Cardio Flashcards
Delayed and diminished carotid pulses
Pulsus Parvus et Tardus…AORTIC STENOSIS
Prominent capillary pulsations in fingertips/nail beds
Widened Pulse Pressure…Aortic Regurg
When do you see Pulsus Paradoxus? (exag. decrease in SBP with inspiration)
Pericardial diseases (Cardiac Tamponade), Severe Asthma and COPD
______ can trigger bronchoconstriction in patients with asthma
Aspirin or beta-blockers
Tx for vasospastic angina
Preventative: CCB
Abortive: Sublingual Nitroglycerin
Young patients (<50), hx of smoking, recurrent chest pain lasting <15 min (at rest/sleep)
Vasospastic angina (Hyper-reactivity of smooth muscle)
ECG findings in vasospastic angina
Leads to transmural myocardial ischemia = ST-elevation
Electrical alternas + Sinus Tachycardia
varying amplitude of QRS complex
PERICARDIAL EFFUSION (b/c swinging motion of heart in the sac= beat-beat variation)–>leads to cardiac tamponade. Tx with with emergency pericardiocentesis
Common Complications after MI:
- Hours-2 days =
- hours-1 week =
- hours - 2 week =
- hours - 1 month =
- 2 days - 1 weeks =
- 1 day - 3 months =
- 5 days - 3 months =
hours - 2 days = Re-infarction
hours - 1 week = Ventricular septal rupture
hours - 2 week = Free wall Rupture
hours - 1 month = Post-infarction Angina
2 days - 1 week = Papillary muscle rupture
1 day - 3 months = Pericarditis (Dressler)
5 day - 3 months = Left ventricular aneurysm (ST-elevation, deep Q waves; thin dyskinetic LV; risk of mural thrombus)
Classic Pericarditis ECG findings
Diffuse ST-segment elevations
won’t be seen in Uremic pericarditis
most accurate test for detecting coronary artery disease
Coronary angiogram (cath lab)
What would you expect LV EDV to be in patient with CHF?
Increased LV EDV: due to renal sodium and H20 retention
SVR: Increased (reflexive)
Which anti-htn med has side effect of peripheral edema?
CCB: Amlodipine/Nifedipine
what stimulates renin from JGA? alpha/beta agonist/antagonist?
Beta agonist
What effect would acute MR have on LA or LV?
Wouldnt change LA size/compliance unless chronic; acutely, have increased LV filling pressures
Tx of afib in patient with Wolf Parkinson White
IV Procainamide (or ibutilide)
Note: do NOT use adenosine, beta blockers, digoxin b/c promotes conduction across accessory pathway and thus VFib
What do you need to monitor when using Amiodarone for arrythmias?
PFTs, LFTs, TFTs. Get baseline levels + cxr before initiating
Effect of _____ on Mobitz type 1 vs 2:
- Vagal manuevers
- exercise/atropine
Vagal: worsens type 1, improves type 2
Exercise/atropine: improves 1, worsens 2
what should you look out for in a patient given nitroprusside?
Cyanide toxicity (most common in pt with renal insuff)! AMS, seizures, coma, lactic acidosis
Tx for cyanide toxicity
(i.e. in a pt given nitroprusside and develops seizures/AMS)
Nitrite + thiosulfate, hydroxycobalamin
what should be started in pts with MI within 24 hours (unless CI)?
