Heart Disease

Methadone is associated with Torsades de pontes.

Nortriptyline and duloxetine could aggravate a patient's Afib 

tag: atrial fibrillation / arrhythmia / TCA  / side effects

Outpatient Diagnosis of Acute Chest Pain in Adults http://www.aafp.org/afp/2013/0201/p177.html

A family h/o of sudden death and recurrent syncope is suspicious for genetic long-QT syndrome. REF

Screening for depression is recommended for secondary prevention in pts w/ STEMI. REF

Use BiDil in a 68 yo AAM with systolic heart failure. REF

In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. REF

CCBs, class I anti-arrhythmics & sotalol increase mortality compared with placebo in pts who are s/p MI. REF

What's the diff in efficacy between ACEIs & ARBs in CAD ? REF

ACEIs are indicated for all pts w/ CHF 2/2 systolic dysfunction, regardless of severity. REF This is a great question which addresses isosorbide dinitrate, BBs, spironolactone & digitalis. As an aldosterone-blocking agent, spironolactone is postulated to work synergistically with angiotensin-converting enzyme (ACE) inhibitors to provide more thorough blockade of the renin-angiotensin-aldosterone (RAA) system. REF

NSAIDs should be avoided in patients with heart failure. REF

Most predictive indicators of perioperative cardiovascular events in the elderly ? REF

What is the definition of systolic hypertension ? REF

How does long QT syndrome kill ? REF

Digitalis is primarily effective in controlling the heart rate at rest, and often does not adequately control heart rate with exercise.  REF

Beta blockers and clonidine worsen depression. For ISH in the elderly use diuretics. REF
- Thiazide diuretics improve osteoporosis.

New LBBB in MI suggests occlusion of the LAD - treat wth thrombolytics. REF
- ST-segment depression suggests ischemia, not infarction.
- MI  => 1mm elevation in 2 1imb leads and >= 2 mm elevation in 2 contiguous precordial leads.

What is the max therapy in NYHA Class III (sob w/ min exertion) heart failure ? REF

Losartan lowers uric acid.

Group II
- Houlihan
- Terrani
- Tolstitz
- Miller
- Khory

Pulmonary hypertension
- Parasternal heave
- Loud S2
- CX - mitral stenosis, lung parenchymal disease
- Echo to confirm
- V/Q for thromboembolic ds if no lung parenchymal disease
- Pulmonary angiogram to investigate any perfusion defects
- Right heart cath if considering vasodilator tx in pt w/ primary pulm htn.

Note: The Circulation document on CHF management is appended below.

Watch this YT on murmurs when able: http://www.youtube.com/watch?v=lFcf5a6BZGw

Childhood murmurs: (REF)

First study for a 60 yo male with intermittent near syncope and trifascicular block ? (REF)

Name the 6 steps in order to manage SVT. (REF)
1. Carotid massage.
2. Adenosine 6 mg
3. Adenosine 12 mg
4. Verapamil
5. BB
6. Propafenone or Flecanide.
7. Electrical cardioversion.

What decreases the rate of sudden death in heart disease ? (REF)

What is maximal medication therapy in CHF ? (REF)
- Lisinopril 40 mg BID
- Carvedilol 25 mg BID
- Lasix 80 mg Daily

Cilostazol is contraindicated in CHF. (REF)  But is beneficial to 3rd deg heart block & HDL. 

In WPW digoxin can shorten the refractory period of the accessory pathway and cx vfib. (REF)

B-type natriuretic peptide > 400 pg/nl means CHF likelihood if 95%. (REF)

Who should receive cardiac testing before surgery ? REF

A patient with symptomatic Ao stenosis has a 50% chance of death in 2 years unless it is replaced. REF

What the problems with giving BBs or clonidine for ISH in a depressed person ? REF

MI - ST elevation >= 1 mm in 2 or more limb leads. REF
     - ST elevation >= 2 mm in 2 or more contiguous precordial leads.
     - ischemic type chest pain
     - changes in cardiac troponins.

State the Jones criteria for acute rheumatic fever. REF

Secondary prevention of cardiac events consists of long-term treatment to prevent recurrent cardiac morbidity and mortality in patients who have either already had an acute myocardial infarction or are at high risk because of severe coronary artery stenosis, angina, or prior coronary surgical procedures. Effective treatments include:
1. ASA and β-blockers after MI.
2. ACE inhibitors in patients at high risk after MI.
3. Angiotensin II receptor blockers in those with CAD.
4. Amiodarone in pts s/p MI with high risk of arrhythmia.

