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Flashcards in CARDIO PACKET 2 TX Deck (17)
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1
Q

Ventricular tachycardia: > ___

When sustained vtach causes s/s of diminished perfusion EMERGENT TX is necessary
______ protocol
________ with 100-360 J, then ______ or lidocaine

A

100

ACLS
DC cardioversion
amiodarone

2
Q

Ventricular fibrillation

Surviving patients need evaluation and intervention (recurrences are common)

__________

  • Exclude coronary disease as underlying cause
  • Revascularization may prevent recurrence

If __ hours after infarction –> manage as other MIs

_______ = treatment of choice if no MI or other correctable causes found

After MI –> ____ outcomes with ICDs

A

coronary arteriography
24
ICD
worse

3
Q

sinus bradycardia:

_______ patients do not require treatment

______ for symptomatic bradycardia or sick sinus syndrome

In patients without evidence of AV nodal or bundle branch conduction abnormality, a ____ chamber atrial pacemaker is reasonable

A

asymptomatic
pacemaker
single

4
Q

sinus tachycardia

_______ OR

______ (anti-arrhythmic) –> slows Na+ influx/prolongs action potential OR

Radiofrequency modification of SA node

A

beta blockers

flecainide

5
Q

PVST

METHODS TO INTERRUPT ATTACKS:
_____ maneuver (doing a crunch and bearing down)
Stretching arms and body
Lower head between knees
Coughing
_________
Carotid sinus massage (one side at a time!!!)

MEDS:
1st line: IV _____ in bolus every 2 minutes prn
Effects: might have flushing and chest discomfort, can promote bronchospasm
2nd line: ____, IV _______, _____
Effect: potential to cause hypotension
____ (short acting beta blocker)
_____

_______ : if hemodynamically ____OR if you cannot use adenosine or verapamil or they don’t work

Synchronized electrical cardioversion beginning at 100 J almost always successful

PREVENTION: _________ radiofrequency –> the catheter tip delivers bursts of high-energy waves that destroy the abnormal areas

A

valsalva
breath holding

ADENOSINE
CCB
verapamil, diltiazem
esmolol
metoprolol

cardioversion
unstable

catheter ablation

6
Q

Atrial Fibrillation:

Patients with atrial fibrillation may spontaneously revert to NSR (normal sinus rhythm)

In acute presentation of a hemodynamically UNSTABLE patients:
MEDS: Rate control with IV _______ (esmolol, propranolol, metoprolol) or ______ (diltiazem, verapamil)
URGENT_______________: only in patients with shock, severe hypotension, pulmonary edema, acute MI
SAVE FOR CRITICALLY ILL PATIENTS because use of cardioversion in a patient with atrial fibrillation > ___ hours increases the risk of thromboembolism

In acute presentation of a hemodynamically STABLE patients, treatment should be focused on ______ CONTROL and assessment for ________ anticoagulate patients at high risk of stroke
MEDS: Attempt rate control with _______ or _____
IF CARDIOVERSION IS CONSIDERED: obtain ___ first to rule out L atrial thrombus  if thrombus present, cardioversion is _____ 4 weeks
ANTICOAGULATION:
Patients with lone atrial fibrillation (and no indications of cardiac disease) DO NOT NEED long term ________

Patients with paroxysmal, persistent, or permanent AF should be evaluated for long term anti-coagulation

______ to an INR target of 2.0-3.0 should be attained and maintained indefinitely (with at least 1 risk factor for stroke)

warfarin is not the best

Four direct-acting oral anticoagulants (DOAC) approved for stroke prevention in patients with atrial fibrillation:

Dabigatran (Pradaxa), Rivaroxaban (_____), Apixaban (______), Edoxaban (Lixiana)

ELECTIVE CARDIOVERSION:

Following appropriate anticoagulation –> still need months of anticoagulation

Recommended for:
_____ episode if AF of recent onset and there is a factor that appears to have initiated it
In patients who are still _____ from the rhythm despite aggressive rate control
Can be ELECTRIC or PHARMACOLOGIC

