Cardiology Flashcards
Orthopnea is most often the result of ________.
Left sided heart failure (also seen with COPD)
HTN emergency is defined as increased BP + acute end organ damage. Usually systolic BP is ≥ ____ and diastolic is ≥ ____.
Systolic ≥ 180
Diastolic ≥ 120
_____ may be seen in cases of malignant HTN and may present with blurred vision.
Retinal damage/papilledema
HTN emergencies are managed by decreasing BP by no more than 25% within the first hour & an additional 5-15% over the next 23 hours. 2 exceptions are:
- ________
- ________
- Acute phase of ischemic stroke (usually BP not lowered unless it is ≥ 185/110 in candidates for thrombolytics and ≥ 220/120 in non-candidates).
- Acute aortic dissection (BP often rapidly reduced to SBP of 100-120 within 20 minutes).
______ or ______ are 2 treatment options for HTN emergencies resulting in: HTN encephalopathy, Hemorrhagic stroke, Ischemic stroke.
Nicardipine & Labetalol
Treatment of aortic dissection includes what class of medication?
Beta blockers (+/- Sodium Nitroprusside)
Treatment of ACS includes what 2 medications?
Nitroglycerin & Beta blockers
Treatment of Acute Heart Failure includes what 2 medications?
Nitroglycerin, Lasix
What medications should be avoided in CHF?
Hydralazine & Beta blockers!! :(
Cardiogenic shock is defined by a decrease in _____ with an increase in _____.
Decrease in cardiac output
Increase in systemic vascular resistance (SVR)
*Often produces increased respiratory effort/distress
Cardiogenic shock should be treated with _____ (small/large) amounts of isotonic IV fluids and oxygen.
Small
*Cardiogenic shock is the only shock in which large amounts of IV fluids are NOT given
_____ drugs are used with cardiogenic shock in order to increase myocardial contractility and CO.
Inotropic: Dobutamine, Epinephrine
Medications that may cause orthostatic hypotension include:
Anti-HTN, vasodilators, diuretics, narcotics, antipsychotics, antidepressants, alcohol.
*Also Parkinson’s and Guillain-Barre
Orthostatic HTN is defined as a fall in systolic BP ≥ ___ and/or a fall of diastolic BP ≥ ___ (with standing following 5 min. of being supine).
Systolic- 20
Diastolic- 10
*If secondary to hypovolemia it may be accompanied by an increase in HR > 15 bpm
One medication used to treat orthostatic hypotension is ______.
Fludrocortisone (also Midodrine)
https://www.slideshare.net/biocat/sonia-eiras
KNOW HF CHART!
MC cause of HF is _____.
CAD
MC causes of R-sided HF are: _____ & ______.
L-sided HF
Pulmonary Dz.
MC form of HF is ______ (systolic/diastolic).
Systolic
Systolic HF is associated with a/n ______ (increased/decreased/preserved) EF and a ____ (S3/S4) gallop.
DECREASED EF and a S3 gallop!
*Thin ventricular walls, dilated LV chamber
Diastolic HF is associated with a/n _____ (increased/decreased/preserved) EF and a _____ (S3/S4) gallop.
INCREASED or PRESERVED EF and a S4 gallop!
*Thick ventricular walls, small LV chamber
NYHA functional classification of breathlessness
http://www.practicenurse.co.uk/index.php?p1=a-z&p2=shortness-of-breath
Clinical manifestations of L-sided HF include (4):
- Dyspnea!!! MC!
- Pulmonary congestion/edema
- HTN, Cheyne-Stokes breathing (deeper, faster breathing with gradual decrease and periods of apnea)
- Dusky, pale skin. Cook extremities. Fatigue.
Clinical manifestations of R-sided HF include (3):
- Peripheral edema
- JVD
- GI/hepatic congestion- anorexia, N/V
The most useful test to diagnose HF is ______.
