Cardio T12-20 Flashcards
- What is sudden cardiac death (SCD)?
Sudden cardiac death is an unexpected non-traumatic death occurring within one hour of symptom onset in a clinically stable patient, primarily caused by ventricular arrhythmias like ventricular fibrillation.
How does sudden cardiac arrest differ from sudden cardiac death?
Sudden cardiac arrest is the sudden loss of cardiac output, which can potentially be reversible with prompt restoration of circulation and oxygenation, while sudden cardiac death refers to the actual death that occurs.
What are the two major causes of sudden cardiac death?
The two major causes of sudden cardiac death are acute coronary syndrome and cardiomyopathies.
What is the primary goal of cardiopulmonary resuscitation (CPR)?
The primary goal of CPR is to maintain circulation in patients experiencing sudden cardiac arrest until cardiac function can be restored.
What are the two main protocols for CPR?
The two main protocols for CPR are Basic Life Support (BLS) for lay rescuers and Advanced Cardiac Life Support (ACLS) for medical professionals.
What steps are included in Basic Life Support (BLS)?
BLS includes checking the patient’s responsiveness, calling for help, performing chest compressions and rescue breaths (30:2 ratio), and using an automated external defibrillator (AED) if available.
What is the Chain of Survival in CPR?
The Chain of Survival includes:
Check responsiveness and call for help.
Immediate CPR.
Early defibrillation.
Early advanced life support.
What are the steps in BLS regarding airway management?
In BLS, airway management involves clearing any obstruction and positioning the airway using head tilt or chin lift maneuvers.
Describe the CPR compression technique.
CPR compressions should be at a rate of 100 compressions per minute and a depth of 5-6 cm. Compressions should continue until emergency medical services (EMS) arrive.
How is an AED used in CPR?
Place one pad on the right chest above the nipple and the other pad on the left side below the nipple. Most AEDs are automatic and will provide prompts for shock delivery; continue CPR after any shock is administered.
What is included in Advanced Life Support (ALS)?
ALS includes continuing CPR, activating the emergency response system, securing the airway (if needed), providing rescue breaths or artificial ventilation, and using a defibrillator for shockable rhythms.
What medical therapy is administered in ALS if defibrillation is ineffective?
If defibrillation does not restore normal rhythm, administer 1 mg of IV epinephrine every 3-5 minutes.
What are acute aortic syndromes (AAS)?
Acute aortic syndromes are emergency conditions involving the aorta that may lead to intramural hematoma, penetrating aortic ulcer, aortic dissection, or rupture.
What is an aortic dissection?
Aortic dissection is a tear in the inner layer of the aorta, causing blood to accumulate in the intima-media space, resulting in a progressively growing hematoma.
What are the main risk factors for aortic dissection?
Age and hypertension are the main risk factors for aortic dissection.
How does a patient with aortic dissection typically present?
Patients with aortic dissection typically present with sudden onset severe pain radiating to the chest, back, or abdomen.
What is a key finding on a chest X-ray in aortic dissection?
A widened mediastinum on chest X-ray is a characteristic finding in aortic dissection.
How is the diagnosis of aortic dissection confirmed in stable vs. unstable patients?
In stable patients, diagnosis is confirmed with a CT angiogram, and in unstable patients, it is confirmed with transesophageal echocardiography (TEE).
What are the treatment options for aortic dissection?
Treatment ranges from conservative measures like blood pressure control to surgery, such as aortic stent graft placement, depending on the severity and location of the dissection.
What are common complications of aortic dissection?
Common complications include complete occlusion of branching vessels and aortic rupture.
What are the two main classifications of aortic dissection?
The two main classifications of aortic dissection are the Stanford and DeBakey classifications.
How does the Stanford classification system categorize aortic dissections?
The Stanford classification is based on whether the ascending aorta (Stanford type A) or descending aorta (Stanford type B) is involved.
What is the DeBakey classification of aortic dissection?
The DeBakey classification categorizes aortic dissection based on its origin and extent:
Type I: involves the ascending aorta and extends beyond it.
Type II: confined to the ascending aorta.
Type III: confined to the descending aorta.
What are common etiology/risk factors for acute aortic syndromes?
Hypertension or trauma
In rare cases, Ehlers-Danlos and Marfan syndrome
What is the pathophysiology of aortic dissection?
A transverse tear in the arterial intima leads to:
Blood entering the intima-media space, creating a false lumen
Hematoma formation that propagates longitudinally downwards
What are the clinical presentations and complications of aortic dissection?
Sudden and severe tearing/ripping chest pain
Asymmetrical blood pressure
Syncope, diaphoresis, confusion, agitation
How is aortic dissection diagnosed?
