1	Cardiology ACP Board Review Course 2008 Internal Medicine Anthony J. Chiaramida, FACP
2	69 year old woman with 18 months of severe post op pain
3	Summary Young Athletes Athletes, Syncope, Sudden death Amyloid, Sarcoid, Thyroid disease PVD Diseases of the aorta Heparin and Warfarin Pregnancy and Systemic diseases Valvular heart disease CAD
4	Athletes and Heart Disease
5	Cardiovascular Risks to Young Persons on the Athletic Field 1/200 000 high school athletes per academic year. Usually congenital cardiovascular diseases. hypertrophic cardiomyopathy. congenital coronary artery anomalies. arrhythmogenic right ventricular dysplasia ?
6	Sudden Death in 387 Young Athletes
7	Cardiac Causes: Sudden Death
8	Hypertrophic Cardiomyopathy
9	Risk Factors for Sudden Cardiac Death in Hypertrophic Cardiomyopathy Major Risk Factors Cardiac arrest (VF) AF Spontaneous sustained VT Family history of premature sudden death Unexplained syncope LV thickness greater than or equal to 30 mm Abnormal exercise BP Nonsustained spontaneous VT
10	Athlete’s heart: typical findings Resting bradycardia, 40 to 60 bpm S3 and S4 are heard in 50% Midsystolic flow murmurs Sinus pauses up to 2.5 seconds 1’AVB and Wenck are common
11	Athlete’s heart: Workup indicated Symptoms Postural syncope, Stokes-Adams Malignant arrhythmia Axis deviation and wide QRS Echo LVH > 13mm Asymmetric septal hypertrophy
12	Commotio Cordis: 14 yr old
13	Syncope
14	Syncope: History postural (orthostatic or vasovagal syncope), exertional or a positive family history (cardiac syncope, long QT ), palpitations (arrhythmia), postictal (neurological syncope), situational (defecation / urination), medication, (polypharmacy in the elderly), LONG QTc organic heart disease (arrhythmias or ischemia). seizure w/o postictal symptoms (hypotension from arrhythmia or vasovagal syncope.
15	Syncope: prognosis
16	Prognosis depends on Diagnosis Vasovagal (21%) No increased mortality Orthostatic (9.4%) No increased mortality Cardiac (9.5%) Double the mortality Neurogenic Increased mortality, double incidence of stroke Unknown (36.6%) Increased mortality
17	Syncope: Physical signs Orthostatic hypotension (8%) 20 mm Hg differences in blood pressure in each arm or signs of aortic stenosis, idiopathic hypertrophic subaortic stenosis, pulmonary hypertension, myxomas, and aortic dissection.
18	LONG QTc Acquired Genetic
19	LONG QTc Arsenic trioxide Cisapride Antiinfective agents: clarithromycin, erythromycin, halofantrine, pentamidine, sparfloxacin Antiemetic agents: domperidone, droperidol Antipsychotic agents: chlorpromazine, haloperidol,mesoridazine, thioridazine, pimozide Methadone Disopyramide Dofetilide Ibutilide Procainamide Quinidine Sotalol Bepridil Amiodarone
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21	Carotid Sinus Reflex Vasodepressor, reduction in sympathetic activity loss of vascular tone and hypotension. This effect is independent of heart rate changes. Cardioinhibitory, increased parasympathetic tone slowing of the sinus rate long PR interval and advanced AV block, alone or in combination.
22	Tilt table testing
23	ACC Workup
24	TORSADE DE POINTES RESULTING FROM THE ADDITION OF DROPERIDOL TO AN EXISTING CYTOCHROME P450 DRUG INTERACTION CASE SUMMARY: A 59-year-old woman on long-term fluoxetine and cyclobenzaprine therapy Baseline QTc was prolonged at 497 msec. Prior to surgery, the patient received droperidol, an agent known to prolong the QT interval. During surgery torsade de pointes, which progressed into ventricular fibrillation. On postoperative day 1, after cyclobenzaprine discontinuation, the QTc decreased toward normal (440 msec
25	WPW: Syncope during tennis
26	Torsade: Syncope on Quinidine
27	Stress Induced Heart Disease?
28	Stress Induced Heart Disease? Present with chest pain or CHF, half after news of unexpected death Coronaries are NORMAL: 25% have ^ QTc EF returns to normal
