same as NSR except thythm is irregular (increases with inspiration)

normal varient (esp w/ slower heart rates)

+- PPM if symptomatic (dual chamber pacing usually preferred over ventricular pacing)

byrady alternating w/ ventricular tachy - permanent pacemaker (PPM) w/ automatic implantable cardioverter defibrillator (AICD)

constant, prolonged PRI (>0.20 sec)

every P wave followed by QRS 

Mgmt: none, observation (may progress)

progressive PRI lengthening - dropped QRS

Mgmt: atropine, epinephrine +- pacemaker if symptomatic

observation if no sx

block commonly in bundle of HIS

Constant/prolonged PRI - dropped QRS

Mgmt: permanent pacemaker 

(progression to 3rd degree AV block common)

AV dissociation: P waves not related to QRS

All P's NOT followed by QRS: decreased CO

Mgmt: Permanent pacemaker definitive

temporary pacing if symptomatic 

flutter, "saw tooth" waves (no P's) @ 250-350 bpm

rate usually REGULAR

vagal, CCB, BB, DCC (direct cardiac compression) if unstable

radiogrequency ablation definitive tx 

no P waves, fibrillatory waves @ 350-600 bpm

IRREGULARLY IRREGULAR rhythm

rate control preferred over rhythm control

rate - vagal, CCB, or BB

Rhythm - DC cardioversion. DCC may also be done after 3-4 weeeks of anticoagulation or TEE showing no atrial thrombi. +- Digoxin

warfarin or ASA as prophylaxis against thromboembolism based on CHADS2 score

atrial quivering (in A fib) causes clots in atria that can embolize to brain/lung

atrial flutter

atrial fibrillation

wandering atrial pacemaker (WAP)

multifocal atrial tachycardia (MAT)

paroysmal supraventricular tachycardia (PSVT)

wolff-Parkinson-white

multifocal atrial tachycardia (MAT)

MAT associated with severe COPD

AV nodal reentry tachycardia (AVNRT) - 2 pathways both WITHIN AV node (slow & fast) MC type

AV reciprocating tachycardia (AVRT) - 1 pathway within the AV node & a second accessory pathway OUTSIDE the AV node (WPW & LGL)

vagal maneuvers

antiarrhythmis (ex procainamide, amiodarone)

radiofrequency abalation definitive treatment 

junctional rhythm- HR 40-60 bpm (intrinsic rate of AV)

accelerated junctional - HR 60-100

junctional tachycardia- HR >100 

premature ventricular complexes 

ventricular tachycardia

ventricular fibrillation

pulesless electrical activity

asystole rhythm (ventricular standstill)

premature beat originating from ventricle - wide, bizarre QRS occurring earlier than expected.

usually the T wave is in the opposite direction of the R. 

Assoc w/ compensatory pause = overall rhythm unchanged b/c it is prevented from reaching the atria by AV node 

usually none needed

remember though that most ventricular arrhythmias start as a PVC

evaluate hemodynamically stable v unstable

 evaluate sustained v non-sustained

sustained = duration of >= 30 sec

hypomagnesemia, hypokalemia

V tach "twists" around baseline

stable sustained- anti-arrhythmisc (amiodarone, lidocaine, procainamide)

unstable w/ pulse - synchronized (direct current) cardioversion (DCC)

VT (no pulse) - defibrillation/CPR 

torsades de pointes - IV magnesium

same as PEA 

CPR, epi, checks for shockable rhythm every 2 min

hypertrophy

away from infarction

cor pulmonale

pulmonary dz; left side heart failure

Tall P wave > 2.5 mm in lead II

biphasic P wave w INITIAL component larger in V₁

cor mitrale

Broad "m" shaped P wave > 0.11 s lead II

biphasic P wave w/ TERMINAL component larger in V₁

Sokolow -lyon : S in V₁ + R in V₅ = 35mm (men), 30 (W)

Cornell: R in aVL + S in V₃ > 24 mm(M); > 20 mm (W)

Other: height of R in aVL > 11 boxes (men); 9 boxes (W)

