Cardiology Flashcards
(179 cards)
1
Q
Stable Bradycardia Treatment
A
Monitor and observe
2
Q
Unstable Bradycardia Treatment
A
Atropine (1st line)
Others: Epi, Dopamine, Transcutaneous Pacing
3
Q
Shockable Rhythms
A
1) V-Fib
2) Pulseless V-Tach
4
Q
Unstable Tachycardia Treatment
A
SYNCHRONIZED Cardioversion
5
Q
Stable Tachycardia (Wide QRS) Treatment
A
Amiodarone (1st line)
Others: Lidocaine, Procainamide
6
Q
Stable Tachycardia (Narrow QRS) Treatment
A
Adenosine (1st)
Then, Beta-blocker, CCB
7
Q
Acute A-Fib Treatment
A
Beta-blocker or CCB
8
Q
WPW Treatment
A
Procainamide preferred (avoid AV nodal blockers)
9
Q
AV Nodal Blockers
A
ABCD= Adenosine Beta Blockers CCB Digoxin
10
Q
Normal PR interval
A
0.12 - 0.2
11
Q
Normal QRS time
A
<0.12 sec (if normal, there is no bundle branch block*)
12
Q
Anterior Leads
A
V1-V4
13
Q
Lateral Leads
A
I, aVL, V5, V6
14
Q
Anterolateral leads
A
I, aVL, V4-V6
15
Q
Inferior Leads
A
II, III, aVF
16
Q
Posterior Leads
A
ST DEPRESSIONS in V1-V2
17
Q
Causes of Left Axis Deviation
A
LBBB LVH Inferior MI Elevated Diaphragm (pregnancy, obesity) Left anterior hemiblock WPW
18
Q
Causes of Right Axis Deviation
A
RVH
Lateral MI
COPD
Left posterior hemiblock
19
Q
Normal Sinus Rhythm Determination
A
Every P-wave followed by QRS
P waves are positive/upright in I, II, and aVF
P waves are negative in aVR
Rate is 60-100
20
Q
Sick Sinus Syndrome (What is it?/Caused by?)
A
Combination of sinus arrest with alternativing paroxysms of atrial tachyarrhythmias & bradyarrhythmias
Caused by sinoatrial node disease and corrective cardiac surgery
21
Q
Sick Sinus Syndrome Management
A
+/- permanent pacemaker if symptomatic
If brady alternating with v-tach –> permanent pacemaker with automatic implantable cardioverter-defibrillator
22
Q
First Degree AV Block Definition
A
Constant, prolonged PR-Interval (>0.20 sec)
QRS follows every P wave
23
Q
First Degree AV Block Treatment
A
None, observation
24
Q
Second Degree AV Block Type I Definition
A
Mobitz I (Wenckebach): Progressive PRI lengthening --> Dropped QRS
25
Second Degree AV Block Type I Treatment
Symptomatic --> Atropine (treat like brady)
| Asymptomatic --> Observation +/- cardiac consult
26
Second Degree AV Block Type II Definition
Mobitz II:
| Constant/Prolonged PRI --> Dropped QRS
27
Second Degree AV Block Type II Treatment
Atropine or temporary pacing
| Progression to 3rd degree block is common so permanent pacemaker is the definitive treatment!
