Cardiology Flashcards
How to calculate rate on ECG (regular)?
300/large squares
OR
1500/small squares
How to calculate rate on ECG (irregular)?
6 x R-R intervals on 10 sec (50 large squares)
Hyperkalemia on ECG?
Peaked T waves
Hypokalemia on ECG?
ST depression
U waves
Hypercalcemia on ECG?
Shortened QT interval
Hypocalcemia on ECG?
Prolonged QT interval
Heart block 1st degree?
Prolonged P-R in every complex, but every QRS has its own P
Heart block 2nd degree?
Mobitz I: gradual prolongation until one P is alone
Mobitz II: fixed P-R with a ratio of P dropped (e.g., 3:1, 4:1)
Heart block 3rd degree?
P-P and R-R are constant but independent
Enzyme to diagnose new MI?
Troponins
Enzyme to diagnose old MI?
CK-mb
Medical acute treatment of MI?
MONA (morphine, O2, nitrates, ASA) BASH (beta blockers, ACE inhibitors, statins, heparin) and copidogrel (if the probability of CAD is high).
Out-patient medical treatment of MI?
ABAS (ASA, betablockers, ACE inhibitors, statins)
Contraindication of Nitrates (MI context)?
Right side STEMI
Chest pain + normal ECG + negative troponins. Next step?
Stress test:
The goal is to get the patient to target heart rate (85% of their maximum)
Diamond classification?
(1) Substernal chest pain, (2) Worse with Exertion, and
(3) Better with Nitroglycerin. 3/3 is called typical, 2/3 is called
atypical, and 0-1 is called non-anginal.
Indications CABG
3 vessel disease or left mainstream disease
Indications angioplasty (PCI)
1, 2 vessel disease
Treatment SVT (stable)
Vagal maneuvers. If that doesn’t work Adenosine (6-12-12), if doesn’t work, BB/CCB
Causes torsade des pointes
Hypokalemia or hypomagnesemia
Prolonged QT
Treatment torsade des pointes
Magnesium
Treatment VTach
Amiodarone
Treatment A Fib (unstable)
Cardiovert
Treatment Afib, stable, new (<48h)
Rate control (BB/CCB) Cardioversion
Treatment Afib, stable, old (>48h)
Anticoagulate -> TEE -> CArdioversion -> Anticoagulate
A Fib, valvular clot
Tx?
Warfarin
A Fib, non-valvular clot.
Anticoagulation treatment?
NOACs (e.g., dabigatran, apixaban and rivaroxaban)
Treatment AFib
RACE (rate control, anticoagulation, cardioversion, etiology)
Anticoagulation AFib
CHA2DS2 VASC
o Chronic heart failure: 1 pt
o Hypertension: 1 pt
o Age 65-74: 1 pt
o Age > 75: 2 pt
o Diabetes: 1 pt
o Stroke: 2 pt
o Vascular disease: 1 pt
o Femaie: 1 pt
Results 0: ASA; 1: ASA or anticoagulation; >2: anticoagulation (warfarin aiming for INR of 2-3) or NOAC
Door needle time (MI)
60 mins to give tPA
Time door balloon (MI)
90 mins
Farmaco Tx for 1º AV block
Generally none, but Atropine if Sx
Farmaco Tx for 2º AV block type I
Generally none, Atropine if Sx.
Review patient’s meds
Tx for 2º AV block type II
Peace, even if asx
Tx for 3º AV block
Peace
Tx Idioventricular rhythym
Peace
Defribilable rhythms
VT/VF
Farma TX unstable VT/VF
Epinephrine-Amiodarone-Epinephrine-Amiodarone
Farma TX PEA/Asystolia
Epinephrine-nothing-Epinephrine-nothing
Definition of Hypertensive urgency
> 210/120 NO target-organ damage
Hypertensive emergency
dBP > 120 + target-organ damage
HTN + CHF/CAD. Ideal tx for HTN?
BB (metropolol, carvedilol) + ACEI
HTN + stroke. Ideal tx for HTN?
ACEI + HCTZ
HTN + CKD. Ideal tx for HTN?
ACEI
HTN + DM. Ideal tx for HTN?
