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Flashcards in Ch_1 - Cardiology Deck (491):
1

Starting with III. ARRHYTHMIAS

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2

The most important issue for anyone admitted with an arrhythmia is ....?

...hemodynamic stability

3

What is hemodynamic instability? [4]

1. Hypotensive (SBP < 90)
2. Dyspnea
3. Altered mental status/confusion d/t inadequate perfusion.
4. Chest pain

4

Mnemonic for hemodynamic instability

things are LOW -- low BP, Shortness (low) of breath, low mentation and the oddball -- chest pain.

5

What must you, as the medical student, do when you find a pt who is hemodynamically unstable?

1. Call your resident!
2. Recheck BP
3. Normal saline is REQUIRED
4. Repeat EKG

6

T/F Palpitations are very non-specific

True

7

T/F Patient w/ palpitations has no disease at all 50% of the time.

True

8

What must you do first if your patient has palpitations?

EKG!

9

Pt with palpitations gets an EKG and it is normal. Next step?

Outpatient - Holter monitor
Inpatient - Telemetry

10

T/F Pt with palpitations should not be medicated if no objective pathology is found.

True

11

What must you exclude in a patient with palpitations? [3]

1. Thyroid disease
2. Alcohol excess (can cause transient episodes of afib)
3. Excessive caffeine intake

12

T/F The testing and treatment are essentially the same for a-fib and a-flutter

True

13

What is the classic presentation of a pt with afib/aflutter? [5]

1. Palpitations of fluttering of the chest
2. Lightheaded
3. "Racing" heart
4. LOC is rare, but possible
5. Chest pain in SOME.

14

T/F loss of consciousness is possible with atrial fibrillation.

True, but it is rare.

15

Your patient has atrial fibrillation. What questions of the patient would your resident/attending most likely ask you in regards to the afib? [6]

Basically, their PMH and diagnostic studies.
1. Hypertension (most common)
2. CHF or cardiomyopathy of any kind
3. Thyroid dz
4. Alcohol or cocaine use
5. Rheumatic fever, particularly of immigrants
6. Previous EKG/Holter/ECHO

16

What is the most important feature of a-fib on physical exam?

irregularly irregular rhythm.

17

What is a wrong way to measure heart rate in patient with afib?

By palpating the radial pulse.

18

Why is palpating the radial pulse a bad way to measure heart rate in afib patient?

All beats are not transmitted sufficiently and may not be felt at the radial pulse b/c the heart is only partially full during a number of beats.

19

What SBP is necessary to feel a radial pulse?

SBP > 90 mm Hg. Weak contractions will not transmit.

20

What does an EKG show for afib? [3]

1. absent P waves
2. QRS < 100 msec
3. Irregularly irregular rhythm based on RR intervals.

May also see fibrillatory waves.

21

For what patients would a Holter monitor be used?

outpatients

22

For what patients would telemetry be used?

inpatients

23

Afib pts would get CK-MB and/or troponin ordered for who?

patients with acute episodes of rapid rate.

24

Afib pts would get ECHO when?

EVERYONE, if not done in last 6 months.

25

Why do an ECHO on afib pt? [2]

1. Detect valve dz (may have led to afib)
2. Look for clots (if present --> anticoagulate)

26

T/F Valvular disease that leads to afib/aflutter needs warfarin in many cases

True

27

Would you do a stress test in an afib pt?

Maybe. They are sometimes useful.

28

An atrial arrhythmia is generally caused by...

...dilated atrium.

29

T/F Ischemia is a frequent cause of atrial arrythmias

False, the cause is generally dilation (eg, volume expansion from heart failure causes dilation)

30

What is the first step in the management of afib/aflutter?

slowing the RATE.

31

What is the heart rate goal in afib/aflutter?

HR< 100-110/min

32

What are the 2 best therapies for afib/aflutter?

1. Metoprolol: 5 mg IV q5 minutes for 3 doses. Then start PO 50 mg bid. Max 200 bid.
2. Diltiazem: 0.25 mg/kg with a second IV dose of 0.35 mg/kg. Then start PO 30 mg qid. Max 120 mg qid.

33

How long does it usually take for Metoprolol and Diltiazem to control the rate?

Within 30 min.

34

If one of these (Metoprolol, Diltiazem) doesn't work and SBP is >90-100 mm Hg, you can do what?

add the other med (ie, if Metoprolol was given alone and BP is over 90, then you can add diltiazem).

35

What is the brand name for metoprolol?

Lopressor

36

What is the brand name for diltiazem?

Cardizem

37

If SBP is low or borderline (ie, < 90), what drug can be used to control the rate in an afib/aflutter pt?

Digoxin

38

Why is digoxin not the first choice in controlling the rate in stable afib/aflutter pts?

b/c it's not good in controlling the HR on exertion.

39

T/F In hospital settings (ie, controlled environment), digoxin is very useful in controlling the rate when afib/aflutter is rapid and BP is low.

True

40

T/F Digoxin is faster than CCBs or BBs in controlling heart rate

False, it is slower acting.

41

T/F Digoxin can raise the BP when the rate of an afib/aflutter pt is controlled.

True! Probably b/c it increases contractility.

42

Dose of digoxin for afib/aflutter pts who have SBP < 90 mm Hg.

0.25 mg IV q 2 hours. PO q 6 hours.

43

Patients with afib/aflutter with SBP< 90 can get digoxin to control the HR. Most pts can be controlled with how many mg?

1-1.15 mg (Dose: 0.25 mg IV q 2 hours) - so in about 8 hours. Notice how this is much slower than with CCB or BB (where pts are controlled within 30 min).

44

What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?

200 bid

45

What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?

120 qid

46

200 bid (Jeopardy)

What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?

47

120 qid

What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?

48

What are other meds in addition to Metoprolol/Diltiazem/Digoxin that can be used for rate control of rapid atrial arrhythmias?

1. CCB: Verapamil
2. BBs: Esmolol (B1), Propranolol (B1, B2), Atenolol (B1)

note: Metoprolol is also B1 blocker.

49

T/F Afib/aflutter pt - Routine cardioversion to sinus RHYTHM is correct.

False, it is NOT correct, routinely.

50

T/F It is correct to slow the RATE with BB, CCB, and occasionally with digoxin.

True

51

When can you urgently cardiovert an afib/aflutter patient?

hemodynamically unstable pt.

52

What are the 2 ways to cardiovert patients into sinus rhythm?

chemically with drugs and electric shock

53

Why would chemical cardioversion with drugs like amiodarone, procainamide, propafenone, or dofetilide not done for afib/aflutter pts?

Most pts will not stay in sinus rhythm with the meds. Also, these meds can cause arrhythmias such as Torsades de pointes, especially with dofetilide and ibutilide.

54

The AFFIRM trial showed what?

AFFIRM = Atrial Fibrillation Follow-up Investigation of Rhythm Management
showed that RATE CONTROL is superior to rhythm control in treatment of afib.

55

Prior to electrically cardioverting a hemodynamically stable afib pt, what must you do?

an ECHO (usually TTE and then TEE if TTE is negative) to look for clots. Shocking with a clot present may cause emboli.

56

Patient with afib has a TEE positive for a clot in the heart. Next best step?

