Cardio Flashcards
Treatment of constrictive pericarditis
Constrictive pericarditis is a product of chronic inflammatory changes in the pericardium that makes it a rigid box.
Peristernal “knock”
tx: Pericardiectomy
Right sided infarct
Right sided infarcts are preload-dependent
Morphine and nitroglycerin should NOT be given in these instances. They are both venodilators
Instead, support their blood pressure with fluid.
Syncope in a CAD patient
Sudden onset syncope in someone with known coronary artery disease or structural heart disease gets admitted for 24 hour telemetry monitoring to try to catch the arrhythmia (often, one is not caught and an event recorder is required to identify it).
Indications for Automatic Implantable Cardioverter Defibrillator (AICD)
Patients with CHF who are referred for AICD placement for primary prevention of cardiac arrhythmias.
class I w/ EF < 30%.
Class II-III with an EF < 35%
Those in class IV are not referred. Bad CHF
Presentation of pericardial tamponade
Hypotension, jugular venous distention, muffled heart sounds (Beck’s Triad)
Treatment of pericardial tamponade
An emergent ultrasound guided pericardiocentesis is the definitive therapy for pericardial tamponade. While cardiology is coming to the bedside to perform it, support their preload with intravenous fluid.
statin therapy for CAD patients
high potency statins are required in known coronary artery disease either rosuvastatin 40 or atorvastatin 80.
Aortic stenosis treatment
Symptomatic or severe aortic stenosis requires valve replacement becuz usually due to calcifications
Mitral valve stenosis is less often from calcification and can therefore respond to valvuloplasty more regularly.
Niacin side effect
Niacin-associated flushing can be treated with aspirin. However, the utility of adding this to a patient already on a statin is debatable.
Evaluation of patient for heart failure
The BNP is the first test in the evaluation of someone who has heart failure, followed by echocardiogram, then catheterization, stress test and PFTs as suggested by patient history.
Long term complication if patient is left with patent ductus arteriosus?
Machine like murmur
Large PDA causes large left-to-right shunt and can lead to pulmonary arterial hypertension
What is central retinal artery occlusion?
acute painless monocular visual loss
cherry-red fovea
Due to atrial fibrillation, infective endocarditis, paradoxical deep vein thrombosis, or atherosclerosis from major arteries
What is central retinal vein occlusion?
acute onset of painless blurred vision in one eye
“blood and thunder”
Retinal hemorrhages, edema, dilated retinal veins, and possibly cotton-wool spots
Aortic regurgitation
Wide pulse pressure
Diastolic decrescendo murmur @ left lower sternal border
Late diastolic rumble (Austin-Flint murmur)
Bounding pulses
Aortic stenosis
Weak S2, murmur decreases with valsalva
Crescendo–decrescendo systolic murmur with radiation to the neck/carotids
mitral regurgitation
Holosystolic murmur radiating to the axilla, increased with maneuvers that increase afterload, such as handgrip.
Which treatments is contraindicated in WPW and Afib?
In patients with Wolff-Parkinson-White with atrial fibrillation, use of atrioventricular nodal–blocking agents should be avoided, especially digoxin, as they can increase the risk of ventricular fibrillation.
Worsening of the murmur on inspiration suggests a
right-sided murmur
Aortic regurgitation
early diastolic murmur along the upper left side of the sternum.
Mitral regurgitation
holosystolic (pansystolic) murmur located at the apex that increases with maneuvers that increase afterload, such as handgrip
Mitral stenosis
mid to late diastolic murmur, best heard at the apex.
Tricuspid regurgitation
holosystolic murmur at the left lower sternal border that increases with deep inspiration
Prophylaxis for toxoplasmosis
Prophylaxis for toxoplasmosis is trimethoprim-sulfamethoxazole (CD4<100)
Toxoplasmosis will often present with flu-like symptoms and lymphadenopathy.
Once a patient is diagnosed with toxoplasmosis by MRI findings, treatment is with sulfadiazine and pyrimethamine.
Tumor marker for ovarian cancer
CA-125
Tumor marker for pancreatic and biliary tract cancer
CA 19-9
Tumor marker for medullary thyroid cancer
Calcitonin
Tumor marker for Colorectal carcinoma
CEA
Subarachnoid hemorrhage
Most common cause of a subarachnoid hemorrhage is a ruptured berry aneurysm.
A definitive treatment to prevent rebleeding is endovascular coiling of the aneurysm.
