Cardiology Flashcards
What is the first line treatment for Afib
Rate control: Metoprolol or Verapamil
if that doesn’t work & duration <48 hours:
Rhythm control: Amioderone or cardioversion
Duration >48hours: Anticoagulation x 21 days BEFORE cardioversion
Common presentation signs of those with Afib
- Elderly, excessive alcohol use
- Symptoms range from syncope, dyspnea, palpitations to no symptoms
- Irregularly irregular pulse
How will a left bundle branch block look on EKG
Upright bunny ears in V4 - V6
How will a right bundle branch block look on EKG
Upright bunny ears in V1-V3
What scoring tool is used to assess the need for anticoagulation
CHADS2VASC
What are the scoring parameters for CHADS2VASC score
0- No anticoagulation
1- 81mg or 325mg of ASA OR anticoagulation
2+ - Anticoagulation
Which leads are you most likely to see atrial flutter in
Leads 2, 3 and aVF
What are the two different types of atrial flutter
Type 1: 250-350 bpm
Type 2: Faster (350-450 bpm)
a 68-year-old female with a history of hypertension and hyperlipidemia presents for a routine check-up. She reports feeling generally well but mentions occasional episodes of mild fatigue, which she attributes to aging. She denies any chest pain, shortness of breath, or palpitations. Her medications include lisinopril and atorvastatin. Vital signs are within normal limits. Physical examination is unremarkable. An EKG is performed as part of her evaluation, which reveals a consistent prolongation of the PR interval greater than > 0.2 seconds (200 ms).
What is the likely diagnosis?
First degree heart block
a 55-year-old male, with no significant medical history, presents to the clinic complaining of occasional lightheadedness and palpitations, particularly during his morning jogs. He denies any chest pain, shortness of breath, or syncope. On examination, his vitals are stable, but his pulse is irregularly irregular. An ECG is performed, revealing a pattern of progressively lengthening PR intervals followed by a non-conducted P wave.
What is the likely diagnosis
Mobitz type 1 –> wenckebach
What pattern/ratio is observed with wenckebach (how often will you see a beat drop)
3:2, 4:3, or 5:4 (predictable)
a 68-year-old female with a history of hypertension presents to the emergency department complaining of dizziness and episodes of near-syncope over the past few days. She reports no chest pain, shortness of breath, or palpitations. Her blood pressure is slightly elevated, and her pulse is slow and irregular. An ECG reveals intermittent, non-conducted P waves without progressive prolongation of the PR interval.
What is the likely diagnosis?
Mobitz type 2
What is mobitz type 2
The impulse is blocked in the bundle of His. Every few beats there will be a missing beat but the PR Interval will not lengthen–> Dangerous to the patient
What is third degree heart block
When the atria and ventricles are acting independently of each other. The P waves will be consistent but will not match up with the QRS complexes
An EKG demonstrates a shorter PR interval, a longer QRS segment and a delta wave - what is the likely diagnosis?
WPW
What is a delta wave
An upward slope at the beginning of a QRS complex
A rapid irregular rhythm >100bpm, with 3 distinct P wave morphologies is indicative of what dx?
Multifocal Atrial tachycardia
Which antihypertensive medications can cause bradycardia
Dihydropyridine CCB
Beta-blockers
Which calcium channel blockers are non-dyhydropyridines
Verapamil
Diltiazem
Which CCB are dyhydropyridines
nifedipine
Nicardipine
Amlodipine
felodipine
When are dyhydropyridines preferred?
When peripheral vasodilation is needed
When are non-dyhydropyridines preferred
When central depression is needed (SA / AV node blockage) - AKA rate control
What type of arrhythmia is most likely to occur with ventricular hypertrophy or ventricular dilation?
V-tach
What 2 murmurs are associated with atrial fibrillation
Mitral stenosis
Mitral regurge
Which type of bundle branch block is always considered to be pathological
LBBB –> can be a sign of an MI (Think left = lousy)
*RBBB is NOT always pathological
On an EKG, a QRS complex lasting longer how many seconds is seen in a BBB
Longer than 120 ms
What pulmonary disorder is a common cause of RBBB
Pulmonary embolism
What acquired infection is a common cause of RBBB
Lyme disease
What are the treatment options for SVT
1: Valsalva
2: Adenosine
3: Ablation (permanent fix)
*If WPW, do NOT give adenosine of CCB
A faster-than-normal heart rate beginning above the heart’s two lower chambers in the atria, AV junction, or SA node associated with no structural abnormalities is descriptive of what arrhythmia
PSVT
a 25-year-old female patient with complaints of sudden onset of a pounding heartbeat, which is regular and “too rapid to count.” She reports that the episodes begin and terminate abruptly and are associated with shortness of breath and chest discomfort. On exam, the patient appears anxious, her heart rate is 170 bpm. EKG demonstrates a shortened PR interval, widened QRS, and delta waves. What is the likely diagnosis?
WPW
a 72-year-old man is admitted for exacerbation of COPD. On the third day, he reports dizziness associated with occasional chest pain. His telemetry reveals an irregular rhythm with a pulse of 124/min. The EKG demonstrates an irregularly irregular rhythm, rate of 120 bpm, discrete P waves before every QRS complex with 4 different P wave morphologies. What is the likely diagnosis?
