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- INR > 10 and not bleeding. Prior to 2003 recommendation was Vitamin K at least 3mg
S/Q or slow IV, as of 2007 oral vitamin K was preferred. In practice this might depend on
how much over 10 the INR was, and the patient's personal bleeding risk factors.
- INR > 10 and bleeding: Vitamin K 10mg slowly IV, fresh frozen plasma 15ml/kg,
optionally also add 50 units of prothrombin complex concentrate.
- derived from a normalization of the Prothrombin Time (PT). PT measures factors II, V,
VII, X and fibrinogen - the extrinsic and common pathways. By contrast aPTT measures the
- 1: normal (popn range is 0.8 to 1.2), corresponds to a PT of 12-15 seconds.
- 2-3: most conditions - DVT, PE, afib
- 2.5 - 3.5: mechanical heart valve
- 3-4: thrombophilia due to antiphospholipid syndrome
Well's Score - DVT
- Active cancer (treatment within last 6 months or palliative) -- 1 point
- Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity)
-- 1 point
- Collateral superficial veins (non-varicose) -- 1 point
- Pitting edema (confined to symptomatic leg) -- 1 point
- Swelling of entire leg - 1 point
- Localized pain along distribution of deep venous system -- 1 point
- Paralysis, paresis, or recent cast immobilization of lower extremities -- 1 point
- Recently bedridden > 3 days, or major surgery requiring regional or general
anesthetic in past 12 weeks -- 1 point
- Previously documented DVT -- 1 point
- 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
Score of less than 2 - deep vein thrombosis is unlikely -> d-dimer
test to further rule out deep vein thrombosis.
- cross-linked fibrin degradation product is an indication that thrombosis is occurring,
and that the blood clot is being dissolved by plasmin.
- "Patients with a normal D-dimer test result and a low or moderate clinical risk
based on the Wells score have a very low risk of DVT and require no further testing"
Well's Score - PE
- clinically suspected DVT - 3.0 points
- alternative diagnosis is less likely than PE - 3.0 points
- tachycardia - 1.5 points
- immobilization/surgery in previous four weeks - 1.5 points
- history of DVT or PE - 1.5 points
- hemoptysis - 1.0 points
- malignancy (treatment for within 6 months, palliative) - 1.0 points
- Score >6.0 - High (probability 59% based on pooled data
- Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data
- Score <2.0 - Low (probability 15% based on pooled data
- Score > 4: do Spiral CT with contrast
- Score < =4: D-dimer
to rule out PE.
- axes: 0.2s horizontal blocks, 0.5mv vertically
- Rate: 300, 150, 100, 75, 60, 50 (pacemakers atria 75, AVN 60, Vent 30-40)
- Rhythm: PR 0.11-0.22, QRS < 0.1, normal QT is 0.4*RRinterval
- Axis: QRS above I, AVG
- Hypertrophy in V1: P < 0.11, R wave for RVH, V1 S wave + V5 R wave > 35mm ->
- Infarction: Q in absence of LBBB - > 0.4s or greater than 1/3 of QRS
in lead III, inverted T, elevated ST (if also elevated T then suspect pericarditis).
Following localizations are somewhat unreliable, vascularity varies greatly:
- anterior (anterior descending branch of left coronary artery): Q in V1-V4
- lateral (circumflex branch of left coronary artery): Q in I and AVL
- posterior (posterior descending artery, usually off right coronary): large R in V1,
significant Q wave in V6, R/S ratio >= 1 in V2
- inferior (variable, may be right or left or both coronary arteries): Q in II, III, AVF
Pediatric (esp. < 8 yo)
- see Harriet-Lane Handbook
- T wave may always be inverted in V5-V6, even by age 5 may have inversion in V1-V2.
Before age 5 may have R > S in V1. Adult pattern emerges @ age 5-8.
- Varying: sinus (sick sinus syndrome), wandering, atrial fib
- Extra: paroxysmal (atrial, nodal, ventricular), atrial flutter,
ventricular flutter, atrial fib, vfib, pvc
- Unifocal PVC in healthy person: No need to evaluate if healthy, CXR rnormal, no LVH, no
BBB, no HTN. Personally, I'd get an echo.
WPW or Wolff-Parkinson-White
- accessory bundle of Kent -> ventricular pre-excitation, shortened PR and longer
appearing QRS, delta wave swoop (nike) between P and QRS.
- Most common tachycardia has narrow QRS, but may have rate-related BBB with wider QRS.
Major risk is that AFib may induce VFib in pts with WPW since auxiliary pathway doesn't
block. Usual pattern is orthodromic -- antegrade through AV node, retrograde through
- familial variant has no gender predominance, sporadic 2:1 male
- 7-20% have Ebstein's
anomaly (tricuspid valve malformation) or other defect
- Cannot interpret exercise stress test and thallium scan can have false positive,
difficult to assess symptoms.
- Usually refer to cardiologist, treat if symptomatic with arrhythmias. Radiofrequency
ablation is @85% successful, EKG normalizes.
