Cardiology Flashcards
Secondary HTN is due to an underlying, identifiable, and often correctable cause. The MC cause is ______.
Renovascular- renal artery stenosis; fibromuscular dysplasia in young pts and atherosclerosis in elderly
_____ is a sign of advanced stage of malignant HTN.
Papilledema
A ___ heart sound is associated with HTN.
A S4 (and loud S2) -suggestive of left ventricular wall thickening
A BP of < ____ mmHg is desirable in the general population and < _____ is desirable in pts with DM, renal disease, or >60y.
<140/90mmHg- general population
<150/90- DM, renal disease, >60y
Initial medication choice for uncomplicated HTN (with no comorbidities) in NON-African Americans includes:
- Thiazide-type diuretic
- ACEI
- ARB
- CCBs
Management of HTN with comorbidities:
- 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)
Treatment of choice for initial therapy in uncomplicated HTN is:
HCTZ
*CI- Gout and DM (due to hyperuricemia and hyperglycemia)
A patient with HTN and hx of DM, nephropathy, CHF, or post-MI is a good candidate for what class of anti-HTN?
ACEI
____ (class of anti-HTN med) is used in HTN with concomitant A fib.
non-DHF–> Verapamil and Diltiazem
*CI–> CHF, 2nd or 3rd degree heart block
_____ is an anti-HTN med known to cause constipation.
Verapamil
____ (class of anti-HTN med) often used in patients with history of MI, tachycardia, angina, acute MI, HF, pheochromocytoma, migraines, and essential tremor.
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
Most common cause of CAD is _____.
Atherosclerosis
RFs for CAD are:
- DM (worst!)
- smoking
- HLD
- HTN
- males
- age > 45y males, >55y women
- FHx, CAD, obesity, inc. CRP
Signs and symptoms of PAD include:
- INTERMITTENT CLAUDICATION
* resting leg pain= limb-threatening ischemia
What are the signs of an acute arterial embolism?
*Hint- 6 P’s
-Paresthesias, pain, pallor, pulselessness, paralysis, poikilothermia (inability to regulate internal body temperature)
Ulcer management…
Wound care and vascular surgery
DO NOT COMPRESS
PE findings with PAD include:
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
How is PAD diagnosed?
- ABI- +PAD if ABI < 0.90 (Normal= 1-1.2)
- GOLD STANDARD= Arteriography
- Hand held doppler- esp in ER
How is PAD managed?
- 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
Treatment for varicose veins includes:
Leg elevation, compression stockings, avoid standing
Superficial thrombophlebitis defined as:
Inflammation/thrombus of superficial vein; benign/self-ltd
*Trousseau’s syndrome of malignancy: migratory thrombophlebitis ass. w/ pancreatic ca.
Signs and symptoms of thrombophlebitis include:
Tenderness, pain, induration, edema, erythema along course of vein, +/- palpable cord
Dx. of superficial thrombophlebitis done by:
Venous duplex US (doppler)- noncompressible vein w/ clot, vein wall thickening
How is superficial thrombophlebitis managed?
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
Virchow’s triad (RFs for DVT) includes:
Venous stasis + Endothelial Damage + Hypercoaguability
Signs and Symptoms of DVT include:
Unilateral swelling/edema of LE, Warm skin, Calf pain/tenderness
-Phlebitis- warmth, erythema, palpable cord
Diagnostic studies for DVT include:
- Venous duplex
- Venography- GOLD STANDARD
- 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!
Management of DVT involves:
Main goal is to prevent PE
- 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
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
Sinus tachycardia is defined by a rate > ____ bpm but rarely > ____ bpm.
> 100 but rarely >130
Sinus bradycardia is a rate < _____ bpm.
60bpm
*Tx= Atropine if symptomatic
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
EKG findings for 1st degree AV block?
Treatment?
Constant, long PR interval (> 0.2 sec)
Tx= none, observation
EKG findings for 2nd degree AV block?
Treatment?
