Common Hospital Cardiac Issues

Question 1

what are some sysmptoms suggestive of ACS?

Answer 1

distress/unwell

diaphoresis

Levine’s sign

EKG → > 1 mm elevation in 2 continguous leads, new LBBB

Question 2

patient demographic that can present w/ “atypical” symptoms

Answer 2

women

elderly

diabetics

Question 3

our initial evaluation to rule out ACS is based on what two things?

Answer 3

history & EKG

Question 4

what might cause false positives troponin levels?

Answer 4

renal disease

myocarditis

cardiac contusion

recent cardiac surgery or cath

Question 5

criteria that makes somebody high risk for ACS

Answer 5

ST elevation or new LBBB

ST depression or T inversion

CP with hemodynamic instability

dynamic EKG changes

known CAD with reminiscent paint

high risk history +/- positive tropnin

Question 6

criteria that makes somebody moderate risk for ACS

Answer 6

atypical CP w/ CAD & normal or unchanged EKG

CP w/ nonspecific ST depression

low risk histoyr w/ normal EKG and + troponin

angina patient w/ rest angina w/ spontaneous resolution or primarily after NTG SL

Question 7

criteria that makes somebody low risk for ACS

Answer 7

atypical CP with negative troponins

Question 8

criteria that makes somebody extremely low risk for ACS

Answer 8

clearly MSK pain

Question 9

intial treatment in patients with chest pain in which the diagnosis is uncertain

Answer 9

admission → observation vs in-patient

MONA (morphin, O2, NTG, aspirin)

ACLS protocol as needed

Troponin-I

telemetry

Question 10

when do we usually check troponin levels?

Answer 10

usually 0, 6, 12 hours

Question 11

what is the TIMI score?

Answer 11

estimates mortality for patients w/ UA and NSTEMI

Question 12

what is included in the TIMI score?

Answer 12

age > 65 yrs

> 3 risk factors for CHD

prior coronary stenosis > 50%

ST segment deviation on admit EKG

> 2 anginal episodes in prior 24 hours

elevated cardiac biomarkers

ususe of asirin in prior 7 days

Question 13

TIMI risk for:

0-1?

2?

3?

4?

5?

6-7?

Answer 13

0-1 → 4.7%

2 → 8.3%

3 → 13.2%

4 → 19.9%

5 → 26.2%

6-7 → 40.9%

Question 14

what are some immediate issues with A fib?

Answer 14

verify rhythm

verify hemodynamic stability

ventricular rate control

BP managment

Question 15

what are some post-immediate issues with A fib?

Answer 15

identification of precipitating factors

consideration of cardioversion (if initially stable)

anticoagulation

Question 16

what are the managment goals of A fib?

Answer 16

minimize symptoms related to A fib

prevent thromboembolic complications (especially stroke)

Question 17

what do we do if a patient in A fib is hemodynamically unstable?

Answer 17

ACLS

Question 18

what are some things we want to know about a patient presenting with A fib?

Answer 18

frequency

duration

precipitating factors & mode of prior termination

vital signs

apical rate

detailed CV exam

Question 19

what does pre-excitation on an EKG indicate?

Answer 19

WPW syndrome

Question 20

what additional testing should be done on A fib patients?

Answer 20

thyroid function tests (TSH, FT4)

CXR looking for pulmonary disease

ambulatory monitoring and/or exercise testing for rate control if indicated

eval for CAD if anti-arrhythmics considered

Question 21

what are some indications for hospitalization in A fib patients?

Answer 21

cardioversion

initiation of anti-arrhythmics

rate managment

tx of associated medical conditions

elderly patients more safely treated in hospital

patients w/ risk of complications from A fib, therapy of A fib

Question 22

what is the beneift to rhythm control in A fib?

Answer 22

maintain sinus rhythm & optimal cardiac output

Question 23

what is the problem with rhythm control in A fib?

Answer 23

at best, 50-60% effective in maintaining sinus rhythm long term

Question 24

with is an adverse efffect to rhythm control of A fib?

Answer 24

pro-arrhythmia (VT, torsades, VF) which can be life threatening

Question 25

who would want rhythm control for A fib?

Answer 25

younger more active patients who benefit from optimal CO or increase risk of bleed especially athlets & occupations with increased risk of trauma patients in who rate is uncontrollable or symptomatically can't tolerate AF patients who request it

Question 26

risk progressively increases after _____ hrs of sustained AF in patients w/ risk factors for stroke

Answer 26

48 hours

Question 27

what does drug therapy do in the rate control approach to A fib?

Answer 27

slows AV donuction **(we're owrried about ventricular rate)** control rate at rest/exercise

Question 28

what drugs do we use for the rate control approach in A fib?

Answer 28

CCB (diltiazem, verapamil) beta-blocker digoxin often a combo is needed

Question 29

alternative if rate control is not obtained via drug therapy

Answer 29

ablate AV node w/ radiofrequency permanent ventricular or AV pacement

Question 30

what are some risk factors that increase a patient's stroke risk with chronic AF?

Answer 30

age \> 65 prior history of stroke diabetes mellitus history of systemic hypertension

Question 31

**anticoagulation reduces stroke incidence to ___ each year**

Answer 31

1%

Question 32

oral anticoagulation CHAD score 0? CHAD score 1? CHAD score 2?

Answer 32

0 → generally not 1 → consider 2 → generally yes

Question 33

for chronic A fib, what should be use for anticoagulation? aspirin? coumadin? NOAC?

Answer 33

aspirin → no coumadin → possible NOAC → yes

Question 34

how should anticoagulation be initiated in chronic A fib patients?

Answer 34

no bridging for NOACs Warafin- no bridging if no history of thromboembolism

Question 35

what is the definition of heart failure?

Answer 35

decreased pump function of the heart due to cardiomyopathy or wall motion abnormality

Question 36

what is the EF in systolic heart failure?

Answer 36

\< 40%

Question 37

what is impaired in diastolic heart failure?

Answer 37

impaired relaxation

Question 38

what are some possible causes of iatrogenic heart failure and/or acute pulmonary edema?

Answer 38

IVF medicatino adjustments or errors transfusion post-operative A fib

Question 39

what should be included in our assessment of heart failure?

Answer 39

focused H & P or consult 12 lead EKG continuous EKG monitoring labs- CBC, BMP, CKMB, troponin, TSH CXR consider 2D echo if iatrogenic

Question 40

acute management for heart failure

Answer 40

IV diuretic, O2, NTG, morphine sodium & fluid restriction avoid NSAIDs avoid empiric use of anti-arrhythmics correct aggravating or precipitating factors

Question 41

managment of systolic heart failure

Answer 41

**ACE inhibitor** beta blocker (once stable) thiazide diuretic in addition to furosemide spironolacton for severe CHF in addition to loop diuretic & ACE-I

Question 42

further managment of heart failure

Answer 42

anticoagulant if AF or hx of systemic or pulmonary embolism isosorbide hydralazine NTG IV

Question 43

management of mild to moderate acute on chronic CHF

Answer 43

IV or oral diuretics unless complicated by a precipitating factor or a concurrent threatening condition many do not require hopsital admission beyond several hours observation in ED

Question 44

management of moderate to severe acute on chronic CHF

Answer 44

admit approach as per acute CHF consider SCU