Cardiology Flashcards
extra atrial contractions (p waves) that can occur at any time and any rate
Premature atrial contraction
Bizarre QRS morphology, T waves in opposite direction, followed by compensatory pause, bad if >3
premature ventricular contraction
most common sustained arrhythmias, leading cause of thrombosis
Atrial fibrillation
2 drugs you can use for chemical cardioversion for a fib
amiodarone, ibutalide
rate lower meds for a fib (3)
BB
CCB
digoxin
how do you treat hemodynamically unstable a fib/ flutter?
cardioversion
Causes of 1st degree heart block
Meds- digoxin, BB< CCB
ischemia/ infarction
lyme dz
calcification
type of heart block where PR interval lengthens then P wave occurs with dropped QRS
Type 1 second degree heart block
type of heart block that have a fixed PR interval with some dropped QRs
Type 2 second degree heart block
causes of torsades de pointes (3)
hypomaganesemia, hypokalemia, diarrhea
Tx for torsades
magnesium, antiarrhythmics, defibrillation
Common meds that cause long QT syndrome
amiodarone, macrolides (EAC), fluoroquinolones
haloperidol, fluoxetine, citalopram, ondansetron
Tx for long QT syndrome
BB, pacmaker, ICD
Class 1 antiarrhythmics (Sodium channels)
lidocaine
procainamide
Class II anitarrhythmics (beta blockers)
Metoprolol, atenolol, etc
Class III antiarrhthmics (K+ channels)
amiodarone, sotalol
Class IV antiarrhythmics (Calcium channel)
verapamil, diltiazem
what drugs does amiodarone interact with? (5)
simvastatin, digoxin, warfarin, sildenafil, fluoroquinolones
ADRs with amiodarone
Hypotension, thyroid issues, pulmonary fibrosis, ocular toxicity
3 meds that can cause secondary HTN
steroids
estrogen
ephedrine
what 2 things is the DASH diet high in?
potassium and calcium
ADR of loop/ thiazide diuretics
decrease potassium
2 ADRs of thiazide diuretics
increase uric acid and lipids
What med conserves potassium but can cause gynecomastia in men
spironolactone
4 ADRs of beta blockers
impotence, fatigue, bradycardia, bronchial constriction (nonselective)
what pregnancy category are ACEIs
category X
Does ACEIs cause hypokalemia or hyperkalemia
hyperkalemia
3 ADRs of alpha blockers
postural HPOTN
improves BPH and urine stream
positive effects on HDL and LDL
2 main causes of HTN in kids?
kidney diseae, coarctatin of the aorta
what is a severely elevated BP (>180/110) with symptoms?
HTN emergency
BP of >180/110 without symptoms
Hypertensive urgency
Tx for HTN urgency or emergency
nitroprusside or labetalol
when do coronary artery lesions need to be procedurally treated?
lesions >70%
A lesion in what coronary artery needs to be treated if >50%
left main
Treatment for stable angina
nitroglycerin (0.4 mg SL)
what drug class prolongs life in stable angina
beta blockers
CP that occurs w/o precipitating factors and can show ST segment elevation
Prinzmetal (variant0 angina (coronary vasospams)
Tx for coronary vasospasm and angina
nitrates, CCB
Good biomarker for early detection of an MI
myoglobin
best biomarker for early detection of an MI
troponin
STEMI complications
arrythmias, CHF, pericarditis, mitral regurg, VSD/ left ventricular aneurysm
ST elevation in leads V1-V2 indicate MI where?
septal wall
ST elevation in V2-V4 indicate a MI where?
anterior wall (LAD)
ST elevation in I,aVL (V5-V6) indicate MI where?
lateral wall (circumfelx artery)
ST elevation in II, III, aVF indicate an MI where?
inferior wall (RCA, PDA)
S1 is the sound of what valves closing?
Mitral and tricuspid
S2 is the sound of what valves closing
Aortic and pulmonic
What does an S3 gallop indicate?
CHF
What does an S4 gallop indicate?
Mitral stenosis
LVH
Acute MI
Where is Erb’s point?
