Cardiovascular Flashcards
(106 cards)
1
Q
What is stable angina?
A
chest pain that is predictable, relieved by rest and/or nitroglycerine
2
Q
What is unstable angina?
A
previously stable and predictable symptoms of angina that are more frequent, increasing or present at rest
3
Q
What is prinzmetal variant angina?
A
coronary artery vasospasm causing ST-segmetn elevations, not associated with clot
4
Q
What are premature beats?
A
- PVC: early wide bizarre QRS, no p wave seen
- PAC: abnormally shaped P wav
- PJC: Narrow QRS complex, no p wave or inverted p wave
5
Q
What is paroxysmal supra ventricular tachycardia?
A
narrow, complex tachycardia, no discernible P waves
6
Q
What is atrial fibrillation/flutter?
A
- A-fib: irregularly irregular rhythm with disorganized and irregular atrial activations and an absence of P waves
- A-flutter: regular, sawtooth pattern and narrow QRS complex
7
Q
What is sick sinus syndrome?
A
- Brady-tachy: arrhythmia in which bradycardia alternated with tachycardia
- Sinus arrest: prolonged absence of sinus node activity (absent P waves) > 3 seconds
8
Q
What is sinus arrhythmia?
A
normal, minimal variations in the SA node’s pacing rate in associated with the phases of respiration
-heart rate frequently increases with inspiration, decreased with expiration
9
Q
What is premature ventricular contractions (PVCs)?
A
early wide “bizarre” QRS, no p wave seen
10
Q
What is ventricular tachycardia?
A
three or more consecutive VPBs, displaying a broad QRS complex tachyarrhythmia
11
Q
What is ventricular fibrillation?
A
erratic rhythm with no discernable waves (P, QRS or T waves)
12
Q
What is Torsades de pointes?
A
polymorphic ventricular tachycardia that appears o be twisting around a baseline
13
Q
What is a NSTEMI?
A
ECG changes such as ST-segment depression, T-wave inversion, or both may be present, cardiac markers will be elevated
14
Q
What is a STEMI?
A
myocardial necrosis (evidenced by cardiac markers in the blood; troponin I or troponin T and CK will be elevated) WITH acute ST-segmetn elevation or Q waves
15
Q
What is pericarditis?
A
chest pain that is relieved by sitting and/or leaning forward
16
Q
What is aortic dissection?
A
severe, tearing (ripping, knife-like) chest pain radiating to the back
17
Q
What is pulmonary embolism?
A
dyspnea (most common) and pleuritic chest pain
-spiral CT is the best initial test
18
Q
What is pulmonary hypertension?
A
dyspnea on exertion, fatigue, chest pain, edema, and syncope
- loud P2, systolic ejection click, parasternal lift
- right heart catheterization confirms the diagnosis
- mean pulmonary artery pressure is >25 mmHg at rest (8-20 mmHg at rest is considered normal)
19
Q
What is carditis?
A
(eg rheumatic fever): migratory joint pains, especially in the knees, ankles, and elbows, chest pain/discomfort
- Jones criteria 2 major or 1 major and 1 minor
- increased antistreptolysin O (ASO) titers
20
Q
What is costochondritis?
A
pain with palpation or movement of the arm
21
Q
What are the most common causes of congestive heart failure?
A
CAD, HTN, MI, DM, - LV remodeling: dilation, thinning, mitral valve incompetent, RV remodeling
22
Q
What are the characteristics of congestive heart failure?
A
- exertional dyspnea (SOB), then with rest
- chronic nonproductive cough, worse in a recumbent position
- fatigue
- orthopnea (late), night cough, relieved by sitting up or sleeping with additional pillows
- paroxysmal nocturnal dyspnea
- nocturia
23
Q
What are the signs of congestive heart failure?
A
- Cheyne-stokes breathing: periodic, cyclic respiration
- Edema: ankles, pretrial (cardinal)
- rales (crackles)
- S4 = diastolic HF (ejection fraction is usually normal)
- S3= systolic HF (reduced EF) with volume overload - tachycardia, tachypnea, (rapid ventricular filling during early diastole is the mechanism responsible for the S3)
- jugular venous pressure: >8 cm
- cold extremities, cyanosis
- hepatomegaly ascites, jaundice, peripheral edema
24
Q
What are the laboratories for congestive heart failure?
