CARDIOLOGY Flashcards
IN ACS
MONA B
3 ACS:
STEMI OR LBBB
NSTEMI
UA
3 UA:
RECENT
PROGRESSIVE
AT REST
MORPHINE OXYGEN NTG ASPIRIN * FIRST COPIDOGREL BETA BLOCKER
LMWH
HEPARIN
EX: ENOXIPARIN
FOLLOW UP:
THEN ACE/ARB UP TO 6 WK FOR NORMAL EF LVF
POST PCI:
ASPIRIN FOR 1 YR
COPIDOGREL FOR 4 WKS
MYOGLOBUN
TROPONIN
I INHIBIT ACTIN: MYOSIN
C - Ca
T - TROPOMYOSIN
CK MB
LDH
1-2 HRS FIRST MARKER
1-2 WKS
1-2 DAYS *RE INFARCTION MARKER
ALWAYS WRONG ANSWER
WHEN STRESS TEST
IN CHRONIC SCENARIOS
WHEN CASE IS EQUIVOCAL OR UNCERTAIN
INCREASE SENSITIVITY BEYOND EKG AND ZYMES
CAN’T EXERCISE 85 MAX HR
COPD
AMPUTATION
STROKE
DIPIRIDAMOL ADENOSINE THALLIUM STRESS TEST
OR
DOBUTAMINE ECHO
UNREADABLE EKG
LBB
PACEMAKER
LVH
THALLIUM TESTING
OR STRESS ECHO
DO NOT GO TO CATH LAB WITHOUT STRESS TEST
YOU GO FIRST TO STRESS TEST IF:
REVERSIBLE ISCHEMIA
IF FIXED DEFECTS
REVERSIBLE ISCHEMIA: DO PCI FOR DEFINE IF CABG OR STENT ANGIOPLASTY
FIXED DEFECTS: DO NOT PCI IS OLD MI
STEMI
DEFINITIVE TTX
PCI UP TO 90’
Tpa 90’ TO 12 HRS
GIIa/IIIb
PATH:
MORE THAN 12 HRS F XIII STABILIZES FIBRIN
Tpa ACTIVATES PLASMINOGEN IN PLASMIN
DEGRADATES FIBRIN IS FIBRIN SPLIT PRODUCTS EX: DDIMERS
MORTALITY BENEFIT IN ACS
ALWAYS LOWER MORTALITY IN ACS
LOWER MORTALITY “IF”
REST NOMORTALITY BENEFIT IN ACS
ALWAYS:
ASA PCI Tpa IN STEMI OR NEW LBBB STATINS COPIDOGREL PRASUGREL TICAGRELOR
IF:
EF LOW: ACE/ARB
IF ST DEPRESSION: HEPARIN
P2Y12 ANT ADP
COPIDOGREL
TICAGRELOL
PRASUGREL
IN ACUTE MI ADD TO ASPIRIN
IN ASPIRIN INTOLERANT
PRASUGREL ADD ONLY AFTER ANGIOPLASTY
CHRONIC ANGINA GOLD STANDARD
MOA:
IVABADRINE»_space; DIASTOLE»_space; EF «_space;O2 COMPS
CHRONOTROPIC NEG / INOTROP + X NODAL Na Ifunny (-) NOR Ca++ NOR AMPc (B-BLOQUER)
RANOLAZINE It blocks late inward sodium currents
GOLD STANDARD:
ASPIRIN + BETA BLOCKERS METOPROLOL
THEN
NITRATES IF PAIN
ACE/AB IF LOW EF
COPIDOGREL PRASUGREL TICAGRELOR IF ACUTE MI OR DON’T TOLERATE ASPIRIN
STATINS
ADJUVANT:
RANOLAZINE/IVABRADINE IF PERSISTS PAIN
NSTEMI GOLD STANDARD
MONA FIRST SCREEN!
NEVER Tpa CASE BUT ALWAYS
LMWH BETTER THAN UNFRACTIONED
PGY2 ADP COPIDOGREL
BASELINE PT PTT INR IT!
