Flashcards in Ch_1 - Cardiology Deck (491):
Starting with III. ARRHYTHMIAS
The most important issue for anyone admitted with an arrhythmia is ....?
What is hemodynamic instability? 
1. Hypotensive (SBP < 90)
3. Altered mental status/confusion d/t inadequate perfusion.
4. Chest pain
Mnemonic for hemodynamic instability
things are LOW -- low BP, Shortness (low) of breath, low mentation and the oddball -- chest pain.
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
T/F Palpitations are very non-specific
T/F Patient w/ palpitations has no disease at all 50% of the time.
What must you do first if your patient has palpitations?
Pt with palpitations gets an EKG and it is normal. Next step?
Outpatient - Holter monitor
Inpatient - Telemetry
T/F Pt with palpitations should not be medicated if no objective pathology is found.
What must you exclude in a patient with palpitations? 
1. Thyroid disease
2. Alcohol excess (can cause transient episodes of afib)
3. Excessive caffeine intake
T/F The testing and treatment are essentially the same for a-fib and a-flutter
What is the classic presentation of a pt with afib/aflutter? 
1. Palpitations of fluttering of the chest
3. "Racing" heart
4. LOC is rare, but possible
5. Chest pain in SOME.
T/F loss of consciousness is possible with atrial fibrillation.
True, but it is rare.
Your patient has atrial fibrillation. What questions of the patient would your resident/attending most likely ask you in regards to the afib? 
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
What is the most important feature of a-fib on physical exam?
irregularly irregular rhythm.
What is a wrong way to measure heart rate in patient with afib?
By palpating the radial pulse.
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.
What SBP is necessary to feel a radial pulse?
SBP > 90 mm Hg. Weak contractions will not transmit.
What does an EKG show for afib? 
1. absent P waves
2. QRS < 100 msec
3. Irregularly irregular rhythm based on RR intervals.
May also see fibrillatory waves.
For what patients would a Holter monitor be used?
For what patients would telemetry be used?
Afib pts would get CK-MB and/or troponin ordered for who?
patients with acute episodes of rapid rate.
Afib pts would get ECHO when?
EVERYONE, if not done in last 6 months.
Why do an ECHO on afib pt? 
1. Detect valve dz (may have led to afib)
2. Look for clots (if present --> anticoagulate)
T/F Valvular disease that leads to afib/aflutter needs warfarin in many cases
Would you do a stress test in an afib pt?
Maybe. They are sometimes useful.
An atrial arrhythmia is generally caused by...
T/F Ischemia is a frequent cause of atrial arrythmias
False, the cause is generally dilation (eg, volume expansion from heart failure causes dilation)
What is the first step in the management of afib/aflutter?
slowing the RATE.
What is the heart rate goal in afib/aflutter?
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.
How long does it usually take for Metoprolol and Diltiazem to control the rate?
Within 30 min.
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).
What is the brand name for metoprolol?
What is the brand name for diltiazem?
If SBP is low or borderline (ie, < 90), what drug can be used to control the rate in an afib/aflutter pt?
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.
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.
T/F Digoxin is faster than CCBs or BBs in controlling heart rate
False, it is slower acting.
T/F Digoxin can raise the BP when the rate of an afib/aflutter pt is controlled.
True! Probably b/c it increases contractility.
Dose of digoxin for afib/aflutter pts who have SBP < 90 mm Hg.
0.25 mg IV q 2 hours. PO q 6 hours.
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).
What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?
What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?
200 bid (Jeopardy)
What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?
What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?
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.
T/F Afib/aflutter pt - Routine cardioversion to sinus RHYTHM is correct.
False, it is NOT correct, routinely.
T/F It is correct to slow the RATE with BB, CCB, and occasionally with digoxin.
When can you urgently cardiovert an afib/aflutter patient?
hemodynamically unstable pt.
What are the 2 ways to cardiovert patients into sinus rhythm?
chemically with drugs and electric shock
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.
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.
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.
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.
When is cardioversion performed for afib?
After rate control if patient is YOUNG and has an otherwise anatomically normal heart.
T/F Afib patient with dilated left atrium or significant valve dz is unlikely to stay in sinus rhythm even after cardioversion.
When is anticoagulation NOT indicated for an afib patient?
If the afib is "new" -- ie, started < 48 hours ago.
If there is a significant risk for stroke in an afib patient, what should the pt get?
Anticoagulation therapy (eg, warfarin)
How do we quantify risk for stroke in afib pt to know whether pt should receive anticoagulation therapy?
What does CHADS2 stand for?
C - dilated Cardiomyopathy
H - HTN
A - old Age (>75)
D - DM
S - prior Stroke or TIA is clear indication
When CHADS score is 0-1, next step?
