CARDIO Flashcards
Treatment for Unstable Bradycardia
1st- Atropine 1st Line
Epinephrine or Dopamine infusion
3rd Degree HB = Transcutaneous pacing 1st Line
Bradycardia causes
Physiologic- vasovagal reaction (MCC), well conditioned, ICP.
Pathologic- BBs, CCBs, Digoxin, Inferior MI
Irregular Rhythm where HR increases during inspiration.
Otherwise NSR
Sinus Arrhythmia
A combination of sinus arrest alternating paroxysms of atrial tachyarrhythmias and bradyarrhythmia
What is the management?
Sick Sinus Rhythm
Management: Permanent Pacemaker if symptomatic.
Heart block that requires permanent pacemaker?
Second Degree AV HB Type II (Mobitz II)
Third Degree AV Block
HB with progressive PRI lengthening leading to a dropped QRS;
Going, Going, Gone
2nd Degree AV Block Type I (Mobitz I)
HB commonly in the bundle of His.
Constant prolonged PRI: 2:1 or 3: 1 P:QRS
What is the management
2nd Degree AV Block Type I (Mobitz II)
Management: Atropine or Temporary pacing
Most common chronic arrhythmia. Irregular/ Irregular rhythm with narrow QRS
No discernable P waves (350-600 BPM)
Atrial Fibrillation
Stable Atrial fibrillation Management
- BBs- Metoprolol or Esmolol (Caution w reactive Airway disease
- CCBs- Diltiazem (Less Verapamil) Non-dihydropyridines
- Digoxin- In elderly (preferred for rate control in patients with HYTN or CHF
All patients with nonvalvular atrial fibrillation should undergo?
Anticoagulation (INR 2-3)
Types of Atrial fibrillation
Paroxysmal- Self terminates w/i 7 days (recurrent).
Persistent- not terminate w/i 7 days
Permanent- AF> 1 year (refractory to cardioversion)
Unstable Atrial fibrillation Management
Synchronized cardioversion
Definitive: Radio frequency Ablation
Unstable Tachycardia: HYTN, AMS, AHF, CP
Narrow QRS
Synchronized cardiovert
Consider Adenosine
Unstable Tachycardia: HYTN, AMS, AHF, CP
Narrow QRS
- Vagal Maneuvers
- Adenosine (If regular and narrow QRS)
- BBs or CCBs
Management of Wolff-Parkinson-White (WPW)
Stable:Procainamide preferred (Class Ia Antiarrhythmic)
Unstable: Synchronized Cardiovert 1st Line
Avoid AV nodal blockers
ABCD= Adenosine, BBs, CCBs, Digoxin
If Left Axis Deviation ECG will show
Lead I QRS upright
aVF QRS downward
If normal Axis deviation
Lead I QRS upright
aVF QRS upright
If Right Axis Deviation
Lead I QRS downward
aVF QRS upright
Normal PR interval
0.12-0.20 seconds (3-5 boxes)
Left Atrial Enlargement in ECG will show
M shape P wave in lead II with larger terminal component
Right Atrial Enlargement in ECG will show
Biphasic and Tall P wave in lead II with larger initial component
Left BBB in ECG will show
Wide QRS >0.12 seconds
Slurred R in V5, V6
Right BBB in ECG will show
Wide QRS > 0.12 seconds (>3 Boxes)
RSR in V1, V2
Right Ventricular Hypertrophy ECG will show
V1: The R is taller than the S (Or R>7mm)
Left Ventricular Hypertrophy ECG will show
S in V1 + R in V5 orV6= >35mm
(Sokolow-Lyon criteria) Large box = 5mm
Small box= 1mm
T wave inversion abnormal when in
Lead I, II, V3-V6 = MI
Normally inverted in aVR
Small box and large box in ECG is
- 04 seconds = 40 mS
0. 20 seconds = 200mS
If the area of infarction is Lateral wall Q/ ST elevation will show in Leads_______
Lead I, aVL, V5, V6
Left circumflex
If the area of infarction is Anterolateral wall Q/ ST elevation will show in Leads_______
Lead I, aVL, V4, V5, V6 (Add V4 to Lateral)
Mid Left Anterior Descending or Left Circumflex
If the area of infarction is Inferior wall Q/ ST elevation will show in Leads_______
Lead II, III, aVF