ACE-I to prevent remodeling (which would lead to DCM)
Recent URI + new-onset CHM
DCM secondary to viral myocarditis (usually coxsackie)
Echo finding in DCM
Dilated ventricles + diffuse hypokinesia (resulting in low EF)
High voltage QRS + lateral ST depression + lateral T-wave inversion
Left Ventricular Hypertrophy (usually due to long standing or secondary htn)
T/F: Mitral stenosis patients commonly develop A-fib due to significant left atrial deviation
True
Loud S1 and diastolic rumbling
Mitral Stenosis
Tx for Aortic Dissection
BETA BLOCKERS, then Vasodilators
–>bb’s help to reduce HR, SBP, and LV contractility
Irregularly irregular rate, ____ p waves, ____ QRS complexes = afib ecg findings
absent
narrow
Management of A-Fib
1a. Rate Control (stable pts): Beta blockers, Diltiazem, Digoxin
1b. Rhythm Control: Anti-arrythmics (i.e. Amiodarone)
2. ALL PATIENTS SHOULD UNDERGO CHADS-VASC thromboembolism risk assessment
Mgmt of pt with acute STEMI
- Medical:
- Oxygen
- Full-dose aspirin (chewed = better absorption)
- Anti-platelet (Clipidogrel/Ticragrelor)
- Nitroglycerin with Morphine (pain)
- Anti-coagulation (heparin)
- Beta blocker - PROMPT REPERFUSION with PCI (ideal, w/in 2 hrs) or fibrinolytic (within 12 hours)
- Start statins after acute
How much carotid stenosis until you need to do surgery (carotid endarterectomy)?
Asx or sx: >60% (men) ; >70% (women)
Management for HCM:
- Avoid volume depletion
- BETA BLOCKERS (pref)…or CCB’s (verapamil/disopyramide)
- ->they prolong diastole and reduce contractility = decreased obstruction
…avoid vasodilators (i thought its good b/c dec afterload) b/c this can in turn decrease preload
mgmt of vasovagal syncope
- Reassurance
- Avoidance of triggers
- Counterpressure Techniques for recurrent eps (assume supine position and do leg raises; leg crossing with muscle tensing; handrgrip; fist clenching)
Syncope associated with emotional/painful stimuli, often ass. with a prodrome (dizziness, pallor, diaphoresis, abdominal pain, sense of warmth)
Vasovagal syncope
predisposition for aortic dissection
<40: many of them from Marfans or cocaine
Most important risk factor in gen population: HYPERTENSION
leads to LV hypertrophy, diastolic HF with preserved EF
severe and long standing HTN (hypertensive heart disease)
Which electrolyte abnormality is a marker for severity of CHF?
Hyponatremia…an independent predictor of adverse outcome
T/F: Increasing Na intake is the initial tx for CHF pts with hyponatremia
False…its to limit water intake
Why does dobutamine help in heart failure?
Primarily acts as Beta-1 agonist = increase contractility (also get inc hr)
Diffuse ST elevation in all leads, except reciprocal depression in aVR
Pericarditis!!! (vs in STEMI, its only ST elevation in select leads)
…Dressler syndrome = post MI pericarditis, within weeks. Tx = NSAIDS
which drugs increase digoxin levels and increase likelihood of toxicity (GI sxs, weakness, arrythmia, neuro signs)?
Amiodarone (decrease digoxin dose by 25% when its started), also verapamil, quinidine, propafenone
What is use-dependance and which anti-arrythmics is this seen with?
-Seen with Class IC (= Flecainide, Propafenone) and Class 4 (CCB Verapamil, Diltiazem)
- enhanced pharm effects during faster heart rates
- class 1C = widening of QRS complex because decrease in impulse conduction during faster hr
- Class 4 = increase PR interval b/c prolong refractory period of AV node
What does hepatojugular reflex indicate?
failing RV that cannot accomodate an increase in venous return with abdominal compression
What do you give patients with chest pain and suspected Acute Coronary Syndrome initially in the ED?
Give Aspirin asap! prevents progression to MI and mortatlity
Tx for STEMI, NSTEMI
STEMI: Immediate cath or thrombolysis
NSTEMI: Anti-coagulation
T/F: Diuretics improve long-term survival in patients with LH failure i.e. post MI
FALSE.
Which meds improve long-term survival in pts with LV failure i.e. post-MI
ACE-I
ARB
Beta-blocker
Mineralocorticoid-R antagonists (Eplerenone, Spironolactone)
Note: CCB, Digoxin and Diuretics = only sx tx
What happens first after MI, papillary muscle rupture or free wall rupture?
