Treatments

Question 1

Pulmonary Valve Stenosis - Dysplastic

Answer 1

usually requires surgical treatment (commissurotomy or pulmonary valve replacement)

Question 2

Pulmonary Valve Stenosis - Domed

Answer 2

percutaneous balloon valvuloplasty

Question 3

Coarctation of the Aorta

Answer 3

resection and surgical repair of coarctation or cardiac catheterization with possible angioplasty or percutaneous balloon dilation and stent of coarctation
o in patients with a pressure gradient > 20 mm Hg (measured with echocardiography/Doppler)

Question 4

Atrial Septal Defect

Answer 4

pulmonary vasodilators or surgical repair (pericardial or prosthetic patch; percutaneous transcatheter device closure), depending on size of defect

Question 5

Patent Foramen Ovale

Answer 5

most patients do not require treatment

unexplained neurological event
 low risk – aspirin
 high risk – warfarin

percutaneous closure if patient cannot take anticoagulants or if PFO > 25 mm

Question 6

Ventricular Septal Defect

Answer 6

pulmonary vasodilators for hypertension and surgical closure

Question 7

Tetralogy of Fallot

Answer 7

surgical correction is definitive before the age of 1

requires endocarditis prophylaxis for procedures

Question 8

Patent Ductus Arteriosus

Answer 8

indomethacin closes PDA (treats premature infants for first 10-14 days of life) by inhibiting prostaglandin, which keeps PDA open in the womb

cardiac catheterization (becoming treatment of choice)

surgical ligation (standard treatment) – must beware of hitting the laryngeal nerve

Question 9

Mitral Stenosis

Answer 9

intervention indicated for symptoms (edema, decline in ability to exercise), atrial fibrillation, or evidence of pulmonary hypertension

percutaneous balloon valvuloplasty is treatment of choice

mitral commissurotomy/valvuloplasty or valve replacement provide long-term relief, but are rare

Question 10

Acute Mitral Regurgitation

Answer 10

threat the cause and life-threatening symptoms: MI (O2, analgesics, nitrates), Infections (antibiotics), Pulmonary Congestion (diuretics), Atrial Fibrillation (beta-blockers, calcium channel blockers, and digitalis therapy)

Afterload Reducing Agents - ACE inhibitors and nitrates

Intra-aortic balloon counterpulsation should be considered if hemodynamically unstable

Question 11

Chronic Mitral Regurgitation

Answer 11

treat prior to development of pulmonary hypertension

surgical mitral valve repair or replacement

percutatneous mitraclip valve repair

Question 12

Mitral Valve Prolapse

Answer 12

surgical repair/replacement of the mitral valve is recommended for patients with moderate to severe MR and left ventricular enlargement

Question 13

Aortic Stenosis

Answer 13

surgery typically indicated for symptoms

surgical risk is typically low even in the very elderly percutaneous valve replacement may be an option for high surgical risk patients

surgery considered for asymptomatic patients with severe aortic stenosis (mean gradient greater than 55 mm Hg) or when undergoing heart surgery for other reasons (eg, coronary artery bypass grafting [CABG])

Beta Blockers to help slow heart rate and improve coronary flow

anticoagulation for mechanical valve replacements

Question 14

Acute Aortic Regurgitation

Answer 14

acute aortic regurgitation requires immediate surgery with valve replacement

requires airway management

administer positive inotorpes (increase force of muscular contraction) and vasodilators as needed

Question 15

Chronic Aortic Regurgitation

Answer 15

afterload reduction with ACE inhibitors, calcium channel blockers, or nitrates

surgery once symptoms emerge or if there is evidence of LV failure

Question 16

ACE inhibitors

Answer 16

relax blood vessels

Question 17

Calcium Channel Blockers

Answer 17

relax and widen blood vessels

Question 18

Nitrates

Answer 18

vasodilators used to treat angina

Question 19

Tricuspid Stenosis

Answer 19

reduce fluid congestion: diuretics for fluid overload + salt restriction

bowel edema: torsemide and bumetanide

ascites (fluid in the peritoneal cavity) and liver engorgement: aldosterone inhibitors

treat arrhythmias with medical therapy

valve replacement is the preferred treatment (Bioprosthetic valve preferred); often along with mitral valve replacement

