1. The document discusses treatment guidelines for a 55-year-old male presenting with chest pain, including administering aspirin, heparin, beta blockers, and transferring the patient for primary angioplasty within 90 minutes. 2. It provides an overview of guidelines for various treatments of acute coronary syndromes, including thrombolytics, primary PCI, facilitated PCI, and rescue PCI. 3. The document reviews evidence and recommendations for therapies like beta blockers, analgesics, and anticoagulants in treating acute coronary syndromes.

1. Todd C. Villines, MD Cardiology Service Cardiology Board Review Part I April 2008 Walter Reed Army Medical Center

2. Outline – Part I CAD Acute Coronary Syndromes (ACS) Chronic CAD Valvular Heart Disease Congenital Heart Disease Physical Exam Pearls

3. A 55 yo male presents to your rural ER with 30 minutes of substernal chest pain, nausea and diaphoresis: - Hx: HTN, tobacco abuse Rx: HCTZ, diltiazem SR - P 96 BP 146/92 Apprehensive. - RRR w/+S4. No murmur. Lungs – clear. Equal pulses. - He is treated with ASA, heparin, IV beta-blocker. clopidogrel 300 mg PO d. tPA eptifibatide IV e. transfer to facility only 1.5 hrs eptifibatide + ½ dose tPA away for primary angioplasty Which of the following should be done next ?:

4. Acute Coronary Syndromes Revascularization

5. Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI † STEMI 1.24 million Admissions per year .33 million Admissions per year Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

6. ACS - Thrombolytics Greatest benefit of thrombolytics in first 1-2 hours from symptom onset! (Golden Hour) ABSOLUTE Contraindications

7. Thrombolytics Relative Contraindications

8. ACS Things you must know… 1. 2. 3. 4. Rescue Angioplasty If no reperfusion in 60-90 mins. (20-40% will not reperfuse) If hemodynamically stable: no treatment! (CK washout ) Accelerated Idioventricular Rhythm (AIVR)

9. Primary PCI Absolute contraindication to thrombolytics STEMI Guidelines: Door to balloon: <90 minutes Highest risk patients benefit the most Treatment of choice in cardiogenic shock Late presentation Rescue angioplasty

10. Primary PCI

11. Primary PCI STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

12. Facilitated PCI

13. Meta-analysis: Facilitated PCI vs Primary PCI 1.03 (0.15-7.13) 3.07 (0.18-52.0) 1.43 (1.01-2.02) 1.03 (0.49-2.17) Mortality Reinfarction Major Bleeding Fac. PCI Better PPCI Better Fac. PCI Better PPCI Better Fac. PCI Better PPCI Better Keeley E, et al. Lancet 2006;367:579. 0.1 1 10 0.1 1 10 0.1 1 10 1.38 (1.01-1.87) 1.71 (1.16 - 2.51) 1.51 (1.10 - 2.08 ) 1.40 (0.49-3.98) 1.81 (1.19-2.77) Lytic alone N=2953 All (N=4500) Lytic +IIb/IIIa N=399 IIb/IIIa alone N=1148

14. A planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI is not recommended and may be harmful. Facilitated PCI using regimens other than full-dose fibrinolytic therapy might be considered as a reperfusion strategy when all of the following are present: a. Patients are at high risk, b. PCI is not immediately available within 90 minutes, and c. Bleeding risk is low (younger age, absence of poorly controlled hypertension, normal body weight). Facilitated PCI I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

15. Rescue and Late PCI

16. Meta-analysis: Rescue PCI vs Conservative Tx Wijeysundera HC, et al. J Am Coll Cardiol. 2007;49:422-430. In 3 trials, enrolling 700 patients that reported the composite end point of all-cause mortality, reinfarction, and HF, rescue PCI was associated with a significant RR reduction of 28% (RR 0.72; 95% CI, 0.59-0.88; P =.001) P RR (95% CI) Conservative Treatment Rescue PCI Outcome <.001 4.58 (2.46–8.55) 3.6 (307) 16.6 (313) Minor bleeding, % (n) .04 4.98 (1.10–22.48) 0.7 (295) 3.4 (297) Stroke, % (n) .04 0.58 (0.35–0.97) 10.7 (354) 6.1 (346) Reinfarction, % (n) .05 0.73 (0.54–1.00) 17.8 (427) 12.7 (424) HF, % (n) .09 0.69 (0.46–1.05) 10.4 (457) 7.3 (454) Mortality, % (n)

17. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is recommended in patients who have received fibrinolytic therapy and have: Cardiogenic shock in patients < 75 years who are suitable candidates for revascularization b. Severe congestive heart failure and/or pulmonary edema (Killip class III) c. Hemodynamically compromising ventricular arrhythmias. Rescue PCI I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

18. Rescue PCI A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is reasonable in patients ≥ 75 years who have received fibrinolytic therapy, and are in cardiogenic shock, provided they are suitable candidates for revascularization.

19. Rescue PCI A strategy of coronary angiography with intent to perform rescue PCI is reasonable for patients in whom fibrinolytic therapy has failed (ST-segment elevation < 50% resolved after 90 min following initiation of fibrinolytic therapy in the lead showing the worst initial elevation) and a moderate or large area of myocardium at risk [anterior MI, inferior MI with right ventricular involvement or precordial ST-segment depression]. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

20. Rescue PCI A strategy of coronary angiography with intent to perform PCI in the absence of any of the above Class I or IIa indications might be reasonable in moderate- or high-risk patients, but its benefits and risks are not well established. The benefits of rescue PCI are greater the earlier it is initiated after the onset of ischemic discomfort. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C

21. Rescue PCI A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is not recommended in patients who have received fibrinolytic therapy if further invasive management is contraindicated or the patient or designee do not wish further invasive care. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

22. Analgesia Morphine remains Class I for STEMI although may increase adverse events in UA/NSTEMI NSAID medications increase mortality, reinfarction, and heart failure in proportion to degree of COX-2 selectivity Discontinue on admission for STEMI Do not initiate during acute phase of management

23. Analgesia Patients routinely taking nonsteroidal anti-inflammatory drugs (NSAIDs) (except for aspirin), both non-selective as well as COX-2 selective agents, prior to STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.

