Cardiac Flashcards
HEART FAILURE
Presents
Heart sounds
Dx labs/tests
Meds to be on
Meds NOT to be on
When should pt’s follow up
Presents:
Here is an easy way to remember whether a sign or symptom is from the left or right side of the heart:
**Both left and lung start with the letter L. Symptoms are lung related, such as dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
**Right-sided heart failure symptoms are GI related (anorexia, nausea, and right upper quadrant abdominal pain)
Presents
Physical exam findings include
-lung crackles, wheezing, tachypnea, tachycardia,
Heart sounds:
-S3 gallop, paradoxical splitting of S2, jugular vein distention (JVD),
-peripheral edema, and hypoxia.
Dx labs/tests:
-BNP
-EKG
-XRAY (check for cardiomegaly)
-ECHO (measure ejc. fraction (+) = <40%)
Meds to be on:
-Diuretic
-ACEi
-ARB
Meds NOT to be on:
-no TZD’s (DM TX, cause edema)
-no NSAIDS
-no CCB
(increase sodium (Na) and fluid retention)
When should pt’s follow up:
-pt gains >2 kilos a day
INFECTIVE ENDOCARDITIS
pressents:
s/s on HEENT?
hands? feet?
Dx text to confirm?
also known as bacterial endocarditis
presents with
-fever and chills that are associated with a new-onset murmur
-anorexia
-weight loss.
- subungual hemorrhages (splinter hemorrhages on the nail bed)
-petechiae on the palate,
-Osler nodes (painful violet-colored nodes on the fingers and toes)
-nontender red spots on the palms/soles (Janeway lesions).
-Funduscopic exam may show Roth spots (retinal hemorrhages). First test done for suspected IE is the transthoracic echocardiogram.
ABDOMINAL AORTIC ANEURYSM
presents:
initial imaging test:
x-ray findings:
Majority of patients with (AAA) are asymptomatic.
If not ruptured but has symptoms, patient complains of abdominal, back, or flank pain.
The person at highest risk is a 70-year-old elderly White male who is a smoker (current or has quit) and has HTN.
The classic initial symptoms of a severe, sharp, excruciating pain in the abdomen, flank, and/or back with a pulsatile abdominal mass occurs in only about half (50%) of patients.
Incidental finding on chest x-ray may show widened mediastinum, tracheal deviation, and obliteration of aortic knob (thoracic aortic dissection).
Initial imaging test is the ultrasound.
Apical impulse:
Located at the fifth intercostal space (ICS) by the midclavicular line on the left side of the chest
Displacement of the Point of Maximal Impulse
occurs during:
1.
2.
left ventricular hypertrophy (LVH) and cardiomyopathy: The point of maximal impulse (PMI) is displaced laterally on the chest and is larger (>3 cm) in size and more prominent.
“to the Left, and Large”
Pregnancy, third trimester: As the uterus grows larger, it pushes up against the diaphragm and causes the heart to shift to the left of the chest anteriorly.
“pushed up and to the Left”
The result is a displaced PMI that is located slightly upward on the left side of the chest. May hear S3 heart sound during pregnancy.
S3 Heart Sound
-Usually indicative of heart failure or congestive heart failure (CHF)
-Occurs during early diastole (also called a “ventricular gallop” or an “S3 gallop”)
-Sounds like “Kentucky”
-Always considered abnormal if it occurs after the age of 40 years
-This can be a normal finding in children, pregnant women, and some athletes (>35 years of age)
S4 Heart Sound
Increased resistance due to a stiff left ventricle; usually indicates LVH
-Considered a normal finding in some elderly (slight stiffness of left ventricle)
Occurs during late diastole (also called an “atrial gallop” or “atrial kick”)
-Sounds like “Tennessee”
-Best heard at the apex (or apical area; mitral area) using the bell of the stethoscope
Benign Variants:
Physiological S2 Split normal if:
S4 in the Elderly
Physiological S2 Split
-Best heard over the pulmonic area (or second ICS on the upper left side of sternum); caused by splitting of the aortic and pulmonic components.
-A normal finding if it appears during inspiration and disappears at expiration.
S4 in the Elderly
-Some healthy elderly patients have an S4 (late diastole) heart sound, also known as the “atrial kick” (the atria have to squeeze harder to overcome resistance of a stiff left ventricle).
-If there are no signs or symptoms of heart/valvular disease, it is considered a normal variant.
-Pathological S4 is associated with LVH due to increased resistance from the left ventricle.
Mitral Area
-The mitral area is also known as the apex (or apical area) of the heart.
-Fifth left ICS is approximately 8 to 9 cm from the midsternal line and slightly medial to the midclavicular line.