ASA and Plavix (Clopidogrel)
Note: this is controversial -- ask attending
anticoagulate with Warfarin, Dabigatran, or Rivaroxaban.
What lab parameter must be monitored with warfarin use?
INR -- keep b/w 2-3 -- problematic and takes several days to achieve.
Is there a need to use heparin to bridge to warfarin for afib patients?
If clot is present, then yes. But usually/otherwise, not needed. Why? b/c heparin causes bleeding and thrombocytopenia.
T/F Rivaroxaban and Dabigatran don't have to be monitored by INR
True, and that's awesome for us and the patient!
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.
T/F Rivaroxaban and Dabigatran cannot be reversed.
True. Warfarin can with PCC, FFP, Vit K...
What is the eficacy of rivaroxaban and dabigatran as compared with warfarin?
at least as effective or even better.
In afib, what is the ATRIAL rate (about)?
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.
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
Clinical features of afib?
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
Tx: Acute Afib in hemodynamically unstable pt
Immediate electrical cardioversion to sinus rhythm.
Three main goals of afib/aflutter management
1. control ventricular rate.
2. restore NSR.
3. Assess need for anticoagulation.
Rate control in afib goal?
What drug is preferred for rate control?
BB > CCB
If LV systolic dysfxn is present, consider what drugs?
Digoxin or Amiodarone (useful in rhythm control)
After rate control of afib, what is next step?
convert to sinus rhythm via cardioversion if patient is a candidate for cardioversion.
What are the candidates for cardioversion? 
1. hemodynamically unstable
2. worsening sx
3. first ever case of afib (<48 hrs)
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
What is risk of cerebrovascular accident (CVA) in patient with afib + underlying heart dz?
4% per year
How many pts coming into the ED actually have an MI?
What qs must be asked if pt has chest pain?
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)
7. Use any meds?
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?
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!
T/F "Yes" to pain on exertion (eg, walking or climbing stairs) means the pain is very likely to be ischemic
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.
If patient has chest pain, should an EKG be done?
If chest pain is cardiac in nature, what meds should be given?
BB (metoprolol 25 mg PO bid)
No O2 unless hypoxic.
T/F In cases of chest pain, you should always get the old EKG
EKG shows ST depression. Next step in management?
EKG shows ST elevation. Next step in management?
Get Cardiology immediately so they can do Angioplasty or thrombolytics.
Diabetes can cause what kind of MI?
"Silent" MI (painless)
Patient has pleuritic chest pain that changes with respiration. Pt has fever, cough, sputum, SOB.
MLDx = PNA
Mx: CXR, Oximeter, ABG
Pt has pleuritic CP. Sharp, SOB, sudden onset.
MLDx = Pneumothorax or PE
Mx = CXR, Oximeter, ABG
CTA for PE
Pt has pleuritic CP. It is positional and is relieved when sitting up.
MLDx - Pericarditis
Mx - EKG and NSAIDs.
Pt has tearing CP that radiates to back. CXR shows wide mediastinum.
MLDx - Aortic dissection
Mx - CTA, MRA, TEE
Pt with chest point tenderness.
MLDx = Costochondritis
No test necessary. May use NSAIDs to relieve pain.
Pt with burning epigastric pain, bad taste in mouth.
MLD = GERD
Mx = improves with liquid antacids/PPIs
Important things to do when pt is hypotensive (SBP<90): 
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.
T/F Hypotension is the number 1 condition in which correction with fluids is more important than getting a specific diagnosis.
T/F treat low BP first and diagnose later.
DDx of hypotension 
5. Drug s/e
There are many others!
Initial clues of dehydration?
High BUN:Creatinine ratio (>15-20:1)
Confirm dehydration how?
Low Urine Na+ (500 mOsm/L)
Initial clues of sepsis?
Initial clues of MI causing cardiogenic shock?
JVD on exam
Confirming MI/Cardiogenic shock
Initial clues of arrhythmia?
What drugs commonly cause/predispose to hypotension?
BB, CCB; confirm with Medication Hx
Initial clues of orthostasis?
BP normalizes lying flat
How to diagnose orthostasis?
initial clues of anaphylaxis?
Foods (seafood, crab, lobster, milk); insect bite; drug rxn
confirm anaphylaxis how?
initial clues of PE?
confirm PE with?
pt with hypotension. You want to start an antiplatelet agent. What should you consider prior to starting tx?
If pt is currently bleeding, these drugs are CI!
What are commonly prescribed anti-platelet agents?
ASA, Clopidogrel, Prasugrel, Ticagrelor.
If pt is currently bleeding, these drugs are CI!