24. Analgesia NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, should not be administered during hospitalization for STEMI because of the increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III

25. Beta-Blockers

26. TREATMENT: Metoprolol 15 mg iv over 15 mins, then 200 mg oral daily vs matching placebo INCLUSION: Suspected acute MI (ST change or LBBB) within 24 h of symptom onset EXCLUSION: Shock, systolic BP <100 mmHg, heart rate <50/min or II/III AV block 1  OUTCOMES: Death & death, re-MI or VF/arrest up to 4 weeks in hospital (or prior discharge) Mean treatment and follow-up: 16 days COMMIT : Study design

27. Effects of Metoprolol Lancet . 2005;366:1622. Death 13% P=0.0006 ReMI 22% P=0.0002 VF 15% P=0.002 Totality of Evidence (N = 52,411) COMMIT (N = 45,852) Increased early risk of shock Risk factors for cardiogenic shock :heart failure, age > 70 , systolic blood pressure < 120, sinus tachycardia > 110 or heart rate < 60, increased time since onset of STEMI symptoms

28. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval > 0.24 sec, 2 nd - or 3 rd -degree heart block, active asthma, or reactive airway disease). It is reasonable to administer an IV beta blocker at the time of presentation to STEMI patients who are hypertensive and who do not have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval > 0.24 sec, 2 nd - or 3 rd -degree heart block, active asthma, or reactive airway disease). Beta-Blockers I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

29. IV beta blockers should not be administered to STEMI patients who have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval > 0.24 sec, 2 nd - or 3 rd -degree heart block, active asthma, or reactive airway disease). Beta-Blockers I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A

30. Anticoagulants Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours (Level of Evidence: C) and preferably for the duration of the index hospitalization, up to 8 days (regimens other than unfractionated heparin [UFH] are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment). (Level of Evidence: A) Anticoagulant regimens with established efficacy include: ♥ UFH (LOE: C) ♥ Enoxaparin (LOE:A) ♥ Fondaparinux (LOE:B) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A

31. Anticoagulants For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed: a. For prior treatment with UFH: administer additional boluses of UFH as needed to support the procedure taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Level of Evidence: C) Bivalirudin may also be used in patients treated previously with UFH. (Level of Evidence: C) Recommendation continues on the next slide. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C

32. Anticoagulants b. For prior treatment with enoxaparin: if the last SC dose was administered within the prior 8 hours, no additional enoxaparin should be given; if the last SC dose was administered at least 8 to 12 hours earlier, an IV dose of 0.3 mg/kg of enoxaparin should be given. c. For prior treatment with fondaparinux: administer additional intravenous treatment with an anticoagulant possessing anti-IIa activity taking into account whether GP IIb/IIIa receptor antagonists have been administered. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

33. Anticoagulants Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C

34. ExTRACT-TIMI 25: Primary End Point (ITT) Death or Nonfatal MI Primary End Point (%) Enoxaparin UFH Relative Risk 0.83 (95% CI, 0.77 to 0.90) P <.001 Days after Randomization 9.9% 12.0% Lost to follow-up = 3 17% RRR Adapted with permission from Antman EM, et al. N Engl J Med . 2006;354:1477-1488.

35. CLARITY-TIMI 28 Primary Endpoint: Occluded Artery (or D/MI thru Angio/HD) Placebo Clopidogrel LD 300 mg MD 75 mg P=0.00000036 Odds Ratio 0.64 (95% CI 0.53-0.76) Clopidogrel better Placebo better n=1752 n=1739 Sabatine N Eng J Med 2005;352:1179. STEMI, Age 18-75 15.0 21.7 0 5 10 15 20 25 Occluded Artery or Death/MI (%) 1.0 0.4 0.6 0.8 1.2 1.6 36% Odds Reduction

36. COMMIT: Effect of CLOPIDOGREL on Death In Hospital Dead (%) Days Since Randomization (up to 28 days) Placebo + ASA: 1,846 deaths (8.1%) Clopidogrel + ASA: 1,728 deaths (7.5%) 0.6% ARD 7% RRR P = 0.03 N = 45,852 No Age limit ; 26% > 70 y Lytic Rx 50% No LD given Chen ZM, et al. Lancet . 2005;366:1607.

37. Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days. Thienopyridines I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

38. In patients < 75 years who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral clopidogrel loading dose of 300 mg. (No data are available to guide decision making regarding an oral loading dose in patients ≥ 75 years of age.) Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) can be useful in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Thienopyridines I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C

39. It is reasonable for patients with STEMI who do not undergo reperfusion therapy to be treated with anticoagulant therapy (non-UFH regimen) for the duration of the index hospitalization, up to 8 days. Convenient strategies that can be used include those with LMWH (Level of Evidence: C) or fondaparinux (Level of Evidence: B) using the same dosing regimens as for patients who receive fibrinolytic therapy. Anticoagulants I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

40. Coronary arteriography may be considered as part of an invasive strategy for risk assessment after fibrinolytic therapy (Level of Evidence: B) or for patients not undergoing primary reperfusion. (Level of Evidence: C) Invasive Evaluation I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C

41. Secondary Prevention Ask, advise, assess, and assist patients to stop smoking – I (B) Clopidogrel 75 mg daily: PCI – I (B) no PCI – IIa (C) Statin goal: LDL-C < 100 mg/dL – I (A) consider LDL-C < 70 mg/dL – IIa (A) Daily physical activity 30 min 7 d/wk, minimum 5 d/wk – I (B) Annual influenza immunization – I (B)

42. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule: LDL-C should be < 100 mg/dL. Further reduction to < 70 mg /dL is reasonable. (Class IIa; LOE: A) If baseline LDL-C is ≥ 100 mg/dL , LDL-lowering drug rx should be initiated. If on-treatment LDL-C is ≥ 100 mg/dL intensify LDL-lowering drug rx (may require LDL-lowering combination is recommended. If baseline LDL-C is 70 to 100 mg/dL , it is reasonable to treat to LDL-C < 70 mg/dL. (Class IIa; LOE: B) Lipid management: 2007 goal: LDL-C << than 100 mg/dL (if TG ≥ 200 mg/dL, non–HDL-C < 130 mg/dL Goals Class I Recommendations Secondary Prevention and Long Term Management NEW NEW

43. If TG are ≥ 150 mg per dL or HDL-C < 40 mg per dL, weight management, physical activity, and smoking cessation should be emphasized. If TGs are 200 to 499 mg per dL , non–HDL-C target should be less than 130 mg per dL. If TGs are 200 to 499 mg/dL , non–HDL-C target is < 130 mg/dL. (Class I; LOE: B) ; further reduction of non–HDL-C to < 100 mg dL is reasonable. (Class IIa; LOE: B) Therapeutic options to reduce non–HDL-C include: More intense LDL-C-lowering rx is indicated Niacin (after LDL-C-lowering rx) can be beneficial ( Class IIa; LOE B) Fibrate therapy (after LDL-C-lowering rx) can be beneficial ( Class IIa; LOE B) If TG are ≥ 500 mg/dL , therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL-lowering rx; and treat LDL-C to goal after TG- lowering rx. Achieving non–HDL-C < 130 mg/dL is recommended. Lipid management: (TG 200 mg/dL or greater) Primary goal: Non–HDL-C < 130 mg/dL Secondary Prevention and Long Term Management Goals Class I Recommendations NEW

