Cardiology Flashcards
what is ck-mb and troponin?
cardio markers
ck-mb - stays elevated x 1-2 days
troponin - stays elevated x 1-2 wks
when do i answer exercise thallium testing or stress echo?
when ekg is unreadable for ischemia: LBBB digoxin use pacemaker in place LVH any baseline abnormality of the ST segment of the EKG
next best diagnostic test to evaluate an abnormal stress test that shows “reversible” ischemia?
angiography
when is coronary bypass appropriate?
once angiogram has been done
name p2y12 receptor blockers and their moa?
clopidopgrel, prasugrel, ticagrelor
they block aggregation of platelets to each other by inhibiting ADP-induced activation of the p2y12 receptor.
prasugrel?
p2y12 antagonist added only for angioplasty!!!
when to give thrombolytics (alteplase)?
chest pain for <12 hrs and STEMI and PCI cannot be performed within 90 minutes of arrival the ED.
when to have urgent angioplasty or PCI?
within <12hr of chest pain and within 90 min since the time of first contact to PCI capable facility
when is lidocaine or amiodarone the answer for acute MI?
only when there is ventricular tachycardia or ventricular fibrillation
factor Xa inhibitors?
what inhibits them?
rivaroxaban, apixaban, edoxaban, betrixaban
inhibited by Andexanet alfa
indirect thrombin inhibitors?
heparin and LMWH
Direct thrombin inhibitors?
what inhibits them?
argatroban, bivalirudin, desirudin, dabigatran
inhibited by Idarucizumab
aortic stenosis?
syncope in old folks;
systolic, cres-decres murmur on R 2nd ICS, radiating to R carotids or R clavicle, Diminished A2, ejection click, paradoxical slitting of S2
Diagnose with TEE (best initial)
Tx with diuretics; balloon dilation if pt too sick to undergo surgery
difference btw bioprosthetic vs mechanical valves?
bioprosthetic lasts less and no anticoagulation required
mechanical lasts more but require warfarin (INR 2-3)
Aortic regurgitation?
SOB and fatigue
diastolic, decres at L sternal border
Diagnosis with TTE
Tx with ACEIs/ARBs and nifedipine
mitral stenosis?
rheumatic fever is most common cause (immigrant, pregnant)
dysphagia, hoarseness, a fib
diastolic rumble after an opening snap (OS)
MS worsens when OS closes to S2
Diagnose with TTE
Tx with diuretics and ballon valvuloplasty (most effective)
mitral regurgitation?
dyspnea on exertion
holosystolic murmur heard best at apex; radiates to axilla
diagnose with TTE
Tx with ACEIs/ARBs and nifedipine
pericarditis Tx?
NSAIDs; Ibuprofen with colchicine
If pain persists then add PO prednisone
pericardial tamponade?
SOB, Hypotension, JVD
pulsus paradoxus (bp drops >10mmhg with inhalation)
electrical alternans
Dx with echo; do EKG
Tx with Pericardiocentesis (best initial therapy)
Pericardial window placement (most effective long term)
most dangerous therapy for P temponade?
diuretics
constrictive pericarditis?
unique features:
kussmaul sign (increase in jvp on inhalation)
pericardial knock
Dx: CXR (calcification), EKG, CT/MRI
Tx: diuretics (best initial therapy)
surgical removal of pericardium (most effective therapy)
Aortic dissection?
severe sudden chest pain radiating to back btw scapula
difference in bp btw L and R arms
Dx: Best initial is CXR (widened mediastium)
Most accurate: CT angio = TEE (when CT angio is CI esp. during renal Insuff.) = MR angio
Tx: BBs immediately, ICU, nitroprusside for further bp control
when to screen for AAA?
ultrasound in men 60-75 who are current or former smokers
when to repair AAA?
> 5.5mm
<5.5mm; monitor it regularly with US q6months - 3years; lifestyle modifications
meds used in rate control of a fib?
atenelol, metroprolol
non dhp ccbs i.e verapamil and diltiazem
WPW syndrome patient should avoid?
warm bath -> causes peripheral vasodilation and rise in body temp -> drop in BP -> sympathetic system is activated -> further increase in HR and worsening sxs
“asymptomatic” severe aortic stenosis patient? next best step?
exercise testing to confirm symptomatic status; if yes then further management
when BBs are contraindicated in pts with ACS?
