Cardiovascular Exam 2 Cards Flashcards
(223 cards)
1
Q
Tunica intima
A
Innermost layer of the artery - elastic and subendothelial layer
2
Q
Artery endothelium
A
Inner lining of tunica intima - clot resistant
3
Q
Tunica media
A
Vasoconstriction - muscle layer
4
Q
Tunica externa
A
Connects arteries to other tissues
5
Q
Atherosclerosis
A
Walled off fatty streaks in the arteries
6
Q
6 steps od atherosclerosis
A
Fatty streak
Fibrous cap
Disruption of vaso vasorum (nevascularization)
Fibrous plaque (muscle tissue
Advanced lesion
Interplaque hemorrhage
7
Q
Foam cells
A
Macrophages that engulf LDL that accumulate into fatty streak and attracts T cells
8
Q
Stable plaque
A
Chest pain on exertion
9
Q
Unstable plaque
A
Chest pain non exertion dependent
10
Q
What makes a plaque more unstable
A
Hemorrhage inside plaque and thin walls
Vaso vasorum makes the plaque grow
11
Q
Positive remodeling
A
Increase in vessel size, makes the plaque less stable
12
Q
Negative remodeling
A
Results in vessell shrinkage causing more stability
13
Q
NUmber of heart attacks that are silent
A
1 in 5
14
Q
Two groups with abnormal heart attack presentation
A
Women and diabetics
15
Q
6 CHD risk equivalents
A
Clinical CHD
Symptomatic carotid artery disease
PAD
AAA
Diabetes
CKD
16
Q
4 Statin benefit groups
A
Clinical ASCVD
LDL greater than or equal to 190 mg/dL
40-75 with DM and LDL 70 to 189
40-75 with 10 year ASCVD risk over 7.5%
17
Q
2 high intensity statins
A
Atorvastatin and Rosuvastatin
18
Q
AAA screening guidlines
A
65-75 who have smoked - B
19
Q
Aspirin use guidlines
A
Class C for 40-59 in 10+% risk - need to assess for bleed risk
20
Q
Prediabetes screening
A
Can screen in 35-70 - B
21
Q
2 populations with abnormal MI presentations
A
Women and diabetics
22
Q
Percent of population that has had an MI
A
3-4% of population
23
Q
How fast a patient needs to get to the cath lab
A
90 minutes from start to finish
30 minutes from diagnosis
24
Q
MCC of MI
A
Atherosclerosis
25
Unstable angina
Pain at rest
26
Stable angina
Pain with exertion
27
Prinzmetal angina
Spasm of coronary vessels - more common in women
28
STEMI
Entire tissue effected - entire blockage
29
NSTEMI
Smaller amount of tissue effected - blood flow partially occluded
30
Acute coronary syndrome
Unstable angina or STEMI/NSTEMI
TIME is TISSUE
31
Ischemia
Occurs when there is any lack of blood flow - causes pain
32
Injury
Prolonged ischemia damages cells but some are able to heal and work again
33
Infarct
Complete cell death, irreversible injury, akinesis on echo
34
Subendocardial infarction
Piece of tissue on the inside - not as serious
35
Transmural infarction
Very concerning - infarct all the way through heart wall
36
EKG signs of an NSTEMI
ST depression and T wave inversion
37
STEMI on EKG
ST elevation with a Q wave beginning to develop
38
Type 1 MI
Caused by a plaque or other atherosclerosis
39
Type 2 MI
Secondary to ischemia - increased oxygen demand or decreased supply d/t spasm or hypotension
40
Type 3 MI
Sudden cardiac death
41
Type 4 MI
Have already had a stent or angioplasty
42
Type 5 MI
