Cardiology

Question 1

STEMI

Answer 1

Symptoms: Chest pain, diaphoresis, n/v, arm/jaw pain, sob

Diagnosis: EKG with ST elevations (leads determine location), serial troponins elevated

Management: Reperfusion with pci or fibrinolysis. Heparin, aspirin, statin, morphine, nitro immediately. Ultimately add 2nd antiplatelet, beta blocker, and ACE inhibitor

Complications: Chronologically: Arrhythmias, pericarditis, papillary muscle rupture, ventricular septal reupture, ventricular aneurysm, ventricular free wall rupture, dressler syndrome, LV failure with pulmonary edema

Specialist and role: Cardiology for PCI

Question 2

NSTEMI

Answer 2

Symptoms: Chest pain, diaphoresis, n/v, arm/jaw pain, sob

Diagnosis: EKG with absence of elevations, serial troponins

Management: If true NSTEMI, Heparin, aspirin, statin, morphine, nitro. Ultimately add 2nd antiplatelet, beta blocker, and ACE inhibitor

Complications: STEMIs, arrhythmias

Specialist and role: Cardiology for stress test or invasive angiography

Question 3

Unstable Angina

Answer 3

Symptoms: Chest pain at rest, diaphoresis, n/v, arm/jaw pain, sob

Diagnosis: EKG with absence of elevations, serial troponins normal

Management: At least do aspirin, statin on presentation. Depending on severity can add MONA BASH

Complications: MI, Arrhythmias

Specialist and role: Cardiology for stress test or invasive angiography

Question 4

Chronic CAD

Answer 4

Symptoms: Asymptomatic or may have occasional anginal pain

Diagnosis: Invasive angiography, coronary CT,

Management: Betablockers, Ace inhibitors, CCB’s, nitrates, ranexa, antiplatelets

Complications: MI, CHF, arrhythmia

Specialist and role: Cardiology if stress test or angiography is necessary

Question 5

Heart Failure with preserved EF

Answer 5

Symptoms: Asx, SOB, fatigue

Diagnosis: Echo

Management: If symptomatic, diuretics, SGLT2, spironolactone

Complications: CHF exac

Specialist and role: Cardiology for med management

Question 6

CHF Exacerbation

Answer 6

Symptoms: SOB, PND, orthopnea, JVD, pitting edema, weight gain

Diagnosis: Rales on exam, BNP, CXR, TTE

Management: Oxygen, IV diuretics. No beta blockers in acute phase unless they are already on it. Send with some combo of ACE/ARB, beta blockers, spironolactone, hydralazine with nitrates, and diuretics depending on severity and only if it is reduced EF. Newer drugs like entresto (Sacubitril/valsartan) and SGLT2 like jardiance (empagliflozin) may be used by cards. Also may need ICD/pacer, LVAD, or heart transplant

Complications: Pulmonary edema, pulmonary effusions, valvular disorders, arrhythmias, cardiogenic shock

Specialist and role: Cardiology if new onset to assess for underlying ischemic heart disease and to start chronic medications if not already on it. Or if need for ICD/pacer, LVAD, or heart transplant

Question 7

Aortic stenosis

Answer 7

Symptoms: Syncope, SOB/heart failure symptoms, Chest pain

Diagnosis: Systolic murmur at right upper sternal border. EKG with LVH. Echo with valve area < 1cm squared and jet velocity > 4 m/s if severe. May need cath if other studies inconclusive

Management: Diuretics for volume overload, antihypertensives if HTN. May need IABP if severe HF. TAVR and surgical management is more definitive management

Complications: Heart failure

Specialist and role: Cardiology if severe HF and for evaluation of balloon angioplasty, TAVR, surgical management

Question 8

Aortic regurgitation

Answer 8

Symptoms: SOB/CHF symptoms, pulmonary edema, cardiogenic shock, chest pain

Diagnosis: Diastolic murmur at RUSB, EKG with LVH, Echo for valve evaluation (may show endocarditis as cause). May need cath if other studies inconclusive