The following increase the risk of mortality: 
1. Oral Glycoprotein IIb/IIIa receptor inhibitors increase risk of mortality compared with ASA.
2. CCBs, Class I Anti-Arrhythmic agents and Sotalol increase mortality in those who are S/P MI.
3. Contrary to decades of large observational studies, multiple randomized, controlled trials show no cardiac benefit from hormone therapy in postmenopausal women.

Tx for systolic vs diastolic heart failure ?   REF

What's the definition of a STEMI ?  Should Plavix be given ? REF

Echo findings: REF

Of the beta-blockers, only sotalol, which delays ventricular depolarization, has been shown to be effective for maintenance of sinus rhythm in patients with chronic atrial fibrillation. REF

What is the number source of excess iodine in the US ? REF

A family history of sudden death and recurrent syncope is highly suspicious for ? REF

What is reccommeded treatment for a 78 yo M smoker with PVCs ? REF

Hypertrophic cardiomyopathy is found in a 13 yo. How to manage ? REF

Contraindication for BBs in CHF ? REF

Name another contraindication for starting BB therapy. REF

Renal insufficiency is associated with increased perioperative CV risks in non-cardiac surgery. REF

Pletal should not be used in patients with which diagnosis ? REF

Name the drug which increases HDL and is beneficial for 3rd degree heart block: REF

Rheumatic Fever - Jone's CMICE B Secr(e)ts - carditis, migratory arthritis, infection, chorea, erythema marginatum, blanching macular trunk rash, systolic ej M, exudative pharyngitis, CRP increase, rapid strep +, no travel, sick [or ticks].
Multaq - do not use in setting of severe LV dysfunction, Amio would be the appropriate antiarrhythmic.
- Work up a dilated cardiomyopathy with severe LV dysfunction.
- Use BBs for rate control in such a person instead of CCBs.

Name the 5 parameters we assess with a 2D echo with Doppler. REF

What is the Levine scale for evaluating murmurs ? REF

The harsh crescendo-decrescendo systolic murmur of HOCM is heard best at the apex and the 
lower sternal border and decreases with sitting, squatting or handgrip. Standing is same effect as valsalva - that is the murmur increases because afterload decreases.

DDX:Heart Block
- Lyme disease (Borrelia burgdorferi) - stage 2 (Bell's palsy, AV block), TX:<9 ceftri, >9 doxy.
Epelerone - Eplerenone is specifically indicated for the reduction of risk of cardiovascular death in people with heart failure and left ventricular dysfunction within 3–14 days of an acute myocardial infarction, in combination with standard therapies and as treatment against hypertension. It appears equivalent to spironolactone but is much more expensive.[1]

Patients with COPD tolerate carvedilol bettter than bisoprolol or metoprolol succinate.

ACA/AHA Stages
A - No structural heart disease but with risk factors.
B - Structural disease w/o sx.
C - Structural disease with heart failure symptoms.
D - Refractor Heart Failure.

NYHA Classes of HF.
Class I - No sx and no limitations.
Class II - Mild sx (SOB, Angina, etc) & slight limitiation to ordinary activity.
Class III - Marked limitation during minimal activity, comfortable at rest only.
Class IV - Severe sx at rest. Bed bound.

Stage B treatment recommendations (2009 update to ACC/AHA 2005 Guidelines)
- Optimal management of HLD.
- Optimal management of HTN.
- β-blockers -  in all pts w/ recent or remote history of MI, regardless of EF or HF (SOR A). - Two large-scale studies have demonstrated that prolonged therapy with an ACEI reduces the risk of a major cardiovascular event even when treatment is initiated months or years after the MI.
- Furosemide is not recommended for use in stage B patients.
- CCBs such as diltiazem can lead to worsening HF and are best avoided. 
- ARBs recommended for post-MI pts w/ or w/o HF intolerant of ACEIs & w/ low LV EF (SOR B). 
- Aldosterone antagonists have not been studied in stage B heart failure and their use is generally recommended for selected patients with moderately severe to severe symptoms and a reduced left ventricular ejection fraction (stages C and D).

Tx of diastolic HF:
- Optimal mgt of HTN
- Control HR and prevent tachycardia.
- Volume mgt with diuretics.
- Tx and prevent myocardial ischemia.
- In addition, promoting regression of hypertrophy and preventing myocardial fibrosis would be of theoretical benefit. 
- Digoxin is recommended for systolic heart failure but not for diastolic heart failure.

