Cardiogenic shock, first question is - due to right heart failure or left heart failure?

Physical helps, crackles - LHF. No crackles and JVD - RHF

RHF - any HF - need to exclude ischemic etiology first. So think of RVMI - EKG showing 1 mm ST
elevation in inferior leads or right sided precordial leads, V4R to V6R.
In case of RHF due to non-ischemic causes include lung conditions such as acute pulmonary embolism,
pulmonary HTN - severe COPD - hypoxia driven, chronic ILD, chronic PS/PR/TR.
This is important to distinguish as management differs, isolated RHF is preload dependent, therefore
RHF induced cardiogenic shock (shock usually means not responding to fluids, but in this case it is
different - continued hypotension after cath in case of RHF is shock) is treated with fluid boluses. If
hypotension persist despite fluids, then give inotropic agents. Dopamine is initial drug of choice.
Dobutamine can decrease PVR and worsens hypotension.
RVMI should be treated the same way as LVMI with aspirin, plavix and aspirin, except nitrates - decrease
preload.
If the RHF is associated with LHF then, fluids are not indicated. Both after load and preload reducers are
used.
Chest pain, hypotension, JVD, and clear lung fields - think of RVMI, pericarditis, and pericardial
tamponade. EKG and troponins will help to rule out RVMI. Pericardial rub and history of recent URI
symptoms will help for pericarditis. Echo is needed for pericardial tamponade.
Intra-aortic balloon pump - after load reduction - cardiogenic shock secondary to LHF.
Post cath hypotension, think of retroperitoneal hematoma - can cause rapid hypovolemic shock and
death. Look for groin hematoma, back or abdominal pain, and flat neck veins.
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Ambulatory blood pressure monitoring (ABPM) - indicated

1. Discrepancy in blood pressure readings at clinic and office
2. Suspected paroxysmal hypertension - episodic symptoms suggesting episodic HTNpheochromocytoma
3. Suspected autonomic dysfunction
4. Refractory hypertension
5. HYPOtension symptoms while on treatment for hypertension

HTN is considered if the readings in - day time 140/90 and NIGHT time 125/75
ABPM is better predictor of future cardiovascular events and all cause mortality than clinic or home
BP readings.

Episodic palpitations, diaphoresis and if you know BP is elevated intermittently - think of

pheochromocytoma.
T wave inversions only in leads V1 and V2 are normal.

----------------IV line associated DVT - remove line and start anticoagulation for 3 months. But in cases where IV access
is required and getting another IV access is difficult - pt's with s/p mastectomy and lymph node
resection or HD pt's, don't remove catheter.
If the DVT symptoms does not improve, then do - routine repeat ultrasound.
If these patients with limited IV access, developed DVT at IV line and the line is occluded - no blood on
pull back, then IV catheter should be salvaged using thrombolytics tPA .
We use this in ICU for patients with difficult IV access and the catheter is occluded, but no DVT.
Anastrazole - aromatase inhibitor - breast cancer positive for hormone receptors - ER/PR/HER - <5% risk
of DVT.
Even in case of superficial DVT, remove the IV line, as the patient at risk for DVT, but no need
anticagulation.
----------------AAA
risk factors :
1. for development - white male, >60 years, smoking cig's, family history of AAA and ATHEROSCLEROSIS.
2. for expansion and rupture - diameter > 5.5 cm, expansion rate >0.5 cm/6months or 1 cm/year - called
rapid rate of expansion, current cig. smoking is highest risk of expansion and rupture.
Repair: surgery itself is risky, therefore only do when
1. Symptomatic
2. diameter >5.5 cm

----------------Syncope patient - next step look at EKG

AV dissociation - AV block
In CAD and heart failure patients, symptoms can worse due to bradycardia - idioventricular rhythm -AV
block
AV block - next step look at ---reversible cause -----medications-betablockers or CCB - stop them
AV block patients with syncope should be treated - when it comes to treatment - first look at QRS
duration - narrow QRS: atropine
- wide QRS: temporary pacing.
Stable asymptomatic AV block pt's - permanent pacemaker.
Symptomatic do something now, asymptomatic can be done later

Aortic stenosis - severe - should have all - angina, syncope, dyspnea, and LATE-peaking murmur.
All three symptoms are correlated - backing of fluid in heart cause SOB and syncope and stage of heart
failure symptoms due to increase in demand chest pain should also occur at same time.
LATE-peaking systolic murmur - due to volume overload in severe aortic stenosis, the murmur prolongs.
MID-peaking means not that severe.
Even though the presentation of syncope sounds like vasovagal, you should rule out structural heart
diseases and conduction abnormalities, as vasovagal syncope is diagnosis of exclusion.

When you think of syncope due to volume depletion, you have to check - reflex signs for hypotension tachycardia

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