ACEI
Secondary effects of dCCB (e.g., amlodipine)
Peripheral edema
Secondary effects of ACEI
↑ Cr, ↑ K
Dry cough, angioedema
Secondary effects of ARB
↑ Cr, ↑ K
Secondary effects of HCTZ
↓ K, ↓ urinary calcium (used for Kidney stones)
HyperGLUC
Secondary effects of BB
↓ HR
Secondary effects of Aldosterone antagonists (e.g., spironolactone)
Gynecomastia, ↑ K
Secondary effects of Hydralazine
Drug-induced lupus
Reflex tachycardia
Secondary effects of Alpha-antagonists (Doxazosin, Prazosin, Terazosin)
Orthotastisc hypotension
Secondary effects of Central (clonidine)
Rebound hypertension
Emergency hypertension initial goal of BP reduction
↓MAP 25% in 4-6 hrs then to normal in 24 hours
Which anti-hypertensive shouldn’t be used with afroamerican patients?
ACEI unless there is a comorbility
Most common cause of secondary hypertension
CKD/End-state renal disease (ESRD)
Treatment of CHF exacerbation
If STEMI/NSTEMI: MONA BASH and cath Not STEMI/NSTEMI • L= Lasix (Furosemide) 40-500 mg IV • M= Morphine 2-4 mg IV • N= Nitrates • O= Oxygen • P= Position • P= Positive airway pressure (CPAD, BiPAP) IMPORTANT: Never start or increase a Beta-Blocker during an exacerbation.
Tx CHF class I
No limitations of activity; no sx with normal activty
(BB+ACEI)
Tx CHF class II
Slight limitation with activity. Comfortable with rest or mild excertion
(BB+ACEI) + Furosemide
Tx CHF class III
Marked limitation of activty. Comforable only at rest
(BB+ACEI) + Furosemide+ [BiDil (isosorbide /hydralazine)+ Spironolactone]
Tx CHF class IV
Any physicial activity brings disconfort; Sx at rest
(BB+ACEI) + Furosemide + [BiDil (isosorbide /hydralazine) + Spironolactone] + Inotrops (e.g., dobutamine)
Causes of CHF
CAD, HTN, valvular, alcohol
Dressler syndrome
Pericaditis post MI (2-8 wk)
Acute pericarditis triad
Chest pain, friction rub, ECG changes (↓PR, diffuse ↑ST)
Causes of pericardial diseases
infectious, autoimmune, trauma, and proximate cancers (breast, lungs, esophagus, lymphoma)
Etiology of pericarditis
Viral (coxsackie) or uremia
Diagnosis of pericarditis in ECG
ECG: ↓ P-R (Pathognomonic); Diffuse ↑ S-T
Echo is not used!!!!!
Treatment of pericarditis
NSAIDS + Colchicine*
- secondary effect: diarrhea
Contraindication of NSAIDs
CKD, thrombocytopenia or peptic ulcer disease (PUD)
Treatment of Pericardial effusion
NSAIDS + Colchicine (Tx of pericarditis) but if it doesn’t work, pericardial window is the next step
Diagnosis of Pericardial effusion
Echo
Sx/sg’s of Pericardial tamponade
Beck’s triad
* JVD
* Hypotension
* ↓ heart sounds
Clear lungs
Pulsus paradoxus > 10 mmHg
Tx of Pericardial tamponade
pericardiocentesis and bolus of IV fluids
Etiology of Constrictive pericarditis
recurrent pericarditis
Dyspnea, fatigue
Mimic right CHF (edema, ascites, splenomegaly)
Pericardial knock
Dx and next step?