Echocardiogram
- EF is the most important determinant (Normal EF 55-60%)
- *EF < 35% = increased mortality :( –> defibrillator placed to reduce mortality
An increased ______ (specific lab value) may identify CHF as the cause for dyspnea in ER.
BNP
*BNP > 100 = CHF likely
____ & ____ are the 2 classes of drugs best for decreasing mortality in pts with CHF.
ACE-I
Beta blockers
Some major side effects of ACE-I include:
HYPERkalemia
Cough
Angioedema
*CI- pregnancy
______ is a safe anti-HTN drug to use during pregnancy.
Hydralazine
_____ (class of drugs) is the most effective treatment for symptom relief in pts with mild-moderate CHF.
Diuretics
*S/E: HYPOkalemia/calcemia/natremia, HYPERglycemia, HYPERuricemia
2 major S/E of sprionolactone are:
- HYPERkalemia
2. Gynecomastia
An example of a sympathomimetic (positive inotrope) that is used in patients with HF + A fib. is: _____.
Digoxin
*Digoxin toxicity- digitalis effect on ECG: downsloping, sagging ST segment
_____ (class of meds) usually not used in systolic HF.
Calcium channel blockers*
*Except angina with HF or normal EF
HF outpatient regimen is:
ACE + Diuretic initially; add B-blockers
*+/- Hydralazine + NTG, Digoxin
CXR findings in congestive HF include:
- Kerley B Lines (short linear markings at lung periphery)
- Butterfly (Batwing) Pattern
- Cephalization of vessels, Perihilar congestion, Cardiomegaly
- Pulmonary edema
Management of acute pulmonary edema/CHF includes:
hint- LMNOP
Lasix, Morphine, Nitrates, Oxygen, Position
The 2 MC etiologies of Acute Pericarditis (acute inflammation of the pericardium) are _____ & _____.
- Idiopathic
- Viral
* Clinical manifestations- 3 P’s: Pleuritic (CP), Persistent, Postural (worse when supine). FEVER usually present.
How is acute pericarditis diagnosed?
- ECG- diffuse ST elevations in precordial leads & associated PR depressions (OPPOSITE in aVR lead- ST depression known as knuckle sign)
- Echo
How is acute pericarditis treated?
- NSAIDs
2. Colchicine
Some etiologies of pericardial effusion include:
PERICARDITIS, malignancy, infxn, radiation therapy
*CXR- cardiomegaly
Restriction of cardiac ventricular filling and decreased cardiac output as a result of a pericardial effusion is known as ______.
Pericardial Tamponade
Beck’s Triad is associated with ______ and consists of what 3 components?
Pericardial Tamponade
- Distant heart sounds
- Increased JVP
- Systemic HYPOtension
_____ is associated with Pericardial Tamponade and is defined as exaggerated >10mmHg decrease in systolic BP with inspiration–> leading to decreased pulses with inspiration.
Pulsus Paradoxus
How is Pericardial Tamponade diagnosed?
ECHO- Effusion + Diastolic collapse of cardiac chambers
*Treatment- Immediate pericardiocentesis!!
Constrictive pericarditis is a thing…see PPP
Treatment- Pericardiectomy
_____ is inflammation of the heart muscle that’s more common in kids. MC due to viral infection.
Myocarditis
____ is the gold standard in diagnosing myocarditis.
Endomyocardial biopsy.
*Done in patients with new onset of HF unrelated to structural dz.
**Treatment- supportive, diuretics, ACE-I, sometimes IVIG
A little about Dilated Cardiomyopathy…
SYSTOLIC dysfunction
- MC 20-60 y/o Men
- *Idiopathic, viral, ETOH, cocaine
- **ECHO- L-ventricular dilation, thin walls; decreased EF
- ***CXR- Cardiomegaly
- **Treatment- Same as HF
Right-sided HF symptoms with Kussmaul’s Sign (increased JVP with inspiration) is associated with ______ (type of cardiomyopathy).
Restrictive Cardiomyopathy
*Treat underlying cause (Amyloidosis is MC cause!)
