Cardiology Flashcards
What does an S3 gallop denote and define the mechanism
Dilated LV
Occurs at beginning of diastole when blood rushes in and splashes within the dilated ventricle
What does the S4 gallop denote and define the mechanism
LVH
Occurs at end of diastole when atrial contraction occurs and sound is blood hitting stiff ventricular wall
CP worse on palpation
Costochondritis
CP worse with positional change
Pericarditis
CP pleuritic
PNA, PE, PTX, Pleuritis, Pericarditis
You have a case of very clear myocardial ischemia. What is the next best step, treatment or diagnosis?
Treatment (ASA, morphine, nitrates, oxygen)
When do CK-MB and troponin rise? What situations are they useful in?
3-6 hrs
CK-MB levels fall after 1-2 days so they’re good for looking for ischemia occurring after an infarct. Troponins stay high for 1-2 wks
What enzyme is one of the earliest to rise in myocardial ischemia?
Myoglobin
A patient comes in with chronic chest pain that is exertional and associated with jaw pain. EKG and troponins don’t establish the dx. What is your next diagnostic test?
Stress test
In what situations would you want a dipyridamole/adenosine thallium stress test or dobutamine echo for diagnostics?
When patients have reduced exercise tolerance and can’t achieve 85% maximum HR (i.e. COPD, obesity, deconditioning, amputation, leg ulcers, previous stroke, dementia)
In what situations would an exercise thallium stress test or stress echo be warranted for diagnostics?
When the EKG is unreadable due to ischemia (i.e. LBBB, ST abnormality at baseline, digoxin use, pacemaker in place, LVH)
Your patient comes in with a stress test for CP that demonstrates reversible ischemia. What is the next step in management?
Angiogram (do whenever there is reversible ischemia)
Angiogram results of myocardial ischemia demonstrates an infarction in LAD territory. At this juncture what may be the next best step in management?
Coronary bypass
What is the most accurate method to determine EF?
Nuclear ventriculogram
Your patient is having mild chest pain and presents with signs and symptoms consistent with myocardial ischemia. Should you do stress testing?
NO! Don’t do stress testing if the patient has current CP
Which treatment for ACS reduces mortality?
Aspirin
Oxygen and morphine do not
What is the mechanism of clopidogrel, ticagrelor, and prasugrel?
Inhibit ADP-induced activation P2Y12 receptor that causes aggregation of platelets
What medication is added to aspirin if a patient is having an acute MI?
An ADP inhibitor (clopidogrel or ticagrelor)
What medication is specifically provided to patients receiving an angioplasty?
Prasugrel
Besides aspirin, which treatments lower mortality in STEMI?
Primary angioplasty and thrombolytics
Angioplasty is one type of percutaneous coronary intervention (PCI). How quickly should this be done from arrival at ED?
90 minutes
Does angioplasty reduce mortality among patients with stable angina?
No
In what situation are thrombolytics given for ACS?
- When catheterization-based therapy is unavailable (i.e. rural hospital or nearest cath hospital is awhile away)
- Within 30 mins of reaching ED
- CP of
How do thrombolytics mechanistically work and why do they need to be provided within a certain time window?
Activate plasminogen to plasmin which chops fibrin strands of clots into D-dimers. The reason it needs to be given quickly is that with time factor VIII stabilizes fibrin and it cannot be cleaved by plasmin.
What medication reduces mortality in ACS but aren’t urgent?
Beta-blockers
ACEi and ARBs reduce mortality of ACS only when ….
There is evidence of left ventricular or systolic dysfunction
What medication should be given to all ACS patients regardless of EKG or troponin findings?
Statins
Why are beta-blockers helpful in ACS? (think mechanism)
Most common cause of death in MI and CHF is arrhythmia. By slowing heart rate they are anti-arrhythmic. They also allow more time for diastolic filling and thus providing oxygen to coronaries.
A patient presents with cocaine-induced chest pain. What medicine do you want to administer for rate control and to prevent arrhythmia?
CCB (i.e. verapamil, diltiazem)
*A beta-blocker will cause unopposed adrenergic effects on alpha receptors causing vasocontriction
In what 3 CP situations should you consider CCB for rate-control and anti-arrhythmic effect?
Cocaine-induced
Beta-blocker allergy
Coronary vasospasm/Prinzmetal angina
What medications would you want to give if an MI patient went into Vtach or Vfib?
Lidocaine or amiodarone
If there is any anatomic complication of an MI (e.g. septal wall rupture, valve rupture, cardiogenic shock, myocardial wall rupture) what is the appropriate means of diagnosis?
Echo
What is the management of a myocardial wall rupture post-MI?
Pericardiocentesis and urgent repair
How can a right-heart catheter (Swan-Ganz) be helpful in diagnosis of septal wall rupture post-MI?