28
Which heart block is most likely to progress to 3rd degree
Mobitz II
29
Third Degree AV Block Definition
AV dissociation: P waves NOT related to QRS
30
Third Degree AV Block Treatment
Acute: Temporary pacing --> PPM
Definitive: PPM
31
Atrial Flutter Management
Stable: Vagal, B-blocker, or CCB
Unstable: Synchronized cardioversion
Definitive: Radiofrequency ablation
*Anticoagulation similar to A-Fib
32
Most common chronic arrhythmia
A-Fib
33
Stable A-Fib Management
RATE CONTROL (preferred in symptomatic Afib)
- B-blocker (metoprolol*, esmolol)
- CCB (diltiazem*, verapamil (nondihydropyridines))
- Digoxin +/- in elderly (preferred rate control in patients with hypotension or CHF)
RHYTHM CONTROL (may be used in younger patients with lone AFib)
- Direct current (synchronized) cardioversion (DCC) is preferred over pharmacologics; DCC can be done if AF present for <48 hours OR after 3-4 weeks of anticoagulation and TEE shows no atrial thrombi
- Pharm control: Ilbutilide, Flecainide, Sotalol, Amiodarone
- Radiofrequency ablation
34
Stable A-Fib Management in patient with hypotension or CHF
Digoxin
35
Unstable A-Fib Management
DCC
36
A-Fib Anticoagulation Risk Stratification
CHA2DS2-VASc Score:
- CHF - 1 point
- HTN - 1 point
- Age(2) >75 - 2 points
- DM - 1 point
- Stroke, TIA, Thrombus - 2 points
- Vascular disease (prior MI, aortic plaque, PAD) - 1 point
- Age 65-74 - 1 point
- Sex (female) - 1 point
Max Score: 9; 2 or more is high risk, 1 is low risk
High risk: chronic oral anticoagulation recommended
Low risk: clinical judgment
37
Anticoagulation options
NOACs (now preferred over warfarin)
Warfarin
Dual antiplatelet therapy (ex. Aspirin + Clopidogrel) --> reserved for patients who cannot be treated with anticoagulation
38
Types of NOACs
Dabigatran (direct thrombin inhibitor)
| Rivaroxaban, Apixaban, Edoxaban (factor Xa inhibitors)
39
Anticoagulation preference in A-Fib
NOACs
40
Warfarin Indications for A-Fib
Preferred in patients with severe chronic kidney disease, contraindications to NOAC (HIV patients on protease inhibitor therapy, patients on CP450 inducing antiepileptic meds), patient preference, cost
41
INR goal for A-Fib
2-3
42
Long QT Syndrome Etiology
Congenital
| Acquired (macrolides, TCAs, electrolyte abnormalities)
43
Long QT Clinical Manifestations
Recurrent syncope (Get EKG in ALL Syncope)
Ventricular arrhythmias
Sudden cardiac death
44
Management of Long QT Syndrome
Discontinue offending drugs and correct electrolyte abnormality
Implantable cardiodefibrillator is definitive for congenital or recurrent ventricular arrhythmias
45
Paroxysmal SVT (PSVT) EKG
HR > 100
Rhythm usually regular with narrow QRS
P waves hard to discern
46
PSVT Management
Stable (Narrow complex):
Vagal Maneuvers
Adenosine (1st line medical treatment)
AV nodal blockers (B-blockers, CCB)
Stable (Wide Complex):
Antiarrhythmics (amiodarone, procainamide if WPW)
Unstable:
DCC
Definitive:
Radiofrequency ablation
47
Wandering atrial pacemaker (WAP) vs Multifocal atrial tachycardia (MAT) EKG
WAP:
HR < 100
3 or more p wave morphologies
MAT:
HR > 100
3 or more p wave morphologies
48
What condition is MAT associated with?
Severe COPD
49
Tx for WAP and MAT
CCB or B-blocker if LV function preserved
50
Stable WPW management
Vagal, antiarrhythmics (procainamide preferred)
51
Unstable WPW Management
DCC
52
Definitive WPW management
Radioablation
53
Junctional Rhythm EKG
P waves inverted (if present) or not seen
Narrow QRS
Regular Rhythm
HR 40-60 bpm (reflecting intrinsic rate of AV junction)
54
Accelerated junctional rhythm EKG
HR 60-100 w/out pwaves (or inverted if present)
55
Junctional tachycardia
HR >100 w/out pwaves (or inverted if present)
56
MC rhythm seen with digitalis toxicity
Junctional rhythms
57
PVC management
No treatment usually needed
58
MC cause of V-tach
Prolonged QT
59
MC cause of Torsades
Hypomagnesemia
| Other: Hypokalemia, prolonged QT, V-tach
60
Stable Vtach treatment
Antiarrhythmics (Amiodarone*, lidocaine, procainamide)
61
Unstable Vtach w/ a pulse
Synchronized cardioversion
62
Vtach w/out pulse
Defibrillation (UNsynchronized cardioversion) + CPR (treat as VFib)
63
Torsades treatment
IV magnesium
| Correct any electrolyte abnormalities
64
VFib treatment
Defibrillation + CPR
65
Pulseless electrical activity (PEA) definition
Organized rhythm on monitor, but patient does not have a palpable pulse (electrical activity is not coupled with mechanical contraction)
66
PEA treatment
CPR + Epinephrine + Check for shockable rhythm every 2 minutes
67
Asystole treatment
CPR + Epinephrine + Check for shockable rhythm every 2 minutes
68
Increased JVP + crackles/rales in lungs
CHF
69
Increased JVP + normal pulm exam
Pericardial tamponade
70
Increased JVP + decreased breath sounds
Tension pneumothorax
71
Causes of ST Depression
ST depression usually = ISCHEMIA
| May be benign (upsloping)
72
