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Clin Med 2 > Cardiomyopathy, HF, PE, AFIB/Aflutter > Flashcards

Cardiomyopathy, HF, PE, AFIB/Aflutter Flashcards

1
Q

What is a disease of the heart muscle?

A

Cardiomyopathy

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2
Q

Cardiomyopathies manifest with what?

A

Various structural and functional abnormalities

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3
Q

What are the classifications of cardiomyopathy?

A
  1. Dilated cardiomyopathy (DCM)
  2. Restrictive cardiomyopathy (RCM)
  3. Hypertrophic cardiomyopathy (HCM)
    - Hypertrophic obstructive cardiomyopathy (HOCM)
  4. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)
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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)

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5
Q

Dilation and impaired contraction of one or both ventricles

A

Dilated cardiomyopathy

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6
Q

What happens to the systolic function in dilated cardiomyopathy?

A

Its impaired, the ejection fraction is <40%

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7
Q

What are the common causes of dilated cardiomyopathy?

A
  1. Idiopathic (most common-often genetic)
  2. Infections (viral myocarditis, Chagas dx)
  3. Toxins (drugs, meds, alcohol)
  4. Tachycardia induced CMP
  5. Stress (takotsubo)- sometimes considered “unclassified”
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8
Q

Infectious cardiomyopathy

A

Begins as an infectious myocarditis

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9
Q

What type of infectious cardiomyopathy is most common?

A

Viral

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10
Q

What type of bacteria can cause infectious cardiomyopathy?

A

Lyme, Mycoplasma

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11
Q

Chagas Disease

A

Protozoan infectious cardiomyopathy

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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

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13
Q

What is performed in pts who do not improve from dilated cardiomyopathy?

A

Endomyocardial biopsy

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14
Q

Dilated CMP; Infectious CMP; Chagas Disease

A 
Protozoan infection (Trypanosoma Cruzi)
Causes acute myocarditis, cardiac enlargement, nonspecific EKG changes, LV apical aneurysms
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15
Q

What can cause left ventricular apical aneurysms?

A

Dilated CMP; Infectious CMP; Chagas Dx

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16
Q

Clinical manifestation of Chagas’ disease

A

HF, Arrhythmias and heart block, thromboembolism, chest pain

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17
Q

What types of thromboembolism can be seen in Chagas Dx

A

Pulmonary embolism, cerebrovascular accident CVA = stroke

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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

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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

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20
Q

What are the causes of toxic cardiomyopathy?

A

Alcohol, cocaine, medications

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21
Q

Alcohol induced cardiomyopathy

A

Correlated to amount and duration of daily drinking

Abstinence can lead to improved cardiac fxn if diagnosed early

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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

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23
Q

How do you treat tachycardia induced cardiomyopathy?

A

Treatment of arrhythmia results in reversal of myocardial dysfunction

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24
Q

What is takotsubo?

A

Stress-induced dilated cardiomyopathy

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25
Q

Precipitated by intense psychological stress, also called “broken heart syndrome”

A

Takotsubo

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26
Q

Stress-induced cardiomyopathy patho

A

Post-menopausal women, LV apical ballooning, ST elevation without CAD

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27
Q

What happens in restrictive cardiomyopathy?

A

Hypertrophy is typically absent, rigid ventricular walls result in diastolic dysfunction, systolic function usually remains normal, there is also biatrial enlargement

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28
Q

What are the causes of restrictive cardiomyopathy?

A

Familial, infiltrative (amyloidosis, sarcoidosis), storage diseases (rare inherited disorders), scleroderma and endomyocardial fibrosis

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29
Q

Hypertrophic cardiomyopathy (HCM)

A

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

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30
Q

Hypertrophic obstructive cardiomyopathy (HOCM)

A

Hypertrophy of the ventricular septum, significant left ventricular outflow tract (LVOT) obstruction

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31
Q

What type of murmur can be heard with HOCM?

A

Harsh crescendo-decrescendo systolic murmur that increases intensity with Valsalva maneuver, decreases intensity with squatting

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32
Q

What are the common symptoms of HOCM?

A

Fatigue, dyspnea, chest pain, palpitations, presyncope or syncope

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33
Q

Clinical manifestations of HCM

A

LV outflow obstruction (HOCM), diastolic dysfunction, myocardial ischemia, mitral regurg, systolic dysfunction (end-stage), HF, supraventricular and ventricular arrhythmias, sudden death

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34
Q

How can you manage hypertrophic cardiomyopathy?

