Cardio Block 1 Flashcards
Location, Quality, Duration, Worse/Better, S/Sxs of Angina
L: retrosternal; radiates to neck, jaw, arm, shoulder, “elephant on chest”, Levine Sign
Q: pressure/burn/squeeze/heavy
D: 2-10min
A/R: exercise, cold, stress / rest, nitro
S/Sxs: S3 or papillary muscle dysfunction murmur during pain episode, sweating (SNS), Nausea (PNS), Tachy
Location, Quality, Duration, Worse/Better, S/Sxs of Rest or Unstable angina
L: same as angina Q: same as angina but more severe D: <20min A/R: same as angina, dec tolerance for exertion/at rest S/Sx: transient heart failure can occur
Location, Quality, Duration, Worse/Better, S/Sxs of MI
L: substernal, radiates similar to angina
Q: heavy, pressure, burning, burning, constriction
D: >30min, but variable
A/R: unrelieved by nitro/rest
S/Sx: N/V, SoB, sweating, weak
Location, Quality, Duration, Worse/Better, S/Sxs of Pericarditis
L: over sternum/apex, radiates to neck or L shoulder
Q: sharp, stabbing, knife-like
D: hrs to days w/ waxing/waning
A/R: deep breath, rotating chest, supine / sitting, leaning
S/Sxs: friction rub (best heard LLD)
Location, Quality, Duration, Worse/Better, S/Sxs of Aortic Dissection
L: anterior chest, radiates to back Q: excruciating, tearing, knife-like D: sudden and unrelenting A/R: HTN, Marfan Syndrome S/Sxs:aortic murmur, HTN, BP asymmetry, large/displaced PMI
Location, Quality, Duration, Worse/Better, S/Sxs of PE
L: substernal or over site of PE Q: pleuritic or angina-like D: sudden onset, lasts minutes-hrs A/R: breathing worsens it S/Sxs: tachy, dyspnea, Signs of RVFailure
Location, Quality, Duration, Worse/Better, S/Sxs of PHTN
L: substernal Q: pressure, oppressive D: similar to angina A/R: worse w/ effort S/Sxs: pain w/ dyspnea, signs of PHTN
What are the key terms associated with the quality of pain for non-cardiac causes of chest pain?
Pneumo w/ pleurisy- pleuritic, local Spot Pneumo- sharp, very local MSK d/o- ache Herpes- burning, itch Esophageal reflux- burning, visceral discomfort Ulcer- visceral burning, ache Gallbladder- visceral Anxiety- variable and transient
What can be heard/best assessed in the aortic area?
What can be heard/best assessed in the pulmonic area?
Ascending aorta
Aortic valve
Ejection clicks
Aortic aneurysms
Pulmonic valve, artery, regurgitation
Lungs
What can be heard/best assessed at Erb’s Point?
Aortic/pulmonic origins
HOCM
Aortic insufficiency (blowing)
What does it mean if cardiac pulsations are visible laterally to the LMCL?
What does a sustained apex impulse mean?
Cardiac enlargement
LVH
How does aortic dissection effect the PMI?
What else can cause these changes to PMI?
Enlarged and displaced
Volume overload, cardiac dilation, hyper-dynamic apical pulse
Pressure overload- hypertrophy, sustained apical pulses
Blocked arteries have what characteristics?
Blocked veins have what characteristics?
Diminished/absent pulse, swelling, pain, cold to touch
Swelling, pain
What forms the anterior border of the heart on a lateral view?
What forms the posterior border?
Inferior- RV, Superior- pulmonary trunk
LV and part of IVC
Characteristics of the S1
Heard at Apex
Forced closure of M/T valves from ventricles in sequence w/ carotid pulse Onset of systole
Mitral= S1 but Tricuspid happens at the same time
Characteristics of the S2
Closure of A/P valves from aortic/pulmonary artery pressure
Onset of diastole
A- R2IC, more intense
P- L2ICS
Characteristics of S3 heart sounds
Most of the time= pathologic
occurs after S2 during ventricle filling as a dull/low pitched sound indicating a volume overload
Indicative of ventricular failure
Systolic HF
What can cause a volume overload and lead to an S3?
Pathological S3 is AKA ? and usually associated w/ ?
CHF, M/T insufficiency
Ventricular gallop- blood entering ventricle during rapid filling phase of diastole creating an early diastole sound and seen w/ swollen lower extremities
Characteristics of S4 heart sounds
Low pitch from HTN of any type late in diastole when atria contract before S1, atrial filling against stiff/non-compliant ventricle
What type of PT positioning is needed to listen for an S4?
What is a pathologic S4 AKA ? and is from ?
Apex with PT in left lateral decubitus
Atrial gallop from pressure overload from HTN of any type
Define Physiological S2 Splitting
Aortic valve closes before pulmonic valve and can be exaggerated by inspiration causing more blood return to RV and prolonging the emptying of the chamber and delay in pulmonic valve closure
Pulmonic region between 2-3LICS
When viewing heart valves from a superior view, what is the sequence of valves from anterior to posterior?
Congenital bicuspid valves are especially linked with what syndrome?
Pulmonic Aortic (Ant), Tricuspid Mitral (Post)
Marfan Syndrome
Where is the Mitral Valve located and how many leaflets does it have?
Between LA and LV
2: anteromedial, posterolateral
Where is the Tricuspid Valve located and how many leaflets does it have?
RA and RV
Anterior, Medial and Posterolateral
What does the RCA supply blood to?
PRAIS P; II, III, aVF Posterior 1/3 of septum R atrium/ventricle AV node Inf/Post LV SA Posterior descending artery- supplies part of septum and accounts for 85% of PTs having right dominant circulation
What does the Left Main Coronary artery turn into and supply blood to?
LAD- ABA; V1-V4
anterior 2/3 of septum, bundle branches, anterior LV (bulk of ventricle)
LCX- SLAP P; V5-V6 1st diagonal=I, aVL= high lateral SA node Lateral LV Atrium, L Posterior LV PDA 8-10% of PTs= Left Dom Circulation
Right dominant circulation means supply from ?
Left dominant circulation means supply from ?
Codominant circulation receives blood from ?
RCA
LCX (LMCA)
RCA and Circumflex
What is K role in cardiac action?
What is Ca role in cardiac action?
Repolarization of AP
Released from sarcoplasma reticulum from ryanodine receptor/Ca release channel to activates muscle contraction by binding to Troponin C to allow actin-myosin cross bridge to occur to shorten sarcomere.
What is the sequence of structures signals pass through in the hearts conduction system?
SA Node Inter-atrial/nodal pathways AV node AV junction/Bundle of His Intraventricular septum- bundle branches Left Anterior/Posterior fascicles Purkinje fibers Myocardial cells in ventricles
Define Cardiac Output
Measurement of the heart’s primary function of delivering oxygenated blood to tissues
CO= SV x HR
Define Preload
What are the 4 components?
Load from IVC/SVC that stretches the heart muscle prior to contraction, the ventricle wall tension at end of diastole
Total blood volume, Distribution of blood volume, Atrial contraction, Compliance
What is used is Preload measured?
How is it measured?
Ventricular End Diastolic Volume/Pressure
DIRECTLY measured by L Heart Catheterization
ESTIMATED during R Heart Catheterization from Pulmonary Wedge Pressure
Define Afterload
It is determined by what two factors?
Force that LV must pump against
Aortic pressure (mean BP) Volume of ventricular cavity/thickness of wall
How do the adrenergic NS and catecholamines inc/dec myocardial contractility?
What positive inotropic drugs increase myocardial contractility?
Inc Ca by stimulating B1 receptor
Digoxin, Isoproterenol, Dopamine, Dobutamine, Caffeine
What substances decrease myocardial contractility?
Negative ionotropic drugs
Anti-arrhythmics- Quinidine, Procainamide, Disopyramide
CCB/BBs
What physiological changes/effects can initially cause tachycardia but at toxic levels/times cause bradycardia?
Hypoxia Hypercapnea Ischemia/Infarct Acidosis ETOH
What are the H’s of ACLS?
Hypovolemia- tachy, narrow QRS; Saline
Hypoxia- brady, cyanosis
H+ excess- low amplitude QRS; Sodium BiCarb
Hypoglycemia- Dextrose
Hypo/perkalemia- po=flat T and origin of U, Mg infusion; per= peaked T, wide QRS; CaCl, NaBiCarb
Hypothermia
What are the T’s of ACLS?
Tension Pneumo- brady, narrow QRS
Tamponade- tachy, narrow QRS
Toxins- prolonged QRS
Thrombus- pulmonary= tachy, narrow QRS; acute MI= abnormal ECG
What are the causes of PEA narrow complexes?
What will be seen on EKG?
What type of issues cause it?
What imaging can be done and r/o a DDx?
Tamponades, Tension Pneumo, Mechanical hyperinflation, PE
Narrrow QRS, mechanical/RV issue
Acute MI, myocardial rupture
Bedside US: LV hyperdynamic, pseudo-PEA
What are the causes of PEA wide complexes?
What will be seen on EKG?
What kind of issue causes it?
Severe hyperkalemia, Na channel blocker toxicity
Wide QRS, metabolic/LV problem
Acute MI pump failure
LV hypo/akinetic, true PEA
Where are baroreceptors located?
What drug influences both inotropic and chronotropic results?
Carotid sinus, Aortic bodies, Base of heart
Epi- inc HR, inc contractility
Define Ejection Fraction
End diastolic volume ejected from ventricles during systolic contractions used to assess primary cardiac function
Normal= 55-75%
EF= SV/end diastolic volume
How is ejection fraction measured?
Echo- done most of the time Nuclear Ventriculography (MUGA) MRI Gold Standard- cardiac catheterization (R sided is best, exact done w/ L sided)
Cardiac hypertrophy causes what heart sounds that can be heard on physical exam?