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!
pt with hypotension. You want to start ASA. What should you consider prior to starting tx?
ASA is CI if pt has allergy.
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.
pt with hypotension. You want to start NTG. What should you consider prior to starting tx?
pt is hypotensive, NTG is CI!
pt w/ hypotension. You want to give them a statin. When should you not do this?
Liver dysfxn, Myositis
When should you not give ACEI?
patient has cough
When should you avoid ARB, Spironolactone, Eplerenone?
When should you avoid spironolactone?
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.
Intro Part 3: ACS
What is the most important part of ACS management?
getting a good History!!!
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.
T/F Enzymes are usually normal when first test is done, even when ischemic event occurs.
If Hx = ACS but EKG =/= ACS, should you treat it as if it's ACS?
T/F ACS = Hx + EKG
From Hx, what clues tell you that the pain is ischemic?
2. Pain on exertion
3. Lasts 15-30 min
4. Doesn't change w/ position, respiration, or palpation
5. Dull, squeezing, pressure
What are the 3 different types of Acute Coronary Syndromes?
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
What is the worst and most dangerous risk factor for ACS?
What is the most commonly found risk factor?
What is the relevance of FH in ACS?
only significant if it's PREMATURE in relative (<65 in female)
What are the common RFs of ACS?
3. Tobacco use
5. Premature dz in 1st-degree relative (parents, siblings)
Why are RFs of ACS important in Mx?
Because if Hx/EKG/Enzymes is equivocal, then RFs are used.
PEx of ACS pt?
MCC finding -- Absence of findings.
May find S3 Ventricular gallop and/or S4 atrial gallop, or rales.
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.
What are the different tests for ACS?
6. Stress test
Troponin begins to rise...
at 3-4 hours
Max sensitivity to Troponin is at....?
Troponin stays positive for..
1-2 weeks after event
Negative first troponin excludes disease?
No! It excludes nothing
Positive troponin suggests...
False positive troponin increase is seen with?
Renal failure, CHF
CK-MB begins to rise...
at 3-4 hours
Max Sn for CK-MB?
Negative first CK-MB excludes...
CK-MB is best test for...
Myoglobin rises at...
T/F Myoglobin is very specific for MI
Mgb can exclude MI...
if negative test at 4 hours
If clear Hx of ACS and abnormal EKG, next step is?
Cath. If those 2 are unclear, then stress test.
Max medical therapy for ACS pt but pain continues. Next step?
Pt w/ possible ACS has SOB but etiology is unclear. Test?
When Hx and EKG are not clear, next step?
What are you looking for in a stress test?
Reversible ischemia is the main thing to look for.
If stress test is abnormal, next step?
ECHO looks for?
Wall and valve motion
Normal wall motion on ECHO...
High troponin with normal wall motion means what?
false positive troponin (eg, Renal failure)
What is telemetry?
Inpatient continuous EKG monitoring
T/F All ACS pts need telemetry.
When should a stress test NOT be done (although it is algorithmically indicated)?
If patient is in pain!
T/F Cath = Angiography
Which instances of ACS is Cath indicated?
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.
All pts with ACS shouldreceive these meds (6)
1. ASA 2+ tab, each 81 mg
2. Metoprolol 25 mg bid
6. Morphine during pain.
Patient with chest pain + EKG with ST depression or T wave inversion + elevated troponins = ???
(possible) NSTEMI treatment?
Plavix, Prasugrel, or ticagrelor
LMW Hep (eg, Enoxaparin 1mg/kg bid) subQ
Evaluate for Angio (cath)
Place on telemetry or ICU
Should treatment of possible NSTEMI start before enzyme results return?
Hx + EKG = ACS
In NSTEMI, where would you most likely expect T-wave inversions?
Inferior leads (II, III, aVF)
Clopidogrel must be given to which subset of ACS pts?
all pts undergoing PCI w/ stent placement and those undergoing fibrinolytic tx.
Pt with STEMI. Tx?
ASA, plavix (or equivalent - prasugrel, ticagrelor)
Thrombolytics or Angioplasty for PCI
Which medication should not be used in STEMI?
When cardio is doing an angioplasty stent w/ PCI, what meds may be used?
GpIIb/IIIa inhibitor such as Eptifibatide or abciximab.
Define Takotsubo CM
sudden ventricular dysfxn from overwhelming emotions. May stimulate MI w/ anterior wall STEMI
When would you know for sure whether a pt has Takotsubo CM or Prinzmetal angina?
Conditions that can cause ST elevations unrelated to acute MI? 
1. Early repolarization (benign)
5. Prinzmetal's variant angina (spasm causes temporary transmural ischemia?)
CCBs may be beneficial in 
1. chest pain assoc w/ cocaine abuse
2. Intolerance to BBs (eg, asthma)
3. Variant/Prinzmetal's angina
Serious complications of MI? 
