cardio Flashcards
(83 cards)
1
Q
EKG left ventricle hypertrophy
A
- Sokolow lyon cirteria: S in V1 and R in V5 >35mm
2. cornell criteria: R in aVL and S in v3 >28mm in men and >20mm in women
2
Q
EKG right ventricle hypertrophy
A
Right axis deviation (lead I down and lead II up) and R wave in V1 >7mm
3
Q
WilliaM MorroW
A
LBBB W shape in v1v2 and M shape in v5v6
RBBB M shape in v1v2 w shape in v5v6
4
Q
ischemis vs infarct
A
ischemia ST deperession
infarctions (MI) ST elevation
5
Q
testing for chest pain order
A
c/p –> EKG –> stress test (+ is ST dep 2mm) –> angiogram –> cabg if 3 vessel dis or left main coronary artery disease or 2 vessel disease in DM; Angioplasty otherwise
6
Q
systolic murmurs and distinguishing charac
A
- AS: harsh sys ejxn murmur,radiation to coratid
- MR: holosystolic, radiation to axilla
- MVP: midsys click
7
Q
diastolic murmurs and distinguishing charac
A
- always abnormal
- AR: early decrescendo
- MS: mid to late low pitched murmur
8
Q
sinus bradycardia
A
- <60, hypotn, lightheaded, BB/CCB excess
- atropine
- pacemaker for chronicity
(a) transcut pacer acutely
(b) transvenous chronically
9
Q
s3 s4 gallops
A
- s3 dilated, MV dis, normal in young adults and in pregnancy high output pts
- s4: hypertrophied, hnt, diastolic dysfxn with stiff ventricle, AS, normal in younger pts and athletes
10
Q
pulsus paradoxus
A
pulmonary
pericardial tamponade, COPD, asthma, tension pneumo, foreign body in airwway
11
Q
pulsus alternans
A
cardiac tamponade
12
Q
pulsus et tardus
A
AS
13
Q
causes of CHF (HEARTFAILED)
A
Htn Endocrine Anemia Rheumatic heart dis Toxins Failure to take meds Arrhytmia Infxn Lung (PE) Electrolytes Diet (excess Na)
14
Q
first degree AV block
A
- can be in normal pts; inc vagal tone; inc bb/ccb use, aging, digitalis
- asymp
- pr prolonged >200msec
- no tx
15
Q
2nd degree av block type 1
A
wenckeback, going going gone
- drug effects or inc vagal tone; SA node dis; right coronary art dis
- asym usually
- no tx;atropine or pacemaker if unstable
16
Q
2nd degree av block type 2
A
- unexpected dropped beats without a change in PR interval, fixed PR and drop
- fibrotic dis of condxn system, prior MI
- sometimes syncope, PROGRESSES TO 3RD DEGREE
- PACEMAKER
17
Q
Third degree av block
A
- no electrical communication between atria and ventricle
- cannon a waves
- no relation between waves
- PACEMAKER
- P-P AND R-R CONSTANT
- ADAM STOKES ATTACKS: BRADYCARDIA, HYPOTN, CANNON A WAVES
18
Q
sick sinus syn (tachy-bradycardia syn)
A
heterogenous do of abn in supravent impulse gen and condxn that lead to intermittent supravent tachy and bradyarrhythmias
1. MC INDICATION FOR PACEMAKER PLACEMENT
19
Q
sinus tach
A
normal response to fear etc, hyperthy, infxn, PE, volume contrxn
20
Q
afib
A
- CHADS2 SCORE: CHF, HTN, age >75, DM, stroke/TIA
- ABCD
anticoag if >48h, beta blockers to control rate, CCB/cardiovert if new onset <48h or if TEE shows no left atrial clot or after 3-6 weeks of warfarin with INR 2-3, Digoxin - risk of thrombotic event is the same whether pt is sym or asym
- rate vs rhythm: RACE vs AFFIRM trial
- BB or digoxin doc in CHF
- pharmocologic cardioversion: if have to then amiodarone, dofetilide, flecainide, ibutilide, propafenone, quinidine
- newer tx: catheter ablation: MAZE procedure; foci from pulm veins MC; destroys ectopic source
21
Q
aflutter
A
sawtooth, rate of 300bpm
1. tx anticoag and rate control; cardiovert if unstable
22
Q
multifocal atrial tach (MAT)
A
- multiple p waves
- copd or resp dis thats why not mx with bb
- narrow q waves, 3 or more unique p waves, rate >100
23
Q
av nodal reentry tacharrhythmia (AVNRT)
A
- dep atria and vent simultaneous;y
