Cardio Flashcards
1
Q
T/F
PACs/ APBs (premature atrial contract = atrial premature beat) is a benign arrhythmia
A
T usually asymptomatic can cause palpitations occasionally --) afib tx when distress or svt
2
Q
when to treat PAC/APB
A
(prem at comp / atr prem beat)
when cause distress or svt
(usually asymptomatic, benign)
3
Q
what does cardiac echo eval for
A
function (ef) valvular abnorm structural abnorm (wall thick/thin/motion)
4
Q
how to manage pt w persistent asymptomatic PACs (prem atr contr)
A
B blockers (rate control)
5
Q
cold mottled limb with minimal swelling and absent distal pulses w recent hx of mi think…
A
acute limb ischemia - from heart thrombus embolization (LV thrombus, la thrombus from a fib) or aortic ischemia
-dx test is echo to eval for wall thrombus
6
Q
next dx test when acute limb ischemia suspected in pt w recent MI
A
echo
for wall thrombus that may have embolized
also immediate aticoagulation and sx eval
7
Q
how long after therapy initiation to HIT
A
5-10 days usually
8
Q
HIT makes prone to what kind of thrombus, V or A
A
venous thrombus
-warmth erythema tenderness swelling
9
Q
which is warm and which is cold A vs V thrombus
A
arterial thrombus - acute limb ischemia, cold
venous thrombus - warm erythematous tedner swollen
10
Q
chest sympx of PE
A
tachypnea
pleuritic chest pain
+ s & s of DVT
11
Q
mgmt of acute limb ischemia after mi
A
immediate anticoag
sx eval
TTE (transthoracic echocardiogram)
12
Q
when does variant/prinzmental angina typically occur
A
at night (midnight - 8am)
13
Q
tx variant prinzmental angina
A
CCB (diltiazem)
or nitrates
14
Q
transient STEs on EKG suggest
A
variant/prinzmental angina
15
Q
T/F
can use BBlockers for variant/prinzmental angina
A
F
CI - can worsen vasospasm
16
Q
T/F
can use ASA for variant/prinzmental angina
A
F
–| prostacyclin, can promote coronary vasospasm
17
Q
T/F variant angina mgmt usually includes cholesterol lowering meds
A
F
variant/prinzmental angina often lacks cv risk factors (can manage cholesterol if coincidental elevation)
18
Q
2 common uses of digoxin
A
inc contractility in CHF
rate control in afib or aflutter
19
Q
T/F
heparin to treat uncomplicated variant angina (prinzmental
A
F
vasospasm not coagulability, no need for hep
20
Q
immediate mgmt of STEMI
A
restore blood flow w PCI or fibrinolysis w/in 90 min of contact (or w/in 120 min if transport to capable hosp needed) – PCI better results
21
Q
best tx for long term mortality in STEMI
A
restore blood flow w PCI or fibrinolysis w/in 90 min of contact (or w/in 120 min if transport to capable hosp needed) – PCI better results
22
Q
T/F
in acute MI goal is reduce cardiac afterload
A
F
restore blood flow (PCI#1, fibriolysis) – nitrates reduce pain but no evidence of long term outcome improvement… BBs can reduce O2 demand but not recommended or proven good before PCI/fibrinolysis… can consider after if not brady already…. no goodness of prophylactic antiarrhythmics after MI…
23
Q
secondary prevention in pt w known CAD
5
A
- DAPT: ASA + P2y12 blocker (clopidogrel, prasugrel, ticagrelor)
- BB
- ACEI/ARB
- statin
- Aldo antag (spironoloactone, eplerenon) if HFrEF +- DM
24
Q
clopidogrel
prasugrel
ticagrelor
=
A
p2y12 inhibitors
antiplatelet
25
typical uses of apixaban
nonvalvular afib
VTE
(direct factor Xa inhibitor, anticoag)
26
isosorbide mononitrate long or short acting nitrate?
