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Flashcards in Cardiovascular Deck (118)
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1

what is the difference between NSTEMI and unstable angina?

NSTEMI has elevations of cardiac biomarkers whereas unstable angina does not

2

pt presents with angina at rest or new onset / increased angina

unstable angina or NSTEMI

3

chronic stable angina

chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved by rest or nitroglycerin

4

sharp, pleuritic chest pain worsened in the supine position and radiates to top of shoulder

acute pericarditis

5

dx. criteria for acute pericarditis (3)

1. pleuritic chest pain
2. friction rub
3. diffuse ST elevation on ecg, w/ PR depression

6

pt presents with abrupt onset, severe pain in thorax; there may be a pulse deficit on P/E, murmur of aortic regurgitation and widening of mediastinum of CXR - dx?

aortic dissection

7

ST elevation in II, III and aVF

inferior wall MI

8

preferred tx. for pts with STEMI

PCI with stent placement
- most effective if done w/in 12 hrs of onset of pain

9

C/I to thrombolytic therapy

prior intracerebral hemorrhage
ischemic stroke w/in 3 months
suspected aortic dissection
active bleeding

10

next diagnostic step in suspected aortic dissection

chest CT

11

when is echocardiogram useful in emergency setting?

pts presenting with chest pain and non-diagnostic ECG

12

classic triad of RV MI

hypotension
clear lung fields
elevated estimated CVP

13

most predictive findings of RV-MI

ST-segment elevation on right-sided electrocardiogram lead V4R

14

what test should all patients with inferior wall MI have done?

right sided ECG

15

primary supportive tx. in RV MI

volume expansion with normal saline

16

pts with RV-MI whose hypotension is not corrected after 1 L of saline should get what drug?

IV dobutamine (inotropic)

17

what two drugs are impaired in RV-MI?

b-blockers }bradycardia
nitrates } makes hypotension worse, inhibiting right heart filling

18

Tx of pt with GERD-related chest pain

rule out cardiac ischemia (i.e. exercise stress test) and then tx. empirically with PPI

19

prolongation of PR interval > 0.2 sec; not assoc with alterations in HR

first degree AV block

20

progressive prolongation of PR interval until there is a dropped beat

Mobitz Type I - Wenkebach

21

dropped beat without progressive prolongation of PR interval

Mobitz Type II block
- usually assoc. with BBB and progresses to third degree block

22

complete absence of conduction of atrial impulses with ventricular bradycardia (30-50 bpm)

third degree heart block

23

pt presents with recurrent, unexpected episodes of palpitations, sweating, dyspnea, chest pain, nausea, dizziness and numbness; sx. peak w/in 10 min and last 15-60 minutes - dx?

consider panic attacks

24

Tx. of panic acttacks

CBT
SSRI- paroxetine

25

pt presents with sudden severe headache, diaphoresis and palpitations; he is very pale

pheochromocytoma - episodic or sustained HTN

26

AV block characterizes by regularly dropped beat (nonconducted P wave every 2nd or 3rd beat)

Mobitz Type II block

27

causes of Mobitz Type I block

absence of heart disease - athletes, elderly
underlying heart disease - ischemia
drugs - CCBs, beta blockers, digoxin

28

Tx of mobitz type II block

pacemaker

29

anti-anginal therapy for chronic stable angina

B-blockers
CCBs
nitrates

30

vascular protective therapy for chronic stable angina

aspirin
statin
ACE inhibitor

31

Ranolazine

novel antianginal agent approved for tx. of chronic stable angina
- should only be used in addition to baseline therapy of BB, CCB and long-acting nitrate

32

when is coronary angiography useful in assessment of chronic stable angina?

when pt still has symptoms despite max medical therapy

33

pt complains of chest pain and dyspnea with asymmetric leg edema, elevated CVP, tachypnea and tachycardia - dx? what test should you do?

suspect PE
- do a CT pulmonary angiography

34

normal wall motion on echocardiography during chest pain excludes...

coronary ischemia or infarction

35

adenosine nuclear perfusion stress test is C/I in what patients?

those with asthma or sig. bronchospastic dz

36

primary approach to diagnosis of CAD in pts who can exercise and have normal resting ECG

exercise ECG testing

37

multiple P waves in a sawtooth pattern with 2:1 ventricular conduction

atrial flutter

38

absence of discernable P waves which are replaced by fibrillatory waves that vary in amplitude, shape and frequency; ventricular rate is irregular

atrial fibrillation

39

symptomatic sinus bradycardia with alternating atrial tachyarrhythmias (A.fib)

sick sinus syndrome

40

wide QRS morphology (QRS > 0.12 sec) and HR > 100/min

ventricular tachycardia

41

when do you add a CCB to a pt with chronic stable angina?

if pt is unable to tolerate BB or they can be added to BB for difficult to control sx

42

should you give clopidogrel to a pt with stable angina?

no - increased risk of bleeding

43

LDL cholesterol target range for CAD

< 100 mg/dL (2.6 mmol/L)

44

what studies should at the very minimum be done in dx. Atrial Fibrillation? 2

transthoracic echo - exclude occult valve or structural heart disease
TSH to exclude hyperthyroidism

