Cardio Block 3 Flashcards

1
Q

What are the RFs for DVT?

What are the most common findings?

A
Hx of DVT
Current CA
Stasis x 6hrs
Endothelium injury
Thrombophilia

Calf pain, Edema, Warmth, Palpable cord

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2
Q

What two tests are sufficient to positively Dx DVT?

When can a DVT be ruled in/out?

A

D-Dimer
Compression US

In: Mod/High probability, Pos compression US
Out: Low probability, Neg D-Dimer

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3
Q

What are the acquired/inherited risk factors of DVTs?

A

Persistent: age, CA, antiphosphoidal Abs, Hx of DVT/PE

Transient: recent surgery/trauma, pregnant, OCP/Hormones, imobile

Inherited: antithrombin 3 deficiency, Protein C/S
Factor 5 Leiden
Prothrombin gene mutaiton

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4
Q

When is a D-Dimer for DVT not recommended?

What blood work up result is considered after a DVT has been Dx’d?

A

Pretest probability is intermediate/high

Factor 5 levels

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5
Q

What is the gray zone of DVT Dx?

What is done to finalize the Dx?

A

Neg US
High probability

CT/MR venography w/ repeat US when D-Dimer is 500ng or higher

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6
Q

What are 5 thrombophilic disorders?

What PE finding is indicative of DVT but unreliable?

A
OCPs
Hormone replacement
Antiphospholpid Ab syndrome
Protein C/S deficiency
Hyperhormocysteinemia
Factor 5 Leiden

Homan Sign- pain w/ foot dorsiflexion

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7
Q

What is the Gold Standard of DVT Dx?

What are the 3 parts of Virchows triad

A

US

Stasis
Hypercoagulability
Trauma

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8
Q

What Tx med can’t be used in pregnant PTs w/ DVTs?

Define AAA

A

Warfarin, LMWH (Enoxaparin) is preferred

Infrarenal aortic diameter of 3cm or more

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9
Q

What are the RFs for AAA?

What is the underlying pathology?

A
FamHx
Syphillis
Men (Caucasian)
Atherosclerosis
Smoking
HTN

Oxidative stress
Aortic wall inflammation
Proteolytic degradation of elastin/collagen

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10
Q

When is US screening for AAA conducted?

When are they surgical?

A

Men 65-75 w/ smoking Hx of at least 100 cigarettes

5.5cm or more
Growth of 0.6-0.8cm over 6mon

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11
Q

When are AAAs monitored for growth?

What are they monitored w/?

A

<5.5cm or growth 0.6cm or less per year

Cereal US

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12
Q

What size of AAAs don’t/need screening?

When do these PT need to be referred to vascular specialist?

A

<3cm, no testing
3-4: Q12mon
4-4.5: Q6mon

> 4.5cm

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13
Q

What can be done for PTs w/ AAAs in attempt to reduce their rupture/surgery likelihood?

Aortic dissection involves what 2 events?

A

Tobacco cessation
BP control
LDL <70
PO BB

Intimal tear
Hemorrhagic extravasation into intima-media space

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14
Q

Aortic dissections are characterized by ? pain and the development of ?

What is the first and second line medical therapy given to these PTs after rupture?

A

Ripping/tearing
AI murmur

IV Labetolol, Esmolol
Nitroprusside

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15
Q

What are three genetic d/os that can cause protein abnormalities leading to aortic dissection?

How can dissections be viewed for Dx?

A

Polycystic kidney- polycystin
Marfans- fibrillin
Ehlers- type 3 procollagen

CT- stable
TEE- unstable

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16
Q

What type of shunt is an ASD?

When are most of these Dx’d?

A

L to R

5th decade

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17
Q

Over time, a large enough ASD can lead to what five issues

What is the classic findings of these w/ auscultation?

A
Pulmonary overcirculation
PHTN
Eisenmenger
R to L shunting
Cyanosis

Wide fixed, split S2

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18
Q

ASDs done affect ? heart structure?

What is the most common and 3 other types of ASD?

A

Coronary artery

Ostium secundum- incomplete adhesion of flap and septum
Ostium primum
Sinus venosus
Coronary sinus septal defect

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19
Q

What is the most common cyanotic congenital heart dz in childhood?

What are the four parts of this d/o?

A

Tetrology of Fallot

PV stenosis- ejection murmur
RVH
VSD, no change w/ respiration
Over riding aorta

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20
Q

What PE finding is characteristic of Tetrology of Fallot?

What makes the Tet spells worse or better?

A

Loud systolic ejection murmur
CXR of boot shaped heart
R sided aortic arch

Worse: worsened pulmonary outflow obstruction
Better: inc systemic vascular resistance

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21
Q

Where does coarctation of the aorta occur?

How can this be identified on PE?

