nafcillin or Oxacillin 1.5gm-2mg q4h x 6weeks
174
If endocarditis is caused by strep viridans, drug to use
Penicillin G 2-3millino units IV q4hrs x 4weeks +/- Gentamycin
175
What type of cardiac damage can endocarditis cause?
Valve damage and congestive heart failure
176
What type of conduction abnormalities can endocarditis cause?
AV block, AFIB
177
What types of peripheral embolization can endocarditis cause?
Digit amputation, septic emboli to lung, renal infarct
178
Which population is at risk and needs Abx prophylaxis?
Cardiac conditions (prosthetic cardiac valve, h/o IE, congenital heart disease, cardiac transplant)
179
Which procedures require Abx prophylaxis for endocarditis?
All dental procedures that involve manipulation of gingival tissue or periapical region, respiratory tract procedures, procedures on infected skin, skin structure or musculoskeletal tissue
180
Which abx can be used as prophylaxis for endocarditis?
Amoxicillin 2gram -one hour before the procedure
181
What is a disorganized, rapid and irregular atrial activation?
AFIB
182
What is the patho behind AFIB
Loss of effective atrial contractility, results in irregular ventricular response
183
What is the HR with AFIB?
Often rapid, 120-160BPM
184
What does AFIB lead to?
Clot formation and subsequent thromboembolic events (leading cause of stroke)
185
Epidemiology of AFIB
Most common sustained arrhythmia, prevalence increases with age, M>F, white>black, hispanic, asian
186
What is the incidence of AFIB?
40-95YO chance is 26% for men and 23% for women
| >5% of population over 70 years
187
The etiology of AFIB is often related to what?
Atrial stretching or scarring
188
Etiologies of AFIB
Acute hyperthyroidism, acute3 vagotonic episode, acute alcohol intoxication, post-op, *Atrial enlargement* disruption of electrical conduction system
189
What is the most common etiology of AFIB?
Atrial enlargement
190
Pathogenesis of AFIB
Elevation in atrial pressure, majority of episodes are triggered by atrial premature beats
191
What can AFIB be triggered by?
Atrial premature beats, other supraventricular arrhythmia; atrial flutter or atrial tachycardia
192
Where are ectopic foci most likely located?
At the ostial portion of the pulmonary veins (site of ablation)
193
Risk factors for AFIB
Age >64, male, HTN, elevated BMI, prolonged PR interval, valvular dx, CHF
194
What is an important risk factor to note for AFIB?
Valvular disease, especially mitral or pulmonic valves
195
What are the classifications of AFIB?
PAF: Paroxysmal
Persistent
“Lone AF”
196
Paroxysmal AFIB (PAF)
Intermittent AFIB, still at same stroke risk of people with persistent AFIB
197
Persistent AFIB
Fails to self-terminate within 7 days & requires intervention in order to convert
198
Permanent AFIB
>12 mos & no longer pursue rhythm control
199
“Lone AF”
Without structural heart disease, lowest risk of complications (not used much anymore)
Basically, had AFIB once and never again
200
What valvular heart diseases are associated with AFIB?
Significant stenosis or regurg, rheumatic heart disease
201
What other diseases are associated with AFIB?
HF, HTN heart disease, acute MI (due to ischemia or stretch)
202
Symptoms of AFIB
Asymptomatic, heart palpitations, light-headedness, pre-syncope, syncope, SOB & exercise intolerance, chest pain, fatigue
203
Common triggers of AFIB episodes
Sleep deprivation, physical illness, post-op, stress, hyperthyroidism, exercise, stimulant meds (sudafed), alcohol, caffeine, dehydration
204
What can be seen with new onset AFIB?
Heart palpitations, fatigue or lightheadedness, dyspnea SOB, angina (chest discomfort)
205
What do you do with a new onset AFIB?
Rate vs, rhythm control, prevent systemic embolization
206
What diagnostic studies can be used for AFIB?
EKG, echocardiogram, stress test, CBC,BMP, TSH (for hyperthyroid)
207
Hx taking for AFIB
Underlying Diane: CAD and CHF, CVA, DM, HTN, COPD, Thyroid disorder
208
Complete CV exam
BP and pulse rate, murmurs, evidence of HF, extremity pulses
209
Look for these associated EKG findings for AFIB
LVH, pathologic Q waves, delta waves short PR interval (WPW), QT interval duration
210
What should be seen in a TTE for AFIB?
