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pulmonary > cardiac > Flashcards

cardiac Flashcards

1
Q

1st degree AV block - ecg change

A

consistent, prolonged PR interval >0.2 d/t AV node delay

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2
Q

1st degree av - pres

A

most asx unless other conditions

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3
Q

1st degree AV - management

A

d/c medications that contribute to AV node blockade: adenosine, BB, CCB, digoxin
-observe

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4
Q

2nd degree AV - ecg

A

type 1: wenkebach - progressive prolongation of PR leading to dropped QRS d/t AV node dz
type 2: mobitz - same PR w/ randomly dropped QRE d/t his-purkinje fiber dz

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5
Q

2nd degree AVB - prese

A

most asx ,some can have syncope / dizziness / CP / palpiations w/ assoc conditions

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6
Q

2nd degree AVB - management

A

type 1 - same as 1st degree

type 2 - REQUIRES PACEMAKER - OFTEN PROGRESSES TO COMPLETE HEART BLOCK!

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7
Q

3rd degree AVB - ecg

A

AV dissociation - no correlation b/n P and QRS w/ ventricular rate b/n 25-40

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8
Q

3rd degree AVB - pres

A

dizzy, syncope, confusion, dyspnea, chest pain, SCD

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9
Q

3rd degree AVB - workup

A
  1. CBC and CMP - r/o infection, metabolic disturbance
  2. CXR
  3. echo
  4. ecg
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10
Q

3rd degree management

A

REQUIRES PACEMAKER!

-discontinue AV blockers - may need IVF, vasopressors for OD CCB and BB

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11
Q

mitral regurgitation- pathophys

A

acute: a/w endocarditis or rupture leading to rapid LA filling w/o time to compensate –> pulmonary edema, reduced CO w/ hypotension and shock
chronic: gradual dilation of LA and LV with LV dysfunction leading to pulmonary hypertension

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12
Q

Mitral regurgitation - causes

A

acute: endocarditis, papillary muscle / chordae tendinae rupture
chronic: MVP, cardiomyopathy, rheumatic fever, marfans

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13
Q

Mitral regurg - pres

A

acute: abrupt onset CHF and shock - dyspnea, thready pulses, orthopnea, peripheral vasoconstriction
chronic: dyspnea on exertion, PND, orthopnea, fatigue, palpitations / AFib

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14
Q

Mitral regurg - murmur

A

holosytolic at apex, radiating to axilla

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15
Q

mitral regurg - PE

A

displaced PMI, holosystolic murmur, JVD, edema,ascites, s3

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16
Q

mitral regurg - dx

A

echo - definitive

cxr: dilated Left heart / cardiomegaly, pulmonary congestion

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17
Q

mitral regurg - tx

A

acute: emergent! ABCs, intraortic balloon pump, MV repair
chronic: afterload reduction w/ vasodilators and diuretics
-w/ asx: mild - monitor clinically q 1 yr
mod - clinically and echo q 1 yr
severe: clinical and echo q 6-12 mo

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18
Q

mitral stenosis - causes

A

1 RHEUMATIC HEART DISEASE! - causes fibrosis and scarring and thus narrowing of valve d/t cross reactivity to strep antigen

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19
Q

mitral stenosis - sx

A
  • worse w/ anything that increase blood flow across mitral valve i.e. exercise, tachycardia
  • often asx until <2.5 cm - sx d/t pulmonary congestions - dyspnea on exertion, orthopnea, PND, fatigue, palpitations
  • adv dz: pulm HTN, RHF sx, hemoptysis and hoarseness (irritated recurrent laryngeal nerve), dysphagia
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20
Q

mitral stenosis - pathology

A
  • increase LA pressure, dilation and pulmonary HTN

- can cause afib!

