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Flashcards in Step Up to medicine - Cardiovascular Deck (503):
1

stable angina pectoris is due to __________ narrowing of _________ vessels

fixed
atherosclerotic

2

what are the top 5 risk factors for stable angina pectoris

DM
HLD
HTN
Cigarette smoking
age
FHx

3

what are the two prognostic indicators for CAD

Left ventricular function
vessels involved

4

which of the vessels involved in CAD purports the worst prognosiss

left main

5

T/F multiple vessel disease is worse that single vessel

T

6

T/F ischemic pain changes with changes in body positioning and breathing

F ( does not change with these changes, these would indicate a different pathology for the pain)

7

Any combination of Hypercholesterolemia
Hypertriglyceridemia impaired glucose tolerance
diabetes hyperuricemia
HTN
Key underlying factor is insulin resistance

Metabolic syndrome X

8

exertional angina with normal coronary arteriogram
exercise testing and nuclear imaging show evidence of myocardial ischemia

syndrome X

9

T/F physical exam in patients with CAD is often normal

T

10

what is the typical outcome of resting ecg in patients with stable angina

normal

11

Q waves present on resting ECG indicate

prior MI

12

how does the diagnosis of angina change with presence of ST elevations or segmeental changes

unstable

13

useful test for patients with an intermediate pretest probability of CAD based upon age gender and symptoms

stress test

14

quick and dirty method for finding a persons maximum HR

220 - age

15

patients with a positive stress test should undergo

cardiac cath

16

what is the parameter by which a stress test is considered postive

ST segment depression
ventricular arrhythmia
hypotension

17

stress test is 75% sensitive if patients can complete what task during the test

increase HR to 85% maximum

18

when is the echo performed in stress echo

after exercise

19

patients with a positive stress echo should undergo

cardiac cath

20

what cardiac pathology does not allow radioactive testing in cardiac workup

left bundle branch block

21

what should be done in cardiac workup if patient cannot exercise

pharmacologic testing

22

how do IV adenosine and dipyramidole work with pharmacologic testing

cause coronary vasodilation which means that the vessels supplying ischemic portions of the heart are already maximally dilated therefore the shunting of blood to the areas of the heart in which the vessels still have vasodilatory capacity will lead to ischemic changes in the vessels that supply ischemic portions of the heart

23

how does dobutamine work in pharmacologic testing in cardiac workup

increases HR, strength of contraction, increases BP

24

can be useful for detecting silent ischemic, arrhythmias, heart rate variability and assess pacemaker/ ICD function

holter monitoring

25

useful testing for unexplained dizziness and syncope if cardiovascular cause suspected

holter monitoring

26

definitive test for CAD

cardiac catheterization

27

most accurate test for detecting CAD

cardiac angiography

28

if CAD is severe typically with three vessel disease what should be done

surgical (CABG) repair

29

what medication is commonly employed in lowering cholesterol and decrease risk for CAD

statins (HMG CoA reductase inhibitors)

30

what types of fats should be avoided in patients with CAD

saturated

31

what medical therapy is indicated for all patients with CAD

aspirin

32

first line therapy that has been shown to decrease the number of coronary events in patients with CAD

beta blocker

33

relieve angina by reducing preload myocardial O2 demand
VERY COMMON

nitrates

34

medical therapy that induces coronary vasodilation and afterload reduction

calcium channel blockers

35

If CHF is present in patients with CAD then what two medications can be added on to the typical therapeutic options of aspirin beta blockers and CCbs

diuretics and ACE inhibitors

36

Mild disease
normal EF
mild angina
single vessel

what should be done in terms of management on top of aspirin therapy

beta blockers and nitrates

consider CCBs if symptoms persist

37

normal EF moderate angina and two vessel disease

coronary angiography to assess for revascularization

38

decreased EF
severe angina
three vessel of left main or LAD disease

angiography to consider CABG

39

T/F oxygen demand is increased in unstable agina

F (only the supply is diminished)

40

significant because it indicates stenosis that has enlarged via throbosis hemorrhage or plaque rupture

unstable angina

41

chronic angina with increasing frequency duration or intensity of chest pain
new onset that is severe and worsening
angina at rest

unstable angina

42

what is the only test that determines the difference between unstable angina and NSTEMI

cardiac enzymes

43

in what order should testing and management be carried out in patients with unstable angina

medically stabilize symptoms first before stress testing or angiography to assess for two/three vessel disease

44

patients with unstable angina should undergo what global management in terms of placement, nuts and bolts medical management

admission to hospital for continuous cardiac enzyme monitoring
establish IV access and give 2L fluids initially
give supplemental oxygen
control pain with nitrates and morphine

45

what is the aggressive medical management employed in a patient with unstable angina

supplemental oxygen
IV fluid resuscitation
beta blockers (if no contraindications)
aspirin/clopidogrel
LMWH
nitrates
K+ and Mg+ replacement (to avoid arrhythmia)

46

duration of aspirin and clopidogrel dual therapy in patients presenting with unstable angina

9 to 12 months

47

PERCENTAGE of patients that recover following initial aggressive medical management in the case of unstable angina

90%

48

what should be done in the management of a patient with USA that responds to initial medical management

stress ECG to assess need for catheerization

49

what is the immediate management in an individual that fails initial medical management in the setting of USA

immediately proceed to the cath lab

50

what is continued following acute treatment of USA

aspirin beta blockers and nitrate

51

what are the two beta blockers typically employed in the treatment of USA

metoprolol and atenolol

52

on top of continuing medical management what should be done in individuals with USA following acute treatment

reduce risk factors

smoking cessation
treat DM HTN HLD

53

t/F following USA a patient should be started on statin regardless of LDL level

T

54

transient ST segment elevation classically occuring at night associated with ventricular dysrhythmia

prinzmetal (variant) angina

55

what two medications are proven helpful with variant angina

CCBs and nitrates (those that vasodilate)

56

due to necrosis of myocardium as a result of an interruption of blood supply

MI

57

most cases of MI are due to

acute coronary thrombosis

58

mortality rate associated with MI

30%

59

what are the two medications that are utilized in the coronary angiography when looking for variant angina

ergonovine or acetylcholine

60

intense substernal pressure sensation
radiation to neck jaw arms back
pain typically unresponsive to nitro
epigastric discomfort

