Internal Cardiology Flashcards
(24 cards)
What is the first step in the treatment for a myocardial infarction?
MONA
- Morphine: vasodilator, muscle relaxant, for pain relief
- Oxygen: if the saturation is <90%
- Nitrates: mixed vasodilatory effect,
- Aspirin: reduces the mortality risk
What are the contraindications of NITRATES?
- Inferior MI
- RCA
- Patients who use sildenafil (viagra)
- Patients with SBP<100mmHg
How is aspirin used with other anti aggregates (DAPT)?
Combine aspirin with either:
1. Ticagrelor: patients <75 years (side effect: dry cough)
2. Clopidogrel: patients >75 years
3. Prasugrel: STEMI patients
Patients who are <75 years and who are undergoing PCI in the next 24hrs —> aspirin alone is enough
What is the next step in therapy after MONA?
BASA
- Beta blockers: decrease pain, infarct size, incidence of ventricular arrhythmia
- Anticoagulants: LMWH\Enoxaparin
- Statins: goal is after 6-8 weeks LDL must be <55 or <50%, if not enough —> add Ezetimibe
- ACEIs: Enalapril
What are the side effects/contraindications of BASA?
- BBs contraindications: hypotension, bradycardia, anterior MI, uncontrolled acute he3art failure
- Statins side effects: muscle pain
- ACEIs side effects: dry cough, angioedema (stop drug immediately), reduced kidney function (>30% —> stop drug immediately)
Patient >65 years old, diabetic and has hyperlipidemia, what type of procedure do you perform?
PCI not CCTA (Coronary CT Angiography)
What is Prinzmetal’s angina?
Vasospastic angina
It has the same clinical picture as MI: ECG changes, high troponin BUT CLEAN PCI
Treatment: CCBs, nitrates
** Aspirin is contraindicated since it causes further spasms
* RCA is the most affected vessel
Absolute contraindications for fibrinolysis:
- Hx. Of cerebrovadcular hemorrhage at any time
- Non-hemorrhagic stroke or other cerebrovascular event within the past year
- Marked HTN SBP>180 and/or DP>110
- Suspicion of aortic dissection
- Active internal bleeding
Relative contraindications for fibrinolysis:
- Current use of anticoagulants
- Recent (<2 weeks) invasive/surgical procedure
- Prolonged (>10 mins) cardiopulmonary resuscitation
- Known bleeding diathesis
- Pregnancy
- Active peptic ulcer
- Hx. Of HTN that is controlled by
Side effects of beta blockers:
- Fatigue
- Reduced exercise tolerance
- Nightmares
- Bradycardia
- Impaired atrioventricular conduction
- LV failure
. Worsening claudication - Intensification of the hypoglycemia produced by hypoglycemic agents (e.g. insulin)
Contraindications for stress test:
- Rest angina within 48 hours
- Unstable rhythm
3 severe aortic stenosis - Acute myocarditis
- Uncontrolled heart failure
- Severe pulmonary HTN
- Active infective endocarditis
Negative stress test results are:
- UPSLOPING ST depressions
- Depression <1mm
Complications of coronary stents
- Restenosis: hyperplasia of the neointima/proliferation of arterial tissue (DES reduces this risk significantly)
- In-stent thrombosis: higher incidence in DES, DAPT for 1 years reduced the risk significantly
Indications for coronary ARTERIOGRAPHY:
10 points
- Patients with chronic stable angina and severe symptoms despite adequate medical treatment
- Symptomatic patients who have diagnostic difficulties and need to confirm the presence of IHD
- Patients who had cardiac arrest and had angina pectoris
- Patients with ventricular dysfunction and angina or evidence of ischemia
- Patients with chest pain in whom diagnostic tests were negative
- Repeated admission to the hospital for suspected acute coronary syndrome
- Patients with aortic stenosis or hypertrophic cardiomyopathy
8.men>45 and female>55 who will undergo cardiac surgery - Patients after MI
- Patients with a high risk of IHD in whom diagnostic tests indicate high risk of coronary event
What is the treatment of Atrial Fibrillation after 48 hours of onset?
Stasis —> is of stroke, therefore;
1. Transesphageal echocardiography (TEE) :
- no thrombus found: synchronized cardio version + amiodarone
- thrombus present:anticoagulants for 6 weeks
Which anticoagulants are used in the reatment of A-fib? And why?
- LMWH (clexane)
- Heparin
- Warfarin: mechanical valve/ severe aortic stenosis/ APLA syndrome (check INR)
- DOAC: Dabigatran, Apixaban, Rivaroxaban (prevent stroke, used in all patients for 4 weeks)
- Dabigatran = direct anti thrombin
** Apixaban and Rivaroxaban = factor X
What are the side effects of statins?
- Myositis
- Hepatotoxicity
what are the most common causes of death in hypertensive patients?
- Essential HTN: heart disease
- 2ndary HTN: renovascular disease
what is the most leading cause for 2ndary HTN?
primary renal disease
Systolic hypertension with wide pulse pressure can be seen in:
- Arteriosclerosis
- Aortic regurgitation
- Thyrotoxicosis 🦋
- Patent ductus arteriosus (PDA)
- Fever 🤒
- Arteriovenous fistula
- Hyperkinetic heart syndrome 💗
HFrEF treatment steps:
- Diuretics (loop; fused/thiazide; metolazone or both)
- ACEI (e.g. lisinopril) if not tolerated then change to ARB (e.g. valsartan)
- Beta blockers (MBC)
If still symptomatic and EF<35% —>
- Add aldosterone antagonists (spironolactone\eplerenone)
If still symptomatic despite maximum dose of ACEI/ARB and EF<35% —>
- Add ARNI (Entresto, aka sacubutiril.valsartan) but stop ACEI/ARB
IF STILL SYMPTOMATIC DESPITE OPIMAL MEDICAL TREATMENT AND EF<35% —>
ICD e
Summary of hypertrophic obstructive cardiomyopathy (HOCM):
- Inheritance pattern: autosomal dominant
- Type of dysfunction: diastolic
- Physical exam:
1. S4 loud
2. Systolic ejection murmur that INCREASES with standing and valsalva, but DECREASES with squatting, handgrip, leg raising, laying down
3. Bisferious carotid pulse - Symptoms: dyspnea, chest pain, dizziness, syncope, arrhythmias, heart failure, SCD
- Echocardiography: LVH, asymmetric septal hypertrophy, SAM, dynamic LV outflow tract obstruction
- ECG findings: LVH, deep inverted T waves in anterior and lateral leads
- Treatment: fluids, BBs, CCBs
Summary of restrictive cardiomyopathy (RCM):
- Impaired diastolic filling
- Main causes: amyloidosis, sarcoidosis, hemochromatosis, carcinoid syndrome, idiopathic, chemotherapy, radiotherapy,scleroderma
- Main clinical features: dyspnea and exercise intolerance, right-sided HF signs (JVD, ascites, hepatomegaly, edema)
- Diangosis: ECG, echocardiography, endomyocardial biopsy
- Echocardiography features: thick myocardium, enlarged left&right atria, nromal left&right ventricles, speckled myocardium in amyloidosis
- ECG findings: low voltage QRS complexes, conduction abnormalities, arrhythmias
- Treatment: treat the underlying cause
