Cardio 11 Flashcards
What are the first thing that should be done In a patient who is having chest pain in the emergency department?
Focus history and physical examination, assessed vital signs, obtain venous access
After the H&P what should be done to a chest pain emergency department patient who is stable? What is a contraindication for the antiplatelet therapy in these patients?
ECG and chest x-ray; administer aspirin if the risk for aortic dissection low
What should be done to unstable patients who are experiencing chest pain in the ED?
Stabilize hemodynamics, check for the underlying causes (PE, pericarditis, aortic dissection, etc)
What are the examples of aliments that should be stabilized in unstable patients with chest pain who present to the ED?
Life-threatening arrhythmias, abnormalities in breathing airway and circulation
What are the two type of ACS that are consistent in ECG?
NSTEMI and STEMI
What should be done for treatment in STEMI and NSTEMI⁉️
For STEMI treat with emergency Catherization or thrombolysis; NSTEMI treat with appropriate anticoagulation
ECG is not consistent with ACS what should be done?
If the Chest x-ray is diagnostic of then underlying cause should be treated; if Chest x-rays not diagnostic then assess for pulmonary embolism, check cardiac markers, assess pericarditis, Assess for aortic dissection
What does antiplatelet therapy with aspirin do in ACS patients?
Reduces the rate of myocardial infarction and overall mortality in patients with ACS
What are all the possible chest radiograph findings in PE?
Atelectasis, infiltrates, pleural effusion, WesterMark’s sign, Hampton hump, Fleischner sign
Why are chest x-rays not good to diagnose PE patients?
Chest x-rays maybe normal
What are CXR actually useful in doing for patients who had chest pain?
Can you rule out other chest pain etiologies such as pneumonia pneumothorax aortic dissection pericardial effusion
When does Dressler’s syndrome present? And what makes it better? And what is seen on EKG?
Presents weeks after MI, improved by leaning forward (pericardium a stretched when laying down), ST elevation in all leads except AVR where ST depression is seen
What is the treatment for Dressler’s syndrome? What should be avoided?
NSAIDs are the treatment of choice and anticoagulation should be avoided to prevent development of hemorrhagic pericardial effusion
What makes pericarditis symptoms worse, what makes it better? What are the EKG findings?
Worst with deep inspiration, improved on leaning forward
When is corticosteroids used as treatment for Dressler syndrome?
Corticosteroids can be used in refractory cases or when NSAIDs are contraindicated
What are the other signs that may occur in Dressler’s syndrome⁉️
Malaise and sometimes fever, increase Erythrocytes sedimentation rate
What is the difference between post MI acute pericarditis and Dressler syndrome?
Post-MI acute pericarditis typically occurs first several days after infarction, Dressler syndrome occurs weeks after MI
What are reversible risk factors for premature atrial contractions? What are the precipitating factors of PACs?
Tobacco and alcohol; tobacco alcohol caffeine and stress should be avoided in patients with PACs even if asymptomatic
What treatment is helpful in premature atrial contraction?
Beta blockers for symptomatic patients
What are PACs?
Premature activation of the atria originating from another site other than SA node; though benign arrhythmia can occur in healthy or unhealthy patients usually asymptomatic but can cause symptoms of skipped beats or palpitations
What is found in PACs on the EKG?
Early P-wave
Looking PACs proceed? When are they treated?
Supra ventricular tachycardia such atrial fibrillation=> only treated when These arrhythmias of her
What type of murmurs in young asymptomatic adults are usually benign and don’t require further evaluation?
Mid-systolic murmurs
What kind of murmurs can echocardiogram identify?
Diastolic and continuous murmurs can identify valvular regurgitation and evaluate for associated structural abnormalities or hemodynamic consequences
Describe the murmur in aortic regurgitation?
High-pitched blowing in quality and heard immediately after A2. Decrescendo diastolic murmur
What is the next best next step after ECG for patients who have aortic dissection with chronic kidney disease⁉️
Transesophageal echocardiogram is preferred and patients who have hemodynamic instability or Renal insufficiency
What should happen if ECG and chest x-ray are not diagnostic?
Assess for PE, pericarditis, aortic dissection, cardiac markers, NSTEMI
Unstable patients complaining of chest pain should be assessed for what underlying causes?
Pulmonary embolism, pericarditis, aortic dissection
What constitutes unstable patients?
Abnormalities in airway breathing circulation or life-threatening arrhythmias
What is the mechanism for aspirin?
