Presentation Tests Treatment Notes

ASA (81 mg x2)

Hx consistent with ischemia = most important Metoprolol (25 mg BID) ACS = Hx of chest pain + EKG
substernal pain on exertion EKG
15-30 min/episode Nitroglycerin
MC risk factor: HTN
dull, squeezing, pressure ACE-inhibitor
Acute Coronary exercise stress test: intermediate risk w/ normal EKG; worst risk factor: DM
S3/S4 Statin
Syndrome looks for reversible ischemia; (also smoking, hyperlipidemia, & family Hx
rales Morphine
catheterize abnormal results 1st degree relative (<55 male, <65 female))
(normal exam does not
exclude ACS) echo: evaluate wall & valve motion, & EF; Ca++-channel blockers used for
normal wall motion excludes MI catheterization/angiography symptomatic relief only, not mortality
telemetry
LMW heparin (SC enoxaparin)
EKG: ST depression
clopidogrel/prasugrel/ticagrelor
chewable ASA (2 x 81 mg)
Troponin I: rises 3-4 hr after pain onset, stays positive no O2 unless hypoxic
NTG
1-2 wks dont wait for troponin or CK-MB results
NSTEMI chest pain statin (LDL goal: <100 mg/dL)
CK-MB: rises 2-4 hr after onset stays positive 1-2 days
-blocker (metoprolol)
(best test of reinfarction); false+ with CHF & renal statins can cause increased LFTs & myositis
ACE-I
failure
morphine
Myoglobin: rises at 1-4 hr
cath/angio despite medical intervention
angioplasty/cath or thrombolytics for PCI
no O2 unless hypoxic
clopidogrel/prasugrel/ticagrelor
EKG: ST elevation eptifibitide or abciximab (glycoprotein
chest pain (DO NOT use heparin)
CXR IIb/IIIa inhibitor) used if PCI & stent
rales chewable ASA
STEMI Echo
S3 NTG
Troponin I: elevated Takotsubo cardiomyopathy due to
JVD statin (LDL goal: <100 mg/dL)
BUN: elevated overwhelming emotions; mimics anterior
-blocker (metoprolol)
wall STEMI
ACE-I
angiography when >70% stenosis 1-2 vessel: medical Rx & possible PCI
EKG: repeat if symptoms change ASA +/- clopidogrel/prasugrel/ticargrel 3 vessel w/ LV dysFx or left main: bypass
Echo (DO NOT use heparin)
CAD/angina
stress test: 80-85% of max HR to assess ST depression -blocker (metoprolol) ASA only in chronic stable angina
on EKG; stress test+ = reversible perfusion defect statin (LDL goal: <100 mg/dL) Ranolazine: Na+-channel blocker for
ACE-I (if EF <35%) refractory angina cases only
LBBB stress test w/ dipyridamole or dobutamine echo
EKG (excludes ischemia & arrhythmia) O2 & elevate head MCC: I AM in high salty fluid
sudden onset dyspnea,
CXR (excludes effusion, cardiomegaly, Furosemide (Lasix) IV 20 mg, double every
relieved by sitting up
congestion/vascular fluid overload) 20-30 min till urine produced Ischemia
+/-rales,
ABG monitor I/O Arrhythmia
Acute Pulmonary +/- peripheral edema
BNP NTG paste, IV, or SL Medication (most common)
Edema (CHF) S3, JVD
Troponin/CK-MB morphine 2-4 mg IV Infection
tachycardia
BUN/Cr: elevated >20:1 (pre-renal azotemia) hemodialysis for refractory cases HTN crisis
diaphoresis, nausea
CBC: hyponatremia transfer to ICU if systolic < 90 mmHg Salty food
echo: determine EF, syst/diast dysFx, valve fx (DO NOT use -blockers in acutely ill pt) Fluid overload (iatrogenic)
Systolic DysFx ACE-I (or ARB if cough; or alternative is AICD if low EF despite medical therapy
CHF hydralazine/nitrate if hyperkalemia) (lowers mortality)
-blocker (metoprolol, carvedilol)
spironolactone for stage III/IV CHF only ACE-I not beneficial in diastolic dysFx
(eplerenone as alternative)
diuretics & digoxin (no mortality benefit)
 biventricular pacemaker if QRS >120 ms
chest pain, dyspnea/CHF, IV anti-hypertensives: labetalol, enalaprilat,
Hypertensive HTN crisis = severe HTN with end-organ
blurry vision, confusion, or nitroprusside (stroke caution: do not lower
crisis damage
renal insufficiency BP > 25% 1st few hrs)

SOB worsens on exertion, systolic dysFx: diated cardio.