- palpitations, sob, angina, syncope
- rate 150-250; p wave buried in qrs or shortly after
- tx coratic massage, valsalva, adenosine, cardiovert if unstable
24
Q
av reciprocating tachy (AVRT)
A
WPW, retrograde p wave seen after a normal qrs, same tx as avnrt
25
paroxysmal atrial tachy
rapid ectopic pacemaker in atrium (not sa node)
1. rate >100; `160, p wave with an unusual axis before each qrs
2. adenosine can be used to unmask underlying atrial activity; cures 90%
3. can use verapamil also if not working then bb/ccb/digoxin
26
premature ventricular contrxn
ectopic source in vent, assoc with hypoxia, electrolytes, hyperthy
1. asym usually, palpitations
2. early wide qrs not precip by p wave; usually followed by a compensatory pause
3. tx cause; unstbale then bb or others
27
vtach
cad, mi, ischemia, electrolytes, can progress to vfib
1. 3+ PVCs
2. cardiovert if unstable and antiarrhtymics (amiodarone, lidocaine, procainamide)
28
vfib
cad, heart dis, cardiac arrest
| 1. immediate cardiovert and acls
29
torsades
long qt syndrome, proarrhythmic response to meds, low K, congential deafness
1. correct hypokalamia, give mg initially and cardiovert if unstabel
30
wpw
unstable cardioconvert
stable procainamide doc
avoid bb ccb digoxin bc can block condxn and force condxn around av node
1. long term ablation
31
CHF tx
1. high risk but nothing: tx risks, acei for dm, atheroscelrotic dis, htn
2. with structural heart dis (MI, left vent sys dysfxn, valve) = acei, bb
3. with prior or current sym+ DIURETICS, acei, bb, digitalis, salt restrxn
4. marked sym despite meds= mech assist, heart transplant, cont iv inotropes, hospice
- dobutamine used acutely to inc contrxn and dec afterload with hydralazine/nitrates; digoxin and acei used chronically
32
classification of chf
1. no limit of act
II = slight limit, comfortable at rest or with mild exertion
III = marked limitation of act, comfortable only at rest
IV confined to complete rest
33
left sided CHF
1. DYSPNEA
| pulm edema, rales, bl basilar rales, pleural effusions, orthopnea,
34
right sided CHF
1. fluid retention dominates
| jvd, peripheral edema, hepatojugular refelx, hepatomegaly, ascites
35
systolic dysfxn CHF
S3, dilated, pmi displaces, cardiomegaly, dec EF, BNP >500, creatinine high, dec sodium
36
diastolic dysfxn CHF
>65yo, pmi sustained, S4, htn, restricted or hypertrophic myopathy, renal dis or htn; normal heart size, normal ef >55%
1. left vent ed pressure inc, co normal, ef normal or inc
2. tx: diureticds first line; maintain rate and BP control via bb acei, arbs or ccbs. digoxin isnt useful in these pts
37
acute systolic chf tx
LMNOP: lasix, morphine, nitrates, oxygen, position upright
- give acei
- dont give bb in decompensated chf but should be started once pt is euvolemic
38
chronic systolic chf tx
control comorbidities and limit sodium and water intake
1. long term bb and acei together help prevent neurohormonal remodeling of heart: all these dec mortality for class II-IV
2. daily ASA and statin recommended for ischemic heart dis for prevention
3. low dose spirinolatone dec mortality risk when given with acei and loops in pt with LV sys dysfxn and class III-IV heart failure (monitor for hyperkalemia)
4. anticoag pts with af and those with hx of embolic events or a mobile left vetn thrombus. consider implantable bivent cardiac defib (ICD) in pts with both an EF <30% and CAD
39
loops lose calcium while thiazides save it
saying
40
loop diuretics : furosemide, ethacrynic acid, bumetanide, torsemide
works on loop of henle, dec Na/K/2CL cotransporter, dec urine concentration, inc ca excretion
