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Internal Med EOR > Cardio 1 > Flashcards

Cardio 1 Flashcards

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1
Q

sensitive sign for stable angina on EKG

A

Horizontal or downsloping ST-segment depression on ECG during an anginal attack is among the most sensitive clinical signs

Nonspecific T-wave changes (flattening or inversion) may be noted

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2
Q

what is considered a positive test for exercise stress test in stable angina

A

ST-segment depression of 1mm is considered to be a positive test

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3
Q

definitive dx stable angina

A

coronary angiography

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4
Q

what is the biggest difference between unstable angina and NSTEMI

A

there is no elevation in cardiac enzymes (troponin) with unstable angina but there is in NSTEMI

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5
Q

NSTEMI vs STEMI

A

NSTEMI - elevation in cardiac enzymes; ST depressions and T wave inversion

STEMI - elevation in cardiac enzymes; ST elevations

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6
Q

what will vasospastic angina show on EKG

A

transient ST elevations in the pattern of the affected artery that resolves with symptom resolution

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7
Q

cardiac enzymes in vasospastic angina

A

may or may not be elevated

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8
Q

gold standard for dx of vasospastic angina

A

coronary angiography with injection of provocative agents (ergonovine, hyperventilation, or acetylcholine)

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9
Q

tx for sinus tachycardia

A

treat underlying disease
beta blockers used in persistent tachycardia in the presence of ACS

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10
Q

tx for sinus bradycardia

A

unstable or symptomatic:
atropine first line
if failure to improve –> temporary pacemaker
epinephrine second line
permanent pacemaker definitive

no sx if asx and stable :)

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11
Q

paroxysmal Afib

A

self terminating within 7 days

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12
Q

persistent Afib

A

fails to self-terminate, lasts > 7 days
requires termination

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13
Q

permanent Afib

A

persistent Afib > 1 year (refractory to cardioversion or cardioversion never tried)

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14
Q

lone Afib

A

paroxysmal, persistent, or permanent without evidence of heart disease

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15
Q

what will EKG show for Afib

A

irregularly irregular rhythm with fibrillatory waves and no discrete P waves
often atrial rate > 250 BPM

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16
Q

tx Afib

A

stable:
rate control - BB (metoprolol, atenolol, or esmolol) or non-dihydropyridine CCB (Diltiazem or Verapamil)

Unstable:
Direct current (synchronized) cardioversion

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17
Q

CHA2DS2-VASc criteria

A

Congestive Heart failure - 1
HTN - 1
Age >/= 75 - 2
DM - 1
Stroke, TIA, thrombus - 2
Vascular disease (prior MI, aortic plaque, PAD) - 1
Age 65-74 - 1
Sex (female) - 1

score 2 or more for Afib = anticoagulation

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18
Q

how to perform cardioversion for Afib

A

duration < 48 hours - cardioversion, amiodarone, obtain echo before
duration > 48 hours - anticoagulation for 21 days prior to cardioversion

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19
Q

what is atrial fluter

A

characterized by rapid, regular atrial depolarizations at a characteristic rate around 300 BPM due to 1 single irritable atrial focus firing at a fast rate with some degree of AV node conduction block

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20
Q

what will EKG show for atrial flutter

A

flutter (sawtooth) atrial waves usually ~300 BPM but no discernible P waves

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21
Q

tx atrial flutter

A

stable:
vagal maneuvers, rate control with BB or non-dihydropyridine CCBs; digoxin if those things don’t work

unstable:
direct current (synchronized) cardioversion

definitive - radio frequency catheter ablation

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22
Q

first degree AV block

A

prolonged PR interval (> 0.2 se) at resting heart rate + all P waves are followed by QRS complex (1:1 conduction)

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23
Q

tx for symptomatic first degree AV block

A

atropine first line

definitive - permanent pacemaker

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24
Q

Mobitz 1 second degree AV block (wenkebach)

A

progressive lengthening of PR interval until an occasional non-conducted atrial impulse (dropped QRS complex)

