Cardio

Question 1

Big picture, what is the difference in the patho of STEMI vs NSTEMI, UA and SA?

Answer 1

STEMI is a 100 percent blockage so the underlying problem is a supply of blood/o2 to the heart. To intervene you need to re open the vessel.

The other 3 are demand and supply problems because the occlusion is less than 100%. This means we can try to fix, relieve, improve conditions by lowering the demand of the heart.

Question 2

What is the diamond classification for angina?

Answer 2

Substernal and left side
Worse on exertion
Relived by NTG

Question 3

3 important physical exam findings unique to MI chest pain?

Answer 3

Non pleuritc, meaning it doesn’t hurt more because of breathing
Non positional, meaning it doesn’t matter if they are leaning forward or back
Non tender, if you push on it, it doesn’t make it worse

Question 4

In most cases what is the best lab for NSTEMI?

When would you want to use another lab, what setting?

Answer 4

Troponin because it peaks first and is very sensitive and specific
CKMB when it is re infarction.

Question 5

What is the next step in management for a STEMI?

Answer 5

Cath lab immediately

Question 6

How do you best manage a NSTEMI?

Answer 6

If troponin is elevated, CATH
If the troponin is not elevated, then you are dealing with unstable angina, so do a stress test next. If stress test is positive, cath.

Question 7

What are the two ways to stress the heart during a stress test?
What are the three modalities to use to evaluate the patient during a stress test and when would you use each one?

Answer 7

Exercise, if not, give adenosine or dobutamine to get the heart going.
EKG, if baseline EKG is normal
ECHO, if baseline EKG is not normal
Nuclear, if previous heart grafting or heart failure

Question 8

How do we know the results of the stress test with echo or nuclear?

Answer 8

Normal tissue moves under rest and stressed
Dead tissue doesn’t move under both
the key is at risk tissue. At rest, it moves and is fine. When stressed, it doesn’t move because of myocardial stunning.

Question 9

Once in the cath lab, when to go CABG or stent?

Answer 9

3 or more vessels or main proximal go CABG.

1 or 2 vessels, stent

Question 10

What meds to give in the acute setting of MI?

Answer 10

MONA BASH C

Morphine, o2, nitrates, aspirin, beta blockers, ace inhibitor, heparin, clopidogrel

Question 11

When to use TPA for acute MI?

Answer 11

When it will take longer than 60 minutes to get to a center with a CATH lab

Question 12

2 reasons why we give beta blockers for MI?

Answer 12

Most people who die from MI, die from ventricular arrhythmias in the first 24 hours. Beta blocker prevent this.
Reduce demand of heart

Question 13

What are some of the main symptoms of congestive heart failure?

Answer 13

JVD, dyspnea, orthopnea, PND, peripheral edema, S3 heart sound, crackles in the lungs, big liver

Question 14

What is the best way to diagnose heart failure?

What EF is heart failure?

Answer 14

BNP first, Echo to get EF and diastolic function, then Left Heart Cath to see if ischemic or not.
less than 50%. normal is about 55

Question 15

What is considered the best test to diagnose heart failure? What else does it tell you?

Answer 15

Left heart cath. If the heart failure is ischemic or not

Question 16

What is the underlying problem in systolic heart failure and diastolic heart failure?

Answer 16

Systolic is a big flaccid ventricle that cannot pump or contract, EF sucks
Diastolic is a ventricle that cannot relax and fill

Question 17

Big picture description of class 1-4 heart failure?

Answer 17

1: no restrictions/symptoms
2. No symptoms during ADLs
3. Symptoms with ADLs
4. Symptoms at rest

Question 18

To treat heart failure starting at class 1, what do all patients get?

Answer 18

Beta blocker and ace inhbitor

Question 19

What do we start giving with class 2 heart failure and why?

Answer 19

Loop diuretic, like furosemide, to get fluid off

Question 20

What two meds to add after you put them on a loop?

Answer 20

ISO hydrolazine and spironolactone

Question 21

Class 4 patients start getting which meds?

Answer 21

Inotropes

Question 22

How do you treat a patient with an EF less than 35 and not class 4 and why?

Answer 22

AICD

Prevent sudden death from ventricular arrhythmias

Question 23

Every heart failure patient also gets which 2 meds?

Answer 23

Aspirin and statin

Question 24

Let’s say you have a patient who has heart failure, come in to the ED with an exacerbation, what is the process to manage the patient.

Answer 24

CXR to look for volume overload
EKG to look for STEMI
BNP to confirm volume overload
Troponin to confirm MI

If EKG and troponin show STEMI, give MONA BASH and cath
If CXR and BNP show volume overload, then it is a true CHF exacerbation and you need to treat with LMNOP> lasix, morphine, nitrates, o2, and position.
If all 4 tests are negative, then need to figure out the underlying cause.

