Cardio Flashcards
Mid-systolic murmurs:
aortic stenosis, pulmonic stenosis
Holo-systolic murmurs
mitral regurgitation, tricuspid regurgitation
Late-systolic murmurs
MVP (always showing up late)
Early-diastolic murmurs
aortic regurgitation, pulmonic regurgitation
Mid/late-diastolic murmurs
mitral stenosis, tricuspid stenosis
What maneuvers increase venous return?
Squatting, LR, lying down
What maneuvers decrease venous return?
Valsalva, standing
S1?
AV valve closure
S1 marks the?
beginning of systole
S1 is loudest at?
Apex
Which valve closes first in S1?
mitral, then tricuspid
S2?
Semilunar valve closure
S2 marks the?
end of systole
S2 loudest at?
Base
Which valve closes first in S2?
Aortic, then pulmonic
S3?
rapid passive ventricular filling
S4?
atrial contraction into ventricles
Elevated BP?
120/129/ <80
Stage 1 HTN?
130-139/ 80-89
Stage 2 HTN?
> 140/>90
HTN urgency?
> 180/120
Treatment for elevated BP?
lifestyle, recheck in 3-6 months
Treatment for stage 1 HTN?
10 year risk <10% –> lifestyle; >10% –> 1 med, check in one month
Treatment for stage 2 HTN?
2 meds, recheck in one month
Sodium restrictions for HTN?
<2.4 g/d
HTN tx: uncomplicated (non-AA)
thiazide diuretics, ACE, ARB
HTN tx: a. fib
BB, ND CCB
HTN tx: angina
BB, CCB
HTN tx: post-MI
BB, ACE
HTN tx: systolic HF
ACE, ARB, BB, diuretics
HTN tx: DM/CKD
ACE, ARB
HTN tx: systolic (isolated) HTN
diuretics +/- CCB
HTN tx: osteoporosis
thiazides
HTN tx: BPH
alpha blockers
HTN tx: AA (non-DM)
thiazides, CCB
HTN tx: gout
CCB, losartan (only arb that doesn’t cause hyperuricemia)
HTN urgency
> 180/>120 + no end organ damage
HTN urgency treatment
Decreased BP by 25% over 24-48 hours using oral agents –> goal <160/<100
HTN emergency
> 180/>120 + end organ damage
HTN emergency treatment
Decrease BP by no more than 25% within first hour, then by an additional 5-15%, over next 23 hours using IV agents
When should you not follow HTN emergency treatment protocol?
-Ischemic stroke: not lowered unless >185/110 in thrombo candidates or >220/120 in non-candidates AND in aortic dissection: rapidly reduce to SBP of 100-120 in 20 minutes
Inferior leads:
II, III, aVF
II, III, aVF leads?
inferior
lateral leads:
I, avL, V5, V6
I, avL, V5, V6?
lateral
septal leads:
V1, V2
V1, V2 leads?
septal
V3, V4 leads?
anterior
Anterior leads?
V3, V4
First degree AV block?
long PR interval (>0.20 sec)
First degree AV block treatment?
observe
Mobitz Type I (Wenckebach)
long, longer, drop
Mobitz Type I treatment
- Symptomatic: atropine, epi, +/- pacemaker
- Asymptomatic: observe +/- cardiac consult
Mobitz Type II
PR constant, random drops
Mobitz Type II treatment
atropine, temporary pacing; permanent pacemaker = definitive
Third degree AV block:
no relationship between P waves and QRS complexes
Third degree AV block treatmnetn
temp pacing –> permanent pacing
Pathologic Q wave definition:
> 0.04 sec, >2 mm deep, >25% depth of QRS complex
Pathologic Q waves may be normal in what leads?
III and aVR
STEMI EKG definition?
ST elevations 1+ mm in at least 2 anatomically contiguous leads + reciprocal changes in opposite leads
STEMI EKG progression?
hyperacute T waves –> ST elevations/depressions –> T wave inversions –> pathologic Q waves
Describe QT in hypocalcemia?
prolonged
Describe QT in hypercalcemia?
QT shortened
Sick sinus syndrome?
brady-tachy syndrome; sinus arrest with alternating paroxysms of atrial tachy and brady
Treatment of sick sinus syndrome?
Permanent pacemaker
MC chronic arrhythmia?
a. fib
Describe P waves in a.fib?
No discernible P waves
Paroxysmal A. fib?
self-terminating within 7 days
Persistent a. fib?
fails to self-terminate, lasts > 7 days
Permanent a. fib?