Anticoagulation with warfarin for at least 3-4 weeks before cardioversion and 4 weeks after cardioversion.
If TEE was negative, start IV heparin and perform CV within 24 hrs. Post-CV anticoagulation for 4 weeks still required.

57

When is cardioversion performed for afib?

After rate control if patient is YOUNG and has an otherwise anatomically normal heart.

58

T/F Afib patient with dilated left atrium or significant valve dz is unlikely to stay in sinus rhythm even after cardioversion.

True.

59

When is anticoagulation NOT indicated for an afib patient?

If the afib is "new" -- ie, started < 48 hours ago.

60

If there is a significant risk for stroke in an afib patient, what should the pt get?

Anticoagulation therapy (eg, warfarin)

61

How do we quantify risk for stroke in afib pt to know whether pt should receive anticoagulation therapy?

CHADS2 score

62

What does CHADS2 stand for?

C - dilated Cardiomyopathy
H - HTN
A - old Age (>75)
D - DM
S - prior Stroke or TIA is clear indication

63

When CHADS score is 0-1, next step?

ASA or
ASA and Plavix (Clopidogrel)
Note: this is controversial -- ask attending

64

CHADS 2+

anticoagulate with Warfarin, Dabigatran, or Rivaroxaban.

65

What lab parameter must be monitored with warfarin use?

INR -- keep b/w 2-3 -- problematic and takes several days to achieve.

66

Is there a need to use heparin to bridge to warfarin for afib patients?

Depends:
If clot is present, then yes. But usually/otherwise, not needed. Why? b/c heparin causes bleeding and thrombocytopenia.

67

T/F Rivaroxaban and Dabigatran don't have to be monitored by INR

True, and that's awesome for us and the patient!

68

T/F Rivaroxaban and Dabigatran are like warfarin in that they take several days to become therapeutic

False, they are therapeutic on the same day you start.

69

T/F Rivaroxaban and Dabigatran cannot be reversed.

True. Warfarin can with PCC, FFP, Vit K...

70

What is the eficacy of rivaroxaban and dabigatran as compared with warfarin?

at least as effective or even better.

71

In afib, what is the ATRIAL rate (about)?

~400 bpm

72

In afib, what is the VENTRICULAR rate? why is it lower than the atrial rate?

b/w 75-175 b/c most atrial impulses are blocked by the AVN.

73

What are the causes of Afib?

1. Heart dz (CAD, MI, HTN, mitral valve dz)
2. Pericarditis, pericardial trauma (eg, surgery)
3. Pulmonary dz (including PE)
4. Thyroid dz (hyper/hypo)
5. Systemic illness (eg, sepsis, malignancy, DM)
6. Stress (eg, postop)
7. Excess alcohol ("Holiday heart syndrome")
8. Sick sinus syndrome
9. Pheochromocytoma.

74

Clinical features of afib?

1. Asymtomamtic
2. fatigue, exertional dyspnea
3. palps, dizzy, angina, syncope
4. irregularly irregular pulse
5. blood stasis --> intramural thrombi --> emboli to brain --> TIA or stroke sx

75

Tx: Acute Afib in hemodynamically unstable pt

Immediate electrical cardioversion to sinus rhythm.

76

Three main goals of afib/aflutter management

1. control ventricular rate.
2. restore NSR.
3. Assess need for anticoagulation.

77

Rate control in afib goal?

60-100 bpm

78

What drug is preferred for rate control?

BB > CCB

79

If LV systolic dysfxn is present, consider what drugs?

Digoxin or Amiodarone (useful in rhythm control)

80

After rate control of afib, what is next step?

convert to sinus rhythm via cardioversion if patient is a candidate for cardioversion.

81

What are the candidates for cardioversion? [3]

1. hemodynamically unstable
2. worsening sx
3. first ever case of afib (<48 hrs)

82

What is risk of cerebrovascular accident (CVA) in patient with "lone afib" (ie, absence of cardiovascular risk factors or underlying heart dz)?

1% per year

83

What is risk of cerebrovascular accident (CVA) in patient with afib + underlying heart dz?

4% per year

84

I. INTRODUCTION

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85

Chest pain

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86

How many pts coming into the ED actually have an MI?

<10%

87

What qs must be asked if pt has chest pain?

OLDCARTS
1. When did pain start?
2. Does it get better/worse with change in position or breathing?
3. How long does it last?
4. Did anything make it better or worse? (eg, rest/exertion)
5. What is the "quality" of the pain? (eg, sharp vs. dull, squeezing vs. pinpoint)
6. Radiate?
7. Use any meds?

88

To evaluate for chest pain, consider these 3 things

1. Is pain cardiac?
2. Does pain change with bodily position or respiration?
3. Is there chest wall tenderness?

89

If pain changes with position or respiration or there is chest wall tenderness, what is the percentage that the pain is ischemic?

~5% - very low!

90

T/F "Yes" to pain on exertion (eg, walking or climbing stairs) means the pain is very likely to be ischemic

True

91

T/F "No" to pain on exertion (eg, walking or climbing stairs) means the pain is very unlikely to be ischemic

False, it is inconclusive.

92

If patient has chest pain, should an EKG be done?

Yes!

93

If chest pain is cardiac in nature, what meds should be given?

Chewable ASA
Nitroglycerin (NTG)
Statin
BB (metoprolol 25 mg PO bid)
Possibly ACEI
No O2 unless hypoxic.

94

T/F In cases of chest pain, you should always get the old EKG

True!

95

EKG shows ST depression. Next step in management?

LMW Heparin

96

EKG shows ST elevation. Next step in management?

Get Cardiology immediately so they can do Angioplasty or thrombolytics.

97

Diabetes can cause what kind of MI?

"Silent" MI (painless)

98

Case #1
Patient has pleuritic chest pain that changes with respiration. Pt has fever, cough, sputum, SOB.
MLDx?
Mx?

MLDx = PNA

Mx: CXR, Oximeter, ABG

99

Case #2
Pt has pleuritic CP. Sharp, SOB, sudden onset.
MLDx?
Mx?

MLDx = Pneumothorax or PE

Mx = CXR, Oximeter, ABG
CTA for PE

100

Case #3
Pt has pleuritic CP. It is positional and is relieved when sitting up.
MLDx?
Mx?

MLDx - Pericarditis

Mx - EKG and NSAIDs.

101

Case #4
Pt has tearing CP that radiates to back. CXR shows wide mediastinum.
MLD?
Mx?

MLDx - Aortic dissection
Mx - CTA, MRA, TEE

102

Case #5
Pt with chest point tenderness.
MLDx?
Mx?

MLDx = Costochondritis

No test necessary. May use NSAIDs to relieve pain.

103

Case #6
Pt with burning epigastric pain, bad taste in mouth.
MLDx?
Mx?

MLD = GERD

Mx = improves with liquid antacids/PPIs

104

Important things to do when pt is hypotensive (SBP<90): [4]

1. Repeat BP manually. Don't use automatic machine
2. Position pt with feet up and head down.
3. Call resident immediately.
4. Give FLUIDS: bolus of 250-500 ml NS over 15-30 min.

105

T/F Hypotension is the number 1 condition in which correction with fluids is more important than getting a specific diagnosis.

True

106

T/F treat low BP first and diagnose later.

