Clinical medicine

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<ol><li> 1. TOP SI 117Clinical Medicine N. Srikanchanawat 1 </li><li> 2. TOPSI117 Cardiology Electrocardiography (EKG) Rate - R-R interval 300-150-100-75-60-50 /min () HR = 300/ 1,500/ 1 = 0.04 s, 1 = 0.2 s ( 5 )Rhythm - 5 1. Rate &lt; 60/min = Bradycardia, &gt; 100/min = Tachycardia 2. QRS complex 0.1 s (2.5 ) - Narrow QRS origin supraventricular - Wide QRS ( 3 ) origin ventricle supraventricular BBB aberrant conduction 3. Regularity Regular 1) Precisely regular NSR, SVT, VT 2) Almost regular ( regular, beat beat) Sinus arrhythmia 3) Irregularly regular - Premature beat () PAC, PVC - Escape beat () atrial/ventricular escape beat Irregular 1) Irregularly irregular - AF, MAT, VF - AF with show AV conduction ( complete AV block) 2) Regularly irregular Heart block (SA/AV block) 4. P wave , lead II - P wave +ve lead II sinus ( high atrium) - P wave ve lead II sinus ( dextrocardia, lead ) - P wave AF, VT, VF, P wave QRS complex 5. P wave &amp; QRS complex ( atrium ventricle ) - origin supraventricular - origin QRS ventricle ( AV dissociation) (e.g. 3rd degree AV block) - Normal sinus rhythm (NSR) 1. Rate: 60-100/min 2. Rhythm: Regular </li><li> 3. TOPSI117 3.4. 5.P wave: + Lt. lateral &amp; Inferior leads ( + lead II) - lead aVR biphasic lead III, V1 PR interval: 3-5 QRS complex: 2.5 Axis - R-S lead I aVF plot mean axis -30 +90 normal axis ( 0-90 quadrant lead I &amp; aVF +) - RAD = +90 lead I -, lead aVF +; (esp. elderly, thin), emphysema, RVH, dextrocardia, lt. posterior hemiblock - LAD = 0 lead I +, lead aVF -; (esp. elderly, obese), diaphragm (e.g. pregnancy, ascites, carcinomatosis peritonei), LVH, lt. anterior hemiblock, hyperK+ - lead I, aVF I +ve, aVF +ve Normal axis I +ve, aVF ve LAD I ve, aVF +ve RAD I ve, aVF -ve Indertermined axis (Extreme RAD)Enlargement/Hypertrophy - Atrial enlargement lead II &amp; V1 P wave + lead II (), biphasic lead V1 ( RA portion LA portion : RA portion +, LA portion -) - RAE criteria: P wave amplitude &gt; 2.5 mm Inferior leads (II, III, aVF) 1) P wave pattern RAE P pulmonale ( severe lung disease e.g. severe COPD resistance lung ) 2) RAE RAD 3) RAE duration RA depolarize LA, RA depolarize LA depolarize - LAE criteria: 1. P wave duration &gt; 3 &amp; LA portion 1 2. P wave LA portion ( V1) amplitude drop isoelectric line 1 mm 1) P wave pattern LAE P mitrale ( mitral valve disease) 2) LAE LAD ( normal axis ) 3) LAE duration LA portion P wave, LA depolarize duration P wave </li><li> 4. TOPSI117 - RVH criteria: 1. RAD (QRS axis &gt; 100) 2. Tall R (R &gt; S) lead V1, Large S (S &gt; R) lead V6 ( normal) - RVH pressure overload volume overload volume overload (e.g. ASD, VSD, PDA, TR) RSR (rabbit ear) lead V1 ( RBBB) - LVH (pressure overload) criteria: 1. R lead aVL &gt; 13 mm (most specific) 2. R lead V5 V6 + S lead V1 V2 &gt; 35 mm 1. LVH 2 criteria criteria criteria 