Cardio 2 Flashcards
1
Q
What is pericardiectomy?
A
“Pericardial stripping” most effect surgical procedure for managing large pericardial effusions.
2
Q
Pulsus paradoxus is defined as a decline of greater than _______ in (sys/dias)_________pressure during inspiration.
A
10-12 mmHg
systolic pressure
Weak pulse during inspiration
3
Q
What causes secondary myocarditis?
A
Non viral pathogens, meds, chemicals,
SYSTEMIC LUPUS
4
Q
What is the BPM for sinus bradycardia?
A
<60 bpm.
5
Q
A patient presents with an ABI of 0.4 and is symptomatic of PAD, what should you do?
A
REFER ASAP!! Emergent.
6
Q
A patient present with Ventricular Tachycardia, but is determined to be chronic and sustained, what would you do next?
A
Treat cause.
Consider chemical or electrical cardioversion
7
Q
Three main steps for treating rheumatic fever.
A
Bed rest
Penicillin
Anti-inflammatory agents
8
Q
Pharm treatment of LONG QT?
A
Beta Blockers.
Mexilitine
9
Q
Disorder of ventricular depolarization resulting in a LONG QT interval
A
LONG QT SYNDROME
10
Q
What does a high dose of dopamine do?
A
Peripheral vasoconstriction. >10 mcg/kg/min
11
Q
True or False: electrical cardioversion restores sinus rhythm in 75-90% of patients
A
True.
It is an initial shock of 100-200 Joules in synchrony with the R wave. If unsuccessful, juice it up to 360 Joules
12
Q
What is the most common cause of Acute Endocarditis?
A
Staph aureus
13
Q
Atrial flutter is commonly associated with________
A
COPD!
14
Q
What is the vasopressor of choice for anaphylaxis?
A
Epinephrine
15
Q
Patients with PVD usually have coexisting _____________disease.
A
Coronary Artery
16
Q
Acute inflammatory pericarditis is usually _____________in duration.
A
Less than 2 weeks
17
Q
Are statins helpful in HF?
A
No benefit has been shown.
18
Q
What is a bacterial or fungal infection of the valvular or endocardial surface of the heart?
A
Acute/Subacute Endocarditis
19
Q
What is obstructive shock?
A
Obstruction to the outflow due to impaired cardiac filling and excessive afterload.
20
Q
Antiarrhytmics maintain sinus rhythm in about ________% of patients.
A
50
21
Q
Nerves and Lange-Nielsen Syndrome is associated with ________ syndrome.
A
LONG QT
22
Q
What might you see on a chest x-ray with dilated cardiomyopathy?
A
Enlarged LEFT VENTRICULAR shadow
23
Q
For a patient with PAD, pain in the calf, and reduced popliteal and pedal pulses, where might the level of obstruction be?
A
Femoral or popliteal
24
Q
What happens to mitral valves during dilated cardiomyopathy?
A
Regurgitation.
Will hear holosystolic murmur.
25
What might you see on an ECG with Wolf-Parkinson-White? (Antidromic)
Abnormally long QRS.
DELTA wave
Short PR
200-300 bpm
26
What is the treatment for ACUTE Ventricular tachycardia?
THIS IS A CODE!!
Cardioversion/ VT algorithm meds
27
More than 3 consecutive PVCs (WIDE QRS!)
Ventricular Tachycardia
29
The junctional rhythm rate is usually______________bpm
35-60
30
What are common symptoms of pericardial effusion?
Chest pain.
Syncope and light-headed
Palpitations
Cough
31
What is happening to the heart in hypertrophic cardiomyopathy?
Myocardium concentrically hypertrophied leading to:
THICKENED and STIFF ventricle.
Can’t FILL-DIASTOLIC HEART FAILURE.
32
What is the definitive therapy for cardiac tamponade?
Removal of pericardial fluid.
33
What are the two main key points for diagnosing heart failure?
History and Physical Examination
34
________is an anti-arrhythmic used to treat atrial______ and atrial________ in patients with heart failure.
Digoxin
Flutter
Fibrillation
35
What might you see on a chest x-ray with heart failure?
“Kerley B lines” (fluid in lungs)
Enlarged heart
36
What is the Venturi effect?
Building muscle in inner septum in LV pushes up against valve walls and increases afterload. (Blood forced through small opening).
CRESCENDO-DECRESCENDO murmur.
37
Many patients with Multifocal Atrial Tachycardia have ________ _________.
Severe COPD.
38
We know A fib causes a 5 fold increase in stroke risk, but what other conditions are we concerned about?
Heart failure, dementia, increased risk of death
Also precipitates hypotension, myocardial ischemia, or other myocardial dysfunction
39
What causes dilated cardiomyopathy?
Generally Idiopathic.
Genetic Mutation
Infection
Alcohol Abuse-STRONGLY RELATED!
40
What is the ejection fraction of heart failure with “reduced ejection fraction” (or systolic heart failure)?
< or = to 40%
41
Second line meds for AVNRT.
Diltiazem
Beta Blockers
*slow down the AV node
42
What are extrinsic causes of sinus node dysfunction?
Drugs, hypothyroidism, electrolyte abnormalities, autonomic dysfunction.
43
Ischemic ulceration of toes, secondary to local trauma that does not heal, is suggestive of _________disease.
Peripheral Vascular
44
In which kind of heart failure have effective therapies been identified?
Reduced Ejection Fraction (Systolic HF)
45
What is restrictive cardiomyopathy?
Muscles in heart are stiff and less compliant. Can’t stretch.
Less blood can fill into ventricle-less can pump out.
HEART FAILURE. (Diastolic)
46
ECG of Supraventricular Tachycardia
NARROW QRS
Regular
P wave embedded
NOT atrial fib.
47
What are some symptoms of PVCs?
Skipped beat
Dizziness
More frequent AT REST
Go away with EXERTION
48
What is the traditional definition of systolic BP in hypotension?
90 or less
49
What drug might cause bradycardia?
Digoxin
| CCBs and BBs
50
What tests should you do if PVCs are frequent and/ or hemodynamically symptomatic?
