TEST 1 Flashcards by Steph Nicolette

initial testing

-conduction- EKG, holter, loop

-HTN- 12 lead, bloods- kidneys, thyroid, lipids (CAD)
-urine- pheochromocytoma, aldosteronism

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PSVT, AF, A FLUTTER

-PSVT: MC
-atrial, multifocal, junctional
-caffeine + alc
-ischemic heart ds
-post MI
-bear down -> adenosine or amiodarone (wide) -> cardioversion if unstable
-prevent with beta blocks and CCB

-AFIB:
-alc + withdrawl
-ischemic heart ds
-mitral stenosis
-cardiomyopathy

-AFLUTTER:
-COPD*
-cardiomyopathy
-atrial septal defect
-same tx as afib

-Ablation can be done for all

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CHA2Ds2VASc and HASBLED, warfarin

-CHAD
-CHF, DM, HTN, vascular disease- 1 point
->65 - 1 point
->75- 2 points
-past stroke- 2 point
-female- + 1
-0- none or ASA, 1- ASA or full, 2+- full

-HASBLED
-HTN- uncontrolled
-abnormal liver or renal function
-stroke
-bleeding
-elderly
-drugs or alc

-WARFARIN
-blocks vitamin K
-reverse with vitamin K and FFP

-direct oral anticoag- renal impairment

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VT, VF, arrest

-VT:
-MC- coronary artery disease after MI
-cardiomyopathy

-VF:
-MC- ischemic heart disease
-ACLC- defib -> epi -> defib -> epi -> amiodarone
-AICD

-cardiac arrest:
-MC coronary artery disease
-low Mg and K

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VT tx

-pulseless tx- ACLS
-stable sustained- synchronized cardioversion + antiarrhythmic
-unstable sustained- synchronized cardioversion
-nonsustained-beta blocker therapy

-treating underlying cause:
-myocardial ischemia- catheter
-cardiomyopathy- echo
-electrolytes
-medication

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sick sinus syndrome, BBB, AV block

-sick sinus syndrome
-myocardial scarring
-d/c med if its causing it
-tx- pacemaker

-BBB- 3 small boxes .12
-tx underlying cause
-RBBB- right pressure
-LBBB- myocardial scarring- LAD*
-tx- r/o underlying disease

-AV block:
-age
-coronary artery disease MI
-secondary diseases

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hypertension: goal and tx guidelines

-2ndary- renal, coarction of aorta, endocrine
-goal- <140/90 -> DM <130/80
-diuretics
-renal comorbid- ACE or ARB
-CAD- beta blocker + ACE or ARB
-HF- beta blocker, ACE or ARB, diuretic

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HTN medications

-ARB (sartan)- vasodilation, decrease preload/after load
-ACE (pril)- hyperkalemia, cough, angioedema, renal
-beta blocker
-CCB- peripheral edema, lightheadedness
-DHP- vasodilate - amlodipine
-nonDHP- contraction - verapamil
-alpha blockers- vasodilate -> orthostatic hypotension*

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meds to avoid with comorbidities

-end stage chronic kidney disease / hyperkalemia /angioedema - ACE and ARB
-hyponatremia- diuretics
-asthma- beta blocker
-gout- thiazide and loop diuretics
-angioedema- ACE
-2nd/3rd degree heart block- beta blockers, nonDHP CCB

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HTN urgency vs emergency

-urgency- >180/>120 without end organ damage
-gradual decrease in MAP -> beta blocker, CCB, ACE

-emergency- >220/>120 with end organ damage
-papilledema, unstable angina, MI, CHF…
-usually caused by 2ndary things or noncompliance
-ASAP tx- reduce MAP by 25% in 1-2 hours -> can leads to ischemic CVA
-IV: esmolol, labetalol, nitroglycerine

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hypotension / orthostatic

-<90/<60
-vasodilation? -> alpha blockers
-cough to increase preload

-orthostatic hypo- decrease 20/10
-med tx- fludrocortisone or midodrine

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cardiogenic shock

-systolic BP <90 with urine output <20ml/hr
-caused by acute MI** and other cardiac emergency events
-tx: ABCs (2 large bore needles, central line arterial line) -> vasopressors (dopamine, norepinephrine)
-balloon pump, ecmo, underlying cause:

-Acute MI- aspirin, heparin, nitrates
-coronary angiogram
-bypass, stent

-cardiac tamponade- pericardiocentesis

-arrythmia- ACLC

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heart failure

-high output- compensation -> anemia, hemochromatosis, pagets, pregnancy, thyrotoxicosis, AV fistula
-MC- low output -> cardiomyopathy, valve stenosis
-systolic- MC CAD
-diastolic- MC left hypertrophy from chronic HTN -> restrictive cardiomyopathy
-left vs right

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CHF dx and classification

-BNP
-imaging- cardiomegaly, B lines, effusions, echo, stress test (ischemia), angiogram -> EKG not really
-classify based on symps and tx based on EF
-Class 1 (normal), 2 (slight limit), 3 (marked limit), 4 (symp at rest)

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heart failure tx

-diuretics -> loop, thiazide, aldosterone antagonist
-ACE or ARB if ACE contraindicated
-beta blockers
-digoxin- not first line
-sacubitril vasartan - neprilysin inhibitor -> increase BNP - for systolic HF
-ICDs- <35% EF
-LVADs- bridge to transplant

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dilated and restrictive cardiomyopathy

-MC- dilated:
-HF symptoms
-alcohol
-CAD

-restrictive:
-collagen -> less relaxation -> bad filling
-right HF symptoms
-EKG low amplitude
-endomyocardial bx

-tx underlying cause
-HF tx
-defib- AICD
-cardiac transplant

hypertrophic cardiomyopathy

-hypertrophic obstructive cardiomyopathy (HOCM)- blockage of flow
-sudden death in people younger than 30*
-dyspnea, chest pain, palpitation
-systolic ejection murmur at lower left sternal border -> increase with valsalva and standing -> decrease with squatting and laying down
-increase carotid pulse
-echo- DX of choice

-tx- avoid exercise
-beta blockers or CCB
-septal myomectomy
-alcohol septal ablation
-aicd

cardiovascular disease

-Lipid deposition -> fibrosis -> calcification -> plaque formation
-peripheral arterial disease
-carotid -> stroke
-cerebral -> CVA, TIA
-coronary- ischemic heart disease

-tobacco and DM

metabolic syndrome

-3 or more:
-triglycerides >150
-HDL <40 (men), <50 (women)
-fasting glucose > 110
-abdominal obesity
-HTN
-family hx of CAD
-obesity

hyperlipidemia

-Mixed hyperlipidemia
-Hypercholesterolemia- genetic
-Hypertriglyceridemia- pancreatitis

-asymptomatic
-xanthoma

fasting lipid panel goals

-Cholesterol < 200 mg/dL
-Triglycerides < 150 mg/dL - more short term
-LDL < 100 mg/dL:
-< 70 for pt with DM, CAD
-Most important for CAD risk*

-HDL > 40 mg/dL men, > 50 mg/dL women -> Protective factor

hyperlipidemia: statins (HMG-CoA reductase inhibitor)

-statins
-inhibits HMG-CoA reductase -> inhibits cholesterol synthesis
-CAD- NEEDS STATIN -> most potent to lower LDL
-smooths

-ADR:
-rhabdo
-myalgia, arthraliga
-high ALT/AST -> check every 3 months

other hyperlipidemia tx

-PSK9 inibitors: mabs ->
-lower LDL
-hypercholesterolemia and CAD
-headache, diarrhea, URI

-niaotinic acid:
-lower triglycerides and increase HDL
-flushing, itch, N/V, skin on fire

-fenofibrates:
-gemfibrozil
-lowers triglycerides
-GI upset

-bile acid binding resins:
-cholestyramine
-lowers LDL -> not triglyceride
-last resort drug
-GI side effect

angina pectoris

-low perfusion of myocardium
-MC- coronary artery disease
-dissection, vasospasm (cocaine + prinzmetals)

-typical (men) vs atypical (women, old, DM, immunocompromised):
-jaw, back of right shoulder
-radiates to right or both arms and back

-stable vs unstable:
-stable:
-<3 mins
-predictable
-relieved with sublingual nitroglycerin
-unstable:
-grouped with acute coronary syndrome
-indicated stenosis that has enlarged
-less response to nitroglycerin
-1 or more:
-angina at rest
-new onset of angina
-increasing pain in stable pts

prinzmetal angina

-vasospasm at rest- exercise capacity preserved -female > men* -75% with atherosclerotic lesion* -cocaine use, early morning -ST elevation but troponins are neg -resolved with meds bc its just a spasm

