CARDIAC Flashcards
What 3 diagnoses would kill a patient who presents with chest pain?
ACS (acute coronary syndrome), Aortic dissection, Pulmonary embolism
Who are the 3 people that experience atypical sxs for ACS?
Women, elderly, diabetics (nausea)
What do we see on an EKH with a STEMI?
Greater than 1mm ST elevation in 2 contiguous leads
New LBBB (can suggest STEMI too)
What are some questions we should ask to rule out acute coronary syndrome?
History/Symptoms (OPQRST)
Discomfort with exertion is more concerning for ACS
Radiation to arm, neck, jaw/teeth
Severity has nothing to do with ACS
What do we look for immediately in the patient’s appearance (sign’s) that may suggest ACS?
Distress, Diaphoresis, and Levign sign
What are some EKG signs for acute coronary syndrome?
ST elevation, T wave inversion, ST depression, or new LBBB
When would we get false positive with troponins?
Renal disease, myocarditis, cardiac contusion, and recent cardiac surgery/cath
How do we know if it’s a thrombus or an embolus causing an NSTEMI?
Thrombotic event (narrowing) → causing a supply/demand issue
If a patient has chest pain and they have any of the following: ST elevation, new LBBB, ST depression, T wave inversion, they’re hemodynamically unstable, have dynamic EKG changes, known CAD (reminiscent of prior events), or positive troponins – what level of risk stratification are they?
High Risk
If a patient has atypical CP with CAD and normal or unchanged EKG; CP with nonspecific ST depression; Low risk with a normal EKG but + troponins; or Anginal pain with spontaneous resolution promptly after NTG – are all examples of what level of risk stratification?
Moderate Risk
If a patient with atypical CP with negative troponins – what level of risk stratification?
Low risk
If we are concerned about someone where in the hospital do we put them?
Observation
What acronym can we use for initial cardiac treatment when the diagnosis is uncertain? What does it stand for?
MONA
Morphine, Oxygen; Nitro; Aspirin
What should we always check for prior to administering nitro?
Phosphodiesterase inhibitors!
What labs should you check for your uncertain cardiac issues?
CBC (anemia?), electrolytes (Potassium & Magnesium), and Troponins (serial)
If you rule out ACS – can you send them home?
No!
If you’ve ruled out ACS and watched them overnight, what does the risk stratification involve to discharge them?
Ability to exercise, prior to workup, prior episodes
Echo or Stress Echo
Stress nuclear imaging
ETT (exercise treadmill test)
Cardiac CathIf we have rules in ACS, how do we treat NSTEMI or UAP?
Aspirin & Plavix (P2Y12 receptor blocker)
Beta Blocker
Heparin
Possible Statin?
If a patient has heart failure + NSTEMI – what should we add to treatment?
Diuretics and NTG IV (to help reduce afterload)
When do we use the TIMI score?
For pretest possibility for ACS
What is the TIMI score?
Age greater than 65
3+ risk factors for CHD
Prior coronary stenosis (greater than 50%)
ST Segment deviation via EKG
2+ Anginal episodes in prior 24 hours
Elevated cardiac biomarkers
Use of aspirin in prior 7 days (just that people who use aspirin are usually at higher risk)
Afib, what 4 things must we identify ASAP?
Verify rhythm, hemodynamic stability, ventricular rate control, BP management
What are the management goals for Afib>
Minimize symptoms, prevent thromboembolic complications (especially stroke); minimize side effects or adverse reactions; minimize risk of bleeding; decrease mortality
: If a patient with Afib is hemodynamically unstable, angina, or prexcitation (WPW) – what do we do?
May require cardioversion
BUUUUTTT risk of embolus must be considered
How do we evaluate someone with Afib?
H&P, ECG, Echo, and any additional testing
What types of additional testing might we need to do for Afib?
Thyroid (TSH), CXR (for pulmonary disease), ambulatory monitoring and/or exercise testing for rate control; eval for CAD if anti-arrhythmics
What types of questions should we ask when taking a history with Afib?
duration, sxs, previous history, presence of underlying heart disease
What do we look for on PE with Afib?
VS, apical rate (NOT the rate the distal radius), detailed CV exam
What are some indications for hospitalization for Afib?
Cardioversion, initiation of anti-arrhythmic, rate management, treatment of associated medical conditions, elderly, patients with risk of complications
What are the pros and cons of rhythm control?