Demonstrates a step-up in oxygen saturation when moving from RA to RV
For any electrical complication of MI (i.e. sinus bradycardia, RV infarction, or 3rd degree block) what is the diagnostic test which is useful?
EKG
What is the treatment of right ventricular infarction occurring post-MI?
Fluid loading
How long after an MI should a patient wait before having sex again?
2-6 weeks
All patients discharged post-MI should go home on what meds?
Aspirin, clopidogrel, statin, beta-blocker, ACEi
There are differences between mgmt of STEMI and NSTEMI.
Are thrombolytics used in NSTEMI?
What anticoagulation is used?
No thrombolytics
LMWH is used
What is the mechanism of heparin?
Potentiates antithrombin which inhibits almost all steps of clotting cascade. Heparin only prevents new clots from forming.
Do nitrates reduce mortality?
No
In chronic angina ACEi or ARBs should be used only if …. (3 situations)
CHF Systolic dysfunction Low EF (LV dysfunction)
Generally, can you do CABG before angiography?
No
What is the main difference in internal mammary artery grafts and saphenous vein grafts during CABG?
Internal mammary artery grafts stay open for 10 yrs whereas saphenous vein grafts occlude after 5 years
In a patient with CAD what role does ranolazine play?
Anti-angina med used to reduce pain if other meds haven’t reduced pain
What are indications for CABG?
1) Three vessel with > 70% stenosis
2) Two stenotic vessels in a diabetic
3) LAD with > 50-70% stenosis
4) Two or three vessels with low EF
What is the LDL goal in a patient with DM?
What is the most frequent side effect of statins?
Liver toxicity
What is the most common cause of erectile dysfunction?
Anxiety
For a patient presenting with acute pulmonary edema what is appropriate management?
Oxygen, furosemide, nitrates, morphine
What is the mechanism of carvedilol?
Antagonist of B1, B2, and alpha receptors
Thus it is anti-arrhythmic, anti-ischemic, and anti-hypertensive
When evaluating the patient with CHF during the CCS portion of the exam what initial tests do you want to order?
CXR
Echo (distinguish systolic vs diastolic dysfunction)
Oximetry
EKG
What is the MOA of imamrinone and milrinone? What effect do they have?
PDE inhibitors which decreased afterload by vasodilating and also increase contractility
How does CHF cause a respiratory alkalosis?
CHF causes hypoxia
Hypoxia causes hyperventilation
The majority of patients with acute pulmonary edema (which should be taken to ICU) will respond to: preload reduction or afterload reduction? If that doesn’t work then what drugs may be the next management step?
Preload reduction
If that doesn’t help (which it should in most) then give contractility increasing agents such as dobutamine, imamrinone, and milrinone
What is the treatment for Vtach associated with acute pulmonary edema?
What about when hemodynamically stable, sustained Vtach?
When with acute pulmonary edema: synchronized cardioversion
Stable: lidocaine, amiodarone, or procainamide
What is the management for Vfib or pulseless Vtach?
Unsynchronized cardioversion
What is nesiritide?
An atrial natriuretic peptide used for acute pulmonary edema preload reduction
What is the utility of measuring the BNP level?
If normal it can rule out CHF. BNP goes up in CHF and can see if SOB in a patient is likely from CHF
What will happen to cardiac output, RAP, wedge pressure, and systemic vascular resistance in acute pulmonary edema?
CO: Decreased
Wedge: Increased
RAP: Increased
SVR: Increased
Which three meds have been shown to reduce mortality in the chronic management of CHF from systolic dysfunction?
ACEi
Beta-blockers
Spironolactone (in more advanced cases)
*Diuretics may have a role but unclear effect on mortality
What role does digoxin have in the chronic mgmt of CHF from systolic dysfunction?
Lessens symptoms and frequency of hospitalizations (no mortality effect)
Patient with systolic CHF presents with gynecomastia and erectile dysfunction on spironolactone. What med do you want to switch him to?
Eplerenone
Diastolic dysfunction CHF is treated with …?
Beta-blockers and diuretics
When are patients with CHF candidates for an implantable defibrillator?
EF remaining below 35%
At what point is a patient a candidate for a biventricular pacemaker in CHF?
When EF 120ms
*QRS >120ms measn ventricles aren’t beating together and forward flow is compromised. The biventricular pacemaker helps gt them on the same page
What is an absolute contraindication to beta-blockers?
Symptomatic bradycardia
In a young patient with SOB worse on exertion and probable valvular heart disease what is the likely cause?
Mitral valve prolapse
Buzzwords
What valvular disease associated with immigrants and pregnant patients?
MItral Stenosis
Inhalation increases murmurs on what side of heart and why?
