cardio by treatment

Question 1

Sinus Bradycardia

Answer 1

Usually none. If symptomatic: atropine

Question 2

Sick Sinus Syndrome

Answer 2

Antiarrhythmic drug for tachy, pacemaker for brady

Question 3

Junctional (Nodal) escape rhythm

Answer 3

Antiarrhythmic drug for tachy, pacemaker for brady

Question 4

Ventricular escape rhythm

Answer 4

Antiarrhythmic drug for tachy, pacemaker for brady

Question 5

1st deg AV block

Answer 5

Usually none

Question 6

2nd deg AV block: Mobitz Type I

Answer 6

Usually none. If symptomatic, IV atropine/isoproterenol. If chronic, pacemaker.

Question 7

2nd deg AV block: Mobitz Type II

Answer 7

Pacemaker, even if asymptomatic

Question 8

3rd deg (complete) AV block

Answer 8

Pacemaker

Question 9

Sinus tachy

Answer 9

Treat underlying cause or use beta-blockers

Question 10

APBs

Answer 10

Avoid precipitants (caffeine, EtOH, stress). Can use BB if needed.

Question 11

Afib (3)

Answer 11

1. control rate: BB, CCB
2. restore sinus rhythm in symptomatic pts:
   a. cardioversion via drugs (Class Ia, Ic, III antiarrhythmics)
   b. maze procedure: incisions in R/L atria to prevent reentry circuits
   c. percutaneous catheter ablation
   d. serious case: catheter ablation of AV node followed by pacemaker.
3. Anticoagulation (using CHADS2) to prevent thrombus.
   0: none or aspirin
   1: aspirin or warfarin
   2 or higher: warfarin (regular blood tests to monitor INR) or dabigatran = direct thrombin inhibitor

Question 12

AVNRT (4)

Answer 12

1. Increase vagal tone via valsalva maneuver/carotid sinus massage
2. IV adenosine, CCB, BB
3. Catheter ablation
4. Class Ia, Ic, III antiarrhythmic drugs

Question 13

Atrial Flutter (4)

Answer 13

1. Electrical cardioversion
2. Temp/permanent pacemaker rapid atrial burst pacing
3. BB/CCH/digoxin to slow ventricular depolarization, THEN use antiarrhtyhmias to slow conduction of atrial monocytes
4. Catheter ablation for chronic therapy

Question 14

AVRT/WPW (3)

Answer 14

1. Na channel blockers (Class Ia and Ic, some class III)
   NOT beta blockers or digitalis which only slow AV node and can increase ventricular rate thru accessory pathway.
2. Acute:
   a. Cardioversion (if hemodynamically unstable)
   b. IV procainamide (class Ia) or ibutilide (class III) if hemodynamically stable
3. Chronic: catheter ablation of accessory pathway, chronic oral

Question 15

Focal Atrial Tachy (3)

Answer 15

1. Remove contributing factors (digitalis?)

2. BB, antiarrhythmics, catheter ablation

Question 16

Multifocal Atrial Tachycardia

Answer 16

Tx aimed at causative disorder (severe pulm dz? Hypoxemia?)

Question 17

VPBs

Answer 17

Reassurance. If needed, BB, If serious, ICD.

Question 18

VT (2)

Answer 18

1. Acute: electric cardioversion or IV antiarrhythmic drug

2. Chronic (e.g. structural aggravating factor): ICD

Question 19

Torsades de Points (2)

Answer 19

1. If drug or electrolyte induced: IV Mg2+ to suppress repeat episodes, beta-adrenergic stimulating agents (isoproterenol) to shorten QT interval, artificial pacemaker
2. If congenital long QT: BBs and implantable defibrillator

Question 20

Vfib (3)

Answer 20

1. prompt electrical defibrillation
2. IV antiarrhythmics, ICD
3. Correct underlying source of arrhythmia

Question 21

Dilated Cardiomyopathy

Answer 21

Treat any acute exacerbation (CHF) = LMNOP
L = Lasix (furosemide)
M = morphine
N = nitrates
O= oxygen
P = position upright/ pee out excess water

Long term control:
salt restriction and diuretics 
ACEi or ARB 
Beta-blocker 
Spironolactone, digoxin or home O2 if severe dz
Prevention of arrhythmias:
amiodarone = safest for AFib 2/2 DCM. 
ICD if LVEF < 35%.
Cardiac transplant if necessary.

Question 22

Hypertrophic Cardiomyopathy (8)

Answer 22

1. Beta-blockers
2. If BB fail, CCB in caution (can reduce intravascular volume → dec LV size –> exacerbate outflow tract obstruction. Similarly, avoid vasodilators.
3. Control AFib aggressively with antiarrhythmic drugs (amiodarone, disopyramide). Avoid digitalis b/c it’s + inotropic → can worsen outflow tract obstruction
4. Anticoagulation if AFib
5. Avoid strenuous exercise
6. Pts at risk (i.e: FamHx of SCD, ventricular wall thickness >30mm, hx of syncope, hx of high-grade Vtach) should receive ICD.
7. Surgery (myomectomy) or a percutaneous septal ablation in pts that don’t respond
8. Genetic counseling

Question 23

Restrictive Cardiomyopathy (2)

Answer 23

1. Treat underlying dz (e.g. iron chelation for hemochromatosis)
2. Treat symptoms: Salt restriction, cautious use of diuretics to improve congestion

Question 24

Chronic Heart Failure w reduced EF (systolic HF)

