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Cardiology Part 3 (Pericardial, Arrythmias) (Pericardial Disease chapter…

- - - - Three components may be auscultated, attributable to atrial systole, ventricular systole, and early rapid ventricular diastolic filling. Pericardial rub intensity and location can vary, but it is characteristically heard at the left lower sternal border. It is best heard during a held end-expiration with the patient leaning forward
    - - concave upward ST-segment elevation and PR-segment abnormalities, with elevation in lead aVR and depression in all other leads. PR-segment abnormalities are due to atrial involvement
    - - to rule out concomitant pericardial effusion
    - - done by pericardiocentesis, will give diagnosis
    - - aspirin, 650-1000 mg every 6 to 8 hours; ibuprofen, 400-800 mg every 8 hours; indomethacin, 50 mg every 8 hours). Slow tapering over a period of 2 to 4 weeks is recommended to reduce the risk of recurrent inflammation or cholchinie, glucocorticoids only if refractory.
        rule out hemodynamically unstable effusions and atrial fibrillation/flutter
    - - with prominent x and y descents.
  - - - 15-50 mL
    - - breast and lung
    - - The fall in left ventricular stroke volume during inspiration manifests as a relative decrease in pulse pressure or peak systolic pressure and is the hallmark finding of pulsus paradoxus (a decrease in the systolic pressure of >10 mm Hg with inspiration)
    - - hypotension, and an elevated jugular venous pressure and pulsus paradoxus.
    - - diastolic collapse of the right atrium and right ventricle, ventricular septal shifting with respiration, and enlargement of the inferior vena cava. With Doppler echocardiography, respiratory variation in mitral inflow can be detected early in the evolution of tamponade
    - - IV fluids normal saline and vasopressors
        
        No diuretics - with exacerbate hemodynamic abnormalities
        
        Pericardiocentesis
      - which patients should tx be avoided in
        
        aortic dissection, can exacerbate dissection and increased
        ventricular outflow
      - surgical therapy
        
        pericardial window
- - - - elevated intracranial pressure, hypothyroidism, hyperkalemia, Lyme disease, and medication effects (most commonly AV nodal blockers, especially β-blockers and digoxin).
    - - trained athletes or during sleep, sinus variation (faster with inspiration)
    - - inappropriate or pathologic sinus bradycardia (sinus node dysfunction) is age-related myocardial fibrosis in the vicinity of the sinus node
    - - First degree
        
        PR prolonged past 200 msec
      - second degree
        
        Mobitz I
        
        prolonges and then drops
        
        Mobitz II
        
        drops randomly
        
        2:1
        
        When 2:1 block is present, Mobitz type 1 versus type 2 block cannot be differentiated
      - Third degree
        
        complete dissociation
        
        physical exam finding
        
        cannon a waves
    - - symptomatic bradycardia without reversible cause
        
        asymptomatic bradycardia with significant pauses (> 3 second sinus) or persistent heart rate < 40/min
        
        atrial fibrillation with 5 second pauses
        
        complete heart block, Mobitz 2
        
        alternating bundle branch
  - - - termination can be done with
        
        carotid, Valsalva, immersion cold water
      - medication
        
        adenosine (6 mg, 12 mg, 12 mg)
      - symptoms of PAC
        
        Symptomatic PACs are typically treated with β-blockers or calcium channel blockers
      - anti-arrhythmics for SVNRT
        
        flecainide or propafenone are contraindicated in patients with structural or ischemic heart disease.
      - classification typesq
        
        Short-RP tachycardias include typical AVNRT, AVRT, and junctional tachycardia
        
        Long-RP tachycardias include atypical AVNRT, sinus tachycardia, atrial tachycardia, and the permanent form of junctional reciprocating tachycardia.
      - treatment of symptomatic PAC
        
        Symptomatic PACs are typically treated with β-blockers or calcium channel blockers.
      - What to look for in AVNRT (slow-fast)
        
        This leads to a short RP interval with a retrograde P wave inscribed very close to the QRS complex. The closely coupled retrograde P waves may be buried in the QRS complexes and may not be visible, or they may appear as a pseudo R′ wave in lead V1 and a pseudo S wave in the inferior leads
        
        antiarrhytmic therapy
        
        in people who can't tolerate BB/CCB, ablation - flecainide or propafenone are contraindicated in patients with structural or ischemic heart disease.
      - name the two irregular rhythms
        
        MAT (multiple different P waves) vs. a.fib
    - - difference between paroxysmal and persistant/long standing
        
        parosysmal spontaneously terminates
        persistent - longer than 7 days
        long -standing at least 1 year
      - less than 48 hours
        
        no need for preprocedural cardioversion
      - greater than 48 hours
        
        will need 3 weeks of anticoagulation prior to procedure
        or TTE performed to look for thrombus and if not there go ahead
      - post procedure
        
        needs to be anticogulated during and 4 weeks after
      - treatment for WPW with afib
        
        procainamide, avoid block AV node (should not be used) because this can get ventricular fibrillation
      - urgent hemodynamically compromised
        
        synchronized cardioversion
      - anti-arrythmics
        
        . Class IC agents (flecainide, propafenone) or ibutilide (an intravenous class III medication) can be considered for pharmacologic cardioversion in patients without structural heart disease.
      - antiarrhythmic
        
        Class IC agents (flecainide, propafenone) or ibutilide (an intravenous class III medication) can be considered for pharmacologic cardioversion in patients without structural heart disease.
      - known complication of ablation
        
        intraprocedural or late tamponade, vascular, stroke, and pulmonary vein stenosis (unexplained dyspnea afterwards)
        
        HR managment
        
        goal is less than 80, AV nodal blockade (dilt drip or metoprolol)
      - atrial flutter originates around the
        
        tricuspid annulus
      - if unstable
        
        then synchronized (100J/200 J)
    - - Class I affect
        
        Na channels
        
        avoid in
        
        CAD, structural heart disease
      - Class II affect
        
        Beta blockade
      - Class III
        
        K blockade
        
        avoid in
        
        CKD
        
        main issue
        
        prolongs the Qtc and thus needs to be initiated in the hospital
        check K and Mg
      - Class IV
        
        Calcium channel
      - amiodorone use in?
        
        Stuctural heart disease and Heart failure,
        
        main problem
        
        thyroid toxicity, hepatotoxicity, lung toxicity, photosensitivity, corneal and lenticular deposits, optic neuropathy, and other neurologic adverse effects. Patients on amiodarone require routine monitoring of thyroid and liver function, pulmonary function testing at baseline and with symptoms, and periodic ophthalmologic evaluation.
    - - EKG
        
        multiple etiology of P waves, irregular
      - acute treatment
        
        Magnesium supplementation (2 grams over 15 minutes and infuse 6 grams over 6 hours) even if normal magnesium, can use metoprolol or diltiazem
    - - if stable
        
        determine if VT or non VT
        
        if VT, then IV amiodarone, if not VT, then IV adenoside
    - - electryolyte disturbances
        
        Mg, Ca, K
      - Qtc prolonged definition
        
        500 msec
      - Treatment
        
        IV Magnesium 2 mg then 2mg-4mg/min infusion, goal to raise 0.5 mEq/L