A

Acyanotic narrowing of descending aorta at origin of ductus arteriosus

Dec femoral pulse
Brachial HTN
Systolic ejection at apex
“3 sign” aortic knob on CXR

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22
Q

What does a VSD sound like?

This is considered acyanotic alone but can be seen in ?

A

Harsh murmur louder w/ smaller defects

Tetrology
Transportation of arteries

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23
Q

What causes a PT to become cyanotic from a VSD?

What syndrome is defined by PHTN and cyanosis from pulmonary vascular obstruction secondary to large R to L shunt?

A

R to L shunt
PHTN
Dyspnea

Eisenmenger syndrome (irreversible)

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24
Q

Peripheral artery dz can represent atheroscletoic disease w/in the aortoilliac system and is then called?

How does classic claudicaton present?

A

Leriche syndrome- thigh, butt, hip pain w/ ED

Replicated w/ exercise
Relieved w/ rest

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25
What is the most common site for claudication from peripheral artery dz? What derm changes can be seen on PE?
Calf Cool, shiny skin w/ dec hair
26
What is a late PE finding of peripheral artery dz? What measurement can be taken for Dx purposes?
Resting pain Ankle brachial index <0.9= >50% stenosis <0.4= ischemia
27
Pregnant PTs w/ DVTs are usually Tx how? Although controversal and not recommended, how can these PTs LMWH levels be monitored?
Therapeutic anticoag x 6mon 6wks post-partum Anti-Xa
28
UFH use requires what lab monitoring? PTs w/ Coarctation and have the PDA closed may present w/ ?
aPTT Circulatory failure Shock
29
In many PTs, coarctation of the aorta occurs ? What feature does this anomaly allow?
Juxtaductal, adjacent to PDA Widens juxtaducta area of aorta so blood can flow forwards from LV
30
What are the 3 types of coarctation?
Preductal- narrowing proximal to ductus arteriosus, seen in Turners. Ductal- narrowing at insertion of ductus arteriosus, appears when ducts closes. Postductal- narrowing distal to ductus arteriosus and most common in adults
31
What medication can be used to maintain the patency of a ductus arteriosus? What is the etiology of acquired cases of aortic coarctation?
Alprostadil, prostaglandin E1 Takayasu arteritis
32
PTs w/ Turners and coarctation generally develop what two compensation mechanisms due to the coarctation? What are the classic PE findings?
LVH, collateral flow around lesion Systolic HTN Diminished/delayed femoral pulses
33
How do adults/older kids w/ aortic coarctation present in clinic? What are the initial diagnostic studies conducted?
Chest pain Cold extremities Claudication Continuous murmur over L anterior chest or L midline back EKG, CXR, Echo
34
In most PTs w/ coarctation, how is the Dx established? What further test will adults possibly need?
Echo w/ doppler MRI/CT
35
What are 3 common complications of aortic coarctation who don't have surgical correction? Adults w/ unrepaired coarctation are at increased risk for what other vascular d/os?
Accelerated CAD Dissection Stroke HF Intracranial aneurysm
36
What is the genetic map of Tuners? What genetic cardiac differences do Turners present w/?
45,XO Bicuspid aorta Coarctation
37
How does coarctation appear on EKG? What surgical procedure corrects this?
LVH- Scott Criteria +35mm Balloon angioplasty Stent placement Surgical correction
38
What is Well's Criteria for PE? What is the PT has a Hx of DVTs?
``` CIB LTS SPC AD Cancer Immobile Bedridden x 3days/major surgery in past 4wks Leg tender/swelling >3cm Pitting edema Collateral veins Alternative Dx (-2pts) Low= 0 Med= 1-2 High= 3 or more ``` Given 1pt DVT likely= 2 or more pts DVT unlikely= 1 or less
39
What is the preferred Dx modality for PTs w/ suspected PE? What is the next best test if PTs kidney can't handle contrast?
CT angiogram of chest D-Dimer- not needed if mod/high probability exists
40
# Define DeBakey Type 2 dissection? What is NOT a RF for AAA
Dissection in only ascending aorta Female gender
41
What systemic Dz may actually be protective against AAA? If PT receives PGE-1 infusion for PDA maintenance, what are common s/e and two things needed on stand by?
DM ``` Apnea Prophylactically intubate HOTN Hyperpyrexia FPP Anti-seizure meds ```
42
What medication is used to close PDAs in premature infants? What PO anti-coagulants can be used for PTs w/ A-fib?
Indomethacin (prostaglandin inhibitor) or Ibuprofen Direct thrombin inhibitor Factor Xa inhibitor
43
