Cardiology Flashcards
When is family history significant in ischemic heart disease?
When the family member is young (female relatives < 65, male relatives < 55 yo)
What is the single worst/most dangerous risk factor for CAD?
DM
How does CAD present?
as chest pain that does NOT change with body position or respiration, NOT associated with chest wall tenderness
What diagnoses do you think of w/ pleuritic pain (changes with respiration)?
PE, PNA, pleuritis, pericarditis, PTX
What diagnosis do you think of with positional chest pain?
pericarditis
What diagnosis do you think of with chest wall tenderness?
costochondritis
A pt comes to ED w/ chest pain (epigastric), a/w sore throat, metallic taste, cough - what do you recommend?
PPIs
An alcoholic pt comes to ED w/ chest pain, N/V, epigastric tenderness. What do you recommend?
amylase and lipase levels
A patient comes to the ED with chest pain, RUQ tenderness, mild fever - what do you recommend?
abdominal U/S to look for gallstones
When CV exam shows S3 gallop, what do you think of?
dilated L ventricle; fluid overload states (CHF, mitral regurg); normal in patients <30
What CV exam shows S4 gallop, what do you think of?
L ventricular hypertrophy; HOCM
What is always the best first diagnostic test for ischemic CP?
EKG
If pt p/w ischemic CP and case gives you a choice b/w treatment first (ASA, nitrates, O2, morphine) and EKG, what do you choose first?
Tx!
What is the most accurate test for ischemic CP?
CK-MB or troponin (both rise 3-6 hrs after start of CP but CK-MB only stays elevated 1-2 days while troponin stays elevated for 1-2 weeks - therefore, CK-MB best test for reinfarction)
Which cardiac enzyme elevates first after MI?
myoglobin
When is stress testing the answer?
when the case is NOT acute and the initial EKG and/or enzyme tests are inconclusive
When are dipyridamole or adenosine thallium stress test or dobutamine ECHO ordered?
For patients who cannot exercise to a target heart rate of > 85% of maximum, complete LBBB, paced ventricular rhythm, preexcitation syndromes (WPW), > 1 mm ST segment depression at rest, LVH w/ repolarization changes, prior h/o revascularization
When is exercise thallium testing or stress ECHO ordered?
When EKG is unreadable for ischemia (L BBB, digoxin use, pacemaker in place, L ventricular hypertrophy, any baseline abnormality of the ST segment of the EKG)
What is the next best diagnostic test to evaluate for “reversible ischemia?”
angiography (note: “reversible ischemia” the most dangerous thing a stress test can show)
What is the best initial tx for all ACS cases?
ASA (lowers mortality) Note: nitrates and morphine do not
What therapies lower mortality in STEMI?
thrombolytics & primary angioplasty (but dependent on time)
In what time frame must angioplasty (a type of PCI) be done for a STEMI?
within 90 min of arrival at the ED
What if PCI cannot be performed within 90 min of arrival at the ED?
thrombolytics should be given (when CP < 12 hours, ST elevation in 2 or more leads, new LBBB) - need to be given w/i 30 min!
What other therapies should be given to ACS patients?
-beta blockers (lower mortality; timing of 1st dose not critical), ACE-Is or ARBs (lower mortality when there is L ventricle dysfunction or systolic dysfunction), statins
What therapies always lower mortality in ACS?
ASA, thrombolytics, primary angioplasty, metoprolol, statins, clopidogrel or prasugrel
What therapies lower mortality in certain situations in ACS pts?
ACE inhibitors & ARBs (if EF is low)
What therapies do NOT lower mortality in ACS pts?
O2, morphine, nitrates, CCBs, lidocaine, amiodarone
When are prasugrel or clopidogrel used?
there is an ASA allergy, the patient undergoes angioplasty and stenting, acute MI
When are CCBs (verapamil, diltiazem) the answer?
pt has intolerance to beta blockers (e.g. severe reactive airway disease), cocaine-induced CP, Prinzmetal’s angina/coronary vasospasm
When is a pacemaker the answer for acute MI?
