Conference Summary 9/8/21

September 8, 2021 , , ,

Residency news and updates:

  • None this week

We will be watching the first quarter of the 2021 EMRAP Cardiology Conference.

Lectures:

8a: Updates on ACS management / Managing Cardiogenic Shock / BREAK

9a: Hypertensive Emergencies / Chest Pain in Pregnancy / BREAK

10a: ECG Bootcamp #1 / Echo 101 / BREAK

11a: LVADs / Managing Acute Pulm Edema

Updates on ACS management

  • Certain NSTEMI’s need reperfusion
  • Immediate invasive (<2h) – 
    • refractory angina, recurrent angina, sustained VT/VF, hemodynamically unstable
    • European guidelines: heart failure 2/2 to NSTEMI, or aVR STE w/ diffuse depressions
  • Early invasive (2-24h): 
    • dynamic ECG (new STD), rising troponin
  • Delayed invasive (24-72h): 
    • DM, CKD, EF < 40%, CABG/PCI w/i 6 month, or post-MI pain
  • Meta-analysis khan;
    • 25% of NSTEMI have OMI – need reperfusion
  • OMI vs NOMI
  • Meyers J emerg Med: 
    • 38% had occlusive disease w/o STE on ECG
    • STE sensitivity not good in occlusive disease
  • Meyers IJC Heart and Vasc 2021 Domo Arigato
    • 41% sensitivity of diagnosing STEMI
  •  90% had >2 findings, 4% had 0 of these findings
  •  DIFOCCULT trial – ⅓ of NSTEMI’s could be identified as OMI on ECG (NSTEMI A group)

Managing Cardiogenic Shock by haney.mallemat@gmail.com @criticalcarenow

  • Takotsubo cardiomyopathy – stress induced, can cause cardiogenic shock
  • Compensated vs decompensated (with stressor, edema) vs cardiogenic shock (decreased perfusion to peripheral tissues)
  • SCAPE 
    • more decompensated; hypertensive – not what this lecture is about
  • Step1: Identify pt is in cardiogenic shock
    • Vital signs, Mental status, Cap refill
    • COLD extremities
    • Hypotension
    • Narrowing pulse pressure = sbp-dbp 
  • Step 2: Identify and confirm: Ultrasound 
  • Step 3: Consult Early
  • Step 4: Resuscitate
    • Small boluses (250c)
    • defend the MAP –increase coronary perfusion
    • start with vasopressors first (NE) – don’t go above 10 mcg Levo, [then step 5: add inotropy – dobutamine (good beta)]
  • Step 5: SUPERCHARGE Cardiac Output (add ionotropy)
    • Dobutamine: good beta, can cause hypotension
    • Epinephrine: good alpha and beta
    • Milrinone: long half-life, can cause hypotension, stuck for 4-6 hours, worse if renal insufficiency
  • Step 6: Check your work
    • Monitor: central line, cvp, new labs (lactate), urine output
    • Intubate?  
      • High risk for acidosis, hypotension, arrest
  • Step 7: CABG, CAth lab?, thrombolysis (not primary unless transport…)
  • Mechanical support – 
    • goals of care (temporary eg myocarditis, wait til PCI/transplant – not curative step)
    • IABP: diastole balloon inflates, systole deflates for suction forward flow…
    • Impella: sits in Left ventricle, pulls blood out of LV into aorta, impella vs IABP no difference…
    • VA ECMO – cath retroperfuses heart, can actually do in the ED… maybe in the future

Hypertensive Emergencies by Jess Mason, MD

  • Core Pendium chapter 
  • Hypertensive emergencies = severe elevations in BP (≥180/120 mm Hg) complicated by acute end-organ dysfunction.
    • Lower bp by 20-25% in 1 hour – SBP 
  • End organ dysfunction aka “emergencies”
    • Neuro emergencies: PRES/RPLS, HTN encephalopathy
    • Cardiac: ACS
    • Pulm: SCAPE
    • Renal: ARF
    • Other: retinal hemorrhages, eclampsia/pre-eclampsia, pheochromocytoma
  • Neuro HTN emergency: nicardipine – quick on and titratable
  • Aortic dissection: reduce HR and bp, esmolol, quick on and off, can add nicardipine for bp (labetalol has 7x more beta blockade than alpha therefore not great for bp)
    • SBP <120 HR <60
  • ACS and pulmonary edema: NG
  • Renal: fenoldopam – less renal injury (or nicardipine in a normal world…)