Inhibits thromboxane A2 production to exert significant antiplatelet affects
What would suggest musculoskeletal chest pain and what can be given for treatment?
Recent trauma or reproducible pin point tenderness, Acetaminophen or oxycodone
When’s heparin given?
MIs, high suspicion or confirmation of PE
What is Wells criteria?
Test the probability of PE; three points for clinical signs of DVT, 1.5 points for previous PE or DVT heart rate above 100 recent surgery or immobilization, One point for him offices or cancer, >4 PE likely
What NSAID is used in pericarditis? What is significant about a patient’s history other than chest symptoms that can be suggestive of pericarditis?
Ibuprofen, recent upper respiratory tract infection
What can be used for chest pain stemming from an acute panic attack?
Benzodiazepine called lorazepam
What are the possible findings in chest x-ray in PE patients?
Usually normal can be abnormal. Westermark’s sign Hyperlucency due Oligemia, Hampton’s hump peripheral wedge of opacity due to pulmonary infarction, Fleischner sign enlarge pulmonary artery
What are the chest x-ray findings for a sending aortic dissection? And what is the setting?
Uncontrolled hypertension setting, widen mediastinum, or irregular aortic contour, inward displacement of atherosclerotic calcification
How does peptic ulcer or perforation present? What made the chest x-ray show?
Acute abdominal pain with radiation to the back or right shoulder and signs of peritonitis. Chest x-ray may reveal pneumoperitoneum with free air under diaphragm
What should be avoiding in pericarditis? Why?
Coumadin, may cause hemorrhagic pericardial effusion
What should be given to a patient if they were having another MI?
Anticoagulation with heparin
What are the associated symptoms with Dressler’s syndrome?
Malaise, Fever, ESR elevated
When would transthoracic echocardiogram be useful in a patient with documented PACs?
In the absence of obvious precipitate like caffeine and alcohol. Is used to assess cardiac/valvular structure and functional abnormalities
How can PAC present? In what scenario can They be dangerous?
Usually asymptomatic however may cause skipped beats or palpitations, can occur singly for a pattern of bigeminy, benign arrhythmia ; they can proceed AFib
What are the most common causes for acute severe aortic valve regurgitation?
Infectious endocarditis and aortic dissection
What kind of aortic regurgitation is more susceptible to cardiogenic shock?
Acute severe aortic regurgitation, signs of cardiogenic shock include tachyCardia hypotension caused impaired Cardiac output and fulminant pulmonary edema
Describe the pulse pressure in acute severe aortic regurgitation?
Thready pulse, reduced or normal pulse pressure
When is coronary CT angiogram be used⁉️
Noninvasive method to assess coronary artery calcification and intraluminal stenosis in patients with suspected coronary heart disease
T-wave inversion’s in Leads V5 and V6 without reciprocal ECG changes are most likely due to what?
Left ventricular hypertrophy with secondary repolarization changes
What can BNP levels be used to differentiate between?
Cardiogenic pulmonary edema and non-cardiac causes of dyspnea
What are the examples of P450 inhibitors?
Acetaminophen, NSAIDS, antibiotics/antifungal’s (metronidazole), Amiodarone, Cimetidine, cranberry juice, ginkgo bilboa, vitamin E, Omeprazole, thyroid hormone, SSRIs (fluoxetine) (COATS)
What are the p450 inducers?
Carbamazepine, Phenytoin, ginseng, Saint Johns wort, oral contraceptive, phenobarbital, rifampin (PORG)
What are excellent sources of vitamin K? What do these due to warfarin efficacy⁉️
Brussels sprouts and spinach, decrease affects of warfarin
What heart defect can be associated with high-frequency hearing loss?
Congenital long QT syndrome
What drugs can cause AFib? What endocrine diseases?
Amphetamines, cocaine, Theophylline; hyperthyroidism, diabetes
What pulmonary etiologies can cause AFib?
Sleep apnea, pulmonary embolism, COPD, acute hypoxia (pneumonia)
What is the most common cause of AFib?
Hypertensive heart disease
How is origin of a fib in pulmonary veins therapeutically useful?
In patients who cannot achieve rate and rhythm control with standard medical therapy catheter-based radio frequency ablation is used to disconnect the PV’s from left atrium
What is a normal systolic drop in inspiration and what is considered pulses paradoxus ⁉️
Systemic arterial pressure normally falls <10mmHg
>10 mmHg is considered pulsus paradoxus
What is the mechanism in which Cardiac Tamponade causes pulsus paradoxus⁉️
Increase pressure in pericardial sac. During inspiration increase systemic venous return in the right heart causes septum to shift to the left cavity reducing LBEDV=> decrease SV=> reduced SBP
Other than cardiac Tampa nod what other conditions can cause pulses paradoxes?
