Cardiovascular Flashcards
(118 cards)
1
Q
what is the difference between NSTEMI and unstable angina?
A
NSTEMI has elevations of cardiac biomarkers whereas unstable angina does not
2
Q
pt presents with angina at rest or new onset / increased angina
A
unstable angina or NSTEMI
3
Q
chronic stable angina
A
chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved by rest or nitroglycerin
4
Q
sharp, pleuritic chest pain worsened in the supine position and radiates to top of shoulder
A
acute pericarditis
5
Q
dx. criteria for acute pericarditis (3)
A
- pleuritic chest pain
- friction rub
- diffuse ST elevation on ecg, w/ PR depression
6
Q
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?
A
aortic dissection
7
Q
ST elevation in II, III and aVF
A
inferior wall MI
8
Q
preferred tx. for pts with STEMI
A
PCI with stent placement
- most effective if done w/in 12 hrs of onset of pain
9
Q
C/I to thrombolytic therapy
A
prior intracerebral hemorrhage
ischemic stroke w/in 3 months
suspected aortic dissection
active bleeding
10
Q
next diagnostic step in suspected aortic dissection
A
chest CT
11
Q
when is echocardiogram useful in emergency setting?
A
pts presenting with chest pain and non-diagnostic ECG
12
Q
classic triad of RV MI
A
hypotension
clear lung fields
elevated estimated CVP
13
Q
most predictive findings of RV-MI
A
ST-segment elevation on right-sided electrocardiogram lead V4R
14
Q
what test should all patients with inferior wall MI have done?
A
right sided ECG
15
Q
primary supportive tx. in RV MI
A
volume expansion with normal saline
16
Q
pts with RV-MI whose hypotension is not corrected after 1 L of saline should get what drug?
A
IV dobutamine (inotropic)
17
Q
what two drugs are impaired in RV-MI?
A
b-blockers }bradycardia
nitrates } makes hypotension worse, inhibiting right heart filling
18
Q
Tx of pt with GERD-related chest pain
A
rule out cardiac ischemia (i.e. exercise stress test) and then tx. empirically with PPI
19
Q
prolongation of PR interval > 0.2 sec; not assoc with alterations in HR
A
first degree AV block
20
Q
progressive prolongation of PR interval until there is a dropped beat
A
Mobitz Type I - Wenkebach
21
Q
dropped beat without progressive prolongation of PR interval
A
Mobitz Type II block
- usually assoc. with BBB and progresses to third degree block
22
Q
complete absence of conduction of atrial impulses with ventricular bradycardia (30-50 bpm)
A
third degree heart block
23
Q
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?
A
consider panic attacks
24
Q
Tx. of panic acttacks
A
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