What are the disadvantages of this hypertrophy?
S3 and S4
Increased stiffness and heart O2 demand
What effects can cause hypertrophy?
What effects can cause dilation?
Chronic contraction against high after load
Prolonged increase of EDV/EDP from high preloads
What type of heart performance change occurs with cardiac dilation?
What are the disadvantages of this dilation?
Initially, increased Frank Starling that tops out and results in decreased CO
Increased wall stress- LaPlace
Increased myocardial O2 demand
PTs presenting with chest pain need x-rays done within ? time frame?
What types of issues can be seen/identified?
30min
Chamber enlargement, Cardiomegaly, Enlarged pericardial sac, Ventricular aneurysms
How long does it take for ventricular aneurysms to appear post-MI?
What are the three types of holosystolic murmurs?
7 days
MR*, TR, VSD
Systolic murmurs from papillary muscle rupture
What four issues can be identified in the great vessels on a chest x-ray?
Calcification- severity (measured w/ continuous wave Doppler)
Aortic aneurysms
Pulmonary artery dilation
Pulmonary venous congestion
What are the primary indications for ordering a CT for cardiac issues?
Gold standard- chronic constrictive pericarditis
Assess great vessels- aortic dissection of STABLE PT
Pericardial abnormalities
CT images of the heart can be used to evaluate what four structures?
Great vessels
Pericardium
Myocardium
Coronary arteries
What are Electron Beam CT scanner used for?
AKA “ultra fast”
TOC to evaluate pericardial disease and cardiac tumors
Coronary artery calcification- Ca within a vessel
Define Agatstan score
Data from EBCT that correlates to atherosclerotic plaque burden, shows CA calcification
Considered cardiac risk predictor independent of other risk factors
MRI of the heart are AKA and best used for ?
What type of material is used the dye?
CMR, differentiating tissues even w/out contrast
Gadolinium- find infarcted/viable myocardium
What is a CMRA?
What are they utilized for?
Coronary angiography- non=invasive, contrast free image
High sensitivity/accuracy for CAD in LMCA, proximal points of coronary vessels and congenital coronary abnormalities
What are the five modes of an Echo
What are the two types of Echos?
1D (M-mode), 2D, 3D, 4D (animations), Doppler- blood flow, function
Trans-Thoracic
Trans-Esophageal- Gold Standard
What are the indications for ordering an echo?
Valve lesions- quantifies regurgitation and stenosis
Ventricular assessment- thickness, mass, estimate EJF
CAD- post-MI motion abnormalities, quality of RV function
Cardiomyopathy
Pericardial disease
What type of test would be ordered to assess a suspected stenotic heart valve?
What do all post-MI PTs receive prior to discharge home?
Doppler Echo
Echo
What are the 3 types of cardiomyopathy?
What test is always ordered for any type?
Dilated, HCM, Restricted
Echo
What is the pay off and down side of using a TTE?
Visualize anterior heart- RV
Can’t see posterior heart
Bad window from “fluffy”
What info does TTE provide?
B PLEAV Blood flow direction (regurg) Paradoxical septum motion LA size Estimated EF Assess LV/RV dilation Valve structure assessment
If exact, definitive LV EF is needed, what test?
What if an estimate is needed?
L sided cath
TTE
What is the primary advantage of doing TEEs?
Increased sensitivity/specificity anatomic abnormality detection
Highly specific for aortic dissection, endocarditis, prosthetic/mechanical valve dysfunction
LA thrombus prior to cardioversion
What additional test can be performed with either TEE or TTE?
TEEs are performed if ? is suspected in the PT?
Venous saline agitation- Bubble Study: identifies intracardiac shunt (ASD/VSD)
Thrombus
What is the only study that can be used to visualize/assess the appendage on the LA?
Why is this capability unique/important?
TEE
Majority of cardiac thrombus originate from here
TEEs allow for user to focus on one structure at a time in a specific pattern in what sequence?
Mitral valve and L chambers Aortic valve L atrial appendage*** R side structures Interatrial septum Base Transgastric area Aorta- asc and desc
Other than CTs, what is the only other test that allows for visualization and assessment of the aorta, both ascending and descending?
If a PTs BP is below ?/? do NOT put them in scanners, instead order ? study
TEE- used for unstable PTs w/ sedation
90/60, TEE
Normal HR for EKG
Normal P wave duration
Normal PR Interval
50-100
<0.12 msec
90-200 msec
Normal QRS duration
Normal QTCs
Normal QRS axis
75-110 msec
M: 390-450; F: 390-460 msec
-30 - +90*
What are the HR for newborns, 2, 4 and 6yrs old?
New: 110-150
2: 85-125
4: 75-115
6: 60-100
What is the criteria for the LAFB and LPFB?
LAFB- <0.12 sec, -45 - -90*, delayed precordium transition qR aVL, normal QRS
LPFB- <0.12sec, +90 - +180*, delayed precordium transition rS I, aVL, aR in III and aVF, normal QRS
EKGs must be done within ? minutes of PTs presenting?
What is the dose of MgSulfate used in V-Fib or pulseless V-Tach?
10m, same as triage time frame
1-2f IV for polymorphic VT
What is the TOC for assessing the LV function?
What is the TOC for assessing myocardial perfusion?
MUGA (AKA Radionuclide Ventriculography)- determines L/R ventricular ejection fraction through T-99m labeling to show blood passing through heart/vessels, ischemia/infarction, and assesses myocardial metabolism
PET scan
Most CA cells work in ? environments
EF from MUGA are usually similar to EJ estimates from ? test?
Anaerobic
Echos
What are the advantages of MUGA tests?
What are the disadvantages of MUGA tests?
30 FAV
Accuracy, RV /LV info simultaneously, No habitus limitations, 30m or less
RAV
Radiation
No info on valves
Less accurate for PTs w/ arrhythmias
What tags are used in cardiac PET scans?
Assessment of perfusion and viability with N-13, Fl-18 or Ru-82 to show areas of impaired flow or injury
When are Holter Monitors used on PTs?
When is an Event/Loop monitor used on PTs?
Continuous ECG for 24-48hrs for suspected frequent arrhythmias/syncope or dizzy
Usually the FIRST non-invasive cardiac rhythm assessment ordered
3 days to 3wks for infrequent arrhythmia Sxs or PTs w/ non-Dx Holter evaluation
When is an Implantable Loop recorder used?
PTs w/ infrequent but concerning Sxs that suggest pathological arrhythmia/unexplained syncope
What test is ordered for all post-MI PTs prior to starting rehab?
Other reasons for ordering a stress test can include ? four things?
Cardiac stress test
Prognosis, Function, Therapy effectiveness, Evaluate exercise induced arrhythmia
What are the absolute contraindications for ordering stress tests?
SPAM HEADS STEMI <2 days Physically disables Acute pericarditis (less than 2wks) Myocarditis
Sx HOCM Endocarditis High ACS risk HF- decompensated Severe aortic stenosis
If PT has high risk of ACS, no stress tests can be done. What test needs to be ordered?
What Dx can PT have and STILL do a stress test?
Coronary angiogram
Chronic pericarditis (more than 2wks)
Define Baye’s Theorem
Probability of a PT having a Dz after a Dx test is completed (Post-Test probability) related to disease probability before the test (Pre-Test Probability) and probability the test provides a true result
Post Test Prob= Pre-Test x Likelihood ratio
When do PTs have a high probability of having CAD
> 85%
Angina in older PTs- >40 M; >60 F
Angina in PTs w/ combination of risk factors- DM, Smoking, Hyperlipidemia
When do PT have an intermediate risk of CAD?
15-85%
Younger PTs, <40 M; <60 F
Angina or non-angina in older PTs >40 M; >60 F
PTs with multiple risk factors
When do PTs have a low probability of CAD?
<15%
Possible angina in PTs w/out combo of risk factors
What baseline EKG abnormalities which preclude EKG based testing?
WALL WPW Any ST depression 1mm or more LVH/Digoxin therapy w/ any ST depression LBBB, paced rhythm or non spcifiv IVCD
What is the most common treadmill protocol?
Bruce protocol- requires PT to reach 85% of max HR w/ 60-65% sensitive/80-85% specific for CAD
Max= 240 - Age
Cardiac stress tests are performed and continued until one of what four events occur?
PAST PT is fatigued Angina Signs of myocardial ischemia in ECG Target HR reached
Treadmill stress tests are done to provide info on what 5 things?
Local TREP Localize areas of ischemia for Tx via Echo, EKG or PET Therapy decision making Risk of CV event Exercise capability Prognosis
What are the markedly positive test findings of a treadmill stress test?
V SIPS Ventricular arrhythmia develops SBP decreases during exercise Ischemia on EKG within 3min of starting/lasting 5min after stopping PT can't exercise for 2min ST depression >2mm
How do pressures change as blood progresses through the heart?
*Low Press RA: 2-8 RV: 15-30/2-8 PA: 15-30/4-12 PCW: 2-10 *Start of high press LA: 2-10 LV: 100-140/3-12 Aorta: 100-140/60-90
When measuring wedge pressure via R-sided cath, what is it AKA?
Swan Gams R sided cath
What are the therapeutic and diagnostic indications for a L-sided cath?
Access through F, B, A and is most common type
Balloon- CAD, C Shock, V stenosis
Intracardiac shunt closure
Cant Left w/ Painful Heart Coronary anatomy in PUNCS LV function Prox aorta dz Hemodynamics pericardial con/restriction
Where is access for a R-sided cath obtained?
Subclavian, Internal Jugular, Brachial or Femoral vein w/ balloon tipped catheter (Swan Ganz) w/out need of fluoroscope
What measurement is indicative of the pressure in the Left Atrium?
When are they done?
Pulmonary Capillary Wedge Pressure provides estimation
Admitted ICU, not done on Out-PT basis
What does an elevated wedge pressure mean?