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21
Q

mitral stenosis murmur

A

diastolic decrescendo low rumbling at apex, increasing w/ inspiration

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22
Q

mitral stenosis PE

A
  • loud S1 (hallmark!!) w/ diastolic murmur, RHF sx

- mitral facies

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23
Q

mitral stenosis dx

A

ecg: atrial enlargement, RAD d/t RVH, a fib
echo: dx - mild d/t LA enlargement

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24
Q

mitral stenosis tx

A

meds: tx afib - CANNOT USE X INHIBITORS MUST USE WARFARIN!
diuretics for pulmonary congestion, BB or CCB for tachycardia
-abx w/ h/o rheumatic: PCN IM> PO take continuously
-if sx: balloon valvotomy and mitral vave surgery when severe

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25
Q

most common arrythmia w/ digoxin

A

paroxysmal atrial tach w/ 2:1 block

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26
Q

multifocal atrial tachycardia is a/w…

A

CHRONIC LUNG DZ…COPD!`

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27
Q

MAT traits

A

rate >100, 3 different p waves w/ variable PR and RR intervals

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28
Q

difference b/n MAT and wondering pacemaker…

A

MAT rate >100, wondering pacemaker 60-100

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29
Q

MAT dx

A
  1. ecg

2. vagal manuever / adenosine doesnt cause av block (because coming from different foci)

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30
Q

MAT treatment

A

w/ LV function preserved: BB, CCB, digoxin, amiodarone, flecanide, propafenone
w/ LV dysf: digoxin, diltiazem, amiodarone

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31
Q

paroxysmal SVT - patho

A

2 mech:

  1. most common: AV nodal reentry - 2 pathways w/in AV node
  2. orthodromic / accessory pathway - “concealed bypass tract”
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32
Q

paroxysmal SVT ecg

A

> 100 w/o P waves for reentry, may see w/ accessorry pathway

NARROW QRS COMPLEX!

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33
Q

paroxysmal SVT causes

A
  1. ischemic heart dz
  2. nodal reentry, accessory pathway
  3. digoxin
  4. caffeine, ETOH
  5. a flutter w/ rvr
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34
Q

paroxysmal svt acute tx

A
  1. vagal manuevers
  2. adenosine (se: headache, flushing, nausea, sob, chest pain)
  3. verpamil, esmolol, digoxin
  4. cardioversin if refractory / unstable
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35
Q

paroxsymal svt prophylaxis

A
  1. digoxin most common
  2. verapamil, BB
    * ablation w/ recurrent symptomatic episodes
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36
Q

PAC - causes

A

adrenergic excess, alcohol, drugs, tobacco, electrolyte disturbance, ischemia

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37
Q

PAC - ecg

A

change in p wave morphology, narrow QRS, pause

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38
Q

PAC - tx

A
  • most asx, w/ sx can give BB

* benign in normal heart, may be precursor to ischemia in w/ structural abnl

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39
Q

PVC - causes

A

hypoxia, electrolyte abnl, stimulants / caffeine, meds, structural dz

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40
Q

PVC - ecg

A

early beat w/ no p wave, wide QRS,

couplet: 2 successive
bigeminy: every other
trigeminy: every third

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41
Q

PVC - workup

A

w/ frequent / recurrent, espeically with structural heart disease need workup b/c at inc risk sudden death - order electrophysiologic study

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42
Q

PVC - TX

A 
if sx (palpiations, dizzy) - BB
w/ recurrent + structural dz may need ICD
43
Q

young patient w/ pleuritic chest pain, worse w/ lying down and improved when sitting, leaning forward. was sick 1 week ago….suggests

A

ACUTE PERICARDITIS

44
Q

hallmark signs pericarditis

A
  1. pericardial friction rub (best heard seated, leaning forward at lower LSB)
  2. pleuritic, positional chest pain (improved seated, leaning forward)
  3. diffuse ST elevation and PR depression
  4. pericardial effusion
45
Q

acute pericarditis causes

A
  1. idiopathic (often postviral) - majority of cases
  2. viral - esp COXSCAHIEIRUS
  3. acute mi - w/in 24 hr
46
Q

acute pericarditis ecg changes

A

4 stages:

  1. diffuse ST elevation and PR depression
  2. normalization of ST and PR
  3. diffuse T wave inversion
  4. normalization of T waves
47
Q

acute pericarditis workup

A
  1. ECG
  2. echo w/ signs of effusion - get TEE
  3. labs: cbc (leukocytosis), elevated ESR, CRP
  4. CXR - r/o pulmonary process
48
Q

acute pericarditis tx

A

uncomplicated:

