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step 2 > Cardiology > Flashcards

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
Q

Pulsus parvus et tardus

A

Decreased amplitude aNd delayed in arterial pulse

Seen in severe aortic stenosis

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26
Q

Labetalol

A

alpha and beta adrenergic
used in hypertensive emergency
rapid onset via IV

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27
Q

Dilated cardiomyopathy

A

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
Q

Indications for antibiotic prophylaxis for valve problems

A

1- prosthetic valve
2-valve problem in transplanted heart
3-previous endocarditis
4-unrepaired cyanotic heart disease

29
Q

II, III, AvF

A

Inferior wall- RIGHT sided infarct

30
Q

V1-V6 MI

A

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
Q

Preload

A

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
Q

Afterload

A

squeezing squeezing squeezing
RESISTANCE ventricles must overcome to empty

related to ARTERIAL tone
-ACE inhibitors reduce arterial tone

33
Q

Aortic stenosis

A

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
Q

Aortic regurg

A

–

35
Q

Mitral stenosis

A

–

36
Q

Mitral regurg

A

–

37
Q

Polyarteritis nodosa

A

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
Q

Temporal arteritis

A

headache, scalp tenderness, diplopia, amaurosis fugax, jaw claudication
high ESR

start steroids, then biopsy
associated with polymyalgia rheumatica

39
Q

Takayasu arteritis

A

–

40
Q

Churg Strauss

A

–

41
Q

Henoch-Schonlein purpura

A

widespread necrotizing vasculitis of arterioles and capillaries
boys> girls, age 3-8
renal involvement, joint, GI

42
Q

Kawasaki disease

A

–

43
Q

Synchronized cardioversion used for….

A

unstable patients with

  • atrial fibrillation
  • atrial flutter
  • atrial tachycardia
  • supraventricular tachycardia
  • ventricular tachycardia
44
Q

Unsynchronized cardioversion used for…

A
  • ventricular fibrillation

- pulseless ventricular tachycardia

45
Q

Hypertensive emergency

A

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
Q

No cath lab available(small rural hosp)-best treatment?

A

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
Q

NSTEMI treatment

A 
HEPARIN (low molecular weight)
aspirin
beta blocker 
nitrates
GPIIb/IIIa meds (eptifibitide, abciximab, tirofiban) if undergoing angioplasty/stenting
48
Q

Complications of MI and treatment

A
  • 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
Q

Post-MI home meds

A

Aspirin
Beta blocker(metoprolol)
Statins
ACE inhibitors (esp if anterior wall)

NO “prophylactic anti-arrhythmic even if having arrythmias)–>INCREASE mortality

50
Q

CHF best tests

A

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
Q

Causes of systolic dysfxn CHF

A

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
Q

Medical Treatment of systolic dysfxn CHF

A
  • 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
Q

Devices with improved mortality for systolic CHF

A

if EF

54
Q

Treatment with improved mortality in diatstolic CHF (preserved EF)

A

Beta blockers only!
diuretics improve symptoms

NOT digoxin

55
Q

Digoxin toxicity

A 
headache
visual changes
vomiting
bradycardia
palpitations
syncope

exacerbated by hyPOkalemia-check electrolytes

56
Q

Subclavian steal synrome

A

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
Q

MItral valve prolapse

A

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
Q

Aortic regurgitation

A 
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
Q

Mitral regurgitation

A

holosystolic murmur radiates to axilla
CHF
hand grip (increased afterload) increases murmur
Tx: ACE/ ARB, valve replacement when dangerously dilated

60
Q

Aortic stenosis

A 
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
Q

Mitral stenosis

A 
diatstolic murmur after opening snap
increase with squatting
CHF
dysphagia
hoarseness
atrial fibrillation
hemoptysis

rheumatic fever most common cause

62
Q

Hypertrophic Obstructive Cardiomyopathy

A

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
Q

Best initial test for aortic dissection

A

Chest x-ray with widening of mediastinum
THEN=angiography
TX-BP control with Beta blocker, nitroprusside and surgical repair

64
Q

Who do you screen for abdominal aortic aneurysm

A

men >65 who have smoking history

65
Q

Patient with painful leg and absent pulses after MI= arterial occlusion secondary to LV thrombus

A

Do echo to check for thrombus
Immediate anticoagulation (at risk for stroke)
Vascular surgery

step 2 (11 decks)

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