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Rotation 2: Adult Primary Care > Cardiovascular (15%) > Flashcards

Cardiovascular (15%) Flashcards

1
Q

AFib is described as an ______ ______ rhythm with (narrow/wide) QRS

A

Irregularly irregular

narrow

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2
Q

What will not be observed on a pt’s EKG with AFib?

A

P waves

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3
Q

What is the ventricular rate of a pt with AFib?

A

80-140 bpm, rarely >170

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4
Q

What is the most common chronic arrythmia?

A

AFib

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5
Q

Most patients with AFib are (asymptomatic/symptomatic)

A

Asymptomatic

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6
Q

In a pt with AFib, what sequela do we worry most about?

A

Thrombus formation, which can embolize and cause ischemic strokes

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7
Q

What is Ashman’s phenomenon?

What dz process is it associated with?

A

Occasional aberrantly conducted beats (wide QRS) after short R-R cycles

AFib

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8
Q

Is Afib more common in men or women? White or black patients?

A

Men

White

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9
Q

What are the 4 types of AFib?

Describe each.

A

Paroxysmal: self-terminating w/in 7 days (usually <24 hrs); ±Recurrent

Persistent: fails to self-terminate, lasts >7 days; Requires termination (medical or electrical)

Permanent: persistent AF >1 year (refractory to cardioversion or cardioversion never tried)

Lone: paroxysmal, persistent or permanent w/o evidence of heart dz

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10
Q

What is recommended tx for a pt with STABLE AFib?

Examples of medications?

A

Rate Control: preferred as initial managmenet in sx AFib pts over rhythm control

BB, CCB, Digoxin

Rhythm Control: Direct current (synchronized) cardioversion is preferred over Rx rhythm control {AFib present <48 hrs, after 3-4 wks of anticoag and TE echo w/o atrial thrombi}

Pharm rhythm control: Ibutilide, Flecainide, Sotalol, Amiodarone

Readiofrequency ablation, paermanent pacemaker

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11
Q

What is recommended tx for pts with UNSTABLE AFib?

A

Direct current (synchronized) cardioversion {DCC}

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12
Q

Is anticoagulation recommended for pts with AFib?

A

YES

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13
Q

What is the CHA2DS2-VASc score and why is it used?

A

Used for determining risk of embolization and need for anticoag

Congestive Heart Failure

Hypertension

A2ge >= 75 y/o

S2troke, TIA, thrombus

Vascular dz

Age 65-74 y/o

Sex (female)

  • Maximum score = 9*
  • >= 2: moderate-high risk, chronic oral anticoag recommended*
  • 1: low risk, anticoag sometimes recommended*
  • 0: very low risk, no anticoag needed*
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14
Q

What are some examples of Non vitamin K antagonist oral anticoagulants (NOAC)?

A

Dabigatran: direct thrombin inhibitor (binds to and inhibits thrombin)

Rivaroxaban, Apixaban, Edoxaban: Factor Xa inhibitors (selectively bind to antithrombin III)

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15
Q

What is the goal for INR in pts on Warafrin?

A

2-3

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16
Q

Is anticoagulant monotherapy or dual therapy superior?

A

monotherapy

Dual should be reserved for pts who cannot be treated with anticoagulation (for reasons OTHER than bleeding risk)

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17
Q

What medications can cause Long QT syndrome?

A

Macrolides

TCAs

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18
Q

What are some clinical manifestations in a pt with Long QT syndrome?

A

recurrent syncope, ventricular arryhtmias, and sudden cardiac death

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19
Q

What is the definitive management of congenital long QT syndrome?

A

Automatic implantable cardiodefibrilator (AICD)

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20
Q

_______ abnormalities may cause a pt to develop Long QT syndrome

A

Electrolyte

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21
Q

In a pt with paroxysmal aupraventricular tachycardia, their HR will be ______

They will have a (irregular/regular) rhythm with (narrow/wide) QRS complexes

____ waves are hard to discern d/t the rapid rate

A

>100 bpm

regular

narrow

P waves

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22
Q

What are the two main pathways of paroxysmal supraventricular tachycardia?

Which is MC?

Describe each.