1. wide QRS > 0.12 sec

2. broad, slurred R in V_5,6

3. deep S in V₁

4. ST elevations V1-V3

1. wide QRS > 0.12 sec

2. RsR' in V_1,2

3. Wide S wave in V₆

LAD (> -30 degrees no other reason for LAD)

initial R in inf. leads

Q in I

S in III

ischemia

(horizontal and downslope always pathological)

acute MI

normal early repolarization abnormalities

LBB

LVH

coronary vasospasm/prinzmetal's angina

pericarditis

Brugada's syndrome

normal variant. seen esp. in thin, healthy AA males

ST elevation > 2 mm CONCAVE diffuse leads w large T waves (esp precordial)

Tall QRS voltage

fishhook (slurring/notching at J point)

ST elevation CONCAVE precordial leads

PR depression seen in the same leads w/ ST elevations

NO reciprocal changes

T wave inversion only present AFTER STE (acute MI may have T wave inversions simultaneously with ST elevations in same leads)

RBBB pattern (often incomplete)

ST elevation V₁-V₃ (often downsloping)

T wave inversions V₁& V₂

+- S wave in lateral leads

nitric oxide

oxygen

adenosine

exercise stress testing (ECG) - treadmill or radionuclide myocardial perfusion imaging (MPI)

pharmacologic stress testing 

stress echocardiography

Bruce protocol: + if ST depression, exercise-induced HTN or hTN, arrhythmias, sx's, heart rate abnormalities

Ind: initial test in most patients w/ normal resting ECG, low cost

Disadvan: does not localize region of ischemia

CI: unable to exercise, baseline ECG abnormalities

either single photon emission computed tomography (SPECT using technetium or thallium) or positive emission tomography (PET)

Benifits of MPI - localization of region of ischemia

done in patients unable to exercise

vasodilators w/ MPI: adenosine or dipyridamole

MOA: coronary vasodilators of normal arteries

Ind: preferred in pts w baseline ECG abnormalities. 

CI: bronchospastic dz (ex severe asthma, COPD), 2nd/3rd degree heart block or sick sinus (adenosine affects SA & AV node)

Caution: avoid vasoconstrictors 24h before test (ex theophylline or caffeine)

localizes regions of ischemia

dobutamine: sympathomimetic that stimulate B₁-mediated, increase HR, increases myocardial O2 demand & provokes ischemia)

Ind: used in pts w CI to vasodilator use or in patients w/ recent vasoconstrictor use

CI: sustained ventricular arrhythmias, significant LV outflow obstruction (severe AS), mod-severe HTN, SBP > 180, aortic dissection, if patient on BB

acute pericarditis 

(may cause pericardial effusion) 

persistent 

pleuritic

postural pain

pericardial friction rub

viral - esp the enteroviruses: coxsackie & echovirus

chest pain: pleuritic (sharp & worse w/ inspiration), persistent, postural (worse w/ lyind down and RELIEVED BY SITTING/LEANING FORWARD) +- radiate to trapezius, back, neck, shoulder, arm, epigastric area & can be associated w/ dyspnea & odynophagia, fever usually

pericardial friction rub: best heard @ end expiration w/ pt upright & leaning forward. 3 components. Pericardial friction rub notoriously variable (can be transient)

ECG 

echocardiogram

acute pericarditis (effusion or tamponade)

isloated pericarditis --> normal ech

1. anti-inflammatory drugs - ASA or NSAIDS x 7-14 days. Colchicine 2nd line management 

2. +- corticosteroids if sx > 48h & refractory to 1st line meds. Dresslers: ASA or colchicine

1. ECG - low voltage QRS complexes suggest large effusion or tamponade, electric alternans: cyclic beat to beat shift in QRS amplitude (heart swinging in fluid)

2. echo - increased pericardial fluid. also good to assess for tamponade 

3. CXR : cardiomegaly

1. observation if small and no evidence of tamponade

2. +- pericardiocentesis if tamponade, large effusion, Pericaridal window drainage if recurrent.

rheumatic disease (valvular)

 mitral (MC)

1. Active carditis

2. Migratory Polyarthritis

3. Subcutaneous nodules

4. Erythema marginatum

5. Sydenham's chorea

fever (101-104)

arthralgias

increased acute phase reactants (increased ESR, CRP)

EKG: prolonged PR interval

sydenham's chorea - rheumatic fever

treat with haloperidol

1. PCN G is DOC (erythromcyin if PCN-allergic) 

2. anti-inflammatory: aspirin (2-6 wk taper); steroids in severe cases & carditis

hypothyroidism

pregnancy

kidney failure

DM

ETOH

obesity

steroids

estrogen

1. most patients asymptomatic

2. may develop xanthomas (esp in eyelids, achilles)