29	Stress Induced Heart Disease?
30	Sarcoid
31	Sarcoid: Cardiac Half have EKG changes: rhythm, conduction, and repolarization. Thallium-201 is useful, although the defects are not specific to sarcoidosis. Echo to find abnl LV function, valvular abnormalities, pericardial effusion, and ventricular aneurysms. Causes 50% of the mortality Steroids if gallium 67 is positive. (probably)
32	Amyloid (AL): Fibrils Between Myocytes
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34	Amyloid: Common presentation EKG has low voltage and Q waves Echo shows thick LV and RV that ‘sparkle’ and restrictive physiology Atrial thrombi in SR, A fib high embolic risk CHF with right sided failure marked worsening of failure after calcium-channel blocker, sometimes prescribed in an attempt to treat diastolic dysfunction.
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36	Amyloid: Physical findings
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40	Cocaine Chest pain is the most common cocaine-related medical problem. rapidly followed by sympathetic stimulation that produces tachycardia and hypertension. In situ thrombus formation.
41	Cocaine and MI 31% to 67% were found to have coronary artery disease, despite average ages ranging from 32 to 38 years Troponin elevation or hx of CAD predicts positive cath
42	Cocaine and chest pain MI in 6 percent. most have symptoms within 24 hours. Can occur with cocaine withdrawal. EKG’s are abnormal in 56% to 84%. 43% without infarction meet the EKG criteria for tPA.
43	Cocaine Infarction: therapy Don’t use Labetolol Causes seizures Lidocaine Aspirin Nitrates (to reduce mean arterial BP by 10 to 15% Benzodiazepine
44	Cocaine Infarction: therapy If ST elevation after NTG and Ca²⁺ blocker; Emergency Cath thrombolysis if a thrombus is detected.
45	Heparin
46	3 heparins
47	LMWH: Lab Measurement? Anti Factor Xa Obesity Renal Insufficiency 0.6 to 1.0 U/ml (lab)
48	LMWH: FDA dosing for renal insufficiency
49	Reversal of LMWH If LMWH is within 8 h, Protamine:1 mg per 100 anti-factor Xa units LMWH (1 mg enoxaparin equals approximately 100 anti-factor Xa units). A second dose of 0.5 mg protamine per 100 anti-factor Xa units: if the bleeding continues. Smaller doses: if the LMWH was injected 8 h before the clinical event requiring neutralization
50	Cardiac sources of emboli: PFO
51	Cardiac sources of emboli: ASD
52	Pregnancy
53	Pregnancy: Very High Risk Pulmonary hypertension (50% mortality) Dilated cardiomyopathy with CHF Marfan’s with dilated aortic root Cyanotic CHD Symptomatic obstructive lesions
54	Peripartum cardiomyopathy
55	PPCM: EF by time
56	PPCM: to remember! More common in women > 30 years old Strong association with gestational HTN Strong association with twin pregnancy Increases in most, normalizes in half 10 to 20 % mortality rate, half with sudden death (role of ICD?)
57	Cardiac arrest
58	Pregnancy associated thrombosis VTE is a leading cause of morbidity and mortality during pregnancy and the puerperium. 5 X the risk of a nonpregnant woman
59	Pregnancy: special problems Mitral stenosis – standard medical RX; commissurotomy or MVR causes fetal loss of 33% Aortic stenosis – restrict activity Both handle volume overload of pregnancy poorly
60	Pig valve or mechanical? Mechanical Coumadin forever Valve lasts forever Bioprosthetic No coumadin Will fail in 10 to 15 yrs
61	Outpatient Anticoagulation dilemma Warfarin causes embryopathy SC and LMWH are ineffective
62	Pericarditis
63	Pericarditis: Acute - EKG
64	Pericarditis: Acute - EKG
65	Pericarditis: Acute Chest pain, friction rub, EKG changes, ESR Presumed to be viral (echo and coxsackie) Aspirin, then NSAID’s Problem is relapse. Real danger of steroid dependency Pericardiectomy is last resort
66	Pericardial Effusion Cancer Lung Breast Dialysis Cardiomegaly, no CHF AIDS Increased CVP Low voltage Diagnosis is by clinical suspicion and echo SO…suspect it if
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68	Tuberculosis: pericardial effusion
69	Hemopericardium
70	Congestive Heart Failure
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73	Prognostic Significance of Heart Failure Stages
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75	Congestive Heart Failure
76	Systolic HF(75%) or Diastolic HF(25%)
77	Which CHF is it? SHF(75%) or DHF(25%) Diastole is relaxation dependant Systole stays normal Thick noncompliant LVH Stiff diabetic heart Infiltrative diseases ALL have normal EF Systole is active power contraction CAD, HTN, DCM all lower the EF ALL have low EF’s
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80	Echo is Diagnostic
81	Diastolic dysfunction: DHF
82	Prevalence of Diastolic Dysfunction in newly diagnosed DM
83	Diagnosis by Echocardiogram
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85	Fluid retention? / diuretics
