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Cardiology Flashcards

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1
Q

when is using troponin not helpful and what should you use instead

A

during re-infarctions - use CK-MB instead

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2
Q

Acute Coronary Syndrome Tx =

A 
MONA BASH C 
m- morphine
o- oxygen 
n - nitrates - HOME (if continuous angina) 
a- aspirin - HOME 
b - beta blockers - HOME 
a- ace inhibitor - HOME
s- statins- HOME 
h- heparin - LMWH 
c- clopridogrel
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3
Q

For ACS tx what are protocols for clopridogrel

A
  • give if stent placed
  • if drug eluting stent - tx = 1 year
  • if metal stent - tx = 1 month
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4
Q

why are beta blockers important for ACS tx

A

prevent mortality in first 24 hrs due to ventricular arrythmias

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5
Q

when should TPA be given for ACS

A

when stents cannot be placed for >60 min

rural settings basically

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6
Q

what type of MI are nitrates contraindicated for

A

right sided - leads II, III, aVF with ST segment elevation - this is due the RV being pre load dependent and nitrates decrease preload

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7
Q

stable angina basics

A

due to fixed atherosclerotic lesions that narrow the major coronary arteries

occurs when O2 demand exceeds available blood supply

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8
Q

coronary ischemia due to

A

imbalance between blood supply and oxygen demand leading to inadequate perfusion

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9
Q

major risk factors for ischemic heart disease

A 
DM
HLD
HTN 
Smoking 
Age: men >45, women<55
FMHX of CAD men <55, women< 65
low levels of HDL
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10
Q

prognostic indicators of CAD

A

LV function - Ejection Fraction

<50% = increased mortality

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11
Q

vessels involved with severe ischemia

A

left main coronary artery - poor prognosis - due to covering 2/3 of heart

2 or 3 vessel CAD - worse prognosis

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12
Q

what is the LDL goal in a pt with CAD

A

<100mg/dL

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13
Q

typical anginal chest pain

A

substernal
worse with exertion
better with rest or NTG

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14
Q

metabolic syndrome X

A

combo of: HTN, hypercholesteremia, hypertrigyceridemia, imparied glucose tolerance, diabetes and hyperuricemia

key factor = insulin resistance (due to obesity)

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15
Q

syndrome X

A

exertional angina with normal coronary arteruigra

pts present with CP after exertion but have no coronary stenosis at catheritization

exercise test and nuclear imagin show evidence of MI
prognosis = excellent

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16
Q

Q Waves are consistent with

A

prior MI

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17
Q

if ST segment of T wave abnormalities are present during an episode of Chest pain –> tx =

A

treat as Unstable angina (USA)

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18
Q

how do you calculate a persons max HR

A

220 - age

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19
Q

what is the best initial test for all forms of CP

A

ECG

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20
Q

stress testing is used in what situations

A
  • to confirm dx of angina
  • to eval response of therapy in patients with documented CAD
  • to ID pts with CAD who may have high risk acute coronary events
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21
Q

what makes for a (+) stress test

A

if any of these occur during exercise

  • ST segment depression
  • CP
  • hypotension
  • significant arrhythmias
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22
Q

