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