MAT
What are the differences between the 3 different types of premature beats in the heart
PAC: Abnormal shaped P wave
PVC: Wide QRS
PJC: Narrow QRS of <.1sec
What is the difference between sinus pause and sinus arrest
Sinus pause <3sec
Sinus arrest >3sec
a 68-year-old woman with a history of chronic heart failure and recent hospitalization for pneumonia presents to the emergency department complaining of sudden onset dizziness and palpitations. She reports adherence to her medication regimen, which includes a diuretic and an antibiotic she started a week ago. On examination, she appears anxious, her blood pressure is 100/60 mmHg, and her heart rate is irregular and fast. An ECG reveals a polymorphic ventricular tachycardia with a characteristic twisting of the QRS complexes around the baseline and serum K+ and Mg2+ are found to be low. What is the likely diagnosis and how do you treat it
Torsades de Pointe
IV mag to prevent vfib
What is the most appropriate treatment in immediate management of a hypertensive emergency
nitroprusside
Which of the following ABI values would most likely confirm the diagnosis of PAD in a patient?
An ABI of .5
What is the most sensitive and specific method to test for PAD
ABI (normal is between 1.4-.9)
What drug class has been shown to improve mortality in patients with systolic heart failure
Beta-blockers
What are 3 medications that can help prevent arrhythmia and ease symptoms in those with HOCM
Diuretics
Beta-blockers
Non-dyhydrpyridines (verapamil / diltiazem)
What are the signs of HOCM on physical exam
S4 gallop
Apical shift
Ejection murmur medial to the apex
What is the treatment for dilated cardiomyopathy
Diuretic (loop)
Ace inhibitor
Beta blocker
What is the most common cause of non-ischemic dilated cardiomyopathy
chronic alcoholism
a 58-year-old man complaining of several months of worsening shortness of breath and ankle swelling. He denies palpitations, lightheadedness, syncope, or chest pain. He has a past medical history significant for hereditary hemochromatosis. On physical exam, his temperature is 37 C (98.6 F), pulse is 78, blood pressure is 130/72 mm Hg, and respiratory rate is 16. He has elevated jugular venous pressure, diminished breath sounds at the lung bases, tender hepatomegaly, and bilateral pitting ankle edema. There are no murmurs, rubs, or gallops. EKG shows low-voltage QRS complexes without any signs of ischemia. His chest x-ray shows a normal-sized heart and bilateral pleural effusions. Echocardiography shows symmetrical thickening of the left ventricle, normal left ventricular volume, and mildly reduced systolic function. What is the likely diagnosis
Restricted cardiomyopathy
What is restricted cardiomyopathy
Right sided heart failure in those with a history of an infiltrative process ( Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, fibrosis)
What are the NYHA heart failure classifications
Class 1: no limitation of physical activity
Class 2: slight limitation in physical activity; comfortable at rest
Class 3: marked physical limitation; comfortable at rest
Class 4: can’t carry on physical activity; anginal syndrome at rest
How do you diagnose heart failure
Dx: BNP, EKG, CXR (Kerley B lines);
** Echocardiography = gold (best to assess size and function of chambers)
What are the 3 beta blockers that have been shown to reduce morbidity and mortality in those with heart failure
Bisoprolol
Carvedilol
Metoprolol succinate (not tartate)
What are the first line agents in those with HEFrEF
Entresto (sacubitril/valasartan)
ACE/ARB
Beta-blockers
Aldosterone antagonists
SGLT2 inhibitos
Diuretics
a 45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin. What is the likely diagnosis
Endocarditis
What are signs seen on physical exam that are indicative of infective endocarditis
Janeway lesions (painless bumps on the palm)
Osler nodes ( painful bumps on the fingers and toes)
Roth spots (hemorrhages on the retina)
splinter hemorrhages
What is the treatment for infective endocarditis
IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
**Prosthetic valve: Add rifampin
What murmur is heard with aortic stenosis
harsh systolic ejection crescendo-decrescendo at the right upper sternal border with radiation to neck and apex
What symptoms will be found with aortic stenosis
Dyspnea, angina, syncope with exertion; squatting increases intensity; split S2
What type of murmur is heard with aortic regurgitation
soft high pitched, blowing, crescendo-decrescendo along left sternal border; loud leaning forward/squatting
What type of murmur is heard with mitral stenosis
diastolic low-pitched decrescendo rumbling with an opening snap heart best at the apex with pt. lying lateral decubitus position
What causes mitral stenosis
eaflets of the mitral valve thicken, stiffen from rheumatic fever → valve doesn’t open well in diastolic; cause = rheumatic heart
What murmur occurs with mitral regurgitation
blowing holosystolic murmur at the apex with split S2 radiating to the left axilla
What causes mitral regurge
CAD, HTN, MVP, rheumatic, heart valve infection; apical S3 = volume overload on the ventricle
What will be heard with mitral valve prolapse
midsystolic ejection click heard best at the apex
What will be heard with tricuspid stenosis
mid-diastolic rumbling murmur at LLSB with opening snap
What will be heard with tricuspid regurgitation
high-pitched holosystolic murmur at LLSB radiates to the sternum and increases with inspiration
What is occurring with tricuspid regurgitation
Tricuspid fails to close fully in systole, blood regurgitates from RV → RA = murmur
What is heard with pulmonary stenosis
harsh, loud, medium pitched systolic murmur heard best at 2nd/3rd left intercostal space that may increase with inspiration
What is heard with pulmonary regurgitation
high pitched early diastolic decrescendo murmur at LUSB that increases with inspiration
what are the screening guidelines for high cholesterol
USPSTF recommends screening for patients with NO evidence of CVD and NO other risk factors should begin at 35 years of age
What 4 demographics typically benefit from statin therapy
Patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
Patients with primary LDL-C levels of 190 mg per dL or greater
Patients WITH diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
Patients WITHOUT diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
What HDL level is considered protective
> 60
What is the optimal LDL level
<100
What is the goal for total cholesterol and what level is considered high
Goal: <200
High: >239
What is primary hypertension
Primary hypertension is defined as a resting systolic BP ≥ 130 or diastolic BP ≥ 80 on at least two readings on at least two separate visits with no identifiable cause.
