Cardiology Flashcards
IHD
The single most dangerous factor for cad
The single most dangerous factor for cad is diabetes
Physical exam for cp
CV: S3: dilated left ventricle
S4: LVH
Jugulovenous distention**
Holosystolic murmur of mitral regurgitation
Chest rakes
General. Distressed, sob, clutching chest
Ext Edema
CAD
the best initial diagnostic test
EKG is Always the best initial diagnostic test but
But if you had to choose btw ekg or meds. You do meds.
What is the most accurate test for cp
CK-MB Or troponon
WhAt is the best test for reinfarction
Ck mb
What is always the wrong answer
LDH level
LDH isoenzymes
Which of the following cardiac enzymes rise first
Myoglobin.
When is stress test the answer
- when the case is NOT acute
- when the initial ekg and or enzyme do NOT establish the dx
When do I Answer dipyramidole stress test or adenosine thallium stress test or dobutamine echo
Ppl who can not exercise > 85% maximin COPD amputation Deconditioning Obesity Dementia Lower extremity ulcer Weakness of previous stroke
No caffeine 24 hours before dypiramidole
The adverse s/e of dypiramidole (HA, cp, bronchoconstriction) can be reversed with aminophylline
When use Sestamibi nuclear stress. Test
Obesity
Large breasts
Reversible ischemia next dx step
Angiography
When is coronary bypass the answer
When angiography has been done
Most accurate test to evaluate EF
Nuclear ventriculogram
Clopidogrl And ticagrelor given when
Added to aspirin for acute mi
When give prasugrel
When angioplasty is done
prasigrel
Clopidogrel
Ticagrelor
Added when
When people get an angioplasty or stent
Which treatments lower mortality in stemi
Thrombolytics
Primary angioplasty
-**they are Very dependent on time
Clopidogrel
Ticagrelor
Prawugrel* also a little tidbit
They are used when
Aspirin allergy
Pt undergoes angioplasty and stenting
PrAsugrel has more efficacy than clopidogrel but causes more BLEEDING
Prasugrel increases bleeding in
Age > 75
Weight <60 kg
When is pacemakers the answer for acute MI
Third degree block Second degree AV block, Mobitz type II Bifascicular block New LBBB Sympyomatic bradycardia
When is Lidocaine or Amiodarone the answer for acute MI
ONLY when there is v tach or v fib
Do not give them to prevent v arrhythmia
Complications of MI
Cardiogenic shock Valve rupture Septal rupture Myocardial wall rupture Sinus bradycardia Third degree complete heart block Right ventricular infarction
Complications of MI
Cardiogenic shock( echo; swan ganz catheter. ACE I and urgent revascularization
Valve rupture : Echo. Ace, nitroprisside, intra aortic balloon pump as a bridge to Sx
Septal rupture : Echo, right heart caty. Ace, nitroprusside, urgent Sx
Myocardial wall rupture : Echo. Periocardecentisis and urgent cardiac repairing ir
Sinus bradycardia - EakG. Atropine followed by pacemaker if still symptomatic
Third degree complete heart block - ekg, canon “a” waves… atropine and pacemaker even if still symptomatic
Right ventricular infarction -( e fluid load
NSTEMI
No thrombolytic use
LMWH»> unfractionated heparin
GpIib/IIIa inhibitors like abciximab
Tirofiban
Eptifibitide lower mortality especially in those undergoin angioplasty
The single greatest benefit of these meds come with a combination of angioplasty and stents
Difference between saphenous vein graft and ima
Svg only good for 5 years
Ima good for 10 yesrs
Indications for CABG
Three coronary vessels >70%
Left MCA with >50-70% stenosis
2 vessels in diabetics
2-3 vessels with low EF
Ranolazine
Anti angina med
Added if other meds do not control pain
Give lipids! Strongest indication
CAD + LDL> 100
Diabetic LDL goal
< 70
Risk Fx for Lipid Tx
Cigarette smoke Family Hx ( male<55, women <65) High BP 140/90 Low HDL< 40 Age >55 females , <45 in males
CAD equivalentS
Diabetes
PAD
Aortic disease
CArotid disease
Sex and the heart
Anxiety»_space; bb as the mcc of ED post infarction
Stop nitrates if starting sildenafil
CHF sounds
S3; splash
S4: bang
Pulmonary edema
CCS tip
Tx: Oxygen, furosemide; nitrates and morphine
This is the worst manifestation of CHF
Ccs; move clock forward only 15-30 and this is a perfect example that all tests and Tx should be ordered at the same time minutes if there is no response to Tx after moving forward the clock, add a
Positive inotrope like dobutamine, inamrinone Or milrinone
Blue box for pulmonary edema
All cases of pulmonary edema and MI need to be placed in the ICU
Important question *
What to do when you have v tach assd with pulmonary edema
Synchronized cardioversion—> v tach assd with pulmonary edema
Or Afib, flutter or svt
Unsyncuronized cardioversion•”—> v fib or v tach with no pulse
Anti arrhythmic•> v tach in someone who is hemodynamics stable
When nesitiride the answer?