Evaluate with:
ECHO
STRESS TESTING
+/- Electrophysiology evaluation
51
Trigger of AVNRT
Caffeine
52
In diagnosing shock you may see elevated __________concentrations of higher than _____mmol/L
Lactic Acid (b/c of inadequate 02 delivery)
2
53
Examples of WIDE REGULAR TACHYCARDIA.
Ventricular Tachycardia
SVT with aberrant conduction
AVRT with antidromic conduction
54
__________is the most effective diuretic in the treatment of heart failure.
Furosemide
55
What is the most commonly infected valve in endocarditis?
Mitral
| Tricuspid in IV drug users
57
PVC’s usually go away during__________.
Exertion
58
___________is the cytokines that mediates septic shock.
TNF-alpha
59
This type of shock occurs when the intramuscular volume is depleted relative to the vascular capacity as a result of blood loss or dehydration.
Hypovolemic Shock.
60
How does long standing hypertension lead to heart failure?
Arterial pressure makes it harder to pump blood into systolic circulation, to compensate the left ventricle hypertrophies (to contract with more force), which increases muscle mass leading to greater 02 demand.
The coronaries are squeezed, which reduces 02 saturation of ventricles. More Demand and Less Supply!
Muscles have weaker contractions. Leading to heart failure.
61
Pitting edema can be a sign of________sided heart failure.
Right
62
What are Class III antiarrhythmics?
Potassium channel blockers
62
What happens to walls of myocardium in dilated cardiomyopathy?
Get thin and weak.
Weak contractions-lower stroke volume
Biventricular congestive heart failure.
65
What is the accessory pathway in WOLF-Parkinson-White Syndrome?
Bundle of KENT
66
Is hypertrophic cardiomyopathy a systolic or diastolic heart failure?
Diastolic
67
____________heart failure is abnormal cardiac relaxation, stiffness, or filling.
Diastolic
68
Ventricular rupture can cause ________________shock.
Cardiogenic
69
What might you find on the feet of patients with endocarditis?
Osler nodes: tender subcutaneous nodules found on the distal pads of the digits.
69
What is the most common type of cardiomyopathy?
Dilated
71
Two major signs of pericardial effusion.
Pericardial friction rub
Pulses paradoxes
73
What causes Rheumatic Fever?
Autoimmune inflammatory response that develops 2-3 weeks after a PHARYNGEAL group A beta-hemolytic streptococcal infection.
74
What are the minor jones criteria for diagnosis of rheumatic fever?
Fever.
Polyarthralgias (inflammation of joints, morning stiffness)
Reversible prolonged PR interval
Elevated ESR or CRP (erthryocyte sedimentation and C-reaction protein)-detect inflammation in the body
75
What is the accumulation of too much fluid in the double-layered, sac like structure around the heart?
Pericardial Effusion
76
What is the targeting resting heart rate for Afib?
<80bpm
77
What happens to the pulse pressure in cardiogenic shock?
Decreases.
78
Management of SIck Sinus Syndrome
ATROPINE
79
Bicuspid aortic valves, rheumatic fever, IV drug use, and sclerotic aortic valves are risk factors for___________.
Endocarditis
80
Long PR interval, LONGER, EVEN LOOOONGER...dropped.
Second Degree AV Block Mobitz Type I (Wenckebach)
81
Rhythm arising from the AV junction.
Junctional Rhythms
82
Bradycardia with P wave ALWAYS followed by QRS. (multiple options)
Sinus brady
First degree AV
Sinus pause/arrest
83
What is the cornerstone of therapy for PAD?
Lifestyle Management!
Smoking
Diabetes
Walking program
84
What happens during squatting with hypertrophic cardiomyopathy?
Systemic Vascular Resistance Increases-Making it harder to eject blood (inc. afterload).
This INCREASES BLOOD IN VENTRICLE, making it LESS obstructed.
Murmur LESS INTENSE.
85
What should all patients with cardiac tamponade receive?
O2
Volume expansion with blood plasma.
Bed Rest with leg elevation (increase venous return).
86
What is the criterion standard for confirming group A streptococcal infection?
Positive Throat Culture.
| Can also have a Rapid Strep or ASO
88
How do you treat all hemodynamically unstable AV blocks?
ATROPINE! (increases firing of SA node)
Treat cause
89
What happens to the PR interval in rheumatic fever?
Prolonged
90
A reduced ejection fraction, increased end diastolic volume, and decreased contractility are signs of ________cardiac dysfunction.
Systolic
91
Anaphylactic shock is a type of __________shock.
Distributive
92
What is the ejection fraction of “Diastolic heart failure” or Preserved Ejection Fraction?
> or = to 50%
93
What are AV nodal blocking agents used to manage Afib?
Beta Blockers
CCBs
Digoxin-when combined with above.
94
What is exercise testing used for?
Detection of ischemic heart disease.
Risk stratification.
95
An abnormal pattern of breathing, deeper and faster followed by decrease and a temporary stop.
Cheyne Stokes
96
Diastolic heart failure is more common in (men/women)________
Women
96
Diltiazem is what kind of drug? What is used to treat?
CCB
High BP and angina
*relaxes blood vessels in the heart, so it doesn’t have to work as hard
98
What category of AFib terminates spontaneously or for a duration of time after intervention that happen with variable frequency?
Paroxysmal
99
Symptoms of acute pericarditis.
Palpitations
Low-grade intermittent fever
Shortness of breath.
Cough
Dysphasia
100
____________shock is characterized by loss of vascular tone.
Distributive
101
What is third spacing?
When too much fluid moves from the blood vessels in the interstitial space-the nonfunctional area between cells. Can cause edema, reduced cardiac output, and hypotension.
102
What’s a major difference in neurogenic claudication and intermittent vascular claudication?
Pain triggered by unsupported standing;relieved by leaning on something “shopping cart sign” (neurogenic claudication)
103
_______sided heart failure is associated with paroxysmal nocturnal dyspnea.
Left
104
What is the goal of rate control treatment of A fib?
Symptom management and prevention of tachycardia-mediated cardiomyopathy
108
What are the causes of sinus bradycardia?
