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**M3 Delights > Cardio Simple Cases > Flashcards

Cardio Simple Cases Flashcards

1
Q

What are the FIVE main groups for causes of CP?

A
  1. cardiac
  2. GI
  3. pulm
  4. Musculoskeletal
  5. Psychogenic
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2
Q

cardiac causes of CP

A
  • Stable angina
  • Unstable angina
  • Acute MI
  • Atypical or variant angina (coronary vasospasm, Prinzmetal’s angina)
  • Cocaine-induced chest pain
  • Pericarditis
  • Aortic dissection: tearing chest pain radiating to back
  • Valvular heart disease, i.e., critical aortic stenosis
  • Cardiac arrhythmia
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3
Q

GI causes of CP

A
  • Esophageal disease (GERD, esophagitis, esophageal dysmotility)
  • Biliary disease (cholecystitis, cholangitis): typically RUQ with radiation to shoulder, may be referred to chest
  • Peptic ulcer disease
  • Pancreatitis
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4
Q

pulm causes of CP

A
  • Pneumonia
  • Spontaneous pneumothorax
  • Pleurisy
  • Pulmonary embolism
  • Pulmonary hypertension/cor pulmonale
  • Pleural effusion
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5
Q

musculoskeletal causes of CP

A
  • Costochondritis
  • Rib fracture
  • Myofascial pain syndromes
  • Muscular strain
  • Herpes zoster
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6
Q

psychogenic causes of CP

A
  • Panic disorders
  • Hyperventilation
  • Somatoform disorders
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7
Q

how does the American Heart Association define ACS

A
  • umbrella term to cover any group of clinical symptoms compatible with acute MI:
    • unstable angina
    • STEMI
    • NSTEMI
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8
Q

History to Elicit in Patients with Suspected Acute Coronary Syndrome (FOUR)

A
  1. determine if there are associated symptoms
  2. ask about cardiac RF
  3. distinguish ischemic from NON-ischemic pain
  4. dont forget ACS can present with atypical symptoms
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9
Q

in a pt with suspected ACS what would you search for in a physical exam

A
  • Vital signs for tachycardia, hypotension, or hypertension.
  • Cardiac exam for murmur, S3 or S4 gallop, auscultation and palpation of pulses.
  • **aortic dissection is a “can’t-miss” diagnosis in a pt presenting with acute CP
    • Although hx may not be classic for aortic dissection, DO NOT prematurely rule this out
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10
Q

x findings suggest y

A
  • Pericardial rub on initial presentation=pericarditis
  • Lung crackles=HF
  • combo of fever, crackles, and DEC breath sounds=pneumonia
  • Unilat leg swelling and/or tenderness=DVT/PE
  • RUQ tenderness=acute cholecystitis
  • epigastric discomfort on palpation=GERD
  • CW tenderness=trauma, costochondritis, and other muscular causes of chest pain (could also be ACS)
  • Pulse and BP differential from side to side=significant peripheral arterial obstruction - including aortic dissection*
  • Diastolic heart murmur=aortic dissection
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11
Q

ideal summary statement

A
  1. Epidemiology and risk factors: 49 year-old man with history of tobacco use and family history of early onset CAD
  2. Key clinical findings about the present illness using qualifying adjectives and transformative language:
  • substernal chest discomfort
  • associated nausea and dyspnea
  • symptoms assoc. w/ exertion and relieved w/ rest.
  • normal PE
  • normal ECG
  • normal troponin
  • normal CXR
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12
Q

nml labs in setting of unstable angina/acute MI

A
  • A normal ECG in the presence of CP should not really change your opinion about unstable angina/ACS, and really only suggests that the patient has not had an MI in the past.
  • nml troponins this early in an MI may also be expected, since a rise does not usually occur until 4-6hr after the infarct.
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13
Q

mc associated symptom in patients with angina or MI

A

DYSPNEA

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14
Q

ECG in PE

A
  • ECG is abnml in 70% of pts with pulmonary thromboembolism.
  • 2 mc abnormalities-sinus tachycardia and nonspecific ST and T-wave changes, do not discriminate among diagnoses.
  • (relatively infrequent) Findings more suggestive of PE:
    • S1Q3T3
      • S wave in lead one
      • Q wave in lead three
      • inverted T-wave in lead three)
    • transient RBBB
    • T-wave inversions in V1-V4.
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15
Q

stable angina vs. unstable angine vs. acute MI

A
  • Stable angina s/s occur chronically and are predictable with exertion.
    • cause: stable atherosclerotic plaque.
  • Unstable angina :CP occurs at rest, is new, is INC in freq, or when its onset is triggered w/ a lower level of exertion.
    • cause: unstable plaque that has ruptured and caused a non-occlusive thrombus.
  • Acute MI: d/t rupture of unstable plaque w/ subsequent occlusive coronary artery thrombosis and myocardial necrosis.
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16
Q