2. LVH LAD 3. EKG pattern LVH sense ( 50% LVH), spec ( EKG LVH pattern 90% LVH ) - severe LVH ( symtoms CHF) amplitude R wave lead aVL , 2 Repolarization abnormalities (Down-sloping ST depression, Asymmetric TWI) - LVH pressure overload volume overload - Pressure overload 2 Repolarization abnormalities (Down-sloping ST depression, Asymmetric TWI) - Volume overload ST depression, Symmetric TWI, lead V5-V6 deep Q wave - HOCM (IHSS) genetic disease; AD; EKG 1. LVH 2. 2 Repolarization abnormalities leads tall R wave 3. Q wave Inferior &amp; Lt. lateral leads ( significant septal hypertrophy) HOCM = hypertrophic obstructive cardiomyopathy; IHSS = idiopathic hypertrophic subaortic stenosis disorganized proliferation muscle fibers septum; sudden death in the young healthy athletes 1) LV outflow obstruction 2) LV impaired diastolic filling ( stiff ) 3) Cardiac arrhythmia Management: Verapamil ( strength ventricular contraction obstruction), -blockerIschemia/Infarction - 3 zones 1. Zone of ischemia , depolarization , repolarization prolong QT, T change - Anterior subendocardial &amp; posterior subepicardial ischemia Symmetrical peaked positive T - Anterior subepicardial &amp; posterior subendocardial ischemia Symmetrical peaked inverted T 2. Zone of injury , depolarization , repolarization ST change </li><li> 5. TOPSI117 --Subepicardial injury ST elevation ( 1 mm) lead , lead ST depression = Reciprocal change - Subendocardial injury ST depression 3. Zone of infarction necrosis , , EKG 4 1) Hr. 2-3 ( injury, ischemia, necrosis) - ST elevation (subepicardial injury) - Giant &amp; peaked T (subendocardial ischemia) - Q wave ( necrosis ) 2) Wk. 2-3 ( injury ) - Q wave - Biphasic T ( turn TWI) 3) Wk. 3 ( injury LV aneurysm ST elevation ) - necrosis (Q wave) &amp; ischemia (TWI) 4) Long-term ( ischemia &gt; 50% ) - necrosis Pathological (Significant) Q wave = Q wave 1 , 1/3 QRS complex Chronic ischemia: T wave Symmetric TWI ( strain pattern Asymmetrical TWI) Persistent ST elevation ( 2 wk. ) LV aneurysm ( remodeling infarct) lead location ischemia/infarction Septal wall: V1-V2 Anterior wall: V3-V4 Extensive anterior wall: V1-V5 (LAD) Anteroseptal wall: V1-V4 Apical wall: V5-V6 Lateral wall: I, aVL Inferior wall: II, III, aVF RV: V1-V2, V3R-V4R Posterior wall: ST depression V1-V2 ( reciprocal change precordial leads )Atrial fibrillation (AF) - CHA2DS2-VASc score ( 2010) risk stroke AF Antiplatelet (ASA) Anticoagulant (Warfarin) stroke 1. CHF LVEF 35% (+1) 2. HT or on medication (+1) 3. Age 75 (+2) 4. DM (+1) 5. Prior Stroke or TIA or Thromboembolism (+2) 6. Vascular disease (Prior MI / Peripheral artery disease / Aortic plaque) (+1) 7. Age 65-74 (+1) 8. Sex category: Female (+1) Score = 0 Low risk ASA 325 mg OD </li><li> 6. TOPSI117 -Score = 1 (Stroke rate = 1.3%/yr.) Moderate risk , counseling + Score 2 High risk Warfarin, keep INR 2-3 (Score = 2: Stroke rate = 2.2%/yr.; Score = 3: Stroke