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PANRE > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Reasons not to order exercise Stress test

A
  1. Meds (Dig,BB,CCB,Amiodarone) 2. unable to exercise 3. AS 4. Other: LBBB, LVH w/ strain, WPW, Paced
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2
Q

RCA feeds what areas of the heart? Leads?

A

RV, RA, SA node, AV node, inferior wall of LV. Leads: II, III, aVF

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3
Q

LAD feeds what areas of heart? Leads?

A

Septum, Anterior wall of LV Leads: V1-V4

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4
Q

Circumflex artery feeds what areas of heart? Leads?

A

Lateral wall of LV, supply from RCA or LAD or Both. Leads: V5, V6, I, aVL

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5
Q

Differential Dx of Stable Angina

A
  • Pericarditis - GERD - PUD - Esophageal Spasm - Biliary Colic - Costochondritis - Cervical Radiculopathy
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6
Q

DDx of Acute Coronary Syndrome

A
  • PE, Pneumothorax - Myocarditis, Pericarditis - Cardiac Tamponade - GERD, PUD, Gastritis - Esophageal spasm/tear - Pancreatitis - Aortic Aneurysm - Shingles
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7
Q

CPK-MB: onset, peak, return to normal

A

Rise w/in 4-8hrs Peak in 12-24hrs Return to nl 3-4 days

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8
Q

Troponin: onset, peak, return to normal

A

Rise w/in 4hrs Peak in 10-24hrs Return to nl >10 days

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9
Q

Pharmacologic stress tests (Dobutamine stress echo, persantine stress test) are best for?

A

evaluating for ACS in pts with aortic stenosis

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10
Q

First line Rx for ischemic heart disease

A

Betablockers

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11
Q

EKG changes with acute STEMI

A
  • incr 1mm above baseline (limb) - incr 2mm above baseline (chest) - 0.08 sec to right of J point, 2 or more cont leads
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12
Q

T wave inversions =

A

Ischemia

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13
Q

Normal Heart Sounds = mechanical S1 S2

A

S1: Closure of mitral and tricuspid valves S2: Closure of aortic and pulmonic valves

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14
Q

Abnormal heart sounds S3 S4

A

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

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15
Q

Ejection Click

A

Aortic/pulmonic stenosis

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16
Q

Opening snap

A

Mitral stenosis

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17
Q

Mid systolic click

A

mitral valve prolapse

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18
Q

Fixed split S2:

A

Atrial-Septal defect

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19
Q

Wide Split S2

A

RBBB

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20
Q

Paradoxical split S2 (expiration)

A

LBBB

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21
Q

Aortic Stenosis

A

Location: RUSB Murmur: Timing: Systolic (S1-S2) **Radiates to neck/carotid**

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22
Q

HOCM/IHSS

A

Location: Murmur: Timing: Gets LOUDER with valsalva, decr. w/ squat

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23
Q

Aortic Regurg

A

Location: LUSB

Murmur: accentuated when the patient sits up and leans forward

Timing: Diastolic (S2-S1)

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24
Q

Mitral Stenosis

A

Location: Apex Murmur: Low, Timing: Diastolic (S2-S1)

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25
Q

Mitral Regurg

A

Location: Apex Murmur: Timing: Systolic (S1-S2) Incr w/ Hand Grip Radiates to back/axillae

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26
Q

Systolic Murmurs (S1-S2)

A

AS, PS MR, MVP, TR, ASD VSD

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27
Q

Diastolic Murmurs (S2-S1)

A

AR, PR MS, TS

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28
Q

What level of murmur is always pathological?

A

IV of VI (Thrill)

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29
Q

Review of Locations:

A
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30
Q

Murmur Summary

A
31
Q

Pericardial Effusion

A
32
Q

Pericardial effusion PE?

A

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)

33
Q

S/S of Cardiac Tamponade

A
  • 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
34
Q
A
35
Q

Heart Failure Diagnostics

A

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

36
Q

HF Tx

A
  1. 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)

  1. 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
  2. B-Blockers: Use in all stable patients with mild, moderate or severe HF
    - Extended-release carvedilol, metoprolol succnate, bisoprolol (unless non-cardiac CI)
  3. Oral K+ sparing agents (Triamterene, amiloride, spironolactone) : watch hyperK
37
Q

Digoxin Tx for HF

MOA

Side Effects

A

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

38
Q

Heart Failure Classification

A

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

39
Q

Elective repair indicated for aortic aneurysm when?

A

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)

40
Q

Imaging for:

  1. Abdominal Aortic Aneurysms
  2. Thoracic Aortic Aneurysms
A
  1. 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

  1. Thoracic
    - CT scan imaging study of choice; MRI can also be used
    - CXR may show calcified outline of dilated aorta
41
Q

5 Ps of acute limb ischemia

Time to treat?

