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Primary Care > Cardiology > Flashcards

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

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2
Q

_____ is a sign of advanced stage of malignant HTN.

A

Papilledema

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3
Q

A ___ heart sound is associated with HTN.

A 
A S4 (and loud S2) 
-suggestive of left ventricular wall thickening
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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

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5
Q

Initial medication choice for uncomplicated HTN (with no comorbidities) in NON-African Americans includes:

A
  1. Thiazide-type diuretic
  2. ACEI
  3. ARB
  4. CCBs
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6
Q

Management of HTN with comorbidities:

A
  1. A fib- BB or CCB (non-DHPs: verapamil, cardizem)
  2. Angina: BBs, CCBs
  3. Post-MI: BBs, ACEI
  4. Systolic HF: ACEI, ARB, BBs, diuretics
  5. DM/CKD: ACEI, ARB
  6. Isolated systolic HTN in elderly: diuretics (+/- CCBs)
  7. BPH: a1 blockers (tamsulosin, alfuzosin, terazosin)
  8. AA (nondiabetic): Thiazides or CCBs
  9. Young, caucasian males: Thiazides–>ACEI, ARB–> BBs
  10. Gout: CCBs, Losartan (only ARB that doesn’t cause hyperuricemia)
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7
Q

Treatment of choice for initial therapy in uncomplicated HTN is:

A

HCTZ

*CI- Gout and DM (due to hyperuricemia and hyperglycemia)

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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

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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

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10
Q

_____ is an anti-HTN med known to cause constipation.

A

Verapamil

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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

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12
Q

Most common cause of CAD is _____.

A

Atherosclerosis

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13
Q

RFs for CAD are:

A
  • DM (worst!)
  • smoking
  • HLD
  • HTN
  • males
  • age > 45y males, >55y women
  • FHx, CAD, obesity, inc. CRP
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14
Q

Signs and symptoms of PAD include:

A
  • INTERMITTENT CLAUDICATION

* resting leg pain= limb-threatening ischemia

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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)

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16
Q

Ulcer management…

A

Wound care and vascular surgery

DO NOT COMPRESS

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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

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18
Q

How is PAD diagnosed?

A
  1. ABI- +PAD if ABI < 0.90 (Normal= 1-1.2)
  2. GOLD STANDARD= Arteriography
  3. Hand held doppler- esp in ER
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19
Q

How is PAD managed?

A
  1. Platelet inhibitors: Cilostazal (PLETAAL)–> good for intermittent claudication, ASA, Plavix
  2. Revascularization: PTA, Bypass grafts, Endarterectomy
  3. Support: foot care, exercise- walk until claudication
  4. Acute arterial occlusion- heparin, thrombolytics, embolectomy
  5. Amputation- if severe/gangrene
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20
Q

Treatment for varicose veins includes:

A

Leg elevation, compression stockings, avoid standing

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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.

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22
Q

Signs and symptoms of thrombophlebitis include:

A

Tenderness, pain, induration, edema, erythema along course of vein, +/- palpable cord

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23
Q

Dx. of superficial thrombophlebitis done by:

A

Venous duplex US (doppler)- noncompressible vein w/ clot, vein wall thickening

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24
Q

How is superficial thrombophlebitis managed?

A

Support is mainstay: elevation, warm compresses, NSAIDs, compression stockings, Severe= bed rest

  1. Aseptic: NSAIDs, Heparin or Warfarin if clot is near saphenofemoral junction
  2. Septic: IV ABX: PCN + AG
  3. Vein ligation/excision- extensive varicose veins, septic phlebitis, persistent s/s despite treatment
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25
Q

Virchow’s triad (RFs for DVT) includes:

A

Venous stasis + Endothelial Damage + Hypercoaguability

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26
Q

Signs and Symptoms of DVT include:

A

Unilateral swelling/edema of LE, Warm skin, Calf pain/tenderness

-Phlebitis- warmth, erythema, palpable cord

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27
Q

Diagnostic studies for DVT include:

A
  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!
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28
Q

Management of DVT involves:

A

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

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29
Q

What is Wells Criteria?

A

Used to assess the probability of a DVT

  • Score < 2= diagnosis highly unlikely
  • > 6 = very likely

*See p. 53 for exact criteria

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30
Q

Sinus tachycardia is defined by a rate > ____ bpm but rarely > ____ bpm.

