Cardiology Flashcards
1
Q
How will the ejection fraction differ in diastolic and systolic heart failure?
A
In DIASTOLIC dysfunction you will have a normal ejection fraction, thus poor relaxation leading to impaired filling. In SYSTOLIC dysfunction you will have a reduced ejection fraction, thus poor contraction.
2
Q
What is the most common etiology of CHF?
A
Coronary Artery Disease.
This is why EVERY patient should get; ASA, Beta Blockers, and Statins.
3
Q
What is the first test that should be ordered in the evaluation of CHF?
A
Echocardiogram. The echocardiogram is used to give additional information (ventricular size and ejection fraction) and not used to diagnose CHF.
4
Q
Which drugs lower mortality in CHF?
A
- ACE/ARB’s and Beta Blockers lower mortality in all patients with CHF.
- Spironolactone and Eplerenone lower mortality in those who have class 3 or 4 CHF.
- Diuretics and Digoxin reduce symptoms only as they do not lower mortality.
5
Q
What are the symptoms of a heart block?
A
- Weakness
- Fatigue
- Light headedness
- Syncope
- Chest pain
6
Q
What is the treatment for a third degree heart block “Complete Heart Block”?
A
Permanent pacing
*Can perform temporary transthoracic/transgenic pacing
7
Q
What on an EKG can identify a third degree heart block?
A
Complete dissociation between the atria and ventricles. The atrial rate may be faster with multiple “P” waves versus less “QRS.”
8
Q
What is the medication of choice for Hypertrophic Cardiomyopathy?
A
- Beta blockers
* Diastolic dysfunction thus diuretics may be utilized
9
Q
What typical drug is contraindicated in HOCM “Hypertrophic Obstructive Cardiomyopathy”?
A
-Diuretics
10
Q
What is the typical heart sound heard with ASD?
A
-Systolic ejection murmur + Wide splitting of S2
11
Q
What is the classic X-ray finding you will see with “coarctation of the aorta”?
A
“Rib notching” or “3” sign.
12
Q
What classic murmur will be heard in patients with PDA?
A
Machine like continuous murmur.
13
Q
What are TET spells?
A
Tet spells are found among patients who have “Tetralogy of Fallot.” The patients may have episodes of Hypercyanosis (Especially during feedings or crying).
*The child will bend down bringing their knees to their chest. (The reason why this is done is because it increases vascular resistance thus adding comfort).
14
Q
What is Eisenmenger syndrome?
A
Commonly seen in patients with VSD.
*Normally the pressure is the greatest in the left ventricle, thus pushing oxygenated blood to the right ventricle through the VSD. Overtime, this excess blood pushed to the right ventricle is too much for the lungs to handle, thus leading to pulmonary congestion. Eventually the increased pressure in the pulmonary vasculature via the right ventricle will lead to a reversal of blood flow, right ventricle to left ventricle, thus deoxygenated blood being pushed systemically.
15
Q
What is the most common cause of secondary HTN?
A
Renovascular disease
16
Q
What are the first line medications for HTN in patients who are otherwise healthy?
A
- Diuretics
- ACE/ARB’s
- Amlodipine
17
Q
What is the difference between HTN urgency and emergency?
A
- Both have blood pressure > 180/120.
* The difference is that with a HTN emergency they will have End Organ Damage!
18
Q
What is the classic clinical presentation for a patient in cardiogenic shock?
A
- HOTN
- AMS
- Cool/Clammy skin
19
Q
How will atrial flutter and atrial fibrillation present on EKG?
A
- Atrial flutter will have a REGULAR rhythm + Sawtooth appearance
- Atrial fibrillation will have a IRREGULARLY IRREGULAR without any “P” waves
20
Q
Why is Adenosine contraindicated in patients with WPW?
A
It may place the patient into V-Tach or V-Fib
21
Q
What is the classic presentation for a patient presenting with angina?
A
Chest pain (Predictable and Reproducible) + Relieved (Rest or Nitro)
*IF it is NEW chest pain or chest pain that is WORSENING then it is “Unstable Angina.”
22
Q
What are the medications of choice for patients with stable angina?
A
- Beta blocker (Increases filling time + Decreases oxygen demand)
- ASA
- Nitro (PRN for chest pain relief)
23
Q
What is the treatment of choice for prinzmetal angina?
A
Calcium Channel Blockers
*This is the best because the pain associated with prinzmetal angina is due to smooth muscle spasms.
24
Q
What should be avoided in prinzmetal angina?
A
Beta Blockers
*This will result in unopposed alpha stimulation thus worsening the symptoms.
25
What will differentiate unstable angina from NSTEMI?
- Both present the same with similar EKG changes
| * NSTEMI will have elevated cardiac biomarkers were unstable angina will not have elevated cardiac biomarkers
26
How long should one monitor clinical suspicion for a MI?
- Most MI's can be excluded > 6 hours, however if highly suspicious one should continue to monitor for 12 hours.
* Troponin I is the most specific for cardiac damage and should be trended.
27
What should you proceed with caution in administering nitrates to patients with inferior MI's?
-Because if one is having an inferior MI if may affect the right ventricle, thus nitrates may caused a sudden and severe drop in blood pressure. This occurs because this area of the heart is "Preload dependent," and if you already lose preload and add more loss with HOTN it will cause even greater HOTN.
28
What medications should be given to ALL patients post MI?
1. ASA (IF allergy then give Clopidogrel)
2. Beta blockers (Metoprolol or Atenolol)
3. ACE Inhibitors
4. Statins
29
What do the guidelines say about screening for AAA?
- Screen all MALES > 65 years + Smoker or Hx of smoking
| * US (GOLD) x 1 time
30
What should steroids be given to a patient with suspected GCA "Giant Cell Arteritis" before doing a Bx?
-Because optic nerve ischemia can develop leading to blindness!
31
What is the only medication with proven benefit in PAD "Peripheral Artery Disease"?
-Cilostazol
32
What is the most common vein affected in patients with superficial thrombophlebitis?
Saphenous vein
33
What are the risk factors for a DVT?
Virchow's Triad
1. Hypercoagulability
2. Stasis
3. Endothelial injury
*not present then its an "Unprovoked DVT"
34
When should a D-Dimer be ordered for a DVT?