Papillary muscle rupture (within 3-5 days)
Free wall rupture occurs 5days - 2weeks later
Acute, severe pulmonary edema and new systolic murmur 3 days after MI
Papillary muscle rupture
shock, distant heart sounds, and JVD 1-2 weeks after MI
Free wall rupture
Digoxin (digitalis) toxicity arrythmia:
Atrial tachy + AV block
T/F: S3 heard in CHF pt
true
isolated systolic hypertension in the elderly
increased stiffness/decreased elasticity of the arterial wall
(SBP >140, DBP <90)
Blue toe syndrome, livedo reticularis, AKI after catheterization
Cholesterol emboli
Screening for AAA
USPSTF recommends men 65-75 who have smoked get a 1-time abdominal US
When do you see Pulsus Paradoxus?
Cardiac Tamponade, Severe asthma or COPD, OSA, Pericarditis, Croup
T/F: Aortic regurg is characterized by pulsus paradoxus
False. Widened pulse pressure.
vs pulsus paradoxus = decrease in amplitude systolic BP >10 on inspiration
T/F: Aortic dissection characterized by widened pulse pressure
false, aortic regurg
Sound created by turbulent flow to ventricles due to increased volume
S3
Mitral regurg, HF
Sound created by atrial contraction fluid hitting stiff ventricle
S4
Aortic stenosis, LVH, Acute MI
Cardiac manifestations of sarcoidosis (pt with Uveitis, dyspnea, erythema nodosum, arthritis, bell’s palsy)
Arrythmia, Heart block, Sudden death. Restrictive cardiomyopathy early, dilated cardiomyopathy late.
Why do patients with sarcoidosis (uveitis, dyspnea, lymphadenopathy) have hypercalcemia?
Increased 1-alpha-hydroxylase mediated vitamin D activation in Macrophages (granuloma)
Uveitis is caused by:
PAIR (including Crohns and UC and Reiters/chlamydia)
Sarcoidosis
causes of Afib
- Hypertensive heart disease (#1), CAD
- Rheumatic mitral valve dz
- OSA, PE
- Hyperthyroidism, Obesity, Alcohol, Cocaine, Theophylline
How to tell if syncope is cardiac or vasovagal/neurogenic?
Cardiac: no prodrome. underlying structural heart dz
Vagal/neuro: prodome = nausea, pallor, dizziness, diaphoresis, warmth
Patient with hypotension has equal diastolic pressures throughout chambers
Cardiac tamponade
Beck’s triad
Cardiac tamponade clinical signs = Hypotension, Increased JVD, distant heart sounds (due to the pericardial effusion)
Mgmt of patient in ED with hypotension, JVD, distant heart sounds, pulsus paradoxus, tachycardia, electrical alterans
This patient has cardiac tamponade.
Need STAT ECHO to dx, and then can surgical/percutanous drainage
Narrow QRS complex
SVT –> typically caused by sinus tachy, aflutter/afib, re-entrant
- ->if hemodynamically stable, can’t give meds…need CARDIOVERSION
- ->otherwise, IV Adenosine. CCB and BB are alternatives.
Ankle-Brachial Index
PVD bitch PVD
Dual platelet therapy
Needed post MI/CAD.
Aspirin + ADP Inhibitor AKA P2y12 receptor blocker (clopidogrel, ticagrelor, ticlodipine)
When does post Mi pericarditis occur?
PERI means around “the date” 4 letters so within 4 days
New S3 after recent travel, no rash, signs of CHF
Viral myocarditis –> causes DCM –> decompensated HF
most common form of paroxysmal SVT
AV nodal re-entrant tachycardia –> re-entrant in AV node.
–>vagal manuevers i.e. cold-water submersion can fix this
Afterload and mixed venous oxygen saturation separate septic shock from cardiogenic/hypovolemic how?
Afterload in septic: low (get vasodilation). Cardiogenic/hypovolemic =high (because constricting down)
MvO2: Septic is high (hyperdynamic circulation due to low afterload, CO is increased and tissues cant extract enough O2. Cardiogenic/hypovolemic low (low tissue perfusion so tissues desperately grab as much O2 as they can)
What drugs should you use for thromboembolism prophy in afib pt?
