cardiology Flashcards
0
Q
soft first heart sound heard with
A
- mitral regurgitation
- long PR interval
- LBBB
- aortic stenosis, aortic regurg
- immobile mitral valve
1
Q
loud first heart sound heard with
A
- mitral stenosis
- short PR interval ie: WPW
- tachycardia
- thyrotoxicosis
2
Q
second heart sound splits with
A
inspiration
3
Q
wide splitting second heart sound heard with
A
- MR, VSD
- RBBB
- pulm artery hypertension
4
Q
fixed second heart sound heard with
A
**ASD-only thing causing fixed!!
5
Q
S3 heard in
A
- normal in children
- mitral regurg
- tricuspid regurg
- CHF
6
Q
S4 heard in
A
- hypertension
- aortic stenosis
- hypertrophic cardiomyopathy
- angina, myocardial infaction
- ACUTE mitral regurg-NOT chronic
7
Q
heart sound-clicks heard in
A
- early systolic-aortic stenosis, pulmonary stenosis
* mid systolic- MVP
8
Q
opening snap heard in*
A
- mitral stenosis, tricuspid stenosis
* shorter the interval, more severe the stenosis is
9
Q
pericardial friction rub heard with
A
pericarditis
10
Q
pericardial knock
A
constrictive pericarditis
11
Q
palpable heave at heart apex
A
LVH
12
Q
Kussmaul sign
A
incease of JVP on inspiration
*see w constrictive pericarditis , RV infarct
13
Q
JVP >4cm above the sternal angle or >9cm above the right atrium is
A
considered abnormal
14
Q
Giant a wave on Jugular venous pulse tracing (cannon a wave)
A
produced when the atrium contracts against resistance as in tricuspid stenosis
15
Q
holosystolic heart murmur heard with
A
mitral regurg
tricuspid regurg
VSD
16
Q
midsystolic heart murmur heard with
A
aortic stenosis
pulmonary stenosis
functional murmur
17
Q
continuous heart murmur is heard with
A
PDA
18
Q
increase in heart murmur with standing and valsalva
A
MVP
hypertrophic cardiomyopathy
(all other maneuvers assoc w all other murmurs)
19
Q
opening snap and loud P2
A
mitral stenosis
20
Q
pulsus tardus pulse pattern assoc with
A
aortic stenosis
21
Q
pulsus bisferiens pulse pattern assoc w
A
aortic regurg
22
Q
pulsus alternans pulse pattern assoc w
A
cardiac tamponade
severe LV failure
23
Q
paradoxical pulse
A
- drop in systolic BP>10mm on inspiration
* see in: cardiac tamponade, airway obstruction, SVC obstruction
24
30 yr old who is 3 months pregnant has a grade 2 early systolic murmur over LSB. the murmur disappears on standing
innocent murmur of pregnancy, no work up if grade 2 or less
25
40 y/o male has a JVP of 3 cm above the sternal angle and increases to 8cm after applying pressure on the liver
* called hepatojugular reflex
| * means impending or active CHF
26
30 y/o has a midsystolic click & late systolic murmur, the murmur increases on standing & valsalva
*MVP
27
wide splitting S2 , soft P2, early systolic click, cannon wave, midsystolic crescendo-decrescendo murmur over LSB
pulmonary stenosis
28
murmur that is machinery and continuous means
PDA
29
holosystolic murmur that increases with inspiration
tricuspid regurg
| if no change w inspiration-VSD
30
most common cause of mitral regurg
MVP
31
clinical features of MVP
* palpitations, cp, supraventricular & ventricular arhythmias
* midsystolic click and late systolic murmur
* stand and valsalva cause click and murmur to occur early
32
complications of MVP
LV failure
systemic emboli from platelet fibrin deposits on valves
sudden death-very rare
33
tx of MVP
* B blocker-palpitations, CP, anxiety or fatigue
* ASA-unexplained TIA w sinus rhythm & no atrial thrombus
* warfarin-recur TIA despite ASA or hx of stroke
* surgery-severe MR
34
indications for ECHO to eval a heart murmur
* presence of cardiac symptoms
* systolic murmur >/= grade 3
* continuous murmur
* any diastolic murmur
* new murmur from previous exam
35
Grades of murmurs
1-very faint, may not hear in all positions
2- quiet, hear immediately after placing a stethoscope
3-moderately loud
4-loud, with a palpable thrill
5-very loud, thrill, may be heard w stethoscope PARTLY OFF chest
6-as above but may be heard w scope ENTIRELY off the chest
36
PCWP-pulmonary capillary wedge pressure
measures LA pressure from R side of heart by blocking R side w balloon
*normal is 6-12mm Hg
37
PCWP is normal with
pulmonary artery hypertension PAH
COPD
pulmonary embolism
38
PCWP increased with these conditions
mitral stenosis
| LV failure
39
hemodynamic monitoring in septic patient or in anaphylaxis will see SVR
decreased
| all other conditions increase SVR
40
Right ventricular infarct clinical features
* one third of patients with INFERIOR MI
* ST elevation : V3R-V6R
* low BP
* increased JVP
* positive Kussmaul sign
* clear lungs
41
RV infarct treatment
* volume loading if hypotension persists
* inotropic support w dopamine or dobutamine
* NO nitrates or diuretics
* all other tx MI-thrombolytic, PCI as indicated
42
clinical features of constrictive pericarditis
rigid pericardium> impaired cardiac filling
* gradual onset dyspnea
* pedal edema
* ascites hepatomegaly, incr JVP
* kussmal sign
43
causes of constrictive pericarditis
* TB, viral
* prior cardiac surgery,radiation
* collagen vasc disorders
* uremia
* malignancy
44
diagnosis of constrictive pericarditis
* EKG: low voltage
* CXR: may see pericardial calcification
* ECHO,CT/MRI-pericardial thickening
* heart cath-**see equalization of diastolic pressures in ALL chambers and ventricular pressure tracing show dip & plateau "square root sign"
* TX: surgical stripping of pericardium
45
clinical features of cardiac tamponade, rapid onset of:
* dyspnea
* hypotension
* tachycardia
* paradoxical pulse
* distant heart sounds, incr JVP
46
causes of cardiac tamponade
* previous pericarditis
| * cardiac trauma of any kind- including perforation during cath or pacer placement
47
DX cardiac tamponade
* EKG: low voltage, ELECTRICAL ALTERNANS w large effusion
* CXR: enlarged heart
* ECHO: see effusion and RA & RV collapse in diastole
* CATH: equalizaion of diastolic pressures in all 4 chambers
48
TX cardiac tamponade
* pericardiocentesis
| * IV volume expansion
49
Acute MI caused by
* plaque rupture of pre-existing 30-50% stenosis of the artery>mural thrombi>complete occlusion>MI
* *slowly developing high grade stenosis DOES NOT precipitate acute MI
50
Inferior coronary ischemia
*II,III,aVF
| right coronary artery
51
anteroseptal coronary ischemia
*V2-V4
| LAD
52
anterior coronary ischemia
V3-V5
LAD
53
lateral coronary ischemia
V5-V6
LAD or circumflex
54
posterior coronary ischemia
V1,V2 (reciprocal)
right coronary artery
55
right ventricular coronary ischemia
V3R, V4R
right coronary artery
56
exercise stress-bruce protocol
*5 stages- 3 minutes each w slope and speed changes
POSITIVE: >/= 1mm ST depression lasts >/= .08seconds flat or downsloping
57
stress testing-poor prognostic factors:
* >2mm ST depression at 5min post exercise
* fall in systolic BP >10-15 mm
* global changes -change in anterior & inferior leads
* ventricular ectopic beats
* ST segment elevation
58
exercise stress testing- absolute contraindications
* severe aortic stenosis
* recent MI
* unstable angina-within 48hours
* uncontrolled arrhythmia
* decompensated heart failure
* acute aortic dissection
* acute pulmonary embolism
59
When to stop the stress test
* achieved predicted HR (200-age)
* severe angina
* development of >2mm ST depression
60
indications for radionuclide myocardial perfusion imaging
| thallium, sestamibi, tetrafosmin (myoview)
* WPW syndrome
* digitalis effect
* baseline ST depression >1mm
* LVH w strain
* prior CABG or coronary interventions
61
pharmacologic stress test
*for those that cant exercise-COPD, arthritis, PAD
62
adenosine or dipyridamole stress test
best for: LBBB, pacemaker
| Contraindications: COPD, asthma, elevated BP, sick sinus, high grade heart block
63
dobutamine stress test
best for :COPD, asthma
64
Medical tx of angina
* *beta blockers-BEST initial therapy
* calcium channel blocker-best if Beta B contraindicated
* nitrates - 14 hour dose free interval
* ranolazine-if remain symptomatic on above therapy
* vasoprotective therapy-all w angina:
- aspirin, clopidogrel if aspirin allergy
- statin-LDL goal<35%
* stop smoking, wt control, exercise
* omega 3 fatty acid, diet rich fruit, veg,extra virgin olive oil, nuts
65
Indications for coronary angiography
* disabling angina symptoms
* high risk criteria on noninvasive testing
* survivor of sudden cardiac death or serious vent. arrhythmia
* symptoms/signs of CHF
* pt who continue to have ischemia in the early postMI or unstable angina setting
66
PCI-percutaneous coronary intervention
* *does NOT reduce future cardiovascular events
* reduces frequency and severity of angina
* does NOT improve survival
*reserved for those who remain symptomatic despite optimal medical tx except for pt w significant silent ischemia on stress testing
67
aspirin + clopidogrel
should be given together for a minimum of 1 year after drug eluding stent and 1 month after bare metal stent
*ASA used indefinately after stent placement
68
indications for CABG
* left main disease >/= 50%
* 3 vessel disease >/= 70% (survival benefit is greatest if EF<50%)
* multivessel CAD in diabetes **CABG is superior to PCI , CABG reduces the rates of death and MI with higher rates of stroke
69
ACS-acute coronary syndrome
* STEMI
* NSTEMI
* unstable angina
70
STEMI
ST elevation
| elevated troponin & CK-MB
71
NSTEMI
ST segmant depression and T wave inversion
| elevated troponin & CK-MB
72
unstable angina