-blocker, ACE-I, spironolactone, diuretics
improves with rest CXR: congestion or pulmonary vascular redistribution diastolic dysFx: hypertrophic card.
Cardiomyopathy (for dilated cardiomyopathy)
rales echo (alternative MUGA or left heart cath) restrictive card: sarcoidosis, amyloidosis,
treat underlying cause (for restrictive card.)
+/- peripheral edema hemochr., cancer, endomyocardial fibrosis
syncope, LOC systolic murmur at LLSB: valsalva & standing EF is preserved
Hypertrophic
chest pain (increases); squatting & leg raise (decreases) -blocker (metoprolol)
Obstruction
S4 gallop echo implantable defibrillator (for syncope) diuretics, ACE-I, dehydration, & digoxin will
Cardiomyopathy
sudden death in athletes left heart catheterization worsen HOCM
NO anticoagulation if present < 48 hr
anticoagulate if risk for stroke (CHAD2) hemodynamic instability = chest pain, SOB,
EKG (if normal, Holter as outpatient, telemetry for cardiomyopathy confusion, hypotension (<90 mmHg systolic)
inpatient) HTN CHAD2 = 0/1: ASA &/or clopidogrel
Arrhythmia palpitations
exclude thyroid disease, alcohol, caffeine CHAD2 = 2+: warfarin, rivaroxaban, or
age >75
dabigatran (no INR monitoring required, not
DM reversible)
prior Stroke/TIA (anticoagulate)
rate control <100 bpm within 30 min causes: HTN (MC), CHF, alcohol, cocaine,
EKG: irregularly irregular rhythm, P-waves absent, metoprolol (5 mg IV every 5 min 3x, then thyroid disease, rheumatic fever
normal QRS oral 50 mg bid, max 200 bid), OR (immigrants), dilated atrium
palpitations, +/- chest pain
A-fib/A-flutter (do not measure HR by radial pulse) diltiazem (0.25 mg/kg, then IV 0.35 mg/kg,
lightheadedness
echo (detects valve disease & clots) then oral 30 mg qid, max 200 qid) other rate control meds: verapamil, esmolo,
Troponin/CK-MB use digoxin if BP is low or borderline propranolol, atenolol
(digoxin doesnt lower BP; slow acting) Cardioversion: a-fib rhythm control
EKG: narrow QRS tachycardia (>160bpm), P-waves
telemetry
absent MCC by abnormal AV conduction vagal
sudden onset palpitations adenosine
SVT no physical findings maneuvers: carotid massage or valsalva
SOB, lightheadedness b-blocker (metoprolol or diltiazem)
echo to exclude other pathology
cardioversion if hemodynamically unstable
troponin/CK-MB are not useful
procainamide, amiodarone, flecainide, or
previous EKG
Wolf-Parkinson palpitations, EKG: small/short P-R, delta waves (early ventricular sotalol
digoxin & Ca++-ch blocker use worsens
White Syndrome lightheadedness, syncope depolarization), SVT alternating w/ v-tach electrophysiology (EP) to identify abnormal
symptoms or arrhythmia
conduction tract for ablation
Multifocal Atrial
a/w COPD 3 P-wave morphologies & normal QRS same as for a-fib/a-flutter NO -blocker (worsens COPD)
Tachycardia
saline bolus if systolic <90 mmHg
EKG: wide QRS, reproducibly regular, sustained VT MCC is previous MI (ischemia), also low
check K+. Mg++, Ca++, O2
EXTREME EMERGENCY >30 sec Mg++, Ca++, or O2, high/low K+, cocaine
V-Tach synchronized cardioversion if unstable
chest pain, confusion, SOB Troponin/CK-MB toxicity, low EF dilated cardiomyopathy
amiodarone, lidocaine, procainamide, &
echo Torsade de Pointes
Mg++ if stable
GIVE CPR!
