Cardiology Flashcards
What electrolyte is used in repolarization of the heart?
K+
What causes fast conduction through the heart?
Na+
What effect does parasympathetic stimulation have on the heart?
Slows heart rate , slows conduction, decreases force of contraction, caused by cholinergic Ach
What effect does sympathetic stimulation have on the heart?
Norepinephrine -adrenergic causes increase rate, increase force of contraction and increase irritability of foci, constricts arteries causing increase in BP
Wandering pacemaker
P wave shape varies, atrial rate less than 100, irregular vent rhythm
MAT multifocal atrial tachycardia
P wave shape varies, rate over 100’ COPD or dig toxicity
A fib
Continuous rapid firing by many atrial foci, continuous atrial spikes, count vent rate — QRS in 6 sec strip x 10
Atrial escape rhythm
60-80, atrial foci assumes pacing
Junctional escape rhythm
40-60, usually no p wave, but may have retrograde atrial polarization causing Inverted p wave
Ventricular escape rhythm
Looks like PVC’s, 20-40, P and QRS do not match
Premature atrial beat
Irritable foci, new atrial beat resets the rhythm
Preventricular beat
Vent irritability caused by low O2, low K+
V tac
A run of three or more PVC, from epi like substances
Paroxysmal atrial tachycardia
Different p wave, rate 150-250
PAT with AV block
More the one P for every QRS, dig excess
Paroxysmal junction all tachycardia
150-250, May have inverted p waves
AV node reentry
aVNRT, vicious cycle
SVT
Any tachycardia that originates above the ventricles
Torsades de pointes
250-350, low K+, long qt syndrome, looks like a twisted ribbon
Atrial flutter
250-350, saw tooth,
Ventricular flutter
250-350, single foci
V fib
Multiple foci, bag of worms
A fib
Caused by many irritable parasystolic atrial foci
WPW
Bundle of Kent, av conduction pathway causing a reentrent SVT
1degree AV block
Retards AV node conduction, PR interval greater than .2 sec or one large square, CONSTANT every cycle
2 degree AV block Wenkebach
PR interval gets longer than drops the QRS, still PR interval great than .2 sec
2 degree AV block Mobit
AV node total block conduction, no progression just a dropped QRS, regular punctual P wave
3rd degree AV block
Total conduction block, usually normal P wave with. Junctional QRS, must have pacemaker
BBB
Block produces a delay in the depol of that vent, right chest leads V1-V2, left chest leads V5-V6’ QRS greater than .12 sec or 3 small blocks
How do you determine axis?
If QRS in lead 1 and AVF are positive = two thumbs up sign
If QRS in lead one is negative, what is the. Axis?
RAD
If the transitional QRS is in V1 or V2 what is the axis?
Right shift
If the transitional QRS is in lead V5 or V6, what is the axis?
Left shift
How Do you determine atrial hyper trophy in an EKG?
V1- dish aspic P wave = AE. The larger P wave is hypertrophied.
How do you determine ventricular hypertrophy in a. EKG?
LVH- mm of S in V1 + mm of R in V5 if greater than 35 then LVH
How do you determine ischemia in an EKG?
Diminished blood flow, inverted T waves
How do you determine injury in an EKG?
ST elevation, acute or recent injury, earliest sign of infarction
What does pericarditis look like on an EKG?
ST segment elevation, flat or concave T wave may be off baseline
What is a clue for subendocardial infarction on an EKG?
ST depression, no through entire wall thickness
Wat are the signs of necrosis on an EKG?
Q wave, significant small box wide or 1/3 the height of the QRS
Which leads would show a lateral infarction?
1 and AVL, circumflex
Which leads should show an anterior infarction?
V1-V4 from LAD
Which leads would show an inferior infarction?
2,3 and AVF, RCA or LCA
Which leads should show a posterior infarction?
V1-V2 large R wave plus ST depression
What does a Pulmonary embolism. Look like on EK g?
S1, Q3’ inverted T 3….. Large s in lead 1’ large Q in 3 and t wave inversion in 3
What cases the heart sounds S1?
Mitral and tricuspid closing
What causes the heart sound S2?
Atrial and pulmonic valve closing
Where is each sound heard the best: mitral, tricuspid, pulmonic, aortic?
Apex, left lower sternal border, left upper sternal border, right upper sternal border
What can cause widened splitting of S2?