A
- CBC, CMP, U/A, +/- glucose, lipids, TSH (occult hyperthyroidism or hypothyroidism)
- Serum BNP: increases with age and renal impairment, low in obese, elevated in HF differentiates SOB in HF from non cardiac issues
- 12-lead EKG
- CXR: Kerley B lines
- echocardiogram (BEST TEST): diagnose, evaluate, manage most useful, differentiates HF +/- preserved LV diastolic function
25
What is the New York Heart failure classification?
- Class I (<5%) without any limitation of physical activity
- Class II (10-15%): patients with slight limitation of physical activity, they are comfortable at rest
- Class III (20-25%): patients with marked limitation of physical activity they are comfortable at rest
- Class IV (35-40%): patients who are not only unable to carry on any physical activity without discomfort but who also have symptoms of heart failure or anginas syndrome even at rest
26
What is the tx of systolic left heart failure?
ace inhibitor + beta blocker + loop diuretic
27
What is the tx of diastolic heart failure?
ace inhibitor + beta blocker or CCB (do not use diuretics in stable chronic diastolic failure)
- lasix - for diuresis
- morphine - reduces preload
- nitrates (NTG) - reduce preload O2
- ACE inhibitor + diuretic (unless contraindicated)
- CCB in diastolic HF
- poor prognosis factors: chronic kidney disease, diabetes, lower LVEF, severe symptoms, old age
- 5-y mortality: 50%
28
What is primary cause of ischemic heart disease?
atherosclerotic occlusion of the coronary arteries
29
What are the major risk factors for coronary artery disease?
- diabetes mellitus (most important and considered a CAD equivalent)
- smoking (#1 preventable factor - cuts risk by 50%)
- hypertension
- high cholesterol/hyperlipidemia (total cholesterol - HDL ratio <5.0)
- family history
- age >45 men, >55 women
- minor risk factors include: obesity, lack of estrogens, homocystinuria, cocaine use, amphetamine use
30
What are the systems of coronary artery disease?
range form asymptomatic (particularly in older women and diabetes) to substernal tightness and/or pain and shortness of breath
31
What are the characteristics of stable angina?
- predictable; presents with a consistent amount of exertion
- the patient can achieve relief with rest or nitroglycerin
- indicative of a stable, flow-limiting plaque
32
What is unstable angina?
- unpredictable; often presents with rest
- defined as any new angina or rapidly worsening stable angina
- limited improvement with nitroglycerin, and usually recurs soon afterward
- indicative of a ruptured plaque with subsequent clot formation in the vessel lumen
33
What is the physical exam findings of coronary artery disease?
- mitral regurgitation murmur and/or S4 during episodes
- may also include signs of CHF from prior MI including elevated JVD, lower extremity edema, and crackles
- other signs of vascular disease including bruits, ischemic ulcers, and diminished pulses
34
How is coronary artery disease dx?
- cardiac catheterization for definitive diagnosis: locate and assess the severity of the lesion (s)
- CXR: to rule out aortic dissection
- Elevated cardiac biomarkers: troponin, CK, and/or CK-MB may be present
- EKG shows ST elevation or depression depending on the severity of ischemia and Q waves
- stress-testing to evaluate simultaneously with EKG, echo, and radionuclide perfusion studies
35
What is the tx for acute coronary syndrome?
- morphine
- oxygen
- nitroglycerin
- aspirin
- ACEIs
- may also use beta-blockers, GPIIb/IIIa antagonists, angioplasty
36
What are the drugs that improve post-MI mortality rates?
- aspirin
- beta-blockers
- ACEIs
- ARBs
- and HMG-CoA reductase inhibitors
- NOT calcium channel blockers
37
What is the prognosis, prevention, and complications of coronary artery disease?
