Cardiology Flashcards
The single worst risk factor for CAD is
diabetes
The mechanism of S3 gallop is
rapid ventricular filling during diastole
S4 gallop is the sound of
atrial systole into a tiff or noncompliant left ventricle
The best initial diagnostic test for ischemic-type pain is
EKG
CK-MB stays elevated 1-2 __
days
Troponin stays elevated 1-2 ___
weeks
Myoglobin elevates as early as 1-4 ____ after the start of chest pain
hours
Which cardiac enzyme rises first in acute chest pain?
Myoglobin
Stress testing is only the answer if the case is ____ and the EKG/other dx tests are inconclusive
NON-ACUTE
Only choose angiography if
the stress test is normal
If patients cannot exercise to a target HR >85% of max, then the answer is
dipyridamole or adenosine thallium stress test or dobutamine echo
EKG will be unreadable for ischemia in which situations?
Left BBB, digoxin, pacemaker, LVH, any baseline ST segment abnormality
Obese patients might need ____ testing for ischemia
sestamibi nuclear stress
To the myocardium, thallium looks like ___
potassium! Na/K ATPase will recognize it! SCIENCE IS COOL
Stress testing should never be performed in a patient with
current chest pain
The most specific method to dx a new infarction 5 days after an MI is
CK-MB
*it will have returned to normal 2-3 days after that first one
The best initial therapy for ACS patients is
aspirin
___ or ___ are added to aspirin in patients with acute MI
Clopidogrel or ticagrelor
P2Y12 antagonists such as clopidogrel work by
blocking platelet aggregation (inhibiting ADP-induced activation of the P2Y12 receptor)
Which therapies lower mortality in STEMI?
thrombolytics and primary angioplasty (time-dependent)
Percutaneous coronary intervention MUST be performed within ___ minutes of arrival at the ED for STEMI
90 minutes
What has the single greatest efficacy in lowering mortality in STEMI?
Urgent angioplasty
Angioplasty is the answer if the question includes a contraindication to
thrombolytics
___ are indicated when the patient has chest pain for <12 hours and has ST elevation in 2+ leads
Thrombolytics
A new left BBB is an indication for
thrombolytics
Beta blockers lower mortality in STEMI, but their timing is
NOT critical
ACEi’s and ARBs only lower mortality if there is ___ or ___
left ventricular dysfunction or systolic dysfunction (LOW EJECTION FRACTION)
What is the most common cause of death in both CHF and MI?
Ventricular arrhythmia brought on by ischemia (beta blockers are both anti-arrhythmic and anti-ischemic!!)
Statins should be given to ALL patients with ___ regardless of EKG or troponin or CK-MB levels
ACS
Treat cocaine-induced chest pain with
calcium channel blockers
Treat coronary vasospasm/Prinzmetal’s angina with
calcium channel blockers
When is a pacemaker the answer for acute MI?
Third-degree AV block Mobitz II, second degree block Bifascicular block New LBBB Symptomatic bradycardia
Lidocaine or amiodarone are the answer for acute MI ONLY when there is ___ or ____
ventricular tachycardia or ventricular fibrillation
All complications of MI result in
hypotension
Treat cardiogenic shock with
ACEi, urgent revascularization
Treat valve rupture with
ACEi, nitroprusside, intra-aortic balloon pump (as bridge to surgery)
Treat myocardial wall rupture with
pericardioentesis, urgent cardiac repair (surgery)
Treat sinus bradycardia with
atropine, then maybe pacemaker
Treat third degree (complete) heart block with
atropine and a pacemaker for sure
Treat right ventricular infarction with
fluid loading
All patients post-MI should go home on
aspirin, clopidogrel (or prasugrel), beta blocker, statin, and an ACE inhibitor
Unlike STEMI, NSTEMI’s are managed with no ___ use, routine use of ___, and ___ to lower mortality
NO thrombolytic use
routine use of heparin
Glycoprotein IIb/IIIa inhibitors to lower mortality
The two medications that decrease mortality in chronic angina are
aspirin and metoprolol
Indications for CABG include ___ coronary vessels with >70% stenosis, left main coronary artery stenosis >50-70%, 2 vessels in a diabetic, and 2-3 vessels with low EF
three coronary vessels w/ 70% stenosis
___ is an anti-angina med that is added only if other meds don’t control the pain
Ranolazine
The LDL goal for patients with CAD and/or diabetes is
<70
LDL > 100 is an indication for
statin therapy
A statin is indicated if the 10-year risk of CAD is
> 7.5%
PCSK9 inhibitors (evolocumab and alirocumab) are ___ medications that do not lower mortality in familial hypercholesterolemia
injectable
What causes rales?
