cardiology board review - ncapa
TRANSCRIPT
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