MI

61

T/F MI can be asymptomatic in up to one third of patients

T

62

painless infarcts or atypical MI more likely in these 4 demographics

women
postoperative
elderly
diabetics

63

less common symptoms of MI

dyspnea
diaphoresis
weakness fatigues
nausea vomiting
snese of impending doom
syncope

64

very early sign of MI that is often missed

peaked T waves

65

ECG sign indivating transmural injury and diagnostic of acute infarct

ST segment elevation

66

evidence for necrosis usually seen late and typically absent acutely

Q waves

67

T/F T wave inversion is specific for MI

F (sensitive not specific)

68

ECG finding associated with subendocardial ischemia

ST segment depression

69

currently the diagnostic gold standard for MI versus USA

cardiac enzymes

70

time period over which troponins return to normal

5-14 days

71

when do troponins reach their peak

24-48 hours

72

what is the utility of CKMB enzymes

reinfarction measurement

73

PROVE IT TIMI 22 trial proved starting this agent should be part of maintenance therapy in MI management

statin (specifically atorvastatin 80mg)

74

what are the 7 agents that should be initiated in the acute treatment of MI

morphine
oxygen
nitrates
aspirin
ace inhibitor
statin
heparin

75

this ultimate treatment should be incorporated to the treatment of all patients being managed for acute MI

revascularization ASAP

76

what is the time period in which revascularization should be attempted in any patient presenting with acute MI

within 90 minutes

77

this outcome occurs with rupture of papillary muscle infarction ischemia

mitral regurg

78

length of time with which patients receiving a bare metal stent should be on dual platelet therapy

one month

79

how long should a patient be on dual platelet therapy following the placement of drug eluting stents

12 months

80

what is the most common cuase of inhospital mortality following MI

CHF

81

what is the treatment for PVCs following acute MI

conservative management (no need for antiarrhythmic agent)

82

what should be done in a stable patient that shows VTach that is sustained

IV amio

83

what should be done in an unstable patient that shows Vtach that is sustain

electrical cardioversion

84

what is the treatment for vfib following MI

immediate desynchronized defibrillation and CPR

85

sinus bradycardia management in the setting of acute MI

observation
if severe atropine may be helpful in increasing HR

86

asystole management in the setting of acute MI

elecrtrical defibrillation if thought to be 2/2 VFIB
transcutaneous pacing if asystole is clearly the cause

87

what is the typical cause for AV block in the setting of MI

infarction of the conduction tracts

88

second or third degree block has a terrible prognosis in the setting of what type of MI

anterior

89

what should be done in second or third degree heart block in the setting of anterior MI

temporary pacing (transcutaneous or transvenous)

90

initial management for heart block secondary to inferior MI

atropine

91

treatment for heart block 2/2 inferior MI that is refractory to initial treatment with atropine

pacemaker

92

T/F recurrent infarction is not as bad in prognosis as initial MIA

F (worse in both acute and long term prognosis)

93

catastrophic mechanical complication of MI that occurs within the first TWO WEEKS after MI

free wall rupture
usually within the first 1-4 days

94

what are the usual immediate complications of free wall rupture

hemopericardium and cardiac tamponade

95

what is the immediate treatment for free wall rupture

hemodynamic stabilization
pericardiocentesis
surgical repair

96

T/F interventricular septal rupture following MI is typically worse in prognosis than frree wall rupture

F (better prognostically)

97

what is the indication for interventricular septal rupture following MI

emergent surgery

98

time table for interventricular septal rupture following MI

within 10 days

99

new onset MR folloiwng MI cause

papillary muscle rupture

100

what is the immediate indication for new onset MR following MI

echo

101

what is the treatment for papillary muscle rupture

surgical (mitral valve replacement typically)

102

why are ventricular pseudoaneurysms considered surgical emergencies

tend to become free wall ruptures if left alone

103

acute pericarditis secondary to MI typically treated with

aspirin

104

what medications are contraindicated in the case of acute pericarditis following MI

NSAIDs

105

Immunologically based syndrome consisting of fever malaise pericarditis leukocytosis and pleuritis occuring weeks to months after an MI

dressler syndrome

106

what is the most effective therapy for dressler syndrome

aspirin

Ibuprofen is a good secondary choice

107

6 main causes/systems leading to chest pain

Cardiac
Pulmonary
GI
Chest wall
psychiatric
cocaine

108

Heart pericardium vascular causes for chest pain

stable angina
USA
variant angina

MI

Pericarditis

Aortic dissection

109

Pulmonary causes for chest pain (3)

pulmonary embolism

PNA

status asthmaticus

110

GI causes for chest pain (4)

GERD
diffuse esophageal spasm
peptic ulcer disease
esophageal rupture

111

Chest wall causes for chest pain (5)

costochondritis
muscle strain
rib fracture
herpes zoster
thoracic outlet syndrome

112

3 main psych causes for chest pain

anxiety panic attacks somatization

113

3 tests that are obtained for practically all patients presenting with chest pain

ECG
troponins
chest xray

114

clinical syndrome resulting from the hearts inability to meet the body's circulatory demands under normal physiologic conditions

CHF

115

what are the two most common causes for systolic CHF dysfunction

HTN and ischemia (MI)(

116

echocardiogram showing impaired relaxation of the left ventricle

diastolic dysfunction

117

which form of CHF is most common

systolic (HTN AND ISCHEMIA MUCH MORE COMMON PATHOLOGIES)

118

most common cause of diastolic CHF

HTN leading to hypertrophy of myocardium

119

aoritc stenosis mitral stenosis and aortic regurg cause what form of CHF

diastolic

120

dyspnea
orthopnea
paroxysmal nocturnal dyspnea
nocturnal cough
confusion and memory impairment in advanced forms
diaphoresis and cool extremities at rest

CHF

121

difficulty breathing in the recumbent position relieved by elecation of the head with pillows

orthopnea

122

rapid filling phase into a noncompliant left ventricular chamber leads to what pathologic heart sound

S3

123

S3 heard best in what position

apex with the bell of the stethoscope

124

S3 occurs at what phase in the cardiac cycle

following S2

125

how to remember S3 S4 and their place in the cardiac cycle

4 is more than 3
tennessee has more letters than kentucky TEN-nes-see relates S4 prior to S1
ken-tuck-Y relates S3 following S2