GIIa/IIIb OR ABXICIMAB
STRATIFY RISK
ONGOING ISCHEMIA?
EARLY “NEXT DAY” vs 90’ PCI
MEDICAL MGMT vs PCI MGMT
PASUGREL / GIIa/IIIb POST PCI
MOA HEPARIN
INHIBITS ANTITHROMBIN THAT INHIBITS THROMBIN
THAT CATALYZES ALMOST ALL PATHWAYS IN COAGULATION CASCADE
THATS WHY ANTITHROMBIN III DEF OR MUTATION IS UNRESPONSIVE TO HEPARIN
LDL FOR STATINS:
190
160
130
RF: PFH: FEM 65 MALE 55 HDL> 40 AGE: MALE 45 FEM 55 HTN TOBACCO BMI DM
RF:
0-1
2-+
CAD EQUIVALENT
GOAL
160
130
100
LIFE STYLE MODIFICATION ALWAYS.
CHF DOC
CARVEDILOL
ANTAGONIST B 1 / B 2 AND ALPHA 1.
SO ANTI
HTN / ARRHYTHMIC /ISCHEMIC.
CCS CASE PULMONARY EDEMA
CLOCK EVERY 15 MINS IN ACUTE DESCOMPENSATED CASES
FOCUSED PE
BASIC SCIENCE CORRELATION
INAMRINOME
MILRINONE
MOA 3 PDE INHIBITORS
» GMPc»_space; Ca++»_space; EXCITATION-CONTRACTION «_space;AFTERLOAD AS NITRATES AND «_space;WEDGE PULM PRESSURE AS SILDENAFIL + INOTROPIC + EFFECTS
DOUBT:
BNP
MAINSTEM: OXYGEN FUROSEMIDE NITRATES MORPHINE CXR EKG OXYMETRY- ABG ECHOCARDIOGRAM
PRELOAD REDUCTION
ACHIEVE MAXIMUN
IN ICU SETTING:
FURTHER MGMT AFTER 60 MIN WITH MAX PRELOAD REDUCTION:
DOBUTAMINE
INAMRINONE
MILRINONE
RESCUERS AFTER LOAD CONSIDER BP> 100
IV ENAPRILAT
IV SINGLE DOSE SPIRINOLACTONE
DIGOXIN NEVER IS JUST RATE CONTROL IN A FIB.
CHF “FURTHER MGMT”
MORTALITY BENEFIT
AND EF 35 OR LOWER
AND QRS > 120 MILLISECONDS
IMPLANTABLE DEFIBRILLATOR
BI-VENTRICULAR PACEMAKER
RE-SYNCHRONIZATION CARDIAC THERAPY
FURTHER MGMT IN CHF
SACUBITRIL /VALSARTAN: NEPRYLISIN INHIBITOR/ARB COMBINATION
IVABRADINE: INOTROPIC NEGATIVE NODAL Na I funny CHANNEL BLOCKER
MORTALITY BENEFIT
NOMORTALITY BENEFIT VISSUAL ISSUES TTX
LOWER EF
SYSTOLIC FAILURE GOLD STANDARD
* MORTALITY BENEFIT
+SXS / READMISSION BENEFIT
ACE/ARB* CARVEDILOL>METO>BISO* EPLERENONE>SPIRONOLACTONE* DIURETICS+ DIGOXIN+ HYDRALAZIN/NITRATES IN BBLOCKERS+ INTOLERANCE
NORMAL EF DIASTOLIC FAILURE EX HTN CARDIOMYOPATHY R V1+ S V5> 35 OR
AMILOIDOSIS TRANSTHYREIN MUT
HEMOCROMATOSIS
SARCOIDOSIS
MAINSTEM THERAPY
BETA BLOCKERS
DIURETICS
RESTRICTIVE
DIASTOLIC
TRANSPLANTS SINGLE TTX
DEFEROXAMIN IN HEMOCROMATOSIS
SYNCOPE
ONSET-RECOVER
