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Internal Med EOR > Cardio 1 > Flashcards

Cardio 1 Flashcards

1
Q

sensitive sign for stable angina on EKG

A

Horizontal or downsloping ST-segment depression on ECG during an anginal attack is among the most sensitive clinical signs

Nonspecific T-wave changes (flattening or inversion) may be noted

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2
Q

what is considered a positive test for exercise stress test in stable angina

A

ST-segment depression of 1mm is considered to be a positive test

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3
Q

definitive dx stable angina

A

coronary angiography

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4
Q

what is the biggest difference between unstable angina and NSTEMI

A

there is no elevation in cardiac enzymes (troponin) with unstable angina but there is in NSTEMI

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5
Q

NSTEMI vs STEMI

A

NSTEMI - elevation in cardiac enzymes; ST depressions and T wave inversion

STEMI - elevation in cardiac enzymes; ST elevations

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6
Q

what will vasospastic angina show on EKG

A

transient ST elevations in the pattern of the affected artery that resolves with symptom resolution

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7
Q

cardiac enzymes in vasospastic angina

A

may or may not be elevated

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8
Q

gold standard for dx of vasospastic angina

A

coronary angiography with injection of provocative agents (ergonovine, hyperventilation, or acetylcholine)

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9
Q

tx for sinus tachycardia

A

treat underlying disease
beta blockers used in persistent tachycardia in the presence of ACS

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10
Q

tx for sinus bradycardia

A

unstable or symptomatic:
atropine first line
if failure to improve –> temporary pacemaker
epinephrine second line
permanent pacemaker definitive

no sx if asx and stable :)

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11
Q

paroxysmal Afib

A

self terminating within 7 days

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12
Q

persistent Afib

A

fails to self-terminate, lasts > 7 days
requires termination

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13
Q

permanent Afib

A

persistent Afib > 1 year (refractory to cardioversion or cardioversion never tried)

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14
Q

lone Afib

A

paroxysmal, persistent, or permanent without evidence of heart disease

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15
Q

what will EKG show for Afib

A

irregularly irregular rhythm with fibrillatory waves and no discrete P waves
often atrial rate > 250 BPM

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16
Q

tx Afib

A

stable:
rate control - BB (metoprolol, atenolol, or esmolol) or non-dihydropyridine CCB (Diltiazem or Verapamil)

Unstable:
Direct current (synchronized) cardioversion

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17
Q

CHA2DS2-VASc criteria

A

Congestive Heart failure - 1
HTN - 1
Age >/= 75 - 2
DM - 1
Stroke, TIA, thrombus - 2
Vascular disease (prior MI, aortic plaque, PAD) - 1
Age 65-74 - 1
Sex (female) - 1

score 2 or more for Afib = anticoagulation

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18
Q

how to perform cardioversion for Afib

A

duration < 48 hours - cardioversion, amiodarone, obtain echo before
duration > 48 hours - anticoagulation for 21 days prior to cardioversion

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19
Q

what is atrial fluter

A

characterized by rapid, regular atrial depolarizations at a characteristic rate around 300 BPM due to 1 single irritable atrial focus firing at a fast rate with some degree of AV node conduction block

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20
Q

what will EKG show for atrial flutter

A

flutter (sawtooth) atrial waves usually ~300 BPM but no discernible P waves

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21
Q

tx atrial flutter

A

stable:
vagal maneuvers, rate control with BB or non-dihydropyridine CCBs; digoxin if those things don’t work

unstable:
direct current (synchronized) cardioversion

definitive - radio frequency catheter ablation

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22
Q

first degree AV block

A

prolonged PR interval (> 0.2 se) at resting heart rate + all P waves are followed by QRS complex (1:1 conduction)

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23
Q

tx for symptomatic first degree AV block

A

atropine first line

definitive - permanent pacemaker

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24
Q

Mobitz 1 second degree AV block (wenkebach)

A

progressive lengthening of PR interval until an occasional non-conducted atrial impulse (dropped QRS complex)

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25
Q

tx Mobitz 1 second degree AV block (Wenkebach)

A

Atropine first line if sx
Epinephrine
pacemaker definitive

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26
Q

Mobitz II second degree AV block

A

constant PR interval before and after non-conducted atrial beat (dropped QRS complex)

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27
Q

treatment Mobitz II second degree AV block

A

symptomatic:
transcutaneous pacing and/or atropine

unstable:
atropine and in most, temporary cardiac pacing to increase pulse rate and cardiac output

definitive - permanent pacemaker required in many patients

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28
Q

third degree AV block

A

complete absence of AV condition where NO atrial impulses conduct to the ventricle, so the atrial activity and ventricular activity are independent of each other.

