1/22/2019 Disclosures - none Cardiology III Matthew K Hysell, MD Spectrum Health Lakeland St Joseph, MI 1 2 Objectives But first… • Review specific high-yield EKG patterns • Frame your mind • Ischemia • Most frequent questions • Ischemia mimics • Treatment of • Electrolytes • Work-up for • Review Cardiac/CV meds • Most common… • Exceptions to the rule • Assorted other entities • • Endocarditis Hard triggers to pull • Tumors • Peer carefully • Hypertensive emergency • What’s trending • Repeat ?’s • At risk populations 3 4 And second … Ischemia EKG’s 5 6 1 1/22/2019 Diaphoretic ~60 y.o. with classic angina Original EKG from pt in CP obs 100% LAD 7 8 4 hour EKG from same pt 70 y.o. woman with typical MI story • A. HEART score • A. HEART risk score risk stratification stratification • B. Heparinize • B. Heparinize and admit and admit • C. Perform • C. Perform bedside echo bedside echo • D. • D. Thrombolysis Thrombolysis 9 10 Another posterior STEMI 50 y.o. man with MI story • A. HEART score risk stratification • B. Heparinize and admit • C. Plan for PE protocol CT • D. Thrombolysis 11 12 2 1/22/2019 90 y.o. man with MI story 77 y.o. with MI story • A. HEART score risk stratification • A. HEART score risk stratification • B. Heparinize and admit • B. Heparinize and admit • C. Plan for CT angio eval PE • C. Perform bedside echo • D. Thrombolysis • D. Thrombolysis 13 14 Another Sgarbossa STEMI 75 yo. Man had MI 3 weeks ago, now with cold • A. HEART score risk stratification • B. Heparinize and admit • C. Perform bedside echo • D. Thrombolysis 15 16 40s y.o. man had MI and intervention 1 week Another pericarditis EKG ago, now with CP • A. HEART score risk stratification • B. Heparinize and admit • C. Perform bedside echo • D. Thrombolysis 17 18 3 1/22/2019 60 y.o. woman with BrCA and pleurisy 20’s y.o. playing beach soccer all day • A. HEART score risk stratification • B. Heparinize and admit • C. Perform bedside echo • D. Thrombolysis Cr = 3 K = 6 LITFL 19 20 It’s wide It’s wider 21 22 It’s widerer Wide and peaked K=9 23 24 4 1/22/2019 Still wide This counts in real life K=7 25 26 70 y.o. man with palpitations 55 y.o. unresponsive in his garage • A. administer • A. Calcium Ca • B. digibind • B. administer K/Mg • C. re-warming • C. atropine • D. thrombolysis • D. set up for TCP K = 3.1 Mg = 1.2 27 28 72 y.o. man with weakness Unresponsive teenager • A. Adenosine • B. Beta blockade • C. Bicarb drip • D. Calcium Dig 2.8 29 30 5 1/22/2019 Post bicarb 31 32 20’s y.o. s/p syncope Irregularly irregular wide • A. adenosine complex tachycardia differential • B. amiodarone • Afib with aberrancy • C. Bicarb drip • Still limited by AVN • D. Cardioversion • QRS appearance consistent • Polymorphic Vtach • More likely to be older pt with heart disease • Some have a wandering baseline • Afib with WPW • Not limited by AVN • Varying QRS but fairly constant voltage • some with delta waved beats • Often in young otherwise healthy pts 33 34 Cardiac Meds • Epi • 1/1,000 • 1/10,000 • Adenosine • Atropine • Beta Blocker – dissection, thyroid storm • Aminophylline 35 36 6 1/22/2019 Thrombolytics for PE Aortic stenosis • Fixed outflow obstruction reliant on preload • Massive • Vasodilation during exercise leads to syncope • Sustained hypotension • LV hypertrophy • Pulselessness • Can lead to angina • Persistent profound brady • Submassive • RV dysfunction by BNP or echo • Myocardial necrosis 37 38 Mitral valve Endocarditis • Acute regurg • Aortic valve most common • Usually 1-2 days post MI • Was previously mitral • Overt cardiogenic shock and pulmonary edema • S. aureus most common cause • Afterload reduction • Nitrates/nipride/cardene • Risk factors – 50% occur with previously normal valves • Prolapse • Congen/rheumatic heart disease • Palpitations, chest pain, orthopnea, fatigue • IVDA • Beta blockers, diuretics • Hemodialysis • HIV/immunosuppression 39 40 Endocarditis physical exam Endocarditis physical exam Splinter Hemorrhage Conjunctival hemorrhage Cutaneous lesions Roth spots Osler’s nodes Janeway lesion Painful, raised Painless, flat 41 42 7 1/22/2019 Endocarditis diagnosis Endocarditis treatment • TTE 60% sensitive, TEE 95% • Minor criteria • Community acquired and native • Surgery sensitive • Predisposing heart condition or valves • Failing antibiotics • Duke Criteria IVDA • PCN + Gent • Abscess enlargement or • Fever over 100.4 development • One major + 3 minor • Hospital acquired or non-native • Vascular phenomena • Recurrent emboli • 5 minor valve or PCN allergy or suspect • Hemodynamic instability • Immunologic phenomena community acquired MRSA • Staph, Q fever, fungal cause • Major Criteria • Microbiologic evidence • Vanco + Gent • Positive blood cultres • Echo findings short of major • Positive echo • New valvular regurg 43 44 Cardiac tumors Hypertensive emergency • SYMPTOMATIC blood pressure > 180/120 • Generally lower 10-20% over first hour • Know stroke numbers • 220/120 if not TPA • 185/110 if TPA • Aggressive management of dissection • And fairly aggressive of SAH 45 46 Take-homes • STEMI mimics are commonly tested on boards • Consider the K on any weird bradycardia • Know inclusions/exclusions for lytics • R-E-L-A-X 47 8.