BCPS 2013: Cardiology I

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A little in the past on my study schedule, but what I'm studying this past week. Acute Decompensated Heart Failure

Parameter Normal ADHF  
MAP 80-100 60-80  
HR 60-80 70-90  
CO/CI 4-7 / 2.8-3.6 2-4 / 1.3-2 Low cardiac output
PCWP 8-12 18-30 Congestion
SVR 800-1200 1500-3000  
CVP 2-6 6-15 Fluid up

*want PCWP 15-18 for optimal filling pressure

Signs and symptoms

Congestion (PCWP) Hypoperfusion (CO)
Dyspnea Fatigue
Peripheral edema Cold extremities
Rales Narrow pulse pressure
Ascites Hypotension
Jugular venous distention Worsening renal function
Hepatomegaly, splenomegaly Hyponatremia

 

Subsets and Therapy

  Warm (CI > 2.2) Cold (CI < 2.2)
Wet (PCWP > 18) Congestion

IV diuretics + IV vasodiliators (venous)

 Congestion and Hypoperfusion
MAP < 50 Dopamine
MAP > 50 Inotrope* or vasodilator (V or A)
Dry (PCWP < 18) Normal

Optimize oral meds

 Hypoperfusion
PCWP < 15 IV fluids
PCWP > 15, MAP < 50 Dopamine
PCWP > 15, Map > 50 Inotrope* or vasodilator (arterial)

*SBP < 90, hypotension, worsening renal function

Home HF meds in ADHF

  • ACEi – caution with uptitration during diuresis and if Scr # more than 0.5 mg/dL above baseline
  • BBlockers – Do not discontinue if stable prior to admission, do not start until euvolemic, hold if hemodynamically unstable
  • Digoxin – goal conc 0.5-0.8 ng/mL, avoid discontinuation, caution if renal function worsens

Drugs for ADHF

Diuretics – congestion

Loop Furosemide 40 PO = Furosemide 20 IV = Bumetanide 1 mg = Torsemide 10 mg
Thiazide Not effective if CrCl < 30, used as adjunct

HCTZ 12.5-25 mg PO, metolazone 2.5-5 mg PO

Chlorothiazide 250-500 mg IV if GI edema (expensive)
Resistance to diuretics Fluid and sodium restriction

Increase dose, frequency, cont infusion

Add thiazide

 

Inotropes – hypoperfusion

Dobutamine

B1 agonist: inotropic, lusitropic, chronotropic

 Dose: 2.5-20 mcg/kg/min

AE: tachycardia, arrhythmia, myocardial ischemia

Consider if hypotension
Milrinone

PDE inhibitor: inotropic, lusitropic

 

 AE: arrhythmia, hypotension

Dose: 0.1-0.75 mcg/kg/min

Consider if on B-blocker

 

Vasodilators – congestion, (Venous $ PCWP for dyspnea), (Arterial  $ SVR for $ CO)

Nitroprusside

Arterial = venous

 Doses: 0.3-3 mcg/kg/min

AE: hypotension, cyanide/thiocyanate toxicity
Nesiritide

# Na excretion, UOP, CI

$ PCWP, SVR, NE, aldosterone

 Doses: 0.01 mcg/kg/min

AE: hypotension, some tachycardia
Nitroglycerine

Venous > arterial (art w/ high doses)

 Doses: 5-200 mcg/min

AE: hypotension, reflex tachycardia, HA

 

Arrhythmias

Drug therapy overview

  • Check thyroid function, K 4-5 mmol/L, Mg > 2 mg/dL, QTc < 500 ms
  • Potential drug causes: QTc prolongation, bradycardia, AV block

 

See figures on last page.

See Table 9.