recent MI CPR defib CPR epi CPR defib after 2 min unsynchronized cardioversion
V-fib treat V-tach without pulse the same
loss of pulse CPR - amiodarone epinephrine or vasopressin if no response
amiodarone (lidocaine alternative)
Bradycardia low systolic < 90 mmHg EKG: determine hemodynamic stability if unstable/symptomatic if stable/asymptomatic
lightheadedness ventricular pacemakers give wide QRS & abnormal T- atropine (0.5-1.0 mg IV; 3 mg max) Sinus brady, 1st degree AV block, or Mobitz I
 = no treatment
confusion, syncope, SOB waves transcutaneous pacemaker Mobitz II or 3rd degree AV block
= pacemaker
Sick Sinus pacemaker if slow (>3 sec pause)
aka tachy-brady syndrome
Syndrome b-blocker if fast
sudden LOC = cardiac or exclude cardiac & neurologic causes
neurologic cause EKG MI
gradual LOC: metabolic Troponin/CK-MB ventricular arrhythmia
vasovagal episode
echo
Syncope sudden recovery of telemetry aortic stenosis
measure O2, glucose, Na+, Ca++
consciousness: cardiac HOCM
MRI for brainstem causes
gradual recovery: seizures, head CT & echo w/o murmur findings are useless seizure
glucose, O2, drug O/D brainstem stroke
increased venous return (squatting or legs
raised) increases all murmur intensities
dyspnea (except MVP & HOCM)
CHF
Valvular Heart echo (best initial assessment) decreased venous return (sudden standing or
edema endocarditis PPx if valve was replaced
Disease catheterization (most accurate test) valsalva) decreases left-sided murmur
murmurs
(except MVP)
congenital/rheumatic fever
handgrip increases afterload; worsens
regurgitations, improves HOCM
echo (best test) ACE-I/ARBs decreased afterload
EKG: AR will show LVH (SV1 + RV5 >35 mm) due to any cause of dilated cardiomyopathy
no ABX PPx before dental procedures unless
Aortic/Mitral CXR: enlarged LA & LV louder with squatting & leg raised
dyspnea, rales, edema valve was replaced
Regurgitation softer with valsalva & standing
AR: diastolic decrescendo murmur @ LLSB surgery: AR EF <50% or LVESD >55mm,
worsens with hand grip ( afterload)
MR: pansystolic @ axilla that radiates MR EF <60% or LVESD >45mm
angina a/w CAD no treatment if asymptomatic
echo (best test)
Aortic Stenosis syncope surgical replacement if symptomatic DO NOT use ACE-I or ARB (worsens)
stress test & angiography (due to CAD)
CHF (worse prognosis) balloon valvulopasty if pt too ill
EKG: biphasic P-waves in V1 & V2 diuretics (fluid overload)
young immigrant MS can cause LA enlargement & a-fib w/
CXR: double bubble, L mainstem bronchus pushing digoxin or -blocker (HR control)
Mitral Stenosis a-fib, dysphagia, hoarseness, pressure on esophagus & recurrent laryngeal
up, straightened L heart border balloon valvuloplasty (or alternative: valve
early onset stroke nerve.
