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IPAP JUNIOR SEM. > Cardio Notes Test II > Flashcards

Cardio Notes Test II Flashcards

1
Q

Any pt that comes in with acute chest pain, what is the FIRST STEP

A

CARDIAC SAFTEY NET

P-position of comfort or feat dangling over bed leaning forward
O-O2 is sat is below 95%
M-Monitor with EKG, SPO2, HR, RR, ETCO2
I- IV, with LABs (CBC, Troponins, BMP)

M-Morphine 2.5-5 mg for acute chest pain as long as BP can tolerate
O- Maintain O2 sat above 95%, avoid O2 toxicity
N- Sublingual Nitro, As long as EKG does not C/I
A- Aspring 326 mg, withhold is suspected Dissection, anuerysyms, recent TIA, or blook cloting D./0

Then evaluate need for PCI withing 90-120 minutes

Think Stable vs unstable angina, ACS, MI, NSTEMI

Long term
B- Betablocker for HF ( Labetalol, propranolol, metoprolol)
A- ACE ( lisinopril)
S- Stating (look at primary prevent guidlines, High intensting atorvastatin or rousuvastatin)
H- LMWH or Heparin (look at CHA2DS2VASc score)
C/T- Clopidogril or Ticagalor ( PY12 drugs, Ticagalor preferred)

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2
Q

A ACS/ CHest Pain pt presetns with fever, what should be you immediate DDx

A

Esophageal rupture or PE

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3
Q

What does the acronym VINDICATES stand for

A 
Vascular
Infextion 
Neoplastic 
Drugs/Degenerative
Inflamatory/Idiopathic 
Congenital 
Autoimmune 
Truma 
Endocrine/ Enviromental 
Something else
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4
Q

What is the leading virus that causes pericarditis

A

Coxsackie B

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5
Q

What is post MI pericarditis called

A

Dresslers syndrome

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6
Q

You see ST elevations with PR depression think

A

Pericarditis

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7
Q

On EKG you wide spread ST depressions with ST elevation in AVR only

What is this

A

Partial Left Main/ 3 Vessel occlusion

NEED CABG!

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8
Q

What is becks triad

A

Triad of S/s of Tamponde
Muffled Heart Sounds
JVD
HOTN

Will also be tachycardic with a Low CO

(Can also have electrical alternans or LOW VOLTAGE QRS complexes, and narrowing pulse pressures)

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9
Q

What is the w/u for pt that presents with esophagitis

A

Upper endoscopy and mucosal biopsy

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10
Q

What does the acronym PIECE for esophagitis mean

A 
PILLS (NSAIDS) 
INFECTIONS 
(Candida, CMV, HSV) 
Eosinophilc 
Caustic 
Everything else ( GERD, PPIs)
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11
Q

What is Jod-Basedow phenomenom

A

A hyperthyroid reaction that is associated with amioderone, Graves Dz, pts with goiters, or thyroiditis

Can present with Chest Pain, and Tachycardia, palpations, dyspnea, arrythmias, and systolic HTN

Understand increased B stimualtion leads to a faster HR

They key is these pts present with a decreased expression of phospholamban

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12
Q

A pt presents with left axis deviation, tearing chest pain, ECG shows no ST changes, and Troponins are NML

Think

A

Aortic dissection 2ndary to Long standing HTN

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13
Q

What are the two etiologies of Angina pectoris

A

Vasospastic diseases like Prinzmetals/ reynauds

And Atherosclerotic Dz

  • Stable angina (SA) and Unstable Angine (USA)
  • MI/ ACS
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14
Q

A pt presents with chest pain that occurs at rest, and in clusters, with transient ST elevations..
think

A

Prinzmetals

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15
Q

What is the earliest and often MC complaint of ACS

A

Dyspnea

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16
Q

What are the cardinal S/s of ACS

A

Dyspnea,
Claudication
Syncope (ominous)
Fatigue

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17
Q

A pt presents iwth atruamatic acute Chest pain with an O2 sat less than 80.. .
What must you do

A

Apply Supplemental assisted ventilation

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18
Q

Before Admin of Asprin in ACS what must you do

A

Check BP in BUE
Check symetric pulses,
Check ECG for LEFT MAIN! May need CABG/ Surgery so no Asprin should be given

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19
Q

What are the labs that are essential to order in the 1st 10 minutes in ACS

A 
CBC
BMP 
Cr and BUN (part of a BMP) 
PPT and Pt or INR 
Lipids 
And Troponins
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20
Q

In ACS how are troponins checked

A

Initially and then at 6 hrs

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21
Q

A female pt or DM pt presents with dyspnea, Epigas pain, Syncope.. think

A

ACS/MI?