86	ACEI: Unless contraindicated!
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88	CHF : Beta blocker Rx Bisoprolol, Carvedilol, Toprol XL recommended for all HF patients with Reduced ejection fraction Symptomatic all stable patients unless contraindicated
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90	Hyperkalemia with aldactone
91	CHF: Biventricular pacing LVEF < 35%, Sinus rhythm, Class III or class IV symptoms who have cardiac dyssynchrony, currently defined as a QRS > 0.12 ms,
92	Dyssynchrony: Echo Diagnosis
93	Biventricular pacing for CHF
94	Biventricular pacing for CHF
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96	Rx of Symptomatic CHF Diuretics (if fluid retention) ACE (universal, unless contraindicated) Withdraw calcium channel blockers and NSAIDS Beta blockers (in all stable patients) If not contraindicated If no IV inotropes used recently, and no fluid retention RST (EF<35) + QRS > 0.12 ICD (EF<30)
97	Which of the following is not generally contraindicated for treatment of patients with symptomatic CHF? NSAID’s Calcium channel blocking drugs Combined use of an ACEI, ARB, and aldosterone antagonist Short-term use of an infusion of a positive inotropic drug (unless palliation in Class D)
98	Heart Transplant
99	Cardiac transplant: candidates End stage failure, 6 month prognosis NO Active malignancy Pulmonary hypertension AIDS Unresolved pulmonary infarction (infection)
100	Transplant waiting list survival: AICD vs control
101	Left Ventricular Assist Device
102	LVAD = Bridging device
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104	Simvastatin: post transplant
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106	NSAIDS (VIOXX) and CHF
107	Class III for CHF NSAID’s Calcium channel blocking drugs Combined use of an ACEI, ARB, and aldosterone antagonist Long-term use of an infusion of a positive inotropic drug (unless palliation in Class D)
108	Atrial Fibrillation
109	Atrial Fibrillation 2.2 million US patients
110	Prevalence: ages 65 to 84
111	“sometimes more is just more”
112	Atrial Fibrillation: Rate control the ventricular response is between 60 and 80 bpm at rest 90 to 115 bpm during moderate exercise
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114	Atrial Fibrillation: IV Rate control CHF present Digoxin Amiodarone CHF absent Beta Blockers Esmolol Metoprolol Propranolol Ca Channel Blockers Diltiazem Verapamil
115	AFib: Rate Control
116	A Fib: Rate control
117	Which drugs for PO rate control?
118	Atrial Fibrillation: Rate Control
119	Rhythm control Convert and keep in sinus rhythm?
120	Affirm: Rhythm vs. Rate control
121	Affirm: toxicity of rhythm control
122	Pharmacologic conversion (SAFE-T) Sotalol 80 mg twice daily for the first week and 160 mg twice daily thereafter Both convert to Sinus about 25% to 30% in one month Amiodarone 800 mg daily for the first 14 days, 600 mg daily for the next 14 days, 300 mg per day for the first year, and 200 mg per day thereafter.
123	Pharmacologic maintenance
124	Maintaining Sinus Rhythm Minimal heart disease Class III drugs Flecainide Propafenone Sotalol Amiodarone dofetilide Heart disease present CHF Amiodarone dofetilide CAD sotalol HTN Flecainide amiodarone
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126	A fib: Pulmonary Vein Ablation
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128	Atrial Fibrillation: Treatment Warfarin 64% decreased risk of stroke compared to placebo Aspirin 22% risk of stroke compared with placebo Balance risk of stroke with risk of bleed Consider Aspirin
129	Atrial Fibrillation: No warfarin 1% risk of stroke if Under age 60 - 65 and (no risk factors) No structural heart disease (= normal echo) No diabetes No prior stroke No hypertension USE aspirin 325 mg/day
130	INR vs. Stroke
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132	vitamin K haplotype enzymeVKORC1 may affect the response to warfarin.
