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Cardiology Crash Course

What should I document in my HPI?


Document what has been going on with the patient since his/her last office visit from a cardiac
perspective.
How has she been feeling or doing from a cardiac standpoint?
Include any stressful situations the pt has experienced; stress can impact their cardiac condition.
New symptoms.
What brings on new symptoms?
Location, quality, severity, modifying factors, etc.
Resolution of old symptoms.
Medication compliance. Has the patient been taking their medications as prescribed?
Do they note a marked difference in their symptoms when they are non-compliant?
Any increases in medication dosages (especially Lasix) to alleviate symptoms.
Documentation kept in home logs (blood glucose, BP, HR, or home weight).
What is it in office today? What does it normally register at home?
Do they have a pulmonary history (COPD, asthma, sleep apnea, etc.)

Atrial Fibrillation, Atrial Tachycardia, Bradycardia, Tachycardia, various heart arrhythmias


(Chronic or Paroxysmal)
When was the Afib/arrhythmia diagnosed?
Experienced any palpitations, sensation of heart racing or fluttering since last office visit.
Compliance with medications, especially blood thinners.
Eliquis, Pradaxa, Xarelto, Coumadin, etc.
Procedures (past ablations, cardioversion)
When was the most recent? Was the ablation successful? Is the patient maintaining sinus rhythm
since the procedure?
Chest pain, SOB, syncope, or dizziness.

Cardiomyopathy (Nondilated ischemic CM, Dilated CM, Takotsubo)


Most recent EF (%)
When was the patient's most recent echocardiogram?
Compliance with medications.
Medical therapy to increase heart function.
ICD in place?
CP, SOB, decreased exercise/functional capacity.

CAD Follow-up
Past procedures (CABG, angioplasty, stent placement, etc.)
How many vessels was the patient's
Experienced any chest pain/angina similar to past episodes prior to MI/CABG/stent placement.
When was the patient's most recent cardiac catheterization? What did it show? (blockages)
When was the patient's most recent stress test? What kind was it? Was it abnormal? (indicative of
possible ischemia)
Is the patient currently on Plavix? Baby ASA?
Most recent lab studies (lipid panel, CMP)
History of carotid US; when was the most recent? Did it show any blockages?
On statin therapy?
LFTs elevated?

Created by Jheneal Atkinson (TJPL for Scribe America)

CP, SOB, or bilateral LE swelling; nausea, vomiting, diaphoresis; pain similar to previous angina?

Congestive Heart Failure (CHF)


What kind of CHF? Systolic or diastolic?
Bilateral LE swelling, CP, or SOB? Recent weight gain? Abdominal distension?
Most recent CXR and labs (BNP).
Is the patient compliant with Lasix?
Has he/she had to take any additional Lasix at home to alleviate swelling?

Valvular Disorders
Valve prolapse, valve stenosis, valve regurgitation, etc.
Most recent echocardiogram
Status of the valvular disorder
Has the patient had a valve replacement?
If so, what kinds (TAVR, valve leaflet repair, mechanical valve, tissue valve).
CP, SOB, decreased exercise capacity?

Palpitations
Location, severity?
Describe the sensation.
fluttering, pounding, racing, or my heart flipping over.
What was the patient doing at onset?
Past similar episodes?
CP, SOB, dizziness, or syncope.

Cardiac Studies (Assess for cardiac status)


Treadmill Stress test - Checks the heart's electrical activity while you are exercising. Measures the
stress placed on your heart by physical exertion. Pt will receive multiple EKGs and have BP
checked.
Nuclear stress test - A diagnostic test used to evaluate blood flow to the heart. During the test, a
small amount of radioactive tracer is injected into a vein. A special camera, called a gamma camera,
detects the radiation released by the tracer to produce computer images of the heart.
Lexiscan - A prescription medication used in a cardiac nuclear stress test. It works by increasing
blood flow in the coronary arteries.
Dobutamine or Adenosine Stress Test - This test is used in people who are unable to exercise. A
drug is given to make the heart respond as if the person were exercising. This way the doctor can
still determine how the heart responds to stress, but no exercise is required.
Stress echocardiogram - Can accurately visualize the motion of the heart's walls and pumping
action when the heart is stressed; it may reveal a lack of blood flow that isn't always apparent on
other heart tests.
Cardiac Imaging
Echocardiogram
Assessment of LVEF (55-60% IS NORMAL) AKA heart function; will also assess current status
of valves.
There are several different kinds of echocardiograms:
TTE (transthoracic) This is a regular echocardiogram. Views of the heart are obtained
by moving the transducer to different locations on your chest or abdominal wall.