Increased hydrostatic pressure in the PULMONARY CAPILLARIES from LEFT HEART PRESSURE OVERLOAD
Left heart pressure overload can cause what physical exam finding?
rales (popping sound)
Rales are a sign of
pulmonary edema
The standard of care for acute pulmonary edema includes what four therapies?
oxygen furosemide nitrates morphine *no concrete mortality benefit tho
The worst manifestation of CHF is
pulmonary edema
Carvedilol is anti-arrhythmic, anti-ischemic, AND
anti-hypertensive
*blocks beta1 and beta2 receptors
Order what four tests for suspected pulmonary edema?
- chest x-ray
- EKG
- oximeter (consider ABG)
- echo
CXR on pulmonary edema patients will show
cephalization of flow, pulmonary vascular congestion, effusion, and/or cardiomegaly
Dopamine has what effect on afterload?
It increases afterload by causing vasoconstriction (alpha 1 AGONIST)
Imamrinone and milrinone are ___ inhibitors
phosphodiesterase inhibitors
hypoxia causes respiratory ___
alkalosis
Cases of pulmonary edema and MI should be placed in the
ICU
Most patients with pulmonary edema will respond to ___ to control acute symptoms
preload reduction alone
Positive inotrope agents used ____ in the ICU include dobutamine (drug of choice), inamrinone and milrinone
INTRAVENOUSLY
Positive inotropes are used as further management in acute ___ after the clock is moved forward 30-60 min and there is no response to preload reduction
pulmonary edema
When ventricular tachycardia is associated with acute pulmonary edema, what should you do?
Synchronized cardioversion (also if pulm edema is a/w afib, flutter, or supraventricular tachycardia)
A normal BNP excludes ___
CHF
Wedge pressure =
left atrial pressure
Left ventricular failure = increased LA pressure
When a CHF patient is still dyspneic after using ACEi’s, beta blockers, diuretics, digoxin, and mineralocorticoid inhibitors, what’s the last resort?
Ivabradine, an SA nodal inhibitor of funny channels (slows HR)
*THERE IS MORTALITY BENEFIT
Diastolic dysfunction is treated with ___ and ____
beta blockers and diuretics
The single most important fact about further management of CHF is that
mortality is decreased by ACEi/ARB, beta blockers, and spironolactone
CHF patients with persistently low EF below 35% are candidates for
implantable defibrillator placement
The absolute contraindication for beta blockers is
symptomatic bradycardia
All valvular heart disease presents with __ as chief complaint
shortness of breath
Valvular heart dz in a young female or genpop =
mitral valve prolapse
Valvular heart dz in a healthy young athelete =
Hypertrophic obstructive cardiomyopathy (HOCM)
Valvular heart dz in immigrant, pregnant =
mitral stenosis
Valvular heart dz in Turner’s syndrome, coarctation of aorta =
bicuspid aortic valve
Valvular heart dz presenting with palpitations, atypical chest pain not with exertion =
mitral valve prolapse
When valvular disease is suspected, what should you do on physical exam?
CV, Chest, and extremities portions! (check for peripheral edema, carotid pulse findings, and gallops)
Systolic murmurs are most likely which four valvular dz’s?
Aortic stenosis
Mitral regurgitation
Mitral valve prolapse
HOCM
Diastolic murmurs are most likely which two valvular diseases?
