Cardio

Heart failure:

#CHF 

Stage A | B |C | D, NYHA I |II |III | IV; Warm&wet

Most recent Echo:

 Framingham criteria: (2 major or 1 major and 2 minor);

-Major: PND/orthopnea, JVP/rales/s3, CXR cardiomegaly/pulm edema 

-Minor: peripheral edema, night cough, DOE, hepatomegaly, pleural effusions, HR>120, wt loss >4.5kg in 5d with diuresis 

-Cause: CAD, HTN, infectious (coxsackie/flu/adeno, mycoplasma pna, lyme, HIV/HCV, Chagas), infiltrative (amyloid, sarcoid), endocrine/nutritional, DM, obesity/OSA, thyroid, acromegaly/GH, pheochromocytoma, thiamine/wet beriberi, carnitine/selenium deficiency, hemochromatosis, tachycardia induced, inflammatory (lupus, scleroderma, RA, Churg-Strauss, Giant cell myocarditis, Hypereosinophilia (Loefflers), idiopathic dilated CM, stress induced CM, peripartum CM, familial dilated CM, HCM, radiation CM, toxin induced CM, Etoh induced, chemotherapy induced

-beta blocker:

-ACE/ARB: (indicated if NYHA 2-4 CrCl >30, K<5); ARNI 

-aldosterone antagonist:  (indicated if EF<35 NYHA 2-4; or MI EF<40 with sx of HF or DM)

-Cr <2.5 in men, 2.0 in women; K<5

-patient counseled to avoid high potassium foods (banana, cantaloupe, potatoes, tomatoes) 

-check BMP at 3d, 1 week, monthly for 3 months 

-start spironolactone at 12.5mg daily 

-start eplerenone at 25mg daily if gynecomastia with above 

-SGLT2 per EMPEROR trial

-Bidil (hydralazine/isosorbide dinitrate) if AA and on goal dose ace/arb, bb without recovery of EF

-Digoxin:  (indicated if EF<40, unable to tolerate BB due to hypotension; afib with suboptimal rate control)

-goal level 0.5-0.9 ng/ml2 

-patient counseled to limit sodium to <2g daily, water to 2L daily; exercise 30 minutes 5 times weekly, limit EtOH to 2 drinks weekly; avoid NSAIDs, CCBs, glitazones 

-last iron panel:  ; per 2023 HFSA (https://doi.org/10.1016/j.cardfail.2023.03.025)


Perera D, Clayton T, Petrie MC, Greenwood JP, O'Kane PD, Evans R, Sculpher M, Mcdonagh T, Gershlick A, de Belder M, Redwood S, Carr-White G, Marber M; REVIVED investigators. Percutaneous Revascularization for Ischemic Ventricular Dysfunction: Rationale and Design of the REVIVED-BCIS2 Trial: Percutaneous Coronary Intervention for Ischemic Cardiomyopathy. JACC Heart Fail. 2018 Jun;6(6):517-526. doi: 10.1016/j.jchf.2018.01.024. PMID: 29852933. 

 

  

#Acute Decompensated Heart Failure

Stage A | B |C | D, NYHA I |II |III | IV; Warm&wet

Most recent Echo:

Now with dyspnea, increased edema, oxygen requirement indicating acute decompensation. CXR with ***.

Likely etiology is medication noncompliance, arrhythmia, ischemia, lifestyle change, acute kidney injury, PE, valvular heart disease

-Home diuretic: ___ 

-Per DOSE trial (NEJM 2012), 2.5x home diuretic dose for goal net negative 1-2L 

-Continuous telemetry, strict I/Os (place foley if needed), daily weights, RFP BID 

-Continue home GDMT: ACEi and Beta blocker unless contraindicated

-continue home jardiance (EMPAG_HF trial)

-Continue home hypertension medications: ____ 

-Oxygen support: BNC, CPAP, ? 



#Non-ischemic DCM

CMR ___. No evidence of LV thrombus was seen. RV function ____. Differential based on findings include dilated cardiomyopathy w/ genetic component (LMN v DSP) vs inflammatory dilated CMP 2/2 chronic myocarditis given prominent lymphadenopathy vs less likely sarcoidosis. Evaluation and plan to date:

-CMR w/ T2 completed FEB23

-GDMT

-Familial/genetic: neg 3 generation fam hx, genetic testing pending completion SEP23

-Biopsy: No acute indication

-Arrhythmia: has frequent PVCs, no hx of known conduction dz or tachyarrhythmia

-Metabolic/endocrine/storage: non-obese, TSH xx, CMP wnl, HA1c xx, GH/Acromegaly not indicated by clinical exam, pending genetic for Pompe, for storage trending towards microcytic anemia, no significant eosinophilia

-Rheumatologic: CRP xx and neg ANA/CCP w/ positive RA latex (insignificant given neg ANA), C3 and C4

-Sarcoid: total 1-25-D xx, angiotensin converting enzyme xx, CMR inconsistent w/ sarcoid

-Amyloidosis: neg SPEP and UPEP screen (<24 to trigger test), A/B/G globulin wnl

-Toxic: no significant EtOH or illicit drug history w/ neg tox screen, no hx of chemotx

-Infectious: neg HIV, EBV, chlamydia, Gonorrhea, T. cruzi, HAV reactive IgG, HBV all non-reactive

 


 

Rhythm

#Atrial fibrillation

New-onset/Paroxysmal (terminates within 7 days)/Persistent (7-12 months)/long standing persistent (>12 months)/permanent

Risk factors include ______. Goal HR <110 bpm. Rate vs rhythm control. CHA2DS2-VASc score is ___ which correlates with a ___ % risk of thromboembolic event in one year without anticoagulation therapy, and a HASBLED of ___, which correlates with a __% of major bleeding in one year.  Patient is currently on anticoagulation therapy with ______. No acute issues are noted at this time. 