44. For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. For all patients, encouraging 30 to 60 min of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). Advising medical supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, HF) is recommended. Encouraging resistance training 2 d per week may be reasonable (Class IIb; LOE: C) Physical activity: 2007 Goal: 30 min 7 d per wk; minimum 5 d per wk Goals Class I Recommendations Secondary Prevention and Long Term Management NEW

45. Goals Class I Recommendations For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162 to 325 mg daily should be given for at least 1 month after bare-metal stent implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 to 162 mg daily. Antiplatelet agents/ anticoagulants: Aspirin Secondary Prevention and Long Term Management CHANGED TEXT

46. Goals Recommendations In patients where the physician is concerned about the risk of bleeding lower-dose 75 to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Class IIa; LOE: C) Antiplatelet agents/ anticoagulants: Aspirin Secondary Prevention and Long Term Management NEW REC

47. Goals Class I Recommendations For all post-PCI patients who receive a drug-eluting stent (DES), clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a bare metal stent (BMS), clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). Antiplatelet agents/ anticoagulants: Clopidogrel Secondary Prevention and Long Term Management CHANGED TEXT

48. Goals Recommendations For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 d. (Class I; LOE: B) Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. (Class IIa; LOE: C) Antiplatelet agents/ anticoagulants: Clopidogrel Secondary Prevention and Long Term Management NEW RECS

49. Goals Class I Recommendations Managing warfarin to INR = 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-STEMI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2 to 2.5 is recommended with low dose aspirin (75 to 81 mg) and a 75 mg dose of clopidogrel. Antiplatelet agents/ anticoagulants: Warfarin Secondary Prevention and Long Term Management NEW REC NEW REC CHANGED TEXT

50. Acetaminophen, ASA, tramadol, narcotic analgesics (short term) COX-2 Selective NSAIDs Nonacetylated salicylates Non COX-2 selective NSAIDs NSAIDs with some COX-2 activity Stepped Care Approach To Pharmacologic Therapy for Musculoskeletal Symptoms with Known Cardiovascular Disease or Risk Factors for Ischemic Heart Disease Select patients at low risk of thrombotic events Prescribe lowest dose required to control symptoms Add ASA 81 mg and PPI to patients at increased risk of thrombotic events * Regular monitoring for sustained hypertension or worsening of prior blood pressure control), edema, worsening renal function, or gastrointestinal bleeding. If these events occur, consider reduction of the dose or discontinuation of the offending drug, a different drug, or alternative therapeutic modalities, as dictated by clinical circumstances. * Addition of ASA may not be sufficient protection against thrombotic events Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007. Available at http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001 .

51. Goals Class I Recommendations ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF ≤ 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Class IIa; LOE: B) Renin-Angiotensin-Aldosterone System Blockers: ACE Inhibitors Secondary Prevention and Long Term Management NEW REC CHANGED TEXT NEW REC

52. Goals Class I Recommendations Use of ARBs is recommended in patients who are intolerant of ACE inhibitors and have HF or have had a STEMI with LVEF ≤ 40%. It is beneficial to use ARB therapy in other patients who are ACE-inhibitor intolerant and have hypertension. Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable. Renin-Angiotensin-Aldosterone System Blockers: ARBs Secondary Prevention and Long Term Management NEW REC NEW REC CHANGED TEXT

53. Goals Class I Recommendations Use of aldosterone blockade in post-STEMI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of ≤ 40% and have either diabetes or HF. Renin-Angiotensin-Aldosterone System Blockers: Aldosterone Blockade Secondary Prevention and Long Term Management CHANGED TEXT

54. Goals Class I Recommendations It is beneficial to start and continue beta- blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without HF symptoms, unless contraindicated. Beta- Blockers Secondary Prevention and Long Term Management CHANGED TEXT

55. A 55 yo male presents to your rural ER with 1-hour of sub- sternal chest pain, nausea and diaphoresis: BP 110/68  Following SL NTG, BP falls to 90/50 Suspected Diagnosis?: As you give tPA + heparin, which of the following are most appropriate next tx?: Additional IV metoprolol d. IV fluid bolus Start nitroglycerin drip e. Place a PA catheter Dopamine drip

56. A 55 yo male presents to your rural ER with 1-hour of sub- sternal chest pain, nausea and diaphoresis: You give the patient tPA, IV fluids and his blood pressure increases and his symptoms and ECG changes are resolving. You notice that his heart rate significantly drops to 40 bpm. The BP remains stable and the patient has no symptoms. Place a transvenous pacemaker d. Observation. Give Atropine 0.5 mg IV atropine if develops sx’s or Atropine 1.0 mg IV hemodynamic change. Mobitz I, 2 nd -degree AVB (Wenckebach)

57. Transvenous Pacing & MI Location Inferior MI Sinus bradycardia (Bezold-Jarish) common Block at AV node Stable escape rhythm AV block is usually transient & well-tolerated TV Pace: Mobitz II or higher &: Symptoms that are unresponsive to atropine Anterior MI Block usually below AV node TV Pace : New bifasicular block Mobitz II or worse regardless of symptoms

58. Outline Arrhythmias & ECGs A 68 yo male presents to your ER after 60 minutes of substernal chest pain, nausea and diaphoresis: Hx: HTN, DM, HLD, Distant MI P 96 BP 146/92 RRR w/+S4. No murmur. Lungs – clear. ECG: 1mm ST-depression infero-laterally that resolves slowly with B-blocker, nitroglycerine & morphine. He rules in for MI: peak MB 30, trop-T 2.4. After stabilization on medical therapy, you recommend which of the following tests to risk stratify this patient?: Exercise stress test d. Myocardial Perfusion Imaging Stress Echo e. None of the above Cardiac Catheterization

59. Post MI Risk Stratification What is the overall best predictor of survival post-MI?: LV Ejection Fraction (EF)

60. Non-STEMI / UA Risk Stratification is key! Immediate High Risk Cardiogenic shock / severe CHF / ischemic MR w/hemodynamic change Recurrent angina despite maximal medical therapy Unstable ventricular arrhythmias Urgent Cath *Don’t give thrombolytics in NSTEMI! High Risk (+) enzymes Dynamic ECG changes Clinical CHF Depressed LV EF GIIb/IIIa Early invasive - Cath during initial Hospitalization

61. Intermediate Risk Diabetics, PVD, Age >65 Prior MI (hx or q-waves on ECG) Aspirin use Rest angina, < 20 minutes No dynamic ST changes Baseline pathologic q-waves Negative enzymes Low Risk None of above Minimal risk factors Minimal or atypical symptoms In General: Best medical therapy In general: Non-invasive risk stratification Cath for: High-risk non-invasive testing results Pre-existing lifestyle-limiting angina Non-STEMI / UA Risk Stratification is key!

