Cardiology Flashcards
1
Q
DDX for palpitations
A
Hypomagnesemia Hyperkalemia Anxiety Alcohol withdrawal Anemia Atrial septal defect Acute coronary syndrome Hypertrophic cardiomyopathy Mitral valve prolapse Hyperthyroidism Thyroid storm Hypoglycemia
2
Q
DDX for DOE
A
Coarctation of the aorta
Mitral regurgitation
CHF
3
Q
DDX for orthopnea
A
CHF (left)
Constrictive pericarditis
4
Q
DDX for edema
A
CHF (right) Pericardial tamponade Dilated cardiomyopathy Restrictive cardiomyopathy Peripheral venous disease Chronic venous insufficiency
5
Q
DDX for syncope
A
Hypocalcemia Anemia Ventricular septal defect Atrial septal defect Coarctation of the aorta Long QT syndrome Myocarditis Hypertrophic cardiomyopathy Aortic stenosis Mitral valve prolapse Abdominal aortic aneurysm Aortic dissection Pulmonary embolism
6
Q
A new left bundle branch block should be treated as an _________
A
Infarction
7
Q
Q waves are specific for ___________ but are a late finding
A
Necrosis
8
Q
Cardiac enzymes
A
Myoglobin
CK-MB
Troponins (preferred)
9
Q
Most pts with negative enzymes can have an MI excluded by _________, but for high risk pts, should continue serial labs for _________ hours
A
8 hours
12-24 hours
10
Q
Reinfarction is diagnosed if troponin increases over ____%
A
20
11
Q
Unstable angina will not have an elevation in:
A
Cardiac enzymes
12
Q
Long PR interval > 0.2 seconds
Treatment?
A
First degree heart block
No treatment
13
Q
PR progressively lengthens until it fails to produce a QRS complex.
Treatment?
A
Mobitz I / Wenckebach
No tx until pt is symptomatic.
Place pacemaker if symptoms are present.
Atropine if unstable
14
Q
Patient will have continuously dropped QRS complex, however there won’t be lengthening of the PR interval.
Treatment?
A
Mobitz II
Pacemaker to prevent progression 3rd degree
15
Q
Signal from atria does not reach ventricle. P waves are independent from QRS complex.
Treatment?
A
Third degree heart block
Pacemaker - may be fatal
16
Q
Wide QRS, RSR pattern in leads V1/V2/V3, S wave wider than R wave in leads 1 and V6.
Treatment?
A
Right Bundle Branch Block
Asymptomatic does not need tx
Symptomatic: pacemaker
17
Q
Wide QRS, notched R wave in leads I/aVL/V5/V6.
Treatment?
A
Left Bundle Branch Block
Must be treated as an MI if new
18
Q
Patients will present with abrupt onset of palpitations and the EKG will show complex tachycardia.
QRS absorbs p waves.
Treatment?
A
Paroxysmal Supraventricular Tachycardia
If hemodynamic instability exists: cardiovert
If stable: vagal maneuvers - valsalva or carotid massage
If this does not work: adenosine - then CCB or BB
19
Q
Wide complex QRS without P waves. Following wide complex QRS, will usually be a compensatory pause. Pts may present with palpitations
Treatment?
A
Premature ventricular contraction
Asymptomatic: no tx
Symptomatic: BB
20
Q
P wave before expected and p wave morphology will differ
Treatment?
A
Premature atrial contraction
Asymptomatic: no tx
Symptomatic: BB
21
Q
Treatment for wide complex tachycardia
A
Unstable: cardiovert
Stable: amiodarone, lidocaine or procainamide
If medication does not convert to sinus, cardiovert
22
Q
Treatment for torsades de pointes
A
Magnesium sulfate is med of choice
Cardiac pacing if ineffective
23
Q
Sawtooth waves at 250-300 bpm (no p waves)
Treatment?