TEE & L heart cathetherization is best test replacement)
palpitations echo (best test) -blocker for palpitations & chest pain
Mitral Valve improves with squatting & leg raised
atypical chest pain mid-systolic click w/ late systolic murmur no treatment if asymptomatic
Prolapse worsens with valsalva & standing
incidental finding EKG & CXR will be normal no endocarditis PPx
chest pain: relieved by treat underlying cause
friction rub on auscultation
sitting up, worse on NSAIDS (ibuprofen & naproxen)
Pericarditis EKG: ST elevation in all leads except AVR, MCC: viral infection
inspiration add colchicine to reduce recurrence risk
PR segment depression
alternative is prednisone for symptoms
also fever, recent lung infection
pulsus paradoxus (>10 mmHg with inspiration)
fluids prevent/reverse tamponade renal failure
SOB, lightheadedness CXR: enlarged heart shadow
thoracocentesis chest wall trauma
Pericardial dyspnea, hypotension, JVD CT: pericardial effusion
pericardial window placement SLE, RA, Wegners
Tamponade tachycardia echo: effusion pressing on right heart: RA & RV
cardiac catheterization: pressure equalization recent MI, cancer of chest organs
sudden loss of pulse diastolic collapse is the first sign
of all chambers in diastole
EKG: low voltage, QRS electrical alternans
Constrictive edema, JVD, Kussmauls S3 pericardial knock surgical removal is best
Pericarditis sign CXR: fibrosis, thickening, calcification diuretics & salt restriction prevents build-up
enlarged liver & spleen Chest CT/MRI shows more detail
 ascities
STOP SMOKING!
angina of the calves ankle/brachial index (ABI): ankle pressure >10% ASA (or clopidogrel) Hx of tobacco smoking
Peripheral Artery pain in legs relieved by rest lower than brachial (ABI <0.9) = obstruction Cilostazol Hx of HTN, DM, hyperlipidemia
Disease decreased peripheral pulses lower extremity Doppler ACE-I for BP pain with exertion, spinal stenosis worse
smooth, shiny skin (severe) angiography Statin (LDL goal: <100 mg/dL) walking downhill, but not uphill
tight glucose control in diabetics
Abdominal Aortic AAA >5.0 cm = surgical repair
USS: all men age >65 who have ever smoked
Aneurysm AAA <5.0 cm = USS in 6 months
CXR: wide mediastinum b-blocker (labetalol) decreases pulse pressure
Thoracic Aortic chest pain radiates to the
CT angiogram, MRA, TEE (90-95% sensit/specif) nitroprusside
Aneurysm back
angiogram with catheter is most accurate surgical repair
Heart Disease & peripartum cardiomyopathy Eisenmengers leads to pulmonary HTN Mitral stenosis
Pregnancy w/ LV dysFx (blood volume increases by 50% in pregnancy) Aortic stenosis
pleuritic chest pain that CXR
changes with respiration oximeter
Pneumonia ABX prophylaxis
dyspnea, fever, cough, ABG
sputum sputum culture
sudden onset pleuritic chest
Pulmonary CT pulmonary angiogram
pain
Embolus CXR, oximeter, ABG
recent surgery
Aortic dissection chest pain radiates to back CXR: wide mediastinum CT angiogram, MRA, TEE
Costochndrtis chest tender on palpation none
GERD epigastric pain, burning improves with antacids
position feet up/head down
Hypotension systolic < 90 mmHg repeat BP manually Tx first, Dx later.
IVF 250-500 mL NS bolus over 15-30 min
BUN: Cr ratio >15-20:1
Dehydration low urine Na+ (<20)
high urine Osm (>500)
CBC: leukocytosis
Sepsis Fever
Blood cultures
BP normalizes lying flat
Orthostasis
Tilt-table test
Premature
Ventricular EKG: alternating normal QRS with wide, premature
incidental finding no specific treatment
Contractions PVCs
(PVCs)
atropine for symptoms
30 heart block recent MI EKG: bradycardia, canon A waves
pacemaker for all pt
EKG: inferior wall MI
RV infarct recent MI
right-sided EKG: V4 STEMI
recent MI, new murmur
Valve Rupture balloon pump in some pt
rales/congestion
recent MI, new murmur
Septal Rupture balloon pump in some pt
increased O2 sat in RV