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Elaina: Hospital Medicine > Cardio Lecture > Flashcards

Cardio Lecture Flashcards

1
Q

how fast should you get an EKG when patient presents with chest pain?

A

10 minutes

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2
Q

how long is the time delay before a troponin may be positive?

A

6 hours

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3
Q

renal disease, myocarditis, cardiac contusion, recent heart surgery may result in what?

A

false positive troponin

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4
Q

between NSTEMI and STEMI, which is more of a thrombotic event? which is more of an embolic event?

A

STEMI = embolic

NSTEMI = thrombotic

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5
Q

besides a thrombotic or embolic event, in what other way may a patient experience cardiac ischemia?

A

supply/demand mismatch

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6
Q

ST elevation, ST depression, CP with hemodynamic instability, dynamic EKG changes are considered where in terms of risk?

A

high risk

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7
Q

if a patient has a high risk history but a negative troponin, where do we place them in terms of risk stratification?

A

high risk

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8
Q

low risk history with a normal EKG but a positive troponin is considered low, medium, or high risk?

A

medium risk

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9
Q

a patient with stable angina that resolves spontaneously or with administration of STG SL is considered low, medium, or high risk?

A

medium risk

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10
Q

if you diagnosis of chest pain is uncertain, how do you manage the patient?

A

MONA (morphine, O2, nitro, aspirin)
ACLS as needed
get CBC, electrolytes
serial troponins and telemetry

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11
Q

how do we manage STEMI/UAP once we rule in the DX?

A 
MONA
dual anti-platelet therapy
heparin
statin (high dose) for secondary prevention
beta blocker
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12
Q

what are the 7 components that make up the TIMI score for evaluating 2 week risk of death, new or recurrent MI, or severe recurring ischemia that requires catheterization?

A

1) age over 65
2) 2+ risk factors for CHD
3) prior coronary stenosis greater than 50 percent
4) ST deviation on admit EKG
5) 2+ angina symptoms in prior 24 hours
6) elevated cardiac biomarkers
7) aspirin within past 7 days

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13
Q

is anticoagulation and considered an immediate issue or post-immediate issue when dealing with atrial fibrillation?

A

post-immediate

first: verify rhythm, hemodynamic instability, ventricular rate control, BP management

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14
Q

is cardioversion considered an immediate issue or post-immediate issue in AFIB?

A

post-immediate

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15
Q

in pre-excitation syndromes, what might be the very first step in management?

A

cardiovert!

risk of embolism becomes second priorty

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16
Q

in terms of afib, is the rate we see on the monitor or the apical rate that we hear on auscultation more important?

A

apical rate! this is the real rate. the machine is misleading because it only picks up on perfusion beats

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17
Q

what diagnostic imaging of choice do we use to look for the presence of a thrombus in the right atria?

A

TEE

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18
Q

in addition to EKGS, echos, biomarkers, etc. what lab should we always get? what imaging should we always get in a patient with AFIB?

A

1) always get TSH

2) always get chest Xray looking for pulmonary disease

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19
Q

mortality rate, stroke rate, bleeding risk, and quality of life were all equal between rate vs. rhythm control in the AFFIRM study. what was the only difference between the two?

A

more hospitalizations in the rhythm control group

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20
Q

what are the benefits to rhythm control for a fib?

A

maintain sinus rhythm, optimal cardiac output, improved LV function over time

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21
Q

which drugs are use in pharmacologic rhythm control for a fib?

A

AMIODARONE, flecainide and others

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22
Q

what is the biggest side effects of rhythm control for a fib?

A

all the drugs are pro arrhythmias (patient can go into VT, torsades)

23
Q

how effective is rhythm control for a fib?

A

only 50-60 percent effective at maintaining SR long term

24
Q

what are our four rhythm control options for a fib?

A

DC Cardioversion
Drugs
MAZE procedure
radiofrequency catheter ablation

25
Q

risk of stroke is MUCH higher after how many hours of being in afib? how do we manage a patient who presents having been in afib for the past 72 hours that wants CV?

A

much higher after 48 hours

if after 48 hours:

1) full anticoagulation (warfarin) for minimum 3-4 weeks
2) come in for DC cardioversion
3) continue warfarin 4 weeks after

26
Q

which carries the highest risk of stroke – shock, drugs, or spontaneous cardioversion?

A

all the same!