Echocardiography: Shows dissection flap, double lumen, pericardial effusion
CT (gold standard): Dissection flap, double lumen, dilatation, hematoma
MRI: Same findings as CT (used if CT is contraindicated)
X-ray: Widened mediastinum
What are the treatment options for aortic dissection?
Surgery:
Immediate for Stanford A or Stanford B with complications
Open surgery with replacement of the dissection with polyester graft
Endovascular aortic repair with stent implantation (in Stanford B with high operative risk)
What is the difference between true and false aneurysms?
True aneurysms: Involve all 3 layers of the arterial wall, can be fusiform or saccular.
False aneurysms: External hematomas with persistent communication to a leaking artery, often due to trauma.
What are aortic dissections?
Separation of the arterial wall layers caused by blood entering the intima-media space after a tear in the internal layer occurred.
How are aneurysms classified?
Aneurysms are classified by their location, such as cerebral, external carotid, iliofemoral, popliteal, and ventricular aneurysms.
What factors influence symptoms of aneurysms?
Symptoms depend on the location and size of the aneurysm.
What are the treatment options for aneurysms?
Surgical and endovascular treatments, depending on the type and whether symptoms or complications are present.
Thoracic Vs Abdominal aortic aneurysm
What is the treatment approach for unstable patients with ruptured aneurysms?
Emergency surgery within 90 minutes.
How should symptomatic patients with impending rupture or leaking aneurysms be treated?
Urgent repair within hours.
What is the recommended approach for asymptomatic patients with aneurysms?
Elective aneurysm repair or surveillance.
What is the general treatment strategy for all patients with aneurysms?
Reduction of atherosclerosis risk factors.
What is Endovascular Aneurysm Repair (EVAR)?
A minimally invasive procedure preferred over open surgery for most aneurysms, where an expandable stent graft is placed via the femoral or iliac arteries.
What is the procedure for open surgical repair of aneurysms?
Laparotomy is performed, and the dilated segment of the aorta is replaced with a tube graft.
- What is the Vaughan-Williams classification used for?
The Vaughan-Williams classification is used to classify antiarrhythmic drugs based on their mechanism of action.
Why are Class I drugs in the Vaughan-Williams classification further subdivided?
Class I drugs are further subdivided because of subtle, yet important differences in their effects on action potentials.
What is the main purpose of the Vaughan-Williams classification?
The main purpose of the Vaughan-Williams classification is to categorize antiarrhythmic drugs by their mechanism of action and their effectiveness with certain types of arrhythmias.
What are the limitations of the Vaughan-Williams classification?
The Vaughan-Williams classification has limitations due to the incomplete understanding of drug mechanisms when it was created. Many antiarrhythmic drugs, especially in Class I and III, have overlapping mechanisms of action that break the classification down, as they could fit into multiple classes.
How do Class III drugs like amiodarone challenge the Vaughan-Williams classification?
Amiodarone, a Class III antiarrhythmic, also blocks sodium and calcium channels, showing that drugs in one class can share mechanisms with drugs in other classes, complicating their classification.
Why do different sources sometimes classify antiarrhythmic drugs differently?
Different sources may classify antiarrhythmic drugs differently because many drugs exhibit multiple mechanisms of action, which makes it possible for them to be assigned to more than one class.
How do the efficacy and safety of antiarrhythmic drugs vary?
The efficacy and safety of antiarrhythmic drugs vary depending on the type of arrhythmia, with some drugs being more effective or safer for certain arrhythmias than others.
What does the table accompanying the Vaughan-Williams classification show?
The table provides an overview of drug classes, their associated arrhythmias, and includes antiarrhythmic agents that are not classified within the Vaughan-Williams scheme.
What has contributed to the increase in cardiac disease in pregnancy?
The increase in cardiac disease in pregnancy is partly due to women with congenital heart disease now having children, but the majority is from acquired heart conditions.
What cardiac conditions can be encountered during pregnancy?
Cardiac conditions encountered in pregnancy include valvular lesions, congenital heart disease, cardiomyopathies, arrhythmias, and ischemic heart disease.
How does pregnancy affect the maternal cardiovascular system?
Pregnancy increases cardiac output (CO), which can cause deterioration in conditions like aortic stenosis, where CO is fixed, while conditions like regurgitant lesions may be well tolerated.
Why is diagnosing cardiac disease during pregnancy challenging?
Many symptoms of cardiac disease, such as breathlessness, palpitations, and syncope, as well as cardiovascular signs like a systolic murmur, mimic normal pregnancy symptoms, making diagnosis difficult.