62. MI: Initial Medical Therapy *Clopidogrel: post-stenting Bare-metal stent: at least 4 weeks and no surgery for 6 weeks Drug-eluting stent (sirolomus, paclitaxel): plavix for 3 months (sirolomus/Cypher) to 6 months (paclitaxel/Taxus) MINIMUM Often given for 1 year (CURE Trial) unless contraindication *162-325mg Heparin: *60 U/kg bolus then 12U/Kg/Hr in patients given lytics or IIb/IIIA

63. MI: Initial Medical Therapy *Warfarin x 3-6 months: LV thrombus, large anterior MI with akinetic anterior wall. -Don’t give warfarin to a patient simply with a depressed EF without Afib or embolism or thrombus (controversial) *

64. Post-MI Complications Acute pulmonary edema, hypotension, new decrescendo systolic murmur at apex PA Catheter (wedged): Papillary Muscle Rupture Treatment: Afterload reduction Nitrates IABP Emergent surgical repair

65. Post-MI Complications Papillary Muscle Rupture Inferior MI’s (PDA) Due to single blood supply to postero-medial papillary muscle

66. Post-MI Complications LV Free Wall Rupture: Large, STEMI, 1 st MI, Anterior MI (LAD) Less common with early reperfusion but may occur earlier (classically ~7d) Treatment: emergent surgery, pericardiocentesis, supportive measures Acute hypotension, JVD, muffled heart sounds Equalization of diastolic pressures on PA catheter

67. Post-MI Complications Ventricular Septal Rupture (Acute VSD): Location less important: Anterior = Inferior Treatment Unstable patient = urgent surgery Afterload reduction, IABP, supportive measures Hypotension, JVD, holosystolic murmur with a thrill PA catheter: “step up” in oxygen saturation from RA to RV

68. SCD Prevention Post-MI Primary Prevention Referral for AICD if ( MADIT I ): Non-sustained VT > 48 hours after MI EF <35% Inducible, non-supressable VT on EP study Best benefit: lower EF (<26%), wide QRS, CHF Wait > 1 month post-MI & 3mos. post CABG MADIT II : Prior MI + EF  30% No EP study

69. 1 ° SCD Prevention Non-ischemic Cardiomyopathy All-cause mortality at 5 years Amiodarone vs placebo HR 1.06, p=0.529 ICD vs placebo HR 0.77, p=0.007 % Mortality SCD-HeFT ½ non-ischemic EF ≤ 35% Amio = Placebo

70. Chronic CAD The ‘Big 4’: Aspirin B-blocker (especially post-MI & depressed EF) Non-dihyrdropyridine CCB (diltiazem) if B-blocker intolerant Statin Ace-I (HOPE & EUROPA trials –vs- PEACE trial) Nitrates (know dosing, tolerance) Recent change: 1 spray, if not gone  911 / ER Non-dihydropyridine CCB (e.g,. amlodipine) – may use with B-blocker No estrogen for CAD: primary prevention (WHI) or secondary prevention (HERS)

71. Chronic CAD Know methods to reduce risk (Board Favorites!): Smoking cessation Diet Weight loss Exercise Lipid management

72. Lipid Management xx * CAD Equivalents: - ASPVD - Diabetes - Multiple risk factors (Framingham > 20%) 2004 ATP III Modifications: In high risk patients: LDL-C goal < 70 is a therapeutic option based on recent clinical trial data (Heart Protection Study, PROVE-IT) High risk: may start statin if LDL-C 100-129 simultaneously with lifestyle changes. High risk: If baseline LDL is <100, can start statin If high risk & high TGs or low HDL-C: use fibrate or niacin to get non-HDL-C to 30mg/dl higher than LDL goal and to raise HDL Moderately high risk (2+ risk factors, 10-20% risk): LDL<100 optional goal

73. Lipid Management LDL goal – get there 1 st ! HDL and TG’s are secondary targets Once LDL to goal: “ Non-HDL chol.” goal: 30 higher than LDL goal (LDL+VLDL+TG’s) – incorporates all atherogenic particles Low HDL (<40 men, <50 women) Exercise, smoking cessation Niacin (most potent), fibrates

74. Notes on Revascularization 2 Goals Symptom relief (angina): PCI or CABG Improved survival: CABG PCI: better than medications for relief of angina & ischemia from obstructive CAD Stenting Complications: Early (1 st month) Acute thrombosis: 24 hours (not subtle - MI) Sub-acute thrombosis: usually < 4 weeks (not subtle - MI) With DES (drug-eluting stents), can occur later until fully endothelialized Late: in-stent restenosis: 1-6 months (angina) Reduced by DES Brachytherapy – FDA approved treatment for symptomatic restenosis (not for prevention!) – no longer done due to DES!!

75. Indications for CABG Left Main > 50% Left main equivalent: >70% proximal LAD & proximal Left Circumflex 3 vessel obstructive CAD, especially if: Depressed EF Diabetics 2 vessel CAD with proximal LAD disease & Depressed EF <OR> Treated diabetics “ Don’t stent the left main”

76. Stress Testing Exercise ECG Sens & Spec = ~ 70%… Bayesian approach to using for diagnosis : High pre-test probability: negative test won’t change management Low pre-test probability: false + > true + Best : intermediate pre-test probability Go directly to imaging (for diagnosis ): LBBB, paced rhythm – use pharm stress Uninterpretable ECG: ST-dep >1mm (e.g. LVH) Inability to exercise Prior revascularization (to localize)

77. Stress Testing Exercise ECG Contraindications: AS Others (common sense) Reasons to stop High-risk findings Low-functional capacity Drop in Systolic BP during exercise Marked ST-changes Prolonged ST-changes >2 mm

78. Stress Testing Perfusion Imaging & Stress Echo More expensive Increased sensitivity & specificity Bayesian approach Low-pre-test probability + positive stress ECG Localizes ischemia Patients with prior revascularization Poor prognosis: Multiple defects, Large defects, increased lung uptake, transient ischemic dilation of LV cavity Normal study – has good prognosis Adenosine / Persantine: avoid if COPD, asthma

79. Endocarditis Prophylaxis Due to limited data re: efficacy of ID prophylaxis, AHA guidelines revised 2007 Major change: only give IE prophylaxis to those at HIGHEST RISK: Prosthetic heart valves (mechanical and bio) Prior history of IE 6 months post-repair of congenital defect (whether by surgery or catheter) Repaired congenital defect with residual defect Complex cyanotic congenital heart disease Valvulopathy in a transplanted heart

