Cardiology Flashcards
Heart failure type that is due to weakened ventricles and has a reduced EF
Systolic heart failure
Heart failure type that is due to a stiff heart, hypertrophy and has a normal EF
Diastolic heart failure
Normal Ejection Fraction
50-65%
Left or Right HF –> blood backs up into the lungs
Left (L = Lungs)
Left or Right HF –> blood backs up into the SVC and IVC
Right (R = Rest of the body)
Left or Right HF –> JVD as a symptom
Right
Most common type of cardiomyopathy
Dilated cardiomyopathy
Four drugs that are used to reduce mortality in systolic HF
- ACE-I
- BB
- Spironolactone
- Hydralazine + nitrate
(You need to BASH the heart to work harder)
Etiologies of Dilated cardiomyopathy
6Ds of dilated cardiomyopathy
- Don’t know - idiopathic (50%)
- Drinking alcohol
- Drugs - cocaine
- Disease - Viral infection
- Doxorubicin (Chemo drug)
- Deficiency in Vit B1
Physical exam finding common with dilated cardiomyopathy
S3 Gallop (3 on its side looks like wide ventricles)
Dx test for dilated cardiomyopathy
ECHO
Echo findings with dilated cardiomyopathy (3)
- ventricular dilation
- decreased ventricular wall thickness
- reduced ejection fraction
Etiologies of Restrictive cardiomyopathy (3)
- amyloidosis (MC)
- sarcoidosis
- hemochromatosis
(AMY HaS restrictive cardiomyopathy)
Increased Jugular venous pressure (JVP) with inspiration
Kussmaul sign
Dx test for restrictive cardiomyopathy
ECHO
Echo findings for restrictive cardiomyopathy
Dilated atrium (MC), also possible ventricular thickening, and diastolic dysfunction
Endomyocardial BX showing apple green biofriengence with congo red staining is diagnostic for…
amyloidosis
autosomal dominant disorder of the heart muscle
hypertrophic cardiomyopathy
most common symptom of hypertrophic cardiomyopathy
dyspnea
murmur found with hypertrophic cardiomyopathy
harsh systolic murmur best heard at Left sternal border
increased with valsalva or standing
decreased with squatting
Dx test for hypertrophic cardiomyopathy
ECHO
Echo findings in hypertrophic cardiomyopathy
left ventricular wall thickening >15 mm
(13mm or greater if they have a FHX)
septum is most common location for thickening
First line treatment for hypertrophic cardiomyopathy
Beta blockers (decreases the heart rate to give the heart a chance to fill)
Second line treatment for hypertrophic cardiomyopathy
nondihydropyridine CCB –> Diltazem and verapamil
type of CCB that slows AV node conduction (decreases HR)
nondihydropyridine CCB –> Diltazem and verapamil
type of CCB that does not affect the AV node
dihydropyridine CCB –> amlodipine
Drugs to AVOID in patients with hypertrophic cardiomyopathy
nitrates and diuretics (decreases preload)
“lifestyle” choices to AVOID in patients with hypertrophic cardiomyopathy
dehydration, over exertion (sports)
Systolic vs Diastolic murmurs: aortic stenosis, mitral regurgitation, pulmonic stenosis, tricuspid regurgitation
systolic
Systolic vs Diastolic murmurs: aortic regurgitation, pulmonic regurgitation, mitral stenosis, tricuspid stenosis
diastolic
heart sound heard between S1 and S2
systolic
heart sound heard between S2 and S1
diastolic
systolic murmur heard best at right upper sternal boarder that radiates to carotids and neck
aortic stenosis
systolic crescendo-decrescendo murmur heard with an S4 gallop. Patient has a history of syncope
aortic stenosis
diastolic decrescendo murmur heard at 2nd ICS of LSB. Patient has a wide pulse pressure
aortic regurgitation
lateral PMI that is hyper-dynamic is found in what type of murmur
aortic regurgitation due to the dilated left ventricle
diastolic murmur with an opening snap heard at the apex. described as rumbling
mitral stenosis
type of murmur associated with a history of rheumatic fever
mitral stenosis
systolic murmur heard at apex and is holosystolic. Has an S3 and a diffuse laterally displaced PMI
mitral regurgitation
most common murmur
mitral valve prolapse
anxious patient complaining of palpitations that has a midsystolic click and a normal PMI
mitral valve prolapse
treatment for mitral valve prolapse
none
first valve to be effected by IV drug use
tricuspid
Right vs left sided murmurs: increase with inspiration
Right
wide fixed split S2 systolic murmur
ASD
high pitched harsh holosystolic murmur with a thrill
VSD
machine like murmur heard in both systole and diastole
PDA
first line treatment for PDA
NSAIDs - indomethacin
Patient with bounding upper extremity pulses and delayed or weak lower extremity pulses. Murmur heard best on their back and is a mid systolic murmur
coarctation of the aorta
cyanotic congenital heart defect that will have both a VSD murmur and a pulmonic stenosis murmur
tetrology of fallot
friction rub is present in which condition
pericarditis
symptoms consistent with pericarditis
orthopnea, pain with laying down, coughing or deep breathing
