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Coronary artery disease

- aka atherosclerotic disease
- ischemic heart disease

1

A 48 y.o woman comes to the office wth chest pain that has been occuring for the past several weeks. Not reliably related to exertion. She is comfortable now. Pain sometimes associated with nausea. No SOB. and pain does not radiate beyonf chest. She has no PMH. What is most likely diagnosis?

GERD

2

Risk factors for CAD

- Diabetes mellitus
- Tobacco smoking
- HTN
- Hyperlipidemia
- Family hx of premature coronary arery disease
- Age above 45 in men and above 55 in women

3

Worst risk factor for CAD

Diabetes mellitus

4

Premature coronary heart disease

- male relative under 55
- female relative under 65

5

Postmenopausal woman develops chest pain immediately on hearing news of her son's death in war. She develops acute chest pain , dyspnea, ST segment elevation in V2 - V4 on ECG. Elevated levels of troponin confirm an acute MI. Coronary angiography is normal including absence of vasospasm with provocative testing. ECG reveals apical LV "ballooning". Mechanism of this disorder?

- massive catecholamine discharge

6

Tako-Tsubo cardiomyopathy

- often occurs in postmenopausal women s/p emotionally stressful event
- manage w/ Beta blockers and ACE inhibitors

7

Most dangerous risk factors in terms of risk or CAD?

Elevated LDL

8

Correcting which risk factor for CAD will result in the most immediate benefit for the patient?

Smoking cessation

9

Chest pain described as dull / "sore" and/or squeezing or pressure-like

ischemic pain
- sharp ("knifelike") or pointlike
- lasts for a few seconds

10

Chest pain that excludes ischemic pain

1. changes with respiration (pleuritic)
2. changes with position of the body
3. changes with touch of the chest wall (tenderness)

** if patient answers yes to the previous questions, likely NOT ischemic

11

Most common cause of chest pain

Gastrointestinal disorders

12

Patient describes chest wall tenderness. Most likely diagnosis?

Costochrondritis

13

Most accurate test for costochondritis

Physical exam

14

Patient describes chest pain that radiates to the back, unequal blood pressure between arms. Most likely diagnosis?

Aortic dissection

15

Most accurate test for aortic dissection

CXR
w/ widened mediastinum
- chest CT, MRI, or TEE confirms the disease

16

Young Pt (< 40) c/o chest pain worse with lying flat, better when sitting up. Likely diagnosis?

Pericarditis

17

Most accurate test for pericarditis

Electrocardiogram with ST elevation every where
PR depression

18

Pt describes epigastric discomfort, pain better when eating. Likely diagnosis?

Duodenal ulcer disease

19

Most accurate test for chest pain

Endoscopy

20

Pt describes chest pain with bad tatse, cough, hoarsness

Gastroesophageal reflux

21

Most accurate test for GERD

Response to PPIs;
- alumnium hydroxide and magnesium hydroxide
- viscous lidocaine

22

Pt describes chest pain with cough, sputum, and hemoptysis. Likely diagnosis?

Pneumonia

23

Most accurate test for pneumonia

CXR

24

Patient describes chest pain with sudden onset SOB, tacycardia, and hypoxia.

Pulmonary embolus

25

Most accurate test for pulmonary embolus

- spiral CT
- V/Q scan

26

Pt complains chest pain with sharp, pleuritic pain, and tracheal deviation. Likely diagnosis?

Pneumothorax

27

Most accurate test for pneumothorax

Chest X-ray

28

Worst prognostic significance for chest pain

Shortness of breath

29

Best initial test for chest pain

Electrocardiogram (EKG)`
- in office setting, the EKG is normal most of time but cannot progress to other testing without this test

30

If patient has acute chest pain in an office/ambulatory setting, what is the next best step to evaluate chest pain?

Transfer to ER
- DON'T ANSWER CARDIAC ENZYMES!!

31

If patient has chest pain in office/clinic for days to weeks, are cardiac enzymes appropriate?

No enzymes

32

If patient has chest pain in emergency department for minutes to hours, are cardiac enzymes appropriate?

Yes enzymes,
after an EKG is performed

33

When the etiology of chest pain is not clear, what is the best tool for evaluation of chest pain?

Exercise tolerance testing (ETT)

34

What are the two best factors for ETT

1. You can read the EKG
2. The patient can exercise (gets heart rate > 85% of maximum)

35

Maximum heart rate

220 - age of patient

36

Best way to detect ischemia on EKG

ST segment depression

37

If you cannot read EKG because of baseline EKG abnormality, what are the 2 best ways to detect ischemia w/o EKG?

- Nuclear isotope uptake: thallium or sestamibi
- Echocardiographic detection of wall abnormalities

38

Reasons for baseline EKG abnormalities

- Left bundle branch block
- Left ventricular hypertrophy
- Pacemaker use
- Effect of digoxin

39

Thallium testing for detection of cardiac ischemia

Normal myocardium will pick up thallium
-if myocardium is alive and perfused, thallium will be picked by Na/K ATPase
-if myocardium is abnormal, thallium has decreased uptake

40

Echocardiogram for detection of cardiac ischemia

Normal myocardium will move on contraction
- abnormal heart has decreased wall motion (dyskinesis, akinesis, or hypokinesis)

41

Ischemia vs infarction

ischemia: decreased perfusion that is detected by REVERSAL of thallium uptake or wall motion that returns to normal after rest period

42

If patient is unable to exercise to detect cardiac ischemia with exercise tolerance testing, what is the best method of detecting cardiac ischemia?

Pharm testing
- Persantine (dipyramidole) or adenosine in combination with thallium or nuclear isotopes
- Dobutamine in combination with echocardiogram

43

How does dobutamine work to detect cardiac ischemia

Dobutamine will increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities on ech

44

Coronary Angiography

- used to detect anatomic location of coronary artery disease
- use to determine whether narrowing should be best dealt with by surgery, angiography, or methods of revascularization

45

Most accurate test for detecting coronary artery disease

Angiography

46

Arterial stenosis

- insignificant when less than 50%
- surgically correctable when > 70%

47

Holter monitoring

- continuous ambulatory EKG monitor that records rhythm
- used for 24 - 72 hrs
- mainly detects rhythm disorders (a-fib, a-glutter, PVCs)
- does not detect ischemia and not for evaluating ST segment

48

48 y.o woman comes to office w/ chest pain that has been occurring over the last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of pain is retrosternal. She has no hypertension and the EKG is normal. What is the next best step?

Exercise tolerance testing

49

Medications that lower mortality in setting of chronic angina

- Aspirin
- Beta blockers
- Nitroglycerin

50

Route of nitroglycerin in chronic angina

Orally or a transdermal patch

51

Route of nitroglycerin in acute coronary syndromes

Sublingual, paste, and IV forms of nitroglycerine

52

Clopidogrel

- aspirin intolerance (e.g. allergy)
- recent angioplasty with stenting
- rarely used with TTP

53

Prasugrel

- thienopyridine medication in same clas as clopidogrel and ticlopidine
- antiplatelet medication best used for angioplasty ad stenting

54

Ticlopidine

- antiplatelet med in rare patient intolerant of both aspirin and clopidogrel
- should not be used if aspirin/clopidogrel intolerance is bleeding
- can cause neutropenia and TTP

55

Ranolazine

- additional therapy for angina refractory or persistent through treatment

56

ACE inhibitors / ARBS: Indications

- low systolic ejection raction/ systolic dysfunction (best mortality beneift)
- regurgitant valvular disease

57

Most common side effect of ACE inhibitors

Cough

58

64 y/o man is placed on lisinopril as part of managing CAD in association with ejection fraction of 24% and symptoms of breathlessness. Although he sometimes has rales on lung exam, the patient is asymptomatic today. PE should minimal edema of lower extremities. Blood tests reveal an elevated level of K that is present on a repeat measurement. EKG is unchanged. What's the best way to manage this patient

Switch from lisinopril to hydralazine and nitrates
- Lisinopril also cause hyperkalemia due to inhibition of aldosterone
- hydralazine will decrease afterload a arterial vasodilator

59

Why should hydralazine be used with nitrates in systolic dysfunction?

