Cardiology Board Review

Jennifer Carlquist PA-C, Central Coast Cardiology, CAQ ER Medicine

Disclosure

I have a relationship with CME4Life, LLC, and sell DVDs of my lectures with their company.

Blueprint

Cardiomyopathy

Dilated

Hypertrophic

Restrictive

Conduction Disorders

Atrial fibrillation/flutter

AV Block

Bundle branch block

PSVT

Premature beats

Sick sinus syndrome

Ventricular tachycardia

Ventricular fibrillation

Torsades de pointes

Heart Failure/CAD

Objectives

Common arrhythmias and their treatment

Demystifying Bundle Branch and AV Blocks

Coronary Artery Disease: Identify patients at risk for CAD, prevention and treatment

Heart Failure: Identify, manage and prevent it

“Conduction Disorders” Things that go bump in the night…

Atrial fibrillation/flutter Atrioventricular block Bundle branch block Paroxysmal supraventricular tachycardia Premature beats Sick sinus syndrome Ventricular tachycardia Ventricular fibrillation Torsades de pointes

Normal conduction

Getting to the root of the

cause

SVT

AFIB/Flutter

WPW Sick sinus VT

PVC’s

Palpitations tree

Sinus Tachycardia

Rate: >100 – 160 BPM

Regularity: Regular

P wave: Present, PR interval constant

__________________ and ________________ can cause sinus tachycardia.

ST causes

Fever

Pain

Hypovolemia

Drugs

How do we treat sinus tach?

47 year old syncopal episode x 2

“I love to Zumba”

Sinus Pause/Arrest

Rate: Varies

Regularity: Irregular, but PR intervals are the same

P wave: Present intermittently

Sick sinus syndrome:

- Digitalis, CA ++ blockers, Antiarrhythmic drugs, CAD,

collagen vascular diseases and or mets

- Reversible? Pacer?

Does he need to go to the

ER?

Supraventricular Tachycardia

Criteria

Rate: 140 - 220 bpm

Rhythm: Regular QRS: Normal or prolonged (>.12

sec)

Usually starts and stops suddenly

Etiology Rapid atrial depolarization overrides the

SA node

Pathway, caffeine, drugs

Clinical Significance Decrease in cardiac output = __________

SVT

These patients will most likely have a ___________ blood pressure.

SVT

Stable?

Adenosine

Unstable?

Synch

PSVT

Stable Valsalva

Unstable Adenosine 6, 12, 12 - (How do we push it?)

Long term solution: BB, ablation

Atrial Fibrillation

Rate: Variable, ventricular response can be fast or slow. Atrial rate is usually over 350 BPM.

Regularity: Irregularly irregular

P wave: None; chaotic atrial activity

Patients lose their ___________ in atrial fibrillation.

Defining AF

Paroxysmal: Atrial fibrillation that lasts from a few seconds to days, then stops on its own

Persistent: Does not stop by itself but will stop if cardioverted

Permanent (long standing persistent) AFIB begets AFIB wont retain sinus

Normal LA with structurally normal hearts are better candidates

Atrial Fibrillation

Causes

We can fix •Thyrotoxicosis •High blood pressure •Heart disease (Valvular) •High cholesterol

Things the patient can fix •Obesity •Smoking •Caffeine •Alcohol abuse •Sleep apnea

Complications

Stroke

CHF

Rate vs Rhythm? Assess/address stroke risk Ablation/Cardiovert

Rate vs

Rhythm

Rate control is non-inferior to rhythm control and may be superior in elderly or co-morbid patients (AFFIRM).

Strict rate control may provide no further benefits (RACE-II)

Insert chart about this

“The second time you want to be a zero…”

1 - strong consideration for AC

2 and up- “No brainer”

BUT - 1 from female (< 65 years old without other risk factors) NO AC

AC choices

Warfarin: needs frequent monitoring

Pradaxa (Direct thrombin inhibitors) – non valvular $8-12 day

No monitoring

No reversal

Pick your poison…

Factor Xa Coumadin

No monitoring

No reversal agents

Rare medication interactions

No food interactions

Renal dosing

Expensive up to $12/day

Needs monitoring

Reversal possible

Medication interactions

Food interactions

Renal insufficiency

Inexpensive

The Anticoagulants

Savaysa 60 mg qs

Eliquis

5 mg bid Xarelto

15 mg bid

Coumadin 5 mg qd

ASA 81 mg

Things to rule out

Post op, coPd, Partying

Infiltrative myxoma

Rheumatic valvular disease

Acute MI

Thyroid

Toxins

Environmental

Get you know your customer

Obese? Sleep apnea

Echo – LAE

Lexiscan – ischemic substrate

Bleeding issues?

HRTF?

BeerGin

How do you choose a drug?

How symptomatic? How long to stay in it – perioperative? Bleeder? How likely to stroke? How much are they in it?

WHAT DO THEY WANT TO DO

Atrial Flutter Rate:

Atrial: 250–350 BPM, Vent: 125–175 BPM

Regularity: Regular

P wave: Saw toothed

Does this patient need AC?

Atrial Flutter Causes

PE

ETOH

Ischemic heart disease

Hypoxia

Digitalis toxicity

Mitral or tricuspid valve disease

AMI

Ectopy The Troublemaker

What causes ectopic beats?

Lots of angry cells…

Atrial

Ventricular

Come in patterns

This ectopy pattern is called ______________ .

ECTOPY