Cardiology Flashcards
worst risk factor for CAD
DM
most common risk factor for CAD
HTN
what counts as premature CAD
male <65
most dangerous part of lipid panel
LDL
greatest improvement in pt outcomes with CAD from which lifestyle modification
smoking cessation
chest wall tenderness is most likely d/t
costochondritis
most accurate test for costochondritis
physical exam
chest pain radiating to back with unequal BP between arms most likely d/t
aortic dissection
most accurate test for aortic dissection
chest x ray (wide mediastinum) confirmed with CT, MRI or TEE
chest pain worse when lying flat, better with sitting, in young (<40) most likely d/t
pericarditis
most accurate test for pericarditis
EKG (ST elevation in all leads and PR depression)
sudden onset SOB, tachycardia, hypoxia most likely d/t
PE
sharp, pleuritic pain, tracheal deviation most likely d/t
pneumothorax
chest pain with ____ has worst prognosis
SOB
chest pain with fever suggests
PE or pneumonia
when is a stress test done
stable pts with chest pain and unclear diagnosis
maximum HR =
220 - pt age
stress testing if EKG can’t be read
nuclear isotope (thallium or sestamibi) or echo
Stress test if pt can’t exercise
Persantine (dipyrimadole) or adenosine with thallium or sestamibi or dobutamine echo
adverse effect with dipyridamole
bronchospasm - avoid in asthmatics
most accurate method of detecting CAD
angiography
significant stenosis
> 70% may be surgically correctable, <50% is insignificant
holter monitor is used to evaluate
rhythm
chronic angina txs that lower mortality
aspirin, BB, nitroglycerin
med used when aspirin intolerance or recent angioplasty with stenting
clopidogrel
med used when chronic angina refractory to other tx
ranolazine
use when intolerant to both aspirin and clopidogrel
triclopidine
adverse effects of triclopidine
neutropenia and TTP
when is prasugrel used
use in those undergoing angioplasty with stenting
adverse effect of prasugrel
> 75 increased risk of hemorrhagic stroke
best mortality of benefit of ACEi/ARB with EF <
40%
most common adverse effect of statins
elevated transaminases
lipid drug with best mortality benefit
statins
lipid drug that raises HDL
niacin
adverse effects of niacin
glucose intolerance, elevation of uric acid, pruritis
lipid drug that lowers triglycerides
genfibrozil
adverse effects of genfibrozil
increased risk of myositis when combined with statins
adverse effects of cholestyramine
GI (constipation, flatus), interacts with meds in gut preventing their absorption
lipid drug lowers LDL but no benefit to patient
ezetimibe
which CCBs do not increase HR
verapamil and diltiazem
CCBs used when BB not tolerated
verapamil and diltiazem
adverse effects of CCBs
edema, constipation, heart block
when are BB contraindicated
severe asthma, prinzmetal angina, cocaine induced chest pain
when is CABG done
3 vessels with >70% stenosis
Left main coronary artery occluded
2 vessel disease in DM
or persistent symptoms despite meds
how long do artery grafts last for
10yrs
how long do vein grafts last for
5 yrs
Best therapy in ACS especially if ST elevation
PCI
ACS is associated with what heart sound
S4 gallop – ischemia causes noncompliance of LV
acute myocardial damage in postmenopausal women immediately after stressful event
tako-tsubo cardiomyopathy
tako-tsubo cardiomyopathy pathology d/t
ballooning and LV dyskinesis
tx for tako-tsubo cardiomyopathy
BB and ACEi
MI with worst prognosis
anterior wall MI
ST elevation in V2 and V4
anterior wall MI
ST elevation in II, III, and aVF
Inferior wall MI
ST depression in V1 and V2
Posterior wall MI
tx for posterior wall MI
no additional tx needed - low mortality
what type of BBB is more dangerous
LBBB
tx of PVCs
no tx - tx worsens outcome
tx for stable angina
aspirin, BB, nitrates
ACS abnormalities show up on EKG
immediately
ACS abnormalities show up on myoglobin
after 1-4 hrs
ACS abnormalities show up on CK-MB
after 4-6hrs
ACS abnormalities show up on troponin
after 4-6 hrs
myoglobin stays elevated for
1-2 days
CK-MB stays elevated for
1-2 days
troponin stays elevated for
10-14 days
first tx for STEMI
aspirin
complications of PCI
rupture, restenosis, hematoma
PCI for STEMI should be done within
90 mins
thrombolytics for STEMI should be given within
30 mins
contraindications to thrombolytics
brain or bowel bleed, surgery within 2 weeks, BP >180/110, nonhemorrhagic stroke within 6 mo
when is heparin used in STEMI
after thrombolytics
STEMI, contraindication to thrombolytics, next step?
