Management of Cardiac Diseases MI HTN Heart failure Renal failure with hyperkalemia

For every ECG, comment on… Rate Rhythm Intervals QRS complex ST-T wave changes

50M- Asymptomatic but BP 160/95

ECG interpretation Rate: 90-95 beats per minute Rhythm: Sinus rhythm Intervals: PR, QRS, QT intervals all normal QRS complex: No pathologic Q waves QRS complex is too big/tall S in V2 + R in V5 >35 mm ST-T wave changes: None

Left ventricular hypertrophy ECG Interpretation Summary of ECG? Left ventricular hypertrophy Hypertension is the most common cause of left ventricular hypertrophy

Hypertension Defined as blood pressure >140/90 In all patients diagnosed with hypertension: Look for target organ damage ECG (for LVH) Urinalysis (for proteinuria) and creatinine Look for other cardiovascular risk factors Fasting glucose/ Hemoglobin A1C for diabetes Lipid profile

Management of Hypertension What is the target BP? <130/80 for patients with diabetes <140/90 for all other patients

Management of Hypertension Lifestyle changes for all patients Exercise 30-60 min for at least 4 days a week Limit alcohol (no more than 2 drinks / day) Low salt <1.5 grams / day Reduce stress

Hypertension: Drugs What drugs you use depends on if the patient has other diseases (co-morbidities) Comorbidity 1st choice drugs to use Past history MI ACE inhibitor and beta blockers Past history stroke ACE inhibitor +/- thiazide diuretic Diabetes ACE inhibitor first, then calcium channel blocker (CCB) or diuretic

Hypertension: Drugs What if the patient has no other diseases? A) Isolated systolic hypertension (Systolic BP >140 but diastolic BP normal <90) Use Thiazide diuretic or Calcium channel blocker If BP still high on one of these drugs, then combine the 2 classes (use diuretic and CCB)

Hypertension: Drugs B) Systolic and Diastolic Hypertension Start with Thiazide diuretic or ACE inhibitor or Calcium channel blocker (CCB) or Beta blocker (BB) or Angiotensin receptor blocker (ARB)

Hypertension: Drugs If BP still not <140/90 on one of these drugs, then combine them. Best combinations are: Thiazide diuretic + ACE inhibitor Thiazide diuretic + CCB ACE inhibitor + CCB If BP still not <140/90 on 2 drugs, add a 3rd class

Hypertension: Drugs General advice: Combining drugs is often more effective than increasing one drug to its maximum dose Don’t combine BB and CCB (risk of complete heart block) Don’t combine ACEI and ARB (risk of hyperkalemia) Don’t choose BB first in patients >60 years old (ok if used in combination, or if used because patient has comorbidity that should be treated with BB)

Examples of Drugs in Each Class Drug Class Drug name Typical doses Thiazide Diuretic Hydrochlorothiazide 12.5-25 mg daily Chlorthalidone ACE inhibitor Ramipril 2.5-10mg daily Perindopril 4-8 mg daily Enalapril 2.5-20 mg BID Lisinopril 10-40mg daily Fosinopril CCB Amlodipine Felodipine Nifedipine (extended release) 30-90mg daily Diltiazem (extended release) 180-420mg daily Verapamil (extended release) 120-360mg daily Start with the low end of the dose range *Start with a dose at the lower end of the dose range

Examples of Drugs in Each Class Drug Class Drug name Typical doses Beta Blockers Metoprolol 25-100mg BID Atenolol 25-100mg daily Bisoprolol 2.5-10mg daily Propranolol 40-120 mg BID Labetalol 100-400mg BID ARB Losartan Telmisartan 20-80mg daily Candesartan 8-32mg daily Valsartan 80-320mg daily Irbesartan 150-300mg daily Start with the low end of the dose range

70F with DM presents with chest pain aVL = reciprocal changes STEMI inferior with Q waves

ECG Interpretation Rate: 60 beats per minute Rhythm: Sinus rhythm Intervals: PR, QRS, QT intervals all normal QRS complex: Pathologic (big) Q waves III, aVF QRS complexes normal size ST-T wave changes: ST elevation II, III, aVF ST depression and T wave inversion aVL