Acute pulmonary edemaa
Preload reduction.
It’s a synthetic version of anp
Pulmonary edema parameters
CO is decreased
SVR is increased
Wedge pressure is increased
RAP music is increased
Hypovolemic shock parameters
Decreased CO
Increased SVR
Decreased wedge pressure
Decreased rap
Septic shock parameters
Increased co
Decreased SVR
Decreased wedge pressure
Decreased rap
Pulmonary hypertension parameters
Decreased co
Increased SVR
Decreased wedge pressure
Increased rAp
Spirinolone gives gynecomastia and ED. Anti androgenic
Switch to what?
Epleronone
Diastolic dysfunctions Tx?
Bb and diuretics
ACe I have not been shown to help do not give spirinolactone or digoxin
EF below 35
Implantahle cardioverterz/ defribillayor
Systolic dysfunction with low EF
Ace I Bb Spirinolactone / epleronone Diuretics Digoxin
Mcc death in CHF
arrhythmia
Single most important fact about CHF inv further mgmt
Mortality decreased by ace, B.B., and spirinolactone
Digoxin decrees Sx but not lower mortality
When is biventricular pacemaker the answer
When EF <35 and qrs> 120 msec
When is warfarin the answer for CHF
Never
Wrong answer
What is an absolute CI to use of bb
Symptomatic bradycardia
Systolic murmurs
Diastolic murmurs
Right sided murmurs
Left sided
Systolic murmurs; As, MR, mvp, and HOCM
Diastolic murmurs: AR and MS
Right sided murmurs : Inc with inhalation
Left sided murmurs: inc with exhalation
Maneuvers on valvular disorders
Most murmurs get louder with squatting or leg raise. You increase venous return
Like … AS, AR, MS, MR and right sided lesions m
Only 2 that become softer! Is hocm and mvp
Opposite for valsava and standing
Effect of handgrip on murmurs
Increases afterload which is what ace does
So…
AR, MR, murmurs worsen and get louder
VSD same thing
Table of handgrip vs amyl nitrate
They have the opposite effect Handgrip (? Increased aftefload) - AS decreased -AR increased - MS negligible - MR increased m - VSD increased - HOCM and Mvp decreased
Amyl nitrate ( decreased afterload) AS increased AR decreased MS negligible MR decreased VSD decreased HOCM and mvp increased
Valvular lesions
Best initial test
Most accurate test
Echo… order TTE first on CCS then tee
Left heart cath
For ccs, order CXR and ekg
Regurgitate lesions tx
Stenotic lesions tx
Vasodilator therapy like ace, ARBs or nifedipine
Stenotic lesions need anatomical repair
MS needs balloon valvuloppasty even if pregnant
Valsava Improves murmur—> diuretics
Amyl nitrate improves murmur —> ACe
AS
Presents with cp*, CHF Sx And syncope
Old patient with HTN
Coronary disease—> 3-5 year survival
Syncope: 2-3 year survival
CHF: 1.5-2 year survival
Increased intensity with leg raises, squatting and amyl nitrate
Decreased intensity with vAlsava, handgrip and standing
Also case may describe delayed carotid upstroke
Dx: best initial is TTE
More accurate is tee and left heart cath is most accurate test. Good for aortic pressure gradient
Normal aortic valve gradient is…
Zero
AR
Causes: HTN, rheumatic heart disease, endocarditis, cystic medial necrosis
Mmc presentation: sob and fatigue
Diastolic decresxendo murmur beard best at the left sternal border
Quinckes pulse: capillaries pulsations in the fingernails
Mussets sigh: head bobbing up and down with each pulse
Hill sign: bp gradient much higher in Le
