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3rd year - Family Medicine > Cardiac > Flashcards

Cardiac Flashcards

1
Q

Why is it important to determine the duration of the angina that the patient has been experiencing?

A

angina lasting <20 minutes = myocardial ischemia angina

> 20 minutes = acute coronary syndrome (i.e. unstable angina or myocardial infarction)

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2
Q

CCS classification of angina

A

class 1 = no limitation of ordinary activity; angina with strenuous, rapid or prolonged exertion

class 2 = slight limitation of ordinary activity; angina with ordinary activity (walking stairs, walking uphill) after meals, in cold, in wind or under emotional stress

class 3 = marked limitation of ordinary activity; angina on walking or climbing short distances under normal condition and at normal pace

class 4 = inability to carry on ordinary activity; angina at rest

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3
Q

Stable angina pathophysiology

A

atherosclerotic plaque narrowing of coronary artery plus endothelial dysfunction decrease blood supply to heart causing ichemia

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4
Q

Stable angina clinical presentation

A

typical angina for <20 minutes

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5
Q

Stable angina management

A

lifestyle

anti-anginal therapy: nitrates PRN, beta blocker

anti-platelet therapy: aspirin or clopidogrel

lipid lowering therapy: statin

if decreased quality of life despite medication or high risk feature on stress testing or significant angina or acute change in angina, mechanical revascularization: percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG)

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6
Q

ACS pathophysiology

A

unstable angina: rupture of atherosclelrotic plaques of coronary arteries causing increased ischemia

STEMI & NSTEMI: disruption of atherosclerotic plaque of coronary arteries causing platelet aggregation and clot formation, causing high grade stenosis or occlusion of coronary artery with or without associated emboli entering microciriculation downstream, resulting in ischemia and infarction of myocardium

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7
Q

ACS clinical presentation

A

typical angina that is severe and prolonged (>20 minutes)

unstable angina can present with any of the following ways

  1. crescendo pattern with increase in frequency, duration or intensity
  2. angina at rest without provocation
  3. new onset of severe angina (CCS class 3) without previous angina
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8
Q

Diagnosis of different ACS types

A

ECG: no ST elevation
Enzyme test: normal
= unstable angina

ECG: no ST elevation
Enzyme test: elevated
= NSTEMI

ECG: ST elevation
Enzyme test: elevated
= STEMI

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9
Q

STEMI management

A

PCI or tPA

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10
Q

Non ST elevated (unstable angina and NSTEMI) ACS management

A
  1. Everyone gets ASA, statin and nitro
  2. Risk stratify

Low Risk Group:
ECG normal
TIMI score 0-2

Intermediate Risk Group
ECG: Normal or T wave inversion
TIMI 3-4
Previous CABG or PCI

High Risk Group
ECG ST shift or deep T wave inversion
TIMI 5-7
Refractory ischemia, heart failure or hypotension

  1. Treatment

Low Risk
Beta blocker
early discharge with follow up

Intermediate risk
Heparin
Clopidogrel
Observation

High risk 
Beta blocker 
Heparin 
GPIIb/IIIa inhibitor or bivalirudin with clopidogrel 
Early cath
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11
Q

How to calculate the TIMI score

A

age >65

> 3 CAD risk factor

prior stenosis

ST depression

elevated cardiac markers

multiple angina within 24 hours

aspirin in last 7 days

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12
Q

Aortic dissection diagnosis

A

Chest CT

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13
Q

What is Tietze syndrome

A

pain accompanied by inflammation (swelling, erythema, heat) is named Tietze syndrome, which is a more severe case of costochondritis

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14
Q

What is dead space

A

Ventilation but no perfusion (ex. PE)

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15
Q

Pretest probability of PE based on Well’s score

A

+1
Active cancer
Hemoptysis

+1.5
Past history of DVT or PE
Recent Immobilization or surgery
Tachycardia >100

+3
Signs or symptoms of DVT
No alternative diagnosis as or more likely than PE

If total points 0-4 then PE is unlikely

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16
Q

Investigations based on Well’s score

A 
Unlikely 
--> D dimer 
If negative = no PE 
If positive 
--> CTPA 
If negative = no PE 
If positive = PE

Likely
–> CTPA
If negative = no PE
If positive = PE

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17
Q

PE management

A

LMWH short term while starting warfarin or DOAC long term

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18
Q

CXR in PE

A

band atelectasis

decreased lung volume on affected side

pulmonary infarct/hemorrhage

edema

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19
Q

ECG in PE

A

Tachycardia

A fib

RV strain (inverted T wave, ST depression in V1-V3)

