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CARDIOVASCULAR Flashcards

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1
Q

what is the indication for sodium bicarbonate therapy in TCA overdose?

A

QRS >100msec

risk for ventricular arrythmia and seizures

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2
Q

what is the worst risk factor for CAD?

what is the most common?

A

worst is diabetes mellitus

MC is HTN

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3
Q

premature coronary disease is defined as
male under…
female under…

is family history a risk factor for CAD?

A

male under 55
female under 65

only a risk factor if family member was PREMATURE and FIRST DEGREE (sibling or parent) – so it is not a positive family history risk factor if the family member was OLD

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4
Q

which value in the lipid panel is the most dangerous to a patient in terms of risk for CAD?

A

a HIGH LDL

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5
Q

tako-tsubo cardiomyopathy

presentation?
tx?

A

acute myocardial damage in postmenopausal women after a stressful/emotional event which causes catecholamine discharge and left ventricular ballooning/dyskinesis

tx is with B blockers and ACEi
**revascularization will not work because coronary arteries are NORMAL (not CAD)

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6
Q

correcting which of the following risk factors for CAD will result in the most immediate benefit for the patient?

DM
tobacco smoking
HTN
HLD
weight loss
A

tobacco smoking

smoking cessation results in the greatest immediate improvement in outcomes for CAD – within 1 year, risk of CAD decreases by half; within 2 years, decreases by 90%

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7
Q

chest pain that is reproducible to palpation =

A

chostochondritis

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8
Q

chest pain worse w lying flat, better sitting up + ekg with overall ST elevations

A

pericarditis

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9
Q

best initial test for all forms of chest pain?

A

ekg

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10
Q

in the office/ambulatory setting, if a patient comes in with chest pain, what is the next steps?

A

ekg –> transfer to ED –> cardiac enzymes

DO NOT GET ENZYMES IN OFFICE SETTING

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11
Q

if patient with chest pain cannot exercise for stress test, what are other options?

which to use in asthmatics?

A

dipyridamole thallium test (decreased uptake of thallium)
or
dobutamine echo (wall motion abnormalities)

use dobutamine in asthmatics since dipyridamole can cause bronchospasm

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12
Q

patient has normal nuclear uptake at rest but decreased with exercise., which returns to normal 2 hrs after exercise. what is next intervention?

coronary angiography
bypass surgery
PCI (angioplasty)
dobutamine echo
nothing
A

coronary angiography (catheterization) to know anatomy to determine whether patient needs bypass or angioplasty

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13
Q

what does coronary angiography determine?

A

who gets bypass surgery vs who gets angioplasty
(detects location of CAD)

most accurate way to detect CAD!

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14
Q

what % of CAD stenosis requires surgery?

A

stenosis of at least 70%

<50% is insignificant

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15
Q

in chest pain, if patient has baseline EKG abnormalities, what is the next test you do?

A

stress echocardiogram or nuclear stress test

since ekg cant be read properly

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16
Q

do not do a exercise stress test if patient currently has…

A

chest pain

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17
Q

what medications will decrease mortality in chronic angina (CAD)?

A

aspirin
beta blockers
nitroglycerin

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18
Q

what form of nitroglycerin do you use for acute angina? for chronic?

A

oral or transdermal for chronic

sublingual, paste of IV in acute

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19
Q

what medication should acute coronary syndrome pt receive upon arrival to ED?

A

2 antiplatelet agents

aspirin + clopidogrel, prasugrel, or ticagrelor

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20
Q

what med has best mortality benefit on patients with low ejection fraction?

A

ace inhibitor

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21
Q

side effects of ace inhibitors?

A 
cough
hyperkalemia (aldosterone usually excretes K)
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22
Q

what do you switch to if patient on ace inhibitor gets hyperkalemia?

A

hydralazine and nitrates

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23
Q

best med to lower LDL?

goal?

A

hmg coa reductase inhibitors (statins!)

less than 100

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24
Q

med with clear mortality benefit in hyperlipidemia?

