Changes

SA node -> AV node -> bundle of His -> left/right bundles -> Purkinje fibers

SA node -> AV node -> bundle of His -> left/right bundles -> Purkinje fibers

==[[Bradyarrhythmias]] and Conduction Abnormalities==

==[[Bradyarrhythmias]] and Conduction Abnormalities==

*H&P: syncope, nausea, vomiting, blurred vision, dizziness. '''Inferior MI''' can be complicated by symptomatic bradycardia and cardiogenic shock due to ischemia of the SA node leading to an increase in vagal tone.

*H&P: syncope, nausea, vomiting, blurred vision, dizziness. '''Inferior MI''' can be complicated by symptomatic bradycardia and cardiogenic shock due to ischemia of the SA node leading to an increase in vagal tone. Beta blocker toxicity.

*Dx: [[sinus brady]], [[SSS]], [[1st degree AV block]], [[2nd degree AV block (Mobitz 1)]], [[2nd degree AV block (Mobitz 2)]], [[3rd degree AV block]]

*Dx: [[sinus brady]], [[SSS]], [[1st degree AV block]], [[2nd degree AV block (Mobitz 1)]], [[2nd degree AV block (Mobitz 2)]], [[3rd degree AV block]]

*Tx: correct electrolytes/hypothermia, '''atropine/dopamine''', transcutaneous pacing, transvenous pacing, leadless pacing, permanent pacemaker

*Tx: Correct electrolytes/hypothermia, Glucagon for beta blocker toxicity, '''atropine/dopamine''', transcutaneous pacing, transvenous pacing, leadless pacing, permanent pacemaker

 

==[[Tachyarrhythmias]]==

==[[Tachyarrhythmias]]==

*H&P: palpitations, syncope

*H&P: palpitations, syncope

* Systolic Dysfunction/HFrEF

* Systolic Dysfunction/HFrEF

** H&P: History of CAD, hypertension, valvular disease, dilated cardiomyopathy (EtOH, Chagas, Coxsackie B), or MI. '''Dyspnea (most sensitive)''', PND, orthopnea, cough, hemoptysis, fatigue; '''S3 (most specific)''', displaced PMI, crackles, signs of right heart failure (S4, JVD, edema)

** H&P: History of CAD, hypertension, valvular disease, dilated cardiomyopathy (EtOH, Chagas, Coxsackie B), or MI. '''Dyspnea (most sensitive)''', PND, orthopnea, cough, hemoptysis, fatigue; '''S3 (most specific)''', displaced PMI, crackles, signs of right heart failure (S4, JVD, edema)

** Dx: LVEF < 40%, enlarged cardiomediastinal silhouette on CXR, elevated BNP

** Dx: Clinical. Supported by TTE (LVEF < 40%), CXR (enlarged cardiomediastinal silhouette on CXR), and labs (elevated BNP)

** Tx: ACEI/ARBs, ARNIs, β blockers, SGLT2 inhibitors, Spironolactone, and LVAD all have mortality benefit; Digoxin and diuretics don't have any mortality benefit but help with symptoms and decrease hospitalizations. For acute exacerbations use LMNOP (lasix, morphine, '''nitrates''', oxygen, positioning).

** Tx: ACEI/ARBs, ARNIs, β blockers, SGLT2 inhibitors, Spironolactone, and LVAD all have mortality benefit; Digoxin and diuretics don't have any mortality benefit but help with symptoms and decrease hospitalizations. For acute exacerbations use LMNOP (lasix, morphine, '''nitrates''', oxygen, positioning).

* Non-systolic Dysfunction/HFpEF

* Non-systolic Dysfunction/HFpEF

*H&P

*H&P

*Dx:

*Dx:

*Tx: Aim is to preserve or increase LV volume. '''Beta blockers (such as metoprolol) increase filling time and decrease inotropy'''. If patient is intolerant (e.g. asthma exacerbations), '''second line is verapamil''' (non-dhp CCB). If medical management fails, use EtOH septal ablation.

*Tx: Aim is to preserve or increase LV volume. '''Beta blockers (such as metoprolol) increase filling time and decrease inotropy'''. If patient is intolerant (e.g. asthma exacerbations), '''second line is verapamil''' (non-dhp CCB). '''If medical management fails''', use EtOH septal ablation. Sudden cardiac death is prevented with ICD implantation.