-PMI or the apical pulse is located in this area.
Aortic Area
-The aortic area is the second ICS to the right side of the upper border of the sternum.
Erb’s Point
-Erb’s point is located at the third to fourth ICS on the left sternal border.
A louder murmur. First time that a thrill is present. A thrill is like a “palpable murmur.”
Grade IV
(6 grades total)
systolic murmurs
the only murmurs that____
MR PM AS MVP
“MR”: (point to patons armpit)
PM
“AS”: (grabs him behind the neck)
MVP: clic
Diastolic Murmurs
AR MS
diastolic = doom
All murmurs with “mitral” in their names are only described as located:
-On the apex (or apical area) of the heart or
-On the fifth ICS on the left side of the sternum medial to the midclavicular line
If an apical/apex murmur occurs during S1, it is _______. If an apical/apex murmur occurs during S2, it is ______
mitral regurgitation (MR)
mitral stenosis (MS)
S3 is a sign of ____; S4 is a sign of _____.
CHF
LVH (left ventricular hypertrophy)
A physiological split S2 is best heard at t
he pulmonic area (upper left sternum).
Rule out AAA in an older male who has a pulsatile abdominal mass that is more than ______. The next step is to order ______
3 cm in width
an abdominal ultrasound and CT
Atrial Fibrillation:
what 2 meds are these pts on?
describe the EKG rhythm
Patient reports a sudden onset of heart palpitations described as feeling like
- “a fish is flopping in my chest”
-“drums are pounding in my chest”
-accompanied by feelings of weakness, dizziness, and tachycardia
Beta Blockers (metoprolol)
Anticoagulant’s
-AFib high risk for a blood clot
rhythm: irregularly irregular
-no P wave (or very minimal)
Paroxysmal Supraventricular Tachycardia
EKG shows tachycardia with peaked QRS complex with P waves present.
-When having an episode, has regular but rapid heartbeat, which starts and stops abruptly (intermittent episodes).
-Can be misdiagnosed as a panic or anxiety attack.
“feels like fluttering in my chest”
-Rapid heart rate can range from 150 to 250 beats/min. Reports previous episodes that resolved spontaneously.
tx:
Valsalva’s maneuver: Holding one’s breath and straining hard, maintain strain for 10 to 15 seconds, then release it and breath normally.
“aPrOXimatly a SUPR TACHY rythm”
Pulsus Paradoxus
Defined as a fall in systolic BP (SBP) of more than 10 mmHg during the inspiratory phase.
-Also known as a paradoxical pulse.
-It is an important physical sign of cardiac tamponade.
what occurs when there are variances in heart rate upon inspiration (increase) and expiration (decrease)?
what is the common population for this??
Respiratory sinus arrhythmia
a young healthy athlete (no Tx needed)
Anterior Wall Myocardial Infarction
Anterior wall MI or an anterior STEMI is the most common type of MI.
-EKG changes include ST segment elevation and Q waves (Figure 2).
-Wide QRS complex on leads V2 to V4 resembles a “tombstone.”
-This finding is called “tombstoning.”
Sinus Rhythm and Sinus Arrhythmia
Sinus arrythmia is a common variation of normal sinus rhythm.
-It is more common in healthy children and young adults.
-The P waves show uniform morphology, and the PP interval increases and decreases during inspiration and exhalation (Figure 3).
Warfarin pearls
if you suspect bleeding?
how long to see dose change difference?
when to skip a dose:
when to give antidote:
-Order an INR with the PT and PTT if you suspect bleeding.
-It may take up to 3 days after changing the warfarin dose to see a change in the INR.
-Warfarin (Coumadin) is an FDA category X drug. It is teratogenic.
-Goal is INR of 2 to 3. If INR is between 4.01 and 4.99, hold one dose. Do not give vitamin K.
-antidote: Vitamin K
Hypertensive retinopathy with arteriovenous nicking.
Elderly are at higher risk for orthostatic hypotension due to
a less active autonomic nervous system and slower metabolism of drugs by the liver (prolongs half-life of drugs).
4 first line HTN medications?
the elderly?
ACE-I (-prils)
ARB (-sartans)
Thiazide Diuretics (-thia, -tha)
-1st for elderly
Calcium Channel Blockers (CCB)
(-dipines)
ACE-Inhibitors (-pril’s) :
what labs do you want to monitor for?
when do we change to an ARB (-sartan’s)?
what labs do you want to monitor for?
Renal function
-GFR
-BUN
-Creatinine
-potassium level (risk of hyperK)
when do we change to an ARB (-sartan’s)?