A

statins

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25
common side effect of statins?
liver dysfunction | get baseline AST/ALT!
26
``` other lipid lowering agents: 1 niacin 2 gemfibrozil 3 cholestyramine 4 ezetimibe ```
1 - will raise HDL 2 - will lower TGs ****increased risk of myositis when statins + gemfibrozil 3 - bile acid sequestrant which decreases absorption ***uncomfortable GI constipation/flatus 4 - lowers LDL WITHOUT ANY ACTUAL HEALTH BENEFIT ** only use these when statins alone cannot control LDL
27
delta wave on ekg means what?
WPW (accessory A-V pathway) delta wave is a slurred upsloping of the QRS
28
recommended AAA screening?
men 65-75 who have smoked cigarettes should get a 1 time abdominal ultrasound
29
``` adverse effects of lipid medications: 1 statins? 2 niacin? 3 fibric acid derivatives (gemfibrozil)? 4 cholestyramine? 5 ezetimibe? ```
1 elevated LFTs, myositis 2 elevated glucose and uric acid (gout), pruritis 3 increased risk of myositis when added to statin 4 flatus and cramping 5 no s/e, but useless med
30
which ca channel blockers have been shown to lower mortality in CAD?
none!
31
which ca channel blockers do NOT increase heart rate?
verapamil and diltiazem **used in patient with severe asthma who cannot use beta blockers
32
adverse effects of ca channel blockers?
edema constipation heart block *rare
33
4 situations where CABG lowers mortality?
severe disease such as: - 3 vessels dz with 70+% stenosis in each - left main coronary artery occlusion - 2 vessel disease in a diabetic - persistent sx despite max medical therapy
34
kussmaul sign
increase in JVP on inhalation | associated withc onstrictive pericarditis
35
what does a triphasic scratchy sound indication?
pericardial friction rub (pericarditis)
36
dressler syndrome
pericarditis several days to weeks after an MI
37
ST elevation in leads II, III, and aVF
acute MI of the inferior wall
38
PR interval >200 ms.......
first degree AV block (requires no tx when isolated)
39
ST elevation in leads V2-V4
acute MI of the anterior wall of LV
40
PVCs present.....what next
check magnesium and potassium if e- are normal, no tx required ***treatment of PVCs only worsens the outcome
41
ST depression in leads V1 and V2
posterior wall MI | reading V1 and V2 are opposite of the others; depression here equals elevation elsewhere
42
first step in a patient with chest pain in ED after the EKG..
ASPIRIN! (clopidogrel if patient cant take aspirin) lowers mortality in ACS and must be given asap do not choose ck-mb, troponins(enzyme tests normal in first 4 hrs), morphine, oxygen, or nitro...they can all be done after! after aspirin, in ACS angioplasty should be NEXT if you must choose best option
43
troponin versus CKMB in their timing postMI which is used for reinfarction detection?
they both rise after 4-6 hours ck-mb normalizes after 1-2 days trops normalize after 10-14 days use ekg + ck-mb to check reinfarction
44
most common cause of death in the first few days after an MI?
v tach or v fib
45
door to balloon time is under __ minutes (angioplasty/PCI) PCI is more or less superior to thombolytics? door to needle time (for thrombolytics)?
90 minutes within arriving to the ED with chest pain more superior under 30 minutes for thrombolytics (within 12 hours of onset)
46
what is the most important consideration in decreasing the risk of restenosis of coronary artery after PCI?
placement of a drug-eluting stent (paclitaxel, sirolimus) this will decrease the local T cell response and reduce the rate of restenosis (<10% versus 15-30% with bare metal stent)
47
absolute contraindications to thrombolytics?
major GI (melena not just occult+) or brain bleeding recent surgery in past 2 weeks severe htn (>180/110) nonhemorrhagic stroke in last 6 months
48
man in ED with chest pain for past hr, EKG shows ST depressions in V2-V4, aspirin has been given, what is next step?
low weight molecular heparin to prevent cot from forming in coronary arteries (does not dissolve clots that already formed) there is no benefit of thrombolytic(tPA) therapy when patient has ACS and NO ST elevations
49
abciximab
a gp2b/3a inhibitor (inhibit platelet aggregation) used in ACS for those undergoing PCI/angioplasting
50
