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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Constriction vs. Tamponade vs. Restriction
Discussed (tested) together because of some overlapping
clinical findings
• Constriction and tamponade are pericardial problems
characterized by enhanced ventricular interdependence
– Increased R heart filling = Reduced L heart filling
• Patients with tamponade are often unstable
• Patients with constriction normally present with heart failure
• Patients with restriction have a myocardial problem that can
resemble constriction but no ventricular interdependence
Use history, clinical exam
, and other clues to help differentiate
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Cardiac Tamponade Constrictive pericarditis Restrictive
cardiomyopathy
Pathophysiology
Accumulation of pericardial
fluid
continuously compresses all
chambers throughout cardiac
cycle, impairing filling
Fibrous pericardium limits
expansion of cardiac chambers,
and shields
them from
intrathoracic pressure (ITP)
changes
Myocardial stiffness limits
expansion
of ventricular
chambers; normal pericardium
that transmits ITP changes
Ventricular
Interdependence
Present
(
discordant RV/LV pressure
changes with inspiration)
Present
(
discordant RV/LV pressure
changes with inspiration)
Absent
(normal, concordant RV/LV
pressure changes due to ITP
transmission)
Kussmaul’s
sign
(inspiratory
éJVP [or
does not drop])
NO
(ITP
drop transmits to RV via
pericardium, so RV can fill)
YES
(RV
cannot expand anywhere
further beyond early diastole)
YES
(stiff RV cannot expand beyond
early diastole)
Elevated JVP
(
what is the RA seeing?)
Absent/
blunted Y descent (RA
can’t empty into RV, even in early
diastole)
Prominent
Y descent
(RA rapidly empties into
underfilled
RV)
Prominent
Y descent
(RA rapidly empties into
underfilled
RV
Pulsus
paradoxus
(inspiratory
ê BP
>12mmHg)
YES
(ITP change
exaggerates
ventricular interdependence)
USUALLY
NO
(mechanism debated; ?related to
lack of ITP transmission)
NO
(no ventricular
interdependence)
Other features
Beck’s triad (low BP, high
JVP,
muffled heart sounds)
Pericardial knock
(rapid early
diastolic filling) +/
- friction rub
Manifestations of systemic
disease
(amyloid, sarcoid)
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Arrhythmias
Key Resources:
• +++ CCS AF Guidelines [NB. Most recent = 2020 update]
• CCS 2020 Syncope Update
• ACC/AHA 2018 Pacing Guidelines
• ESC 2021 Pacing Guidelines
• CCS VT Guidelines
• ACLS Guidelines
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Screening for Atrial Fibrillation (AF)
• General Population
– pulse-based screening or rhythm-based screening at all routine health
assessments in people >65yrs
– follow-up with ECG assessment if “irregularly irregular”
• Cardiac Implantable Electrical Device (PPM, ICD)
– interrogate all high atrial rate episodes for possible AF
• Non-lacunar Embolic Stroke of Unknown Source
– ”at least 24h of ambulatory ECG monitoring ”
• Longer monitoring if AF is still suspected but not proven
CCS 2020 AF Update
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AF Etiology & Initial Investigations
Major Guideline: CCS 2020
Major Considerations:
• Always look for an etiology/precipitant
(EtOH, drugs, withdrawal, ischemia, PE,
valves, thyroid disease, OSA, infection, sleep
deprivation, acute pulmonary disease … )
• Basic Workup for new AF:
• Document rhythm
• ECHO – assess LV size and function, LA size, valve ..
• CBC, lytes (Ca, Mg), Cr, Coags, TSH for all
• LFT before amiodarone prescription
• A1C, FBG, Fasting lipid profile as part of comprehensive
cardiac risk assessment
• Always assess patient AF-related symptoms
and quality of life (CCS-SAF), assess patients
with AF for frailty, cog impairment,
dementia, depression
CCS – SAF Scale – Symptoms of AF
Class 0 Asymptomatic
Class I Minimal symptoms or 1 episode without syncope or CHF
Class II Symptoms have minimal effect:
-
Mild awareness if in persistent/permanent AF
-
Rare episodes (“less than a few per year”) in those
w/ paroxysmal AF.