What is the most serious complication that can arise from A-Fib? What diameter do vessels need to be for veins to be classifed as varicose?
Thromboembolism >3mm
44
What is the CHA2DS2VASc criteria? Peripheral artery dz is associated with 3 RFs?
CHF HTN Age >75 DM Stroke Vascular Dz Age 65-74 Sex, female Smoking, DM, Age Atherosclerosis
45
What are c/i to lower limb vericose vein ablation therapy? How are vericose veins dx and how are they Tx?
``` Pregnancy Thromboembolism Mod/Sev peripheral artery dz Joint dz affecting mobility Congenital venous abnormality ``` Duplex US Compression/elevation
46
What is the most common systemic vasculitis in the US? This Dz almost never presents before ? age
GCA 50y/o
47
How do PTs w/ GCA present? How is it Tx?
Amaurosis Fugax Claudication in jaw HA No vision loss- pred Vision loss- Methylpred
48
What PO anti-coag is similar to Warfarin but doesn't require monitoring? Define Kussmaul sign
Dabigatran Inc of CVP rather than decrease from R sided HF
49
Kussmaul signs are frequently seen in PTs w/ ? two issues Periodic BP measurements should be a part of routine preventative health assessments starting at age ?
Constrictive pericarditis RV infarction 3y/o
50
What is the most appropriate initial medication for Diabetics w/ HTN? What is the most common cause of Secondary HTN?
ACEI Renal parenchymal Dz
51
HCM is characterized by ? What movement reduces/increases AS?
Medium pitch, mid-systolic murmur decreasing w/ squatting/inc w/ straining Dec w/ Straining Inc w/ Squatting
52
How is MR characterized? What is this type of murmur rarely associated w/?
Blowing systolic murmur radiating to axilla Syncope
53
How is PS characterized? Acute MI frequently presents w/ what 2 Sxs and rarely w/ what 2?
Widely split S2 Not changed w/ maneuvers Frequent: Chest pain, SoB Rare: Fever, Myalgia
54
Restrictive pericarditis is most commonly from ? and shows ? on Echo What study is useful for establishing Dx/pathway of complex arrhythmias including SVT?
Amyloidosis Impaired diastolic Electrophysiology
55
Thiazide diuretics are most likely to cause ? E+ disturbance? What medication needs to be avoided in PTs w/ WPW?
Hypokalemia Digoxin/CCBs- dec refractory, inc AV node refractory causing faster ventricular rates
56
What are two findings seen in central retinal artery occlusions? What is seen in chronic HTN PTs?
Cherry red fovea Boxcar segmentation AV nicking
57
What is the first finding that can indicate worsening CHF? What is the major predisposing risk factor to the development of A-Fib?
Inc in weight during daily checks MS
58
What drugs are most likely to cause a Lupus-like reactions and pericarditis? What are examples of causes of high output HF?
``` Procainimide Hydralazine Methyldopa Isoniazid Phenytoin ``` ``` Reduced systemic vascular resisitance in: Thyrotoxicosis Animia Pregnancy BeriBeri Pagets Dz AV malformation ```
59
What is the most common cause of acute arterial occlusion in the upper extremities in adults over 40y/o? PTs w/ Marfans frequently/rarely have what 2 cardiac conditions?
Thoracic outlet syndrome Common: MVP, AR Rare: RAE, PS, VSDs
60
What are the major criteria for the Dx of Marfans? What are the absolute c/i to giving thrombolytic therapies?
Ectopia lentis Aortic root dilation Aortic dissection ``` Hermorrhagic stroke Stroke in past 1yrs Intracranial neoplasm Internal bleeding, actively Suspected dissection ```
61
How is renal artery stenosis identified? How does primary aldosteronism affect E+ balances?
Abnormal radionuclide uptake in affected kidney High Na Low K
62
What is the only E+ loss that effects Digoxin metabolism? Revascularization of the Left Main artery is indicated when stenosis is greater than ?
K loss 50%
63
What type of ventricular arrhythmia leads to death? What is the TOC for these PTs?
VT Inplanted Defib
64
What type of physiological cahnge/shift can predispose Pts to skin ulcers?
Leaking fibrinogen/GF into interstitial space Leukocyte aggregation/activation Loss of cutaneous lymphatic network
65
What is the definitive Tx to correct MR from papillary muscle rupture? What PT population has the highest risk for HTN?
MV replacement Black, non-hispanic
66
AHA recommends what PTs receive ABX prophylaxis? PTs w/ prosthetic MV or AV should keep INR between ?
Prosthetic heart valves Heart transplant w/ valve dz Un/repaired cyanotic CHD MV: 2.5-3.5 AV: 2-3
67
What heart measurement is an indirect measurement of the left atria filling pressure? What is a classic finding of cardiac tamponade?
Pulmonary capillary wedge pressure Pulsus paradoxus
68
What is the last in sequence of events to occur in peripheral artery dz? What Sx usually precedes this finding?