133	Survival in the 30 Days after an IschemicStroke among Patients with Nonvalvular Atrial Fibrillation, According to the Antithrombotic-Medication Status at Admission.
134	Incidence Rates of Ischemic Stroke and Intracranial Hemorrhage According to INR at the Time of the stroke
135	Severity of the Neurologic Deficit at Discharge and 30-Day Mortality Rates, According to aspirin/INR at Admission
136	Investigational Therapy of A Fib
137	Surgical Risk : Not Clearance!
138	Surgical risk
139	Surgical risk
140	Surgical Risk: Major Predictors MI < 30 days decompensated CHF Heart Block V Tach with Bad LV function Uncontrolled A Fib AS, IHSS.
141	Major Predictors: 3 A’s, 2 B’s and a C 1: AMI, A Fib, AS 2: Block or VT/Bad LV 3: CHF
142	Predictors of Surgical Risk Minor predictors abnormal EKG; LVH, LBBB, STD rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled systemic hypertension. advanced age, Intermediate predictors mild angina pectoris, Previous MI by Hx or Q waves compensated or prior CHF, and diabetes mellitus. Creatinine > 2.0
143	Procedural risk
144	High Risk Surgical Procedures
145	High Risk (5% mort) Procedures Major emergency Aortic and other major vascular surgery; PVD , Prolonged Procedures Shifts (fluid or blood)
146	Surgical Risk by Procedure Low-risk ( < 1%) endoscopic and dermatologic, cataract surgery, and breast surgery. Intermediate-risk (<5%) carotid endarterectomy, head and neck surgery, intraperitoneal and intrathoracic, orthopedic, and prostate.
147	Any 2 of 3 àpreop noninvasive testing Any angina, Any MI evidence, Any CHF, DM Debilitated (Can’t bowl, or vacuum, or walk up a hill Vascular or emergency surgery
148	Preop: Beta blocker If beta blockers were used recently HTN Angina Arrhythmias OR High risk cardiac patient undergoing vascular surgery Start days or weeks before elective surgery, achieve a resting heart rate of 50 to 60 bpm.
149	Preop therapy: Delay post PCI Angioplasty Delay one week to allow vessel healing Stent placement Allow (minimum 2) 4 weeks. Stent thrombosis when elective noncardiac surgery is performed within two weeks of stent placement is very high, as is the frequency of MI and death
150	Periop therapy: ICD off immediately before surgery on again postoperatively to prevent unwanted discharge due to spurious signals that the device might interpret as ventricular tachycardia or fibrillation. Finally, if emergent cardioversion is required, the paddles should be placed as far from the implanted device as possible and in an orientation likely to be perpendicular to the orientation of the device leads (i.e., anterior-posterior paddle position is preferred).
151	Valvular Heart Disease
152	Cardiac Murmur: physical exam Respiration- right sided murmurs Valsalva- HCM and MVP much louder Standing- HCM and MVP louder Squatting- HCM and MVP disappear
153	Innocent Murmur grade 1 to 2 intensity at LSB no other sounds no other clicks no LVH no RVH no change with standing or valsalva
154	VHD: Endocarditis Prophylaxis Low risk category Secundum ASD Repaired ASD previous CABG MVP w/o MR Pacemaker AICD High risk category Prosthetic heart valve Previous endocarditis Complex cyanotic CHD
155	VHD: Endocarditis Prophylaxis Low risk procedures intubation brochoscopy with biopsy* endoscopy with biopsy* TEE* Vaginal hysterectomy* Vaginal delivery* IUD, abortion, sterilization cardiac catheterization High risk procedures Sclerotherapy for varices Biliary tract surgery Intestinal mucosa surgery Prostate surgery Cystoscopy
156	Pressure or Volume Overload?
157	Pressure overload
158	Aortic Stenosis
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160	Aortic Stenosis: Surgical disease 90% 1 -2 year mortality for medical therapy severe AS and CHF
161	Aortic Stenosis: Follow up Annual echocardiogram Catheterization, not stress test for CAD Symptoms are failure (dyspnea), angina, and syncope Vasodilators contraindicated
162	Aortic regurgitation: f/u and Rx Diagnose: Serial echo’s to follow Systolic function LV cavity size in systole and diastole Treat: Chronic vasodilator therapy Symptomatic; not surgical candidate Asymptomatic; severe regurgitation
163	Aortic regurgitation: AVR Class I Symptomatic EF .25 to normal Asymptomatic, but EF 0.25 to 0.49 CABG
164	AR: Vasodilator Indications Symptoms LV dysfunction LV dilatation HTN and any AR.
165	Mitral Stenosis
166	Mitral Stenosis: Anticoagulation 1. Patients with atrial fibrillation, paroxysmal or chronic. 2. Patients with a prior embolic event.