GRADUAL: METABOLIC/TOXICOLOGY
SUDDEN-GRADUAL: NEURO
SUDDEN-SUDDEN : COR
PE+ VALVULAR DZ PE- ISCHEMIC ARRHYTHMIA
DO NOT DOPPLER CAROTID CMA IS NOT THE CAUSE BUT VERTEBRAL BRAIN STEM
CARDIAC AND NEURO EXAM EKG HOLTER OUTPATIENT TELEMETRY INPATIENT CHEM GLUCOSE OXYMETRY CARDIAC ENZYMES FU 4 HRS AFTER ECHOCADIOGRAM: IF PE+ M/R/G HEAD CT IF FND HA OR SEIZURE
PAD
BIT: ABI .9
MAT: ANGIOGRAPHY
ASA ACE/ARB EXCERCISE AS TOLERATES CILOSTAZOL PDE INHIBIT LIPID CONTROL STATINS VORAPAXAR ANTIPLATELET or ASA+COPIDOGREL
AAA
65-75 EX OR SMOKER ABD US
> 5 CM SURGERY LAPLACE T=PR
A FIB /FLUTTER CHF HTN AGE 75 DM STROKE
US VS STABLE ACUTE < 48 HRS VS CHRONIC RATE CONTROL BB CCB DIGOX ANTICOAGULATION: CHADS 2 o + NOAC >>> WARFARIN ANTIDOTE: FFP - VITK Xa INHIBITORS ANTIDOTE: ANDEXANET RIBAROXABAN APIXABAN DIRECT THROMBIN ANTIDOTE: IDARUCIZUMAB DABIGATRAN
SINDROMES DE PRE EXCITATCION O CON PR CORTO
SVT/WPW
SVT UNSTABLE:
SYNCRONIZED CARDIOVERSION
STABLE
1-VAGAL
2-ADENOSINE
3-LONG TERM: ABLATION RADIOFREQUENCY
WPW: DELTA WAVE EKG MAT: ELECTROPHYSIOLOGY AV BLOCKERS DEGENERATE IN V TACK TTX : PROCAINAMIDE
VT
QT LARGO SYNDROMES
JIERWEL
BRUGADA NIELSEN ETC
SYNCHONISMO MACROLIDOS QUINOLONES .. AGENTS IA QUINIDINE ETC
ALWAYS CHECK AND TREAT MG FIRST
STABLE:
AMIODARONE
LIDOCAINE
PROCAINAMIDE
MAGNESIUM TORSADE DE POINTES
UNSTABLE:
SYNCHRONIZED CADIOVERSION
VF
DEFIBRILATE UNSYNCRONIZED CARDIOVERSION EPI IV DEFIBRILATE AMIODARONE OR LIDOCAINE DEFIBRILATE CPR
CCS ANY ARRHYTHMIA
EKG -HOLTER -TELEMETRY
CARDIAC - BLOOD PRESSURE MONITORING
MAGNESIUM PHOSPH CALCIUM POTASSIUM
TOXICOLOGY
THEN
TEE: TRANS ESOPHAGEAL ECHO-CARDIOGRAM
CCS CASE
STEMI V2-V4
PULSE OXY EKG IV MORPHINE ASPIRIN METOPROLOL NG SL LISINOPRIL FOR ALL AMI STOP AFTER 6 WKS FOR NORMAL EF
ORDER: CKMB EVERY / 2 HRS ADMIT TO ICU NPO BED REST PNEUMATIC DEVICE COMPRESSION COPIDOGREL IV BIVALOURIDIN FOR 48 HRS BETTER THAN UNFRACTIONED HEPARIN IV EPIFIBATIDE IIa/IIIb
CONSULT CARDIOLOGY
CARDIAC ANGIOPLASTY IF < 90 MIN AND Tpa IF 90- 12 HRS
INTRARAORTIC BALOOM FOR UNSTABLE PATIENTS TIME TO CATH LAB OR GIVE THEM 1 ST DOSE Tpa THE TRANSFER TO NEXT LAB CATH FACILITY.