Hydralazine in an arterial vasodilator that decreases afterload
- used w/ nitrates to dilate coronary arteries so that blood isn't stolen away from coronary perfusion when afterload is decreased w/ hydrazalines

60

Lipid Management in CAD

Patients use statins w/ CAD with an LDL above 100 mg/dL

61

Aside from CAD, other conditions in which lipids should be controlled to < 100 mg/dL

- Peripheral artery disease (PAD)
- Carotid disease (not stroke)
- Aortic disease ( the artery, not the valve)
- Diabetes mellitus

62

Most common adverse effect of statins

Liver dysfunction
- elevation of transaminases

63

Why are statins considered to have some mortality benefit?

Statins have antioxidant effect on endothelial lining of coronary arteries

64

Niacin

- used to lower lipid levels
- associated w/ glucose intolerance, elevation of uric avid level and itchiness due histalimine rlease
- excellent ADDITION to statins if full lipid control not achieved with statins alone

65

Gemfibrozil

- fibric acids lower triglyceride levels more than statins however, less mortality benefit than statins
- caution using with statins due to increased risk of myositis

66

Cholestyramine

- bile acid sequestrant but often has interactions with other drugs in gut by blocking their absorption
- associated with uncomfortabe GI complaints such as constipation and flatus

67

Ezetimibe

- lowers LDL level w/o any evidence of actual benefit to patient
- no better than placebo in terms of endpoints (e.g. MI, stroke or death)

68

Statin: adverse effect

- elevations of transaminases (liver fxn tests)
- myositis

69

Niacin: adverse effect

- elevation in glucose and uric acid level
- pruritis

70

Fibric acid derivatives: adverse effect

- increased risk of myositis when combined with statins

71

Cholestyramine: adverse effect

Flatus and abdominal discomfort

72

Ezetimibe: adverse effect

- well tolerated and nearly useless

73

Dihydropyridine calcium channel blockers

- Nifedipine
- Nitrenipine
- Nicardipine
- Nimodipine

74

Dihydropyridine calciums affect mortality of CAD patients in which way?

They INCREASE mortality in patients with CAD b/c they raise heart rate
- the increased HR will increase myocardial oxygen consumption

75

Which calcium channel blockers are used in CAD?

Verapamil
Diltiazem

76

Indications for use of CCB in CAD

- Severe asthma precluding use of B-blockers
- Prinzmetal variant angina
- Cocaine induced chest pain (B-blockers are contraindicated)
- Inability to control pain w/ maximal medical therapy

77

Calcium channel blockers: Adverse effects

- Edema
- Constipation (verapamil most often)
- Heart block (rare)

78

Which diagnostic test is best to evaluate patient for revascularization?

- Angiography to determine whether patient needs CABG or angioplasty

79

Indications for coronary artery bypass grafting (CABG)

- Three vessels > 70% stenosis in each vessel
- Left main coronary artery occlusion
- Two-vessel disease in a patient with diabetes
- Persistent symptoms despite maximal medical therapy

80

Pts that benefit the most from CABG

- patients with EF < 35%

81

Which grafted veins are used for CABG

- Internal mammary artery grafts last 10 yrs before occlusion
- Saphenous vein grafts remain patent reliably for 5 years

82

Percutanous coronary intevention

- aka angioplasty
- best therapy for acute coronary syndromes esp those with ST segment elevation
- does not provide clear mortality benefit for stable CAD patients

83

Maximal medical therapy in stable CAD

- ASpirin
- Beta Blockers
- ACEis / ARBs
- Statin

84

70 y.o F comes to ED w/ crushing substernal chest pain for the last hr. The pain radiates to her left artm and is associated with anxiety, diaphoresis, and nausea. She describes the pain as "sore" and "dull" and clenches her fist in front of her chest/ She has a hx of hyperension What is most likely to be found in this patient?

S4 gallop b/c ishemia leading to noncompliance of left ventricle

85

Kussmaul sign

- increase in JVP on inhalation
- often associated with constrictive pericarditis or restrictive cardiomyopathy
- "scratchy" sound in pericardial friction rub

86

Dressler synrome

- complication of myocardial infarction that occurs several days after MI and is much rarer than simpler ventricular iscemia

87

Patent ductus arteriosus (PDA)

- continuous "machinery" murmur t

88

Displaced point of maximal impulse (PMI)

- characteristic of left ventricular hypertrophy as well as dilated cardiomyopathy
- anatomic abnormality that can't occur with an acute coronary syndrome

89

70 y.o F comes to the emergency department w/ crushing substernal chest pain for the last hr. Which of the following EKG findings would be associated with the prognosis?

ST elevations in V2 - V4
- corresponds to the anterior wall of the left ventricle
- signifies an acute myocardial infarction

90

Premature ventricular complexes (PVCS)

- should not be treated
- associated with an acute infarction
- treatment of PVCs only worsens outcome

91

70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hour. An EKG shows ST segment elevation in V-2. What is the most appropriate next step of management in this patient?

Aspirin
- lowers mortality and important to administer as quickly as possible
- initiate therapy before moving patien to the ICU

92

70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hr. An EKG shows ST segment elevation in leads V2 - V4. Aspirin has been given to the patient to chew. What is the most appropriate next step in management?

Angioplasty is associated with greatest mortality benefit

93

Pt c/o chest pain, when to do an EKG

- immediately at onset of pain
- ST elevation progresses to Q waves over several days to a week

94

Myoglobin

- becomes abnormal 1-4 hrs
- duration of myoglobin elevation is 1-2 days

95

CK-MB

- becomes abnormal 4-6 hrs
- duration of elevated CK-MB for 1-2 days

96

Troponin

- becomes abnormal in 4-6 hrs
- duration of elevated troponin is 10-14 hrs

97

Difficulty of using troponin levels in detection of myocardial infarctions

- Troponin can't distinguish btwn reinfarction occurring several days after 1st event
- Renal insufficiency can result in false positive tests since troponin is excreted via kidneys

98

If pt c/o of new chest pain within a few days of first cardiac event, how do you manage this condition?

Concern for reinfarction
1. Perform an EKG to detect NEW ST segment abnormalities
2. Check CK-MB levels
** after two days, the CK-MB levels should have returned to normal
3. Transfer to ICU if new infarction

99

Most common cause of death in first several days of MI

Ventricular arrhythmia (v-tach, v-fib)

100

ST segment elevation myocardial infarction (STEMI)

- best initially managed with aspirin (orally or chewed).
- clopidogrel can be used an alternative to aspirin if there is an allergy

101

Angioplasty vs Thromobolytics

Angioplasty is superior to thrombolytics b/c
- Survival and mortality benefit
- Fewer hemorrhagic complications
- Likelihood of developing MI complicatins (less arrhythmia, less CHF, fewer septal ruptures, few episodes of tampanade)

102

PCI

- standard of care is expected to be performed within 90 minutes of patient arriving in ED with chest pain

103

Complications of PCI

- Rupture of coronary artery on inflation of the balloon
- Restenosis (thrombosis) of the vessel after angioplasty
- Hematoma at the site of entry into artery

104

Which of the following is most important in decreasing the risk of restenosis of the coronary artery after PCI?