Warfarin or Direct X Inhibitor (Apixaban/Rivaroxaban/Dabigatrin)
–>NOT ASPIRIN OR CLOPIDOGREL
how do you avoid flushing rxn from Niacin?
It is Prostaglandin-medicated vasoDILATION
–>avoid using Aspirin
Atrial fluid is most commonly caused by:
ectopic foci in pulmonary veins
Atrial flutter is most commonly caused by:
reentrant circuit around tricuspid annulus
Most common cause of Mitral regurg
Mitral valve prolapse (myxomatous degeneration of mitral valve)
Why do you give Adenosine or perform vagal manuevers in patient with some form of supraventricular tachycardia?
Because these cause AV block (aids in dx)
- abolish AV dependent arrythmias i.e. re-entrant tachy like Paroxysmal SVT
- unmask hidden p waves in atrial flutter/fib
- if MAT, atrial tachy is not disrupted
what drugs do you avoid in WPW?
AV nodal blocking drugs like Adenosine, beta blockers, CCB (verapamil), and digoxin
–>promotes conduction across accessory pathway
(these are typically drugs used from SVT’s so keep this exception in mind)
what drugs do you use for WPW
Class IA and IC anti-arrythmics (avoid adenosine/beta blocker/digoxin)
what’s one way clinically distinguish SVT from VT?
Supraventricular tachycardia’s respond to Adenosine/vagal manuevers. Vtach does not
tx of vtach
Amiodarone is first line. can also use sotalol, procainamide.
(avoid adenosine/beta blockers/digoxin)
T/F: Chronic therapy is always necessary for patients with Vfib
False
IF vfib not ass. with MI, need chronic therapy (amiodarone or ICD)
If vfib within 48 hours of MI, don’t need therapy
If you can’t measure patient BP and they have absent pulse and heart sounds, what arrythmia do they have?
VFib
Atropine treats _______cardia
bradycardia
so NOT supraventricular tachycardia
3 things to do for VFib
Cardioversion
CPR
Epinephrine
P-R >0.20, a QRS follows each P
1st degree Heart Block
tx for DCM
similar to CHF
Digoxin, diuretics, vasodilators,
why do all patients with pericarditis get an echo?
to r/o pericardial effusion
loud s1 vs soft s2
MS vs AS
Tx for mitral stenosis
Diuretics and beta blockers (pulm congestion ; dec HR and CO)
Can do Percutaneous balloon valvulopasty. Watch out for Afib developing
Patient with Aortic Stenosis develops new murmur
Mitral regurg. LV hypertrophy pulls mitral valve annulus apart
causes of Aortic Stenosis
calcification of congenital bicuspid aortic valve (doesn’t necessary present in childhood)
rheumatic fever
calcifcation of tricuspic aortic valve in elderly
early/mid/late peaking systolic murmur
Aortic stenosis. Early = mild, late = severe
Parvus et tardus pulses
Aortic stenosis
Tx for Aortic stenosis
aortic valve replacement. meds don’t really help
T/F: Aortic regurg murmur increases with handgrip
True…this increases SVR = increased backflow through valve
most common cause of MR
MVP (in developed countries)
HTN urgency vs emergency
Emergency includes end-organ damage, need IV meds
(urgency can use oral)
for both SBP>220 or DBP>120
Signs of end-organ damage (htn emergency)
Eyes: Papilledema CNS: AMS, ICH, HTN ecenphalopathy Kidneys: Renal failure, hematuria Heart: USA, MI, CHF w/pulm edema, Aortic dissection Lungs: pulm edema
what causes PRES?
Posterior Reversible encephalopathy syndrome…caused by htn emergency
what are the sxs of PRES?
Headache, AMS, visual changes, seizure. high BP overwhelms autoregulation of cerebral vessels = arteriolar dilation and fluid into brain
–>Radiograph = opsterior cerebral white matter edema
imaging for Aortic dissection
TEE and CT
note: CXR will show widened mediastinum
most important factor in tx of peripheral vascular dz
STOP SMOKING
When do you use the ankle-brachial index?