Increased vagal influence on the normal pacemaker.
Physical fitness.
Meds: Beta Blockers
109
The rate of ventricular tachycardia is _________bpm
>120 (Typically 160-240). RAPID!
110
Pre-excitation syndromes involves a ________accessory pathway.
Congenital
111
In Left sided heart failure blood gets backed up in the________
Lungs
112
What is the main goal in management of hypovolemic shock?
Restore volume lost.
Hemorrhagic shock>blood substitutes
Non hemorrhagic shock>isotonic crystalloid in IL increments.
115
This medication may improve pain and walking distance in patients with PAD
Cilostazol
117
In term of the CHADS VASc score, what is >2 mean?
High risk, anticoagulation.
118
What is the initial test of choice for acute pericarditis?
ECHO (but shows limited view of pericardium)
120
What should be performed on all patients with suspected purple tissue pericarditis?
Pericardiocentesis (fluid analysis and culture)
121
What is the most common chronic arrhythmia?
Afib
122
Ventricular tachycardia is ______ or more consecutive ventricular beats
3
126
Anaphylaxis is caused by type I, _________mediated hypersensitivity response.
IgE
127
What might you find in a blood test in myocarditis?
Elevated Troponin and Creatine Kinase levels.
128
How does percutaneous balloon pericardiotomy work?
Creates a pleura-pericardial direct communication, allowing for drainage of fluid into the pleural space.
129
The most common viral cause of myocarditis is________.
Coxsackie B.
130
1 in 4 people over ____ years old can expect to develop Afib in their lifetime
40
131
What are causes of nontraumatic hemorrhagic hypovolemic shock?
GI bleed
AAA rupture
Ectopic pregnancy rupture
132
In septic shock, the primary insult is due to systemic vasodilation and therefore an (inc/dec) ______in afterload.
Decrease
133
What is the NORMAL vertical height of the external jugular vein pulsation?
<3cm above the sternal angle.
134
Upon physical exam you notice a JVD and peripheral edema, with an irregular and rapid pulse.
Afib.
135
How do you treat PVCs?
Not much you can do.
HEALTHY LIFESTYLE CHANGES.
MAYBE use Beta-blockers or Calcium Channel Ablation
136
Ventricular tachycardia has a ________QRS complex
Wide
137
What is a normal hearts ejection fraction?
Around 55-65%
138
In terms of CHADS VASc score, what does 1 mean?
moderate risk, anticoagulant, ASA or no therapy.
139
What is the HR for SIRS?
>90
140
Afib causes a ______fold increase risk of stroke.
5
141
Why do you do a CT or MRI for acute pericarditis?
Rule out any extra cardiac disease.
143
How do you treat NONSUSTAINED CHRONIC VT?
CORRECT UNDERLYING CAUSE
CONTROL RATE AND DECREASE RECURRENCE W/ Beta Blockers and Calcium Channel Blockers
Radio frequency ablation if refractory
Pacemaker
144
Not a true block, more of a delayed or slowed AV conduction.
First Degree AV Block
145
What med could use to manage bradycardia?
Atropine
146
Ejection fraction is usually (is/is not)________preserved in diastolic heart failure. Why?
IS
ABNORMAL CARDIAC FILLING (not contractility) Less blood overall getting pumped into body, but not less % that is actually in the heart.
148
Someone suddenly dies waking up to a new alarm clock. What causes this?
Long QT syndrome
148
______ and _______diuretics both decrease preload on the heart but are not associated with improved survival in patients with congestive heart failure.
Loop and Thiazides
149
Common symptom of AVNRT.
Faint-lose adequate BP to perfuse to brain. SOB and chest pain.
150
What are Class I antiarrhythmics?
Fast Sodium Channel Blockers
151
What is something really important to not miss in sinus tachycardia?
BLOOD CLOTS IN LUNGS!!
153
Thought to be either an ESCAPE RHYTHM b/c other pacemakers aren’t working OR due to INCREASED AUTOMATICITY.
Accelerated idioventricular rhythm
157
What kind of heart sound does pericarditis make?
Leather rubbing on leather. Scratching or grating.
158
Most common cause of palpitations in patients with structurally normal heart beats.
AVNRT
159
EKG of ventricular tachycardia has ________QRS and BPM of ______
WIDE QRS (more than 3 PVC)
>120.
Can’t ID a P wave
161
What is an inflammation of the heart muscle caused by an acute viral infection or a post viral immune response?
Myocarditis
165
What does atropine do?
Increases the firing of the SA node and conduction through the AV.
Opposes actions of vagus nerves
166
What meds do you use to treat CONGENITAL long QT syndrome?
Beta Blockers
Mexiletine (sodium channel blocker)
167
What is hypertrophic cardiomyopathy?
Asymmetric thickening of walls of bottom 1/2 of heart with disorganization.
168
What do you do if there is an escape rhythm in accelerated idioventricular rhythm?
Treatment contraindicated since it’s the ONLY THING KEEPING THE HEART GOING.
170
Is hypertrophic cardiomyopathy autosomal dominant or recessive?
Dominant
171
What is the main genetic mutation causes LQTS?
LQT1 (40 to 55%)
172
If Wenckebach is symptomatic and hemodynamically unstable, what might you do?
ATROPINE!
Temporary Cardiac pacing.
(If stable, just monitor with pads)
173
Signs of hypovolemic shock.
Tachycardia.
Hypo
Oliguria
Pale Skin
175
What is the target ambulatory rate for Afib?
<100 bpm
176
For a patient with PAD, if pain is found in the calf, thigh or hip, where might the level of obstruction be?
Aorta or Iliac
177
What is the pathophysiology of ventricular tachycardia?
REENTRANT DYSRHYTHMIA
SECONDARY TO OR A COMPLICATION OF SOMETHING ELSE.
- ischemia
- dilated cardiomyopathy
- chronic coronary disease
- many more.
178
What is the best treatment for long term control of a recurrent or very symptomatic PVC?
Electrophysiological studies and catheter ablation.
179
Anaphylactic shock is a type of ____________shock.