Placement of drug eluting stent (paclitazel, siroliums)
- inhibit the local T cell response which reduces rate of sternosis

105

Absolute contraindications to thrombolytics

- Major bleeding into the bowel (melena) or brain (any type of CNS bleeding)
- Recent surgery (within the last 2 weeks)
- Severe hypertension (above 180/110)
- Nonhemorrhagic stroke within the last 6 months

106

Pt comes to a small rural hospital w/o catherization lab. The patient has chest pain and ST segment elevation. What is the most appropriate next step in the management of the patient?

Administer thrombolytics now
- better than angioplasty delayed by several hrs
- mortality benefit of thombolytics extend to 12 hrs

107

Best initial therapy for acute coronary syndrome?

Asprin
- best used for everyone

108

Indication for clopidogrel in ACS

- when aspirin not tolerated, those undergoing angioplasty and stenting

109

Indication for Beta blockers in ACS

- used in everyone
- effect is not dependent on time - starting anytime during admission

110

Indication for ACE inhibitors and ARB in ACS

- used in everyone
- benefits those with ejection fraction < 35%

111

Indication for statins in ACS

- used in everyone
- benefits those with LDL > 100 mg/ dL

112

Indication for oxygen and nitrates in ACS

- used everyone
- no clear mortality benefit

113

Indication for heparin in ACS

- after thrombolytics / PCI to prevent restenosis
initial therapy with ST depression and other non- STEMI events (unstable angina)

114

Indication for calcium channel blockers in ACS

- when beta blockers can't be used
- cocaine induced pain
- Prinzmetal variant or vasospastic variant angina

115

Most dangerous risk factors in terms of risk or CAD?

Elevated LDL

116

Man comes to the emergency department w/ chest pain for the last hr that is crushing in quality and does not change w/ respiration or position of his body. EKG shows ST segment depression in leads V2 - V4. Aspirin has been given. What is the most appropriate next step in management?

Heparin
- heparin will prevent clot formation in coronary arteries but does not dissolve already formed clots
- there is no ST ELEVATION, no benefit of thrombolytics

117

Glycoprotein IIb/IIIa Inhibitors (Abciximab, Tirofiban, Eptifibitide)

- used in ACS in those are to undergo angioplasty and stenting
- inhibit the aggregation of plateletss.
- led to reduction in mortality in those w/ ST depression, particularly in patients whose troponin or CK-MB levels
- not useful in acute STEMIs separate from angioplasty and stenting

118

tPA (thrombolytics) best used in which patients?

- ST elevation MI patients

119

Heparin is best used in which patients?

- non-STEMI patients

120

Glycoprotein IIa/IIIb inhibitors are best in used in which patients?

non-STEMO patients and those undergoing angioplasty and stenting

121

If in non-STEMI ACS, when all meds have been given, and patient has persistent pain, S3 gallop or CHF develop, worse EKG changes or SVT, rising troponin levels. Next step?

Urgent angiography and possible angioplasty

122

Complications of acute MI

- Bradycardia
- Tachycardia
- Tamponade/Free wall rupture
- Ventricular tachycardia/ventricular fibrillation
- Valve/septal rupture

123

Sinus bradycardia in setting of MI

- common w/ MI if vascular insufficiency of the SA node

124

3rd degree (complete) AV block

- will have CANNON A WAVES
- obtain EKG to distinguish 3rd degree AV block vs sinus bradycardia

125

Cannon A waves

- produced by atrial systole against closed tricuspid valve
- tricuspid valve is closed b/c essence of 3rd degree block is that atria and valves are contracting separate
- JVD is bouncing up into the neck

126

Right ventricular infarction

- associated w/ new inferior wall MI and clear lungs
- diagnosed by flipping EKG from usual left side to right side of chest

127

R coronary artery supplies

- RV
- AV node
- inferior wall of heart

128

R ventricular infarction: treatment

- High volume fluid replacement
- avoid nitroglycerin to RV infarctions which markedly worsen cardiac filling

129

Tamponade/free wall rupture s/p MI

- takes several days s/p infarction for wall to scar and weakens enough to rupture
- look for sudden loss of pulse
- lungs are clear and is cause of pulseless electrical activity

130

Tamponade/Free Wall Rupture: Diagnosis

- emergency echocardiography

131

Ventricular Tachycardia/Ventricular Fibrillation s/p MI

- can cause sudden
- must use EKG to distinguish v-tachycardia and v-fibrillaiotn
- both treated w/ cardiovarsion/defibrillation

132

Septal rupture/Valve rupture s/p MI

- new onset of murmur and pulmonary congestion

133

Ventricular septal rupture best heard where?

- can be seen s/p MI
- best heart at LLSB

134

Mitral regurgitation

- can occur s/p MI
- best heard at apex w/ radiation to axilla

135

Most accurate test to detect valve rupture and septal rupture

- Echocardiogram

136

Septal rupture

- look for increase in oxygen saturation as you go from right atrium to right ventricle

137

Intraaortic balloon pump

- used when there is acute pump failure from anatomic problem that can be fixed in OR
- contracts and relazes w/ natural heartbeat
- helps give a "push forward to the blood"

138

Reinfarction or extension of infarction

- patient often presents w/ either inferior or anterior infarction
- look for reoccurrence of pain, new rales on exam, bump up CK-MB and even suddent onset of pulmonary edema

139

Reinfarction or extension of infarction

- repeat EKG
- retreat w/ angioplasty and sometimes thrombolytics in addition to usual meds (aspirin, metoprolol, nitrates, ACE, statins)

140

Aneurysm/ Mural Thrombus

- detected with echocadiogramy
- treated w/ heparin followed by warfarin

141

Pt s/p MI presents w bradycardia and cannon A waves. Likely dx?

3rd degree AV block

142

Pt s/p MI presents w/ bradycardia. No cannon A waves on EKG. Likely dx?

Sinus bradycardia

143

Pt s/p MI w/ PMH of inferior wall MI, clear lungs, tachycardia, hypotension w/ nitroglycerin. Likely dx?

RV infarction

144

Pt s/p MI with new murmur, rales/congestion. Likely dx?

Valve rupture

145

Pt s/p MI with new murmur, increase in oxygen saturation on entering the right ventricle. Likely dx?

Septal rupture

146

Pt s/p MI with loss of pulse, need EKG to answer question. Likely diagnosis

Ventricular fibrillation

147

Before patient w/ MI is discharged. Which test should be done?

Stress test
- to determine if angiography is needed
- angiogrpay determines need for revascularization

148

Meds needed for postinfarction patients

Every MI patient should go home:
- Aspirin
- Beta blockers (metoprolol)
- Statins
- ACE inhibitors

149

ACE inhibitors are best used for which type of MI patients?

