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Jens rapid review cardio


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Jens rapid review cardio

  1. 1. Cardiology Board Review Jens Johansson PGY2 ARMC Emergency Medicine
  2. 2. Tachycardia- Narrow Complex Atrial Flutter • Regular 280-340 • Block 2:1 (MC- 150 BPM), 3:1, 4:1 representing Atrium to Ventricle conduction- can be variable-> Irregular rhythm. QRS narrow unless BBB present. TX: • Unstable: Synchr Cardioversion (less success if chronic AF- anatomic abnormality not fixed w/ cardioversion • Stable: CCB, BB, Amiodarone, Digoxin
  3. 3. Atrial Fibrillation • Disorganized atrial conduction with irregular conduction to ventricles • No discernable p- wave with irregular QRS • QRS narrow unless BBB TX: • Unstable: Synchr Cardioversion (less success if chronic AF or permanent A-fib) • Stable: Rate control- BB, CCB, Digoxin, Amiodarone, Anticoagulation-ASA, Heparin, Warfarin based on CHADS2 Score.
  4. 4. Multifocal Atrial Tachycardia • Often mistaken for A-fib, but 3 or more discernable p- waves, Irregular rate, 100-180 BPM. • Narrow QRS, but can be wide QRS with BBB • 2/2 lung dz TX: • Treat underlying lung dz, Rate control with CCB
  5. 5. Supraventricular Tachycardia • Reentry Tachycardia • Abrupt onset and termination differentiates from Sinus Tach • Precipitated by PAC or PVC (if AVRT) • Requires 2 different conduction pathways with different refractory times • Regular rate, p- waves absent, QRS narrow unless BBB • Types: • AVNRT- Conduction pathways within AV node • AVRT- Conduction pathways between Atria and Ventricle • Atrial Reentry Tachycardia- Conduction pathways within atria TX: • Unstable-Synchr. Cardioversion • Stable- Vagal maneuver, Adenosine, BB, CCB, Procainamide
  6. 6. • Preexitation Syndromes- WPW • Men> Women, 10% of Ebstein Anomaly (Tricuspid anomaly- atrialization of RV/ CHD) • Accessory pathway/ Bundle of Kent circumvents AV node, connect. atrium to bundle of His. • Orthodromic SVT/ Narrow QRS (95%): • Antegrade conduction vie AV node/Retrograde via accessory pathway. TX: • Unstable- Synchr. Cardioversion • Stable- CCB, BB, Adenosine, Procainamide • Antidromic SVT/ Wide QRS and short PR (5%): • Antegrade conduction via accessory pathway, retrograde via AV node. • Wide QRS/ Delta wave. Can be indistinguishable from V-Tach. TX: • Unstable: Synchr. Cardioversion • Stable: Procainamide, Amiodarone • NO CCB/BB/Dig, Adenosine (blocks AVN, allowing conduction via accessory pathway)
  7. 7. Tachycardia- Wide Complex Monomorphic Ventricular Tachycardia • Single ventricular ectopic focus with wide QRS 2/2 depolarization via myocardium (not as rapid as His- Purkinje fibers). • Absent P- waves, rate >140, QRS> 160 mS In favor of VT vs SVT w/ aberrancy: • Fusion beats- fusion of wide ectopic beats and normal QRS • Capture beats- Narrow QRS captured between wide QRS • AV dissociation • >50 yrs, cardiac dz TX: • Unstable: Pulse- Synchronized cardioversion, Pulseless- unsynchronized defibrillation • Stable: Amiodarone, Procainamide, correct underlying etiology
  8. 8. Polymorphic Ventricular Tachycardia (Torsade de Pointes) • Wide complex QRS, 180-240, wave like appearance. • Baseline EKG may show long QT Prolonged QT: • Congenital: Jervell-Lange- Nielson, Romano-Ward • Meds: Antiarrhythmics 1A, IIIA, TCA, Phenothiazine, antipsychotics • Electrolyte: Hypo K, Hypo Mg • ICH TX: Unstable: Pulse- Synchr cardioversion, Pulseless- Defibrillation Stable: Mg, Overdrive pacing or Isoproterenol (incr HR-> Shorter QT)
  9. 9. Ventricular Fibrillation • Hyperirritable ventricular myocardium 2/2 Ischemia, scarring, antiarrhythmics, a-fib, cardioversion. • Disorganized, irregular rapid waveform with no discernable P or QRS. TX: • ACLS, Defibrillation, or will degenerate in to Asystole. • Epinephrine, Amiodarone, Mg
  10. 10. Cardiac Devices Ventricular Pacing- Temporary Indications: • Bradycardia with hemodynamic Instability • Bradycardia with significant escape rhythms • Overdrive pacing • Standby for: • Stable bradycardia • Acute MI with Sinus node dysfunction • Mobitz II or third degree block • Cardiac Ischemia with new LBBB or RBBB • Transcutaneous pacer- pads to ant-post chest. Limited by body habitus. • Transvenous pacer- via Cordis catheter to IJ or SC.