heparin is best for ___ MI | tPA (thrombolytics) is best for ____ MI
NSTEMI STEMI
51
LMWH vs unfractionated heparin which is superior in terms of mortality benefit
LMWH
52
cannon A waves + bradycardia
bounding jvp up into the neck (atrial systole against a closed tricuspid) = A and V are out of coordination 3rd degree complete AV block tx: atropine --> pacemaker if atropine is ineffective
53
right coronary artery supplies....
right ventricle AV node inferior wall of heart
54
treatment for right ventricular infarction
high volume fluid replacement | no nitroglycerin since it worsens filling
55
sudden loss of pulse/pulseless electrical activity several days after MI
free wall rupture! tx: emergent pericardiocentesis on the way to the OR!
56
treatment for v fib or v tach?
cardioversion/shock
57
a step up in oxygen saturation from the right atrium to the right ventricle indicates.... most accurate test for dx?
valve or septal rupture presents with new onset murmur and pulmonary congestion echocardiogram for both valve and septal ruptures
58
name the post-MI complication? 1 - bradycardia and cannon A waves 2 - sudden loss of pulse, JVP 3 - inferior wall MI in hx, clear lungs, tachy, hypotension with nitro 4 - new murmur + rales/congestion 5 - new murmur + increasing oxygen sat from right atrium to ventricle 6 - loss of pulse, need EKG to answer dx
``` 1 - 3rd degree AV block 2 - tamponade/free wall rupture 3 - RV infarction 4 - valve rupture 5 - septal rupture 6 - ventricular fibrillaton ```
59
all post-MI patients should go home on these meds
aspirin B blocker (metoprolol = specific) statins ace inhibitor --> Acei are best for anterior wall infarctions because of the high likelihood of developing systolic dysfunction * *clopidogrel or prasugrel IF intolerant of aspirin or post-stenting * *ARB if intolerant of ACEi
60
prophylactic antiarrythmics ___mortality
increase!! | do not give prophylactic antiarrythmics like amiodarone, flecainide etc
61
can a patient have sex after an MI?
yes if they are symptom free and post MI stress test is normal
62
s3 versus s4
s3 is right after S2 | s4 is right before S1
63
most likely dx for dyspnea: 1- sudden dyspnea + clear lungs 2- sudden dyspnea + wheezing and increased expiratory phase 3- slower onset, fever + sputum + unilateral rhonchi 4- decreased breath sounds unilaterally + tracheal deviation 5- circumoral numbness + caffeine use + hx of anxiety 6- pallor, gradual over days to weeks 7- pulsus paradoxus, decreased heart sounds, JVD 8- palpitations and syncope 9- dullness to percussion at bases 10- long smoking hx and barrel chest 11- recent anesthetic use, brown blood not improved with oxygen, clear lungs, cyanosis 12- burning building or car, wood burning stove, suicide attempt
``` 1- PE 2- asthma 3- pneumonia 4- pneumothorax 5- panic attack 6- anemia 7- tamponade 8- arrythmia 9- pleural effusion 10- COPD 11- methemoglobinemia 12- Carbon monoxide poisoning ```
64
what is the best initial test for ejection fraction/chf? which is more accurate: TTE, TEE?
TTE TEE
65
which three beta blockers are the only ones with proven benefit for low ejection fraction CHF?
metoprolol (beta 1 spec) bisoprolol (beta 1 spec) carvedilol (nonspecific B with alpha 1 blocking)
66
meds given for low ejection fraction CHF?
B blocker ACEi/Arb spironolactone (inhibits aldosterone) diuretics (lower sx, do NOT lower mortality) digoxin (lower sc, DOes NOT lower mortality, DOES decrease hospitalizations)
67
mc cause of death from CHF?
arrythmia/sudden death
68
what is management of a chf patient who develops gynecomastia?
switch spironolactone to eplerenone
69
adverse effects of spironolactone?
gynecomastia | hyperkalemia
70
II, III, aVF MI...dont give....
nitrates
71
do beta blockers, diruetics, spironolatone, and digoxin have benefits in diastolic dysfunction chf?
beta blockers and diuretics YES | digoxin and spironolactone NO
72
diuretics or indicated or contraindicated in HOCM?
contraindicated | decrease V = increased obstruction by large septum
73
if there is pulmonary edema from an arrythmia, first step after ekg is...
cardioversion
74
patient comes in with jvd, sob, rr 38, rales and s3 gallop...best initial step? oximeter echo iv furosemide metoprolol
iv furosemide
75
