management of cardiac diseases. for every ecg, comment on… rate rhythm intervals qrs complex st-t...

Management of Cardiac Diseases

For every ECG, comment on…

• Rate

• Rhythm

• Intervals

• QRS complex

• ST-T wave changes

50M- Asymptomatic but BP 160/95

ECG interpretation

• Rate: 90-95 beats per minute

• Rhythm: Sinus rhythm

• Intervals: PR, QRS, QT intervals all normal

• QRS complex:

– No pathologic Q waves

– QRS complex is too big/tall

• S in V2 + R in V5 >35 mm

• ST-T wave changes: None

ECG Interpretation

• Summary of ECG?

Left ventricular hypertrophy

Hypertension

• Defined as blood pressure >140/90

• In all patients diagnosed with hypertension:

– Look for target organ damage

• ECG (for LVH)

• Urinalysis (for proteinuria) and creatinine

– Look for other cardiovascular risk factors

• Fasting glucose/ Hemoglobin A1C for diabetes

• Lipid profile

Management of Hypertension

• What is the target BP?

–<130/80 for patients with diabetes

–<140/90 for all other patients

Management of Hypertension• Lifestyle changes for all patients

– Exercise 30-60 min for at least 4 days a

week

– Limit alcohol (no more than 2 drinks /

day)

– Low salt <1.5 grams / day

– Reduce stress

Hypertension: Drugs• What drugs you use depends on if

the patient has other diseases (co-

morbidities)Comorbidity 1st choice drugs to

usePast history MI ACE inhibitor and beta

blockersPast history stroke ACE inhibitor +/- thiazide

diureticDiabetes ACE inhibitor first, then

calcium channel blocker (CCB) or diuretic

Hypertension: Drugs

• What if the patient has no other diseases?

A) Isolated systolic hypertension

(Systolic BP >140 but diastolic BP normal

<90)

– Use Thiazide diuretic or Calcium channel blocker

– If BP still high on one of these drugs, then

combine the 2 classes (use diuretic and CCB)

Hypertension: Drugs

• B) Systolic and Diastolic Hypertension

• Start with

– Thiazide diuretic or

– ACE inhibitor or

– Calcium channel blocker (CCB) or

– Beta blocker (BB) or

– Angiotensin receptor blocker (ARB)

Hypertension: Drugs

• If BP still not <140/90 on one of these drugs,

then combine them. Best combinations are:

– Thiazide diuretic + ACE inhibitor

– Thiazide diuretic + CCB

– ACE inhibitor + CCB

• If BP still not <140/90 on 2 drugs, add a 3rd

class

Hypertension: Drugs

• General advice:

– Combining drugs is often more effective than increasing

one drug to its maximum dose

– Don’t combine BB and CCB (risk of complete heart

block)

– Don’t combine ACEI and ARB (risk of hyperkalemia)

– Don’t choose BB first in patients >60 years old

(ok if used in combination, or if used because patient has

comorbidity that should be treated with BB)

Examples of Drugs in Each Class

Drug Class Drug name Typical doses

Thiazide Diuretic Hydrochlorothiazide 12.5-25 mg daily

Chlorthalidone 12.5-25 mg daily

ACE inhibitor Ramipril 2.5-10mg daily

Perindopril 4-8 mg daily

Enalapril 2.5-20 mg BID

Lisinopril 10-40mg daily

Fosinopril 10-40mg daily

CCB Amlodipine 2.5-10mg daily

Felodipine 2.5-10mg daily

Nifedipine (extended release)

30-90mg daily

Diltiazem (extended release)

180-420mg daily

Verapamil (extended release)

120-360mg daily*Start with a dose at the lower end of the dose range

Examples of Drugs in Each Class

Drug Class Drug name Typical doses

Beta Blockers Metoprolol 25-100mg BID

Atenolol 25-100mg daily

Bisoprolol 2.5-10mg daily

Propranolol 40-120 mg BID

Labetalol 100-400mg BID

ARB Losartan 25-100mg daily

Telmisartan 20-80mg daily

Candesartan 8-32mg daily

Valsartan 80-320mg daily

Irbesartan 150-300mg daily

70F with DM presents with chest pain

ECG Interpretation

• Rate: 60 beats per minute


• Intervals: PR, QRS, QT intervals all normal

• QRS complex:

– Pathologic (big) Q waves III, aVF

– QRS complexes normal size

• ST-T wave changes:

– ST elevation II, III, aVF

– ST depression and T wave inversion aVL

ECG Interpretation

• Summary of ECG?

