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Flashcards in Cardiology Deck (147):
1

Statins
-lovastatin
-pravastatin
-atorvastatin
-rosuvastatin

decreases synthesis of cholesterol in liver by inhibiting HMG-CoA reductase

best drug to lower LDL
increases HDL

side effects: muscle injury (test CK in any patient on a statin with muscle symptoms), hepatic dysfunction (check LFT before you start, and then again later if there is a clinical indication to do so)

2

ezetimibe

cholesterol absorption inhibitor

impairs dietary and biliary cholesterol absorption at the brush border of the intestine

-does not affect TG or fat-soluble vitamin absorption
-primarily lowers LDL
-side effects:myalgias, increased LFTs

3

fibrates

gemfibrozil, fenofibrate

primary effect on triglycerides and also raise HDL 5-20%

Fibrates work primarily by reducing hepatic secretion of VLDL

Side effects: myositis and LFT elevation

4

Bile acid sequestrants
aka bile-acid binding resins

Cholestyramine, colestipol, colesevelam

Primarily lower LDL (10-20%)
so not as strong as an effect as is seen with high intensity statins (50%)

Can serve a dual role in diabetics, as it lowers HbA1C in these patients by 0.5%

Side effects: GI side effects, LFT elevation, bad taste

Cholestyramine can bind C.Diff toxin!

5

Niacin

Primary effect on HDL

Side effect: flushing, but this improves with continued use, or prevent with dose at bedtime (sleep through the side effects), aspirin/NSAID use

6

Omega-3 fatty acids

Primary effect on TGs
Can be added on to other treatments
side effect: fishy burp

7

SE: facial flushing

niacin

8

SE: elevated LFT, myositis

statin, fibrates, ezetimibe

9

SE: Gi discomfort, bad taste

bile acid binding resins

10

Best effect on HDL

niacin

11

Best effect on TGs

fibrates

12

Best effect on LDL/cholesterol

statins

13

Binds C. difficile toxin

cholestyramine

14

2013 AHA/ACC guildelines
Who should be on statins?

1. Those with clinical ASCVD
-acute coronary syndrome
-myocardial infarction
-stable or unstable angina
-revascularization procedures
-stroke or TIA
-peripheral arterial disease

2. Anyone with LDL>190
3. Diabetics (type 1 and 2), and between age 40-75yo
4. 10-year ASCVD risk of 7.5% between age 40-75 (this calculation based on diabetes, anihypertensive use, age, SBP, total cholesterol, tobacco use)

15

Angina

chest pain associated with myocardial ischemia

chest discomfort, pressure sensation, "like something is sitting on my chest"

-left-sided, midsternal
-radiates to back/jaw/left arm
-diaphoresis, SOB, palpitations

atypical symptoms:
-female, diabetic, older
-abdominal pain, exercise intolerance, generalized fatigue

16

Myocardial ischemia

myocardial oxygen demand exceed oxygen supply
predisposing factors:
-atherosclerosis
-shock
-hypoxemia
-anemia
-coronary artery vasospasm

increased demand:
-vigorous exertion
-tachycardia
-HTN
-ventricular hypertrophy
-increased catecholamines

17

stable (predicatable) angina

resolves with rest, does not occur at rest

diagnosed with exercise or pharmacologic stress test

Labs: cardiac enzymes (troponin I, CKMB)

18

How do we treat stable angina?

1. Beta blockers decrease HR and contractility

2. CCBs promote coronary and peripheral vasodilation, and decrease contractility

3.Nitrates: promote peripheral venous vasodilation (decrease preload, which decreases oxygen demand on the heart)

19

Prinzmetal angina (variant angina)

Caused by coronary artery vasospasm (NOT atherosclerosis)

RF: smoking
More often in younger patients (

20

What is the major RF associated with Prinzmetal angina?

smoking (

21

How does Prinzmetal angina present?

Pain at rest occurring at night, lasting 5-15 minutes
often indistinguishable from classic angina

22

How is prinzmetal diagnosed?

Coronary arteriography shows no sign of high grade coronary artery stenosis

in the setting of recurrent CP at rest, and transient ST-segment elevation on ECG

23

What medication class is used first-line to treat Prinzmetal angina?