-if pt gets angioedema (facial/neck swelling- that can happen at any time)
-sartans have a dry cough side effect
ACE-Inhibitors (-pril’s):
good or bad for the kidney’s??
stage 1-2 = good!
stage 3-4 = bad
Thiazide Diuretics (-thia, -tha)
bad for those with:
good for:
bad for those with:
Hyper:
-triglycerides
-uric acid
-glucose
HCTZ:
H= hyperglycemia
C= crystals
T= triglycerides
Contraindications:
-Gout
-Hypotension
-Hypokalemia
-Renal failure
-Lithium treatment
-Sensitivity to sulfa drugs and thiazides
good for:
-Osteoporosis
Calcium Channel Blockers (CCB)
(-dipines) :
what are 2 typical side-effects?
Bad for those with:
ankle Edema
Headache
(lower dose if pt has these)
Bad for those with:
-HF
-GERD
BP medication and pregnancy:
good to give:
bad to give:
good to give:
-Nifedipine (New)
-Labetalol (Little)
-Methyldopa (Mama)
bad to give:
-no ACE-I/ARBS
-no Statins
-no Dmards, Methotrexate
Isolated Systolic HTN
preferred TX in elderly?
only top # is elevated
-CCB
-Thiazide diuretics
HTN and Diabetes
preferred tx?
ACE-I
ARBs
Raynauds Phenom
blood flow disorder.
precipitated by:
-cold temp
-stress
Tx:
-CCB
-avoid triggers
Aldosterone Receptor Antagonist Diuretics
“potassium sparing diuretics)
Spironolactone (aldactone)
Side Effects
-Gynecomastia, galactorrhea
-Hyperkalemia
-Gastrointestinal (GI; vomiting, diarrhea, stomach cramps)
-postmenopausal -bleeding
-erectile dysfunction
Beta-Blockers (-lol’s)
good for?
bad for?
they are also used to tx:
safety issue
2 types:
-Cardioselective beta-blockers (B1 receptors)
-Nonselective beta-blockers (inhibits both B1 and B2 receptors)
good for?
-Ejc. fraction <40% (HF)
-Hx of MI
bad for?
–effects respiratory (asthma/COPD)
they are also used to tx:
-hyperthyroid
-anxiety
-raynauds phenom
(slows everything down)
safety issue:
BB’s can mask s/s of hypoglycemia!
Furosemide (lasix)
pt education:
loop diuretic
-last in body for 6-8 hours
-can cause hyperK
-monitor wt at home (this is the best indicator of fluid status)
-too much too quick = ototoxicity
Digoxin (Lanoxin)
commonly used for pt’s w/:
how does it work?
we must monitor _____ daily
what if the HR is <60?
Toxicity s/s:
Dig level of toxicity:
why is hypoK significant w/toxicity?
Antidote?
commonly used for pt’s w/:
-HF
-A-Fib
how does it work?
-decrease HR (allowing ventricles to refill)
-increases contractility
we must monitor HR daily
what if the HR is <60?
-hold dose
-call HCP
Toxicity s/s:
-green-yellow halos around eyes
-dysrhythmias
-v-tac/v-fib
Dig level of toxicity:
>2 ng/ml
why is hypoK significant w/toxicity?
-HypoK makes it easier for body to slip into Dig Tox.
Antidote= Digbind
Peripheral Arterial Disease (PAD)
s/s
biggest risk factor
go-to DX test
s/s:
-purple skin tone
-hyperpigment/shiny
-decreased blood flow
-decreased pain w/ rest dangling (I.E.: intermittent claudication)
biggest risk factor:
-Smoking
go-to DX test
-ABI (ankle-brachial index)
– Divide BP of arm (highest BP side) of affected ankle
– <0.9 = PAD
Alpha-1 Blockers/Antagonists ( -zosin)
–Alpha-blockers are not first-line drugs for HTN, except if patient has preexisting BPH.–
-TERAzosin (Hytrin): Used for both HTN and BPH (starting dose 1 mg PO at bedtime)
-DOXazosin (Cardura): Used for both HTN and BPH
-TAMsulosin (Flomax): Used for BPH only
**TERA and TAMy DOX it! you have got to try these zOOOsins. “this taste so good it feels sinful- omg im getting dizzy lol”
-Potent vasodilators.
-Side effects: Dizziness and hypotension.
-Give at bedtime at very low doses and slowly titrate up.
Side Effects:
-“First-dose orthostatic hypotension” is common (warn patient).
-Side effects are dizziness and postural hypotension (common side effect).
-May cause severe hypotension and reflex tachycardia.