167	MS: Balloon Valvotomy or surgical repair? 1. Symptomatic patients (NYHA Class II, III, or IV), moderate or severe MS (mitral valve area <1.5 cm ² )
168	Mitral regurgitation: MVR Surgery indicted with Class III or Class IV symptoms Asymptomatic with decreased LVEF
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170	MR: Surgery in Nonischemic MR 1. Acute symptomatic MR. 2. Class II, III, or IV and normal LV function defined as: EF > 0.60 and end-systolic dimension < 45 mm. 3. Symptomatic or not mild or moderate LV dysfunction, ejection fraction 0.30 to 0.60, and end-systolic dimension 45 to 55 mm. 4. NOT FOR VERY BAD OR VERY DILATED LV!
171	Surgery: MR and AR summary Symptomatic OR Dilated LV OR Decreased EF
172	Prosthetic Valve Diseases
173	Thromboembolism rates for mechanical aortic valves
174	Valve Replacement With a bioprosthetic valve 1. Patients who cannot or will not take warfarin therapy. 2. Patients >65 years* needing AVR who do not have risk factors for thromboembolism.†
175	Valve Replacement With Mechanical Valve Patients with expected long live spans Patients with a mechanical valve in place in another position
176	Bioprosthetic failure rate over time
177	Bioprosthetic valve failure over time
178	Mechanical or Porcine?
179	Ball Cage Valve
180	Porcine Bioprosthetic Valve
181	Bileaflet Valve
182	Intravascular Hemolysis
183	red cell distribution width
184	Bioprosthetic Heart Valve f/u Antibiotic prophylaxis Aspirin (low dose 80 to 100mg) Warfarin If Risk factor present Atrial fibrillation Severe LV dysfunction Previous thromboembolism Hypercoagulable condition
185	Mechanical Heart Valve f/u Antibiotic prophylaxis Aspirin (low dose 80 to 100mg) Class IIa Warfarin for all mechanical valves Risk of thromboemboli is 1 to 2% per year Mitral position more likely source INR 2.5 to 3.5 AVR bileaflet INR 2.0 to 3.0 Starr-Edwards (AVR or MVR) INR 2.5 to 3.5 (MITRAL or Ball need More)
186	Prosthetic Valve: Noncardiac Surgery or Dental Care STOP Coumadin 72 hours before STOP Aspirin 1 week before If you’re really worried about it (means high risk) Put on UFH when INR drops under 2 STOP UFH 6 hrs before Restart UFH 24 hrs after
187	Diseases of the Aorta
188	Thoracic aortic aneurysm Upper back pain Coughing and wheezing Hoarse voice Difficulty swallowing Edema in the neck or arms Horner's syndrome
189	Aortic Aneurysm: Thoracic Typically asymptomatic Pain predicts expansion or dissection Rupture can be the initial manifestation Ascending aorta Hemopericardium infarction Treatment Surgical only
190	Aortic Aneurysm: Repair 2.6 percent mortality for urgent repair -- that is, within seven days after a surgical consultation. 11.7 percent mortality among patients who underwent emergency repair -- that is, within 24 hours after a surgical consultation. repair these aneurysms prophylactically when the diameter reaches 5.5 to 6.0 cm, regardless of a patient's symptoms
191	Abdominal aneurysm: 64 slice CTA
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194	Aneurysm repair survival
195	Aortic Aneurysm: Abdominal
196	Aortic Aneurysm: Abdominal Ages 70’s and 80’s Size predicts risk ( > 5cm) Pain; most are symptomatic Rupture may be initial manifestation Typically retroperitoneal Hemorrhage may be retarded Occult blood loss may last days to weeks
197	Aortic Aneurysm: Abdominal Diagnosis Cross table lateral X-Ray CT Scan MRI Preoperative workup for coronary disease if not emergent
198	Jonathan Larson Jonathan Larson was sent home from two different New York City hospitals – one diagnosed him with the flu, the other food poisoning – only for him to die alone in his apartment of an aortic dissection before his hit play opened on Broadway.