> 1 year; refractory to cardioversion or nerve tried
Lone a. fib?
paroxysmal, persistent, or permanent without evidence of heart disease
CHADSVASC
CHF or LVEF <40% (1) HTN (1) Age 75+ (2) DM (1) Stroke/TIA/thromboembolism (2) Vascular disease (1) Age 65-74 (1) Sex: Female (1)
CHADSVASC Score interpretation
2+: mod risk; chronic oral anticoags
1: low risk; clinical judgement
0: no anticoag risk
Treatment for unstable a. fib:
DC cardioversion
What type of drug is diltiazem?
ND-CCB
MCC of atrial flutter
HF
Atrial flutter tx: stable
vagal, CCB/BB
Atrial flutter tx: unstable
DC
Atrial flutter tx:
radiofrequency ablation
Long QT can be caused by?
macrolides, TCAs, and electrolyte abnormalities
Definitive treatment of long QT?
AICD
What type of PSVT is most common?
AVNRT
Describe AVNRT?
two pathways within the AV node (slow and fast)
Describe QRS of AVNRT?
Narrow w/ no discernible P waves
Describe AVRT?
1 pathway in the AV node and a second accessory pathway outside of the AV node
Types of AVRT?
orthodromic and antidromic
Orthodromic is antegrade via?
AV node
Antidromic is antegrade via?
accessory
orthodromic is retrograde via?
accessory pathway
Antidromic is retrograde via?
AV nod
Orthodromic is wide or narrow?
Narrow
Antidromic is wide or narrow?
wide
Tx of stable orthodromic AVRT?
vagal, adenosine, IV verapamil
Tx of unstable orthodromic AVRT?
DC
Tx of stable antidromic AVRT?
flecainidine, procainamide, amiodarone
What drugs must be avoided in WPW?
digoxin, verapamil, BB
Tx for multifocal atrial tachycardia?
CCB, BB
Describe EKG of premature ventricular complexes?
T wave opposite direction of QRS
Tx of PVCs?
no treatment needed; BB if symptomatic; if frequent, w/u for heart disease
Describe ventricular tachycardia?
3+ consecutive PVC at a rate of >100 bpm
Where does ventricular tachycardia originate?
Bundle of His
MCC of ventricular tachycardia
CAD with prior MI
Describe sustained v-tach?
> 30 seconds; almost always symptomatic; life threatening; can progress to v. fib
Describe non-sustained v-tach?
brief, limited, usually asymptomatic
Two types of ventricular tachycardia
monomorphic or polymorphic
Tx: sustained, stable v-tach?
amiodarone, procainamide, sotolol (does not respond to vagal or adenosine)
Tx: unstable v-tach?
DC, followed by amiodarone
Tx: no pulse v-tach?
defib + CPR
Name two non-D ccb?
diltiazem, verapamil
What rhythm do most ventricular fibrillations start with?
VT
MCC of ventricular fibrillation?
ischemic heart disease
Chronic treatment of f. fib?
amiodarone or ICD (unless within 48 hours of acute MI, then recurrence rate is low; no LT tx needed)
What lumen reduction becomes symptomatic?
70%
Worst RF for CAD?
DM
Most important modifiable RF for CAD?
cigarette
MC RF for CAD?
HTN
Angina classifications?
I: only with strenuous activities; no limitations
II: with more prolonged or rigorous activities; slight limitations
III: with usual activity; marked limitations
IV: at rest; often unable to carry out any physical activity
Most useful non-invasive test for CAD?
stress test
If a stress test is positive for CAD, what test should be undergone?
cardiac cath
Definitive test for CAD?
cardiac cath
Tx for CAD?
nitro, BB (CCB), ASA, statin
Definitive tx for CAD
PTCA vs. CABG
When is PTCA preferred?
1 or 2 vessel without left main
When is CABG preferred?
L main, 3 vessel or critical (70%), LVEF <40
When does pain at rest occur with ACS?
90% occlusion
What signs indicate an inferior wall MI is likely?
chest pain + bradycardia
First cardiac marker detected?
myoglobin
Most specific/sensitive cardiac marker?
Troponin I/T
What conditions cause falsely elevated troponins?
renal failure, advanced HF, acute PE, CVA
What is the exception to the benign upsloping rule?
de Winter’s sign (upsloping ST depression with prominent T-waves) –> likely LAD proximal occlusion
What types of ST depressions are likely ischemic?
horizontal and down (upsloping benign)
What types of ST elevations are likely ischemic?
convex or straight (concave can be non-ischemic)
UA and NSTEMI treatment?