A

AV Nodal Reentry Tachycardia (AVNRT): 2 pathways both w/in the AV node (slow and fast), MC

AV Reciprocating Tachycarida (AVRT): 1 pathway w/in the AV node and a 2nd accessory pathway OUTSIDE the AV node

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23
Q

What are two examples of AV Reciprocating Tachycaridas (AVRT)?

A

Wolff-Parkinson-White (WPW)

Lown-Ganong-Levine (LGL) Syndrome

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24
Q

What are the two types of conduction patterns that may be seen in a pt with paroxysmal supraventricular tachycardia?

Which is MC?

Describe each.

Which one leads to narrow vs wide complex tachycardia?

A

Orthodromic (95%): impulse goes nown the normal AV node pathway first and returns via the accessory pathway in circles, perpetuating the rhythm –> narrow complex tachycardia

Antidromic (5%): impulse goes down the accessory pathway first and returns to the atria via the normal pathway –> wide complex tachycardia (mimics ventricular tachycardia)

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25
Q

What is the 1st line tx for SVT?

Caution for use in pts with what comorbidity?

A

Adenosine

pts with asthma or COPD = may cause bronchospasm

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26
Q

For pts with Stable narrow complex PSVT, _______ maneuvers may help to decrease HR.

Explain the pathophysiology

A

Vagal maneuvers

vagus nerve stimulation releases acetylcholine which in turn decreases HR

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27
Q

AV Nodal blockers such as _____ or _____ may be used in pts with stable narrow complex PSVT

A

BB

CCB

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28
Q

What pharmacologic tx is recommended for pts with stable wide complex PSVT?

What if WPW is suspected?

A

Antiarrhythmics i.e. Amiodarone

Procainamide if WPW is suspected

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29
Q

If a pt has unstable PSVT, what is the recommended tx?

A

Direct current (synchronized) cardioversion

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30
Q

What is considered definitive managment for a pt with PSVT?

A

Radiofrequency ablation

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31
Q

What condition is described below:

Multiple ectopic atrial foci generate impulses that are conducted to the ventricles

What is the expected HR in a pt w/ this condition?

How many P wave morphologies?

A

Wandering atrial pacemaker

HR: <100 bpm

>= 3 P wave morphologies

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32
Q

Multifocal atrial tachycardia is considered to be the same as wandering atrial pacemaker, except for what?

What condition is MAT usually associated with?

MAT is difficult to tx, but what medications may be helpful?

A

HR > 100 bpm

Classically associated with severe COPD

CCB (Verapamil) or BB if LV fxn is preserved

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33
Q

___________ is a condition where there is an accessory pathway (bundle of Kent) that pre-excites the ventricles, leading to a slurred wide QRS

A

Wolff Parkinson White

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34
Q

What findings will be seen on EKG of a pt with WPW?

A

DELTA WAVES (slurred QRS upstrokes)

Wide QRS >0.12 seconds

Short PR interval

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35
Q

What is recommended tx for a pt with STABLE WPW?

What to avoid? Acronym to remember?

A

Vagal manuevers (valsalva, carotid massage if no carotid bruits present)

Antiarrhythmics (Class 1A: Procainamide preferred, Amiodarone, Flecainide, Ibutilide)

Avoid the use of AV nodal blockers, as this may lead to worsening of the tachyarrhythmia

_ABCD_ = _A_denosine, _B_eta Blockers, _C_alcium Channel Blockers, _D_igoxin

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36
Q

What is the recommended 1st line tx for a pt with UNSTABLE WPW?

A

Direct current (synchronized) cardioversion

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37
Q

What is the definitive management for a pt with WPW?

A

Radiofrequency ablation

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38
Q

Lown-Ganong-Levine Syndrome is characterized by a (short/long) PR interval with a (narrow/normal/wide) QRS complex

A

short PR interval

normal QRS complex

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39
Q

What node becomes the dominant pacemaker of the heart in AV junctional rhythms?

