CARDIOLOGY
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1
1. CARDIOLOGY
By Willie T. Ong, MD, MPH, FPCP, FPCC
ADVANCED CARDIAC LIFE SUPPORT
Basic principle: To sustain life, (1) blood must circulate and (2) blood must be
oxygenated optimally.
General guidelines: Take command. Obtain brief history.
Identify and treat reversible cause:
5H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyperkalemia or
hypokalemia (other metabolic problems), Hypothermia.
5T’s: Tablets (drug overdose, accidents), Tamponade cardiac, Tension
pneumothorax, Thrombosis coronary (MI), Thrombosis pulmonary
(embolism).
Step 1: Circulation.
Auscultate the precordial area for a heartbeat while palpating for the carotid
pulse.
If negative, start CPR.
Note: Place bedboard. Do effective 4-5 cms sternal compressions.
Step 2: Oxygenate Optimally.
Is the patient cyanotic? Is the patient still breathing?
If negative, check airway and do ambu bagging with 'tight' face mask.
Note: Give 100% oxygen. Make sure ambu bag tube is connected to the oxygen
tank. Suction secretions as needed. Hyperventilate initially.
Step 3: Treat the Cardiac Rhythm. Assess by cardiac monitor.
Done simultaneously:
1. Insert IV line.
2. Intubate patient if necessary (for asystole, electromechanical dissociation,
bradyarrhythmia, or persistently unstable rhythms).
3. Get ABG's if with pulse (treat hypoxemia and acidosis).
I.
Rhythm: Asystole (Silent Heart)
1. Continue CPR. Obtain IV access.
2. Epinephrine (1 mg/ampule) 1-2 ampules IV stat q 3-5 minutes
continuously until there is a cardiac rhythm or until CPR is stopped. May
give epinephrine 1 mg ampule in 10 ml NSS via ET tube q 3-5 minutes if no
IV line is inserted yet.
3. If unable to rule out fine ventricular fibrillation, defibrillate with 360 Joules.
4. Atropine 1 mg IV; repeat q 3-5 min. Maximum of 3 mg.
5. Consider external or transvenous pacing.
6. Consider Bicarbonate 1 amp (1 meq/kg) if more than 15 minutes have
elapsed since the heart has stopped.
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MEDICINE BLUE BOOK
II.
Rhythm: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
1. Defibrillate with UNsynchronized 200 Joules stat, repeat with 300 Joules
if unsuccessful, then 360 Joules.
2. Continue CPR between defibrillations or until a defibrillator is available.
3. If no conversion, give epinephrine 1 ampule prior to next defibrillation for
cases of resistant or fine ventricular fibrillation. Repeat q 3-5 minutes as
needed.
4. Continue Defibrillation until rhythm is converted to sinus.
5. Consider anti-arrhythmic drugs:
a. Amiodarone 150-300 mg (1-2 ampules) slow IV in 10 minutes for resistant
ventricular fibrillation or ventricular tachycardia. Repeat dose if
necessary.
or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May
repeat bolus 40 mg (0.5 mg/kg) IV after 5 minutes. Maximum of 200 mg
(3 mg/kg). If necessary, increase drip rate by 1 mg/min to maximum of 4
mg/min. May give Lidocaine via ET tube plus 10 ml NSS.
6. For polymorphic ventricular tachycardia (torsade de pointes), give Magnesium
Sulfate 1-2 gm IV diluted in 100 ml D5W and given in 2 minutes.
7. Consider Sodium Bicarbonate 1 amp slow IV.
III.
Rhythm: Unstable Ventricular Tachycardia with Pulse
For presence of chest pain, dyspnea, MI, heart failure, or systolic BP  90 mm Hg:
1. Cardiovert with synchronized 100, 200, 300 Joules. If patient is awake
give Midazolam 2-5 mg IV for sedation. May omit precordial thump.
2. Consider anti-arrhythmics:
a. Amiodarone 150-300 mg (1-2 ampules) slow IV in 10 minutes. Repeat dose
if necessary.
or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May
repeat bolus 40 mg (0.5 mg/kg) IV after 5 minutes. Maximum of 200 mg.
3. If no conversion, cardiovert at synchronized 360 J, or if recurrent
ventricular tachycardia, cardiovert again starting at previously
successful energy level, then after conversion, continue medications.
IV.
Rhythm: Stable Ventricular Tachycardia with Pulse
1. Precordial thump.
2. Give anti-arrhythmic drugs:
a. Amiodarone 150 mg slow IV (1 ampule) in 10 minutes.
or b. Lidocaine 50-100 mg (1 mg/kg) IV and then start drip at 2 mg/min. May
repeat bolus 40 mg (0.5 mg/kg) IV every 5 minutes until VT resolves.
Maximum of 200 mg.
3. If drugs fail, cardiovert with synchronized 100, 200 Joules.
4. Treat accordingly if cardiac rhythm degenerates.
CARDIOLOGY
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3
V.
Rhythm: Bradycardia
A. For chest pain, dyspnea, drowsiness, heart failure, or systolic BP < 90 mm Hg:
1. Atropine 0.5-1 mg IV stat. Maximum of 3 mg (0.04 mg/kg). May give via
ET tube with 10 ml NSS.
2. Continue CPR support if HR  40 bpm.
3. Consider external or transvenous pacing.
4. Consider Dopamine drip or Epinephrine drip as a temporizing measure.
B. For type II second degree & third degree AV block, consider external or
transvenous pacing.
C. If without symptoms, observe!
VI.
Rhythm: Electromechanical Dissociation (EMD)
Definition: Sinus rhythm by cardiac monitor but without palpable pulses. No BP.
Etiology: EMD can be secondary to inadequate fluid volume, pericardial
tamponade, tension pneumothorax, hypoxemia or acidosis. Less
correctible causes include massive MI, prolonged ischemia during
resuscitation and pulmonary embolus.
1. Continue CPR.
2. Correct primary problem (see etiology).
3. Epinephrine 1 mg IV q 3-5 min
4. Consider Bicarbonate 1 amp (44 meq) slow IV.
VII.
Rhythm Successfully Converted to Sinus Rhythm:
1. If Systolic BP  100 mm Hg:
Obtain laboratory exams: ABG, ECG (check for MI), CXR
CBC, Na, K, RBS, Creatinine
2. If Systolic BP  90 mm Hg:
i. Start Inotropics: Dopamine with or without Dobutamine.
ii. Correct low volume, acidosis and hypoxemia.
iii. Do ABG and other laboratory exams if feasible.
Final Advice:
a. Adequate airway, ventilation, oxygenation, chest compression and
defibrillation are more important than initiating IV line and injecting
medications.
b. IV medications should be given by bolus with few exceptions. After each IV
medicine, give 20-30 ml bolus of IV fluid and elevate the extremity.
c. Do most of your interventions in the first 10 minutes of the CPR. Otherwise,
the chance of reviving the patient decreases markedly.
d. Lastly, treat the patient, not the cardiac monitor.
Source: Adapted from Guidelines 2000 for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation, Vol. 102, No. 8, August 22, 2000.
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MEDICINE BLUE BOOK

