Cardio Block 2 Cram Flashcards
UA/NSTEMI Medical Therapies
BB- beneficial in acute MI O2- <90% Nitro- sublingual then IV, avoid in inf MI and Sev AS, c/i in PDE5 inhib in past 24hrs Statin- all PTs w/ ACS @ high intensity Anti-platelet- ASA for all Morphine- caution Anti-coag- UFH or LMWH
Acute Decompensated HF
S/Sxs: Exertional dyspnea, orthopnea
Dx: BNP +500
CXR: Kerley Bs, Effusion, Cardiomegaly
Tx: BiPap, Nitro, Furosemide, HOTN w/ no shock- Doubtamine/HOTN w/ shock- NorEpi
College of Cardio Staging categories
A- high risk, no Sxs/Dz
B- structure Dz w/out Sxs
C- structure Dz w/ Sxs
D- refractory HF
Why are NSAIDs avoided in HF?
Na retention Negative ionootropic effects Direct cardiotoxicity Impaired ACEI/Diuretic response Inc renal dysfunction
NYHA HF Classifications
1- ASx
2- Sxs w/ ordinary activity
3- ASx only at rest
4- Sx at rest
Nitroprusside contains cyanide ligands which can accumulate and cause toxicity which manifests as ?
N/V
Anorexia
AMS
What is the most common vasculitis in the US?
GCA
S/Sxs- monocular vision loss, unilateral HA, jaw claudication
ESR >50 but Biopsy= Dx
Tx high dose NSAID, No vision loss= prednisone PO, + Vision loss= IV Methylprednisolone
Assoicated w/ Polymyalgia Rheumatica
What maneuvers increases HCM
What maneuver decreases it?
Valsalva and Standing due to decreased venous return
Squatting- increased venous return
What are the top two most common Sxs of HCM?
First- death
Common- dyspnea, chest pain
Peripheral Artery Dz
Caused by atherosclerosis
Presents w/ intermittent claudication, cool/shiny skin and dec hair
PE: cool to touch and decreased pulses
Dx: ankle brachial index (<0.9= stenosis, <0.4= ischemia)
THESE PTS ARE REQ’D TO BE ON STATINS
What is the classic presentation of Conn Syndrome?
Primary Hyperaldosteronism- common cause of 2* HTN
HTN, Unexplained HypoK, Metabolic alkalosis
Rheumatic Fever
Hx of GAS- Strep Pyogens Infxn S/Sxs: Fever, Red lesions on trunk/extremities, Non-tender joint lumps JONES Criteria Tx: PCN/Macrolide, ASA 2 Major, 1 Major 2 Minor; 5 minor
All PTs w/ Systolic HF need to be on what 2 meds?
ACEI/ARB
BB- Metoprolol Succinate is DOC
CHADS2VASC use and score method
Estimates risk of stroke in PTs w/ A-fib
CHF, HTN, Age (75 or more=2), DM, Stroke/Clot (2), Vascular Dz, Age, Sex (F-1)
Aortic Stenosis
Old PT- calcification of trileaflet valve
Young PT- bicuspid
NARROW Pulse Press, syncope, dyspnea
Crec/Decrec Systol murmur w/ S4, can radiate to carotid
Dec w/ Valsalva
Tx w/ Valve replacement
Associations w/ endocarditis and colonic neoplasms are most closely linked to ?
Strep Gallolyticus
S. Bovis Biotype I
Aortic Regurgitation
Abnormal leaflet on proximal root
S/Sxs: CHF, Dyspnea, Fatigue
PE: WIDE pulse pressure, 5 Sign Names
Dx w/ Echo
Tx- Diuretics, Digoxin, ACEI, Na restriction
Surgery if EF <55% or end diastolic >55mm
Regardless of etiology, what med is beneficial for Sx and ASx PTs w/ reduced LV systolic function?
ACEI
Mitral Stenosis
Exertional dyspnea, Hemoptysis
Loud S1, Open Snap, Low diastolic rumble at apex
Prophylaxis if undergoing procedures prone to bacteremia
What two meds can be used in the presence of heart block to increase HR?
Atropine
Isoproterenol
A 10yr atherosclerotic CV Dz score of __% is an indication to start a statin
> 7.5%
Mitral Regurg
Dyspnea
Blowing holosystolic mrmur heard at apex to axilla
Manage: Nitroprusside, Dobutamine, Intra Aorta Bolloon, Surgery
Mitral Valve Prolapse
Non-exertional chest pain, dyspnea
Mid-systolic click w/ late systolic murmur
Dx w/ Echo
What are the first two drugs usually utilized in HF and why?