Size of atria, size & fxn of R & L ventricules, *valvular heart disease* pericardial disease, atrial thrombus
211
Which types of valvular heart disease can be seen on TTE for AFIB?
Mitral regurg and mitral stenosis
212
Which type of echocardiogram is more sensitive for testing atrial thrombus?
TEE transesophageal
213
Additional testing for AFIB
```
Exercise stress testing-assess for ischemic heart disease
Heart monitors (hollers, event recorders)
```
214
What are the goals of therapy for AFIB?
1. Rhythm control (if not yet permanent)
2. Reduce risk of stroke and other peripheral emboli
3. Prevent tachycardia mediated CMP and ischemia
4. Alleviate symptoms
215
What are some indications for urgent direct current (DC) cardioversion for AFIB?
1. Active ischemia
2. Unstable hemodynamics
3. Evidence of organ hypoperfusion
4. Severe manifestations of HF (pulmonary edema)
5. The presence of WPW syndrome
216
What are some indications fo Ron-urgent DC cardioversion?
New onset or newly recognized AFIB
| Pts with persistent AF who are limited by their symptoms
217
What are some reasons not to cardiovert for AFIB?
Known AFIB & minimally symptomatic, multiple comorbidities, unlikely to maintain NSR, benefits of cardioversion decrease after age 80, paroxysmal AFIB
218
What must be done prior to cardioversion?
Control ventricular rate & provide IV heparin
219
If AFIB duration is >48HOURS..
Full anticoagulation or assessment for atrial thrombus prior to cardioversion
220
What other types of drugs can be used for cardioversion?
Antiarrhythmic meds can be used but not likely as effective
221
AFIB with RVR can reach what BPM?
>150bpm
222
Complications of rapid AFIB
Ischemia, pulmonary edema, tachycardia induce CMP (LV dilation, cellular morphologic changes)
223
What is the pharmacological treatment of AFIB with RVR?
1. BBs
2. CCBs
3. Digoxin
4. Amiodarone
224
What is first line treatment for AFIB with RVR?
BBs, CCBs
225
For immediate control of AFIB, which BBs should be used?
IV Metoprolol (start 5mg IVP) or IV propranolol
226
What BB can be used as chronic therapy for AFIB with RVR?
Oral Metoprolol (TID or Toprol XL once daily)
227
What other BBs can be used as chronic therapy for AFIB RVR
Oral Atenolol (once daily)
228
What BB can be used for chronic therapy for patients with liver failure?
Oral Nadolol
229
What BB can be used for chronic therapy for heart failure patients?
Oral Carvedilol
230
Which CCB should be used for immediate control of rapid AFIB?
IV Diltiazem (10-15mg IVP)* or Diltiazem gtt 5-15mg/hr for continuous infusion titrate to desired HR
231
What other CCB can be used for immediate control of rapid AFIB
IV Verapamil
232
What can be used for chronic CCB therapy for rapid AFIB?
Oral Diltiazem 3x/day or once daily long acting
233
What other drug can be used for rapid afib?
Oral Verapamil (3x/day or once daily long acting)
234
Digoxin for rapid AFIB (IV)
Less effective for rate control during exercise
| Can be added to BB if not working
235
Digoxin
Loading dose is initially higher, then use maintenance dose for everyday
Plasma digoxin levels should be monitored periodically (risk of dig toxicity)
236
Amiodarone for AFIB
Maintains SR, can slow rate for refractory AFIB with RVR after maximizing BB and CCBs
237
Amiodarone SEs
Abnormal liver fxn tests, pulmonary toxicity, most common pulmonary toxicity is chronic interstitial pneumonitis
238
Ischemic stroke is the most frequent what?
Arterial embolization from AFIB
239
CHADS2 is what?
Assesses the annual risk of stroke
240
CHADS2 score of 0
No anticoagulation
241
CHADS2 score 1&2
Consider CHA2DS2 VASc scoring system (intermediate risk)
242
CHADS2 score of >3
High risk (definitely provide anticoagulation)
243
What makes up the CHADS2 score?
CHF, HTN, age >75, DM, stroke or TIA
244
You get one point for each category on CHADS2 for everything except what?
Prior stroke or TIA 2 points
245
What makes up the CHA2DS2 VASc model?
