Cardio Flashcards
Timing of afib that is “paroxysmal”… vs persistent… vs permanent
Paroxysmal- within 7 days
Persistent - beyond seven days
Permanent- beyond a year
Possible symptoms of afib?
Chest pain SOB Palpitations (probably “racing”) Decreased exercise tolerance Fatigue Dizziness
Two big buckets to categorize the etiology/cause of afib?
Cardiac
Non-cardiac
Cardiac causes of afib?
HTN, CHF, valvular (MR, MS), …CAD
Non-Cardiac causes of afib?
Hyperthyroidism (thyrotoxicosis)
OSA
?alcohol,cocaine
Most important complication of afib? And the second most important?
Stroke from atrial emboli
Heart failure
Investigations to consider for new onset afib?
Labs
- CBC - anemia, infection
- TSH, Cr, lytes, ALT, ALP
- lipids, A1c - for risk stratification
- coags (INR, baseline)
ECG - ?afib, hypertrophy CXR - signs of heart failure, COPD ECHO - valvular dysfunction, EF, thrombus, wall abnormalities Stress test - ?CAD Holter - capture afib Sleep study - ?OSA
Treatment for afib - 2 major problems to deal with…
Rate/rhythm control - thought to be pretty equal
Anticoagulation
When considering starting antithrombotic for afib, what risk tools can you use to help you?
hint - why do you want to start the med and what makes you worried about starting the med
CHADS-65 - annual stroke risk
HASBLED or SPARC tool to assess bleeding risk
Patient goes into rapid afib… you ask “are they hemodynamically stable”… what symptoms and signs tell you about this?
hypotension
SOB
chest pain - ?coronary ischemia
decreased LOC
Is there a role for ASA in stroke prevention for a patient with (non-valvular) afib?
Bonus: Unless they have.. (2 things specifically in the CHADS65 algorithm)
No, not for run of the mill afib.
In CHADS65, ASA indicated for CAD and PAD
(CCS/CHRS 2020 Comprehensive Guideline Update: Atrial Fibrillation)
What antithrombotic should you use for afib if indicated?
DOAC.. any of them are reasonable choices.
eg. rivaroxaban (Xeralto) 20 mg PO daily
apixiban (Eliquis) 5 mg PO BID…
Always look up the drug for dosing and other considerations.
Patient asks you, “do I need to stop my DOAC to go to the dentist? Or to get my colonoscopy?” - where can you find a handy dandy algorithm for this???
Hint: when you stop a OAC, you worry about a clot… thrombosis…
Thrombosis Canada (http://thrombosiscanada.ca) Perioperative Anticoagulant Management Algorithm
What do you worry about when considering cardioverting someone with afib?
Inadvertently causing a stroke - atrial thrombus
Patient thinks they have been having chest pain, it sounds like stable angina on HPI.
What approach would curbsiders/cardionerds suggest you take to assess CVD risk?
Hint: 4+2
Assess CVD risk
1. qualitative - ask about RF (HTN, DM, smoking
2. quantitative - Risk tool (framingham)
3. Family history - father <55, mother <65 yo
4. Consider coronary artery calcification score
Escalate Management
1. lifestyle (diet, exercise, weight loss, smoking…)
2. risk modifying - ASA, statin - also manage the modifiable RF (DM, HTN, DLD)
What is stable angina?
TNotes: symptom complex resulting from an imbalance between oxygen supply and demand in the myocardium
Curbsiders: Stable angina occurs when coronary atherosclerosis builds up over time, and symptoms (nausea, dyspnea, chest pain, etc.) are unmasked by stress (physical, emotional)
What are the three criteria for typical angina?
- Symptoms (chest tightness/discomfort… SOB, nausea, anxiety)
- predictably provoked by activity (3Es - exercise, eating, emotion)
- brief duration (<15 min) relieved by rest or nitrates
Bonus: What is different about CVD in women…?
MI’s tend to present atypically.. consider getting an ECG when a woman with risk factors complains of “reflux”..
Stable angina may occur in the absence of a discrete obstruction, especially in women
- Stress testing and EKG may be positive, but focal large artery stenosis is absent on angiography
- Treatment consists of aggressive risk factor modification (treatment of comorbid conditions, exercise, smoking cessation, etc.), and antianginal therapy (bb, nitro)
Separate the medication treatment for stable angina into risk modifying (2) and symptom modifying (3-4)…
Risk modifying for stable angina
- ASA, statin
Symptom modifying
- BB, CCB, nitrates, PCI (if STABLE angina, stenting does not change outcomes, but it can help with symptoms)
What is a Coronary Artery Calcium scan/score?
What imaging modality does it use? (US, xray, CT, MRI)
What does it show?
Bonus: should you show it to your patients?
- CT scan
- detects calcium deposits in the coronary arteries
- CAC score is an independent marker of risk for cardiac events, cardiac mortality, and all-cause mortality and can help guide lifestyle and pharmacological risk factor modification
- Yes, just showing patients the plaque on CT imaging can improve outcomes :)
You’re running a code, ECG shows bradycardia, no pulse. What is a likely culprit and what do you give immediately?
ie. bradycardia PEA arrest
Any patient who has had a bradycardia PEA arrest has hyperkalaemia until proven otherwise
calcium carbonate 2g IV to stabilize myocardium
ECG changes of pericarditis?
diffuse ST elevation (+/- depressed PR segment) and reciprocal changes in aVR
after 2-5 days, may progress to T-wave changes, flattening then inversion
Most common cause of pericarditis?
Bonus: other common cause, hint metabolic
idopathic, presumed to be viral
uremia
“Diagnostic triad” of pericarditis?
chest pain, friction rub, ECG changes