exercise induced ischemia results in

A

subendocardial ischemia, producing ST segment depression

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23
Q

pts with a (+) stress test –>

A

go to get cath

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24
Q

exercise induced ischemia is evidenced by

A

wall motion abnormalities

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25
stress echocardiography can detect
- can assess LV size and function - can dx valvular dz - can be used to ID CAD in the presence of pre-existing ECG abnormalities
26
pts with (+) stress echo -->
go to cardiac cath
27
types of stress test
exercise ECG --> ST segment depression exercise or dobutamine echocardiogram --> wall motion abnormalities exercise or dipyridamole perfusion study (thallium/technetium) --> decreased uptake of the nuclear isotope exercise)
28
areas of reversible ischemia may be rescued with
percutaneous coronary intervention or CABG
29
pharm stress test
IV adenosine, dipyridamole, or dobutamine - adenosine and dipyridamole - cause generalized coronary vasodilation - further worsening dz arteries - dobutamine - increased myocardial o2 demand by increasing HR, bp, and cardiac contractility
30
holter monitor uses
detecting silent ischemia (ECG changes not accompanied by symptoms) evaluating arrhythmiasm heart rate variability and assess pacemaker and implantable cardioverter-defribillator function evaluating unexplained syncope and dizziness - continuous monitoring 24-72hr
31
definitive test for CAD
coronary angiography
32
indications for cardiac catheterization
after + stress test acute MI with intent of performing angiogram and PCI pt with angina + noninvasive test are non dx angina that occurs despite medical therapy angina that occurs soon after MI any angina that is a dx dilemma for eval of valuvar dz and to determine need for sx intervention
33
most accurate method for identifying the presence and severity of CAD
coronary arteriography (angiography) standard test for delineating coronary anatomy
34
most accurate method of determining a specific cardiac dx
cardiac catheterization
35
main purpose of coronary arteriography
ID pts with sever coronary dz and to determine whether revascularization is needed
36
coronary stenosis > 70%
may be significant | can produce angina
37
on a arteriography what qualifies as severe and in need of revascularization
left main or three vessel dz
38
standard of care for stable angina
aspirin beta blocker (only ones that lower mortality) nitrates for CP
39
diet modifications for ischemic heart disease
reduce intake of saturated fats <7% | reduce cholesterol <200mg per day
40
side effects of nitrates
HA orthostatic Hypotension tolerance syncope
41
aspirin basics in CAD
indicated in all pts with CAD decrease morbidity reduces risk of MI
42
beta blockers basics in CAD
block sympathetic stimulation of heart reduce HR, BP, and contractility , Cardiac work reduce myocardial oxygen consumption reduce the frequency of coronary events
43
first line choices for beta blockers in CAD
atenolol and metoprolol
44
nitrates in CAD
cause generalized vasodilation | relieved angina - reduce preload myocardial oxygen demand - reduce LVEDV
45
calcium channel blockers in CAD
cause coronary vasodilation and afterload reduction reduces contractility secondary tx when beta blockers and nitrates not fully effective DO NOT DECREASE mortality
46
if CHF also present along with CAD tx with
ACE- I and/or diuretics
47
revascularization basics in CAD
DOES NOT reduce incidence of MI does result in significant improvement of symptoms
48
mild CAD disease
normal EF mild angina single vessel dz tx - aspirin, beta blockers and nitrates (+Ca channel blockers if symptoms dont improve)
49
moderate CAD disease
normal EF moderate angina two vessel dz tx - if nml regiment does work consider arteriography + PCI or CABG
50
severe CAD disease
decreased EF severe angina 3 vessel/ left main or left anterior descending dz tx - coronary angiography and possibly CABG
51
Percutaneous coronary intervention (PCI)
coronary angioplasty with ballon and stenting best used for proximal lesions
52
risk in PCI
higher frequency of revascularization procedures restenosis is a significant problem - however if it does not occur at 6 months your golden
53
CABG
standard of care for high risk dz main indicators: - 3 vessel dz with >70% stenosis in each vessel left main coronary dz with >50% dz - left ventricular dysfunction
54
unstable angina (USA) pathophysiology
oxygen demand is unchanged - supply is decreased secondary to reduced resting coronary flow indicates stenosis that has enlarged via thrombosis, hemorrhage, or plaque rupture --> may lead to total occlusion of a coronary vessel
55
example of pts with USA
- pt with chronic angina with increasing frequency, duration, or intensity of CP - pts with new onset angina that is severe and worsening - ts with angina at rest
56
what is the difference between USA and NSTEMI
NSTEMI - has elevated cardiac enzymes while USA does NOT
57
stress testing only detects flow limiting high grade lesions so even with a (+) stress test what can be missed
an MI can be missed due to an MI being an acute plaque rupture onto a moderate lesion
58
pts with USA have a higher risk of adverse events during a
stress test - they should be stabilized with medical management prior to performing one or undergo cardiac cath
59
tx of USA
admit MONA BASH C Clopidogrel for 2 days glycoprotein IIb/IIIa ihibitors (abciximab, tirofiban) - if pt undergoing stenting
60
DOC for the H in MONA BASH C
Low molecular weight heparin - specifically enoxaprin
61
variant angina | prinzmetal
transient coronary vasospasm that is usually accompanied by a fixed atherosclerotic lesion (but can occur in nml coronary ateries as well) - angina at rest and associated with ventricular dysrhythmias that can be life threating - angina classically occurs at night
62
hall mark of prinzmetal
transient ST segment elevation on ECG during CP which represents transmural ischemia
63
definitive test for prinzmetal
coronary angiography - displaying coronary vasospasm when pt given IV ergonovine or acetylcholine to provoke vasocosntriction
64
tx of prinzmetal
calcium channel blockers and nitrates and risk modification
65
MI is due to
necrosis of myocardium as a result of interruption of blood supply --> after thrombotic occlusion of coronary artery previously narrowed by atherosclerosis
66
most cases of MI are due to
acute coronary thrombosis - atheromatous plaque ruptures into vessel lumen and thrombus forms on top of this lesion --> vessel occlusion
67
Mortality rate of MI
30% and half of deaths are prehospital
68
clinical features of MI
intense substernal pressure (crushing elephant on chest) radiation to neck, jaw, arms, or back (left side) pain does not respond to NTG epigastric discomfort diaphoresis, dyspnea, weakness, fatigue, N/V, syncope can be asymptomatic in 1/3 - women, post op pts, elderly, diabetics
69
ECG markers of ischemia/infarction
Peaked T waves - occur very early ST segment elevation - transmural injury and can be dx of acute infarct Q waves - evidence of necrosis - late sign - old infarct T wave inversion ST segment depression - subendocardial injury
70
what comb of symptoms strongly indicates acute MI
substernal CP persisting longer than 30 min | diaphoresis
71
presentation of a RV infarct
``` inferior ECG changes hypotension elevated jugular venous pressure hepatomegaly clear lungs ```
72
what is contraindcated in RV infarct
nitrates or diuretics as will cause cardiovascular collapse due to RV being preload dependent
73
anterior infarct ECG changes
ST segment elevation in V1-V4 (acute/active) Q waves in leads V1-V4 (late changes)
74
posterior infarct ECG changes
large R waves in V1 and V2 ST segment depression in V1 and V2 upright and prominent T waves in V1 and V2
75
lateral infarct ECG changes
Q waves in leads I and aVL (late change)
76
inferior infarct ECG changes
Q waves in leads II, III and aVF (late change)
77
ST segment elevation infarct indicates
transmural - involves entire thickness of wall tends to be larger
78
Non ST segment elevation infarct indicates
subendocardial - involves inner 1/3 to 1/2 of the wall - tends to be smaller
79
CHF pt with EF <35% and not Class IV tx = ?
AICD to prevent sudden cardiac death
80
tx of CHF exacerbation
``` LMNOP L - lasix M - morphine N - nitrates O - oxygen P- position ```
81
gold standard for myocardial injury test
cardiac enzymes
82
troponin (trop I and T)
increases within 3-5hrs peaks at 24hrs returns to normal 5-14 days must do serial troponins every 8hrs for 24hrs
83
how can Troponin I be falsely elevated
in renal failures pts
84
CK-MB
increases within 4 to 8hrs reaches peak at 24hrs returns to normal 48-72hrs - thus making it more helpful in detecting recurrent infarction
85
the higher the peak and the longer the enzyme levels
the more severe the myocardial injury and the worse the prognosis
86
In MI what drugs are shown to reduce mortality
aspirin beta blocker ace inhibitors
87
a high frequency of PVCs may predict
VFIB | VT
88
HTN affects on afterload
increases afterload and thus oxygen demand
89
tx of an MI patient
``` admit aspirin beta blockers ace i statins oxygen nitrates morphine sulfate heparin revascularization ```
90
aspirin basics for MI
- antiplatelet agent reduces coronary reocclusion by inhibiting platelet aggregation on top of the thrombus has been shown to reduce mortality
91
beta blocker basics for MI
block stimulation of HR and contractility to reduce oxygen demand and decrease the incidence of arrhythmias reduce remodeling of the myocardium post MI reduce mortality
