Cardio, Pulm, and Vascular Flashcards
Chest pain questions….
when did pain start?
where is it? what does it feel like? how severe?
does it radiate?
have you felt like this before?
at rest? with exertion? both?
constant? intermittent?
SOB, N/V, diaphoresis, palpitations, fatigue, dizziness, syncope, sense of impending doom
dx tests for chest pain
EKG
CXR
Pulse ox
CBC, CMP, D-dimer, cardiac enzymes, BNP
Echo
if pt has chest pain, what do we do first?
assess vitals
cardiac monitor, IV access, O2
focused hx and physical exam
if pt is stable with chest pain, what do you do
obtain 12 lead EKG and CXR
Administer aspirin if pt is at low risk for aortic dissection
if pt is unstable with chest pain, what do you do?
stabilize ABCs
tx arrhythmias according to ACLS
check for life-threatening chest pain dx: AMI, massive PE, tension pneumothorax, pericardial tamponade
what is this?
pressure, heaviness, tightness, fullness, squeezing in the center or left of the chest precipitated by exertion and relieved by rest
can radiate shoulders, arms, neck, jaw
ANGINA
angina is indicative of what
some type of ischemic event happening in coronaries
anginal equivalents occur in whom
what is it?
women, elderly, diabetic pts
atypical presentation
examples of atypical angina presentation
SOB N/V Diaphoresis Fatigue Dizzy/lightheadedness Weak Palpitations Syncope
symptoms are stable and resolve with rest
stable or unstable angina
stable
increasing severity/frequency/duration OR occurs at risk
stable or unstable angina
unstable
non-occlusive thrombus
ischemia with elevated cardiac enzymes
NSTEMI or STEMI
NSTEMI
occlusive thrombus
transmural infarction
NSTEMI or STEMI
STEMI
CAD risk factors
Male sex
Age over 55 yrs
DM
HLD
HTN
Family hx of CAD
Tobacco
Obesity
History of atherosclerotic disease, prior MI, CVA/TIA, peripheral arterial disease
two things used to calculate MI risk
HEART score
TIMI score
HEART SCORE: what 5 parts of it
- how suspicious is the hx for ACS (0-2)
- EKG changes (0-2)
- Age (0-2)
- # of risk factors (0-2)
- Initial troponin value (0-2)
EKG and CAD - what do we see
resting EKG may be normal
ST-T wave changes: T wave inversions, ST depression or elevation
Cardiac enzymes and CAD
initial troponin then TREND
can’t rule out MI based on single set or just the initial cardiac enzymes – trend!
Stress test and CAD
exercise or pharmacologic
only do if you’re UNSURE if pt is having ACS
do NOT do with STEMI
high sensitivity troponin (hs-cTN assay) is ____ and ____ determinant of myocardial injury
sensitivity and specific
what lab results are indicative of acute MI
acutely elevated hs-cTN over 100
or
values less than 100 ng/L BUT have a 2 hour change of greater than 10 ng/L
chronic elevations of hs-cTn are indicative of what
chronic heart issues
for regular troponins, we trend the value every ___ hours for a total of ___ values
6 hours
3 values
ACS possible + EKG complete
high sensitivity troponin testing at time 0 is LOW (15 or below for men, 10 or below for women)
what do you do next?
you assess if it has been over 6 hours since chest pain/angina onset
if it is –> acute MI ruled out
if it is not – test troponins again at 2 hours
troponin testing at 2 hours
what happens?
delta 3 or less
delta 4-9
3 or less: acute MI ruled out
4-9: tropnin test again at 6 hours
troponin test at 6 hours (since chest pain)
delta < 12 ng/mL from time 0
delta 12+ ng/mL from time 0
less than 12: acute MI ruled out
12+: acute MI present
if at time 0, troponin is high (over 100 ng/mL WITHOUT ESRD, what is it?
MI
if at time 0, high troponin (over 100) + ESRD - what do you do
repeat troponin testing at 2 hours
if chest pain began over 12 hours ago, what does a negative delta mean?
it does not rule out recent MI
Clinical features of acute coronary syndrome - what do you do next? (3 things)
aspirin + analgesia + EKG
EKG shows ST elevation or new LBBB or true posterior MI
STEMI or NSTEMI
STEMI
EKG shows ST depression or T inversion - what do you do?
what does that tell us?
raised troponin
if raised - NSTEMI
if normal - unstable angina
what do we monitor during a stress test?
