CV 2

Question 1

A female presents to the ED with chest and upper abdominal pain that started 40 minutes ago and rates it as an 8/10. It has not responded to antacids. The pain is aching, does not radiates, and no vomiting. She has no SOB & mentions a similar episode for 10 minutes earlier today. What diagnosis?

Answer 1

MI

Question 2

What do you see on this ECG? What is it most consistent with?

Answer 2

ST depression (that’s greater than 1mm); T wave inversion in V5 & V6

Most consistent with Myocardial Ischemia

Question 3

What is the major difference between UA & NSTEMI?

Answer 3

NSTEMI there are abnormal cardiac markers (troponins) that indicate cell necrosis.

With UA, no cell necrosis has occurred (yet)

Question 4

What is the pathology behind UA or NSTEMI?

Answer 4

Complex coronary lesions, stenosis with plaque rupture, hemorrhage, or thrombus

Question 5

What happens if you miss the diagnosis of an UA or an NSTEMI?

Answer 5

UA has a high risk of developing an MI

NSTEMI will progress to a larger MI/death

Question 6

What are the major symptoms of UA or NSTEMI?

Answer 6

Substernal chest pain/discomfort at rest, that lasts longer than 10 minutes

Question 7

What might you see on PE with UA or NSTEMI?

Answer 7

S4 gallop is common! Variables changes in LV function

Question 8

So, what’s the criteria to diagnose NSTEMI?

Answer 8

ONE value (serial markers every 6-8 hours) >99th percentile of upper reference limit

* Classic curve of troponins: Starts slightly elevated, peaks, and comes back down

*Remember values that are elevated but not quite in the 99th percentile, you should be suspicious of (troponin should never be elevated)

Question 9

What’s the one type of patient who might give you a false positive on troponins?

Answer 9

Those with chronic renal failure

Question 10

What are some of the risk factors to UA or NSTEMI?

Answer 10

Older than 65

Prior coronary stenosis

ST seg deviation

2 or more angina episodes in prior 24 hours

Question 11

You have a patient you are concerned has UA or NSTEMI, but their first biomarkers are negative, ECG is normal, what do you do?

Answer 11

Continuous monitoring, serial ECG’s, and serial troponins

Question 12

If absolutely everything came back stone cold normal for 24 hours, what do you do with your patient who you were concerned about UA or NSTEMI?

Answer 12

Stress test/imaging

Question 13

Your patient that you thought had an MI but was normal for 24 hours just had a stress test done and it came back positive for ischemia – what do you do? What if it had come back negative?

Answer 13

Positive à Cath lab (possible revascularization)

Negative à Discharge

Question 14

Let’s say the patient you’re concerned about an MI has ST depression, positive troponins and still has chest pain – what do you do?

Answer 14

NTG (3 in the ED)

ASA (chew 325mg)

Start oral beta-blocker

Can add CCB

**SINCE THERE ARE ELEVATED TROPONINS ITS AN NSTEMI SOOOOO ADD:

Full Anticoag (LMWH)

Prasugrel or Trcagrelor

Question 15

For our patient that has a NSTEMI, we have started her on all the appropriate meds, what do we do next?

Answer 15

Most NSTEMI’s should be considered for revascularization

Question 16

What factors would favor revascularization?

Answer 16

Recurrent angina/ischemia, elevated troponins, ST depression on ECG, Develop CHF or EF (that’s less than .40), sustained VTach

Question 17

A woman presents with 7 day history of 3/10 chest discomfort and SOB. She describes it as fullness. She has had increasing fatigue, but today she is very fatigued with increasing SOB at rest – what diagnosis?

Answer 17

Pericardial effusion (with possible tamponade)

Question 18

What would we see on PE with pericardial effusion with compression – tamponade?

Answer 18

JVD, soft heart sounds but clear lungs, hypotensive –> varying BP’s

Question 19

What do you see on this ECG?

Answer 19

Low voltage (in both limb and precordial leads) with flat T waves

Question 20

When we see low voltage on ECG & we are concerned about pericardial effusion what diagnostic test must we order? What would we see?

Answer 20

Echo – RA/RV collapse in early diastole

Thus we would have to re-evaluate the BP to see if a drop of >10mmHg in systolic BP occurs with INSPIRATION

*If so, that indicates PULSUS PARADOXUS à CARDIAC TAMPONADE

Question 21

What is cardiac tamponade?

Answer 21

Pericardial effusion elevates to a pressure causing compression of the heart.

Leads to progressive limitation of diastolic filling & is FATAL if not recognized and aggressively treated

Question 22

What 3 things are often associated with tamponade, what are they known as?

Answer 22

Beck’s triad = decline in arterial pressure,

elevation of systemic venous pressure, and quiet heart

Question 23

If we give someone with tamponade a small amount of IV fluid what would we expect to happen?

