Cardio Notes Test II Flashcards
(270 cards)
1
Q
Any pt that comes in with acute chest pain, what is the FIRST STEP
A
CARDIAC SAFTEY NET
P-position of comfort or feat dangling over bed leaning forward
O-O2 is sat is below 95%
M-Monitor with EKG, SPO2, HR, RR, ETCO2
I- IV, with LABs (CBC, Troponins, BMP)
M-Morphine 2.5-5 mg for acute chest pain as long as BP can tolerate
O- Maintain O2 sat above 95%, avoid O2 toxicity
N- Sublingual Nitro, As long as EKG does not C/I
A- Aspring 326 mg, withhold is suspected Dissection, anuerysyms, recent TIA, or blook cloting D./0
Then evaluate need for PCI withing 90-120 minutes
Think Stable vs unstable angina, ACS, MI, NSTEMI
Long term
B- Betablocker for HF ( Labetalol, propranolol, metoprolol)
A- ACE ( lisinopril)
S- Stating (look at primary prevent guidlines, High intensting atorvastatin or rousuvastatin)
H- LMWH or Heparin (look at CHA2DS2VASc score)
C/T- Clopidogril or Ticagalor ( PY12 drugs, Ticagalor preferred)
2
Q
A ACS/ CHest Pain pt presetns with fever, what should be you immediate DDx
A
Esophageal rupture or PE
3
Q
What does the acronym VINDICATES stand for
A
Vascular Infextion Neoplastic Drugs/Degenerative Inflamatory/Idiopathic Congenital Autoimmune Truma Endocrine/ Enviromental Something else
4
Q
What is the leading virus that causes pericarditis
A
Coxsackie B
5
Q
What is post MI pericarditis called
A
Dresslers syndrome
6
Q
You see ST elevations with PR depression think
A
Pericarditis
7
Q
On EKG you wide spread ST depressions with ST elevation in AVR only
What is this
A
Partial Left Main/ 3 Vessel occlusion
NEED CABG!
8
Q
What is becks triad
A
Triad of S/s of Tamponde
Muffled Heart Sounds
JVD
HOTN
Will also be tachycardic with a Low CO
(Can also have electrical alternans or LOW VOLTAGE QRS complexes, and narrowing pulse pressures)
9
Q
What is the w/u for pt that presents with esophagitis
A
Upper endoscopy and mucosal biopsy
10
Q
What does the acronym PIECE for esophagitis mean
A
PILLS (NSAIDS) INFECTIONS (Candida, CMV, HSV) Eosinophilc Caustic Everything else ( GERD, PPIs)
11
Q
What is Jod-Basedow phenomenom
A
A hyperthyroid reaction that is associated with amioderone, Graves Dz, pts with goiters, or thyroiditis
Can present with Chest Pain, and Tachycardia, palpations, dyspnea, arrythmias, and systolic HTN
Understand increased B stimualtion leads to a faster HR
They key is these pts present with a decreased expression of phospholamban
12
Q
A pt presents with left axis deviation, tearing chest pain, ECG shows no ST changes, and Troponins are NML
Think
A
Aortic dissection 2ndary to Long standing HTN
13
Q
What are the two etiologies of Angina pectoris
A
Vasospastic diseases like Prinzmetals/ reynauds
And Atherosclerotic Dz
- Stable angina (SA) and Unstable Angine (USA)
- MI/ ACS
14
Q
A pt presents with chest pain that occurs at rest, and in clusters, with transient ST elevations..
think
A
Prinzmetals
15
Q
What is the earliest and often MC complaint of ACS
A
Dyspnea
16
Q
What are the cardinal S/s of ACS
A
Dyspnea,
Claudication
Syncope (ominous)
Fatigue
17
Q
A pt presents iwth atruamatic acute Chest pain with an O2 sat less than 80.. .
What must you do
A
Apply Supplemental assisted ventilation
18
Q
Before Admin of Asprin in ACS what must you do
A
Check BP in BUE
Check symetric pulses,
Check ECG for LEFT MAIN! May need CABG/ Surgery so no Asprin should be given
19
Q
What are the labs that are essential to order in the 1st 10 minutes in ACS
A
CBC BMP Cr and BUN (part of a BMP) PPT and Pt or INR Lipids And Troponins
20
Q
In ACS how are troponins checked
A
Initially and then at 6 hrs
21
Q
A female pt or DM pt presents with dyspnea, Epigas pain, Syncope.. think
A
ACS/MI?
