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(BQ) Part 2 book Cardiology clinical questions presents the following contents: Examination, arrhythmias, congenital heart diseases, heart failure and hypertension, medications. Invite you to consult.
? SECTION V EXAMINATION 108 EXAMINATION What are the abnormal pulses in my patient and what cardiac conditions are they associated with? KEY CONCEPT Important information about the patient cardiac status is obtained by physical examination of arterial pulses A differential diagnosis can be made by inspecting the arterial blood pressure and central/ peripheral pulses Patient being evaluated presents with abnormal pulses on physical exam HISTORY Listen for murmurs, rubs, gallops, location of cardiac impulse, parasternal lifts PHYSICAL EXAM SYNTHESIS SWP = Small Weak Pulse HKP = HypoKinetic Pulse DP = Delayed Pulse LBP = Large Bounding Pulse DPP = Double Peak Pulse PWSD = Palpable Waves: in Systole, in Diastole AAP = Alteration of Amplitude Pulse DPDI = Decreased Pulse or absent During Inspiration SULE = Slower Upstroke of Lower Extremity pulse compared to upper extremity/disparity in amplitude PP = Pulsus Parvus (dimished left ventricular stroke volume, narrow pulse pressure, increased peripheral vascular resistance) HV = HyopVolemia LVF = Left Ventricular Failure RC = Restrictive Cardiomyopathy MS = Mitral Stenosis PT = Pulses Tardus: aortic stenosis with delayed systolic peak, left ventricular obstruction KERKP = HypERKinetic Pulse-increased LV stroke volume, wide pulse pressure, decreased peripheral vascular resistance: AV fi stulas, mitral regurgitation, ventricular septal defect BWC = Bisferiens/Water hammer/Corrigan: aortic regurgitation, hypertrophic cardiomyopathy DICR = DICRrotic: low stroke volumes, dilated cardiomyopathy PALT = Pulsus ALTernans: severe impairment of LV function PPAR = Pulsus paradoxus: tamponade, airway obstruction, superior vena cava obstruction RFD = RadioFemoral Delay: coarcation of aorta E XAM I NATI O N E EPIPHANY DISCUSSION PEARLS 109 SWP = PP HKP = HV or LVF or RC or MS DP = PT LBP = HERKP DPP = BWC PWSD = DICR AAP = PALT DPDI = PPAR SULE = RFD The arterial pulse begins when the aortic valve opens and left ventricle contracts There is a rapid rise called the anacrotic notch; then during isovolumic relaxation, there is a reversal of flow prior to aortic valve closure which is called the incisura Palpate all pulses and note for any differences between them, as well as simultaneous palpation of pulses on each side of the body Palpation of pulses can also give information about heart blocks and irregular rhythms: regular irregular pulses are seen in PAC/PVC, irregular irregular pulses seen in atrial fibrillation REFERENCE 1) Chizner M, ed Classic Teachings in Clinical Cardiology: A Tribute to W Proctor Harvey Cedar Grove, NY: Laennec; 1996 2) Fauci AS, Braunwald E, Isselbacher KJ, et al., eds Harrisons Principles of Internal Medicine 15th ed New York, NY: McGraw-Hill; 2007 110 EXAMINATION What is the likely heart murmur I hear? KEY CONCEPT HISTORY Auscultation of murmurs is reliable and cost effective to make diagnosis of various heart conditions Asymptomatic/symptomatic patient with murmur presenting with or without respiratory distress, pallor, cyanosis, clubbing, diaphoresis, chest pain Note intensity 1–6 (1 being barely audible, being heard without stethoscope without contact to chest) PHYSICAL EXAM Note the configuration (crescendo, decrescendo, diamond shaped, plateau), onset and cessation, location, radiation, time during cardiac cycle, and response to maneuvering Two-dimensional Echo and color Doppler flow IMAGING SYNTHESIS (cont on next page) Systolic Murmurs: MR = Mitral Regurgitation TR = Tricuspid Regurgitation VSD = Ventricular Septal Defect IM = Innocent Murmur AS = Aortic Stenosis PS = Pulmonic Stenosis HOCM = Hyertrophic Obstructive CardioMyopathy MVP = Mitral Valve Prolapse ASD = Atrial Septal Defect CAV = Calcific Aortic Valve HS = Holosystolic MDE = Midsystolic Ejection MSM = MidSystolic Murmur MSC = MidSystolic Click and murmur IA = Inaudible A2 Diastolic Murmurs: AR = Aortic Regurgitation PR = Pulmonic Regurgitation MS = Mitral Stenosis TS = Tricuspid Stenosis ED = Early Diastolic MRD = Mid-Rumbling Diastolic E XAM I NATI O N 111 Continuous Murmurs: PDA = Patent Ductus Arteriosus CONT = CONTinuous venous hum SYNTHESIS (cont from previous page) E EPIPHANY MR/TR/VSD = HS IM = MDE AS/PS/HOCM/ASD = MSM MVP = MSC CAV = IA AR/PR = ED MS/TS = MRD PDA = CONT The presence of murmurs should be taken into the context of the patient with importance of noting presence of known cardiac and symptoms DISCUSSION PEARLS The approach to the patient should first determine if murmur is systolic or diastolic Diastolic and continuous murmurs should be evaluated by echocardiogram and cardiac catheterization if appropriate Systolic murmurs grade 1–2 without symptoms, or other findings not require further workup Systolic murmurs 1–2 with symptoms or cardiac findings or grade or higher holosystolic or late should be evaluated with echocardiography All diastolic/holosystolic/late systolic murmurs are pathologic Early and midsystolic murmurs may be functional Accentuation during inspiration implies origination on the right side and during expiration implies origination on the left side Valsalva reduces intensity of most by reducing ventricular filling except MVP and HOCM (which are louder upon standing) Most murmurs are louder following PVC (except regurgitant murmurs) REFERENCE 1) Fustr V, O’rourke RA, Walsh RA, et al., eds Hurst’s The Heart 12th ed New York, NY: McGraw-Hill; 2008 2) Fauci AS, Braundwald E, Isselbacher KJ, et al., eds Harrison’s Principles of Internal Medicine 15th ed New York, NY: McGraw-Hill; 2007 112 EXAMINATION Does my patient need preoperative cardiac testing for noncardiac surgery? KEY CONCEPT HISTORY The decision to perform preoperative cardiac testing for noncardiac surgery is best on underlying cardiac conditions, risk factors, type or procedure, and the patient’s functional capacity HPI: Patient with underlying cardiac condition undergoing noncardiac surgery PMH: Coronary artery disease, congestive heart failure, aortic dissection, peripheral artery disease, stroke, diabetes SH: Smoking, alcohol ECG: ST-segment elevation, ST-segment depression, deep Q waves (>1 mm), PR interval irregularly variable, narrow QRS complex ELECTROCARDIOGRAM IMAGING SYNTHESIS X-ray: Cardiomegaly, cephalization of pulmonary vessels (increased distribution of flow to apices), pleural effusion ECHO: Left ventricular ejection fraction 2); history of myocardial infarction (beyond 30 days), diabetes mellitus PFC = Poor Functional Capacity with 10 METs 1) Fleisher LA, et al ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Circulation 2007;116:1971–962 114 EXAMINATION How I interpret my patients Swanz–Ganz catheterization? KEY CONCEPT HISTORY PHYSICAL EXAM The interpretation of a Swanz–Ganz catheterization is based upon the measurements of the right atrial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and vital signs HPI: Dyspnea, palpitations, fatigue, chest pain PMH: Congestive heart failure, hypertension, pulmonary hypertension, pericarditis SH: Smoking, alcohol Hypotension, fever, peripheral edema, elevated jugular venous pulse, pulsus paradoxus (decrease in systolic blood pressure [>10 mm Hg] on inspiration), Kussmaul’s sign (absence of inspiratory decline in jugular venous pressure) Low voltage, sinus tachycardia, electrical alternans (beat to beat QRS variability) ELECTROCARDIOGRAM IMAGING SYNTHESIS ECHO = Diastolic collapse of right atrium and right ventricle; left atrial collapse; left ventricular ejection fraction 35 mm Hg) PCWP = Pulmonary Capillary Wedge Pressure 6–12 mm Hg CO = Cardiac Output L/min SVR = Systemic Vascular Resistance 800–1440 mm Hg [I] = Increased [D] = Decreased CG-SH = CardioGenic Shock SS = Septic Shock HVL = HypoVoLemia P-HTN = Pulmonary HyperTeNsion TAMP = Pericardial TAMPonade E XAM I NATI O N E EPIPHANY DISCUSSION 115 BP[D] + RAP[I] + PAP[I] + PCWP[I] + CO[D] + SVR[I] = CG-SH BP[D] + RA[D] + PAP[D] + PCWP[I] + CO[I] + SVR[D] = SS BP[D] + RA[D] + PAP[D] + PCWP[D] + CO[D] + SVR[I] = HVL PAP[I] = PHTN BP[D] + RA[I] + PA[I] + PCWP[I] + CO[D] + SVR[I] = TAMP Swanz–Ganz catheterization is an effective and rapid technique for patients in need of hemodynamic monitoring for diagnosis and treatment of shock and complications of heart failure 1) Chatterjee K, et al The Swan-Ganz Catheters: Past, Present, and Future: A Viewpoint Circulation 2009;119:147–152 REFERENCE 116 EXAMINATION Does my patient need screening for an abdominal aortic aneurysm (AAA)? KEY CONCEPT HISTORY The goal is to identify patients with AAA before rupture occurs and to balance this against performing an unnecessary test in low risk populations HPI: Age, the vast majority of patients will be asymptomatic PMH: Known vascular disease (coronary artery disease, peripheral vascular disease, collagen vascular disease), risk factors for vascular disease (hypertension, hyperlipidemia, diabetes) FH: Aortic aneurysm or dissection SH: Tobacco use Pulsatile mass in epigastrium upon palpation PHYSICAL EXAM Abdominal ultrasound: Abdominal aortic diameter >3 cm IMAGING SYNTHESIS E EPIPHANY AAA = Abdominal Aortic Aneurysm M-60-FAM = Men 60 years of age or older with FAMily history of AAA M-65-TOB = Men who are 65 to 75 years of age who have ever used TOBacco ABD-US = Refer patient for ABDominal UltraSound for 1-time screening for detection of AAA M-60-FAM = ABD-US M-65-TOB = ABD-US M E DI C AT IO N S PEARLS REFERENCE 247 – Patients with serious allergic reactions to medications and/or multiple drug allergies may be at an increased risk for hypersensitivity reactions despite the low risk of cross-reactivity 1) Johnson JJ, Green DL, Rife JP, Limon L Sulfonamide cross-reactivity: fact or fiction? Ann Pharmacother 2005;39:290–301 2) Furosemide (Lasix®) Package Insert — Sanofi Aventis, September 2008 3) Bumetanide Package Insert — Bedford Labs, June 2005 This page intentionally left blank INDEX Page numbers followed by f or t indicate figures or tables, respectively A AAA See Abdominal aortic aneurysm (AAA) Abdominal aortic aneurysm (AAA) screening for, 116–117 ultrasound, 116 Abnormal electrocardiogram findings, 172 patterns, identification of, 172 physiologic hypertrophy, 172 Abnormal pulses, 108 ACC See Active cardiac condition (ACC) Acebutolol, 215 ACE inhibitors, 23, 25, 188–190, 201 Acetaminophen increase INR, drug interactions, 220 Active cardiac condition (ACC), 112 Active reactive airway disease beta blockers, avoiding of, 121 AD See Aortic dissection (AD) Amiodarone, 220, 244–245 class III antiarrhythmic medication, 244–245 Amyloid cardiomyopathy diagnosis of, 76–77 electrocardiogram, 76 endomyocardial biopsy, 77 Anaphylaxis, sulfa allergy, 246 Angiography, 22 coronary, 8–9, 30, 200 high-risk, 43 radionuclide, 212 Angiotensin converting enzyme inhibitors, 41 Annuloplasty, 59 Anticoagulate (AC), 22, 88, 89 warfarin, management of, 216–217 Antimicrobial therapy, 72 Antiplatelet therapy, 22 Anxiety disorders, 206 Aortic aneurysm, rupture of, 117 Aortic dissection (AD), 81, 84 CT scan, 84 patients, management of, 84–87 X-ray, 86 Aortic regurgitation, surgery need, 50–51 Aortic stenosis, 56–57 surgery, need, 48–49 Aortic valve replacement, 48–51 Arrhythmias, 173 benign repolarization, 174 sinus arrhythmia, 174 Arrhythmogenic right ventricular dysplasia (ARVD) electrocardiogram, 166–167 Arterial pulse, 109 Arthrocentesis, 216 ARVD See Arrhythmogenic right ventricular dysplasia (ARVD) ASD See Atrial septal defect (ASD) Aspirin, 22, 23 perioperative management, indications with, 218 surgical perioperative management, 218–219 249 250 INDEX Asystole, 224 Athletes, 134, 