7/23/16 Flashcards
what two drugs are the best options to add to aspirin in acute coronary syndrome when angioplasty and stenting is planned?
ticagrelor or prasugrel (P2Y12 inhibitors)
what is the management of a patient to with low ejection fraction who is experiencing hyperkalemia on ACE inhibitors?
switch to HYDRALAZINE and NITRATES
what are the drugs that lower morbidity in chronic angina?
aspirin, beta blockers, nitroglycerin
what is the most common adverse effect of statin medications?
liver dysfunction (pts should have their AST and ALT tested routinely); myositis is much less likely
what drug can be added to statins if full lipid control is not achieved? what are the side effects?
niacin; glucose intolerance, elevation of uric acid level, pruritus from a transient release of histamine
what lipid-lowering drug can increase risk of myositis when combined with statins?
fibrates
what are the indications to use CCBs (verapamil, diltiazem) in CAD?
- severe asthma precluding the use of beta-blockers
- Prinzmetal variant angina
- cocaine-induced chest pain (beta-blockers thought to be contraindicated)
adverse effects of CCBs
edema, constipation (verapamil most often), heart block
what are the indications for CABG?
- THREE VESSELS with at least 70% stenosis in each vessel
- LEFT MAIN coronary artery occlusion
- TWO-vessel disease in pts with DIABETES
increase in jugular venous pressure on inhalation
Kussmaul sign = constrictive pericarditis or restrictive cardiomyopathy
Normally the neck veins should go DOWN on inhalation
triphasic “scratchy” sound on cardiac auscultation
pericardial friction rub
PMI displaced toward axilla
left ventricular hypertrophy or dilated cardiomyopathy
EKG signs of anterior wall MI (what ventricle is the anterior wall? what artery is occluded?)
ST elevation in leads V2-V4; left ventricle; LAD
EKG signs of inferior wall MI (what ventricle is the inferior wall? what artery is occluded?)
ST elevation in leads II, III, and aVF; right ventricle; right coronary artery
EKG signs of posterior wall MI (what ventricle is the inferior wall? what artery is occluded?)
ST DEPRESSION in leads V1 and V2; inteventricular septum; posterior descending artery
what is first-degree AV block?
PR interval greater than 200 milliseconds
indications for clopidogrel in acute coronary syndrome
clopidogrel is indicated when a pt has intolerance to aspirin or has undergone angioplasty with stenting
what enzyme levels should you check if you suspect reinfarction within a few days of a cardiac event?
CK-MB (should have returned to normal after 2 days)
when is heparin used in the tx of acute coronary syndrome?
heparin is the initial therapy for ST depression and other NON-ST ELEVATION events (unstable angina), also used in ST elevation infarction after thrombolytics/PCI to PREVENT RESTENOSIS, in pts with a CARDIAC THROMBUS, or if SEVERE CHF is seen on echo
when are glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide) used in acute coronary syndrome?
GPIIb/IIIa meds reduce mortality in ST depression and other NON-ST ELEVATION events (unstable angina), also used in ST elevation infarction for angioplasty and stenting
what are cannon A waves?
sign of third-degree (complete) AV block (typically after right ventricular infarction); bounding jugulovenous wave bouncing up into the neck, produced by atrial systole against a CLOSED TRICUSPID VALVE (because atria and ventricles are contracting separately and OUT OF COORDINATION with each other)
tx for cannon A waves
all symptomatic bradycardias are treated first with atropine and then by placing a pacemaker if the atropine is not effective
what should you worry about in a post-MI pt who has new-onset ST elevation in II, III, and aVF, clear lungs, tachycardia, and hypotension after nitroglycerin administration? what is the tx?
right ventricular infarction; treat with high-volume fluid replacement. avoid nitroglycerin because it markedly worsens cardiac filling
what valve rupture is most likely post-MI? where is it best heard?
mitral regurgitation; heard best at apex with radiation to the axilla
what should you worry about in a post-MI pt who has sudden loss of pulse and jugulovenous distention?
tamponade/wall rupture
what test does every pt need to get before leaving the hospital after recovering from an acute coronary event?
stress test (unless pt remains symptomatic) to determine if angiography is needed
what medications should all pts go home on after an acute coronary event?
aspirin, beta blockers (metoprolol), statins, ACE inhibitors (best for ANTERIOR wall infarctions because of the high likelihood of developing systolic dysfunction)
what combination of drugs should you worry about in pts with erectile dysfunction post-MI?
NITRATES and SILDENAFIL should NOT be combined, hypotension can result because they are both vasodilators
what is the medication most likely to cause erectile dysfunction post-MI?
beta-blockers
MI is a common cause of _______ cardiomyopathy
dilated
what is the most common cause of CHF?
hypertension resulting in cardiomyopathy or abnormality of the myocardial muscle (over time, the heart dilates, resulting in systolic dysfunction and low ejection fraction)
when is an S3 heard?
S3 is a volume overload condition, happens during rapid filling phase of diastole, too much volume entering ventricle causes chordae tendinae to tense, causing S3
dyspnea in a pt with recent anesthetic use, BROWN BLOOD not improved with oxygen, clear lungs on auscultation, cyanosis
methemoglobinemia
best initial test for CHF
transTHORACIC echo (if dyspnea is acute and you cannot wait for an echo to be done, get a BNP LEVEL)