UMEM Educational Pearls - Cardiology

Title: AMI versus Aneurysm

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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AMI versus Aneurysm For ECG distinction between AMI versus ventricular aneurysm, look for reciprocal changes and height of T-waves: 1. Reciprocal ST depression strongly favors AMI. 2. Large T-waves in leads with Q waves and STE is likely AMI. Ventricular aneurysm usually gives you "blunted" or flat T-waves in those leads.

Category: Cardiology

Title: Non-ACS causes of elevation troponins

Keywords: Troponin, cause, Non-ACS (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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Non-ACS causes of elevation troponins: 1. acute PE 2. Stanford A aortic dissections 3. acute heart failure 4. strenuous exercise (e.g ultra-endurance activities) 5. cardiac toxins 6. ablation therapy/cardiversion 7. cardiac infiltrative diseases 8. post-heart transplant (may persist up to 3 mos) 9. cardiac contusion 10. sepsis 11. rhabdomyolysis

Category: Cardiology

Title: Ventricular dysrhythmias in pregnanc

Keywords: Dysrhythmia, Pregnancy, Treatment, Procainamide (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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Ventricular dysrhythmias in pregnancy Amiodarone should be considered a last choice in pregnancy. It is the only class D antiarrhythmic, and even short infusions can be associated with fetal hypothyroidism, IUGR, fetal bradycardia, and prematurity. Lidocaine or procainamide are preferred. Also, cardioversion/defibrillation/pacing is considered safe in any stage of pregnancy.

Category: Cardiology

Title: GI Bleed and Myocardial Ischemia

Keywords: GI Bleed, Myocardial Ischemia, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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GI Bleed and Myocardial Ischemia Myocardial ischemia or infarction occurs in up to 20% of patients with significant UGI bleeds. For reasons that are uncertain, the majority of these patients have "silent" MIs (i.e. no pain). It's also unclear whether these patients develop MI purely because of hypoperfusion or because the stress causes a plaque to rupture and thrombose. Whenever you have a patient with a massive UGIB, get an ECG early, regardless of whether or not the patient is having chest pain, and if it's concerning, get cardiology involved early as well. anecdote--I've seen 2 patients with STEMI in the presence of an UGIB, one at Mercy and one at UMMS; neither had chest pain; both got transfused, seen by GI, and went cath within several hours; the takeaway--get both consultants involved EARLY!

Category: Cardiology

Title: Cardiovascular trauma

Keywords: Cardiovascular, CXR, ECG, rupture (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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Cardiovascular trauma Up to 40% of traumatic aortic ruptures/disruptions in patients surviving to the ED will be associated with normal-looking mediastinums on CXR. Therefore, a CTA or angiogram should be ordered purely based on a good mechanism of sudden deceleration.

Category: Cardiology

Title: Rapid Atrial Fibrillation Treatment

Keywords: Afib, Atrial Fibrillation, Treatment (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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Rapid Atrial Fibrillation Treatment 50% of patients with new AF spontaneously convert within 48 hours AF > 48 hours --> chances of spontaneous conversion decreases and chance of embolization increases significantly Most EM texts and lecturers still recommend diltiazem as first line medication for early rate control Patients in whom beta blockers are preferred: AMI, thyrotoxicosis, or if patient is already on BBs NEVER combine IV beta blockers and IV calcium channel blockers --> synergistic effect will cause hemodynamic compromise; start with one type of medication and stay with it

Category: Cardiology

Title: Blunt Chest Trauma

Keywords: Chest, Trauma, Aortic, murmur (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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The most common valvulopathy after blunt chest trauma is acute aortic insufficiency. These patients will present with a new diastolic murmur. Stability depends on the degree of AI. On the other hand, if a chest trauma patient presents with a new systolic murmur, think about acute septal rupture. These patients are much more often unstable, or may die before arrival. These diagnoses may be missed in the unstable patient because physicians focus on the abdomen in the unstable patient. Pay attention to the heart sounds also!

Category: Cardiology

Title: Calcium Affect on ECG

Keywords: ECG, Calcium, hypercalcemia, hypocalcemia (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
Click here to contact Amal Mattu, MD

Calcium's main effect on the ECG appears to be on the duration of the ST segment, such that: 1. Hypercalcemia shortens the ST segment, producing also a short QTc. 2. Hypocalcemia prolongs the ST segment, producing also a long QTc. As an aside, there are only three conditions in which a short QTc is typically noted: hypercalcemia, digitalis toxicity, and a recently described syndrome that causes sudden death--"the short QT syndrome" (in which the QTc may be < 300ms...that's REALLY short!). As another aside, there are only two conditions that prolong the QTc via prolongation of the ST segment--hypocalcemia and hypothermia.

Category: Cardiology

Title: Infective endocarditis (IE)

Keywords: Endocarditis, treatment, vancomycin (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
Click here to contact Amal Mattu, MD

Infective endocarditis (IE) The most common overall cause of IE is Streptococcus viridans. The most common cause of IE in injection drug users is Staphylococcus aureus. The most common cause of IE in patients with prosthetic valves is also Staphylococcus species; in the first two months postop coag-negative Staphylococcus predominates, and after that the most common causes are Staphylococcus aureus, Streptococcus viridans, and enterococcus. In treating IE of prosthetic valves and/or in injection drug users, the addition of rifampin to the standard regimen of nafcillin/vancomycin + gentamycin is often recommended in order to add additional gram positive coverage.

Category: Cardiology

Title: Helpful clues to distinguishing pericarditis vs. STEMI

Keywords: Pericarditis, STEMI, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
Click here to contact Amal Mattu, MD

Helpful clues to distinguishing pericarditis vs. STEMI Pericarditis: PR depression in multiple leads, PR elevation > 2 mm in aVR; friction rub (specific though not sensitive) Remember that PR depression mainly only shows up in viral pericarditis, not other types STEMI: horizontal or convex upwards (like a tombstone) STE, ST depression in any lead aside from aVR and V1, STE in III > II

Category: Cardiology

Title: Cyanide toxicity

Keywords: Cyanide, itroprusside, hypotension (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 10/2/2023)
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Be alert for cyanide toxicity when using sodium nitroprusside * Toxicity from sodium nitroprusside can be seen in as little as 2-4 hours with rates > 4.0 mcg/kg/min * Patients with hepatic and renal dysfunction are at greatest risk * Clinical signs of toxicity include altered mental status (agitation, restlessness), tachycardia, ventricular arrhythmias, and eventually hypotension * The classic anion-gap metabolic acidosis is a pre-terminal event - do not wait for this to develop to raise suspicion of toxicity! Reference: Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:148-9.