Cardiology Flashcards
1
Q
Secondary HTN is due to an underlying, identifiable, and often correctable cause. The MC cause is ______.
A
Renovascular- renal artery stenosis; fibromuscular dysplasia in young pts and atherosclerosis in elderly
2
Q
_____ is a sign of advanced stage of malignant HTN.
A
Papilledema
3
Q
A ___ heart sound is associated with HTN.
A
A S4 (and loud S2) -suggestive of left ventricular wall thickening
4
Q
A BP of < ____ mmHg is desirable in the general population and < _____ is desirable in pts with DM, renal disease, or >60y.
A
<140/90mmHg- general population
<150/90- DM, renal disease, >60y
5
Q
Initial medication choice for uncomplicated HTN (with no comorbidities) in NON-African Americans includes:
A
- Thiazide-type diuretic
- ACEI
- ARB
- CCBs
6
Q
Management of HTN with comorbidities:
A
- A fib- BB or CCB (non-DHPs: verapamil, cardizem)
- Angina: BBs, CCBs
- Post-MI: BBs, ACEI
- Systolic HF: ACEI, ARB, BBs, diuretics
- DM/CKD: ACEI, ARB
- Isolated systolic HTN in elderly: diuretics (+/- CCBs)
- BPH: a1 blockers (tamsulosin, alfuzosin, terazosin)
- AA (nondiabetic): Thiazides or CCBs
- Young, caucasian males: Thiazides–>ACEI, ARB–> BBs
- Gout: CCBs, Losartan (only ARB that doesn’t cause hyperuricemia)
7
Q
Treatment of choice for initial therapy in uncomplicated HTN is:
A
HCTZ
*CI- Gout and DM (due to hyperuricemia and hyperglycemia)
8
Q
A patient with HTN and hx of DM, nephropathy, CHF, or post-MI is a good candidate for what class of anti-HTN?
A
ACEI
9
Q
____ (class of anti-HTN med) is used in HTN with concomitant A fib.
A
non-DHF–> Verapamil and Diltiazem
*CI–> CHF, 2nd or 3rd degree heart block
10
Q
_____ is an anti-HTN med known to cause constipation.
A
Verapamil
11
Q
____ (class of anti-HTN med) often used in patients with history of MI, tachycardia, angina, acute MI, HF, pheochromocytoma, migraines, and essential tremor.
A
Beta blockers
*Use with caution in patients with DM because it masks sympathetic symptoms of hypoglycemia
**Propranolol is non-selective- caution in patients with asthma/COPD
12
Q
Most common cause of CAD is _____.
A
Atherosclerosis
13
Q
RFs for CAD are:
A
- DM (worst!)
- smoking
- HLD
- HTN
- males
- age > 45y males, >55y women
- FHx, CAD, obesity, inc. CRP
14
Q
Signs and symptoms of PAD include:
A
- INTERMITTENT CLAUDICATION
* resting leg pain= limb-threatening ischemia
15
Q
What are the signs of an acute arterial embolism?
*Hint- 6 P’s
A
-Paresthesias, pain, pallor, pulselessness, paralysis, poikilothermia (inability to regulate internal body temperature)
16
Q
Ulcer management…
A
Wound care and vascular surgery
DO NOT COMPRESS
17
Q
PE findings with PAD include:
A
Pulses: decreased or absent +/- bruits, dec cap refill
Skin: atrophic skin changes- muscle atrophy, thin/shiny skin, hair loss, thickened nails, cool limbs, no edema, painful, black areas of necrosis @ points of trauma
Color: pale on elevation, dusky red with dependency, cyanosis
18
Q
How is PAD diagnosed?
A
- ABI- +PAD if ABI < 0.90 (Normal= 1-1.2)
- GOLD STANDARD= Arteriography
- Hand held doppler- esp in ER
19
Q
How is PAD managed?
