cardiology Flashcards
when do you need to do urgent cath in unstable angina
hemodynamic instability • HF • recurrent rest angina despite therapy • new or worsening MR murmur • sustained VT
initial tx of someone with unstable angina/nstemi and tini score of 0-2
Low risk. Begin aspirin, β-blocker, nitrates, heparin, statin, clopidogrel. Predischarge stress testing and angiography if testing reveals significant myocardial ischemia
initial tx of someone with unstable angina/nstemi and timi score of 3-7
Intermediate to high risk. Begin aspirin, β-blocker, nitrates, heparin, statin, clopidogrel, and early angiography followed by revascularization
other causes of st elevation
Consider acute pericarditis, LV aneurysm, takotsubo (stress)
cardiomyopathy, coronary vasospasm (Prinzmetal angina), acute stroke, or normal variant.
door to balloon time
90 min
transfer to pci capable hospital within how many minutes
120min
when should you start spironolactone after stemi
3-14 days after if LVEF does not improve over 40% and clinical HF or DM
when to give thrombolytics in stemi
Administer thrombolytic agents when PCI is not available and cannot be achieved within 120 minutes
with transfer
contraindications to thrombolytic tx in stemi
The most commonly encountered contraindications include active bleeding or high risk for bleeding (recent
major surgery). BP >180/110 mm Hg on presentation is a relative contraindication.
when do you do cabg in acute stemi setting
CABG is indicated acutely for STEMI in the presence of thrombolytic PCI failure or mechanical complications
(papillary muscle rupture, VSD, free wall rupture).
indications for pacing in acute mi
asystole
• symptomatic bradycardia (including complete heart block)
• alternating LBBB and RBBB
• new or indeterminate-age bifascicular block with first-degree AV block
criteria for icd post mi
> 40 days since MI
• LVEF ≤35% and NYHA functional class II or III or LVEF ≤30% and NYHA functional class I
• >3 months since PCI or CABG
signs of post mi VSD or papillary wall rupture
Patients with VSD or papillary muscle rupture develop abrupt pulmonary edema or hypotension and a loud holosystolic murmur and thrill.
signs of free wall rupture after mi
LV free wall rupture causes sudden hypotension or
cardiac death associated with pulseless electrical activity
when should you give pregnant pt with cardiomyopathy anticoagulation
Anticoagulation with warfarin is recommended for women with peripartum cardiomyopathy with LVEF <35%.
recommendation for future pregnancy once pt suffered peripartum cardiomyopathy
avoid future pregnancy
giant cell myocarditis
form of dilated cardiomyopathy with biventricular enlargement, refractory ventricular arrhythmias, and rapid progression to cardiogenic shock in young to middle-aged adults
first line tx for hocm
beta blocker
how to tx afib and hocm
warfarin regardless of chadsvasc score. noacs 2nd line
indication for hocm surgery/ablation
outflow tract gradient of >50 mm Hg and continuing symptoms despite maximal drug therapy.
indications for icd in hocm
Previous cardiac arrest
Spontaneous sustained VT
Family history of sudden death (first-degree relative)
Unexplained syncope
LV wall thickness ≥30 mm
Blunted increase or decrease in SBP with exercise
Nonsustained spontaneous VT ≥3 beats
who should be screened for hocm
All first-degree relatives of patients with HCM should have genetic counseling and, in the absence of a documented genetic mutation in the proband, echocardiographic screening. Ongoing screening is recommended throughout adulthood starting at
age 12 years because of the possibility of disease expression at any age
who should be screened for hocm
All first-degree relatives of patients with HCM should have genetic counseling and, in the absence of a documented genetic mutation in the proband, echocardiographic screening. Ongoing screening is recommended throughout adulthood starting at
age 12 years because of the possibility of disease expression at any age
clues that patient may have amyloid cardiomyopathy
Neuropathy, proteinuria, hepatomegaly, periorbital ecchymosis, bruising, low-voltage ECG. Diagnosis can be confirmed with abdominal fat pad aspiration.
clues that patient may have sarcoid cardiomyopathy
Bilateral hilar lymphadenopathy; possible pulmonary reticular opacities; and skin, joint, or eye lesions.
