Cardiology Flashcards
What are the clinical signs of cardiac tamponade?
Beck triad: hypotension, JVD, decreased heart sound
Pulsus paradoxus: >10 mm Hg drop in SBP during inspiration
lungs will be clear to oscillation
What is pulsus paradoxus and how might this present in a in a question?
Pulsus paradoxus: >10 mm Hg drop in SBP during inspiration
described as “distal pulses become undetectable to palpation during inspiration”
inspiration = increased venous return = increased right heart volumes, normally this results in expansion of the right ventricle into the pericardial space. With with impaired pericardial space (fluid) the interventricular septum deviates to left ventricle affecting end-diastolic volume & forward stroke volume
When should males be screened for abdominal aortic aneurysm?
Age 65-75, with any smoking history via a one-time abdominal ultrasound.
Acute pericarditis etiology
viral (adenovirus, coxsackievirus, influenza virus)
autoimmune disease
Uremia
Post myocardial infraction
treatment for hypertriglyceridemia
Fibrates drugs names and indication
Fibrate (gemfibrozil, fenofibrate)
Effective for decreasing triglyceride levels; indicated for severe hypertriglyceridemia (500-1000)
Mechanical complications of acute MI
hemodynamic compromise 1st fe days after an MI = mechanical complications for MI. The infarcted myocardium is the softest and most prone to rupture.
-> Mitral regurgitation due to papillary muscle rupture
Left ventricle free wall rupture
Interventricular septum rupture
Lisit the pharmacological therapy used to prevent recurrent coronary events?
Dual antiplatelet therapy: Aspirin & P2y12 receptor blocker (clopidogrel)
Beta blcokers
ACEi/ARBs
HMG-CoA reductase Inhibitors (statins)
Aldosterone antagonist (spironolactone, eplerenone) ->in patients w left ventricular ejection fraction <40% who have heart failure sxs or DM
Lipid guideline for starting statin therapy. HINT 5 indications
1) <19y/o w a familial hypercholesterolemia
2) LDL >190 = high intensity statin
3) DM + 40-75 y/o = high intensity statin
4) 40-75 y/o w/o DM + LDL > 70 & <190 get 10 year risk ASCVD
——–> >20% = high intensity statin w goal to reduce LDL by >50%
———> >7.5% - <20% = moderate statin w goals to reduce LDL by 30-49%
———> 5-7.5% suggest statin
———> <5% = lifestyle changes
5) any form of CVD
Lipid normal reference range
Total cholesterol <200 mg/dl
Triglyceride <150
HDL >60
LDL<130
Which HMG COA reductase inhibitors are the most potent?
Rosuvastatin (high intensity at 20-40 mg) is the most potent followed by atorvastatin (40-80mg)
What is the MOA of HMG-COA reductase inhibitor (statins)?
Block the effects of hydoxymethylglutaryl- CoA (HMG-COA) reductase, a rate-limiting step of the hepatic production of cholesterol.
Thereby encouraging the use to LDL receptor = reducing LDL in the blood
Cardio-protective by stabilizing atherosclerotic plaques.
What are the side effects of HMG-CoA reductase inhibitor?
Hepatoxicity (increase LFTs)
Myopathy (myalgia, rhabdo-> increased CK). Worse when combined with Niacin and Fibrates.
Contraindication in pregnancy and persistently elevated LFTs
Which two lipid lowering drugs are known to decrease cardiovascular risk?
HMG-COA reductase inhibitor
PCSK9 inhibitors
Alirocumab & Evolocumab belongs to which lipid lowering drug?
PCSK9 inhibitors
Names of PCSK9 inhibitor drugs
Alirocumab & Evolocumab
What are the names of bile acid sequestrants drugs?
Cholestyramine
Colestipol
Colesevelam
What is the MOA of bile acid sequestrants?
Disrupts the enterohepatic recycling of bile acid via blocking bile intestinal absorption.
Decreased bile absorption
↑ bile fecal removal
↑ LDL receptor upregulation on hepatocytes
decrease serum LDL
Increase hepatic synthesis of bile.
Which bile acid sequestrants are often used to treat biliary obstruction related pruritis?
Cholestyramine
What is a side effect of bile acid sequestrants?