Check BG (BMP and CMP), EKG, And Troponins
22
Q
What are the Rsk fxs for ACS
A
Age over 55 Male HTN Familial Hypercholestermia DM Smoking (Most modifiable) Smoking obesity HDZ in a 1* relative (Male less than 55 yr or Female less than 65 yrs)
23
Q
If a pt presetns with ST elevations and Chest pain, and you admin Nitrates and the chest pain resolves and the St elvations disappear…
What does the pt have
A
Prinzmetals angina
24
Q
If a ACS pt does not improve with subling Nitro,. What is the next step
A
IV nitro
25
What is the main C/I to NTG admin
RV MI
26
How often should ECK be repeated in suspected MI
Q5-10 MIN
27
What are the commom ECG findings in a NSTEMI
May be NML
Can have ST depressions
Or Deep Twave inversions of 1mm or more
WILL HAVE POS TROPONINS
28
What are the Dx criteria for a STEMI
ST elevations in contiguous leads,
NEW LBBB
Or Carousel Sign of Post MI
29
A pt with prinzmetals should be placed on what type of monitor
A holter monitor for 24 hrs
30
Can you give BB to a prinzmetal pt?
NO, it will worses Coronary vascon
31
Should you give BB to a pt in cardiogen shock or ADHF?
No, they are negative inotropes and will cause the pt to tank
32
What are the three accepted BB in CAD managment
Metoprolol
Bisproplol
Carvedilol
33
Before giving a pt a betablock what must be r/o
That the HR can support it, they are not in ADHF, that they have already been given nitrates, and we have confirmed the pt is not on a stimulant
34
An ACS pt presents with underlying HF, what medication can allieviate congestion
IV loop diuretic (furosemide)
35
What is the DOC for severe and persistnet chest pain
IV morphine 2-4 mg q5-15 min
36
What is the Tx appraoch to a pt with UA or NSTEMI
Anthithrombic Tx
( Clopidigrel/ ticagrelor)
Asprin
May need Anticoagulation Tx as well with Heparin/ LMWH
This prevents thrombin or emboli from the plaques
37
What are the 7 factors of a TIMI score
Age greater than 65
More than 3 rsk fx for CAD
Prior Stenosis greater than 50%
St depression s
More than 2 anginal events
Troponins
Or use of ASprin in the previous 7 days
38
If the Heart score is less than 3, what is the Tx appraoch
The pt is said to be low risk and can be seen in an outpt non emergent setting
39
In pts with heart scores greater than 3 with a TIMI greater than 3
What is the tx appraoch
Plan early invasive angiography with PCI or CABG as necessary
40
In pts with herat scores greater than or equal to 3 with TIMI scores less than 3…
What is the Tx approach
These pts require noninvasive stress testing with Tx tailored to the results
41
Pts with grace scores greater than 140 require…
Early intervention of Angiograpyhy withing 12 hrs
42
Pts with grace scores between 109 and 140 require
Delayed Angiography? Reprofusion within 72 hrs
43
Pts with a grace score less than 109 require..
Noninvasive testing to determine need for Coronary angiography/ Reprofusion
44
Do we care about grace scores in pts with STEMI
NO!
| They need PCI within 90-120 minutes
45
What are the HIGH rsk pts who do not have MI but still require Angiography within 12 hrs
```
Hemodynamically unstable
Cardiogenic shock
LVHF
Recurrent or Persistent Angina
New or Worseing Mitral Regurg
New VSD
Sustained VTac/ Vfib
```
46
What is areteriolosclerosis
Can either be hyaline or hyperplastic
Hyaline is protien deposited in the vessel walls
Hyprplastic in an expansion fo the basmenent membrane of the vessel wall
47
What is medial calcific sclerosis
Calcification of the tunica media
Visuallize of X-rays, asymptomatic
48
What are the most common arteries affected by arteriosclerosis
1. ABD aorta
2. Coronary Arteries
3. Popliteal artery
4. Carotids
49
What are the modifiable and nonmodifiable RSK FX for areteriosclerosis
```
Mod:
HTN
DM
Smoking
High LDL w/ Low HDL
```
NonMod:
Age
FMHx
African Americans
50
Where in the vessel is injury to the endothelium most likely to occur
At arterial bifurcations (wall stress)
51
What is the pathological progression of arterioslerosis
1. Injury to the endothelium with leaking of LDL into the intima
2. Macrophages scavenge the LDL creating foam cells
3. Foam cells form Fatty streaks from Platlets+ endothelial cells
4. Produces and extracellualr matrix, aka a plaque (The transition from asymptomatic to symptomatic)
5. Foam cells necrose leading to metaloprotieinase of cells, causing plaque rupture (symptomatic)
6. Platlets aggregate aroudn rupture occluding vessle with a fibrin clot leading to subsequent ischemia beyond the clot. (Symptomatic)
52
What percent of vessel occlusions present with S/s
70% of vessel occlusion produces S/s
53
Where does the ABD aorta begin ( common site for aneurysm)
Below the level of L2
54
What are 4 major complications for a dislodged plaque
Besides MI or Stroke
Livedo reticularis (web lik vein skin pattern)
Hollenhorst plaques in the retina
AKI
Or gangrene
55
A pt presents with Chronic HTN and DM, they have excess glucoes and protiens in the blood, what are they at an increased Rsk of developing
Arteriolosclerosis (Hyaline)
Which can cause HTN and DM neuropoathy and Lacunar Infarcts in the brain
Looks like a glassy pink appearnce in the vessel wall
56
A pt presents with severe acute elevations in BP, with an onion skin look to the vessel wall
Think
Hyperplastic arteriolocsclerosis
MC effects the renal, retinal, and intestinal arteries
57
What is Monckberg sclerosis
Medial calcific sclerosis or the internal lamina and tunica media
58
On X-ray you see a ‘pipestem appearance of the Aorta”
Think
Monckberg sclerosis
59
What is the defintion of dyslipidemia
Elevaed LDL with a Low HDL
60
What is the rate limiting step of cholestrol synthesis and is the MOA of statins
Conversion of HMG-CoA to mevalonate is catalyzed by HMG-CoA reductase (rate limiting step of cholesterol synthesis)
HMG-CoA reductase inhibitors (Statins) inhibit this conversion
61
What transports choleserol and TriGs from the liver to the cells and back..