92
ace inhibitor basics for MI
initiate within hours of hospitlization reduce mortality
93
statins basics for MI
reduce the risk of further coronary events stabilize plaques and lower cholesterol
94
statin of choice for MI patients
atorvastatin 80mg
95
revascularization benefit is highest when
performed <90min of pts arrival
96
urgent CABGs are performed when
mechanical complications of acute MI cardiogenic shock life threatening ventricular arrhythmias failure of PCI
97
thrombolytic therapy for MI
outcome is best if given within 6hrs indications: ST segment elevation in 2 contiguous ECG leads - in pts with pain onset <6hrs who have been refractory to NTG
98
thrombolytic of choice for MI
alteplase alternatives - streptokinase, tenecteplase, reteplase, lanotelplase and urokinase
99
absolute contraindications to thrombolytic therapy
``` trauma previous stroke recent invasive procedure or surgery dissecting aortic aneurysm active bleeding or bleeding diathesis ```
100
papillary muscle infarction/ ischemia leads to
mitral regurgitation - pt presents with new murmur tx - emergent surgery - with valve replacement + afterload reduction with sodium nitroprusside or intra-aortic ballon pump
101
pts who suffer an acute MI have a high risk of what developing
stroke for the next 5 years the lower the EF and the older the pt the higher the risk of stroke
102
complications of acute MI
pump failure = CHF - mc cause of in hospital mortality - tx if mild ace-i and diuretic arrhythmias - PVCs - tx - obs - Afib - VT - tx - if stable - IV amiodarone - if unstable = electrical cardioversion - V fib - immeidate unsynchronized defib and CPR - sinus tach - worsens ischemia - av block - if 1st degree or 2nd degree type I = no tx - but if 2nd deg type II or 3rd degree pacemaker is indicated and IV atropine initially
103
what arrhythmia is a common occurance in the early stages of an acute MI
sinus bradycardia - especially right sided/ inferior MIs may be protective - reduces myocardial oxygen demand - tx - if symptomatic = atropine
104
if asystole is clearly the cause of an arrest s/p acute MI tx =
transcutaneous pacing - however mortality is very high
105
if there is repeat ST segment elevation on ECG within the first 24 hrs after infarction suspect
suspect recurrent infarction
106
mechanical complications of an acute MI
free wall rupture - occurs during 1st 2 weeks post MI - mc 1-4 days s/p MI --> leads to hemopericardium and cardiac tamponade rupture of interventricular septum - within 10 days of MI papillary muscle rupture ventricular pseudoaneurysm - seen by bedside echo ventricular aneursym acute pericarditis dressler syndrome
107
tx of free wall rupture s/p acute MI
usually fatal hemodynamic stabilization immediate pericardiocentesis surgical repair
108
MC cause of death in first few days after MI
is ventricular arrhythmia (VTach or VFib)
109
acute pericarditis s/p MI - tx
aspirin NSAIDs, corticosteroids are contraindicated (may hinder myocardial scar formation)
110
dressler syndrome s/p MI
immuno based syndrome - fever, malaise, pericarditis, leukocytosis, and pleuritis occurring weeks to months after MI tx = aspirin (1st line) and IBU 2nd line
111
the most common cause of noncardiac chest pain in the ED
GI disorders
112
if NTG relieves the pain then
a cardiac cause is more likely (although esophageal spasm) is still a possibility
113
cardiac cause of the pain is highly unlikely if what symptoms appear
if CP changes with respiration (pleuritic) or if there is tenderness of chest wall
114
CHF overview definition
results from the hearts inability to meet the body's circulatory demands under nml physiologic conditions often both systolic and diastolic dysfunction
115
pathophys of CHF - frank sterling relationship
in nml heart incresing preload -> increase contractility when preload is low (rest) - there is little difference between nml and failing heart but --> with exertion a failing heart produces relatively less contractility and symptoms occur
116
systolic dysfunction
impaired contractility - decreased EF | heart is too flabby to squeeze blood out
117
causes of systolic dysfunction
``` ischemic heart dz recent MI HTN - cardiomyopathy valvular dz myocarditis (post viral) ```
118
diastolic dysfunction
impaired ventricular filling during diastole impaired relaxation or increased stiffness of ventricle or both heart is too thick = no space for blood to fill
119
echo of a heart with diastolic dysfunction will show
impaired relaxation of LV
120
in high output HF an increase in cardiac output is needed for
the requirements of peripheral tissues for oxygen
121
causes of high output HF
``` chronic anemia pregnancy hyperthyroidism AV fistulas Wet beriberi paget dz of bone Mitral regurg aortic insufficiency ```
122
causes of diastolic dysfunction
MCC = HTN leading to myocardial hypertrophy valvular dz - aortic stenosis, mitral stenosis, and aortic regurg restrictive cardiomyopathy - amyloidosis, sarcoidosis, hemochromatosis
123
symptoms of left sided heart failure
dyspnea - secondary to pulm congestion/edema orthopnea - stack pillows for relief paroxysmal nocturnal dyspnea - awake 1-2hrs after sleep due to SOB nocturnal cough confusion and memory impairment - inadequate brain perfusion diaphoresis and cool extremities at rest
124
signs of left sided HF on exam
displaced PMI - due to cardiomegaly ``` pathologic S3(ventricular gallop) - rapid filling S4 gallop - stiff LV ``` crackles/rales dullness to percussion decreased tactile fremitus
125
NYHA classification of heart failure
I - symptoms only with vigorous activity II - symptoms with prolonged or mod exercise - slightly limiting III - symptoms with usual daily activities extremely limiting IV - symptoms occur at rest
126
symptoms /signs of Right sided HF
``` peripheral pitting edema nocturia - due to increased venous return JVD hepatomegaly/heptojuglar reflex ascites right ventricular heave ```
127
Pathologic S3
rapid filling phase into noncompliant LV chamber (LV failure) nml in kids - pathologic in adults heard best at apex with bell of stethoscope S3 follow S2 (kentucky noise) low freq diastolic sound tx - diuretics for symptomatic relief
128
S4 gallop
atrial systole as blood is ejected into a noncompliant or stiff LV chamber heard best at left sternal border withbell of stethoscope S4 precedes S1 (tennesse sound)
129
pathophys behind crackles/rales seen in CHF
caused by fluid spilling into alveoli indicating pulmonary edema rales heard over lung bases suggest at least moderate severity of LV HF
130
what is the cause of the dullness to percussion and decreased tactile fremitus seen in pts with HF
pleural effusion
131
what tests do you want in a new pt with CHF
CXR - pulm edema, cardiomegaly, r/o COPD ECG + cardiac enzymes - r/o MI CBC - anemia Echo- estimate EF, r/o pericardial effusion
132
normal pulse pressure pulse pressure change seen in CHF
nml = 30-50 (systolic - diastolic) CHF < 30
133
Murmur chart
``` S D ------------------------------ A - S / A - R P - S . / P - R T - R . / T - S M - R / M - S ```
134
grades of murmurs | what needs a workup
``` I - S1S2 > Murmur II - S1S1 = murmur -------------------------- III - S1S2 < Murmur IV - palpable thrill V - almost 6 - stethoscope half off chest VI - hear without stethoscope ``` below line need workup = echo and any diastolic murmur
135
mitral stenosis basics
blood backs up in LA -> LA dilation -> blood in lungs path - Rheumatic heart disease - young pt 20-30s atrial stretch --> possible A FIb
136
mitral stenosis auscultation =
diastolic murmur - best heard at cardiac apex - 5th ICS MCL | opening snap followed by low pitched diastolic rumble
137
aortic insufficiency (regurgitation) basics
weak floppy valve -> blood backs up into LV --> dilated floppy heart path - infection or infarction, aortic dissection head bobbing, uvula bobs widened pulse pressure tx - medical emergency - replace valve
138
acute and chronic presentation of aortic insufficiency (regurgitation)
acute - cardiogenic shock, flash pulmonary edema, tearing chest pain (if aortic dissection) radiating to back chronic - CHF and CP
139
auscultation of aortic insufficiency (regurgitation)
diastolic murmur - best heard at base of heart - 2nd ICS right sternal border pistol shots heard over the femoral arteries
140
aortic stenosis basics
stiff valve --> little blood gets through --> LV dilates -> big loose floppy heart --> HF symptoms path - atherosclerosis, calcium deposits bicuspid valve - speeds up stenosis
141
presentation of aortic stenosis patient
old man with atherosclerosis | CP, HF symptoms, syncope
142
auscultation of aortic stenosis
systolic murmur - best heard at the base of the heart right sternal border a crescendo decresendo murmur that radiates to carotid arteries aorit S4 diminished and delayed carotid upstrokes
143
mitral insufficiency basics
leaflets dont come together -> increased pressure in LA --> blood backs up into lungs -> left atrial sketch -> afib + CHF symptoms endocarditis - staph, papillary rupture s/p MI, Rheumatifc fever
144
mitral insufficiency presentation acute vs chronic
acute - cardiogenic shock, flash pulmonary edema, Chronic - CHF, afib
145
mitral insufficiency auscultation
holostyolic murmur - high pitched blowing murmur best heard at apex 5th ICS MCL
146
MS, MR , AS, AR what worsens these murmurs what improves these murmurs
increasing venous return - squatting, leg lifting - worsens murmur decreasing venous return - valsalva maneuver - improves murmur
147
hypertrophic cardiomyopathy murmur (HCOM) basics