nonspecific EKG changes
| normal troponin and CK-MB
73
duration of clopidogrel therapy
* minimum of one year with:
- no stent
- bare or drug eluding stent
- CABG
* ASA indefinately
74
Unstable angina
*angina at rest or minimal exertion, usually lasts >10 minutes
* new onset of severe angina within the prior 4-6 weeks
* recent increase in frequency and/or intensity of chronic angina
**if enzymes are +: NSTEMI
75
Unstable angina or NSTEMI
* HIGH RISK: coronary angiography indicated in 24-48 hours
* presence of any of these risk factors:
- new ST segment depression
- elevated troponin or CK MB
- recurrent angina at rest or low level activity despite rx
- strong + stress test
- CHF symptoms or EF/= 3
76
TIMI risk score (>/= 3 is high risk)
* age 65 or greater
* 3 or more traditional CAD risk factors
* ASA use in past week
* documented CAD w 50%or greater stenosis
* severe angina, 2 or more episodes within 24 hours
* ST segmant deviation of .05mV or more\
* elevated cardiac enzymes
77
Treatment of unstable angina or NSTEMI
* ASA
* clopidogrel or prasugrel or tricagrelor
* beta blocker
* nitrates
* LMWH or UFH or fondaparinux
* statin
* if HIGH risk: coronary angiography to determine other options
78
GPI -> GP IIb/IIIa inhibitors
| *abciximab, eptifibatide, tirofiban
not given before cardiac cath , decision to give these drugs or not is made at PCI
79
Indications for hospitalization in chest pain:
* ST elevation on EKG
* ST depression or T wave inversion on EKG
* + CK MB
+ troponin I or T
* Hx suggestive of unstable angina w normal EKG
* concurrent CHF, hypotension, or transient mitral regurgitatin
80
Tx STEMI
* O2, MS, nitrates, beta blocker, asa and plavix
* Heparin/LMWH 48 hours
* ACE-start when the pt is Hemodynamically STABLE
* high dose statin-atorvastatin 80mg
* cath lab available-Primary PCI is superior to lysis **within 90 minutes "door to balloon"time of initial medicl contact
* cath NOT available: fibrinolytic within 30 minutes or consider transfer to PCI able hospital
81
Transfer to primary PCI is favored if:
* door to balloon time < 90 minutes
* pt presenting >3 hours after onset of symptoms
* cardiogenic shock
* high risk of intracranial hemorrhage or bleeding
82
Indications for fibrinolytic therapy
* acute CP typical of MI
* EKG criteria of STEMI
- ST elevation 1mm or more in 2 or more leads in inferior or lateral
- ST elevation 2mm or more in at least 2 contiguous anterior leads
- new LBBB
83
Use fibrinolytic therapy
*12 hours (PCI for those with ongoing ischemia or those at high risk)
84
fibrinolytic agents
* tPA (alteplase), reteplase, tenecteplase, streptokinase(No heparin w streptokinase)
* give IV heparin for 48 hours if the first 3 above agents are used, maintain PTT 1.5 to 2 X control (50-70)
85
benefits of fibrinolytic therapy
* decrease infarct size
* improvement in LV function
* decrease mortality
86
bleeding complications of fibrinolytic therapy
* intracerebral bleeding 1% (if occurs mortality 50-65%)
| * risk factors:older age, lower body weight, female sex, prior stroke, systolic BP>160
87
Absolute contraindications to fibrinolysis
* any prior intracranial hemorrhage
* known structural cerebral vasc lesion-AV malformation
* ischemic CVA within 3 months
* known malignant intracranial neoplasm
* suspected acute aortic dissection
* active bleeding or bleeding diathesis (EXCLUDES menses)
* significant closed head injury or facial trauma within 3 months
88
Relative contraindications fibrinolysis
* BP >180/110 on presentation
* prior ischemic stroke >3 months
* prolonged CPR>10min
* major surgery within 3 weeks
* internal bleeding within 2-4 weeks
* pregnancy
* non compressible vascular punctures
* active PUD
* current use of anticoagulants
* for streptokinase: prior exposure >5 days ago or prior allergic rxn
89
Feature that suggest successful reperfusion after fibrinolysis
* complete resolution of CP
* improvement of ST elevation >50% in EKG after 60 minutes
* development of reperfusion arrhythmias:
- accelerated idioventricular rhythm
- PVCs
90
Indications for coronary angiography after fibrinolytic therapy
* failure of reperfusion (persistent CP and ST elevation >90 min)
* coronary artery reocclusion (re elevation of ST or recur CP)
* recurrent angina in the early hospital course
* positive stress test before discharge
91
Indications of full dose anticoagulation after STEMI
**UFH or LMWH followed by warfarin for 3-6 months
* severe CHF
* ventricular thrombus on ECHO
* large dyskinetic region on anterior wall MI
92
Indicatons for PCI (angioplasty/stent) in acute STEMI:
* can be done within 90 minutes
* contraindications to fibrinolytic therapy
* cardiogenic shock: SBP20, oliguria
* hypotension and hemodynamic instability
* pt presents >12 hr after onset of CP w cont CP or ST elevation
* high risk pt tx initially w fibrinolytics in non PCI hosp transfer for diagnostic cath as soon as possible
* non high risk pt transfer if ischemic symptoms persist
93
no benefit of late PCI (after one week) of
occluded infarct related artery
94
treatments that IMPROVE SURVIVAL after MI:
* fibrinolytic tx or PCI in STEMI
* ASA,Plavix
* beta blockers
* ACE inhibitors-even if normal LV function and normal BP
* anti lipid therapy
* smoking cessation
* exercise
* ICD insertion if EF 30% or less AFTER 30 days of MI
* eplerenone in EF5)
95
Cardiovascular complications of Cocaine
* myocardial ischemia and infarction
* LVH
* systolic dysfunction & dilated cardiomyopathy
* reversible profound myocardial depression after binge use
* cardiac dysrhythmias
96
First line tx of cocaine induced MI or ischemia
* oxygen
* nitroglycerine
* benzodiazepine
97
second line therapy in cocaine induce MI or ischemia
* verapamil
* phentolamine
* coronary angiography if conservative tx fails
98
agents to AVOID in cocaine induced MI or ischemia
* **Beta blockers ***increase vasoconstriction induced by cocaine!
* thrombolytics not routinely used
99
HOPE trial
* Ramipril (ACE)
* reduces risk of MI, CVA,death from CV dz in pt with known vascular disease (CAD, PVD, CVA) or diabetes and one additional risk factor
100
Heart protection study
* statins
* in patients at high risk of coronary event, simvastatin reduces risk of death, MI, CVA irrespective of cholesterol levels
101
Courage trial
*PCI in stable CAD does NOT reduce risk of death, MI or other major CV event even when added to optimal medical therapy
102
complications of PCI
* mortality 0.1-0.3%
* periprocedural MI 5-30%
* stent thrombosis
* restenosis
* bleeding
103
recurrent CP with ST elevation lasting 20-30 minutes. no exertional CP
* prinzmetal angina
- no beta blockers
- tx: acute: sublingual NTG, long term tx: nitrate or calcium channel blocker
104
a patient w anterior wall MI, EF 30%, LDL 140, what medications the pt should be discharged on?
```
ASA
B blocker
statin
ACE
plavix x 1 year
```
105
elderly pt admitted w syncope and normal EKG on admission. after meals he feels dizzy and EKG shows ST elevation in II, III, AVF that lasts for 20 minutes. what does this indicate?
needs angiography
106
on 6th day after MI, patient lapses into coma, no pulse but EKG shows RSR
*cardiac rupture and pt in PEA
107
inferior wall MI + RBBB, what artery is involved?
right coronary
108
severe dyspnea on day 5 after MI with decreased BP, increased JVP, ECHO shows RV collapse in diastole. what is problem
* cardiac tamponade
- pericardialcentesis
- stop anticoagulants
109
acute STEMI with SOA, BP 100/70, incr JVP,, crackles midway up both lungs. what drug is contraindicated?
* beta blocker
| * pt in frank heart failure with acute MI-NO BB's given in this case
110
low back pain after cardiac cath with drop in HCT indicates
retroperitoneal hematoma
111
stable angina, 75% stenosis of circumflex, LDL 140. how should this patient be treated?
medical therapy
112
what to do if patient develops recurrent angina 2 weeks after acute MI?
cardiac cath
113
what is the initial treatment of a pt w second degree Mobitz II heart block after acute inferior MI?
atropine IV to increase vagal tone
114
how to treat a patient who develops broad complex regular tachycardia at rate of 100 after fibrinolytic therapy
observe
115
how to treat frequent PVCs within 24 hours after MI?
no tx
116
how to treat sustained VT or VF WITHIN 48 hours after MI?
amiodarone or procainamide if stable, if unstable cardiovert of defibrillate
117
how to treat sustained VT or VF 48 hour AFTER MI?
EP studies and ICD insertion
118
after an acute anterior MI, pt has SBP 70, confusion, poor urine output. right heart cath shows PCW of 22, cardiac index 1.4. how to treat?
pt in cardiogenic shock
| *tx PCI or CABG so needs to go to cath lab to determine
119
how to evaluate exertional CP in pt with coronary stent?
exercise nuclear stress test
120
what are the neurological complications after CABG?
neurocognitive dysfunction
121
treatment of AF that is assoc w hemodynamic instability, pulmonary edema, unstable angina
urgent cardioversion
122
tx of AF in pt that is stable
* slow heart rate w beta blocker, calcium channel blocker (diltiazem or verapamil), digoxin or combo
* if AF persists-rate control and warfarin
- if persists and need rhythm control, 48 hr need heparin & TEE before cardioversion
123
management of AF
* rate control and chronic anticoagulation is recommended strategy for most patients, rhythm control is not superior to rate control.
