Transcript - Catalyst

Cardiology!
Cardiology!!!!!!
Michael Krug, MD
Hospital Medicine
[email protected]
Chest Pain DDx
•
•
•
•
•
Cardiac
Pulmonary
GI
Chest Wall
Psych
What are some cardiac causes of chest pain?
Cardiac
•
•
•
•
•
ACS
Stable Angina
Pericarditis
Aortic Dissection
Cocaine
What are some pulmonary causes of chest pain?
Pulmonary
•
•
•
•
PE
Pneumothorax
Pneumonia
Pleuritis
What are some GI causes of chest pain?
GI
•
•
•
•
•
Esophagitis
Ulcer
Hepatobiliary
Pancreatitis
Esophageal rupture
What are some chest wall causes of chest pain?
Chest Wall
•
•
•
•
Costochondritis
Trauma
Strain/Overus
Herpes Zoster
Psych
• Panic/Anxiety
• Hyperventilation
• Somatization
Case
• 67yo man with substernal chest pain when he walks
farther than 4 blocks. Pain resolves when he sits down
to rest. Has been going on 3 weeks.
• PMH: HTN, HL
• PE: normal VS, well appearing
CV: RRR no m/g/r
Chest: clear Ext: no edema
What will you do: admit patient, cardiac cath, exercise
echocardiogram stress test, nuclear medicine stress test?
Ischemic Heart Disease
• Chronic Stable Angina
Vs.
• Acute Coronary Syndromes (ACS)
– Myocardial Infarction
– Unstable Angina
Angina
3 key components:
• Substernal chest pain or discomfort
• Provoked by exertion or emotional stress
• Relieved by rest and/or nitroglycerin
Atypical presentations not uncommon:
especially in women or diabetics (dyspnea,
dyspepsia, etc)
Angina: Stable or Unstable?
Stable Angina Diagnosis
• History
• Risk Factors (Age, Sex, tobacco, DM, lipids,
HTN, Family Hx)
• Testing
Workup for Stable (or low risk
Unstable – more on this later) Angina
• Exercise treadmill stress tests:
– ECG
– Echocardiogram
– Nuclear Imaging
• Pharmacologic “stress” tests
– Nuclear Imaging
– Echocardiogram
• CT Angiography
• Coronary Angiography (aka cath)
Workup for Stable (or low risk
Unstable – more on this later) Angina
Test choice depends on level of suspicion and
contraindications
Exercise is better if possible
– More information
– Predicts morbidity/mortality
Exercise ECG
• Exercise with goal of getting to 85% of max
heart rate or 10 METS
– Tries to precipitate ECG changes
• Good for:
– Evaluation of patients at low risk
– Predicting morbidity/mortality
– post-MI risk stratification for patients without
cath
Exercise ECG
• Bad for (contraindications):
– Patients with resting ECG abnormalities
– Patients who cannot exercise d/t pulmonary or
musculoskeletal problems
Stress Echocardiogram
• May use exercise or pharmacologic stress
(dobutamine)
– Must stop beta blockers if using dobutamine
• Uses wall motion to assess for ischemia/MI
– Done in 2 phases (rest and stress)
• Can ask to evaluate valves, EF at same time
Stress Echocardiogram
• Good for:
– Patients with “equivocal” results on exercise ECG
– Patients with question of CHF or valvular disease
– Often less expensive than nuclear medicine
• Bad for:
– Obese patients or women with a lot of breast
tissue (poor view)
Nuclear Medicine Stress
• Uses radioactive tracer to show blood flow
– Thallium, MIBI, Cardiolite, Myoview
• Two sets of images: rest and stress
– Rest images show healthy heart and infarct
– Stress images, when compared with rest images,
show areas of stress-induced ischemia
• Most machines compute an EF
• Can use exercise or pharmacologic stress
– Exercise probably better
Nuclear Medicine Stress
Nuclear Medicine “Stress”
• Can also eval coronaries with Nuclear
medicine using coronary vasodilators (so no
Stress involved)
• Adenosine and dipyridamole are coronary
vasodilators
• Relies on differences in dilation and flow in
diseased vessels
• No caffeine or theophylline before testing
Nuclear Medicine Stress and “Stress”
Tests
• Good for:
– Obese patients
– Patients with equivocal exercise ECGs
• Bad for:
– Adenosine/dipyridimole contraindicated in severe
asthma/COPD as causes bronchoconstriction
Coronary Angiography
• Good for:
– High pretest probability patients that you are
considering intervention on
– Pts with severe abnormalities on other studies
– ACS management (different topic)
• Bad for:
– Workup of lower risk patients
– Kidney disease (contrast), invasive so chance of
complications
Cardiac CT
• CT Angiography
– Contrast directly images coronary arteries
– Good anatomy, less studied, more contrast and
radiation than cath
• CT Calcium Scoring
– High calcium correlates with CAD
– Sometimes used for risk assessment
Stable Angina: Medications
• Medical Management
• Angioplasty/Stenting
• CABG
Back to the Case
• Your patient is diagnosed with CAD and, over
time, is started on:
–
–
–
–
–
–
Aspirin
Atorvastatin
Diltiazem
Lisinopril
Metoprolol
Nitroglycerine
Which of these are helping with symptoms?