______ (type of cardiomyopathy) is associated with sudden cardiac death in adolescent kids due to ventricular fibrillation.
Hypertrophic Cardiomyopathy
*Hear a murmur similar to AS murmur that is DECREASED in intensity when pt is SQUATTING or SUPINE!
**Treatment- BETA BLOCKERS, Myomectomy, ETOH ablation
Rheumatic fever- ….
See PPP
Key points- children 5-15 y with previous GABHS infxn
*Manifestations: JONES criteria, FEVER, ARTHRALGIA
**Treatment- ASA, Pen G or Erythromycin
Heart Sounds Review…
S1: AV valve closure- beginning of systole, heard best at apex
S2: Semilunar valve closure- end of systole, heard best in aortic and pulmonic areas (physiologic- inspiration splits the S2; fixed split- seen with ASD and VSD)
S3: Rapid, passive, ventricular filling. Commonly heard in kids and adolescents.
S4: Atrial contraction. Seen with HTN, LVH, & Aortic stenosis
Harsh/Rumble sound think: _______.
Blowing sound think: ______.
- STENOSIS: AS, MS
2. REGURG: AR, MR
Location of Intensity of Murmurs:
“Apple Pie Tastes Mmmmm”
Aortic: R 2nd ICS
Pulmonic: L 2nd ICS
Tricuspid: L 4th ICS
Mitral: L 5th ICS
Inspiration _____ (increases/decreases) venous return on the R side and _____ (increases/decreases) venous return on the L side.
Increases on the Right
Decreases on the Left
AS leads to _____ (increased/decreased) afterload.
Increased! Pressure overload.
Aortic Stenosis Complications: Angina, Syncope, CHF
“ASC: ASC”
Helpful tool :)
_____ is a systolic ejection crescendo-decrescendo murmur at RUSB that radiates to Carotid.
Aortic Stenosis
*Treatment- Valve replacement only effective treatment!
Common causes of Aortic Regurgitation are:
Rheumatic heart disease, Endocarditis
AR can lead to LV volume overload–> LV dilation–> CHF
fyi
_____ presents as a diastolic, decrescendo, blowing murmur maximal at LUSB.
Aortic regurgitation
*Hill’s sign is most sensitive–> popliteal artery systolic pressure > brachial artery by 60mmHg
**Diagnosed- ECHO
***Treatment- Vasodilators (ACEI, ARBs, Nifedipine), Surgery!
MC cause of Mitral Stenosis is: _____.
Rheumatic Heart Disease!
MS can lead to pulmonary congestion and pulmonary HTN
:(
Clinical manifestations of MS:
Dyspnea, Pulm HTN, A fib (CVA), R-sided heart failure, Dysphagia (atrial enlargement compresses esophagus)
_____ is associated with an early-mid diastolic rumble at apex, esp in LLD position.
Mitral Stenosis
- Diagnosis: Echo, ECG- LAE +/- A fib
- *Treatment: Valvotomy or valve replacement
_____ is the MC cause of Mitral Regurgitation.
MV prolapse
*Ischemia/infarction are also known causes
Clinical manifestations of MR include:
- Acute –> pulmonary edema, dyspnea
2. Chronic –> A fib
_____ is described as a blowing, holosystolic murmur at the apex.
MR
Management of MR involves:
- Surgical repair and vasodilators (for nonoperative patient)
____ valve is the most commonly involved valve in infective endocarditis.
MV (except in IV drug users it is the tricuspid)
____ is defined as infection of normal valves with a virulent organisms (S aureus).
Acute Bacterial Endocarditis
____ is defined as an indolent infection of abnormal valves with less virulent organism.
Subacute Bacterial Endocarditis
*Think Strep Viridans
Clinical manifestations of bacterial endocarditis:
- FEVER, ECG conduction abnormalities
- Janeway lesions (macules on palms and soles)
- Roth spots (retinal hemorrhages with pale centers)
- Osler’s nodes (tender nodules on the pads of digits)
How is bacterial endocarditis diagnosed?