RBBB pulmonic valve stenosis
Fixed splitting of S2 is caused by?
Atrial septal defect
Paradoxical splitting of the S2 is caused by?
LBBB
After S1, the opening of the aortic or pulmonic valves for stenosis is called an?
Ejection click
What are the systolic murmurs?
Aortic stenosis, pulmonic stenosis, mitral regurgitation and tricuspid regurgitation, VSD, MVP
What murmur begins after S1, May have an ejection click, high frequency, best heard in the RUSB, and radiates to the neck?
Aortic stenosis
What murmur begins after S1, May have a click, and is loudest at the left upper sternal border?
Pulmonic stenosis
What holosystolic murmur is heard best at the apex, blows, radiates to the axilla and does not change with respiration?
Mitral valve regurgitation
What murmur is holosystolic, heard at the left lower sternal border, radiates to the right of the sternum, is blowing and increases with inspiration?
Tricuspid regurgitation
What murmur is holosystolic, high pitched, may have a thrill and does NOT change with inspiration or radiate?
VSD….. Louder = smaller
Describe the murmur of MVP.
Midsystolic click, late systolic murmur heard best at the apex.
List the diastolic murmurs.
Mitral valve stenosis, tricuspid stenosis, aortic regurgitation,pulmonic regurgitation,
What is a blowing murmur in early diastole strongest along the left sternal border heard best siting leaning forward and exhaling.
Aortic valve regurgitation
What is an early diastolic murmur heard best in the left upper sternal border?
Pulmonic regurgitation
This murmur begins after S2, loudest at first, low pitched, heard at apex and in the left lateral decubidis position.
Mitral valve stenosis
This murmur is in early diastole, heard best at lower sternum near xiphoid process?
Tricuspid regurgitation
This is the only continuous murmur?
PDA
How does digoxin therapy look on EKG?
ST scooped depression, mild PR prolongation
How does hyper kalmia look on EKG?
Peaked T wave
How does severe hyperkalemia look on EKG?
Flattened P wave, wide QRS
How does hypojalemia look on EKG?
ST depression, flattened T, prominent U
How does hypercalcemia reflect on the EKG?
Shortened QT interval
How does hypocalcemia look on the EKG?
Prolonged QT interval
Quinidine
Use for a fib with WPW. Give with BB.
Quinidine toxicity?
Diarrhea, cinchonism, vasodilation, TdP
Procanamide
a fib with WPW
Lidocaine cardio use
Use for PVC
2nd choice after amiodarone for V tachs
Dilantin
Use for arrthymia due to DIG toxins, causes hyperplasia of the gums
Describe what beta blockers do.
Use for SVT and PSVT
Useful in suppressing tackyarrhythmias induced by excessive catecholamines (exercise or emotional stress)
Slow vent rage in a fib or a flutter
May terminate Re entrant SVT. Do not prolong QT
Amioderone uses.
Grand daddy! Decrease SA node firing rate, suppress automaticity, interrupt reentrant circuits, preserves CO,
USE: reentrant tachycardia, a fib, a flutter, SVT with bypass tracts
Tachycardia, fibrillation, more effective than lidocaine
Amiodarone toxicity.
Pulmonary toxicity, TdP, hyper/hypo thyroid
Must monitor with EKG, CXR, thyroid, PFT, LFT
Verapamil
CCB. DO NOT USE in: wide complex tachycardia, A fib with WPW, SSS, AV block w/o a pacemaker.
Medications used in PSVT treatment.
Adenosine 6 mg
Adenosine 12mg
Verapamil
Digoxin
Pacemaker indications.
Symptomatic AV node block, mob it’s and type 3.
Long QT syndrome. Recurrent VT. SVT.
Cardiomyopathy. Cardiac arrest. Syncope. NSVT w prior MI
How do you treat a bradyarrhythmias?
Increase HR by anti cholinergic drugs (atropine), B receptor agonists (isoproterenol) or a pacemaker
What is the number one cause of dilated cardio myopathy?
Idiopathic with coxsackie virus mist common viral
Causes of dilated cardiomyopathy?
Idiopathic, HTN, doxorubicin, beri beri, coxsackie virus
Clinical presentation of dilated cardiomyopathy?