Inferior ST elevation myocardial

infarction

Inferior and Right sided MI

• 30-50% of Inferior MI’s also involve

the right ventricle

• Typically supplied by the same artery

(right coronary artery)

• Always check right sided leads when

you see an inferior MI

Check right sided leads in inferior MI

ECG changes in ST elevation MI (STEMI)

ECG changes in Non ST elevation MI (NSTEMI)

STEMI vs NSTEMI• STEMI: • Entire thickness of the muscle wall is

necrosed• Complete blockage of blood vessel

• NSTEMI:• Only part of the

thickness of the

muscle wall is necrosed

• Partial blockage of

vessel

Management

• Goals of medical therapy:

– Reduce pain

– Prevent further thrombosis

• Antiplatelet agents

• Anticoagulants

– Prevent arrhythmia

– Prevent ventricular remodelling (slows

progression of scarring and ventricular

dilation)

Medications: Pain• Nitrates– Vasodilation of coronary arteries

– Decrease preload (venous vasodilation)

– Decrease afterload (arterial vasodilation)

– Be careful of hypotension (especially with aortic stenosis, right ventricular MI)

• Morphine

• Avoid NSAIDS (e.g. ibuprofen, naproxen)– Increases risk of death, reinfarction, heart failure

Medications: Antithrombotic• Aspirin

– 162-325mg Po chewed x 1 then 75mg-100mg daily

– Patient needs to take indefinitely

– Decreases mortality

– Give as soon as you suspect an MI

• Consider clopidogrel

– 300mg PO x 1 then 75mg daily for 1-12 months

– Small additional benefit

Medications: Anticoagulants

• Heparin

– Decreases risk of death and re-infarction

– If using unfractionated heparin IV,

monitor PTT

– Duration is at least 48 hours

Medications: Preventing arrythmia

• Beta blockers– Decreases mortality and ventricular arrythmias

– Start within 24 hours

– Contraindications

• Acute heart failure

• Heart block

• Asthma

• Hypotension

• No role for antiarrythmics such as lidocaine

• No role for calcium channel blockers

Medications

• ACE inhibitors

– Especially beneficial in those with heart

failure

– Start within 24 hours

– Prevents left ventricular remodelling

Reperfusion

• Especially important for STEMI’s to reopen blockage

• 2 options (if available)

A) Fibrinolytics• If symptoms started less than 24 hours ago

• Contraindications: Uncontrolled hypertension, stroke in last 3

months, previous intracranial hemorrhage

• For STEMI patients only

B) Percutaneous coronary intervention (PCI)• If symptoms started less than 12 hours ago

• If the “door to balloon” time can be less than 90 minutes

• For STEMI patients. Can consider for NSTEMI patients

62M with previous MI. Now short of breath

ECG Interpretation• Rate: 75 beats per minute


• Intervals:

– PR interval wide: First degree AV block

– QRS Wide: RBBB pattern

– QT interval normal

• QRS complex: No pathologic (big) Q waves, Normal size

QRS

• ST-T wave changes: T wave inversion III, aVF

ECG Interpretation

• Summary of ECG?

Right bundle branch block

T wave inversion in inferior leads

Causes of RBBB

• Structural heart disease

– Old MI, ischemia, inflammation,

• High right ventricular pressure

– Lung disease (Asthma, COPD, interstitial lung

disease)

– Pulmonary embolus

• Hypertension

This is his Xray. What is the diagnosis?