CCB (diltiazem) and nitrates promote vasodilation in the coronary arteries
Smoking cessation is also very important

24

Why avoid beta blockers in Prinzmetal angina?

they may exacerbate vasospasm

25

Causes of CP

MSK- costochondritis
GERD
Esophageal spasm (relieved by nitrates)
Cocaine intoxication
Hyperventilation
Herpes zoster
Aortic stenosis
Trauma
Pulmonary embolism
Pneumonia
Pericarditis
Pancreatitis
Angina
Aortic dissection
Aortic aneurysm
Infarction
Neuropsychiatric diseases

26

ST segment elevation only during brief episodes of chest pain

Prinzmetal angina (coronary vasospasm)

27

Patient is able to localize the pain by pointing to it, and it is tender to palpation

Costochondritis

28

Rapid onset sharp chest pain that radiates to the scapula

aortic dissection

29

Rapid onset sharp pain in a 20-year old, with associated dyspnea

spontaneous pneumothorax, which is more common in young males

30

occurs after heave meals and is improved by antacids

GERD, maybe esophageal spasm, but still needs to be worked up

31

sharp pain lasting hours-days and is somewhat relieved by sitting forward

pericarditis

32

pain made worse by deep breathing and/or motion

musculoskeletal pain, pleuritic chest pain (irritation of the lining of the lung)

33

chest pain in a dermatomal dist

zoster

34

MCC noncardiac chest pain

GERD
musculoskeletal pain

35

acute onset dyspnea, tachycardia, confusion in a hospitalized patient

PE

36

widened mediastinum on CXR

aortic dissection

37

How does nitroglycerin relieve pain?

dilates peripheral veins
decreases preload
reduces myocardial O2 demand

38

inhibits COX1 and COX2

aspirin

39

ADP receptor inhibitor

clopidogrel
ticlopidine

40

Glycoprotein 2b/3a inhibitor

TIrofiban, Eptifibatide
abciximab

41

Activates antithrombin

heparin. enoxaparin

42

converts plasminogen to plasmin

streptokinase

43

streptokinase reversal agent

aminocaproid acid

44

drugs that can cause type 2 heart block (Mobitz I)

beta blockers
digoxin
calcium channel blockers

45

Narrow QRS, rate>100

SVT

46

No relationship between pulses and QRS

complete heart block

47

3 p-wave readings, rate>100

MAT

48

rate

bradycardia

49

PR interval >0.2 second

first degree heart block

50

Early, wide WRS beat without p-wave

PVT

51

wide QRS, HR 160-240

ventricular tachycardia

52

PR interval becomes longer with dropped beat

second- degree type I heart block

53

chaotic pattern, no P wave, no QRS

ventricular fibrillation

54

PR normal, occasional dropped beat

2nd degree type 2 heart block

55

sawtooth pattern

atrial fibrillation

56

no p waves, narrow QRS, iregularly irregular

atrial fibrillation

57

sinusoidal pattern of QRS

torsades des pointes

58

Which heart med is associated with pulmonary fibrosis and therefore requires pre-check of PFT and diffusion capacity every 6 months?

amiodarone

59

contraindications to triptans

sulfa allergy
pregnancy
CAD
Prinzmetal angina

60

which drugs block transmission through the AV node?

beta blockers
nondihydropyridine CCBs
digoxin
adenosine

61

stones, bones, groans, and psychiatric overtones

hypercalcemia (consider hyperparathyroidism)

62

diastolic murmur best heard at left lower sternum that increases with inspiration

tricuspid stenosis

63

late diastolic murmur with opening snap (no change with inspiration)

mitral stenosis

64

systolic murmur best heard in the second right interspace, parasternal

aortic stenosis

65

late systolic murmur best heard at apex

mitral prolapse

66

Diastolic murmur with widened pulse pressure

aortic regurgitation

67

holosystolic murmur at the left lower sternum that is louder with inspiration

tricuspid regurgitation

68

holosystolic murmur heart at the apex, and radiates to the axilla

mitral regurgitation

69

systolic murmur best heard in the second left interspace, parasternal

pulmonic stenosis

70

things that can cause acute pericarditis

viral infection
TB
lupus
uremia
renal failure
neoplasm
drugs (INH, hydralazine)
Post- MI inflammation (Dressler syndrome)
radiation
recent heart surgery