Check BG (BMP and CMP), EKG, And Troponins

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22
Q

What are the Rsk fxs for ACS

A 
Age over 55 
Male 
HTN 
Familial Hypercholestermia 
DM 
Smoking (Most modifiable) 
Smoking 
obesity 
HDZ in a 1* relative 
(Male less than 55 yr or Female less than 65 yrs)
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23
Q

If a pt presetns with ST elevations and Chest pain, and you admin Nitrates and the chest pain resolves and the St elvations disappear…

What does the pt have

A

Prinzmetals angina

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24
Q

If a ACS pt does not improve with subling Nitro,. What is the next step

A

IV nitro

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25
Q

What is the main C/I to NTG admin

A

RV MI

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26
Q

How often should ECK be repeated in suspected MI

A

Q5-10 MIN

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27
Q

What are the commom ECG findings in a NSTEMI

A

May be NML
Can have ST depressions
Or Deep Twave inversions of 1mm or more

WILL HAVE POS TROPONINS

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28
Q

What are the Dx criteria for a STEMI

A

ST elevations in contiguous leads,
NEW LBBB
Or Carousel Sign of Post MI

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29
Q

A pt with prinzmetals should be placed on what type of monitor

A

A holter monitor for 24 hrs

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30
Q

Can you give BB to a prinzmetal pt?

A

NO, it will worses Coronary vascon

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31
Q

Should you give BB to a pt in cardiogen shock or ADHF?

A

No, they are negative inotropes and will cause the pt to tank

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32
Q

What are the three accepted BB in CAD managment

A

Metoprolol
Bisproplol
Carvedilol

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33
Q

Before giving a pt a betablock what must be r/o

A

That the HR can support it, they are not in ADHF, that they have already been given nitrates, and we have confirmed the pt is not on a stimulant

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34
Q

An ACS pt presents with underlying HF, what medication can allieviate congestion

A

IV loop diuretic (furosemide)

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35
Q

What is the DOC for severe and persistnet chest pain

A

IV morphine 2-4 mg q5-15 min

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36
Q

What is the Tx appraoch to a pt with UA or NSTEMI

A

Anthithrombic Tx
( Clopidigrel/ ticagrelor)
Asprin

May need Anticoagulation Tx as well with Heparin/ LMWH

This prevents thrombin or emboli from the plaques

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37
Q

What are the 7 factors of a TIMI score

A

Age greater than 65

More than 3 rsk fx for CAD

Prior Stenosis greater than 50%
St depression s

More than 2 anginal events

Troponins

Or use of ASprin in the previous 7 days

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38
Q

If the Heart score is less than 3, what is the Tx appraoch

A

The pt is said to be low risk and can be seen in an outpt non emergent setting

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39
Q

In pts with heart scores greater than 3 with a TIMI greater than 3

What is the tx appraoch

A

Plan early invasive angiography with PCI or CABG as necessary

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40
Q

In pts with herat scores greater than or equal to 3 with TIMI scores less than 3…
What is the Tx approach

A

These pts require noninvasive stress testing with Tx tailored to the results

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41
Q

Pts with grace scores greater than 140 require…

A

Early intervention of Angiograpyhy withing 12 hrs

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42
Q

Pts with grace scores between 109 and 140 require

A

Delayed Angiography? Reprofusion within 72 hrs

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43
Q

Pts with a grace score less than 109 require..

A

Noninvasive testing to determine need for Coronary angiography/ Reprofusion

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44
Q

Do we care about grace scores in pts with STEMI

A

NO!

They need PCI within 90-120 minutes

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45
Q

What are the HIGH rsk pts who do not have MI but still require Angiography within 12 hrs

A 
Hemodynamically unstable 
Cardiogenic shock 
LVHF 
Recurrent or Persistent Angina 
New or Worseing Mitral Regurg 
New VSD 
Sustained VTac/ Vfib
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46
Q

What is areteriolosclerosis

A

Can either be hyaline or hyperplastic

Hyaline is protien deposited in the vessel walls

Hyprplastic in an expansion fo the basmenent membrane of the vessel wall

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47
Q

What is medial calcific sclerosis

A

Calcification of the tunica media

Visuallize of X-rays, asymptomatic

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48
Q

What are the most common arteries affected by arteriosclerosis

A
  1. ABD aorta
  2. Coronary Arteries
  3. Popliteal artery
  4. Carotids
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49
Q

What are the modifiable and nonmodifiable RSK FX for areteriosclerosis

A 
Mod: 
HTN 
DM 
Smoking 
High LDL w/ Low HDL

NonMod:
Age
FMHx
African Americans

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50
Q

Where in the vessel is injury to the endothelium most likely to occur

A

At arterial bifurcations (wall stress)

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51
Q

What is the pathological progression of arterioslerosis

A
  1. Injury to the endothelium with leaking of LDL into the intima
  2. Macrophages scavenge the LDL creating foam cells
  3. Foam cells form Fatty streaks from Platlets+ endothelial cells
  4. Produces and extracellualr matrix, aka a plaque (The transition from asymptomatic to symptomatic)
  5. Foam cells necrose leading to metaloprotieinase of cells, causing plaque rupture (symptomatic)
  6. Platlets aggregate aroudn rupture occluding vessle with a fibrin clot leading to subsequent ischemia beyond the clot. (Symptomatic)
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52
Q

What percent of vessel occlusions present with S/s

A

70% of vessel occlusion produces S/s

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53
Q

Where does the ABD aorta begin ( common site for aneurysm)

A

Below the level of L2

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54
Q

What are 4 major complications for a dislodged plaque

A

Besides MI or Stroke

Livedo reticularis (web lik vein skin pattern)
Hollenhorst plaques in the retina
AKI
Or gangrene

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55
Q

A pt presents with Chronic HTN and DM, they have excess glucoes and protiens in the blood, what are they at an increased Rsk of developing

