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Cardiology Flashcards

1
Q

Clues it is NOT cad and MI

A

Change with respiration
Change with position
Chest wall tender to touch

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2
Q

Next step in management of chest pain in ED

Versus in stable patient in office

A
  1. Always EKG
  2. In office stress test if stable and NO current chest pain
  3. In Ed cardiac enzymes
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3
Q

If underlying EKG anomaly such as LBB, hyper trophy, pacemaker, next step instead of exercise with EKG?

A

Nuclear isotope uptake- thallium

Or

Echo for wall abnormalities

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4
Q

Coronary angiography

A

Gold standard for detecting cad

Determine whether surgery or angioplasty needed

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5
Q

Best 3 meds for lowering mortality in angina

A

Aspirin and beta blockers

Then nitroglycerin

ACE inhibitors/ARB if low ejection fraction or systolic dysfunction

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6
Q

Side effects hmg coA reductase inhibitors aka statins

A

Liver damage-monitor LFTs

No need to monitor CPk but other effect is myositis

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7
Q

Side effects of ACE INHIBTORS

A

Cough

Hyper kalmia

Angioedema

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8
Q 
Adverse effects of non-useful lipid meds
Niacin
Fibrates
Colestyramine
Ezetimibe
A

Niacin-high glucose, high Uris acid, pruritis
Fibrates-myositis when with statins
Chokestyramine-flatus, ab cramps
Ezetimbe-none

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9
Q

Calcium channel blockers use

A

no mortality benefit in cad

Useful in prinzmetal angina
Raynaud
Hypertension

Side effects-edema, constipation(ESP verapamil), and heart block

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10
Q

Coronary artery bypass grafting (CABG)

A

Best when

  1. 3 vessels 70% occluded
  2. Left main occlusion
  3. 2 vessel disease in diabetic
  4. Persistent angina symptoms after max therapy

Detect degree of disease with angiography

Arteries last longer than vein grafts

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11
Q

Per cutaneous Coronary Intervention aka Angioplasty

A

Best for ACUTE coronary syndrome ESP. STEMI within 90 minutes of arrival

not ideal for angina-no long term mort benefit

Complications:
Rupture of artery
Restenosis
Hematoma at entry-femoral artery hematoma

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12
Q

> 20 mm Hg decrease in blood pressure on inhalation

A

Pulsus paradoxus

Cardiac tamponade

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13
Q

Increase in JVP on inhalation

A

Kussmaul sign

Constrictive pericarditis/restrictive cardiomyopathy

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14
Q

Displaced PMI to axilla

A

LVH secondary to dilated cardiomyopathy

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15
Q

Most important CAD risk factors

A 
Diabetes mellitus
Hypertension
Tobacco 
Hyperllipidemia
Family history in FIRST DEGREE and YOUNG relative ( mortality below 55in male and 65 in female)
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16
Q

V1-V4 ST elevation

A

Anterior wall MI

Highest mortality if untreated

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17
Q

Acute MI next best steps

A

EKG

If already confirmed on EKG:
1. Aspirin/ clopidegrel if aspirin allergy
2. Angioplasty within 90 minutes
Focus on mortality benefit
Morphine, nitroglycerin, cardiac enzymes (negative for first 4hours) should also be done /given but no mort benefit
3. Monitor in ICU once treatments given
4. Defibrillate if develop ventricular arrhythmia in ICU
5. pre-discharge STRESS test if no longer symptomatic to assess need for angiography

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18
Q

Troponin

A

Positive in 4-6 hours
Remains abnormal for 10-14 days
NOTgood for detecting reinfarction

