UMEM Educational Pearls - Cardiology

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
Click here to contact Semhar Tewelde, MD

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.

Show References

Category: Cardiology

Title: Hypertrophic Cardiomyopathy

Keywords: hypertrophic cardiomyopathy (PubMed Search)

Posted: 8/12/2012 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD

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).


Show References

Category: Cardiology

Title: Takotsubo Cardiomyopathy

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

Posted: 8/5/2012 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD

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 

Show References

Category: Cardiology

Title: Yamaguchi Cardiomyopathy

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

Posted: 7/29/2012 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD

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.


Show References

Category: Cardiology

Title: Atrial Fibrillation

Keywords: Atrial fibrillation, a fib (PubMed Search)

Posted: 7/15/2012 by Semhar Tewelde, MD (Updated: 2/5/2023)
Click here to contact Semhar Tewelde, MD

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 









Show References

Category: Cardiology

Title: cocaine effects on the heart

Keywords: cocaine (PubMed Search)

Posted: 7/1/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

[Pearls provided by Dr. Semhar Tewelde]

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


Show References

Category: Cardiology

Title: Sgarbossa Criteria

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

Posted: 6/24/2012 by Semhar Tewelde, MD (Updated: 7/15/2012)
Click here to contact Semhar Tewelde, MD

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)

Show References

Category: Cardiology

Title: chest pain HPI and predictors of ACS

Keywords: chest pain, acute coronary syndrome, history of present illness, predictor (PubMed Search)

Posted: 6/17/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

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.

Show References

Category: Cardiology

Title: new uses for therapeutic hypothermia

Keywords: hypothermia, cardiogenic shock (PubMed Search)

Posted: 6/10/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD


[pearl provided by Dr. Semhar Tewelde]
Therapeutic Hypothermia... Broadening its use beyond cardiac arrest survivors

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.

Show References

Category: Cardiology

Title: Myocarditis part II

Keywords: myocarditis (PubMed Search)

Posted: 6/3/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

[Pearl provided by Dr. Semhar Tewelde]
The diagnosis of myocarditis is complex. The ECG is a widely used screening tool despite low sensitivity; findings vary from nonspecific T-wave and ST-segment changes to ST-segment elevation mimicking an acute myocardial infarction.

Cardiac biomarkers lack specificity, but may help to confirm the diagnosis of myocarditis; higher levels of troponin T have been shown to be of prognostic value by predicting M&M.
Cardiovascular magnetic resonance (CMR) has evolved as a noninvasive and valuable clinical tool for the diagnosis of myocarditis. The initial changes in myocardial tissue during the first phase of myocardial inflammation represents an attractive target for successful CMR-based imaging diagnosis. The gold standard is endomyocardial biopsy (EMB). The Dallas criteria defines acute myocarditis by lymphocytic infiltrates associated w/ necrosis.

The prognosis ranges from full recovery, development of dilated cardiomyopathy, or death.
Tx strategies remain limited to standard heart failure therapy and supportive therapy. Immunomodulating and immunosuppressive therapy have been effective, particularly in a single-center trial (TIMIC study) in chronic virus-negative inflammatory cardiomyopathy. Immunosuppression therapy is also beneficial for acute giant cell myocarditis, sarcoidosis, and autoimmune diseases, such as lupus carditis.

Show References

Category: Cardiology

Title: myocarditis part I

Keywords: myocarditis (PubMed Search)

Posted: 5/27/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

[pearl provided by Dr. Semhar Tewelde]

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

Symptoms range from asymptomatic, dyspnea (most commonly) and chest pain, to presentations with signs of myocardial infarction, pericardial effusion with cardiac tamponade, to devastating illness with cardiogenic shock
Etiologies to consider 
        Bacteria (tuberculosis, strep pneumonia, chlamydia, legionella, mycoplasma)
        Fungi (candida, aspergillosis, actinomyces, crypotococcus)
        Helminthic (trichinella, echinococcus)
        Protozoal (toxoplasma, trypanosoma)
        Viral (adeno, echo, parvo, entero e.g., coxsackie, HSV, CMV, EBV, HIV)
        Rickettsial (coxiellia,  rickettsia)
        Spirochetes (borrelia, treponema, leptospirosis) 
        Autoimmune diseases (celiac, churg-strauss, crohn's/UC, dermatomyositis, giant cell, 
        lupus, RA, sarcoidosis, kawasaki)
        Toxic reactions to drug (amphetamines, anthracyclines, catecholamines, cocaine, phenytoin)
        Others (ethanol, copper, iron, radiotherapy, thyroid storm)