S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign. A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain

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20
Q

ABG in PE

A

Hypoxemia

Hypocapnia

High Aa gradient

Respiratory alkalosis

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21
Q

Pneumonia management

A

Outpatient
Previously well and no abx use in last 3 months -
Macrolide OR doxycyline

Comorbidities or abx use in last 3 months -
Respiratory fluoroquinolone OR beta lactam + macrolide

Inpatient
Ward - resp fluoroquinolone

ICU - beta lactam + (macrolide OR resp fluoroquinolone)

Resp fluoroquinolone - (moxi, femi, levofloxacin)
beta lactam - (cefotaxime, ceftriaxone)
Macrolide - (azithro, clarithro, erythro)

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22
Q

Pneumothorax risk factors

A

asthma, COPD, lung procedures

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23
Q

Panic attack clinical presentation

A

panic attack is an abrupt surge of intense fear of intense discomfort that
1. peaks within minutes and
2. is time limited with
3. 4+ of the following symptoms
palpitation / heart pounding
sweating
trembling / shaking
sensation of shortness of breath or smothering
feeling of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, lightheaded or faint
chills or heat sensation
paresthesia (numbness or tingling sensation)
derealization (feeling of unreality) or depersonalization (being detached from one self)
fear of losing control or going crazy
fear of dying

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24
Q

Panic attack management

A

Benzo PRN

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25
Q

Causes of secondary hypertension

A

renovascular hypertension: renal artery stenosis, fibromuscular dysplasia

renal hypertension: chronic kidney disease including polycystic kidney disease and diabetic nephropathy, kidney transplant

endocrine: hypothyroidism, hyperthyroidism, hyperaldosteronism, Cushing’s syndrome, pheochromocytoma, hyperparathyroidism

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26
Q

Guidelines for diagnosis of HTN

A
  1. Elevated BP reading at office, home or pharmacy
  2. Hypertension visit 1

BP 180/110 + = hypertension

AOBP 135/85 +
OBPM 140/90 +
NO = no hypertension, annual BP measurement recommended
YES = out of office assessment (ABPM preferred or HBPM diagnostic series or OBPM alternate method)

  1. Hypertension visit 2 (within 1 month)
Daytime ABPM or HBPM 135/85+ 
24h ABPM 130/80+ 
NO = white coat hypertension 
(complete HBPM or ABPM to confirm and if still below then no hypertension and annual BP measurement recommended) 
YES = hypertension
  1. OBPM Hypertension visit 2
    140+ or 90+ then go to step 4
  2. Hypertension visit 3
    160+ or 100+
    YES = hypertension
    NO = go to step 5
  3. Hypertension visit 4-5
    140+ or 90+
    YES = hypertension
    NO = no hypertension (annual BP measurement recommended)
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27
Q

Hypertensive urgency

A

asymptomatic and BP >180/110

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28
Q

Hypertensive emergency

A

BP > 180/110 with end organ damage

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29
Q

How often should follow up occur for patients with hypertension

A

hypertensive patients with lifestyle modification alone should be followed up at 3-6 months interval

patients on antihypertensive medication treatment should be followed up every 1-2 months until readings on 2 consecutive visits are below target, then follow up at 3-6 months interval

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30
Q

Physical exam components for a patient with hypertension

A

weight, waist circumference, height vitals: blood pressure, heart rate

neurological:
cognitive assessment for dementia
look for signs of stroke including gait, cranial nerves, speech, motor, sensory, reflexes

eye: fundoscopy for signs of hypertensive retinopathy including papilledema, hemorrhage, AV nicking
cardiovascular: signs of heart failure or left ventricular dysfunction including elevated JVP, displaced apex, peripheral edema, auscultate for S3, S4, loud A2, heart murmur

peripheral vascular: palpate peripheral pulses for peripheral vascular disease, auscultate for bruit at renal arteries

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31
Q

Indications for investigation for hypertension due to renovascular disease

A

patients with >2 of the following should be investigated for renovascular hypertension:

sudden onset or worsening of hypertension at age <30 years or >55 years

presence of abdominal bruit

hypertension resistant to >3 antihypertensive medications

increase in serum creatinine >30% with use of ACE inhibitor (ACEI) or ARB

atherosclerotic vascular disease (coronary artery disease, peripheral vascular disease), particularly in patients who smoke or have dyslipidemia

recurrent pulmonary edema associated with hypertensive surges

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32
Q

Indications for investigation for hypertension due to hyperaldosteronism

A

patients with any of the following should be investigated for hyperaldosteronism

hypertensive patients with spontaneous hypokalemia (K < 3.5 mmol/L)

