Cardiology

Study Guide by Specialty (formerly PennHSPPrimer.com)
Cardiology

Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.

Code Blue: Pulseless VT/VF/PEA/Asystole

Causes: 6H’s (hypovolemia, hypoxia, hypothermia, hypoglycemia, hypo/hyperkalemia, hydrogen acidosis) or 6T’s (thrombosis, tachycardia, trauma, tension pneumothorax, tamponade, toxins)
If no pulse: start CPR x 2 minutes, bag valve mask ventilation, place defibrillator pads, and get IV access
Both scenarios can get pulse/rhythm checks every 2 minutes, epinephrine 1mg IV every 3-5 minutes, and treatment of reversible causes
If pulseless VT or Vfib go ahead then defibrillate (unsynched) and continue defibrillating during pulse/rhythm checks. Pulseless VT or Vfib can get amiodarone 300mg bolus, second dose can be 150mg.
If PEA arrest or asystole do not defibrillate.
ROSC (return of spontaneous circulation): if has a mental status then do not cool, if does not have mental status then do head CT to ensure no bleed and consider hypothermia protocol

Bradyarrythmias

Get EKG first to see if sinus bradycardia or heart block
Sinus bradycardia with hypotension/shock, loss of consciousness: atropine 0.5mg IV then 0.5mg-1.0mg in 3-5 min then 0.5mg-1.0mg in 3-5 min, dopamine (2-10 mcg/kg/min or epinephrine (2-20 mcg/kg/min) infusion; transcutaneous pacing (with fentanyl/midazolam)
First degree heart block (PR interval > 200) or second degree heart block Mobitz type 1 (PR intervals get longer then dropped beat): no intervention
Second degree heart block Mobitz type 2 (PR intervals are unchanged then dropped beat) or complete heart block (PR intervals variable because P and QRS are not synched): directly to transcutaneous pacing (with fentanyl/midazolam)

Tachyarrhythmias

First question: narrow complex QRS (Afib/SVT/sinus tachycardia) or wide complex QRS (VT/Vfib).
Second question: pulse (Afib/SVT/sinus tachycardia/VT) or no pulse (pulseless VT, Vfib, PEA, asystole)
See above for code situation tachyarrhythmias
Sinus tachycardia is usually gradual on telemetry where as Afib/SVT/VT/Vfib are usually sudden on telemetry
Stable = relatively normal respirations, normal mental status, normal blood pressure, no severe chest pain: treat medically
Unstable = agonal/severely tachypneic, depressed mental status, hypotensive, or chest pain: shock right away
Stable atrial fibrillation with rapid ventricular response (stable Afib with RVR): give metoprolol 5mg IV every 5 min up to 3 times, then can give diltiazem 10-20mg IV every 5 min up to 3 times (careful in CHF patients). If resolves, start PO of metoprolol or diltiazem, whichever broke the Afib RVR. Goal HR<110. If persistent, give amiodarone IV bolus 150mg and start amiodarone drip 1mg/min.
Unstable atrial fibrillation with rapid ventricular response (unstable Afib with RVR): proceed directly to synched cardioversion
Stable supraventricular tachycardia (stable SVT): try vagal maneuver (blow into syringe, cold water towel over face, bear down like a bowel movement), then try carotid massage (only one side at a time, no collaterals), if unsuccessful then place backboard and push adenosine (1st dose 6mg, 2nd dose 12mg, 3rd dose 12mg) with warning to patient they will feel flushed/nauseous/impending doom. If no response then synched cardioversion. Suppress future SVT with PO metoprolol. If refractory consider amiodarone 150mg bolus and drip at 1mg/min.
Unstable supraventricular tachycardia (unstable SVT): proceed directly to synched cardioversion

