Cardiac HY Flashcards
LLSB Holosystolic murmur + apical diastolic rumble
VSD
(Intraventricular Septal Defect)
IVDU
subacute fevers & malaise
new murmur heard on auscultation
Dx/Dxt (2)/Tx
Infective Endocarditis
Blood Cx (1st)
TEE (2nd)
empiric abx → Penicillin + Vancomycin
IV drugs get PV meds
–septic emboli on CXR–
What 3 types of pts need ppx antibiotics before surgery?
Endocarditis hx
Mechanical Valves in place
Unrepaired Cyanotic Congenital Heart Defect (ToF, TGA, TAPVR, PTA, HPLH)
2 Blood culture (+) bugs that require colonoscopies
Clostridium Septicum
Streptococcus BOVIS
Very short female with chronic calf pain (claudication)
Dx/Dxt/Tx?
Coarctation of Aorta (Turner syndrome)
Xray (Rib Notching s/t collateral intercostal circulation)
Surgery (repair aorta)
Murmurs associated with wide pulse pressure
SBP–DBP >60mmHg (wide)
Aortic Regurgitation/Insufficiency
Patent Ductus Arteriosus
Wide, fixed split of the S2 heart sound
ASD
Neonate with heart failure
upward-slanting palpebral fissures
epicanthal folds
transverse palmar crease
protruding tongue/ sandal gap
Dx of heart defect?
Endocardial Cushion Defect
(Down’s syndrome)
Life long treatment of new prosthetic aortic valve?
Therapeutic target:
Life long anti-coagulation (usually Warfarin)
INR 2.5– 3.5
3m hx of new heart valve
now dark urine and indirect hyperbilirubinemia
valvular hemolysis
(valves shearing blood cells)
High pitched mid-systolic click at the apex
worsens with valsalva (lowers pre-load)
Mitral Valve Prolapse
(prolapse clacks)
MCC of death within 24hrs of having an MI
(ex: pt dies intra-op during PCI placements)
V-Fibrillation
Recent MI now has dyspnea, crackles, and
holosystolic murmur at apex
Mitral insufficiency
s/t Papillary Muscle Rupture
Recent MI now has dyspnea, crackles, and
holosystolic murmur at LLSB
VSD
s/t Intraventricular Septal Rupture
Recent MI now has
Low voltage EKG (fluid in pericardium)
Cardiac arrest (PEA: pulseless electrical arrest)
Cardiac Tamponade
s/t ventricular FREE wall rupture
diastolic murmur at the apex with opening snap
Mitral Stenosis
(stenosis snaps)
Always get an Echo for what 4 types of murmurs?
Diastolic (deadly)
3/6 (or higher)
Holosystolic
Symptomatic
Presents with fever, malaise, joint pain, non-pruritic red rash, heart problems
± skin nodules
Recent hx of URI
Dx/Tx/Cx?
Rheumatic Fever (GAS)
Penicillin V + NSAIDs
Mitral Stenosis → A-fib
(J♡NES criteria: joint pain travels, Pericarditis/Murmur, nodules on skin, erythema marginatum,
Sydenham chorea).
Anticoagulant used to treat A-fib in a pt with
◆Valvular heart problem
or
◆hx of Rheumatic Fever
(probably won’t give away h/o RF but may say pt is an immigrant w/murmur)
Warfarin
INR 2-3
(use warfarin if A-fib s/t valvular problem)
Opening snap at the apex diastolic murmur:
Biggest risk factor for this murmur:
Most common arrhythmia present:
Anticoagulant strategy if this arrhythmia is present:
Mitral Stenosis
Rheumatic Fever
Atrial Fibrillation
Warfarin (if A-fib s/t valvular problem)
Middle age female, very short, syncopal episodes + systolic murmur (RUSB)
Dx?
Turner syndrome
(BICUSPID aortic valve → Aortic Stenosis)
Exercise Stress test is c/i in AS
Hx of RF + Continuous, Involuntary, irregular movements of the extremities
Dx/Tx?