126

crackles and rales at the bases of the lungs in CHF indicates what pathologic process

pulmonary edema 2/2 fluid spilling into the alveoli

127

dullness to percussion and decreased tactile fremitus of the lower lung fields is a sign of

pleural effusion

128

peripheral pitting edema
nocturia
JVD
hepatomegaly
ascites
right ventricular heave

all signs of what sidded HF

rightr

129

T/F given enough time left sided HF will always lead to right sided HF

T

130

short horizontal lines near periphery of the lung near the costophrenic angles and indicate pulmonary congestion secondary to dilation of pulmonary lymphatic vessels

kerley B lines

131

prominent interstitial markings and pleural effusion a sign of what on CXR

CHF

132

what is the initial test of choice in suspected CHF

transthoracic echo

133

what is the importance of obtaining a TTE in the diagnosis of CHF

gives us the EF

134

cutoff for preserved left ventricular function in patients treated for CHF

>40%

135

T/F ECG is often very helpful in CHF diagnosis

F (not particularly unless there is a component of MI or USA)

136

consider this test to rule out CAD as an underlying cause for CHF

coronary angiography

137

test used to assess dynamic response of HR heart rhythm and BP in the setting of CHF

stress testing

138

conservative management of systolic dysfunction of CHF

sodium restriction
water restriction
smoking cessation
weight loss
etoh decrease

139

most effective means of providing symptomatic relief to patients with moderate to severe CHF
recommended for patients with systolic failure and volume overload

diuretic

140

T/F diuretics improve mortality in patients with CHF

F (not been shown)

141

most potent diuretic that is usually used

lasix

142

lasix is what type of diuretic

loop

143

HCTZ is what type of diuretic

thiazide

144

T/F spironolactone has been shown to have survival benefits in patients with CHRF

T

145

spironolactone used in what types of CHF

advanced forms

146

which aldosterone antagonist does not cause gynecomastia

eplerenone

147

usual initial treatment for symptomatic CHF patients

ACE inhibitor and diuretic

148

T/F ACE inhibitors have reduced mortality benefit

T

149

CONSENSUS and SOLVD trials proved what point

ACE inhibitors reduce mortality in patients with CHF

150

T/F all patients with CHF should be on a ACE inhibitor regardless of symptomatology

T

151

ACE inhibitors should be started at a low dose to avoid

hypotension

152

patients that experience dry cough with ACE inhibitors can be switched to what type of medication

ARBs (-sartans)

153

beta blockers are shown to decrease mortality in CHF for what specific patient demographic

post MI CHF

154

stable patients with mild to moderate CHF should be given

beta blockers

155

what are the three beta blockers known to be safe in CHF

metoprolol
bisoprolol
carvedilol

156

useful agent in patients with EF <40%, severe CHF or severe Afib

digitalis

157

typically employed for patients with refractory symptoms despite being on diuretic ACE inhibitor and aldosterone antagonist

digitalis

158

two medications commonly employed in patients who cannot tolerate ACE inhibitors

hydralazine and isosorbide dinitrates

159

4 medication types that are contraindicated in CHF

metformin (can cause lethal lactic acidosis)
thiazolidinediones (fluid retention)
NSAIDs increase risk of CHF exacerbation
negative inotropic antiarrhythmics

160

what are the medications that reduce mortality in diastolic heart failure

none

161

what are the two devices that shown to reduce mortality in select patients

ICD prevents SCD

162

indicated for patients at least 40 days poist MI EF,35% and class II or III symptoms despite optimal medicla treatment

ICD

163

biventricular pacemaker in patients with QRS >120 ms

CRT

164

T/F most patients that meet criteria for CRT are also candidates for ICD and receive combined devices

T

165

last alternative if all else fails in CHF management

heart transplant

166

acute dyspnea associated with elevated left sided filling pressures with or without pulmonary edema

acute decompensated HF

167

what are the two most common causes for acute decomp HF

LH systolic or diastolic dysfunction

168

severe form of HF with rapid accumulation of fluid in the lungs

flash pulmonary edema

169

DIFFERENTIAL FOR RAPID RESPIRATORY DISTRESS

PULMONARY EMBOLISM ASTHMA pna AND FLASH PULMONARY EDEMA

170

diagnostic tests for an individual with flash pulmonary edema

chest xray
ecg
ABG BNP
echo
coronary angio (possibly)

171

what is the management of a patient with acute pulmonary (flash) edema

oxygenation and ventilation assistance
diuretics
dietary sodium restriction
nitrates

172

present in 50% of adults who undergo holter monitoring and mean nothing in a healthy heart

PACs

173

what is the treatment for asymptomatic PACs

usually just observation

174

what is the treatment for symptomatic PACs (palpitations)

beta blockers

175

causes for PVCs

hypoxia
electrolyte abnormalities
stimulants
caffeine
medications
structural heart disease

176

why is the QRS wider in PVCs than with regular electrical activity of the heart

through the ventricular muscle and not the conduction pathways, therefore takes a longer time

177

patients with frequent repetitive PVCs and underlying heart disease are at increased risk for

sudden death (Vfib etc)

178

what test should be ordered in patients with PVCs and underlying structural or physiologic heart disease

electrophysiology test (may benefit from ICD)

179

multiple foci in the atria firing continuously in a chaotic pattern causing a totally irregular rapid ventricular rate

atrial fib

180

atrial rate in afib is usually over ______bpm but are blocked at the AV node so ventricular rate ranges between ___ and ____

400
75
175

181

T/F PVCs in patients with normal hearts is associated with increased mortality

T

182

what are the causes for afib (9) (double H triple S triple P E)

1. Heart disease: CAD, MI, HTN, mitral valve disease
2. Pericarditis and pericardial trauma (e.g., surgery)
3. Pulmonary disease, including PE
4. Hyperthyroidism or hypothyroidism
5. Systemic illness (e.g., sepsis, malignancy
6. Stress (e.g., postoperative)
7. Excessive alcohol intake (“holiday heart syndrome”)
8. Sick sinus syndrome
9. Pheochromocytoma

183

acute hemodynamically unstable afib treatment

immediate cardioversion

184

acute afib in a hemodynamically stable patient

rate control (60-100bpm)
beta blockers
CCBs (alternatively)

185

delivery of a shock that is in synchrony with the QRS

cardioversion

186

delivery of shock that is NOT in conjunction with the QRS complex

defibrillation

187

if left ventricular dysfunction is present in the setting of afib
what two medications can be considered

amio or dig

188

three cases of cardioversion being appropriate in afib

hemodynamically unstable
those with worsening symptoms
those having their first ever case of AFib