IF low clinical suspicion (HIGH sensitivity but LOW specificity)
35
How does respiration affect murmurs?
- INSPIRATION = INCREASES right sided murmurs
- EXPIRATION = INCREASES left sided murmurs
* Inspiration will increase right ventricular filling but decreases left ventricular filling.
36
What are the most common symptoms in a patient with aortic stenosis?
1. Dyspnea
2. Angina
3. Dizziness
37
Which valvular abnormality will present with a "Water Hammer Pulse"?
Aortic Regurgitation
38
What are the most common etiologies in endocarditis?
Streptococcus Viridans or Staph. Aureus (IVDU)
39
How will patients with endocarditis present?
-New murmur or a change in murmur + Fever
40
What is the first test to order in patients with suspected endocarditis?
-BLOOD CULTURES
* ECHO is performed after blood cultures have been gathered.
* Antibiotics are given after 3 blood cultures 1 hour apart have been collected.
41
What is the classic EKG finding present in patients with pericarditis?
Diffuse ST elevations + PR depression
42
What is "Beck's Triad" and when will it be found?
Cardiac tamponade
1. HOTN
2. JVD
3. Muffled heart sounds
43
Under what percentage for ejection fraction is considered systolic (HREF) dysfunction?
-EF
44
What is the most common etiology for CHF?
CAD
45
What are the most common symptoms of CHF?
1. Fatigue
2. SOB / Orthopnea / Paroxysmal Nocturnal Dyspnea
3. Pedal edema
4. JVD
5. S3 Gallop
46
What other tests should be performed aside from an ECHO for CHF?
- EKG
* This should be performed to screen for arrhythmias and for "Q Waves" (Old Infarct), LVH, or other signs of ischemia.
- CXR
* Used to evaluate dyspnea not CHF
47
What are the main drugs in the treatment of lowering mortality for CHF?
1. ACE/ARB's
2. Beta Blockers
- Carvedilol
- Bisoprolol
- Metoprolol Succinate
*NEVER give beta blockers during acute exacerbations
48
What are the main drugs in the treatment of reducing symptoms for CHF?
1. Diuretics (Reduce fluid overload)
2. Digoxin (Decreases time spent hospitalized)
3. Spironolactone or Eplerenone (Class 3 and 4 CHF)
4. Nitrates + Hydralazine (If symptoms / AA)
5. ICD (IF EF
49
When should an ICD be used?
1. EF 1 year.
50
What tests should be performed for an acute exacerbation of CHF?
1. ECG (Arrhythmias / MI)
2. BNP (Sensitive but not specific, as a normal BNP excludes CHF but an elevated BNP can be variety)
- BNP > 400 increased likelihood of CHF
- BNP
51
What are the treatments for an acute exacerbation of CHF?
LMNOP
1. Loop diuretic
2. Morphine
3. Nitrates
4. Oxygen
5. Position (Head up) + Positive pressure
*AVOID Beta blockers / Ca Channel Blockers
52
What is the most common etiology of cardiomyopathy?
-Genetic components
53
What are the 3 main types of cardiomyopathy?
1. Dilated Cardiomyopathy
2. Hypertrophic Cardiomyopathy
3. Restrictive Cardiomyopathy
54
What is the most common complication arising from cardiomyopathies?
CHF
55
What are the symptoms of cardiomyopathy?
The same as CHF
56
What are the diagnostics for cardiomyopathy?
Echocardiogram (Distinguish between 3 types)
57
What is the etiology of "Dilated cardiomyopathy"?
- Ventricles become dilated thus decreasing the ability of the ventricle to contract.
* Systolic dysfunction
58
What is the treatment of "Dilated cardiomyopathy"?
-Same as CHF
59
What is the etiology of "Hypertrophic cardiomyopathy"?
- Normal ventricles or ventricles with reduced filling capacity + Hypertrophic (Larger) ventricles + PRESERVED EF
* Diastolic dysfunction
60
What are the treatments for "Hypertrophic cardiomyopathy"?
1. Beta Blockers + (Follows BB) Calcium Channel Blockers
61
What is the etiology of "Restrictive cardiomyopathy"?
Reduced filling capacity WITHOUT Hypertrophic (Larger) ventricles + REDUCED contraction of the ventricles
*Least common
*Diastolic dysfunction leading to Systolic dysfunction
62
What is the treatment of "Restrictive cardiomyopathy"?
NONE
63
How do you distinguish hypertrophic cardiomyopathy versus hypertrophic obstructive cardiomyopathy "HOCM"?
IN "HOCM" the SEPTUM causes an obstruction to the normal blood flow out of the aorta and is most commonly seen in young healthy athletes who die suddenly.
64
What is the most common symptom of HOCM?
Dyspnea
65
What is the treatment for HOCM?
Beta Blockers
*CONTRAINDICATIONS = Diuretics
66
What can an ASD eventually lead to if it is not treated?
1. CHF
| 2. Respiratory infections
67
Whats the heart murmur associated with an ASD?
Systolic ejection murmur + Wide fixed splitting of S2
68
Whats the best test to confirm ASD diagnosis?
Echocardiogram
69
Whats the treatment for an ASD?
Most will close spontaneously, however surgery my be performed
70
What are the most common presentations for coarctation of the aorta?
1. HTN
| 2. Respiratory distress
71
What are the physical examination findings associated with coarctation of the aorta?
Reduced Blood Pressure + Reduced pulse in the LE
72
How is a coarctation of the aorta diagnosed?
1. Echocardiogram
2. CXR (GOLD)
- Rib Notching
- 3 Sign
73
What is the treatment for a coarctation of the aorta?
-Surgical
74
What is a PDA originally the connection between?
A PDA is a patent "Ductus Arteriosus," which is the failure of the ductus arteriosus to close and become the "Ligamentum Arteriosum" between the aorta and pulmonary artery.
*Aorta > Pulmonary Artery
75
What is responsible for allowing the ductus arteriosus to remain open?
1. Low Oxygen
| 2. Prostaglandins
76
What murmur is associated with a PDA?
Machine like continuous murmur
77
How is a PDA diagnosed?
Echocardiogram
78
What are the mainstay treatments for a PDA?