Exertional intolerance, atypical cp, dyspnea, orhtopnea, edema, crackles on pulm exam
What does the echo show in dilated cardiomyopathy?
Dilated thin left vent with low EF
What cardiomyopathy is the MC cause of heart transplant?
Dilated
What is an inherited disorder AND a common cause of sudden cardiac death in young athletes?
Hypertrophic cardiomyopathy.
What happens in the heart during hypertrophic cardiomyopathy?
Hypertrophy leads to left vent outflow obstruction and impaired filling which leads to pulmonary congestion
What does the echo show in HOCM?
Septal wall thickness increased and EF of 80-90 %
How to treat hypertrophic cardiomyopathy?
No sports, beta blocker to decrease heart rate and improve filling time
CCB to improve ventricle compliance
If you hear an S3 think?
CHF
If you hear an S4 think?
MI
What causes restrictive cardiomyopathy?
An infiltration process like amyloidosis or sarcoidosis . Damage to muscle wall leads to diastolic noncompliance with elevated filling pressure leading to pulmonary congestion
Clinical presentation and dx of restrictive cardiomyopathy?
Exertion intolerance, fluid retention, right heart failure with JVD, s3,s4,
Diagnose with echo showing decreased EF 25-50% and normal LV thickness
Treatment for restrictive cardiomyopathy?
Diuretics, ACEI, BB or transplant
What is the number one cause of CHF?
Ischemic heart disease
What is ventricle volume before contraction?
Preload
What is the pressure then ventricle pushing against called?
Afterload
Clinical presentation and PE of a patient with CHF?
Dyspnea, orthopnea, PND, fatigue, edema, exercise intolerance
JVD, rales, edema, asities
What are the signs of right sided heart failure?
Systemic issues like JVD, asities
What are the signs of left sided heart failure?
Think pulmonary like orthopnea, dyspnea, rales, PND
What are signs of CHF on X-ray?
Cardiomegaly, increased pulmonary vasculature, pleural effusions, kerley b lines
What is normal EF?
50-70%, below 35 is failure
Treatment for CHF?
Low sodium diet, loop diuretics #1, ACEI use early to decrease hypertrophy, ARB as needed,
What Meds do you avoid in patients with CHF?
Steroids, NSAIDs, CCB
Normal BP?
120/80
Stage 1 BP?
140-159/90-99
Goal for BP treatment? In diabetics and renal failure?
Less than 140/90, DM and renal less than 130/80
Work up for BP should include?
Optic fundi, carotids, heart, renal mass, renal artery bruit, pulses, skin
UA, glucose, cholesterol, potassium, EKG
What is the first line medication for HTN treatment?
Thiazide s
Lifestyle modifications
When should you suspect secondary HTN?
Onset less than 30 or greater than 50, worsening of controlled HTN, failure to respond to treatment, hypokalemia, liable HTN, headache palpitations and sweating, renal failure after ACEI.
Headaches, palpitations and sweating with HTN think?
Pheochromocytoma
Number one treatment for HTN emergency!
IV nitroprusside
Clinical dx of cardio genie shock from hypotension.
SBP less than 90 or a decrease from baseline from 30
Treatment for carcinogenic shock (hypotension)?
Dopamine increased cardiac output and BP
Dobutamine increases cardiac output
Definition of Orthostatic hypotension?
Decrease in SBP of 20 or DBP of 10 when recumbent to standing
Etiology eps of Orthostatic hypotension?
Antipsychotic Meds, diuretics, alpha blockers, ACEI, ETOH, vasodilators
Parkinson’s disease
Polyneuropathies
Modifiable risk factors for MI?
Dyslipidemia, smoking, HTN, activity level, obesity, DM
Non modifiable mi risk factors.
Age, gender, family hx
Describe clinical presentation of MI.
Pain severe and intolerable, retro sternal may radiate to shoulder or jaw, greater than 20 min, crushing constricting in nature, this is caused by ischemia not infarct
Who may have a painless MI?
Elderly and women
Describe process of creatine kinase in an MI.
Increases at 3-6 hrs
Normal at day 2-4
Peaks at 24 hrs
Check every 8 hrs
Describe troponin process during MI.
Increases at 2/4 hrs.
Peaks at 10-24 hrs.
Persist 5/12 days
Test of choice for people who present late
Classic patter of EKG for MI?
ST elevation and q waves
ST elevation describes what type of injury pattern!