3rd deg heart block, Mobitz II 2nd deg heart block, bifascicular block, new L BBB, symptomatic bradycardia
When is lidocaine or amiodarone the answer for acute MI?
when V tach, Vfib
How do you diagnose cardiogenic shock as a result of acute MI?
ECHO, Swan-Ganz (R heart) catheter
What is Tx for cardiogenic shock as a result of acute MI?
ACE-I, urgent revascularization
How do you diagnose valve rupture as a result of acute MI?
ECHO
What is Tx for valve rupture as a result of acute MI?
ACE-I, nitroprusside, IABP as a bridge to surgery
How do you diagnose septal rupture as a result of acute MI?
ECHO, R heart catheter showing a step up in saturation from R atrium to R ventricle
What is Tx for septal rupture as a result of acute MI?
ACE-I, nitroprusside, URGENT SURGERY
How do you diagnose myocardial wall rupture as a result of acute MI?
ECHO
What is Tx for myocardial wall rupture as a result of acute MI?
pericardiocentesis, urgent cardiac repair
How do you diagnose sinus bradycardia as a result of acute MI?
EKG
What is Tx for sinus bradycardia as a result of acute MI?
atropine, followed by transcutaneous cardiac pacing if there are still sxs (e.g. hypotension, dizziness, heart failure, syncope, bradyarrhythmia)
How do you diagnose 3rd deg (complete) heart block as a result of acute MI?
EKG, canon “a” waves
What is Tx for sinus bradycardia as a result of acute MI?
atropine & a pacemaker even if sxs resolve
How do you diagnose R heart infarct as a result of acute MI?
EKG showing R ventricular leads
What is Tx for R heart infarct as a result of acute MI?
fluid loading
Post-MI discharge instructions?
ASA, Clopidogrel (or prasugrel), a beta blocker, a statin, and an ACEI
How long should one wait after MI to have sex?
2-6 weeks
What is different in mgmt of NSTEMI vs. STEMI?
In NSTEMI, no thrombolytic use, heparin used routinely (LMWH better; lowers mortality), glycoprotein IIb/IIIa inhibitors (e.g. eptifibatide, tirofiban, abciximab) lower mortality (particularly in those undergoing angioplasty)
What therapies should always be used for STABLE angina?
ASA, metoprolol (lower mortality)
When should ACE-Is and ARBs be used in stable angina?
CHF, systolic dysfunction, low EF
When is angiography done for stable angina pts?
to see if they are a candidate for CABG
What are the indications for CABG?
-three coronary vessels w/ > 70% stenosis -L main coronary artery stenosis > 70%
What are coronary artery disease equivalents?
DM, PAD, aortic disease, carotid disease
What is the goal LDL in CAD pts? In CAD + DM pts?
< 100; < 70
What is the most common side effect of statins?
liver toxicity (elevated transaminases); rhabdomyolysis is NOT the most common adverse effect and no need to check CPK levels
What is the most common cause of erectile dysfunction post-MI?
anxiety
What meds are contraindicated w/ sildenafil?
nitrates
What are the mainstays of therapy for pulmonary edema (e.g. 2/2 CHF)?
O2, furosemide, nitrates, morphine
What tests should be ordered on the first screen (AT THE SAME TIME) of a CCS case for CHF?
CXR, EKG, oximeter, ECHO
What will CXR show for pulm edema?
pulmonary vascular congestion, cephalization of flow, effusion, cardiomegaly
What will EKG show for pulm edema?
sinus tachycardia, atrial and ventricular arrhythmia
What will oximeter show for pulm edema?
hypoxia, respiratory alkalosis
What will ECHO show in pulm edema?
distinguishes systolic from diastolic dysfunction
What therapy do you try on a CCS case of pulmonary edema when O2, furosemide, nitrates, and morphine have been tried and pt is still SOB after the clock has been moved forward?
positive inotrope (e.g. dobutamine, amrinone, milrinone)
What Tx is used when Vtach/Afib/Aflutter/supraventicular tachycardia a/w acute pulmonary edema?
synchronized cardioversion
What Tx used for Vtach/Vfib a/w acute pulmonary edema WITHOUT A PULSE?
unsynchronized cardioversion
When is a BNP level the answer?
to r/o CHF in pt who is SOB (negative test excludes CHF)
What happens to CO, SVR, wedge pressure, adn R atrial pressure in pulmonary edema?
down, up, up, up
What imaging should all CHF patients get once their pulmonary edema is stabilized?
