Cardio Flashcards
What is the normal range for the PR interval?
0.12-0.2 seconds
What is the normal duration for a QRS complex?
Less than 0.12 seconds
What is the normal QTc?
Less than 0.44 seconds
What defines pathological Q waves?
More than 0.04 seconds or more than one-third of the QRS amplitude
What are the EKG findings for RAA (P pulmonale)?
Increased P wave amplitude
What are the EKG findings for LAA (P Mitrale)?
Increased P wave duration (possible biphasic)
How many centimeters above the sternal angle defines JVD?
7 cm
What is the hepatojugular reflux?
distention of neck veins upon applying pressure to the liver
What is Kussmaul’s sign? What causes it?
(↑ in jugular venous pressure [JVP] with inspiration): Often seen in cardiac tamponade and constrictive pericarditis.
What causes the S4 heart sound?
Decreased ventricular compliance
What causes the S3 heart sound?
Volume overload
What causes bounding peripheral pulses?
Compensated aortic regurgitation
What is pulsus paradoxus, and what does it mean?
(↓ systolic BP with inspiration): Pericardial tamponade;
What is pulsus alternans, and what does it mean?
(alternating weak and strong pulses): Cardiac tamponade or impaired left ventricular function
What is pulsus parvus et tardus, and what does it mean?
(weak and delayed pulse): Aortic stenosis.
What are the ABCDs of a-fib management?
Anticoagulate
Beta blockers
Cardiovert/CCBs
Digoxin (in refractory cases)
What are the components of the CHA2 DS2 -VASc scoring system to estimate stroke risk in atrial fibrillation
■ CHF (1 point) ■ HTN (1 point) ■ Age ≥ 75 (2 points) ■ Diabetes (1 point) ■ Stroke or TIA history (2 points) ■ Vascular disease (1 point) ■ Age 65–74 (1 point) ■ Sex category (female) (1 point)
What types of drugs can cause first degree or mobitz type I AV blocks?
Beta blockers
CCBs
Digoxin
What is the treatment for mobitz type I AV block?
Atropine PRN
What is the treatment for mobitz type II AV block?
Pacemaker placement
What is the prognosis for mobitz type II AV block?
Frequently progresses to third degree AV block
What is the most common indication for a pacemaker placement?
Sick sinus syndrome
What are the components of the PIRATES mnemonic for remembering the causes of a-fib?
Pulmonary disease Ischemia Rheumatic heart disease Anemia/atrial myxoma Thyrotoxicosis Ethanol Sepsis
What is the timeframe in which you can cardiovert a patient out of a-fib?
Less than 2 days, otherwise may throw a clot
True or false: atrial flutter is treated similarly to a-fib?
True
What are the EKG findings of multifocal atrial tachycardia?
At least 3 different P-wave morphologies
What is AV nodal reentry tachycardia? How does it appear on EKG
A reentry circuit in the AV node depolarizes the atrium and ventricle nearly simultaneously.
Rate 150–250 bpm; P wave is often buried in QRS or shortly after.
What is the treatment for AVNRT?
Cardiovert if hemodynamically unstable. Carotid massage, Valsalva, or adenosine can stop the arrhythmia.
What causes AVRT? What are the EKG findings?
An ectopic connection between the atrium and ventricle that causes a reentry circuit. Seen in WPW.
A retrograde P wave is often seen after a normal QRS. A preexcitation delta wave is characteristically seen in WPW.
What is the treatment for AVRT?
Same as AVNRT
What causes paroxysmal atrial tachycardia? EKG findings?
Rapid ectopic pacemaker in the atrium (not sinus node).
Rate > 100 bpm; P wave with an unusual axis before each normal QRS.
What is the treatment for paroxysmal atrial tachycardia?
Adenosine can be used to unmask underlying atrial activity by slowing down the rate.
An EF of less than what percent indicates systolic dysfunction?
50%
What is the earliest and most common presenting symptom of systolic dysfunction?
Exertional dyspnea
Orthopnea
PND
True or false: both digoxin and diuretics confer a mortality benefit with systolic heart dysfunction
False–neither do
What is the underlying pathophysiology of systolic heart dysfunction?
The heart compensates for ↓ EF and ↑ preload through hypertrophy and ventricular dilation (Frank-Starling law), but the compensation ultimately fails, leading to ↑ myocardial work and worsening systolic function.
What is the treatment for acute systolic heart failure?
Aggressive diuresis
SHould Beta blockers be continued or stopped during a CHF exacerbation?
