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)
5-medication regimen for management of CHF due to systolic dysfunction (low ejection fraction); which improve mortality?
improve mortality (ABS): ACE inhibitors, Beta blockers, Spironolactone symptom relief: Diuretics (loop), DIGOXIN (if it starts with D, it does NOT lower mortality!)
what is the management for a pt with severe CHF who develops gynecomastia?
switch spironolactone to EPLERENONE
what treatments lower mortality in CHF?
HI ABS!: Hydralazine/nitrates (alternative tx if ACE inhibitor causes hyperkalemia), Implantable defibrillator, ACE inhibitors, Beta blockers, Spironolactone
what are the indications for a implantable defibrillator vs a biventricular pacemaker?
Implantable defibrillator: for those with ischemic cardiomyopathy and ejection fraction below 35%
Biventricular pacemaker: for those with dilated cardiomyopathy and ejection fraction under 35% AND a WIDE QRS ABOVE 120 MILLISECONDS
medication regimen for management of CHF due to diastolic dysfunction (preserved ejection fraction)
BETA BLOCKERS and DIURETICS (no other drugs have proven benefit)
initial therapy of acute pulmonary edema
oxygen, loop diuretics, morphine, nitrates
what can you give to a pt with acute pulmonary edema whose dyspnea did not respond to therapy acutely with preload reduction?
positive inotropic agents: dobutamine, amrinone, or milrinone
explain the effects of inhalation vs exhalation on right or left sided murmurs
right sided murmurs (tricuspid, pulmonic) increase with inhalation because inhalation increases venous return to right side of heart. left sided murmurs (mitral, aortic) increase with exhalation because exhalation squeezes blood out of the lungs and into the left side of the heart
what type of stenotic valve needs surgical replacement and what type needs dilation with a balloon?
AORTIC stenosis needs SURGICAL REPLACEMENT, whereas MITRAL stenosis is DILATED with a balloon
what are the 4 unique features of presentation for mitral stenosis?
- dysphagia (left atrium pressing on esophagus)
- hoarseness (LA pressing on laryngeal nerve)
- atrial fibrillation and stroke (from enormous LA)
- hemoptysis
management of regurgitant valve lesions
vasodilation with ACE inhibitors/ARBs, surgical correction when left ventricular end systolic diameter is above 40mm or ejection fraction drops below 60%
what systemic pathologies can cause aortic regurgitation?
Marfan syndrome, anklosing spondylitis, Reiter syndrome, syphilis
what are the 5 unique features of presentation for aortic regurgitation?
- wide pulse pressure
- wide, bounding pulse
- pulsations in nail bed
- BP in legs as much as 40 mmHg above arm BP
- head bobbing
what are the 3 unique features of presentation for mitral valve prolapse?
- atypical chest pain
- palpitations
- panic attack
unlike other valvular heart diseases, NO SIGNS OF CHF!
best initial therapy for HOCM; what medications should you avoid?
best initial therapy: beta blockers
avoid: ACE inhibitors, diuretics, digoxin, hydralazine (anything that decreases left ventricular chamber size by decreasing afterload)
medications for HCM
beta blockers, diuretics
what are the differences and similarities in the medication regimen for dilated vs hypertrophic cardiomyopathy?
spironolactone and digoxin are helpful only in DILATED cardiomyopathy. otherwise, both types of cardiomyopathy are treated with ACE inhibitors, beta blockers, and diuretics
what does amyl nitrate do to the heart?
it is a direct arterial vasodilator so it decreases afterload (simulates effect of ACE inhibitors/ARBs)
how do positional changes affect chest pain associated with pericarditis?
worsened by lying flat and improved by sitting up
tx for idiopathic pericarditis
presumed to be viral in etiology with Coxsackie B virus; tx with NSAIDs and colchicine (decreases recurrences)
EKG, echo, and right heart catheterization findings in cardiac tamponade
EKG: different heights of QRS complexes between beats
Echo: right atrial and ventricular diastolic collapse
R heart catheterization: equalization of pressures in diastole
tx of constrictive pericarditis
- DIURETICS USED FIRST to decompress filling of heart and relieve edema and organomegaly
- SURGICAL REMOVAL of pericardium
spinal stenosis pain is worse when walking ____ hill
spinal stenosis pain is worse when walking down hill, because of leaning back
ABI of _______ means disease is present
less than 0.9 (greater than 10% difference between ankles and brachial arteries)
most effective medication for peripheral artery disease, what else is part of initial therapy?
