cardiology Flashcards
Acronym for etiology of dilated cardiomyopathy
ABCD-PIG
5 components tetralogy of fallot
- pulmonary valve stenosis
- VSD
- over riding aorta
- right ventricle hypertrophy
- right sided aortic arch
crescendo-decrescendo, with a loud S2, cyanosis
tetralogy fallot
when does tetralogy of fallot become a problem
when the PDA closes, 2-10 days
tx for neonate coarctation short term/long term
prostaglandins, in tropes, give as little o2 as possible. will need surgery
restriction for coarctation
exercise and watch for bacterial endocarditis
murmur for ASD
fixed split S2, rumble
most common ASD
ostium secundum
tx for ASD
most close on own, others will have to be closed surgically
VSD murmur
holosystolic or pansystolic
heart sound for CHF
parasternal lift, enlarged, diminished first heart sound, S2 gallop
Tx of CHF
- ACE !!!!! (will decrease after load and help renal perfusion) make it easier for weak heart to pump b/c resistance is decreased.
- ARB
- BB (decrease catecholamine levels, that predispose to arrythmias)
- Diuretics
best dx test for CHF
ECHO
patient with CHF and EJ is less than 35= tx?
Pacer
acute pulmonary edema /decompensated CHF
- decreased L ventricle contractility 2. increase preload, 3. increase after load (resistance)
USE CPAP or BIPAP!!!!
Acute exacerbation of CHF acronym
LMNOP (lasix, morphine, nitro, oxygen and position (elevate head of bed)
cushing syndrome features
buffalo hump, hyper pigmentation of striated and hypertension!!
tx for patient with HTN and chronic kidney dz
ACE (renal protective) until GFR goes bad & creatinine is 2=stop HTN.
Tx for HTN emergency
Reduce MAP by 25% in the first couple of hours, then gradually reduce over 24 hours using IV labetolol, Nipride, and Nicardipine, enalaprilat
only exception of HTN emergency 24 hour rule?
aortic dissection
tx for atherosclerosis
stop smoking, control HTN, DM and dyslipidemia, reduce weight, exercise and diet
what is metabolic syndrome
- abdominal obesity
- triglycerides >150
- HDL 110
- HTN
length and tx of stable angina
3 minutes and relieved with nitro
EKG finding of stable angina
ST depression and nonspecific t wave changes
definitive dx procedure for ischemic heart dz
coronary angiography
What two medications should all stable angina patients be on?
Aspirin and BB (ACE or CCB) can also be used for blacks, DM and renal patients
What is dressers syndrome
post MI, pericarditis, fever, leukocytosis, and pleural effusion. usually occurs 1-2 weeks after the event
define STEMI
ST elevation >1mm in two contiguous leads
Posterior leads
V1, V2
AnteroLateral leads
V4, V5, V6
time frame for coronary angiography PCI
90 mins
time frame for thrombolytics
3 hours (some benefit up to 12)
absolute contraindication for thrombolytics
stroke in last 3 mont, hemorrhagic stroke ever, acute bleeding, brain cancer, trauma, suspected aortic dissection, major surgery in the last 3 weeks, prolonged CPR, DM retinopathy, prey, and active PUD
relative risk of thromolytics
Bp>180 and anticoagulants
causes of aortic aneurysm
atherosclerosis is the most common, syphilis, giant cell arteritis, trauma and marfans
dx study for abdominal aortic aneurysm
US
dx study for thoracic aortic aneurysm
CT or MRI
Leriche syndrome
erectile dysfunction (with clogged iliac arteries
gold standard to dx peripheral vascular dz
angiography, other tests doppler US, ABI
the six Ps may be part of the arterial problem, what are they?
Pallor, pain, pulselessness, parenthesis, poikilothermia and paralysis
tx of PAD
stop tobacco, control DM, HTN and hyperlipidemia, med=
BB, ACE, antiplatelets
tx for temporal art
1-2 month high prednisone steroids, taper and switch to aspirin
DVT is associated with
surgery, prolonged bed rest, oral contraceptives and inherited clotting disorder, most commonly =factor V Leiden
virchows triad
hypercoagbility, stasis, damage to the vein
what is S4
stiff as a board. Rushing blood against a hypertrophic, thick ventricle wall
are diastolic or systolic murmurs worse
diastolic are pathological murmurs
occurring during ventricle filling
diastolic murmurs
name the diastolic murmurs
mitral and triscupid stenosis and aortic/pulmonic regurg
what is S3
sack of beans, blood entering a dilated ventricle
Mitral stenosis
rumble, mid-diastolic holo
rheumatic fever should be linked to what murmur
mitral stenosis
widen pulse pressure, b/c blood is going back into the heart, early diasystolic decrescendo murmur
is aortic regurg.
most common valvular dz in the US?