EKG - AV dissociation; evidence of atrial (P waves) and ventricular (QRS complexes) activity which are independent of each other and an atrial rate faster than the ventricular rate

regular P-P intervals and regular R-R intervals independent of each other

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29
Q

tx third degree AV block

A

symptomatic and stable:
Atropine if sx bradycardia!!!
if unresponsive –> temporary pacing (transcutaneous or transvenous)

unstable:
urgently treated atropine and in most cases temporary cardiac pacing to increase HR and cardiac output

definitive - permanent pacemaker

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30
Q

tx paroxysmal supraventricular tachycardia

A

stable (regular, narrow complex):
vagal maneuvers
adenosine if vagal maneuvers ineffective

stable (wide complex):
antiarrhythmics: IV procainamide or IV amiodarone

Unstable:
direct current (synchronized) cardioversion should be performed urgently in most

Definitive - radiofrquency catheter ablation

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31
Q

what is multifocal atrial tachycardia most commonly associated with

A

severe COPD

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32
Q

what will EKG show for multifocal atrial tachycardia

A

irregularly, irregular rhythm + 3 or more identifiable P wave morphologies

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33
Q

tx multifocal atrial tachycardia

A

non-dihydropyridine CCB

Avoid BB if underlying pulmonary disease

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34
Q

what will EKG show for Wolff-parkinson-white

A

delta wave (initial slurred upstroke of QRS)
PR interval that is short (<0.12 s)
Wide QRS complexes ( > 0.12)

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35
Q

tx WPW

A

stable + Afib:
procainamide preferred

stable + no Afib:
vagal maneuvers and Adenosine if vagal maneuvers not helpful

unstable:
direct current (synchronized cardioversion)

definitive - radio frequency catheter ablation

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36
Q

EKG torsades de pointes

A

polymorphic ventricular tachycardia (cyclic alterations of the QRS amplitude on EKG around the isoelectric line) aka sinusoidal waveform

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37
Q

tx torsades de pointes

A

IV magnesium sulfate
isoproterenol or transvenous overdrive pacing if refractory

congenital - beta blockres

stable:
synchronized cardioversion

pulseless:
prompt defibrillation (unsynchronized) cardioversion

38
Q

EKG vfib

A

disorganized high frequency undulations w erratic pattern of electrical impulses, fibrillation waves of varying amplitude, shape, and periodicity, occurring at a rate above 320/minute with no identifiable P waves, QRS complexes, or T waves.

39
Q

tx Vfib

A

unsynchronized cardioversion (defibrillation) + prompt high quality CPR

administer epinephrine and amiodarone if sustained vfib after 3 shocks

40
Q

EKG vtach

A

regular, wide complex tachycardia with no discernible P waves

41
Q

tx vtach

A

stable:
amiodarone or procainamide

unstable:
direct current (synchronized) cardioversion

pulseless:
unsynchronized cardioversion (defibrillation) + CPR

chronic therapy - BB
Implantable cardioverter-defibrillator (ICD) to prevent VF

42
Q

what is dilated cardiomyopathy characterized by

A

systolic dysfunction (impaired contraction, EF < 40%) and dilation of one or both ventricles

43
Q

sx dilated cardiomyopathy

A

left sided failure - dyspnea on exertion, fatigued, impaired exercise capacity

right sided failure - peripheral edema, jugular venous distention

44
Q

PE dilated cardiomyopathy

A

S3 gallop hallmark - represents rapid filling of a dilated ventricle

lateral displacement of the maximal point of impulse due to cardiac enlargement

left sided failure - crackles/rales

right sided failure - peripheral edema, jugular venous distention, positive hepatojugular reflux with inspiration, ascites

45
Q

dx dilated cardiomyopathy

A

echocardiogram - can identify systolic dysfunction and ventricular dilation

46
Q

tx dilated cardiomyopathy

A

ACEI for mortality reduction
BB
Mineralocorticoid receptor antagonists
Sx control with diuretics