A

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

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35
Q

What procedure is used to improve LVOT?

A

Alcohol septal ablation or septal myectomy

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36
Q

What is a C/I for alcohol septal ablation

A

C/I under 21 years old, increased risk or ventricular arrhythmias under age 40 too

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37
Q

ARVC

A

Arrhythmogenic right ventricular cardiomyopathy

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38
Q

ARVC

A

Myocardium of RV is replaced by fibrous and/or fibro-fatty tissue

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39
Q

Patho of ARVC

A

Ventricular arrhythmias (VTACH), RV fxn is abnormal with regional akinesis or dyskinesis, global RV dilation and dysfunction

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40
Q

What can cause sudden cardiac death in young adults?

A

ARVC

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41
Q

Symptoms of ARVC

A

May be silent, palpitations, syncope, atypical chest pain, dyspnea

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42
Q

Diagnosing ARVC

A

Echocardiogram, Cardiac MRI genetic testing, endomyocardial biopsy

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43
Q

Treatment of ARVC

A

ICD Implantable cardiac defibrillator, antiarrhythmic drugs, no competitive sports, cardiac transplant if progressive and debilitating after optimal use of other treatments

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44
Q

Cardiac output = what

A

HR x SV

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45
Q

Stroke volume

A

How much blood is ejected with each beat

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46
Q

Cardiac output

A

How much blood is ejected in one minute

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47
Q

Preload

A

Loading condition of the heart at the end of diastole, right before systole (maximum diastolic stretch for that contraction)

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48
Q

What is preload determined by?

A

Mainly by venous return to the heart

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49
Q

Afterload

A

The force that the contracting heart must generate to eject blood from the filled heart

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50
Q

What is afterload determined by?

A

Ventricular wall tension, peripheral vascular resistance (PVR)

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51
Q

Cardiac contractility

A

The ability of the heart to contract

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52
Q

Ionotropic influence is what?

A

Increases the cardiac contractility

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53
Q

What is a positive inotropic action?

A

Digitalis, sympathetic stimulation

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54
Q

What is a negative inotropic action?

A

Akinesis secondary to myocardial infarction

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55
Q

What is LVEF?

A

Left ventricular ejection fraction, the % of blood leaving the heart each time it contracts

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56
Q

What is a normal EF? Or LVEF?

A

55-65%

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57
Q

What is the clinical diagnosis of HF based on?

A

Careful hx, PE and objective data

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58
Q

Impairment of ventricular filling or ventricular ejection

A

Heart Failure

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59
Q

What is low output HF?

A

Pumping or filling ability of the heart is impaired (most common type)

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60
Q

Right sided heart failure

A

Blood backs up into the systemic venous system (legs, hepatic veins, GI tract)

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61
Q

What are the causes of right-sided heart failure?

A

Left-sided HF (most common cause), severe or chronic pulmonary dx, pulmonic valve stenosis

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62
Q

Left-sided HF

A

Blood backs up into lungs (pulmonary edema), and into right heart and systemic venous system
Can be both systolic or diastolic dysfunction

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63
Q

Causes of left-sided HF

A

Acute myocardial infarction, chronic CAD/multiple infractions, CMPs, LV hypertrophy

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64
Q

Systolic dysfunction

A

Impaired ejection of blood from the heart during systole (HF with reduced EF/HFrEF)

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65
Q

What type of dysfunction is there HF with reduced ejection fraction?

A

Systolic

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66
Q

Diastolic dysfunction

A

Impaired filling of the ventricles during diastole (HF with preserved EF/HFpEF)

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67
Q

Which type of dysfunction has preserved EF?

A

Diastolic dysfunction

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68
Q

What are some common causes of systolic dysfunction?

A

Ischemic Heart disease idiopathic dilated cardiomyopathy, HTN, valvular disease

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69
Q

How does HTN cause systolic dysfunction?

A

Chronic pressure overload causes remodeling

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70
Q

What are the causes of diastolic dysfunction?

A

Longstanding HTN (stiff ventricles), restrictive CMPs, valvular disorders (mitral vale stenosis)

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71
Q

NY Heart Association functional classification of HF

A

Class 1-4

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72
Q

Class 1 HF

A

Symptoms onyl with significant activity

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73
Q

Class 2 HF

A

Symptoms with ordinary activity of daily living

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74
Q

Class 3 HF

A

Symptoms with only minimal exertion

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75
Q

Class 4 HF

A

Symptoms at rest

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76
Q

What are the common symptoms of HF?