2. Wall/valve rupture
In first 2-3 days after MI, what is the most serious MI complication?
Management of PVCs?
None, don't treat!
Key features of 3rd deg AVB
Canon A waves
Treatment of 3rd deg AVB?
Atropine first if Sx
Pacemaker later in all
Key features of Sinus Bradycardia
bradycardia w/o canon A waves
Treatment of bradycardia
Atropine if Sx!
Pacemaker only if Sx persist
Key features of tamponade/wall rupture?
Sudden loss of pulse, (distended neck veins)
Tamponade/wall rupture Tx?
Key features of RV infarction
Inferior wall MI in Hx, clear lungs, tachycardia
Tx of RV infarction
Valve rupture key features?
new murmur, rales/congestion
Tx of valve rupture
Surgery, some need balloon pump
Key features of septal rupture
increase in O2 sat on entering RV
Tx of septal rupture
Surgery, some need balloon pump
Key features of Vfib
loss of pulse
Tx of Vfib
What is max HR?
220 - Age = Max HR
When doing a stress test, what should the HR be to properly assess heart function via EKG or ECHO?
80-85% of max HR.
What is 80% of max HR for 70 y/o patient?
(220 - 70)0.80 = 0.8x150 = 120 bpm
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
T/F LVH, LBBB, Pacemaker, and Digoxin make EKG reading difficult.
True, so need a stress test.
Different types of stress tests?
Exercise stress ECHO
Nuclear stress test
TEsts have equal SN and Sp
Define "reversible" defect on Angio
defect in perfusion with exercise, but not seen at rest.
Why do an Angio?
To determine who should undergo bypass surgery.
Stenosis of __% in a vessel is "significant"
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.
Management of 3-vessel dz w/ LV dysfxn or Left Main Coronary dz
Which drugs lower mortality in CAD?
ASA +/- Clopidogrel, Prasugrel, Ticagrelor
BB (Metoprolol, Nebivolol)
Statins to LDL goal < 100 mg/dL
ACEI if EF < 40%
Pt w/ CAD. Give statin. What is LDL goal?
Pt w/ CAD. Give ACEI when?
If EF < 40%
Pt w/ chronic stable angina. Tx?
Pt w/ chronic stable angina with persistent pain.
ASA + long-acting NTG
What is ranolazine?
Na+ channel blocker used in refractory angina.
What drug is used in refractory angina?
Ranolazine (Na channel blocker)
CAD + LDL > 100 == ??
When is a CAD pt given statins
everyone with CAD (in real life) is given Statins
Most common a/e of statins?
1) increased LFTs (AST/ALT) in 2-3% of patients
2) Myositis in <1% of pts.
Pt on statin presents with LFTs 3-5x upper limit of normal. Next step?
Stop the med.
What are the other circustances when you want to get an LDL < 100 mg/dL (i.e., start a statin)
3) Aortic disease
4) Carotid disease
What are the MC precipitants of acute pulmonary edema? 
2. Any arrhythmia
5. Salty food diet
6. Iatrogenic fluid overload
7. Hypertensive crisis
CP of acute pulmonary edema?
sudden onset of SOB worse when supine and relieved when sitting upright
Physical exam of Acute pulm edema?
2. S3 ventricular gallop
4. Peripheral edema
6. Diaphoresis and Nausea
If sx/sy of acute pulm edema are present, what is next best step?
2. Elevate head of bed
3. Call resident
4. Attach Oximeter
5. Make sure ABG is done.
6. Connect to telemetry
Diagnostic tests for Acute Pulmonary Edema?
1. EKG -- to r/o arrhythmia and ischemia
2. CXR - congestion/vascular fluid overload, effusions, cardiomegaly
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.
Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
S3 ventricular gallop
Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
JVD, peripheral edema
BUN:Creatinine ratio in CHF
CHF --> pre-renal azotemia --> increase reabsorption --> increase BUN:Cr (>20:1)
Na content in plasma in CHF
CHF pt with Hypokalemia and metabolic alkalosis. Why?
chronic Diuretic use
Lasix is not K+ sparing and contraction alkalosis occurs with depleted volume.
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.
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
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.
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.
Refractory cases of pulm edema are treated with?
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.
T/F Acutely ill patients should be given BBs
What are the positive inotropes used in the ICU for pts in CHF?
Dobutamine, Imamrinone, Milrinone.
If CHF pt is sick enough for the ICU, who should you get?
T/F CPAP/BiPAP might be necessary in CHF pt.
What is Nesiritide?
IV Atrial Natriuretic peptide
What is the IV ANP drug called?