Associated with Coronary artery bypass graft (CABG)
43
Myocardial stunning
Heart stops contracting to save its tissue and comes back when it is reperfused
44
Hibernating myocardium
Result of prolonged reduction in blood flow leads to non-beating of select tissue - MUGA scan reveals the tissue is still alive
45
Widowmaker
LAD coronary artery block
46
Right coronary artery
Marginal - posterior heart
Posterior Descending
SA and AV nodes
Left Ventricle
47
Left coronary artery
Circumflex - lateral
Anterior descending - interventricular septum
48
Area and ECG leads for right coronary artery
II, III, aVF - inferior heart and right ventricle
49
Area and ECG leads for Posterior descending coronary artery
Posterior wall
50
Area and ECG leads for Left anterior descending coronary artery
Septal wall, Anterior wall and LV - V1-4
51
Leads and and area for Left coronary artery (LCX)
Lateral wall - I, aVL, V5, V6
52
Typical MI chest pain
Male 50+, Femaile 60+
Center of chest
Heavy
L shoulder radiation, etc
Sudden and constant - 2-5 minutes
53
Alleviating/Aggravating factors in MI
Alleviating - NTG, rest
Aggravating - Activity, morning, sex, cotisol, cold
54
PE of heart attack patient
May have non - gray, diaphoretic, sick LOOKING patient, not normal appearance
55
Substance that can cause chest pain
Cocaine
56
First line tests for chest pain
EKG +/- cardiac biomarkers
Good to have a baseline EKG
57
TIMI risk score
Assess likelihood that they are having an MI - risk of becoming a STEMI
58
TIMI risk score interpretation
0-2 Low risk
3-4 Intermediate risk
5+ High risk
59
Seven TIMI risk factors
Age over 65
3+ CAD risk factors
Prior CAD
Aspirin use in past seven days
Severe angina - 2+ events in 24 hours
ST deviation on EKG over .5mm
Elevated cardiac biomarkers
60
5 categories for HEART score
Hx
ECG
Age
Risk factors
Troponin
61
HEART score interpretation
0-3 discharge
4-6 observe
7-10 admit
0,1, or 2 for each parameter
62
History heart score levels
0 - Nonspecific or not concerning for ACS
1 - Mixed typical and atypical presentation
2 - Traditional features of ACS
63
EKG heart score levels
0 - Normal EKG
1 - EKG with repolarization abnormalities but without ST depression
2 - With ST depression or elevation not formerly present
64
Age heart score levels
0 - Under 45
1 - 45-65
2 - 65+
65
Risk factors heart score levels
0 - No risk factors
1 - 1-2 risk factors
2 - 3+ risk factors or documented atherosclerotic disease
66
Troponin heart score levels
0 - At discriminative level, Under .04 ng/mL AccuTroponin
1 - 1-3 times discriminative level, .04-.12 ng/mL AccuTroponin
2 - 3+ times discriminative level, .12+ ng/mL AccuTroponin
67
First test for patient with chest pain and when it should be done
EKG within 10 minutes
68
Serial EKG monitoring
If normal but you suspect
Do at 15-30 minute intervals for first two hours
69
Earliest EKG finding for ACS
Peaked T waves
70
Later EKG findings for ACS
ST elevation in 2+ contiguous leads
71
Evolution of STEMI after ST elevation
Q wave develops
T inverts it and then normalizes
72
3 Cardiac enzymes
Myoglobin
CK-MB
Troponins - Are the best!!
