We present some tips that we hope you will find helpful in your practice. These are not guidelines or critical pathways. The care given to each patient must be individualized to their particular circumstances.
HOME | CONTENTS | SEARCH | PRACTICE PROFILE | MEET THE PHYSICIANS | WHAT'S NEW |
CARDIAC RESOURCE | HEALTHY HEARTS | LINKS
ACUTE PULMONARY EDEMA WITHOUT ST ELEVATION ON ECG
A. Diurese with IV diuretics and monitor electrolytes
B. Topical or IV Nitroglycerin
C. If unstable coronary disease is felt to be playing a role, prescribe enteric coated aspirin and anticoagulate with intravenous heparin or subcutaneous lovenox 1 mg/kg q 12 hours.
D. Order echo if not previously done for same condition
E. Order serial cardiac biomarkers and ECGs if unstable coronary disease is felt to be playing a role
F. Consider cardiology consult, especially if this is first episode of CHF, complicated by other cardiac conditions, or poor response to therapy
G. Antiarrythmic therapy is usually reserved only for sustained VT (greater than 30 seconds and rate greater than 110) or symptomatic bradycardia.
ANTIPLATELET AGENTS AFTER CORONARY STENT PLACEMENT
After placement of a coronary stent, two antiplatelet agents are administered concomitantly for a month. One is aspirin. The other is Plavix. Ticlid can be used for patients with adverse reactions to Plavix.
After the 4 week period, aspirin alone is continued indefinitely. However, if the patient received brachytherapy (intracoronary radiation therapy) then plavix must be continued along with the aspirin for a year. If the partient has received a drug eluting stent then Plavix should be continued at least 3 to 6 months and preferably 12 months.
A. Order echo and thyroid function tests, if not previously done for this condition. Clinical circumstances will dictate whether a workup for venous thromboembolic disease or coronary artery disease should be undertaken.
B. Rate control with IV diltiazem and/ or IV verapamil and/or IV beta blocker and/or IV digoxin. Digoxin takes the longest to slow the ventricular response. Digoxin will not lower the blood pressure which may or may not be beneficial depending on the patient's blood pressure. For chronic heart rate control, begin p.o. beta blocker / diltiazem / verapamil / digoxin. Check rate control during physical activity as well. Digoxin tends to be the least effective at controlling the rate with physical activity. None of these agents are terribly effective at converting the fibrillation back to sinus or preventing recurrent fibrillation in the future. Beta blockers are more likely to be effective in preventing reoccurrences than calcium blockers or digoxin.
C. Consider IV Heparin or subcutaneous low molecular weight heparin followed by p.o. Coumadin, unless contraindicated. Target INR is 2.0 to 3.0.
D. If the duration of the arrhythmia is known to be less than 48 hours, consider early cardioversion. Otherwise patient will require 3-4 weeks of anticoagulation keeping INR 2.0 to 3.0 before cardioversion and continued anticoagulation for one month thereafter. The use of TEE guided cardioversion to obviate the need for 4 weeks of anticoagulation prior to cardioversion is currently being explored.
E. Consider cardiology consult or telephone discussion re: electrical or chemical cardioversion.
F. Studies have no morbidity or mortality advantage for a strategy of maintaining sinus rhythm with cardioversion and antiarrhythmic agents compared to simply maintaing rate control of the atrial fibrillation and anticoagulating with coumadin. The latter strategy is certainly a reasonable consideration for elderly patients with atrial fibrillation that is asymptomatic once rate control is achieved.
A. Chest x-ray
B. ECG
C. Begin diuretic if fluid overloaded.
D. Control contributory factors - salt /fluid intake, HTN, obesity. If patient is in atrial fibrillation, good rate control must be achieved.
E. Monitor basic metabolic panel and magnesium
F. Order echo (unless previously done for this condition)
G. Consider ACE - inhibitor / angiotensin receptor blocker / nitrates & hydralazine if EF low
H. Consider spironolactone if EF is low and creatinine < 2.6 and K < 5.1
I. Consider beta blockers once patient is euvolemic and on angiotensin antagonists
J. Consider cardiology consult or telephone discussion once echo, chest x-ray and ECG are available to consultant
K. All patients with CHF who are not responding to Rx or who have signs of significant valvular disease should have a cardiology consult.
A. Chest x-ray
B. If history, physical exam, chest x-ray are equivocal, order a BNP level.
C. Always order a Doppler echocardiogram if there is a suggestion of congestive heart failure.
D. A stress test can help evaluate for coronary artery disease producing dyspnea as an anginal equivalent. The stress test can be combined with pulse oximetry to look for exercise induced oxygen desaturation which, in the absence of clear-cut heart failure, indicates pulmonary disease.