ACUTE MYOCARDIAL INFARCTION
Data:
Table 1-1. Molecular Markers in the Diagnosis of Acute Myocardial Infarction.
Tests
Time to
Detection
Peak
Duration
Most Common Sampling
Schedule
Troponin T
Sn = 94 %
Sp = 60 %
3 -12
hours
24 hours
5 -14 days
Once at least 12 hours
after chest pain
Troponin I
Sn = 95 %
Sp = 90 %
3 - 12
hours
24 hours
5 - 10 days
Once at least 12 hours
after chest pain
CK-MB
3 - 12
hours
24 hours
2 - 3 days
Every 12 hours X 3;
start at 6 hours after
chest pain
Source: Modified from Braunwald, E., Zipes D.P., Libby P. (Eds.) (2001). Heart Disease: A
Textbook of Cardiovascular Medicine, (p. 1132). Philadelphia: W.B. Saunders Company.
Table 1-2. Killip Classification of AMI with Expected Hospital Mortality Rate.
Killip
Clinical Presentation
Expected
Class
Hospital
Mortality
I
No signs of pulmonary or venous congestion
0-5%
II
III
IV
Moderate heart failure or presence of bibasal rales,
S3 gallop, tachypnea, or signs of right heart failure
including venous (JVP) and hepatic congestion
Severe heart failure, rales  50 % of the lung fields or
pulmonary edema
10-20 %
Shock with systolic pressure  90 mm Hg and
evidence of peripheral vasoconstriction, peripheral
cyanosis, mental confusion and oliguria
85-95 %
35-45 %
Source: Forrester, J.S. et al (1976). Medical therapy of acute myocardial infarction by
applications of hemodynamic subsets. NEJM, 295, 913-56.
CARDIOLOGY
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5
 Orders:
Admit to ICU
Sample diagnosis: Acute MI, ST-elevation, anterior wall, Killips-1, day 1
Diet: Low salt, low fat diet
VS: q 1 hour and record; Temp q 4 hour
Nursing: I and O q shift. Complete bed rest with no bathroom privileges. High back rest.
Limit visitors. Anti-embolic stockings.
IVF: D5W 500 ml x 10 ml/hr
Diagnostics: CK-MB, CPK-Total, Troponin T or Troponin I
ECG stat then repeat after 12-24 hours
Portable Chest X-ray, semi-sitting
CBC with platelet count, Na, K, Ca, Mg, RBS, BUN, Creatinine, Urinalysis
Baseline PT, PTT (if contemplating anti-coagulation or thrombolytic therapy)
Lipid Profile
Therapeutics:
1. Initial ER Management (STAT):
a. Oxygen at 2-4 liters/min via nasal cannula x 24 hours (especially if with
heart failure or Oxygen saturation < 90%)
b. Nitrates: (defer for SBP  90 mm Hg)
Nitrostat 0.4 mg SL up to 3 doses stat q 5min and PRN for chest pains
then start Isosorbide Dinitrate (Isoket) Drip x 24-48 hours until chest pain
subsides
then shift to Transderm patch 5-10 mg OD to anterior chest wall
or Isosorbide mononitrate (Imdur) 60 mg OD AM
or Isosorbide dinitrate (Isordil) 10-20 mg TID (6 am-12-6 pm)
c. Pain relief: Give adequate analgesia with
Morphine 4 mg IV stat and PRN q 30 min up to 3 doses defer for SBP 90
mm Hg (If with Inferior wall MI, give only 2-3 mg IV of Morphine
because of risk of arrhythmia.)
d. Aspirin 160-325 mg tab stat dose then 80 mg tab BID PC indefinitely
2. Consider Thrombolytic Therapy:
Indication: Patients presenting within the first 12 hours of chest pains with
large anterior wall ST-elevation MI or inferior wall MI with anterior wall
(V1-V3) reciprocal changes (see Thrombolytic Therapy in MI for full
contraindications list)
3. Heparin:
Indication: For large anterior wall MI, atrial fibrillation, persistent chest pains,
or presence of LV thrombus
a. Heparin 5000 units IV bolus then Heparin Drip: D5W 200 ml + Heparin
10,000 units at 14 ugtts/min (700 units/hour) using an infusion set
Check PTT q 12 hours with target PTT of 1.5-2X the control
Give Heparin for 2-5 days then overlap with Warfarin for 3 months if
desired.
b. Low Molecular Weight Heparin: Enoxaparine (Clexane) 0.4 ml SC BID
for 5 days.
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MEDICINE BLUE BOOK
4. Beta-blockers:
Indication: All patients without contraindication to beta-blocker therapy. Most
beneficial in patients with tachycardia, anterior wall MI, hypertension,
recurrent ischemic pain, atrial fibrillation. Avoid in patients with
moderate to severe CHF, wheezing, AV blocks and heart rate < 55 beats
per minute. Start therapy early (<12 hours). Try to achieve a target HR of
55-60 bpm.
Metoprolol 50 mg ½ -1 tab q 8-12 hours
or Esmolol 10-20 mg IV
Beta-blockers should be continued indefinitely in patients with no
contraindication.
5. ACE-inhibitors:
Indication: All patients with anterior wall MI. Most beneficial for Killips
II or higher, LV EF  40, large anterior wall MI, clinical CHF, and with
no contraindication to ace-inhibitors.
Captopril 25 mg ¼ tab q 12 hr x 2 days then ½ tab q 12 hr, defer for SBP 
100 mm Hg. For BP spikes in hypertensive patients, may give Captopril
25 mg ½ -1 tab PO or SL.
6. Consider Statins: Atorvastatin 20 mg tab OD or Simvastatin 20 mg tab OD HS
7. Diazepam 2-5 mg tab BID (especially for anxious patients)
8. Duphalac 20-30 ml HS defer for LBM. Instruct patients not to strain.
9. Optional Meds: Antacids, H2-blockers.
Other Cardiac Meds:
1. Diuretics: Furosemide 40 mg tab or 20-40 mg IV stat dose for frank CHF
2. Lidocaine Drip: For high grade ventricular arrhythmias early post-MI
3. Amiodarone PO or Drip: For persistent high-grade ventricular arrhythmias
4. Avoid calcium-channel blockers:
a. Nifedipine PO or SL is contraindicated in AMI or unstable angina
b. Diltiazem, Verapamil: In patients with contraindication to beta-blocker
therapy, verapamil or diltiazem may be given for relief of ongoing
ischemia or control of ventricular response in AF in the absence of CHF,
LV dysfunction, or AV blocks.
5. Metabolic enhancers: (Not proven to be beneficial post-MI)
Co-Enzyme Q10 10 mg tab 1 tab TID
Trimetazidime (Vastarel) 20 mg tab TID
For Non ST-elevation MI with No Congestion, Give
1. Metoprolol 50 mg ½ - 1 tab BID
or
2. Diltiazem 30 mg BID-TID
For Non ST-elevation MI with Pulmonary Congestion, give
1. Ace-inhibitors (as above)
2. Diuretics PRN
Avoid calcium-channel blockers in patients with heart failure.
CARDIOLOGY
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7
THROMBOLYTIC THERAPY IN MI
A. Indications for Thrombolytic Therapy in MI:
1. Chest pain consistent with AMI
2. ECG changes:
a. ST-segment elevation > 1 mm in at least 2 contiguous limb leads or
b. ST-segment elevation > 2 mm in at least 2 contiguous chest leads or
c. New left bundle branch block
3. Time from chest pains to thrombolytic therapy:
a. Less than 6 hours: most beneficial
b. 6-12 hours: lesser but still important benefits
c. 12-24 hours: diminishing benefits but may still be useful in selected
patients (e.g. those with ongoing chest pain)
B. Absolute Contraindications to Thrombolytic Therapy in MI:
1. Active internal bleeding (excluding menstruation)
2. Recent (within 2 weeks) invasive or surgical procedure
3. Suspected aortic dissection
4. Previous history of hemorrhagic cerebrovascular accident or subarachnoid
hemorrhage
5. Recent head trauma or known intracranial neoplasm
6. Persistent BP > 200/120 mm Hg
C. Relative Contraindications to Thrombolytic Therapy in MI:
1. Known bleeding diathesis (severe thrombocytopenia, coagulopathies) or current
use of anticoagulants
2. Previous streptokinase treatment given for the past 6 to 9 months (in which case,
give TPA)
3. BP  180/100 mm Hg on at least 2 readings
4. Active peptic ulcer disease
5. History of thrombotic cerebrovascular accident
6. Prolonged CPR of  10 minutes or traumatic CPR
7. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic condition
8. Pregnancy
D. Treatment Regimen:
1. ASA 325 mg tab now then OD
2. Diphenhydramine 50 mg IV push
3. Hydrocortisone (Solucortef) 100-200 mg IV push
4. STREPTOKINASE 1.5 M IU in 90 ml D5W over 1 hour (100 ugtts/min) in a
soluset. Watch out for hypotension and reperfusion arrhythmias.
5. PTT now and q 6 hours x 24 hours then q 12 hours. No IM injections or
arterial punctures. Watch IV sites for bleeding.
6. Optional (associated with increase bleeding risk): Heparin 5000 units IV
bolus then 500-1000 units/hr IV to maintain PTT at 1.5-2X the control.
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MEDICINE BLUE BOOK

UNSTABLE ANGINA
Data:
A. Indications for Cardiac Catheterization and Possible Coronary Angioplasty:
(Available in UP-PGH, Philippine Heart Center, St. Luke’s & Chinese General Hospital)
1. Patients with persistent chest pains despite maximal medical therapy for 48 hours
2. Patients with high-risk profile: Clinical heart failure, dynamic ST segment
changes, S3 gallop, hypotension, prolonged ongoing chest pain ( 20 minutes)
 Orders:
Admit to ICU:
Diet: Soft, low salt diet when stable
VS: q 1 hour and record;
Nursing: I and O q shift
IVF: D5W 500 ml x KVO
Diagnostics:
ECG stat then repeat for persistent chest pains
CK-MB, CPK-TOTAL (to rule out AMI) twice q 12 hours
Troponin T or I (positive in microinfarcts suggesting a poorer prognosis)
CBC, K, Creatinine, Baseline PT, PTT, Portable Chest X-ray
Therapeutics:
O2 at 2-4 lpm via nasal cannula
1. Nitrates (same regimen as in Acute MI)
2. Heparin for 5 days, if stable
Indications: For patients at high risk of complications - prolonged ongoing
chest pains ( 20 min), clinical heart failure, angina with hypotension or
dynamic ST-T wave changes
a. Low Molecular Weight Heparins:
Enoxaparin (Clexane) 0.4 ml (40 mg) SC BID (1 mg/kg BID)
or b. Regular Heparin: Heparin 5000 u IV bolus then Heparin Drip: D5W 200 ml +
Heparin 10,000 units at 14 ugtts/min (700 u/hr) using an infusion set
Check PTT q 12 hours with target PTT of 1.5-2 X the control.
3. Aspirin 325 mg tab stat dose then ASA 80 mg 1 tab BID PC indefinitely
or
Clopidogrel (Plavix) 75 mg tab OD for patients unable to take ASA
4. Metoprolol 50 mg ½ -1 tab q 8-12 hr (if no contraindications)
and/or Diltiazem 30 mg tab BID-TID may be added in patients with persistent
chest pains (watch out for bradycardia with Metoprolol).
5. Other Meds
a. Morphine 4 mg IV stat for pain relief
b. Diazepam 2-5 mg tab BID (especially for anxious patients)
6. Medical strategies for persistent chest pains (In patients without heart failure)
a. Increase beta-blocker dosage
b. Increase nitrates dosage (e.g. up to Imdur 60 mg tab BID or Isordil 40 mg
tab QID)
c. Add Diltiazem PO to the above regimen