A

Think sudden onset in affected limb

  1. Pain (early)
  2. Paresthesia (early)
  3. Pulselessness
  4. Pallor
  5. Poikilothermia (cold)
  6. Paralysis

Tx w/in 3 hrs (irreversible damage at 6 hrs)

42
Q
A
43
Q

Occlusive Cerebrovascular Disease

Study of Choice

When intervention required?

A

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

44
Q

Giant Cell (Temporal) Arteritis

  • Sxs, PE, TX
A

>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)

45
Q

Peripheral Arterial Disease

  1. Risk Factors
  2. Sxs:
  3. Tx:
A
  1. Risk factors: male gender, smoking, increasing age, HTN, DM
  2. 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).
  3. 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
46
Q

Virchow’s Triad

what is it and what does it indicate

A

Venous stasis,

vascular injury,

hypercoagulability

Indicates DVT

47
Q

Typical presentation of DVT?

Dx study of choice?

Tx of DVT?

A

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,

48
Q

Venous insufficiency

vs

Arterial insufficiency

A

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
49
Q

Hypertension:

  1. Normal
  2. Prehypertension
  3. Stage 1
  4. Stage 2
A
  1. Normal : >120/80
  2. Prehypertension: 120-139 / 80-89
  3. Stage 1: 140-159 / 90-99
  4. Stage 2: _>_160 / > 100
50
Q

Work up for Hypertension?

A
  1. 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
  2. Labs: CBC, Lytes, Cr, Fasting Blood Sugar, Lipid Panel, UA (also to r/o 2º causes)
  3. CXR, EKG, Echocardiogram
51
Q

First step for tx of HTN?

A

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)
52
Q

HTN Tx Goals:

A

BP Treatment Goals:

  • <140/90
  • <130/80 in DM, CKD
  • <120/80 in CHF
53
Q

Rx for HTN

A

Stage I Hypertension

• Thiazide diuretic unless compelling indication

Stage II Hypertension

• Thiazide + 2nd line agent unless compelling indication

54
Q

Compelling Indications for HTN Tx

A

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
55
Q

HTN Tx Rx contraindications

A

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

56
Q

First and second line agents in tx of HTN

A

First ling agent: thiazide diuretic

Second line agents: ACE1, Beta Blocker, DHP CCB

• ARB: alternative to ACE1 with cough

57
Q

Third line agents for HTN Tx?

A

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)
58
Q

Best Rx in AA w/ HTN?

A

Black American: Incr. severity, prevalence, m/m

  • CCB + Diuretic
  • Less effective = ACE1/BB
59
Q

Treating HTN in pregnancy

Rx to avoid:

DOC?

A

Pregnant: no ACE/ARB!

  • DOC: Methyldopa
  • Alt: BB/Hydralazine
60
Q

MAP Formula

A

MAP ≈ DP + 1/3(SP-DP)

61
Q

Hypertensive Crisis

two types and definition

ETIOL

Tx

A
  1. 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)

  1. 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)

62
Q

Cause of catecholamine induced HTN crisis?

Treatment/DOC?

Rx to avoid?

A

ETIOL: Pheo, Cocaine, MAOI, Amphetamine, rebound

Tx: Fluid + Benzo

DOC: Phentolamine

NO BB

63
Q

Hyperlipidemia chart

A
64
Q

Hyperlipidemia Risk Factors

A
  1. Cigarette Smoking
  2. Hypertension (even if treated)
  3. HDL-C <40 (Subtract 1 for HDL >60)
  4. Family History or CHD (1st degree relative)
  • Male <55
  • Female <65
  1. Age:
  • Male >45
  • Female >55
65
Q
A
66
Q

Elevated Triglycerides

When to treat? Goal?

Tx / Rx?

A

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)
67
Q

HMG CoA Reductase Inhibitors

DOC for?

Lipid effects?

CI in: ?

Major SE: ?

A

*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

68
Q

Niacin

DOC for?

Lipid effects?

CI in: ?

Major SE: ?

A

*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

69
Q

Fibrates

DOC for?

Lipid effects?

CI in: ?

Major SE: ?

A

*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

70
Q

Bile Acid Binders

DOC for?

Lipid effects?

CI in: ?

Major SE: ?

A

*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

71
Q

Cardiogenic Shock

Defined:

PE:

Tx:

Rx to avoid:

A

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).

72
Q

Metabolic Syndrome

Risk Factors (5)

Dx = ?

A

Risk Factors:

  1. Increased waist circumference: >40” in males or >35” in females
  2. Triglycerides >150
  3. Low HDL-C: <40 in males or <50 in females
  4. Increased BP (>130/85)
  5. Fasting Blood Glucose: >100mg/dl

3+ or DM = diagnosis

73
Q

Metabolic Syndrome Tx?

A
  • Increased lifestyle modifications
  • Treat HTN & DM

• *Add aspirin to daily medications

74
Q

Hypertensive Emergency Rx (by Dx)

  • Need to add why?
A

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

PANRE (6 decks)

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