UMEM Educational Pearls - Cardiology

Title: creatinine clearance

Keywords: creatinine clearance, medication adverse effects (PubMed Search)

Posted: 10/22/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Recent studies have identified that a significant cause of morbidity and mortality in women, elderly, and patients with renal failure is the failure to consider renal insufficiency in dosing certain anticoagulants and anti-platelet medications, resulting in bleeding complications. Medications should be based on creatinine clearance, NOT SERUM CREATININE. When the creatinine clearance is < 30 mL/min, the dose of any renally-excreted medications should be decreased.

For example, an 85 yo woman that is 110 lbs and has a serum creatinine of 1.2 (sounds normal!) actually has a creatinine clearance < 30, which means that she has relative renal insufficiency. Her dosages of medications (e.g. enoxaparin) should be adjusted for this.

Creatinine clearance can easily be calculated via computer programs that you can "google" (e.g. just google "creatinine clearance calculation"). If you enter the patient's gender, age, weight, and serum creatinine, the programs will calculate the value for you.

Category: Cardiology

Title: Atrial Fibrillation

Keywords: atrial fibrillation, myocardial infarction (PubMed Search)

Posted: 10/14/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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New onset atrial fibrillation is rarely the sole manifestation of myocardial infarction. In other words, in the absence of accompanying chest pressure, dyspnea, diaphoresis, or other anginal equivalents, a rule-out ACS workup in not supported by the literature and is not cost-effective.

The two exceptions to the statement above are elderly and diabetic patients, in whom subtle presentations of ACS are common with or without atrial fibrillation.

Category: Cardiology

Title: Acute MI Reperfusion

Keywords: acute myocardial infarction, reperfusion, ami (PubMed Search)

Posted: 10/7/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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In the treatment of an acute ST-elevation MI, there are three major signs of successful reperfusion:

T-wave inversion within the first 4 hours. If the T-wave inversions occur beyond 4 hours, it's uncertain.
Resolution of the STE by at least 70% in the lead with maximal STE.
Development of a "reperfusion arrhythmia," most notably accelerated idioventricular rhythm (AIVR), which looks like V.Tach but the rate is only 60-120. Remember, V.Tach should have a rate > 120.

Persistent pain/symptoms OR absence of STE resolution by 90 minutes warrants strong consideration of rescue angioplasty.

Category: Cardiology

Title: Valvular Disorders--Hypertrophic cardiomyopathy

Keywords: Valvular Disorder, Hypertrophic Cardiomyopathy (PubMed Search)

Posted: 9/30/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Hypertrophic cardiomyopathy is associated with a systolic murmur loudest at the apex, and it may radiate to the base. The murmur increases with maneuvers that cause ventricular filling to decrease (e.g. valsalva, standing). The murmur decreases with maneuvers that cause ventricular filling to increase (e.g. trendelenburg, isometric exercises, squatting). These patients have primarily diastolic dysfunction, and so they should be treated with beta blockers to help improve diastolic filling time.

Category: Cardiology

Title: ACS in the elderly

Keywords: myocardial infarction, misdiagnosis (PubMed Search)

Posted: 9/23/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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The consequences of missed MI in the elderly are dramatic: 50% of elderly patients with an MI missed by the ED or primary care doctor will be dead within 3 days.

Category: Cardiology

Title: Acute Pericarditis

Keywords: Acute Pericarditis, Pericardial effusion (PubMed Search)

Posted: 9/16/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Acute pericarditis Up to 60% of patients with acute pericarditis are asssociated with a pericardial effusion. Grading of the effusion is as follows:

"Small" = less than 10 mm of echo-free space (anterior plus posterior)
"Moderate" = 10-20 mm
"Severe" = > 20 mm.

Ideally, the effusion echo-free space is measured at the onset of the QRS complex in diastole. Small effusions do not mandate admission in and of themselves. Severe effusions mandate admission. For moderate effusions, it's a judgement call and probably depends on how good the follow up is and also the patient's symptoms.

Category: Cardiology

Title: mitral valve prolapse

Keywords: mitral valve prolapse, mitral regurgitation, endocarditis (PubMed Search)

Posted: 9/9/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Mitral valve prolapse is one of the most common valvulopathies and, although usually benign, it can predispose to atrial dysrhythmias, bacterial endocarditis with systemic embolization, and sudden death. If these patients have an audible murmur (as opposed to just the click), it implies that there is regurtitant flow and these patients are then generally considered candidates for bacterial endocarditis before procedures which can induce bacteremia. This includes dental extraction!

