Cardiology Flashcards
What is the first line therapy for Cardiogenic shock?
Dobutamine (Beta Agonist) is first line therapy
What is the most common organism involved in Acute pericarditis?
Coxsackie B Virus, Hep B, and CMV
What ECG signs are seen with acute pericarditis?
ST elevations, PR depression in most leads
WHat is Pulsus Paradoxus?
Classic finding in pericardial effusion
Abnormally large decrease in systolic BP (>10 mmHg) and pulse wave amplitude during inspiration
What CXR finding do you see with Acute pericarditis?
Water bottle heart, cardiomegaly
What is the gold standard for diagnosing Pericardial effusion? what confirms the dx?
Echo-shows fluid between layers of pericardium
Pericardiocentesis: confirms dx
What is cardiac tamponade? what is a common cause?
Emergency! Occurs when large pericardial effusion compresses the heart, or greatly reduces CO
common cause: Penetrating trauma to the heart
What are the s/s of cardiac tamponade?
Sharp, stabbing CP (worsened by deep breathing or coughing), dyspnea, nonproductive cough
PE: Beck’s Triad-JVD, Arterial hypotension, muffled heart sounds
What is the gold standard for diagnosing Cardiac tamponade?tx?
ECHO
Tx: urgen pericardiocentesis!! (by echo guidance)
What is COnstrictive pericarditis? What are the common causes?
Diffuse thickening of the pericardium with possible calcifications
Associated with TB, radiation therapy, cardiac surgery, or following viral pericarditis
What are the S/S of constrictive pericarditis? how is it tx?
Slowly progressive dyspnea and fatigue, weakness
PE: LE edema, Ascites, elevated JVP, pericardial Knock, + kussmaul sign (evidence of Rt heart failure)
Tx: NSAID, Corticosteroids, Colchicine, Pericardiectomy
What is Dressler syndrome?
Postmyocardial infarction Pericarditis
Occurs 2-5 days after infarction due to inflammatory rxn to transmural myocardial necrosis
What are the s/S of infective endocarditis?
New systolic murmur, Roth spots, osler nodes, Janeway lesions, splinter hemorrhages
How do you dx Infective endocarditis?
Transesophageal Echocardiogram (TEE)-may show vegetations on valves
Blood cultures: 3 sets at least 1 hour apart
What are the most common valves affected in infected endocarditis?
Mitral valve most commonly affected
Tricuspid valve most common in IV drug users
What are the most common organisms involved in infective endocarditis?
Native valves + IV drug users: Staph aureus
Prosthetic valves: Staph epidermidids
Subacute endocarditis: Streptococcus viridans
Enfective endocarditis: What abx are given while Blood culture is pending? If prosthetic valve? native valve, community? If MRSA?
- Vancomycin + gentamycin
- Prosthetic valve=Vanco + gentamycin + Rifampin
When does rheumatic fever occur and what are the most common valves involved?
Occurs 2-3 weeks following a beta-hemolytic Strep phargyngitis
- Mitral valve-most common
- Aortic valve
What are the signs and symptoms of Rheumatic fever?
- Subcutaneous nodues on extensor surfaces
- Sydenham’s chorea: involuntary movements
- Erythema marginatum: painless pink rash with well defined edges; central clearing
- PE: new murmur–mitral regurgitation
HOw do you diagnose Rheumatic fever? How to you treat?
Dx: + Antistreptolysin O (90%)
Tx: NSAIDs, beta-lactams, corticosterois
prophylaxis: Benzathine penicillin G q 4 weeks
What is the most appropriate initial diagnostic test in the evaluation of a patient with signs and symptoms consistent with stable angina? Tx?
Nuclear stress test
Tx: Sublingual nitroglycerin
(Will reduce effects of GERD and esophageal spasm as well)
What is Printzmetal angina?
Occurs in younger patients at rest; Squeezing CP, 2-5 minutes
What leads show an inferior wall MI? what artery is involved?
ST elevation in lead II, III, and aVF
Right coronary artery
What leads show a lateral wall MI? What artery is involved?
I, AVL, V5 and V6
LAD, LCA, and CFX
What leads show an anterior wall MI? artery?
V1-V4
LAD
What leads and arteries are involved in posterior wall MI?
