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Cardiology Flashcards

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Royal College: Emergency Medicine 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
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2
Q

DDX for DOE

A

Coarctation of the aorta
Mitral regurgitation
CHF

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3
Q

DDX for orthopnea

A

CHF (left)

Constrictive pericarditis

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4
Q

DDX for edema

A 
CHF (right)
Pericardial tamponade
Dilated cardiomyopathy
Restrictive cardiomyopathy
Peripheral venous disease
Chronic venous insufficiency
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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
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6
Q

A new left bundle branch block should be treated as an _________

A

Infarction

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7
Q

Q waves are specific for ___________ but are a late finding

A

Necrosis

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8
Q

Cardiac enzymes

A

Myoglobin
CK-MB
Troponins (preferred)

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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

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10
Q

Reinfarction is diagnosed if troponin increases over ____%

A

20

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11
Q

Unstable angina will not have an elevation in:

A

Cardiac enzymes

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12
Q

Long PR interval > 0.2 seconds

Treatment?

A

First degree heart block

No treatment

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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

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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

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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

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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

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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

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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

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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

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20
Q

P wave before expected and p wave morphology will differ

Treatment?

A

Premature atrial contraction
Asymptomatic: no tx
Symptomatic: BB

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21
Q

Treatment for wide complex tachycardia

A

Unstable: cardiovert
Stable: amiodarone, lidocaine or procainamide
If medication does not convert to sinus, cardiovert

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22
Q

Treatment for torsades de pointes

A

Magnesium sulfate is med of choice

Cardiac pacing if ineffective

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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
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24
Q

Irregularly irregular rhythm with narrow QRS usually

A

Atrial fibrillation

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25
Q

Management of atrial fibrillation if stable

A
  1. Rate control: BB, CCB, digoxin

2. Rhythm control - cardioversion, radiofrequency ablation

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26
Q

Management of atrial fibrillation if unstable

A

Direct current (synchronized) cardioversion

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27
Q

Anticoagulation for atrial fibrillation

A 
CHA2DS2-VASc score
2 - anticoagulants recommended
Congestive heart failure
Hypertension
Age > 75
Diabetes mellitus
Stroke, TIA, thrombus
Vascular disease
Age 65-74
Sex (female)
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28
Q

Increased BP + acute end organ damage

A

Hypertensive emergencies

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29
Q

Hypertensive emergencies are usually seen with systolic blood pressure > ______ and/or diastolic BP > _______

A

180
120
though, no specific threshold

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30
Q

4 types of damage seen with hypertensive emergencies

A
  1. Neurological damage
  2. Cardiac damage
  3. Renal damage
  4. Retinal damage
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31
Q

Ruling out neurological damage with hypertensive emergency

A

Neurological exam

May need CT to r/o stroke

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32
Q

Ruling out cardiac damage with hypertensive emergency

A

ECG
CXR to r/o dissection, look for pulmonary edema
CK-MB / troponin

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33
Q

Ruling out renal damage with hypertensive emergency

A

UA - proteinuria and/or hematuria

May need chemistries to look for increased BUN/Cr

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34
Q

Ruling out retinal damage with hypertensive emergency

A

Malignant HTN/Grade IV - papilledema

may present with blurred vision

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35
Q

Management of hypertensive emergency

A

Decrease BP by no more than 25% within the first hour and an additional 5-15% over the next 23 hours using IV agents

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36
Q

Signs/symptoms of shock (cardiogenic or hypovolemic)

A 
Generally acutely ill
AMS
Decreased peripheral pulses
Tachycardia
Skin usually cool and mottled
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37
Q

Laboratory tests for shock (cardiogenic or hypovolemic)

A
  1. CBC
  2. BMP
  3. Lactate
  4. Coag studies
  5. Cultures (looking for sepsis)
  6. ABG
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38
Q

Etiologies of hypovolemic shock (hemorrhagic)

A

GI bleed, AAA rupture, massive hemoptysis, trauma, ectopic pregnancy, postpartum hemorrhage

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39
Q

Etiologies of hypovolemic shock (non-hemorrhagic)

A

Vomiting, bowel obstruction, pancreatitis, severe burns, diabetic ketoacidosis

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40
Q

Diagnosis of hypovolemic shock

A 
Vasoconstriction (High SVR)
Hypotension
Low CO
Decreased pulmonary capillary pressure
CBC: high hgb, hct
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41
Q

Management of hypovolemic shock

A
  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
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42
Q