159 exercise-induced sudden cardiac death in, 173 hearts’ ECG, 175f poor R wave progression, 175 Atrial fibrillation, 52, 217, 220 acute management of, 120–121 coumadin, 122–123 echocardiogram, 120, 122 electrocardiogram, 120, 122 management of, 120 Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 121 Atrial flutter, acute electrocardiogram, 124 management of, 124–125 Atrial septal defect (ASD), 180–181 chest X-ray, 180 closure of, 181 decision to close, 180 echocardiogram, 180 electrocardiogram of, 180 history for, 181 Atrioventricular (AV) block, 214 2nd degree type 1, 130–131 electrocardiogram, 130, 150–151 management of, 130 patients with, 151 2nd degree type II electrocardiogram, 132, 152–153 management of, 132–133 nodal blockers, 159 3rd degree electrocardiogram, 128, 154–155 management of, 128–129 Atrioventricular nodal reentry tachycardia (AVNRT) electrocardiogram of, 164–165 Atypical angina See Cardiac syndrome X Austin Flint murmur, 50 AV block See Atrioventricular (AV) block AVNRT See Atrioventricular nodal reentry tachycardia (AVNRT) Azathioprine, 220 B Barbiturates, 220 Benzodiazepines, 224 Beta-blockers, 23, 45 differences, 214–215 drugs, metoprolol, 23 overdose, treatments, 224–225 toxicity, 225 Beta-lactam antibiotics, 66 Bioprosthetic heart valve, 220 Biventricular hypertrophy in ventricular septal defect (VSD), 184 Blood cultures, 72 Blood pressure levels patient, management of, 206–207 Bradycardia, 214, 224, 228 Brugada syndrome electrocardiogram, 126 management of, 126–127 patients with, 127 sudden cardiac death (SCD), 126 Bundle of Kent, 158 INDEX C CABG See Coronary artery bypass graft (CABG) CAD See Coronary artery disease (CAD) Calcium channel blockers, 41, 236 drugs, Carbamazepine decrease INR, drug interactions, 220 Cardiac amyloidosis, 77 Cardiac arrest, Cardiac computed tomography patient needs, 16–17 Cardiac computed tomography (CCT), 16 Cardiac conditions pulses, abnormal, 108–109 Cardiac device infection, 72 Cardiac function doxorubicin, 212–213 Cardiac medications IV to PO, 238–239 pregnancy/lactation, 240–241 Cardiac MRI, in cardiac syndrome X, 78 Cardiac pacing, patient needs, 12–13 Cardiac syndrome X cardiac MRI, 78 electrocardiogram, 78 patient, management of, 78–79 Cardiac tamponade, 80f electrocardiogram, 82 management of, 82–83 X-ray, 82 Cardiac transplant, 62 Cardiogenic shock cause of, 201 patient, management of, 200–201 251 Cardiomyopathy, 10 Cardiovascular complications of endocarditis, 64 Cardiovascular medications, 232 hypersensitivity reactions, 242–243 from IV to PO, 238–239 during pregnancy and lactation, 240–241 side effects and complications of, 232–233 Cardio/vascular surgery, 87 Carvedilol, 215, 225 CCT See Cardiac computed tomography (CCT) CHD See Congenital heart disease (CHD) Chest X-ray in atrial septal defect (ASD), 180 CHF See Congestive heart failure (CHF) Cholestyramine, 220 Chronic stable angina (CSA) patient management, 40–41 Cimetidine, 220 Clopidogrel, 22 Cocaine induced chest pain patient management, 44–45 toxic effects of, 44 Colchicine, 81 Color Doppler flow, 110 Compression ultrasonography, 92, 94 Congenital bicuspid aortic valve, 48 Congenital heart disease (CHD), 8, 10, 60, 62 defect repair, 62 Congenital long QT syndrome, 228 252 INDEX Congestive heart failure New York Heart Association, 192–193 Congestive heart failure (CHF), 8, 10, 180 Conjunctival petechiae, 70 Coronary angiogram, 78 Coronary angiography, 8–9, 30 Coronary artery bypass graft (CABG), 16, 32–33 efficacy comparision, 32 radionuclide myocardial perfusion scan, 32 stress echo, 32 Coronary artery disease (CAD), 8, 10, 12, 20, 48, 196, 204, 224 patients with, 197 risk stratification in, 10 Coronary artery vasospasm, 30 CSA See Chronic stable angina (CSA) CT angiogram in acute pulmonary embolism (PE), 98 in pulmonary embolism (PE), 96 CT scan, in aortic dissection (AD), 84 Cyclophosphamide therapy, 212 D Decrescendo diastolic murmur, 64 