* all need long term anticoag w warfarin unless contraindication
* 2 strategies to cardioversion
- short term antigoag w heparin and cardioversion if TEE w no thrombus
- 3 weeks of warfarin then cardioversion
* if convert to sinus, rhythm maint meds not used in most
124
CHADS2 scoring
```
CHF (any hx of it) or EF<35% 1 point
HTN (prior hx) 1 point
age 75 or older 1 point
diabetes 1 point
prior CVA,TIA, systemic embolic event 2 points
```
125
CHADS2 scoring and tx for AF
score 0: no rx or ASA
score 1: ASA or anticoagulant tx
score 2 or more: anticoagulant tx
126
anticoagulant therapy for AF
* warfarin INR 2-3
* pradaxa (dabigatran) direct thrombin inhibitor, 150mg BID
* xarelto (rivaroxaban) factor Xa inhibitor, 20mg daily
* eliquis (apixaban) factor Xa inhibitor 5mg BID
127
surgery in AF pt on warfarin
| *LOW risk: CHADS2 score 0-2, interruption
* HIGH risk: CHADS2 score 5-6, recent CVA/TIA, mech.mitral valve or rheumatic valve dz
- stop warfarin 5 days before procedure
- brige w LMWH or other starting 3 days before procedure
- resume LMWH 24hr p minor surg, 488-72hr major surg
- warfarin restart 122-24hr after surgery
128
AVNRT-AV nodal reentrant tachycardia
*antegrade conduction by slow pathway and retrograde conduction by fast pathway
* TX:
- vagal
- adenosine, if no response-verapamil
- maintenance-BB,digoxin, verapamil, flecainide, propafenone
- recurrent-radiofreq. ablation
129
atrial tachycardia
* originates site in atria other than the SA node
* rate 140-250
*causes: dig toxic, pulmonary dz, prior cardiac surgery
*Tx: slow rate w BB, diltiazem or verapamil
attempt conversion w procainamide, or amiodarone
recur-cardioversion or catheter ablation
130
atrial flutter
*HR 250-350, vent.rate usually 150
*tx:same as a fib
131
WPW syndrome
| *short PR interval, wide QRS complex, delta waves
* indications for EP study and catheter ablation
- AF, A flutter or SVT
- unexplained syncope
- recur palpitations
- No tx for asymptomatic WPW
132
Wide complex tachycardia
**DO NOT use verapamil
```
TX:
-IV amiodarone or procainamide
-cardioversion if hemodynamic compromise
-pulseless-defib
ICD for hemodynam. impt sustained VT and structural heart dz
```
133
Torsades de Pointes-causes (QT prolongation)
* antiarrhythmic drugs
* metabolic: hypokalemia, hypomagnesemia, hypocalcemia, hypothyroidism
* psychotropic drugs
* antihistamines
* antibiotics
* congenital QT prolongation
* starvation, anorexia, liquid protein diet, cisapride
134
Tx torsades de pointes
* IV magnesium even if Mg is normal
* stop offending drugs
* over drive pacing
* lidocaine or bretylium can be used
135
antiarrhythmic drugs
* IA-quinidine, procainamide, disopyramide
* IB-lidocaine, tocainide, mexilene
* IC-flecanide, propafenone
* II-beta blockers
*III-amiodarone, dronedarone, bretylium, sotalol, ibutilide, dofetilide
*IV-verapamil, diltiazem
Other-digoxin, adenosine
136
toxicity of antiarrhythmic drugs
all can cause proarrhythmic effect EXCEPT: BB & CCB
137
toxicity of quinidine
thrombocytopenia
138
potential toxicity of procainamide
SLE
139
potential toxicities of amiodarone
* pulmonary fibrosis
* NASH
* hypo or hyperthyroidism
* increase warfarin action
* increase digoxin levels
140
potential digoxin toxicity
* hyperkalemia
* hypotension
* renal failure
* altered mental status
141
Indications for permanent pacemakers
* alternating BBB
* symptomatic complete or 2nd degree AV block-Mobitz 1 or 2
* asymptomatic complete heart block with HR<40
* sinus pauses
* symptomatic bifascicular block
* neurocardiogenic syncope w >3 second pauses induced by minimal carotid sinus pressure
* AF w pauses >5 seconds
142
causes of syncope
* neurally mediated-vasovagal
* orthostatic-drug induced
* autonomic nerv. system-diabetes, parkinsons
* cardiac syncope
143
causes of cardiac syncope (6mo mortality >10%)
* CAD
* cardiomyopathy
* valvular heart disease
* tachy or bradyarrhythmias
* genetic (family hx syncope or sudden death)
- familial dilated cardiomyopathy, WPW, QT syndromes
- arrhythmogenic RV cardiomyopathy
- brugada syndrome
- catecholalaminergic polymorphic VT
144
diagnosis of cardiac syncope
* implantable loop recorder-greatest diagnostic yield and cost effectiveness
* EKG,ECHO,stress test, tilt table, event and holter monitors
145
Long QT syndrome
* QTC >460ms males, >440ms female
* incr risk torsades
* syncope and sudden death can occur
* emotional & physical stress or loud noise can trigger sync/death
TX
- Beta blocker, if ineffective> BB + ICD w dual chamber pacing
- no participation in athletic activities
- ICD for recurrent syncope, cardiac arrest or sustained VT
146
Brugada Syndrome
*EKG: incomplete RBBB, coved ST elevation lead V1 to V3
these patterns can be intermittent and makes dx difficult
* hx of syncope increases risk of sudden death due to polymorphic VT
* ICD placement for recurrent syncope
147
Radiofrequency ablation is indicated for
* recurrent SVT-all types
* WPW syndrome
* atrial flutter-type I (II,III, aVF)
* control of vent rate in A fib
* idiopathic ventricular tachycardia
148
First degree heart block
* PR interval >0.20s
| * may be normal or caused by drugs: BB, diltiazem verapamil, digoxin
149
Second degree Mobitz I - Wenckebach
* progressive increase in PR interval followed by a drop beat
* narrow QRS
no tx needed
150
Second degree Mobitz II
* fixed PR interval with drop beats in 2:1, 3:1, 4:1 fashion
* QRS usually wide
* may progress suddenly to complete AV block
| * needs pacemaker
151
Third degree heart block - complete AV block
* no conduction from atrium to ventricle
* no relation of p wave to QRS
* usually wide QRS
* vent rate 30-50
| * pacemaker needed
152
CHF - due to systolic dysfunction
* dyspnea, edema
* increased BNP
* decreased EF
* ECHO-dilated ventricles, incr LA size, decr contractility
153
CHF-due to diastolic dysfunction
* dyspnea, edema, BNP increased
* EF normal >50%
ECHO: normal contractility, increased LA size, ventricle size normal
154
treatment of systolic dysfunction CHF
* ACE inhibitors, ARBs
* diuretics-loop, may need add thiazide, spironolactone in tol.