What are the risks for women with cardiac conditions during pregnancy?
Women with cardiac conditions during pregnancy are at risk for CHF, hypoxia, arrhythmias and sudden cardiac death (SCD), bacterial endocarditis, venous thromboembolism, angina, myocardial infarction (MI), and aortic dissection.
When is pregnancy not advised for women with cardiac conditions?
Pregnancy is not advised for women with poor cardiac function, particularly those with Eisenmenger syndrome or pulmonary hypertension, due to high maternal death risk.
Which cardiac conditions are relatively well tolerated during pregnancy?
Conditions like atrial septal defect (ASD), ventricular septal defect (VSD), repaired tetralogy of Fallot, and coarctation of the aorta are relatively well tolerated during pregnancy.
Which cardiac conditions pose a significant risk during pregnancy?
Marfan syndrome and bicuspid aortic valve carry significant risks during pregnancy.
What may need to be altered in women with cardiac conditions during pregnancy?
Medications may need to be altered, and anticoagulation may be required for some women with cardiac conditions during pregnancy.
What anticoagulation regimen is typically followed for mechanical valves during pregnancy?
Anticoagulation for mechanical valves during pregnancy usually involves using unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) in the 1st trimester, switching to vitamin K antagonists for the 2nd and 3rd trimesters. Before planned delivery (36 hours), UFH is reintroduced (aPTT>2 of control). UFH is stopped 4-6 hours before surgery and resumed 4-6 hours after the operation.
What are the first diagnostic tests used if cardiac problems arise during pregnancy?
ECG and echocardiography are the first diagnostic tests, as they are non-invasive and safe for the fetus. If insufficient, chest radiography, CT, MRI, and cardiac catheterization may be used.
How is hypertension in pregnancy divided?
Hypertension in pregnancy is divided into two major groups:
- Hypertension without proteinuria: includes pre-existing chronic hypertension and gestational hypertension.
- Hypertension with proteinuria: includes pre-eclampsia and eclampsia.
What is gestational hypertension?
Gestational hypertension is hypertension that occurs after 20 weeks of gestation without proteinuria. It typically returns to baseline within 12 weeks of delivery.
What are the risk factors for gestational hypertension?
Risk factors for gestational hypertension include chronic kidney disease, diabetes, first pregnancy, age over 40, obesity, and family history.
What is the management of gestational hypertension?
Management of gestational hypertension includes beta-blockers and calcium channel blockers. ACE inhibitors, ARBs, and diuretics are contraindicated.
What is pre-eclampsia?
Pre-eclampsia is a condition of widespread vascular endothelial dysfunction and vasospasm, defined by hypertension and proteinuria (>300 mg/day) after 20 weeks of gestation.
What are the risk factors for pre-eclampsia?
Risk factors for pre-eclampsia include age extremes (young or old), obesity, diabetes, and a family history of pre-eclampsia.
How is pre-eclampsia classified?
Pre-eclampsia is classified as:
- Mild: Hypertension (>140/90) with proteinuria, presenting as asymptomatic, headache, or edema.
- Severe: Hypertension (>160/110) with proteinuria and severe features such as hypertensive crisis, pulmonary edema, DIC, elevated liver enzymes, acute renal failure, hemolytic anemia, and others.
What is the management of pre-eclampsia?
The management of pre-eclampsia typically involves delivery. Antihypertensive therapy, such as methyldopa, nifedipine, beta-blockers (labetalol and metoprolol), and hydralazine, may also be used.
What is eclampsia?
Eclampsia is pre-eclampsia with seizures, which can occur in the pre-, intra-, or postpartum periods.
How is eclampsia managed?
Eclampsia management includes seizure control with IV magnesium sulfate and blood pressure control with labetalol and epidural analgesia to relieve pain and cause vasodilation in the lower extremities.
What is peripartum cardiomyopathy (PPCM)?
Peripartum cardiomyopathy (PPCM) is a rare form of dilated cardiomyopathy marked by left ventricular (LV) systolic dysfunction, occurring from 1 month before to 6 months after delivery, most commonly right after delivery.
What is the suspected cause of PPCM?
The cause of PPCM is unclear but is thought to involve an immunological component.
What is the prognosis for women with PPCM?
A little over half of women with PPCM make a complete recovery, but recurrence is common in subsequent pregnancies, especially if cardiac function has not fully recovered.
What are the signs and symptoms of PPCM?
The signs and symptoms of PPCM are often typical of chronic heart failure.
What are the four criteria for diagnosing PPCM?
The four criteria for diagnosing PPCM are:
- Heart failure in the last month of gestation or within 5 months of delivery.