Management: Antihypertensives if HTN, Aortic valve replacement

Complications: Heart failure, cardiogenic shock

Specialist and role: Cardiology/CT surgery if acute severe AR with aortic valve replacement

Question 9

Mitral stenosis

Answer 9

Symptoms: SOB/CHF symptoms, A fib due to atrial stretch

Diagnosis: Diastolic murmur with opening snap at cardiac apex, ekg with left atrial englargement or A fib, echo. Cath if other studies are inconclusive

Management: Diuretics and low salt diet for heart failure symptoms. Balloon valvuloplasty if severe (<1.5 cm squared) as it is usually rheumatic heart disease. Replacement in rare instances

Complications: CHF

Specialist and role: Cardiology if severe for evaluation of valvuloplasty or surgery

Question 10

Mitral regurg

Answer 10

Symptoms: CHF exac, pulmonary edema, cardiogenic shock

Diagnosis: Systolic apex murmur. Echo. Look for infection/infarction for all insufficiency murmurs

Management: Chronic can be managed with ACE/BB whereas more acute will need IV nitro and IABP and mitral valve replacement

Complications: A fib, CHF exac

Specialist and role: Cardiology/CT surgery if severe for mitral valve replacement

Question 11

Hypertrophic cardiomyopathy

Answer 11

Symptoms:

Diagnosis:

Management:

Complications:

Specialist and role:

Question 12

Mitral valve prolapse

Answer 12

Symptoms:

Diagnosis:

Management:

Complications:

Specialist and role:

Question 13

Pericarditis

Answer 13

Symptoms: Chest pain leaning forward, pleuritic

Diagnosis: Pericardial rub, EKG with diffuse ST elevations, Echo may show pericardial effusion. Consider viral, ACS, uremia, or rheumatic causes

Management: Rule out ACS, then aspirin or NSAID’s with colchicine

Complications:

Specialist and role: Cardiology to ensure not ACS

Question 14

Pericardial effusion

Answer 14

Symptoms:

Diagnosis:

Management:

Complications: Tamponade

Specialist and role:

Question 15

Cardiac tamponade

Answer 15

Symptoms: Vague but may include SOB/CHF from reduced cardiac output as well as syncope

Diagnosis: Becks triad (JVD, distant heart sounds, hypotension), EKG with electrical alternans, TTE shows pericardial effusion

Management:

Complications: Cardiogenic shock

Specialist and role: Pericardiocentesis or pericardial window for recurrent effusions

Question 16

Constrictive pericarditis

Answer 16

Symptoms: SOB/CHF symptoms

Diagnosis: TTE will show findings suggestive

Management: Diuretics and low sodium diet help but pericardiectomy is definitive treatment

Complications: CHF exac

Specialist and role: Cardiology to determine need for pericardiectomy

Question 17

Syncope

Answer 17

Symptoms: Lightheaded, dizzy

Diagnosis: EKG, echo, carotid dopplers if concern

Management: Treatment of underlying cause if cardiac etiology identified. Review meds

Complications:

Specialist and role: Cards/neuro if etiology found

Question 18

Hyperlipidemia

Answer 18

Symptoms: Asx

Diagnosis: Lipid levels and ASCVD calculation

Management: Statins and pcsk9 (evolocumab or repatha and alirocumab or praluent) lower LDL the most. Fibrates lower TG the most

Complications: Cardiovascular disease; ACS/stroke

Specialist and role: None

Question 19

Hypertriglyceridemia

Answer 19

Symptoms: Asx

Diagnosis: Lipid levels

Management: Fibrates

Complications: Pancreatitis

Specialist and role: None

Question 20

Primary Hypertension

Answer 20

Symptoms: Asx, headaches, n/v if very high

Diagnosis: BP

Management: ACE/ARB, calcium channel blocker, thiazides, beta blockers, hydralazine for short term

Complications: Stroke, dissection

Specialist and role: None

Question 21

Hypertensive Urgency

Answer 21

Symptoms: Asx, headache, n/v

Diagnosis: BP > 180/120 without end organ damage

Management: BP reduction over several hours with hydralazine/labetalol and oral agents

