Cardiology Flashcards
Low Dose ASA for CVD and CRC
adults 50-59 years with ASCVD risk of 10% and no increased risk of bleeding
HFrEF - mechanism & cause
impaired contractility
CAD/ischemia
HFpEF - mechanism & cause
stiffed LV w/ abnormal relaxation
HTN, aging, obesity, DM, CAD
HFrEF - therapy for all (symptomatic or asymptomatic)
ACE/ARB + BB
HFrEF- ARNI (valsartan/sacubrintril)
for chronic HFrEF who tolerate ACE/ARB
HFrEF - Aldosterone Antagonists
- symptomatic HF (III-IV)
- after acute MI
Ivabradine
sinus node monitor
for HFrEF III-IV with EF <35%, sinus rhythm and HR >70
max dose of BB
HFrEF - Isosorbide Dintrate-Hydralazine
symptomatic HF intolerant to ACEI/ARB
AA with III-IV HF
Implantable Cardioverter-Defebrillators in HF
EF <35%, II or III
only in IV if transplant candidate or LVAD
Cardiac Resynchronization Thearpy in HF
EF <35%, II-IV
sinus rhythm with either LBBB or QRS >150
Phlebotomy in CHD Patients
Hct >65% + symptoms
Anterior Infarct EKG
V3-V4
Septal V1-V2
Lateral Infarct EKG
I, aVL, V5-V6
Inferior Infarct EKG
II, III, aVF; need right sided EKG!
Posterior Infarct EKG
St depressions V1-V4
ST elevations in inferior or lateral leads
Initial Therapy for all ACS
Aspirin, Antiplatelet, nitrates, heparin
Initial Therapy within first 24 hours for ACS
BB
Statin
ACEI, ARB, aldosterone antagonist if indicated
Clopidogrel use in ACS
preferred agent if thrombolytic therapy is performed
Ticagrelor use in ACS
preferred therapy for STEMI, NSTEMI
AE: dyspnea
Prasugrel use in ACS
preferred in PCI performed
not for those older than 75 or history of TIA or stroke
Treatment for Left Ventricular Apical Thrombus
anticoagulation with warfarin for 3 months
Treatment of right ventricular infarction
bolus, positive inotropes (dopamine, dobutamine)
Free Wall Rupture Symptoms
sudden CP, syncope –> PEA
Rx sugery/pericardiocentesis
Acquired VSD after MI
septal wall rupture, usually within 3-5d
holosystolic murmur at LLSB
Acute Severe MR after MI
papillary muscle rupture w/in a few days
Treatment of all Stable Angina
Low Dose ASA, statin, BB
Alternate Treatments for Refractory Stable Angina
CCB, nitrates, Ranolazine
Stable Angina defined as
reproducible CP or pressure for at least TWO MONTHS
precipitated by exertion or emotional stress
RCRI Risk Factors
DM treated with insulin HF CAD CVD CKD
When to start pre-operative beta blocker
3 RCRI risk factors or if needed for other medical condition (CAD)
4 METs =
1 flight of stairs
heavy house work (scrubbing floors)
Aortic Stenosis Murmur
late peaking systolic murmur
RSB, 2ICS
Murmur associated with Coarctation of the Aorta
harsh systolic murmur; often loudest over back/scapula
can have murmur from collateral intercostal vessels
Coarctation of Aorta Presentation in Children
2-3 weeks w/ shock
weak pulses
poor feeding
Coarctation of Aorta Presentation in Adults
HTN, asymptomatic to HF, exertional leg fatigue
Figure 3 sign on x-ray
Rib notching on x-ray
Figure 3 Sign in Coarctation of Aorta
dilation above and below area of coarctation
Types of ASD
secundum > primum > sinus venous
Murmur of ASD
systolic murmur in pulm area (like pulm stenosis)
fixed S2 Split (delay of pulm valve to close)
can have diastolic murmur at LLSB (flow across tricuspid)
Holt-Oram Syndrome
ASD
Upper limb defects
Axis - Normal
positive in I, AVF
Axis - LAD
positive in I, negative in AVF
Axis - RAD
Negative in I
positive in AVF
Axis - Extreme RAD
negative in I, AVF
Sinus Rhythm means . . .