Cardiac involvement is suggested by the presence of arrhythmias, conduction blocks, or HF. Diagnosis is
supported by CMR imaging with gadolinium.
clues that patient may have hemochromotosis
Abnormal aminotransferase levels, OA, diabetes, erectile dysfunction, and HF; elevated serum ferritin and transferrin saturation level.
utility of ambulatory ecg
Indicated for frequent (at least
daily) arrhythmias
exercise ecg indication in arrhythmias
Indicated for arrhythmias
provoked by exercise
utility of event monitor
Indicated for infrequent
arrhythmias >1-2 min in
duration
small recorder held on chest when symptomatic
loop recorder utility
Indicated for infrequent
symptomatic brief arrhythmias
Saves previous 30 s to 2 min
ECG signal when patient
activates the recorder
inplanted loop recorder utility
Indicated for very infrequent
arrhythmias
chads2vasc
1 point each is given for:
• HF
• hypertension
• diabetes
• vascular disease (previous MI, PAD, aortic plaque)
• female sex
• age 65 to 74 years
2 points each are given for:
• previous stroke, TIA, or thromboembolic disease
• age ≥75 years
Provide anticoagulation for a score ≥1 in men and ≥2 in women.
what agent can you use for valvular afib meaning mechanical valve or mod to severe rheumatic mitral stenosis
only warfarin
likely cause of svt that is terminated with adenosine
AVNRT and AVRT
tx of MAT
address underlying dx
pulmonary and cardiac disease, hypokalemia, and hypomagnesemia.
Metoprolol is the drug of choice followed by verapamil
Aortic stenosis
Mid-systolic;
crescendo decrescendo
severe as: high pitched, late-peaking murmur; diminished and delayed carotid upstroke
bicuspid valve without calcification will have systolic ejection click followed by murmur
Aortic regurgitation
Diastolic; decrescendo
murmur is heard over LLSB over the valve, but RLSB (dilated aorta) is heard best when leaning forward
mitral stenosis
Diastolic; low pitched,
decrescendo
best heard apex in left lateral decubitus
Loud S1; tapping apex beat;
opening snap after S2
Mitral
regurgitation
Systolic; holo-,
mid-, or late
systolic
apex; radiates to underarm or back
systolic click with prolapse
tricuspid regurgitation
Holosystolic
LLSB radiates to LUSB
tricuspid stenosis
Diastolic; low pitched, decrescendo;
increased intensity during inspiration
pulmonary regurgitation
Diastolic; decrescendo
LLSB
pulmonary stenosis
Systolic; crescendo-decrescendo LUSB Pulmonic ejection click after S1 (diminishes with inspiration)
radiates to clavicle
HOCM murmur
Systolic;
crescendo decrescendo
LLSB
ASD
Systolic; crescendo decrescendo RUSB Fixed split S2; right ventricular heave;
VSD
Holosystolic LLSB Palpable thrill; murmur increases with hand-grip, decreases with amyl nitrite
Murmurs that increases with valsalva vs decrease
Increase: HOCM MVP
Decrease: AS MR
Murmur that increases with laying down squatting, leg raise vs decrease
Increase: AS MR
Decrease HOCM MVP
Murmur that increases with handgrip/phenylephrine vs decrease
Increase: MR
Decrease MVP HOCM AS
Murmur that increases with amyl nitrate vs decrease
increase MVP HOCM AS
Decrease MR
tx for pericarditis
colchicine and nsaid
prevention for Rheumatic fever after GAS infection
GIven penicillin or eythromyocin
prophylaxis in patient with rheumatic fever
Patients with a history of RF require long-term prophylactic penicillin, and patients with rheumatic valvular disease should continue
prophylaxis for at least 10 years after the last episode of RF or until at least 40 years of age
serial follow up interval for asymptomatic severe as
6-12 months in asymptomatic patients with severe AS, every 1-2 years in patients with moderate AS, and every 3-5 years in those with mild AS.
when do you do surgery for aortic root in bicuspid AS
aortic root diameter is >5 cm with additional risk factors for dissection (family history, rate of progression ≥0.5 cm/year) or >5.5 cm without risk factors.
screening for bicuspid aortic valve and root
Asymptomatic patients with severe aortic valve stenosis or regurgitation require echocardiography every 6-12 months; those with mild stenosis or regurgitation require it every 3 to 5 years.
The ascending aortic diameter should be assessed annually by echocardiography if the aortic root or ascending aorta dimension
is >4.5 cm and every 2 years if the dimension is <4.0 cm.
causes of acute AR
IE or aortic dissection
tx for acute AR
Schedule immediate aortic valve replacement for patients with acute AR. Bridging medical therapy includes sodium nitroprusside and IV diuretics. Dobutamine or milrinone are also indicated if the BP is unacceptably low.
tx for chronic AR
For chronic symptomatic AR, valve replacement is indicated regardless of LV systolic function.
