Cardiology Flashcards
Stable Angina
Chest discomfort due to myocardial ischemia. Occurs with exacerbation, relieved by rest.
What determines myocardial demand for O2?
HR, SBP, contractility, LV wall stress
Why does subendocardium get ischemic during tachycardia?
Because it receives its blood during diastole, so when tachycardia occurs, diastole preferentially shortens
Most common cause of stable angina
Vasospasm, AS, HOCM, HTN
How to treat asymptomatic patients with moderate framingham risk?
Daily aspirin
Is it recommended to treat women with hormone replacement to prevent heart disease?
No
Is it recommended to test homocysteine?
No
How to screen for CAD?
Dont do it.
How to determine typical vs atypical vs nonanginal cp?
Retrosternal
Relieved by rest/nitro
Exacerbated by activity or stress
1 is nonanginal
2 is atypical
3 is typical
How to use stress testing to diagnose angina?
Patients with low probability don’t require stress test, patients with high probability should be started immediately on medical management. Patients with intermediate pretest probability should receive stress test.
How to choose a stress test?
Patients with baseline changes in EKG shouldn’t get EKG stress, patient’s who can’t exercise need chemical stress.
Dipyridamole for nuclear perfusion, dobutamine for echo
Contraindications for EKG exercise stress
LBBB, ST depressions, WPW, LVH or on digoxin
Contraindications for echo
LVOT obstruction
Wall motion abnormalities
Obese
Contraindications for nuc perfusion
Asthma
hypotension
conduction disease
Goal of exercise or chemical stress
To achieve 80% of max heart rate.
Coronary angiography
Goal standard for patients at high risk or abnormal stress tests. Though patients with abnormal stress tests can be managed medically.
Therapy for chronic stable angina
1) lifestyle modifications
2) Antianginal meds + vascular protective meds
Initial medication regimen for chronic stable angina
Beta blocker, aspirin, long acting nitrate, statin (high intensity for >75, moderate intensity for
How to manage chronic stable angina if symptoms persist on first pass?
Increase B blocker dose, increase nitrate dose, add CCB.
How to manage chronic stable angina if symptoms persist on second pass?
consider ranolazine, refer for angio
Should antiplatelet agents besides aspirin be used in chronic stable angina?
No, only if contraindication to aspirin
Is PCI effective in chronic stable angina?
Not effective in reducing mortality, but effective in controlling symptoms and increasing quality of life.
How to follow up patients with stable angina?
Repeat EKG’s not recommended if there hasn’t been a change in symptoms or meds.
Repeat stress test contraindicated unless there is a change in symptoms
How to work up a patient with anginal chest pain
Get an ekg, if positive, stemi, then cath or TPA
If negative, then get biomarkers, if those are positive, then NSTEMI, cath if TIMI 3-7. If negative then eventually get a stress test.
If biomarkers are negative, then UA. Geta stress test eventually.
How to treat ACS patients
MONA BASH Morphine O2 Nitro Aspirin + clop
Beta blocker
Acei
Statin
Heparin
Sinus arrest
2 or more seconds of pause on EKG
Sick sinus syndrome
AKA brady tachy. SA nodal disease where bradycardia or pauses are followed by SVT or Afib
Indications for pacing
Symptomatic bradycardia (5sec Alternating bundle branch blocks
How to treat AV blocks with bradycardia?
Atropine
First degree heart block
PR>200ms. Usually asymptomatic but associated with heart failure and death.
Second Degree heart blocks
Mobitz I - wenchybach
Mobitz II - Dropped beats without Pr elongation, defect is within ventricular conduction system
Pace
Third degree heart block
Complete P and Q dissociation. QRS can be wide or narrow. Pace.
SV arrhythmias
Can be regular (SVT) or irregular (Afib/aflutter/mat)
SVT
Patient has palps, syncope, dyspnea, fatigue
HR usually >150, no P or T waves.
Tx: adenosine or shock
Afib
No p waves If unstable: shock If stable: rhythm control = rate control For rhythm: if Afib for cardiovert If afib >48 hours, TTE ->TEE, cardiovert if no LA thrombus
Torsades
Wide complex, give mag
Vtach
Wide complex, treat with shock or amio
How to work up heart failure
EKG, Echo, BNP, LH cath if new and acute
How to treat CHF (everybody)
H2O
How to treat NYHA class III or IV
Add spironolactone, add furosemide, add ISDN or hydralazine
How to treat CHF if EF
Defibrillator placement
How to treat CHF if in ICU?
Dobutamine
How to work up CHF exacerbation
Get EKG, Echo, BNP, Trop If stemi, LH cath +MONABASH If negative, not CHF If positive, its a true exacerbation and treat with LMNOP Lasix, morphine, O2, Nitro, Position
How to conduct ACLS if patient has a pulse?
Arrhythmia (everything but sinus tach or NSR)? Symptomatic? No? Give IVF, O2 and Tele. If symptomatic, check if stable. If SBP>90 and no AMS or CP, then stable. Give drugs: Amiodarone for wide and fast, adenosine for narrow and fast, atropine for slow.
If not stable, then shock or pace.
Diastolic murmurs
Mitral stenosis, aortic regurgitation
Mitral stenosis (Path, sxs, murmur, tx)
Path: Rheumatic heart disease
Sxs: CHF, Afib
Murmur: Diastolic rumble with opening snap
Tx: Balloon valvuloplasty, then replace
Aortic regurgitation
Path: Infection, infarction, aortic dissection.
Acute presentation: Cardiogenic shock, flash pulm
Chronic: CHF, Chest pain
Murmur: Diastolic at base
Tx: Acute: Emergent replacement
Chronic: Urgent replacement
Systolic murmurs
Mitral insufficiency, aortic stenosis
How to treat carotid stenosis if asymptomatic?
Surgery or stent if stenosis >70%
How to treat carotid stenosis?
Surgery or stent if stenosis >50%