80. Endocarditis Prophylaxis No prophylaxis: Bicuspid AoV Acquired valvular heart disease Prior surgical valve repair Isolated SECUNDUM ASD Surgically repaired ASD, VSD or PDA Pacemakers, defibrillators History of rheumatic disease without valvular dysfunction Deliver or C-section

81. Endocarditis Prophylaxis Changes: limited procedures need prophylaxis: Dental procedures GI, GU, Resp and skin: Only if doing procedure involving active infected tissue with ‘bugs’ known to cause IE: must be on abx at time of procedures

82. Endocarditis Prophylaxis No Post-treatment 20 mg/kg IM or IV 600 mg IM or IV Clindamycin OR 50 mg/kg IM or IV 1 g IM or IV Cefazolin or ceftriaxone Allergic to penicillins or ampicillin and unable to take oral medication 15 mg/kg 500 mg Azithromycin or clarithromycin OR 20 mg/kg 600 mg Clindamycin OR 50 mg/kg 2 g Cephalexin* Allergic to penicillins or ampicillin - oral 50 mg/kg IM or IV 1 g IM or IV Cefazolin or ceftriaxone OR 50 mg/kg IM or IV 2 g IM or IV Ampicillin Unable to take oral medication 50 mg/kg 2 g Amoxicillin Oral Children Adults Regimen: single dose 30 to 60 min before procedure Agent Situation

83. Aortic Stenosis History: angina, syncope, CHF (classic triad) Exam: Crescendo-decrescendo murmur Best at RUSB; may be heard at apex (Gallavardin’s) Radiates to carotids Increases with squatting Delayed & diminished carotid upstroke +S4 & sustained PMI Soft or delayed A2; loss of physiologic splitting Increased severity if: Later peaking murmur Soft or absent S2 Loss of physiologic splitting (single S2) Diminished carotid upstroke

84. Aortic Stenosis Prevalence increases with age (“senile, calcific AS”) Young patient with ejection click = bicuspid Ao valve ~1 in 200 people 30-40% with coarctation have a bicuspid Ao Valve Increased risk for aortic dissection or ascending aneurysm ECG : LVH, LAE; LBBB in some Echo : accurate Measures velocity Gradient = 4v 2 Aortic Valve Area: <1 cm 2 severe

85. Aortic Stenosis Bleeding tendency: Increased colonic angiodysplasia Acquired vonWillebrand disease Cath: not needed to “confirm” echo data Usually done to eval for obstructive CAD in patients referred for aortic valve replacement Treatment No medical treatment Beware of vasodilators or diuretics (decrease preload) Symptoms = surgery! No role for balloon valvuloplasty

86. Aortic Stenosis Surgical Therapy (cont.) Symptoms = surgery! Prostheses: Mechanical – more durable; requires anticoagulation Bioprosthetic: less durable; short-term coumadin only Infective endocarditis risk is the same in both types of valves

87. 50 yo M c/o progressive DOE and fatigue. BP 160/58. Pulse is bisferens. CV exam: systolic thrill at the apex & over the bounding carotid arteries. + systolic ejection sound. +S3, soft S1 and a decrescendo diastolic murmur at the base that is high-pitched, early peaking and last throughout diastole. Also: 3 rd and 4 th interspaces at LLSB you hear a presystolic rumble. An echocardiogram confirms your clinical impression You recommend which of the following?: MV replacement and AV replacement with a mechanical prosthesis MVR and AVR with a bioprosthesis in the aortic position. AVR with a mechanical prosthesis. Vasodilator therapy and observation for six months. Diuretic therapy and observation for six months.

88. Aortic Insufficiency Chronic History – well-tolerated until severe CHF symptoms when severe Exam: Wide pulse pressure accounts for myriad of peripheral pulsating organs Water-hammer pulses, etc… Auscultation Early diastolic, decrescendo murmur Blowing (“cooing dove”, “wind blowing through leaves”), high-pitched Pt. sitting up, leaning forward Afterload sensitive – increases with handgrip Austin-Flint (diastolic): mimic MS due to AR jet

89. Aortic Insufficiency Chronic Etiologies: Treatment: Surgery if: symptoms, EF<50% or increasing LV cavity size on serial echocardiograms Mechanical AVR if <65 yo Bioprosthetic AVR if > 65 yo or can’t take coumadin

90. Aortic Insufficiency Acute! Medical emergency Hx: severe symptoms Cardiogenic shock, syncope Exam – classic exam signs not usually present Softer, shorter diastolic murmur (may not even be audible) Etiologies: endocarditis, aortic dissection, trauma, mechanical valve dysfunction Treatment: emergent surgery

91. Mitral Stenosis Etiology: Rheumatic Fever History: disease often latent Dyspnea – often misdiagnosed as asthma in young pt. Hemoptysis, hoarseness New-onset atrial fibrillation (esp. during pregnancy) Don’t tolerate tachycardia well due to transmitral pressure Exam: Loud S1 Opening snap in early diastole (after S2) Diastolic rumble Loud P2 if pulmonary hypertension

92. Mitral Stenosis ECG: LAE, RAE RVH (RAD) - No LVH Treatment Medical: lasix, ? B-blockers, limit activity Correct: if mod-severe MS + symptoms or pulmonary hypertension Balloon valvuloplasty if possible based on valve characteristics (unlike in AS) Open commissurotomy, surgical repair or replacement

93. 55 yo M with a 5 year hx of a “murmur”. No symptoms but he admits to doing little activity. He no longer walks to the office and does not have to walk stairs to the 3 rd floor “because there is an elevator”. Exam: Normal carotids. Clear lungs. PMI is diffuse in the 5 th intercostal space, midclavicular line. Grade III/VI holo-systolic murmur heard best at the apex. Echo: floppy mitral valve with severe posterior leaflet prolapse, severe MR. Mildly dilated LV with EF 45-50% You recommend which of the following?: Close observation and repeat TTE with clinical change. Start ramipril and repeat TTE in 4 months. Refer to surgery for mitral valve replacement. Refer to surgery for mitral valve repair. Start long-actin nifedipine and repeat TTE in 1 year.