1. Premature Infants = Indomethacin (Prostaglandin Inh.)
| 2. Others = Surgical ligation / Percutaneous Catheter Closure
79
What are the 4 characteristics of "Tetralogy of Fallot"?
1. RVH (Right Ventricular Hypertrophy)
2. VSD (Ventricular Septal Defect)
3. Overriding aorta
4. Right ventricular outflow obstruction (Pulmonary HTN)
80
What is murmur is associated with "Tetralogy of Fallot"?
Harsh / Systolic ejection murmur / Heard best at LSB
81
How is "Tetralogy of Fallot" diagnosed and treated?
```
Diagnosed = Echocardiogram
Treated = Surgical repair
```
82
What is Eisenmenger syndrome as it is associated with a VSD?
With a VSD initially there will be a left > right shunt which will eventually lead to pulmonary HTN. As the pressures increase in the pulmonary vasculature and into the right ventricle the shunt will then be reversed going right > left and becoming "Acyanotic" into the systemic circulation.
83
What murmur is associated with a VSD?
1. Holosystolic murmur that DOES NOT change with respiration
84
How is a VSD diagnosed and treated?
```
Diagnosed = Echocardiogram
Treated = Spontaneous closure unless symptomatic child which will then require surgical repair
```
85
What is the definition of HTN?
Systolic > 140 / Diastolic > 90 (At least 2 occasions)
*IF > 60 years then treat systolic > 150 or diastolic > 90 (Unless they have DM / CKD then treated as normal values)
86
What are the 2 stages of HTN?
1. Stage 1:
- Systolic: 140-159
- Diastolic: 90-100
2. Stage 2:
- Systolic: > 160
- Diastolic: > 100
87
What is the most common cause of HTN and secondary cause?
1. Primary HTN "Essential" most common
| 2. Renal disease (Most common secondary cause)
88
What are the symptoms of HTN?
1. Asx or HA (Even though some sources deny the claim)
89
When suspicious of HTN what should one be cautious of and what orders should be performed?
End Organ Damage
1. U/A
2. Urine micro albumin
3. EKG
4. CBC
5. BMP
6. Lipid panel
90
What should the physical examination include is HTN is suspected?
1. Fundoscopy (Hemorrhage or Papilledema)
2. Thyroid
3. Carotid / Renal bruits
4. Size and rhythm of heart
5. Crackles in the lungs
6. Pedal edema
7. Confusion or weakness
91
What is the INITIAL treatment for HTN?
1. LIFESTYLE RECOMMENDATIONS
- Diet "DASH"
- Weight loss
- Smoking cessation
- ETOH moderation
- Sodium moderation
- Exercise
*IF these DO NOT work then initiate pharmaceutical approach.
92
What is the typical pharmaceutical approach for treatment of HTN?
Stage 1 (140-160 / 90-100)
1. Diuretic (HCTZ / Chlorthalidone) or
2. ACE/ARB's or
3. Amlodopine
93
What is the typical pharmaceutical approach for treatment of HTN?
Stage 2 (> 160 / >100)
2 Drug regimen (Diuretic + Another drug)
| *The other drugs is typically indicated based on their current co-morbid condition.
94
What is the typical pharmaceutical approach for treatment of HTN + DM?
Stage 2 (> 160 / >100)
Diuretic + ACE/ARB's (Protects the kidney)
95
What is the typical pharmaceutical approach for treatment of HTN + CHF/Ischemia/CAD?
Stage 2 (> 160 / >100)
Diuretic + Beta Blockers or ACE/ARB's
96
What is the typical pharmaceutical approach for treatment of HTN + Angina?
Stage 2 (> 160 / >100)
Diuretic + Beta Blockers or Ca Channel Blockers
97
What is the typical pharmaceutical approach for treatment of HTN + BPH?
Stage 2 (> 160 / >100)
Diuretic + Alpha Blockers
98
What is the typical pharmaceutical approach for treatment of HTN + Hyperthyroid?
Stage 2 (> 160 / >100)
Diuretic + Beta Blockers
99
What is the typical pharmaceutical approach for treatment of HTN + CKD?
Stage 2 (> 160 / >100)
Diuretic + ACE/ARB's
100
What is the typical pharmaceutical approach for treatment of HTN + Reynauds?
Stage 2 (> 160 / >100)
Diuretic + Ca Channel Blockers
101
What is the typical pharmaceutical approach for treatment of HTN + Migraines?
Stage 2 (> 160 / >100)
Diuretic + Beta Blockers or Ca Channel Blockers
102
What is the definition of resistant HTN?
HTN that is non responsive to at least 3 medications (1 must be a diuretic)
103
Who should you begin to evaluate for secondary causes of HTN?
1. Resistant HTN
| 2.
104
What are clues that secondary HTN may be due to "Renal Artery Stenosis"?
-Abdominal Bruit
105
What are clues that secondary HTN may be due to "Hyperaldosteronism"?
-Hypokalemia + Hypernatremia
| Low K) + (High Na
106
What are clues that secondary HTN may be due to "Primary Kidney Disease"?
Elevated creatinine
107
What are clues that secondary HTN may be due to "Pheocromocytoma"?
ACUTE episodes of HTN + HA + Palpitations + Sweating
108
What are clues that secondary HTN may be due to "Cushings"?
- Moon Face
- Central Obesity
- Buffalo Hump
- Proximal muscle weakness
109
What are clues that secondary HTN may be due to "Sleep Apnea"?
-Obese men who snore
110
What are clues that secondary HTN may be due to "Coarctation of Aorta"?
- HTN as a child
| - HTN of UE + Diminished in the LE (Low pulses)
111
What is the definition of a HTN urgency?
-Severely elevated HTN systolic > 180 / diastolic > 120
112
What are the complications associated with HTN urgency?
The patient is typically Asx and NO end organ damage
113
What is the treatment for a HTN urgency?
DO NOT BRING DOWN TOO QUICKLY = MI or CVA
*CONTRAINDICATED = Sublingual Nifedipine (Drops to quickly)
One should aim to lower the blood pressure gradually over 1-2 days by initiating control with 2 BP medications then f/u in 2 days
114
What is the definition of a HTN emergency?
Severely elevated HTN systolic 120
115
What are the complications associated with HTN emergency?