V1 and V2
RCA, CFX
What leads and artery are involved in anterolateral MI?
V4-V6
CFX
What leads and artery are involved in Anteroseptal MI?
V1 and V2
LAD
What medications should you avoid in Long QT syndrome?
Macrolides and Fluoroquinolones (may prolong QT interval)
What med is used to treat HTN in pregancy?
Hydralazine
What are the common causes of secondary HTN?
Most common cause: Renal Parenchymal Disease
CHAPS
- Cushings
- Hyperaldosteronism (primary)
- Coarctation of the Aorta
- Pheochromocytoma
- Renal artery stenosis
What is the clinical defn of renal artery stenosis? what med is contraindicated?
HTN that is resistant to 3 or more medications
Renal artery bruit on exam
ACE Inhibitors are C/I!!
What are the symptoms of pheochromocytoma? how is it dx?
Paroxysms of HA, flushing, sweating, palpitations, and fluctuating BP
- Dx: elevated urinary vanilyl mandelic acid (VMA)
- A metabolite of catecholamines
What is Hypertensive emergency? HOw is it tx?
Diastolic >130; Situation that requires RAPID (within 1 hour) lowering of BP
Increased risk of target organ damage
Tx: Nitroprusside sodium IV or IV esmolol
What is Hypertensive urgency? How is it tx?
Should be corrected within 24 hours of presentation
Systolic >180, Diastolic >120
Not associated with target organ damage–>main diff between urgency and emergency
Tx: Oral clonidine
What is malignant HTN and how is it tx?
Life threatning secondary to elevated BP resulting in Grade IV hypertensive retinopathy, papilledema, cardiovascular or renal compromise and encephalopathy
>220/140
TOC: IV nitroprusside if HTN encephalopathy; oral labetolol if papilledema without encephalopathy
Papilledema indicates End organ damage!
How do you screen for Abdominal Aortic aneurysm? How do you monitor?
How do you dx thoracic aneurysms?
AAA–>US for screening; MOnitor changes with CT scan\
Thoracic: CT with contrast, Aortography
How do you treat Aortic aneurysms?
Tx: Monitor with periodic US if <5 cm
AAA> 5.5 cm or undergone rapid expansion (>5 mm in 6 months)–>Surgery
How do you distinguish Stanford A aortic dissections from Standford B dissections?
- Standford A–Ascending Aorta
- Tx: Surgical emergency! IV Labetolol and IV nitroprusside
- stanford B–>Distal to Left subclavian
- Treat with beta blocker and conservative tx
- Followed by serial CT scans every 6 months
What are the sxs of Aortic dissection? How do you dx?
Severe chest/flank/back pain-described as “tearing, ripping, or sharp”
Presence of unexplained syncope in male pt >60 y/o should raise possibility
PE: variation in BP >20 mmHg difference between arms
Dx: TEE (unstable) or thoracic MRI (stable)
CXR: widened mediastinum with enlarged aortic knob
What is Giant cell Arteritis? Sxs?
50% also have polymyalgia rheumatica (PMR)
Sxs: acute onset of HA, jaw pain, exacerbated by chewing, monocular blindness, visual abnormalities (Amaurosis fugax)
PE: enlarged temporal artery, pulseless
What is the gold standard of dx Giant cell arteritis? What is the tx?
Gold standard: Superficial temporal artery Bx
Elevated ESR (90%)
Complication: Blindness seconary to occlusion of central retinal artery
Tx: high dose prednisone (60 mg/day) and low dose ASA
What is the medical tx and pt ed for peripheral artery dz?
Cilostazol (phophodiesterase Inhibitors): Increases claudication distance by 40-60%
Walking recommended because it increases angiogenesis
What is the difference in ulcers in Chronic venous insufficiency and Chronic arterial insufficiency?
Chronic venous insufficiency: Painless ulcers most commonly located at the medial malleolus; pigmentation
Chronic arterial insufficiency: Painful “punched out” ulcers on pale, necrotic base; Intermittent claudication more common
What are the values of Ankle-brachial index?
- 1.0 normal, <0.9 indicates dz
- <1.0 chronic occlusive dz
- <0.7 claudication
- <0.3 pain at rest
How do you treat a coronary artery spasm?