Question 20

Mild Tricuspid Regurgitation

Answer 20

manage with diuretics

monitor with regular echocardiography

Question 21

Severe Tricuspid Regurgitation

Answer 21

reduce fluid congestion: diuretics for fluid overload + salt restriction

bowel edema: torsemide and bumetanide

ascites (fluid in the peritoneal cavity) and liver engorgement: aldosterone inhibitors

treat arrhythmias with medical therapy

Annuloplasty (retains patient’s own tissues); valve replacement when this cannot happen

Question 22

Pulmonary Valve Regurgitation

Answer 22

Rarely needs specific therapy other than treatment of primary cause: pulmonary hypertension, carcinoid (bioprosthetic valve replacement), Tetralogy of Fallot Repair (bioprosthetic valve replacement)

Question 23

Hypertension

Answer 23

thiazide diuretics (best for African Americans and obese) reduce plasma volume initially, then reduce peripheral vascular resistance long-term

long-acting Calcium Channel Blockers cause peripheral vasodilation

ACE Inhibitors or ARB (NOT BOTH); ACE Inhibitors are first-line for patients with HF, symptomatic LV dysfunction, STEMI/NSTEMI, diabetes, systolic dysfunction, proteinuric chronic kidney disease

Question 24

Hypertensive Emergency

Answer 24

captopril, oral clonidine or hydralazine, or nitrates

Question 25

Dislipidemia

Answer 25

healthy lifestyle assumed to be taking low dose aspiring and treatment for co-morbid conditions statins for patients with o previously diagnosed atherosclerotic cardiovascular disease o LDL cholesterol over 190 mg/dL o diabetes, LDL over 70, age 40-75 o calculated 10-year CV risk 7.5% or greater, age 40-75

Question 26

Metabolic Syndrome

Answer 26

optimal management of blood pressure, blood sugars, and lipids; weight management

Question 27

Chronic Stable Angina Acute Treatment

Answer 27

Sublingual Nitroglycerin cause=es decreased myocardial oxygen demand by producing systemic vasodilation acts in 1-2 minutes and can be repeated at 3-5 minute intervals; if pain is not relieved or improving after 5 minutes, call 911

Question 28

Chronic Stable Angina Initial Therapy

Answer 28

Beta Blockers inhibits sympathetic stimulation of the heart, reducing heart rate and contractility the only medication that has demonstrated to prolong life in patients with CAD

Question 29

Chronic Stable Angina First-Line Therapy

Answer 29

Ranolazine relieves ischemia by reducing myocardial cellular sodium and calcium overload via inhibition of late sodium current of the cardiac action potential no affect on HR and BP

Question 30

All patients with Chronic Stable Angina should be on:

Answer 30

a beta-blocker, a statin, ranolazine (first-line), and aspirin

Question 31

Unstable Angina

Answer 31

``` antiplatelet agents lipid-lowering statin agents cardiovascular antiplatelet agents beta blockers anticoagulants thrombin inhibitors nitrates ACE inhibitors ``` long-term medications: beta-blockers, ASA (aspirin), ACE inhibitor, and statin

Question 32

Unstable Angina Invasive Approach

Answer 32

invasive approach may require Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG) o Patients with unacceptable symptoms despite medical therapy to its tolerable limits. o Patients with left main coronary artery stenosis greater than 50% with or without symptoms. o Patients with three-vessel disease with LV dysfunction (EF less than 50% or previous transmural infarction). o Patients with unstable angina who after symptom control by medical therapy continue to exhibit ischemia on exercise testing or monitoring. o Post-myocardial infarction patients with continuing angina or severe ischemia on noninvasive testing.

Question 33

Prinzmetal Angina

Answer 33

avoid precipitants is top priority, such as smoking or cocaine avoidance of triggers, nitrates for acute episodes, and long-term nitrates and calcium channel blockers prophylactically coronary stenting for medically resistant vasospasms

Question 34

NSTEMI

Answer 34

bed rest with continuous ECG monitoring for ST-segment deviation and cardiac arrhythmias4 Anti-ischemic Therapy: nitrates, beta-blockers, oxygen if needed Antithrombotic Therapy: Antiplatelet Drugs (aspirin, clopidogrel or prasugrel, ticagrelor) and Anticoagulant Drugs (heparin, bivalirudin, fondaparinux) Highly variable and potentially life-threatening course; most will be managed with Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG) – if cardiac markers are found to be elevated or ST-T wave changes are viewed on the ECG; occurs within 48 hours of presentation

Question 35

MI Prehospital Care

Answer 35

o Intravenous access o Supplemental oxygen if oxygen saturation is less than 90% via pulse oximetry o Immediate administration of aspirin o Nitroglycerin for active chest pain, given sublingually or by spray o Telemetry and prehospital ECG, if available

Question 36

MI ED Therapy

Answer 36

o On arrival, all patients should have a 12-lead ECG performed immediately. o If aspirin has not been given, then 162–325 mg of aspirin should be administered. o Patients should have continuous cardiac ECG monitoring and two separate intravenous lines. o Sublingual nitroglycerin and intravenous morphine should be administered for pain. o Oxygen saturation should be monitored noninvasively; supplemental oxygen if needed. o A portable chest radiograph should be ordered but should not delay reperfusion. o Echocardiography may be considered if the diagnosis of MI remains in doubt. o Oral β-blockers should be administered to all patients, unless there is a contraindication. o An anticoagulant should be administered to all patients unless a contraindication exists. In patients with ST elevation who receive fibrinolytics, 48 hours of anticoagulant should be administered

Question 37

MI Reperfusion Therapy

Answer 37

o Patients with medical care within 12–24 hours of symptom onset are considered for reperfusion. o Fibrinolysis or Percutaneous Coronary Intervention (PCI) o Both strategies improve patency of the infarct-related artery, reduce infarct size, and lower mortality rates. o The goal of reperfusion therapies is a door-to-needle time of 30 minutes (for fibrinolysis) and a door-to-balloon inflation time of less than 90 minutes (for PCI). o PCI has been shown to be superior to fibrinolysis when it is performed without significant delay by experienced clinicians in experienced centers. o Fibrinolysis should be reserved for chest pain patients in the first 1 to 3 hours of symptoms; after 3 hours PCI is the preferred treatment. o Following reperfusion, all patients benefit from early administration of a P2Y12 inhibitor in addition to aspirin (clopidogrel, prasugrel, or ticagrelor).

Question 38

What is the most important immediate therapy for patients with a MI?

Answer 38

aspirin

Question 39

Heart Failure with Reduced Ejection Fraction/ Systolic

Answer 39

* Beta Blockers * ACEI * ARNI * Hydralazine plus Nitrate * Aldosterone Antagonists. * Diuretics and Digoxin for symptom relief

Question 40

Heart Failure with preserved Ejection Fraction/ Diastolic

Answer 40

• There is limited direct evidence to support a specific drug regimen to treat HFpEF. • Control fluid overload with diuretics • Treat hypertension o Mineralocorticoid receptor antagonist in patients with HFpEF who can be appropriately monitored. o ACEI, ARBs, CCBs, and beta blockers are used as need to treat hypertension but lack proven efficacy to alter clinical outcomes in HFpEF. • Statins might be of benefit in patients with HFpEF. • Prevent rapid heart rates o Restoration and maintenance of sinus rhythm is preferred to rate control in atrial fibrillation

Question 41

Acute Heart Failure and Pulmonary Edema

Answer 41

o in pulmonary edema, have patient in sitting position with legs dangling over the side of the bed – facilitates respiration and reduces venous return o morphine is highly effective in pulmonary edema o IV Diuretics o Nitrates  reduce BP and LV filling pressures o IV Nesiritide  vasodilator that reduces ventricular filling pressures and improves cardiac output

Question 42

Heart Failure

Answer 42

ACEI, ARBs, Beta Blockers, Diuretics

Question 43

Sinus Bradycardia

Answer 43

none if asymptomatic admit for monitoring if pacing is syncopal; stop medications which may be contributing refer for pacemaker if recurrent/symptomatic/nor reversible cause

Question 44

AV Nodal Re-entry Tachycardia

Answer 44

* May respond to vagal maneuvers * First-line medication is IV adenosine * Second-line medications are calcium channel blockers (verapamil, diltiazem) and beta blockers (esmolol, metoprolol) * Cardioversion (shock) if the patient is unstable and/or medications ineffective * Long-term treatment can include catheter ablation (first-line) or suppression with calcium channel blockers or beta blockers

Question 45

AVRT

Answer 45