Asthma and COPD
What is the mechanism for asthma or COPD causing pulses paradoxes? What is the drop during inspiration normally?
The drop in intrathoracic pressure is greatly exaggerated (up to 40mmHg). This negative pressure causes pulling of blood in the pulmonary vasculature=> decreasing left ventricular preload; 2-5mmHg
What precludes the interventricular septum from shifting towards the left ventricle during inspiration in a patient who has aortic regurg, even if they have pericardial effusion or cardiac Tamponade?
The increase in LVEDP
Describe classic chest pain resulting from anxiety? What short acting benzodiazepine can be given to these patients?
Sense of impending doom, tachypnea, numbness of the lips and digits; alprazolam is short acting, used to treat panic attacks and anxiety disorders.
Beta blockers are indicated in what?
Acute myocardial infarction, heart failure, chronic angina
What percentage of people with 1mm ST depression will not have significant coronary disease⁉️
Tent to 30%
What are the medications that are used for gastric reflux?
H2 receptor agonist (ranitidine) or protein pump inhibitors (omeprazole)
What are the classical symptoms for gastric reflux?
Worst when lying down, symptoms report 30 to 60 minutes after eating, relief with antacids
What explains the chronic cough and hoarseness in GERD?
Chronic cough is due to reflux of gastric secretions into the lungs, hoarseness results from reflux-induced laryngitis
What is the use for fish oil supplements?
High in omega-3 polyunsaturated fatty acid’s can effectively reduce serum triglyceride levels however not found to improve cardiovascular outcomes or mortality
What is cardiac index?
Relates cardiac output from left ventricle in one minute to body surface area thus relating heart performance to size of individual
Bilateral delay and slow rising carotid pulses are indicative of what disease?
Aortic stenosis
What are indicative of severe AS⁉️
Pre-syncope, delayed carotid upstroke, late peaking systolic murmur (because so much fluid backed up in LV)
S3 can be heard in which patients?
Chronic severe mitral regurgitation, chronic aortic regurgitation, heart failure, occasionally in high cardiac output states such as pregnancy or Thyrotoxicosis
What is the difference in presentation for MS and developed and developing countries?
MS in developing countries presents at age 30 to 50 with symptomatic as the result of rheumatic heart disease; in developed countries congenital MS and symptoms present much earlier
How long dose infective endocarditis symptoms occur without progression⁉️
Few weeks
What heart problems can result in Fever, weight loss and systemic emboli?
Infective endocarditis, cardiac myxoma
What is the diagnosis and management for cardiac myxoma?
Echocardiogram and prompt surgical resection
What is the RA pressure, PCWP, cardiac index, SVR, mixed venous oxygen saturation (Mv02) for septic shock?
Septic shock causes overall peripheral vasodilation; both RA PCWP Will be normal or decreased, cardiac index will be increased, SVR decreased, MvO2 increased
What causes decreased or low normal PCWP in septic shock?
Due to capillary leakage which will cause decrease preload
Explain the increase in cardiac output as a response to reduced SVR in septic shock?
In order to maintain peripheral tissue perfusion
How does septic shock result in increased mixed venous oxygen saturation?
Increased cardiac output results in increased flow and less time for oxygen extraction, May result in tissue hypoperfusion and eventually lactic acidosis
Explain the Mv02 in Neurogenic shock⁉️
Decrease in cardiac output results in lower flow and greater extraction of oxygen therefore MvO2 is usually low
What type of shock results from cardiac Tamponade⁉️
Obstructive cardiogenic shock
What kind of shock results from mineralocorticoid deficiency? How does it present?
It’s a form of distributive shock that usually presents with hypo perfusion from low aldosterone levels. Patient have low SVR with associated hyperkalemia and hyponatremia
At what point can cardiac output decrease in septic shock?
Late septic shock
What are the combination of symptoms that are indicative of septic shock?
Tachycardia, tachypnea, hypotension, and mental status change
Will causes pleuritic pain?
Pneumothorax PE, periCarditis
What is the differential diagnosis of chest pain that also is associated with nocturnal pain?
