Cardiology 3 Flashcards
stress test of choice for patient with paced ventricular rhyhthm
Pharmacologic radionuclide perfusion imaging
stress test of choice for patient with LBBB
Pharmacologic radionuclide perfusion imaging
Contraindications to pharmacologic stress test
- reactive airway disease
- on dipyridamole or theophylline
First line for restless leg syndrome
- avoid meds that worsen RLS (antidepressants, antidopaminergic agents)
- behavioral interventions (exercise, reduction of caffeine, massage)
management of vertebral compression fracture
- early mobility (ambulate and resume normal activity ASAP)
- PT
treatment duration of VTE
IF provoked – 3 months
IF temporary persistent of a provoking factor (eg prolonged immobility following leg surgery) – extend duration to total 6-12 months
rosacea management
- skin care, sun protection, avoidance of flushing triggers (hot drinks, hot or cold weather, alcohol, spicy foods)
IF mild topical antibiotics (metronidazole)
OR topical azelaic acid
Treatment of more severe rosacea
oral abx (tetracyclines)
Most important predictive factor in determining a cancer patient’s prognosis
performance status
acute pericarditis vs STEMI on EKG
- pericarditis = positional pain
- STEMI = localized ST elevations
ECG changes in acute pericarditis + timing
1) Diffuse, concave ST elevations across + reciprocal ST depression in leads aVR and V1 (within hours)
2) normalization of ST and PR segments (within first few days)
3) diffuse T wave inversions
4) normalization of ECG OR persistent T wave inversion (over next few weeks)
Management of patient with refractory AF with RVR
TEE to rule out left atrial appendage thrombus then cardioversion
What are the high-intensity statins?
- Atorva 40 or higher
- Rosuvastatin 20 mg or higher
Statin intensity based on ASCVD
IF greater than 20% = high intensity statin
IF less than 20% = moderate intensity statin
Intensity of statin therapy in secondary prevention of ASCVD in patients with established ASCVD (ACS, stable angina, stroke or TIA, CABG)
Age less than 75 = high intensity
Age over 75 = moderate intensity
hypomagnesemia presentation
- fatigue, weakness, muscle cramps, tremor, hyprreflexia
Common cause of hypomagnesemia
chronic PPI use
Indications for primary PCI with STEMI
- within 12 hours of symptom onset
- within 90 minutes from first medical contact to device time at PCI facility
Differentiating STEMI from pericarditis on EKG
- pericarditis = diffuse ST elevation + *depression of PR segment in the limb and left precordial leads
Definition of HCM
LV wall thickness greater than 15 mm at any location
Indications for beta blockers and CCBs in HCM
Patients with LVOT obstruction and symptoms of heart failure
management of HCM patient refractory to medical therapy
- surgical septal myectomy or alcohol septal ablation
other cause of an S3
- normal in healthy young adults
Percutaneous mitral balloon valvotomy vs. surgery for symptomatic mitral stenosis
- percutaneous mitral balloon valvotomy is preferred if favorable valvular morphology
Contraindications to percutaneous mitral balloon valvotomy for mitral stenosis
- moderate or severe MR
- LA thrombus
Management of congenital long QT syndrome
1) avoid meds associated with prolonged QT
2) avoid strenuous exercise + electrolyte abnormalities
3) start beta blocker (decrease risk of symptomatic arrhythmia’s and SCD)
IF syncope or VT –> implantable ICD
Definition of prolonged QT in males and females
Male = 450 Female = 470
Other meds that can cause prolonged QT
- TCA’s
- SSRIs
- opioids (methadone, oxycodone)
cor pulmonale is
RV failure due to pulmonary or chest wall disease
Diagnosis and management of patient with tender or pulsatile mass at cath site
- hematoma with potential pseudo aneurysm formation
- stat US
Management of pseudoaneurysm arising from cath
- US-guided compression or US-guided thrombin injection into the cavity
Why is cath needed prior to valve surgery?