hypertensive patients with marked diuretic induced hypokalemia (K < 3 mmol/L)

patients with hypertension refractory to >3 antihypertensive medication

hypertensive patients with incidental adrenal adenoma

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33
Q

Indications for investigation for hypertension due to pheochromocytoma

A

patients with any of the following should be investigated for pheochromocytoma

paroxysmal or severe (blood pressure >180/110)

sustained hypertension refractory to usually anti-hypertensive therapy

patients with hypertension and multiple symptoms suggestive of catecholamine excess (headaches, palpitations, sweating, panic attacks, pallor)

hypertension triggered by beta-blockers, MAO inhibitors, micturition or changes in abdominal pressure

patients with incidentally discovered adrenal mass or multiple endocrine neoplasia (MEN2A, MEN2B, von Recklinghausen’s neurofibromatosis, von Hippel-Lindau disease)

34
Q

Investigations for pheochromocytoma

A

screening for pheochromocytoma include 24 urinary
total metanephrine and urinary metanephrine-to-creatinine ratio

high 24 urinary total metanephrine and urinary metanephrine-to-creatinine ratio should be followed up with MRI to visualize adrenal tumors

35
Q

Investigations for renal vascular hypertension

A

captopril-enhanced radioisotope renal scan - contraindicated in patients with chronic kidney disease GFR<60

Doppler sonography

MR angiography

CT angiography - contraindicated in patients in renal failure (i.e. abnormally high creatinine)

36
Q

Investigations for hyperaldosteronism

A

screening for hyperaldosteronism include plasma aldosterone and plasma renin activity

high plasma aldosterone and plasma renin activity followed up with maneuvers for autonomous hyper-secretion of aldosterone (saline loading test, fludrocortisone suppression test, plasma aldosterone to plasma renin activity ratio or captopril suppression test)

37
Q

Indications for antihypertensive use

A

1) average diastolic blood pressure >100mmHg or systolic blood pressure >160mmHg even if without any target organ damage or other cardiovascular risk factors
2) average diastolic blood pressure >90mmHg with macro vascular target organ damage or cardiovascular risk factors (other than hypertension)
3) average systolic blood pressure >140mmHg with macro vascular target organ damage

38
Q

Antihypertensives medication guidelines

A

1st line anti-hypertensives

  • thiazide and thiazide-like diuretics, which have the most evidence
  • beta blocker (in patients age <60 years)
  • ACEI) (in non-black patients)/ARB
  • long acting calcium channel blocker (CCB)

1) initial mono therapy with any of 1st line
if systolic blood pressure is 20mmHg above target or diastolic blood pressure is 10mmHg above target, consider start combination therapy

2) if not achieve target blood pressure with mono therapy, add on medications from another class of 1st line anti-hypertensives

recommended combinations =
(thiazide / thiazide-like diuretics or CCB) + (ACEI or ARB or beta blocker)
combinations NOT recommended =
(non-dihydropyridine CCB + beta blocker)
(ACEI + ARB)

3) if hypertension still not at target with >2 anti-hypertensives from 1st line classes, may add other anti-hypertensive drugs not from 1st line classes
e.g. alpha blockers - Doxazosin, Prazosin, Terazosin
centrally acting agents - clonidine, guanfacine, methyldopa
non-dihydropyridine CCB - verapamil, diltiazem

39
Q

HTN management for hypertensive patients with coronary artery disease

A

ACEI, ARB and beta blocker preferred over other 1st line therapies

preferred combination = ACEI + dihydropyridine CCB

40
Q

HTN management for hypertensive patients with recent myocardial infarction (MI)

A

initial therapy = (ACEI or ARB) + (beta blocker or dihydropyridine CCB)

41
Q

HTN management for hypertensive patients with heart failure

A

initial therapy = (ACEI or ARB) + beta blocker

aldosterone antagonist (e.g. Spironolactone) may be added

42
Q

HTN management for hypertensive patients with stroke

A

blood pressure control usually not indicated in setting of acute stroke unless very high post stroke

preferred combination = ACEI + thiazide / thiazide-like diuretics

43
Q

Management for hypertensive patients with non-diabetic chronic kidney disease

A

ACEI and ARB preferred over other 1st line therapies

thiazide / thiazide-like diuretics preferred as additive anti-hypertensive therapy

44
Q

Management for hypertensive patients with renovascular disease

A

ACEI or ARB used with caution due to risk of acute renal failure or unilateral kidney disease

consider intervention (angioplasty & stunting or surgery) if hypertension despite >3 anti-hypertensive combination therapy, deteriorating kidney function, bilateral renal artery lesion or recurrent episode of flash pulmonary edema