27
Q

what is the alternative option in your patient presenting past the 48 hour mark who wants to get cardioverted sooner than 4 weeks?

A

fully anticoagulate with heparin or LMWH
proceed with CV
warfarin continued for 4 weeks post CV as with other option

28
Q

if a TEE is performed and thrombus is ruled out, what can we jump straight to?

A

DC cardioversion without having to anticoagulate

29
Q

long term success rate with the MAZE procedure?

A

90 percent

30
Q

short term success rate with catheter-based radiofrequency ablation?

A

65-80 percent

31
Q

enough about rhythm control, what do we actually do 80 percent of the time?

A

rate control

32
Q

which drugs are used for rate control? what do they all cause?

A

diltiazem, beta blockers, or digoxin

all cause hypotension bc decreased cardiac output (digoxin is exception; it slows the heart but increases cardiac output)

33
Q

alternative to drugs for rate control?

A

AV node ablation, permanent ventricular or AV pacemaker

34
Q

what scoring system do we use to decide if we want to fully anticoagulate our atrial fibrillation patient who opts for rate control?

A

CHADSDS-VASC

CHF: 1
Hypertension: 1
Age over 75: 2
Diabetes Mellitus: 1
Stroke/TIA HX: 2
Vascular disease: 1
Age 65-74: 1
Sex (female): 1

max score is 9

35
Q

should a patient with a CHAD score of 1 be anticoagulated?

A

consider

36
Q

should a patient with a CHAD score of 2 be anticoagulated?

A

yes

37
Q

how should we initiate anticoagulation in a patient who decides to go with rate control?

A

warfarin with heparin bridge

no bridge for novel oral anticoagulants

38
Q

if patient with AFIB has no prior history of thromboembolism or presence of thrombus, do we bridge them to warfarin?

A

nope! no heparin needed

39
Q

what are our three options when treating wolf parkinson white? what drugs do we HAVE to avoid?

A

1) cardioversion primary objective
2) rate control with amiodarone
3) ablation (TOC)

AVOID diltiazem or beta blocker – will put them into torsades

40
Q

systolic heart failure is characterized by an ejection fraction less than what?

A

less than 40

41
Q

what is the primary culprit of acute pulmonary edema in the hospital setting?

A

IVF administration

42
Q

what must we always give when a patient with CHF receives a transfusion?

A

IV diuretics

transfusion fluids have very high oncotic pressure and pull fluid into the circulation – can promote pulmonary edema

43
Q

which cardiac arrhythmia can precipitate acute pulmonary edema in CHF?

A

atrial fibrillation (bc it decreases the effectiveness of the heart pump)

44
Q

how do we medically manage mod-severe acute heart failure in the hospital setting?

A

1) IV diuretic
2) O2 (they are hypoxic from the pulmonary edema)
3) NTG
4) morphine for pain

45
Q

what should the sodium intake and fluid intake of a patient in heart failure be?

A

sodium limited to 2g/day

fluid restricted to 1-1.5 L/day

46
Q

what medications must be avoided in the setting of acute heart failure in the hospital?

A

NSAIDS (can cause hyperkalemia, Na retention)

antiarrhythmics

47
Q

you should always _____ the head of the bead in acute heart failure

A

elevate

48
Q

true or false — you should give your patient in acute heart failure a beta blocker to help protect his heart

A

FALSE

will make it worse – wait until stable

49
Q

you should consider an intensivist/cardiology consult if your patient presents with this triad during heart failure

A

1) hypotension SBP less than 90
2) oliguria
3) low cardiac output (cool, pale extremities, weak pulses)

50
Q

which two beta blockers have shown benefit over time for patients with left ventricular dysfunction to heal the heart and improve function?

A

carvedilol and metoprolol

51
Q

which drug is sometimes used for systolic heart failure, because it helps control heart rate while also increasing cardiac output?

A

digoxin

52
Q

when should we consider intubation in our patient in acute heart failure?

A

severe hypoxemia or respiratory acidosis not responding to therapy

53
Q

SO. in general – how do we treat mild-moderate acute on chronic heart failure? do they require admission?

A

IV or oral diuretics

unless complicated by a precipitating factor (MI) or life threatening condition (electrolyte imbalance, arrhythmias) these patients do NOT require hospital admission beyond a few hours of observation in the ED as outpatient

Elaina: Hospital Medicine (11 decks)

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