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19
Q

Ck-mb

A

Detectable in 4-6 hours
Remains abnormal1-2 days
BETTER for reinfarction

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20
Q

Early decresendo diastolic murmur at left sternal border

A

Aortic dissection

Think marfans

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21
Q

Opening snap in early diastole

A

Mitral stenosis

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22
Q

Wide fixed splitting of second heart sound

A

Atrial Septal Defect

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23
Q

Third heart sound

A

Normal in healthy young adults

Abnormal In Dilated ventricles/CHF

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24
Q

Pericardial friction rub

leathery, scratchy sound heard through systole and diastole

A

Pericarditis

usually viral in origin

Tx: NSAIDs-ibuprofen

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25
Pulsus parvus et tardus
Decreased amplitude aNd delayed in arterial pulse Seen in severe aortic stenosis
26
Labetalol
alpha and beta adrenergic used in hypertensive emergency rapid onset via IV
27
Dilated cardiomyopathy
most commonly due to HTN concentric hypertrophy makes stiff ventricle--> decreased left vent volume--> back up to lungs--> pulm congestion treat with negative inotropes to reduce preload: beta blockers and Ca2+ channel blockers reduce afterload with: candesartan
28
Indications for antibiotic prophylaxis for valve problems
1- prosthetic valve 2-valve problem in transplanted heart 3-previous endocarditis 4-unrepaired cyanotic heart disease
29
II, III, AvF
Inferior wall- RIGHT sided infarct
30
V1-V6 MI
right sided precordial leads--> indicate R ventricular involvement can see signs of heart failure- such as elevated JVP which increases with inspiration (Kussmaul) and S3 gallop also hypotension/altered mental status due to low CO Treat aggressively with fluids
31
Preload
filling, filling, filling myocardial STRETCH at end of diastole related to VENOUS return, and tone vs. POOLING - nitroglycerin causes venous pooling to reduce pre-load - loop diuretics reduce preload
32
Afterload
squeezing squeezing squeezing RESISTANCE ventricles must overcome to empty related to ARTERIAL tone -ACE inhibitors reduce arterial tone
33
Aortic stenosis
heard at R upper sternal border crescendo/decrescendo systolic ejection murmur radiating to neck angina, syncope, heart failure, dyspnea on exertion if handgrip/valsalva and increase afterload (resistance ventricles face) then will decrease sound of murmur as less flows to ventricle congenital bicuspid valve or calcifications in elderly TX: beta blockers or valve replacement
34
Aortic regurg
--
35
Mitral stenosis
--
36
Mitral regurg
--
37
Polyarteritis nodosa
Vasculitis of medium to small vessels associated with Hep B or C abdominal pain/abdominal angina, skin lesions and ulcers nephropathy, neuropathy, arthritis p-ANCA dx: biopsy of peripheral lesions for necrotizing vasculitis
38
Temporal arteritis
headache, scalp tenderness, diplopia, amaurosis fugax, jaw claudication high ESR start steroids, then biopsy associated with polymyalgia rheumatica
39
Takayasu arteritis
--
40
Churg Strauss
--
41
Henoch-Schonlein purpura
widespread necrotizing vasculitis of arterioles and capillaries boys> girls, age 3-8 renal involvement, joint, GI
42
Kawasaki disease
--
43
Synchronized cardioversion used for....
unstable patients with - atrial fibrillation - atrial flutter - atrial tachycardia - supraventricular tachycardia - ventricular tachycardia
44
Unsynchronized cardioversion used for...
- ventricular fibrillation | - pulseless ventricular tachycardia
45
Hypertensive emergency
BP over systolic 180 and diastolic 120 PLUS end organ damage- EX increased intracranial pressure and renal failure ``` Treatment:IV meds lower BP but not to normotensive IV sodium nitroprusside IV nitroglycerin IV labetalol IV esmolol IV hydralazine IV enalapril ```
46
No cath lab available(small rural hosp)-best treatment?
thrombolytics (tPA, streptokinase) if no contraindication: - melena - CNS bleed - recent surgery (last 2 weeks) - severe hypertension >180/110 - nonhemorrhagic stroke last 6 mo - diabetic retinopathy RELATIVE contraindication -prolonged CPR (trauma/bleeding likely)
47
NSTEMI treatment
``` HEPARIN (low molecular weight) aspirin beta blocker nitrates GPIIb/IIIa meds (eptifibitide, abciximab, tirofiban) if undergoing angioplasty/stenting ```
48
Complications of MI and treatment