- Blood cultures- before abx
- ECG
- Echo
- Labs- leukocytosis, anemia, increased ESR and RF
DUKE Criteria for diagnosing Endocarditis
See PPP p. 57
Acute endocarditis treated with (what medications): _____
Nafcillin + Gentamicin OR
Vancomycin for MRSA or PCN allergic
Subacute endocarditis treat with: ______.
Penicillin or Ampicillin + Gentamicin
Vanc- IVDA
Endocarditis Prophylaxis Indications:
Cardiac Conditions:
- Artificial Heart Valves
- Prior hx of endocarditis
- Congenital Heart Disease
Procedures:
- Dental
- Respiratory
- Procedures involving infected skin/MSK tissues (I&Ds)
Treatment: Amoxicillin or Clindamycin if PCN allergic
_____ is MC cause of CAD.
Atherosclerosis
Common RF for CAD include:
DM, smoking, HLD, HTN, males, Age (>45 men, >55 women), family hx
Substernal CP brought on by exertion is known as _____.
Angina (4 classes)
Clinical manifestations of angina are:
Substernal, exertional CP that radiates to arm and is usually SHORT in DURATION (less than 30 min, usually 1-5 min!)
*Pain relieved with rest or NG
ST _____ (depression/elevation) is a classic ECG finding with ischemic heart disease.
Depression
____ is the most useful noninvasive screening tool for ischemic heart disease.
Stress testing
*Coronary angiography is the gold standard!!
The 2 most common revascularization techniques for management of angina are PTCA and CABG.
Indications for PTCA are:
1 or 2 vessel dz NOT involving the left main coronary artery and in whom ventricular function is normal/near normal (stents reduce rate of restenosis).
Indications for CABG are:
Left main coronary artery dz, symptomatic or critical stenotic (>70%), 3-vessel dz, or decreased EF (<40%)
Medical management of angina involves:
- NG
- Beta blockers- 1st line for chronic management
- CA Channel blockers
- ASA- prevents platelet activation/aggregation
What are the EKG findings for artrial flutter?
- Saw tooth waves at 250-350 bpm (NO P waves)
2. Rate is usually regular
How is atrial flutter managed?
- Stable- vagal, beta blocker or calcium channel blocker
- Unstable- direct current (synchronized) cardioversion
- Definitive- radiofrequency ablation
* Anticoag use is similar to A. fib
What are the EKG findings for atrial fibrillation (AF)?
- Irregularly irregular rhythm with narrow QRS usually
- NO P waves (fibrillatory waves at 350-600 bpm)
- Ventricular rate is usually 80-140 bpm
______ is the most common chronic arrhythmia.
A fib
- Most pts are asymptomatic
- BUT, the ineffective quivering can cause thrombi to form which can embolize and cause ischemic strokes :(
Etiologies of a fib include:
Cardiac dz, ischemia, pulmonary dz, infxn, cardiomyopathies, electrolyte imbalances, idiopathic, endocrine or neurologic disorders, increasing age, genetics, hemodynamic stress, meds, drug or alcohol use.
*Men > women, whites > blacks
Types of a fib include…
- Paroxysmal: self-terminating within 7 days (usually < 24hrs)
- Persistent: fails to self-terminate, lasts > 7 days. Requires termination (medical or electrical)
- Permanent: persistent AF > 1 year (refractory to cardioversion or cardioversion never tried)
- Lone: paroxysmal, persistent, or permanent without evidence of heart dz
Management of A fib includes:
- STABLE:
a. Beta blockers- Metoprolol, Esmolol (be careful in pts with reactive airway dz)
b. Calcium channel blockers- Diltiazem, Verapamil
c. Digoxin- used in the elderly. Digoxin is preferred for rate control in patients with hypotension or CHF!! Not generally used in active patients
Rhythm control may be used in _____ (younger/older) patients with ____ (type) A fib.
