Cardio Flashcards
1
Q
Delayed and diminished carotid pulses
A
Pulsus Parvus et Tardus…AORTIC STENOSIS
2
Q
Prominent capillary pulsations in fingertips/nail beds
A
Widened Pulse Pressure…Aortic Regurg
3
Q
When do you see Pulsus Paradoxus? (exag. decrease in SBP with inspiration)
A
Pericardial diseases (Cardiac Tamponade), Severe Asthma and COPD
4
Q
______ can trigger bronchoconstriction in patients with asthma
A
Aspirin or beta-blockers
5
Q
Tx for vasospastic angina
A
Preventative: CCB
Abortive: Sublingual Nitroglycerin
6
Q
Young patients (<50), hx of smoking, recurrent chest pain lasting <15 min (at rest/sleep)
A
Vasospastic angina (Hyper-reactivity of smooth muscle)
7
Q
ECG findings in vasospastic angina
A
Leads to transmural myocardial ischemia = ST-elevation
8
Q
Electrical alternas + Sinus Tachycardia
varying amplitude of QRS complex
A
PERICARDIAL EFFUSION (b/c swinging motion of heart in the sac= beat-beat variation)–>leads to cardiac tamponade. Tx with with emergency pericardiocentesis
9
Q
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 =
A
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)
10
Q
Classic Pericarditis ECG findings
A
Diffuse ST-segment elevations
won’t be seen in Uremic pericarditis
11
Q
most accurate test for detecting coronary artery disease
A
Coronary angiogram (cath lab)
12
Q
What would you expect LV EDV to be in patient with CHF?
A
Increased LV EDV: due to renal sodium and H20 retention
SVR: Increased (reflexive)
13
Q
Which anti-htn med has side effect of peripheral edema?
A
CCB: Amlodipine/Nifedipine
14
Q
what stimulates renin from JGA? alpha/beta agonist/antagonist?
A
Beta agonist
15
Q
What effect would acute MR have on LA or LV?
A
Wouldnt change LA size/compliance unless chronic; acutely, have increased LV filling pressures
16
Q
Tx of afib in patient with Wolf Parkinson White
A
IV Procainamide (or ibutilide)
Note: do NOT use adenosine, beta blockers, digoxin b/c promotes conduction across accessory pathway and thus VFib
17
Q
What do you need to monitor when using Amiodarone for arrythmias?
A
PFTs, LFTs, TFTs. Get baseline levels + cxr before initiating
18
Q
Effect of _____ on Mobitz type 1 vs 2:
- Vagal manuevers
- exercise/atropine
A
Vagal: worsens type 1, improves type 2
Exercise/atropine: improves 1, worsens 2
19
Q
what should you look out for in a patient given nitroprusside?
A
Cyanide toxicity (most common in pt with renal insuff)! AMS, seizures, coma, lactic acidosis
20
Q
Tx for cyanide toxicity
A
(i.e. in a pt given nitroprusside and develops seizures/AMS)
Nitrite + thiosulfate, hydroxycobalamin
21
Q
what should be started in pts with MI within 24 hours (unless CI)?
A
ACE-I to prevent remodeling (which would lead to DCM)
22
Q
Recent URI + new-onset CHM
A
DCM secondary to viral myocarditis (usually coxsackie)
23
Q
Echo finding in DCM
A
Dilated ventricles + diffuse hypokinesia (resulting in low EF)
24
Q
High voltage QRS + lateral ST depression + lateral T-wave inversion
A
Left Ventricular Hypertrophy (usually due to long standing or secondary htn)
25
T/F: Mitral stenosis patients commonly develop A-fib due to significant left atrial deviation
True
26
Loud S1 and diastolic rumbling
Mitral Stenosis
27
Tx for Aortic Dissection
BETA BLOCKERS, then Vasodilators
| -->bb's help to reduce HR, SBP, and LV contractility
28
Irregularly irregular rate, ____ p waves, ____ QRS complexes = afib ecg findings
absent
| narrow
29
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
30
Mgmt of pt with acute STEMI
1. Medical:
- Oxygen
- Full-dose aspirin (chewed = better absorption)
- Anti-platelet (Clipidogrel/Ticragrelor)
- Nitroglycerin with Morphine (pain)
- Anti-coagulation (heparin)
- Beta blocker
2. PROMPT REPERFUSION with PCI (ideal, w/in 2 hrs) or fibrinolytic (within 12 hours)
3. Start statins after acute
31
How much carotid stenosis until you need to do surgery (carotid endarterectomy)?
