Why guess when you could know? Gold Standard. Cardiac catheterization (Angiogram) Invasive Risks: Infection, hematoma, death

Transcription

1 Why guess when you could know? Gold Standard Cardiac catheterization (Angiogram) Invasive Risks: Infection, hematoma, death

2 PCI decisions Number of vessels involved Surgeon experience level The anatomic complexity of the lesions Likelihood of complete revascularization How well-preserved left ventricular systolic function Low complexity coronary anatomy

3 WHO CRITERIA significant stenosis as 70% diameter narrowing, ( 50% for left main CAD) assessment of fractional flow reserve (FFR) 0.80 can also be considered to be significant

4 Indications for CABG CABG is the preferred treatment for: 1. Left main coronary artery 2. Disease of all three coronary vessels LAD,LCX and RCA 3. Diffuse disease not amenable to treatment with a PCI. The 2005 ACC/AHA guidelines: Also high-risk patients: severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus

5 Other indications large amount of potentially ischemic myocardium those who are not candidates for long-term dual antiplatelet therapy Previous failed prior PCI Patients with ischemic cardiac arrest Anatomically complex disease may also be considered for CABG.

6 The Cardiology Happy Meal BB ACEI Statin ASA/Antiplatelet Fix It All

7 The Happy Meal: Not so happy? I feel dizzy now I don t want to be on all these medications Phase II Cardiac Rehab

8 MI Complications Dressler's syndrome (Pericarditis) CHF Arrhythmia Left ventricular Aneurysm LV Thrombus

9 Complication

10 Prevention Diet, exercise for lipid lowering Stop smoking Treat HTN, DM Reduce inflammation Reduce stress

11 Heart Failure

12 What is missing? What is the dx? Coreg NTG Lisinopril Lasix Multaq

13 Growing problem one million Americans are admitted for heart failure per year...and up to 20% are readmitted within 30 days.

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15 EXAM DOE, PND, orthopnea, rales Weight loss/gain, poor appetite S3, MR murmur, displaced PMI, HR JVD, HJR, pedal edema, ascites CXR (pulmonary edema) Decreased mentation Oliguria

16 MI Valve disease Causes Anemia Thyroid Toxins

17 CASE: 57 y/o male with low EF Stopped using CPAP gained weight s/p hip replacement Last year had EF of 62% now 36% holter showed poor rate control Cardiomyopathy. Should ve had the ablation Should ve kept using the CPAP If hip hurts, swim!

18 NYHA HF Classification

19 Can have both

20 How do we acutely treat CHF? L=Lasix Pressure = BiPap M=Morphine N=Nitrates O=Oxygen P = Pressure

21 Patients with LVEF 40% or less with symptoms or prior symptoms, unless contraindicated, to reduce morbidity and mortality ACEI Asymptomatic patients with LVEF 35% or less Common ACEI: Lisinopril, Ramipril, Enalapril Check potassium, serum creatinine, and blood pressure within one week of initiation or dosage increase in the elderly, and within one to two weeks of initiation or dose

22 If fluid retention Loops preferred, but thiazides can be considered for patients with hypertension and mild fluid retention. Diuretics Furosemide: initial 20 to 40 mg once or twice daily, max total daily dose 600 mg Bumetanide: initial 0.5 to 1 mg once or twice daily, max total daily dose 10 mg Torsemide: initial 10 to 20 mg once daily, max total daily dose 200 mg

23 Beta blockers Stable patients with LVEF 40% or less with sx If hypotension occurs, separate betablocker from other hypotensive agents (e.g., ACEI), or decrease diuretic dose Don t stop abruptly Use Metoprolol Succinate (Toprol XL, Coreg)

24 Special Populations Use an aldosterone antagonist for patients with class II to IV heart failure...if CrCl is > 30 ml/min and potassium is < 5 meq/l. Consider adding hydralazine plus isosorbide dinitrate in African Americans with class III or IV symptomatic heart failure.

25 Don t make it worse NSAIDS Glitazones Diltiazem Verapamil Procardia Sotolol Dronaderone

26 Fight or flight Rubber band theory Heart fails = stress = catecholamine release RAAS activates Retain sodium, heart rate goes up Increased sodium = increased fluids = more failure

27 Things the patient can fix Lifestyle, diet Things we can fix Anemia Arrhythmia HTN Infection Thyroid disease

28 Treatment Less fluid in More fluid out = Loop diuretics Low salt (2 g max/d) ACEI Cardiac Rehabilitation Patient education

29 Cardiomyopathies

30 Dilated 95% (floppy) Hypertrophic 4% (bulky) Restrictive 1% (squished)

31 Dilated: Floppy Heart Mechanism=Bad Muscle Function Males Idiopathic 30% Drugs (Cocaine/Adriamycin) Thyroid (hypo or hyper) Peripartum Infection CHF = SOB/Rales and JVD/S3

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33 HOCM When is it usually diagnosed?

34 HOCM

35 Something is in the way. Syncope Chest pain DOE Dyspnea at rest Palpitations MR S4 S3

36 HOCM Clues DOE in a young patient Athlete syncopal during exercise Palpitations, orthopnea

37 ECG Findings Which would you rather have as your wine glass?

38 Restrictive Cardiomyopathy I have CHF symptoms, with a normal size heart.

39 Heart is normal size, but is too stiff to relax Restrictive Cardiomyopathy Least common cause of cardiomyopathy Amyloidosis or scarring most common cause, sarcoidosis, scleroderma About 70% of people die within 5 years after symptoms begin unless heart transplant

40 Symptomatic treatment usually not helpful Treatment Hemachromatosis, the exception (ir0n studies) Cardiac MRI in addition

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