Deep venous thrombosis (DVT), 92, 220 diagnosis of, 92–93 patient, management, 94–95 DHF See Diastolic heart failure (DHF) Diastolic decrescendo murmur, 84, 86 Diastolic heart failure (DHF) acute management of, 190–191 Digoxin in systolic heart failure, 189 toxicity management of, 226–227 Dilated tricuspid annulus, 58 Diltiazem, 236 Diuretic, for sulfa allergy, 246–247 Dobutamine, 234 Dopamine, 234 Doxorubicin, in cardiac function, 212–213 Drug interactions, 220, 227 DVT See Deep venous thrombosis (DVT) Dye allergy/contrast, 242–243 E ECG See Electrocardiogram (ECG) ECHO See Echocardiogram (ECHO) Echocardiogram (ECHO), 10–11 in acute atrial flutter, 124 in acute pericarditis, 80 in acute pulmonary embolism (PE), 98 in amyloid cardiomyopathy, 76 in aortic dissection, 86 aortic regurgitation, patient, 50 aortic stenosis, 48 in atrial fibrillation, 120, 122 in atrial septal defect (ASD), 180 in cardiac tamponade, 82 in energy beverage, 134 in heart murmur, 110 in intra-aortic balloon pump (IABP) counterpulsation, 42 INDEX in left ventricular thrombus (LVT), 88 in myocardial infarction (MI), 28, 200 right/inferior, 36 in myocarditis, 104 in patent foramen ovale (PFO), 182 in peripartum cardiomyopathy (PPCM), 90 in pheochromocytoma, 102 in preoperative cardiac testing, 112 in pulmonary embolism (PE), 96 in right bundle branch block, 176 stress, 10 in Swanz–Ganz catheterization, 114 in syncope, 208 systolic heart failure, 189 trans esophageal, 10 trans thoracic, 10 in ventricular septal defect (VSD), 184 Echogenic oscillating intracardiac mass, 60, 64, 66, 68 Ehlers-Danlos syndrome, 84 Electrocardiogram (ECG) abnormal/normal variant, 172–175 in acute atrial flutter, 124 in acute pericarditis, 80 in amyloid cardiomyopathy, 76 in arrhythmogenic right ventricular dysplasia (ARVD), 120, 122, 166–167 athlete heart, 175f atrial fibrillation, 120–121, 120f in atrial septal defect (ASD), 180 253 atrioventricular (AV) block 2nd degree type I, 130, 150–151, 150f 2nd degree type II, 132, 152–153, 152f 3rd degree, 128, 154–155, 154f in atrioventricular nodal reentry tachycardia (AVNRT), 164–165, 164f–165f benign repolarization, 174f in Brugada syndrome, 126 in cardiac syndrome X, 78 in cardiac tamponade, 82 during chest pain, 35 in chronic stable angina, 40 in elevated troponins, 38 in energy beverage, 134 hypercalcemia, changes of, 140–141 hyperkalemia, changes of, 136–137, 137f in hypertensive emergency, 194 hypocalcemia, changes of, 142–143 hypokalemia, changes of, 138–139, 138f in intra-aortic balloon pump (IABP) counterpulsation, 42 in left bundle branch block (LBBB), 146–147, 146f left ventricular hypertrophy, 148–149, 148f in myocardial infarction (MI), 28 right/inferior, 36 patient’s high-densitylipoprotein (HDL) levels, 198 patient’s low-density-lipoprotein level (LDL), 196 254 INDEX Electrocardiogram (ECG) (Cont.) in pheochromocytoma, 102 in premature ventricular contractions (PVC), 156, 156f in preoperative cardiac testing, 112 QT interval, 168–169, 168f right bundle branch block (RBBB), 144–145, 144f, 176 R wave progression, 175f sinus arrhythmia, 174f STEMI infarct/injury on, 34–35 in Swanz–Ganz catheterization, 114 in syncope, 208 in torsade de pointes (TdP), 160, 160f tricyclic antidepressant (TCA), 170–171 in unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI), 20, 22 Wolff-Parkinson-White (WPW) syndrome, 158f, 162–163, 162f Electrophysiological studies, 2–3 Elevated troponins, in electrocardiogram, 38 Encephalopathy, 236 Endocarditis, 60–61 Duke’s criteria, 60–61 medical treatment, 70–71 prophylaxis, 62–63 treatment of, 70–71 Endomyocardial biopsy, 213 in amyloid cardiomyopathy, 77 in myocarditis, 105 Energy beverage consumption, 134–135 electrocardiogram, 134 Epinephrine, 224, 234 Epstein anomaly, 158 Ergonovine, administration of, 30 Erythromycin, 220 Esmolol, 236 Exercise-induced sudden cardiac death, 173 F Fatigue, 236 Fibrinolytic therapy, 27 Fibrosis, 53 Fistula, 64 