Created by Jheneal Atkinson (TJPL for Scribe America)

TEE (transesophageal echocardiogram) Used when other views of the heart needed; the
probe is passed down the esophagus instead of being moved over the outside of the chest
wall. TEE shows clearer pictures of your heart, because the probe is located closer to the
heart and because the lungs and bones of the chest wall do not block the sound waves
produced by the probe.
Stress Echocardiogram Combination of a stress test with an echocardiogram. An
echocardiogram is done both before and after your heart is stressed either by having you
exercise or by injecting a medicine that makes your heart beat harder and faste
Doppler echocardiogram - Looks at how blood flows through the heart chambers, heart
valves, and blood vessels.
PLEASE NOTE: An Echo can be used as part of a stress test and with an electrocardiogram (EKG or ECG) to
help your doctor learn more about the patient's heart.
Heart Monitors
Holter Monitors - Sometimes called continuous EKGs (electrocardiograms). This is because Holter
monitors record the heart rhythm continuously for 24 to 48 hours. These sensors pick up your heart's
electrical signals, and the monitor records your heart's rhythm.

Event Monitors Can be worn for up to 2 weeks. Event monitors are similar to Holter monitors. Worn
while the pt do normal daily activities. Most event monitors have wires that connect the device to
sensors that are stuck to the chest using sticky patches.

Continuous Loop Recorders Can be worn for 2 to 4 weeks. This type of monitor is helpful when the
patient experience symptoms of slow, fast or irregular heart beats less frequently or have abnormal
rhythms lasting more than a few seconds.

Implantable Loop Recorders Can be worn up to 2 years. Used if other event monitors can't provide
enough data. Implantable loop recorders are about the size of a pack of gum. This type of event monitor
is inserted under the skin on the chest. No wires or chest sensors are used.

Cardiac Procedures
CABG
Coronary artery bypass graft (CABG) surgery reestablishes sufficient blood flow to deliver
oxygen and nutrients to the heart muscle.
The bypass graft for a CABG can be a vein from the leg or an inner chest wall artery.
Cardiac catheterization
Used to diagnose CAD. If significant blockages are found, stents will be placed.
Cardiac ablation
Cryoablation, MAZE procedure, AV node ablation, alcohol ablation, etc.
Coronary stent placement
A stent is inserted into the clogged artery with a balloon catheter. The balloon is inflated and the
stent expands and locks in place. This holds the artery open and allows blood to flow more
freely.
Tilt Table
used to evaluate the cause of unexplained fainting (syncope). may also be appropriate to
investigate the cause of fainting if you've fainted only once, but another episode would put you
at high risk of injury due to your work environment, medical history, age or other factors.
PTCA - Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure

Created by Jheneal Atkinson (TJPL for Scribe America)

to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.
PCI - Percutaneous Coronary Intervention (PCI, formerly known as angioplasty with stent) is a nonsurgical procedure that uses a catheter (a thin flexible tube) to place a small structure called a stent
to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known
as atherosclerosis.
When is PCI or PTCA considered a treatment option? The primary indications are treatment
of angina pectoris (stable or unstable), myocardial ischemia, and acute MI (particularly in
patients with developing or established cardiogenic shock).
Cardiac Devices
AICD placement Used to treat people with certain kinds of cardiomyopathy, survivors of
cardiac arrest, people with PMHx of Vtach, Vfib or other erratic arrhythmias, or CHF.
Pacemakers - used to treat slow rhythms (Bradycardia).
Implantable cardioverter defibrillators (ICD) restore normal heart rhythm when the heart
beats too fast, and can also act as a pacemaker for slow heart rates.
Biventricular pacemakers are devices specifically used to treat arrhythmias associated
with certain complications of heart failure.
Insertable cardiac monitoring devices record heart activity to help detect suspected
arrhythmias or to rule out the presence of a heart rhythm problem.
When was the most recent interrogation? What is the battery life?

How do other disorders impact cardiac conditions?