189

what is the use of ibutilide procainamide flecainide sotalol or amiodarone in afib

pharmacologic conversion if electrical cardioversion is unfeasible or doesnt work

190

when should anticoagulation be employed in the setting of atrial fibrillation

present greater than 48 hours

191

what are the timing parameters for anticoagulation surrounding cardioversion

3 weeks before and 4 weeks afterwards

192

what is the INR goal in anticoagulation in patients with afib prior to and following cardioversion

2-3

193

what can be done (in theory) to avoid 3 weeks of anticoagulation prior to cardioversion in the case of afib)

TEE to image the left atrium for thrombus, if none, start IV heparin and perform cardioversion within 24 hours

194

T/F if the TEE route is carried out to expedite cardioversion, patients still need to be anticoagulated 4 weeks following cardioversion

T

195

what are the two agents typically used in the setting of chronic afib for rate control

beta blockers
CCBs

196

patients with lone afib or afib in the absence of any underlying heart disease or cardiovascular risk can take what medication

aspirin

197

patients with afib and underlying CVD or risk factors need what type of anticoagulation

warfarin

198

what is the most common cause for aflutter

heart failure

199

ECG exhibiting a saw tooth baseling with a QRS complex appearing after every second or third tooth

aflutter

200

flutter waves seen best in which lead

II III AvF (inferior leads)

201

how many different P wave morphologies are required to make the diagnosis of MAT

3

202

MAT is identical to this separate diagnosis except that the heart rate in this other entity is between 60-100

wandering atrial pacemaker

203

MAT is strongly associated with what type of disease

lung disease

204

if LV function is not preserved in MAT what medication can be given

digoxin

205

T/F electrical cardioversion is often effective in MAT

F (not effective do not use)

206

what is the most common cause of PSVT

nodal re-entry tachycardia`

207

ECG will show what characteristic in PSVT

narrow complexes with no discernible P waves (P waves buried in the QRS)

208

what is the underlying process in orthodromic AV reentrant tachycardia

accessory pathway between the atria and ventricles that conducts retrogradely

209

what would be seen on ECG in orthodromic reentry AV tachy

narrow QRS complexes with P waves may or may not be discernible depending on the rate (could bne buried, re-entrant circuit takes longer the self contained AV reentry, therefore P waves have a higher chance to be revealed)

210

Six (6) causes of SVT

a. Ischemic heart disease
b. Digoxin toxicity—paroxysmal atrial tachycardia with 2:1 block is the most
common arrhythmia associated with digoxin toxicity
c. AV node reentry
d. Atrial flutter with rapid ventricular response
e. AV reciprocating tachycardia (accessory pathway)
f. Excessive caffeine or alcohol consumption

211

paroxysmal atrial tachycardia with 2:1 block is the most
common arrhythmia associated with ___________ toxicity

digoxin

212

what is the agent of choice for correcting SVT

IV adenosine

213

what is the reason that IV adenosine is the agent of choice in SVT

short duration of action and effectiveness in terminating SCTs
works by decreasing sinoatrial and AVE nodal activity

214

what agents can be used in patients with SVT if left vent function is preserved as an alternative to IV adenosine

Iv verapamil and IV esmolol (less commonly digoxin)

215

treatment preferred if episodes of SVT are recurrent and symptomatic

radiofrequency cardiac ablation

216

narrow complex tachycardia and short PR interval with upward deflection seen before thje QRS complex

WPW syndrome

217

what is the typical treatment used for WPW syndrome

radiofrequency cardiac ablation

218

WHAT DRUGS should be avoided in WPW syndrome

drugs that act through blocking AV conduction (beta blockers CCBs digoxin) as they can facilitate conduction through the accessory pathway

219

rapid repetitive firind of three or more PVCs in a row at a rate between 100 and 250

ventricular Tachy

220

ventricular tachy typically originates where in the conduction structure

below the bundle of his

221

what is the most common cause for ventricular tachy

prior MI with CAD

222

causes for V tach

a. CAD with prior MI is the most common cause
b. Active ischemia, hypotension
c. Cardiomyopathies
d. Congenital defects
e. Prolonged QT syndrome
f. Drug toxicity

223

Vtach progresses to what arrhythmia if left untreated

Vfib

224

T/F Vtach lasts longer than 30 seconds and is almost always symptomatic

T

225

brief limited runs of VT is an indipendent risk factor for SCD in what cases

with concurrent CAD and LV dysfunction

226

connan A waves in the neck secondary toi AV dissociation and variable S1 intensity commonly associated with

Vtachy

227

what are the more serious presentations of Vtachy

sudden death
cardiac shock

228

ecg showing wide and bizarre QRS complexes with tachycardia

Vtachy

229

all QRS complexes are identical in this form of Vtach

monomorphic

230

QRS complexes are different in this form of Vtach

polymorphic

231

T/F VT also responds to vagal maneuvers as with PSVT

F (does not)

232

what should be given to patients with hemodynamically stable patients with mild symptoms and systolic BP >90

IV amio
IV procainamide
IV sotalol
(one of these)

233

hemodynamically unstable patients with Vtachy or with severe symptoms treatment

immediate synchronous DC cardioversion

234

what mnedication is given following DC cardioversion

amiodarone (sustains rhythm)

235

nonsustained VT with no underlying heart disease a recent MI or evidence of left ventricular dysfunction or symptomatology

order electrophysiologic study

236

electrophysiology study shows inducible rhythm in the case of nonsustained VT, what should be done

placement of ICD

237

second line treatment for unsustained Vtach

amiodarone

238

most episodes of Vfib happen following

Vtach

239

T/F if Vfib is not associated with MI we shouldnt expect it to recur

F (Vfib not associated with MI has a higher rate of recurrence)

240

what two treatments can be utilized in the treatment of patients with Vfib not associated with MI

prophylactic amiodarone or placement of ICD

241

T/F if Vfib follows MI by <48hours then the outcome is bleak and recurrence rate is high

F (prognosis is good and recurrence is low)

242

T/F chronic therapy is needed for patients with Vfib secondary to MI

F (not necessary)

243

most common cause for vfib

ischemic heart disease

244

cannot measure BP
unconscious patient
absent heart sounds and pulse

vfib

245

ECG no strial P waves can be identified
no QRS complexes can be identified

VFIB

246

what is the immediate treatment for vfib

(MEDICAL EMERGENCY)
IMMEDIATE cardiac defibrillation and CPR
immediate initiation of unsynchronized DC cardioversion immediately, if equipment not on hand, begin CPR immediately
up to three sequential shocks to establish another rhythm