- AV block and bradycardia-tx=atropine, pacemaker if atropine insufficient - Right ventricular infarction- tx= high VOLUME FLUID and no nitroglycerin - Tamponade/free wall rupture- several days post-MI- sudden loss of pulse (scar tissue weak)-tx= emergency pericardiocentesis as proceed to OR - V tach/V fib- loss of pulse, do EKG-tx=should already be monitored in ICU-synch (tach) or unsynch(fib) cardioversion - Valve/septal rupture-new onset murmur and pulm congestion, increased O2 sat from righ A to right V, tx= Echo for dx, Intraaortic Balloon Pump to support hemodynamics untill surgery - Reinfarction-recurrence of pain, new rales, bump in Ck-MBs, Tx= repeat EKG, retreat with usual meds and angioplasty - Aneyrysm/Mural thrombus-Dx=echo, treat thrombi with heparin then warfarin
49
Post-MI home meds
Aspirin Beta blocker(metoprolol) Statins ACE inhibitors (esp if anterior wall) NO "prophylactic anti-arrhythmic even if having arrythmias)-->INCREASE mortality
50
CHF best tests
DYSPNEA plus orthopnea S3 gallop (after S2) also JVD, PND, periph edema Echo! to assess EF- TTE ok- best initial test BNP is next test only if cannot wait for echo
51
Causes of systolic dysfxn CHF
results in low EF and dilation of heart 1. hypertension--> dilated cardiomyopathy 2. valve disease 3. infarction also: alcohol, postviral myocarditis, radiation/chemo, Chagas, thyroid disease, peripartum cardiomyopathy, thiamine deficiency
52
Medical Treatment of systolic dysfxn CHF
- ACE inhib or ARB- all patients-LOWER MORTALITY (if hyperkalemic-switch to hydralazine/nitrates-also LOWER MORTALITY) - Beta blocker- metoprolol, or carvedilol (antiischemia, slow, rate and O2 demand, antiarrhythmic) LOWER MORTALITY - Sprionolactone-for advanced stages, inhibit effects of aldosterone (risk hypERkalemia and gynecomastia), eplerenone-no gynecomastia LOWER MORTALITY - Diuretics-treat symptoms (NO DECREASED mortality) - Digoxin- treat symptom of dyspnea and reduce hospitalizations (NO DECREASED mort)
53
Devices with improved mortality for systolic CHF
if EF
54
Treatment with improved mortality in diatstolic CHF (preserved EF)
Beta blockers only! diuretics improve symptoms NOT digoxin
55
Digoxin toxicity
``` headache visual changes vomiting bradycardia palpitations syncope ``` exacerbated by hyPOkalemia-check electrolytes
56
Subclavian steal synrome
stenosed subclavian artery "steals" blood from vertebral artery when using arms significantly (more blood demand) results in light-headedness and vertigo check BP in both arms and do doppler/ CTA of subclavian/carotid vasculature
57
MItral valve prolapse
midsystolic click presents with Panic attacks, atypical chest pain, palpitations anatomic variant, Marfan, or Ehler's Danlos Increased with increased filling of LV (either preload or afterload)-handgrip or squatting decrease with Valsalva and standing Tx: beta blocker when symptomatic, can do repair or stitch-rarely needed
58
Aortic regurgitation
``` diastolic decrescendo murmur at left sternal border CHF water hammer pulses wide pulse pressure head bobbing ``` caused by enlarged heart/aorta-HTN, MI, Marfans syphilis increased afterload increases murmur Tx: ACEi/ARB or nifedipine (decrease afterload), repair when acute valve rupture
59
Mitral regurgitation
holosystolic murmur radiates to axilla CHF hand grip (increased afterload) increases murmur Tx: ACE/ ARB, valve replacement when dangerously dilated
60
Aortic stenosis
``` systolic crescendo decresendo murmur at second right intercostal space and radiate to carotid artery Angina syncope CHF left ventricular hypertrophy ``` squatting increases sound of murmur can be due to congenital bicuspid valve or calcification with age TX: valve replacement
61
Mitral stenosis
``` diatstolic murmur after opening snap increase with squatting CHF dysphagia hoarseness atrial fibrillation hemoptysis ``` rheumatic fever most common cause
62
Hypertrophic Obstructive Cardiomyopathy
genetic assymetric hypertrophy of septup which blocks left ventricular OUTflow dyspnea, chest pain, syncope, and sudden death in healthy athletes NO TX WITH ACEi or ARB, digoxin or hydralazine-decrease ventricular filling and cause collapse of ventricle best TX:beta blockers, implatable defibrillators ablation of septum
63
Best initial test for aortic dissection
Chest x-ray with widening of mediastinum THEN=angiography TX-BP control with Beta blocker, nitroprusside and surgical repair
64
Who do you screen for abdominal aortic aneurysm
men >65 who have smoking history
65
Patient with painful leg and absent pulses after MI= arterial occlusion secondary to LV thrombus
Do echo to check for thrombus Immediate anticoagulation (at risk for stroke) Vascular surgery

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