CARDIOLOGY
9
CONGESTIVE HEART FAILURE
(For Systolic Heart Failure)

Data: Systolic vs. Diastolic Heart Failure:
1. Systolic Heart Failure: Markedly dilated left ventricle, low ejection fraction
(problem with systolic LV contraction phase). Treatment approach indicated below.
2. Diastolic Heart Failure: Normal left ventricle size, usually concentrically
hypertrophied, normal ejection fraction (problem with diastolic LV relaxation phase
and stiff LV). Treatment is different from systolic heart failure. Give beta-blockers
and calcium-channel blockers.
Table 1-3. General Outline in the Management of Chronic Congestive Heart Failure
Based on New York Heart Association (NYHA) Functional Classification.
Management
NYHA
Class II
Class III
Class IV
Class I
Vaso-Dilators: Ace-inhibitors
or Angiotensin receptor
antagonists
Lifestyle Changes: Restrict
physical activity and restrict
salt intake








Low-dose Beta-blockers*
?


?
Diuretics**: Furosemide and
Spironolactone




Digoxin




Dobutamine, Dopamine and/or
Nitroprusside




Intraortic Balloon Pump
and Heart Transplantation




* Studies show that low-dose carvedilol, metoprolol or bisoprolol is a useful adjunct to
the conventional regimen for CHF. However, dosages of ace-inhibitors and diuretics
should first be maximized.
** Diuretics may be given to achieve relief of edema and normalization of the jugular
venous pressure.
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MEDICINE BLUE BOOK
 Orders:
Diet: NPO if dyspneic; Soft, low salt diet when more stable (Na  2 gm/day)
Limit Total Fluid Intake to 1.0-1.2 liters/day
VS: q 1 hour and record
Nursing: I and O q shift strictly. Consider foley catheter insertion (hourly urine outputs).
Weigh patient daily. CBR with no bathroom privileges. High back rest.
IVF: D5W 500 ml X KVO or 10 ml/hr
Diagnostics: CBC, Na, K, Ca, Mg, RBS, Creatinine, Urinalysis, ECG
Portable Chest X-ray semi-sitting, 2-D Echo with Doppler
Treatment Approach: Mnemonic 5 D's (Diet, Diuretics, vaso-Dilators, Digitalis,
Dilatrend)
- Oxygen at 2-4 lpm via nasal cannula
- For Acute Congestion: Stepwise approach  Oxygen, Furosemide IV,
Morphine IV as last resort
- Correct precipitating factors: Arrhythmia, uncontrolled HPN, anemia,
pulmonary infection, thyrotoxicosis, change inappropriate medications,
emotional stress
1. Diuretics: (For acute CHF, fluid overload or edema)
a. Furosemide (Lasix) 20-40 mg IV then maintain on PO later, may
double subsequent doses if no urine output in 20-30 mins (e.g. give Lasix
40 mg IV then 80 mg IV after 30 minutes). If still without urine output,
start Lasix drip and consider stat peritoneal or hemodialysis for resistant
cases
 b. Spironolactone (Aldactone) 25 mg tab OD-TID for CHF class III to IV.
2. Vaso-Dilators:
a. Ace-inhibitors: First-line agents for chronic heart failure.
Captopril 25 mg ½ -1 tab q 6-12 hr. Maximum dose of Captopril 50 mg tab
TID
or Enalapril 5-10 mg tab OD-BID, maximum dose of Enalapril 20 mg BID.
Maximize dose of ACE-inhibitors to achieve symptomatic relief of dyspnea.
In patients with contraindication to ACE-inhibitors (e.g. acute renal failure),
you may use Hydralazine 10-25 mg TID and ISDN (Isordil) 10-20 mg TID.
b. Angiotensin receptor antagonists: Alternate drug if with ace-inhibitor
cough; e.g. Losartan 50 mg ½ -1 tab OD (maximum dose of Losartan
50 mg 1 tab BID).
3. Digitalis: Most beneficial in patients with atrial fibrillation.
Digoxin 0.25-0.5 mg IV then complete loading dose if needed
or Digoxin (Lanoxin) 0.25 mg tab BID X 3 days then ½ - 1 tab OD thereafter.
4. Consider low dose beta-blockers for heart failure.
Addition of Carvedilol (Dilatrend) 6.25 mg tab BID. Watch out for
hypotension and CHF within the first 4 hours after intake.
5. Other therapeutic options as indicated:
a. Coenzyme Q10 10 mg tab TID has some possible benefit.
b. Nitrates: Transderm patch for 1 dose only if with no underlying CAD.
c. ASA 80-160 mg PO OD as indicated.
CARDIOLOGY
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11
6. Supportive Medications for CHF:
a. If BP  80 mm Hg, use Dopamine Drip or Norepinephrine (Levophed) Drip
(if persistently hypotensive)
b. If BP 90-100 mm Hg, use Dobutamine Drip
c. If BP  110 mm Hg, use Nitroprusside Drip (Not Available)

HYPERTENSIVE URGENCY & EMERGENCY
Data:
A. Hypertensive Urgency: No end organ damage; try oral medications first. Lower BP
within 2-3 days.
B. Hypertensive Emergency: Presence of changes in sensorium, papilledema, or heart
failure. Use IV drugs stat. Lower BP within 24 hours.
 Orders:
Admit to:
Diet: NPO temporarily till stable
VS: BP q 15 minutes till stable
Nursing: Complete bed rest without bathroom privileges
Diagnostics: CBC, Creatinine, K, ECG, Urinalysis
Chest X-ray, Fundoscopy
Therapeutics:
A. Per Orem or Sublingual Treatment:
Mnemonic for anti-hypertensives that can be given sublingually: 3 C’s
1. Nifedipine (Calcibloc): 5-10 mg SL or PO (bite and swallow punctured
capsule), repeat as needed q 30 minutes, then 5-10 mg PO or SL q 6-8 hr
or Calcibloc OD 30 mg PO OD-BID. Maximum dose is 90 mg/day,
contraindicated in patients with AMI or Unstable Angina.
2. Captopril (Capoten): 25 mg ½ -1 tab SL or PO q 30 mins as needed.
3. Clonidine: 75 mcg tab SL or PO q hr (Maximum of 700 mcg)
B. Intravenous Treatment: See appendix section on IV drips, p. 207.
Mnemonic for anti-hypertensives that can be given intravenously: NAIC
1. Nicardepine IV: Duration of action: 3-6 hr
2. Hydralazine (Apresoline) IV: 5-10 mg IV q 3-6 hr (0.1-0.5 mg/kg/dose;
maximum of 20 mg per dose), or give 25-50 mg PO QID.
Duration of action: 3-6 hr.
3. Isosorbide dinitrate IV (especially for patients with concomitant CAD)
4. Clonidine (Catapres) IV: May give 1 amp (150 mcg/1 ml amp) SC, IM or IV
with patient supine.
5. Nitroprusside IV (not available): 0.25-10 mcg/kg/min IV (50 mg in D5W
250 ml), titrate to desired BP using an infusion set.
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MEDICINE BLUE BOOK
SUPRAVENTRICULAR TACHYCARDIA
 Orders:
Diet: Full diet when stable (no coffee, tea or soft drinks)
VS: q 1 hour; Hook to Cardiac Monitor
Diagnostics: CBC, RBS, Na, K, Ca, Mg
CK-MB, Troponin T or I, BUN, Creatinine, T4, TSH Irma
repeat ECG after conversion to sinus rhythm
Chest X-ray, 2-D Echo when stable
Therapeutics:
- Unilateral carotid massage (Check for carotid bruits first)
- Attempt vagal maneuvers before drug therapy
A. Pharmacologic Therapy
1. If Systolic BP  90 mm Hg, choose from the following options:
a. Calcium-channel blockers:
Verapamil 2.5-10 mg IV over 2-3 minutes, wait 10-15 min before next
dose (may give Calcium Gluconate 1 gram IV over 3-6 minutes prior
to Verapamil); then 40 mg PO q 6 hours or Verapamil SR 240 mg
½-1 tab PO OD. Duration of action is 15 min.
or Diltiazem (Ritemed Diltiazem☺) 30-60 mg PO TID
b. Beta-Blockers:
Esmolol 10-20 mg IV (page 207). Duration of action is 9 minutes.
or Metoprolol 50 mg ½ tab PO stat dose then BID
c. Adenosine (Cardiovert) 6 mg/2 ml vial
i. Therapeutic indications:
Initial dose: 3 mg given as a rapid IV bolus (over 2 seconds)
Second dose: If first dose fails within 1-2 min, give 6 mg rapid IV bolus
Third dose: If 2nd dose fails within 1-2 min, give 12 mg rapid IV bolus
ii. Precautions for use: Avoid in COPD and asthmatic patients, mild
hypotension occurs.
2. If Systolic BP  90 mm Hg or with heart failure
a. Digoxin (Lanoxin) 0.5 mg IV or PO, wait 2 hours before full effect
of initial dose is established then aliquots of 0.25 mg IV q 4-6 hours as
needed (Loading dose of 1-1.25 mg IV); then Digoxin 0.25 mg ½ - 1
tab OD. Contraindicated in patients with WPW in AF. Defer Lanoxin
for HR  60 bpm. Duration of action is 2 hours.
3. Adjuncts: Diazepam 2 mg tab BID
B. Synchronized Cardioversion
- Ideally patient should be in NPO x 6 hr, digoxin level  2.4 and K+ normal.
1. Midazolam 2.5 mg IV until amnesic
2. If stable, cardiovert with synchronized 25-50 J, increase by 50 J increments.
3. If refractory to drug treatment or unstable (e.g. hypotensive or severe
ischemia caused by the tachycardia), start with 75-100 J, then increase to 200
J if needed.
CARDIOLOGY


