#3 Cardiac Flashcards
(72 cards)
1
Q
CAD
what med should you hold if pt has severe CAD?
note: presents w/ wide variety of Sxs
A
CAD
severe CAD –> hold clopidrogrel
Sxs (for reference)
- CP, SOB, DOE, dizzy, palp, leg swelling, wt gain
- syncope, shock, pulm congestion, rales
2
Q
3 Types/Classification of ACS
A
3 Types/Classification of ACS
- STEMI
- NSTEMI
- Unstable Angina
3
Q
Types/Classification of ACS
- which is a/w complete obstruction
- which is a/w intermittent occlusion/myocardial necrosis
- which is a/w occlusion that auto-reperfused
A
Types/Classification of ACS
- STEMI = complete obstruction
- NSTEMI = intermittent occlusion/myocardial necrosis
- Unstable Angina = occlusion that auto-reperfused
4
Q
ACS: STEMI sides
- which side presents w/ epigastric pain, bradycardia, elevated JVP, inferior distribution, dont want to lay flat
- which side presents w/ HoTN, tachycardia, ant/lat distribution, SOB, rales
A
ACS: STEMI sides
- R side = epigastric pain, bradycardia, elevated JVP, inferior distribution, dont want to lay flat
- L side = HoTN, tachycardia, ant/lat distribution, SOB, rales
5
Q
ACS: STEMI
- 2 things needed to make Dx
- What time frame are cardiac enzymes NOT definitive
A
ACS: STEMI
- Dx = clinical + EKG
- cardiac enzymes < 6 hr from Sx onset NOT definitive
6
Q
ACS: STEMI and EKG
- what needs to be seen (and in how many leads) to make Dx
A
ACS: STEMI w/ EKG Dx
- ST elevation ( > .1mV/ 1mm) in 2 contiguous leads
7
Q
Management for ACS (general)
4 things given if ACS suspected
A
Management for ACS (general)
- ACS suspected –> MONA
- Morphine
- O2
- NG
- ASA
8
Q
Tx for STEMI (ACS)
- what med given immed
- what type of procedure for Tx (2 options)
- 3 meds given as post-care
Note: MC cause = plaque rupture
A
Tx for STEMI (ACS)
- Clopidrogrel given immed
- procedure for Tx
- cath lab (PCI)
- Fibrionolytics (if no cath lab w/in 90 min) - 3 meds given as post-care
- statin
- B-blocker
- ACE/ARB
9
Q
Tx of STEMI: L vs R
- R = Pt w/ Inferior STEMI w/ RCA occlusion
- what to give immed
- what to avoid - L = Pt w/ ant or lat STEMI
- what do the need reduced (what med to give)
- what to avoid
A
Tx of STEMI: L vs R
- R = Pt w/ Inferior STEMI w/ RCA occlusion
- immed IVFs
- avoid Nitrates - L = Pt w/ ant or lat STEMI
- need afterload reduced –> give nitro
- avoid IVFs
(NOTE OPP OF R SIDED STEMI)
10
Q
ACS: NSTEMI vs Unstable Angina Presentation
- what Sx do both have
- what do both have on EKG
- How do they differ in regards to labs
A
ACS: NSTEMI vs Unstable Angina Presentation
- common sx = Angina
- common EKG finding = non-spp ST changes
(UA can be norm) - differ w/ labs
- STEMI = (+) Cardiac enzymes
- UA = (-) Cardiac enzymes
11
Q
ACS: STEMI and EKG
- what indicates ischemia on EKG
- what other abn seen
A
ACS: STEMI and EKG
- ischemia on EKG = ST depression
- Other abn = T wave inversions
12
Q
ACS: NSTEMI Tx
- 3 meds given immed
- not as urgent as STEMI, but when do they need to be taken to cath lab by for PCI
note: post care = SAME as STEMI
A
ACS: NSTEMI Tx:
Immed Meds
- clopidrogrel
- LMWH/UFH
- Statin
- need to be taken to cath lab by for PCI w/in 72 hrs
13
Q
ACS Tx: dosing, CIs
- ASA: loading dose and lifelong dose
- Plavix/Clopidrogrel: loading dose and lifelong dose
- What med cant be give if HoTN, Inferior MI, Viagara use in last 24 hrs
- What med CI if Hr < 60, SBP <90, heart block, Hf, H/o bronchospastic dz or cocaine use
A
ACS Tx: dosing, CIs
- ASA
- loading dose = 325 mg
- lifelong dose = 81 mg - Plavix/Clopidrogrel
- loading dose = 400-600 (mg?)