A

SOB especially with exertion (DOE), orthopedist, PND paroxysmal nocturnal dyspnea, weight gain, swelling-ankle edema, increased abd girth

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77
Q

What other symptoms can be seen with HF?

A

Chest pain or pressure, fatigue, weakness, heart palpitation if associate arrhythmia

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78
Q

What are triggers for a new diagnosis of HF?

A

Acute MI, recent MI, AFIB with RVR or other tachyarrythmias

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79
Q

What are triggers for pts with known HF (triggers for decompensation)

A

Change it diet- increased salt, increased fluid

Change in medication- reduction in diuretic doses missed doses, non-compliance

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80
Q

PE findings of HF

A

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

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81
Q

What can be seen on an EKG for someone with HF?

A

Arrhythmias (AFIB), acute or prior MI, acute ischemia, LVH

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82
Q

What lab studies are done for someone with HF?

A

BNP, troponin, creatinine kinase, CK-MB, CBC, CMP, kidney fxn, liver fxn

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83
Q

What radiographic studies can be used for HF?

A

CXR and echocardiogram for new diagnoses

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84
Q

CXR findings in HF

A

Blunting of costrophrenic angles, pulmonary vein engorgement, cephalization, Kerley B lines, caridomegaly

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85
Q

What does pulmonary vein engorgement look like on a CXR for HF?

A

Increased interstitial markings

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86
Q

What are Kerley B Lines?

A

Thickened horizontal linear opacities in the subpleural region, which meet the pleura at right angles (HF)

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87
Q

What are the goals of therapy for HF?

A

Clinical improvement of symptoms, reduction of mortality and morbidity risk, reduction in rate of hospitalization

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88
Q

What are some ways to manage HF?

A

Determine underlying etiology, severity of syndrome, correct systemic factors, lifestyle mods, remove excess fluid, ultrafiltration, implantable devices

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89
Q

What is the treatment for HTN in HF?

A

ACE inhibitor, ARB, or ARNI (angiotensin receptor neprilysin inhibitor)
BB C/I during acute decompensated CHF

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90
Q

Why are BB C/I in heart failure?

A

Due to bradycardia, can worsen CHF

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91
Q

What is used to treat ischemic heart disease in HF?

A

Aspirin, BB, statin and revascularization

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92
Q

What is used to treat valvular disease in HF?

A

Surgical correction

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93
Q

What is the step-wise pharmacological management of HF?

A

Reduce fluid and improve symptoms, reduce afterload and improve CO, improve remodeling (less scar tissue), improve outcomes in African Americans, reduce hospitalization

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94
Q

How do you reduce fluid and improve symptoms for HF?

A

Diuretics

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95
Q

How do you reduce afterload and improve CO for HF?

A

ACE inhibitor, ARB, or ARNI

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96
Q

How do you improve remodeling for HF?

A

Beta-blockers

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97
Q

How do you improve outcomes in African Americans with HF?

A

Hydralazine and Bidil (Isosorbide Dinitrate)

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98
Q

How do you reduce hospitalizations for HF?

A

Digoxin

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99
Q

Which diuretics are used to reduce fluid levels in HF pts?

A

Furosemide (Lasix) with Spironolactone

Budesonide and Torsemide (stronger than lasix)

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100
Q

Which ACE inhibitors are used to reduce afterload and improve CO?

A

Lisinopril, Captopril

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101
Q

Which ARBs are used to reduce afterload and improve CO?

A

Irbesartan, Losartan, Valsartan (used if pt cant tolerate ACE-I)

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102
Q

What beta-blockers are used to improve remodeling and lessen scar tissue?

A

Carvedilol and Metoprolol

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103
Q

What is the treatment for acute decompensated HF?

A 
IV Loop diuretics (furosemide) q12 to q6
Rate control (CCB or BB)
ACE-I for systolic dysfunction (or ARB)
Monitor electrolytes
Monitor kidney fxn
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104
Q

What else needs to be monitored in a pt with acute decompensated HF?

A

Hospitalize! Monitor strict ins and outs (fluid in/urine out), daily weights, 2gm daily sodium restriction, 1.5L daily fluid restriction

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105
Q

What is the daily sodium restriction for someone with acute decompensated HF?

A

2gm/Day

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106
Q

What is the daily fluid restriction for someone with acute decompensated HF?