rate = 3.2%/yr.; Score = 4: Stroke rate = 4%/yr.) Digoxin (Digitalis, Lanoxin) delay AV conduction HR C/I: 2nd degree AV block, VT, VF, HOCM Digitalis toxicity arrhythmia (), SE: N/V, Xanthopsia, Bradycardia Digitalis toxicity , , , K+ , Ca+ ( HCTZ) Digitalis toxicity 1. Digoxin 2. HypoK+ 3. Digoxin specific sheep Fab fragmentsCoronary artery disease (CAD) - Risk factors for CAD 6 1. Age 45 (male), 55 (female) menopause ( surgical menopause ) 2. Family history of premature CAD (1st degree relative): Age &lt; 55 (male), &lt; 65 (female) ( Hx CAD , , balloon, CABG, Hx SCD) 3. DM 4. HT (BP 140/90) 5. HDL &lt; 40 ( on treatment); &gt; 60 risk factor 6. Active smoker; -1 ( study 1 risk CAD ) - Angina pectoris definition: Chest discomfort cardiac ischemia - Typical angina characteristic 3 1. Retrosternal chest pain ( referred pain) 2. Precipitated by exertion/emotional stress 3. Relieved by rest/NTG 2 = Atypical angina; 1 = Non-angina ( cardiac) - chest pain Non-diagnostic chest pain - Acute myocardial infarction (AMI) Dx criteria ( 2/3 ) 1. Angina 2. EKG myocardial ischemia 3. Cardiac enzyme +veAcute Coronary Syndrome (ACS) Initial management </li><li> 7. TOPSI117 - MONA Morphine sulfate 2-4 mg IV add 2-8 mg q 5-15 min O2 cannula 3 LPM, keep O2 sat. &gt; 90% ( impaired O2 lung HF ) NTG 0.4 mg 1 tab SL q 5 min ( 3 ) (C/I: BP drop esp. RV infarct ) ASA gr. V (325 mg) 1 tab stat + Clopidogrel - MONA 12-lead EKG w/in 10 min ST elevation (STEMI) Non-ST elevation (UA/NSTEMI); monitor EKG repeat q 5-10 min, ST elevation new LBBB AMI - STEMI UA/NSTEMI Clopidogrel (Plavix) 1. If plan TT - Age &lt; 75 loading dose 300 mg (4 tab) - Age &gt; 75 loading dose 75 mg (1 tab) 2. If plan 1 PCI loading dose 600 mg (8 tab) 3. If no reperfusion therapy loading dose 300 mg (4 tab) - 1-blocker C/I cardiogenic shock 3 AME 1. Atenolol 5 mg IV, repeat q 5 min 2. Metoprolol 5 mg IV drip () in 1-2 min, repeat q 5 min (max = 15 mg) 3. Esmolol 50 g/kg (up to 200-300 g/kg ultrashort action -blocker) - chest pain / CHF / HT NTG IV drip rate 5-10 g/min add 5-20 g q 5 min SBP 90 mmHg - plan 1 PCI GPIIb/IIIa inhibitor (GPI) (Abciximab, Eptifibatide, Tirofiban) 1 PCI continue 12 hr. (Abciximab) 24 hr. (Eptifibatide, Tirofiban)STEMI - Reperfusion therapy w/in 12 hr. Thrombolytic therapy (TT) / 1 Percutaneous coronary intervention (1 PCI) - .. 3 hr. TT ( C/I): SK 1.5 MU (in 5%D/W 100 cc) IV drip in 1 hr. Door-to-needle time ( .. TT) 30 min - 3 hr. 1 PCI (CAG + stent/balloon) Door-to-balloon time ( .. balloon) 90 min Door to needle/balloon time transfer .. - Door-to-balloon time 90 min () transfer TT transfer high risk ( TIMI risk score for STEMI ) - TIMI risk score for STEMI mortality rate 30 STEMI TT high risk transfer PCI (= Facilitated PCI) - PCI 1. .. PCI (Door-to-balloon time &lt; 90 min) </li><li> 8. TOPSI117 2. 