What is the only diuretic proven to improve survival in HF?
ACEI- anti-HTN, dec AL, Inhib RAAS, Prevent remodel
BB- anti-HTN, dec O2 consumption, anti-arrhythmic effect
Spirinolactone
Difference between aortic dissection and aortic coarctation BP measurements?
Dissection- low arm BP, high leg BP
Coarc- high arm BP, low leg BP
MAT
Elderly/COPD PTs
Irr/Irr w/ rate 100-200
3 different P-waves w/ 3 different PR morphologies
Tx- CCBs, O2 NEVER use electricity
1* Block
Can be caused by Digitalis, Ischemia, BBs, Inflammation, Cardiomyopathies
Regular rhythm, PR interval >0.20sec
Can also be caused by Lyme Carditis
Define the Cardiac Box
Anterior chest wall w/ highest likelihood to sustain injury from penetrating trauma: RV is most commonly injured structure
Type 2 Blocks, 1 and 2
Type 1/Wenk: irregular rhythm w/ PRs progressively longer then dropped
Type 2/Mobitz: Fixed PR interval w/ dropped beat
3* Block
From Age, Infection or Digitalis
Tx:
Sxs- Atropine, Isoproterenol
Definitice- pacemaker
WPW
Accessory path through bundle of Kent that bypasses AV node and connects atria to ventricles Triad= 1- D/up slope wave 2- QRS > 20msec 3- PR <120msec
Atherosclerosis begins with injury to the ?
Injury results from the accumulation of ? and ? leading to ?
Intimal endothelium
Lipids and inflammation causing turubulent flows and intimal damage
Alcoholic cardiomyopathy is a form of ?
What are other causes of this form of HF?
Dilated cardiomyopathy, causes systolic CHF
Coxsackie B, pregnancy, idiopathic, genetic
RBBB
Wide QRS
“Bunny Ears” V1
Wide S Led 1/V6
Define Cor Pulmonale
Most common chronic cause- COPD
Most common acute cause- Pulmonary Embolism
Causes- Amiodarone induced fibrosis, Sarcoidosis
Severe lung dz elevated pulmonary artery pressure transmits back into RV causing RV failure
Manage- R heart cath
Atypical MI presentation
Female
Elderly
Diabetic
Viral myocarditis can lead to ? which presents w/ diffusely decreased systolic function and ?
What is the most common cause of sudden cardiac death post-MI?
Dilated cardiomyopathy
Chamber dilation
Ventricular arrhythmia
LBBB
Wide QRS >120msec
Large R in V1
Neg QS or rS in V1
PSVT
Presents w/ palpitations and anxiety
HR between 120-200
Mange: Vagal, Adenosine (DOC) 6mg then 12mg w/ saline flushes
Unstable- conversion
Pathology of mesenteric ischemia is similar to ?
Atherosclerosis in stable angina affecting watershed areas
Watershed- splenetic flexure (SMA), rectosigmoid junction (IMA)
Native valve w/ IE will be due to ?
IV drug user w/ IE is due to ? microbe?
Less than a year post-valve transplant will be ?
More than a year post transplant will be ?
Strep V/Staph A
Staph A/Strep V
Strep Epidermis/Staph Aureus
Strep V/Staph A
PTs need to be in LLD to listen for ? 3 murmurs?
PTs need to stand from squat to listen for ?
MS, S3, S4
MVP, HOCM
Non-ejection mid systolic click can be what 2
Ejection click will either be one of ? 2
MVP/TVP
AS/PS
Soft heart sounds can be due to ? 4 things
Low CO
Obesity
Emphysema
Pericardial effusion
What causes a soft S2?
What causes a loud S2?
AS/PS
HTN/PHTN
What can cause paradoxical splitting?
Define S3
Define S4
LBBB, AS, HTN, V-Fib, TR, WPW
3= Rapid ventricle filling, best heard w/ bell at apex 4= Pressure overload, best heard w/ bell at apex and is ALWAYS pathological
PTs w/ MI are at risk of free wall rupture from day ? to day ? and will result in a ?
