Common Hospital Cardiac Issues Flashcards
what are some sysmptoms suggestive of ACS?
distress/unwell
diaphoresis
Levine’s sign
EKG → > 1 mm elevation in 2 continguous leads, new LBBB
patient demographic that can present w/ “atypical” symptoms
women
elderly
diabetics
our initial evaluation to rule out ACS is based on what two things?
history & EKG
what might cause false positives troponin levels?
renal disease
myocarditis
cardiac contusion
recent cardiac surgery or cath
criteria that makes somebody high risk for ACS
ST elevation or new LBBB
ST depression or T inversion
CP with hemodynamic instability
dynamic EKG changes
known CAD with reminiscent paint
high risk history +/- positive tropnin
criteria that makes somebody moderate risk for ACS
atypical CP w/ CAD & normal or unchanged EKG
CP w/ nonspecific ST depression
low risk histoyr w/ normal EKG and + troponin
angina patient w/ rest angina w/ spontaneous resolution or primarily after NTG SL
criteria that makes somebody low risk for ACS
atypical CP with negative troponins
criteria that makes somebody extremely low risk for ACS
clearly MSK pain
intial treatment in patients with chest pain in which the diagnosis is uncertain
admission → observation vs in-patient
MONA (morphin, O2, NTG, aspirin)
ACLS protocol as needed
Troponin-I
telemetry
when do we usually check troponin levels?
usually 0, 6, 12 hours
what is the TIMI score?
estimates mortality for patients w/ UA and NSTEMI
what is included in the TIMI score?
age > 65 yrs
> 3 risk factors for CHD
prior coronary stenosis > 50%
ST segment deviation on admit EKG
> 2 anginal episodes in prior 24 hours
elevated cardiac biomarkers
ususe of asirin in prior 7 days
TIMI risk for:
0-1?
2?
3?
4?
5?
6-7?
0-1 → 4.7%
2 → 8.3%
3 → 13.2%
4 → 19.9%
5 → 26.2%
6-7 → 40.9%
what are some immediate issues with A fib?
verify rhythm
verify hemodynamic stability
ventricular rate control
BP managment
what are some post-immediate issues with A fib?
identification of precipitating factors
consideration of cardioversion (if initially stable)
anticoagulation
what are the managment goals of A fib?
minimize symptoms related to A fib
prevent thromboembolic complications (especially stroke)
what do we do if a patient in A fib is hemodynamically unstable?
ACLS
what are some things we want to know about a patient presenting with A fib?
frequency
duration
precipitating factors & mode of prior termination
vital signs
apical rate
detailed CV exam
what does pre-excitation on an EKG indicate?
WPW syndrome
what additional testing should be done on A fib patients?
thyroid function tests (TSH, FT4)
CXR looking for pulmonary disease
ambulatory monitoring and/or exercise testing for rate control if indicated
eval for CAD if anti-arrhythmics considered
what are some indications for hospitalization in A fib patients?
cardioversion
initiation of anti-arrhythmics
rate managment
tx of associated medical conditions
elderly patients more safely treated in hospital
patients w/ risk of complications from A fib, therapy of A fib
what is the beneift to rhythm control in A fib?
maintain sinus rhythm & optimal cardiac output
what is the problem with rhythm control in A fib?
at best, 50-60% effective in maintaining sinus rhythm long term
with is an adverse efffect to rhythm control of A fib?
pro-arrhythmia (VT, torsades, VF) which can be life threatening
who would want rhythm control for A fib?
younger more active patients who benefit from optimal CO or increase risk of bleed
especially athlets & occupations with increased risk of trauma
patients in who rate is uncontrollable or symptomatically can’t tolerate AF
patients who request it
risk progressively increases after _____ hrs of sustained AF in patients w/ risk factors for stroke
48 hours
what does drug therapy do in the rate control approach to A fib?
slows AV donuction (we’re owrried about ventricular rate)
control rate at rest/exercise
what drugs do we use for the rate control approach in A fib?
CCB (diltiazem, verapamil)
beta-blocker
digoxin
often a combo is needed
alternative if rate control is not obtained via drug therapy
ablate AV node w/ radiofrequency
permanent ventricular or AV pacement
what are some risk factors that increase a patient’s stroke risk with chronic AF?
age > 65
prior history of stroke
diabetes mellitus
history of systemic hypertension
anticoagulation reduces stroke incidence to ___ each year
1%
oral anticoagulation
CHAD score 0?
CHAD score 1?
CHAD score 2?
0 → generally not
1 → consider
2 → generally yes
for chronic A fib, what should be use for anticoagulation?
aspirin?
coumadin?
NOAC?
aspirin → no
coumadin → possible
NOAC → yes
how should anticoagulation be initiated in chronic A fib patients?
no bridging for NOACs
Warafin- no bridging if no history of thromboembolism
what is the definition of heart failure?
decreased pump function of the heart due to cardiomyopathy or wall motion abnormality
what is the EF in systolic heart failure?
< 40%
what is impaired in diastolic heart failure?
impaired relaxation
what are some possible causes of iatrogenic heart failure and/or acute pulmonary edema?
IVF
medicatino adjustments or errors
transfusion
post-operative
A fib
what should be included in our assessment of heart failure?
focused H & P or consult
12 lead EKG
continuous EKG monitoring
labs- CBC, BMP, CKMB, troponin, TSH
CXR
consider 2D echo if iatrogenic
acute management for heart failure
IV diuretic, O2, NTG, morphine
sodium & fluid restriction
avoid NSAIDs
avoid empiric use of anti-arrhythmics
correct aggravating or precipitating factors
managment of systolic heart failure
ACE inhibitor
beta blocker (once stable)
thiazide diuretic in addition to furosemide
spironolacton for severe CHF in addition to loop diuretic & ACE-I
further managment of heart failure
anticoagulant if AF or hx of systemic or pulmonary embolism
isosorbide
hydralazine
NTG IV
management of mild to moderate acute on chronic CHF
IV or oral diuretics
unless complicated by a precipitating factor or a concurrent threatening condition
many do not require hopsital admission beyond several hours observation in ED
management of moderate to severe acute on chronic CHF
admit
approach as per acute CHF
consider SCU