Which ST depressions are pathologic
Horizontal and downsloping
73
Which ST elevations are pathologic
Convex down (most likely ischemic)
74
Which ST elevations may be benign
Concave up
75
Etiologies of ST elevation
1. Acute MI
2. LVH
3. LBBB
4. Acute Pericarditis
5. Early repolarization abnormalities
6. Coronary artery vasopasm/prinzmetal angina/cocaine
7. Brugada syndrome
76
Early repolarization abnormalities EKG
DIFFUSE CONCAVE ST elevations
Large T waves
Tall QRS voltage
Fishook (slurring/notching) at the j point
77
Acute pericarditis EKG
- DIFFUSE CONCAVE ST elevations in the precordial leads (V1-V6)
- PR depressions in the same leads with the ST elevations
- Lead aVR: ST depression and PR elevation (opposite of precordial leads)
- NO reciprocal changes
78
Brugada Syndrome EKG
- RBB pattern (often incomplete) in V1-V3
- ST elevation in V1-V3 (often downsloping)
- Twave inversions in V1 and V2 +/- S wave in lateral leads
79
Demographic group associated with Brugada
Asian males
80
Brugada syndrome cause and manifestations
Genetic disorder associated with syncope, sudden cardiac death
81
Most common arrhythmia with brugada
Ventricular arrhythmias
82
Brugada management
AICD to prevent death from V Fib
83
When are left sided murmurs best heard in regards to breathing?
End expiration
84
When are right sided murmurs best heard in regards to breathing?
End inspiration
85
What does inspiration do to stroke volume
Decreases, but CO stays the same due to an increase in HR
86
Gold standard test for diagnosing CAD, PAD, renal artery stenosis, and AAA
Angiography
87
Most useful test to diagnose heart failure
Echocardiogram
88
Biggest risk factor for CAD
Diabetes
89
Most important modifiable risk factor for CAD
Smoking
90
How much of the lumen is occluded to cause symptomatic CAD?
>70%
91
Class I Angina
Angina only with unusually strenuous activity. No limitations of activity.
92
Class II Angina
Angina with more prolonged or rigorous activity. Slight limitation of physical activity.
93
Class III Angina
Angina with usual daily activity. Marked limitation of physical activity.
94
Class IV Angina
Angina at rest. Often unable to carry out any physical activity.
95
Levine's Sign
Clenched fist over chest
96
Classic angina description
Substernal chest pain brought on by exertion/anxiety (sometimes radiating to arm/jaw) and relieved with rest/nitroglycerin (predictable pattern)
97
Classic EKG finding for angina
```
ST depression (horizontal or downward)
if LVH present = increase in adverse outcomes
```
98
Most useful noninvasive screening tool for angina
Stress Testing
99
Angina definitive management
1. Percutaneous Transluminal Coronary Angioplasty
| 2. CABG
100
Indication for percutaneous transluminal coronary angioplasty
1 or 2 vessel disease NOT involving the left main coronary artery and in whome ventricular function is normal/near normal.
101
CABG indications
Left main coronary artery disease
Symptomatic or critical (>70%) stenotic 3-vessel disease
Decreased left ventricular ejection fraction (<40%)
102
Medical management of angina
1. Nitrates
2. B-Blockers
3. CCB
4. Aspirin
103
1st line drug for chronic management of angina
B-Blockers
104
Contraindication to nitrates
SBP <90
RV infarct
Use of sildenafil & other PDE-5 inhibitors
105
UA/NSTEMI EKG
ST depressions &/or T-wave inversions = Subtotal occlusion (EKG may be normal)
106
STEMI EKG
ST elevations in two or more consecutive leads = Total occlusion
107
UA vs NSTEMI
Cardiac enzymes elevated in NSTEMI (EKG may be the same)
108
Patients with "silent MI"
Women, elderly, diabetics, & obese
109
Symptoms of atypical MI
abdominal pain, jaw pain, or dyspnea WITHOUT chest pain
110
Inferior MI physical exam findings
Chest pain + bradycardia +/- S4
111
Progression of EKG changes in STEMI
Hyperacute (peaked) T-waves -->
ST elevations -->
Q waves -->
T wave inversions
112
Pathologic Q-wave definition
Q wave > 0.03 sec & 0.1 mv deep
| Q wave depth at least 25% of associated R wave
113
Most sensitive and specific cardiac marker
Troponin
114
Other causes of increased troponin
Renal failure
Advanced heart failure
Acute PE
CVA
115
Management of STEMI
1. Reperfusion therapy (most important) - PCI or thrombolytics
2. Antithrombotics - Asprin, Heparin
3. Adjuntive therapy - B-Blockers, ACE, Nitrates, Morphine
116
PCI indication in STEMI
Best w/in 3 hours of sx onset (esp w/in 90 min)
| PCI is superior to thrombolytics
117
Thrombolytic indication in STEMI
PCI is not an option/unable to get PCI early
118
CI of Betablockers in STEMI
```
HR <50
SBP <100
Decompensated CHF
2nd/3rd degree heart block
Severe asthma/COPD
Shock
Cocaine induced MI
```
119
CI of ACE Inhibitors in STEMI
Renal failure
| SBP <100
120
AMI protocol for ACS
EKG w/in 10 min
Door to thrombolytics w/in 30 min
Door to PCI w/in 90 min
121
STEMI AMI protocol
```
B-Blockers
Nitro
Asprin
Heparin
ACEI
Reperfusion!!!