Valve replacement also is indicated for asymptomatic patients with LVEF <50%.
Combined aortic root replacement with aortic valve replacement is used when
an associated aortic root aneurysm is present.
when does mitral stenosis present after RF
20-40 years after
how should you treat afib with Mitral stenosis
warfarin regardless of chads 2 vasc
mitral stenosis tx
percutaneous balloon mitral commissurotomy is indicated for symptomatic patients (NYHA functional class II, III, or IV) and for asymptomatic patients when the valve area is <1.0 cm2.
optimal settings for mitral percutaneous commissure
pliable leaflets, minimal commissural fusion, and minimal valvular or subvalvular calcification
when do you do mitral surgery for stenosis
Mitral valve surgery (repair if possible) is indicated in patients with symptomatic (NYHA functional class III-IV) mitral stenosis when balloon valvotomy is unavailable or contraindicated or the valve morphology is unfavorable.
causes of acute mitral regurg
patients with chordae tendineae rupture resulting from
myxomatous valve disease or endocarditis.
causes of chronic mitral regurg
- MVP
- IE
- HCM
- ischemic heart disease
- ventricular dilatation
- Marfan syndrome
indications for surgery in MR
- acute MR
- chronic symptomatic MR
- asymptomatic MR with LVEF <60% or LV end-systolic diameter >40 mm
- PH caused by MR
- new-onset AF
- chronic severe primary MR when another cardiac surgery is planned
what is the preferred surgical goal for mitral regurg. replace or repair
repair is preferred over replace
what should you do with patients with unexplained TIA with MVP and sinus rhythm and no atrial thrombi
aspirin then warfarin if recurrent neurological episodes
Treat patients with MVP and having palpitations, chest pain, anxiety, or fatigue
beta blocker
when do you do surgery for mvp
Surgery is required for significant MR, a flail leaflet caused by a ruptured chorda, or marked chordal
elongation.
primary causes of tricuspid regurg
Marfan syndrome and congenital disorders such as Ebstein anomaly (abnormalities of the tricuspid valve and right ventricle) and AV canal malformations.
secondary causes of tricuspid regurg
IE, carcinoid syndrome, PH, and
RF.
tx for tricuspid regurg
Consider tricuspid valve surgery in patients undergoing left-sided valve surgery who have severe tricuspid regurgitation or in
patients with symptomatic tricuspid regurgitation unresponsive to medical management.
target INR for aortic prosthetic valve without thromboembolism risk factors
2.5
target INR for aortic prosthetic valve with thromboembolism risk factors
3.0
All patients with mechanical prosthetic valves of any type should receive what with warfarin
aspirin
when do you not need to interrupt anticoagulation in a patient with a prosthetic valve
cataract surgery
how to approach stopping ac prior to surgery in an aortic prosthetic valve
stop 4-5 days before restart as soon as possible after
bridge when it pt is high risk for thromboembolism
what are the findings of an asd
fixed splitting of the S2, a pulmonary midsystolic murmur, and tricuspid diastolic flow murmur
whats the most common form of ASD and ecg
ostium secundum defect, which usually occurs as an isolated abnormality. The ECG shows right axis deviation and partial RBBB
when is closure indicated for ASD
Closure is indicated for right atrial or right ventricular enlargement, large left to right shunt, or symptoms
ASD surgery types
Select percutaneous device closure for ostium secundum ASD and surgical closure for ostium
primum ASD and associated mitral valve defects
what should you do if patient had a reversal shunt R to L
do not pick closure !
signs of coarctation of aorta
Characteristic findings include hypertension, diminished femoral pulses, radial-to-femoral pulse delay, and a continuous murmur audible over the
back. In patients with aortic coarctation and a bicuspid aortic valve, an ejection click or a systolic murmur may be heard.
tx for coarctation
Schedule balloon dilation for patients with a discrete area of aortic narrowing, proximal hypertension, and a pressure gradient >20 mm Hg.
pda murmur
A continuous “machinery” murmur is
heard beneath the left clavicle. Bounding pulses and a wide pulse pressure may also be noted.