EKG findings consistent with pericarditis
diffuse ST segment elevation, decreased PR
cardiac sounds beast heard at left sternal boarder when patient is leaning forward
aortic regurgitation and friction rub
Beck’s triad is diagnostic for…
cardiac tamponade
Beck’s triad includes…
- JVD
- hypotension
- muffled heart sounds
EKG finding consistent with cardiac tamponade
electrical alternans (QRS changes shape in every lead)
Two diagnosis associated with sudden cardiac death and successful resuscitation
hypertrophic cardiomyopathy (associated with exercise), prolonged QT (not exercise induced)
Rhythm strip with PR interval longer than 0.2 seconds. One P wave per QRS
First degree AV block
Rhythm strip with progressive lengthening PR interval then a skipped QRS complex
Type I second degree AV block (Wenckebach)
Treatment for First degree AV block
none
Treatment for Type I second degree AV block
None
Rhythm strip with a fixed PR interval and an occasionally dropped QRS
Type II second degree AV block (Mobitz)
Treatment for Type II second degree AV block
pacemaker
Rhythm strip that shows no association between P and QRS complexes. P waves happening at a regular interval.
Third degree AV block
Treatment for Third degree AV block
Pacemaker
R and R’ seen in V4-V6
Left BBB
R and R’ seen in V1-V3
Right BBB
Which type of new onset BBB should you be concerned for an MI
Left
Bradycardia alternating with tachycardia
Sick sinus syndrome
rhythm strip that does not have P waves visible and has a irregularly irregular rate
A. fib
Medications used for rate control in A.fib
Metoprolol, diltiazem, verapamil
Rhythm control in A.fib
Cardioversion and amioderone
First line treatment in a stable patient with SVT
carotid massage or valsalva
medication used to treat SVT
adenosine
Medications that can cause Torsades de Pointe
zofran, macrolides, TCAs
electrolyte abnormalities that can cause Torsades de Pointe
low K and low Mg
Medication used in patients with Torsades
Magnesium sulfate
Target INR on Warfarin
2.5
Rhythm strip with widened QRS and delta waves
Wolff-Parkinson White
Early and wide QRS without a P wave
PVC
abnormally shaped P wave
PAC
narrow QRS with no or an inverted P wave
premature junctional complex
treatment for V. fib
unsynchronized cardioversion (defibrillation)
treatment for unstable monomorphic V. tach
synchronized cardioversion
treatment for unstable polymorphic V. tach
unsynchronized cardioversion
treatment for stable V. tach
amioderone
most common congenital heart defect
VSD
most common cyanotic congenital heard defect
tetrology of fallot
transient cyanotic episodes commonly associated with crying or exertion, improved with squatting or bringing knees to chest
tet spells - symptom of tetrology of fallot
CXR finding associated with tetrology of fallot
Boot shaped heart (upturned apex)
treatment of tetrology of fallot
surgery, and prostaglandins (alprostadil) until surgery to keep PDA open
Genetic disorders associated with tetrology of fallot
down syndrome, Digeorge syndrome
Two CXR findings consistent with coarctation of the aorta
- posterior rib notching
2. figure 3 sign
congenital heart defect that can be a secondary cause of hypertension
coarctation of the aorta
cramping of the lower extremities on exertion is a symptom of which congenital heart defect
coarctation of the aorta
Which congenital heart defect also my have a wide PP
PDA
most common cause of Right heart failure
Left heart failure
S3 gallop is found in which type of heart failure
systolic HF (and dilated cardiomyopathy)
S4 gallop is a abnormal finding that is seen in which type of heart failure
Diastolic
Symptoms of Left or Right HF: dyspnea, orthopnea, cough, frothy sputum
Left
Symptoms of Left or Right HF: edema, JVD, N/V, hepatojugular reflux
Right
NY Heart Association Functional Heart Failure Classes (1-4)
- NO symptoms
- mild symptoms but can do ADLs
- only comfortable at rest, cannot do ADLs
- Symptoms even at rest
Best test to diagnose HF
ECHO
Best INITAL test for HF
CXR
Signs of HF on CXR (2)
- Kerley B line
2. Butterfly/Batwing appearance
Lab value important for diagnosing and treatment response of heart failure
BNP
lifestyle modifications important in HF
smoking cessation
Diet: low sodium and fluid restriction
Meds used in heart failure that only treat symptoms (have no effect on mortality)
Loop diuretics, digoxin
ADRs of digoxin
visual changes, increased K, arrhythmias
Treatment of acute decompensated heart failure
Lasix Morphine Nitrates Oxygen Position - sitting up, legs off bed (LMNOP - Morphine is controversial in practice)
most common patient populations to see atypical symptoms of acute coronary syndrome
women, elderly, and DM pts
patient has chest pain at rest that is not relieved by nitro, they have a negative EKG and troponin - DX?