Stopped
What are the components of the LMNOP mnemonic for the treatment of acute systolic HF?
Lasix (furosemide) Morphine Nitrates Oxygen Position (upright)
What are the lifestyle modifications for CHF?
Lower Na and fluid intake
What is the pharmacologic therapy for chronic CHF?
Beta blockers and ACEIs/ARBs
Diuretics
What is the one diuretic that has been shown to decrease mortalaty in chronic HF patients?
Spironolactone
When is daily ASA and a statin indicated in the treatment of chronic HF?
If underlying cause is a MI
What are the procedural treatments for HF?
ICD
LVAD
When is an ICD indicated in the treatment of HF?
If EF is less than 35%
What is the extra heart sound associated with systolic HF? non-systolic?
systolic = S3 Non = S4
What will an EKG and echo typically show with systolic dysfunction?
Q waves and a decreased EF
What will an EKG and echo typically show with non-systolic dysfunction?
LVH Normal EF (more than 55%)
What is the general pathophysiology of non systolic heart dysfunction?
Decreased ventricular compliance with normal systolic function
The ventricle has either impaired active relaxation (ischemia) or impaired passive filling (scarring)
What are the s/sx of non-systolic HF?
Unstable angina SOB DOE arrhythmias MI
What is the treatment for non-systolic HF?
Diuretics
Maintain BP
True or false: digoxin is useful for patients with non systolic HF
False
What is the most common loop diuretic?
Furosemide (lasix)
What are the side effects of loop diuretics?
Hypokalemia
Hypocalcemia
Ototoxic
What are the side effects of thiazide diuretics?
Hypokalemic metabolic alkalosis Hyperglycemia (GLUC) Hyperlipidemia Hyperuricemia Hypercalcemia
What are the three major K sparing diuretics?
Spironolactone
Triamterene
Amiloride
What is the classic carbonic anhydrase inhibitor?
Acetazolamide
What are the side effects of CAIs?
hyperchloremic metabolic acidosis
What are the contraindications to mannitol use?
Pulmonary edema
Anuria
What is the most common form of cardiomyopathy?
Dilated
What are the physiological characteristics of dilated cardiomyopathy?
LV dilation and decreased EF 2/2 impaired contractility
What are the known secondary causes of dilated cardiomyopathy?
EtOH
Myocarditis
Postpartum status
Drugs
Which antineoplastic agent classically causes dilated cardiomyopathy?
Doxorubicin
What are the three major infectious causes of dilated cardiomyopathy?
Coxsackievirus
HIV
Chagas disease
What is the underlying pathophysiology of hypertrophic cardiomyopathy?
Impaired relaxation
What is the underlying pathophysiology of restrictive cardiomyopathy?
Impaired elasticity
What happens to LV cavity size at the end of diastole in the following types of cardiomyopathy:
Dilated
Hypertrophic
Restrictive
Dilated - Increased Markedly
Hypertrophic - Decreased
Restrictive - Increased
What happens to LV cavity size at the end of systole in the following types of cardiomyopathy:
Dilated
Hypertrophic
Restrictive
Dilated - Increased Markedly
Hypertrophic - Decreased markedly
Restrictive - Increased
What happens to EF in the following types of cardiomyopathy:
Dilated
Hypertrophic
Restrictive
Dilated - Decreased
Hypertrophic - Increased or normal
Restrictive -decreased or normal
What happens to heart wall thickness in the following types of cardiomyopathy:
Dilated
Hypertrophic
Restrictive
Dilated - Decreased
Hypertrophic - Increased
Restrictive - Increased
How do you diagnose cardiomyopathies?
Echo
What is the treatment for cardiomyopathies?
Address underlying etiology if known
Treat CHF
What is the inheritance pattern of hypertrophic obstructive cardiomyopathy?
AD
What is the murmur heard with HOCM? What increases the intensity?
a systolic ejection crescendo-decrescendo murmur that ↑ with ↓ preload
What is the treatment for HOCM?
beta blockers
Myomectomy
What is the general cause of restrictive cardiomyopathy?
Infiltrative diseases
What are the s/sx of restrictive cardiomyopathy?
Left and right sided heart failure
What is the treatment of restrictive cardiomyopathy?
Judicious use of diuretics and vasodilators
What are the 4 risk equivalents of CAD
DM
AAA
Symptomatic carotid artery disease
PAD
Are cardiac enzymes elevated with prinzmetal angina?