Aortic regurgitation
Mitral stenosis
All right sided murmurs increase with
inhalation (both stenosis and regurgitation of tricuspid valves)
All left sided murmurs increase with ___
exhalation (mitral and aortic valve lesions)
The only two murmurs that become SOFTER with squatting and leg raise are __ and __
Mitral Valve Prolapse and Hypertrophic obstructive cardiomyopathy (MVP and HOCM)
*think of MVP and HOCM like with athletes who do lots of squats, squatting helps the murmur get softer in MVPs and athletes
Handgrip, because it increases afterload, functions as the opposite of an
ACE inhibitor
Aortic and mitral regurgitation are treated with ___ so their murmurs will get worse (louder) with ___
ACE inhibitor
handgrip
Handgrip worsens the murmur of ____
VSD (also AR and MR)
regurgitant murmurs are best treated with
vasodilator therapy
If valsalva/standing improves the murmur, __ are indicated
diuretics
If amyl nitrate improves murmur (aka handgrip worsens) ___ are indicated
ACE inhibitor
The best initial diagnostic test for aortic stenosis is
TTE; TEE is more accurate, left heart cath is most
Valsalva, standing, and amyl nitrate all worsen the murmur of
MVP and HOCM
Handgrip improves the murmurs of __ and __ so ACE inhibitors will not treat them
MVP and HOCM
The best initial therapy for aortic regurgitation is
ACEi, ARBs, and nifedipine + furosemide (loop diuretic)
The most common cause of mitral stenosis is
rheumatic fever
Balloon valvuloplasty works in mitral stenosis but not aortic stenosis because
in MS, the valve is fibrosed, but in AS it’s calcified
Mitral regurg is caused by
dilation of the heart
Broken heart syndrome, aka
Takotsubo cardiomyopathy
The best initial therapy for pericarditis is
NSAIDs; have patient follow up in clinic in 1-2 days and if it persists, add prednisone then colchicine if it still doesn’t stop
Two unique features of cardiac tamponade are __ and __
pulsus paradoxus and electrical alternans
Alterations of the axis of the QRS complex on EKG =
electrical alternans
Equalization of all the pressures in the heart during diastole in right heart catheterization =
pericardial tamponade
Best initial therapy for cardiac tamponade =
pericardiocentesis; long term, do a pericardial window placement
Do not give diuretics for cardiac ___
tamponade
Constrictive pericarditis presents with SOB then signs of chronic ___
right heart failure
Signs of chronic right heart failure include
edema, JVD, HSM, ascites
Unique features of constrictive pericarditis include ___ and __
Kussmauls sign (increase JVP on inhalation, not to be confused with Kussmaul breathing seen in DKA) Pericardial knock (extra diastolic sound from heart hitting a calcified pericardium)
Chest X-ray showing calcification of pericardium =
constrictive pericarditis
Best initial therapy for constrictive pericarditis =
diuretics; most effective is surgical removal of pericardium
Difference in blood pressure between LEFT AND RIGHT ARMS =
Thoracic aorta dissection
Widened mediastinum on CXR =
thoracic aortic dissection. Most accurate test is CT angio
In suspected aortic dissection, move clock forward and order either __, __, or __ regardless of what EKG shows
CT angio, TEE, or MR angiography (all three equally accurate)
Abdominal aortic aneurysms are repaired when they are __ cm
> 5cm
Men age __ who are current or former smokers should be screened for AAA
65-75 yrs old
Acute arterial embolus will be very sudden in onset with loss of pulse and a cold extremity. __ and __ are often in the history
AS and afib
Smooth shiny skin?
Peripheral arterial disease
Best initial test for peripheral arterial disease is
ankle-brachial index (>10% disease)
Angio is most accurate test
Hospitalized patients with a-fib should be placed on
telemetry
Other tests to order for a patient with newly diagnosed A-fib include these four:
Echo
Thyroid function
Electrolytes
Troponin/CKMB
Unstable a-fib patients should undergo immediate
synchronized electrical cardioversion
Long term use of ___ plus anticoagulation in a-fib patients is better than cardioversion
rate control medications such as metoprolol, diltiazem, or digoxin
CHADS2 is a scoring system to indicate the need for __ in A-fib patients
anticoagulation
There is NO need for ___ when anticoagulating a-fib patients
heparin bridging (this is because a-fib is a long term risk disease for stroke, and heparin carries an immediate bleeding risk)
CHADS-VASc stands for:
CHF Hypertension Age >75 Diabetes Stroke/TIA Vasclar disease + age 65-74 Sex (female)
Score of 2+ needs anticoag
Bleeding with warfarin is reversible with
FFP
What reverses dabigatran?
Idarucizumab
Treat multifocal atrial tachycardia (MAT) with
oxygen first, then diltiazem
Supraventricular tachycardia has a ___ rhythm
regular
All cases of dysrhythmia should undergo ___
transthoracicechocardiography (TTE)
If vagal maneuvers do not work in SVT patients, use __
IV adenosine
Best long term management for SVT is
radiofrequency catheter ablation
SVT that can alternate with ventricular tachycardia is
Wolff Parkinson White syndrome
If SVT worsens after the use of CCBs or digoxin or beta blockers, it might be ___
wolff parkinson white
Delta wave on EKG =
WPW
Best initial therapy if a patient is in SVT or VT from WPW =
Procainamide
Best long term tehrapy for WPW is
radiofraquency catheter ablation (just like SVT)
___ should always be given in patients with
Torsad de pointes
Ventricular fibrillation presents as
sudden death
Always treat V-fib with
unsynchronized cardioversion
Initial diagnostic testing for syncope should include these six things:
Cardiac/neuro exam EKG Glucose Pulse ox CBC Cardiac enzymes
Patients requiring admission for syncope usually get put on a
Holter monitor (a 24-72 hour continous ambulatory EKG)
The most important thing to do in syncope cases is to
Excluse a cardiac cause!
For syncope you’ll usually be ordering these 4 tests:
EKG
Cardiac enzymes
Echo
Head CT
