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PANCE > Cardiology - 13% > Flashcards

Cardiology - 13% Flashcards

1
Q

Atrial Fibrillation Anticoagulation

CHA2DS2VASc + Anticoag Meds

A

Atrial thrombi form after 48 hr of AF, usu in L atrial appendage

CHA2DS2VASc >/= 2

  • CHF
  • Hypertension
  • Age > 75yo = 2pts
  • Age 65-74 yo
  • DM
  • Stroke, TIA, Thrombus = 2 pts
  • Sex - Female
  • Vasc dz

​Score 0 - ASA 81 - 325 mg daily

Score 1 - ASA or Anticoag

Score 2+ - Anticoag

Warfarin (Coumadin)

  • PT and INR - 2-3 is therapeutic
    • bridge with Heparin or Enoxaparin for 3-5 d
  • Hepatic metabolism CYP2C9
  • Enhance Warfarin - Fluconazole, amiodarone, sulfamethoxazole, grapefruit juice, etoh
  • Reversal with Vit K and FFP

DOACs

  • Dabigatran (direct thrombin), Rivaroxaban, Apixaban, Edoxaban
  • Immediate action
  • no routine lab monitor
  • Adjust for renal insufficiency
  • Dabigatran reversal - Idarucizumab
  • Xa inhibitor rev - Andexanet alpha
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2
Q

Atrial Fibrillation

Eti, Sxs, Dx, Tx

A

Irregularly Irregular rhythm - SVT

MCC - mitral valve stenosis, hyperthyroidism

3 types

  • Paroxysmal - AF terminates spont or win 7d
  • Persistent - AF > 7d and need pharm or DCCV to terminate
  • Permanent - AF remains despite mult interventions and attempts to regain SR

Sxs:

  • Stable AF - SOB, Chest Pain, Dizziness, Fatigue
  • Unstable AF - CHF, hypotension, unctrl angina

Dx:

  • EKG - Irregular irreg rhythm, No discernable P waves, Atrial rate >300bpm, variable and irreg QRS
  • Labs - CBC, BNP, DDimer, Cardiac enzymes, TSH
  • Echo - valvular, tachy med CMO
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3
Q

Atrial Fibrillation

Treatment

A

Rate control - BB (metop, Esmolol), **CCB (Diltiazem, Verapamil) - slow condution through AV node, or digoxin (for CHF or hypotension)

Rhythm Control - Direct current CV,antiarrhythmic meds

  • Amiodarone (class 3 K+ blocker) - prolong QT, check liver and TSH/T4,
    • blue/gray skin pigment, ocular toxicity (halo vision), interstitial lung dz (Rountine PFT)
  • Sotalol - Class 3 - prolong QT
    • avoid in CHF, asthma, renal
  • Flecainide, Propafenone - Class 1C Na ch - pill in pocket

Treatment Algorithm

  • Unstable - DCCV
  • Stable
    • <48 h
      • DCCV or
      • Rate Control/anticoag = 3 wks before come back for DCCV or antiarrhythmics
    • >48 h -
      • Rate control/anticoag
      • TEE - no clot, then DCCV
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4
Q

NSTEMI/STEMI

Treatment

A

Reperfusion is KEY - done w/in 12 hrs of onset

Immediate Tx in ED

  1. ASA 325mg
  2. Nitroglycerine subling 0.4mg x3 q5m (no for RV infarc)
  3. O2 if <90%
  4. Morphine - avoid if hypotensive, if pain is not relieved with 3 NTG

After stabilization:

  1. BB (metoprolol, atenolol preferred)
    • hold if CHF (decr contractility at first)
  2. Statin
  3. ACEI/ARBS - pril - if on LV dysfunction
    • prevent ventricular remodeling
    • decr mortality

PCI

  • best within 90 mins
  • TOC in cardiogenic shock - hypotensive in setting of MI
  • > thrombolytics

Thrombolytics/Fibrinolytics

  • use if PCI is not available
  • new EKG ST elev, LBBB
  • time onset of sxs <12 hr
    • Alteplase (tPa) - activates plasminogen to destroy clots
    • Streptokinase - less effective than tPa, less chance of ICH

Maintenance

  • Antiplatelet therapy
    • Aspirin - inhibits plt activation and aggregation via COX1
    • P2Y12 inhibitor - 5-7 d washout
      • Plavix/clopidegrol,
      • Ticagrelo/Brilinta - quicker onset, cant use higher then ASA 100 mg
      • Prasugrel (avoid if hx TIA/CVA or >75yo)
  • Anticoagulant therapy
    • Unfrc Heparin - binds to antithrombin
    • LMWH - better for DM
  • Anti-ischemic therapy
    • BB - decr symp drive
    • Nitrates - venodilation
    • CCB - verapamil/diltiazem - decr contractility
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5
Q

STEMI

ACS

Coronary Artery Disease

A

Sxs:

  • CP, L arm pain, N/V, dyspnea, diaphoresis

Leads

  • V1, V2, V3, V4- Anterior → LAD
  • V1, V2 - Septal
  • I, aVL, V5, V6 - Lateral → Circumflex
  • II, III, aVF - inferior → RCA

Dx

  • ST elevation >/= 1 mm in at least 2 anatomically contiguous leads + reciprocal changes in opposite leads
  • A NEW LBBB = STEMI
  • Ele Trop > 0.08
    • Appears 3-12 hrs
    • Peaks 24-48 h
    • Lasts 5-14 days
  • Ele CK-MB
    • Appears 3-12 hrs
    • Peaks 24 h
    • Lasts 2-3 days
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6
Q

