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Family Medicine Clerkship- Case files > Cardiac problems > Flashcards

Cardiac problems Flashcards

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
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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
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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
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4
Q

What is the FIRST diagnostic test that should be done in the case of suspected MI?

A
  • ECG and chest x ray
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5
Q

What ECG changes are indicative of angina?

A
  • ST segment changes ( elevation or depression) - T wave inversion
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6
Q

What ECG changes indicate past cardiac pathology?

A
  • Q waves
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7
Q

What heart condition can mask ECG changes indicative of angina?

A
  • Left bundle branch block
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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

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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
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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
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11
Q

What drug combination reduces the risk of subsequent myocardial infarction?

A
  • Nitroglycerin and beta adrenergic antagonist
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12
Q

What diuretic reduces short term mortality in acute MI?

A
  • ACE inhibitors => prevent left ventricular remodeling and recurrent ischemic events
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13
Q

Why might magnesium sulfate use be indicated in MI?

A
  • Prevent the entry into torsades de pointes in the case of hypomagnesmia.
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14
Q

What diet should be recommended for individuals post anginal attack or MI?

A
  • Reduced saturated fat and cholesterol diet
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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
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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
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17
Q

What symptoms are associated with larger MIs?

A
  • Cardiogenic nausea and vomiting are associated with larger MIs
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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
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19
Q

What physical exam signs are indicative of atherosclerotic disease?

A
  • Diminished peripheral pulses - Bruits
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20
Q

What physical exam signs are indicative of heart failure?

A
  • Pulmonary edema - Rales - jugular venous distension - hepatojugular relflux
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21
Q

What signs are indicative of chest pain due to a pleural cause?

A
  • shallow, painful breathing
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22
Q

What are signs of pneumothorax?

A
  • asymmetric chest expansion with unilateral hyperresonance to percussion and diminished breath sounds
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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
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24
Q

What studies should be done in suspected angina and MI?

A
  • ECG
  • Chest x ray
  • serum values of cardiac enzymes
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25
Q

What are the symptoms of MI?

A
  • Anginal symptoms that last >30 minutes
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26
Q

What are the symptoms of pericarditis?

A
  • Sharp pain radiates to trapezium - increases with respiration - decreases with sitting forward
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27
Q

What studies should be done in suspected pericarditis?

A
  • Friction rub - ECG - +/- pericardial effusion
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28
Q

What are the symptoms of aortic dissection?

A
  • Sudden onset of tearing pain with radiation to the back
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29
Q

What studies should be done in suspected aortic dissection?

A
  • Chest x ray - Widened mediastinum on CT - Transesophageal echo - MRI
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30
Q

What are the symptoms of heart failure?

A
  • Exertional chest pain and dyspnea
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31
Q

What studies should be done in suspected heart failure?

A
  • chest x ray - displaced apical impulse - edema (pulmonary and lower extremities) - jugular venous distension - cardiac gallop - murmurs
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32
Q

What are the symptoms of pneumonia?

A
  • Dyspnea - Fever - Cough - Pleuritic pain
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33
Q

What studies should be done in suspected pneumonia?

A
  • Chest x ray - egophony - dullness to percussion
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34
Q

What are the symptoms of pneumothorax?

A
  • Unilateral sharp pleuritic pain of sudden onset - Chest x ray findings - unilateral decreased breath sounds and/or hyperresonace
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35
Q

What are the symptoms of pulmonary embolism?

A
  • Sudden onset of pleuritic pain - tachycardia - tachypnea - hypoxemia
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36
Q

What studies should be done in suspected pulmonary embolism?

A
  • D dimer - V/Q scan - CT chest - Pulmonary angiogram
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37
Q

What are the symptoms of costochondritis?

A
  • Localized pain that is easily reproducible - tender to palpation
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38
Q

What is the next diagnostic step in new onset congestive heart failure?

A
  • Serial cardiac enzymes and ECGs - CBC, electrolytes, renal function, hepatic function tests - Echocardiogram
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39
Q

What is the initial therapy for new onset congestive heart failure?

A
  • Telemetry monitoring - IV diuretics - Oxygen
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40
Q

What is telemetry monitoring?

A
  • Telemetry monitoring is when caregivers monitor the electrical activity of your heart for an extended time. Electrical signals control your heartbeat.
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41
Q

What are common causes of CHF?

A
  • Coronary artery disease - Hypertension
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42
Q

What are the two actions of furosemide that would be most beneficial to patients with CHF?

A
  • diuretic effect - immediate vasodilatory action on bronchial vasculature
43
Q

What are symptoms of right sided heart failure?

A
  • 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
Q

How might left sided heart failure manifest?

