Cardio Flashcards
Treatment for child with coarctation of the aorta presenting in cardiogenic shock?
PGE1 (to keep ductus arteriosus open)
Acute Aortic Dissection early Tx:
Esmolol (short acting B1 easily titratable)
Prinzmetal’s angina.
d/t
EKG findings
Tx
Do not give ____? Why? What other related condition should you not give this med?
Substernal chest pressure at rest and during activity worse in the AM and with smoking.
Dx: Transient ST Elevations on EKG
Tx: CCB, Nitrates
Do not give Propranolol. Unopposed alpha vasoconstriction can cause death. Don’t give Propranolol in Intermittent Claudication (for the same reason).
EKG findings of myocardial infarction.
Sustained ST elevations (transmural)
Transient or sustained ST depressions
Q waves (Old MI)
Digoxin
MOA
What is it used for?
Blocks Na/K ATPase of cardiac myocytes to slow conduction through SA and AV nodes.
For A.Fib
Digoxin Toxicity S&S.
Antidote?
Yellow vision
Abd pain
2º AV Node Type I (Wenckebach) Block.
Tx: Digoxin Immune Fab
S&S of Left sided Heart Failure (weeks after Anterior MI.)
Most likely caused by?
Dyspnea, crackles
↑ PCWP (> 15) and ↑ RA pressure (>6)
d/t Ventricular Aneurysm (ST elevations in V1-V4)
What is the 1st line med in all Acute Coronary Syndromes?
Aspirin. (Clopidogrel if unable to tolerate). Reduces morbidity and mortality.
Management of Symptomatic A. Fib
Dx?
Dx: TEE to check for intracardiac thrombus OR
Anticoagulate for 3 wks before cardioversion
LBBB
No R in V1
Tall R in V6
RBBB
RSR1 “Rabbit ears”
Hypo/Hypercalcemia EKG changes?
Hypocal = “po“longed QT.
Hypercalcemia is opposite (shortened QT)
What is Kussmaul’s sign?
JVP Increased with Inspiration
[Norm JVP= 6-8]
Aortic Stenosis keywords
Pulmonic Post (L 2 ICS)
Ejection
“Parvus”
Radiates to Carotids
Assoc: Turner’s Syn, Heyde’s angiodysplasia of colon
Mitral Regurg keywords
@ Apex
Radiates to Axilla
Blowing
Marfan’s (also seen in Aortic Regurg)
Papillary mm. rupture
Weight loss meds
Mitral Valve Prolapse keywords
@ Apex
Midsystolic (Think MVP of the mid-season)
Better w/ squat
Klinefelter
Hypertrophic (Systolic) Cardiomyopathy keywords
LSB
S in V1 + R(V5/V6) > 35mm
Louder w/ Valsalva, standing, vasodilators, diuretics (anything that ↓ preload/afterload)
Tx: BB, CCB
Aortic Regurg keywords
@ LSB/Pulmonic post (L 2 ICS)
High pitched blowing
Flash pulmonary edema
(Austin Flint, Duroziez, Corrigan, DeMusset, Quincke),
Marfan’s (also seen in Mitral Regurg)
Syphilis
Tx: Hydralazine, ACEi, CCB
Valve replace if Austin Flint
HAC V?
What is Austin Flint? Significance?
backward flow of blood hitting mitral valve leaflet.
Time to REPLACE the AORTIC VALVE
What is Duroziez sign?
Femoral bruit
What is Corrigan’s Pulse?
Water hammer bounding pulse
What is DeMusset’s sign?
Head Bobbing
What is Quincke’s Pulse?
Pulsating Nail Bed
Mitral Stenosis keywords
@ Apex
Hemoptysis
Mid-diastolic rumble with *Opening snap*
Loud S1
Rheumatic Fever, Group A Strep.
Tx: Balloon Valvotomy
What can cause 1st Degree AV Block?
Vagal tone
Wenckebach Tx.
Stop BB, CCB, or Digoxin
Atropine
Tx. for Mobitz 2, 3rd Degree AV Block, and Sick Sinus Syndrome
Pacemaker (Transcutaneous pacing)
A. Fib Tx parameters
1) Anticoagulate if CHADS2 >=2.
2) If 48 hrs, Anticoagulate,
3) If 3-6 weeks of Warfarin (INR 2-3) can cardiovert
Multifocal Atrial Tachycardia Tx
BB or CCB for rate control
Tx. for AVNRT or AVRT
1) Carotid massage, Valsalva.