Pharmacologic examples:
IV ______: needs continuous monitoring by ECG for 3 hours
________: for both cardioversion and maintenance therapy

Can also use dofetilide, propafenone, felcainide, sotalol

FOR RECURRENT PAROXYSMAL A FIB (episodes of A Fib begin suddenly and usually stop spontaneously):
_______ pharmacologic cardioversion = “pill in the pocket treatment”
Without CAD or structural heart disease: flecainide or propafenone in addition to beta blocker or non-dihydropyridine CCB

Give first dose in a controlled environment

FOR REFRACTORY (UNMANAGEABLE) A FIB: 
If it causes persistent symptoms or limits activity --> \_\_\_\_\_\_\_ of foci in and around the pulmonary veins
A

beta blockers
CCBs
ELECTRO CARDIOVERSION
48

RATE
ANTICOAGULATION
beta blockers
CCBs

TEE
delayed
anticoagulation

warfarin
xaralto
eliquis

initial
symptomatic
ibutilide
amiodarone

on demand
catheter ablation

7
Q

WPW

RADIOFREQUENCY ________ is the procedure of choice in patients with accessory pathways

Complications: AV block, cardiac tamponade, and thromboembolic events

________: if hemodynamically compromised

PHARMACOLOGIC THERAPY

Meds:

Class IA: _______ (IV)

Class III: _______

Avoid ______ and _____

Afib with concomitant antegrade conducting bypass tract presents as irregular, wide complex arrhythmia and must be managed differently

A

CATHETER ABLATION
cardioversion
procainamide
ibutilide

beta blockers
ccbs

8
Q

pre. mature ventricular complexes

no ____ needed

A

tx

9
Q

atrial flutter ___ - ___ bpm

NON-CHRONIC ATRIAL FLUTTER

Meds:
Class III anti-arrhythmic: IV _______

50-70% of patients return to sinus rhythm within 60-90 minutes*

AVOID class I and III agents (ex. _______) in the ______ setting because of possible induction of 1:1 conduction (collapse)

_______ cardioversion – 90% convert after 25-50J

CHRONIC ATRIAL FLUTTER - Harder to control rate than atrial fibrillation

Meds:
Anticoagulation (stroke risk IN chronic a fib)
Antiarrhythmics: ______and dofetilide (with AV nodal blocker, not verapamil)

_________

A

250-350

ibutilide
procainamide
prehospital
electrical

anticoagulation
amiodarone
catheter ablation

10
Q

heart block

1st degree: no ___ is generally needed

2nd degree
Mobitz type I: good prognosis – _________ pacemaker if symptomatic

Mobitz type 2: _________ pacing required if it progresses to complete heart block

3rd degree:

Requires ____ pacing (if delayed, use temporary pacing)

INTRAVENTRICULAR CONDUCTION BLOCK - Common and may be transient

RBBB (right bundle branch block): often seen in patients with normal structural hearts

LBBB (left bundle branch block): two components (anterior and posterior); more often a marker of underlying disease including ischemic heart disease

New LBBB indicative of acute MI

TREATMENT:

Treatment of any potentially ______ cause (myocardial ischemia, medication effect)

Asymptomatic patients: NO specific treatment

Symptomatic patients: IV _____

Patients with cardiac syncope with normal heart rates and rhythm but bifascular or trifasicular block on ECG should also be considered for pacing

A

tx
AV alternative
prophylactic ventricular
permanent

reversible
atropine

11
Q

TREATMENT OF ACUTE PERICARDITIS:

  • Restrict _____ until symptoms subside (~3 months for athletes)
    o Symptoms subside in several days to weeks
  • ___ 750-1000 mg q 8 hours for 1-2 wks w/ a taper (↓ the dose 250-400 mg every 1-2 wks)

