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Back To Basics: Cardiology Review I

Back To Basics: Cardiology Review I. Michael Froeschl, MD FRCPC Assistant Professor of Medicine. Overview. CAD Atherosclerosis Stable Obstructive CAD Unstable CAD: Acute Coronary Syndrome ECG/Arrhythmia Review Bradydysrhythmias Tachydysrhythmias Syncope. NB: Key Feature Questions.

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Back To Basics: Cardiology Review I

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  1. Back To Basics:Cardiology Review I Michael Froeschl, MD FRCPC Assistant Professor of Medicine

  2. Overview • CAD • Atherosclerosis • Stable Obstructive CAD • Unstable CAD: Acute Coronary Syndrome • ECG/Arrhythmia • Review • Bradydysrhythmias • Tachydysrhythmias • Syncope

  3. NB: Key Feature Questions Learn how to answer them!

  4. 1. Two Concepts • Ischemia: Tissue oxygen demand exceeds tissue oxygen supply • Infarction: Tissue necrosis secondary to tissue ischemia

  5. ↓ Supply Coronary obstruction Microvascular obstruction ↓ Perfusion pressure ↓ PaO2 ↓ Hemoglobin ↑ Demand ↑ Heart Rate ↑ Contractility ↑ Wall Tension 1. Supply-Demand Mismatch

  6. 1. CAD Obstructive CAD ACS Atherosclerosis

  7. Mode-of-Life Issues Smoking Diet Exercise Alcohol Stress Medical Issues Dyslipidemia Hypertension Diabetes Mellitus Obesity 1a. Atherosclerosis Targets INTERHEART, Lancet 2004

  8. 1a. Atherosclerosis Targets “Vascular Protection” • ASA • Statins • ACE-Inhibitors or ARBs • Beta-Blockers

  9. 1b. Stable Obstructive CAD Usual manifestation is Angina Pectoris: (“strangling”) chest pain secondary to myocardial ischemia

  10. 1b. Stable Obstructive CAD: DX • Clinical assessment in all • Chest Pain • Sqeezing retrosternal • Brought on by stress • Relieved by rest or NTG • Patient (age, gender, vascular risk) • Physical exam and basic blood work 3/3: Typical anginal CP 2/3: Atypical anginal CP 0-1/3: Non-anginal CP

  11. 1b. Stable Obstructive CAD: DX • Testing in some (for diagnosis and prognosis) • Functional Assessment (“stress test”) • Exercise ECG • Dipyridamole Perfusion Scan • Dobutamine Echocardiogram • Anatomical Assessment • Coronary Angiography (conventional, CT)

  12. 1b. CCS Angina Severity Scale I Ordinary activity does not cause angina; angina only with increased activity II Slight limitation of ordinary activity (> 2 blocks level, > 1 flight of stairs) III Marked limitation of ordinary activity (< 2 blocks level, < 1 flight of stairs) IV Inability to carry out any activity without discomfort; symptoms may be present at rest

  13. 1b. Stable Obstructive CAD: MX • Vascular Protection (ASA, statin, ACE-I/ARB) • Beta-Blocker (non-DHP CCB if not tolerated) • NTG • Address Risk Factors • Possibly Revascularize (PCI or CABG)

  14. 1c. Acute Chest Pain • Management: • ABC • Vitals • IV, O2, Monitor

  15. 1c. Acute Chest Pain: DDX • Myocardial Ischemia • PE • Aortic Dissection • Pneumothorax • GI Rupture • Other (pericarditis, pneumonia, GERD/PUD/gastritis, MSK, skin)

  16. ↓ Supply Coronary obstruction Microvascular obstruction ↓ Perfusion pressure ↓ PaO2 ↓ Hemoglobin ↑ Demand ↑ Heart Rate ↑ Contractility ↑ Wall Tension 1c. Acute Myocardial Ischemia

  17. 1c. Acute Coronary Syndrome • Definition: myocardial ischemia due to acute coronary insufficiency • 90% due to plaque rupture, thrombus +/- spasm

  18. 1c. Two Manifestations of ACS

  19. Complete Coronary Occlusion No blood flow beyond Transmural ischemia ST-elevation on ECG Localizes Reciprocates Threatened Coronary Occlusion Decreased blood flow Subendocardial ischemia ST-depression or normal Not localizing No reciprocal ST ↑ 1c. Two Manifestations of ACS