Apoprotiens
62
What is a chylomicron
A microscopic particle of blended fat found in the blood and lymph; formed during the digestion of fats
Contains Protein 1-2%, Triglyceride 85-95%, and cholesterol 3-6%
63
How can you estimate the VLDL level
TriGs/5
64
What is the Apoprotien that moves LDL around
Apo-B100
65
What is the desiarble Total Cholesterol level
Less than 200
200-239 is borderline
240 or more is high
And higher than 280 is very high
66
What is the total cholestoral calculation
LDL+HDL+(TriGs/5)
67
How often should adults over the age of 20 be screened for high cholestreol
Every 5 years
68
What is an optimal LDL level
Less than 100 is op
```
100-129 is near optimal
130-159 is borderline
160-189 is high
190 or more is very high
(high Statin required)
```
69
What are good or bad HBL levels
Less than 40 is bad
| Higher than 60 is good
70
What are NML TriGs level
Less than 150 is NML
150-199 is borderline
200-499 is high
And anything higher than 500 is very high
71
What is the 10 yr ASCVD rish assesment based on
NonMod:
Age, race, sex
```
Mod:
Total C
HDL
SBP and DBP
Tx of HTN
DM
Smoking
```
72
What are the 4 ASCVD equivalents
ACS within the past 12 months
Previous MI
Previous CVA
PAD (ABI less than 0.85, a Hx of revasc, or amputation)
73
What are the High risk conditions for 2* prevention of ASCVD
```
Age over 65
Familial hypercholestermia
Prior Bypass or PCI
DM
HTN
CKD
Smoking
LDL greater than 100 despite maxiamlly tolerated Statin. + ezetimibe
Hx of CHF
```
74
What makes a pt Very High risk in the 2* prevention calculator
2 major ASCVD events or 1 Major +2 high risk conditions
Very High Risk pts need LDL-c reduction to below 70 mg/dl
Not very high risk pts need 50% decrease in LDL
75
A DM pt has a History of MI and HTN
They are 65 yrs old
What is the treatment approach to prevent ASCVD
2* prevention with 1 major 2 high risk conditions
High intensity statin with goal of LDL-C less than 70
If goal not met- add exetimibe
If goal still not met add a PCSK-9 inhibitor (ends in maub)
76
What is the Tx approach for pts with Previous MI with no other Hx or Risk conditions
Look at age..
Older or younger than 75
If younger: High intensity statin with 50% reduction goal
If High statin is not tolerated then Mod statin can be used
If LDL is still greater than 70 add ezetimibe
If the pt is older:
Use either a mod or high intensity statin depending on pt tolerance
77
What are the risk ENHANCING fxs for ASCVD
FMHx of ASCVD (Male less than 55, female less than 65)
Preeclampsia or menopause before 40
Metabollic syndrome
HIV, RA, Psoriasis, Lupus, ART
CKD
LDL routinely above 160
South Asian decent
Triglycerides routinely above 175
ABI less than 0.9 if diabetic
78
What is the criteria for metabolic syndrome
Requires three of any of the following
Waist 40 inches men or 35 inches women
Tri Gs above 175
HDL less than 40 men or 50 women
BP greater than 130/85 or taking HTN meds
Or Fasting gl greater than 100
79
What are the 5 steps to primary prevention of ASCVD
1. LDL greater than 190?
2. Dm?
3. Age greater than 75? Or 20-39
4. Risk calc
5. Cac score
80
A 34 year old male with an LDL of 165 witha. Family Hx of premature ASCVD (father at age 40)
What is his primary prevention of ASCVD approach
Moderate intensity statin
81
When do we initiate statins for pts 0-19 yrs old in primary prevention of ASCVD
If they have familial hypercholesteremia
82
When do we initiate statins in pts older than 75 in primary prevention
In LDL is 70-190 and the pt accepts the risk and can tolerate the ADE ( if CAC is zero then they can decline)
83
A 41 pt with metabollic syndrome presents for primary prevention of ASCVD
LDL-C is 165 with a 6% Risk calculation
What is the Tx approach
Risk descussion for a mod intensity statin
Pt is in the age range for risk stratificatoin and has a high risk enhancer.