47
Q

what is hypertrophic cardiomyopathy

A

autosomal dominant genetic disorder of inappropriate LV and/or RV hypertrophy resulting in left ventricular outflow obstruction, diastolic dysfunction and myocardial ischemia

48
Q

PE for hypertrophic cardiomyopathy

A

S4
Pulsus bisferiens: biphasic pulse - aortic waveform with 2 peaks per cardiac cycle, a small one followed by a strong and broad one

systolic murmus (harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and LLSB; no carotid radiation usually

49
Q

describe the systolic murmur in hypertrophic cardiomyopathy and when it increases and decreases in intensity

A

harsh crescendo-decrescendo systolic murmur that begins slightly after S1 and is heard best at the apex and LLSB. usually no carotid radiation

increased murmur intensity with decreased venous return (valsalva, standing, assuming upright posture from squatting, sitting, supine position

decreased intensity with standing to sitting, squatting or supine position, leg raise, handgrip

50
Q

dx hypertrophic cardiomyopathy

A

echocardiography - asymmetric ventricular wall thciekcness 15 mm or greater, small LV chamber size

EKG - LVH, prominent abnormal Q waves

51
Q

tx hypertrophic cardiomyopathy

A

BB
Non-dihydropyridine CCB are alternatives

52
Q

what is restrictive cardiomyopathy

A

diastolic dysfunction in a non-dilated, rigid ventricle, which impedes ventricular filling

53
Q

common etiologies of restrictive cardiomyopathy

A

amyloidosis
sarcoidosis - suspect in younger patients w unexplained syncope
hemochromatosis

54
Q

sx restrictive cardiomyopathy

A

right sided - peripheral edema, JV, hepatomegaly (right sided sx MC than left sided)

left sided - dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue, cough

55
Q

PE for restrictive cardiomyopathy

A

peripheral edema, JVD - right

crackles - left

Kussmauls sign - either lack of inspiratory decline or an increase in JVD with inspiration

S4 MC than S3

56
Q

dx restrictive cardiomyopathy

A

echocardiogram - non-dilated ventricles with normal thickness, marked dilation of both atria

endomyocardial bx - definitive; amyloidosis is associated w apple-green birefringence w Congo red stain under polarized light microscopy

57
Q

tx restrictive cardiomyopathy

A

treat underlying disorder

58
Q

what is the most common type of HF

A

HF with reduced ejection fraction - post MI most common cause

59
Q

heart failure with preserved ejection fraction is characterized by

A

diastolic dysfunction and a normal or increased ejection fraction

60
Q

gallops in HF

A

S3 - systolic dysfunction

S4 - diastolic dysfunction

61
Q

how to dx HF

A

echocardiogram

62
Q

New York Heart association function class for HF

A

Class 1 - no symptoms, no limitation during ordinary physical activity
Class 2 - mild symptoms (dyspnea or angina), slight limitation during ordinary activity
Class 3 - symptoms caused marked limitation in activity even with minimal exertion; comfortable only at rest
Class 4 - symptoms even while at rest, severe limitations, and inability to carry out physical activity

63
Q

general tx HF

A

ACEI or ARB, BB, diuretic

can addd mineralocorticoid receptor antagonist and SGLT2 inhibitors

64
Q

most common valve affected in infective endocarditis

A

mitral (M > A > T > P)

exception is IV drug users –> Tricuspid

65
Q

organisms that cause bacterial endocarditis

A

acute + infection of NORMAL valves = S. aureus
Subacute + infection of abnormal valves = S. viridian’s
IV drug related = S. aureus
Prosthetic valve = S aureus and S epidermidis

patients w CRC and UC = Streptococcus gallolyticus (Bovis)

HACEK - usually native valves

66
Q

what are the HACEK organisms

A

Haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae

these are gram negative organisms

67
Q

sx endocarditis

A

persistent fever (MC)
new onset murmur
osler nodes - painful or tender raised nodules on the pads of the digits and palms
laneway lesions - painless erythematous macula on palms and soles
splinter hemorrhages - linear reddish-brown lesions under nail bed
Roth spots - retinal hemorrhages w central clearing

68
Q

2 most important tests to dx endocarditis

A

blood cultures
transesophageal echocardiography

69
Q

modified duke criteria for endocarditis

A

Major:
2 + blood cultures by organisms known to cause endocarditis

endocardial involvement documented by either + echocardiogram or clearly established new valvular regurgitation