- systolic bp <90 mmhg
- severe bradycardia
- 2nd or 3rd deg AV block
- peripheral vascular diseases
- uncompensated CHF
- cardiogenic shock
- asthma or emphysema that is sensitive to beta agonist
diastolic murmurs?
AR and MS
behcet’s syndrome?
recurring oral
genital ulcers
Eye lesions (uveitis; tx with Topical steriod)
Skin lesions (sterile pustule with erythematous margins within 48hrs after an aspetic needle prick)
vasculitis (unknown reasons)
seen in pt from korea, japan and easter Mediterranean
long term therapy for CONGENITAL torsades de pointes?
beta blockers
*contraindicated in acquired TdP because bradycardia may prolong QT interval further and worsen the sxs
drugs to avoid in HOCM?
diuretics, ACE/ARBs, nitrates (anything that reduces preload)
BBs are beneficial (increase vent contractility, increase vent volume and compliance)
what are Canadian HTN education program (CHEP) recommendations?
initial therapy for isolated HTN are:
Thiazide/Thiazide like diuretics, beta blockers(younger patient <60yrs), ACE inhibitors (non black pt), long acting CCBs, ARBs
treatment of post-thrombotic syndrome? what are signs and sxs?
Tx is Graduated compression (reducing underlying venous HTN)
Sxs - pain, cramps, heaviness, paresthesia, and pruritis
Sign - pretibial edema, skin induration, hyperpigmentation, redness, venous ectasia, and compression pain
heparin overdose?
Tx with Protamine sulfate
First line drugs to use in CKD?
ACE inhibitors/ARBs
Slight elevation in creatinine is acceptable and therapy should continue unless hyperkalemia develops
what is the assessment of severe AS?
Mean gradient is >40 mmhg
Aortic valve area is <1.0 cm2
Worsening of SVT after the use of CCBs or Digoxin?
WPW syndrome
Avoid the use of AV nodal blockers such as BBs, CCBs, digoxin or adenosine
which thrombolytic therapy is preferred? Tissue plasminogen activator or streptokinase?
TPA > streptokinase
when to use Amiodarone IV 300 mg in VF and pulseless VT?
after 3rd defibrillation, CPR and epinephrine
following successful reversion of Vfib with defibrillation, what is next step?
amiodarone IV for 24 to 48 hrs
ppx before dental procedure is required in pts with what valvular diseases?
hx of infective endocarditis;
prosthetic valves;
cardiac transplant patients with valvulopathy;
unrepaired cyanotic congenital heart disease
what is normal PR interval?
120ms - 200ms
what is normal QT interval?
400ms - 440ms
what is normal qrs interval?
60ms - 100ms
abnormal diastolic dysfunction with impaired ventricular filling and increased filling pressures?
Hypertrophic cardiomyopathy
Obstruction is caused by systolic anterior motion of the mitral valve against the hypertrophied septum
what conditions can cause QT prolongation?
HypoKalemia
HypoCalcemia
HypoMagnesemia
Type 1a Antiarrhythmic (quinidine, procainamide)
What is medical treatment of neurogenic orthostatic hypotension?
Midodrine (alpha 1 adrenergic agonist)
Fludrocortisone (mineralocorticoid)
Droxidopa (Norepinephrine precursor)
Target BP in Diabetic pt with microalbuminuria?
What is best Initial therapy?
130/80
ACE inhibitors
(DHP CCBs are 2nd line)
Range of Albumin to creatinine ratio in Men and Women that indicates microalbuminuria?
ACR in men: 2.0 - 20 mg/mmol
ACR in Women: 2.8 - 28 mg/mmol
What receptors are responsible for dyspnea in pulmonary congestion?
Juxtacapillary (J) receptors
What medication provides greatest mortality benefit in hypertensive patients with DM and ESRD?
ACE inhibitors
When Inpatient management of DVT patients is needed?
Massive DVT (ileofemoral);
symptomatic PE;
High risk for bleeding with anticoagulants;
Presence of co morbid conditions
Drugs to avoid in Raynaud’s phenomenon?
Beta Blockers
Cisplatin
Bleomycin
Drug of choice for termination of SVT in hemodynamically stable pt?