long acting
27
when to use colchicine in context of MI
when postinfarction pericarditis (rub, chest pain)
28
uses of DAPT
dual antiplatelet theray (ASA + P2Y12 inhib [clopidogrel, prasugrel, ticagrelor])
- nstemi - reduces recurrent MI
- anti stent thrombosis (give for 12 mos)
29
how long DAPT for prevention of coronary stent thrombosis
at least 12 mos
| recommended in all drug-eluting stent pts
30
```
severe or resistent HTN
HTN onset v age 35
sudden ^ BP
^ Cr .5-1 after ACEI or ARB wo BP reduction
systolic epigastric bruit
```
50 yo F w any of above should be screened for __
fibromuscular dysplasia
-abnormal cell dev in arterial wall
(noninflammatory, nonatherosclerotic)
31
50 yo F w any 1 of these 5 characteristics should be screened for fibromuscular dysplasia
```
severe or resistent HTN
HTN onset v age 35
sudden ^ BP
^ Cr .5-1 after ACEI or ARB wo BP reduction
systolic epigastric bruit
```
32
fibromuscular dysplasia
| pathogenesis & presentation
abnormal cell dev in arterial wall
(noninflammatory, nonatherosclerotic)
- resistant HTN (renal a stenosis)
- amaurosis fugax [fleeting darkness - painless transient vision loss uni or bi], horner's, TIA, stroke (brain ischemia - carotid or vertebral a)
- non-specific HA, pulsatitle tinnitus, dizziness (also carotid or vertebral a)
33
amaurosis fugax =
fleeting darkness - painless transient vision loss uni or bi - e.g. from embolus, fibromuscular dysplasia
34
which arteries does FMD fibromuscular dysplasia usually affect
renal
carotid
vertebral
but can affect any
35
dx FMD
fibromuscular dysplasia
- CTA
- Duplex US
- cath-based digital subtraction arteriography if above noninvasive not diagnostic
36
aldo/renin activity ratio in FMD
```
~10 (v20)
fibromuscular dysplasia (secondary hyperaldosteronism)
```
37
aldo/renin activity ratio in primary hyperaldosteronism
> 20
because primary aldo suppresses renin
e.g. adrenal hyperplasia, adenoma
38
how to diff between adrenal hyperplasia vs adenoma as cause of primary hyperaldosteronism
adrenal vein sampling
39
cushingoid findings
```
central obesity
purple striae
proximal muscle wasting
glucose intolerance
hypertension
```
40
1st test for GCA giant cell arteritis
ESR elevated
41
fever fatigue HA transient monocular vision loss jaw claudication =
presentation of GCA
| giant cell arteritis
42
elevated plasma free metanephrines in this secondary cause of hypertension
pheochromocytoma
43
classic triad of
episodic headache, sweating, palpitations
w tachycardia =
presentation of pheochromocytoma
44
FMD fibromuscular dysplasia
| classically presents in what demo
F age `15-50
45
low PCWP + high MvO2 =
septic shock
- low pulm cap wedge press (peripheral vasodilation
- high mixed venous O2 (less systemic vascular resistance, faster flows, inc cardiac output adds to effect, tissues pull out smaller proportion of O2)
46
go-to lab for differentiating CHF from other causes of dyspnea
proBNP
| sns 90, sp 76, ppv 83
47
dressler syndrome
post MI pericarditis... usually 1-6 wks post MI
48
uremic pericarditis
pleuritic CP
pericardial friction rub
uremia
from ARF w uremia ^60
tx = dialysis
49
how to treat uremic pericarditis
dialysis
| rapidly resolves chest pain and reduces size of pericardial effusion
50
how long after MI for dressler's
1-6 wks
| post-MI pericarditis
51
indications for pericardiocentesis
s&s of cardiac tamponade
-hypot, JVD, pulsus paradoxus
or diagnostic if pericardial effusion etiology unclear
52
ekg findings in uremic pericarditis
NOT classic pericarditis diffuse STEs
| normal EKG i think...