G Glyco protein IIb/IIIa (GP2B3A) inhibitors eptifibatide, 20 tirofiban, 20 H HCM See Hypertrophic cardiomyopathy (HCM) Heart block, 12, 68 Heart murmur, echocardiogram, 110 Hemodynamic instability/ cardiogenic shock, 20 Heparin anticoagulation, reversal of protamine sulfate, 222–223 Heparin induced thrombocytopenia (HIT), 230 antibodies, 231 management of, 230–231 High-density-lipoprotein (HDL) levels contraindications, 199 INDEX electrocardiogram, 198 niacin effects, 199 patient, management of, 198–199 High surgical bleeding risk, 218 His–Purkinje system, 133 HIT See Heparin induced thrombocytopenia (HIT) Holosystolic murmur, in ventricular septal defect (VSD), 184 HTN See Hypertension (HTN) Human immunodeficiency virus, 65 Hydralazine, 236 Hypercalcemia electrocardiogram, changes of, 140–141 Trousseau sign, 142 Hyperkalemia electrocardiogram, changes of, 136–137 physical manifestations of, 139 Hyperlipidemia, 48 Hypertension (HTN), 10, 20, 48 carotid ultrasound, 206 electrocardiogram, 206 emergency, 195 paroxysmal, episodes of, 207 renal ultrasound, 206 subcategory of, 206 Hypertensive emergency management of, 194–195 nitroprusside effects, 195 Hypertrophic cardiomyopathy (HCM), 10 Hypertrophy, 173 Hypocalcemia, electrocardiogram changes, 142–143 Hypokalemia, electrocardiogram changes, 138–139 Hypotension, 200, 224, 234 255 I IABP See Intra-aortic balloon pump (IABP) Ibutilide, in acute atrial flutter, 125 ICD See Implantablecardioverter-defibrillator (ICD) Implantable-cardioverterdefibrillator (ICD), 14–15 Initial reperfusion strategy in acute ST elevation myocardial infarction (STEMI), 26 Inotropes, 234 in shock/heart failure, 234–235 Intra-aortic balloon pump (IABP), 42–43 counterpulsation, 42 use of, 43 echocardiogram, 42 electrocardiogram, 42 IV antihypertensive, 236–237 uses, 236–237 J Janeway lesion, 60, 64, 70 K Ketoconazole, 220 Kussmaul’s sign, 82 L Labetalol, 215, 236 Labile blood pressure, management of, 206–207 Lactation, cardiac medications, 240–241 Laparoscopic cholecystectomy, 216 LBBB See Left bundle branch block (LBBB) 256 INDEX LDL See Low-density-lipoprotein level (LDL) Left bundle branch block (LBBB), electrocardiogram, 146–147 left ventricular hypertrophy, 147 Left ventricular (LV) dysfunction, 54 Left ventricular ejection fraction (LVEF), 8, 90 Left ventricular hypertrophy, 48, 50 electrocardiogram, 148–149 Left ventricular hypertrophy (LVH), 147, 148 electrocardiogram of, 148 Left ventricular thrombus (LVT), 79 cardiac MRI, 88 development of, 89 echocardiogram, 88 management of, 78, 88–89 Lepirudin, liver dysfunction, 231 Long QT syndrome (LQTS), 161, 168 Loop diuretics, 246 Low-density-lipoprotein level (LDL) electrocardiogram, 196 management of, 196–197 patient, management of, 196–197 Low gradient aortic stenosis, 48 Low-molecular-weight heparin, 94, 99 LQTS See Long QT syndrome (LQTS) LV dysfunction See Left ventricular (LV) dysfunction LVEF See Left ventricular ejection fraction (LVEF) LVH See Left ventricular hypertrophy (LVH) LVT See Left ventricular thrombus (LVT) M Marfans disease, 10 Marfan’s syndrome, 84 Mechanical heart valve (MHV), 60, 62 Metabolic equivalents (METS), 112 Metabolic syndrome diagnosis of, 202–203 management of, 204–205 patient, management of, 204–205 Metoprolol, 215 Metoprolol tartrate, 22 Metronidazole, 220 METS See Metabolic equivalents (METS) MHV See Mechanical heart valve (MHV) MI See Myocardial infarction (MI) Milrinone, 234 Mitral regurgitation, 54–55 surgery, need, 54–55 Mitral stenosis, 52–53, 57 pregnant patient, management, 56–57 surgery, need, 52–53 Mitral valve prolapse, 64 repair, 55 surgery, 55 Mobitz II See Atrioventricular (AV) block, 2nd degree type II Morphine sulfate pain relieve, 22 INDEX Multiple endocrine neoplasia, 100 Murmurs, 108 asymptomatic/symptomatic patient with, 110 diastolic/holosystolic/late systolic, 111 sternotomy scar, 62 systolic/diastolic, 111 Myocardial infarction (MI), 8, 10, 12, 20, 