Some P waves that are NOT followed by QRS
- Mobitz I: Progressive PR lengthening followed by dropped QRS
Tx if symptomatic- Atropine, Epi, +/- pacing
- Mobitz II: Constant, long PR followed by dropped QRS
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
Atrial flutter is represented by “saw tooth” waves on EKG at ___ to ____ bpm.
Treatment?
250-350bpm
NO P WAVES
-rate is usually REGULAR
Tx=
- Stable= vagal, BB, or CCB
- Unstable= DCC
- Definitive= radiofrequency ablation
- Anticoag use is similar to afib
EKG findings for A. fib…
Irregularly irregular rhythm w/ narrow QRS
Management of STABLE A fib includes Rate and/or Rhythm control. These options are…
- Rate Control:
- BBs: Metoprolol, Esmolol
- CCBs: Diltiazem, Verapamil
- Digoxin +/- elderly, preferred for rate control in patients with HYPOtension or CHF - Rhythm Control:
- DCC (preferred over pharm rhythm control)
- Pharm control: Flecainide, Sotalol, Amiodarone
- Radiofrequency ablation: permanent pacemaker; catheter ablation, or surgical “MAZE”
Management of UNSTABLE A. fib entails…
DCC
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
Antiplatelet v. Anticoag
See p. 57-58 of study guide
PSVT EKG findings…
- HR > 100bpm
- Rhythm usually regular with narrow QRS
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
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
PVC EKG findings…
- Wide, bizarre QRS earlier than expected
- T wave is in the opposite direction of QRS usually
Torsades De Pointes is MC due to what electrolyte abnormality?
HYPOmagnesemia and HYPOkalemia
Management of dangerous cardiac events:
- Stable, sustained VT: Amiodarone, lidocaine, Procainamide
- Unstable VT w/ pulse: Synchronized cardioversion
- VTach (no pulse): defib (unsynchronized) + CPR
- Torsades: IV Mg, correct electrolytes
- V. fib: Unsynchronized cardioversion (defib) + CPR
- PEA: CPR + Epi + Check for shockable rhythm q 2 min
- Asystole: Tx like PEA
MC valve affected by infective endocarditis is the ____ valve.
Mitral
M>A>T>P
*EXCEPTION- Tricuspid MC in IVDU
MC organism at play in Acute Bacterial Endocarditis (ABE) is ____.
S aureus
*In IVDU it is MRSA, pseudo, and candida
Peripheral manifestations of infective endocarditis include:
- Janeway lesions: painless erythematous macules on the palms & soles
- Roth spots: retinal hemorrhages w/ pale centers. Petechiae (conjunctiva, palate)
- Osler’s Nodes: tender nodules on the pads of the digits
- Splinter hemorrhages of proximal nail bed, clubbing, and hepatosplenomegaly
Dx Studies for endocarditis:
- Blood cx before ABX- 3 sets at least 1 hr apart
- EKG
- Echo- obtain TTE first (TEE is more sensitive)
- Labs: CBC- Leukocytosis, Anemia
* Major and Minor duke criteria on p. 60 and 61
Treatment of infective endocarditis includes:
- Acute- Nafcillin + Gentamicin OR Vanc + Gent (if PCN allergic or MRSA suspected)
- Subacute- PCN or Ampicillin + Gentamicin
- Prosthetic valve- Vanc + Gent + Rifampin
- Fungal- Amphotericin B
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
Rheumatic fever mainly affects what age group?
Children 5-15y
*GABHS
What is JONES criteria for Rheumatic Fever?
2 Major or 1 Major + 2 Minor
- Major
- Joint (polyarthritis)
- Oh my heart (active carditis)
- Nodules (sub-q)
- Erythema marginatum
- Sydenham’s chorea (p. 61) - Minor
- Clinical: Fever > 101.3F, arthralgia
- Lab: inc. ESR, CRP, leukocytosis; EKG: long PR
Management of rheumatic fever involves…
- Anti-inflammatory: ASA +/- corticosteroids
2. PCN G ABX (or erythromycin if PCN allergic)
3 primary causes of HYPERcholesterolemia are:
- HYPOthyroidism
- Pregnancy
- Kidney failure
Primary causes of HYPERtriglyceridemia are:
- DM
- ETOH
- Obesity
- Steroids
- Estrogen
May develop xanthomas or xanthelasma (lipid plaques on eyelids) with what diagnosis?