p waves before QRS
upright p waves in I, II; inverted in avR
Aortic Regurgitation Murmur
LV dilation and large stroke volume = bounding pulses diastolic decrescendo murmur - RSB (root), LSB (valve) can have early peaking SEM
Bicupsid AV Murmur
incidental SEM
VSD Types
perimembranous
juxta-arterial
muscular
inlet
VSD murmur
due to pulmonary resistance
pan systolic murmur loudest at LLSB
can have diastolic rumble at apex (MV)
Murmurs and inspiration
increased right sided pressures so will increase the sound of right sided murmurs
Standing –> Squating & Murmurs
Increase LV Preload –>
Increase LS stenosis, decreased LS regurg & HoCM
Leg Raise & Murmurs
Increase LV Preload –>
Increase LS stenosis, decreased LS regurg & HoCM
Squat to Stand & Murmurs
Decrease LV Preload –>
Decrease LF stenosis, increase LS regurg & HOCM
Valsalva & Murmurs
Decrease LV Preload –>
Decrease LF stenosis, increase LS regurg & HOCM
Hand Grip & Murmurs
increase LV afterload
decrease LS stenosis
increase L sided regurg
decrease HOCM
HOCM Physiology
LVH
Diastolic Dysfxn
Systolic Anterior Motion of Mitral Valve
LV outflow obstruction
HOCM Rx
BB
Surgery
Evaluation of Aortic Stenosis
ECHO +/- cardiac cath if unclear
Aortic Stenosis Mean Gradient
mild <20 mmHg
severe >40 mmHg
AAA, size for surgical repair
5.5cm
expansion >0.5cm/yr
AAA, size for more frequent monitoring
4-5cm; 6-12m monitoring w/ US
Infective Endocarditis, evaluating for large abscesses
TEE
Anticoagulation during pregnancy
warfarin is less then 5mg daily
LMWH if >5 mg warfarin daily
Aortic Regurg Surgery for Asymptomatic Folks
asymptomatic and LV EVD >50 mmHg or EF <50%
Aortic Root/Ascending Aorta Indication for Surgery
> 45mm
Cardiac Amyloid Clues
preserved systolic, severe diastolic and pulm HTN/regurg
pseudo-infarct, Q waves V1-3 w/o wall abnormalities
Acute Limb Ischemia next steps
anticoagulation + diagnostic angiography
Mitral Regurg Murmur
systolic murmur at apex +/- some locks
Mitral Regurg Pathophys problems
volume overload w/ LV dilation + LA HTN –> right side/pul HTN
Mitral Regurg Preferred Surger
repair > replacement > clip (if not candidate)
Mitral Regurg Indications for surgery
symp + LV >30
asymp + LV 30-60 +/- LV ESD >40mmHg
other cardiac surgery planned
new onset a fib or pulm HTN
Screening for Thoracic Aneurysms
Marfan, Ehlers-Danlos, Loeys-Dietz, family history, BAV
Thoracic Aneurysm Medical treatment
BP <130/80
BB preferred
Treatment for Thoracic Aneurysm
> 5.5 cm or 0.5cm/year repair
CTD: consider 4.5-5.0
Surgery for Thoracic Aneurysm, open vs endovascular
open for ascending, arch, root
endovascular for descending
VSD closure
Qp:Qs ratio >2, evidence of LV volume overload, or IE
Tetraology of Fallot - Main Problems!