A

Arteriolosclerosis (Hyaline)

Which can cause HTN and DM neuropoathy and Lacunar Infarcts in the brain

Looks like a glassy pink appearnce in the vessel wall

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56
Q

A pt presents with severe acute elevations in BP, with an onion skin look to the vessel wall

Think

A

Hyperplastic arteriolocsclerosis

MC effects the renal, retinal, and intestinal arteries

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57
Q

What is Monckberg sclerosis

A

Medial calcific sclerosis or the internal lamina and tunica media

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58
Q

On X-ray you see a ‘pipestem appearance of the Aorta”

Think

A

Monckberg sclerosis

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59
Q

What is the defintion of dyslipidemia

A

Elevaed LDL with a Low HDL

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60
Q

What is the rate limiting step of cholestrol synthesis and is the MOA of statins

A

Conversion of HMG-CoA to mevalonate is catalyzed by HMG-CoA reductase (rate limiting step of cholesterol synthesis)

HMG-CoA reductase inhibitors (Statins) inhibit this conversion

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61
Q

What transports choleserol and TriGs from the liver to the cells and back..

A

Apoprotiens

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62
Q

What is a chylomicron

A

A microscopic particle of blended fat found in the blood and lymph; formed during the digestion of fats
Contains Protein 1-2%, Triglyceride 85-95%, and cholesterol 3-6%

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63
Q

How can you estimate the VLDL level

A

TriGs/5

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64
Q

What is the Apoprotien that moves LDL around

A

Apo-B100

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65
Q

What is the desiarble Total Cholesterol level

A

Less than 200

200-239 is borderline
240 or more is high
And higher than 280 is very high

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66
Q

What is the total cholestoral calculation

A

LDL+HDL+(TriGs/5)

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67
Q

How often should adults over the age of 20 be screened for high cholestreol

A

Every 5 years

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68
Q

What is an optimal LDL level

A

Less than 100 is op

100-129 is near optimal 
130-159 is borderline 
160-189 is high 
190 or more is very high
 (high Statin required)
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69
Q

What are good or bad HBL levels

A

Less than 40 is bad

Higher than 60 is good

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70
Q

What are NML TriGs level

A

Less than 150 is NML
150-199 is borderline
200-499 is high
And anything higher than 500 is very high

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71
Q

What is the 10 yr ASCVD rish assesment based on

A

NonMod:
Age, race, sex

Mod: 
Total C 
HDL 
SBP and DBP 
Tx of HTN 
DM 
Smoking
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72
Q

What are the 4 ASCVD equivalents

A

ACS within the past 12 months

Previous MI

Previous CVA

PAD (ABI less than 0.85, a Hx of revasc, or amputation)

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73
Q

What are the High risk conditions for 2* prevention of ASCVD

A 
Age over 65 
Familial hypercholestermia 
Prior Bypass or PCI 
DM 
HTN 
CKD 
Smoking 
LDL greater than 100 despite maxiamlly tolerated Statin. + ezetimibe 
Hx of CHF
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74
Q

What makes a pt Very High risk in the 2* prevention calculator

A

2 major ASCVD events or 1 Major +2 high risk conditions

Very High Risk pts need LDL-c reduction to below 70 mg/dl

Not very high risk pts need 50% decrease in LDL

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75
Q

A DM pt has a History of MI and HTN
They are 65 yrs old

What is the treatment approach to prevent ASCVD

A

2* prevention with 1 major 2 high risk conditions

High intensity statin with goal of LDL-C less than 70

If goal not met- add exetimibe

If goal still not met add a PCSK-9 inhibitor (ends in maub)

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76
Q

What is the Tx approach for pts with Previous MI with no other Hx or Risk conditions

A

Look at age..
Older or younger than 75

If younger: High intensity statin with 50% reduction goal

If High statin is not tolerated then Mod statin can be used

If LDL is still greater than 70 add ezetimibe

If the pt is older:
Use either a mod or high intensity statin depending on pt tolerance

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77
Q

What are the risk ENHANCING fxs for ASCVD

A

FMHx of ASCVD (Male less than 55, female less than 65)

Preeclampsia or menopause before 40

Metabollic syndrome

HIV, RA, Psoriasis, Lupus, ART

CKD

LDL routinely above 160

South Asian decent

Triglycerides routinely above 175

ABI less than 0.9 if diabetic

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78
Q

What is the criteria for metabolic syndrome

A

Requires three of any of the following

Waist 40 inches men or 35 inches women

Tri Gs above 175

HDL less than 40 men or 50 women

BP greater than 130/85 or taking HTN meds

Or Fasting gl greater than 100

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79
Q

What are the 5 steps to primary prevention of ASCVD

A
  1. LDL greater than 190?
  2. Dm?
  3. Age greater than 75? Or 20-39
  4. Risk calc
  5. Cac score
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80
Q

A 34 year old male with an LDL of 165 witha. Family Hx of premature ASCVD (father at age 40)

What is his primary prevention of ASCVD approach

A

Moderate intensity statin

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81
Q

When do we initiate statins for pts 0-19 yrs old in primary prevention of ASCVD

A

If they have familial hypercholesteremia

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82
Q

When do we initiate statins in pts older than 75 in primary prevention

A

In LDL is 70-190 and the pt accepts the risk and can tolerate the ADE ( if CAC is zero then they can decline)

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83
Q

A 41 pt with metabollic syndrome presents for primary prevention of ASCVD

LDL-C is 165 with a 6% Risk calculation

What is the Tx approach

A

Risk descussion for a mod intensity statin

Pt is in the age range for risk stratificatoin and has a high risk enhancer.

