Cardiology Flashcards
CK-MB timeline
present: 4-6hrs
peak: 12-24hrs
gone: 3-4 days
predict re-infarction
CK-MB 1 vs 2
CK-MB 1: plasma
CK-MB 2: myocardial tissue (more specific)
causes for elevated troponin
myocardial injury
renal disease
polymyositis/dermatomyositis
aortic dissection, next test
CXR
confirmed by: TEE > CTA > MRA
PE signs on EKG
S1 Q3 T3
lead 1 shows S wave
lead 3 shows Q wave
lead 3 shows inverted T wave
confirm diagnosis PE
spiral CT
lung scan
pulmonary angiogram
symptoms of pericarditis
sharp, positional, pleuritic
relieved by leaning forward
pericardial rub
EKG signs pericarditis
diffuse ST elevation
NO elevation Q waves and CK levels normal
responds to NSAIDS
Posterior: leads and artery involved
V1, V2: tall broad initial R wave ST depression Tall upright T wave usually occurs in a/w inferior or lateral MI artery: Posterior Descending
anteroseptal infarction: leads and artery involved
V1, V2, V3
LAD
anterior infarction: leads and artery involved
V2, V3, V4
LAD
lateral infarction: leads and artery involved
I, aVL, V4, V5, V6
LAD or circumflex
STEMI EKG
T wave inversion: onset, disappearance
onset: 6-24hrs
disappearance: months to years
criteria for a positive stress test
> 2mm ST depression OR
>10mmHg decrease in systolic BP
STEMI EKG
Q waves longer than 0.04sec: onset, disappearance
onset: one to several days
disappearance: years to never
criteria for a positive stress test
> 2mm ST depression OR
>10mmHg decrease in systolic BP
indications for CABG
- L main coronary dx
- 3 vessel dx and LV dysfunction
- 2 vessel dx with DM
- symptoms despite medical therapy or SE from therapy
indications for PCI
-1 or 2 vessel disease
what interventions lower mortality?
ASA BB Clopidogrel TPA Statins if LDL >100 angioplasty
treatment for third degree HB
symptomatic = atropine asymptomatic = pacemaker
treatment for first degree HB
nada
1st deg HB = PR > 0.12-0.20
treatment for V-tach
stable = amniodarone, lidocaine unstable = shock
treatment for V-fib
shock always
Mitral Stenosis: who, long-term effects
MC 2/2 Rheumatic Fever (immigrants) Rarely genetic 2/3 Female (pregnant) Large LA --> A-fib --> strokes Large LA --> hoarseness, dysphagia
describe mitral stenosis murmur
opening snap following S2
diastolic rumble
MR diagnosis: EKG, CXR, ECHO
EKG: LVH, LAE
CXR: Cardiac enlargement, vascular congestion
ECHO: LA and/or LV dilation
MR treatment medical/surgical
Medical: vasodilator, digitalis, diuretic, anticoag
Surgical: replace valve is still symptomatic with medical therapy
MVP: who gets it
MC congenital valvular lesion
MC females, connective tissue disease
MVP murmur:
describe?
heard best?
Worse/better?
mid-to-late systolic click, late systolic murmur, heard best at apex
worse w/ valsalva (decreased preload, less blood more murmur)
better with squatting (increased afterload, more blood less murmur)
MVP: complications
serious arrhythmia and sudden death
SVT arrhythmias
Adenosine
BB
CCB: diltazem, verapamil
Digitalis
Multifocal Atrial Tachycardia: describe EKG findings
P wave morphology and PR interval varies from beat to beat (at least 3 to be diagnostic)
irregular supraventricular rhythm 100-200 bpm
each QRS is preceded by a p-wave
Multifocal Atrial Tachycardia: treatment
digoxin
CCB
Multifocal Atrial Tachycardia: cause?