GI upset
Decreased fat-soluble vitamins (DEKA)
–> Prolonged PT/INR due to decreased vitamin K affecting the production of vitamin-dependent clotting factors
Contraindicated in severe hypertriglyceridemia.
What is the MOA of Ezetimibe?
It blocks intestinal absorption of cholesterol
What is a known side effect of ezetimibe
increased liver enzymes
What are fibrates drugs?
Gemfibrozil, Fenifibrate
What is the side effects of fibrates?
Increased risk of cholesterol gallstones
Worsen myopathy when combined with statins
What is are the side effects of niacin (vitamin B3)?
Skin flushing and burning sensation of the face, generalized itching, paresthesias, headache after use 20-30 mins
peptic ulcer disease
Hyperuricemia
worsen myopathy when combined with a statin.
In treating A fib in a patient with a mechanical valve, which anti-cogaulation should be used?
Warfarin
What steps should be taken if considering a electrical rhythm control for a patient with A Fib?
1)Transesophageal Echo to r/o Left atria thrombus
2) positive signs of a thrombus = anti-coag x3 weeks then cardiovert
3)continue Anti-coag x4 weeks after cardioversion.
Which anti-arrhythmic drug should not be used in a patient with structural or coronary heart disease?
Flecainide
amiodarone can be used.
What does CHA2DS2-VAS score stand for, how is it used?
Congestive heart failure
HTN
Age >75 —-> 2 points
Diabetes
Stroke —> 2 points
Vascular disease
Age 65-74
Sex: female
men >2 or women >3 = anticoagulation
multifocal atrial tacycardia is associated with?
COPD
what is the difference between Wandering atrial pacemaker and multifocal atrial tachycardia?
Both MAT and WAP have >3 distinct P wave morphologies originating from atrial foci however,
MAT has a rate >100
WAP has a rate <100
what is ventricular tachycardia?
> 3 consective premature ventricular contraction
What are the painless lesions on the hands which occur with endocarditis?
Janeway lesion
What are the painful lesions on the hands which occur with endocarditis?
osler’s nodes
what is the rise in jugular pressure that occurs with inspiration in a patient with pericardial tamponade called?
Kussmal sign
what are side effects of amiodarone?
pulmonary fibrosis, hepatoxicity, thyroid dysfunction (hyper or hypo thyroidism)
what is the treatment for angina in a patient who is allergic to nitrates?
CCB
What is the treatment for prinzmental angina?
CCB
What does a severe elvation of BP (180/120) w/o endorgan dysfunction define?
Hypertensive urgency
Which class of antihypertensive medication can cuaes hypokalemia?
thiazide diuretics
Which class of antihypertensive medication can cause hyperkalemia?
ACE, ARB, Aldosterone antagonists
AAA screening
1 time screening via abdomina U/S in men 65-75 y/o
what is abdominal aortic aneurysm?
localized dilation of the aorta due to weakening of the vessel wall. A diameter >3cm is considered an aneurysm
What is the most common site for a AAA?
infrarenal
AAA is commonly associated with which modifiable risk factor?
Smoking
What is aortic dissection ?
a tear in the intimal layer of the aorta, allowing blood to flow between the intima and the media layers, creating a false lumen
What is the most common risk factor for aortic dissection?
HTN
Explain how the stanford type a classification differs from standford type B classification for aortic dissection?
Stanford type A involved the ascending aorta. which Stanford type B involves the descending aorta
How is stanford type A aortic dissection treated?
surgically with preoperative BP control
How is stanford type B aortic dissection treated?
Medically with beta blockers (labetalol)
What is homan’s sign
calf pain on passive foot dorsiflexion (unreliable for the presence of DVT)
what is the diagnostic work up for DVT?
DVT unlikely = dimer to r/o DVT. If >500 then compression U/S w doppler.
DVT likely = compression U/S w doppler. Pos if non-compression of imaged vein w pressure.
Neg if full compressibility.
when should IVC be considered in a patient with DVT?
1) crcl <30
2) bleeding that makes anticoag contraindicated
what is rheumatic fever?
an autoimmune inflammatory disease involving the joints, heart, skin, nervous system after an episode of untreated group a street pharyngitis
what are the two streptococcal antibody titers
anti-deoxynucleoside B or antistreptolysin O
How is rheumatic fever diagnosed?