- lifelong dose = 75 (mg?) - NG = CI w/ HoTN, Inferior MI, Viagara use in last 24 hrs
- BB = CI if Hr < 60, SBP <90, heart block, Hf, H/o bronchospastic dz or cocaine use
14
Q
ACS: Prognosis
- TIMI risk score indicates what mortality by STEMI
- Kilip Class indicates what type of mortality
A
ACS: Prognosis
- TIMI risk score = 30 day mortality by STEMI
- Kilip Class = inhospital mortality
15
Q
ACS: Complication
- what should you suspect in pt who develops HF and audible murmur
- why does this need emergent surg
A
ACS: Complication
Develop HF and audible murmur –> Acute Mitral Regurg
- need emergent surg b/c ischemia –> necrosis
16
Q
Pt presents w/ substernal CP that occurs only w/ activity. Pt says that stopping to rest relieves his Sxs
Dx?
A
Dx = Stable Angina
17
Q
Pt presents w/ substernal CP that has been happening more freq recently, worsening, and lasting longer. Pt very recently the CP has now begun to happen at rest
Dx?
A
Dx = Unstable Angina
18
Q
Stable Anging Dx
- What is the main form of Dx testing
- more definitive method
A
Stable Anging Dx
- main form of Dx testing = Stress Test
- more definitive method = CCTA
19
Q
Stable Angina Tx
- what 4 meds given to Symptomatic pts
- what can be added if these dont work
A
Stable Angina Tx
- what 4 meds given to Symptomatic pts
- NTG
- Beta blocker
- ASA daily
- Statin (mod-high) - these dont work –> add CCB
20
Q
Vascular Dz/Atherosclerosis
- what is it instigated by
- what gets incr in the body –> inflam –> and utimately leads to what
A
Vascular Dz/Atherosclerosis
- instigated by endothelial disruption
- inc lipids –> inflam –> calcification
21
Q
permanent, localized dilation of artery
- in most pts the first Sx = death
(> 4 cm = usu diagnostic)
A
permanent, localized dilation of artery = Aortic Aneurysm
- in most pts the first Sx = death
(> 4 cm = usu diagnostic)
22
Q
- Connective tissue d/o
- AAA
- inflam dz (giant cell, takayasu, bechets, etc)
- Infxn (syphilis)
- Decelerating Trauma
6 .Chronic dissection - Genetic Syn (Marfans, Loeys-Dietx, Ehler-Danlos, Turners)
causes of what
A
Causes of Aortic Aneurysm
- Connective tissue d/o
- AAA
- inflam dz (giant cell, takayasu, bechets, etc)
- Infxn (syphilis)
- Decelerating Trauma
6 .Chronic dissection - Genetic Syn (Marfans, Loeys-Dietx, Ehler-Danlos, Turners)
23
Q
Location of Aortic Aneurysms
- occur before ligamentum arteriosum
- occur below ligamentum arteriosum
- occur below diaphragm
A
Location of Aortic Aneurysms
- ascending = before ligamentum arteriosum
- descending = below ligamentum arteriosum
- AAA = below diaphragm
24
Q
Which types of aortic aneurysm STRONGLY a/w
Main tx for Dx
A
Descending and AAA = STRONGLY a/w PVD
Dx test = CT
25
Tx of aortic aneurysm (all types)
1. Sxs -->
2. surg is done when size > ______
Tx of aortic aneurysm (all types)
1. Sxs --> surg
2. surg is done when size > 5.5 cm
26
What d/o s precipitated by tear in vascular intima --> blood enters media --> disrupts blood vessels
Aortic Dissection
| - precipitated by tear in vascular intima --> blood enters media --> disrupts blood vessels
27
Aortic Dissection Progression
1. which affects coronary arteries
2. which interferes w/ periph blood flow
Aortic Dissection Progression
1. proximal = affects coronary arteries
2. distal = interferes w/ periph blood flow
28
Pt presents w/ abrupt onset of chest/thoracic pain that he describes as sharp/tearing. Pt looks to be in distress. Vitals: BP 170/90, HR 125. On exam you are able to feel 2 radial pulses but only 1 pedal pulse, hear aortic regurg. CXR shows mediastinal widening of 9 cm
Dx (gen and spp)
What test to get to confirm Dx?