73
Step 2 for chest pain workup
Cardiac enzymes - not needed if ST elevations seen
74
Serum troponin trends
Increase in 3-6 hours
Peak 24-48 hours
Take 5-14 days to return to baseline
Repeat 3 times to ensure intervention is working
75
CK-MB
Less sensitive and specific than troponins
Increase 4-8 hours
Peak 24 hours
Normal 2-3 days later
Positive if over 5%+ of total CK
76
Creatine kinase isoenzymes
CK-BB - Brain/Lungs
CK-MB - Heart
CK/MM - Muscles
77
Myoglobin and LDH
Most sensitive early marker for an MI
Used if they are presenting early
78
2 ways to do a stress test and qualifications for one
Exercise or pharm - need to be able to walk for 5 minutes or climb two flights of stairs
Usually for young women with atypical symptoms
79
Absolute CIs for Stress test
Drop in SBP
Severe angina
V Tach
ST elevation over 1 mm
80
Relative CIs of stress test
Fatigue
Other EKG changes
81
3 things that make a stress test hard to perform
WPW syndrome
Ventricular rhythm
ST depression at rest
LBBB
82
Vasodilators for stress test
Adenosine
Dipyridamole
Regadenoson
Cause flushing, metallic taste, SOB
83
Adrenergic stimulating agents for stress test
Dobutamine - similar symptoms
Use for those with asthma
84
Definitive MI procedure
Coronary angiogram - gets done a lot in real life - very invasive
85
Prep for coronary angiogram
NPO for 4-6 hours
IV fluids to flush dye
No metformin 48 hours prior
86
Treatment of Aneurysmal CAD
Harder to treat than single blockage - may use CABG
87
Ventriculogram
Inject dye into LV - Helps estimate ejection fraction
88
Indications for coronary angiograms
Life limiting stable angina
High CAD likelihood
Sudden death/Arrhythmia
Valvular problems
STEMI
89
Risks of coronary angiogram
Femoral aneurysm
AKI
90
Troponins in unstable angina
May be negative
91
Admission orders for ACS
Telemetry, bedrest, Oxygen to keep sats at 95% IF NEEDED, Nitrates (.4 mg x 3) and ASA chewed(162-325)
92
Other drugs for ACS
Morphine
Beta blocker - if not brady or heart block
ACEI
Must be started on statin w/in 48 hours
93
Repurfusion goals for ACS
Door to baloon (stent) - 90 minutes
Door to needle (thrombolysis) - 30 minutes
94
CI and SE of nitroglycerin
Right ventricular infarct - preload issue
Can cause headache and other hypotensive symptoms will begin to tolerate
95
Longer acting nitros
Isordil or Imdur
96
Long term aspirin dose
81 - no benefit with increase
97
P2Y 12 inhibitors for ACS
Clopidogrel - Not as good as the other two
Prasugrel
Ticegrelor
Need to stop for 5 days for CABG
MUST have alongisde ASA treatment
98
Glycoprotein inhibitors that can be added for ACS
Tirofiban
Eptifibatide
Abciximab
May be considered in high risk patients
99
Indirect thrombin inhibitors for ACS
May add heparin if allergic to ASA
Angiomax is DIRECT and an add on
100
Beta blockers for ACS
Metoprolol
Carveidolol
Should be started within 24-48 hours
CI in CHF, Heart block, Hypotention
101
Ranexa
Ranolazine
For stable angina to decrease calcium load -can be used with viagra
No effect on BP
QT prolongation
102
Contraindications for ACEI
Angioedema
COPD - be mindful
103
Target INR for warfarin w/out mech valve
2-3
104
CCB for ACS
Third line after beta blocker, Nitro, ASA, ARB - can cause HF without BB
105
Fibrinolytic use for ACS
tPA/Altepase
Only for a STEMI when PCI is not available
Risk of brain bleed
Use a PPI/H2 blocker to avoid gastric ulcers
106
Absolute contraindications to fibrinolytic therapy
Prior intercranial hemorrhage
Known malignant intercranial neoplasm
Stroke in the past 3 months
Head or facial trauma in past 3 months
107
Therapy for post-PCI
Dual antiplatelet therapy ASA and P2Y12 antagonist - longer if a med elluding stent for 3-12 months
108
Athrectomy
Roto-routering the artery
109
How to tell prinzmetal from blockage
Must do PCI to be sure - patient usually does not have risk factors. Early morning occurence and more in females
110
Pharm for prinzmetal angina
Nitrates and CCBs (diltaezem and amplodipine) Beta blockers are NOT first line
111
Post MI complications
Ischemia
Mechanical
Arrhytmic
Embolic
Inflammatory