Etiologies of cardiogenic shock

A

Cardiac disease - myocardial infarction, myocarditis, valve dysfunction, congenital heart disease, cardiomyopathy, arrhythmias

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43
Q

Management of cardiogenic shock

A
  1. Oxygen, isotonic fluids (not large amounts of fluid)
  2. Inotropic support - dobutamine, amrinone, intra aortic balloon pump
  3. Treat underlying cause
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44
Q

Most common cause of systolic congestive heart failure

A

Coronary artery disease

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45
Q

Most common cause of diastolic congestive heart failure

A

HTN

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46
Q

In diastolic dysfunction, ejection fracture is _________. In systolic dysfunction, ejection fraction is __________

A

Normal

< 50%

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47
Q

Fatigue, SOB, orthopnea, PND, chronic cough, pedal edema, JVD, S3 gallop, S4 gallop

A

Congestive heart failure

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48
Q

S3 gallop is seen with _______ heart failure

A

Systolic

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49
Q

S4 gallop is seen with _________ heart failure

A

Diastolic

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50
Q

Crackles, orthopnea, and PND are seen more with __________ heart dysfunction

A

Left sided

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51
Q

JvD, hepatojugular reflux, pedal edema, ascites are seen more with ________ heart dysfunction

A

Right sided

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52
Q

Diagnosis of congestive heart failure

A
  1. Clinical
  2. Echo with ejection fracture
  3. ECG
  4. CXR
  5. Stress testing
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53
Q

Treatment for diastolic dysfunction

A

Manage sx and treat comorbid conditions. No medications proven

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54
Q

Treatment for systolic dysfunction

A

ACEI/ARBs

BB

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55
Q

Never give _____ during an acute exacerbation of CHF and also be careful with _____

A

BB

CCB

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56
Q

Most acute exacerbations of CHF present with:;

A

Acute pulmonary edema

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57
Q

Treatment of acute exacerbation of CHF

A 
LMNOP
Loop diuretic
Morphine
Nitrates
Oxygen
Position (head up)
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58
Q

Substernal chest pain that is usually brought on by exertion (due to decreased supply and increased demand) - 4 different classes of severity

A

Angina pectoris

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59
Q

Levine’s sign

A

Clenched fist over chest

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60
Q

Diagnosis of angina pectoris

A
  1. ECG initial test
  2. Angiography gold standard
  3. Stress testing
  4. Stress echocardiogram
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61
Q

Classic ECG finding in angina pectoris

A

ST depression

50% have normal resting ECG

62
Q

Management of angina pectoris

A
  1. PTCA - 1-2 vessel not including left main

2. CABG - left main, >70% stenosis, 3 vessel disease, decreased ejection fraction

63
Q

Coronary spasms leading to transient ST elevations usually without MI

A

Variant (Prinzmetal) Angina

64
Q

Signs/symptoms of variant (prinzmetal) angina

A

CP usually nonexertional, often occurring at rest. Often occurs in morning, with hyperventilation, emotional stress or cold weather

65
Q

Diagnosis of variant (prinzmetal) angina

A
  1. ECG - +/- transient ST elevation
  2. Angiography - vasospasms
  3. Symptoms + ST elevations resolve with CCB or nitro
66
Q

Management of variant (prinzmetal) angina

A

CCB - drug of choice

Nitrates as needed

67
Q

ECG and cardiac enzymes with stable angina

A

Normal

68
Q

Treatment for stable angina

A 
Lifestyle modifications 
Control HTN, diabetes, hyperlipidemia
Statin, Aspirin, Beta blocker
Nitroglycerin
PCI or CABG if cannot be controlled with medications
69
Q

__________ is a very specific predictor of ACS (ST segment elevation)

A

Diaphoresis

70
Q

Do not want to give pts with a right sided MI _______ as this will cause a severe drop in BP

A

Nitrates

71
Q

Inferior MI

A

Leads II, III, and aVF

72
Q

Anterior MI

A

Leads V1-V4

73
Q

Lateral MI

A

Leads I, aVL, and V5-V6

74
Q

Myoglobin begins to rise after _______ and stays elevated for a couple of days

A

1 hour

75
Q

CK-MB will rise after _________ and will stay elevated for a couple of days

A

4 hours

76
Q

Troponins rises after _____ and will stay elevated for up to 2 weeks

A

4 hours

77
Q

Unstable angina _______ have elevation in cardiac enzymes

A

will not

78
Q

NSTEMI and STEMI ______ have elevation in cardiac enzymes

A

will

79
Q

Treatment for acute coronary syndrome (unstable angina, NSTEMI, STEMI)