What does a reduced pressure mean?
Volume overload- wet (S3 sound, 3rd spacing)
Volume depletion- dry (give fluids)
What are the indications for a R-sided cath?
AH AS ES ED PM
Assess filling pressures and CO in PTs w/ HF
Volume/vascular resistance in PTs w/ sepsis
Evaluate intracardiac shunts
Evaluate pericardial disease
Peri-operative monitoring PTs w/ high risk of HF during procedures
What are the relative contraindications for doing caths?
DIPS BARS Digitalis toxicity Infection Psych illness Stroke in past month Bleeding Anemia Renal impairment Systemic HTN
What are the primary diagnostic indications for electrophysiologic studies?
What are the primary therapeutic indications?
Recurrent/difficult arrhythmia including SVT, V-Tach, sudden death
Assess pharmacologic/implanted device efficacy
Ablation of recurrent arrhythmias unresponsive to medical therapy
What tests can be done for PTs 4 days post-MI to test function?
What are the four steps of the clinical approach to a cardiac PT?
Echo, MUGA, Stress test
Anatomic/Physiologic
Etiology
Function
What are the cardinal Sxs of heart dz?
D FACES
Palpitations, Dyspnea** Fatigue, Angina, Claudication, Edema, Syncope
Sxs of MI Sxs of Angina Sxs of Pericarditis Sxs of Aortic Dissection Sxs of Valve Dz Sxs of CHF Sxs of Tamponade
Pressure radiating into L arm
Pain resolving w/ rest: pressure, squeeze, tight, heavy
Feels better when leaning fwd
Sharp or ripping/tearing
Associated w/ Sxs: Aortic stenosis= syncope
Swollen extremities
Dyspnea, inability to move fatigue
Atypical MIs can happen in female, elder, or diabetic PTs and can have pain located where or accompanied ?
Any PT with ? pain needs to be worked up as an MI until proven otherwise
Neck, Back, Jaw, Head, Belching
Jaw
What two CV causes of chest pain present with dyspnea?
What three non-CV causes of chest pain present w/ dyspena?
Angina: 2-10min of pain
MI: +30min of pain
PE, Pneumonia w/ pleurisy, Spot Pneumo
What would be seen on an EKG if PT had PHTN?
What type of EKG axis deviation is seen w/ PEs?
Lead 2, Large P-wave +2.5mm w/ dyspnea
Q1S3T3, RAD/ERAD
Pink frothy sputum is usually associated w/?
PE or MS
What cardiac issues can cause palpitations?
What are the non-cardiac causes of palpitations?
V CAPS
Valve Dz, Cardiomopathy, A-Fib/Flutter, , Prematures, SVT
Anxiety, Stimulants, ETOH
Hyperthyroid- Low TSH, High T3/4, isolated systolic HTN
What are the 3 types of edema?
What is the sequence of edema accumulation?
Peripheral
Abdominal (ascites)
Dependent- pitting (3rd spacing)
Lower extremities, neck, ascites
What are the 8 (5 modifiable, 3 non-modifiable) traditional atherosclerotic risk factors?
What is the limit for defining HTN?
What are the ages for m/w when risks increase?
Smoking, HTN, Dyslipidemia, DM, Obese/Dec PT
Adv Age, Male, FamHx (consider high risk if adopted)
> 140/90 on three different visits
M:>45; W: >55
Diabetics have a ___ increase for CVDz
What risk factors contribute to metabolic syndrome and which one is omitted?
3-5x higher
HTN, Hypertriglyceridemia, Low HDL, Insulin resistance, Visceral obesity (NO LDL)
What type of FamHx is of concern for cardiac PT risk factors?
M: 1* relative w/ CAD Dx before 55
W: 1* relative w/ CAD Dx before 65
What are the Non-Traditional risk factors for cardiac PTs?
Homocysteine Lipoprotein Small LDL size Pro-inflammatory markers Subclinical atherosclerosis Coronary calcification- seen on EBCT End stage renal Dz Chronic inflammatory dz (Chrons, Lupus) HIV/AIDS
Where does homocysteine come from?
What does it require?
Methionine metabolism
B12 and Folate
PTs w/ congenital deficiencies related to homocysteine metabolism will be at early risk of ?
What happens when the AA rises to dangerous levels and what is done about it?
Premature atherosclerosis
CV events, PO folate is given but no evidence showing decreased events
What is the circulating lipoprotein that is similar to LDL
Lipoprotein A levels are highly dependent on ? factor
Lipoprotein A- B100
Inheritance, >20mg/dl= inc risk of CVDz
LDL numbers are correlated with the levels of ?
What is the acute phase reactant?
Insulin resistance
CRP- reflects instability rather than burden and not independently reliable unless PT has INTERMEDIATE risk
What imaging modality is used as a screening tool for CAD in ASx PTs
What is a bad score from this test?
CT scan
EBCT score +100= atherosclerotic
Normal chest is ____ than it is _____
Abnormalities of the chest shape can lead to secondary cardiac conditions including ?
Wider than deep
PHTN
Define Pectus Excavatum
Define Pectus Carinatum
AKA Funnel Chest; lower sternum is depressed causing heart/great vessel compression
Sternum displaced anterior which increases A/P diameter and compresses costal cartilages (COPD/Barrel, Obese, Age)
Define Thoracic Kyphoscoliosis
What leads are Septal, Anterior, Lateral
Abnormal spinal curvature and vertebrae rotation deforms the chest, possible abnormal lung sounds
1, 2- Septal
3, 4- Ant
5, 6- Lat
What causes Regularly Irregular HRs
What causes irregular irregular HR?
Cadence ie- ventricular trigeminy
A-fib/flutter
What is cyanosis usually associated with?
What is abnormal/different about PTs presentation that are in septic shock?
Increased levels of reduced/unsaturated Hgb
HOTN but warm
What are the 3 things that primarily cause peripheral cyanosis?
What causes central cyanosis?
Cold/vasoconstriction response, HF, Shock- circulatory failure, PT will be cold w/ HOTN
Complex etiologies causing impaired oxygenation (cardiac/pulmonary R to L shunting
Define Eisenmenger Syndrome
Define Erythrocytosis and when is it seen
Condition that causes increased pressure from R side to L side of heart through ASD/VSD
Too many RBCs, seen in PTs w/ chronic etiologies that are compensating to their cyonotic state (CA, Heart Dz/F)
What does Pallor of the sclera indicate
What three areas can be checked?
Anemia- inadequate Hgb
Check conjunctiva, lips and mucous membranes
What are causes of bilateral edema?
Severe systemic edema due to cardiac causes may manifest as ? or ?
CV Dz (most commonly HF, especially R sided) Kidney Dz associated w/ proteinuria, hypoalbuminemia
Sacral edema or Hepatomegaly
What conditions can cause an enlarged PMI?
HTN, HCM, LVH, Atrial Myxoma (benign tumor in L atrium that enlarges and act like mitral stenosis, causes shifting of heart, most common benign tumor)
JVP is usually associated with ?
Why is measuring JVP in PTs w/ visible JVD not routinely done?
Volume overload like in CHF (+S3)
Little/no benefit since JVD= abnormal increase of CVP
What is the difference between the arterial and venous pulses in the neck?
Where does the JVP fill from?
Arterial= single upstroke Venous= two peaks and two troughs per cycle
Above from SVC
How does inspiration or posture alter the JVP?
Resp- volume of atria increases, dec w/ inspiration
Post- dec as PT sits up and if they’re healthy
Interpretation of the JVP waveform determines ? 3 things
What are the 5 elements of the wave form?
Structure, function, electrical abnormalities of heart, primarily on R side
A wave X descent C wave V wave Y descent
Characteristics of JVP “a wave”
Atrial contraction
Precedes S1 in diastole
Inc A= any condition causing increased resistance to R atrial emptying
No a waves in A-Fib (no S4)
Characteristics of JVP “x descent”
Atrial relaxation
Prominent X waves in- constrictive pericarditis, pericardial tamponade
Eliminated by tricuspid regurgitation (pan/holosystolic systolic, blowing murmur)
What is the most common PE finding in PTs w/ constrictive pericarditis?
What other condition also has this finding?
Pericardial knock
Cardiac tamponade
Most common PE Dx finding for pericarditis?
Most common PE Dx finding for tamponades and constrictive pericarditis?
Friction rub (pericarditis, tamponade, myocarditis)
Pericardial knock
Characteristics of JVP “c wave”
Bulging tricuspid valve/ventricular contraction during systolic contraction, mostly not present in every PT
Characteristics of JVP “v wave”
Increased atrial pressure during venous return after systole
Especially prominent in PTs w/ tricuspid regurg
Characteristics of “y descent”
Reduced pressure w/ tricuspid valve opening and atrial emptying during diastole
Impacted by factors impairing atrial emptying (like a waves)
What will Pericardial Effusion, Constrictive Pericarditis and/or Pericardial Tamponade change to JVP?
Parodoxical JVP
Kussmaul sign: JVP rises w/ inspiration
Define Cannon A Waves
What can cause these?
Aria contracting against a closed tricuspid valve
A-flutter, Premature atrial rhythm/tachy, 3* block, Ventricular ectopics/tachycardia, Junctional rhythm
Define Large A Waves
What causes them?
Increased atrial contraction pressure
Tricuspid stenosis, R HF, PHTN
Someone with a prominent JVP “c wave” has what issue?
What does a Precipitous X Descent mean?
Tricuspid Regurgitation
Pericardial constriction or Cardiac tamponade
What causes large V Waves?
C-V waves: tricuspid regurg (raised JVP, large V wave, rapid Y descent) or ASD
What causes a Slow, Rapid or Sharp Y descent?
Slow- tricuspid stenosis
Rapid- tricuspid regurgitation
Sharp- constrictive pericarditis
Total JVP measurement can also be AKA ?
