Cardiovascular Part 1

Question 1

What is signs and symptoms from imbalance between myocardial oxygen supply and demand with no elevation of biomarkers and no pathologic ST segment elevation

Answer 1

Unstable Angina

Question 2

Acute chest pain lasts

Answer 2

<24 hours

Question 3

Visceral pain feels

Answer 3

poorly localized and dull, heavy or aching

Question 4

Initial approach to chest pain includes

Answer 4

prompt triage

Visceral pain, abnormal vitals, significant risk factors, dyspnea => place in bed, cardiac monitor, IV, oxygen, ECG

Question 5

What PE characteristic increases the likelihood of AMI greatest

Answer 5

radiation to right arm or shoulder

Question 6

Factors that decrease the likelihood of AMI

Answer 6

Pleuritic
Positional
Sharp
Reproducible with palpation
Inframammary location
Not exertional

Question 7

Who commonly has atypical presentations of ACS?

Answer 7

Women
Nonwhite minorities
Diabetics
Elderly
Psych pts/AMS

Question 8

Cardiac risk factors include

Answer 8

Age > 40
Male or postmenopausal female
HTN
Smoking
High cholesterol
Diabetes
Truncal obesity
 Family history
Sedentary lifestyle
Cocaine use

Question 9

Does absence of chest pain rule out MI?

Answer 9

No

33% do not have CP

Question 10

Does chest wall tenderness on palpation rule out MI?

Answer 10

No

15% have this

Question 11

Chest pain that is sharp or dull and is worse with breathing should consider

Answer 11

costochondritis

Question 12

What cardiac enzyme is most sensitive for MI?

Answer 12

Troponin

Question 13

What cardiac enzyme is best to see reinfarction

Answer 13

CK-MB

Question 14

Define hypoxia

Answer 14

Deficiency in oxygen supply or availability to tissues

Question 15

Define ischemia

Answer 15

Oxygen deprivation with inadequate removal of metabolites due to reduced perfusion. Occurs when there is an imbalance between oxygen demand and supply

Question 16

Hearing rales on PE Is suggestive of

Answer 16

LV dysfx

left sided CHF

Question 17

JVD, peripheral edema, hepatojugular reflex on PE is suggestive of

Answer 17

right sided CHF

Question 18

Changes in II, III, & aVF indicate what infarct area and occlusion to which vessel

Answer 18

Inferior Infarct

RCA

Question 19

Changes in lateral leads (I, aVL, V5, V6) indicate what infarct area and occlusion to which vessel

Answer 19

Lateral Infarct

Left circumflex

Question 20

Changes in V1-V6 indicate what infarct area and occlusion to which vessel

Answer 20

Anterior

LAD (left anterior descending)

Question 21

V1 with tall R waves and ST depression indicate what infarct area and occlusion to which vessel

Answer 21

Posterior MI

Right Coronary Artery

Question 22

Changes precordial leads + I & aVL indicate what infarct area and occlusion to which vessel

Answer 22

Anterolateral

Left Main Artery

Question 23

Changes in II, III, aVF, and V1 indicate what infarct area and occlusion to which vessel

Answer 23

Inferoposterior MI

Right Coronary Artery

Question 24

What type of angina can demonstrate ST elevation on ECG

Answer 24

Prinzmetal

Question 25

PCI should goals are within _____ of ED arrival OR fibrinolysis within _____ if PCI cannot be done

Answer 25

90min | or fibrinolysis within 30min

Question 26

ABSOLUTE contraindications to fibrinolytics

Answer 26

Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g., arteriovenous malformation) Known intracranial neoplasm Ischemic stroke within 3 mo Active internal bleeding (excluding menses) Suspected aortic dissection or pericarditis

Question 27

Is history of GI bleed a contraindication to ASA in unstable angina/MI?

Answer 27

No | Only withhold in case of true allergy

Question 28

If true allergy to ASA exists, what should be used instead?

Answer 28

Clopidogrel

Question 29

If Clopidogrel is given when can the patient receive a CABG

Answer 29

Hold clopidogrel for 5 days if possible | should still give in ED if appropriate

Question 30

What drugs are used in PCI but not in fibrinolytics

Answer 30

GP IIb/IIIa Inhibitors: | Abciximab, Eptifibatide, Tirofiban

Question 31

When using unfractionated heparin, you should monitor _____. | Try to d/c after _____ hours to reduce risk of _____

Answer 31

Unfractionated Heparin: Monitor PTT d/c after 48 hrs to reduce risk of thrombocytopenia

Question 32

LMWH monitored by

Answer 32

Do not need to monitor PTT

Question 33

Nitrates should be used with caution in what type of MI?

Answer 33

Inferior MI nitrates reduce preload and may cause hypotension due to RV involvement

Question 34

When should BB be used in ACS?

Answer 34

``` Start oral (not IV) in pts with STEMI or NSTEMI within 24 hrs unless: Signs of heart failure Low cardiac output state Increased risk for cardiogenic shock Prolonged PR, 2nd or 3rd degree heart block, active asthma, reactive airway disease cocaine use! ```

Question 35

What roles do ACEI play in MI treatment

Answer 35

should be started orally within 24hrs MI | -reduced mortality

Question 36

When should ACEI not be used in MI treatment

Answer 36

HOTN, renal failure, hx angioedema, renal artery stenosis

Question 37

How should postprocedural chest pain be approached?

Answer 37

ACS symptoms shortly after PCI should be assumed to have vessel closure until proven otherwise. Treat aggressively for ACS. Could also be pericarditis.

Question 38

Are cardiac risk factors good predictors of risk for MI or ACS?

Answer 38

NO

Question 39

A change in troponins 2 hours apart of _____ is significant, and can be seen in AMI

Answer 39

0.05

Question 40

RF for Cardiogenic Shock

Answer 40

``` Elderly Female Acute or prior ischemic event Prior medical hx Hx MI CHF Diabetes ```

Question 41

MCC of cardiogenic shock

Answer 41

Large MI | -->pump failure

Question 42

Tx changes if pt has cardiogenic shock and acute MI

Answer 42

No Nitroglycerin if SBP <90 | No BB

Question 43

Tx cardiogenic shock hypotension if no improvement from small fluids or if pulmonary congestion present

Answer 43

``` Use vasopressors (Dopamine) and/or inotropes (dobutamine) ``` * Dobutamine DOC if SBP>90 * SBP <70 then atleast use dopamine

Question 44

If dopamine is ineffective in the treatment of hypotension secondary to cardiogenic shock the next DOC is

Answer 44

norepinephrine

Question 45

Cardiogenic shock + acute MI | best treatment targeted for MI

Answer 45

PCI preferred to thrombolytic Mortality decreased with revascularization

Question 46

Do CHF symptom severity predict outcome?

Answer 46

Yes

Question 47

MC non-cardiac causes acute of CHF

Answer 47

noncompliance to diet/meds

Question 48

Normal Eject Fraction is

Answer 48

60%

Question 49

Pattern of progression respiratory symptoms in CHF

Answer 49

Exertional dyspnea Paroxysmal nocturnal dyspnea Orthopnea Dyspnea at rest

Question 50

(+) hepatojugular reflex with

Answer 50

right sided failure

Question 51

Kerley B Lines on CXR

Answer 51

CHF

Question 52

Obesity raises/lowers BNP

Answer 52

lower

Question 53

BNP may be increased in

Answer 53

CHF pulmonary HTN PE MI

Question 54

Standard initial treatment for CHF

Answer 54

``` Cardiac monitoring Pulse oximetry Oxygen 12 Lead ECG, Labs, CXR IV access Frequent vitals Foley cath if critical pt ```