13
ATRIAL FIBRILLATION (AF)
Data:
A. Is the patient in acute AF (onset of less than 48 hours) or chronic AF?
B. Treat the etiology of the AF, e.g. hypoxia, electrolyte imbalance (K, Ca, Mg), heart
failure, severe ischemia, mitral stenosis, thyrotoxicosis, hypertension, chronic
anxiety, lung disease, fever etc.
 Orders:
Diet: Low salt diet when stable
VS: q 1 hour, auscultate full minute heart rate
Nursing: Complete bed rest. Hook to cardiac monitor (if acute AF).
Diagnostics: CBC, K, Ca, Mg, Creatinine
Digoxin assay, 2-D Echo with doppler, T3, T4, TSH Irma
Therapeutics: Treat the etiology or precipitating factor.
Slow the ventricular rate with pharmacologic therapy
A. Acute AF with rapid ventricular response (HR  100 bpm):
1. If Systolic BP  90 mm Hg and not in heart failure:
a. Verapamil 2.5-10 mg IV over 2-3 minutes, wait for 10-15 min. before
next dose then 40 mg PO q 6 hours or Verapamil SR 240 mg PO OD.
Duration of action is 15 mins.
or
b. Metoprolol 50 mg ½-1 tab PO stat dose then BID
2. If Systolic BP  90 mm Hg or with heart failure:
a. Digoxin (Lanoxin) 0.5 mg IV or PO, wait for 2 hours before full effect
of initial dose is established then aliquots of 0.25 mg IV q 4-6 hours as
needed (Loading dose of 1-1.25 mg IV); then Digoxin 0.25 mg ½ - 1
tab OD. Contraindicated in patients with WPW in AF. Defer Digoxin
for HR  60 bpm.
3. Consider medical cardioversion for AF < 48 hours in onset. Consult the
Cardiology Blue Book for indications and benefits of cardioversion.
B. Chronic AF:
1. Same as above if with rapid heart rates
2. For patients with high-risk for stroke (e.g. prior CVA, TIA, valvular heart
disease, HPN, DM, CHF, LA size > 45 mm or CAD), anticoagulate with
warfarin to attain a target protime INR of 2-3.
Loading dose: Warfarin (Coumadin) 5 mg tab PO X 2-3 days only. Recheck
Protime on the 3rd day.
Usual maintenance dose: Warfarin (Coumadin) 2.5 mg 1 tab OD PO defer
if with bleeding episodes.
3. Antiplatelets if with contraindication to Warfarin:
Aspirin 325 mg 1 tab PO OD after meals
C. Synchronized Cardioversion:
If medical therapy fails, or if with severe cardiovascular compromise, may do
synchronized cardioversion in extreme cases. Sedate patient first.
14

MEDICINE BLUE BOOK
PREMATURE VENTRICULAR CONTRACTIONS &
VENTRICULAR TACHYCARDIA

Data:
A. In patients without heart disease (normal ECG, normal 2-D echocardiography), PVC's
have not been shown to be associated with any increased morbidity or mortality. If
with heart disease, we may need to treat the patient. Tailor treatment for each patient.
B. Complications: Ventricular tachycardia, ventricular fibrillation, sudden cardiac death
C. Lown's Grading of PVC's:
GRADE:
0
none
1a
< 30/hr < 1/min
1b
> 1/min
2
> 30/hr
3
multiform, bigeminy, trigeminy
4a
couplets
4b
salvos
5
R on T phenomenon
D. Anti-Arrhythmic Drug Classes:
Class I (blocks sodium channels):
IA - Quinidine, Procainamide, Disopyramide (SV & V)
IB - Lidocaine, Phenytoin, Tocainide (V)
IC - Flecainide (V)
Class II (Beta-blockers):
Propranolol (SV & V)
Class III (blocks potassium channels):
Amiodarone, Sotalol (SV & V)
Class IV (blocks calcium channels):
Verapamil (SV)
Legend: SV= drugs used to treat Supraventricular Arrhythmias
V= drugs used to treat Ventricular Arrhythmias
 Orders:
Admit to:
Diet: Soft diet when stable
VS: q 1 hour, record number of PVC's per minute
Nursing: Hook to cardiac monitor
Diagnostics: CBC, Serum K, Ca, Mg, T3, T4, TSH
24-48 hour Holter Monitoring or Loop Recorders (check for episodes
of ventricular tachycardia)
ECG, 2-D Echo with doppler
CARDIOLOGY

15
Treatment Plan:
1. Consider age of patient and the cardiac status. Most important considerations
for admission and treatment are the following:
a. Symptomatic patients with dyspnea, syncope, or dizziness
b. (+) Organic heart disease, especially post-myocardial infarction
c. Low ejection fraction of  40%
d. Lown's grading  4a
2. Look for a possible secondary etiology for PVC’s and treat this, e.g. CAD,
thyroid diseases, acidosis, alkalosis, hypercapnea, hypoxia, hyperkalemia,
hypokalemia, digitalis excess, mitral valve prolapse, cardiomyopathy, or
connective tissue disorders.
Therapeutics:
1. Decrease precipitating factor, e.g. control anxiety and avoid alcohol, digitalis,
caffeine, coffee, softdrinks or tea.
2. Treat the underlying cause, e.g. give nitrates for CAD, correct electrolyte
imbalance, etc.
3. Supportive: Oxygen, sedatives
4. Treatment for PVC's or Ventricular Tachycardia after correcting other factors:
a. Beta-blockers - empiric and cheap treatment (esp. for patients with MVP)
b. Lidocaine IV bolus and drip for acute episodes only.
c. If resistant, consider Amiodarone IV or PO:
Amiodarone preparation: 150 mg/3 ml vial
i. IV loading dose: 500-1000 mg per 24 hr IV loading doses (5-10 mg/kg
body weight per 24 hr)
Sample orders: Give 150 mg slow IV push over 10-30 minutes (with BP
and HR monitoring) followed by D5W 250 ml + 150-300 mg IV
Amiodarone to run for 24 hours. Supplemental doses of 150 mg IV
over 10-30 minutes may be given for recurrent arrhythmias especially
during the early phases of dosing.
or ii. Oral Loading Dose: (10 mg/kg body weight per day for 2 weeks)
Amiodarone 200 mg 1 tab PO TID for 2 weeks
Then maintenance of Amiodarone 200 mg 1 tab OD thereafter
iii. Amiodarone's side effects include hyperthyroidism, hypothyroidism,
and interstitial pulmonary fibrosis. Check thyroid function every 3-6
months.
5. For ventricular tachycardia or cardiac arrest due to ventricular fibrillation,
Implantable Cardioverter/Defibrillators (ICD) are proven to be beneficial
in preventing sudden cardiac death. However, ICD’s are very expensive.
Consult a cardiologist-electrophysiologist.
16

MEDICINE BLUE BOOK
PREMATURE ATRIAL CONTRACTIONS

Data:
PAC's are usually benign and can be found in 60% of normal adults. If patient is
asymptomatic, treatment is usually not required.
 Orders:
Diagnostics: CBC, K, Mg, T3, T4, TSH
24-48 hours Holter monitoring if with symptoms (check for paroxysmal
atrial fibrillation or supraventricular tachycardia)
ECG, 2-D Echo
Therapeutics:
1. Remove precipitating factors: fever, anxiety, mitral valve prolapse, specific
food (alcohol, tobacco, tea, coffee, or amphetamines)
2. If symptomatic and with palpitations:
a. Sedatives: Diazepam 2 mg 1 tab OD HS and as needed.
b. Beta-blockers: Metoprolol 50 mg ½-1 tab BID
or c. Calcium-channel blockers:
- Verapamil 40 mg 1 tab TID
- Diltiazem 30 mg 1 tab BID-TID
CARDIOLOGY


