Cardiology part 4 Flashcards
(138 cards)
1
Q
Antiplatelet therapy after Coronary Stenting
A
x
2
Q
trx
A
x
3
Q
what is the recommended duration of therapy antiplatelet therapy after coronary stenting?
A
- DAPT (dual antiplatelet therapy=aspirin + P2Y12 receptor blocker) for minimum of 6-12 months after Bare Metal stent or Drug eluting stent placement
- DAPT for minimum of 4 weeks in select patients after BMS
- Continue DAPT for a total of 30 months if pos
4
Q
what is perioperative management of antiplatelet therapy after coronary stenting if elective surgery?
A
defer surgery until after minimum DAPT duration
5
Q
what is perioperative management of antiplatelet therapy after coronary stenting if urgent surgery?
A
continue P2Y12 receptor blocker or hold for shortest duration possible
6
Q
what is perioperative management of antiplatelet therapy after coronary stenting if high risk of severe surgical bleeding?
A
continue aspirin unless high risk of severe surgical bleeding
7
Q
Trastuzumab
A
x
8
Q
side effects
A
x
9
Q
what are the side effects of trastuzumab?
A
cardiotoxicity
10
Q
what is the incidence of cardiotoxicity?
A
5% with trastuzumab monotherapy, but it is 25% with trastuzumab combined with anthracycline (eg doxorubicin) and cyclophosphamide.
11
Q
MOA
A
x
12
Q
how does trastuzumab work?
A
monoclonal Ab that targets HER2
13
Q
managment
A
x
14
Q
what is the management of trastuzumab only cardiotoxicity?
A
reversible
15
Q
what is the management of chronic anthracycline + trastuzumab cardiotoxicity?
A
not reversible because dose related due to myocyte necrosis , destruction, and replacement of fibrous tissue
16
Q
when should you hold trastuzumab?
A
- if CHF develops
- if LVEF decreases by >=16% from baseline, or by 10-15% from baseline to below the lower limits of normal
17
Q
Statin induced Myopathy
A
x
18
Q
risk
A
x
19
Q
what are the risks that lead to statin induced myopathy?
A
prolonged vigorous excercise
20
Q
management
A
x
21
Q
what are the indications for discontinuation of statin therapy?
A
Asyx patients with CK > 10 x Upper Limit of Normal
22
Q
if the elevation of CK is temporally related to excercise, then what should you do?
A
recheck CK levels and restart atorvastatin if the levels have normalized
23
Q
RBC transfusion
A
x
24
Q
indications
A
x
25
what are the general indications for RBC transfusion?
Hgb <7g/dL
26
when would transfusion be appropriate for Hgb of 7-8?
cardiac surgery, oncology patients in trx, CHF
27
when would transfusion be appropriate for Hgb of 8-10?
- syx anemia,
- ongoing bleeding
- ACS
- noncardiac surgery
28
if Hgb >10, would you ever transfuse?
nope not generally
29
Heart Auscultation
x
30
where do you hear the aortic valve best?
2nd ICS to the right of sternal border
31
where do you hear the pulmonic valve best?
2nd ICS to the left of sternal border
32
where do you hear Erbs point ?
3rd ICS to the left of sternal border
33
where do you hear Tricuspic Valve best?
5th ICS to the lower left of sternal border
34
where do you hear Mtiral valve Best?
apex, PMI and 5th intercostal space at mid clavicular line
35
Antithrombotic Therapy in Patients with mechanical Heart Valves
x
36
risk
x
37
what are the risks of throomboembolism in patients per year with mechanical prosthetic valves with no anticoag vs with aspirin vs with warfarin?
no anticoag: 4%
w aspirin: 2%
w warfarin: <1%
38
who has higher risk of stroke mitral mechanical valves or aortic valve prosthesis?
mitral valve have twic the risk of stroke
39
risk
x
40
what are considered risk factors/comorbidities in those with artificial valves?
Atrial fibrillation, severe left ventricular dysfunction EF <=30%, prior thromboembolism, presence of hypercoagulable state
41
management
x
42
what are current guidelines for INR for patients with aortic valve replacements and no risk factors (i.e. no a fib, severe left ventricular dysfunction EF <=30%, prior thromboembolism, presence of hypercoagulable state)?
INR of 2-3 using aspirin and warfarin
43
what is the goal warfarin INR if patients have mitral valve replacement, aortic valve replacement with presence of risk factors, in the first 3 months after aortic valve replacement?
INR of 2.5 to 3.5 using aspirin and warfarin
44
in patient who can't take warfarin, how much aspirin do you give?