Third left inetercostal space (left sternal border)
is mitral regurg a systolic or diastolic murmur?
systolic
In mitral regur there is ____ cardiac output and _____ volume preload
There is decreased cardiac output and increased volume preload
– “floppy” or myxomatous degeneration of mitral valve
– May develop significant mitral regurgitation
mitral valve prolapse
What will you hear with mitral valve prolapse?
mid-systolic click and possible late systolic murmur
Tx for mitral regurg
beta blockers or surgery
holosystolic murmur that radiates to axill and is frequently accompanied by a thrill
mitral regurgitation
is aortic stenosis a systolic or diastolic murmur
systolic
what causes aortic stenosis?
narrowign of the valvue due to dicuspid AS, senile calcific, rheumatic AS
3 common symptoms of aortic stenosis
syncope *during exercise), angina (hypertrophied left ventricle), dyspnea (from heart failure)
common signs of aortic stenosis (4)
delayed carotid upstroke
systolic ejection murmur
soft, sincle S2 (only hear P2)
S4, sustained and forcefull pmi
description of aortic stenosis
crescendo -decrescendo, possible ejection click. radiates to carotids/ neck. heard best in 2nd ICS RSB
What findings will be present on an EKG w/ aortic setnosis
LVH
Tx for aortic stenosis
diuretics, digoxin. Balloon valvuloplasy (temporary). aortic valve replacement is the gold standard
Aortic valve doesn’t close properly allowing blood
to flow backwards into the left ventricle causing
left ventricular dysfunction and CHF
aortic regurgitation
what are some causes of aortic regurgitation
root dilattion (HTN and age) aortic dissection infective endocarditits Marfan syndrome rheumatic dz
is aortic regurg a systolic or diastolic murmur?
diastolic
symptoms of aortic regurg
left ventricular failure (dyspnea, orthopnea)
syncope
angina
pulmonary edema (if acute)
: high‐pitched decrescendo blowing
murmur heard along the left sternal border heart
• Radiated to apex
aortic regurgitation
: low pitched mid‐diastolic
rumble caused by reverberation of regurgitant flow
against the anterior leaflet of the mitral valve
Austin Flint murmur
What is Quincke’s sign and what is it associated with?
pulsation of the capillary bed in the nail, aortic regurg
What is Corrigan’s pulse and what is it associated with?
Carotid pulse w/ rapid rise and rapid fall, aortic regurg
What is Hill’s signa dn what is it associated with?
higher systolic BP in popliteal compared to brachial, aortic regurg
what will you see on EKG with aortic regurg
LVH
Treatment for aortic regurg
surgery (pain before EF <55%)
medical- diuretics, ACEI, beta blockers
number one cause of mitral stenosis
rheumatic fever
2 main symptoms of mitral stenosis
Hemoptysis and hoarsness (due to enlarged left atrium iminging on left recurrent laryngeal nerve)
Medical tx for mitral stenosis
Diuretics (main one)
digoxin
beta blocks
– Holosystolic murmur with R sided signs
• ↑JVP, hepatomegaly, peripheral edema
• Murmur↑ with inspiraƟon and↓with expiraƟon
tricuspid regurgitation
Scratchy, heard better with patient leaning forward
pericardial friction rub
Harsh, loudest in late systole
PDA
with HOCM (hypertrophic cardiomyopathy) when will the murmur be heard more?
standing (heard less when squatting since there is more blood flow)
When is the mitral regurg murmur heard best
when patient is squatting
What is the Jones criteria used for?