17
INFECTIVE ENDOCARDITIS (Treatment)
Data:
Table 1-4. Two Traditional Classifications for Infective Endocarditis (IE).
Acute Bacterial IE
Subacute Bacterial IE
Pathogenic organism
Staph. aureus (virulent)
Strep.viridans, Enterococci
(less virulent)
Clinical presentation
High fever, acute course
Low grade fever,
subacute course
Cardiac pathology
Normal cardiac valves,
Damaged valves,
no murmurs
(+) murmur
Prognosis
Fatal in 6 weeks if
Better prognosis
untreated
Table 1-5. Duke’s Diagnostic Criteria for Infective Endocarditis.
I. Criteria for Infective Endocarditis:
A. Two major criteria or
B. One major and three minor or
C. Five minor criteria using definitions for these criteria as listed below
D. Possible infective endocarditis: findings consistent with infective endocarditis
that fall short of the criteria listed above
II. Major Criteria:
A. Positive blood culture results for infective endocarditis
Typical microorganisms for infective endocarditis: Streptococci viridans,
HACEK group, Strep. bovis, Staph. aureus, or enterococci recovered from
two or more blood cultures.
B. Either positive echocardiographic study result for infective endocarditis:
Oscillating intracardiac mass, abscess or new dehiscence of prosthetic valve
or new valvular regurgitation.
or Persistently positive blood culture results: microorganism consistent with
IE recovered from one or more blood cultures drawn more than 12 hrs apart.
III. Minor Criteria: (Mnemonic: PF-VIME)
A. Predisposing heart condition or injected drug user
B. Febrile syndrome
C. Vascular phenomena: Arterial embolism, central nervous system hemorrhage,
conjunctival hemorrhage, Janeway lesions.
D. Immunologic phenomena: Immune-complex glomerulonephritis, rheumatoid
factor, false-positive VDRL test, Osler's nodes, or Roth spots
E. Microbiologic evidence: Positive blood culture results but not positive for
major criterion
F. Echocardiogram: Suggestive of infective endocarditis but not positive for
major criterion
Source: Durack, D.T. (1998). Infective and non-infective endocarditis. In R. C. Schlant & R.
Wayne Alexander (Eds.), Hurst’s: The Heart (p. 2221). New York: McGraw-Hill
Companies, Inc., with permission.
18

MEDICINE BLUE BOOK
 Orders:
Admit to:
Diet: DAT
VS: q 4 hours, include temperature
Diagnostics: For Acute bacterial endocarditis: Blood C/S (3X in 30 minutes): ideally
before antibiotic treatment
For Subacute bacterial endocarditis: Blood C/S 3X in 6 hours
CBC, Creatinine, Urinalysis (to check for complications)
Rheumatoid Factor (positive if  6 weeks of infective endocarditis)
2-D Echo with doppler (50-80% sensitive except if with  2 mm
vegetations)
Transesophageal Echocardiography (TEE) (90% sensitive)
Therapeutics:
A. Acute Bacterial Endocarditis Empiric Therapy (Including IV Drug
Abuser):
Target: Staphylococcus aureus
1. Nafcillin or Oxacillin 2 gm IV q 4 hr
or
Vancomycin 500 mg IV q 6 hr or 1 gm IV q 12 hr (1 gm in 250 ml D5W
infused slowly over 1hr q 12 hr) X 4 weeks IV
+
2. Gentamicin 100-200 mg IV (2 mg/kg), then 80 mg (1-1.5 mg/kg) IV q 8 hr
X 3-5 days
Note: Therapy can be changed once blood culture and sensitivity results
are available.
B. Subacute Bacterial Endocarditis Empiric Therapy:
Target: Strep. viridans, Enterococci
1. Penicillin G 2-4 mil units (12-24 million units/day) IV q 4 hr X 4 weeks IV
or
Ampicillin 2 gm (12 g/day) IV q 4 hr
+ 2. Gentamicin 80 mg (1-1.5 mg/kg) IV q 8 hr X 2 weeks IV
Note: Choice between low dose or high dose Penicillin depends on the
susceptibility of the microorganism and the clinical course of the patient. Use a
higher dose for more toxic patients.
C. Clinical Course:
1. Defervescence after 3-7 days.
2. Repeat Blood C/S 2 and 4 weeks after the end of treatment to detect
relapse.
CARDIOLOGY

19
INFECTIVE ENDOCARDITIS (PROPHYLAXIS)
A. Cardiac Conditions Associated with Endocarditis: (prophylaxis recommended)
1. High-risk category: Prosthetic cardiac valves, previous bacterial endocarditis,
cyanotic congenital heart disease, surgically constructed systemic-pulmonary
shunts or conduits.
2. Moderate-risk category: Rheumatic heart disease (acquired valvular dysfunction),
mitral valve prolapse with valvar regurgitation and/or thickened leaflets, other
congenital cardiac malformations (e.g. VSD, PDA, primum ASD, coarctation of
the aorta, and bicuspid aortic valve), hypertrophic cardiomyopathy.
B. Prophylaxis for Dental, Oral, Upper Respiratory Tract or Esophageal
Procedures:
1. Oral: Amoxicillin 2 gm orally 1 hour before procedure, no need for a repeat
dose 6 hours later; Children: 50 mg/kg orally 1 hour before procedure
Penicillin allergy: Clindamycin 600 mg orally 1 hour before procedure
or
Cephalexin 2 gm orally 1 hour before procedure
2. Parenteral: Ampicillin 2 gm IM or IV 30 minutes before procedure
C. Prophylaxis for Gastrointestinal and Genitourinary Procedures:
1. Parenteral: Ampicillin 2 gm IV plus Gentamicin 1.5 mg/kg IM or IV (not to
exceed 80 mg) 30 min before procedure; followed by Ampicillin
1 gm IV 6 hours later
Penicillin allergy: Vancomycin 1 gm IV infused slowly over 1 hour
+
Gentamicin 1.5 mg/kg IM or IV (not to exceed 80 mg),
1 hour before procedure
Source: Adapted from the 1997 AHA Recommendations for Prevention of Bacterial Endocarditis.
20


MEDICINE BLUE BOOK
ACUTE RHEUMATIC FEVER & PROPHYLAXIS
Data:
Table 1-6. Jones Criteria for Acute Rheumatic Fever.
Major Manifestations
Mnemonic: CACES
1.
2.
3.
4.
Carditis *
Polyarthritis **
Chorea
Erythema
marginatum
5. Subcutaneous
nodules
Minor Manifestations
Supporting Evidence of
Antecedent Group A
Streptococcal Infection
1. Clinical findings:
1. Positive throat culture
Arthralgia
or rapid streptococcal
Fever
antigen test
2. Laboratory findings:
2. Elevated or rising
Elevated acute phase
streptococcal antibody
reactants
titer
(Erythrocyte
sedimentation rate,
C-reactive protein)
Prolonged PR interval
If supported by evidence of preceding group A Streptococcal infection (+) ASO titer,
the presence of:
A. Two major manifestations, or
B. One major and two minor manifestations, indicates a high probability of
acute Rheumatic Fever (RF).
* 1. Carditis: (1) new significant murmur usually mitral regurgitation or aortic
regurgitation, (2) pericardial friction rubs or signs of pericardial effusion, (3)
increase heart size, or (4) congestive heart failure
** 2. Arthritis:  2 joints and migratory type
 Orders:
IVF: D5NM 1 liter X 24 hr
Diagnostics: CBC, ASO (Anti-Streptolysin O test is always increased)
ESR, C-Reactive Protein (weekly to monitor progress of treatment)
Throat cultures for Streptococci
ECG (check for prolonged PR interval)
Chest X-ray, 2-D Echo with doppler
CARDIOLOGY

21
Acute Rheumatic Fever (Continuation):
Therapeutics:
- Bed rest to lessen joint pains.
1. Penicillin G IV or Ampicillin IV X 10 days to eradicate throat infection
2. For Arthritis only:
ASA alone at 75 mg/kg/day x 2 weeks followed by half the dose x 2-3 weeks,
e.g. ASA 325 mg 3 tabs q 4 hr (maximum of 9 grams/day) for pain and
fever, taper dose with clinical improvement. Joint pain usually decreases
within 24 hours of initiation of aspirin treatment.
3. For Mild Carditis:
ASA alone at 75 mg/kg/day x 6-8 weeks then taper gradually
4. For Moderate to Severe Carditis:
a. Prednisone at 1-2 mg/kg/day x 2-3 weeks then taper
e.g. Prednisone 5 mg 3 tabs q 6 hr (60-120 mg/day)
+ b. ASA 75 mg/kg/day x 6-8 weeks then wean gradually
Treat until ESR is normal.
Taper steroids while giving ASA for 6-8 weeks to prevent rebound carditis.
5. Diazepam tablet PO if with chorea.
6. Rheumatic Fever Prophylaxis:
IM: 1.2 million units Penicillin G Benzathine IM every 3-4 weeks
or PO: Penicillin V 250 mg cap BID or Erythromycin 250 mg cap BID
7. Duration of RF Prophylaxis:
For rheumatic fever without carditis, give for 5 years or until 30 years old.
For rheumatic fever with mild carditis, give until 45 years old.
For rheumatic fever with moderate to severe carditis, lifetime prophylaxis is
recommended especially if there is increased risk for contracting
streptococcal sore throat, i.e. patient lives in a crowded community or in
close contact with children.
Source: Adapted from Homer and Schulman, Journal of Rheumatology, 1995.
22