FUNGAL Cerebrospinal fluid analysis
Elevated white blood cell count (10s-100s)
Lymphocytic predominance
Significantly elevated pressure
Decreased glucose
Elevated protein
BACTERIAL Cerebrospinal fluid analysis
VERY HIGH white blood cell count (1000s)
Neutrophilic predominance
Significantly elevated pressure
Decreased glucose
Elevated protein
VIRAL Cerebrospinal fluid analysis
Elevated white blood cell count (10s-100s)
Lymphocytic predominance
Slightly elevated pressure
Normal glucose
Normal protein
DeBakey classification of aortic dissection
Type I- involves the ascending aorta, arch, and descending thoracic aorta.
Type II is confined to the ascending aorta
Type IIIa involves the descending thoracic aorta between the left subclavian artery and the celiac artery.
Type IIIb dissection involves the thoracic and abdominal aorta after the left subclavian artery.
Stanford classification of aortic dissection
Type A - Any dissection that involves the ascending aorta- Surgery
Type B- involves the descending thoracic or thoracoabdominal aorta distal to the left subclavian artery without involvement of the ascending aorta (medical management)
Stable angina
Chest pain or substernal pressure that is brought on by exertion that lasts less than 15 minutes and is relieved by rest or nitroglycerin.
Confirmed by ST-segment depression on a stress ECG
Unstable angina
Chest pain at rest or with minimal exertion that is not entirely relieved by nitroglycerin
Cardiac enzymes are negative
Rouse v. Pitt County Memorial Hospital
Attending physician can be vicariously responsible for residents’ negligence under the borrowed-servant doctrine
Hypomagnesemia
Common in alcoholics
Prolonged QT interval on ECG
Tremor, hyperactive deep tendon reflexes, and tetany. Patients may have a positive Chvostek and Trousseau sign (similiar to Hypocalcemia)
Tx: IV magnesium sulfate
Hypercalcemia
kidney stones, muscle and bone pain, constipation and non-specific abdominal pain, and psychiatric symptoms such as anxiety, depression, or cognitive dysfunction
shortened QT interval
Tx: vigorous fluid resuscitation, bisphosphonate therapy, and calcitonin.
Central venous access
Defined as a catheter tip located in the superior vena cava, the right atrium, or the inferior vena cava
Internal jugular vein-Risk of pneumothorax
Subclavian vein- Lowest risk of infection. Higher risk of pneumothorax.
Femoral vein- Highest rate of infections due to proximity to groin
Indications for valve replacement in infective endocarditis
1) Prosthetic valve endocarditis
2) Uncontrolled infection leading to conduction abnormalities, periannular suppuration, and fistula despite appropriate antibiotic treatment for at least 1 week
3) Repeated systemic embolizations despite appropriate antibiotic treatment
4) severe valvular disease resulting in refractory congestive heart failure
Right Bundle Branch Block (RBBB)
Widened QRS complex
“MarroW” (Bunny ears in V1)
Lead V1= M
Lead V6= W
Left Bundle Branch Block (LBBB)
Widened QRS complex
“WilliaM” Bunny ears in V6
Lead V1= W
Lead V6= M
What is Brugada syndrome?
Genetic disease
Look for sudden death in a young asian man
ECG findings- persistent ST elevations in the V1–V3 leads with a right bundle branch block appearance with or without terminal S waves in the lateral leads
Treatment for Brugada syndrome
Implantable cardioverter defibrillator (ICD)
Most patients die from ventricular tachycardia (VT)/ventricular fibrillation
Contraindications to Beta blockers during MI
- Heart rate of < 60/min
- Systolic blood pressure of < 120 mmHg
- Second- and third-degree AV blocks
- Moderate to severe congestive heart failure
Sensory innervation- Median Nerve
Median Nerve- Palmar aspect of lateral 3.5 digits and thenar eminence
Sensory innervation- Ulnar Nerve
Medial 1.5 digits and hypothenar eminence
Sensory innervation- Radial nerve
Dorsal aspect of lateral 3.5 digits and anatomical snuffbox
Sensory innervation- musculocutaneous nerve
Sensory innervation to the radial side of the forearm.
Most common valvular disease caused by rheumatic heart disease
Mitral stenosis
Loud S1, along with a mid-diastolic rumble at the cardiac apex.