True

107

DDx of hypotension [8]

1. Dehydration
2. Sepsis
3. MI
4. Arrhythmia
5. Drug s/e
6. Orthostasis
7. Anaphylaxis
8. PE
There are many others!

108

Initial clues of dehydration?

High BUN:Creatinine ratio (>15-20:1)

109

Confirm dehydration how?

Low Urine Na+ (500 mOsm/L)

110

Initial clues of sepsis?

Leukocytosis
Fever

111

Confirm sepsis?

blood cultures

112

Initial clues of MI causing cardiogenic shock?

Rales
S3
JVD on exam

113

Confirming MI/Cardiogenic shock

CXR
ECHO
High BUN
Troponin

114

Initial clues of arrhythmia?

Palpitations
Syncope

115

Confirm arrhythmia?

EKG

116

What drugs commonly cause/predispose to hypotension?

BB, CCB; confirm with Medication Hx

117

Initial clues of orthostasis?

BP normalizes lying flat

118

How to diagnose orthostasis?

tilt-table test

119

initial clues of anaphylaxis?

Foods (seafood, crab, lobster, milk); insect bite; drug rxn

120

confirm anaphylaxis how?

Allergy Hx
Elevated Eosinophils

121

initial clues of PE?

sudden SOB
recent surgery

122

confirm PE with?

CTA

123

pt with hypotension. You want to start an antiplatelet agent. What should you consider prior to starting tx?

Bleeding risk

If pt is currently bleeding, these drugs are CI!

124

What are commonly prescribed anti-platelet agents?

ASA, Clopidogrel, Prasugrel, Ticagrelor.

If pt is currently bleeding, these drugs are CI!

125

pt with hypotension. You want to start heparin or enoxaparin. What should you consider prior to starting tx?

Bleeding risk. If pt is currently bleeding, these drugs are CI!

126

pt with hypotension. You want to start ASA. What should you consider prior to starting tx?

Allergy.

ASA is CI if pt has allergy.

127

pt with hypotension. You want to start BB agent. What should you consider prior to starting tx?

Check for Low BP, severe asthma, COPD.

B1B is not necessarily CI, but should be avoided if possible.

128

pt with hypotension. You want to start NTG. What should you consider prior to starting tx?

pt is hypotensive, NTG is CI!

129

pt w/ hypotension. You want to give them a statin. When should you not do this?

Liver dysfxn, Myositis

130

When should you not give ACEI?

patient has cough
Hyperkalemic

131

When should you avoid ARB, Spironolactone, Eplerenone?

Hyperkalemia

132

When should you avoid spironolactone?

Gynecomastia, Hyperkalemia

133

Patient has heme-positive brown stool. Can he be given an anti-platelet agent such as ASA, Plavix, Effient, ticagrelor or heparin?

If that's the ONLY finding, then it's OK to give.

134

Intro Part 3: ACS

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135

What is the most important part of ACS management?

getting a good History!!!

136

Aren't elevated Troponin and CK-MB and EKG important too?

Yes, but less so than Hx b/c they take 3-4 hours to elevate.

137

T/F Enzymes are usually normal when first test is done, even when ischemic event occurs.

True!

138

If Hx = ACS but EKG =/= ACS, should you treat it as if it's ACS?

YES!

139

T/F ACS = Hx + EKG

True

140

From Hx, what clues tell you that the pain is ischemic?

1. Substernal
2. Pain on exertion
3. Lasts 15-30 min
4. Doesn't change w/ position, respiration, or palpation
5. Dull, squeezing, pressure

141

What are the 3 different types of Acute Coronary Syndromes?

Unstable angina
NSTEMI
STEMI

142

From Hx, what clues tell you the pain is NOT ischemic?

1. Left or right sided
2. Worsens OR improves with position or breathing
3. Sharp (knife like)
4. Stabbing or point-like
5. Few seconds in duration
6. Continuous for hours and hours or 1-2 days

143

What is the worst and most dangerous risk factor for ACS?

Diabetes Mellitus

144

What is the most commonly found risk factor?

HTN

145

What is the relevance of FH in ACS?

only significant if it's PREMATURE in relative (<65 in female)

146

What are the common RFs of ACS?

1. DM
2. HTN
3. Tobacco use
4. Hypercholesterolemia
5. Premature dz in 1st-degree relative (parents, siblings)

147

Why are RFs of ACS important in Mx?

Because if Hx/EKG/Enzymes is equivocal, then RFs are used.

148

PEx of ACS pt?

MCC finding -- Absence of findings.

May find S3 Ventricular gallop and/or S4 atrial gallop, or rales.

149

T/F One EKG is good enough in the assessment of ACS

False! Make sure to do a repeat EKG. Also, make sure to compare to any previous EKGs pt had.

150

What are the different tests for ACS?

1. Troponin
2. CK-MB
3. Mgb
4. Cath
5. BNP
6. Stress test
7. ECHO
8. Telemetry

151

Troponin begins to rise...

at 3-4 hours

152

Max sensitivity to Troponin is at....?

12-18 hours

153

Troponin stays positive for..

1-2 weeks after event

154

Negative first troponin excludes disease?

No! It excludes nothing

155

Positive troponin suggests...

MI

156

False positive troponin increase is seen with?

Renal failure, CHF

157

CK-MB begins to rise...

at 3-4 hours

158

Max Sn for CK-MB?

12-18 hrs

159

CK-MB lasts...

1-2 days

160

Negative first CK-MB excludes...

nothing

161

Positive CK-MB...

suggests MI

162

CK-MB is best test for...

detecting re-infarction

163

Myoglobin rises at...

1-4 hours

164

T/F Myoglobin is very specific for MI

False

165

Mgb can exclude MI...

if negative test at 4 hours

166

If clear Hx of ACS and abnormal EKG, next step is?

Cath. If those 2 are unclear, then stress test.

167

Max medical therapy for ACS pt but pain continues. Next step?

Cath

168

Pt w/ possible ACS has SOB but etiology is unclear. Test?

BNP

169

Normal BNP...

excludes CHF

170

abnormal BNP...

is non-specific

171

When Hx and EKG are not clear, next step?

Stress test

172

What are you looking for in a stress test?

Reversible ischemia is the main thing to look for.

173

If stress test is abnormal, next step?

Cath

174

ECHO looks for?

Wall and valve motion
Estimates EF

175

Normal wall motion on ECHO...

excludes MI

176

High troponin with normal wall motion means what?

false positive troponin (eg, Renal failure)

177

What is telemetry?

Inpatient continuous EKG monitoring

178

T/F All ACS pts need telemetry.

True

179

When should a stress test NOT be done (although it is algorithmically indicated)?

If patient is in pain!

180

T/F Cath = Angiography

True

181

Which instances of ACS is Cath indicated?

1. STEMI
2. ST depression with persistent CP despite ASA, Plavix, Hep, Lopressor, and Nitrates
3. ST depression with recurrent CP
4. Recurrent episodes of ischemic-type CP with normal EKG
5. Reversible ischemia on stress test.

182

All pts with ACS shouldreceive these meds (6)

1. ASA 2+ tab, each 81 mg
2. Metoprolol 25 mg bid
3. NTG
4. ACEI
5. Statin
6. Morphine during pain.

183

Patient with chest pain + EKG with ST depression or T wave inversion + elevated troponins = ???

NSTEMI

184

(possible) NSTEMI treatment?