Distributive
180
How does increased pulmonary blood pressure effect the right side of the heart?
Right Side has to pump harder, which can lead to hypertrophy and ultimately failure.
(I.e. Chronic lung diseases)
181
Patients with ________disease can present with continuous rest pain that is prominent at night (relieved by standing).
Peripheral vascular
182
What is the most common pathophysiology of a PVC?
Reentrant circuit, which is typically secondary to a healed MI.
183
________________heart failure is a dysfunction resulting in cardiac contractile function.
Systolic
184
What are the 3 categories of Afib and their defining characteristics?
Paroxysmal-terminates spontaneously
Persistent >7 days
Chronic-no treatment to restore.
185
What are important pieces of patient history with AV block?
Lyme disease
History of heart disease
Cardiac procedures
Level of fitness
186
What is the most common cause of left sided heart failure?
RIGHT SIDED HF. (Wants you to realize that they are both connected, and both back up systems in the body. )
186
Beta-blockers are recommended in all stages of (acute/chronic)______heart failure.
Chronic
187
Incidence of PVC increase with:
AGE
CV disease
Electrolyte abnormalities (K+, Mg++, Ca++)
188
Pharmacological Rx options for ACQUIRED LONG QT syndrome.
Magnesium Sulfate
Isoproterenol
Lidocaine
Phenytoin
Sodium bicarbonate
189
HR of Junctional Tachycardia
100-120
190
What are three methods for removing pericardial fluid?
1) emergency subxiphoid percutaneous drainage
2) pericardiocentesis
3) Percutaneous balloon pericardiotomy
191
What are pathological causes of sinus tachycardia?
Alcohol withdrawal
Anemia
Heart failure
Hypokalemia
191
These rhythms arise from the AV junction and disrupt the atrial pacemaking.
Junctional Rhythms
192
What is the body temp criteria for SIRS?
Higher than 100.4 or lower than 96.8
193
Hypertrophic cardiomyopathy causes up to _______of cardiac deaths in young athletes.
1/3
194
Does chest pain in pericarditis get worse when lying down or sitting forward?
Lying down
196
Rate of AVNRT
140-280, regular
196
HR of accelerated Junctional Rhythm
80-100
198
In hypovolemia afterload is___________.
Increased.
199
What chemicals might you use to treat SUSTAINED CHRONIC VT?
AMIODARONE
LIDOCAINE
201
_________is a drug that affects the renin-angiotensin-aldosterone system. It limits cardiac remodeling in heart failure.
Spiranolactone
202
During HF, you may see ________limb lead voltage.
Low
203
What are nonpharmacologic treatments for CONGENITAL QT syndrome?
Permanent dual chamber PACEMAKER
IMPLANTABLE CARIDIOVERTER-DEFRIBILLATOR
204
What is a first line med for AVNRT?
IV adenosine-slows conduction in AV node
206
What is the rate control Tx of Afib
Beta blockers and calcium channel blockers to block the AV node.
Maybe Digoxin (needs extra monitoring)
207
What is “holiday heart” usually?
Afib.
208
The heart failure in which the heart is SQUEEZING hard enough, but not FILLING hard enough.
Diastolic Heart Failure (or preserved ejection fraction)
209
How does a massive pulmonary embolism cause obstructive shock?
Increases RV afterload.
210
What is the most common cause of palpitations in patients with structurally normal heart beats?
AVNRT
212
What is end-diastolic volume?
The volume of blood right before systole.
Synonymous with preload. (Which is the STRETCH of cardiac cells prior to contraction).
212
What it the BPM for sinus tachycardia?
>100
212
Young athletes have a _______x higher risk of death from sudden cardiac arrest than non-athletes
3
213
What heart sound is usually associated with hypertrophic cardiomyopathy?
S4 (or S3)
214
Compliance with________treatment is essential to preventing acute rheumatic fever.
Strep throat.
215
What causes symptoms in neurogenic shock?
Loss of SYMPATHETIC branch of the autonomic nervous system (largely T5-L2). The parasympathetic branch’s effects dominate.
BRADYCARDIA!
216
What test should you do with patients with lower extremity exertional pain?
ABI (ankle-brachial index).
217
In septic shock, the skin is ____________.
Warm and Dry.
219
What are the major JONES criteria for Rheumatic fever?
Carditis
Erythema marginatum
Subcutaneous nodules
Joint Pain/Swelling
220
Name 3 causes of left-sided heart failure.
Ischemic heart disease.
Long-standing hypertension
Dilated Cardiomyopathy
221
A fast heart bead from a signal above the ventricles.
Supraventricular Tachycardia
222
How do you treat acute VT?
AN ACLS/CODE SCENARIO!
Cardioversion and VT algorithm meds
224
Causes of Junctional Rhythms
Myocarditis.
CAD
Digitalis Toxicity
225
How would manage a junctional rhythm?
ATROPINE!!
Treat underlying cause
Pacemaker
225
What is happens to the heart walls in hypertrophic cardiomyopathy?
Walls are thick and heavy.
Hypercontractile
Asymmetrical muscle growth
Less FILLING-LESS PUMPED
LEFT VENTRICLE
226
A patient presents with anorexia, nausea, early satiety, and abdominal fullness, what kind of heart failure might you suspect and why?
Right Sided Heart Failure (peripheral congestion, body system getting back up with fluid because blood not able to flow into Right Side of heart).
227
What is the leading cause of sudden cardiac arrest/death in young athletes?
Hypertrophic Cardiomyopathy
228
What is pulse pressure?
The difference between the systolic and diastolic pressure readings.
230
What is a major complication of pericarditis and pericardial effusion?
Cardiac Tamponade-Life threatening!!
232
What relieves chest pain associated with acute pericarditis?
Leaning forward while seated.
233
SIGNS and SYMPTOMS of LONG QT SYNDROME.
- asymptomatic
- syncope
- apparent seizures
- sudden cardiac arrest
234
What is the primary reason we give vasopressors in hypovolemic shock management?
To restore BP until fluid resuscitation can take place. A temporary method.
235
When would you use rhythm control to manage Afib?