Class III Symptoms have moderate effect on QOL:
-
Moderate awareness most days with
persistent/perm AF
-
More common episodes (”more than every few
months”) or more severe symptoms in pts with
paroxysmal AF
Class IV Symptoms have severe effect on QOL:
-
Syncope due to AF and / or
-
CHF due to AF and / or
-
Unpleasant symptoms in pts with persistent/perm
AF and / or
-
Frequent and highly symptomatic episodes in pts w
paroxysmal AF
CCS 2020 AF Update
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AF: Prevention and Treatment
Major Considerations cont’d:
• Prevention = modifiable risk
factor management
• Achieve rate control with b-
blocker, CCB, or digoxin
• AF with pre-excitation (WPW):
àDC cardioversion (or
procainamide)
• Rhythm control preferred if QoL
impaired (symptomatic despite
rate control) or hemodynamically
unstable (DC cardioversion)
This cutoff of 130/80 Is not mentioned in the CCS text
anywhere, only in this figure! We suggest just go with HTN
Canada guidelines for resting BP target.
CCS 2020 AF Update
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CCS 2020 AF Update
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What about Atrial Flutter (AFL)?
“It is recommended that patients with Atrial Flutter be stratified and treated in the
same manner as patients with atrial fibrillation.”
126
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Anticoagulation in AF/AFL
• DOACs are 1st line for almost everyone
– VKA (i.e. warfarin) should be used instead of DOAC for valvular AF (CCS 2016, 2018 and 2020
definition):
• Mechanical heart valves
• Rheumatic mitral stenosis
• Moderate-severe non-rheumatic mitral stenosis
– Warfarin should also be considered (class IIa) in patients with new onset AF ≤ 3 months post-valve
replacement (surgical or percutaneous)
*NEW* FRAIL-AF (Circulation, 2023) looked at elderly (>75) frail patients with AF who were already on
VKA and randomized to change to DOAC vs stay on VKA.
• Surprisingly, more bleeding was observed in those who were switched to DOAC (15.2%) compared to
those who continued VKA (9.4%), trial stopped early.
– Criticisms – small trial (n=1330), bleeding events were self reported and the primary outcome was driven by minor
bleeding
, not major bleeding. No formal guideline recommendations have incorporated this trial.
– No difference in ischemic/embolic events
– Ta ke A way # 1 – if elderly frail patient stable on VKA can continue
– Ta ke A way # 2 – caution in extrapolating results of other RCTs to populations excluded from enrolment (frail elderly)
CCS 2020 AF, CCS 2020 Valve
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Anticoagulation in CKD/ESRD
Calculate CrCl using Cockroft – Gault at baseline, and
at least annually:
• Stage 3 CKD (eGFR >30) – A/C as usual
• Stage 4 CKD (eGFR >15 <30) – A/C as usual
– “Non randomized data supports the use of
OAC for AF”
– “The CCS recommends that a DOAC is
preferred over VKA”
– “A pi xaba n and r iv aroxa ban a re ap pr ov ed fo r
use with stage 4 CKD”
• Stage 5 CKD (eGFR <15) : “ we suggest that such
patients not routinely receive anticoagulation
therapy or antiplatelet therapy
for AF”
REFERENCE: Dosing per manufacturer
• Apixaban
– 5mg PO BID
– 2.5 mg PO BID if 2/3: ≥80 years, ≤ 60kg, creatinine
≥133umol/L
• Dabigatran
– 150 mg PO BID
– 110 mg PO BID if age > 75 years or eCrCl 30-49 mL/min
• Edoxaban
– 60 mg PO daily
– 30 mg PO daily if CrCL 30-50 mL/min, ≤ 60kg, or
concomitant use of potent P-glycoprotein inhibitors
• Rivaroxaban
– 20 mg PO daily
– 15 mg PO daily if CrCl 30-49mL/min
CCS 2020 AF Update
RENAL-AF RCT
(Circulation 2022):
AF w CHADS≥2 on dialysis randomized to apixaban vs VKA (n=154)
Major (+ clinically relevant) bleeding rate high : 32% Apixa, 26% VKA at 1 yr
Embolic/stroke rate low: 3% both groups …. Hence anticoagulating this group controversial!
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