Cardiovascular Flashcards
(182 cards)
1
Q
Causes of Takotsubo Cardiomyopathy
A
disordered response of the myocardium d/t enormous amount of catecholamine being produced (i.e. stress, grief)
2
Q
Takotsubo cardiomypoathy
A
Stress-induced cardiomyopathy
Mimics a STEMI
Typically follows severe emotional or physiologic stress
May be due to an anatomic predisposition to ischemia in states of extreme catecholaminergic tone
3
Q
Takotsubo cardiomyopathy: Labs/Dx
A
ST-elevations or pronounced T-wave inversions
Cardiac Cath is required to make the diagnosis through an absence of significant coronary disease on angiography
- kinesis of the LV apex (apical ballooning)
4
Q
Wolff-Parkinson-White syndrome: EKG changes
A
delta waves
wide QRS
shortened PR
ST-T wave repolarization abnormalities
pseudo-inferior MI pattern suggesting accessory AV conduction
5
Q
Wolff-Parkinson-White syndrome: complications
A
tachyarrhythmias that can lead to VF and death
6
Q
Wolff-Parkinson-White syndrome: what meds are contraindicated?
A
nodal blocking agents: digoxin, beta blockers, CCBs
7
Q
Wolff-Parkinson-White syndrome: treatment
A
ablation
8
Q
Grade I murmur
A
barely audible
9
Q
Grade II murmur
A
audible but faint
10
Q
Grade III murmur
A
moderately loud; easily heard
11
Q
Grade IV murmur
A
loud; associated with a thrill
12
Q
Grade V murmur
A
very loud; heard w/one corner of stethoscope lifted off the chest
13
Q
Grade VI murmur
A
loudest
14
Q
A murmur heard at the 5th ICS is associated with…
A
the apex of the heart
mitral valve
15
Q
A murmur heard at the 2nd or 3rd ICS is associated with…
A
base of the heart
aortic valve
16
Q
A murmur heard during systole is associated with…
A
mitral regurgitation
aortic stenosis
Ms. ArD & Mr. AsS
17
Q
A murmur heard during diastole is associated with…
A
mitral stenosis
aortic regurgitation
Ms. ArD & Mr. AsS
18
Q
arterial ulcers: presentation
A
Punched out or stellate appearance
Painful
Surrounding red, tight skin
May be pale or have eschar
Often associated with trauma and occur over pressure points
19
Q
most common cause of lower extremity ulcers
A
chronic venous stasis disease
20
Q
venous stasis ulcers: presentation
A
Typically appear on the lower legs above the ankle
Tender, shallow
Exudative with granulation tissue at the base
Irregular borders
21
Q
AHA recommendation for daily sodium intake for hypertension
A
<1.5g/day
22
Q
S1
A
mitral/tricuspid (AV) valves close
aortic/pulmonic (semilunar) valves open
23
Q
S2
A
mitral/tricuspid (AV) valves open
aortic/pulmonic (semilunar) valves close
24
Q
period between S1 and S2
A
systole
25
period between S2 and S1
diastole
26
S3
increased fluid states (e.g. heart failure, pregnancy)
27
S4
stiff ventricular wall (e.g. MI, LVH, chronic hypertension)
28
HFrEF
systolic failure
inability to contract
results in decreased cardiac output
29
HFpEF
diastolic failure
inability to relax and fill
results in decreased cardiac ouptut
30
acute heart failure
L sided failure
abrupt onset
usually follows MI or valve rupture
can result in LVH d/t L ventricular failure 2/2 chronic hypertension
31
chronic heart failure
R sided failure
develops as a result of inadequate compensatory mechanisms that have been employed over time to improve cardiac output
result of L sided failure
32
L heart failure: S/Sx
dyspnea at rest
coarse rales all over lung fields
wheezy frothy cough
appears generally healthy except for the acute event
S3 gallop
murmur of mitral regurgitation (systolic murmur loudest at apex)
33
R heart failure: S/Sx
Appears chronically ill
JVD
Diffuse chest wall heaves
Displaced PMI
S3 and/or S4
hepatomegaly
splenomegaly
Abdominal fullness
dependent edema d/t increased capillary hydrostatic pressure
paroxysmal nocturnal dyspnea
fatigue on exertion
34
NYHA Functional Classification of Heart Failure: Class I