53
this tx rapidly improves chest pain and decreases size of pericardial effusion in uremic pericarditis
dialysis
54
arrhythmia most specific for digitalis tox
a tach w AV block
- inc ectopy in atria or ventricles - a tach
- inc vagal stim - av block
55
diff a tach vs a flut
a tach 150-250 bpm
| a flut 250-350 bpm
56
which is faster, a tach or a flut
a flut
a tach 150-250 bpm
a flut 250-350 bpm
57
a tach w av block most specific for this drug toxicity
digoxin
- inc ectopy in atria or ventricles - a tach
- inc vagal stim - av block
58
digoxin MOA
```
blocks KKNaNaNa ATPase
in intra Na
dec exchange w Ca++
inc intra Ca++
inc contractility (positive inotropy)
```
also stim vagus (negative chronotropy)
59
t/f
| digoxin tox causes atrial flutter
```
false
a tach (ectopy)
av block (vagus stim)
```
60
t/f
| digoxin tox causes a fib
```
false
a tach (ectopy)
av block (vagus stim)
```
61
t/f
| digitalis tox causes mobitz II av block
f
path of conduction system below av node does that
```
digoxin does
a tach (ectopy)
av block (vagus stim)
```
62
t/f digitalis causes multifocal atrial tachy
f
think that implies shifting foci?...
```
digoxin does
a tach (ectopy... just one?)
av block (vagus stim)
```
63
common causes of afib
```
atrial volume delta (chf, diuresis)
adrenergic input (inf, stress, thyrotoxixosis)
pulm process (ra volume delta)
pe (check for dvt in afib)
e- abnorm
thyrotoxixosis/other drugs
```
64
afib originates
| aflut originates
fib pulm vein inlet ectopy
flut tricusp annulus reentrant
65
how tx afib if hypotens
no bb or ccb (ok if normotense)
-- dig, amio
digoxin amiodarone
66
target rate control in afib to prevent...
v 110
to prevent tachy cardiomyopathy
anticoagulate to ppx thrombus, not rhythm control (m&m evidence not there)
67
t/f
| control rhythm to prevent clot in afib
f
anticoagulate
no m&m evidence for rhythm control
control rate v110 to prev tachy cardiomyopathy
68
pt comes in to ED screaming ACS (acute coronary syndrome), what are you going to do
nitroglycerin (relieves spasm)
aspirin (stabilizes plaque)
oxygen if needed
trop, 12 lead EKG, call medicine and cards
```
then BB (reduce short term mortality)
and ACEI (reduce long term mortality if certain it is an MI
```
then maybe even heparin and clopidogrel
69
CABG is reserved for
3-vessel disease or more
or
left main stem equivalent
70
pt has single vessel STEMI, next step
angioplasty with drug-eluting stent
(requires one year clopidogrel)
consider bare metal stent (1 month clopidogrel) or angioplasty alone (no clopidogrel) if high risk of non-compliance with clopidogrel
71
old guy with angina, JVD but clear lungs, and STEMI in leads II III aVF
think
act
avoid
R sided infarct
give IVMF because right-sided infarcts are preload dependent
avoid ntiroglycerin and morphine because they are venodilators and will make it worse
72
outpatient with functionally impairing exertional angina but normal EKG, next step
treadmill ecg stress test
| do when exertional angina with no ecg abnorms and can ambulate
73
when to get dobutamine stress echo for outpatient exertional angina
if
baseline ecg abnorms, or
any contraindication to ambulation
(cane, amputee, etc.. not positive treadmill ecg stress test)
74
times to get nuclear stress test for outpatient exertional angina
bundle branch block
poor view on echo
previous bypass
75
when to get angiography for outpatient exertional angina
NSTEMI, STEMI, or positive stress test
76
what test to get for outpatient exertional angina when
- normal ecg and can walk
- normal ecg can't walk
- bbb poor view on echo, previous bypass
- angiography
normal ecg and can walk
-treadmill ecg stress test
normal ecg can't walk
-dobutamine echo
bbb poor view on echo, previous bypass
-nuclear stress test
angiography
-NSTEMI, STEMI, positive stress test
77
cardiac enzymes may take up to __ hours to peak so can only be considered negative after at least __ sets separated by __ hours or after __ hours of ongoing chest pain
cardiac enzymes may take up to 18 hours to peak so can only be considered negative after at least 2 sets separated by 6 hours or after 18 hours of ongoing chest pain
78
elderly man with significant cardiac history and risk factors comes to ED with angina and ecg is abnormal but consistent with baseline and enzymes are negative, next step?
