Cardiology Flashcards
1
Q
pathology of myocardial infarction
A
occlusion of a coronary vessel
2
Q
patient presentation of myocardial infarction
A
chest pain that is worse with exertion, better with rest, relieved with nitrates in a hypertensive, diabetic, dyslipidemic smoker, who is old
3
Q
diagnosis of myocardial infarction
A
ST segment changes = STEMI
biomarker elevation = NSTEMI
Stress test = CAD
Coronary angiogram = best test
4
Q
treatment of myocardial infarction
A
MONA = morphine, oxygen, nitrates, aspirin
BASH = ß blocker, ACE-i, statin, heparin
Coronary angiography with stent (single vessel disease)
CABG (multi-vessel disease)
tPA if no transport available (>60mins)
5
Q
risk factors and goals for myocardial infarction
A
HTN = <140/90 Diabetes = A1c < 7.0 Smoking = cessation dyslipidemia = LDL <100, better <70; HDL > 40, better > 60 age = women >55, men >45
6
Q
story of MI
A
left-sided/substernal
worse with exertion
better with rest
7
Q
physical exam of MI
A
nonpositional
nonpleuritic
nontender (not reproducible)
8
Q
Pain, relief, trops, ST changes in stable angina
A
Pain = exercise
relief = rest + nitrates
trops = negative
ST changes = none
9
Q
Pain, relief, trops, ST changes in unstable angina
A
pain = @ rest
relief = none
trops = negative
ST changes = none
10
Q
Pain, relief, trops, ST changes in NSTEMI
A
pain = @ rest
relief = none
trops = elevated
ST changes = none
11
Q
Pain, relief, trops, ST changes in STEMI
A
pain = @ rest
relief = none
trops = increased
ST changes = elevated
12
Q
ACUTE treatment options in MI
A
ASA = first drug to give
Nitrates = second
Angioplasty = no clopidogrel needed, only in single-vessel disease
Bare-metal stent = clopidogrel x1mo, only in single-vessel disease
Drug-eluting stent = clopidogrel x1yr, only in single-vessel disease
CABG = left mainstem equivalent or multi-vessel disease
tPA = no PCI is available within 60mins transport time
Door-to-ballon = 90mins
13
Q
door to balloon time in MI
A
90 mins
14
Q
chronic treatment options in MI
A
ß blocker = <140/90, HR <70 ACE-i = BP <140/90 Aspirin = antiplatelet Clopidogrel = antiplatelet Statins = LDL < 100 (prefer <70)
15
Q
imaging in MI
A
EKG = test of choice, no baseline abnormality Echo = EKG abnormality, no CABG Nuclear = CABG, Baseline Wall defects, LBBB
16
Q
stress test
A
exercise = test of choice, no contraindication to exercise with feet
pharm = any reason why they can’t get on a treadmill of any kind
- dobutamine and adenosine
17
Q
complications of MI
A
RV failure = right-sided EKG, NO NITRATES
aneurysm = diagnosed by echo
arrhythmia = vtach/vfib - ventricular ectopy from dying cells; Brady/blocks - AV nodal dysfunction
18
Q
left sided heart failure
A
pulmonary edema, shortness of breath, crackles, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea
S3
19
Q
right sided heart failure
A
JVD, peripheral edema, abdominal pain
20
Q
systolic heart failure
A
floppy (ischemic/chronic), leaky (valves), or dead (ischemic)
depressed ejection fraction
poor forward flow
21
Q
diastolic heart failure
A
stiff ventricle, unable to fill
pericardium (tamponade, constrictive pericarditis)
restrictive or hypertrophic cardiomyopathy
22
Q
NYHA classifications of heart failure
A
I = no symptoms, unlimited exertional capacity II = slight limitation: comfortable with exertion and rest, but without unlimited capacity (ok ADLs) III = moderate limitation: comfortable at rest only (no ADLs) IV = severe limitations, patient is dyspneic at rest
23
Q
diagnostic choices for heart failure
A
cxr ekg bnp 2d echo nuclear angiogram, LV gram angiogram, coronaries
24
Q
cxr in heart failure
A
large heart, generally useless
25
ekg in heart failure
old ischemia, generally useless
26
bnp in heart failure
if elevated, likely heart failure, but cannot discern left/right, diastolic/systolic
27
2d echo in heart failure
test of choice
| gives much information including EF and diastolic failure, valve lesions
28
nuclear imaging in heart failure
gives EF and reversible ischemia
29
angiogram, LV gram in heart failure
