Cardio EM part 2

Question 1

atrial fibrillation is characterized by about how many atrial depolarizations per minute? what ventricular rate is typically seen?

Answer 1

400-600 depolarization/minute

ventricular rate 120-180

Question 2

if your patient with atrial fibrillation is not hemodynamically stable, what should your first priority be?

Answer 2

DC cardioversion

Question 3

what are three major consequences of prolonged atrial fibrillation

Answer 3

1) thromboembolism
2) hypotension and decreased organ perfusion (decreased EF)
3) pulmonary congestion

Question 4

untreated atrial fibrillation that lasts for 48-72 hours puts you at risk for what?

Answer 4

thromboembolism

Question 5

if hemodynamically stable, what is the initial goal? how do we treat?

Answer 5

rate control

IV diltiazem effective for rapid control (slows AV node)
alternative: IV beta blocker (esmolol)

Question 6

if atrial fibrillation is present for over 48-72 hours, how will you manage your patient? (3 steps)

Answer 6

1) fully anticoagulate for 3 weeks (coumadin)
2) cardioversion 3 weeks after initiation of coumadin
3) continue anticoagulation for one month

Question 7

your patient has had atrial fibrillation for 72 hours. you perform a TEE and rule out the presence of a thrombus. what should you do next?

Answer 7

you can skip the anticoagulation phase

jump straight to DC cardioversion

Question 8

if your patient does not wish to undergo DC cardioversion or take oral medications to control their a-fib, what is the alternative?

Answer 8

ablation (both acceptable)

Question 9

what is the IV medication that has been approved for rapid conversion of recent onset atrial fibrillation and flutter? how effective is it?

Answer 9

ibutilide, 45-50 percent effective

Question 10

what is the main difference in treatment of a hypertensive urgency vs. hypertensive emergency?

Answer 10

hypertensive urgency = warrant BP lowering over a few hours

hypertensive emergency = warrant BP lowering within 1 hour

Question 11

what are some examples of hypertensive urgencies vs. hypertensive emergencies?

Answer 11

hypertensive urgencies = high BP over 200/100 with optic disc edema, progressive target organ (kidney, heart) complications, perioperative HTN

hypertensive emergencies = hypertensive encephalopathy, hypertensive nephropathy

Question 12

HA, irritability, confusion, altered mental status in your hypertensive patient characterize what emergency?

Answer 12

hypertensive encephalopathy

Question 13

hematuria, proteinuria, progressive kidney dysfunction and necrosis may be signs of what?

Answer 13

hypertensive nephropathy

Question 14

when is the only circumstance that you would consider lowering BP in your patient who is having an acute ischemic stroke?

Answer 14

if the BP is over 200/110

brain will auto-regulate perfusion

Question 15

when lowering blood pressure, you should lower it no more than ___ percent within 2 hours, then more gradual lowering over _____ hours to a goal of ______

Answer 15

no more than 25 percent within 2 hours

gradual lowering over 2-6 hours to BP of 160/110

Question 16

what can excessive lowering of BP lead to?

Answer 16

coronary, cerebral, renal ischemia

Question 17

what is the one exception that does require aggressive lowering of BP?

Answer 17

acute aortic dissection

Question 18

what are two calcium channel blockers used to lower BP during a hypertensive urgency/emergency?

Answer 18

nicardipine, clevipine

Question 19

the pathologic dilatation of a segment of blood vessel is also known as what?

Answer 19

aortic aneurysm

Question 20

what is the most common cause of aortic aneurysm?

Answer 20

atherosclerosis

Question 21

what percentage of patients die from acute rupture of aortic aneurysm?

Answer 21

50 percent

Question 22

75 percent of abdominal aneurysms are below which arteries?

Answer 22

renal arteries

Question 23

what will you note on PE of a patient with an abdominal aortic aneurysm?

Answer 23

pulsatile, non-tender mass

Question 24

you should screen male _____ over the age of __ with at least one of which 3 risk factors for aortic aneurysm?

Answer 24

male smokers over 60 years old with risk factors:

1) FH off AAA
2) presence of PAD/atherosclerosis
3) presence of peripheral artery aneurysms

Question 25

patients with an aortic aneurysm less than 5 cm have a ___ percent risk of rupture over 5 years

Answer 25

1-2 percent chance of rupture

Question 26

patients with an aortic aneurysm greater than 5 cm have a ___ percent risk of rupture over 5 years

Answer 26

20-40 percent chance

Question 27

what does surgical treatment of an aortic aneurysm consist of?

Answer 27

operative excision with graft replacement

Question 28

when will you always do surgery for an aortic aneurysm, no matter if the patient is symptomatic or not?

Answer 28

6.5 cm

probable surgery if over 5 cm