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Flashcards in MTB 2 CK - Cardio Deck (102):
1

Normal splitting

S1 A2|P2
during inhalation (drop in intrathoracic pressure, increased venous return, longer pulmonary ejection time)

2

Wide splitting

S1 A2| |P2
Conditions that delay RV emptying (pulmonic stenosis, RBBB)
Exaggeration of normal

3

Fixed splitting

S1 A2| |P2
Seen in ASD (increased RV filling). Always there, similar to wide splitting...

4

Paradoxical splitting

S1 P2| |A2
Delayed LV emptying (aortic stenosis, LBBB)
P2 occurs before A2 which is abnormal.
On inhalation, P2 is prolonged, moves closer to A2, can be no splitting

5

(Maneuver and effect)
-Inhalation
-Exhalation
-Hand grip
-Valsalva
-Rapid squatting

-Increased right heart sounds
-Increased left heart sounds
-(increased SVR) Increased intensity of MR, AR, VSD, MVP murmurs (all things where flow is going backwards); decreases intensity of AS, HCOM (less fluid moving forwards to make a big sound)
-(decreased venous return/preload increases LV outflow obstruction) increases intensity of MVP and HCOM
-(increases venous return/preload) decreases HCOM

6

GI disorders associated with chest pain (4)

Ulcer disease
Cholelithiasis
Duodenitis
Gastritis

7

Around what age do the protective effects of estrogen wear off for women?

55-60yo

8

Pro ischemic pain qualities

soreness, dullness, squeezing, pressure-like pain

9

Anti-ischemic pain qualities

sharp, knifelike, lasting a few seconds

10

Fever + chest pain suggests

PE or pneumonia

11

Office chest pain days to weeks. Cardiac enzymes?

No

12

Office chest pain minutes to hours. Cardiac enzymes?

Yes

13

maximum HR equation

220-age

14

What if you can't read the EKG? What test do you order

Thallium or sestamibi uptake scan.
Echo

15

Remember the difference in ischemia and infarction!

!

16

Holter monitor does not detect

ischemia (don't do it for chest pain!!)

17

Holter monitor does detect

arrhythmia

18

Chronic angina meds (3)

Aspirin
B-blocker
Nitroglycerin

19

When to give Clopidogrel (CAD)

if aspirin intolerant (allergy)
w/ recent angioplasty w/ stenting

20

Prasugrel: don't give to patients >75yo due to

risk of hemorrhagic stroke

21

Give ticlopidine if (CAD)

allergic to aspirin and clopidogrel (but not bc of bleeding!)

22

Ticlopidine adverse effects

neutropenia, TTP

23

When to give statins for CAD

LDL >100

24

What do you need to check regularly in a patient on a statin?

AST/ALT
Liver dysfunction MC adverse effect

25

Niacin adverse effects

glucose, uric acid, itchy

26

fibric acid adverse effects

myositis with statins

27

ezetimibe adverse effects

well tolerated but useless

28

CCB in CAD

may increase mortality by raising HR

29

When to use CCB in CAD

1. Severe asthma
2. Prinzmetal angina
3. Cocaine-induced angina (B-blocker CI)

30

Adverse effects of CCB

1. Edema
2. Constipation
3. Heart block (rare)

31

PCI vs. med mgmt in chronic angina

medical mgmt is better

32

Don't use PCI for...

stable patients

33

Heart sound associated with acute coronary syndrome

S4

34

Kussmaul sign

increase in JVP on inhalation
--constrictive pericarditis, restrictive cardiomyopathy

35

continuous machine like murmur

PDA

36

Which is worse MI in V2-V4 or MI in II, III, aVF?

V2-V4--this is anterior wall. Higher mortality than inferior wall (II, III, aVF)

37

Pathologic potential of first degree AV block?

Very little

38

Should you treat PVCs?

Nope

39

Leads V1 and V2 should be read...

backwards (ST elevation is actually depression and depression is actually elevation) because they are posterior leads

40

O2, NG, aspirin, morphine--which to give first in acute MI?

Aspirin. The only one that lowers mortality

41

What is the earliest cardiac enzymes become elevated?

4hr

42

Myoglobin onset

1-4hr

43

Myoglobin duration

1-2d

44

CK-MB onset

4-6hr

45

CK-MB duration

1-2d

46

Troponin onset

4-6hr

47

Troponin duration

10-14d

48

2 problems with troponin levels

1. cannot detect reinfarction during window of elevation
2. if patient has renal insufficiency can have false positive troponins (renally excreted)

49

How do we detect reinfarction w/in a few days of first?

CK-MB

50

MCC of death after recent MI

ventricular arrhythmia

51

PCI vs thrombolytics in ACS

PCI

52

Warfarin in ACS

NOT USED. used for clots in venous side of circulation. no use in coronary disease

53

Heparin in ACS

usually given at the time of PCI but discontinued long term

54

Which is better, immediate thrombolytics or delayed angioplasty?