OR

  • ______. 600 mg q 8 hours for 1-2 wks w/ a taper (↓ the dose by 200-400 mg every 1-2 wks)
  • _______ should be added to NSAIDs to prevent recurrences

o 0.5-0.6 mg once or twice daily and continued for at least 3 months – no need to taper

o Last week of treatment – the dosage can be reduced every other day for patients < 70 kg or one a day for patients > 70 kg

o If colchicine can’t be tolerated:

§ More significant _________: cyclophosphamide, azathioprine, IV human immunoglobulins, interleukin-1 receptor antagonists (anakinra), or methotrexate  these can be treatments for some of the causes (cancer, CT disease)

§ Pericardial stripping (________
– surgical removal of pericardium) may be considered

  • Major early complication = tamponade (occurs in less than 5% of pts)
  • May have recurrences in the first few weeks or months
  • In REFRACTORY CASES of acute pericarditis: ________ for 6 months

o _____ is used to assess the effectiveness of tx – once the levels are normal –> taper tx

o _______ in doses of 25-50 mg q 8 hours can be ADDED instead of ibuprofen

o Systemic _____ can be added in refractory cases or if there is autoimmune origin (like SLE or RA)

A
activities
ASA
ibuprofen
colcichine 
immunosuppression
pericardiectomy

colchichine
CRP
indomethacin
corticosteroids

12
Q

constrictive pericarditis

TREATMENT: aimed at the specific ____ initially

If lab evidence of ongoing inflammation (↑ ___, ____, etc.): anti-inflammatories may be of benefit

Once hemodynamics are evident –> mainstay of therapy = _________

problems that appear to be like RHF (peripheral edema, ascites, etc.) so treat like other disorders of RHF (aggressive diuresis):

__________ (oral TORSEMIDE or BUMETANIDE if bowel edema is suspected OR IV FUROSEMIDE) AND ______ AND ALDOSTERONE ANTAGONISTS (especially in the presence of ascites & liver congestion)

Aquaphoresis may be of value to remove salt and water out of the body safely

If diuresis fails —> surgical ________ (with continued diuresis)

Morbidity & mortality are high (up to 15%)

Poor prognosis in: Prior radiation, renal dysfunction, higher pulmonary systolic pressures, abnormal LV systolic function lower serum sodium level, liver dysfunction and older age

A
etiology
ESR, CRP
dieuretics
LOOP DIURETICS
THIAZIDES
pericardectomy
13
Q

pericardial effusion (cardiac tamponade)

TREATMENT: treat _______ cause of the effusion!!!!!

______: for pain relief

If small effusion, can carefully observe ____ and changes in paradoxical pulse

If large effusion or there is cardiac tamponade present ——> _________
-fluid withdrawl from pericardial sac – can be diagnostic or therapeutic

If effusion reoccurs or becomes persistent —> pericardial ______ (cut a hole/window)
-create an opening in pericardial sac – ↓ risk for large effusions or pressure to develop

A
underlying
NSAIDs
JVP
periocardiocentesis
window
14
Q

Dressler’s syndrome

Post MI
_____ and ______- 3 months
Don’t use ____ or steroids: can impair healing

Refractory
_______- 6 months
______ is used to assess effectiveness of tx; once normalized can taper

__________ instead of ibuprofen (recurrent pericarditis)
-Add colchicine for 3 months to prevent recurrence

A

ASA, colcichine
NSAIDs

colchichine
CRP

indomethacin

15
Q

Myocarditis

Subacute disease

  • Dilated cardiomyopathy
  • _______ recovery

Chronic disease

  • Mild dilation of the LV and eventually present with more restrictive cardiomyopathy
  • ____ and _____ if LVEF is <40%
  • ______ if myopericarditis related CP
  • Colchicine if pericarditis predominates
  • Arrhythmias should be suppressed

Fulminant myocarditis
Aggressive short-term support
Including an _____) or an LV assist device
_____ support may be temporarily required and has noted success

Giant cell myocarditis
May be responsive to _________ agents
2/3 in a study in 2013 reached at least partial remission
Freedom from severe heart failure and need for transplantation
Prone however to _______ arrhythmias

-Specific ______ indicated when infecting agent is identified
-Exercise limited during the recovery phase
______ should be avoided
-No benefit from steroids or intravenous immunoglobulin (IVIG)
-Interferon may have supportive role
-Overall, if improvement does not occur, many patients may be eventual candidates for cardiac transplantation or long term use of a newer LV assist device
-Patients in which myocarditis is suspected
-Should see a cardiologist at a tertiary care center where facilities are available for diagnosis and therapies available to treat a fulminant case

Facility should have support devices and transplantation options available.

