cardiology board review - ncapa
TRANSCRIPT
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Cardiology Board Review
Jennifer Carlquist PA-C, Central Coast Cardiology, CAQ ER Medicine
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Disclosure
I have a relationship with CME4Life, LLC, and sell DVDs of my lectures with their company.
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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
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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
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“Conduction Disorders” Things that go bump in the night…
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Atrial fibrillation/flutter Atrioventricular block Bundle branch block Paroxysmal supraventricular tachycardia Premature beats Sick sinus syndrome Ventricular tachycardia Ventricular fibrillation Torsades de pointes
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Normal conduction
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Getting to the root of the
cause
SVT
AFIB/Flutter
WPW Sick sinus VT
PVC’s
Palpitations tree
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Sinus Tachycardia
Rate: >100 – 160 BPM
Regularity: Regular
P wave: Present, PR interval constant
__________________ and ________________ can cause sinus tachycardia.
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ST causes
Fever
Pain
Hypovolemia
Drugs
How do we treat sinus tach?
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47 year old syncopal episode x 2
“I love to Zumba”
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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?
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Does he need to go to the
ER?
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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 = __________
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SVT
These patients will most likely have a ___________ blood pressure.
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SVT
Stable?
Adenosine
Unstable?
Synch
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PSVT
Stable Valsalva
Unstable Adenosine 6, 12, 12 - (How do we push it?)
Long term solution: BB, ablation
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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.
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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
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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
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Complications
Stroke
CHF
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Rate vs Rhythm? Assess/address stroke risk Ablation/Cardiovert
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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)
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Insert chart about this
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“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
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AC choices
Warfarin: needs frequent monitoring
Pradaxa (Direct thrombin inhibitors) – non valvular $8-12 day
No monitoring
No reversal
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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
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The Anticoagulants
Savaysa 60 mg qs
Eliquis
5 mg bid Xarelto
15 mg bid
Coumadin 5 mg qd
ASA 81 mg
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Things to rule out
Post op, coPd, Partying
Infiltrative myxoma
Rheumatic valvular disease
Acute MI
Thyroid
Toxins
Environmental
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Get you know your customer
Obese? Sleep apnea
Echo – LAE
Lexiscan – ischemic substrate
Bleeding issues?
HRTF?
BeerGin
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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
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Atrial Flutter Rate:
Atrial: 250–350 BPM, Vent: 125–175 BPM
Regularity: Regular
P wave: Saw toothed
Does this patient need AC?
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Atrial Flutter Causes
PE
ETOH
Ischemic heart disease
Hypoxia
Digitalis toxicity
Mitral or tricuspid valve disease
AMI
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Ectopy The Troublemaker
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What causes ectopic beats?
Lots of angry cells…
Atrial
Ventricular
Come in patterns
This ectopy pattern is called ______________ .
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ECTOPY