Right Coronary Artery (RCA)
If the area of infarction is Anterior wall Q/ ST elevation will show in Leads_______ and _______ Artery
V1 through V4
Left Anterior Descending Artery
If the area of infarction is Posterior wall Q/ ST elevation will show in Leads_______and ______Artery
ST Depression in V1-V2 RCA, L circumflex artery
Sinus tachycardia with narrow QRS complexes of >150 BPM
Management- Stable and Unstable
Paroxysmal Ventricular Tachycardia
Stable- Adenosine (Narrow) Amiodorone (Wide) –> BBs
Unstable- Synchronized Cardiovert (Def.= Ablation)
Atrial fibrillation Pharmacologic rhythm control
Ibutilide or Flecainide
Multiple ectopic Atrial Foci
> 100 MAT Multifocal Atrial Tachycardia
<100 WAP Wandering Atrial Pacemaker
Tx: CCB or BB if LV function preserved
Multifocal, Bigeminy, or Trigeminy PVCs Tx
No treatment needed
> 3 consecutive PVCs >100 BPM
Stable V-Tachycardia: Amiodorone, Lidocaine, Procainamide
Unstable V- Tach w pulse: Synchronized cardiovert
V-Tach no pulse: Defibrillation
Torsades de Pointe management
IV magnesium
PEA or Asystole
CPR + Epinephrine + shockable rhythm check every 2 minutes.
ST depression usually indicates
Ischemia (reversible if oxygen to tissue corrected)
transmural (full thickness of heart wall)
ST Elevation usually indicates
Infarction (Dead tissue)
Significant if >1mm in Limb lead or >2mm in precordial (0over the heart)
Diffuse concave ST elevation in precordial leads v1-v6
PR depression in ST elevation leads
Acute Pericarditis
Low voltage QRS complex
Electrical Alternans
Large Effusion or Pericardial Tamponade
Non-specific ST/T changes
S1Q3T3 most specific for
Pulmonary Embolism
MC ECG Finding =Sinus Tachycardia
(Most specific ECG changes = S1Q3T3
What does S1Q3T3 mean
Wide S in Lead I
Q wave in Lead III
T wave inversion in Lead III
Definitive Diagnosis (Gold Standard) for CAD, PAD, renal artery stenosis, and Abdominal Aortic Aneurysms
CT Angiography
Most useful to diagnose HF
Echocardiogram
TTE- less invasive
TEE- more invasive better image (Post. cardiac structure)
Initial Test for patients with normal ECG
Exercise Stress Treadmill Test
CI: if unbale to exercise
Photon Emission Tomography that localizes regions of ischemia
Radionuclide Myocardial Perfusion
Stress testing done in patients unable to exercise done with myocardial perfusion imaging
Localizes region of ischemia
Pharmacological Stress testing
Pharmacological Stress testing uses what drugs
CI: in what patients
Adenosine or Dipyridamole
Asthma, COPD –> vasospasm
Localizes area of ischemia + depicts wall abnormalities, views structure/function of heart
Used in patients CI of vasodilators:
Stress Echocardiography (Used Dobutamine)
Assesses Arterial pulses, Abdominal Aortic Aneurysms, or DVTs
Ultrasound
Venous Duplex in DVTs
MCC by atherosclerosis: Reduces Lumen 70% –> symptomatic.
RFs: DM-II (Worse factor, Smoking (Most modifiable), hyperlipidemia, HTN, >45 in men or >55 women, FMHx
Coronary Artery Disease
Chest < 30 minutes (1-5 minutes) relieved w rest/Nitro
Dyspnea, nausea, diaphoresis; predictable pattern
epigastric or shoulder pain
Angina Pectoris (Stable Angina)
Acute Coronary Syndrome includes
Myocardial ischemia 2T coronary Artery Thrombosis
Unstable Angina
NSTEMI
STEMI (ST Elevation Myocardial infarction)
Angina new in onset > 30 minutes
ST elevation Total occlusion
Positive Cardiac Enzymes.
STEMI (Pain at rest = 90% occlusion)
Angina new in onset > 30 minutes
ST Depression and or T wave inversion partial occlusion
Positive Cardiac Enzymes.