- must control diabetes - considered a CAD equivalent causing MI to often present atypically in these patients
- manage hypertension (<140/90 mmHg)
- manage cholesterol levels (LDL <70 mg/dL)
- encourage smoking cessation and alcohol abstention
- MI prevention with aspirin or clopidogrel (for ASA sensitivities)
- angina prevention with beta-blockers to lower HR, increase myocardial perfusion time and decrease cardiac workload
- nitrates + calcium channel blockers in severe or recurring cases
38
Who should routinely get aspirin?
USPSTF recommendations
- adults aged 50 to 59 years with >10% 10-year CVD risk (grade B)
- adults aged 60 to 69 years with >10% 10-year CVD risk (grade C)
- persons in this age group who are not at increased risk of bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit
39
What is endocarditis?
inflammation of the lining or valves of the heart caused by the presence of bacteria in the bloodstream, typically introduced via dental or medical procedures in the mouth, intestinal tract or urinary tract
40
What are the symptoms of endocarditis?
fever and a new-onset heart murmur
41
What is acute bacterial endocarditis?
infection of normal valves with a virulent organism (S. aureus)
42
What is subacute bacterial endocarditis?
indolent infection of abnormal valves with less virulent organisms (S. viridians)
43
What is the bacteria that caused endocarditis with intravenous drug users?
staphylococcus aureus
44
What is the bacteria that causes endocarditis with prosthetic valve?
staphylococcus epidermidi
45
What is the Duke's Criteria?
Definite: 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria
Possible: 1 major and 1 minor criterion, or 3 minor criteria
Major:
-blood cultures: S. aureus, S. viridians, S. Boris or other typical species x 2, 12 hours apart
-drug users: staphylococcus, non-drug users: streptococcus
-echocardiogram: vegetations are seen (tricuspid - IV drug users, mitral-non drug users)
-New regurgitant: murmur
Minor
-risk factors, fever 100.5, vascular phenomena (splinter hemorrhages, Janeway lesions: painless, palms and soles), immunologic phenomena (Osler node: raised painful tender; Roth spots: exudative lesions on the retina)
46
What are the classic signs of infective endocarditis?
- Osler's nodes - tender "ouchy" nodules
- Janeway lesions - painless macules
- roth spots on the retina
- splinter hemorrhages on the nail bed
- clubbing
47
What is the tx of endocarditis?
- Empiric treatment: IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
- prosthetic valve: add rifampin
- high-risk patients prophylaxis for procedures: Amoxicillin - 2 g 30-60 minutes before procedure
48
How is primary hypertension defined?
a resting systolic BP >130 or diastolic BP >80 on at least two readings on at least two separate visits with no identifiable cause
49
What is ACC/AHA classification of BP?
-normal: <120/80 mmHg and <80 mmHg
-elevated: 120-129 mmHg and <80 mmHg
-stage 1: 130-139 mmHg or 80-89 mmHg
-stage 2: >140 mmHg or >90 mmHg
JNC 8 hypertension definitions nota dress but tx threshold defined
50
For children between 1 and 13 year of age what is normal BP?
both systolic BP (SBP) and diastolic (DBP) <90th percentile
51
For children between 1 and 13 year of age what is elevated BP?
SBP and/or DBP >90th percentile but <95th percentile or 120/80 mmHg to <95th percentile (whichever is lower)
52
For children between 1 and 13 year of age what is stage 1 hypertension?
SBP and/or DBP >95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower)
53
For children between 1 and 13 year of age what is stage 2 hypertension?
SBP and/or DBP >95th percentile + 12 mmHg or >140/90 mmHg (whichever is lower)
54
What are ACC/AHA blood pressure targets?
- target blood pressure: <130/80
| - targets for patient with comorbidities: <130/80
55
What are JNC 8 tx targets?