247

treatment for persistent vfib following sequential shocks

continue CPR
consider intubation
epi (1mg bolus initially and then every 3-5minutes)
attempt to defibrillate again 30s-1min following first epi dose

248

if vfib persists past administration of epi, intubation and reshock

IV amiodarone followed by shock
(lidocaine, magnesium procainamide alternatives)

249

If cardioversion is successful in vfib, what next

maintain continuous IV infusion of the effective antiarrhythmic agent
ICD mainstay of chronic therapy in these patients (those at risk for VF)

250

bradycardia clinically significant when persistent below what threshold

45bpm

251

pathologic causes for bradycardia (3)

cardiac ischemia
increased vagal tone
antiarrhythmic drugs

252

what medication can be used to raise BP in the case of persistent bradycardia

atropine

253

prolonged PR interval with a QRS following each P wave

1st degree heart block

254

progressive prolongation of PR interval until a P wave fails to conduct

Mobitz type I

255

T/F type I heart block is a benign condition that does not require treatment

T

256

Pwaves fail to conduct sudndenly without a preceding PR interval prolongation
often progresses

Mobitz II

257

where is the conduction defect in a Mobits II

His-Purkinje system of conduction

258

what is the necessary treatment for MObitz II

placement of PCI

259

absence of conduction of atrial impulses to the ventricles; no correspondence between P waves and QRS complexes

complete HB

260

what is the treatment of choice for complete heart block

cardiac pacemaker

261

Most common type of cardiomyopathy

dilated cardiomyopathy

262

ischemia infection alcohol casuing dysfunction of left ventricular contractility leads to what type of cardiomyopathy

dilated

263

what is the prognosis for dilated cardiomyopathy

poor
most die within 5 years of diagnosis

264

what is the most common cause for dilated cardiomyopathy

idiopathic

265

toxins that lead to dilated cardiomyopathy

alcohol
doxorubicin
adriamycin

266



ALL CAUSES FOR dilated cardiomyopathy (>;))


a. CAD (with prior MI) is a common cause
b. Toxic: Alcohol, doxorubicin, Adriamycin
c. Metabolic: Thiamine or selenium deficiency, hypophosphatemia, uremia
d. Infectious: Viral, Chagas disease, Lyme disease, HIV
e. Thyroid disease: Hyperthyroidism or hypothyroidism
f. Peripartum cardiomyopathy
g. Collagen vascular disease: SLE, scleroderma
h. Prolonged, uncontrolled tachycardia
i. Catecholamine induced: Pheochromocytoma, cocaine
j. Familial/genetic

267

what heart sounds are typically associated with dilated cardiomyopathy

S3 S4 and mitral regurg or tricuspid insufficiency

268

what is the common pathology associated with the enlarged ventricles of dilated cardiomyopathyt

cardiac arrhythmia

269

this type of testing might be warranted in a patient with DCM with no cause and fam hx of disease

genetic testing

270

what is the treatment for DCM

(similar to treatment for CHF)
beta blockers
diuretics
dig

271

should be considered because DCM patients have risk of embolization

anticoagulation

272

Hypertrophic cardiomyopathy mode of inheritance

autosomal dominance

273

diastolic dysfunction due to a stiff hypertrophied ventriclewith elevated diastolic filling pressures

HTCM

274

what kind of obstruction can occur in patients with assymmetric hypertrophy of the ventricular septum

dynamic outflow obstruction

275

dyspnea on exertion
chest pain
syncope after exertion or the valsalva
palpitations
arrhythmias
cardiac failure
sudden death
years without symptomatology

HTCM

276

sustained PMI
loud S4
systolic ejection murmur
decreases with squatting lying down or straight leg raise
intensity increased with valsalve and standing (decreases LV size and increases obstruction)

HTCM

277

effect of the murmur with HTCM with sustained handgrip

decrease due to increased systemic resistance leading to decreased gradient across aortic valve

278

rapidly increasing carotic pulse with two upstrokes indicative of

HTCM

279

what is the test that establishes the diagnosis of HTCM

cardiac echo

280

T/F asymptomatic patients with HTCM do not need treatment

T

281

what is the initial drug used in symptomatic patients with HTCM

beta blockers

282

used in HTCM if patient nonresponsive to beta blockers

CCBs

283

surgery for HTCM

myomectomy

284

opening snap followed by a low pitched diastolic rumble and presystolic accentuation

mitral stenosis

285

S2 followed by opening snap

mitral stensosi

286

the distance between S2 and the opening snap of mitral stenosis tells us

severity of the valvular disease

287

long standing disease of mitral stenosis can lead to what clinical findings

(right heart failure)
right ventricular heave
JVD
pulmonary congestion
hepatomegaly
ascites

288

most important test in confirming mitral stenosis

echocardiogram

289

what are the two medications commonly used in mitral stenosis

diuretics (if signs of RHF)
beta blockers (decrease HR and CO)

290

what are t he two options surgically for mitral stenosis

perc balloon valvuloplasty
open commissurotomy and mitral valve replacement

291

when the aortic valve falls below what threshold is the cardiac output not able to increase with exertion, resulting in angina

0.7

292

what is the cause for mitral regurg with long standing aortic stenosis

LV dilation pulls the leaflets of the mitral valve apart resulting in MR

293

what are the three main causes for aortic stenosis

calcification of a bicuspid valve
calcification in the elderly
rheumatic fever

294

development of what symptoms would be a sign that aortic stenosis is worsening

syncope
angina
CHF

295

which of angina syncope and CHF in the setting of aortic stenosis carries the worse prognosis

CHF

296

harsh crescendo-decreascendo systolic murmur
heard in second right intercostal space
radiating to carotid arteries
soft S2
S4
parvus et tardus
sustained PMI
precordial thrill

aortic stenosis

297

what is parvus et tardus

delayed and diminished carotid upstrokes

298

which test is diagnostic in aortic stenosis

echocardiography

299

what is the definitive diagnostic test in aortic stenosis

cardiac angiography

300

what test can measure valve gradient and calculate valve area in aortic stenosis

cardiac catheterization

301

what is the treatment for aortic stenosis

valvular replacement in all symptomatic patients

302

treatment for asymptomatic aortic stenosis

none

303

inadequate closure of aortic valve leaflets causing blood to flow into left ventricle during diastole

aortic regurg

304

what occurs in the left ventricle in response to aortic regurgitation

LV dilation and hypertrophy to maintain stroke volume

305

5 year survival for chronic regurgitation

75%

306

how long do patients typically survive following onset of angina with aortic regurg