Dx = Aortic Dissection
- spp = promixal (b/c aortic regurg)
(could also have tamponade/coronary dissection)
Confirm Dx = CT
29
Tx of Aortic Dissection
1. Strict control of what 3 things
2. what type of aggressive support
3. Main thing needed
Tx of Aortic Dissection
1. Strict control of BP, HR (w/in 20 min) and pain
- BP goals: < 120 SBP
- HR goals: 60
2. aggressive fluid support
3. NEED SURGERY
30
Aortic Stenosis: Etiology
1. What type a/w pts w/ HTN, HLP, ESRD and > 70 y/o
2. what type a/w bicuspid AV
3. what type a/w MV dz
Aortic Stenosis: Etiology
1. Calcific = a/w HTN, HLP, ESRD and > 70 y/o
2. Congenital = a/w bicuspid AV
3. Rheumatic heart Dx = a/w MV dz
31
Aortic Stenosis: Pathophys
| - what does the narrowed aortic valve orifice lead to (4 things)
Aortic Stenosis: Pathophys
- narrowed orifice leads to
1. fixed CO
2. Pulm HTN
3. LVH and decr EF
4. Mitral regurg
32
What murmur has loud, hard, high pitched mid-systolic crescendo-descrescendo murmur that radiates to the RUSB and carotids
Aortic Stenosis
- loud, hard, high pitched mid-systolic crescendo-descrescendo murmur that radiates to the RUSB and carotids
"ARMS Rest"
33
1. Large, diffuse PMI
2. Delayed carotid upstroke
3. murmur decr w/ valsalva and standing
4. EKG: shows LVH w/ strain
A/w which murmur
Aortic Stenosis PE/EKG findings
1. Large, diffuse PMI
2. Delayed carotid upstroke
3. murmur decr w/ valsalva and standing
4. EKG: shows LVH w/ strain
34
Tx of Aortic Stenosis
1. what 2 meds 1st line/ given for BP control
2. what is the definitive Tx
3. name of other procedure can be done
Tx of Aortic Stenosis
1. meds 1st line/ given for BP control = ACE/diuretic
2. definitive Tx = valve Replacement
3. TAVR (if surg CI)
35
Incompetence of aortic valve --> decr CO --> HF
Aortic Regurg
| - Incompetence of aortic valve --> decr CO --> HF
36
Aortic Regurg: Acute vs Chronic
1. which is a/w Endocarditis and Retrograde dissection
2. which is mainly a/w valvular dz (Rheumatic, Bicuspid valve, infective endocarditis)
3. which a/w rapid hemodynamic collapse and fulminant HF
Aortic Regurg: Acute vs Chronic
1. Acute = a/w Endocarditis and Retrograde dissection
2. Chronic = a/w valvular dz (Rheumatic, Bicuspid valve, infective endocarditis)
3. Acute = rapid hemodynamic collapse and fulminant HF
37
what murmur has soft, high pitched, early diastolic descrescendo at Erbs point (3rd ICS)
Aortic Regurg
- soft, high pitched, early diastolic descrescendo at Erbs point (3rd ICS)
38
Aortic Regurg
1. what 2 things will incr the murmur
2. other than ECHO what else for Dx
Aortic Regurg
1. end expiration + leaning forward --> incr murmur
2. Dx = ECHO + blood cultures (endocarditis)
39
Aortic Regurg Tx
1. what is the mainstay of Tx
2. what med to avoid
