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61-80 of 364 results with category "Cardiology"
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Early Atherosclerosis Detection
50 middle-aged asymptomatic subjects free of vascular disease underwent carotid ultrasound (CUS) for risk stratification were also invited to undergo coronary computed tomography angiography (CCTA) or coronary artery calcium score (CAC) to identify which of the 3 imaging modalities was best at identification of early atherosclerosis
Atherosclerosis was observed in 28%, 78%, and 90% of subjects using CAC, CCTA, and CUS, respectively
36 patients with a CAC score = 0, 69% and 86% had atherosclerosis on CCTA and CUS, respectively
Concordance between modalities was highly variable
CUS and CCTA detection of plaque were significantly more sensitive than CAC
Considering the prevalence of subclinical disease on CUS and CCTA, the threshold at which to treat warrants further research
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The importance of new ST-segment depressions (STD) and/or T wave inversions (TWI) in lead aVL have not been emphasized or well recognized across specialties. Computer-assisted ECG readings typically report these findings as normal or nonspecific.
There is growing evidence that changes in lead aVL are abnormal, and that paying attention to that lead can be clinically useful. Reciprocal changes presenting as STD or TWI in lead aVL may be indicative of a significant coronary artery lesion and can sometimes be the only ECG manifestation of acute MI.
STD in lead aVL is considered a sensitive marker for early inferior STEMI, and has been shown to help differentiate STEMI from pericarditis. Another recent retrospective study suggests that TWI in aVL might be associated with significant LAD lesions.
Bottom Line: Paying close attention to subtle changes and abnormalities in lead aVL may help in early identification and initiation of therapy for patients who are having an acute MI.
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Myocardial Infarction in Women After Childbirth
World Health Organization reports that obesity is the 5th leading cause of global death with the highest impact on women <65 years of age
The association of obesity and cardiovascular risk in young women is currently being researched
A recent nationwide cohort looking at obesity and future cardiovascular risk looked at Danish women giving birth (2004-2009) and followed them a median time of 4.5 years
This study grouped women via pre-pregnancy body mass index (BMI)
1. Underweight (BMI <18.5)
2. Normal weight (BMI <25)
3. Overweight (BMI <30)
4. Obese (BMI >30)
Data revealed that healthy women of fertile age, pre-pregnancy obesity alone was associated with increased risk of myocardial infarction in the years after childbirth
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Question
A 48 year old woman has acute chest pain and palpitations over the past several hours. She has felt similar palpitations in the past but never sought medical attention. She arrives to your ED alert and anxious. HR = 270, BP=130/100. ECG is below. What’s the diagnosis and treatment?
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Pacing Atrioventricular Block
- Atrioventricular (AV) block is classically treated with restoration of heart rate via right ventricular pacing, however high rates of right ventricular pacing is associated w/ left ventricular systolic dysfunction
- A recent multi-center randomized control trial (RCT) assessed the efficacy of right vs biventricular pacing in heart failure w/ AV block [BLOCK HF Trial]
- Primary outcomes of: morbidity, mortality, and adverse left ventricular remodeling were shown to be significantly lower in biventricular vs right ventricular pacing
- In patients with a high rate of pacing and/or an abnormally low left ventricular ejection fraction biventricular pacing may be more advantageous than conventional right ventricular pacing
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Differentiation between right and left ventricular origin of premature beats can be useful clinically.
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PVCs arising from the right ventricle have a left bundle branch block morphology (dominant S wave in V1)
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PVCs arising from the left ventricle have a right bundle branch block morphology (dominant R wave in V1)
Left Ventricular premature beats are more often associated with heart disease and may precipitate ventricular fibrillation, whereas right ventricular premature beats are commonly seen in individuals with normal hearts.
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Assessment of Intermediate Coronary Lesions
- Coronary angiography alone to assess CAD is fraught with subjectivity
- Fractional flow reserve (FFR) has become the standard to assess/quantify obstructive CAD; it determines the myocardial flow in the presence of stenosis identifying the lesion responsible for ischemia
- FFR assesses focal stenosis, but does not consider diffuse atherosclerotic narrowing or microcirculatory dysfunction as contributors of ischemic heart disease
- An index of microcirculatory resistance (IMR) can be concomitantly measured with FFR during cardiac catheterization to specifically evaluate the microvasculature
- Coronary flow reserve (CFR) was the 1st proposed method for assessment of intermediate coronary lesion, but proved suboptimal because of its variability especially in patients with microvascular dysfunction (diabetes, prior MI, etc.)