COPD
elderly with respiratory failure
atrial flutter: formation
p-waves always look the same
multiple P waves before QRS
atrial flutter: treatment
BB
CCB: diltazem, verapamil
Digitalis
when do you use adenosine
ONLY with SVT
A fib: treatment
- anti-coagulate! INR 2-3
- symptomatic/unstable (rhythm control)= shock
- asymptomatic/stable (rate control)= BB, CCB (verapamil, diltiazem), digoxin, pulse
WPW: treatment
acute:
- unstable: shock
- stable: procainamide
chronic: - ablation
V-tach: definition
- 3+ consecutive ventricular beats at >120bpm
- wide, bizarre QRS complexes
V-tach: etiology
- ischemia, post-MI
- cardiomyopathies
- metabolic (hyperkalemia)
CHA2DS2-VASc Score
CHF +1 HTN 140/90 +1 Age 75+ +2 DM +1 Stroke/TIA/thromboembolism +2 Vascular disease: MI, PAD, aortic plaque +1 Age 65-74 +1 Sex: female +1
coagulation if
>1 males
>2 females
Secondary causes of HTN
- Renal parenchymal disease
- Renovascular disease
- Primary aldosteronism
- Pheochromocytoma
- Cushing’s syndrome
- Hypothyroid
- Primary hyperparathyroidism
- Coarctation of the aorta
Initial workup for HTN
- UA
- Chemistry panel
- Lipid panel
- Baseline EKG
Request further workup for HTN if
- Severe or malignant HTN
- Need 3+ drugs
- sudden rise in BP
- started before 30yo w/o h/o HTN
PVC: cause, definition, treatment
cause: normal people, MC following MI
definition: wide QRS (>120msec), bizarre morphology, compensatory pause
symptomatic Rx: BB
asymptomatic Rx: observation, treatment with arrhythmic may worsen survival
indications for urgent dialysis
AEIOU
A = metabolic acidosis 6.5, EKG abn
I = ingestion: methanol, ethylene glycol, salicylate, lithium, sodium valproate, carbamazepine
O = volume overload s/p diuretics
U = uremia, symptomatic: encephalopathy, pericarditis, bleeding
Thiazide S/E
HyperGLUC Glycemia Lipidemia Uric Acid Calcium
electrolyte abn = low Na, low K, high Ca
hypertrophic cardiomyopathy: EKG findings
aVL: tall R
V3: deep S
inverted T/repolarization changes in: I, aVL, V4-V6
hypertrophic cardiomyopathy: murmur
- Harsh crescendo-decrescendo systolic murmur heard best at the apex and lower left sternal border
- increases with less preload: valsalva, standing
- louder with more preload: passive leg raise
- louder with more afterload: handgrip, squatting
hypertrophic cardiomyopathy: mutation, cause of outflow obstruction
cardiac myosin binding C gene
cardiac beta-myosin heavy chain gene
hypertrophied interventricular septum
abnormal motion of mitral valve leaflets = systolic anterior motion (SAM)
when do you do carotid endarterecomy (CEA)?
Men
asym: 60+%
sym: 70+% (face-neuro symp w/i 6mo)
Women
both asym/sym: 70+% stenosis
PAC: treatment
asym: stop tobacco and alcohol
sym: Beta blocker
pulsus paradoxus: definition, when do you see it
Cardiac Tamponade
COPD
Asthma
drop in systolic BP >10mmHg during inspiration.
Cardiac tamponade –> increased pressure in pericardium –> RV and LV compete for space –> on inspiration RV fills and shifts LV over making it smaller –> less SV –> decreased BP on inspiration of >10
Beck’s triad
hypotension
distended neck veins
muffled heart sounds
cardiac tamponade
RF for CAD
- worst?
- MC?
- correcting which RF has the most immediate benefit?
- DM (worst RF)
- smoking (most immediate benefit for stopping)
- HTN (MC RF)
- HLD: LDL is the most dangerous
- FH premature CAD: M45, F>55
what S/S exclude cardiac ischema as a D/D?
positional
pleuritic
tender
When do you do a ETT?
chest pain, unknown etiology
EKG not diagnostic
ETT, pt can’t exercise?
- Dipyradamole/adenosine + Thalium/sestambi
- Dobutamine + ECHO
specificity/sensitivity equal for
dipyradamole thallium = dobutamine echo
ETT, pt has EKG baseline abn
Exercise with…
- Nuclear isotope: thallium or sestambi
- ECHO
specificity/sensitivity equal for
Exercise thallium = exercise ECHO
when can you NOT use dipyradamole for ETT?
can’t use with asthma
Treatment for lower mortality for chronic angina
ASA
BB (B1 specific)
Nitroglycerin
Nitroglycerin treatments for acute vs. chronic angina
Chronic: oral, transdermal
Acute: sublingual, paste, IV
Antiplatelet therapy for ACS patient
1) ASA
2) P2Y12 receptor: clopidogrel, prasugrel, ticagrelor
-NOTE: when angioplasty and stenting are planned DO NOT USE Clopidogrel
When to use Clopidogrel
- Combo with ASA for ACS
- ASA intolerence like an allergy
- Recent angioplasty with stenting
Prasugrel: when to use and not use
use: antiplatelet med, before angio/stenting
don’t: can cause hemorrhagic stroke in 75yo+
Ticlopidine: when to use and not use
use: anti-platelet Rx in rare pt where both ASA and clopidogrel not indicated
can’t use if ASA and clopidogrel are not indicated because of bleeding. Ticlopidine will inhibit platelets too
S/E: neutropenia, TTP
ACE/ARB:
when to use them
when do you switch to diff class?
- low EF% in systolic dysfunction
- Regurgitant valvular disease
-switch to hydralazine + nitrates if cough, elevation in K+
what’s the MC adverse effect of statin meds?
Liver dysfunction (1% have elevated transaminases) must get LFTs at start and during treatment
other S/E: myositis, rhabdomyolysis
Niacin: effect and S/E
raise HDL
S/E: elevate glucose and UA, pruritus
Gemfibrozil: effect and S/E
lower TG
S/E: myositis when combined with statin
Cholestyramine: effect and S/E
binds bile acid
S/E: flatus and abd cramping
Ezetimbe: effect and S/E
lowers LDL, no evidence of benefit to pt
S/E: well tolerated and nearly useless
Use CCB verapamil/diltiazem in CAD only in pts with:
- Severe asthma preventing use of BB
- Prinzmetal variant angina
- Cocaine-induced chest pain (can’t use BB)
- Can’t control pain with max medical therapy
NOTE: verapamil/diltiazem are CCB which do NOT increase HR
CCB: adverse effects
- Edema
- Constipation (MC verapamil)
- Heart block (rare)
