Cardiology Flashcards
How does digoxin work and when is it indicated
NA+K+Pump inhibition
Rate control through slowed AV node conduction
2nd line treatment for AFIB and CHF
Peri infarction pericarditis occurs when
Less than 4 days from procedure
Mechanism of action of fibrates
Inhibit bile acid synthesis ; best for hypertriglyceridemia .
PPARA goes in and actives MORE LPL —> decreased availability of fatty acids ==> VLDL can’t activate.[decrease in triglycerides]
This PROMOTES gallstones, avoid in gallbladder disease patients
MOA of fish oil in hypertry.
Fish oil increases bile acid synthesis ; decreasing cholesterol saturation
MOA of ezetimibe
Block cholesterol absorption decreasing liver liver cholesterol stores and reducing biliary cholesterol content
2 side effects of statin therapy
Myopathy
And
Hepatic dysfunction
What is the drug of choice for hemodynamically good ; Vtach?
Amiodarone
Adverse affects of Amiodarone
Bradycardia
QT prolongation
When do you give fibrates
If severe triglyceridemia over 500
What is the peripheral resistance in hypovolemic patients
High due to stress, fluids decreases this.
1st line medical management of AFIB
Beta blocker
If an arrythmia originates below the average node think what type of QRS complex
Wide
Hemodynamics of :
Cardiac
Hypovolemic
Distributive
Obstructive
Cardiac = high preload,, low cardiac output, high vascular resistance
Hypovolemic = low preload, low cardiac output, high vascular resistance
Distributive = high right sided preload, low left sided ventricular output, high cardiac ouptut, low vascular resistance
Obstructive = low preload, high cardiac output, low vascular resistance
Explain the murmur of mitral stenosis
Best heard at the cardiac APEx = OPENING SNAP
Mid diastolic murmur
MC due to RHDz
Echo = Increased left atrial size with normal LV ejection fraction
Most important risk factor for aortic dissection
Hypertension
Describe the physiologic murmur of pregnancy
Increased blood production @ 6 weeks leads to ventricular dilation and increased CO
-Pulmonic flow murmur = increased w/ inspiration @ the left upper/mid sternal boarder
-S3 = increased FILL of an enlarged LV
-Venous Hum = continuous brisk blood flow through JVD
Atrial thrombi associated with AFIB are most commonly associated with what anatomic part
The left atrial appendage
Best way to determine SVT vs V tach
SVT = narrow complex tach
VT = WIDE complex tach!
AFIB mechanical intervention
Synchronized CARDIOVERSION
Vfib and Vtach can get what mechanical intervention
DEFIBRILLATOR!
MOA of ezetimibe
Decreases intestinal choleserol absorption leading to decreased liver cholesterol, requiring the liver to to increase LDL receptor expression = pulling cholesterol from the bodies circulation
STOMACH
MOA of PCK9 inhibitor
Increases LDL receptors on the liver hepatocyte increasing removal from circulation
Aortic rupture causes what findings
Immediate DEATH
Flat neck veins and mediastinal widening
Cardiac Tamponade causes
Becks triad : HYPOTN / Venous Distention / Dimensioned Heart Sounds
Distended neck veins and slightly enlarged cardiac contour
Narrow pulse pressure
Indomethacin vs PGE1 for PDA.
PDA = closes around day 3 of birth, patient would present with EARLY PULM DECLINE
Indomethacin = CLOSES ; inhibits prostaglandins synthesis which would close the PDA.. HELPS PDA
PGE1= OPENS ; vasodilator that prevents PDA closure= so blood can still bypass the lungs! In Tetrology of Fallot
Calcium scoring is only good when
No symptoms [ZERO]
But suspicious risk
Levels of triglycerides elevated but less than 500 get what
Statin therapy!
Normal ejection fraction is around what?