71

Acute pericarditis H and P

worse when supin
better when sitting up, leaning forward
dyspnea
pericardial friction rub
pulsus peridoxus (SBP drops more than 10mmHg during inspiration)
EKG changes (global ST elevation), PR depression

The pericardial effusion is usually transudative (thin, watery, low in protein)

If exudative, consider neoplasm, fibrotic disease, TB

Acute pericarditis:
Echo- pericardial effusion
CXR- enlarged globular canteen heart

Tx: treat the underlying cause

72

Constrictive pericarditis

diffuse thickening of pericardium
decreased diastolic filling
decreased cardiac output

most common causes are radiation and heart surgery

symptoms- consistent with heart failure, Kussmaul sign

73

What causes dilated cardiomyopathy?


ischemic heart disease
chronic alcohol use
chronic cocaine use
doxodubicin
CoxsackieB
Beriberi
Chagas
hemochromatosis
peripartum cardiomyopathy
S3

74

What causes restrictive cardiomyopathy?

amyloidosis
sarcoidosis
hemochromatosis

(infiltrative causes)

75

What causes hypertrophic cardiomyopathy?

aotosomal dominant
systolic murmur
sudden death in young athlete
S4
avoid diuretics, restrict exercise

76

indications for prophylactic antibiotics against infectious endocarditis

NOT rheumatic heart disease, and NOT GU/GI procedures
prosthetic cardiac valves
previous infective endocarditis
Some congenital heart diseases (unrepaired heart defect)
cardiac transplants with valvulopathy
unrecovered heart transplant

If indicated, give 2g amoxicillin 30-60 minutes prior to procedure

77

Endocarditis predisposing factors

congenital heart defects
IVDA
prosthetic heart calces

78

normal blood pressure

79

prehypertension

120-139/ 80-89

counsel these patients to stop smoking, reduce alcohol intake, reduce sodium in their diet, and lose weight

80

hypertension

>140/90

3 readings on 3 separate occasions

81

Essential hypertension risk factors

family history
high sodium diet
tobacco use
obesity
age
black> white

82

MCC secondary hypertension

kidney diseases, such as
chronic renal insufficiency
end stage renal disease
renal artery stenosis

83

How do we treat renal disease in end-stage hypertension?

ACEI to delay progression

84

renal artery stenosis

MCC fibromuscular dysplasia of renal artery

85

renal artery stenosis >50yo

MCC atherosclerosis

86

signs and symptoms of renal artery stenosis

renal artery bruit

87

What tests can be used to diagnose renal artery stenosis?

MRA of renal arteries- MOST FREQUENTLY used screening test

spiral CT scan of renal arteries with IV contrast

renal artery duplex scan- is time- consuming (2 hours) and requires well- trained operator

renal arteriogram- gold standard, but invasive

88

Why are ACEI contraindicated in renal artery stenosis?

They impede renal blood flow and renal GFR, thereby accelerating renal issues

89

Combination OCPs and HTN

obese, women, >35yo

poorly controlled HTN is a contraindication to starting OCP
-stop OCP and change to progestin-only pill if hypertensive, or use IM medroxyprogesterone

90

Pheochromocytoma and HTN

young patients
screen for MEN

Episodic HTN
diaphoresis
tachycardia
palpitations
headache

24-hr urine: catecholamines, VMA
serum: metanephrines, normetanephrines
CT or MRI: see the tumor?