Sydenham’s Chorea (s/t molecular mimicry)
self resolves
Involuntary, irregular movements of the extremities
+ new or worsening OCD and/or a tic disorder
Dx/Tx?
PANDAS
(Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections)
Self-Resolves
Hx of RF
SBP decreases by more than 10 with inspiration
Low voltage EKG (tiny QRS complex) or alternans (QRS points up and down)
Dx/Tx?
Cardiac Tamponade
u/s guided pericardiocentesis
CXR: Water bottle shaped heart
Neck veins distend on inspiration
Prominent JVP waves
Dx/Tx
Constrictive Pericarditis → (calcified pericardial tissue)
Pericardiectomy (CT guided?)
(Kussmaul sign)
On EKG Diffuse ST elevations and diffuse PR depressions
Dx/Tx?
Acute Pericarditis
NSAIDs+Colchicine (together)
(if recent MI, Aspirin only)
Fib vs tach rule
Fib rule: → unequal spaces between QRS (A-fib/V-fib)
Tach rule: → equal spaces between QRS complex (v-tach/SVT)
ventricle vs atrial (above ventricle) rule
ventricle (V-fib/V-tach) → Wide QRS
atrial/above (A-fib, SVT, WpW) → Narrow QRS
Pt is Hemodynamically unstable (≤ 90/50s)
Bradycardia <60 bpm → NBSIM
Tachycardia >100 bpm → NBSIM
Unstable + Brady → Transcutaneous Pacer
Unstable + Tachy → Synchronized Cardioversion
Management for V-Fibrillation
Defibrillate (Unsynchronized cardioversion)
V-fib → D-fib
Regular, Wide QRS, Tachycardia
V-Tach
Management for mono-morphic
1. Pulseless V-tach
2. BP <90/50 (pulse + unstable) V-tach
3. stable V-tach
Management for
4. Pulseless poly-morphic V-tach (TdP)
5. BP <90/50 (pulse + unstable) TdP
6. Stable Tdp
- Defibrillate (Unsynchronized cardioversion)
- Synchronized cardioversion
- Amiodarone
- Defibrillate
- Defibrillate
- IV Magnesium
Regular, Narrow QRS, Tachycardia
Supraventricular Tachycardia (SVT)
Treatment algorithm for
Supraventricular Tachycardia (SVT)
1st: vagal maneuver (massage carotids, cold water, blow a straw)
2nd: Adenosine (if, 1st fails)
3rd: Verapamil, Diltiazem, or Beta Blocker (after Adenosine)
sawtooth pattern on EKG
Atrial Flutter
Management of A-Fib & A-Flutter:
1. Unstable (BP <90/50s)
2. Any pt NOT unstable
- Synchronized Cardioversion
-
1st give a Beta Blocker or (Diltiazem/Verapamil) → Rate Control
───
2b. Anticoagulation
2c. Amiodarone → Rhythm Control
───
AC can be anything: DOACs, Heparin, LMWH (enoxaparin), Warfarin
(MUST be Warfarin if h/o valvular dz)
Pt presents with palpitations and tachycardia
h/o smoking or COPD
EKG shows irregular tachycardia with messed up/weird looking P waves all over
Dx/Tx/BRF?
Multifocal Atrial Tachycardia
Diltiazem/Verapamil (NDDHP-CCB)
Stop smoking! (biggest risk factor)
Bradycardia + Long PR interval only
(aka bigger than one big box)
Dx/Tx?
1º heart block
no treatment
Bradycardia + Long PR interval that keeps getting longer until QRS disappears
Dx/Tx?
2º heart block (Mobitz I)
no treatment
Bradycardia + Long PR interval and QRS disappears after 1-2 beats
(QRS complex present once then disappears the reappears and disappears etc.)
Dx/Tx?
2º heart block (Mobitz II)
Permanent Pacemaker
Bradycardia + QRS complexes very far apart (like ~ 10 boxes apart), but regular
2-3 P waves without a QRS complex before one shows up
(Kinda looks like A-Fib except its brady/not tachy & regular/not irregular)
Dx/Tx?