unilateral septum hypetrophy -> covers the aortic opening -> left ventricular outflow obstruction
148
pt with HCOM
ppl with sarcomere mutations young athlete with sudden death or SOB or Syncope with exertion FMHX is signficant
149
auscultation of HCOM
sounds like AS (systolic murmur) but more blood improves the murmur opposite of AS
150
tx of HCOM
avoid dehydration beta blockade maintain preload no exercise
151
mitral valve prolapse basics
leaflets too big donnt touch well due to excessive or. redundant mitral leaflet tissue due to myxomatous degeneration of leaflets and/or chordae tedineae congenital young women, pregnant women
152
auscultation of mitral valve prolapse
murmur gets better with more blood - mitral regurg but better with more blood midsystolic or late systolic click mid to late systolic murmur
153
tx of mitral valve prolapse
avoid dehydration | beta blockade
154
tx of NYHA classifications
``` I = ace-I + beta blocker II = ^^ + diuretics (furosemide, bumetanide) III = ^^ + spironolactone or hydralazine and isosorbide dinitrate (BiDil) IV = ^^ + LVAD, transplant ```
155
initial test of choice for CHF
``` echocardiogram - determines whether systolic or diastolic - determines the cause - estimates EF shows chamber dilation/hypertrophy ```
156
BNP
released from the ventricles in response to ventricular volume expansion and pressure overload useful for differentiating between dyspnea caused by CHF and COPD
157
BNP levels >150 a NT pro-BNP <300
correlate strongly with the presence of decompensated CHF virtually excludes a dx of HF
158
what is a common cause of CHF that can be treated by reducing preload and afterload
HTN
159
systolic dysfunction HF - tx =
sodium restriction <4g/ fluid restriction 1.5 to 2.0 L weight loss/smoking cess/exercise ``` diuretics spironolactone ace -i beta blockers digitalis hydralazine ```
160
role of diuretics in HF tx
most effective means of providing symptomatic relief | DONT REDUCE MORTALITY
161
diuretic of choice for HF
loop diuretics - furosemide - most potent thiazides - hydrochlorothiazide - modest potency
162
role of spironolactone in HF tx
(aldosterone antagonist) PROLONG SURVIVAL effective only in advanced stages of HF - III and IV monitor K+ and renal function
163
what is an alternative to spironolactone that does not cause gynecomastia
eplerenone
164
role of ACE-I in HF tx
cause venous and arterial dilation ---> decreased preload and decreased afterload REDUCE MORTALITY prolong survival and alleviate symptoms in all grades of CHF
165
what is a contraindication for spironolactone in the tx of patients with HF
renal failure
166
what combo is the initial tx for HF patients who are symptomatic
diuretics (loop) and ACE- I (prils) standard also includes beta blocker
167
what is an indication for the use of ACE-I in HF
LV systolic dysfunction with EF <40%
168
why do you always start pts with a low dose on ACE-I
to prevent hypotension
169
if patients have a persistent cough while on ACE-I what med do you switch to
ARBS - angiotensin II receptor blockers (artans)
170
what signs are you monitoring in a pt with CHF
weight - unexplained weight gain can be an early sign of worsening CHF peripheral edema electrolytes, K, BUN, dig levels
171
MCC of death from CHF =
sudden death from ventricular arrhythmias ischemia -> provokes ventricular arrhythmias
172
role of beta blockers in tx of CHF
DECREASE MORTALITY in pts with post MI HF slow the progression by slowing down tissue remodeling
173
beta blocker of choice for HF
carvedilol
174
digatlis
+ inotropic agent useful in pts with EF <40%, severe CHF, AFib short term relief - no change to mortality serum digoxin levels should be checked periodically
175
role hydralazine and isosorbide dinitrates play in CHF tx
used in pts who dont tolerate ACE-I COMBO IMPROVES MORTALITY in African americans with CHF
176
what meds are contraindicated in CHF
metformin - potentially lethal lactic acidosis thiazolidinediones - fluid retention NSAIDs - increase risk of CHF exacerbation
177
role of an ICD in CHF tx
LOWERS MORTALITY - prevents sudden death cardiac death indicated for pts - >40 days post MI with EF <35% and class II or III CHF not controlled
178
cardiac resynchronization therapy role in CHF tx
biventricular pacemaker indications > 40 days post MI with EF <35% class II or III CHF not controlled + prolonged QRS >120msec
179
diastolic dysfunction HF tx
NO MEDS DECREASE MORTALITY beta blockers diuretics DIGOXIN AND SPRIONOLACTONE SHOULD NOT BE USED
180
signs of digoxin toxicity
GI - N/V and anorexia Cardiac - ectopic (ventricular) beats, AV block, A Fib CNS - visual disturbances, disorientation
181
Calcium channel blockers (CCB) role in CHF tx
no role -may increase mortality BUT amlodipine and felodipine are safe to use in CHF (if another indication like HTN exists that needs controlling)
182
what is the overall 5 year mortality rate of CHF
50%
183
tx of class I and II HF (mild)
mild restriction of sodium intake and physical activity start loop diuretic if volume overload or pulmonary congestion is present use an ACE-I as first line agent
184
tx of class II and III HF (moderate)
start a diuretic (loop) and ACE-I (pril) add a beta blocker if mod dz is present and the response of nml tx is suboptimal
185
tx of class III and IV HF (mod -severe)
add digoxin (to loop and ACE-I) in pts with class IV symptoms who are still symptomatic despite above tx - add Spironolactone
186
ventricular assist device (VAD) role in CHF tx
used to support LV and RV or both pump is implanted in the abdominal cavity with cannulation to the hart system controller and battery worn externally lifelong anticoagulation with heparin or warfarin is required without exceptions due to the devices being so thrombogenic
187
acute decompensated HF signs and causes
acute dyspnea - elevated left sided filing pressure with or without pulmonary edema MC - due to lV systolic or diastolic dysfunction flash pulmonary edema - severe form of HF with rapid accumulation of fluid in the lungs
188
tx of acute compensated HF
oxygenation and ventilatory assistance with nonrebreather face mask, NPPV, or intubation diuretics to tx volume overload and congestive symptoms (MOST IMPORTANT) ^^^ nitrates
189
pts in acute compensated HF with pulmonary edema despite use of oxygen and diuretics and nitrates may benefit from what tx
dobutamine (inotropic agent) -works much quicker then digoxin which takes weeks
190
premature atrial complexes
early beat arises within atria firing on its own early P waves that differ morphology nml QRS may be a precursor of ischemia in a diseased heart
191
causes and tx of symptomatic premature atrial complexes
causes: adernergic excess, drugs, alcohol, tobacco, electrolyte imbalances, ischemia and infection tx if symptomatic = beta blockers
192
premature ventricular complexes
early beat fires on its own from ventricle then spreads to other ventricle since conduction is not going thru nml pathways but thru ventricular muscle = slower than nml --> WIDE QRS complex that is bizarre with compensatory pause buried P wave presence in nml hearts - associated with increased mortality
193
PVCs causes and tx
can occur in pts with and without structural heart disease causes: hypoxia, electrolyte abnormalities, stimulants, caffeine, meds, structural heart dz tx - beta blockers if symptomatic - dizziness, palpitations
194
pts with frequent, repetitive PVCs and underlying heart disease are at increased risk for
sudden death due to VFib
195
the use of antiarrhythmic drugs to suppress PVCs after MIs increases
the risk of death
196
PVCs couplet bigeminy trigeminy
couplet - 2 successive PVCs bigeminy - sinus beat followed by a PVC trigeminy - 2 sinus beats followed by a PVC
197
atrial fibrillation pathophys
multiple foci in the atria fire continously in a chaotic pattern - totally irregular, rapid ventricular rate atrial rate >400 bpm but most of these impulses are blocked at the AV node so ventricular rate = 75-175
198
pts with AFib and underlying heart disease are at increased risk for
thromboembolism | hemodynamic compromise
199
causes of AFib
``` heart dz - CAD, MI, HTN, surgery pericarditis and pericardial trauma pulm dz - PE hyperthyroidism or hypothyroidism systemic illness stress excessive alcohol intake sick sinus syndrome pheochromocytoma ```
200
clinical features of afib
fatigue and exertional dyspnea palpitations, dizziness, angina syncope irregularly irregular pulse blood stasis
201
blood stasis mechanism in afib
- secondary to ineffective contraction - leads to formation of intramural thrombi which can embolize to the brain
202
dilated cardiomyopathy
chambers are dilated - thin walled - floppy little actin and myosin overlap - decreased contractiliy problem pumping so systolic HF
203
some causes of dilated cardiomyopathy
viruses wet beriberi alcohol ischemia
204
hypertrophic cardiomyopathy (HCM)
asymmetric septal wall thickening -> left ventricle outlet obstruction -> covers aortic opening genetic mutation in sarcomeres
205
presentation of HCM
young athlete syncope, SOB, sudden death murmur sounds like AS but gets better with increased venous return
206
tx of HCM
etoh ablation - for poor surgical candidates myectomy - remove obstruction in muscle ACID for pts with increased risk of death (prior ventricular arrhythmias)
207
concentric hypertrophy cardiomyopathy
diastolic HF | filling problem
208
causes of restrictive cardiomyopathy
sarcoidosis amyloid hemachromatosis cancer and fibrosis
209
sarcoidosis in cardiomyopathy
- echo = patchy all over - pt with pulmonary disease - african american Dx - cardiac MRI --> endomyocardial biopsy tx - glucocorticoids