Rheumatic Fever
What are major criteria for the Jones criteria (need 2 of these)
carditits, polyarthritits, syndenham chorea, erythema marginatum, subuaneous nodules)
What the minor criteria for Jones criteria (need 2 if there is only 1 major criteria met)
fever, arthralgias, prolonged PR interval, increased ESR/CRP
Tx for rheumatic fever
Salicylates, corticosteroids, PCN (ro erythromycin)
what condition will present with splinter hemorrhages, painful violaeous raised lesions on hands and fee (Osler’s nodes), painless erythematous lesions (janeway lesions), and retinal hemorrhages (rother’s spots)
infective endocarditits
what criteria is used for endocarditits
Duke
Decrease in contractile function of either
ventricle in the absence of pressure overload,
volume overload or coronary artery disease
resulting in CHF
dilated cardiomyopathy
Tx for dilated cardiomyopathy
DAD (diuretics, ACEI, digoxin)
– Systolic ejection murmur that does not usually
radiate to the neck
• Maneuvers to increase the murmur intensity
–Standing up from a squatting position
• Maneuvers to decrease the murmur
intensity
–Squatting maneuver
Hypertrophic cardiomyopathy
Tx for hypertrohpic cardiomyopathy
Beta blocks
CCB (verapamil)
surgery, alcohol ablation
Myocardium changes and becomes stiffer
causing restriction of left ventricular filling &
reduced stroke output
restrictive cardiomyopathy
Causes of restrictive cardiomyopathy
infiltrative diseases (amyloidosis, hemochromatosis, carcinoid syndrom, sarcoidosis)
Tx for restrictive cardiomyopathy
tx underlyign dz, diuretics and beta blockers may be helpful
LDL goal for moderate risk factors
<130
LDL goal for no risk factors
<160
LDL for lots of risk factors
<100
what to monitor with statins
LFTs and 3 montsh and 6 months then yearly then monitor CPK if myalgias
what does niacin help increase
HDL
contraindications with niacin
pregnancy and liver dz
how can you minimize flushing with niacin?
ASA/NSAIDs and titrate slowly
contraindications with fibrates
pregnancy, liver and renal disease
what do fibrates help lower
triglycerides
ADR of fibrates
cholelithiasis, hepatotoxicity, myositits
C/I with bile acid binding resins
bowel obstruction and high triglycerides
what nerve primarily innervates the heart?
Vagus
Heart valve closure sequence
Mitral, tricuspid, aortic pulmonic (many things are possible)
5 Ps of an acute arterial occlusion
Pain, pallor, paresthesia, pulselessness, poikliothermia (cold)
do coronary veins have valves?
No
what supplies blood to the AV node?
Right coronary artery (posterior descending artery)
ADR with aldosterone antagonists?
hyperkalemia
Drug class that decreases Na and Cl reabsoprtion in the ascending loop of Henle and can cause hypokalemia and hypomagnesemia.
loop diuretics
does digoxin increase survival?
No
occlusion of what artery will result in contralateral hemiplegia with hemisensory loss as well as homonymous hemianopia
middle cerebral
most common type of shock
septic
what type species most often causes septic shock
Gram negative
Labs to get on everyone who is in shock
CBC, blood type cross-match, coagulation parameters, electrolytes, glucose, UA, serum creatinine, LDH, ECG, cardiac biomarkers
What should urine output be?
0.5 ml/kg/hr or greater
What are inotropes?
dobutamine, dopamine, epi
increase CO by increasing HR and contractiligy
What are pressors?
dopamine, phenylephrine - increase vascular tone
Greater than 20 mm Hg drop in systolic BP or a drop greater than 10 mm Hg in diastolic between supine and sitting and /or standing
postural hypotension
most important factor for HTN
genetic predisposition
Exacerbations of HTN
alcohol, tobacco, lack of exercise, polycythemia, use of NSAIDs, low K+ diet
elevated BP associated w/ papilledema and either encephalopathy or nephropathy
malignant HTN
EKG findings with LVH
deep S waves in V1 and V2 and tall R waves in V5 and V6
drug classes shown to reduce mrotality after MI and in patients with heart failure
beta blockers
ACEI
who do beta blockers tend to be more effective in?
Younger white patients
What do beta blockers do?
Decrease heart rate and cardiac output
drug class that can help with HTN in black and elderly patients
calcium channel blockers
drug class that can be used with BPH and HTN
alpha blocker
what is a renin inhibitor that can be used for HTN
aliskiren
Why must you not decrease the BP too rapidly in a HTN urgency/ emergency
can lead to cerebral ischemia
Drugs to give for an aortic dissection
nitroprusside, Beta blocker (labetalol, esmolol)
preferred HTN agent during pregnancy
nitroprusside
Oral agents for less severe HTN emergencies
clonidine
captopril
nifedipine
___ sided heart failure cuases: dyspnea + cough, fatigue, paroxysmal nocturnal dyspnea, gallops, exercise intolerance
left
____ sided heart failure causes: distended neck veins, heaptic congestion, decreased appetite, dependent pitting edema
right
In what type of heart failure may an S4 gallop be heard?
diastolic heart failure
most useful imaging study for CHF
echocardiography
what lab is typically elevated with CHF?
