1
Q
What does a S4 gallop indicate?
A
- S4 gallop is an additional atrial sound made by a STIFFENED VENTRICLE - S4 is heard in ventricular hypertrophy, MI, and in older adults
2
Q
In the case of potential MI when/how often should markers of cardiac damage be taken?
A
- Creatinine kinase, MB isoenzyme (CK-MB), troponin T and troponin I done stat and every 6-10 hours
3
Q
What is the next step in the therapy of unstable angina pectoris/MI in the ED?
A
- Morphine => analgesia, reduce circulating catecholamines, and reduce myocardial oxygen consumption; given if nitroglycerin cannot alleviate discomfort
- Oxygen => can be discontinued after 6 hours if O2 sat is normal
- Nitroglycerin => given sublingually every 5 minutes for a total of 3 doses ( in the absence of hypotension/other nitrgen ie sildenafil use); can advance to IV or transdermal routes
- Aspirin=> 325mg should be chewed and swallowed
- Beta adrenergic antagonist => reduces cardiac damage and may limit infarct size
- Glycoprotein IIb/IIIa inhibitors => reduce end point of death or recurrent ischemia when given in addition to standard therapy for unstable angina or NSTEMI with catheterization
4
Q
What is the FIRST diagnostic test that should be done in the case of suspected MI?
A
- ECG and chest x ray
5
Q
What ECG changes are indicative of angina?
A
- ST segment changes ( elevation or depression) - T wave inversion
6
Q
What ECG changes indicate past cardiac pathology?
A
- Q waves
7
Q
What heart condition can mask ECG changes indicative of angina?
A
- Left bundle branch block
8
Q
Define unstable angina.
A
-Angina of new onset or, - Angina at rest or, - Angina with minimal exertion or, - Angina with a crescendo pattern with episodes of increasing frequency, severity, or duration
9
Q
What are the various etiologies of angina?
A
- Atherosclerosis accounts for 90% of angina
- Coronary artery spasm
- Cocaine induced injury
- Aortic dissection
- Embolism due to endocarditis, prosthetic heart valves, or myxoma
10
Q
What is the primary treatment in myocardial infarction (in subacute setting)?
A
- Aspirin
- Beta adrenergic antagonist
- ACE-I
- Statin Therapy
- Heparin or Clopidogrel may also be given [or abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat)]
- Glycoprotein IIb/IIIa inhibitors should be given in the case of unstable angina
11
Q
What drug combination reduces the risk of subsequent myocardial infarction?
A
- Nitroglycerin and beta adrenergic antagonist
12
Q
What diuretic reduces short term mortality in acute MI?
A
- ACE inhibitors => prevent left ventricular remodeling and recurrent ischemic events
13
Q
Why might magnesium sulfate use be indicated in MI?
A
- Prevent the entry into torsades de pointes in the case of hypomagnesmia.
14
Q
What diet should be recommended for individuals post anginal attack or MI?
A
- Reduced saturated fat and cholesterol diet
15
Q
What are the risk factors for CAD?
A
- diabetes
- dyslipidemia
- age
- hypertension
- tobacco use
- family history of premature CAD
- male gender/postmenopausal status
- left ventricular hypertrophy
- homocystinemia
16
Q
What drug has been shown to decrease major adverse cardiovascular events when given wtihin a few days after the onset of acute coronary syndrome?
A
- HMG -CoA reductase inhibitor => statin
17
Q
What symptoms are associated with larger MIs?
A
- Cardiogenic nausea and vomiting are associated with larger MIs
18
Q
What is the major factor that differentiates MI from angina?
A
- Both are due to increased myocardial demand for oxygen - Agina will resolve in less than 5 minutes with rest - MI typically persists for >20-30 minutes
19
Q
What physical exam signs are indicative of atherosclerotic disease?
A
- Diminished peripheral pulses - Bruits
20
Q
What physical exam signs are indicative of heart failure?
A
- Pulmonary edema - Rales - jugular venous distension - hepatojugular relflux
21
Q
What signs are indicative of chest pain due to a pleural cause?
A
- shallow, painful breathing
22
Q
What are signs of pneumothorax?
A
- asymmetric chest expansion with unilateral hyperresonance to percussion and diminished breath sounds
23
Q
What are the symptoms of angina?