When difficult to rate control.
Younger.
Triggered from Acute illness.
236
Following restoring fluid balance and increasing MAP through vasopressors what is the next step in managing septic shock?
Antibiotics
237
Tachycardia-Brady syndrome.
Sick sinus syndrome: drugs, meds, toxins.
238
How would you treat chronic nonsustained ventricular tachycardia?
Beta Blockers or CCBS
Radio frequency ablation if refractory.
Possibly defribrillator/pacemaker
239
If a younger person presents with new onset A fib, what should you also test for?
Hyperthyroidism
240
What is the initial test of choice for carotid atherosclerosis?
Duplex Ultrasonography
241
Neurogenic shock is usually caused by a traumatic _________injury.
Spinal Cord
| Above the T6 thoracic vertebra
242
What happened to the central venous pressure in hypovolemic shock?
Low.
246
Cardiac output is _______in hypovolemia.
Decreased
248
With right sided heart failure blood gets backed up into the _______ which leads to __________congestion.
Body.
Systemic Vein
249
When ventricles have become the pacemaker of the heart.
Ventricular Escape Rhythm.
“DYING HEART”
250
When treating A fib with antiarrhythmics, what is Class I?
Fast Sodium Channel Blockers
251
What tests might you do for a frequent PVC?
Echo
Stress
+/- electrophysiology evaluation
252
_________is the most common cause of cardiogenic shock.
MI
254
You suspect A fib, what diagnostics would you order?
- Echocardiogram
- Ambulatory rhythm monitoring for pts who have very erratic Sx presentation
- Metabolic profile, thyroid panel
256
Treatment for Junctional Rhythm.
Not much. TREAT UNDERLYING CAUSE
257
An S3 during INSPIRATION is indicative of______sided heart failure.
Right.
260
What are the signs and symptoms of accelerated idioventricular rhythm?
A WIDE RANGE! (Often occurs in post-MI settings)
263
Afterload_________in cardiogenic shock.
Increases.
264
What is hepatomegaly and what kind of heart failure is associated with it?
Fluid build up in liver.
Right
265
What are the A fib Tx options for rhythm control?
Cardioversion
Antiarrhthymics (either short term with a loading dose, or long term)
Ablation
266
JVD’s are a sign of_______sided heart failure.
Right
267
When does accelerated idioventricular rhythm most often occur?
POST-MI setting
268
What is important to be aware of in regards to LONG QT syndrome?
Can be genetic, but INCOMPLETE PENETRANCE. CAN SUDDENLY SHOW UP.
269
_________is a hormone secreted by the ventricles that can be used as a screening test for heart failure.
BNP (Brain Natriuretic Peptide)
270
When examining the foot of a patient with PAD, what might you find?
Delayed capillary refill
Loss of hair, thin skin, brittle nails
Cool
Dependent rubor (purple feet)
Arterial ulcers (critical)
271
What might you see on a chest radiography with acute pericarditis?
Normal (may show cardiomegaly).
272
What is Beck’s Triad?
Hypotension.
Muffled Heart Sounds
JVD
275
Junctional Rhythm ECG
Retrograde p waves.
36-60bpm
277
The heart failure in which the heart is FILLING enough, but not SQUEEZING enough.
Systolic Heart Failure or “REDUCED EJECTION FRACTION”
278
Isolated early beats that arise from ECTOPIC focus in the atria.
Premature Atrial Complex
278
What are some major complications with acute pericarditis?
Cardiac Tamponade
Pericardial Effusion
Recurrence in 15-32% of patients
Constrictive Pericarditis
279
When the atria and ventricles are beating independently.
3rd Degree Complete AV Block
280
What are A fib symptoms caused by?
Decreased cardiac output (decreased diastolic filling and decreased ventricular conractibility)
281
The peripheries are (cool/warm)______in a patient with cardiogenic shock.
Cool
281
What might you see on an ECG in restrictive cardiomyopathy?
Low-amplitude QRS
283
How do you manage all hemodynamically stable AV blocks?
Monitor, be ready with pads
283
Pericardial disease can cause ______________shock.
Obstructive
| Pericardial tamponade. Constrictive pericarditis
283
Peripheral vascular disease is diagnosed if the ankle-brachial index is less than_______
0.9
285
WIDE IRREGULAR TACHYCARDIAs
Ventricular Fibrillation
Polymorphic Ventricular Tachycardia
Torsades de Pointes
WPW with Afib
286
Black athletes have an increased risk with a ____x rate of sudden cardiac death than white athletes
3
289
Septic shock is a subclass of ________shock.
Distributive
291
_______shock is a condition in which decreased blood flow in the smallest blood vessels results in inadequate blood supply to the body’s tissues.
Distributive.
293
What are causes of traumatic hemorrhagic hypovolemic shock?
Loss of blood from injury.
Hemothorax
Hemoperitoneum
Fracture (femur, pelvis)
295
What are the major characteristics of cardiac tamponade?
Elevated intrapericardial pressure that RESTRICTS venous return and ventricular filling.
296
What are 3 categories of right sided heart failure?
Decreased RV contractility.
Increased RV pressure (from increased resistance)
RV volume overload (tricuspid regurgitation).
297
How do you treat SUSTAINED CHRONIC VT?
Sustained
- correct underlying cause
- depending on stability: chemical cardioversion, electrical cardioversion
298
What happens in a valsalva maneuver or standing with hypertrophic cardiomyopathy?
Venous return decreases (decreased PRELOAD).
OBSTRUCTION GETS LARGER.
Murmur INCREASES
299
Classic description of Afib.
Irregularly irregular rate and rhythm.
299
How would you treated acquired Long QT?
MAGNESIUM SULFATE!!
300
Is hypertrophic cardiomyopathy diastolic or systolic dysfunction?
Diastolic
301
What test is necessary when initiating therapy for heart failure with diuretics and/or ACE/ARBs?
CMP-get baseline evaluation of electrolytes and creatinine.
302
When ventricles are going too fast and “driving the ship”?
