Cardiac Lecture Flashcards
Renal Disease
Myocarditis
Cardiac contusion
Recent cardiac surgery or cath
..what do they all have in common?
Can all cause false positives in elevated troponins
ST elevation or new LBBB
T wave inversion
ST depression
EKG signs of acute coronary syndrome
>1 mm elevation in 2 contiguous leads
New LBBB
STEMI
ST elevation or new LBBB
ST depression or T inversion
CP w/ hemodynamic instability
Dynamic EKG changes
Known CAD w/ reminiscent pain
High risk Hx +/- w/ positive troponin
high risk CAD
Atypical CP w/ CAD and normal or unchanged EKG
CP w/ nonspecific ST depression (dominant R leads)
Low risk Hx w/ normal EKG and + troponin
Angina Pt with rest angina w/ spont resolution or promptly after NTG SL
moderate CAD risk
Atypical CP is a ____ risk for CAD
LOW
Thrombotic =
NSTEMI
Embolic= ?
STEMI
what is MONA?
Morphine
Oxygen
Nitro
Aspirin
Patient dependent (Prior episodes, Prior work up, Abilty to exercise)
2 D Echo (TTE)
ETT
Stress Echo
Stress nuclear imaging (technetium 99mTc sestamibi)
Cardiac catheterization
Ways to R/O ACS
Aspirin/ antiplatlet agents
P2Y12 receptor blocker
beta blocker
heparin
..tx for?
NSTEMI/UA
What is dual anti-platelet therapy?
Aspirin/antiplatelet agents
P2Y12 receptor blocker
PRN: diuretics, NTG
Long term: beta blockers, statins
tx for?
Heart failure
Age ≥ 65
≥ 3 risk factors fpr CHD
Prior coronary stenosis ≥ 50%
ST segment deviation on admit EKG
≥ 2 anginal episodes in prior 24 hours
Elevated cardiac biomarkers
Use of aspirin in prior 7 days
TIMI score
(Thrombosis in MI Score)
2 week risk of death, new or recurrent MI, or severe recurrent ischemia requiring revascularization
TIMI
Verify rhythm
Verify hemodynamic stability
Ventricular rate control
Blood pressure management
A Fib
Test of choice when looking for…
Valvular disease
Atrial size
LV size and function
LVH
Peak RV/PA pressures.
Pericardial disease
TTE
True or False…
You would use a TEE when looking for presence of a LA thrombus
True
Benefit: Maintain sinus rhythm and optimal cardiac output.
Improved LV fcn over time.
Drugs: Flecainide, Propafenone, Sotalol, Dofetilide and Amiodarone
Problem: At best, 50-60% effective in maintaining SR long term.
A fib rhythm control
Adverse effects include pro-arrhythmia (VT, Torsades, VF) which can be life threatening.
A fib rhythm control
Which tx for a fib is “worse/not as effective”
*higher 4 year mortality rate
*more strokes
*more hospitalizations
RATE CONTROL or RHYTHM CONTROL
Rhythm control
(both groups have similiar bleeding and similar life score/fxn tho)
Younger, more active patients who benefit from optimal CO or ↑risk of bleed, especially athletes, occupations with ↑risk of trauma.
Patients in whom anticoagulation is contraindicated or have adverse reactions to anticoagulants.
Patients in whom rate is uncontrollable or symptomatically can’t tolerate AF.
Patients who request it.
A fib rhythm control
If pt is in A fib for >48 hours, must have out patient anticoagulation for ______ weeks before CV cardioversion can be tried
3-4 weeks
Cardiology consult
DC cardioversion
Pharmacological cardioversion
Non pharmacological approaches( Maze procedure, Radiofrequency Catheter ablation)
Rhythm control options for A fib
Drug therapy: Slow AV conduction, control rate at rest/exercise.
Drugs: Ca-Blocker (Diltiazem, Verapamil), B-blocker, Digoxin; often combination needed, e.g. Diltiazem plus Digoxin.
A fib rate control
Risk factors
Age >65
Prior History of stroke
Diabetes mellitus
History of systemic hypertension
risk for stroke with chronic a fib
- LV dysfunction/CHF
- ↑LA size
- other aortic or mitral valve disease
HIGH stroke risk with a fib
-age<60 years, heart disease (preserved LV function, Nl LA, no HTN) and no other risk factors
LOW risk of stroke with a fib
With a fib, anticoagulation reduces incidence of stroke to __% per year
1%
CHADS VAS score of:
0
1
>2
should the pt be anticoagulatd?
0= generally no 1= consider 2+= generally yes
*what should be used to anticoagulate to prevent stroke:
Decreased Stroke Risk
Decreased bleed risk
Increased cost
Increased frequency of dosing for some
Limitted by renal disease
Reversal available only for dabigatran (direct thrombin inhibitor)
Novel Oral AntiCoagulant (NOAC)
no bridging required
Cardioversion is primary objective.
Rate control secondary option with Amiodarone
Ablation consideration.
WPW
Anticoagulants should be held for how long before procedures?
3-4 days
(the resumed post-procedure)
True or False…
You can use heparine or LMWH periprocedure for patients who are at very high risk of emboli (ie rheumatic mitral stenosis, mechanical hear valve, prior thromboembolism)
True
Decreased pump function of the heart due to cardiomyopathy (dilated or hypertrophic) or wall motion abnormality
Heart failure
an EF <40% is what type of HF?
Systolic
Impaired relaxation of the heart is what type of HF?
Diastolic
Systolic
Diastolic
L sided
R sided
types of HF
IV diuretic
O2
NTG – SL, Transcutaneous
Morphine
Sodium restrict (2g/D)
Fluid restrict (1-1.5 l /D)
Avoid NSAIDS (helps avoid HyperK and Na retention as well as vasodilator prostaglandin inhibition)
Avoid empiric use of anti-arrhythmics
Correct aggravating or precipitating factors
Acute management of HF
ACE inhibitor
Beta blocker (once stable)
Carvedilol vs metoprolol
Digoxin
ABG
Potassium replacement
Thiazide diuretic in addition to furosemide
Spirinolactone (25mg) for severe CHF in addition to loop diuretic and ACE-I (monitor K)
management for systolic HF
IV or oral diuretics
Unless complicated by a precipitating factor (eg, recent MI) or a concurrent threatening condition (eg, electrolyte imbalance, azotemia, symptomatic arrhythmias) many do not require hospital admission beyond several hours observation in ED or as OutPt.
mild to moderate acute on chronic CHF