1. s.e. = ototoxicity, hypokalemia, hypocalcemia, dehydration, gout
41
thiazides : hctz, chlorothiazide, chlorthalidone
early distal tubule
1. dec nacl reansorption leading to dec diluting capacity of nephron, dec ca excretion
1. se= hypokalemic met alkalosis, hyponatremia, hyperglycemia, hyperlipidemia, hyperurecimia, hypercalcemia
42
k sparing : spirinolactone, triamterene, amiloride
cortical collecting tubule
1. aldosterone antagonist
2. triamterene and amiloride block na channels
3. se = hyperkalemia, gynecomastia, hirsutism, sex dysfxn
43
carbonic anhydrase inh acetazolamide
proximal convoluted tubule
1. NaHCO3 diuresis dec total body NaCO3
2. hyperchloremic met acidosis, neuropathy, NH3 toxicity, sulfa allergy
44
osmotic agents mannitol
proximal tubule, creates inc tubular fluid osmolarity leading to inc urine flow
1. se = pulm edema, dehydration
2. contraind in anuria and CHF
45
dilated cardiomyopathy
- MC
- LV dilation and systolic dysfxn present for dx (EF low); can relax but cant contract
- 2MCC of secondary dilated myoptahy is ischemia nad long stnading htn; also alcoholism
- MC indication for heart transplant
- ESV diameter increases
- subendocardial fibrosis
- ECHO is dx; LBBB is common on ekg
- acei,bb,spirinolactone, avoid ccbs in chf
46
hypertrophic cardiomyopathy
- diastoic dysfnxn; impaired filling ; freq involves intervent septum leadign to imparied ejection frxn
- inc contractility makes it worse or by left vent filling eg exercise, valsalve, vasodilators, dehydration
- echo is diagnostic-systolic ant motion of the MV
- tx: bb are mainstay for sym relief; ccb second line, disopyramide occasionally; dec tachycardia
47
restrictive cardiomyopathy
- "sarcoid, amyloid, hemochromatosis, cancer, and fibrosis"
- right side HF sym predominate, s4, s3, kussmauls, ascites
- ECHO dx, cardiac bx reveals fibrosis, ekg LBBB
- least common
48
constrictive cardiomyopathy
Kussmauls, Knock, Konstrictive pericarditis
- secondary to open heart, radiation, postviral
- heart expands and hits the wall=knock
- dx thickened pericardium
- tx pericardiotomy = remove it
49
NSTEMI dx
dx by serial cardaic enzymes and ekg
50
stable angina tx
asa, bb (these 2 dec mortality)
- tx acute sym with asa, o2, iv nitroglycerin, iv morphine, iv bb
- chronic: asa, bb (ccb is second line for symptomatic control only)
- heparin bc clot in process of forming
51
unstable angina tx
- add clopidogrel, unfx heparin or enoxaparin, and glycoprotein iib/iiia (eg eptifibatide, tirofiban, abciximab)
- if no help, TIMI >3, troponin inc, or st changes >1mm should be given heparin and scheduled for angiography or cabg
- no elevated enzymes
- heparin bc clot in process of forming with PCI and GPIIB/IIIA
52
STEMI
- elevated enzymes
- TPA 30 min with st elevation or LBBB bc clot formed already
- st elevation 1mm in 2 leads
- PCI in 90 minutes
- best predictor of survival is EF
- no TPA if sx, melena, or BP>180/100
53
post MI stress test
- submaximal: 4-7 days after to se if cabg still needed, at a lower heart rate
- maximal: at HR 80%; 3-6weeks after
54
discharge meds for MI
```
ABCDE
Aspirin,antianginals, ACEi&dc@6wk if EFn
BB and BP
Cholesterol and cigs
DM and diet
Exercise and education
```
55
sequence of EKG changes
peaked t waves-->ST elevation--> Q wave--> t wave inversion--> st normal--> t wave normal over several hours to days
56
indications for a CABG
```
DUST
Depressed vent fxn
Unable to do PCI (diffuse dis)
Stenosis of left main coronary art
Triple vessel disease
```
57
dresslers syn
post MI 2-10weeks autoimm process
| -fever, pericarditis, pleural eff, leukocytosis, inc ESR
58
timeline of post MI complications