Pt with CHF is in ICU. He was given O2, diuretics, nitrates, morphine, dobutamine, and put on CPAP. Still hypoxic. Next best step?
In outpatient clinic, what clinical signs point you to pulmonary edema?
Dyspnea, Peripheral edema, and Rales.
There's no EKG, CXR, ABG!
Pt with CHF needs which diagnostic test after acute phase is over?
ECHO tells us about...
Systolic vs Diastolic dysfxn
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
CHF therapy depends on what?
Systolic vs. Diastolic failure (determine by ECHO)
T/F Systolic dysfxn is sometimes used interchangeably w/ Dilated CM
What is systolic dysfxn?
Heart can relax (diastole) but cannot contract well.
Diastolic failure is opposite.
What are the treatment options for Systolic dysfxn?
4. Diuretics and Digoxin
5. Biventricular Pacemaker
6. Automatic implantable cardioverter defibrillator (AICD)
7. Hydralazine + Nitrates
T/F All ACEI are equal in efficacy
T/F ARBs are an alternative to ACEI and the #1 use for ARB is if pt has cough with ACEI
What are the commonly prescribed BBs for CHF (Systolic dysfxn)
Metoprolol, Carvedilol, Bisoprolol
When is spironolactone recommended?
used only in advanced stage Class III or IV CHF.
What is Class III/IV CHF?
Sx w/ minimum exertion or at rest
a/e of Spironolactone?
Hyperkalemia (K+ sparing)
Which aldosterone antagonist does not cause gynecomastia?
Eplerenone -- it still can, but less so than Spironolactone
T/F Diuretics have a mortality benefit
False, but are useful in pts w/ fluid overload
T/F Digoxin has a mortality benefit
False, but decreases sx in those ill despite other treatments
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.
When is an AICD appropriate?
It lowers mortality in those w/ Persistently low EF despite maximal medical therapy.
Pt is unable to take ACEI or ARB. Persistent hyperkalemia is the reason. Next best step to control systolic dysfxn?
Hydralazine and Nitrates.
Are there any medications or devices proven to lower mortality in diastolic dysfunction pts?
What is the standard of care for Diastolic dysfunction?
Beta blockers: Metoprolol, Carvedilol, Bisoprolol
T/F ACEI are beneficial in Diastolic dysfxn pts
T/F Hypertensive Crisis = hypertensive emergency
Define Hypertensive emergency
severe HTN w/ end-organ damage
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
Managing htn emergency
IV anti-HTN meds:
Labetalol (a1, B1, B2- blocker)
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.
any cardiac muscular disorder that impairs the function of either contraction or relaxation.
T/F In cardiomyopathy, EF is always low
False, it can be high or low
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
CM pt will show what on CXR ?
congestion or pulmonary vascular redistribution
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.
Systolic dysfxn = ___1___ CM = relaxes _2_ / contraction _3_
2. relaxes OK
3. contraction Poor
Diastolic dysfxn = ___1___ CM = relaxes _2_ / contraction _3_
define restrictive Cm
neither contracts or relaxes well.
Causes of restrictive CM
4. Endomyocardial Fibrosis
Treatment of Dilated CM
Same as Tx for systolic dysfxn:
BB, ACEI/ARB (Hydralazine+Nitrates), Spironolactone/Eplerenone, Diuretics
Treatment of Hypertrophic CM
Same Tx as Diastolic dysfxn
Tx of Restrictive CM
Correct underlying cause
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.
How is HOCM and hypertrophic CM similar from a treatment standpoint?
What increases the outflow tract obstruction in HOCM?
Anything that EMPTIES the ventricle
What clinical symptoms is HOCM assoc with?
Syncope and rarely sudden cardiac death in healthy young athletes.
What will you be asked on rounds in regards to HOCM?
1. Episodes of lightheaded ness
4. Previous studies (EKG, ECHO).
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!
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)
What is the initial test for HOCM?
What would EKG show for HOCM?
Left axis deviation, pseudo Q waves in V1-V3, ventricular arrhythmias.
What is the most accurate test for HOCM?
Left heart catheterization
Treatment of HOCM
Beta blocker - Metoprolol - FIRST THERAPY
Implantable defibrillator (for syncope prevention).
Which medication/state can worsen HOCM?
Diuretics (deplete volume)
SVT clinical presentation?
Sudden onset of palps/racing heart that may lead to SOB.
What is the approximate HR in SVT?
What are the specific physical exam findings of SVT
There are none.
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.
SVT is often caused by...
An abnormal conduction pathway around the AVN
What are the important clinical characteristics to consider for SVT?
Speed of onset of symptoms
Diagnose SVT with?