Post-MI complications include ? 2
3-14 days
Cardiac tamponade
Post-MI VSD or MR
Restrictive Cardiomyopathy
From Amyloydosis, Sarcoidosis, Hemachromatosis or TEF
Kussamal Sign, Sx of HF, peripheral edema and dyspnea
EKG= low voltage, non-specific changes
Echo= preserved systolic function
How do you determine Restrictive from Constrictive pericarditis?
Where does Loop/Thiazide diuretics exert their effects? Where does Spirinolactone exert it’s effect?
Restrictive= pericardial knock
L/T: LoH and DCT- promote K loss
S: antagonizes aldosterone, preserves K levels
What maneuver increases HOCM?
Define Spike Dome pulse
Valsalva
Double carotid pulse due to HOCM
What is the triad of aortic dissection?
Rheumatic heart disease usually affects ? valve and can lead to what 3 things?
Sharp tearing pain, BP difference between arm/leg and widened mediastinum on CXR
Dx w/ CT/TEE
MS- HF, A-FIb, Pulm Edema
ACEIs are the anti-HTN DOC for what 3 conditions?
What is the most common cause of non-ischemic cardiomyopathy?
HTN, DM, Microalbuminemia
Chagas- T. Cruzi
Ebstein abnormality have ? accessory pathway and Tx includes ?
WPW
TV repair, Ablation
What measurement can be used to guide therapeutic efficacy?
What can this measurement be used to determine the severity of ?
Pulmonary Artery Occlusion Pressu (AKA Pulmonary wedge pressure)
LV failure, MS, pathology that increases LA pressure
What is the initial approach to restoring hr in hemodynamically unstable bradycardia due to viral illness?
Inotropic support/pacing
How to differentiate MS and TS
TS is most commonly caused by ?
TS is louder during inspiration (Carvallo Sign)
RV dilation, PHTN
What 3 Sxs are indicative of severe TS?
If cardioversion is done improperly, what arrhythmia can be produced?
Pulses in neck, Pulsatile liver, Anasarca (whole body swelling)
V-Fib
What is the MOA of Nitroprusside
ANP is released due to stretch and is associated with what 2 things?
Increased cyclic GMP which activates Ca sensitive K channels in cell membrane
Inc vascular permeability, rapid fluid shift to interstitial space
LFTs need to be obtained prior to starting HF/MI PTs on what med?
MOA of Digoxin
PTs w/ digoxin toxicity present w/ ? Sxs
Statins
Inc contractility and dec AV conduction by inhibiting Na/K/ATPase
N/V/D, blurry yellow vision
Persistent dry cough from ACEI use is due to ?
What is the most serious reaction due to amiodarone use?
Bradykinin accumulation
Interstitial lung dz
Presents w/ SoB, dry cough and R side HF
AAA
What is the presenting triad?
Older male w/ smoking and HTN Hx
US to screen, CT to track progression (>4cm Q6mon, >5cm surgery)
Abd Pain, HOTN, Pulsatile mass
What screening is done on all men between 65-75 w/ smoking Hx
What is the first DOC for A-Fib in PTs w/ compensated HF?
CT for AAA
Carvedilol
What are the 6 P’s of a thromboemblism?
What is the most common site for them to get lodged?
Parasthesia, Pallor, Pulselessness, Poikilothemia, Paralysis, Pain OOP
Femoral Artery bifurcation
How is thrombophlebitis managed?
How are vericose veins Dx and Tx?
US to r/o DVT
Warm compress, NSAID, Elevation, Ambulation
Duplex US
Elevation/compression socks
What can cause Symptomatic Bradycardia
What is the sequence of treatment for bradycardia
Inc vagal tone, BB/CCBs, Digoxin
Atropine, TC Pacing, Dopamine, Epie
What causes V-Fib?
How is it treated?
Ischemic heart dz and ventricle dysfunction
Defib w/ max joules 200J biphasic
What causes V-Tach
What does it look like on EKG
E+ imbalance
Acid-Base change
Hypoxia
MI
HR >100
QRS >120msec
Loss of QS peak
How is V-tach treated?
Stable- amiodarone, lidocaine, procainamide
Unstable- conversion
Pulseless- Defib
What sign is seen w/ DVTs/
What imaging is used and how is it treated?
