• if unable to exer., low exer. tol, or recent MI. Se & Sp  similar to exercise.

• Preferred if LBBB (requires imaging since ECG not interpretable).

HR (must achieve ≥85% of max pred HR [220-age] for exer. test to be dx),

• BP response,

• peak double product (HR × BP; nl >20k),

• HR recovery (HRpeak – HR1 min later; nl>12)

Post-PCI complications

•  Cholesterol emboli syndrome (typically in middle-aged & elderly and w/ Ao atheroma)

• renal failure (late and progressive, eos in urine);

• mesenteric ischemia (abd pain, LGIB, pancreatitis);

• intact distal pulses but livedo pattern and toe necrosis

dx of STEMI if old LBBB:

• ≥1 mm STE concordant w/ QRS (Se 73%, Sp 92%),

• STD ≥1 mm V1–V3 (Se 25%, Sp 96%) or

• STE ≥5 mm discordant w/ QRS (Se 31%, Sp 92%)

Paciente con elevación ST en I y aVL

Area anatomica?

Arteria?

Area: cara lateral

A: Circunfleja izquierda

Paciente con elevación ST en V4R e infradesniveles V1 y V2

Area anatomica?

Arteria?

Area: ventriculo derecho

A: A coronaria derecha proximal

Paciente con elevación ST v1 y v2

Area anatomica?

Arteria?

Anatomia: septo

A: LAD (Left anterior descending coronary artery)

Paciente con desniveles ST V1-V3 (supradesniveles V7-V9)

Area anatomic aafectada?

Arteria?

Anatom: cara posterior

A: arteria coronaria derecha / circunfleja izquierda

Paciente con elevacion de ST en V1-V2 y V4R

Fármaco antiisquemico CI

Inhibidor directo trombina

I: principalmente para sustituir el tx con heparina en pacientes con trombocitopenia inducida por heparina

•  Invasive strategy = routine angiography w/in 72 h

• Immediate (w/in 2 h) if:
• refractory/recurrent ischemia,
• hemodynamic or electrical instability
• S/S HF or new or worsening mitral regurgitation
• Sustained VT or VF
• Recurrent angina or ischemia at rest or with low level activities despite intensive medical therapy

• Delayed (ie, acceptable anytime w/in 72 h) if:
• diabetes,
• EF <40%,
• GFR <60,
• post-MI angina,
• PCI w/in 6 mo,
• prior CABG or
• high-risk stress results
• GRACE risk score 109-140
• TIMI ≥2

Treadmill score ≤-11

large perfusion defect (esp. anterior)

multiple perfusion defects

(100 mg en 90min)

Bolo: 15mg

Infusión:

1. 50 mg 30 minutos siguientes
2. 35mg en 60 minutos siguientes

Any prior ICH

Intracranial neoplasm, aneurism, AVM

Nonhemorragic stroke or closed head trauma w/in 3 mo

Active internal bleeding or known bleeding diathesis

Suspected aortic dissection

Backup TP or initiate transvenous pacing if:

• 2° AVB type II;

• BBB + AVB

•  Transvenous pacing (TV) if:

• 3° AVB;

• new BBB + 2° AVB type II;
• alternating LBBB/RBBB(can bridge w/ TP until TV, which is best accomplished under fluoroscopic guidance)

Ventricular aneurism

8-15% incid. (esp. ant)

Persist STE

Tx:

Surgery or perc repair if:

• HF
• Thromboemcoli
• arrhytmia

ICD (NEJM 2008;359:2245)

•  If sust. VT/VF >2 d post-MI not due to reversible ischemia

•  Indicated in 1° prevention of SCD if post-MI w/

• EF ≤30–40% (NYHA II–III) or

≤30–35% (NYHA I);

need to wait ≥40 d after M

Indicaciones diagnósticas de colocaión de cateter arteria pulmonar (Pocket)

•  Diagnosis and evaluation

• Ddx of
• shock (cardiogenic vs. distributive; esp. if  trial of IVF failed or is high risk) and of
• pulmonary edema (cardiogenic vs. not; esp. if trial of diuretic failed or is high risk)

• Evaluation of
• CO,
• intracardiac shunt,
• pulmonary HTN,
• MR,
• tamponade

• Evaluation of unexplained dyspnea (PAC during provocation w/ exercise, vasodilator)

sx w/ minimal activity

NYHA?