classic sign for eisenmenger PDA
clubbing and oxygen desaturation that affects the feet but not the hands
tx for PDA
Closure of a PDA is indicated for left-sided cardiac chamber enlargement in the absence of severe PH. A tiny PDA without other
findings requires no intervention.
patients who need prophylaxis for IE
prosthetic cardiac valve
• history of IE
• unrepaired cyanotic congenital heart disease
• repaired congenital heart defect with prosthesis or shunt (≤6 months post-procedure) or residual defect
• valvulopathy following cardiac transplantation
• prosthetic material used for cardiac valve repair (annuloplasty rings and chords)
surgeries that require prophylaxis
dental procedures that involve mucosal bleeding
• procedures that involve incision or biopsy of the respiratory mucosa
• procedures in patients with ongoing GI or GU tract infection
• procedures on infected skin, skin structures, or musculoskeletal tissue
• surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials
dosing for IE prophylaxis
Most patients requiring prophylaxis will be undergoing dental procedures, and the indicated antibiotic is oral amoxicillin 30 to
60 minutes before the procedure.
testing for endocarditis
TTE is sufficient to rule out IE in low-probability patients, but a TEE is indicated to rule-in IE in patients with high probability
of disease. Obtain a TEE particularly in the setting of Staphylococcus aureus bacteremia. TEE is the test of choice to identify
a paravalvular abscess.
Community-acquired native valve IE tx
Vancomycin or ampicillin-sulbactam plus gentamicin
Nosocomial-associated IE tx
Vancomycin, gentamicin, rifampin, and an antipseudomonal β-lactam
Prosthetic valve IE tx
Vancomycin, gentamicin, and rifampin
duration of tx for IE
Continue treatment for 4 to 6 weeks except in uncomplicated rightsided native valve endocarditis caused by MSSA, which can be treated for 2 weeks
surgery indications for thoracic aneurysm
- aortic diameter >5.0 cm (>4.5-5.0 cm for Marfan syndrome)
- aortic diameter >4.5 cm and undergoing other heart surgery
- rapid growth >0.5 cm/yr
medication response for acute dissection
IV BB add nitroprusside if BP not controlled
when is emergent surgery indicated for dissection
Emergent surgery is required for type A dissection (involving the ascending aorta) or intramural hematoma
screening for AAA
One-time ultrasonographic screening is indicated to detect an asymptomatic AAA in any man between the ages of 65 and
75 years who has ever smoked and in selected men ages 65 to 75 years who have never smoked
surgery indication for AAA
Schedule surgical or endovascular repair of AAAs ≥5.5 cm in diameter, those growing ≥0.5 cm per year, or symptomatic AAAs.
Ruptured AAA requires emergent surgery
monitoring guidelines for AAA
Patients with an unrepaired AAA require ultrasonographic monitoring at 6- to 12-month intervals if the AAA measures 4.0 to
5.4 cm and every 2 to 3 years for smaller AAAs.
pathonomonic for arteroemboli in the eye
transient vision loss (a golden or brightly
refractile cholesterol body within a retinal artery [Hollenhorst plaque] is pathognomonic)
what test should you perform if patient has normal or borderline abi resting score but suspicious symptoms
exercise abi
what testing should be done prior to surgery for pad
Noninvasive angiography with duplex ultrasonography, CTA, or MRA is performed for anatomic delineation of
PAD in patients requiring surgical or endovascular intervention.
how do you calculate abi
ratio of the highest systolic arm BP (regardless of side) compared with the highest systolic ankle BP
for that side
normal ABI
ABI positive for pad
ABI level for resting ischemia
Normal ABI is >0.9 to ≤1.40.
• ABI ≤0.90 is compatible with PAD.
• ABI ≤0.40 is associated with ischemic rest pain.
what if abi is >1.4 what should you do next
When the ABI is >1.40, select a toe-brachial index to provide a better assessment of lower extremity perfusion
best tx for PAD
exercise therapy
what is the best optimaztion for patients with PAD
- BP goal <130/80 mm Hg
- aspirin (preferred over clopidogrel)
- high-intensity statin therapy
- cilostazol for patients with intermittent claudication
when do you do surgery for pad
Select angioplasty or surgery for patients who do not improve with medical therapy or have pain at rest or poorly healing ulcers.
signs of patient with atrial myxoma
fever, anorexia, and weight loss
murmur that sounds like ms but with a tumor flop
where do myxomas orignate vs angiosarcoma
Myxomas are commonly in left atria vs angioscarcomas are commonly in right atria