3º heart block (Complete heart block)
Permanent Pacemaker
Unstable (BP <90/50s or AMS) Bradycardia management
Transcutaneous pacing
(seems like NBME doesn’t care for first-line: IV atropine; but Q banks)
Hemodynamically stable + Polymorphic V-Tach (TdP)
NBSIM?
IV Magnesium
Tachycardia on EKG
Wide QRS, with a slurred, slanted start
short PR interval (< 1 big box)
Dx/Acute Tx/Long-Term Tx?
Wolf Parkinson White
Acute: Procainamide
Long-Term: Electrical Ablation (via cardiac cath)
Ablate accessory pathway (bundle of Kent) that connects atria to ventricles & bypasses AV node
→ ventricular pre-excitation.
AMS + flushed skin + dilated pupils + dehydrated
Wide QRS Tachycardia + short fat QRS in aVR
Dx/Tx?
Tricyclic Antidepressants (TCA) Toxicity
Sodium Bicarbonate
(TCAs: Desipramine/Imipramine, Amitriptyline/Nortriptyline)
Anticholinergic toxidrome: fast fiddle/ hot hare/ blind bat/ dry bone/ empty flask/ red beet/ mad hatter
s/t sodium channel blockade
Dx/Tx?
Hyperkalemia
1. Calcium Gluconate
2. Insulin + D5W (glucose)
3. Albuterol (Beta 2 agonist)
4. Kayexelate
────
EKG shows Wide QRS + Tall, peaked P waves
Treatment for A-Fib with WpW
(irregular tachycardia, wide complex QRS, short PR)
What about unstable WpW?
Procainamide (stable)
Synchronized Cardioversion (unstable)
EKG shows a small bump at the end of the S in the QRS complex
(looks like an ST elevation, but it’s not. There’s a discrete bump as the S ends)
aka Osborn or J wave
Dx?
Hypothermia
7 Drugs that improve survival/mortality in patients with CHF?
(one of which primarily in Black pts)
ACE inhibitors (Ramipril, Enalapril, Lisinopril)
ARBs Angiotensin Receptor Blockers (Valsartan, Losartan)
ARNI: ARBs + Neprylysin inhibitors (Valsartan + Sacubitril)
Beta blockers (Carvedilol, Metoprolol)
Spironolactone, Eplerenone (MR antagonist)
SGLT-2 Inhibitors (Empagliflozin)
In African Americans combo of
Dinitrite Isosorbide + Hydralazine
Acute Coronary Syndrome management (5)
(1st) Aspirin full dose
(2nd) Heparin Anti-Coagulation
(3rd) Clopidogrel Anti-Platelet
for chest pain:
Morphine or Nitrate
–––
(NO nitrate if II,III, aVF changes)
Chest pain worse at night w/ hx of ST elevations & non-occluded coronary arteries
Patient is an active smoker and middle aged or younger
± stimulant/cocaine use
Dx/Tx?
Variant Angina
CCB (any kind) + advise smoking cessation
(Transient coronary vaso-spasms → avoid Beta Blockers)
Pulmonary Embolism
1. ABG findings __pH __Co2
2. Calcium & Potassium levels
3. NBSIM
4. Diagnostic confirmatory test
- ↑ pH (Respiratory Alkalosis) ↓ CO2 (Hyperventilating)
- ↓Ca2+ ↓K+
- IV Heparin
- CT Angiography (+ct)
––––
FYI: basic blood is negatively charged thus positive ions are bound
When is Tissue plasminogen activator (tPA) indicated in Pulmonary Embolism
Unstable (AMS, ≤90/50s)
or
Echo has evidence of R heart strain
•RV enlarged/bulging/abnormal septal motion
•RV same size as LV
Biggest risk factor for Mitral Stenosis?
associated with what arrhythmia?
Rheumatic Fever history
Atrial Fibrillation
Recent MI with sudden onset severe LLE pain.
pulses are absenet
Dx/Tx(2)/Dxt?