  20. 1c. ACS

  21. 49M with chest pain X 1 hour:

  22. 1c. STEMI • ABC; Vitals; IV, O2, Monitor • HX, O/E, ECG: STEMI • Acute reperfusion therapy (ART): lytics vs PPCI • ASA, NTG, BB (if safe), clopidogrel, anti-coagulation (UFH), morphine

  23. 1c. STEMI • Contraindications to Lytics: • 90-min assessment • CP • ECG • +/- Reperfusion Arrhythmia • Hemorrhagic stroke ever • Ischemic stroke < 3 mos • Intracranial AVM • Intracranial malignancy • Head trauma < 3 mos • Active bleeding • Aortic dissection

  24. 1c. NSTE ACS • ABC; Vitals; IV, O2, Monitor • HX, O/E, ECG: NSTE ACS • ASA • Risk Stratify (HX, PE, ECG, TNT) • Treat accordingly

  25. 1c. Complications Post-MI • Recurrent ischemia • HF/shock • Arrhythmia • Mechanical • Thromboembolic • Pericarditis • Depression

  26. 1c. Prognosis Post-MI • LV systolic function remains the most important determinant of prognosis post-MI • Usually assessed by means of echocardiogram prior to discharge

  27. 1c. Secondary Prevention: RX • ASA in all • Statin in almost all (LDL < 2) • ACE-I in most • Beta-Blocker • NTG if angina • Clopidogrel x 1 year post-ACS, post-stent • Treat risk factors

  28. 1c. Secondary Prevention: Life • Smoking • Diet • Exercise • Weight • Alcohol • Stress

  29. 2. ECG = EKG • Identify the study • Setting • Technical Details • Read: rate, rhythm, axis, alphabet • Interpret • Previous

  30. 2a. Electrical Anatomy The heart is a pump coordinated and powered by an integral electrical system

  31. 2a. Electrical Anatomy The SA Node has the steepest slope of spontaneous Phase 4 depolarization and therefore is the dominant pacer

  32. 2a. Electrical Anatomy Atrial depolarization normally flows from top to bottom and from right to left

  33. 2a. Electrical Anatomy The AV Node delays then relays electrical activation to the ventricles

  34. 2a. Electrical Anatomy The His-Purkinje System conducts electrical activation to all areas of both ventricles

  35. 2a. Electrical Anatomy • Three phases of ventricular depolarization: • Septum LR • (atrialrepolarization occurs simultaneously)

  36. 2a. Electrical Anatomy 2. Depolarization of both ventricles simultaneously from endocardium to epicardium

  37. 2a. Electrical Anatomy Ventricular repolarization ensues, from epicardium to endocardium

  38. 2a. The 12-Lead ECG

  39. 2a. PQRSTU QRS Segments Intervals PR ST TP PR QT

  40. 2a. PQRSTU PR ST TP Segments Intervals PR ST PR QT QRS

  41. 2a. Reading an ECG • Rate • Rhythm • Axis • Alphabet

  42. 1. Rate: “Count-Off” Method Start 150 75 Normal Rate = 60-100 bpm 100 60 300

  43. 2. Rhythm • Normally, the sinus node controls the entire heart • This is known as “Normal Sinus Rhythm” (NSR): • P wave axis is normal (0-90°) • Each P is followed by a QRS • Each QRS is preceded by a P

  44. 3. QRS Axis • If QRS + in I AND II, QRS axis is normal • If QRS not + in I AND II, you must calculate QRS axis • To do so, use leads I and aVF to identify the 90°-quadrant • Then use the isoelectric lead to quantify QRS axis (to nearest 30°)

  45. 4. Alphabet • P waves • PR (segments and intervals) • QRS (Qs, height, width) • ST segments • T waves • QT interval

  46. Arrhythmia = Dysrhythmia • Slow • Fast • Normal rate

  47. 2b. Bradydysrhythmias • Sinus Node • Sinus brady, pause, arrest, block • “AV Node” • 2° AVB (Type I and Type II) • 3° AVB

  48. 2b. AV Block Nodal 1° AVB 2° AVB I 3° AVB Infra-Nodal 2° AVB II 3° AVB

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