ASA + clopidogrel + BB + LMWH
STEMI treatment?
immediate and prompt with PCI within 90 minutes of presentation or thrombolysis within 12 hours of symptom onset
-ASA + prasugrel/ticagrelor/clopidogrel + UF heparin + BB + statins + ACE
PCI must occur within how long of symptom onset?
12 hours
Absolute CI to thrombolytics?
Previous ICH, non-hemorrhagic stroke within 6 months or closed head/facial trauma within 3 months, intracranial neoplasm/aneurysm/AVM, active internal bleeding, suspected aortic dissection
What drugs require caution in RV (inferior wall) MI?
nitrates and morphine
Tx for cocaine induced MI?
ASA, NTG, heparin, benzos, CCB (! no BB!)
Dressler’s syndrome:
post-MI pericarditis + fever + pulmonary infiltrates
What score is used to estimate mortality in unstable angina and NSTEMI?
TIMI score
TIMI score
- Age 65+ (1)
- 3+ CAD RF (1)
- Known CAD (stenosis 50+%) (1)
- ASA use in past 7 days (1)
- Severe angina (2+ episodes in 24 hours) (1)
- EKG ST changes 0/5+ mm (1)
- positive cardiac markers (1)
What is a worrisome TIMI score?
3+
What does the TIMI score show?
% risk at 14 d of all-cause mortality, new or recurrent MI, severe ischemia requiring urgent revascularization
When do you use the HEART score?
Use in 21+ y/o presenting with symptoms of ACS; do not use of ST segment elevation 1+ mm
HEART score
-history: slightly suspicious (0), moderately (1), highly (2)
-EKG: normal (0), non-specific repolarization disturbances (1), significant ST deviation (2)
-Age: less than 45 (0), 45-64 (1), 65+ (2)
-RF: none (0), 1-2 RF (1), 3+ (2)
Troponin: less than normal (o), 1-3x normal (1), >3x normal (2)
HEART score interpretation
0-3: discharged
4-6: admitted
7+: early invasive measures
Definitive test for variant (prinzmetal) angina?
coronary angiography (coronary vasospasm when given IV ergonovine or acetylcholine)
Tx of variant (prinzmetal) angina?
CCB, nitrates, +/- ASA, heparin, benzos (no BB!)
MCC of HF?
CAD
Systolic or diastolic MC HF?
systolic
Is EF increased or decreased in systolic HF?
decreased
Is EF increased or decreased in diastolic HF?
Normal or increased
Left HF MCC?
CAD
Right HF MCC?
left-sided heart failure
pink frothy sputum is associated with?
hF
MCC of transudative pleural effusion?
CHF
What breathing pattern is associated with HF?
Cheyne-Strokes: deeper, faster breathing with gradual decrease and periods of apnea
HF initial test?
echo
Tx HF?
ACE (1)/ARb (2) +/- BB + diuretics (symptoms)
Tx of HF + a. fib?
digoxin
What drugs are CI in HF?
metformin and NSAIDs
MCC of pericarditis?
viral and idiopathic
Mneumonic for pericarditis?
pleuritic, persistent, postural (relieved with leaning forward)
What is heard on auscultation with pericarditis?
pericardial friction rub
EKG of pericarditis?
ST elevation –> pseudo-normalization –> T wave inversion –> resolution (no reciprocal changes)
What EKG sign is seen with pericarditis?
knuckle sign: ST elevation with PR depression in same lead
Treatment of pericarditis?
ASA or NSAIDs x 7-14 days; second line colchicine
Cause of constrictive pericarditis?
chronic pericarditis; idiopathic/viral
MC symptom of constrictive pericarditis
dyspnea
Sign seen with constrictive pericarditis?
Kusmmaul’s sign: increased JVD during inspiration
What is heard on auscultation with pericarditis?
pericardial knock
What condition shows a square root sign on cardiac cath?
constrictive pericarditis
Definitive treatment of constrictive pericarditis?
pericardiectomy
MCC of myocarditis?
Viral specifically enteroviruses (coxsackie)
What may be seen on x-ray with myocarditis?
cardiomegaly
What may be seen on EKG with myocarditis?
sinus tachy (MC)
Gold standard for dx myocarditis?
biopsy
Tx of myocarditis?
diuretics, ACE, IVIG
What rash is seen with Lyme disease?
erythema migrans
Mneumonic for rheumatic fever (just say the menumonic)
JONES CAFE PAL
JONES CAFE PAL: major criteria
Joint involvement: polyarthritis 2+ joints; lower to upper; medium large joints MC O looks like a heart: myocarditis Nodules Erythema marginatum (MC on trunk) Sydenham chorea
JONES CAFE PAL: minor criteria
CRP
Arthralgias
Fever 101.3 +
ESR
Prolonged PR interval
Anamnesis of rheumatism
Leukocytosis
Diagnostic criteria for rheumatic fever
throat cultures growing GABHS or ASO pos + 2 major OR
1 major and 2 minior
Rheumatic fever is assoc with what valve dz?
mitral stenosis
Tx of rheumatic fever?