Show References

Category: Cardiology

Title: Peripartum cardiomyopathy part II

Keywords: peripartum cardiomypathy, cardiomyopathy (PubMed Search)

Posted: 5/20/2012 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

[This week's cardiology pearl provided by Dr. Semhar Tewelde]

PPCM is diagnosed  by echocardiography and increasingly confirmed and complemented with cardiac MRI after the ddx has been ruled-out i.e. pregnancy associated myocardial infarction, valvular heart disease, unrecognized congenital heart disease, hypertensive emergency, amniotic fluid or pulmonary embolism, or pre-eclampsia
PPCM has no histological classification and the role of routine endomyocardial biopsy (EMB) is controversial and remains unclear
Tx includes management of acute heart failure: non-invasive ventilatory/mechanical ventilation, diuretics, vasodilators (nitroglycerine/nitroprusside), inotropes (dobutamine/milrinone), pressors (dopamine), heparin, mechanical circulatory support (IABP, ECMO, LVAD), and finally cardiac transplant 
PPCM has a mortality rate as high as 30%


Show References

Category: Cardiology

Title: peripartum cardiomyopathy

Keywords: peripartum, cardiomyopathy (PubMed Search)

Posted: 5/13/2012 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

[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

By definition, the LV ejection fraction (LVEF) is generally <45% and dilated
LV diastolic assessment often reveals a restrictive pattern, indicating elevated LV filling pressure
Risk factors associated with PPCM  include multiparity, twin pregnancy, extremes of reproductive age, and prolonged tocolysis
The most common presenting symptoms in PPCM include dyspnea, peripheral edema, and fatigue
The ECG typically  demonstrate sinus rhythm or sinus tachycardia
Left bundle branch block develops in up to 50% of cases and based on studies on long term outcomes in patients with systolic heart failure, may serve as a predictor of mortality


Show References

Category: Cardiology

Title: gender and MI mortality

Keywords: mortality, coronary artery disease, myocardial infarction (PubMed Search)

Posted: 5/6/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

Increasing literature over recent years has demonstrated that young women (1) DO have MIs, (2) present more atypically than men, and (3) are more often misdiagnosed than men. Two recent trials have now also confirmed that young women have a higher in-hospital mortality compared to men, even when properly diagnosed. They may be due to lack of aggressive workups or treatment, or perhaps other as-yet unidentified factors.

The takeaway points are simple: be very wary when women (incuding young women) present with any cardiopulmonary complaints or anginal equivalent-type symptoms; and treat them aggressively.

Show References

Category: Cardiology

Title: non-invasive cardiac imaging and radiation

Keywords: radiation, coronary artery disease, stress testing, cardiac testing (PubMed Search)

Posted: 4/29/2012 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

Here's some numbers to consider regarding typical radiation exposre associated with cardiac imaging tests relative to naturally occurring background radiation exposure:

Test type                                                                                     Relative exposure       
Naturally occurring annual background radiation
   exposure for a person living in the US (~ 3 mSv)                                  1
Coronary artery calcium score                                                                0.5
Cardiac CT angiography                                                                         1-4
Nuclear stress test (single-photon emission CT)                                       3-4
Exercise treadmiil testing (with no imaging)                                             0
Cardiac MRI/echocardiogram                                                                   0

[above estimates are typical, but may vary between individuals and among different centers]

Show References

Category: Cardiology

Title: EKG interpretation--who's the expert?

Keywords: ECG, EKG, electrocardiogram, electrocardiography, acute coronary syndrome (PubMed Search)

Posted: 4/23/2012 by Amal Mattu, MD
Click here to contact Amal Mattu, MD


[Pearl provided by Dr. Semhar Tewelde]

Who are the experts at deciphering ECG's

Authors looked at 240 ECGs which activated the cath  lab activation for STEMI.   They excluded patients with LBBB or paced rhythms.  Retrospective chart reviews were used to determine if there was actually a STEMI. The ECGs were then shown to 7 experienced interventional cardiologists and interpreted for acute STEMI.  

Of 84 subjects, there were 40 patients with a true STEMI and 44 without (13 of whom had NSTEMI)  Recommendations for immediate PCI varied widely, from 33%-75%.  Sensitivities were 53%-83%, specificities 32%-86%, PPV 52%-79%, and NPV 67%-79%. When the cardiologist chose non-ischemic ST elevation, LVH was thought to be the cause in 6% to 31% and old MI/aneurysm in 10% to 26%.