3. When is surg only indicated (AVR)
Aortic Regurg Tx
1. mainstay of Tx = control HTN
2. avoid b-blocker
3. Surg only indicated (AVR) if Sxs present
40
What valve d/o is a/w Rheumatic Fever
- what the the cause of rheum fever
- what type of attack on heart does it cause
note also a/w calcific process (ESRD)
Mitral Stenosis = a/w Rheumatic Fever
| - cause of rheum fever =strep --> AI attack on heart
41
Mitral Stenosis: Pathophys
1. narrowed mitral valve orifice --> what 3 things
2. decr LV filling -->
Mitral Stenosis: Pathophys
1. narrowed mitral valve orifice -->
- Hypertrophy
- Afib
- Pulm HTN
2. decr LV filling --> decr CO
(--> periph vasoconstriction)
42
Pt presents w/ hoarse voice, DOE, R HF, and a fib. On exam you hear a diastolic opening snap and low pitched diastolic rumble. You also note incr JVP and narrowed pulse pressure
Dx?
Dx = Mitral Stenosis
43
Tx of Mitral Stenosis
1. 2 supportive meds
2. 2 ways to manage A fib
3. Other option (gen)
Tx of Mitral Stenosis
1. 2 supportive meds = BB, CCBs
2. 2 ways to manage A fib
- rate control
- anti-coagulation
3. Other option (gen) = surgery
44
Mitral Regurg Types
1. Another name for primary
2. Another name for secondary
3. Which is a/w destruction of valve
4. which is a/w LV remodeling or papillary dysfxn
Mitral Regurg Types
1. Another name for primary = degenerative
2. Another name for secondary = functional
3. Primary/degen = a/w destruction of valve
4. Secondary/function = a/w LV remodeling or papillary dysfxn
45
Mitral Regurg: Acute vs Chronic
1. which a/w MI, endocarditis, Trauma
2. which a/w myxomatous, ischemic, dilated cardiomyopathy, rheumatic, HOCM
Mitral Regurg: Acute vs Chronic
1. Acute = a/w MI, endocarditis, Trauma
2. Chronic = a/w myxomatous, ischemic, dilated cardiomyopathy, rheumatic, HOCM
46
Mitral Regurg Sxs: Acute vs Chronic
1. which a/w ischemia, chordal rupture, flash pulm edema
2. which a/w progressive dyspnea, a fib, worsening HF sxs, cardiomyopathy
Mitral Regurg Sxs: Acute vs Chronic
1. Acute = ischemia, chordal rupture, flash pulm edema
2. Chronic = progressive dyspnea, a fib, worsening HF sxs, cardiomyopathy
47
Which type of Mitral Regurg is a/w MVP
Primary/degen Mitral Regurg is a/w MVP
48
Tx of Mitral Regurg
1. What med given
2. what is ultimate Tx thats needed
3. what must be done for acute Mitral regurg
Tx of Mitral Regurg
1. med = B-Blocker
2. ultimate Tx needed = surg
3. acute Mitral regurg --> EMERGENT surg
49
Syncope: Cardiogenic vs Vasovagal
1. a/w abrupt LOC w/ no defensive wounds
- a/w FOOSH w/defensive wounds
2. a/w prodrome of N/, dizzy, diaphoresis, weakness, flushing
- a/w litte/no prodrome
3. a/w Bezhold-Jarsich reflex
4. a/w physical activity/exercise
- a/w situations:cough, defecation, dehydration
