Cardio 2 Flashcards
EKG premature atrial complexes
early P waves that differ in morphology from the normal sinus P wave
tx premature atrial complexes
usually asx - no treatment
symptomatic - beta blockers
are QRS complexes typically wide or narrow in premature ventricular complex
WIDE QRS - bc it is usually due to muscle contraction outside of the original pathway = slower contraction
EKG Afib
irregularly irregular rhythm (irregular RR intervals and excessively rapid series of tiny, erratic spikes on EKG with a waxy baseline and NO IDENTIFIABLE P WAVES)
tx Afib
unstable - cardioversion
stable - RATE control > rhythm control – BB > CCB
BUT if LVEF - use metoprolol, digoxin, or amiodarone
anticoagulation based on CHA2DS2VASc score (warfarin vs DOAC (apixaban, rivaroxaban, edoxaban)
goal INR range on warfarin
2-3
CHA2DS2VASc
CHF (1)
HTN (1)
Age >/= 75 (2)
DM (1)
Stroke, TIA (2)
Vascular dz (MI, aortic plaque) (1)
Age 65-74
Sex (female = 1)
what CHA2DS2VASc score for anticoagulation in afib
2 or more males
3 or more females
if Afib is present for > 48 hours (or unknown period of time), anticoagulant patients for ________
3 weeks before and at least 4 weeks after cardioversion
EKG Aflutter
saw-tooth baseline with a QRS complex appearing every second or third “tooth” (P wave)
tx for aflutter
same as for afib
multifocal atrial tachycardia is commonly see in people who have
COPD
EKG MAT
variable P wave morphology and variable PR and RR intervals
at least 3 different P wave morphologies are requires to make an accurate diagnosis
tx MAT
underlying cause
tx paroxysmal supraventricular tachycardia
IV adenosine
definitive - radio frequency catheter ablation
prevention: CCB or BB
EKG for Wolff-parkinson-white syndrome
wide complex tachycardia (can also be narrow), short PR interval (<0.12), delta wave (upward deflection seen before the QRS complex)
tx WPW
stable - procainamide
unstable - cardioverson
definitive - radio frequency ablation
what is sustained vtach
duration of at least 30 seconds or causes hemodynamic collapse in < 30 seconds
what electrolyte abnormalities can lead to vtach
hypomagnesemia
hypokalemia
hypocalcemia
what medication can lead to vtach
digoxin
tx vtach
stable - amiodarone or procainamide
unstable - cardioversion
pulseless - defibrillator + CPR
chronic - BB and ICD
tx torsades de pointes
IV mag sulfate
congenital - BB
unstable - cardioversion
pulseless - defibrillator + CPR
tx Vfib
defibrillator + CPR
epinephrine and amiodarone per ACLS
when is angina considered unstable
angina at rest, generally lasting longer than 20-30 minutes
new onset angina
change in angina pattern
EKG for unstable angina
ST segment depression
new deep T wave inversions or flattening
cardiac enzymes unstable angina
negative CK and troponin = ischemia without cell death
tx unstable angina/NSTEMI
MONA BASH
morphine
oxygen
nitrates
aspirin + P2Y12 inhibitor
beta blockers
acei
statin
heparin (enoxaparin)
what is the difference between NSTEMI and unstable angina
positive cardiac biomarkers in NSTEMI
reperfusion therapy for STEMI
PCI > Fibrinolytics
PCI within 90 minutes
thrombolytics within 30 minutes if PCI is not possible
triad of right ventricular infarction
increased JVP
clear lungs
positive kussmaul sign (increase in JVP during inspiration)
the treatment for right ventricular MI (inferior or posterior wall MI) is treated the same as a STEMI except for what meds should be avoided?