Normal JVP ____ w/ inspiration
H2O JVP
Falls
Kussmaul sign is seen w/ ? JVP finding?
Kussmaul findings suggest ? issues
JVP rising w/ inspiration
Impaired filling of RV due to fluid in pericardial space or,
Poorly compliant myocardium/pericardium
What are the DDx for Kussmaul JVP findings
Define the Hepato-Jugular Reflux and who is it seen in
Constrictive Pericarditis, Restrictive Cardiomyopathy
PE technique to visualize JVP by pressing on RUQ in PTs w/ RHF or passive hepatic congestion
Define Pulse Pressure
What can cause this to increase or decrease?
Difference between Systolic and Diastolic arterial pressures
Inc- aortic regurgitation, conditions that increase SV/contraction
Dec- hypovolemia, severe LVF, mitral stenosis
A full pulse exam includes assessing pulses where?
Palpating pulses has what two purposes
Carotid, radial, brachial, femoral, popliteal, posterior tibial and dorsalis pedis
Patency and contraction of LV
Which pulse location is the most accurate reflection of the aortic pulse?
All pulses are assessed for what 5 things?
Carotid
Rate, Rhythm, Strength, Contour, Symmetry
A normal pulse is characterized by what 3 things?
Define the Dicrotic Notch
Rapid rise in early systole, Short Plateau, Gradual descent
Interrupts descending limb and represents aortic closure
Define Hypokinetic pulse
Define Hyperkinetic pulse
Hypo- decreased LV pressure, SV, outflow obstruction
Hyper- increased LV pressure, SV w/ decreased peripheral resistance (hyperthryroid, Epi)
Define Bisferiens Pulse
Define Pulsus Alternans
Bis- pulse w/ two palpable beats during systole (HOCM, AS/insufficiency, ejection of inc SV like exercise, fever, PDA)
PA- variation in pulse amplitude from changing systolic pressure, confirmed w/ BP (Systolic HF, LV failure-S3)
Define Pulsus Parvus et Tardus
Define Pulsus Paradoxus
PPT- slow rate of pressure increase, small pulse pressure, late associated w/ severe aortic stenosis (2RICS, old PTs, young congenital)
PP- exaggerated decrease 10mm or more of SBP during inspiration (tamponade, constrictive pericarditis, HOTN shock, obstructive pulmonary dz- asthma/COPD, large PEs)
What are the three things that cause restrictive cardiomyopathy?
Stethoscope diaphragm and bell are used for what sounds?
Amyloidosis, Sarcoidosis, Hemochromatosis
D- high S1/2, AR, MR, pericardial friction rubs, through precordium
B- more sensitive, low S3/4, MS
Define Thrills
Define Heave/Lift
Palpable low frequency murmurs most commonly associated w/ grades 4-6
Movement of precordium that’s associated w/ large ventricle or HF
What can cause widened splitting of S2
What causes fixed spitting of S2?
Delayed P/Early A closures through expiration from RBBB or Pulmonic Stenosis
Constant splitting through exp/inspiration from ASD
Define Paradoxical splitting
What part of the cardiac cycle would the tightening of the tendon chordae happen?
Reversed splitting- P closes before A from LBBB, AS (dec A), chronic HTN (inc A)
S3
What can cause an increased intensity of S3?
Most common etiologies of S4 sounds are from ?
Increased venous return to heart- leg raise
Increased arterial press/CO- hand grip, brief exercise
LVH from any cause (HTN)
Characteristics of opening snaps
Early diastolic high pitched heard between apex and L sternal border most commonly due to MS causing doming of leaflets during diastole
Not changed by respiration
Disappears w/ worsening MS
Reduced interval between A2 and Snap= worsening MS
Define the Austin Flint murmur
Severe AS
Mitral valve leaflet displacement and turbulent mixing of antegrade mitral and retrograde aortic flow
Mid-diastolic, low pitched rumbling murmur best heard at Apex
“Not a true MS”
Characteristics of Ejection Clicks
Early Systolic high pitched sound usually from valve dz (AS, PS, Pulmonic Stenosis)
Mid systolic- sudden opening/regurg of M/T valves during systole (MV prolapse)
Nearly all diastolic murmurs are ?
Systolic murmurs are either ? or ?
Pathologic- MS/TS
Pathologic or benign- AS/PS
What info is used to describe murmurs?
Two continuous murmurs
TIPS
Time/Duration, Location, Intensity, Pitch/Quality, Shape/Configuration
Venous hum, PDA
MR will radiate and be heard ?
AS will radiate and be heard ?
Axilla
Neck
What are the Grade 1-6 criteria for grading murmurs
1- barely audible
2- faint-med intensity
3- easily heard, no thrill
4- easily heard, possible thrill (vibration in stethoscope)
5- easily heard but requires stethoscope to touch chest, possible thrill
6- no stethoscope needed
Grade 3-4= worrisome
High frequency pitch/quality implies ?
High- increased velocity
Low- reduced velocity
Harsh pitch= ?
Blowing pitch= ?
Rumbling pitch= ?
Associated w/ severity
Regurgitation murmur
Diastolic in nature- Austin Flint, AR, MR
Define Crescendo
Defie Decrescendo
Define Crescendo/Decrescendo
Builds intensity
Reducing intensity- early diastolic of AR
Diamond shaped murmur of AS
Any factor that increases blood volume/preload will increase murmur intensity w/ ? exception?
How is preload inc/dec
MV Prolapse and Hypertrophic Cardiomyopathy- more affected by pressure gradient across valve
Inc w/ venous return, dec w/ less venous return
What causes after load to inc/dec?
After load generally augments ? murmurs and reduces ? murmurs
Inc- inc systemic vascular resistance (BP at aorta)
Dec by reduced systemic resistance (BP at aorta)
Augments regurg
Reduces stenotic
How does inspiration change the action of the heart?
Increases preload, augments R sided murmurs and S2 splitting, Decreases venous return to L side of heart/murmurs
How does standing change load on the heart?
Reduces preload
Augments intensity of MVP (mid systolic click) and HOCM from widened pulse gradient at R atrium
Minimal effect on other systolic murmur
How does squatting change load on the heart?
Increases preload and afterload
Reduces MVP/HCM intensity
Limited effect on other murmurs- regurg/stenotic
How does leg elevations alter blood to the heart?
How can you inc/dec HOCM/MVP?
Increases preload, reduces MVP and HOCM
Inc- stand, valsalva
Dec- squat, leg elevate
How does valsalva alter blood flow to the heart?
Inc then dec afterload and preload
Augments MVP and HOCM intensity from widened pressure gradients to R Atrium
How does hand grips alter blood flow to the heart?
Increases afterload
Augments MR, MVP, AR, and VSD
Reduces AS, HCM
How does amyl nitrate alter blood flow to the heart?
How does phenylephrine alter blood flow?
Reduces preload and afterload from vasodilation
Inc HOCM and AS
Reduces MR, AR
Inc afterload
Inc MR, AR
Red HOCM, AS
How does amyl nitrate alter blood flow to the heart?
How does phenylephrine alter blood flow?
Reduces preload and afterload from vasodilation
Inc HOCM and AS
Reduces MR, AR
Inc afterload
Inc MR, AR
Red HOCM, AS
Stops prolonged erection
Why and when are the following drugs taken through the day? Lisinopril Simvastatin Metformin Gabapentin Aspirin
L- BP in morning S- Cholesterol at bed M- DM at morning and evening dinner G- nerve pain, breakfast, lunch and bed Aspirin- heart health at breakfast
What are the two major lipids of plasma
How are they transported?
Cholesterol and Triglycerides
Lipoproteins
What is the most common clinical manifestation of lipid d/o?
Severe hypertriglyceridemia is primarily associated w/ increased risk of ? but not linked to ?
Atherosclerotic cardiovascular dz from inc levels of B-100s
Pancreatitis, but CVDz risk
CV score +5%= statin, don’t worry about TGL
Cholesterol is precursor for ?
What are TGLY made of?
Fat soluble vitamins
Steroid hormones- cortisol, estradiol, progestins, testosterone
3 FA on glycerol molecule
What is the importance of Apolipoproteins
Amphipathic molecules on lipoproteins that act as keys to receptors
What drugs work in the liver?
How do statins exert their needed effect?
Niacin, Statin, Fibrates
Inhibit the rate limiting step in cholesterol synthesis: HMGCoA Reductase which binds ACoA to free cholesterol to make cholesterol esters
Where are chylomicrons retrieved from?
What anti-oxidant is found in the blood stream?
Lymph system
Apo-B and Apo-C transfer from HDL to chylomicrons
Apo-E
Liver uses ? and ? to make VLDL
What medication can be injected to lower cholesterol?
Cholesterol and TGLY
PCSK-9i
What type/class of drug is used for management of TGLY levels?
What does Niacin do?
Fibrates
Cholesterol and TGLY management
Macrophages eat bad cholesterol until they die and turn into ?
What are the 3 layers of vessels?
Foam cells= atherosclerosis
Intima, Media, Adventicia
What is it called when a vessel needs its own blood supply?
Vasovasorum- located in adventitia
Sequence of events to make atherosclerosis
Tear in endothelial layer
LDL/cholesterol enters tear
Monocyte turns in macrophage and eats LDL/cholesterol
Inflammation occurs
Death to foam cells leading to necrosis between intima and media layer
Necrotic area turns into fibrous cap
Cap ruptures and becomes thrombus until dislodged and made into an embolis
Difference between exo/indogenous pathways of lipoprotein transport system
Slide 16 Lect 5
What’s the difference between Primary and Secondary dyslipidiemia
Start checking cholesterol levels in kids at ? age?
Primary- genetics
Secondary- weight, DM, renal/thyroid disease
9-11y/o
FamHx- 5y/o
BPs @ 5-6y/o
What would a PTs BUN levels be if they have liver dz?