112
Dressler's syndrome
Potentiall immune response that damages the endocardium
113
Right ventricular infarct
1/3 inferior wall infarctions
Hypotension, ascites, JVD
Give fluids
114
Post MI VSD
Rupture between L and R ventricles
Holosystolic murmur
Becomes a problem if there is a right to left shunt
115
Pappillary muscle rupture
MI complication - mitral valve regurg
116
LV aneurysm
Outpouching - space for blood to clot in
117
Post MI discharge
3-5 days after for MOST patients
118
Post MI patient education
Lifestyle modifications
Med compliance
Need clearance for work, driving (1 wk) sex (6 wk - need to be symptom free)
119
SSRI that prolongs QT
Escitalopram (Lexapro)
120
Systolic dysfunction
Decrease in myocardial contractility
121
Diastolic cardiac dysfunction
Decrease in LV relaxation and filling
122
Myocarditis
Infectious or non-infectious etiology leading to necrosis, dysfunction, and dilated cardiomyopathy
123
2 mechanisms that can lead to myocarditis
Host mediated and autoimmune mediated
124
4 infectious causes of myocarditis
Adenovirus
Coxsakie virus
CMV
COVID
125
3 noninfectious causes of myocarditis
Alcohol
Anthracyclines
Cocaine
126
Epidemiology of myocarditis
Patients 20-50
Higher mortality in men
127
Pericardial friction rub
Heard best leaning forward
Like rubbing a baloon
128
BNP red flag
Over 100 for tissue injury
129
Indication for endomyocardial biopsy
Unexplained problematic changes - gold standard but don't use a lot
130
Treatment for myocarditis
NSAID, Arrhythmia management, ACEI
131
Treatment for non-infectious myocarditis
Stop agent, treat when symptomatic
132
3 Types of cardiomyopathy
Hypertrophic
Dilated
Restrictive
133
Dilated cardiomyopathy menumonic
Alcohol
Berberi (wet)
Coxsackie
Cocaine
Chagas
Doxyrubicin
134
Presentation of dilated cardiomyopathy
Pulsus alternans
135
Diagnosis of dilated cardiomyopathy
Echo and BNP
136
Treatment for dilated cardiomyopathy
Heart transplant
Defibrilator implant
137
Restrictive cardiomyopathy
Non-dilated ventricle with diastolic dysfunction - fibrotic with atrial enlargement
138
Causes of restrictive cardiomyopathy
Sarcoidosis
Fabry or Hemochromatosis
Usually from chest radiation
139
Hypertrophic cardiomyopathy
Typically genetic issue
Buildup of myocytes in the heart septum
Outpouching of septum blocks the aortic valve
Look for on a sports physical - more pronounced with valsalva
140
Management of hypertrophic cardiomyopathy
Avoid volume depletion
Beta blockers or Verapamil - NO DIURETICS
Septal myectomy or alcohol ablation
Screen 1st degree relatives
141
Diagnosis for ischemic cardiomyopathy
Tissue akinesis on an echo - tissue that does not move
142
Left ventricular wall that is concerning for hypertrophic cardiomyopathy
Greater than 1.5 cm
143
Fatty infiltration of the heart
Causes arrhythmogenic cardiomyopathy -genetic. Non-compacted myocardium
144
Stress induced cardiomyopathy
Broken heart syndrome - develops acutely
Left ventricular apical ballooning on echo
145
When do we want to do a stress test
To catch symptoms we aren't seeing on an EKG that we aren't currently seeing
146
Preserved ejection fraction
60%+
147
Reduced ejection fraction
Under 40%
148
5 year survival rate for heart failure
50%
149
Readmission rate for heart failure
20-25% at 60 days
50% at 6 months
150
Acute heart failure
Symptoms began in the last few days
151
Chronic heart failure
Long term symptoms with worsening fatigue/dyspnea
152
High out put HF
Heart is unable to meet the peripheral needs - anemia, sepsis
153
Low output heart failure
Heart can't get enough blood out
154
Uncertain ejection fraction
40-50%
155
Diastolic heart failure
Can't get enough blood into the ventricle - HFpEF
156
MCC of right sided heart failure
Left sided heart failure
Also possible with a pulmonary problem
157
NYHA criteria
CAN CHANGE over time
I - No limitation of activity w/ no symptoms
II - Slight limitation and symptoms with ordinary activity
III - Marked limitation of physical activity with less than ordinary symptoms
IV - Symptoms at rest
158
AHA stages of heart failure