BP
EKG changes
Echo changes
when do we stop a stress test?
if pt develops chest pain, SOB, ST changes (elev or dep) or has decreased BP or ventricular arrhytmias
when observing a pt for “ACS rule-out”, what do you do
serial cardiac enzymes
stress testing
substernal chest pain lasting 2-5 minutes only with activity and never with rest
stable angina
EKG changes/enzyme changes/exercise stress test with stable angina
NO EKG CHANGES
NO ENZYME ELEVATION
STRESS TEST USUALLY NEG
medical management of stable angina
nitrates - sublingual nitro PRN for chest pain (if no relief call 911) - can take every 5 min for 3 doses in 15 min
beta blockers
+/- calcium channel blockers
antiplatelet medications:
aspirin, plavix or both
variant angina or vasospastic angina
angina 5-15 min usually at rest and often between midnight and early AM
prinzmetal angina
EKG of prinzmetal angina
ST elevation ONLY during chest pain episodes
tx of prinzmetal angina
nitrates + calcium channel blockers
dx prinzmetal angina
coronary angiography
you are about to give a pt nitroglycerin…. what should you ask?
if they recently took sildenafil, vardenafil, tadalafil
WOMEN TAKE THESE TOO
clinical presentation of acute coronary syndrome
chest pain, heaviness, or pressure
SOB
radiates
weakness or fatigue
N/V
diaphoresis
palpitations
dizziness or syncope
when high sensitivity troponin is high (like 200), what do you think?
MI
STEMI initial mgmt
ABCs
Cardiac monitoring (telemetry)
IV access
SL nitro
Aspirin - chewed
+/- beta blocker
anticoag (unfractionated heparin)
Call cardiology
acronym used for initial ACS tx
what has changed?
MONA
Morphine
Oxygen
Nitro
Aspirin
M and O are slowly becoming less used
morphine with STEMI is assoc with what?
increased mortality in STEMI
oxygen with STEMI is assoc with what
increased early myocardial injury and increase infarct size
why must you call cardiology ASAP with a STEMI
because they need to be sent to cath lab ASAP - door to percutaneous coronary intervention is important to improve outcomes
when do you consider fibrinolytics with a STEMI
if PCI is not readily available within 120 minutes
** unless contraindicated! **
gold standard for dx CAD
coronary angiography
PCI interventions (2)
angioplasty and stenting
factors to consider for CABG
number of vessels that are occluded
anatomic complexity of lesions
likelihood to have successful revascularization with PCI
Co-morbidities
initial mgmt for NSTEMI
same as STEMI except:
no thrombolytics
PCI if not contraindicated
can medically manage with heparin continuous infusion and aspirin
PCI contraindications
renal failure
sepsis
unstable pt
do you use MONA with UA/NSTEMI or STEMI or both
BOTH
do you use nitrates with UA/NSTEMI or STEMI or both
both
do you use beta blockers with UA/NSTEMI or STEMI or both
both
do you use anticoagulation with UA/NSTEMI or STEMI or bith?
both
do you use thrombolytics with UA/NSTEMI or STEMI or both
only STEMI and only if PCI is not avail
do you use revascularization with UA/NSTEMI or STEMI or both
later with UA/NSTEMI
early with STEMI
contraindications to nitro
hypotension, right ventricle infarction/inferior MI, recent PDE5 inhibitors (sildenafil)
6 peri-infarction emergencies
Peri-infarction pericarditis***
Acute mitral regurg***
Dressler’s Syndrome ***
Hemorrhage/bleeding
Arrhythmias (bradycardia)
Rupture of LV free wall or intraventricular septum
usually occurs soon after MI (first 2-3 days)
transient
pericardial rub on physical exam
pericardial inflammation +/- effusion
what dx?
PIP - peri-infarctino pericarditis
tx of peri-infarction pericarditis
supportive - self-limited
tylenol
aspiring +/- colchicine
NO NSAIDS
what should be avoided in peri-infarction pericarditis
NSAIDS
pericarditis can happen for many reasons other than post-MI
what are they?