Complications: Stroke, dissection

Specialist and role:

Question 22

Hypertensive Emergency

Answer 22

Symptoms: Asx, headache, n/v

Diagnosis: BP > 180/120 with signs of end organ damage (MI, stroke, encephalopathy, dissection, renal failure)

Management: Cardene drip to lower BP by 20% within the first hour, then oral agents to lower it by additional 10% over next 24 hours. Rapid lowering in patients with dissection/hemorrhagic stroke. Labetalol for pregnant patients. Do not lower in ischemic stroke

Complications: Stroke, dissection

Specialist and role: ICU

Question 23

A fib

Answer 23

Symptoms: Chest pain, palpitations, syncope, pulmonary edema

Diagnosis: EKG with irregularly irregular and absent p waves, TTE to check valvular or nonvalvular

Management: Unstable tachyarrhythmia = cardioversion. Rate control preferred with beta blockers IV, cardizem push, cardizem drip. Make sure not hypotensive, otherwise amio drip. Digoxin if concurrent CHF. Rhythm control with pharmacologic cardioversion (amiodarone, sotalol, etc.), or DCCV, or catheter ablation. May need TEE to rule out clot before DCCV. Anticoagulation if CHADs2Vasc indicates and no contraindication (consider HASBLED) otherwise watchman. If valvular will need warfarin

Complications: Cardiac arrest, MI, stroke

Specialist and role: Cardiology if starting new medications (anticoagulants or rate/rhythm) or if RVR for adjusting medications, or if need for cardioversion/ablation

Question 24

SVT/AVNRT

Answer 24

Symptoms: Chest pain, palpitations, syncope, pulmonary edema

Diagnosis: EKG showing regular tachycardia, usually > 150

Management: Unstable tachyarrhythmia = cardioversion. Vagal maneuvers. Adenosine. May need radiofrequency ablation following

Complications: Cardiac arrest

Specialist and role: Cardiology for medication management and possible ablation

Question 25

V Tach

Answer 25

Symptoms: Asx, chest pain, palpitations, syncope, cardiac arrest Diagnosis: Make sure no PPM/ICD as cause, bundle branch blocks at baseline. NSVT if 3 or more PVC's that terminate within 30 seconds. Monormorphic or Polymorphic or Torsades. Echo to check for structural heart disease as cause Management: Unstable tachyarrhythmia = synchronized cardioversion. Unless pulseless, in which case it is defibrillation (unsynchronized). IV amio. Mag if torsades. NSVT can receive beta blockers if symptomatic then amio if additional required and possible ablation/ICD. Review meds for QT prolonging agents Complications: Cardiac arrest Specialist and role: Cardiology for medication management and evaluation for ICD or ablation

Question 26

V Fib

Answer 26

Symptoms: Cardiac arrest Diagnosis: EKG showing Management: Defibrillation Complications: Specialist and role: Cardiology post acute management for ICD or ablation

Question 27

Asystole

Answer 27

Symptoms: Cardiac arrest Diagnosis: Management: ACLS Complications: Specialist and role:

Question 28

Sinus bradycardia

Answer 28

Symptoms: Syncope, confusion, hypotension Diagnosis: EKG, TSH, examination for cyanosis Management: Rate < 50 with poor perfusion and AMS or chest pain = Atropine then transcutaneous pacing. Give oxygen. Check for medications that can be reversed like digoxin, BB, CCB Complications: Cardiac arrest, end organ damage Specialist and role: Cardiology for determination of medications and PPM placement need. May need loop recorder outpatient

Question 29

1st degree heart block

Answer 29

Symptoms: Syncope, confusion, hypotension Diagnosis: EKG with PR > 200ms, TSH Management: Rate < 50 with poor perfusion and AMS or chest pain = Atropine then transcutaneous pacing. Give oxygen. Check for medications that can be reversed like digoxin, BB, CCB Complications: Cardiac arrest Specialist and role: Cardiology for determination of medications and PPM placement need. May need loop recorder outpatient