Cannot change over time - only get worse
A - Risk factors without structural heart failure
B - Structural heart disease with s/s of HF
C - Structural heart failure with prior or current symptoms
D - Refractory heart failure with difficulty functioning
159
2 positive chronotropic agents
Atropine
Beta agonists
160
2 negative chronotropic agents
Slow heart rate
Beta blockers
Non-DHP CCBs
161
Arterial vasodilators for heart failure
Nitrates
Hydralazine
162
First physiological response to low CO
SNS stimulates increased HR and contractility (BB reverse) and sodium resorption to retain water (Diuretics reverse)
163
ADH and HF
increased ADH and Thirst b/c of low baroreceptor response
Hyponatremia can result
164
ANP and BNP
ANP - from atria w/ shorter half life
BNP - from ventricles with higher half life
165
Preload
Venous return and end diastolic volume
166
Afterload
Aortic impedence going out of the heart
167
Assessing edema
Start distally and work your way up
168
Grade for pitting edema
Gradex2mm
169
Something to watch for in scrotal edema
May need catheter for urinary retention
170
Pulsus alternans
Pathognomic for LV heart failure
171
Gallops and heart failure
S3 with systolic
S4 with diastolic
172
Purpose of diagnostics for HF
Usually not to diagnose but to determine CAUSE
173
CXR for HF
Cardiomegaly over half
Kerley B lines
Diffuse infiltrates not likely d/t pneumonia
174
Kerley B lines
Horizontal lines on the periphery of the lungs
175
BNP for heart failure
High negative predictive value - if they don't have it, no HF
Get a level with exacerbation
Gives an idea of fluid load - not to monitor treatment
176
BNP interpretation
Under 100 - unlikely
100-500 - Possible
500+ CHF very likely
177
NT - Pro-BNP interpretation
Has a longer half life than BNP
Under 300 - Unlikely
300-1800 - Possible
1800+ - CHF very likely
178
Troponins
Significant elevation indicates ischemia
Can also be elevated in chronic HF because of ongoing injury and remodeling
179
Class I indication
Is recommended/indicated, considered negligent not to use
180
Class IIa indication
Should be considered - evidence is in favor of efficacy
181
Class IIb indication
May be considered - efficacy is less well established
182
Class III indication
Is NOT recommended, not useful or effective and may cause harm
183
Goal of heart failure treatment
Likely not able to completely reverse - goal is to alleviate s/s - most recommendations geared towards HFrEF
184
BNP echo thresholds
pro-BNP over 125
BNP over 35
185
Follow up for stable CHF patients
Every 1-6 months depending on comoebid conditions
186
Rule of 2s
No more than 2 grams of fluid and 2 Liters of fluid per day
187
Class I recommendationfor HFpEF
Diuretics as need - Thiazide (HCTZ, Metolazone, Chloorthalidone IV) or loop (Furosemide, Turosemide, Bumetanide)
CHECK RENAL FXN AND K+
Monitor weight!
188
Potassium for lasix rule
10 mE K+ for 20mg of lasix
189
Class IIa recommendation for HFpEF
SGLT2i - Jardiance (end in -flozin) regardless of DM status
190
Class 2b recommendations for HFpEF
ARNi
MRA
ARB
191
5 Lifestyle modifications for CHF
Tobacco and alcohol cessation
Sodium restriction
Daily weight monitoring
Weight loss in obese patients
Increase exercise
192
Class I recommendations for HFpEF - first line
MUST BE Stage C
ARNi in NYHA II-III, ACEi/ARB in II-IV
BB
MRA
SGLT2i
Diuretics as needed
193
Class I recommendations for HFpEF second line
Hydralazine (esp. if african american)
ICD
CRT
194
Class I third line recommendations
Durable MCS
Cardiac Transplant
Palliative care
195
ACEi's and ARBs for HFrEF
Enalapril, Captopril, Lisinopril
Watch renal fxn and K+
Watch for cough or angioedema
Preferred over ACEi
May change to ARB if not tolerated IIa or add one if aldosterone antagonist is CI IIb
DO NOT combine ACE+ARB+Aldosterone antagonist III
196
Beta blockers for HFrEF
Carvedolol, Metoprolol succinate, Bisoprolol
197
Aldosterone antagonist for HFrEF
Spironolatone and Eplerenone
CI if GFR<30 or Potassium>5
Watch out for bronchospasm
198
Neprylysin inhibitors
ENTRESTO - sacubitril and valsartan!!
