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Back To Basics: Cardiology Review I

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Title: No Slide Title Author: Dr. Anthony Tang Last modified by: Faculty of Medicine Created Date: 1/29/1997 1:14:00 PM Document presentation format – PowerPoint PPT presentation

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Title: Back To Basics: Cardiology Review I


1
Back To BasicsCardiology 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
1. Supply-Demand Mismatch
  • ? Supply
  • Coronary obstruction
  • Microvascular obstruction
  • ? Perfusion pressure
  • ? PaO2
  • ? Hemoglobin
  • ? Demand
  • ? Heart Rate
  • ? Contractility
  • ? Wall Tension

6
1. CAD
Obstructive CAD ACS
Atherosclerosis
7
1a. Atherosclerosis Targets
  • Mode-of-Life Issues
  • Smoking
  • Diet
  • Exercise
  • Alcohol
  • Stress
  • Medical Issues
  • Dyslipidemia
  • Hypertension
  • Diabetes Mellitus
  • Obesity

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 (gt 2
    blocks level, gt 1 flight of stairs)
  • III Marked limitation of ordinary activity (lt 2
    blocks level, lt 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
  1. Myocardial Ischemia
  2. PE
  3. Aortic Dissection
  4. Pneumothorax
  5. GI Rupture
  6. Other (pericarditis, pneumonia,
    GERD/PUD/gastritis, MSK, skin)

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

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
1c. Two Manifestations of ACS
  • 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 ?

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
  1. Hemorrhagic stroke ever
  2. Ischemic stroke lt 3 mos
  3. Intracranial AVM
  4. Intracranial malignancy
  5. Head trauma lt 3 mos
  6. Active bleeding
  7. 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
Risk Assess High Interm Low
HX Ongoing CP CPgt20 min resolved New/progrCCS 3-4
O/E ?BP, S3, MR, rales N N
ECG ST? trans ST? T inv N
TNT gt0.1 0.01-0.1 lt0.01
26
TX High Interm Low
Admit? Yes Yes No
RX ASA NTG BB clopidogrel ?-coag GP 2B3A-I ASA NTG BB clopidogrel ?-coag ASA NTG SL BB
IX Coronary Angio Inpt stress Outpt stress
27
1c. Complications Post-MI
  • Recurrent ischemia
  • HF/shock
  • Arrhythmia
  • Mechanical
  • Thromboembolic
  • Pericarditis
  • Depression

28
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

29
1c. Secondary Prevention RX
  • ASA in all
  • Statin in almost all (LDL lt 2)
  • ACE-I in most
  • Beta-Blocker
  • NTG if angina
  • Clopidogrel x 1 year post-ACS, post-stent
  • Treat risk factors

30
1c. Secondary Prevention Life
  • Smoking
  • Diet
  • Exercise
  • Weight
  • Alcohol
  • Stress

31
2. ECG EKG
  • Identify the study
  • Setting
  • Technical Details
  • Read rate, rhythm, axis, alphabet
  • Interpret
  • Previous

32
2a. Electrical Anatomy
The heart is a pump coordinated and powered by an
integral electrical system
33
2a. Electrical Anatomy
The SA Node has the steepest slope of spontaneous
Phase 4 depolarization and therefore is the
dominant pacer
34
2a. Electrical Anatomy
Atrial depolarization normally flows from top to
bottom and from right to left
35
2a. Electrical Anatomy
The AV Node delays then relays electrical
activation to the ventricles
36
2a. Electrical Anatomy
The His-Purkinje System conducts electrical
activation to all areas of both ventricles
37
2a. Electrical Anatomy
  • Three phases of ventricular depolarization
  • Septum L?R
  • (atrial repolarization occurs simultaneously)

38
2a. Electrical Anatomy
2. Depolarization of both ventricles
simultaneously from endocardium to epicardium
39
2a. Electrical Anatomy
Ventricular repolarization ensues, from
epicardium to endocardium
40
2a. The 12-Lead ECG
41
2a. PQRSTU
QRS
Segments
Intervals
PR
ST
TP
PR
QT
42
2a. PQRSTU
PR
ST
TP
Segments
Intervals
PR
ST
PR
QT
QRS
43
2a. Reading an ECG
  1. Rate
  2. Rhythm
  3. Axis
  4. Alphabet

44
1. Rate Count-Off Method
Start
150
75
Normal Rate 60-100 bpm
100
60
300
45
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

46
3. QRS Axis
  1. If QRS in I AND II, QRS axis is normal
  2. If QRS not in I AND II, you must calculate QRS
    axis
  3. To do so, use leads I and aVF to identify the
    90-quadrant
  4. Then use the isoelectric lead to quantify QRS
    axis (to nearest 30)

47
4. Alphabet
  • P waves
  • PR (segments and intervals)
  • QRS (Qs, height, width)
  • ST segments
  • T waves
  • QT interval

48
Arrhythmia Dysrhythmia
  1. Slow
  2. Fast
  3. Normal rate

49
2b. Bradydysrhythmias
  • Sinus Node
  • Sinus brady, pause, arrest, block
  • AV Node
  • 2 AVB (Type I and Type II)
  • 3 AVB

50
2b. AV Block
Nodal 1 AVB 2 AVB I 3 AVB
Infra-Nodal 2 AVB II 3 AVB
51
2b. AV Block
  • Nodal AVB is more benign because
  • Causes are often functional (as opposed to
    infranodal block which is almost always
    structural)
  • If progression to CHB, nodal escapes available

52
90F presents with fatigue
53
2c. Tachydysrhythmia
SVT NCT WCT
VT WCT
54
2c. NCT
  • Regular Irregular
  • AVN-Indep AVN-Dep AF
  • ST AVNRT MAT
  • AFL AVRT AFL/AT
  • AT variable block

55
75F to ER with palpitations
56
25F to ER with palpitations
57
72M without symptoms
58
2c. Atrial Fibrillation 2 Issues
  • Symptoms
  • Rate Control
  • (BB, CCB, dig)
  • vs
  • Rhythm Control
  • (e.g. amiodarone)
  • Stroke Risk (CHADS2)
  • CHF/LVEF lt 35 1
  • Hypertension 1
  • Age gt 75 1
  • Diabetes 1
  • Stroke (embolic) 2

2 OAC 1 ASA or OAC 0 ASA
59
2c. WCT
  • VT
  • AV Dissociation
  • Fusion/Capture Beats
  • Bizarre QRS Axis
  • Wide QRS
  • QRS Concordance
  • DDX
  • SVT Aberrancy
  • Accessory Pathway
  • Pacemaker
  • Bundle Branch Block
  • Metabolic derangement

60
66M prior MI with palpitations
61
2c. Torsades de Pointes
  • Polymorphic VT due to a long QTc (often with a
    characteristic appearance)
  • Causes
  • Congenital
  • Acquired
  • Electrolyte disturbances (Hypo K, Ca, Mg)
  • Drugs (antipsychotics, antidepressants,
    antibiotics, antiarrhythmics)
  • Other

62
3. Syncope
Neurocardiogenic CSH Vasovagal Situational
Pipes Subclavian Steal VBI Migraine
Pump Obstruction Arrhythmia
Fluid Hypovolemia
63
Questions?
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