  1. NSAIDS: ibuprofen 600 mg tid or indomethacin 50 mg tid - taper q 1-2 weeks
  2. ASA - preferred w/ recent MI 750-1000 mg tid, then to bid then qd
  3. colchicine - adjunt to nsaids
  4. corticosteroids - for CT dz / refractory to nsaids
    * most resolve 1-3 weeks
49
Q

indications for surgery w/ acute pericarditis

A

pericardiocentesis if:

  1. cardiac tamponade
  2. purulent / tuberculous / neoplastic effusions
    - do pericardial biopsy w/ recurrent effusions
50
Q

constrictive pericarditis - background

A

rigid, fibrotic pericardial sac that impairs LATE diastolic filling (in tamponade all of filling is impaired)

51
Q

constrictive pericarditis causes

A

-most idiopathic or viral

52
Q

constrictive pericarditis pres

A

2 main:

  1. fluid overload - JVD, ascites, hepatomegaly, edema
  2. decreased cardiac output - fatigue, dyspnea on exertion, palpitations, dec exercise tolerance
53
Q

constrictive pericarditis - PE

A
  • **JVD w/ Kussmaul sign (no decreased in JVD w/ inspiration)
  • pericardial knock: a/w rapid decline in ventricular filling
  • edema
54
Q

constrictive pericarditis - workup

A
  1. ECG - nonspecific, may have afib
  2. echo - increased thickness w/ decreased late diastolic filling
    * *3. CT / MRI - best to show increased thickness and calcification
  3. cath - shows equal diastolic pressures and rapid y descent in ventricular pressure (sq root sign) when filling stops
55
Q

constrictive pericarditis tx

A
  1. aimed at underlying cause
  2. diuretics w/ overload
    * admit w/ fever, large effusion, tamponade, refractory
    - watch for coagulopathies, immunocompromised
56
Q

contraindication w/ pericarditis

A

DON’T GIVE HEPARIN AND DON’T DO EXERCISE STRESS TEST!!! RISK OF HEMORRHAGE!

57
Q

new heart murmur and fever suggests…

A

INFECTIVE ENDOCARDITIS!

58
Q

infective endocarditis pathogens

A

acute: staph aureus
subacute: strep viridans (alpha-hemolytic)
native value: most d/t strep viridans, then staph and enterococci
prosthetic valve: early (win 60 days) staph epidermidis > aureus, then late (>60 d) strep
IV drug users: staph aureus affecting TRICUSPID VALVE

59
Q

presentation - infective endocarditis

A

fever, malaise, fatigue weight loss, CVA / TIA sx
splinter hemorrhages, roth spots
janeway lesions: nontender hemorrhagic lesions on palms / soles
oslers nodes: TENDER raised red lesions on hands / feet
sx of CVA (increased embolic risk!!!)

60
Q

diagnosis infective endocarditis

A

dukes criteria! 2 major or 1 major w/ 3 minor or 5 minor

major: visual vegetation / abscess on valve or displacement of prostehtic valve, new murmur / valve regurg, positive blood cultures x 2 for causative org
minor: PE findings, fever, vascular changes, predisposing heart conditions, positive culture
* *want TEE for echo

61
Q

infective endocarditis tx

A

start antibiotics AFTER 3 blood cultures, do empiric tx first x 4-6 weeks
native valve: unasyn / augmentin + gentamycin
PCN allergy: vanco + gentamycin + cipro
prosthetic (<12 mo since surgery): vanco + gentamycin + rifampin
-prophylactic antibiotics for oral, gi/gu surgeries

62
Q

most common valve affected

A

MITRAL VALVE!! MVP is predisposing!

63
Q

prognosis

A

almost all fatal if untreated!

complications: heart failure and CVA d/t emboli

64
Q

patient w/ acute onset searing chest pain radiating to back w/ long-standing h/o HTN…

A

AORTIC DISSECTION!