94. Mitral Regurgitation Chronic History: reflect poor cardiac output & elevated LA pressures Dyspnea / CHF Multiple Etiologies Exam: HSM murmur best at apex; may radiate to axilla Increases: afterload (sustained handgrip) or Increased venous return (leg elevation) Decreases with standing, valsalva, inspiration Hyperdynamic apical impulse Soft S1 Little respiratory variation Wide splitting of S2 (early closure of A2)

95. Mitral Regurgitation Chronic Medical Treatment Afterload reduction Diuresis Surgical: repair (rather than valve replacement) if feasible! Timing – controversial; want to perform BEFORE LV dysfunction occurs In general – severe MR &: Symptoms EF <55-60% Dilating LV size on TTE Afib Pulmonary HTN

96. Mitral Regurgitation Mitral Valve Prolapse Most common valvular cause of MR & need for MVR Exam: Mid-systolic click followed by murmur (“click-murmur syndrome”) Maneuvers that decrease Preload (valsalva, standing) move clicks closer to S1 and murmur starts earlier Ejection sound of AS or PS – does not move

97. Mitral Regurgitation Mitral Valve Prolapse Spectrum of disease Concern – “floppy” redundant MV leaflets with MR and myxomatous changes Mild increase risk for embolic stroke No anticoagulation prophylaxis SBE prophylaxis if: MR OR myxomatous leaflets on echo

98. Mitral Regurgitation Acute MR Also: Ischemic Ruptured chord in severe MVP Large V-waves on PA catheter Decrescendo systolic murmur at apex Most common cause: endocarditis

99. R-sided Murmurs in Brief TR Usually secondary: RV dilation or pulmonary hypertension PE, numerous causes of pulmonary HTN, RV disease Murmur (when heard): HSM LLSB – increases w/inspiration Prominent V-waves, pulsatile liver Endocarditis in drug users TS + TR, flushing, diarrhea = carcinoid syndrome Tx – underlying cause, ring if fixing mitral valve PS – congenital; ejection click Noonan’s syndrome: low-set ears + PS Tx – balloon valvuloplasty

100. Congenital Heart Disease

101. Atrial Septal Defect (ASD) A 30 yo female is found to have cardiomegaly on a CXR obtained as part of routine physical examination. She is active, can walk indefinitely without symptoms. Cardiac exam: grade II/VI SEM at the 2 nd intercostal space, LUSB. 2 nd heart sound is widely split and does not very with respiration. CXR: cardiomegaly with full pulmonary vascular markings. Echo: enlarged RV and paradoxical septal motion. DIAGNOSIS ?

102. Atrial Septal Defect (ASD) Exam (cc: “SOB”) SEM LUSB Fixed splitting of S2 RV volume overload Secundum : 70% IRBBB or RBBB, right axis NO SBE prophylaxis if isolated Primum : IRBBB or RBBB, left axis Associated MV or TV disorders Treatment: closure for Qp/Qs >1.5:1 or symptoms, in general Surgical or percutaneous Amplatzer device – FDA approved 2001 Secundum Primum Sinus venosus Coronary Sinus 4 2

103. Patent Foramen Ovale PFO Common: 20-30% of all patients Usually not patent if LA pressure > RA pressure & not “stretched” Consider PFO or ASD if cryptogenic stroke in a young patient Especially with atrial septal aneurysm Consider eval for clotting disorder Long-term warfarin (over ASA) for clinical event Closure if recurrent event on anticoagulation (FDA guidelines) or large shunt

104. Ventricular Septal Defect Most close in childhood spontaneously or surgically + Endocarditis prophylaxis Exam Loud murmur w/thrill (gr. 3-6), pan-systolic Afterload dependent – increases with sustained handgrip (like MR) Large – pulmonary HTN (loud P2), RV heave Treatment – closure if large

105. Congenital Heart Disease Others Patent Ductus Arteriosus (PDA) Preferential clubbing of toes (but not fingers) if R to left shunt Tx: surgical ligation or other form of closure Continuous “machine-gun murmur Heard in infraclavicular fossa

106. Congenital Heart Disease Others Coarctation of the Aorta CXR Loss of aortic knob Rib notching due to collateral recruitment Increased circle-of-Willis berry aneurysms (CVA) Bicuspid AoV – 40-60% Turner’s Syndrome Ejection click & SEM at LLSB Delayed femoral pulses Hypertension in arms

107. Physical Exam Pearls… Physiologic Splitting S2: splits with inspiration Persistently Split S2 Delayed closure of Pulmonic Valve Normal respiratory variation RBBB, PE, Pulmonic Stenosis, PVC from LV Paradoxically Split S2 Splits during EXPIRATION Delayed closure of Aortic valve LBBB, Severe AS, RV pacemaker, PVC from RV Fixed Splitting of S2: fixed A2-P2 = ASD Bisferens pulses: significant AI; HCM; AV fistula

108. Todd C. Villines, MD Cardiology Service Cardiology Board Review Part II 2008 Walter Reed Army Medical Center

109. Outline – Part I CAD Acute Coronary Syndromes (ACS) Chronic CAD Valvular Heart Disease Congenital Heart Disease Physical Exam Pearls

110. Outline – Part II CHF / Cardiomyopathies Arrhythmias & ECGs Pericardial Disease Peripheral Vascular Disease Preoperative Evaluation Miscellaneous Test Taking Strategies

111. CHF – Systolic Dysfunction Most common: Ischemic Hypertensive Dilated CM Evaluation Cause usually evident in history Extensive workup usually not needed or revealing Echo Ischemic evaluation Thyroid studies for all Consider iron studies

112. Chronic Treatment Systolic CHF ACE-I – all patients B-blockers: metoprolol sustained release, carvedilol and bisoprolol Benefit in all classes – class I-IV if used appropriately Start when patient is clinically stable and euvolemic “ Start slow & go slow” Spironolactone (RALES): class III & IV – on other standard therapies

113. Chronic Treatment Systolic CHF Digoxin – sxs despite Ace-I, BB, diuretic & possibly spironolactone No reduced mortality Reduces symptoms & hospitalizations Careful in renal dysfunction Warfarin – for afib, mechanical valve, embolic event (not just if depressed EF) Can use amlodipine for BP – no effect on mortality No diltiazem or verapamil Non-pharmacologic interventions

114. Systolic Dysfunction Therapy Overview xx

115. Cardiac Resynchronization Therapy (CRT) “Biventricular Pacing” Current Indications NYHA class III or IV heart failure LVEF ≤ 35% In NSR (not studied in afib) Evidence of ventricular dyssynchrony Currently: based on QRS width QRS > 120 msec Most evidence in LBBB, but RBBB included FUTURE: echo evidence of dysynchrony better than ECG Most also candidates for ICD

116. CRT: CARE HF Trial NYHA III or IV LVEF ≤ 35% In NSR QRS > 120 msec Bi-V –vs- Meds alone Improved Symptoms CV Death CV Hospitalization Total Mortality