A 
MONA 
morphine
oxygen
nitrates
aspirin (chewed)
All pts should also get loading dose of a P2Y12 drug (clopidogrel, prasugrel, ticagrelor)
80
Q

Treatment if pt has inferior MI:

A

Avoid nitrates (causes severe drop in BP) -give pts fluids instead

81
Q

All patients with a STEMI should receive:

A

Heparin

82
Q

PCI is preferred to thrombolytics, but must be done within ___________ of arrival to hospital

A

90 minutes

83
Q

Thrombolytics should be given within ________ of hospital arrival - indicated if chest pain has been present < 12 hours and lacks CI

A

30 minutes

84
Q

Most common cause of death within first few days after an MI is _______________, therefore continuous rhythm monitoring is required

A

Ventricular tachycardia or ventricular fibrillation

85
Q

Dressler syndrome

A

Autoimmune mediated pericarditis - pts present with pericarditis, fever, malaise, and leukocytosis 2-10 weeks post MI. Give an aspirin

86
Q

All pts post MI should be continued on:

A

Beta blocker
ACE
Statin
Dual antiplatelet therapy (clopidogrel and aspirin) is used for one year

87
Q

In order to be considered aneurysmal, an AAA must be at least > _______

A

3 cm

88
Q

Risk factors for AAA

A

Atherosclerosis (MC)
Age > 60 y/o
Smoking
Males, Caucasians

89
Q

Classic presentation of AAA (when not asymptomatic)

A 
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
Q

Diagnosis of AAA

A
  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
Q

Management of AAA > 5.5 cm

A

Immediate surgical repair even if asymptomatic

92
Q

Management of an AAA with expansion of > 0.5 cm in 6 months

A

Immediate surgical repair even if asymptomatic

93
Q

Management of AAA > 4.5 cm

A

Vascular surgeon referral

94
Q

Management of AAA 4-4.5 cm

A

Monitor by US every 6 months

95
Q

Management of AAA 3-4 cm

A

Monitor by US every year

96
Q

Medicational management of AAA

A

Beta blockers

Also decrease risk factors

97
Q

65% of aortic dissections are ________

A

Ascending

98
Q

_________ aortic dissections are associated with a high mortality

A

Ascending

99
Q

Most important risk factor for aortic dissection

A

HTN

100
Q

Risk factors for aortic dissection

A 
HTN
Marfan Syndrome
Age 50+
Men 
Cocaine use
101
Q

Signs/symptoms of aortic dissection

A

Chest pain - severe, tearing, ripping, knife-life
N/V
Diaphoresis

102
Q

Physical exam sign of aortic dissection

A

Decreased peripheral pulses - radial, carotid or femoral

103
Q

Diagnosis of aortic dissection

A
  1. CT scan with contrast - TOC
  2. MRI angiography - gold standard
  3. TEE
  4. CXR
104
Q

What will show on CXR with aortic dissection?

A

Widening of the mediastinum

105
Q

Management of Stanford A / DeBakey I and II aortic dissections, or type III with complications

A

Involve the ascending aorta / aortic arch

Surgery

106
Q

Management of Stanford / DeBakey III aortic dissections

A

Are limited to descending aorta
Esmolol, Labetalol -1st line
Sodium nitroprusside, nicardipine if needed

107
Q

How often should aortic dissection be imaged if not surgically fixed?

A

3, 6 and 12 mo to look for progression, redissection and/or new aneurysm formation

108
Q

Definitive diagnosis for all valvular disease is reached with:

A

Echocardiogram

109
Q

Most symptoms of valvular disease are similar to that of CHF

A

SOB and chest discomfort

110
Q

Holosystolic murmurs

A

Mitral regurgitation
Tricuspid regurgitation
VSD

111
Q

Increases sound of all murmurs, except mitral valve prolapse and HOCM (decreases)

A

Squatting
Leg raise
Handgrip

112
Q

Systolic crescendo-decrescendo murmur heard best at the second right intercostal space - radiates to the neck