2 major OR 1 major and 2 minor
Major: JONES
Joints (migratory polyarthritis)
Oh my heart (active carditis)
Nodules (subcutaneous)
Erythema marginatum (macular red no itchy rash
Sydenham chorea (involuntary jerky movements)
Minor
fever >101
arthralgia
prolonged PR interval
Evelated ESR, CRP
management for rheumatic fever
1st line: abx: penicillin G
-> pen allergy: erythromycin
Anti-inflammatory: aspirin +/- steroids
what is the most common valve affected by rheumatic fever?
mitral -> regurgitation that later develops into stenosis.
what is the treatment for rheumatic heart disease?
Penicillin
1) 5yr or until 21 ->no evidence of carditis
2)10 yrs or until 21 -> evidence of carditis but no valvular abnormalities
3) 10 yrs or until 40 -> evidence of carditis + valvular abnormalities
whichever time frame is longer
what is the treatment for rheumatic heart disease if there is no evidence of carditis?
Penicillin for 5yr or until 21
which ever is longer
what is the treatment for rheumatic heart disease if there is evidence of carditis but no valvular
penicillin for 10 yrs or until 21, which ever is longer.
what is the treatment for rheumatic heart disease if evidence of carditis + valvular abnormalities?
penicillin for 10 yr or until 40 yr old whichever time frame is longer
prinzmetal angia
episodic nocturnal chest pain that wakes the patient up at night. Last 10-15 mins
What 1 warning to know about beta blockers?
can mask hypoglycemia symptoms
What are some end-organ damage (5) finding associated with HTN emergency?
BP >180/120 + end organ damage
1) intracerebral hemorrhage (speech/vision changes)
2) Ischemic stroke
Hypertensive encephalopathy (confusion, HA)
Hypertensive Nephropathy (increased SCr)
3)Acute heart failure (cough, pink-tinged sputum)
4) acute coronary syndrome
5) Aortic Dissection
what is the treatment for HTN urgency?
Clonidine
What is the treatmennt for HTN emergency?
Nitroprusside
What is the most common cause of myocarditis?
viral MC (enteroviruses, Coxsackievirus)
myocarditis presentation ?
Prodrome viral sxs then sxs of dilated cardiomyopathy
treatment for myocarditis
supportive: ACEi, diuretics, BBs
what are the causes of pericarditis?
1) viral (coxsackievirus)
2) Dressler syndrome (post MI pericarditis + fever + pleural effusion)
What is dressler syndrome?
inflammation of the pericardial sac after an MI with fever and pleural effusion
What are EKG findings for pericarditis?
1) Diffuse concave ST elevation in all precordial leads
2) PR depression
what is the treatment of pericarditis?
NSAIDs or ASA
what is pulsus paradoxus?
> 10mmHg decreased in systolic pressure w inspiration
associated cardiac tamponade
what is constrictive pericarditis?
loss of pericardial elasticity (restriction of ventricular diastolic filling)
pericardial knock
high-pitched, knocking-like sound resulting from the abrupt cessation of ventricular filling due to a rigid, non-compliant pericardium, as seen in constrictive pericarditis.
recommended regimen for endocarditid prophlaxis when undergoing dental procedures?
2g (2000mg) of amoxicillin before procedure
2g of cephalexin if pen allergy
Cilostazol what does it do and how is it used?
Cilostazol -> suppress platelet aggregation & vasodilate arterial-> increase claudication free walking distance. Contraindicated in HF-> specific for PAD
Lateral malleolus ulcers are associated with?
Peripheral arterial disease
“L-A-teral Ulcers”
The 6 Ps of Acute arterial occlusion include?
1) Paresthesias
2) pain
3) pallor
4) pulselessness
5) poikilothermia
6) paralysis
superficial thrombophlebitis is commonly caused by?
IV catheterization, pregnancy, varicose veins
migratory thrombophlebitis vs localized superficial thrombophlebitis?
Trosseau sign: migratory thrombophlebitis = malignancy
Isolated palpable cord, red, painful edema along the vein = superficial thrombophlebitis