Constrictive pericarditis
Best step:
- CxR: shows calcifications
- Echo
Tx of Constrictive pericarditis
Diuretics and salt retention. If this doesn’t work, pericardiotomy
Causes of Dilated cardiomyopathy
Viral
Ischemia
Valvular disease
Infectious
Metabolic
Alcoholic (wet beriberi)
Autoinmune
Treatment of Dilated cardiomyopathy
Same as CHF (BB, ACEI, diuretics)
Etiology of Hypertrophic cardiomyopathy (HCM)
Autosomal dominant mutation
Pathofisology of Hypertrophic cardiomyopathy (HCM)
Obstructs the aortic outlet
Differences between Hypertrophic cardiomyopathy (HCM) and Aortic Stenosis
Hypertrophic cardiomyopathy is found in young people
Improves with preload
Hypertrophic cardiomyopathy (HCM) is known for…
Sudden death of athletes
Treatment of Hypertrophic cardiomyopathy (HCM)
Avoid dehydration (AKA no sports), BB/CCB, myectomy, implantable defibrillator, transplant
Causes of Restrictive cardiomyopathy
Sarcoid
Amyloid
Hemochromatosis
Cancer
Fibrosis
Cardiomyopathy of wet beriberi
Dilated cardiomyopathy
Young patient + aortic systolic murmur + dysnea in excertion + syncope + athlete. Next step? Dx?
Echo; Hypertrophic cardiomyopathy (HCM)
Restrictive cardiomyopathy + Pulmonary disease. Dx and next step?
Sarcoidosis.
Cardiac MRI and myocardial Bx
Restrictive cardiomyopathy + Cirrhosis/DM. Dx and next step?
Hemochromatosis.
Ferritin and genetic test
Restrictive cardiomyopathy + peripheral neuropathy. Dx and next step?
Amyloid.
Treatment of Myocarditis
Prevent dehydration
Treat CHF
Anticoagulation
Treat cause
Meds to avoid in Hypertrophic cardiomyopathy (HCM)
Avoid nitrates, ACEI, and diuretics as they increase left ventricular outflow tract and worsen symptoms. Also avoid digoxin and hydralazine
Young patient, angina, SOB, systolic murmur at the base that improves with leg raise and worsens with Valsalva
Hypertrophic cardiomyopathy
Young patient SOB, diastolic murmur on the apex with rumbling with opening snap. Dx, etiology, and next step?
Mitral stenosis, rheumatic disease, ballon valvulopasty
Which murmurs should be treated?
Treat all diastolic murmurs and all greater-than-grade-III systolic murmurs
CHF, chest pain, rumbling diastolic murmur at the base that improves with valsalva. Dx?
Aortic insufficiency
Old patient, atero sclerosis, CHF, syncope, Systolic murmur crescendo-decrescendo murmur at the base (improves with valsava, worsens with leg raise). Dx? Tx?
Dx: Aortic stenosis
Tx: (Sx replacement + CABG) or TAVR*
- Transcatheter aortic valve replacement
Possible tx for aortic Stenosis and their complications
Surgical replacement + CABG
* Complications: Acute kidney injury and fribillation
Transcatheter aortic valve replacement (TAVR)
* Complications: Residual aortic regurgitation and need for pacemaker
MI, cardiogenic shock, acute pulmonary edema, Holosystolic murmur at the apex that worsens with leg raise. Dx and pathogenesis?
Acute mitral insufficiency, rupture papillary muscle or chordae tendinae),
Young woman, with holosystolic murmur at the apex that worsens with valsava improves with leg raise)
Mitral valve prolapse
In addition to common Sx of CHF and SOB, which valvulopathy was
* Hoarness
* Dysphagia
* AFib
* Hemoptysis
Mitral stenosis
Cough –> prodome –> syncope. Dx and next step?
Vasovagal syncope, tilt table (tx with BB is controversial)
Syncope without prodome.
Most likely dx?
Arrhythmia
Indications of statins
o Vascular disease (MI, carotid stenosis, peripheral vascular disease, cerebrovascular disease)
o LDL > 190 mg/dL (10 mmol/L)
o LDL 70 mg/dL (4 mmol/L)-190 mg/dL (10 mmol/L) + age 40-75 + DM
o LDL 70 mg/dL (4 mmol/L)-190 mg/dL (10 mmol/L) + cardiovascular risk factors (HTN, smoking, obesity, family Hx, XY > 45 y-o/XX > 55 y-o
Secondary effects of statins
↑ LFTs (most common), rhabdomyolysis
Secondary effects of Fibrates
myositis and ↑ LFTs (don’t give with statins)
Secondary effects of Ezetimibe:
diarrhea
Secondary effects of Bile acid sequestrants:
diarrhea
Secondary effects of Niacin:
flushing (treat with ASA)
Definition of metabolic syndrome
Central obesity: men waist circumference > 94; women waist circumference > 80
2 of the following:
* TG > 1.7 mmol (150 mg)
* HDL < 1 mmol (40 mg) in XY, 1.3 mmol (50 mg) in XX
* BP > 130/85
* Fasting glucose > 5.6 mmol (100 mg)
Does hypertriglyceridemia increase the risk of cardiovascular disease?
