Cardio Flashcards
NYHA Classes of HF
I (No symptoms) II (Slight limitation in physical activity - SOB climbing stairs) III (Marked limitation of physical activity - SOB around the house doing chores) IV (Inability to perform activity without significant discomfort)
Optimal medical therapy for CHF
BB, loop diuretic, aldosterone antagonist
Criteria for biventricular pacing in HF patients
Must meet all: LVEF less than 35 NYHA II,III,IV LBBB with QRS greater than 150
Criteria for ICD
Primary prevention - Prior MI and LVEF less than or equal to 30 OR NYHA II/III and LVEF less than or equal to 35. Secondary prevention - Prior VF or unstable VT without reversible cause OR prior sustained VT with underlyng cardiomyopathy
What do deep Q waves indicate?
Prior MI
Pt presents with inferior wall MI 2 weeks following RCA stent placement. What happened?
Stent thrombosis is a rare but serious complication typically occuring within 30 days and usually associated with premature cessation of DAPT. Make sure you counsel and aggressively screen for med compliance.
Clinical features of Compartments Syndrome
Common
- Pain out of proportion to injury
- Pain increasing in passive stretch
- Rapidly increasing and tense swelling
- Paresthesia (early)
Uncommon
- Reduced sensation
- Motor weakness (hrs)
- Paralysis (late)
- Reduced distal pulses
Complication of CS
Renal failure from anoxic muscle necrosis/rhabdo
Rarely can get DIC from microangiopathic hemolytic anemia
Diagnostic tool of choice for CS
Direct tissue pressure measurement. Serial measurements are needed even if original pressure is normal. Pressure above 30 is diagnostic or delta pressure (diastolic bp minus compartment pressure) less than 20-30.
Patients with elevated pressure that does not rapidly correct require fasciotomy
Number 1 determinant of prognosis is time to surgery
RBC transfusion thresholds
Less than 7 - def
7-8 for cardiac surgery, onc patients on treatment, and HF
8-10 for symptomatic anemia, ongoing bleeding, ACS, noncardiac surgery
Hemodynamic measurements in shock
How would cardiac tamponade present with respect to hemodynamic parameters?
Rapid accumulation of blood in pericardial space leads to increased RA and RV pressure but there is also characteristic equalization of RA, RV end diastolic, and PCWPs
Patient with persistent pain, swelling and accentuated pulsation near access point for recent cardiac cath
Likely pseudoaneurysm of R CFA. Happens when bleeding from inadequately sealed arterial puncture site remains confined within the periarterial connective tissue. Leads to contained hematoma that has ongoing communication with the arterial lumen. Diastolic pressure equalizes between artery and confined hematoma resulting In blood flow in and out of the hematoma cavity with systole
Presents as tender, pulsatile mass with a sytolic bruit. Dx is confirmed on US
Small pseudoaneurysms can be treated with US guided compression or thrombin injection into cavity. Largery or rapidly expanding ones are at risk of rupture and need surgical repair.
Main risk factor is inadequate post-procedural compression to achieve hemostasis
Cessation of DAPT is not recommended unless there is life threatening bleed bc of risk of stent thrombosis
Femoral AV fistula
Presents with localized pain, no mass and a continuous bruit. Sometiems evaluated by lower extremity angio if initial US is nondiagnostic. Angio can also evaluate for femoral artery dissection or thrombosis in a patient with evidence of distal leg ischemia .
hematoma after cath
Small local hematoma (localized swelling that is non-pulsatile with no bruit) can be managed with symptomatic relief and reassurance.
Obviously large RP bleed is different.
WPW pattern plus symptomatic tachyarrythmia
WPW Syndrome
WPW pattern triad is short PR, delta wave, wide QRS
Acute mitral regurg features
Cause
- Ruptured mitral chorda tendinae from MVP, endocarditis, RHD, or trauma
- Papillary muscule rupture due to MI or trauma
Clinical
- Rapid onset pulm edema
- biventricular HF
- hypotension, cardiogenic shock
Physical exam
- Diaphoresis, cool extremities
- JVD, crackles
- Hyperdynamic cardiac impulse
- Apical decrescendo systolic murmur (often absent)
Management
- Bedside echo
- emergent surgery
Who is at risk for mitral chorda tendineae rupture?
Patients with MVP esp when it is related to underlying connective tissue disease (marfan, ED)
Velvety skin with scar formation is supposed to indicate connective tissue disease (esp ED)
ED vs Marfans
Acute rheumatic fever
Inflammatory condition following group A strep. Migratory arthritis, carditis or valvulitis, CNS involvement with chorea, erythema marginatum, and subq nodules. Chronic MR is a common sequela of rheumatic fever. acute MR is rare.
What is a common side effect of CCBs?
Peripheral edema (reported incidence of 25% after 6 months of therapy) likely due to preferential dilation of precapillary vessels (arteriolar dilation) which leads to increased cap hydrostatic pressure and fluid extrav into interstitum
Dihydropyridine CCBs (amlodipine and nifedipine) are potent arteriolar dilators and cause more peripheral edema than non-DHP CCBs (diltiazem and verapamil).
Other side effects of CCBs are HAs, flushing, dizziness.
Renin angiotensin system blockers (ACE or ARB) causes post capillary venodilation and can normalize the increased capillary hydrostatic pressure. Combo of CCBs and ACEs improved risk of peripheral edema compared to CCB alone
Side effects of ACE?
angioedema
nonpitting swelling of subq or submucosal tissue and most commonly affects lips, tongue, face, and upper airway
Do not cause peripheral or dependent edema
Side effects of glyburide
Derm side effects (photosensitivity reactions, maculopapular eruptions, purpura, urticaria)
Side effects of HCTZ
most common are electrolyte imbalances (hyponatremia, hypokalemia), renal failure, hyperuricemia (may precipitate acute gout), and elevated glucose and lipids.