A
Atrial flutter Stable: vagal, BB or CCB Unstable: synchronized cardioversion Definitive management: radiofrequency ablation Anticoagulation similar to AFib
24
Q
Irregularly irregular rhythm with narrow QRS usually
A
Atrial fibrillation
25
Management of atrial fibrillation if stable
1. Rate control: BB, CCB, digoxin
| 2. Rhythm control - cardioversion, radiofrequency ablation
26
Management of atrial fibrillation if unstable
Direct current (synchronized) cardioversion
27
Anticoagulation for atrial fibrillation
```
CHA2DS2-VASc score
2 - anticoagulants recommended
Congestive heart failure
Hypertension
Age > 75
Diabetes mellitus
Stroke, TIA, thrombus
Vascular disease
Age 65-74
Sex (female)
```
28
Increased BP + acute end organ damage
Hypertensive emergencies
29
Hypertensive emergencies are usually seen with systolic blood pressure > ______ and/or diastolic BP > _______
180
120
though, no specific threshold
30
4 types of damage seen with hypertensive emergencies
1. Neurological damage
2. Cardiac damage
3. Renal damage
4. Retinal damage
31
Ruling out neurological damage with hypertensive emergency
Neurological exam
| May need CT to r/o stroke
32
Ruling out cardiac damage with hypertensive emergency
ECG
CXR to r/o dissection, look for pulmonary edema
CK-MB / troponin
33
Ruling out renal damage with hypertensive emergency
UA - proteinuria and/or hematuria
| May need chemistries to look for increased BUN/Cr
34
Ruling out retinal damage with hypertensive emergency
Malignant HTN/Grade IV - papilledema
| may present with blurred vision
35
Management of hypertensive emergency
Decrease BP by no more than 25% within the first hour and an additional 5-15% over the next 23 hours using IV agents
36
Signs/symptoms of shock (cardiogenic or hypovolemic)
```
Generally acutely ill
AMS
Decreased peripheral pulses
Tachycardia
Skin usually cool and mottled
```
37
Laboratory tests for shock (cardiogenic or hypovolemic)
1. CBC
2. BMP
3. Lactate
4. Coag studies
5. Cultures (looking for sepsis)
6. ABG
38
Etiologies of hypovolemic shock (hemorrhagic)
GI bleed, AAA rupture, massive hemoptysis, trauma, ectopic pregnancy, postpartum hemorrhage
39
Etiologies of hypovolemic shock (non-hemorrhagic)
Vomiting, bowel obstruction, pancreatitis, severe burns, diabetic ketoacidosis
40
Diagnosis of hypovolemic shock
```
Vasoconstriction (High SVR)
Hypotension
Low CO
Decreased pulmonary capillary pressure
CBC: high hgb, hct
```
41
Management of hypovolemic shock
1. ABCDE's - 2 large IV lines or central
2. Volume resuscitation
3. Control source of hemorrhage, +/- packed RBCs
4. Prevention of hypothermia, treat any coagulopathies
42
Etiologies of cardiogenic shock
Cardiac disease - myocardial infarction, myocarditis, valve dysfunction, congenital heart disease, cardiomyopathy, arrhythmias
43
Management of cardiogenic shock
1. Oxygen, isotonic fluids (not large amounts of fluid)
2. Inotropic support - dobutamine, amrinone, intra aortic balloon pump
3. Treat underlying cause
44
Most common cause of systolic congestive heart failure
Coronary artery disease
45
Most common cause of diastolic congestive heart failure
HTN
46
In diastolic dysfunction, ejection fracture is _________. In systolic dysfunction, ejection fraction is __________
Normal
| < 50%
47
Fatigue, SOB, orthopnea, PND, chronic cough, pedal edema, JVD, S3 gallop, S4 gallop
Congestive heart failure
48
S3 gallop is seen with _______ heart failure
Systolic
49
S4 gallop is seen with _________ heart failure
Diastolic
50
Crackles, orthopnea, and PND are seen more with __________ heart dysfunction
Left sided
51
JvD, hepatojugular reflux, pedal edema, ascites are seen more with ________ heart dysfunction
Right sided
52
Diagnosis of congestive heart failure
1. Clinical
2. Echo with ejection fracture
3. ECG
4. CXR
5. Stress testing
53
Treatment for diastolic dysfunction
Manage sx and treat comorbid conditions. No medications proven
54
Treatment for systolic dysfunction
ACEI/ARBs
| BB
55
Never give _____ during an acute exacerbation of CHF and also be careful with _____
BB
| CCB
56
Most acute exacerbations of CHF present with:;
Acute pulmonary edema
57
Treatment of acute exacerbation of CHF
```
LMNOP
Loop diuretic
Morphine
Nitrates
Oxygen
Position (head up)
```
58
Substernal chest pain that is usually brought on by exertion (due to decreased supply and increased demand) - 4 different classes of severity
Angina pectoris
59
Levine's sign
Clenched fist over chest
60
Diagnosis of angina pectoris
1. ECG initial test
2. Angiography gold standard
3. Stress testing
4. Stress echocardiogram
61
Classic ECG finding in angina pectoris
ST depression
| 50% have normal resting ECG
62
Management of angina pectoris
1. PTCA - 1-2 vessel not including left main