ASA
Plavix, Prasugrel, or ticagrelor
LMW Hep (eg, Enoxaparin 1mg/kg bid) subQ
Evaluate for Angio (cath)
Place on telemetry or ICU

185

Should treatment of possible NSTEMI start before enzyme results return?

YES!
Hx + EKG = ACS

186

In NSTEMI, where would you most likely expect T-wave inversions?

Inferior leads (II, III, aVF)

187

Clopidogrel must be given to which subset of ACS pts?

all pts undergoing PCI w/ stent placement and those undergoing fibrinolytic tx.

188

Pt with STEMI. Tx?

ASA, plavix (or equivalent - prasugrel, ticagrelor)
Thrombolytics or Angioplasty for PCI

189

Which medication should not be used in STEMI?

Heparin

190

When cardio is doing an angioplasty stent w/ PCI, what meds may be used?

GpIIb/IIIa inhibitor such as Eptifibatide or abciximab.

191

Define Takotsubo CM

sudden ventricular dysfxn from overwhelming emotions. May stimulate MI w/ anterior wall STEMI

192

When would you know for sure whether a pt has Takotsubo CM or Prinzmetal angina?

after Angio

193

Conditions that can cause ST elevations unrelated to acute MI? [5]

1. Early repolarization (benign)
2. Hyperkalemia
3. Pericarditis
4. CM
5. Prinzmetal's variant angina (spasm causes temporary transmural ischemia?)

194

CCBs may be beneficial in [3]

1. chest pain assoc w/ cocaine abuse
2. Intolerance to BBs (eg, asthma)
3. Variant/Prinzmetal's angina

195

Serious complications of MI? [4]

1. Arrhythmia
2. Wall/valve rupture
3. Hypotension
4. Pericarditis

196

In first 2-3 days after MI, what is the most serious MI complication?

Arrhythmia

197

Management of PVCs?

None, don't treat!

198

Key features of 3rd deg AVB

Bradycardia
Canon A waves

199

Treatment of 3rd deg AVB?

Atropine first if Sx
Pacemaker later in all

200

Key features of Sinus Bradycardia

bradycardia w/o canon A waves

201

Treatment of bradycardia

Atropine if Sx!
Pacemaker only if Sx persist

202

Key features of tamponade/wall rupture?

Sudden loss of pulse, (distended neck veins)

203

Tamponade/wall rupture Tx?

Needle thoracocentesis
Surgery

204

Key features of RV infarction

Inferior wall MI in Hx, clear lungs, tachycardia

205

Tx of RV infarction

Fluids

206

Valve rupture key features?

new murmur, rales/congestion

207

Tx of valve rupture

Surgery, some need balloon pump

208

Key features of septal rupture

New murmur
increase in O2 sat on entering RV

209

Tx of septal rupture

Surgery, some need balloon pump

210

Key features of Vfib

loss of pulse
need EKG

211

Tx of Vfib

Unsynchronized cardioversion

212

What is max HR?

220 - Age = Max HR

213

When doing a stress test, what should the HR be to properly assess heart function via EKG or ECHO?

80-85% of max HR.

214

What is 80% of max HR for 70 y/o patient?

(220 - 70)0.80 = 0.8x150 = 120 bpm

215

If pt has LBBB and you want to do a stress test. What kind is preferred?

Chemical stress test w/ Dipyrimadole thallium or Dobutamine stress ECHO

216

T/F LVH, LBBB, Pacemaker, and Digoxin make EKG reading difficult.

True, so need a stress test.

217

Different types of stress tests?

Exercise stress ECHO
Nuclear stress test
Dipyrimadole thallium
Adenosine thaliium
Dobutamine ECHO
TEsts have equal SN and Sp

218

Define "reversible" defect on Angio

defect in perfusion with exercise, but not seen at rest.

219

Why do an Angio?

To determine who should undergo bypass surgery.

220

Stenosis of __% in a vessel is "significant"

>70%

221

Management of 1- or 2-vessel dz

medical management and possible angioplasty, which may decrease Sx compared w/ meds, but there is no clear mortality benefit w/ the use of angioplasty in chronic stable angina.

222

Management of 3-vessel dz w/ LV dysfxn or Left Main Coronary dz

CABG surgery

223

Which drugs lower mortality in CAD?

ASA +/- Clopidogrel, Prasugrel, Ticagrelor
BB (Metoprolol, Nebivolol)
Statins to LDL goal < 100 mg/dL
ACEI if EF < 40%

224

Pt w/ CAD. Give statin. What is LDL goal?

<100 mg/dL

225

Pt w/ CAD. Give ACEI when?

If EF < 40%

226

Pt w/ chronic stable angina. Tx?

ASA alone

227

Pt w/ chronic stable angina with persistent pain.

ASA + long-acting NTG

228

What is ranolazine?

Na+ channel blocker used in refractory angina.

229

What drug is used in refractory angina?

Ranolazine (Na channel blocker)

230

CAD + LDL > 100 == ??

Statin

231

When is a CAD pt given statins

everyone with CAD (in real life) is given Statins

232

Most common a/e of statins?

1) increased LFTs (AST/ALT) in 2-3% of patients
2) Myositis in <1% of pts.

233

Pt on statin presents with LFTs 3-5x upper limit of normal. Next step?

Stop the med.

234

What are the other circustances when you want to get an LDL < 100 mg/dL (i.e., start a statin)

1) PAD
2) Diabetes
3) Aortic disease
4) Carotid disease

235

II. CHF

blank

236

What are the MC precipitants of acute pulmonary edema? [7]

1. Ischemia
2. Any arrhythmia
3. Non-adherence
4. Infection
5. Salty food diet
6. Iatrogenic fluid overload
7. Hypertensive crisis

237

CP of acute pulmonary edema?

sudden onset of SOB worse when supine and relieved when sitting upright

238

Physical exam of Acute pulm edema?

1. Rales
2. S3 ventricular gallop
3. JVD
4. Peripheral edema
5. Tachycardia
6. Diaphoresis and Nausea

239

If sx/sy of acute pulm edema are present, what is next best step?

1. OXYGEN
2. Elevate head of bed
3. Call resident
4. Attach Oximeter
5. Make sure ABG is done.
6. Connect to telemetry

240

Diagnostic tests for Acute Pulmonary Edema?

1. EKG -- to r/o arrhythmia and ischemia
2. CXR - congestion/vascular fluid overload, effusions, cardiomegaly
3. BNP
4. Troponin/CK-MB

241

How can BNP be useful in pt w/ acute pulm edema?

If Hx/Px and CXR are not clear, BNP can help diagnose CHF b/c normal BNP will exclude APE.

242

Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
Rales

Auscultation
CXR
BNP

243

Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
S3 ventricular gallop

EKG changes?
CXR
BNP
Troponin/CKMB

244

Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
JVD, peripheral edema

CXR?
BNP

245

BUN:Creatinine ratio in CHF

CHF --> pre-renal azotemia --> increase reabsorption --> increase BUN:Cr (>20:1)

246

Na content in plasma in CHF

Hyponatremia

247

CHF pt with Hypokalemia and metabolic alkalosis. Why?

chronic Diuretic use
Lasix is not K+ sparing and contraction alkalosis occurs with depleted volume.