A
- Platelet inhibitors: Cilostazal (PLETAAL)–> good for intermittent claudication, ASA, Plavix
- Revascularization: PTA, Bypass grafts, Endarterectomy
- Support: foot care, exercise- walk until claudication
- Acute arterial occlusion- heparin, thrombolytics, embolectomy
- Amputation- if severe/gangrene
20
Q
Treatment for varicose veins includes:
A
Leg elevation, compression stockings, avoid standing
21
Q
Superficial thrombophlebitis defined as:
A
Inflammation/thrombus of superficial vein; benign/self-ltd
*Trousseau’s syndrome of malignancy: migratory thrombophlebitis ass. w/ pancreatic ca.
22
Q
Signs and symptoms of thrombophlebitis include:
A
Tenderness, pain, induration, edema, erythema along course of vein, +/- palpable cord
23
Q
Dx. of superficial thrombophlebitis done by:
A
Venous duplex US (doppler)- noncompressible vein w/ clot, vein wall thickening
24
Q
How is superficial thrombophlebitis managed?
A
Support is mainstay: elevation, warm compresses, NSAIDs, compression stockings, Severe= bed rest
- Aseptic: NSAIDs, Heparin or Warfarin if clot is near saphenofemoral junction
- Septic: IV ABX: PCN + AG
- Vein ligation/excision- extensive varicose veins, septic phlebitis, persistent s/s despite treatment
25
Virchow's triad (RFs for DVT) includes:
Venous stasis + Endothelial Damage + Hypercoaguability
26
Signs and Symptoms of DVT include:
Unilateral swelling/edema of LE, Warm skin, Calf pain/tenderness
-Phlebitis- warmth, erythema, palpable cord
27
Diagnostic studies for DVT include:
1. Venous duplex
2. Venography- GOLD STANDARD
3. D-dimer- sensitive but not specific, (-) r/o DVT in LOW risk patient. Used in probable or high-risk patient with (-) venous US to determine is serial US needed!
28
Management of DVT involves:
Main goal is to prevent PE
1. Anticoagulation therapy- Heparin-->Warfarin
* MOA: Inhibits thrombin (potentiates antithrombin III)
* *Monitor PTT (not necessary for LMWH)
When bridging- Warfarin should overlap with heparin for at least 5 days
-AVOID veggies with lots of Vitamin K- spinach, kale, brussel sprouts, greens
29
What is Wells Criteria?
Used to assess the probability of a DVT
- Score < 2= diagnosis highly unlikely
- > 6 = very likely
*See p. 53 for exact criteria
30
Sinus tachycardia is defined by a rate > ____ bpm but rarely > ____ bpm.
>100 but rarely >130
31
Sinus bradycardia is a rate < _____ bpm.
60bpm
*Tx= Atropine if symptomatic
32
Sick Sinus Syndrome (brady-tachy syndrome) is a combo of sinus arrest w/ alternating paroxysms of atrial tachy and bradyarrhythmias.
How is it treated?
+/- permanent pacemaker
33
EKG findings for 1st degree AV block?
Treatment?
Constant, long PR interval (> 0.2 sec)
Tx= none, observation
34
EKG findings for 2nd degree AV block?
Treatment?
Some P waves that are NOT followed by QRS
1. Mobitz I: Progressive PR lengthening followed by dropped QRS
Tx if symptomatic- Atropine, Epi, +/- pacing
2. Mobitz II: Constant, long PR followed by dropped QRS
35
EKG findings for 3rd degree AV block?
Treatment?
P waves not related to QRS
-All P waves not followed by QRS
Tx= Temporary pacing--> perm pacemaker
36
Atrial flutter is represented by "saw tooth" waves on EKG at ___ to ____ bpm.
Treatment?
250-350bpm
NO P WAVES
-rate is usually REGULAR
Tx=
1. Stable= vagal, BB, or CCB
2. Unstable= DCC
3. Definitive= radiofrequency ablation
4. Anticoag use is similar to afib
37
EKG findings for A. fib...