Answer 24

ID and correction of underlying condition causing HF
Elimination of precipitating factors (arrhythmias, acute infxn, drugs)
DO NOT use CCBs (verapamil or diltiazem as they are neg inotropes)
Management of HF:
ACC/AHA treatment guidelines:
Class A: High Risk:
lifestyle, ASA, ACEi, statin, BB
Class B: asymptomatic HF:
all of the above + ICD if poor LV func
Class C: symptomatic HF:
all of above + ICD if LV systolic dysfunc (prev VTach, brady); CRT if LVEF < 35% and QRS wide
Class D: end-stage HF
all of above + inotropes, ICD as bridge to transplant, CRT as needed, LVAD/other
“Accepted sequence of therapy”-Lilly:
start w an ACEi (or H/T) + diuretic if congestive
If no ACEi, use ARB
For pts w/o recent clinical deterioration, volume overload, or other contraindication: add beta blocker

Question 25

Acute Heart Failure w preserved EF (diastolic) (4)

Answer 25

1. Warm and dry: they’re fine, do nothing, maybe diet changes 2. Cold and dry: inotropes 3. Warm and wet (LHF): diuretics + ACEi/ARB prior to goal weight, then beta blockers once not acute 4. Cold and wet (R and LHF): vasodilators, then diuretics

Question 26

Acute Pulm Edema

Answer 26

``` LMNOP L = Lasix M = morphine N = nitrates O = oxygen P = position upright ```

Question 27

stable angina

Answer 27

sublingual nitrate (nitroglycerin?) with “drug holiday” to prevent tolerance

Question 28

unstable angina/NSTEMI (3)

Answer 28

1. aspirin and/or clopidogrel or heparin, BB, CCB, nitrates. 2. If advanced: stent/bypass/angioplasty 3. Assess TIMI to decide PCI or CABG vs conservative

Question 29

STEMI (7)

Answer 29

FIRST: chewed aspirin 2. platelet inhibitor (clopidogrel or ticagrelor) 3. heparin 4. nitroglycerin (except in inferior MI-why??) 5. morphine 6. ideally, emergent PCI within 90 minutes 7. Long term: beta blocker (metoprolol, carvedilol), aspirin, ACEi, statin

Question 30

pheochromocytoma

Answer 30

phentolamine, phenoxybenzamine (alpha blockers)

Question 31

Valvular Heart Dz (4)

Answer 31

Structural → surgery Types of valves: St Jude mechanical bileaflet valve (trap door), bioprosthetic valve (eg hancock pig valve), Starr-Edwards (ball in socket), Bjork-Shiley (“toilet seat”)

Question 32

Familial Hypercholesterolemia

Answer 32

Most commonly statins + diet low in cholesterol and sat fat

Question 33

Defective ApoB

Answer 33

Niacin, statin, or ezetimibe.

Question 34

AD/AR hypercholesterolemia

Answer 34

AR: Most commonly statins + diet low in cholesterol and sat fat AD: usually doesn’t respond to statins; can offer LDL apheresis (removal of LDL similar to dialysis) or liver transplant.

Question 35

Familial combined hyperlipidemia

Answer 35

Lifestyle change, statin

Question 36

Type III hyperlipoproteinemia

Answer 36

Low fat diet, niacin and/or fibrates

Question 37

Familial hypertriglyceridemia

Answer 37

Low fat diet, niacin or fibrates

Question 38

LPL deficiency

Answer 38

Low fat diet, niacin, fibrates, omega-3

Question 39

Long QT 1

Answer 39

Beta blocker, avoid increase in HR

Question 40

Long QT 2

Answer 40

Avoid hypokalemia, avoid sudden intense situations (difficult), lifestyle changes to avoid loud alarming sound, quiet areas

Question 41

Long QT 3

Answer 41

Mexiletine, flecanide

Question 42

Brugada syndrome

Answer 42

Possibly ICD

Question 43

VSD (2)

Answer 43

Medical: digoxin/furosemide, optimize nutrition, monitor Surgical: If persistent or if develop CHF/PVR/valvular issue, repair in cath lab

Question 44

PDA (2)

Answer 44

Medical: intomethacin, ibuprofen (NSAID) to close PDA in premature Surgical: closure if develop CHF/Failure to thrive/pulmonary HTN. Cath easy.

Question 45

ASD (2)

Answer 45

Usually asymptomatic. | Surgical: closure if RV too overloaded or if pulm HTN/thromboembolism risk develops. Cath easy.

Question 46

AV canal defect

Answer 46

Always surgical, by 3-6 mo of age

Question 47

Eisenmenger’s syndrome (2)

Answer 47

Medical: Pulm vasodilators (sildenafil, etc), birth control, AVOID systemic vasodilators and exercise. Surgical: transplant

Question 48

Pulmonary atresia (2)

Answer 48

1. PGE to maintain PDA! | 2. Surgical: open PV if possible. If RV dependent coronary sinusoids, AVOID opening pulm valve- can cause MI

Question 49

Tricuspid atresia

Answer 49

Fontan surgery (bypass RV)

Question 50

Tetralogy of Fallot

Answer 50

Surgical repair of VSD and PS

Question 51

Truncus arteriosus

Answer 51

“surgical repair in infancy”

Question 52

TAPVR

Answer 52

NO PROSTAGLANDINS.

Question 53

TGA (2)

Answer 53

``` Balloon atrial septostopy (maximize atrial mixing) Surgical repair (arterial swtich) ```

Question 54

Hypoplastic left heart syndrome

Answer 54

Surgical repair: 3 procedures  heart transplant curative.

Question 55

Pericarditis

Answer 55

NSAIDs + colchicine

Question 56

Cardiac tamponade (4)

Answer 56

Pericardiocentesis, pericardial window surgery. Fluids given to maintain normal BP until pericardiocentesis can be performed. O2 to reduce workload on the heart. Treat cause of tamponade.