Screening recommendations: 1) Breast cancer: age 40-74 mammogram q2 2) Lung cancer: adults 55-80 with >30 pack-year smoking hx, current smoker, or quit in last 15 years with low-dose CT scan 3) AAA: age 65-74 with history of smoking via one-time US 4) Colon cancer: age 50-75 colonoscopy q10, or yearly FOBT 5) Cervical cancer: women 21-65 pap smear q3 6) HepC: adults born 1945-65 with one-time anti-HCV antibody 7) HIV: adults 15-65 with one-time HIV Ab screen 8) Osteoporosis: women 65+ with DEXA CARDIOLOGY ARRHYTHMIAS: First degree AV heart block: prolonged PR interval >200 with no dropped QRS. Tx is observation if normal QRS duration or EP testing if prolonged QRS. Second degree Mobitz type I AV heart block/Wenckebach: progressive PR elongation with dropped QRS, block at AV node, atropine improves, vagal maneuver worsens, low risk of complete heart block Second degree Mobitz type II AV heart block: PR interval remains constant, block below AV node, atropine (increases HR) worsens, vagal maneuver improves, requires pacemaker. Third-degree AV block: P-QRS dissociation, refer for pacemaker, and do temporary cardiac pacing in meantime. Can be due to Lyme disease. Multifocal atrial tachycardia: etiology is due to acute exacerbation of pulmonary disease (COPD), electrolyte imbalance (hypokalemia) or sepsis; clinical findings are rapid irregular pulse with >3 P wave forms and atrial rate >100. Tx is underlying issue or AV blockade (verapamil) (rate control) if persistent Premature atrial complexes (PACs): benign but need to stop precipitating factors (tobacco, alcohol, stress) first. If symptomatic, use BB. Supraventricular and ventricular arrhythmias: tx with procainamide esp if WPW syndrome. Flecainide can also be used for SVAs. Supraventricular arrythmias: narrow QRS, tachy, retrograde P waves or absent P waves buried in QRS includes atrial flutter, atrial fibrillation, atrial tachy; rate control with BB or CCB or digoxin. Supraventricular tachycardia: can terminate with carotid sinus massage or adenosine 1) Regular – AVNRT, AVRT, A flutter, A tachy, sinus tachy 2) Irregular – A fib, MAT, A flutter (variable) 3) Causes: drug-induced, 4) Dx: no P waves, narrow complex QRS 5) Tx: vagal maneuver, adenosine if symptomatic, consider BB for ppx Paroxysmal supraventricular tachycardia: 1) Most commonly AVNRT and palpitations is most common presentation. AVNRT is due to a fast and slow pathway that leads to reentry mechanism. Vagal maneuvers (carotid sinus massage, cold-water immersion, Valsalva) increase parasympathetic tone and slows down AV node conduction, terminating AVNRT. 2) Can also be due to AVRT (WPW) or paroxysmal atrial tachycardia. Ventricular fibrillation: chaotic, irregular waveforms with no identifiable P waves, QRS, or T waves. Tx is shock (defibrillation). V fib most common arrhythmia peri-MI responsible for cardiac arrest. Ventricular tachycardia: EKG shows regular, wide-complex tachycardia and can alter jugular venous pulsations (Cannon A waves). Due to reentry in ventricular muscle. Can be due to loop diuretics. Tx with amiodarone/procainamide/lidocaine if stable or synchronized cardioversion if unstable. Torsades de Pointes (TdP): twisting of points, due to acquired QT prolongation, hypokalemia, hypomagnesemia, hypocalcemia 1) Causes: a. Diuretics, macrolides, fluoroquinolones, amiodarone, flecainide, SSRI, haloperidol, ondansetron, methadone 2) Tx: a. Stable – IV magnesium b. Unstable – defibrillation Causes of QT prolongation 1) Electrolytes: hypocalcemia, hypokalemia, hypomagnesemia 2) Medications: a. antiarrhythmics b. antibiotics c. psychotropics, d. opioids (methadone, oxycodone) e. antiemetics 2) Inherited a. Romano-Ward syndrome (auto dominant) b. Jervell & Lange-Nielsen syndrome (auto recessive) Atrial fibrillation: irregular rhythm and absent P waves. Foci comes from pulmonary veins. Treat rate with BB or CCB if stable to get under 110 bpm. If want to tx rhythm cause unstable, then use TTE to make sure no clots and then cardiovert (synchronized) or use flecainide (class 1C drug with slowest rate of binding and dissociation so has “use dependence” at faster heart rates. Widens QRS). CHADS-VASC score determines AC indication (warfarin, apixaban). Afib with mitral stenosis requires warfarin AC regardless of score. Lone Afib is not treated with anything. 