Tribuna
63. RAE (1884)
IX. ACC / AHA GUIDELINES FOR MANAGEMENT OF AMI (Medicine Notes) Initial Recognition and Management in the ER
Initial evaluation of the patient ideally should be accomplished within 10 minutes of his / her arrival at the ER
NO more than 20 minutes should elapse before an assessment is made At the ER, patient with Suspected MI should immediately Receive:
O2 Support
SL Nitrates (Defer if BP < 90 or HR < 50)
Adequate Analgesia (Morphine or Mependine)
ASA 160-325mg orally
12 L ECG must be done:
o ST Segment Elevation (> 1mV in contiguous leads)
o Presence makes patient a Candidate for Immediate Reperfusion Therapy by Fibrinolysis, PTCA **IMPORTANT Notes:
Acute MI, LBBB = Manage like ST-Segment Elevation MI
NSTEMI = should NOT receive Thrombolytic Therapy 1) Thrombolysis
Greatest benefit initiated within 6 hours from the onset of symptoms
Benefit also observed when begun 12 hours
Associated with High Risk for ICH, which occurs within 1st day of Therapy
Factors that Increase Risk for ICH:
o Age > 65 y/o o BW < 70kg o Systemic HPN
o Administration of Tissue Plasminogen Activator 2) Primary PTCA
May be performed as alternative to Thrombolytics
Provided that it can be accomplished promptly with prompt access to „E‟ CABG HOSPITAL MANAGEMENT
1. First 24 Hours
Confirm MI by Serial ECG and measurement of Cardiac Enzymes
Reinfarction and Death frequently occurs within the 1st 24 hours
Limit Physical Activities for at least 12 hours
Anxiety and Pain – appropriate Analgesics
Prophylactic Antiarrhythmias – NOT recommended in the 1st 24 hours of Hospitalization a. Increased Risk for Embolic Stroke:
o Large Anterior Wall MI **Risk is reduced by Early Administration of Heparin o LV Mural Thrombus
b. Thrombolytics o Streptokinase
o Anisoylated Plasminogen Streptokinase Activator Complex (APSAC) o Urokinase
c. Heparin Administration AFTER Thrombolysis shows:
o Limited evidence of Benefit for Streptokinase, APSAC, Urokinase
o Improved Clinical Outcome with ALTEPLASE – IV at least 48 hours after administration of Alteplase
**NOTE: High Dose IV Heparin – Recommended when PTCA was done d. Medications:
o Aspirin
o IV Nitrates for 24-48 hours after hospitalization
o ACE Inhibitors – should be continued in patients with impaired LV systolic function (EF < 40%) or CHF o On Admission: Lipid Profile, Serum Electrolytes including Mg
2. After 1st 24 Hours
Continue ASA, B-Blocker, ACE-Inhibitor
Patients with MI that is spontaneous or provoked in the days to weeks after AMI should undergo:
o Elective Coronary Angio o Consider PTCA or CABG
However, this does NOT salvage myocardium nor reduce Reinfarction or Death
Thus, reserve the said procedures for survivors who have preserved LV systolic function and spontaneous or provoke Ischemia
X. COMPLICATIONS (Medicine Notes) A. Pericarditis
o Patients with Recurrent Chest Pain
o Should receive High Dose ASA (650mg q4 to 6 hrs)
o Should receive Diuretics and an Afterload Reducing Agent C. Cardiogenic Shock
o Intra-Aortic Balloon Pump
o E Coronary Angio PTCA CABG D. RV Infarction and Dysfunction
o Intravascular Volume Expansion and Inotropic Agent E. Atrial Fibrillation
o Manifestation of extensive LV systolic dysfunction o Hemodynamic Compromise
o Direct Cardioversion
