2) Cardiology (Part 1) Flashcards

1
Q

Non-modifiable coronary heart disease risk factors

A
  • Age
  • Male sex
  • Family history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Modifiable coronary heart disease risk factors

A
  • Hyperlipidemia
  • Hypertension
  • Diabetes mellitus
  • Metabolic syndrome
  • Cigarette smoking
  • Obesity
  • Sedentary lifestyle
  • Heavy alcohol intake
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Markers for CHD

A
  • Elevated lipoprotein (a)
  • Hyperhomocysteinemia
  • Elevated high-sensitivity C-reactive protein (hsCRP)
  • Coronary arterial calcification detected by CT (CAC)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Atherosclerosis

A
  • Pathological process in which coronary arteries become narrowed by the buildup of fatty material in their walls
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Atherosclerotic plaques

A
  • Lead to narrowing of the artery lumen

- Decrease blood flow and oxygen delivery to the coronary arteries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

CAD diagnosis

A
  • Cardiac catheterization (often after an abnormal cardiac stress test)

Or

  • CT angiography
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

CAD treatment

A
  • Treat Modifiable Risk Factors (Hyperlipidemia, Hypertension, Diabetes mellitus, Metabolic Syndrome, Cigarette Smoking, Obesity, Sedentary Lifestyle, Heavy Alcohol Intake)
  • Low-dose aspirin 75-100mg/daily for secondary prevention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Primary prevention (preventing 1st heart attack)

A
  • Mostly don’t prescribe low-dose aspirin
  • Sometimes used in select adults aged 40-70 years who have a higher risk of developing ischemic heart disease but not an increased bleeding risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Angina

A
  • Limitation of Coronary Blood Flow
  • Decreased Oxygen supply to the heart muscle
  • Pt. develops chest pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Classic history of angina

A
  • Chest discomfort, usually described as “heaviness” “pressure” “squeezing” “smothering” or “choking”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Levine’s sign (pt making fist over sternum describing pressure)

A
  • Can radiate to either shoulder and to both arms (especially the ulnar surfaces of the forearm and hand)
  • Can arise in or radiate to the back, interscapular region, root of the neck, jaw, teeth, and epigastrium
  • Angina is rarely localized below the umbilicus or above the mandible
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Anginal “equivalents” symptoms

A
  • Dyspnea
  • Nausea
  • Fatigue
  • Faintness
  • More common in elderly and diabetic patients
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Types of angina

A
  • Prinzmetal’s Variant Angina/Vasospastic Angina
  • Stable Angina
  • Unstable Angina
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Prinzmetal’s Variant Angina

A
  • Caused by coronary artery vasospasm resulting in transmural ischemia
  • Severe ischemic pain that usually occurs at rest and is associated with transient ST-segment elevation
  • Diagnosed with coronary angiography demonstrating transient coronary spasm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Stable angina

A
  • Transient myocardial ischemia
  • Caused by exertion typically is relieved in 1–5 min by slowing or ceasing activities and even more rapidly by rest and sublingual nitroglycerin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Unstable angina

A
  • Part of “Acute Coronary Syndrome”
  • Has at least one of three symptoms
  • Can have ECG changes, but has negative troponins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Symptoms indicative of unstable angina

A
  • Ooccurrence at rest (or with minimal exertion) lasting >10 min (usually more than 20 min)
  • Relatively recent onset (i.e., within the prior 2 weeks)
  • Crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previous episodes)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Stable angina Tx

A
  • Treat modifiable risk factors
  • Nitrates
  • Beta or Calcium Channel Blockers, Ranolazine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Prinzmetal’s Variant Angina Tx

A
  • Nitrates

- Calcium channel blockers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Unstable angina Tx

A
  • Admission

- Dual antiplatelet therapy + glycoprotein IIb/IIIa inhibitor + anticoagulation with heparin +/- statin +/- cardiac cath

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Unstable Angina (UA) ischemic symptoms