45
Q

Management for hypertensive patients with diabetes

A

ACEI and ARB preferred for patients with cardiovascular or kidney disease

preferred combination = ACEI + dihydropyridine CCB

46
Q

non-dihydropyridine CCB contraindication

A

heart failure

47
Q

blood pressure equation

A

blood pressure = cardiac output (stroke volume x heart rate) / peripheral vascular resistance (inversely proportional to vascular diameter)

48
Q

Thiazide diuretic MOA

A

thiazide diuretics block Na-Cl symporter, decreasing Na reabsorption in distal convoluted tubule, which result in increased Na & H2O renal excretion to decrease stroke volume

49
Q

ACEi MOA

A

ACEI inhibits ACE to decrease renin-angiotensin-aldosterone (RAA) system and increased bradykinin

decreased RAA increase Na and H2O renal excretion, resulting in decreased stroke volume and vasodilation

increased bradykinin cause vasodilation, decreasing peripheral vascular resistance

50
Q

ACEi side effects

A

electrolyte abnormalities: hyperkalemia

acute renal failure with decreased GFR

angioedema

interaction with K sparing diuretics, ARB and NSAID cough

51
Q

ARB MOA

A

ARB block angiotensin AT1 receptors, which cause vasodilation

decreased aldosterone to increase Na and H2O renal excretion, resulting in decreased stroke volume

decreased sympathetic activity

52
Q

BB MOA

A

block beta 1, beta 2 and / or alpha adrenergic receptors

beta 1 selective blocker most commonly prescribed

beta 1 blockade “1 heart” = decrease heart rate, decrease heart contractility and decrease RAA, thereby decreasing cardiac output and causing vasodilatation

beta 2 blockade “2 lungs” = bronchoconstriction and increased vascular resistance

53
Q

CCB types and examples of each

A

dihydropyridine (DHP) CCB end with “-dipine” including Amlodipine, Nifedipine

non-dihydropyridine (NDHP) CCB including Verapamil, Diltiazem

54
Q

Indication for DHP CCB

A

DHP CCB may be indicated in patients with comorbidities that could also be treated with DHP CCB including Raynaud’s and migraine

55
Q

CCB MOAs

A

DHP CCB decrease Ca influx in vascular smooth muscle, causing vasodilatation to decrease peripheral vascular resistance

NDHP CCB decrease Ca influx in cardiomyocyte, decreasing heart contraction to decrease cardiac output

56
Q

K sparing diuretic indication in hypertension

A

2nd line antihypertensive diuretic

Amiloride and Triamterene usually used in mild to moderate hypertension with normal renal function

Spironolactone usually used in hypertensive patients with severe heart failure

57
Q

K sparing diuretic MOAs

A

Amiloride & Triamterene: inhibit ENaC sodium channel in collecting duct, leading to Na & H2O renal excretion to decrease stroke volume

Spironolactone: block aldosterone receptor in collecting duct, leading to Na & H2O renal excretion to decrease stroke volume

58
Q

Loop diuretics indication in hypertension (Lasix)

A

2nd line antihypertensive diuretic

usually indicated in hypertensive patients with volume overload (from renal failure, heart failure or cirrhosis)

59
Q

Loop diuretic contraindication

A

sulfa allergy

60
Q

Thiazide diuretic contraindication

A

sulfa allergy

61
Q

Loop diuretic MOA

A

inhibit Na-K-2Cl symporter on thick ascending limb, decreasing Na reabsorption leading to increased Na & H2O renal excretion to decrease stroke volume

62
Q

What is malignant hypertension

A

hypertensive emergency

63
Q

What is hypertensive crisis

A

hypertensive urgency

64
Q

Malignant hypertension management

A
  1. Admit to ICU
  2. Stabilize
  3. Treat underlying cause
  4. usually reduce blood pressure slowly to prevent ischemic damage

usually reduce mean arterial pressure 10-20% in first hour and then reduce by 25% gradually over next 23 hours compared to baseline

target blood pressure <170/110 mmHg

1st line = IV Labetalol (beta blocker) or IV Nitroprusside (vasodilator)

5) Address target organ damage and symptoms
6) after 24 hours of blood pressure control, then discharge from ICU and start on oral anti-hypertensive medication

65
Q

Acute target organ damage in hypertensive emergency can include what?