A
  • pulmonary congestion (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, wheezing, tachypnea, cough) - pulmonary rales - S3 gallop - Cheyne-stokes respiration - pleural effusion - pulmonary edema
45
Q

What are signs common to left/right heart failure?

A
  • tachycardia - cardiomegaly - cyanosis - oliguria - nocturia - peripheral edema - weakness, fatigue, confusion - decreased mental status - insomnia - decreased exercise tolerance - headache - stupor/coma
46
Q

Severe cardiac failure can lead to what electrolyte disturbance?

A
  • Dilutional hyponatremia
47
Q

Vascular congestion can lead to what liver abnormalities?

A
  • increased liver transaminases and jaundice
48
Q

What is the gold standard diagnostic modality in the evaluation of CHF?

A
  • Echocardiogram
49
Q

What are the other effects of morphine besides its analgesic and anxiolytic properties?

A
  • Morphine is also a venodilator and arterial dilator => results in a reduction in preload and an increase in cardiac output
50
Q

In an outpatient setting what drug is considered first line in a patient with CHF?

A
  • ACE-I ( also helps with reduced left ventricular function) because it inhibits remodeling - thiazide diuretics may be used as an adjunct
51
Q

What are the contraindications to ACE-I use in congestive heart disease?

A
  • pregnancy - hypotension - hyperkalemia - bilateral renal artery stenosis - used with caution in patients with renal insufficiency
52
Q

What are the benefits of beta blockers in CHF?

A
  • reduce sympathetic tone - reduce cardiac muscle remodeling - reduce mortality in patients with an ejection fraction
53
Q

What drug reduces mortality in advanced heart failure?

A
  • Aldosterone antagonist => spironolactone * watch for hyperkalemia
54
Q

What kind of calcium channel blocker is used in diastolic heart failure?

A
  • Nondihydropyridine calcium channel blockers (diltiazem and verapamil)
55
Q

What calcium channel blocker is permitted in systolic heart failure?

A
  • 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
Q

CHF patients with prolonged QRS duration can be best treated with?

A
  • Pacemaker
57
Q

What diagnostic tests should be done in the initial presentation of hypertension?

A
  • Blood glucose - serum potassium - creatinine - calcium levels - hematocrit - UA - ECG
58
Q

What are non pharmacological changes to treat hypertension?

A
  • Diet ( high potassium and calcium diet-DASH diet) - alcohol limitation to no more than 2 drinks per day - exercise - weight reduction - smoking cessation
59
Q

What is the first line drug for treating hypertension?

A
  • thiazide diuretic
60
Q

How does cardiovascular disease risk correlate with blood pressure?

A
  • Risk of cardiovascular disease doubles with each increase in blood pressure of 20/10 mmHg above 115/75
61
Q

Which demographic groups have a higher risk of hypertension?

A
  • African Americans - Elderly
62
Q

What are the various stages of hypertension?

A
  • Stage 1: 140/90 - Stage 2: 160/100 (start with two anti-hypertensive medicines)
63
Q

What anti-hypertensive agents are indicated in patients with diabetes and hypertension?

A
  • ACE-I - Angiotensin receptor blocker - Diuretic - Calcium channel blocker - Beta blocker
64
Q

What anti-hypertensive agents are indicated in patients with high risk coronary artery disease and hypertension?

A
  • ACE-I - Beta blocker - diuretic - calcium channel blocker
65
Q

What anti-hypertensive agents are indicated in patients with congestive heart failure and hypertension?

A
  • ACE-I - Angiotensin receptor blocker - Beta blocker - Diuretic - Aldosterone antagonist
66
Q

What anti-hypertensive agents are indicated in patients post myocardial infarction and hypertension?

A
  • ACE-I - Beta blcoker - Aldosterone agonist
67
Q

What anti-hypertensive agents are indicated in patients with chronic kidney disease and hypertension?

A
  • ACE-I - Angiotensin receptor blocker (ARB)
68
Q

What anti-hypertensive agents are indicated in patients with hypertension to prevent recurrent cerebrovascular event?

A
  • ACE-I - Diuretic
69
Q

What is the next diagnostic step in the likely diagnosis of a benign cardiac dysrhythmia?

A
  • 12 lead ECG
70
Q

What is the next therapeutic step in a patient with benign cardiac dysrhythmia?

A
  • 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
Q

What familial heart syndromes and cause irregular heart palpitations?

A
  • 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
Q

What heart condition is associated with a mid systolic click (with or without a late systolic murmur)?

A
  • Mitral valve prolapse
73
Q

What is the next diagnostic step in suspected MVP?

A
  • at least one echocardiogram
74
Q

What is supraventricular tachycardia?

