5. Cardiology Flashcards
Risk factors of MI ?
- DM. “Worst risk factor”
- Hyperlipidemia. “elevated LDL”
- HTN. “most common”
- smoking.
- Age (men>45, women>55)
- Family hx of premature CAD or MI in 1st degree.
- Low levels of HDL.
Prognostic indicators of CAD ?
A. Left ventricular function (EF):
- Normal >50%.
- If <50%, associated with increased mortality.
B. Vessels involved (severity/extent of ischemia):
- LMA, poor prognosis coz it covers 2/3 of heart.
- 2 or 3 vessels or CAD, worse prognosis.
Typical chest pain ?
- Characterized as discomfort/pressure rather than pain.
- Time duration >2 mins.
- Provoked by activity/exercise.
- Radiation (i.e. arms, jaw)
- Does not change with respiration/position.
- Associated with diaphoresis/nausea.
- Relieved by rest/nitroglycerin.
Atypical chest pain ?
- Pain that can be localized with one finger.
- Constant pain lasting for days.
- Pain lasting for a few seconds.
- Pain reproduced by movement/palpation.
The detection of ischemia on an ECG stress test is
based on presence of ?
- ST segment depression.
- or chest pain, hypotension or significant arrhythmias.
- Patients with a positive stress test result should undergo cardiac catheterization
What is the definitive test for CAD?
Coronary angiography.
Standard care for stable angina “ chronic coronary syndrome” ?
- Aspirin.
- B-blockers.
- only 2 above lowers mortality.
- Statin.
- Nitrates “for pain”
- Risk factors modifications .
The distinction between USA and NSTEMI is based entirely on ?
- Cardiac enzymes.
- NSTEMI has elevation of troponin or CK-MB
Treatment of acute coronary syndrome ?
- Aspirin (300 mg).
- Heparin. (LMWH or Enoxaparin)
- Ticagrelor 180 mg (P2Y12 inhibitors).
- O2 (if <95%)
- Morphine.
- Nitro (always check BP)
What is the Thrombolysis in Myocardial Infarction (TIMI) Score ?
Is used to determine the likelihood of ischemic events or mortality in patients with unstable angina or non–ST-segment elevation myocardial infarction (NSTEMI)
(TIMI) Score factors ?
- Hx:
- Age>65 -> 0-1.
- > 3 CAD risk fsctors -> 0-1.
- Known CAD -> 0-1.
- ASA use in past 7 days -> 0-1.
- Presentation:
- Severe angina (> 2 episodes in last 24 hrs) -> 0-1.
- ST changes -> 0-1.
- Positive cardiac marker -> 0-1.
Ticagrelor use in post ACS ?
- 180 mg (P2Y12 inhibitors).
- for 12 months but depends on the type of stent. if drug stent -> 6 months.
Complications of acute MI ?
- Pump failure (CHF).
- Arrhyrhmias.
Transradial approach: Benefits ?
- Stay in bed not required
- Shortening of hospitalization
- Decreased costs of hospitalization
- Decreased risk of complication
- Lower need for blood transfusion.
Transradial approach: Benefits
• Mainly useful in ?
– Peripheral artery disease
– Abdominal aorta aneurysm
– Obese people
– Blood clotting problems increased INR
SYNTAX scale ?
Anatomical assessment of lesion in coronary areteries in patient with multivessel disease or with lesion in Left Main
Risk factors of Restenosis ?
- Long lesion.
- Narrow vessel.
- Amount and lenght of implanted stents. (multiple stenosis).
- Inappropriate stent deployment.
- DM
Stent thrombosis is ?
Sudden occlusion of previously treated vessel that usually leads to ST-elevation myocardial infarction.
New York Heart Association (NYHA) Classification ?
- NYHA class I: nearly asymptomatic
- NYHA class II: symptoms after prolonged or moderate exertion.
- NYHA class III: symptoms occur with usual activities.
- NYHA class IV: symptoms occur at rest.
Common Symptoms of Heart Failure ?
- Dyspnea on exertion
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Fatigue
- Lower extremity edema
- Cough, usually worse at night
- Nausea, vomiting, anorexia, ascites
- Nocturia
- Sleep disorders
Common Physical Findings of Heart Failure ?
§ Elevated jugular venous pressure § Hepatojugular reflux § Displaced apical impulse § S3 gallop § Pulmonary rales § Hepatomegaly § Peripheral edema § Ascites § Signs of cardiac cachexia
Tests to order for a new patient with CHF ?
- CXR (pulmonary edema, cardiomegaly, rule out COPD).
- Echocardiogram (estimate EF, rule out pericardial effusions).
- ECG.
- Cardiac enzymes (to rule out MI).
