cardiac and vascular emergencies Flashcards
1
Q
ischemic heart disease (aka coronary artery disease) can be broken down into what two categories
A
- stable angina
- acute coronary syndrome
2
Q
acute coronary syndrome can be broken down into what three categories
A
- STEMI
- NSTEMI
- unstable angina
3
Q
clinical presentation
- pressure, heaviness, tightness, fullness, or squeezing in the center or left of the chest precipitated by exertion and relieved by rest
A
angina (pectoris)
4
Q
the anginal equivalents: exertional dyspnea, nausea, diaphoresis, weakness, palpitations, syndrome are more commonly in what patient population
A
- elderly
- diabetic
5
Q
diagnostic testing for angina
A
- 12-lead EKG
- stress testing
- coronary angiography
6
Q
pharmacologic stress echocardiogram is performed using what drug
A
dobutamine
7
Q
indications for pharmacologic stress echo
A
- unable to exercise
- inability to achieve target HR during exercise (beta-blocker)
8
Q
technique of radionuclide myocardial perfusion imaging
A
- rest images obtained
- exercise or pharmacologic stress induced
- radioactive tracer administered under stress conditions
- exercise/stress images obtained
- perfusion defect will be seen in areas of hypoperfusion
9
Q
treatment regimen for stable angina
A
- nitrates
-
beta blockers: first line for chronic angina
- CCB: no response to nitrates and beta blockers
-
antiplatelet medication
- asa
- clopidogrel (plavix)
10
Q
management of low risk patients with normal EKG
A
- observation
- serial cardiac enzymes
- stress testing and CT coronary angiography, can assist CV risk stratification in ED
11
Q
Variant Angina (prinzmetal angina, vasospastic angina) typically have what episodes of chest pain
A
- episodes of angina (5-15 min)
- usually at rest and often between midnight and early morning
12
Q
what is diagnostic for Variant Angina (prinzmetal angina, vasospastic angina)
A
- coronary angiography
13
Q
treatment of Variant Angina (prinzmetal angina, vasospastic angina)
A
- nitrates
- CCB
14
Q
workup of chest pain in the ED includes
A
- EKG
- CXR
- pulse oximetry
- labs: CBC, CMP, D-dimer, lipids, BNP, cardiac enzymes (Troponing, CK-MB)
- echocardiogram
- angiography
15
Q
initial management of STEMI
A
- MONA
- morphine
- oxygen
- nitroglycerin
- aspirin 325 mg, chewed
- beta blocker
- anticoagulation: unfractionated heparin
16
Q
preferred mechanism for revascularization in STEMI
A
- PCI: Percutaneous coronary intervention
- if not available in 120 minutes -> fibrinolytics
17
Q
what are the absolute contraindications to thrombolytics
A
- hx of hemorrhagic CVA
- ischemic CVA in last 3 months
- presence of a cerebral vascular malformation or intracranial malignancy
- suspected aortic dissection
- active bleeding
- significant closed-head or facial trauma within the preceeding 3 months
18
Q
what is the gold standard for diagnosing CAD? what interventions can it do
A
coronary angiography
- interventions:
- angioplasty
- stenting
19
Q
revascularization options
A
- PCI
- fibrinolytic therapy: tPA
- antiplatelet therapy: glycoprotein IIb/IIIa inhibitor
- CABG
20
Q
define a NSTEMI
A
- non-occlusive thrombus
- ischemia with elevated cardiac enzymes
21
Q
clinical presentation
- CP with increasing severity, frequency, duration
- occurs at rest
- not relieved with rest and/or nitroglycerin
A
unstable angina
22
Q
inital managment of NSTEMI/unstable angina
A
- MONA
- morphine
- oxygen
- nitroglycerin
- asa 325 mg, chewed
- beta blocker
- anticoagulation: unfractionated heparin
- revascularization (PCI, if needed)
- no thrombolytics
23
Q
ask about the use of what before giving nitroglycerin
A
- sildenafil
- vardenafil
- tadalafil
24
Q
clinical presentation
- usually occurs soon after MI (first 2-3 days)
- transient
- +/- chest discomfort
- PE: pericardial rub
- echo: pericardial effusion
A
- per-infarction pericarditis (PIP)
25
treatment of per-infarction pericarditis (PIP)
* ASA + colchicine
* **\*avoid NSAIDS\***
26
clinical presentation
* chest pain, tachypnea, dyspnea
* hypotension, JVD, muffled heart sounds, pulsus paradoxus
pericardial tamponade
27
how is acute mitral regurgitation diagnosed
* TTE: transthoracic echocardiogram
28
ischemia to papillary muscle post MI can cause
acute mitral regurgitation
29
What is Dressler's syndrome
* postcardiac injury syndrome
* develops weeks-months post MI
* secondary form of pericarditis
30
treatment of Dressler's syndrome
* NSAIDs
* corticosteroids or colchicine if refractory
31
clinical presentation
* fever, cough, dyspnea, orthopnea
* palatal, conjunctival, or subungual petechiae, splinter hemorrhage, oslers node, janeway lesions, roth spots
endocarditis
32
how is endocarditis diagnosed