No. However, when severe (10 mmol – 885 mg) associated with pancreatitis
Classic ECG finding in atrial flutter.
“Sawtooth” P waves.
Definition of unstable angina.
Angina is new, is worsening, or occurs at rest.
Antihypertensive for a diabetic patient with proteinuria.
ACEI.
Beck’s triad for cardiac tamponade.
Hypotension, distant heart sounds, and JVD.
Drugs that slow AV node transmission.
β-blockers, digoxin, calcium channel blockers.
Hypercholesterolemia treatment that leads to flushing and pruritus.
Niacin.
Murmur—hypertrophic obstructive cardiomyopathy (HOCM).
Systolic ejection murmur heard along the lateral sternal border
↑ with Valsalva maneuver and standing.
Murmur—aortic insufficiency.
Diastolic, decrescendo, high-pitched, blowing murmur
that is best heard sitting up; ↑ leg rise with ↓ preload (handgrip
maneuver) and valsava.
Murmur—aortic stenosis.
Systolic crescendo/decrescendo murmur that radiates to the neck; ↑ with ↑ leg raise
Murmur—mitral regurgitation.
Holosystolic murmur that obscure S1 and S2 that radiates to the axillae or carotids.
Murmur—mitral stenosis.
Diastolic, opening snap, mid- to late, low-pitched murmur.
Treatment for atrial fibrillation and atrial flutter.
If unstable, cardiovert. If stable or chronic, rate control with
calcium channel blockers or β-blockers.
Treatment for ventricular fibrillation.
Immediate cardioversion.
Autoimmune complication occurring 2–4 weeks post-MI.
Dressler’s syndrome: fever, pericarditis, ↑ ESR.
JVD and holosystolic murmur at the left sternal border, 5th intercostal space.
Treatment?
Treat existing heart failure and replace the tricuspid valve.
Diagnostic test for hypertrophic cardiomyopathy.
Echocardiogram (showing thickened left ventricular wall and outfl ow obstruction).
A fall in systolic BP of > 10 mmHg with inspiration.
Pulsus paradoxus (seen in cardiac tamponade).
Classic ECG findings in pericarditis.
Low-voltage, diffuse ST-segment elevation.
Definition of hypertension.
BP > 140/90 on three separate occasions two weeks apart.
Eight surgically correctable causes of hypertension.
Renal artery stenosis, coarctation of the aorta,
pheochromocytoma, Conn’s syndrome, Cushing’s syndrome, unilateral renal parenchymal disease, hyperthyroidism, hyperparathyroidism.
Diagnostic tests for a pulsatile abdominal mass and bruit.
Abdominal ultrasound and CT.
Indications for surgical repair of abdominal aortic aneurysm.
> 5.5 cm, rapidly enlarging, symptomatic, or ruptured.
Treatment for acute coronary syndrome.
Morphine, O2, sublingual nitroglycerin, ASA, IV β-blockers,
heparin.
What is metabolic syndrome?
Abdominal obesity, high triglycerides, low HDL, hypertension, insulin resistance, prothrombotic or
proinflammatory states.
Appropriate diagnostic test?
■ A 50-year-old man with angina can exercise to 85% of maximum predicted heart rate.
Exercise stress treadmill with ECG.
Appropriate diagnostic test?
■ A 65-year-old woman with left bundle branch block and severe osteoarthritis has unstable angina.
Pharmacologic stress test (e.g., dobutamine echo).
Target LDL in a patient with diabetes.
< 70.
Signs of active ischemia during stress testing.
Angina, ST-segment changes on ECG, or ↓ BP.
ECG findings suggesting MI.
ST-segment elevation (depression means ischemia),
flattened T waves, and Q waves.
Coronary territories in MI.
Anterior wall (LAD/diagonal)
Inferior (PDA)
Posterior (left circumflex/oblique, RCA/marginal)
Septum (LAD/diagonal).