Question 25

What is now considered normal, elevated, stage 1, stage 2, urgency, and emergency BP levels?

Answer 25

``` Less than 120 and less than 80 Less than 130 and less than 80 Less than 140 and less than 90 Over 140 and over 90 Over 180 and 120 (no signs of end organ damage) End organ damage ```

Question 26

How to treat elevated BP?

Answer 26

LSM

Question 27

How to treat stage 1 HTN?

Answer 27

LSM plus 1 med if there are risk factors/comorbidities

Question 28

How to treat stage 2 HTN?

Answer 28

LSM plus 2 meds

Question 29

How to make a diagnoses of HTN?

Answer 29

2 readings, 2 weeks apart, 2 separate visits

Question 30

What 2 types of meds to give for someone with HTN with heart failure or CAD?

Answer 30

Beta blocker and ace

Question 31

What two types of meds to give for someone with HTN and had a stroke?

Answer 31

Ace and thiazides

Question 32

What med to give for HTN for someone with CKD?

Answer 32

Ace or arb except stage 4 CKD

Question 33

What to give for HTN to someone with diabetes?

Answer 33

Ace

Question 34

What can you give to a patient who only has HTN and no other comorbidities or risk factors?

Answer 34

Thiazides, calcium channel blocker or ace

Question 35

What are the three main LSM for HTN and what is the recommendation for each?

Answer 35

Diet, less than 2.4 grams of salt per day Exercise, 30 minutes a day Weight, lose weight if BMI over 25 with HTN

Question 36

What is the side effect to remember for Dihydropyridine calcium channel blockers for HTN?

Answer 36

Peripheral edema

Question 37

2 side effects for both ace and arbs? | 2 just for ace?

Answer 37

Increase in CR, and hyperkalemia | Cough and angioedema

Question 38

2 side effects of thiazides?

Answer 38

Hypokalemia and hypercalcemia

Question 39

2 Side effect of spironolactone? | 2 situations to use spironolactone?

Answer 39

``` Gynocomastium and hyperkalemia CHF class 3 and HTN due to hyper aldosteronism ```

Question 40

What is the arterial and venous dilator And side effect for each?

Answer 40

Hydralazine, reflex tachy | ISO nitrate, dont use with other nitrates of PDE 5, massive hypotension

Question 41

First line therapy for high cholesterol?

Answer 41

Lifestyle modifications

Question 42

4 types of patients that get a statin?

Answer 42

Vascular dx Really high LDL, over 190 LDL between 70 and 189, age 40-75 and diabetes LDL between 70 and 189, age 4–75 and calculated risk

Question 43

What are the two high intensity statins and dose?

Answer 43

Atorvastatin 40 or 80 mg | Rosuvastatin 20 or 40 mg

Question 44

What are the two moderate intensity statins to know?

Answer 44

Atorvastatin 10 and 20 mg | Rosuvastatin 5 and 10 mg

Question 45

4 labs to get a baseline for before putting someone on a statin?

Answer 45

Lipids A1C CK LFTs

Question 46

How often to check lipids? How often do you check CK and LFTs?

Answer 46

Yearly | Only check them when the patient is symptomatic

Question 47

What happens when a patient gets patient statin induced myositis or statin induced hepatitis?

Answer 47

Stop the statin and wait for the problem to get resolved and then put them on a lower dose statin

Question 48

What is second line treatment after statins and what is the effect?

Answer 48

Fibrates | Raise HDL

Question 49

Effect of ezetimibe and side effect to know?

Answer 49

Lower LDL | Diarhrea

Question 50

Side effect of niacin to know, how to treat it, and effect of niacin on cholesterol?

Answer 50

Flushing, aspirin, raise HDL and lower LDL

Question 51

Big difference between stable and unstable angina? | What is the big difference between unstable angina and then moving into NSTEMI and STEMI?

Answer 51

stable angina is pain with exertion and can be relived with rest. unstable is pain at rest and nothing relieves it while it lasts. unstable angina, there is no heart damage, so no rise in biomarkers. the other two have damage and will have rise in biomarkers.

Question 52

5 risk factors for heart disease?

Answer 52

diabetes, smoking, overweight, high cholesterol, high BP

Question 53

Grade 1-6 for murmurs? When to work up a murmur? How to diagnose murmur?

Answer 53

1: heart sounds greater than murmur 2: heart sounds equal to murmur 3: heart sounds softer than murmur 4: palpable thrill 5: stethoscope half off chest 6: can hear murmur without stethoscope systolic, grade 3 and above or any diastolic murmur Echo

Question 54

``` What is the most common cause of mitral stenosis? Typical age? What drives the symptoms of MS? Where is it best heard? Give away buzz word? ```

Answer 54

``` rheumatic heart disease younger atrial dilation (afib) and fluid back up in lungs, basically CHF apex opening snap ```

Question 55

treatment of MS?