* digoxin-decreases hopitalizations
* B blockers-coreg, metoprolol,bisoprolol
* vasodilators-hydralazine, isosorbide
* biventricular pacing, ICD
155
treatment of diastolic dysfunction CHF
* diuretics
* ACE,ARBs
* BB
* nondihydropyridine calcium blockers
156
CHF in blacks
*Isosorbide + hydralazine added to standard tx in blacks with stage III&IV heart failure reduces mortality
157
drugs to be AVOIDED IN CHF
NSAIDS
TZDs
diltiazem
verapamil
158
contraindication of beta blockers
* signs of clinically unstable heart failure
* asthma, COPD
* HR<100
* 2nd or 3rd degree heart block
159
BNP level and interpretation in CHF patient
*500 decompensated CHF
160
to do biventricular pacemaker in pt with heart failure must meet ALL of these criteria (also called cardiac resynchronization therapy)
* NYHA class III-IV symptoms while on optimal therapy
* QRS of 120 msec or greater
* EF 35% or less
-this device assoc w 50% reduction in mortality for progressive CHF
161
Implantable cardioverter-defibrillator (ICD)
* NYHA class II & III on optimal tx and expect to survive >1yr
* hx hemodynamically stable ventricular arrhythmia-syncope, near syncope, or cardiac arrest
* ischemic or non isch. cardiomyopathy with EF 35% or less
* EF 35% or less 40 days out from MI
162
ACC/AHA heart failure staging
A-at risk, no structural disease or symptoms
B-structural dz but no symptoms
C-structural dz w prior or current symptoms
D-refractory symptoms
163
NYHA functional classes
I-asymptomatic
II- slight limitation of physical activity
III-marked limitation of physical activity
IV-inability to perform any physical activity without symptoms
164
Hypertrophic cardiomyopathy
* marked LVH without a cause
* LV outflow obstruction> mitral regurgitation
* mutatin, autosomal dominant transmission
* s/s: dyspnea, angina, syncope, sudden death
*cardiac findings
-harsh midsystolic murmur, incr w stand/valsalva
-S4,brisk carotid upstroke, blowing murmur at apex (MR)
EKG:LVH, Qwaves in leads I, aVL, V5-V6
165
treatment of hypertrophic cardiomyopathy
* BB or nondihydro.CCB or disopyramide
* pt w outflow obstr or symptoms on pharm therapy
- dual chamber pacing, percutaneous septal ablation, surgical septal myectomy
*see above
166
Indications for ICD insertion in hypertrophic cardiomyopathy
| *pt w hx cardiac arrest, sustained VT, hx sudden death in first-degree relative
- nonsustained VT on holter monitor
- abnl BP response to exercise
- syncope in young person, family hx of sudden death in 2 or more family members
- marked ventricular hypertrophy >30mm
167
things to avoid in hypertrophic cardiomyopathy
* competative sports, alcohol, hot tubs, sauna
* vasodilators-nitrates, dihydro CCB, hydralazine, ACE/ARBs, minoxidil, sildenafil
*positive inotropes:epi, norepi, isoproterenol, dopamine, dobutamine, digoxin
168
follow up on pt with hypertrophic cardiomyopathy
* annual exercise stress test & holter monitor
| * all first degress relatives should be screened by ECHO every 5 years
169
signs of severe aortic stenosis
+S4
paradoxical splitting of 2nd heart souns
late peaking of murmur
170
ECHO findings of aortic stenois
Moderate AS: mean gradient 25-40, valve area 1-1.5cm2
| Severe AS: mean grad >40, valve area <1cm2
171
clinical features of severe aortic stenosis
* angina, syncope, dyspnea, heart failure
* acquired deficiency of von Willebrand factor due to stress-dependent cleavage of von W factor (Heydes syndrome)-GI bleeding from submucosal angiodysplasia
172
Indications for aortic valve replacement
* symptomatic pt w severe AS-angina, SOA, syncope
* asymptomatic pt if: EF4.5cm or annual incr <0.5cm
* asymptomatic pt w moderate-severe AS undergoing CABG or aortic aortic root reconstruction
173
Normal cardiac measurements
* LVEF >55%
| * LVEDD <3.5cm
174
Indications for surgery for severe MR
* symptomatic w EF30%or more and LVESD 55mm or less
* asymptomatic with: EF60%or less, LVESD 40mm or more
- PASP 50mm or more at rest or 60 or more w exercise
- new onset AF or pulm artery hypertension
* Mitral valve repair if able otherwise MV replacement
175
indications for surgery for severe AR
* symptomatic
| * asymptomatic if any of these: EF 55mm, LV diastolic dimension >70mm, PAP increase by 25mm or more after exercise
176
Indications for surgery for Mitral stenosis
* symptomatic with valve area 1.5cm2 or less or PASP of 50mm or more at rest or 60mm or more w exercise
* asymptomatic w PAP increase of 25mm or more after exercise
* percutaneous valvotomy is best if can and less than moderate MR present and no clot by TEE, others valve replaced
177
types of prosthetic cardiac valves
* biological
| * mechanical-more durable
178
anticoagulation after valve replacement
* warfarin + aspirin 100mg x 3 month any type valve
* biologic valve and low risk pt, can discontinue coumadin but take aspirin for life
* mechanical valve-coumadin + asa indefinately, aortic valve INR2-3, mitral valve 2.5-3.5 INR
179
bridge anticoagulation prior to surgery
* indicated for mitral valve
* indicated for aortic valve if other risk factors present:
- A fib, prior thromboembolism, LV systolic dysfunction
- hypercoagulable condition, older generation mech. valve
- more than one mech valve, prosthetic valve that is not a bileaflet mech valve
* in low risk, coumadin stop 48-72 hr before and restart 24hr after
180
Indications for endocarditis prophylaxis
* prosthetic heart valves-bioprosthetic and homograft valves
* prior hx of endocarditis
* unrepaired cyanotic congenital heart defects
* completely repaired congenital heart defect w prosthetic material or device during the first 6 months after the procedure
* repaired congenital heart dz w residual defects at the site or adjacent to the site of the prosthetic device
* cardiac valvulopathy in a transplanted heart
181
Conditions not requiring prophylaxis
* acquired valvular heart dz
* MVP w or without MR, thickened or redundant leaflets
* bicuspid aortic valve
* hypertrophic cardiomyopathy
* 6 mo after repair of congenital heart defect
182
Procedures requiring prophylaxis
* all dental procedures where involvement of gingival tissue or periapical region of teeth or perforation of oral mucosa
* resp procedures that involve incision or bx of resp mucosa-tonsils, adenoids, bronchoscopy w biopsy
* GI/GU procedures only w active GI/GU infection
* procedures on infected skin, skin structures or musculoskeletal tissue
* surgery to place prosthetic heart valve or prosthetic intravascular or intracardiac material
183
dental procedures not requiring prophylaxis
* routine anesthetic injections
* dental xrays
* placement and removal of orthodontic appliances or adjustments of those, or placement of braces
184
respiratory procedures not requiring prophylaxis
* intubation
* bronchoscopy without biopsy
* tympanostomy tube placement
185
GI procedures not requiring prophylaxis
* TEE
| * endoscopy with or without biopsy
186
GU procedures not requiring prophylaxis
*vaginal delivery or c sections
*in UNINFECTED tissue:
| foley cath, D&C, therapeutic abortion, sterilization procedures. insertion/removal of IUD
187
other procedures not requiring prophylaxis
* heart cath, angioplasty, pacemaker , defibrillator insertion, coronary stents
* circumcision
* piercings and tattoos
188
standard regimen for endocarditis prophylaxis
*dental or respiratory: amox 2 gm 30-60 min prior to procedure or ampicillin 2gm IV/IM or cefazolin or ceftriaxone 1 gm IV/IM
PCN allergy: clindamycin 600mg po, cefalexin 2 gm po, or azith or clarithromycin 500mg po
* GU/GI at time of active infection
- amox 2gm po or ampicillin 2gm IV/IM
- PCN allergy-vanco 1-2gm over 1-2 hrs
* if PCN causes anaphylaxis, angioedema or urticaria-avoid cephalosporins
189
PFO-patent foramen ovale
* remains patent in up to 30% of population
* suspect in young pt w cryptogenic stroke
* stroke more common if PFO assoc w atrial septal aneurysm
* incr risk severe decompression syndrome
* best diagnostic test: TEE w saline injection to show R-L shunt
* consider closure if recurrent stroke
190
Causes of acute pericarditis
* idiopathic 80+%
* infectious-viral TB bacterial
* acute MI,aortic dissection, trauma, chest radiation, card.surgery
* neoplasm, uremia, autoimmune dz
* drugs:dantrolene,doxorubicin, hydralazine,INH,procainamide,phenytoin
191
Poor prognostic factors with acute pericarditis
* Temp >38
* subacute onset-several weeks
* cardiac tamponade
* immunocompromised
* hx oral anticoagulants
* trauma
* myopericarditis
* large pericardial effusion (echo free space >20mm)
192
Treatment of acute pericarditis
* ASA or NSAID+colchicine
* steroids if no response to above
* pericardiocentesis-if pericardial tamponade or suspect purulent or neoplastic pericarditis
* recur rate 15-30%
193
Best prophylaxis for recurrent pericarditits
colchicine
194
definition of primary pulmonary hypertension
*mean PA pressure >25mm at rest or >30mm with exercise
increase incidence in women age 40-50
195
Clinical features of primary pulmonary hypertension
* gradual onset of dyspnea
* incr JVP with prominent a waves
* edema
* loud P2
* EKG: RV hypertrophy, right axis deviation
* ECHO: RV and RA enlargement , RVH, TR
* PFT: nl or mild restrictive
* lung scan: diffuse patchy defects
* spiral CT-may be needed to determine PPH from PE
196
complications of primary pulmonary hypertension
* RV failure
| * sudden death
197
treatment of primary pulm hypertension (PPH)
* diuretics, nifedipine, sildenafil
* warfarin, INR 2-3
* oral bosentan-endothelial receptor antagonist
* IV epoprostenol-refractory
* lung transplant
198
Causes of pulmonary artery hypertension
* primary
* collagen vasc dz:CREST,scleroderma, SLE,RA
* cardiac L to R shunts: ASD,VSD, PDA
* HIV
* drugs and toxins
* pulm venous hypertension: LV dysfxn, L side valve dz
* hypoxemic lung dz: COPD, interstitial lung dz, sleep apnea, obesity, hypoventilation syndrome, chronic pulmonary thromboembolic disease
199
diagnostic work up for pulmonary artery HTN
ANA, HIV, TSH
ECHO
PFT
CT chest
200
clinical features aortic dissection
* sudden onset severe anterior or posterior chest pain
* obstr of branches of aorta may lead to :
- MI, CVA, unequal carotid or brachial pulses
* acute AR -> CHF
201
types of aortic dissection
type A-ascending aorta
| type B-limited to transverse or descending aorta
202
causes of aortic dissection
* HTN
* marfan syndrome
* Ehlers-danlos syndrome
* coarctation, bicuspid aortic valve
* 3rd trimester pregnancy
203
treatment of aortic dissection
* lower SBP 100-120 with IV beta blockers (HR 60) + IV nitroprusside followed by oral therapy
* surgery for type A w ascending aorta involvement
204
diagnosis of peripheral artery disease
*ABI-systolic ankle pressure/brachial pressure measured by doppler
1-1.3 normal
.91-.99 borderline
.41-.90 mild-moderate
<.40 severe
205
PAD- location of claudication and site of disease
* buttock-aortoiliac dz
* thigh-common femoral
* upper calf- superficial femoral
* lower calf- popliteal
206
PAD-risk factor modification
* treat hypertension and elevated lipids
* quit smoking
* supervised exercise program **most effective therapy of claudication
207
PAD- pharmacological therapy
* antiplatelet agents: ASA or clopidogrel
| * pletal (cilostazole), ginko biloba, statin, ramipril
208
PAD-revascularization
* for lifestyle-limiting claudication or to salvage a threatened limb
* angioplasty-for short-segment stenosis in large caliber vessel
* surgery-preferred for popliteal & tibial arteries or multivessel dz
209
abdominal aneurysm screening
* one time screening w ultrasound for men ages 65-75 who have ever smoked
* men 60 or older w first degree relative w abdominal aortic aneurysm
210
Indications for surgery for abdominal aneurysm
* size 5.5cm or larger or rate of expansion >.5cm/yr
* symptomatic aneurysm of any size
* semiannual screen for asymptomatic aneurysm >4cm
211
Indications for surgery for thoracic aneurysm
* symptomatic: dysphagia, back pain, hoarseness
* dissection
* ascending aortic diameter >50-60mm
* descending aortic diameter >60-70mm
* descending aortic diameter 70mm or more in pt w high surgical risk
* rapid growth 10mm or more in a year in aneurysm <50mm
212
monitoring of thoracic aneurysm in pts dont meet criteria for repair
*serial CTor MRI
213
Athletic heart
* physiological increase in LV thickness, cavity size in response to intensive endurance training.