A

1.5L daily

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107
Q

Which electrolytes need to be monitored for someone with acute decompensated HF?

A

Potassium and Magnesium

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108
Q

What is the treatment for someone in severe hemodynamic compromise?

A

Intubation, CCU admission, inotropic agents, vasoconstrictors, mechanical/surgical interventions

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109
Q

What inotropic agents are given to pts who have severe hemodynamic compromise?

A

Dobutamine or Milrinone

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110
Q

What vasoconstrictors are used for someone who has severe hemodynamic compromise?

A

Dopamine, Epinephrine, Phenylephrine, Vasopressin

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111
Q

What mechanical and surgical interventions are necessary for someone who has severe hemodynamic compromise?

A

Intra-aortic balloon counter pulsation, percutaneous and surgically implanted LV assist devices and cardiac trans plantations

112
Q

What is a common cause of systolic CHF?

A

Ischemic heart disease

113
Q

What is a common cause of diastolic CHF?

A

Longstanding HTN

114
Q

What is the pericardium?

A

Sac of visceral and parietal layers

115
Q

What stabilizes the heart in anatomic position?

A

Pericardium

116
Q

Pericardium functions

A

Reduces contact between the heart and surrounding structures

117
Q

The pericardial cavity has how much fluid?

A

15-50ml of plasma

118
Q

What is an effusion?

A

The presence of abnormal amount of fluid

119
Q

Pericardial effusion

A

Many etiologies, there is acute, subacute and chronic

A complication: Cardiac tamponade

120
Q

What does a cardiac tamponade result in?

A

Compression of the heart

121
Q

Pericardial effusion etiologies

A

Acute pericarditis, autoimmune dx, post MI or s/p cardiac surgery, sharp or blunt chest trauma, malignancy, renal failure, myxedema, aortic dissection, meds

122
Q

Symptoms of PE and cardiac tamponade

A

Chest pain/pressure, chest discomfort, lightheaded, palpitations, SOB, cough

123
Q

Si/PE of pericardial effusion

A

Pericardial friction rub

124
Q

Si/PE or Cardiac Tamponade

A

Tachycardia, tachypnea, hepatojugular reflex, pulsus paradoxus, beck’s triad

125
Q

What is Pulsus Paradoxus?

A

Si of cardiac tamponade, decrease in BP by 10mmHg during inspiration

126
Q

What is Beck’s Triad?

A
  1. Hypotension
  2. Muffled heart sounds
  3. JVD
127
Q

What is Beck’s triad found in?

A

Cardiac tamponade

128
Q

PE and cardiac tamponade diagnostics

A
  1. Echocardiogram
  2. Electrocardiograph EKG
  3. CXR
  4. +/- CT or MRI
129
Q

What can be seen on an EKG for PE and cardiac tamponade?

A

Low voltage, tachycardia, and electrical alternans

130
Q

What is electrical alternans?

A

Get a change in amplitude depending on which lead you are at

131
Q

What will a CXR show for PE and cardiac tamponade?

A

Varies depending on etiology and size of effusion, can see cardiomegaly for pts with chronic PE

132
Q

What is required to establish a diagnosis of PE and cardiac tamponade?

A

Echocardiography

133
Q

What types of echcardiographies are there?

A

TTE transthoracic and TEE transesophageal

134
Q

Treatment options for PE and cardiac tamponade

A

Directed at underlying cause- percutaneous pericardiocentesis, surgical pericardectomy with drainage

135
Q

When is a procedure indicated for PE or cardiac tamponade?

A

If emergent hemodynamic instability/cardiac tamponade

Sampling of effusion for diagnostic purposes with unclear etiology

136
Q

What is pericarditis?

A

Inflammation of the pericardial sac

Can be acute, recurrent and chronic

137
Q

Pericarditis epidemiology

A

Most common disorder involving pericardium

138
Q

Etiology of pericarditis

A

Idiopathic/Infectious: viral (most common), bacterial, fungal, Lyme
Neoplasticism, Iatrogenic, Drugs, Metabolic disorder

139
Q

What types of neoplasms cause pericarditis?

A

Malignancies of lung/breast, Hodgkin’s

140
Q

Iatrogenic causes of pericarditis

A

Post MI (Dressler Syndrome), radiation therapy, metabolic disorders, Rheymatologic dx

141
Q

What drugs can cause pericarditis?

A

Isoniazid, Hydralazine

142
Q

What are some complications of pericarditis?