A young patient has angina at rest with ST-segment elevation. Cardiac enzymes are normal.
Dx?
Prinzmetal’s angina
Common symptoms associated with silent Mls.
CHF, shock, and altered mental status.
The diagnostic test for pulmonary embolism.
V/Q scan.
An agent that reverses the effects of heparin.
Protamine.
The coagulation parameter affected by warfarin.
PT.
A young patient with a family history of sudden death
collapses and dies while exercising.
Hypertrophic cardiomyopathy.
Endocarditis prophylaxis regimens.
Oral surgery—amoxicillin for certain situations.
GI or GU procedures— not recommended
The 6 P’s of ischemia due to peripheral vascular disease.
Pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia.
Virchow’s triad.
Stasis, hypercoagulability, endothelial damage.
The most common cause of hypertension in young women.
OCPs.
The most common cause of hypertension in young men.
Excessive EtOH.
Most common non-ichemic cause of chest pain
Gastrointestinal
Menstruating woman
Chest pain
Menstruating women almost never have MI
Risk fx of CAD
- Dm: worse
- Tobacco: most inmediate benefit if corrected
- HTN: most common
- Hyperlipidemia
- Family Hx: 1st degree + premature (male <55; female <65)
- Age (male >45; women >55)
- Renal disease
Woman
Chest pain after stressful event
MI
Ventricular “ballooning” on Echo
Dx and Tx
Takotsubo cardiomyopathy
Tx: beta blockers and ACE inhibitors
Acute myocardial damage most often occurring in postmenopausal women immediately following an overwhelming, emotionally stressful event (Massive catecholamine discharge). This leads to “ballooning” and left ventricular dyskinesis.
Chest pain differential
Best initial test for chest pain
ECG
Best test when uncertain etiology of chest pain
Stress test
Stress test modalities and indications
Ttx for CAD
- ASA
- BB: 1st line tx. Don’t use in severe asthma, prizmental angina, and cocaine.
- ACE-i: specially if low EF. Cough and low K as 2nd effects
- Statin: goal LDL < 70. Liver dysfunction most common adverse effect
Dihydropyridine CCBs (nifedipine) increase mortality (don’t use). Non-Dihydropyridine CCBs may replace BB.
Patient with CAD. High LDL despite statin at maximum dose.
Next step to treat dyslipidemia?
PCSK9 Inhibitors
Evolocumab and alirocumab
ACS are associated to what on auscultation?
S4 gallop
Decrease of 10 mmHg in BP on inspiration
Pulsus paradoxus: Tamponade
Increase in JVD on inspiration
Kussmaul sign: Constrictive pericarditis
Triphasic scratchy sound on auscultation
Friction rub: pericarditis
Continuous machinery murmur
Shunt: patent ductur (PDA)
Point of maximal impulse displaced to axila
LV hyperthrophy
Tx of PVCs in ACS?
Should NOT be treated!
You Dx a STEMI
Best initial step in management?
ASA + other antiplatelet
And call cath lab
Antiplatelet: clopidogrel, prasugrel, ticagrelor
Consultation almost never the right choice
Best antiplatelet if patient undergoing angioplasty and stening
Prasugrel
Contraindications of thrombolytics
- Major bleeding (bowel or CNS)
- Recent Sx (2 weeks)
- Recent nonhemorrhagic stroke (6 momths)
- Recent trauma/head injury
- Severe HTN
- Bleeding disorder
e
Indications of ACS meds
In what ACS is heparine indicated
NSTEMI: as part of initial therapy
STEMI: indicated but after revascularization
Tx differences between ACS presentations
When to use tPA (thrombolytics) in ACS
STEMI
Glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors (antiagregation) are best for
NSTEMI undergoing PCI or stenning
Complication of ACS
Patient with ACS with new murmur and Step-up in O2Sat from RV to LV in ACS
important difference in SatO2 between RV and LV
Septal rupture
Complication of ACS
Patient with ACS, bradycardia and cannon A waves
3rd degree AV block
Complication of ACS
Patient with ACS, bradycardia and no cannon A waves
Sinus bradycardia
Complication of ACS
Patient with ACS with sudden loss of pulse and JVD
Tamponade vs wall rupture
Complication of ACS
Patient with inferior MI, tachycardia, hypotension with nitro
RV MI
Complication of ACS
Patient with ACS, new murmur, rales/congestion on lungs
Valve rupture
Most common cause of CHF.