no limitations on physical activity
35
NYHA Functional Classification of Heart Failure: Class II
slight limitations of physical activity but comfortable at rest (physical activity results in fatigue, palpitations, dyspnea, angina)
36
NYHA Functional Classification of Heart Failure: Class III
marked limitations of physical activity but comfortable at rest
3 pillows to sleep but able to sleep
- ACEI indicated
37
NYHA Functional Classification of Heart Failure: Class IV
severe; inability to carry out any physical activity without discomfort (symptomatic at rest
-continuous IV inotropic support indicated
38
Heart failure: labs/Dx
ABG: hypoxemia, hypocapnia
BMP normal unless chronic heart failure is present
Obtain baseline BNP or NT-proBNP
UA
CXR: pulmonary edema, Kerley B lines, effusions
TTE to assess L ventricular function
EKG may show deviation or underlying problem: acute MI, dysrhythmia
PFTs for wheezing
39
Heart failure: non pharmacologic management
sodium restriction
rest/activity balance
weight reduction
40
Heart failure: pharmacologic management
**1st line: diuretics**
ACEI or ARB
beta blocker
Sacubitril/valsartan (Entresto) - useful for HFrEF
Digoxin
ACs for AFib
41
dilated cardiomyopathy
dilation of the heart muscle
most common type of cardiomyopathy
42
hypertrophic cardiomyopathy
hypertrophy of the left, and occasionally the right, ventricle
43
restrictive cardiomyopathy
scarring/stiffening of the heart muscle
the least common type of cardiomyopathy
44
arrhythmogenic right ventricular dysplasia
irregular heart rhythms caused by the dying of muscle tissue in the right ventricle that is replaced by scar or fat tissue
45
transthyretin amyloid cardiomyopathy (ATTR-CM)
abnormal protein buildup (deposits of amyloid protein fibrils) in the walls of the left ventricle
46
cardiomyopathy: routine management
Three drug combination for most patients with HF: diuretic, ACEI/ARB, beta blocker
- Beta blockers once euvolemia is achieved
47
cardiomyopathy: long-term management
Lifestyle changes: diet, exercise, sleep patterns, stress reduction, avoidance of alcohol and other drugs
Maintaining treatment of comorbidities
48
cardiomyopathy: acute management
Symptomatic relief: vasodilators to reduce preload and afterload (nitrates, hydralazine, nitride, nesiritide, ACEIs/ARBs, diuretics)
Inhibition of neurohormonal activation: ACEIs/ARBs, beta blockers, aldosterone antagonists
49
inpatient management of acute pulmonary edema
supplemental O2 while awaiting ABGs
sitting or semi-fowler position
Morphine 2-4mg IVP, repeat 20-30 min PRN, stop if hypercapnia occurs
Furosemide 40mg IVP; repeat in 10 min if no response
Severe bronchospasm: inhaled sympathomimetics
Severe pulmonary edema: nitroprusside, hydralazine for afterload and preload reduction
If cardiac index remains low: dobutamine
50
hypertension: S/Sx
elevated BP
epistaxis in the late afternoon
dizziness/lightheadedness
S4 r/t LVH
AV nicking (chronic sign)
severe: suboccipital pulsating headache, occurring early in the morning and resolving throughout the day
tearing chest pain may indicate aortic dissection
51
hypertension: labs/Dx
rule out secondary causes
- renovascular disease studies
- CXR if cardiomegaly suspected
- plasma aldosterone level to rule out aldosteronism
- AM/PM cortisol levels to rule out Cushing's syndrome
CBC, BMP, ca, phos
cholesterol, triglycerides
UA, uric acid
EKG
52
JNC Normal BP
SBP <120 and DBP <80
53
JNC elevated BP
SBP 120-129 and DBP >80
54
JNC stage 1 hypertension
SBP 130-139 or DBP 80-89
55
JNC stage 2 hypertension
SBP >140 or DBP >90
56
hypertension: pharmacologic management for non-African American
thiazide diuretic
ACEI
ARB
CCB
57
hypertension: pharmacologic management for African American
thiazide diuretics
CCB?