Asx or sx: >60% (men) ; >70% (women)
32
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
33
mgmt of vasovagal syncope
1. Reassurance
2. Avoidance of triggers
3. Counterpressure Techniques for recurrent eps (assume supine position and do leg raises; leg crossing with muscle tensing; handrgrip; fist clenching)
34
Syncope associated with emotional/painful stimuli, often ass. with a prodrome (dizziness, pallor, diaphoresis, abdominal pain, sense of warmth)
Vasovagal syncope
35
predisposition for aortic dissection
<40: many of them from Marfans or cocaine
Most important risk factor in gen population: HYPERTENSION
36
leads to LV hypertrophy, diastolic HF with preserved EF
severe and long standing HTN (hypertensive heart disease)
37
Which electrolyte abnormality is a marker for severity of CHF?
Hyponatremia...an independent predictor of adverse outcome
38
T/F: Increasing Na intake is the initial tx for CHF pts with hyponatremia
False...its to limit water intake
39
Why does dobutamine help in heart failure?
Primarily acts as Beta-1 agonist = increase contractility (also get inc hr)
40
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
41
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
42
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
43
What does hepatojugular reflex indicate?
failing RV that cannot accomodate an increase in venous return with abdominal compression
44
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
45
Tx for STEMI, NSTEMI
STEMI: Immediate cath or thrombolysis
NSTEMI: Anti-coagulation
46
T/F: Diuretics improve long-term survival in patients with LH failure i.e. post MI
FALSE.
47
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
48
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
49
Acute, severe pulmonary edema and new systolic murmur 3 days after MI
Papillary muscle rupture
50
shock, distant heart sounds, and JVD 1-2 weeks after MI
Free wall rupture
51
Digoxin (digitalis) toxicity arrythmia:
Atrial tachy + AV block
52
T/F: S3 heard in CHF pt
true
53
isolated systolic hypertension in the elderly
increased stiffness/decreased elasticity of the arterial wall
(SBP >140, DBP <90)
54
Blue toe syndrome, livedo reticularis, AKI after catheterization
Cholesterol emboli
55
Screening for AAA
USPSTF recommends men 65-75 who have smoked get a 1-time abdominal US
56
When do you see Pulsus Paradoxus?
Cardiac Tamponade, Severe asthma or COPD, OSA, Pericarditis, Croup
57
T/F: Aortic regurg is characterized by pulsus paradoxus
False. Widened pulse pressure.
| vs pulsus paradoxus = decrease in amplitude systolic BP >10 on inspiration
58
T/F: Aortic dissection characterized by widened pulse pressure
false, aortic regurg
59
Sound created by turbulent flow to ventricles due to increased volume
S3
| Mitral regurg, HF
60
Sound created by atrial contraction fluid hitting stiff ventricle
S4
| Aortic stenosis, LVH, Acute MI
61
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.
62
Why do patients with sarcoidosis (uveitis, dyspnea, lymphadenopathy) have hypercalcemia?
Increased 1-alpha-hydroxylase mediated vitamin D activation in Macrophages (granuloma)
63
Uveitis is caused by:
PAIR (including Crohns and UC and Reiters/chlamydia)
| Sarcoidosis
64
causes of Afib
- Hypertensive heart disease (#1), CAD
- Rheumatic mitral valve dz
- OSA, PE
- Hyperthyroidism, Obesity, Alcohol, Cocaine, Theophylline
65
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
66
Patient with hypotension has equal diastolic pressures throughout chambers
Cardiac tamponade
67
Beck's triad
Cardiac tamponade clinical signs = Hypotension, Increased JVD, distant heart sounds (due to the pericardial effusion)
68
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
69
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.
