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Internal Medicine - Emma > Cardiovascular > Flashcards

Cardiovascular Flashcards

(60 cards)

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0
Q

Describe Sx associated with myocardial ischemia

A

Visceral pain
Dull, aching, tight
Sometimes “burning”
Poorly localized

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1
Q

Signs of pleuritis

A

Increased pain with inspiration and cough

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2
Q

Important life threatening causes of chest pain (3)

A

Myocardial ischemia
Pulmonary embolus
Aortic dissection

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3
Q

Risk factors for CHD (6)

A 
Diabetes mellitus
Smoking
HTN
Dyslipidemia
Fam Hx
Abdominal obesity

Also: age, cocaine use

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4
Q

Pain in pericarditis

A

Pleuritic
Relieved by sitting forward
Can radiate to shoulder/trap due to diaphragmatic irritation

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5
Q

Worrisome features in angina (2)

A

More than 20 min of pain

Pain at rest => UNSTABLE!

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6
Q

Characteristics of aortic dissection (3)

A

Abrupt and Most intense at onset
Tearing pain
Radiates to back

Unequal BP between arms
Use transesophageal ECG to detect at bedside

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7
Q

Chest pain DDx (8)

A

HEART:
Angina => worse with emotion or exercise, relieved by NO/rest, retrosternal pressure like pain
MI
Pericarditis => Sx pleuritic and positional, pericardial rub
Aortic dissection => Sx abrupt, most intense at start, radiates to back

LUNGS:
Pneumothorax => tachypnea, hyperresonant, tracheal deviation
PE => Sx pleurisy and dyspnea

ESOPHAGUS:
Gastrointestinal disease => GERD, esophag spasm

MSK:
MSK => worse on movement/palpation

NEURO:
Neuropathic => VZV

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8
Q

ECG findings - ST depression >1mm

A

Ischemia!

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9
Q

ECG findings - ST elevation

A

Acute MI => only in area of infarction

Perdicarditis => ALL leads involved, may have PR depression

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10
Q

ECG findings - RBBB

A

Right heart strain! => ex. In PE

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11
Q

ECG findings - LBBB

A

Underlying heart disease such as ischemia or HTN

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12
Q

Causes of low CO in cardiogenic shock (3)

A

Right heart failure => pulmonary embolism
Decreased venous filling of heart => tension pneumothorax
Obstruction of outflow => cardiac tamponade

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13
Q

Causes of distributive shock (3)

A

Low SVR resulting from: sepsis, adrenal insufficiency, anaphylaxis

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14
Q

Definition of shock

A

Decreased perfusion and oxygen delivery to body
SBP < 60mmHg
May manifest as organ failure => renal, CNS, lactic acidosis

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15
Q

Pulsus paradoxus is associated with….

A

Cardiac tamponade
Definition: On inspiration, a drop in systemic arterial pressure greater than 10mmHg.
In states in which the ventricle cannot expand outward (e.g. tamponade) or in which the drop in intrathoracic pressure with inspiration is profound (e.g. status asthmaticus), the septal shift is exaggerated and the difference in BP is larger.

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16
Q

Hypovolemic shock: CO, SVR, JVP
Cardiogenic shock
Distributive shock

A

Hypovolemic shock: decrease CO, increase SVR, decrease JVP
Cardiogenic shock: decrease CO, increase SVR, increase JVP
Distributive shock: increase CO, decrease SVR, decrease JVP

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17
Q

Causes of cardiogenic shock (7)

A

MI, cardiomyopathy, tamponade => pump failure
Arrhythmia
Valve failure
Tension pneumothorax, massive PE => Obstructed outflow

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18
Q

Causes of hypovolemic shock (4)

A

Hemorrhage
Diarrhea
Heat stroke
Third spacing

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19
Q

Causes of distributive shock (4)

A

Sepsis
Anaphylaxis
Adrenal crisis
Myxedema coma

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20
Q

Treatment of shock

A

Decreased JVP => hypovolemic OR distributive shock => IV fluids => NS/RL
Anaphylaxis => epinephrine
Adrenal insuff (hyponat, hyperkal, hypogly, abdo pain, eosinophilia, mild hypercal)=> ACTH stim test => IV steroids
Sepsis => blood and urine cultures => empirical ABx
Myxedema => “hypo” syndrome (hypotherm, hypogly, hyponat, hypovent) => TSH/T4 => exogenous thyroid hormone

Increased JVP => cardiogenic shock => CXR (PE, cardiomyopathy, tamponade, pneumothorax) + ECG (PE=> RBBB, MI => ST dep or elevation) + echocardiogram
Pneumothorax => insert chest tube => midclav 2nd intercostal space
Swan-Ganz pulmonary artery catheter => L atrial filling pressure