ASA 2-6 weeks with taper +/- corticosteroids; pen G in acute phase
MC site of PAD?
superficial femoral artery (hunter canal)
MC RF for PAD
smoking
Leriche’s syndrome:
claudication (buttocks, thigh), impotence, decreased femoral pulses
Dependent rubor is seen with?
PAD
Hanging foot over bed helps with pain?
PAD
Painful ulcers at LM with clean margins?
PAD
Test for PAD?
ABI
Gold standard test for PAD?
arteriography
ABI is + for PAD at?
<0.90
Tx for PAD?
Cilostazol is mainstay
Acute arterial occlusion MC location?
common femoral artery
MCC of acute arterial occlusion?
a. fib
Skeletal muscule can tolerate x of ischemia?
6 hours
Tx of acute arterial occlusion?
IV heparin, emergency embolectomy
Chronic venous insufficiency MC occurs after?
superficial thrombophlebitis, after DVT, or trauma to leg
Which type of LE deficiency has edema?
chronic venous insufficiency
Which type of LE deficiency has decreased pulses?
PAD
Improves with walking/elevation; worse with sitting/standing?
chronic venous insufficiency
Uneven, medial mallelolus, less painful ulcers?
chronic venous insufficiency
Stasis dermatitis is seen with?
chronic venous insufficiency
Atrophic skin changes are seen with?
PAD
Atrophie blanch is seen with?
chronic venous insufficiency
Dx of chronic venous insufficiency
trendelenburg test
Tx of chronic venous insufficiency
stockings, leg elevation
AAA: focal dilation of aortic diameter at least x diameter at level of renal arteries; typically >
1-1.5 x
>3 cm (normal 2 cm)
MC location of AAA
infra-renal (between renal arteries and iliac bifurcation)
AAA tx: 3-4 cm
US every year
AAA tx: 4-4.5
US every 6 months
AAA tx: 4.5-5.5
vascular surgery referral
AAA tx: 5.5+ or >0.5 growth in 6 months
immediate surgery
AAA criteria for: US every year
3-4 cm
AAA criteria for: US every 6 months
4-4.5 cm
AAA criteria for: vascular surgery referral
4.5-5.5 cm
AAA criteria for: immediate surgery
5.5+ or >0.5 growth in 6 months
AAA I:
l. subclavian to renal
AAA II:
L. subclavian to aortic bifurcation
AAA III:
mid-descending to aortic bifurcation
AAA IV:
upper abdominal aorta and all or none of infrarenal
CM of AAA:
fullness, throbbing pain in hypogastrium and lower back
Symptoms of impending rupture AAA?
sudden onset of severe pain in back and lower abdomen, radiating to groin, buttocks, legs; grey-turner and cullen sign
Acute leakage/rupture AAA?
1) severe back pain/abdominal pain
2) syncope or hypotension
3) tender, pulsatile mass
+/- flank ecchymosis
*** no further testing –> emergent lapartomy
Acute GI bleed in patients who underwent prior aortic grafting?
-Aortoenteric fistula
Initial test in suspected AAA?
US
Test for pre-op planning in AAA?
CT scan
Gold standard AAA?
angiography
MC site for aortic dissection?
ascending
Stanford A:
proximal AD
Stanford B:
distal AD (not involving ascending)
DeBakey I:
ascending + descending
DeBakey II:
confined to ascending
DeBakey III:
not involving ascending
Most important predisposing RF to aortic dissection?
HTN
CM of ascending AD?
anterior chest pain
CM of aortic arch AD?
neck/jaw pain
CM of descending AD?
interscapular pain
Describe vascular symptoms of AD?
decreased peripheral pulses; variation in pulse/BP
Dx of aortic dissection?
CT with contrast
Gold standard aortic dissection?
MRI angio
Type A AD tx?
surgical emergency; open!
Type B AD tx?
medical management; lower BP as quickly as possible with IV BB –> SBP 100-120
Stanford A CM?
new onset aortic regurgitation
Stanford B CM?
HTN
Most specific sign for DVT?
> 3 cm calf difference
Initial test for DVT?