MEDICINE BLUE BOOK
CARDIO-PULMONARY CLEARANCE
Data:
Table 1-7. Modified Goldman's Classification: Cardiac Risk Stratification in
Patients Undergoing Non-cardiac Surgery.
Risk Factor
1. History
 Age  70 years
 MI within previous 6 months, unstable angina within 3 months or
chronic stable angina with CCS (Canadian Cardiovascular Society)
class III or IV angina
2. Physical Examination
 S3 gallop or jugular vein distention, decompensated CHF
 Severe aortic stenosis or mitral stenosis
3. Electrocardiogram
 Rhythm other than sinus or PACs on last preoperative ECG
  5 PVCs/min documented at any time before operation
4. General status
 PO2  60 or PCO2  50 mmHg, K  3.0 or HCO3  20 meq/l, BUN 
50 or Crea  3.0 mg/dl, abnormal SGOT, signs of chronic liver
disease, or patient bedridden from noncardiac causes
5. Operation
 Intraperitoneal, intrathoracic, or aortic operation
 Emergency operation
Goldman's Class
1. Class I: 0-5 points
2. Class II: 6-12 points
3. Class III: 13-25 points
4. Class IV:  26 points
Points
5
10
11
3
7
7
3
3
4
Total =
53
Incidence of Life-Threatening
Complications
(low risk)
1-2 %
(intermediate risk)
5-7 %
(intermediate risk)
16 %
(high risk)
56 %
Source: Modified from Goldman L, et al (1997). Multifactorial index of cardiac risk in
noncardiac surgical procedures. NEJM, 297, 845.
CARDIOLOGY

23
II. Diagnostics:
A. Basic Exams: CBC, FBS, K, Creatinine, ECG, Chest X-ray PA-L
B. Other Helpful Tests: Platelet count, PT, PTT, Urinalysis
C. Optional Tests as Indicated: ABG, Total Bilirubin, Albumin, SGOT,
2-D Echo with doppler
III. Treatment Approach:
A. Correct anemia, poor nutritional status, hypovolemia, polycythemia,
hypertension, electrolyte abnormality, cardiac arrhythmia, high blood sugar,
pulmonary disease causing hypoxemia, adrenal hyporesponse secondary to longterm steroid use.
B. CP clearance and need for intraoperative monitoring. Three basic questions:
1. What is the medical status of the patient?
a. What is the functional capacity of the patient? Can the patient climb at least
two flights of stairs with ease?
b. What is the patient's Goldman's Classification (Class I – IV)?
Note: Low-risk patients to clear have good functional capacity and are
Goldman’s Class I.
2. What is the operative procedure?
a. High-risk surgery: Emergency major operation, aortic and other major
peripheral vascular surgery, anticipated prolonged surgery with large blood
loss.
b. Intermediate risk surgery: Carotid endarterectomy, head and neck,
intraperitoneal and intrathoracic, orthopedic, prostate surgery.
c. Low-risk surgery: Breast, cataract, endoscopy, superficial procedures.
3. What type of anesthesia is to be used?
From high-risk to low-risk: General anesthesia, spinal anesthesia,
subarachnoid block, regional anesthesia, local anesthesia.
C. Based on the answers above, we can now estimate the operative risk involved.
Low-risk patients undergoing low-risk procedures have low operative risk.
Conversely, high-risk patients undergoing high-risk procedures have high
operative risk and need intraoperative monitoring. For other combinations of risk,
the physician is advised to use his/her clinical judgment before clearing the
patient.
24

MEDICINE BLUE BOOK
DYSLIPIDEMIA
A. Screening:
In patients without coronary heart disease (CHD), the National Cholesterol Education
Program (2001) recommends screening with a complete lipid profile (total
cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride) after a 12 hours fast
for all adults  20 years of age once every 5 years and as indicated.
B. Positive Risk Factors (Add 1 point each):
Age and gender (male  45, female  55 or premature menopause in women without
estrogen replacement), current cigarette smoker (ten or more cigarettes per day),
hypertension, family history of premature coronary artery disease (myocardial
infarction or sudden cardiac death before age 55 in a male first degree relative and
before age 65 in a female first degree relative), and low HDL cholesterol < 40 mg/dl.
C. Negative Risk Factor: Subtract by 1 point if HDL  60 mg/dl
D. Normal Values: Ideal Lipid Profile
- Total Cholesterol (TC)  200 mg/dl
- LDL  130 mg/dl
- HDL  40 mg/dl
- Triglycerides (TG)  200 mg/dl
E. Recommended Treatment
Table 1-8. National Cholesterol Education Program (NCEP) Recommended Cut-off
Treatment Levels in Adults: Based on at Least Two Results Taken 8 Weeks Apart.
Cardiac Risk
Start Drug Therapy
Start Diet
Treatment
Category
(After 8-week trial of diet)
Therapy Only
Goal
Total Chol
LDL
LDL
LDL
0-1 risk factors;
> 280 mg/dl
< 160mg/dl
 190 mg/dl
 160mg/dl
No CHD
(7.3 mmol/l)
(4.1 mmol/l)
(4.9 mmol/l)
(4.1 mmol/l)
2 or more risk
factors;No CHD
> 240 mg/dl
(6.2 mmol/l)
 160 mg/dl
(4.1 mmol/l)
 130mg/dl
(3.4 mmol/l)
< 130mg/dl
(3.4 mmol/l)
(+) CHD, DM
> 200 mg/dl
< 100 mg/dl
 130 mg/dl
 100 mg/dl**
or CHD risk
(5.2 mmol/l)
(2.6 mmol/l)
(3.4 mmol/l)
(2.6 mmol/l)
equivalents*
Note: Conversion factor from mg/dl to mmol/l: multiply by 0.0259
* CHD risk equivalents comprise: (1) diabetes, (2) other clinical forms of atherosclerosis
(symptomatic carotid artery disease, peripheral arterial disease, and abdominal aortic
aneurysm), (3) multiple positive risk factors which includes consideration of the
following - older age group, very high total cholesterol, low HDL, heavy cigarette
smoker, and untreated and high blood pressure.
** In patients with CHD and LDL levels between 100-130 mg/dl, the physician should
exercise clinical judgement in deciding whether to initiate drug therapy.
Source: Executive Summary of the Third Report of the National Cholesterol Education Program
(NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III). JAMA Vol. 285 (19):2486-97, May 16, 2001.
CARDIOLOGY

25
F. Treatment Approach:
1. Goal of treatment: Set treatment goal for target LDL
2. Start with Non-Pharmacologic Treatment:
a. Diet therapy: Moderation in diet; increase intake of fish and vegetables.
Diet for 8 weeks, then recheck Lipid Profile after 8 weeks. If repeat LDL
values fall above the cut-off levels for starting drug treatment, initiate
treatment with Statins.
b. Aggressive coronary heart disease risk reduction: Smoking cessation,
hypertension control, Aspirin treatment for documented coronary disease.
c. Weight reduction if obese
d. Increase physical activity (e.g. brisk walking, swimming)
e. Consider stopping beta-blockers and thiazide diuretics
f. Correct hyperglycemia (if diabetic) and replace thyroid hormones (if
hypothyroid)
3. Drug treatment of choice:
a. Type IIa: Increased LDL cholesterol and normal triglyceride ( 200 mg/dl):
#1Statins, #2 Probucol, #3 Fibrates, #4 Nicotinic acid
b. Type IIb: Increased cholesterol and increased triglyceride (200-400 mg/dl):
#1 Statins or Fibrates, #2 Nicotinic acid
c. Type IV: Normal cholesterol but increased triglyceride:
#1Fibrates, #2 Nicotinic acid, #3 Fish oil
G. Available Lipid Lowering Agents:
1. Statins as first-line drugs: (proven to prolong life with regular use)
Atorvastatin (Lipitor) 10 mg, 20 mg, 40 mg, 80 mg tab: 10-80 mg tab OD HS
Simvastatin (Vidastat☺, Zocor) 10 mg, 20 mg, 40 mg: 5-40 mg/day,
start with 5-10 mg OD HS.
Pravastatin (Lipostat) 10 mg, 20 mg tab: 10-40 mg OD HS
Fluvastatin (Lescol 40 mg, Lescol XL 80 mg tab): 1 tab OD HS
2. Fibrates:
Gemfibrozil (Reducel☺, Lipigem ☺ 300 mg & 600 mg cap, Lopid O.D. 900 mg
cap): 300-600 mg BID or Lopid O.D. 900 mg OD
3. Nicotinic Acid:
Nicotinic Acid (generic) 50 mg, 100 mg tab:
50 mg OD then increase up to 100 mg TID
4. Others:
Fish Oil gel capsule (Trianon Omegabloc) 1 cap TID
26