Aldosterone antagonists:

The addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in the Randomized Aldactone Evaluation Study (RALES) to reduce rates of death and hospital readmissions in selected patients with moderate to severe symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF) (SOR B). More recently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) trial found that the addition of eplerenone in heart failure patients with mild symptoms (NYHA class II) and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths. Current AHA guidelines call for the addition of an aldosterone antagonist to an ACE inhibitor and a β-blocker in selected patients with moderately severe to severe symptoms of heart failure and a reduced LVEF.

Although the addition of digoxin can be of benefit in selected heart failure patients by reducing the risk for hospitalization, it has not been shown to reduce mortality (SOR B). Amiodarone, which is the preferred antiarrhythmic agent for preventing recurrent atrial fibrillation or symptomatic ventricular arrhythmias in heart failure patients, has been found to have a neutral impact on survival (SOR A). Cardiac resynchronization therapy (CRT) has been shown to improve survival in patients with advanced heart failure (NYHA class III or IV) with a QRS interval >0.12 sec (SOR A), but evidence of benefit in patients with a QRS interval <0.12 sec is lacking. It has been reported that unlike in heart failure patients with a QRS interval exceeding 0.12 sec, CRT does not improve peak oxygen consumption or survival in patients with narrow QRS intervals. Calcium channel blockers can lead to worsening heart failure and an increased risk of cardiovascular events and should be avoided.

The aldosterone antagonists used for heart failure are spironolactone and eplerenone. Although studies have demonstrated reduced hospitalization rates and improved survival in select heart failure patients with use of these drugs, their use in heart failure carries a risk for life-threatening hyperkalemia. As a result, these drugs should be withheld, even from patients meeting recommended criteria, if there is significant renal dysfunction or hyperkalemia. Guidelines from the American Heart Association recommend avoiding aldosterone antagonists in patients with a serum potassium level >5.0 mEq/L and a serum creatinine level >2.5 mg/dL for men or >2.0 mg/dL for women. Moreover, serum creatinine may not be an accurate measure of renal function in elderly patients or others with low muscle mass, so confirmation that creatinine clearance exceeds 30 mL/minute is recommended.

The recommended starting dosage for spironolactone is 12.5 mg daily and for eplerenone is 25 mg daily, with subsequent titration up to 25 mg daily and 50 mg daily, respectively, as appropriate. It is important to be aware that the risk for hyperkalemia is increased in patients on higher dosages of ACE inhibitors. NSAIDs and COX-2 inhibitors should be avoided in patients taking aldosterone antagonists, and potassium supplements should be discontinued or reduced. Close monitoring of serum potassium is recommended; serum potassium levels should be checked 3 days and 7 days after starting an aldosterone antagonist, followed by monthly measurement for the first 3 months (SOR C).

Current American Heart Association guidelines recommend that a β-blocker, specifically either carvedilol, misoprolol, or metoprolol succinate, be prescribed to all patients with stable heart failure due to a reduced left ventricular ejection fraction. These three β-blockers have all been shown to prolong survival in patients with current or prior symptoms of heart failure. A class effect cannot be assumed, however. For example, in the β-Blocker Evaluation of Survival Trial (BEST), the use of bucindolol failed to produce a significant overall survival benefit in patients with advanced heart failure. Similarly, a survival benefit has not been demonstrated for atenolol or nebivolol. Studies have shown short-acting metoprolol to be less effective than sustained-release metoprolol succinate in reducing the risk of death in patients with chronic heart failure.

According to the ACC/AHA guidelines for heart failure management, most stable heart failure patients should receive β-blocker therapy with carvedilol, bisoprolol, or metoprolol succinate (the long-acting form of metoprolol.) These drugs have been shown in randomized, controlled trials to lower morbidity, mortality, and hospitalization rates when started at quite low doses and titrated upward as tolerated, regardless of age, sex, race, hyperglycemia, hyperlipidemia, or cause of the heart failure. Although sustained-release metoprolol succinate is a preferred treatment for heart failure, immediate-release metoprolol tartrate is not. β-Blockers other than extended-release metoprolol, bisoprolol, and carvedilol have been found not to change heart failure outcomes. Similarly, the effects of β-blockers on facets of the metabolic syndrome also vary across the class. Carvedilol causes little change in glycemic control and may improve lipid control.