* ECHO:symmetric LVH, wall thickness<12mm, LA size & filling pattern is normal
```
EKG: sinus bradycardia
sinus arrest
wandering pacemaker
Mobitz I
no Q waves or deep T wave inversion, incr QRS voltage
```
214
superficial thrombophlebitis-clinical features
*erythema
*tenderness and edema along involved vein
TX:local heat, elevation, NSAID, compression stockings
215
superficial thrombophlebitis-indications for ultrasound
* involvement of saphenous vein
* evidence of clinical extension
* edema of leg > than expected
* if diagnosis is uncertain
216
Risk factors for extension to deep veins with superficial thrombophlebitis
* more than 5cm of superficial thrombophlebitis
* location close to deep system-5cm or less from saphenofemoral/saphenopopliteal junction
*medical risk factors for DVT
217
rhythm-normal
Pwaves upright in II,aVF and inverted in aVR
each QRS preceded by p wave
PR interval is constant
218
long PR interval
first degree AV block
219
short PR interval
WPW
| nodal rhythm
220
widened QRS interval (.06-.1s)
```
LBBB
RBBB
VPCs
hyperkalemia
quinidine toxicity
```
221
Prolonged QT interval
congenital
hypokalemia
hypocalcemia
drugs
222
normal axis
lead I +
| lead aVF +
223
right axis
lead I -
| lead aVF +
224
left axis
lead I +
| lead aVF -
225
ST elevation seen in
MI
pericarditis
coronary spasm
226
inverted T waves seen in
```
MI
ventricular strain
increased intracranial pressure (subarachnoid bleed)
digitalis effect
hypokalemia, hypocalcemia
```
227
infarction
ST elevation
T inversion
Q waves
228
Ischemia
ST depression or symmetric T wave inversion
229
Pericarditis EKG
diffuse ST elevation w concavity upward
| absence of reciprocal changes and t wave inversions
230
Hypokalemia EKG
prominent U wave
ST depression and T wave inversion
prominent P waves in II, III, aVF
231
44 y/o white male hx exertional dyspnea w minimal activity for a few weeks. known idiopathic congestive cardiomyopathy for one year, meds: dig, lasix, ace, coreg, spironolactone. EKG-LBBBw QRS duraton 140ms. ECHO: EF 22%, marked LV enlargement, severe systolic dysfxn, recommend?
biventricular pacemaker and ICD insertion
232
50 y/o male seen for annual exam, has S3, midsystolic click followed by systolic murmur that radiates to axilla, louder w standing. ECHO-severe MR and prolapse of posterior mital valve leaflet. LVED diameter 52mm and EF 46%. recommend?
Mitral valve surgery
233
40y/o asymptomatic female routine exam. extremities brisk distal pulses w "pistol shot" heard w auscultation over peripheral arteries, early decrescendo diastolic murmur LLSB, ECHO-severe AR. EF 40%, recommend?
aortic valve replacement
234
16 y/o male has 4/6 holosystolic murmur LLSB. does not change with respiration, increases w hand grip. likely diagnosis?
VSD
235
45 y/o male sudden onset L hemiparesis. hx low grade fever, wt loss, exertional dyspnea , few episodes of sudden syncope for past few weeks. BP 130/80, weak L arm & leg. heart-loud P2, low pitch early diastolic sound & apical syst. murmur that changes w positon. Hgb 9, sed rate 90. likely diagnosis?
atrial myxoma
236
20 y/o male on basketball team routine exam. HR 50, BP 110/70, soft S3 and grade I syst ejection murmur LLSB, decreases w standing and valsalva, incr after exercise. EKG: Mild LVH sinus brady and sinus arrest w pause up to 1 second. ECHO normal. recommend?
no tx needed
237
16 y/o female w recurrent LOC, most recent w awakening by alarm clock. exam HR 60, BP 120/80, no neuro deficits. heart exam normal. EKG shows prolonged QT interval. most impt question to ask her
if there is history of sudden death in the family
238
64 y/o pt w one month hx of exertional CP and 2 episodes of syncope after exertion in last 2 weeks. exam: HR&BP good . S4+ and grade 3 ejection m LLSB and aortic area. and radiates to carotids and decr intensity w standing. ECHO: 40mm gradient aortic valve and mild LVH. recommend?
Coronary angiography then aortic valve replacement
239
26 y/o male to ER w palpitations of 2 hours. exam HR 170, BP 110/70, regular cannon waves on JVP w each heart beat . EKG shows narrow complex SVT. now recommend?
IV adenosine
240
exam of the heart in a pt w WPW will show
loud S1
241
54 y/o black male w long hx HTN presents w 2 hr hx severe CP radiating to back. right carotid pulse is weaker, early diastolic mumur LLSB. EKG: LVH, ST elevation II,III, aVF. CXR: widening of the mediastinum. now recommend?
IV beta blockers
242
52 y/o white male w recur attacks of CP on exertion for 3 months. last a few min and are relieved by rest. exam normal, resting EKG normal. exercise stress: 3mm horizontal ST depression lasting >.08s in leads V2-5 w 4th minute of Bruce protocol and HR is 90. test stopped . ST depression persists 10 min p exercise, no CP during the test. now recommend?
cardiac cath
243
26 y/o male w brief syncopal episode while playing football. denies any SOA, Palpitations or CP. Exam: S4+, grade 4 crescendo-decrescendo syst. murmur LSB. louder w stand and valsalva. decreases w squatting. likely diagnosis?
hypertrophic cardiomyopathy
244
16 y/o male routine exam. no complaints. very active-football. exam: S2 wide split no change w respiration, grade 2 mid-syst. murmur pulmonary area and mid-diastolic murmur LLSB. likely diagnosis?
ASD
EKG-may see RBBB
CXR- prominent pulm artery, large RV
245
46 y/o male ICU acute anteroseptal MI. thrombolytics given, IV NTG,heparin, propranolol, asa. 3rd day sudden SOA. exam-rales both lungs, loud grade 4 holosystolic murmur LSB. does not change w respiration. Swan: RA,RV,PCW pressures all increased, O2 sats: RA 72%, RV 84%, PA 85%. likely diagnosis?
rupture of interventricular septum
246
42 y/o male w severe substernal CP x 2 hours. nausea & diaphoresis. exam: jugular venous engorgement w + kussmauls sign, BP 82/60, HR 90, +S4, no murmur. CXR-clear lungs. EKG: inferior MI. swan: pressures normal, except RA incr at 18. sats equal. tx
volume loading
| thrombolytics
247
68 y/o female confused, disoriented. no hx available, exam HR 100, BP 80/60, T99, marked confusion, Hgb 9.5,wbc 12K, bun/cr 40/1.8, cxr normal. swan pressures all normal but SVR is decreased. likely cause of shock?
septic shock
248
38 y/o female w 4 mo hx fatigue, incr SOA, ankle edema, abdominal swelling, born in China, here for 3 years. exam: engorged jugular veins, +kussmauls, 2+ ankle edema, 2+ ascites, enlarged liver, sharp early 3rd heart sound CXR-incr pulm marking EKG: low voltage limb leads. ECHO: incr RA&RV pressure incr PCW pressure. now recommend?
surgical stripping of pericardium
249
42 y/o male progressive SOA and marked weakness x 3days. hx chronic RF on dialysis x 1 year. exam: BP 86/70, syst pressure drop to 66 after deep inspiration, engorg. neck veins, HR 100 and paradoxical pulse of 20mm. EKG low voltage limb leads. ECHO pericard effusion w RV collapse, CXR cardiomegaly, lungs clear. R heart cath:RA,RV,PA,PCW pressures incr, recommend?
pericardiocentesis
250
32 y/o female progressive SOA for 6 hours. exam-mod resp distress, BP 130/80, HR 100, lungs rales b/l to mid lungs. +S3 +S4, loud grade 4 pansystolic murmur at apex. decr intensity w inspiration. R heart cath all pressures increased, dx and tx
Acute mitral regurg
| IV nitroprusside to get stable then surgical consult
251
55 y/o male recurrent CP w exertion, exam unremarkable, EKG normal. exercise stress: 3mm horizontal ST depression anterior leads stage 2 Bruce and HR 100. test terminated due to CP. ST depression persists 10min p exercise. coronary angiogram : triple vessel dz w EF 32% recommend?
CABG
** 3 vessel disease and low EF => surgery
252
50 y/o black male w acute inferior MI, 10 min after completion of thrombolytics he has slight nausea and EKG shows short run of wide complex rhythm. best approach?
observe
253
44 y/omale has acute anterior wall MI tx w thrombolytics, heparin, asa , propranolol. hosp course is uncomplicated. stress test shows no ischemia and EF 52%. night before discharge, rhythm on monitoring shows short run of v tach, now recommend?
discharge on asa and propranolol
254
44 y/o female passes out at home and presents to ER. recently started on quinidine for control of premature beats found on holter monitor. she is alert and VSS. EKG is normal. one hour later its noted she has torsades de point. recommend?
* stop quinidine
* give magnesium
* atrial or ventricular over drive pacing
255
72 y/o female w SOA. Hx HTN on HCTZ many years. BP 180/100, HR 110, engorg neck veins, rales to mid scapula b/l.+S3, +S4 EKG: LVH. CXR pulm edema initially tx w IV diuretics w improvement in symptoms, now recommend?