- reduce BP to <140/90 mmHg for everyone <60 including those with a kidney disorder or diabetes
- reduce BP to <150/90 mmHg for everyone > 60
56
What are tx guidelines for normal bp?
evaluate yearly and encourage healthy lifestyle changes
57
What are the tx guidelines for elevated bp?
recommend healthy lifestyle changes and reassess in 3-6 months
58
What is the tx guidelines for stage 1?
assess ten-year risk using ASCVD risk calculator
- if risk <10% start healthy lifestyle management and reassess in 3-6 months
- if risk >10% or CVD, DM, CKD - lifestyle mod + 1 medication - reassess in 1 month
- if goal met after 1 month - reassess 3-6 months
- if goal not met after 1 month, consider different med or titrate
- continue monthly follow-up until goal achieved
59
What is the tx guidelines for stage 2?
health lifestyle + 2 BP-lowering medications
- if goal met after 1 month - reassess in 3-6 months
- if goal not met after 1 month, consider different med or titrate
- continue monthly follow-up until goal achieved
60
For non-black patients, including those with diabetes what should the initial treatment be?
- ACE inhibitor or ARB
- long-acting calcium channel blockers (most often a dihydropyridine such as amlodipine)
- or a thiazide-like diuretic (chlorthalidone or indapamide)
- for stage 2 HTN: the recommendation is
- 2 BP-lowering medications of different classes
61
For black adults what tx is recommended?
2 or more medications are recommended to achieve a target of less than 130/80 mmHg
-thiazide-type diuretics and/or calcium channel blockers are more effective in black adults at lowering BP alone or in multi drug regimens
62
Some antihypertensive are contraindicated or indicated in certain disorders
- CBC's for angina pectoris
- ACEI or ARB for diabetes with proteinuria
- ACE inhibitors are associated with cough, angioedema and can cause hyperkalemia, they are contraindicated in pregnancy
- spironolactone can cause hyperkalemia
- beta blockers contraindicated in asthma and may cause impatience
- CCB cause leg edema
- verapamil and diltiazem are rate control CCBs
- alpha-blockers treat HTN and BPH
- hydralazine may cause lupus-like syndrome and can cause pericarditis
63
What is hypertensive emergency?
BP usually >180/120 with impending or progressive end-organ damage
64
What is hypertensive urgency?
BP usually >180/120 without signs of end-organ damage
65
What is malignant HTN?
diastolic reading >140 associated with papilledema and either encephalopathy or nephropathy
66
What is the tx of hypertensive emergency?
sodium nitroprusside (drug of choice)
67
What is the tx of hypertensive urgency?
clonidine (drug of choice)
68
What is malignant hypertension?
hydralazine
69
What are the screening guidelines for hyperlipidemia?
- USPSTF recommends screening for patients with NO evidence of CVD and NO other risk factors should begin at 35 years of age
- NCEP recommends screening all adults at age 20 years regardless of risk factors
70
Who are the four groups most likely to benefit from statin therapy?
- patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
- patients with primary LDL-C levels of 190 mg per dL or greater
- patients WITH diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
- patients WITHOUT diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk >7.5%
risk assessment for 10-year and lifetime risk is recommended using an updated ASCVD risk calculator
71
What are the treatment targets for hyperlipidemia?
there are no recommendations for or against specific target levels LDL-C or non-HDL-C in the primary or secondary prevention of ASCVD
72
What are the lipid goals for LDL?
<100 optimal
100-129 near-optimal
130-159 borderline high
160-189 high
73
What are the lipid goals for total?
<200 desirable
200-239 borderline high
>239 high
74
What are the lipid goals for HDL?
>60 protective
41-59 borderline
<40 at risk
75
What is high-intensity statin therapy?
- daily dosage lowers LDL-C by approximately >50% on average
- atorvastatin (lipitor), 40 to 80 mg
- rosuvastatn (crestor), 20 (40) mg
76
What is moderate-intensity statin therapy?
- daily dosage lowers LDL-C by approximately 30% to 50% on average
- atorvastatin, 10 (20) mg
- rosuvastatin, (5) 10 mg
- simvastatin (Zocor), 20 to 40 mg
- provastatin (pravachol), 40 (80) mg
- lovastatin (mevacor), 40 mg
- fluvastatin XL (lescol XL), 80 mg
- fluvastatin, 40 mg twice daily
- pitavastatin (livalo), 2 to 4 mg
77
What is low-intensity statin therapy?