248

T/F ECHO is needed in the acute management of acute pulmonary edema

False. Initial therapy is not altered whether CHF is systolic or diastolic.

249

Treatment of APE?

1. O2, elevated head of bed
2. LASIX IV q 20-30 min until urine is produced
3. Strict I/O monitoring to make sure there's response
4. NTG (paste, IV, or sublingual)
5. Morphine 2-4 mg IV

250

If no furosemide was previously used, how should it be given?

Start with 10 mg, then 20 mg, then 40 mg, then 80 mg via IV push.

251

If furosemide was previously used, how should it be given?

Start with usual IV dose. Ex: If pt had taken 40 mg bid, then give 40 mg IV, then 80 mg, then 160 mg q 20-30 min until urine is produced.

252

Refractory cases of pulm edema are treated with?

Hemodialysis

253

Who should be sent to the ICU?

1. Those where O2, diuretics, nitrates, and morphine don't control the Dyspnea
2. Those w/ SBP < 90 mmHG, making diuretics difficult
3. Acute MI or ventricular arrhythmia pts.

254

T/F Acutely ill patients should be given BBs

False

255

What are the positive inotropes used in the ICU for pts in CHF?

Dobutamine, Imamrinone, Milrinone.

256

If CHF pt is sick enough for the ICU, who should you get?

Cardiology

257

T/F CPAP/BiPAP might be necessary in CHF pt.

True

258

What is Nesiritide?

IV Atrial Natriuretic peptide

259

What is the IV ANP drug called?

Nesiritide

260

Pt with CHF is in ICU. He was given O2, diuretics, nitrates, morphine, dobutamine, and put on CPAP. Still hypoxic. Next best step?

Intubate!

261

In outpatient clinic, what clinical signs point you to pulmonary edema?

Dyspnea, Peripheral edema, and Rales.

There's no EKG, CXR, ABG!

262

Pt with CHF needs which diagnostic test after acute phase is over?

ECHO

263

ECHO tells us about...

EF
Systolic vs Diastolic dysfxn
Valvular dysfxn

264

Pt with CHF. What important findings can you look for on EKG?

1. Q waves - sx of old infarct
2. LVH: S wave in V1 and R wave in V5 > 35 mm
3. Afib or aflutter

265

CHF therapy depends on what?

Systolic vs. Diastolic failure (determine by ECHO)

266

T/F Systolic dysfxn is sometimes used interchangeably w/ Dilated CM

T

267

What is systolic dysfxn?

Heart can relax (diastole) but cannot contract well.
Diastolic failure is opposite.

268

What are the treatment options for Systolic dysfxn?

1. ACEI
2. BB
3. Spironolactone
4. Diuretics and Digoxin
5. Biventricular Pacemaker
6. Automatic implantable cardioverter defibrillator (AICD)
7. Hydralazine + Nitrates

269

T/F All ACEI are equal in efficacy

True

270

T/F ARBs are an alternative to ACEI and the #1 use for ARB is if pt has cough with ACEI

True

271

What are the commonly prescribed BBs for CHF (Systolic dysfxn)

Metoprolol, Carvedilol, Bisoprolol

272

When is spironolactone recommended?

used only in advanced stage Class III or IV CHF.

273

What is Class III/IV CHF?

Sx w/ minimum exertion or at rest

274

a/e of Spironolactone?

Gynecomastia
Hyperkalemia (K+ sparing)

275

Which aldosterone antagonist does not cause gynecomastia?

Eplerenone -- it still can, but less so than Spironolactone

276

T/F Diuretics have a mortality benefit

False, but are useful in pts w/ fluid overload

277

T/F Digoxin has a mortality benefit

False, but decreases sx in those ill despite other treatments

278

How is a biventricular pacemaker useful?

lowers mortality if there's Systolic dysfxn and there's a QRS>120 ms. The BVP "resynchronizes" the ventricles so they beat more efficiently together.

279

When is an AICD appropriate?

It lowers mortality in those w/ Persistently low EF despite maximal medical therapy.

280

https://icd.ices.on.ca/Portals/0/images/cvml_0077a_ICD-res1.jpg

ICD

281

http://my.clevelandclinic.org/PublishingImages/heart/bivpm.jpg

Biventricular pacemaker

282

Pt is unable to take ACEI or ARB. Persistent hyperkalemia is the reason. Next best step to control systolic dysfxn?

Hydralazine and Nitrates.

283

Are there any medications or devices proven to lower mortality in diastolic dysfunction pts?

No

284

What is the standard of care for Diastolic dysfunction?

Beta blockers: Metoprolol, Carvedilol, Bisoprolol
Diuretics

285

T/F ACEI are beneficial in Diastolic dysfxn pts

False

286

T/F Hypertensive Crisis = hypertensive emergency

T

287

Define Hypertensive emergency

severe HTN w/ end-organ damage

288

Sx of hypertensive emergency

End-organ damage sx:
1. CNS: Confusion
2. Heart: CP
3. Lung: SOB, CHF
4. Eye: blurry vision
5. Renal insufficiency

289

Managing htn emergency

IV anti-HTN meds:
Labetalol (a1, B1, B2- blocker)
Enalaprilat
OR
Nitroprusside

290

Pt seen in ED with HTN emergency. He is given Enalaprilat. Later patient says he feels dizzy and gets a stroke. How could this have been avoided?

Make sure not to lower BP > 25% in first few hours to prevent a stroke.

291

Define Cardiomyopathy

any cardiac muscular disorder that impairs the function of either contraction or relaxation.

292

T/F In cardiomyopathy, EF is always low

False, it can be high or low

293

T/F In most cases of CM the patient feels SOB, which worsens on exertion and improves w/ rest. Rales and peripheral edema can be present,

True and true

294

CM pt will show what on CXR ?

congestion or pulmonary vascular redistribution

295

What 2 tests are technically more accurate for the EF?

1. Nuclear ventriculogram (MUGA)
2. Left heart cath

Neither test is routinely done, but they are more accurate than ECHO.

296

Systolic dysfxn = ___1___ CM = relaxes _2_ / contraction _3_

1. Dilated
2. relaxes OK
3. contraction Poor

297

Diastolic dysfxn = ___1___ CM = relaxes _2_ / contraction _3_

1. Hypertrophic
2, Poorly
3. Well

298

define restrictive Cm

neither contracts or relaxes well.

299

Causes of restrictive CM

1. Sarcoidosis
2. Amyloidosis
3. Hemochromatosis
4. Endomyocardial Fibrosis
5. Cancer.

300

Treatment of Dilated CM

Same as Tx for systolic dysfxn:
BB, ACEI/ARB (Hydralazine+Nitrates), Spironolactone/Eplerenone, Diuretics

301

Treatment of Hypertrophic CM

Same Tx as Diastolic dysfxn
BB
Diuretics

302

Tx of Restrictive CM

Correct underlying cause

303

What is HOCM?

Hypertrophic Obstructive CM:
Idiopathic/genetic w/ an abnormal shape to the septum of the heart that leads to a physical obstruction to the outflow of blood.

304

How is HOCM and hypertrophic CM similar from a treatment standpoint?

Beta-blockers

305

What increases the outflow tract obstruction in HOCM?

Anything that EMPTIES the ventricle

306

What clinical symptoms is HOCM assoc with?