New Atrial Fibrillation/Afib

Post-operative stress, sepsis, ischemia, CHF, mitral valve regurgitation, pericarditis, lung inflammation (PE, pneumonia, COPD), alcohol, hyperthyroidism
Initial testing: TSH, troponin, urine toxicology, EKG, echocardiogram
CHADS2VASc score: CHF=1, HTN=1, age>65=1 or age>75=2, diabetes=1, stroke=2, vascular disease (MI/PAD)=1, sex category female=1. If 0 can use aspirin, if 1 consider anticoagulant, if 2+ strongly consider anticoagulant
Bridging heparin/warfarin in the hospital: only bridge if has had a stroke before from Afib or if CHADS2VASc score >4-5
If not in Afib RVR: start metoprolol tartrate (12.5-25mg every 6 hours) in the hospital and roll into daily metoprolol succinate ER dose
Stable atrial fibrillation with rapid ventricular response (stable Afib with RVR): give metoprolol 5mg IV every 5 min up to 3 times, then can give diltiazem 10-20mg IV every 5 min up to 3 times (careful in CHF patients). If resolves, start PO of metoprolol or diltiazem, whichever broke the Afib RVR. Goal HR<110. If persistent, give amiodarone IV bolus 150mg and start amiodarone drip 1mg/min.
Unstable atrial fibrillation with rapid ventricular response (unstable Afib with RVR): proceed directly to synched cardioversion

Chest Pain/Acute Coronary Syndrome

Differential for chest pain (most common): cardiac (angina/acute coronary syndrome, pericarditis, aortic dissection, aortic stenosis), pulmonary (pneumonia, pleuritis, pulmonary embolism), GI (esophagitis, GERD, ulcer, esophageal spasm or rupture, pancreatitis, cholelithiasis), musculoskeletal (costochondritis), dermatologic (herpes zoster), or psychiatric (anxiety)
If ST elevations/depressions or dynamic T wave changes: compare with prior EKG and call Cardiology
If unstable angina/NSTEMI/STEMI: aspirin 324mg (chewable 81mg x 4), Plavix (clopidogrel) 300-600mg (based on proximity to left heart catheterization timing, careful if patient has IDDM and may need surgical CABG instead of stent), pain control (nitroglycerin preferred over morphine), heparin bolus and drip (re-bolus with every subtherapeutic PTT and check PTT in 6 hours), beta blocker (metoprolol tartrate to HR 50-60), high dose statin (atorvastatin 80mg or rosuvastatin 40mg), ACE inhibitor (usually at end of hospital stay, can use enalapril or lisinopril). Keep HR 50-60, BP ~120/80 to minimize excess oxygen demand.

Systolic Congestive Heart Failure/CHF

Causes of new systolic CHF or CHF exacerbation: cardiac (ischemia, hypertension, valvular disease, tachyarrhythmias, Takotsubo’s stress cardiomyopathy, myocarditis); systemic (NSAID use, diltiazem use, anthracycline chemotherapy, anemia, hypothyroidism, sleep apnea, renal failure, sarcoid, amyloid, lupus, thiamine deficiency, iatrogenic, genetic); lifestyle (medication noncompliance or inadequate dose, dietary indiscretion, alcohol, cocaine)
New diagnosis initial testing: EKG, echocardiogram, troponin, proBNP, TSH, urine toxicology if drugs suspected
NYHA classification: Class 1 (CHF but no symptoms), Class 2 (slight limitation), Class 3 (marked limitation), Class 4 (significant limitation)
ACC/AHA classification: Stage A (at risk of CHF but no symptoms), Stage B (structural disease but no symptoms), Stage C (structural disease with symptoms), Stage D (refractory needing advanced therapies)
Diuresis: If known home dose, double it and give 1-2 times daily with goal 1-2L net negative. 1.5L fluid restriction with a low sodium diet. Bad kidneys (CKD) mean you need to start at a higher dose to be effective but careful if the patient is diuretic-naive. Lasix (furosemide) PO to IV is 2:1. Bumex (bumetanide) PO to IV is 1:1. Torsemide has no IV option. Some patients need metolazone (thiazide diuretic) given 30 minutes before the loop diuretic (Lasix/Bumex/torsemide) to potentiate the loop diuretic usually metolazone 2.5-5mg daily or MWF but this can also cause significant hypokalemia. Diurese until pulmonary edema is gone, legs not swollen, JVP normalizes, serum bicarbonate (CO2) rises, and/or creatinine rises. Convert to PO diuretic usually less than the IV equivalent based on whether or not the home dose was sufficient. Advise patient to take an extra diuretic dose and call the office if gains 5 pounds in 2 days.
Mortality benefiting therapies: beta blockers (only metoprolol succinate ER, carvedilol, and bisoprolol); ACEI inhibitors or ARBs (enalapril, lisinopril, losartan, valsartan); spironolactone (specific situations), isosorbide dinitrate with hydralazine for African American patients, Entresto (sacubitril-valsartan), biventricular pacing (specific situations)