84
What zre the 2 high intenstisty statins
```
Atorvastatin (40-80mg)
and Rosuvastatin (20-40mg)
```
85
What are the 4 mod intensity statins
Atorvastatin (10-20mg)
Rosuvastatin (5-10mg)
Simvastatin (20-40mg)
Pravastatin (40-80mg)
86
How much time should be allowed to pass before adjusting statin tx
4 weeks
87
What are the ADE of statin Tx
Myalgias
Myopthay (CK> 10 x ULN)
Rhabdo
Liver toxic (Rare)
88
When should AST.ALT be chesked after statin tx
Baseline, 4 and 12 weeks
Beyond that only needed in pt presents with ADE
89
What are the prominemt fxs that increased the risk of statin induced myopathy
```
Age greater than 75
Being a woman
Renal insuff
Hepatic Dysfunc
Hypothyroidism
Grape juice
ETOH abuse
Asian ancestry
```
90
So atorvastatin or pitavastatin require renal adjustments
NO
91
Which statin is not protein bound
Pravastatin
92
Becasue statins are highly protein bound, they may dispalce what other medication
Warfarin!
93
What is an absolute C/I to statin Tx
Active liver Dz or unexplained elevations in Hepatic enzymes
94
Can preg pts be put on statins
NOPE!
95
Grapefruit juice and Red Yeast rice effect statins how
Grapefruit: increased rsk of myopathy
Red yeast: increased rsk of rhabda
96
If you use statins and fibrinc acid derivatives together
What is the outcome
Sever myopathy !! Rhabo
So dont use gemfibrozil with a statin
97
When useing statins with niacin, what is the risk
Myopathy, rhabdo, or liver tox
98
Use of amioderone, diltiazne or verapamil with statins increase the risk of what condition
Myopathy
99
If a pt is on warfarin, what statn should be used
Pravastatin
100
If a pt is on amlodipine , what statin shoul be used
Rosuvastatin
101
If a pt is on amioderone what statin should be used
Rosuvastatin
102
If a pt is on digoxin, what statin should be used
Rosuvastatinn
103
If a pt just really loves grapfruit juice, what statins should be used
Prava, rosuva, or pivastatin
104
If a pt is on ranolazine what statin can they be put on
Atorvastatin
105
What is the MOA of fibric acid derivates
Stimulates lipoprotein lipase activity which hastens the removal of chylomicrons and VLDL from the plasma (subsequently decreases TG)
106
What is the DOC for lowering TriGs
Fibric acid derivatives
107
A pt has HIV, and the tx is raising thier TriGs for viral protease tX
What drug can we use to lower thier TriGs
Fibic Acid Derivates
108
What is the MOA of Ezetimibe
Selective inhibitor of intestinal absorption of cholesterol and phytosterols at the brush border
Effective even in the absence of dietary cholesterol because it inhibits reabsorption of cholesterol excreted in the bile
109
What are the two PCS K9 inhibitors are what are thier MOA
Aliro and Evolocumab
Human monoclonal antibody that inhibits the PCSK9 enzyme, stopping it from binding to the low-density lipoprotein receptors (LDLR)
By inhibiting the binding of PCSK9 to LDLR, the number of available LDLRs increases to clear LDL from the blood
110
What are the ADE of PCS K9 inhibitors
Nasopharyngitis, injection site reactions, and influenza
111
What are the screening recommednations for hyperlipidemia
For men 20-35 y/o and women 20-45 years old in increased risk of CHD such as obesity, smoking, DM, PMHx, HTN
112
What is the w/u for rhabdo
CK, creatine, and UA for myoglobinuria
113
What percentage of vessel usually needs to be occluded to be symptomatic
Around 70 % with exertion
| Around 90% at rest
114
When is the left ventricel perfused
During diastole
115
What are the vascodialtors produced by the endothelium
NO, prostacyclin, EDHF
CO2 and Lactic acid also vasodilate
116
What are the vascon produced by the endothelium
Endothelin 1
117
What is stunned myocardium
Short-term, total or near total reduction of coronary blood flow
Then Reestablishment of coronary blood flow
Subsequent LV dysfunction of limited duration
118
What is hibernating myocardium
State of persistently impaired myocardial and LV function at rest due to chronically reduced coronary blood flow that can be partially or completely restored to normal either by improving blood flow or by reducing oxygen demand
These are your chronic stable angina pts. This is a long time problem, EF is low over several years. It’s a protective mechanism.