* blood cultures x 3 (at least an hour apart)
* echo: identify affected valves
33
cxr: cardiomegaly, cephalization, and kerley b lines are consistent with what
heart failure
34
treatment for heart failure
* sublingual nitrates for active cp without hypotension
* **ACE-I**
* **directics: furosemide**
* sodium restrictions
35
admission criteria to ICU for heart failure
* pulmonary edema
* cardiogenic shock
* concomitant MI or ischemia
36
most common type of cardiomyopathy
dilated cardiomyopathy
37
clinical presentation
* dyspnea
* PE: S3 gallop, rales, increased jugular venous pressure
* Cxr: cardiomegaly, pulmonary congestion
dilated cardiomyopathy
38
hypertrophic cardiomyopathy has a risk for
sudden cardiac death
39
clinical presentation
* dyspnea, syncope, angina
* PE: S4 gallop, biphasic carotid pulse
* Echo, MPI: small left ventricle and diastolic dysfunction
hypertrophic cardiomyopathy
40
treatment of hypertrophic cardiomyopathy
* beta blockers or CCB
* surgical or nonsurgical ablation of the hypertrophic septum
41
clinical presentation
* decreased exercise tolerance, dyspnea, peripheral edema
* PE: S3
* echo: reduced LV function
* fibrosis or infiltration of ventricular wall
restrictive cardiomyopathy
42
treatment for restrictive cardiomyopathy
* diuretics until
* cardiac transplant
43
hypertensive urgency
* SBP \> or = 180; DBP \> or = 120
* no end organ damage
44
hypertensive emergency
* SBP \> or = 180; DBP \> or = 120
* acute end organ damage
* cerebrovascular
* cardiac
* renal
45
treatment of hypertensive emergencies
* ICU
* **treat end organ damage, not absolute BP**
* reduce MAP by \<20-25% within 1 hour
46
medical management of asymtomatic thoracic aortic aneursym
* aggressive BP control
* beta blockers
* serial imaging (CT, MRA at 6 months)
47
when is surgery required for thoracic aortic aneursym
* symptomatic
* rapid aneurysm expansion
* growth \> 0.5 cm in 6 months
* \> 5.o cm
48
management of asymptomatic abdominal aortic aneursym \< 5.5 cm
* observation
* ultrasound q 6 mo-1yr
49
complications of abdominal aortic aneursym
* rupture
* aneursym thrombosis
* thromboembolism
50
when is surgery required for abdominal aortic aneursym
* asymptomatic AAA \> 5.5 cm
* rapidly expanding
* growth \> 0.5 cm in 6 months
* associated with peripheral arterial aneurysm or PAD
51
clinical presentation
* "ripping" or "tearing" chest pain radiating to the back
thoracic aortic dissection
52
clinical presentation
* severe back, abdominal, or flank pain + hypotension and shock
* abdominal aortic dissection
53
treatment of acute ascending thoracic aortic dissection
cardiac surgical emergency
54
treatment of descending thoracic aortic dissection
* managed medically if hemodynamically stable and without end organ damage
55
imaging used to evaluate for aortic dissection
* CT angiography: hemodynamically stable
* Multiplanar TEE Transesophageal Echocardiogram: hemodynamically unstable
56
initial management of aortic dissection
* intubation: if hemodynamically unstable or airway compromise
* ICU
* morphine
* reduce SBP to 100-120, HR \< 60
* IV beta blocker
* CT
57
management of asymptomatic carotid disease
* aspirin + statin
* consider CEA: Carotid endarterectomy if stenosis \> 70%
58
management of symptomatic carotid disease (TIA, stroke)
* Carotid endarterectomy if \>70% stenosis
59
where doe DVTs most often occur
* lower extremities and pelvis
60
treatment of DVT
* anticoagulation
* low molecular weight heparin
* heparin followed by warfarin
61
risk factors for pulmonary embolism
* virchows triad
* endothelial damade
* hypercoagulability
* stasis of blood flow
62
gold standard diagnostic for Pulmonary embolism
pulmonary angiography
63
what EKG pattern is rare but consistent with PE
* S1 Q3 T3
64
hamptoms hump on CXR is associated with
pulmonary embolism
65
Westermark sign on CXR is consistent with
pulmonary embolism
66
physical exam when assessing for acute limb ischemia needs to include
* neuro exam **bilaterally**
* ****assess sensation and strength
* pulses
* doppler for PT, DP
* ankle brachial index (ABI)
* \< 0.4 -\> significant ischemia
67
six P's associated with acute limb ischemia
* **Pain**
* **Pulselessness**
* **Pallor**
* **Paresthesias**
* **Paralysis**
* **Poikilothermy**
68
imaging to assess acute limb ischemia
* CTA, MRA
* threatened limbs require immediate surgical revascularization
69
initial management of acute limb ischemia
* anticoagulation
* prior to diagnostic imaging
70
define acute mesenteric ischemia
* acute, sudden onset of intestinal hypoperfusion
71
treatment of acute mesenteric ischemia
* systemic anticoagulation and pain management
* +/- angioplasty with stent
* +/- exploratory lapartomy (if peritoneal signs)