Corrigans pulse: high bounding pulse . Aka water hammer pulse
Duroziez sign: murmur heard over femoral artery
Dx: Best initial test TTE More accurate is tee Most accurate app is left heart cath For ccs, choose CXR and ekg
Tx:
Ace arbs and nifedipine are best initial therapy
For ccs, add loops
EF>55 Or LVESD <55= surgery
MS
MCC is rheumatic fever
Pregnant immigrant
Sx:
dysphagia
Hoarseness
A fib
Diastolic rumble after an opening snap
Murmur increases in intensity with leg raising, squatting and expiration DX Best initial TTE More accurate is tee Most accurate left heart cath Ccs, order ekg and cxr (LAH, straights of the left heart border and elevation of the left main stem bronchus Tx:best initial diuretics Most effective is balloon valvuloplasty
MR
HTN, IHD,And any condition that dilates the heart
Mc Sx is DOE
Holosystolic murmur that obscures S1 And S2. Best heArd at the apex and radiates to the axilla
S3 gallop- when fluid overload states like CHF it MR*
Murmur increases in intensity with leg raising, squatting or handgrip ( same as AR)
Standing valsava And amyl nitrate decrease intensity
Best initial test TTE
More accurate tee
Treatment is same as A Regurgitation
Ace, arbs, and nifedipine
Inc ccs, Add loops
Sx when EF< 60 or lvesd > 40 mm
VSD
Asymptomatic: holosystolic murmur At LLSB
Large defects: sob
Murmur increases in intensity with leg raising squatting and exhalation ( just like MS)
Dx first test echo
More accurate cath
Tx mild defects don’t need mechanical closure
ASD
Small ASDs are asymptomatuc
Large ones—> sob and parasternAl heave
*** fixed splitting of S2. Most important * step 3 tests this
Dx with echo
Tx percutaneous or catheter devices
Repair — >1.5:1
Wide P2 delayed
RBBB
PS
RVH
Pulmonary HTN
Paradoxical A2 delayed
LBBB
LVH
AS
HTN
Dilated cardiomyopathy
Presents And managed just like CHF so treat with ace, ARBs, B.B. and spirinolactone
MCC: ischemia , Alcohol, Adriamycin, radiation and chagas
HOCM
Sob and S4 gallop ( LVH and decreased compliance of Ventricle)
Echo shows normal EF
Tx B.B. and diuretics
Restrictive cardiomyopathy
Sob, as with All cardiomyopathy And kussmauls sign
Mainstay of diagnosis: - Echo
- Most accurate is endomyocardial biopsy
- Cath shows rapid x and y descent
Amyloid: low voltage on ekg
Speckled pattern on echo
Tx: diuretics abd treat the underlying cause.
Pericarditis
Dx
Tx
Best initial test EKG
- shows diffuse ST elevTion
And PR depression
Tx is with nsaids+ colchicine
Advance the clock 1-2 daysand go to the office and add prednisone orally *
advance clock again 1-2 days
Pericardial tamponade
On ccs, also examine the lungs
Pulsus paraxodus!
Electric Alternans on ekg!
Dx
Best initial : EKG shows low voltage and electric alternans
Most accurate echo
Right heArt cAth shows equalization of pressures during diastole
Tx
Best initial therapy pericardiocentesis
Most effective therapy is pericardial window placement
Most dangerous therapy diuretics
Constrictive pericarditis
Sob and sign of righ heart failure like… Edema Hepatodplenomegaly Ascites Jvd
Pericardial knock!
Kussmaul sign!
Dx test
CXR
EKG
CT and mri
Tx
Best initial: diuretic
Most effective: surgical removal of the pericardium
Aortic dissection
Best initial test CXR
Most accurate test ct angio
Tx
B.B.
