Cardio Lecture

Question 1

how fast should you get an EKG when patient presents with chest pain?

Answer 1

10 minutes

Question 2

how long is the time delay before a troponin may be positive?

Answer 2

6 hours

Question 3

renal disease, myocarditis, cardiac contusion, recent heart surgery may result in what?

Answer 3

false positive troponin

Question 4

between NSTEMI and STEMI, which is more of a thrombotic event? which is more of an embolic event?

Answer 4

STEMI = embolic

NSTEMI = thrombotic

Question 5

besides a thrombotic or embolic event, in what other way may a patient experience cardiac ischemia?

Answer 5

supply/demand mismatch

Question 6

ST elevation, ST depression, CP with hemodynamic instability, dynamic EKG changes are considered where in terms of risk?

Answer 6

high risk

Question 7

if a patient has a high risk history but a negative troponin, where do we place them in terms of risk stratification?

Answer 7

high risk

Question 8

low risk history with a normal EKG but a positive troponin is considered low, medium, or high risk?

Answer 8

medium risk

Question 9

a patient with stable angina that resolves spontaneously or with administration of STG SL is considered low, medium, or high risk?

Answer 9

medium risk

Question 10

if you diagnosis of chest pain is uncertain, how do you manage the patient?

Answer 10

MONA (morphine, O2, nitro, aspirin)
ACLS as needed
get CBC, electrolytes
serial troponins and telemetry

Question 11

how do we manage STEMI/UAP once we rule in the DX?

Answer 11

MONA
dual anti-platelet therapy
heparin
statin (high dose) for secondary prevention
beta blocker

Question 12

what are the 7 components that make up the TIMI score for evaluating 2 week risk of death, new or recurrent MI, or severe recurring ischemia that requires catheterization?

Answer 12

1) age over 65
2) 2+ risk factors for CHD
3) prior coronary stenosis greater than 50 percent
4) ST deviation on admit EKG
5) 2+ angina symptoms in prior 24 hours
6) elevated cardiac biomarkers
7) aspirin within past 7 days

Question 13

is anticoagulation and considered an immediate issue or post-immediate issue when dealing with atrial fibrillation?

Answer 13

post-immediate

first: verify rhythm, hemodynamic instability, ventricular rate control, BP management

Question 14

is cardioversion considered an immediate issue or post-immediate issue in AFIB?

Answer 14

post-immediate

Question 15

in pre-excitation syndromes, what might be the very first step in management?

Answer 15

cardiovert!

risk of embolism becomes second priorty

Question 16

in terms of afib, is the rate we see on the monitor or the apical rate that we hear on auscultation more important?

Answer 16

apical rate! this is the real rate. the machine is misleading because it only picks up on perfusion beats

Question 17

what diagnostic imaging of choice do we use to look for the presence of a thrombus in the right atria?

Answer 17

TEE

Question 18

in addition to EKGS, echos, biomarkers, etc. what lab should we always get? what imaging should we always get in a patient with AFIB?

Answer 18

1) always get TSH

2) always get chest Xray looking for pulmonary disease

Question 19

mortality rate, stroke rate, bleeding risk, and quality of life were all equal between rate vs. rhythm control in the AFFIRM study. what was the only difference between the two?

Answer 19

more hospitalizations in the rhythm control group

Question 20

what are the benefits to rhythm control for a fib?

Answer 20

maintain sinus rhythm, optimal cardiac output, improved LV function over time

Question 21

which drugs are use in pharmacologic rhythm control for a fib?

Answer 21

AMIODARONE, flecainide and others

Question 22

what is the biggest side effects of rhythm control for a fib?

Answer 22

all the drugs are pro arrhythmias (patient can go into VT, torsades)

Question 23

how effective is rhythm control for a fib?

Answer 23

only 50-60 percent effective at maintaining SR long term

Question 24

what are our four rhythm control options for a fib?

Answer 24

DC Cardioversion
Drugs
MAZE procedure
radiofrequency catheter ablation

Question 25

risk of stroke is MUCH higher after how many hours of being in afib? how do we manage a patient who presents having been in afib for the past 72 hours that wants CV?

Answer 25

much higher after 48 hours if after 48 hours: 1) full anticoagulation (warfarin) for minimum 3-4 weeks 2) come in for DC cardioversion 3) continue warfarin 4 weeks after

Question 26

which carries the highest risk of stroke -- shock, drugs, or spontaneous cardioversion?

Answer 26

all the same!

Question 27

what is the alternative option in your patient presenting past the 48 hour mark who wants to get cardioverted sooner than 4 weeks?