Irregularly irregular rhythm w/ narrow QRS
38
Management of STABLE A fib includes Rate and/or Rhythm control. These options are...
1. Rate Control:
- BBs: Metoprolol, Esmolol
- CCBs: Diltiazem, Verapamil
- Digoxin +/- elderly, preferred for rate control in patients with HYPOtension or CHF
2. Rhythm Control:
- DCC (preferred over pharm rhythm control)
- Pharm control: Flecainide, Sotalol, Amiodarone
- Radiofrequency ablation: permanent pacemaker; catheter ablation, or surgical "MAZE"
39
Management of UNSTABLE A. fib entails...
DCC
40
Assessment of risk embolization involves CHA2DS2-VASc which is:
- CHF: 1 pt
- HTN: 1 pt
- Age ≥ 75: 2 pts
- DM: 1 pt
- Stroke, TIA, thrombus: 2 pts
- Vascular dz (prior MI, aortic plaque, PAD): 1 pt
- Age 65-74: 1 pt
- Sex category (female): 1 pt
-If score is 2+ pt is at a moderate-high risk and chronic oral anticoagulation is recommended
41
Antiplatelet v. Anticoag
See p. 57-58 of study guide
42
PSVT EKG findings...
- HR > 100bpm
| - Rhythm usually regular with narrow QRS
43
What is the 1st line med for SVT?
Adenosine (for stable, narrow complex)
Amiodarone (for stable, wide complex)
UNSTABLE= DCC
*caution in patients with asthma/COPD as it may cause bronchospasm
44
EKG findings for WPW?
Treatment?
Delta wave (slurred QRS upstroke), wide QRS (>0.12 sec) and short PR interval
Tx= Vagal maneuvers, Procainamide, Amiodarone
AVOID AV nodal blockers (ABCD)
Adenosine, BBs, CCBs, Digoxin
45
PVC EKG findings...
- Wide, bizarre QRS earlier than expected
| - T wave is in the opposite direction of QRS usually
46
Torsades De Pointes is MC due to what electrolyte abnormality?
HYPOmagnesemia and HYPOkalemia
47
Management of dangerous cardiac events:
1. Stable, sustained VT: Amiodarone, lidocaine, Procainamide
2. Unstable VT w/ pulse: Synchronized cardioversion
3. VTach (no pulse): defib (unsynchronized) + CPR
4. Torsades: IV Mg, correct electrolytes
5. V. fib: Unsynchronized cardioversion (defib) + CPR
6. PEA: CPR + Epi + Check for shockable rhythm q 2 min
7. Asystole: Tx like PEA
48
MC valve affected by infective endocarditis is the ____ valve.
Mitral
M>A>T>P
*EXCEPTION- Tricuspid MC in IVDU
49
MC organism at play in Acute Bacterial Endocarditis (ABE) is ____.
S aureus
*In IVDU it is MRSA, pseudo, and candida
50
Peripheral manifestations of infective endocarditis include:
1. Janeway lesions: painless erythematous macules on the palms & soles
2. Roth spots: retinal hemorrhages w/ pale centers. Petechiae (conjunctiva, palate)
3. Osler's Nodes: tender nodules on the pads of the digits
4. Splinter hemorrhages of proximal nail bed, clubbing, and hepatosplenomegaly
51
Dx Studies for endocarditis:
1. Blood cx before ABX- 3 sets at least 1 hr apart
2. EKG
3. Echo- obtain TTE first (TEE is more sensitive)
4. Labs: CBC- Leukocytosis, Anemia
* Major and Minor duke criteria on p. 60 and 61
52
Treatment of infective endocarditis includes:
1. Acute- Nafcillin + Gentamicin OR Vanc + Gent (if PCN allergic or MRSA suspected)
2. Subacute- PCN or Ampicillin + Gentamicin
3. Prosthetic valve- Vanc + Gent + Rifampin
4. Fungal- Amphotericin B
53
Endocarditis prophylaxis indications include:
- Prosthetic heart valves
- Heart repairs using prosthetic material
- Prior hx of endocarditis
- Congenital heart disease
- Cardiac valvulopathy in transplanted heart
* Give Amox 2g before procedure (dental, I & D, rigid bronchoscopy)
* *Clinda if PCN allergic
54
Rheumatic fever mainly affects what age group?