SVT shows what on EKG?
Rapid, narrow complex (<100 msec) tachycardia, usually around 160 bpm. No P waves, no fibrillation waves, no flutter waves.
What unit should SVT pts be in?
Why should an ECHO be done for SVT?
To r/o other pathology. Nothing specific for SVT.
Are CK-MB and Troponin useful in SVT?
No, but they always seem to be done.
Tx of SVT
1. Vagal maneuvers: carotid massage, valsalva, gagging, and diving reflex
3. Metoprolol, or Diltiazem
4. Electrical cardioversion (for rare cases of hemodynamically unstable or non-responsive to other therapies).
How does WPW present on EKG?
SVT alternating w/ Vtach
Delta wave found incidentally
What is a delta wave?
sign of conduction around AV node -- early depolorization of ventricles.
How does WPW present clinically?
Occasionally w/ Syncope
What is the PR interval in WPW?
SHORT (<0.12 s) d/t accessory conduction.
On rounds, when going over the WPW pt, what will you be asked?
Worsening sx or arrhythmia w/ use of Digoxin/CCB/BB
Previous cath or EP studies
What is the most accurate test for WPW?
Electrophysiology (EP) study - cath into heart tests cardiac circuits.
Treatment of WPW?
1. Procainamide (DOC), Amiodarone, Flecainide, or Sotalol [use for SVT occurring at the moment]
2. Radiofrequency catheter Ablation (permanent, long-term)
T/F Most WPW pts are not having an arrhythmia at present moment.
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.
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.
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!
Which arrhythmia is associated w/ COPD or severe lung dz?
MAT (Multifocal Atrial Tachycardia)
MAT on EKG?
At least 3 different P-wave morphologies, with variable PR and RR intervals and normal QRS width.
Treatment of MAT?
Same as Afib/aflutter, but may want to avoid BB (b/c of COPD association).
May also Oxygenate and ventilate.
Would you use electrical cardioversion for MAT?
No, it's ineffective.
All pts with Ventricular Fibrillation need to have...
CPR started immediately followed by an Unsynchronized cardioversion.
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.
Vfib = __ + __ = Vtach w/o a pulse
CPR + electric unsynchronized shock
T/F Lidocaine > Amiodarone for ACLS
What is the sequential plan for V-fib?
2. Unsynchronized shock
4. Epi (or ADH)
6. Shock again 2 min after 1st shock
8. Amiodarone (or lidocaine)
T/F V-tach is always considered an extreme emergency
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.
Normal QRS --??
Wide QRS in Vtach --??
>120 ms and reproducibly regular.
What is sustained Vtach?
30 sec or more of VTach
What is non-sustained Vtach?
<30 sec of Vtach pattern
Which pts commonly get runs of nonsustained Vtach?
ED w/ limited hemodynamic effects
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?
What is the most common cause of Vtach?
Myocardial ischemia -- so always check for Hx of MI!
Vtach patient should get what checked?
1. CK-MB, Troponin
2. e- levels (K, Mg, Ca)
4. Medications pt is on
Any anti-arrhythmic except which class can cause arrhythmia?
Low levels of which electrolytes can cause Vtach?
Can low O2 cause Vtach?
What levels of K+ (generally) can cause vtach?
High or low
What illicit drug can cause Vtach?
Ventricular tachycardia is possible d/t any CM. Which CM is most commonly associated w/ Vtach?
Dilated CM w/ low EF
Unstable pts w/ Vtach need...
immediate SYNCHRONIZED cardioversion to sinus rhythm.
Unstable = ?
SBP < 90, AMS, CP, and Dyspnea
Stable patients w/ Vtach are treated with...
Mg + Anti-arrhythmic (Amiodarone, Lidocaine, or Procainamide).
What is the most important issue with Bradycardia?
If patient has pulse < 60, next step?
EKG for etiology
Which bradycardias require no further Tx?
First degree AV block
Mobits I second degree AV block
Mobitz II and 3rd degree treatment?
Pacemaker required even if Asx!
If acute Sx...Atropine then Pacemaker
Each large boc on EKG is how many seconds? milliseconds?
2 sec, 200 ms
Over how many boxes will be considered bradycardia?
after 5 boxes. (300 -- 150 -- 100 -- 75 --60...that's 5)
Why does pacemaker make it difficult to interpret ischemia?
Wide complex QRS and abnormal T-waves are present w/ pacer spikes
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
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.
What is sick sinus syndrome?
AKA "tachy-brady syndrome" - alternating fast and slow HR.
If SSS pt has too slow of a rate (eg, pause > 3 s), tx?
If SSS pt has too fast of a rate? Tx?
What does the EKG show for Sick sinus syndrome?