MEDICINE BLUE BOOK
INDICATIONS FOR PERMANENT PACEMAKER INSERTION

Data:
There is general agreement that a permanent pacemaker should be implanted in
the following conditions (Class I Indications):
A. Complete Heart Block with
1. (+) Symptoms due to the AV block (e.g. syncope, heart failure)
2. Asystole  3 seconds by holter monitoring even if without symptoms
3. HR  40 bpm even without symptoms (any escape rhythm  40 bpm)
B. 2nd Degree AV block, permanent or intermittent, with symptomatic
bradycardia
C. Sinus node dysfunction with symptomatic bradycardia. In some patients this
due to long-term essential drug therapy for which there are no
acceptable alternatives e.g. digoxin for tachycardia-bradycardia
syndrome.
D. Carotid sinus stimulation causing recurrent syncope or asystole  3 seconds in
the absence of any medication that depresses the sinus node or AV
conduction.
Additional Data:
1. Patients should not be taking any drug that depresses the heart rate (i.e. digoxin,
amiodarone, beta-blockers etc.). For example, digoxin needs 5 days to be completely
excreted by the body, hence, we may opt to temporize the patient for 5 days even if
he/she fulfills the above criteria.
2. The key clue in most of the above indications is the presence of symptoms.
3. Acute MI cases who develop bradyarryhthmias are usually treated with temporary
internal pacing since the problem is reversible. Inferior wall MI is associated with
edema of the AV node which usually resolves in 1- 2 weeks.
4. In poor patients who cannot afford permanent pacing, drug therapy with Bricanyl 2.5
mg tab BID-TID may be given with inconsistent results. In severe symptomatic cases,
permanent pacing is the only alternative. The cheapest pacemaker available costs
around Php 50,000.
CARDIOLOGY


