UMEM Educational Pearls - Cardiology

Etiological agent is the parasite Trypanosoma cruzi

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Autoantibody-associated congenital heart block (CHB), also know as neonatal lupus, is responsible for the majority (~60-90%) of CHB

This is secondary to maternal antibodies that cross the placenta and may disappear postnatal

Neonatal lupus can result in diffuse myocardial disease both with and without conduction disturbances, structural defects, and electrophysiologic anomalies

Overall mortality is up to 30%, with 15% mortality before 3 months of age

More than 65% of surviving newborns require pacemakers

Maternal screening and fetal echocardiography has allowed routine prenatal diagnosis 

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Aortic valve (AV) stenosis associated with gastrointestinal angiodysplasia

Proteolysis of Von Willebrand (type 2A) as it passes through the stenotic valve is one culprit of bleeding

Hemostatic abnormalities e.g. GI bleed are often corrected after AV replacement

Valve replacement is only recommended for cardiac symptoms

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Which patient has a better blood pressure, the patient with a blood pressure of 110/40 or the patient with a blood pressure of 90/60?

Mean arterial pressure (MAP) is generally considered to be the organ perfusion pressure in an individual. Because MAP requires an inconvenient calculation, we've all been taught...misled perhaps...into focusing on systolic blood pressure (SBP) as a marker of how well-perfused a patient is, and we tend to ignore the diastolic blood pressure (DBP).

It's important to remember, however, that we spend most of our lives in diastole, not systole. As a result, our organs spend more time being perfused during diastole than systole. The MAP takes this into account: MAP = (SBP + DBP + DBP)/3. DBP is more important than SBP!

So which patient is perfusing his vital organs better, the one with a BP of 110/40 or the one with a BP of 90/60? Do the MAP calculation...90/60 is better than 110/40!

Pay more attention to those diastolic BPs!

Lyme disease is the most prevalent arthropod zoonosis in the Northern hemisphere

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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)

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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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Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (typically asymmetric) that occurs in the absence of pressure overload or storage/infiltrative disease.

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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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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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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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[Pearls provided by Dr. Semhar Tewelde]

Cocaine...
1. causes systolic and diastolic dysfunction, arrhythmias, and atherosclerosis even in young users with relatively few cardiac risk factors, typically TIMI risk score <1

2. decreases myocardial contractility and ejection fraction by blocking sodium and potassium channels within the myocardium

3. prolongs the PR, QRS, and QT intervals on the ECG

4. users have a higher overall incidence of MI (odds ratio 3.8 to 6.9)

5. -induced chest pain is associated with acute MI in approx. 6% of cases

6. increases the risk of MI by 24-fold in the first hour after use

7. contributes to approx. 1 of every 4 MIs  between 18 and 45 years of age

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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

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For patients presenting to the ED with chest pain,  we've been taught that “classic” or “typical” presentations for ACS (chest pressure with radiation to the left neck/jaw/shoulder/arm, dyspnea, diaphoresis, nausea, vomiting, lightheadedness) are most worrisome. Yet, many of the patients that present with typical symptoms end up having negative workups for ACS. What are the symptoms that truly predict ACS? Three major studies have demonstrated that the best predictors of ACS in patients presenting to the ED with chest pain are (not necessarily ranked in order):
1. chest pain that radiates to the arms, especially if the pain radiates bilaterally or to the right arm
2. chest pain associated with diaphoresis
3. chest pain associated with vomiting
4. chest pain associated with exertion

The description of the chest pain (e.g. "pressure" or "squeezing," etc.), the dyspnea, nausea, lightheadedness, and pain at rest were, surprisingly, not helpful at predicting ACS.

The simple takehome point is the following: always ask your patient with chest pain if the pain radiates, if there was associated diaphoresis, if there was associated vomiting, and if the pain is associated with exertion. If the answers to any of these 4 questions is "yes," think twice before labeling the patient with a non-ACS diagnosis.

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New studies are utilizing mild therapeutic hypothermia as a treatment option in cardiogenic shock. These studies have reported improved circulatory support, an increase in systemic vascular resistance, and reduction in vasopressor use which ultimately may result in lower cardiac oxygen consumption. The preliminary results suggest that mild therapeutic hypothermia could be a therapeutic option in hemodynamically unstable patients independent of current recommendations which support its use in cardiac arrest survivors.

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[pearl provided by Dr. Semhar Tewelde]

Myocarditis is an under-diagnosed cardiac disease resulting from a broad range of infectious, immune, and toxic etiologies

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[pearl provided by Dr. Semhar Tewelde]

Peripartum cardiomyopathy (PPCM) is a relatively rare idiopathic form of heart failure that occurs during the last months of pregnancy or the first months after delivery

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