Ventricular Tachycardia
303
The impulse comes from the AV node and spreads to atria and ventricles. The P waves are absent
Junctional Rhythm
304
In hypovolemic shock the initial BP may be stable, why is this?
Compensatory vasoconstriction may maintain BP.
305
A fib is rarely threatening, so what is the biggest reason we treat it?
Because it causes a 5 fold increase in stroke risk
305
What is the most common cause of endocarditis from dental procedures?
Strep Viridans (amoxicillin, one dose, administered before the procedure)
306
P waves in Afib.
Absent.
307
A patient presents with fatigue, shortness of breath, and orthopnea, what kind of heart failure might you suspect and why?
Left Sided Heart Failure (pulmonary system is getting backed up).
308
What happens to the pulse pressure in hypovolemic shock?
Narrows.
309
_________cardiomyopathy is a form of cardiac disease in which the ventricles are too stiff to contract adequately.
Restrictive (leads to diastolic heart failure)
309
What does SIRS stand for?
Systemic Inflammatory Response System
309
Tachypnea, Tachycardia, hypotension, and high WBC are suggestive of ________shock.
Septic
310
How is clinical impact determined in pericardial effusion?
The SPEED of fluid accumulation.
311
Myocarditis often follows what?
Upper Respiratory Infection
311
For a patient with PAD with severe pain in the forefoot relieved by dependency, pain/numbness in the foot with walking, where might the level of obstruction be?
Tibial or pedal
313
When do PVCs “go away”?
With exertion.
315
The divisions of chronic ventricular tachycardia are _________ and _____________
Sustained.
Nonsustained VT (<30 sec)
316
What is the most common cause of supraventricular tachycardia?
WOLF-Parkinson_white syndrome.
317
How do you treat accelerated idioventricular rhythm?
USUALLY NOTHING.
318
Should you use AV blocking meds in Afib?
NO! Can increase conduction via accessory pathway.
321
What might you find on an ECG for myocarditis?
Saddle shaped ST elevations.
T-wave inversion
322
What is the primary management of neurogenic shock?
Correction of persistent hypotension with vasopressors and inotropes
322
What is the treatment of choice in acute coronary syndrome?
Reperfusion percutaneous coronary intervention (angioplasty-restores blood flow in the blocked artery).
323
Pericarditis is characterized by___________,______________, and____________.
Chest pain.
Pericardial friction rub.
Serial ECG changes
324
Volume losses of over 15% of the total intramuscular volume result in ___________and progressive tissue ________.
Hypotension.
Hypoxia
325
What causes AVNRT?
Fast heart beat.
Electrical signal looping back on its self.
Causes atrial and ventricular contraction.
326
In LONG QT SYNDROME:
QTC>________msec in men
QTC>________msec in women
440
460
327
_________is leg pain when walking which resolves with rest.
Claudication
328
What is the most common cause of septic shock in hospitalized patients?
Infection with gram-positive or gram-negative organisms. Distributive Shock
330
Signs and symptoms of ACUTE VT.
-can be asymptomatic w/palpitations.
NORM: some degree of hemodynamics compromise
- syncope
- shortness of breath
- chest pain
- cardiac arrest
- shock
- death
A STEP AWAY FROM VFIB
330
Treatment of Torsades de Pointes
IV Magnesium!!
331
What happens to the heart rate and venous pressure in cardiac tamponade?
Rise. (Heart trying to get blood out).
332
Coronary atherosclerosis is the most common cause of_________________
Left Sided Heart Failure (damage to myocardium, blood not getting to heart tissue, heart unable to work).
332
Name 3 differential diagnosis’ for acute pericarditis.
Acute Gastritis
Angina Pectoris
Myocardial Infarction
(Many more)
332
What might you see on the ECG in cardiac tamponade?
Alternation of QRS. Swinging of heart.
333
What happens to systolic BP in late HF?
Decreased.
333
_________is a distributive type of shock resulting in hypotension, occasionally with a slowed heart rate, that is attributed to the disruption of autonomic pathways within the spinal cord.
Neurogenic shock. (Can occur after damage to central nervous system, such as a spinal cord injury).
335
What is a WIDE COMPLEX RHYTHM, rate of 60-120 bpm?
Accelerated idioventricular rhythm
336
What should you consider in patients complaining of stomach pain (greater than signs presented) and weight loss?
Mesenteric ischemia
337
Are PVCs more common in men or women?
Men
338
All drugs that have been shown to decrease mortality in heart failure have been shown to do so by affecting remodeling which is due to increased _________stimulation and decreased (hormone)_____________production.
Sympathetic.
Aldosterone
338
Prolonged PR interval. Everything else normal.
First Degree AV block
339
How do you treat atrial flutter
Antiarrhythmics
340
Sinus arrhythmia results in irregular ________rate
Ventricular
340
What is the atrial rate in atrial flutter?
250-350bpm
340
How do you treat neurogenic shock?
IV fluids and Vasopressors.
342
When treating A fib with antiarrhythmics, what is Class II?
Beta Blockers
343
What can cause non hemorrhagic hypovolemic shock?
Burns.
Vomiting/diarrhea/dehydration
Hyperosmolar states (diabetic keoacidosis)
Third spacing (ascites, pancreatitis)
344
What are Class II antiarrhythmics?
Beta Blockers
344
You see sawtooth in II, III, and aVF.
Atrial Flutter
344
What is pericardiocentesis?
Echo guided needle drainage used in diagnosing and treating pericardial effusion.
346
What might cause rheumatic fever?
Episode of untreated Group A Streptococcal Pharyngitis
347
What happens to the stroke volume and arterial pulse pressure in cardiac tamponade?
Fall. Too much pressure.
350
How do pulmonary arterioles respond to hypoxia?
They constrict, which raises Pulmonary BP. (Caused by chronic lung disease)
350
AV Block Cause
Increased vagal tone
Fibrosis of conduction system
Ischemic Heart disease
Congenital
Drugs
351
You hear rales and crackles during auscultation, what may this indicate?
Congestive Heart Failure
352
Describe the two pathways within the AV node.
Slow-conducts slowly, short refractory.
Fast-conducts rapidly, long refractory.
