Cardiovascular Conditions

Brady arrhythmia And Blocks

• Shift patient on to appropriate oral drugs once the arrhythmia has been controlled.
• Monitor for drug toxicities and recurrences so as to titrate the dose
• Evaluate and refer for electrophysiological studies.
• Monitor INR for patients on anticoagulant therapy.
• Evaluate and refer for electrophysiological studies.

Patient education

• Emphasize need for compliance and regular follow up.
• Prepare for further intervention depending upon the cause. Valvular heart disease may be managed by repair or replacement. Reentrant tachycardia can be managed with radiofrequency ablation, coronary heart block requires temporary often followed by permanent pacing, coronary artery disease requires revascularisation.
• Emphasize need for compliance and regular follow up.

Reference

Tachyarrhythmias. In: Harrison’s Principles of Internal Medicine. Braunwald E, Fauci AS, Karper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1292-1309.

Ventricular Tachycardia

Salient features

Run of three or more consecutive ventricular beats at a rate >120 beats/min. If the rate of consecutive ventricular beats is >100/min,it is called accelerated idioventricular rhythm which is a benign condition, usually occurring following the thrombolytic therapy. Diagnosis is made by ECG, suggested by independent P wave, fusion or capture beats, uniformity of QRS vectors in the V leads (concordance) & a frontal plain QRS axis > -30.

1. Haemodynamically stable -

   Inj. Lidocaine 1 mg/kg IV bolus (3 ml) followed by repeated 0.5-1 mg/kg boluses at 5 min intervals upto a total of 3 mg/kg to attain desirable response followed by IV infusion 2-4 mg/min. Endotracheal or IM administration in extreme cases (300 mg).
   If no effect of Lidocaine and DC conversion is not available,
   Inj. Procainamide 15 mg/kg loading dose followed by 2-5 mg/min maintenance infusion.

2. Haemodynamically unstable VT or no response to lidocaine

   Synchronized DC shock starting with 50-200 Joules.

3. In ventricular fibrillation

   Unsynchronized 200 Joules followed by 360 Joules if required.

4. Maintenance treatment

   Tab. Procainamide 250-650 mg 4 to 6 hourly.
   Or
   Tab. Flecainide 100 mg 8-12 hourly

Sustained Atrial Fibrillation

1. Rapid digitalization done as in section on CHF followed by maintenance dose.
2. Tab. Warfarin 5 mg daily with titration as per INR (maintain about 1.5 to 2) in patients with documented clots or thromboembolic episodes.
   In cases of elective DC cardioversion (100 to 400 Joules), 3 weeks of anticoagulation required.
3. Treatment of underlying condition like thyrotoxicosis.

Supraventricular Tachycardia (PSVT)

• Reassure the patient especially if no haemodynamic disturbance present at a time when the patient has symptoms.
• Vagal stimulation by drinking cold water, Valsalva manoeuver, carotid massage etc.

1. Tab. Atenolol 25-100 mg/day as single or divided doses.
   Or
   Tab. Metoprolol 50-200 mg/day as a single dose or divided doses.
   Or
   Tab. Verapamil 40mg thrice a day.
   Or
   Tab. Amiodarone 150-200mg/day (in resistant cases).

Patient should be referred to a higher center for maintenance treatment/definitive treatment.

Arrhythmia

These disorders are important to recognize for proper management. Arrhythmia’s are frequently intermittent (paroxysmal) and may be classified based on

• Ventricular Vs supraventricular.
• Narrow QRS Vs wide QRS.
• Regular Vs irregular.
• Clinically benign Vs those associated with haemodynamic compromise (lower the ejection fraction (EF), poorer the prognosis).
• Diagnostic tests include ECG during attack of arrhythmia or 24-hour Holter monitoring (if no abnormality seen in ECG on presentation).

Treatment

Identify and treat precipitating factors.

Pulmonary Embolism / Infarction

Investigations

• Chest roentgenogram- oligaemia in lung fields and typical wedge shaped infarction, arterial blood gas analysis.
• ung scanning and pulmonary angiography, D-Dimer ELISA and latex agglutination, echocardiography, contrast plethysmography and venous ultrasound for deep vein thrombosis.
• Blood cultures in case of septic emboli.