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84
Q

What zre the 2 high intenstisty statins

A 
Atorvastatin (40-80mg) 
 and Rosuvastatin (20-40mg)
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85
Q

What are the 4 mod intensity statins

A

Atorvastatin (10-20mg)
Rosuvastatin (5-10mg)
Simvastatin (20-40mg)
Pravastatin (40-80mg)

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86
Q

How much time should be allowed to pass before adjusting statin tx

A

4 weeks

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87
Q

What are the ADE of statin Tx

A

Myalgias
Myopthay (CK> 10 x ULN)
Rhabdo
Liver toxic (Rare)

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88
Q

When should AST.ALT be chesked after statin tx

A

Baseline, 4 and 12 weeks

Beyond that only needed in pt presents with ADE

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89
Q

What are the prominemt fxs that increased the risk of statin induced myopathy

A 
Age greater than 75 
Being a woman 
Renal insuff 
Hepatic Dysfunc 
Hypothyroidism 
Grape juice 
ETOH abuse 
Asian ancestry
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90
Q

So atorvastatin or pitavastatin require renal adjustments

A

NO

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91
Q

Which statin is not protein bound

A

Pravastatin

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92
Q

Becasue statins are highly protein bound, they may dispalce what other medication

A

Warfarin!

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93
Q

What is an absolute C/I to statin Tx

A

Active liver Dz or unexplained elevations in Hepatic enzymes

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94
Q

Can preg pts be put on statins

A

NOPE!

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95
Q

Grapefruit juice and Red Yeast rice effect statins how

A

Grapefruit: increased rsk of myopathy

Red yeast: increased rsk of rhabda

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96
Q

If you use statins and fibrinc acid derivatives together

What is the outcome

A

Sever myopathy !! Rhabo

So dont use gemfibrozil with a statin

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97
Q

When useing statins with niacin, what is the risk

A

Myopathy, rhabdo, or liver tox

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98
Q

Use of amioderone, diltiazne or verapamil with statins increase the risk of what condition

A

Myopathy

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99
Q

If a pt is on warfarin, what statn should be used

A

Pravastatin

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100
Q

If a pt is on amlodipine , what statin shoul be used

A

Rosuvastatin

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101
Q

If a pt is on amioderone what statin should be used

A

Rosuvastatin

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102
Q

If a pt is on digoxin, what statin should be used

A

Rosuvastatinn

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103
Q

If a pt just really loves grapfruit juice, what statins should be used

A

Prava, rosuva, or pivastatin

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104
Q

If a pt is on ranolazine what statin can they be put on

A

Atorvastatin

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105
Q

What is the MOA of fibric acid derivates

A

Stimulates lipoprotein lipase activity which hastens the removal of chylomicrons and VLDL from the plasma (subsequently decreases TG)

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106
Q

What is the DOC for lowering TriGs

A

Fibric acid derivatives

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107
Q

A pt has HIV, and the tx is raising thier TriGs for viral protease tX

What drug can we use to lower thier TriGs

A

Fibic Acid Derivates

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108
Q

What is the MOA of Ezetimibe

A

Selective inhibitor of intestinal absorption of cholesterol and phytosterols at the brush border

Effective even in the absence of dietary cholesterol because it inhibits reabsorption of cholesterol excreted in the bile

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109
Q

What are the two PCS K9 inhibitors are what are thier MOA

A

Aliro and Evolocumab

Human monoclonal antibody that inhibits the PCSK9 enzyme, stopping it from binding to the low-density lipoprotein receptors (LDLR)

By inhibiting the binding of PCSK9 to LDLR, the number of available LDLRs increases to clear LDL from the blood

110
Q

What are the ADE of PCS K9 inhibitors

A

Nasopharyngitis, injection site reactions, and influenza

111
Q

What are the screening recommednations for hyperlipidemia

A

For men 20-35 y/o and women 20-45 years old in increased risk of CHD such as obesity, smoking, DM, PMHx, HTN

112
Q

What is the w/u for rhabdo

A

CK, creatine, and UA for myoglobinuria

113
Q

What percentage of vessel usually needs to be occluded to be symptomatic

A

Around 70 % with exertion

Around 90% at rest

114
Q

When is the left ventricel perfused

A

During diastole

115
Q

What are the vascodialtors produced by the endothelium

A

NO, prostacyclin, EDHF

CO2 and Lactic acid also vasodilate

116
Q

What are the vascon produced by the endothelium

A

Endothelin 1

117
Q

What is stunned myocardium

A

Short-term, total or near total reduction of coronary blood flow
Then Reestablishment of coronary blood flow
Subsequent LV dysfunction of limited duration

118
Q

What is hibernating myocardium

A

State of persistently impaired myocardial and LV function at rest due to chronically reduced coronary blood flow that can be partially or completely restored to normal either by improving blood flow or by reducing oxygen demand

These are your chronic stable angina pts. This is a long time problem, EF is low over several years. It’s a protective mechanism.