Unstable Angina & NSTEMI

ACS

Coronary Artery Disease

A

Previously stable & predictable => more freq and intense

new onset or severe or worsening angina, occurs at rest

Dx -

  • EKG - ST depr or T w inv
  • Normal CKMB and trop = UNSTABLE ANGINA
  • Abn Trop = NSTEMI**
  • high risk - L heart cath
  • low risk - echo, noninvasive test

Tx

  • progression to MI if untreated
  • Nitroglycerin and morphine
  • Stress test - if cath or revasc necessary
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7
Q

Anaphylactic Shock

A

food allergy, insect stinc, iodinated contrast, blood transfusion

Mediated IgE ab response => release of mast cells => loss of vascular tone & incr cap permeability => HYPOTENSION

Sxs

  • bronchospasm, angioedema, urticaria, rash, profuse rhinorrhea,
  • N/V, tachycardia

Tx

  • Epinephrine - IM 1:1000 autoinjector 0.3mg/injection for adult patients
  • IV Epi
  • antihistamines
  • CS
  • IV Fluids/volume
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8
Q

Aortic Aneursym/Dissection

Vascular Disease

A

Tear through all three layers of artery (intima, adventia, media) w/ blood pooling

RF - atherosclerotic, HTN, HLD, smoking*

Sxs:

  • tearing chest pain; r->back
  • hypotensive, tachycardic, tachypnea
  • Cool extremities
  • diaphoretic
  • back/flank pain when unruptured

Dx:

  • Screen with US for any M > 65yo who have smoked >100cigs/lifetime
  • different BP in R and L UE
  • CXR - first line - widened mediastinum
  • CT*** - gold
  • Trop/BNP r/o MI
  • EKG

Tx:

  • Thoracic Aorta
    • Type A - Ascending Aorta => Immediate Surgery
    • Type B - Descending/Abdominal => HTNsive mgmt to prevent progression
      • <3cm = observe
      • 3-5.5 = CT q 6 mos surveillance
      • >5.5 = Surgery - stent to reinforce aorta
  • Long term management
    • BB - control HR/HTN, DM
    • at least 6 mos anticoag with Warfarin or DOAC
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9
Q

Aortic Regurgitation

Valvular Disease

A

Congenital bicuspid valve, Dilated aortic root, Aortic dissection; Marfan’s syndrome (large diameter), Syphilis/Lupus

Sxs:

  • Syncope, SOB, CHF, pulm edema
  • blowing, decrescrendo DIASTOLIC murmur
  • widen pulse pressure (180/50), Corrigan/water hammer pulse, bounding femoral
  • RUSB 2nd ICS
  • Murmur is louder with increase venous return (squatting)

Dx:

  • Echocardiogram - TEE is better

Tx:

  • Aortic Valve replacement
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10
Q

Aortic Stenosis

Valvular Disease

A

Usu d/t atherosclerotic dz, stiffened AV; congenital AS, bicuspid AS

Sxs:

  • Dizziness, syncope w/ exertion - not enough blood going to body
  • angina, SOB
  • delayed carotid upstroke

Dx:

  • RUSB 2nd ICS
  • Harsh crescendo-decrescendo murmur (louder with squatting)
  • Radiates to Carotids

Tx:

  • Balloon valvuloplasty temporary
  • Total AV Replacement
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11
Q

Arterial Occlusion or Thrombosis

Vascular Disease

A

Recent injury, clot in med/small artery vessel d/t A Fib

MC in anterior calf or forearm

Sxs: 6Ps

  • Pain
  • Pallor
  • Pulselessless
  • Poikilothermia - loss of heat
  • Paresthesias
  • Paralysis

Dx:

  • Doppler US for blood flow

Tx:

  • Surgical Emergency - angioplasty, stent or embolectomy
  • Anticoag - Heparin or LMWH
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12
Q

Printzmetal Angina

Coronary Artery Disease

A

vasospasm - smooth m contractions

Eti - Worse with Triptans, ergotamine, cocaine, smoking, > 50yo, F

non-exertional CP

cyclical - usu in the morning

Dx:

  • EKG - ST or T waves elevations, Inverted U waves
  • Normal trop and CKMB

Tx - CCBs

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13
Q

Stable Angina

Coronary Artery Disease

A

Angina brought on by exertion, emotional upset - relieved w/ stress in a few mins (<15mins)

Sxs

  • Levine’s sign
  • tightness, pressure
  • indigestion/burning r-> L chest or mid sternum, jaw, shoulder

Dx

  • EKG usu normal w/ temporary ST depression, T wave depression or inv
  • neg trops
  • Stress test - exercise or pharmological (adenosine or Persantine)
    • hold negative chronotropics (HR - BB, CCB, digoxin) morning of Stress test
  • Coronary angio - gold std***

Tx

  • ASA - antiplatelets (inhibits COX1)
  • BB - neg chronotropic - Decr HR, decr O2 demands
    • avoid if SBP <100, HR < 60
  • CCB - decr BP and vasospasms
  • Nitrates - vasodilate, decr pre/afterload, dilate coronaries;
    • decr cardiac O2 (ask about Viagra, cialis - hypotension)
  • Ranolazine (Ranexa) - no affect on HR and BP
  • Statin- decr LDL
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14
Q

Cardiac Tamponade

Traumatic/Infectious Heart Condition

A

fluid compromises refilling - collapsed R ventricle (weakest wall) and impairs CO

Sxs:

