UMEM Educational Pearls - By Semhar Tewelde

Title: Pericarditis

Keywords: Pericarditis (PubMed Search)

Posted: 9/16/2012 by Semhar Tewelde, MD
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Pericarditis is based on clinical diagnosis; typically two of four criteria are found (pleuritic chest pain, pericardial rub, diffuse ST-segment elevation, and pericardial effusion).

Most common cause of pericardial disease in the world is tuberculosis vs. idiopathic or viral causes in developed countries.

Treatment of pericarditis should be targeted at the cause.

NSAIDs and newer literature suggest colchicine are first line for most cases, except in systemic inflammatory diseases or pregnancy where low dose prednisone is often the preferred agent.

Most causes of pericarditis have a good prognosis and are self-limited.

The most feared complication is constrictive pericarditis.

Title: Lyme Carditis

Keywords: Lyme disease, Lyme carditis, AV block (PubMed Search)

Posted: 9/2/2012 by Semhar Tewelde, MD
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Lyme disease is the most prevalent arthropod zoonosis in the Northern hemisphere

Lyme carditis (LC), first reported in 1980, occurs in 1.5–10% of untreated adults in USA

Symptoms develop on average within a month after the onset of erythema migrans

Symptoms range from asymptomatic to dyspnea, syncope, chest pain, and fluctuating degrees of atrioventricular block

Temporary pacing is usually necessary in approximately 30%

Prognosis is favorable and complete recovery occurs in more than 90%

Tx typically consists of three weeks of oral or parenteral antibiotics after continuous cardiac monitoring in any symptomatic patients

Title: Arrhythmogenic right ventricular dysplasia

Keywords: ARVD, ARVC, cardiomyopathy, triangle of dysplasia, ICD (PubMed Search)

Posted: 8/26/2012 by Semhar Tewelde, MD
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Arrhythmogenic right ventricular dysplasia (ARVD) is a heritable form of cardiomyopathy, characterized by the replacement of myocytes with adipose and fibrous tissue leading to arrhythmias, right ventricular failure, and sudden cardiac death (SCD)

The areas of the myocardium most affected are localized to the the inflow tract, outflow tract, and apex of the right ventricle (triangle of dysplasia)

Most common symptoms are palpitations, syncope, and SCD in 27, 26, and 23% of patients, respectively

ECG findings include T-wave inversions in V1–V3 (85% ), epsilon waves (in 33%), as well as a QRS duration >110 ms in V1-V3 (64%)

Dx is based on a combination of characteristics family history, ECG/arrhythmia, cardiac imaging (MRI/Echo), and endomyocardial biopsy

ARVD patients are at high risk for sudden cardiac death and often recommended ICD placement

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Category: Cardiology

Title: Negative T waves

Keywords: T wave inversions, negative T waves, ACS, PE (PubMed Search)

Posted: 8/19/2012 by Semhar Tewelde, MD
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Pulmonary P waves (S1Q3T3 pattern + clockwise rotation) are specific for PE, but not sensitive.
This study examines if an ECG can discriminate between ACS vs. PE
- 40 patients with PE & 87 patients with ACS
- All had negative T waves in the precordial leads (V1-V4) on the admission ECG
The PE group had negative T waves commonly present in leads II, III, aVF, V1, V2, but less frequent in leads I, aVL, and V5 to V6 (p <0.05).
The ACS group had negative T waves in leads III and V1 in 1% compared with 88% of patients with PE (p <0.001).
Sensitivity, specificity, positive predictive value, and negative predictive value for Dx of PE were 88%, 99%, 97%, and 95%, respectively.
Negative T waves in both leads III and V1 may suggest PE can be differentiated from ACS in patients with negative T waves in the precordial leads.

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Category: Cardiology

Title: Hypertrophic Cardiomyopathy

Keywords: hypertrophic cardiomyopathy (PubMed Search)

Posted: 8/12/2012 by Semhar Tewelde, MD
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Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (typically asymmetric) that occurs in the absence of pressure overload or storage/infiltrative disease.

HCM demonstrates remarkable diversity in disease course, age of onset, pattern and extent of LVH, degree of obstruction, and risk for sudden cardiac death.

Exertional dyspnea and chest pain are the most common symptoms, presumably related to diastolic dysfunction, obstructive physiology, and ischemia.

First line therapy is medical treatment with beta or calcium channel blockers used to prolong diastolic filling and blunt dynamic intra-cavitary gradients.