infectious, radiation, post-cardiac injury syndrome, drugs/toxins, metabolic, malignancy, collagen vascular disease, immune-related, idiopathic
how does cardiac tamponade present
chest pain
tachypnea
dyspnea
physical exam of cardiac tamponade
hypotension
JVD/distended neck veins
muffled heart sounds
tachycardia
pericardial rub
what will EKG show on cardiac tamponade
sinus tachy
low voltage
what will CXR show with cardiac tamponade
enlarged cardiac silhouette
what will echo show with cardiac tamponade
effusion
tx of cardiac tamponade
drainage of pericardial effusion: pericardiocentesis
percutaneous or surgical
monitoring of cardiac tamponade
what needs to be done prior to discharge
continuous telemetry
frequent vital signs for 24-48 hours
repeat echo prior to discharge
causes of acute mitral regurg
ischemia to papillary muscle
left ventricle dilation or true aneurysm
papillary muscle or chordal rupture (2-7 days after infarct)
physical exam on acute mitral regurg
hypotension and new murmur
dx of acute mitral regurg
transthoracic or transesophageal
tx of acute mitral regurg
emergency surgery
dressler’s syndrome AKA
post-cardiac injury syndrome
when does dressler’s syndrome develop
weeks to months post MI
how does dressler’s syndrome present
pleuritic chest pain, fever, malaise
physical exam of dressler’s syndrome
pericardial friction rub
labs of dressler’s syndrome
leukocytosis, elevated ESR
CXR of dressler’s sydnrome
pleural and/or pericardial effusion or pulm infiltrates
tx of dressler’s syndrome
NSAIDS
Corticosteroids or colchicine if refractory
endocarditis physical exam findings
osler nodes (on fingers)
janeway lesions (on hands)
splinter hemorrhages (nails)
roth spots (eyes)
endocarditis clinical presentation
fever, chills, cough, dyspnea, orthopnea, fatigue
physical exam of endocarditis
palatal, conjunctival, or subungual petechiae: splinter hemorrhages, osler nodes, janeway lesions, roth spots, pallor, splenomegaly, heart murmur
stroke or emboli can occur
labs for endocarditis
blood culture (3 times) before antibiotics
leukocytosis
elevated ESR
echo for endocarditis
vegetation of valves
get transesophageal or transthoracic (if TEE is inconclusive)
risk factors for endocarditis
artificial heart valves
congenital heart defects
history of endocarditis
damaged heart valves
IV drug use
Poor dentition/dental infection
how many major and minor criteria are needed for endocarditis
2 major
1 major + 3 minor
or 5 minor
what are major criteria for endocarditis
only need 2 major
1 major + 3 minor
blood culture
vegetation
new valvular regurg
tx of endocarditis
antibx (prolonged: 6 weeks) of vancomycin + rocephin (good empiric tx)
if antibx don’t work, surgery needed (50% of cases)
presentation of HF
dyspnea
fatigue
diaphoresis
early satiety
cough
orthopnea
PND
edema
physical exam with HF
tachycardia
tachypnea
rales
JVD
S3-4
Lower extremity edema
ascites
EKG heart failure
maybe arrhythmias
ischemia
heart block
Labs heart failure
CBC
CMP
TSH
cardiac enzymes
BNP
CXR HF
cardiomegaly, cephalization, kerley B lines, maybe pulm edema
echo HF
ejection fraction
valves
pericardium
wall motion abnormalities
ECHO BEST WAY TO ASSESS***
tx for HF
IV access
control of airway, oxygen
telemetry
sodium and fluid restriction
strict I&Os, daily weights
+/- inotrope (dep on severity)
chronic HF meds (once stable); beta blocker; ACE-I; diuretics, +/- digoxin
DIURETICS: FUROSEMIDE
first line tx for HF
furosemide
definition of hypertensive urgency
systolic: 180+
diastole: 120+
no end organ damage
definition of hypertensive emergency
systolic: 180+
diastolic: 120+
acute end-organ damage: cerebrovascular, ophthalmologic, cardiac, renal
primary causes of HTN
new dx of HTN
non-adherence of meds
secondary causes of HTN
sleep apnea
renal artery stenosis
pheo
coarctation of aorta
pseudotumor cerebri
chronic steroid therapy
cushings
thyroid/parathyroid
primary hyperaldosteronism
preg
end-organ compromise signs of HTN
neuro
loss of consciousness, visual fields, focal motor/sensory deficits
end-organ compromise signs of HTN
ophthalmologic
fundoscopic exam: retinal hemorrhages, papilledema, AV nicking
end-organ compromise signs of HTN
cardiovascular
elevated JVP
lung crackles
murmur
asymmetrical pulses
end-organ compromise signs of HTN
renal
urine output
BUN/Cr on labs
HTN urgency tx
established htn pts
rest
increase dose
add add’l med
adhere to Na+ restriction
HTN urgency tx
new htn pt
bp reduction over several hours
rest
HTN emergency tx
hospitalized (usually ICU)
workup secondary htn causes
tx end-organ damage not just bp
reduce bp
switch from iv to oral once bp stable
how to reduce BP in HTN emergency
reduce MAP by 20-25% within 1 hour
IV labetalol
IV labetalol tx what
HTN emergency
elderly male smoker with CAD, emphysema, and/or renal impairment
not always symptomatic
if symptomatic:
substernal, back or neck pain, +/- dyspnea, stridor, cough, dysphagia, hoarseness, SVC syndrome
TEARING CHEST PAIN
what dx?