Immediate thrombolytics

55

1, 2 tx for ST segment depression

1. Aspirin
2. Heparin

56

Thrombolytics for ST depression ACS

No. no clot.

57

Utility of GP2B3A inhibitors

--Not helpful in STEMI alone
--Helpful in STEMI/ACS with angioplasty or stenting
--Helpful in NSTEMI

58

Stable angina meds

...

59

Weight loss affects

BP

60

Exercise affects

HDL

61

Smoking affects

HDL

62

when is the only time tPA is beneficial?

STEMI

63

What is Heparin best for?

non-STEMI

64

All of the complications of MI can have this symptom

Hypotension.

Will not lead you towards one diagnosis

65

MI complication w/ cannon A wave

Third degree heart block

66

TX of bradycardia after MI

Atropine
Pacemaker prn

67

RV infarction--artery?

Right coronary artery

68

RV infarction exam finding

clear lungs

69

RV infarction, wall?

inferior

70

RV infarction dx

flip EKG leads, elevation in RV4

71

Right coronary artery supplies (3)

RIght ventricle
Inferior wall
AV node

72

TX of RVI

high-volume fluid replacement

73

Tx to avoid in RVI

nitroglycerin

74

Presentation of free wall rupture

tamponade
sudden loss of pulse/pulseless electrical activity
clear lungs

75

Vtach/Vfib tx

cardioversion/defibrillation

76

Valve/septal rupture presentation

New onset murmur
New onset pulmonary congestion

77

After MI if you have an increase in O2 sat between RA and RV

Septal rupture

78

Intraaortic balloon pump

Never a permanent device
Bridge to surgery for valve replacement or transplant for 24-48hr

For acute pump failure or anatomic problem that can be fixed in OR

79

Ventricular aneurysm tx

none needed

80

Ventricular mural thrombus tx

heparin then warfarin

81

Post-MI stress test

to determine residual ischemia, need for revascularization (angina)

Would do angiography next if +

82

Post-MI angiography

to determine need for revascularization w/ angioplasty or CABG
(don't do if infarcted w/ dead myocardium, only if reversible)

83

Prophylactic anti-arrhythmics

DO NOT USE. INCREASE MORTALITY

84

Transthoracic vs transesophageal echo for CHF

Transthoracic

85

Utility of TEE

most accurate test to evaluate valve function and diameter

86

When is nuclear ventriculography the best test for CHF?

Rarely. When giving chemo (doxorubicin)

87

bNP

if normal, rules out CHF.
Do this if w/ acute SOA the etiology is not clear and can't wait for an echo

88

Tests to determine ETIOLOGY (not diagnosis of) CHF

EKG--MI, heart block
CXR--dilated cardiomyopathy
Holter monitor--paroxysmal arrhythmias
Cardiac cath--Precise valve diameters, septal defects
CBC--Anemia
TSH--high and low levels can cause CHF
Endomyocardial biopsy--rarely done; sarcoid, amyloid, infections
Swan-Ganz catheter--distinguishes CHF from ARDS; not routinely done

89

Drugs that lower CHF mortality

ACE-I, B-blocker, Spironolactone
Hydralazine + Nitroglycerin
Implantable defibrillators

90

Tx of systolic CHF

ACE-I--everyone gets this
B-blocker--metoprolol, bisoprolol, carvedilol only
spironolactone--class III, IV
diuretics--loop, to control symptoms
digoxin--to control symptoms and decrease hospitalizations
hydralazine + NG--in substitution for ACE-I

91

CCB in systolic CHF

no benefit

92

+ inotropes in systolic CHF

no benefit

93

Routine anticoagulation w/ warfarin in CHF

never a right answer is there is no clot

94

TX of diastolic CHF

B-blockers--definitely
Diuretics--definitely
DO NOT USE--digoxin, spironolactone
Uncertain: ACE-I, ARB, hydralazine

95

Diuretics in HCOM?

No! will increase obstruction

96

Tests for pulmonary edema

BNP, CXR, ABG, EKG, Echo
These will help determine ETIOLOGY of pulmonary edema

97

most important acute test for pulmonary edema and why

EKG--an arrhythmia could be the etiology

98

Best initial therapy in pulmonary edema

1. Diuretics
O2, morphine, nitrates, ACE-I

99

3 approaches of treating pulmonary edema

preload reduction, positive inotropes, afterload reduction

100

preload reduction therapy in pulmonary edema

diuretics, nitrates

101

+ inotropes in PEd

dobutamine, amnirone/milrinone
Used in acute setting (ICU) when unresponsive to preload reduction

102

afterload reduction in PEd

nitroprusside, hydralazine acutely
ACE-I long term if systolic dysfunction