Cardio Flashcards
Sudden vs gradual LOC
Sudden loss usually has cardiac or neruologic etiology such as arrhythmia or seizure
Gradual Loss usually stems from toxins or metabolic problems such as hypoglycemia, hypoxia or drug intonations
vaso vagal syncope can be sudden or gradual in onset
sudden or gradual regaining of conciousness
Sudden regaining usually has a cardiac etiology such as arrhythmia, valve disease or ischemia
gradual usually stems from tonic-clonic generalized seizures (post octal state of confusion for 24hrs
LOC and regaining are both sudden. Next best step (NBS)
cardiac evaluation
exam normal: ischemia or arrhythmia - needs EKG, telemetry monitor, and troponin level
exam abnormal: need echocardiogram, exclude AS< HOCM, MS
Abnormal cardiac findings for LOC
HOCM: harsh systolic ejection murmur louder with decreased preload (standing) LLsternal
AS: pulses parvus et trades, paradox split S@ systolic crescendo decrecendo
MS: opening snap and mid diastolic murmur, pulmonary edema (sever with split of S2)
CAD risk factors
DM (most serious) Hypertension (most common) family history of premature CAD Hyperlipidemia Tabacco Smoking Age >45 men, >55 women renal disease
Most likely Dx and Most Accurate test
Chest wall tenderness
Costochondritis
Physical exam
Most likely Dx and Most Accurate test
chest pain with radiation to the back unequal BP arms
Aortic dissection
Chest X-ray with widened mediastinum, chest CT, MRI or TEE confirms
Most likely Dx and Most Accurate test
Chest Pain worse with lying flat meter with sitting, young (<40)
Pericarditis
EKG with ST elevation everywhere, PR depression
Most likely Dx and Most Accurate test
chest pain with Epigastric pain better when eating
Duodenal ulcer disease
Endoscopy
Most likely Dx and Most Accurate test
Chest pain with bad taste, cough and horseness
GERD
response to PPI, aluminum hydroxide and magnesium hydroxide, viscous lidocaine
Most likely Dx and Most Accurate test
chest pain with cough, sputum and hemoptysis
Pneumonia
Chest X ray
Most likely Dx and Most Accurate test
chest pain with sudden onset shortness of breath, tachycardia and hypoxia
Pulmonary embolism
Spiral CT, V/Q scan
Most likely Dx and Most Accurate test
Chest pain as sharp pleuritic pain, tracheal deviation
Pneumothorax
Chest xray
Best initial test for all Chest pain
EKG
Indication and signs of ischemia with exercise tolerance test
indication: determine presence of ischemia
ST segment depression
Indication and signs of ischemia with exercise thallium or exercise echo
inability to read EKG, baseline ST segment abnormalities
Decreased uptake of nuclear isotope or wall motion abnormalities
Indication and signs of ischemia with dipyridamole thallium or dobutamine echo
inability to exercise to target HR.. (stop caffeine before dipyridamole)
Decreased uptake of nuclear isotope or wall motion abnormalities
Exam findings that indicate coronary angiography
Normal at least decreased with exercise and then normal at rest again. reversible ischemia and can benefit from angio. No change means irreversible “fixed” defect or dead tissue.
angio is the most accurate method to detect CAD and which intervention is needed
Angioplasty vs CABG
angioplasty (precutaneous coronary intervention)- 1-2 vessels the persists past medical therapy. best therapy in acute coronary syndrome, no change in mortality
CABG- 3 vessels, left main or 2 vessels in diabetics, >70% (lowers mortality)
First line stable anginia teraphy
Beta Blocker. decrease myocardial contractility, HR, and O2 demand. Decreased HR, prolongs diastole, increased percussion.
Most common adverse effects of statin medications
Lyver dysfunction: elevated transaminases. routine AST ALT testing
myositis, and rhabdo soccer in less the 0.1% worsened by gemfibrozil
Clear indications for statin use
acute coronary syndrome MI/ Stenting Any arterial disease 10yr risk of CAD >7.5% CAD- LDL goal <70
Should yo use calcium channel blockers in CAD?
CCB increases mortality in CAD bc of raising heart rate effect.