Order B.B. with ekg and CXR. Move the clock forward then and order…
No matter what the ekg shows order…
Ct angio = tee= mra
Then give Nitroprusside! to control the bp
All cases need to go to the icu and a surgical consultation will be needed
PAD
Dx
Tx
Ccs tip
Best initial test ABI
Most accurate test angio
Tx Aspirin
ACEi
Cilolastazol
Exercise as tolerated lipid control with goal <100
Ccs tip: move the clock forward several weeks to see if meds are working and if the pain progresses—> surgical bypass
Marginally effective Pentoxifylline
Not helpful ca blockers
Spinal stenosis
Pain that’s worse walking downhill and better when walking uphill or sitting or cycling
Pulses and skin exam are normal
Arterial occlusion
Pain + pallor. + pulseless = Arterial occlusion
arterial embolus
Which 2 condition seen with this
AS and A fib
A fib
Dx
Ccs tip
Tx
Dx
EKG
IP—> telemetry
OP—> holter
Ccs tip
Order: Echo, TSH and T4, electrolÿtes, trop Or ck-mmb
Tx:
Stable—>rate control with iV B.B., diltoazem or digixin
Once rAte is controlled—> anticoagulation with warfarin, dabigatran to INR 2-3
Unstable ( bp less than 90, CHF, or confusion or cp
Use chads score C: CHF H: HTN A: Age > 75 D/: diabetes S: stroke/TIA
Score 0-1—> Aspirin
Score >_ 2•> warfArin, dabihAtran, rivaroxoban, apixAvban
** bridging with heparin is the WRONG answer
Multfocal Atrial Tachycardia (MAT)
Polymorphic p waves in association with COPD/emphysema.
Tx
oxygen first then diltiazem
Do not give B.B. **
SVT
Dx
Tx
Ccs tip
Dx if ekg doesn’t show svt—> holter monitor or telemetry
Best initial Tx
unstable patients —> synchronized cardioversion
Stable_-> vagal maneuvers
If vAgal maneuvers don’t work —> IV adenosine
**
Best long term treatment —> radiofrequency catheters ablAtion
Ccs—> all causes of dysrhythmia need TTE
WPW
Svt that can alternate with v tach
* worsening of svt with Ca channel blockers or digoxin
Best initial test ekg showing delta waves!
Most accurate test electrophysiological studies
Best initial therapy procainamide!!! IF the svt or v tach is from wpw
- best long term therapy is radio frequency catheter ablation
V tach
Presentation
Dx
Tx
Palpitations
Syncope
Cp
Sudden death
Best initial test ekg
If ekg doesn’t show —> telemetry
Most accurate is electrophysiological studies
Tx
unstable—> synchronized cardioversion
Stable _—> amiodarone, lidocaine, procainamide
Magnesium
V fib
Presents
Dx
Tx
Presents as sudden death
Dx ekg
Tx unsynchronized cardioversion!!
Syncope
What to order
- CBC (anemia)
- bmp (glucose): hypoglycemic seizure
- pulse ox ( hypoxia)
- cardiac enzymes (ck mb or troponin
- ekg!
- echo
- head ct
- cardiac and neurological exams
Syncope
Ccs tip
Move the clock forward to get initial test results
OP—> holter monitory
IP—> telemetry
Repeat ck mb or troponin
Urine and blood tox screen
If etiology is not clear, move the clock forward and order:
Holter Telemetry urine tox repeat cardiac enzymes Tilt table Electrophysiological studies
Bottom line on ccs, order: EKG Echo Cardiac enzymes Head ct
PAD Tx
Aspirin ACE inhibitor Exercise Cilostazol Statins
Marginally effective: pentoxifylline!
Ineffective: Ca channel blocker
S3 atrial gallop
S3—> fluid overload like … CHF or MR
But
Normal in patients <30
MR Rx
Ace, arbs And nifedipine
For ccs add a loop
Surgery —>LVEF is < 60 or LVESD > 40 mm
AR Tx
Ace, arbs And nifedipine
For ccs add a loop
Surgery —>LVEF is < 55% or LVESD > 55 mm
ASD Tx
Percutaneous or catheter devices
Repair—> if shunt ratio exceeds 1.5 to 1
Dilated cardiomyopathy Dx and Tx
Echo is best initial
MUGA Or nuclear ventriculogram is most accurate
Ace
Arbs
BB
Spirinolactone
When Synchronized cardioversion
Unsynchronized
Synchronized cardioversion —> anything other than v fib and pulse less v tach
Unsynchronized—> v fib, pulseless v tach