Aortic stenosis
tx mitral stenosis
do not give fluids, do not give diuretics. GIVE med to help after load CCB, ACEI (prevent remodeling)
Ask the question why is valve stenosis?
Tx: Left sided endocarditis
give antibiotics
most frequency cause of mitral and aortic valve disorders
congential, rheumatic, connective tissue disorders, and infection
tx for aortic regurg?
surgery
murmur is described as “blowing”
regurgitation murmur
murmur is described as blowing and arterial pulses large and bounding
aortic regurg
unstable bradycardia–leading to hypotension tx with?
atropine and positive chronotropic: epi or dopamine
unstable tachy
Synchronized cardiovert and adenosine
SVT (first try)
- vagal
- adenosine
- synchronized cardiovert
a fib treatment
convert for instable pt.
stable pt if in a fib for more than 48 hour anticoagulant for 3-4 weeks. hour if risk of clot
medical management of rate control with afib
digoxin and amiodarone
chemical conversion of both aflutter and a fib use
ibutilide
treat for flutter
similar to fib, electro conversion or medical conversion
tx for V tach with hypotension or loss of consciousness
syn cardiovert, medical intervention includes amiodarone, lidocaine and procainamide
name the AV blocks
first (prolonged PR), second degree (mobitz one (prolonged until dropped) and two and complete 3rd degree block
explain 2 degree heart block type 2
rhythm is regular, but extra p’s are present not conducting QRS. The p interval is fixed.
osler nodes, janeway lesions, roth spots and splinter hemorrhage are associated with
Endocarditis
Dx endocarditis
2 sets of blood cultures 1 hour apart, and echo
top three bugs for endocarditis
strep viridan, staph aureus and enterococci
tx for endocarditis
gentamicin, vanco, rocephin
age range for mechanical vs. bioprostheses valve
younger than 65 get mechanical
do mechanical or bioprostheses valves need anticoagulants
mechanical The INR is 2.5-3.5 (they last longer too)
do patient’s with sustain v-tach have a better or worse survival rate after a CABG?
better, due to revascularization
type of fibrolytic that should not be given twice
streptokinanse (antibody build up)
both mitral and tricuspid regurg are blowing holosystolic murmurs, describe that difference in location?
tricuspid is best heard left of the sternal border and mitral is best heard at the apex and radiates to the axilla
what is the most common primary tumor that metastasizes to the heart?
malignant melanoma
What is Thromboangitis obliterans or Buerger dz?
inflammatory dz affecting the small and medium arteries of distal extremities. Common in Asian men and smokers. Venous insufficiency and ulcers are also commonly seen in the LE
prominent U waves on EKG
hypokalemia
J point elevation
hypothermia
medication that help PAD
cilostazol
best study to further investigate PVC after an EKG has been done?
electrophysiology study
what is the most efficient way to increase cardiac output?
increase heart rate
patients with grade 1 or 2 systolic murmur with no symptoms can be followed with
EKG and Chest x rays
patient with diastolic murmur or greater than grade 2 systolic murmur or any grade + symptoms can be followed with
ECHO
If a patient has anginal symptoms the best next step is…..
coronary arteriogram or dobutamine stress tests
patient has profound bradycardia and tachycardia =SA node dysfunction, another name for this is?
tachybrady syndrome
Goal for INR before cardioversion
1.8 for 3 weeks
What dysrhythmia can amiodarone cause?
sinus bradycardia and AV block
what dysrhythmia can digoxin cause
junctional rhythm
what dysrhythmia can adenosine cause
afib
name two drugs indicated to prevent recurrent v-tach
Sotalol and amiodarone
what is a physiological S2 split?
the ventricles closing at different times
a fixed S2 split is heard in patients with …
ASD
a prolonged S2 spilt is heard in patients with
pulmonary embolus and pulmonary valve stenosis
patient is on diuretic that is not potassium sparing, what heart arrhythmia can occur
ventricular (tachycardia)
venous stasis ulcers are
painless and erythematous
arterial ulcers are
painful and pallor
what is the difference between a physiological and paradoxical S2 split
paradoxical occurs during expiration phase and is associated with LBBB
’s the define orthostatic hypotension?
drop in 20mmHg systolic and 10mmHg diastolic
medication that can be used to control the ventricular rate during rapid atrial fib
BB
major side effects of amiodarone are
thyroid, photo dermatitis, liver, CNS
What is flecainde?