A

Large pericardial effusion, cardiac tamponade

143
Q

What diagnostics are used to evaluate for pericarditis?

A

EKG, CBC, cardiac biomarkers, inflammatory markers, +/-CXR, echo

144
Q

Symptoms of pericarditis

A

Chest pain (pleuritic) that is sharp and worse with inspiration, +/- viral URI type complaints

145
Q

Signs/PE of pericarditis

A

Classic picture: Patient sitting up and leaning forward, pericardial friction rub

146
Q

Pericarditis diagnostic aids

A

ECG* most useful, WBC, ESR, CRP for inflammation, Troponin, +/- CXR, +/- echocardiogram

147
Q

You need 2 or more of the following to diagnose pericarditis:

A
  1. Pericardial Chest pain
  2. Pericardial friction rub
  3. Changes on EKG
  4. New or worsening pericardial effusion
148
Q

How do you manage pericarditis if caused by idiopathic or viral?

A

NSAIDs or Aspirin + Colchicine + Proton Pump Inhibitor

149
Q

How do you manage pericarditis if caused by Dressler Syndrome?

A

Colchicine 3 mos+ Aspirin for 2 weeks

150
Q

What are the indications for glucocorticoid therapy (pericarditis)

A

Refractory pericarditis, immune mediated causes

151
Q

When should a pt be hospitalized for pericarditis?

A

Fever >100.4, evidence of suggesting tamponade, large PE, acute trauma, Warfarin/antiplatelet therapy, failure to respond to NSAID therapy, elevated troponin

152
Q

Inflammation of the endocardium, usually heart valves

A

Endocarditis

153
Q

3/4 of patient’s with endocarditis (IE) have what?

A

Pre-existing structural cardiac abnormality

Acute (Short Incubation) and Subacute (Long Incubation)

154
Q

Risk factors for endocarditis

A

> 60YO, males, IVDA, poor dentition/dental infection requiring invasive dental procedure, structural heart disease, congenital HD, prosthetic valve, chronic hemodialysis, intravascular devices

155
Q

What structural heart diseases make you at risk for endocarditis?

A

Valvular disease

156
Q

What congenital heart disease make you at risk for endocarditis?

A

ASD, VSD, TOF

157
Q

Endocarditis etiology

A

Staph strep, enterococci, strep bovis, HACEK organisms

158
Q

What are the HACEK organisms?

A

Haeomophius aphrophilus, actinobacillis acntinomycetemcomitans, cardiobaterium hominis, eikenella corrodens, kingella species

159
Q

What organisms are required to meet Duke’s criteria for diagnosis?

A

HACEK

160
Q

Endocarditis symptoms

A

Non-specific like cough, SOB, arthralgias, fever

161
Q

Signs/PE of endocarditis

A

Embolism events, inflammatory lesions, splinter hemorrhage’s, fever, new heart murmur

162
Q

What embolic events can happen in endocarditis?

A

Petechiae and Janeway lesions: on palms and soles of feet

163
Q

What inflammatory lesions can happen in endocarditis?

A

Osler nodes: Painful raised lesions of fingers, toes, and feet
Roth spot: exudative lesions of the retina

164
Q

What symptoms can be seen with endocarditis?

A

Non specific like cough SOB, arthralgias, fever

165
Q

Si/PE for endocarditis

A

Fever, new heart murmur, splinter hemorrhages, embolic events (digits, lung, kidney) petechiae, Janeway lesions, inflammatory lesions: Osler nodes and Roth spot

166
Q

How do you diagnose endocarditis?

A

Blood culture x3, echocardiogram, +/- CRX, CBC, urinalysis, rheumatoid factor

167
Q

Which echocardiogram is better for endocarditis?

A

Transesophageal TEE is better than TTE

168
Q

What is Duke’s criteria?

A

Criteria to diagnose endocarditis

169
Q

What are the major criteria listed in Duke’s criteria?

A

> 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
Q

What is the minor criteria for Duke’s criteria?

A

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
Q

What is the diagnosis requirement for Duke’s criteria of endocarditis

A

2 major OR 1 major and 3 minor OR 5 minor

172
Q

What is the empiric therapy treatment for endocarditis?

A

Vancomycin 15-20mg/kg/dose BID-TID + Ceftriaxone 2gr every 24h

173
Q

If endocarditis caused by MSSA, drug to use

A

Nafcillin or Oxacillin 1.5gm-2mg q4h x 6weeks

174
Q

If endocarditis is caused by strep viridans, drug to use

A

Penicillin G 2-3millino units IV q4hrs x 4weeks +/- Gentamycin

175
Q

What type of cardiac damage can endocarditis cause?