INCLUDES End organ damage
* Malignant HTN
* Hypertensive Encephalopathy
116
What is the definition of malignant HTN?
1. HTN emergency
2. Ophthalmolgical findings (Papilledema + Exudates + Retinal hemorrhages)
3. AKI (Hematuria / Proteinuria) and/or
4. Focal neurological findings
117
What is the definition of HTN Encephalopathy?
1. Cerebral edema:
- HA
- Confusion > Seizure > Coma
118
What are the diagnostics for HTN emergency?
Focal neurological findings = MRI (R/o stroke)
119
What is the treatment for HTN emergency?
GOAL: Reduce BP of diastolic to 100 over 6 hours until controlled then begin PO tx until the diastolic is
120
What is the definition of cardiogenic shock?
A shock state characterized by reduced perfusion and oxygenation of tissue which if not treated will lead to cell death, organ failure, and death.
*Basically the heart cannot pump normally
121
What is the most common etiology of cardiogenic shock?
Most common = MI
*Can occur from anything that causes the heart to stop pumping efficiently
122
What are the symptoms of cardiogenic shock?
1. HOTN
2. AMS
3. Cool / Clammy skin
4. Chest pain
5. Dyspnea
6. Findings:
- HR (Increased)
- Metabolic Acidosis (Late finding)
- Elevated cardiac biomarkers
123
What is the treatment for cardiogenic shock?
Stabilize:
| 1. Aggressive IVF > Pressors (NE / Dopamine) PRN
124
What is the most common age affected by orthostatic HOTN?
> 65 years due to autonomic dysfunction and becomes an inadequate response to postural changes
125
What are the causes of orthostatic HOTN?
1. Medications
2. Hypovolemia
3. Anemia
4. Heart Disease
5. DM
6. Parkinson's
126
What are the signs and symptoms of orthostatic HOTN?
Upon standing the patient feels... dizzy with palpitations and even becomes syncopal
127
How is the diagnosis made for orthostatic HOTN?
Take the blood pressure while the patient is lying down followed by after the patient had been standing for a couple minutes.
*Systolic BP Falls > 20mmHg / diastolic BP Falls > 10mmHg
128
What is the treatment for orthostatic HOTN?
1. Treat underlying condition
| 2. IF no underlying condition... INCREASE fluids and Na
129
What is the pharmaceutical treatment for orthostatic HOTN?
Fludrocortisone "Mineralcorticoid" (GOLD)
130
What is the most common cardiac arrhythmia?
Atrial Fibrillation
131
What are patients with Atrial Fibrillation at an increased risk for and why?
Strokes secondary to thrombus formation because of the constant quivering of the atria causing the blood to become stagnant and allowing a clot to form.
132
What are the signs and symptoms of atrial flutter/atrial fibrillation (Worsening of flutter)?
1. Palpitations
2. SOB
3. Chest Pain
133
What are the diagnostics for Atrial fibrillation?
ECG:
| -Irregularly Irregular without "P" waves
134
What are the diagnostics for Atrial flutter?
ECG:
- Regular with "Saw tooth" pattern
- Atrial rate of > 300 bpm
- Ventricular rate of > 150 bpm
135
What is the treatment for both atrial flutter and atrial fibrillation IF
Cardioversion (GOLD) and/or Rate control
*Safe if the patient has been symptomatic
136
What should be performed if this is the first episode?
Echocardiogram to evaluate for thrombus formation "Trans-esophageal Echo"
137
What is the treatment for both atrial flutter and atrial fibrillation IF > 2 days of symptoms?
*High risk of thrombus formation.
1. Rate control (GOLD)
- Beta Blockers
- Ca Channel Blockers (Verapimil or Diltiazem)
2. Cardioversion (IF Requested)
* First order ECHO to r/o thrombus formation and IF NO thrombus then give "Heparin" prior to the cardioversion. IF YES there is a thrombus then you must anticoagulate with "Warfarin" for 4 week prior to cardioversion.
138
What must you always include in every plan for the treatment of atrial flutter or atrial fibrillation?
Long term anticoagulation therapy with either ASA or Warfarin based on the "CHADS2" score.
139
What is the CHADS2 Score in association with long term treatment of atrial flutter or atrial fibrillation?
```
C- CHF (1 point)
H- HTN (1 point)
A- Age of 75 (1 point)
D- Diabetes (1 point)
S- Stroke or TIA in past (2 points)
```
*IF 0 = ASA / 1 = ASA or Warfarin / > 1 = Warfarin
140
What are the types of heart blocks?
1. First Degree
2. Second Degree:
- Mobitz 1 "Wenckebach"
- Mobitz 2
3. Third Degree
141
What is the definition and treatment for a first degree heart block?
- Prolonged "PR Interval" > 0.20
| * No treatment required
142
What is the definition for a second degree (Mobitz 1 "Wenckebach") heart block?
-"PR Interval" progressively prolongs and lengthens until it completely drops a "P wave" and "QRS complex."
143
What is the treatment for a second degree (Mobitz 1 "Wenckebach") heart block?
IF Asx = No treatment
IF Sx (Signs of hypoperfusion) = Pacemaker
144
What is the definition for a second degree (Mobitz 2) heart block?
Same as Mobitz type 1 with the dropping of a "P wave" and "QRS complex" except without the progressive prolongation or lengthening of the "PR Interval."
*No change in "PR Interval"
*Patient may arrive with Syncope
145
What is the treatment for a second degree (Mobitz 2) heart block?
EVERYONE gets Pacemaker because this could eventually lead to a 3rd degree "Complete" block.
146
What is the definition for a third degree heart block?
"Complete heart block" as no signals cross from atria to ventricle.
-Complete disassociation of the "P" waves from the "QRS complexes" as seen with a deficit between the two.
147
What is the treatment for a third degree heart block?
Pacemaker (Fatal)
148
What is the pathophysiological cause of a RBBB?
Electrical activity within the purkinje fibers are slowed
149
Where does the majority of the Right bundle receive its blood supply?
LAD
*Also supports the Left bundle
150
What are the diagnostics for a RBBB?
ECG:
- Wide "QRS" > 0.12
- RSR "Rabbit Ears" in leads V1 or V2
- S wave wider than R wave in V5 and V6
151
What is the treatment for a RBBB?