``` • If hemodynamically stable: o Adenosine o Calcium channel blocker • If not hemodynamically stable: o Cardioversion • If AFib is present: o Do NOT use AV blocking maneuvers or medications, can increase conduction via the accessory pathway o Cardioversion vs other antiarrhythmics • Long-term: o Catheter ablation is treatment of choice ```

Question 46

Atrial Fibrillation

Answer 46

Rate Control/AV Nodal Blocking Agents o Beta-Blockers and Calcium Channel Blockers o goal is >80 bpm at rest and >100 bpm ambulatory Rhythm Control o Preferred when  Symptomatic despite rate control  Are difficult to rate control  Develop tachycardia-mediated cardiomyopathy  Are younger  Have a first episode or have Afib triggered by acute illness  Hemodynamically unstable=urgent cardioversion o Cardioversion  restores sinus rhythm in 75-90% of patients  initial shock 100-200 Joules, additional attempt 360 Joules  Afib recurs in 40-60% of patients at 3 months, and in 60-80% of patients at 12 months o Antiarrhythmics  Class I Fast Sodium Channel Blockers  Class II Beta Blockers  Class III Potassium Channel Blockers  Class IV Slow Calcium Channel Blockers  Class V Variable Mechanism o Ablation  radiofrequency catheter ablation  cryogenic freezing  cauterizes short circuits that are causing Afib

Question 47

Atrial Flutter

Answer 47

ventricular rate control with antiarrhythmics anticoagulation may be necessary due to increased stroke risk

Question 48

Premature Ventricular Contractions

Answer 48

underlying cause if there is one no underlying cause, but bothersome: beta blockers or calcium channel blockers if refractory may proceed to radiofrequency ablation

Question 49

Ventricular Tachycardia

Answer 49

Acute: This is an ACLS/Code scenario; Cardioversion and VT algorithm medications Chronic: Sustained: Correct underlying cause if possible (ischemia/infarction, metabolic derangement, medication toxicity); Depending on patient stability may either go to the ACLS algorithm; Chemical cardioversion with amiodarone, lidocaine, procainamide, or sotalol; or Electrical cardioversion Nonsustained VT (NSVT): Correct underlying cause, Control rate and decrease recurrence with β-blockers or calcium channel blockers; Radiofrequency ablation if refractory (stubborn; resistant); If underlying heart disease is present, patients may end up with and Implantable Cardioverter Defibrillator (ICD) +/- Pacemaker

Question 50

Accelerated Idioventricular Rhythm

Answer 50

Often none, but careful monitoring. If felt to be an escape rhythm, treatment is actually contraindicated since it’s the only thing keeping the heart going.