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25
tx Mobitz 1 second degree AV block (Wenkebach)
Atropine first line if sx Epinephrine pacemaker definitive
26
Mobitz II second degree AV block
constant PR interval before and after non-conducted atrial beat (dropped QRS complex)
27
treatment Mobitz II second degree AV block
symptomatic: transcutaneous pacing and/or atropine unstable: atropine and in most, temporary cardiac pacing to increase pulse rate and cardiac output definitive - permanent pacemaker required in many patients
28
third degree AV block
complete absence of AV condition where NO atrial impulses conduct to the ventricle, so the atrial activity and ventricular activity are independent of each other. EKG - AV dissociation; evidence of atrial (P waves) and ventricular (QRS complexes) activity which are independent of each other and an atrial rate faster than the ventricular rate regular P-P intervals and regular R-R intervals independent of each other
29
tx third degree AV block
symptomatic and stable: Atropine if sx bradycardia!!! if unresponsive --> temporary pacing (transcutaneous or transvenous) unstable: urgently treated atropine and in most cases temporary cardiac pacing to increase HR and cardiac output definitive - permanent pacemaker
30
tx paroxysmal supraventricular tachycardia
stable (regular, narrow complex): vagal maneuvers adenosine if vagal maneuvers ineffective stable (wide complex): antiarrhythmics: IV procainamide or IV amiodarone Unstable: direct current (synchronized) cardioversion should be performed urgently in most Definitive - radiofrquency catheter ablation
31
what is multifocal atrial tachycardia most commonly associated with
severe COPD
32
what will EKG show for multifocal atrial tachycardia
irregularly, irregular rhythm + 3 or more identifiable P wave morphologies
33
tx multifocal atrial tachycardia
non-dihydropyridine CCB Avoid BB if underlying pulmonary disease
34
what will EKG show for Wolff-parkinson-white
delta wave (initial slurred upstroke of QRS) PR interval that is short (<0.12 s) Wide QRS complexes ( > 0.12)
35
tx WPW
stable + Afib: procainamide preferred stable + no Afib: vagal maneuvers and Adenosine if vagal maneuvers not helpful unstable: direct current (synchronized cardioversion) definitive - radio frequency catheter ablation
36
EKG torsades de pointes
polymorphic ventricular tachycardia (cyclic alterations of the QRS amplitude on EKG around the isoelectric line) aka sinusoidal waveform
37
tx torsades de pointes
IV magnesium sulfate isoproterenol or transvenous overdrive pacing if refractory congenital - beta blockres stable: synchronized cardioversion pulseless: prompt defibrillation (unsynchronized) cardioversion
38
EKG vfib
disorganized high frequency undulations w erratic pattern of electrical impulses, fibrillation waves of varying amplitude, shape, and periodicity, occurring at a rate above 320/minute with no identifiable P waves, QRS complexes, or T waves.
39
tx Vfib
unsynchronized cardioversion (defibrillation) + prompt high quality CPR administer epinephrine and amiodarone if sustained vfib after 3 shocks
40
EKG vtach
regular, wide complex tachycardia with no discernible P waves
41
tx vtach
stable: amiodarone or procainamide unstable: direct current (synchronized) cardioversion pulseless: unsynchronized cardioversion (defibrillation) + CPR chronic therapy - BB Implantable cardioverter-defibrillator (ICD) to prevent VF
42
what is dilated cardiomyopathy characterized by
systolic dysfunction (impaired contraction, EF < 40%) and dilation of one or both ventricles
43
sx dilated cardiomyopathy
left sided failure - dyspnea on exertion, fatigued, impaired exercise capacity right sided failure - peripheral edema, jugular venous distention
44
PE dilated cardiomyopathy
S3 gallop hallmark - represents rapid filling of a dilated ventricle lateral displacement of the maximal point of impulse due to cardiac enlargement left sided failure - crackles/rales right sided failure - peripheral edema, jugular venous distention, positive hepatojugular reflux with inspiration, ascites
45
dx dilated cardiomyopathy
echocardiogram - can identify systolic dysfunction and ventricular dilation
46
tx dilated cardiomyopathy