Moral, even cardiologists can be wrong... EM physicians must scrutinize every ECG and challenge ourselves to be the best at interpreting ECG's.


Show References

Category: Cardiology

Title: Chest pain after a negative stress test

Keywords: coronary artery disease, acute coronary syndromes, stress test (PubMed Search)

Posted: 4/15/2012 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

(from Dr. Semhar Tewelde)

Stress testing is one modality used to screen for CAD. The goal is to identify a fixed obstruction to coronary blood flow (typically plaque > 50%) such as in stable angina. However, in ACS, both USA and AMI, the underlying pathophysiology is plaque rupture (typically  plaque < 50%) and thrombus formation that may not have been significant enough to cause a positive stress test.

The use of a prior negative stress test to determine the disposition of ED chest pain patients is questionable. The history of present illness should dictate patient disposition. In one study 20.7% of patients presenting to the ED with a negative stress test within three years of presentation still had significant CAD defined as a positive cardiac markers, subsequent positive stress test of any type, cardiac catheterization requiring intervention, or death due to medical cardiac arrest within 30 days of ED presentation.


Show References

Category: Cardiology

Title: The Athlete's Heart Part II

Keywords: athlete, ventricular hypertrophy (PubMed Search)

Posted: 4/8/2012 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

(Pearl provided by Dr. Semhar Tewelde)

Physiological LV hypertrophy in trained athletes is defined by an isolated increase in QRS amplitude, normal axis, normal atrial and ventricular activations patterns, and normal ST-segment T-wave replorization; athletes of African/Caribbean descent have prominent cardiovascular remodeling leading to pronounced voltage criteria for LV hypertrophy and BER

Despite the presence of voltage criteria for LVH, pure QRS voltage criteria for LVH in an asymptomatic athlete without family hx of cardiovascular diseases or SCD, and lack of non-voltage ECG criteria does not warrant systematic evaluation with echocardiography.

In other words, young patients, especially men, especially those of African/Caribbean descent, will be expected to have large voltage QRS complexes and sometimes abnormal repolarization, and this is not necessarily a pathologic finding.

Show References

Category: Cardiology

Title: the athlete's heart and ECGs

Keywords: athlete, electrocardiogram, electrocardiography (PubMed Search)

Posted: 4/1/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

Pearl provided by Dr. Semhar Tewelde

The Athlete's Heart and ECG Abnormalities
Up to 80% of athletes have common training related ECG changes/abnormalities including: sinus bradycardia, asymptomatic sinus pause, sinus arrhythmia, first degree AV block, incomplete right bundle branch block, benign early repolarization (BER), and isolated QRS voltage criteria for left ventricular (LV) hypertrophy.

Approximately 5% athletes exhibit uncommon training unrelated ECG changes/abnormalities including: T-wave inversions, ST-depression, pathological Q-waves, left axis deviation/left anterior fasicular block, right axis deviation/left posterior fasicular block, right ventricular hypertrophy, complete left or right bundle branch block, long or short QT interval, ventricular pre-excitation/WPW, Brugada pattern, and arrhythmogenic right ventricular dysplasia (ARVD).

Show References

Category: Cardiology

Title: cardiogenic shock

Keywords: hypothermia, cardiogenic shock (PubMed Search)

Posted: 3/25/2012 by Amal Mattu, MD (Updated: 2/5/2023)
Click here to contact Amal Mattu, MD

Cardiogenic shock pearls from Dr. Semhar Tewelde:

1. CS is most commonly secondary to a large MI where > 40% of the myocardium is involved; however mechanical, valvular, dysrhythmogenic, and infectious etiologies should also be considered: papillary or chordal dysfunction, free wall or septal defects disease, insuffiency of any valve, myopericarditis, endocarditis, Tako-tsubo, end stage cardiomyopathy, and tamponade.
2. Incidence of 5-10% STEMI and 2.5-5% NSTEMI
3. Mortality ~50%
4. Immediate coronary reperfusion is the best treatment (NNT 8). Medical therapy is a distant second choice in management, with reperfusion and pressors as needed. Early intra-aortic balloon pump use is key.
5. Recent case reports have shown imporved outcomes when induced hypothermia was used in patients refractory to traditional therapy with pressors/inotropes/IABP.