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Cardiology Board Review Chest Pain Rule out and Heart Failure Maxwell Afari , MD

8-1-14. Cardiology Board Review Chest Pain Rule out and Heart Failure Maxwell Afari , MD. Stress Testing.

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Cardiology Board Review Chest Pain Rule out and Heart Failure Maxwell Afari , MD

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  1. 8-1-14 Cardiology Board ReviewChest Pain Rule out and Heart FailureMaxwell Afari, MD

  2. Stress Testing • Cardiac stress testing is the preferred diagnostic test in symptomatic patients with intermediate coronary artery disease probability. High Risk (think Cath), Low Risk (don’t stress)

  3. Exercise stress testing is preferred as long as patient can exercise and has a normal baseline EKG (no LVH, WPW,LBBB, paced rhythm) • Among patients with resting ECG abnormalities limiting ST-segment analysis, the addition of imaging aids diagnostic accuracy and provides improvement in localizing the site and extent of ischemia (think Exercise Stress Echo, Exercise Sestamibi(technetium)). • Pharmacologic Stress Test is indicated for patient who is unable to exercise or if the risk for a false-positive study is increased, such as with LBBB. • Vasodilators–Dipyridamole(aka Persantine) or Adenosine can cause bronchoconst- COPD, Asthma). Regadeneson aka Lexiscan is adenosine A2a receptor which is heart specific receptor and spares lungs. Ok in COPD/Asthma). • Myocardial perfusion ImagingRadio-isotopes- Thalium or Technetium aka sestamibi)Also think Dobutamine Stress Echo as an option for imaging

  4. Exercise Tolerance and if EKG can be interpreted or not is the basics Pharmacolological(Dipyridamole, Adenosine, Lexiscan/Regadeneson) Can the Patient Exercise? No Imaging Dobutamine Stress Echolexiscan/Sestambi Yes Exercise Stress Imaging (Exercise Stress Echo, Exercise Stress Sestamibi Is the EKG Interpretable No Yes Exercise Stress Test

  5. Heart Failure Management-Decrease Mortality • ACEi (Lisinopril etc)-decrease mortality • Beta Blocker (Carvedilol, metoprolol, Bisoprolol) HF stage 1-2 (Hold in decompensated HF) • ARB (Losartan etc)- Don’t use both ACE1 and ARB • Aldosterone Antagonist (Spironolactone etc). Consider if EF <30%, class 3-4 Heart Failure. • Cardiac Rechronization Therapy (CRT) – EF<35%, QRS>120 • ICD For primary prevention if EF<30%, Patient on maximum medical therapy • Hydralazine+nitrates-Consider if cant tolerate ACE1 or ARB, Blacks in class 3-4 Heart Failure (decreases mortality)

  6. HF Management-Doesn’t change mortality • Diuretics • Digoxin • Omega 3 Fatty Acids • Diet (2g Sodium) • Exercise • Anticoagulation for EF <30%

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