A big GUN. It potently blocks sodium channel current in the myocardium and is used in life threatening V-tach and V-fib or in refactory SVT
what age should you start screen for cholesterol
20
3 best meds to prolong life after an MI?
bb, ace, and aspirin.
what is preload
ventricular end diastolic volume, it is the pressure that fills the ventricle during diastole
how do you decrease preload
dilate veins, which slows the return of blood from the veins (nitrates) or use diuretics
how do you increase preload
add intravascular volume
what is afterload
think arteries…the resistance that the heart faces during systole.
meds that decrease afterload
arterial dilators: ACEI and hydralazine
inspiration makes negative pressure in the intrathoracic, how does this affect right atrial and ventricle preloads?
inspiration=increased preload (less pressure for venous return to face means more blood to the heart)
you dx pt with pheo and massive HTN, med to use?
phentolamine
med for true HTN emergency (encephalopathy)
IV nitroprusside, IV esmolol, they drop BP dramatically and suddenly
Hyperkalemia, Lyme dz, MI and lithium can all cause what heart problem
AV block
what is ibutilide used for and what is a major SE?
to cardiovert out of a fib or flutter. SE is torsades de pointes
tx for constrictive pericarditis
pericardiectomy
pt presents with tachycardia, tachypnea, narrow pulse pressure, JVD and pulses paradoxes…you should think
cardiac tamponade
Electrical alternans define, this isdpathognomonic for?
alternation of QRS complex amplitude or axis between beats and a possible wandering base-line. EFFUSION
big difference between cardiac tamponade and right ventricle infarction?
only right ventricle will have Kussmaul
one way to determine tx for pulmonary artery HTN is to do a vasodilator challenge, what med should be used if the PA pressure is reduced?
CCB-nifedipine
if PAH doesn’t respond to vasodilators then what meds can be used?
bosentan, iloprost
stage 1-4 heart disease
class 1: symptoms but no affect on physical activity class 2: angina with activity class 3 patients must limit activity due to angina class 4 cannot carry on any physical activity
A 70 year old female presents for a routine checkup. On physical exam you auscultate a murmur that radiates from the apex of the heart to the left axilla. Which heart murmur is most often associated with this description?
A murmur that radiates from the apex to the left axilla is consistent with mitral regurgitation.
A 56 year old male with severe congestive heart failure is making modifications to his diet plan and asks you about sodium intake. Which of the following is the best advice to give this patient?
CHF patients should be counseled to limit their sodium intake to 2-3 grams or less to properly maintain fluid homeostasis.
Although there may be many causes of hypertension, which of the following is the most common cause of secondary hypertension?
renal artery stenosis
Which is more potent epi or Isoproterenol positively chronotropic agent?
Isoproterenol
He states he has fatigue, shortness of breath, ankle swelling that gets worse during the day, and he sleeps on two pillows at night. He denies syncope or palpitations. Physical examination shows jugular venous distension, S3 gallop, hepatomegaly, and 2+ pitting edema of both legs and ankles. Left ventricular ejection fraction as determined by echocardiography is 35 percent. what Cardiomyopathy is suspected?
Dilated cardiomyopathy may be defined as an ejection fraction of less than 40% in the presence of increased left ventricular dimension (left ventricular end-diastolic size more than 115% of that calculated for age and body surface area).
Which of the following is the most important modifiable risk factor for coronary artery disease in patients
smoking
What heart rhythm abnormality can be caused by propranolol overdose?
AV block
Which of the following is the most common cause of restrictive cardiomyopathy?
Amyloidosis
Patients with a diagnosis of Systemic Lupus Erythematosus have a disposition toward acquiring which cardiac abnormality?
pericarditis
What is the earliest sign or symptom of congestive heart failure?
Dyspnea on exertion
are q waves always present in ST elevation MI?
no
tachycardia is a regular, wide-QRS complex tachycardia with only one (“mono”) repeating QRS morphology.
monomorphic ventricular tachycardia
ECG this morning shows inverted P-waves in the inferior leads. Which of the following would be this patient’s most likely rhythm?