AKAs for HDL, LDL and Chylomicrons
0
HDL- Apo-A1
LDL- Apo-B100
Chylomicrons- Apo B-48
How often are PTs cholesterol levels screened?
When/how often are PS ASCVD scores calculated?
Once every 5yrs starting @ 20y/o, done w/ fasting lipids, LDL levels are NOT included
40-75yrs old Q4-6yrs w/out ASCVD or DM w/ LDL 70-189
What lab finding is our marker for identifying PTs what are not responding/handling Statin therapy?
ALT elevations
What are the 3 areas on the body where excess cholesterol can build up and be externally visible?
What are the two high intensity statins?
Xanthelasma, Tendon Xanthomata, Arcus senilus
Atorvastatin- 40-80mg
Rosuvastatin- 20mg
What are themoderate intensity statins?
Ator- 10mg Rosu- 10mg Simva- 20-40mg Prava- 40-80mg Lova- 40mg Fluva- XL 80mg/ 40mg BID Pita- 2-4mg
What are the two low intensity statins?
Why is statin therapy discontinued?
Prava- 10-20mg
Lova- 20mg
Severe muscle Sxs/Fatigue
Work up for possible Rhabdo- order CK, creatinine and UA for myoglobinuria
What pre-existing conditions can signal PT will be increased risk for muscle symptoms while using statins?
How long can PTs have muscle Sxs before secondary causes need to be searched for?
Hypothyroid, Dec renal/hepatic function, Polymyalgia reheumatica, Steroid myopathy, Vit D deficient, Primary muscle dz
2mon
What are the 4 statin benefit groups?
Pts w/ clinical ASCVD
LDL 190 or higher
40-75y/o diabetics w/ LDL 70-189
40-75y/o w/ LDL 70-189 AND ASCVD of 7.5% or higher
Clinical ASCVD includes ? conditions
TIA Revascularization Acute coronary syndromes- MI Hx, angina Peripheral artery dz Stroke
What type of effects do HMG-CoA reductase inhibitors (AKA Statins) exert?
What type of effects do Bile Acid Sequestrants exert?
Dec LDL and TGLY, Inc HDL
Adverse- transaminitis, myopathy
Dec LDL, Inc HDL and TGLY
Adverse- constipation, bloating
What type of effects do Cholesterol Absorption Inhibitors exert?
What type of effects does Niacin exert?
Dec LDL and TGLY, Inc HDL
Adverse- rare allergic Rxn
Dec LDL and TGLY, Inc HDL
Adverse- flushing (reduced w/ Aspirin, don’t use Naperson)
What types of effects do Fibric Acid Derivatives exert?
Don’t treat Triglyceride levels unless they’re above what amount?
Dec LDL, Inc HDL and TGLY
Adverse- Nausea, Gallstone
500 or higher (Tx w/ Fibrates, Nicotinic acid, Omega 3 Acids)
What are the risk factors for PTs to develop metabolic syndrome?
Abd obesity- +40"/35" High TGLY- 150 or higher HDL- less than 40m/50w BP- 130/85 or higher Fasting glucose- 110 or higher (not LDL)
What adjunct is given to PTs when treating metabolic syndrome and they have intermediate/high CV risk?
90% of metabolic syndrome treatment errors are primary care issues that include what issues?
ASA and lipid management
Wrong drug/dose
PT needs combo Tx
Non-compliant PT
What two PCSK9 monoclonal antibodies have shown to further reduce ASCVD risks when added to statin therapies in high risk PTs?
What bile sequestrant and fibrate combo have shown progress in reducing CV events in male populations?
Alirocumab and Evolucamab and Ezetimibe
Cholestyramine and Gemfibrozil
Which fibrate is contraindicated to use w/ statins?
Gemfibrozil- 30x increased risk of myopathy
EKG ST elevation means?
ST depression/inversion means?
Transmural Ischemia and/or injury
Subendocardial Ischemia w/ abnormal repolarizatiton or death
Stable angina= ? compensation
Acute coronary sydrome= ? compensation
70% or less occlusion
71% or above
90%= pain at rest
While walking, coronary blood flow represents ?% of total CO
5%
Define Ischemic Heart Dz
Define Angina Pectoris
Imbalance between myocardial blood supply and demand leads to hypoxia and increased waste metabolites
Uncomfortable chest sensation from ischemia, most common clinical presentation and most commonly from atherosclerosis
Define Stable Angina
Define Variant Angina
Transient midline/left anterior angina precipitated w/ activity/emotions causing temporary ST depression and relieved w/ rest
Angina at rest from coronary spasm causing transient ST elevation between midnight and 4am, not ruled out with troponins, r/o by PCI
Define Silent Ischemia
Define Unstable Angina
ASx ischemia detected by EKG and labs
Increased angina from less exertion or at rest; all PTs are admitted
Change of baseline, first time/new onset, any pain at rest
Time is not issue but typically beyond 20min
What is the Fatty Streak
Endothelial dysfunction between 17-25y/o
Allows LDL entry and modification and monocyte aggregation
Monocytes-> macrophages and foam cell formation
What is needed for oxidation to transform LDL to fatty streaks?
What 3 factors affect coronary vascular resistance?
Inflammation
Accumulation of metabolites
Endothelial derived substances (NO- dilation; Endothelin 1- constrictor)
Neural innervation- A adrenergic and B2 adrenergic
What drug has positive inotropic effect and utilized as last resort when heart is failing?
One medication that can be given that decreases morbidity and mortality
Digoxin
Aspirin
What are the 3 major clinical consequences of HDz
Myocardial injury- stunned or hibernating
Acute Sxs- un/stable, variant, cardiac syndrome X
Necrosis leading to MI- irreversible, Sx or silent
What is cardiac syndrome X
Define Stunned myocardium
Young/healthy PT that have heart attack without atherosclerosis and is usually genetically linked
Short term near/total reduction of coronary flow re-established by PCI and followed w/ subsequent, limited LV dysfunction
Define Hibernating Myocardium
Persistently impaired myocardial and LV function at rest from chronically reduced coronary blood flow but is reversible
This is a chronic stable angina PT*
Conduct PET or Dobutamine Echo to determine perfusion and possible angiography if cells are viable
What are the anginal equivalent Sxs?
The mortality rate of stable angina is best predicted by?
Dyspnea, Sweating, Fatiuge, Dizzy/Light headed, Gastric urtications
Degree of LV function assessed by Echo (CO, EF), exercise capacity and severity of Sxs
What are the 3 anginal equivalents of stable/classic angina?
Dyspnea, LV dysfunction (light headed, dizzy), Fatigue
Prinzmetal angina spasm is thought to be a combo of what two factors?
What meds can be given?
Sympathetic activity and Endothelial dysfunction
Stress test will produce normal test results
CCBs preferred, DO NOT use BB
Nitro can be given acutely
Of the 3 major clinical presentations of heart disease, where do the atypicals fall in?
What 3 questions are asked during a diagnostic evaluation of stable angina?
Myocardial necrosis leading to MI
Is chest pain substernal, retrosternal, or epigastric?
Sxs brought on predictably by stress or exertion?
PTs Sxs relieved by nitro or within 5min of rest?
3 yes= typical angina
2 yes= atypical angina
Less than 2 yes= non-anginal
What are the 5 questions/point scale used for determining risk factor points of CAD?
55 or older male/65 or older female CAD or CV Dz Pain not reproducible by palpitation Pain worse w/ exercise PT assumes pain is cardiogenic
What are the 4 cardinal features of angina
How is it typically described by PTs?
Character of discomfort, Site and distribution, Provocation, Duration
Pressure w/ feeling of strangling/anxiety
Atypical PTs describe as vague and atypical
What does a peaked P-wave in Lead II mean?
What labs/rads are ordered and in what time frame?
PHTN
EKG- 10m, if not diagnostic, repeat 5-10m intervals CXR- 30m Fibrinolytics- 30m PCI- 90m, 120min if transfer is needed Labs- CBC, Chem-7, Troponin, UA, glucose, lipids Treadmill test- low/mod risk Nuclear test- if EKG abnormalities OR, Exercise echo Rx Stress Test if PT can't exercise Coronary angiography if PT is high risk
What is the difference between Coronary Angiography and Revascularization
CA- dye injection
ReVasc- stent placement
What are the 3 criteria are are the end points for stress tests?
Sxs limit continuation
Ischemia 0.10mV or more or horizontal ST depression/elevation
BP decrease by 10mmHg or more during exercise
What are the 3 criteria for a positive stress test?
Pos= 0.10mV or more horizontal ST depression Neg= no exercise abnormalities at 85% max HR Non-Dx= <85% max HR w/ no EKG evidence of ischemia
What are the 3 goals of therapy in chronic ischemic heart Dz?
How is stable angina managed?
Dec anginal attacks
Prevent acute coronary syndromes-MI
Prolong survival
Type of episode- acute or chronic
First line- nitrates, sublingual
Rest/stop doing activity
All PTs with stable ischemic heart disease can get which immunization?
What is the pharmacological treatment for them?
Influenza- possible reduced inflammation processes
AKA Vasculo Protective Regiment Anti-platelet therapy (ASA, Clopidogrel) Lipid lowering- statin/CSPK9 BBs- meto/? ACEIs- if high risk PT- lisinopril Rarely CCBs- last resort
What are the uses and perks of using BBs
Primary preventinon/first line therapy of anti-angina therapy
Only drug proven to prevent re-infarct and increase survival chances post-MI
HR goal 55-60
Beta 1- pos ion/chornotropic
Beta 2- vaso/broncho dilators
What 4 BBs can be selected for use and the perks of use
Non-Sel: Propanolol
B1 Sel: Meto/Atenolol
Intrinsic sympathomimetic activity
Alpha/Non-Sel: Carvedilol, Labetolol
PTs with ischemia +65y/o get ? BB
PTs under 65 get ? one?