Anterior wall infarctions b/c of high likelihood of developing systolic dysfunction

150

Clopidogrel

- used for those intolerant of aspirin or post-stenting

151

ARBS

- used for MI patients with cough on ACE inhibitor

152

Prophylactic antiarrhythmic medications

- don't use amiodarone, flecainide or any rhythm controlleing med to prevent development of v-tach

153

Sexual issues postinfarction

1. Don't combine nitrates w/ sildenafil
2. Erectile dysfunction (usually from anxiety)
3. Pt doesn't have to wait after an MI to begin sexual activity
4. If post-MI stress test is normal, pt can engage in exercise program

154

Congestive Heart Failure

- dysfunction of heart as pump of blood
- dyspnea is most common function
- can be due to either systolic or diastolic dysfunction

155

Diastolic dysfunction

- inability of heart to "relax" and receive blood
- ejection fraction is preserved and sometimes even above normal

156

Most common causes of systolic dysfunction (3)

1. Infarction
2. Cardiomyopathy (2/2 HTN)
3. Valve disease

157

Less common causes of systolic dysfunction

- Alcohol
- post viral myocarditis
- Doxorubicin use
- Chagas disease
- Hemochromatosis

158

CHF: presentation

- dyspnea
- pulmonary edema, in worst form
- orthopnea (worse when lying flat, relieved when sitting up)
- Rales on lung exam
- JVD
- paroxysmal nocturnal dyspnea (sudden worsening at night)
- S3 gallop

159

Pt presents with sudden onset dyspnea with clear lungs. Likely dx?

Pulmonary embolus

160

Pt presents w/ sudden onset dyspnea, wheexing, increased expiratory phase. Likely dx?

Asthma

161

Pt presents w/ slower onset dyspnea, sputum, unilateral rales/rhonci

Pneumonia

162

Pt presents w/ dyspnea, circumoral numbness, caffeine use, hx of anxiety. Likely dx?

Panic attack

163

Pt presents w/ pallor, gradual onset dyspnea over days to weeks. Likely dx?

Anemia

164

Pt presents w/ dyspnea, pulsus paradoxus, decreased heart sounds, JVD. Likely dx?

Tamponade

165

Pt presents w/ dyspnea, palpitations, syncope. Likely dx?

Arrhythmia of almost any kind

166

Pt presents w/ dyspnea, dullness to percussion at bases. Likely dx?

Pleural effusion

167

Pt presents w/ dyspnea, long smoking hx, barrel chest. Likely dx?

COPD

168

Pt presents w/ dyspnea, recent anesthetic use, brown blood not improved w. oxygen, clear lungs on auscultation, cyanosis. Likely dx?

Methemoglobinemia

169

Pt presents w/ dyspnea, burning building or car, wood burning stove in winder, suicide attempt. Likely dx?

Carbon monoxide poisoning

170

Most important test in CHF

Echocardiography

171

Best initial test to evaluate ejection fraction

Transthoracic echo

172

Most accurate test to evaluate ejection fraction

MUGA or nuclear vetriculography

173

When is nuclear ventriculography used to evaluate ejection fraction

- necessary when precision is needed
- example if giving doxorubicin for chemo but need to ensure maximum treatment w/o cardiomyopathy

174

BNP level is used t evaluate

- acute SOB with unclear etiology
- normal BNP excludes CHG

175

Best test to detemine CHF 2/2 MI or heart block

EKG

176

Best test to determine CHF 2/2 dilated cardiomyopathy

CXR

177

Best test to determine CHF 2/2 paroxysmal arrhythmias

Holter monitoring

178

Best test to determine precise valve diameter

Cardiac catherization

179

Best test to determine CHF 2/2 abnormal thyroid levels (high or low)

Thyrid function tests (T4/TSH)

180

Best test that distinguishes CHF from ARDS

Swan Ganz right heart catherization

181

Systolic Dysfunction (Low Ejection Fraction): Test

- ACE inhibitors
- Beta Blockers
- Spironolactone
- Diuretics
- Digoxin

182

Specific B-blockers beneficial in systolic dysfunction

- Metoprolol (specific B-1 antagonists)
- Bisoprolol (specific B-1 antagonists)
- Carvedilol (nonspecific B-blocker w/ alpha blocker)

183

Why B-blockers (carvedilol, metoprolol, bisoprolol) are beneficial in systolic dysfunction

- Antiischemic effect
- Decrease in HR leading to decreased oxygen consumption
- antiarrhythmic effect

184

Most common cause of death from CHF

- Arrhythmia/sudden death

185

Spironolactone

- beneficial b/c it inhibits effects of aldosterone
- effective in later stages of CHF (stages III and IV)

186

Spironolactone: adverse effects

- Hyperkalemia
- Gynecomastia

187

Eplerone

- alternative to spironolactone
- inhibits aldosterone
- doesnt have antiandrogen effects that leads to gynecomastia

188

Pt w/ CHF who develops gynecomastia?

Switch from spironolactone to eplerone

189

Indications for diuretics in CHF

- initial therapy in CHF w/ low ejection fraction
- often loop diuretic with ACEi/ARB

190

Digoxin

- doesn't lower mortality in CHF
- used to control symptoms of dyspnea and will decrease frequency of hospitalixations

191

74 y/o A-A man w/ hx of dilatered cardiomyopathy 2/2 o MI in past is seen in office. He is asymptomatic and is maintained on lisinopril, furosemide, metoprolol aspirin, and digoxin. Lab tests reveal elevated K level. EKG is unchanged. Best management?

Switch from lisinopril to hydralazine and nitroglycerin

192

Non pharm treatments that have mortality benefit in CHF

1. Implantable defribrillator: used in for EF < 35% and ischemic cardiomyopathy
2. Biventricular pacemaker: used in dilated cardiomopathy and ejection fraction < 35% and a wide QRS > 120ms

193

Drugs w/ mortality benefit in CHF

- ACEi/ARBS
- Spironolactone or eplerone
- Beta blockers
- Hydralazine/nitrates
- Implantable defibrillator

194

Diastolic Dysfunction (CHF w/ preserved EF)

- B-blockers are beneficial
- Diuretics are used to control symptoms of fluid overload

195

HOCM (hypertrophic obstructive cardiomyopathy)

- congenital disease w/ asymmetrically enlarged (hypertrophic) septum leading to an obstruction of LV outflow tract
* diuretics are contraindicated b/c they increase obstruction**

196

Pulmonary edema

- most severe form ofCHF
- rapid onset of fluid accumulating in lungs

197

Pulmonary edema: presentation

- Rales
- JVD
-S3 gallop
- Edema
- Orthopnea

198

Pulmonary edema: diagnostic tests

- BNP is etiology of dyspnea is unclear
- CXR shows vascular congestion with filling of blood vessels towards the head
- Respiratory alkalosis on ABG
- EKG
- Echo

199

Best test to do in acute pulmonary edema

EKG
** if pt has arrhythmia (a-fib, a-flutter, or v-tach) best thing to do is rapid cardioversion

200

Correcting which risk factor for CAD will result in the most immediate benefit for the patient?

Smoking cessation

201

Chest pain described as dull / "sore" and/or squeezing or pressure-like

ischemic pain
- sharp ("knifelike") or pointlike
- lasts for a few seconds

202

Chest pain that excludes ischemic pain

1. changes with respiration (pleuritic)
2. changes with position of the body
3. changes with touch of the chest wall (tenderness)

** if patient answers yes to the previous questions, likely NOT ischemic

203

Most common cause of chest pain

Gastrointestinal disorders

204

Patient describes chest wall tenderness. Most likely diagnosis?