Only use CCB in CAD if
- sever asthma (preclude use of BB)
- prinzmetal angina
- cocine induced chest pain (BB contraindicated)
Adverse effects of calcium channel blockers
Edema
constipation
heart bloak
ADR Niacin
Elevation in glucose anuric acid level, pruritus
Aspirin reduces flushing
ADR cholestyramine
flatus and abdominal cramping
What is an S4 gallop? What is associated with it
S4 gallop is the sound of atrial systole as blood is ejectied into a stiff ventricle.
acute coronary syndromes (ACS) are associated with an S4 gallop because of ischemia leading to noncompliance of the left ventricle
Kussmaul Sign
increase in JVP on inhalation.
associated with constrictive pericarditis or restrictive cardiomyopathy
EKG MI Findings with prognosis
Anterior (worse): V2-V4 ST elevation
Inferior: II,III, aVF ST elevation
Posterior/ Septal (best): V1-V2 ST depression
Lateral: I, VL,VR, V5, V6
Most appropriate first step in MI
Aspirin and a second anti-platelet- lowers mortality in ACS
- angioplasty (greatest mortality benefit) within 90min
- thrombolytics (less mortality benefit)
Checking for reinfaction
EKG new ST segment abnormalities
CK-MB- better at detaching reinfection returns to normal in 24-48 hrs
Decreasing risk of restenosis after stenting
P2Y12 antiplatelets: Clopidogrel, Prasugrel (best evidence)
Drug-eluting stent (paclitacel, sirolimus)- inhibit local T cell response
Complications of PCI
Rupture of coronary artery with inflation
Restenosis
Hematoma at site of entry to artery (femoral artery)
Distal cholesterol embolization
Symptoms of distal; cholesterol embolization
lived reticularis
eosinophilia/eosinophiluria after cath
low complement
high ESR
Contraindications to throb-lyrics
major bleeding into bowel or brain recent surgery (2weeks) Severe hypertension (>180/110) Nonhemorrhagic struck within 6mos
Time of correct answer to thrombolytics
in any patient with chest pain and ST segment elevation within 12hrs of onset of pain. ideal within 30min of ED door, best benefit within 2hours of pain
Treatment in chest pain with st segment depression
LMW heparin (better than unfrac interns of mortality) prevent clot from growing and closing off artery
GP2b3a (abiximab)- best for non st elevlation undergoing pci and stent
PCI indication in non ST elevation ACS
Not better: -persistent pain S3 gallop of CHF Worse EKG or sustained ventricular tachy rising troponin
MI Complication Bradycardia
Sinus Brady- insufficiency of SA node
3 AV Block- cannon A waves
Atropine
pacemaker (if atropine not effective)
MI Complications Tachycardia: Right ventricular infaction
inferior was MI and clear lungs
treat with high volume fluid replacement avoid nitroglycerin (worsens cardiac filling)
MI Complications Tachycardia: Tamponad / Free wall rupture
Sevral days
sudden loss of pulse
lungs are clear
PEA
Emergency pericariocentesis
Repair
MI Complications Tachycardia: V Tach/ V fib
monitor MI in ICE for several days
defibrillator/ cardioversion
MI Complications Tachycardia: Valve or septal rupture
new onset murmur
pulmonary congestion
Mitral regurgitation- apex and radiation to axila
Ventricular septal- LL sternal border, step up oxygenation
Most accurate test: Echo
MI Complications Tachycardia: extension of the infection/reinfaction
recurrence of pain
new rales
new bump in CKMB
sudden pulmonary edema
Redo MI treatment
Discharge meds for MI
Aspirin (forever) & P2Y12 (12mo) Beta Blocker Statin ACEi (AWMI or EF <40) Spironalactone if EF<40
Prophylactic antiarrythmics increase mortality
Causes of CHF
infection
cardiomyopathy
valvular disease
Presentation fo CHF (clinical diagnosis)
Orthopnea peripheral edema rales JVD paroxysmal nocturnal dyspnea S3 gallop Pulmonary edema (worst form of CHF)
Hemodynamic changes in CHF
decreased CO increased PWCP increased LVED volume increased TPR no changes in CVP
CHF tests
Echo (most important- evaluated EF) TTE (best initial exam Nuclear ventriculogram (most accurate- rare use)
CHF cause tests
EKG- MI, heart block Xray- Dilated cardiomyopathy Holter- paroxysmal arrhythmia Cath- valve and septal defect CBC anemia Thyroid function Biopsy- amyloid, sarcoid and most accurate for infections.