5. a/w EKG and electrolyte abn, anemia
Syncope: Cardiogenic vs Vasovagal
1. Cardiogenic = abrupt LOC w/ no defensive wounds
- Vasovagal = FOOSH w/defensive wounds
2. Vasovagal = prodrome of N/, dizzy, diaphoresis, weakness, flushing
- Cardiogenic = litte/no prodrome
3. Cardiogenic = Bezhold-Jarsich reflex
4. Cardiogenic = physical activity/exercise
- Vasovagal = situations (cough, defecation, dehydration)
5. Cardiogenic = EKG and electrolyte abn, anemia
(vasovagal = norm EKG or a fib)
50
what dz can be painless, often has elevated cardiac enzymes and convex ST segments
Myocarditis
- can be painless, often has elevated cardiac enzymes and convex ST segments
- also often concurrent w/ pericarditis
51
non-spp inflammation of sac around the heart that is typically caused by virus (has viral prodrome)
pericarditis
52
Pt presents w/ acute CP that is sharp and pleuritic. Pain is worse when lying down and better leaning forward. On exam pt has fever, you hear a friction rub, see distended neck veins, pulsus paradoxus, and hear muffled heart sounds.
Dx?
Dx = pericarditis
53
Dx of Pericarditis
1. CXR shows
2. classic EKG finding
3. other test can be used for Dx
4. 2 signs of systemic infxn seen
Dx of Pericarditis
1. CXR --> effusion
2. EKG --> diffuse ST segment elevation
3. other test can be used for Dx = ECHO
4. 2 signs of systemic infxn seen
- leukocytosis
- fever
54
Tx of Pericarditis
1. lst line med for first event (class + 2 ex)
2. med for preventing recurrence
3. med for refractory cases
Tx of Pericarditis
1. lst line med for first event = NSAIDS
- Ibuprofen, Indomethacin
2. prevent recurrence --> Colchicine
3. refractory cases --> GCCs
55
d/o of ventricular compression that is commonly idiopathic
Pericardial Tamponade
| - d/o of ventricular compression that is commonly idiopathic
56
Pericardial Tamponade
1. what determines severity
2. cause decr in what 3 things
Pericardial Tamponade
1. rate of fluid acculm determines severity
2. cause decr in ventricular size, CO and BP
57
Pericardial Tamponade: Severity
1. which a/w Asx
2. which a/w trauma, hemorrhage
3. which a/w tachycardia, dyspnea, distended neck veins, muffled heart sounds, narrow pulse press, Sxs worse when lying flat
Pericardial Tamponade: Severity
1. Subacute = a/w Asx
2. Rapid = a/w trauma, hemorrhage
3. Acute = a/w tachycardia, dyspnea, distended neck veins, muffled heart sounds, narrow pulse press, Sxs worse when lying flat
58
Pt presents to ED w/ tachycardia, dyspnea. Sxs worse when lying flat. On PE you see Kussmaul's sign, feel faint pulses, hear muffled heart sounds, see distended neck veins, narrow pulse press. EKG shows low voltage and electrical alternans. CXR show large silhouette
Dx?