Calcium channel blockers (Nifedipine)
What are the different classes of Heart failure?
- Class I: Asymptomatic
- Class II: Symptomatic with angina with exertion, but no paint at rest
- Class III: Symptomatic with minimal exertion (ordinary activities cause angina or pain)
- class IV: Symptomatic at rest
What is the most common cardiomyopathy?
Dilated cardiomyopathy
What is dilated cardiomyopathy? what is the most common cause?
Impaired contractability; systolic dysfunction
Most common cause: chronic alcohol abuse
What are the signs of dilated cardiomyopathy? dx? How do you tx?
Signs of LEFT congestive heart failure, S3 gallop
Systolic dysfunction and LV dilations are essential for dx
dx: Transthoracic Echo
Treat CHF; abstinence from alcohol is essential
Who does Tako Tsbuo cardiomyopathy commonly affect? What is seen on Echo?
Commonly seen in postmenopausal women after a major discharge of catecholamines
ECHO: Left ventricle apical ballooning
What is Hypertrophic cardiomyopathy (HOCM)?
Massive hypertrophy of the septum; Impaired relaxation of LV (impaired diastolic filling–>pulmonary congestion)
Most common cause of sudden death in young athletes; exclusively genetic
Hypertrophic cardiomyopathy: what are the common signs? How is it dx?
PE: systolic murmur that increases with valsalva maneuver, decreses with squatting (only other murmur that does this besides MVP); JVP with A wave
Dx: Echo-interventricular septal hypertrophy
CXR- boot shaped heart; ECG: Long QT syndrome is the first sign in children; Abnormal Deep Narrow Qs
How is HOCM tx?
First line: Beta blockers
Second line: CCB
May eventually need ablation of hypertrophic septum, or dual chamber pacing
What is restrictive Cardiomyopathy? what is the most common cause?
Impaired diastolic filling; Impaired Elasticity
Fibrosis–>stiffness and inabiity of chambers to fill
Most common cause: Amyloidosis
What are teh s/S of restrictive cardiomyopathy? What is the key to diagnosing restrictive cardiomyopathy? Tx?
sxs of Right sided heart failure
Echo is key to diagnosis: Small thickened LV
may need endomyocardial biopsy
Tx: diuretics
What is a common SE from ACE inhibitors?
Angioedema
Distinguish the sxs of RHF from LHF
- RHF: Elevated JVP and ankle edema; Dependent edema, hepatomegaly
- LHF: Dry cough, exertional dyspnea, Hypotension, perivascular and interstitial edeam, 3-pillow orthopnea, S3 heart sound
What are the most common C/I of exercise stress test?
- Aortic stenosis
- Unstable angina
What are common causes of heart block?
- Hyperkalemia
- Lyme dz
- MI
- Lithium
What is first degree AV block?
ECG: prolonged PR>0.2 seconds, Constant
Asymptomatic, no Tx necessary
What is Wenckebach AV block?
second degree AV block–Mobitz II
ECG: PR intervals progressively lengthen until skipped QRS
Tx: no tx unless symtomatic bradycardia–>pacemaker
What is a Mobitz II heart block?
Secondary AV block
ECG: randomly skipped QRS without change in PR interval
Tx: Permanent dual chamber pacemaker insertion
What is a third degree block?
Complete block
Occurs when atria and ventricles are controlled by different pacemakers
ECG: no relationship btwn P waves and QRS
Ventrical rate (QRS) slower than atrial rate (P waves)
Tx: Ventricular pacemaker (initially a temporary pacemaker can be inserted until a permanent one can be implanted
What is Wolff-Parkinson-White syndrome (WPW)? what drugs are C/I?
Young males, palpitations, SOB, lightheadedness
ECG: delta wave in LEad II; Short PR interval
Tx: Radiofrequency ablation
C/I: digoxin and CCB
Who is Paroxysmal supraventricular tachycardia commonly seen in? How is it tx?
Young patients with healthy hearts
Tx: DOC: IV adenosine
Recurrent episodes: Radiofrequency ablation
Prevention: betablocker or verapamil, or diltiazem
What is seen in both RBBB and LBBB
Prolonged QRS duration (>.12 sec)
What does this show?
