Cardiology

Question 1

When stable angina becomes unstable angina, then NSTEMI

Answer 1

pain is worsening with less work
more pain with same work
refractory to nitroglycerine

NSTEMI with troponins

Question 2

CAD RF

Answer 2

same as vascular disease:

Modifiable: 
DM
Smoking 
HTN
Dyslipidemia 

Non modifiable:
Age (M>45 F>55)
FH

Question 3

Diamond classification risk of CAD with symptoms

Answer 3

Substernal
Worse with exercise
relieved by Nitro

3/3 - typical
2/3 - atypical

Question 4

CAD associated SXS

Answer 4

Dyspnea
NV
Diaphoresis

Question 5

DX of CAD

Answer 5

ECG w/ ST Elevation or new LBBB

• STEMI goes to Cath
• R/O NSTEMI with triponin

If no, do STRESS TEST

Question 6

STRESS TEST
Goal
Positive if:

Answer 6

85% maximum HR, have them sustain it
+ if CP or EKG or ECHO is positive
Nuclear stress test with perfusion can show reversibility

Question 7

Cardiac cath

Answer 7

tells you extent

R/O prinzmetals

Question 8

Pateint presents with Angina - Acute Therapy

Answer 8

Aspirin
Nitrates (can alleviate pain BUT avoid if right-sided: 2,3 AVF)
MONA BASH
Morphine, Oxygen, Nitrates, Aspirin, BB, Aspirin , Statin Heparin

tPA / heparin acutely only if within 12 hours and no Cath available

Question 9

Chronic therapy for CAD risk factors

Answer 9

Statin (high potency)
DM - A1C <7 or 80-120 sugars
HTN 140/90

Question 10

The four groups that should be on a high-intensity statin

Answer 10

Any vascular disease ( Stroke, CAD, PVD, Carotid stenosis)
LDL > 190

do ASCVD calculation, takes into account RF

Question 11

What are the high intensity statins and their doses
-Caution if: _____ or ______. If either of those, then start on _____
If there is SA, then _____

Answer 11

Atorvastatin 40, 80
Rosuvastatin 20, 40

Liver or renal disease, go to moderate intensity
SA, stop, then start at lower

Question 12

Statins: Baseline tests
SA tests
how often lipids

Answer 12

A1C, CK and LFTs
SA - Hepatits: LFTs , muscle: CK
Lipids every year
A1C q3mo

Question 13

Myositis sxs

Answer 13

Sorness, weakness, muscle pain

Question 14

Fibrates

Answer 14

LDL down, HDL up, second line to statins

Question 15

In a pateint with an arrythmia, what makes them unstable?

Answer 15

CP
SOB
AMS
SBP<90

If unstable, pace slow shock fast

Question 16

What arrythmias are fast, narrow and what do you give them if pt is stable?

Answer 16

Afib
Aflut
SVT

Can give Adenosine (rythem controll)
usually for Afib/ flut give Dilt (CCB). Can give B block (both for rate controll)

Question 17

What arrythmias are fast, wide and what do you give them if pt is stable?

Answer 17

VT/VF
Torsods

Amiodarone

Question 18

What arrythmias are slow, and what do you give them if pt is stable?

Answer 18

Heart BLocks 1 2a 2b 3
1 and 2a (wenky) get atropine
otherwise pace

Question 19

When to do CPR?

What to do in CPR?

Answer 19

In cardiac arrest: the heart has stopped (No BP / No pulse)

Shock? Drug, 2 min CPR, Drug, 2min CPR
Start with Epi. Shock only in Vtach, Vfib. If it is PEA / Asystoli, give nothing on first break.