75-325mg/day
45
in all patients who have aortic or mitral valve replacements, how much aspirin do you give in addition to warfarin?
75-100mg/day
46
Approach to Adult Cardiac Arrest
x
47
Approach to Adult Cardiac Arrest
x
48
Step 1 of cardiac arrest is?
start CPR, give oxygen and attach monitor/defibrillator
49
Step 2 are assess rhythm and decide if it is either ____ or ____
VF/pulseless VT or PEA/Asystole
50
if VF/Pulseless VT, then what do you do?
defibrillator shock
51
if VF/Pulseless VT, then what do you do after you defibrillator shock?
CPR x 2min, airway, IV/IO access, epinephrine every 3-5 minutes.
52
if PEA/Asystole, then what do you do ?
CPR x 2min, airway, IV/IO access, epinephrine every 3-5 minutes, so no shock needed.
53
After CPR x 2min, airway, IV/IO access, epinephrine every 3-5 minutes, what do you do?
pulse and rhythm check every 2 min, treat reversible causes
54
what do you after checking pulse and rhythm check?
identify if shockable rhythm (VF/pulseless VT) or unshockable rhythm (PEA/Asystole)
55
what should you always remember to do instead of giving epi on the third shockable rhythm?
give amiodarone
56
Adult Tachycardia Algorithm (with pulse)- ACLS
x
57
what is the first steps of ACLS with pulse?
identify and treat underlying cause:
- maintain patent airway; assist breathing if needed
- oxygen
- cardiac monitor to identify rhythm; monitor blood pressure and oximetry
58
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and the answer is yes, what is the next step?
- synchronized cardioversion,
| - if regular narrow complex, consider adenosine
59
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and the answer is no, what is the next step?
ask if the QRS is >0.12 seconds
60
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and there is prolonged QRS, what is the next step?
IV access, 12 lead EKG, give adenosine if regular and monomorphic, consider antiarrhythmic infusion, consider exper consultation
61
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and the QRS is not prolonged, what is the next step?
IV access, 12 lead EKG, vagal maneuvers, adenosine (if regular rhythm), beta blocker or CCB, consider exper consultation
62
PEA/Asystole
x
63
define
x
64
what does PEA mean?
refers to an organized cardiac rhythm (eg sinus bradycardia, atrial fibrillation) that is unable to generate sufficient cardiac output to create a measurable blood pressure or palpable pulse
65
cause
x
66
what is the underlying cause typically?
severe hypovolemia, massive PE, markedly impaired left ventricular contractility
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risk
x
68
what is a risk for PEA and asystole?
lightning injury, rhabdomyloyslsis w renal failure,
69
managment
x
70
what is the management of Asystole ?
chest compressions while giving vasopressors (epi or vasopressin) and identifying and treating reversible causes
71
complications
x
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what is a complication of PEA?
asystole (complete absence of organized cardiac electrical activity
73
reversible causes
x
74
what are reversible causes of Asystole/PEA?
5 H's: Hypovolemia, Hypoxia, Hydrogen ions (acidosis), hypokalemia or hyperkalemia, hypothermia
5T's: Tension Pneumo, Tamponade cardia, Toxins (narcotics, BDZs), Thrombosis (Pulmonary or Coronary), Trauma
75
Narrow Complex Tachycardias
x
76
Trx
x
77
what is treatment for Narrow Complex Tachycardias that is HD stable?
adenosine
78
what is treatment for Narrow Complex Tachycardias that is HD unstable?
synchronize cardioversion
79
Types
x
80
what are types of Narrow Complex Tachycardias ?
SVT's (i.e. Afib with RVR)
81
what are various types of SVT?
AVNRT (atrioventricular nodal reentrant tachycardia), Sinus tachy, AV reentrant tachycardia (AVRT), Afib, and A flutter
82
define
x
83
what are the components of SVT arrhythmias?
- mostly narrow QRS complex tachcyardia.
- usually there are no regular P waves as they are buried in the QRS complexes, but retrograde P wave can occur.
- retrograde P waves : seen in the beginning or end of a QRS complex when the atria and ventricles a
84
Abdominal Aortic Aneurysm (AAA)
x
85
Anatomy
x
86
what is the anatomy of AAA?
most commonly affects infrarenal aorta (>=3cm)
87
Risks
x
88
what are the risks of AAA?
smoking (highest risk), male sex, older, white ethnicity, family hx of AAA, atherosclerotic disease
89
Screening
x
90
what is the screening of AAA?
abd ultrasound in men age 65-75 y.o. who have ever smoked
91
symptoms
x
92
what are the syx of AAA?