Treatment

Primary therapy

1. Medical
   1. Inj. Streptokinase 250,000 units IV as loading dose over 30 min followed by 100,000 units every hour for up to 12-72 hours.
   Or
   Inj. Urokinase 4400 U/kg IV over 10 mins – 4400 U/kg every hour for upto 12 to 24 hours
   Or
   Inj. rt-PA 100 mg continuous IV infusion over 2 hours.
   2. Inj. Dobutamine IV infusion at the rate of 5 to 10 mcg/kg/min.
   3. Oxygen 100% inhalation (except in cases of COPD/cor pulmonale)
   4. Pain relief with NSAIDs or narcotics.
2. Catheter based suction embolectomy, local mechanical dispersion, local pharmacological thrombolysis.
3. Surgical embolectomy.
4. Secondary prevention

   1. Inj. Heparin 5000 IU-10,000 IU over 5 minutes followed by an IV infusion at the rate of 15-25 units/kg/hour. Check prothrombin time (PT) after 6 hours and titrate     INR to 1.5 to 2.3 times control. Complete blood count (CBC) for heparin associated thrombocytopenia (HAT).
   2. Tab. Warfarin is initiated on the first day of documenting PT within therapeutic range in a dose of 10 mg daily for 2 days. The subsequent maintenance dose depends     on PT with an overlap of 5 days with heparin (stop heparin when INR>2). A target INR of 2.0 to 3.0 is achieved and therapy is continued for at least a year.
   (CAUTION: Protamine sulphate is an antidote to overdosage with heparin with 1 mg neutralising 100 IU of heparin given within 75 minutes (maximum 50 mg).      Vitamin K 1-10 mg acts as an antidote to warfarin overdose.
   3. Tab. Aspirin 80 mg/day following a full course of warfarin.
   4. Inferior vena caval obstruction (IVC) with greenfield or bird’s nest filter to prevent recurrent embolisation from deep vein thrombosis (DVT).

Monitoring and follow up

• Complete course of anticoagulant therapy with INR at regular intervals. First INR after 16 hours of warfarin.
• Inferior vena caval filters for recurrent emboli.
• Evaluate for hypercoagulable states such as protein C and S deficiencies, factor V leiden, antithrombin III deficiency, plasminogen deficiency, and elevated factor VIII.

Patient education

• Prophylaxis against deep vein thrombosis and pulmonary embolism in high-risk settings with graduated compression stockings, pneumatic compression, IVC interruption and heparin therapy.

References

Pulmonary Thromboembolism; In: Harrison’s Principles of Internal Medicine. Braunwald E, Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1508-1513.

Congestive Heart Failure (CHF)

• Since it is a syndrome, appropriate examination & investigations like chest x-ray, ECG, ABG and echocardiography should be done to identify the cause.
• Identify precipitating factor – arrhythmia’s, fluid overload, thyroid disease, (See also Hypothyroidism & Hyperthyroidism) infection; anaemia, pregnancy, pulmonary embolism, dietary or medical noncompliance.

Nonpharmacological

• Restrict physical activity and bed rest in propped up position with a back rest.
• Oxygen inhalation – high flow oxygen 10 litres/min through facemask or 60% venturi mask.
• Dietary sodium restriction (2-3 g/day- no added salt in cooking and no table salt).
• Fluid restriction depending on output and other conditions.
• Dialysis or ultrafiltration or mechanical fluid removal (ascitic tap, paracentesis etc).
• Discontinue drugs with negative inotropic action (high dose betablockers, calcium-antagonists etc.).

Pharmacological

Consists of a judicious mix of vasodilators, diuretics and inotropic support.

1. In severe/acute cases Inj. Frusemide 40-80 mg IV stat and repeated after 2-3 hours. Individualise the maximum dose upto 200 mg/day.
   Maintenance dose is 40 mg IV 12 hourly till clinical improvement is seen.
   And
   Tab. Spironolactone 25-200 mg daily, may be used in combination with above.
   Or
   Tab. Chlorthiazide 250-500 mg/day.
   Or
   Tab. Indepamide 2.5-5 mg/day.
   Or
   Tab. Benzthiazide 25mg + Tab. Triamterene 50 mg/day.
   High dose of Frusemide infusion i.e. 10 mg/h undiluted and1 mg/h as continuous infusion can be used in refractory patient.
2. Tab. Enalapril 2.5-20 mg/day may be given as a single or two divided doses.
   Or
   Tab. Lisinopril 2.5-20 mg/day as a single daily dose.
3. Tab. Isosorbide mononitrate 60 mg/day preferably as slow release preparation
   given at night.
4. Digoxin is indicated in fast ventricular rate (e.g. in atrial fibrillation).
   Inj. Digoxin 1 mg IV, followed by 0.5 mg at 8 and 0.25 mg at 16 hours Or 0.5 mg followed by 0.25 mg PO at 8, 16 and 24 hours (rapid digitalization) followed by 0.125-0.375 mg/day as maintenance dose.
   Or
   Tab. Digoxin 0.5 mg first day, followed by 0.25 mg/day (slow digitalization)
5. Tab. Carvedilol 3.125 – 25 mg per day in single/or two divided doses (useful if persistent tachycardia, idiopathic dilated cardiomyopathy)- dose to be doubled, if required, only after 2 weeks.
6. Inj. Heparin 5000 U 12 hourly SC if the patient is bed ridden.