210
amyloidosis in cardiomyopathy
echo - bright and speckled pattern peripheral neuropathy fat pad biopsy (gingival biopsy)
211
hemachromatosis in cardiomyopathy
cirrhosis and bronze diabetes screen with ferritin which will be elevated --> genetic testing tx - phlebotomy or deferoxamine
212
definitive tx for cardiomyopathy
transplant
213
causes of pericardial dz
infections - virus (coxsackie) bacteria (staph/strep), fungal, TB autoimmune - RA, lupus, dressler, Uremia penetrating trauma > blunt trauma aortic dissection cancer - breast, lung, esophageal, lymphoma
214
pericarditis
viral, urimia CP, pleuritic, positional (leaning forward better, leaning back worse)
215
dx of pericarditis
ECG - diffuse ST segment elevation everywhere | and depressed PR segment is key
216
tx of pericarditis
NSAIDs and Colchicine - best no NSAIDs if - CKD, thrombocytopenia, peptic ulcer dz no colchicine if - dose limiting due to diarrhea steroids - worst due to increasing the recurrence of pericarditis (especially viral)
217
tx of pericarditis if the cause is uremia
dialize - diaylsis is curative
218
dx test of choice for pericardial effusion
echo - see the fluid
219
tx of pericardial effusion if refractory
pericardial window - allowing fluid to drain into a body cavity to be absorbed
220
presentation of pericardial tamponade
CHF symptoms - specifically Right sided HF --> becks triad - hypotension, JVD, decreased heart sounds pulsus paradoxus >10mmHg clear lungs
221
tx of pericardial tamponade
pericardiocentesis - if cant be done right away then IVF to increase BP temporarily
222
constrictive pericarditis
recurrent pericarditis --> scaring forming a rigid box as the heart expands in diastole --> pericardial knock is heard diastolic CHF presentation
223
dx test of choice for constrictive pericarditis and tx
dx - echo tx - pericardiectomy - remove rigid portion
224
dx of afib
ECG - irregularly irregular rhythm - irregular RR intervals NO P WAVES
225
tx of afib
if hemodynamically unstable --> immediate electrical cardioversion if stable --> rate control (60-100) beta blockers or CCBs --> - if <48hrs --> cardioversion - if >48 hours --> either TEE or anticoagulate for 3wks --> cardioversion
226
cardioversion basics
delivery of shock that is in synchrony with QRS complex terminates certain dysrhythmias - PSVT or VT
227
an electric shock during a T wave can cause
V fib
228
indications for cardioversion
afib atrial flutter VT with plse SVT
229
defibrillation basics
delivery of shock that is not in synchrony with QRS complex purpose is to convert a dysrhythmia to a normal sinus rhythm
230
indications for defribillation
vfib | VT without a pulse
231
indications for automatic implantable defribillator
vfib | VT that is not controlled by medical therapy
232
in afib if LV systolic dysfunction is present what should you consider adding to the tx regiment
digoxin or amiodarone
233
candidates for cardioversion in afib
hemodynamically unstable those with worsening symptoms those having first ever case of afib
234
if pharmacologic cardioversion is going to happen for afib what drugs do you use
``` parenteral ibutilide procainamide flecainide sotalol amiodarone ```
235
anticoagulation in afib pts
prevents embolic CVA if >48hrs risk for embolization = 2-5% anticoagulate pts 3wks before and 4wks after INR of 2-3 is goal
236
how to avoid anticoagulating 3wks before cardioversion
TEE - transesophageal echocardiogram - images LA if no thrombus --> start IV heparin and perform cardioversion within 24hrs then 4wks of anticoagulation
237
chronic afib anticoagulation
>60 tx with warfarin risk is increased in pts with heart dz as well
238
in afib what is superior rate or rhythm control
rate control
239
aflutter pathophys
one irritable automaticity focus in atria fires 250-350bpm --> the longer refractory period in the AV node allows only 1/2 1/3 flutter waves to conduct to the ventricles
240
causes of atrial flutter
heart failure (MC association) RHD CAD COPD
241
atrial flutter ECG
saw tooth baseline with a QRS after every 2nd or 3rd tooh best seen in inferior leads - II, III, and aVF
242
multifocal atrial tachycardia
occurs in COPD pts | ecg - variable p wave morphology at least 3 different types of P waves
243
tx of multifocal atrial tachcardia
if LV function is not preserved use digoxin diltiazem or amiodarone if LV function is preserved - CCB, beta blockers, digoxin amiodarone, IV flecainide and IV propafenone
244
paroxysmal supraventricular tachycardia pathophys
most often due to reentry two pathways within AV node one fast one slow so the reentrant circuit is within the AV node initiated or terminated by PACs
245
most common cause of SVT
PSVT
246
ECG of PSVT
narrow QRS complexes with no discernible P waves since they are buried in QRS complexes
247
causes of PSVT
ischemic heart disease digoxin toxicity - most common arrhythmia associated with digoxin toxicity
248
narrow QRS complexes suggest that the arrhythmia originates
at or above the level of the AV node
249
wide QRS complexes suggest that the arrhythmia originates
outside of the normal conducting system or there is a supraventricular arrhythmia with coexisting abnormality in the HIS-purkinje system
250
side effects of adenosine
``` HA flushing SOB chest pressure nausea ```
251
tx of PSVT (nonpharm)
maneuvers that stimulate the vagus delay AV conduction and thus block the reentry mechanism - valsalva manuever, carotid massage, breath holding, head immersion in cold water (ice bag to face)
252
acute tx of PSVT (pharm)
IV adenosine - DOC - short duration of action and effectivess in terminating SVTs IV verapamil (CCB) and IV esmolol (BB) or digoxin are alternatives for pts with preserved LV function
253
prevention of PVST
verapamil or beta blockers radiofrequency catheter ablation of either AV node or accessory tract
254
wolf parkinson white syndrome pathophys
accessory conduction pathway from atria to ventricle through the bundle of kent --> causes premature ventricular excitation because it lacks the delay seen in the AV node
255
wolf parkinson white syndrome may lead to
paroxysmal tachycardia
256
dx of wolf parkinson white
ecg - delta wave (upward deflection seen before QRS complex) narrow complex tachycardia short PR interval
257
tx of wolf parkinson white syndrome
radiofrequency catheter ablation of one arm of the reentrant loop procainamide or quinidine
258
what drugs should you avoid in wolf parkinson white syndrome
drugs that are active on AV node (digoxin, verapamil, beta blockers) --> they accelerate conduction through the accessory pathway
259
ventricular tachycardia
rapid and repetitive firing of 3 or more PVCs in a row at a rate of 100-250bpm originate below bundle of HIS
260
causes of VTach
``` CAD with prior MI = MCC active ischemia, hypotension cardiomyopathies congenital defects prolonged QT ```
261
sustained Vtach
>30seconds always symptomatic associated with hemodynamic compromise life threatening can progress to vfib
262
nonsustained vtach
brief self limited runs of vtach asymptomatic when CAD and LV dysfunction are present - risk factor for sudden death
263
VTach after an MI
poor prognosis especially if it is sustained
264
what cause 75% of cardiac arrests
vfib | Vtach
265
torsades de pointes
rapid polymorphic Vtach can lead to afib associated with factors that prolong QT interval tx - IV magnesium
266
clinical features of Vtach
palpitations, lightheadedness, dyspnea sudden cardiac death cardiogenic shock cannon A waves in neck
267
dx of vtach
wide and bizarre QRS complexes monomorphic or polymorphic does NOT respond to vagal maneuvers or adenosine
268
the presence of VT or PVCs in pts with underlying heart dz and LV dysfunction are at high risk for
risk for sudden death
269
pt with wide (>0.12) QRS tachycardia suspect
VTach
270
tx of sustained vtach
hemodynamically stable pts - IV amiodarone, IV procainamide or IV sotalol unstable pts - immediate synchronous DC cardioversion followed bby IV amiodarone ICD (unless EF = nml)
271
tx of unstained vtach
no underlying heart dz - dont tx if underlying heart dz - ICD placement pharm therapy = 2nd line - amiodarone
272
wide complex tachycardia in adults with hx of structural heart dz is much more likely to be due to
Vtach than SVT
273
cardiac arrest definition
sudden loss of output potentially reversible if circulation and oxygen delivery are promptly restored
274
sudden cardiac death definition
unexpected death within 1hr of symptom onset secondary to cardiac cause
275
narrow complex tachycardias originate
above ventricles
276
wide complex tachycardias originate
within ventricles and are more ominous because they are more likely to progress to vfib
277
vfib basics
multiple foci in ventricles fire rapidly leading to chaotic quivering of the ventricles and no cardiac output most episodes begin with vtach except acute ischemia
278
if vfib develops ,48hrs of an acute MI
long term prognosis is favorable and recurrence rate is low
279
causes of vfib
ischemic heart dz = mcc antiarrhythmic drugs - especially those that cause torsades de pointes afib with very rapid ventricular rates in pts with wolf parkinson white syndrome
280
clinical features of afib
cannon measure bp | absent heart sounds and pulse
281
dx of vfib
ecg - no atrial p waves, no QRS complexes
282
tx of vfib
medical emergency - immediate defribillation and CPR give up to 3 sequential shocks if persists --> CPR - intubate - epi 1mg every 3-5 min (decreases defribillation threshold by increasing myocardial and cerebral blood flow IV amiodarone followed by shocks if cardioversion is successful maintain IV infusion of effective agent - typically amiodarone