- CBC (anemia).
- Natriretic peptides (BNP)
Echocardiogram rule in CHF ?
A. Initial test of choice—should be performed whenever CHF is suspected based on history, examination, or CXR.
B. Useful in determining whether systolic or diastolic dysfunction predominates, and determines whether the cause of CHF is due to a pericardial, myocardial, or valvular process.
C. Estimates EF (very important): Patients with systolic dysfunction (EF <40%) should be distinguished from patients with preserved left ventricular function (EF >40%).
Standard ttt of CHF ?
- Treatment should be according to NYHA classification.
- all patient should decrease sodium and water intake.
- All patient should take B-blockers and ACE inhibitors.
- Then we add drugs according to NYHA classes:
- NYHA II: Add Loop diuretics “for symptoms”and Thiazide diuretics.
- NYHA III: Add Spironolactone and vasodilators (hydralazine).
NYHA IV: Inotrops (Digitalis (useful in patient with EF <40%, severe CHF, or severe AFib)).
………… - Valsartan/sacubitril
Killip classification ?
Designed to provide a clinical estimate of the severity of circulatory derangement in the treatment of acute MI.
- Stage I: No heart failure.
- Stage II: HF.
- Stage III: Severe heart failure.
- Stage IV: Cardiogenic shock.
What is the difference between ACC/AHA classification and NYHA ?
- ACC/AHA stages of HF based on structure and damage to heart muscle.
- NYHA Functional Classification: severity based on symptoms and physical activity.
ACE inhibitors in HF should be uptitrated to
- The dosages shown to be effective in large trials.
- They should not be titrated based on symptomatic improvement
Virchow’s Triad - Causes of Thrombosis ?
- Changes in the blood vessel wall
- Changes in the blood flow
- Changes in the blood composition
Strong predisposing factors of PE?
- Fracture (hip or leg).
- Hip or knee replacement.
- Major general surgery.
- Major trauma.
- Spinal cord injury.
What are principal markers of high risk of early death in acute PE ?
Shock and hypotension.
What is related to intermediate risk of short-term mortality in PE ?
- RV dysfunction.
- Myocardial injury.
Symptoms of PE ?
- Dyspnoea 80%
- Chest pain 52%
- Cough 20%
- Hemoptysis
- Cyanosis
- Collapse.
Signs of PE ?
- Tachypnoea (>20/min) 70%
- Tachycardia (>100/min) 26%
- Pulmonary component of the second tone
- Raised jugular venous pressure
Assesment of clnical probability of PE ?
- Wells score:
1. Previous DVT or PE -> +1.5
2. Recent surgery or immobilization -> +1.5
3. Caner -> +1
4. Hemoptysis -> +1.
5. HR>100 -> +1.5.
6. Clinical signs/symptoms -> +3.
7. PE is most likely -> 3
Wells score results interpretation ?
- Clinical probability (3 level):
- Low: 0-1
- Intermediate: 2-6
- High: >7
- Clinical probability (2 level):
- PE unlikely: 0-4
- PE likely: >4
D-dimer ?
- The product of a cross-linked fibrin.
- Very high negative predictive value.
- Very low positive predictive value.
- Negative D-dimer result in a highly sensitive assay safely excludes the PE in a patients with low or moderate clinical risk.
Compression ultrasonography (CUS) ?
• 90% of PE is due to DVT in lower limb.
• CUS has 90% sensitivity and 95% specificity for
diagnosing proximal DVT
• Thus finding a proximal DVT in patients with suspected PE is sufficient to start anticoagualnt treatment
TTT of Acute AFib in a hemodynamically unstable patient ?
Immediate electrical cardioversion to sinus rhythm
TTT of Acute AFib in a hemodynamically stable patient ?
A. Rate control -> B-blockers (Metoprolol) - u can also use amiodarone. B. Check TEE. C. Anticoagulation. D. Cardioversion.
Treatment approach of AFib depends on which scores ?
- CHA2-DS2-VAS score.
- HAS-BLED score.
CHA2-DS2-VAS score :
- Estimate the risk of stroke for patients with atrial fibrillation.
- Age: 0-1-2.
- Sex: F 1. M 0
- CHF hx: 0-1.
- HTN hx: 0-1.
- Stroke/TIA/TE: 0-2.
- Vascular disease history: 0-1.
- DM hx: 0-1
HAS-BLED score ?
- Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.
- HT (uncontrolled): 0-1.
- Renal disease: 0-1
- Liver disease: 0-1.
- stroke hx: 0-1.
- Prior bleeding: 0-1.
- INR: 0-1
- Age: >65
- Meds: 0-2
- Alcohol: 0-1