Monitoring

• Strict intake-output charting and daily weight as well as abdominal girth.
• Symptomatic relief and resolution of signs and symptoms of failure.
• Serum electrolytes & uric acid.
  In case of refractory failure and for management of underlying cause, refer the patient to a higher centre.

Patient education

• Explain need to control salt intake and bed rest or regular compliance with medication.
• Patient should be advised to contact the physician if symptoms of digitalis toxicity e.g anorexia, nausea and vomiting or worsening of heart failure.
• Diuretics should be taken in the morning and if two doses a day are required second dose should be given before 4 PM.

References

1. Heart Failure. In: The Merck Manual . Beers MH & Berkow R (eds), 1999, pp 1682-92.
2. Heart Failure. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1319-1329.

Myocardial Infarction (MI)

Salient features

• Sudden death is 1st manifestation in significant number of patients. Some patients may be asymptomatic and detected on routine ECG.
• Chest pain similar to anginal pain is the commonest symptom, usually begins at rest, no response to nitrates, lasts >20 minutes and patient may have associated dyspnoea, hypotension, sweating, altered sensorium and cyanosis. Diagnosed by typical ECG changes.

Treatment (preferably in CCU)

Nonpharmacological

Diagnosis should be made as soon as possible (within 20 minutes of arrival in hospital). Admit in CCU (if available), oxygen inhalation (4-6 litre/min), bed rest, ensure IV access, continuous cardiac monitoring, avoid visitors and outside influences. e.g. radio, newspapers.

Pharmacological

1. Inj. Morphine 2-4 mg IV, repeated 4-6 hourly, if needed.
2. Tab. Aspirin 150-325 mg PO administered on admission.
3. Tab. Nitroglycerine 0.3-0.6 mg sublingual.
   First 24 hours
4. Confirm MI by cardiac enzymes estimation and ECG.
5. Thrombolysis should be done within 6-12 hours with following. There is slightly increased risk of intracranial haemorrhage – if age >65, weight <70 kg,
   hypertension, and with TPA.
   Inj. Streptokinase 250,000 units IV as loading dose over 30 min followed by 100,000
   units every hour for up to 12-72 hours.
   Or
   Inj. Urokinase 4400 U/kg IV over 10 min then 4400 U/kg every hour for up to 12-24 hours
   Or
   Inj. rt-PA 100 mg contrinuous IV infusion over 2 hours.
6. Primary PTCA may be done as an alternative to thrombolysis.
7. Close monitoring as mortality is maximum in the first 24 hours.
8. Adequate analgesia.
9. Limit physical activities at least for 12 hour.
10. Do not use prophylactic antiarrhythmics but should be readily available.
11. Inj. Heparin 1000 units/h IV infusion for 72 h (more useful with TPA).
12. Inj. Nitroglycerin as in angina if pain continuing and no hypotension, bradycardia/excessive tachycardia (24-48 h).
13. If no contraindication Inj. Metoprolol 2 mg IV every 2 minutes for 3 injections; if well tolerated follow with 50 mg PO started 15 minutes after last IV dose and given every 12 hourly for 48 hours. Then it may be changed to 100 mg once a day.
14. If no hypotension or contraindications and uncomplicated MI Tab. Enalapril 5 mg 2 times a day PO.
15. Measure serum lipids and electrolytes.
    After first 24 hours
16. Continue aspirin, beta-blockers, nitroglycerine, heparin, ACE I, analgesia (if required).
17. Observe and treat any complication – high-dose aspirin if pericarditis, Diuretics if congestive heart failure, defibrillation (if haemodynamic compromise) of AF, atropine if blocks/bradycardia, intra-aortic balloon if severe hypotension.

Indication for urgent angiography/angioplasty
Ischaemic episodes (spontaneous/provoked) and preserved left ventricular systolic function.
Indications of temporary pacing:
Sinus bradycardia unresponsive to drugs, Mobitz type II AV block, Third degree AV block, Bilateral bundle branch block (BBB), Newly acquired BBB, and Bifascicular or trifascicular block.
Indications for urgent surgery:

• Failed PTCA with persistent chest pain or haemodynamic instability.
• Persistent or refractory ischaemia who is not a candidate for catheter intervention.
• Cardiogenic shock and coronary anatomy not amenable to PTCA.
• Mechanical abnormality leading to pulmonary edema/hypotension e.g., papillary muscle rupture or acute ventricular septal defect.