199	Aortic Dissection
200	Aortic Dissection: Proximal
201	Aortic Dissection: Proximal
202	Aortic root dissection causing STEMI and Hemopericardium
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204	Hemopericardium
205	Aortic Dissection MRI in all hemodynamically stable patients and TEE in patients who are too unstable to be moved
206	Aortic Dissection Ascending Aorta Surgical emergency (MI, stroke, tamponade) Descending aorta Medical therapy IF totally stable Surgical therapy IF any change or instabilty
207	Aortic dissection
208	Aortic Dissection IV antihypertensive therapy Nipride plus beta blocking agent Systolic 100 to 120 mm hg IV labetolol OK NO hydralazine, minoxidil, or diazoxide
209	Peripheral Vascular Disease
210	Prevalence of PVD by Age and Sex
211	Risk factors for lower extremity PVD
212	PVD: Thromboangitis obliterans Pathology (biopsy diagnostic) Panvasculitis Inflammatory intraluminal thrombus Starts in digits, progresses cephalad Presents with Digital sensitivity claudication Treatment Stop smoking Buerger’s disease Autoimmune reaction to tobacco use Women Ages 15 to 50 Vasculitis of small to medium-sized arterioles
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215	PVD: Microcirculation
216	The First Tool to Establish the PAD Diagnosis: The HPI, ROS, and Physical Examination Pulse intensity should be assessed and should be recorded numerically as follows: 0, absent 1, diminished 2, normal 3, bounding
217	Calculating the Ankle–Brachial Index
218	Exercise ABI Confirms the PAD diagnosis Assesses the functional severity of claudication May “unmask” PAD when resting the ABI is normal
219	Arterial Duplex Ultrasound Testing
220	Noninvasive Imaging Tests
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222	Fontaine’s classification I Asymptomatic IIa mild claudication IIb mod-severe claudication III ischemic rest pain IV ulceration or gangrene
223	Therapy for Claudication Statin LDL < 100 Hypertension control 130/80 DM 140/90 Non DM Aspirin or Plavix Cilostazol (100 mg BID) Exercise Training
224	Statins: Carotid plaque regression
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226	Right Superficial Femoral Artery before and after endovascular Treatment.
227	Surgery for Critical Limb Ischemia Patients who have significant necrosis of the weight-bearing portions of the foot, an uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or a very limited life expectancy due to co-morbid conditions should be evaluated for primary amputation.
228	PVD: Acute arterial occlusion Trauma History ( crushing, penetrating, and deceleration ) Thrombosis in situ Occurs with occlusive or aneurysmal disease Embolism Source is cardiac LA and LV, not valves A fib Paradoxical is right to left shunt
229	Endocarditis
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238	Potential Need for Surgical Intervention Early or repeat embolization Anterior mitral leaflet vegetation, esp with size >10 mm² Increase veg size after 4 weeks of therapy Heart failure unresponsive to medical therapy Severe valve damage or abscess New heart block³
239	Native Valve Endocarditis: Surgery Acute AR or MR with heart failure. Acute AR with tachycardia and early closure of the mitral valve. Fungal endocarditis. Evidence of annular or aortic abscess, sinus or aortic true or false aneurysm. Valve dysfunction and persistent infection after 7 to 10 days of appropriate antibiotic therapy, as indicated by presence of fever, leukocytosis, and bacteremia, provided there are no noncardiac causes for infection.
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241	Surgery:Prosthetic Valve Endocarditis 1. Early prosthetic valve endocarditis (first 2 months or less after surgery). 2. Heart failure with prosthetic valve dysfunction. 3. Fungal endocarditis. 4. Staphylococcal endocarditis not responding to antibiotic therapy. 5. Evidence of paravalvular leak, annular or aortic abscess, sinus or aortic true or false aneurysm, fistula formation, or new-onset conduction disturbances. 6. Infection with gram-negative organisms or organisms with a poor response to antibiotics.