observation and repeat cardiac enzymes at 6 hours
cardiac enzymes may take up to 18 hours to peak so can only be considered negative after at least 2 sets separated by 6 hours or after 18 hours of ongoing chest pain -- after ruling out NSTEMI with enzymes, can consider stress tests or reassurance
79
TF
| LAD plus LCX disease = L mainstem equialent
T
80
what angiography results indicate medical managment for CAD
non-occlusive or non-obstructing CAD
81
man in ED with STEMI and nearest PCI center 85 min away
| what do you do
tPA (streptokinase IV) most critically
also asa bb acei hepariniv
and transfer to PCI center
(magic number is 60 minutes for transport and 90 minutes door-to-baloon)
82
stage I heart failure drug tx
II
III
IV
I - bb acei asa statin
II - add furosemide
III - add spironolactone, isosorbide dinitrate / hydralazine (bidil) combo
IV - iv dobutamine and ventricular assist device until transplant
83
symptomatic stages of heart failure
I - no limitations
II - comfortable walking
III - comfortable at rest only
IV - uncomfortable at rest
84
when to refer for AICD (automated implantable cardioverter defibrillator) for primary prevention of cardiac arrhythmias in setting of heart failure
EF v35% class II or III (comfortable walking comfortable at rest)
or EF v30% class I (unlimited comfort)
not for class IV uncomfortable at rest -- dobutamine and ventricular assist device until transplant for these
85
tf
| give / change bb dose in setting of heart failure exacerbation
f
| don't mess with it, worsens chf exacerbation
86
how does sublingual nitroglycerin work
venodilation, reducing preload, makes heart work less
87
What does an ACI do
reduces afterload
good for cardiac remodeling
good for BP control
88
tf
| st depressions in V1-V4 is an NSTEMI
F
| STEMI (posterior infarct)
89
interpret BNP
v200 is not heart failure
| ^500 is heart failure
90
when is left heart cath done for heart failure
reserved for after heart failure diagnosed
| to ascertain if ischemic or non-ischemic (late in workup)
91
difference between heart failure and ARDS
how to assess
cardiogenic vs non-cardiogenic pulmonary edema
echo and PCWP (normal in ARDS)
-- specifically if PCWP v12 noncardiogenic, if PCWP ^12 cardiogenic
92
treatment for aortic stenosis
surgical valve replacement
maybe baloon valvuloplasty as a bridge to surgical replacement IF hyemodynamically unstable or a poor surgical candidate
93
treatment for mitral valve stenosis
baloon valvuloplasty
94
when can aortic stenosis be medically managed and reevaluated in 3 months
asymptomatic and non-severe (valve area ^.9cm^2 and mean gradient v60mmhg)
95
symptomatic tricuspid valve regurge in setting of past iv drug use - treat
valve replacement
96
old lady with asymptomatic 4/6 murmur
| next step
TTE thrans thoracic echocardiogram
TTE for any murmur ^4/6 or continuous regardless of symptoms
97
when is observation until symptoms arise appropriate for a heart murmur
v3/6 and systolic only
98
when to workup a heart murmur in otherwise completely healthy asymptomatic person
TE for any murmur ^4/6 or continuous regardless of symptoms
or family history of HOCM, bicuspid aortic valve, or connective tissue disorder - get TTE
99
treatment of choice for constrictive pericarditis, e.g. in setting of lupus
pericardiectomy
100
treat pericardial effusion while waiting for pericardocentesis
IVMF - increase R heart pressure to get more blood pumping through
101
when is pericardial window the treatment of choice for pericardial effusion
after fluid has reaccumulated after pericardiocentesis...
102
diagnose and treat acute pericarditis
ecg
| ibuprofen, colchicine 2nd line
103
tf
| steroids for acute pericardititis
f
ibuprofen, colchicine 2nd line
steroids cause bad rebound...