o DIGITALIS to Slow the Ventricular Response F. Ventricular Fibrillation
o Direct Current Countershock G. Monomorphic Ventricular Tachycardia
o Direct Current Countershock if with associated angina and congestion o If NOT, should be treated with:
XI. PREPARATION FOR DISCHARGE
A. Should undergo Stress-Testing Exercise
o Submaximal at 4-7 day; or symptom limited at 10-14 days o This is done to:
Assess patient‟s functional capacity and ability to perform test at home or work
Evaluate efficacy of patient‟s current medical regimen
Stratify risk for subsequent cardiac event B. Long Term Management
o Meds: ASA, Beta-Blocker, Selected Dose of ACE-Inhibitors o Weight reduction
o Diet – Low Fat and Cholesterol (Target LDL < 100mg/dL) o Smoking cessation
o
Formal Cardiac Rehab Program or engage in 20 minutes of exercise at least at level of brisk walking at least 3x per week Temporary Pacemaker Insertion (TPI) Patients with:
o Sinus Bradycardia, unresponsive to meds o Mobitz Type II 20 AV Block
Failed PTCA with Persistent Chest Pains or Hemodynamic Instability
Persistent or recurrent ischemia refractory to meds and NOT candidate for catheter intervention
Cardiogenic Shock and Coronary Artery, NOT amendable to PTCA
Mechanical Abnormality, leading to severe Pulmonary Congestion and Hypotension (eg. Papillary Muscle Rupture, MR, VSD)
RHEUMATIC HEART DISEASE
RHEUMATIC HEART DISEASE
I. RHEUMATIC FEVER (JONE‟S CRITERIA)
Acute Rheumatic Fever (ARF) is a multisystem disease resulting from Autoimmune Reaction to infection with Group-A Streptococci (cardiac valvular damage may persist after other features have disappeared)
RF is a Hypersensitivity Reaction induced by Group-A B-Hemolytic Streptococcus
In RF, Antibodies against M-Proteins of certain strains of Streptococcus Cross-React with Tissue Glycoproteins in the Heart, Joints, and other tissues
A. Major Manifestations
Carditis (40-60%) Pancarditis involving the pericardium, myocardium, and endocardium Migratory Polyarthritis (75%) Most often affecting the ankles, wrists, knees, elbows
Syndenham’s Chorea (<10%) Involuntary jerking movements
Erythema Marginatum Evanescent macular eruption w/ round borders, usually concentrated on trunk Subcutaneous Nodules Found over extensor surfaces of joints
B. Minor Manifestations 1. Clinical:
Arthralgia (joint pains)
Fever
2. Laboratory Findings of:
Elevated Acute Phase Reactants (ESR / CRP)
Prolonged PR interval
PLUS Supporting Evidence of Antecedent Group-A Strep Infection o (+) Throat Culture or Rapid Strep-Antigen Test
o And/or Elevated or Rising Strep-Antibody Test
III. PE OF A PATIENT WITH MITRAL STENOSIS (MS) A. Inspection / Palpation
o Malar flush with pinched and blue facies
o In patients with sinus rhythm and severe pulmonary hypertension or associated tricuspid stenosis, the JVP reveals prominent a waves due to vigorous right atrial systole
o RV Tap (due to enlarged RV) B. Auscultation
o S1 is usually accentuated and slightly delayed
o Splitting of S2 (there is Delayed Closure of Pulmonic Valve) o Opening Snap
o Low pitched rumbling Diastolic Murmur
IV. PERCUTANEOUS TRANSLUMINAL MITRAL VALVE COMISSUROTOMY (PTMC)
Right Atrium Transluminal approach to Left Atrium Mitral Valve (Creates a whole in the septum between the LA and RA)