ECHO (to assess whether systolic dysfunction w/ low EF or diastolic dysfunction w/ normal EF)
What should all systolic CHF pts gets for long-term therapy?
ACE-Is, beta blockers, spironolactone (decrease mortality, spironolactone only does so for advanced symptomatic disease)
Have diuretics or digoxin been shown to decrease mortality in systolic CHF pts?
No (but both have been used to decrease sxs)
What drugs can be used interchangeably with ACE-Is for systolic CHF?
ARBs
What 2 beta blockers have evidence for lowering mortality in systolic CHF?
metoprolol and carvedilol
How is diastolic CHF treated?
beta blockers (metoprolol and carvedilol) & diuretics
What drugs definitely do NOT help in diastolic dysfunction?
digoxin and spironolactone
What intervention is indicated for CHF patients with EF < 35%?
implantable defibrillator/cardioverter placement (most common cause of death in CHF pts is sudden death from arrhythmias)
When is a biventricular pacemaker the answer for CHF?
in pts with SEVERE CHF and a QRS duration >120 msec (a/w decrease in mortality in these pts)
Is warfarin ever an answer for CHF?
No, generally a wrong answer
What is an absolute contraindication for use of beta blockers?
symptomatic bradycardia (NOT asthma, emphysema)
Think of which valvular heart disease in young female, general population?
mitral valve prolapse
Think of which valvular heart disease in healthy young athletes?
HOCM
Think of which valvular heart disease in immigrants, pregnant women?
mitral stenosis
Think of which valvular heart disease in Turner’s syndrome, coarctation of aorta?
bicuspid aortic valve
Think of which valvular heart disease in patient with palpitations, atypical chest pain not w/ exertion?
mitral valve prolapse
When you suspect valvular disease, which exams should you order on CCS?
CV, chest, extremities
When you hear a systolic murmur on exam, which valvular problems should you think of?
aortic stenosis, mitral regurgitation, mitral valve prolapse, HOCM
When you hear a diastolic murmur on exam, which valvular problems should you think of?
aortic regurgitation, mitral stenosis
Do right-sided murmurs increase or decrease in intensity with inhalation?
increase
Do left-sided murmurs increase or decrease in intensity with exhalation?
increase
Do squatting and lifting the legs in the air decrease or increase venous return to the heart?
increase
Do the Valsalva maneuver and standing up decrease or increase venous return to the heart?
decrease
What are the only two murmurs that get softer with squatting and leg raise?
mitral valve prolapse and HOCM
What effect does handgrip have on murmurs?
Handgrip increases afterload (compresses arteries of the arm), so pushes blood backward into the heart and therefore makes AR, MR, and VSD murmurs louder, makes MVP, HOCM murmurs softer (enlarges the L ventricle); makes AS murmur softer (can’t have murmur if no blood flow)
What effect does amyl nitrate have on murmurs?
Amyl nitrate is a vasodilator that decreases afterload, has the opposite effect of handgrip (improves AR and MR murmurs; worsens HOCM, MVP, AS murmurs)
Is the murmur of mitral stenosis affected by handgrip or amyl nitrate?
No
Where is aortic stenosis murmur best heard? How does it sound?
2nd R intercostal space, radiates to carotids (APT-M); crescendo-decrescendo systolic murmur w/ normal S1, diminished S2, paradoxical split S2
Where is pulmonic valve murmur best heard?
2nd L intercostal space
Where are aortic regurg, tricuspid, VSD murmurs best heard?
lower L sternal border
Where is MR murmur best heard?
apex (5th intercostal space), radiates to axilla
Describe grading intensity of murmurs.