Arterial ulcers, usually in feet/areas of pressure Claudication
69
When do venous ulcerations typically develop? What is the most common location for these to develop?
Secondary to venous incompetence/chronic edema Medial ankle
70
What trifecta leads to diabetic ulcers? HPV is commonly associated with ? but not ?
Atheroscleorsis Arterial insufficiency Diabetic neuropathy Venereal warts Myocarditis
71
What 2 viruses are most commonly associated with myocarditis? What two are most likely to cause pericarditis?
Coxsacie Echovirus Coxsackie CMV
72
How does LVH present on EKG? Is coarctation cyanotic or acyanotic?
Tall R in Lead 1, aVL Deep S waves Poor R wave progression Scotts criteria- 35mm Acyanotic
73
What is the NYHA HF classifications? What is the College of Cardiology staging crtieria?
1: ASx 2: Sx w/ normal activity 3: Asy only at rest 4: Sxs at rest A: high risk, no Sx/Dz B: Dz w/out Sxs C: Dz w/ Sxs D: refractory heart failure
74
What medication could be given to PTs w/ coarctation and HTN? How would COPD w/ cardiac strain present on EKG?
ARB- protects kidneys Tall R waves Deep S waves RAD Tall P waves
75
What is a normal pulmonary artery systolic pressure value? Define Cor Pulmonale
25mmGH HF secondary to lung Dz
76
Lung Dzs are a cause of ? sided HF What strong CCBs are used in PTs w/ Raynauds?
R Verapamil Diltiazem
77
How does an atrial myxoma present? What heart issue does this mimic?
Inducible diastolic murmur w/ bending over, disappears w/ sitting up MS
78
Loud P2 is always indicative of ? What are the 5 categories of PHTN?
PHTN 1: idiopathic, CT Dz, CHD, pulmonary arterial HTN 2: result of L sided HDz 3: lung dz/dec O2 4: occlusion of pulmonary vasculature 5: unclear mechanism
79
Which categories of PHTN can be Tx with meds? What has to be done prior to conducting CT angiogram, what is the f/u exam if PT is ineligible for this?
1 and 4 CrCl/BUN VQ scan
80
PHTN causes ? looking feature seen on pulmonary angiography? What meds are used to treat PHTN?
"Pruned tree" vasculature Endolthelium blockers- prevents dilation Prostacyclin- causes dilation PD-5 inhibs- Sildenafanil (viagra/cialis)
81
Sildenafil can't be used within 24hrs of ? What are two risks of femur Fx?
Nitro Fat embolism Blood loss
82
Sympathetic responses to the CV system travel through ? vertebral structures? Contusions of the heart are Tx like?
From medulla to T1-5 Myocarditis
83
What would the troponin levels be if they're from a PE etiology? What drugs are used for triglyceride lowering therapy?
1-10 Fibrate- Gemfibrozil
84
Diabetics w/ HTN should be put on one of what two ACEIs? PTs that are cold/clammy, confused, HOTN, and tachy have ? type of shock?
Enalapril Lisinopril Cardiogenic
85
What would be two hallmark findings of a PT suffering from anterior wall MI? What would be seen if they were having an inferior wall MI?
Tachy, HOTN Brady, HOTN
86
What drug is used in intubated PTs that are suffering from HOTN? What is the best way to monitor cardiogenic shock resuscitation? What drug can be added to inc one of these monitored indicators?
Dobutamine Ins and Outs, especially outs NorEpi
87
What is the most common cause of the development of a prominent S4? What type of genetic issue is HOCM that usually causes mutations in the development of ?
HTN Autosomal dominant Myocardial contractile apparatus
88
What are the only two holosystolic, blowing murmurs over the sternum w/out radiation? What drug is given to PTs Dx'd w/ MRSA IE?
TR, VSD VSD won't change w/ inspiration IV Vancomycin
89
What microbe is the most common cause of IE in the US? What is given to PTs as a endocarditis prophylaxis prior to dental procedures?
Strep Viridians Amoxocillin
90
What is the most likely Dx for PTs w/ wide pulse pressure? AVRT= ?
AR WPW
91
What type of lesion is Hypoplastic Left heart Syndrome? What would be heard on PE?
Cyanotic, no LV Loud P2 Hyperactive precordium from large RV
92
What drug can be used to keep PDA open in PTs w/ Hypoplastic Left Heart Syndrome? What can be given to inc their BP?
Alprostadil older than 12mon surgery repair Dopamine
93
Normally, PDA connects ? to ? What treatment needs to be avoided in PDA PTs?
Aorta Pulmonary artery O2
94
What EKG abnormality is associated w/ ADS? ASDs smaller than ? close sponataneously
RBBB- rabbit ears <8mm
95
What is the most common cardiac congenital abnormality in adults? What is the most common one in infants?
ASD- acyanotic VSD, membranous
96
What are the 4 types of VSDs? VSDs that don't are Sx and cause CHF receive ? med?