Transmural events
Injury pattern showing ST depression.
Subendocardial ischemia
Treatment of MI?
M- morphine (pain control, decrease BP)
O- o2
N- nitrates (dilate arteries, improve pre/afterload)
A-ASA
H-heparin
B-bets blockers (control BP and decrease risk of sudden death)
Bets blockers contraindicated in whom?
2nd and 3rd degree heart block
Absolute contraindications for thrombolytics?
Active bleeding Aortic dissection Recent head trauma or neoplasm Hx of CVA Major surgery or trauma in last 2 wks
Define angina.
Chest pain that builds rapidly in 30 sec, disappears 5-15 min, produced by activity and relieved by rest
Patient presentation of angina?
Achy dull, mid sternal discomfort with radiation to left shoulder, neck or arm
Diagnostic test for angina?
Positive stress test or perfusion test
Treatment for angina?
Improve risk factors, manage lipids, b blockers, control sx, revascularization with PTCA or CABG
What is unstable angina?
New onset angina, increasing angina, onset at rest
Treatment for unstable angina?
ASA, b blocker, ACEI, revascularization
Classic triad for acute pericarditis?
Chest pain, pericardial friction rub, EKG abnormalities
Most common etiology of acute pericarditis?
Viral from coxsackie virus
Patient presents with retro sternal CP with radiation to left back and trap, coughing and deep breathing increases pain, leaning forward decreases pain.
Acute pericarditis.
Acute pericarditis on EKG?
ST elevation with upright T waves in MOST leads
Treatment of acute pericarditis?
NSAIDs, steroids, symptomatic tx
This is fluid In the pericardial sac and inability to fill chambers in diastole which leads to decreased stroke volume and decreased cardiac output
Cardiac tamponade
Classic triad of cardiac tamponade?
JVD, muffled heart sounds, pulsus paradoxus
Treatment of cardiac tamponade?
Drain fluid
What is a pericardial effusion?
Prolonged or severs inflammation leading to fluid accumulation around heart
A large pericardial effusion can turn into?
Cardiac tamponade.
Treatment for pericardial effusion or cardiac tamponade?
Pericardialcentesis
What is the stretch of myocardial fibers before contraction?
Preload, the more fibers are stretched the greater the force of the contraction
Symptoms of left sided heart failure are?
Dyspnea, orthopnea, PND, fatigue, diaphoresis, rales
Sx of right sided heart failure are?
Peripheral edema, JVD, RUQ pain
What is acute pulmonary edema?
Severe acute form of left sided heart failure when elevated capillary pressure pushes fluid into the lungs
Tachycardic patient with tachypnea and frothy sputum and rales think?
Acute pulmonary edema
How does an ACEI work?
Blocks the conversion of angiotensin 1 to angiotensin 2 and therefore decreases blood pressure
What is the most common cause of heart failure in the first week of life?
Hypo plastic left heart syndrome
What is hypo plastic left heart syndrome?
Underdevelopment of the left side of heart and aorta. Blood from lungs uses PDA and foramen ovale to mix on right side and right vent pushes blood to body.
What is transposition of the great vessels?
When the aorta comes from the right vent and the pulmonary artery for the left vent
X-ray shows absence of pulmonary artery with narrow mediastinum and narrow heart base. What is the disease?
Transposition of the great vessels
IV med for treatment of HTN emergency?
IV nitroprusside
Presentation of patient with aortic stenosis?
Dyspnea with exertion or syncope
Systolic ejection murmur with crescendo de crescendo and radiation to the carotids is?
Aortic stenosis
Mitral stenosis is common in whom?
Adults that had rheumatic fever as a child
Harsh mid diastolic murmur heard best at apex is?
Mitral stenosis
When stimulated this nerve provides blockage in conduction through the AV node and puts the breaks on, can help in PSVT.
Vagus nerve
Cholesterol panel abnormal… Who do you treat with Meds?
Patient t with 2 or more risk factors or LDL over 160.
What causes acute rheumatic fever.
Inflammatory dz due to group A strep infection
Jones criteria for RF… What are major criteria?
Carditis, polyarthritis, chorea (rapid purposeless movements), erythema marginatum (macules with central clearing) subcutaneous nodules
Jones criteria minor criteria?