ACEI for mortality reduction BB Mineralocorticoid receptor antagonists Sx control with diuretics
47
what is hypertrophic cardiomyopathy
autosomal dominant genetic disorder of inappropriate LV and/or RV hypertrophy resulting in left ventricular outflow obstruction, diastolic dysfunction and myocardial ischemia
48
PE for hypertrophic cardiomyopathy
S4 Pulsus bisferiens: biphasic pulse - aortic waveform with 2 peaks per cardiac cycle, a small one followed by a strong and broad one systolic murmus (harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and LLSB; no carotid radiation usually
49
describe the systolic murmur in hypertrophic cardiomyopathy and when it increases and decreases in intensity
harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and LLSB. usually no carotid radiation increased murmur intensity with decreased venous return (valsalva, standing, assuming upright posture from squatting, sitting, supine position decreased intensity with standing to sitting, squatting or supine position, leg raise, handgrip
50
dx hypertrophic cardiomyopathy
echocardiography - asymmetric ventricular wall thciekcness 15 mm or greater, small LV chamber size EKG - LVH, prominent abnormal Q waves
51
tx hypertrophic cardiomyopathy
BB Non-dihydropyridine CCB are alternatives
52
what is restrictive cardiomyopathy
diastolic dysfunction in a non-dilated, rigid ventricle, which impedes ventricular filling
53
common etiologies of restrictive cardiomyopathy
amyloidosis sarcoidosis - suspect in younger patients w unexplained syncope hemochromatosis
54
sx restrictive cardiomyopathy
right sided - peripheral edema, JV, hepatomegaly (right sided sx MC than left sided) left sided - dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue, cough
55
PE for restrictive cardiomyopathy
peripheral edema, JVD - right crackles - left Kussmauls sign - either lack of inspiratory decline or an increase in JVD with inspiration S4 MC than S3
56
dx restrictive cardiomyopathy
echocardiogram - non-dilated ventricles with normal thickness, marked dilation of both atria endomyocardial bx - definitive; amyloidosis is associated w apple-green birefringence w Congo red stain under polarized light microscopy
57
tx restrictive cardiomyopathy
treat underlying disorder
58
what is the most common type of HF
HF with reduced ejection fraction - post MI most common cause
59
heart failure with preserved ejection fraction is characterized by
diastolic dysfunction and a normal or increased ejection fraction
60
gallops in HF
S3 - systolic dysfunction S4 - diastolic dysfunction
61
how to dx HF
echocardiogram
62
New York Heart association function class for HF
Class 1 - no symptoms, no limitation during ordinary physical activity Class 2 - mild symptoms (dyspnea or angina), slight limitation during ordinary activity Class 3 - symptoms caused marked limitation in activity even with minimal exertion; comfortable only at rest Class 4 - symptoms even while at rest, severe limitations, and inability to carry out physical activity
63
general tx HF
ACEI or ARB, BB, diuretic can addd mineralocorticoid receptor antagonist and SGLT2 inhibitors
64
most common valve affected in infective endocarditis
mitral (M > A > T > P) exception is IV drug users --> Tricuspid
65
organisms that cause bacterial endocarditis
acute + infection of NORMAL valves = S. aureus Subacute + infection of abnormal valves = S. viridian's IV drug related = S. aureus Prosthetic valve = S aureus and S epidermidis patients w CRC and UC = Streptococcus gallolyticus (Bovis) HACEK - usually native valves
66
what are the HACEK organisms
Haemophilus aphrophilus Actinobacillus Cardiobacterium hominis Eikenella corrodens Kingella kingae these are gram negative organisms
67
sx endocarditis
persistent fever (MC) new onset murmur osler nodes - painful or tender raised nodules on the pads of the digits and palms laneway lesions - painless erythematous macula on palms and soles splinter hemorrhages - linear reddish-brown lesions under nail bed Roth spots - retinal hemorrhages w central clearing
68
2 most important tests to dx endocarditis
blood cultures transesophageal echocardiography
69
modified duke criteria for endocarditis