A
  • Rest angina usually more than 20 minutes, new onset angina that limits physical activity, increasing angina that is more frequent, longer, and occurs with less exertion than previously
  • With or without EKG changes in contiguous leads (ie T wave inversions, ST segment depressions)
  • NO elevation of troponin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Non-STEMI ACS symptoms

A
  • Same as unstable angina, but troponin is elevated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

STEMI ACS symptoms

A
  • ST segment elevations of 1 mm (0.1 mV) in 2 anatomically contiguous leads or 2 mm (0.2 mV) in 2 contiguous precordial leads
  • OR new left bundle branch block and presentation consistent with ACS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Plaque rupture in ACS

A
  • Rupture of the fibrous cap of an atheromatous plaque

- Exposure of highly thrombogenic, necrotic core material rich in red cells

25
Q

ACS occlusion status

A
  • Unstable angina = partial obstruction
  • Non-STEMI = larger obstruction with occlusion of lumen
  • STEMI = complete occlusion of lumen
26
Q

Diagnosis of ACS

A
  • ECG is the best initial test

At least 2 of the following

  • History (angina or angina equivalent)
  • Acute ischemic ECG changes
  • Typical rise and fall of cardiac markers
  • Absence of another identifiable etiology
27
Q

Patient history indicating ACS

A
  • Chest discomfort (pain, tightness, dull, heaviness, etc.)
  • Fatigue
  • Weakness
  • SOB
  • Activity at onset
  • Risk factors
28
Q

5 most important history-related factors (in order of importance)

A

1) Nature of the chest pain
2) History of Coronary Heart Disease
3) Sex/gender
4) Age
5) Number of traditional risk factors

29
Q

Physical examination

A
  • Vital signs
  • Skin color/diaphoretic
  • Neck
  • Lung sounds
  • Heart sounds
  • Lower extremity exam
  • In considering thrombolytics (“clot busters”), cursory neuro exam
30
Q

Lung sounds to look for in ACS physical examination

A
  • Rales/crackles = fluid out of the capillaries into the alveoli
31
Q

Heart sounds to look for in ACS physical examination

A
  • Friction rub
  • New murmur
  • Acute mitral valve regurgitation or a VSD
  • Pericardial effusion/tamponade
32
Q

ECG in ACS

A
  • Tool for looking at acute ischemia to the coronary arteries that supply areas of the heart
  • REMEMBER about 50% may be initially normal, but then develop ST changes
33
Q

Unstable angina and non-STEMI ECG in ACS

A
  • May be normal or abnormal
34
Q

STEMI ECG in ACS

A
  • By definition, ST segment elevation in contiguous leads (or new LBBB) in the setting of ischemic symptoms
35
Q

Troponin I or T (cTnI or cTnT)

A
  • Cardiac biomarkers/enzymes

- The time of presentation and every 3-6 hours for 6-12 hours

36
Q

High-sensitivity Troponin (hs-cTn) I or T

A
  • Cardiac biomarkers/enzymes

- The time of presentation and every hour x 1-3 hours

37
Q

False positives in cardiac biomarker testing

A
  • Pulmonary embolism
  • Myocarditis
  • TYakotsubo cardiomyopathy
  • Chronic kidney disease
  • Rare analytical problem (heterophile antibodies)
38
Q

False negatives in cardiac biomarker testing

A
  • Excessive biotin use
39
Q

Initial interventions with ACS

A
  • Assess and stabilize airway, breathing, and circulation
  • Provide Oxygen (ONLY IF O2 Sat is <90% patients in respiratory distress
  • Establish IV access
  • Treat sustained ventricular arrhythmia rapidly according to ACLS protocols
  • Vitals, history, labs
  • Portable CXR
40
Q

Labs ordered in suspected ACS

A
  • Cardiac biomarkers x3
  • CBC
  • CMP
  • PT/INR
  • PTT
41
Q

Initial medications for ACS

A
  • Aspirin
  • Nitroglycerin
  • Beta Blockers
  • Morphine
  • Statin
42
Q

STEMI management

A
  • Immediate reperfusion therapy
  • Do not wait for troponin results
  • Straight to cath lab if there are ST segment elevations in EKG in contiguous leads
43
Q