119
Q

A pt can present with only Dyspnea and still have..

A

Angina

120
Q

A pt with typical symptoms of angina pectoris who have no evidence of significant atherosclerotic coronary stenosis on coronary angiograms

Think

A

Cardiac Syndrome X

121
Q

DM pts are at an increased risk of what kind of ishcemia

A

Silent

Also more common in women and the elderly ( the atypicals)

122
Q

What is diamond critera

A

For typical vs atypical chest pain

Typical is Substeranl, Worse with exertion, and relieved by NTG

3/3 is typical
2/3 is atypical
0-1/3 is non anginal

123
Q

A pt with a recurring MI, in the same day, what lab can detect this

A

Myoglobin or CK, troponins will already be elevated

124
Q

A pt presents with a Heart score of 1-3 and is stable, what is the tx approach

A

D/c from hospital, follow up with PCM

125
Q

Pt presents with Heart score above 3, and a timi 1-2
And is stable

What is the approach

A

Non invasive testing

Treadmill, pharm stress test, ect

126
Q

PT with a Heart score >3 and a timi > 3 or grace >140
And is stable

Approach?

A

12 hr Invasive angiography

If grace is 109-139 then 72 hours

127
Q

A pt with a Heart score >3, TIMI> 3, or grace > 150
Is UNSTBALE or High risk

What is the approach

A

2H time to invaisive angiography

128
Q

What are the numbers for a duke treamdill score

A

Low risk is score >5
Intermediate is score from
4 and -11

High risk is any score less than -11

129
Q

A duke score of 5+ has what 5 year survival

A

97%

130
Q

A duke score of 4 to -11 has what 5 yr survival

A

90%

131
Q

A duke score less than -11 has what 5 year survial

A

65%

132
Q

If a pt is unable to excercise, waht drug is used in pharm testing

A

Dobutamine

133
Q

What are the three drugs often used in Stable angina

A

The three classes of medications most commonly used are β-adrenergic blockers, organic nitrates, and calcium channel blockers (LAST RESORT)

134
Q

What is the only drug proven to prevent reinfarctionf and increase survival post MI

A

BB

135
Q

When are ACE inhibitors used in angina pts

A

Consider in High risk pts

Does not treat angina its self but contributing fx: HTN, DM, CKD< LVEF less than 40%

136
Q

When is coronary revasc preferred (3 circumstances)

A

(1) Anginal symptoms do not respond to antianginal drug therapy
(2) Medications causes unacceptable side effects
(3) There is high-risk coronary disease, which warrants revascularization

137
Q

When would a pt get a bare metal stent vs a drug eludiong stent

A

DES is perferrd,

BMS when the pt can not tolerate dual antiplatelt therapy

138
Q

When should a pt get a CABG

A

If >50% left main stenosis

3 or more vessel CAD or if LvEF is less than 50%

139
Q

If a pt receives a DES for SIHD , how long do they required antiplatelet tx

A

6 months of Asprin +clodiagrl. Ticagrelor

140
Q

If a pt receives a BMS for SIHD, how long do they require antiplatlet tx

A

A least 1 month 1 asprin + PY12 inhibitor

141
Q

If a pt gets a DES for ACS

How long do they require antiplatlet Tx

A

12 month asprin + PY12 inhibitor

142
Q

What are the two types of CABG and which is superior

A 
Native vessle and 
arterial flap(**)
143
Q

A pt presents with TachyHR and a new S3 murmur

Think

A

STEMI

144
Q

What defines a TRUE posterior MI

A

ST elevations in II, III, AVF

Tall R wave with ST depression in V1 V2,

145
Q

What conditions can lead to non atherosclerotic Coronary emboli

A 
Severe anemia 
Blood D/o 
Shock 
Vasospasms 
Angiography 
DVT with R-L shunt

Lupus
Takayasus
Kawasakis
Giant Cell arteritis

146
Q

How many negative sets of troponins rules out an MI

A

3 sets

147
Q

When do troponins rise, peak and return to baseline

A

Rise in 3-4 hrs
Peak at 18-36
And return to baseline in 7-10 days

148
Q

What are the basic considewrations for a pt with UA/NSTEMI

A

Asprin ASAP and Ticagrelor

GPiib/IIIA rarely used anymore is tx with above meds are started within 30-45 min of PCI

Then consider Heparin vs LMWH

UFH is preferred if planning early invasive management given less bleeding than with LMWH

LMWH is preferred if planning a conservative management approach given lower mortality, MI, & revascularization

149
Q

When would you use bivalirudin for antithrombin tx in a UA/Nstemi

A

Use if Heparin-induced thrombocytopenia occurs

150
Q

Should UA/NSTEMI pts receive fibrinolytics

A

HELL TO THE NO!

151
Q

When should fibrinolytics be used in STEMI MGMT ?

