Thursday, August 23, 2012
The ABCDEFG approach to Managing a patient with Heart Disease:
Assessment of Cardiovascular Risk – modifiable and non-modifiable Risk factors and ACLS H and Ts – History and Physical Exam; Arterial Blood Gases (ABGs); Air (O2); Anti-Platelet agents – Aspirin – to be chewed to bypass First Pass Metabolism by liver and instantaneous action within seconds – shown to decrease mortality, Plavix (Clopidogrel); ACE inhibitors – prils (oral) –prilat (IV) – shown to decrease mortality and promote ventricular wall remodeling; ARBs (-sartans); Anticoagulants – Start with LMWH (Enoxaparin action is monitored with aPTT and action is reversed with Protamine Sulfate) and Warfarin then discontinue Enoxaparin after 5-7 days – monitor PT/INR reverse with Vitamin K or Pradaxa (dabigatran etexilate – no monitoring needed) for AF to prevent Stroke, Analgesics for pain – narcotics; Anti-arrhythmics – (Class 1,2,3,4 – So,Be,Po, Ca – MOA – Sodium channel, Beta blockers, Potassium channel, Calcium channel blockers respectively) ACLS 2010 removed ATROPINE from management of Asystole/PEA, Antibiotics for IE (Infective Endocarditis – most commonly Left sided due to high pressure - suspect IV drug abuse in Right Sided IE – tricuspid – involvement due to S. aureus send cultures before starting Broad spectrum Antibiotics – may be culture positive or negative); Alteplase (Thrombolytic use beneficial within 6 hours of start of symptoms); Angiography or cardiac catheterization with or without Balloon Angioplasty and Stenting (drug eluded).
Beta-Blockers – Beta-1 selective bisoprolol (Zebeta), carvedilol (Coreg), metoprolol (Lopressor) – have been shown to reduce mortality; elevate the leg end of the Bed after a MI; Blood Culture and Serology and enzymes– before starting Antibiotics for IE and to find the cause of cardiomyopathy.
Calcium Channel Blockers (CCBs) – -dipines, diltiazem and verapamil - amlodipine (Norvasc), diltiazem (Cardizem), felodipine, nifedipine (Procardia), nisoldipine (Sular), verapamil (Calan) are used for diastolic heart failure(when your heart has a hard time filling with blood) and to lower Blood Pressure. NOT used for Systolic Heart Failure (inability of the week ventricles to pump out blood); Chest X-Ray (CXR) to detect pulmonary cause (Cor-Pulmonale – Right sided Heart Failure secondary to lung disease), Trauma – mediastinal widening, congenital heart disease – Boot shaped heart in TOF, Egg on a string appearance in TGA, Cardiomegaly (Cardio Thoracic ratio > 50% on a CXR PA view); Cardiac Enzymes – GPBB (Glycogen Phosphorylase isoenzyme BB – elevated 1-3 hours after ischemia and peak in 7 hours), Troponin T and I (released within 2-4 hours after ischemia, peak in 12 hours and persist up to 7 days), Creatine Kinase – MB (CK-MB is relatively specific without skeletal muscle damage and levels peak in 10-24 hours and persists for 2-3 days; Coronary Artery Bypass Grafting using Internal Mammary Artery Graft, Radial Artery or Saphenous veins (CABG types – traditional CABG using heart-lung bypass machine, CABG done on a beating heart - Off-pump CABG, and the newer Minimally Invasive Direct CAB (MIDCAB)surgery performed without cutting ribs or sternum; Cholesterol-Lowering drugs – Statins are FIRST LINE therapy (also known as HMG CoA reductase inhibitors – major side effects include myopathy including Rhabdomyolysis and Hepatotoxicity – elevated liver enzymes and latest addition is early CATARACTS) – mainly lower LDL (BAD) cholesterol, also modestly lower Triglycerides (TGs) and raise HDL (GOOD) cholesterol – atorvastatin (Lipitor), Simvastatin (Zocor), Selective Cholesterol Absorption Inhibitors – ezetimibe (Zetia), Other therapies for dyslipidemias include Resins also called Bile acid Sequestrant or Bile acid binding Drugs, Fibrates (Fibric acid derivatives), and Niacin (Nicotinic Acid); Cardiac Monitor in the ER – Telemetry Floor, 24 hour Holter monitoring or event monitoring at home; Cardiac Tamponade – diagnose clinically or using EKG and Echocardiogram or Chest CT/MRI– perform ultrasound or CT guided Pericardiocentesis or Surgical pericardiectomy (pericardial window); Cardiomyopathy – 5 types include Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Restrictive cardiomyopathy, Arrhythmogenic right ventricular dysplasia (ARVD), and Unclassified type – find cause and treat accordingly;
Thank you for updating your Medical Knowledge at Online Health Expert.
Dr. Harish Malik
Online Health Expert