A
- Substernal pressure for less than 30 minutes - Radiation to arm, neck, jaw +/- Dyspnea, N/V, diaphoresis - increases with exertion - decreases with rest and nitroglycerin
24
Q
What studies should be done in suspected angina and MI?
A
- ECG
- Chest x ray
- serum values of cardiac enzymes
25
What are the symptoms of MI?
- Anginal symptoms that last \>30 minutes
26
What are the symptoms of pericarditis?
- Sharp pain radiates to trapezium - increases with respiration - decreases with sitting forward
27
What studies should be done in suspected pericarditis?
- Friction rub - ECG - +/- pericardial effusion
28
What are the symptoms of aortic dissection?
- Sudden onset of tearing pain with radiation to the back
29
What studies should be done in suspected aortic dissection?
- Chest x ray - Widened mediastinum on CT - Transesophageal echo - MRI
30
What are the symptoms of heart failure?
- Exertional chest pain and dyspnea
31
What studies should be done in suspected heart failure?
- chest x ray - displaced apical impulse - edema (pulmonary and lower extremities) - jugular venous distension - cardiac gallop - murmurs
32
What are the symptoms of pneumonia?
- Dyspnea - Fever - Cough - Pleuritic pain
33
What studies should be done in suspected pneumonia?
- Chest x ray - egophony - dullness to percussion
34
What are the symptoms of pneumothorax?
- Unilateral sharp pleuritic pain of sudden onset - Chest x ray findings - unilateral decreased breath sounds and/or hyperresonace
35
What are the symptoms of pulmonary embolism?
- Sudden onset of pleuritic pain - tachycardia - tachypnea - hypoxemia
36
What studies should be done in suspected pulmonary embolism?
- D dimer - V/Q scan - CT chest - Pulmonary angiogram
37
What are the symptoms of costochondritis?
- Localized pain that is easily reproducible - tender to palpation
38
What is the next diagnostic step in new onset congestive heart failure?
- Serial cardiac enzymes and ECGs - CBC, electrolytes, renal function, hepatic function tests - Echocardiogram
39
What is the initial therapy for new onset congestive heart failure?
- Telemetry monitoring - IV diuretics - Oxygen
40
What is telemetry monitoring?
- Telemetry monitoring is when caregivers monitor the electrical activity of your heart for an extended time. Electrical signals control your heartbeat.
41
What are common causes of CHF?
- Coronary artery disease - Hypertension
42
What are the two actions of furosemide that would be most beneficial to patients with CHF?
- diuretic effect - immediate vasodilatory action on bronchial vasculature
43
What are symptoms of right sided heart failure?
- venous congestion -nausea/vomiting - distension/bloating - constipation - abdominal pain - decreased appetite - fluid retention - weight gain - peripheral edema - jugular venous distension - hepatojugular reflux - hepatic ascites - splenomegaly
44
How might left sided heart failure manifest?
- pulmonary congestion (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, wheezing, tachypnea, cough) - pulmonary rales - S3 gallop - Cheyne-stokes respiration - pleural effusion - pulmonary edema
45
What are signs common to left/right heart failure?
- tachycardia - cardiomegaly - cyanosis - oliguria - nocturia - peripheral edema - weakness, fatigue, confusion - decreased mental status - insomnia - decreased exercise tolerance - headache - stupor/coma
46
Severe cardiac failure can lead to what electrolyte disturbance?
- Dilutional hyponatremia
47
Vascular congestion can lead to what liver abnormalities?
- increased liver transaminases and jaundice
48
What is the gold standard diagnostic modality in the evaluation of CHF?
- Echocardiogram
49
What are the other effects of morphine besides its analgesic and anxiolytic properties?
- Morphine is also a venodilator and arterial dilator =\> results in a reduction in preload and an increase in cardiac output
50
In an outpatient setting what drug is considered first line in a patient with CHF?
- ACE-I ( also helps with reduced left ventricular function) because it inhibits remodeling - thiazide diuretics may be used as an adjunct
51
What are the contraindications to ACE-I use in congestive heart disease?
- pregnancy - hypotension - hyperkalemia - bilateral renal artery stenosis - used with caution in patients with renal insufficiency
52
What are the benefits of beta blockers in CHF?
- reduce sympathetic tone - reduce cardiac muscle remodeling - reduce mortality in patients with an ejection fraction
53
What drug reduces mortality in advanced heart failure?