Costochrondritis

205

Most accurate test for costochondritis

Physical exam

206

Patient describes chest pain that radiates to the back, unequal blood pressure between arms. Most likely diagnosis?

Aortic dissection

207

Most accurate test for aortic dissection

CXR
w/ widened mediastinum
- chest CT, MRI, or TEE confirms the disease

208

Young Pt (< 40) c/o chest pain worse with lying flat, better when sitting up. Likely diagnosis?

Pericarditis

209

Most accurate test for pericarditis

Electrocardiogram with ST elevation every where
PR depression

210

Pt describes epigastric discomfort, pain better when eating. Likely diagnosis?

Duodenal ulcer disease

211

Most accurate test for chest pain

Endoscopy

212

Pt describes chest pain with bad tatse, cough, hoarsness

Gastroesophageal reflux

213

Most accurate test for GERD

Response to PPIs;
- alumnium hydroxide and magnesium hydroxide
- viscous lidocaine

214

Pt describes chest pain with cough, sputum, and hemoptysis. Likely diagnosis?

Pneumonia

215

Most accurate test for pneumonia

CXR

216

Patient describes chest pain with sudden onset SOB, tacycardia, and hypoxia.

Pulmonary embolus

217

Most accurate test for pulmonary embolus

- spiral CT
- V/Q scan

218

Pt complains chest pain with sharp, pleuritic pain, and tracheal deviation. Likely diagnosis?

Pneumothorax

219

Most accurate test for pneumothorax

Chest X-ray

220

Worst prognostic significance for chest pain

Shortness of breath

221

Best initial test for chest pain

Electrocardiogram (EKG)`
- in office setting, the EKG is normal most of time but cannot progress to other testing without this test

222

If patient has acute chest pain in an office/ambulatory setting, what is the next best step to evaluate chest pain?

Transfer to ER
- DON'T ANSWER CARDIAC ENZYMES!!

223

If patient has chest pain in office/clinic for days to weeks, are cardiac enzymes appropriate?

No enzymes

224

If patient has chest pain in emergency department for minutes to hours, are cardiac enzymes appropriate?

Yes enzymes,
after an EKG is performed

225

When the etiology of chest pain is not clear, what is the best tool for evaluation of chest pain?

Exercise tolerance testing (ETT)

226

What are the two best factors for ETT

1. You can read the EKG
2. The patient can exercise (gets heart rate > 85% of maximum)

227

Maximum heart rate

220 - age of patient

228

Best way to detect ischemia on EKG

ST segment depression

229

If you cannot read EKG because of baseline EKG abnormality, what are the 2 best ways to detect ischemia w/o EKG?

- Nuclear isotope uptake: thallium or sestamibi
- Echocardiographic detection of wall abnormalities

230

Reasons for baseline EKG abnormalities

- Left bundle branch block
- Left ventricular hypertrophy
- Pacemaker use
- Effect of digoxin

231

Thallium testing for detection of cardiac ischemia

Normal myocardium will pick up thallium
-if myocardium is alive and perfused, thallium will be picked by Na/K ATPase
-if myocardium is abnormal, thallium has decreased uptake

232

Echocardiogram for detection of cardiac ischemia

Normal myocardium will move on contraction
- abnormal heart has decreased wall motion (dyskinesis, akinesis, or hypokinesis)

233

Ischemia vs infarction

ischemia: decreased perfusion that is detected by REVERSAL of thallium uptake or wall motion that returns to normal after rest period

234

If patient is unable to exercise to detect cardiac ischemia with exercise tolerance testing, what is the best method of detecting cardiac ischemia?

Pharm testing
- Persantine (dipyramidole) or adenosine in combination with thallium or nuclear isotopes
- Dobutamine in combination with echocardiogram

235

How does dobutamine work to detect cardiac ischemia

Dobutamine will increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities on ech

236

Coronary Angiography

- used to detect anatomic location of coronary artery disease
- use to determine whether narrowing should be best dealt with by surgery, angiography, or methods of revascularization

237

Most accurate test for detecting coronary artery disease

Angiography

238

Arterial stenosis

- insignificant when less than 50%
- surgically correctable when > 70%

239

Holter monitoring

- continuous ambulatory EKG monitor that records rhythm
- used for 24 - 72 hrs
- mainly detects rhythm disorders (a-fib, a-glutter, PVCs)
- does not detect ischemia and not for evaluating ST segment

240

48 y.o woman comes to office w/ chest pain that has been occurring over the last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of pain is retrosternal. She has no hypertension and the EKG is normal. What is the next best step?

Exercise tolerance testing

241

Medications that lower mortality in setting of chronic angina

- Aspirin
- Beta blockers
- Nitroglycerin

242

Route of nitroglycerin in chronic angina

Orally or a transdermal patch

243

Route of nitroglycerin in acute coronary syndromes

Sublingual, paste, and IV forms of nitroglycerine

244

Clopidogrel

- aspirin intolerance (e.g. allergy)
- recent angioplasty with stenting
- rarely used with TTP

245

Prasugrel

- thienopyridine medication in same clas as clopidogrel and ticlopidine
- antiplatelet medication best used for angioplasty ad stenting

246

Ticlopidine

- antiplatelet med in rare patient intolerant of both aspirin and clopidogrel
- should not be used if aspirin/clopidogrel intolerance is bleeding
- can cause neutropenia and TTP

247

Ranolazine

- additional therapy for angina refractory or persistent through treatment

248

ACE inhibitors / ARBS: Indications

- low systolic ejection raction/ systolic dysfunction (best mortality beneift)
- regurgitant valvular disease

249

Most common side effect of ACE inhibitors

Cough

250

64 y/o man is placed on lisinopril as part of managing CAD in association with ejection fraction of 24% and symptoms of breathlessness. Although he sometimes has rales on lung exam, the patient is asymptomatic today. PE should minimal edema of lower extremities. Blood tests reveal an elevated level of K that is present on a repeat measurement. EKG is unchanged. What's the best way to manage this patient

Switch from lisinopril to hydralazine and nitrates
- Lisinopril also cause hyperkalemia due to inhibition of aldosterone
- hydralazine will decrease afterload a arterial vasodilator

251

Why should hydralazine be used with nitrates in systolic dysfunction?

Hydralazine in an arterial vasodilator that decreases afterload
- used w/ nitrates to dilate coronary arteries so that blood isn't stolen away from coronary perfusion when afterload is decreased w/ hydrazalines

252

Lipid Management in CAD

Patients use statins w/ CAD with an LDL above 100 mg/dL

253

Aside from CAD, other conditions in which lipids should be controlled to < 100 mg/dL

- Peripheral artery disease (PAD)
- Carotid disease (not stroke)
- Aortic disease ( the artery, not the valve)
- Diabetes mellitus

254

Most common adverse effect of statins

Liver dysfunction
- elevation of transaminases

255

Why are statins considered to have some mortality benefit?