200–201 complications of, 28–29 cardiogenic shock, 200–201 echocardiogram, 36, 200 electrocardiogram, 36 hypotension, 200 intra-aortic balloon pump, 201 management of, 36 patients post-STEMI, 28 patient with right/inferior, 36–37 pulmonary artery catheterization, 200 Swanz imaging, 36 Myocardial perfusion imaging, indications/criteria for, 6–7 Myocarditis causes of, 105 chest pain, characteristics of, 104 echocardiogram, 104 endomyocardial biopsy, 105 patients, management, 104–105 New York Heart Association classification congestive heart failure patient’s, 192–193 echocardiogram, 192 Niacin, in patient’s high-densitylipoprotein (HDL) levels, 199 Nitroglcerin, IV antihypertensive, 236 Nitroglycerin, pain relieve, 22 Nitroglyercine, chronic stable angina, 41 Nitroprusside, in hypertensive emergency, 195 Noncardiac surgery, preoperative cardiac testing for, 112–113 Nonselective beta blockers, 31 Non-ST-elevation myocardial infarction (NSTEMI) patient management of, 22–23 Norepinephrine, 234 NVE See Native valve endocarditis (NVE) O Oral anticoagulant therapy, 81 Osler node, 60, 64, 70 Oxprenolol, beta blockers, 214, 215 P N National Cholesterol Education Program (NCEP), 199 Native valve endocarditis (NVE) infective endocarditis, 70 for surgery, 64–65 New-onset valvular regurgitation murmur, 60 257 Pacemaker, infected management of, 72–73 Palpation, 109 Panic disorder, 207 Paracentesis, 216 Patent foramen ovale (PFO) echocardiogram, 182 management of, 182–183 258 INDEX PE See Pulmonary embolism (PE) Penbutolol, 215 Percutaneous balloon mitral valve valvotomy, 53 Percutaneous balloon mitral valvuloplasty, 56 Percutaneous coronary intervention (PCI), 30, 32–33 radionuclide myocardial perfusion scan, 32 stress echo, 32 Pericardiectomy, 81 Pericardiocentesis, 81, 83 Pericarditis, acute, 81 colchicine, 81 echocardiogram, 80 electrocardiogram, 80 management of, 80–81 Peripartum cardiomyopathy (PPCM) diagnosis of, 90–91 echocardiogram, 90 pregnant patient, 90–91 risk factors for, 91 Perivalvular abscess, 68 PFO See Patent foramen ovale (PFO) Phenylephrine, 234 Pheochromocytoma, 100 avoiding beta blockers, 103 diagnosis of, 100–101 echocardiogram, 102 electrocardiogram, 102 patients, management, 102–103 Phosphodiesterase inhibitors, 22 Pindolol, 215 PPCM See Peripartum cardiomyopathy (PPCM) Pregnancy cardiac medications, 240–241 coumadin, avoiding of, 99 mitral stenosis, 56–57 peripartum cardiomyopathy, 90–91 women with mitral stenosis, 57 Premature ventricular contractions (PVC) contraindications in, 157 electrocardiogram of, 156 management of, 156–157 Preoperative cardiac testing, 113 echocardiogram, 112 electrocardiogram, 112 X-ray, 112 Prolonged QT interval, 224 electrocardiogram of, 168 Propafenone, 220 Propranolol, 215, 225 Prosthetic valve endocarditis (PVE), 67–69 infective endocarditis, 66 medical treatment, 66–67 for surgery, 68–69 treatment of, 66–67 Prosthetic valves, 218 Protamine sulfate, 222–223 Pseudopheochromocytoma, 207 Pulmonary artery catheterization, in myocardial infarction, 200 Pulmonary artery systolic pressure, 52 Pulmonary embolism (PE), 97, 220 acute management of echocardiogram, 98 patients, management, 98–99 CT angiogram, 98 diagnosis of, 96–97 echocardiogram, 96 V/Q scan, 96, 98 Pulmonary hypertension, 52, 54 PVE See Prosthetic valve endocarditis (PVE) INDEX Q QT-c interval, 228–229 QT interval, electrocardiogram, 168–169 R Radionuclide angiography (RNA), 212 Radionuclide myocardial perfusion scan in coronary-artery bypass graft (CABG), 32 in percutaneous intervention (PCI), 32 Raynaud’s phenomenon, 30 RBBB See Right bundle branch block (RBBB) Renal failure, Rhabdomyolysis, 139 Rheumatic heart disease, 56 Rifampin, 220 Right bundle branch block (RBBB), 126 echocardiogram in, 176 electrocardiogram, 144–145, 176 patient, management of, 176–177 Right-side electrical conduction system, 176 RNA See Radionuclide angiography (RNA) Roth spots, 60, 64, 70 S Salvage