1) Causes of Afib include: a. mitral stenosis, mitral regurg, hypertensive heart disease (most common), CAD, hypertrophic cardiomyopathy, ASD, post cardiac surgery, b. Hyperthyroidism is common cause of sudden-onset Afib so need TSH and T4 workup; obesity, alcohol abuse, and drugs (cocaine, theophylline, amphetamines) c. OSA, PE, COPD, acute hypoxia 2) Tx: a. Rate control (ABCD) – amiodarone, BB, CCB, digoxin Atrial Flutter: back-to-back atrial depolarizations that show sawtooth pattern. Tx same as afib (BB, CCB, and anticoagulation) Sinus bradycardia: symptoms are syncope, lightheadedness, and fatigue. Will have hypotension and pulse <50. Tx is oxygen for hypoxemia; if no hypotension, AMS, chest pain, or failure à observe. If have those, give atropine (increases HR). If no response, do transcutaneous pacing or IV dopamine or IV epi. If no response, transvenous pacing. Wolff-Parkinson-White syndrome: paroxysmal supraventricular tachycardia (AVRT) due to accessory pathway (bundle of Kent) that goes from atrium to ventricle bypassing AV node. EKG shows delta waves (preexcitation impulse), short PR interval, ST/T wave abnormalities. Atrial fib can occur in 30%. Can lead to V fib and reentrant tachycardia. Tx with cardioversion if unstable and with procainamide (class IA)/amiodarone if stable. Do not block AV node (avoid carotid sinus massage, BB) since will worsen WPW into atrial fib. AVNRT – reentrant pathway is localized to AV node and goes around and around. AVRT – reentrant is not in AV node (Ex: WPW) Arrythmias: 1) Holter monitoring is for catching intermittent arrhythmias outpatient. MYOCARDIAL INFARCTION: Standard MI therapy includes oxygen if below 90%, nitrates, aspirin, anticoagulation with heparin, beta blockers, PCI if necessary, and statins ASAP. Prompt restoration of flow improves long-term mortality and prevents peri-MI pericarditis. Presents as substernal chest pain, left sided neck pain, diaphoresis, and dyspnea is consistent with ACS. S4 can be heard due to myocardial dysfunction. EKG is first test to dx MI: ST elevations, ST depressions in 2 contiguous leads, T wave inversions, peaked T waves, Q waves are prior infarcts ACS risk factors: DM, HTN, HLD, age, male gender, smoking biggest factor 1) MI acute treatment: requires cardiac enzyme elections a. STEMI- positive troponin, ST elevations i. Oxygen if O2 sat <90% ii. If cath lab available: dual antiplatelet therapy - aspirin and plavix (clopidogrel); beta blocker if not contraindicated, then cath lab within 90 min iii. No cath lab available - do fibrinolytics/alteplase (tPA) iv. DO NOT GIVE NITRATES in RV infarct due to hypotension, but it is ok in LV infarct since decreases fluid in lungs (can also give Lasix for LV infarct). Give fluid bolus in RV infarcts instead, even if euvolemic. b. NSTEMI- positive troponin, no ST elevation i. High risk: cath lab ii. Moderate risk: stress test or pharm test iii. Low risk: nitrates, aspirin, clopidogrel, statin, heparin, BB 2) Stable Angina (no EKG abnormality) – nitrates for sx a. Evaluate for CAD with exercise test b. Betablockers are first line, then CCBs and nitrates c. Do not give nitrates for STEMI since decreases preload and causes hypotension 3) Unstable angina (pain at rest or no improvement with nitroglycerin) – same acute management as NSTEMI, but no ST elevation and negative troponin a. aspirin, clopidogrel, nitrates, BB, AC (heparin), statin NSTEMI long term mortality benefit: dual antiplatelet therapy (aspirin, clopidogrel (P2y12 inh)), BB, statin, ACEi/ARB, aldosterone antagonist (spironolactone, eplerenone) STEMI long term mortality benefit: supplemental O2, aspirin, clopidogrel, nitrates sublingual, BB, statin, anticoagulation. For pulmonary edema, give furosemide. For persistent pain/HTN/CHF, give nitroglycerin. For unstable bradycardia, give atropine. For persistent severe pain, give morphine. Atypical presentations of ACS occur in women, elderly, and DM pt. They may not present with chest pain. EKG is first test. PAD often precedes MI, more so than acute limb ischemia. MI localization 2) Inferior wall MI from RCA occlusion: ST changes in 2,3, aVF and depressions in 1 and aVL. Will see Kussmaul’s sign, JVD, diaphoresis, and clear lungs. Often are RV infarcts, so give IV fluids. i. AV node same supply (RCA) as inferior wall 3) RV MI from RCA (inferior wall MI) leads to ST elevation in V4-V6R. Presents as chest pain, hypotension, but no pulmonary edema. 3) Posterior wall MI from RCA or LCX occlusion leads to ST changes in 1, aVL, V1-V3. 4) Anterior MI from LAD infarct leads to changes in V2-V4 5) Lateral wall MI from LCx leads to changes in 1, aVL, V5, V6 and depression in inferior leads (2,3, aVF) 6) Expecting elevations from depressions: PAILS (anterior depression à look for posterior elevations) Complications of MI: Ventricular fibrillation (reentrant ventricular arrhythmia) within 1 hour and can lead to cardiac arrest. 1) Acute pericarditis – pleuritic chest pain that improves when sitting up, diffuse ST elevation and PR depression. Can occur within a few days (often <4 days). Do echo. Best way to prevent is early coronary reperfusion therapy.