2) Adenosine.
3) Cardiovert if hemodynamically unstable
Tx. Unstable supraventricular tachycardia
Synchronized Cardioversion (If conscious add sedation)
CHF acute exacerbation management
LMNOPA:
Lasix, Morphine, Nitrates, O2, Position upright, ACEi/ARB
Cilostazol MOA, indications, and contraindications
Phosphodiesterase inhibitor that decreases platelet aggregation and causes arterial vasodilation, that used for Intermittent Claudication and PVD.
Contraindicated in CHF
NYHA Class I
No limitations.
NYHA Class II
Slight activity limits. Comfortable at rest, but ordinary activity results in angina, dyspnea, fatigue, or palpitations. Tx: ACEi, BB, Loops for exacerbations
NYHA Class III
Comfortable ONLY at rest. Tx: ACEi, BB, Loops, Spironolactone
NYHA Class IV
Symptoms at rest. Can’t carry out any physical activity without discomfort. Tx: ACEi, BB, Loops, Spironolactone
Tx of Ventricular Tachycardia
Cardioversion is your PAL (Procainamide, Amiodarone, Lidocaine)
What EKG abnormality is Brugada Syndrome associated with?
V. Fib
Torsades can be d/t taking what medications?
Haloperidol
Atypical antipsychotics
Torsades de Pointes tx
Mg
Chronic CHF Tx
Chronic CHF is BADS
BB
ACEi/ARB, ASA
Diuretics (Loops + Thiazide + Spironolactone)
Statin
Loop Diuretics [Lasix, Ethacrynic Acid, Torsemide]
MOA
AE
↓ Na/K/Cl/Ca reuptake.
Ototoxicity, HypO-K and Ca
Which Loop diuretic is not part of the Sulfa family?
Ethacrynic Acid
Thiazides [Chlorothiazide, Chlorthalidone]
MOA
AE?
↓ NaCl reuptake.
Cause HypO-K and alkaLOsis, HyperGLUC
Aldosterone antagonists/K sparing [Spironolactone, Triamterene, Amiloride]
MOA
AE
Spironolactone: aldosterone rec antagonist
Triamterene, Amiloride: block Na channels
HyPER-K, Gynecomastia
Carbonic Anhydrase Inhibitors MOA
AE
Decreased HCO3- retention
HyPER-Chloremia and aCidosis, Sulfa allergy
Wet Beriberi
B1 deficiency manifesting as:
Tachycardia, vasodilation, ↓ SVR, ↑ JVP, DOE, Edema
What is the gold standard for diagnosing atherosclerosis or if there’s unstable angina?
Coronary Angiography
Angina Pectoris Acute tx.
MONAB:
Morphine, O2, Nitrates, ASA + ACEi, BB
Angina Pectoris Chronic tx
“BAN”
BB
ACEi + ASA
Nitrates
NSTEMI tx
CASH CAB:
Cath,
ASA,
Statin,
Heparin
Clopidogrel,
ACEi,
BB
What does it mean if you see ST Elevations in II, III, aVF? What blood supply is affected?
What do you do?
Inferior MI (which will involve the RV 50% of the time), RCA/PDA and LCA.
- Right sided MI will usually have Hypotension and Bradycardia (RCA s> SA node)
Dx: Get Right-sided EKG
Tx: Give Fluid Bolus (because RV function will be ‘preload’ dependent)
What meds are contraindicated in RV infarction?
NITRATES contraindicated in RV infarction
If there’s a Coronary A. Reocclusion after MI, what labs do you look at?
CK-MB
ST depression V1-V2 indicates what?
Acute Posterior Wall Transmural Infarct
If an MI pt. is in heart failure (hypoxia, S3, pulm edema) or Cardiogenic shock, DON’T give what?
NO BB. Gives ACEi
STEMI tx
Angiography.
PCI within 90 min.
>90 then do TPA
Most common cause of death following acute MI?
Tx?
Ventricular Arrhythmia
Tx: Immediate unsynchronized Cardioversion
Post MI complication Day 1
Heart failure
Arrhythmia is most common complication (within 24 hrs, and days 2-4) following MI.
Post MI complications days 3-7 (or 5-10)
Intraventricular septal rupture: hemodynamic instability and new holosystolic murmur @ LSB
Ventricular free wall rupture: leads to hemopericardium/ cardiac tamponade with Beck’s triad
Papillary mm. rupture: mitral regurg and left heart failure
Post MI complication Weeks-Mo. after
CHF, persistent ST Elevation, mitral regurg, ventricular aneurysm
Which lipid lowering agent causes angioedema?