When signals for the heart to contract originate from sources other than the SA node, the p-waves on ECG tend to be inverted. Inverted P-waves should make you think Junctional rhythm first.
major criteria for rheumatic fever
The major criteria for rheumatic fever include: polyarthritis, carditis, erythema marginatum, chorea, subcutaneous nodules.
Which of the following is the most common immediate complication following surgical repair of an abdominal aortic aneurysm?
MI
Which of the following patients would benefit most from a coronary artery bypass graft (CABG) procedure? what disease artery benefits the most from being bypassed
Those patients with proximal LAD involvement, triple vessel disease, or double vessel disease with concomitant diabetes have been shown to benefit most from CABG.
the most common finding for a positive stress test?
ST segment depression of greater than 1 mm
Which of the following cardiac serum markers will most likely be elevated within 1-3 hours following a myocardial infarction?
Though Troponin levels are more diagnostic of true infarction, myoglobin levels are the first to rise. Myoglobin usually rises within 1-3 hours and is usually the 1st cardiac enzyme marker to be elevated. The other cardiac enzymes begin elevating between 3 and 6 hours.
What is the target INR for a patient with a mechanical heart valve?
2.5 to 3
what is a normal corrected QT?
a normal corrected QT is generally defined as less than 450 and anything greater than this represents a prolonged QT interval, which increases the risk for ventricular tachycardia (in particular torsades de pointes
A 37 year old male presents to the clinic with a red rash in ring form covering his trunk and portions of his lower extremities as well as a fever. He also complains of bumps under the skin of his arms and legs, that you recognize as subcutaneous nodules. Which of following heart murmurs is most commonly noted as a late sequelae of this disease?
The mitral valve is most commonly affected in rheumatic heart disease, the late sequelae of acute rheumatic fever. Mitral stenosis is the classic valvular complication associated with rheumatic heart disease, which is noted to have a low-pitched diastolic rumble, possibly with opening snap early in the course of the disease
Which of the following ECG changes indicates that transmural ischemia is occurring?
ST elevation
the test of choice in this unstable patient presenting with likely acute thoracic aortic dissection.?
Gated CT chest angiography i
what is worse a fib or atrial flutter?
Atrial flutter generally has a rate of 250-350 bpm, has the risk of transferring that rate to the ventricles, sending the patient into ventricular tachycardia. A fib, with the rate well over 350 bpm, generally does not transfer that high a rate to the ventricles, and therefore is the most common chronic sustained arrythmia.
Which characteristics is classically associated with monomorphic ventricular tachycardia?
Monomorphic ventricular tachycardia is a regular rhythm, wide-QRS complex tachycardia with only one (“mono”) repeating QRS morphology.
treatment of choice for recurrent cases of Rheumatic fever
Monthly injections of benzathine penicillin
what test is used to evaluate the excitability of the myocardium, and may also reproduce the tachycardia. good for patient who most likely has a diagnosis of Wolff-Parkinson-White syndrome. WPW is a syndrome of excitability in which re-entry pathways lead to tachyarrhythmias.
Electrophysiology study
what is Thromboangiitis obliterans, or Buerger’s disease,
is a rare vasculitis in which inflammation causes obstruction of blood vessels in the hands and feet resulting in the listed symptoms, often associated with smoking. Raynaud’s phenomenon is similar in presentation to Buerger’s disease and may be difficult to initially distinguish.
best drug for patient with cardiogenic shock. There are multiple causes for cardiogenic shock which result in pump failure.
Dobutamine is a vasopressor that enhances myocardial contractility and decreases the cardiac workload, and therefore is the drug of choice in this condition
At times congestive heart failure patients are placed on dopamine to yield diuretic effects. Dopamine, however produces different peripheral responses depending on the dose administered. At what dosing level does dopamine exert the desired effect of diuresis?
2-5 ug/kg/min administered intravenously
does Digoxin help with mortality or symptoms of CHF
symptoms
In coronary artery bypass grafting, which vessel has been shown to yield the greatest longevity after the procedure?
internal mammary
Which of the following drugs is used to modify the heart rate in a patient who presents with an irregularly irregular rhythm on ECG?
Diltiazem
Which of the following medications is most important when treating a patient with dilated cardiomyopathy and an ejection fraction of 50%?
ACE
Diffuse ST segment elevation is indicative of
pericarditis.
This ECG finding is characteristic of Prinzmetal’s angina.
Transient ST segment elevations
True or False, Serial Troponins that are negative rule out all causes of acute coronary syndrome.
False
Total occlusion of a coronary artery is a characteristic of ST elevation MI?
