Cardiology Flashcards
Reasons not to order exercise Stress test
- Meds (Dig,BB,CCB,Amiodarone) 2. unable to exercise 3. AS 4. Other: LBBB, LVH w/ strain, WPW, Paced
RCA feeds what areas of the heart? Leads?
RV, RA, SA node, AV node, inferior wall of LV. Leads: II, III, aVF
LAD feeds what areas of heart? Leads?
Septum, Anterior wall of LV Leads: V1-V4
Circumflex artery feeds what areas of heart? Leads?
Lateral wall of LV, supply from RCA or LAD or Both. Leads: V5, V6, I, aVL
Differential Dx of Stable Angina
- Pericarditis - GERD - PUD - Esophageal Spasm - Biliary Colic - Costochondritis - Cervical Radiculopathy
DDx of Acute Coronary Syndrome
- PE, Pneumothorax - Myocarditis, Pericarditis - Cardiac Tamponade - GERD, PUD, Gastritis - Esophageal spasm/tear - Pancreatitis - Aortic Aneurysm - Shingles
CPK-MB: onset, peak, return to normal
Rise w/in 4-8hrs Peak in 12-24hrs Return to nl 3-4 days
Troponin: onset, peak, return to normal
Rise w/in 4hrs Peak in 10-24hrs Return to nl >10 days
Pharmacologic stress tests (Dobutamine stress echo, persantine stress test) are best for?
evaluating for ACS in pts with aortic stenosis
First line Rx for ischemic heart disease
Betablockers
EKG changes with acute STEMI
- incr 1mm above baseline (limb) - incr 2mm above baseline (chest) - 0.08 sec to right of J point, 2 or more cont leads
T wave inversions =
Ischemia
Normal Heart Sounds = mechanical S1 S2
S1: Closure of mitral and tricuspid valves S2: Closure of aortic and pulmonic valves
Abnormal heart sounds S3 S4
S3: Volume overload (CHF)- can be normal in young, healthy S4: pressure overload (HTN,LVH/Ischemia)- **Never Normal** both heard best w/ bell in left lateral decubitus @ apex
Ejection Click
Aortic/pulmonic stenosis
Opening snap
Mitral stenosis
Mid systolic click
mitral valve prolapse
Fixed split S2:
Atrial-Septal defect
Wide Split S2
RBBB
Paradoxical split S2 (expiration)
LBBB
Aortic Stenosis
Location: RUSB Murmur: Timing: Systolic (S1-S2) **Radiates to neck/carotid**
HOCM/IHSS
Location: Murmur: Timing: Gets LOUDER with valsalva, decr. w/ squat
Aortic Regurg
Location: LUSB
Murmur: accentuated when the patient sits up and leans forward
Timing: Diastolic (S2-S1)
Mitral Stenosis
Location: Apex Murmur: Low, Timing: Diastolic (S2-S1)
Mitral Regurg
Location: Apex Murmur: Timing: Systolic (S1-S2) Incr w/ Hand Grip Radiates to back/axillae
Systolic Murmurs (S1-S2)
AS, PS MR, MVP, TR, ASD VSD
Diastolic Murmurs (S2-S1)
AR, PR MS, TS
What level of murmur is always pathological?
IV of VI (Thrill)
Review of Locations:
Murmur Summary
Pericardial Effusion
Pericardial effusion PE?