- Absence of other identifiable cause for heart failure.
- Absence of recognizable heart disease in the last month of pregnancy.
- LV systolic dysfunction with an ejection fraction (EF) of less than 45%.
What is the treatment for PPCM?
The treatment for PPCM includes the termination of pregnancy as soon as possible. If after delivery, β-blockers, nitrates, and diuretics may be given if necessary.
- What is aortic regurgitation (AR)?
Aortic regurgitation (AR) is a valvular heart disease characterized by incomplete closure of the aortic valve, leading to reflux of blood from the aorta into the left ventricle during diastole.
What are the two types of aortic regurgitation?
The two types of aortic regurgitation are acute and chronic AR.
What are common causes of acute aortic regurgitation (AR)?
Acute AR is commonly caused by infective endocarditis, aortic dissection, or chest trauma.
What are common causes of chronic aortic regurgitation (AR)?
Chronic AR is often caused by congenital bicuspid valve, rheumatic heart disease, and dilation of the aortic root (e.g., Marfan syndrome, Ehlers-Danlos syndrome, syphilis).
What happens in acute aortic regurgitation (AR) physiologically?
Acute AR often leads to rapid deterioration of left ventricular (LV) function, pulmonary edema, and cardiac decompensation.
What is a characteristic auscultatory finding in aortic regurgitation (AR)?
A characteristic auscultatory finding in AR is a high-pitched, decrescendo early diastolic murmur.
What is the significance of a widened pulse pressure in aortic regurgitation (AR)?
Widened pulse pressure is a diagnostic finding in AR and is often associated with a water hammer pulse, head bob with heartbeat, and pulsating carotid arteries.
How is aortic regurgitation (AR) diagnosed?
AR is primarily diagnosed using transthoracic echocardiography, which assesses LV function, aortic valve morphology, severity of regurgitation, and the condition of the aortic root and ascending aorta.
What is the main treatment for severe aortic regurgitation (AR)?
The main treatment for severe AR is aortic valve replacement, sometimes with long-term anticoagulation if a mechanical valve is used.
What is the medical management for patients with AR who have heart failure or hypertension?
ACE inhibitors, ARBs, and beta-blockers are useful in patients with AR who have heart failure or hypertension.
What is the indication for surgical intervention in aortic regurgitation (AR)?
Surgical intervention is indicated for symptomatic patients with severe AR or asymptomatic patients with significant AR if the resting LVEF is ≤50% or LV systolic diameter is >50 mm.
What are nonpharmacological treatments for hypertension?
Nonpharmacological treatments for hypertension include lifestyle changes such as diet modifications, exercise, and stress reduction.
When is pharmacological treatment initiated for hypertension?
Pharmacological treatment is initiated when nonpharmacological measures fail to control hypertension.
What are the ABCDs of pharmacological treatment for hypertension?
The ABCDs of pharmacological treatment are: A – ACE inhibitors or Angiotensin-receptor blockers (ARBs), B – β-blockers, C – Calcium Channel Blockers (CCBs), D – Diuretics.
What is the initial treatment approach for blood pressure (BP) below 150/90?
For BP below 150/90, one primary antihypertensive is used.
What is the treatment approach for blood pressure (BP) above 150/90?
For BP above 150/90, two primary antihypertensives are used.
How should antihypertensive choice be tailored to the patient?
The choice of antihypertensives should consider the patient’s ethnicity, pregnancy status, comorbidities (e.g., diabetes), and age.
What is the follow-up procedure after initiating antihypertensive treatment?
Follow-up should occur one month after initiation. If BP is controlled, reassess in 3-6 months; if uncontrolled, adjust the treatment.
What is the next step if the BP goal is not reached with one drug?
If the BP goal is not reached with one drug, increase the dose or add a second drug.
What is a first-line drug for hypertensive patients with diabetes mellitus or renal disease?
ACE inhibitors (e.g., lisinopril, enalapril) or ARBs (e.g., losartan, valsartan) are preferred for patients with diabetes or renal disease.
What side effect is common with ACE inhibitors and ARBs, and when should they not be used?
ACE inhibitors and ARBs can increase potassium (K+) and should not be used in pregnant patients or together.
What are the side effects of thiazide diuretics?
Thiazide diuretics can reduce potassium (K+) and sodium (Na+), and increase glucose and cholesterol levels.
What are the side effects of Calcium Channel Blockers (CCBs) like nifedipine?
CCBs may cause headaches, constipation, and GERD.
What is a contraindication for using β-blockers in hypertensive patients?
β-blockers are contraindicated in patients with aortic regurgitation.
What are the side effects of β-blockers?