Right BBB
What is this?
Left BBB
What is the most common cause of sudden cardiac death?
V. fib
What is this? How is it treated?
V. Fib
totally erratic tracing, no P waves or QRS
Tx: CPR, immediate cardioversion
What is this? How is it treated?
- V. Tach
- 3+ PVCs in a row
- Regular, wide QRS complexes independent of P waves
- Dx: Holter monitor
- Tx: Electrical cardioversion follwed by antiarrhythmic meds (Flecainide)–>Can quickly deteriorate to V fib.
- To prevent recurrent VT: Sotalol and Amiodarone
What can cause Torsades de Pointes?
Can occur spontaneously, with hypokalemia or hypomagnesemia, or drug induced
Drugs: TCA, erythromycin, haloperidol, Ibutilide
How do you tx Torsades de Pointes?
Magnesium, beta blockers
What is the most common chronic arrhythmia?
A fib
What is this? How do you treat?
A. fib
- Synchronized cardioversion
- A min INR of 1.8 (x 3 weeks) is rec. before cardioversion
- Anticoagulate with warfarin
- Betablocker and Amiodarone should also be used
What it is this? How is it tx?
Atrial Flutter
Rate control with CCB, BB
Long term tx: amiodarone
Most common cyanotic congenital Heart disease? what are it’s characteristics?
Tetralogy of Fallot
- (P.O.S.H)
- Pulmonary stenosis, Overriding Aorta, Septal defect (VSD), RVH
- R to left shunt
- crescendo-decrescendo holosystolic
What are TET spells and were are they seen?
Hypercyanotic episodes, seen with Tetralogy of Fallet
A medical emergency followed by syncope
What is the most common congenital heart disease?
Ventricular Septal Defect (VSD)
Harsh, holosystolic murmur; no murmur at birth but appears a few weeks later
L to R shunt
What is the most common type of Atrial septal defect?
Ostium Secundum
What is an important characteristic of ASD? ECG finding? What does the patient need to know about changing altitudes?
Wide Fixed Split S2
ECG: RAD
More susceptible to O2 desaturation at high altitudes and decompression sickness during deep sea diving
What is the characteristic murmur for PDA? How is it treated?
Continuous, rough, machinery pansystolic murmur
Tx: Indomethacin is routinely adminstered to help close a PDA
WHat is the main PE finding found with Coarctation of the Aorta?
HTN in the UE and normal or low BP in the LE
Weak femoral pulses, exaggerated radial pulses
Seen in Turner’s syndrome
CXR: rib notching and cardiomegaly
ECG: LVH
What is Mitral stenosis?
Mid-diastolic murmur with an opening snap
heard best at apex
Echo: Fish mouth
Jugular A wave
What is mitral regurgitation?
Blowing holosystolic murmur
What is the murmur of MVP?
Mid to late systolic murmur; midsystolic click
Increased with standing/valsalva
Decreased with squatting
Thin females with minor chest wall deformities
What is the murmur of Aortic stenosis?
- Harsh, midsystolic decrescendo crescendo
- Right sternal border, radiates to neck
- Narrow pulse pressures
- +thready carotids, + thrill
- Increases with leaning forward
What is Aortic Regurgitation?
- blowing decrescendo diastolic murmur
- Widened pulse pressures; Bounding “water hammer” pulses
- Chronic: Austin flint murmur
- Increases with leaning forward
- Tx: Nitroprusside
What is the most common Valve disorder of the elderly?
Aortic stenosis
What is orthostatic hypotension?
drop in systolic BP (of at least 20 mmhg or >10 mmHg of diastolic) immediately upon arising from the sitting to standing position
If rise in pulse is >15 bpm: Depleted volume is most likely cause
How does Hypercalcemia and hypocalcemia show on ECG?
Hypercalcemia: Shortend QT
Hypocalcemia: prolonged QT
“Too much too soon, too little too late”
What is this?
RVH
R wave>Swave in V1
What is this?
Left Ventricular Hypertrophy
S wave in V1 + R wave in V5=More than 35 mm
What BP meds are best for AA?
CCB or Thiazides
ACE Inhibitors tend to not be effective, and AA have higher risk for Angioedema