I: only heard w/ special maneuvers II & III: majority of murmurs IV: thrill present (palpable vibration) V: heard w/ stethoscope partially off chest VI: stethoscope not needed to hear it
Best initial test when valve lesion suspected?
ECHO (on CCS TTE 1st, then TEE if TTE not fully diagnostic)
Most accurate test when valve lesion suspected?
L heart catheterization (measures pressure gradients)
What is the best therapy for regurgitant lesions (murmurs that worsen w/ handgrip)? What if patient progresses despite tx?
ACE-Is (reduces afterload); surgical replacement of valve
How are stenotic lesions best treated?
anatomic repair
If standing/valsalva maneuver improves the murmur, what tx indicated?
diuretics
If amyl nitrate improves the murmur, what tx indicated?
ACE-I (aortic regurg, mitral regurg, VSD)
What is the Px for aortic stenosis patients if: -coronary disease -syncope -CHF
-3-5 years -2-3 years -1.5-2 years
What is the best initial diagnostic test if you suspect AS?
TTE (TEE is more accurate)
What is the most accurate diagnostic test for AS?
L heart catheterization (allows measurement of pressure gradient across the valve)
What is the normal pressure gradient across the aortic valve?
70 mm Hg).
What is the best initial therapy for AS? Treatment of choice?
Diuretics; valve replacement (porcine and bovine valves last 10 years on average but need NO anticoagulation; mechanical valves last indefinitely but need warfarin for INR of 2-3 and 2.5-3.5 if suffer systemic embolus despite anticoag tx)
How does the murmur of AR sound and where is it best heard?
diastolic decrescendo murmur; best heard at L sternal border
What is the best initial diagnostic test if you suspect AR?
TTE (TEE is more accurate)
What is the most accurate diagnostic test for AR?
L heart catheterization (allows measurement of pressure gradient across the valve)
What is the best initial therapy for AR?
ACE-Is, ARBs, and nifedipine; add loop diuretic (e.g. Furosemide) in CCS cases
When is surgery indicated in AR?
When EF < 55% or L ventricular end systolic diameter > 55 mm (even if patient asymptomatic)
What is the most common cause of MS?
rheumatic fever
Describe the murmur of MS.
diastolic rumble after opening snap
What is the best initial diagnostic test if you suspect MS?
TTE (TEE is more accurate)
What is seen on CXR in MS?
straightening of the L heart border and elevation of the L mainstem bronchus; +/- “double density” in cardiac silhouette (from L atrial enlargement)
What is the Tx for MS?
diuretics best initial tx (but do not alter progression); balloon valvuloplasty is the most effective tx (pregnancy not a contraindication)
What causes MR?
HTN, ischemic heart disease, any other condition that causes dilation of the heart
Describe the murmur of MR. Where is it best heard?
holosystolic, obscures both S1, S2; heard best at apex, radiates to axilla: S3 gallop often present
What is the best initial diagnostic test if you suspect MR?
TTE (TEE is more accurate)
What is the best initial therapy for MR? When is surgery indicated?
-ACE-Is, ARBs, nifedipine (decrease rate of progression of disease) -surgery when LVEF 40 mm (even if asxatic)
Describe nature and location of VSD murmur.
holosystolic murmur at lower L sternal border
Initial test for VSD murmur; most accurate test?
ECHO; catheterization (determines degree of L –> R shunting most precisely)
Tx of VSD?
mild defects can be left alone; larger ones need surgery (I think)
Describe nature of ASD murmur
fixed split S2
Dx of ASD?
ECHO
Tx of ASD?
percutaneous or catheter devices; repair indicated when shunt ratio > 1.5:1
What conditions cause a wide P2 delayed S2 split?
RBBB, pulmonic stenosis, R ventricular hypertrophy, pulm HTN
What conditions cause a paradoxical A2 delayed S2 split?
LBBB, aortic stenosis, L ventricular hypertrophy, HTN
What are the causes of dilated cardiomyopathy?
ischemia, EtOH, adriamycin, radiation, Chagas’ disease
Tx of dilated cardiomyopathy?