Major: 2 + blood cultures by organisms known to cause endocarditis endocardial involvement documented by either + echocardiogram or clearly established new valvular regurgitation Minor: predisposing condition fever vascular and embolic phenomena (janeway lesions, septic arterial or pulmonary emboli) immunologic phenomena (Osler's nodes, Roth spots, + RH factor, acute glomerulonephritis) + blood culture not meeting major criteria + echocardiogram not meeting major criteria 2 major OR 1 major + 3 minor OR 5 minor
70
aortic stenosis
harsh, low-pitched, mid-0late parking, systolic, crescendo-decrescendo murmur best heard at the RUSB Radiates to carotid arteries increased intensity - sitting while learning forward, increased venous return (squatting, supine, leg raise), expiration decreased murmur intensity - decreased venous return (valsalva, standing, inspiration) or increased after load (handgrip) weak, delayed carotid pulse S4
71
dx aortic stenosis
echocardiogram
72
tx aortic stenosis
aortic valve replacement
73
aortic regurgitation
high-pitched, blowing (soft), decrescendo or sustained, diastolic murmur best heard over Erb's point increased murmur intensity sitting up while learning forward, holding breath in end expiration, increased venous return (squatting, supine, leg raise), increased after load (handgrip) decreased murmur intensity - decreased venous return (valsalva, standing, inspiration) bounding pulses wide pulse pressure
74
tx aortic regurg
after load reducers - ACEI, ARBs, Nifedipine, Hydralazine surgery!
75
MC cause mitral stenosis
rheumatic heart disease
76
mitral stenosis
prominent S1 opening snap loud P2 mitral facies low-pitched, mid-diastolic, rumbling murmur best heard at mitral area/apex increased murmur intensity w left lateral decubitus, expiration, increased venous return (squatting, leg raise, lying supine) decreased intensity with decreased venous return (valsalva, standing)
77
tx mitral stenosis
percutaneous balloon valvuloplasty if noncalficied valves
78
MC cause mitral regurgitation
mitral valve prolapse
79
Mitral regurgitation
high pitched, blowing, holosystolic murmur best heard at the apex, often w radiation to the left axilla, sub scapular region, or upper sternal borders increased murmur intensity w left lateral decubitus, expiration, increased venous return (squatting, leg raise, lying supine); increased after load (handgrip) decreased murmur intensity with decreased venous return (valsalva, standing)
80
tx mitral regurg
after load reducers - ACEI, ARBs, hydralazine, nitrates repair preferred over replacement
81
mitral valve prolapse
mid-late systolic click best heard at the apex click may be followed by a high-pitched mid-late systolic murmur of mitral regurgitation earlier click and longer duration - valsalva, standing delayed click and shorter duration - squatting, leg raise, supine, handgrip
82
tx mitral valve prolapse
reassurance + BB
83
tx myocarditis
supportive
84
tx pericarditis
NSAIDs + colchicine steroids if can't use NSAIDs
85
pulmonic regurgitation
graham steell murmur - brief high-pitched decrescendo early diastolic blowing murmur maximally at the left upper sternal border increased with inspiration, increased venous return (squatting, leg raise, supine) decreased with decreased venous return (valsalva, standing), expiration
86
tx pulmonic regurg
no tx needed in most pulmonic valve replacement definitive
87
tricuspid stenosis
mid-diastolic murmur at left lower sternal border increased intensity with squatting, laying down, leg raise, inspiration opening snap
88
tx tricuspid stenosis
decrease right atrial volume overload w diuretics and sodium restriction
89
tricuspid regurg
high-pitched holosystolic soft-blowing murmur at the subxiphoid area, left mid sternal border or right mid sternal border with little to no murmur radiation increased intensity with inspiration, increased venous return (squatting, leg raise, supine) decreased intensity with standing, valsalva, expiration carvallo's sign - increased murmur intensity with inspiration
90
tx tricuspid regurg
diuretics; if LV dysfunction, standard HF therapy repair > replacement if severe despite medical therapy
91

Internal Med EOR (17 decks)

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