119
A pt can present with only Dyspnea and still have..
Angina
120
A pt with typical symptoms of angina pectoris who have no evidence of significant atherosclerotic coronary stenosis on coronary angiograms
Think
Cardiac Syndrome X
121
DM pts are at an increased risk of what kind of ishcemia
Silent
Also more common in women and the elderly ( the atypicals)
122
What is diamond critera
For typical vs atypical chest pain
Typical is Substeranl, Worse with exertion, and relieved by NTG
3/3 is typical
2/3 is atypical
0-1/3 is non anginal
123
A pt with a recurring MI, in the same day, what lab can detect this
Myoglobin or CK, troponins will already be elevated
124
A pt presents with a Heart score of 1-3 and is stable, what is the tx approach
D/c from hospital, follow up with PCM
125
Pt presents with Heart score above 3, and a timi 1-2
And is stable
What is the approach
Non invasive testing
| Treadmill, pharm stress test, ect
126
PT with a Heart score >3 and a timi > 3 or grace >140
And is stable
Approach?
12 hr Invasive angiography
If grace is 109-139 then 72 hours
127
A pt with a Heart score >3, TIMI> 3, or grace > 150
Is UNSTBALE or High risk
What is the approach
2H time to invaisive angiography
128
What are the numbers for a duke treamdill score
Low risk is score >5
Intermediate is score from
4 and -11
High risk is any score less than -11
129
A duke score of 5+ has what 5 year survival
97%
130
A duke score of 4 to -11 has what 5 yr survival
90%
131
A duke score less than -11 has what 5 year survial
65%
132
If a pt is unable to excercise, waht drug is used in pharm testing
Dobutamine
133
What are the three drugs often used in Stable angina
The three classes of medications most commonly used are β-adrenergic blockers, organic nitrates, and calcium channel blockers (LAST RESORT)
134
What is the only drug proven to prevent reinfarctionf and increase survival post MI
BB
135
When are ACE inhibitors used in angina pts
Consider in High risk pts
| Does not treat angina its self but contributing fx: HTN, DM, CKD< LVEF less than 40%
136
When is coronary revasc preferred (3 circumstances)
(1) Anginal symptoms do not respond to antianginal drug therapy
(2) Medications causes unacceptable side effects
(3) There is high-risk coronary disease, which warrants revascularization
137
When would a pt get a bare metal stent vs a drug eludiong stent
DES is perferrd,
| BMS when the pt can not tolerate dual antiplatelt therapy
138
When should a pt get a CABG
If >50% left main stenosis
| 3 or more vessel CAD or if LvEF is less than 50%
139
If a pt receives a DES for SIHD , how long do they required antiplatelet tx
6 months of Asprin +clodiagrl. Ticagrelor
140
If a pt receives a BMS for SIHD, how long do they require antiplatlet tx
A least 1 month 1 asprin + PY12 inhibitor
141
If a pt gets a DES for ACS
| How long do they require antiplatlet Tx
12 month asprin + PY12 inhibitor
142
What are the two types of CABG and which is superior
```
Native vessle and
arterial flap(**)
```
143
A pt presents with TachyHR and a new S3 murmur
Think
STEMI
144
What defines a TRUE posterior MI
ST elevations in II, III, AVF
Tall R wave with ST depression in V1 V2,
145
What conditions can lead to non atherosclerotic Coronary emboli
```
Severe anemia
Blood D/o
Shock
Vasospasms
Angiography
DVT with R-L shunt
```
Lupus
Takayasus
Kawasakis
Giant Cell arteritis
146
How many negative sets of troponins rules out an MI
3 sets
147
When do troponins rise, peak and return to baseline
Rise in 3-4 hrs
Peak at 18-36
And return to baseline in 7-10 days
148
What are the basic considewrations for a pt with UA/NSTEMI
Asprin ASAP and Ticagrelor
GPiib/IIIA rarely used anymore is tx with above meds are started within 30-45 min of PCI
Then consider Heparin vs LMWH
UFH is preferred if planning early invasive management given less bleeding than with LMWH
LMWH is preferred if planning a conservative management approach given lower mortality, MI, & revascularization
149
When would you use bivalirudin for antithrombin tx in a UA/Nstemi
Use if Heparin-induced thrombocytopenia occurs
150
Should UA/NSTEMI pts receive fibrinolytics
HELL TO THE NO!
151
When should fibrinolytics be used in STEMI MGMT ?