Answer 27

fully anticoagulate with heparin or LMWH proceed with CV warfarin continued for 4 weeks post CV as with other option

Question 28

if a TEE is performed and thrombus is ruled out, what can we jump straight to?

Answer 28

DC cardioversion without having to anticoagulate

Question 29

long term success rate with the MAZE procedure?

Answer 29

90 percent

Question 30

short term success rate with catheter-based radiofrequency ablation?

Answer 30

65-80 percent

Question 31

enough about rhythm control, what do we actually do 80 percent of the time?

Answer 31

rate control

Question 32

which drugs are used for rate control? what do they all cause?

Answer 32

diltiazem, beta blockers, or digoxin all cause hypotension bc decreased cardiac output (digoxin is exception; it slows the heart but increases cardiac output)

Question 33

alternative to drugs for rate control?

Answer 33

AV node ablation, permanent ventricular or AV pacemaker

Question 34

what scoring system do we use to decide if we want to fully anticoagulate our atrial fibrillation patient who opts for rate control?

Answer 34

CHADSDS-VASC ``` CHF: 1 Hypertension: 1 Age over 75: 2 Diabetes Mellitus: 1 Stroke/TIA HX: 2 Vascular disease: 1 Age 65-74: 1 Sex (female): 1 ``` max score is 9

Question 35

should a patient with a CHAD score of 1 be anticoagulated?

Answer 35

consider

Question 36

should a patient with a CHAD score of 2 be anticoagulated?

Answer 36

yes

Question 37

how should we initiate anticoagulation in a patient who decides to go with rate control?

Answer 37

warfarin with heparin bridge no bridge for novel oral anticoagulants

Question 38

if patient with AFIB has no prior history of thromboembolism or presence of thrombus, do we bridge them to warfarin?

Answer 38

nope! no heparin needed

Question 39

what are our three options when treating wolf parkinson white? what drugs do we HAVE to avoid?

Answer 39

1) cardioversion primary objective 2) rate control with amiodarone 3) ablation (TOC) AVOID diltiazem or beta blocker -- will put them into torsades

Question 40

systolic heart failure is characterized by an ejection fraction less than what?

Answer 40

less than 40

Question 41

what is the primary culprit of acute pulmonary edema in the hospital setting?

Answer 41

IVF administration

Question 42

what must we always give when a patient with CHF receives a transfusion?

Answer 42

IV diuretics transfusion fluids have very high oncotic pressure and pull fluid into the circulation -- can promote pulmonary edema

Question 43

which cardiac arrhythmia can precipitate acute pulmonary edema in CHF?

Answer 43

atrial fibrillation (bc it decreases the effectiveness of the heart pump)

Question 44

how do we medically manage mod-severe acute heart failure in the hospital setting?

Answer 44

1) IV diuretic 2) O2 (they are hypoxic from the pulmonary edema) 3) NTG 4) morphine for pain

Question 45

what should the sodium intake and fluid intake of a patient in heart failure be?

Answer 45

sodium limited to 2g/day fluid restricted to 1-1.5 L/day

Question 46

what medications must be avoided in the setting of acute heart failure in the hospital?

Answer 46

NSAIDS (can cause hyperkalemia, Na retention) | antiarrhythmics

Question 47

you should always _____ the head of the bead in acute heart failure

Answer 47

elevate

Question 48

true or false --- you should give your patient in acute heart failure a beta blocker to help protect his heart

Answer 48

FALSE will make it worse -- wait until stable

Question 49

you should consider an intensivist/cardiology consult if your patient presents with this triad during heart failure

Answer 49

1) hypotension SBP less than 90 2) oliguria 3) low cardiac output (cool, pale extremities, weak pulses)

Question 50

which two beta blockers have shown benefit over time for patients with left ventricular dysfunction to heal the heart and improve function?

Answer 50

carvedilol and metoprolol

Question 51

which drug is sometimes used for systolic heart failure, because it helps control heart rate while also increasing cardiac output?

Answer 51

digoxin

Question 52

when should we consider intubation in our patient in acute heart failure?

Answer 52

severe hypoxemia or respiratory acidosis not responding to therapy

Question 53

SO. in general -- how do we treat mild-moderate acute on chronic heart failure? do they require admission?

Answer 53

IV or oral diuretics unless complicated by a precipitating factor (MI) or life threatening condition (electrolyte imbalance, arrhythmias) these patients do NOT require hospital admission beyond a few hours of observation in the ED as outpatient