Loop diuretics:
he administration of intravenous loop diuretic therapy has been a mainstay in the management of acute decompensated heart failure. When prescribing loop diuretics in this setting, a number of strategies have been employed. The National Heart, Lung, and Blood Institute conducted the Diuretic Optimization Strategies Evaluation (DOSE) trial to study the effectiveness and safety of continuous administration as compared to a bolus administered every 12 hr. The study also compared low-dose therapy (equivalent to the patient’s previous oral dose) and high-dose therapy (2.5 times the previous oral dose). This prospective, randomized, controlled study of 308 patients with acute decompensated heart failure found no significant differences between the continuous and bolus strategies in terms of benefit, worsening renal function, or median length of hospital stay. Although the study found no difference using a global symptom assessment scale between low-dose and high-dose therapy, it did find high doses to be associated with greater net fluid loss, weight loss, and relief from dyspnea. In addition, a greater risk for a transient worsening of renal function was seen in the high-dose group (SOR A).
Felker GM, Lee KL, Bull DA, et al: Diuretic strategies in patients with acute compensated heart failure. N Engl J Med 2011;364(9):797-805.

Furosemide 1st, then HCTZ, then Metolazone.
The practitioner should begin with oral furosemide, 20 to 40 mg once daily. Dose titration goals are maintenance of adequate renal perfusion, avoidance of symptomatic hypotension, and achievement of stable weight. Hydrochlorothiazide, 25 mg, can be added with refractory fluid overload to escalating furosemide doses. With doses of oral furosemide of 120 mg twice daily, 2.5 to 5.0 mg of metolazone can be added 30 minutes before each dose for improved diuresis. Adding metolazone should be approached with caution because of the potential for severe hypokalemia and hypomagnesemia. The practitioner may switch furosemide to bumetanide, 2 to 4 mg/d, with 2.5 mg of metolazone added as needed. http://archinte.jamanetwork.com/article.aspx?articleid=647336

Cardiac Resynchronization Therapy:
Cardiac resynchronization therapy (CRT) has been shown to improve survival in patients with advanced heart failure (NYHA class III or IV) with a QRS interval >0.12 sec (SOR A), but evidence of benefit in patients with a QRS interval <0.12 sec is lacking. It has been reported that unlike in heart failure patients with a QRS interval exceeding 0.12 sec, CRT does not improve peak oxygen consumption or survival in patients with narrow QRS intervals. Calcium channel blockers can lead to worsening heart failure and an increased risk of cardiovascular events and should be avoided.

Second-generation dihydropyridine calcium channel blockers (e.g., amlodipine) may be helpful in the management of hypertension and angina in patients with concurrent heart failure (HF). Unlike older non-dihydropyridine calcium channel blockers, they do not depress ventricular function. However, they have not been shown to improve mortality outcomes in heart failure patients. Unlike the non-dihydropyridine calcium channel blockers, which depress both conduction system function and contractility, these drugs can be safely given with β-blockers in HF patients.

From the standpoint of management of HF and decreasing HF-related morbidity and mortality, it makes sense to maximize dosages of drugs that have been shown to yield mortality benefit (ACE inhibitors, angiotensin receptor blockers, β-blockers, aldosterone antagonists) before adding calcium channel blockers. Second-generation dihydropyridine calcium channel blockers (such as amlodipine) may have a greater role in patients with concurrent angina after the use of β-blocker therapy has been optimized, or for those in whom β-blockade is contraindicated.

Below this point sort factually (someday)
This patient has signs of heart failure with fluid retention. Diuretics produce symptomatic benefits more rapidly than any other drug for heart failure and are the only agents that can adequately control fluid retention. Loop diuretics, such as furosemide, are more effective than thiazide diuretics for controlling sodium and free water clearance (SOR C).

Although β-blockers should be prescribed for all patients with heart failure, they should not be started until the patient is sufficiently stable; specifically, it is recommended that β-blockers not be started while patients are hospitalized in intensive care or when they have even minimal evidence of fluid overload or volume depletion (SOR C).

Aldosterone antagonists are relatively weak diuretics that are prescribed to improve survival in selected patients with severe symptoms and a reduced left ventricular ejection fraction (SOR B). The combination of hydralazine and nitrates is generally recommended for African-American patients with moderate to severe symptoms only if they are already on optimal therapy with ACE inhibitors, β-blockers, and diuretics (SOR B).

Cardiovascular studies that Sajeet is reviewing: ( I need to look these up).







Coronary Artery Surgery Study




New York Heart Association class

Seattle Heart Failure Model

Breathing Not Properly study






Antiarrhythmic Versus Implantable Defibrillator (AVID) 

Marc Curvin,
Apr 20, 2013, 9:29 AM