Carvedilol
Metoprolol
Which BB can be used in pregnancy?
What are the contraindications for using BBs?
Labetolol
Brady, below 50bpm PRI > 0.24, 2* or 3* block Decomp HF Hx of asthma Caution w/ diabetics
Don’t use ? class drug in PTs on cocaine?
What CCBs are used?
BBs- causes coronary spasms
Diltiazem, Verapamil, Amlodipine preferred
Non-DHPs: Dec ion/chronotropy and after load; C/I in brady or systolic HF
DHPs: dilators that decrease afterload, A/F/N-dipine
What is the first line medication for treating PTs/ with ischemic heart dz but have bradycardia or AV blocks
What is a new medication that can be used in place of BB or w/ BB therapy?
DHPs- Amlo/Felo/Nifedipine
Ranolazine- late Na channel blocker
What are the adverse effects of Organic Nitrates?
What are the adverse effects of BBs
HA, HOTN, Reflex Tachy
Brady cardia, dec LV contraction, Bronchoconstriction, masks hypoglycemia, fatigue
What are the adverse effects of CCBs
What are the adverse effects of Ranolazine
HA, flushing, dec LV contractility on V/D
Bradycardia on V/D
Edema on N/D
Constipation, especially on V
Dizzy, HA, constipation, nausea
Post MI, what two meds can be used in combo for anti-platelet therapy?
PTs w/ HTN, previous MI or exertional angina should be placed on ?
Aspirin and Clopridgel
BB
When art PTs placed on ACEI therapy
No benefit to angina, helps reduce remodeling of heart
Benefit for HTN, DM, CKD< LVEF <40% require ACEI
Usually monitoring is done on PTs who remain Sx on medical therapy, however revascularization is considered and pursued if ?
Angina Sxs don’t respond adequately to drug therapy
Unacceptable s/e on meds
PT is high risk coronary dz and revascularization is known to improve survival
What is the CABG to PCI ratio
What determines if a PT gets a PCI or CABG?
1 CABG : 3 PCIs
One or two vessel involvement, +70%= PCI
3 vessels or LMain disease w/ intermediate/complex anatomy or impaired left ventricular systolic function= CABG
DM with 2 vessels
Significant LV failure
Revascularization by any technique does not reduce MI/death risk from CAD in PTs w/ ? and ?
What was the COURAGE trial and what did it show?
Chronic stable angina and preserved left ventricle function, medical management is key
Clinical Outcomes Utilizing Revascularization and AGgressive drug Evaluation- showed PCI was no better than max medical therapy at reducing mortality and cardiac events in PTs w/ stable CAD but may be more effective at long term Sx relief
PCI is AKA ?
What drugs are given during this procedure?
What two are given prior to procedure?
Percutaneous Transluminal Coronary Angiography- places drug eluding stents in PTs w/ 1 or 2 vessel disease and is Procedure of CHOICE
Abciximab, Eptifibatide, Tirofiban
ASA, Clopidogrel
When is a CABG procedure preferred?
When do you do PCIs?
Large amount of myocardium is at risk (3 vessels or LM)
STEMI, NSTEMIs not responding to max medical therapy
What does CABG stand for?
What are the two types done?
Corornary Artery Bypass Grafts
Native veins- section of saphenous “superfluous” vein and sutured from base of aorta to RCA segment down stream of stenosis, high re-occlusion rate
Arterial graft- most common, uses internal mammary “superfluous” branch of subclavian and anastomosed distally to LM/LCX, more resistant/long lasting
For revascularization, ALL STEMIs get _____
In order to revascularize a PT, one of what two criteria must be present?
Angiography- PCI
Severe/refractory angina
Severe ischemia on stress testing
What two meds are always given to PTs prior to PCIs?
ASA and Clopidogrel
What are the 3 benefits of PCI
What are the 3 benefits of CABG
Less invasive, Shorter In-PT and easier recovery, Superior to Rx therapy to relive angina
More effective for long term, Most complete revascularization, Greater survival in PTs w/ greater than 50% LM stenosis or w/ impaired LV function
Prinzmetal angina is also associated with what other two issues?
All PTs with DM and CAD are placed on ? med?
Raynauds and Migraine HAs
ACEI
LDL lowering therapy in PTs w/ Dx or suspected CAD are placed on what 3 meds
What drug is used during the MI algorithm but has not mortality/morbidity benefit?
High potency statin, Ezetimibe, PCSK9 inhibitors
Nitro
What meds are used when BBs are contraindicated for the prevention of MI and reduce Sxs?
What factor Xa inhibitor can be combo’d with ASA or Clopidogrel?
CCBs, Long acting Nitrates
Rivaroxaban, not good for non-compliant PTs
When is fibric acid derivatives considered for use?
What are the four functional changes that occur to the heart as scarring?
High risk PTs w/ elevated triglycerides and LDL is at target on statin therapy, don’t combine
Stunning, Hibernation, Reconditioning, Remodeling
What is the one med we use to stop ventricular remodeling?
What two chemicals are naturally secreted by vessels in response to damage to inhibit platelet aggregation and activation?
BBs, ACEIs
Prostacyclin- aggregation and activation
NO- activation and dilation
In presence of injury, become constrictive
What are 3 drugs that can decrease anti-thrombotic effects?
Partial occlusion of a vessel leads to ? or ?
Full occlusion leads to ? or ?
TPA, NO, Prostacyclin
UA or NSTEMI
STEMI
When considering the rupture of a plaque, how do you know if it’s superficial or deep?
There is never a serum biomarker with what heart issue?
Superficial/minor- self limiting
Deep w/ obstruction- ACS syndrome
UA, no troponin
Always have one w/ NSTEMI
You can’t Dx PT with STEMI if they have a normal ?
How are NSTEMIs initially treated?
EKG, must have ST elevation
Medical management for 24-72hrs
What are some causes coronary thrombus N/STEMI appearing issues but are non atherosclerotic issues?
What is the one exception?
Anemia, HOTN, Stenosis, Aortic Dissection, Procedure complication, Embolic phenomenon, Blunt trauma
Coronary artery spasm- variant or Printzmetal
What are some non-atherosclerotic conditions that can be used as DDx for N/STEMI issues?
Acute Coronary Syndrome encompasses ? 3 issues?
Lupus, Takayasus, Kawasakis, Giant Cell Arteritis, Polycythemia, Sickle Cell, Cocaine
UA, NSTEMI, STEMI
What will a transmural entire thickness MI, what will MI show?
How to distinguish between UA or NSTEMI?
STEMI, transmural= entire thickness of wall
Lab test for troponin
What are the early changes during trasnmural infarctions
2m: ATP decrease
10m: Irreversible injury- VT/VF
24min: Wavy myofibrils
12hr: Hemorrhage, edema
24hrs: Coagulation necrosis- eosinophils
2-4d: Total coagulation necrosis- monocytes
Stopped w/ BB/ACEIs
What are the late changes during a transmural infarct?
5-7d: yellow softening by macrophages
7+d: granulation/ventricular remodel
7wks: fibrosis and scarring complete, PT can start PT
What functional changes can occur during transmural events?
Impaired contractility/compliance- hyokinetic, akinetic, dyskinetic seen on echo
Myocardial stunning- limited LV dysfucntion
Ischemic precondition- MI w/ recent angina experience less morbidity/mortality
Ventricular remodel- thinning/dilation of wall
What is the most common Sx of cardiac ischemia +85y/o?
What two meds used in combo improve LV function and long term survival?
Dyspnea
BB and ACEI, PTs need to be on these upon d/c
Every PT with suspected MI is treated the same in what steps?
O2, Monitor, IV, Hx, PE, EKG, CXR, Labs- Chem 7 (CK, E+), CBC (anemia), lipids, UA, troponin, CKMB, myoglobin
How to diagnose ACS from UA/NSTEMI
What med is not used in PTs w/ UA?
Sxs, EKG abnormalities, serum markers of myocardial necrosis
CCBs
All inferior wall acute MIs need ? prior to Nitro administration?
What vessel supplies lateral, inferior, septal, anterior areas on EKG
Right sided EKG V4R
2, 3, AvF- inf, RCA
1, AvL- LCX or 1st diagonal branch
V1, V2- first 1/3= PDA, bottom 2/3=LAD
Pos AVR and V1 mean one of what 2 things?
What vessels supply SA, AV, Bundle, RBB, LBB
LM occlusion, PE
SA- RCA in 70% AV- RCA in 85% Bundle of His- LAD RBB- Prox= LAD, Distal= RCA LBB- Ant= LAD, Post= LAD and PDA
How long does it take to rule out a MI w/ no troponin results on labs?
What are the two Troponin Cardiac markers?
12hrs= 100% r/o, this is why troponins are never ordered on outpatient basis
I and T, I is most sensitive
Inc of either is Dx for MI
What is the use of CKMG for MIs?
What is the first marker to rise and fall within 24hrs?
Proves MI re-infarction, rise 5x above baseline is Dx
Myoglobin, CKMB and troponin are second
What are the timelines for cardiac biomarkers to rise, peak and return to baseline?
Troponin: R 3-4hrs, P 18-36hrs, B 7-10 days
CK: R 3-8hrs, P 24hrs, B 2-3 days
How often are repeat EKGs ordered post-MI while inpatient?
On an echo, heart wall motion that is waving =?
If it’s no moving then it’s ?
Every day
Dyskinetic
Akinetic
How do you rule in/out MIs in pregnant PTs?
What if PE is suspected?
CT angiogram
Creatinine >1.5- order VQ scan to r/o PE but don’t order CT angiogram, will kill kidneys
What are the 4 classes of drugs used in ischemic heart disease?
What is the trifecta sequence of EKG changes during STEMIs?