3. hyypertriglycerides may cause pancreatitis

in patients 35 or older without risk factors

earlier if risk factors

statins 

Bile acid sequestrants

fibrates (gemfibrozil, fenofibrate)

niacin

Niacin (nicotinic acid)

fibrates (gemfibrozil, fenofibrate)

fibrates (gemfibrozil, fenofibrate)

statins

niacin may cause hyperglycemia so use caution in DM pts

hyperuricemia

hyperglycemia

flushing, HA, warm sensation & pruritis - prostaglandin mediated

hepatotoxicity

hyperglycemia

PUD

myositis/myalgias/rhabdomyolysis (esp when used w/ fibrates & niacin)

hepatitis (increased LFTs)

increased LFTs

myositis & myalgias esp w/ concomitant statin use (d/t CYP3A4 related reduction in statin metabolism)

increased bile lithogenicity (gallstones)

used for hypertriglyceridemia 

salmon, flaxseed, canola oil, soybean oil, nuts

cholestyramine

colestipol

colesevelam

(the bile acid sequestrants)

GI side effcts : N/V, bloating, increased LFT's

increases TG (good for pts with increased LDL and normal TG) osteoporosis w/ long term use

may impair absorption of digoxin, warfarin, fat soluble vitamins (so give those meds 1 hour before or 4 hrs after BAS)

Ezetimibe (Zetia)

may be used w/ statins 

mitral

exception is IVDA (tricuspid valve MC)

1. acute bacterial endocarditis (ABE) : infection of NORMAL valves (staph mc, esp MRSA)

2. subacute bacterial endocarditis (SBE) : ABNL valves (S. viridans)

3. endocarditis C IVDA (MRSA)

4. Prosthetic valve endocarditis (PVE): early w/n 60 days (staph epidermis)

haemophilus

actinobacillus

cardiobacterium

eikenella

klingella

assoc w/ large vegetations. often cx negative. Gram -

1. fever (80-90% including FUO), anorexia, wt loss, fatigue. EKG conduction abnormalities

2. peripheral manifestations

- janeway lesions -painless erythematous macules on palms/soles

roth spots - retinal hemorrhage w/ pale center, petechiae (conjunctiva, palate)

Oslers nodes: tender nodules on pads of digits

1. blood cultures. 3 sets @ least 1h apart

2. EKG : prone to arrhythmias

3. Echo: obtain TTE first the TEE if necessary

4. labs: CBC: leukocytosis, anemia, increased ESR/RF

Major

• sustained bacteremia : 2 + blood cx
•  endocardial inv. (+ on echo), new valvular regurgitation (AR, MR)

Minor

• predisposing condition (abnl valves, IVDA, catheters),
• fever (> 38 C, 100.4 F)
• vascular & embolic phenomena: janeway lesions, septic arterial or pulmonary emboli, ICH
• immunologic phenomena: osler nodes, roth spots, + RF, acute glomerulonephritis
•  + blood cx not meeting major criteria
• + echo not meeting major criteria (ie. worsening murmur) 

nafcillin + gentamicin x 4-6 weeks 

OR

Vancomycin (MRSA/PCN allergic) + Gentamicin

pencillin/ampicillin + gentamicin

vancomycin is IVDA

amphotericin B

capsofungin if severe + valve sx/replacement (tx 6-8 wks)

AFTER 

but with SBE if pt is not stable - BEFORE

1. prosthetic (artificial) heart valves
2. heart repairs using prosthetic material (not including stents)
3. prior h/o endocarditis
4. congenital heart disease

 Amoxicillin 2g 30-60m before (Clinda 600mg PCN allergy)

1. Dental: involveing manipulation of gums, roots of the teeth, oral mucosa perforation
2. respiratory: sx on respiratory mucosa, rigid bronchoscopy
3. procedures involving infected skin/musculoskeletal tissues (including abscess I&D)

Amoxicillin 2g 30-60m before (Clinda 600mg PCN allergy)

left v right sided

systolic vs diastolic 

high versus low output

L-sided heart failure - 90%

(pulmonary dz 2nd most common)

decreased EF assoc w/ S3 gallop (S3= filling of dilated ventricle)

systolic MC form of CHF

normal/increased ejection fraction assoc w/ S4 gallop

(S4 = atrial contration w/ stiff ventricle)