Dx of Peripheral Vascular Dz
T/F: Intermittent claudication indicates severe PVD
False, it actually is associated with good prognosis
Cramping leg pain that is reliably reproduced by walking the same distance, completely relieved by rest
Intermittent claudication, associated with peripheral vascular dz (usually good prognosis if this is present)
The 6 P’s of acute arterial occlusion (embolization)
Pain Pallor Polar (cold) Paralysis Paresthesias Pulselessness (using doppler to assess)
When would you give a patient with diabetes statin?
Any diabetic >40 years old should be on a statin, decreased lifetime risk. So even if their cholesterol is within normal limits, they should get the statin .
where does aortic dissection pain radiate?
Anterior chest or interscapular back. “Knifelike”
How do you make dx of aortic dissection?
TEE is very good!
CXR shows widened mediastinum, CT angiography is also very good (can’t use if renal insuff though b/c nephrogenic systemic fibrosis from gad contrast).
T/F: You should get a BNP level whenever you’re worried about cardiac invovlement
False.
Get it when you have a patient with dyspnea to see if its related to CHF.
What murmur would you expect a patient with aortic dissection to develop?
Aortic Regurg…decrescendo diastolic murmur
most common valvular abnormality in rheumatic fever
Mitral Stenosis (this is uncommon in developed countries)
Septal hypertrophy + __________ = HCM
Systolic anterior leaflet motion of mitral valve
Contact btwn mitral valve and septum = LVOT
what kind of murmur is heard in HCM?
Harsh Crescendo-Decrescendo @ apex and LSB
murmur that radiates to the carotids
Aortic stenosis
Patient that is >40 and non-diabetic gets a statin when 10 year risk is > _____ %
7.5
First line tx for chronic stable angina
BETA BLOCKERS
CCB are also used but not first line
How do beta blockers, ccb and nitrates help alleviate angina?
Beta blockers: dec myocardial contractility and HR
CCB: Coronary artery vasodilation (increase O2 supply) and systemic arterial dilation (dec afterload)
Nitrates: Venodilation = dec preload
what are the 2 ways to reperfuse the heart (increase blood flow through coronary arteries) immediately after STEMI?
PCI (Percutaneous intervention) or fibrinolysis
Narrow QRS complexes
SVT
T/F: You need to defribillate in a patient with afib and sxs
False, you need to do Cardioversion!
Defibrillation is for vfib
Why does pulsus paradoxus occur in tamponade?
Normal: Inspiration = decreased intrathoracic pressure = increased venous return
In tamponade, RV expansion is limited due to the fluid surrounding the heart, so causes septal deviation and you get less filling in the LV
what are the anti-ischemic and anti-anginal effects of nitrates due to?
They are vaso/veno dilators. Systemic vasodilation = decreased preload and LVEDV and reduces myocardial oxygen demand by reducing wall stress
systolic murmur that decreases on intensity when squatting and/or leg raise
HOCM. Squatting and leg raise = increased venous return (and thus preload)
T/F: Valsalva and hand grip decrease preload
false. Valsalva decreases preload but hand grip increases after load
strongest predictor of stent thrombosis (pt presents with MI after recent stent placement) in first 12 months
medication noncompliance: they need double platelet therapy (Aspirin + Clopidogrel/Ticragrelor/Prasugrel)
What kind of shock leads to an increased mixed venous o2?
Septic (inability of tissues to extract O2 due to hyperdynamic circulation…CO is increased to maintain perfusion because SVR is low)
Which shock leads to a decreased afterload?