- Aldosterone antagonist =\> spironolactone \* watch for hyperkalemia
54
What kind of calcium channel blocker is used in diastolic heart failure?
- Nondihydropyridine calcium channel blockers (diltiazem and verapamil)
55
What calcium channel blocker is permitted in systolic heart failure?
- Calcium channel blockers in general are contraindicated in systolic heart failure due to an increase in mortality EXCEPT the dihydropyridine calcium channel blocker amlodipine
56
CHF patients with prolonged QRS duration can be best treated with?
- Pacemaker
57
What diagnostic tests should be done in the initial presentation of hypertension?
- Blood glucose - serum potassium - creatinine - calcium levels - hematocrit - UA - ECG
58
What are non pharmacological changes to treat hypertension?
- Diet ( high potassium and calcium diet-DASH diet) - alcohol limitation to no more than 2 drinks per day - exercise - weight reduction - smoking cessation
59
What is the first line drug for treating hypertension?
- thiazide diuretic
60
How does cardiovascular disease risk correlate with blood pressure?
- Risk of cardiovascular disease doubles with each increase in blood pressure of 20/10 mmHg above 115/75
61
Which demographic groups have a higher risk of hypertension?
- African Americans - Elderly
62
What are the various stages of hypertension?
- Stage 1: 140/90 - Stage 2: 160/100 (start with two anti-hypertensive medicines)
63
What anti-hypertensive agents are indicated in patients with diabetes and hypertension?
- ACE-I - Angiotensin receptor blocker - Diuretic - Calcium channel blocker - Beta blocker
64
What anti-hypertensive agents are indicated in patients with high risk coronary artery disease and hypertension?
- ACE-I - Beta blocker - diuretic - calcium channel blocker
65
What anti-hypertensive agents are indicated in patients with congestive heart failure and hypertension?
- ACE-I - Angiotensin receptor blocker - Beta blocker - Diuretic - Aldosterone antagonist
66
What anti-hypertensive agents are indicated in patients post myocardial infarction and hypertension?
- ACE-I - Beta blcoker - Aldosterone agonist
67
What anti-hypertensive agents are indicated in patients with chronic kidney disease and hypertension?
- ACE-I - Angiotensin receptor blocker (ARB)
68
What anti-hypertensive agents are indicated in patients with hypertension to prevent recurrent cerebrovascular event?
- ACE-I - Diuretic
69
What is the next diagnostic step in the likely diagnosis of a benign cardiac dysrhythmia?
- 12 lead ECG
70
What is the next therapeutic step in a patient with benign cardiac dysrhythmia?
- Restrict caffeine, alcohol, and drugs (stimulants and diuretics) for the next 2 weeks - keep a diary of symptoms or possible triggers - follow up with patient in 2 weeks
71
What familial heart syndromes and cause irregular heart palpitations?
- familial prologned QT syndrome (can be autosomal dominant and affect females more)
- hypertrophic cardiomyopathy (autosomal dominant)
\* watch out for a family history of syncope and sudden death
72
What heart condition is associated with a mid systolic click (with or without a late systolic murmur)?
- Mitral valve prolapse
73
What is the next diagnostic step in suspected MVP?
- at least one echocardiogram
74
What is supraventricular tachycardia?
- caused by a cardiac source of the arrhythmia that is not in the ventricle - includes: atrial fibrillation, atrial flutter, focal atrial tachycardia, multifocal atrial tachycardia, AV nodal reentrant tachycardia
75
What rhythm disorder is classically found concurrently in COPD?
- multifocal atrial tachycardia
76
What is Wolf-Parkinson-White?
- WPW syndrome is caused by an accessory track between the atria and ventricles that conducts electrical impulses in addition to the AV node.
77
What is the classic WPW ECG finding?
- slurring on the upstroke of the QRS complex = delta wave
78
What is Brugada syndrome?
- Ion channel disorder that is most common in asian males
- on ECG it presents as ST segmetn elevation in leads V1-V3
- Can cause dangerous arrhythmias that result in death
79
What is sick sinus syndrome?
- Dysfunction fo the SA node that leads to bradycardia and can cause fatigue and syncope
- There is also a tachycardia-bradycardia variety of sick sinus syndrome in which supraventricular tachycardia is also present and is associated with palpitations and angina pectoris
80
What is considered a dangerous QTc?