  • Pulsus paradoxus - > 10 mmHg decrease in systolic when pt inspires
  • Tachycardia, Tachypnea
  • Narrow pulse pressure (180/130)
  • Kussmaul’s sign - rise in JVP on inspiration
  • Beck’s Triad***
    • ​JVD
    • Muffled heart sounds
    • Hypotension

Dx

  • CXR - water shapped, jug shaped heart, > 50% of mediastinum
  • EKG - electrical alternans

Tx -

  • give fluids for volume expansion to tx hypotension
  • pericardiocentesis immediately
  • Pericardiectomy - window
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15
Q

Cardiogenic Shock

A

Eti - Acute MI, ventricular arrhythemias, Heart block, Valvular HD, BB/CCB overdose

Pump failure - depressed CO = hypoperfusion = kidney, resp, lliver failure

Sxs

  • Hypotensive
  • Tachy
  • S3 gallop
  • cool, clammy, pale, ashen skin, oliguria, pulm edema (fluid backing up)

Dx - ICU monitor w/ Swan gaz cath, monitor CO and index

Tx

  • vasopressor - norepi, dopamine,
  • Inotropes - (help incr contractility) = Dobutamine, Milrinone
  • Intraortic pump
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16
Q

Congestive Heart Failure

eti, sxs, dx

A

Left Sided HF

  • Volume overload - S3
  • Dyspnea, SOB, exertional fatigue, Orthopnea, PND
  • Enlarged or displaced apical pulse dt LVH

Right Sided HF

  • Edema, wt gain, JVD, HJR,
  • Hepatomegaly, RUQ pain, RV heave

Dx:

  • CXR - Kerley B lines, Pulm effusion/edema
  • Labs - CBC, TSH (high output), BNP, BUN/Cr, BNP
    • if HyperK - avoid ACE-I
  • Echocardiogram* - assess fx
  • NYHA
    • Class I - Risk but no symp
    • Class II - risk with vigorous activity
    • Class III - sxs w/ ADLs or min activity
    • Clas IV - sxs at rest
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17
Q

Congestive Heart Failure

systolic vs diastolic

A

High CO failure - high demands for blood circ - thyroid storm, beriberi (B1 thiamine deficiency), Paget’s Dz of bone, AV Fistula, etc

Low CO failure = 1. Systolic Dysfunction 2. Diastolic Dysfunction

Systolic Dysfunction - decr contractility, CO - LVEF < 50%

  • Valvular dz
  • Ischemic CMO
  • Dilated CMO - viral, etoh, postpartum, chemo-induced Doxorubicin

Diastolic Dysfunction - impaired ability of hear to relax - LVEF >50%

  • restrictive CMO amyloidosis, sacroidosis
  • HOCM
  • HTN
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18
Q

Congestive Heart Failure

treatment

A

Sxs control, reduce cardiac workload - treat HTN, control fluids (2L fluid restriction)

  1. Loop Diuretics - Furosemide, Torsemide
    • reduce NaCl abs = free water excretion
    • monitor K, Mg, Na
    • SE - ototoxic sulfa allergy
    • need K supplement
  2. ACE-I or ARBS - statins, sartans
    • prevent remodeling of heart = lowers mortality
    • decr preload and afterload - 1st line for systolic dysfx
    • monitor Cr - renal dysfx => may cause hyperK
  3. BB - Carvedilol, Metop-succinate XL, Bisoprolol
    • prolongs survival, incr LVEF
    • control rate, prevents arrhythmias
  4. Mineralocorticoid (Aldosterone) Receptor Antagonist - Spironolactone
    • ​​Aldosterone - contributes to cardiac hypertrophy and fibrosis
    • decr fluid retention
    • monitor K for hyperK - check labs 3-4 d*, few wks after ( cant use if K>5)
    • SE - gynecomastia
  5. ICD - risk of VT and VF
    • ​​if Acute MI EF <30%
    • Class II or II and EF <35% w/ sxs
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19
Q

Right Bundle Branch Block

Conduction Disorders

A

Conduction comes from L ventricle so widened QRS

V1 - R-R’, V2 (bunny ears), V3

RBBB in asymptomatic - fine

new RBBB + CP = occlusion in L anterior descending artery

new RBBB + dyspnea = Pulm embolism, myocarditis

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20
Q

First Degree Atrioventricular Block

Conduction Disorders

A

constant prolonged PR Intvl = > 200 msec or 0.2

no tx necessary, monitor

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21
Q

Second Degree Atrioventricular Block

Type I

Conduction Disorders

A

Mobitz 1 - Wenckebach

progressively lengthening PR interval until P wave drops, PR then resets

r/o hyperK or digoxin toxicity

Tx:

  • none if asymp
  • Atropine, epinephrine, +/- pacemaker
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22
Q

Second Degree Atrioventricular Block

Type II

Conduction Disorders

A

PR interval constant until P wave drops randomly

Tx:

  • Atropine
  • Temporary pacing
  • Permanent pacemaker definitive
  • progression to 3rd degree high
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23
Q

Third Degree Atrioventricular Block

Conduction Disorder

A

No relationship btwn P and QRS - atrial and ventricles are firing separately. All P waves not followed by QRS = Decr CO

Sxs:

  • Syncope, Dizziness, acute HF, hypotension, cannon A wave

Tx:

  • Permanent Pacemaker
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24
Q

Atrial Flutter

Conduction Disorders

A

Atrial focus of ~250-350 bpm

Sxs:

  • SOB, dizziness, fatigue

Dx:

  • EKG - Saw tooth pattern, regular rhythm
  • Atrial rate 240-320bpm
  • Ventricular 150bpm

Tx:

  • Rate control BB, CCB, Digoxin*
  • Anticoag if CHAD Vasc >/=2
    • Warfarin or DOAC
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25
Q

Left Bundle Branch Block

Conduction Disorders

A

L ventricle will depolarize from impulses from R ventricle - partially or completely outside conduction system = Widened QRS

  • Completely LBBB > 0.12 seconds
  • Incomplete LBBB < 0.12 secs but can develop into complete

Signifies Ischemia and structural heart disease

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26
Q

Premature Atrial Contractions

Conduction Disorders

A

ectopic focus but still impulse goes through AV and bundle of His so normal QRS complex

P wave morphology depends on where ectopic beat is - close to SA node = normal looking P wave, otherwise, it is wider

If impulse is close to AV node, atria depolarize opposite direction = retrograde P wave

Next beat has longer interval

Tx - none, BB, CCB

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27
Q

Premature Ventricular Contractions

Conduction Disorders

A

Ectopic beat from ventricular foci - wide QRS complex >0.12s + opposite deflection

not a/w P wave

Sxs - palpitations

Tx - BBs and other anti-arrhythmics

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28
Q

Sinus Arrhythmias

Conduction Disorders

A

Irregular patterns in rate of NSR

  1. Respiratory or phasic
    • normal - decreases w/ age
    • Inspiration - increase sinus rate (inhibits vagal tone)
    • Expiration - rate declines
  2. Nonrespiratory or nonphasic
    • not related to respiratory cycle
    • d/t normal, diseased heart or digitalis intoxication
  3. Nonrespiratory, ventriculophasic sinus arrhythmias
    • 3d AV block
    • intermittent differences in PP intvls
29
Q

Sick Sinus Syndrome

Conduction Disorders

A

Dysfunction of Sinus node’s automaticity and impulse generation

EKG:

  • sinus rhythm with resting HR of 60bpm
  • Sinus pause < 3s
  • Sinus arrest > 3 s
  • tachy-brady alterations

MC in elderly

Worse with digitalis, CCB, BB, antiarrhythmic

Tx - permanent pacemaker

30
Q

Torsades de Pointes

Conduction Disorders

A

Sudden cardiac arrest

a/w palps, dizziness, syncope

EKG - polymorphic V Tach

either from HypoK or HypoMg

rate btwn 150-250

Either cease spontaneously or degenerate into VFib

Tx- IV Magnesium

Cardiovert if unstable

31
Q

Ventricular Fibrillation

Conduction Disorders

A

Uncoordinated quivering of ventricle w/ no useful contractions

No P waves, QRS Complexes, or T waves,

Rate 150-500 bpm

pulseless

Tx:

  • Severe hypotension or LOC = Sync Cardioversion
  • Pulseless V Tach = Defib and CPR
    • 1mg IV bolus epi, q 3-5 mins
    • Defib 30-50sec
    • Refract V Fib - IV Amiodarone
  • Implantable Defib
32
Q

Ventricular Tachycardia

Conduction Disorders

A

a/w CAD, MI, Structural Heart Dz

Three or more consecutive Ventricular Premature Beats

Regular rhythm - Wide and regular >120, wide QRS >0.12

Tx:

  • Cardioversion if unstable
    • Stable → IV amiodarone
    • Unstable w/ pulse → sync cardioversion
    • VT no pulse → Defib
    • Evential ICD placement
  • Non-sustained VT
    • No heart diz or asymp - no tx
    • Heart dz, recent MI - electrophysiology study
33
Q

Dilated Cardiomyopathy

A

Systolic dysfunction => ventricular dilation => decreased contractial function => reduced CO

Eti:

  • MC in 20-60yo, M, idiopathic 50%
  • viral myocarditis - Enteroviruses (Coxsackie B), Chagaz dz
  • Toxic - etoh abse, cocaine, doxorubicin, radiation

Sxs:

  • systolic HF - fatigue, DOE
  • mitral or tricuspid regurg
  • lateral displaced PMI
  • S3 if

Dx:

  • CXR - enlarged heart, pulm edema, pleural effusion
  • Echo - LV dilation, decr EF, regional or global LV hypokinesis

Tx:

  • HF Tx - ACEI, diuretics, BBS, Digoxin, NA restrictionn
  • ICD if EF < 30-35%

DDx

  • Takotsubo CMO - broken heart syndrome, apical L ventricular ballooning d/t catecholamine surge
34
Q

Endocarditis

dx, tx

Traumatic/Infectious Heart Condition

A

Modified Duke Criteria

Major

  • bacteremia 2+ blood culture
  • Echo w/ evidence of vegetation
  • Newly dx valvular regurgitation

Minor

  • RFs - IVDU, indwelling cath, weird valvular morphology
  • Fever > 38C or 100.4F
  • Vasc or embolic phenomena - Janeway lesions
  • Immunologic phenom - Osler nodes (ouch), Roth spots, acute GMN
  • Positive blood cultures not meeting major criteria

Tx

  • Acute/Native Valve
    • Nafcillin + Gentamicin; Vanco if MRSA+
  • Subacute (HACEK organisms)
    • Pencillin or Ampicillin + Gentamicin
    • Vanco if MRSA+
  • Prosthetic valve
    • Vanco+Gentamicin + Rifampin (For S aureus)
  • Fungal
    • Ampho B for 6-8 wks
35
Q