Arthralgia, fever, increased ESR, increased CRP
What is jones criteria to diagnose acute rheumatic fever?
Mist have 2 major or 1 major and 2 minor for diagnosis.
What is an aortic aneurysm?
Dilation of the aorta….. May pop
Most common location for aortic aneurysm?
Abdominal aorta, 90% below the renal artery
Risk factors for aortic aneurysm?
Smoking, HTN, age, hyperlipidemia
Presentation of hypo gastric or lower back pain, steady gnawing with pulsatile abdominal mass?
Aortic aneurysm
Screening for AAA?
One time ultrasound for men 65-75 who have smoked. If found screen every 4 months if less than 4cm and surgery of greater than 5 cm
Most common location for aortic dissection?
Ascending aorta #1
Descending sorts distal to left subclavian artery #2
Patient presents with severe chest pain with sudden onset, with ripping or tearing pain, difference of BP between arms and decreased loc?
Aortic dissection
CXR for aortic dissection?
Widened mediastinum
Gold standard test for aortic dissection?
MRI
Treatment for aortic dissection?
Monitor BP, central line, bets blocker, morphine, surgery consult
Arterial embolism causes?
A fib/flutter
Mitral stenosis
Infarct
Post one placements
What are the 5 P’s of arterial embolism?
Pain Pallor Pulseless Paresthesias Paralysis
How do you diagnose an arterial embolism?
Echo or arteriogram
Treatment of arterial embolism?
Heparin and embolectomy
Chronic arterial occlusion is more commen where? What are the risk factors?
Lower extremities,
Atherosclerosis #1, smoking, cholesterol, DM, HTN
PE of arterial occlusion?
Decreased pulse, bruits, ischemic skin changes and ulcers.
Arterial insufficiency with foot claudication think?
Buergers dz
How to diagnose arterial occlusion?
Ankle/brachial index
Doppler
Arteriography
Treatment for arterial occlusion?
Stop smoking!
Decrease cholesterol, ASA or clopidogril, angioplasty
What is giant cell arteritis?
Granulomatosis vasculitis of the temporal artery
A patient presents with headache, jaw claudication, vision loss, fever and fatigue with a painful temporal artery. How do you diagnose and treat?
Artery biopsy
And corticosteroids
Describe polyarteritis nodosa?
Multi system vasculitis of medium sized arteries. Patient presents with fever, malaise, wt loss, anorexia, abdominal pain. Dx by biopsy. Treat with high dose steroids or cyclophosphamide.
Describe churg Strauss syndrome.
Multi system vasculitis of medium arteries. Typical presentation of asthma, eosinophilia, lung involvement. Middle aged patient with new onset asthma. Dx with biopsy. Tx with high dose steroids or cyclophosphamide.
What is thrombophlebitis?
Inflammatory thrombosis involving superficial veins of LE. Vein is palpable, tender and red. Dx on clinical findings but must rule out DVT. Tx with warm compress, NSAIDs, LMWH or IV abx if drug user.
What is a venous thrombosis?
Clot in deep vein of extremities.
What is virchows triad?
Venous stasis
Vascular damage
Activation of coag system
What are the risk factors for venous thrombosis?
Immobilization, hyper coag state, post op, trauma, BCP, cancer, obesity, pregnancy, smoking
Sx of venous thrombosis?
Pain and swelling at site and distal to site
How can you diagnose venous thrombosis?
Ultrasound, venogram, positive d dimer
Who should get DVT prophylaxis?
All high risk.
LMWH
Stockings,
Pneumatic leg compression
How do you treat venous thrombosis?
Heparin
Warfarin 3-6 months
Vena cave filter for recurrent episodes
What is a varicose vein?
Swelling and pain in superficial veins of the LE from incompetence of the saphenous vein. Treat conservatively, vein striping, sclerosing agent
What is endocarditis and what are some predisposing conditions?
Infection of valve leaflet
MVP, valvular dz, prosthetic valve, congenital abnormalities, IV drug user
MC bacteria in acute endocarditis?
Staph aureus, fatal less than 6 wks
MC bacteria in subacute endocarditis?
Strep viridans, fatal 6 wks to 1 yr
In early onset prosthetic valve endocarditis what is the most common pathogen?
Less than 60 days post op-staphylococci
Late onset prosthetic endocarditis most common pathogen?