β-blockers can cause bronchoconstriction and increased triglycerides.
What is the use of loop diuretics in hypertension treatment?
Loop diuretics, such as furosemide, are used in patients with heart failure or chronic kidney disease (CKD).
What is a second-line drug for patients with primary hyperaldosteronism?
Aldosterone antagonists are used for patients with primary hyperaldosteronism.
Which drug should be avoided in combination with ACE inhibitors or ARBs?
Direct renin inhibitors should not be used with ACE inhibitors or ARBs.
What is the initial step of pharmacological treatment for hypertension?
The initial step combines an ACE inhibitor or ARB with a calcium antagonist or a diuretic (A + C/D).
What is the second step of pharmacological treatment for hypertension?
The second step combines an ACE inhibitor or ARB with a calcium antagonist and a diuretic (A + C + D).
What is the third step in hypertension therapy?
The third step adds an extra hypertensive agent (e.g., spironolactone, beta-blocker, or alpha-blocker) to the previous regimen.
What are examples of fixed combination antihypertensive drugs?
Examples include: Tarka (trandolapril/verapamil), Zestoretic (lisinopril/hydrochlorothiazide), Exforge (valsartan/amlodipine), Hyzaar (losartan/hydrochlorothiazide).
- What are acyanotic heart defects?
Acyanotic heart defects are congenital cardiac malformations affecting atrial or ventricular walls, heart valves, or large blood vessels. They involve a left-to-right shunt, leading to pulmonary hypertension and right heart hypertrophy.
What are common causes of acyanotic heart defects?
Common causes include genetic defects (e.g., trisomies), maternal infections (e.g., rubella), and maternal use of drugs or alcohol during pregnancy.
How do acyanotic heart defects affect the heart physiologically?
Acyanotic heart defects cause a left-to-right shunt, leading to increased pulmonary blood flow, pulmonary hypertension, and right heart hypertrophy.
What are typical symptoms of acyanotic heart defects in infants?
Infants may be asymptomatic or present with exercise intolerance, failure to thrive, and symptoms of heart failure.
What is the role of heart murmurs in diagnosing acyanotic heart defects?
Characteristic heart murmurs are important clues for diagnosing acyanotic heart defects, which are confirmed via echocardiography.
What imaging techniques are used to diagnose and plan surgery for acyanotic heart defects?
Echocardiography, chest x-ray, MRI, and cardiac catheterization are used to diagnose and plan surgery for acyanotic heart defects.
What are the treatment options for acyanotic heart defects?
Acyanotic heart defects are treated via catheter procedures or surgery. Supportive therapy (e.g., diuretics, inotropic agents) is used in cases of heart failure or if surgery cannot be performed.
What are common complications of untreated acyanotic heart defects?
Common complications include arrhythmias, embolisms, and infective endocarditis, especially if treatment is delayed.
What are the types of atrial septal defect (ASD)?
The types of ASD include ostium primum ASD (15%), ostium secundum ASD (80%), and sinus venosus defect (5%).
What is the pathophysiology of atrial septal defect (ASD)?
ASD results from impaired growth or excessive resorption of the atrial septa in utero, causing a left-to-right shunt and sometimes paradoxical emboli.
What is an ostium primum ASD?
Ostium primum ASD (15%) is located near the crux of the heart and is often associated with malformed AV valves, resulting in varying degrees of regurgitation.
What is an ostium secundum ASD?
Ostium secundum ASD (80%) is located in the region of the fossa ovalis and is the most common type of atrial septal defect.
What is a sinus venosus defect?
Sinus venosus defect (5%) is located near the entry of the superior vena cava and is often associated with partial connection of right pulmonary veins to the right atrium.
How is atrial septal defect (ASD) diagnosed?
ASD is diagnosed using echocardiography.
What is the treatment for atrial septal defect (ASD)?
In children with ASD, spontaneous closure may occur. If needed, treatment involves surgical patch repair.
What is the most common congenital heart defect?
Ventricular septal defect (VSD) is the most common congenital heart defect.
What is the primary cause of ventricular septal defect (VSD)?
VSD is commonly associated with Down syndrome.
What are the two types of ventricular septal defect (VSD)?
The two types of VSD are perimembranous (80%), located in the membranous septum, and muscular (15-20%), completely surrounded by muscle.
What can happen if the left-to-right shunt in VSD is not treated?
If untreated, the increased blood volume from the left-to-right shunt can cause pulmonary hypertension, leading to Eisenmenger syndrome and cyanosis around the lips and fingertips.
How is ventricular septal defect (VSD) diagnosed?
VSD is diagnosed using echocardiography and can present with a holosystolic murmur.
