Category: Cardiology
Keywords: bradycardia, pacemaker (PubMed Search)
Posted: 11/18/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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A few pearls regarding pacing a patient with an unstable bradycardia:
If the patient has an implanted pacemaker (which isn't working properly), the transcutaneous pacing pads should be placed at least 10 cm away from the implanted PM pulse generator.
Placement of a transvenous pacemaker is absolutely contraindicated if the patient has a prosthetic tricuspid valve.
Neither transcutaneous or transvenos pacing is likely to work in the setting of severe acidosis or severe hypothermia. Severely hypothermic patients, in fact, have very irritible myocardial tissue and therefore attempts at pacing may produce ventricular dysrhythmias.
Category: Cardiology
Keywords: elderly, geriatric, chest pain, acute coronary syndrome (PubMed Search)
Posted: 11/11/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Atypical presentations of ACS in the elderly are common.
Only 40% of patients > 85yo present with chest pain. Dyspnea is the most common presenting complaint in these patients. Other atypical presentations include isolated nausea, vomiting, diaphoresis, or syncope.
The presence of an atypical presentation is not reassuring in terms of prognosis. Patients presenting atypically have a 3-fold higher in-hospital mortality (13% vs. 4%). This doesn't even include the patients that are inadvertently discharged home because of failure to diagnose ACS.
Category: Cardiology
Keywords: congestive heart failure, high output failure (PubMed Search)
Posted: 11/4/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Although CHF is usually associated with low cardiac output, "high output failure" can occur as well. In this condition, cardiac output is normal or even high but not high enough to meet markedly elevated metabolic demands of the heart in certain conditions. Those conditions include: severe anemia, thyrotoxicosis, lartge arteriovenous sunts, Beriberi, and Paget disease of the bone.
Category: Cardiology
Keywords: electrocardiography, cardiac ischemia (PubMed Search)
Posted: 10/28/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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The T-wave in lead V1 is usually inverted or flat. When the T-wave is upright, especially if it is tall (taller than the T-wave in lead V6), be worried about cardiac ischemia...especially if the large upright T-wave is a new finding compared to prior ECGs.
LVH, LBBB, and misplaced precordial leads are the other causes of tall upright T-waves in lead V1. In the absence of any of these three conditions, worry about ischemia.
Marriott described this finding many years ago and refers to it as "loss of precordial T-wave balance."
Category: Cardiology
Keywords: creatinine clearance, medication adverse effects (PubMed Search)
Posted: 10/22/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Recent studies have identified that a significant cause of morbidity and mortality in women, elderly, and patients with renal failure is the failure to consider renal insufficiency in dosing certain anticoagulants and anti-platelet medications, resulting in bleeding complications. Medications should be based on creatinine clearance, NOT SERUM CREATININE. When the creatinine clearance is < 30 mL/min, the dose of any renally-excreted medications should be decreased.
For example, an 85 yo woman that is 110 lbs and has a serum creatinine of 1.2 (sounds normal!) actually has a creatinine clearance < 30, which means that she has relative renal insufficiency. Her dosages of medications (e.g. enoxaparin) should be adjusted for this.
Creatinine clearance can easily be calculated via computer programs that you can "google" (e.g. just google "creatinine clearance calculation"). If you enter the patient's gender, age, weight, and serum creatinine, the programs will calculate the value for you.
Category: Cardiology
Keywords: atrial fibrillation, myocardial infarction (PubMed Search)
Posted: 10/14/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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New onset atrial fibrillation is rarely the sole manifestation of myocardial infarction. In other words, in the absence of accompanying chest pressure, dyspnea, diaphoresis, or other anginal equivalents, a rule-out ACS workup in not supported by the literature and is not cost-effective.
The two exceptions to the statement above are elderly and diabetic patients, in whom subtle presentations of ACS are common with or without atrial fibrillation.
Category: Cardiology
Keywords: acute myocardial infarction, reperfusion, ami (PubMed Search)
Posted: 10/7/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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In the treatment of an acute ST-elevation MI, there are three major signs of successful reperfusion:
Persistent pain/symptoms OR absence of STE resolution by 90 minutes warrants strong consideration of rescue angioplasty.
Category: Cardiology
Keywords: Valvular Disorder, Hypertrophic Cardiomyopathy (PubMed Search)
Posted: 9/30/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: myocardial infarction, misdiagnosis (PubMed Search)
Posted: 9/23/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: Acute Pericarditis, Pericardial effusion (PubMed Search)
Posted: 9/16/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: mitral valve prolapse, mitral regurgitation, endocarditis (PubMed Search)
Posted: 9/9/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: fondaparinux, anticoagulation, acute coronary syndromes (PubMed Search)
Posted: 9/2/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: GPIIB/IIIA inhibitors, acute coronary syndrome, antiplatelet medications (PubMed Search)
Posted: 8/26/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: acute coronary syndromes, cardiac risk factors (PubMed Search)
Posted: 8/19/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Vascular
Keywords: mesenteric ischemia, elderly, geriatric, abdominal pain (PubMed Search)
Posted: 8/12/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: amiodarone, adverse effects, arrhythmias (PubMed Search)
Posted: 8/12/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: enoxaparin, heparin, bleeding, complications (PubMed Search)
Posted: 8/5/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: myocardial, infarction, complications, papillary, VSD, murmur (PubMed Search)
Posted: 7/29/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: hyperglycemia, ACS, STEMI, coronary, ischemia (PubMed Search)
Posted: 7/22/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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Category: Cardiology
Keywords: pericarditis, treatment, colchicine, steroids (PubMed Search)
Posted: 7/15/2007 by Amal Mattu, MD
(Updated: 11/1/2024)
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