65
Q

types of aortic dissection

A

Type A: proximal to subclavian - involves ascending aorta

Type B: distal to subclavian - involves descening aorta

66
Q

aortic dissection causes

A

1 HTN (70%)

in non-hypertensive, think CT dz - Ehlers
danlos and marfan
trauma, 3rd tri prego
aortic coarctation, bicuspid aortic valve

67
Q

aortic dissection pres

A
  • acute onset stabbing / tearing / searing chest pain, radiates to abdomen, back, scapula
    • prox most a/w chest pain
    • distal most a/w back / interscapular pain
  • most hypertensive
  • diaphoretic
  • asymm pulses/ bp in UE
  • neuro changes, LE weakness / paralysis
68
Q

aortic dissection diagnosis

A

best CT! chest and abdomen!
TEE good for unstable, but rarely done
CXR - wide mediastinum (>8mm)
angiography shows extent of dissection

69
Q

aortic dissection tx

A

MUST IMMEDIATELY LOWER BLOOD PRESSURE - ALWAYS GIVE IV BB 1ST! to decrease wall tension
-esmolol - good for bradycardia and asthmatic b/c short-acting (book / test answer)
-labetolol 20 mg over 2 min, then 40-80 mg over 10 prn or 2 mg/min infusion
-propranolol
-most often won’t get BP down enough…give IV nitroprusside (book answer - dont give b/c get cyanide poisoning!! cyanide is byproduct) …GIVE NICARDIPINE!
**goal BP: SBP 100-120
*avoid hydralazine! increases wall stress
Type A - surgical emergency!
Type B - medical management, do surgery w/ refractory symptoms or signs of malperfusion i.e. gut, kidney

70
Q

aortic dissection - maintenance

A

need BB for blood pressure control and annual CT to monitor false lumen - if equal / greater than 6 need surgery

71
Q

70 y/o w/ acute onset back pain x 1 hr. hx smoking, CAD, HTN. on exam, hr 116 and pulse 80/76 w/ pulsatile mass…what happened and test?

A

rupture AAA!!!! do CT!

72
Q

whats a AAA?

A

dilation in aorta twice its normal size or larger.

RF: smoking, HTN, family hx, increased age (>55 men and > 70 women)

73
Q

AAA pres

A

most asx

74
Q

testing for AAA…

A

screen >65 men w/ hx smoking w/ abdominal u/s!

u/s cannot detect rupture!! do CT!! (see retroperitoneal blood!)

75
Q

indications for repair…

A
  1. size 5 cm or larger
  2. symptomatic
  3. rapidly enlarging
    - do open or endovascular repair
76
Q

t wave inversion and wide q waves on ecg suggests…

A

ACUTE MI!!

-w/o q waves = ischemia

77
Q

anti-htnsive meds to avoid in pt w/ hx nephrolithiasis…

A

loops! increase urinary calcium excretion! not good w/ ho calcium oxalate kidney stones

78
Q

28 y/o AA male w/ dyspnea, mild substernal chest pain. S4 gallop w/ murmur best hear at LLSB, decreases w/ squatting and asymmetric LVH - septum twice as thick…dx and treatment…

A

HYPERTROPHIC CARDIOMYOPATHY!
1st line for symptomatic is adrenergic blockers = BETA BLOCKERS b/c decrease diastolic dysf and hr (dec o2 demand): metoprolol w/ target HR 50-60, propranol, atenolol
-septal myotomy = gold std w/ refractory to meds, dual vent pacing is less effective; minimal aerobics and AVOID DIGITALIS!
NITRATES CONTRAINDICATED!!!

79
Q

week old baby boy w/ VSD w/ dyspnea, tachycardia and poor weight gain…tx…

A

1st line: digoxin, diuretics and afterload reduction to reduce pulmonary congestion!
2nd line: w/ failed medical tx or large VSD do surgical closure
-observe only if asx

80
Q

fundoscopic findings and causes…

  1. cotton wool spots
  2. drusen
  3. microaneurysm
  4. macular star
  5. deep retinal hemorrhages
A
  1. cotton wool - HTN (nerve fiber infarcts)
  2. drusen - ARMD
  3. microaneurysm - diabetic retinopathy
  4. macular star - malignant HTN
  5. diabetes
81
Q

what type of shock worsens w/ IVF administration?

