A Cardiologist s Guide to Love A brief overview of what everyone should know about Palpitations, Heartache and Heartbreak! Eric J Dueweke, MD FACC Disclosure No one has yet to offer to pay me for my opinion. No significant (or insignificant) industry relationships. References included on slides and available per request. 2 1
Palpitations You decide to celebrate Valentines by seeing an urgent add on patient to your clinic: 19 year old woman with no past medical history who experienced three minutes of palpitations while drinking Red Bull and studying for an organic chemistry final. Your Plan: A. Tell her to drop organic chemistry and take finance; that s where the money is! B. Echocardiogram, stress test, referral to EP. C. Prescribe metoprolol; titrate to coma. D. Reassure and offer an event recorder. 4 What Are Palpitations and Why Do I Care? Palpitations are an unpleasant awareness of the heartbeat. Common cause of presentation ~ estimated at 16%. Extensive differential diagnosis; benign to malignant. Cause is cardiac 43%, psychiatric 31%, other 10%. Am J Med 1996; 100:138 5 2
Myriad Causes of Palpitations Signs of Cardiac Etiology Male Sex Description of Irregular Heart Beat History of Heart Disease Event Duration > 5 Minutes 6 Description Matters Flip-Flop Premature beats, atrial or ventricular. Rapid Fluttering sustained rhythm; consider regular or irregular to help determine the cause. Pounding in the neck implies A-V dissociation. What provokes palpitations and what relieves them? Associated symptoms; pay attention to syncope! 7 3
Testing - Choose Wisely Electrocardiogram Snapshot in Time 24 48 Hour Holter Monitor Continuous, limited time. 30 Day Event Recorder Series of 2-3 minute loops Implantable Loop Recorder Long term monitoring An EKG is always a great place to start! LVH, Q waves, Prolonged QT, Preexcitation, RBBB/LBBB EP Study, Echocardiogram, Stress Test, LHC 8 When Should I Refer? High risk symptoms: Syncope, Chest Pain, Poorly Tolerated Known history of underlying cardiac disease Intractable or sustained symptoms Known diagnosis with challenge in management We are happy to see any patient who is concerned! 9 4
Time for a Test of Knowledge 54 year old male with a history of prior myocardial infarction has had several episodes of palpitations lasting several minutes. He often feels heavy beats in his neck. He thinks he passed out last time they occurred. What diagnosis are you considering? A. Sinus Tachycardia B. AV Nodal Reentrant Tachycardia C. Atrial Fibrillation D. Premature Ventricular Contractions E. Ventricular Tachycardia 10 The Beat Goes On 38 year old woman presents with palpitations occurring a couple times per month. They typically last 20 30 minutes. Last time she had the symptoms, they stopped abruptly after she picked up a heavy piece of furniture. What test do you order: A. Electrocardiogram B. 24 Hour Holter Monitor C. 30 Day Event Recorder D. Implantable Loop Recorder E. EP Study 11 5
Take Home Points Recognize when palpitations are likely to be benign. Recognize how to use testing to elucidate etiology. Know when to manage and when to ask for help. 12 Heartache Chest Pain Most Popular Times for Breakup 13 6
Matters of the Heart Your 64 year old patient goes out on a date. He unfortunately forgot to ask you if he was healthy enough for romance and presents to the emergency department 3 hours later with crushing chest discomfort, radiating down both arms, relieved with nitroglycerin and associated with nausea. What is the most worrisome clinical feature? A. Crushing chest discomfort B. Radiating down both arms C. Relieved with nitroglycerin D. Associated with nausea E. He s wearing Axe body spray. 14 Rational Clinical Exam - JAMA 15 7
Rational Clinical Exam - JAMA 16 Rational Clinical Exam - JAMA 17 8
Diamond and Forrester Score 18 Diamond and Forrester 19 9
Classification of Angina Definition used from original Diamond Forrester Model 1. Substernal Chest Pain or Discomfort 2. Provoked by Exertion or Emotional Stress 3. Relieved by Rest or Nitroglycerin Having 3/3 is typical, 2/3 atypical, 0-1 / non-specific. 20 Putting It All Together HEART Score 21 10
HEART Score Risk Factors Diabetes Current (or recent < 1 month) Smoker Diagnosed Hypertension Diagnosed Hyperlipidemia Family History of CAD Obesity 22 HEART Score 23 11
Take Home Points When evaluating chest pain, risk assessment is key. There are validated algorithms to help, use your cell phone! Testing is only needed when it is going to change management. 24 Heartbreak Elevated Troponin You are in your heart-shaped Jacuzzi and the pager rings : STAT Consult: 98 year old male admitted with a hip fracture; troponin is 0.056 ng/ml.activate cath lab? Your Response: A. Turn up the bubbles and ignore the page. B. Transfer to cath lab; he s Rob s problem now. C. Take an aspirin (and statin, beta blocker etc) and call me in the morning. D. Tell Ortho to fix the hip and stress him next week. 26 12
Heartbreak So is it an MI? Universal Definition of an MI: Rise / Fall of troponin with at least one value > 99 th percentile. And. Symptoms of ischemia New pathologic Q waves on an EKG New ST-T changes or LBBB Confirmed coronary thrombus Imaging evidence of loss of myocardium 27 Types of MI Type I Plaque rupture leading to coronary thrombosis Type II Secondary to supply/demand mismatch Type III Sudden cardiac death Type IVa Related to PCI Type IVb Stent thrombosis Type V Related to CABG 28 13
Do Type I and II Present Differently? 29 Do Type I and II Present Differently? 30 14
Type II MI So, it s not so bad, right? 31 Do Type I and II Present Differently? 32 15
Ok, great, now what do I do? 33 Potential Therapy Aspirin / Beta Blockade Aspirin has shown to reduce risk of mortality in patients with high APACHE II scores in MICUs. Benefit seems to be highest in the sickest patients. Aspirin use reduced the risk of mortality in GI bleed! Some studies have shown a potential benefit for beta blockade in sufficiently resuscitated septic patients. 34 16
Potential Therapy - Statins A meta-analysis in 2015 showed no benefit of statins in reducing mortality in critically ill patients. A subsequent study demonstrated that the benefit may be present in less-sick populations (lower APACHE II score). A large retrospective study was able to classify the benefit by the degree of troponin elevation those with lower or no elevated troponin did better but there was no improvement in patients with high troponins. 35 So, what should I do? 36 17
Personal Protocol 38 Justification 39 18
Take Home Points Management of asymptomatic troponin elevation is challenging with a scant evidence basis compared to ACS. The indication to intervene is to make a patient feel better or live longer; when proof is lacking, perhaps doing nothing is better? We should be careful of what we call ACS. 40 19