Syncope and rarely sudden cardiac death in healthy young athletes.

307

What will you be asked on rounds in regards to HOCM?

1. Episodes of lightheaded ness
2. LOC
3. CP
4. Previous studies (EKG, ECHO).

308

Random: 25 year old female with extensive smoking history with chest pain possibly due to CAD. Next best step?

Pregnancy test before any invasive procedures like a Cath!

309

Physical findings of HOCM?

1. S4 atrial gallop
2. Systolic c-d murmur at LLSB
3. Murmur worse/louder with decreased preload (valsalva, standing)
4. Murmur better/softer with increased preload (squatting, leg raise)

310

What is the initial test for HOCM?

ECHO

311

What would EKG show for HOCM?

Left axis deviation, pseudo Q waves in V1-V3, ventricular arrhythmias.

312

What is the most accurate test for HOCM?

Left heart catheterization

313

Treatment of HOCM

Beta blocker - Metoprolol - FIRST THERAPY

Implantable defibrillator (for syncope prevention).

314

Which medication/state can worsen HOCM?

Diuretics (deplete volume)
ACEI/ARBs
Dehydration
Digoxin

315

SVT clinical presentation?

Sudden onset of palps/racing heart that may lead to SOB.

316

What is the approximate HR in SVT?

160/min

317

What are the specific physical exam findings of SVT

There are none.

318

T/F ischemia is a common cause of SVT

False, if you think a pt has an acute MI and you think that's causing palps, question whether they have an SVT.

319

SVT is often caused by...

An abnormal conduction pathway around the AVN

320

What are the important clinical characteristics to consider for SVT?

Palpitations
Lightheadedness
Speed of onset of symptoms

321

Diagnose SVT with?

EKG

322

SVT shows what on EKG?

Rapid, narrow complex (<100 msec) tachycardia, usually around 160 bpm. No P waves, no fibrillation waves, no flutter waves.

323

What unit should SVT pts be in?

Telemetry unit

324

Why should an ECHO be done for SVT?

To r/o other pathology. Nothing specific for SVT.

325

Are CK-MB and Troponin useful in SVT?

No, but they always seem to be done.

326

Tx of SVT

1. Vagal maneuvers: carotid massage, valsalva, gagging, and diving reflex
2. ADENOSINE
3. Metoprolol, or Diltiazem
4. Electrical cardioversion (for rare cases of hemodynamically unstable or non-responsive to other therapies).

327

How does WPW present on EKG?

SVT
SVT alternating w/ Vtach
Delta wave found incidentally

328

What is a delta wave?

sign of conduction around AV node -- early depolorization of ventricles.

329

How does WPW present clinically?

Palpitations
Lightheaded
Occasionally w/ Syncope

330

What is the PR interval in WPW?

SHORT (<0.12 s) d/t accessory conduction.

331

On rounds, when going over the WPW pt, what will you be asked?

Previous EKG
Worsening sx or arrhythmia w/ use of Digoxin/CCB/BB
Previous cath or EP studies

332

What is the most accurate test for WPW?

Electrophysiology (EP) study - cath into heart tests cardiac circuits.

333

Treatment of WPW?

1. Procainamide (DOC), Amiodarone, Flecainide, or Sotalol [use for SVT occurring at the moment]
2. Radiofrequency catheter Ablation (permanent, long-term)

334

T/F Most WPW pts are not having an arrhythmia at present moment.

True

335

If WPW patient is not having an arrhythmia at the present moment, what is next best step?

Refer to EP study to identify the abnormal accessory conduction tract. Eliminate the tract immediately w/ ablation.

336

Which drugs must be avoided in WPW?

AV nodal blocking agents - BB, CCB, Digoxin b/c these may accelerate the current going through the accessory path.

337

Why does current go faster to the ventricles through the accessory path as opposed to the normal AV node path?

B/c there's no AVN pause component!

338

Which arrhythmia is associated w/ COPD or severe lung dz?

MAT (Multifocal Atrial Tachycardia)

339

MAT on EKG?

At least 3 different P-wave morphologies, with variable PR and RR intervals and normal QRS width.

340

Treatment of MAT?

Same as Afib/aflutter, but may want to avoid BB (b/c of COPD association).
May also Oxygenate and ventilate.

341

Would you use electrical cardioversion for MAT?

No, it's ineffective.

342

All pts with Ventricular Fibrillation need to have...

CPR started immediately followed by an Unsynchronized cardioversion.

343

CPR =??

chest compressions at 100/min and respirations. 2 Ventilations per 30 compressions (30:2). No response --> Epi or Vasopressin and shock again while doing CPR.

344

Vfib = __ + __ = Vtach w/o a pulse

CPR + electric unsynchronized shock

345

T/F Lidocaine > Amiodarone for ACLS

False. opposite

346

What is the sequential plan for V-fib?

1. CPR
2. Unsynchronized shock
3. CPR
4. Epi (or ADH)
5. CPR
6. Shock again 2 min after 1st shock
7. CPR
8. Amiodarone (or lidocaine)

347

T/F V-tach is always considered an extreme emergency

True!

348

Any sustained Vtach needs the following rapid response:

1. Call resident
2. Check BP
3. If SBP < 90, give bolus of NS and activate "code" for emergency response (call for help)
4. Hook up continuous EKG
5. Check for CP, cnfusion, or SOB
6. Get a cardioverter/defibrillator INTO THE ROOM just in case.

349

Normal QRS --??

<100 ms

350

Wide QRS in Vtach --??

>120 ms and reproducibly regular.

351

What is sustained Vtach?

30 sec or more of VTach

352

What is non-sustained Vtach?

<30 sec of Vtach pattern

353

Which pts commonly get runs of nonsustained Vtach?

ICU
telemetry
ED w/ limited hemodynamic effects

354

What are the 3 most important issues of Vtach on the wards?

1. Is BP normal (SBP>90-100)?
2. Are brain, heart, and lungs perfused?
3. Is the VT continuing?

355

What is the most common cause of Vtach?

Myocardial ischemia -- so always check for Hx of MI!

356

Vtach patient should get what checked?

1. CK-MB, Troponin
2. e- levels (K, Mg, Ca)
3. Oxygen
4. Medications pt is on
5. EKG

357

Any anti-arrhythmic except which class can cause arrhythmia?

Beta-blockers

358

Low levels of which electrolytes can cause Vtach?

Low Mg
Low Ca

359

Can low O2 cause Vtach?

yes

360

What levels of K+ (generally) can cause vtach?

High or low

361

What illicit drug can cause Vtach?

Cocaine

362

Ventricular tachycardia is possible d/t any CM. Which CM is most commonly associated w/ Vtach?

Dilated CM w/ low EF

363

Unstable pts w/ Vtach need...

immediate SYNCHRONIZED cardioversion to sinus rhythm.

364

Unstable = ?

SBP < 90, AMS, CP, and Dyspnea

365

Stable patients w/ Vtach are treated with...

Mg + Anti-arrhythmic (Amiodarone, Lidocaine, or Procainamide).

366

What is the most important issue with Bradycardia?

hemodynamic Stability

367

If patient has pulse < 60, next step?

EKG for etiology

368

Which bradycardias require no further Tx?

Sinus brady
First degree AV block
Mobits I second degree AV block

IF ASYMPTOMATIC!