A

AV node ;)

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40
Q

The most common rhythm seen with digitalis toxicity and myocarditis is ______

A

AV junctional dysrhythmia

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41
Q

In an AV junctional dysrhythmia, the P waves are usually (negative/positive) in leads where they are normally (negative/positive), or are ______

A

negative (inverted)

positive (I, II, aVF)

absent

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42
Q

Junctional Rhythm: heart rate is usually ____-____ bpm (reflecting the intrinsic rate of the AV junction)

Accelerated Junctional: heart rate is ____-____bpm

Junctional Tachycardia: heart rate is _____ bpm

A

Junctional: 40-60 bpm

Accelerated Junctional: 60 - 100 bpm

Junctional Tachycardia: >100 bpm

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43
Q

(Ventricular/Atrial) dysrhythmias are frequently unpredictable, unstable and potentially lethal because stroke volume and coronary flow are compromised

A

Ventricular

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44
Q

Ventricular dysrhythmias are associated with (narrow/wide), _____ QRS complexes

A

wide

bizarre

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45
Q

With a premature ventricular contraction (PVC), the ____ wave is in the opposite direction of the QRS usually

A

T wave

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46
Q

Most ventricular arrythmias occur after a _____

A

PVC

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47
Q

What tx is recommended for PVCs?

A

no tx usually needed

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48
Q

What condition is described below?

a cardiac rhythm in which each normal beat is followed by an abnormal one

A

Ventricular bigeminy

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49
Q

Torsades De Pointes is most commonly due to ________, and _________.

Its appearance on EKG is often described as ….

A

Hypomagnesemia, hypokalemia

“Party streamer” (ventricular tachycardia that twists arounf baseline)

50
Q

Management for stable sustained VT?

Unstable VT with pulse?

VT (no pulse)?

Torsades de pointes?

A

Stable sustained VT: Antiarrhythmics (Amiodarone, Lidocaine, Procainamide)

Unstable VT w/ a pulse: Synchronized cardioversion

VT (no pulse): Defibrillation (unsynchronized cardioversion) + CPR (tx as VFib)

Torsades de pointes: IV Magnesium, correct electrolyte abnormalities

51
Q

Appearance of VFib on EKG?

What is the tx for VFib?

A

Coarse ventricular fibrillation

Unsynchronized cardioversion (defibrillation) + CPR

52
Q

Describe pulseless electrical activity and its management

A

Organized rhythm seen on a monitor but pt has no palpable pulse

Management: CPR + epinephrine + check for shockable rhythm every 2 minutes

53
Q

What is the tx for asytole?

What is the appearance on an EKG?

A

Same as PEA: CPR, epi, check for shockable rhythm every 2 minutes

54
Q

What is ischemia?

A

Inadequate tissue perfusion

55
Q

What is the most common cause of coronary artery disease?

A

Atherosclerosis

56
Q

What are possible etiologies of CAD?

A

Atherosclerosis (MC), coronary artery vasospasm, aortic stenosis, aortic regurgitation, pulmonary HTN, severe systemic HTN, hypertrophic cardiomyopathy

57
Q

What is the worst risk factor for CAD?

What is the most important modifiable risk factor for CAD?

What are other RF for CAD?

A

Worst: DM

Modifiable: Cigarette smoking

HLD, HTN, male, age, FHx, obesity, hyperhomocysteinemia, increased CRP

58
Q

What are the first step in the development of an atherosclerotic plaque?

A

Fatty streaks

lipid deposition in the WBCs which leads to smooth muscle proliferation

59
Q

Usually, ____% lumen reduction is when pts become symptomatic in CAD

A

>= 70%

60
Q

What are the 4 classes of angina pectoris?

Describe each.

A

I. Angina only with unusually strenuous activity, no limitations of activity

II. Angina with more prolonged or rigorous activity, slight limitation of physical activity

III. Angina with usual daily activity, marked limitation of physical activity

IV. Angina at rest, often unable to carry out any physical activity

61
Q

Describe the sx experienced by a pt with angina pectoris

(location, localization, exertional or nonexertional, duration, relieved with, precipitated by)

A

substernal CP that is poorly localized, non pleuritic, exertional

Readiation to the arm (esp. ulnar surfaces of the forearm and hand), teeth, lower jaw, back, epigastrium

usually short in duration (<30 min, typically 1-5 min)

Pain relieved with: rest of NTG (predictable pattern)

Pain precipitated by exertion/anxiety

62
Q

What is Levine’s sign and what condition is it associated with?