58
hypertension: pharmacologic management for diabetics
ACEI (or ARB)
59
hypertension: pharmacologic management for adults with CKD
ACEI - slow the progression of CDK and decrease proteinuria
60
hypertension: treatment algorithm for initial treatment
1 month
then increase the dose
then add a second drug
continue to assess monthly until goal is reached
61
Using an ACEI and ARB together is a risk for
hyperkalemia
62
first line treatment for hypertension
thiazide diuretics
63
hypertensive urgency
>180/110
May or may not be associated with severe headache, SOB, epistaxis, severe anxiety
64
hypertensive urgency: treatment
oral therapies such as clonidine
65
hypertensive emergency
>180/120
Requires immediate (within 1 hour) BP reduction to prevent or limit target organ damage
or
<180/120 with any of the following:
-malignant hypertension
-hypertensive encephalopathy
-ICH
-unstable angina
-acute MI
-acute heart failure
-dissecting aortic aneurysm
-eclampsia
66
hypertensive emergency: management
ICU
nicardipine, sodium nitroprusside (Nitride)
For compelling conditions (e.g. aortic dissection, severe preeclampsia, eclampsia, pheochromocytoma crisis): SBP should be reduced to <140 in the first hour
- <120 in aortic dissection
For adults without a compelling condition: SBP should be reduced by no more than 25% within the first hour
- if stable, to 160/100 within the next 2-6 hours
- cautiously to normal during the next 24-48 hours
Lowering BP too quickly can damage blood flow to organs accustomed to functioning at high levels and cause ischemia or infarction
67
stable angina
exertional
most common
68
Prinzmetal's angina
occurs at various times, including rest
d/t sudden influx of intracellular calcium
- treat w/CCBs
ST elevations on EKGs rather than depressions
Dx of exclusion often in Cath lab
69
unstable angina
pre-infarction, rest or crescendo, coronary syndromes
70
microvascular angina
metabolic syndrome
71
angina: labs/Dx
EKG: normal with ST depressions
Exercise EKG
Serum lipid levels
definitive diagnostic procedure: coronary angiography
72
Normal lipid panel
total cholesterol <200
triglycerides <150
VLDL <150
LDL <100
HDL 40-60
73
angina: management
Diet
Low dose aspirin
Nitrates
Beta blockers
CCBs
Optimize lipid panel values
Identify patients who would benefit from statin therapy
-ASCVD
-elevated LDL
-DM
74
Bile acid sequestrates
lower LDL
may increase triglycerides
Examples:
-cholestyramine (Questran)
-Colesevelam
-colestipol
75
Fibrates
lower triglycerides
slightly lower LDL
possibly elevate HDL
Examples:
-gemfibrozil
-fenofibrate
-fenofibric acid
76
Cholesterol absorption inhibitor
used w/statin to lower LDL
Example:
-ezetimibe (Zetia)
77
Niacin
lowers LDL and triglycerides
elevates HDL
high doses may cause "flushing" sensation which will pass
78
How are ACEIs helpful after MI
prevent ventricular remodeling
79
MI/ACS management
ASA 325 to chew
NTG SL Q5 min x3
O2
12 lead EKG
Morphine
Furosemide if pulmonary edema present
Metoprolol IV x3 if not contraindicated
ACEIs
Heparin vs Lovenox
Monitor therapeutic coagulation values
80
Normal INR
0.8-1.2 s
81
Normal aPTT
28-38 sec
82
normal PT
11-16 sec
83
normal PTT
60-90 sec
84
MI/ACS: indications for pharmacologic revascularization
Unrelieved chest pain (>30 min and <6 hrs) with ST elevations >0.1 mV in two or more contiguous leads
85
MI/ACS: contraindications for pharmacologic revascularization (tPA)
Prior ICH
Ischemic stroke within 3 months
Intracranial or intraspinal surgery within 2 months
Significant closed head trauma or facial trauma within 3 months
Structural cerebral vascular lesion or malignant intracranial neoplasm
Suspected aortic dissection
Severe uncontrolled hypertension (>185/110)
Active bleeding or risk thereof, including abnormal coagulation values
86
PVD: pathology
arteriosclerotic narrowing of the lumen of arteries resulting in decreased blood supply to the extremities
87
PVD: Causes/Risk factors
atherosclerosis
HLD
smoking
DM
88
PVD: S/Sx
**Common first symptom: intermittent claudication, calf pain**
increased pain with elevation of lower extremities