104
aortic stenosis vs mitral insufficiency murmur
AS - systolic crescendo decrescendo
| MR - holosystolic
105
decrescendo diastolic murmur
aortic insufficiency
106
what to do for sudden onset syncope in pt with known CAD or structural heart disease
admit for 24 hr tele to try to catch the arrhythmia
107
statin reccommendation in known CAD pt
high dose statin
atorvastatin 80mg or
rosuvastatin 40mg
108
middle and high potency statin drugs
lovastatin pravastatin simvastatin
(middle potency)
atorvastatin rosuvastatin
(high potency)
109
why is 40mg the max dose of simvastatin
side effects and black box warning with amlodipine
110
when to start ezetemibe in known CAD pt
if already on a statin - combo can decrease MI and strokes but not overall cv disease or mortality
111
when to start niacin in known CAD pt
no longer recommended as second agent on top of statin not proven effective, but still used by some in absence of evidence
-- just know flushing side-effect, aspirin ppx against flushing, and that it increases HDL
112
old guy 96yo with healthy BP and lipid panel on rosuvastatin, continue or discontinue rosuvastatin?
discontinue
-statins improve 10 y mortality risk, not doing anything for this guy anymore -- he does not Need it as his lipid panel and cv status is great, so in old folks try to deescalate therapy/polypharmacy as much as you can
113
when to stop a statin
low risk patient
| or no 10 year mortality benefit (e.g. pt in late 90s)
114
normal lipid panel
total cholesterol v200
ldl v100
HDL ^60
triglycerides v150
115
start statin in middle-aged dude screened at health fair and found to have high LDL low HDL prediabetic A1c a little HTN but asymptomatic?
No. counsel diet/lifestyle
start statin (atorvastatin or rosuvastatin) for for high risk pt (HAS DISEASE) -- CAD or DM stroke PAD etc or TONS of ASCVD risk factors
116
TF
| lisinopril and HCTZ both cause hyperkalemia
F
ACEIs and ARBS do cause HYPERkalemia
HCTZ causes HYPOkalemia
117
how do thiazide diuretics and loop diuretics affect potassium
HYPOkalemia
118
main se of amlodipine
peripheral edema
119
main se's of ACIs and ARBS
inc Cr and HYPERkalemia
ACEIs cause angioedema too
120
main se of metoprolol
bradycardia
121
TF
| thiazide diuretics cause both hyperkalemia and hyponatremia
T
| los dos
122
TF
| beta blocker is first-line for htn
Fish
| not first line for htn anymore, 2nd line, but first line for known CAD so will often see
123
blood pressure goal in pt age ^60yo withOut DM or CKD
v150/90
124
blood pressure goal in pt age 18-59yo or ^60 With DM or CKD
v140/90
125
1st line antihypertensives
2nd line
3rd line
thiazide diruetic, CCB, ACEI/ARB
(and according to comorbidities -- BB if CAD, ACEI if DM)
higher doses of above
BB, hydralazine (vasodilators), aldosterone antagonists, furosemide (other diuretics)
126
blood pressure goal in pt age ^60yo withOut dm or ckd
blood pressure goal in pt age 18-59yo or ^60 With DM or CKD
v150/90 goal ^60 no dm or ckd
v140/90 goal v60 or ^60 With DM or CKD
127
when is midodrine added to CV med regimen
moa
in setting of adrenal insufficiency to increase blood pressure
alpha1 agonist
128
old lady with orthostatic dizziness and hr 50 and afib, what to do with metoprolol
reduce metoprolol (se bradycardia... e.g. symptomatic near-syncope)
129
```
1st degree AV block
2nd degree AV block type 1
2nd degree AV block type 2
3rd degree AV block
idioventricular rhythm
```
```
1 - PR prolonged but fixed
2 type 1 - PR lengthens till QRS dropped
2 type 2 - PR fixed but randomly dropped QRSs
3 - P QRS dissociation
idiov - no p waves, QRS wide, non-tachy
```
130
which AV blocks are commonly misread
2 type 1 - PR lengthens till QRS dropped
vs
3 - P QRS dissociation
commonly confused
131
manage 3rd degree av block (complete dissoc)
pace it
transcutaneous pacing if pt unstable -- then fix cause if reversible
tranvenous while in the hospital
implantable pacemaker for long term
132
CHADS2 score
```
CHF hx 1
HTN hx 1
Age^75 1
DM hx 1
Stroke or TIA hx 2
```
for cardioembolic stroke risk in AFib
133
treat AFib based on CHADS2 score
```
0 - aspirin vs reassurance
1 - OAC or asa
2 or more
-NOAC (dabigatran, apixaban, rivaroxaban)
-or Warfarin if NOACs unavailable
```
134
CHA2DS2 VaSc score
```
CHF hx 1
HTN hx 1
Age^65 1 ^75 2
DM hx 1
Stroke or TIA hx 2
```
```
Vascular dz (MI PAD aortic plaque) 1
Sex F 1
```
for cardioembolic stroke risk in AFib
```
0 - aspirin vs reassurance
1 - OAC or asa
2 or more
-NOAC (dabigatran, apixaban, rivaroxaban)
-or Warfarin if NOACs unavailable
```
135
AFib with RVR and evidence of CHF exacerbation, pt stable -- rate control drug?