Discharge from hospital

Treadmill test – submaximal at 4-7 day or symptom limited (10-14 days)

Aim:

• To assess functional capacity and ability to perform work at home/work.
• Evaluate efficacy of current medical regimen.
• Risk stratification for future.

Long term management

• Aspirin, beta-blockers and ACEI (selected patients) – indefinite period.
• Achieve ideal weight.
• Control lipids (LDL <100 mg% with or without drug).

Patient education

• Advise patient to stop smoking, weight reduction, regular exercise (20 minutes brisk walk at least 3 times a week), restrict fat intake to control serum lipids.

References

1. AHA guidelines for the management of patients with acute myocardial infarction. Journal of Amer College of Cardiology, 1996; 28: 1328-1419.
2. Myocardial Infarction. In: The Merck Manual 1999; pp. 1668-1681.

Unstable Angina

1. Tab. Aspirin 300 mg stat. If aspirin is given before arrival at hospital, note saying that it has been given should be sent with the patient.
2. Inj. Nitroglycerine 5 mcg/min IV infusion, increase to dose by 2.5 to 5 mcg every few minutes until pain is controlled (monitor BP).
3. Continue other drugs as above
4. Inj. Heparin – unfractionated – 1000 U/h or low molecular weight heparin (enoxaparine) 1 mg/kg (0.6 ml for 60 kg) 12 hourly.
5. Angioplasty/CABG may be done if no relief with medication or disease is progressive.

Follow up

• Assess the risk factors like diabetes, obesity, hyperlipidaemia, hypertension, smoking and correct these factors.
• Correct anemia, if present.
• Worsening angina/unstable angina requires further investigation and should be referred to a higher center.

Angina Pectoris

1. Tab. Isosorbide dinitrate 5 mg sublingual during the attack, dose repeated as required
   Or
   Tab. Nitroglycerin 0.3-0.6 mg sublingual
2. If attacks are more than twice a week, regular drug therapy is required.
   Tab. Isosorbide mononitrate 20 mg 2 times a day PO, may be increased to 120 mg per day is required.
3. If no contraindications exist Tab. Metoprolol 50 mg 2 times a day
   Or
   Tab. Atenolol 50 mg/day PO
4. If beta-blockers are contraindicated or angina persists Tab. Diltiazem 60-120 mg/day PO
5. Tab. Aspirin 100-150 mg per day PO
   Or
   Tab. Ticlopidine 250 mg 2 times a day If patient can not tolerate Aspirin Tab. Clopidogrel 75 mg/day, if available.
6. If still ischaemia is not controlled Tab. Nicorandil 5 mg 3 times a day can be started.

Cardiomyopathy

The Cardiomyopathies and Myocarditis. In: Harrison’s Principles of Internal Medicine. Braunwald E, Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1359-1365.

Acute Pericarditis

1. Tab. Aspirin 650 mg orally every 3 to 4 hours.
   Or
   Tab. Ibuprofen 400 mg orally every 6-8 hours for 1 week.
2. In the absence of relief within 48 hours (non-infective cases only) Tab.
   Prednisolone 20-60 mg per day for 3-4 days.
3. Antibiotics should be used only in case of documented purulent pericarditis emperically to cover Pneumococci, Meningococci, Staphylococci, H. influenzae (Ampicillin + Gentamicin) may be used.
4. Anticoagulants are not to be used except in case of prosthetic valves when Heparin may be used.
5. Treatment of primary disease causing pericarditis.
   Complications of the pericarditis are pericardial effusion, constrictive pericarditis and recurrent pericarditis.
   Pericardial effusion
   Pericardial effusion occurs when pericarditis leads to accumulation of fluid in pericardial cavity. Echocardiography is diagnostic.

Treatment

• As above for pericarditis.
• Diagnostic tap for effusion.
• Pericardiocentesis in case of a large effusions or tamponade.
• Pericardiostomy with drainage for large effusions with rapid refilling.
  Constrictive pericarditis is the restriction induced by a thickened fibrous pericardium as a sequelae of pericarditis. Tuberculosis is the commonest cause. Treatment is surgical excision. Pericardiectomy for recurrent pericarditis or constrictive pericarditis.