transfer for PCI
what drugs should be given in STEMI but are not time dependent
BB, ACEi, statins
first tx in NSTEMI
heparin - prevents clot formation
what type of heparin is superior for NSTEMI
LMWH
NSTEMI undergoing angioplasty and stenting, give
Glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban, eptifibitide)
NSTEMI, all meds given but not better
PCI
what drugs are NOT given in STEMI
GPIIb/IIIa, CCBs, or warfarin
what drugs are NOT given in NSTEMI
thrombolytics, CCBs, or warfarin
most common cause of death post MI
ventricular arrhythmia (keep in ICU)
Recurrence of pain, new onset of rales, sudden onset pulmonary edema
reinfarction
suspected reinfarction, next step
EKG for new ST abnormalities, and CK-MB levels
tx for reinfarction
repeat angioplasty
tx for symptomatic sinus bradycardia
atropine if symptomatic, pacemaker if ineffective
sinus bradycardia post MI d/t
vascular insufficiency of SA node
what are Cannon A waves
bounding of jugulovenous wave bouncing into neck
cannon waves and Sinus bradycardia
third degree AV block
tx for third degree AV block
pacemaker
third degree AV block post MI is associated with
RV infarction
New inferior wall MI and clear lungs
RV infarction
dx of RV infarction
flip EKG, ST elevation in RV4
the Right coronary artery supplies
RV, AV node, inferior wall
tx of RV infarct
high volume fluid replacement
avoid ____ in RV infarct
nitroglycerine
Several days after MI – sudden loss of pulse
tamponade or free wall rupture
dx of tamponade or free wall rupture
emergency echo
tx for tamponade or free wall rupture
emergency pedicardiocentesis
tx for V tach or V fib
cardioversion/defibrillation
New onset murmur and pulmonary congestion post MI
valve or septal rupture
most accurate test for valve or septal rupture
echo
Step up in oxygen (from RA to RV)
septal rupture
mitral valve regurge is best heard
at apex with radiation to axilla
ventricular septal rupture is best heard
at lower left sternal border
pericarditis post MI
dressler syndrome
dx of persistent ischemia post MI
stress test before discharge
ACEi are best for what type of MI
anterior wall
should prophylactic antiarrhythmics be used post MI
no - increase mortality
routine post MI care
Aspirin, BB (metoprolol), statins, ACEi
should dipyramidamole be used post MI
NO
post MI erectile dysfunction is most often due to
anxiety, but can be from BB
how long do you have to wait post MI to have sex
you don’t
Decrease of BP >10 on inspiration
pulsus paradoxus
pulsus paradoxus is associated with
cardiac tamponade
kussmaul sign is most often associated with
constrictive pericarditis or restrictive cardiomyopathy
most common cause of hospital admission
CHF
most common cause of death in CHF
arrhythmia
cause of CHF
Infarction → dilation → regurgitation → CHF
Dyspnea on exertion, peripheral edema, rales, JVD, PND, S3 gallop
CHF
CHF with low EF
systolic dysfunction
CHF with preserved EF
diastolic dysfunction
best initial test for CHF
TTE
most accurate test for EF
MUGA or nuclear ventriculography
when do u get BNP
acute SOB with unclear etiology and no time for echo
swan ganz cath can distinguish
CHF from ARDS (but not routinely done)
adverse effect of lisinopril
hyperkalemia
B1 specific BB
metoprolol and bisoprolol
nonspecific BB with a1 blockage
carvedilol