Greater than 60 days - strep
Common presentation of patient with endocarditis?
Fever, chills, new onset murmur, janeway lesion, Osler nodes, Roth spots, splinter hemorrhages
What is a janeway lesion?
Small erythematosus lesions on palms and soles, sign of endocarditis
What is an Osler node?
Small tender nodules on pulp of digits, common in endocarditis
What is a Roth spot?
Lesion on retina on one with endocarditis.
Dx tool of choice for endocarditis?
Transesophageal echo #1
Transthoracic echo #2
If patient has prosthetic valve MUST do TEE
How do you treat endocarditis?
Abx 4-6 wks minimum
Who should get endocarditis prophylaxis?
Prosthetic valve or heart transplant, hx of endocarditis, heart defect, mouth procedures, soft tissue, abdominal infections
What medications are given for endocarditis prophylaxis?
Amoxicillin/ampicillin
If allergy clindamycin
Describe aortic stenosis.
Due to left vent outflow obstruction, leads to increase left vent pressure and hypertrophy.
A systolic murmur that radiates to neck and increased when leaning foreword?
Aortic stenosis
A cardiac stress test is contraindicated ins patient with a symptomatic murmur of?
Aortic stenosis
What is aortic insufficiency and the acute and chronic causes?
Due to abnormal leaflets or proximal aortic root
Acute -endocarditis or dissection
Chronic-HTN, marfans
What has a diastolic blowing murmur on LSB? With weakens pulse pressure and hammer pulses?
Aortic insufficiency
What med is give given to a patient with symptomatic bradycardia post MI?
Atropine 0.5mg every 5 min up to 3 mg total
IV drug user with pleuritic chest pain, fever, Roth spots, janeway lesion and Osler nodes?
Endocarditis caused by staph aureus.
Valve affected by IV drug users?
Tricuspid
Oval, pale retinal lesion surrounded by hemorrhages?
Roth spot. Infective endocarditis
Hemorrhagic painless macular plaques on palms and soles?
Janeway lesions
Small painful modular lesions on pads of fingers?
Osler nodes
Renal arteries emerge from?
Abdominal aorta
Blood supply to the colon?
Celiac trunk
What supplies blood to the lower extremities?
Common iliac artery to the internal and external iliac arteries
Occlusion to this can cause acute bowel ischemia.
Inferior mesenteric artery
No beta blockers in a patient with?
Peripheral vascular disease, reactive airway dz or heart block!
Four findings in tetralogy of fallot?
Pulmonary stenosis, VSD, overriding aorta, RVH. Blue squatting smurf
Best med for HTN with heart failure?
BB, ACEI
Best med for HTN with post MI?
BB, then ACEI
Best HTN med for diabetes?
ACEI, ARB
Best HTN med for renal dz?
ACEI, ARB
Best HTN med for recurrent stroke?
Thiazides, ACEI
Contraindications to thiazides?
Gout
Contraindications to potassium sparing diuretics?
Hyperkalemia
Contraindications to ACEI/ARB?
Prego, renal artery stenosis, hyperkalemia
Contraindications to nondihydropine CCB?
Heart block, heart failure
Contraindications to BB?
Heart block, asthma, depression, cocaine abuse
Contraindications to. Alpha blocker?
Orthostatic hypotension, heart failure
Sharp chest pain, worse lying down, better sitting up
Pericarditis
Systolic ejection murmur in LUS border
Aortic stenosis
Troponin appearance and duration?
2-4 hrs, 5-10 days good for late presenters
CK-MB appearance and duration?
3-6 hrs 2-4 days peaks at 24 hrs
ST depression?
Subendocardial ischemia
ST elevation?
Transmural ischemia
EKG change in II, III, aVF?
Inferior, RCA
EKG changes in I, aVL, V5, V6?
Lateral, circumflex
EKG changes in V2-V4
Anterior, LCA
EKG changes in V1-V2?
Posterior, RCA or circumflex
EKG changes in V3-V6?
Apical,
LAD or circumflex
EKG changes in I, aVL, V4-V6?
Anteriolateral, LAD or circumflex
EKG changes in V1-V3?
Anterioseptal, LAD
Pericardial friction rub?
Acute pericarditis
What causes diffuse ST elevation and upright T waves on EKG?
Acute pericarditis
Foot drop is from compression of what nerve?
Paroneal