A

Only when pci is not available within 90-120 minutes

152
Q

What should be performed immeditaely for ROSC pts with Stemi on ECG

A

Angiography and PCI

153
Q

A pt with a TIMI score of 3 that needs invasive surgery should be placed on what antithombic tx

A

LMWH

154
Q

What are all the meds that a pt with a STEMI or new LBBB be put on

A 
Aspirin 
PY12 
Nitro 
BB 
UFH/LMWH 
Statin
155
Q

When should ACEI be started for StEMI pts

A

Within 24 hrs

156
Q

What mediaction must be stopped if starting statins

A

NSAIDS

157
Q

What is the clinical sig of Wellens syndrome

A

Wellen’s syndrome is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD).

extremely high risk for extensive anterior wall MI within the next few days to weeks.

158
Q

Should pericarditis pts get NSAIDs

A

No it increased mortatlity

159
Q

How should pts that present with cardiogenic shock after discharge for a MI

A

Treat as stage D-class 4-acute-decompensated-HF (Inotropes, IABP, LVAD, heart transplant)

160
Q

A pt presents post my with pericardial dz…

Think

A

Dresslers

161
Q

What are three drugs that can induce pericarditis

A

Hydralazine
Methyldopa
Isoniazid

Also procanamide!! And phenytoin

162
Q

What is the Tx approach to Acute pericarditis

A

NSAIDS (indomethacin)

Can combine with colchicine

163
Q

What autoimmune conditions can lead to pericarditis

A

RA and Lupus

164
Q

What is the common viral infex for pericarditis

A

Coxsackie B

165
Q

What makes a pt with pericardits high risk

A 
Fever greater than 100. 4
Pericard effusion 
Tamponade 
Immuncomp 
Warfarin use 
Acute truama 
Failure to improve with 7 days of NSAID tx 
Elevated troponins =myopericarditis
166
Q

When would you use corticosteroids in a pt with acute pericarditis

A

Only if NSAIDs and colchicine failed

However my exacerbate viral pericarditis and increase reoccurance

167
Q

What is the MOA of Colchicine

A

Inhibits neurtophil motility and decreased inflamation

168
Q

A pt presents with Acute pericardits post MI (dresslers) what is the Tx

A

Asprin (not NSAIDs that impede healing) and colchicine

169
Q

What is the definition of Constrictive pericarditis

A

Impariment of diastolic filling without impairment of systolic function

170
Q

You hear a pericardial knock during diastole

Think

A

Constrictive pericarditis

171
Q

How does constrictive pericarditis effect the atria

A

Way cause Afib from increased pressures

172
Q

A pt presents on echo with thickened pericardium, and abrupt cessation of LV and RV diastolic filling

What two other finding would they have

A

Biatrial enlargment

Intervent shift/ flattening

173
Q

What is the Dx imaging for constrictive pericarditis

A

Cardiac MRI

174
Q

What is the Dx of choice for constrictive pericarditis

A

Cardiac MRI

175
Q

What is the Tx for constrictive pericarditis

A

Pericardiectomy

176
Q

What are the s/s of obstructive shock

A

HOTN, Tachy HR, decreased CO

177
Q

What is pulsus paradoxis

A

A 10 mmHg drop in Systolic BP on inspiraton

Classic sign of tamp

Can also happen in asthma ,OSA, croup, and pericarditis

178
Q

What is EWARTs sign

A

Dullness to percussion over the left subscap area.. sign of pericardial effusion

179
Q

A pt with equal pressures in all 4 chambers of the heart, has what ..

A

Pericardial effusion leading to tamp

180
Q

What is the Image of choice for effusions

A

Echocardiography

181
Q

If the fluid is bloody on pericadiocenteis think

A

Truama, CA, PE

182
Q

IF the fluid is chylous on pericardiocentes think

A

Thorcic ducy injury ot leukemia inflitration

183
Q

If the fluid is purulent on pericardiocentesis think

A

Infection

Look a WBC, Proteins, Glucose
or LDH

184
Q

What is the NML pericardial fluid level

A

15-50 mls

185
Q

What are common causes of Pericardial effusions

A

Viral/bacterial pericarditis

Hypothyroidism (Increased perm)

CHF (increase in cap pressure)

Cirrhosis (oncotic pressure)

Aortic Disect

Radiation

Post MI

Uremia with CKD

186
Q

Pt presents with dyspnea, dysphagia, and hoarsness of the voice, +/- hiccups, and JVP with a dominant x descent

Think

A

Effusion

187
Q

How do effusions look on EKG

A

Flat T waves or Low voltage QRS

188
Q

What is the hallmark EKG finding of effusion

A

Electical alternans

189
Q

What is a 1st line Tx for Tamponadde

A

IV fluids

190
Q

A pt presents with intermitten claudication, -peripheral edema, Absent/diminished pedal pulses, Black eschar on the toes, +/- smooth round sores on the toes or feet …

Think what kind of PVD

A

Arterial

191
Q

A pt presetns with dull achy leg pain, lower leg edema, with irregular sores with irregular borders, -/+ yellow or ruddy skin