353
What medication may be used to treat multifocal atrial tachycardia?
Verapamil
353
Tension pneumothorax limits ______(l/r) ventricular filling by obstruction of __________return.
Right
Venous
353
What is the diagnostic tool of choice with cardiac tamponade?
ECHO!
354
Nonpharm treatment of Long QT
Permanent dual chamber pacemaker
Left cardiac sympathetic enervation
Implantable defibrillator.
355
Who is more likely to get AVNRT?
Women 3:1
355
Following Cardioversion: Afib recurs in ___________of patients at 3 months and___________after 12 months.
40-60%
60-80%
356
Does everyone experience symptoms with Afib?
Absent in 1/3
357
What would you find on exam with a patient with A fib?
Irregular and rapid pulse.
| Maybe a murmur, gallop, JVD or peripheral edema.
357
What is the traditional Mean Arterial Pressure in hypotension?
60-65
358
What should be avoided when treating cardiac tamponade?
Positive-pressure mechanical ventilation. Decrease venous return and aggravate signs and symptoms of tamponade.
360
What is the most common chronic arrhythmia?
A fib
360
What arrhythmia presents with an absence of P waves?
A fib
360
You see erratic, disorganized atrial activity between discrete QRS complexes in an irregular pattern on an EKG, what condition is this likely to be? Irregular irregularity
A fib
360
What category of Afib would include failed treatment to restore or maintain sinus rhythm that is now just an effort to treat rate and symptoms?
Chronic/Permanent
360
True or false: if a pt undergoes a successful cardioversion, they will never have A fib again.
False.
In 3 mos, it will recur in 40-60% of pts
In 12 mos, it will recur in 60-80% of pts
360
If Nonsustained Chronic VT is sustained what might you use to treat it?
Radio frequency ablation
360
Accelerated idioventricular rhythm is a _______complex rhythm, rate of __________
WIDE
60-120 bpm
360
SUPER NARROW QRS complex, WITHOUT p-waves.
Junctional Rhythm
360
________heart failure results from the ventricles unable to adequately FILL with blood.
Diastolic
360
An S3 on expiration is indicative of _________sided heart failure.
LEFT
360
The cause of __________is reflex changes in the effect of vagal input on the normal pacemaker.
Sinus arrythmia
360
What is the main ECG characteristic of a premature atrial complex?
P wave usually different in contour from normal P wave.
360
What is caused by a combo of congenital accessory pathways leading to tachycardia (formed during development of heart)?
Wolff-Parkinson-White
360
What are you REALLY concerned about in regards to Afib?
STROKES! Twice as likely to be fatal!
360
If no cause for PVC is found, what meds could you give?
BBs or CCBs
360
What work up might you order for Junctional Rhythm?
Electrolytes
TSH
EKG
360
Blood work for AV block
Electrolytes
TSH
360
Tension pneumothorax is a type of ____________shock.
Obstructive
360
What happens to cardiac output (or the stroke volume) in hypovolemic shock?
Reduced.
360
JVP is ______ and CVP is _________in cardiogenic shock.
Elevated.
Elevated.
360
What does a low dose of dopamine do in terms of shock management?
Increases HR and contractility (gets more blood into the body)
360
Preload is ________ in cardiogenic shock.
Increased.
360
What causes oliguria in hypovolemia?
Antidiuretic hormone is released. Body is trying to retain what fluid it can.
360
What causes bradycardia in neurogenic shock?
Unopposed vagal activity. (Exacerbated by hypoxia)
360
Acute inflammatory pericarditis is most common in ________-
Males <50 y/o
360
In acute pericarditis chest pain is worse with ______, ________,________,and _________.
Inspiration.
Lying flat
Swallowing
Body movement
360
How do you treat acute pericarditis?
Restrict activity.
TREAT CAUSE!
If no pericardial effusion-stable patients with viral may be discharged.
360
What are major risk factors for endocarditis?
Rheumatic
Bicuspid Aortic Valves
Calcification or sclerotic aortic valves
Tetralogy of Fallot
Intravenous drug use.
360
What is the typically antibiotic used to treat endocarditis?
Penicillin
360
What medication is strongly contraindicated for hypertrophic cardiomyopathy?
Digoxin
Increases contraction force, which increases the obstruction
360
Intermittent claudication, absent pulses, and dry skin are all signs of ______________ disease.
Peripheral Vascular
360
Pharm treatments for PAD.
Platelet inhibitors
STATIN! (High-intensity)
Pharm adjuncts for smoking cessation
360
What are surgical interventions for PAD?
Angioplasty
Bypass procedures
361
How do ACE inhibitors improve blood flow?
Dilate blood vessels.
362
What causes Afib?
Heart Failure
Diabetes
High BP
Hyperthyroidism
Age
Heart Disease
363
Symptoms of CHRONIC VT
Sustained Palpitations (shortness of breath, presyncope/syncope)
Nonsustained: Asymptomatic or syncope
364
Cardiac output is __________in cardiogenic shock.
Decreased.
366
What should you do if you see a wide irregular QRS?
Be worried! Get pads on!!
367
Why would you want to decrease aldosterone production when treating heart failure?
When dysregulated, it increases water in the kidneys, which can increase BP and blood volume, adding more work on the heart.
368
How do you treat ventricular escape rhythm?
Pacemaker
ATROPINE
Treat cause
369
What is the resting target heart rate when treating Afib with rate control? Ambulatory target heart rate?
<80
<100
*Rate control meds can be difficult to tolerate, so sometimes aim is <100 overall
369
What happens to the diastolic pressure in hypovolemic shock?
Elevated.
369
In acute pericarditis, erythrocytes sedimentation rate is usually_______.
Elevated
370
EKG of VT
BIG WIDE QRS, pretty uniform in a lead. CAN’T ID a P WAVE
370
_________are the most common cause of acute pericarditis.
Viruses
371
What are the four types of shock?
Hypovolemic
Cardiogenic
Obstructive
Distributive
372
“Ventricles are driving the ship!”
Ventricular Tachycardia. BAD!!
373
When would you choose to treat rhythm control over rate control with AFib?