subaortic VSD
infundibular or valvular pulmonary stenosis
aortic override
right ventrical hypertrophy
TOF associated genetics
DiGeorge/22q11.2
TOF repair
VSD patch closure and relief of PS/right ventricular outflow tract w/ transannular patch placement
Consequences of TOF repair
pulmonary valve regurg
ABI - values for PAD
< 0.9
ABI - when values are >1.4
usually due to noncompressible calcified arteries
perform toe-brachial index
<0.7 is diagnostic for PAD
ABI - when to do exercise ABI
high pretest probability and normal value between .91-1.40
Medical Therapy for PAD
ASA
smoking cessation, supervised exercise
cilostazol
Radiation and Pericardium
acute pericarditis is earliest
constrictive pericarditis
Most Common Chemotherapy agents with cardiotoxicity
Anthracyclines, doxorubicin
MABs: trastuzumab
Benign murmurs; decrease when . . .
standing!!
Differences between constrictive pericarditis and restrictive cardiomyopathy
restrictive: elevated BNP >100; evidence of pulm HTN, rise and fall of left and right systolic pressures with respiration
Cardiac Angiosarcomas
usually associated with pericardial effusions
highly vascular
Cardiac Angiosarcomas
usually associated with pericardial effusions
highly vascular
TIMI score - things to consider
age >65 3 cardiac RF (HTN, DM, HLD, tobacco, family hx) Known CAD ASA in last 7 days severe angina (2 epi in 24 hours) >0.5mm ST Changes \+ biomarkers
CHA2 DS2 Vasc
CHF, HTN age, >65, >75 x 2 DM Stroke/TIA x 2 Vasc Disease Female
Benefits of Ordering TEE versus TTE
high pretest probability for abscess/IE complication
aortic abnormalities
left atrial thrombus
Premature CAD
less than 55 in males
less than 65 in females
Ventricular Interdependence
constrictive pericarditis
Bridging Medical Therapy for Acute MR
nitroprusside
balloon pump
Endocarditis Prophylaxis
hx of endocarditis
congenital heart disease
bioprosethetic valve
cardiac transplant w/ regurg
Anthracycline AE
irreversible dilated Cm
ICD indication
ventricular arrhythmia >30 sec or cardiac arrest
Contraindications to Vasodilators/Adenosine
produce hyperemia and flow disparity
CI in bronsospastic airway disease, sick sinus syndrome, hypotension, high degree AV block
must hold caffeine 12-24 hours before
Acute AR Dissection Target BP
<120 within 1 hour
VTE prophylaxis for mechanical heart valve
warfarin + low dose ASA
Anticoagulation during pregnancy
2nd and 3rd trimester - warfarin
Diagnostic test for CAD when LBBB is present
vasodilator stress test
Calcium Artery Scoring
intermediate risk, tells arthersclerosis nd not obstruction
1-99 mild, 100-399 mod, >400 severe
FFA (Cardiac Testing)
add to CTA and angiography to provide functional information and specificity for obstructive CAD
ratio of blood flow distal to stenosis to blood flow proximal
When to withhold BB from stress testing
exercise stress testing, at least 24 hours before
Contraindications to exercise stress testing
baseline EEG is abnormal
- LBBB, LVH, paced, >1mm ST depression
Diagnosis of Ischemia on Exercise EKG Stress Testing
horizontal or downslopping ST segment at least 1mm
Diagnosis of Significant Obstructive Disease of EKG Stress Testing
hypotension or lack of BP augmentation
Dobuatmine Stress Testing
increases myocardical oxygen demand
CI in baseline HTN, unstable angina, severe tachyarrhythmias, HCM, severe AS, large aortic aneurysms
Carney Complex
multiple atrial myxomas at a young age
Giant Cell Myocarditis
myocarditis with high AV block in young people
trasutuzmab cardic toxicity
reversible LV dysfxn
Severe AS mean gradient and valve area
> 40
<1
Severe AS, concern for low flow, low gradient test
dobutamine ECHO
Chronic Aortic Regurg Surgery when
symptoms
LV <50
LV dilation
Chronic Severe Mitral Regurg surgery
Symptoms, EF>30, LVESD >40
HCM Surgery
symptoms or syncope despite medical therapy
outflow gradient >50