Pericardial rub
Ewart’s sign
ECG: low voltage & flat T waves
CXR: water bottle heart (>250cc)
Test of choice: echo (effusion & degree of collapse)
Pericardiocentesis (diagnostic & therapeutic)
S/S of Cardiac Tamponade
- Beck’s Triad: hypotension, JVD, muffled heart tones
- Tachycardia
- Dyspnea
- Shock
- Pulsus pardoxus
- Right heart failure
- ECG: low voltage, electrical alternans
- Echo: pericardial effusion, compression of cardiac chambers
Heart Failure Diagnostics
CXR = cephalization, pulmonary congestion
BNP = B-type Natriuretic Peptide < 100 makes heart failure unlikely when combined w/ nl EKG
NT-proBNP = N Terminal pro BNP < 300 makes heart failure unlikely when combined w/ nl EKG
• CPK, CK-MB and Troponin I
HF Tx
- Diuretic Rx: Most effective for symptomatic relief: moderate to severe HF (K+ depletion)
– Mild fluid retention = thiazide diuretic (HCTZ, chlorthalidone, metolazone)
– Severe HF = oral loop diuretic (Furosemide, bumetanide, torsemide)
- ACEI: First-line in patients with EF < 40% and in patients with reduced EF yet are asymptomatic
- ARB are alternate (i.e. cough) but CI in pregnancy - B-Blockers: Use in all stable patients with mild, moderate or severe HF
- Extended-release carvedilol, metoprolol succnate, bisoprolol (unless non-cardiac CI) - Oral K+ sparing agents (Triamterene, amiloride, spironolactone) : watch hyperK
Digoxin Tx for HF
MOA
Side Effects
MOA: Controls symptoms of decreased contractility
- Inotropic effects = affects contractility
- Controls rate in Afib
- Useful with CHF symptoms despite diuretic and ACEI therapy
Side effects
– Digitalis toxicity = yellow-blue tinged vision, diplopia, N/V, confusion, fatigue, sinus bradycardia
– Arrhythmia = AV block
Heart Failure Classification
Stage A: At Risk, no structural Dz, no Sxs, + Risk Factors
- Tx: Control HTN, Lower Cholest, lifestyle mod (quit ETOH/Tob, exercise)
Stage B: Early HF: + structural Dz, no Sxs
- Tx: All Stage A, ACEI(low EF); B-Blocker (low EF), ICD/Revasc/valve surg)
Stage C: HF: structural Dz + Sxs: EF <40%
- Tx: All; salt restriction, tx sleep d/o, add Dig surg as needed
Stage D: End Stage HF: marked Dz, hospitalizatoin
Elective repair indicated for aortic aneurysm when?
Elective repair indicated when aortic aneurysm:
Abdominal: ≥ 5 cm diameter (rarely rupture if <5cm) or has undergone rapid expansion (>0.5 cm in 6 months)
Thoracic: 5-6cm (higher risk of morbidity/mortality from ascending repair)
Imaging for:
- Abdominal Aortic Aneurysms
- Thoracic Aortic Aneurysms
- Abdominal
- Abdominal US = diagnostic study of choice for initial screening, with routine f/u
Frequency depends on size: Q2 yrs if < 4 cm, Q6 mo if near/at 5 cm
– Contrast enhanced CT scan or CTA = 5 cm: more accurate, visualizing structure necessary for surgical repair
- Thoracic
- CT scan imaging study of choice; MRI can also be used
- CXR may show calcified outline of dilated aorta
5 Ps of acute limb ischemia
Time to treat?
Think sudden onset in affected limb
- Pain (early)
- Paresthesia (early)
- Pulselessness
- Pallor
- Poikilothermia (cold)
- Paralysis
Tx w/in 3 hrs (irreversible damage at 6 hrs)
Occlusive Cerebrovascular Disease
Study of Choice
When intervention required?
Duplex US is imaging/screening modality of choice
- CTA or MRA demonstrates full anatomy of cerebrovascular circulation
- Intervention required:
– >50% stenosis in a symptomatic patient
– 80% stenosis in an asymptomatic patient
– 30-50% stenosis requires ongoing surveillance and aggressive risk factor reduction
Giant Cell (Temporal) Arteritis
- Sxs, PE, TX
>50yo, Med-Lrg vessels (MC temporal artery), 50% have polymyalgia rheumatica, 25% w/ lrg vessel involvement (TAA).
- Sxs: HA, scalp tenderness, diplopia, jaw claudication, throat pain, nl PE (temporal artery may be nodular, tender, pulseless). anterior ischemic optic neuropathy can lead to blindess
- ESR >50; CRP nl; anemia (normochromic normocytic); elevated alk phos
Dx: gold standard is prompt temporal artery Bx.
Tx: Prednisone 60mg PO QD x 1 mo then taper, screen for TAA (17X more likely)
Peripheral Arterial Disease
- Risk Factors
- Sxs:
- Tx:
- Risk factors: male gender, smoking, increasing age, HTN, DM
- Claudication = most common complaint. Weak distal LE pulses; Atrophic changes, foot pain relieved by dependancy, dependant rubor w/ blanching on elevation; ABI <0.9 (<-0.5 = severe reduction in flow).
- Tx: Aggressive risk factor reduction, Smoking cessation, lipid reduction, Diabetic foot care, Weight loss, Consistent & moderate exercise, Phosphodiesterase inhibitors (Cilostazol 100mg PO BID), Antiplatelet agents, Endovascular or surgical intervention
Virchow’s Triad
what is it and what does it indicate
Venous stasis,
vascular injury,
hypercoagulability
Indicates DVT
Typical presentation of DVT?
Dx study of choice?
Tx of DVT?