Membranous Muscular AV canal Outlet septum Furosemide
97
What is the most common cardiac issue seen in Down's? Define Hyperoxia test
A-V Canal ABG is drawn >200g- Cardiac Dz unlikely 50-150- mixing lesion (truncus, tricuspid atresia) <50- two circuits w/ mixing
98
What are the two cyanotic lesions that will be on the test? What are 3 others that will be distractors?
Transposition Tetralogy Truncus arterious Tricuspid atresia Anomalous pulmonary venous
99
What is the timeline from Dx to fixing of transposition of the vessels or death will occur? How do you ID transposition on an x-ray?
6hrs "Egg on a string" w/ Pt being cyanotic
100
Kids w/ tricuspid atresia usually also have ? RV failure is also associated w/ ? finding on PE?
VSD Heave
101
What is the whole issue of Tetralogy? What is the condition called if an ASD is added to the tetrology?
PS Pentology of Fallot
102
How does uremic pericarditis present? How is it Tx?
High Cr/BUN EKG- ST elevation, PR depression in multiple Dialysis
103
PT w/ HOTN/Tachy is in ? shock PT w/ HOTN/Brady is in ? shock
Cardiac Neurogenic
104
Where does PHTN show on EKG? What changes this to Cor Pulmonale
Large P-waves on Lead 2 Edema JVD Loud P2
105
Why would a 30 year old PT who smokes already have COPD? What needs to be looked for on PE for obstructive sleep apnea?
Alpha-1 trypsin Dz ``` Mallampati score of 3 1- complete visualization of soft palate 2- complete visualization of uvula 3*- visualization of only base of uvula 4- soft palate not visible at all Polysomnograpy ```
106
PT experiencing pain around an IV site w/ not streaks/heat has a ? How is it Tx?
Thrombophlebitis Warm compression NSAIDs
107
Where are acute thrombo embolisms created and thrown from? PT w/ CTA showing numerous PEs would be classified as ?
A-fib, Left atria Group 4
108
Restrictive pericarditis will have ? EF and is usually caused by ? How does Takosubo's look on Echo?
Preserved Sarcoidosis Apical ballooning
109
How do you Dx Rheumatic heart Dz? PT w/ calf pain when walking can have an expected ankle brachial index below ?
``` JONES J- large O- carditis N- nodules E- erythema marginatum S- synchorea ``` 0.9
110
PT w/ low brachial ankle index needs to have ? issue r/o Examining new born who is cyanotic, palpation of the chest produces heave, what needs to be done for ? issue
CAD Bring knees to chest Tetrology
111
PT w/ CA, abdominal ascites, significant LE edema, no change of JVP w/ inspiration. CXR reveals calcified ring around heart is ? What is the most important initial therapy for vericose veins?
Constrictive pericarditis Compression
112
What is the difference in available studies for PTs w/ suspected dissections? All STEMI PTs get ?
HTN- CT HOTN- no scans Caths
113
What drug is most associated w/ causing TR? What other cardiac anomaly is associated w/ TR?
Lithium Epstein anomaly
114
PT w/ brachial index of 1 and claudication needs to have what 2 steps done for Tx?
Statin | Low ABI= Exercise stress test to rule CAD in/out
115
An vessel needs to be stenosis _% in order to be symptomatic? What drug is used for, and only for, peripheral artery dz?
71% Pletal (Cilostazol) Vasodilator
116
BNP will be artificially low for what two issues? PT w/ bilateral claudication in thighs/calf/feet will most likely have occlusion in what area?
Body fat Pericarditis Thighs: abdomen Calf: popliteal Feet: tibial artery
117
What is the criteria for using Dobutamine? What are the most common causes of cardiogenic, neurogenic, hypovolemic shock and criteria?
HOTN Cardiogenic shock Exhausted all other options Volemic- fluid
118
How does pericarditis present on EKG? What drugs do are used to Tx and prevent reoccurence?
Diffuse ST elevation (+1mm) PR depression Concave ST upslope Pathognomonic for pericarditis Tx: NSAID (Indomethacin) if viral Prevent: Colchicine ASA if acute/Dressler's Steroids- refractory to NSAID, Colchicine, ASA (anaphylactic reaction to ASA= straight to steroid)
119
What is the sequence of changes seen on EKG during a MI? What happens with a prolonged QT interval?
Hyper acute T waves ST depression ST elevation Q wave development Torsades
120
``` What leads are high lat? What leads are inferior? What leads are septal? What leads are anterior? What leads are lateral? ```
``` 1, aVL- diagonal 2, 3, aVF (RCA) V1, V2- (LAD), posterior= RCA V3, V4- LAD V5, V6 (LCX) ```
121
What is more common, NSTEMI or STEMI? What are 3 things that can cause an ST depression?
NSTEMI- 70% of MIs in US Digoxin Ischemia Hypo-K
122
Inferior MI in 2, 3, aVF will have reciprocal changes where? What is the next step after these are confirmed?