A

> 100 but rarely >130

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31
Q

Sinus bradycardia is a rate < _____ bpm.

A

60bpm

*Tx= Atropine if symptomatic

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32
Q

Sick Sinus Syndrome (brady-tachy syndrome) is a combo of sinus arrest w/ alternating paroxysms of atrial tachy and bradyarrhythmias.

How is it treated?

A

+/- permanent pacemaker

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33
Q

EKG findings for 1st degree AV block?

Treatment?

A

Constant, long PR interval (> 0.2 sec)

Tx= none, observation

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34
Q

EKG findings for 2nd degree AV block?

Treatment?

A

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

  1. Mobitz II: Constant, long PR followed by dropped QRS
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35
Q

EKG findings for 3rd degree AV block?

Treatment?

A

P waves not related to QRS
-All P waves not followed by QRS

Tx= Temporary pacing–> perm pacemaker

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36
Q

Atrial flutter is represented by “saw tooth” waves on EKG at ___ to ____ bpm.

Treatment?

A

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
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37
Q

EKG findings for A. fib…

A

Irregularly irregular rhythm w/ narrow QRS

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38
Q

Management of STABLE A fib includes Rate and/or Rhythm control. These options are…

A
  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
Q

Management of UNSTABLE A. fib entails…

A

DCC

40
Q

Assessment of risk embolization involves CHA2DS2-VASc which is:

A
  • 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
Q

Antiplatelet v. Anticoag

A

See p. 57-58 of study guide

42
Q

PSVT EKG findings…

A
  • HR > 100bpm

- Rhythm usually regular with narrow QRS

43
Q

What is the 1st line med for SVT?

A

Adenosine (for stable, narrow complex)
Amiodarone (for stable, wide complex)

UNSTABLE= DCC

*caution in patients with asthma/COPD as it may cause bronchospasm

44
Q

EKG findings for WPW?

Treatment?

A

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
Q

PVC EKG findings…

A
  • Wide, bizarre QRS earlier than expected

- T wave is in the opposite direction of QRS usually

46
Q

Torsades De Pointes is MC due to what electrolyte abnormality?

A

HYPOmagnesemia and HYPOkalemia

47
Q

Management of dangerous cardiac events:

A
  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
Q

MC valve affected by infective endocarditis is the ____ valve.

A

Mitral
M>A>T>P

*EXCEPTION- Tricuspid MC in IVDU

49
Q

MC organism at play in Acute Bacterial Endocarditis (ABE) is ____.

A

S aureus

*In IVDU it is MRSA, pseudo, and candida

50
Q

Peripheral manifestations of infective endocarditis include:

A
  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
Q

Dx Studies for endocarditis:

A
  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
Q

Treatment of infective endocarditis includes:

A
  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
Q

Endocarditis prophylaxis indications include:

A
  • 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
Q

Rheumatic fever mainly affects what age group?

A

Children 5-15y

*GABHS

55
Q

What is JONES criteria for Rheumatic Fever?

A

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
Q

Management of rheumatic fever involves…

A
  1. Anti-inflammatory: ASA +/- corticosteroids

2. PCN G ABX (or erythromycin if PCN allergic)

57
Q

3 primary causes of HYPERcholesterolemia are:

A
  1. HYPOthyroidism
  2. Pregnancy
  3. Kidney failure
58
Q

Primary causes of HYPERtriglyceridemia are:

A
  1. DM
  2. ETOH
  3. Obesity
  4. Steroids
  5. Estrogen
59
Q

May develop xanthomas or xanthelasma (lipid plaques on eyelids) with what diagnosis?

A

HLD

60
Q

When do you start screening for HLD?

A
  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
Q

To initiate Statin therapy you want to determine 10 year ASCVD risk score!! (online tool). RF include:

A

Gender, age, race, smoking, BP, Cholesterol levels, and DM

62
Q

Begin statin in…

A
  1. DM1 or 2 between 40-75

2. ≥21 w/ LDL > 190mg/mL

63
Q

Best meds to lower…

  1. LDL:
  2. TGs:

To increase:

  1. HDL

For DM2:

4.

A
  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
Q

Best drug to increase HDL is:

A

Niacin

*May cause hyperuricemia, gout, and HYPERglycemia

65
Q

Best drug to decrease LDL is:

A

Statins

*May cause myalgias/rhabdo and hepatitis

  • *Atorvostatin and Rosuvastatin are the strongest in the class
  • **Fewest drug reactions with Pravastatin and Rosuvastatin :)
66
Q

Best drug to decrease TGs is:

A

Fibrates!

