Cardio Flashcards
Pain characteristics that make ischemia less likely
Sharp, knife like, last for a few seconds
Changes with respiration, position, touch of the chest wall (tenderness)
How to calculate maximum heart rate
220 minus age, so for me it’s 194
Alternatives to exercise stress test
Persantine (dipyridamole, avoid in asthmatics) or adenosine in combo with nuclear isotopes such as Thallium or sestamibi
Or Dobutamine with echo
Nitro and ministration in chronic versus acute angina
Chronic: oral or transdermal patch
Acute: sublingual, paste, IV
Antiplatelet agents that should be given in ACS
Aspirin plus clopidogrl, prasugrel, or ticagrelor (P2Y12 Receptor inhibitors)
Clopidogrel commonly used if aspirin allergy
Prasugrel Best if undergoing angioplasty and stenting but increases risk of hemorrhagic stroke in patients over 75
Best mortality benefit in chronic angina
Aspirin and beta blockers
Target LDL in coronary artery disease (or PAD, carotid disease, aortic disease, stroke, diabetes)
Less than 100 mg/dL
If diabetes, less than 70 mg/dL
Most common side effect of statins
Liver dysfunction, myositis/rhabdo is rare
Measure LFTs not CPK
Why are statins so great for Improving mortality
They have an antioxidant effect on the endothelial lining of the coronary arteries in addition to lowering the LDL
Use fibrates with caution why?
Why is cholestyramine not used as much?
Side effects of Niacin?
Fibrates: If used in combo with statins have increased risk of myositis
cholestyramine: blocks absorption of other medications and has G.I. side effects
Niacin: elevation in glucose in uric acid level, pruritis
Why not to use Dihydropyridine CCB’s in CAD?
They raise the heart rate, reflex tachycardia
Especially Nifedipine
Can use verapamil and diltiazem, which do not increase the heart rate, when beta blockers are contraindicated: severe asthma, Prinzmetal angina, cocaine induced chest pain
When to do CABG instead of standing in CAD
If at least three vessels are involved, or the left main is involved, or two vessels in diabetic
Mortality is highest with what type of STEMI
Anterior wall, ST elevation in leads V2-V4
Order of therapy and STEMI patient
Aspirin first, then angioplasty
Cardiac markers will be normal in the first four hours
Morphine, oxygen, nitrates should be given immediately but do not clearly lower mortality
Beta blockers, statins, ACE inhibitors do lower mortality but are not dependent on time, should be given before discharge
Cardiac marker timeline
Myoglobin: shows up at 1 to 4 hours, stays elevated 1 to 2 days
CK – MB: 4-6 hours; 1 to 2 days
Troponin: 4 to 6 hours; 10 to 14 days
Renal insufficiency he can result in false positive troponins
Best for decreasing the risk of restenosis in coronary arteries after PCI
Placement of drug eluting stents
Warfarin is not used here, useful in DVT/PE
Heparin is used during the procedure but not long-term
Absolute contraindications to thrombolytics
Major bleeding: G.I. or brain
Recent surgery in the last two weeks
Severe hypertension above 180/110
Non-hemorrhagic stroke within the last six months
ACE inhibitors have the most benefit in what patients?
In those with systolic dysfunction, ejection fraction below 40%
When to give heparin in MI
If ST depression but no ST elevation or in unstable angina
Heparin will prevent a clot from forming
If there is no ST elevation, there is no benefit of TPA
Meds useful when undergoing angioplasty and Stenting or if non-ST elevation MI
Glycoprotein IIb/IIIa inhibitors: abciximab, tirofiban, eptifibatide
TPA is only good for?
ST – elevation MI
If PC I not available, use within 12 hours of start of chest pain
Which is better in terms of mortality: LMWH or unfractionated heparin?
LMWH
3rd° AV block will have what waves?
Cannon A waves
Produced by atrial systole against a closed tricuspid valve
How to find the right ventricular infarct
How to treat?
Flip the EKG leads to the right side, will have ST elevation in RV4
Treat with high-volume fluid replacement, avoid nitro
Diagnosis/treatment of tamponade/free wall rupture
Emergency echo, emergency pericardiocentesis on the way to the OR
Elevated JVD but lungs are clear, sudden loss of pulse
Post MI complications that present with new onset murmur and pulmonary congestion
Both valve rupture and septal rupture, echocardiogram is the best test
Septal rupture will also present with a step up in oxygen saturation as oxygen blood from the LV mixes with blood in the RV
How to treat acute pump failure
IABP: intra-erotic balloon pump helps push blood forward, serves as a bridge to surgery for valve replacement or transplant for 1 to 2 days
Signs of a second infarct
Recurrence of pain, new rails on exam, bump in CKMB, sudden onset of pulmonary edema
All postinfarction patients should go home on?
BASA
Aspirin, beta blockers – metoprolol, statins, ACE inhibitors ace: best for anterior wall infarctions because of high likelihood of developing systolic dysfunction
How myocardial infarction leads to CHF
Other causes of CHF (systolic dysfunction) besides infarction
Infarction leads to dilation which leads to regurgitation leading to CHF
Others: cardiomyopathy and valve disease
Recent anesthetic use, brown blood not improved with oxygen, clear lungs on auscultation, cyanosis, think?