unstable angina
patient has chest pain at rest that is not relieved by nitro, they have a negative EKG but positive troponin - DX?
NSTEMI
patient has chest pain at rest that is not relieved by nitro, they have ST segment elevation on EKG and positive troponin - DX?
STEMI
New LBBB is a _____ until proven otherwise
STEMI
this cardiac enzyme is elevated 2-3 hours after an MI and remains elevated for 10 days, can also be elevated with CKD, PE and trauma
troponin
this is the first cardiac enzyme to peak (increase)
myoglobin
this cardiac enzyme may be used for early reinfarction due to it returning to baseline after 72 hours
CKMB
ST elevation found in these leads in an inferior MI
II, III, and AVF
artery occluded in a inferior MI
right coronary artery
treatment for patient with acute coronary syndrome
MOAN BASH M-morphine O- oxygen A- aspirin N- Nitro
B- BB
A - ACE-I
S - statin
H - heparin ( or anticoagulation)
contraindications to giving nitroglycerin
viagra (sidenifil) use within 24 hrs, systolic BP less than 90, or inferior MI with right ventricular involvement
First line re-perfusion therapy in acute coronary syndrome
PCI - cath and stent
You have a patient having a STEMI but they are 3 hours away from a hospital that does PCI, what medication can you give them for re-perfusion
Thrombolytic - TPA (cut off is 90 mins to cath lab)
patient with chest pain at rest that is transient, EKG changes when patient is having symptoms - DX?
prinzmetal variant angina (or cocaine induced MI)
treatment for prinzmetal variant angina
CCB (nifedipine) or nitrates (same tx for cocaine induced MI)
which medication is contraindicated in patients with prinzmetal variant angina
beta blockers (same as cocaine induced MI)
Post MI pericarditis
Dressler’s syndrome
treatment for dressler’s syndrome
aspirin or colchicine (avoid NSAIDs)
triad of right ventricular infarction
- increased JVP
- Clear lungs
- Kussmal’s sign (Increased JVP with inspiration)
chest pain exacerbated by activity but relieved by rest or nitroglycerine
stable angina
test of choice to diagnosis stable angina
stress test - EKG changes may show down slopping ST segments
medication used to treat congenital or stable QT prolongation
propranolol
ADRs of administering prostaglandins
apnea, hypotension, fever
taking lithium during pregnancy can cause what cardiac abnormality?
Ebstein’s anomaly
list risk factors for primary hypertension
age, obesity, family history, African American race
most common cause of secondary hypertension
renal artery stenosis
other common causes of secondary hypertension
renal artery stenosis, coarctation of aorta, cushing’s syndrome, pheochromocytoma, OSA
stage one hypertension
systolic of 130-139 or diastolic of 80-89
stage two hypertension
systolic >140 or diastolic >90
what is necessary to make a DX of HTN
Two separate readings at two separate events
lifestyle modifications used to treat HTN
weight loss, DASH diet, decreased ETOH, exercise
First line medication in patients with HTN and DM or CKD
ACE-I or ARB
First line medications in patients with HTN and of African American race
Thiazide or CCB (amlodipine)
beta blockers should not be used as initial mono therapy to treat HTN except if the patient has which comorbidity?
heart failure with reduced EF
goal of HTN treatment
<140/<90
if HTN is refractory to many meds you need to think of ____ and order which test?
secondary causes like renal artery stenosis —> order a renal ultrasound
Pt with a blood pressure over 180/120 without any symptoms - DX?