Limits breakdown of ANP and BNP
Replace ACEI/ARB with a 36 hour washout period for ACEi none for ARB
CI in angioedema with ACEi
199
Hydralazine/Nitrate for CHF
I - For black patients already on an ACEi and beta blocker
IIa - If failure of ACE/ARB
Hydralazine, Isosorbide dinitrate
200
Corlanor
Helps with sinus rate - if HR is 70+ with sinus rhythm
IIa indication
201
Digoxin
Anti-arrhythmic medication
Toxicity
Helps with heart rate and contractility - slows HR
202
CCB's with CHF
Only amlodipine and felodipine (NOT non-DHP)
Safe but not beneficial
203
Drugs to avoid in CHF
Amiodarone and Dofetilide
NSADIs
Thiazolidinedones
204
Indication for cardiac rehab
NYHA class II or III
205
CRT
Cardiac Resynchronization Therapy
Class I second line recommendation
Time ventricles and atria to beat together -implant
206
Waiting period for primary prevention of sudden cardiac death
Waiting for ICD
NYHA class II or III
1 yr survival min
EF under 35%
40 days post MI
90 days post dx
No waiting if they have had cardiac arrest (secondary prevention)
207
ICD
Implantable cardioverter defibrilators - implanted for primary or secondary prevention
208
3 Causes of acute decompensated HF
Medication noncompliance, Tachyarrhythmias, High salt diet
209
Presentation of acute decompensated HF
Acute pulmonary edema, Pink frothy sputum, Rales, Diaphoresis and cyanosis
210
Diagnostics for Acute decompensated HF
Echo
CXR
EKG
BNP
CMP
Cardiac enzymes
CBC
What am I looking for with each one?
211
Goal of O2 management for acute HF
94%, high flow NOT rebreather
212
Diuretic management for acute HF
Intravenous for consistency
Observe daily weights
Can add a HCTZ PO or Chlorothiazide IV, Metolazone or AA
213
Vasodilators for Acute HF
Be mindful of BP if using
Nitroglycerin for MI
Nitroprusside concerning for CN toxicity
Morphine effective for pulm edema may cause respiratory depression
214
Nesiritide
Recombinant BNP - expensive and not very useful
215
ACE/ARB in acute HF
Continue if already on, initiate once patient is stable
216
Beta Blockers for acute HF
Only once stabilized - if the EF is low we don't want to slow the heart down
217
Inotropic agents for Acute HF
Milirone Hypotension
Dobutamine - HTN
Pressors - last resort options, watch vitals, can cause arrhythmias
218
Ultrafiltration
Like dialysis to remove fluid from HF patients
219
Mechanical Cardiac Assistance MCA
Intra aortic balloon to create pressure or implanted left ventricular device
220
LVAD
Left ventricular assist device
Battery pack worn - helps with pumping in LV
221
Cardiac index
Cardiac Output/Body Surface Area - adjusts for heart size to see if enough blood is perfusing the body over time
222
Agents for Cardiogenic shock
Vasopressors
Dopamine - Acts mostly on renal at low doses, peripheral vasoconstrict at high doses
Dobutamine - Vasoconstriction less kidney action
Norepinephrine - Last ditch
223
Circulatory support devices for cardiogenic shock
Intra-aortic balloon
LVAD
