Cardio Flashcards
Pt has atypical chest pain and mid systolic click on physical exam. Dx? What’s found on physical exam? Test? Rx?
Mitral valve prolapse. On physical exam murmur will be worse with standing and valsava. Improves with squatting. Do echo to confirm. Give beta blockers to reduce palpitations and chest pain.
Management of heart failure? Acute? Chronic?
EKG (need to rule out mi)and CXR (Evaluated fluid Overload.)
Then Rx with Oxygen, Diuretics, Nitrates, Morphine.
Give Dobutamine if pt fails O2, diuretics, nitrates, morphine.
Chronic give Ace and BB. Spiranolactone for class II and IV.
How to manage unstable angina and NSTEMI (medical and invasive)? Acute and chronic.
Treatment same as MI except no TPA.
Give O2, nitrates, morphine, Aspirin, Clopidegrol ( not before cabg and wait 5 days if given), beta blockers, unfractionated heparin or Enoxparin (drug of choice.)
Adjunct Eptifibatide (gp2b3a blocker) if pt is getting stent.
If patient fails to improve with medical therapy or if ichemia on EKG persist for more than 48 hrs then Invasive: Cath lab for coronary angiography and revascularization. Don’t do anything if pt has many severe comorbidities.
Chronic Rx: Aspirin, Clopidegrol (DAPT 6 months), Beta blockers, Statins, Nitrates.
(Warfarin if high risk for thromboembolism)
Manage HTN, DM, HLD, Smoking Cessation.
How to manage unstable angina and NSTEMI (medical and invasive)? Acute and chronic.
Treatment same as MI except no TPA.
Give O2, nitrates, morphine, Aspirin, Plavix ( not before CABG and wait 5 days if given), beta blockers, unfractionated heparin or Enoxparin (drug of choice.)
Adjunct Eptifibatide (gp2b3a blocker) if pt is getting stent.
If patient fails to improve with medical therapy or if ichemia on EKG persist for more than 48 hrs then Invasive: Cath lab for coronary angiography and revascularization. Don’t do anything if pt has many severe comorbidities.
Chronic Rx: Aspirin, Plavix (DAPT 6 months), Beta blockers, Statins, Nitrates.
(Warfarin if high risk for thromboembolism)
Manage HTN, DM, HLD, Smoking Cessation.
How to manage unstable angina and NSTEMI (medical and invasive)? Acute and chronic.
Treatment same as MI except no TPA.
Give O2, nitrates, morphine, Aspirin, Plavix ( not before CABG and wait 5 days if given), beta blockers, unfractionated heparin or Enoxparin (drug of choice.)
Adjunct Eptifibatide (gp2b3a blocker) if pt is getting stent.
If patient fails to improve with medical therapy or if ichemia on EKG persist for more than 48 hrs then Invasive: Cath lab for coronary angiography and revascularization. Don’t do anything if pt has many severe comorbidities.
Chronic Rx: Aspirin, Plavix, Beta blockers, Statins, Nitrates.
(Warfarin if high risk for thromboembolism)
Manage HTN, DM, HLD, Smoking Cessation.
Treatment for aortic stenosis? Treatment for mitral and aortic regurg, rx for mitral stenosis?
Aortic stenosis is surgical dz need to replace valve. Regurgitation rx is to reduce preload give diuretics, ace or arbs. For mitral stenosis- ballon valvuloplasty.
Seen in pregnant pts after they had viral illness as a child, Pt has hoarseness, dysphagia. Dx? Test? Rx?
Mitral stenosis caused by rheumatic fever. TEE is the best test. EKG will show biphasic p waves. CXR will show double bubble due to straightening of the left sternal border and pushing of the left main stem bronchus. All this due to the enlargement of the left atrium. Left heart cath is the most accurate. Rx: ballon valvuloplasty.
Hypotension, JVP, pulsus paradoxus. Dx? Cause? Test? Rx?
Pericardial tamponade. Cancer, infection, viral, SLE. Do echo. EKG will show electrical alternans ( variation in height of the QRS) ct will be quicker then echo sometimes and will show obvious fluid. rx: pericardiocentesis or pericardial window.
Hypotension, edema, ascities, JVP, pericardial knock( why?) cause? Test? Rx?