369

Mobitz II and 3rd degree treatment?

Pacemaker required even if Asx!
If acute Sx...Atropine then Pacemaker

370

Each large boc on EKG is how many seconds? milliseconds?

2 sec, 200 ms

371

Over how many boxes will be considered bradycardia?

after 5 boxes. (300 -- 150 -- 100 -- 75 --60...that's 5)

372

Why does pacemaker make it difficult to interpret ischemia?

Wide complex QRS and abnormal T-waves are present w/ pacer spikes

373

Treatment of Unstable Bradycardia of any etiology?

1. Atropine 0.5 -1.0 mg IV immediately (max 3 mg)
2. Transcutaneous pacemaker
3. Permanent Transvenous pm

374

On EKG of atrial pacemaker, there may be 2 spikes. What are they?

The first pacer spike triggers the Atrium.
The second pacer spike triggers the Ventricle.

375

What is sick sinus syndrome?

AKA "tachy-brady syndrome" - alternating fast and slow HR.

376

If SSS pt has too slow of a rate (eg, pause > 3 s), tx?

Pacemaker

377

If SSS pt has too fast of a rate? Tx?

BB

378

What does the EKG show for Sick sinus syndrome?

Missing P waves, temporary Asystole-like picture, and restarting of P-waves spontaneously.

379

Sx of SSS?

dizzy, confused, syncope, fatigue, CHF

380

80-90% of the mortality with syncope is from ____ etiology?

cardiac and neurologic

381

What are the most dangerous causes of syncope? [6]

1. MI
2. Ventricular arrhythmia
3. Aortic Stenosis
4. HOCM
5. Seizure
6. Brainstem stroke

382

For almost any type of syncope, what is the inpatient evaluation? [5]

1. EKG
2. CK-MB, Troponin
3. Telemetry
4. ECHO
5. O2, Glc, Na, and Ca level

383

T/F In most cases, the cause of syncope will not be found

True

384

For syncope, what is not your job, and what is?

Not your job to find a definite cause, but rather to find something that could be dangerous.

385

HPI and PEx of Syncope must include?

1. Was LOC sudden or gradual?
2. Was recovery sudden or gradual?
3. Any murmurs on exam?

386

Most likely cause of sudden LOC?

Cardiac and neurologic causes (eg, MI, Seizures)

387

Most likely cause of gradual LOC?

Toxi-metabolic causes: low Glc, Hypoxia, Drug OD

388

Sudden regaining of consciousness usually points to a diagnosis of?

Cardiac cause: arrhythmia, MI, HOCM, or Aortic stenosis

389

Gradual regaining of consciousness usually points to a diagnosis of?

Seizures, low glc, hypoxia, and drug OD

390

If murmur is present, what is the cause of the syncope?

AS, MS, HOCM

391

What is Bigeminy?

Every other beat is a PVC. Normal beats in between with narrow QRS (<100 ms). PVC with wide QRS.

392

Does bigeminy need specific treatment?

Nope

393

Can carotid disease cause syncope?

No! So no need to get carotid doppler!

394

If you suspect a brainstem lesion causing syncope, what test should you get? And not get?

Do NOT get CT of head. Do get MRI. CT is useless.

395

Should you get an EEG in syncope pt?

EEG would not help much..."low yield" test.

396

If suspecting a cardiac cause of syncope, should you get an EKG?

Absolutely!

397

If suspecting a cardiac cause of syncope, should you get an ECHO?

Depends...only if you hear a murmur. If no murmur, then ECHO is pretty useless.

398

What can all forms of valve dz have in common?

1. Dyspnea
2. CHF
3. Murmurs
4. Edema
5. Congenital or rheumatic fever

399

Best initial test for valve dz?

ECHO

400

Most accurate test for valve dz?

Cath (can detect pressure difference)

401

Should endocarditis prophylaxis be given to a pt with valve dz?

NO! Only if the valve was replaced.

402

What decreases the intensity of mitral valve prolapse murmur?

increased venous return.

403

What decreases the intensity of HOCM murmur?

increased venous return (more blood in ventricle = less obstruction)

404

What actions can increase VR?

Raising legs passively
Squat from standing position

405

What actions can decrease VR?

Standing
Valsalva

406

What action can increase afterload?

Handgrip

407

Handgrip can worsen ____ lesions.

Mitral and aortic regurge

408

Handgrip may improve which murmur?

HOCM (keeps more blood in heart and decreases outflow obstruction).

409

Aortic and Mitral Regurgitation can occur from any cause of _____ ______

dilated CM

410

As heart dilates, the valve leaflets ___

separate

411

Cardiac dilation = ?

regurgitation

412

Other than dilated CM, what are the other causes of regurtitant valve pathology?

HTN
MI
Endocarditis
Myxomatous degeneration
Rare: Marfan's, Ehlers-Danlos, Ankylosing Spondylitis.

413

T/F Most people with AR or MR are symptomatic

False

414

When Sx, pts with MR/AR present w/ ?

Dyspnea, Rales, and Edema. Similar/Same as clinical presentation of Dilated CM.

415

Murmur of AR is a _____ murmur heard best at____

diastolic decrescendo..............Lower Left Sternal Border. Not in the "aortic area"!

416

MR murmur is a _____ murmur type

pansystolic/holosystolic best heard at lower left heart border radiating to axilla.

417

Both AR and MR become louder with ____

leg raise, handgrip, squatting [things that increase Venous Return and Afterload]

418

Both AR and MR become softer with ____

Valsalva and standing...and ACEI/ARBs
(decrease VR and Afterload)

419

Best test for AR/MR

ECHO

420

EKG of AR?

LVH --- S wave in V1 and R wave in V5 > 35 mm

SV1 + RV5 > 35 mm = LVH

421

CXR of MR and AR

Enlarged Left Atrium and Left Ventricle

422

Initial therapy for AR/MR?

ACEI/ARBs or (Nifedipine?)

423

Is there a need for Abx ppx before a dental procedure for AR or MR?

No, unless valve has been replaced.

424

When is surgery (repair/replace) indicated for MR or AR?

When the EF drops or the Left Ventricular End-Systolic Diameter increases.

425

Surgery indication for AR?

When EF < 50-55%
OR
LV End-Systolic Diameter (>50-55 mm) - about 2 inches

426

Surgery indication for MR?

EF < 60%
OR
LV End-systolic Diameter > 45 mm

427

Aortic stenosis triad?

Angina
CHF
Syncope

428

Most common symptom of AS?

Angina

Not syncope!

429

Symptom of AS --> Worst prognosis

CHF

Not syncope!

430

Why is angina so common in pts with AS?

1) co-existent CAD is very common in these pts
2) stenotic aortic valve is physically in the way of perfusing the coronaries
3) Resultant LVH compresses coronaries
4) micro-calcific emboli travel to coronaries (rare)

431

Diagnosis of AS?

ECHO

432

EKG change in AS?

severe LVH

recall: SV1 + RV5 > 35 mm

433

Why would stress tests and angiography be done in AS pts?

Angina!
Also, angio is good for diagnosing AS (looks at pressure Dx. Also, angio useful before surgical replacement of valve b/c bypass is frequently done at the same time.

434

Symptomatic AS pts - treated how?

"All" need surgical valve replacement (AVR)

435

What is done to patients with AS who are too ill to undergo valve replacement?