Which are helping mortality?
Angina: Medications
Drugs which improve mortality
• Antiplatelet agents (usually Aspirin)
• Statins
• ACE inhibitors
• Beta Blockers (probably)
Drugs which lessen symptoms
• Nitrates
• Beta Blockers
• Calcium Channel Blockers
• Ranolazine
What about Angioplasty/Stenting
• Does Angioplasty/Stenting help with mortality,
symptoms, or both?
Angina: Angioplasty/Stenting
• No mortality benefit in most cases
– For angina that is (ACS is different topic)
• More effective at relieving symptoms than
medications BUT higher risk of complications
• Stents last longer than angioplasty
• Stents involve post-procedure meds for at
least one month
– Requires good adherence
– Bad idea if surgery necessary
Angina: Drug-Eluting Stents
• Lower rate of short-term re-stenosis
• Possibly? Increased risk for long term
thrombosis
• Require post-stent clopidogrel for 12 months
or more
• Beware stopping clopidogrel for
minor/elective procedures
73yo man with chest pain
ECG: STEMI
Progresses in stages:
1) hyperacute T waves
2) ST Elevation
3) T wave inversion
4) Q waves
Anterior MI
• Leads V1-V5
– V1-V3 = anteroseptal
– V4-V6 + I = anterolateral
• Predominantly LV
• Sicker, more CHF
different 72yo man w/ chest pain
Inferior MI
• Leads II, III, aVF
• Predominantly RV, some LV
• Volume responsive if
hypotension. Careful with
nitro
• Can get bradycardia if sinus
node involved
3rd 72yo man with chest pain
Left Bundle Branch Block
• A new LBBB is the same as ST elevation when
evaluating ACS
4th 72yo man with chest pain
Pericarditis
Hx: positional chest pain – improved sitting
up/leaning forward.
Exam: friction rub
ECG:
• ST elevations – typically not anatomical, diffuse,
ST rises obliquely in straight line
• Typically no associated T wave inversions
• PR depression
Treatment: colchicine + NSAIDs (use aspirin as
NSAID if post-MI pericarditis aka “dressler’s
syndrome”)
5th (and final) 72yo man with chest
pain
NSTEMI/Unstable Angina
• Subendocardial damage (vs. STEMI is
transmural)
• Can see: ST depressions, T wave inversions. Q
waves less likely
NSTEMI/Unstable Angina
• Only distinction between unstable angina and
NSTEMI is cardiac enzyme bump, which you
only know in hindsight
• Management is very similar
73yo man with chest pain
• How do we treat ACS?
STEMI vs. NSTEMI/UA
What do we do the same, what is different?