NSTEMI
Angina new in onset > 30 minutes
ST elevation/depression
Negative Cardiac Enzymes.
Unstable Angina
Chest pain that occurs in the a.m MC or 2T cocaine use
Coronary Artery Vasospasm (Prinzmetal Angina)
Management: CCBs Cocaine: Benzodiazipine “NO BBs”
Cardiac Enzyme that returns to baseline in 7-10 days and peaks at 12-24 hours
Troponin I and T
Most Sensitive and specific
Cardiac Enzymes CK and CK-MB return to baseline in _____
3-4 days
Inhibits receptors on platelet surface
Aspirin, Clopidrogel, Tecagrelor, Prasugrel
Antiplatelets P2Y12
Block binding site for fibrinogen in platelets
Abciximab
Eptifibatide
Tirofiban
Antiplatelets GP IIb/IIIa
Anticoagulant through inactivation of thrombin
Warfarin, Heparin, LMWH
Fondaparinux, Dabigatran, Rivarobaxan, Apixaban
Anti-Thrombotic Therapy
Activates plasmin–> clot breakdown
Prevents clots and Thrombus
Streptokinase, Alteplase, Anistreplase
Fibrinolytic
Coumadin (Warfarin) Affects
PT and INR
Heparin affects
PTT
Reversal (Antidote) for Heparin or LMWH
Protamine Sulfate
Reversal Antidote for Coumadin (Warfarin)
Vitamin K
Vitamin K dependent Coagulation Factors II, VII, IX, X
Extrinsic Pathway (PT)
Antithrombotic Tx in UA, STEMI, NSTEMI
Antiplatelet- P2Y12 or GP IIb/IIIa
Antithrombin- Heparin, warfarin, FDR-A
MONA
BBs (Metoprolol) CCBs in vasospastic DO (Verapamil/Diltiazem)
Thrombolytic only in STEMI- (Adjunct therapy ACE)
HF with normal EF; +/- gallop is _____
Forced atrial contraction into a “stiff” ventricle
Thick walls small chamber
Diastolic HF
Gallop S4
HF with reduced EF; +/- gallop is _____
Forced atrial contraction into a “sloshing” ventricle
Thin walls dilated (Large) chamber.
Systolic HF (MC)
Gallop S3
HF MCC by coronary Artery Disease and Hypertension
Left sided HF
HF MCC by Left sided HF
Right sided Heart failure
HF most common symptom
Dyspnea
other: Edema, JVD, GI/hepatic congestion
Diagnosis of HF
Most important determinant of prognosis
Echocardiogram EF
Normal = 55-60% <35%= Increased Mortality
Enzyme that may identify CHF as cause of dyspnea
> than ____ level
B-Type Natriuretic Peptide (BNP) >100= CHF Likely
1st Line of HF, decreases remodeling, and decrease mortality in post-MI
–> hyperkalemia, cough, angioedema
1st dose renal insufficiency
ACE Inhibitors -pril
Decreases mortality, Incr. EF, and reduces Ventricle size
Not in vasospastic DO
BBs -lol
No increase in Bradykinin –> no cough or Angioedema
ARBs -sartan
Most effective treatment for mild-mod HF/ Edema
works at loop of Henle–> hyperglycemia/uricemia hypokalemia/calcemia/natremia
Loop Diuretics -ide
Aldosterone antagonist; Potassium sparing: added in severe CHF
–> Hyperkalemia and Gynecomastia
Spironolactone
Epleronone= better
Best in African Americans
–> hyperglycemia/uricemia
Hyponatremia/kalemia
Hydrochlorothiazide (Also CCB)
Metolazone
Medication that lowers mortality and hospitalization
Leads to Increase of BNP: used in class II-IV w reduced EF
Sacubitril-Valsartan (Entresto)
cephalization occurs at Pulmonary capillary wedge pressure (PCWP) of ______ .
Worsening of dyspnea, rales, pink frothy sputum.
12-18 mmHg of PCWP
Normal = 6-12 mmHg
MC Caused by enterovirus (coxsackie); fever usually +
Chest pain that is worse with inspiration: worse when supine, relieved by sitting or leaning forward.