283
sinus bradycardia
Clinically significant <45 caused: ischemia, increased vagal tone
284
tx of sinus bradycardia
atropine - elevates sinus rate by blocking vagal stimulation to the Sinoatrial node
285
sick sinus syndrome
sinus node dysfunction characterized by persistent spontaneous sinus bradycardia elerly, dizzy, confused, syncope, fatigue, CHF
286
defribrillation and asystole
doesnt really work epi and CPR
287
pulseless electrical activity (PEA)
electrical activity on the monitor but no pulses even with doppler grim prognosis
288
first degree AV block
PR interval is prolonged (>0.20sec) a QRS follows each P wave no tx
289
second degree AV block type I (wenckebach)
progressive prolongation of PR interval until a P wave fails to conduct (qrs dropped) no tx
290
second degree AV block type II
P wave fails to conduct suddenly without preceding PR interval prolongation QRS just drops suddenly often progresses to complete heart block site block is in His-purkinje system tx - pacemaker
291
third degree complete AV block
absence of conduction of atrial impulses to the ventricles - no communication between the 2 characterized by AV dissociation tx - pacemaker
292
chemo drugs that cause dilated cardiomyopathy
doxorubicin | adriamycin
293
infectious causes of dilated cardiomyopathy
viral chagas dz lyme dz HIV
294
vasovagal syncope
vagus nerve stimulation --> dumps Ach --> bradycardia and vasodilation decrease in systolic BP of 50mmhg typically there is a prodrome (they know its coming)
295
causes of vasovagal syncope
visceral organ stimulation - (cough, defecation, micturition) carotid bodies - (turning head, shaving, tie too tight) psychogenic - (site of blood)
296
dx and tx of vasovagal syncope
dx - tilt table test (not really necessary) tx - beta blockers
297
orthostatic syncope
systolic drop >20 diastolic >10 HR >10
298
causes of orthostatic hypotension
volume down causes: - diarrhea - dehydration - diuresis - hemorrhage ANS issues: - diabetes - parkinson's - advanced age
299
tx of orthostatic hypotension
volume down - IVF ANS - doesnt respond to fluids - get up slowly
300
cardiogenic syncope
mechanical: - valve problem - rest no issue - issue with exertion young athlete - HCOM old person random exertion - Aortic Stenosis Arrhythmia: - sudden no prodrome - dx halter monitor or event recorder
301
neurogenic syncope
posterior circulation issue - vertebrobasilar insufficiency dx CT angiogram
302
LDL
brings cholesterol to the periphery -- if too much accumulates there it leads to plaque formation
303
HDL
bring cholesterol back to liver for processing
304
who needs statin
1 - vascular dz- MI, CVA, PVD, CS 2- LDL >190 3 - LDL 70-189 + age (40-75) + DM 4 - LDL 70-189 + age (40-75) + calculated
305
ppl who dont need statins
LDL <70
306
high intensity statins
atorvastatin 40-80 | rosuvastatin 20, 40
307
those who should be on moderate intensity statins
age >75 liver dz renal dz
308
moderate intensity statins
``` atorvastatin 10, 20 rosuvastatin 5,10 simvastatin 20,40 pravastatin 40,80 lovastatin 40 ```
309
how often should lipids be assessed
annually
310
if signs of statin toxicity
stop statins and when symptoms get better start them again
311
basline studies needed before statins
lipid panel A1c CK LFTs
312
ADR of statins
myositis and hepatitis --> if pt develop these stop statins and then restart on lower doses
313
if you cant use a statin next best drug
fibrates - same ADR profile (myositis and increased LFTs)
314
fibrates
decrease TGLs and increase HDL lipoprotein lipase inhibitor
315
ezetimibe
decrease LDL prevent cholesterol absorption ADR - fatty stool osmotic diarrhea
316
niacin
increase HDL and decrease LDL decrease FA release Decrease LDL synthesis ADR - flushing tx with prophylactic aspsirin
317
bile acid resins
decrease LDL decrease bile acid resorption adr - diarrhea
318
ST segment elevation in inferior leads II, III, aVF
inferior wall MI - most commonly RCA 4:1 (LCX)
319
ST elevation in V1-v6
anterior MI - LAD
320
posterior wall MI
ST depression in v1-v3 ST elevation I and aVL (LCX) ST depression in I and aVL (RCA)
321
ST elevation I, aVL, V5, V6 | ST depression II, III, aVF
lateral wall MI LCX
322
right ventricle MI signs
RCA ST elevation in V4-V6r
323
decreased CO in CHF -->
increase in RAAS --> increased ADH --> increase angiotensin II
324
increase in angiotensin II leads to
vasoconstriction of afferent and efferent glomerular arterioles (more so in efferent) increased intraglomerular pressure to maintain GFR decreased Na delivery to distal tubules
325
ST depression in V1-v3 ST elevation I and aVL = ? ST depression I and aVL = ?
elevation in I and aVL = LCX depression in I and aVl = RCA
326
ST depression in V1-v3 ST elevation I and aVL = ? ST depression I and aVL = ?
elevation in I and aVL = LCX depression in I and aVl = RCA
327
S4 indicates
a stiff LV which occurs in the setting of: -restrictive cardiomyopathy or - hypertrophy from prolonged HTN
328
ascending aortic aneurysm leads to -->
aortic regurgitation (diastolic murmur)
329
severe Aortic stenosis signs
- delayed (slow rising) and diminished (weak) carotid pulses - single and soft S2 - mid to late peaking systolic murmur with max intensity at 2nd R ICS radiating to the carotids
330
pulsus parvus and tardus
- delayed (slow rising) and diminished (weak) carotid pulses
331
prominent capillary pulsations in the fingers or nail beds is seen in
aortic regurgitation - due to the widened pulse pressure
332
Most common side effect of amiodarone
pulmonary toxicity - longer term use months to years
333
acute limb ischemia causes
- cardiac/ arterial embolus (severe and sudden) - arterial thrombus - iatrogenic/ blunt trauma
334
clinical signs of acute limb ischemia
``` pain pallor parethesias pulselessness poikilothermia (cool extremity) paralysis (late sign) ```
335
management of acute limb ischemia
anticoagulation - heparin thrombolysis vs sx
336
DVT presentation
dull aching pain swelling tenderness of LE pulse is present
337
cause of ascending aortic aneurysms
cystic medial necrosis | connective tissue disorders
338
cause of descending aortic aneurysms
atherosclerosis
339
CXR of thoracic aortic aneursyms
widened mediastinal silhoutte increased aortic knob tracheal deviation
340
decreased left ventricular preload can be seen in
cardiac tamponade
341
septic shock cardiac findings
hypotensive, tachy reduced cardiac afterload -- decreased systemic vascular resistance --> due to overall peripheral vasodilation decreased pulmonary capillary wedge pressure increased mixed venous O2 saturation
342
what is the initial tx of choice for a hyperthyroidism pt with afib
beta blockers
343
meds for stable afib pt
beta blockers diltiazem digoxin
344
CHA2DS2-VASc score = thromboembolic risk
``` C- CHF H- HTN A2 - age >75 (2pts) D- Diabetes mellitus S- stroke/TIA/thromboembolism (2pts) V-vascular dz (prior MI, periph artery dz, plaques) A- age 65-74 (1pt) S- sex category female ``` max score = 9
345
major side effects for amiodarone
cardiac - sinus brady, heart block QT prolongtion pulm - chronic interstitial pneumonitis endocrine - hypo/hyperthyroidism GI/hepatic - elevated transaminases, hepatitis occular - corneal microdeposits, optic neuropathy derm = blue gray skin discoloration neuro - peripheral neuropathy
346
MCC of mitral regurgitation in a developed country
mitral valve prolapse
347
lifte style modifications recommended for HTN
diet: <2.4g salt per day, K supplements, DASH, no etoh exercise: 30min/day or 2hrs per week Weight: lost weight if obese, or BMI>25
348
stage 1 HTN
systolic < 140 diastolic <90 LSM or if 10% risk LSM + 1 drug
349
stage 2 HTN
systolic >140 diastolic >90 LSM + 2 drugs
350
hypertensive urgency vs emergency
>220 systolic + >120 diastolic only difference is that emergency has end organ damage papilledema, HA, AMS
351
tx for HF or CAD + HTN
beta blocker (carvedilol, metoprolol) - ACE-I
352
tx for stroke + HTN
thiazide + ACE-I
353
tx for CKD + HTN
ACE-I or ARB (except in stage IV)
354
tx for diabetes + HTN
ACE-I
355
tx for new onset HTN alone
thiazides, ACE-I (except if your black), CCB
356
dihydroperidine CCB (dipines) basics
ADR - peripheal edema anti anginal
357
ACE- ARBS basics
ADR- increased creatinine and K other ADR for ACE-I = dry cough + angioedema
358
tx of HTN during angioedema caused by ACE-I
ARBs
359
thiazides basics
HCTZ - works on the collecting duct - ADR - decreased k+ | will also decreased urinary Ca which helps prevent kidney stones
360
beta blockers basics for HNT
useful for HF with decreased EF ADR - decreased HR, Obstructive lung disease
361
Spironolactone | epleronone
ADR - increased K and sprinolacotne (gynecomastia) so use epleronone instead CHF class III
362
Hydrazaline
arteriolar dilator - useful for CKD V - ADR - reflex tachycardia and drug induced SLE
363
isosorbide nitrate
venous dilator | dont use with other nitrates or PDE I
364
alpha antagonist
useful if also treating BPH but can cause orthostatic hypotension
365
ADR of clonidine
rebound hypertension
366
tx of hypertensive emergency
IV nitrates or CCB to get MAP down 25% in first 2-6hrs
367
hyperaldosteronism (primary aldosteronism)
refractory HTN or HTN and hypokalemia renin > 20 CT pelvis
368
hypercalcemia and HTN
polyuria, AMS, "moans, bones, groans" kidney stones check free Ca
369
aortic coarctation
children = warm arms, cold legs, claudications adults = rib notching, BP differential in legs and arms CXR, angiogram, CT angio
370
renovascular HTN
DM or glomerulonephritis young woman = FMD old guy RAS renal bruit, hypo K