HTN, RCMP

anemia

thyrotoxicosis

beriberi

Paget's dz of bone

HTN

CAD

1. Dyspnea MC symptom.  Initally exertional --> orthopnea (dyspnea when pt is supine --> increased venous return & cardiac work) & paroxysmal nocturnal dyspnea (same reasons) --> dyspnea @ rest
2. Pulmonary congestion/edmea: rales (fluid in alveoli), rhonchi, chronic nonproductive cough (commoly miss) esp w/ pink frothy sputum (surfactant), wheezing "cardiac asthma" d/t airway edema, pleural effusion. Nocturia

• HTN
• rapid/shalllow breathing (tachypnea)
• cheyne stoke's breathing (deeper faster breathing w/ gradual decrease & periods of apnea)
• cyanosis
• S3 (systolic)
• S4 (diastolic)
• increased adrenergic activation: dusky, pale skin; diaphoresis, sinus tachy, cool extremities (d/t poor perfusion & periohal arterial vasoconstriction), fatigue, AMS

• peripheral edema: ex. pitting edema in legs
• JVD: increased JVP
• GI/hepatic congestion: anorexia, N/V d/t edema of GI tract, hepatosplenomegaly, RUQ tenderness, hepatojugular reflex (increased JVP w/ liver palpation); cyanosis

echocardiogram

• measures ventricular function & EF

EF

• normal EF = 55-60 (EF < 35 increases mortality) 
• EF <35% = cardio defibrillatory placement to reduce mortality 

decreased EF

thin ventricular walls

dilated LV chamber

+S3

normal/increased EF

thick ventircular walls

small LV chamber

+ S4

cephalization of flow

kerley B lines

butterfly pattern

 cardiomegaly infiltrates

pleaural effusions

pulmonary edema

indicates severity & prognosis of HF

ventricles release BNP during vol. overload in attempt to reverse the process (causing decreased RAAS activation, decreased TBFV, increased NA excretion)

BNP > 100 means CHF is likely 

echo

CXR

Increased BNP

ACEI - prils

vasodilators (decreased afterload, and preload)

hydralazine

vasodilator (decreased afterload)

diuretics 

decreased preload 

HCTZ, metolazone for mild-moderate

loops -severe

sympathomimetics (positive inotropes)

digoxin -only one used long term

ACEI

ARB's

BB

Nitrates + hydralazine

spironolactone

CCB

(exceptions: angina w/ HF or normal EF)

35% 

(b/c they poorly tolerate arrhythmias)

norm pulm capillary wedge pressure (PCWP) 6-12 mmHg

• cephalization of flow: increased vascular flow to apices as result of increased pulm. venous pressure. Seen when PCWP 12-18 mmHg
• Kerly B lines: short linear markings @ lung periphery of lower lung fields when PCWP 18-25 mmHg.

LMNOP

L: lasix

M: morphine (reduce preload/heart strain)

N: nitrates (venodilators, reduce preload/heart strain)

O: oxygen

P: position (upright to decreased venous return)

Nesiritide

CHF

1. BB, ACEI, & CCB : HR & BP control & relief of ischemia. 
2. Diuretics for volume overload
3. CCB helpful for diastolic (unlike systolic where is is generally not helpful or even harmful).  
4. Exceptions for CCB & sys: angina w/ HF or normal EF

myocarditis

• compared to adults, the majority of children w/ myocarditis present w/ acute or florid HF (often mild in adults)

viral infection (or post viral immune cardiac damage) - enteroviruses (esp. coxsackie B) & echovirus

• 17% of pts w/ SIDS have evidence of myocarditis peaks in infancy (btwn 6-12 mos) and adolescence (16y) overall it is a rare dz in children

• viral: enteroviruses (esp. coxsackie B) MCC & echoviruses
• Bacterial: Rickettsial (lyme dz, rocky mountain spotted fever, Q feveR)
• Fungal: actinomycosis, coccidiomycosis, histoplasmosis, candidiasis
• Parasitic: trichinosis, toxoplasmosis
• toxic : scorpion envenomation, diphtheria toxins
• Autoimmune: SLE, rheumatic fever, RA, kawasaki, UC
• Systemic: uremia, hypothyroidism
• Meds: methyldopa, abx (tetracycline, amph B, PCN), cyclophosphamide, acetazolamide, indomethacin, isonizid, phenytoin, sulfa, clozapine