Treatment of arrhythmias

Pulseless VT/VF Epinephrine, Vasopressin, Amiodarone, Lidocaine, eval reversible causes
PEA Epinephrine, Vasopressin, eval reversible causes
Sx Bradyarrhythmia If unstable: atropine 0.5-1.0 mg IV, repeat up to 3.0 mg
Sx Tachycardia If unstable: cardioversion

If stable: narrow/regular (SVT) – Vagal maneuvers, adenosine, β blockers, CCB, ablation

Note: avoid CCB and digoxin if WPW, adenosine 6/12 mg (caution in severe CAD)
Afib (narrow/irregular)
  1. Control ventricular rate (β blockers, CCB (diltiazem, verapamil), digoxin)
  2. Rate (leave in AF) OR rhythm control (restore sinus rhythm)
  • Rate control with drugs listed above
  • Rhythm control with electric cardioversion or antiarrhythmic drugs

IA (quinidine, procainamide), IC (flecainide, propofenone), III (amiodarone, sotalol, ibutalide, dofetilide)

  1. Anticoagulation
  • Rate control: chronic anticoagulation ASA or warfarin (INR goal 2-3) (CHADS2 score)
  • Rhythm depends on timing
    • < 48 hrs AF, no anticoagulation needed  prior to cardioversion
    • > 48 hrs AF, anticoagulation for 3 wks prior and 4 wks after CV
  1. Consider long term antiarrhythmics if pt still symptomatic despite rate control
Vtach, Vfib Cardiovert (shock) patients, give Epi or vasopressin as needed

Consider amiodarone or lidocaine during CV and after for prophy

Patients with LVEF < 30 to 40% should have implantable cardioverter defibrillator (ICD)
Torsades Mg
Special populations HF – amiodarone and dofetilide (LV dysfxn post MI) neutral effect on mortality

Post MI – ecainide, flecainide, moricizine, 1A meds # mortality

Dofetilide neutral mortality LV dysfxn post MI

 

Pulmonary Arterial Hypertension

Signs and symptoms

Dyspnea w/ exertion, fatigue, chest pain, syncope, weakness, orthopnea, peripheral edema (fluid backs up), liver congestion, ascites, hemodynamics (mPAP > 25, PCWP < 15, PVR > 3), RV hypertrophy

Treatment

Goal: relieve acute dyspnea, improve exercise capacity and QOL

Vasodilator response testing: epoprostenol, inhaled nitric oxide, IV adenosine

Initial treatment algorithm

Supportive care
Oxygen
Anticoagulation: warfarin goal INR 1.5-2.5 to prevent catheter thrombosis, VTE
Immunizations
Birth control
Oral CCB
If no sustained response to CCB:
Low risk High risk
1st line: ERA or PDEIs (oral)

Alt: epoprostenol, treprostinil (IV)

iloprost (inhaled), treprostinil (SC)

 1st line: epoprostenol, treprostinil (IV)

Alt: ERA or PDEIs (oral)

iloprost (inhaled), treprostinil (SC)

ERA: endothelin receptor antagonist (e.g. sentans)                      PDEIs (e.g. sildenafil)

Prostacyclin analogs (e.g. epoprostenol)

See Table 16.

Hypertensive Crises (Urgency and Emergency)

HTN urgency: acute elevation in BP > 180/120 without organ damage

HTN emergency: HTN with organ damage (encephalopathy, intracranial hemorrhage, angina or MI, pulm edema, aortic dissection, retinopathy, $ UOP or AKI, eclampsia)

Treatment

Urgency: goal to $ BP within 24 hrs

Agents (Table 18): captopril, clonidine, minoxidil, nifedipine, labetalol

 

Emergency: goal to $ MAP 25% or diastolic BP to 100-110 mmHg within 30-60 min

Agents (Table 17): sodium nitroprusside, esmolol, labetalol, nicardipine, nitroglycerin, hydralazine, enalaprilat, fenoldopam, clevidipine

Preferred agents for crises based on comorbidities

Acute aortic dissection Esmolol alone or w/ nicardipine or nitroprusside

(BB first!)
Acute HF Nitroprusside, nitroglycerin, nesiritide, ACEi with diuretics if pulm edema (no BBs)
Stroke (ischemic, hemorrhagic) Labetalol, nicardipine
Acute MI BB with nitro, if HR < 70 nicardipine, clevidipine
Acute pulm edema Nesiritide, nitroglycerin, nitroprusside
AKI Fenoldopam, nicardipine, clevidipine
Eclampsia Hydralazine, labetalol, nicardipine
HTN encephalopathy Nitroprusside, labetalol, fenoldopam, nicardipine
Perioperative HTN Clevidipine, esmolo, nicardipine, nitro
Sympathetic crisis Nicardipine and such (avoid unopposed BB)

 

 

Cardiac Muscle

cardiology