- Any patient with a QTc \>500msec is at increased risk for dangerous dysrhythias
- Can be the result of medications such as quinidine, procainamide, sotalol, amiodarone, and TCAs
81
What are non-cardiac etiologies of palpitations?
- anemia
- electrolyte disturbances
- hyperthyroidism
- hypothyroidism
- hypoglycemia
- hypovolemia
- fever
- pheochromocytoma
- pulmonary disease
- vasovagal syncope
82
What labs might rule in/out non-cardiac etiologies of palpitation?
- CBC
- chemistry panel
- TSH
- If pheochromocytoma is suspected: 24hr urine colection for catecholamines/metanephrines
83
What is the indicated treatment for supraventricular rhythm disturbances?
- Beta blockers or calcium channel blockers
84
How might SVT be treated nonpharmacologically?
- carotid sinus massage
- valsalva maneuver
- cold application to the face
\* all trigger vagus nerve
85
What are the pharmacologic treatments of SVT?
- IV adenosine: demonstrates reentry SVT
- Beta blockers or Calcium channel blockers: if not reentry SVT/ie IV adenosine does not work
86
What medications are recommended for patients with atrial fibrillation?
- Warfarin
- Beta blocker or calicum channel blocker
87
What should be done prior to cardioversion to rule out thrombus?
- Transesophageol echocardiogram should be done prior to cardioversion
88
What class of antiarrhythmics should NOT be used in the context of structural cardiac disease or cardiac hypertrophy?
- Class 1C: Flecainide or Propafenone
89
What drug can be given to patients who are in stable ventricular tachycardia?
- Amiodarone ( or lidocaine in iodine allergy) can be given to patients who are in stable ventricular tachycardia
- Most need to be immediately defibrillated
90
What is the most comon cause of ventricular arrhythmia?
ischemia
91
What is the next diagnostic step in suspected stroke/cerebrovascular accident?
- CT scan WITHOUT contrast to exclude hemorrhage, tumor, or abscess
- blood sugar, drug screen, coagulation studies, serum electrolytes, renal functiontests, lipid profile,a nd CBC
- ECG
92
When is a patient who has had a stroke eligible for thrombolytic therapy?
Less than 3 hours since the onset of symptoms
93
When might a carotid Doppler study be indicated in a stroke patient?
- History of recent TIA
94
What is the greatest risk factor for stroke?
- hypertension
- Others include: diabetes, older age, male sex, family history, dyslipidemia, smoking, and sickle cell disease ( in children)
95
How would a middle cerebral artery stroke present ( wen dominant hemisphere is involved)?
- Aphasia, contralateral hemiparesis, sensory loss, spatial neglect, contralateral conjugate gaze
96
How might a stroke in the anterior cerebral artery present?
- Foot and leg deficits more frequent than arm deficits
- Cognitive and personality changes
97
Stroke in the territory of hte vertebraobasail area would present as?
- motor or sensory loss in ALL FOUR limbs, crossed signs, disconjugate gaze, nystagmus, dysarthria, and dysphagia
98
Stroke in the cerebellar region presents as?
Ipsilateral limb ataxia and gait ataxia
99
What might hypertension in the context of a stroke indicate?
- intracranial hemorrhage
- hypertensive encephalopathy
100
What conditions shoould be met for thrombolytic therapy to be initiated in the case of a stroke?
- Less than 3 hours since presentation
- Blood pressure below 185/110 ( use labetalol, nicardipine, and sodium nitroprusside)
101
When should aspirin be given to stroke patients?
- Aspirin should be given within 48 hours of a non-hemorrhagic stroke except for when thrombolytic therapy is given
102
What thrombolytic should patients be given if treated within 3 hours of a stroke?
Recombinant tissue-type plasminogen activator (rTPA)
103
What is a serious post stroke complication?
- Post stroke cerebral edema: can lead to herniation of brain stem, resulting in death
- Can be treated with mannitol or decompression surgery
104
When is carotid enarterectomy indicated?
Carotid endarterectomy (CEA) can reduce hte risk of stroke in someone with a history of previous TIA/CVA AND carotid artery stenosis \>70%
- noninvasive carotid balloon angiopasty and stenting is now also an alternative
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