Constrictive pericarditis. Chronic infection and inflammation or post radiation of the pericardium leads to thickening and fibrosis. “Knock” is 3rd heart sound from filling of the ventricle hitting the fibrotic pericardium. CT or MRI shows thickened pericardium with calcifications
What is the management of symptomatic bradycardia?
IV atropine if fails then transcutaneous pacing if fails then pacemaker
When is IV adenosine given?
Supraventricular tachycardias
Pt presents with palpitations and dizziness, BP is 60/30, hr is 240. EKG shows narrow complex tachycardia. Next step in management ?
Supra ventricular tachycardias. D&C cardioversion (givens when there is unstable vitals and refractory chest pain)
The drug of choice for paroxysmal ventricular tachycardia. How does it work?
Adenosine decreases the conduction through the av node. Vagal maneuvers should be attempted before medications.
Syncope with exertion or exercise . Dx? (2)
Aortic Stenosis, Hypertrophic cardiomyopathy
Syncope with prior hx of MI, Cardiomyopathy, CAD or reduced ejection fraction. Dx?
Ventricular arrythymias
Hyperkalemia, Hypomagneiusm or medications that prolong QT interval and cause syncope. Dx?
Tordes De Pointes
Family Hx of sudden death, prolong QT with triggers such as emotion, stress, exercise causing syncope. Dx?
Congenital long QT syndrome
Emotion, stress, prolong standing (due to autnomic dysfunction) causing syncope? Dx?
Vasovagal syncope
Sinus pauses, prolonged PR interval and prolong ORS interval causing syncope. Dx? (2)
Sick sinus syndrome, AV block
Pt post CABG and valve replacement c/o weakness, chest tightness. Crackles are heard on lung exam. EKG shows absent P waves, irregularly irregular rhythm and narrow QRS complex. Next step in management
DC Cardioconversion
Which heart sound is associated with MI?
S4. ischemia causes stiff ventricle
Name 3 organisms that can cause subacute bacterial endocarditis? How is this acquired?
Viridians Streptococci, Enteroccoci and Staph epidermidis ( coagulase negative staph) Remember Staph aureus causes Acute endocarditis. You can get this from bacteremia possible if a patient had a procedure done.
How to treat and MI that occurs in leads II, III, and AVF?
This is a R ventricular wall MI. When this is infarcted it leads to decrease cardiac output and hypotension. for this MI never give Nitro. Give fluid bolus so you can treat the hypotension.
No p waves, Narrow QRS complexes conducted at irregular intervals. Rx ?
A. Fib. Due chads - anti coagulation. Manage cause. Mechanical cardioconversion - no help. Pharmocologic cardioconversion - amiaderone, dofetilide, flecainide, ibutilide, propafenone. Ablation is definitive rx.
Complete failure of impulse to conduct from atria to ventricles. The P waves become unrelated to QRS. They conduct separately. Rx?
Third degree or complete AV block. Rx with pacemaker.
PR interval greater than 200ms
First degree AV block
Block in the purkinje system leads to constant PR interval and dropped beat. Dx? Rx ?
Mobitz type 2. No treatment.
Intermittent AV nodal block. That leads to longer and longer PR interval with dropped beat
Wankebach. Mobitz type 1
Ascending aortic aneurysm are due to what? Descending aortic aneurysm are due to what?
Ascending due to cystic medial necrosis (occurs with aging) and connective tissue disease such as Marfans and Ehlers Danlos. Desencing aortic aneurysm are associated with atherosclorosis.
Rx or pulmonary edema?
Sit patient upright, O2, diuretics, morphine, nitrates
Rx of Mitral Stenosis? Mitral regurgitation?
Mitral stenosis: Diuretics and Salt restriction. Ballon valvulotomy is standard of care. If Afib exist then Anticoaug and Digitalis. Mitral regurgitation: need to increase forward flow and prevent pulmonary venous htn so give Dieurectics, Salt restriction, (ACE and ARB)- decrease afterload. If medical therapy fails and symptoms are severe- Surgery is valve replacement.
Test and Rx for Aortic Stenosis.
Clinical exam. EXG shows left ventricular hypertrophy. CXR shows calcification of the valve. Echo shows thick valve with decrease motion. Rx: Endocarditis rx no longer needed. Surgery advised when patient experiences syncope, ortho stasis, valve area is < 0.8cm. Ballon valvuloplasty if pt is too ill for surgery.