1, aVL R sided EKG
123
What two medications can be given during brady/instable PTs? What is the TOC for confirming/Dx dilated cardiomyopathy?
Atropine/Isoproterenol Trans thoracic echo
124
What are the 3 types of restrictive cardiomyopathy? What will be seen on CXR and how is it Dx?
Amyloidosis Sacroidosis Hemchromatosis Normal x-ray Biopsy
125
What can be given to PTs w/ sarcoidosis induced cardiomyopathy? What is the most and second most common location for hypertrophy to occur in HCM?
Steroids Septum LV
126
What will be seen on CXR of HCM? What is the TOC for Dx?
Normal heart Doppler Echo
127
What 3 things are avoided in PTs w/ HCM? What can be used?
Digoxin Dilators Exertion CCBs, BBs, amiodarone for arrhythmias Improve diastolic function
128
Normal sinus rhythm has upright P-waves in what leads? What is a normal sinus, junctional and ventricular rate?
1, 2, 3, aVF Sinus: 60+ Junction: 40-60 Ventricle: 20-40
129
How do you figure out max tachy rate? What is a common cause of tachy, narrow complex rhythms?
220-age Hypovolemia
130
How is A-Fib Tx? How is A-flutter Tx?
Vagal, Adenosine, CCB/BB, conversion A1 meds- Procainamide/Quinidine Amiodarone Conversion
131
What med is used for Torsades if the Qc is normal? What is used if the QTc is prolonged?
Lidocaine Mg Sulfate
132
Sequence of drugs for wide complex V-Tach When are PDAs necessary for life?
Procainamide Amiodarone Lidocaine Tetrology Transposition of vessels
133
What do different BNP levels mean" What is the sequence of Tx of HF?
<1000: unlikely decompensated CHF >500: likely decompensated 100-500: uncertain Ventilation Tx dysrhthmias Reduce PL- nitro, loop, morphine Reduce AL- nitro, ACEI, prussie
134
What are the 3 parts of HF?
Inc PL Inc AL Dec contractility
135
JNC8 BP goals
60+ <150/90 59- <140/90 DM/CKD: <140/90 White: Thiazide, ACEI/ARB, CCB Black: Thiazide, CCB CKD: ACEI/ARB
136
What causes 95% of HTN? What are the causes of Secondary HTN?
Essential HTN- no identifiable cause ``` Renal/VascularDz Obstructive sleep apnea Pheo Estrogen Steroids Drugs Coarctation- kids* Cushings Hyperaldosteronism ```
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What are the first two meds given for HTN control? What is the last resort?
ACEI- first in CKD/DM CCB- amlodipine BB
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DOC for neurologic HTN DOC for dissections
Nicardipine/Clevidipine Labetalol Esmolol Nitroprusside Metoprolol
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DOC for acute MI HTN DOC for acute HF
Nitro Esmolol Metoprolol Nitro Furosemide Nitroprusside
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DOC for renal HTN DOC for pregnancy HTN
Nicardipine/Clevidipine Labetolol Fenoldopam Hydralazine Labetolol Mg sulfate- pre/eclampsia
141
What does the acronym SHOCKD mean What is the Metabolic Syndrome
``` Causes of shock Sepsis Hypovolemia Obstructive Cardiac Kortisol Distributive ``` ``` Inc risk for atheroscleortic Dz, having 3 of: Obesity TG >150 HDL <40/<50 in female Fastin glucose >110 HTN- BP >140/90 ```
142
Old person exercising and has syncope is most likely due to ? What if they're young?
AS WPW, HCM
143
What 4 systemic factors increase Metabolic Syndrome risks for dz? Time for rise, peak and normal for myoglobin, CK-MB and troponin
Lupus RA HIV CKD M: 1-3h, 6-8h, 12-18h C: 3-6h, 18-24hr, 48-72hr T: 4-6h, 18-24h, 7-10day
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Difference Type A/B dissection Chart on
``` A= proximal/ascending aorta, surgery B= distal aorta, medical therapy ``` Pg 64
145
What Txs are given to PTs w/ venous thrombosis? When is a D-Dimer ordered?
LMWH, Coumadin Low risk DVT Mod/High= US
146
Rheumatic fever is associated with ? valve issue? Define Austin Flint murmur
MS Early diastolic decrescendo from AR Wide PP, hypoperfusion (HOTN) Thick LV on CXR
147
What does IVDA do to the TV? What drug is added for IE from a Gram Neg organism but can't be given alone?
TS Gentamicin
148
What's the difference of areas affected between myocarditis and pericarditis? What is Beck's Triad?
Myo: transmural Per: only pericardium Tamponade: Muffled sounds JVD HOTN
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ASD is common w/ ? type of block? VSD is common w/ ? type of block?
RBBB (rabbit ears) Fixed split S2 Mid systolic ejection murmur LBBB (Deep S in V1, High R in V6) Constant machinery
150
What microbe is likely to cause pericarditis in ImmComp PTs around the world? Dressler's can appear up to _wks after MIs
TB 12wks
151