beta blockers
nitrates
ccb
opioids
NSAIDs
so still can use - oxygen, aspirin + P2Y12 inhibitor, acei, statin, anticoagulant
indications for PCI
patients with coronary artery disease and resultant angina involving one or two vessels but not involving the left main coronary artery and in those with normal ventricular function
diabetics with single vessel disease
indications for CABG
left main coronary artery involvement with > 50% stenosis, > 70% stenosis three-vessel disease, or decreased left ventricular ejection fraction < 40%
diabetics with multi vessel disease
tell me about HFrEF
most common type
post MI MCC
systolic dysfunction
decreased ejection fraction < 40%
S3 gallop
tell me about HFpEF
diastolic dysfunction
normal ejection fraction
S4 gallop
NYHA functional classes
I = no sx, no limitations during normal activity
II = mild symptoms (dyspnea, angina), slight limitation during normal activity
III = sx cause marked limitation in activity (even with minimal exertion); comfortable only at rest
IV = sx even at rest, severe limitations, inability to carry out physical activity
Long-term management of HF
ACEI/ARB/ARNI
diuretic
beta blocker (reduces mortality) - metoprolol, carvedilol, bisoprolol
can add spironolactone or eplerenone as well as an SGLT2 inhibitor (dapagliflozin, empagliflozin)
if AA - can add hydralazine plus nitrate if persistent sx
what is hypertensive emergency
SBP >/= 180 and/or DBP >/= 120 in addition to end-organ damage
tx hypertensive emergency
reduce mean arterial pressure by 10-20% in the first hour, then gradually by another 10% over the remaining 23 hours
meds - IV nicardipine, clevidipine, labetolol
tx for hypertensive urgency
BP should be lowered within 24 hours with oral meds (Clonidine or Captopril) by 25%
define cardiogenic shock
SBP < 90 with urine output < 20 mL/hour and adequate left ventricular filling pressure
decreased cardiac output and increased systemic vascular resistance (vasoconstriction) and increased pulmonary capillary wedge pressure
MCC cardiogenic shock
acute MI
what is generally the measure of the PCWP in cardiogenic shock
what are the goals if you need to use a swan-ganz catheter
> 15 mmHg
goals with swan-ganz - keep cardiac output > 4 L/min, Cardiac index (CI) > 2.2, PCWP < 18
tx cardiogenic shock
no fluids
NE generally preferred
dobutamine instead if borderline low BP
definition of orthostatic hypotension
decrease in SBP of at least 20 and/or decrease in DBP of at least 10 mmHg
what physical exam test can you do for orthostatic hypotension
tilt table test — BP reduction at a 60 degree angle
tx orthostatic hypotension
increase salt and fluids
gradual postural change
compression stockings
exercise
d/c affection meds
fludrocortisone (mineralocorticoid) or midodrine (alpha 1 adrenergic agonist) if sx continue
Fludrocortisone > Midodrine
vessel involvement and area of claudication for peripheral arterial disease
aortic bifurcation/common iliac = buttock, hip, groin
femoral artery/branches = thigh, upper 2/3 of the calf
popliteal artery = lower 1/3 of the calf, ankle, foot
tibial and peroneal arteries = foot
sx peripheral arterial disease
LE pain with ambulation, exercise, movement; relieved with rest
decreased, weak, absent pulses
atrophic skin changes - shiny, dry skin; hair loss, thickened nails, cool limbs
wound on lateral malleolus
foot and leg pallor on elevation; dependent rubor
dx peripheral arterial disease
ABI = most useful screening
Duplex ultrasonography - evaluate further extent
Arteriography = gold standard; usually only performed if revascularization is planned
ABI ranges peripheral arterial disease
normal = 0.9 - 1.3
ABI > 1.3 is due to non compressible vessels and indicates severe dz
claudication when ABI < 0.7
rest pain when ABI < 0.4
sx of chronic venous insufficiency
leg pain worsened with prolonged standing and sitting with feet dependent
leg pain improved with ambulation and leg elevation
stasis dermatitis - eczematous rash and brownish/purple rash (hemosiderin deposition)
ulcers on medial malleolus
PITTING leg edema
what vein most commonly affected in chronic venous insufficiency
greater saphenous vein