Younger patients with Lone A. fib.
- Direct current (synchronized) cardioversion- Can be done if A fib < 48 hrs OR after 3-4 weeks of anticoagulation and a TEE shows no atrial thrombi
- Pharmacologic rhythm control- Ibutilide, Flecainide, Sotalol, Amiodarone
- Radiofrequency abalation- permanent pacemaker; catheter-based ablation or surgical ‘MAZE’ procedure
UNSTABLE A. fib is treated with:
Direct current cardioversion (DCC)
Use of anticoagulation in patients with A fib…
All patients with nonvalvular A fib. should undergo both:
A. Assessment of the risk of embolization- the CHADS2 or CHA2DS2-VASc score mainly determines risk.
B. Determine if the risk of embolization and stroke exceeds the potential risk of bleeding from anticoagulation. This is mainly determined by clinical judgment and a thorough discussion with the patient.
SEE PAGE 14 OF PPP FOR CHA2DS2-VASc SCORING
DO IT
Anticoagulation agents for A fib include…
- Non-vitamin K antagonist oral anticoagulants (NOAC): usually preferred over warfarin due to similar/lower rates of bleeding and you don’t have to check INR and fewer drug interactions.
* Dabigatran, Rivaroxaban, Apixaban, Edoxaban - Warfarin- usually bridged until therapeutic with INR goal of 2-3.
- Dual antiplatelet therapy: Aspirin + Clopidogrel. May be reserved for patients who can’t be treated with anticoagulation for reasons other than bleeding risk.
What are the EKG findings for SVT?
- HR > 100
- Rhythm usually regular with narrow QRS complexes
- P waves hard to discern due to the rapid rate
How is SVT managed?
- Stable (Narrow Complex)- vagal maneuvers. ADENOSINE is the 1st line medical treatment for SVT
- Stable (Wide Complex)- Antiarrhythmics- Amiodarone. Procainamide if WPW suspected.
- Unstable- Direct current cardioversion
- Definitive Management- Radiofrequency ablation
In a _______ (type of rhythm) one ventricle depolarizes slightly later than the other causing two “joined QRS’s” to appear on EKG. This causes a widened QRS with 2 peaks to appear on EKG.
Bundle Branch Block
The diagnosis of a Bundle Branch Block is mainly based on a widened QRS of ____ seconds or more.
0.12
A ____ (RBBB/LBBB) has a 2 dramatic peaks with a deep V in the middle and a _____ (RBBB/LBBB) has 2 peaks with a small scoop between the 2.
- RBBB
- LBBB
See p. 195 of Dubin
Check leads __ and __ for a RBBB.
V1 & V2
Check leads __ and __ for a LBBB.
V5 & V6
Premature beats can be caused by a number of factors. Atrial and Junctional foci become irritable because of…
See p. 123 Dubin
*Mainly adrenergic substances!
A ventricular focus can be made irritable by…
See p. 134 Dubin
*Mainly low oxygen!! Also low K and certain pathologies (MVP)
____ originates suddenly in an irritable ventricular automaticity focus and produces a giant ventricular complex on EKG.
Premature Ventricular Contraction (PVC)
- T wave is usually in the opposite direction of the QRS
- *Assoc. with a compensatory pause
- A HR of 150-250 is known as :
- A HR of 250-350 is known as:
- A HR of 350-450 is known as:
- 150-250: Paroxysmal Tachycardia
- 250-350: Flutter
- 350-450: Fibrillation
____ is defined as ≥3 consecutive PVCs at a rate > 100bpm (usually b/w 120-300). A prolonged QT is a common predisposing condition.
Ventricular tachycardia
MC cause of Torsades de Pointes is _____.
HYPOmagnesemia
How is VT managed?
- Stable sustained- Amiodarone
- Unstable VT w/ a pulse- Synchronized cardioversion
- VT (no pulse)- Defibrillation (UNsynchronized cardioversion) + CPR
- Torsades- IV mag
What is the treatment for Ventricular Fibrillation?