A

Valve damage and congestive heart failure

176
Q

What type of conduction abnormalities can endocarditis cause?

A

AV block, AFIB

177
Q

What types of peripheral embolization can endocarditis cause?

A

Digit amputation, septic emboli to lung, renal infarct

178
Q

Which population is at risk and needs Abx prophylaxis?

A

Cardiac conditions (prosthetic cardiac valve, h/o IE, congenital heart disease, cardiac transplant)

179
Q

Which procedures require Abx prophylaxis for endocarditis?

A

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
Q

Which abx can be used as prophylaxis for endocarditis?

A

Amoxicillin 2gram -one hour before the procedure

181
Q

What is a disorganized, rapid and irregular atrial activation?

A

AFIB

182
Q

What is the patho behind AFIB

A

Loss of effective atrial contractility, results in irregular ventricular response

183
Q

What is the HR with AFIB?

A

Often rapid, 120-160BPM

184
Q

What does AFIB lead to?

A

Clot formation and subsequent thromboembolic events (leading cause of stroke)

185
Q

Epidemiology of AFIB

A

Most common sustained arrhythmia, prevalence increases with age, M>F, white>black, hispanic, asian

186
Q

What is the incidence of AFIB?

A

40-95YO chance is 26% for men and 23% for women

>5% of population over 70 years

187
Q

The etiology of AFIB is often related to what?

A

Atrial stretching or scarring

188
Q

Etiologies of AFIB

A

Acute hyperthyroidism, acute3 vagotonic episode, acute alcohol intoxication, post-op, Atrial enlargement disruption of electrical conduction system

189
Q

What is the most common etiology of AFIB?

A

Atrial enlargement

190
Q

Pathogenesis of AFIB

A

Elevation in atrial pressure, majority of episodes are triggered by atrial premature beats

191
Q

What can AFIB be triggered by?

A

Atrial premature beats, other supraventricular arrhythmia; atrial flutter or atrial tachycardia

192
Q

Where are ectopic foci most likely located?

A

At the ostial portion of the pulmonary veins (site of ablation)

193
Q

Risk factors for AFIB

A

Age >64, male, HTN, elevated BMI, prolonged PR interval, valvular dx, CHF

194
Q

What is an important risk factor to note for AFIB?

A

Valvular disease, especially mitral or pulmonic valves

195
Q

What are the classifications of AFIB?

A

PAF: Paroxysmal
Persistent
“Lone AF”

196
Q

Paroxysmal AFIB (PAF)

A

Intermittent AFIB, still at same stroke risk of people with persistent AFIB

197
Q

Persistent AFIB

A

Fails to self-terminate within 7 days & requires intervention in order to convert

198
Q

Permanent AFIB

A

> 12 mos & no longer pursue rhythm control

199
Q

“Lone AF”

A

Without structural heart disease, lowest risk of complications (not used much anymore)
Basically, had AFIB once and never again

200
Q

What valvular heart diseases are associated with AFIB?

A

Significant stenosis or regurg, rheumatic heart disease

201
Q

What other diseases are associated with AFIB?

A

HF, HTN heart disease, acute MI (due to ischemia or stretch)

202
Q

Symptoms of AFIB

A

Asymptomatic, heart palpitations, light-headedness, pre-syncope, syncope, SOB & exercise intolerance, chest pain, fatigue

203
Q

Common triggers of AFIB episodes

A

Sleep deprivation, physical illness, post-op, stress, hyperthyroidism, exercise, stimulant meds (sudafed), alcohol, caffeine, dehydration

204
Q

What can be seen with new onset AFIB?

A

Heart palpitations, fatigue or lightheadedness, dyspnea SOB, angina (chest discomfort)

205
Q

What do you do with a new onset AFIB?

A

Rate vs, rhythm control, prevent systemic embolization

206
Q

What diagnostic studies can be used for AFIB?

A

EKG, echocardiogram, stress test, CBC,BMP, TSH (for hyperthyroid)

207
Q

Hx taking for AFIB

A

Underlying Diane: CAD and CHF, CVA, DM, HTN, COPD, Thyroid disorder

208
Q

Complete CV exam

A

BP and pulse rate, murmurs, evidence of HF, extremity pulses

209
Q

Look for these associated EKG findings for AFIB

A

LVH, pathologic Q waves, delta waves short PR interval (WPW), QT interval duration

210
Q

What should be seen in a TTE for AFIB?