D. Consider a cardiology consult if significant abnormality on echo or stress test.
E. Consider further pulmonary workup, including pulmonary function tests, if cardiac workup is unrevealing.
F. Don't forget about other causes of dyspnea such as deconditioning, anemia and metabolic acidosis.
Isolated early peaking systolic ejection murmur in the absence of cardiac symptoms does not require echo. Otherwise, do echo and consult or have a telephone discussion with cardiologist if clinically significant pathology found.
Note: -Clinically significant valve disease requires antibiotic prophylaxis.
-Severe asymptomatic MR or AR requires follow up echos at least yearly. Progressive LV enlargement or the development of systolic dysfunction are the usual indications for valve surgery in asymptomatic patients.
-Indication for surgery in MS or AS is symptoms, not valve area. Follow up echos are less useful for stenotic than regurgitant lesions in the absence of symptoms. On the average, patients with aortic stenosis will have a 0.1cm^2 per year decrease in valve area.
PALPITATIONS / INTERMITTENT DIZZINESS / PRE-SYNCOPE
Excellent references on this topic include Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl J Med 1998;338:1369-1373 and Zimetbaum PJ, Josephson ME. The evolving role of ambulatory arrhythmia monitoring in general clinical practice. Ann Intern Med 1999; 130:848-856.
Not all palpitations are due to an an arrhythmia. Many simply represent a forceful heart beat during normal sinus rhythm. This does not generally require any evaluation or treatment other than reassurance.
Palpitations require diagnostic evaluation when (1) clinical data suggest an arrhythmic etiology, (2) there is evidence of underlying organic heart disease or (3) when the patient demands a workup. If there is no evidence of underlying organic heart disease and the palpitations are well tolerated and not sustained, reassurance without ambulatory monitoring may be sufficient. If a workup is required, the following is suggested:
A. Obtain cardiac event recorder. A cardiac event monitor is more likely to be of diagnostic yield than a Holter monitor. However, if symptoms occur frequently, a Holter monitor may be used first. If the symptoms do not occur during the Holter monitoring period, an event recorder should then be obtained. An insertable loop recorder can be placed by a cardiologist for very infrequent events
B. If clinically significant arrhythmias documented (i.e. more than just APCs or VPCs), then get echocardiogram, then consider a cardiology consult.
C. Symptomatic APCs and/or VPCs in absence of other cardiac signs and symptoms are best treated by reassurance of their benign nature. If that is not sufficient, a trial of beta blockade may be used.
D. Sensation of palpitations when someone lies down in bed is common and often represents an awareness of normal sinus rhythm or isolated APCs and VPCs rather than a serious arrhythmia.
E. If the event recorder documents normal sinus rhythm during the complaint of palpitations the best treatment is reassurance. Beta blockers may be considered if reassurance is insufficient.
F. Documentation of normal sinus rhythm while a patient is experiencing dizziness or lightheadedness rules out an arrhythmic etiology for those symptoms.
*Patients who have had frank syncope should have prompt cardiac consult.
SUSPECTED CAD / ANGINA / SCREENING FOR CAD / PRE-OP EVALUATION (stable patient)
PERFORM STRESS TEST---CONSIDER A CARDIOLOGY CONSULT IF ABNORMAL
A. How to choose the stress test:
| Resting ECG | On Digoxin? | Able to exercise* (and not on negative chronotropes) | Stress Test |
| Normal | No | Yes | Treadmill Stress Test |
| Abnormal ** | No | Yes | Treadmill Stress with Echo or Radionuclide imaging |
| Normal | Yes ** | Yes | Treadmill Stress with Echo or Radionuclide imaging |
| Abnormal | Yes | Yes | Treadmill Stress with Echo or Radionuclide imaging |
| Normal or Abnormal | Yes or No | No | Dobutamine Stress with Echo or Radionuclide imaging OR Adenosine/Persantine Stress Radionuclide imaging |
* If the patient is able to exercise but negative chronotropic meds were not or could not be discontinued, then consider adenosine radionuclide stress test
**If the baseline ST segment depression is less than 1mm, then a routine treadmill could be done first. If that is abnormal, then stress testing should be repeated with echo or nuclear imaging. Greater degrees of baseline ST depression, right bundle branch block, and WPW should be tested with an imaging modality. Left bundle branch block and paced rhythms are best tested by adenosine radionuclide, even if the patient can run to a diagnostic heart rate on the treadmill.