What two drugs can cause pericarditis but w/out Lupus like syndrome? What is the pathological process behind pericarditis?
``` Anthracycline antineoplastics (Doxorubicin, Daunorubicin) Minoxidil ``` Dilation, inc permeability, leukocyte exudation, fibrin deposit, inflammation, dec space
152
What type of pericarditis has the highest mortality of almost 50%? What are 4 types of acute pericarditis?
Purulent Serous- thin exudate Serofibrinous- bread/butter Suppurative- bacterial, inflammation Hermorrhagic- TB, cancer
153
What medication is c/i during acute pericarditis? How long does this med stay in circulation after d/c?
Warfarin 5 days
154
What are four things that can cause friction rubs on exam? 10% of PTs w/ pericarditis can present with a normal ?
Pericarditis Tamponade Myocarditis Pleuritis EKG
155
All pericarditis PTs get what three things? What labs are ordered?
CXR, EKG, Echo CBC, ESR/CRP, Enzymes Fever= culture PPD/HIV- if not done ANA/RF- suspected rheumatoid d/o
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Transition from effusion to tamponade occurs around __mL of fluid What are three conditions that can cause pericardial effusion?
>250mL Inc permeability: hypothyroid Inc hydrostatic press: CHF Dec oncotic press: cirrhosis
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How long after an MI can a free wall rupture occur and cause an effusion? What does pericardial effusion do to JVP?
3-5 days Inc w/ dominant x-descent
158
Hiccups longer than ? are pathological for ? How do pericardial effusions look on EKG?
6wks Effusion from irritation of phrenic nerve Flat T, low voltage
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What is the first Dx/TOC for pericardial effusions? Pulsus paradoxis is more indicative of a ?
Echo Tamponade
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Pathophysiology of tamponades cause what two events? What does a tamponade do to the JVP?
Inc atrial pressure, dec venous return Inc ventricle pressure, dec diastolic filling Loss of Y descent
161
What findings make you think of a tamponade from malignant effusion?
Tamponade w/out inflammatory signs
162
What is the difference in lab results for pericardial effusion from exudate or from transudate?
``` Ex: malignant, infection, CT d/o (external) SpecGrav >1.015 Protein >3 Serum/protein >0.5 Serum/LDH >0.6 Serum/glucose<1.0 ``` Trans: hypothyroid uremia radiation trauma Opposite of Exudate
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How can you Tx cardiac tamponade? What drug is used to prevent recurrence of constrictive pericarditis?
Inc fluids to stretch heart Pericardiocentesis Colchicine
164
Constrictive pericarditis mimics ? What is the initial and definitive way to Dx?
R sided HF TTE Biopsy CMR to determine constrictive vs restrictive
165
What PE findings would be seen in PTs w/ constrictive pericarditis? How does this present on EKG/CXR?
Precordial knock before S3 EKG: ST/T-wave changes Tachy, Low voltage, A-Fib CXR: calcifications, minimale silhouette enlargement
166
What image is ordered to assess pericardial thickness? What is ordered to differentiate effusion from scarring?
CT MRI
167
What does cardiac cath allow for PTs w/ constrictive pericarditis? What is the only effective Tx for severe/chronic cases?
Biopsy Definitive distinction between constrictive/restrictive Pericardectomy
168
All CA PTs are hyper-? What is HF from pericarditis?
Coagulable Myocarditis
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The more ? a thrombus is, the more dangerous it is Define Phlegmasia Cerulea dolens Define Phlegmasa alba dolens
Proximal PCD: cyanotic hue PAD: pallor w/ edema
170
What labs are ordered for DVT work ups? What test has the highest sensitivity/specificity for DVTs, but which one is 100% accurate?
``` PT and PTT CBC w/ platelet Renal/LFT UA D-dimer ``` Doppler US Venography but invasive
171
Venous thromboembolism is ?+? What is the Tx of choice of VTEs?
PE + DVT LMWH* (Lovenox) UFH (needs PTT monitoring) Xa inhib- Fondaparinux* PO Factor Xa inhib- Rivaroxaban
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LMWH/Fonda use overlapped w/ Coumadin has to occur for at least ? days When can you d/c one of the meds?
5 days, remains for 5 days after use D/c LMWH/Fonda on day 5/6 if INR is in range for two days
173
What platelet level indicates HIT and need to stop heparin? What are the only two issues with using Rivaroxaban?
<100K/microl Similar to warfarin but, BID dosing for 3wks then one/day (don't give to forgetful/incompetent PTs, use Coumadin) $
174