3 hr. 3. C/I TT 4. Killip class 3 - Killip class mortality rate STEMI ( Killip class 3 PCI) Class Definition Mortality rate 1 No CHF 6% 2 S3 gallop / Basal lung crepitation 17% 3 Pulmonary edema 30-40% 4 Cardiogenic shock 60-80% - CAG TVD / DVD with Proximal LAD stenosis with LV dysfunction / LM disease plan CABGUA/NSTEMI - Cardiac enzyme Risk stratification ACC/AHA guidelines Cardiac enzyme CK-MB: +ve &gt; 3x UNL, MI 6 hr., peak 24 hr., baseline 72 hr. Troponin (Tn): sense CK-MB, CK-MB, +ve suspected MI - High risk ( PCI) 1. Recurrent angina ischemia at rest full medication 2. TnT/TnI 3. New ST depression 4. HF / New MR / MR 5. Cardiac stress test High risk 6. Hemodynamic unstable 7. Sustained VT 8. S/P PCI w/in 6 mo. / S/P CABG 10. TIMI risk score/GRACE score High risk 11. LVEF &lt; 40% - TIMI risk score (TRS) for UA/NSTEMI PCI Score 0-2 Low risk; Score 3 High risk History 1. Age 65 2. Risk factors for CAD 3 ( 6 ) 3. Known CAD: stenosis 50% 4. ASA use in past 7d Presentation 5. Severe angina 2 episodes in past 24 hr. </li><li> 9. TOPSI117 6. ST changes 0.5 mm 7. Cardiac enzyme +ve - High risk Invasive strategy plan PCI - Low risk Conservative strategy Repeat Troponin - plan PCI ( high risk) - 2 Cardiac stress test (threadmill / dobutamine stress echo.) - myocardial ischemia plan PCI - myocardial ischemia Medication (ASA, Clopidogrel, LMWH (Enoxaparin), ACEI, -blocker, Statin, Nitrate, Omeprazole, Senokot, Ativan)Home medication - ASA 75-162 mg/d - Clopidogrel (Plavix) 75 mg OD 1 mo. ; 1 PCI with drug eluting stent 1 - 1-blocker (cardioselective) C/I; MI 2 AM 1. Atenolol 50-100 mg/d ( ) 2. Metoprolol 25-50 mg bid (up to 100 mg/d) - ACEI reverse LV remodeling; Captopril short-acting SE ( BP drop ) SE .. Captopril 6.25 mg ( x2 ) then 12.5 mg in next 2 hr. then 25 mg in next 12 hr., then 50 mg bid H/M Captopril 50 mg bid; stable long-acting ACEI , LVEF , risk factors for CAD , DM - SE ACEI non-productive cough ( ), angioedema ( laryngeal edema) SE ARB Losartan (Cozaar), Valsartan (Diovan) - Spironolactone (Aldactone) 25-50 mg/d LVEF &lt; 40%, HF, DM Spironolactone Cr 2.5 mg/dl (), 2 mg/dl (), K+ &lt; 5 mmol/L - Atorvastatin (Lipitor) 80 mg/d 2 mo. F/U Goal: LDL &lt; 100 (must) LDL &lt; 70 (optional; ) - Advice Lifestyle modification (, , ); add Fibrate Nicotinic acid - Medication aggressive 1. Previous CAD 2. CAD equivalence ( CAD) 3 DM, AAA, PVDHeart failure (HF) </li><li> 10. TOPSI117 - HF EF 2 1. Systolic HF: EF &lt; 40-50% 2. Diastolic HF (HF with preserved EF, HFPEF): EF &gt; 40-50% - HF Dx S&amp;S + CXR Dx HF 3 1. S&amp;S dyspnea, PND, orthopnea, fatigue, abdominal discomfort, ascites, anasarca, engorged neck vein, gallop, crepitation, pitting edema 2. Investigation 1) CXR cardiomegaly, pulmonary edema, pleural effusion ( ARDS) 2) EKG STEMI, NSTEMI ( cardiac enzyme ) 3) Echocardiography EF, chamber size 4) Serum BNP &amp; NT-pro BNP HF NT-pro BNP &gt; 400 (BNP BNP BNP R/O ve +ve emergency) 3. Therapeutic diagnosis - NYHA Functional class (FC) FC Definition 1 