Children 5-15y
*GABHS
55
What is JONES criteria for Rheumatic Fever?
2 Major or 1 Major + 2 Minor
1. Major
- Joint (polyarthritis)
- Oh my heart (active carditis)
- Nodules (sub-q)
- Erythema marginatum
- Sydenham's chorea (p. 61)
2. Minor
- Clinical: Fever > 101.3F, arthralgia
- Lab: inc. ESR, CRP, leukocytosis; EKG: long PR
56
Management of rheumatic fever involves...
1. Anti-inflammatory: ASA +/- corticosteroids
| 2. PCN G ABX (or erythromycin if PCN allergic)
57
3 primary causes of HYPERcholesterolemia are:
1. HYPOthyroidism
2. Pregnancy
3. Kidney failure
58
Primary causes of HYPERtriglyceridemia are:
1. DM
2. ETOH
3. Obesity
4. Steroids
5. Estrogen
59
May develop xanthomas or xanthelasma (lipid plaques on eyelids) with what diagnosis?
HLD
60
When do you start screening for HLD?
1. High risk- >1 RF or 1 severe RF; start screening at 20-25y for M; 30-35 for F
2. Low risk- initiate screening at age 35 for males; 45 for females
61
To initiate Statin therapy you want to determine 10 year ASCVD risk score!! (online tool). RF include:
Gender, age, race, smoking, BP, Cholesterol levels, and DM
62
Begin statin in...
1. DM1 or 2 between 40-75
| 2. ≥21 w/ LDL > 190mg/mL
63
Best meds to lower...
1. LDL:
2. TGs:
To increase:
3. HDL
For DM2:
4.
1. Lower LDL= Statins, Bile acid sequestrants
2. Lower TGs= Fibrates, Niacin, Omega III (Lovaza)
3. Increase HDL= Niacin, fibrates
4. DMII: Fibrates and statins (Niacin may cause HYPERglycemia so use with caution!)
GOALS:
LDL < 100, TC < 200, HDL > 60
64
Best drug to increase HDL is:
Niacin
*May cause hyperuricemia, gout, and HYPERglycemia
65
Best drug to decrease LDL is:
Statins
*May cause myalgias/rhabdo and hepatitis
* *Atorvostatin and Rosuvastatin are the strongest in the class
* **Fewest drug reactions with Pravastatin and Rosuvastatin :)
66
Best drug to decrease TGs is:
Fibrates!
67
What drug can cause increased TGs?
Bile acid sequestrants
68
Clinical identification of Metabolic Syndrome requires 3 or more of the following 5 factors:
1. Abdominal Obesity:
- Men= Waist > 40 inches
- Women= Waist > 35 inches
2. Triglycerides: ≥150mg/dL
3. HDL Cholesterol:
- Men= <40mg/dL
- Women= <50mg/dL
4. BP ≥130/ ≥85 mmHg
5. Fasting glucose ≥110mg/dL
69
MC causes of L-sided HF are ____ and ____.
CAD and HTN
*also valvular dz and cardiomyopathies
70
A little more about systolic HF...
- Dec. EF, +/- S3 gallop, Systolic MC form of HF
| - Etiology: post-MI, dilated cardiomyopathy, myocarditis
71
A little more about diastolic HF...
- Nml/Inc EF, +/- S4 gallop
- Etiology: HTN, LVH, elderly, valvular heart disease, cardiomyopathies (hypertrophic, restrictive), constrictive pericarditis
72
NYHA Functional Classes
AND
ACC/AHA CHF Guidelines
Class I- no s/s, no limit during ordinary activity
...