  11. 11. Pacemaker- Permanent Indications: Third degree block, Sick sinus, Severe CHF Generator: generates impulse Lead: deliver impulse EKG: • Pacer spikes before P and QRS if paced. • Wide QRS/ LBBB pattern. • Demand pacemaker may not have spikes if rhythm is nml Failure: • Generator- device or battery • Lead- fracture, dislodging, migration of lead • Myocardium- fibrosis, electrolyte imbalance
  12. 12. Pacer Failure on EKG • • • • • • Rate less than preset= Generator failure Bradycardia but absent spikes= Failure to pace Impulses fires inappropriately despite nml rhythm= failure to sense Impulse/ spike without causing P or QRS= failure to capture Pacer falsely senses activity of heart therefore and inhibits pacing= Oversensing Pacer incorrectly misses activity of heart and therefore sends impulses= Undersensing CXR • Pacer with thin coil to atrium, single ventricle or both ventricles • Defibrillator with thicker shocking coil in atrium and ventricle Interrogation/ Trouble shooting • Use manufacturer specific magnet held close to Pacemaker. • Most pacers will switch from demand to fixed mode (preset rate for each pacer) with use of any magnet. • IECD will turn off with magnet.
  13. 13. AICD (Automatic Inplantable Cardioverter Defibrillator) • Delivers defibrillatory shock to apex of right ventricle if VF or VT • Almost always combined with pacemaker Indications: • High risk for dysrhythmia • Sever CHF • Brugada Syndrome • Hypertrophic Cardiomyopathy Failure: • Generator • Sensing • Lead • Inappropriate discharge: Can turn off AICD with magnet
  14. 14. Hypertensive Urgency Hypertensi on • Elevation of BP without acute end- organ injury. • Potentially harmful if sustained, usually DBP >130 mmHg. TX: • Gradual reduction in BP over 24 hrs with Outpatient PO meds: HCTZ, or BB (CAD), Lisinopril (CHF, RF, DM). • Outpatient evaluation of labs for end- organ damage.
  15. 15. Hypertensive Emergency Hypertension with acute end- organ damage, usually >130 mmHg • Hypertensive encephalopathy, ICH, Ischemic stroke • Renal Failure • ACS, CHF, Pulm edema • Aortic Dissection • Retinal hemorrhage/papilledema • PIH TX: • Reduce MAP by 20% over next hour with IV meds: • Nicardipine (incr HR), Nitroglycerine (incr HR), Esmolol (short acting, easily titrated), Labetalol (for PIH, worsen bronchospasm), Sodium Nitroprusside (poss, cyanide tox, give w/ BB for elev of HR), Enalapril (avoid in Renal Artery stenosis)
  16. 16. Hyperadrenergic Syndromes • Cocaine • Methamphetamine • Pheochromocytoma TX: • Avoid Beta Blockers- allows unopposed alpha stimulation on blood vessels-> further elevation of BP. • Caution with cardioversion of dysrhythmia if hyperadrenergic state since irritable myocardium. • Phentolamine (alpha blocker) for Pheochromocytoma and Cocaine • Benzo’s
  17. 17. Aortic Dissection Aortic Emergencies Tear of aortic intima with blood leaking in to media • Abrupt, excruciating pain epigastrum/ chest radiating through to back • If aortic branch vessel occlusion: • Neuro deficits, paraplegia, CHF, ACS, Abdominal pain, flank pain/RF, syncope • Tamponade, HTN, unequal pulses, aortic insufficiency • CXR: wide mediastinum, pleural effusion, apical cap, media separated from calcified intima, blurred aortic knob. • TEE, CT, CT Aortogram, MRI Types: • Debakey I: ascending/descending, II: ascending, III: descending • Stanford A: Ascending , B: Descending TX: • Start IV BB for HR control (Esmolol, Labetalol). Add Vasodilator (Nitroprusside) if needed to bring BP down to SBP ~100. Analgesia (morphine to reduce sympathetic output. • Surgery for ascending dissection, Medical mgmt. for descending dissection.
  18. 18. AAA • True aneurysm, >3cm or incr diameter by 50%. Rupture risk incr @ 5cm. • MC abdominal and infra- renal. Grows 4 mm/yr once over 3cm. Most commonly asymptomatic until rupture. • White, smoker, hypertensive male with CAD. • If pain, sudden onset in flank, abdomen, chest, back, often pulsatile mass, hypotensive, unequal pulses. Imaging: Abd XR, US, CT contrast, angiogram, MRI TX: • Immediate Surgery consultation/OR • Optimize BP (not to low/ not to high: BP meds/ pressors) • Crossmatch PRBC’s • IVF