91

Pheochromocytoma treatment

surgically remove the tumor
pharmacologic contrl of HTN, pre-operatively

Alpha- blocker before beta- blocker (labetalol would be a suitable plan B, since it blocks both alpha and beta blockers)

92

Primary hyperaldosteronism: Conn syndrome

HTN
hypokalemia
metabolic alkalosis
high PAC: PRA ratio
Treat this with surgical removal of tumor
possibly pre-treat with an aldosterone antagonist such as spironolactone or epleronone

93

Cushing syndrome

Cushingoid features
obesity
hirsutism
buffalo hump
glucose intolerance

Dexamethasone suppression test

94


Coarctation of the aorta- focal narrowing

kink in the hose
associated with:
1. Congenital aortic valve
pathology
2. Turner syndrome
3. Patent ductus arteriosis

high BP in arms but low BP in the legs, and weak dosalis pedis pulses

Diagnosis: LVH on EKG, echocardiogram

Treatment: surgical repair

95

Hyperparathyroidism

hypercalcemia
-confusion ans psychosis
-calcium kidney stones
-constipation

96

Hypertensive urgency

SBP>180 or higher
or DBP>120 or higher

No sumptoms, no evidence of end organ damage

If there is evidence of end organ damage then we call this hypertensive emergency

97

Hypertensive emergency

SBP>180 or higher
or DBP>120 or higher

with signs of end organ damage:
-renal failure
-changes in mental status
-papilledema
-retinal vascular changes
-unstable angina
-MI
-aortic dissection
-pulmonary edema

98

How do we treat hypertensive urgency and hypertensive emergency?

reduce DBP to 100mmHg
with something that will work quickly
-in the first 2 hours, initial decrease should not exceed 25% of presenting pressure

lowering it too much would risk ischemia

start maintenance oral antihypertensive

99

High BP in UE but low BP in LE

coarctation of the aorta

100

proteinuria

renal disease

101

hypokalemia

Cushing disease (primary hypoaldosteronism) or renal artery stenosis

102

tachycardia, diarrhea, heat intolerance

hyperthyroidism

103

hyperkalemia

renal failure

104

episodic sweating, tachycardia

pheochromocytoma

105

What tests do you order when you're trying to rule out infectious endocarditis?

1. rule out infection with blood/urine cultures, UA, +/- CXR
2. Toxicology screen
3. Rule out pancreatitis with amylase/lipase
4. rule out MI with EKG and cardiac enzymes x3

106

Beta blockers that reduce mortality in CHF

bisoprolol
carvedilol
extended-release metoprolol

107

antihypertensive to use in DM

ACEI or ARB

108

antihypertensive to use in heart failure (multiple

ACEI, ARB, Beta- blocker, aldosterone antagonist

109

antihypertensive to use in BPH

alpha-1 antagonists

110

antihypertensive to use in left ventricular hypertrophy

ACE I or ARB, which lower afterload

111

antihypertensive to use in hyperthyroidism

propanolol

112

antihypertensive to use in osteoporosis

thiazides

113

antihypertensive to use in benign essential tremor

beta blociers

114

antihypertensive to use in postmenopausal woman

thiazides, which will help with retaining calcium and reduce risk of osteopososis

115

migraines

beta blockers

116

antihypertensive to with the side effect of first-does orthostatic hypertension

alpha blockers

117

antihypertensive to with the side effect of hypertrichosis

minoxidil

118

antihypertensive to with the side effect of dry mouth, sedation, severe rebound HTN

clonidine (wears off every six hours or so)

119

antihypertensive to with the side effect of bradycardia, impotence, asthma exacerbation

Nonselective beta blockers

120

antihypertensive to with the side effect of reflex tachycardia

vasodilators

121

antihypertensive to with the side effect of cough

ACE-I

122

antihypertensive to avoid in patients with sulfa allergy

thiazides and loop diuretics

123

antihypertensive to with the side effect of angioedema

ACE-I

124

antihypertensive to with the side effect of development of drug- induced lupus

hydralazine

125

antihypertensive to with the side effect of cyanide toxicity

sodium nitroprusside

126

consequences of longterm treatment with NE

ischemia/necrosis of fingertips and toes
mesenteric ischemia
renal failure

127

underlying mechanism of cardiogenic shock

failure of the pump

128

underlying mechanism of extracardiogenic shock

pump compression

129

underlying mechanism of hypovolemic shock

not enough fluid to pump

130

mechanism of anaphylactic shock

vasodilation, releaes of vasodilatory agents (histamine)