```
122
UA or NSTEMI AMI Protocol
```
B-Blockers
Nitro
Asprin
Heparin
NO emergent reperfusion or ACEI (unlike STEMI)
```
123
Cocaine Induced MI AMI protocol
```
Aspirin
Nitro
Heparin
Anxiolytics
(*AVOID B-Blockers b/c of vasospasm)
```
124
Dressler syndrome
Post-MI pericarditis +
Fever +
Pulmonary infiltrates
125
Prinzmetal Angina Tx
CCBs (drug of choice)
| Nitrates as needed
126
Prinzmetal Angina EKG
Transient ST elevations that resolve with CCBs or nitro
127
Prinzmetal Angina clinical manifestations
CP, usually NONexertional and occurring at rest
128
Absolute contraindications to thrombolytics in ACS
```
Previous intracranial hemorrhage
Non-hemorrhagic stroke w/in 6 months
Closed head/facial trauma w/in 3 months
Intracranial neoplasm, aneurysm, AVM
Active internal bleeding
Suspected aortic dissection
```
129
MC cause of heart failure
CAD
130
MC cause of R-sided HF
L-sided HF
| Also, pulmonary disease, mitral stenosis
131
Systolic vs Diastolic HF
Systolic:
- Decreased EF
- +/- S3 gallop
- Most common form of HF
- Etiologies: Post-MI, DILATED cardiomyopathy, myocarditis
Diastolic:
- Normal/Increased EF
- +/- S4 gallop
- Normal cardiac size (stiff/noncompliant ventricle)
- Etiologies: HTN, LVH, elderly, valvular heart disease, cardiomyopathies, constrictive pericarditis
132
Classifying of HF
Class I - No symptoms, no limitation during ordinary physical activity
Class II - Mild symptoms, slight limitation of activity
Class III - Sxs cause marked limitation in activity
Class IV - Symptoms present at rest
133
MC sx of L-sided HF
Dyspnea
134
Cheyne-Stokes breathing
Associated with L-side HF
| Deeper, faster breathing w/ gradual decrease & periods of apnea
135
R-sided HF physical exam
Peripheral edema
JVD
GI/hepatic congestion: anorexia, n/v, HSM, RUQ tenderness, hepatojugular reflex
136
Diagnosis of HF
Echo (most useful)
CXR (esp useful in congestive HF)
BNP
137
CXR findings with HF
Cephalization of flow --> Kerley B lines --> Butterfly pattern --> cardiomegaly
Pleural effusions --> pulmonary edema
138
Initial management of HF
ACE + Diuretic (for sxs) --> Add beta blockers as needed
139
Best 2 meds for decreasing mortality of HF
ACE > Beta-blockers
140
Management of acute pulmonary edema/CHF
LMNOP:
| Lasix, Morphine, Nitro, Oxygen, Position (place upright)
141
2 MC causes of pericarditis
Idiopathic
| Viral
142
MC Viral causes of pericarditis
Enteroviruses-Coxsackie; Echovirus
143
Drugs that cause pericarditis
Procainamide
INH
Hydralazine
144
Clinical manifestations of pericarditis
3 P's:
- Pleuritic CP
- Persistent CP
- Postural CP (worse supine, relieved sitting forward)
Physical:
Pericardial friction rub (best heard at end expiration while upright and leaning forward
145
Pericarditis diagnostics
EKG: DIFFUSE ST elevations in precordial leads (concave up in V1-V6)
Echo: Assesses complications (effusion/tamponade)
146
Pericarditis management
Aspirin/NSAIDs x 7-14 days
Colchicine (2nd line)
+/- steroids if sxs >48 hours refractory to 1st line meds
147
Pericardial effusion EKG
Low voltage QRS
| Electrical alternans
148
Management of pericardial effusion
Observation if small & no tamponade
| +/- Pericardiocentesis if tamponade or large
149
Knuckle sign
Lead aVR: PR elevation with ST depression reflects atrial injury in acute pericarditis