117. Chronic Treatment Primary Diastolic CHF Clinical syndrome of CHF with LVEF > 50% Causes – many: HTN, ischemia or infarct, infiltrative diseases Amyloid on echo: “sparkling”, thick myocardium Treatment – no consensus Treat HTN aggressively Lasix for symptoms Good rate control – esp. with a-fib Ace-I, BB No digoxin Address ischemia – if a factor Revascularization, nitrates, b-blockers

118. CHF Exacerbation Acute Treatment You know this stuff! Identify precipitating factors Ischemia, diet, arrhythmia, anemia, infection, thyroid, etc… Know drugs to avoid & that can exacerbate systolic CHF: Metformin, NSAIDS, Thiazoladinediones & ALL antiarrhythmic medications except Amiodarone Standard therapies – common sense Diuresis, afterload, nitrates, oxygen Vasopressors & inotropes - if needed

119. Sudden Death in the Young Things to Think about Hypertrophic Cardiomyopathy Anomalous coronary artery Inherited Long-QT syndrome Sudden death with startling Brugada Syndrome RV Dysplasia Premature CAD Coronary Dissection Drug-induced (esp. cocaine) Idiopathic / Familial PE

120. Hypertrophic Cardiomyopathy History Often no symptoms 15-25% prior syncope – with exertion 20-30% chest pain Dyspnea, palpitations, fatigue Physical Exam** (know this) Murmur: crescendo-decrescendo at LLSB Increased murmur with decreased LV cavity size (decreased venous return) with standing, valsalva or nitro No radiation to neck and brisk carotid upstroke (unlike AS) Also: MR, S4, prominent PMI

121. Hypertrophic Cardiomyopathy ECG LVH, LAD pseudoinfarct pattern (prominent septal q waves infero-laterally) Echo Concentric form Asymmetric form– commonly involving the septum (HOCM) No competitive sports Tx: B-blocker or CCB (control rate for filling) Surgical myectomy OR non-surgical ethanol septal ablation if significant outflow gradient: ~5% of patients currently.

122. Atrial Fibrillation

123. Atrial Fibrillation Evaluation ALL: thyroid studies, Echo & CXR Look for underlying cause of new onset or accelerated rate in chronic afib patient Acute Management Unstable = urgent cardioversion Stable Control Rate: BB, CCB 1 st line Digoxin – slower onset and not good for high adrenergic tone Anticoagulation – if able & indicated Risk factors for CVA: CHF, increasing age, hx of HTN, diabetes, hx of CVA/TIA, structural heart dz (LAE, significant valvular disease)

124. Atrial Fibrillation New onset: known < 48 hours Consider cardioversion Anticoagulation (Lovenox, UFH) Chemical: ibutilide best acutely risk of torsades with severe LV dysfunction Electrical - synchronized Coumadin for 3-4 weeks after (“atrial stunning”) > 48 hours or unknown: 2 choices Warfarin x 3-4 weeks then cardioversion TEE to r/o thrombus & cardioversion Coumadin for 3-4 weeks

125. Atrial Fibrillation Anticoagulation Aspirin Lone = <65 yo, no structural heart disease, & no HTN Contraindication to warfarin (intracranial bleed or neoplasm, serious falls risk) All others get warfarin… ACTIVE-W: ASA + Plavix inferior to coumadin Anticoagulation 3-4 weeks prior to elective cardioversion 3-4 week after cardioversion…at least In general, need long-term if indicated INR 2-3 for chronic & paroxysmal Similar risk for stroke!

126. Atrial Fibrillation Antiarrhythmic Therapy Average efficacy of antiarrhythmics: 50-60% Rate control – vs- Rhythm control: AFFIRM – no difference in QOL, stroke risk Increased strokes in rhythm control arm when stopped warfarin because of recurrent afib So…either option is fine if no symptoms but BOTH take warfarin if indicated (see prior slide) Use of Antiarrhythmics: Don’t tolerate a-fib hemodynamically (CHF patient, restrictive cardiomyopathy, etc…) Symptoms of afib ( palpitations) despite rate control

127. Atrial Fibrillation Antiarrhythmic Therapy Amiodarone Best efficacy at maintaining NSR Least pro-arrhythmic Drug of choice if CAD or depressed EF Know: interacts with warfarin & digoxin (increases potency of both) Know: side-effects Thyroid – baseline, at 3 months, then every 6 months Pulmonary – baseline PFTs and CXR; CXR q 6 months. PFTs with any symptoms or CXR change. Liver – baseline LFTs and every 6 months Corneal – baseline optho exam, then for symptoms

128. Atrial Flutter Treated similarly to atrial fibrillation (anticoagulation, rate control) More difficult to rate control than fib Often coexists with atrial fibrillation Can be terminated with overdrive pacing Consider curative ablation if difficult to manage Narrow complex & rate ~150: think flutter ?

129. Multifocal Atrial Tachycardia Pulmonary disease Theophylline Use Low K+ & Mg+ Treatment: underlying cause + : Rate control – no digoxin No cardioversion if stable

130. PSVT Re-entrant tachycardias: AVNRT, AVRT Therapy: Acute & Stable: 1. Vagal maneuver. 2. Adenosine 6-12 mg IVP 3. AV Nodal agents Chronic – BB; most can be ablated if recurrent or frequent

131. Wolf-Parkinson-White Symptoms or A-fib: referral for ablation A-fib that is usually wide-complex and irregular Associated with Ebstein’s anomaly Downward displacement of TV valve 22 yo with a history of frequent palpitations

132. Wolf-Parkinson-White A-fib in WPW: “Wide complex, irregular” Tx: IV Procainamide…NOT dilt, verapamil, b-blocker or digoxin! 22 yo with “rapid heart beat” goes to ER. BP is stable. Treatment?

133. Wide-Complex Tachycardia Wide-complex tachycardia VT –vs - SVT with aberrancy

134. Wide-Complex Tachycardia Assume VT History - older age, heart disease, CAD AV-dissociation = VT Capture or Fusion beats = VT QRS duration: wider more likely VT RBBB with LAD – likely VT

135. Atrial Fibrillation Antiarrhythmic Therapy PVC’s Never treat asymptomatic PVCs Risk of ventricular ectopy is related to underlying structural heart disease Know ACLS 2000 Guidelines re: WCT VF or pulseless VT Shock x 3, epi or vasopressin, then Amio (not lidocaine) Stable, monomorphic VT Procainamide If depressed EF  Amio

136. A 35 yo male presents to the emergency room complaining of chest pain for the past 24 hours. Pain is worse when lying flat and worse with deep inspiration. No JVD. BP 136/76 Normal heart sounds except for a friction rub. Acute Pericarditis: 1. Diffuse ST-elevation & 2. PR-depression *may evolve to T-wave inversions (later) Dx - at least 2: Chest pain ECG changes Rub