45

who is coronary angiography reserved for?

lifestyle limiting angina despite tx
positive results on stress testing
successful resuscitation from sudden cardiac death
ventricular tachycardia

46

coronary calcium testing - who gets this test?

asx. pts with a 10-20% 10 yr risk category
young pts with strong family history of premature CVD

47

how do you diagnose pre-excitation?

short PR interval
presence of delta wave
- if tachycardia - dx. is WPW syndrome

48

wide QRS complex and HR between 60-100/min

idioventricular or slow ventricular tachycardia

49

three or more p-wave configurations on ECG w/ assoc. tachycardia; commonly seen in chronic lung disease patients

multifocal atrial tachycardia

50

what test is indicated in a pt with chronic stable angina who is experiencing lifestyle limiting angina despite optimal medical therapy?

coronary angiography

51

coronary revascularization is beneficial in stable angina pts who meet the following conditions:

- refractory to medical tx
- large area of ischemic myocardium and high risk criteria on stress testing
- high risk coronary anatomy (Left main or 3-vessel dz)

52

what 3 conditions are "cannon waves" present in?

3rd degree heart block
pulmonary HTN
ventricular tachycardia

53

a wide QRS tachycarida, in the presence of known structural heart disease (esp prior MI) is almost certainly...

ventricular tachycardia

54

what is important drug to initiate in NSTEMI?

BB - reduces infarct size, decreases frequency of recurrent MI and improves short/long term survival

55

indications for intra-aortic balloon pump

cardiogenic shock unresponsive to med. tx
acute mitral regurg. secondary to papillary mm. dysfunction
ventricular septal rupture
refractory angina

56

how does an intra-aortic balloon pump work?

reduces afterload during systole and increases coronary perfusion during diastole

57

what type of infarct predisposes to papillary muscle rupture and acute mitral regurg?

inferior wall infarcts

58

signs of ventricular aneurysm

intractable ventricular tachyarrrhythmia
systemic emboli
heart failure

59

how does ventricular free wall rupture manifest?

pericardial tamponade, cardiovascular collapse or pulseless electrical activity

60

new systolic murmur with palpable thrill 2-7 days following STEMI

ventricular septal defect or ischemic mitral regurgitation
- next steps: echo and surgery

61

pt presents with severe, sharp, tearing chest pain; pain radiates widely and is assoc. with syncope, systemic ischemia or heart failure

aortic dissection

62

physical findings assoc. with aortic dissection

acute aortic regurg (diastolic murmur at base)
myocardial ischemia
cardiac tamponade/hemopericardium
hemothorax/exsanguination

63

sick sinus syndrome consists of...

sinus bradycardia
sinus arrest
sinus exit block

64

tachycardia-bradycardia syndrome

rapid ventricular conduction during episodes of atrial fibrillation with resting bradycardia between episodes

65

symptomatic sinus dysfunction is an indication for what?

pacemaker implantation

66

effects of Donepezil on heart

Achesterase inhibitor - causes increased vagal tone, bradycardia and AV block

67

cardiac effects of Trazodone

palpitations and ventricular ectopy

68

next best step in pt with cardiac arrhythmia who is unstable

electrical cardioversion

69

what test should you order in pt with sinus tachycardia?

TSH level to test for hyperthyroidism

70

what is adenosine used for?

1. terminates AV nodal re-entrant tachycardia
2. can reveal flutter waves during adenosine-induced AV block

71

elevated resting sinus rate in the absence of recognized cause and an exaggerated rate response to exercise

inappropriate sinus tachycardia

72

Tx. inappropriate sinus tachycardia

CCB or BB
- refractory cases - sinoatrial node ablation

73

CHA2DS2 ASc risk score

CHF
HTN
age > 75- 2 pts
Diabetes
Stroke or TIA - 2 points
Vascular disease (prior MI, PAD, Aortic plaque)
Age 65-74
Sex (F)

74

what do you do with a 25 yo patient with PVCs and structurally normal heart

no additional investigation or tx. needed

75

first-line therapy for PVCs

beta blocker - metoprolol OR CCB - verapamil

76

medical therapy of sustained ventricular tachycardia

amiodarone, procainamide, flecainide
- does not improve survival in pts with VT or structural disease

77

primary eligibility criterion for ICD implantation

EF < 35%, regardless of presence or absence of coronary disease or arrhythmias

78

ICD implantation is not indicated for whom?

pts who experience ventricular arrhythmias less than 48 hours after acute STEMI - these should be managed medically

79

indications for pacemaker placement

symptomatic sinoatrial node dysfunction
symptomatic bradycardia due to 2nd or 3rd degree block

80

pt presents with recurrent syncope as well as a family history of syncope triggered by activity or sudden death/cardiac arrest due to torsades - dx?

long QT syndrome - most likely congenital

81

acquired long QT syndrome

female sex
hypokalemia, hypomagnesemia
structural heart disease
previous QT interval prolongation
history of drug-induced arrhythmia

82

when is digoxin used in HF treatment?

added to other therapy in pts with NYHA class III/IV heart failure - strictly for symptom control (no survival benefit)

83

HF with EF < 45% diagnosed between 3 months before and 6 months after delivery (usually first month post-partum)

peripartum cardiomyopathy

84

what do you suspect in pt with elevated CVP, pulmonary crackles, S3 and S4 heard, any cardiac murmus and LE edema

heart failure

85

next best step in pt with new-onset heart failure

cardiac angiography

86

what is radionuclide ventriculogram useful for?

confirming the EF if clarification is needed

87

what test should be ordered in all patients with newly suspected heart failure?

echocardiography

88

BNP > 500 suggests what?

acute heart failure

89

what drugs are recommended for all NYHA class 1 and 2 patients, regardless of symptoms or functional status?