A

Aortic stenosis

113
Q

Heard best at the left upper sternal border with an ejection click

A

Pulmonic Stenosis

114
Q

Holosystolic murmur heard best over the apex that radiates to the axilla

A

Mitral regurgitation

115
Q

Mid systolic click with a possible late systolic murmur

A

Mitral valve prolapse

116
Q

Holosystolic murmur heard best at the left mid sternal border

A

Tricuspid regurgitation

117
Q

Decrescendo murmur with a blowing quality heart best at the left sternal border

A

Aortic regurgitation

118
Q

Decrescendo murmur

A

Pulmonic regurgitation

119
Q

Low pitch rumble heard best at the apex

A

Mitral stenosis

120
Q

Heard best at the 4th intercostal space at the left loewr sternal border

A

Tricuspid stenosis

121
Q

Infection of the endocardial surface of the heart, which extends to the heart valves

A

Endocarditis

122
Q

Risk factors for endocarditis

A 
Valvular heart disease
Congenital heart disease
Prosthetic heart valves
Immunosuppression
Age > 60 y/o
Injection drug users
123
Q

Most common etiology of endocarditis in native valves

A

Streptococci viridans

124
Q

Most common etiology of endocarditis in those who are injection drug users

A

Staphylococcus aureus

125
Q

Most common etiology of endocarditis in those with prosthetic valve endocarditis

A

Staphylococcus epidermidis

126
Q

Fever, anorexia, weight loss, fatigue, ECG conduction abnormalities

A

Endocarditis

127
Q

Painless erythematous macules on the palms and soles

A

Janeway Lesions

Endocarditis

128
Q

Retinal hemorrhages with pale centers. Petechiae (conjunctiva and palate)

A

Roth spots

Endocarditis

129
Q

Tender nodules on the pads of the digits

A

Osler’s Nodes

Endocarditis

130
Q

Splinter hemorrhages of proximal nail bed, clubbing, hepatosplenomegaly

A

Endocarditis

131
Q

Diagnostic studies for endocarditis

A
  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
Q

Major Duke Criteria

A
  1. Sustained bacteremia (2 blood cultures)
  2. Endocardial involvement on echo
  3. New aortic or mitral regurg
133
Q

Minor Duke Criteria

A
  1. Predisposing condition
  2. Fever
  3. Janeway lesions, etc.
    • blood culture
    • echo not meeting major criteria
134
Q

Clinical criteria for infective endocarditis based on Duke’’s Criteria

A

2 major or
1 major + 3 minor or
5 minor

135
Q

Indications for surgery with endocarditis

A 
Refractory CHF
Persistent or refractory infxn
Invasive infection
Prosthetic valve
Recurrent systemic emboli
Fungal infxns
136
Q

Management of endocarditis (acute)

A

Nafcillin + gentamicin OR

Vanco + gentamicin

137
Q

Management of endocarditis (prosthetic valve)

A

Vancomycin + gentamicin + rifampin

138
Q

Management of endocarditis (fungal)

A

Amphotericin B

139
Q

Pericardial effusion causing significant pressure on the heart leading to cardiac output

A

Cardiac tamponade

140
Q

Signs/symptoms of cardiac tamponade

A

Beck’s triad

Pulsus paradoxus

141
Q

Pulsus paradoxus

A

Cardiac tamponade
Exaggerated > 10 mmHg decrease in systolic BP with inspiration
Decreased pulses with inspiration

142
Q

Beck’s triad

A

Cardiac tamponade

  1. Distant (muffled) heart sounds
  2. Hypotension
  3. JVD
143
Q

Diagnosis of cardiac tamponade

A
  1. Echocardiogram - presence of effusion + diastolic collapse of cardiac chambers
144
Q

Management of cardiac tamponade

A

Pericardiocentesis (immediate!)

145
Q

Increased fluid in pericardial space

A

Pericardial effusion

146
Q

Etiologies of pericardial effusion

A

Same as acute pericarditis (viral and idiopathic)

147
Q

Signs/symptoms of pericardial effusion

A

Distant (muffled) heart sounds

+/- symptoms of pericarditis

148
Q

Diagnosis of pericardial effusion

A
  1. ECG - low voltage

2. Echocardiogram - pericardial fluid, no hemodynamic compromise

149
Q

Management of pericardial effusion

A

Treat underlying cause

Pericardial window if recurrent

150
Q

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

A

Peripheral vascular disease

151
Q

Diagnosis of peripheral vascular disease

A

ABI - positive if ratio is < 0.9

152
Q

All pts with peripheral vascular disease should receive, however first step is a:

A

Aspirin

Supervised 12 week exercise regimen

Emergency EOR (12 decks)

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