70
Ankle-Brachial Index
PVD bitch PVD
71
Dual platelet therapy
Needed post MI/CAD.
Aspirin + ADP Inhibitor AKA P2y12 receptor blocker (clopidogrel, ticagrelor, ticlodipine)
72
When does post Mi pericarditis occur?
PERI means around "the date" 4 letters so within 4 days
73
New S3 after recent travel, no rash, signs of CHF
Viral myocarditis --> causes DCM --> decompensated HF
74
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
75
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)
76
What drugs should you use for thromboembolism prophy in afib pt?
Warfarin or Direct X Inhibitor (Apixaban/Rivaroxaban/Dabigatrin)
-->NOT ASPIRIN OR CLOPIDOGREL
77
how do you avoid flushing rxn from Niacin?
It is Prostaglandin-medicated vasoDILATION
| -->avoid using Aspirin
78
Atrial fluid is most commonly caused by:
ectopic foci in pulmonary veins
79
Atrial flutter is most commonly caused by:
reentrant circuit around tricuspid annulus
80
Most common cause of Mitral regurg
Mitral valve prolapse (myxomatous degeneration of mitral valve)
81
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)
1. abolish AV dependent arrythmias i.e. re-entrant tachy like Paroxysmal SVT
2. unmask hidden p waves in atrial flutter/fib
3. if MAT, atrial tachy is not disrupted
82
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)
83
what drugs do you use for WPW
Class IA and IC anti-arrythmics (avoid adenosine/beta blocker/digoxin)
84
what's one way clinically distinguish SVT from VT?
Supraventricular tachycardia's respond to Adenosine/vagal manuevers. Vtach does not
85
tx of vtach
Amiodarone is first line. can also use sotalol, procainamide.
(avoid adenosine/beta blockers/digoxin)
86
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
87
If you can't measure patient BP and they have absent pulse and heart sounds, what arrythmia do they have?
VFib
88
Atropine treats _______cardia
bradycardia
| so NOT supraventricular tachycardia
89
3 things to do for VFib
Cardioversion
CPR
Epinephrine
90
P-R >0.20, a QRS follows each P
1st degree Heart Block
91
tx for DCM
similar to CHF
| Digoxin, diuretics, vasodilators,
92
why do all patients with pericarditis get an echo?
to r/o pericardial effusion
93
loud s1 vs soft s2
MS vs AS
94
Tx for mitral stenosis
Diuretics and beta blockers (pulm congestion ; dec HR and CO)
Can do Percutaneous balloon valvulopasty. Watch out for Afib developing
95
Patient with Aortic Stenosis develops new murmur
Mitral regurg. LV hypertrophy pulls mitral valve annulus apart
96
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
97
early/mid/late peaking systolic murmur
Aortic stenosis. Early = mild, late = severe
98
Parvus et tardus pulses
Aortic stenosis
99
Tx for Aortic stenosis
aortic valve replacement. meds don't really help
100
T/F: Aortic regurg murmur increases with handgrip
True...this increases SVR = increased backflow through valve
101
most common cause of MR
MVP (in developed countries)
102
HTN urgency vs emergency
Emergency includes end-organ damage, need IV meds
(urgency can use oral)
for both SBP>220 or DBP>120
103
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
```
104
what causes PRES?
Posterior Reversible encephalopathy syndrome...caused by htn emergency
105
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
106
imaging for Aortic dissection
TEE and CT
| note: CXR will show widened mediastinum
107
most important factor in tx of peripheral vascular dz
STOP SMOKING
108
When do you use the ankle-brachial index?
Dx of Peripheral Vascular Dz
109
T/F: Intermittent claudication indicates severe PVD
False, it actually is associated with good prognosis
110
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)
111
The 6 P's of acute arterial occlusion (embolization)
```
Pain
Pallor
Polar (cold)
Paralysis
Paresthesias
Pulselessness (using doppler to assess)
```
112
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 .
113
where does aortic dissection pain radiate?
Anterior chest or interscapular back. "Knifelike"
114
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).
115
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.
116
What murmur would you expect a patient with aortic dissection to develop?