Ref: Gibbons RJ, et al. ACC/AHA Guidelines for Exercise Testing: Executive Summary Circulation. 1997;96:345-354
B. Stress & Dobutamine echos are technically difficult in the following categories of patients:
1. Obese
2. COPD
3. Known technically difficult echo in the past
In these situations consideration should be given towards stress nuclear (thallium, sestamibi) studies: (exercise if able to exercise, adenosine, persantine or dobutamine if unable to exercise)
C. Asymptomatic patient with positive stress ECG but no chest pain on treadmill
--OR--
Patient with atypical chest pain and positive stress ECG but no chest pain on treadmill
IN THESE TWO SITUATIONS THE NEXT STEP IS GENERALLY A STRESS ECHO OR STRESS RADIONUCLIDE
Additional notes:
Adenosine and persantine should be avoided in patients prone to bronchospasm (reactive airway disease, not fixed airway disease).
Dobutamine should be avoided in patients prone to tachyarrhythmia and ventricular ectopy.
If the clinical diagnosis is unstable angina or new onset angina, a prompt consult, usually in the hospital or chest pain center, should be obtained.
Who should undergo pre-operative screening with a stress test?
When you see a patient for a pre-op internal medicine exam, ask yourself if this is a patient whom you would do a stress test on if you were just seeing him/her for a general medical exam and not for a pre-op exam. If the answer is yes, then it would be prudent to do the stress test prior to the surgery. If the answer is no, then there is no need to do a stress test simply because surgery is planned.
All patients with abdominal aortic aneurysm, peripheral vascular disease and cerebrovascular disease are at risk for coronary artery disease and should generally be screened prior to any vascular procedure.
UNSTABLE ANGINA / CHEST PAIN / RULE OUT MI
A. Institute Rx:
1. Enteric coated aspirin
2. IV Heparin or subcutaneous lovenox one mg/kg q 12 hours
3. Topical or IV Nitroglycerin
4. beta blocker if not contraindicated
B. Order serial enzymes and ECG
C. Antiarrythmic therapy is usually reserved only for sustained VT (greater than 30 seconds and rate greater than 110) or symptomatic bradycardia.
D. Consider early cardiology consult especially if there are positive biomarkers or serial ECG changes. If patient rules out, is stable, and there is a low clinical suspicion that the chest pain is of cardiac origin, then consider stress test first.
Note: These guidelines are based on the consensus American College of Cardiology/American Heart Association Guidelines for the indications for echocardiography. (Circulation Vol. 95, No. 6 March 18, 1997 pg. 1687-1744) and the consensus American College of Cardiology/American Heart Association Guidelines for the management of patients with valvular heart disease (J Am Coll Cardiol. 1998;32:1486-588)
II. CHEST PAIN
IV. SOURCE OF EMBOLI
V. PALPITATIONS
VI. SYNCOPE
All Patients with suspected aortic or mitral disease should have baseline echo.
In the absence of symptoms, we generally do not operate on patients with aortic or mitral stenosis and no significant regurgitation.
Serial echos to monitor the severity of the stenosis once the diagnosis has been made are not mandatory. Follow up echos should be done when clinically indicated based on signs and symptoms.
Patients with severe aortic or mitral regurgitation should be followed with at least yearly echocardiograms.
Echos are not indicated to exclude the presence of mitral valve prolapse in patients with ill-defined symptoms in the absence of other clinical data to suggest mitral valve prolapse.
In the absence of symptoms or a new murmur, serial echos are not indicated for monitoring patients with mitral valve prolapse.
Serial echos are not required for follow up of mild regurgitation in the absence of new symptoms or new findings on physical examination.
Fever and a new regurgitant murmur suggests that an echo should be done to exclude the presence of vegetations. A new systolic ejection murmur is common in febrile patients and is not an indication for an echocardiogram.
Echos are not mandatory for the routine follow up of patients with prosthetic valves in the absence of new symptoms or physical findings. However a baseline echocardiogram should be done about two to three months after placement of a new prosthetic valve to establish a baseline for comparison in case there is a future suspicion of valvular dysfunction.
Echocardiograms are not routinely indicated for early peaking systolic ejection murmurs that do not increase in intensity with the Valsalva maneuver in association with normal carotid upstrokes and an otherwise normal physical examination in the absence of symptoms. This would generally apply to the innocent flow murmur or a murmur of the aortic sclerosis in the elderly patients.
RETURN TO ECHO TABLE OF CONTENTS
With a normal cardiac exam, normal ECG and normal chest x-ray, echocardiography has a low yield in the evaluation of chest pain. Chest pain suspected of being anginal in origin should be initially evaluated by stress testing. Echocardiography to rule out mitral valve prolapse in patients with atypical chest pains is a low yield procedure and unlikely to influence management.
RETURN TO ECHO TABLE OF CONTENTS
Echocardiograms are required for the initial evaluation of congestive heart failure. Once an echocardiogram has been done and the etiology of congestive heart failure is established, repeating echos for future CHF evaluations is unlikely to affect management. In addition echocardiograms are not indicated for routine follow up of patients with congestive heart failure whose clinical status is stable. Follow up echos may be useful in following progression of pulmonary hypertension and LV function.
