Cardio Flashcards
Stable Angina Presentation
Pain with exertion relieved by rest Neg troponins Negative ST Elevation ~70% occlusion
Unstable Angina Presentation
Pain at rest Nothing relieves the pain Negative Troponins Negative ST Elevation ~90% occlusion
NSTEMI presentation
Pain at rest Nothing relieves the pain Positive troponins Negative ST Elevvation ~90% occlusion
STEMI
Pain at rest Nothing relieves the pain Positive troponins Positive ST Elevation 100% Occlusion
Risk Factors for MI
Diabetes HTN HLD Obesity Family Hx Age >45M, >55 F
MI Presentation
Associated Symptoms
SOB, Nausea/Vomiting, Presyncope
Non-pleuritic pain, Non-positional pain, Non-tender
Angina Diagnostic Workup
- ECG
- Troponins
- Stress Test
Angina
Normal ECG
Positive Troponins
What next
Urgent Cath
Angina
ST Elevation
What Next
Emergent Cath
Angina
Normal ECG
Negative Troponins
Positive Stress Test
Elective Cath
MI 3 or more occluded Vessels
Perform CABG
MI 1 or 2 occluded vessels
Place Stent
Contraindicated in Right sided MI, (II, III, aVF)
Nitrates
Right sided infarcts are preload dependent, require preload support give IV fluids
Medical management before Cath lab in angina/MI
MONA BASH Morphine Oxygen Nitrates Aspirin (ALWAYS GIVE FIRST) Beta Blockers ACEi Statin Heparin
What medications should a patient receive on discharge post MI?
Aspirin
B-Blocker
ACEi
Statin
Post MI, when do you add Nitrates to discharge medications
If patient has continuing chest pain
When do you add clopidogrel? For how long?
When a stent is placed
DES-1 year
Bare Metal- 1 month
When do you use tPa
When access to a cath lab is far away (60 Minutes)
Sx of right sided heart failure
JVD Peripheral Edema HSM DOE Displaced PMI S3
Sx Left sided Heart Failure
DOE-Crackles Orthopnea PND Abdominal pain Weight Gain Displaced PMI S3
Diagnostic Tests in HF
BNP (released when RA stretches)
2D Echo
[Left Heart Cath-Ischemic or not]
CHF Stage I Treatment
Beta- blockers, ACEi/ARB
CHF Stage II Treatment
Stage I + Loop Diuretic (Furosemide)
CHF Stage III Treatment
Stage I and II + Isosorbide Dinitrite and hydralazine
CHF Exacerabtion Work up
CXR
BNP
ECG
Troponins
CHF Exacerbation Treatment
Furosemide Morphine Nitrate Oxygen Position
What murmurs need a work-up?
Any systolic murmur grade 3+ and any diastolic murmur
Dx Test for Murmur
TTE, if not good then
TEE
Mitral Stenosis
Path, Dx, Tx
Pt-Younger (20-30), Rhuematic Disease Sx: CHF, A-fib Dx: Rumbling Diastolic, with an opening snap best heard at the apex Tx: Balloon Valvuloplasty Valve Replacement
Aortic insufficiency (Regurgitation) Path, Dx, Tx
Pt: Infection/Infarction Aortic Dissection Sx: Acute- Cardiogenic shock, Flash pulm Edema Chronic-CHF, Chest Pain Dx: base of heart (2 ICS RSB) Rumbling Diastolic murmur Tx: Valve replacement
Aortic Stenosis
Path, Dx, Tx
Atherosclerosis, Ca Depostion Pt: Older male Sx: Chest pain, CHF, Syncope Dx: Systolic, crescendo-decrescendo; Base of the heart Tx: Replacement
Mitral Insufficiency (Regurg) Path, Dx, Tx
Sx: Acute-cardiogenic shock, Flash Pulmonar Edema
Chronic: CHF, A-Fib
Dx: Apex, Holosystolic, high pitched blowing
Maneuvers to increase venous return to the heart
Squatting/ Leg Lift
Maneuver to decrease venous return to the heart
Valsalva
HOCM Pathology
Asymmetric septum hypertrophy causing left ventricular outlet obstruction
HOCM patient, Dx, Tx
Young athlete with SOB, syncope with exertion, Family history of sudden cardiac death
Dx: systolic murmur (Sounds like AS), more blood improves the murmur
Tx: B-Blockers, avoid dehydration
Mitral Valve Prolapse
Dx, Tx
Patient is usual a young woman
Dx: like mitral regurg, but improves with more blood
Tx: Avoid dehydration
B-Blockers
Causes of Restrictive Cardiomyopathy
Amyloidosis, Sarcoid, Hemochromatosis
Restrictive Cardiomyopathy presentation
Sx of diastolic heart failure
perform Echo
Dx of Restrictive cardiomyopathy
Amyloid-Myocardial biopsy
Sarcoid- Endomyocardial biopsy
Hemo-Ferritin increased, genetic test
Treatment restrictive cardiomyopathy
Beta blockers are equal to CCB
Gentle Diuresis
Transplant
Treat underlying cause