CILOSTAZOL, aspirin, stopping smoking
best initial test vs most accurate test for aortic dissection
best initial test: CXR
most accurate test: angiogram
tx for aortic dissection
- beta blockers: decrease the “shearing forces” that are worsening the dissection
- nitroprusside: beta blockers must be given BEFORE to protect against reflex tachycardia of nitroprusside
- surgical correction
who needs to be screened for aortic aneurysm and how?
men who ever smoked above 65 with ultrasound
pathogenesis of peripartum cardiomyopathy
antibodies are made against myocardium, causing LV dysfunction that is often reversible
lateral leads on EKG
I, aVL, V5-V6
tx for esophageal spasms
calcium channel blockers
EKG, cardiac enzymes, response to nitroglycerin, and tx for Prinzmetal angina
EKG: ST elevation
Cardiac enzymes: normal
Response to nitrogylcerin: yes
Tx: calcium channel blockers for long-term, which reduce arterial spasm
medication regimen for cor pulmonale
prostacyclin, antiendothelin (bosentan), PDE5 inhibitors (sildenafil), and CCBs
acceptable rate-control agents for atrial fibrillation
beta blockers, CCBs, or digoxin (slow ventricular rate)
tx for WPW syndrome
procainamide or quinidine (class IA antiarrhythmics)
describe the CHADS2 score that dictates atrial fibrillation management
CHF +1 Hypertension +1 Age greater than 75 +1 Diabetes +1 Stroke or TIA +2 0 = aspirin; more than 2 = warfarin
if a pt’s ptosis is relieved by an ice pack, what dx should you consider?
myasthenia gravis; cold temperature improves muscle strength by inhibiting breakdown of acetylcholine at the neuromuscular junction, thereby increasing acetylcholine availability to the nicotinic receptor. confirm with ACETYLCHOLINE RECEPTOR ANTIBODIES
what medication lessens ventricular remodeling in the weeks to months following MI that can lead to dilatation of the ventricle?
ACE inhibitors
when is carotid endarterectomy recommended? what is the medical management of those who do not get surgery?
- SYMPTOMATIC carotid stenosis of greater than 70%
- MEN with ASYMPTOMATIC carotid stenosis of greater than 60%
Otherwise: antiplatelet agents and statins, annual Duplex ultrasound, risk factor optimization
how can you prevent oxygen toxicity when a pt is on mechanical ventilation?
reduce FiO2 as soon as possible to below 60%
which class of antiarrhythmics causes prolonged QRS complex duration with faster heart rates?
class IC (flecainide, propafenone; think of corn flakes and phone)
what drug can be used in a pt who had a PE/DVT who do not want daily injections (heparin) or have difficulty with dietary restrictions or frequent INR monitoring (warfarin)? what is the down-side to this drug?
rivaroxaban (direct factor Xa inhibitor); there is no antidote in the event of major hemorrhage
what are the best markers indicating resolution of DKA?
serum anion gap and beta-hydroxybutyrate levels (predominant ketone in DKA)
what are the opportunistic infection prophylaxes that should be given to an HIV pt and at what CD4 counts?
- CD4 less than 200: TMP/SMX for Pneumocystis jiroveci pneumonia (PCP)
- CD4 less than 100: azithromycin for Mycobacterium avium complex, TMP/SMX (which they should already be getting) for toxoplasmosis
dx and causative organism: granulation tissue in ear canal, facial nerve paralysis in an elderly diabetic pt
malignant otitis externa; pseudomonas aeruginosa. this is a serious infection of the ear that can progress to osteomyelitis of the skull base and destruction of the facial nerve
what is Ramsay Hunt syndrome?
herpes zoster infection in the ear that presents with facial nerve palsy and vesicles in the auditory canal and auricle
what should you consider in a pt with acute limb ischemia following an MI?
arterial embolus from left ventricular thrombus
what CBC abnormality is seen in pts with obstructive sleep apnea?
elevated hematocrit levels (kidneys respond to hypoxemia by increasing erythropoietin)
initial tx of cocaine toxicity and myocardial ischemia
oxygen and IV BENZODIAZEPINES (reduce sympathetic outflow which reduces anxiety and agitation, improve BP and HR, and alleviate cardiovascular sx)
optic disc hyperemia
methanol intoxication
decreased sensation over the 4th and 5th fingers and weak grip = what nerve and where is it entrapped?
ulnar nerve entrapment at the elbow (where the nerve lies at the medial epicondylar groove)