27
HYPERTENSION
Data:
Seventh Joint National Committee Classification:
I. Hypertension Category Systolic (mm Hg)
Normal
 120
Prehypertension
120 - 139
Hypertension
Stage 1 (mild)
140 - 159
Stage 2 (moderate-severe)
 160
Diastolic (mm Hg)
and  80
or 80 - 89
or 90 - 99
or  100
Note: Take at least 2 readings on separate occasions to diagnose hypertension.
II. Recommendations for Follow-up Based on Initial Set of Blood Pressure
Measurements for Adults
Initial Screening Blood Pressure (mmHg) Follow-up Recommended
Systolic
Diastolic
 120
120 - 139
and  80
or 80 - 89
140 - 159
 160
or 90 - 99
or  100
Recheck in 2 years.
Advise healthy lifestyle and
recheck in 1 year.
Confirm hypertension in 2 months.
Evaluate or refer to source of care
within 1 month.
III. Recommended Laboratory Tests:
CBC, Urinalysis, Potassium, FBS, Creatinine, Calcium
Total Cholesterol, HDL, LDL, Triglycerides
ECG
IV. Approach to Treatment:
A. Rule out correctable and secondary causes of hypertension first.
These include drug-induced hypertension, thyroid or parathyroid disease, chronic
kidney disease, renovascular disease, coarctation of the aorta, primary
aldosteronism, chronic steroid therapy and Cushing’s syndrome, and
pheochromocytoma.
B. Encourage Lifestyle Change for Essential Hypertension
1. Stop smoking.
2. Lose weight if overweight. Maintain body mass index of 18.5 – 24.9 kg/m2.
For every 10 kilogram of weight loss, BP drops by approximately 5-20 mm Hg.
3. Reduce sodium intake ( 2 gm of sodium or approximately  6 gm of sodium
chloride).
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MEDICINE BLUE BOOK
4. Healthy diet. Consume a diet rich in vegetables, fruits and low fat dairy
products. Reduce dietary saturated fat and cholesterol intake for overall
cardiovascular health. Reducing fat intake also helps reduce calorie intake,
which is important for control of weight in type II diabetes
5. Engage in regular aerobic exercise once BP is controlled. At least 30 minutes
per day, most days of the week. Brisk walking is good exercise.
6. Limit alcohol intake to less than 1 oz/day of ethanol (24 oz of beer, 8 oz of
wine, or 2 oz of 80-proof whiskey)
7. Maintain adequate dietary potassium, calcium and magnesium intake.
C. Choice of Antihypertensive Drugs Based on Patient Characteristics. (List
includes compelling indications.)
1. Diabetic patients and those with chronic kidney disease: Use ace-inhibitors
or angiotensin II antagonists to delay diabetic nephropathy.
2. Young patients: Use beta-blockers unless contraindicated.
3. Coronary artery disease patients: Use beta-blockers, calcium-antagonists.
Avoid hydralazine.
4. Heart failure patients: Use ACE-inhibitors and/or diuretics. Generally
avoid beta-blockers and calcium-antagonists.
5. Athletes: Avoid beta-blockers and diuretics.
6. Broncho-pulmonary disease patients: Use Verapamil and other calciumantagonists. Avoid beta-blockers.
7. Peripheral vascular disease patients: Use calcium-antagonist (nifedipine),
vasodilators, or ace-inhibitors. Avoid beta-blockers.
8. Dyslipidemic patients: Avoid beta-blockers and diuretics.
9. End-stage renal disease patients: Use calcium-antagonists, diuretics and
centrally-acting agents. Caution on ace-inhibitors.
10. For stroke patients: Use ACE-inhibitors and/or diuretics.
11. Elderly patients: Use diuretics. Generally use lower dosages. Be wary of
pseudohypertension wherein the elevated BP is due to brachial artery
atherosclerosis and not hypertension per se.
D. Treatment Goal and Guide:
1. For hypertensive patients with diabetes or renal disease, the target BP is
< 130/80 mm Hg. For other patients without cardiovascular risk factors, the
BP goal is < 140/90 mm Hg.
2. JNC VII recommends the use of thiazide-type diuretics as first line treatment
unless with contraindications. Two diuretics locally available are Aldazide
given at ½ tablet a day and Natrilix. The most commonly used thiazide-type
diuretic hydrochlorothiazide may soon be available.
CARDIOLOGY
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29
DRUG LIST OF ANTI-HYPERTENSIVES & CARDIAC DRUGS:
ACE-Inhibitors
Captopril (Capoten, Primace ☺) 25 mg, 50 mg tab
PO- 25-50 mg BID-TID; CHF: 6.25-50 mg TID; maximum dose of 150 mg/day
Cilazapril (Vascace) 1 mg, 2.5 mg tab (Php 28 / tab)
PO- 1/2 tab OD X 2 days then 1-2 tabs OD
Enalapril (Hypace ☺, Renitec) 5 mg, 10 mg, 20 mg tab
PO- 10-20 mg OD-BID; maximum dose of 40 mg/day
Imidapril (Norten ☺, Vascor ☺) 5 mg, 10 mg tab
PO- 5-10 mg OD; maximum dose of 20 mg/day
Lisinopril (Zestril) 5 mg, 10 mg, 20 mg tab
PO- 10-20 mg/day; CHF-5-20 mg/day
Perindopril (Coversyl) 2 mg, 4 mg tab
PO- 4 mg/day OD-BID; CHF: 2-4 mg/day
Quinapril (Accupril) 5 mg, 10 mg, 20 mg tab
PO- 10-20 mg/day single or 2 divided doses; CHF dose: 5-10 mg OD
Ramipril (Tritace) 1.25 mg, 2.5 mg, 5 mg, 10 mg tab
PO- 1.25 – 2.5 mg OD-BID; maximum dose of 10 mg/day
Angiotensin II Antagonists (and diuretic combination)
Losartan (Cozaar, Lifezaar ☺) 50 mg tab
PO- ½ - 2 tabs OD
Losartan & Hydrochlorothiazide (Hyzaar) 50 mg/12.5 mg combination
PO- ½ - 2 tabs OD in A.M.
Telmisartan (Micardis, Pritor) 40 mg, 80 mg tab
PO- 40-80 mg tab OD
Telmisartan & Hydrochlorothiazide (Micardis Plus) 40/12.5 mg, 80/12.5 mg tab
PO- 1 tab OD in A.M.
Beta-Blockers
Atenolol (Therabloc ☺, Tenormin) 50 mg, 100 mg tab
PO- 50-100 mg PO OD
Betaxolol (Kerlone) 10 mg, 20 mg tab
PO- 10-20 mg tab OD
Bisoprolol Fumarate (Concore) 5 mg tab
PO- 1 tab OD
Carvedilol (Dilatrend) 6.25 mg, 25 mg tab
PO- 25-50 mg tab OD-BID; CHF dose: 3.125-12.5 mg BID
Metoprolol Succinate (Betazok) 100 mg tab
PO- 100-200 mg OD
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MEDICINE BLUE BOOK
Metoprolol Tartrate (Neobloc ☺, Betaloc, Cardiosel) 50 mg, 100 mg tab
PO- 50-100 mg BID to TID
Nadolol (Corgard) 40 mg tab
PO- 40-80 mg/day
Pindolol (Visken) 5 mg tab
PO- 5-15 mg/day single dose
Propranolol HCl (Inderal) 10 mg, 40 mg tab
PO- 10-40 mg TID to QID
Calcium- channel Antagonists
Nifedipine
PO- Calcibloc OD ☺ 30 mg tab OD; Odipin 40 mg ½ - 1 tab OD
PO- Adalat 1 Retard tab OD; Adalat 30 mg GITS tab OD-BID
Preferred maximum dose: 90 mg/day
Note: High-dose short acting Nifedipine has been associated with an increase in
mortality.
Diltiazem HCl (Ritemed Diltiazem ☺, Dilzem, Diltelan, Tildiem) 30 mg tab, 60 mg tab,
90 mg SA tab, 180 mg SR tab
PO- 30-60 mg TID, SA tab BID, 1 SR tab OD
Verapamil (Isoptin,Verelan) 40 mg tab, 80 mg tab, 180 mg SR tab, 240 mg SR tab
PO- 40-80 mg tab TID, 240 mg SR caplet OD
Nimodipine (Nimotop) 30 mg tab, 10 mg/50 ml IV infusion
PO- 1-2 tabs q 4-8 hourly
IV- 1-2 mg/hr
Nicardepine HCl (Cardepine) 10 mg tab, 20 mg tab, 40 mg SR cap, 2 mg/2 ml vial,
10 mg/10ml vial
PO- 10-40 mg tab TID or 1 SR cap BID
IV- 2-7 mg IV bolus or IV infusion (See p. 207)
Amlodipine (Norvasc) 5 mg tab, 10 mg tab
PO- 2.5-10 mg OD; Maximum dose of 10 mg/day
Felodipine (Plendil ER) 2.5 mg tab, 5 mg tab, 10 mg ER tab
PO- 2.5-10 mg OD-BID
Manidipine (Minadil, Caldine) 10 mg tab, 20 mg tab
PO- 10-20 mg OD
Lacidipine (Lacipil) 2 mg tab, 4 mg tab
PO- 2-4 mg tab OD
CARDIOLOGY
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31
Centrally Acting Drugs
Clonidine HCl (Catapres, Melzin) 75 mcg tab, 150 mcg tab, 150 mcg/ml amp,
2.5 mg TTS-1
PO- 75-150 mcg BID, maintenance of 0.3-1.2 mg/day, maximum of 2.4 mg/day
IV, IM, SC- 1 amp via SC, IM or IV routes for hypertensive crisis
Transdermal- TTS-1 One patch per week
Methyldopa (Aldomet, Dopetens, Meldopa, UL Methyldopa) 125 mg tab, 250 mg tab,
500 mg tab
PO- 250-500 mg TID
Diuretics
Spironolactone+Butizide (Aldazide ☺) 25mg/2.5mg tab
PO- ½ -2 tabs/day
Preferred dose: ½ tab OD
Indapamide (Natrilix SR) 1.5 mg tab
PO- 1 tab OD
Bumetamide (Burinex) 1 mg tab
PO- 1 mg tab OD
Furosemide (Lasix) 40 mg tab, 20 mg/2 ml amp
PO- ½ - 1 tab OD-BID
IM, IV- 20-40 mg
Furosemide + Amiloride (Frumil) 40 mg/15 mg tab
PO- 1-2 tabs/day
Spironolactone (Aldactone) 25 mg tab, 50 mg tab, 100 mg tab
PO- 50-100 mg/day in single or divided doses
Hydrochlorothiazide* 25 mg tab
PO- 12.5 - 50 mg/day
Preferred dose: 12.5 mg or ½ tab OD
* Not Available
Note: For hypertension, lower doses of diuretics are preferred because of less side-effects
such as electrolyte abnormalities. If BP is still elevated, combine diuretics with other
anti-hypertensives preferably Ace-inhibitors.
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MEDICINE BLUE BOOK
Vasodilators
Hydralazine HCl (Apresoline) 10 mg tab, 25 mg tab, 50 mg tab, 20 mg amp
PO- 50-200 mg/day; 25 mg BID-TID
IV, IM- 5-10 mg slow IV q 3-6 hours; Maximum of 3.5 mg/kg/day
Starting dose: 25 mg BID
Prazosin HCl (Minipress) 1 mg tab
PO- 0.5-2 mg OD-QID
Starting dose: 0.5 mg BID
Terazosin HCl (Hytrin) 1 mg tab, 2 mg tab, 5 mg tab
PO- 1-5 mg tab OD
Starting dose: 1 mg at bedtime
☺Cheapest Anti-Hypertensives & Cardiac Drugs (Mnemonic: ABCD)
I. Ace-inhibitors:
Enalapril (Hypace) 5 mg, 10 mg, 20 mg tab
PO- 5-20 mg tab OD (Php 15.00 per 10 mg tab)
or Imidapril (Norten, Vascor) 5 mg, 10 mg tab
PO- 5-10 mg tab OD (Php 20.00 per 10 mg tab)
II. Angiotensin II Antagonists:
Losartan (Lifezaar) 50 mg tab
PO- 1-2 tabs OD (Php 20.20 per 50 mg tab)
III. Beta-blockers:
Metoprolol (Neobloc) 50 mg tab, 100 mg tab
PO- ½ - 1 tab BID (Php 8.00 per 100 mg tab)
IV. Calcium-channel Antagonists:
Nifedipine (Calcibloc OD) 30 mg tab
PO- 1 tab OD (Php 27.00 per 30 mg tab)
V. Diuretics:
Spironolactone+Butizide (Aldazide) 25mg/2.5mg tab
PO- ½ tab OD (Php 9.50 per tab)
Note: For poor patients with mild to moderate hypertension, use beta-blockers and/or
low-dose diuretics. For severe hypertension, use calcium-channel antagonists.
CARDIOLOGY
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33
LOW MOLECULAR WEIGHT HEPARINS: FOR DVT & UNSTABLE ANGINA
Treatment Indications and Recommended Dosages:
1. Prevention of DVT for General Surgery / Orthopedic Surgery:
a. Dalteparin (Fragmin) 2500 IU SC OD
or
b. Enoxaparin (Clexane) 20 mg/0.2 ml SC OD
or
c. Nadroparin (Fraxiparine) 0.3-0.4 ml SC OD
Note: LMW Heparins may be started 12 hours after surgery if OK with the
surgeon. Heparin prophylaxis is continued until the patient is ambulatory.
2. Treatment for Deep Venous Thrombosis:
a. Dalteparin (Fragmin) 100 IU/kg SC BID
or
b. Enoxaparin (Clexane) 1 mg/kg SC BID
or
c. Nadroparin (Fraxiparine) 0.9 mg/kg SC BID (see recommended dosages below)
3. Treatment for Unstable Angina and Non Q-wave MI:
a. Enoxaparin (Clexane) 1 mg/kg SC BID
or
b. Dalteparin (Fragmin) 100 IU/kg SC BID
Available Formulations of Low Molecular Weight (LMW) Heparins:
1. Dalteparin Sodium (Fragmin)
Formulation: 2500 IU / 0.2 ml or 5000 IU / 0.2 ml
Sample dosage for a 50 kg patient for treatment of Unstable Angina:
5000 IU SC BID
2. Enoxaparine (Clexane)
Formulation: 40 mg/0.4 ml inj and 20 mg/0.2 ml injection
Sample dosage for a 60 kg patient for treatment of DVT:
60 mg or 0.6 ml SC BID
3. Nadroparin Calcium (Fraxiparine)
Formulation: 0.3 ml and 0.4 ml (0.2 ml and 0.6 ml also available)
3 ½ hours half-life, activity up to 24 hours
Body Weight
Treatment of DVT
Surgical Prophylaxis
< 50 kg
0.3-0.4 ml BID
0.2-0.3 ml OD
50-70 kg
0.4-0.6 ml BID
0.3-0.4 ml OD
> 70 kg
0.6-0.8 ml BID
0.4-0.6 ml OD
Note:
1. Precautions: Bleeding disorders, hepatic insufficiency, first trimester of pregnancy.
2. Technique: Right and left SC tissue at the anterolateral or posterolateral abdominal
wall; inject vertically.
Source: Adapted from Weitz , J. (1997). Low-Molecular-Weight Heparins. NEJM 337, 10, 691.
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MEDICINE BLUE BOOK
THE CARDIAC PATIENT WITH OTHER MEDICAL DISORDERS
Cardiac (Hypertension, Congestive Heart Failure) & Renal Failure
1. The following drugs may be used for hypertension:
a. Calcium-channel antagonists
b. Centrally-acting drugs
2. The following drugs may be used for congestive heart failure:
a. Vasodilators:
e.g. Prazosin (Minipres) 1 mg tab OD-TID
Apresoline 25 mg tab PO TID
b. Caution with Ace-inhibitors (increases potassium)
Cardiac (Coronary Artery Disease) & Gastrointestinal Bleeding
1. Mortality in patients with gastrointestinal bleeding is usually secondary to
coronary artery disease and not to the bleeding per se.
2. The following drugs for coronary artery disease cannot be routinely given:
Thrombolytics, heparin, warfarin or aspirin
3. Correct anemia from the gastrointestinal bleeding (anemia aggravates CAD)
4. Consider Clopidogrel (Plavix) 75 mg tab OD
or low dose Aspirin (Cor 30) at 30 mg OD
Cardiac (Hypertension) & Diabetes Mellitus
1. Five Stages of Diabetic Nephropathy:
Stage 1: Hyperfiltration (increase GFR)
Stage 2: Incipient stage (microalbuminuria)
Stage 3: Overt stage (macroalbuminuria)
Stage 4: Azotemia (increase creatinine)
Stage 5: End stage renal disease
2. Therapeutics:
a. Ace-inhibitors and Angiotensin II-antagonists are best for stages 1-3
b. Calcium-channel blockers are best for stages 4-5
c. Beta-blockers cover up hypoglycemic symptoms and may also increase lipids
d. Diuretics can increase blood sugar and lipids
Cardiac (Atrial Fibrillation or Acute Myocardial Infarction) & Pneumonia
1. Caution with giving nebulization with beta-2 agonists as this may precipitate
arrhythmias
2. May use saline nebulization or Ipratropium Bromide (Atrovent) nebulization