| 2. CABG - left main, >70% stenosis, 3 vessel disease, decreased ejection fraction
63
Coronary spasms leading to transient ST elevations usually without MI
Variant (Prinzmetal) Angina
64
Signs/symptoms of variant (prinzmetal) angina
CP usually nonexertional, often occurring at rest. Often occurs in morning, with hyperventilation, emotional stress or cold weather
65
Diagnosis of variant (prinzmetal) angina
1. ECG - +/- transient ST elevation
2. Angiography - vasospasms
3. Symptoms + ST elevations resolve with CCB or nitro
66
Management of variant (prinzmetal) angina
CCB - drug of choice
| Nitrates as needed
67
ECG and cardiac enzymes with stable angina
Normal
68
Treatment for stable angina
```
Lifestyle modifications
Control HTN, diabetes, hyperlipidemia
Statin, Aspirin, Beta blocker
Nitroglycerin
PCI or CABG if cannot be controlled with medications
```
69
__________ is a very specific predictor of ACS (ST segment elevation)
Diaphoresis
70
Do not want to give pts with a right sided MI _______ as this will cause a severe drop in BP
Nitrates
71
Inferior MI
Leads II, III, and aVF
72
Anterior MI
Leads V1-V4
73
Lateral MI
Leads I, aVL, and V5-V6
74
Myoglobin begins to rise after _______ and stays elevated for a couple of days
1 hour
75
CK-MB will rise after _________ and will stay elevated for a couple of days
4 hours
76
Troponins rises after _____ and will stay elevated for up to 2 weeks
4 hours
77
Unstable angina _______ have elevation in cardiac enzymes
will not
78
NSTEMI and STEMI ______ have elevation in cardiac enzymes
will
79
Treatment for acute coronary syndrome (unstable angina, NSTEMI, STEMI)
```
MONA
morphine
oxygen
nitrates
aspirin (chewed)
All pts should also get loading dose of a P2Y12 drug (clopidogrel, prasugrel, ticagrelor)
```
80
Treatment if pt has inferior MI:
Avoid nitrates (causes severe drop in BP) -give pts fluids instead
81
All patients with a STEMI should receive:
Heparin
82
PCI is preferred to thrombolytics, but must be done within ___________ of arrival to hospital
90 minutes
83
Thrombolytics should be given within ________ of hospital arrival - indicated if chest pain has been present < 12 hours and lacks CI
30 minutes
84
Most common cause of death within first few days after an MI is _______________, therefore continuous rhythm monitoring is required
Ventricular tachycardia or ventricular fibrillation
85
Dressler syndrome
Autoimmune mediated pericarditis - pts present with pericarditis, fever, malaise, and leukocytosis 2-10 weeks post MI. Give an aspirin
86
All pts post MI should be continued on:
Beta blocker
ACE
Statin
Dual antiplatelet therapy (clopidogrel and aspirin) is used for one year
87
In order to be considered aneurysmal, an AAA must be at least > _______
3 cm
88
Risk factors for AAA
Atherosclerosis (MC)
Age > 60 y/o
Smoking
Males, Caucasians
89
Classic presentation of AAA (when not asymptomatic)
```
Older male > 60 y/o
Severe back or abdominal pain
presents with hypotension/syncope
Tender, pulsatile abdominal mass
May complain of unilateral groin/hip pain
```
90
Diagnosis of AAA
1. Abdominal ultrasound - initial test of choice
2. CT scan - especially for thoracic aneurysm
3. Angiography - gold standard
4. MRI/MRA
5. Abdominal radiograph
91
Management of AAA > 5.5 cm
Immediate surgical repair even if asymptomatic
92
Management of an AAA with expansion of > 0.5 cm in 6 months
Immediate surgical repair even if asymptomatic
93
Management of AAA > 4.5 cm
Vascular surgeon referral
94
Management of AAA 4-4.5 cm
Monitor by US every 6 months
95
Management of AAA 3-4 cm
Monitor by US every year
96
Medicational management of AAA
Beta blockers
| Also decrease risk factors
97
65% of aortic dissections are ________
Ascending
98
_________ aortic dissections are associated with a high mortality
Ascending
99
Most important risk factor for aortic dissection
HTN
100
Risk factors for aortic dissection
```
HTN
Marfan Syndrome
Age 50+
Men
Cocaine use
```
101
Signs/symptoms of aortic dissection
Chest pain - severe, tearing, ripping, knife-life
N/V
Diaphoresis
102
Physical exam sign of aortic dissection
Decreased peripheral pulses - radial, carotid or femoral
103
Diagnosis of aortic dissection
1. CT scan with contrast - TOC
2. MRI angiography - gold standard
3. TEE
4. CXR
104
What will show on CXR with aortic dissection?
Widening of the mediastinum
105
Management of Stanford A / DeBakey I and II aortic dissections, or type III with complications
Involve the ascending aorta / aortic arch
| Surgery
106
Management of Stanford / DeBakey III aortic dissections
Are limited to descending aorta
Esmolol, Labetalol -1st line
Sodium nitroprusside, nicardipine if needed
107
How often should aortic dissection be imaged if not surgically fixed?