Causes of heart failure

• Develops after other diseases damage or weaken the

heart

• The ventricles become weak, dilated and do not pump

blood efficiently through the body (systolic failure)

• The ventricles become stiff and do not fill well

between heartbeats (diastolic failure)


• Coronary artery disease and myocardial infarction

– Ischemia to heart muscle

• Hypertension

– Heart muscle must work harder

• Valvular heart disease

– Damaged valves causes heart to work harder


• Cardiomyopathy

– Damage to heart muscle from infection, alcohol, drugs,

thyrotoxicosis, lupus, or idiopathic (no cause found)

• Myocarditis

– Inflammation to heart muscle from viral infection or

autoimmune disease

• Congenital heart defects

– Healthy parts work harder

New York Heart Association functional classification

Class Definition

I No symptoms

II Symptoms with ordinary activity

III Symptoms with less than ordinary activity

IV Symptoms at rest or with any minimal activity

Drugs used in heart failureDRUG Mechanism of action For

patientAngiotensin converting enzyme (ACE) inhibitors

Dilates blood vesselsDecreases blood pressureImproves blood flowDecreases work of heart

Live longerFeel better

Angiotension II receptor blockers (ARBs)

Same as ACE inhibitor Live longerFeel better

Beta Blockers Slows heart rateDecreases blood pressure

Live longer Feel better

Drugs used in heart failureDRUG Mechanism of action For

patientDigoxin Increase heart muscle

contractionSlows heartbeat

Feel better

Diuretics Increases urinationPrevents fluid accumulation

Feel better

Hydralazine and nitrates

Dilates blood vessels Feel better

Aldosterone antagonist

Reverses scarring of heartPrevents fluid accumulation

Feel betterLive longer

Treatment of acute heart failure

• Supplemental oxygen

• Loop diuretics (e.g. Furosemide)

– Give intravenously in acute heart failure

• Nitrates

– Nitroglycerin (either intravenous or with

patch) or

– Isosorbide dinitrate

Treatment of chronic heart failure

• Educate patient

• Cardiovascular risk reduction

• Lifestyle modification (exercise, decrease stress)

• Limit salt (1-3 gms daily)

• Limit fluid (1.5-2 litres daily)

• Limit alcohol

• Treat cause (ie hypertension, ischemia)

Chronic heart failure: All patients

• Diuretic therapy as needed for symptom relief

• Angiotensin converting enzyme (ACE) inhibitor

– Use ARB if patient cannot tolerate ACE inhibitor. Not both.

• Beta blocker

– Best ones to use are carvedilol, bisoprolol, or metoprolol

– May initially worsen symptoms, so start only once fluid

retention has been treated with diuretics

Chronic heart failure: If NYHA III-IV

• Add digoxin

• Add hydralazine and nitrates

• Add spironolactone

75F with palpitations

ECG Interpretation

• Rate: 150 beats per minute

• Rhythm: Not sinus rhythm

– No p waves

– Irregular

• Intervals: QRS normal, QT normal

• QRS complex: No pathologic Q waves, Normal size

QRS

• ST-T wave changes: None

ECG Interpretation

• Summary of ECG?

Atrial fibrillation

Management of atrial fibrillation

• Example 1- 75 F with palpitations

– On examination, BP = 60/40, HR = 150

– She is diaphoretic and presyncopal

– Is this patient stable or unstable?

• Unstable

– How will you treat her?


Unstable patients

– Urgent electrical cardioversion if

available


• Synchronized cardioversion

– Start with 100 Joules of energy

– There is a risk of stroke with

cardioversion

• Start heparin before cardioversion

• If possible, anticoagulate for at least 4

weeks after


• Example 2- 75 F with palpitations

– On examination, BP = 130/85, HR = 140

– She has no chest pain and feels well

otherwise

– Is this patient stable or unstable?

• Stable

– How will you treat her?