1. Asx = No treatment
| 2. Sx = Pacemaker
152
What is are the diagnostics for a LBBB?
ECG:
- Wide "QRS" > 0.12
- R is "Notched" in V5 and V6
153
What is the treatment for a LBBB?
1. Asx = No treatment
2. Sx = Pacemaker
*ALWAYS treat this and suspect MI or infarction
154
What is the presentation of a patient suspected of "Paroxysmal Supraventricular Tachycardia"?
Tachycardia that is intermittent and abrupt and patients will present with abrupt onset of PALPITATIONS and "Racing heart."
155
What are the diagnostics for a patient suspected of "SVT"?
ECG:
-Narrow complex tachycardia
*Be on the look for WPW d/t adenosine contraindication for worsening to V-Tach or V-Fib.
156
What is the treatment of an individual in SVT?
Assess if they're hemodynamically unstable:
- HOTN
- SOB
- Chest pain
- AMS
* IF Unstable = Cardiovert
* IF Stable = Vagal maneuvers (Valsalva/Carotid massage) which will hopefully allow you to see "P waves" + Adenosine (GOLD) 6mg / 12mg
157
What are the symptoms of PVC's?
1. Asx, however if symptomatic "Palpitations"
158
What are the diagnostics for PVC's?
ECG:
| -Wide complex "QRS" without "P waves" + Compensatory pause after the "QRS"
159
Why is there a compensatory pause after the wide complex "QRS" in PVC's?
Because the AV node will be blocked for a short period not allowing the signal from the SA node to reach the ventricle, however then the AV node clears up and a normal "P wave" and "QRS complex" are seen.
160
What is the treatment for PVC's?
1. Asx = NO treatment necessary
| 2. Sx (Palpitations) = Beta Blocker
161
What are the symptoms of PAC's?
1. Asx, however if symptomatic "Palpitations"
162
What are the diagnostics for PAC's?
ECG:
| -An early "P wave" before expected + Different morphology of the "P wave"
163
What is the treatment for PAC's?
1. Asx = NO treatment necessary
| 2. Sx (Palpitations) = Beta Blockers
164
What is the definition of Sick Sinus Syndrome?
SA node dysfunction associated with fibrous tissue covering the SA node
165
What is the diagnostics for Sick Sinus Syndrome?
ECG:
- Alternations between bradycardia and tachycardia
- Sinus arrest without an appropriate escape rhythm
- An inappropriate response to stress
*Symptoms are inconsistent and non-helpful
166
What are the treatment for Sick Sinus Syndrome?
Pacemaker
167
What is the definition of ventricular tachycardia?
Wide complex tachycardia (PVC's) x 3 consecutive PVC's
*Treat ALL wide complex tachycardia as V-Tach
168
What is the treatment for V-Tach?
IF Unstable = Cardioversion
IF Stable:
1. Amiodorone or Procainamide
2. Cardiovert (IF pharmaceuticals do not convert)
169
What is the definition of "Torsades De Pointes"?
Polymorphic ventricular tachycardia due to prolonged QT interval
170
What is the treatment for "Torsades De Pointes"?
1. Withdraw offending drugs +
2. Correct electrolyte abnormalities +
3. Cardiac Pacing +
4. IN ACUTE setting:
- Mg Sulfate
171
What is the definition of ventricular fibrillation?
No organized electrical activity
172
What is the treatment for ventricular fibrillation?
STAT: (In this order) "CC SESA"
1. Cardioversion
2. CPR
3. Shock
4. Epinephrine
5. Shock
6. Amiodarone
173
What is the definition of stable angina?
Myocardial ischemia from exertion (INCREASE O2 demand)
174
What is the definition of Prinzmetal angina?
Myocardial ischemia due to coronary artery spasming and OCCURS AT REST
175
What are the risk factors for angina?
1. HTN
2. Smoking
3. Hyperlipidemia
4. DM
5. Obesity
176
What are the symptoms of stable angina?
1. Chest Pain with exertion + relieved with rest or Nitro.
- NEVER OCCURS AT REST
2. Chest pain is predictable
177
What are the risk factors for stable angina?
CAD (Coronary Artery Disease)
178
What are the diagnostics for stable angina?
1. ECG:
- Normal
2. Cardiac biomarkers = NOT ELEVATED
* STEMI = ELEVATED
*IF diagnosis is unclear = Perform stress testing
179
What are the diagnostics for Prinzmetal angina?
1. ECG:
- ST segment elevations which return immediately to baseline after the episodes (Lasts 5-15 minutes)
* STEMI = Will not return to baseline so quickly
2. Cardiac biomarkers = NOT ELEVATED
* STEMI = ELEVATED
*IF diagnosis is unclear = Perform stress testing
180
What are the treatments for Stable Angina?
Same treatment as HTN and ensure comorbidities are controlled (DM and hyperlipidemia)
1. ASA + Beta Blocker + Nitro (GOLD)
-Beta blocker: Reduces heart rate which allows increased ventricular filling and thus reduces oxygen demand
(Ca Channel Blockers if Beta Blockers are contraindicated or maxed which is when you add the Ca Channel Blockers)
-Nitro: Reduces the chest pain
*IF can't control symptoms with pharmaceuticals then REFER for angiography and revascularization
181
What are the treatments for Prinzmetal Angina?
Ca Channel Blockers to remove the spasming of smooth muscles.
*DO NOT use beta blockers in prinzmetal angina as this may worsen the spasming due to unopposed alpha receptors.
182
What conditions are associated with "Acute Coronary Syndrome"?
1. UNSTABLE Angina
2. NSTEMI
3. STEMI
183
What are the diagnostics for "Acute Coronary Syndrome"? (1)
1. ECG:
- IF UNSTABLE Angina or NSTEMI you will signs of ischemia (ST Depression or T Wave Inversion).
- IF STEMI you will have (ST Elevation > 1 mm in at least 2 leads)
* REPEAT every 10 minutes
* The first ECG change IF infarction will be "Hyperacute T Waves"
* Treat a "NEW LBBB" as an infarction
184
What are the diagnostics for "Acute Coronary Syndrome"? (2)
1. Cardiac Enzymes:
- CK-MB (Rise in 4 hours and stay elevated for a couple of days)
- Troponins (GOLD especially Troponin-I) (Rise > 4 hours and stay elevated for 2 weeks)
* IF Troponin increases > 20% then reinfarction is diagnosed. (Because of this you should always trend serial cardiac biomarkers as negative biomarkers can excuse diagnosis in 6 hours, but should continue high risk > 12 hours).