B-blocker (carvedilol)
ACE-i (lisinopil)
- improve mortality

90

when do you initiate spironolactone and digoxin in HF?

NYHA III-IV patients

91

what can you give a patient with HF who is intolerant of an ACEi (hyperkalemia, renal insufficiency)?

hydralazine + nitrate
- also improve survival but not as much as ACEi

92

eplerenone - indications

HTN
LV dysfunction after MI
instead of spironolactone in CHF

93

contraindications to spironolactone

serum creatinine > 2.5 md/dL
K+ > 5 mmol/L

94

what two CCBs can be used in HF patients if symptoms are not adequately controlled by BB or ACEIs?

amlodipine
felodipine

95

failure of a bioprosthetic aortic valve leads to ...

aortic insufficiency

96

widened pulse pressure, bounding peripheral/carotid pulses, holodiastolic murmur on left upper sternal border best heard when pt is leaning forward

aortic regurgitation

97

fixed splitting of S2 and ventricular heave

ASD

98

what do you do with murmurs that are grade 2/6 sysolic murmur or less

if asymptomatic, these are considered benign and require no further testing

99

indications for transthoracic echocardiography (murmurs)

- grade 3/6 or louder systolic murmus
- any diastolic or continuous murmur
- new murmur diagnosed

100

accentuated P2, opening snap and low-pitched, diastolic rumble

mitral stenosis - usually due to Rheumatic disease

101

systolic murmur best heard at left lower sternal border that increases with intensity during inspiration

tricuspid regurgitation

102

what maneuvres increase the murmur of hypertrophic cardiomyopathy

valsalva manuevre
squat-to-stand

103

rapid upstrokes of carotid arteries with a systolic murmur?

hypertrophic cardiomyopathy

104

Acute A-fib Rx in unstable patient

Immediate electrical cardioversion to sinus rythym

105

Acute A-fib Rx in stable patient (3)

1. Rate control (DOC: B-blockers; CCB's, in LVSD- digoxin, amiodarone)
2. Cardioversion E>Pharm (ibutilide, procainamide, flecainide, sotalol, amiodarone)
2. Anticoagulation

106

Atrial flutter rx

similar to A-fib

107

multifocal atrial tachycardia dx

vagal maneuvers or adenosine to show av block w/out disrupting the atrial tachycardia

108

multifocal atrial tachycardia Rx

improving oxygenation and ventilation
LV function ok: CCBs, B-Blockers, Digoxin, amiodarone, IV flecainide and IV propafenone
LV not preserved: Digoxin, diltiazem or amiodarone

109

Paroxysmal Supraventricular Tachycardia Rx maneuvers (4)

Stimulate the vagus delay AV conduction and thus re-entry mechanism: Valsalva, carotid sinus massage, breath holding, head immersion in cold water

110

Paroxysmal Supraventricular Tachycardia Acute Rx

DOC: adenosine 6 mg rapid IV push
Iv Verapamil or IV esmolol or Digoxin
Cardioversion if unaffective

111

Paroxysmal Supraventricular Tachycardia prevention

DOC: Digoxin
Verapamil or B-blocker
Ablation of AV node

112

Rx W-P-W

Ablation
Consider amiodarone 150 mg IV over 10 min.
Pharm(esp if patient goes into a-fib): procainamide or quinidine

113

Avoid drugs active on AV-node in W-P-W

Digoxin, B-Blocker, CCB, Adenosine
may accelerate conduction

114

Rx: Sustained VT with hemodynamically stable patients

ACLS guidelines: IV amiodarone 150 mg IV over 10 min; IV procainamide or
IV sotalol > IV lidocaine or IV bretylium

115

Rx: Sustained VT with hemodynamically unstable patients

Immediate synchronous DC cardioversion
Follow with Amiodarone to maintain sinus rhythm

116

Rx: Nonsustained VT

No underlying heart condition: NO treatment
Underlying heart disease: order electrophysio study
- if inducible S-VT give amiodarone

117

V-fib Rx

Immediate Defibrillation and CPR indicated
continues after shock EPI (1 mg bolus initially)

118

Pulseless electrical Activity causes

5H's and 5T's (due cpr)
Hypovolemia, hypoxia, H+ (acidosis), hypo/hyperkalemia, hypothermia
Tension Pneumo, Tamponade, Toxins (Narcs, BZ), Thrombosis (Pulm/cardiac), Trauma