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Cardiovascular

  • Links
  • Anticoagulation
  • EKG and Rhythm Interpretation
  • Heart Failure
  • Homocysteine
  • Hypertension
    •
  • Lipids and Prevention
  • MI
  • Pressure Meds (CCM)
  • Syndrome X
  • Valvular Disorders
    •

    Links

    Anticoagulation

    Warfarin Excess

    EKG and Rhythm Interpretation

    Basic

    Pediatric (esp. < 8 yo)

    Rhythm

    WPW or Wolff-Parkinson-White

    Block

    Miscellaneous

    Heart Failure (outpatient)

    Valsalva test

    Physiology

    Activity and Symptoms: In class IV failure

    Therapies

    Systolic failure

    Desired BP with CHF: sysolic 110. Desire minimal orthostatic Sx if pt class IV.

    Diastolic Failure

    Homocysteine

    Hypertension

    Urgent Care Evaluation: New BP Elevation

    Supplemental Hypotensive agents

    Diet

    Special cases

    Lipids and Prevention (rev 1/31/2003)

    NHLBI Guidelines

    1. Hyperlipidemia
      The NHLBI Guidelines page has the best references, but in general the "guidelines" on hyperlipidemia are confusing. A better approach would be to use a risk factor calculator to estimate a 10 year risk of ischemic event, then base interventions on a risk benefit model adjusted for age (years of life gained). In general incorporation of age and family history isn't handled very elegantly by the current guidelines. (If I get time, maybe I'll write a paper on this!)
      The guidelines are really written for persons < 65 yo (to some extent, age 45-65). For persons older than 65 there's a serious "clinical judgement" component.
      1. risk factors
        As of 2/2003 I suspect obesity will eventually be incorporated as an independent risk factor, perhaps expressed as abdominal girth parameters. My other hunch is that peripheral testosterone activity will one day be considered a finer disriminant risk factor than gender. Xanthelasmas and xanthomas aren't formally part of risk factor assessment, but in the presence of elevated triglycerides they should probably prompt testing for a familial hyperlipidemia disorder and may indicated more aggressive therapy. Homocystine levels are falling out of favor as unoficial risk factors.
        1. HDL < 40 (used to be < 35)
        2. Hypertension
        3. Family History
          CHD in 1st degree male relative age < 55, female age <65
        4. Smoking
        5. Age
          men < 45, women < 55
      2. Goals
        LDL < 100 is desired universally. Initiate dietary therapy when exceed the goal level (but this almost always fails, or only works for a year or two). The gap between initiating dietary therapy vs. initiating drug therapy is a cost/benefit issue. The meds have more known toxicity than diet, and we can be sure that not all the long term toxicities (or benefits) are fully known. Presumably if the meds were 100% safe and totally free there would be no diet/drug "gap". Clinical judgement (assess individual risk factors for drug side-effects, consider informal risk factors such as abdominal girth, etc) may operate within this "gap", but doing nothing is certainly supported, perhaps along with yearly monitoring.
        Note that all the recommendations are really optimized for patients age 45-65, outside that range things are trickier.
        1. 0-1 risk factors
          1. Diet if > 160
          2. Drugs if > 190
            if 10 year risk is > 10% using risk calculatory, I'd say use drugs when LDL > 160
        2. 2 or more risk factors
          All men over age 45 and women over 55 have one risk factor, and most of this population with LDL > 130 will also have HDL < 40. So most healthy men with good lifestyles and elevated lipids over age 45 fall into this group.
          A 10 year risk calculation is used to guide interventions, so it makes more sense to just use the Framingham Risk Calculator approach from the start!. As age increases the point at which to initiate drug therapy falls, though one may mitigate the decision based on estimates of drug toxicity, drug interactions, etc. Since the risk calculators just work off risk factors, and since these goals also incorporate risk factors, this could probably have been more simply expressed as a age-cutoff.
          1. diet if > 130
          2. 10 year risk > 10%: drugs at > 130
          3. 10 year risk < 10%: drugs at > 160
        3. CHD/Diabetes, lots of risk factors
          1. diet if > 100
          2. drugs if > 100-130
      3. Some comments on therapy
        1. Hyperlipidemia and Dementia
          There may be a significant relationship between cellular cholesterol metabolism and Alzheimer's. There is a relationship between vascular disease and dementia. It is not known whether treating hyperlipidemia with a statin reduces or increases one's risk of Alzheimer's disease or other dementias.
        2. ASA 75 mg/qD for 5 year risk of at least 3%

    General Guidelines

    These are old. As of 2003 it's statins all the way, and their effect is only partly due to lowering LDL.

    Names and classes

    Bile Acid Sequestrants

    Expensive, taste awful, GI problems, cause vit K and folate deficiency (beware use with Coumadin). Give with vitamins. Must mix with juice.

    HMG CoA Reductase Inhibitors (Statins)

    Give with evening meal or at bedtime.

    Monitor LFTs +/- CK q6w fo 3 mo, then q8w for 1st year then q6months.

    Avoid use with erythromycin, warfarin

    Triglyceride Metabolism Modifiers

    Nicotinic Acid (Niacin)

    Do not substitute, avoid sustained release preparations. Rarely used any more. Very poorly tolerated.

    Fibric Acids

    Lopid (gemfibrozil). Very rarely used.

    Dangerous Combinations

    Effective Combinations

    (These are old combinations.)

    Dosages

    MI

    Markers

    Pressure Meds (CCM)

    afterload and preload reduction: HTN, pulmonary edema

    a) intravenous medications:

    b) oral medications (or both)

    management of hypertension (not preload/afterload)

    a) labetolol (Trandate, Normodyne)

    b) propranolol: beta block; 1-10 mg IV then 3 mg/hr. Total blockade with 0.1 mg/kg. PO 80-640 mg qD; onset 2h durn 12h.

    inotropes and vasopressors

    a) DOPAMINE: beta 1 and alpha. typical use 500-1500 mcg/min. At 2-5 mcg/kg/min may have renal vasodilatation (renal dose), at > 15 mcg/kg/min effect is predominantly alpha (vasoconstriction). Esp. good for septic shock. (dopamine = norepinephrine + dobutamine)

    b) DOBUTAMINE: beta 1 >> beta 2. typical use 800-2000 mcg/min. In range 5-15 mcg/kg/min greatest affect on CO, small chg PVR (up or down). Esp. for cardiogenic shock, CHF, post MI.

    Syndrome X

    Valvular Disorders

    General

    Mitral Valve Regurgitation

    Author: John G. Faughnan.  The views and opinions expressed in this page are strictly those of the page author. Pages are updated on an irregular schedule; suggestions/fixes are welcome but they may take weeks to months to be incorporated. I reserve copyright except where noted, if you want to repost or quote a page just ask. Anyone may freely link to anything on this site and print any page; no permission is needed for linking,  printing, or distributing printed copies.