Answer 55

balloon plasty, maybe replace but these pts are younger and would need multiple placements throughout life.

Question 56

What is the only valve we do a balloon plasty on?

Answer 56

MS

Question 57

top three causes of aortic regurgitation?

Answer 57

infection, infarction, dissection

Question 58

What will be the main difference between acute or chronic aortic regurgitation?

Answer 58

acute will be like shock systems | chronic will be more CHF symptoms

Question 59

where will we hear aortic regurgitation? description of what you hear? Treatment?

Answer 59

right side 2nd sternal border crescendo, decrescendo replace

Question 60

main cause of AS?

Answer 60

atherosclerosis, calcification

Question 61

cause of MR?

Answer 61

infection and infarction

Question 62

where do you hear MR? | Buzzword for MR?

Answer 62

apex | holosystolic

Question 63

What are the 4 murmurs that follow the principle, more blood in the heart, more murmur?

Answer 63

MS, MR, AS, AR | so, if you increase venous return you increase murmur, vice versa.

Question 64

How do you increase venous return and how do you decrease venous return?

Answer 64

squat, leg lift | valsalva maneuver

Question 65

What are the two murmurs that follow the Principe, more blood in the heart, less murmur or makes it better?

Answer 65

mitral valve prolapse | hypertrophic cardiomyopathy

Question 66

What exactly is the problem with hypertrophic cardio?

Answer 66

the ventricular septum is beefy so it covers the aortic outlet causes left ventricular outlet obstruction.

Question 67

most common presenting patient and what is the pathology?

Answer 67

young athlete | sarcomere mutation

Question 68

What is HCM like and explain the difference?

Answer 68

it is basically like AS but young athlete and more blood softens the sound

Question 69

treatment for HCM? what kind of murmur is HCM?

Answer 69

avoid dehydration and beta blockers/CCB | systolic

Question 70

Pathology of MVP? typical patient? What is it like but difference? treatment?

Answer 70

congenital young woman MR but more blood makes it better avoid dehydration and beta blockers

Question 71

3 causes of dilated cardiomyopathy to remember?

Answer 71

virus, alcohol, and ischemia

Question 72

3 symptoms of HCM to remember?

Answer 72

DOE, syncope, and sudden death

Question 73

What essentially is concentric cardiomyopathy? | Patho of it?

Answer 73

diastolic CHF | HTN

Question 74

3 primary causes of restrictive cardiomyopathy?

Answer 74

amyloid, sarcoid, and hemachromatosis

Question 75

associated health conditon with amyloid, sarcoid and hemachromatosis?

Answer 75

peripheral neuropathy pulmonary disease cirrhosis or DM

Question 76

2 big causes of pericarditis?

Answer 76

viral infection | uremia

Question 77

two words to describe the pain of pericarditis?

Answer 77

pleuritic and positional

Question 78

What is the test to diagnose pericarditis and what is considered the best one but not used?

Answer 78

EKG | but best is MRI

Question 79

4 options for treatment of pericarditis and which one is the best?

Answer 79

NSAIDS and colchicine, best nsaids alone, not in CKD, bleeding problems and PUD colchicine alone steroids, worst choice

Question 80

What does EKG show for pericarditis?

Answer 80

diffuse ST elevations or depressed PR

Question 81

How to best diagnose pericardial effusion? | treat if it is caused by pericarditis?

Answer 81

echo | treat pericarditis, may need to do pericardial window to drain

Question 82

becks triad of tamponade?

Answer 82

jvd, hypotension, decreased heart sounds

Question 83

if we have a pericardial knock, what are we dealing with? How to diagnose? treatment?

Answer 83

constrictive pericarditis echo cut the pericardium out. hard fibrous pericardium from chronic pericarditis

Question 84

What is the equation to deal with when we are talking about syncope?

Answer 84

``` MAP = CO X SVR CO = SV X HR SV = contractility and pre load ```

Question 85

What is vasovagal syncope? | Treat?

Answer 85

vagus nerve is stimulated and dumps a bunch of ACH causing bradycardia and massive vasodilation. visceral organs, carotids, and psychogenic

Question 86

how do we diagnose orthostatic hypotension based on numbers?

Answer 86

systolic greater than 20, diastolic greater than 10 and HR greater than 15 when going from laying to standing

Question 87

What are the two most common causes of orthostatic hypotension? treatment?

Answer 87

volume down, diarrhea, dehydration etc dysfunctional ANS, old person fluids

Question 88

3 mechanical heart problems causing syncope?

Answer 88

valve problem, arrhythmia,