CHF - SOB with minimal exertion or at rest is what class
III or IV
adverse effects of spironolactone
hyperkalemia, gynecomastia
med that inhibits aldosterone but no antiandrogenic effects
eplerenone
implantable defribillator in CHF (systolic dysfunction) if EF
<35%
biventricular pacemaker for CHF (systolic dysfunction) if
Dilated cardiomyopathy and EF 120) with persistent symptoms
drugs with mortality benefit in CHF with systolic dysfunction
ACEi/ARBs, BB, spironolactone/eplerenone, hydralazine/nitrates, implantable defibrillator
routine anticoagulation for CHF (systolic dysfunction)
WRONG unless clot in heart
drugs with clear mortality benefit in CHF (diastolic dysfunction)
BB
drugs with NO clear mortality benefit in CHF (diastolic dysfunction)
digoxin and spironolactone
drug for symptom control in CHF (diastolic dysfunction)
diuretics - but contraindicated in HOCM
Rales, JVD, S3 gallop, Edema, orthopnea, ascites and hepatosplenomegaly
acute pulmonary edema
most important acute test for acute pulmonary edema
EKG
chest x ray for acute pulmonary edema shows
cephalization of flow
acid base disorder in acute pulmonary edema
respiratory alkalosis - from hyperventilation (CO2 leaves easier than O2 enters)
best initial tx for acute pulmonary edema
remove large volume with loop diuretic (furosemide, bumetinide)
oxygen, morphine, nitrates
IV form of atrial natriuretic peptide, only a weak diuretic so no mortality benefit
nesiritide
meds for acute afterload reduction
Nitroprusside and Hydralazine
phosphodiesterase inhibtors (amironone and milrinone) effect on heart
increase contractility and decease afterload
digoxin effect on heart
increases contractility, but takes several weeks
most common valve disease in rheumatic fever
mitral stenosis
valve disease associated with aging and calcification
aortic stenosis
regurge valve diseases most commonly from
HTN and ischemic heart disease
right sided valve diseases increase with
inhalation
left sided valve disease increases with
exhalation
best initial test for valvular heart disease
ech
most accurate test for valvular heart disease
cath
all valvular heart diseases benefit from
diuretics
which valve disease to Look for in young adult, pregnant immigrant
mitral stenosis
dysphagia, hoarseness, A fib and stroke, hemoptysis, murmur
mitral stenosis
EKG in mitral stenosis shows
LA hypertrophy shows as biphasic P wave in Leads V1 and V2
x ray in mitral stenosis shows
second bubble behind heart
Murmur – diastole, just after opening snap
mitral stenosis
tx for mitral stensosis
diuretics, Na restriction, Balloon valvuloplasty, warfarin for a fib, rate control
poorest prognosis with aortic stenosis
CHF - 2 yr survival
Murmur – systolic, crescendo-decrescendo. Heard best at second right intercostal space, radiates to carotid artery.
aortic stenosis
angina, syncope, CHF, murmur
aortic stenosis
EKG in aortic stenosis shows
LVH. S wave in V1 plus R wave in V5
tx of aortic stenosis
valve replacement
Murmur – pansystolic (holosystolic), obscuring S1 and S2. Radiates to axilla.
mitral regurgitation
tx for mitral regurgitation
ACEi/ARBs are best – decrease rate of progression
when is valve replacement indicated in mitral regurge
heart starts to dilate, LVESD >40 or EF <60%
Murmur – diastolic, decrescendo. Heard best at lower left sternal border.