Question 51

Long QT Syndrome

Answer 51

Congenital: beta blockers and implantable cardioverter-defibrillator (nonpharmacologic) Acquired: magnesium sulfate, isoproterenol, lidocaine, phenytoin, and sodium bicarbonate, or temporary pacing (nonpharmacologic)

Question 52

First Degree AV Block

Answer 52

no specific therapy if asymptomatic Pacemaker may be considered if: Pacemaker syndrome: uncomfortable awareness of one's heart beat because of the loss of atrioventricular synchrony; First degree AV block with concurrent neuromuscular disease.; Patients with a wide QRS complex in conjunction with prolongation of the PR interval

Question 53

Second Degree AV Block Motbitz Type I

Answer 53

Symptomatic and hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate Symptomatic and hemodynamically unstable: atropine and temporary cardiac pacing Mobitz type I and asymptomatic bradycardia not due to a reversible etiology: Permanent pacemaker is not indicated; Regularly follow-up, including a surface ECG, every 6 to 12 months. Mobitz type I and symptomatic bradycardia not due to a reversible etiology: Permanent pacemaker

Question 54

Second Degree AV Block Mobitz Type II

Answer 54

treat underlying cause Hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate Hemodynamically unstable: atropine and temporary cardiac pacing No reversible etiology: permanent pacemaker.

Question 55

Third Degree AV Block

Answer 55

Hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate Unstable patients: atropine and temporary cardiac pacing. Once hemodynamically stable, look for underlying reversible causes. Once underlying reversible causes of heart block have been excluded, permanent pacing is usually indicated.

Question 56

Tachy-Brady Syndrome

Answer 56

Hemodynamically unstable: ACLS protocol with atropine, dopamine, or epinephrine as well as temporary cardiac pacing. Hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate The long-term management depends on the extent of symptoms and conduction abnormalities as well as the likelihood of recurrence or progression leading to subsequent problems. Patients with bradycardia which is symptomatic: permanent pacemaker is not indicated; Follow with intermittent examinations.

Question 57

Torsades de Pointes

Answer 57

underlying cause IV Magnesium (maybe Potassium); check troponins Temporary Pacing Isoproterenol Permanent pacemaker may be necessary, especially for bradycardia dependent TdP

Question 58

Hypovolemic Shock

Answer 58

The goal is to restore the volume lost Hemorrhagic shock use blood substitutes Non hemorrhagic shock use isotonic crystalloid in 1L increments Vasopressors are used only as a temporary method to restore BP until fluid resuscitation take place

Question 59

Cardiogenic Shock

Answer 59

The main goal is to improve myocardial function Arrhythmia should be treated Reperfusion percutaneous coronary intervention (PCI)/stent is the treatment of choice in acute coronary syndrome (ACS) Inotropes (contractility - afterload) and vasopressors (vasoconstriction - preload)

Question 60

Obstructive Shock

Answer 60

The key is to identify and reverse the cause of the obstruction Massive PE - IV thrombolytics Pericardial Tamponade - pericardiocentesis via needle decompression Tension pneumothorax - needle thoracostomy, finger thoracostomy, or tube thoracostomy

Question 61

Septic Shock

Answer 61

The initial approach to the patient with septic shock is the restoration and maintenance of adequate intravascular volume (CVP 8-12 mmHg) Requires LARGE volumes of fluid for resuscitation (>2L) due to capillary leakage  warm fluids to avoid hypothermia and coagulopathy Vasopressors to keep mean arterial pressure (MAP) above 65 mm Hg Prompt institution of appropriate antibiotic

Question 62

Systemic Inflammatory Reponse

Answer 62

If septic, treat with appropriate antibiotics Vasoactive drugs for refractory hypotension Glucose control Supplemental oxygen Consultation for underlying causes/complications

Question 63

Neurogenic Shock

Answer 63

Primary management is the correction of persistent hypotension (despite fluid resuscitation) with vasopressors and inotropes