A

Size of atria, size & fxn of R & L ventricules, valvular heart disease pericardial disease, atrial thrombus

211
Q

Which types of valvular heart disease can be seen on TTE for AFIB?

A

Mitral regurg and mitral stenosis

212
Q

Which type of echocardiogram is more sensitive for testing atrial thrombus?

A

TEE transesophageal

213
Q

Additional testing for AFIB

A 
Exercise stress testing-assess for ischemic heart disease 
Heart monitors (hollers, event recorders)
214
Q

What are the goals of therapy for AFIB?

A
  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
Q

What are some indications for urgent direct current (DC) cardioversion for AFIB?

A
  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
Q

What are some indications fo Ron-urgent DC cardioversion?

A

New onset or newly recognized AFIB

Pts with persistent AF who are limited by their symptoms

217
Q

What are some reasons not to cardiovert for AFIB?

A

Known AFIB & minimally symptomatic, multiple comorbidities, unlikely to maintain NSR, benefits of cardioversion decrease after age 80, paroxysmal AFIB

218
Q

What must be done prior to cardioversion?

A

Control ventricular rate & provide IV heparin

219
Q

If AFIB duration is >48HOURS..

A

Full anticoagulation or assessment for atrial thrombus prior to cardioversion

220
Q

What other types of drugs can be used for cardioversion?

A

Antiarrhythmic meds can be used but not likely as effective

221
Q

AFIB with RVR can reach what BPM?

A

> 150bpm

222
Q

Complications of rapid AFIB

A

Ischemia, pulmonary edema, tachycardia induce CMP (LV dilation, cellular morphologic changes)

223
Q

What is the pharmacological treatment of AFIB with RVR?

A
  1. BBs
  2. CCBs
  3. Digoxin
  4. Amiodarone
224
Q

What is first line treatment for AFIB with RVR?

A

BBs, CCBs

225
Q

For immediate control of AFIB, which BBs should be used?

A

IV Metoprolol (start 5mg IVP) or IV propranolol

226
Q

What BB can be used as chronic therapy for AFIB with RVR?

A

Oral Metoprolol (TID or Toprol XL once daily)

227
Q

What other BBs can be used as chronic therapy for AFIB RVR

A

Oral Atenolol (once daily)

228
Q

What BB can be used for chronic therapy for patients with liver failure?

A

Oral Nadolol

229
Q

What BB can be used for chronic therapy for heart failure patients?

A

Oral Carvedilol

230
Q

Which CCB should be used for immediate control of rapid AFIB?

A

IV Diltiazem (10-15mg IVP)* or Diltiazem gtt 5-15mg/hr for continuous infusion titrate to desired HR

231
Q

What other CCB can be used for immediate control of rapid AFIB

A

IV Verapamil

232
Q

What can be used for chronic CCB therapy for rapid AFIB?

A

Oral Diltiazem 3x/day or once daily long acting

233
Q

What other drug can be used for rapid afib?

A

Oral Verapamil (3x/day or once daily long acting)

234
Q

Digoxin for rapid AFIB (IV)

A

Less effective for rate control during exercise

Can be added to BB if not working

235
Q

Digoxin

A

Loading dose is initially higher, then use maintenance dose for everyday
Plasma digoxin levels should be monitored periodically (risk of dig toxicity)

236
Q

Amiodarone for AFIB

A

Maintains SR, can slow rate for refractory AFIB with RVR after maximizing BB and CCBs

237
Q

Amiodarone SEs

A

Abnormal liver fxn tests, pulmonary toxicity, most common pulmonary toxicity is chronic interstitial pneumonitis

238
Q

Ischemic stroke is the most frequent what?

A

Arterial embolization from AFIB

239
Q

CHADS2 is what?

A

Assesses the annual risk of stroke

240
Q

CHADS2 score of 0

A

No anticoagulation

241
Q

CHADS2 score 1&2

A

Consider CHA2DS2 VASc scoring system (intermediate risk)

242
Q

CHADS2 score of >3

A

High risk (definitely provide anticoagulation)

243
Q

What makes up the CHADS2 score?

A

CHF, HTN, age >75, DM, stroke or TIA

244
Q

You get one point for each category on CHADS2 for everything except what?

A

Prior stroke or TIA 2 points

245
Q

What makes up the CHA2DS2 VASc model?