Class I:

no sx w/ ordinary activity;

class II:

sx w/ ordinary activity;

class III:

sx w/ minimal activity;

class IV:

sx at rest

Consider if:

EF ≤35%

QRS >120 ms

symptomatic HF

reduction 36% mort & EF increase in NYHA III-IV

reduction 25% mort if:

EF <30%

QRS>120

NYHA II-III (esp if QRS >150 or LBBB)

Afro-americanos

NYHA III-IV (+ IECA-B-Bloq): persistentemente sintomáticos

CI IECA/ARAII

• Intol farm
• Hipotension

• IR

previous myocardial infarction (MI),

LV remodeling

• (including left ventricular hypertrophy [LVH] or
• low ejection fraction), or

asymptomatic valvular disease

• •  Stress-induced (Takotsubo = apical ballooning):
• mimics MI (pain, ± STE & ↑ Tn; deep TWI & ↑ QT);
• mid/apex dyskinesis;
• ? Rx w/ bB, ACEI;
• usu. improves over wks (JAMA 2011;306:277)

• • Metab/other:
• hypothyroid.,
• acromegaly,
• pheo,
• OSA,
• thiamine,
• selenium or carnitine defic

• •  ? Endomyocardial biopsy (JACC 2007;50:1914):
• yield 10% (of these, 75% myocarditis, 25% systemic disease);
• 40% false [-]  rate (patchy dis.) & false [+]  (necrosis →inflammation)
• no proven Rx for myocarditis; 
• ∴ biopsy if:
• acute & hemodyn compromise (r/o GCM, ANEM);
• arrhythmia or RCMP features (r/o infiltrative); or
• suspect toxic, allergic, tumor

• elite athletes
• (wall usually <13 mm & symmetric and nl/↑ rates of tissue Doppler diastolic relaxation; Circ 2011;123:2723),

• •  Systolic murmur:
• crescendo-decrescendo; LLSB;
• ↑ w/ Valsalva & standing (↓ preload)

• •  ± mid-to-late or holosystolic murmur of MR at apex

•  Echo:

no absolute cutoffs for degree of LVH but

• septum/post. wall ≥1.3 suggestive,
• as is septum >15 mm;

• other findings include
• dynamic outflow obstruction,
• SAM,
• MR

•  MRI:

hypertrophy + patchy delayed enhancement (useful for dx & prog) ( JACC CV Imag

2012;2:370)

• If sx refractory to drug Rx + obstructive physiology ( ∇  >50 mmHg):
• (a) Surgical myectomy:
• long-term ↓ symptoms in 90% (Circ 2005;112:482)
• (b) Alcohol septal ablation (Circ CV Interv 2011;4;256; JACC 2011;58:2322):
• gradient ↓ by ~80%,
• only 5–20% remain w/ NYHA III–IV sx;
• 14% require repeat ablation or myectomy.
• Good alternative for older Pts, multiple comorbidities.
• Complic:
• transient (& occ. delayed) 3° AVB w/ 10–20% req. PPM; VT due to scar formation.
• No clear benefit of dual-chamber pacing ( JACC 1997;29:435; Circ 1999;99:2927)

• ECG:
• ↓ QRS amplitude (50%),
• pseudoinfarction pattern (Qw),
• AVB (10–20%),  
• hemiblock (20%),
• BBB (5–20%)

• Echo:
• biventricular wall thickening (yet w/ low voltage on ECG),
• granular sparkling texture (30%),
• biatrial enlargement (40%),
• thickened atrial septum,
• Valve thickening (65%),
• diastolic dysfxn,
• small effusions

• Serotonin:
• carcinoid,
•  serotonin agonists,
• ergot alkaloids

Clinical manifestations (Circ 2000;101:2490)

• •  Right-sided > left-sided heart failure with peripheral edema > pulmonary edema

• •  Diuretic “refractoriness”

• •  Thromboembolic events

• •  Poorly tolerated tachyarrhythmias;
• VT → syncope/sudden cardiac death

Biatrial enlargement (on ecochardiog)

LVEDP>RVEDP

concordance of LV & RV pressure peaks during respiratory cycle

Neoplastic (<10%)

Common: metastatic (lung, breast, lymphoma, leukemia, RCC)

Rare: primary cardiac & serosal tumors (mesothelioma)

•  ECG:

• may show diffuse STE (concave up) & PR depression (except in aVR: ST ↓ & PR ↑),

• TWI;
• classically and in contrast to STEMI,
• TWI do not occur until STs normalize
• Stages:
• (I) STE & PR ↓;
• (II) ST & PR normalize;
• (III) diffuse TWI;
• (IV) Tw normalize

• ECG may show evidence of large effusion
• w/ low voltage &
• electrical alternans (beat-to- beat Δ in QRS amplitude and/or axis due to swinging heart)

•  Steroids (usually systemic; occ. intrapericardial)

• only for
• systemic rheum or autoimmune disorder,
• uremic,
• preg.,
• contraindication to NSAID,
• or refractory idiopathic dis.