Echocardiograms are not indicated to evaluate pedal edema in patients without dyspnea, pulmonary venous congestion, neck vein distention or hepatic congestion especially when there is clinical evidence of lower extremity venous insufficiency.
RETURN TO ECHO TABLE OF CONTENTS
In patients with atrial fibrillation, echocardiography is not necessary to rule out the presence of intra cardiac thrombi if Coumadin will be started anyway.
RETURN TO ECHO TABLE OF CONTENTS
Echocardiography is not indicated in the workup of palpitations unless a clinically significant arrhythmia is first documented. Occasional atrial premature contractions, non-sustained supraventricular tachycardia and occasional PVC’s do not necessarily mandate echocardiography, in the absence of other cardiac problems.
RETURN TO ECHO TABLE OF CONTENTS
Echocardiography is not indicated for recurrent syncope of known etiology.
Echocardiography is not indicated for classic neuro-cardiogenic (vasovagal) syncope.
Echocardiography is not indicated for recurrent syncope with no clinical evidence of heart disease.
Echocardiography is indicated for syncope of uncertain etiology when there is a clinical suspicion of heart disease.
RETURN TO ECHO TABLE OF CONTENTS
RETURN TO MAIN TABLE OF CONTENTS
WHEN TO ORDER A TILT TABLE TEST
Note: These guidelines are based on the American College of Cardiology Consensus document published in the Journal of the American College of Cardiology Vol 28, No. 1, July 1996:263-75
I. Conditions in Which Tilt Table Testing Is Warranted
A. The evaluation of recurrent syncope or a single syncopal event accompanied by physical injury or motor vehicle accident or occurring in a high risk setting (e.g., commercial vehicle driver, machine operator, pilot, commercial painter, surgeon, window-washer, competitive athlete) and presumed to be, but not conclusively known to be (by medical history or other evidence), vasovagal in origin.
1. Patients in whom there is no history of or overt evidence for organic cardiovascular disease and in whom the historical aspects are suggestive of vasovagal episodes (i.e., episodes tend to occur while standing or sitting; are associated with prodromal symptoms, such as dizziness, diaphoresis, nausea and weakness, or a "flushed feeling").
2. Patients in whom organic cardiovascular disease is present, but in whom historical aspects are suggestive of vasovagal episodes and in whom other causes of syncope have not been identified by appropriate testing (including conventional electrophysiologic study).
3. As part of the overall evaluation of unexplained syncope despite absence of historical features suggesting a diagnosis of vasovagal syncope in I) patients without a history of or overt evidence for organic cardiovascular disease and in whom vasovagal syncope may be a potential cause ; ii) in patients with concomitant cardiovascular disease after appropriate testing to rule out other potential causes of syncope.
B. The further evaluation of patients in whom an apparent specific cause of syncope has been established by physiologic recordings either during a spontaneous event or by demonstration of reproduction of symptoms during electrophysiologic/hemodynamic study (e.g., asystole, high grade atrioventricular (AV) block), but in whom the demonstration of susceptibility to hypotension-bradycardia of a neurally mediated origin may affect treatment plans (e.g., use of education, reassurance or pharmacologic therapy instead of education, reassurance or pharmacologic therapy instead of or in conjunction with implantable pacemaker therapy).
C. Evaluation of recurrent exercise-induced syncope when a thorough history and physical examination, 12-lead ECG, echocardiogram and formal exercise tolerance testing demonstrate no evidence of organic heart disease.
II. Conditions in Which Tilt Table Testing Is Relatively Contraindicated
A. Syncope with clinically severe left ventricular outflow obstruction.
B. Syncope in the presence of critical mitral stenosis.
C. Syncope in the setting of known critical proximal coronary artery stenoses.
D. Syncope in conjunction with known critical cerebrovascular stenoses.
III. Conditions in Which Tilt Table Testing Is Not Warranted
A. Single syncopal episode, without injury and not in a high risk setting, in which clinical features clearly support a diagnosis of vasovagal syncope.
B. Syncope in which an alternative specific cause has been established by physiologic recordings either during a spontaneous event or by demonstration of reproduction of symptoms during electrophysiologic/hemodynamic study and in which the potential additional demonstration of a neurally mediated contribution to the etiology would not alter treatment plans.
Dan Sorajja, M.D., Syncope While Driving: Clinical Characteristics, Etiologies, and Prognosis.
http://www.cardiosource.com/ExpertOpinions/accel/interviewdetail.asp?interviewID=245
accessed May 19, 2006