Only when pci is not available within 90-120 minutes
152
What should be performed immeditaely for ROSC pts with Stemi on ECG
Angiography and PCI
153
A pt with a TIMI score of 3 that needs invasive surgery should be placed on what antithombic tx
LMWH
154
What are all the meds that a pt with a STEMI or new LBBB be put on
```
Aspirin
PY12
Nitro
BB
UFH/LMWH
Statin
```
155
When should ACEI be started for StEMI pts
Within 24 hrs
156
What mediaction must be stopped if starting statins
NSAIDS
157
What is the clinical sig of Wellens syndrome
Wellen’s syndrome is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD).
extremely high risk for extensive anterior wall MI within the next few days to weeks.
158
Should pericarditis pts get NSAIDs
No it increased mortatlity
159
How should pts that present with cardiogenic shock after discharge for a MI
Treat as stage D-class 4-acute-decompensated-HF (Inotropes, IABP, LVAD, heart transplant)
160
A pt presents post my with pericardial dz…
Think
Dresslers
161
What are three drugs that can induce pericarditis
Hydralazine
Methyldopa
Isoniazid
Also procanamide!! And phenytoin
162
What is the Tx approach to Acute pericarditis
NSAIDS (indomethacin)
| Can combine with colchicine
163
What autoimmune conditions can lead to pericarditis
RA and Lupus
164
What is the common viral infex for pericarditis
Coxsackie B
165
What makes a pt with pericardits high risk
```
Fever greater than 100. 4
Pericard effusion
Tamponade
Immuncomp
Warfarin use
Acute truama
Failure to improve with 7 days of NSAID tx
Elevated troponins =myopericarditis
```
166
When would you use corticosteroids in a pt with acute pericarditis
Only if NSAIDs and colchicine failed
However my exacerbate viral pericarditis and increase reoccurance
167
What is the MOA of Colchicine
Inhibits neurtophil motility and decreased inflamation
168
A pt presents with Acute pericardits post MI (dresslers) what is the Tx
Asprin (not NSAIDs that impede healing) and colchicine
169
What is the definition of Constrictive pericarditis
Impariment of diastolic filling without impairment of systolic function
170
You hear a pericardial knock during diastole
Think
Constrictive pericarditis
171
How does constrictive pericarditis effect the atria
Way cause Afib from increased pressures
172
A pt presents on echo with thickened pericardium, and abrupt cessation of LV and RV diastolic filling
What two other finding would they have
Biatrial enlargment
Intervent shift/ flattening
173
What is the Dx imaging for constrictive pericarditis
Cardiac MRI
174
What is the Dx of choice for constrictive pericarditis
Cardiac MRI
175
What is the Tx for constrictive pericarditis
Pericardiectomy
176
What are the s/s of obstructive shock
HOTN, Tachy HR, decreased CO
177
What is pulsus paradoxis
A 10 mmHg drop in Systolic BP on inspiraton
Classic sign of tamp
Can also happen in asthma ,OSA, croup, and pericarditis
178
What is EWARTs sign
Dullness to percussion over the left subscap area.. sign of pericardial effusion
179
A pt with equal pressures in all 4 chambers of the heart, has what ..
Pericardial effusion leading to tamp
180
What is the Image of choice for effusions
Echocardiography
181
If the fluid is bloody on pericadiocenteis think
Truama, CA, PE
182
IF the fluid is chylous on pericardiocentes think
Thorcic ducy injury ot leukemia inflitration
183
If the fluid is purulent on pericardiocentesis think
Infection
Look a WBC, Proteins, Glucose
or LDH
184
What is the NML pericardial fluid level
15-50 mls
185
What are common causes of Pericardial effusions
Viral/bacterial pericarditis
Hypothyroidism (Increased perm)
CHF (increase in cap pressure)
Cirrhosis (oncotic pressure)
Aortic Disect
Radiation
Post MI
Uremia with CKD
186
Pt presents with dyspnea, dysphagia, and hoarsness of the voice, +/- hiccups, and JVP with a dominant x descent
Think
Effusion
187
How do effusions look on EKG
Flat T waves or Low voltage QRS
188
What is the hallmark EKG finding of effusion
Electical alternans
189
What is a 1st line Tx for Tamponadde
IV fluids
190
A pt presents with intermitten claudication, -peripheral edema, Absent/diminished pedal pulses, Black eschar on the toes, +/- smooth round sores on the toes or feet …
Think what kind of PVD
Arterial
191