Pericarditis Presentation
Viral, Uremia
Pt: Pleuritic chest pain, and positional
Pericarditis Dx and Tx
Best MRI, First ECG ( Diffuse ST Elevations and Depressed PR segments)
Tx: NSAIDs and colchicine the best
Contraindications for NSAIDs Pericarditis treatment
CKD, Thrombocytopenia, PUD
Pericardial Effusion Path, Dx, Tx
caused by Pericarditis
Dx: Echo
Treat the pericarditis, if continues perform pericardial window
Cardiac Tamponade Presentation
CHF Sx
Becks Triad (JVD, Hypotension, Muffled Heart sounds)
Pulsus Paradoxus >10mmHg
Clear Lungs
Tamponade Treatment
Pericardiocentesis
if cant reach OR quickly give IV fluids
Constrictive Pericarditis Path, Presentation, Dx, Tx
Due to chronic pericarditis Sx: Diastolic CHF Pericardial Knock Dx: Echo Tx: Pericardiectomy
Vasovagal Syncope Presentation, Tx
Situational and reproducible with a prodrome
Vasovagal organ stimulation, carotid body stimulation (micturation, defecation, coughing)
Tx: Beta blockers
Orthostatic Syncope Presentation, Tx
Standing up get dizzy Dx: Systolic change 20 Diastolic change 10 HR change 15 Tx: Fluids
Orthostatic Syncope causes
Diarrhea, Dehydration, Diuresis, Hemorrhage
Diabetes, Parkinsons, Age
Syncope caused by valvular lesions
exertional syncope (AS or HOCM)
Dx: Echo
TX; Depends on lesion
Syncope due to Arrhythmia
Sudden loss of consciousness without prodrome
Tx: Depends on the arrhythmia
Syncope Due to Arrhythmia workup
ECG
24 hour Holter monitor
Event Recorder
Who should receive Statin Therapy
- Anyone with Valvular disease
- if LDL >190
- if LDL is 70-189 aged 40-75 with diabetes
- LDL 70-189 aged 40-75 with calculated 10 year risk for MI
What are the Statins used for therapy and dosages for high and moderate
High - Atorvastatin 40, 80 Rosuvastatin 20, 40 Moderate- Atorvastatin 20, 40 Rosuvastatin 10, 20
When should you use moderate statin therapy
age >75, statin intolerance, liver or renal disease
What tests should you run before statin therapy
HbA1c, CK, LFTs, Lipids
Recheck Lipids in one year
recheck HbA1c if patient has DM
If muscle soreness or weakness develop after starting statin therapy what should you do
perform CK and UA
LFTs if with hepatitis
discontinue Statin until symptoms resolve and then restart at lower dose
Hypertension treatment for Elevated Stage
<130/<80
Lifestyle modifications and f/u in 6 months
Hypertension treatment for Stage 1
<140/<90
Lifestyle modifications f/u 3 months or
lifestyle modifications and 1 medication follow up in 1 month
Hypertension treatment for stage 2
> 140/>90
2 medications follow up in 1 month
Hypertension treatment for patients with comorbid conditions
HF: Beta blockers, ACEi
Stroke: ACEi, HCTZ
CKD: ACE/ARB unless stage IV
DM: ACE
CCB Side Effects and uses
SE: Peripheral edema
Antianginal DO NOT USE IN HF
ACEi/ARB Side effects
Increase creatinine and potassium
Use ARBs for ACE angioedema
Thiazides Side Effects
Decrease potassium and calcium
Can be used for kidney stones
Fast Narrow Arrhythmias
SVT, A-fib/flutter
Fast Wide Arrhythmias
V-tach, Torsades
Slow Wide Arrhythmias
3rd degree AV block, Idioventricular
Slow Narrow Arrhythmias
Sinus Brady, 1st and 2nd (type i and ii) heart block
SVT Tx
- Adenosine-stable
2. shock
A-Fib/flutter Tx
- Beta-blocker=CCB
2. Shock
V-tach Tx
Amiodarone
Torsades Tx
Magnesium
A-fib workup, stable, old, and cardiovert
- Rate control, CCB= Beta blockers
- old, >48 hr or unknown
- TTE-valvular or non-valvular
- Anti-coagulate for 3 weeks with warfarin
- TEE and cardioversion
- Anti-coagulate for 1 month
A-fib workup, unstable
Cardiovert, shock
when should you anti-coagulate in A-fib
if CHADSS score is greater than 2
CHADSS SCORE
CHF HTN Age >75 DM Stroke Stroke 0-none 1- ASA or anticoag >2 anticoagulate
When there is a valvular lesion what changes for anticoagulation
bridge with LMWH if going for a procedure, give warfarin
if patient has a slow rhythm and is unstable what do you do
PACE
What rhythms can you give atropine
Sinus Brady, 1st degree AV block, 2nd degree type 1
What drugs are used for a pharmacologic stress test
Adenosine/dobutamine