1. 1st day= HF tx with nitroglycerin and diuretics
2. 2-4days: arrhythmia, pericarditis
3. 5-10days:left vent wall rupture (acute pericardial tamponade causing electrical alternans, pulseless elec activity, pap muscle rupture (MR)
4. weeks to months: ventricular aneurysm (CHF, arrhythmia, persistent st elevation, MR, thrombus formation)
59
hypercholesterolemia
- total cholesterol >200, LDL >130, trig >500, hdl20yo and repeat q5years if high
- total chol >200 twice is dx
- start medical therapy with CAD LDL >130, with 2+risk factors LDL >160, with 0-1risk factors LDL>190
60
BP goal
1. <130/80
61
lipid lowering agents
1. statins: hmgcoared inh; dec LDL/triglycerides; se inc lfts, myositis, warfarin potentiation
2. lipoprotein lipase stimulators (fibrates): gemfibrizol; inc lipoprotein lipase leading to inc vldl and trig catabolism; dec tri and inc hdl; se gi ipset, cholelithiasis, myositis, inc lfts
3. chol absorption inh: ezetimibe; dec ldl; se gi and engioedema
4. niacin: dec fatty acid release from adipose, dec hepatic syn of ldl; inc hdl dec ldl; se skin flushing stopped with asa, parasthesias, pruritis, gi, inc lfts
5. bile acid resins: cholestyramine, colestipol colesevelem; binds bile acids to dec stores so inc ldl catabolism; dec ldl; se gi lfts myalgia, can dec absoprtion of other drugs
62
htn meds
1. stage 1: 140/90: thiazides for most pts; others can be considered for combo
2. stage 2: >160/100; 2 drug combo usually thiazide plus others (scei, srbs, bb, ccb)
3. ABCD: Acei/arbs, BB, CCB, Diuretics
63
secondary htn
```
CHAPS
Cushings
Hyperaldosterone (Conns)\
Aortic coarctation
Pheochromocytoma
Stenosis of renal arts
```
64
hypertensive urgency, emergency, malignant
1. htn urgency: high bp with only mild/moderate sym(HA,syncope,cp) without end organ damage; tx with oral hypertensives (BB, clonidine, acei) with goal dec bp in 24-48hrs
2. htn emergency: sig high bp with sym og impending end organ damage such as arf, intracranial hemm, papilledema, ecg changes of ischemia or pulm edema); tx IV meds (labetalol, nitroprusside, nicardipine) to lower MAP by no more than 25% over the first 2 hours to prevent cerebral hypoperfusion or coronary insuff
3. malig htn: progressive renal failure and or encephalopathy with papilledema
4. htn crises are dependent on end organ damage extent not bp measurement
65
renal art stenosis
- in 50 atherosclerosis
-dx MRA or renal art doppler us
- tx angioplasty or stenting
- consider ACEi as adjunctive in uni dis
no ACEi in bl dis bc accelerates failure by preferential dilation of efferent arteriole
66
OCP use
htn in women >35yo and with long standing use
67
pheochromocytoma
-dx with urine metanephrines and catecholamine levelsl; sx removal of tumor after tx with both a and b blocker
68
centrally acting adrenergic agonists
methyldopa, clonidine
- inh sympatheitc nervous system via central a2 adrenergic rec
- se= somnolence, ortho hypotn, impotence, rebound htn
69
a1 blockers
-prazosin, terazosin, phenoxybenzamine
70
vasodilators
- hydralazine: se HA, lupus like syndrome
| - minoxidil: se orthostasis, hirsutism
71
pericarditis
- friction rub, inc jvp, pulsus paradoxus (dec sys bp >10 on insp)
- diffuse st elevation and PR depressions followed by t wave inversions
- avoid corticosteroids as tx for post MI within a few days after MI as can predispose to ventricular wall rupture
- effusions: transudate (chf, fluid overload, dec protein), exudate(pericasrdial inj), serosanguinaous (tb, ca), frank blood
- echo shows right atrial and right ventricle diastolic collapse; cxr shows enlarged globular heart
- ekg whos electrical alternans