242	Coronary Artery Disease
243	Primary prevention with aspirin
244	Aspirin/GI bleeds by age
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246	No Sx’s
247	Stable Angina: Management Guidelines Aspirin (80 – 150mg) (Plavix if allergic) Beta blocker ACE Rx; if DM or LV dysfunction Statin: a target LDL <100 mg/dL. But <70 mg/dl if high risk
248	Stable Angina: Cath Indications Disabling symptoms (CCS III or IV) High risk results on noninvasive testing Survival from sudden death or serious ventricular arrhythmia Symptoms and signs of CHF Patients with a high likelihood of severe CAD
249	Likelihood of triple vessel disease
250	Surgery or medical management
251	Optimal Medical Therapy with or without PCI for Stable Coronary Disease
252	Secondary Prevention
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255	Stable Angina: LDL target Below 100
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258	COX-2 and major cardiovascular consequences prothrombotic/antithrombotic shift toward thrombosis; an increase in sodium and water retention, worsening edema, CHF, hypertension loss of the protective COX-2 upregulation in the setting of myocardial ischemia and infarction, which leads to a larger infarct size, greater thinning of the infarcted region increased tendency to myocardial rupture
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263	Emergency Duties and Deaths from Heart Disease among US Firefighters
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266	Hyperlipidemia
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268	Statins Contraindications Absolute Active or chronic liver disease Relative Don’t use with macrolides, gemfibrozol, nicin Lower LDL 18 to 55% Raise HDL 5 to 15% Lower TriG 7 to 30%
269	"Statin monitoring" Statin monitoring CK before RX (ATPIII) Q 6-12 weeks check for muscle soreness AST, ALT initially and at 12 weeks, then annually Stop or lower statin if CK is 10X normal Stop or lower statin if AST, ALT 3X normal Don’t use gemfibrozil with statins
270	Bile acid sequestrants Contraindications Absolute Dysbetalipoproteinemia TriG > 400mg/dl Relative TriG > 200 mg/dl Lower LDL 15 to 30% Raise HDL 3 to 5% TriG increase or no change
271	Niacin Contraindications Absolute Chronic liver disease Severe gout Relative DM, PUD, hyperuricemia Lower LDL 5 to 25% Raise HDL 15 to 35% Lower TriG 20 to 50%
272	Fibric acids Contraindications Absolute Severe renal disease Severe liver disease Lower LDL 5 to 20% Raise HDL 10 to 20% Lower TriG 20 to 50%
273	CAD in Women
274	Decreasing mortality from CAD
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276	Young women with MI: plaque erosion, not rupture
277	Women and CAD: presentation #1
278	Women and CAD: presentation #2
279	Women: lifestyle changes Stop smoking 30 minutes of moderate-intensity activity daily Diet saturated fat intake to 10% of calories cholesterol intake to 300 mg/d, limit intake of trans fatty acids. Weight BMI between 18.5 and 24.9 kg/m2 and a waist circumference 35 in. Depression evaluate for, and treat Measure estrogen levels (premenopausal)
280	Which statement about women and heart disease is true? Presenting symptoms are the same as in men Vascular dysfunction is less common in women Cardiac cath is 100% diagnostic Low exercise level is predictive of risk Estrogen failure is not an association
281	Women and CAD: Summary Presenting symptoms are different Vascular dysfunction more common Cardiac cath can miss the diagnosis Low exercise level is predictive of risk Estrogen failure is an association
282	Hormone replacement therapy Not for primary or secondary prevention of CAD
283	CAD: Drug Interactions in Men
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285	Safety of PDE-5i 5 years of clinical experience in over 20 million men. heart and vascular disease, DM, HTN, after having radical surgery on dialysis after transplantation (both kidney and liver) on protease inhibitors after receiving spinal cord injury in elderly men. The incidence of myocardial infarction (MI) and death in men taking sildenafil is less than the age-adjusted incidence in the general population.