Right-side
Inhalation decreases intrathoracic pressure which increases venous return and thus more blood on right side
Exhalation increases murmurs on what side of heart?
Left-side
What effect does squatting and lifting legs in the air do to venous return?
Increases venous return
*Squatting will suddenly squeeze veins of legs and cause increased venous return
What effect does valsalva and suddenly standing do to venous return?
Decrease venous return
*Because Valsalva increases intrathoracic pressure
Which murmurs become louder with squatting and lifting legs in the air? Which become softer?
Louder: AS, AR, MS, MR, and all right-sided
Softer: HOCM murmur, MVP
Valsalva and standing both make which murmurs sound louder?
HOCM and MVP
What hemodynamic consequence does handgrip have and which murmurs will sound louder? (Hint: 3)
Increases afterload (but since veins in arm aren’t as big as in leg then there will be no effect on venous return)
AR, MR, and VSD will become louder
What hemodyanmic consequence does amyl nitrate have on murmurs and why?
It decreases afterload by vasodilating arteries and thus AR, MR, and VSD will be softer
What effect does amyl nitrate have on murmurs of MVP and HOCM? Why?
It makes them louder because it allows further emptying of LV which decreases LV size and increases degree of obstruction and prolapse in HOCM and MVP, respectively
What effects do handgrip and amyl nitrate have on AS?
Handgrip makes it softer
Amyl nitrate makes it louder
Where are pulmonic valve murmurs best heard?
Second left intercostal space
What murmurs are best heard at the lower left sternal border?
AR, tricuspid regurgitation, and VSD
What is the best initial test for diagnosis valve lesions?
What is the most accurate?
Initial: Echo
Accurate: Left heart catheterization
Regurgitant lesions are best treated with what meds?
Vasodilator therapy such as ACEi and ARBs
What is the best treatment for stenotic valvular lesions?
Anatomic repair
T/F
Diuretics can help any valve lesion which improves with valsalva
True
But in cases with stenosis anatoomic repair is still best
Anything which makes the LV smaller has what effect on murmurs of HOCM and MVP?
Increases intensity
Do bioprosthetic valves need anticoagulation?
No, but they don;t last as long as the mechanical valves which do require anticoagulation
Diastolic decrescendo murmur heard at left sternal border =
Aortic regurgitation
Quincke pulse, corrigan pulse, musset’s sign, duroziez’s sign, and hill sign are seen with what murmur? What are they each?
Quincke pulse: arterial or capillary pulsations in fingernail
Corrigan’s: water-hammer, high-bounding pulses
Musset’s: head bobbing up and down with each pulse
Duroziez: murmur heard over femoral artery
Hill sign: BP gradient much higher in lower extremities
What is medical mgmt of AR?
What is mgmt when EF
Medical mgmt: ACEi/ARB, nifedipine, or loop diuretic
Low EF: surgical mgmt
Rheumatic heart disease, endocarditis, and cystic medial necrosis can all cause what murmur?
AR
Rheumatic fever in immigrants and pregnant patients are at greater risk for what valvular condition?
Mitral stenosis
What are common presenting symptoms of mitral stenosis? (Hint: think anatomy)
Dysphagia, hoarseness, and afib
Opening snap followed by diastolic rumble =
Mitral stenosis
Based on listening to the murmur of mitral stenosis how can you determine how advanced a case it is?
The opening snap occurs earlier (that is, closer to S2)
Straightening of the left heart border and elevation of the left mainstem bronchus on CXR may indicate which valvular condition?
MS
What is the best initial therapy for MS?
What is the most effective therapy?
Initial: diuretics
Effective: balloon valvuloplasty
A holosystolic murmur heard best at apex and obscuring the S1 and S2 is …
MR
Ischemic heart disease and conditions which dilate the heart can cause which left heart valvular disorder?
MR
What is the best initial therapy for MR?
ACEi/ARB, nifedipine, loop diuretic
*If EF
Fixed S2 splitting is caused by …
ASD
Explain which types of cardiac conditions cause wide S2 splitting and which cause paradoxical S2 splitting?
Normally the aortic valve closes a little before the pulmonic. When inspiring there is increased venous return which causes the pulmonic valve to stay open longer which makes a noticeable split when they close.
Pathologies of right heart that delay pulmonic closure cause wide S2 (e.g. RBBB, pulmonic stenosis, RVH, pulmonoary HTN)
Pathologies that delay closure of aortic valve are often of left heart (e.g. LBBB
What are common causes of dilated cardiomyopathy?
Ischemic Alcohol Chagas disease Adriamycin Radiation
What is the treatment for all forms of dilated cardiomyopathy?
ACEi/ARB, beta-blockers, spironolactone
*Digoxin decreases symptoms but doesn’t prolong survival
What is the mainstem of therapy of hypertrophic cardiomyopathy?
