Cardiology Flashcards
What features suggest cardiac syncope and how should it be evaluated?
- suggested by a sudden loss of consciousness and sudden regaining of consciousness
- begin with a cardiac exam
- those with abnormalities should have an echo while those with a normal exam should get ECG, telemetry, and cardiac enzymes
What is the most likely cause of chest pain?
GI disorder
What is the worst risk factor for coronary artery disease?
What is the most common risk factor?
What is the most dangerous lipid profile abnormality?
Which, if changed, provides the fastest benefit?
- worst is diabetes
- most common is hypertension
- elevated LDL is the worst
- smoking cessation provides the quickest risk reduction
What family history of coronary artery disease is considered a personal risk factor for CAD?
must be a first degree relative with premature CAD; either a male less than 55 or a female less than 65
Describe the pathogenesis, presentation, and treatment of Takotsubo cardiomyopathy.
- a massive catecholamine discharge causes acute myocardial damage, ballooning and left ventricular dyskinesias, leading to acute heart failure and death
- presents as chest pain, typically in a postmenopausal women who has just undergone immense stress
- treat with beta blockers and ACE inhibitors; revascularization plays no role since the arteries are fine
What features of chest pain are not consistent with ischemic heart disease?
it should not be positional, pleuritic, or reproducible on palpation
For those with chest pain, what accompanying symptom conveys the worst prognosis?
shortness of breath
What is the best initial test for chest pain?
always an ECG
When is “get cardiac enzymes” the right answer?
- for cases of acute chest pain presenting to the ED
- do not get for chronic pain or patients in the office
What role does stress testing play in the evaluation of chest pain?
stress testing is used to evaluate chest pain where the etiology is unclear and ECG is not diagnostic
For patients undergoing evaluation of chest pain, when are the following indicated:
- ECG
- exercise tolerance test
- exercise thallium
- exercise echo
- dipyridamole thallium
- dobutamine echo
- angiogram/cath
- ECG: always the best first test
- exercise ECG: used when the ECG is non-diagnostic
- exercise thallium: used when an exercise ECG can’t be read due to baseline abnormalities
- exercise echo: used when an exercise ECG can’t be read due to baseline abnormalities
- dipyridamole thallium: used when an exercise ECG can’t be done because the patient can’t exercise
- dobutamine echo: used when an exercise ECG can’t be done because the patient can’t exercise
- angio: used to decide on CABG versus angioplasty; it is also the most accurate test for detecting CAD and can be used if non-invasive testing is equivocal
What is dipyridamole testing? When can and when can’t it be used?
- it is a nuclear scan used in the evaluation of chest pain if a patient can’t exercise and the ECG was non-diagnostic
- may induce bronchospasm so avoid in asthmatics
What is a dobutamine echo? When can and when can’t it be used?
- it is an echo done following injection of dobutamine, which increases myocardial oxygen demand to provoke any inducible ischemia
- performed when an ECG was non-diagnostic and a patient can’t exercise
- contraindicated for ventricular arrhythmias, severe hypertension, LV outflow obstruction, and concurrent beta-blocker use
When is cardiac catheterization or angiogram used?
- typically used to evaluate patients in whom reversible ischemia has been demonstrated to decide on CABG versus angioplasty
- may also be used in some instances to diagnose CAD if non-invasive testing was equivocal since it is the most accurate test
What is the most accurate test for coronary artery disease?
catheterization
At what point does coronary stenosis become significant and at what point does it become surgically correctable?
- not significant until greater than 50%
- not surgically correctable until greater than 70%
Describe the workup for cardiac chest pain.
- ECG
- Stress Test
> exercise or chemical ECG if initial ECG normal
> exercise or chemical echo if initial ECG abnormal - angiography
- medical therapy or intervention
What medications lower mortality for those with chronic angina?
only aspirin and beta-blockers
What formulations are used for the treatment of chronic angina versus acute coronary syndrome?
- for chronic angina, oral and transdermal formulations are used
- for ACS, rapid acting sublingual, paste, and IV are used
How do beta blockers reduce mortality in those with chronic angina?
they reduce isotropy and heart rate thereby decreasing oxygen demand and prolonging diastole which increases coronary perfusion
What is the LDL goal for those with CAD and equivalents?
less than 70
What is the most common adverse effect of statin medications?
liver dysfunction, which is why patients should undergo routine monitoring of LFTs
What side effects are associated with:
- statins
- niacin
- fibrates
- cholestyramine
- statins: transaminitis and myositis
- niacin: flushing/pruritis, hyperglycemia, and hyperuricemia
- fibrates: myositis when combined with statins
- cholestyramine: GI upset
What is evolovumab?
a PCSK9 inhibitor which disinhibit hepatic clearance of LDL but do not have any mortality benefit