4 years

307

how long do patients typically survive following onset of CHF with aortic regurg

2 years

308

4 main causes for acute aortic regurgitation

infective endocarditis
trauma
aortic dissection
iatrogenic

309

causes for primary valvular aortic regurgitation (6)

rheumatic
biscupid aortic valve
marfans
ehlers danlos
ankylosing spondylitis
SLE

310

causes for aortic root disease leading to aortic regurg (6)

syphilitic aortitis
osteogenesis imperfecta
aortic dissection
behcet
reiter syndrome
systemic HTN

311

widened pulse pressure concerning for what valvular disease

aortic regurgitation

312

low pitched diastolic rumble due to competing flow anterograde from the LA and retrograde from the aorta

austin flint murmur
aortic regurgitation

313

rapidly increasing pulse that collapses suddenly as arterial pressure decreases rapidly in late systole and diastole

water hammer pulse, indicates aortic regurg

314

what happens to aortic regurg with handgrip sustained

increases

315

what is the utility of echo in aortic regurg

assess chronic patients for surgery over time

316

what is the treatment for chronic asymptomatic aortic regurg

conservative
restrict salt
diuretics vasodilators
afterload reduction
restriction of strenuous activity

317

what is the definitive treatment for aortic regurgitation

surgical replacement

318

abrupt elevation of left atrial pressure in the setting of normal LA size and compliance with pulmonary edema
possible hypotension and shock due to decreased CO

acute MR

319

gradual elevation of left atrial pressure in setting of dilated LA and LV
pulmonary HTN can result from chronic backflow

chronic MR

320

3 main acute causes for MR

endocarditis
papillary muscle ruption (infarction)
chordae tendinae rupture

321

4 main chronic causes for MR

rheumatic fever
mitral valve prolapse
marfans
cardiomyopathy

322

T/F chronic MR has a worse prognosis than acute MR

F (acute is worse prognostically)

323

holosystolic murmur at the apex radiating to the back or clavicle

MR

324

what arrhythmia is common seen with MR

afib

325

what diagnostic tests can show signs of MR

CXR
echo

326

device used as a bridge to surgery for MR

IABP

327

what medication outcome should be sought in patients with symptomatic MR

afterload reduction

328

what is the definitive treatment for MR

valvular replacement

329

results from a failure of the tricuspoid valve to close completely during systol causing regurgitation of blood into the RA

tricuspid regurg

330

TR regurg usually 2/2

RV enlargement

331

what is the most common cause for tricuspid regurg with LV dilation

left ventricular failure

332

when is tricuspid endocarditis typically seen

IV drug users

333

congenital malformation of the tricuspid valve in which there is a downward displacement of the valve into the RV

epstein anomaly

334

TR regurg usually asymptomatic unless what occurs

development of RGF or Pulmonary HTN

335

what would be expected to be some of the symptoms of tricuspid regurg

ascites
hepatomegaly
edema
JVD
pulsatile liver
prominent V waves in jugular venous pulse with rapid y descent
inspiratory S3 along LLSB
blowing holosystolic murmur at LLSB increased with inspiration reduced during expiration or valsalva

336

how is the diagnosis of tricuspid regurg made

echo

337

treatment for volume overload and venous congestion/edema of TR regurg

diuretics

338

what needs to be absent in order for tricuspid valve resplacement surgery to be an available option

pulmonary hypertension

339

typical mid systolic click and murmuer

mitral valve prolapse

340

common valvular disease in patients with connective tissue disorders

MVP

341

most common cause of MR in developed countried

MVP

342

what do standing and valsalva do in regard to the murmur involved with MVP

increase

343

what does squatting down have in terms of effect on MVP

decrease

344

what is the most useful diagnostic tool for MVP

echo

345

what should be used for the atypical chest pain that can accompany MVP

beta blockers shown to be helpful

346

T/F MVP often requires surgery

F (often benign, asymptomatic for peoples entire lives)

347

most common valvular abnormality 2/2 rheumatic heart disease

mitral stenosis

348

what are the major signs of acute rheumatic fever

migratory arthritis
acute myocarditis
subcutaneous Nodules
erythema marginatum
syndenham chorea

349

what medication should be given to patients with streptococcal pharyngitis to avoid rheumatic fever

penecillin or rythromycin

350

how is acute rheumatic fever treated

NSAID

351

what marker is used to track treatment progress

C-RP

352

infection of the endocardial surface of the heart

endocarditis

353

acute endocarditis most commonly caused by

staph aureus

354

acute endocarditis happens on what type of heart valve

normal

355

if acute endocarditis is left untreated what is the outcome

fatal in 6 weeks

356

subacute endocarditis caused by

strep viridans and enterococcus

357

subacute endocarditis occurs on what type of valves

previously injured

358

what are the more rare forms of native valve endocarditis

HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kindella)

359

most common organism for prosthetic valve endocarditis

staph epi (and then staph aureus)

360

Endocarditis in IV drug users

Right sided endocarditis

361

what valve is typically involved in right sided endocarditis

tricuspid

362

which bug is most common in right sided endocarditis

staph aureus

363

what are the four main complications from endocarditis

cardiac failure
myocardial abscess
various solid organ damage from showered emboli
glomerulonephritis

364

what combination of Duke criteria is necessary for the diagnosis of endocarditis

2 major
1 major 3 minor
5 minor

365

what are the major DUKE criteria

sustained bacteremia
endocardial involvement diagnosed by echo or by new valvular murmur on clinical exam

366

what are the minor DUKE criteria for endocarditis

predisposing condition (abnormal valve or abnormal risk)
fever
vascular phenomena (septic arterial or pulmonary emboli mycotic aneurysms intracranial hemorrhage janeway lesions)
Immune phenomena (Glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor)
Positive blood cultures not meeting major crit
Positive echo not meeting major crit

367

what is the treatment for endocarditis

extended parenteral antibiotics (4-6 weeks)

368

what are the two factors necessary to warrant endocarditis antibiotic prophylaxis

qualifying cardiac indication:
prosthetic heart valve
history of infective endocarditis
congenital heart disease
cardiac transplant with vulvulopathy