ACE-Is, ARBs, beta blockers, spironolactone; digoxin decreases sxs but does NOT prolong survival
What does ECHO show in dilated cardiomyopathy?
normal EF
Tx for HOCM?
beta blockers, diuretics (digoxin and spironolactone do NOT benefit)
What are some causes of restrictive cardiomyopathy?
sarcoid, amyloidosis, hemochromatosis, cancer, myocardial fibrosis, glycogen storage diseases
What sign is present in restrictive cardiomyopathy?
Kussmaul’s sign (increase in jugular venous pressure on inhalation)
Dx of restrictive cardiomyopathy?
ECHO 1st; cardiac cath (rapid x and y descent); endomyocardial bx is the single most accurate diagnostic test of etiology
What does EKG show in restrictive cardiomyopathy?
low voltage
Tx of restrictive cardiomyopathy?
diuretics, correct underlying cause
Describe presentation of pericarditis.
pleuritic sharp brief positional CP; friction rub (in 30% patients)
What causes vast majority of pericarditis?
viruses
What is best initial test for pericarditis and what will it show?
EKG (ST segment elevation in all leads; PR segment depression pathognomonic but not always present)
Tx of pericarditis?
NSAID (indomethacin, naproxen, ASA, ibuprofen); advance clock 1-2 days, have patient visit office; if pain persists add prednisone PO and advance clock 1-2 more days
How does pericardial tamponade present?
SOB, hypotension, JVD, clear lungs
What does bp measurement show in pericardial tamponade?
pulsus paradoxus (decr of bp >10 mm Hg on inhalation)
What will EKG show in pericardial tamponade?
low voltage and electrical alternans (alternation of height QRS complex from heart moving back and forth in chest)
Most accurate diagnostic test for pericardial tamponade? What does it show?
ECHO - shows diastolic collapse of R atrium and R ventricle
What does R heart catheterization show in pericardial tamponade?
equalization of all the pressures in the heart during diastole (wedge pressure = R atrial pressure = pulmonary artery diastolic pressure)
Tx of pericardial tamponade?
pericardiocentesis is best initial tx; most effective long-term tx = pericardial window placement; NO DIURETICS (DANGEROUS)
Unique features of constrictive pericarditis?
-Kussmaul’s sign (increase in JVP on inhalation) -pericardial knock (extra diastolic sound from heart hitting a calcified thickened pericardium)
Dx of constrictive pericarditis?
-CXR: calcification -EKG: low voltage -CT/MRI: thickening of pericardium
Tx of constrictive pericarditis?
-best initial Tx: diuretic -most effective Tx: surgical removal of pericardium (pericardial stripping)
Dx of aortic dissection?
-best initial test: CXR (widened mediastinum) -most accurate test: CT angiography
Tx of aortic dissection?
-beta blockers (order with 1st CCS screen, along with EKG, CXR) -then no matter what CT angiography, TEE, or MRI (all 3 equally accurate) -order nitroprusside to get SBP < 100 -place in ICU -surgical consult, with surgical correction
When do you screen for AAA?
in men > 65 yo who were smokers (with U/S)
When do you repair AAA?
when > 5 cm; monitor smaller ones
Dx of PAD?
-best initial test = ankle-brachial index (ABI test) (normal = >0.9); blood pressure in the legs should be equal to or greater than pressure in the arms; if > 10% difference, obstruction present -most accurate test = angiography
Tx of PAD?
-best initial tx: ASA, ACE-I (bp control), exercise, cilostazol, stains (LDL should be < 100) CCBs NOT helpful
Dx of AFib?
EKG; if EKG does not show answer, a patient in the hospital should be on telemetry; outpatients get Holter monitor
What else to order once AFib has been established?
-ECHO (clots? valve fxn? L atrial size?) -thyroid function test (T4 and TSH) -BMP (K+, Mg2+, Ca2+) -troponin or CK-MB (appropriate in some acute onset cases)
Tx of Afib?