3, 6 and 12 mo to look for progression, redissection and/or new aneurysm formation
108
Definitive diagnosis for all valvular disease is reached with:
Echocardiogram
109
Most symptoms of valvular disease are similar to that of CHF
SOB and chest discomfort
110
Holosystolic murmurs
Mitral regurgitation
Tricuspid regurgitation
VSD
111
Increases sound of all murmurs, except mitral valve prolapse and HOCM (decreases)
Squatting
Leg raise
Handgrip
112
Systolic crescendo-decrescendo murmur heard best at the second right intercostal space - radiates to the neck
Aortic stenosis
113
Heard best at the left upper sternal border with an ejection click
Pulmonic Stenosis
114
Holosystolic murmur heard best over the apex that radiates to the axilla
Mitral regurgitation
115
Mid systolic click with a possible late systolic murmur
Mitral valve prolapse
116
Holosystolic murmur heard best at the left mid sternal border
Tricuspid regurgitation
117
Decrescendo murmur with a blowing quality heart best at the left sternal border
Aortic regurgitation
118
Decrescendo murmur
Pulmonic regurgitation
119
Low pitch rumble heard best at the apex
Mitral stenosis
120
Heard best at the 4th intercostal space at the left loewr sternal border
Tricuspid stenosis
121
Infection of the endocardial surface of the heart, which extends to the heart valves
Endocarditis
122
Risk factors for endocarditis
```
Valvular heart disease
Congenital heart disease
Prosthetic heart valves
Immunosuppression
Age > 60 y/o
Injection drug users
```
123
Most common etiology of endocarditis in native valves
Streptococci viridans
124
Most common etiology of endocarditis in those who are injection drug users
Staphylococcus aureus
125
Most common etiology of endocarditis in those with prosthetic valve endocarditis
Staphylococcus epidermidis
126
Fever, anorexia, weight loss, fatigue, ECG conduction abnormalities
Endocarditis
127
Painless erythematous macules on the palms and soles
Janeway Lesions
| Endocarditis
128
Retinal hemorrhages with pale centers. Petechiae (conjunctiva and palate)
Roth spots
| Endocarditis
129
Tender nodules on the pads of the digits
Osler's Nodes
| Endocarditis
130
Splinter hemorrhages of proximal nail bed, clubbing, hepatosplenomegaly
Endocarditis
131
Diagnostic studies for endocarditis
1. Blood cultures - before abx initiation - 3 sets at least 1 hour apart if pt is stable
2. ECG
3. Echo
4. Labs - leukocytosis, anemia, increased ESR, rheumatoid factor
132
Major Duke Criteria
1. Sustained bacteremia (2 blood cultures)
2. Endocardial involvement on echo
3. New aortic or mitral regurg
133
Minor Duke Criteria
1. Predisposing condition
2. Fever
3. Janeway lesions, etc.
4. + blood culture
5. + echo not meeting major criteria
134
Clinical criteria for infective endocarditis based on Duke''s Criteria
2 major or
1 major + 3 minor or
5 minor
135
Indications for surgery with endocarditis
```
Refractory CHF
Persistent or refractory infxn
Invasive infection
Prosthetic valve
Recurrent systemic emboli
Fungal infxns
```
136
Management of endocarditis (acute)
Nafcillin + gentamicin OR
| Vanco + gentamicin
137
Management of endocarditis (prosthetic valve)
Vancomycin + gentamicin + rifampin
138
Management of endocarditis (fungal)
Amphotericin B
139
Pericardial effusion causing significant pressure on the heart leading to cardiac output
Cardiac tamponade
140
Signs/symptoms of cardiac tamponade
Beck's triad
| Pulsus paradoxus
141
Pulsus paradoxus
Cardiac tamponade
Exaggerated > 10 mmHg decrease in systolic BP with inspiration
Decreased pulses with inspiration
142
Beck's triad
Cardiac tamponade
1. Distant (muffled) heart sounds
2. Hypotension
3. JVD
143
Diagnosis of cardiac tamponade
1. Echocardiogram - presence of effusion + diastolic collapse of cardiac chambers
144
Management of cardiac tamponade
Pericardiocentesis (immediate!)
145
Increased fluid in pericardial space
Pericardial effusion
146
Etiologies of pericardial effusion
Same as acute pericarditis (viral and idiopathic)
147
Signs/symptoms of pericardial effusion
Distant (muffled) heart sounds
| +/- symptoms of pericarditis
148
Diagnosis of pericardial effusion
1. ECG - low voltage
| 2. Echocardiogram - pericardial fluid, no hemodynamic compromise
149
Management of pericardial effusion
Treat underlying cause
| Pericardial window if recurrent
150
Presentation is that of angina in the legs (leg pain with exertion and relieved with rest). Lower extremities may show pallor, ulcerations, diminished pulses, and hair loss
Peripheral vascular disease
151
Diagnosis of peripheral vascular disease
ABI - positive if ratio is < 0.9
152
All pts with peripheral vascular disease should receive, however first step is a:
Aspirin
| Supervised 12 week exercise regimen