- tx pericardiocentesis --> window or balloon pericardiotomy
72
AS
- mc sym: syncope, chf, angina
-pulsus parvus et tardus, paradoxical split s2
-dx echo=thick AV
txz; replace AV, balloon valvuloplasty canbridge to repalcement
-sx if valve area <0.8cm2
73
AR
- causes: rheumatic fever, ankylosing spond, syphillis etc
- widened pulse press= quinkes pulses, corrigans water hammer, duroziez femoral bruit
- dx echo dilated LV and aorta
- tx: vasodilator therapy: dihydropyridines or acei
- sx replacement with EF 55
74
MS
- mc rheumatic fever, pregnant with inc volume
- inc LA--> inc afib-->stroke; dysphagia hoarseness = inc LA on rec laryngeal nerve
- opening snap
- dx echo
- tx: antiarrhthmics for sym relief digoxin and BB
- mitral balloon valvotomy and valve replacement for severe cases bc its fibrosis
75
MR
- ischemic LV dilation=regurge
- EF45 = replace MV
- dx: echo, angigraphy can assess severity
- vasodilators(acei), digitalis, diuretics, anticoag
76
MVP
- P's: pain, palitations, syncope
- worse with valsalve and HOM
- better with squatting
- labs: echo displaced valve leaflets
- tx: endocarditis prophylaxis if murmur; bb for cp/arrhythmia
77
aortic dissection
- assym pulses and BP measurments
- neuro deficits may be seen if aortic arch or spinal art are involved
- ekg xray first; ct angiography gold standard of imaging ; TEE
- 2 classificaitons: DeBakey(inv both asc and desc type I, only asc type II, only desc type III); stanford(asc is type A and all others is typeB)
- asc dissexns are sx emergencies while desc ones can be treated medically with BP and rate control
- dont give thrombolytics
78
tx for valvulopathies
- valsalva makes hocm and mvp worse so no diuretics either
- MSAS: balloon and replace
- MRAR: ACE and amyl nitrate(opp of handgrip)
- HOCM and MVP: BB
79
DVT
- OCP use
- dx: doppler us, spiral CT or vq scan
- neg ddimer can be used to rule out PE in low risk pts
- tx: initial anticoag with iv unfrxed heparin or SQ LMWH followed by warfarin for total of 3-6months ; consider IVC filter in those with contraind
- hosp pts get prophylaxis of exercise, antithrombotic stockings, sq unfx hep
80
PAD
- aortoiliac dis:lerishe syn(butt claudication, dec fem pulses, impotence)
- femoropopliteal: calf claudication, dec pulses below
- acute ischemia: emboli from heart; acute occlusions mc occur at bifurcations distal to last palpable pulse; blue toe syn cholesterol atheroembolism
- severe ch ischemia: atrophy, pallor, hair loss, gangrene/necrosis
- dx ABI (rest pain ABI<.4), high ABI is clacification of art); doppler us; arteriography and digital subtraction angiography are necessary for sx eval
- tx: ASA, cilostazol and thromboxan inh; angioplasty stenting; bypass
- avoid BB in PAD secondary to B2mediated peripheral vasoconstrxn
81
Lymphedema
- from sx lymph node dissection, parasite infection (eg filariasis swelling of bl lower ext with no cardio problems), congenital malformation of lymphatic system like milroy's disease(kids with progressive bl swelling of extremities)
- tx sympotomatic no cure; diuretics are ineffective and relatively contraindicated; exercise, massages, and pressure garments to mobilize fluid
82
syncope
- secondary to cerebral hypoperfusion
- cardiac causes: valve lesions, arrhythmias, PE, tamp, dissxn
- noncardiac: orthostatic, neuro TIA/Stroke, met abn, neurocardiogenic syn (vasovagal/mictururition), psych
83
Digoxin
- competes with K so if theres dec K then theres more digoxin and will be toxicity
- BB inc K so it inh digoxing toxicity so do acei/arbs/spirinolcatone
- se: yellow halo, blurred vision, GI prob
- tx: digibind only for acute OD with CNS and ekg sym