Question 30

2nd degree heart block type 1

Answer 30

Symptoms: Syncope, confusion, hypotension Diagnosis: EKG with progressively prolonged PR then dropped beat, TSH Management: Asymptomatic look for reversible causes and treat accordingly. If unstable with rate < 50 with poor perfusion and AMS or chest pain = Atropine then transcutaneous pacing. Can also do dopamine drip. Give oxygen Complications: Cardiac arrest Specialist and role: Cardiology for determination of medications and PPM placement need. May need loop recorder outpatient

Question 31

2nd degree heart block type 2

Answer 31

Symptoms: Syncope, confusion, hypotension Diagnosis: EGK with fixed PR then dropped beat, TSH Management: If stable, monitor with transcutaneous pacing pads in place. Review meds. If unstable with Rate < 50 with poor perfusion and AMS or chest pain = Atropine then transcutaneous pacing. Can also do dopamine drip. Give oxygen. Complications: Cardiac arrest Specialist and role: Cardiology for determination of medications and PPM placement need. May need loop recorder outpatient

Question 32

3rd degree av block

Answer 32

Symptoms: Syncope, confusion, hypotension Diagnosis: EKG with disassociation of p waves and qrs complexes, TSH Management: If stable, monitor with transcutaneous pacing pads in place. Review meds. If unstable with Rate < 50 with poor perfusion and AMS or chest pain = Atropine then transcutaneous pacing. Can also do dopamine drip. Give oxygen. Complications: Cardiac arrest, end organ ischemia Specialist and role: Cardiology for determination of medications and PPM placement need. May need loop recorder outpatient

Question 33

Aortic Dissection

Answer 33

Symptoms: Chest pain, abdominal pain, CHF exac if involves aortic valve Diagnosis: CTA or US Management: Maintain BP control systolic < 120 and heart rate < 60 with labetalol drip. CT surgery if type A. Vascular surgery if type B and signs of malperfusion (renal failure, shock liver, elevated lactate suggesting mesenteric or tissue ischemia) or expanding hematoma/aneurysm. Medical management if asymptomatic type B with BP control and heart rate control as above Complications: Aortic regurg with acute CHF/pulmonary edema, Tamponade, MI Specialist and role: Cardiology, CT surgery, or vascular surgery depending on location

Question 34

Thoracic aortic Aneurysm

Answer 34

Symptoms: Chest/abdominal/back pain Diagnosis: CTA Management: Symptomatic is endovascular repair/surgery. Asymptomatic is BP control with beta blocker preferably and surgical consultation to determine need for repair Complications: Dissection, MI Specialist and role: CT surgery

Question 35

Atrial Flutter

Answer 35

Symptoms: Chest pain, palpitations, syncope Diagnosis: EKG showing regular sawtooth with rate of 150 exactly usually Management: Treat like A fib Complications: Cardiac arrest Specialist and role: Cardiology for medication management and cardioversion/ablation if necessary

Question 36

Sinus pauses

Answer 36

Symptoms: Asx, syncope Diagnosis: EKG showing prolonged pauses Management: If asx no treatment required but discontinue offending medications. PPM if symptomatic Complications: Cardiac arrest Specialist and role: Cardiology for evaluation of PPM

Question 37

Prosthetic heart valves

Answer 37

Things to know: Continue warfarin. Do not use any vitamin K reversals without cardiology approval

Question 38

Infective Endocarditis

Answer 38

Symptoms: Diagnosis: Management: Complications: Specialist and role:

Question 39

Abdominal Aortic aneurysm

Answer 39

Symptoms: Abdominal/back pain, hypotension if ruptured Diagnosis: Pulsatile abdominal mass, ultrasound for asymptomatic detection or during FAST exam, otherwise CTA Management: If ruptured or nonruptured but symptomatic, surgery; if asymptomatic smoking cessation or if large, elective surgery. Endovascular repair is an alternative to surgery Complications: Ruptured AAA, end organ ischemia Specialist and role: Vascular surgery if necessary