A pt presetns with dull achy leg pain, lower leg edema, with irregular sores with irregular borders, -/+ yellow or ruddy skin
With sores located on the ankles …
Think what kind of PVD
Venous
192
What are the Rsk factors for PVD/PAD
Obestiy, DM2, Varicosites, or lymph obstruction
193
What is gangrene
Tissue infarcts
194
What is the classic S/s of PAD
Claudication
195
An ABI below 0.9 is DX of what condition
Occlusive arterial Dz
196
An ABI less than 0.4 is Dx of what
Rest pain
As well as ulcers and pedal gangrene
197
What are the indications for doing an ABI
AbNML or absent pedal pulses,
Age greater than 20 y/rs
Or age 50-69 with DM or smoking
198
An ABI greater than 1.3 in the setting of DM or ESRD should prompt what…
Dopplet waveform
Or Duplex Doppler
Toe pressures to eval for PAD
199
Falsely elevated ABIs can be a result of what condition
Artiololsclerosis which is common in CKD pts
200
What are the MOD rsk factors for PAD
Smoking cessation
BG control
TX of Dyslipidemia
TX of HTN
201
What are the three Tx options for PAD
Asprin
Bypass
Or amputation if comp
202
What questionarre screens for PAD
Edinburg claudication quistionarre
203
What are the 6ps of acute PAD
```
Pain,
Pallor
Parasthsai
Paralysis
Poikilothermia
Pulslessness
```
204
What is leriche syndrome
ED in the setting of PAD
205
A pt presents with PAD with pain in the hip, buttock or thigh
Where is the occlusion
Aortoiliac occlusive dz
206
A pt presents with PAD and calf/thigh pain
Where is the occlusion
Common femoral artery
207
Pain is the upper 2/3 of the claf is what kind of PAD
Superficial femoral artery occlusion
208
Calf pain in the lower 1/3 is what kind of PAD
Popliteal artery occlusion
209
A pt presetns with pallor on elevation and rubor with dependency.. think
PAD
210
Thickening of the nails, lost of hear on the legs
Are both signs of…
PAD
211
What three pt groups should automatically get ABI
≥50 years old with a history of smoking or diabetes
≥50 years old with a history of exertional leg pain or nonhealing extremity wound
≥65 years old
212
What is the gold standard of PAD dx
Arteriography
213
Spinal stenosis can mimic PAD?
Yes both present with hip, leg pain
214
What is the 1st line Tx for PAD/claudication
Lifestyle changed: excercise with meticulous foot care
215
What is the MOA of cliostazol
Phosphodiesterase inhibitor/direct vasodilator
Improves symptoms and increases walking distance
NOT used in Heart Failure patients
216
What antiplatlet tx are indicated for PAD MGMT
Asprin or clopidigrel
217
An ABI less than 0.9 is assoc with what fold increase in CVD events
2-4 x increase
218
What are the two non invasive tests for PAD
ABI and 6 minute walk test
219
What are the two main dz of the aorta and how are they defined
Aneurysm
Location: Thoracic or abdominal or both
Defined:
-dilation of the thoracic aorta >4cm in diameter
-dilation of the abdominal aorta > 3cm in diameter
Dissection
Location: Can occur at any point of the aorta
Defined: a tear in the intima layer of the vessel
220
What is ectasia
Artreial dilation less than 150 perccent
221
What is a True aneurysm
Involves all three vessle of the aortic wall, (I-M-A)
222
What is a “false” pulsatile hemoatoa “aneurysm”
Disruption of the aortic wall or an graft/vessel, with containment of blood by fibrous capsule made of surroiunding tissue
223
What is the duration of onset that differs acute vs chroinc A. Disection
Less than 2 weeks is acute
| Greater than 2 wks is chronic
224
What are the NML measurments of the Aorta
At the base: 3-4 cm
Ascending: 2.5-3.5
Descending: 2-2.5 cm
225
When does the ABD aorta start
Below T12
226
What are the 3 fx that deterimne afterload?aortic pressure
Volume of blood during systole
Vessel wall compliance
Resistance
227
What are the three types of aneurysms
Ascending and descending thoracic
And abdominal
Can also be saccular, fusiform, or psuedoaneurysm
228
What is the difference of aneurysm and ectasia
Ectasia: increased diameter but less than 50% increase from normal
Aneurysm: increased diameter at least 50% increase from normal
229
What is the most common location from abdominal aneurysms
Abdominal
230
What are the highrisk groupd for THoracic aneurysms
Older than 65
Male over female
HTN!
231
Ascending thoracic aneurysm requires..