HLD
When do you start screening for HLD?
- High risk- >1 RF or 1 severe RF; start screening at 20-25y for M; 30-35 for F
- Low risk- initiate screening at age 35 for males; 45 for females
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
Begin statin in…
- DM1 or 2 between 40-75
2. ≥21 w/ LDL > 190mg/mL
Best meds to lower…
- LDL:
- TGs:
To increase:
- HDL
For DM2:
4.
- Lower LDL= Statins, Bile acid sequestrants
- Lower TGs= Fibrates, Niacin, Omega III (Lovaza)
- Increase HDL= Niacin, fibrates
- DMII: Fibrates and statins (Niacin may cause HYPERglycemia so use with caution!)
GOALS:
LDL < 100, TC < 200, HDL > 60
Best drug to increase HDL is:
Niacin
*May cause hyperuricemia, gout, and HYPERglycemia
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 :)
Best drug to decrease TGs is:
Fibrates!
What drug can cause increased TGs?
Bile acid sequestrants
Clinical identification of Metabolic Syndrome requires 3 or more of the following 5 factors:
- Abdominal Obesity:
- Men= Waist > 40 inches
- Women= Waist > 35 inches - Triglycerides: ≥150mg/dL
- HDL Cholesterol:
- Men= <40mg/dL
- Women= <50mg/dL - BP ≥130/ ≥85 mmHg
- Fasting glucose ≥110mg/dL
MC causes of L-sided HF are ____ and ____.
CAD and HTN
*also valvular dz and cardiomyopathies
A little more about systolic HF…
- Dec. EF, +/- S3 gallop, Systolic MC form of HF
- Etiology: post-MI, dilated cardiomyopathy, myocarditis
A little more about diastolic HF…
- Nml/Inc EF, +/- S4 gallop
- Etiology: HTN, LVH, elderly, valvular heart disease, cardiomyopathies (hypertrophic, restrictive), constrictive pericarditis
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
The MC symptom of L-sided HF is ____.
Dyspnea- due to pulmonary congestion/edema
*CHF MC cause of transudative pleural effusions
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
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
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
Increase in ____ (specific lab value) may ID CHF as the cause of dyspnea in ER.
BNP
*If BNP > 100 then CHF is likely
Diet and Exercise recommendations with HF
- Na restriction <2g/d
- Fluid restriction <2L/d
- Exercise
- Smoking cessation
1st line treatment drug for HF is ____.
ACEI
*Drug Rxns= HYPERkalemia, Cough and angioedema
**CI= hypotension and pregnancy
____ (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!!
____ (class of drugs) is most effective treatment for symptoms for mild-moderate CHF.
DIURETICS
*WARNING- HYPOkalemia and calcemia, HYPERglycemia, and HYPERuricemia
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
Meds that decrease mortality in HF:
ACEI, ARB, BBs, nitrates + hydralazine
HF outpatient regimen:
ACEI + diuretic initially, add BB +/- hydralazine + NTG, digoxin
How is acute pulmonary edema/CHF managed?
*Hint: LMNOP
- Lasix
- Morphine
- Nitrates
- Oxygen
- Position (upright to decrease venous return)
A murmur that is harsh/rumble suggests ____.
Stenosis! Aortic or Mitral
A murmur that is blowing suggests _____.
Regurg! Aortic or Mitral
___ and ____ murmurs are heard during systole.
AS and MR
____ and ____ murmurs are heard during diastole.
AR and MS
Squatting, leg raise, and lying down help to ____ (increase/decrease) venous return.
Increase–> increases murmurs and venous snap
AS and MVP ____ (increase/decrease) with handgrip while AR and MR _____ (increase/decrease) with handgrip.
Decrease- AS and MVP
Increase- AR and MR
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
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
How is tricuspid stenosis managed?
Decrease right atrial volume overload with diuretics and Na+ restriction