gold standard, invasive, generally not needed
30
angiogram, coronaries
determine CAD state: ischemic cardiomyopathy vs. not
31
treatments everyone in heart failure gets
ß-blocker, ACE-i
salt restriction <2g NaCl
fluid restrict <2L H2O
32
treatments in ischemic heart failure
add aspirin, add statin
33
treatment if EF <35%
must be >/= NYHA III
| AICD
34
treatment in NYHA stage I
ß blocker + ACE-i
35
treatment in NYHA stage II
BB + ACE-i
| loop diuretics
36
treatment in NYHA stage III
BB + ACE
loop diuretics
hydralazine/isosorbide dinitrate, spironolactone
37
treatment in NYHA stage IV
BB + ACE
loop diuretics
hydralazine/isosorbide dinitrate, spironolactone
pressors
38
path of congestive heart failure
systolic vs diastolic
right vs left
ischemic vs non-ischemic
39
patient in congestive heart failure
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, peripheral edema, crackles, jvd
40
diagnosis in CHF
1st: BNP
then: 2D echo = trans thoracic echo
Best: LV ventriculogram
41
treatment in CHF
systolic: NYHA stage
Diastolic: control BB
42
grade I murmur
S1, S2 > murmur (murmur is softer)
43
grade II murmur
S1, S2 = murmur (murmur is equal)
44
grade III murmur
S1, S2 < murmur (murmur is louder)
45
grade IV murmur
palpable thrill
46
grade V murmur
1/2 stethoscope off chest, still audible
47
grade VI murmur
no stethoscope is needed
48
when to investigate a murmur
any diastolic murmur
| any systolic murmur >/= 3/6 (more than II)
49
how to investigate murmur
2D echo to evaluate all murmurs
50
path of mitral stenosis
rheumatic heart disease, stenosis of valve
decreased forward flow during DIASTOLE
atrial stretch
51
patient with mitral stenosis
Afib with CHF symptoms
opening snap
diastolic decrescendo murmur
52
diagnosis of mitral stenosis
echo
53
treatment of mitral stenosis
balloon valvotomy
| valve replacement
54
path of aortic stenosis
calcification, sclerosis of outflow from ventricle
55
patient with aortic stenosis
old men with atherosclerosis
shortness of breath, syncope, chest pain
crescendo-decrescendo murmur
2nd ICS, R sternal border
56
diagnosis of aortic stenosis
echo
57
treatment of aortic stenosis
valve replacement
| balloon doesn't work
58
follow up for aortic stenosis
CABG assessment if replacing valves
59
what to think if young person with aortic stenosis
bicuspid aortic valve
60
path of MVP
congenital defect
61
patient with MVP
women, especially pregnant
| sounds like mitral regard, opening snap
62
diagnosis of MVP
echo
63
treatment of MVP
valve replacement
64
path of mitral regurgitation
```
acute = infarction, infection, ruptured papillary muscle, chordae tendinae
chronic = prolapse, ischemia
```
65
patient with mitral regurg
```
acute = fulminant CHF, hypoxemia, hypotension
Chronic = AFib, exertional dyspnea, HOLOSYSTOLIC murmur, radiating to the axilla
```
66
diagnosis of mitral regurg
echo
67
treatment of mitral regurg
valve replacement
68
path of aortic regurg/insufficiency
ischemia, infection, dissection
69
patient with aortic regurg
```
usually sick, hypotension, CHF
decrescendo murmur at aortic valve
wide pulse pressure
water-hammer pulse (bounding)
quincke's pulse (nail beds)
head bobbing
```
70
diagnosis of aortic regurg
echo
71
treatment of aortic regurg
valve replacement
| intra-aortic balloon pump
72
path of hypertrophic cardiomyopathy
sarcomere defect
73
pt with HOCM
sudden cardiac death
dyspnea, syncope with exertion
young patient
74
diagnosis of HCOM
echo
75
treatment of HOCM
avoid exercise/dehydration
ß-blockade
myotomy
76
path of dilated cardiomyopathy
decrease contractility
| virus, EtOH, ischemia, chemo
77
pt with dilated cardiomyopathy
systolic CHF: orthopnea, PND, DOE, crackles, dyspnea, JVD
78
dx of dilated cardiomyopathy
echo = dilated
79
tx of dilated cardiomyopathy
CHF: BB, ACE-i, diuretics
avoid/stop etoh
avoid/stop chemo
transplant
80
path of HOCM
genetics, sarcomeres
81
pt with HOCM
murmur = aortic stenosis
| young athletes - sudden cardiac death, syncope, dyspnea on exertion
82
what increases most murmurs?