ACS Treatment: the very basics
• IV
• O2
• Monitor
ACS Meds
Everyone gets (unless contraindications):
Aspirin
Clopidogrel
Beta Blockers
Nitrates
Statin (for goal LDL <100)
Morphine
ACE inhibitor (usually later, not on presentation)
ACS Meds
Most get:
Heparin or LMWH (exception is low risk
NSTEMI/UA)
Some get:
GP IIb/IIIa inhibitors
– Given if symptoms refractory to typical options, or
at discretion of cath lab
ACS Meds
Contraindications
• Clopidogrel
• Bleeding problem
• Plan for CABG (should be off clopidogrel for 5d prior)
• Beta Blocker
• Hypotension or bradycardia
• Nitrate
• R sided infarct, hypotension, PDE inhibitor use (sildenafil,
etc)
• Heparin/LMWH
• History of HIT, bleeding problem, severe thrombocytopenia
STEMI treatment
• Emergent cardiac catheterization
• Thrombolytics if cath unavailable in <90
minutes
– Probably less effective if good cath lab available
– Risk of hemorrhagic stroke
What NSTEMI/UA patients get cath?
•
•
•
•
•
Continued pain despite medical management
CHF
Elevated risk by risk assessment tool (TIMI >2)
New ECG changes or arrhythmia
Elevated troponin
What NSTEMI/UA patients get cath?
TIMI Risk Score for NSTEMI/UA
Prognostic Variables:
• Age >65
• >= 3 traditional CAD risk factors
• Documented CAD with >=50% diameter stenosis
• ST-segment deviation
• >= 2 anginal episodes in the past 24 hours
• Aspirin use in the past week
• Elevated cardiac biomarkers
TIMI Risk Score (sum of the above)
0-2 Low Risk
3-4 Intermediate Risk
5-7 High Risk
55yo man with palpitations
Atrial Flutter: ECG
•
•
•
•
Atrial rate almost always 300
Vent. Rate usually 150 (2:1), sometimes less
“sawtooth” flutter wave
Due to circuit around tricuspid valve
Atrial Flutter: Treatment
• If there’s an underlying cause, treat it (MI,
thyrotoxicosis, etc)
• Rate control (like in A. Fib)
• Radiofrequency catheter ablation
• Stroke prophylaxis (like in A. Fib)
PSVT: ECG
• Fast, narrow, regular
• Sometimes see retrograde p-waves (they
follow the QRS)
PSVT: Treatment
• Maneuvers: Valsalva, carotid massage, diver’s
reflex
• Abortive treatment: adenosine, electricity,
beta blockers
• Prophylaxis: beta blockers, sometimes other
antiarrhythmics
• Definitieve treatment: ablation if possible
Atrial Fibrillation: ECG
• Irregularly irregular; may be fast or slow
• Fibrillating P waves
Atrial Fibrillation: Treatment
• Symptom Control
• Stroke Prevention
Case
• 79yo man presents with lightheadedness
• PE: 75/42 123 24 90% on RA
Gen: Uncomfortable, disoriented
CV: irreg irreg, tachy, no murmur
• ECG: A. Fib with RVR
Pop quiz hot shot: what do you do? What do
you do?
Case
• 79yo man presents with palpitations
• PE: 128/68 108 14 97% on RA
Gen: well appearing, NAD
CV: irreg irreg, no murmur
• ECG: A. Fib
• PMH: HTN, osteoarthritis
What do you recommend for symptom control?
Stroke risk?
Atrial Fibrillation: Cardioversion
• Can be done electrically or pharmacologically
• Electrical cardioversion if hemodynamically
unstable
• Consider cardioversion if symptomatic despite
other efforts and left atrium not gigantic
– Must anticoagulate for 2-4 weeks prior to shock OR
transesophageal echo to eval for existing clot prior to
shock (unless emergency – then shock anyway)
Rhythm vs. Rate control in A. Fib
• Similar morbidity, mortality, and QOL
• Rate control: simpler, cheaper, less
iatrogenesis from antiarrhythmics and/or RFA
• Most treated with rate control
• Younger patients with significant
symptomatology often get rhythm control
– May be some benefit to sinus rhythm over
decade(s)
A. Fib: Rate/Rhythm control meds
Rate Control
• Beta Blockers
• Calcium Channel Blockers (Diltiazem)]
• Digoxin
Rhythm Control
• Amiodarone and Dronedarone
• Pulmonary vein ablation
• Other meds (sotalol, etc) infrequently used
A. Fib: Stroke Prevention
A. Fib Stroke Prevention
• CHADS2
A. Fib Stroke Prevention
• CHADS2 0 -> no treatment
• CHADS2 1 -> aspirin or anticoagulation
• CHADS2 2 -> anticoagulation
• Of course patient preference and
contraindications should be considered
A. Fib Stroke Prevention
• Warfarin
– Requires monitoring
– Can reverse with vitamin K
• Dabigatran/Apixiban/Rivaroxaban
– Slightly more effective than warfarin
– No monitoring
– No reversal agent (yet)
• Aspirin (less effective)
55yo with lightheadedness
How can we get rid of her lightheadedness?