B blocker
256
54 y/o pt has grade 2 syst ejection murmur and grade 3 early diastolic murmur . ECHO: severe AR with mild LV dilation, EF 56% now recommend?
medical follow up and repeat ECHO and gated blood pool study in one year
257
drugs shown to improve survival after MI
aspirin
B blockers
thrombolytic tx
258
drugs capable of causing the proarrhythmic effect
quinidine
procainamide
sotalol
259
digoxin trial showed
* works well in a fib w RVR w heart failure if unable to take BB
* shown to decrease hospitalizations
* withdrawal of digoxin is detrimental
260
SOLVD trial - enalapril
DECREASES: death, hospitalizations, CHF
261
carvedilol study
decreases mortality
| decreases cardiovascular hospitalizations
262
2 FDA drugs approved in Heart failure
coreg-target 25mb BID
toprol XL - target 200mg/d
263
AHEFT trial
combination Isosorbide dinitrate & hydralazine:
increases survival of african americans, esp females
264
treatment of symptomatic a fib
anticoagulate
control rate
AV node ablation & permanent pacemaker
improves EF and quality of life
265
CHADS2 of 1 or less
can use ASA alone in a. fib
266
CHADS2 of 2 or more
tx a fib with coumadin or pradaxa
267
pradaxa
inhibits thrombin so less hemorrhage risk except if hx GI bleed
decreases strokes by 34% over coumadin
268
medication contraindicated in right ventricular infarct
NTG
269
treatment of right ventricular infarct
volume expansion
| if not successful-dobutamine
270
think RV infarction in patient with
inferior wall MI-ST elevation II, III, aVF
hypotension
+JVD
CLEAR lungs
271
indications for urgent CABG in STEMI
* persistent ischemia w signif heart muscle at risk and cant do PCI or fibrinolytics
* failed primary coronary intervention
* cardiogenic shock
272
fibrinolysis for STEMI preferred if
less than 3 hours onset of symptoms and invasive tx not available
door to balloon > 90minutes or
door to needle >60 minutes
273
primary coronary intervention for STEMI- always better outcome than thrombolytics especially if:
* door to balloon time 3 hours from onset of symptoms
| * diagnosis is in doubt
274
high risk unstable angina:
* ischemic discomfort >20 minutes
* ongoing rest pain
* accelerated tempo of ischemia
* exam: pulm edema, S3, new MR murmur, hypotension, brady or tachycardia, age >75
* EKG: transcient ST-Tchanges >0.05mV, new BBB, new sustained VT
* cardiac markers increased
275
7 independent predictors-risk score unstable angina:
* 3 or more CAD risk factors
* ASA used in past 7 days
* known CAD w stenosis of 50% or more
* 2 or more angina events in past 24 hours
* ST segment deviation >0.5mm
* elevated cardiac markers-CK-MB or troponin
276
bare metal stents
use if poor compliant patient
risk of bleeding
non cardiac surgery
277
drug eluding stents
*work by decreasing small muscle hyperplasia-inhibit cell cycle-local effect of stent
* decreases rate of restenosis
| * STRICT- MUST take ASA and plavix forever
278
PTCA indicated for patient w 2 or 3 vessel disease with:
significant proximal LAD lesion
suitable anatomy
no diabetes
normal LV function
279
Class I indications for aCABG with stable angina
* significant Left Main disease
| * 3 vessel disease (survival benefit best in those w EF <50% or ischemia
280
avoid adenosine or persantine stress testing if
COPD
281
avoid dobutammine stress test if
arrhythmia
282
"RULES" for stress testing
* can exercise-do exercise stress test
* abnormal EKG- add imaging
* can not exercise-pharmacologic stress plus imaging
283
S/S constrictive pericarditis
* fatigue
* dyspnea
* wt gain-increased abdominal girth
* nause
* edema
284
treatment for constrictive pericarditis
pericardiectomy
285
on cardiac cath if see all pressures almost identical:
RA=PA=PCW think
pericardial tamponade
286
Becks triad-cardiac tamponade
= atrial and pericardial pressures
pulsus paradoxus
hypotension (late sign)
287
EKG differentiation of acute MI vs pericarditis
* acute MI T's are inverted
| * pericarditis T's are upright
288
S/S acute pericarditis
* pericardial friction rub
* chest pain
* diffuse ST elevation
* *needs ECHO to check for effusion and get hemodynamics
289
Most common causes of acute pericarditis
idiopathic
infection
dresslers
trauma/surgery
290
Chronic mitral regurg- indications for surgery:
* acute symptomatic
* chronic symptomatic
* asymptomatic with:
* EF,60%
* or LVESD >40mm
* or new a fib
* or PHTN >50 at rest or >60 with exercise
291
symptoms of acute severe mitral regurg
* acute volume overload:pulm edema, acute PHTN
* shock
* S3, early diastolic rumble
* *urgent surgery, to get to surgery may need balloon pump, nitroprusside, dobutamine
292
causes of acute severe mitral regurgitation
ruptured chordae tendinae
ruptured papillary muscle
endocarditis
293
etiology of mitral regurg
dilated cardiomyopathy
```
MVP
rheumatic
CAD
endocarditis
drugs
```
294
common symptoms MVP
```
palpitations
atypical CP
panic, anxiety
dyspnea
fatigue
```
295
mid systolic click
MVP
296
dx MVP
ECHO: 2mm prolapse
297
surgical indications for mitral stenosis
* repair is preferred over replacement
* NY heart III-IV
* severe MS w PHTN>60mm
298
mitral valve percutaneous balloon valvotomy indications:
* NY class II-IV (symptomatic)
* asymptomatic w PHTN 50 at rest, >60 w exercise (PASP)
* moderate to severe mitral stenosis
* NO LA clot
* No more than mild mitral regurgitation
* non operative patient
299
asymptomatic severe mitral stenosis can suddenly progress to pulmonary edema due to
#1: A fib
* poor prognosis -75% die within 10 years
* all need long term anticoagulation
300
Medical tx mitral stenosis
* avoid extreme physical exertion
* B blockers
* lower rate w CC blockers
* salt restriction
* occassionally need diuretics
301
Indications for AVR in aortic regurgitation
* symptomatic
* asymptomatic w EF75 or LVESD >55
* having CABG or heart surgery and has chronic severe AR
302
medication to avoid in severe chronic aortic regurg
Beta blockers-prolong filling time and worsen condition
303
chronic severe aortic regurg medical treatment
```
*vasodilators;
hydralazine
nifedipine
felodipine
ACE
```
304
severe aortic regurgitation on ECHO see
pressure 1/2 time <150ms
| premature closure of mitral valve
305
acute aortic regurgitation S/S and treatment
* urgent surg eval
* pulm edema, shock, ischemia
* CXR may be normal
* may not have murmur
* confirm diagnosis w ECHO
306
common causes of aortic regurgitation
* bicuspid or calcified valve
* rheumatic heart disease
* endocarditis
* HTN
* ascending aortic dissection
307
aortic stenosis indications for valve replacement
* severe AS w EF<50%-ALL
* severe AS and symptomatic
* severe AS to moderate AS and need CABG/heart surgery
* *balloon valvuloplasty is not done except for palliative pt only
308
Aortic stenosis exercise testing
**contraindicated if symptomatic
*useful in asymptomatic-see if really is symptomatic
309
aortic stenosis surveillence
* severe-yearly
* moderate- every 1-2 years
* mild-every 3-5 years
310
lateral MI leads
I, aVL, V5, V6
311
inferior MI leads
II,III, aVF
*right ventricular infarct will usually see: hypotension, +JVD, lungs CLEAR
312
right ventricular MI leads (usually due to RCA obstruction)
V4R
313
murmur mitral stenosis
* Austin flint
| * no opening snap
314
ICD benefit for
* EF 35% or less
| * class 1 month after MI
315
anterior MI leads
V1-2-3-4
316
use of iontropic meds in heart failure
* *increase mortality in all studies
* only use as palliative tx w refractory heart failure so pt can be dismissed and is not candidate for transplant or surgery
317
austin flint murmur indicates
functional mitral stenosis due to severe aortic regurg
318
opening snap is heard with
mitral stenosis
319
for pt undergoing qualifying procedure, for what heart condition is infective endocarditis prophylaxis indicated?
prosthetic cardiac valve
320
for patient w qualifying heart condition, what procedure is infective endocarditis prophylaxis recommended?
dental extraction
321
1st degree AV block
PR >200ms
observe
if symptomatic: stop BB & CC blockers
322
2nd degree AV block -Mobitz I (wenchebach)
progressive lengthening of p wave until drop QRS then repeats
observe
discontinue nodal blockers if symptomatic
323
2nd degree AV block- Mobitz II
***needs pacemaker!!
multiple blocked beats
can progress to complete heart block
324
3rd degree AV block-complete heart block
no relation p waves to QRS
**needs pacemaker
325
SVT DO NOT GIVE
Beta blockers
treat underlying cause ie asthma, dehydration...
if no cause and recur-catheter ablation
326
CHADS2 scoring (for tx of atrial fib)
* score 1 or less-aspirin
* score 2 or more-coumadin or pradaxa
```
CHF
HTN
age 75 or older
DM
S2: 2 points if prior TIA/CVA or embolic event,mitral stenosis or prosthetic valve
```
327
WPW EKG clues
delta wave-slur up on QRS
short PR interval
**needs ablation-only cure
328
EKG with hypercalcemia
short ST
329
alternans on EKG think
pericardial effusion
| tamponade
330
EKG with hyperkalemia
peak T waves
wide QRS-looks like diffuse ST elevation
slow conduction
331
Long QT syndrome
first deflection of Q to end of T wave
*Tx: non select BB then ICD
332
cardiogenic shock in acute MI
*due to large MI with extensive damage >40% of myocardium in most
7% of Acute MI's
90% occur at hospital
**#1 cause of hospital deaths
333
hemodynamic criteria of cardiogenic shock in acute MI
SBP 15 (high filling pressures)
334
clinical criteria of cardiogenic shock in acute MI
hypoperfusion:
* cool extremities
* mottled skin
* decreased urinary output
335
therapy of cardiogenic shock in acute MI
* intra-arterial BP monitoring
* right heart monitoring of cardiac index
* inotropics
* intra-aortic balloon counterpulsation
* early revascularization-improves 6 month survival
336
ICD of benefit for:
EF 35% or less
>1 month AFTER MI if indicated
class <3 NY heart classification
337
ICD implantation is NOT indicated for:
* class 3 or higher of NY heart
* first month after acute MI
* EF >35%
* VT in first 24-48 hours after MI-this has no longterm prognostic implication during this time
338
47 y/o male w ischemic cardiomyopathy, prior CABG, has EF 25%, has dyspnea on moderate exertion. consider what treatment?