classic aortic aneurysm - thoracic
elderly male smoker with CAD, emphysema, and/or renal impairment
not always symptomatic
if symptomatic:
pulsating abdominal mass +/- abdominal/back pain
what dx?
classic abdominal aortic aneurysm
what dx?
hypotension/hemodynamic instability with pulsating abdominal mass +/- abdominal/back pain
ruptured aortic aneurysm in abdomen
which is more common: abdominal or thoracic aortic aneurysm
abdominal
risk of thoracic aortic aneurysm is determined by what
size of aneurysm
if thoracic aortic aneurysm is asymptomatic - how is it found and how is it managed?
found: incidentally CXR/CT - widened mediastinum
managed: aggressive BP and HR control (systolic under 120, HR between 60-80) through beta-blockers, symptom surveillance
what must BP and HR control be in thoracic aortic aneurysm
BP: less than 120
HR: 60-80
mgmt of thoracic aortic aneurysm if symptomatic, rapid aneurysm expansion, size
surgical
surgical mgmt of thoracic aortic aneurysm if:
symptomatic
rapid aneurysm expansion (growth of more than .5 cm in 6 mos)
greater than 5.0 cm
mgmt for asymptomatic AAA less than 5.5 cm
observation
surveillance and risk factor modification: US every 6 mos - 1 yr
complications of AAA
rupture (high mort/morb)
aneurysm thrombosis
thromboembolism (acute limb ischemia can result)
when do you do surgical management of AAA
asymptomatic but over 5 cm
rapidly expanding (growth of .5+ cm in 6 mos)
assoc with peripheral arterial aneurysm or PAD
emergent condition in which the inner layer of the aorta tears, blood then surges through the tear, causing the rest of the aorta layers to dissect
what dx
aortic dissection
if the blood filled channel ruptures through the outside aortic wall of aortic dissection, what happens
often fatal
symptoms of aortic dissection
ripping or tearing chest pain radiating to the back
severe back, abdominal, or flank pain + hypotension and shock
signs of hemodynamic compromise
risk factors for aortic dissection
uncontrolled HTN
atherosclerosis
pre-existing aortic aneurysm
bicuspid aortic valve
aortic coarctation
connective tissue disease (marfan syndrome)
cocaine use
preg
male gender with advanced age
De Bakey Aortic Dissection Type 1 originates in ____ aorta, propagates at least to aortic arch and often beyond it distally
ascending
De Bakey Aortic Dissection Type II originates in _____ aorta and is/is not confined to ascending organ
ascending
IS CONFINED
De Bakey Aortic Dissection Type III originates in ____ and extends distally down aorta or rarely retrograde into aortic arch and ascending aorta
descending aorta
Stanford Type A aortic dissection
all involve the ascending aorta regardless of site of origin
Stanford Type B aortic dissection
NOT involving ascending aorta
ascending or descending aorta dissection – emergency
ASCENDING
how is descending thoracic aortic dissection (type B) managed?
medically
as long as hemodynamically stable and without end-organ complications
how to distinguish between the type A (ascending) and type B (descending) aortic dissection in hemodynamically stable pt
CT angiography - initial screening study in hemodynamically stable pt
how to distinguish between the type A (ascending) and type B (descending) aortic dissection in hemodynamically UNstable pt
multiplanar transesophageal echo
hemodynamically unstable aortic dissection: management
intubate - airway compromise
bedside TEE
emergency vascular surgery consult
admit to ICU
morphine for pain
BP control: 100-120 SP; HR < 60
IV beta blocker
medication for hemodynamically UNSTABLE aortic dissection - this is for BP control and HR control
include ideal limits
beta blocker IV
SBP: 100-120
HR: <60
2 kinds of acute arterial occlusion
acute limb ischemia
acute mesenteric ischemia
3 causes of acute arterial occlusion
embolus
thrombosis
trauma
sudden decrease in limb perfusion that causes a potential threat to limb viability
symptoms appear from hours to days - new or worsening claudication to paralysis
acute limb ischemia
clinical presentation of acute limb ischemia
sudden, dramatic onset: embolus or thrombosis
embolus
clinical presentation of acute limb ischemia
gradual: embolus or thrombosis
thrombosis
Six Ps of acute limb ischemia
pain
pulselessness
pallor
paresthesias
paralysis
poikilothermia (difficult to regulate body temp)
should you do a neuro exam for acute limb ischemia?
if so, what do you assess?