Ventricular Tachycardia (VT)
• Wide and fast
• Can be mimicked by SVT with abberancy
– p-wave dissociation, capture beats, or fusion beats
= VT
– When in doubt, call it VT
Arrhythmias: Fast
•
•
•
•
Atrial Fibrillation
Atrial Flutter
Paroxysmal supraventricular tachycardia
Ventricular tachycardia
Case
43yo presents to your clinic after hospitalization
for tachyarrhythmia. Here is her ECG:
Whaddayathink?
Wolf Parkinson White Syndrome
Case
• 75yo with exertional shortness of breath.
Once he was running fast and chasing his
grandson and he passed out
• PE: BP 130/78, pulse 58
CV: 3/6 midsystolic murmur
Ext: trace edema bilaterally
ECG
What else do you want from PE?
Valvular Aortic Stenosis
• Symptoms: DOE, Angina, exertional syncope,
CHF
• Exam:
– harsh murmur best at RUSB, midsystolic,
“crescendo-decrescendo,” radiates to carotids
• Best heard leaning forward
• Decreases with valsalva, squat release, handgrip
– Diminished carotid pulses (parvus et tardus)
Aortic Stenosis
• Treatment: surgery, should be done before
CHF develops
– Surgery if symptoms and valve area <1.0 cm2
Case
• 3/6 systolic ejection murmur, radiates to
carotids, best heard at RUSB
• Murmur increases with valsalva and squat
release
Your diagnosis, please?
Hypertrophic Cardiomyopathy
• Murmur sounds similar to valvular AS
– Due to dynamic outflow obstruction from large
ventricles
• Murmur intensity increases with squat
release, valsalva
• Both valvular AS and HCM murmurs decrease
with hand grip
– Hand grip increases intensity of murmurs due to
backward flowing blood (AR, MR, VSD)
Mitral Regurgitation
• Sx: Fatigue, weakness, exertional dyspnea
• Exam: Holosystolic murmur at apex radiating
to left axilla
– (holosystolic think MR or VSD or TR)
• Treatment: treat for CHF, surgery if severe
disease
Case
• 68yo with a history of endocarditis, but you
can’t tell from the OSH pages of nursing notes
which valve was involved
• PE: 143/65 85 14 96% on RA
• CV: blowing diastolic murmur at L sternal
border
• What murmur is this?
Aortic Regurgitation (Aortic
Insufficiency)
• Sx: exertional dyspnea, angina, CHF
• Exam:
– blowing diastolic murmur at L sternal border
– Widened pulse pressure, strong pulses (“water
hammer”)
• Tx: surgical. Mild disease treat for CHF
Question
• What are the complications of mitral stenosis?
Mitral Stenosis
• Sx: dyspnea, pulmonary edema, A. Fib
• Exam: soft diastolic murmur at apex
• Tx: treat A. fib if present, diuretics for
pulmonary edema, surgery if severe
Tricuspid Stenosis
•
•
•
•
Rare
Usually due to rheumatic heart disease
Sx: peripheral edema, JVD, ascites
Diastolic murmur along LSB. Increases w/
inspiration
• Diuretics if mild, surgery if severe
Tricuspid Regurgitation
• Usually functional: due to RV failure or
pulmonary hypertension
• Sx: edema, ascites, prominent pulsatile JVD
• Exam: systolic murmur along L sternal border
• Tx: diuretics, rarely surgery
What is going on in this ECG?
3rd degree AV block
• No conduction between A and V
• QRS can be wide or narrow dep on where
ventricular conduction originates
• Usually requires pacer unless reversible cause
(ischemia, AV blocking drug, etc)
Which would you rather have?