STATINS
LFT 6 MOS FU
CCS CASE
WHILE IN ICU THE NURSE CALLS YOU: ACUTE MI POSTERIOR SUDDEN DROP IN HR AND BP AMS NO CHEST PAIN
DZ:
THIRD DEGREE A-V BLOCK
EKG: COMPLETE AV BLOCK IV ATROPINE IVA NSS IV DOPAMINE TRANS CUTANEOUS PACEMAKER
CCS CASE PMH: ARRHYTHMIA NOT TAKING ANY MEDICATION BP: 80/60 HR:160 CHEST PAIN DIAPHORESIS JVD DISTANT HEART SOUNDS
PULSE OXY OXYGEN EKG: V TACK CARDIAC MONITORING BP MONITORING IVA NSS
ORDER:
DC CARDIO-VERSION 100 ... 360J IF PERSISIT AMIODARONE FOLLOWED BY LIDOCAINE ABG BMP CBC CARDIOLOGY CONSULT ECHO-CARDIOGRAM
STABLE PATIENTS:
AMIODARONE > LIDOCAINE > IPIFIBATIDE
TREATMENT OF THE UNDERLYING CAUSE.
CCS CASE
RECENTLY DISCHARGED FROM THE HOSPITAL FOR ACUTE MI BROUGHT TO THE ER FOR PALPITATIONS WHILE YOU EXAMINE HIM BECAME UNRESPONSIVE AND LOSE HIS PULSE.
ORDER:
EKG: VENT FIBRILATION PULSE OXY IV ACCESS OXY THERAPY CARDIAC MONITORING BP MONITORING ABG
ORDER:
ASYNCHRONIZED CARDIO-VERSION CPR DEFIBRILLATION AT 360 J INTUBATION AMIODAROE >> LIDOCAINE BICARBONATE
CCS CASE
CP RADIATES TO NECK AND LEFT ARM 2 FLOORS
NTG IF PAIN ON ATENOLOL
COMPLETE PE VITALLY STABLE
EKG: NORMAL
ADMISSION TO WARD SERIAL CARDIAC ENZYMES EVERY 8 HOURS TELEMETRY AMBULATE AT WELL ORAL PROPRANOLOL ORAL NG ORAL ASPIRIN CBC BMP ECHO LIPID PROFILE ATORVASTATIN IRRESPECTIVE TO LIPID PROFILE RESULT
IF THERE IS A HISTORY OF WORSENING PHYSICAL FUNCTION OR FREQUENCY PAIN PROCEED WITH ANGIOGRAPHY TO DECIDE CABG OR NOT
ORDER: ATENOLOL ASPIRIN NITROGLYCERIN STATIN ORAL SCHEDULE FOR CARDIAC CATHETERIZATION AFTER 2 WK
CCS CASE HTN DM HE DENIES CHEST PAIN PAD CLEARANCE BEFORE FEMOROPOLPITEAL, BY PASS LIPID PROFILE CHOLESTEROL LDL 292 INITIAL EKG WAS OK YOU DECIDE STRESS TEST SHOWS: REVERSIBLE ISCHEMIA INFERIOR WALL
ORDER:
FASTING LIPID PROFILE TOTAL 212 LDL138 TG 152 HDL 52
BMP
CBC
ORDER:
STATINS FORWARD THE CLOCK 6 MOS TO RESCHEDULE FOR SERUM CK AND LFT
LYFE STYLE MODIFICATIONS: STOP SMOKING
NICOTINE PATCH - BUPROPION / VARENCYCLINE CI IN CARDIOVASCULAR DISEASE OR DEPRESSION.