hypertensive urgency
Pt with blood pressure over 180/120 with a headache or chest pain
hypertensive emergency (due to them having symptoms of end organ damage)
goal of treatment for a HTN emergency
reduce MAP by 10-20% in first hour, and then by 5-15% over the next 23 hours
treatment for hypertensive urgency
oral anti-HTN meds - since end organ damage has not yet occured
treatment for hypertensive emergency
IV anti-HTN meds (labetolol, nicardipine), admission
Patient comes in with JVP, BP of 88/60 and you hear crackles on lung exam. Patient appears pale and had cool skin. What are you concerned about?
cardiogenic shock
pulmonary capillary wedge pressure >15 mm makes which diagnosis?
cardiogenic shock
treatment of cardiogenic shock
fluids, pressors (dobutamine, norepi), and oxygen
drop in blood pressure of >20 mmHg systolic or >10 mmHg diastolic when patient is moved to an upright position
orthostatic hypotension
orthostatic hypotension without a compensatory increased in heart rate is indicative of which cause
autonomic dysfunction
treatment of orthostatic hypotension
increased Na and Fluids
decrease in heart rate and BP that leads to fainting, often associated with a stressful trigger
vaso-vagal syncope
what test may reproduce symptoms of vaso-vagal syncope
tilt-table test
According to the USPSTF when should you start screening for cholesterol
35 yo
Name the two high intensity statins
Atorvastatin and Rosuvastatin
Most common side effect of statins
myalgia (should get CK to rule out rhabdo)
An LDL over ____ indicated treatment with statin in a patient with no comorbidities
190
Triglycerides over _____ put the patient at risk for pancreatitis
500
treatment for isolated high triglycerides
Fibrates (finofibrate, gemfibrozil), second line Niacin, although lifestyle changes can make a big impact on TG
Name 2 ADRs associated with Niacin
flushing, and hyperglycemia
xanthomas are a symptom of…
high cholesterol
back pain, pulsatile mass, hypotension - DX?
abdominal aortic anerurysm
severe, tearing/ripping knife like chest pain radiating to back - DX?
Aortic dissection
screening criteria for aortic aneurysm
Male over 65 who has ever smoked
size of aortic aneurysm that indicated the need for surgery
> 5.5 cm
CXR finding indicative of aortic dissection
widened mediastium
gold standard test for aortic dissection
MRI angiography
variating in pulses between L and R arms should indicate which DX
aortic dissection
treatment for ascending dissecting aorta
surgical emergency
treatment for descending dissecting aorta
beta blockers
signs and symptoms of arterial occlusion/embolism
6Ps Pain paralysis pallor paresthesia polar/poikilothermia pulselessness
gold standard test for diagnosis arterial embolism/thrombosis
angiography
treatment of arterial thrombosis
anticoagulation (heparin), embolectomy within 4-6 hours of symptoms
abnormal connection between arteries and veins, bypassing the capillary system
arteriovenous malformation (AVM)
most common presenting symptom of an AVM
intercranial hemorrhage
gold standard for diagnosing and treating and AVM
angiography
giant cell arteritis is most common in this population
woman over 50
pt with headaches, jaw claudication, amaurosis fugax, and a tender temporal artery – DX?
giant cell arteritis
studies used to diagnose giant cell arteritis
ESR >100, temporal artery BX definitive
treatment of giant cell arteritis
high dose prednisone
dangerous complication of giant cell arteritis
blindness
patient with claudication, pain with exercise, shiny atrophic skin – DX?
peripheral artery disease
studies to diagnose PAD
ABI
treatment of PAD
lifestyle changes, smoking cessation, aspirin/plavix, revasculatrization surgery
inflammation of the wall of the vein which can lead to clot formation, common after IV insertion
phlebitis/thrombophlebitis
gold standard diagnostic study for phlebitis/thrombophlebitis
venous duplex US
treatment for phlebitis
elevation, warm compress, NSAIDs
treatment for thrombophlebitis
heparin - 1 month
leg fullness and pressure, pain with exertion, dilated superficial veins visible - DX?
varicose veins
treatment for varicose veins
compression, elevation, surgery
stasis dermatitis, non-healing ulcers over medial malleolus are common findings of …
venous insufficiency
virchow’s triad
stasis
hypercoaguable state
trauma
homan’s sign is used to test for…
DVT
woman over 35 who smoke and take OCP are at greatest risk for…
DVT
studies to diagnose DVT
venous duplex, d-dimer if low risk, venography is gold standard
treatment for DVT
anticoagulation for 3-6 months