- Utilization of FFR, IMR, and CFR together support the existence of differentiated patterns of ischemic heart disease & may help to determine future ischemic events
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There is debate and confusion regarding where and how to measure ST elevation (STE). Do you measure the STE at the J-point? Or at 40 msec after the J-point? And how much STE is considered significant? The current guidelines have clarified this issue.
- STE should be measured at the J-point.
- STEMI is defined by STE ≥ 1 mm in at least 2 contiguous leads, with the exception of leads V2-V3.
- STEMI is defined by STE ≥ 2 mm in leads V2-V3 in men.
- STEMI is defined by STE ≥ 1.5 mm in leads V2-V3 in women.
For more cardiology pearls from the 2013 literature , check out Amal Mattu's Articles You've Gotta Know!
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Metoprolol Usage Cardioprotective
- Intravenous (IV) metoprolol is sparingly used in STEMI given concern about precipitation of cardiogenic shock (COMMIT/CCS-2 Trial)
- A recent study (n=220) looked at usage of IV metoprolol versus controls in patients with STEMI and a killip class II or less prior to primary PCI
- MRI was preformed 5-7 days after STEMI revealing reduced infarct size and increased left ventricular ejection fraction in the IV metoprolol group
- IV beta-blockade appears cardioprotective in those with a low killip score and should be considered prior to primary PCI in certain subgroups
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- 5 practical considerations (History, ECG, Age, Risk factors, & Troponin) are scored (0,1,or 2 points each) depending on the extent of the abnormality.
- A HEART score (0-10) can be quickly determined without complex calculations
- Low scores (0-3) exclude short term MACE with >98% certainty
- High scores (7-10) have high (>50%) MACE rates
- The HEART score performed significantly better than TIMI and GRACE scores
Bottom-line: The HEART score can help to objectively risk stratify ED patients with chest pain into low, intermediate, and high risk groups. Using the HEART score can also facilitate more efficient and effective communication with colleagues.
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- 1312081410_International_Journal_of_Cardiology_2013_Backus.pdf (371 Kb)
- 1312081419_Neth_Heart_J_2008_Six.pdf (144 Kb)
ECG Following Cardiac Transplant
- Suturing of donor atria to the corresponding structures of a recipient’s residual atria produces two sets of P-waves:
- A small native P-wave (often so small it may not been visualized)
- Followed by a donor P-wave of normal size associated w/ a QRS complex
- A complete or incomplete right bundle branch develops in >80% transplant recipients
- ~7–25% of recipients also demonstrate a left anterior fascicular block (LAFB)
- The transplanted heart contracts faster than the atrial remnant secondary to autonomic denervation frequently resulting in an increased resting heart rate
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- 1311241245_N_Engl_J_Med_2013_Nielsen.pdf (497 Kb)
- 1311241245_N_Engl_J_Med_2013_Rittenberger.pdf (317 Kb)
- 1311241246_N_Engl_J_Med_2002_Hypothermia_after_Cardiac_Arrest_Study_Group.pdf (172 Kb)
- 1311241246_N_Engl_J_Med_2002_Bernard.pdf (102 Kb)
- 1311241246_Resuscitation_2013_Gebhardt.pdf (551 Kb)
Utility of Intra-Aortic Balloon Pump (IABP)
- IABP therapy has not been proven to reduce mortality in all-comers with cardiogenic shock complicating acute myocardial infarction (IABP-SHOCK II)
- A recent retrospective review of IABP therapy in patients with mechanical complications (ventricular septal rupture [VSR] or mitral regurgitation [MR]) following acute myocardial infarction has proven efficacious in this subset
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- IABP reduced mortality in patient with shock (61% vs 100%, p = 0.04)
- IABP reduced preoperative mortality (11% vs 88%, p <0.001)
- Post infarction VSR or MR with signs of cardiogenic shock should be considered for an IABP as a bridge to emergent surgical repair
- Patients with mechanical complications without shock were not shown to benefit from an IABP and should undergo cardiac surgery after medical stabilization
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Diagnosis of STEMI in patients with LBBB can be challenging. Guidelines that previously recommended emergent reperfusion for these patients have been reconsidered to avoid inappropriate cath lab activation and fibrinolytic therapy.
The 2013 ACC/AHA STEMI guidelines no longer consider new or presumably new LBBB a STEMI equivalent. This dramatic change may prevent inappropriate therapy for some, but fail to help identify patients with LBBB who are having STEMI's. Delayed reperfusion in this population could be fatal and is estimated to affect 5,000-10,000 patients per year in the US alone.