PROS = maintain sinus rhythm, improved LV function → Amiodarone
CONS = At best, 50-60% effective, adverse effects include pro-arrhythmia (VT, torsades, VF)
Who gets rhythm control?
Younger, more active people who benefit from CO or increased risk of bleed
Those who anticoag is contraindicated
Patients who request it
Patients who’s rate is uncontrollable or symptomatically can’t tolerate AF
If we are going to do rhythm control (cardiovert) and it’s been longer than 48 hours – what do we do?
Full anti-coag for minimum 3-4 weeks
What are the options for rhythm control?
Cardiology consult
Cardiovert or pharmacological cardiovert
Non-pharm approaches (Maze procedure or catheter ablation)
What must we know when doing a cardiology consult?
What you want!
Cardiac history, important comorbids, history of current hospitalizations, Labs (CBC, BMP, Mg, TSH), EKG, and echo
What are some alternative options to cardioversion?
TEE
Full anticoag with unfractionated heparin
Surgical
Catheter + Radiofrequency ablation
After we cardiovert someone, what must the patient be on?
Warfarin! X 4 weeks with INR 2-3
What are some options to treat Afib and prevent embolization?
LAA amputation
LAA occlusion (Watchman system)
What’s the more frequent approach to handling Afib?
Rate control (controlling the AV conduction!) → symptom monitoring & BP management (be sure to prevent stroke!)
What is the goal of rate control in Afib?
Slow AV conduction, control the rate at rest AND with exercise
What are some examples of drugs we use for rate control?
CCB (Diltiazem or verapamil); BB; or Digoxin
What’s an alternative rate control approach if meds don’t work?
Ablate AV node or AV Pacemaker
What are some of the risk factors to a stroke with chronic AF?
Age greater than 65
Prior Hx of stroke
DM
History of systemic HTN
A person with Afib and LV dysfunction/CHF with increased LA size or other mitral valve disease are examples of what level risk for a stroke?
High risk
A person with Afib, under the age of 60 with heart disease and no other risk factors – are examples of what level risk for stroke?
Low risk
What will decrease the risk of stroke in a patient with Afib to 1%/year?
Anticoagulation!
If a patient has a CHADS2Vasc score of 2 or greater, do we anticoag them?
Yes!
If a patient has a CHADS2Vasc score of 1, do we anticoag them?
Consider it
What does CHADSVASC stand for?
Congestive HF
HTN
75+
DM
Stroke
Vascular disease (prior MI, PAD, or plaque)
Age 64-75
Sex Category (Female)
do we use aspirin to anticoag someone?
No
What meds can we use to anticoag someone with afib?
Coumadin or NOAC (immediately effective and don’t have to be monitored)
How should anticoag be initiated in someone with Afib?
Warfarin = bridging (if hx of thromboembolism)
NOAC’s = no bridging
When we see Afib in someone, what other diagnosis should we rule out?
WPW (cardiovert or Amiodarone to control rate)
If a patient is about to under go a joint replacement surgery, we check meds and see that they’re on an anticoag, what must we do?
Hold Anticoag x 3-4 days
OR bridge Heparin or LMWH is at especially high risk of emboli
Why would a patient about to undergo a THA be at especially high risk of an embolism?
Rheumatic mitral stenosis; mechanical heart valve; or prior thromboembolism
What is systolic HF vs. diastolic?
Systolic = EF
What would cause iatrogenic HF or acute pulmonary edema?
IVF, medication adjustments/errors, Transfusion, post-operative, AF
How do we manage acute/uncompensated heart failure?
IV diuretic, O2, NTG, morphine, sodium restriction, fluid restriction, Avoid NSAIDS (to avoid hyperK)
What must the patient do when we prescribe diuretics?
Monitor daily weights & elevate HOB
If a patient has HF along with hypotension, oliguria, and low cardiac output – what MUST we do?
Intensivist/Cardiology consult!
What other medications should we consider for HF?
Digoxin, ABG, Potassium replacement, Thiazide diuretic, spironolactone, along with an ACE
If a patient has mild-moderate acute-on-chronic CHF how do we treat them?
IV diuretics – be sure to r/o precipitating factors or a concurrent threatening condition (electrolyte, azotemia, arrhythmias)
Most DO NOT require hospital admission!!