Acute Limb Ischemia
IV Heparin (1st step) →
CT Angiogram w/contrast of LE →
Embolectomy (surgical emergency)
Treatment of Acute CHF exacerbation
1st IV Furosemide
If edema persists → ACE-I → Nitrate
(FAN of CHF management)
presents with carditis and migratory (spreading) arthritis
Dx/Tx?
Rheumatic fever
penicillin V + NSAIDs
(eradicates GAS)
––––
causes chorea-like movements (Sydenham chorea)
JONES criteria
2 medications contraindicated in Right Heart MI
(II, III, avF)
Nitroglycerin
Opioids
These are a NO for RHF
—
Divine didn’t mention this, but
Technically, Beta Blockers (if Brady)
Treatment of Right Heart MI (II,III,avF)
Normal Saline
Recent DVT and then stroke.
Dx/NBSIM?
Cryptogenic Stroke
PFO (Patent Foramen Ovale)
TEE with a Bubble Study (bubbles travel to left side heart)
systolic murmur radiating to the neck and axilla
RUSB
Aortic Stenosis
Bounding Pulses
Wide Pulse Pressures
Diastolic Decrescendo murmur
Severe stages → harsh, crescendo-decrescendo systolic murmur
Aortic regurgitation
systolic murmur in the 2nd Left ICS
S2 widely split
Pulmonic Stenosis
(wide not fixed split like ASD)
Holosystolic murmur at LLSB
that increases with Inspiration
─
VERSUS
─
Holosystolic murmur at LLSB + apical diastolic rumble or Thrill
Tricuspid regurgitation
─
VSD
Kawasaki disease
•5+ day Fever
•Unilateral cervical LAD
•Edema/Desquamation of hands/feet
•Red Rash/Eyes/Tongue
Mc Age group:
MC Ethnicity:
Tx (2)?
children < 5 years
Asian & Pacific-Islander
Tx: IvIg + Aspirin
get an ECHO
dx/tx?
Tip: look at how it changes in the center
V-Fib
D-Fibrillate
Below is another example
dx/tx?
Tip: look at QRS complex (wide or narrow?) & look at R-R interval (Regular or Irregular)
V-Tach
Unstable → SCV
Stable → Amiodarone
Below is another more obvious example of V-Tach
again, wide QRS, Regular R-R intervals
dx/tx/2 NBME causes
Tip: Look at certain strips and observe the amplitude
Torsade de Pointes
(Regular + Wide complex + Sinusoidal ampl)
Unstable: D-Fib
Stable: IV Magnesium
—
•QT prolonging drugs
• Hypo E’lytes (hypokalemia, hypomagnesemia, Hypocalcemia)
(can progress to V-Fib)
Flip to compare V-Tach vs TdP
6 steps to Reading an ECG on NBME
First, r/o MI → ST segments (Elevations/Depressions)
Next:
• Rate (brady/tachy) → 300/150/100/75/60/50
• QRS (wide/narrow or tall/inverted) nl 1.5 little boxes
• R-R interval (regular/irregular)
List the next 5 steps
T wave (inverted/peaked) → MI/ Hyperkalemia
PR int. nl 1 big box (depressed/long/sh) → Peri/AVb/WpW
QT int. nl 2 boxes (long/short) → E’Lytes, Meds
P waves (consistent/morphology) → MFAT
Extra waves present?
• U wave (inverted, after T wave) → Hypokalemia
• Delta wave (slurred upstroke start to QRS) → WpW
• J wave (tiny hump after S wave) → Hypothermia
QT prolongation causes on NBME?
(4)
Ziprasidone (Anti-psychotic)
Hypo– E’lytes (Hypocalcemia)
Sumatriptan (Migraines)
Ondansetron (Nausea)
2 Antipsychotics with High Risk of Metabolic Syndrome
Olanzapine
Clozapine (agranulocytosis)
Harsh, systolic murmur at cardiac base + ↓ S2 sound
Aortic Stenosis
(or Crescendo Decrescendo at RUSB)
s/t Chronic RF, Calcified valves, or Bicsupid valves
