1. Cardiology Consult Update
LCDR Olamide Oladipo, MC, USN Cardiology Staff

2. Presenter Disclosure Information
Olamide Oladipo, DO
Cardiology Staff
FINANCIAL DISCLOSURE:
No relevant financial relationship exists

3. Objectives Discuss cardiac vs. non-cardiac chest pain.
Discuss common causes of syncope from a cardiologist standpoint.
Review approach to palpitations.

4. Outline Define various chest pain
Diagnostic tests for typical /atypical chest pain
Define syncope
Review varying causes of syncope
Basic diagnostics test for syncope
Causes of palpitations
Monitors available to evaluate palpitations.

5. Chest Pain

6. Classification of “Chest Pain”

7. Non-cardiac Chest Pain

8. Risk Stratification Exercise testing Pharmacologic testing
Exercise treadmill test
Exercise stress echocardiogram
Exercise myocardial perfusion scan
Pharmacologic testing
Dobutamine stress echocardiogram
Regadenoson myocardial perfusion scan
Anatomic testing
Cardiac gated CT scan
Left heart catheterization

9. Exercise Treadmill Testing
Treadmill ECG interpretation also employed with exercise stress echo and MPS
Those with a baseline abnormal ECG
Ventricular pre-excitation (Wolff-Parkinson-White pattern)
Contraindications
Acute MI within 2days
Ventricular paced rhythm
Ongoing unstable angina
Uncontrolled cardiac arrhythmia with hemodynamic compromise
Left bundle branch block
Greater than 1 mm ST depression at rest
Symptomatic severe AS
Physical inability

10. Syncope

11. Definition of Syncope
Transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.

12. Broad Categories of Syncope
Neurally-mediated (reflex)
Orthostatic hypotension
Cardiac
– Arrhythmias
– Structural disease
Cerebrovascular (rare 4th categoryy)
– Vascular steal syndromes

13. Reflex Syncope

14. Orthostatic Syncope

15. Cardiac Syncope

16. Diagnostic Tests Cardiac tests Neurally-mediated tests – Echo
– Tilt table test
– Prolonged ECG monitoring
– Carotid sinus massage
– Stress test
– EP study
– Implantable loop recorder

17. Palpitations

18. Definition of Palpitations
A sensation of rapid or irregular beating of the heart”
- Single “skipped” beats
- Feeling of being unable to catch one’s breath
- Single pounding sensations
- Rapid, regular pounding in neck
- Palpitations that are worse at night
- Palpitations associated with emotional distress

19. Causes: Cardiac Atrial fibrillation/flutter
Premature supraventricular or ventricular contractions
Bradycardia caused by advanced arteriovenous block or sinus node dysfunction
Sinus tachycardia or arrhythmia
Supraventricular tachycardia
Bradycardia-tachycardia syndrome (sick sinus syndrome)
Ventricular tachycardia
Multifocal atrial tachycardia
Wolff-Parkinson-White syndrome

20. Non-arrhythmic cardiac causes
Atrial or ventricular septal defect
Mitral valve prolapse
Pacemaker-mediated tachycardia
Cardiomyopathy
Congenital heart disease
Pericarditis
Congestive heart failure
Valvular disease (e.g., aortic insufficiency, stenosis)

21. Causes: Others Psychiatric
Medications - Digitalis - Phenothiazine - Theophylline - Beta agonists
- Anxiety disorder
- Panic attacks
Substance - Street drugs (e.g., cocaine, Meths) - Alcohol - Caffeine
Extracardiac - Anemia - Electrolyte imbalance
- Fever Hyperthyroidism
- Pheochromocytoma

22. Diagnostic Tests ECG Echo if suggestive of structural abnormalities
Holter (24-48hr)
14day continuous monitoring
30day event monitor
30day continuous monitoring

23. Palpitations Algorithm
A sensation of rapid or irregular beating of the heart” – Taber’s

24. Summary Exercise treadmill test for chest pain with normal EKG
If reflex syncope; okay to order echo to ensure no structural abnormalities if EKG is abnormal.
Appropriate monitor consult +/- routine cardiology consult.

25. Questions