67
Q

What drug can cause increased TGs?

A

Bile acid sequestrants

68
Q

Clinical identification of Metabolic Syndrome requires 3 or more of the following 5 factors:

A
  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
Q

MC causes of L-sided HF are ____ and ____.

A

CAD and HTN

*also valvular dz and cardiomyopathies

70
Q

A little more about systolic HF…

A
  • Dec. EF, +/- S3 gallop, Systolic MC form of HF

- Etiology: post-MI, dilated cardiomyopathy, myocarditis

71
Q

A little more about diastolic HF…

A
  • Nml/Inc EF, +/- S4 gallop
  • Etiology: HTN, LVH, elderly, valvular heart disease, cardiomyopathies (hypertrophic, restrictive), constrictive pericarditis
72
Q

NYHA Functional Classes

AND

ACC/AHA CHF Guidelines

A

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
Q

The MC symptom of L-sided HF is ____.

A

Dyspnea- due to pulmonary congestion/edema

*CHF MC cause of transudative pleural effusions

74
Q

What do you find on a PE in a patient with L-sided HF?

A

HTN, tachypnea, Cheyne-Stokes breathing, cyanosis, S3 or S4 gallops

-Dusky, pale skin; diaphoresis, sinus tachycardia, cool extremities, fatigue, AMS

75
Q

The MC symptom of R-sided HF is _____.

A

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
Q

Most useful tool in diagnosing HF is ____.

A

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
Q

Increase in ____ (specific lab value) may ID CHF as the cause of dyspnea in ER.

A

BNP

*If BNP > 100 then CHF is likely

78
Q

Diet and Exercise recommendations with HF

A
  • Na restriction <2g/d
  • Fluid restriction <2L/d
  • Exercise
  • Smoking cessation
79
Q

1st line treatment drug for HF is ____.

A

ACEI

*Drug Rxns= HYPERkalemia, Cough and angioedema

**CI= hypotension and pregnancy

80
Q

____ (class of meds) is added after ACEI in patients with HF.

A

Beta blockers

*If not able to tolerate ACEI or beta blocker consider Hydralazine. Safe in pregnancy!!

81
Q

____ (class of drugs) is most effective treatment for symptoms for mild-moderate CHF.

A

DIURETICS

*WARNING- HYPOkalemia and calcemia, HYPERglycemia, and HYPERuricemia

82
Q

For a patient with HF and A fib ____ would be a reasonable drug to decrease symptoms.

A

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
Q

Meds that decrease mortality in HF:

A

ACEI, ARB, BBs, nitrates + hydralazine

84
Q

HF outpatient regimen:

A

ACEI + diuretic initially, add BB +/- hydralazine + NTG, digoxin

85
Q

How is acute pulmonary edema/CHF managed?

*Hint: LMNOP

A
  • Lasix
  • Morphine
  • Nitrates
  • Oxygen
  • Position (upright to decrease venous return)
86
Q

A murmur that is harsh/rumble suggests ____.

A

Stenosis! Aortic or Mitral

87
Q

A murmur that is blowing suggests _____.

A

Regurg! Aortic or Mitral

88
Q

___ and ____ murmurs are heard during systole.

A

AS and MR

89
Q

____ and ____ murmurs are heard during diastole.

A

AR and MS

90
Q

Squatting, leg raise, and lying down help to ____ (increase/decrease) venous return.

A

Increase–> increases murmurs and venous snap

91
Q

AS and MVP ____ (increase/decrease) with handgrip while AR and MR _____ (increase/decrease) with handgrip.

A

Decrease- AS and MVP

Increase- AR and MR

92
Q

AS and MVP ____ (increase/decrease) with amyl nitrate while AR and MR _____ (increase/decrease) with amyl nitrate.

A

Increase- AS and MVP

Decrease- AR and MR

93
Q

Pulmonic stenosis is a congenital dz of the young that sounds like ____.

A

Harsh, midsystolic ejection crescendo-decrescendo (Max @ LUSB)

*Treated- balloon valvuloplasty

**Regurg doesn’t need to be treated and is almost always congenital

94
Q

How is tricuspid stenosis managed?

A

Decrease right atrial volume overload with diuretics and Na+ restriction

Primary Care (12 decks)

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