BNP
initial therapy for CHF
early inititaion o ACEI, beta blocker (improve ejection fraction)
When the ejection fraction falls below 35 what is indicated?
IMplantable cardioverter-defibrillators (ICDs)
what may a fundoscopic retinal exam show for a HTN patient?
AV nicking or “copper wire” apperance of vessels
2 medication classes that increase BP
NSAIDs and OCPs
who are thiazide diuretic C/I in?
gout, DM, nephrolithiasis (especially calcium based)
with HTN emergency what may eye exam show?
papilledema, retinal hemorrhages, exudates
tx for atherosclerosis
smoking cessation, control of HTN, DM, dyslipidemia , weight loss
what most commonly causes ischemic heart disease?
insufficient oxygen supply to cardiac muscle from atherosclerotic narrowing
criteria for metabolic syndrome
Three or more of: Abdominal obesity triglycerides >150 HDL 110 HTN
what is the most common presentation of unstable angina?
rest angina
when is unstable angina suspected?
pain is less responsive to NTG, lasts longer, occurs at rest or with less exertion than previous angina
what is considered to be a positive stress test
ST segment depression of 1 mm
what test is the definitive diagnosis of ischemic heart disease
coronary angiography
ADRs of nitrates
HA, anusea, light-headedness, HYPOTN
first line therapy for chronic angina, this drug class prolongs life
beta blockers
when are CCB used w/ unstable angina?
beta blockers are C/I or have been maximized
what is included in acute coronary syndrome?
UA, NSTEMI, STEMI
what do patients with an MI die of?
V-fib
who are more likely to present atypically with a MI?
women, patients with DM, elderly
Syndrome that develops 1-2 weeks post MI that includes pericarditits, fever, leukocytosis, pericardial or pleural effusion
Dressler syndrome
Patients with ST segment depression are usually considered to have what?
UA or NSTEMI
What does a patient with transiet ST segment changes of >0.5 mm that develop during symptomatic episode and resolve suggest?
acute ischemia and CAD
A new left bundle branch block on ECG is highly suspicious for what?
new MI
STEMI tx
Aspiring + clopidogrel
coronary angiography + PCI w/i 90 minutes
thrombolytic therapy w/i first 3 hours
what is the most common congenital structural malformation?
congenital heart anomalies
4 things in tetraology of fallot
VSD, aorta over VSD, pulmonary stenosis, right ventricular hypertrophy
most common type of ASD
ostium secundum
what condition is AV septal defect common in?
downs syndrome
most common valvular disease in the US
aortic stenosis
common features of valvular heart disease
dyspnea, fatigue, decreased exercise tolerance
how are carotid pulses with aortic stenosis?
thready
how are carotid pulses with aortic insufficiency
bounded pulses, widdened pulse pressure
congenital heart defect- murmur is srescendo-decrescendo holosystolic at LSB that radiates to back. Infant has cyanosis, clubbing, loud S2
tetralogy of fallot
congenital heart condition- systolic ejection murmur at 2nd LICS. wide, fixed S2
ASD
continuous (machinery) murmur , wide pulse pressure, hyperdynamic apical pulse
PDA
systolic, LUSB and left interscapular area, may be continuous. Infants can present with CHF, older children w/ systolic HTN Or murmur. different BPs in upper and lower extremitites
coarctation of the aorta
Murmur heard in 2nd RICS, radiates to neck and LSB. Often loud with a thrill.
aortic stenosis
murmur heard in 2-4 LICS, radiates to apex and RSB. high pitch, blowing
aortic regurgitation
Murmur heard at apex, low pitch. Heard best with patient in left lateral position, full exhalation. Midiastolic
mitral stenosis
murmur heard at apex. radiates to left axilla. pansystolic.
mitral regurgitation
murmur heard at LLSB, holosystolic. radiates to right sternum and xiploid. medium blowing. increases w/ inspiration
tricuspid regurg
murmur heard at LICS, mid-systolic. crescendo-decrescendo. Radiates to left shoulder and neck.
