Cardio Lecture Flashcards
how fast should you get an EKG when patient presents with chest pain?
10 minutes
how long is the time delay before a troponin may be positive?
6 hours
renal disease, myocarditis, cardiac contusion, recent heart surgery may result in what?
false positive troponin
between NSTEMI and STEMI, which is more of a thrombotic event? which is more of an embolic event?
STEMI = embolic
NSTEMI = thrombotic
besides a thrombotic or embolic event, in what other way may a patient experience cardiac ischemia?
supply/demand mismatch
ST elevation, ST depression, CP with hemodynamic instability, dynamic EKG changes are considered where in terms of risk?
high risk
if a patient has a high risk history but a negative troponin, where do we place them in terms of risk stratification?
high risk
low risk history with a normal EKG but a positive troponin is considered low, medium, or high risk?
medium risk
a patient with stable angina that resolves spontaneously or with administration of STG SL is considered low, medium, or high risk?
medium risk
if you diagnosis of chest pain is uncertain, how do you manage the patient?
MONA (morphine, O2, nitro, aspirin)
ACLS as needed
get CBC, electrolytes
serial troponins and telemetry
how do we manage STEMI/UAP once we rule in the DX?
MONA dual anti-platelet therapy heparin statin (high dose) for secondary prevention beta blocker
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?
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
is anticoagulation and considered an immediate issue or post-immediate issue when dealing with atrial fibrillation?
post-immediate
first: verify rhythm, hemodynamic instability, ventricular rate control, BP management
is cardioversion considered an immediate issue or post-immediate issue in AFIB?
post-immediate
in pre-excitation syndromes, what might be the very first step in management?
cardiovert!
risk of embolism becomes second priorty
in terms of afib, is the rate we see on the monitor or the apical rate that we hear on auscultation more important?
apical rate! this is the real rate. the machine is misleading because it only picks up on perfusion beats
what diagnostic imaging of choice do we use to look for the presence of a thrombus in the right atria?
TEE
in addition to EKGS, echos, biomarkers, etc. what lab should we always get? what imaging should we always get in a patient with AFIB?
1) always get TSH
2) always get chest Xray looking for pulmonary disease
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?
more hospitalizations in the rhythm control group
what are the benefits to rhythm control for a fib?
maintain sinus rhythm, optimal cardiac output, improved LV function over time
which drugs are use in pharmacologic rhythm control for a fib?
AMIODARONE, flecainide and others
what is the biggest side effects of rhythm control for a fib?
all the drugs are pro arrhythmias (patient can go into VT, torsades)
how effective is rhythm control for a fib?
only 50-60 percent effective at maintaining SR long term
what are our four rhythm control options for a fib?
DC Cardioversion
Drugs
MAZE procedure
radiofrequency catheter ablation
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?
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
which carries the highest risk of stroke – shock, drugs, or spontaneous cardioversion?
all the same!
what is the alternative option in your patient presenting past the 48 hour mark who wants to get cardioverted sooner than 4 weeks?
fully anticoagulate with heparin or LMWH
proceed with CV
warfarin continued for 4 weeks post CV as with other option
if a TEE is performed and thrombus is ruled out, what can we jump straight to?
DC cardioversion without having to anticoagulate
long term success rate with the MAZE procedure?
90 percent
short term success rate with catheter-based radiofrequency ablation?
65-80 percent
enough about rhythm control, what do we actually do 80 percent of the time?
rate control
which drugs are used for rate control? what do they all cause?
diltiazem, beta blockers, or digoxin
all cause hypotension bc decreased cardiac output (digoxin is exception; it slows the heart but increases cardiac output)
alternative to drugs for rate control?
AV node ablation, permanent ventricular or AV pacemaker
what scoring system do we use to decide if we want to fully anticoagulate our atrial fibrillation patient who opts for rate control?
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
should a patient with a CHAD score of 1 be anticoagulated?
consider
should a patient with a CHAD score of 2 be anticoagulated?
yes
how should we initiate anticoagulation in a patient who decides to go with rate control?
warfarin with heparin bridge
no bridge for novel oral anticoagulants
if patient with AFIB has no prior history of thromboembolism or presence of thrombus, do we bridge them to warfarin?
nope! no heparin needed
what are our three options when treating wolf parkinson white? what drugs do we HAVE to avoid?
1) cardioversion primary objective
2) rate control with amiodarone
3) ablation (TOC)
AVOID diltiazem or beta blocker – will put them into torsades
systolic heart failure is characterized by an ejection fraction less than what?
less than 40
what is the primary culprit of acute pulmonary edema in the hospital setting?
IVF administration
what must we always give when a patient with CHF receives a transfusion?
IV diuretics
transfusion fluids have very high oncotic pressure and pull fluid into the circulation – can promote pulmonary edema
which cardiac arrhythmia can precipitate acute pulmonary edema in CHF?
atrial fibrillation (bc it decreases the effectiveness of the heart pump)
how do we medically manage mod-severe acute heart failure in the hospital setting?
1) IV diuretic
2) O2 (they are hypoxic from the pulmonary edema)
3) NTG
4) morphine for pain
what should the sodium intake and fluid intake of a patient in heart failure be?
sodium limited to 2g/day
fluid restricted to 1-1.5 L/day
what medications must be avoided in the setting of acute heart failure in the hospital?
NSAIDS (can cause hyperkalemia, Na retention)
antiarrhythmics
you should always _____ the head of the bead in acute heart failure
elevate
true or false — you should give your patient in acute heart failure a beta blocker to help protect his heart
FALSE
will make it worse – wait until stable
you should consider an intensivist/cardiology consult if your patient presents with this triad during heart failure
1) hypotension SBP less than 90
2) oliguria
3) low cardiac output (cool, pale extremities, weak pulses)
which two beta blockers have shown benefit over time for patients with left ventricular dysfunction to heal the heart and improve function?
carvedilol and metoprolol
which drug is sometimes used for systolic heart failure, because it helps control heart rate while also increasing cardiac output?
digoxin
when should we consider intubation in our patient in acute heart failure?
severe hypoxemia or respiratory acidosis not responding to therapy
SO. in general – how do we treat mild-moderate acute on chronic heart failure? do they require admission?
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