-Give at bedtime. Start at very low doses and titrate up slowly until good BP control. Advise patient to get out of bed slowly to prevent postural hypotension.
-Not a first-line choice for HTN except for men with both HTN and benign prostatic hyperplasia (BPH). Alpha-blockers relax smooth muscle found on the bladder neck and prostate gland and relieve obstructive voiding symptoms such as weak urinary stream, urgency, and nocturia.
African Americans (including people with DM): ______ or ______ may be more effective.
Thiazides or CCBs
findings in hypertensive retinopathy
copper and silver wire arterioles, arteriovenous nicking
from those in diabetic retinopathy
neovascularization, cotton-wool spots, microaneurysms
Isolated systolic HTN in the elderly: Preferred medications are
low-dose thiazide diuretic or CCB (long-acting dihydropyridine).
To assess orthostatic hypotension, measure both the ____ and ____
supine (first), and standing BP.
ACEIs or ARBs: Use for HTN in pts w/ ___, ____, and ____. It may cause a _______ (10%).
DM, CKD (stage 1 and 2), and HF
dry cough
Careful when combining ACEIs with potassium-sparing diuretics (e.g., _______,______) because of increased risk of
triamterene, spironolactone
hyperkalemia.
“Tri? I am terene! but I’m still peeling the banana in a SPIral…. now I feel like I’m going in a spiral)
Bilateral renal artery stenosis: ACEIs or ARBs will precipitate
acute renal failure
Alpha-blockers are not first-line drugs for HTN, except if
patient has preexisting BPH
Women with HTN and osteopenia/osteoporosis should receive ________
thiazides.
-Thiazides help bone loss by slowing down calcium loss (from the bone) and stimulating osteoclasts.
Lifestyle Modifications when in HF
Restrict or abstain from alcohol.
-Smoking cessation if smoker; weight loss.
-Restrict sodium to 2 to 3 g/d.
-Fluid restriction (1.5–2 L/d) may help some patients.
DVT Etiology (three categories):
-Stasis: Prolonged travel/inactivity (more than 3 hours), bed rest, CHF
-Inherited coagulation disorders: Factor C deficiency, Leiden, and so forth
-Increased coagulation due to external factors: Oral contraceptive use, pregnancy, bone fractures especially of the long bones, trauma, recent surgery, malignancy
(have you recently traveled? do you have a family hx of clots? recent injuries? medications?)
DVT Treatment Plan
what maneuver?
first imaging?
labs?
-Homan’s sign: Lower leg pain on dorsiflexion of the foot (low sensitivity)
-CBC, platelets, clotting time (PT/PTT, INR), D-dimer level, chest x-ray, EKG
-**Ultrasonography (whole leg or proximal leg)
Hospital admission, low-molecular-weight heparin subcutaneous or IV, then warfarin PO (Coumadin); or initial episode duration of treatment with DOACs for at least 3 months.
For recurrent DVT or elderly, antithrombotic treatment may last a lifetime.
NYHA class II heart disease
Ordinary physical activity results in fatigue, exertional dyspnea
First-line medication for stable HF is
an ACEI or ARB.
The _______ heart sound is a sign of HF, although it can also be heard in pregnant women and children/young adults.
S3
Raynaud’s phenomenon: Think of the colors of the ________as a reminder for this disorder.
Medications include
American Flag
CCBs (nifedipine, amlodipine).
Lipid Profile:
ASCVD risk cutoff: when do we initiate treatment?
Total Cholesterol:
Triglycerides:
LDL:
HDL:
TX before meds?
Get Lipid profile Q:
unless “indicated” (for example___)
_______ if newly dx
________ if well controlled
ASCVD risk cutoff: when do we initiate treatment? (other than lifestle mods) – 7.5%
Total Cholesterol: <200
Triglycerides: <150
LDL: <100
HDL: 40-60 (the higher the better)
TX before meds?
lifestyle modifications
Get Lipid profile Q: 5 years
unless “indicated” (for example high BMI)
– Q 3-6 months if newly dx
– Q 6-12 months if well controlled
Triglycerides >_____ increases risk for pancreatitis
what is the Tx for this?
> 500
Fenofibrate
symptoms of high cholesterol levels
Xanthelasma
Xanthelasma
cholesterol deposites on pts eyelids visually seen during an exam
elderly pop- normal
youngsters= check lipid profile
Hyperlipidemia Tx:
mainstay:
First line meds:
Four groups that benefit from meds:
mainstay: lifestyle mods
First line meds: -statin’s
Four groups that benefit from meds:
1. primary prevention (increased ASCVD risk w/NO event)
- Secondary prevention (had cardiovascular event, increased risk for a 2nd event
- LDL >190
- Pt’s with DM
The 2 high intensity statins
Atorvastatin (Lipitor)
Rosuvastatin (Crestor) * stronger at same dose
Statin complications:
1.