Chest Pain in Pregnancy by Britt Guest, DO

  • Increase in maternal death: 
    • due to death from cardiomyopathy, CVA, cardiovascular “catastrophes”
  • Risk factors: 
    • Race/ethnicity: African americans >3.4x risk of dying
    • Age >40y/o >30x higher than 20 y/o female
    • HTN: increases risk of MI 13x; Heart failure 8x
  • Pt presentations: chest pain, sob, palpitations
  • Uncomfortable causes: 
    • acid reflux, rib pain, increased RR, increased minute ventilation, Inc HR (15-20%)
  • Pregnant = natural stress test:
    •  inc O2 demand, increased minute ventilation, increased blood volume (inc O2 carrying capacity), inc CO
    • Total Blood Volume up by 50%, CO up by 30-50%
    • IVC compression – dec venous return, Aorta compression – inc afterload
  • Dangerous causes
  1. MI: 3x higher risk, majority have it postpartum period, cardiac muscle takes a year to return to normal
  • Causes: SCAD (43%), coronary atherosclerosis, thrombus in normal artery, coronary spasm
  • SCAD vs atherosclerosis – dx made in cath lab
    • Atherosclerosis: PCI preferred over thrombolysis, ASA + Hep
    • SCAD: conservative management – stent may worsen dissection, heparin could make problem worse
  1. PE: clinical prediction rules not validated in pregnant pt’s, D-dimer increased normally in pregnancy, definitive dx requires imaging
  • Postpartum cardiomyopathy: “rare” 1/1000 cases
    • Risk factors: increased age, multifetal pregnancies, gestational HTN
    • Workup:
      • Bnp increase in normal pregnancy–not most reliable
      • ECG
      • ECHO! 
        • Diagnosing PPCM:
          • HF in late pregnancy or up to 5 months postpartum
          • No other cause for HF
          • LVEF <45%
      • Acute HF: loop, CPAP/BIPAP, NG
      • Long-term: AC (hep), BB, Dig 
    •  Prognosis: linked to LVEF
      • EF< 30%: 5-10% rate of death or cardiac transplant 1 year postpartum
  • Take home points: 
    • Cp, sob, palpitations-normal changes OR pathologic? 
    • Risk of cmy, pe, ami is higher in 3rd trimester and postpartum
    • If you need imaging study-get it
    • Ami think SCAD–avoid heparin and thrombolytics
    • Treatment of pregnant patient is similar to non pregnant patients 

ECG Bootcamp #1 by Amal Mattu, MD

  • MI in LBBB
  • ECG: 
    • STE in contiguous, posterior STEMI, LBBB with sgarbossa, pacemaker with sgarbossa, post-arrest ACS (no longer new LBBB since 2013)
  • Rule of appropriate discordance: 
    • QRS up, little STD (ST should never be in the same direction); OR QRS down, little STE
  • Sgarbossa
    • A – concordant STE > 1 mm any lead – very specific, doesn’t need to be contiguous
    • B – concordant STD > 1 V1, V2, or V3 – very specific, doesn’t need to be contiguous
      • (V1, V2, V3 where the QRS normally points down)
    • C – discordant STE > 5 mm (not in modified; less specific)
      • (When the QRS points down, you normally see a little bit of STE)
  • Revised/modified Sgarbossa
    • A and B are the same.
    • Modified C: STD:S-wave > 25% – really accurate
      • Ratio of STD:S wave size more useful than 5 mm
  • Takehome: revised sgarbossa…

Echo 101 by Amir Tabibnia, DO

  • Cardiac US indications: effusion/tamponade, undifferentiated hypotension, dyspnea, cardiac arrest, TVP, syncope, blunt trauma, acute chest pain
  • Phased array probe w cardiac preset.
    • Parasternal long: cardiac convention (marker to R shoulder), ED (L hip)
    • Parasternal short: cardiac convention (L shoulder)
    • 4 chamber probe L
    • Subxiphoid : probe left
    • IVF: probe inferior
  • PSL
  • Something about a diamond ¯\_(ツ)_/¯ – rule of thirds; L atrium, outflow tract, and RV should all be equivalent size
  • LV systolic function: assess muscle thinning or thickening
    • EPSS – 0.7; LVEF = 75.5 – (2.5 x EPSS)
    • Fractional shortening – endocardium of free wall and interventricular septum should come in 25-40% is normal
  •  
  •  PSS – 3 views; high parasternal, mid parasternal (fish mouth); low parasternal (money shot, papillary muscles)
    • Good for wall motion abnormalities
    • WMA: compare to ECG, limited assessment of WMA in LVH
    • SALPI mnemonic
  • A4C
    • Good for takotsubo
    • Can assess WMA and EPSS
  • SX
    • Great for pericardial effusions (dynamic view, tilt to look for pericardial effusions)

LVADs– ran out of time

Managing Acute Pulm Edema

  • Heart Failure | CorePendium 
  • Not all pulmonary edema is cardiogenic…
  • Diastolic heart failure (preserved EF): heart doesn’t relax, can’t fill properly
  • Systolic (reduced EF)
  • R sided HF →  fluid backs up into body
  • APE: 
    • Sympathetic overdrive
    • Fluid in lung →  resp distress →  terrifying →  sympathetic response →  peripheral vasoconstriction (inc afterload) →  worsens renal perfusion →  RAAS activation →  sodium retention and more vasoconstriction →  redistribution of blood →  inc preload
  • BIPAP vs CPAP
    • fairly equivocal- Core compendium.
    • start CPAP at 10 cm H2O or BiPAP at 10/5 cm H2O and adjusting up as the patient tolerates and with clinical response.
    • FiO2 @100% 
  • US: B lines, anterior lung fields, more than 3 between 2 ribs
    • BLUE protocol: 97% sensitive, 95% specific
    • 1-2 B-lines just means inc pulmonary density, means nothing, huge differential
  • CXR
    • Can suggest volume overload
  • NG
    • Lower doses: decrease preload (<100 mcg/min(
    • Afterload reduction at 100-250 mcg/min
    • Start IV infusion at 400 mcg/min for 2-5 min and titrate (she starts high and titrates down)
    • SL 400 mcg = 80 mcg/min IV bioavailability-wise
    • Bolus dosing NG prevents ICU admission; can go up to 1-2 mg
    • Beware if preload dependent eg pericardial tamponade
    • Ask about viagra…
  • ACE inhibitor for afterload reduction
    • Beware if renal impairment
    • Not 1st line, after initial resuscitation
    • Captopril, enalaprilat
  • Morphine: Increased 30d mortality
    • Except hospice/palliative
  • Diuretics
    • Not initially
    • Good if total body volume overload (not just lungs)
    • Effective if poor renal perfusion
  • APE + Hypotensive: High mortality, cardiogenic shock
    • Fluid challenge (250-500 cc aliquots)
    • Pressors – NE

Authors