With sores located on the ankles …

Think what kind of PVD

A

Venous

192
Q

What are the Rsk factors for PVD/PAD

A

Obestiy, DM2, Varicosites, or lymph obstruction

193
Q

What is gangrene

A

Tissue infarcts

194
Q

What is the classic S/s of PAD

A

Claudication

195
Q

An ABI below 0.9 is DX of what condition

A

Occlusive arterial Dz

196
Q

An ABI less than 0.4 is Dx of what

A

Rest pain

As well as ulcers and pedal gangrene

197
Q

What are the indications for doing an ABI

A

AbNML or absent pedal pulses,

Age greater than 20 y/rs

Or age 50-69 with DM or smoking

198
Q

An ABI greater than 1.3 in the setting of DM or ESRD should prompt what…

A

Dopplet waveform
Or Duplex Doppler

Toe pressures to eval for PAD

199
Q

Falsely elevated ABIs can be a result of what condition

A

Artiololsclerosis which is common in CKD pts

200
Q

What are the MOD rsk factors for PAD

A

Smoking cessation
BG control
TX of Dyslipidemia
TX of HTN

201
Q

What are the three Tx options for PAD

A

Asprin
Bypass
Or amputation if comp

202
Q

What questionarre screens for PAD

A

Edinburg claudication quistionarre

203
Q

What are the 6ps of acute PAD

A 
Pain, 
Pallor 
Parasthsai 
Paralysis 
Poikilothermia 
Pulslessness
204
Q

What is leriche syndrome

A

ED in the setting of PAD

205
Q

A pt presents with PAD with pain in the hip, buttock or thigh

Where is the occlusion

A

Aortoiliac occlusive dz

206
Q

A pt presents with PAD and calf/thigh pain

Where is the occlusion

A

Common femoral artery

207
Q

Pain is the upper 2/3 of the claf is what kind of PAD

A

Superficial femoral artery occlusion

208
Q

Calf pain in the lower 1/3 is what kind of PAD

A

Popliteal artery occlusion

209
Q

A pt presetns with pallor on elevation and rubor with dependency.. think

A

PAD

210
Q

Thickening of the nails, lost of hear on the legs

Are both signs of…

A

PAD

211
Q

What three pt groups should automatically get ABI

A

≥50 years old with a history of smoking or diabetes

≥50 years old with a history of exertional leg pain or nonhealing extremity wound

≥65 years old

212
Q

What is the gold standard of PAD dx

A

Arteriography

213
Q

Spinal stenosis can mimic PAD?

A

Yes both present with hip, leg pain

214
Q

What is the 1st line Tx for PAD/claudication

A

Lifestyle changed: excercise with meticulous foot care

215
Q

What is the MOA of cliostazol

A

Phosphodiesterase inhibitor/direct vasodilator

Improves symptoms and increases walking distance

NOT used in Heart Failure patients

216
Q

What antiplatlet tx are indicated for PAD MGMT

A

Asprin or clopidigrel

217
Q

An ABI less than 0.9 is assoc with what fold increase in CVD events

A

2-4 x increase

218
Q

What are the two non invasive tests for PAD

A

ABI and 6 minute walk test

219
Q

What are the two main dz of the aorta and how are they defined

A

Aneurysm
Location: Thoracic or abdominal or both

Defined:
-dilation of the thoracic aorta >4cm in diameter
-dilation of the abdominal aorta > 3cm in diameter

Dissection
Location: Can occur at any point of the aorta
Defined: a tear in the intima layer of the vessel

220
Q

What is ectasia

A

Artreial dilation less than 150 perccent

221
Q

What is a True aneurysm

A

Involves all three vessle of the aortic wall, (I-M-A)

222
Q

What is a “false” pulsatile hemoatoa “aneurysm”

A

Disruption of the aortic wall or an graft/vessel, with containment of blood by fibrous capsule made of surroiunding tissue

223
Q

What is the duration of onset that differs acute vs chroinc A. Disection

A

Less than 2 weeks is acute

Greater than 2 wks is chronic

224
Q

What are the NML measurments of the Aorta

A

At the base: 3-4 cm
Ascending: 2.5-3.5
Descending: 2-2.5 cm

225
Q

When does the ABD aorta start

A

Below T12

226
Q

What are the 3 fx that deterimne afterload?aortic pressure

A

Volume of blood during systole

Vessel wall compliance

Resistance

227
Q

What are the three types of aneurysms

A

Ascending and descending thoracic
And abdominal

Can also be saccular, fusiform, or psuedoaneurysm

228
Q

What is the difference of aneurysm and ectasia

A

Ectasia: increased diameter but less than 50% increase from normal

Aneurysm: increased diameter at least 50% increase from normal

229
Q

What is the most common location from abdominal aneurysms

A

Abdominal

230
Q

What are the highrisk groupd for THoracic aneurysms

A

Older than 65
Male over female
HTN!

231
Q

Ascending thoracic aneurysm requires..

A

Emergent surgery

232
Q

What are the inherted conditions that can lead to ascending aortic aneurysm

A

Marfan, Ehlers-Danlos, Bicsupic Aortic Valves, Familial aortis aneurysms

233
Q

What is the land mark that defines descending thoracic aneurysms

A

Start distal to the left subclav artery

234
Q

What are the common etiologies for descedning thoracic aneurysms

A

Atherosclerosis

Salmonella, syphillis, TB, Staph/Strep

Takayasu or Giant Cell Arteritis

235
Q

Describe the murmur of Aortic regurg

A

Diastolic blowing murmur of aortic regurgitation

236
Q

What is the #1 imaging study for Thoracic aneurysms

A

TEE Is # 1

Can do a CT with or without con

MRI

US of ABD Aorta/ branches

237
Q

A pt presents on Xray with elagment of the aortic knob, loss of the AP window, and a mediastinum at 8cm at a minimum…
Think