137. Acute Pericarditis MANY Causes: Viral / Idiopathic – most common Search for underlying cause - guided by the history Don’t “pan-lab”! Consider HIV / ppd Usually not 1 st presentation of systemic disease Echo all to rule-out large effusion MB & Troponin + in up to 25% of patients

138. Chest Pain suggestive of Pericarditis ECG Diagnostic ? Age < 40 & no other suspected systemic illness or traumatic ANY: JVD, Pulsus Paradoxus, +Cardiac Enzymes, Poor Pain Control in ER, No social support Admit / Reconsider If YES to ANY = Admit + Echo Suspect Pericarditis ? YES ECHO NO Large or Moderate Effusion Small Effusion -NSAIDS & F/U NO One Approach (MKSAP) Who to Admit ? Admit: - suspect serious underlying cause (e.g. - uremic) or on immunosuppressive Consider: 1. MI 2. Aortic Dissection 3. PE 4. Pneumothorax 5. Esophageal Rupture 6. Pancreatitis

139. Acute Pericarditis Refractory symptoms: further diagnostic work-up Suspect Tb if persistent symptoms after 2 weeks and risk factors Treatment NSAIDS Also, may use colchicine up front Steroids – ONLY if refractory and an underlying cause has not been found 7-10 day tapering course

140. Despite treatment, the patient returns complaining of problems “catching his wind”. P 105 BP 90/60 PA Cath: RA 18mmHg PA 32/18 PCWP 19 Physical Exam signs ? ECG Findings ? Echo Findings ? Treatment ? Etiologies ?

142. Pericardial Effusion Pericardiocentesis Indications Tamponade Hemopericardium Suspected bacterial or tuberculous pericarditis Pericardial window biopsy best to dx Tb Rapid reaccumulation post-drainage

143. Dx: Constrictive Pericarditis Clinically: Suggestive history + signs of RV failure, DOE Exam: Kussmaul (increased JVD with inspiration) – with prominent x & y descent of venous waves Diastolic Knock (audible S3) RV overload signs 55 yo F with hx of Breast CA treated with surgery & XRT 12 years ago complains of DOE x 1 yr. CXR: Recurrent R effusion. TTE – no effusion. BP 110/60 P 110. JVP 12 & increases with inspiration. Which of the following is the next most appropriate test??: Liver scan d. Spiral CT of lungs Bilateral mammogram e. Transesophageal Echo (TEE) MRI of heart

144. Constrictive Pericarditis Etiologies: XRT, post-surgery, post-pericarditis - Tb, cocci (long-list) CXR: pericardial calcification on lateral Best: CT or MRI - pericardial thickening (>4-5mm) Echo in all to assess hemodynamics TTE: insensitive to pericardial thickness PA Cath: equalization of pressures Treatment: Pericardiectomy if severe symptoms & can tolerate the procedure

145. pp 68 yo M found to have mid-line pulsatile mass. Hx: HTN, CABG Rx: ASA, ramipril, atenolol, HCTZ Careful ROS – no symptoms (no abd pain, back pain, etc) P 78 BP 132/84 Ultrasound: 5.5 cm AAA below renals Which is most appropriate at this time? Increase B-blocker to pulse of 60 d. Increase ACE-I Repeat u/s in 1 year e. Refer for surgical repair Tell patient to limit physical activity Dx: AAA Surgery Abdominal: >4.5- 5.0 cm or expanding (.5cm/6 mos or 1cm/yr) Thoracic AA & no sx’s: >6cm or compressing local structures If no indication for surgery, serial u/s surveillance

146. Carotid Disease Know when to refer to surgery! AHA guidelines: Symptomatic Patients TIA or CVA past 6 mos + >70% stenosis of ipsilateral carotid Acceptable: Sx’s + 50-69% stenosis Asymptomatic Patients Stenosis  60% + surgical risk <3% + life-expectancy > 5 years Reminder: PVD = CAD for lipid management, risk-factor reduction

147. Aortic Dissection Hx: “ripping” CP radiating to back HTN, Marfan’s**, crack cocaine use, bicuspid aortic valve Exam: HTN, AI murmur, muffled heart sounds if extends to pericardium CXR – widened mediastinum Dx: TEE, CT or MRI

148. Aortic Dissection - Treatment IV B-blocker (labetolol) first! – reduce sheer stress Nitroprusside if needed (SBP>100 after labetolol) & only with b-blocker first! If ascending aorta involved (type A) = surgery Non-ascending aorta = medical therapy Beware – can involve coronary ostia (MI) Variant – Aortic intramural hematoma – treat the same as dissection (no heparin / anti-coagulants) Classification

149. Peripheral Arterial Disease Atherosclerosis of arteries to legs ABI < 0.90 – good screening tool Best if do before & after exercise Claudication: pain relieved with rest Pseudo-claudication with spinal stenosis: pain relieved with SITTING (not standing still) Vascular surgeries – high-risk surgeries; account for 70% of operative mortality Preop guidelines – know these! Buerger disease (thromboangiitis obliterans) – medium/small artery necrosis ONLY if smokes

150. 77 yo male pre-op aorto-bifemoral bypass for severe PVD. Hx: DM II, tobacco use. No hx of MI or heart problems. Able to walk 1 city block slowly – limited by claudication. ECG – inferior MI – age-undetermined. What do you recommend to the surgeons? Proceed to surgery – no further preop evaluation Preop Catheterization & Revascularization if needed Preoperative dipyridamole-thallium myocardial scintigraphy d. Cancellation of surgery - surgical risk too high

151. Pre-Operative Evaluation A Must Know! Risk Stratify the Patient Risk Stratify the Surgery

155. Miscellaneous Strep bovis endocarditis Order a colonoscopy Cannon a-waves A-V dissociation Complete heart block, RV Pacing (not a-v sequential) Reasons for endomyocardial biopsy Transplant rejection (rarely adriamycin toxicity) Rarely done Low-yield in sarcoid; ETOH CM – use hx

156. Test Taking Strategies Rest prior to the test – they are long days Time is not an issue with this test (unlike the in-service exams) If you don’t know, trust your training experience & judgment “ Is this how we would treat this patient at Walter Reed?” “ Is this how we do things here?” You know this stuff & come from a premier program!

157. Test Taking Strategies Rely on your knowledge Don’t watch for patterns (“last 2 answers were C so this one can’t be C”) Steady pace & don’t panic if you don’t know a question My personal method: Before reading the question, I quickly scan the answers to see what type of question is it Don’t actually read the answers or think about them yet. e.g. - Are they asking for medicines or treatments ?, diagnoses ?, best test to order ?, etc… This helps me pick up on what is important as I read the often long clinical scenarios