For stable patients:

• Control the heart rate

a) Beta blockers or

b) Calcium channel blockers or/and

c) Digoxin

Management of atrial fibrillation• Beta Blockers (BB)

• Acute: Can use IV

– E.g. Metoprolol 2.5-5mg IV. Can repeat

every 5 minutes to a maximum of 15 mg

over 15min

• Chronic:

–Aim for HR <80 at rest and <110 with

exercise

– E.g. Metoprolol start at 25mg BID (max

100mg BID)


• Beta blockers

– Be careful of side effects:

• Low BP

• Worsening heart failure

• Bronchospasm (especially in asthma

patients)


• Calcium channel blockers (CCB)

– Generally, do not combine with beta blockers

• Risk of complete heart block

– Options:

• Diltiazem start at 30mg QID (maximum 90mg QID)

• Verapamil start at 40mg QID (maximum 90mg QID)

• Amlodipine, Nicardipine, Felodipine, or Nifedipine

do not work to slow down HR


• Digoxin

– Can be combined with BB or CCB

– Not as effective as BB or CCB

– Use if

• HR still not controlled with BB or CCB

• Cannot tolerate BB or CCB (e.g. heart

failure, low BP)


• In example 2, you successfully

control the patient’s heart rate to 70

bpm at rest with metoprolol 50mg

BID.

• She is discharged from hospital


• She comes back to hospital 6 months

later with right sided hemiparesis

• CT head confirms an ischemic stroke


Quality assurance

• Why has this happened?

• Can you think of any strategies that

may have improved her care or

prevented this from happening?


• Anticoagulation for atrial fibrillation

• Afib is associated with ischemic

strokes

– Clots may form in the left atrium

– These clots may embolize to the brain


• Risk factors for stroke:

– Mitral stenosis (**high risk**)

– Previous stroke (**high risk**)

– Age >65

– Hypertension

– Heart failure

– Diabetes

– Female

Management of atrial fibrillation• What can you do to reduce the risk of

stroke?

– Anticoagulants such as warfarin reduces

stroke risk by over 60%

– Aspirin 75-325 mg daily (used

indefinitely) reduces stroke risk by about

30%

• Can combine aspirin with clopidogrel to

further reduce stroke risk but this increases

risk of bleeding


Summary: Chronic stable patients

• Rate control with BB, CCB, or Digoxin

• In any patient with any risk factor for stroke

• If available and can monitor, use warfarin

• If warfarin not available, start aspirin 75-325mg daily

• If at high risk of stroke (>1 risk factor, previous stroke, or

mitral valve stenosis) and warfarin not available, combine

aspirin and clopidogrel 75 mg/day if no bleeding problems

Quiz

• A 50 year old man presents with

central chest pressure. ECG:

Quiz

• Question 1:

What is the diagnosis?

A) Inferior ST elevation MI

B) Inferior non-ST elevation MI

C) Anterolateral ST elevation MI

D) Anterolateral non-ST elevation MI

E) Right sided ST elevation MI

Quiz

• Question 1:

What is the diagnosis?

A) Inferior ST elevation MI

B) Inferior non-ST elevation MI

C) Anterolateral ST elevation MI

D) Anterolateral non-STE elevation MI

E) Right sided ST elevation MI

Quiz

• Question 2 (same patient as question 1):

What medication should not be used to treat the

MI?

A) Metoprolol

B) Diltiazem

C) Aspirin

D) Clopidogrel

E) Morphine

Quiz

• Question 3

A 50 year old diabetic patient sees you in clinic for

control of his hypertension. What is his target BP?

A) 120/70

B) 125/75

C) 130/80

D) 135/85

E) 140/90

Quiz

• Question 4 (same patient as Question 3):

His BP is 150/95. What medication class would you

use first to treat his hypertension?

A) ACE inhibitor

B) Beta blocker

C) Calcium channel blocker

D) Thiazide diuretic

E) Nitrate

Quiz

• Question 5

A 55 year old man is very short of breath. Chest X ray

shows heart failure. What should you not start right away?

A) Loop diuretic (e.g. furosemide)

B) Nitrate

C) Oxygen

D) ACE inhibitor

E) Beta blocker

management of cardiac diseases. for every ecg, comment on… rate rhythm intervals qrs complex st-t...

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