• myocellular damage --> myocardial necrosis & dysfunction --> +- HF (d/t systolic dysfunction, cardiac enlargement & myocardial fibrosis)

• viral prodrome: fever, myalgias, malaise x several days --> HF sx
• HF sx: dyspnea @ rest, exercise intolerance, syncope, tachypnea, tachycardia, hepatomegaly.  Impaired systolic function (S3 +- S4).  Severe: hypotension, poor pulses & perfusion, AMS. GI sx: megacolon
• +- pericarditis simultaneously: fevers & CP, pericardial friction rub, pericardial effusion

1. CXR: cardiomegaly class (dilated cardiomyopathy) +- normal
2. ECG: sinus tacy MC, +- atrial/junctional/ventricular arrhythmias. +- normal. +- show pericarditis (precordial ST elevations w/ associated PR depressions), pericardial effusion (alternans)
3. cardiac enzymes: + CK-MB & troponin (myocardial necrosis d/t disease process - not usually occlusion) + cardiac enzymes helps distinguish myocarditis from chronic DCMP
4. echo: ventricular dysfunction. +- pericardial effusion or MR. Echo most useful to assess cardiac fcn
5. Endomyocardial bx: gold standard in diagnosing myocarditis.  commonly shows infiltrations of lymphs w/ myocardial tissue necrosis. Done in pts w/ new onset of HF unrelated to structural dz. helps w/ dx & prognosis

supportive mainstay of tx, standard regimens for HF

• diuretics, afterload reducing agents (ex ACEI),
• inotropic drugs if severe (dopamine, dobutamine, milrinone)

BB generally not used in management in peds

IVIG in some pts have been helpful

• idiopathic MC cause, autoimmune
• viral myocarditis (ex. enteroviruses)
• toxic: ETOH, cocaine, pregnancy 
• XRT, doxorubicin, daunorubicin 

• systolic HF sx - both right and left sided
• embolic phenomena, arrhythmias
• viral myocarditis: viral prodroma a few weeks --> signs of HF or CP, + cardiac enzymes, nonspp ST-T changes

• L heart failure - pulmonary congestion: rales, tachy, cough, pleural effusion
• R heart failure - peripheral edema, increased JVP, hepatic congestion

• Echo - left ventricular dilation (thin walls), decreased EF, regional or global LV hypokinesis 
• CXR - cardiomegaly, pul. edema, pleural effusion

standard systolic HF tx 

• ACEI, diuretics, digoxin, BB, Na restriction

Implantable defibrillator if EF < 35% 

infiltrative dzs 

• amyloidosis MCC
• sarcoidosis, hemochromatosis
• scleroderma, metastatic dz, idiopathic 

• right sided failure sx more common than left
• poorly tolerated tachyarrhythmias

Kussmauls' sign : increased JVP w. inspiration

R. heart failure: peripheral edema, increased JVP, hepatic congestion

echo

•  ventircles nondilated w/ normal wall thickness
• marked dilation of BOTH atria
• diastolic dysfxn w/ normal or near normal systolic fxn

no specific tx

treat underlying cause

• diastolic dysfunction d/t impaired ventricular relaxation/filling
• subaortic outflow obstruction - hypertrophied septum
• systolic anterior motion (SAM) of mitral valve & SAM is increased w/ 1. increased contractility (exertion) 2. decreased LV volume (ex decreased venous return, dehydration)

1. often asymptomatic
2. dyspnea (90%) most common initial complaint
3. angina pectoris, syncope
4. arrhythmias AF; VT/VF (palpitation, syncope)
5. sudden cardiac death: esp in adolescent/preadolescent children (esp. exertion) d/t vent. fibrillation

1. harsh systolic cre-decresc murmur @ LUSB similar to AS 
2. decrease murmur intesntiy: increase venous return (ex squatting, lying down) b/c increase LV volume preserves outflow
3. increased murmur w/ decreased venous return (valsalva & standing) & exertion (b/c decreased LV volume & increased contractility wll decrease CO) amyl nitrate
4. usually no carotid radiation. Normal pulse, Loud S4, +- MR

• echo - asymmetric wall thickness (esp septal), SAM mitral valve
• ECG: LVH
• avoid exertion, implantable defibrillator to prevent VF

• medical: BB, verapamil, disopyramide
• cautious use of digoxin, nitrates, & diuretics (digoxin increases contractility while nitrates & diuretics decrease volume)
• surgical: myomectomy, ETOH ablation