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REINFARCTION: [NEW CP episode within few days of first episode] INITIAL management?
1. EKG [see NEW ST abnl]
2. CK-MB: (see inc levels) [nl CK-MB disappears 24-48hrs 2 days after 1st MI]
STEMI
ANGIOPLASTY (PCI)
[Decrease Mortality]
Do within 90minutes (if
avail)
Complications of ANGIOPLASTY
(PCI):
-Ruptures coronary artery on
ballon inflation
-Restenosis/thrombosis
-Hematoma @entry site (femoral)
Cardiology Notes 1
Don’t use Thrombolytics if got:
-Bleed in bowel (melena) or Brain (ANY type of CNS bleeding)
-Recent surgery (w/in last 2wks)
-Severe htn (>180/110)
REMEMBER:
Which is better for SURVIVAL & MORTALITY benefit?
= ANGIOPLASTY
-Can answer “THROMBOLYTICS” in any pt w/CP & STEMI within first 12 hours of CP onset
(thrombolytics: Mortality benefits extends to 12hours from CP onset)
= pt w/CP enters ER doors → give THROMBOLYTICS within 30mins
Cardiology Notes 2
ST-depression
-ST-depression, CP. Aspirin given. What’s next?
=Heparin (LMWH) =URGENT
[=prevents clot growing/forming more in coronary arteries. It won’t dissolve already formed clots]
///////////////////////////////////////////////////////////////////////////
Acute MI complication QUESTIONS
-What’s most likely diagnosis? [common Q]
-HEART RATE = key clue
BRADYCARDIA
Sinus- Bradycardia [SA node fkd] = NO Cannon A Third-degree (complete) AV block: = Bardycardia,
waves Cannon A waves.
(moa: atrial systole against closed tricuspid)
(Tricuspid closed bc 3rd degree block…Atria &
ventricles contract out of coordination with each
other)
(‘cannon = bounding jugulovenous wave back into
neck’ see: RV infract & Third-degree AV block
link!)
Symptomatic Bradycardia
Tx: ATROPINE (FIRST); then Place PACEMAKER if atropine not effective
TACHYCARDIA:
RV infarct: link New INFERIOR wall Tamponade/free wall rupture VTach/VFib:
MI (II, III, aVF) + Clear lungs auscul; [several days post-MI….wall -Sudden death; Loss Pulse.
Tachy,HoTN with NG use scars/weakens-then rupture] NEED EKG to answer Q
-“sudden pulse loss”; JVD; clear -tx:
-dx: RV4 (Right chest)*** lungs Cardioversion/defibrillation
Cardiology Notes 3
(see Check ST-elevation) emergency
[RCA supplies: RV/AV node/Inferior -dx: Echocardiogram emergency
wall -tx: Pericardiocentesis emergency
-Inferior wall MI has 40% chance on way to OR to repair it
has RV infarction ]
-Intraaortic Balloon pump is temporary BRIDGE to surgery for valve replacement for 24-to-48hrs)
Angioplasty-PCI or Bypass
surgery
Cardiology Notes 4
POST-INFARCTION take home meds:
-ASPIRIN
-BB (metoprolol)
-Statins
-ACE-I
QUESTIONS – HY
POSTINFARCT – SEX PROBLEMS
-Do not combine nitrates/NG with Sildenafil [pt taking 2 drugs…has HYPOTENSION. Likely
cause?...vasodilators]
-Erectile dysfunction postinfarction Most Commonly from: ANXIETY
-ED due to Meds? = Beta-Blockers (propranolol/metoprolol)
-Patient does not have to wait after an MI to have sex. If no symptoms, then can have sex immediately
[bc sex doesn’t last long enough to have excess inc myocardial oxy consumption]
-If Post-MI stress test nl, pt can do any form of Exercise program. Including sex
/////////////////////////////////////////////////////////////////////////////////////
CONGESTIVE HEART FAILURE
-sx: Dyspnea [insufficient oxy to tissues & fluid builds in lung]
-dt: MI → DILATED CM & dec EF (= systolic dysfunction; won’t pump) → Regurge → CHF
Cardiology Notes 5
WHAT’S THE MOST LIKELY DIAGNOSIS? For DYSPNEA
Sudden onset; Sudden, Slower, fever, Circumoral Pallor, gradual over
clear lungs wheezing, inc sputum, numbness/mouth; days to weeks
= Pulmonary expiratory phase unilateral caffeine use, h/o =Anemia
emboli = Asthma rales/rhonchi anxiety
=Pneumonia = Panic attack
Pulse paradoxus, Palpitations, Dull percussion Long smoking hx, Recent anesthetic use,
dec heart sounds, syncope at BASES barrel chest brown blood not
JVD =Arrhythmia of =Pleural effusion =COPD improved with
=Tamponade any kind oxygen, clear lungs
auscultate, cyanosis
=Methemoglobinemia
Burning building
or car, wood-
burning stove in
winter, suicide
attempt
=Carbon
monoxide poison
Dx: ECHO (diagnoses CHF) (distinguish systolic vs diastolic dysfunction) [NOT: EKG, CXR, BNP)
To evaluate Ejection Fraction.
CHF clues. Best INITIAL test? Most ACCURATE test? Acute SOB with etiology of dyspnea
= transTHORACIC ECHO = MUGA (Multiple-gated is NOT Clear
acquisition scan) or Nuclear And you cannot wait for ECHO to
ventriculography be done.
-dx: BNP
[TEE: Transesophageal Echocardiogram = more accurate then both to evaluate heart VALVE function &
diameter. TEE not for CHF eval.]
“Nuclear testing” = rarely needed (for precision) (ex: Chemo w/doxorubicin – trying to give max chemo
but not cause cardiomyopathy)
Nuclear Ventriculogram = precision of WALL MOTION problems
Cardiology Notes 6
Septal defects
CBC: T4/TSH: thyroid funct. Endomyocardial biopsy Swan-Ganz right
-Anemia =Both high & low -Rarely done heart catheterization:
thyroid levels cause CHF -excludes infiltrative -Distinguish CHF from
disease: sarcoid/amyloid ARDS; not routine
-biopsy is “most accurate
test” for some infections
Cardiology Notes 7