A pt still has symptoms despite treating rate.
Rate control has been difficult or not well tolerated.
The pt is younger
First episode or A fib is triggered by acute illness
They develop tachycardia-mediated cardiomyopathy
374
If there is an underlying heart disease present with nonsustained chronic VT what might you use to treat it?
Implantable Cardioverter Defibrillator (ICD) +/- Pacemaker
374
What is the most common cause of palpitations in a structurally normal heart?
Paroxysmal supraventricular tachycardia
375
What is POCUS?
Point of Care Ultrasound
376
Afib causes a______fold increase in risk of heart failure.
3
376
What is the antibiotic of choice for rheumatic fever?
Penicillin
378
A patient dies from cardiac arrest after being woken up from his loud alarm in the morning
Torsades de Pointes
378
What meds may be given for acute pericarditis?
Aspirin: 750-1000mg every 8 hrs, taper (or Ibuprofen)
Colchicine: .5-.6 mg for 3 mo
379
Arrythmias and dysrhythmias can cause______________shock
Cardiogenic
380
What are the SIRS criteria? ( in terms of RR and WBC)
Presence of 2 or more of the following:
- RR>20 or hyperventilation w/ arterial carbon dioxide tension <32mmgh
- abnormal white blood cell count
381
An EKG shows rates ranging from slow to extremely rapid, but irregular, what condition is this likely to be?
A fib
382
BP of bradycardia
<60
383
Risk factors for DVT
Many! Sitting > 4 hours, family history, over 60 years old, cancer & cancer treatment, polycythemia, overweight, smoking, pregnancy, OCP, serious illness, IV drug use. Genetic condition that results in resistance to activated C proteins -> Factor V Leiden mutation. And more!
384
Patient has painful, hot, red swollen area on left calf, which is >3 cm larger in circumference than right calf, they also just flew back from China on a 17 hour flight, what is likely diagnosis?
DVT
385
Best treatment for DVT
Prevention! with early ambulation, anticoagulation, intermittent compression devices, compression stockings, IVC filters, hydration.
386
Following a DVT, 50% of patients experience this condition that is characterized by pain, swelling, redness and sores in area of past DVT? What is treatment?
Post Thrombotic Syndrome
DVT treatments, or capsaicin or menthol cream can help
387
When should you refer a patient with suspected DVT?
Multiple or proximal thromboses, or in unusual places like renal, hepatic or cerebral veins. Or if they are really big!
388
First line treatment of DVT
Anticoagulants: start IV heparin and transition to oral warfarin taken for 3-6 months. Other anticoagulants are available also.
389
What is the main concern regarding DVT?
Pulmonary embolisms
392
Arterial aneurysms are ________the normal size.
>1.5 x
393
If patient has a suspected DVT, what testing would you order?
D-dimer can rule out low probability, but Ultrasound performed by a tech is the definitive test.
Watch out for obese patients -> possible false negatives
394
What is the Virchow Triad?
3 factors that are important in the development of venous thrombosis:
- venous stasis
- activation of blood coagulation
- vein damage
Rudolf Virchow
395
Who should definitely be routinely screened for Abdominal Aortic Aneurysms (AAA)?
Men ages 65-75 who have ever smoked
396
Most detectable symptom of AAA?
Tearing back pain
Other Sx may include: trouble swallowing, chest pain, SOB, feeling of fullness or pain in abdomen, or feeling "heartbeat in abdomen"
397
Treatment of AAA?
If ruptured: stent/graft
If not ruptured and <5 cm, watch and evaluate every 6 months for growth, and treat w/ b-blockers, statins, lower BP and quit smoking. If >5 cm, send to surgeon for evaluation
398
Risk factors for AAA?
Male, smoker, white, cardio-pulmonary disease, being a large person, and 1st degree relative with AAA
399
The separation of the intimacy and media of a vessel that creates a false lumen which then tears and creates surging of blood into abdominal cavity is?
Aortic dissection
20% of pts will die before reaching the hospital. Hospital mortality is 30% for proximal dissection and 10% for distal. Hard to catch, fix or predict.
400
Arterial aneurysm in the lower leg
Peripheral artery aneurysm.
Half of people with these will also have aneurysmal abdominal aorta.
401
The vast majority of arterial aneurysms are found where?
Behind the popliteal.
402
What age greatly increases your risk of DVT?
>60
403
What is the most common inherited cause of DVT in white populations?
Inherited blood-clotting disorder.
* resistance to activated protein C, natural anticoagulant
404
What are symptoms of DVT?
History of little movement.
Pain
Hot
Red
Swollen
Or NO symptoms
405
Pain in ______squeeze is a common exam finding in DVT.
calf
406
When is D-Dimer used in DVT diagnostics?
for ruling out low probability cases
407
What is the mainstay of therapy for DVT?
anticoagulation (prevent pulmonary embolism)
408
When to refer DVT?
Presence of large iliofemoral or IVC thrombosis.
Clots in unusual locations.
409
What are signs of post thrombotic syndrome?
Redness.
Discoloration
Sores/Ulcers
Skin breakdown
Swelling
Pain, ache, burning, itching
410
Most detectable symptom of AAA?
Tearing back pain- if ruptured
They are usually asymptomatic.
Other Sx may include: trouble swallowing, chest pain, SOB, feeling of fullness or pain in abdomen, or feeling "heartbeat in abdomen"
411
Treatment of AAA?
If ruptured: stent/graft
If not ruptured and <5 cm, watch and evaluate every 6 months for growth, and treat w/ b-blockers, statins, lower BP and quit smoking. If >5 cm, send to surgeon for evaluation. Elective repair (EVAR - endovascular aortic repair) is very effective
412
Arterial aneurysm in the lower leg
Peripheral artery aneurysm.
Half of people with these will also have aneurysmal abdominal aorta.
413
3 types of Thoracic Aortic Aneurysms?
Ascending aortic aneurysm, aortic arch aneurysm, or descending aortic aneurysm.
These account for 10% of aneurysms, but have an almost 100% mortality rate.
All have different treatments and approaches.
