Cardiology

Question 1

HTN

1. Stage 1
2. Stage 2
3. Comorbidities & Tx
   
   1. CAD
   2. CHF
   3. Smoke/Kidney/LIver

Answer 1

1. Stage 1: >140/90 => THZ/CCB/ACEi/ARB
2. Stage 2: >160/100 => THZ + Comorbid conditions
3. Comobrid tx
   
   1. CAD = BB + ACEi + Nitrate/CCB
   2. CHF = BB + ACEi + Isonitrite/Spiranolactone
   3. Smoke/kidney/liver = ACEi/ARB

Question 2

HTN Tx

1. Goals x 2
2. Rules x 3

Answer 2

JNC 8 Treatment for HTN

• BP goals:
  
  • Age < 60 or Diabetic/CKD: 140/90
  • Age > 60: 150/90
• Treatment: #1 is always lifestyle modifications
  
  • Nonblack: THZ, CCB, ACE-i > ARB
  • Black or >75: THZ, CCB
  • CKD (+/- DM): ACEi/ARB (even if old/black)
• Medications
  
  • THZ (Chlorthalidone)
  • CCB (-dipine)
  • ACEi (-pril)
  • ARB (-sartan)

Question 3

torsades de pointes

Answer 3

• ECG will show rhythm > 100 bpm + frequent QRS axis/morphology variation
• Mcc acquired or congenital long QT interval syndrome (drugs or hypokalemia)
• Treatment is
  
  • Unstable: defibrillation
  • Stable: intravenous magnesium sulfate and stopping the offending drug

Question 4

Arrhythmia => palpitations, dizziness, syncope, SCD

• Caused by: prolonged QT or Hypokalemia/Hypomagnesemia

Answer 4

torsades de pointes = form of polymorphic ventricular tachycardia. fluctuating amplitude of the QRS complexes which appear to twist around the isoelectric line => V.fib

Question 5

Answer 5

Left Bundle Branch Block

• ECG will show:
  
  • Wide QRS >.12 sec
  • Broad, slurred R in V4 and V6
  • Deep S in V1 and V2
  • ST elevations in V1 - V3
• Comments: New LBBB + Chest Pain = MI until proven otherwise
• Cause: Senile fibrosis of conduction system, chronic HTN/ischemia/CHF and valvular disease

Question 6

Bundle Branch Blocks

Lt vs Rt

Answer 6

Bundle branch blocks are abnormal conduction abnormalities (not rhythm disturbances) in which the ventricles depolarize in sequence, rather than simultaneously, thus producing a wide QRS complex (> 120 msec) and a ST segment with a slope opposite that of the terminal half of the QRS complex.

Question 7

Tetralogy of Fallot

Answer 7

• Patient with a history of episodes of cyanosis (tet spells) and squatting for relief
• PE will show pulmonic stenosis, right ventricular hypertrophy, overriding aorta, VSD
• CXR will show “boot-shaped” heart
• Comments: Most common cyanotic congenital heart disease
• Mnemonic: PROVe:: Pulmonic stenosis, Right ventricular hypertrophy, Overriding aorta, VSD

Question 8

Answer 8

Supraventricular Tachycardia

• All tachydysrhythmias that arise above the bifurcation of the bundle of His
• Characteristics:
  
  • Atrial rate 120-200
  • Rhythm: regular
  • Narrow QRS
• Causes
  
  • Pre-excitation syndromes (WPW)
  • Mitral disease
  • Digitalis toxicity
  • Drugs and toxins
  • Hyperthyroidism
• Treatment:
  
  • Vagal maneuvers (Valsalva)
  • Adenosine (first-line medication), ßBs, CCBs
  • Unstable: synchronized cardioversion

Question 9

Premature Atrial Contractions (PACS)

Answer 9

• Pt = skipped beats/palpitations via psychological stress, stimulants (caffeine, tobacco, alcohol)
• P = Extra beats that originate outside sinus node = ectopic atrial pacemaker
• Dx = Holter monitor
  
  • Different morphology from sinus P waves
  • Appears interspersed throughout an underlying rhythm
• Tx = most asx & benign
  
  • sxs = CCB or BB

Question 10

When is bridgings indicated during interruption (surgery) of oral anticoagulation (warfarin) in patients with atrial fibrillation

Answer 10

• CHA2DS2-VASc score 0-1 and duration of interruption < 1 week = no bridging
• CHA2DS2-VASc score >1 or duration of interruption > 1 week = bridging needed (LMWH/unfractionated heparin).