185
How are UNSTABLE Angina and NSTEMI/STEMI differ in diagnosis?
-UNSTABLE Angina will NOT have cardiac biomarker elevations, whereas STEMI/NSTEMI WILL HAVE cardiac biomarker elevations.
186
What is the treatment for ALL patients presenting with ACS?
IMMEDIATELY give:
1. Morphine
2. Oxygen
3. Nitrates (AVOID if on Phosphodiesterase-5 Inhibitors or if suspected INFERIOR MI as it will cause HOTN)
4. ASA (Chewable)
5. Beta Blocker (Metoprolol or Atenolol)
6. Statin (Atorvastatin)
187
IF STEMI is diagnosed what is the next step in the treatment?
1. Heparin (ALL) + PCI (GOLD compared to thrombolytics)
* PCI must be done within 90 minutes of arrival.
* IF PCI unavailable or unable to get to a center within 90 minutes then give "Thrombolytics." (Give if chest pain
188
What are the contraindications for "Thrombolytic therapy"?
1. Coagulation disorder
2. Severe HTN
3. Internal bleeding
4. Hemorrhagic stroke
189
IF NSTEMI or UNSTABLE Angina what is the next stop in the treatment?
1. Ticagrelor "Brilinta" or
| 2. GP IIb/IIIa Inhibitors
190
What is the long-term post treatment for NSTEMI/STEMI?
ALL patients should be continued on...
1. ASA
2. Beta Blockers (Metoprolol or Atenolol)
3. ACE/ARBs
4. Statin
*Clopidogrel if ASA allergy
191
IF suspect MI associated with cocaine use what is the treatment and treatment modification?
1. Treat the same as all ACS
| 2. AVOID Beta Blockers and replace with "Benzodiazepines"
192
What is the definition of an Aortic dissection/aneurysm?
- An aneurysm is a dilation of the aorta (Usually BELOW the renal artery).
- A dissection is a tear in the aortic wall.
193
What is the screening guidelines for AAA?
A one time screening in the following risk factors:
1. Men
2. > 65 years
3. Smoker or Hx of smoking
*Dissection is associated with "Marfan's syndrome" or "Ehler's-Danlos Syndrome"
194
What are the symptoms of an AAA?
1. Abdominal or back pain
2. Pulsatile abdominal mass
* Most are asx until a dissection occurs.
195
What are the symptoms of an AAA dissection?
1. Elder man + Severe TEARING chest pain to inter scapular back pain.
196
What are the diagnostics for a AAA or dissection?
1. US (GOLD)
2. Dissection (BP differences between both arms)
3. CXR (Widened mediastinum)
* TEE, CT, MRI (More specific than CXR)
197
What are the treatments for an AAA?
1. IF 5.5 cm = SURGICAL REPAIR
198
What are the treatments for a dissection?
1. IF "Type-A or Ascending Aorta" = Surgery
2. IF "Type-B or Descending Aorta" = Beta Blocker and surgery IF complete rupture or EOD.
*IMAGING x every 6 months to look for degeneration.
199
What are majority of emboli caused from?
Secondary to MI or AFIB and travel to the lower extremities.
200
Where are the most common location of emboli?
Blockages occur at areas of excessive plaque formation or at bifurcations.
*Femoral artery (Most common)
201
What are the symptoms of a LE emboli?
Acute ischemia:
1. Pain
2. Weakness
3. Numbness
4. Asx (Because most emboli are due to chronic plaque formation, thus still capable of collateral circulation)
202
What is the treatment for acute embolism?
1. Anticoagulation
203
What is the definition of "Giant Cell Arteritis"?
Vasculitis of the extracranial branches of the carotid artery.
204
What are the symptoms of "Giant Cell Arteritis"?
1. HA
2. Jaw claudication
3. Visual disturbances
4. Scalp tenderness
205
What are the diagnostics of "Giant Cell Arteritis"?
1. Women > 50
2. ESR (ELEVATED)
* IF ESR is not elevated then it virtually excluded the diagnosis.
3. Temporal artery Bx (GOLD)
206
What is the treatment of "Giant Cell Arteritis"?
1. Prednisone (This is important because this will help to AVOID blindness from optic nerve ischemia)
* DO NOT wait for Bx to start the prednisone if "GCA" is suspected.
207
What are the systolic murmurs?
1. Aortic Stenosis
2. Pulmonic Stenosis
3. Mitral Regurgitation
4. Mitral Valve Prolapse (MVP)
5. Tricuspid Regurgitation
208
What is the etiology of Aortic Stenosis?
1. Elderly due to calcifications of the aorta.
2. Congenital bicuspid or unicuspid valve disorder.
3. Rheumatic disease
209
What are the symptoms of Aortic Stenosis?
1. Dyspnea
2. Angina
3. Dizziness
4. Syncope
210
What does the murmur Aortic Stenosis sound like?
1. Systolic
2. Crescendo-Decrescendo
3. Heard best at:
- 2nd Right ICS + Radiating to Neck
211
What is the treatment for Aortic Stenosis?
1. IF Symptoms:
| - Surgical correction (HIGH risk of SCD)
212
What are the symptoms of pulmonic stenosis?
1. Dyspnea
2. Fatigue
3. Syncope
213
What does the murmur Pulmonic Stenosis sound like?
1. Systolic
2. Heard best at:
- Left Upper Sternal Border + Ejection Click
214
What is the treatment for Pulmonic Stenosis?
1. Balloon Valvotomy, however if severe then must have surgically corrected.
215
What is the etiology of Mitral Regurgitation?
1. MVP
| 2. CAD
216
What are the symptoms of mitral regurgitation?
1. Asx
2. Dyspnea
3. Fatigue
217
What does the murmur for Mitral Regurgitation sound like?
1. HOLOsystolic (Lasting entirety of systole)
2. Heard best at:
- Apex + Radiates to the Axilla.