Question 20

What is and what are the causes of Dialated Cardiomyopathy

DX

How do you treat it

Answer 20

Big heart, causes systolic failure. 
Ischemia
Valve dz
idiopathic
infectious 
metabolic 
alcoholic 
autoimmune 

DX - CXR, US

Treat - HF medications

Question 21

HOCM

Answer 21

Teens , Big ventrical obstructs outflow, sudden death in teens, tx with B blockers

Question 22

Restrictive Cardiomyopathy

Causes

Answer 22

Sarcoid, Amyloid, hemachromatosis, cancer, fibrosis

TX - gentle diuresis, xplant

Question 23

What are Systolic and diastolic heart failure, and what are the causes

Answer 23

Systolic cant push blood forward
-Dialated cardiomyopathy, ischemic tissue, leaky valves

Diastolic cannot fill
-hypertrophy, infiltration, pericardial/deposition dizeases as well

Question 24

Pathogenisis of HTN induced HF

Answer 24

Heart gets big and beefy, eventually becomes floppy. Catecholamines initially help overcome the hypertension, but eventually leads to neural hormonal cardiac remodeling

Question 25

Symptoms of chronic CHF Symptoms of acute CHF exacerbation

Answer 25

``` CHRONIC (L sided failure) Exertional dyspnia Orthopnia - When lying flat Paroxysmal nocturnal dyspnia - waking up at night ``` crackles / Rales (R sided failure) Leg swelling Peripheral Edema Hepatomegaly ACUTE - JVD - S3

Question 26

DX of CHF Under what % of EF is classified as Diastolic falure

Answer 26

BNP can help determine if the body is volume overloaded or not TTE - tells you if if its systolic / diastolic. under 55% is Systolic HF

Question 27

Treatment of CHF (non acute) How to reduce preload How to reduce Afterload

Answer 27

Everyone: Cardiac Diet Ace Bblock ``` Consider adding: Furosimide Nitrates hydralizine (biDil?) Spironilactone ``` Reduce Preload <>Reduce fluid -cardiac diet: <2g NaCl / day and <2l fluid/day -Furosimide: Slight limitations (II) / Significant -Isosorbide dinitrate (nitrates) : only comfortable at rest (III) Reduce Afterload <> -Ace inhibitors (Lisinopril) (II) -Spironilactone Hydralizine (III and up) NOTE: Isosorbide dinitrate + Hydralizine = Bi Dil Reduce risk of sudden cardiac death -B-blocker ``` Reduce Sxs (not mortality) -Digoxin ``` ``` Conisder AICD if EF<35% Consider Dobutamine (or other ionotrope) if need help to ventricular assist device ```

Question 28

Acute exacerbation of CHF Causes: SXS: Tx: (If ischemic?)

Answer 28

--Causes-- -Usually volume overload from: medication noncompliance dietary noncompliance ischemia arrythmia SXS: - Crackles - JVD - edema (acute) - elevated BNP * Confirm with Echo Make sure to rule out other causes of Dyspnia (PE, asthma, COPD, PNA, Anxiety) Tx: aggressive Furosemide Afterload reduction (BP controll) Preload reduction (diuresis and nitrates) **Never start or increase Bblocker during exacerbation if ischemic: Add ASA and Statin

Question 29

Acronym for all the actions to consider with CHF exacerbation

Answer 29

``` Lasics Morphine? Nitrates Oxygen postion ```

Question 30

What is Hypertensive Urgency -tx? What is Hypertensive Emergency -Tx? How can you tell if there is end organ damage

Answer 30

Hypertensive Urgency: >180/110 without evidence of end organ damage -IV or orals Hypertensive Emergency >180/110 with evidence of end organ damage -IV dilt or Nitrates to dec 25% in 6 hrs, then orals for 24 hours End Organ Damage: Retninal hemorrhage HF - JVD, crackles, edema CNS - AMS, visual fields

Question 31

What are some circumstances where BP is less strictly managed

Answer 31

Not long to live (institutionalized / elderly) Pts on dialysis - may get hypotensive Orthostatic hypotension