What are the AHA classifications of hypertension
Normal: < 120/80 mmHg
Elevated: 120–129 mmHg and < 80 mmHg
Stage 1: 130–139 mmHg or 80-89 mm Hg
Stage 2: ≥ 140 mm Hg or ≥ 90 mm Hg
What is considered a hypertensive crisis
Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems or immediate hospitalization if there are signs of organ damage.
What medications are better for managing blood pressure in black adults
Thiazide-type diuretics and/or calcium channel blockers are more effective in black adults at lowering BP alone or in multidrug regimens
Which patients are beta blockers contraindicated in
Those with asthma
When are alpha blockers beneficial
With BPH and HTN issues
What is a side-effect occasionally seen with hydralazine and when is hydralazine used
-Lupus like symptoms and pericarditis
- Hydralazine can be used for chronic HTN
In a hypertensive emergency, how quickly does the blood pressure need to be reduced in order to prevent the start of end organ damage
Within an hour it needs to be. reduced by 10-20%
What are the signs and symptoms of hypertensive encephalopathy
the insidious onset of headache, nausea, and vomiting, followed by nonlocalizing neurologic symptoms such as restlessness, confusion, and, if the hypertension is not treated, seizures and coma.
What is the drug of choice to treat hypertensive urgency
Nitroprusside
What is the drug of choice to treat hypertensive emergency
Nitroprusside
What is the drug of choice to treat malignant hypertension (hypertensive retinopathy)
Clevedipine / nitroprusside
What leads in a EKG look at the anterior/ septal` wall of the heart
V1 - V4
What leads in an EKG look at the lateral walls of the heart
I, aVL, V5, V6
What leads on an EKG look at the inferior portion of the heart
II, III, aVF
What is the gold standard to diagnose myocarditis
end-myocardial biopsy
What is the most common cause of myocarditis
viral enterovirus (Coxsackie), EBV, HIV, VZV
a 45-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis presents to the emergency department with dyspnea, cough and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. What is the likely diagnosis
Pericarditis
What are signs of pericarditis
- chest pain that is relieved by sitting or leaning forward
- pericardial friction rub
- Dressler’s syndrome
What is Dressler’s syndrome
Pericarditis within 1 month following an MI, trauma, or surgery
Where is Erb’s point and what is the significance
It is the middle left sternal border when listening to the heart–> Where you will hear a pericardial friction rub
How do you diagnose pericarditis
An EKG which will demonstrate diffuse, ST-segment elevations in the precordial leads (V1-V6)
What is the most common presentation of peripheral artery disease
intermittent claudication (Thigh and upper calf are most common locations)
What is Leriche syndrome
Leriche syndrome refers to a buildup of plaque in the iliac arteries → claudication, impotence, decreased femoral pulses
What are the 6 P’s to look for with an acute arterial embolism
Pain
Pulslessness
pallor
Paresthesia
poikilothermia (inability to regulate temperature)
Paralysis
What is the mainstay treatment for PAD and why
Cilostazol (anti platelet) because it also helps with the intermittent claudication
What is homans sign and when is it seen
Pain in the calf when the foot is dorsiflexed
- Will occur with phlebitis
How do you diagnose phlebitis
Duplex US
What is the mainstay treatment for those with ARF and do not have carditis
Antistreptococcal prophylaxis should be maintained continuously after the initial episode of ARF to prevent recurrences - PENICILLIN G - for 5 years or until they turn 21 (if that is before the 5 yr tx is complete)
Which valve is most commonly effected by ARF
Mitral
- will see regurge unless it is in late stage then you will hear mitral stenosis
How do you dx rheumatic heart
Clinical presentation and echo
*Labs: ↑ anti-streptolysin O (ASO) titers
What type of prophylaxis is given to those with rheumatic heart and are allergic to penicillin
sulfadiazine
What is amaurosis Fugax and when is it seen
Sudden temporary monocular blindness that occurs with giant cell arteritis