Class IV- s/s even while at rest, severe limits and inability to carry out physical activity
ACC/AHA CHF Guidelines-
see p. 64
73
The MC symptom of L-sided HF is ____.
Dyspnea- due to pulmonary congestion/edema
*CHF MC cause of transudative pleural effusions
74
What do you find on a PE in a patient with L-sided HF?
HTN, tachypnea, Cheyne-Stokes breathing, cyanosis, S3 or S4 gallops
-Dusky, pale skin; diaphoresis, sinus tachycardia, cool extremities, fatigue, AMS
75
The MC symptom of R-sided HF is _____.
Systemic fluid retention:
-Peripheral edema (pitting edema in legs), may develop cyanosis
- Jugular venous distention (JVD)
- GI/hepatic congestion- anorexia, N/V, hepatosplenomegaly, RUQ tenderness, hepatojugular reflex
76
Most useful tool in diagnosing HF is ____.
Echo
- Normal EF= 55-60%
- EF < 35%= increased mortality- defib placement to reduce mortality
CXR= esp. useful in CHF Cephalization of flow- cardiomegaly infiltrates, pleural effusions, pulmonary edema
77
Increase in ____ (specific lab value) may ID CHF as the cause of dyspnea in ER.
BNP
*If BNP > 100 then CHF is likely
78
Diet and Exercise recommendations with HF
- Na restriction <2g/d
- Fluid restriction <2L/d
- Exercise
- Smoking cessation
79
1st line treatment drug for HF is ____.
ACEI
*Drug Rxns= HYPERkalemia, Cough and angioedema
**CI= hypotension and pregnancy
80
____ (class of meds) is added after ACEI in patients with HF.
Beta blockers
*If not able to tolerate ACEI or beta blocker consider Hydralazine. Safe in pregnancy!!
81
____ (class of drugs) is most effective treatment for symptoms for mild-moderate CHF.
DIURETICS
*WARNING- HYPOkalemia and calcemia, HYPERglycemia, and HYPERuricemia
82
For a patient with HF and A fib ____ would be a reasonable drug to decrease symptoms.
Digoxin
*+ Ionotrope, Negative chronotrope (decreases HR)
**S/E= seizures, dizziness, N/V/D, Visual disturbances, Gynecomastia
***Digoxin toxicity= downslopping, sagging ST segment, HYPOkalemia worsens it
83
Meds that decrease mortality in HF:
ACEI, ARB, BBs, nitrates + hydralazine
84
HF outpatient regimen:
ACEI + diuretic initially, add BB +/- hydralazine + NTG, digoxin
85
How is acute pulmonary edema/CHF managed?
*Hint: LMNOP
- Lasix
- Morphine
- Nitrates
- Oxygen
- Position (upright to decrease venous return)
86
A murmur that is harsh/rumble suggests ____.
Stenosis! Aortic or Mitral
87
A murmur that is blowing suggests _____.
Regurg! Aortic or Mitral
88
___ and ____ murmurs are heard during systole.
AS and MR
89
____ and ____ murmurs are heard during diastole.
AR and MS
90
Squatting, leg raise, and lying down help to ____ (increase/decrease) venous return.
Increase--> increases murmurs and venous snap
91
AS and MVP ____ (increase/decrease) with handgrip while AR and MR _____ (increase/decrease) with handgrip.
Decrease- AS and MVP
Increase- AR and MR
92
AS and MVP ____ (increase/decrease) with amyl nitrate while AR and MR _____ (increase/decrease) with amyl nitrate.
Increase- AS and MVP
Decrease- AR and MR
93
Pulmonic stenosis is a congenital dz of the young that sounds like ____.
Harsh, midsystolic ejection crescendo-decrescendo (Max @ LUSB)
*Treated- balloon valvuloplasty
**Regurg doesn't need to be treated and is almost always congenital
94
How is tricuspid stenosis managed?
Decrease right atrial volume overload with diuretics and Na+ restriction
