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  • Anticoagulation
  • DVT and Pulmonary Embolus
  • EKG and Rhythm Interpretation
  • Heart Failure
  • Homocysteine
  • Hypertension
  • Lipids and Prevention
  • MI
  • Peripheral Vascular Disease
  • Pressure Meds (CCM)
  • Valvular Disorders

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    Warfarin Excess




    DVT and Pulmonary Embolus

    Well's Score - DVT

    (via Wikipedia)

    1. Active cancer (treatment within last 6 months or palliative) -- 1 point
    2. Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) -- 1 point
    3. Collateral superficial veins (non-varicose) -- 1 point
    4. Pitting edema (confined to symptomatic leg) -- 1 point
    5. Swelling of entire leg - 1 point
    6. Localized pain along distribution of deep venous system -- 1 point
    7. Paralysis, paresis, or recent cast immobilization of lower extremities -- 1 point
    8. Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks -- 1 point
    9. Previously documented DVT -- 1 point
    10. Alternative diagnosis at least as likely -- Subtract 2 points

    Interpretation: (Possible score -2 to 9)

    Score of 2 or higher - deep vein thrombosis is likely -> Duplex Ultrasonography
    Score of less than 2 - deep vein thrombosis is unlikely -> d-dimer test to further rule out deep vein thrombosis.

    D-Dimer test

    Well's Score - PE

    (via Wikipedia)

    Traditional interpretation

    Alternate interpretation

    EKG and Rhythm Interpretation


    Pediatric (esp. < 8 yo)


    WPW or Wolff-Parkinson-White



    Heart Failure (outpatient)

    Valsalva test

    Serum brain natriuretic peptide (BNP)


    Activity and Symptoms: In class IV failure


    Systolic failure

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

    Diastolic Failure



    Urgent Care Evaluation: New BP Elevation

    Supplemental Hypotensive agents


    Special cases

    Lipids and Prevention

    NHLBI Guidelines

    1. Risk estimation (ATP III, 2004)

      The risk estimation guidelines are a mess, because they combine two different models -- a Framingham data based model (Bayesian, see NHLBI risk calculator) and a predictive risk factor model. Diabetes and Family History, for example, are a part of the 2nd and missing from the Framingham model -- probably because the deta was not recorded. LDL is estimated in the Framingham model from HDL and total cholesterol, but is a part of the risk factor approach

      This is not good. A 48 yo male with fifteen years of diabetes, but good BP, non-smoker and not-too-bad lipids wouldn't get Statins from the Framingham model, but they would from the Risk Factor model.
      Item Risk calculation model Risk factor approach
      Age x x
      Gender x x
      Total Cholesterol x  
      HDL Cholesterol x x
      LDL Cholesterol   x
      Smoker x x
      Hypertension x x
      Family history   x
      Diabetes   x

      * HDL > 60 is a negative risk factor
      Family History is CHD in 1st degree male < 55 or female < 65
      Smoking is undefined - certainly if in past month.
      Age in risk factor model is > 45 for men, > 55 for women.

    2. LDL Levels to initiate drug therapy

      This is a compromise model (ATP III) based on LDL results. If someone meets only one of the two model criteria, then my guess is that it's really a matter of patient preference and clinical judgment.

      LDL Level Risk Factor Framingham 10 yr risk
      > 100 CHD or "equivalent"* > 20%
      > 130 2 + (ex. 46 yo male smoker) 10 - 20%
      > 160 2 + (ex. 46 yo male smoker) < 10%
      > 190 Treat based on LDL alone.

      CHD equivalents include Diabetes, symptomatic carotid artery disease, peripheral arterial disease, and abdominal aortic aneurysm.

    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.)




    Peripheral Vascular Disease

    Ankle-brachial index

    Measure at ankle and arm, repeat post treadmill

    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.

    Valvular Disorders


    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 years to be incorporated. Anyone may freely link to anything on this site and print any page; no permission is needed for citing, linking,  printing, or distributing printed copies.