Statins have antioxidant effect on endothelial lining of coronary arteries

256

Niacin

- used to lower lipid levels
- associated w/ glucose intolerance, elevation of uric avid level and itchiness due histalimine rlease
- excellent ADDITION to statins if full lipid control not achieved with statins alone

257

Gemfibrozil

- fibric acids lower triglyceride levels more than statins however, less mortality benefit than statins
- caution using with statins due to increased risk of myositis

258

Cholestyramine

- bile acid sequestrant but often has interactions with other drugs in gut by blocking their absorption
- associated with uncomfortabe GI complaints such as constipation and flatus

259

Ezetimibe

- lowers LDL level w/o any evidence of actual benefit to patient
- no better than placebo in terms of endpoints (e.g. MI, stroke or death)

260

Statin: adverse effect

- elevations of transaminases (liver fxn tests)
- myositis

261

Niacin: adverse effect

- elevation in glucose and uric acid level
- pruritis

262

Fibric acid derivatives: adverse effect

- increased risk of myositis when combined with statins

263

Cholestyramine: adverse effect

Flatus and abdominal discomfort

264

Ezetimibe: adverse effect

- well tolerated and nearly useless

265

Dihydropyridine calcium channel blockers

- Nifedipine
- Nitrenipine
- Nicardipine
- Nimodipine

266

Dihydropyridine calciums affect mortality of CAD patients in which way?

They INCREASE mortality in patients with CAD b/c they raise heart rate
- the increased HR will increase myocardial oxygen consumption

267

Which calcium channel blockers are used in CAD?

Verapamil
Diltiazem

268

Indications for use of CCB in CAD

- Severe asthma precluding use of B-blockers
- Prinzmetal variant angina
- Cocaine induced chest pain (B-blockers are contraindicated)
- Inability to control pain w/ maximal medical therapy

269

Calcium channel blockers: Adverse effects

- Edema
- Constipation (verapamil most often)
- Heart block (rare)

270

Which diagnostic test is best to evaluate patient for revascularization?

- Angiography to determine whether patient needs CABG or angioplasty

271

Indications for coronary artery bypass grafting (CABG)

- Three vessels > 70% stenosis in each vessel
- Left main coronary artery occlusion
- Two-vessel disease in a patient with diabetes
- Persistent symptoms despite maximal medical therapy

272

Pts that benefit the most from CABG

- patients with EF < 35%

273

Which grafted veins are used for CABG

- Internal mammary artery grafts last 10 yrs before occlusion
- Saphenous vein grafts remain patent reliably for 5 years

274

Percutanous coronary intevention

- aka angioplasty
- best therapy for acute coronary syndromes esp those with ST segment elevation
- does not provide clear mortality benefit for stable CAD patients

275

Maximal medical therapy in stable CAD

- ASpirin
- Beta Blockers
- ACEis / ARBs
- Statin

276

70 y.o F comes to ED w/ crushing substernal chest pain for the last hr. The pain radiates to her left artm and is associated with anxiety, diaphoresis, and nausea. She describes the pain as "sore" and "dull" and clenches her fist in front of her chest/ She has a hx of hyperension What is most likely to be found in this patient?

S4 gallop b/c ishemia leading to noncompliance of left ventricle

277

Kussmaul sign

- increase in JVP on inhalation
- often associated with constrictive pericarditis or restrictive cardiomyopathy
- "scratchy" sound in pericardial friction rub

278

Dressler synrome

- complication of myocardial infarction that occurs several days after MI and is much rarer than simpler ventricular iscemia

279

Patent ductus arteriosus (PDA)

- continuous "machinery" murmur t

280

Displaced point of maximal impulse (PMI)

- characteristic of left ventricular hypertrophy as well as dilated cardiomyopathy
- anatomic abnormality that can't occur with an acute coronary syndrome

281

70 y.o F comes to the emergency department w/ crushing substernal chest pain for the last hr. Which of the following EKG findings would be associated with the prognosis?

ST elevations in V2 - V4
- corresponds to the anterior wall of the left ventricle
- signifies an acute myocardial infarction

282

Premature ventricular complexes (PVCS)

- should not be treated
- associated with an acute infarction
- treatment of PVCs only worsens outcome

283

70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hour. An EKG shows ST segment elevation in V-2. What is the most appropriate next step of management in this patient?

Aspirin
- lowers mortality and important to administer as quickly as possible
- initiate therapy before moving patien to the ICU

284

70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hr. An EKG shows ST segment elevation in leads V2 - V4. Aspirin has been given to the patient to chew. What is the most appropriate next step in management?

Angioplasty is associated with greatest mortality benefit

285

Pt c/o chest pain, when to do an EKG

- immediately at onset of pain
- ST elevation progresses to Q waves over several days to a week

286

Myoglobin

- becomes abnormal 1-4 hrs
- duration of myoglobin elevation is 1-2 days

287

CK-MB

- becomes abnormal 4-6 hrs
- duration of elevated CK-MB for 1-2 days

288

Troponin

- becomes abnormal in 4-6 hrs
- duration of elevated troponin is 10-14 hrs

289

Difficulty of using troponin levels in detection of myocardial infarctions

- Troponin can't distinguish btwn reinfarction occurring several days after 1st event
- Renal insufficiency can result in false positive tests since troponin is excreted via kidneys

290

If pt c/o of new chest pain within a few days of first cardiac event, how do you manage this condition?

Concern for reinfarction
1. Perform an EKG to detect NEW ST segment abnormalities
2. Check CK-MB levels
** after two days, the CK-MB levels should have returned to normal
3. Transfer to ICU if new infarction

291

Most common cause of death in first several days of MI

Ventricular arrhythmia (v-tach, v-fib)

292

ST segment elevation myocardial infarction (STEMI)

- best initially managed with aspirin (orally or chewed).
- clopidogrel can be used an alternative to aspirin if there is an allergy

293

Angioplasty vs Thromobolytics

Angioplasty is superior to thrombolytics b/c
- Survival and mortality benefit
- Fewer hemorrhagic complications
- Likelihood of developing MI complicatins (less arrhythmia, less CHF, fewer septal ruptures, few episodes of tampanade)

294

PCI

- standard of care is expected to be performed within 90 minutes of patient arriving in ED with chest pain

295

Complications of PCI

- Rupture of coronary artery on inflation of the balloon
- Restenosis (thrombosis) of the vessel after angioplasty
- Hematoma at the site of entry into artery

296

Which of the following is most important in decreasing the risk of restenosis of the coronary artery after PCI?

Placement of drug eluting stent (paclitazel, siroliums)
- inhibit the local T cell response which reduces rate of sternosis

297

Absolute contraindications to thrombolytics

- Major bleeding into the bowel (melena) or brain (any type of CNS bleeding)
- Recent surgery (within the last 2 weeks)
- Severe hypertension (above 180/110)
- Nonhemorrhagic stroke within the last 6 months

298

Pt comes to a small rural hospital w/o catherization lab. The patient has chest pain and ST segment elevation. What is the most appropriate next step in the management of the patient?

Administer thrombolytics now
- better than angioplasty delayed by several hrs
- mortality benefit of thombolytics extend to 12 hrs

299

Best initial therapy for acute coronary syndrome?

Asprin
- best used for everyone

300

Indication for clopidogrel in ACS

- when aspirin not tolerated, those undergoing angioplasty and stenting

301

Indication for Beta blockers in ACS

- used in everyone
- effect is not dependent on time - starting anytime during admission

302

Indication for ACE inhibitors and ARB in ACS

- used in everyone
- benefits those with ejection fraction < 35%

303

Indication for statins in ACS

- used in everyone
- benefits those with LDL > 100 mg/ dL

304

Indication for oxygen and nitrates in ACS

- used everyone
- no clear mortality benefit

305

Indication for heparin in ACS

- after thrombolytics / PCI to prevent restenosis
initial therapy with ST depression and other non- STEMI events (unstable angina)

306

Indication for calcium channel blockers in ACS

- when beta blockers can't be used
- cocaine induced pain
- Prinzmetal variant or vasospastic variant angina

308

Man comes to the emergency department w/ chest pain for the last hr that is crushing in quality and does not change w/ respiration or position of his body. EKG shows ST segment depression in leads V2 - V4. Aspirin has been given. What is the most appropriate next step in management?