- define the coronary anatomy (around 40% of patients with severe AS require concurrent CABG)
description of EKG in hyperkalemia
- wide complex/widened QRS + regular + no P waves + T wave peaking
Only indication for medical therapy in severe AR
- patients who aren’t surgical candidates
Evidenced lifestyle interventions to reduce risk of CV disease
- Mediterranean-style diet
- Dietary approaches to stop hypertension (DASH) diet
- moderate but not excessive EtOH intake
foods you should cut down on with mediterranean diet
- decreased red meat, salt, saturated fats
Management of anti platelets before CABG
- Stop P2Y12 inhibitors 5-7 days before surgery
- continue ASA (reduces rate of early graft occlusion and overall mortality)
DAPT duration after stent placement
At least 6-12 months
*Aspirin continued indefinitely
Management of DAPT after stent if surgery
- Elective surgery: Defer surgery until after minimum DAPT duration
- Urgent surgery: Continue P2Y12 or hold for shortest duration possible
- Continue ASA unless high risk of severe surgical bleeding
Presentation of stent thrombosis
- STEMI within first month after stent placement
Indications for AAA repair
1) Diameter greater than 5.5 cm
2) Increase in diameter of 0.5 cm or greater in *6 month period
3) symptomatic
When cardiac evaluation is required before surgery
- 2 or more (history of ischemic heart disease, history of stroke, DM2 on insulin, preop creatinine greater than AND poor functional capacity (less than 4 METS)
- this is in the absence of a high-risk cardiac condition
Presentation of atrial myxoma
- constitutional symptoms (fatigue, low grade fever, weight loss)
- systemic embolization (TIAs, strokes)
- symptoms of mitral valve disease (dyspnea, orthopnea, cough, p edema)
treatment of atrial myxomas
- surgical resection
VS + Other features of pericardial tamponade
- hypotension + tachycardia
- rapid “x” descent in the neck veins
Initial work up of chronic pericardial effusion
- basic labs
- TSH
- anti-ds-DNA
- complement levels
Signs of tamponade on TTE
Hypotension + RV collapse
Medication associated with higher rates of recurrent pericarditis in pericarditis
- steroids
myopericarditis clinical features
pericarditis + one of following:
- elevated cardiac enzymes
- new depressed LVEF
- Imaging showing myocarditis (cardiac MRI)
Management of HFpEF
- exercise training in cardiac rehab
- diuretics
- BP management for after load reduction
- adequate control of ventricular rate (below 80) (not aggressive)
Meds that haven’t been shown to be beneficial in HFpEF
Beta-blockers
Angiotensin system blockers
Aldosterone antagonists
Management of patient with mild AS who is short of breath at night
- cardiac event monitor for paroxysmal AF (Frequent complication of MS that can cause symptomatic heart failure and pulmonary edema when laying flat at night)
Initial evaluation of AF
- TSH
AF initial presentation
- dyspnea, dyspnea on exertion
- palpitations
- dizziness, presyncope
Management of rheumatic fever (patient presenting with mitral stenosis)
- continuous antibiotic prophylaxis (to prevent recurrent GAS pharyngitis and limit risk of progression of rheumatic heart disease)
- IM penicillin G benzathine every 3-4 weeks (first dose will also treat any current GAS colonization)
rheumatic fever clinical features
- fever, arthritis, chorea, heart failure
management of HFrEf patient on entresto with chronic cough
- stop entresto
benefits of rate vs rhythm control of AF
- rhythm control = higher rate of medication toxicity
Rate vs rhythm control of AF
- rate control generally preferred due to higher risk of SEs with antiarrythmic drugs (particularly risk of proarrhythmias, including tornado), but many prefer rhythm control in younger patients with a lower risk of proarrhythmias
Next step after STEMI patient is treated with TPA in facility without cath lab
Transfer STAT to facility with cath lab (reocclusion is relatively common after initial repercussion)
what are the antianginals?