progresses to pain at rest
cold/numbness to extremities
shiny/hairless skin
dependent rubor
pallor
cyanosis
ulcerations
reduced pulses
89
PVD: labs/Dx
**1st line: ankle-brachial index (ABI) <0.9** (least invasive)
doppler US to evaluate flow
X-rays may show calcification
Arteriography: most definitive test, but invasive
90
PVD: management
Lifestyle changes:
-Stop smoking/tobacco
-Exercise, stop during pain and resume when pain subsides to develop collateral circulation
-weight reduction as needed
Cilostazol (Pletal)
manage DM, HLD
angioplasty
bypass surgery
amputation
91
chronic venous insufficiency: pathology
impaired venous return d/t either destruction of valves, changes d/t DVT, leg trauma, or sustained elevation of venous pressure
92
chronic venous insufficiency: causes/risk factors
more common in women
may have genetic predisposition
Hx of leg trauma
may be associated with varicose veins
93
chronic venous insufficiency: S/Sx
BLE heaviness and pain relieved with elevation of the legs or with walking
edema after prolonged standing
skin discoloration
numbness
tingling
pruritis
telangiectasis and varicosities are frequently seen
stasis leg ulcers
dermatitis
cool to touch
94
chronic venous insufficiency: labs/Dx
r/o edema d/t HF and other causes
95
chronic venous insufficiency: management
bed rest with legs elevated to diminish edema
compression stockings
weight reduction, exercise
aspirin may accelerate healing
treat dermatitis/ulcers
acute weeping dermatitis
- tap water compresses
- hydrocolloid dressings
- hydrocortisone cream
96
pericarditis
inflammation of the pericardium
97
pericarditis: causes
viruses: most common cause
post MI
renal failure
neoplastic, TB, septicemia
endocarditis
collagen diseases (e.g. scleroderma, RA, SLE, etc)
drug/trauma induced
98
pericarditis: S/Sx
very localized retrosternal/precordial chest pain, pleuritic in nature
pain increased by deep inspiration, coughing, swallowing, or recumbent
pain relieved by sitting forward
SOB 2/2 pain w/inspiration
malaise
headache
99
pericarditis: physical findings
pericardial friction rub - best heard w/patient leaning forward; high pitched
pleural friction rub may also be present (creaking/scratching sound/sandpaper)
fever may be present depending on underlying cause
100
endocarditis
infection of the endothelial surface of the heart
usually affects the valves
**Dx of infective endocarditis must be considered and excluded in all patients with a heart murmur and FUO**
101
endocarditis: causes
usually caused by bacteria
known valvular heart disease; esp in rheumatic, bicuspid aortic valve/mitral valve prolapse with significant regurgitation
recent dental/oropharyngeal surgery
GU instrumentation
surgery of the respiratory tract
congenital heart disease
prolonged use of IV catheters or TPN
patients with burns
hemodialysis
102
endocarditis: S/Sx
fever and malaise
night sweats
weight loss
general "sick" feeling
103
endocarditis: physical findings
murmur often present
fever
Osler's nodes
petechiae
purpura
pallor
splinter hemorrhages
splenomegaly
Janeway lesions
Roth spots
104
Osler's nodes
painful red nodules in the distal phalanges
seen in endocarditis
105
Splinter hemorrhages
linear, subungal splinter-appearing
seen in endocarditis
106
Janeway lesions
small painless macules on the palms and soles
Seen in endocarditis
107
Roth spots
small retinal infarcts, white in color, encircled by areas of hemorrhage
seen in endocarditis
108
endocarditis: labs/Dx
WBC normal or elevated, but always a left shift
TEE for valvular damage
BC for causative organism
- three separate cultures at three separate sites in 1 hour
ESR always elevated
109
endocarditis: management
Subacute endocarditis (delayed): empiric therapy is generally not started until BC results
Acute endocarditis (rapidly progressive): usually due to staphylococcus aureus (both MRSA and MSSA), streptococci, and enterococci
-empiric therapy: vancomycin until BC results
110
pericarditis: labs/Dx