YES - BILATERALLY
assess sensation
assess strength
pulses
what do you do to measure pulses with acute limb ischemia
doppler for posterior tibialis and dorsalis pedis
ankle-brachial index of less than .4 indicates significant ischemia
what vascular imaging for acute limb ischemia
CTA, MRA - performed in pts with viable limbs
anticoagulate prior and monitor progression
threatened limbs require what
immediate surgical revascularization - intraoperative arteriography
initial mgmt of acute limb ischemia
anticoag
close monitoring
surgery as soon as exam worsens
what must you do ASAP with acute limb ischemia
consult vascular surgery!
acute suddent onset of intestinal hypoperfusion
acute mesenteric ischemia
elderly pt with afib
severe abdominal pain, out of proportion to physical exam
what dx?
acute embolic occlusion
PAD aka
mesenteric thrombosis
mesenteric thrombosis symptoms
chronic post-prandial pain, food aversion, weight loss, +/- hematochezia
imaging for acute mesenteric ischemia
KUB - more for complications
CT angiography - imaging of choice
tx of acute mesenteric ischemia
systemic anticoagulation and pain mgmt
+/- angioplasty with stent
+/- exploratory laparotomy if peritoneal signs
risk factors for DVT
recent surgery
prolonged bed rest
oral contraceptives
hormone replacement therapy
recent trip
malignancy
factor V leiden, hypercoagulable states
Virchow’s triangle assoc with what
DVT
Virchow’s triangle (assoc with DVT) is what
endothelial damage
hypercoagulability
stasis
clinical presentation of DVT
swelling, pain/discomfort, edema (unilateral usually)
physical exam of DVT
erythema, warmth, swelling
labs with DVT
D-Dimer elevated
D-Dimer elevated with what
DVT
dx test of choice for DVT
duplex ultrasound
tx of DVT
anticoag: heparin, bridge to warfarin
acute onset of chest pain and/or dyspnea
pleuritic chest pain, dyspnea, cough, hemoptysis, syncope
what dx?
PE
physical exam of PE
tachypnea, tachycardia, hypoxia, unilateral extremity, edema
PE labs
d-dimer elevated
EKG labs for PE
sinus tachy
CXR for PE
normal
sometimes Hampton’s hump and Westermark sign
gold standard for dx of PE
pulm angiography
Well’s critera for what dx
PE
What is well’s criteria?
clinical signs/symptoms of DVT
PE is most likely dx
tachy (over 100 bpm)
immobilization/surgery in previous 4 weeks
prior DVT/PE
hemoptysis
active malignancy (tx within 6 months)
using well’s criteria - what is low risk, intermediate risk, and high risk
low: less than 2 pts
intermediate: 2-6 points
high risk: over 6 points
using well’s criteria
pe is unlikely if below what number
pe is likely if over what number
4 or below - unlikely
above 5 - likely
If Well’s criteria suggests that a PE is unlikley, what do you do
start with D dimer
If well’s criteria suggests PE is likely, what do you do?
check CTA
tx of PE
supplemental O2
IV access
cardiac monitoring
anticoag
any breech of the lung surface of chest wall allowing air to enter the pleural cavity causing what
lung to collapse
primary pneumothorax =
spontaneous
secondary pneumothorax =
related to COPD, CF, pneumonia, malignancy
when is primary pneumothorax most common
in tall, young males
____ forms due to one-way valve where air can enter but cannot leave
tension pneumothorax
tension pneumothorax is most commonly ___
traumatic
what kind of pneumothorax is a medical emergency
tension
tx of primary spontaneous pneumothorax
resolve on own sometimes
can observe and repeat CXR if less than 15-20% lung involvement
preferred tx for symptomatic pneumothorax
tube thoracostomy
tx for tension pneumothorax
needle decompression first then chest tube placement
condition characterized by paroxysmal attacks of reversible bronchospasm, mucus plugging, and inflammation of the trachobronchial tree
asthma
physical exam of acute exacerbation of asthma
SOB
wheezing
cough
resp distress
use of accesspry muscles/nasal flaring
what should you NOT be fooled by with ashtma
quiet chest!
tx of asthma
airway - oxygen
beta 2 agonist
steroids
nebulized anticholinergic
refractory asthma attack that does not respond to initial tx
status asthmaticus
asthma complication that is medical emergency
status asthmaticus - ICU usually