Appropriate therapy for secondary prevention of cardiovascular events
Patient with prior MI and CAD
Statin
ASA
ACE or ARB
BB (reduce short term morbidity in patients with recent MI as well as long term mortality if continued)
In addition, patient should undergo further eval for risk stratification (TTE, perfusion stress test, possible cath)
Fibrate therapy
Gemfibrozil or fenofibrate
Reduces triglyceride levels in patients with severe hypertriglyceridemia (above 800)
Direction of Left to right shunt by oximetry
Find the location of “step-up” in O2 sat.
If it’s from IVC/SVC to RA, then the location is atrial. Etiology is ASD, partial anomolous pulm venous drainage, ruptured sinus of valsalva, VSD with tricuspid regurg or coronary fistula to RA
If it’s from RA to RV then it’s venticular. Etiology is VSD, PDA with pulm regurg, or coronary fistula to RV
If it’s from RV to Pulm Artery then it’s great vessels. Etiology is PDA or aorto-pulmonary window
VSD murmur
Harsh holosytolic murmur with max intensity over Left third and fourth intercostal spaces and a palpable thrill
Brachial to femoral pulse delay
Seen in patients with coarctation
PDA murmur
Continuous murmur heard at left infraclavicular area. Causes L to R shunting from aorta to main pulm artery
TOF
Most common cyanotic congenital heart defect
1) RV outflow obstruction
2) Overriding aorta
3) RVH
4) VSD
ASD on auscultation
Fixed splitting of S2
Excerise stress testing factors associated with increased risk of adverse cardiovascular events
Clinical
- Poor exercise capacity
- exercise induced angina at low workload
- fall in systolic BP from baseline
- chronotropic incompetence
ECG
- greater than 1mm ST depression (flat or downsloping)
- ST depression at low workload
- ST elevation In leads without Q waves
- Ventricular arrhytmias.
Patients with high risk features likely have atherosclerotic disease and would benefit from revascularization and should undergo cath.
Patients without high risk features but with anginal symptoms refractory to several months of optimal medical management should also undergo cath
Management of new onset AF
Assess rate vs rythym control
Patients who are hemodynamically unstable get cardioverted emergently
Stable patients will receive medical therapy (BBs, dilt, digoxin) to control ventricular rate. Rate control with medical therapy can often convert back to sinus. Rhythm control (amiodarone) should be considered in patients unable to achieve adequate rate control with recurrent symptomatic episodes (palps, lightheadedness, SOB, angina) or with HF symptoms in setting of underling LV sytolic dysfunction
Regardless of whether or rate or rhythm control is used, patients with AF need to undergo CHADS-VASC score assessment to estimate thromboembolic risk. If 0, then low risk and no further therapy is needed. If 2 or more, patient will need anticoagulation with warfarin or other (dabigatran, rivaroxaban, apixaban). Therapy in patients with a score of 1 is case by case,
CHADS-VASC
9 points max
CHF (1)
HTN (1)
Age 75 or up (2)
DM (1)
Stroke/TIA/PE (2)
Vascular disease - prior MI, peripheral artery disease, aortic plaque (1)
Age 65-74 (1)
Sex - female (1)
Management of unstable angina/NSTEMI
Patients with ACS should be treated with guideline directed medical therapy
DAPT
Nitrates
BB
Statin
Anticoagularion (unfractionated heparin, LMWH, bivalirudin or fondaparinux)
Predictors of major cardiac complications with noncardiac surgery (revised cardiac risk index)
Clinical risk factors
- High risk surgery (vascular)
- History of ischemic heart disease
- HF
- history of stroke
- IDDM
- Prep creatine above 2
Rate of cardiac death, nonfatal cardiac arrest, or nonfatal MI
- No risk factors is 0.4
- 1 (low risk) is 1
- 2 (mod risk) is 2.4
- 3 or more (high) is 5.4
Preop cardiac eval for noncardiac surgery should be done first. Active high risk cardiac conditions (unstable angina or decompensated HF) need to be stabilized prior to surgery. Low risk surgury, patient RCRI less than 1% or patients able to perform more than 4 METS can go to surgery. If not low risk and greater than 1% and cannot perform 4 METs, the nfurther cardiac eval needs prior to surgery (TTE, stress test)
cardiac risk associated with the particular surgery should be considered (separate card)
Cardiac risk strat for noncardiac surgical procedures based on surgery type
High risk - Aortic/major vascular, peripheral vascular
Intermediate risk (1-5%) - Carotid endart, Head/neck, intraperitoneal/intrathoracic, ortho, prostate
Low risk (less than 1%) - ambulatory or superficial procedure, endoscopy, breast, cataract
What does LCx supply?
Lateral wall LV
cardiovascular effects of cocaine intox
Physio
- hypertension, tachycardia
- coronary vasoconstriction
- increased platelet activity and thrombus
clinical
- MI or ischemia
- Aortic dissection
- neuro ischemia or stroke
treatment
- Benzo (first line) and nitro
- BB contraindicated
- CCBs for persistent CP
- Phentolamine (alpha blocker) for persistent HTN
- cath for myocardial ischemia
Unless there is suspicion for dissection, aspirin should be given to patients with cocaine related chest pain. Only give plavix when acs is confirmed (ST changes, elevated trop).
Mechanical complications of acute MI