Septic
components of CHA2DS2-VASc score
CHF HTN Age>75 (2) DM Stroke/tia/thromboembolism (2) Vascular dz (prior MI, PVD, etc) Age 65-74 Sex category (female)
CHF sxs in a patient with normal EF
Heart failure with preserved EF (HFpEF) = DIASTOLIC DYSFUNCTION.
due to HTN with LVH, restrictive CM, HCM, sarcoid (infiltrative CM)
most common cause of death after MI
Vfib
T/F: Afib and Vfib both respond to defibrilliation
False
AFib: Cardioversion
VFib: Defibrillation
effects of AGII (i.e. in a pt with CHF)
- preferential vasoconstriction of Efferent Renal Arteriole = increase intraglomerular P = maintain GFR
- decrease in renal blood flow from constriction of both afferent and efferent glomerular arterioles = increase renal vascular resistance
- Stim of Na reabosorption in proximal tubule and release of aldosterone (which inc Na reab in CD)
T/F: Patient in Afib always gets cardioversion
False.
Hemo stable: Rate control with Beta Blockers or CCB (Diltiazem or Verapamil). digoxin is a low option.
Hemo unstable: Rhythm control w/ cardioversion
Patient on digoxin develops Vtach few days after furosemide started. Why and mgmt?
Either due to hypokalemia/hypomagnesemia directly from the furesomide or b/c diuretics potentiate arrythmic effects of digoxin. Get serum electrolytes and serum digoxin levels.
Fast and Narrow Arrythmia (stable)
N in narrow means use adeNosine –> Atrial rhythms (afib/flutter/SVT/sinus tachy)
Fast and Wide Arrythmia (stable)
W is made of 2 V’s and flipped over is an M. So use aMiodarone for these Ventricular arrythmias (vfib/vtach/TORSADES)
exertional dyspnea + S4
Diastolic HF, most commonly from LVH from long-standing HTN
Tx of pericarditis
NSAIDS and Colchicine
viral may need anti-viral; uremic needs dialysis
Most common causes of Afib, Aflutter
Afib: Ectopic foci in pulmonary veins
Aflutter: Re-entrant circuit around tricuspid annulus
Digitalis toxicity arrythmia
atrial tachycardia with AV nodal block
Systemic noninflammatory dz that affects Renal and Internal Carotid Arteries
Fibromuscular Dysplasia
- ->ICA: Recurrent Headaches (most common sx of FMD)
- ->Renal a. stenosis: Htn from 2nd HyperAldosteronism
Look for a subauricular bruit in a young pt. May have pulsatile tinnitus, neck/flank pain
Patients with PAD and intermittent claudication have a 20% risk of ____ and ____ in the next 5 years
MI and Stroke (MI higher risk)
increased JVP on inspiration (instead of normal decrease)
Kussmaul Sign
- constrictive pericarditis (TB/viral)
- restrictive CM
- RA or RV tumor
T/F: S3 indicates LV failure and requires diuretics
True
What do you actually see on EKG when electrical alterans is present?
You look at the peak of the QRS complexes and see varying amplitudes
systolic murmur that increases when patient stands up
HCM ejection murmur. Standing up decreases venous return to the heart
when is paradoxical splitting seen?
Conditions that prolong aortic valve closure: Aortic Stenosis and LBBB
Chagas patient will have recently traveled and present with cardiac dz (i.e. DCM or CHF) and _______/_______
megacolon/megaesophagus
Systolic murmur at the apex that decreases with squatting
MVP (so its not only HCM that reduces with increases VR)
–>Apex = mitral valve
These patients get secondary prevention of CVD with statin:
- LDL>____
- Hx of
- current dz (2):
- LDL>190
- Hx of MI, ANGINA, TIA/stroke, PAD
- DM or CKD
What is a pericardial knock?
Very specific sign of Constrictive Pericarditis
–>mid-diastolic squeaky sound
T/F: Cardiac amyloidosis will show increased ventricular wall thickness (concentric hypertrophy) on ECHO (restrictive cardiomyopathy), especially in absence of HTN hx. may have heavy proteinuria, waxy skin, enlarged tongue, neuropathy, hepatomegaly
True (amyloidosis in general)
How are you going to handle all “identify the rhythm” questions
- Determine rate (tachy vs brady)
2. Determine QRS complex: >.12 = ventricular;
Stable arrythmias medical tx:
Fast and narrow
Fast and wide
Slow
fast and Narrow = adeNosine [atrial]
fast and Wide = aMiodarone {VVide = Ventricular)
Slow = Atropine (anticholinergic)
Afib/flutter tx: rate or rhythm?