-unstable pts (SBP < 90, CHF, confusion, CP): immediate synchronized electrical cardioversion (do this w/ the first screen) -stable pts: rate control (beta blockers - metoprolol, esmolol; CCBs - diltiazem; digoxin [slow onset of action; used in CHF pts]) OR rhythm control (flecainide for pts w/o structural heart disease; dronedarone or amiodarone for pts w/ LVH; sotalol or dronedarone for pts w/ CAD w/o heart failure; amiodarone or dofetilide for pts with CHF; radiofrequency ablation for refractory pts)
How do you determine need for warfarin or dabigatran in Afib patients?
-CHADS2 score! (CHF, HTN, age > 75, DM, stroke/TIA) - if score 3 or more -> anticoag w/ warfarin; if not, ASA; stroke/TIA buys 2 points -If anticoagulation w/ warfarin or dabigatran indicated, aim for INR 2-3
Tx of Aflutter?
Same as Afib
Which rate control med do you choose for Afib/Aflutter if ischemic heart disease, migraines, graves disease, pheo?
beta blocker
Which rate control med do you choose for Afib/Aflutter if asthma?
CCB
Which rate control med do you choose for Afib/Aflutter if borderline hypotension?
digoxin
How does multifocal atrial tachycardia (MAT) present?
like an atrial arrhythmia in patient with COPD/emphysema
What does EKG show in MAT?
tachycardia, polymorphic P waves (different atrial foci), irregular chaotic rhythm
What is the ventricular rate in SVT?
160-180
For SVT: -best tx in unstable pts? -best tx in stable pts? if that doesn’t work? -best long-term tx?
-synchronized cardioversion -vagal maneuvers; IV adenosine -radiofrequency catheter ablation
How does WPW present?
SVT that can alternate with Vtach; worsening of SVT after use of CCBs, digoxin, alcohol
Dx of WPW?
EKG (delta wave + ST/T wave changes + PR interval < 120 msec [<3 small boxes]); accurate test = electrophysiologic studies
Tx of WPW?
-initial Tx: procainamide -long-term: radiofrequency catheter ablation
Dx of Vtach?
-EKG; if not present on EKG, telemetry -most accurate = electrophysiologic studies
Tx for hemodynamically stable Vtach? unstable Vtach?
-amiodarone, lidocaine, procainamide, magnesium -synchronized cardioversion
How does Vfib present?
as sudden death
Dx of Vfib?
EKG
Tx of Vfib
-unsynchronized cardioversion
What is the sequence of defibrillation for someone in Vfib?
-CPR -reattempt defibrillation -IV epinephrine or vasopressin -reattempt defibrillation -IV amiodarone or lidocaine -reattempt defibrillation -several cycles of CPR b/w each shock
What is the treatment for torsades de pointes in stable patients? in unstable patients (hemodynamic instability or AMS)?
Mg2+ (and then temporary overdrive pacing if that doesn’t work); immediate defibrillation
What etiologies do you think of with sudden LoC?
cardiac etiology, neurologic (seizures)
What etiologies do you think of with gradual LoC?
toxic-metabolic problems, hypoglycemia, drug toxicity/intoxication, anemia, hypoxia
What etiologies do you think of with sudden regaining of consciousness?
cardiac etiology, rhythm disorder vs. structural disease
What etiologies do you think of with gradual regaining of consciousness?
neurologic (SZ)
What tests do you order on the initial CCS screen for syncope?
cardiac & neuro exams, EKG, chemistries (glucose), oximeter, CBC, cardiac enzymes (CK-MB, troponin)
If initial tests ordered in w/u for syncope show murmur, what do you then order?
ECHO
In what situations should you order a head CT w/ syncope?
if neuro exam is focal, h/o of head trauma due to syncope, HA, SZ described or suspected (also order EEG)
What should you order if initial w/u for syncope not clear?
-Holter monitor and telemetry for outpatients -repeat check of CK-MB and troponin 4 hours later -urine and blood tox screens -consider tilt table testing (neurocardiogenic/vasovagal syncope) -electrophysiological testing
What do you do if a ventricular dysrhythmia is diagnosed as etiology of syncope?
implant cardioverter/debrillator
What etiology causes >80% of mortality from syncope?
cardiac
What is the most important medication in patients w/ asymptomatic L ventricular dysfunction?