**ST elevations in all leads
-return of ST segment to normal in a few days followed by temporary T wave inversion
Depression of PR segment**
ESR elevated
BC if bacterial cause suspected
CBC to r/o infx
baseline BMP
echo to confirm presence of pericardial fluid or other abnormalities
111
pericarditis: Management
1st line: colchicine
NSAIDs
-indomethacin
-ketorolac
-ibuprofen
Corticosteroids only for refractory pericarditis or very severe symptoms
-can increase viral replication
ABX if bacterial infx
**Monitor for tamponade (hypotension, JVD, muffled/distant heart sounds, pulsus paradoxus)**
112
Adverse effects of amiodarone
hypo/hyperthyroidism
interstitial lung disease
elevated LFTs
skin photosensitivity
corneal deposits
optic neuropathy
113
Before starting amiodarone, what should you check
thyroid levels
LFTs
baseline PFTs
referral to ophthalmology for monitoring may be needed
114
metabolic syndrome
large waistline: men >40 in, women >35 in
hypertension
hyperglycemia
high triglycerides, low HDL
115
Indications for urgent referral to a vascular surgeon or vascular laboratory in patients with ischemic arterial ulcers
Cellulitis
Gangrene
Visible tendon or bone at the ulcer base
Severe infection
ABI <0.5
116
Wolff-Parkinson-White Syndrome: S/Sx
during episodes of tachyarrhythmia:
-diaphoresis
-cool skin
-hypotension
-crackles d/t pulmonary vascular congestion
117
aortic stenosis: symptoms
dyspnea
heart failure
angina
syncope on exertion
systolic murmur over the 2nd R ICS radiates to carotid arteries
S4 gallop
118
1st line therapy for hyperlipidemia
statin
2nd line: niacin
119
digoxin toxicity
GI upset
visual disturbances with yellow-green halos
palpitations, dyspnea, syncope
bradycardia, PVCs, LBBB
**diltiazem potentiates the effects of digoxin**
120
Indications for statin therapy
Clinical evidence of ASCVD
Elevated LDL >190
Age 40-75 with diabetes and LDL 70-189 but no ASCVD
LDL 70-189 with no diabetes or ASCVD, but estimated 10-year risk of ASCVD >7.5
121
Statins potentiate the effects of what medications?
anticoagulants
122
TEE or TTE for endocarditis?
TEE is more specific
123
Patients with a history of ventriculostomies such as tetralogy of Fallot have an increased risk of...
ventricular tachycardia
124
Diagnostic test for POTS
tilt table test
125
S4 gallop is most commonly associated with...
aortic stenosis
126
Holosystolic murmurs are most often associated with...
mitral valve regurgitation
127
An opening snap can be heard in patients with...
mitral valve prolapse
mitral valve regurgitation
128
cardiac tamponade: S/Sx
Beck's Triad:
-hypotension
-JVD
-muffled/distant heart sounds
pulsus paradoxus
decreased cardiac output
tachycardia
increased RR
weak peripheral pulses
cool skin
dark yellow urine
EKG: low voltage, no ST or T wave changes
129
cardiac tamponade: labs/Dx
echo
130
cardiac tamponade: management
pericardiocentesis
diuretics are contraindicated - may cause intravascular volume depletion and worsen hypotension
131
1st medication to give for suspected or confirmed cardiac ischemia
aspirin due to anti platelet effect
132
1st choice for management of ischemic cardiac pain due to vasodilatory effects
nitroglycerin
133
1st medication to give for acute heart failure
IV diuretic
134
pericardial effusion: S/Sx
dyspnea
fatigue
weight loss
occasional fever
dry cough
constant chest pain
pericardial friction rub
135
pericardial effusion: management
Assess cardiac function with TTE
Pericardiocentesis
136
PE: management
anticoagulant therapy for 3 months after initial therapy
137
Goal BP for patients with CKD
<130/80 if proteinuria is also present
138
ACE Inhibitors: mechanism
reduce afterload, preload, systolic wall stress
increase cardiac output without increasing heart rate
139
Cushing's triad
increased SBP, decreased DBP (widening pulse pressure)
decreased RR
decreased HR
140
When do you see Cushing's triad?
acute elevations of ICP
141
STEMI: management
**Priority: PCI**
fibrinolytic therapy within 30 mins of admission to the hospital
142
HFpEF or HFrEF: which has better outcomes?
