CV Note

EXERCISE TREADMILL TESTING INDICATION

當病人出現疑似CAD的symptoms，resting ECG表現為正常，且自身條件足以進行，peak heart rate至少要達(220 − age) x 85%。若原本EKG已有不正常finding，可能sensitivity and specificity會下降。當ST-segment depression (horizontal or downsloping > 0.1 mV and lasting > 0.08 sec) 應強烈懷疑CAD。在女性、atypical 或 no chest pain、anemia的患者可能出現False positives的情形。

MYOCARDIAL PERFUSION IMAGING

注入nuclear medicine(dipyridamole or adenosine) induce coronary vasodilation,增加healthy coronary arteries flow，stenosis的血管flow相對減少，dipyridamole (Persantine) or adenosine會造成bronchoconstriction，COPD是一個重要的contraindicationas。

Functional Classification of Heart Disease

Class I: No limitation of physical activity. (正常人)

Class II: Slight limitation of physical activity. (輕微)

Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms. (明顯的症狀)

Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest. (連休息也會有症狀)

Hypertension

First-line：diuretics, beta blockers, ACEI, ARB, CCB.

Goal is SBP<135–140 systolic, DBP<80–85 (<130/80 in patients with DM or CKD).

A、ACEI：Side effects include angioedema, hyperkalemia and azotemia (particularly in pts with elevated Cr), nonproductive cough-->substitute an ARB

B、Beta Blockers：Relative contraindi-cations include bronchospasm, CHF, AV block, bradycardia, and insulin-dependent diabetes.

C、CCB

1、DHP：

長效：Amlodipine, Nifedipine-MR

短效：Nifedipine, Nicardipine

降低 afterload, 擴張coronary artery, 減低inotropic(但Amlodipine可能在LVF使用)

2、NDPH：verapamil, diltiazem

減低inotropic更明顯，應避免在急性CHF使用

D、Diuretics：

Major side effects include hypokalemia, hyperglycemia, and hyperuricemia 

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主動脈剝離

胸部主動脈剝離--HTN(看到胸部血壓會高)
腹部主動脈剝離--atherosclerosis(粥喝到肚子)


先使用beta blocker

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DM Medication

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Empyema

leukocytosis,
low pH (<7.20),
low glucose (<60 mg/dL),
high LDH (lactate dehydrogenase),
elevated protein
may contain infectious organisms

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Indications for chest drain insertion

Indications for chest drain insertion

• Pneumothorax
  
  
  • in any ventilated patient
  • tension pneumothorax after initial needle relief
  • persistent or recurrent pneumothorax after simple aspiration
  • large secondary spontaneous pneumothorax in patients over 50 years
• Malignant pleural effusion
• Empyema and complicated parapneumonic pleural effusion
• Traumatic haemopneumothorax
• Postoperative—for example, thoracotomy, oesophagectomy, cardiac surgery

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CAD Risk Factor

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Warfarin

Common clinical indications for warfarin 
1. atrial fibrillation, 
2. artificial heart valves, 
3. deep venous thrombosis
4. pulmonary embolism 
5. antiphospholipid syndrome. 
6. after heart attacks (myocardial infarctions)

	Condition	Points
C	Congestive heart failure	1
H	Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)	1
A	Age ≥75 years	1
D	Diabetes mellitus	1
S2	Prior Stroke or TIA	2

Score	Risk	Anticoagulation Therapy	Considerations
0	Low	Aspirin	Aspirin daily
1	Moderate	Aspirin or Warfarin	Aspirin daily or raise INR to 2.0-3.0, depending on patient preference
2 or greater	Moderate or High	Warfarin	Raise INR to 2.0-3.0, unless contraindicated

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Hyperlipidemia

TG: DM，酒，ESRD，hepatitis，B-blocker，estrogen，gucocorticoid
LDL：hypothyroidism，cholestasis，Thiazide


estrogen會同時升高TG、HDL


TC = HDL+LDL+TG/5

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CSF

Normal values (CSF):

CSF opening pressure: 50–180 mmH2O Glucose: 40–85 mg/dL. Protein (total): 15–45 mg/dL. Lactate dehyrogenase: 1/10 of serum level. Lactate: less than 35 mg/dL. Leukocytes (WBC): 0–5/µL (adults / children); up to 30/µL (newborns). Gram stain: negative. Culture: sterile. Specific gravity: 1.006–1.009. Syphilis serology: negative. Gross appearance: Normal CSF is clear and colorless. Differential: 60–70% lymphocytes; up to 30% monocytes     and macrophages; other cells 2% or less.

Bacterial Meningitis Glucose (mg/dL): Normal to marked decrease.  <40 mg/dL. Protein (mg/dL) (Marked increase)  > 250 mg/dL. WBCs (cells/µL) >500 (usually > 1000).  Early: May be < 100. Cell differential: Predominance of Neutrophils (PMNs) Culture: Positive Opening Pressure Elevated

Fungal Meningitis Glucose (mg/dL): <40 mg/dL (Low) Protein (mg/dL) (moderate to marked increase) 25 -500 mg/dL WBCs (cells/µL) Variable (10 -1000 cells/µL) <500cells/µL. Cell differential: Predominance of Lymphocytes Culture: Positive (fungal) Opening Pressure Variable

Tubercular Meningitis Glucose (mg/dL): <40 mg/dL (Low) Protein (mg/dL) (moderate to marked increase) 50 -500 mg/dL WBCs (cells/µL) Variable (10 -1000 cells/µL) <500cells/µL. Cell differential: Predominance of Lymphocytes Culture: Positive for AFB Opening Pressure Variable

Viral Meningitis Glucose (mg/dL): Normal   (> 40 mg/dL.) Protein (mg/dL) <100 mg/dL (moderate increase) WBCs (cells/µL) < 100 cells/µL. Cell differential: Early: neutrophils. Late: lymphocytes. Culture: Negative Opening Pressure Usually normal

文章取自此處

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Anti-arrhythmia

Class	Basic Mechanism	Comments
I	sodium-channel blockade	Reduce phase 0 slope and peak of action potential.
IA	- moderate	Moderate reduction in phase 0 slope; increase APD; increase ERP.
IB	- weak	Small reduction in phase 0 slope; reduce APD; decrease ERP.
IC	- strong	Pronounced reduction in phase 0 slope; no effect on APD or ERP.
II	beta-blockade	Block sympathetic activity; reduce rate and conduction.
III	potassium-channel blockade	Delay repolarization (phase 3) and thereby increase action potential duration and effective refractory period.
IV	calcium-channel blockade	Block L-type calcium-channels; most effective at SA and AV nodes; reduce rate and conduction.

引用自此

Class Ia Procainamide Quinidine Disopyramide	Class II Propranolol Atenolol Nadolol Metoprolol Pindolol Esmolol	Others Bretylium Digoxin Adenosine Phenylephrine Midodrine Fludrocortisone
Class Ib Lidocaine Mexiletine Phenytoin Moricizine	Class III Ibutalide Sotalol Amiodarone
Class 1c Flecainide Propafenone	Class IV Verapamil Diltiazem

Structure heart diseaseàI C

LV dysfunction or CADàIII

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