- beta blockers
- CCBs
- nitrates
- *ranolazine
Advise on second pregnancies in patients with a history of periparum cardiomyopathy and persistent LV dysfunction
Advise to avoid future pregnancy (high risk of further decline in LV function, recurrent heart failure, and death with subsequent pregnancies)
Management of peripartum cardiomyopathy
- standard heart failure management
IF hemodynamic instability –> urgent delivery
Hemodynamics of pericardial tamponade
*equalization of RA and RV end diastolic pressure and pulmonary wedge pressure
ECG abnormalities associated with ASD
- first degree AV block
- right axis deviation
- incomplete or complete RBBB
takotsubo treatment
- supportive (recovery of LV function within a few weeks typically)
Location + description of VSD
- holosystolic
- 3rd or fourth intercostal space along the left sternal border
- often palpable thrill
Hypotension in the acute setting of STEMI indicates
RVMI
Management of RVMI
- NO nitrates (decrease RV preload)
- bolus fluids
echo intervals for AS surveillance
mild – q3-5 years
moderate – q1-2 years
severe – q6-12 month
Absolute contraindications to fibrinolytic for STEMI
- CVA within the last 3 months (ischemic or nonischemic)
- prior history of intracranial hemorrhage (time unlimited)
Management of Mobitz type I and type II
IF symptomatic +2:1 – permanent pacemaker regardless of whether type I or II
*only in absence of reversible cause (medication SE or ischemia)
Type 1 Mobitz – typically requires no intervention
Clinical features of unilateral diaphragmatic paralysis
- supine hypoxemia
- elevated hemidiaphragm
- following cardiac surgery (occurs due to phrenic nerve injury) (or can be caused by viral infection, trauma, or a tumor)
workup of suspected diaphragmatic paralysis
“sniff test” using fluoroscopy (normal diaphragm moves downward during inspiration and the paralyzed side has paradoxical upward movement)
How to best hear for aortic regurgitation
- have patient sit up, lean forward, and hold their breath in full expiration with diaphragm placed along left sternal border at 3rd or 4th intercostal space
aortic regurgitation description
- early decrescendo diastolic murmur
- high-pitched, blowing in quality
Description of mitral stenosis
- loud first heart sound
- opening snap after S2 (best heard at apex)
- low-pitched diastolic rumble at apex
Ebstein’s anomaly clinical features
- tricuspid regurg + RV abnormalities
Tricuspid regurgitation clinical features
- holosystolic murmur along left sternal border + increases in intensity with inspiration
Murmur caused by ASD
- mid-systolic ejection murmur due to increased flow through pulmonic valve
Indication for ICD post - MI
- EF below 30% at least 40 days post-MI and 3 months post revascularization
Other indication for ICD in EF
- EF equal to or less than 35% + NYHA class II or III symptoms
Indications for ICD placement for secondary prevention
- prior VF or unstable VT without reversible cause
- prior sustained VT with underlying cardiomyopathy
Evidence -based benefit of inotropes in low flow and CHF exacerbations
- decrease dyspnea
* actually increase mortality, hypotensive episodes, and arrhythmias
Management of cocaine chest pain
IF acute STEMI – immediate cath lab (cocaine increases thrombogenicity)
- benzos, aspirin, nitroglycerin
- beta-blockers are contraindicated
Management of AF with RVR
- treat underlying cause (even if hemodynamically unstable) – sepsis, hypoxia, CHF, etc
Etiologies of constrictive pericarditis
- viral pericarditis
- cardiac surgery or radiation therapy
- TB pericarditis
constrictive pericarditis clinical features
- fatigue + DOE
- signs of RH failure (peripheral edema, ascites, elevated JVP)
- low voltage QRS or AF on EKG
workup of suspected constrictive pericarditis
TTE
Most common cause of mortality in patients after being cath’d
RP bleeds
RP bleed clinical features
sudden hypotension + drop in Hgb + back pain
AF management in this setting of mitral stenosis
- Warfarin (regardless of CHADS-VASc)
* mitral stenosis carries an especially high risk of thromboembolic events
Use of CHADS-VASc
NONVALVULAR AF
Mitral valve prolapse murmur description
- single or multiple non-ejection clicks
- mid to late systolic murmur of MR
Affect of valsalva on murmurs
Decreases all murmurs except
- HCM (decreased LV volume and increased gradient)
- MVP (decreased LV volume and increased leaflet prolapse)
How does valsalva affect murmurs
decreases venous return
How does standing affect murmurs
decreases venous return
Affect of standing on murmurs
Decreases all murmurs except (same as valsalva)
- HCM (decreased LV volume and increased gradient)
- MVP (decreased LV volume and increased leaflet prolapse)
How does squatting affect murmurs
- increases venous return
- increases after load by kinking of femoral arteries
Effect of squatting on murmurs
- increases – AR, MR, VSD
- decreases – HCM, MVP
How does handgrip affect murmurs
- increases after load, increases BP
Effect of handgrip on murmurs
- increases AR, MR, VSD
- decreases HCM, AS
Limb lead reversal ECG
- AVR and AVL are flipped so T wave positive in AVR
Target INR for mechanical valves
Mechanical aortic = 2.5 for patients (unless additional RF’s)
Mechanical mitral = 3.0
Restrictive cardiomyopathy vs. constrictive pericarditis
- restrictive = abnormal elastic properties of the myocardium (typically due to infiltrative disease)
- constrictive pericarditis = reduced chamber compliance from pericardium
comedonal acne vs inflammatory
inflammatory = red and painful comedonal = isolated comedones
water deprivation test interpretation
shrimp dick