Inferior ST elevation myocardial infarction ECG Interpretation Summary of ECG? Inferior ST elevation myocardial infarction

Inferior and Right sided MI 30-50% of Inferior MI’s also involve the right ventricle Typically supplied by the same artery (right coronary artery) Always check right sided leads when you see an inferior MI

Check right sided leads in inferior MI

ECG changes in ST elevation MI (STEMI)

ECG changes in Non ST elevation MI (NSTEMI)

STEMI vs NSTEMI STEMI: Entire thickness of the muscle wall is necrosed Complete blockage of blood vessel NSTEMI: Only part of the thickness of the muscle wall is necrosed Partial blockage of vessel

Management Goals of medical therapy: Reduce pain Prevent further thrombosis Antiplatelet agents Anticoagulants Prevent arrhythmia Prevent ventricular remodelling (slows progression of scarring and ventricular dilation)

Medications: Pain Nitrates Morphine Vasodilation of coronary arteries Decrease preload (venous vasodilation) Decrease afterload (arterial vasodilation) Be careful of hypotension (especially with aortic stenosis, right ventricular MI) Morphine Avoid NSAIDS (e.g. ibuprofen, naproxen) Increases risk of death, reinfarction, heart failure

Medications: Antithrombotic Aspirin 162-325mg Po chewed x 1 then 75mg-100mg daily Patient needs to take indefinitely Decreases mortality Give as soon as you suspect an MI Consider clopidogrel 300mg PO x 1 then 75mg daily for 1-12 months Small additional benefit

Medications: Anticoagulants Heparin Decreases risk of death and re-infarction If using unfractionated heparin IV, monitor PTT Duration is at least 48 hours

Medications: Preventing arrythmia Beta blockers Decreases mortality and ventricular arrythmias Start within 24 hours Contraindications Acute heart failure Heart block Asthma Hypotension No role for antiarrythmics such as lidocaine No role for calcium channel blockers mechanism of action - decrease heart rate, myocardial contractility and therefore oxygen consumption Immediate beta-blocker therapy appears to reduce the magnitude of infarction and incidence of associated complications in subjects not receiving concomitant fibrinolytic therapy, the rate of reinfarction in patients receiving fibrinolytic therapy, and the frequency of life-threatening ventricular tachyarrhythmias.

Medications ACE inhibitors Especially beneficial in those with heart failure Start within 24 hours Prevents left ventricular remodelling

Reperfusion Especially important for STEMI’s to reopen blockage 2 options (if available) A) Fibrinolytics If symptoms started less than 24 hours ago Contraindications: Uncontrolled hypertension, stroke in last 3 months, previous intracranial hemorrhage For STEMI patients only B) Percutaneous coronary intervention (PCI) If symptoms started less than 12 hours ago If the “door to balloon” time can be less than 90 minutes For STEMI patients. Can consider for NSTEMI patients

62M with previous MI. Now short of breath

ECG Interpretation Rate: 75 beats per minute Rhythm: Sinus rhythm Intervals: PR interval wide: First degree AV block QRS Wide: RBBB pattern QT interval normal QRS complex: No pathologic (big) Q waves, Normal size QRS ST-T wave changes: T wave inversion III, aVF

ECG Interpretation Summary of ECG? Right bundle branch block T wave inversion in inferior leads

Causes of RBBB Structural heart disease Old MI, ischemia, inflammation, High right ventricular pressure Lung disease (Asthma, COPD, interstitial lung disease) Pulmonary embolus Hypertension In this patient, with old MI, this is likely the cause of the RBBB

This is his Xray. What is the diagnosis? Congestive heart failure X Ray shows: Cardiomegaly (Heart shadow is >50% of the widest diameter of the thorax), Increased vascular markings in the upper half of the X ray, alveolar edema (Increased interstitial markings especially in the perihilar area)

Causes of heart failure Develops after other diseases damage or weaken the heart The ventricles become weak, dilated and do not pump blood efficiently through the body (systolic failure) The ventricles become stiff and do not fill well between heartbeats (diastolic failure) In this case, the patient had a history of MI, which probably damaged and weakened the heart leading to heart failure.