Mitral regurgitation
Holosystolic murmur heard best at the apex with radiation to the axillae
Long asymptomatic period, so when patients present, they are typically in heart failure
Mitral valve prolapse (MVP)
Late systolic crescendo murmur with a mid-systolic click
Myxomatous degeneration, which is a pathological connective tissue deterioration, is the main cause of MVP.
Takotsubo cardiomyopathy/ stress-induced cardiomyopathy/ “broken heart” syndrome
Often occurs in post-menopausal women due to an emotional or physical stressor and presents similarly to an ST segment elevated myocardial infarction with chest pain, ECG changes, and mildly elevated troponins.
It is reversible, resolving within days to weeks.
Surveillance of Ascending Aortic Aneurysms
- 5-4.5cm Do annual CT angiogram and echo for aortic valve
- 5- 5.4cm Do biannual CT angiography nd echo for aortic valve
Symptomatic/ ruptured or aneurysms > 5.5 cm in diameter- Do surgery
Surveillance of descending Aortic Aneurysms
4-5cm - Do annual contrast CT
5-6cm- Do biannual contrast CT
Defibrillation is reserved for 2 distinct dysrhythmias
1) Pulseless ventricular tachycardia
2) Ventricular fibrillation
Hemodynamically stable patient with supraventricular tachycardia
In a hemodynamically stable patient with supraventricular tachycardia, intravenous adenosine is the initial drug treatment of choice.
Hemodynamically UNstable patient with supraventricular tachycardia
Synchronized cardioversion is the preferred treatment for unstable SVT, defined as SVT with hypotension, active chest pain, hypoxemia, abnormal mentation, and/or pulselessness.
“widened mediastinum” on xray
Thoracic aortic aneurysms are typically asymptomatic and found incidentally on chest x-ray, appearing as a “widened mediastinum,” which is a non-specific sign. The diagnosis is confirmed with a contrast-enhanced CT of the chest.
As a general rule in any advanced cardiac life support protocol, if the patient is unstable as a result of an arrhythmia, shocks of some sort will be required:
Bradycardia (transcutaneous pacing)
Tachycardia (synchronized cardioversion)
Pulseless (defibrillation)
If the patient is stable, medications can typically be tried first.
First-line therapy in Prinzmetal (variant) angina is
calcium channel blocker such as diltiazem, nifedipine, or amlodipine.
Hyperventilation syndrome
leads to respiratory alkalosis, hypocarbia, and secondary hypocalcemia.
only beta blockers studied and proven effective for heart failure patients with reduced ejection fraction (EF) are
metoprolol succinate, carvedilol, and bisoprolol.
ACE-i/ARB and beta-blockers are the mainstay of HFrEF
Bicipital tendonitis
Anterior shoulder pain, worst near the bicipital groove. Pain may be exacerbated with supination and/or flexion of the elbow.
Yergason’s and Speed’s tests may be positive.
Intravenous medications that can be used to treat hypertensive emergencies include
nitroprusside, nicardipine, clevidipine, labetalol, and fenoldopam.
Superior vena cava (SVC) syndrome is diagnosed with
CT venography
“Pemberton’s Sign”. When the patient brings his/her hands up to the face, this leads to obstruction of the thoracic outlet causing facial edema, congestion, and eventually respiratory distress.
Cardiac abnormalities associated with Turner syndrome
Bicuspid aortic valve that can lead to aortic stenosis later in life
Aortic coarctation
first-line medications in treating chronic myelogenous leukemia
Tyrosine kinase inhibitors (TKIs) such as imatinib, dasatinib.
TKIs inhibit the BCR-ABL tyrosine kinase, the constitutive abnormal gene product of the Philadelphia chromosome, in CML
Complete heart block is a medical emergency that requires immediate temporary transcutaneous pacing.
The deterioration of third degree heart block to asystole is unpredictable and all patients should have a transcutaneous pacer until transvenous pacer can be setup.
Treatment of Phyllodes tumor
Benign or malignant
Wide local excision
Increased CO
Decreased PVR
Decreased PCWP
Anaphylactic (distributive) shock
Decreased CO
Decreased PVR
Increased PCWP
Neurogenic shock
Low CO
High PVR
High PCWP
Obstructive (tamponade, tension pneumothorax), or cardiogenic shock states
When is the only time defibrillation is used?
ventricular fibrillation or pulseless ventricular tachycardia
asystole or pulseless electrical activity
high-quality chest compressions and epinephrine
Atropine
stable symptomatic bradycardia
Amiodarone
stable patients with wide complex (QRS ≥0.12 seconds) tachycardia