Test and Rx for Aortic Regurigitation?
Test: EKG LVH hypertrophy. CXR and Echo shows LV dilation and aortic dilation. Rx: Diuretics and salt restriction, ACE - decrease afterload to increase forward flow.
Rx for Hypertrophic Cardiomyopathy?
CCB and Beta blockers
Rx for Dilated Cardiomyopathy?
Same as systolic heart failure: acute O2, nitrates, morphine, Diuretics. Chronic: ACE, Beta blocker, and spiranolactone for CLASS 3 and 4
Rx for acute pericarditis?
Rx underlying cause. add NSAID and steroids.
Rx for Sinus Brady?
No symptoms then no treatment. If symptoms are there then Atropine. That fails then pacemaker.
PR interval greater than 200ms. Dx? Rx?
1st AV block. No treatment.
PR gets progressively longer then drops.Dx? Rx?
Second degree AV block type I (Wankebach) no treatment.
P wave and QRS are divorced. Dx? Rx?
Third degree AV Block. Rx: Pacemaker
Explain CHADS score what does it stand for?
CHADS indication for anticoagulation. CHF, HTN, AGE, Diabetes, Stroke. Score < 2 give aspirin. Score > 2 give Warfarin
Rx for PSVT?
- Carotid Massage then adenosine(slows conduction through AV node) (massage to increase vagal tone slows down heart rate.) 2. Betablocker or CCB (Diltiazem and Verapamil), Digitalis. Cardioversion if patient is unstable.
This rhythm disorder seen in elderly patients with chronic lung dz who experience respiratory failure. Dx? Rx?
Multifocal atrial tachycardia. Diltiazem and Verapamil. Avoide beta blockers due to lung dz.
Rx for Atrial Flutter?
Verapamil, Diltiazem and beta blockers. Cardiovert if unstable.
Rx for WPW?
Procainimide is the best medication. Cardiovert if unstable. Ablation is definitive treatment. Avoid CCB and betablocker since they can block conduction through the normal pathway which is the pathway that conducts properly anyway.
Young lady who develops progressive CHF. Dx?
Viral myocarditis form cosaxie B.
Which 2 drugs should you be cautioned with sildenifil? Why?
Nitrates and alpha blockers can cause profound HTN.
Pt presents with diarrhea, nausea, vomiting and decreased appetitite and complains of increased fatigue and palpitations. Also has blurry vision, scotoma. Liver spam is 8cm and spleen is no palatable. Pt takes aspirin, metoprolol, digitoxin and statin. Best initials tests?
Digoxin drug level.
Pt develops AV block after having an infective endocarditis. Dx?
Perivalvular Abscess
A holosystolic murmur is heard on Iv drug abuser with inspiration. Dx?
Tricupsid Valve Regurigitation
Name the 3 major complications of MI on the heart? What murmurs are associated with them?
- Papillary muscle rupture-systolic murmur that radiates to axilla 2. Interventricular septum rupture - holosytolic murmur that radiates to the left sternal bord. 3, Left ventricular free wall rupture
Name 4 causes of high output cardiac failure.
- Pagets Dz 2. Anemia 3. Thyroxtoicosis 4. Trauma from AV fistula (Catherization, Atherscolorosis and Cancer can cause fistulas as well)
Post MI there is acute Hypotension with clear lungs and Kssumaul Sign. Dx? Test?
Right ventricular Failure. Echo shows hypokinetic RV.
Post MI within 3-5 days patient develops pulmonary edema and new holosystolic murmur. Dx? Test?
Papillary Muscle Rupture. Echo shows severe mital regurgitation with flail leaflet.
Post MI within 3-5 days pt develops shock and chest pain, new holosystolic murmur and biventricular failure. Dx? Test?
Interventricular Steptum Rupture/Defect. Echo shows left to right shunt at level of ventricle. Increase in O2 lvel in R atrium.
Post MI within 5 days - 2 weeks pt develops shock and chest pain. JVD and Distant Heart sounds present Dx? Test?
Free wall rupture. Echo shows pericardial effusion with tamponade.
Name 5 toxcities associated with amiodarone.