A

Clenched fist over chest

Angina pectoris

63
Q

What are three examples of anginal equivalents?

A

Dyspnea, Epigastric pain, Shoulder pain

instead of the classic chest pain

64
Q

During an episode of angina pectoris, a pt may have what signs/sx on PE?

A

Often normal, but may present with:

+/- S4 gallop

+/- signs of left ventricular failure (S3, pulmonary edema)

Evidence of HLD (xanthelasma)

65
Q

In the workup of a pt with angina pectoris, what should be initially performed?

After that?

What is considered gold standard?

A

ECG often initial test

Stress test after initial ECG

Angiography is gold standard

66
Q

What is the classic finding on ECG for a pt with angina pectoris?

A resting ECG will be normal in what % of pts with stable angina?

The presence of _______ hypertrophy is associated with increased adverse outcome.

A

ST depression (especially horizontal or downsloping)

Resting ECG is NORMAL in 50% of pts with stable angina

left ventricular hypertrophy

67
Q

What is the most noninvasive screening tool used in pts with angina pectoris?

What would be considered a positive result?

A

Stress testing

ST depressions, hypotension/hypertension, arrythmias and/or sx

68
Q

________ is used to localize regions of ischemia in a pt with baseline ECG abnormalities, and gives more information than an ECG

__________ are used in pts unable to tolerate exercise

These are contraindicated in patients who have ______

A

Myocardial Perfusion Imaging Stress

Pharmacologic agents (Adenosine or Dipyridamole)

Asthma

69
Q

A stress echocardiogram assesses (left/right) ventricular function, in conjunction with ____(drug)____, a positive inotrope/chronotrope that increases myocardial O2 demand and provokes ischemia

A

Left ventricular

Dobutamine

70
Q

A ________ is performed with dobutmaine infucion, can assess perfusion and wall motion abnormalities, and may be used as an alternative to a stress test

A

Cardiac MRI

71
Q

What are the two options for revascularization techniques for the definitive management of angina?

A

Percutaneous transluminal cornoary angioplasty (PTCA)

Coronary Artery Bypass Graft (CABG)

72
Q

What is the indication for undergoing PTCA?

Placement of what can reduce restenosis?

A

1 or 2 vessel disease not involving the left main coronary artery and in whom ventricular function is normal/near normal

Stents

73
Q

What medication combination is considered effective for prevention of coronary stent thrombosis?

A

ASA + Clopidogrel (Plavix)

74
Q

What are the indications for CABG?

A

left main coronary artery dz, symptomatic or critical stenotic (>70%) 3-vessel dz or decreased left ventricular EF <40%

75
Q

What are 4 examples of medications that can be used for the medical management of angina?

A

Medications that increase myocardial blood supply and decrease demand

NTG (oral, spray, patch)

BB (cardioselective: metoprolol, atenolol; nonselective: propranolol, nadolol)

CCB (nondihydropyridines: diltiazem, verapamil)

ASA

76
Q

What calss of medications is indicated for use in patients with prinzmetal angina?

A

Nondihydropyridine CCB (Diltiazem and Verapamil)

77
Q

What class of medications are 1st line for chronic management of angina?

A

BB

78
Q

NTG should not be used in patients with SBP <___mmHg, pts with ______ infarction, or if they are also taking medications such as ______

A

CI in: SBP <90 mmHg, RV infarction, Sildenafil (and other PDE-5 Inhibitors)

79
Q

What is the MOA of ASA?

A

Prevents platelet activation/aggregation by inhibiting cyclooxygenase

–> decreasing thromboxane A2 and inhibiting prostaglandins

80
Q

What is the classic pharmacologic outpatient regimen for patients with angina?

A

Daily ASA, SL NTG prn, daily BB and statin

81
Q

If a pt presents with c/o CP, what emergent conditions should be on your differential? (x6+)

What tests/labs/studies would be appropriate to order in a pt c/o CP?

A

MI

PE (CT Angiogram)

Esophageal rupture (CXR)

Tension PTX (CXR)

Aortic dissection (CT aorta w/ contrast)

Cardiac Tamponade

Orders: CXR, EKG, Cardiac Enzymes, CBC, CMP, Coags

82
Q

What is the most common cause of heart failure?