A

incomplete
ACEI, beta blockers
NSAIDs

IABP
ECMO

immunosuppressive
ventricular

antibiotic
digoxin

16
Q

Drug Induced and Toxic myocarditis

If ECG changes, arrythmias, heart failure:
-_______, ______, chloroquine, disopyramide, antimony-containing compounds, arsenic

Hypersensitivity reactions resulting in cardiac dysfunction:
-_______, penicillins, _____ and other medications

Cocaine:
-_______ used in patients with fixed stenosis

With documented coronary spasm

     - CCBs 
     - nitrates 

Cancer chemo:
_______ may reduce the negative effects on myocardial function
-NSAIDS, alcohol, and strenuous physical exercise could be harmful

A

phenothiazines, lithium

sulfonamides, ASA

beta blockers

beta blockers

17
Q

Endocarditis

Cover initially for staphylococci, streptococci and enterococci
-_____1 g every 12 h IV + ______ 2 g every 24 h

Change regimen when culture and sensitivity come back

After starting antibiotics, obtain f/u blood cultures q 48-72 hours until clearance of bacteremia

Recently, new data has begun to support the use of oral antibiotics after 2 weeks of IV for certain organisms

Viridans Streptococci:

  • For penicillin-susceptible, use ______, 18 Million units IV continuously or in 4 to 6 divided doses
  • Or ______ 2 g IV daily X 4 weeks
  • Can shorten to 2 weeks if gentamicin, 3 mg/kg IV q 24 his added to either
  • Vanco as alternative if patient allergic to PCN or ceftriaxone
  • ______: 6 week course of penicillin or ceftriaxone (can add 2 weeks of gentamicin at start of therapy)

Other streptococci:
PCN resistant Streptococci
-PCN G _____ (4-6 weeks) + _____ (2 weeks)

PCN susceptible Streptococci

  • PCN G (4-6weeks) ± _____ (2 weeks)
  • Cefazolin (4-6 weeks)
  • _______ (4-6 weeks), possible addition of vanco and rifampin
Enterococci: 
-\_\_\_\_ + Gentamycin ( 4-6 weeks) 
-\_\_\_\_\_ + Gentamycin ( 4-6 weeks) 
Ampicillin + Ceftriaxone (4-6 weeks) 
Vancomycin + Gentamycin ( 4-6 weeks) 

Staphylococci:
MSSA

_____/Oxacillin 6 weeks

Cefazolin 6 weeks

MRSA

_______

Daptomycin

Prothestic Valves

MSSA

Nafcillin/Oxacillin (6 weeks) + Rifampin (6 weeks) + Gentamicin (2 weeks)

Cefazolin (6 weeks) + Rifampin (6 weeks) + Gentamicin (2 weeks)

MRSA

Vanco/Dapto (6 weeks) + Rifampin (6 weeks) + Gentamicin (2 weeks)

Surgery
Acute heart failure unresponsive to medical therapy gets a valve replacement even if there is an active infection

Infections not responsive to correct antimicrobial therapy after 7-10 d (fevers, + blood cultures) should have valve replaced

If it is fungal, _____ almost always required

if abscesses appear in aorta or septum

Recurrent infection with same organism

Continuing embolization

Surgery to correct valve dysfunction must occur before hemodynamic deterioration begins.

A

vanco, ceftriaxone

penicillin G
ceftriaxone
prosthetic. valve

high dose
gentamycin

gentamicin
ceftriaxone

PCN G
ampicillin

nafcillin

vancomycin

surgery