Rx:
Vasopressors
Dobutamine => beta 1 agonist => increase cardiac contractility
Norepinephrine => alpha and beta 1 => distributive and cardiogenic
Phenylephrine => pure alpha 1 agonist => increase SVR w/o increasing CO

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21
Q

Three stages of atherosclerotic plaque formation

A
  1. Endothelial dysfunction => fatty streak= smooth muscle cells in intima and accumulation of lipid
  2. LDL enters endothelium => oxidized => macrophages come and recruit fibroblasts and other inflamm cells
  3. Smooth muscle + CT + lipids incorporated into plaque => fibrous cap formation => narrow artery lumen

Plaques can rupture and lead to thrombosis

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22
Q

Characteristics of unstable angina

A
  • angina that occurs AT REST

- significant change in the pattern of existing chronic angina

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23
Q

Symptoms to look for in atypical angina

A

Jaw pain
Dyspnea

=> think diabetes

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24
Other PE findings of atherosclerosis (7)
``` Arteriovenous nicking Copper wire changes in retinal vaculature Third heart sound Fourth heart sound Arterial bruits Diminished peripheral pulses Xanthomas ```
25
S4
It occurs just after atrial contraction and immediately before the systolic S1 caused by the atria contracting forcefully in an effort to overcome an abnormally stiff (decreased compliance of ischemic myocardium) or hypertrophic ventricle
26
S3
occurs soon after the normal two "lub-dub" heart sounds (S1 and S2). The S3 is associated with heart failure.
27
Reasons for stopping an exercise stress test (used to Dx CHD)
``` Mod/severe chest pain Dyspnea Dizziness >2mm ST segment depression => test = positive of ST segment depression >1mm Fall in SBP >10mmHg Sustained ventricular tachycardia ```
28
Causes of false positive ST depression on exercise stress test (4)
LBBB LVH WPW syndrome Digoxin
29
Tools to Dx CHD (5)
1. Exercise stress test (look at ECG for ST depression >1mm) 2. Radiolabeled tracers such as sestamibi to determine regional myocardial perfusion 3. Pharmacological stress test with selective vasodilators such as dipyridamole, adenosine => blood shunted away from atherosclerotic vessels 4. Dobutamine stress echocardiography to look for wall motion abnormalities 5. Coronary angiography => GOLD STANDARD
30
Treatment of stable angina (ABCDEs)
A: aspirin, ACE inhibitors, antianginals (Beta blockers, calcium channel blockers, Nitro) B: beta-blockers and BP control C: cholesterol and smoking cessation, CABG (if severe), coronary stents (percutaneous coronary intervention) D: diet and diabetes control E: education and exercise
31
Side effects of beta blockers (4)
Fatigue Impotence Bradycardia Worsening of CHF
32
When to consider CABG over medical management of CHD
Left main disease OR LAD + proximal left circumflex Three vessel disease w/ reduced EF Severe proximal LAD stenosis Survivors of sudden cardiac death/ V.tach/fib
33
Complete occlusion of the coronary artery often results in ....... (ECG)
STEMI! Leads to necrosis of the myocardium May occur throughout entire thickness => pathological Q waves
34
Mechanisms that compromise coronary blood flow/oxygen supply (8)
Atherosclerotic plaque rupture Demand ischemia => tachycardia, hypotension, severe hypoxia Coronary artery dissection Coronary vasospasm => drugs, Prinzmetal angina In situ thrombus formation => hypercoagulable Coronary embolism Vasculitis => Kawasaki CO poisoning
35
Complications leading to death from AMI (5)
``` Arrhythmias => heart block, V.tach/fib Heart failure => cardiogenic shock Ventricular rupture => usually within 3-5 days Ventricular septal defects Mitral papillary rupture Reinfarction (>1 month later) ```
36
Prognostic factors for UA or NSTEMI (7)
``` TIMI risk score (/7) Age >65 At least 3 risk factors for CAD Known CAD with at least 50% stenosis ST segment changes At least 2 episodes of angina in past 24 hrs Aspirin use in past week Elevated CPK-MB or troponin ```
37
Tx of a patient with possible MI
1. Rapid clinical assessment => vitals, Hx, P/E, 12 lead ECG 2. Give OXYGEN 3. Give 162-325mg ASPIRIN 4. Give SL NITROGLYCERIN (0.4mg every 5 min x 3) => beware hypotension 5. Consider IV morphine for pain and pain-related sympathetic drive 6. Give IV beta blockers to control HR and relieve myocardial demand 7. Treat with a statin, oral ACE inhibitors,
38
Thrombolytic therapy agents
Streptokinase Alteplase Tenecteplase Reteplase
39
Absolute contraindications for thrombolysis (6)