371
pheochromocytoma HTN
``` pallor palpitations pain perspiration pressure ``` 24hr urinary metanephrines CT
372
cushings
diabets, HTN, central obesity, Moon facies low dose Dexa, ACTH level high dose DEXA
373
fast arrhythmia with narrow QRS
either SVT or AFib
374
SVT basics
no P waves HR > 150 and regulr tx - adenosine 6mg --> 12mg --> 12mg
375
afib basics
no p waves irregularly irregular heart rate <150 CCBs = beta blockers for rate control except in CHF use digoxin or amiodarone
376
saw tooth pattern =
atrial flutter
377
fast arrhythmia with wide QRS
torsades or V tach
378
torsades basics
changing amplitude (ribbon like) tx magnesium (amiodarone too)
379
v tach basics tx
stable - amiodarone unstable - shock
380
in valvular afib DOC for anticoagulation =
warfarin
381
Slow rhythm and wide QRS
3rd degree AV block or idioventricular rhythm no atropine for either rhythm but pace them
382
slow rhythm and narrow QRS
sinus brady - atropine and pace 1st degree block - atropine and pace 2nd degree type I block - atropine and pace 2nd degree type II block - pace
383
differences between AV blocks
1st - just PR prolongation - no dropped beats 2nd type I - PR prolongation with drop after 2nd type II - nml PR length with random dropped beats
384
fast and narrow rhythm tx =
adenosine
385
fast and wide rhythm tx =
amiodarone
386
squatting increases the intensity of all murmurs except
MVP and HCM
387
clinical manifestations of acute pericarditis
chest pain pericardial friction rub diffuse ST elevation and PR depression pericardial effusion without tamponade
388
diastole dysfunction in constrictive pericarditis
early diastole - rapid filling late diastole - halted filling
389
constrictive pericarditis - when intracardiac volume reaches the limit set by the noncompliant pericardium
ventricular filling is halted abruptly
390
in cardiac tamponade ventricular filling
is impeded throughout diastole
391
if pat has clinical signs of cirrhosis (ascites, hepatospleomegaly) and distended neck veins perform tests to r/o out
constrictive pericarditis
392
imaging test of choice for dx of pericardial effusion and cardiac tamponade
echo
393
CXR findings of pericardial effusion
cardiac silhoutte - water bottle appearance enlarged heart without pulmonary vascular congestion
394
cardiac tamponade causes
rapid accumulation of. 200ml or slow accumulation of 2L mechanically impairs diastolic filling pressures in RV, LV, RA, LA equalize decreased stroke volume decreased cardiac output
395
becks triad
hypotension | muffled heart sounds JVD
396
pulsus paradoxus
systolic bP drop >10mmHg on inspiration
397
complications of mitral stenosis
hemoptysis - due to elevated LA pressure ruptures anastomoses of small bronchial veins thromboembolism - afib
398
tricuspid regurg
IV Drug users, LV failure - mcc blowing holosystolic murmur at LLSB
399
pt with new murmur and unexplained fever or bacteremia suspect
endocarditis
400
acute endocarditis
MCC - staph aureus | nml heart valves
401
subacute endocarditis
strep viridans and enterococcus | damaged heart valves
402
prosthetic valve endocarditis
staph epidermidis > staph aureus
403
endocarditis in IV drug users
staph aureus is MCC other causes include streptoccoci, enteroccocci, candida and pseudomonas
404
dx of endocarditis
``` DUKE criteria (2 maj, 1 maj + 2min, 5 min) TEE ```
405
situations that require prophylactic tx for endocarditis
proesthetic heart valves hx of infective endocarditis congenital heart dz dental procedures
406
nonbacterial thrombotic endocarditis (1) nonbacterial verrucous endocarditis (2)
1 - metastic cancer - deposits of fibrin and platelets along closure line of cardiac valve leaflets 2- aortic valves in SLE pts - small warty vegetations on both side sof valve leaflets
407
first step if pt has severe HA and markedly elevated BP
lower Bp(hydraazine) then CT --> if CT neg --> LP
408
managment of hypertensive crisis
reduce mean arterial pressure by 25% in 1-2 hrs if severe - IV hydralazine, esmolol, nitroprusside, labetalol, NTG
409
types of aortic dissections and dx
type a = ascending - anterior chest pain - tx surgical + IV beta blockers, IV sodium nitroprusside type b = descending - interscapular back pain - tx medical dx - cxr - widened mediastinum >8mm on AP view + TEE
410
presentation of. aortic dissection
severe tearing/ripping/stabbing pain abrupt onset anterior chest or back of the chest pulse or bP asymmetry between limbs
411
predisposing factors for aortic dissections
long standing HTN cocaine, trauma Connective tissue diseases (marfans, ehlers danlos) 3rd trimester of pregnancy
412
AAA
located between renal arteries and iliac bifurcation more common in. men 65-70 (women more likely to tear) multifactorial - atherosclerotic weakening of aortic wall, HTN, trauama, vasculitis, smoking syphillis, and CT diseases marfasn - thoracic more tho
413
clinical features of AAA
sense of fullness pulsatile mas on abd exam ecchymoses on back and flanks, around umbilicus
414
presentation of ruptured AAA
abd pain hypotension palpable pulsatile abdominal mass emergency laparotomy indicated
415
test of choice for AAA
US of abdomen
416
meds that improves long term survival in pts with LV systolic dysfunction
beta blockers ACE-I ARBs mineralcorticoid receptor antagonists hydralazine + isosoribide nitrates in black
417
symmetric duskiness and coolness of all fingertips can be caused by
pressers such as NE - lead to ischemia of distal fingers and toes secondary to vasospasm not painful
418
raynauds phenomenom
finger ischemia that is typically painful and due to cold exposures or stress
419
Formation of AV fistulas can occur from
trauma --> leading to high output cardiac failure by shunting blood from arterial side to venous side --> increasing cardiac preload -->HF
420
CHA2DS2-VSAc score interpretation
0 - no tx 1- aspirin or more 2 - blood thinner (wafarin, -bans)
421
drugs that inhibit cyp450 --> increasing warfarin effect
``` acetominophen, NSAIDs ABX, antifungals amiodarone thyroid hormones cimetidines cranberry juice + vit E omeprazole SSRIs ```
422
drugs that induce cyp450 --> decreasing warfarin effect
``` st johns wort, ginseg carbameapine, phenytin rifampin OCPs phenobarbital ```
423
dx test of choice for cardiac tamponade
echo
424
some causes of. low pulmonary capillary wedge pressure
acute PE due to impaired blood flow sepsis hypovolemic shock
425
complication of mitral stenosis
afib --> thromboembolic stroke --> hemiparesis
426
beta blocker overdose
bradycardia AV block hypotension diffuse wheezing antidote = glucagon
427
in cardiogenic shock what happens to the pulmonary capillary wedge pressure
pulmonary capillary wedge pressure will be elevated
428
SVR in sepsis, hypovolemia, cardiogenic shock
sepsis - decrease SVR hypovolemia - increase SVR cardiogenic shock - increase SVR
429
non selective beta blockers can trigger
bronchoconstriction in patients with underyling asthma
430
late complication of radiation therapy
constrictive pericarditis
431
pts with endocarditis with abnormal conduction on ECG --> think
perivalvular abscess
432
fibromuscular dysplasia
women, internal carotid artery stenosis -> recurrent headaches, pulsatile tinnitus, TIA, stroke renal artery stenosis -> secondary HTN subaruicular systolic bruit, abd bruit tx - antiarrhythmias (ACE-I or ARBs)
433
pheochromocytoma presentation
secondary HTN - due to secretion of catecholamines episodes of HA sweating, diaphoresis
434
primary hyperaldosternism
secondary HTN decreased K+ metabolic alkalosis
435
conditions associated with AFIB
HTN, CAD, CHF, valvular dz, hypertrophic cardiomyopathy obstructive sleep apnea, PE, COPD, acute hypoxia obesity, hyperthyroidism, DM, Alcohol
436
cushing syndrome
``` central obesity glucose intolerance hirsutism abdominal striae elevated BP ```
437
digoxin toxicity
GI - anorexia, N/V, abd pain cardiac - life threatening arrhythmias neuro - fatigue, confusion, weakness, color vision alterations
438
viral myocarditis
young pt viral prodrom causes - parvovirus B19, coxsackie, HSV -6, adenovirus, HIV, influenza eho - 4 chamber dilation, impaired contractile function
439
renovascular dz clues
HTN resistant to tx malignant HTN (end organ damage) onset of severe HTN > 55y/o asymmetric renal size abdomial bruit unexplained increase in serum creatinine >30% after starting on ACE-I or ARBs
440
renin pathway
low bp or low volume -> JGC -> converts angiotensinogen --> angiotensin I --> ace converts it into --> angiotensin II --> vasoconstriction + increased aldosterone
441
management of symptomatic bradycardia and/or complete heart block
transcutaneous pacing
442
supravalvular aortic stenosis
aortic outflow obstruction - develop LV hypertrophy and can have exertional anginal due to subendocardial ischemia -> increased myocardial oxygen demand during exercise
443
primary hyperparathyroidism
``` muscle weakness recurrent kidney stones neuropysch problems hypercalcemia secondary HTN ```
444
MEN type I
hyperparathyroidism pancreatic tumors pituitary tumors
445
MEN type II a
medullary thyroid carcinoma pheochromocytoma parathyroid hyperplasia
446
MEN type IIb
medullary thyroid carcinoma pheochromocytoma mucosal neuromas marfanoid habitus
447
ADR of dihydropyridine Ca channel antagonist
peripheral edema
448
peristent AFIB in WPW syndrome patient should be treated with
if unstable - electrical cardioversion if stable - rhythm control with ibutilide or procainamide
449
pain relief from NTG is due to
decreased LV wall stress
450
inf wall MI with delayed presentation followed by sudden onset hypotension, dyspnea, tachypnea, pulm edema and a soft systoli cmurmur is indicative of