- SA: miss 1-2 cycle but return in step
- AV block
- Primary: PR more than 0.2 second
- Secondary (2:1, 3:1, 4:1, etc)
- Mobitz Type I (Wenckebach): PR progressively increases then drop QRS
- Mobitz Type II: drop QRS abruptly -- greater risk of complete block.
- Complete: ventricular pacemaker gives erratic rate of 20-40
- BBB QRS > 0.11s, cannot assess for LVH, if LBBB cannot assess for Q
- RBBB: rabbit ears -- RsR' in V1 or V3, wide S in V5-V6
- LBBB: mountain -- RR' in V5 or V6, wide S in V1-V2
- large pulmonary infarction RV strain/ischemia pattern: S1Q3, inverted T
waves V1-V4, ST depressed II, transient RBBB
- LV aneurysm: anteroseptal infarct on EKG with persistent ST elevation.
- electrolytes: U wave with low K, short QT with high Ca, long QT with low Ca
- dig toxicity
- short QT, inverted T
- PAT with block (>1 P for each QRS), AV block, multifocal tachycardia
- quinidine: long QT syndrome/roller coaster
- 90% specific, useful if suspect CHF but not confident enough to order ECHO.
- inflate cuff to 15mm above systolic then pt performs Valsalva
- Positive findings: maintain beats throughout Valsalva (abnormal persistence of increased
BP) and failure of beats to reappear after Valsalva ended (but cuff still on; BP once down
fails to jump up again)
Serum brain natriuretic peptide (BNP)
- helps differentiate heart failure from noncardiac conditions in a patient with dyspnea
(70-90% specific depending on level, 400 is very high).
- can't distinguish diastolic from systolic heart failure
- volume depletion -> incr renin & decr renal perfusion -> incr Cr, BUN and
SIADH -> hyponatremia. If add ACE may get sudden decr BP.
- hyponatremia is marker for hi renin state and poor prognosis. Rx with ACE over 8 days.
Watch for incr K, BUN, Cr. in this setting. Alternative is hydralazine
Activity and Symptoms: In class IV failure
- activity > decr. renal perfusion > incr. Na/fluid retention >
increased failure sx.
- good day followed by bad days due to overactivity.
- titrate diuretics and teach adjusting of activity/meds/diet.
- Angiotensin II receptor blockers (Teveten/eprosartan, Micardis/telmisartan,
Cozaar/losartan, Diovan/valsartan and about a hundred other "sartans") may be of
use, studies pending.
Desired BP with CHF: sysolic 110. Desire minimal orthostatic Sx if pt class IV.
- ACE inhibitors (first line)
- digoxin for symptomatic relief (fatigue)
- has 2 phase distribution: may be best given in evening and levels done in am.
- serum levels related to toxicity, not efficacy
- rare to go over 0.125 to 0.25 mg per day
- diuretic for symptomatic relief (congestion), thiazide 2-3 times/week for mild CHF,
otherwise avoid diuretics if mild
- beta blockers (not class IV) - carvedilol (Coreg) is a now popular beta blocker/alpha-1
antagonist added to ACE, digoxin, diuretics. usually can't go above 12.5 mg BID. Can cause
fluid retention, require more diuretics.
- spironolactone (aldosterone receptor antagonist): one large good study showed major
benefit in class III/IV when added to ACE inhibitor. 12.5-25 mg qD. Significant
hyperkalemia risk. Note Indocin and other NSAIDs can increase K.
- older: isordil (160 mg) + hydralazine (300 mg) -- titrate to target dose
- fluid restriction: 1500 ml/day (old?)
- ref: AFP 2006
- if CHF and EF on U/S > 40% Rx as diastolic
- avoid digoxin (contrary to old habits)
- beta blocker is first line therapy ) (cardevilol, Coreg, see above)
- can be prone to hypotension w/ diuretics, so use with care
- ACE & ARB of course
- Spironolactone (Aldactone) may help
- calcium channel blockers can impair LV function, don't look so great in trials.
Vasodilators also not so great.
- fasting serum homocysteine of 12 umol/l -> odds ratio 4.8
- can also do 4 hour methionine load test if IHD without other risk factors
- Rx. with 1 mg of folic acid day
Urgent Care Evaluation: New BP Elevation
- NSAID, other meds
- fundi, heart
- Cr, K, Uric, BUN, Na, Glu
- EKG, CXR
Supplemental Hypotensive agents
- OS Cal 800 mg qD
- Micro K 30-40 mEq Daily
- low salt
- regular salt + Ca blocker?
- age < 40: ternormin
- difficult HTN in younger person: prazosin/doxazosin + diuretic
- older: diuretic
- alcoholic, tobacco addict: clonidine
- NSAIDS (block many agents)
- greatest increase in BP: indocin, naprosyn, piroxicam
- least incr in BP: ibuprofen, aspirin, sulindac
- supplement, esp. renin dependent: clonidine
- resistant HTN
- tenormin or lopressor + HCTZ + Hydralazine (<200 mg/day)
- lopressor or labetolol + Lasix + Minoxodil
- 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.
||Risk calculation model
||Risk factor approach
* 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.