RATE CONTROL: Beta Blockers or CCB (verapamil, diltiazem)
Why arrythmia do you use beta blocker/CCB to control?
Afib/flutter (stable)
Typical vs atypical for cardiac chest pain (angina)
Typical (3/3): Substernal; exertional; relieved by nitroglycerin
Atypical = 2/3
If someone has no ST changes on EKG, negative troponin, but suspect cardiac chest pain? What if they can’t use a treadmill?
-Stress test. If normal baseline EKG can use EKG, otherwise ECHO.
-Can medically induce: Dobutamine or Adenosine
+ stress test = straight to Cath
What is a + stress test and how do you manage?
-+ chest pain during test or imaging modality changes
-EKG: ST elevations/t wave inversions
-Echo: Dyskinesia (akinesis)…dead things don’t move
(if akinesis at rest and during stress = Infarct; if only during exercise = Ischemia, shows salvagable tissue)
–>+ stress test = CATHETERIZATION
What if asked for the “best test” for dx of coronary artery disease?
Catheterization. can tell severity of stenosis and r/o prinzmetal (if they were clean coronary arteries but producing ischemia, its prinz)
Which medications are you giving someone presenting with true angina?
1st and foremost: ASPIRIN ASPIRIN ASPIRIN ASPIRIN
MONA BASH
Morphine, O2, Nitrates, Aspirin, Beta blocker, Ace-I, Statin, Heparin
Which MONA BASH medications are avoided in right sided infarcts (II, III, aVF)?
Nitrates
Name the 3 loop diuretics (can use these in heart failure patients to decrease preload)
Furesomide
Bumetanide
Torsemide
“-mide, -nide”
Afterload reduction in HF patients
- ACE-I for everyone
2. if its pretty bad, add Spironolactone or Hydralazine
Preload reduction in HF patients
- Decrease salt and fluid intake (everyone)
- If worse, Furesomide (or bumetanide)
- if pretty bad, can add Isosorbide dinitrate (venodilator)
When is dobutamine used in HF patients?
Dire situation, when prepareing for transplant or ventricular assist device. Its an inotropic med (continuous infusion)
Why are all HF patients on a beta blocker?
Reduce arrythmia and remodeling…reduces risk of sudden cardiac death.
…if EF<35% use AICD (defribillator) or Digoxin
If a HF patient has ischemia, what meds should they also be on?
Aspirin and Statin
MONA BASH vs LMNOP?
MONA BASH: Acute ischemia (EKG changes/MI)
LMNOP: CHF patients…Lasix, Morphine, Nitrates, O2, POSITION (sitting up). don’t use beta blocker during acute exacerbations
T/F: Patient with acute CHF exacerbation needs beta blocker
False, never start one during acute ep (but they need one after to reduce risk of sudden cardiac death).
Give LMNOP during acute ep
T/F: You should avoid dehydration/BB/CCB in concentric hypertrophy
True, it leads to diastolic HF. BB allow ventricle to fill
T/F: Give beta blocker/diuretics/ACE-I for dilated cardiomyopathy
True, its a systolic CHF
Aortic stenosis-like murmur heard at the apex and improves with increased preload
HOCM
Tx for HCM
Avoid dehydration
Give beta blockers (or CCB) to allow an increase in ventricular filling (keep HR low)
how do you differentiate btwn amyloid, sarcoid, and hemochromatosis as cause of restrictive CM?
Amyloid: look for peripheral neuropathy. Do a fat pad bx
Sarcoid: pulm dz. Do endomyocardial bx
Hemochromatosis: cirrhosis/DM. screen ferritin (Increased Fe and ferritin, low TIBC)
T/F: The worse the mistral stenosis (usually caused by RF), the later the snap
False. Earlier snap = worse
For which valvular disease (read: murmur) does balloon valvuloplasty work (vs having to straight replace the valve)?