Endocarditis

eti, sxs

Traumatic/Infectious Heart Condition

A

MC Native Valve infx - Mitral - Strep viridans, S aureus, Enterococcus

IVDU - S aureus in tricuspid; Prosthetic - S. aureus or fungal if w/in 2 mos of implantation

Sxs:

  • Fever,
  • non spec sx - dyspnea, CP
  • Murmur
  • Janeway lesions - painless macules on palms and soles
  • Roth spots - retinal hemorrhages w/ pale centers
  • Petechiae
  • Splinter hemorrhages
36
Q

Primary Hypertension

Diagnostic Criteria

A

start screening at 18yo

Primary HTN resting systolic BP >= 130 or diastolic BP >/= 80 on at least two readings, on at least two separate visits with no identifiable cause

Sxs

  • Fundoscopy - AV nicking in retinal a., Retinal hemorrhages, papilledema, cotton wool spots
  • LVH - displaced apical pulse

Dx

ACC/AHA Guidelines

  • Normal - < 120/80
  • Elevated - 120-129 / < 80 mmHg
  • Stage 1 - 130-139 or 80-89 mmHg
  • Stage2 - >/= 140 mm Hg or >= 90 mm Hg

JNC-8 Guidelines

  • Gen pop, age < 60yo = BP < 140/90 mmHg
  • Gen pop, age > 60yo = BP < 150/90 mmHg
  • Pts w/ DM or CKD (regardless of age) = < 140/90 mmHg
37
Q

Primary Hypertension

Medications

A

LSM - Weight reduction, DASH diet, Decrease Na intake, no etoh, aerobic exercise

For Gen pop and all DM

  • Non-black - Thiazide diuretic, or ACEI/ARB, or CCB or combo
  • Black - Initiate Thiazide diuretic or CCB alone or in combo
    • low renin state***

Chronic Kidney dz

  • ACE I or ARB
  • careful if >75 with CKD risk of hyperK

Thiazide Diuretics

  • ‘Chlorthalidone, HCTZ, chlorothiazide’
    • Blocks Na and Cl reabs
    • Good for osteoporosis - incr Ca reabs
    • Good for AA pts, careful with gout or hypercholesteremia
    • Full anti-HTN effects 12 wks
    • SE - hypokalemia, sulfa allergies, gout and DM

CCBs

  • Dihydropyridine - ‘dipine’
    • ‘Amlodipine, nifedipine’
    • No effect on cardiac contractility & conduction
    • Effective in elderly
  • Non-dihydropyridine - ‘verapamil” & ‘diltiazem’
    • Vasodilator
    • Affects contractility and conduction; avoid in HFrEF
    • Monitor for arrhythmias

ACE - ‘pril’

  • ‘Lisinopril, catopril, enalapril, ramipril’
    • Systolic HF, prior MI, CKD Renal protective - preferred for DM
    • SEs - Bradykinin - cough; incr risk of angioedema, hyperkalemia
    • C/i preggo

ARB - ‘sartan’

  • ‘Losartan, irbesartan, valsartan’
    • same as above
    • NO cough
    • Should not be used with ACE
    • c/i preggo

BB

  • Acute MI, angina, migrain pervention, hyperthyroid, migraine, tremor
  • SE - impotence, postural hypotension, bradycard, depression
  • wean to stop over 1-2 wks

Mineralocorticoid Receptor antagonist

  • “Spironolactone, Eplerenone”
  • antagonist aldosterone at distal convoluted renal tubule = incr NaCl and water excretion
  • for CHF and acute MI w/ low EF
  • careful with Hyper K - do not start if K > 5

Others

  • Central acting a adrenergic agonist “clonidine”
  • Direct arterial dilators “hydralazine, minoxidil”
  • Pregnancy - acute - labetalol, hydralazine
  • Chronic - labetalol, nifedipine,
    • methyldopa (check LFT, cause hepatits, hemolytic anemia)
38
Q

Hypertensive Urgency and Emergencies

A

Urgency

SBP >180 or > 120 w/ no evidence of end organ damage

No need to emergently lower BP

Goal = lower BP by 25% over 24 hrs = outpatient

Emergency

>220 or > 130

Accelerated HTN - BP w/ target organ damage - CP, SOB, blurred vision

Malignant HTN - elevated BP a/w papilledema and other signs of EOD

Decr BP < 25% over 1 hr

Tx

  • ICU admission
  • Sodium Nitroprusside for HTN Emergency - watch for cyanide toxicity
  • Nicardipine - just BP, not HR
  • Hydralazine in eclampsia
  • Nipride for pheo crisis
  • Clonidine for HTN urgency
39
Q

Hyperlipidemia

Eti, screening guidelines

Normal Values

A
  1. Primary (familial) HLD or hypercholesterolemia - overproduction or defective clearance of TG
  2. Secondary Hypercholesterolemia - 2/2 obesity, DM*, htn, smoking, sedentary, CKD

Sxs

  • Xanthelasmas - lipid deposits on eyelids
  • Xanthelomas - tendenous, with familial hypercholesterolemia

Dx - Fasting lipid profile

  • LDL <100
  • HDL >60 mg/dL
  • Total Cholesterol < 200 mg/dL
  • Triglyceride < 150

Screening - >7.5% 10 year ACSVD

  • Pts w/ high CVD risk (HTN, DM, tobacco, FH heart dx)
    • Males start at 25-30 yo
    • Females at 30-35 yo
  • Pts w/ lower CV risk
    • Males start at 35 yo
    • Females start at 45 yo
40
Q