Ezetimibe (cholesterol absorp inhibitor)
How to diagnose and tx. Renal A. stenosis?
MRA or Renal A. Doppler US. Tx: Angioplasty, stenting, ACEis ONLY if unilateral
Conn’s syndrome Triad
HTN, HypO-K and AlkaLOsis. Increased Aldo v Renin
Malignant HTN
S&S
Tx?
>180/120.
Retinal hemorrhages, exudates, encephalopathy, papilledema (NOT Renal failure)
Tx: IV Sodium Nitroprusside (1st line), Hydralazine, Labetolol (if no COPD), Enalapril
Mean Arterial Pressure
[SBP + 2(DBP)] / 3
ACEi Adverse Effects
HyPER-K, Angioedema, Cough
MOA of Methyldopa
centrally acting adrenergic agonist
Constrictive Pericarditis keywords
pericardial knock
Aortic Dissection keywords
Spiral CT angiography, Between media & adventitia, diastolic decrescendo @ aortic post
Stanford A of Aortic Dissection
Left Subclavian, Proximal. Surgical emergency
Stanford B of Aortic Dissection
Left Subclavian, Distal. Medically manage
Debakey I
Ascending & Descending
Debakey II
Ascending
Debakey III
Descending
Leriche Syndrome
Butt claudication, v femoral pulses, impotence
What drains to Right lymphatic Duct
R Head and Neck, R upper extremity, Heart, Lungs
Vasovagal syncope
excess parasympathetics. Tilt-table test. Tx BB
Brugada Syn keywords
Na chan mutation in myocytes. ST elevation V1-V3 + RBBB + S waves in lateral leads.
Goal LDL for CAD/equivalents i.e. DM, PAD, Symptomatic Carotid a. dz, abdominal aortic aneurysm
Goal LDL for 0-1 risk factors
Goal LDL for 2+ risk factors
When is measuring PCWP (~Left Atrial pressure) helpful?
for checking severity of LV HF, quantifying degree of mitral stenosis, inc. in tamponade, restrictive cardiomyopathy, hypertrophy, for checking for pulmonary HTN
Loud holosystolic murmur @ LSB that is non-cyanotic
Ventricular Septal Defect
What would an Atrial Septal Defect sound like?
wide, fixed split S2
Tx. of Asymptomatic Sustained Monomorphic Vtach
Procainamide
Tx. of Symptomatic Sustained Monomorphic Vtach
Cardioversion
Tx. of Narrow QRS SVT
Adenosine
Tx. of Severe Bradyarrhythmias causing hemodynamic collapse
Transvenous pacing
What is the most appropriate next step in management in a patient with Intermittent Claudication?
Check Ankle-Brachial Index (ABI)
Venous hum
systolic/diastolic @ RSB quiets with pressure to jugular vein
Still murmur
early systolic, @ LSB, normal split S2
Peripheral pulmonary a. stenosis of the newborn
mid systolic, radiates to back and axilla, resolves in 3-6 mo.
Tx. for Atrial Flutter (hemodynamically stable pt)
Verapamil Metoprolol
What is the leading cause of isolated mitral regurgitation requiring surgery?
mitral valve prolapse
Tx. for 2nd Degree AV block (Wenckebach)?
Atropine, BB, CCB, Digoxin
Tx. for Mobitz II?
Pacemaker
Tx. for 3rd Degree AV Block?
Pacemaker
What is the most common indication for pacemaker placement?
Sick Sinus syndrome
Tx. Atrial Fib?
Anticoagulate if >48 hrs
BB, CCB, Dig Cardioversion
Tx. for AVNRT and AVRT?
If unstable: Cardioversion
Stable: carotid massage, valsalva, Adenosine
Tx: Unstable Supraventricular Tachycardia
Circulation, Airway, Breathing
Synchronized Cardioversion
Defibrillation (not in synchrony with QRS) is Tx for what?
V. Fib
V. Tach no pulse
Cardioversion (in synchrony with QRS) is tx for what?
A. Fib/ A. Flutter
SVT
VT w/ pulse
CHF Dx?
Labs?
Tx?
Dx: Clinical diagnosis. Check EKG, BNP, 2D Echo.
Labs: ↓ Cardiac Index, ↑ SVR and LVEDV
Tx:
Restrict fluid and salt (H2O <2L/d, Na <2g/d), ACEi/ARB, BB, Lasix, Spironolactone, Imdur, Hydralazine
AICD for Ejection Fraction <35.