A

hypertensive encephalopathy including papilledema

acute ischemic stroke

intracranial hemorrhage

acute left ventricular failure

acute coronary syndrome

acute aortic dissection

acute kidney injury

eclampsia of pregnancy

66
Q

5 big risk factors for ischemic heart disease

A

1) dyslipidemia (high total cholesterol, high LDL, low HDL)
2) smoking
3) diabetes
4) hypertension
5) family history of premature cardiovascular disease (1st degree relative with CVD at <55 years for men or <65 years for women) – this doubles your Framingham risk score

67
Q

What is the definition of metabolic syndrome

A

central obesity based on waist circumference (>101cm for men; >88cm for women)

plus 2+ of following:
hypertriglyceridemia (>1.7)
low HDL cholesterol (<1 for men, <1.3 for women)
hypertension (>130/85 or treatment for hypertension)
high fasting glucose (>5.6 mmol/L) or diabetes

68
Q

What is the Framingham risk score

A

Framingham risk score used to calculate 10 year future risk of cardiovascular disease for patients with NO history of cardiovascular disease

69
Q

How often should screening for dyslipidemia occur

A

every 3-5 years if Framingham risk score <5%

every year if Framingham risk score >5%

70
Q

Statin indications

A 
High risk (FRS >20%) 
start statin in all patients 
Intermediate risk (FRS 10-19%) 
start statin if LDL cholesterol is high (>3.5) or apoprotein B >1.2 or non-HDL cholesterol >4.3 
if do not satisfy treatment threshold but higher risk based on secondary testing, then start statin 
Low risk (FRS <10%) 
start statin if LDL cholesterol >5 or familial hypercholesterolemia 
if do not satisfy treatment threshold and FRS 5-9% but higher risk based on secondary testing, then start statin
71
Q

LDL target

A

LDL cholesterol <2 or >50% decrease in LDL cholesterol

72
Q

What does non invasive cardiac testing include

A

1) non-invasive stress testing

2) rest echocardiogram for left ventricular ejection fraction

73
Q

Indications for non invasive cardiac testing

A

patients satisfying any of the criteria below should undergo both non-invasive stress testing and rest echocardiogram:

adults age >30 with >2 angina criteria

male age >40 and female age >60 with 1 angina criteria

male age <40 and female <60 with 1 angina criteria and other cardiovascular risk factors

74
Q

Requirements to be able to complete exercise stress test

A

ECG normal

Ability to exercise to 85% heart rate

75
Q

What is the strongest prognostic factor in ischemic heart disease

A

left ventricular ejection fraction

76
Q

Indications for invasive angiography

A

high pre-test likelihood of ischemic heart disease (male >50 with 3 angina criteria)

high risk features on non-invasive stress test or left ventricular ejection fraction on echocardiogram

history of sudden cardiac arrest

life-threatening arrhythmia on ECG

77
Q

Long term angina relief

A

1st line = beta blockers
beta blocker recommended for patients with MI or reduced ejection fraction or heart failure
dose of beta blocker usually titrated to target resting heart rate of 55-60 BPM

2nd line = dihydropyridine calcium channel blocker

3rd line = long acting nitrate

78
Q

vessels used for cabg

A

saphenous vein or internal mammary artery

79
Q

what is secondary prevention of ischemic heart disease

A

intervention for patients with history of ischemic heart disease to slow worsening of coronary artery disease or prevent cardiovascular event (myocardial infarction, stroke)

80
Q

What does secondary prevention of ischemic heart disease include

A
  1. surveillance
  2. all of the primary prevention interventions (see above)
  3. anti-platelet agents
    ASA 81 mg or Clopidogrel 75 mg

Post ACS or PCI with stent placement, P2Y12 receptor antagonist should be added to Aspirin for at least 12 months
P2Y12 receptor antagonist can be any of the following Clopidogrel, Prasugrel, Ticagrelor

Post CABG aspirin 100-325mg daily started within 6 hours after surgery for 1 year

  1. Renin-Angiotensin-Aldosterone system blockers
    ACEI indicated in all patients with ischemic heart disease, especially if left ventricular ejection fraction <40%, hypertensive, diabetic or chronic kidney disease

for patients intolerant to ACEI, ARB can be used as a substitute

aldosterone blocker (Spironolactone) indicated in post-MI patients with all of the following:
on therapeutic dose of ACEI and beta blocker
left ejection fraction 0-40%
have diabetes or heart failure

  1. beta blockers
    beta blockers indicated in all patients with ischemic heart disease, especially if patient has any of the following
    left ventricular ejection fraction 0-40%
    history of MI or ACS
    heart failure
  2. cardiac rehabilitation
  3. Statin
    statin for all patients with ischemic heart disease (even if normal lipid profile)

3rd year - Family Medicine (9 decks)

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