Cardiac Issues Flashcards
Three examples of bad heart things that present with chest pain that are life threatening
ACS, aortic dissection, pulmonary embolism
What three populations typically present with “atypical” symptoms? (but as Emily Downs astutely noticed maybe its men that are the “atypical” patients).
Women, elderly, diabetics
How soon do we want to get an ECG within when a patient presents with chest pain
10 minutes
What criteria must be met to a diagnose a STEMI?
Greater than or equal to 1 mm elevation in two contiguous leads
Time delay for Troponin?
6 hours
What are some causes of high troponins that false positives?
Renal disease, myocarditis, cardiac contusion, recent cardiac surgery or cath
ST elevation, ST depression or T wave inversion, chest pain with hemodynamic instability are all high, moderate, or low risk signs?
High
What electrolytes are important to monitor when someone presents with chest pain? (or which ones were mentioned)
Potassium and manegsium
What is the gold standard to rule out ACS?
Cardiac catheterization
NSTEMI – how do we treat?
Aspirin/anti-platelet agents
(dual anti-platelet therapy), beta blocker, heparin, statin therapy
What is the TIMI score?
Thrombolysis in Myocardial Infarction Score
What is the TIMI used for?
to determine the likelihood of ischemic events or mortality in patients with unstable angina or non-ST segment elevation
Age greater than or equal to 65, 3 or more risk factors for CHD, prior coronary stenosis of 50 percent or more, ST segment deviation on admit EKG, 2 or more anginal episodes in 24 hours, elevated cardiac biomarkers, and use of aspirin in prior 7 days are all part of what scoring system?
TIMI score
If you have a TIMI score of 6, what is your percent risk?
50 percent
If you have a TIMI score of 2, what is your percent risk?
8.3%
If we believe someone is in atrial fibrillation, what 4 actions must we take immediately?
Verify rhythm, verify hemodynamic stability, ventricular rate control, blood pressure management
After we have taken care of the first 4 immediate actions, we have to do these 3 things – the “post immediate issues”
Identification of precipitating factor(s), consideration of cardioversion (rhythm vs rate), and anticoagulation
Minimize symptoms related to a fib, prevent thromboembolic complications, minimize side effects of adverse reactions, minimize risk of bleeding, and decrease mortality are all????
Management goals of a fib
Besides and ECG and an echo for evaluating a fib, what other test should we order?
Thyroid function tests, chest x-ray looking for pulmonary disease, and possibly ambulatory monitoring and/or exercise testing for rate control
When should we hospitalize patients with a fib?
- Cardioversion
- Initiation of anti-arrhythmics
- Rate management
- Treatment of associated medical conditions
- elderly patients more safely treated in hospital
- Patient with risk of complications from A fib
What are the benefits of rhythm control?
Maintain sinus rhythm and optimal cardiac output
What chamber of the heart has improved function over time with rhythm control?
Left ventricle
Percentage wise, how effective is rhythm control effective in maintaining sinus rhythm long term?
50-60%
What are some adverse effects of rhythm control?
Pro-arrhythmias (VT, Torsades, VF) which can be life threatening
Hospitalizations are higher for the rhythm or the rate group?
Rhythm
Who gets rhythm control?
- Younger, more active patients who benefit from optimal cardiac output
- Those at risk of bleed, especially athletes, occupations with risk of trauma
- Patient in whom anticoagulaton is contraindicated
- Patients in whom rate in uncontrollable or symptomatically can’t tolerated A fib
- Patients who request it
Risk of stroke greatly increases after how many hours of being in A fib?
48 hours
If someone has been in a fib for more than 48 hours (or we don’t know how long), how long do we fully anticoagulate?
3-4 weeks
If someone has been in a fib for less than 24 hours can we attempt a cardioversion?
YUP
If someone has been in a fib for more than 48 hours, we cannot attempt a cardioversion, so what do we do?
Fully anti-coagulate for 3-4 weeks
When preparing for a cardiology consult what two things must you know? (this is a stupid question)
Know what you want
Know information about the patient
What are the goals of a surgical approach to a fib?
- Isolate pulmonary veins for LA
- Remove LA appendage
- Interrupt re-entrant pathways
Percentage wise, how effective is a surgical approach in maintaining sinus rhythm long term?
90%
Is rate control or rhythm control more common?
Rate control
What are the two steps to rate control?
- Control the rate – symptom monitoring, blood pressure management
- Prevent stroke (anticoagulation)
When we use the rate control approach, and we use drug therapy, we are trying to slow ______ conduction.
AV
slows the number of impulses making it to the ventricle
What drugs do we commonly use for rate control?
Calcium channel blockers – mainly Diltiazem.
Beta-blockers, digoxin.
When using the rate control approach, is one drug usually enough?
No – often need a combination of medications
If rate control is not obtained with medications, what is our next step?
Ablate AV node with radiofrequency, then pacemaker
What are risk factors of chronic a fib and stroke?
Age greater than 65, prior history of stroke, diabetes mellitus, history of systemic hypertension
If a patient has increased LA size, LV dysfunction, and aortic valve disease, are they at a high, low, or very low risk for a stroke?
High
If someone has a CHAD2ds2 score of 1, do we anticoagulate?
we consider it!
score of 0, generally not
score of 2, generally yes
Can we use aspirin as an anti-coagulant?
No!
What are NOAC’s?
Novel Oral Anticoagulants (Dabigatran)
Do we have to use bridging therapy when starting someone on an NOAC?
no!
When do we not have to bridge to warfarin?
If there is no history of thromboembolism
For WPW, what is our primary objective in terms of treatment?
Cardioversion
If someone is being anticoagulated and needs to have a procedure, when do we start holding their medication?
3-4 days preprocedure, and then resume postprocedure
Decreased pump function of the heart due to cardiomyopathy or wall motion abnormality
Heart failure
Thickened walls of the heart describes hypertrophic or dilated cardiomyopathy?
hypertrophic
What are some things that can cause dilated cardiomyopathy?
Toxins, diseases, alcoholism
An ejection fraction less than _____ percent is systolic heart failure
40
Is left or right heart failure more common?
Left
What will you see on chest x-ray of someone with heart failure?
Increased vascular markings toward the apices, cephalization of the vessels, Kerley B lines, enhancement of hilum, pleural effusions
How do we acutely manage heart failure?
IV diuretics, oxygen, sodium restriction (2g/d), and fluid restriction (1-1.5 l/d)