Hyperlipidemia

Medications

A

Hyperlipidemia 2018 guidelines

  1. any clinical ASVD, stroke, TIA, PAD
  2. LDL > 190
  3. Diabetic 40-75, mod intensity; if > 7.5% then higher intensity
  4. 40-75y LDL 70-189
    1. Risk 5-20% = mod intensity
    2. >/=20% = high
    3. FH ASCVD, ele CRP, smoke, Ca score > 100

HMG-CoA Reductase Inhibitors - “Statins”

“Atorvastatin 40-80, Rosuvastatin 20-40”

  • decrease LDL, Reduce infl of plaques, lower Trigs, incr HDL
  • check LFTs and CPK before starting statin
  • SEs - anorexia, wt loss, aches, myalgias, C/I preggo
  • Myopathy r/o rhabdo - c/i prior muscle symptoms, myalgias (weakness, stiffness) - check CPK, need IV reh2o for renal failure
    • Avoid w/ fibrates, macrolides (clarith/erythr), amiodarone, verapamil, protease inhibitors, antifungals, grapefruit juice

PCSK9 Inhibitor

  • Evolocumab/Repatha, Alirocumab/Praluent
    • ​Liver cells to remove LDL
    • good for patients who cant tolerate statins
    • once a month, 2x/wk injection
    • Hypercholesteremia

Bile acid sequestrants

  • “cholestyramine, colestipol, coleselevam”
  • Binds w/ bile acid in intestines, mainly for familial hypercholestremia
  • Dont use if fasting TG > 300
  • SE - lots of GI issues
  • C/i - bowel obstruction, hypertriglyceridemia induced pancreatitis
  • Inhibits abs of warfarin, digoxin, propanolol, thyroid hormones

Ezetimibe (Zetia)

  • Inhibits gut absorption of cholesterol; reduce LDL > 20%
  • add to statin to help decr LDL
41
Q

Hypertriglyceridemia

A

Excerbation of uncontrolled DM, obesity, sedentary

Sxs

  • Asymp until TG > 1000-2000 - incr risk of pancreatitis
  • Midepigastric pain (chest/back) - TTP
  • Dyspnea

Tx

  • LSM - low fat/carbs, exercise, limit etoh
  • Fibrates - Gemfibrozil, Fenofibrate - decr LDL, incr HDL
    • do not use it with statin - incr risk myositis and rhabdo
42
Q

Hypertrophic Obstructive Cardiomyopathy

A

Hereditary - Autosomal Dom, early MI death, young athletes

Hypertrophied Ventricular septum = Impaired ventricular relaxation/filling

Sxs:

  • Dyspnea, Angina, Syncope - esp during exertion
  • Sudden cardiac death - due to V fib
  • S4“a-stiff-wall” if outflow obstruction present
  • Harsh cres-decres murmur at LLSB
    • murmur increases intensity with Valsalva or standing - reduced LV volume/preload increases obstruction

Dx:

  • Echo - asymmetrc wall thickeys > 15mm, small LV chamber size
  • EKG - LVH, atrial enlargement
  • CXR - cardiomegaly

Tx:

  • Counseling - avoid dehydration and extreme exertion/exercise
  • BB - first line, CCB
  • Avoid Digoxin (incr contractility), Nitrates and diuretics (decr’s LV volume)
  • Surgical - myectomy - definitive if refrc to medical tx
  • ICD For high risk
43
Q

Hypovolemic Shock

A

Eti

  • Nonhemorrhagic - deh2o, burns, pancreatitis
  • Hemorrhagic - trauma, ruptured ectopic, GI bleed

Sxs

  • weak pulse, oliguria
  • hypotension, tachycard, AMS

Tx

  • Nonhemorrhagic - rapid volume repletion - 2L of 0.9% NS or LR
    • UO for effectiveness - 30mL / hr
    • watch for hyperchloremic acidosis - HA, confused
  • Hemorrhagic shock = PRBCs
    • keep Hgb >7 g/dl
  • Vasopressor only after volume replaced
44
Q

Mitral Regurgitation

Valvular Disease

A

Widened mitral valv = Mitral valve prolapse, dilated CMO, ischemic HD

backward flow into LA

Sxs:

  • Signs of pulm congestion - pulm effusion, edema
  • dyspnea, PND, orthopnea
  • 4th ICS, midclavicular
  • _holosystolic apical murmur, blowing, r-> axilla****_

Dx:

  • TTE echocardiogram

Tx

  • Diuretics
  • antihypertensive
  • MV replacement
45
Q

Mitral Stenosis

Valvular Disease

A

MCC Rheumatic fever (aka GABHS); stiffened mitral valves

Sxs:

  • decrease CO, CHF, Afib common
  • 4th ICS, midclavicular
  • low pitched, DIASTOLIC rumble murmur
  • opening snap

Dx:

  • Echocardiogram

Tx:

  • MVR
  • diuretics for mild-mod
46
Q

Mitral Valve Prolapse

Valvular Disease

A

Sxs

  • Mid to late systolic click
  • worse with standing and Valsalva maneuvers
  • Panic attacks, palps, young females

Dx

  • exam + echocardiogram

Tx

  • BB - propanolol
  • aerobic exercise
  • Hydration, caffeine
  • Mitral valve repair
47
Q

Obstructive Shock

A

Eti - physical obstruction - PTE, Cardiac tamponade, tension PTX

Tx - relieve obstruction, volume

48
Q

Atrioventricular Nodal Reentry Tachycardia

Paroxysmal Supraventricular Tachycardia

A

SVT with abrupt onset and offset

Any tachyarrhythmias arising from above Bundle of His

Reentry circuit in or near AV node - electrical impulse travel in circular pattern => heart beats fast and regular

