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Internal Medicine > 2) Cardiology (Part 1) > Flashcards

2) Cardiology (Part 1) Flashcards

1
Q

Non-modifiable coronary heart disease risk factors

A
  • Age
  • Male sex
  • Family history
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2
Q

Modifiable coronary heart disease risk factors

A
  • Hyperlipidemia
  • Hypertension
  • Diabetes mellitus
  • Metabolic syndrome
  • Cigarette smoking
  • Obesity
  • Sedentary lifestyle
  • Heavy alcohol intake
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3
Q

Markers for CHD

A
  • Elevated lipoprotein (a)
  • Hyperhomocysteinemia
  • Elevated high-sensitivity C-reactive protein (hsCRP)
  • Coronary arterial calcification detected by CT (CAC)
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4
Q

Atherosclerosis

A
  • Pathological process in which coronary arteries become narrowed by the buildup of fatty material in their walls
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5
Q

Atherosclerotic plaques

A
  • Lead to narrowing of the artery lumen

- Decrease blood flow and oxygen delivery to the coronary arteries

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6
Q

CAD diagnosis

A
  • Cardiac catheterization (often after an abnormal cardiac stress test)

Or

  • CT angiography
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7
Q

CAD treatment

A
  • Treat Modifiable Risk Factors (Hyperlipidemia, Hypertension, Diabetes mellitus, Metabolic Syndrome, Cigarette Smoking, Obesity, Sedentary Lifestyle, Heavy Alcohol Intake)
  • Low-dose aspirin 75-100mg/daily for secondary prevention
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8
Q

Primary prevention (preventing 1st heart attack)

A
  • Mostly don’t prescribe low-dose aspirin
  • Sometimes used in select adults aged 40-70 years who have a higher risk of developing ischemic heart disease but not an increased bleeding risk
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9
Q

Angina

A
  • Limitation of Coronary Blood Flow
  • Decreased Oxygen supply to the heart muscle
  • Pt. develops chest pain
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10
Q

Classic history of angina

A
  • Chest discomfort, usually described as “heaviness” “pressure” “squeezing” “smothering” or “choking”
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11
Q

Levine’s sign (pt making fist over sternum describing pressure)

A
  • Can radiate to either shoulder and to both arms (especially the ulnar surfaces of the forearm and hand)
  • Can arise in or radiate to the back, interscapular region, root of the neck, jaw, teeth, and epigastrium
  • Angina is rarely localized below the umbilicus or above the mandible
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12
Q

Anginal “equivalents” symptoms

A
  • Dyspnea
  • Nausea
  • Fatigue
  • Faintness
  • More common in elderly and diabetic patients
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13
Q

Types of angina

A
  • Prinzmetal’s Variant Angina/Vasospastic Angina
  • Stable Angina
  • Unstable Angina
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14
Q

Prinzmetal’s Variant Angina

A
  • Caused by coronary artery vasospasm resulting in transmural ischemia
  • Severe ischemic pain that usually occurs at rest and is associated with transient ST-segment elevation
  • Diagnosed with coronary angiography demonstrating transient coronary spasm
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15
Q

Stable angina

A
  • Transient myocardial ischemia
  • Caused by exertion typically is relieved in 1–5 min by slowing or ceasing activities and even more rapidly by rest and sublingual nitroglycerin
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16
Q

Unstable angina

A
  • Part of “Acute Coronary Syndrome”
  • Has at least one of three symptoms
  • Can have ECG changes, but has negative troponins
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17
Q

Symptoms indicative of unstable angina

A
  • Ooccurrence at rest (or with minimal exertion) lasting >10 min (usually more than 20 min)
  • Relatively recent onset (i.e., within the prior 2 weeks)
  • Crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previous episodes)
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18
Q

Stable angina Tx

A
  • Treat modifiable risk factors
  • Nitrates
  • Beta or Calcium Channel Blockers, Ranolazine
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19
Q

Prinzmetal’s Variant Angina Tx

A
  • Nitrates

- Calcium channel blockers

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20
Q

Unstable angina Tx

A
  • Admission

- Dual antiplatelet therapy + glycoprotein IIb/IIIa inhibitor + anticoagulation with heparin +/- statin +/- cardiac cath

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21
Q

Unstable Angina (UA) ischemic symptoms

A
  • Rest angina usually more than 20 minutes, new onset angina that limits physical activity, increasing angina that is more frequent, longer, and occurs with less exertion than previously
  • With or without EKG changes in contiguous leads (ie T wave inversions, ST segment depressions)
  • NO elevation of troponin
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22
Q

Non-STEMI ACS symptoms

A
  • Same as unstable angina, but troponin is elevated
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23
Q

STEMI ACS symptoms

A
  • ST segment elevations of 1 mm (0.1 mV) in 2 anatomically contiguous leads or 2 mm (0.2 mV) in 2 contiguous precordial leads
  • OR new left bundle branch block and presentation consistent with ACS
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24
Q