Answer 23

BP will go up for a short period of time since CO is extremely Volume Sensitive

Question 24

How do we treat cardiac tamponade?

Answer 24

Pericardiocentesis

Question 25

A patient presents to the ED with severe SOB that awoke him abruptly from sleep. He denies any form of chest pain. He has a history of an MI 1 year ago and has not been compliant with his medications. His O2 sat is 90% and he is becoming more anxious with more difficulty breathing - what diagnosis?

Answer 25

acute pulmonary edema

Question 26

What might you find on PE with acute pulmonary edema?

Answer 26

Crackles & rales Apical holosystolic murmur (mitral regurg) & S3 gallop JVD

Question 27

What diagnostic test should you get with acute pulmonary edema?

Answer 27

ECG CXR – vascular redistribution, alveolar edema in a “butterfly” pattern, with Kerly B lines BNP – elevated (due to increased filling pressures)

Question 28

How do we treat acute pulmonary edema?

Answer 28

This is a medical emergency!!! Give O2! Morphine sulfate (venodilator & reflex withdrawal of sympathetic NS) IV diuretics Nitrates (especially if elevated BP) to decrease preload

Question 29

A patient presents to the ER with a racing heart and palpitations for the past 5 hours. He denies any SOB. On PE his BP 155/90 and his rhythm is irregular at 150bpm – what diagnosis?

Answer 29

Atrial Fibrillation

Question 30

What do you see on this EKG?

Answer 30

Afib

Question 31

In Afib, how might the pulses vary between over the heart and radial?

Answer 31

Radial will be less because the heart hasn’t filled enough to create an appropriate output

Question 32

What is our first priority when we have a patient in AFib?

Answer 32

Assess hemodynamic stability (BP, P, and sxs)

Question 33

If a patient is not stable and in Afib – what do you do?

Answer 33

Cardioversion

Question 34

If a patient in stable and in Afib – what do you do next?

Answer 34

Echo – to look for underlying cardiac or pulmonary precipitating factors Figure out how long it has been present for Control their rate with Diltiazem

Question 35

What happens if you learn the person’s Afib has been present for \>48 hours?

Answer 35

You must **fully anticoagulated for 3 weeks** before cardioversion

Question 36

If a patient has persistent/recurrent Afib how do you manage them?

Answer 36

Rhythm control (cardiovert + meds or ablation) Rate control (leave in afib & anticoag)

Question 37

What medication can you give for rapid conversion of recent onset Afib or Aflutter?

Answer 37

Ibutilide

Question 38

A patient comes to the ED with severe HA & Nausea. She has also been confused. Hx of HTN & dyslipidemia but stopped all meds when she lost her job. She also smokes 2ppd. Her current BP is 230/130 – what diagnosis?

Answer 38

HTN Emergency!

Question 39

What do you look for on PE with HTN Emergencies?

Answer 39

EYES! – Arteriolar narrowing, A/V nicking, disc margins & papilledema

Question 40

What labs do you want to check with HTN Emergencies?

Answer 40

Kidney’s (UA for protein) Along with CBC, INR, PTT, and Lytes

Question 41

If a patient is asymptomatic with high BP – how would we treat them?

Answer 41

Do not require emergent Rx

Question 42

BTW, what is considered high BP?

Answer 42

Greater than 200/110

Question 43

What’s the difference between a HTN urgency & HTN Emergency?

Answer 43

Urgency = Lower BP within a few hours (no more than 25% within 2 hours) Emergency = Lower BP within 1 hour (to avoid HTN encephalopathy, nephropathy)

Question 44

What do we need to make sure of when we suspect a HTN urgency?

Answer 44

It’s not an MI

Question 45

What meds are 1st line for HTN Emergencies?

Answer 45

Nicardipine or Clevipine

Question 46

What other meds can you use of a htn emergency?

Answer 46

Labetolol, Esmolol, IV NTG

Question 47

A patient brought in by EMS developed acute abdominal pain 25 minutes ago. Hx includes CHD, HTN, and PAD & he’s a heavy smoker. In route to the ED he becomes progressively hypotensive. He’s given fluids & his BP drops near 60mmHg (systolic) – what diagnosis are you thinking?

Answer 47

Aortic aneurysm

Question 48

What could have been seen on PE for this patient long ago to prevent his current state of aortic aneurysm?

Answer 48

Pulsatile aortic mass in the stomach

Question 49

What do we monitor AA’s with to make sure they’re not expanding too much?

Answer 49

Ultrasound

Question 50

Who should be screened with an ultrasound for AAA’s?

Answer 50

Male smokers over 60 who… - Have a family history of AAA - Presence of PAD/atherosclerosis - Presence of peripheral artery aneurysms

Question 51

If a patient is asymptomatic when do we stent the aorta to prevent AAA?

Answer 51

Always do surgery if greater than 6.5cm Probably surgery if greater than 5 cm