286	PDE-5i clearly contraindicated NO crossover for 24 hours
287	Acute Coronary Syndromes
288	Acute Coronary Syndromes
289	Acute Coronary Syndromes
290
291	No symptoms
292	No symptoms
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294	Thromobolytic or PCI
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296
297	ST elevation (STEMI)
298	Unstable Angina and NSTEMI
299	NSTEMI/UA: Antiplatelet Rx Class I and the cornerstone of therapy Aspirin (all) Thienopyridines (Plavix) (all) IIbIIIa (if high risk)
300	Clopidogrel in UA to Reduce Events
301	IIB/IIIA Rx: UA/NSTEMI IIbIIIa Class I if high risk (PCI planned)
302	Heparin
303	Subtherapeutic aPTT predicts ischemia
304	UA/NSTEMI High Risk Features Age > 75 worsening pain CHF Hypotension ST depression BBB
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306	"CONTRAINDICATIONS" CONTRAINDICATIONS PR > 0.24 sec or worse AV block HR < 50 / min BP < 90 mm History of Asthma or Recent IV inotropes for CHF or fluid retention Beta blockers without ISA Metoprolol Propranolol Atenolol Or ultra short-acting esmolol
307	"Esmolol" Esmolol 0.1 mg/kg/min IV Titrate increments of 0.05 q 10 to 15 minutes Max 0.3 mg/kg/min Metoprolol 5mg over 1 to 2 minutes Repeat q5min for 15mg total Then 25mg po q6hrs X 48 hrs
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309	Class III: NOT recommended Nitrates within 24hrs of Viagra Dihydropyridine without Beta blockers Calcium channel blocker Nifedepine is prototype of this class
310	Statins: CARE
311	Effects of Atorvastatin on Stroke in UA/NSTEMI
312	Comparison of Intensive and Moderate Lipid Lowering with Statins after Acute Coronary Syndromes
313	Statin Post MI: High dose benefit
314	Assess risk Higher risk is due to More unstable plaque Which gives greater chance of benefit from aggressive therapy
315	Noninvasive risk assessment Rest LVEF < 35% on echo or MUGA Exercise LVEF < 35% Stress SPECT induced perfusion defect in anterior wall Abnormal BP, or EKG response to stress Lung uptake (CHF) on rest thallium
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317
318	"Early" Early Invasive Therapy
319	PCI Indications: NSTEMI/UA Class I a. Recurrent ischemia despite intensive anti-ischemictherapy. b. Elevated troponin level. c. New ST-segment depression. d. CHF symptoms or new or worsening MR. e. Depressed LV systolic function. f. Hemodynamic instability. g. Sustained ventricular tachycardia. h. PCI within 6 months. i. Prior CABG.
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322	Bare metal stent failure over time
323	Eluting metal stent failure over time
324	Both stents can fail over time
325	MEDICATIONS AT HOSPITAL DISCHARGE 1. Instructions! 2. Aspirin 75 to 325 mg/d 3. Clopidogrel (plavix) 75 mg/qd 4. b-Blocker (else document contraindications) 5. Nitrates (Class IC) Lipid-lowering agent and diet in patients with LDL cholesterol >130 mg/dL (target < 70 or 100) Niacin or Gemfibrizol for HDL < 40 7. ACEI for LVEF < 40 or CHF By echo, MUGA, or ventriculogram
326	Women vs. Men
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328
329
330	ACS: The vulnerable plaque Sudden total or near-total arterial occlusion frequently develops in arteries that previously appeared to have minimal stenosis.
331	Include LBBB and age >75yrs
332	Diagnose before troponins! ST elevation on the 12-lead ECG and Symptoms of STEMI, reperfusion therapy should be initiated as soon as possible and is not contingent on a biomarker assay.
333	Thromobolytic or PCI
334	STEMI: PCI or Thrombolytic?
335	STEMI: PCI vs Thrombolysis
336
337
338	Enrollment to balloon time predicts 30 day mortality
339	Symptom to balloon time predicts one year mortality
340	"ASA ( 162 to 325..." ASA ( 162 to 325 mg ) ASAP; continue 75 to 162 mg indefinitely.
341	Plavix: ST elevation MI benefit
342	STEMI: Enoxaparin/UFH
343	STEMI: Beta Blocker Rx Beta Blocker Oral is Class IA Toprol XL IV Tachyarrhythmias HTN) Metoprolol 5mg x 3 doses)
344
345	STEMI: ACEI PO within the first 24 hours Anterior infarction, Pulmonary congestion, or LVEF less than 0.40, in the absence of hypotension (systolic blood pressure less than 100 mm Hg or less than 30 mm Hg below baseline) ARB if ACEI intolerant
346	MEDICATIONS AT HOSPITAL DISCHARGE Aspirin 75 to 162 mg/d Clopidogrel 75 mg/qd b-Blocker Statin ACEI for patients with CHF, LV dysfunction (EF<0.40) hypertension, or diabetes