Anti-platelet, BB, CCB, ACEI
Hyper acute T wave, Depression, Elevation, Q waves
What two fibrinolytics are used for MI PTs?
For testing purposes, give MI PTs O2 if puls-ox is below ?
TPA (Tenecte,Alte/Reteplase) or Streptokinase
90%
What are the 3 steps of UA and NSTEMI treatment plans?
Anti-ischemis: BB, nitrates, +/- CCB or ACEI
Anti-thrombotic: anti platelet- ASA/Clopanti,coagulant- LMWH, unfractionated heparin
Adjuncts: statin, ACEIs for ALL Pts
Why do we give all PTs w/ MIs BB?
What CCBs do we give for anti-ischemic therapy?
Lower mortality rate and sets HR goal of 60bpm, don’t use if less than 50bpm
Non-DHPs: Diltiazem, Verapamil; caution w/ edema and constipation
Don’t use for LV dysfunction
Don’t use nitrates as anti-ischemic therapy if it’s ? type of failure
What P2Y12 inhibitors are used for UA/NSTEMI antithrombotic therapy?
What GP2b/3a inhibitors are used?
RV failure
Clopidogrel (cheaper, higher bleed risk), Prasugrel, Ticagrelor (lowest chance of causing bleeding, expensive, reversible), Cangrelor
Abciximab, Eptifibatide, Tirofiban
E/T= small molecule agents, don’t induce immune response
What anti-coagulants are used in UA/NSTEMI therapy?
LMWH- most commonly used, no lab testing, Enoxaparin
UFH- slow onset, monitor PTT, preferred for PCI since it’s reversible
Bivalirudin- used if heparin induced thrombocytopenia occurs
What is the MOA and benefit of Bivalirudin use
When/why is Fondaparinux used?
Direct thrombin inhibitor
Less associated bleeding
Conservative management of UA/NSTEMI to decrease bleeding
Similar to LMWH, indirect 10a inhibitor but no Thrombin inhibit
UA/NSTEMI treatment is conservatively managed w/ meds unless ?
Early invasive management (within 24-48hrs) of UA/NSTEMI is based on ?
Ischemic episodes return
Stress test indicates residual inducible ischemia
TIMI risk
What are the parts of the Thrombolysis in Myocardial Infarction risk score
+65y/o
3 or more risk factors: Age, Sex, FamHx, Smoking, HTN, Hypercholesterol, DM, Obese
Coronary stenosis of 50% or more by angiography
ST deviation on presenting EKG
2 anginal episodes in 24hrs
ASA use in prior 7 days
Elevated troponin or CKMB
0-1: ASA and d/c
3 or more- bad
How is STEMI clinically defined on EKG?
When does a MI PT NOT receive nitro?
ST elevation in 2 contiguous/precordial leads (2,3,AvF; 1, AvL; V5,V6; V3,V4; V1,V2)
New LBBB
Consistent presentation of ACS
Hemodynamic instable, HF, decreased neurologic function
All STEMI PTs get an PO BB within ?? hrs of onset of AMI?
What statin is started ASAP?
Within 24hrs unless c/i
Atorvastatin
STEMI PTs get Fibrinolytics within ? time frame and under ? condition
What are the absolute contraindications for using Fibrinolytics in MI?
90-120min and Sxs are <12hrs old
Prior intracranial hemorrhage Structural cerebral vascular lesion Intracranial neoplasm Ischemic stroke in past 3mon Active internal bleeding (doesn't include menses) Suspected dissection/pericarditis
? drugs is a venodilator?
What aer the long term management and secondary prevention steps of STEMI
Nitro
ACEI w/in 24hrs- includes ASx and EF >40%, all CHF, reduced EF <40%, Anterior wall MI or ARB if can’t tolerate ARB (-sartan)
What drugs are not given for long term management/secondary prevention of STEMI?
What type of STEMI PTs get an Aldosterone antagonist?
CCBs
HF, Spirinolactone
What medicatoin must be stopped in all STEMI PTs
What do all STEMI PTs get prior to d/c
NSAID- avoid in HF and reduced LVEF except for ASA
Echo
When do STEMI PTs get anti-coag w/ Warfarin?
Large anterior MI
LV aneurysm on TEE or Echo(7days post-MI)
LV thrombus
What is the dispostion for PTs with likelihood/risks for ACS?
Low L/Low R= out PT eval
Intermediate L/Low R= out PT eval
Intermediate/Intermediate= in PT w/ telemetry
Intermediate/high L/High R= Cardiac care unit
What are the 5 scenarios that require admission for PTs w/ ACS?
Continuous chest pain Positive serum makers Significant/new ST abnormalities Wellens T-waves- new/deep inversions Hemodynamically unstable High risk stress test results- +/-
How is Wellens treated/managed?
Deep inverted/biphasic T waves due to LAD occlusion, seen in V2/V3, get to PCI due to poor medical management outcomes
PT may be pain free at time of EKG w/ normal/barely elevated enzymes but are at extremely high risk for massive anterior MI in following days
If no cardiologist is present, who manages Wellen Syndrome PTs?
What about STEMI, NSTEMI or angina?
Internal Med
STEMI- cardiology or Internal Med
NSTEMI- Internal med, may end at cardiology
Angina- internal med
What dosage of aspirin is given to PTs upon arrival?
What anti-depressant can be used for depressed PTs post-MI?
81-325mg, 325 preferred and chewed
81mg at discharge
Sertraline or any SSRI
PTs presenting with one of these 5 NSTEMI characteristics are sent to cath lab immediatley?
Hemodynamic instable/cardiogenic shock(BP 90/60, cold and clammy, AMS, chest pain, “sick” looking”
Severe LV dysfunction/HF
Recurrent/persistent rest angina despite medical therapy
New/worsening MR or new VSD
Sustained ventricular arrhythmias
Fibrinolytics AKA thrombolytics have no clear survival benefit for ? cardiac PTs?
When is the use of firbrinolytic preferred?
UA or NSTEMI, never ever give
Small area of ischemia will be made worse by swelling
Contraindicated for PCI, no PCI available within next 90min
No PT ever goes to CABG without going through ? first
How long after MI does LV aneurysm take to development?
PCI
7 days
What two meds are used for treating MI induces pericarditis/Dressler’s?
What anti-coag can cause cardiac tamponade if given to these PTs but prevents transmural thrombus
ASA, Colchicine (viral= high dose NSAIDs)
Warfarin
MI Sinus Brady causes ?
MI Sinus Tachy causes?
RCA/Inf Wall- Inc vagal tone, dec SA node perfusion
Ant wall- Pain, Anxiety, volume depletion (dopamine)
MI APBs, A-Fib causes ?
MI VPBs, VT and VF causes?
HF, Atrial ischemia
HF, Ventricle ischemia
MI AB Blocks 1, 2, 3 cause?
IMI= inc vagal tone, dec AV perfusion
AMI= destruction of conduction tissue
Define Cardiogenic Shock
How is it treated?
Dec CO and HOTN w/ poor peripheral perfusion due to >40% LV death
Ionotropic drugs (Dobutamine) but cycle continues until LVAD implant or transplant
What test is done prior to all post-MI PT discharge and is is used to gather the most useful prognostic indicator?
PEs are _% sensitive and _% specific for detecting valve Dz
Echo to get LVEF
70% and 98%
What are the Systolic murmurs by position?
When do the get Echos?
AS- RUSB PS/PDA- LUSB HCM- Erb's TR, VSD- LLSB MR, MVP- Apex
Grade 3 or higher
What are the Diastolic murmurs by postition?
What do all diastolic murmurs gert?
PI, Split S2- LUSB
AI- Erb’s
TS- LLSB
MS- Apex
Echos
What are the 3 continuous murmurs?
What is the sequence of interventions for brady/BLS?
PDA- LUSB
Arteriovenous malformation
Venous hum
Atropine, Transcutaneous Pacing, Dopamine, Epi
What vision change can occur w/ Digitalis toxicity?
Pancarditis is AKA ?
Yellow vision
Myocarditis
What are the 2 types of WPW?
How is it treated?
Orthodromic- narrow QRS, symptomatic, Delta waves
Antodromic- wide QRS
Tx w/ Procainimide or conversion
Definitive Tx- ablation
What type of BBB is equivalent to STEMI?
VSD is most commonly associated w/ ? and ASDs are most commonly associated w/ ?
LBBB
VSD- LBBB
ASD- RBBB, PEs most commonly associated here
Sequence of treatment of PSVT
3 PVCs in a row is called ?
Stable- vagal, adenosine 6mg/flush, 12mg/flush,
V-tach
What are the causes behind Sinus Brady?
BB, CCBs, Digoxin Inc vagal tone Hypo thyroid, temp, sugar SSS Obstructive apnea
If blood glucose is less than 60, what is the Tx?
How many Joules are used for defib on Vfib?
Glucose
200J biphasic
PT on hydrochlorothizide and develops U-waves, what is the cause?
How is V-tach treated?
Hypokalemia
Stable= amiodarone, lidocaine, procainamide
Unstable= cardioversion
Pulseless- defib
What meds can cause Torsades?
How is it treated?
Antipsychotics, Methadone (SSRIs preferred for depressed MI PTs)
Unstable- defib
Stable- IV MgSulfate and d/c offender
What is the most common cause of R sided HF?
L sided HF
What are the grading scales for systolic murmurs?
1- barely audible 2- faint but immediately audible 3- easily heard 4- easily heard and w/ palpable thrill 5- loud, hear w/ light tough of stethoscope 6- audible w/out stethoscope
What are the grading scales for diastolic murmurs?
1- barely
2- faint but audible
3- easily heard
4- very loud
Murmurs of what characteristics are classified as benign murmurs?
Early/mid systolic- MVP Soft, grade 1 or 2 Vary w/ respiration Normal exam/work up No FamHx
What are pathologic murmurs and what do all get for imaging?