acute MR due to posteromedial papillary muscle rupture
451
clinical presentation of amyloidosis in cardiomyopathy
unexplained CHF proteinuria left ventricular hypertrophy in the absence of HTN hx
452
ADR of class IC anti arrhythmics (fleicande)
increase in QRS duration
453
statins MOA
inhibit HMG CoA reductase -. intracellular synthesis pathway decrease coenzyme q10 synthesis
454
ACE-I moa
extracellular enzyme blocker and increase levels of bradykinin
455
the strongest predictor of AAA expansion and ruputre =
smoking | diameter of AAA and speed of expansion of AAA
456
younger pt has exertional dyspnea pounding heart sensation when lying on left side widened pulse pressure dx=
AR - increase in LV size bring the ventricular apex close to the chest wall
457
the most common cause of AR in developed countries =
aortic root dilation or congenital bicuspid valve
458
complication of aortic dissection
AR and cardiac tamponade
459
most common ectopic foci in afib
pulmonary veins
460
underlying pathophys of atrial flutter
involves reentreant circuit around the tricuspid annulus
461
murmurs that require workup
diastolic and continous murmurs ECG --> echo
462
murmur that does nOT require workup
midsystolic murmur in otherwise young asymptomatic adult
463
decreased tracer uptake in technetium 99 scan at rest and with exercise indicates
fixed defect - likely scar issue with decreased perfusion and CAD
464
decreased tracer uptake in technetium 99 scan only with exercise indicates
ischemia and CAD (reversible)
465
dx test of choice for aortic dissection causing hemopericardium and rapidly progessing cardiac tamponade
CT angiography
466
increased incidence of orthostatic hypotension in the elderly is due to
progressively decreasing baroreceptor sensitivity and defects in the myocardial response to this reflex
467
GFR changes in the elderly
decreases -> promotes sodium retention
468
common causes of pulm HTN
LV systolic or diastolic dysfunction tx - loop diuretics and (ACE-I or ARBs)
469
ventricular aneursym
late complication of MI (wks to months) | ECG - persistent localized ST seg elevation and eep Q waves in the leads correspondingto previous MI
470
modification with greatest benefit on decreasing high BP
1) weight loss 2 DASH diet 3 exercise 4 sodium
471
tx of hypertrophic cardiomyopathy
neg inotropic agents: | beta . bockers, verapamil, disopyramide (not first line due to ADR)
472
situational syncope
neurally mediated syncope associated with micturition, cough, defecation
473
what is the tx for acute thormbotic occlusions
heparin
474
MOA of dihydropyridiine CCBs
decreases afterload by systemic vasodilation
475
exertional heat stroke
strenous activity in hot humid weather dehydration, obesity core temp >104, AMS, organ/tissue damage
476
management of exertional heat stroke
rapid cooling fluid resuscitation electrolyte correction management of end organ complications
477
cardiac sarcoidosis
dz of noncasseating granuloma infiltration of the myocardium and can result in serios arrhythmias cardiomyopathy HF sudden cardiac death
478
lyme carditis
1-2 months after borrelia burgdorferi inf AV block is the MC abnormality seen
479
common cardiac issues in marfans syndrome
mitral valve prolapse | aortic dilation -> aortic dissection -> aoritc regurgitation = early diastolic murmur
480
hypovolemic shock cardiac values
decreased CO decreased BP decreased PCWP increased SVR
481
abrupt onset of regular tachycardia that resolves with cold water immersion =
PSVT - can be treated with vagal maneuvers
482
MOA of vagal maneuvers to terminate AV nodal reentrant tachycardia
increase parasympathetic tone -> temporary slowing of conduction in the AV node --> increase in the AV node refractory period --> termination
483
MCC of sudden cardiac arrest in the immediate post infraction period in pts with acute MI
reentrant ventricular arrhythmias (vfib)
484
tricuspid regurgitation affect during inspiratioin
murmur increases
485
dobutamine moa
strong affinity for beta 1-r, weak affinity for beta-2-r + alpha 1-r stimulate increased myocardial contractility -> increased EF -> reduced LV end systolic volume improvement of symptoms of decompensated HF
486
clinical signs of acute decompensated HF
acute dyspnea, orthopnea HTN, Hypotension(if severe) accessory muscle suse, tachycardia, tachypneic diffuse crackles with possible wheezes JVD, peripheral edema
487
tx of acute decompensated HF
O2 and furosemide + NTG - HTN NE or dobutamine - hypotension
488
cardiac signs of cor pulmonale
tricuspid regurgitation murmur ECG - RBBB, RAD, RVH, RA enargment echo - pulm HTN, dilated RV, right heart cath (gold standard) - RV dysfunction, elevated pulmonary artery systolic pressure >25mmHg
489
abnormal causes of S3
HF restrictive cardiomyopathy high output states
490
abnormal causes of S4
acute MI young adults, kids ventricular hypertrophy
491
MCC of aortic stenosis > 70 y/o and <70 y/o
>70 - senile calcific aortic stenosi < 70 - bicupsid aortic valves
492
pulsus paradoxus can be seen in
cardiac tamponade severe asthma severe COPD
493
chagas disease
preceded by megacolon dilated carditis protozoal infection
494
diptheria myocarditis
preceded by URI underdeveloped country no vaccine hx
495
MC site of occlusion in peripheral vascular dz
superficial femoral artery (hunter cannal) smoking = biggest risk factor
496
calf claudication buttock and hip claudication + cave claudication
femoral or popliteal aortoilliac occlusive
497
Normal ABI is between
0.9 - 1.3 | >1.3 - is due to noncompressible vessels and indicates severe disease
498
cholesterol embolization syndrome
due to showers of cholesterol crystals triggered by surgical or radiographic intervention blue/black toes
499
superficial thrombophlebitis
local tenderness, erythema, along course of superficial vein UE - site of IV infusion LE - varicose vein association tx - analgesics - monitor for spread or cellulitis
500
cardogenic shock
decreased CO increased SVR increased PCWP
501
hypovolemic shock
decreased CO increased SVR decreased PCWP
502
neurogenic shock
decreased CO decreased SVR decreased PCWP
503
Septic shock
increased CO decreased SVR decreased PCWP
504
afterload reducing agents
NTG | nitroprusside
505
what is the best indicator that tht etx of shock is effective
monitoring urine output as well as a pulmonary artery catheter and/or central venous line
506
septic shock is asociated with
severe peripheral vasodilation (flushing, warm skin)
507
hypovolemic shock is associated with
peripheal vasoconstriction (cool skin)
508
most common cause of. death in ICU
septic shock
509
SIRS
``` 2 or more: Fever > 38 or hypothermia <36 hyperventilation or PaCO2 <32 tachy increased WBCs ```
510
ADR of nitroprusside
cyanide toxicity especially in those with continouse infusions lactic acidosis, AMS, Seizure Coma
511
tx of vasospastic angina
CCB for prevention and NTG for abortive tx
512
long standing systemic HTN ECG signs
high voltage QrS complexes lateral ST segment depression lateral T wave inversion
513
when is metoprolol C/I in the tx of an acute MI
when pulmonary edema is present along with acute decompensated HF
514
MCC of constrictive pericarditis in developing countries
tuberuculosis
515
presentation of interventricular septum
3-5 days after MI suddent onset cardiogenic shock with hypotension biventricular failure new harsh holosystolic murmur with palpable thrill at the. left sternal border
516
what lifestyle modification can greatly decrease TGLs
reducing or no longer consuming alcohol
517
ventricular aneursyms
5days to 3 months post PI thin and scarred fibrotic myocardium ecg - presents with persistent ST segment elvation after recent MI can eventually lead to --> MR
518
ECG findings that suggest an arrhytmia that can cause syncope
``` inappropiate sinus brady sinoatrial block sinus pauses AV block nonsustained ventricular arrhthyias short or prolonged QTc interval ```
519
symptomatic management of carotid stenosis is. required whwen
TIA CVA, stenosis 70-99%
520
digoxin and furosemides role in CHF
provide symptomatic relief but will not decrease mortality
521
MCC of isolated AR in a young adult in developed countries
congenital bicupsid aortic valves
522
uremic pericarditis
BUN levels >60 no classical pericarditis ECG findings tx- hemodyialysis
523
pathphys behind the ADR of niacin
high dose niacin -> flushing - due to prostaglandin induced periheral vasodilation and can be reduced by low dose aspsirin
524
primary mitral valve abnormality in pts with hypertrophic cardiomyopathy is the presence of
systolic anterior mitral valve - > anterior motion of the mitral valve leaflets towards the interventricular septum and when connected to thickened septum during systole to LV outflow tract obstruction
525
what is the most common finding associated with HF and an elevated BNP
S3 - sign of increased cardiac filling pressures
526
hemodynamics in HF
decreased contractility decreased CO increased afterload increased SVR
527
the goals of the initial therapy of aortic dissection
pain control reduction of systolic bp to 100-120 decreased CV contractility to reduce aortic wall stress (tx of these 2 beta blockers)
528
most important predisposing factor associated with the development of aortic dissection
systemic HTN if <40 y/o 50% are due to marfans syndrome
529
electrical alternans + sinus tachy
large pericardial effusion
530
poor prognostic factors for CHF
``` hyponatremia resting tachycardia s3 mod to severe MR LBBB severe LV dsyfunction pulm HTN ```

Step 2 Rotation Cards (14 decks)

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