The Sgarbossa ECG criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥ 3 has high specificity (>98%) and positive predictive value for acute MI and angiography-confirmed coronary occlusion. The following algorithm has been recently proposed to identify the high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guidelines.
Watch this video to review Sgarbossa criteria and the modified Sgarbossa rule.
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Secondary Prevention in AMI
Just as aspirin is pivotal in the treatment of acute coronary syndrome, medications such as beta-blocker, statins, and angiotensin-converting enzyme inhibitors have been proven to be essential in secondary prevention of AMI.
Patients after AMI are typically discharged on appropriate secondary prevention medications; however the prescribed doses are often far below the proven efficacy based on clinical trials.
A review of 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008) illustrated that only 1 in 3 patients were prescribed these medications at goal doses.
Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently ~25%.
Optimal medication dosing and appropriate titration is integral to prevention of further morbidity and mortality.
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First-degree atrioventricular (AV) block is defined as an abnormally prolonged PR-interval >200ms. Although traditionally considered to be a benign clinical entity, not all first degree AV blocks are treated the same.
Markedly prolonged PR-intervals (PR >300ms) can cause symptoms and hemodynamic compromise due to inadequate timing of atrial and ventricular contractions. Consider the following ECG from a 32 YOF with intermittent episodes of syncope and dizziness…
There is marked first degree AV block (PR=434 ms). When the PR-interval gets too long, AV dyssynchrony compromises ventricular filling and decreases cardiac output, similar to the so-called pacemaker syndrome.
Current ACC/AHA guidelines state that permanent pacemaker implantation is reasonable for marked first degree AV block with hemodynamic compromise or symptoms similar to those of pacemaker syndrome. (Class IIa, Level of Evidence B). The guidelines caution that pacemakers are not indicated in asymptomatic patients with isolated first degree AV block.
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Attachments
- 1310272020_ACC:AHA_Pacemaker_Guidelines.pdf (1,524 Kb)
- 1310272159_1st_Degree_AVB._Benign_or_Curable_Cardiac_Disease.pdf (247 Kb)
Ebstein's Anomaly
- Congenital defect of the tricuspid valve (TV) and the right ventricle (RV)
- TV septal and posterior leaflets are apically displaced resulting in "atrialization" of a portion of the right ventricle (ultimately a large right atrium and small right ventricle)
- ~40-50% of individuals with Ebstein anomaly have evidence of Wolf-Parkinson-White, secondary to the atrialized right ventricle
- ECG abnormalities include:
- Right atrial enlargement or tall and broad P waves (Himalayan P waves)
- Prolonged PR interval
- Right bundle branch block
- Low amplitude QRS complexes in the right precordial leads
- T wave inversions V1-V4 and/or Q waves V1-V4
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Question
A 48 year-old female presents to the ED with progressive dyspnea and chest discomfort over the past 3 months. HR = 105, BP = 100/60 mmHg, with mild JVD on exam. Her ECG is shown below. What ECG abnormalites are present? What does your differential diagnosis include? What is the best initial diagnostic test?
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- 1310132023_ECGs_with_small_QRS_voltages.pdf (578 Kb)
- 1310132023_Low_QRS_voltage_and_its_causes.pdf (108 Kb)
Acute Aortic Syndromes
Classically, aortic dissection is considered the primary culprit in patients with chest pain that radiates to the back (aortic pain) or chest pain combined with ischemia (cerebral, cardiac, peripheral), syncope, or cardiac arrest. However, it should not be your only concern: the rate of aortic rupture is much higher in penetrating atheromatous ulcer (42%) and intramural hematoma (35%) than in aortic dissection (types A 7.5% and type B 4.1%).
Chest pain with concomitant ischemic symptoms and acute decompensation should prompt consideration of several etiologies under the umbrella of aortic syndromes and not limited to dissection :
- Penetrating atheromatous ulcer - rupture of an atheromatous plaque through the internal elastic lamina, with subsequent localized medial disruption and potential dissection, pseudoaneurysm formation, or free rupture
- Intramural hematoma - rupture of the vasa vasorum or hemorrhage within an atherosclerotic plaque followed by aortic wall infarct
- Aortic dissection- an intimal tear with resultant propagation within the middle third of the medial layer of the aorta
- Aneurysm leak or rupture - progressive vessel dilation and increased wall tension
- Traumatic transection - rapid deceleration forces or direct trauma, commonly shearing distal to left subclavian artery at aortic isthmus where the aorta is fixed by ligamentum arteriosum