Diastolic Congestive Heart Failure/CHF

Causes of new diastolic CHF or diastolic CHF exacerbation: longstanding hypertension, aging, hypertrophic cardiomyopathy
Diuresis: If known home dose, double it and give 1-2 times daily with goal 1-2L net negative. 1.5L fluid restriction with a low sodium diet. Bad kidneys (CKD) mean you need to start at a higher dose to be effective but careful if the patient is diuretic-naive. Lasix (furosemide) PO to IV is 2:1. Bumex (bumetanide) PO to IV is 1:1. Torsemide has no IV option. Diurese until pulmonary edema is gone, legs not swollen, JVP normalizes, serum bicarbonate (CO2) rises, and/or creatinine rises. Convert to PO diuretic usually less than the IV equivalent based on whether or not the home dose was sufficient. Advise patient to take an extra diuretic dose and call the office if gains 5 pounds in 2 days.

Flash Pulmonary Edema

Consider in hypertensive emergency with CHF or renal failure
Give diuretic (start with Lasix 40mg IV if diuretic naive, if on diuretics consider Lasix 80mg IV, if CKD/ESRD may need Lasix 120mg IV) but this will take time to work
Give nitroglycerin sublingually (can give drip if needed) to vasodilate, lower BP, and reduce fluid returning to heart/lungs
Give hydralazine IV to arteriodilate, deliver blood to kidneys, and suppress the RAAS activation

Hypertensive Urgency/Emergency

Hypertensive urgency = BP > 180/120 without end organ damage: treat by giving oral medications or if persistent can give IV
Hypertensive emergency = BP > 180/120 with end organ damage (stroke, altered mental status, cardiac ischemia, AKI): treat with IV and possibly drip
IV anti-hypertensives: labetalol 10-20mg IV (preferred if not bradycardic), hydralazine 10mg IV (wears off quicker, don’t use in aortic dissection)
Drip/infusion anti-hypertensives: nicardipine (calcium channel blocker), labetalol (beta blocker), nitroglycerin (nitrate)

Hypertension

For first anti-hypertensive: if diabetic or CKD Cr <3, choose ACEI/ARB. If systolic CHF, choose ACEI/ARB or carvedilol. If African American, choose thiazide or calcium channel blocker. If asthma/COPD/cocaine use try to avoid metoprolol. If CKD try to avoid diuretic, spironolactone and if Cr >3 avoid ACEI/ARB unless on HD.
Categories: ABCD + others
A (ACEI/ARB): lisinopril (10-40mg daily), losartan (25-100mg daily)
B (beta blocker): carvedilol (3.125-25mg daily), labetalol (100-300mg TID)
C (dihydropyridine calcium channel blocker): amlodipine (5-10mg daily), nifedipine (30-90mg daily)
D (diuretic): hydrochlorothiazide (12.5mg-25m daily), spironolactone (25-100mg daily)
Other: hydralazine (25-100mg TID), clonidine (0.1-0.3mg patch every 72hrs or 0.1-0.3mg pill every 8 hours)

Pericarditis

Symptoms/signs: sharp pleuritic chest pain worse laying flat, better when sitting up, may have PR depressions, diffuse ST elevations, usually has a normal echocardiogram
Causes: usually viral, also uremia/renal failure, autoimmune, bacterial/TB, post-MI, chest trauma or surgery
Treatment: preferably NSAIDs with colchicine, or colchicine alone, less preferably prednisone (high risk of recurrence)

Pulmonary Embolism (PE), Deep Vein Thrombosis (DVT)

If have PE, do four extremity dopplers so if clot forms in the future you know if you failed anticoagulation or if the clot was already there
If concern for submassive/massive PE that might need a PE response team consult for catheter-directed thrombolysis or mechanical thrombectomy, check BP (<90/60), troponin, proBNP, echocardiogram, and persistence of severe symptoms even after therapeutic anticoagulation for several days
First provoked DVT/PE: 3 months anticoagulation
First unprovoked DVT/PE: 6 months anticoagulation
Cancer DVT/PE: treat as long as cancer is still active (could be lifelong)
Massive PE, second DVT/PE, autoimmune or hereditary clotting disorder, lifelong immobility, common femoral (very proximal) DVT: discuss possibility of lifelong anticoagulation