Cancer & Chemotherapy - Heart damage is most often related to the total (cumulative) dose of
chemotherapy drug given.
Stress Increases the HR; may cause increased EtOH intake, which damages the heart.
Pulmonary Function - Obstructive sleep apnea may increase the risk of recurrent heart attack, and
abnormal heartbeats, such as atrial fibrillation.
Review all medications associated with all of the aforementioned coronary conditions.
Plavix, Effient, and Brilinta Given after stent placement and MI (STEMI and NSTEMI)
Diuretics Used to treat CHF patients.
Beta blockers used to control HR; indicated for some heart arrythmias, including Afib.
Sodium channel blockers Rythmol and Flecainide; indicated for Afib and other heart arrythmias;
used to control rhythm.
Cholesterol medications - Repatha, statins; new class of injectable medications (Praluent, etc.)
CHF Medications Corlanor, Lasix
Anti-arrhythmics - Amiodarone (Cordarone, Pacerone). Bepridil Hydrochloride (Vascor),
Disopyramide (Norpace), Dofetilide (Tikosyn). Dronedarone (Multaq), Flecainide (Tambocor), Ibutilide
(Corvert), Lidocaine (Xylocaine), Procainamide (Procan, Procanbid), Propafenone (Rythmol),
Propranolol (Inderal), Quinidine (many trade names), Sotalol (Betapace), Tocainide (Tonocarid).
Anticoagulants Indicated for patients with Atrial Fibrillation; Pradaxa, Eliquis, Xarelto, or Coumadin.
Cardiomyopathy Medications - Medications including diuretics, beta blockers, angiotensin-converting
enzyme (ACE) inhibitors, angiotensin receptor blockers, aldosterone inhibitors, hydralazine, nitrates,
digoxin, anticoagulants, or antiarrhythmic medications may be prescribed.
Aim with medical therapy is to increase heart function; the doctor will often keep the patient on
medical therapy for 3 months then order an echo to re-evaluate heart function.

Created by Jheneal Atkinson (TJPL for Scribe America)

Please also review the medications discussed in CRT for management of hyperlipidemia, DM, and HTN.

Miscellaneous Additional Information


Common Graft/Cath Terminology (CABG)
LIMA, LAD, OM1, OM2, RCA, RIMA, Diag, Diag2, Circ, OM3, PDA, Ac Mar, Ramus,

CX (circumflex), Post Lat


Proximal, mid, distal

(American College of Cardiology)


Common Types of Heart Defects
PFO - Patent foramen ovale; a hole in the heart that didn't close the way it should after birth.
ASD - A hole in the wall that separates the top two chambers of the heart; allows oxygen-rich
blood to leak into the oxygen-poor blood chambers in the heart.
VSD - VSD is a hole in the wall separating the two lower chambers of the heart. In normal
development, the wall between the chambers closes before the fetus is born, so that by birth,
oxygen-rich blood is kept from mixing with the oxygen-poor blood. When the hole does not
close, it may cause higher pressure in the heart or reduced oxygen to the body.
Coarctation of the Aorta - A narrowing of the major artery (the aorta) that carries blood to the
body. This narrowing affects blood flow where the arteries branch out to carry blood along
separate vessels to the upper and lower parts of the body. CoA can cause high blood pressure or
heart damage.
Ebstein's Abnormality - A malformed heart valve that does not properly close to keep the

Created by Jheneal Atkinson (TJPL for Scribe America)

blood flow moving in the right direction. Blood may leak back from the lower to upper
chambers on the right side of the heart. This syndrome also is commonly seen with ASD (or a
hole in the wall dividing the two upper chambers of the heart).
Review normal and abnormal physical exam findings discussed in CRT. See your scribe handbook.
Abnormal Physical Exam Findings (Pulmonary)
Crackles Caused by fluid in the lungs; often described as fine, medium, and coarse.
Wheezes Can be inspiratory, expiratory, or both; caused by air moving through airways narrowed by
constriction or swelling of airway or partial airway obstruction.
Rhonchi - coarse rattling respiratory sounds, usually caused by secretions in bronchial airways.
Abnormal Physical Exam Findings (Cardiac) - The normal heart rhythm contains two audible heart sounds
called S1 and S2 that give the well-known "lub-dub" rhythm; they are caused by the closing of valves in the
heart. First heart sound: caused by atrioventricular valves - Mitral (M) and Tricuspid (T). Second heart sound
caused by semilunar valves -- Aortic (A) and Pulmonary/Pulmonic (P).
Murmur - blowing, whooshing, or rasping sound heard during a heartbeat; caused by rough blood flow
through the heart valves or near the heart.
Rubs - caused by the beating of the heart against an inflamed pericardium or lung pleura.
Gallops When an S3 and S4 is auscultated on exam; sounds like a galloping horse.

Paradoxical S2 Occurs when the pulmonary valve closes before the aortic valve.
Metallic
Sources

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American Heart Association


WebMD
Cath Lab Digest
Mayo Clinic
Medline Plus
Wikipedia
National Sleep Foundation
The University of Chicago School of Medicine
American College of Cardiology

Created by Jheneal Atkinson (TJPL for Scribe America)