-TSH/TTE ordered; Alcohol? 

-Continue home rate/rhythm control

-Continue/hold home anticoagulation: 

-Continue with home dose of Coumadin (___ mg M/Tu/W/Th/F/Sa/Su), pharmacy consulted for assistance of dosing while inpatient

-Continue to monitor daily coag panels; will adjust dosing as needed.  

-Continuous telemetry 

 

#Bradycardia

Last EKG without PR/Qtc prolongation

Symptomatic/asymptomatic

TSH, troponin

  

Chest pain and chest pain syndromes:

#Chest pain:  

Differential diagnosis: ACS, pericarditis, aortic dissection, pneumonia, pleuritis, pneumothorax, PE, pulmonary hypertension, esophageal reflux, esophageal spasm, peptic ulcer disease, costochondritis, herpes zoster, anxiety

-Admit to telemetry for cardiac monitoring

-NPO for risk stratification with ____ tomorrow morning; 

-Continue aspirin 81 mg daily

-Monitor q4 hour vitals, and daily EKGs

-Daily CBC and RFPs



Contraindications to exercise EKG include an inability to exercise and baseline ECG abnormalities (e.g., ST-segment depression >1 mm, left bundle branch block, left ventricular hypertrophy, paced rhythm, or preexcitation).


 

#Atypical chest pain/Non-cardiac chest pain

Hemodynamically stable with benign exam, negative troponin x 1, CXR without abnormality, EKG with . History significant for ***. Grace (admission to 6 month mortality after ACS)=   ;TIMI (mortality in ACS)= ;HEART (6week risk of major adverse cardiac event)=  . Last risk stratification showed __. Low concern for ACS given these findings, though patient in need of admission for risk stratification. 

-Continuous telemetry 

-Trend troponins

-EKG qAM and PRN for CP 

-Risk stratification tomorrow with *** 

  

#Elevated troponin

Troponin level **. Not >99th percentile (0.03). Patient without any symptoms of chest pain, dyspnea, etc. Will continue to trend.  

-Continuous telemetry 

-Trend troponins x3 

-EKG qAM and PRN for CP 

  

#ACS - Unstable Angina

Patient with typical chest pain, though no ST elevations on EKG and troponins now increased. TIMI score of *** and GRACE of *** indicating low/intermediate/high risk. Need for early invasive/delayed invasive/ischemia-guided strategy. Cards consulted, appreciate recs.  

- Aspirin 325mg load; 81mg qd thereafter 

-Plavix (for PCI) loading dose of 600mg followed by 75mg PO qd thereafter. (Fibrinolysis) <75yo 

LD of 300mg/>75yo no LD 

- Start heparin gtt for ACS 

-Atorvastatin 80mg PO QD 

-Metoprolol 25-100mg PO q12hrs (hold parameters HR<55, SBP< 90) 

-Captopril 6.25mg PO q8hrs (hold parameters SBP<90)  

-Nitro gtt: 10mcg/min titrate to effect (don't exceed 200mcg/min) 

-LHC *** 

  

#ACS - NSTEMI

Patient with elevated troponin to *** with no ST elevations on EKG. Likely Type II secondary to *** though cannot rule out type I. TIMI score of *** and GRACE of *** indicating low/intermediate/high risk. Need for early invasive/delayed invasive/ischemia-guided strategy. Cards consulted, appreciate recs.  

- Aspirin 325mg load; 81mg qd thereafter 

-Plavix (for PCI) loading dose of 600mg followed by 75mg PO qd thereafter. (Fibrinolysis) <75yo 

LD of 300mg/>75yo no LD 

- Start heparin gtt for ACS 

-Atorvastatin 80mg PO QD 

-Metoprolol 25-100mg PO q12hrs (hold parameters HR<55, SBP< 90) 

-Captopril 6.25mg PO q8hrs (hold parameters SBP<90)  

-Nitro gtt: 10mcg/min titrate to effect (don't exceed 200mcg/min) 

-LHC *** 


In older patients with frailty, routine early invasive strategy did not increase days alive out of hospital at 1 year; consider watchful observation and careful evaluation (PMID: 36877502)

  

#Chronic myocardial injury

Troponin level elevated at ** (above 99th percentile of .04), though is at baseline, likely secondary to **renal failure, etc***. Patient without any chest pain, dyspnea or symptoms of ACS 

-D/c troponin given patient at baseline and without symptoms 

-Troponin, EKG if patient has chest pain.  

  

 #MINS 

Elevated troponin after surgery without symptoms of ischemia