Methemoglobinemia
Most important test in CHF
Echo, best way to distinguish systolic from diastolic dysfunction, determine EF
Best initial test: TTE
Most accurate: MUGA or nuclear ventriculography
TEE is best at evaluating heart valve function and diameter, but is not necessary for evaluating CHF
How to treat systolic dysfunction CHF
Ace inhibitors, beta blockers, spironolactone, diuretics, digoxin
Best beta blockers: metoprolol, bisoprolol, carvedilol; antiischemis, decrease O2 demand, and antiarrhythmic
What does digoxin do for CHF?
Control symptoms of dyspnea and decreases the frequency of hospitalizations but does not decrease mortality
What treatments have a mortality benefit in stock dysfunction CHF
Ace inhibitors/ARB us, beta blockers, spironolactone, hydralazine/nitrates, ICD (ischemic), pacemaker (dilated with wide QRS)
Treatment for diastolic dysfunction, a.k.a. CHF with preserved ejection fraction
Beta blockers and diuretics
Not beneficial: digoxin, Spironolactone
On the fence: ACEI, ARBs, hydralazine
CHF on CXR
Vascular congestion with blood vessels filling towards the head
If chronic: heart enlargement and pleural effusions
ABG an early pulmonary edema
Respiratory alkalosis due to hyperventilation
Pulmonary edema treatment
Pre-load reduction: LMNO
Loops, morphine, nitrate, oxygen
Positive inotropic agents: Dobutamine, Amrinone and milrinone (phosphodiesterase inhibitors)
Afterload reduction: ace/ARB, nitroprusside and IV hydralazine in acute Setting
What murmurs increase with inhalation and why
Right-sided murmurs: tricuspid and Pulmonic, as inhalation increases venous return to the right side of the heart
Opposite for left heart murmurs, as they increase with exhalation when blood is squeezed out of the lungs into the left side of the heart (except for MVP and HOCM)
Treatment of valvular heart disease
Diuretics
Mitral stenosis: balloon dilation
Aortic stenosis: surgical removal
Regurgitated valves: basal dilator therapy: ACE/ARBs, nifedipine, hydralazine, surgery before heart dilates too much
When do you think mitral stenosis caused by rheumatic fever
Immigrant or pregnancy: which increases plasma volume that has to go through a narrow valve
Features unique to mitral stenosis
Dysphasia from LA pressing on the esophagus, hoarseness from it pressing on laryngeal nerve, a fib and stroke from enlarged LA, hemoptysis, LA pushing up the left main stem bronchus
Diagnostic tests for valve disordes
Initial: TTE, TEE is more accurate
Best: catheterization
EKG in mitral stenosis may show?
A fib, left atrial hypertrophy seen with biphasic P-wave in leads V1 and V2
Treatment for mitral stenosis
Diuretics, sodium restriction, balloon valvuloplasty, may need valve replacement
Afib: warfarin an INR of 2 to 3, rate control with digoxin, beta blockers for diltiazem/verapamil
Treatment for mitral/ aortic regurgitation
Vasodilators: ace inhibitors or ARBs, digoxin then diuretics for CHF symptoms,
valve replacement:
mitral regurgitation when LV ESD gets above 40 mm and EF drops below 60%
Aortic regurgitation when LVESD gets above 55 mm and EF drops below 55%
MVP is seen in? What is unique about its presentation?
In Marfan and Ehlers Danlos
Symptoms of CHF are typically absent, will have atypical chest pain, palpitations, panic attack
Murmur increases with less blood in the heart, as in Valsalva and standing
Murmur decreases with increasing left ventricular chamber size as in squatting or handgrip
Commonalities in all forms of cardiomyopathy
All present with shortness of breath, typically worsened by exertion, and will have edema, rales, and JVD
Diagnosed with echo, treat with diuretics
Differences between HCM and other forms of cardiomyopathy
HCM may have an S4 gallop and fewer signs of right heart failure searches ascites and enlargement of the liver and spleen
Treatment for HCM and HOCM
Beta blockers
verapamil and disopyramide – negative inotropes
Diuretics may help and HCM but a contraindicated in HOCM
NO spironolactone or digoxin
HOCM: ICD if syncope, ablation of septum, surgical myomectomy is ultimate therapy
Increase in JVP on inhalation in seen in? And called?
Restrictive cardiomyopathy, Kussmaul sign
Types of cardio myopathy
Dilated: systolic dysfunction
Hypertrophic: diastolic dysfunction, preserved ejection fraction
Restrictive: combo,EF may be normal or elevated
What will you see an echo and right heart cath in tamponade?
Right atrial and ventricular diastolic collapse on echo
Equalization of pressures and diastole on RH cath
Best initial test in constrictive pericarditis
CXR: shows calcification in fibrosis
Echo next to exclude RV hypertrophy or cardio myopathy
Diuretics in Tamponade or constrictive pericarditis?
Not for Tamponade, will decrease feeling pressure in may worsen the collapse of the right heart
Yes for constrictive pericarditis, used to decompress the filling of the heart and relieved edema and organomegaly
Best first and then most accurate test for aortic dissection
First: CXR, Will see widened mediastinum
Most accurate: angiography
MRA = CTA = TEE
Most dangerous heart disease in pregnant woman
Peripartum cardiomyopathy: antibodies against the myocardium, LV dysfunction, repeat pregnancies are at risk