Acute pericarditis
Pericardial friction rub is best heard when
upright and at end of expiration
Acute Pericarditis (Dressler) Treatment
Aspirin (NSAID) or Colchicine
Restriction of cardiac ventricular filling leading to decreased output.
Diastolic collapse of cardiac chambers
Pericardial Tamponade
Pericardial Tamponade Triad
Beck’s Triad: Muffled HS, JVP, hypotension.
What is pulsus paradoxus in Pericardial Tamponade
> 10mmHg decrease in systolic BP with inspiration
Pericardial Knock high pitched 3rd HS 2t sudden stop of ventricular filling is associated with?
Constrictive pericarditis
What is the difference between constrictive pericarditis and Acute pericarditis
Constrictive pericarditis- Calcified pericardium
(Pericardiectomy Tx)
Acute pericarditis- Inflamed pericardium
Inflammation of the heart muscle most commonly caused by the Coxsackie Virus.
Dx: Bx is Gold standard: X-ray = cardiomegaly
S/Sx: fever, myalgias, malaise, with exercise intolerance
Myocarditis
Myocarditis treatment
Supportive: ACE, Dopamine, IVIG
What are the types of cardiomyopathies
Hypertrophic: 4%: Dyspnea MC; large septum: Sudden death: >15mm Syst Anterior wall motion of MV
Dilated-95%: Coxsackie: LVD: <30-35% EF= AICD
Restrictive-1% Amyloidosis/Sarco MCC: R heart failure:
normal wall thickness.
Hypertrophic cardiomyopathy Treatment
1st Line- BBs
ICD placement: Myomectomy: Alcohol Septal Ablation
Dilated Cardiomyopathy Treatment
HF Tx- ACEi, diuretics, BBs
AICD if <30-35%
Cause- infection with GABHS (Strep Pyogenes). Stimulates Ab production to host–> organ damage
2-6 week onset
Rheumatic Fever
Rheumatic fever most common valve affected
Mitral Valve 75-80%
what is the criteria for rheumatic fever
JONES criteria (Polyarthritis MC)
Joints (MC), Oh my heart (Carditis), Nodules, Erythema Marginatum, Sydenham’s chorea (MAJOR CRITERIA)
Rheumatic Fever Treatment
Penicillin G (Erythromycin if PCN allergy)
Aspirin
Erythema Multiforme is associated with
Herpes HSV (Target Lesion with Halo)
SOAPS- Sulfa, hypoglycemic, A-convulstant, PCN, NSAIDS
Erythema Migrans is associated with
Lyme Disease
Erythema Infectiousum is associated with
Parvo B19 (5th Disease) URI S/Sx 3-4 days prior to rash
Erythema Marginatum is associated with
Rheumatic Fever (Macule with central clearing)
Systolic Murmurs
MR: AS: TR: MVP: + HCM and PS
Diastolic Murmurs
AR: MS: MS: TS
“Crescendo-Decrescendo” Radiates to carotid [Aortic]
MC valve disease
Opening Ejection click: Increased= sitting leaning FWD
-Pulsus parvous e Tardus-
Aortic Stenosis
Tx-Not effective (No Nitrates/dilators in mod-severe)
“Holosystolic blowing” [Apex] radiates to axilla
Increase w Left lateral decubitis * handgrip
MCC- MVP Rheumatic disease
Mitral Regurgitation
Tx- Sx repair
“Mid-late systolic ejection click” [Apex] MC young women.
MCC: Marfan’s, Ehler’s Danlos, Osteogenesis Imperfecta
Increased with Valsalva/standing
Mitral Valve Prolapse
Tx- BB only (Good prognosis)
“Harsh Crescendo-Decrescendo” Associated with activity CP. Dyspnea MC complaint [LLSB]
Increased with Valsalva * Standing: +/- S4
HCM
Tx-BBs 1st line– myectomy
“Holosystolic High Pitched” [L midsternal border]
Carvallo’s sign- Increases with inspiration
Tricuspid Regurgitation
Tx- Diuretics (sx-severe)
“Decrescendo Blowing” [LUSB] rheumatic/endocarditis
Increased w sitting forward
Double pulse carotid upstroke- “Head bobbing” Musets
Aortic Regurgitation
Tx: ACEi— Sx definitive
“Opening snap” + mid-systolic rumble [Apex LLD]
Always Rheumatic fever
P Mitrale +/- A-fib
Mitral Stenosis
Tx- Mitral Valve Repair
“Mid-diastolic Rumble” [LLSB xyphoid]
R sided HF: increased with inspiration
Tricuspid Stenosis
Diagnosis of Hypertension is made after
> = X2 Elevated readings on >=X2 different visits.