aortic regurgitation
tx for aortic regurge
ACEi/ARBs or nifedipine delay progression
valve replacement in aortic regurge indicated when
acute valve rupture or EF 55
de musset sign
head bobbing (aortic regurge)
hill sign
BP in legs as much as 40 > than in arms (aortic regurge)
quinke pulse
pulsations in nail bed (aortic regurge)
water hammer pulse
wide, bounding (aortic regurge)
which conditions are associated with mitral valve prolapse
marfans and ehler danlos
which valvular disease is most often asymptomatic
mitral valve prolapse
dx of mitral valve prolapse
echo is best (cath should rarely be done)
murmur - midsystolic clock
mitral valve prolapse
tx of mitral valve prolapse
BB when symptomatic, then valve repair (with catheter)
Atypical chest pain, palpitations, panic attack, murmur
mitral valve prolapse
all forms of cardiomyopathy benefit from
diuretics
dilated cardiomyopathy is ___ dysfunction
systolic = low EF
tx for dilated cardiomyopathy
ACEi/ARBs, BB – lower mortality
Diuretics and digoxin - control symptoms
If wide QRS – biventricular pacemaker improves symptoms and survival
hypertrophic cardiomyopathy is ___ dysfunction
diastolic = preserved EF
most common cause of hypertrophic cardiomyopathy
HTN
heart sound associated with hypertrophic cardiomyopathy
S4 gallop
hypertrophic cardiomyopathy symptoms worsened by
increased HR and decreased LV size
best initial test for hypertrophic cardiomyopathy
echo
most accurate test for hypertrophic cardiomyopathy
cath
Septal Q waves in inferior and lateral leads
HOCM (not MI)
Systolic anterior motion of mitral valve
HOCM
best initial tx for hypertrophic cardiomyopathy
BB
what tx is always WRONG for hypertrophic cardiomyopathy
digoxin and spironolactone
increased jugulovenous pressure on inhalation
kussmaul sign
tx of restrictive cardiomyopathy
tx underlying cause, diuretics
best initial test of restrictive cardiomyopathy
echo
most accurate test for restrictive cardiomyopathy
endometrial biopsy
speckling of septum on echo or cardiac MRI
amyloidosis
which valve diseases do not increase with expiration
HOCM, MVP
All murmurs decrease with less blood except
HOCM, MVP
Standing and valsalva ____ venous return to heart
decrease
Handgrip _____ LV emptying
decreases
Amyl nitrate_____LV emptying
increases
amyl nitrate mimicks
ACEi
Squatting and leg raise increase, standing and valsalva decrease, handgrip decreases, amyl nitrate increases
AS
Squatting and leg raise increase, standing and valsalva decrease, no effect with handgrip or amyl nitrate
MS
Squatting and leg raise increase, standing and valsalva decrease, handgrip increases, amyl nitrate decreases
AR and MR
Squatting and leg raise decrease, standing and valsalva increase, handgrip decreases, amyl nitrate increases
MVP and HOCM
most common infection causing pericarditis
viral (coxsackie B)
most common connective tissue disorder causing pericarditis
SLE
EKG on pericarditis shows
ST elevation all leads, PR depression
tx of pericarditis
NSAIDs
tx of pericarditis that decreases recurrences
colchicine
in pericardial tamponade which side of heart is compressed first
right - thinner walls
Hypotension, tachycardia, distended neck veins, clear lungs, pulsus paradoxus
pericardial tamponade
most appropriate test for pericardial tamponade
echo
EKG in pericardial tamponade shows
electrical alternans
pericardial tamponade on x ray
globular heart
pericardial tamponade on echo
RA and RV diastolic collapse
right heart cath in pericardial tamponade shows
equilization of pressures in diastole
tx of pericardial tamponade
pericardiocentesis, IV fluids, window in pericardium if recurrent
what worsens pericardial tamponade
diuretics
heart sound with constrictive pericarditis
knock in diastole
tx of constrictive pericarditis
diuretics first, then surgical removal of pericardium
best initial test for PAD
ABI, <0.9 = disease
most accurate test for PAD
angiogram
best initial tx for PAD
aspirin, smoking cessation, cilostazol
single most effective med for PAD
cilostazol
best initial test for aortic dissection
x ray
Pain between scapulae, difference in BP between arms
aortic dissection
most accurate test for aortic dissection
angiography
tx of aortic dissection
control BP - BB, nitropruside, surgery
for aortic dissection what must be done before starting nitropruside
BB - prevents reflex tachycardia
heart disease most dangerous to pregnant woman
peripartum cardiomyopathy
heart disease second most dangerous to pregnant woman
eisenmenger
tx for peripartum cardiomyopathy
ACEi/ARB, BB, spironolactone, diuretics, digoxin
peripartum cardiomyopathy usually happens when after delivery
post partum
after peripartum cardiomyopathy LV dysfunction doesn’t improve then
cardiac transplant, no repeat pregnancy of will provoke enormous antibody production
peripartum cardiomyopathy MOA
antibodies against myocardium