device, 73 Seizures, 236 Severe tricuspid regurgitation, 58 Sildenafil, 22 Sodium nitroprusside, 236 Sotalol, 215 Splinter hemorrhage, 60, 70 259 SRT-POS See Stress testing positive (SRT-POS) Stable angina, chronic, 40 electrocardiogram, 40 ST elevation myocardial infarction (STEMI), 24 acute management, 24–25 initial reperfusion strategy, 26–27 STEMI See ST elevation myocardial infarction (STEMI) Stenosis, on echocardiogram, 52 Stress echo in coronary-artery bypass graft (CABG), 32 in percutaneous intervention (PCI), 32 in unstable angina (UA)/nonST-elevation myocardial infarction (NSTEMI) patient, 22 Stress testing, 4–5 Stress testing positive (SRT-POS), 21 Sulfa allergy diuretic, 246–247 Surgical treatment with valve repair, 64 Swanz–Ganz catheterization, 114, 115 echocardiogram, 114 electrocardiogram, 114 interpretation of, 114–115 X-ray, 114 Swanz imaging in right/inferior myocardial infarction (MI), 36 Syncope, patient with, 208–210 Systolic heart failure digoxin effect, 189 echocardiogram, 188 260 INDEX Systolic heart failure (Cont.) management of, 188–189 peripheral edema, 188 X-ray, 188 T Tachycardia, 234 Tachypnea, 236 TCA See Tricyclic antidepressant (TCA) TdP See Torsade de pointes (TdP) TEE See Transesophageal echocardiogram (TEE) Thoracocentesis, 216 Thrombocytopenia, 231 Thrombolysis in myocardial infarction (TIMI) risk score, 20, 21 Thrombosis, 231 Torsade de pointes (TdP), 228–229 acute management of, 160–161 electrocardiogram of, 160 management, 160 treatment of, 161 TR See Tricuspid regurgitation (TR) Transesophageal echocardiogram (TEE), 84 Tricuspid regurgitation (TR), 58–59 Tricuspid valve replacement, 59 Tricyclic antidepressant (TCA) electrocardiogram, 170–171 toxicity of, 170 Tricyclic antidepressants, 101 Trimethoprimsulfomethoxazole, 220 Troponins, 22, 23, 25, 38 patient management, 38–39 Trousseau sign, 142 U UFH See Unfractionated heparin (UFH) Ultra high cardiovascular event risk, 218 Ultrasound in abdominal aortic aneurysm, 116 carotid, 206 renal, 206 Unfractionated heparin (UFH), 230 Unstable angina (UA)/nonST-elevation myocardial infarction (NSTEMI) electrocardiogram, 20, 22 management of, 22–23 stress echo, 22 thrombolysis in myocardial infarction risk score, 20–21 U.S Preventive Services Task Force (USPSTF) recommends, 117 V Valve replacement, 48, 62 Variant angina (VA) management of, 30–31 Vasopressin, 234 Vasopressors, 234 in shock/heart failure, 234–235 Venous thromboembolism, 216 Ventricular arrhythmias, 229 Ventricular septal defect (VSD), 184–185 biventricular hypertrophy, 184 closure of, 184 echocardiogram, 184 holosystolic murmur, 184 patients with, 184 X-ray, 184 Verapamil, 236 INDEX Von Hippel–Lindau syndrome, 100 V/Q scan, in pulmonary embolism (PE), 96, 98 VSD See Ventricular septal defect (VSD) W Warfarin, 216 anticoagulation, management of, 216–217 INR, 220–221 drug interactions for, 220 for surgery, 216 Wells criteria, 96 Wenckebach block See Atrioventricular (AV) block, 2nd degree type Wolff-Parkinson-White (WPW) syndrome 261 electrocardiogram, 158, 162–163 patient, management of, 158–159 tachycardia, 158 WPW syndrome See WolffParkinson-White (WPW) syndrome X X-ray in aortic dissection, 86 in cardiac tamponade, 82 in preoperative cardiac testing, 112 in Swanz–Ganz catheterization, 114 in systolic heart failure, 188 in ventricular septal defect, 184 ... EPIPHANY 133 2- AVB -2 + REV = T-REV 2- AVB -2 + SBC = PM 2- AVB -2 + ASYS-3 = PM 2- AVB -2 + EXER = PM 2- AVB -2 + V-40 = PM 2- AVB -2 + POST-MI = PM 2- AVB -2 + NMD = PM 2- AVB -2 + ABL = PM In patients with 2nd degree... Treatment JAMA 20 09;3 02( 18) :20 15 20 22 2) Hirsch AT ACC/AHA Guidelines for the Management of PAD Circulation 20 06;113:e463 This page intentionally left blank ? SECTION VI ARRHYTHMIAS 120 ARRHYTHMIA... LS, et al 20 11 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 20 06 guideline) Circulation 20 11; 123 :104– 123 2) Fang MC, et al The net clinical