Treatment

1. Antitubercular therapy (for details see tuberculosis – Tuberculosis, Cutaneous, Meningitis, other section)
2. Tab. Prednisolone 1 mg/kg for 2 weeks and then taper off in next 4 weeks.
   Recurrent pericarditis may require intravenous methyl prednisolone pulses, colchicine 1 mg daily or pericardiectomy.
   Monitoring
   Monitor symptomatic relief so as to stop NSAIDs or taper steroids.
   Watch for complications (clinical course, echocardiography, chest roentgenograms) and refer to a higher centre for appropriate management.
   Ensure treatment of the underlying cause.

Patient education

• Reassurance that viral pericarditis is self-limiting with monitoring for complications is sufficient.
• Patients with tubercular or purulent aetiology must be educated to ensure compliance and adequate therapy.
• Myxedema must be adequately treated and emphasize the need for follow up and compliance.
• Uraemia, malignancy etc. require referral for specialized care and management.
• Rheumatic fever patients must receive prophylaxis and follow up at a higher centre for management of valvular involvement.
• Drug induced pericarditis must be prevented by educating the patient against future use.
• Emphasize the need for post myocardial infarction, follow up with echocardiography and other measures including life-style modification, drugs, revascularisation etc.

Infective Endocarditis

1. No response to medical treatment (specially in prosthetic valve endocarditis)
2. Worsening heart failure and the lesion is correctable
3. Acute onset cardiac complication due to infection e.g. septal perforation/valvular damage/stroke perivalvular extension of infection.
4. Large (> 1 cm diameter) hypermobile vegetation with increased risk of embolism.

• Prophylaxis: When undertaking interventional procedures (dental extraction, upper respiratory tract) to take prophylactic treatment with following:
  Cap. Amoxycillin 3 g orally 1 hour preoperatively or Cap. Clindamycin 600 mg 1 hour preoperatively.
  Higher risk patients with prosthetic valves, genitourinary procedures Inj. Amoxycillin 2 g IV + Inj. Gentamicin 120 mg IV before procedure followed by Cap. Amoxycillin 1 g orally 6 hours postoperatively.
  Substitute Vancomycin 1 g IV over 100 min in case patient is allergic to penicillin.

Reference

Prevention of Bacterial Endocarditis. Dajani AS, Taubert KS et al (eds), JAMA 1997; 277: pp 1794-1801.

Rheumatic Fever

1. Tab. Aspirin 80-100 mg/kg divided in 4-6 equal doses after food.
2. In patients with evidence of severe carditis and congestive failure or pericarditis:
   Tab. Prednisolone 1-2 mg/kg for 4-6 weeks followed by administration of Aspirin (which should be started 1 week before stopping prednisolone).
   Duration of treatment for arthritis is 4-6 weeks and for carditis is 3-6 months.
3. Treatment of congestive heart failure, if present (see the section on CHF).
4. In case of chorea
   Tab. Haloperidol 0.05 mg/kg/day.
5. All patients with acute rheumatic fever should be treated with as if they have group A Streptococci infection whether or not the organism is not actually recovered from culture.
   Inj. Procaine penicillin 10 lac units/day IM
   Or
   Inj. Benzathine penicillin 1.2 MU single IM injection
   Or
   Oral penicillin B 500 mg twice daily for 10 days.
   Secondary prophylaxis with
   Tab. Penicillin V, 250 mg 2 times a day
   Or
   Inj. Benzathine penicillin 1.2 MU (if weight >37 kg) or 0.6MU (if weight
   <37 kg) IM every 3 weeks
   Or
   If patient is allergic to penicillin
   Tab. Erythromycin 250 mg 2 times a day

1. Rheumatic fever with carditis and residual valvular involvement atleast until 40 years or sometimes even lifelong.
2. Rheumatic fever with carditis and no residual valvular involvement, for 10 years or upto 21 years or whichever is longer.
3. Rheumatic fever without carditis, for 5 years or until 21 years whichever is longer.

Monitoring

1. Monitor blood levels of salicylates.
2. Watch for salicylate toxicity (ototoxicity, hyperventilation and metabolic acidosis).
3. Follow up for response to fever and decrease in acute phase reactants to reduce salicylates or taper steroids.
4. Echocardiography for monitoring complications of carditis.

Patient education

• Explain consequences of rheumatic fever and ensure monitoring to rule out residual valvular involvement and compliance with prophylaxis
• Patients with valvular involvement should report to cardiologist for evaluation and further management.
• Explain the importance of prophylaxis against rheumatic carditis as detailed earlier.

Reference

Acute rheumatic fever. In: Medicine International No.18, 1997, pp 100-105.