avoid?
BB, digoxin, or amiodarone
(yes amio can control rate or rhythm)
NOT CCB - avoid in CHF Exacerbation as can decrease EF
136
ACLS stands for
advanced cardiac life support
137
code blue on pt found in bed with apparent emesis and probable aspiration
act - first priority, others
COMPRESSIONS (CAB)
-moving partially oxygenated blood better than not moving oxygenated blood, Compressions Save Lives
Then airway, breathing, IV access, epi etc
138
unstable bradycardia of any kind gets ____ as first step
transcutaneous pacing
unstable bradycardia of any kind gets Transcutaneous Pacing as first step
139
girl took all of Mom's metoprolol in suicide attempt, in ED with unstable bradycardia needing hemodynamic support, act
transcutaneous pacing
-unstable bradycardia of any kind gets Transcutaneous Pacing as first step
Then consider glucagon as antidote to BB, Epi and Dopamine to inc hr, Atropine to temporize hr while infusion gets started
140
medically treat
Afib that is stable
Aflutter that is stable
SVT
wide-complex monomorphic tachycardia that is stable
Vtach/Vfib arrest
torsades
panic attack
Metoprolol (and Amiodarone) - afib that is stable
Metoprolol - aflutter that is stable
Adenosine - SVT
Amiodarone - wide-complex monomorphic tachycardia that is stable
DC Cardioversion shock - Epi if shock doesn't work - Amiodarone after epi - vtach/vfib arrest
Mg - torsades
Lorazepam - panic attack
141
no P waves, resting hr ^150, QRS narrow =
SVT
142
describe SVT on ekg
no P waves, resting hr ^150, QRS narrow
143
pt with SOB and tachycardia but stable, EKG no P waves, resting hr ^150, QRS narrow
dx
treat
SVT
Adenosine IV push 6mg followed by 12mg and 12 mg again if failure to break rhythm
144
get rate control in A-fib/A-flutter
Metoprolol
| ..Amiodarone for rhythm... and rate control in Afib too...
145
when to terminate resuscitory efforts in ACLS
after 20-25 minutes or more of cardiac rest in a pulseless electrical activity or asystole
146
when is lidocaine used in ACLS
in Vtach or Vfib arrest after 2 doses of amiodarone
147
when is defibrillation used in ACLS
in Vtach or Vrib only
148
when is Epi used in ACLS
in all forms of cardiac arrest, given q3-5 minutes
149
when are the following used in ACLS
Lidocaine
Defibrillation
Epi
Lidocaine - in Vtach or Vfib arrest after 2 doses of amiodarone
Defibrillation - in Vtach or Vrib only
Epi - in all forms of cardiac arrest, given q3-5 minutes
150
92 yo pt found in hospital bed with rigor mortis, dependent pooling of blood, and cold (room temperature) -- activate acls?
no
call time of death
if pt was found this way buried in snow on a mountain, then maybe attempt resuscitation and don't declare dead until warm-dead... but he his in a hospital bed in a controlled environment not expose environment