A

CAD

83
Q

_____ _____ is the inability of the heart to pump sufficient blood to meet the metabolic demands of the body at normal filling pressures

A

Heart Failure

84
Q

What are the most common causes of left sided heart failure?

A

CAD and HTN

other causes include valvular disease and cardiomyopathies

85
Q

What is the most common cause of right sided heart failure?

A

Left sided failure

Pulmonary dz (COPD, pulmonary HTN) mitral stenosis

86
Q

Is systolic or diastolic the more common form of heart failure?

A

Systolic

87
Q

Systolic heart failure is characterized by a (decreased/normal/increased) ejection fraction, a (S3/S4) gallop, and is commonly seen in pts post -_____, with _____, and _____.

A

decreased EF

+/- S3 gallop

post-MI, with dilated cardiomyopathy, and myocarditis

88
Q

Diastolic heart failure is characterized by a (decreased/normal/increased) ejection fraction, a (S3/S4) gallop, and is associated with a (small/normal/large) cardiac size, and is commonly seen in pts with _____, (left/right) ventricular hypertrophy, and in what population?

A

normal/increased EF

+/- S4 gallop = forced atrial contraction into a stiff ventricle

Normal cardiac size

HTN, left ventricular hypertrophy, in the elderly

89
Q

What is the difference between high and low output heart failure?

A

High output HF occurs when the metabolic demands of the body exceeds normal cardiac function (ex: thyrotoxicosis, wet beriberi, severe anemia, AV shunting, and Paget’s dz of the bone)

Low output HF is an inherent problem of myocardial contraction, ischemia, and chronic HTN

90
Q

Acute heart failure is largely (systolic/diastolic) and can occur during what three pathophysiological events?

A

Systolic

HTN crisis, acute MI, papillary muscle rupture

91
Q

Chronic heart failure is typically seen in patients with ______ cardiomyopathy or _____ dz

A

dilated cardiomyopathy or valvular dz

92
Q

Describe the NYHA functional classes of Heart Failure

A

Class I: No sx, no limitation during ordinary physical activity

Class II: Mild sx (dyspnea and/or angina), slight limitation during ordinary activity

Class III: Sx cause marked limitation in activity (even with minimal exertion) comfortable only at rest

Class IV: Sx even while at rest, severe limitations and inability to carry out physical activity

93
Q

Leading up to heart failure, the initial insult results in (decreased/increased) afterload, (decreased/increased) preload, and/or (decreased/increased) contractility.

The injured heart then tries to make short term compensations that over time promote CV deterioration–compensations include what three things?

A

Increased afterload

Increased preload and/or decreased contractility

Compensations include:

  1. Sympathetic NS activation
  2. Myocyte hypertrophy/remodeling
  3. RAAS activation(fluid overload, ventricular remodeling/hypertrophy leading to CHF)
94
Q

(Left/Right) sided heart failure leads to (decreased/increased) pulmonary venous pressure from fluid backing up into the lungs

A

Left

Increased

95
Q

(Left/Right) sided heart failure leads to (decreased/increased) systemic venous pressure, which leads to signs of systemic fluid retention

A

Right

Increased

96
Q

What are some classic clinical manifestations of Left sided heart failure?

A

Dyspnea (most common sx), orthopnea, paroxysmal nocturnal dyspnea

Pulmonary congestion/edema: rales, rhonchi, chronic nonproductive cough, pink frothy sputum, transudative pleural effusions

PE: HTN, Cheyne-stokes breathing (deeper, faster breathing with gradual decrese and periods of apnea), S3, S4, lateral displaced PMI

Increased adrenergic activation: dusky pale skin, diaphoresis, sinus tachycardia, cold extremities, AMS

97
Q

What are the classic signs and sx of a pt with right sided heart failure?

A

Peripheral edema

JVD

GI/hepatic congestion (anorexia, NV, RUQ TTP, hepatosplenomegaly, hepatojugular reflex)

98
Q

What is the most useful test to dx a pt with heart failure?

What is the most important determinant of prognosis in a pt with heart failure?

A

Most useful: Echocardiogram

Most important determinant of prognosis: Ejection fraction

Noraml EF: 55-60%

99
Q

What are the findings that will be seen on echo of a pt with systolic HF?