Aortic Regurg...decrescendo diastolic murmur
117
most common valvular abnormality in rheumatic fever
Mitral Stenosis (this is uncommon in developed countries)
118
Septal hypertrophy + __________ = HCM
Systolic anterior leaflet motion of mitral valve
Contact btwn mitral valve and septum = LVOT
119
what kind of murmur is heard in HCM?
Harsh Crescendo-Decrescendo @ apex and LSB
120
murmur that radiates to the carotids
Aortic stenosis
121
Patient that is >40 and non-diabetic gets a statin when 10 year risk is > _____ %
7.5
122
First line tx for chronic stable angina
BETA BLOCKERS
| CCB are also used but not first line
123
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
124
what are the 2 ways to reperfuse the heart (increase blood flow through coronary arteries) immediately after STEMI?
PCI (Percutaneous intervention) or fibrinolysis
125
Narrow QRS complexes
SVT
126
T/F: You need to defribillate in a patient with afib and sxs
False, you need to do Cardioversion!
Defibrillation is for vfib
127
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
128
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
129
systolic murmur that decreases on intensity when squatting and/or leg raise
HOCM. Squatting and leg raise = increased venous return (and thus preload)
130
T/F: Valsalva and hand grip decrease preload
false. Valsalva decreases preload but hand grip increases after load
131
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)
132
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)
133
Which shock leads to a decreased afterload?
Septic
134
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)
```
135
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)
136
most common cause of death after MI
Vfib
137
T/F: Afib and Vfib both respond to defibrilliation
False
AFib: Cardioversion
VFib: Defibrillation
138
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)
139
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
140
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.
141
Fast and Narrow Arrythmia (stable)
N in narrow means use adeNosine --> Atrial rhythms (afib/flutter/SVT/sinus tachy)
142
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)
143
exertional dyspnea + S4
Diastolic HF, most commonly from LVH from long-standing HTN
144
Tx of pericarditis
NSAIDS and Colchicine
| viral may need anti-viral; uremic needs dialysis
145
Most common causes of Afib, Aflutter
Afib: Ectopic foci in pulmonary veins
Aflutter: Re-entrant circuit around tricuspid annulus
146
Digitalis toxicity arrythmia
atrial tachycardia with AV nodal block
147
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
148
Patients with PAD and intermittent claudication have a 20% risk of ____ and ____ in the next 5 years
MI and Stroke (MI higher risk)
149
increased JVP on inspiration (instead of normal decrease)
Kussmaul Sign
- constrictive pericarditis (TB/viral)
- restrictive CM
- RA or RV tumor
150
T/F: S3 indicates LV failure and requires diuretics
True
151
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
152
systolic murmur that increases when patient stands up
HCM ejection murmur. Standing up decreases venous return to the heart
153
when is paradoxical splitting seen?
Conditions that prolong aortic valve closure: Aortic Stenosis and LBBB
154
Chagas patient will have recently traveled and present with cardiac dz (i.e. DCM or CHF) and _______/_______
megacolon/megaesophagus
155
Systolic murmur at the apex that decreases with squatting
MVP (so its not only HCM that reduces with increases VR)
| -->Apex = mitral valve
156
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
157
What is a pericardial knock?
Very specific sign of Constrictive Pericarditis
| -->mid-diastolic squeaky sound
158
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)
159
How are you going to handle all "identify the rhythm" questions
1. Determine rate (tachy vs brady)
| 2. Determine QRS complex: >.12 = ventricular;
160
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)
161
Afib/flutter tx: rate or rhythm?
RATE CONTROL: Beta Blockers or CCB (verapamil, diltiazem)
162
Why arrythmia do you use beta blocker/CCB to control?
Afib/flutter (stable)
163
Typical vs atypical for cardiac chest pain (angina)
Typical (3/3): Substernal; exertional; relieved by nitroglycerin
Atypical = 2/3
164
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
165
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
166
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)
167
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
168
Which MONA BASH medications are avoided in right sided infarcts (II, III, aVF)?