Heparin
- heparin will prevent clot formation in coronary arteries but does not dissolve already formed clots
- there is no ST ELEVATION, no benefit of thrombolytics

309

Glycoprotein IIb/IIIa Inhibitors (Abciximab, Tirofiban, Eptifibitide)

- used in ACS in those are to undergo angioplasty and stenting
- inhibit the aggregation of plateletss.
- led to reduction in mortality in those w/ ST depression, particularly in patients whose troponin or CK-MB levels
- not useful in acute STEMIs separate from angioplasty and stenting

310

tPA (thrombolytics) best used in which patients?

- ST elevation MI patients

311

Heparin is best used in which patients?

- non-STEMI patients

312

Glycoprotein IIa/IIIb inhibitors are best in used in which patients?

non-STEMO patients and those undergoing angioplasty and stenting

313

If in non-STEMI ACS, when all meds have been given, and patient has persistent pain, S3 gallop or CHF develop, worse EKG changes or SVT, rising troponin levels. Next step?

Urgent angiography and possible angioplasty

314

Complications of acute MI

- Bradycardia
- Tachycardia
- Tamponade/Free wall rupture
- Ventricular tachycardia/ventricular fibrillation
- Valve/septal rupture

315

Sinus bradycardia in setting of MI

- common w/ MI if vascular insufficiency of the SA node

316

3rd degree (complete) AV block

- will have CANNON A WAVES
- obtain EKG to distinguish 3rd degree AV block vs sinus bradycardia

317

Cannon A waves

- produced by atrial systole against closed tricuspid valve
- tricuspid valve is closed b/c essence of 3rd degree block is that atria and valves are contracting separate
- JVD is bouncing up into the neck

318

Right ventricular infarction

- associated w/ new inferior wall MI and clear lungs
- diagnosed by flipping EKG from usual left side to right side of chest

319

R coronary artery supplies

- RV
- AV node
- inferior wall of heart

320

R ventricular infarction: treatment

- High volume fluid replacement
- avoid nitroglycerin to RV infarctions which markedly worsen cardiac filling

321

Tamponade/free wall rupture s/p MI

- takes several days s/p infarction for wall to scar and weakens enough to rupture
- look for sudden loss of pulse
- lungs are clear and is cause of pulseless electrical activity

322

Tamponade/Free Wall Rupture: Diagnosis

- emergency echocardiography

323

Ventricular Tachycardia/Ventricular Fibrillation s/p MI

- can cause sudden
- must use EKG to distinguish v-tachycardia and v-fibrillaiotn
- both treated w/ cardiovarsion/defibrillation

324

Septal rupture/Valve rupture s/p MI

- new onset of murmur and pulmonary congestion

325

Ventricular septal rupture best heard where?

- can be seen s/p MI
- best heart at LLSB

326

Mitral regurgitation

- can occur s/p MI
- best heard at apex w/ radiation to axilla

327

Most accurate test to detect valve rupture and septal rupture

- Echocardiogram

328

Septal rupture

- look for increase in oxygen saturation as you go from right atrium to right ventricle

329

Intraaortic balloon pump

- used when there is acute pump failure from anatomic problem that can be fixed in OR
- contracts and relazes w/ natural heartbeat
- helps give a "push forward to the blood"

330

Reinfarction or extension of infarction

- patient often presents w/ either inferior or anterior infarction
- look for reoccurrence of pain, new rales on exam, bump up CK-MB and even suddent onset of pulmonary edema

331

Reinfarction or extension of infarction

- repeat EKG
- retreat w/ angioplasty and sometimes thrombolytics in addition to usual meds (aspirin, metoprolol, nitrates, ACE, statins)

332

Aneurysm/ Mural Thrombus

- detected with echocadiogramy
- treated w/ heparin followed by warfarin

333

Pt s/p MI presents w bradycardia and cannon A waves. Likely dx?

3rd degree AV block

334

Pt s/p MI presents w/ bradycardia. No cannon A waves on EKG. Likely dx?

Sinus bradycardia

335

Pt s/p MI w/ PMH of inferior wall MI, clear lungs, tachycardia, hypotension w/ nitroglycerin. Likely dx?

RV infarction

336

Pt s/p MI with new murmur, rales/congestion. Likely dx?

Valve rupture

337

Pt s/p MI with new murmur, increase in oxygen saturation on entering the right ventricle. Likely dx?

Septal rupture

338

Pt s/p MI with loss of pulse, need EKG to answer question. Likely diagnosis

Ventricular fibrillation

339

Before patient w/ MI is discharged. Which test should be done?

Stress test
- to determine if angiography is needed
- angiogrpay determines need for revascularization

340

Meds needed for postinfarction patients

Every MI patient should go home:
- Aspirin
- Beta blockers (metoprolol)
- Statins
- ACE inhibitors

341

ACE inhibitors are best used for which type of MI patients?

Anterior wall infarctions b/c of high likelihood of developing systolic dysfunction

342

Clopidogrel

- used for those intolerant of aspirin or post-stenting

343

ARBS

- used for MI patients with cough on ACE inhibitor

344

Prophylactic antiarrhythmic medications

- don't use amiodarone, flecainide or any rhythm controlleing med to prevent development of v-tach

345

Sexual issues postinfarction

1. Don't combine nitrates w/ sildenafil
2. Erectile dysfunction (usually from anxiety)
3. Pt doesn't have to wait after an MI to begin sexual activity
4. If post-MI stress test is normal, pt can engage in exercise program

346

Congestive Heart Failure

- dysfunction of heart as pump of blood
- dyspnea is most common function
- can be due to either systolic or diastolic dysfunction

347

Diastolic dysfunction

- inability of heart to "relax" and receive blood
- ejection fraction is preserved and sometimes even above normal

348

Most common causes of systolic dysfunction (3)

1. Infarction
2. Cardiomyopathy (2/2 HTN)
3. Valve disease

349

Less common causes of systolic dysfunction

- Alcohol
- post viral myocarditis
- Doxorubicin use
- Chagas disease
- Hemochromatosis

350

CHF: presentation

- dyspnea
- pulmonary edema, in worst form
- orthopnea (worse when lying flat, relieved when sitting up)
- Rales on lung exam
- JVD
- paroxysmal nocturnal dyspnea (sudden worsening at night)
- S3 gallop

351

Pt presents with sudden onset dyspnea with clear lungs. Likely dx?

Pulmonary embolus

352

Pt presents w/ sudden onset dyspnea, wheexing, increased expiratory phase. Likely dx?

Asthma

353

Pt presents w/ slower onset dyspnea, sputum, unilateral rales/rhonci

Pneumonia

354

Pt presents w/ dyspnea, circumoral numbness, caffeine use, hx of anxiety. Likely dx?

Panic attack

355

Pt presents w/ pallor, gradual onset dyspnea over days to weeks. Likely dx?

Anemia

356

Pt presents w/ dyspnea, pulsus paradoxus, decreased heart sounds, JVD. Likely dx?

Tamponade

357

Pt presents w/ dyspnea, palpitations, syncope. Likely dx?

Arrhythmia of almost any kind

358

Pt presents w/ dyspnea, dullness to percussion at bases. Likely dx?