Category: Cardiology

Title: fondaparinux in ACS

Keywords: fondaparinux, anticoagulation, acute coronary syndromes (PubMed Search)

Posted: 9/2/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Fondaparinux is a selective factor Xa inhibitor. Benefits of fodaparinux vs. heparin when anticoagulants are used in ACS: 1. It is not associated with heparin induced thrombocytopenia. 2. Significant reduction in 30-day and 6-month mortality vs. enoxaparin. 3. Significant reduction in bleeding complications. 4. Safer in patients with renal insufficiency vs. enoxaparin. Unfractionated heparin should be continued while the patient goes for PCI.

Category: Cardiology

Title: Acute Coronary Syndrome (our number one area of liability) [Part 2]

Keywords: ACS, Legal, documentation (PubMed Search)

Posted: 9/1/2007 by Michael Bond, MD (Updated: 4/25/2024)
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Acute Coronary Syndrome (our number one area of liability) [Part 2]

Describing the character of the pain is the most common element of the history (Braunwald and Lee & Goldman).
The history is the threshold issue and determines whether the patient enters risk stratification (Braunwald).
The most atypical features of chest pain are sharp, pleuritic and positional pain.
One-third of all patients with an MI have no chest pain.
One set of cardiac enzymes violates a strong national standard of practice.
Serial enzymes do not rule out unstable angina.
If discharging a patient, document why you felt the patient did not have ACS.
The plaintiff attorney literature advises litigators to focus on the history.

Thanks again to Larry Weiss, MD, JD Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Category: Cardiology

Title: GPIIB/IIIA inhibitors in NSTE-ACS

Keywords: GPIIB/IIIA inhibitors, acute coronary syndrome, antiplatelet medications (PubMed Search)

Posted: 8/26/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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The 2007 ACC/AHA Guidelines for management of patients with unstable angina and non-STEMI were just released. They once again suggest the use of abciximab (Reopro) as the preferred glycoprotein receptor antagonist in patients that are going for PCI. If there is an anticipated delay to PCI, then eptifibatide (Integrilin) or tirofiban (Aggrastat) are preferred. The best evidence for these medications is in patients being managed invasively rather than just medically.

Category: Cardiology

Title: ACS and cardiac risk factors

Keywords: acute coronary syndromes, cardiac risk factors (PubMed Search)

Posted: 8/19/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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The presence of "classic" cardiac risk factors (i.e. risk factors identified in the Framingham studies) is most useful for predicting the long-term risk of developing CAD, but they have limited utility at ruling out acute coronary syndrome. A recent study (ref below) from the CRUSADE registry (multicenter registry including tens of thousands of patients with ACS), for example, demonstrated that 10.5% of patients with proven non-STE MI had NONE of the traditional cardiac risk factors. NEVER rule out ACS just because a patient has few or no cardiac risk factors. The decision to admit and risk stratify patients should always be based on your HPI (OLDCAAR). [Roe MT, Halabi AR, Mehta RH, et al. Documented traditional cardiovascular risk factors and mortality in non-ST-segment elevation myocardial infarction. Am Heart J 2007;153:507-514.]

Category: Cardiology

Title: amiodarone agony

Keywords: amiodarone, adverse effects, arrhythmias (PubMed Search)

Posted: 8/12/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Times when amiodarone should be avoided in wide complex tachycardias: 1. prolonged QT or torsade de pointes -- amiodarone prolongs QT and may induce torsade or cause torsade to become intractable 2. pregnancy -- amio is the only class D antiarrhythmic...use anything else, even electricity! 3. rapid Afib with WPW -- the only published literature says this causes hemodynamic deterioration 4. AIVR -- turns it into asystole...a clean kill! 5. pseudo-VTach caused by hyperK, TCAs, and similar meds -- these are actually not VT but just wide complex tachycardias (that look like VT) caused by poisoned sodium channels...amiodarone further blocks the sodium channels and can cause asystole 6. pulseless VT or VFib cardiac arrest -- you won't actually make the patient worse, but the ONLY evidence indicates that all amio does is increase survival to ICU without improved mental status and without increasing survival to discharge...so essentially you take up more ICU beds and increase costs

Category: Cardiology

Title: heparins in ACS

Keywords: enoxaparin, heparin, bleeding, complications (PubMed Search)

Posted: 8/5/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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The risk of bleeding complications related to enoxaparin increases in patients with renal insufficiency. In fact, many recommend that unfractionated heparin be used instead of low molecular weight heparin in these patients because there is more safety data regarding unfractionated heparin. If enoxaparin is used, the dose should be cut in half (or given only once per day instead of every 12 hours) when the GFR is < 30 mL/min (GFR can be easily calculated by google-able GFR calculators on the internet).