EXERCISE
LOW FAT DIET
CCS CASE
HPI:
SOB
PMH SEVERAL MI
ON DIGOXIN DIURETICS AND ACE
PE: JVD BL RALES TACHYCARDIA TACHYPNEA III/VI SYSTOLIC MURMUR S3 BLL EDEMA
FOCUSED PE
VITALY STABLE
PULSE OXY OXY THERAPY CARDIAC MONITORING BLOOD PRESSURE MONITORING NG SL IV MORPHINE
EKG
ABG
CXR
ORDER
CKMB E/ 8 HRS
ECHO
BNP
ADMIT TO ICU SEMI SITTING POSITION BED REST PNEUMATIC COMPRESION DEVICE NPO SWANZ GANZ CATHETER
IV FUROSEMIDE EVERY 20 MINUTES
IV MORPHINE
IV NG
IV DOBUTAMINE
IV ENALAPRILAT
EF LESS 30 % IV SPIRONOLACTONE INHIB R-A-A SYSTEM WATER RETENTION EFECT
NESIRITIDE : SYNTHETIC ANP
AFTER STABILIZATION
DIGOXIN ORAL
CARVEDILOL PO
CCS CASE DYSPNEA DIFFICULTY THINKING HEADACHE MILD PALPITATIONS HTN ON THIAZIDES
PULSE OXY OXY THERAPY EKG LVH SV1+RV5>35 ST DEPRESSION HCM CARDIAC MONITORING BP MONITORING BMP UA LIPID PROFILE TSH
ORDER: TRANSFER TO ICU NPO BED REST PNEUMATIC COMPRESSION DEVICE
IN ICU YOU CANT GIVE IN ER NEED ARTERIAL LINE: NITROPRUSIATE
TARGET 20 % REDUCTION MEAN BP 160/100 6 FIRST HOURS
INTERVAL HISTORY AND MONITORING VITALS
ADVANCE CLOCK TO GET BP
AFTER CONTROLLED WARD
WITHDRAWN ARTERIAL LINE AND IV DRUGS TO ORAL
PO THIAZIDE ACE/ARB OR ATENOLOL ACCORDING TO YOUR CASE.
CCS CASE
SWELLING IN HIS LL
EXERTIONAL SOB
ACUTELY DISTRESSED
2 BOOTLES OF DRINK/DY
95/60
HR 100
PMI LAT DISPLACED
ALCOHOLIC CARDIOMIOPATHY
DO FOCUS PE AS UNSTABLE PT ORDER: PULSE OXY OXYGEN THERAPY EKG CARDIAC MONITORING BP MONITORING CXR: CARDIOMEGALY FULL CHAMBERS KELLYS LINES ECHO DILATED CHAMBERS EF < 25 % INSUFFICIENT MV TP PV ACEI CARVEDILOL DIGOXIN FUROSEMIDE NYHA III IV EPLERENONE SPIRONOLACTONE LMWH COUNSEL STOP ALCOHOL
CCS CASE LOUD S1 OPENING SNAP BIBASILAR RALES JVD SOB + HEMOPTISIS
MS CASE
CXR: STRAIGHT LEFT HEART BORDER BIPHASIC O WAVES V1 LARGE ATRIUM ECHO: DILATED LA CARDIAC CATHETERIZATION: IF OUTLET < 1 CM SEVERE MS NEED EMERGENT COMISUROTOMY OR REPLACEMENT
SALT RESTRICTION FUROSEMIDE FU IN 2 WKS ADVANCE CLOCK NO IMPROVEMENT BALOOM VALVULOPLASTY.