No
What are the only two drugs that have been shown to have a mortality benefit in the treatment of angina?
ASA
Beta blockers
What defines unstable angina?
new onset chest pain that is accelerating or occurs at rest
What is the range of scores in the TIMI risk score?
0-7
When is heparin indicated in the treatment of a NSTEMI?
Patients with chest pain refractory to medical therapy, a TIMI score of ≥ 3, a troponin elevation, or ST changes > 1 mm should be given IV heparin and scheduled for angiography and possible revascularization
What is the best predictor of survival with an MI?
Left ventricular EF
What can an EKG show with a STEMI, besides ST elevation?
New LBBB
What is the progression of EKG changes with a STEMI?
Peaked T waves → ST-segment elevation → Q waves → T-wave inversion → ST-segment normalization → T-wave normalization over several hours to days.
In inferior wall MI, avoid nitrates. Why?
Risk of severe hypotension
What are the four indications for a CABG?
- Unable to stent
- Left main coronary artery disease
- Triple vessel disease
- Depressed ventricular function
When are thrombolytics indicated in the treatment of a STEMI? (3)
- PCI cannot be performed with 90 mins
- No contraindications
- the patient presents within 3 hours of chest pain onset,
When does HF usually present post MI?
First day
When do arrhythmias/pericarditis usually present post MI?
2-4 days
When does left ventricular free wall rupture present post MI?
5-10 days
When does ventricular aneurysm present post MI?
Weeks to months later
What are the s/sx of Dressler syndrome
Fever Pericarditis Pleural effusions Leukocytosis Increased ESR
How often are lipids levels monitored? When does screening start, typically?
q 5 years for 35+ males and 45+ females, if not high risk
When are high, intermediate, and low intensity statins indicated for the treatment of CAD?
■ ≥ 7.5% 10-year risk → high-intensity statin.
■ Between 5% and 7.5% 10-year → moderate-intensity statin.
■ ≤ 5% 10-year risk → no statin.
What are the LDL and HDL criteria for dyslipidemia?
■ LDL > 130 mg/dL
or
■ HDL < 40 mg/dL
What is the first intervention for dyslipidemia?
The first intervention should be a 12-week trial of diet and exercise in a patient with no known atherosclerotic vascular disease.
What is the effect of fibrates on lipid levels?
Decreases triglycerides
Increases HDL
What is the effect of statins on lipid levels?
Decreases LDL
Decreases Triglycerides
What is the effect of cholesterol absorption inhibitors (ezetimibe) on lipid levels?
Decreases LDL
What is the classic cholesterol absorption inhibitor?
Ezetimibe
What is the effect of niacin on lipid levels?
Increases HDL
Decreases LDL
What are the bile acid resins?
Cholestyramine
Colestipol
Colesevelam
What is the effect of bile acid resins on lipid levels?
Decreases LDL
What is the BP goal for patients 60+?
150/90
What is the BP goal for patients less than 60 or with DM/CKD?
140/90
What are the two HTN drugs that are safe in pregnancy?
Labetalol
Hydralazine
Why should you not lower the BP more than 25% in the first 2 hours of a HTN emergency?
Prevent cerebral hypoperfusion or coronary insufficiency
What is the treatment for HTN 2/2 renal disease?
ACEIs to slow progression of renal disease
What is a common cause of HTN in young women?
OCP use
What is the metabolic disturbance with Conn syndrome?
Hypokalemic alkalosis
What are the components of the CARDIAC RIND mnemonic for causes of pericarditis?
Collagen vascular disease Aortic dissection Radiation Drugs Infections Acute renal failure Cardiac (MI) Rheumatic fever Injury Neoplasms Dressler syndrome
Pulsus paradoxus is classically seen in what?
Cardiac tamponade
What are the EKG changes seen in pericarditis?
Diffuse ST segment elevation and/or ST depression
What is the treatment for pericarditis?
addressing the underlying cause
Corticosteroids and NSAIDs
Which is more important in the setting of cardiac tamponade: the rate of filling, or the amount?
rate
What are the components of Beck’s triad for cardiac tamponade?
Hypotension
JVD
Distant heart sounds
What is Kussmaul’s sign?
Increased JVD on inspiration
What is the treatment for tamponade?
Aggressive volume expansion with IVFs
Urgent pericardiocentesis
Over how many centimeters is repair indicated for AAA?
5 cm
When can aortic stenosis lead to symptoms in childhood?
If bicuspid or unicuspid valve
What are the three major s/sx of aortic stenosis?