150
Beck's Triad
Associated with tamponade:
1. Muffled heart sounds
2. JVD
3. Hypotension
151
MC symptom of constrictive pericarditis
Dyspnea
152
Kussmaul's sign
Increased JVD during inspiration associated with constrictive pericarditis and restrictive cardiomyopathy
153
Heart sound associated with constrictive pericarditis
Pericardial knock: high pitched 3rd heart sound due to sudden cessation of ventricular filling
154
Treatment of constrictive pericarditis
Pericardiectomy (definitive treatment)
| Diuretics for symptomatic control
155
MC cause of myocarditis
Viral infection (enterovirus (esp. coxsackie))
```
Others:
Bacteria (rickettsial, chagas, diptheria);
Fungal;
Parasitic;
Scorpion envenomation;
SLE, rheumatic fever, rheumatoid arthritis, Kawasaki
Meds
Uremia
```
156
Meds associated with myocarditis
Clozapine***
| Methyldopa, tetracycline, penicllin, isoniazid, etc.
157
Classic CXR with myocarditis
Cardiomegaly (may be normal)
158
Gold standard of diagnosing myocarditis
Endomyocardial biopsy
159
Management of myocarditis
1. Supportive (mainstay) - diuretics, ACE I, inotropic drugs (dopamine, dobutamine, milrinone)
2. Beta blockers not used in management of peds patients
3. IVIG may be helpful in some patients
160
MC cause of dilated cardiomyopathy
Idiopathic (50%)
161
Apical left ventricular ballooning following stress
Takotsubo Cardiomyopathy
162
MC cause of restrictive cardiomyopathy
Amyloidosis
| Others: Sarcoidosis, idiopathic myocardial fibrosis
163
Treatment of restrictive cardiomyopathy
No specific treatment, treat underlying cause
164
MC initial complaint of hypertrophic cardiomyopathy
Dyspnea
165
Hypertrophic cardiomyopathy murmur
Harsh systolic crescendo-decresendo murmur: best heart @ LLSB (similar to AS)
Decreased murmur intensity with INCREASED venous return (squatting, lying suping)
Increased intensity with DECREASED venous return
166
Rheumatic Fever diagnostic criteria
JONES criteria
167
JONES criteria for Rheumatic Fever
Major criteria (2 pts):
- Joint (migratory polyarthritis)
- Oh my heart (active carditis)
- Nodules (subcutaneous)
- Erythema marginatum
- Sydenham's chorea
Minor criteria (1 pt):
- Fever >101.3
- Arthralgia
- Increased ESR/CRP/leukocytosis
- Prolonged PR on EKG
PLUS supporting evidence of recent GAS infection
168
MC valve affected by Rheumatic fever
Mitral (75%-80%)
| Aortic (30%)
169
Rheumatic fever management
1. Aspirin x 2-6 weeks with taper +/- steroids
| 2. Pen G (erythromycin if PCN-allergic)
170
Fixed split of S2
Left to Right shunts (ASD, VSD) or
| Delayed pulmonary closure (pulmonary HTN, mitral regurgitation)
171
Physiologic split of S2
Inspiration splits S2 into A2 followed by P2
172
Systolic ejection click
Mitral valve prolapse
173
Diastolic opening snap
Mitral valve stenosis
174
MC valve affected by Rheumatic fever
Mitral (75%-80%)
| Aortic (30%)
175
Rheumatic fever management
1. Aspirin x 2-6 weeks with taper +/- steroids
| 2. Pen G (erythromycin if PCN-allergic)
176
Fixed split of S2
Left to Right shunts (ASD, VSD) or
| Delayed pulmonary closure (pulmonary HTN, mitral regurgitation)
177
Physiologic split of S2
Inspiration splits S2 into A2 followed by P2
178
Systolic ejection click
Mitral valve prolapse
179
Diastolic opening snap
Mitral valve stenosis