leg raise/squat
83
what decreases most murmurs?
valsalva
84
what increase HOCM and MVP murmurs?
valsalva
85
what decreases HOCM and MVP murmurs?
leg raise/squat
86
why is the mech of murmur different in HOCM and MVP?
increased blood = fill heart more = less obstruction from hypertrophy or valve
87
dx of HOCM
echo = asymmetric hypertrophy
88
tx of HOCM
```
avoid dehydration
avoid exercise
BB = CCB (rate control)
etoh ablation, myectomy
AICD if increased risk of death
transplant
```
89
path of concentric hypertrophic cardiomyopathy
HTN
90
pt with concentric hypertrophic cardiomyopathy
diastolic CHF
91
dx of concentric hypertrophic cardiomyopathy
echo = concentric hypertrophy
92
tx of concentric hypertrophic cardiomyopathy
```
DIA CHF
- avoid dehydration
- BB = CCB (Rate)
- control BP
transplant
```
93
path of restrictive cardiomyopathy
amyloid, sarcoid, hemachromatosis, cancer, and fibrosis
94
pt with restrictive cardiomyopathy
DIA CHF
amyloid -> neuropathy
sarcoid -> pulmonary disease
hema -> cirrhosis, bronze diabetes, CHF
95
dx of restrictive cardiomyopathy
echo = restrictive
amyloid -> fat pad biopsy
sarcoid -> cardiac MRI -> biopsy
hema -> ferritin -> genetics
96
tx of restrictive cardiomyopathy
```
DIA CHF
- BB = CHF
gentle diuresis
transplant
underlying disease
```
97
etiologies of pericardial disease
infection - viral, bacterial, fungal, TB
autoimmune - rheumatoid arthritis, lupus, Dressler's, uremia
trauma - penetrating, blunt, aortic dissection
cancer - breast, lung, esophageal, lymphoma
98
path of pericarditis
viral, uremia
99
pt with pericarditis
chest pain = pleuritic and positional
100
dx of pericarditis
1st: EKG shows PR depressions, diffuse ST elevations
best: MRI
101
tx of pericarditis
NSAIDs + colchicine
NSAIDs - c/I CKD, thrombocytopenia, PUD
colchicine - c/I diarrhea
*no longer use steroids*
102
f/u of pericarditis
increase recurrence after steroids
| hemodialysis for uremia
103
path of pericardial effusion
pericarditis
104
pt with pericardial effusion
pericarditis
105
dx of pericardial effusion
echo = effusion
106
tx of pericardial effusion
pericardial window
107
path of pericardial tamponade
RV cannot fill
108
pt with pericardial tamponade
JVD + hypotension + decrease heart sounds (Beck's triad)
clear lungs
pluses paradoxus > 10mmHg
109
dx of pericardial tamponade
echo
110
tx of pericardial tamponade
pericardiocentesis
111
f/u of pericardial tamponade
IVF in real life
112
path of constrictive pericarditis
pericarditis
113
pt with constrictive pericarditis
diastolic CHF
| pericardial knock
114
dx of constrictive pericarditis
echo
115
tx of constrictive pericarditis
pericardiectomy
116
hypertension medications
```
CCB
ACE
ARB
thiazide
loop
BB
art-dilator
veno-dilator
spironolactone
clonidine
```
117
side effect of CCB
peripheral edema
118
indication for CCB
JNC8, angina
119
side effect of ACE
increase K, cough, angioedema
120
indication for ACE
JNC8
121
side effect of ARB
increase K, no cough, no angioedema
122
indication for ARB
ACE-i intolerance
123
side effect of thiazide
decrease K, urinary symptoms, inc gout
124
indications of thiazide
GFR > 60
125
side effect of loop
decrease K, urinary symptoms
126
indication of loop
GFR < 60
127
BB side effect
decrease HR, hypertriglyceridemia, hyperglycemia
128
bb indications
CAD, CHF
129
art-dilator side effects
reflex tachycardia
130
art-dilator indications
CHF
131
veno-dilator side effects
c/I sildenafil = hypotension
132
veno-dilator indications
CHF
133
spironolactone side effects
increase K, gynecomastia
134
indications of spironolactone
CHF
135
clonidine side effect
rebound HTN
136
clonidine indications
never
137
normal BP
<120/80
138
stage I hypertension
140/90
139
stage II hypertension
160/100
140
diagnosis of hypertension
screen everyone
2 readings, 2 weeks, 2 visits
best: ambulatory monitoring
141
treatment for pre-hypertension
lifestyle modifications
142
treatment for stage I HTN
1 med
143
tx for stage II HTN
2 med
144
tx for HTN urgency
orals
145
HTN urgency
180/110
146
hypertensive emergency treatment
IV
147
hypertensive emergency
end organ damage
148
JNC-8 tx guidelines
```
>60, no disease = 150/90
everyone else = 140/90
CCB, thiazide, ACE/ARB are ok
old and black = no ACE/ARB
CKD = ACE/ARB
no ßblockers (4th line)
```
149
path of cholesterol
need enough to make cells
too much makes plaques
plaques make atherosclerosis
150
pt with cholesterol
HDL is good
LDL is bad
Non-HDL cholesterol is what matters
151
dx of cholesterol
lipid panel
152
tx of cholesterol
diet and exercise
| adherence
153
f/u cholesterol
statins, others
154
who gets a statin?