- daily dosage lowers LDL-C by <30% average
- simvastatin, 10 mg
- pravastatin, 10 to 20 mg
- lovastain, 20 mg
- fluvastatin, 20 to 40 mg
- pitavastatin, 1 mg
78
What is dx of hypertriglyceridemia?
obtain fasting lipid panel beginning at age 20 and repeated every 5 years
- normal <150 mg/dL
- mild hypertriglyceridemia 150 to 499 mg/dL
- moderate hypertriglyceridemia 500 to 866 mg/dL
- very high or severe hypertriglyceridemia 886 mg/dL
79
What is the tx of hypertriglyceridemia?
- triglyceride level should be reduced to <500 mg/dL to prevent this pancreatitis
- isolated triglycerides are treated with fibrates (gemfibrozil and fenofibrate and niacin
- omega-3 fatty acids
- statins have a modest triglyceride- lowering effect (typically 10 to 15%) and may be useful to modify cardiovascular risk in patietns with moderately elevated triglyceride levels
- however, they should not be used alone in patients with severe or very severe hypertriglyceridemia
- niacin may cause hyperglycemia so caution in patients with DM
- flushing treated with daily aspirin, will have a beneficial effect on HDL cholesterol
80
What are the effects on lipids and side effects of statin?
- Lipitor 10-80 mg
- triglyceride reduction 20-40%
- LDL 18-55%
- HDL 5-15 increase
- side effects: myopathy, rhabdomyolysis, increase LFTs
81
What are the effects on lipids and side effects of fibrates?
- Fenofibrate (tricor) 48-145 mg daily/gemfibrozil (lopid) 600 mg BID
- triglyceride reduction 40-60%
- LDL 5-30% increase
- HDL 15-25
- side effects: rhabdomyolysis espeically with a gemfibrozil + statin combo
82
What are the effects on lipids and side effects of niacin?
- OTC IR -.5-2 g BID-TID/OTC SR 250-750 QD-BID/Niacin 500 mg - 2 g QHS
- triglyceride reduction 30-50%
- LDL 5-10% increase
- HDL 5-10
- side effects: flushing, worsening glycemic control, increase LFTs (worse with SR niacin)
83
What are the effects on lipids and side effects of fish oil 2-4 g total EPA/DHA daily?
- OTC 3 capsules daily/Omacor 1-2 g BID
- triglyceride reduction 30-50%
- LDL 5-10% increase
- HDL 5-10
- side effects: fishy aftertaste, gastrointestinal upset
84
What are the pearls of intermittent claudication?
occurs distal to the level of stenosis or occlusion
-dull, aching pain calf pain with walking
-aggravated by exercise
-relieved with rest (usually within 10 minutes)
-cramping
-numbness, weakness, giving way
Physical
-hair loss lower extremities
-thinning of skin
-diminished pulses
85
How is intermittent claudication diagnostics?
an ankle-brachial index (ABI), which uses Doppler measurements to compare the BP in the upper and lower extremities, is a highly sensitive and specific test
- an ABI of <0.9 indicated significant disease
- angiography remains the gold standard
86
What is the tx for intermittent claudication?
```
Stop smoking first line
-graduated exercise - walk to point of claudication, rest, then continue walking
-control HTN, DM, weight
-ASA + clopidogrel
-cilostazol
Surgery
-angioplasty
-bypass grafting
```
87
What are the pearls of asymptomatic PAD?
Screen patients with abnormal or absent pedal pulse
- age > 70
- ages 50-69 with a history of smoking or DM
88
What is the diagnostics of asymptomatic PAD?
- asymptomatic
- screen with ABI
- <0.9 diagnostic
- 0.91 -1.3 normal, no further testing
89
What is the tx of asymptomatic PAD?
preventive treatment: ASA, lipid-lowering, blood pressure control
90
What are the pearls of PAD or PVD?
- occlusive atherosclerotic disease of lower extremities (noncardiac vessels)
- sites: superficial femoral artery (most common), popliteal, aortoiliac
- risk factors: smoking, hyperlipidemia, DM, HTN
- pain in one or more lower extremity muscle groups
- cramping of thigh, calf, or buttocks
- intermittent claudication
- rest pain - prominent at night (wakes the patient up)
- Diminished or absent pulses
- muscle atrophy
- hair loss
- thick toenails
- pallor
91
What is the diganostics of PAD or PVD?