Age <65, age 65-74, age>75, female gender, HTN, stroke/TIA, vascular disease, DM
246
Which categories do you get two points on for CHA2DS2-VASc model?
Stroke/TIA, Age >75
247
What is most commonly used for anticoagulation for AFIB?
Warfarin, frequent blood draws are required for monitoring
248
What other anticoags can be used for AFIB?
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
249
Which competitively depletes functional vitamin K reserves and hence reduces synthesis of many active clotting factors?
Warfarin
250
What is checked for warfarin?
INR: PT test/PT normal
PT: Prothrombin time (measure of clotting time)
251
What is the dosing for Warfarin when being used for AFIB?
Start daily dose and allow 5-7 days to reach therapeutic levels, adjust dose after 3 days
252
When should you “bridge” Warfarin with LMWH Heparin?
Not usually necessary for AFIB, recent or ongoing stroke or other embolus, known arterial thrombus, currently hospitalized (because its easy)
253
Warfarin compared to newer anticoagulants for AFIB
Similar or lower rates of ischemic stroke, similar or lower rates of major bleeding, do not require frequent lab draw*
Expensive
254
What are the indications for hospitalization for AFIB
Immediate anticoagulation (bridge), ablation of accessory pathway (WPW), treatment of associated medical problem (could be what triggered AFIB), management of rate or sick sinus syndrome
255
Commonly occurs after initiation of an antiarrhythmic drug for AFIB
Atrial flutter
256
Usually rapid, ventricular rate of 150bpm
Atrial flutter
257
Atrial rate is 250-350bpm
Atrial flutter
258
What are some associated disorders with Aflutter?
Hyperthyroidism, HF, obesity, obstructive sleep apnea, sick sinus syndrome, pericarditis, PE, pulmonary dx
259
Clinical manifestations of Aflutter
Palpitations, lightheaded, SOB, tachycardia, evidence of CHF
260
Diagnostic studies used for Aflutter
EKG, Echocardiogram, TEE if cardioversion is being considered, consider exercise stress testing
261
What will the TTE echocardiogram look for for Aflutter?
Size of RA and LA, size and function of RV and LV, assess for pericardial and valvular disease
262
Complications of Aflutter
Cardiac ischemia, pulmonary edema, tachycardia induced CMP, thromboembolism
263
Treatment considerations for Aflutter
Control ventricular rate, convert to NSR, maintain NSR, prevention of systemic embolization
264
Rate control of aflutter
More difficult to control than AFIB
BB or CCB used, Digoxin can be added
Amiodarone: rarely used
Radio frequency catheter ablation
265
Radio frequency catheter ablation is used for what?
Type 1aflutter
266
What does the radio frequency catheter ablation do?
Its a lates the IVC-TA area, maintains sinus rhythm after procedure with a 65-100% success rate
267
What is the IVC-TA area for aflutter?
Large macroreentrant pathways in RA involving obligatory pathway between inferior vena cava (IVC) and the tricuspid annulus (TA)
268
What % of people have recurrent atrial arrhythmias with radiofrequency catheter ablation?
7-44%
269
What are some antiarrhythmic meds used for conversion from aflutter to sinus rhythm?
Only 20-30% effective
| Dronedarone, Flecainide, Sotalol, Dofetilide, Amiodarone
270
When should anticoagulation therapy be used for aflutter?
Prior to RF catheter ablation- 4 weeks
After RF catheter ablation- 1 mo
With recurrent aflutter or AFIB after ablation, plan indefinite anticoag if CHADS2 score >1
271
What is the treatment for Dilated CMP if the pts EF <35%
ICD
272
What is the treatment for Dilated CMP if the pt has a significant arrhythmia?
ICD even before EF is <35%
273
What types of pts with Dilated CMP should be considered for an ICD?
Family Hx of sudden death OR known LMNA gene mutation
274
LMNA gene mutations
Sudden cardiac death is prominent; most common identified cause of genetic DCM
275
Management of hypertrophic obstructive CMP
ICD, septal myectomy or alcohol ablation
276
What types of meds can be used to treat HCM?
BBs, Verapamil, Diuretics, ACE-I or ARB
277
What are some radiographic features of restrictive CMP?
Pulmonary venous HTN, pulmonary edema, mild cardiomegaly, LA enlargement, LA appendage