A

Age <65, age 65-74, age>75, female gender, HTN, stroke/TIA, vascular disease, DM

246
Q

Which categories do you get two points on for CHA2DS2-VASc model?

A

Stroke/TIA, Age >75

247
Q

What is most commonly used for anticoagulation for AFIB?

A

Warfarin, frequent blood draws are required for monitoring

248
Q

What other anticoags can be used for AFIB?

A

Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)

249
Q

Which competitively depletes functional vitamin K reserves and hence reduces synthesis of many active clotting factors?

A

Warfarin

250
Q

What is checked for warfarin?

A

INR: PT test/PT normal
PT: Prothrombin time (measure of clotting time)

251
Q

What is the dosing for Warfarin when being used for AFIB?

A

Start daily dose and allow 5-7 days to reach therapeutic levels, adjust dose after 3 days

252
Q

When should you “bridge” Warfarin with LMWH Heparin?

A

Not usually necessary for AFIB, recent or ongoing stroke or other embolus, known arterial thrombus, currently hospitalized (because its easy)

253
Q

Warfarin compared to newer anticoagulants for AFIB

A

Similar or lower rates of ischemic stroke, similar or lower rates of major bleeding, do not require frequent lab draw*
Expensive

254
Q

What are the indications for hospitalization for AFIB

A

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
Q

Commonly occurs after initiation of an antiarrhythmic drug for AFIB

A

Atrial flutter

256
Q

Usually rapid, ventricular rate of 150bpm

A

Atrial flutter

257
Q

Atrial rate is 250-350bpm

A

Atrial flutter

258
Q

What are some associated disorders with Aflutter?

A

Hyperthyroidism, HF, obesity, obstructive sleep apnea, sick sinus syndrome, pericarditis, PE, pulmonary dx

259
Q

Clinical manifestations of Aflutter

A

Palpitations, lightheaded, SOB, tachycardia, evidence of CHF

260
Q

Diagnostic studies used for Aflutter

A

EKG, Echocardiogram, TEE if cardioversion is being considered, consider exercise stress testing

261
Q

What will the TTE echocardiogram look for for Aflutter?

A

Size of RA and LA, size and function of RV and LV, assess for pericardial and valvular disease

262
Q

Complications of Aflutter

A

Cardiac ischemia, pulmonary edema, tachycardia induced CMP, thromboembolism

263
Q

Treatment considerations for Aflutter

A

Control ventricular rate, convert to NSR, maintain NSR, prevention of systemic embolization

264
Q

Rate control of aflutter

A

More difficult to control than AFIB
BB or CCB used, Digoxin can be added
Amiodarone: rarely used
Radio frequency catheter ablation

265
Q

Radio frequency catheter ablation is used for what?

A

Type 1aflutter

266
Q

What does the radio frequency catheter ablation do?

A

Its a lates the IVC-TA area, maintains sinus rhythm after procedure with a 65-100% success rate

267
Q

What is the IVC-TA area for aflutter?

A

Large macroreentrant pathways in RA involving obligatory pathway between inferior vena cava (IVC) and the tricuspid annulus (TA)

268
Q

What % of people have recurrent atrial arrhythmias with radiofrequency catheter ablation?

A

7-44%

269
Q

What are some antiarrhythmic meds used for conversion from aflutter to sinus rhythm?

A

Only 20-30% effective

Dronedarone, Flecainide, Sotalol, Dofetilide, Amiodarone

270
Q

When should anticoagulation therapy be used for aflutter?

A

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
Q

What is the treatment for Dilated CMP if the pts EF <35%

A

ICD

272
Q

What is the treatment for Dilated CMP if the pt has a significant arrhythmia?

A

ICD even before EF is <35%

273
Q

What types of pts with Dilated CMP should be considered for an ICD?

A

Family Hx of sudden death OR known LMNA gene mutation

274
Q

LMNA gene mutations

A

Sudden cardiac death is prominent; most common identified cause of genetic DCM

275
Q

Management of hypertrophic obstructive CMP

A

ICD, septal myectomy or alcohol ablation

276
Q

What types of meds can be used to treat HCM?

A

BBs, Verapamil, Diuretics, ACE-I or ARB

277
Q

What are some radiographic features of restrictive CMP?

A

Pulmonary venous HTN, pulmonary edema, mild cardiomegaly, LA enlargement, LA appendage

Clin Med 2 (4 decks)

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