Other Cardio Pearls

 Medications to be avoided in decompensated heart failure: ß-blocker.

 Medical Tx for stable angina: ASA, ß-blocker, CCB, and/or nitrate, Statin. all before coronary
angiography.
 Indications for Sx repair of AAA: >5.5 cm, enlargement >0.5 cm in 1 year, >4.5 cm in a Pt who is
undergoing cardiac Sx for another reason.
 Subclavian's steal Syndrome: Pt presents w/ dizziness & vision changes that worsen w/ the extension of
the left arm, there is also a bruit over the left subclavicular region.
 Subclavian Steal Syndrome: 1st test of choice = ultrasound.
 Bicuspid Aortic valve/Mild Aortic Stenosis= Ejection click followed by an ejection murmur. however the
presence of a normal physiologically split S2 & normal peripheral pulses--> Bicuspid aortic valve.
 Coronary angiography should be performed before elective valve Sx in Pts w/ known or suspected CAD.
 Tx of mild symptomatic mitral stenosis = ß-blocker. Because this will lower the heart rate which will
allow for more time for the blood to flow from the left atrium to the left ventricle.
 Tx of mild mitral stenosis + a fib = Anticoagulation + digoxin/antiarrhythmic's.
 Of soft or Absent aortic component of the S2 = most indicative of Severe aortic stenosis.
 AVS = systolic ejection murmur at the RUSB, (low-volume, slow-raising) carotid pulse = pulses parvus et
tardus, soft S2.
 Pulmonary edema 2/2 Mitral stenosis Tx = IV diuretics + ß-blocker. IV nitroprusside is not indicated due
to much of stenosis.
 Severe aortic stenosis = pressure gradient >40 mmHg, or Valve Area <1 cm.
 New mid-systolic murmur after inferior MI, the murmur is most likely due to papillary muscle dysfunction
= Mitral Regurgitation.
 REMEMBER: Dual antiplatelet (ASA + Plavix/Effient) therapy >>ASA alone.
 Effient (Prasugrel)= CONTRAINDICATED in Pts w/ CVA. This is because prasugrel has hd risk for
intracranial bleeding.
 Atrial fibrillation + Diastolic rumbling murmur = Rheumatic Mitral Stenosis.
 For Pts w/ STEMI who fail fibrinolytic therapy & has Signs of HF, NEXT STEP = Emergent PCI.
ABSOLUTELY NOT repeat fibrinolytic's.
 For Pts w/ STEMI who fail fibrinolytic therapy w/out signs of HF, & it appears to be a small STEMI: MAY
CONSIDER ß-blocker or Plavix.
 Cardiac rehabilitation--> id mortality risk.
 Hypotension in the setting of RV infarction: 1st = IVF, if refractory, Inotropic agents.
 ST-elevation & lead aVR = ACS w/ obstruction of the left main coronary artery.
 In Pts w/ Infective endocarditis + Acute heart failure--> ABX + Urgent Valve Replacement.
 AVNRT = regular, narrow-complex tachycardia W/ Retrograde P waves falling w/in or after the QRS
complex.
 WPW syndrome Tx: (I) Stable = procainamide or Ibutilide. (II) Unstable = Electrical Cardioversion.
 Meds CONTRAINDICATED w/ WPW syndrome = medications that inhibit conduction through the AV node
but not the accessory pathway: Digoxin, Adenosine, ß-blockers, CCB's.
 MCC of severe HTN in young Pts w/ normal thyroid, normal kidneys, normal inflammatory markers, High
Renin activity = Fibromuscular Dysplasia.
 Adenosine should be used at Lower dose in Pts w/ heart transplant, 2nd or 3rd AV block, Sick Sinus
Syndrome w/out pacemaker.
 Stable VT Tx = Amiodarone, Procainamide, Lidocaine.
 Unstable VT Tx = Unsynchronized Cardioversion.
 Presence of: Atrial Tachycardia w/ 2:1 AV block = Digoxin Toxicity.
 Cardiac Lyme disease--> can cause arrhythmias, myocarditis, pericarditis, 1st, 2nd, 3rd degree AV block.
These are reversible w/ Abx.
 Tx of cardiac Lyme disease = IV Rocephin.
 Alpha-blockers (-zosin) ≈ Orthostatic Hypotension.
 In the setting of suspected medication overdose: hypotension, bradycardia, hyperglycemia, metabolic
acidosis ≈ CCB overdose.
 Immunosuppressive therapy is NOT RECOMMENDED routine viral myocarditis. Prednisone is mainly used
for: rapidly progressive HF due to giant-cell, sarcoid, eosinophilic myocarditis.
 REMEMBER: Colchicine & NSAIDs are not used w/ MYOCARDITIS, only w/ pericarditis.
 Type B Aortic dissection = a dissection that involves the descending aorta or the arch distal to the origin
of the left subclavian artery, W/OUT involvement of the Ascending Aorta.
 The presence of WIDESPREAD DEEPLY INVERTED T waves on EKG≈ Intracranial hemorrhage.
 It is okay to give a full/normal dose of ASA + Plavix antiplatelet therapy for NSTEMI, even if Pt has a
history of ischemic stroke.
 HCM murmurs: IMPROVES w/ H in preload (from squatting). WORSENS w/ I in preload (Valsalva).
 NSTEMI, Goal for coronary angiography = 24 hours.
 Ebstein Anomaly = ventricular displacement of the tricuspid valve resulting in a regurgitant or stenotic
valve & a small right ventricle. In 80% of the Pts, there is a PFO or ASD present permitting right-to-left
shunting of blood.
 Ebstein Anomaly is correlated w/ WPW syndrome.
 Tx of Recurrent Malignant Pericardial Effusion = Sx Subsxiphoid Pericardiotomy.
 The most appropriate stress test for Pt w/ an uninterpretable EKG = Myocardial perfusion imaging
(Exercise nuclear stress test), or, Echo imaging during stress.
 Elective procedures for Pts w/ chronic asymptomatic afib is okay, as long as HR <110.
 Pts w/ mechanical valve on warfarin w/ therapeutic INR, they NEED ASA as well.
 Pts w/ congenital cyanotic heart disease, will need Antibiotic prophylaxis 1 hr prior to dental work.
 Most appropriate Next test for a Pt w/ unexplained recurrent syncope, w/ normal echo & normal event
recorder = Tilt-Table Test.
 In Pts w/ secondary Hemochromatosis, Iron Chelation therapy has been shown to improve survival.
 Acute heart failure w/ atrial arrhythmia in a young Pt w/in 2 years after heart transplant = Acute
Allograft Projection.
 Postpartum cardiomyopathy: HF occurring w/in 4-5 months after giving birth.
 REMEMBER: Cardiac Sarcoidosis will COMMONLY have normal myocardial biopsy.
 Pt w/ SOB, history of scleroderma, physical exam: Accentuated P2 heart sound, right ventricular heave,
& evidence of right heart failure. DIAGNOSIS = Pulmonary Artery Hypertension.
 1st line diagnostic testing for Chagas disease = Serological testing for IgG ab to Trypansoma Cruzi.
 Tx of Symptomatic Atrial Myxoma = Sx Excision.
 Pt w/ intermittent fevers, progressive dyspnea, early diastolic sound followed by mid--diastolic murmur
at the apex = cardiac Myxoma.
 Tx of Asymptomatic Long-QT Syndrome = ß-blocker.
 Indications for ICD in Pts w/ Long-QT Syndrome = past MI, symptomatic while on ß-blocker, QTc >500.