ACE-Is (beta blockers are also an option) - can delay the onset of symptomatic CHF and potentially prolong survival
What are the acquired causes of long QT syndrome (which can lead to torsades)?
-chronic renal failure -liver disease -electrolyte abnormalities (hypoMg2+, hypoK+) -drugs (sotalol, antibiotics [macrolides, pentamidine, TMP-SMX], psychotropic drugs [risperidone, phenothiazines, TCAs], antihistamines [terfenadine, astemizole])
What valvular problem do you think w/ “systolic murmur heard in apex, radiates to axilla, increases with grip maneuver, and decreases with Valsalva”?
mitral regurgitation
What are the four most common causes of acute heart failure?
papillary muscle rupture (usu elderly), infective endocarditis, rupture of chordae tendinae (younger adults), chest wall trauma with compromise of the valvular apparatus
How do you confirm rupture of chordae tendinae?
ECHO
What is a pathologic Q wave? What does it indicate?
deep Q wave on EKG; indication of prior MI
What medication is recommended for all patients with stable angina, prior acute coronary syndrome, or L ventricular dysfunction?
-beta blocker (unless severe asthma or COPD) - reduce overall mortality and morbidity in patients with CAD -add CCBs if initial treatment was not successful or beta blockers are contraindicated -Amlodipine is also a 2nd line Tx for pts with stable angina where beta blockers are contraindicated
What anticoagulation preventive methods are indicated for patients with stable angina/secondary prevention of future MI?
-ASA -Clopidogrel if ASA allergy -Warfarin if cannot tolerate either ASA or Clopidogrel (goal INR 2.5-3.5)
When do you skip exercise stress testing and go straight to coronary angiography for stable angina patients?
patients at high risk of underlying CHF: when there is evidence of heart failure (edema, low EF on ECHO, etc.), a high likelihood of severe CAD, EKG abnormalities, or disabling anginal sxs
What are primordial, primary, secondary, tertiary, and quarternary prevention?
-primordial: preventing formation of risk factors -primary: action taken before patient develops disease -secondary: action that halts/delays progression of disease -tertiary: action that limits impairments/disabilities when disease has advanced beyond early stages -quarternary: activities that limit consequences of excessive intervention by health system
What meds decrease metabolism of warfarin? Increase it?
-Decrease: amiodarone, cephalosporins, ciprofloxacin, erythromycin, fluconazole -Increase: rifampin, phenobarbital
When do you perform tilt table testing in a patient whom you’re s/f vasovagal syncope? 24 hour Holter monitoring?
-when Dx is uncertain -when there are EKG changes, or clinical features s/o arrythmia
What side effect is hydrochlorothiazide a/w?
photosensitivity (HCTZ is a sulfonamide)
What side effect are ACE-Is a/w?
angioedema, urticaria
What major side effects is amiodarone a/w?
pulmonary toxicity (e.g chronic interstitial pneumonitis), thyroid dysfunction, abnormal liver function tests, bone marrow suppression, skin discoloration, photosensitivity
What are the sxs of digoxin toxicity?
N/V, anorexia, confusion, visual disturbances, cardiac abnormalities
What drugs inhibit renal tubular section of digoxin (and therefore increase risk of digoxin toxicity)?
verapamil, quinidine, amiodarone, spironolactone
How is cardiotoxicity in patients undergoing chemotherapy with anthracyclines (e.g. doxorubicin, daunorubicin) monitored?
radionuclide ventriculography (to monitor EF)
How is the management of cocaine-related chest pain different from that of other chest pain?
-basically the same but treat early with benzodiazepines (e.g. lorazepam) -if persistent HTN, add phentolamine (alpha antagonist which also decreases coronary vasospasm)
What is the Tx for acute pericarditis after an MI?
ASA (not NSAIDs - may increase risk of myocardial rupture)
What side of the heart does endocarditis 2/2 IV drug use typically involve?