218
What is the treatment for Mitral Regurgitation?
1. IF asx then no treatment
2. IF symptoms:
- Vasodilators, however is severe or worsening then surgical repair.
219
What are the symptoms of MVP?
1. Asx
2. Chest pain
3. Palpitations
4. Anxiety
*Women
220
What does the murmur for MVP sound like?
1. MID-sysolic click + Potential Late Systolic
| * Depends on the severity of regurgitation.
221
What is the treatment for MVP?
1. Beta Blockers
222
What is the etiology of Tricuspid Regurgitation?
1. Dilation of the RIGHT atrium and ventricle.
223
What are the symptoms of Tricuspid Regurgitation?
1. NON-SPECIFIC
| 2. CHF (Right sided)
224
What does the murmur for Tricuspid Regurgitation sound like?
1. HOLOsystolic
2. Heard best at:
- Left Mid-Sternal Border, however if SEVERE it will disappear.
225
What are the treatments for Tricuspid Regurgitation?
1. Diuretics (For symptoms) and treatment of CHF
| 2. IF Severe then surgery.
226
What are the diastolic murmurs?
1. Aortic Regurgitation
2. Pulmonic Regurgitation
3. Mitral Stenosis
4. Tricuspid Stenosis
227
What is the etiology of Aortic Regurgitation?
1. Dilation of the aortic root
2. Congenital bicuspid valve
3. Rheumatic disease (Most common)
228
What are the symptoms of Aortic Regurgitation?
1. Asx
| 2. Wide Pulse Pressure "Water Hammer Pulse"
229
What will the murmur for Aortic Regurgitation sound like?
1. BLOWING
2. IF it worsens it will become systolic (HOLOsystolic)
3. Heard best at:
- Left Sternal Border
230
What is the treatment for Aortic Regurgitation?
1. IF symptoms = Surgical
231
What is the etiology of Pulmonic Regurgitation?
1. Pulmonary HTN (Most common)
232
What does the murmur for pulmonic regurgitation sound like?
1. Decrescendo and just like Aortic regurgitation (BLOWING at Left sternal border)
233
What is the etiology of Mitral stenosis?
1. Rheumatic disease
234
What are the symptoms of Mitral Stenosis?
1. SOB
| * Pregnancy will exacerbate the symptoms or may cause the symptoms.
235
What does the murmur for Mitral Stenosis sound like?
1. LOW pitch rumble
2. Heard best at:
- Apex
236
What is the treatment for Mitral Stenosis?
1. Balloon valvotomy or Surgical
2. Control symptoms:
- Beta Blockers
- Diuretics
237
What is the etiology of Tricuspid Stenosis?
1. Rheumatic disease
238
What does the murmur for Tricuspid stenosis sound like?
1. Heard best at:
| - 4th ICS at the Left sternal border.
239
What is the treatment for Tricuspid Stenosis?
1. ACE-I + Diuretics (Symptoms)
| 2. If no improvements = Surgical
240
What condition is PAD associated with?
CAD
| -It is angina in the legs associated with leg pain with exertion + relieved by rest.
241
What are the diagnostics for PAD?
1. ABI (The ratio of the BP in the ankles and arms)
| * The test is positive =
242
What are the treatments for PAD?
1. ASA (All patients)
2. Monitor and correct the patients BP, lipids, and glucose.
3. Supervised 12 week exercise program (GOLD)
4. Cilostazol (Only medication to reduce pain)
243
What is the etiology of phlebitis/thrombophlebitis?
A thrombus within a superficial vein causes inflammation of the surrounding tissue.
*Most commonly affects individuals with varicose veins.
244
What are the symptoms for phlebitis/thrombophlebitis?
1. Pain
2. Tenderness
3. Erythema
4. Palpable cord (Thrombus)
245
What are the diagnostics for phlebitis/thrombophlebitis?
1. Duplex US
246
What are the treatments for phlebitis/thrombophlebitis?
1. Elevation
2. Warm compress
3. Compression stockings
4. NSAID's
*IF DVT or high risk of DVT = Anticoagulation
(LMWH or Warfarin x 4 weeks)
247
What are the risk factors for DVT's?
1. OCP use
2. Pregnancy
3. Cancer
4. Recent hospitalization or immobilization
*Some may have unprovoked DVT's
248
What are the symptoms of DVT?
1. UNILATERAL lower extremity:
- Pain
- Erythema
- Swelling
2. Homan's sign (Calf pain with dorsiflexion)
249
What are the diagnostics for a DVT?
1. Well's Criteria and IF:
| - 2 or elevated D-Dimer = US
250
What are the treatments for a DVT?
1. Heparin + Warfarin (Together)
* Overlap the medications x 5 days
2. Continue Warfarin x 3-6 months (INR 2-3)
3. IF Unprovoked DVT:
- Continue Warfarin indefinitely
251
Why should you overlap the prescription for Heparin + Warfarin for DVT treatment?
It takes a few days for warfarin to take effect and warfarin inhibits protein C and S initially, which therefore might increase the risk for clot formation over the first few days.
252
What is the definition of varicose veins?
Veins that become dilated > 3mm which is most commonly caused by faulty valves that cause blood to pool and dilate the veins.
253
What are the symptoms of varicose veins?
1. Dilation of veins
| 2. Leg pain + Swelling
254
What are the diagnostics for varicose veins?
1. Duplex US to evaluate reflux
255
What are the treatments for varicose veins?
1. Compression hose stockings + Leg elevation (GOLD)
| 2. Sclerotherapy
256
What are the diagnostics for valvular diseases?
Echocardiogram
257
How will inspiration affect murmurs?
Inspiration INCREASES right ventricular filling and DECREASES left ventricular filling thus:
- Right murmurs INCREASE with inspiration
- Left murmurs INCREASE with expiration
258
How does squatting/leg raising/handgrips affect the heart?
They INCREASE vascular resistance (Afterload) and INCREASE ventricular filling (Preload).
*The murmurs will all INCREASE with increased pre-load and after-load, except in MVP, which will DECREASE the murmur.
259
How does DECREASING the preload affect the murmur?
DECREASES the sound of all murmurs, except MVP which will INCREASE.
260
What is the definition of Endocarditis?