Differentiating between unstable angina and NSTEMI

A
  • based on whether the troponins INC
  • may require serial measurements of troponins.
  • No troponin increase = No MI
17
Q

Criteria for acute MI

A
  • Rise and fall of troponin or CK myocardial band (CK-MB) plus ONE of the following:
    • Symptoms consistent with MI
    • ECG changes indicating MI (ST-segment elevation or depression)
    • New pathologic Q waves
    • Findings on percutaneous coronary intervention (PCI)
18
Q

What is the appropriate in the acute management of a pt with ongoing CP d/t unstable angina

A
  • sublingual nitroglycerin
  • beta blockers
  • ASA
  • heparin
  • statin
  • angiography with PCI
19
Q

Unstable Angina Admission Orders

A
  • bed rest
  • PO metropolol
    • reduce infarct size and freq of MI
    • improve short- and long-term survival
  • telemetry monitoring
    • detect tachyarrhythmias and bradyarrhythmias that may occur in the setting of an acute MI.
  • anticoagulation w/ heparin drip or subq LMWH
  • (stress test in the morning)
20
Q

ECG Waves and Intervals

A
  • P wave: sequential activation (depolarization) of the right and left atria
  • QRS complex: right and left ventricular depolarization (normally the ventricles are activated simultaneously)
  • ST-T wave: ventricular repolarization
  • U wave: unclear - probably represents “afterdepolarizations” in the ventricles
  • PR interval: time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex)
  • QRS duration: duration of ventricular muscle depolarization
  • QT interval: duration of ventricular depolarization and repolarization
  • RR interval: duration of ventricular cardiac cycle (an indicator of ventricular rate)
  • PP interval: duration of atrial cycle (an indicator of atrial rate)
21
Q

12-Lead ECG Interpretation

A
  • leads V1-V4 : anterior wall
  • leads II, III, aVF : inferior portion of the heart
  • leads I, aVL, V5, V6 : lateral myocardial wall
22
Q

define reciprocal changes

A

ST elevations in the inferior leads and ST depressions in the lateral leads

23
Q

when should Immediate diagnostic coronary angiography be considered

A

pts w/ CP and STEMI or new LBBB w/ the goal of angioplasty within 90 mins

24
Q

Awaiting further lab testing is unnecessary and dangerous

A

cardiologists say about STEMI, “Time is myocardium.”

25
Q

Criteria to Diagnose a LBBB on the ECG

A
  • The heart rhythm must be supraventricular in origin.
  • The QRS duration must be = or > 120 ms.
  • There should be a QS or rS complex in lead V1.
  • There should be a monophasic R wave in leads I and V6.
26
Q

absolute contraindications for thrombolytic therapy include

A
  • Strong suspicion of dissection of the aorta
  • Pericardial effusion
  • Active GI or other internal bleeding
  • Brain tumor, AV malformation, or aneurysm
  • Ischemic stroke in preceding 6 months
    • a verified TIA is an exception
  • Previous ICH or SAH
  • Intracranial procedure or recent head trauma
  • Severe known bleeding disorder: coagulation abnormality, thrombocytopenia, etc.
27
Q

Coronary Artery Bypass Graft (CABG) vs. Percutaneous Transluminal Angioplasty

A
  • PTCA with or without stenting produces a similar survival rate to CABG but is assoc w/ a higher rate of recurrent symptoms and target vessel revascularization (this may be changing with the use of drug-eluting stents).
  • CABG may be preferred in:
    • left main lesions
    • complex proximal LAD disease w/ other unfavorable lesions (three-vessel dz)
    • pts w/ LV dysfunction or DM.
28
Q

GP IIb/IIIa Inhibitors in Angioplasty for STEMI

A
  • abciximab or eptifibatide inhibits platelet aggregation, may prevent platelet adhesion to the vessel wall.
  • theres INC r/o bleeding (especially when used in combo w/ fibrinolytics) and can cause thrombocytopenia within 24 hours of initiation
  • they improve outcomes in patients with STEMI.
29
Q

Anatomy of Coronary Artery Occlusions and Infarction

A
  • Inferior infarction typically assoc w/ an RCA lesion
  • Anterior or lateral infarctions usually associated with L. circumflex and LAD occlusions
30
Q

Discharge Medications Following an MI & Stent Placement

A
  • ASA
  • beta blocker
  • clopidogrel
  • sublingual nitroglycern PRN
  • statin (HMG CoA reductase inhibitor)

**M3 Delights (2 decks)

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