Missing P waves, temporary Asystole-like picture, and restarting of P-waves spontaneously.
Sx of SSS?
dizzy, confused, syncope, fatigue, CHF
80-90% of the mortality with syncope is from ____ etiology?
cardiac and neurologic
What are the most dangerous causes of syncope? 
2. Ventricular arrhythmia
3. Aortic Stenosis
6. Brainstem stroke
For almost any type of syncope, what is the inpatient evaluation? 
2. CK-MB, Troponin
5. O2, Glc, Na, and Ca level
T/F In most cases, the cause of syncope will not be found
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.
HPI and PEx of Syncope must include?
1. Was LOC sudden or gradual?
2. Was recovery sudden or gradual?
3. Any murmurs on exam?
Most likely cause of sudden LOC?
Cardiac and neurologic causes (eg, MI, Seizures)
Most likely cause of gradual LOC?
Toxi-metabolic causes: low Glc, Hypoxia, Drug OD
Sudden regaining of consciousness usually points to a diagnosis of?
Cardiac cause: arrhythmia, MI, HOCM, or Aortic stenosis
Gradual regaining of consciousness usually points to a diagnosis of?
Seizures, low glc, hypoxia, and drug OD
If murmur is present, what is the cause of the syncope?
AS, MS, HOCM
What is Bigeminy?
Every other beat is a PVC. Normal beats in between with narrow QRS (<100 ms). PVC with wide QRS.
Does bigeminy need specific treatment?
Can carotid disease cause syncope?
No! So no need to get carotid doppler!
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.
Should you get an EEG in syncope pt?
EEG would not help much..."low yield" test.
If suspecting a cardiac cause of syncope, should you get an EKG?
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.
What can all forms of valve dz have in common?
5. Congenital or rheumatic fever
Best initial test for valve dz?
Most accurate test for valve dz?
Cath (can detect pressure difference)
Should endocarditis prophylaxis be given to a pt with valve dz?
NO! Only if the valve was replaced.
What decreases the intensity of mitral valve prolapse murmur?
increased venous return.
What decreases the intensity of HOCM murmur?
increased venous return (more blood in ventricle = less obstruction)
What actions can increase VR?
Raising legs passively
Squat from standing position
What actions can decrease VR?
What action can increase afterload?
Handgrip can worsen ____ lesions.
Mitral and aortic regurge
Handgrip may improve which murmur?
HOCM (keeps more blood in heart and decreases outflow obstruction).
Aortic and Mitral Regurgitation can occur from any cause of _____ ______
As heart dilates, the valve leaflets ___
Cardiac dilation = ?
Other than dilated CM, what are the other causes of regurtitant valve pathology?
Rare: Marfan's, Ehlers-Danlos, Ankylosing Spondylitis.
T/F Most people with AR or MR are symptomatic
When Sx, pts with MR/AR present w/ ?
Dyspnea, Rales, and Edema. Similar/Same as clinical presentation of Dilated CM.
Murmur of AR is a _____ murmur heard best at____
diastolic decrescendo..............Lower Left Sternal Border. Not in the "aortic area"!
MR murmur is a _____ murmur type
pansystolic/holosystolic best heard at lower left heart border radiating to axilla.
Both AR and MR become louder with ____
leg raise, handgrip, squatting [things that increase Venous Return and Afterload]
Both AR and MR become softer with ____
Valsalva and standing...and ACEI/ARBs
(decrease VR and Afterload)
Best test for AR/MR
EKG of AR?
LVH --- S wave in V1 and R wave in V5 > 35 mm
SV1 + RV5 > 35 mm = LVH
CXR of MR and AR
Enlarged Left Atrium and Left Ventricle
Initial therapy for AR/MR?
ACEI/ARBs or (Nifedipine?)
Is there a need for Abx ppx before a dental procedure for AR or MR?
No, unless valve has been replaced.
When is surgery (repair/replace) indicated for MR or AR?
When the EF drops or the Left Ventricular End-Systolic Diameter increases.
Surgery indication for AR?
When EF < 50-55%
LV End-Systolic Diameter (>50-55 mm) - about 2 inches
Surgery indication for MR?
EF < 60%
LV End-systolic Diameter > 45 mm
Aortic stenosis triad?
Most common symptom of AS?
Symptom of AS --> Worst prognosis
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)
Diagnosis of AS?
EKG change in AS?
recall: SV1 + RV5 > 35 mm
Why would stress tests and angiography be done in AS pts?
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.
Symptomatic AS pts - treated how?
"All" need surgical valve replacement (AVR)
What is done to patients with AS who are too ill to undergo valve replacement?
What is the role of ACEI/ARBs in AS?