HFrEF
HFpEF is managed with diuresis and BP control, but there is no medical treatment proven to reduce mortality and morbidity
143
HFpEF or HFrEF: L ventricle is normal in size
HFpEF
144
HFpEF or HFrEF: associated with exercise intolerance
both
145
HFpEF or HFrEF: associated with pulmonary hypertension
both
146
HFpEF or HFrEF: dilated left ventricle
HFrEF
147
aortic dissection: presentation
severe, sudden onset back pain between shoulder blades
tearing, ripping, stabbing chest pain
BP unequal in both arms
CXR: widened mediastinum
148
aortic dissection: management
emergent CT angiogram
cardiac surgery consult
149
Intervention that decreases the final size of the infarcted myocardium in the acute phase of an anterior STEMI
PCI
150
Intervention for patients who do not stabilize after PCI or fibrinolytic therapy
IABP counterpulsation therapy
151
Who is IABP counterpulsation therapy indicated for?
patients with mechanical defects such as VSD or mitral regurgitation
152
In decompensated heart failure, what medications may support cardiac function and cardiac output?
IV inotropic agents (e.g. dobutamine)
-especially useful for patients who can't tolerate vasodilator therapy
-useful for afterload reduction
153
acute onset AFib: management
cardiac glycosides (e.g. digoxin) to increase contractility and decrease HR
CCBs to control ventricular response
154
statins: side effect
elevated CK d/t skeletal muscle breakdown
155
heart failure r/t dilated cardiomyopathy: management
1. Afterload reducing agent (ACEI)
2. IV inotropic agent
3. LVAD after medical management has been maximized
156
VTach is most frequently associated with
heart failure
157
2nd degree AV block Type II is most frequently associated with
anterior wall MI
158
junctional tachycardia is most frequently associated with
digoxin toxicity
159
hypertrophic cardiomyopathy: presentation, EKG
syncope
non-radiating systolic murmur
biphasic P wave in leads V1 and V2
Deep narrow Q waves in lateral leads I, aVL, V5, V6
160
hypertrophic cardiomyopathy: confirmed by?
echo
161
What medications are contraindicated in systolic heart failure but can be used to treat tachycardia in diastolic heart failure?
CCBs
162
most likely etiology of aortic valve disease in elderly
calcification
163
most likely etiology of aortic valve disease in adults (not elderly)
congenital bicuspid aortic valve
164
Rheumatic fever as a child can cause...
mitral stenosis
165
hypertension: management
1. diuretics
2. ACE, ARB, CCB
166
common complication of CEA
hypoglossal nerve damage
-tongue deviates to ipsilateral side of surgery
-order swallow study
167
sudden cardiac death following MI is usually caused by..
VF 2/2 myocardial scarring
--ICD
168
Right coronary artery: EKG leads
Inferior leads: II, III, aVF
169
Left circumflex artery: EKG leads
Lateral leads: I, aVL, V5, V6
Inferior leads: II, III, aVF
170
Left anterior descending (or interventricular artery): EKG leads
Septal: V1, V2
Anterior: V3, V4
171
Diagonal branch: EKG leads
Lateral leads: I, aVL, V5, V6
172
Lateral leads
I
aVL
V5
V6
173
Anterior leads
V3
V4
173
Septal leads
V1
V2
174
Inferior leads
II
III
aVF
175
nitroglycerin
ventilator used to increase myocardial blood flow
176
acute ventriclar septal defect
complication of MI
acute onset SOB and CP
associated with cardiogenic shock
177
Which valvular disorder is most commonly associated with an aortic aneurysm?
aortic regurgitation
178
Patients with Marfan syndrome commonly have which valvular disorders?
mitral valve prolapse
mitral regurgitaiton
179
complications after anterior MI
Post-infarct angina
Ventricular rupture
Septal aneurysms
Arrhythmias
L heart failure
Cardiogenic shock
Acute mitral regurgitation
180
Valve most often affected by endocarditis
tricuspid
181
IVDU is associated with what valvular disorder?
mitral valve regurgitation