What is the reversal agent for Rivaroxaban? Embolic strokes can only occur in the ?
Andexxa Brain
175
Why is LMWH superior to UFH on inpatient settings? What criteria must be met inorder for PTs w/ VTE to be Tx on outpatient basis?
Reduces mortality and bleeding risks Stable/normal VS Low bleeding risk No severe renal insufficiency- normal Chem 7 System in place for LMWH use and monitoring Surveilance/Tx of recurrent VTEs
176
What is the Chem panel set up and data inputs?
Na Cl BUN K HCO3 Cr At the end= Glucose
177
How long is Coumadin used when Tx DVTs? When is an IVC filter used?
3-6mon Anticoags are c/i Recurrent embolism w/ anticoag therapy Recurrent embolism w/ PHTN Urgent surgery w/out time for anticoag
178
What is done for PTs suffering from a TIA? What med has the highest effect on lowering TGs?
Give ASA, Dipyridamole Admit to stroke unit Fibrinates- Gemfibrozel
179
Strep infections lead to ? and will present w/ ? murmur PT getting dental Tx and has to stop Warfarin, what is the next step?
MR- diastolic decrescendo murmur at apex No bridging is necessary
180
Old PT w/ lower extremity skin changes and discomfort relieved w/ elevation will have what PE finding? Fist Sx/complain of AS
LE edema Dyspnea
181
Tx for V-Fib What is the most common congenital heart Dz?
Defib VSD
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Who is classified as a medical PT and can be Tx for DVTs on outpatient basis?
Previous VTE Ca Immobility Inherited/acquired hypercoag
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What DVT prophylaxis drug can be taken PO w/out inc bleed risk? Arterial thromboembolism will present w/ ? Sxs
Rivaroxaban Pain Paresthesis Pallor Absent pulses
184
Suppurative phlebitis w/ fevers and chills is called ? Define Trousseau Syndrome
Suppurativel thrombophlebitis Migratory superficial thrombophlebitis associated w/ adenocarcinomas
185
Most common location for superficial thrombophlebitis to occur? What PT population gets lipodermatosclerosis?
Great saphenous vein DM
186
What is the difference between pulse/no pulse in veins/arteries that are varicosed? Varicose vein Tx is best with ?
Pulse= problem in vein No pulse= problem in artery Sclerotherapy
187
What is the most common vascular d/o If vascular pain is better w/ walking then its ? where if it's worse w/ walking then its ?
Chronic lower extremity venous dz Better- vein Worse- arteries
188
What can PTs w/ chronic venous insufficiency do to improve their Sxs? What is pruritus in the LE indicative of?
Limb elevation Walking Chronic venous insufficiency
189
All PTs w/ chronic venous insufficiency/ulcers need to be on ? med What causes lymphedema?
ASA Primary: High protein content Secondary: Filarisis (MC)
190
What is the only issue we've covered that has non-pitting edema? What has to be avoided with this condition?
Lymphedema Limb injury
191
What happens to untreated lymphedema? What is Beurger's Dz
Resistant to Tx due to subcutaneous fibrosis Vascular Dz in chronic smoking involving both arteries and veins leading to foot claudication Triad: ??? Thromboangitis obliterans
192
? heart murmur isn't pathological in early life? MOA of Gemfibrizil Aortaenteric fisutal
Systolic Activates lipoprotein lipase to increase VLDL clearance MC seen on duodenum from AAA complication
193
What are the three processes leading to peripheral artery dz? What causes plaque?
Structure changes Lumen narrowing Spasm Tear, macrophages, foam cells
194
What is the time frame from arterial occlusion to surgical management? What type of injury starts the peripheral artery disease etiology?
<6hrs or irreversible ischemia Endothelial dysfunction
195
What PE finding would be seen if the popliteal artery is occluded 90%? What questionnaire is used for peripheral artery disease screening?
Muscle atrophy Ulcer Edinburghs
196
What are the 6 Ps of PADzin order? What is the time frame to correct it?
Pain Pallor Paresthesia Paralysis Poikilothermia Pulselessness 6hrs
197
Aortailiac occlusive dz Common femoral artery
Butt hip thigh Thigh and/or calf
198
Superficial femoral artery Popliteal artery
Upper 2/3 calf Lower 1/3 calf
199
What are the 4 acyanotic lesions? What is the only type of ASD that does not have RAD?
ASD PFO VSD PDA Ostium primum- LAFB
200
What is the Dx test for ASD? PTs w/ ASDs can't do what recreational activity?
Echo- primary test for Dx Bubble study Scuba dive
201
Why do infants w/ VSD have failure to thrive? If PT w/ VSD has a new diastolic murmur, what is it?
Large heart pressing on esophagus interferes w/ feeding R to L shunt from increasing pulmonary pressure