Pleural effusion

359

Pt presents w/ dyspnea, long smoking hx, barrel chest. Likely dx?

COPD

360

Pt presents w/ dyspnea, recent anesthetic use, brown blood not improved w. oxygen, clear lungs on auscultation, cyanosis. Likely dx?

Methemoglobinemia

361

Pt presents w/ dyspnea, burning building or car, wood burning stove in winder, suicide attempt. Likely dx?

Carbon monoxide poisoning

362

Most important test in CHF

Echocardiography

363

Best initial test to evaluate ejection fraction

Transthoracic echo

364

Most accurate test to evaluate ejection fraction

MUGA or nuclear vetriculography

365

When is nuclear ventriculography used to evaluate ejection fraction

- necessary when precision is needed
- example if giving doxorubicin for chemo but need to ensure maximum treatment w/o cardiomyopathy

366

BNP level is used t evaluate

- acute SOB with unclear etiology
- normal BNP excludes CHG

367

Best test to detemine CHF 2/2 MI or heart block

EKG

368

Best test to determine CHF 2/2 dilated cardiomyopathy

CXR

369

Best test to determine CHF 2/2 paroxysmal arrhythmias

Holter monitoring

370

Best test to determine precise valve diameter

Cardiac catherization

371

Best test to determine CHF 2/2 abnormal thyroid levels (high or low)

Thyrid function tests (T4/TSH)

372

Best test that distinguishes CHF from ARDS

Swan Ganz right heart catherization

373

Systolic Dysfunction (Low Ejection Fraction): Test

- ACE inhibitors
- Beta Blockers
- Spironolactone
- Diuretics
- Digoxin

374

Specific B-blockers beneficial in systolic dysfunction

- Metoprolol (specific B-1 antagonists)
- Bisoprolol (specific B-1 antagonists)
- Carvedilol (nonspecific B-blocker w/ alpha blocker)

375

Why B-blockers (carvedilol, metoprolol, bisoprolol) are beneficial in systolic dysfunction

- Antiischemic effect
- Decrease in HR leading to decreased oxygen consumption
- antiarrhythmic effect

376

Most common cause of death from CHF

- Arrhythmia/sudden death

377

Spironolactone

- beneficial b/c it inhibits effects of aldosterone
- effective in later stages of CHF (stages III and IV)

378

Spironolactone: adverse effects

- Hyperkalemia
- Gynecomastia

379

Eplerone

- alternative to spironolactone
- inhibits aldosterone
- doesnt have antiandrogen effects that leads to gynecomastia

380

Pt w/ CHF who develops gynecomastia?

Switch from spironolactone to eplerone

381

Indications for diuretics in CHF

- initial therapy in CHF w/ low ejection fraction
- often loop diuretic with ACEi/ARB

382

Digoxin

- doesn't lower mortality in CHF
- used to control symptoms of dyspnea and will decrease frequency of hospitalixations

383

74 y/o A-A man w/ hx of dilatered cardiomyopathy 2/2 o MI in past is seen in office. He is asymptomatic and is maintained on lisinopril, furosemide, metoprolol aspirin, and digoxin. Lab tests reveal elevated K level. EKG is unchanged. Best management?

Switch from lisinopril to hydralazine and nitroglycerin

384

Non pharm treatments that have mortality benefit in CHF

1. Implantable defribrillator: used in for EF < 35% and ischemic cardiomyopathy
2. Biventricular pacemaker: used in dilated cardiomopathy and ejection fraction < 35% and a wide QRS > 120ms

385

Drugs w/ mortality benefit in CHF

- ACEi/ARBS
- Spironolactone or eplerone
- Beta blockers
- Hydralazine/nitrates
- Implantable defibrillator

386

Diastolic Dysfunction (CHF w/ preserved EF)

- B-blockers are beneficial
- Diuretics are used to control symptoms of fluid overload

387

HOCM (hypertrophic obstructive cardiomyopathy)

- congenital disease w/ asymmetrically enlarged (hypertrophic) septum leading to an obstruction of LV outflow tract
* diuretics are contraindicated b/c they increase obstruction**

388

Pulmonary edema

- most severe form ofCHF
- rapid onset of fluid accumulating in lungs

389

Pulmonary edema: presentation

- Rales
- JVD
-S3 gallop
- Edema
- Orthopnea

390

Pulmonary edema: diagnostic tests

- BNP is etiology of dyspnea is unclear
- CXR shows vascular congestion with filling of blood vessels towards the head
- Respiratory alkalosis on ABG
- EKG
- Echo

391

Best test to do in acute pulmonary edema

EKG
** if pt has arrhythmia (a-fib, a-flutter, or v-tach) best thing to do is rapid cardioversion

392

74 y.o F comes to the ED w/ acute onset SOB, RR of 38 bpm, S3 gallop, and JVD. What's the best initial step?

IV furosemide
- acute management to remove large amts of fluid

393

CHF: Treatment

Initial therapy of pulmonary edema w/
- Oxygen
- Loop diuretics (e.g. furosemide or bumetanide)
- Morphine
- Nitrates

394

CHF: Treatment options

- Preload reduction ( w/ furosemide or bumetanide)
- Positive inotropic agents (e.g dobutamide)
- Afterload reduction (w/ ACEis / ARBs)

395

Positive ionotropes in setting of CHF

- Dobutamine
- Amrinone and milrinone - phosphodiesterase inhibitors increase contractility and decrease afterload

396

Digoxin

positive ionotrope that increases contractility but does not have effect for several weeks

397

Afterload reduction in CHF

- Long term setting: ACEis/ ARBs
- Acute setting: nitroprusside and IV hydralazine

398

Rheumatic fever

- associated with any form of valve disease
- mitral stenosis is most common

399

Regurgitant valvular disease

- associated w. hypertension and ischemic heart disease
- infarction automatically leads to regurgitation which leads to dilation

400

Right heart sided lesions: heart sounds

- tricuspid and pulmonic valves increase in intensity or loudness w/ inhalation
- inhalation will increase venous return to the heart

401

Left sided lesions (mitral valve and aortic valve): presentation

- increase w/ exhalation
- exhalation will "squeeze" blood out of the lungs and into the left side of the heart

402

Best initial test for all valvular heart disease

Echocardiogram
- TEE is most sensitive and specific than TTE

403

Most accurate test for valvular heart disease

Catherization
- allows for precise measurement of valve diameter as well as exact pressure gradient across the valve

404

Mitral stenosis: treatment

- dilated w. a ballooon

405

Aortic stenosis: treatment

Surgical replacement of aortic valve

406

Regurgitant lesions: treatment

- respond best to vasodilator therapy w/ ACEi, ARBs, nifedipine, or hydralazine
- ** surgical replacement of regurgitant valves must be done before valve dilates too much **

407

Mitral stenosis

- often caused by rheumatic fever
- critical narrowing by 1 cm ˆ2

408

Why should we worried about pregnant patients who emigrated from country w. high prevalence of rheumatic fever?

Pregnancy increases plasma by 50% which now must traverse narrow valve which can lead to pregnancy induced cardiomyopathy

409

Mitral stenosis: presentation

- dyspnea and CHF
- dysphagia (from dilated LA pressing on esophagus)
- hoarseness (LA pressing on laryngeal nerve)
- atrial fibrillation and stroke (from enlarged LA)
- hemoptysis

410

Mitral stenosis: physical findings

diastolic murmur (