Nitrates
169
Name the 3 loop diuretics (can use these in heart failure patients to decrease preload)
Furesomide
Bumetanide
Torsemide
"-mide, -nide"
170
Afterload reduction in HF patients
1. ACE-I for everyone
| 2. if its pretty bad, add Spironolactone or Hydralazine
171
Preload reduction in HF patients
1. Decrease salt and fluid intake (everyone)
2. If worse, Furesomide (or bumetanide)
3. if pretty bad, can add Isosorbide dinitrate (venodilator)
172
When is dobutamine used in HF patients?
Dire situation, when prepareing for transplant or ventricular assist device. Its an inotropic med (continuous infusion)
173
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
174
If a HF patient has ischemia, what meds should they also be on?
Aspirin and Statin
175
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
176
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
177
T/F: You should avoid dehydration/BB/CCB in concentric hypertrophy
True, it leads to diastolic HF. BB allow ventricle to fill
178
T/F: Give beta blocker/diuretics/ACE-I for dilated cardiomyopathy
True, its a systolic CHF
179
Aortic stenosis-like murmur heard at the apex and improves with increased preload
HOCM
180
Tx for HCM
Avoid dehydration
| Give beta blockers (or CCB) to allow an increase in ventricular filling (keep HR low)
181
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)
182
T/F: The worse the mistral stenosis (usually caused by RF), the later the snap
False. Earlier snap = worse
183
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)
184
Tx for mitral stenosis
1. Preload reduction
2. severe: Balloon valvotomy. Can do valve replacement.
3. Look out for AFib! tx w/ anticoagulation, may need cardioversion
185
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)
186
What are the 2 EKG changes you have to know for pericarditis?
diffuse ST elevation (except uremic)
| PR SEGMENT DEPRESSION = PATHOGNOMONIC
187
Tx of Pericariditis
NSAIDS AND COLCHICINE
| nsaids CI if CKD, dec platelets, PUD
188
What is kussmauls signs and when is it seen?
Increase in JVP on inspiration. CONSTRICTIVE PERICARDITIS!!!!!!!!!! can also be seen in RCM
189
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)
```
190
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)
191
Person who turns his head or shaving and passes out briefly
vasovagal syncope (trigger: overactive carotid sinus)
192
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
193
narrow tachycardia with loss of p waves vs wide tachycardia without p waves
```
Supraventricular tachycardia (narrow) or afib if irregular
VTach (wide)
```
194
how do you tx AV block? 1, 2nd etc
Bradycardia!!! So Atropine! expect narrow QRS since signals coming from atria
195
Vascular dz or LDL > _____ = STATIN
190
196
Niacin causes ____ HDL, ___ LDL, ___ TG. Treat flushing with _____
Increase HDL, Decrease LDL, no effect TG. Tx w/aspirin
197
Side effect of statins (and fibrates)
Myositis, Increase LFTs. Just stop the statin and restart at a lower dose.
198
which lipid lowering drugs cause fatty stools/osmotic diarrhea
Ezetimibe and Bile acid resins (block absorption)
199
ACEI, ARB, Thiazide, Loops, Spironolactone all affect potassium. How?
Thiazides and loops are potassium wasting.
| ACEI, ARB, and Spironolactone increase K
200
difference between spironolactone and eplerenone (aldo antagonists)
s causes gyneomastia, e does not
201
tumor of adrenal medulla
Kids: Neuroblastoma (less likely to cause HTN)
Adults: Pheochromocytoma (episodic HTN/HA)
202
how do you tx pheochromo (episodic htn)
1. Phenoxybenzamine (ALPHA ANTAGONIST): have to do this first (before beta blocker) to avoid htn crisis
2. Propranolol
3. Tumor resection
(all of these in order)
203
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
204
how do you tx acute chf exacerbation?
aggressive diuresis with IV Furosemide
| -->do NOT start/inc Beta blocker during acute CHF ep
205
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)
206
how do you distingush supraventricular tachycardia from sinus tachy?
HR>150 and LOSS OF P WAVES
207
what sxs would you expect PBC patient to have in additional to abdominal pain/gallstone type pain?
Fatigue, PRURITIS, jaundice