2nd Degree Heart Block
» 2nd degree Mobitz I (Wenkebach)
• Lengthening PR then dropped beat. Usually benign
(Rx pacemaker only if symptomatic)
» 2nd degree Mobitz II
• Regularly dropped beats. More ominous. Rx pacemaker
Atrioventricular blocks
• 1st degree: long PR; benign
• 2nd degree
– Type I (Wenkebach): lengthening PR, then
dropped beat; usually benign
• Type II: Regularly dropped beats: more
ominous
• 3rd degree: No A-V conduction: usually
requires pacer
Sick Sinus Syndrome
• AKA Tachy-Brady syndrome
• Baseline bradycardia +/- AV block punctuated
by tachyarrhythmias
• Rx: pacer for bradycardia + beta blocker for
tachyarrhythmias if needed
Case
74yo with stage IV colon cancer with worsening
exertional dyspnea for past 10 days
PE: BP 90/40, pulse 112, RR 34, SpO2 92%
Uncomfortable
CV: tachycardic, + JVP
Chest: clear to auscultation bilaterally
Ext: trace edema bilaterally
Thoughts?
Cardiac Tamponade
• Pericardial effusion restricting cardiac filling
• Physical exam findings
– Hypotension, tachycardia
– BP drop with inspiration (pulsus paradoxus. >10mmHg
change)
– JVP
• ECG: usually sinus tach. Rarely alternans
• Diagnose with combination of history, exam,
pulsus paradoxus, bedside ultrasound
– Formal echo should be confirmatory not for dx
Cardiac Tamponade
• Causes:
– Trauma, Cancer, Uremia, Infection (TB, Pus),
Serositis
• Treatment
– Pericardiocentesis
– Correct underlying problem
– Pericardial window
Case
• 55yo hard living man presents with progressive
dyspnea and LE edema
• PE: 100/60 107 26 86% on RA
• +JVD
• CV: tachycardic, s1s2 and s3, no murmur, PMI in left
armpit
• Ext: 2+ bilat LE edema
• Chest: rales bilaterally to mid-lung
• Labs: BNP 550
What is going on here? Tell me how you know
CHF: New Diagnosis
• Echocardiography is essential
• Acute dyspnea with BNP <100 is unlikely to be
due to CHF
– But BNP not a reliable measure of severity of
chronic HF
• Evaluate new or worsening CHF for ischemia
CHF: Classification
NYHA Functional Class:
I – asymptomatic
II – symptomatic, slight limitation in physical activity
III – symptomatic, marked limitation of physical
activity
IV – inability to perform any physical activity w/o
symptoms
ACC/AHA classification – class III overlaps with C
and D
Question
• Name the CHF meds that improve mortality:
CHF: Meds
All NYHA classes:
• ACE inhibitor (or ARB)
• Beta Blocker
• Diuretic as needed
Mortality Benefit
CHF: Meds
NYHA class II-IV (moderate to severe sx)
• ACE inhibitor (or ARB)
• Beta Blocker
• Spironolactone
• For black patients, hydralazine/
isosorbide dinitrate
• Diuretic as needed
• Digoxin
mortality
benefit
CHF: ICDs/resynch therapy
ICD for:
• Hx cardiac arrest or significant ventricular
arrhythmia OR
• EF <=35% + NYHA class II or III despite med
therapy
Cardiac Resynchronization (bi-V pacer) for:
• EF <=35% + NYHA III or IV + wide QRS
Pearls
• Aspirin, statin, ACE, beta-blocker for prior MI
• Don’t stop antiplatelet agents in patients with
stents
• ACE, Beta-blocker, aldosterone antagonist for CHF
• Rate control preferable for most patients with Afib
• CHADS2 score helps guide anticoagulation; don’t
cardiovert non-anticoagulated patients unless
they’re unstable
Pearls
• Aortic valve is usually surgical; mitral valve often
isn’t
• Symptomatic bradycardia usually needs a
pacemaker
• SVT may respond to meds or ablation
• VT requires ICD; ICD also indicated in CHF with EF
< 35%
• Cardiogenic shock: Think MI, but remember PE
and tamponade!