Beta blockers and diuretics
What is Kussmaul’s sign? Which form of cardiomyopathy is it found in?
Increase in jugular venous distension seen on inhalation.
Restrictive cardiomyopathy
What is the single most accurate test of etiology of restrictive cardiomyopathy?
Endomyocardial biopsy
What is the classic presentation of pericarditis?
Pleuritic CP better when sitting up and leaning forward
Buzzword
Friction rub on exam
Pericarditis
Buzzwords
ST segment elevation in all leads
PR segment depression in lead II
Pericarditis EKG findings (the latter is pathognomonic)
What is the best initial therapy for pericarditis?
Colchicine combined with an NSAID
What is the classic presentation of pericardial tamponade?
SOB, hypotension, jugular venous distension (Kussmaul’s sign), muffled heart sounds pulsus paradoxus, electrical alternans
Describe the physiology of pulsus paradoxus
Inhalation causes increased venous return to right heart which compresses the LV and reduces SBP. In pericardial tamponade the whole heart is compressed so on inhalation it decreases by > 10 mmHg
Equalization of all pressures in the heart during diastole seen on right-heart cath should make you suspicious of ….
Pericardial tamponade
What is the best initial therapy for pericardial tamponade? What is the most effective long-term therapy?
Initial: pericardiocentesis
Long-term effectiveness: pericardial window placement
A patient presents with SOB, edema, and jugular venous distension. CXR shows calcification encircling the heart. What is the dx?
What is the best initial mgmt? Most effective?
Constrictive pericarditis (often with signs of chronic right heart failure)
Initial: diuretic
Most effective: pericardial stripping (surgical removal of pericardium)
Buzzword
Difference in BP between left and right arms
Aortic dissection
In a thoracic aorta dissection case what medicines should you start quickly? What do you order for diagnosis?
Beta-blockers and nitroprusside
CTA/MRA/TEE (any are correct)
What should you screen for in men >65 yo who have smoker or currently do?
Abdominal aortic aneurysm with ultrasound
When abdominal aortic aneurysms are greater than ____ they are repaired surgically
5 cm
What is the best initial test for dx of peripheral arterial disease? Most accurate?
Initial: ABI
Accurate: Angiography
Cilostazol is a medication used in what condition and why?
PAD because it is a vasodilator capable of helping the symptoms of claudification in the legs
Do CCBs help in PAD? Why?
No. CCBs dilate the muscular layer of the artery but the narrowing in the artery is closer to the lumen of the vessel
You find afib on an EKG of a patient who comes in the ED. What additional tests may you want to order?
Echo (look for valve function, clots, or LA size)
Thyroid testing
Electrolytes
CK-MB/Troponins
Tx of unstable afib
Synchronized cardioversion
What defines being hemodynamically unstable?
SBP
Tx stable afib
1) Rate control patients with beta-blockers, CCB, or digoxin
2) Anticoagulate if persisted > 2 days or unsure how long its been present
Should you heparin bridge patients with afib before placing them on warfarin?
No
What is the use of CHADS2? What are its components? How does it dictate treatment decision?
Estimates the risk of stroke in patients with afib
C= CHF; H = HTN; A = Age >75; D = DM; S = Stroke or TIA (worth two points)
If patients have score of 1 put on ASA
If patients have score 2 or greater than warfarin
Tx of unstable aflutter
Synchronized cardioversion
Tx of stable aflutter
Rate control similar to afib and consider anticoagulating
Polymorphic P waves in an arrhythmia associated with COPD is ….
What is tx?
Multifocal atrial tachycardia (MAT)
Oxygen first then diltiazem (DO NOT GIVE B-BLOCKERS)
Tx unstable SVT (initial mgmt)
Synchronized cardioversion
Tx stable SVT (initial mgmt)
Vagal maneuvers. If those don’t work then give IV adenosine
Tx SVT (long-term mgmt)
Radiofrequency catheter ablation
Worsening of SVT after giving CCB or digoxin may actually be what arrhythmia?
Wolf-Parkinson-White Syndrome
Tx Wolf-Parkinson-White (best initial)
Procainamide
Tx Wolf-Parkinson-White (best long-term mgmt)
Radiofrequency catheter ablation
SVT alternating with Vtach may indicate what arrhythmia?
WPW
Tx unstable Vtach
Synchronized cardioversion
Tx stable Vtach
Amiodarone, lidocaine, procainamide, magnesium
What is torsades de pointes and what should always be given?
Undulating Vtach often caused by prolonged QT interval
Magnesium should always supplement medical or electrical mgmt
Tx Vfib
Unsynchronized cardioversion
Tx pulseless VTach
Unsynchronized cardioversion
What should you order for concern of syncope?
EKG, Troponins/CK-MB, Echo, Head CT