Sxs:

  • Palps, SOB, Angina, Syncope, Lightheadedness

Dx

  • EKG rate at 150-250 bpm
  • P wave buried in QRS or after
  • Holter monitor to catch eps

Tx:

  • Cardiovert if hemodynamically unstable
  • Vagal maneuvers
  • Adenosine**
49
Q

Wolf Parkinson White

Paroxysmal Supraventricular Tachycardia

A

Presence of abn accessory pathway (Bundle of Kent fibers) btwn atria and ventricles

Type of orthodromic AVRT

Sxs:

  • Palps, dyspnea, dizziness, rarely cardiac death

Dx:

  • EKG - shorted PR intvl, widened QRS, delta waves

Tx:

  • observed if asymp
  • Acute tx - Procainamide**
  • Radio freq ablation is curative
50
Q

Atrial Septal Defect

Congenital Heart Disease

A

opening in atrial septum; L => R shunt

2nd MC congenital HD

Sxs

  • Asymp until 30yo
  • >30yo present w/ dyspnea, and CP
  • >50yo present w/ atrial arrhythmias - A fib and RVF

Dx

  • PE - widely split and fixed S2 into A2
  • systolic ejection murmur at 2nd-3rd LICS
  • Echo - definitive**

Tx

  • Small, centrally located ASD - close spontaneously < 3mm
  • Mod to large ASD = Transcatheter closure or surgical repair btwn 2-6 yo
51
Q

Coarctation of the Aorta

Congenital Heart Disease

A

Narrowing of aorta; MC below origin of L subclavian Artery

Sxs:

  • Higher BP in arms than legs (> 20 mmHg difference)
  • Decr pulses in legs, bounding pulses in arms
  • Bicuspid AV in 50-70% of pts

Dx

  • Radial-femoral pulse delay
  • EKG w/ LVH
  • CXR - notching of ribs, figure 3
  • Echo, CT or MRI - definitive

Tx

  • Balloon angioplasty w/ stent placement or surgical correction
  • Prostaglandin E1 - to keep PDA open
52
Q

Patent Ductus Arteriosus

Congenital Heart Disease

A

Connection btwn aorta and pulm artery after birth (from ductus arteriosus connection that failed to close); L =>R shunt

Sxs

  • FTT, poor feeding, tachycardia, tachypnea

Dx

  • Harsh, continuous machinery murmur at 2nd ICS LUSB
  • Widened pulse pressure w/ low DSP
  • Echo*

Tx

  • Indomethacin for premature babies
  • Surgical or catheter connection
53
Q

Tetralogy of Fallot

Congenital Heart Disease

A

Only Cyanotic CHD - Defect that causes deficient O2 flow out of heart and into body

Four Main Characteristics

  • RV outflow obstruction aka Pulmonary stenosis
  • R ventricular hypertrophy
  • Overriding aorta
  • Ventricular septal defect

Sxs

  • Tet spells - hypercyanotic eps during crying or feeding, relieved with squatting

Dx

  • Echo - gold
  • CXR - boot shaped heart

Tx

  • Surgery w/in 1st year of life
  • Prostaglandin E1 - keep PDA open
54
Q

Ventricular Septal Defect

Congenital Heart Disease

A

MC CHD in childhood;

Opening in ventricular septum - shunt btwn ventricles, L→ R shunt

Sxs

  • Child tires easily, can’t keep up with children
  • Loud pitch harsh, holosystolic murmur

Dx

  • Echo
  • EKG - mod to severe VSD shows LVH

Tx

  • Surgical closure
55
Q

Pericardial Effusion

Traumatic/Infectious Heart Condition

A

2/2 to pericarditis, uremia, cardiac truam

Sxs:

  • painful or painless, depending on rate of effusion
  • cough
  • dyspnea
  • pressure

Dx

  • EKG - electrical alternans, non-spec T wave changes, low QRS voltage
  • Echo - fluid surrounding heart

Tx

  • Observe is small
  • Pericardiocentesis if + tamponade or large effusion
56
Q

Pericarditis

Traumatic/Infectious Heart Condition

A

idiopathic or viral - restrictive pressure on heart

echovirus, coxsackie, HIV, TB

Sxs:

  • Dyspnea, fatigue, weakness
  • Sharp, pleuritic substernal CP => relieved by sitting upright or leaning forward
  • Friction rub
  • pericardial knock

Dx

  • ele WBC
  • EKG
    • Diffuse ST seg elevations - concave (smiley)
    • PR depression
    • J point notching

Tx

  • NSAIDs or Aspirin x 7-14d
  • Colchicine 2nd line
  • avoid CS - recurrent pericarditis
57
Q

Peripheral Arterial Disease

Vascular Disease

A

MCC Atherosclertoic Dz - important risk factor for CV and cerebrovascular M&M

Sxs:

  • intermittent claudication - foot or lower leg pain - relieved by rest
  • As condition develops, pain at rest develops
  • Femoral or distal pulses weak or absent
  • Aortic, iliac or femoral bruit may be present
  • Skin changes - loss of hair, shiny atrophic skin, pallor w/ dependent rubor
  • Severe, chronic = numbness, tingling, ischemic ulceration

Dx:

  • ABI - upper and lower extremities
    • 0.9-1.2 = normal
    • <0.9 = PAD
    • <0.4 = severe disease
  • Arteriography- gold std - occlusion