Lipids: hypercholesterolemia >240, hypertriglyceridemia >250
- ankle: brachial index (ABI) testing
- if <0.90 (diagnostic)
- doppler: reduced or interrupted flow
- arteriography (gold standard)
92
What is the tx of PAD or PVD?
-prevention of atherosclerosis control HLD, HTN, weight, DM
-manage primary hyperlipidemia: statins, diet, exercise
-graduated exercise: walk to point of claudication, rest, then continue walking
-footcare
-reduce BP
-stop smoking
-most important medical intervention:
-ASA + ticlopidine or clopidogrel (symptomatic relief)
-cilostazol (PDE inhibitors)
Surgery
-angioplasty (preferred)
-adjunctive stenting
-bypass grafting
93
What are the characteristics of a diastolic murmur?
- almost always indicates heart disease
- these are two basic
- early decrescendo diastolic murmurs signify regurgitant flow through an incompetent semilunar valve, more commonly aortic
- rumbling diastolic murmurs in mild or late diastole suggest stenosis of an atrioventricular valve, most often mitral
94
What is aortic regurgitation?
- diastolic murmur
- soft high pitched, blowing diastolic murmur along LSB with patient sitting, leaning forward after exhaling
- maneuver: sitting leaning forward
- chestpiece position: Erbs-point
- chestpiece: diaphragm
95
What is mitral stenosis?
diastolic low-pitched decrescendo and rumbling with opening snap at the apex
- maneuver: supine left side down
- chestpiece position: mitral
- chestpiece: bell
96
What is pulmonary regurgitation?
high pitch, decrescendo murmur at LUSB, increases with inspiration
- left upper sternal border (LUSB)
- maneuver: sitting leaning forward
- position: pulmonic
- chestpiece: diaphragm
97
What is tricuspid stenosis?
mid diastolic rumbling at LLSB with opening snap
- lower left sternal border (LLSB)
- maneuver: supine
- position: tricuspid
- chestpiece: bell
98
What are midsystolic murmurs?
- midsystolic (ejection) murmurs are the most common kind of heart murmur they may be
- pathologic (secondary to structural cardiovascular abnormalities)
- physiologic (secondary to physiologic alteration in the body)
- innocent (not associated with any detectable physiologic or structural abnormality)
- midsystolic murmurs tend to peak near mid systole, and usually stop before S2
- the crescendo-decrescendo shape is not always obvious to the ear, but the gap between the murmur and S2 helps to distinguish midsystolic from pansystolic murmurs
99
What is aortic stenosis?
systolic ejection crescendo-decrescendo RUSB
- manuever: sitting
- chestpiece position: aortic (RUSB)
- chestpiece: diaphragm
100
What is pulmonic stenosis?
harsh midsystolic ejection crescendo-decrescendo murmur with widely split S2 at LSB that radiated to the left shoulder and neck
- maneuver: supine
- chestpiece position: tricuspid
- chestpiece: bell
101
What is hypertrophic cardiomyopathy?
medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining
- S4 gallop and apical lift with a thick, stiff left ventricle
- maneuver: supine
- chestpiece position: mitral
- chestpiece: diaphragm
102
What is mitral valve prolapse?
midsystolic ejection click at apex
- maneuver: supine
- position: mitral
- chestpiece: diaphragm
103
What is a pansystolic (holosystolic) murmurs?
are pathologic
- they are heard when blood flows from a chamber of high pressure to one of lower pressure through a valve or other structure that should be closed
- the murmur begins immediately with S1 and continues up to S2
104
What is mitral regurgitation?
blowing holosystolic murmur at apex with a split S2
- maneuver: supine
- chestpiece position: mitral (apex)
- chestpiece: diaphragm
105
What is tricuspid regurgitation?
high pitched holosystolic murmur at mid LSB
- maneuver: supine
- position: tricuspid
- chestpeice: diaphragm
106
What is ventricular septal defect?
harsh holosytolic murmur heard best at the LSB with wide radiation and a fixed, split S2
- maneuver:supine
- chestpiece position: tricuspid (LLSB)
- chestpiece: diaphragm