ICD
339
67 y/o male in ER w one hour CP, 164/96-hr 94, EKG marked ST elevation V1-V6, I, aVL. tx w ASA, LMWH, TNKase, NTG, B blocker and no resolution of ST elevation =>transferred, now SBP 100, HR 94, EKG 5mm ST elevation of same leads. signs of systemic hypoperfusion likely cause?
cardiogenic shock due to severe LV dysfunction
optimal tx for this patient is urgent PCI
340
70 y/o male longstanding ischemic dilated cardiomyopathy w EF 25%, to ER w 2 wk history of increased fatigue, SOA, wt gain and increased sleepiness. BP 92/78, HR 110. expected on physical exam?
JVD
displaced apical pulse
cool extremities
(Not kussmauls sign)
341
60 y/o male active & asymptomatic, referred for new LBBB on screening EKG. vs: 140/70, hr 68, no JVD, no S3, no murmur. ECHO: mild enlarged LV, EF 30%, CXR: mild cardiomegaly. what meds should be started?
ACE
| B blocker
342
72 y/o female previously healthy has acute anterior MI. ECHO EF 20% w mild MR, EKG sinus w QRS 115ms, ACE and B blockers started. do you recommend EP study, ICD or cardiac resyncrinization prior to discharge?
NO-this is acute, so none are indicateddd
343
79 y/o female to ER w SOA at rest, Hx of HTN, recent ECHO:concentric LVH, EF 60%, no valve disease. VS: 192/68, hr 124, rr 20 sat 86% on room air. EKG: a fib w RVR, CXR: pulmonary edema. what treatment?
control BP and HR, diuretics are mainstay of tx for her
344
48 y/o male had inferior MI 2 days ago, uncomplicated, now has new onset of CHF w +S3, holosystolic murmur at apex, BP 122/82, HR 94. next step in evaluation?
ECHO
| diagnosis is either ventricular septal perforation or mitral regurg, both can be complication of AMI
345
35 y/o female w multiple ER visits for CP assoc w stress. EKG normal, exam-soft late systolic murmur and possible click. appropriate test?
exercise ECHO because she has murmur-likely MVP
346
75 y/o male w COPD, HTN, DM pre-op evaluation for fem-pop bypass. exam-+S3, EKG: LVH. appropriate test to evaluate chest pain?
dobutamine ECHO- he has CPOD
347
heart murmur which does not need ECHO evaluation?
grade 2 mid systolic murmur
usually aortic sclerosis
very common
348
55 y/o female w severe mitral stenosis. asymptomatic, VSS. wants to join gym and wants to know if this is ok?
she can engage in any degree of exercise, limited only by her symptoms
349
62 y/o male w DM has + stress test: 2mm ST depression at end of stage 1 Bruce protocol. heart cath: L main 25%, LAD 85%. L circ 75% , RCA 50%, EF 45%. meds:asa, diltiazem, glipizide. next step?
CABG
Reason: Diabetic, 2 vessel disease (inclusing LAD), mild decreased LV function (EF 45%), High risk stress test + in stage I
350
68 y/o female hx angioplasty 4 yr ago. Increase angina , relief w NTG past 3-4 wks. now 30" CP no relief w 3 NTG. Meds: asa, statin, B blocker, VSS, EKG: 1.5mm ST depression V3-V6. 20" of IV heparin and NTG and pain is gone and EKG normal. first troponin is mildly incr. most appropriate disposition?
admit, ASA, heparin, load on plavix, schedule heart cath in AM
351
79 y/o female in ER-dizzy, CP X 24hours. Hx HTN. no HRT. exam: 95/65, HR 114, +JVD 12cm, lungs clear, +kussmauls, + pulsus paradoxus. EKG: ST elevation II,III,aVF, depression I,aVL,V1-3. in addition to prompt reperfusion, most appropriate initial management?
volume expansion
352
60 y/o male, hx HTN.asymptomatic & active. normal recent stress test, soft early diastolic murmur. VSS. ECHO: severe AR, EF 55%. care strategy?
monitor and tx w ACE inhibitor during surveillence
353
70 y/o female. Hx HTN,hyperlipid, severe aortic stenosis. admit w heart failure, pulm edema and hypotension. labs ok. EKG: 1-2mm ST depression II,III, V5, V6. CXR: pulm edema. ECHO: severe aortic stenosis & normal LV function. appropriate management?
coronary angiography then proceed directly to aortic valve replacement
354
65 y/o male. Hx HTN, hyperlipid. ECHO (has murmur):severe AS, normal LV function. says asymptomatic and walks daily, golfs frequently. next step?
exercise treadmill test
* to determine if truely asymptomatic w exercise
* if is asymptomatic the ECHO in 6 months to 1 year
* if he is symptomatic, needs surgery
355
36 y/o male has sudden squeezing, sharp CP radiating to neck & shoulders. VSS. + friction rub. CXR-mild heart enlargement silhouette. EKG: diffuse 2-3mm ST elevation. labs normal. diagnosis and next step?
acute pericarditis
get ECHO to r/o compression from effusion , other pathology
Tx- if above w/up negative, treat w NSAIDS
356
definition of a positive ETT-exercise treadmill test
flat or down sloping ST segment depression >1mm and occuring 80msec following the J point
357
reasons to discontinue ETT
ST segment depression >2mm
decrease in SBP >15 mm Hg
development of VT
development of CP, SOA, lightheadedness
358
false + ETT
occur in 15-20% overall, up to 20-30% in females- so pre test probability is important
359
likely cause of reversible ST segment elevation on ETT
coronary artery spasm
360
MPI-myocardial perfusion imaging- with adenosine (not exercise) is the test of choice for patients with
LBBB
| paced ventricular rhythm
361
MPI stress tests use thallium or technetium IV that are tracers that distribute to heart tissue in proportion to BLOOD FLOW.injected at the peak of stress they can show:
* ischemia-these areas take up LESS tracer than surrounding tissue but will show normal distribution at rest some time (hours) later.
* infarcted areas- show under perfusion both during exercise and at rest
362
gold standard for the diagnosis of CAD
coronary angiography
carries 1%complication rate
363
normal RA pressure
*7 in upright position=JVD
364
normal RV pressure
30/7
365
normal PCWP
<12
366
PCWP >15-18
LV failure
367
PCWP 15-25 causes
dyspnea at rest
orthopnea
interstitial edema
368
PCWP>35 acutely causes
frank pulmonary edema
369
if diastolic pressures in all 4 chambers of the heart think:
pericardial tamponade
| constrictive pericarditis
370
septic shock is mainly due to
*low SVR-systemic vasc resistance
*pt will have LOW: BP,SVR,PCWP
and HIGH:CO
371
alcoholic cardiomyopathy
cant be dx by biopsy, it is dx by history and exclusion of other causes
372
Pulsus paradoxus-
*see in: constrictive & pericardial conditions, asthma, tension pneumothorax
* decreased pulse volume with inspiration,SBP decreases by >10mm with inspiration
* when severe, may hear heartbeat but no pulse felt during inspiration.
373
pulsus bisferiens
*bifid with 2 systolic peaks per cardiac cycle
*see with: aortic regurgitation ( w or w/o stenosis!)
hypertrophic cardiomyopathy
374
Pulsus alternans
* varying pulse pressure with a regular pulse rate
| * see with: severe LV disease of any cause
375
Pulsus tardus
slow upswing
| *aortic stenosis
376
pulse in aortic dissection
* pulse asymmetry
* can see good pulses in upper extremities and diminished pulses or absent pulses in lower extremity , or can see pulses on one side of body and not on other
377
PAD pulses
may see decreased or absent pulses
378
fixed split S2
ASD
379
S3
* normal in children
| * if present >age 40 is abnormal:acute ventricular decompensation, severe aortic or mitral regurgitation
380
S4
caused by ventricular filling during atrial contraction, ventricle is so stiff & delayed relaxation
* ischemic heart dz, AS,MR, hypertrophic & diabetic cardiomyopathy, hypertensive heart dz w concentric LVH
* NOT heard w a fib
381
systolic abdominal bruits suggest
* renal vascular HTN
| * renal artery stenosis dx-renal angiography, CT angiogram or MRA
382
VSD is seen more commonly with these MI types
* anterior
| * inferior
383
with ACS, arrhythmias in the first 48 hours
* due to acute ischemia
| * do NOT imply need for long term antiarrhythmic therapy
384
Plavix (clopidogrel)
used for all proven ACS scenarios except NOT used if CABG id imminent or going immediately to cath lab
* but all who do go to cath lab will be put on it
* genetic test CYP2C19-this liver enzyme is required for plavix to work properly and 2-14% are poor metabolizers (they dont make the plavix active)
* PPI's decrease effectiveness of plavix
385
fibrolytic therapy
*NOT given to patient with unstable angina or NSTEMI-it INCREASES mortality!!