Tx:

  • Stop smoking
  • Stent - only if short and proximal (femoral and < 0.3 cm); never stent otherwise
  • Everything else = BYPASS
  • Meds
    • ASA
    • Statin
    • Cilostazol
  • Exercise regimen
58
Q

Pulmonic Stenosis

Valvular Disease

A

Congenital

Sxs

cyanosis at birth, fatigue, dyspnea

2nd LICS

JVD, RV hypertrophy heave

59
Q

Restrictive Cardiomyopathy

A

Impaired diastolic relaxation - stiff ventricles decreases filling

Eti - infiltrative diseases - Amyloidosis MCC, Sarcoidosis, hemachromatosis, scleroderma, chemo, XRT

Sxs:

  • RS HF more common
  • Chest pain, dyspnea, edema, ascites
  • Kussmaul’s sign - JVP incr with inspiration

Dx:

  • Echo - usual normal systolic contraction
  • Speckled appearance - infiltrative disorder

Tx:

  • Na restriction, caution diuretics
  • treat underlying disorders
  • Poor prog
60
Q

Septic Shock

A

Eti - bacterial - immune sys reaction = local vasodilation

Sxs

  • confusion, hypoxemia, oliguria
  • Hypotensive needing pressors (Norepi), tachy

Dx - ele plasma lactate (higher = sicker), leukos

Tx

  • Broad spectrum abx w/in 1st hour = GOAL
  • IV fluid hydration - 30mL/kg in first 3 hrs
  • Vasopressors - Norepi, Vasopressin
61
Q

Syncope - DDX

A

Reflex Syncope

  • feels it coming on - lighthead, diaphoretic, pallor, N
  • young adults
  • Vasovagal or situational

Orthostatic Syncope

  • elderly, dehydrated, gastroenteritis
  • ETOH, Nitrates, BB, Antidepressants; Autonomic Dysfunction
  • Tilt table test - systolic BP drop >20 w/ standing
  • tx
    • Fludrocortisone - mineralocorticoid - hang onto fluid.
    • Midodrine - vasopressor activity

Cardiogenic Syncope

  • no premonition - sudden hypotension
  • arrhythmia or aortic/mitral stenosis, HOCM
62
Q

Thrombophlebitis

Vascular Disease

A

Inflammation of superficial vein, usu d/t injury aka need stick

Sxs:

  • pain, erythema at site
  • vein feels hardened

Dx:

  • Venous duplex US - noncompressible vein

Tx:

  • NSAIDs
  • elevation
  • compression stockings
63
Q

Tricuspid Regurgitation

Valvular Disease

A

Pulm htn, dilated RV, endocarditis, ebstein anomaly

Sxs

  • JVD, ascites, perip edema
  • high pitch pansystolic murmur, accentuated w/ inspiration
  • LLSB

Tx

diuresis, severe TR, then VR

64
Q

Varicose Vein

Vascular Disease

A

Dilated, tortuous superficial veins 2/2 defective valve structures; weak vein wall = incr intraluminal pressures, rev of venous flow (pooling)

Eti: Incr Estrogen = preg, stress of legs, prolonged standing, obesity

Sxs:

  • Dilated, tortuous superficial veins
  • dull ache or pressure w/ prolonged standing, relieved w/ elevation

Dx - clinical

Tx:

  • Conservative - leg elevation, compression stockings, avoid prolonged standing
  • Sclerotherapy, radiofreq or laser ablation
65
Q

Venous Thrombosis - DVT

A

RF - smoking, preg, malignancy, OCPs, stationary

Sxs

  • Virchow’s triad - stasis of blood flow, hypercoaguable state, vascular damage
  • unilateral LE pain and swelling

Dx

  • LE venous Doppler
  • +D-Dimer

Tx

  • Anticoag - Hep or Enoxaparin
  • DOAC - anticoag for 3-6mos
  • IVC Filter
66
Q

Venous Ulcer Disease

Vascular Disease

A

Leg pain worse w/ dependency, standing/prolonged sitting

Improves w/ walking, elevation of leg; Cyanotic leg w/ dependency

Sxs:

  • ULCERS over medial malleolus* - ankle or knees
    • (arterial ulcers are heels and toes)
  • uneven ulcer margins
  • Stasis dermatitis - eczematous rash, thickening of skin
  • brownish pigmentation
  • Pulses and temp usu normal
  • Prominent edema common

Tx

  • below-knee compression
  • brisk walk
  • Prognosis for this condition as poor
67
Q

Secondary Hypertension

A

Secondary - d/t an identifiable cause

  • HTN in esp in young or old
  • stage 2 HTN
  • abrupt onset
  • Drug resistance
  • clinical cause

Renal Vascular HTN - recurrent flash pulm edema, abd bruit

  • Fibromuscular Dysplasia - young women
    • tx balloon angioplasty

Pheochromocytoma - 4Ps - palpitations, htn, perspiration, pain headache

Primary Hyperaldosteronism

  • retain water and Na - BP goes up
  • hypoKalemia, order plasma adolesterone:plasma renin activity ratio
  • tx - aldosterone antagonist - Eplerenone or Aldactone (Spironolactone)
68
Q

SVT/PSVT

A

Sxs

  • Regular >150 bpm
  • no P waves
  • no discernable PR intvl
  • narrow QRS
  • palps, dyspnea, CP, syncope

Tx

  • Valsalva
  • Carotid massage
  • Adenosine 6mg then 12 mg

PANCE (15 decks)

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