Emergent surgery
232
What are the inherted conditions that can lead to ascending aortic aneurysm
Marfan, Ehlers-Danlos, Bicsupic Aortic Valves, Familial aortis aneurysms
233
What is the land mark that defines descending thoracic aneurysms
Start distal to the left subclav artery
234
What are the common etiologies for descedning thoracic aneurysms
Atherosclerosis
Salmonella, syphillis, TB, Staph/Strep
Takayasu or Giant Cell Arteritis
235
Describe the murmur of Aortic regurg
Diastolic blowing murmur of aortic regurgitation
236
What is the #1 imaging study for Thoracic aneurysms
TEE Is # 1
Can do a CT with or without con
MRI
US of ABD Aorta/ branches
237
A pt presents on Xray with elagment of the aortic knob, loss of the AP window, and a mediastinum at 8cm at a minimum…
Think
CXR
238
AAA most commonly effects what segment of the aorta
AAA most often affects the segment of aorta between the renal and inferior mesenteric arteries
239
What are the high risk groups for ABD AAA
65 and older
Male gender, white
Smoking
Atheroslerosis
HTN
Dyslipidemia
Family history AAA
Presence of other peripheral aneurysm
240
A pt presents with abd pain either in the left flank or lower back, +hydronephrosis, pulsating abd mass
Think
AAA
241
What is the measurement that defines Aneurysm in the abdominal aorta
Greater than 3 cm
242
What is the imaging TOC for stable aS/s pts with abd aneurysm
US
243
What is the imaging TOC for S/s STABLE anuerysm pts
CT scan
244
WHat is the recommended screening for AAA
65-75 yr with any smoking history with US
Do not screen females who have never smoked
245
An Aneurysm less than 4.0 should have what approach
Watchfull waiting
246
What is the criterai for surgical intervention in Aneurysms
Rate of enlargment greatert than 0.5 cm in 6 months or greater than 1cm in a year
247
What is the threeshold for surgical intervent in aneurysms
Ascending thoracic: 5-6 cm
Descening thoracic: 6-7
Abdominal: 5.5 cm or greater
248
What are the C/I to surgical repair of an aneurysm
Life expect <1year
Terminal Dz
Recent MI
U/angina
249
What two cystic medial necrosis syndromes lead to dissections
Marfans and Ehler-Danlos
250
Type B dissections are assoc with what S/s
Pain between the scapula, back, and abdominal pain
251
A pt presents with a new diastolic murmur, dyspnea, hemoptysis, HOTN, +/- tampanoda, renal insuff. And PAD
Syncope
Think
Aortic Dissection
252
A pt presents with UE blood pressure diff. Think
Aortic Dissection
253
What are the triad of S/s of Aortic dissection
Pain (sharp/tearing), Mediastinal widending, Pulse pressure variations greater than 20mmhg
254
What is the Test of CHOICE for Aortic dissection
TEE or Chest CT with Contrast
255
What is the tx approach to acute dissections
```
Morphine for pain
BP control
(propranolol, labetalol, esmolol)
Airway MGMT
Bedside TEE (unstable)
CT or MRI (Stable)
```
ADMIT
And deterime surgery approach
256
What is the best initial step to MGMT of aortic dissection
BP conctrol with Labetalol
257
What is the tx appraoch to lymphedema
Avoid limb injury
Skiin hygeine
Compression bandages (intensive) and lymphedema sleeves (Maintenance)
Excercise daily while wearing compresion
Massage
If left untreated can lead to subQ fibrosis
258
What is superficial thrombophlebitis
Bening D/o
Erthyema, indurataion, and tenderness along a SUPERFICIAL vein
Usually spontatneous or following IV cath
259
What are the triad of suppurative phlebitis
IV cath, FEVER, chills
| Treat surgically
260
What is buergers disease
An inflamatory cause of phlebitis
Only in smokers, may lead to amputation and death
Gets worse the more you smoke
261
What is trousseau syndrome
Recurrent superficail thrombophlebitis asscoited with cancer
262
What is the treatment to thrompbophlebitis ( superficial)
```
Bed rest
Elevation
Moist heat
Compression
NSAIDs
Pain Med
```
263
What is phlegmasia alba dolens
A DVT that wholly occludes the abilty to drain a limb, all draininage is dependent on superficial venous drainage
Typically appears in cancer or peripartum pts
THERE IN NO ARTERIAL ISCHEMIA
264
WHat is phlegmasia cerulea dolens
Rare complication of ALBA, where the superficial venous system become overwhelmes leading to massive edema and compartment syndrome
(Pain, pallor, parasthesai..ect)
PT Should be consulted to vasc surgery asap
265
What is the Dx choice for most pts with 1st episode of DVT
Compressive Duplex Doppler US
266
What is the gold standard Dx for DVT
Venography
267
When should we treat aS/s DVTs
If unprovoked, D Dimer greater than 500, Larger than 5cm, CA pt, recurrent, immobilized, or COVID
268
What is the DOC for DVT
Factor Xa inhibitors
Special cases:
Liver Dz, preg, or CA: LMWH
Poor med complicane, MS or CKD: VKA
269
What is the 5 step approach to DVT or PE tx
```
1 O2 and fluids
2 Anticoag (LMWH or Factor Xa)
3 Thombolysis if in shock
4 Vena cava filters
5 Surgery
```
270
What is the criteria for high risk disesctions
Impedning rupture, greater than 5mm per year expansion, recurrent pain, HOTN, or uncontrolled HTN
These pts need surgical repair even if its ABD aorta