Usually greater than 60%
What does the heart look like in HFreF vs HFpeF
HFreF = thin non compliant weak ventricles
HFpeF = dialted and stiff ventricles
Classifications of heart failure based on ventricle structure
HFReF = thin non compliant weak ventricle = S3 SOUNDS
HFPeF = dilated large stiff ventricles = S4 SOUNDS!
HFReF stage A treatment
Lifestyle changes
HFrEF stage B treatment is likely
ACEI or ARB
B Beta Blocker
HFrEF stage C think what meds
Diuretics for sxs
ACE/ARB/ARNI/SGLT2
*ARNI =1st line
HFrEF stage D think what treatment
Inotropes
Loop diuretics 4 main points
Sxs control ONLY
Decrease total body water; removing heart fluid; relieving sxs
Decreases NA and Chloride absorption in loop of henle
Hypovolemic; increase in sCr; Ototoxic
CONTRA = Sulfa Allergy
What kind of diuretic can you use in sulfa allergy
Ethacrynic acid
ARNI FOUR MAIN POINTS
Sacubitril and Valsartan
Prevents the breakdown of BNP
Promotes diueresis, natiruesis, and vasodilation
Could cause hypotension, sCr increase, hyperK+, if angioedema/36hr of ACE rxn/use
ACEI four main points
Blocks production of AT2 ; which increases bradykinin
Decreases ventricular remodeling and fibrosis
Prevents progression of heart failure
Increased sCr, hyperK, dont use in prior angioedema
Beta blockers 4 main points
Inhibits beta adrenergic receptors and decreases catacholamines
Decreases heart rate and constriction
Can correct abnormal arrythmias ; heart selectives - BMAE ; best in asthmatics
Contra if bad lung disease
Aldosterone antagonists [4]
Blocks aldosterone in the kidney heart and vasculature
CrCl greater than 30mL/min
K less than 5 in order to use
Class 2-4 HF mainstay
Epileronone > Spironolactone for gynecomastia
SLGT2 four main points
Diuretic and hemodynamic effects to decrease mortailty
Mainstay effect with good kidney, glucose function
GFR greater than 20-30 to use
Causes UTIs cause you pee the sugar
Bidil four main points
Vasodilates arterial and venous vasodilation
HF benefit only in AA
Can cause HA ; Drug induced Lupus
Dont use with sildenfil = hypotension
Ivabradine four main points
Inhibits NA + channels in SA node reducing heart rate
NO MORTALITY BENEFIT
Must also be on a B blocker, HR above 70, and normal sinus rhythm,
Can cause AFIB = discontinue the agent ; hypertension can occur
Not used in ADHF
Digoxin four main points
Inhibits Na+ and K+ pump increases heart contractility
Improves exercise tolerance not mortality
Causes bradycardia, heart blocks, N/V, anorexia
Less than 0.5-2 levels in the serum for HF, monitor electrolytes and renal function
Anything over 2 can be considered toxicity
HFpEF treatment algorithm
Diuretics as needed
SGLT2
ARNI
MRA
ARB
ADHF stages 1-4
1 = normal ; warm and normal
2 = fluid overload over 18 PWP ; pulmonary congestion ; warm and wet
3 = hypoperfusion ; warm and dry
4 = pulm congestion and hypoperfusion; cold and dry
3 step treatment steps for ADHF
1.Diuretics
2.Inotropes
3.Inotropes and Diuretics
_Vasodilators prn.