Category: Cardiology

Title: post-MI complications

Keywords: myocardial, infarction, complications, papillary, VSD, murmur (PubMed Search)

Posted: 7/29/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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Post-MI patient develops acute pulmonary edema + hypotension + new systolic murmur = VSD or paplillary muscle rupture Treatment = inotropic support + afterload reduction (as tolerated) + OR ASAP (balloon pump is temporizing)

Category: Cardiology

Title: hyperglycemia and ACS

Keywords: hyperglycemia, ACS, STEMI, coronary, ischemia (PubMed Search)

Posted: 7/22/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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--50% of all STEMI patients have elevated admission glucose levels (>140 mg/dL) --hyperglycemia at the time of admission is an independent risk factor for in-hospital and 1-year mortality in patients wih STEMI --hyperglycemia induces reduced microvascular perfusion and has adverse effects on platelet function, fibrinolysis, and coagulation --tight control of glucose levels during and after STEMI is recommended by the ACC/AHA guidelines and appears to lower acute and 1-year mortality rates

Category: Cardiology

Title: treatment of acute pericarditis

Keywords: pericarditis, treatment, colchicine, steroids (PubMed Search)

Posted: 7/15/2007 by Amal Mattu, MD (Updated: 4/25/2024)
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-Most patients with acute pericarditis are effectively treated with high-dose aspirin or NSAIDS + colchicine - Aspirin dose: 2-4 gms/day - Colchicine dose: 1-2 mg for first day, then 0.5-1 mg/day for 3 months - The use of steroids in first-time acute pericarditis should be avoided, as it has been found to increase the chances of recurrence

Category: Cardiology

Title: Acute Pericarditis

Keywords: Pericariditis, TB, Viral (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/25/2024)
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Acute Pericarditis Viral and idiopathic causes account for 80-90% of cases of acute pericarditis (AP) in immunocompetent patients from developed countries. Therefore empiric treatment and extensive search for an underlying cause is unnecessary in the majority of cases we see. However, the etiology of AP in developing countries is very different, with TB-related AP predominating. 70-80% of cases from Sub-Saharan Africa and more than 90% of HIV-related cases of AP are tuberculous. Therefore, in the U.S. tuberculous pericarditis should be strongly considered among immigrants/visitors from developing countries and among patients with HIV.

Category: Cardiology

Title: Dyspnea

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/25/2024)
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Elderly are more likely to present with dyspnea (49% [the most common anginal equivalent]), diaphoresis (26%), nausea and vomiting (24%), and syncope (19%) as a primary complaint. The takeaway point: always get that ECG early in elderly patients with these complaints, even when CP is absent!

Category: Cardiology

Title: Syncope

Keywords: Syncope, CHESS, San Francisco (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/25/2024)
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Syncope Patients with syncope that are considered to be relatively low risk for complications clinically (i.e. those patients that are not clear-cut admissions) should be evaluated for the 5 CHESS criteria (from the San Francisco Syncope Rules). If they meet none of those criteria, then they are considered to be at very low risk for short-term adverse outcomes and they can be discharged for outpatient follow-up. If they do have any CHESS criteria, they are considered to be at higher risk and admission should be strongly considered. CHESS criteria: history of CHF, hematocrit < 30, ECG abnormalities, shortness of breath, presenting systolic pressure < 90.

Category: Cardiology

Title: Cardiac Output After Age 35

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/25/2024)
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After the age 35, cardiac output decreases by approximately 1% per year. That means that elderly patients are at much higher risk for CHF, especially when they are stressed in some way. CHF can develop in the elderly as a result of any stype of infection or other non-cardiac insult. If decompensated CHF is diagnosed in an elderly patient, don't forget to evaluate the patient carefully for potential non-cardiac causes.