2 Major Criteria OR
1 Major and 2 Minor Criteria PLUS
Evidence of Preceding Infection
Management of Rheumatic Fever
Diagnostics: include ASO Titer, ESR, CRP, Throat Swab CS, ECG, 2D Echo Treatment
For Infection: Pen-G or Ampicillin IV x 10 days
For Arthritis alone: ASA 75mg/kg/day x 2 weeks (when 1/2 dose – for 2-3 weeks)
For Mild Carditis: ASA 75mg/kg/day x 6-8 weeks, then taper
For Mod to Severe Carditis: Add Prednisone 1-2mg/kg/day x 2-3 weeks; continue both ASA and Prednisone until Normal ESR is reached
For Chorea: Dizepam tab PO Prophylaxis:
Penicillin-G 1.2 M „u‟ q 3-4 weeks RF without Carditis: 5 years until 30 y/o
Penicillin-V 250mg/cap BID RF with Mild Carditis: until 45 y/o
Erythromycin 250mg/cap BID RF with Mod-Sev Carditis: Lifetime
NOTE: JVP vs CVP
JVP is measured from Sternal Angle
CVP is measured from Midclavicular Line
Difference of CVP from JVP is 5 (therefore, 3 + 5 = 8)
Normal JVP = 3cm
Normal CVP = 8cm
INFECTIVE ENDOCARDITIS
INFECTIVE ENDOCARDITIS
I. CLASSIFICATION OF INFECTIVE ENDOCARDITIS (IE)
ACUTE BACTERIAL IE SUBACUTE BACTERIAL IE
Pathogenic Organism Staph. Aureus (Virulent) Strep. Viridans, Enterococci (Less Virulent) Clinical Presentation High Fever, Acute Course Low Grade Fever, Subacute Course
Cardiac Pathology Normal cardiac valves, No Murmurs Damaged Valves, (+) Murmurs Prognosis Fatal in 6 weeks if Untreated Better Prognosis
II. DUKE‟S CRITERIA FOR INFECTIVE ENDOCARDITIS (IE) A. Criteria for Infective Endocarditis
o Two Major Criteria, or
o One Major and Three Minor, or
o Five Minor Criteria using definitions for these criteria as listed below
o Possible Infective Endocarditis: findings consistent with Infective Endocarditis that fall short of the criteria listed above B. MAJOR Criteria
o 1) Positive Blood Culture Results for Infective Endocarditis
Typical Organisms for Infective Endocarditis: Streptococci viridans, HACEK Group, Strep bovis, Staph aureus, or Enterococci recovered from Two or More Blood Cultures
o 2) Either Positive Echocardiography Study result for Infective Endocarditis: Oscillating Intracardiac Mass, Abscess or New Dehiscence of Prosthetic Valve or New Valvular Regurgitation
Or Persistently Positive Blood Culture Results: Microorganism consistent with IE recovered from One or more Blood Cultures drawn more than 12 Hours Apart
C. MINOR Criteria (Mnemonic: PF-VIME)
o 1) Predisposing Heart Condition or Injected Drug User o 2) Febrile Syndrome
o 3) Vascular Phenomena: Arterial embolism, CNS hemorrhage, conjunctival hemorrhage, Janeway lesions o 4) Immunologic Phenomena: Immune-complex Glomerulonephritis, rheumatoid factor, false-positive
VDRL test, Osler‟s nodes, or Roth spots
o 5) Microbiologic Evidence: Positive Blood Culture results, but NOT Positive for Major Criterion o 6) Echocardiogram: Suggestive of Infective Endocarditis, but NOT Positive for Major Criterion III. MANAGEMENT
A. Diagnostic
o Blood CS x 3 Sites; CBC, Crea, U/A, RF o 2D Echo with Doppler, TEE
B. Treatment:
Acute IE 1) NAFCILLIN or OXACILLIN 2g IV q4 or VANCOMYCIN 500mg IV q6 or 1g IV q12 x 4weeks 2) GENTAMYCIN 100-200mg IV, then 80mg IV q8 x 3-5 days
Subacute IE 1) PEN-G 2-4 M „u‟ IV q4 x 4 weeks or AMPICILLIN 2g IV q4 2) GENTAMYCIN 80mg IV q8 x 2 weeks
OTHER CARDIOVASCULAR DISEASES