Cardiology Flashcards
When stable angina becomes unstable angina, then NSTEMI
pain is worsening with less work
more pain with same work
refractory to nitroglycerine
NSTEMI with troponins
CAD RF
same as vascular disease:
Modifiable: DM Smoking HTN Dyslipidemia
Non modifiable:
Age (M>45 F>55)
FH
Diamond classification risk of CAD with symptoms
Substernal
Worse with exercise
relieved by Nitro
3/3 - typical
2/3 - atypical
CAD associated SXS
Dyspnea
NV
Diaphoresis
DX of CAD
ECG w/ ST Elevation or new LBBB
- STEMI goes to Cath
- R/O NSTEMI with triponin
If no, do STRESS TEST
STRESS TEST
Goal
Positive if:
85% maximum HR, have them sustain it
+ if CP or EKG or ECHO is positive
Nuclear stress test with perfusion can show reversibility
Cardiac cath
tells you extent
R/O prinzmetals
Pateint presents with Angina - Acute Therapy
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
Chronic therapy for CAD risk factors
Statin (high potency)
DM - A1C <7 or 80-120 sugars
HTN 140/90
The four groups that should be on a high-intensity statin
Any vascular disease ( Stroke, CAD, PVD, Carotid stenosis)
LDL > 190
do ASCVD calculation, takes into account RF
What are the high intensity statins and their doses
-Caution if: _____ or ______. If either of those, then start on _____
If there is SA, then _____
Atorvastatin 40, 80
Rosuvastatin 20, 40
Liver or renal disease, go to moderate intensity
SA, stop, then start at lower
Statins: Baseline tests
SA tests
how often lipids
A1C, CK and LFTs
SA - Hepatits: LFTs , muscle: CK
Lipids every year
A1C q3mo
Myositis sxs
Sorness, weakness, muscle pain
Fibrates
LDL down, HDL up, second line to statins
In a pateint with an arrythmia, what makes them unstable?
CP
SOB
AMS
SBP<90
If unstable, pace slow shock fast
What arrythmias are fast, narrow and what do you give them if pt is stable?
Afib
Aflut
SVT
Can give Adenosine (rythem controll)
usually for Afib/ flut give Dilt (CCB). Can give B block (both for rate controll)
What arrythmias are fast, wide and what do you give them if pt is stable?
VT/VF
Torsods
Amiodarone
What arrythmias are slow, and what do you give them if pt is stable?
Heart BLocks 1 2a 2b 3
1 and 2a (wenky) get atropine
otherwise pace
When to do CPR?
What to do in CPR?
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.
What is and what are the causes of Dialated Cardiomyopathy
DX
How do you treat it
Big heart, causes systolic failure. Ischemia Valve dz idiopathic infectious metabolic alcoholic autoimmune
DX - CXR, US
Treat - HF medications
HOCM
Teens , Big ventrical obstructs outflow, sudden death in teens, tx with B blockers
Restrictive Cardiomyopathy
Causes
Sarcoid, Amyloid, hemachromatosis, cancer, fibrosis
TX - gentle diuresis, xplant
What are Systolic and diastolic heart failure, and what are the causes
Systolic cant push blood forward
-Dialated cardiomyopathy, ischemic tissue, leaky valves
Diastolic cannot fill
-hypertrophy, infiltration, pericardial/deposition dizeases as well
Pathogenisis of HTN induced HF
Heart gets big and beefy, eventually becomes floppy. Catecholamines initially help overcome the hypertension, but eventually leads to neural hormonal cardiac remodeling
Symptoms of chronic CHF
Symptoms of acute CHF exacerbation
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
DX of CHF
Under what % of EF is classified as Diastolic falure
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
Treatment of CHF (non acute)
How to reduce preload
How to reduce Afterload
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
Acute exacerbation of CHF
Causes:
SXS:
Tx:
(If ischemic?)
–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
Acronym for all the actions to consider with CHF exacerbation
Lasics Morphine? Nitrates Oxygen postion
What is Hypertensive Urgency
-tx?
What is Hypertensive Emergency
-Tx?
How can you tell if there is end organ damage
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
What are some circumstances where BP is less strictly managed
Not long to live (institutionalized / elderly)
Pts on dialysis - may get hypotensive
Orthostatic hypotension
ASCVD
Gender Race Age Total cholesterol HDL cholesterol Systolic BP BP medications? DM? Smoker?
Anyone over 10% gets orals
Everyone gets diet
DASH diet
Dietary approach to stop hypertension Low Na (<2300mg/day, High K and Mg) Portion sizing 30min excercise / day Goal BMI < 25
TX for HTN
TX for HTN with: CAD CHF CVA Dm CKD
African Amercians
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
What is acute pericarditis vs Chronic pericarditis?
What are some causes?
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
Sxs of pericarditis
Tests for DX?
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
TX of pericarditis
NSAIDS and colchicine
Sxs of tampanad due to effusion from pericarditis
TX
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
SX, Exam findings and TX of Rapid effusion (due to trauma, pericarditis etc)
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
DDX of Syncope
Women 3-2-1 PE
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
Causes of orthostatic hypotension
DX of orthostatic Hypotension
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
Vasovagal Snycope
cause?
Dx?
Tx?
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.
Mechanical Cardiac dz as a cause of Syncope
- different causes
- Dx
Obstruction - PE, AS, HOCM, Myxoma
Sxs may be exertional , may have a murmer
DX w/ Echo
Arrythmia as a cause of Syncope
Will proly dx with holter
May need antiarrythmics or AICD (automatic implantable cardiac diffibrilator) to tx it if sever