-Infection of the endocardial surface of the heart, which also extends to the heart valves.
261
What are the risk factors for Endocarditis?
1. Prosthetic heart valves
| 2. IVDU
262
What is the most common etiology of Endocarditis?
1. Organisms:
- Streptococci Viridans = Prosthetic / Native valves.
- S. Aureus = IVDU (Most common) + Vegetation on the right of heart valve.
263
What are the symptoms of Endocarditis?
1. New or change in previous murmur + Fever
2. Janesway Lesions (Painless palms/soles)
3. Osler Nodes (Painful on fingers/toes)
4. Roth spots (Pale retinal lesion surrounded by hemorrhages)
264
What are the diagnostics of Endocarditis?
1. Obtain blood cultures (3 separated by 1 hour)
* Must obtain prior to giving Abx
2. ECHO (Order after the blood cultures)
3. Duke's Criteria
265
Whats the Duke's criteria for Endocarditis?
*2 Major / 1 Major + 3 Minor / 5 Minor:
1. Major:
- (+) Blood cultures
- Vegetations on Echocardiogram
- New regurgitant murmur
2. Minor:
- Fever
- Vascular Phenomenon (Emboli of organs)
- Immunological Phenomenon (Roth/Janesway)
- (+) Blood cultures of uncommon pathogens
266
What are the treatments for Endocarditis?
1. (Ceftriaxone or Vancomycin) + Gentamicin
| * Continue until the cultures are returned then treat based on the culture.
267
What is the prophylactic treatment for Endocarditis?
1. Amoxicillin
268
Who are indicated for prophylaxis against endocarditis?
Give IF:
- Hx of Endocarditis
- Prosthetic valves
- Unrepaired cyanotic congenital heart disease
- Cardiac transplant patients
269
When should patients be treated prophylactically for Endocarditis?
Give IF:
- Dental procedures affecting the gingiva
- Invasive respiratory procedures
- Invasive treatment of skin infections
270
What is the etiology of pericarditis?
Inflammation of the pericardium and is most commonly associated with viruses or idiopathic.
271
What are the symptoms of pericarditis?
1. Pleuritic chest pain:
- Worsened with inhalation and supine positions
- Improved while sitting
2. Friction Rub
* Grating sound heard with bell
272
What are the diagnostics of pericarditis?
1. ECG:
- DIFFUSE ST-elevations + PR depression
2. CXR:
- Enlarged cardiac silhouette
3. Troponins (Elevated, however not infarction)
4. ECHO (Distinguish b/w MI and Pericarditis) with pericarditis they'll have a pericardial effusion without wall motion abnormalities.
273
What are the treatments for pericarditis?
-NSAID's
274
What is the etiology of cardiac tamponade?
-This occurs due to an excess pericardial fluid which then exerts pressure onto the heart thus leading to filling and hemodynamics being compromised.
275
What are the symptoms of cardiac tamponade?
1. Beck's Triad:
- HOTN
- Muffled Heart Sounds
- JVD
2. Pulsus Paradoxus (A drop in BP of at least 10mmHg with inhalation)
276
What are the diagnostics of cardiac tamponade?
1. ECG:
- Electrical alternans (QRS complexes alternate in amplitude)
2. CXR:
- Enlarged cardiac silhouette + Clear lung fields
3. ECHO:
- Pericardial effusion + Chamber collapse
4. Pericardiocentesis (GOLD for Dx/Tx)
277
What tests are found among a BMP (Chem-7)?
1. Na
2. K
3. Cl
4. Bicarbonate
5. BUN
6. Creatinine
7. Glucose
278
What tests are found among a CMP (Chem-12)?
1. Na
2. K
3. Cl
4. Bicarbonate
5. BUN
6. Creatinine
7. Glucose
8. Proteins total and Albumin
9. Bilirubin (Liver)
10. AST (Liver)
11. ALT (Liver)
12. ALP (Liver)
279
How many classes of Heart failure are there associated with NYHA classifications?
4
280
What is the definition of NYHA heart failure Class 1?
1. No limitations of physical activity
2. No fatigue with exercising
3. NO symptoms (Angina / Dyspnea)
281
What is the definition of NYHA heart failure Class 2?
1. SLIGHT limitations of physical activity
| 2. Symptoms with EXERCISE
282
What is the definition of NYHA heart failure Class 3?
1. MARKED limitations of physical activity
2. Comfortable at REST
3. Symptoms with LESS EXERCISE
283
What is the definition of NYHA heart failure Class 4?
1. CANNOT perform physical activity without discomfort
| 2. Discomfort at REST
284
What is the definition of Takotsubo Cardiomyopathy?
"Stress Induced Cardiomyopathy" which occurs after a major catecholamine discharge occurs thus HYPOcontractility of the left ventricles apex.
*Mimics an acute MI
285
What are the symptoms and diagnostics for Takotsubo cardiomyopathy?
The symptoms mimic an acute MI with retrosternal chest pain. The diagnostics are similar to include; an ECG (MI changes), cardiac biomarkers that are suggestive of an MI, and cardiac catheterization (Reveals HYPOcontractility of the left ventricular apex + patent coronary arteries).
*Patients usually return to baseline in 2 months.
286
What are the stages of infection and sepsis?
1. "SIR's" (Systemic Inflammatory Response Syndrome)
2. Sepsis
3. Severe Sepsis
4. Septic Shock
287
"SIR's" (Systemic Inflammatory Response Syndrome)?
2 or more of the following:
1. Temperature > 38C or 90
3. RR > 20 or PCO2 12,000 or 10% Bands
288
Sepsis?
SIR's + Suspected infectious source
289
Severe sepsis?
Sepsis + EOD + HOTN/Hypoperfusion
290
What are the signs of hypoperfusion in severe sepsis?
1. Lactic acidosis
2. Oliguria
3. AMS
291
Septic Shock?
Sepsis-induced HOTN despite adequate fluid resuscitation + Signs of Hypoperfusion
292
What is the definition of orthostatic HOTN?
> 20mmHg drop in systolic BP or
| > 10mmHg drop in diastolic BP when moving from supine and sitting/standing positions.
293
How can you tell if postural HOTN is associated with Hypovolemia?
If the postural HOTN is associated with an increase in pulse > 10bpm.