Asymptomatic 2 Symptomatic with moderate exertion 3 Symptomatic with minimal exertion 4 Symptomatic at rest - HF acute &amp; chronic HF - Acute HF 2 1. Acute cardiogenic pulmonary edema 2. Acute decompensation of chronic HF chronic HF precipitate acute HF - HF S&amp;S = Compensated HF precipitate decompensate Infection, Na+ intake , , arrhythmia, MI, stress, PE, drug ( Na+ ), anemia, thyrotoxicosis, IE, RF, pregnancy - Initial management for acute HF LMNOP 1. Lasix (Furosemide) 20-80 mg IV ( severity &amp; renal function); urine 15-30 min double dose 2. Morphine sulfate 3-5 mg IV in 2-3 min; repeat in 3-5 min Naloxone 2 mg IV; add 2 mg total 10 mg 3. Nitrates NTG 0.6 mg SL q 5-10 min 3-4 NTG Nitroprusside IV drip 4. O2 cannula 3-5 L/min; Po2 O2 mask with bag 8-10 L/min, keep O2 sat. &gt; 90% 5. Position: Fowlers position (+) Lasix preload &amp; pulmonary congestion; MO &amp; NTG venodilator preload </li><li> 11. TOPSI117 position Fowlers position V.R. preloadHypertension (HT) - 1. Essential (1) HT (95%) 2. 2 HT (5%) organic cause - Cause of 2 HT 1. Renal Parenchyma (DM, PKD, GN), Renovascular (Atherosclerosis, FMD, PAN, Scleroderma) 2. Endocrine Hyperaldosteronism, Cushings, Pheochromocytoma, Myxedema, HyperCa2+ 3. Other Medication, OSA , CoA, Polycythema vera - JNC 7 Classification SBP DBP category Category BP Normal &lt; 120/80 Pre-HT 120/80 HT stage 1 140/90 HT stage 2 160/100 - severity 1. Mild HT = BP 140/90 (HT stage 1) 2. Moderate HT = BP 160/100 (HT stage 2) 3. Severe HT = BP 180/110 - BP Dx HT 1. BP 5-10 min BP 2 1 min 2. BP 1-2 1 wk. BP Dx HT - Target organ damage (TOD) 1. LVH Echo. / EKG 2. Microalbuminuria (20-300 mg/d) 3. Extensive atherosclerotic plaque Radiological / U/S 4. HT retinopathy grade 3, 4 - Management - Mild HT - TOD, Risk factors for CAD &lt; 3 LSM 1-3 mo. F/U: BP &gt; 140/90 mmHg Monotherapy (start 1 ) - TOD and/or Risk factors for CAD 3 Monotherapy (start 1 ) - Moderate HT - TOD, Risk factors for CAD &lt; 3 LSM 1 mo. F/U: BP &gt; 140/90 mmHg Drug combination (start 2 ) - TOD and/or Risk factors for CAD 3 Drug combination (start 2 ) </li><li> 12. TOPSI117 - Severe HT Drug combination - start Anti-HT (A = ACEI, C = CCB, D = Diuretics) Step1 ( 1 ) &lt; 55 yr. A, 55 yr. C or D Step 2 ( 2 ) A+C or A+D Step 3 ( 3 ) A+C+D Step 4 (Persistent HT) add : -blocker, -blocker, Spironolactone, Diuretic , consult HT - Elderly Isolated systolic HT 1st line Anti-HT Diuretics (e.g. HCTZ) electrolyte condition SE (e.g. HypoNa+, HypoK+) Gout - Goal: - General: BP 140/90 mmHg - DM / Renal disease : BP 130/80 mmHg - Urine protein 1 g/d: BP 125/75 mmHg - Age 80 yr. ( ISH): BP 150/80 mmHgHypertensive crisis - HT crisis HT emergency &amp; HT urgency - HT emergency = HT + Acute TOD Acute TOD HT HT emergency 1. Aorta Acute aortic dissection, Symptomatic aortic aneurysm 2. Heart Acute LV failure, AMI, UA 3. Brain HT encephalopathy, ICH, SAH, Cerebral infarction...</li></ol>