INTERNAL MEDICINE - Twist of Lemons

INTERNAL MEDICINE

CARDIOVASCULAR

Angina Pectoris ? MOA: Insufficient oxygen supply to cardiac muscle, most commonly caused by atherosclerotic narrowing and less commonly by

constriction of coronary arteries; CAD = MC cause ? Stable angina: syndrome of precordial discomfort of pressure from transient myocardial ischemia ? PREDICTABLE!

o >70% stenosis; normal troponin/CK-MB; resting EKG normal; during episode >1mm ST depression +/- T wave o Diagnosis:

? Symptoms ? ECG: ST depression 1mm = positive test; inversion / flattening T waves; normal in 25% ? myocardial imaging: exercise stress test (most useful / cost effective), echo, coronary angiography o Treatment: aspirin, nitrates, B-blockers, Ca channel blockers, ACE-I, statin, coronary angioplasty, CABG ? B-blockers prolong life in patients with coronary disease and are first line therapy for chronic angina ? Unstable: when pain is less responsive to NTG, lasts longer, occurs at rest / less exertion ? ANY CHANGE ? eval o Diagnosis: EKG = normal between attacks; stress test; angiography = gold (assess severity of coronary artery lesions when considering PCI or CABG) o Treatment: antiplatelets, B-blockers, NTG, CCB, revascularization, ACE-I, statins ? Prinzmetal: transient coronary artery vasospasm within normal coronary anatomy or site of atherosclerotic plaque o Smoking = #1 RF!! o Diagnosis: ACS work up (CK, CK-MB, troponins ? may be normal / EKG ? may have transient STE); coronary angiography with injection of provoking agents into coronary artery = gold o Treatment: nitrates and CCB; propranolol = contraindicated ? Variant: transient, abrupt, marketed reduction in luminal diameter of coronary artery ? symptomatic MI ? Long-acting nitrate should include daily 8-10 hour tx free interval to prevent drug tolerance

Cardiac Arrhythmias/Conduction Disorders ? Normal sinus: normal rate (60-100) and rhythm; impulse originates in SA node; p waves upright; regular intervals ? Sinus tach: HR >100; exercise, excitement, illness ? Sinus brady: HR 50-60 ? Atrial fibrillation/flutter: irritable sites in atria fire rapidly (400-600bpm); rapid pacemaking ? atrial quivering; ventricles beat

slower bc AV node blocks some atrial impulses o Sx: Elderly/alcohol use; syncope, dyspnea, palpitations o Dx: EKG: no discrete p waves; irregularly irregular o Tx: rate ? CCB (diltiazem / verapamil) or beta blocker (metoprolol); rhythm (48 hrs = anticoagulare 21 days prior to cardioversion) ? CHADS2 score (CHF, HTN, age >75, DM, stroke hx) ? 2+ points = heparin ? coumadin; 1 = aspirin or coumadin; 0 = no therapy or aspirin)

? AV block: o 1st degree: PR >.2 ? delay at AV node or bundle of His o 2nd: ? 1: longer, longer, drop ? Wenckebach (some impulses are blocked) ? 2: some dropped (impulse blocked in bundle of His) o 3rd: p's and q's have no correlation ? no atrial impulses transmitted to ventricles ? complete AV dissociation

? Bundle branch block: QRS > .12sec; possible due to MI o Left: R and R' (upward bunny ears) V4-V6 o Right: R and R' (upward bunny ears) V1-V3

? Paroxysmal SVT: HR 150-250 o Paroxysmal SVT ? no structural abnormalities; faster than normal HR begins above two lower chambers in atria, AV or SA node o AV nodal re-entrant tachy o WPW: impulse travels between atria and ventricles through bundle of kent; ? EKG: bundle of kent fibers and delta wave on EKG; short PR, long QRS, delta wave ? Don't give adenosine or CCB o MAT: irregularly tachy, narrow QRS, abnormal 3 p waves with different morphology; HR >100

o Tx: stable = Valsalva; symptomatic = adenosine; definitive = radiofrequency ablation ? Premature beats: usually benign; may cause palpitations/ increased frequency with caffeine

o PVC = widened QRS; PAC = abnormal p wave earlier than expected; PJC: narrow QRS (8cm,

cyanosis, hepatomegaly, jaundice o NY heart failure classification:

? Class 1: ................
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