DM HTN CHF
SOB AND LEG SWELLING
FOCUSED PE: JVD TKC BL CRACKLES LL EDEMA
ORDER: OXYG PULSE OX CADIAC MONITOR IVA
ORDER: CBC CHEM 8 PT,PTT CARDIAC ENZYMES E/ 8 HRS LFT EKG 12 LEADS NTG SL AND ASPIRIN (CAN ALSO BE GIVEN HERE) CXR PORTABLE IV LASIX ONE TIME MORPHINE ONE TIME BOLUS NITROGLYCERINE TOPICAL DECREASE PRELOAD IF THE APATIENT IS > 150/90 CAN USE NITROGLICERINE IV CONTINOUS IF HYPOTENSIVE BP< 100 USE DOPAMINE IV CONTINUOS
MOVE THE CLOCK TO GET THE LABS LFT TAKE 2 HRS THE REST 1 HR SO MOVE THE CLOCK 1HR FORWARD INTERVAL CHECK ORDER VITALS IF STABILIZED ORDER ECHOCARDIOGRAM CHANGE LOCATION: ICU
CCS CASE
DM HTN CHF
SOB AND LEG SWELLING
FOCUSED PE: JVD TKC BL CRACKLES LL EDEMA
DZ:
ACUTE DESCOMPESATED HEART FAILURE
ORDER: OXYG PULSE OX CADIAC MONITOR IVA
ORDER: CBC CHEM 8 PT, PTT CARDIAC ENZYMES E/ 8 HRS LFT EKG 12 LEADS NTG SL AND ASPIRIN (CAN ALSO BE GIVEN HERE) CXR PORTABLE IV LASIX ONE TIME MORPHINE ONE TIME BOLUS NITROGLYCERINE TOPICAL DECREASE PRELOAD IF THE PATIENT IS > 150/90 CAN USE NITROGLICERINE IV CONTINUOUS IF HYPOTENSIVE BP< 100 USE DOPAMINE IV CONTINUOUS
MOVE THE CLOCK TO GET THE LABS LFT TAKES 2 HRS THE REST 1 HR SO MOVE THE CLOCK 1HR FORWARD INTERVAL CHECK ORDER VITALS IF STABILIZED ORDER ECHO-CARDIOGRAM CHANGE LOCATION: ICU FLUID RESTRICTION MONITOR INPUT OUTPUT LIPID PROFILE
MOVE THE CLOCK
GET ECHO CARDIOGRAM REPORT
MOVE THE CLOCK NEXT DAY ROUND 9 AM
END OF CASE
ACEI/ARB ONCE TH
E PATIENT IS STABLE
AFTER 2 OR 3 DAYS
REPEAT CHEM 8 IF RENAL FUNCTION IS SATBLE
IT CAN BE ADDED
SPIRONOLACTONE: ONCE THE PATIENT STABILIZES UNLESS SERUM POTASSIUM 5.0 OR MORE
BETA BLOCKER PRIOR TO HOSPITAL DISCHARGE.
RASH > 5 DYS FEBRILE CERVICAL LAD SWELLING OF FEET AND HANDS
CONJUNCTIVAL INJECTION
STRAWBERRY TONGUE
KAWASASKI .
ORDER: IV LINE CBC BMP UA LFT CPR ESR BLOOD CULTURES URINE C S CXR
ORDER: STAT OF IVIG CONTINUOUS ASPIRIN ORAL CONTINUOUS CHANGE LOCATION TO WARD CALL PEDIATRIC CARDIOLOGY
NYHA III/IV ADD?
EPLERENONE»_space; SPIRONOLACTONE
GIIa/IIIb
NSTEMI or POST PCI
EMRGENCY HTN
GOAL
ICU
NTG/ARTERIAL LINE -NITROPRUSSIATE/LABETALOL
20% PS+2PD/3 MEAN BP 160/100 6 FIRST HOURS
FENOLDOPAM: ASTHMA
AS
OVERALL SV PROGNOSIS
ANGINA
SYNCOPE
DOE=CHF
5 YRS
3 YRS
2 YRS
RIGHT MI
POSTERIOR INFERIOR CONSIDERATIONS
80 R DOMINANT AV NODE PLUS VAGAL TONE IN R PTS = AV CONDUCTION DEFECTS SO ATROPINE DOBUTAMINE IT AND PACEMAKER IT NTG AND DIURETICS WORSENS RV PTS IV FLUID THEM DON'T NITRATE! THEM DON'T B BLOCKADE IF HR < 60
SECOND LINE NEVER FIRST LINE ANTI HTN MEDICATIONS
CLONIDINA/RESERPINE/GUANETIDINE/TRIMETAPHAN ALL - SYMPATIC CENTRAL/GANGLIONAR ANTAGONIST
DIRECT ARTERIOLAR DILATORS
HYDRALAZINE/MINOXIDIL REFLEX TKC SLE LIKE HISTONES +
ALPHA BLOCKERS REFLEX TKC EDEMA
SPIRONOLACTONE/TRIAMTERENE