Dobutamine for cardiogenic shock.
Tx. HOCM
BB, CCB, avoid dehydration
Tx. of Acute Angina
MONAB (Morphine, O2, Nitrates, ASA/ACEi, BB)
Tx. Chronic Angina
Nitrates, ASA/ACEi, BB
How do Nitrates work?
Dilate capacitance vessels (veins) and ↓ ventricular preload
NSTEMI
Dx?
Tx?
Myocardial infarction marked by elevated Troponin I and CK-MB without ST elevations
Tx: Stable: Clopidogrel, Heparin
Unstable: Cardiac Catheterization/PCI
STEMI
Dx?
Tx?
Goals after hospitalization?
EKG, Troponins
Tx:
Angiography and PCI w/in 90 min
If no PCI, then TPA for thrombolysis
PMONAB: Plavix, Morphine, O2, Nitrates, ASA/ACEi, BB (but not if heart failure or cardiogenic shock. Just give ACEi)
On d/c: BASH –> BB, ACEi/ARB, Statin, Heparin
Goal: <130/80, A1C<7, LDL<70
Fibrates (Gemfibrozil)
MOA
Effects on lipid profile
Adverse SE?
↑ LPL
↓ TGs and ↑ HDL
! LFTs, myositis
Ezetimibe (Cholesterol absorption Inhibitors)
MOA
Effects on Lipid Profile
Adverse SE
↓ absorption at brush border to ↓ LDL
! diarrhea, angioedema
Niacin
MOA
Effects on Lipid Profile
Adverse SE
↓ LDL synthesis and thus ↑ HDL
! skin flushing, LFTs
Cholestyramine (Bile Acid resin)
Effects on Lipid Profile
Adverse SE
↓ LDL
! diarrhea, LFTs
Vasovagal syncope
d/t?
dx?
Tx?
excess parasympathetic stimulation (i.e. carotid stim, coughing, micturition, defecation)
Dx: Tilt-Table Test
Tx: BB
Neurogenic Shock
d/t?
Dx?
Tx?
hypotension, bradycardia, and hypothermia with + focal neurological deficit
unopposed vagal tone causes vasodilation which then ↓ SVR, which is why ↓ PCWP. In addition, vagal tone promotes ↓ HR, which then ↓ CO and ↓ BP
“warm and dry extremities” (also seen in septic shock)
Dx: CT angio, MR angio, US of Carotids
Tx: DA, Vasopressin, Atropine for bradycardia
What is the tx. for acute decompensated Systolic Heart Failure refractory to medical management?
Milrinone: PDE inhibitor that increases cAMP and therefore increases cardiac contractility.
Dobutamine
Dopamine
What is a feared complication of Carotid Endarterectomy (CEA)?
Hyperperfusion Syndrome:
Increased blood flow after stenosis is released that causes headache, seizure, hemorrhage in pts. who have a high degree of stenosis or recently suffered a stroke
Cardiogenic Shock
d/t?
Dx?
Tx?
heart failure causes ↓ CO, ↓ BP so the body tries to compensate by ↑ SVR, ↑ HR and when blood comes back to left atrium, ↑ PCWP
“pale cool skin”, JVP
d/t heart failure e.g. MI
Dx: EKG, Troponins
Tx: Fluids, Dobutamine, inotropes, anti-arrhythmics (Adenosine, Amiodarone, BB), Intra-aortic balloon pump
Septic Shock
d/t
Dx?
Tx?
↓ SVR (~↓ BP) which then leads to
↓ PCWP (~Left Arterial Pressure: too little fluid in)
↑ HR ↑ CO
“warm and dry” extremities
suspect in pts. with penetrating abdominal wounds and GI contamination
Tx: Fluids, Broad spectrum ABX (? GI: Cipro, Metronidazole, Vanco), Norepinephrine to vasoconstrict peripheral arterioles
Anaphylactic Shock
↓ SVR (~↓ BP) which then leads to
↓ PCWP (~Left Arterial Pressure: too little fluid in)
↑ HR ↑ CO (heart wants to raise the system’s volume and flush out allergen?)
Tx: DVT
SQ Heparin x 5d then Coumadin x 6 mo. [INR 2.0-3.0]
Post MI complication 3-7 days
Intraventricular septal rupture: hemodynamic instability and new holosystolic murmur @ LSB