2.
what do we monitor for and when?
Statin complications:
1. Drug-induced hepatitis
2. Rhabdomyolysis
what do we monitor for?
Drug-induced hepatitis
-presents w/jaundice& abdominal pain
-monitor LFT’s!! PRIOR to starting and @ the 12 wk mark
-if LFT’s are 3X more than normal = DC statin
Rhabdomyolysis
-presents w/dark urin/muscle pain/fatigue
-assess for new muscle pain
-monitor ck/cr levels (it will be 5-10X more the normal limit)
- Rhabdomyolysis
Nitrates (Nitroglycerine)
used for:
how to take at home:
when to cal 911:
used for: Angina
how to take at home: Q 5 min in a 15 minute time frame
when to cal 911:
if pain doesnt resolve after 1st dose
-stop activity
-take nitro, wait 5 min
-pain? take another nitro- call 911
Amiodarone (Pacerone)
used for:
what meds need to be reduced?
long term effect?
“fixes PACE”
used for:
-A-fib
-ventricular arrythmias
what meds need to be reduced?
-anticoagulents
-ex: eliquis, pradaxa, xarelto, warfarin
(reduce them by30-50% if on amiodarone)
“AM I D ONE? i want none of the anticoag cluster F- Im at WAR with my X - ARELTO. im gunna get that ELIQent PRADA bag”
long term effect?
-eyes: optic neuropathy, corneal deposites, eye exam indicated
-Thyroid: Hypo/Hyper (amnioderone contains iodine which regulates thyroid)
-Lungs: Pulmonary Toxicity (***MOST dangerous SE. need baseline X-Ray & pulmonary function test Q 3 months)
Fibrates
used for:
especially good for:
Ex: Fenofibrate (Tricor)
——use if tri’s are >500
used for: Hyperlipidemia
especially good for:
-decreasing triglycerides
-increasing HDL
______ and ______ are best agents for lowering triglycerides.
Niacin and fibrates
Other Lipid-Lowering Medications
Bile Acid Sequestrants
ex:
Cholestyramine (Questran Light),
Colestipol (Colestid),
Colesevelam (Welchol)
*take 1 hr before other meds
-severe GI side effects
Cholesterol-Absorption Inhibitors
ex: Ezetimibe (Zetia)
“cholesterol will EZET MIBE?”
-Absorbs cholesterol from the small intestines
-combination of a statin with ezetimibe recommended for some high-risk ASCVD patients
Main tx used for a DVT:
ALWAYS tx DVT
anticoagulents/antiplatelets
-ex: eliquis, pradaxa, xarelto, warfarin
**initial dose will be different than maintenance dose
-tx will last 6 months DVT
these prevent clots- they do not dissolve current ones.
Aspirin:
what is it and how does it work?
commonly used for:
what if pt has an allergy?
pt education:
what is it and how does it work?
-anti-platelet
- decreased platelets ability to clump together
commonly used for:
-CAD
-Stroke
-osteo & rheumatoid arthritis
what if pt has an allergy?
-give plavix instead
** preferred if ot had a stent
pt education:
-s/s of GI bleeds
-stop taking 7-10 days prior to surgery
Statins may cause ______ effects
cognitive effects
(e.g., memory loss, confusion)
-reversible upon discontinuation of statin therapy.
-Remember, the brain and nerves are mostly fat.
Patients on simvastatin and lovastatin should avoid
Also, they should not mix these two statins with
avoid grapefruit juice.
macrolides.
BMI Classification:
Underweight
Normal weight
Overweight
Obese
Grossly obese
Underweight <18.5
Normal weight 18.5–24.9
Overweight 25–29.9
Obese 30–39.9
Grossly obese >40
Waist Circumference
Males: >__ inches
Females: >__ inches
Males: >40 inches
Females: >35 inches
metabolic syndrome criteria
At least three characteristics (out of five) must be present to diagnose metabolic syndrome:
-Abdominal obesity
(>40 inches in men and >35 inches in women)
-BP>130/85 mmHg
-Elevated fasting plasma glucose (>100 mg/dL)
-Elevated triglycerides (>150 mg/dL) or on drug treatment for elevated triglycerides
-Decreased HDL (<40 mg/dL in men and <50 mg/dL in women)
Nonalcoholic Fatty Liver Disease
-associated with metabolic syndrome and/or obesity.
-Look for slight elevation of ALT and AST (not related to alcohol or medications)
-and negative hepatitis A, B, and C.