Immediate reperfusion therapy

A
  • Most common is immediate cardiac cath (angioplasty/percutaneous intervention)
  • Goal: door to balloon 90 minutes
44
Q

Non-STEMI and unstable angina management

A
  • Admission, cardiac monitoring, serial ECGs

Plus

  • Anti-platelet medications (Aspirin + GP IIB/IIIA INHIBITORS(Integrilin/ReoPro) + Adenosine diphosphate (ADP) receptor antagonists(Ticagrelor/Brilinta or prasugrel/Effient or clopidogrel/Plavix)

Plus

  • Anticoagulation (UF Heparin or LMWH)

Plus

  • Cardiology Consult (Usually get a Cardiac cath)
45
Q

Long term management of ACS after hospital discharge

A
  • Dual antiplatelet therapy x 12 months at least (Aspirin + ADP inhibitor)
  • Statin
  • ACE-I or ARB
  • Beta Blocker
46
Q

Acute pericarditis

A
  • Inflammatory process involving pericardium
  • Can occur as acute, sub-acute or chronic form
  • Most common of all disease processes involving the pericardium
47
Q

Acute pericarditis causes

A
  • Variety of etiologies (most commonly post infectious)
  • May be associated with a pericardial effusion & even tamponade
  • Can become chronic or recurrent
  • Can develop into constrictive pericarditis
48
Q

Symptoms of pericarditis

A
  • Chest pain is usually presenting symptom
  • Often sharp, typically retrosternal piercing, & pleuritic in nature with radiation to left shoulder
  • Pain aggravated by deep breathing & lying supine
  • Pain is non-exertion & may be steady or even crushing in nature & may mimic acute MI
  • Pain may also be in epigastric area & increased with swallowing
  • If acute infectious etiology, patient is most comfortable sitting up & leaning forward
  • Fever usually follows onset of CP
49
Q

PE findings in pericarditis

A
  • Pericardial friction rub
  • Scratchy, rough, gritty sound
  • Best heard using diaphragm applied firmly along lower LSB with patient sitting upright & leaning forward
  • May be accentuated in inspiration
50
Q

Pericarditis treatment

A
  • NSAIDs + Cholchicine
51
Q

Aortic dissection

A
  • Much less common than an MI
  • Extreme emergency & can lead to death in minutes
  • Blood can dissect up or down aorta
  • Blood dissecting up around great vessels can close off carotids
  • Blood can dissect down to coronaries & shut them off
52
Q

Risk factors for ascending aortic dissection

A
  • HTN
  • Cystic medial necrosis
  • Marfan’s syndrome
53
Q

Risk factors for descending aortic dissection

A
  • Atherosclerosis
  • HTN
  • Increased incidence
  • Coarctation of aorta; Bicuspid AV,AS, 3rd trimester of pregnancy in otherwise normal women (rare), Rarely traumatic
54
Q

Symptoms of aortic dissection

A
  • Sudden onset of severe sharp anterior or posterior chest pain with “ripping” or tearing quality
55
Q

PE findings of aortic dissection

A
  • Unequal Blood pressure readings in the RUE and LUE
  • Asymmetry of carotid or brachial pulses
  • New onset of Aortic Regurgitation murmur
  • Neurologic abnormalities if there is interruption of carotid artery flow
56
Q

Aortic dissection diagnosis

A
  • “90% will have an abnormal CXR, Mediastinal widening
  • CT Angiogram (fast & sensitive)
  • Echocardiogram (evaluates aortic valve)
57
Q

Aortic dissection Tx

A
  • ICU monitoring

- Antihypertensive therapy to maintain systolic BP below 120 mm Hg, using IV agents, followed by oral therapy

58
Q

Descending aortic dissection Tx

A
  • Stabilized medically with antihypertensives
59
Q

Ascending aortic dissection Tx

A
  • Immediate surgical repair