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