CAD dx

-EKG- normal in 25% -> ST depressions (nonspecific) -stress test- at least 2 leads ST depression -> + test -stress test can be done with SPECT, nuclear, pharm use if unstable -echo- wall abnormalities, EF -cardiac catheterization (angiography) -> DEF DX (high timi/grace score)

CAD/stable angina medication tx

-1. 1st line for stable angina- beta blocker (increase O2)-> DO NOT USE FOR PRINZMETAL -2. 2nd line- CCB non-DHP -> FIRST LINE FOR PRINZMETAL -3. nitrates- -angina persisting with monotherapy -nitroglycerin- episodic -isosorbide and hydralazine- long acting -SE- flushing, orthostatic hypotension -late Na channel blocker- ranolazine

CAD/angina revascularization tx

-balloon angioplasty -drug eluding stents -> 12 months need aspirin and clopidogrel (antiplatelet) -bare metal stents -> 1 month of dual antiplatelet therapy (DAPT) -bypass (CABG): -triple vessel ds with >70% stenosis of each vessel -left main coronary disease > 50% stenosis -YOU CAN NEVER PUT A STENT IN LEFT MAIN CORONARY unless the other option is death

acute coronary syndrome

-1. unstable angina -2. NSTEMI -> partial thickness necrosis -3. STEMI- full thickness necrosis

myocardial infarction

-MC cause is thrombosis -ruptured plaque -> thrombus -> occlusion -MC in atypical symptom pts -> atypical chest pain, fatigue, weakness, abd pain, sweating -hyper or hypotension -inferior wall MI -> bradycardia/heart block -pathological Q waves - infarction- remodeling (past the 90 min mark)

NSTEMI

-nstemi and unstable angina -> ST depression or T wave inversions -positive cardiac enzymes -unstable angina- neg enzymes but the EKG shows depressions

cardiac enzymes

-gold standard dx of MI -+ in STEMI and NSTEMI -release with necrosis -3 sets every 6 hrs -Troponin T and I most specific* -Increases 4-8 hours -Peaks 12-24 hours -Normalizes 5 to 14 days -CK-MB: -Increases 4-6 hours -Peaks in 12-24 hours -Normalizes 48-72 hours -Myoglobin: -Increases 1-4 hours -Peaks 4-6 hours -Normalizes in 24 hours

MI with corresponding artery

-Inferior MI- right coronary artery -posterior MI- posterior descending artery -septal MI- left anterior descending -anterior MI- left anterior descending -lateral MI- left anterior descending or circumflex

MI tx: MONAB

-Morphine- pain -Oxygen -Nitroglycerine (NTG) -Aspirin -> use adenosine diphosphate inhibitor (antiplatelet) if allergic (clopidogrel, ticlopidine, prasugrel) -> caution if CABG in 7 days -Beta blocker -Statins- reduce further events (CAD) -Unfractionated heparin or low molecular weight heparin (LMWH) -unfractionated- less thrombus and fibrin -LMWH- inactive factor Xa ASAP REPERFUSION...

MI reperfusion

-ASAP -angioplasty OR thrombolytics -PCI > thrombolysis -cath within 90 mins* -Drug eluding stent (DES) and Bare mental stents (BMS) with DAPT -thrombolytic within 30 mins -tissue plasminogen activators (alteplase, reteplase, teneceplase) -> Dissolves clot by activating tissue plasminogen -CONTRAINIDICATIONS: -hemorrhagic CVA -CVA within past year -intracranial neoplasm -active internal bleeding -sus aortic dissection -trauma or major surgery < 2 weeks -RELATIVE CONTRAINDICATIONS: -trauma past 2-4 weeks -major surgery in past 3 weeks -BP >180/110 -prolonged traumatic CPR -recent internal bleeding -diabetic retinopathy -pregnancy -PUD -current use of anticoag

unstable angina management

-TIMI and GRACE scale -low score -> conservative: -antiplatelet -anticoagulation -high score -> invasive -cardiac angiogram/plasty

cocaine induced MI

-vasospasm -constriction of coronary arteries -dx- EKG-> stemi, + troponins, + Utox -tx- -CCB and nitrates -ASA and heparin/LMWH until CAD ruled out -NO beta blockers due to risk of vasospasm

-aspirin/antiplatelet -statin -beta blocker? CCB?