Plaque rupture in ACS

A
  • Rupture of the fibrous cap of an atheromatous plaque

- Exposure of highly thrombogenic, necrotic core material rich in red cells

25
ACS occlusion status
- Unstable angina = partial obstruction - Non-STEMI = larger obstruction with occlusion of lumen - STEMI = complete occlusion of lumen
26
Diagnosis of ACS
- ECG is the best initial test At least 2 of the following - History (angina or angina equivalent) - Acute ischemic ECG changes - Typical rise and fall of cardiac markers - Absence of another identifiable etiology
27
Patient history indicating ACS
- Chest discomfort (pain, tightness, dull, heaviness, etc.) - Fatigue - Weakness - SOB - Activity at onset - Risk factors
28
5 most important history-related factors (in order of importance)
1) Nature of the chest pain 2) History of Coronary Heart Disease 3) Sex/gender 4) Age 5) Number of traditional risk factors
29
Physical examination
- Vital signs - Skin color/diaphoretic - Neck - Lung sounds - Heart sounds - Lower extremity exam - In considering thrombolytics ("clot busters"), cursory neuro exam
30
Lung sounds to look for in ACS physical examination
- Rales/crackles = fluid out of the capillaries into the alveoli
31
Heart sounds to look for in ACS physical examination
- Friction rub - New murmur - Acute mitral valve regurgitation or a VSD - Pericardial effusion/tamponade
32
ECG in ACS
- Tool for looking at acute ischemia to the coronary arteries that supply areas of the heart - REMEMBER about 50% may be initially normal, but then develop ST changes
33
Unstable angina and non-STEMI ECG in ACS
- May be normal or abnormal
34
STEMI ECG in ACS
- By definition, ST segment elevation in contiguous leads (or new LBBB) in the setting of ischemic symptoms
35
Troponin I or T (cTnI or cTnT)
- Cardiac biomarkers/enzymes | - The time of presentation and every 3-6 hours for 6-12 hours
36
High-sensitivity Troponin (hs-cTn) I or T
- Cardiac biomarkers/enzymes | - The time of presentation and every hour x 1-3 hours
37
False positives in cardiac biomarker testing
- Pulmonary embolism - Myocarditis - TYakotsubo cardiomyopathy - Chronic kidney disease - Rare analytical problem (heterophile antibodies)
38
False negatives in cardiac biomarker testing
- Excessive biotin use
39
Initial interventions with ACS
- Assess and stabilize airway, breathing, and circulation - Provide Oxygen (ONLY IF O2 Sat is <90% patients in respiratory distress - Establish IV access - Treat sustained ventricular arrhythmia rapidly according to ACLS protocols - Vitals, history, labs - Portable CXR
40
Labs ordered in suspected ACS
- Cardiac biomarkers x3 - CBC - CMP - PT/INR - PTT
41
Initial medications for ACS
- Aspirin - Nitroglycerin - Beta Blockers - Morphine - Statin
42
STEMI management
- Immediate reperfusion therapy - Do not wait for troponin results - Straight to cath lab if there are ST segment elevations in EKG in contiguous leads
43
Immediate reperfusion therapy
- Most common is immediate cardiac cath (angioplasty/percutaneous intervention) - Goal: door to balloon 90 minutes
44
Non-STEMI and unstable angina management
- Admission, cardiac monitoring, serial ECGs Plus - Anti-platelet medications (Aspirin + GP IIB/IIIA INHIBITORS(Integrilin/ReoPro) + Adenosine diphosphate (ADP) receptor antagonists(Ticagrelor/Brilinta or prasugrel/Effient or clopidogrel/Plavix) Plus - Anticoagulation (UF Heparin or LMWH) Plus - Cardiology Consult (Usually get a Cardiac cath)
45
Long term management of ACS after hospital discharge
- Dual antiplatelet therapy x 12 months at least (Aspirin + ADP inhibitor) - Statin - ACE-I or ARB - Beta Blocker
46
Acute pericarditis
- Inflammatory process involving pericardium - Can occur as acute, sub-acute or chronic form - Most common of all disease processes involving the pericardium
47
Acute pericarditis causes
- Variety of etiologies (most commonly post infectious) - May be associated with a pericardial effusion & even tamponade - Can become chronic or recurrent - Can develop into constrictive pericarditis
48
Symptoms of pericarditis
- Chest pain is usually presenting symptom - Often sharp, typically retrosternal piercing, & pleuritic in nature with radiation to left shoulder - Pain aggravated by deep breathing & lying supine - Pain is non-exertion & may be steady or even crushing in nature & may mimic acute MI - Pain may also be in epigastric area & increased with swallowing - If acute infectious etiology, patient is most comfortable sitting up & leaning forward - Fever usually follows onset of CP
49
PE findings in pericarditis
- Pericardial friction rub - Scratchy, rough, gritty sound - Best heard using diaphragm applied firmly along lower LSB with patient sitting upright & leaning forward - May be accentuated in inspiration
50
Pericarditis treatment
- NSAIDs + Cholchicine
51
Aortic dissection
- Much less common than an MI - Extreme emergency & can lead to death in minutes - Blood can dissect up or down aorta - Blood dissecting up around great vessels can close off carotids - Blood can dissect down to coronaries & shut them off
52
Risk factors for ascending aortic dissection
- HTN - Cystic medial necrosis - Marfan’s syndrome
53
Risk factors for descending aortic dissection
- Atherosclerosis - HTN - Increased incidence - Coarctation of aorta; Bicuspid AV,AS, 3rd trimester of pregnancy in otherwise normal women (rare), Rarely traumatic
54
Symptoms of aortic dissection
- Sudden onset of severe sharp anterior or posterior chest pain with “ripping” or tearing quality
55
PE findings of aortic dissection
- Unequal Blood pressure readings in the RUE and LUE - Asymmetry of carotid or brachial pulses - New onset of Aortic Regurgitation murmur - Neurologic abnormalities if there is interruption of carotid artery flow
56
Aortic dissection diagnosis
- “90% will have an abnormal CXR, Mediastinal widening - CT Angiogram (fast & sensitive) - Echocardiogram (evaluates aortic valve)
57
Aortic dissection Tx
- ICU monitoring | - Antihypertensive therapy to maintain systolic BP below 120 mm Hg, using IV agents, followed by oral therapy
58
Descending aortic dissection Tx
- Stabilized medically with antihypertensives
59
Ascending aortic dissection Tx
- Immediate surgical repair

Internal Medicine (14 decks)

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