CARDIAC MANAGEMENT

Coronary Artery Disease

• The most common disease that leads to heart failure.
• Stepwise evaluation includes history, physical exam, stress test (ECG), stress/pharmacological radionuclide or echocardiographic test, coronary angiographic study.
• Treatment strategies are:
  • Medication.
  • Interventional revascularization.
  • Surgical revascularization.
• In regards to any of the above treatments, patients should also receive ASA, beta blocker, and ACE inhibitor.
• Risk modification is essential.

Hypertensive Heart Disease

• One of the most common conditions that leads to heart failure, both systolic and diastolic dysfunction.
• JNC VII blood pressure goal:
  • <140/90 in patient without risk factors
  • <130/80 in patient with heart failure, renal failure and diabetes
• Monitor home or out of hospital/clinic BP record.
• Prescribe medications that helps decrease LVH.
• Non-pharmacologic treatment is also important, such as low salt intake, exercise, weight reduction.

Dilated Cardiomyopathy

• Patient with dilated cardiomyopathy should be evaluated for the etiologies which require specific treatment.
• Idiopathic - Usually by exclusion, thought to be viral related.
• Alcoholic - Diagnosed by history. Alcohol abstinence is essential.
• Myocarditis - Diagnosis confirmed by endocardial-myocardial biopsy. In the early phase, steroid and immunosuppresive therapy have been tried.
• Others: Drugs-toxin induced, peripartum, blunt chest trauma, hemochromatosis, etc.

Hypertrophic Cardiomyopathy

• With or without dynamic outflow tract obstruction.
• Usually cause left ventricular diastolic dysfunction.
• Echocardiogram is essential for diagnosis.
• Management includes control of BP, negative inotropic drugs, avoid dehydration in outflow tract obstruction case. If the patient has a clinical picture of heart failure, be careful when using diuretic or vasodilators.
• Dual chamber pacing with short AV interval may improve symptomatic outflow tract obstruction in some patients.
• In severe outflow tract obstruction, treatment may include interventional alcoholic induces septal infarction, surgical septal myectomy.
• Patient with sudden death or cardiac arrest history in the family requires further evaluation (include family members) for possible ICD implantation.

Valvular Heart Disease

• Needs echocardiogram and/or cardiac catheterization to confirm the severity.
• Systolic dysfunction caused by aortic stenosis usually improves after valvular surgery.
• Systolic dysfunction caused by aortic regurgitation and particularly mitral regurgitation may deteriorate after valvular surgery.
• Significant mitral regurgitation secondary to dilated cardiomyopathy needs maximum afterload reduction therapy.

Arrhythmia

• Diagnosed by history, physical examination, ECG, cardiac monitoring (Holter monitoring vs arrhythmia monitor depends on frequency of the event), electrophysiologic study.
• Sustained tachycardia can cause left ventricular systolic dysfunction which should improve or resolve when the tachycardia has been controlled or eliminated.
• Treatment:
  • Asymptomatic PAC, PVC or nonsustained tachycardia should not receive pharmacological therapy.
  • Symptomatic PAC, PVC should be treated with education and reassurance first.
  • Most antiarrhythmic medicines have deleterious effects in heart failure patients with systolic dysfunction except for amiodarone, beta blockers (some) and dofetilide.
  • Pacemaker therapy is indicated in appropriate, symptomatic or drug (that is necessary for heart failure treatment program) induced bradycardia.
  • ICD