A

CXR

238
Q

AAA most commonly effects what segment of the aorta

A

AAA most often affects the segment of aorta between the renal and inferior mesenteric arteries

239
Q

What are the high risk groups for ABD AAA

A

65 and older
Male gender, white

Smoking

Atheroslerosis

HTN

Dyslipidemia

Family history AAA

Presence of other peripheral aneurysm

240
Q

A pt presents with abd pain either in the left flank or lower back, +hydronephrosis, pulsating abd mass

Think

A

AAA

241
Q

What is the measurement that defines Aneurysm in the abdominal aorta

A

Greater than 3 cm

242
Q

What is the imaging TOC for stable aS/s pts with abd aneurysm

A

US

243
Q

What is the imaging TOC for S/s STABLE anuerysm pts

A

CT scan

244
Q

WHat is the recommended screening for AAA

A

65-75 yr with any smoking history with US

Do not screen females who have never smoked

245
Q

An Aneurysm less than 4.0 should have what approach

A

Watchfull waiting

246
Q

What is the criterai for surgical intervention in Aneurysms

A

Rate of enlargment greatert than 0.5 cm in 6 months or greater than 1cm in a year

247
Q

What is the threeshold for surgical intervent in aneurysms

A

Ascending thoracic: 5-6 cm

Descening thoracic: 6-7

Abdominal: 5.5 cm or greater

248
Q

What are the C/I to surgical repair of an aneurysm

A

Life expect <1year
Terminal Dz
Recent MI
U/angina

249
Q

What two cystic medial necrosis syndromes lead to dissections

A

Marfans and Ehler-Danlos

250
Q

Type B dissections are assoc with what S/s

A

Pain between the scapula, back, and abdominal pain

251
Q

A pt presents with a new diastolic murmur, dyspnea, hemoptysis, HOTN, +/- tampanoda, renal insuff. And PAD
Syncope

Think

A

Aortic Dissection

252
Q

A pt presents with UE blood pressure diff. Think

A

Aortic Dissection

253
Q

What are the triad of S/s of Aortic dissection

A

Pain (sharp/tearing), Mediastinal widending, Pulse pressure variations greater than 20mmhg

254
Q

What is the Test of CHOICE for Aortic dissection

A

TEE or Chest CT with Contrast

255
Q

What is the tx approach to acute dissections

A 
Morphine for pain 
BP control 
(propranolol, labetalol, esmolol) 
Airway MGMT 
Bedside TEE (unstable) 
CT or MRI (Stable)

ADMIT
And deterime surgery approach

256
Q

What is the best initial step to MGMT of aortic dissection

A

BP conctrol with Labetalol

257
Q

What is the tx appraoch to lymphedema

A

Avoid limb injury

Skiin hygeine

Compression bandages (intensive) and lymphedema sleeves (Maintenance)

Excercise daily while wearing compresion

Massage

If left untreated can lead to subQ fibrosis

258
Q

What is superficial thrombophlebitis

A

Bening D/o

Erthyema, indurataion, and tenderness along a SUPERFICIAL vein

Usually spontatneous or following IV cath

259
Q

What are the triad of suppurative phlebitis

A

IV cath, FEVER, chills

Treat surgically

260
Q

What is buergers disease

A

An inflamatory cause of phlebitis

Only in smokers, may lead to amputation and death

Gets worse the more you smoke

261
Q

What is trousseau syndrome

A

Recurrent superficail thrombophlebitis asscoited with cancer

262
Q

What is the treatment to thrompbophlebitis ( superficial)

A 
Bed rest 
Elevation 
Moist heat 
Compression 
NSAIDs 
Pain Med
263
Q

What is phlegmasia alba dolens

A

A DVT that wholly occludes the abilty to drain a limb, all draininage is dependent on superficial venous drainage

Typically appears in cancer or peripartum pts

THERE IN NO ARTERIAL ISCHEMIA

264
Q

WHat is phlegmasia cerulea dolens

A

Rare complication of ALBA, where the superficial venous system become overwhelmes leading to massive edema and compartment syndrome
(Pain, pallor, parasthesai..ect)

PT Should be consulted to vasc surgery asap

265
Q

What is the Dx choice for most pts with 1st episode of DVT

A

Compressive Duplex Doppler US

266
Q

What is the gold standard Dx for DVT

A

Venography

267
Q

When should we treat aS/s DVTs

A

If unprovoked, D Dimer greater than 500, Larger than 5cm, CA pt, recurrent, immobilized, or COVID

268
Q

What is the DOC for DVT

A

Factor Xa inhibitors

Special cases:
Liver Dz, preg, or CA: LMWH
Poor med complicane, MS or CKD: VKA

269
Q

What is the 5 step approach to DVT or PE tx

A 
1 O2 and fluids 
2 Anticoag (LMWH or Factor Xa) 
3 Thombolysis if in shock 
4 Vena cava filters 
5 Surgery
270
Q

What is the criteria for high risk disesctions

A

Impedning rupture, greater than 5mm per year expansion, recurrent pain, HOTN, or uncontrolled HTN

These pts need surgical repair even if its ABD aorta

IPAP JUNIOR SEM. (43 decks)

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