Causes of heart failure Coronary artery disease and myocardial infarction Ischemia to heart muscle Hypertension Heart muscle must work harder Valvular heart disease Damaged valves causes heart to work harder

Causes of heart failure Cardiomyopathy Damage to heart muscle from infection, alcohol, drugs, thyrotoxicosis, lupus, or idiopathic (no cause found) Myocarditis Inflammation to heart muscle from viral infection or autoimmune disease Congenital heart defects Healthy parts work harder

New York Heart Association functional classification Class Definition I No symptoms II Symptoms with ordinary activity III Symptoms with less than ordinary activity IV Symptoms at rest or with any minimal activity

Drugs used in heart failure Mechanism of action For patient Angiotensin converting enzyme (ACE) inhibitors Dilates blood vessels Decreases blood pressure Improves blood flow Decreases work of heart Live longer Feel better Angiotension II receptor blockers (ARBs) Same as ACE inhibitor Beta Blockers Slows heart rate

Drugs used in heart failure Mechanism of action For patient Digoxin Increase heart muscle contraction Slows heartbeat Feel better Diuretics Increases urination Prevents fluid accumulation Hydralazine and nitrates Dilates blood vessels Aldosterone antagonist Reverses scarring of heart Live longer

Treatment of acute heart failure Supplemental oxygen Loop diuretics (e.g. Furosemide) Give intravenously in acute heart failure Nitrates Nitroglycerin (either intravenous or with patch) or Isosorbide dinitrate

Treatment of chronic heart failure Educate patient Cardiovascular risk reduction Lifestyle modification (exercise, decrease stress) Limit salt (1-3 gms daily) Limit fluid (1.5-2 litres daily) Limit alcohol Treat cause (ie hypertension, ischemia)

Chronic heart failure: All patients Diuretic therapy as needed for symptom relief Angiotensin converting enzyme (ACE) inhibitor Use ARB if patient cannot tolerate ACE inhibitor. Not both. Beta blocker Best ones to use are carvedilol, bisoprolol, or metoprolol May initially worsen symptoms, so start only once fluid retention has been treated with diuretics

Chronic heart failure: If NYHA III-IV Add digoxin Add hydralazine and nitrates Add spironolactone

75F with palpitations

ECG Interpretation Rate: 150 beats per minute Rhythm: Not sinus rhythm No p waves Irregular Intervals: QRS normal, QT normal QRS complex: No pathologic Q waves, Normal size QRS ST-T wave changes: None

ECG Interpretation Summary of ECG? Atrial fibrillation

Management of atrial fibrillation Example 1- 75 F with palpitations On examination, BP = 60/40, HR = 150 She is diaphoretic and presyncopal Is this patient stable or unstable? Unstable How will you treat her?

Management of atrial fibrillation Unstable patients Urgent electrical cardioversion if available

Management of atrial fibrillation Synchronized cardioversion Start with 100 Joules of energy There is a risk of stroke with cardioversion Start heparin before cardioversion If possible, anticoagulate for at least 4 weeks after

Management of atrial fibrillation Example 2- 75 F with palpitations On examination, BP = 130/85, HR = 140 She has no chest pain and feels well otherwise Is this patient stable or unstable? Stable How will you treat her?

Management of atrial fibrillation For stable patients: Control the heart rate Beta blockers or Calcium channel blockers or/and Digoxin

Management of atrial fibrillation Beta Blockers (BB) Acute: Can use IV E.g. Metoprolol 2.5-5mg IV. Can repeat every 5 minutes to a maximum of 15 mg over 15min Chronic: Aim for HR <80 at rest and <110 with exercise E.g. Metoprolol start at 25mg BID (max 100mg BID)

Management of atrial fibrillation Beta blockers Be careful of side effects: Low BP Worsening heart failure Bronchospasm (especially in asthma patients)

