Cardiology Flashcards
Tx that lowers mortality with acs
Aspirin, beta blockers (lower hr so more time for CA perfusion), statin, p2y12antag
Acei or arb if low EF
Heparin if nstemi
Thrombolytics only for stemi or new lbbb
Glycoprotein IIb/IIIa inhib
Mortality lowering treatment in stemi
Angioplasty (pci, within 90 min of arrival at ed) or if not possible, thrombolytics (within 30 min of arrival, and CP<12 hours)
Also beta blockers, asa, Acei or arb, statin
Both ACEI and ARBs can cause
Hyperkalemia
Chronic CaD mortality benefiting meds outpt
Aspirin and metop
Acei or arb only if CHF/other EF issue
Indications for cabg
- 3 vessels >70% stenosis
- left main stenosis 50-70%
- 2 vessels + dm
- 2 vessels with low EF
Ranolazine
Med for anginal pain, decreases o2 demand in heart muscle
Saphenous vein vs internal mammary artery graft for cabg
Artery patent 10 yrs, vein only 5
Give statin if…
- stroke or CAD (goal ldl<70)
- usually with DM
- ascvd>7.5%
Most common statin AE
Liver tox - check lfts periodically
Rhabdo less common - don’t need to check cpk routinely
CHF initial tx and tests
Tx: O2, furosemide, nitrates, morphine
Tests: cxr, ekg (expect tachy, maybe arrhythmia), pulse ox (hypoxia and resp alk), echo (systolic vs diastolic)
Chronic CHF tx
- systolic: acei, arb, beta blocker (or hydral + nitrates if CI), digoxin to decrease sx but no mortality benefit, MRA (eg spirono, eplerenone - give with patiromer to bind k if Hyperkalemia), plus minus diur (no mortality benefit)
- diastolic: MRA (don’t overuse diur)
Beta blocker, ace and arb, MRA, and sglt2 all have mortality benefit
When to order bnp?
To figure out if sob is cardiac (elevated in CHF) vs reapiratory
Ivabradine
Blocks sa node so slows HR, only works if in sinus, add to chronic CHF tx if all other meds not working
Causes transient bright vision
When do you need bivent pacemaker?
HFrEF and wide qrs
Murmurs that get louder with decreased venous return (eg valsalva, standing)
HOCM, MVP
Murmur ausc
- AS - second right intercostal, rádiate to carotids, louder with increased preload or decreased after load, cresc-decreased systolic, carotid upstroke
- pulm valve at second left intercostal
- tricuspid and AR and vsd at llsb
- ar: diastolic decresc
- vsd: holosystolic, worse with increased flow, no tx if mild
- asd: fixed splitting
- mr at apex and radiate to axilla, holosystolic, louder with increased flow, often s3, tx = Acei/arb, nifed, loop, surgical repair if bad
- ms (think RF or pregnancy) - sx = dysphagia and hoarseness from enlarged la compressing esoph and recurrent laryngeal, diastolic rumble with OS, louder with increased flow, tx diuretics and balloon
Valve lesions best initial and other tests
Best initial = echo
Most accurate = left heart cath to measure pressures
Add ekg and cxr
Valve replacement
AS: Tavr > surgery > balloon
Can’t do tavr for regurgitation
Bioprosthetic lasts 10 yrs but no ac needed, mechanical lasts longer but need warfarin to get to inr 2-3
MS do balloon valvuloplasty (stretch fibrosis that causes ms vs doesn’t work for as bc that’s caused by calcification)
Pericarditis dx test and tx
Test = ekg (st elev in all leads, pr dep in lead 2)
Tx = nsaid and colchicine, if pain persists add oral pred
Repair AAA when
Over 5cm
Pericardial disease - give diur for __ but not __
Constrictive pericarditis, not tamponade
Meds in afib
If chadsvasc 0-1, just asa, else:
Rate control with beta blockers, calcium channel blockers, or digoxin - ccb if asthma or migraine, dig if hypotn
Then anticoagulant - DOAC unless metallic heart valve or MS then warfarin
If can’t control hr with rate control agents alone or sx, Antiarrhythmics:
- no cad or struc heart dz, do flecainide or propafenone
- lvh - class 3 dronedarone or amio
- cad - sotalol or droned
- CHF - amio or dofetilide
Worsening of svt with ccb or dig?
WPW
Tx: procain, sotalol or amio
Long term: radiofreq ablation
Syncope work up
Ekg, trop/ckmb, echó, head ct
MAT vs afib vs sinus tachycardia vs svt on ekg
MAt is irregular, narrow complex, variable p wave morphology bc multiple ectopic atrial foci usu iso copd or other acute illness
Afib irreg irreg wo p waves
Svt regular, p usu inverted and often buried in qrs, usu dt reentrant circuit
Axis deviation
RAD is 90-180 deg (neg in I and pos in avf) - rvh or strain (pe), lateral stemi, copd
Lad is pos in I, neg in II, neg in avf - lvh, lbbb, inferior mi
Normal is pos qrs in I and avf
Ebstein’s anomaly
Downward displacement of tv—> regurg
When you stop ac prior to surgery, when do you have to bridge?
If on warfarin and chadsvasc high risk
- not necessary on DOAC because of quick onset of action once you restart
Takotsubo cause and dx findings
Catecholamine aurge with stress —> myocardial stunning, causing increased basilar contraction and decreased mid and apical contraction, troponin leak, normal Cath
Self resolves
Aortic dissection management
Pain control, iv beta blockers, sodium nitroprusside for persistent htn, emergency surgical repair for ascending
How does CKD affect anemia and the heart?
- Hypertension causes concentric hypertrophy
- Anemia causes eccentric hypertrophy Because tissues have unmeet, oxygen demand, causing vasodilation, which drops systemic, vascular resistance, and increases volume overload, causing LV dilation. Myocardial hypoxia with anemia can also directly injure the heart, decreasing contractile function, and causing compensatory LV dilation.
- Anemia occurs by various mechanisms. First, less erythropoietin and inflammation (high ferritin, low iron) causes decreased red blood cell production. Second, uremia causes platelet dysfunction (bleeding) and red blood cell fragility, both increasing red blood cell loss.
What do we do for patients with MI and bradycardia?
Atropine. Pacing if no response to atropine. Epinephrine contraindicated, because it increases myocardial oxygen demand.
AC and inr goal for patients with prosthetic aortic vs mitral valve
Warfarin
Aorta with no risk fx - inr 2-3
Risk fx (af, low ef, hypercoag etc) or mitral - 2.5-3.5
EKG findings in stemi
1mm in 2 contig leads except more in v2 and v3 or new lbbb and sx
Do pci within 2 hours or fibrinolytics