IV adenosine
“Adore the SUV”
Drug of choice to terminate stable pt with TdP?
IV Magnesium
“Twist da Magnet”
Constantly prolonged PR interval and a P wave always followed by a QRS complex?
First degree Heart Block
Progressive PR interval prolongation followed by a P wave with a dropped QRS complex?
Mobitz type 1 (second deg HB)
Also called Wanckebach
Constant PR interval followed by a P wave with a dropped QRS complex?
Mobitz type 2 (Second deg HB)
ECG shows complete AV node dissociation with no relationship between the P waves and QRS complexes?
Third deg heart block
Medical emergency
Initially tx with IV access, O2, bp monitoring, transcutaneous pacing
Then permanent pacemaker or ICD
Drugs that decrease both preload and afterload? i.e venous and arterial vasodilator
ACE inhibitors, ARBs, Nitroprusside, Prazosin
What is phlegmasia cerulea dolens?
Acute treatment of cyanide toxicity?
Sodium Nitrate and Sodium Thiosulfate
Murmurs increase with valsalva/standing (decrease in venous return) and decrease with leg raise/squatting (increase in venous return)
HOCM and MVP
CHA2DS2-VASc score?
Congestive heart failure (1) hypertension (1) Age >75 (2) Diabetes Mellitus (1) Stroke/TIA (2) Vascular Disease (1) Age 65-75 (1) Sex Female (1)
What are absolute contraindications for Thrombolytics?
Bleeding diathesis(tendency to bleed easily);
Head or facial injury within last 3 months;
GI bleeding within last 4 weeks;
Prior intracranial hemorrhage;
Ischemic Stroke within 3 months
Suspected Aortic dissection
most common side effect of ASA?
Ringing in both ears!
Tx for WPW in stable pts?
IV Procainamide or IV amiodarone
“Proclaim the Wolves”
What is the most common cause of death within the 1st year of heart transplant?
Infection
Patients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency should take what?
Combination of hydralazine and oral nitrate
Isosorbide/hydralazine
What is the most common cause of mitral stenosis?
Rheumatic Fever
ST elevation in Lead II, III, AVF where lead II and III has equal ST elevation. V1-V3 has ST depression. Where is the most likely occlusion?
Left circumflex artery
WPW syndrome plus Right atrium enlargement and reduced vascular markings on CXR?
Ebstein anomaly
drugs with rebound HTN after abrupt discontinuation?
Clonidine and Guanfacine
Best initial treatment for Multifocal Atrial Tachycardia?
First give O2 then Diltiazem
What is multifocal atrial tachycardia (MAT) associated with?
COPD/Emphysema
What to AVOID in multifocal atrial tachycardia?
Beta Blockers
Best initial management for stable SVT pt?
vagal maneuvers (carotid sinus massage, ice immersion of the face, valsalva) If that fails, then IV adenosine
Type of cardioversion required for unstable Vfib or pulsless VT?
Unsynchronized cardioversion (defibrillation)
what is phytonadione?
vitamin K used in warfarin induced bleeding
What wave on ECG is associated with hypothermia?
J wave or Osborn wave
What meds are contraindicated during Aortic dissection?
Direct vasodilators like hydralazine diazoxide
What are the ACLS guidelines for vfib/pVT?
cpr–>defib–>cpr–>defib–>epi –>cpr –>defib–>amiodarone
(120J - 200J) for biphasic defib or 360J for monophasic defib
Best recommended antihypertensive medication in pts with CAD?
Beta Blockers
What is the effect of Potassium on Digoxin?
Hypokalemia Worsens the Digoxin Toxicity.
Digoxin completes for Na-K ATPase channels with Potassium.
What is the treatment for hyperkalemic emergency i.e Sine wave pattern on EKG?
Calcium gluconate and Insulin plus glucose
What does a, c, v means in normal JVP waveform?
“a” wave is caused by right atrial contraction, closely followed by tricuspid valve closure;
“c” wave is caused by right ventricular contraction, against a closed tricuspid valve;
“v” wave, representing the peak of right atrial filling, just prior to reopening of the tricuspid valve
What causes cannon a wave?
AV dissociation like Ventricular tachycardia, complete AV heart block
What causes prominent v waves?
Tricuspid regurgitation; there is elevation of right atrial pressure throughout ventricular systole