Balloon valvuloplasty

436

What is the role of ACEI/ARBs in AS?

Can worsen symptoms and don't help

437

When can diuretics be useful in pts with AS?

in cases of fluid overload. Note that pts with AS are very prone to volume depletion.

438

Acute CHF + AS treated with?

Digoxin

No BB d/t acute CHF (decrease contractility not a good idea)

439

Young immigrant + CHF -- think about which valve problem>?

Mitral Stenosis

440

young immigrant with rheumatic fever years ago and chronic mv scarring with MS may have what symptoms with MS?

Dysphagia
Hoarseness
Afib
Stroke at early age.

441

MS can cause atrial __ which leads to ____ and pressure on the ______ and ______

atrial enlargement....Afib and pressure on the esophogus (dysphagia) and recurrent laryngeal nerve (hoarseness)

442

EKG change on MS?

Left atrial enlargement = biphasic P wave in V1 and V2.

443

CXR for MS?

Left atrial enlargement
"Double Bubble" extra density behind the heart
Pushing up the Left main stem bronchus
Straightening of left heart border.

444

Best test for MS

TEE -- fish mouth shape MV

445

Most accurate test for MS

Left heart cath

446

Tx of MS

Diuretics for fluid overload
Balloon valvuloplasty (MVR if fails)
Digoxin or BB for atrial arrhythmia control

447

Role of endocarditis ppx for MS?

none unless replaced MV

448

Most pts with MVP are (sx or asx)

Asx

449

When MVP is Sx, what are the sx?

Palps
Atypical chest pain (not related to exertion and not relieved by rest)

450

Describe murmur of MVP

Mid-systolic click followed by Late-systolic murmur of MR.

451

MVP worsens with?

Valsalva and standing (decreased VR)

452

MVP improved with?

Squatting and leg raise (increase VR)

453

Dx of MVP?

ECHO

454

EKG of MVP?

normal

455

CXR of MVP?

normal

456

Treatment of MVP?

If Asx - nothing (no endocarditis PPX)
Sx (palps and CP) - BB

457

Marfan syndrome may present with what valve abnormality?

Floppy mitral valve (MVP, MR) --> sudden cardiac death.

and Cystic medial necrosis--> Aortic dissection.

458

Acute pericarditis CP?

CP that changes with position and respiration.

459

Pain of acute pericarditis is better with? worse with?

better w/ sitting up
worse w/ lying down and inspiration

460

Acute pericarditis on auscultation?

70-75% - nothing!
25-30% - friction rub

461

Things to ask of /look for in patient suspected of pericarditis?

1. fever or recent infection (esp lungs)
2. renal failure (uremia)
3. Chest wall trauma/heart surgery
4. Conn tissue disorder (eg, Lupus)
5. Recent MI
6. Cancer of chest organs

462

Most common class of infections that can cause pericarditis...

viruses!

any infection can do it though

463

EKG of pericarditis

ST-elevations in all leads except aVR.
PR-segment depressions (more specific!)

464

the lead that does not have ST elevations in acute pericarditis is usually lead ___?

aVR

465

Tx pericarditis

Tx underlying cause.
NSAIDs (ibuprofen, naproxen) for most cases. Colchicine can be added to NSAID to decrease recurrence.

If above doesn't work, Prednisone can be used.

466

What is CP of Pericardial Tamponade?

Hemodynamic dz that presents w/ SOB and lightheadedness from hypotension.
Hypotension
JVD with clear lung fields
Tachycardia
Pulsus paradoxus (decrease >10 SBP on inhalation)
Decreased and muffled heart sounds

467

what is the relationship b/w heart rate and pericardial tamponade ?

tachycardia is present and when it isn't tamponade is very unlikely.

468

Pt with BP 85/30, HR 120, JVP 13, and decreased heart sounds. What is the MLDx? And what are the possible causes?

MLDx = Pericardial tamponade
infections (most viral), CT disorders, cancers, recent MI, uremia, chest trauma,

469

What can pericadial tamponade look like on CXR?

pericardial effusion enlarges heart shadow in both left and right direction.

470

ECHO of pericardial tamponade

effusion pressing on RIGHT side of heart with right atrial and ventricular DIASTOLIC collapse as FIRST SIGN.

471

EKG shows low voltage....what are the possible causes?

Obesity, large breasts, COPD, pericardial tamponade

472

EKG of pericardial tamponade may show low voltage and another interesting finding...

"electrical alterans" - variation in height of QRS complexes b/c heart "swims" in the fluid.

473

Pt with pericardial tamponade gets Cath for whatever reason. What do you expect to see with diastolic pressures?

Equal pressures in ALL 4 chambers during diastole.
Note: cath rarely done

474

Treatment of pericardial tamponade?

Fluids! -- prevent and possibly reverse tamponade (push back)

Needle peri-cardiocentesis

Pericardial window placement.

475

What is constrictive pericarditis due to?

Chronic pericardial INFECTION or INFLAMMATION leads to chronic thickening, fibrosis, and calcification of the pericardium.

476

CP of constrictive pericarditis

1. Edema
2. JVD
3. Kussmaul's sign (paradoxical increase in JVP on inhalation)
4. Enlarged Liver and Spleen
5. Ascites
6. Pericardial "KNOCK" from filling of ventricle hitting fibrotic pericardium.

Note that 1-5 are Right sided HF signs and symptoms.

477

What is Kussmaul's sign?

inhalation --> paradoxical increase in JVP.
Normally inhalation --> increase VR --> decrease JVP.

478

CXR of constrictive pericarditis?

fibrosis, thickening, and calcification of pericardium

479

Chest CT/MRI of constrictive pericarditis?

fibrosis, thickening and calcification of pericardium in much better detail.

480

ECHO comparison b/w pericardial tamponade and constrictive pericarditis

ECHO less useful in Constr peri b/c fluid level is normal and heart moves normally.

481

Treatment of constrictive pericarditis?

Surgical removal is the only effective tx.
Diuretics and salt restriction (decrease R-sided HF sx) - sx relief only

482

T/F PAD is angina of the calves...

True

483

PAD CP?

Think stable angina
1. Pain in legs relieved by REST
2. decreased peripheral pulses
3. smooth, shiny skin in severe cases.

484

Risk factors of PAD?

HTN, DM, HLD, TOBACCO SMOKING!

485

How can pain be better in PAD?

rest, dangling over edge of bed

486

pain worse in PAD?

worse on ANY type of exertion
(spinal stenosis is worse with walking DOWNHILL)

487

Diagnostic testing for PAD?

1. ABI
2. Dopplers of LE
3. Angiography

488

A normal person's Ankle pressure will ____ arm (brachial) pressure when _____.

equal
lying flat

489

When upright, ankle pressure is normally ____ than arm pressure

greater
thus, ABI 1.0-1.2 are NORMAL! - mind blown!

490

If ankle pressure is lower than brachial pressure by more than ___ % (i.e. ABI ___), then we suspect _____???___

>10%
ABI <0.9
obstruction to flow of blood in legs

491

PAD Tx

1. STOP SMOKING, STOP SMOKING, NOW
2. ASA (Plavix 2nd line)
3. Cilostazol
4. ACEI for HTN
5. Statins b/c PAD = ASCVD
6. Tight glc control