R side (most other cases of endocarditis are L sided)
What is a major side effect of thiazolidinedione meds (e.g. pioglitazone) in patients with underlying CHF?
fluid retention (can cause pulmonary edema) due to activation of receptors (PPAR-gamma) in collecting tubule of nephron
What is Beck’s triad?
refers to classic triad seen in pericardial effusion: hypotenson, muffled/distant heart sounds (due to fluid around heart), elevated JVP
What is the Tx for cardiac tamponade?
rapid pericardiocentesis
What are the two most commonly used antihypertensive agents used in managmenet of hypertensive crisis?
-IV nitroglycerine OR -IV nitroprusside
What is the intervention most likely to slow rate of AAA progression in someone being medically managed?
smoking cessation (not HTN control)
What drugs are used for rate control in pts w/ Afib w/ RVR?
verapamil, diltiazem (both class IV antiarrythmics)
Describe the murmur of mitral valve prolapse.
mid systolic click followed by late systolic murmur
Describe managment of supratherapeutic INR for pts on warfarin.
- INR < 5: hold warfarin x 1-2 days or decrease dose 2. INR 5-9: hold warfarin and resume when INR therapeutic; give low-dose Vitamin K PO if increased risk of bleeding 3. INR > 9: hold warfarin and give high-dose Vitamin K PO 4. for any serious or life-threatening bleeding: hold warfarin, give IV Vit K, FFP, factor 7a, or prothrombin factor concentrate
What conditions can cause multifocal atrial tachycardia?
-hypoxia (esp in elderly) -COPD (esp in elderly) -hypokalemia -hypomagnesemia -coronary/hypertension/valvular disease -meds (i.e. theophylline, aminophylline, isoproterenol)
Tx of multifocal atrial tachycardia?
- eliminate contributing factors (e.g. hypoxia, COPD) 2. beta blockers in those w/ no contraindications if #1 doesn’t work (verapamil in pts w/ asthma/COPD)
What are the sxs in Horner’s syndrome?
- miosis 2. ptosis 3. anhidrosis
What should you do first w/ patient with Horner’s syndrome?
- MRA of head and neck (r/o carotid dissection) 2. if MRA yields unclear results –> catheter angiography
Tx of carotid dissection?
anticoagulation with platelet agents and/or heparin
What is the Tx for hyponatremia in patients w/ advanced CHF?
water restriction
Which cardiac meds can cause peripheral dependent edema as side effect?
diltiazem, nifedipine, amlodipine (the calcium antagonist therapies)
What is first degree AV block?
lengthening of PR interval > 0.2 sec
Tx of first degree AV block?
find and remove offender (drugs [CCBs, beta blockers], electrolyte abnormalities, etc.)
What is second degree AV block, Mobitz type I?
progressive prolonged PR interval, followed by nonconducted P wave
What is risk of complete heart block in Mobitz type I 2nd degree AV block?
low risk
What is second degree AV block, Mobitz type II?
PR interval constant w/ intermitten nonconducted P waves
What is risk of complete heart block in Mobitz type II 2nd degree AV block?
higher risk
Tx of symptomatic Mobitz type I and all Mobitz type II AV block?
pacemaker
How do you make Dx of CHF?
H&P: 2 major or 1 major and 2 minor criteria: -major: PND, orthopnea, elev JVP, rales, 3rd heart sound, increased cardiac silhouette, pulmonary vascular congestion on CXR -minor: B/L LE edema, nocturnal cough, DOE, tachycardia, pleural effusion, hepatomegaly
What is the Tx for symptomatic aortic stenosis patients?
aortic valve replacement
What are INR goals for patients w/ mechanical valves?
-2.5 (range 2-3) for pts w/ AVR w/ bileaflet MV -3 (2.5-3.5) for pts w/ MVR w/ bileaflet MV or pts w/ bileaflet AVR w/ Afib; add ASA if these pts suffer a systemic embolus despite warfarin
What region of the heart does the: -L circumflex -L anterior descending -L main -R coronary supply?
-L circumflex: lateral and posterolateral L ventricle -L anterior descending: anterior L ventricle -R coronary: R ventricle and inferoposterior L ventricle