All diastolic- MS TS, AR, PR All pansystolic- MR TR VSD Late systolic- AS/PS Loud Continuous- venous hum, PDA, AV malformation
ALL GET ECHOS
Systolic ejection murmurs
Pansystolic murmurs
AS- 2RICS and neck
PS- 2-3LICS
MR- apex to axilla
TR- LLSB to RLSB
Late systolic murmurs
Early diastolic murmurs
MVP- apex to axilla
AR- L sternum
PR- upper R of sternum
Mid to Late diastolic murmurs
Define Acute Rheumatic Fever
MS- apex
2-3 wk delayed sequel of pharyngeal infection w/ Group A Strep w/ scarlet fever but not from GAS skin infections
What physical response occurs during ARF?
Aschoff nodule- source problem of all issues
High fever
Valvulitis, usually mitral
Non-itching pruritis- erythema modulotum
Joint pain starting one at a time
PAINLESS subcutaneous nodules (endocarditis= painful)
Rapid involuntary muscle movement of face
What would bee seen on physical exam in PTs presenting weeks after infection but now with ARF?
Throat exudates and high fever
No runny nose, cough= GAS don’t cause these
What are the major Jones Criteria
Joints- migratory polyarthritis in large joints of UE w/ Rubor, Palor, Calor and Tumor
O- myocarditis w/ pericardial effusion
Nodules, subcutaneous
Erythema marginatum
Sydenhams chorea- AKA St Vitus Dance, stops during sleep, rare in adults, rarer in males
What imagine modality is used to view Jones Criteria
Firm/painless nodules nearly always occur due to ?
Echo, no scanners
Carditis
ARF erythema marginatum presents with what characteristics?
Non pruritic, non-painful serpentinous eruption on trunk, proximal trunk and center returns to normal before margins
What are the minor Jones criteria
Arthralgia w/out arthritis
Fever 101-104
Elevated ESR and CRP
Prolonged PR interval**
What are the diagnostic tests for RF show on labs/rads
Strep culture or Rapid Strep
Strep Ab Titer- ASO or AntiDNase B w/ elevated CRP and ESR
CXR w/ cardiomegaly and/or HF
ECG- blocks
What type of diagnostic info is used for making a Dx of ARF
GAS pharyngitis infection
+ throat culture
+ rapid strep Ab test
Elevated/rising strep Ab test- ASA, Anti-DNase B, or Antistreptozyme
How many major/minor criteria are needed from Jones Criteria to make a Dx
When can a presumptive Dx of ARF be made?
Two major or,
One major and two minor criteria
Chorea as only manifestation
Indolent carditis- PTs failing to seek early Tx
Recurrent RF PT w/ Hx of ARF are presumed to have recurrence w/ any manifestation
What are the DDx of RF
Bacterial endocarditis- painful nodules Viral myocarditis- cultures, low myocytes/lymphocytes Lupus Serum Sickness RA Infectious arthritis
What part of ARF can’t be treated/slowed?
What are the major goals of treatment
Valve damage
Relief of acute Sxs
Eradication of GAS
Prophylaxis from future GAS infections
Most PTs are admitted
How is ARF Treated?
ABX- PCN x 10 days regardless of pharyngitis presence
HF management and anti-inflammatory- ASA 80-100mg kids/4-8g in adults
Therapy is continued until all Sxs are gone and/or ESR/CRP are normal
Bed rest
How is ARF Carditis treated?
How is the rash treated?
HF and Blocks Tx w/ conventional therapy
Valve repair/replacement for non-reponsive HF
No specific Tx needed
What ABX are used for treating ARF
Therapy x 10 days Kids under 27kg= Penicillin VK 250mg b/tid \+28kgs= Penicilin VK 500mg b/tid Bicillin LA IM- once in lieu of PO PCN Kids- 600K units Adults 1.2M units
PCN Allergic- Azithromycin, Clarithromycin, Clindamycin (Macrolides)
What is RF prevention therapy
Primary= Dx and ABX Tx of GAS tonsillopharyngitis
Secondary= Hx of Dx increases PTs risk, limit Dz severity w/ prophylaxis
How long after illness does it take RF TPs to develop heart issues?
10-20yrs
Mitral stenosis- most common
Aortic valve
Rarely Tricuspid
What is Carvallo’s sign?
What are the 3 Diastolic murmurs
Pansystolic murmur that is louder w/ inspiration and helps distinguish from MR
Austin AR MS at rest
Large P wave over 2.5 in lead 2 more than 4mm in height is due to ?
What are the 4 atypical MI presenters
Cor pulmonale- chronic from COPD, acute from PE. PTs presents w/ edema, fatigue and signs of R sided HF
DM, Old, Female, CHF
Dx HTN
What decreases after load but can be treated with?
3 separate visits of 140/90
Dantrolene
Difference Pitting and Non-Pitting edema
What is the difference between a low and high output HF
Pitting- CV cause
Non- lymph
High- due to high metabolic state or shunting of blood that inc O2 demand- hyperthyroid, Beriberi, AV fistula, Paget’s, Anemia, Pregnancy
Low- depressed Ejection Fraction; dilated cardiomyopathy, chronic HTN, Valvular HDz
What are the four stages of HF Staging/Classification
A- high risk w/out Sxs or Dz
B- structural Dz w/out Sxs
C- structural Dz and Sxs
D- refractory HF
What are the 4 classifications of the New York Heart Association?
1- ASx
2- Sx w/ ordinary activity
3- ASx only at rest
4- Sxs at rest
What are the JNC 8 Guidelines of HTN?
Under 60 or Diabetic= 140/90
Over 60= 150/90
Tx: 1st line always lifestyle mod.
Non Af.Am.= Thiazide, ACEI, or ARB or CCB
Af.Am= Thiazide or CCB
CKD, with or w/out DM= ACEI or ARB
For HTN PTs, when are the re-evaluated, referred and what are not used together?
What PE finding proves a PT has renal artery stenosis?
Titrate up or add therapy after 1mon if not at goal
Don’t combine ACE/ARB
If more than 3 drugs are needed= referral to HTN specialist
Bruis
PTs presenting w/ MI Sxs need to have what drug use r/o prior to giving nitro?
Other than inferior MI, what other cardiac issue needs to avoid Nitro use?
Phosphodiesterase inhibitors (Viagra) in past 24hrs
RV Infart and Severe Aortic stenosis
All PTs with ACS get ? med despite lab baseline levels?
High intensity statin (Atorva/Rivustatin)- LDL +190 or ASCV risk +7.5%
Long term STEMI care
How are aneurysms seen?
ASA/Clopidogril
Warfarin- large Anterior MI
TEE, Echo
What risk does the combo of smoking and contraceptives have?
What HTN emergency drug is metabolized into cyanide?
Venous thrombosis
Sodium Nitroprusside
Caution before giving Clarithromycin (macrolide ABX) to PTs taking what class of medication?
Class 1A/B/C, 2 3 and 4 drugs
Statins- QT prolongation and hearing loss
Rebound HTN emergencies occur w/ sudden d/c of what anti-HTN drug?
Imaging choices for suspect DVT?
Clonidine/Methyldopa
Duplex US to Venography
What two murmurs increase w/ valsalva?
How can HOCM present and be confused for something else?
HOCM, MVP
Large amplitude QRS
Deep na`rrow Q in inf/lat leads mimicking lat/inf MI
Tall R in V1-V2 mimicking post MI/RVH
PACs can be signs of ?
Do you stop CPR to place AED?
Atherosclerosis
Yes
PT with anemia, low Hct/Hgb and is suffering from MI has what type of MI?
If PT is getting hypoglycemia on BBs, what diuretic can be given to counteract the effect?
High out put
Thiazide diuretic
Which diuretic causes Ca to go up?
PT w/ MI and HTN emergency, EKG shows ST elevation in V2-4, what drug can be used for HTN?
Thiazide- up
Loop- down
Nitro
Avoid Enalaprilat
PTs w/ LV failure need to receive Enalaprilat, how do you know it’s LVF?
What is the DOC for aortic dissections?
Rales/crackles, leg edema, no JVD, fatigue, dyspnea, EJF <40%
Esmolol
What drug is the DOC for excess catecholamine excess states such as phenochromocytoma?
If troponin is greater than ___ it’s always a MI
Phentolamine; Pts presents Sx/transient HTN for 10-15m then self resolves
10
What blood thinner can be used in STEMIs?
What class drug is not used in UA?
UFH
CCBs
Statin use is contraindicated for use in ? PT population?a
What time of day is it used?
Pregnant/feeding
At night, when cholesterol synthesis is highest
What are the 3 bile acid sequestrants?
Don’t use them if ? is normal in the PT
Cholestyramine
Colestipol- must use w/ statin
In PTs w/ normal TG levels
How are PSK9 inhibitors administered?
What drug can be given to PTs for asthma/steroid reasons but may reverse anti-HTN med effects?
IM only
Naprosyn
What causes RAD?
Hypo K causes ? ekg findings?
LPFB, RVH, Lateral MI, PE, COPD
U waves, ST depression, Flat T wave
What drugs are likely to causes orthostasis and present with warning of first dose syncope?
Criteria for HTN urgency/emergency
A1 blockers- Doxa/Terazosin
RF causes what type of heart murmur?
Squatting/hand grips effect on murmur
Mitral stenosis
> ???
Valsavla effect on murmurs
ECG finding of L atrial enlargement
AS dec w/ valsalva
HOCM inc
Greater negative deflection/at least 1mm wide and deep in V1
Factor 5 Layden
Pregnant
Not contraindicated in fibrolytics
R sided HF Tx
Which mechanism best explains why excess adipose tissue leads to atherosclerosis?
BiPap Nitrate Furosimide Dobutamine- not in shock NorEpi- shock
Production of proinflammatory cytokines