GERD/esophageal motility
Explain the findings for single photon in mission CT scan⁉️
Decreased tracer uptake at both rest and exercise indicates a scar with decreased perfusion and CAD; reversible defect indicates inducible ischemia and likely CAD
Why are appetite suppressant’s contraindicated in patients with CAD?
Appetite suppressant’s are sympathomimetics that can cause elevations in HR and BP
Why are Metformin contraindicated in cardiovascular and chronic kidney disease?
Metformin can cause lactic acidosis in patients with pre-existing hypoxia
Why are Erythropoietin contraindicated in patients with cardiovascular disease?
Can increase mortality in these patients, also cause thromboembolic events and stroke
What is the most common cause of atheroembolism (cholesterol embolism)?
Recent Cardiac Catheterization
What is atheroembolism ⁉️
Atherosclerotic plaque disrupted leading to cholesterol debris showered into circulation resulting in partial or total occlusion of arterioles with resultant tissue or organ ischemia
What are the risk factors for Atheroembolism?
Advanced age obesity smoking hypercholesterolemia hypertension and diabetes
What are the skin manifestations atheroembolism⁉️
Blue toe syndrome (cyanotic with intact pulses), livedo reticularis
What are Hollenhorst plaques, and what do they indicate⁉️
Atheroembolism resulting in Bright yellow plaques in retinal artery; indicate proximal source such as internal carotid artery
What is the difference between atheroembolism that results in Renal dysfunction and contrast nephropathy?
Atheroembolism renal dysfunction persist beyond two weeks compared to contrast nephropathy which which resolves within one week
Allergic reactions to iodine typically occur in with patients?
Patients who have history of contrast reactions or atopic diseases.
What are the possible manifestations of allergic reaction’s to iodine?
Immediate reactions may cause flushing, pruritus and angioedema however delayed hypersensitivity reactions occurs day at days after resulting in various cutaneous manifestations
What kind of cyanosis can result in digital clubbing?
Chronic hypoxemia that can result from right to left shunt
What are the possible side effects of ACEi?
Cough, hyperkalemia, increased serum creatinine (often transient)
What is a rare complication of ACEi?
Angioedema resulting in non-pitting swelling of the lips tongue face the larynx causing (airway obstruction)
What is Visceral angioedema⁉️
Typically presents with abdominal pain, ascites, vomiting and diarrhea
What are some of the physical examination findings for hyperthyroidism⁉️
Hypertension, tremors hyperreflexia proximal muscle weakness, lid lag, AFib
What is seen in constrictive pericarditis chest x-ray?
Pericardial calcifications
What is the sound heard in constrictive pericarditis?
Pericardial Knock at the result of noncompliant heart
Are ascites and lower extremity edema present in superior vena cava syndrome?
No
What is stress-induced cardiomyopathy?
Transient LV dysfunction in the absence of CAD. Caused by intense physical or emotional stress. Presents with substernal chest pain dyspnea, ECG abnormalities and elevated cardiac biomarkers
Describe JVP in inferior vena cava obstruction?
Usually reduced Or normal
What does echocardiogram show in cor pulmonale?
Pulmonary hypertension, dilated right ventricle and/leads to tricuspid regurgitation
What can lead to cor pulmonale?
Severe lung disease (COPD), pulmonary vascular disease, obstructive sleep apnea
What are the echocardiography findings in cardiac amyloidosis⁉️what are other findings associated with Amyloidosis?
Normal or nondilated left ventricular cavity, increased ventricle wall thickness; Periorbital purpura, proteinuria, hepatomegaly
What discerns between RHF due to LHF and right heart failure due to constrictive pericarditis?
Clear lung fields with constructive periCarditis
What is the mechanical deficiency in constrictive pericarditis? What are the common antecedents⁉️
Calcified pericardium leading to limited diastolic filling; idiopathic or pericardial involvement from prior cardiac surgery (CABG, cardiac valve surgery), mediastinal irradiation, TB, malignancy, uremia
What physical findings is consistent with the large pericardial effusions? Is chest pain associated?
Inability to palpate the PMI, diminished heart sounds; no
What can cause pericardial effusion?
Most commonly idiopathic (usually from viral illness), metastatic or primary neoplasm, post MI, trauma, Uremia, AI, hypothyroidism, bacterial or fungal infections
What is the proper treatment of a fib due to hyperthyroidism?
Beta blockers initially, until patient is euthyroid with thionamide, radioiodine or surgery
What drugs are used for AF patients? What drugs are used for AF patient with hyperthyroidism⁉️
Digoxin and CCBs are often used for rate control in AF patients however if caused by hyperthyroidism they will not be effective for heart rate and a symptom control therefore must use BBs
What drugs that can be used for paroxysmal AF that would not be wise for AF due to hyperthyroidism?