HTN resulting in a cardiomyopathy or abnormality of the myocardial muscle
SOB
+
Sudden onset, clear lungs
Dx?
Pulmonary embolus
SOB
+
Sudden onset, wheezing, increased expiratory phase
Dx?
Asthma
SOB
+
Slower, fever, sputum, unilateral rales/rhonchi
Dx?
Pneumonia
SOB
+
Decreased breath sounds unilaterally, tracheal deviation
Dx?
Pneumothorax
SOB
+
Circumoral numbness, caffeine use, history of anxiety
Dx?
Panic attack
SOB
+
Pulsus paradoxus, decreased heart sounds, JVD
Dx?
Tamponade
SOB
+
Palpitations, syncope
Dx?
Arrhythmia
SOB
+
Dullness to percussion at bases
Dx?
Pleural effusion
SOB
+
Long smoking history, barrel chest
Dx?
COPD
SOB
+
Burning building or car, wood-burning stove in winter, suicide attempt
Dx?
Carbon monoxide poisoning
Best initial test for CHF in the outpatient context
Transthoracis echo
Patient with systolic CHF in outpatient management with ACE-i but hyperkalemia.
Management?
Patiromer
Magement of hyperkalemia if you want to keep using ACE-i or ARBs in any Dx
Male patient with systolic CHF in management with spironolactone + gynecomastia
Management?
Switch spironolactone to eplerenone
Which systolic CHF medications have proven mortality improvement and which have not
Lower mortality
* ACE-i/ARBs
* BB
* Hydralazine/nitrates (e.g., BiDil) in severe systolic CHF
* Spironolactone
Do NOT lower mortality
* Digoxine
* Furosemide
Medications with proven benefits in dyastolic CHF
Spironolactone
Diruetics
Digoxine and BB have NOT proven benefits
ACE-i and ARBs are uncertain
How do loop diuretics and thiazides change Ca++ and K+
Ca++
* Loops loose Calcium (hypoCalcemia)
* Thiazides take it in (hyperCalcemia)
K+: both produce hypoKalemia
Both produce hyperuricemia as well
Side effects of thiazides
HyperGLUC (hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia)
HypoKalemia
HypoNatremia
S3 vs S4 gallop
An S3 gallop signifies rapid ventricular filling in the setting of fluid overload and is associated with dilated cardiomyopathy.
An S4 gallop signifies a stiff, noncompliant ventricle and ↑ “atrial kick,” and may be associated with hypertrophic cardiomyopathy.
Which medications have proven mortality benefit in chronic treatment of angina?
Only ASA and BB
Complications of ACS
Death
Arrythmia
Rupture
Tamponade
Heart failure
Valvular disease
Aneurysm
Dressler’s syndrome
Emboli
Reinfraction
DARTH VADER
Tx WPW
Acute: Procainamide Or Amiodarone
Chronic: ablation
Possible causes of PEA
5H and 5 T
Hypovolemia
Hypoxia
Hydrogen
Hyper or hypo K+
Hypothermia
Tamponade
Trauma
Toxic
Thrombosis
Tension pneumothorax
Med to reverse NOACs
Rivaroxaban, apizaban, edoxaban
Andexanet
Med to revert dabigatran
idarucizumab
Meds to reverse Warfarin
Prothrombin complex concentrate (PCC)
If arrythmia not clear and ECG not clear either
Next step?
eletro physiology studies
Tx of primary HTN in pregnant women
Metildopa
BB
Hydralazine
BP in upper limb > BP in lower limb
Dx?
Coarctation of aorta
Episodic HTN
Flushing
Dx?
Pheochromocytoma
Patient with osteoporosis and HTN
Best initial tx for HTN?
Thiazides
Patient with hyperthyroidism and HTN
Best initial tx for HTN?
BB
Echo reporting: Systolic anterior motion of mitral valve
Dx?
Hyperthrophic obstructive cardiomyopathy (HOCM)
