Cardiology Consult Update LCDR Olamide Oladipo, MC, USN Cardiology Staff

Presenter Disclosure Information Olamide Oladipo, DO Cardiology Staff FINANCIAL DISCLOSURE: No relevant financial relationship exists

Objectives Discuss cardiac vs. non-cardiac chest pain. Discuss common causes of syncope from a cardiologist standpoint. Review approach to palpitations.

Outline Define various chest pain Diagnostic tests for typical /atypical chest pain Define syncope Review varying causes of syncope Basic diagnostics test for syncope Causes of palpitations Monitors available to evaluate palpitations.

Chest Pain

Classification of “Chest Pain”

Non-cardiac Chest Pain

Risk Stratification Exercise testing Pharmacologic testing Exercise treadmill test Exercise stress echocardiogram Exercise myocardial perfusion scan Pharmacologic testing Dobutamine stress echocardiogram Regadenoson myocardial perfusion scan Anatomic testing Cardiac gated CT scan Left heart catheterization

Exercise Treadmill Testing Treadmill ECG interpretation also employed with exercise stress echo and MPS Those with a baseline abnormal ECG Ventricular pre-excitation (Wolff-Parkinson-White pattern) Contraindications Acute MI within 2days Ventricular paced rhythm Ongoing unstable angina Uncontrolled cardiac arrhythmia with hemodynamic compromise Left bundle branch block Greater than 1 mm ST depression at rest Symptomatic severe AS Physical inability

Syncope

Definition of Syncope Transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.

Broad Categories of Syncope Neurally-mediated (reflex) Orthostatic hypotension Cardiac – Arrhythmias – Structural disease Cerebrovascular (rare 4th categoryy) – Vascular steal syndromes

Reflex Syncope

Orthostatic Syncope

Cardiac Syncope

Diagnostic Tests Cardiac tests Neurally-mediated tests – Echo – Tilt table test – Prolonged ECG monitoring – Carotid sinus massage – Stress test – EP study – Implantable loop recorder

Palpitations

Definition of Palpitations A sensation of rapid or irregular beating of the heart” - Single “skipped” beats - Feeling of being unable to catch one’s breath - Single pounding sensations - Rapid, regular pounding in neck - Palpitations that are worse at night - Palpitations associated with emotional distress

Causes: Cardiac Atrial fibrillation/flutter Premature supraventricular or ventricular contractions Bradycardia caused by advanced arteriovenous block or sinus node dysfunction Sinus tachycardia or arrhythmia Supraventricular tachycardia Bradycardia-tachycardia syndrome (sick sinus syndrome) Ventricular tachycardia Multifocal atrial tachycardia Wolff-Parkinson-White syndrome

Non-arrhythmic cardiac causes Atrial or ventricular septal defect Mitral valve prolapse Pacemaker-mediated tachycardia Cardiomyopathy Congenital heart disease Pericarditis Congestive heart failure Valvular disease (e.g., aortic insufficiency, stenosis)

Causes: Others Psychiatric Medications - Digitalis - Phenothiazine - Theophylline - Beta agonists - Anxiety disorder - Panic attacks Substance - Street drugs (e.g., cocaine, Meths) - Alcohol - Caffeine Extracardiac - Anemia - Electrolyte imbalance - Fever - Hyperthyroidism - Pheochromocytoma

Diagnostic Tests ECG Echo if suggestive of structural abnormalities Holter (24-48hr) 14day continuous monitoring 30day event monitor 30day continuous monitoring

Palpitations Algorithm A sensation of rapid or irregular beating of the heart” – Taber’s

Summary Exercise treadmill test for chest pain with normal EKG If reflex syncope; okay to order echo to ensure no structural abnormalities if EKG is abnormal. Appropriate monitor consult +/- routine cardiology consult.

Questions