Dx = Pericardial Tamponade
59
Tx of Pericardial Tamponade
1. supportive measure to sustain preload
2. Acute Tx --> 2 methods
Tx of Pericardial Tamponade
1. supportive measure to sustain preload = fluids
2. Acute Tx --> 2 methods
- pericardiocentesis
- pericardial window
60
Dx HTN
1. how many BP readings needed
2. what classifies someone as having Stage I HTN (actual HTN)
3. BP > 160/100 = what stage/severity
4. MC type (2 names)
Dx HTN
1. need 2 BP readings to make Dx
2. what classifies someone as having Stage I HTN
- BP 140-159/90-99
3. BP > 160/100 = stage2/severe HTN
4. MC type = primary/essential
61
Tx HTN (goals)
1. general BP goal
2. goal for pts > 60
3. 3 HTN meds safe to give in preg
Tx HTN (goals)
1. general BP goal < 140/90
2. pts > 60 --> < 150/90
3. 3 HTN meds safe to give in preg
- Labetolol (1st line)
- Methyldopa
- Nifedipine
62
Tx of HTN for specific groups
1. if black what meds do you NOT give
2. 3 situations you should add B-blocker to HTN therapy
3. 2 dz you add on CCB
Tx of HTN for specific groups
1. if black do NOT give ACE/ARBs
2. 3 situations you should add B-blocker to HTN therapy
- HF, post MI, CAD
3. 2 dz you add on CCB
- CAD, DM
note mainstay = generally ACE/ARB
63
Acute HTNsive Crisis: Urgency vs Emergency
1. which a/w end organ damage
2. which is often d/t medication non-compliance
3. which is a/w flash edema, schistocytes, RBCs/casts
4. which defined at BP > 180/120
5. which does not need admission/ acute lowering of BP
Acute HTNsive Crisis: Urgency vs Emergency
1. E = a/w end organ damage
2. U = d/t medication non-compliance
3. E = a/w flash edema, schistocytes, RBCs/casts
4. U = BP > 180/120
5. U = not need admission/ acute lowering of BP
64
Pt presents w/ HA, dyspnea, CP, neuro deficits, paresthesias, and nausea. BP is 190/140. EKG shows LVH but pts labs are norm and there is no evid of end organ damage
Dx?
Dx = Hypertensive urgency
| BP > 180/120 but no end organ damage
65
Tx of Hypertensive Crisis (Emergency)
1. goal = reduce MAP by 25% in first ____ then goal = ___/___ in the next 6 hrs
2. 3 meds for Tx
Tx of Hypertensive Crisis (Emergency)
1. goal = reduce MAP by 25% in 1st 2 hrs then goal = 160/100 in the next 6 hrs
2. 3 meds for Tx
- IV Nitroprusside
- Labetolol
- Nicardipine
66
Pt presents w/ Sxs of congestion, elevated JVP, enlarged liver border and swelling
L or R sided CHF
Pt presents w/ Sxs of congestion, elevated JVP, enlarged liver border and swelling
- R sided CHF
67
Pt presents w/ Sxs of poor forward flow, fatigue, generalized weakness, dyspnea, orthostasis and rales
L or R sided CHF
Pt presents w/ Sxs of poor forward flow, fatigue, generalized weakness, dyspnea, orthostasis and rales
- L CHF
note common sxs for both = abn renal fxn, S3 gallop
68
Dx of CHF
1. EKG: likely normal?
2. what test is good for ruling out CHF
Dx of CHF
1. EKG: likely ABNORMAL
2. BNP = good for ruling out CHF
69
1. vascular congestion
2. cardiomegaly
3. pulm edema --> Kerley B lines
4. moose sign
5. big silhouette
signs of what on CXR
signs of CHF on CXR
1. vascular congestion
2. cardiomegaly
3. pulm edema --> Kerley B lines
4. moose sign
5. big silhouette
70
CHF: name that type/classification
- which has evid of congestion
- Tx goal = lower intravascular vol w/loop diuretic
- give vasodilators (NTG, nitroprusside)
CHF: Wet and Warm (pulm edema)
- Evid of congestion
- Tx goal = lower intravascular vol w/loop diuretic
- give vasodilators (NTG, nitroprusside)
71
CHF: name that type/classification
- norm BP --> vasodilators
- reduced BP --> vasopressors/inotropcis
CHF: Wet and Cold (Cardiogenic shock)
- norm BP --> vasodilators
- reduced BP --> vasopressors/inotropcis
72
CHF: name that type/classification
- fluids
- may need mechanical supp or transplant
- could be most dangerous
CHF: dry and cold (hypovolemic shock)
- fluids
- may need mechanical supp or transplant
- could be most dangerous