131

mechanism of neurogenic shock

vasodilation, loss of autonomic-regulated vascular tone

132

mechanism of septic shock

vasodilation, massive release of inflammatory mediatiors

133

AAA risk factors

tobacco use
age>55
atherosclerosis
htn
family history

usually asymptomatic, pulsatile abdominal mass, abdominal bruit, hypotension, severe abdominal pain

radiology: us
CT or MRI if the US is positive

134

AAA screening

all men between 65-75 who have a history of smoking

1-time screening abdominal US

follow with
US every 6 months if
5.5cm in men or >5cm in women

or if diameter has increased by more than 0.5cm in a 6-month interval (should be having abdominal ultrasounds every 6 months)

or if the aneurysm is symptomatic (tenderness, pain in abdomen or back)

135

Aortic dissection

key difference between aortic dissection and AAA is that dissections tend to occur in the thorax, in the aortic arch.

RIsk factors: HTN, trauma, coarctation of the aorta, syphilis, Ehlers-Danlos syndrome, Marfan syndrome

Tear in the intima of the aorta
blood forces its way into the media and forms a false lumen

Stanford A- ascending aorta
B- confined to the distal aorta, below the branches

H and P: acute ripping/tearing chest pain radiating to the back

syncope or TIA, decreased peripheral pulses

EKG:
normal
+/- LVH

Radiology: CXR (widening of the mediastinum)

CT of the chest with contrast

B/L upper and lower extremity pulses, if unequal will be indicative of aortic dissection

Treatment: stabilize BP with beta blocker that will minimize the slope of rise of BP

Stanford A- emergency surg
Stanford B- beta blocker, surgery if uncontrolled

136

Peripheral vascular disease

atherosclerosis of peripheral arteries

HTN, DM, coronary disease

symptoms- claudication- leg pain that comes with activity and improves with rest

Skin changes- dryness, ulcers, decreased leg hair growth

erectile dysfunction

PVD- ankle-brachial index (ABI)
ratio ankle SBP: brachial SBP
ABI0.4: severe disease

137

What are components of conservative medical management of peripheral artery disease?

smoking cessation
glucose and BP control
daily exercise to increase collateral flow
cilostazol to improve flow to LE and decrease claudication (improves flow to LE and decreases claudication, more effective than pentoxifylline which is supposed to make RBCs more bendy)
contraindicated if any heart failure, due to increased mortality

Daily aspirin or clopidogrel to reduce cardiovascular events

Statin therapy to reduce cardiovascular events and increase pain-free walking distance

138

PVD surgical interventions

angioplasty
bypass grafting
amputate if there is prolonged ischemia

139

PVD and CAD

screen them with cardiac stress test before surgery

140

varicosities

dilated veins due to incompetent valves

blood pools in the veins
H and P:
enlarged veins, visible veins, palpable veins, increased skin pigmentation, edema, ulceration

141

How do we treat varicose veins?

weight reduction, avoid prolonged standing, leg elevation

compression stockings

sclerotherapy (injection of a substance that causes injury and thrombosis)

thermal ablation (external or internal)

surgery or ligation of the vein

142

AVM

abnormal communication between arteries and veins

palpable, warm, pulsating masses if superficial
pain
local ischemia

Treat: surgical removal or sclerosis if in brain or bowel where it might bleed

143

DVT

blood clot in large vein
usually in the lower extremity
RF: prolonged inactivity (travel or immobilization), recent surgery

Ted hose, SCDs, heart failure, hypercoag states

Cancer, pregnancy, OCPs, tobacco use, vascular trauma

DVT: hemostasos, hypercoagulability, vascular endothelial damage

H and P:
often asymptomatic
deep leg pain
calf sweeling and warmth

Homan sign (very unreliable)
measure circumference of the calf

Labs:
D-dimer
compressive venous ultrasound

Ts: elevate the leg
LMWH or unfractionated heparin, warfarin (long-term)

IVC filter (Greenfield filter) if the patient can't take warfarin

144

Dilates veins

nitroglycerine

145

dilates veins and arteries

dihydropyridine CCBs

146

dilates arteries

hydralazine

147

dilates veins and arteries

nitroprusside