A
  • 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
Q

What rhythm disorder is classically found concurrently in COPD?

A
  • multifocal atrial tachycardia
76
Q

What is Wolf-Parkinson-White?

A
  • WPW syndrome is caused by an accessory track between the atria and ventricles that conducts electrical impulses in addition to the AV node.
77
Q

What is the classic WPW ECG finding?

A
  • slurring on the upstroke of the QRS complex = delta wave
78
Q

What is Brugada syndrome?

A
  • 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
Q

What is sick sinus syndrome?

A
  • 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
Q

What is considered a dangerous QTc?

A
  • 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
Q

What are non-cardiac etiologies of palpitations?

A
  • anemia
  • electrolyte disturbances
  • hyperthyroidism
  • hypothyroidism
  • hypoglycemia
  • hypovolemia
  • fever
  • pheochromocytoma
  • pulmonary disease
  • vasovagal syncope
82
Q

What labs might rule in/out non-cardiac etiologies of palpitation?

A
  • CBC
  • chemistry panel
  • TSH
  • If pheochromocytoma is suspected: 24hr urine colection for catecholamines/metanephrines
83
Q

What is the indicated treatment for supraventricular rhythm disturbances?

A
  • Beta blockers or calcium channel blockers
84
Q

How might SVT be treated nonpharmacologically?

A
  • carotid sinus massage
  • valsalva maneuver
  • cold application to the face

* all trigger vagus nerve

85
Q

What are the pharmacologic treatments of SVT?

A
  • IV adenosine: demonstrates reentry SVT
  • Beta blockers or Calcium channel blockers: if not reentry SVT/ie IV adenosine does not work
86
Q

What medications are recommended for patients with atrial fibrillation?

A
  • Warfarin
  • Beta blocker or calicum channel blocker
87
Q

What should be done prior to cardioversion to rule out thrombus?

A
  • Transesophageol echocardiogram should be done prior to cardioversion
88
Q

What class of antiarrhythmics should NOT be used in the context of structural cardiac disease or cardiac hypertrophy?

A
  • Class 1C: Flecainide or Propafenone
89
Q

What drug can be given to patients who are in stable ventricular tachycardia?

A
  • Amiodarone ( or lidocaine in iodine allergy) can be given to patients who are in stable ventricular tachycardia
  • Most need to be immediately defibrillated
90
Q

What is the most comon cause of ventricular arrhythmia?

A

ischemia

91
Q

What is the next diagnostic step in suspected stroke/cerebrovascular accident?

A
  • 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
Q

When is a patient who has had a stroke eligible for thrombolytic therapy?

A

Less than 3 hours since the onset of symptoms

93
Q

When might a carotid Doppler study be indicated in a stroke patient?

A
  • History of recent TIA
94
Q

What is the greatest risk factor for stroke?

A
  • hypertension
  • Others include: diabetes, older age, male sex, family history, dyslipidemia, smoking, and sickle cell disease ( in children)
95
Q

How would a middle cerebral artery stroke present ( wen dominant hemisphere is involved)?

A
  • Aphasia, contralateral hemiparesis, sensory loss, spatial neglect, contralateral conjugate gaze
96
Q

How might a stroke in the anterior cerebral artery present?

A
  • Foot and leg deficits more frequent than arm deficits
  • Cognitive and personality changes
97
Q

Stroke in the territory of hte vertebraobasail area would present as?

A
  • motor or sensory loss in ALL FOUR limbs, crossed signs, disconjugate gaze, nystagmus, dysarthria, and dysphagia
98
Q

Stroke in the cerebellar region presents as?

A

Ipsilateral limb ataxia and gait ataxia

99
Q

What might hypertension in the context of a stroke indicate?

A
  • intracranial hemorrhage
  • hypertensive encephalopathy
100
Q

What conditions shoould be met for thrombolytic therapy to be initiated in the case of a stroke?

A
  • Less than 3 hours since presentation
  • Blood pressure below 185/110 ( use labetalol, nicardipine, and sodium nitroprusside)
101
Q

When should aspirin be given to stroke patients?

A
  • Aspirin should be given within 48 hours of a non-hemorrhagic stroke except for when thrombolytic therapy is given
102
Q

What thrombolytic should patients be given if treated within 3 hours of a stroke?

A

Recombinant tissue-type plasminogen activator (rTPA)

103
Q

What is a serious post stroke complication?

A
  • Post stroke cerebral edema: can lead to herniation of brain stem, resulting in death
  • Can be treated with mannitol or decompression surgery
104
Q

When is carotid enarterectomy indicated?

A

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

Family Medicine Clerkship- Case files (13 decks)

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