Half life of dobutamine
2 mins
*It’s. A beta 1 agonist
Cardiac conduction cycle
SA —> AV —> Bundle of His —> Purkinje Fibers
Two main types of cells in cardiac conduction
NA + = atria; ventricular ; purkinje cells
CA 2+ = SA and AV node
Pacemaker cell phases
4 to 0 to 3
Na + Ca 2+ + decrease in K+
2 main goals of antarrythmics
Decrease automaticity
Prolong refractory signals
1234 agents for antiarrythmics
Class 1 = NA+ blockers;
Class 2 = K+ channel blockers
Class 3
Class 4 = CCBs
Class 1 anti arrhythmic agents pnuemonic
Double Quarter Pounder = Vtach ; WPW = procainamide IV
Lettuce mayo = Vtach ; lidocaine = IV, causes seizures ; crosses the BLOOD BRAIN BARRIER
Fries please = SVTs ; contra in HF ; visual taste disturbance
Amiodarone affects where
B blocker, Na+ , K+ blockers
Good in HF
Half life of 60 days
Loading dose required
Need annual labs, eye exams, LFTs
Dronerdarone is contraindicated in
HF and AFIB
K+ antiarrythmics have what warning
QT prolongation
Initiation of what two drugs requires hospitalization
Sotalol
Dofetilide
What med can pharmacologically get a patient out of AFIB
Ibutilide
What type of CCBs are used in arrythmias
Non dihydrperidine
Verapimil and Dilitiezem
What type of CCBs are used in HTN
Dihydrpuridine
-Amlopidine
-Nicardipine
Works mostly in the periphery to vasodilate; decease SVR and BP
Corarny artery vasodilation
Side effects = gingival hyperplasia ; peripheral edema ; flushing
Alpha 2 agonists do what
Stimulate alpha 2 in the brain
Reduces sympathetic outflow
Decreased SVR/HR/BP
If stop fast = reflex tachycardia !
Do not use statins in
Liver disease
Muscle damage in the past = measure CPK
Dont use eztemibe in what patients
Pregnant breast feeding; liver disease
Fibrates can do what to LDL if tri’s are high
Increase LDL ; can exacerbate gallbladder disease
‘PCSK9 is given how?
Injection ; prevents breakdown of the LDL receptors to bind body LDL
2 unusual signs for thoracic aortic anuerysm
Hoarse + Stridor
[Ripping tearing pain is common]
What size TAA is a high risk for rupture
Greater 5 cm
What artery is accessed in repair of TAA
Femoral artery
2 diseases high risk for TAA
Marfans
GCA
What is the screening protocol for AAA
If they ever smoked = screening abdominal U/S age 65 x 1
Size 3.5-4.4 = annual U/S
Size 4.4 - 5.4 = U/S every 6-12 months
Positive Periumbilical mass with pain radiating to the back think what
AAA
What structural complication can lead to aortic dissection
Aortic Regurgitation
-Also, cardiac Tamponade
Mc risk factor for AD
Hypertension
What out he goal and treatment for AD
Decrease Bp to less than 120 in the first hour
With BB and CCBs
PADz improves with what; treatment should include what two thing
Limbs in the dependent position
-often has absent distal pulses
1) Statin
2) ASA
Vasculitis effects what joints and where is this ; what is a defining feature
Proximal joints
[shoulders ; pelvic girdle]
NO MUSCLE WEAKNESS
Worst complication associated with progressive vasculitis
Blindness
What it’s he treatment of thrombophlebitis
Heat pack and NSAIDS
What group of pulm hypertension does DVT fall in
Group 4
Proximal DVT treatment
LMWH , heparin , factor 10a inhibitors
AC Treatment after DVT in provoked vs. unprovoked VTE
Provoked = 3 months ; after major surgery/ pregnancy/ COCs /active malignancy
Unprovoked = lifelong ; unexplained
Venous insufficiency is worse when? Presents how?
When dependent ; usually presents unilaterally
If someone is moderate risk for CAD what can you consider
Stress test
3 features of stable angina
Lasts less than 10 mins
Gets better with rest or nitro
ST Depression on ECG
What three drugs can improve survival in stable angina, based on what?
ASA
BB
Statins
ASCVD risk greater 10%
Printzmetals usually effects what artery?