Medically refractory symptoms are caused by severe obstruction from systolic anterior motion of the mitral valve; these patients are candidates for invasive septal reduction therapy with surgical myectomy or alcohol septal ablation.

Patients with HCM are at increased risk for sudden death, annual rate of SCD is ~1%. ICDs are recommended for all patients with prior arrest/sustained ventricular tachycardia (class I recommendation).

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Category: Cardiology

Title: Takotsubo Cardiomyopathy

Keywords: takotsubo cardiomyopathy, stress cardiomyopathy, broken-heart syndrome (PubMed Search)

Posted: 8/5/2012 by Semhar Tewelde, MD
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Takotsubo cardiomyopathy a.k.a. stress cardiomyopathy is an acute reversible disorder characterized by left ventricular (LV) dysfunction most commonly affecting postmenopausal women

The LV adopts the shape of an octopus trap (“takotsubo”) describing the narrow neck and broad base globular form during systole

Symptoms include precordial chest pain, dyspnea, or heart failure presenting with pulmonary edema mimicking ACS

Mayo Clinic Diagnostic Criteria

- Suspicion of AMI based on symptoms and STEMI on ECG

- Transient hypokinesia or akinesia of the middle and apical regions of LV

- Functional hyperkinesia of the basal region of LV

- Normal coronary arteries (luminal narrowing <50%)

- Absence of recent head injury, ICH, HCOM, myocarditis, or pheochromocytoma

Treatment is symptomatic and determined based on complications during the acute phase; occasionally requiring IABP or ECMO

Prognosis is better than those with ACS, however initial LVEF is similar to those seen with ischemic heart disease

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Category: Cardiology

Title: Yamaguchi Cardiomyopathy

Keywords: yamaguchi cardiomyopathy, apical hypertrophic cardiomyopathy, hypertrophic cardiomyopathy (PubMed Search)

Posted: 7/29/2012 by Semhar Tewelde, MD
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Yamaguchi Cardiomyopathy

Yamaguchi cardiomyopathy a.k.a. apical hypertrophic cardiomyopathy (AHCM) was first described 1976 in Japanese patients.

AHCM is a variant of hypertrophic cardiomyopathy that is nonobstructive with predominant involvement of the apex of the heart.

AHCM is frequently misdiagnosed as ACS or STEMI since the typical ECG abnormalities include giant inverted T waves or ST elevation in the mid precordial leads, however coronaries are characteristically clean on cardiac catheterization.

Echocardiography classically used to diagnosis HCM may frequently miss AHCM because hypertrophy is only localized to the apex.

Nuclear magnetic resonance imaging or angiography reveals the pathognomonic "ace of spades" configuration of the left ventricle with systolic obliteration of the apical region.

Unlike HCM sudden cardiac death is very uncommon.

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Category: Cardiology

Title: Atrial Fibrillation

Keywords: Atrial fibrillation, a fib (PubMed Search)

Posted: 7/15/2012 by Semhar Tewelde, MD (Updated: 4/20/2024)
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Atrial fibrillation is most commonly associated with cardiovascular disease

Non cardiac causes: pulmonary disease/PE, hyperthyroidism, sympathomimetics, drugs/ETOH

AFFIRM & RACE trials compared outcomes of a fib patients treated w/ rate vs. rhythm control

- No significant difference in survival between groups

Risk of thromboembolic CVA

- Rhythm control = Rate control + anticoagulation

New data challenges the need for strict heart rate control

- Resting heart rate should be <110 bpm

Use CHADS2 score to identify who requires anticoagulation based on %risk of emboli

- Chronic heart failure, HTN, Age>75, DM, Stroke/TIA

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Category: Cardiology

Title: Sgarbossa Criteria

Keywords: Sgarbossa Criteria, MI, LBBB (PubMed Search)

Posted: 6/24/2012 by Semhar Tewelde, MD (Updated: 7/15/2012)
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Sgarbossa et al, initially identified patients with MI and left bunde branch block (LBBB) from the GUSTO trial; these ECGs were compared to the ECGs of patients with chronic CAD and LBBB

LBBB is defined by 3 criteria QRS >125msec, V1- QS or rS, and R wave peak time 60ms with no q wave in leads I, V5, V6

After a criteria to identify MI with LBBB was estabilshed it was tested on patients presenting with chest pain and

The study resulted in Sgarbossa criteria; 3 independent predictors of MI in setting of LBBB

1.) ST segment concordance of 1mm any lead (greatest odd ratio, i.e. most specific)

2.) ST depression 1mm V1- V3

3.) Excessive ST discordance greater than 5mm (lowest odds ratio)