Anti-arrhythmic drugs (amiodarone flecainimide) can be used for maintenance of sinus rhythm and paroxysmal AF, however should just use BBs and treat the underlying hyperthyroidism. Anti arrhythmics can cause thyroid dysfunction.
Why won’t shock or Ibutilide work in hyperthyroid AF patients?
Electrical or chemical cardioversion will not likely restore sinus rhythm in AF patients if underlying cause is hyperthyroidism/hyperadrenergic state
How do BBs work in hyperthyroidism AF patients⁉️
Controls heart rate and hyperadrenergic symptoms, decrease his conversion of T4 into T3 and peripheral tissues
What can cause transient AV block and slower ventricular rate in AF? What is the draw back?
Adenosine and carotid sinus massage, not effective for long term rate control
What kind of arrhythmias does Lidocaine treat?
Ventricular arrhythmias
When are BBs and CCBs given for AF and when is synchronize electrical cardioversion given⁉️
Chemicals are given to AF with rapid ventricular response to control rate, shock is given to hemodynamically unstable patients with rapid AF
What type of syncope is considered when are young women passes out provoked by strong emotion?
Vasovagal
How is vasovagal syncope diagnosed?
Clinical diagnosis may undergo tilt table testing in order to rule out orthostatic static hypotension
What is the treatment for neurocardiogenic (Vasovagal) syncope⁉️
Reassurance, avoidance of triggers, counterpressure techniques for recurrent episodes
What are the physical counterpressure maneuvers?
In order to improve venous return and cardiac output and a board syncopal episodes. This should be done in a prodromal phase, Lake Crossing with tense muscles, handgrip and tensing to our muscles would clinch fist=> Lie supine with leg raised
What are the ECG findings in cardiac Amyloidosis?
Low-voltage
What are the other findings besides cardiac in hereditary hemachromatosis?
Hypergonadism with decreased libido and erectile dysfunction in men, DM, skin pigmentation, Arthropathy, liver disease
What is the difference in etiologies of ascending and descending aortic aneurysm?
Ascending due to cystic medial necrosis or connective tissue disorders. Descending due to atherosclerosis
What are the descending aortic aneurysm’s findings on x-ray?
Widen mediastinal silhouette (in upper portion involving aortic knob), increase aortic knob, widen aorta, tracheal deviation
What is used to confirm diagnosis of thoracic aortic aneurysm (TTA)⁉️Why?
Chest x-ray cannot always distinguish TAA from torturous aorta and therefore CT scan with contrast is usually necessary to confirm diagnosis
Reflex disease are related to what?
Acid hypersecretion, obesity, pregnancy, lower esophageal pressure, smoking, hiatal hernia, increased gastric pressure.
What is used to confirm the diagnosis of achalasia⁉️
Endoscopy and manometry
What is malignant hypertension? Hypertensive encephalopathy⁉️
Hypertensive emergency with retinal hemorrhages exudates or papilledema; hypertensive emergency with cerebral Edema, neurologic symptoms
How do syncope occur in patients with fixed Outflow obstruction (severe AS)⁉️
These patients cannot increase cardiac output in response to exercise induced vasodilation=> hypotension=> transient cerebral hypo perfusion=> decreased exercise tolerance, presyncope or syncope
Differential for exertional syncope or what?
Ventricular arrhythmias due to MI or ischemia, outflow tract obstruction (AS or HOCM)
What is the treatment for dilated cardiomyopathy? What can halt or reverse progression of cardiomyopathy?
Salt and water restriction, diuretics as needed, ACE, BBs, mineralocorticoid receptor antagonist, Digoxin if needed; alcohol
What is the treatment for acute decompensated heart failure if patient has elevated or normal BP? If hypotension or shock?
Both would be given supplemental oxygen and IV loop diuretic however normal or elevated BP would be given IV vasodilator (nitroglycerin) and hypotensive or shock would be given vasopressor (norepinephrine)
What suggest severe disease in acute decompensated heart failure?
Hypotension as opposed to hypertension (most commonly seen)
What is the primary mitral valve motion in patients with hypertrophic cardiomyopathy⁉️
Systolic anterior motion of mitral valve anterior motion of mitral valve leaflets towards the interventricular thicken septum this contact during systole leads to left ventricular outflow tract obstruction