UNsynchronized Cardioversion + CPR
What is the management for Pulseless Electrical Activity?
CPR + Epinephrine + Check for “shockable” rhythm every 2 minutes
*Asystole is treated the same!!
Unstable angina, NSTEMI, and STEMI all fall under the umbrella of ____.
Acute Coronary Syndrome (ACS)
EKG findings for UA and NSTEMI may include: ____ & ____.
ST depressions &/or T wave Inversions!
A little about anginal pain…
Retrosternal “pressure” that lasts > 30 min and is NOT relieved by rest/nitroglycerin. May radiate.
- Levine’s sign: clenched fist on chest
- *Frequency is highest in AM +/- dypsnea
- **Pain at rest usually indicates > 90% occlusion
Silent MIs may are atypical and may be seen in women, elderly, diabetics and obese patients. Symptoms include:
Abdominal pain, jaw pain, or dyspnea without CP
EKG findings for a STEMI include…
ST elevations ≥ 1mm in ≥ 2 anatomically contiguous leads +/- reciprocal changes in the opposite leads. A new LBBB is considered STEMI equivalent.
*see p. 25 PPP for ST elevations and artery/area involved!!!
The management of UA or NSTEMI involves a 2 part approach of:
- Antithrombotic therapy
2. Adjunctive therapy & Assess risk factors (TIMI score)
Antithrombotic therapy can be broken down into Anti-platelet drugs and Anticoagulants.
Examples of anti-platelet drugs include:
- Aspirin
2. Clopidogrel- good in pts with aspirin allergy
Examples of anticoagulants include:
- Unfractionated Heparin- good for ACS pts with EKG changes or + cardiac markers
- LMWH- Lovenox- must be renally dosed
Adjunctive anti-ischemic therapy for UA or NSTEMI includes:
- Beta blockers- Metoprolol
- Nitrates
- Morphine- relieves pain, causes VENODILATION (decreasing preload)
- Ca channel blockers
3 part approach to managing STEMI:
- REPERFUSION therapy
- Antithrombotics
- Adjunctive therapy
Reperfusion therapy must be done within ___ hours of symptoms onset. Includes either PCI or Thrombolytics.
12
PCI is SUPERIOR to thrombolytics. Must be done within ___ hours of sx onset.
3
*May need to do CABG if > 3-vessel dz, L main coronary artery, or decreased left ventricle EF
Aspirin is an antithrombotic drug of choice in STEMI and lowers mortality by ___ %.
20%–> chewed for faster absorption
Adjunctive therapy for STEMI includes:
- Beta blockers
- ACE-I
- Nitrates
- Morphine
Remember “MONA” regimen for management of ACS
M- Morphine
O- Oxygen
N- Nitrates
A- Aspirin
Want to avoid _____ (class of medicine) in cocaine induced MIs due to vasospasm.
Beta blockers
What is Dressler syndrome?
Post-MI pericarditis + fever + pulmonary infiltrates
_____ is the medicine of choice for variant angina and cocaine-induced vasospasm.
Ca channel blockers and NTG
A TIMI score ≥ ___ shows a benefit to invasive angiography to reduce mortality with a UA or NSTEMI
3
Absolute contraindications to thrombolytic therapy include:
- Previous ICH
2. Non-hemorrhagic stroke within 6 months or closed head/facial trauma within 3 months
The most common causes of transudative pleural effusions in the United States are heart failure and cirrhosis. Conditions associated with transudative pleural effusions include:
- Congestive heart failure
- Liver cirrhosis
- Severe hypoalbuminemia
- Nephrotic syndrome
- Acute atelectasis
- Myxedema
- Peritoneal dialysis
- Obstructive uropathy
- End-stage kidney disease
WPW may present like:
A 25 year-old male with history of syncope presents for evaluation. The patient admits to intermittent episodes of rapid heart beating that resolve spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which of the following is the treatment of choice in this patient?
Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome.
