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

=Congestive Heart Failure=

=Congestive Heart Failure=

* Systolic Dysfunction/HFrEF

* Systolic Dysfunction/HFrEF

** H&P: History of CAD, hypertension, valvular disease, dilated cardiomyopathy (EtOH, Chagas, Coxsackie B), or MI. Dyspnea, PND, orthopnea, cough, hemoptysis, fatigue; S3, 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==

==STEMI==

==STEMI==

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

*Tx: 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'''.

** 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:  

* < 7.5% give moderate dose statin

* < 7.5% give moderate dose statin

|}

|}

=Essential Hypertension=

=Essential Hypertension=

*H&P:  

*H&P:  

*Dx: BP > 130/90 on three separate occasions or BP ≥ 180/1120 or with evidence of end organ damage. Primary/Essential Hypertension (95% of cases). Rule out secondary causes. DDx includes secondary HTN (5% of cases; suspect if patient very young, very old, very high BP, or refractory to treatment), secondary causes listed below:

*Dx: BP > 130/90 on three separate occasions or '''BP ≥ 180/120''' or with evidence of end organ damage. Primary/Essential Hypertension (95% of cases). Rule out secondary causes. DDx includes secondary HTN (5% of cases; suspect if patient very young, very old, very high BP, or refractory to treatment), '''secondary causes listed below:'''

** Endocrine: [[Conn syndrome]] (most common), [[Cushing's syndrome]], [[Pheochromocytoma]], [[Hyperthyroidism]], [[Hyperparathyroidism]]

** Endocrine: [[Conn syndrome]] (most common), [[Cushing's syndrome]], [[Pheochromocytoma]], [[Hyperthyroidism]], [[Hyperparathyroidism]]

** Renal: bilateral [[RAS]], [[PKD]], [[CKD]], '''glomerular disease (nephrotic and nephritic syndromes)'''

** Renal: bilateral [[RAS]], [[PKD]], [[CKD]], '''glomerular disease (nephrotic and nephritic syndromes)'''

** Other: [[Cocaine]], [[OSA]], [[OCPs]], [[Coarctation]]

** Other: [[Cocaine]], [[OSA]], [[OCPs]], [[Coarctation]]

* Tx: For SBP 121-130, start with 8-12 weeks lifestyle modifications and reassess. If SBP 131-139 or DBP 81-89, '''risk stratify based on 10-yr ASCVD risk, if > 10%, start medication, if < 10%, can do trial of lifestyle modifications'''. For stage 2 hypertension (>140/90), '''start treatment with 2 medications.''' When starting medication, start with 1 or 2 agents depending on severity, reassess efficacy every month and up the dose or add another agent as needed. ACEI/ARB (good for kidney protection, don't do both), Dihydropyridine CCB (better for HTN) > non-dihydropyridine CCB (better for rate control), Beta Blockers (cardiac selective (MAN BABES) > non-selective), Thiazide-Like Diuretics > Thiazide-Type Diuretics. For most patients, the combination of ACEI/ARB + CCB is the best, so start with one of these two classes so that the second can be added later for synergy. Special population considerations: [[CHF]] (avoid CCBs, use beta blockers, ACEI/ARBs, spironolactone), [[CKD]] (use ACEI/ARB), Pregnancy (hydralazine, labetalol, nicardipine, methyldopa), post-MI (use beta blockers + ACEI/ARB), Blacks (CCB + thiazide-like diuretic), Cocaine (don't give beta blockers due to unopposed alpha).

* Tx: For SBP 121-130, start with 8-12 weeks lifestyle modifications and reassess. If SBP 131-139 or DBP 81-89, '''risk stratify based on 10-yr ASCVD risk, if > 10%, start medication, if < 10%, can do trial of lifestyle modifications'''. For stage 2 hypertension (>140/90), '''start treatment with 2 medications.'''  

** When starting medication, start with 1 or 2 agents depending on severity, reassess efficacy every month and up the dose or add another agent as needed.  

** ACEI/ARB (good for kidney protection, don't do both), Dihydropyridine CCB (better for HTN) > non-dihydropyridine CCB (better for rate control), Beta Blockers (cardiac selective (MAN BABES) > non-selective), Thiazide-Like Diuretics > Thiazide-Type Diuretics.  

** For most patients, the combination of ACEI/ARB + CCB is the best, so start with one of these two classes so that the second can be added later for synergy.  

** Special population considerations: [[CHF]] (avoid CCBs, use beta blockers, ACEI/ARBs, diuretics, spironolactone); [[CKD]] (use ACEI/ARB); Pregnancy (hydralazine, labetalol, nicardipine, methyldopa); post-MI (use beta blockers + ACEI/ARB, spironolactone); Blacks (CCB + thiazide-like diuretic); Cocaine ('''lorazepam, don't give beta blockers due to unopposed alpha'''); BPH (diuretics, alpha 1 antagonists)

* Hypertensive Urgency BP > 180 + mild symptoms

* Hypertensive Urgency BP > 180 + mild symptoms

* Hypertensive Emergency BP > 180 + ominous symptoms

* Hypertensive Emergency BP > 180 + ominous symptoms

*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