Question 32

ASCVD

Answer 32

``` Gender Race Age Total cholesterol HDL cholesterol Systolic BP BP medications? DM? Smoker? ``` Anyone over 10% gets orals Everyone gets diet

Question 33

DASH diet

Answer 33

``` Dietary approach to stop hypertension Low Na (<2300mg/day, High K and Mg) Portion sizing 30min excercise / day Goal BMI < 25 ```

Question 34

TX for HTN ``` TX for HTN with: CAD CHF CVA Dm CKD ``` African Amercians

Answer 34

HTN with no cormorbid: Ace-I Thiazide CCB CAD- BB / Ace-I .....Nitrates, CCB CHF- BB / Ace-I .......Nitrates+ Hydralizine (Bidil), Spironilactone CVA- Thiazide, CCB DM- Ace-i CKD- Ace-i (avoid if CKD stage 4!!) Dont give Ace-I to aftrican americns UNLESS there is DM

Question 35

What is acute pericarditis vs Chronic pericarditis? What are some causes?

Answer 35

Acute Pericarditis (an inflamatory condition) that MAY cause an effusion - that COULD lead to tampanad. Chronic Pericarditis can lead to fibrosis arund the heart - constriction (knock) (DX with echo, treat with pericardectomy) Causes - autoimmune, cancers, trauma, infection

Question 36

Sxs of pericarditis Tests for DX?

Answer 36

``` Positional pain (lean forward, its better) reproducible ``` ECG (all you need) - Diffuse ST segment elevation - PR segment depression (PATHOPNEUMONIC) Echo - will only show an effusion, not inflamation

Question 37

TX of pericarditis

Answer 37

NSAIDS and colchicine

Question 38

Sxs of tampanad due to effusion from pericarditis TX

Answer 38

CHF sxs! - DOE, PND, Orthopnea - Findings: JVD, Crackles, Edema TX - "treat the cause" - tons of things can cause it. - if refractory and recurrent, you can get a pericardial window

Question 39

SX, Exam findings and TX of Rapid effusion (due to trauma, pericarditis etc)

Answer 39

SXS: Exam findings: Becks Triad -JVD, Distant Heart sounds, hypotension can also see clear lungs* and pulses paradoxis ( more than 10mm differense in systolic BP during inspiration) TX: Pericardiocentesis

Question 40

DDX of Syncope Women 3-2-1 PE

Answer 40

``` VasoVagal Orthostatic -Nervous system broken (elderly, Diabetic) -Lack of sympathetic tone from Sepsis -Low Preload (Hypovolemia) ``` Mechanical Cardiac Dz Arrythmia Neuro - Vertebrobasilar Insuficiency -CTA - Seizure - look for post ichtal - Stroke - CT - Narcolepsy PE Electrolytes

Question 41

Causes of orthostatic hypotension DX of orthostatic Hypotension

Answer 41

Orthostatic - Nervous system broken (elderly, Diabetic) - Lack of sympathetic tone (Sepsis, anaphalxis, addisons) - Low Preload (Hypovolemia) (Diuretics, Hemmorhage, dehyd) BP Orthostatics (laying down, sitting, standing) - Systolic DECREASE by 20 - Diastolic DECREASE by 10 - HR INCREASe by 10 Very low percentage get DX Can give IVF if severe

Question 42

Vasovagal Snycope cause? Dx? Tx?

Answer 42

Vagus nerve activates way more than it should Cuases include cough, defication, micturition, turning head, shaving Tilt table diagnosis it! Tx - usually trigger avoidance. Could give fludricortisone or do surgery if super serious.

Question 43

Mechanical Cardiac dz as a cause of Syncope - different causes - Dx

Answer 43

Obstruction - PE, AS, HOCM, Myxoma Sxs may be exertional , may have a murmer DX w/ Echo

Question 44

Arrythmia as a cause of Syncope

Answer 44

Will proly dx with holter | May need antiarrythmics or AICD (automatic implantable cardiac diffibrilator) to tx it if sever