Question 11

Stroke risk

Answer 11

Question 12

• Child sxs all c/in hrs
  
  • Kernigs + –>
  • petechial rash head to toe –>
  • rapid necrotizing purpura –>
  • cardiac shock

Answer 12

Meningococcal meningitis

Question 13

Orthostatic Hypotension

Answer 13

• C/in 3 min of changing positions (sit => stand)
  
  • Decrease in SBP > 20 or DBP > 10

Question 14

Answer 14

• MI or infarct
• EKG
  
  • >3 consecutive ectopic ventricular beats
  • AV dissociation = QRS >120, Rate >100
  • Wide complexes, Fusion beats, Capture beats
• Tx
  
  • Pulseless: immediate defibrillation
  • Unstable: synchronized cardioversion
  • Stable: procainamide, amiodarone, synchronized cardioversion (refractory)
  • If unsure, manage all wide complex tachycardias as ventricular tachycardia

Question 15

Valsalva/Squat/Leg elevation/Volume expansion/Alpha agonist

1. Increase what murmur
2. Decrease what murmur

Answer 15

1. Aortic stenosis
2. HOCM

Question 16

Long QT syndrome

Answer 16

• QT interval > 460 msec (W); > 440 msec (M)
• Pt = palpiataions, syncope, SCD
• P = meds, physical/emotional stress
• Tx
  
  • Stable = metoprolol + cardiology referral
  • Unstable = torsades de pointe = Mg

Question 17

Mean Arterial Pressure

Answer 17

• MAP = tissue perfusion
  
  • Nl adult = 70–100 mm Hg in adults.
  • 60 req to perfuse coronary arteries, brain, and kidneys.
• MAP = (CO x SVR) + CVP
• MAP = DBP + 1/3 (SBP-DBP) = [(2 x diastolic)+systolic] / 3

Question 18

Infective Endocarditis PE Findings

Answer 18

• FROM JANE = Staph/Strep
• Fever
• Roth spots (eyes)
• Osler nodes (ouch on fingers pads)
• Murmurs (MOST COMMON)
• Janeway lesions (painless red lesions on extremities)
• Anemia
• Nail bed hemorrhage
• E mboli

Question 19

Answer 19

A. Flutter

• EKG
  
  • Sawtooth pattern, Narrow QRS
  • Atrial rate: 250-300/minute
  • Ventricular rate: 150- +/-30
  • AV node conducts every 2 or 3 atrial impulses
• Tx
  
  • Stable = Adenosine
  • Unstable = Syn cardiovert

Question 20

Answer 20

A. Fib

• EKG
  
  • Irregularly irregular
  • No P waves
  • Narrow QRS unless conduction block or accessory pathway
  • Variable ventricular response rate
• Tx
  
  • Stable = Adenosine
  • Unstable = Syn cardiovert

Question 21

Answer 21

Ventricular Fibrillation

• EKG
  
  • Wide-complex, disorganized
  • No cardiac output or pulse
• Pt = Incompatible with life => pulseless
• Tx = Defibrillation, ACLS

Question 22

Answer 22

Normal sinus rhythm

• Rate 60-100
• Regular rhythm with P for every QRS
• PR interval 120-200
• QRS 60-100

Question 24

Amiodarone Side effects

Answer 24

• Tx = VT > SVT
  
  • Class 3 = inhibit K out => prolonged action potentional
  • Class 2 = beta blocker
  • Class 4 = CCB
• Adverse
  
  • Hypotension > bradycardia, Heart block, prolonged QT
  • Interstitial lung dz
  • Hypothyroid/Hyperthryoid
  • Hepatitis, Epidiymitis

Question 25

Premature Ventricular Contractions (PVCs)

Answer 25

* EKG * Earlier QRS -\> compensatory pause * Wider bizarre QRS c/o preceding P wave * Path = MV prolapse

Question 26

Cocaine should not get what medication

Answer 26

beta-blocker can cause unopposed alpha effects leading to worsening symptoms and blood pressure.

Question 27

CCB Types & Fxn

Answer 27

* Vascular disorders (HTN, raynauds, etc..) * Dihydropyridines "**-****pines"** * Amlodipine (many side effects) * Nicardipine, Nifedipine, Felodipine * Rate Control = SVTs * Phenylalkylamines = **Verapamil** (most effect on AV node) * Benzothiazepines = **Diltiazem** * CCB Toxicity * SA/AV node slowing, vasodilation * Bradycardia, hypotension, hyperglycemia