RCA
Rule out cocaine use
Mainstay treatment for Unstable Angina and NSTEMI
Dual AP therapy : ASA + Clopidogrel
UFH/LMWH
PCI could be indicated if TIMI greater 3
4 common findings in STEMI physical exam
Positive JVD
Mitral regurgitation
Pulm Edema
S3 sound +
Location of STEMI vs. artery effected
Inferior = RCA
Lateral = LCx 1, AVL
Anterior Septal = LAD
2 common complications post inferior MI
Sinus bradycardia
AV blocks
Papillary muscle rupture often leads to what
Mitral regurgitation
-Holosystolic murmur radiating the the axilla
How long should post MI patients be on DAPT
At least 1 year
What two drugs can reduce cardiac remodeling post MI
BB
ACE/ARB
Free wall rupture often results in quick what?
Death
MC etiology of pulmonary stenosis
Tetralogy of Fallot
Location and sound of Pulmonary stenosis
2-3rd Left ICS
Decreases with inspiration*
Ejection click with parasternal lift
Starts asxs then progressive dyspnea —> syncope
Pulmonic regurgitation location and sound
3rd Left ICS
Early Diastolic heart murmur
Soft high pitched; DECRESCCENDO
Increases with inspiration [RINSPIRATION]
Atrial septal defect is association with what etiology
Down syndrome
ASD is a what shunt
Left to Right
ASD is assoc with what physical exam findings
Positive JVD with increased RA volume
Flow murmur heard best at the 2nd ICS
Fixed split S2 ; doesn’t change with inspire/expire
ASD can progress to what?
Eisnemrhens syndrome
Right to left shunt
What allows fetal blood flow to bypass the lungs
Foremen ovale
In individuals less than 55 y/o what is the MC reason for stroke
PFO
When is cyanosis worse in PFO
If you as the person to stand = increased RA pressure = increased Right to Left Shunt
Talk about treatment for PFO
ASA could be taken to prevent blood clots
Anticoagulants if PFO is large
PFO does not usually change with age and will require surgery if causing adverse sxs.
4 compartments of tetralogy of fallot
Pulmonic Stenosis
VSD
RVH
Overriding Aortic Arch
What type of VSD is known to spontaneously close
Muscular VSD
Membranous requires surgery*
VSD is what location and sound
Heard best at the LLSB
Holosytolic murmur // Harsh-Soft //
Handgrip increases the sound = increase in afterload
Left to right shunt
MVP sound and location and associated with what diseases
Floppy mitral valve
Systolic click
That is louder with standing and valsalva = decrease in preload on the right side of the heart
Tricuspid stenosis sis common when
Right heart disease
IV drug users
Tricuspid stenosis murmur ; TXM?
Mid Diastolic Rumble Left LSB
Venous return increases during inspiration = louder with inspire!
TXM = diuretics to decrease congestion
Tricuspid regurgitation think what? [4]
Holosystolic murmur increases with inspiration
Best heard with the bell
Louder sitting upright or standing or with inspiration = carvollos sign
TXM = diuretics
Mitral regurgitation think what? [4]
Blowing systolic murmur heard at the APEX radiate to the axilla
Increases with collagen deposits ; #1 MVP ; Post MI
Retrograde flow from LV to LA
TXM = surgery or nitrates/diuretics if shock : vasopressors
Aortic regurgitation? [4]
Diastolic crescendo decrescendo
Softer with inspiration ; causes LVH
Quincke, corrigan sign = art Bp incr, dec ; musset sign = head bobble
TXM = vasodilators or Inotropes
Mitral stenosis [4]
Opening snap ; diastolic murmur
MC : rheumatic heart; MVP in the US; r/o outflow obstructions like myxoma
Can lead to AFIB
TXM = nitrates or diuretics to decrease dyspnea
A P T M for locations of murmurs
A = aortic murmurs [ 2nd Right ICS ]
P = pulmonic murmurs [ 2nd Left ICS ]
T = tricuspid murmurs [LLSB]
M = mitral murmurs [ APEX of the heart ]
What grade murmurs have palpable thrill s
Grade 3 and above
Aortic stenosis [4]
1 Cause : CA2+ deposits ; SAD = syncope ; angina ; DOE
Left ventricular heave noted systolic ; HARSH crescendo decrescendo 2nd ICS ; radiates to carotid
Positive narrow pulse pressure
TXM = balloon surgery; TAVR replacement
Pericarditis in the following settings = what?