Homans- dorsiflex foot and squeeze calf
Sx w/ duplex, venography is gold standard
Tx w/ Heparin/LMWH
Direct anti-coag w/ Doax
What is the TIMI score method
Older than 65 3 or more CAD risk factors CAD/stenosis 50% or more ASA in past 7 days 2 or more angina episodes in past 24hrs ST change 0.5mm or more Pos cardiac marker
0-2= low 3-4= mod 5-7= high
Define Pulsus Bisferiens
Define Pulsus Parvus et Tardus
Double wave from AR and AS
Slow uprising of carotid stroke due to severe AS
Define Pulsus Alternans
Alternation in amplitude w/ cyclic dip in SBP from LV dysfunction
HTN emergency criteria and reduction goals
Eclampsia/Pheo: SBP <140 in first hour
Aorta Dissection: <120 in first hour
Non compelling condition=
Max 25% in first hour
160/100 in 4-6hrs
Normal within 24-48hrs
How is acute HTN pulmonary edema treated?
Reduce BP 20-30%
Relieve Sxs
Diuresis
IV nitro first
IV Nicradipine if pregnant/systolic dysfunction
How is cocaine/meth induced HTN emergency treated?
What med is NOT used and where else is it not used?
IV Benzos: Lorazepam or Diazepam
Labetolol, or in Tx of Decompensated HF induced systolic dysfunction
What is the most common form of cardiomyopathy
How does Takotsubo Cardiomyopathy present?
Dilated, either idiopathis or alcohol abuse
Tx w/ absenence, ACEI, Diuretics
Apical ballooning on echo w/ ST elevation and abnormal/transient wall motions
What are the JNCA8 BP recommendations?
60 or older= <150/90
Under 60= <140/90
18 w/ CKD= <140/90 w/ ACEI/ARB
18 w/ DM= <140/90
How does cardiogenic shock present?
How is it Tx?
Lethargy, Confuseion, Somnolence
Dobutamine/Dopamine, NS and O2
What is the FROM JANE acronym for endocarditis?
What causes this infection in native valves or IV drug users?
Fever, Roth Spots, Osler Nodes, Murmur, Janeway, Anemia, Nail hemorrhage, Emboli
Native= Staph A on TV IVDA= Strep or Staph on MV
How does pericarditis present on EKG?
How is it treated?
PR depression, aVR PR elevation, diffuse concave ST elevation
NSAID, Colchicine, Steroids if refractory
What causes Pulsus Paradoxus and how does it present?
Becks- muffled, JVD, HOTN
EKG w/ low QRS and alternans
Echo shows RV collapse
How is A-Fib rate controlled?
How is A-Flutter tx?
Rate control- BB
Ventricle rate +100- CCBs
(Metoprolol, Diltiazem)
Unstable= conversion
Rate control- CCB/BB then ablation
How is HOCM treated?
How does it present on EKG?
No exertion, BB, CCB, activity restriction
Large amplitude QRS, Deep narrow Q in Inf/Lat leads, Tall R in V1,V2
How is Prinzmetal treated?
Non-DHP CCBs and Nitrates
Class 1a Drugs, Uses, S/e, MOAs
Quinidine, Procainamide, Disopyramide
SVT, VT
Torsades, Lupus like syndrome
Na channel blocker, slows Phase 0 upstroke, slows conduction
Class 1b Drugs, Uses, S/e, MOAs
Lidocaine, Mexiletine
VT
Confusion, Seizure
Na blocker that shortens Phase 3
Class 1c Drugs, Uses, S/e, MOAs
Propafenone, Flecainide, Encainide
SVT, VT
Exacerbates VT, Neg Inotropy, Heart block
Na channel blockage, slows Phase 0 upstroke
Class 2 Drugs, Uses, S/e, MOAs
Propanolol, Metoprolol
SVT, A-Fib
Bronchospasm, Impotence, Fatigue
Dec Phase 4 and blocks B receptors
Class 3 Drugs, Uses, S/e, MOAs
Amiodarone, Sotalol Bretylium (IV)
SVT, VT, A-Fib
Photosensitivity, pulmonary/liver toxicity
Sota S/e= Torsades, BB effects
Blocks K channels to prolong Phase 3 and refractory period
Class 4 Drugs, Uses, S/e, MOA
Verapamil, DIltiazem
SVT, A-Fib
Brady, AV block, HOTN
Slows Phase 4 and AV conduction
Which BB are non-selective?
Which ones are B1 specific?
Propanolol, Labetolol
Atenolol, Acebutolol
Diltiazem and Verapamil are strong ? while DHPs are strong ?
What can cause constrictive pericarditis?
Cardiopressants
Vasodilators
TB, Radiation, Post-cardiotomy
How does constrictive pericarditis present on exam?