Qualifying procedure
Dental procedures
procedures involving biopsy or incision of respiratory mucosa
procedures involving infected skin or musculoskeletal tissue

369

associated with debilitating illnesses susch as metastatic cancer
sterile deposits of fibrin and platelets forming along the closure line of cardiac valve leaflets
vegetations can embolize to the brain or periphery

marantic endocarditis (nonbacterial thrombotic endocarditis)

370

typically involving the aortic valves in individuals with SLE
characterized by the formation of small warty vegetations on both sides of valve leaflets and may present with regurgitant murmurs
can be a source of systemic embolization

libmann sacks endocarditis

371

what is the most common type of atrial septal defect

ostium secundum

372

what are the three types of ASDs

ostium secundum (central portion opening)
ostium primum (low in septum)
Sinus venosus (high in the septum)

373

what is the rare but serious complication that can occur with ASD

pulm HTN

374

what is the tell tale sign on clinical exam for ASD

fixed split S2

375

what is the diagnostic test for ASD

TEE with bubble study (bubbles can be seen crossing through the defect often used and can aid in the Dx)

376

what are the CXR findings c/w ASD

Large pulm arteries
increased pulm markings

377

pulmonary HTN for ASD typically occurs after what age if at all

40

378

late complication of ASD in which irreversible pulm HTN leads to reversal of shunt, HF and cyanosis

eisenmenger syndrome

379

most common of the congenital cardiac malformations

VSD

380

what happens to the shunt in VSD if PVR becomes larger than SVR

reversal of shunt and potential eisenmenger syndrome

381

sign symptoms of eisenmenger syndrome

high PVR
SOB
dyspnea on exertion
chest pain
syncope
cyanosis

382

harsh blowing holosystolic murmur with thrill at fourth left intercostal space that decreases with valsalva and handgrip

VSD

383

is a louder or softer VSD more concerning

softer (smaller VSD causes louder murmur)

384

what is the structure that is responsible for the enlarged cardiac silhouette seen on CXR in VSD

enlargement of the pulmonary artery

385

what are the complications associated with VSD

endocarditis
progressive aortic regurg
heart failure
pulmonary HTN and shunt reversl (eisenmengers)

386

when is endocarditis PPX not recommended in VSD

uncomplicated and no prior history of endocarditis

387

narrowing/constriction of aorta usually at the origin of left subclavian artery near ligamentum arteriosum

coarctation of the aorta

388

hypertension in the upper extremities and hypotension in the lower extremitis

coarctation of the aorta

389

well developed upper body with underdeveloped lower bodyu

coarctation of the aorta

390

CXR showing notching of the ribs

coarctation of the aorta

391

prevalence of this cardiac malformation is increased in patients with Turner syndrome

coarctation of the aorta

392

what are the 4 main complications associated with coarctations of the aorta

severe HTN
rupture of cerebral aneurysms
infective endocarditis
aortic dissections

393

communication between the aorta and pulmonary artery that persists after birth

patent ductus arteriosus

394

what are the two factors that maintain patent ductus arteriosus during fetal development

low O2 tension
prostaglandins

395

when does cyanosis occur in PDA

late

396

cardiac malformation associated with rubella syndrome
high altitude
premature births

PDA

397

continuous machine like murmur at the left second intercostal space
RVH
wide pulse pressure and bounding peripheral pulses

PDA

398

CXR showing increased pulmonary vascular markings
dilated pulmonary artery
enlarged cardiac silhouette
calcifications in tract coming off of the aorta

PDA

399

If pulmonary vascular disease is absent what is the treatment for PDA

surgical ligation

400

when is surgery contraindicated in PDA

when there is significant right to left shunting

401

what is the medication that can be used for closure of PDA

indomethacin

402

medication used to keep PDA open in cases of transposition

PGE1

403

Ventricular septal defect
right ventricular hypertrophy
pulmonary artery stenosis
overriding aorta

tetrology of fallot

404

tetrology of fallot arise secondary to defects in the development of what structure

infundibular septum

405

most common symptom of tetrology of fallot

cyanosis

406

degree of symptoms in tetrology of fallot depends on

degree of pulmonary outflow obstruction

407

three substances that can be used in patient with frequent tet spells that are refractory to mechanical position to correct

oxygen
morphine
beta blockers

408

what is the diagnostic modality of choice in tet of fallot patient

echo

409

CXR showing boot shape to the heart

TOF

410

what is the treatment for TOF

surgery

411

two most common causes of death following surgery for TOF

sudden cardiac death and CHF

412

hypertensive emergency defined as

systolic above 220
diastolic above 120

in addition to end organ damage

413

elevated BP levels of hypertensive emergency without end organ damage

urgency

414

5 systems that need to be assessed in a patient with blood pressures in the emergency range

eyes : papilledema
CNS: AMS or hemorrhage, confusion
kidneys: failure, hematuria
heart: USA, MI, CHF, aortic dissection

415

radiographic condition postulated to be caused by autoregulatory failure of cerebral vessels as well as endothelial dysfunction

PRES

416

insidious onset of headache altered level of consciousness visual changes and seizures with posterior cerebral white matter edema
hypertensive or normotensive

PRES

417

how should BP be brought down in hypertensive emergencies

reduce MAP by 25% in 1 to 2 hours (get the patient out of danger and then decrease gradually)

418

rate typically sought for BP decrease in hypertensive urgency

normotensive in 24 hours

419

long standing HTN
cocaine use
trauma
connective tissue diseases
bicuspid aortic valve
coarctation
third trimester pregnancy

aortic dissection

420

what are the two classifications of aortic dissection

type A
Ascending
Type B (distal to subclavian)
descending

421

servere tearing rippin stabbing pain
typically abrupt in onset
anterior or back opf chest interscapular

aortic dissection

422

anterior chest pain is more common with what type of aortic dissection

A

423

posterior chest pain more common with what type of aortic dissection

B

424

CXR finding typical for aortic dissection

widened mediastinum

425

which is more accurate for aortic dissection MRI or CT

MRI

426

best test for determining the extent of dissection in aorta for surgery

angiography

427

what medication should be initiated immediately in aortic dissection

beta blockers
IV nitroprusside (BP below 120)

428

most type A dissections are treated as surgical emergencies to avoid

MI aortic regurg or cardiac tamponade

429

what is the typical management of type B dissections

lower blood pressure, IV beta blockers
morphine for pain

430

abnormal localized dilation of aorta typically between the renal arteries and iliac bifurcation