- 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.
||Framingham 10 yr risk
||CHD or "equivalent"*
||2 + (ex. 46 yo male smoker)
||10 - 20%
||2 + (ex. 46 yo male smoker)
||Treat based on LDL alone.
CHD equivalents include Diabetes, symptomatic carotid artery disease,
peripheral arterial disease, and abdominal aortic aneurysm.
These are old. As of 2003 it's statins all the way, and their effect is only partly due
to lowering LDL.
- Beware drug interactions and pregnancy
- Many require monitoring of CBC, LFT, a few CK. Typically q2-6 months.
- Beware muscle pain. It's not clear that we fully understand the effect of statins on
muscles, and, incidentally, on the CNS.
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.
- Cholestyramine: Cholybar, Questran, Questran Light.
Try: Questran Lite, 2 scoops in 8 oz water by bedside. Take before bedtime.
- Colestipol: Colestid (monitor LFT, CBC)
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
- GI upset, rash, hepatoxic, increased glucose and urea
- ASA 325 mg qD will decrease flushing
- a niacin dose of less than 1000 mg total daily is not worth continuing
- regimen: 100 mg and 500 mg tabs available
- 100 mg BID x 1 wk
- 200 mg BID x 1 wk
- 300 mg BID x 1 wk
- 500 mg BID x 1 wk (check chem 26, +/- CK)
- 1000 mg BID (ck chem 26 in 6 weeks, aim for 750-1000mg BID)
- monitor LFT, glucose +/- CK
Lopid (gemfibrozil). Very rarely used.
- gallstones, rhabdomyolysis with Mevacor
- need low HDL-cholesterol, elevated LDL-cholesterol, and elevated triglycerides to merit
use (per Parke-Davis and FDA)
- baseline LFT then q6-12 months
- mevacor and lopid (rhabdomyolysis)
- mevacor and niacin (maybe muscle injury)
(These are old combinations.)
- lower the LDL: Questran and Niacin or Questran and Mevacor
- lower TRIG: Lopid and Niacin (watch LFTs!)
- Niacin and Colestid
- Lopid and Colestid
- Mevacor and Colestid
- Niacin: 3-12 gm qD
- Questran or Questran Light
- 5 gm = 1 packet = 1 scoop
- 1-6 times per Day (TID)
- 5 gm = 1 packet = 1 scoop
- 3-6 times per Day (TID)
- 600 mg, 1 tab 30 minutes before breakfast and supper
- myoglobin: early marker, can be used in d/dx in ED
- troponin I or T: Become elevated in 3-12 hours, remain elevated 7-10 days. Can show a
recent MI has occurred. Elevation related to worse prognosis. Has largely replaced CK-MB.
Measure at ankle and arm, repeat post treadmill
- 1 - 1.4: Normal
- Less than 0.95, significant narrowing of one or more blood vessels in the legs is
- Less than 0.8, pain in the foot, leg, or buttock may occur during exercise (intermittent
- Less than 0.4, symptoms may occur when at rest. * 0.25 or below, severe limb-threatening
PAD is probably present.
afterload and preload reduction: HTN, pulmonary edema
a) intravenous medications:
- NTG: IV 0.2 -20 mcg/kg/min; esp. dec PL, less dec AL. Good if angina.
- NIPRIDE: IV 0.5-10 mcg/kg/min; esp. dec AL, less dec PL. (check thiocynate levels) Onset
3s, durn 3m.
- diazoxide: 50-150 mg IV q5m or 7.5-30 mg/min (onset 5m, durn 4-24h); esp dec AL. Do not
need art line, often with beta-blocker and diuretic. (reflex inc HR). Dangerous if aortic
dissection, angina, MI. Always give with strong diuretic.
- isosorbide dinitrate 3mg bolus IV q5min has been used in some trials for acute pulmonary
edema with improved results (1998)
b) oral medications (or both)
- captopril 6.5-13 mg PO q8h. onset 15m; durn 4-6h. Sublingual Captopril 12.5 repeat in 60
minutes is being used @1997.
- prazosin: 2-5 mg PO q6h; balanced dec PL and AL.
- good with BPH
- less s/e than prazosin
- good with BPH
- less s/e than prazosin
- hydralazine: 50-100 mg PO q6h or 10-20 mg IV (onset 10-30 min, durn 2-4 h); esp dec AL,
often use with beta blocker (reflex tach).
management of hypertension (not preload/afterload)
a) labetolol (Trandate, Normodyne)
- initial dose 20 mg IV then 20-40 mg q10-30 minutes to pressure better or max 300 mg
- IV infusion: 200 mg in 200 ml D5 at 2 mg/min (stop when BP ok)
- Onset 10-30 min, durn. 3-6h. May continue PO.
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.
Mitral Valve Regurgitation
Author: John G. Faughnan.
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