Minor:
predisposing condition
fever
vascular and embolic phenomena (janeway lesions, septic arterial or pulmonary emboli)
immunologic phenomena (Osler’s nodes, Roth spots, + RH factor, acute glomerulonephritis)
+ blood culture not meeting major criteria
+ echocardiogram not meeting major criteria

2 major OR 1 major + 3 minor OR 5 minor

70
Q

aortic stenosis

A

harsh, low-pitched, mid-0late parking, systolic, crescendo-decrescendo murmur best heard at the RUSB

Radiates to carotid arteries

increased intensity - sitting while learning forward, increased venous return (squatting, supine, leg raise), expiration

decreased murmur intensity - decreased venous return (valsalva, standing, inspiration) or increased after load (handgrip)

weak, delayed carotid pulse

S4

71
Q

dx aortic stenosis

A

echocardiogram

72
Q

tx aortic stenosis

A

aortic valve replacement

73
Q

aortic regurgitation

A

high-pitched, blowing (soft), decrescendo or sustained, diastolic murmur best heard over Erb’s point

increased murmur intensity sitting up while learning forward, holding breath in end expiration, increased venous return (squatting, supine, leg raise), increased after load (handgrip)

decreased murmur intensity - decreased venous return (valsalva, standing, inspiration)

bounding pulses

wide pulse pressure

74
Q

tx aortic regurg

A

after load reducers - ACEI, ARBs, Nifedipine, Hydralazine
surgery!

75
Q

MC cause mitral stenosis

A

rheumatic heart disease

76
Q

mitral stenosis

A

prominent S1
opening snap
loud P2
mitral facies
low-pitched, mid-diastolic, rumbling murmur best heard at mitral area/apex

increased murmur intensity w left lateral decubitus, expiration, increased venous return (squatting, leg raise, lying supine)

decreased intensity with decreased venous return (valsalva, standing)

77
Q

tx mitral stenosis

A

percutaneous balloon valvuloplasty if noncalficied valves

78
Q

MC cause mitral regurgitation

A

mitral valve prolapse

79
Q

Mitral regurgitation

A

high pitched, blowing, holosystolic murmur best heard at the apex, often w radiation to the left axilla, sub scapular region, or upper sternal borders

increased murmur intensity w left lateral decubitus, expiration, increased venous return (squatting, leg raise, lying supine); increased after load (handgrip)

decreased murmur intensity with decreased venous return (valsalva, standing)

80
Q

tx mitral regurg

A

after load reducers - ACEI, ARBs, hydralazine, nitrates

repair preferred over replacement

81
Q

mitral valve prolapse

A

mid-late systolic click best heard at the apex
click may be followed by a high-pitched mid-late systolic murmur of mitral regurgitation

earlier click and longer duration - valsalva, standing

delayed click and shorter duration - squatting, leg raise, supine, handgrip

82
Q

tx mitral valve prolapse

A

reassurance + BB

83
Q

tx myocarditis

A

supportive

84
Q

tx pericarditis

A

NSAIDs + colchicine
steroids if can’t use NSAIDs

85
Q

pulmonic regurgitation

A

graham steell murmur - brief high-pitched decrescendo early diastolic blowing murmur maximally at the left upper sternal border

increased with inspiration, increased venous return (squatting, leg raise, supine)

decreased with decreased venous return (valsalva, standing), expiration

86
Q

tx pulmonic regurg

A

no tx needed in most
pulmonic valve replacement definitive

87
Q

tricuspid stenosis

A

mid-diastolic murmur at left lower sternal border

increased intensity with squatting, laying down, leg raise, inspiration

opening snap

88
Q

tx tricuspid stenosis

A

decrease right atrial volume overload w diuretics and sodium restriction

89
Q

tricuspid regurg

A

high-pitched holosystolic soft-blowing murmur at the subxiphoid area, left mid sternal border or right mid sternal border with little to no murmur radiation

increased intensity with inspiration, increased venous return (squatting, leg raise, supine)

decreased intensity with standing, valsalva, expiration

carvallo’s sign - increased murmur intensity with inspiration

90
Q

tx tricuspid regurg

A

diuretics; if LV dysfunction, standard HF therapy

repair > replacement if severe despite medical therapy

91
Q
A

Internal Med EOR (17 decks)

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