pulmonary stenosis
what will happen to INR if someone on warfarin is given amiodarone
INR increases
does blood from the pericardial sac clot or not clot when put in a tray?
not clot
tx for thrombophlebitits
LMWH for 1 month
how does restrictive cardiomyopathy occur?
deposition into or near myocardial cells
non-cardiac hypoxia (pneumoia, COPD) commonly causes what arrhythmia?
a-fib
what 2 murmurs are associated with a-fib
mitral stenosis, mitral regurgitation
what drug can produce blue vision?
sildenafil
best medication for BP support in cardiogenic shock
dobutamine
vitamin deficiency that causes igh output cardiac failure
thiamine (beri beri)
roth spots (retinal hemorrhages) in a drug user are most likely caused by what organism?
staph aureus
Tx for mitral valve prolapse
reassurance and beta blockers
austin flint murmur (low pitched rumbling murmur heart best at apex) is associated with which murmur
aortic regurgitation
pathognomonic finding for rheumatic fever
aschoff bodies (subcutaneous nodules)
Major Jones criteria (rheumatic fever) 5
Carditits migratory polyarthritits subq nodules erythema marginatum chorea
what cardiac abnormality is associated with bicuspid aortic valvue
coarctation of the aorta
an ABI less that what indiates PAD?
ABI
HTN agent associated with edema in lower extremitites
CCB
size an aortic aneurysm can get before surgery si needed
5.5 cm
becks traid (pericardial tamponade)
distant heart sounds, JVD and hypotension
what cardiac enzyme peaks first?
CKMB
stroke + fever=
endocarditits
preferred medication for endocarditits prophylaxis
ampicillin
what BP med causes blood levels of lithium to increase?
HCTZ
AV narrowing and venous nicking are associated with what condition
HTN
cotton wool patches and neovascularization is associated with what condition
DM
most common EKG changes with hypothyroidism
low voltage and sinus bradycardia
MOA of thrombolytic medication
activates plasminogen to plasmin. the plasmin disolves the fibrin in a thrombus
tx for viral pericarditits
NSAIDS
what is the initial symptom of diastolic heart failure?
dyspnea
diastolic heart failure is associated with what?
is a stiff, non-compliant left ventricle
a diastolic rumbling murmur heard best at the left lower sternal margin and the xiphoid. augmented during inspiration
tricuspid setnosis
a low pitched, blowing decrescendo diastolic murmur, heard best at the left intercostal space along the left sternal border
aortic regurgitation
what produces permanent fibrosis in small veins and relieves all symptoms of vericose veins
compression sclerotherapy
2 antibiotic classes to be avoided in individuals with long QT syndrome
macrolides and fluoroquinolones
drug with alpha and beta blocking action that is good to rapidly lower BP
labetalol
symptoms of aotic stenosis
Syncope, angina, dyspnea
loud crescendo-decrescendo systolic murmur, radiates to carotids.
aortic stenosis
low pithced mid siastolic murmur w/ opening snap.
mitral stenosis
loud holosystolic murmur radiating to the axilla
mitral regurgitation
Fixed split 2nd heart sound, may ahve RBBB
ASD
cause of bacterial endocarditits in non-drug useds
strep viridans
criteria for endocarditits
Duke’s
tx for endocarditits from strep viridans
PCN G or ceftriaxone
Tx for bacterial endocarditits from staph aureus
nafcillin/ oxacillin (vanco if MRSA)
4 main causes of restrictive cardiomyopathy
amyloidosis, hemochromatosis, sarcoidosis, carcinoid
systolic ejection murmurs that decreases with squatting and increases with standing or dehydration
hypertrophic cardiomyopathy
Bp med that can cause cyanide toxicity and high anion gap acidosis
nitroprusside
Tx for WPW
procainamide
Tx for Vtach (w/ and w/o pulses)
with pulses- synchronized cardioversion. Without pulses- unsynchonized cardioversion
who are diuretics more potent in?
african americans, the elderly, and obese patients
how does atherosclerosis develop?
fatty streak (accumulation of lipis and macrophages) –> subendothelial space and take up lipid (foam cells) –> fibrous cap