``` Previous intracranial hemorrhage Significant closed head injury within past 3 mo Stroke within 1 yr Intracranial malignant neoplasms Aortic dissection Active bleeding ``` Relative contraindications include: uncontrolled HTN, distant Hx stroke, recent trauma/surgery, pregnancy, current use of anticoagulants
40
STEMI vs. NSTEMI
STEMI = full thickness damage to myocardium, complete occlusion of major coronary artery, complications are more common NSTEMI = partial thickness, complete occlusion of minor artery or partial occlusion of major artery, milder elevations in troponin and CPK-MB compared to STEMI, may see T wave inversions on ECG, thrombolytic Tx is harmful (i.e. NO streptokinase)
41
Major risk factors for congestive heart failure (5)
``` Coronary heart disease Hypertension Diabetes Valvular heart disease Cardiomyopathy => amyloid, drug-related, idiopathic ```
42
BP is determined by SVR and CO. CO is in turn determined by _________, _________, and ____________.
Preload, contractility and afterload
43
Frank Starling law of the heart
As preload is increased, the stroke work or contractility (inotropy) of the heart is also increased. The relationship between increasing preload and CO, in a heart with decreased contractility/ejection fraction....i.e. Post MI etc.
44
Causes of high output heart failure (rare)
Hyperthyroidism beri beri => thiamine deficiency Arteriovenous malformation => increased metabolic demands!
45
DDx dyspnea + dilated cardiomyopathy (7)
``` Post MI HTN Valvular Toxic (Rx, cocaine etc) Viral (coxsackie!!) Hemochromatosis Hypothyroidism ```
46
Tx acute pulmonary edema in CHF
LMNO Lasix (decrease preload) Morphine (venodiltor and anxiolytic) Nitroglycerin (arterial and venous dilator AND coronary vasodilator) Oxygen (decrease pulmonary vasoconstriction)
47
Tx CHF caused by systolic dysfunction
``` ACE inhibitors ARBs Beta blockers Diuretics Fluid and salt restriction Cardiac glycosides (ex. Digoxin) Inotrope infusions Ventricular assist devices ```
48
Causes of absent P waves
Failure of SA node to fire => sinus arrest => Sick Sinus Syndrome Failure of SA node to excite atria => sinus exit block Also atrial fibrillation => no organized atrial activity
49
Difference between first, second and third degree AV block
Both cause a prolongation of the PR interval (>200msec) First degree: generally no Sx or significant bradycardia Second degree: leads to a blocked beat => QRS fails to follow a P wave Third: COMPLETE heart block, no relationship between P waves and QRS complex (variable PR interval), P waves fail to conduct to ventricles => slower pacemaker takes over
50
Difference between Type 1 and Type 2 second degree AV blocks
Type 1 Wenkebach => PR intervals progressively lengthen until a P wave fails to conduct (i.e. A P wave that is NOT followed by a QRS), AV nodal disease Type 2 => dropped beat occurs suddenly, infranodal disease, higher risk of progressing to complete heart block
51
Indications for permanent pacemaker (3)
Complete heart block w Sx Sinus node dysfunction w Sx Bifasicular block with intermittent type 2 second degree AV block Type 2 second degree AV block after an MI
52
Approach to tachycardia
Look at HR => >100 Look at QRS complex => wide (supraventricular OR ventricular) or narrow (always supraventricular)? Narrow? => regular or irregular look at P waves => Present? Absent? Sawtooth? P waves before QRS? Wide? => look at morphology => variable vs. uniform
53
Tx for hemodynamically stable SVT (i.e. How to block the AV node)(5)
``` Vagal maneuvers (valsalva/ carotid sinus massage) Adenosine Beta blockers Calcium channel blockers Digoxin ```
54
Three main Tx concerns in Atrial Fibrillation
Rate control Rhythm control Anticoagulation
55
Causes of prolonged QT interval (4)
Medications => type 1A and III antiarrhythmics, phenothiazines, tricyclic antidepressants Electrolyte disorders => hypokalemia, hypomagnesemia, hypocalcemia Congential Ischemia
56
Major causes of secondary HTN (10)
``` Renovascular disease Intrinsic kidney disease Primary aldosteronism Pheochromocytoma Cushing syndrome Hyper AND hypoyroidism Obstructive sleep apnea Coarctation of the aorta Drugs (ex. OCP, alcohol) ```
57
The 7 "Ps" of pheochromocytoma
``` Pounding headache Perspiration Palpitations Pallor Pyrexia Pressure (BP) elevations Postural Sx ``` Usually lasting 10-60min
58
Signs of target organ damage in HTN
``` LV heave S4 Edema (pulmonary and peripheral) Carotid bruits Neurological deficits Diminished pulses Aneurysms Arteriovenous nicking, papilledema, hemorrhages Renal bruits ```
59
The six Ps of acute peripheral arterial occlusion
``` Pulselessness Pallor Poikilothermia (temperature varies with ambient temp) Pain Paralysis Paresthesias ```

Internal Medicine - Emma (5 decks)

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