Tx systolic CHF
ACE/ARB- all patients at any stage
BB (metropolis and carvedilol)- antiarrhythmics not for acute CHFSpironolactone- first line (eplerenone is gynecomastia develops)
Diuretics- symptomatic control
Valvular Disease Diagnostic Tests
Best Initial: Echo (TEE more sensitive)
Most Accurate: Catherterization
Right sided increase in inhalation
left with exhalations
murmurs that dont change HOCM and MVP
Valvular Disease Treatment
Stenosis: correction of anatomy
Regurg: vasodilator therapy (ACE/ARB, nifedipine, hydralazine). Surgical correction before heart dilation.
Mitral Stenosis Clues
Pregnant and Immigrant (RF)
SOB, CHF
- Dysphagia (dilated LA)
- Hoarseness (LA pressing laryngeal nerve)
- A-fib and stroke from emornouse LA
- Hemoptysis
Mitral Stenosis Murmur
after s2 with opening snap
increased by equating and leg raising
Aortic stenosis clues
old or bicuspid valve
angina
syncope]left ventricular hypertrophy
Aortic Stenosis murmur
systolic crescendo decrescendo murmur
second right intercostal space
standing, handgrip, and valsalva decrease murmur
Mitral Regurgitation
Holosystolic
radiates to axilla
worse with handgrip, equating and leg raise
Aortic regurgitation
Wide pulse pressure water hammer (bounding) pulse Quincke pulse (nail bed) Hill Sign (BP legs 40 more then arms) Head Bobbing (de Musset sign) Diastolic decrescendo murmur
Cardiomyopathy Best initial test
Echo. also most accurate
Dilated Cardiomyopathy
causes
MI and ischemia
ABCCCD alcohol beri beri cocaine coxsackie (post viral) chagas Drugs (doxorubicin, radiation)
Hypertrophic Cardiomyopathy
HF with preserved ejection fracture. heart can’t relax to fill in diastole
HTN most common cause
HOCM
hypertrophic obstructive cardiomyopathy
genetic, septum is abnormally shaped. asymmetrical obstruction between septum and valve leaflet blocks blood leaving heart.
systolic anterior motion of heart
HOCM tx
beta blockers best initial
ace and diuretics contraindicated
Restrictive cardiomyopathy
heart neither contracts nor relaxes. causes: sarcoidosis amyloid hemochromatosis end-myocardial fibrosis scleroderma
Pericarditis causes and tx
Infection: Coxsackie(mcc), Staph, Strep, fungal
Connective tissue: SLE (mcc), Wegener, good pasture, RA, PAN
TX: NSAID +Colchicine
Pericarditis presentation
sharp chest pain that changes with respiration. worse with laying flat “stretch of pericardium”
EKG- defuse st elevation and PR segment depression (more specific)
Pericardial Tamponad
Hypotension,
Tachycardia
Distended Veins
Clear Lungs.
tx: pericardiocentesis. window
Constrictive pericarditis
Kussmaul sign
Knock- extra heart sound from filling again pericardium
Signs of RHF
Xray best initial
MRI/ CT most accurate
square root sign on cardiac cath
PAD “most likely diagnosis”
Leg pain walking up or down hills received by rest loss of hair loss of sweat glands loss of sebaceous glands (smooth shinny skin)
PAD testing and tx
ABI- best initial
angiogram- most accurate
cilostazol- most effective
aspirin or vorapaxar
place on statin
surgery
Peripartum Cardiomyopathy
Antibodies against myocardium develops after delivery most cases LV dysfunction (reversible but if not must undergo transplant). will worsen if pregnant again worst cardiac condition in pregnancy
Peripartum Cardiomyopathy TX
ACE/ARB (if after delivery) BB Spironalactone diuretics digoxin
Eisenmenger syndrome (pregnancy)
development of right to left shunt from pulmonary hypertension. preexisting VSD
2nd worst cardiac condition in pregnancy..