Typical presentation = unilateral leg pain and swelling
– Tenderness of calf muscle compression
– Pain on dorsiflexion of the foot (Homans’ sign = only 50% reliable)
– Increased calf circumference by >3 cm (Measured 10 cm below tibial tuberosity)
Duplex US of limb to Dx and spiral chest CT to r/o PE
Tx: Anticoagulation x 3 mo (min): Lovenox (LMWH) w/ bridge to Warfarin (maintain INR of 2.0-3.0), check Q6wks,
Venous insufficiency
vs
Arterial insufficiency
Venous: Progressive pitting edema of the lower leg (primary presenting symptom)
- Stasis pigmentation = brown hemosiderin skin hyperpigmentation
- Stasis dermatitis = tough, fibrous subcutaneous tissue
- Induration; Varicosities
- Stasis ulceration = painless, large, wet, irregular, slow to heal
Arterial: Claudication; Cool, thin, hairless skin; Muscle atrophy, Atrophic nails
- Ulcerations = Painful, Shallow, Round, Dry
- Gangrene
Hypertension:
- Normal
- Prehypertension
- Stage 1
- Stage 2
- Normal : >120/80
- Prehypertension: 120-139 / 80-89
- Stage 1: 140-159 / 90-99
- Stage 2: _>_160 / > 100
Work up for Hypertension?
- PE: - S4 heart sound
- r/o Secondary HTN
- check for end organ damage:
- Eyes: (AV nicking, cotton wool spots, hard exudates, flame shaped hemorrhages)
- Kidney Fxn - Labs: CBC, Lytes, Cr, Fasting Blood Sugar, Lipid Panel, UA (also to r/o 2º causes)
- CXR, EKG, Echocardiogram
First step for tx of HTN?
Lifestyle modification (LSM)
- Weight reduction (5-20 mmHg/10kg)
- DASH Eating plan (8-14 mmHg)
- Dietary Sodium Reduction (2-8 mmHg)
- Aerobic Physical Activity (4-9 mmHg)
- Moderate ETOH consumption (2-4 mmHg)
HTN Tx Goals:
BP Treatment Goals:
- <140/90
- <130/80 in DM, CKD
- <120/80 in CHF
Rx for HTN
Stage I Hypertension
• Thiazide diuretic unless compelling indication
Stage II Hypertension
• Thiazide + 2nd line agent unless compelling indication
Compelling Indications for HTN Tx
Compelling indications
- Ischemic Heart Disease: Angina: BB and/or CCB; Post MI: BB + ACE1
- Congestive Heart Failure:
- Asymptomatic (Class I or II): BB + ACE1
- Symptomatic (Class III or IV): BB + ACE1 + K sparing diurectic
• Diabetes or CKD: Blood pressure goal <130/80
- Without proteinuria: thiazide/ACE1
- With proteinuria: ACE1 or ARB
- May tolerate up to 30% increase in cr
- Discontinue to >30%, Class V, Hyperk ⇒ add loop
- Cerebrovascular Disease: Primary Prevention: ACE1 or Secondary: ACE1 + Thia
- Benign prostatic hypertrophy: Alpha Antagonist
HTN Tx Rx contraindications
Contraindications & unfavorable effects
*ACE inhibitors: Angioedema, cough, pregnancy, hyperkalemia
ARB: Pregnancy, hyperkalemia, angioedema
*Beta Blockers: Asthma, reactive airway disease, COPD, bradycardia, heart blocks
Calcium channel blockers: heart blocks
Methyldopa: liver disease
Diuretics: gout
First and second line agents in tx of HTN
First ling agent: thiazide diuretic
Second line agents: ACE1, Beta Blocker, DHP CCB
• ARB: alternative to ACE1 with cough
Third line agents for HTN Tx?
Third line agents:
- Alpha blockers (esp with BPH)
- Methyldopa (esp in pregnancy)
- Clonidine (last line or for hypertensive urgency)
- Vasodilators
- Hydralazine (pregnancy, as add on)
- Minoxidil (last line)
- Aliskiren (potentially with CKD & Proteinuria)
Best Rx in AA w/ HTN?
Black American: Incr. severity, prevalence, m/m
- CCB + Diuretic
- Less effective = ACE1/BB
Treating HTN in pregnancy
Rx to avoid:
DOC?
Pregnant: no ACE/ARB!
- DOC: Methyldopa
- Alt: BB/Hydralazine
MAP Formula
MAP ≈ DP + 1/3(SP-DP)
Hypertensive Crisis
two types and definition
ETIOL
Tx
- Urgency: no end organ damage
- DBP >115
- Mostly due to non-compliance
Tx: Lower BP in 24-48 hours. *DOC: resume current therapy (Alt: Clonidine + 1rst line agent)
- Emergency: Acute end organ damage! (CNS, CVS, Renal, Eyes)
- DBP >130
- Acute exacerbation of chronic, ETOH/Drug withdrawl or drugs/meds
Tx: Decrease MAP by 25% over 1-3 hours. *ICU, IV Meds (sodium nitroprusside/labetalol)
Cause of catecholamine induced HTN crisis?