How does it present on EKG?
Ascites, Hepato/Spleno megaly, Friedrich sign- prominent Y descent more than X descent
Low voltage, flat T wave
How are Constrictive Pericarditis and Cardiac Tamponade different?
Constrictive: y > x \+ Kussmaul 1/3 pulsus paradoxus Pericardial knock Mod HOTN
Tamponade: x > y No JVP Pulsus paradoxus always No Knock Severe HOTN
How is constrictive pericarditis treated?
What is the classic quartet of Cardiac Tamponade
Diuretics, Na restriction, Pericardiectomy
HOTN, Inc JVP, Tachy, Pulsus Paradoxus
Becks- HOTN, Inc JVP, Muffled heart
What meds need to be avoided in cardiac tamponade PTs?
What causes loud/soft S1?
Diuretics and vasodilators
Loud: short PR interval, LA pressure, High CO
Soft: 1* Block, calcified mitral valve, High LV diastolic pressure, Occasionally MR
Wide fixed splitting S2 is associated with ?
What is widened splitting associated with?
ASD
RBBB, PHTN, MR, VSD
What is paradoxical splitting associated with?
Pericardial friction rub is due to what 3 events?
LBBB, AS, HTN, LV FIb, TR, WPW
Ventricle and Atrial systole, Ventricle Diastole
What are the 3 systolic ejection murmurs?
These are AKA ? and caused by ?
AS, PS, HOCM
High output murmurs:
Anemia, Thyrotoxicosis, Pregnancy, Fistula, Kids, Fever
What are the 2 high pitched diastolic decrescendo murmurs?
What are the low pitched diastolic murmurs/mid-diastolic rumbles
AR PR
MS, TS, Severe AR producing Austin Flint
What are the 4 high flow murmurs?
What are the continuous murmurs?
MR, PDA, VSD, ASD
PDA, Mammary souffle, Coronary AV fistula, Hum
What are the normal JVP waveforms and what do the mean?
A= atrial contraction, precedes carotid pulse
X= atrial relaxation
C= bulging of TB during RV diastole
X prime= descent of heart base during ventricle diastole
V= atrial filling
Y descent= atrial emptying after carotid pulse
What causes Giant A waves?
What causes Cannon A waves?
Atrial contraction against resistance
Atrial contraction against closed TV
What causes C-V waves?
What causes Sharp Y descents?
Regurgitation of blood into venous system, TR
Increased venous pressure, constrictive pericarditis
What med is used during UA/NSTEMI as a Xa inhibitor?
What is the other drug that can be used but with different MOA?
Bivalirudin
Fondaparinux- indirect Xa inhibitor w/out affecting thrombin
What is the possible s/e of lidocaine drips?
What is the most common etiology of V-Tach?
Seizures
CAD w/ prior MI?
What is a common s/e from taking Enalapril?
What is the primary advantage of using Bivalirudin instead of UFH during UA/NSTEMI?
Hyperkalemia
Less chance for bleeding
What’s the major difference in Tx between STEMI and NSTEMI?
What does the Left Main supply blood to?
Fibrinolytics are only used in STEMIs
LAD= Ant 2/3 septum, Bundles, LV anterior surface
LCX- LatPost LV, LA, SA node in 25%
What does the RCA supply blood to?
Inf/Post wall LV RA/RV Post 1/3 of septum SA node in 70% AV node PDA in 85%
Why does adipose tissue lead to atherosclerosis?
What med do we used for depressed Post-MI PTs?
Produced pro-inflammatory cytokines
Sertraline or any SSRI
What medication is not indicated for use in UA?
What cardiac conditions is associated w/ Bisferiens pulses?
LMWH, 2b/3a inhib, ASA, Clopidorgrel
NOT CCB
AR
What is the most common outcome for PTs that develop VSDs post-MI?
Dx test for AAA?
HF
Abd US
Preferred imaging modality for examining pericardial effusions?
What are the Major Criteria for blood cultures testing for IE?
Echo
2 Pos draws 12hrs apart
Persisitant Positive
Single pos w/ Cox Burnetti or IgG AB titer >1:800
What’s the most common Sxs of PTs w/ MVP?
What ABX are used to Tx IE?
Palpitations
Strep= IV PCN 12-18M units
Staph, O-susc= IV Nafcillin and
Genta/Cefazolin and Genta
Staph, O-resis= IV Vancomycin
PCN Allergy= Ceftriaxone or Vancomycin