US
gold standard for DVT?
venography
Wells Criteria for DVT?
active cancer (1)
bedridden >3 days or major sx in 4 weeks (1)
calf swelling >3 cm (1)
collateral superficial veins (1)
Entire leg swollen (1)
Localized tenderness to deep venous system (1)
Pitting edema, one leg (1)
Paralysis, paresis, or recent plaster immobilization (1)
Previously documented DVT (1)
alt. diagnosis as likely or more likely (-2)
wells criteria dvt: (-2) to 0:
d-dimmer
- If + –> US (if negative r/o)
- If (-) –> r/0
wells criteria DVT: 1-2
d-dimer -If - --> r/o -If + US -----> If (-) r.o If non-diagnostic, repeat US q 2-3 d for 2 weeks if (+) anticoag
Wells criteria DVT 3
All get US; d-dimer to risk stratify
(-) us and dimer --> r/o
(+) d-dimer:
(+): US anticoag
(-) US repeat in one weekIf patient has DVT with coagulation problems? tx?
lifetime anti-coag
1st DVT with reversible RF?
3 months
1st DVT with idiopathic cause: proximal
LT
1st DVT with idiopathic cause; distal
3 months if severely symptomatic; US surveillance if asymptomatic
Anticoag used in pregnancy?
LMWH
MC predisposing condition for PE?
Factor V Leiden
MC symptom of PE
Dyspnea
MC sign of PE
tachy
PERC criteria:
-Age 50+
-HR 100+
SaO2 <95
-Unilateral leg swelling
-Hemoptysisi
-Recent surgery, trauma (4 weeks)
-Prior PE/DVT
-Hormone use
Wells criteria: PE
Signs/symptoms of DVT (3)
PE # diagnosis (3)
HR >100 (1.5)
Immobilization at least 3 days or surgery in 4 weeks (1.5)
Previous DVT/ PE (1.5)
Hemoptysis (1)
Malignancy with treatment in 6 months (1)
Wells Criteria: <2 (PE)
d-dimer
Wells criteria: 2-6 (PE)
high sensitivity d- dimer
Wells criteria: >6 (PE)
CT angio
Best initial test for PE
Helical CT
Gold standard test for PE
pulmonary angio
CXR: PE
westermark’s sign; hamptom’s hump
Westermark:
avascular markings distal to embolus
Hamptoms hump
wedge shaped infiltrate
EKG finding in PE
S1Q3T3
S1Q3T3
PE
Describe S1Q3T3
wide deep S in lead I, isolated Q and T wave inversion in lead III
ABG PE
resp alk –> resp acidosis
Tx PE
heparin –> warfarin
MC valve affected in non-IVDA in endocarditis?
Mitral valve
MC valve affected in IVDA in endocarditis?
Tricuspid
MCC of sub-acute endocarditis?
strep viridans
MCC of acute endocarditis?
staph aureus
MCC of endocarditis in IVDA?
staph aureus
MCC of endocarditis in men 50 y/o with a history of GI/GU procedures?
enterococcus
MCC of endocarditis in prosthetic valve within 60 days of surgery?
staph epidermis
MCC of endocarditis in prosthetic valve >60 d of surgery?
strep viridans
Painless lesions on soles/palms seen in endocarditis?
Janeway
Retinal hemorrhages seen in endocarditis?
Roth
Tender spots on pads of digits seen in endocarditis?
Osler’s nodes
Dx of endocarditis
Blood cultures x 3;
Echo: TTE, then if non-diagnostic TEE (if prosthetic valve, do TEE first)
Endocarditis prophylaxis is required for those who have:
- prosthetic heart valve
- Heart repairs using prosthetic cardiac valve
- Prior hx of endocarditis
- Congenital heart disease (unrepaired cyanotic, repaired congential heart dz with prosthetic material during first 6 months)
- Cardiac valvulopathy in transplanted heart
Endocarditis prophylaxis is required for these procedures?
- dental: manipulation of gums, root of teeth, oral mucosa perforation
- respiratory: surgery on respiratory mucosa, rigid bronchoscopy
- Procedures involving infected skin/MSK (including I&D)
- Not needed for GI/GU
Endocarditis prophylaxis
amox 2 g 30-60 minutes prior
-Clinda 600 mg if PCN allergic
Endocarditis (acute; native)
nafcillin + gent x 4-6 weeks
or vanco + gent
Endocarditis (subactue, native)
PCN or amp + gent
-Vanco in IVDA
Fungal endocarditis
amphotericin B x 6-8 weeks
Prosthetic endocarditis
Vanc + gent + rifampin