• Systemic steroids appear to ↑ rate of pericarditis recurrence (Circ 2008;118:667).

Soplo: holosistolico (crescendo-decrescendo)

Foco max auscultación: Borde esternal derecho

irradiación: carotidas

↑:

 al levantar las

 piernas o ponerse en cuclillas.

Estenosis aortica

(Dx dif: HCM [

• •  Systolic murmur:
• crescendo-decrescendo; LLSB;
• ↑ w/ Valsalva & standing (↓ preload)

• •  ± mid-to-late or holosystolic murmur of MR at apex

])

Soplo: Holosistolico

Foco max auscultación: apice card

irradiación:

↑:cuclillas, elevación de piernas, empuñamiento

Insuficiencia mitral

(EF: inversa a prolapso mitral [clic mediosistolico, soplo medio tardio])

Soplo: diastolico en decrescendo

mid-to-late diastolic rumble at apex

Foco max auscultacion: borde esternal izquierdo

Irradiacion: carotidas

↑:

• con la posición de cuclillas,
• empuñamiento o
• elevación de piernas
• Sentarse hacia delante
• Espiración (Pocket)
  

Insuficiencia aortica

• ↑ w/ sitting forward, expir, handgrip;

• severity of AI  ∝  duration of murmur (except in acute and severe late);

• Austin Flint murmur:
• mid-to-late diastolic rumble at apex (AI jet interfering w/ mitral inflow)

•  Signs of severity:

• late-peaking murmur,

• paradoxically split S2 or inaudible A2,

• small and delayed carotid pulse (“pulsus parvus et tardus”),

• LV heave(tirón),  

• S4 (occasionally palpable)

•  AVR:

• indicated in
• sx AS (almost invariably severe; if not, look for another cause of sx) &
• asx severe AS [AVA<1cm]+ EF < 50%.

• May consider if asx but either
• sx or
• ↓ BP w/ exercise

(can carefully exercise asx AS to uncover sx, do not exercise sx AS) or

• extremely severe

(AVA <0.6 cm2, mean  ∇  >60 mmHg, aortic jet >5 m/s).

• Reasonable if asx mod-severe AS and undergoing CV surgery.

•  In chronic AI,

management decisions based on LV size and fxn (and before sx occur)

•  Surgery (AVR, replacement or repair if possible)

• sx (if equivocal, consider stress test)

• severe AI (if not severe, unlikely to be cause of sx)
• asx severe AI and
• EF ≤ 50% or
• LV dilation
• end syst. diam. >50–55 mm or
• end diast. diam. >70–75 mm, esp. if progression) or
• undergoing cardiac surgery

•  Acute decompensation (consider ischemia and endocarditis as precipitants)

• IV afterload reduction (nitroprusside),

• ± inotropes (dobuta),

• IABP,

• Avoid vasoconstrictors

surgery usually needed for acute severe(≥0.4cm2) MR as prognosis is poor w/o MVR

•  Surgery (repair [preferred if feasible] vs. replacement w/ preservation of mitral apparatus)

• sx severe MR,
• asx severe MR and
• EF 30–60% or
• LV sys. diam. >40 mm

• consider MV repair for asx severe MR w/ preserved EF, esp. if new AF or PHT
• if AF, maze procedure or pulm vein isolation may → NSR and prevent future stroke

•  In Pts undergoing CABG w/ mod–sev fxnal MR, consider annuloplasty ring

•  Percutaneous MV repair:

• edge-to-edge clip less effective than surgery,

• but ? consider for elderly, fxnal MR or low EF (NEJM 2011;364:1395);

• percutaneous valve under study

Clinical manifestations (Lancet 2009;374:1271)

•  Dyspnea and pulmonary edema (if due to RHD, sx usually begin in 30s)

• precipitants:
• exercise, fever, anemia, volume overload (incl. pregnancy), tachycardia, AF

•  Atrial fibrillation:

onset often precipitates heart failure in Pts w/ MS

•  Embolic events:

commonly cerebral, esp. in AF or endocarditis

•  Pulmonary:

hemoptysis, frequent bronchitis (due to congestion), PHT, RV failure

•  Ortner’s syndrome:

hoarseness from LA compression of recurrent laryngeal nerve