Painless
No fever
Post MI
Positive TOXIC APPEARING
Painless = neoplastic
No fever = uremic
Post MI = Dresslers ; ESRs/CRPs elevated
Positive TOXIC APPEARING = BACTERIAL
1 side effect of colchicine and dont use with what med class?
Diarrhea
NOT w/ Macrolides
Constrictive pericarditis think what 3 findings in addition and what TXM
-Purulent infections effusions
-Kussmauls breathing
-Edema
TXM = diuresis I ; DX = catheterization
Cardiac Tamponade is assoc with what 4 findings
Pulsus pardoxous
Low systolic BP = narrow pulse pressure
+PEA Shock
Water Bottle Heart on CXR
What three pops get HIS right away
LDL over 190
DM with ASCVD risk over 7.5 %
DM with LDL over 70
What defect often causes familial hypercholesterolemia
LDL receptor gene defects
BEST DIET = Mediterranean
Greater than what tri’s = risk of pancreatitis
1000
Secondary causes of increased lipids [4]
Hypothyroidism = gut increases cholesterol absorption and decreases clearance. HIGH LDL.
Metabolic syndrome
Liver Dz
EXOG. Estrogen / Progesterone
Native valves with IE are commonly what bacteria
Staph A
Prosthetic valves in IE are commonly what bacteria
Strep viridans
GBS infective endocarditis usually infects what 2 populations
Cirrhosis
DM2
HACEK infective endocarditis organisms infect what population
Hameophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella
HIV
Osler nodes vs. Janeway lesions
Osler nodes = painful ; [fingers and toes] nodes [red tender bumps with pale centre]
Janeway = painless ; septic thromboemboli [palms and soles]
MC Valve Dz affected in IE
MVP
Best study to eval for valve vegetations in IE
TEE
Prophylactic DOC for IE and in what 3 cases
Amoxicillin
“Break Skin”
-Dental
-Respiratory
-Skin structural procedures
Duke criteria requires what
2 majors
1 major + 1 minor
Or 3 minors
Minor criteria for IE
Fever over 100.4
JONES
Predisposition to IE
Major criteria IE
+blood current
+vegetation on TEE/Echo
Immunologic phenomena of IE [4]
Osler nodes
Roth spots
Elevated RF
Glomerulonephritis
Diastolic dysfunction think // systolic think
Diastolic = S4 sounds
Systolic = S3 sounds
1st line treatment in HF think
ACEI / ARB
Digoxin optimal serum level in HF treatment
0.5 -2
Dilated cardiomyopathy often leads to what
Tricuspid regurgitation
Hyperaldosteronism labs = [4]
Low K+
High Bp
High aldosterone
Low renin
Talk about RAAS system
Baroreceptors sense low blood pressure/low blood volume
Release of renin in the kidney
Activates AT to AT1 [AT released by the liver]
Lungs release ACE [Activates AT1–> AT2] [AT2 activation = blood vessel constriction]
AT2 causes adrenal gland to release ALDOSTERONE
ALDOSTERONE tells the kidneys to reabsorb NaCl and H20 follows = increase blood volume/pressure
What drugs can cause trigger a PHEO [4]
TCAs
Metoclopramide
Naloxone
Antidopinergic agents
Coaractation of the aorta [4]
Rib notching and figure 3 sign
Delated weak femoral pulses
Systolic murmur in the infraclavicular area under the left scapula
TXM = surgical
5 meds/drugs that can cause HTN
EPO
NSAIDS
OCPs
CC
Cocaine and Cold meds
Labs in Cushings are often ; txm for HTN induced?
Increased glucose ; low K+
HTN TXM = Spironolactone
History of what is often present in renal artery stenosis [4]
Atherosclerosis
Women lesser than 50 yrs with an ABD Bruit and increased creatinine
DX = renal arteriography
TXM = stent ; DO NOT USE ACEI