Management of atrial fibrillation Calcium channel blockers (CCB) Generally, do not combine with beta blockers Risk of complete heart block Options: Diltiazem start at 30mg QID (maximum 90mg QID) Verapamil start at 40mg QID (maximum 90mg QID) Amlodipine, Nicardipine, Felodipine, or Nifedipine do not work to slow down HR

Management of atrial fibrillation Digoxin Can be combined with BB or CCB Not as effective as BB or CCB Use if HR still not controlled with BB or CCB Cannot tolerate BB or CCB (e.g. heart failure, low BP)

Management of atrial fibrillation In example 2, you successfully control the patient’s heart rate to 70 bpm at rest with metoprolol 50mg BID. She is discharged from hospital

Management of atrial fibrillation She comes back to hospital 6 months later with right sided hemiparesis CT head confirms an ischemic stroke

Management of atrial fibrillation Quality assurance Why has this happened? Can you think of any strategies that may have improved her care or prevented this from happening?

Management of atrial fibrillation Anticoagulation for atrial fibrillation Afib is associated with ischemic strokes Clots may form in the left atrium These clots may embolize to the brain

Management of atrial fibrillation Risk factors for stroke: Mitral stenosis (**high risk**) Previous stroke (**high risk**) Age >65 Hypertension Heart failure Diabetes Female

Management of atrial fibrillation What can you do to reduce the risk of stroke? Anticoagulants such as warfarin reduces stroke risk by over 60% Aspirin 75-325 mg daily (used indefinitely) reduces stroke risk by about 30% Can combine aspirin with clopidogrel to further reduce stroke risk but this increases risk of bleeding

Management of atrial fibrillation Summary: Chronic stable patients Rate control with BB, CCB, or Digoxin In any patient with any risk factor for stroke If available and can monitor, use warfarin If warfarin not available, start aspirin 75-325mg daily If at high risk of stroke (>1 risk factor, previous stroke, or mitral valve stenosis) and warfarin not available, combine aspirin and clopidogrel 75 mg/day if no bleeding problems

Quiz A 50 year old man presents with central chest pressure. ECG:

Quiz Question 1: What is the diagnosis? Inferior ST elevation MI Inferior non-ST elevation MI Anterolateral ST elevation MI Anterolateral non-ST elevation MI Right sided ST elevation MI

Quiz Question 1: What is the diagnosis? Inferior ST elevation MI Inferior non-ST elevation MI Anterolateral ST elevation MI Anterolateral non-STE elevation MI Right sided ST elevation MI

Quiz Question 2 (same patient as question 1): What medication should not be used to treat the MI? Metoprolol Diltiazem Aspirin Clopidogrel Morphine

Quiz Question 2 (same patient as question 1): What medication should not be used to treat the MI? Metoprolol Diltiazem Aspirin Clopidogrel Morphine

Quiz Question 3 A 50 year old diabetic patient sees you in clinic for control of his hypertension. What is his target BP? A) 120/70 B) 125/75 C) 130/80 D) 135/85 E) 140/90

Quiz Question 3 A 50 year old diabetic patient sees you in clinic for control of his hypertension. What is his target BP? A) 120/70 B) 125/75 C) 130/80 D) 135/85 E) 140/90

Quiz Question 4 (same patient as Question 3): His BP is 150/95. What medication class would you use first to treat his hypertension? A) ACE inhibitor B) Beta blocker C) Calcium channel blocker D) Thiazide diuretic E) Nitrate

Quiz Question 4 (same patient as Question 3): His BP is 150/95. What medication class would you use first to treat his hypertension? A) ACE inhibitor B) Beta blocker C) Calcium channel blocker D) Thiazide diuretic E) Nitrate

Quiz Question 5 A 55 year old man is very short of breath. Chest X ray shows heart failure. What should you not start right away? A) Loop diuretic (e.g. furosemide) B) Nitrate C) Oxygen D) ACE inhibitor E) Beta blocker

Quiz Question 5 A 55 year old man is very short of breath. Chest X ray shows heart failure. What should you not start right away? A) Loop diuretic (e.g. furosemide) B) Nitrate C) Oxygen D) ACE inhibitor E) Beta blocker