Mitral stenosis (think of it as being the one caused by an infection i.e. Rheumatic fever so its the one you can tx w/o replacing)
Tx for mitral stenosis
- Preload reduction
- severe: Balloon valvotomy. Can do valve replacement.
- Look out for AFib! tx w/ anticoagulation, may need cardioversion
T/F: Mitral regurg and MVP present the same way
False.
MR: Worse with increase preload, better w/valsalva. Tx with preload reduction; due to infx or infarction (papillary mm rupture after MI)
MVP: Better with more blood (dec murmur) i.e. leg raise/squatting. Tx w/increase preload (avoid dehydration and give BB)…presents in a young women (congenital)
What are the 2 EKG changes you have to know for pericarditis?
diffuse ST elevation (except uremic)
PR SEGMENT DEPRESSION = PATHOGNOMONIC
Tx of Pericariditis
NSAIDS AND COLCHICINE
nsaids CI if CKD, dec platelets, PUD
What is kussmauls signs and when is it seen?
Increase in JVP on inspiration. CONSTRICTIVE PERICARDITIS!!!!!!!!!! can also be seen in RCM
What 2 signs are pretty unique to constrictive pericarditis?
Kussmaul sign (increase JVP on inspiration) Pericardial Knock (extra diastolic sound from heart hitting a calcified/thick pericardium)
how do you tx pericardial effusion
Same as pericarditis: Nsaids and colchicine.
If recurrent: create pericardial window (hole)
If tamponade: urgent pericardiocentesis (no time getting an echo)
Person who turns his head or shaving and passes out briefly
vasovagal syncope (trigger: overactive carotid sinus)
Syncope with no prodrome
95%: Arrythmia
IF theres FND, consider vertebrobasilar insufficiency (insufficient posterior circulation flow), would need a CTangio or carotid US to dx
narrow tachycardia with loss of p waves vs wide tachycardia without p waves
Supraventricular tachycardia (narrow) or afib if irregular VTach (wide)
how do you tx AV block? 1, 2nd etc
Bradycardia!!! So Atropine! expect narrow QRS since signals coming from atria
Vascular dz or LDL > _____ = STATIN
190
Niacin causes ____ HDL, ___ LDL, ___ TG. Treat flushing with _____
Increase HDL, Decrease LDL, no effect TG. Tx w/aspirin
Side effect of statins (and fibrates)
Myositis, Increase LFTs. Just stop the statin and restart at a lower dose.
which lipid lowering drugs cause fatty stools/osmotic diarrhea
Ezetimibe and Bile acid resins (block absorption)
ACEI, ARB, Thiazide, Loops, Spironolactone all affect potassium. How?
Thiazides and loops are potassium wasting.
ACEI, ARB, and Spironolactone increase K
difference between spironolactone and eplerenone (aldo antagonists)
s causes gyneomastia, e does not
tumor of adrenal medulla
Kids: Neuroblastoma (less likely to cause HTN)
Adults: Pheochromocytoma (episodic HTN/HA)
how do you tx pheochromo (episodic htn)
- Phenoxybenzamine (ALPHA ANTAGONIST): have to do this first (before beta blocker) to avoid htn crisis
- Propranolol
- Tumor resection
(all of these in order)
what medication should NOT be used (don’t add it, don’t increase if currently taking) during an Acute CHF exacerbation?
beta blocker!!! this is a mainstay of CHF tx b/c prevents arrythmia and remodeling…but NOT FOR ACUTE EXACERBATION
how do you tx acute chf exacerbation?
aggressive diuresis with IV Furosemide
–>do NOT start/inc Beta blocker during acute CHF ep
T/F: Since Afib is an atrial tachy, you use adenosine
False, other atrial tachy you use adenosine but Afib = RATE CONTROL with BETA BLOCKER/CCB (vera, dil)
how do you distingush supraventricular tachycardia from sinus tachy?
HR>150 and LOSS OF P WAVES
what sxs would you expect PBC patient to have in additional to abdominal pain/gallstone type pain?
Fatigue, PRURITIS, jaundice