*give to STEMI or new LBBB if no contraindications
386
antiarrhythmic drugs in ACS
preferred is amiodarone for VT,VF
lidocaine only if needed-if no VT,VF do not give it. it has increased half-life in pt w HF and those on propranolol. prophylactic use is harmful
387
primary risk factors for CAD
* age
* family hx of early CAD
* smoking
* HTN
* male
* diabetes
* elevated LDL
388
HDL is increased by
exercise
estrogens
niacin
small amounts of ETOH intake
389
HDL is decreased by
smoking
| androgens
390
```
LDL goals:
>160 = high risk
130-159 = borderline high
101-129 = ok
<100 =optimal
```
<70 if has CAD or diabetes
* *lipids may be falsely low for up to 2 months after MI or cardiac surgery
* once LDL tx, then HDL is targeted, then TG
391
CABG
* for all w significant Left Main or left main equivalent (proximal LAD plus proximal circumflex)
* for all with 3 vessel disease
*all with 2 vessel disease and significant prox LAD and either abnormal LV function (EF<50%) or ischemia on noninvasive testing
392
CABG improves SYMPTOMS & SURVIVAL in:
* left main dz or left main equivalent (2 vessel dz with one vessel being proximal LAD)
* 3 vessel dx w LV dysfunction
* diabetes
393
CABG improves symptoms of angina in 1 and 2 vessel disease but
does NOT improve survival!
394
complications after STEMI
| *rupt of papillary muscle: 3-7 days after INFERIOR MI, get ECHO and urgent cariothoracic surgery
* VSD: 3-7 days after ANTEROSEPTAL MI , rapid shock, loud, holosystolic murmur, ECHO and surgery urgently
* free wall rupture of the LV: 3-7 days after LARGE ANTERIOR MI, most are elderly hypertensive women, see sudden syncope, few heroic saves w surgery
395
Peripheral artery disease causes
* atheriosclerosis: most common middle age and older, 2 risk factors:smoking, diabetes, they are at incr risk MI and stroke
* trauma
* arteritis-Takayasu arteritis, connective tissue disease
* Buerger dx (thromboangitis obliterans) esp male
396
PAD diagnosis
ABI before & after exercise:best for degree of functional impairment
doppler u/s: visualize artery and blood flow
*arteriogram: best test for location of the disease
CT & MR angiography- good noninvasive artery imaging
397
Tx of PAD
* noninvasive
- stop smoking
- exercise 30" daily
- pletal (cilostazol)-only if normal LV
- trental (pentoxifylline)
* many tx w percutaneous angioplasty & stents
| * acute occlusion: heparin to protect collateral circulation the embolectomy is TOC
398
Vasospastic disorders:
* Primary raynauds
- constriction of small arteries and arterioles
- acrocyanosis when cold
- may see livedo reticularis
-tx:
calcium channel blockers
biofeedback
nitroglycerine if CCB ineffective
399
Patients with atherosclerotic carotid artery disease are at a HIGHER RISK OF
MI than of having TIA/CVA
400
carotid endarterectomy
* indicated for lesions >70% stenosis
* stenting if high risk for endarterectomy
* medical rx: asa or plavix
401
suspect spontaneous dissetion of the internal carotid artery if:
* unilateral headache
* TIA
* dilated pupil
* cholesterol emboli on funduscopic exam
| * usually resolve w no tx, excellent recovery im most
402
causes of cerebral embolic events of cardiac origin
* atrial fib 45%
* acute MI 15%
* ventricular aneurysm
* mechanical valve
* valvular heart disease
* endocarditis
* other cardiac abnl
403
TIA
*
*no longer related to duration of symptoms
*definition: a period of ischemia without infarction
*Ischemic stroke definition: ischemia w infarction
CNS includes: brain, sp cord, retina
404
most emboli to the lower extremities originate
in the heart
405
Thoracic aortic aneurysms
* tend to dissect as well as rupture
* Predisposing factors:HTN,cystic medial necrosis, bicuspid aortic valve, coarctation aorta, 3rd trimester pregnancy
* aortic dissection is major cause death in Marfan syndrome
406
aneurysm diagnosis
CT & MRI for possible dissection.
| TEE is accurate for descending thoracic aortic dissection
407
Tx aortic aneurysm
* decrease BP immediately w B blockers and nitroprusside in needed
* ascending aortic dissections at greater risk complications and always need surgery
* descending are usually medically treated
408
thoracic aortic aneurysms
* ascending: surgery if 5.5cm, 5 cm if Marfans
* descending: 6.5cm
* also surgery if small but enlarging, or if have symptoms, or putting pressure on surrounding structures or of trauma origin
409
AAA-abdominal aortic aneurysm
* tend to rupture rather than dissect
* monitor with u/s or CT every 6mo - 1 year if 4-5.4cm
* 5.5cm need repair, or if expanding >.5cm in 6 mo need surgery
* patients are placed on B blockers during observation period
* endovascular stenting-most common way to repair localized infrarenal aneurysm
* peri-operative for aneurysm, acute MI or CAD related problems are cause of 70% of peri-op mortality
410
sick sinus syndrome
```
do not need electrophysiologic testing
prognosis is good
only 2 indications for tx w pacemaker:
-symptomatic
-tachyarrhythmia needing tx that may precipitate bradycardia
```
411
indications for permanent pacemaker
Mobitz II
| complete heart block
412
atrial flutter
* atrial rate 230-320, 2:1 AV block most common, usually reentry
* usually indicates heart or pulmonary disease
* vagal maneuvers or adenosine slow vent rate and allow better dx
* r/o pulm emboli (often multiple) and thyroid dx
* most effective Tx: electrical DC cardioversion, low energy 10-50J
* always shock if hemodynamically unstable, but dont keep doing shocks if they keep going back in
* antiarrhythmic drugs
* anticoagulate w chronic a flutter,radiofreq ablation cure most
413
anticoagulation in atrial fibrillation, 2 choices:
*anticoag X 3weeks, then cardiovert , then 4 more weeks anticoag
* IV heparin or LMWH, do TEE, cardiovert within 24 hours, then anticoag for 4 more weeks
* *if <48hours since onset of a fib you can cardiovert all patients without any anticoagulation**
414
MAT-multifocal atrial tachycardia
* see mostly in pulm dz and those on theophylline
* can be due to very low K+ and Mg++
if theophylline cant be stopped, put on diltiazem or verapamil to suppress
415
PSVT
* rate 150-230
* narrow compleses
* tx: vagal, adenosine(drug of choice) or verapamil
* radiofreq ablation can cure many of these
416
WPW
* preexcitation syndrome
* PR interval <.12s due to delta waves
* tx: most symptomatic and no dysrhythmias
* WPW w narrow complex tachycardia:vagal, cardioversion, adenosine, procainamide, verapamil -as any SVT
* *never tx acute A fib or flutter in person w WPW with :DIGOXIN,VERAPAMIL OR B BLOCKERS, DO use procainamide if any shock or deterioration, CURE-ABLATION
417
PVC's
*in pt w hx MI and EF<40%, freq PVCs are an indication of high risk of sudden cardiac death
simple PVC's that are asymptomatic-no tx needed if LV function is normal.
* B blockers are first line tx
* complex PVCs -pairs, triplets-do not need tx if asymptomatic and no heart disease
418
DO NOT USE THIS DRUG FOR ANY WIDE COMPLEX TACHYCARDIA IN THE EMERGENCY SETTING!!
verapamil
| 30% would rapidly deteriorate
419
Torsades de points
* form of polymorphic VT
* preceded by prolonged QT interval and sometimes U waves
* common causes:
- quinidine, procainamide, class Ia antiarrhythmics, dofetilide and other class III AADs(sotalol)
- tricyclics are common cause
- very low K+ or Mg++
420
treatment of torsades
* increase the atrial rate with isoproterenol
* overdrive pacing
* Mg++ sulfate-give if pt has contraindications to the above 2 options (acute MI, severe ischemic heart disease)
* shock only as a last resort
* DO NOT give quinidine,procainamide or any class Ia-worsens!!
421
AVOID VERAPAMIL WITH:
* atrial fib or flutter occurring in WPW
* wide complex tachycardias
* B blockers-relative contraindication because both are negative chronotropes and negative inotropes
422
OKAY to use VERAPAMIL
* MAT
* PSVT (2nd choice after adenosine)
* WPW with narrow complex tachycardia
* HTN
* severe concentric LVH
* symptomatic tx in HCM
* to control the ventricular response to A fib or flutter in otherwise healthy heart
423
syncope due to autonomic dysfunction:
*orthostatic hypotension due to autonomic dysfunctioncauses symptoms with no increase in heart rate with standing or during vertical phase of tilt table test
* first tx is support hose and increased salt intake
| * midodrine or fludrocortison can be added
424
Hypertrophic cardiomyopathy (prior called IHSS)
* *assoc w sudden cardiac death-likely due to ventricular arrhythmia
* no cure except cardiac transplant
* sudden death is most frequent in young pt w familial form
* person w this often present c hx of exercise induced syncope or severe dyspnea
* EKG may be normal but often see inferior to lateral Q waves (hypertrophied septum) and LVH
* confirm dx w ECHO, also need holter & radionuclide stress
425
restrictive cardiomyopathy
* this is not reversible
| * causes:amyloidosis, sarcoidosis, hemochromatosis, lipid storage diseases
426
Immediate tx of acute pulmonary edema
* sit with legs dangling-decreases venous return
* 100% O2
* morphine-decrease anxiety and decrease vasoconstriction
* lasix-causes venodilation even before the diuresis
* digoxin if not on it and no contraindication to it
* IV NTG or nitroprusside if SBP>100
* dobutamine if SBP<90
427
Eisenmenger syndrome
*occurs in patients with large intracardiac shunt when the pulmonary vasc resistance becomes greater than systemic vasc resistance so the shunt becomes right to left
* result of severe pulm HTN which can occur early or late in pt w large cardiac left to right shunt of any type.
* cyanosis comon
* only tx is heart-lung transplant
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