Angina
CHF
Syncope
What is pulsus parvus et tardus, and what does it indicate?
Weak, delayed carotid upstroke, associated with aortic stenosis
Once symptoms appear with aortic stenosis, how long do patients have to live, if untreated?
5 years
What is the etiology of acute vs chronic aortic regurgitation?
Acute: Infective endocarditis, aortic dissection, chest trauma.
Chronic: Valve malformations, rheumatic fever, connective tissue disorders.
What are the s/sx of acute aortic regurg?
Acute: Rapid onset of pulmonary congestion, cardiogenic shock, and severe dyspnea.
What are the s/sx of chronic aortic regurg?
Slowly progressive onset of dyspnea on exertion, orthopnea, and PND.
What is the treatment for aortic regurgitation?
Vasodilator therapy (dihydropyridines or ACEIs) for isolated aortic regurgitation until symptoms become severe enough to warrant valve replacement.
What is the most common etiology of mitral valve stenosis?
Rheumatic heart disease
What are the s/sx of mitral stenosis?
Symptoms range from dyspnea, orthopnea, and PND to infective endocarditis and arrhythmias.
What is the treatment for aortic stenosis?
Antiarrhythmics (β-blockers, digoxin) for symptomatic relief; mitral balloon valvotomy and valve replacement are effective for severe cases.
What are the two major etiologies of mitral valve regurgitation?
Primarily 2° to rheumatic fever or chordae tendineae rupture after MI.
What is the treatment for mitral valve regurgitation?
Antiarrhythmics if necessary (AF is common with LAE; nitrates and diuretics to ↓ preload). Valve repair or replacement for severe cases.
Aortic aneurysms are most commonly associated with what disease process?
Atherosclerosis
What are the s/sx of a AAA?
Asymptomatic but pulsatile abdominal mass or abdominal bruit
What is the screening test for AAA?
Screen all men 65–75 years of age with a history of smoking once by ultrasound for AAA (see Figure 2.1-16).
Aortic dissections are most commonly associated with what disease process?
HTN
What are the classic PE findings of aortic dissection?
Asymmetric pulses and BP measurements.
What is the diagnostic imaging modality of choice for an aortic dissection?
CT angio
What is the treatment for aortic dissection?
Monitor and medically manage BP and heart rate as necessary. Avoid thrombolytics. Begin β-blockade before starting vasodilators to prevent reflex tachycardia.
What are the components of virchow’s triad?
- hemostasis
- Endothelial damage/trauma
- hypercoagulability
What is the treatment for a DVT?
IV unfractionated heparin or SQ LMWH, followed by PO warfarin for 3-6 months
how can you roughly locate the presence of a clot in the lower extremity?
occur at bifurcations distal to the last palpable pulse
Pain at rest usually occurs at what ABI?
less than 0.4
A very high ABI can indicate what pathology?
Calcification of the arteries
What are the 6 P’s of acute ischemia?
Pain Pallor Paralysis Pulselessness Paresthesias Poikilothermia
What is the role of exercise in the treatment of claudication?
Helps to develop collateral circulation
What are the medications that can improve symptoms of claudication?
ASA
Cilostazol
Thromboxane inhibitors
What is the most common cause of lymphedema in the developed world?
Surgical side effect
What is the role of diuretics in the treatment of lymphedema?
Ineffective, and relatively contraindicated
What are the major features that distinguish syncope from a seizure?
Unlike syncope, seizures may be characterized by a preceding aura, tonic-clonic activity, tongue-biting, bladder and bowel incontinence, and a postictal phase.
Cardiac causes of syncope are typically associated with what symptoms?
Very brief or absent prodromal symptoms
h/o exertion
Lack of association with changes in position
What should be done to r/o cardiogenic causes of syncope?
Holter monitor
ECG
Echo
Stress test
What should be done to r/o neurological causes of syncope?
Heat CT
EEG
When does reinfarction typically occur s/p MI?
0-48 hours
When does ventricular septal typically occur s/p MI?
hours-1 week
When does free wall rupture typically occur s/p MI?
Hours-2 weeks
When does postinfarction angina typically occur s/p MI?
hours - 1 month
When does papillary muscle rupture occur s/p MI?
2 days - 1 week
When does pericarditis occur s/p MI?
1 day - 3 months
When does a left ventricular aneurysm typically occur s/p MI?
5 days - 3 months
ST/segment elevations and deep Q waves in the same lead as a recent, previous MI = ?
free wall rupture