___ can be used in ICU acute setting if sob/pulm edema did not respond to preload reduction in order to increase contractility and decrease afterload
dobutamine (positive inotrope) digoxin is also a + inotrope but takes weeks to take effect
76
mc valvular disease from rheumatic heart dz?
mitral stenosis
77
naturally inhalation will increase intensity of which two heart valve location? and exhalation will increase which two?
inhalation = right side increases (tricuspid and pulmonic) exhalation = left side inreased return to heart from lungs (mitral and aortic)
78
valve disease best initial test? most accurate test?
best initial = echo (NOT xray) most accurate = catheterization
79
only give endocarditis ppx with 2 scenarios...
prior endocarditis or valve has been replaced
80
critical narrowing of mitral stenosis is defined as
less than 1 cm squared of valve surface area but tx still is based on presence of symptoms
81
what heart valve lesion can present with dysphagia and hoarseness?
mitral stenosis can cause LA enlargemend which can press on laryngeal nerve or esophagus
82
diastolic murmur after an opening snap | squatting and leg raising increase intensity
mitral stenosis
83
tx for mitral stenosis
balloon valvulosplasy --> valve procedure only if this fails warfarin for a fib to an INR of 2-3 rate control with digoxin, b blocker, or diltiazem/verapamil diruetics and Na restriction
84
2 causes of aortic stenosis
congenital bicuspid A valve | aging calcifications
85
tx for aortic stenosis?
valve replacement | not valvuloplasty
86
holosystolic murmur, obscuring s1 and s2, radiating to axilla what happens w handgrip?
mitral regurg worsens due to increased backward flow
87
handgrip _____ afterload worsens what 2 murmurs?
increases aortic and mitral regurg
88
best tx for mitral regurg?
ACEi or ARB (decrease rate of progression) replace valve when LV end systolic diameter is >40 mm or ejection fractions is below 60%
89
diastolic derescendo murmur at LLSB , better w handgrip, worse with standing/valsalva, water hammer pulse or head bobbing
aortic regurg
90
when to replace aortic valve?
EF <55% or LVend sys diameter >55mm
91
valsalva and standing make MVP ___ | handgrip and squatting make MVP ___
worse | better
92
2 mur murs that dont increase w expiration
MVP | HOcM
93
systolic anterior motion of the mitral valve and septal Q waves are classic for...
HOCM
94
best initial therapy for both HOCM and HCM
beta blockers
95
tx for HOCM patient with syncope?
implantable defibrillator +/- ablation of the septum --> myomectomy is sx persist
96
which to give in dilated vs hypertrophic cardiomyopathy? ``` beta blockers diuretics acei/arb spironolactone digoxin ```
hcm = betaB and diuretics dilated = all 5
97
handgrip decreases ______ role in hocm?
LV emptying it improves hocm by making the heart fuller which decreases the obstruction
98
diffuse st elevations? whats the more specific finding?
pericarditis PR segment depressions
99
colchicine role in pericarditis tx
it decreases recurrences!
100
best initial test for patient with smooth shiny leg skin and pain in calves on exertion?
best initial test for PAD is ABI (ankle brachial index) normally they are equal (ration =1) or ankle is a little higher due to gravity if ratio is <0.9, then disease is present
101
best initial tx for PAD?
aspirin stop smoking cilostazol (vasidilator; MOST effective drug for PAD)
102
best initial and most accurate tests for aortic dissection?
initial = CXR to look for widened mediastinum most accurate = angiography
103
AAA repair is indicated when width > than???
5 cm
104
what is the worse cardiac disease in pregant woman?
peripartumc ardiomyopathy ( Ab made against myocardium) second worst would be eisenmenger syndrome
105
eisenmenger syndrome
development of a right to left shunt from pulmonary htn person has a VSD with a left to right shunt that reverses with significant pulm htn
106
best tx for pericarditis?
nsaids plus colchicine
107
the high intensity statins?
atorvastatin | resuvostatin
108
mc place for ectopic foci that cause a fib? a flutter?
pulmonary veins a flutter often due to circuit around the tricuspid annulus
109
what risk factor has strongest association with stoke
htn

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