Treatment/DOC?
Rx to avoid?
ETIOL: Pheo, Cocaine, MAOI, Amphetamine, rebound
Tx: Fluid + Benzo
DOC: Phentolamine
NO BB
Hyperlipidemia chart
Hyperlipidemia Risk Factors
- Cigarette Smoking
- Hypertension (even if treated)
- HDL-C <40 (Subtract 1 for HDL >60)
- Family History or CHD (1st degree relative)
- Male <55
- Female <65
- Age:
- Male >45
- Female >55
Elevated Triglycerides
When to treat? Goal?
Tx / Rx?
Treat LDL first!
Treat non-HDL after LDL is at goal. Goal is 30 above LDL goal.
If initial trigs >500!
- Treat trigs before LDL
- Aggressive LSM
- Fibrate (or niacin)
HMG CoA Reductase Inhibitors
DOC for?
Lipid effects?
CI in: ?
Major SE: ?
*DOC in most cases of HLP
effects: LDL decr 20-55%; HDL incr 5-15%; TG decr 7-30%
CI: pregnancy or breastfeeding, active liver disease, elevated LFTs,
Triglycerides over 400
SE: myalgia, myopathy, hepatotoxicity
Niacin
DOC for?
Lipid effects?
CI in: ?
Major SE: ?
*Most effective for low HDL
Lipid effects: LDL: ↓ 10-25%; HDL: ↑ 15-35%; TG: ↓ 20-50%
CI: pregnancy or breastfeeding, active liver disease,active peptic ulcer
Caution: gout/hyperuricemia, DM, statin use
SE: Flushing, gout, hyperglycemia
Fibrates
DOC for?
Lipid effects?
CI in: ?
Major SE: ?
*DOC for trigs >400 on presentation!
Lipid effects: LDL: ↓ 5-20%; HDL: ↑ 10-20%; TG: ↓ 20-50%
CI: active liver disease, gallbladder disease,ezetimibe use
Caution: pregnancy, renal impairment, statin use,
SE: Dyspepsia, cholelithiasis, elevated LFT
Bile Acid Binders
DOC for?
Lipid effects?
CI in: ?
Major SE: ?
*Mostly for patients who have failed other medications
*Peds & Pregnancy!
Lipid effects: LDL: ↓ 15-30%; HDL: ↑ 3-5%; TG: ~ little effect (may increase TG)
CI: GI Obstruction, hypertriglyceridemia, pancreatitis
Caution: pregnancy, renal impairment, statin use
SE: GI obstruction, pancreatitis, rash
Cardiogenic Shock
Defined:
PE:
Tx:
Rx to avoid:
Global hypo-perfusion (*sustained SBP<90)
PE: similar to any other shock:
esp *s/s of Heart Failure with systemic signs of shock
Labs: cardiac markers, lactate, BNP; EKG: MI; CXR: s/s of HF; Echo: global hypokinesis
Tx: make Dx, assess for *revascularization, maintain RV pre-load (esp in RV infarct): fluid bolus. Pressor support: Dopamine/epi for hypotensive pts, Dobutamine, Noreip,
Intra-aortic baloon pump, LVAD
Great care with nitrates, morphine, vasodilators (decreases pre-load).
Metabolic Syndrome
Risk Factors (5)
Dx = ?
Risk Factors:
- Increased waist circumference: >40” in males or >35” in females
- Triglycerides >150
- Low HDL-C: <40 in males or <50 in females
- Increased BP (>130/85)
- Fasting Blood Glucose: >100mg/dl
3+ or DM = diagnosis
Metabolic Syndrome Tx?
- Increased lifestyle modifications
- Treat HTN & DM
• *Add aspirin to daily medications
Hypertensive Emergency Rx (by Dx)
- Need to add why?
Hypertensive Emergency
Hypertensive encephalopathy: Nicardipine, labetalol, esmolol, or enalaprilat
Stroke (if systolic >220): Nicardipine, labetalol
Subarachnoid hemorrhage: Nicardipine, labetalol, or esmolol
Myocardial ischemia: Nitroglycerin, labetalol, or esmolol
CHF: Nitroprusside, nitroglycerin, enalaprilat or nicardipine
Aortic dissection: Nitroprusside and β-blocker
Renal failure: Nitroprusside, labetalol, or nicardipine.
Pheochromocytoma: Phentolamine; or labetalol; or nitroprusside
Eclampsia/preeclampsia: Hydralazine, labetalol, or oral nifedipine
