Cardiac Lecture

Question 1

Renal Disease
Myocarditis
Cardiac contusion
Recent cardiac surgery or cath

..what do they all have in common?

Answer 1

Can all cause false positives in elevated troponins

Question 2

ST elevation or new LBBB
T wave inversion
ST depression

Answer 2

EKG signs of acute coronary syndrome

Question 3

>1 mm elevation in 2 contiguous leads
New LBBB

Answer 3

STEMI

Question 4

ST elevation or new LBBB

ST depression or T inversion

CP w/ hemodynamic instability

Dynamic EKG changes

Known CAD w/ reminiscent pain

High risk Hx +/- w/ positive troponin

Answer 4

high risk CAD

Question 5

Atypical CP w/ CAD and normal or unchanged EKG

CP w/ nonspecific ST depression (dominant R leads)

Low risk Hx w/ normal EKG and + troponin

Angina Pt with rest angina w/ spont resolution or promptly after NTG SL

Answer 5

moderate CAD risk

Question 6

Atypical CP is a ____ risk for CAD

Answer 6

LOW

Question 7

Thrombotic =

Answer 7

NSTEMI

Question 8

Embolic= ?

Answer 8

STEMI

Question 9

what is MONA?

Answer 9

Morphine
Oxygen
Nitro
Aspirin

Question 10

Patient dependent (Prior episodes, Prior work up, Abilty to exercise)

2 D Echo (TTE)

ETT

Stress Echo

Stress nuclear imaging (technetium 99mTc sestamibi)

Cardiac catheterization

Answer 10

Ways to R/O ACS

Question 11

Aspirin/ antiplatlet agents
P2Y12 receptor blocker
beta blocker
heparin

..tx for?

Answer 11

NSTEMI/UA

Question 12

What is dual anti-platelet therapy?

Answer 12

Aspirin/antiplatelet agents
P2Y12 receptor blocker

Question 13

PRN: diuretics, NTG

Long term: beta blockers, statins

tx for?

Answer 13

Heart failure

Question 14

Age ≥ 65

≥ 3 risk factors fpr CHD

Prior coronary stenosis ≥ 50%

ST segment deviation on admit EKG

≥ 2 anginal episodes in prior 24 hours

Elevated cardiac biomarkers

Use of aspirin in prior 7 days

Answer 14

TIMI score

(Thrombosis in MI Score)

Question 15

2 week risk of death, new or recurrent MI, or severe recurrent ischemia requiring revascularization

Answer 15

TIMI

Question 16

Verify rhythm

Verify hemodynamic stability

Ventricular rate control

Blood pressure management

Answer 16

A Fib

Question 17

Test of choice when looking for…

Valvular disease

Atrial size

LV size and function

LVH

Peak RV/PA pressures.

Pericardial disease

Answer 17

TTE

Question 18

True or False…

You would use a TEE when looking for presence of a LA thrombus

Answer 18

True

Question 19

Benefit: Maintain sinus rhythm and optimal cardiac output.
Improved LV fcn over time.

Drugs: Flecainide, Propafenone, Sotalol, Dofetilide and Amiodarone

Problem: At best, 50-60% effective in maintaining SR long term.

Answer 19

A fib rhythm control

Question 20

Adverse effects include pro-arrhythmia (VT, Torsades, VF) which can be life threatening.

Answer 20

A fib rhythm control

Question 21

Which tx for a fib is “worse/not as effective”

*higher 4 year mortality rate
*more strokes
*more hospitalizations

RATE CONTROL or RHYTHM CONTROL

Answer 21

Rhythm control

(both groups have similiar bleeding and similar life score/fxn tho)

Question 22

Younger, more active patients who benefit from optimal CO or ↑risk of bleed, especially athletes, occupations with ↑risk of trauma.

Patients in whom anticoagulation is contraindicated or have adverse reactions to anticoagulants.

Patients in whom rate is uncontrollable or symptomatically can’t tolerate AF.

Patients who request it.

Answer 22

A fib rhythm control

Question 23

If pt is in A fib for >48 hours, must have out patient anticoagulation for ______ weeks before CV cardioversion can be tried

Answer 23

3-4 weeks

Question 24

Cardiology consult

DC cardioversion

Pharmacological cardioversion

Non pharmacological approaches( Maze procedure, Radiofrequency Catheter ablation)

Answer 24

Rhythm control options for A fib

Question 25

Drug therapy: Slow AV conduction, control rate at rest/exercise. Drugs: Ca-Blocker (Diltiazem, Verapamil), B-blocker, Digoxin; often combination needed, e.g. Diltiazem plus Digoxin.

Answer 25

A fib **rate control**

Question 26

Risk factors Age \>65 Prior History of stroke Diabetes mellitus History of systemic hypertension

Answer 26

risk for stroke with chronic a fib

Question 27

- LV dysfunction/CHF - ↑LA size - other aortic or mitral valve disease

Answer 27

HIGH stroke risk with a fib

Question 28

-age\<60 years, heart disease (preserved LV function, Nl LA, no HTN) and no other risk factors

Answer 28

LOW risk of stroke with a fib

Question 29

With a fib, **anticoagulation reduces incidence of stroke to \_\_% per year**

Answer 29

1%

Question 30

CHADS VAS score of: 0 1 \>2 should the pt be anticoagulatd?

Answer 30

``` 0= generally no 1= consider 2+= generally yes ```

Question 31

\*what should be used to anticoagulate to prevent stroke: Decreased Stroke Risk Decreased bleed risk Increased cost Increased frequency of dosing for some Limitted by renal disease Reversal available only for dabigatran (direct thrombin inhibitor)

Answer 31

Novel Oral AntiCoagulant (NOAC) no bridging required

Question 32

Cardioversion is primary objective. Rate control secondary option with Amiodarone Ablation consideration.

Answer 32

WPW

Question 33

Anticoagulants should be held for how long before procedures?

Answer 33

3-4 days (the resumed post-procedure)

Question 34

True or False... You can use heparine or LMWH periprocedure for patients who are at very high risk of emboli (ie rheumatic mitral stenosis, mechanical hear valve, prior thromboembolism)

Answer 34

True

Question 35

Decreased pump function of the heart due to cardiomyopathy (dilated or hypertrophic) or wall motion abnormality

Answer 35

Heart failure

Question 36

an EF \<40% is what type of HF?

Answer 36

Systolic

Question 37

Impaired relaxation of the heart is what type of HF?

Answer 37

Diastolic

Question 38

Systolic Diastolic L sided R sided

Answer 38

types of HF

Question 39

IV diuretic O2 NTG – SL, Transcutaneous Morphine Sodium restrict (2g/D) Fluid restrict (1-1.5 l /D) Avoid NSAIDS (helps avoid HyperK and Na retention as well as vasodilator prostaglandin inhibition) Avoid empiric use of anti-arrhythmics Correct aggravating or precipitating factors

Answer 39

Acute management of HF

Question 40

ACE inhibitor Beta blocker (once stable) Carvedilol vs metoprolol Digoxin ABG Potassium replacement Thiazide diuretic in addition to furosemide Spirinolactone (25mg) for severe CHF in addition to loop diuretic and ACE-I (monitor K)

Answer 40

management for **systolic HF**

Question 41

IV or oral diuretics Unless complicated by a precipitating factor (eg, recent MI) or a concurrent threatening condition (eg, electrolyte imbalance, azotemia, symptomatic arrhythmias) many do not require hospital admission beyond several hours observation in ED or as OutPt.

Answer 41

**mild to moderate** acute on chronic CHF