- mostly asyx,
- may have abd, back or flank pain
- lower limb ischemia and/or thromboembolism
- rupture often presents with Abd distention and shock
93
management
x
94
what is the management of AAA?
- smoking cessation is key!
| - aspirin and statin therapy
95
when is elective repair recommnded for?
- Large (>=5.5 cm) aneurysms
- rapidly enlarging aneurysms (>= 0.5cm in 6 months)
- AAA associated with PAD or aneurysm
96
follow up imaging
x
97
what is follow up imaging for AAA?
```
medium artery (4-5.4cm): U/S q 6-12 months
smaller: U/S q 2-3 years
```
98
risks of rupture
x
99
what are the three biggest risk factors for aneurysmal ruptures?
large diameter (20% risk in aneurysms >6cm), rate of expansion (>0.5 cm in 6 months), and current cigarette smoking
100
Cardiovascular Effects of Cocaine Intoxication
x
101
pathophys
x
102
what are the pathophysiology of cardiovascular effects of cocaine intoxication?
HTN and Tachy, coronary vasoconstriction, increased platelet activity and thrombus formation
103
syx
x
104
what are syx of cocaine intox?
CP in the middle of chest and upper sternal area,nausea, mild occipital headache
105
complications
x
106
what are the complications of cocaine intoxication?
MI or infrarct, aortic dissection, neurologic ischemia or stroke
107
trx
x
108
what is the initial mangement treatement goals of MI due to cocaine intox?
reduction of myocardial oxygen demand and improvment in myocardial oxygen supply
109
what is the initial treatment for cocaine intoxication in persistent CP with minimal EKG changes ?
-BDZ (reduce sympathetic outflow) and nitroglycerin (alleviates HTN and MI)
110
what is the second line treatment for persistent chest pain with minimal EKG changes in the setting of cocaine intoxication?
CCBs
111
what is the treatment for persistent HTN in the setting of cocaine intoxication?
phentolamine (alpha receptor antagonist)
112
if ST elevation persists in setting of cocaine intox, what is appropriate next step?
aspirin then PCI (cocain that encourage thrombus formation and cause thrombotic occlusion of coronary arteries) even in young patients.
113
if there is an MI due to cocaine intox, what do you do?
PCI
114
when are fibrinolytics (eg alteplase) recommended?
only in patients with STEMI for whom PCI cannot be performed within 2 hours of first medical contact
115
complications
x
116
what are the complications of cardiovascular effects of cocain intox?
acute aortic dissection of the ascending aorta
117
acute aortic dissection of the ascending aorta
x
118
syx
x
119
what are syx of aortic dissection of the ascending aorta?
new neuro findings of right sided weakness, severe, sharp, tearing CP or Back Pain
120
risk
x
121
what are the risks associated iwth aortic dissections?
HTN (Most common), marfan sydnrome, cocaine use
122
PE
x
123
what are the physical exam findings of aortic dissection?
>20mmHg variation in SBP between arms
124
complications
x
125
what are the complications of aortic dissection?
stroke (carotid arteries), acute aortic regurg (aortic valves), horner syndrome (superior cervical sympathetic ganglion), acute MI (coronary artery), pericardial effusion/cardiac tamponade (pericardial cavity), hemothorax (pleural cavity), LE weakness or ischemia (spinal or common iliac arteries), abd pain (mesenteric artery)
126
dx
x
127
what is the dx imaging needed for acute dissection of the ascending aorta?
CT angiography
128
pathophys
x
129
how do focal neuro deficits deficits occur?
carotid artery involvement (eg obstruction by intimal flap, extension of dissection into carotids) leading to cerebral ischemia
130
Detection of Left to Right Shunt by Oximetry
x
131
dx
x
132
what is the best measure of oxygenation saturation changes between atria and ventricles?
right and left heart cath
133
location of shunt
x
134
what are the three most common locations of potential shunts?
atrial, ventricular , and great vessels
135
causes of specific shunts
x
136
if you're in the level of the atria and you have step up in O2 % saturation from superior/inferior vena cava to right atrium, what are the possible causes?
- ASD
- Partial anomalous pulm venous drainage
- Ruptured sinus of valsalva
- VSD with tricuspid regurg
- coronary fistula to right atrium
137
if you're in the level of the ventricle and you have step up in O2 % saturation from right atrium to right ventricle, what are the possible causes?
- VSD
- PDA with pulm regurg
- coronary fistual to right ventricle
138
if you're in the level of the great vessels and you have step up in O2 % saturation from right ventricle to pulm artery, what are the possible causes?
- PDA
| - Aorto-pulmonary window