Can worsen symptoms and don't help
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.
Acute CHF + AS treated with?
No BB d/t acute CHF (decrease contractility not a good idea)
Young immigrant + CHF -- think about which valve problem>?
young immigrant with rheumatic fever years ago and chronic mv scarring with MS may have what symptoms with MS?
Stroke at early age.
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)
EKG change on MS?
Left atrial enlargement = biphasic P wave in V1 and V2.
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.
Best test for MS
TEE -- fish mouth shape MV
Most accurate test for MS
Left heart cath
Tx of MS
Diuretics for fluid overload
Balloon valvuloplasty (MVR if fails)
Digoxin or BB for atrial arrhythmia control
Role of endocarditis ppx for MS?
none unless replaced MV
Most pts with MVP are (sx or asx)
When MVP is Sx, what are the sx?
Atypical chest pain (not related to exertion and not relieved by rest)
Describe murmur of MVP
Mid-systolic click followed by Late-systolic murmur of MR.
MVP worsens with?
Valsalva and standing (decreased VR)
MVP improved with?
Squatting and leg raise (increase VR)
Dx of MVP?
EKG of MVP?
CXR of MVP?
Treatment of MVP?
If Asx - nothing (no endocarditis PPX)
Sx (palps and CP) - BB
Marfan syndrome may present with what valve abnormality?
Floppy mitral valve (MVP, MR) --> sudden cardiac death.
and Cystic medial necrosis--> Aortic dissection.
Acute pericarditis CP?
CP that changes with position and respiration.
Pain of acute pericarditis is better with? worse with?
better w/ sitting up
worse w/ lying down and inspiration
Acute pericarditis on auscultation?
70-75% - nothing!
25-30% - friction rub
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
Most common class of infections that can cause pericarditis...
any infection can do it though
EKG of pericarditis
ST-elevations in all leads except aVR.
PR-segment depressions (more specific!)
the lead that does not have ST elevations in acute pericarditis is usually lead ___?
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.
What is CP of Pericardial Tamponade?
Hemodynamic dz that presents w/ SOB and lightheadedness from hypotension.
JVD with clear lung fields
Pulsus paradoxus (decrease >10 SBP on inhalation)
Decreased and muffled heart sounds
what is the relationship b/w heart rate and pericardial tamponade ?
tachycardia is present and when it isn't tamponade is very unlikely.
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,
What can pericadial tamponade look like on CXR?
pericardial effusion enlarges heart shadow in both left and right direction.
ECHO of pericardial tamponade
effusion pressing on RIGHT side of heart with right atrial and ventricular DIASTOLIC collapse as FIRST SIGN.
EKG shows low voltage....what are the possible causes?
Obesity, large breasts, COPD, pericardial tamponade
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.
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
Treatment of pericardial tamponade?
Fluids! -- prevent and possibly reverse tamponade (push back)
Pericardial window placement.
What is constrictive pericarditis due to?
Chronic pericardial INFECTION or INFLAMMATION leads to chronic thickening, fibrosis, and calcification of the pericardium.
CP of constrictive pericarditis
3. Kussmaul's sign (paradoxical increase in JVP on inhalation)
4. Enlarged Liver and Spleen
6. Pericardial "KNOCK" from filling of ventricle hitting fibrotic pericardium.
Note that 1-5 are Right sided HF signs and symptoms.
What is Kussmaul's sign?
inhalation --> paradoxical increase in JVP.
Normally inhalation --> increase VR --> decrease JVP.
CXR of constrictive pericarditis?
fibrosis, thickening, and calcification of pericardium
Chest CT/MRI of constrictive pericarditis?
fibrosis, thickening and calcification of pericardium in much better detail.
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.
Treatment of constrictive pericarditis?
Surgical removal is the only effective tx.
Diuretics and salt restriction (decrease R-sided HF sx) - sx relief only
T/F PAD is angina of the calves...
Think stable angina
1. Pain in legs relieved by REST
2. decreased peripheral pulses
3. smooth, shiny skin in severe cases.
Risk factors of PAD?
HTN, DM, HLD, TOBACCO SMOKING!
How can pain be better in PAD?
rest, dangling over edge of bed
pain worse in PAD?
worse on ANY type of exertion
(spinal stenosis is worse with walking DOWNHILL)
Diagnostic testing for PAD?
2. Dopplers of LE
A normal person's Ankle pressure will ____ arm (brachial) pressure when _____.
When upright, ankle pressure is normally ____ than arm pressure
thus, ABI 1.0-1.2 are NORMAL! - mind blown!
If ankle pressure is lower than brachial pressure by more than ___ % (i.e. ABI ___), then we suspect _____???___
obstruction to flow of blood in legs