140/90 mmHg
Types of HTN
Primary- Idiopathic w RF
Secondary-Renal Artery Stenosis MCC, BC (estrogen), NSAIDS: Aldosteronism (conn’s Hyper-), Pheo (“Refractive”)
Pseudo Resistant- Decr. Adherence/Tx or white coat
HTN w/o organ damage: oral drug used an treatment?
HTN Urgency
Decrease BP by 25% 24-48 hrs PO to < 160/100
DOC: Clonidine or Captopril
HTN w Organ damage >180/120: Tx?
HTN Emergency
Neuro= Nicardipine, Labetolol or Clevidipine
Cardio= Dissection-Esmolol/Labetalol
ACS- Nitro+ BBs
HF-Nitro (Nitroprusside) + Lasix
Renal=Fenoldopam
Hypertensives
Contraindicated medications for CHF or 2nd/3rd HBs
CCBs Specially Non-dehydropyridines
Hypertensives:
Contraindicated in 2nd/3rd HBs and decompensated HF
BBs
Hypertensives:
Contraindicated in Pregnancy
ACEi
Hypertensives:
CI in sulfa allergies
Loop Diuretics
Hyoertensives:
CI in renal failure/ hyponatremia
Potassium Sparing diuretics
Spironolactone + Eplerenone
Signifies an advanced stage of malignant hypertension
Fundoscopic Papilledema
Goal BP for over 60 y/o
< 150/90
Initiation of Statin therapy guildelines
DM I-II = 40-75 yoa
> 7.5% Risk MI or stroke in 10 years
> 21 with LDL> 190 mg/dL
Any atherosclerotic cardiovascular disease
Best meds to lower LDL
Statins (DM-II) SE: Myalgias
Best meds to lower triglycerides
Fibrates (Severe renal Dz/Hepatic) or Niacin
Best meds to increased HDL
Niacin (hyperglycemia/ flushing)
Only lipid lowering medication safe in pregnancy
Bile Acid Sequestrants (Cholest- /Colest-)
High intensity Statin
Atorvastatin
Rosuvastatin
Low intensity
Pravastatin
Lovastatin
Fluvastatin
Simvastatin
Fever of unknown origin (80-90%), fatigue, anorexia, WL
Janeway lesions; Roth Spots, Osler’s nodes, Splinter hemorrhages
Infective Endocarditis
Infective Endocarditis MC Valve Involved
Mitral
MC IV Drug User Infective Endocarditis valve involved
Tricuspid
What is a Janeway Lesion
Painless erythematous macules @ palms and soles
Osler @ pads of digits
What is a Roth spot
Retinal hemorrhages
Infective Endocarditis DX + Tx?
Dx- Blood cultures X3 sets 1 hour apart: Inc- ESR/RF
Duke Criteria
Tx- Nafcillin+ Gentamycin 4-6 weeks (Vanco if MRSA)
Prophylaxis Indications for Endocarditis
Amoxicillin 2G 30-60 min prior to procedure
Clindamycin if PCN allergy
MCC of Endocarditis Normal valve/Abnormal? IVDU? Prosthetic valve?
Normal valve= Virus or S. Aureus
Abnormal = S. Viridans
IVDU= MRSA
Prosthetic Valve= S. Epidermis
Clinical Manifestation of Peripheral Arterial disease X5
Resting leg pain: Intermittent claudication: Gangrene: Acute Arterial Embolism:
Atherosclerotic disease of lower extremity
Quickest non-invasive most useful screening tool for Chronic PAD?
positive if ABI < 0.90 (Ankle-Brachial Index norm 1-1.2)
Gold standard Dx tool for PAD?
Tx?
Arteriography
1st- Cilastazol (claudication) –> Angiplasty/Saph bypass grafts
PE findings in PAD
Pain, paralysis, pale (on elevation), Pulseless, paresthesia:
Lateral malleolus ulcers ( Medial Malleolus= CV insuff.)