Diastolic HF?

A

Systolic HF: Decreased EF, thin ventricular walls, dilated LV chamber, (+) S3

Diastolic HF: Normal/Increased EF, thick ventricular walls, small LV chamber, (+) S4

100
Q

A CXR is especially useful in the dx of what type of heart failure?

What will be seen?

A

Congestive HF

Cephalization of flow, Kerley B lines, Butterfly pattern, Cardiomegaly infiltrates, pleural effusions, pulmonary edema

101
Q

Increased ______ may identify CHF as the cause for dyspnea in the ER

A

Increased B-type natriuretic peptide (BNP)

102
Q

What part of the heart releases BNP during volume overload?

A

Ventricles

103
Q

BNP of ______ is indicative of CHF

A

>100

104
Q

Initial management of HF is ______ and a ______ for sx

The best two drugs to decrease HF associated mortality are:

A

ACE-I and diuretic for sx

ACE-I > BB are the best two drugs for decreasing mortality

105
Q

What are the diet restrictions for a pt with HF?

A

Sodium restriction <2g/d

Fluid restriction <2L/day

exercise, smoking cessation

106
Q

What is the 1st line medication for tx of HF?

A

ACE-I

107
Q

What are some examples of medications that decrease afterload in patients with HF?

A

ACE-I (-pril)

ARB (-artan)

BB (-olol)

Hydralazine + Nitrates

108
Q

What are some examples of medications that decrease preload in patients with HF?

A

Loop Diuretics (Furosemide, Bumetanide, Torsemide) may cause hypOkalemia/calcemia/natremia

Potassium Sparing Diuretics (Spironolactone, Eplerenone) may cause hypERkalemia

HCTZ may cause hypOnatremia/kalemia

Metolazone may cause hypOnatremia/kalemia

109
Q

What are some examples of positive inotropic medications that can be used in the short term management of severe acute CHF?

A

Sympathomimetics (positive inotropes) –> Digoxin, Dobutamine, Dopamine

110
Q

________ is synthetic BNP and is only used in ER or inpatient settings for pts with HF

A

Nesiritide

decreases RAAS activity and increases Na+ excretion

111
Q

Medications that decrease mrotality in patients with HF include…

A

ACE-I

ARB

BB

Nitrates + Hydralazine

Spironolactone

112
Q

Which medication is not generally used in pts with systolic HF, except in angina with HF or normal HF?

A

CCB

113
Q

What is the outpatient regimen for HF?

A

ACE-I + Diuretic initially, then add BB; +/- hydralazine + NTG, Digoxin

114
Q

An implantable cardioverter defibrillator should be placed in patients with EF of what?

Why?

A

<35%

they tolerate arrythmias poorly

115
Q

What are two novel medications for systolic HF?

A

Ivabradine

Sacubitril-Valsartan (Entresto)

116
Q

What condition is described below?

Acute decompensated HF with worsening of baseline sx, pulmonary congestion (worsening of dyspne, rales, pink frothy sputum, etc)

A

CHF

117
Q

What are some examples of CXR findings in a pt with CHF?

A

Cephalization of flow –> Kerley B lines –> batwing/butterfly appearance –> pulmonary edema

Cephalization: increased vascular flow to the apices as a result of increased pulmonary venous pressure (pulmonary capillary wedge pressures of 12-18 mmHg; normal is 6-12 mmHg)

118
Q

In CHF, Kerley B lines will be present on CXR when the pulmonary capillary wedge pressure is between _____ mmHg

Butterfly (batwing) appearance will be present when the PCWP is _____ mmHg

A

Kerley B: 18-25 mmHg

Butterfly (batwing): >25 mmHg

119
Q

Management of acute pulmonary edema/CHF can be remembered with the acronym “LMNOP”, which stands for:

A

Lasix

Morphine

Nitrates

Oxygen

Position (place upright to decrease venous return)

120
Q

What is the recommended course of management for a pt with diastolic HF?

A

heart rate control, BP control, and relief of ischemis (BB, ACE-I, CCB), and diuretics for volume overload

121
Q
A
122
Q
A

Rotation 2: Adult Primary Care (14 decks)

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