Yes
A 55-year old male presents with acute onset right flank pain radiating to his periumbilical area for the past 2 hours. He states his pain causes urinary urgency but he cannot urinate. He has had several episodes of nonbilious vomiting. BP 165/87, P 105, RR 22, O2Sat 99% room air, T 98.7F. Abdomen is nontender. Urine dipstick reveals only large hematuria. Which of the following is the next best step in diagnosing this patient’s condition?
possible kidney stones get a KUB
What type of valvular disease can rheumatic fever cause?
mitral STENOSIS
how do you increase the hypertrophic cardiomyopathy murmur?
valsalva
Bumetanide (Bumex)
strong loop diuretic, used in moderate to severe CHF
What heart rhythm abnormality can be caused by propranolol overdose?
AV block Propranolol is a beta blocker. Due to the ability of this drug class to slow the heart, an overdose could cause an AV block or sinus bradycardia.
“Tet spells” are presumed to be due to acute increase in pulmonary vascular resistance, clinically manifesting as acute episodes of systemic cyanosis followed by syncope, which may result in hypoxia and death. The treatment of a “tet spell” is to increase systemic vascular resistance to allow for temporary reversal of the shunt. name a vasopressor
Phenylephrine is a vasopressor that increases systemic vascular resistance.
what is the most common cause of CHF?
coronary artery disease
a bnp below what level rules out CHF
2 dx that need prophylactic antibiotics
prosthetic valve, prior endocarditis, cyanotic heart defect
what are the three major criteria for endocarditis
2 positive blood cultures
positive ECHO
new murmur
what are the minor criteria for endocarditis
Fever
Embolic event (janeway)
Immunological event (osier)
Positive blood culture
gold standard for dx myocarditis
myocardial biopsy
what is the first line tx for pericarditis
aspirin and nsaids
normal BMI
18.5-24.9
3 dx when paradoxical pulse is mentioned
pericarditis, pleural effusion, and cardiac tamponade and obstructive lung dz.
a pathologic S3 is most often associated with?
CHF
mid systolic click, you should think
mitral valve prolapse
name 3 medications used for pharmacological stress test
adenosine, dobutamine, and dipyridamole
two valve disorders common with marfans
aortic regurgitation and mitral valve prolapse
2 most common causes of aortic stenosis
bicuspid valve + calcification and CAD
Elderly person presents with dypnea, angina, syncope, but EKG is normal. What is the dx
aortic stenosis
aortic valve is best heard when pt is in what position?
sitting up and leaning forward
what is tietze syndrome
costochondritis
James bundle, think
lown-ganong-levine syndrome
subacute endocarditis is most often what bug
strep viridans
A blalock procedure corrects what congenital heart condition
tetralogy of fallot
a “3” sign and rib notching =
coarctation of the aorta
name 4 things that constitute a positive stress test
a drop in blood pressure, a new arrhythmia, an increases in angina symptoms, ST depression
can you use clot busting drugs in a new LBBB
yes within 3 hours
RSR prime in leads V1 or V2, you should think
RBBB
patient is taking aldosterone antagonist (aka spirolactone )what labs must to watched
K+ (may become hyperkalemic)
what does digoxin do?
helps with cardiac contractility
Inferior MI what artery is blocked
RCA
Anterior MI what artery is blocked
LCA
Posterior MI what artery is blocked
posterior descending artery off the RCA
Bundle of kent : think?
WPW
biphasic P wave, should make you think of
left atrial enlargement
U waves
hypokalemia
spironlactone SE
gynecomastia
Lead 1 has a positive QRS and AVF has a negative QRS, what is the axis?
left axis deviation
when taking statins measure the creatinine kinase due to
rhabdomyolysis
what is ezetimibe
lowers LDL by decreasing intestinal absorption of cholesterol
counting rate on an EKG what are line values
300, 150, 100, 75, 60
what two leads determine the axis of the heart
Lead 1 and AVF
RSR prime in V5 or V6
LBBB
what meds lower trigycerides
fibrin acid derivatives
Lateral wall MI is caused by the blockage of what artery?
LEFT CIRCUMFLEX artery
describe junctional rhythm
50 beats per minute, QRS is narrow and no P wave
most common cause of sudden cardiac death
v-fib
patient is taking ACE, must watch
serum creatinine and potassium
what does ST depression represent
ischemia
You note a tachycardic rhythm with three different P-wave morphologies, and R-wave progression across the precordial leads. name the rhythm
Multifocal atrial tachycardia