A

CARDIOGENIC!!! pump failure leads to loss of 15-20% of CO - treat first w/ VASOPRESSORS OR INOTROPIC AGENTS!!! fluids worsen condition

82
Q

whats treatment for neonate w/ machine gun murmur?

A

INDOMETHACIN! baby has patent ductus arteriosus - NSAIDS close PDA!

83
Q

trousseau’s syndrome

A

migratory thrombophlebitis and involvement of superficial veins at unusual sites and is assoc w/ malignancy - esp adenocarcinoma
-tx w/ HEPARIN until malignancy gone. warfarin is INEFFECTIVE!

84
Q

benefit of spironolactone in pt w/ mi

A

blocks aldosterone-mediated ventricular remodeling!

85
Q

silent MI common in…?

A

elderly diabetic!

common pres: dyspnea and weakness!! changes in mental status, arrythmias, hypotension

86
Q

ischemic pain at rest and worse at night w/ transient ST elevation…

A

PRINZMETAL ANGINA!!!

87
Q

key diagnostic hallmark of prinzmetal angina???

A

coronary vasospasm on coronary angiography!

88
Q

prinzmetal angina tx?

A

-nitrates, CCB

89
Q

CHF framingham diagnosis requirements…

A

1 major and 2 minor sx

90
Q

CHF framingham major criteria

A
  1. acute pulmonary edema
  2. S3
  3. neck vein distension
  4. JVD
  5. PND
  6. pos hepatojugular reflux
  7. rales
  8. cardiomegaly
91
Q

CHF framingham minor criteria

A
  1. extremity edema
  2. night cough
  3. D on E
  4. hepatomegaly
  5. pleural effusion
  6. decreased vital capacity by 1/3
  7. HR 120 or more
  8. 4.5 kg weight loss or more over 5 days of treatment
92
Q

postpartum cardiomyopathy…

A
  • must be in 3trd trimester or w/in 6 mo of delivery
  • 1/2 recover (mortality of 10-20%)
  • same treatment as CHF, no ACE-I
  • *avoid future pregnancies!
93
Q

J point (osborn wave) seen w/ ?

A

hypothermia!

94
Q

dyspnea on exertion, palpitations, hemoptysis w/ low pitched diastolic rumble at apex….

A

mitral stenosis! most d/t rheumatic dz!

-increased s1 and opening snap common

95
Q

holosystolic murmur at mid LSB?

A

VSD!

96
Q

marfan w/ wide pp, high pitched blowing diastolic murmur w/ water hammer pulse…

A

AR!

-no treatment needed unless sig MR or arrythmia!

97
Q

holosystolic murmur at LSB that increases w/ inspiration…

A

TR!

98
Q

pulsus paradoxus?

A

drop in systolic BP >10 in inspiration! a/w cardiac tamponade!!!

99
Q

patient w/ bp 250/150, lethargic, headache w/ visual disturbance and mental status changes w/ hx asthma…tx?

A

malignant htn!

  • nitroprusside infusion (nitroglycerin alt)
  • no BB in asthmatic!
100
Q

signs of cor pulmonale on ECG..

A

RAE: tall P in II, III, AvF
RVH: tall R in v1-3, deep S in v6 w/ st changes

101
Q

tx for SVT

A
  1. vagal
  2. adenosine 6 then 12
  3. verapamil 2.5 then 5
    * cardiovert if unstable
102
Q

teen w/ fever, arthritis, nodule on extensor tender and pink rash w/ central clearing and increased ESR…dx?

A

rheumatic!

-test for antistreptolysin o titer!

103
Q

high risk conditions that need abx prophylaxis…

A
  1. marfan
  2. coarctation
  3. pda
  4. prosthetic valves
104
Q

paradoxical split s2

A
  • normal: widened of s2 d/t increased blood flow to heart in inspiration
  • paradoxical: narrowing of split d/t delay of left ventricular conduction
    * LBBB, MI, AS, HTN

pulmonary (16 decks)

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