AAA

431

average ages for diagnosis of AAA

65=70

432

most cases of AAA what process is occuring in vessel

atherosclerosis

433

5 things other than atherosclerosis that predispose to AAA

HTN smoking vasculitis truama pos famHx

434

pulsatile mass on abdominal exam

AAA

435

sudden onset of severe pain in the back or lower abdomen with ecchymoses on back and flanks and ecchymoses aroiund umbilicus

AAA rupture

436

Grey turner sign

ecchymoses on flank/back

437

cullen sign

ecchymoses around umbilicus

438

triad of abdominal pain
hypotension
palpable pulsatile abdominal mass

AAA rupture

439

AAA rupture treatment

immediate laparotomy and repair

440

test of choice to evaluate location and size of AAA

US

441

test that can be used in hemodynamically stable patients with AAA for preop planning

CT

442

size at which surgical repair of AAA should be recommended

>5cm diameter

443

most common site for peripheral vascular disease

superficial femoral artery

444

what is the most important risk factor for PVD

smoking

445

patient with PVD and intermittent claudication prognosis

best

446

patient with PVD and rest pain / non healing ulcers prognosis

bad

447

ABI above what value indicates severe PVD

1.3

448

claudication ABI

<0.7

449

rest pain ABI in PVD

<0.4

450

gold standard for diagnosing and locating PVD

arteriography

451

conservative management for PVD

stop smoking!
graduated exercise program
foot care
atherosclerosis reduction
avoid extreme temp
aspiring +/- ticlopidine/clopidogral
cilostazol

452

three indications for PVD surgery

rest pain
ischemic ulcerations
severe symptoms refractory to conservative therapy

453

two main options for surgery in PVD

angioplasty
bypass

454

most common site of acute arterial occlusion

common femoral artery

455

most common site and cause for embolus of acute arterial occlusion

heart afib

456

6 Ps of acute arterial occlusion

pain
pallor
poikilothermia (cold blooded)
paralysis
paresthesias
pulseless

457

three tests usually obtained in acute arterial occlusion

arteriogram
ecg (MI, afib)
echo (valves thrombus shunts)

458

amount of time that skeletal muscle can tolerate ischemia

6 hours

459

what is the immediate therapy for embolus causing acute arterial occlusion

immediate IV heparin
surgical embolectomy with cutdown and fogarty balloonm)

460

when is bypass employed for acute arterial occlusion

failure of embolectomy

461

small discrete areas of tissue ischemia
blue black toes
renal insufficiency
abdominal pain or bleeding

treatment

cholesterol embolization syndrome\

Do not anticoagulate
control BP
surgical only in very extreme circumstances

462

aneurysm resulting from damage to aortic wall 2/2 infection

mycotic aneurysm

463

what is a luetic heart

complication of spyphilitic aortitis in which the dilation of the proximal aorta blocks the aortic branches most commonly the coronaries

needs surgical repair

464

virchows triad

venous stasis
endothelial injury
hypercoaguable

465

lower extremity swelling/pain
calf pain on ankle dorsiflexion
palpable cord
fever

DVT

466

initial test for DVT

doppler and duplex US

467

duplex is good for what location of DVT

proximal

468

most accurate test for DVT of calf

venography

469

intermediate to high pretest probability of DVT plus Doppler +

begin anticoagulation

470

intermediate to high pretest prob of DVT with neg doppler

repeat doppler 2-3days for 2 weeks

471

low-intermediate pretest prob of DVT and soppler neg

no need for anticoagulation

472

painful blue swollen leg following DVT

phlegmasia cerulea dolens

473

indicated treatment for phlegmasia cerulea dolens

venous thrombectomy

474

how long should warfarin be kept following DVT

3-6 months

475

indicated for DVT/PE massive with hemodynamic instability

systemic thrombolytics

476

treatment for patient with DVT and absolute contraindication to anticoagulation

inferior vena cava filter

477

what is the typical preceding illness that leads to venous stasis

DVT (destroys valvs in the system)

478

what is the reason for the brawny induration and bron black color of sjkin in chronic venous insufficency

extrav of proteins and RBCs

479

what is the complication common with chronic venous stasis

venous ulceration

480

how does elevation of legs differ in chronic venous insufficiency versus acute arterial insufficency

provides relief in venous disease

481

mildly painful ulcears rapidly recurring
above the medial malleolus

chronic venous stasis

482

three main treatment s to combat complications of chronic venous insufficiency

leg elevation
avoiding long periods of sitting and standing
compression stockings

483

superficial thrombophlebitis in lower extremities usually associated with

Varicose veins

484

superficial thrombophlebitis in upper extremity usually associated with

IV placement

485

neoplasms of the heart are commonly of what origin

metastatis

486

benign helatinous growth usually pedunculated and arising from the interatrial septum of the heart in the region of the fossa ovalis

atrial myxoma

487

fatigue fever syncope palpitations malaise and a low pitched diastolic murmur that changes character with changing body position

atrial myxoma

488

tachycardia decrease in BP and malfunction of underperfused organ systems

shock

489

fever and possible site of infection in shock patient

septic

490

trauma gi bleed vomiting or diarrhea in shock patient

hypovolemic

491

MI angina or heart disease in shock patient

cardiogenic

492

JVD present in a shock patient

cardiogenic

493

spinal cord injury or neurologic deficits are present

neurogenic shock

494

initial steps in ALL shock patients

establish two large bore venous catheters +/- central line and art line
fluid bolus of 2L
draw CBC lytes renal funcrtion PT/pTT
ECG CXR
pulse ox
vasopressors if still hypotensive following fluids

495

Changes in the following for cardiogenic shock
CO
SVR
PCWP

-
+
+

496

Changes in the following for hypovolemic shock
CO
SVR
PCWP

-
+
-

497

Changes in the following for neurogenic shock
CO
SVR
PCWP

-
-
-

498

Changes in the following for septic shock
CO
SVR
PCWP

+
-
-

499

treatment

start with ABCs!
fluid resuscitation

500

most common cause for cardiogenic shock

MI

501

vassopressor usually used in cardiogenic shock

dopamine

502

what is more important in hypovolemic shock, the rate or amount of loss

rate

503

% of blood loss in following classes of hypovolemic shock
I
II
III
IV

10-15%
20-30
30-40
40>