1. Management of Cardiac DiseasesMI
HTN
Heart failure
Renal failure with hyperkalemia

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

3. 50M- Asymptomatic but BP 160/95

4. 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

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

6. 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

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

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

9. 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

10. 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)

11. 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)

12. 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

13. 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)

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

15. 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
mg BID
Labetalol
mg BID
ARB
Losartan
Telmisartan
20-80mg daily
Candesartan
8-32mg daily
Valsartan
80-320mg daily
Irbesartan
mg daily
Start with the low end of the dose range

16. 70F with DM presents with chest pain
aVL = reciprocal changes
STEMI inferior with Q waves

17. 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

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

19. 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

20. Check right sided leads in inferior MI

21. ECG changes in ST elevation MI (STEMI)

22. ECG changes in Non ST elevation MI (NSTEMI)

23. 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

24. 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)

25. 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

26. Medications: Antithrombotic
Aspirin
mg 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

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

28. 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.

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

30. 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

31. 62M with previous MI. Now short of breath

32. 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

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

34. 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

35. 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)

36. 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.

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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)

44. 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

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

47. 75F with palpitations

48. 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

49. ECG Interpretation
Summary of ECG?
Atrial fibrillation

50. Management of atrial fibrillation
Example 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?

51. Management of atrial fibrillation
Unstable patients
Urgent electrical cardioversion if available

52. 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

53. Management of atrial fibrillation
Example 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?

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

55. 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)

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

57. 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

58. 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)

59. 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

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

61. 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?

62. 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

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

64. 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 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

65. 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 mg 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

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

67. 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

68. 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

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

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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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