Seen in Increased estrogen OCPs, pregnancy, prolonged standing and obesity.
venous Stasis ulcers, pain/edema relieved with elevation, tortuous veins: Tx
Varicose Veins
Tx: Elastic compressions: Sclerotherapy/ Laser Ablation
Cerulea Albans + Cerulea Dolens are ass. with what?
Deep Vein Thrombosis
Albans= white pallor Dolens= Cyanotic Hue
what is the triad for DVT?
Virchow’s Triad
Venous Stasis, hypercoagulation, and endothelial damage
Most specific symptom/ sign of DVT
Unilateral LE swelling >3cm
DVT Dx (1st Line and GS) and Tx?
Dx- Venous duplex US “1st Line” Venography GS
D-Dimer Wells score< 1
Tx- LMWH (PTT 1.5-2.5) Preferred in PREGO/Malignancy
Male >60, severe back or abdominal pain with syncope/hypotension
+ tender pulsatile abdominal mass.
Abdominal Aortic Aneurysm
MC RF for Abdominal Aortic Aneurysm
Atherosclerosis#1—–> >60, smoking, HTN
Surgical repair recommendations for AAA
Immediate- >5.5 cm or 0.5 w/i 6 mos
> 4.5 cm= Sx referral
4-4.5 cm = Monitor every 6 mos
> 3= US every year
AAA Dx + Tx ?
Dx- 1st Line US TOC= CT GS=Angiography
TX: Initial= BBs Definitive= Sx
MC site for AAA
Infrarenally
Most important predisposing factor is HTN: Sudden
Severe tearing pain @ chest/upper back.
Decreased peripheral pulses, new onset aortic regurgitation.
Aortic Dissection (Tear of Aorta Intima)
Aortic Dissection Dx? Tx?
TOC-CT GS-MRI Angiography CXR- Widening Media
Tx-Esmolol/Labetalol (100/120 <60BPM target) +
Nitroprusside or Nicardipine
Non-atherosclerotic inflammatory medium artery and vein disease. Strongly associated with tobacco.
Distal extremity ischemia, ulcers, and gangrene.
Thromboangiitis Obliterans (Buerger’s Disease)
Aortic Dissection type that involves the ascending aorta and aortic arch and beyond distally
Debakey Type I
Aortic Dissection type that involves the ascending aorta
Debakey Type II
Aortic Dissection type that involves the descending aorta
Debakey Type III
Inflammation or thrombus of a superficial vein: Palpable cord non-compressible vein
MC in IV catheterization, trauma, pregnancy, varicose V
Superficial Thrombophlebitis
Superficial Thrombophlebitis Dx + Tx?
Dx- Venous Duplex US
Tx- Supportive: NSAID, stockings, elevate extremity
Heparin or warfarin: Phlebectomy
MC occurs after superficial thrombophlebitis, DVT or trauma. Leg pain/edema, color improves with elevation
Stasis dermatitis- scaling, itching, rash, erosion, crusting
Brownish hyperpigmentation.
Chronic Venous insufficiency
Most common primary cardiac tumor in adults (rare). Pedunculated.
Flu like, fever, palpitations, +/- murmur 90% Atrial
Atrial Myxoma
Dx with tilts (what is tilts)
Postural Hypotension (Orthostatic) After 5 min. supine
< Sys. BP >= 20 mmHg
Dia >= 10mmHg
> 15 BPM increase within 2-5 min of quiet tanding
4 main types of shock
Distributive
Obstructive
Cardiogenic
Hypovolemic
Distributive shock
Neuro, Endo, Septic, Anaphylactic
Obstructive
PE, Tamponade, PTX, Aortic Dissection
Cardiogenic
MI, arrhythmia, HF
Hypovolemic
Blood loss
Fluid Loss
Difference between SIRS and Sepsis?
Systemic Inflammatory Response Syndrome
SIRS- state of systemic inflammation
Sepsis- Presence of SIRS with a source of infection
What is the difference between Sepsis and septic shock
Septic shock is sepsis with refractory HYTN
Systemic Inflammatory Response Syndrome (SIRS)
you musts have at least 2 of the following?
Temperature
Tachycardia
Tachypnea
WBC >12,000 or <4,000