==Restrictive Cardiomyopathy==

==Restrictive Cardiomyopathy==

=Acute Coronary Syndromes=

=Acute Coronary Syndromes=

==Unstable Angina/NSTEMI==

==Unstable Angina/NSTEMI==

*Tx: NSTEMI with '''high risk features (refractory pain, TIMI score ≥ 3)''' should get PCI

*Tx: NSTEMI with '''high risk features (refractory pain, TIMI score ≥ 3)''' should get PCI. '''No role for thrombolytic therapy in NSTEMI'''

**'''No role for thrombolytic therapy in NSTEMI'''

** MONA BAsH—'''morphine/metoclopramide (for pain/nausea), oxygen (if SpO2 <95%/breathless), nitrates, ASA, β-blockers (''if LVEF < 40%, HTN, tachycardic, no heart failure''), Antiplatelet (if doing angioplasty/stenting, prasugrel or ticagrelor are preferred agents), (spironolactone?), Heparin (LMWH)'''.  

** MONA BAsH—'''morphine/metoclopramide (for pain/nausea), oxygen (if SpO2 <95%/breathless), nitrates, ASA, β-blockers (''if LVEF < 40%, HTN, tachycardic''), Antiplatelet (if doing angioplasty/stenting, prasugrel or ticagrelor are preferred agents), (spironolactone?), Heparin (LMWH)'''.  

** Send home on 12 months DAPT (if stending/angioplasty performed), ACEI/ARB, and statin.

** Send home on 12 months DAPT (if stending/angioplasty performed), ACEI/ARB, and statin.

==STEMI==

==STEMI==

*Tx: '''PCI within 90 minutes.''' Standard MONA BAsH—'''morphine/metoclopramide (for pain/nausea), oxygen (if SpO2 <95%/breathless), nitrates, ASA, β-blockers (''if LVEF < 40%, HTN, tachycardic, no heart failure''), Antiplatelet (if doing angioplasty/stenting, prasugrel or ticagrelor are preferred agents), (spironolactone?), Heparin (LMWH)'''. Look out for complications (DARTH VADER mnemonic). '''PCI for patients with ST depression on exercise stress ECG test'''. Afib as a complication of MI or cardiac surgery usually '''resolves spontaneously within a few days'''. Send home on 12 months DAPT (if stenting/angioplasty performed), ACEI/ARB, and statin.

*Tx: '''PCI within 90 minutes (door-to-balloon time).''' PCI for patients with '''ST depression on exercise stress ECG test'''.

** MONA BAsH—'''morphine/metoclopramide (for pain/nausea), oxygen (if SpO2 <95%/breathless), nitrates, ASA, β-blockers (''if LVEF < 40%, HTN, tachycardic, no heart failure''), Antiplatelet (if doing angioplasty/stenting, prasugrel or ticagrelor are preferred agents), (spironolactone?), Heparin (LMWH)'''.  

** Look out for complications (DARTH VADER mnemonic).  

** Afib as a complication of MI or cardiac surgery usually '''resolves spontaneously within a few days'''.

=Dyslipidemia=

=Dyslipidemia=

! Group !! Intervention

! Group !! Intervention

|-

|-

| 21+ w/ ASCVD or LDL > 190 || High dose statin

| 21+ '''w/ ASCVD''' or LDL > 190 || High dose statin

|-

|-

| 40+ w/ LDL 70-189 w/o diabetes || Calculate 10-yr ASCVD risk:  

| 40+ w/ LDL 70-189 w/o diabetes || Calculate 10-yr ASCVD risk:  

*H&P: Possible history of recent MI, improved when leaning forward, can have pleuritic chest pain, cardiac rub

*H&P: Possible history of recent MI, improved when leaning forward, can have pleuritic chest pain, cardiac rub

*Dx: Can show calcifications on CXR

*Dx: Can show calcifications on CXR

*Tx: '''High-dose aspirin for post-MI acute pericarditis, otherwise NSAIDs and colchicine for normal pericarditis'''.  

*Tx: '''High-dose aspirin''' for post-MI acute pericarditis, otherwise '''NSAIDs and colchicine''' for normal pericarditis.

 

==[[Cardiac Tamponade]]==  

==[[Cardiac Tamponade]]==  

*H&P: Beck's triad

*H&P: Beck's triad