- Pulmonary fibrosis 2. Hypo and hyperthyroidism 3. Corneal deposits -no changes in vision 3. Hepatoxicity- elevated AST and ALT 4. Skin changes - bluish-gray discoloration
67 yo man with HLD and DM presents with a couple of months of exertional syncope and fatigue and dyspnea. What will be found on exam? Dx?
Systolic Ejection Murmur Crescendo Descrendo from Aortic Stenosis (Syncope, Angina, Dyspnea). After SI and Before S2. Pt can also have pulsus parvus et tardus ( pulse that rises gradually and has a delayed peak) can also have a prolonged cardiac impulse at the apex
Opening snap diastolic murmur Dx?
Mitral Stenosis
HTN and Tearing chest pain radatiting to back Dx?
Aortic Dissection
HTN and abdominal bruit with mutiple/maximum HTN therapy Dx?
Renal Artery Stenosis
HTN with abdominal pulsating mass Dx?
Abdominal Aortic Aneurysm
Sarcoidosis, Amylodosis and Hemacrhomotosis can all cause restrictive cardiomyopathy. which one can be reversed? How?
Hemachromotosis through phlebomtomy - removal of iron.
You ask the patient to sit up and lean forward you apply the stesthescope with firm pressure. You hear a Descrensdo Diastolic Heart Murmur. Dx?
Aortic regurigitation due to In YOUNG Adults Bicupsid Aortic Valve in developed countries and Rheumatic heart dz in developing countrires.
Name 2 Heart conditions associated with Marfans Syndrome.
Aortic Dissection ( sudden onset of neck and chest pain) and MVP ( Early diastolic Murmur)
Young healthy patient develops pitting edema, ascities, bibasilar crackles, elevated JVP after having a URI. Dx? What will the test show? Rx?
Acute Congestive heart failure 2/2 dilated cardiomyopathy 2/2 viral myocarditis 2/2 s/p URI. Echo will show dilated ventricles and hypokinesis. - common cause of acute heart failure in adults. Rx is supportive -diuresm, beta blockers and acei.
3 conditions where clopidegrol is need in ACS.
- If patient can’t tolerate aspirin. 2. If patient had UA/NSTEMI five aspirin for life and clopidegrol for a year. 3. Post PCI clopidegrol for 30 days if Bare metal stent, 1 year if DES.
When is concentric hypertrophy seen? When eccentric hypertrophy seen?
Concentric hypertrophy- chronic pressure overload - aortic stenosis
Eccentric hypertrophy- chronic volume overload with valve regurgitation
Mid diastolic opening snap dx?
Mitral stenosis
In primary pulmonary HTN. What is not present ? And why?
Bibasilar crackles because bibasilar crackles would be seen when there is left heart failure. Pulmonary HTN still shows signs of right heart failure - cor pulmonale.
INR < 5 , INR 5-9 , INR >9 what to do?
- Omit next warfarin does 2. Stop warfarin temporarily 3. Give oral vit k
Explain what each is associated with on ECG: Reentry? Electromechanical dissociation? Increased automaticity?
Reentry is V. Fib seen after MI. Electromechanical dissociation seen in pulmonary thromboembolism and cardiac tamponade. Increased automaticity seen with dig toxicity.
Explain how CHF cause edema!
CHF leads to decrease circulating volume which causes renal hypoperfusion that leads activation of RAAS from the JGA complex. Ang II causes vasocontriction of the efferent arteriole to increase GFR and Aldosterone cause more sodium and water retention. This further exacerbates the CHF.
New onset aortic regurgitation? New onset mitral regurgitation ?
- Aortic dissection 2. Papillary wall muscle rupture
First initial test for CHF? Most accurate test?
- Echo 2. MUGA
Electrical alternans dx?
Pericardial effusion from cardiac tamponade
Rx for stable vtach?
IV amiodarone
What is becks triad? What’s is the for?
Hypotension, JVP, muffled heart sounds for pericardial effusion 2/2 cardiac tamponade 2/2 viral pericarditis
Rx for cocaine induced vasospasm? What drug to avoid?
Give benzo avoid beta blockers that can lead unoppose alpha stimulation that can worsen the vasoconstriction.
Increase R atrial pressure, increase PCWP, DECREASE CI, increase SVR, decrease MVO2. What type of shock?
Cardiogenic shock
Decrease R atrial pressure, decrease PCWP, increase CI, DECREASE SVR, INCREASE MVO2 what type of shock?
Septic shock