vascular disease (CVA, PVD, CAD)
LDL >/= 190
LDL 70-189 + age 40-75 + diabetes
LDL 70-189 + age 40-75 + calculated (risk factors)
155
high intensity statin
atorva 40, 80
| rosuva 20, 40
156
moderate intensity statin
```
atorva 10, 20
rosuva 5, 10
simva 20, 40
prava 40, 80
lova 40
```
157
low intensity statin
simva 5, 10
prava 10, 20
lova 20
158
check lipids
q1y
159
check A1c
DM = q3mo
160
check CK
muscle soreness/myalgias
161
check LFTs
hepatitis
162
good effect of statin
decrease LDL, TG
163
bad effect of statin
myositis, increase LFT
164
good effect fibrates
decrease Tchol, increase HDL
165
bad effect of fibrates
myositis, increase LFT
166
good effect of ezetimibe
decrease LDL
167
bad effect of ezetimibe
diarrhea
168
good effect of bile acid resins
decrease LDL
169
bad effect of bile acid resins
diarrhea
170
good effect of niacins
increase HDL, decrease LDL
171
bad effect of niacins
flushing, pre-tx with aspirin to avoid
172
tx vfib
amiodarone
| shock
173
tx vtach
amiodarone
| shock
174
tx torsades
magnesium
| shock
175
tx SVT
adenosine
| shock
176
tx 1deg block
atropine
| pace
177
tx 2deg block type 1
atropine
| pace
178
tx 2deg block type 2
pace
179
tx 3deg block
pace
180
codes - no pulse
CPR
181
codes - shock delivered
CPR
182
codes - anything
CPR
183
all codes
epi
184
VT/VF codes
epi, amio
185
PEA, asystole
epi
186
path of afib with RVR
underlying stressor
| ischemia, infection, structural heart
187
pt with afib with RVR
palpitations, asymptomatic
188
dx of afib with RVR
EKG
189
tx of afib with RVR
no heart failure: BB or CCB
heart failure: dig, amio
shock: shock
190
path of afib
PIRATES =
| ischemia, infarction, structural heart
191
pt with afib
palpitations, asymptomatic
192
dx of afib
ekg
193
tx of afib
rate control = rhythm control
rhythm: cardiovert after TTE, TEE, one month of anticoagulation
rate: BB, CCB
rate: anticoagulant with CHADS2
194
what is CHADS2
```
C - CHF
H - HTN
A - age >75
D - Diabetes
S - stroke
S - stroke
score 0 = aspirin
score 1 = rivaroxaban, apixaban
score 2+ = warfarin or -axabans
```
195
path of vasovagal syncope
visceral stimulation: micturition, coughing, sneezing
carotid stimulation: turning head, tight tie, boxer blow
psychogenic: sight of blood
cardioinhibitory surge = hypotension, bradycardia
196
pt with vasovagal syncope
prodrome
one of the pathologies
situational
197
dx of vasovagal syncope
tilt-table
198
tx of vasovagal syncope
ß blockers
199
path of orthostatic syncope
volume down = dehydration, diarrhea, diuresis, hemorrhage
| autonomic nervous system = age, diabetes, Shy-Drager (Parkinson's)
200
pt with orthostatic syncope
orthostats
201
dx of orthostatic syncope
orthostatics
202
tx of orthostatic syncope
rehydrate/transfuse
steroids if that fails
cautious standing in elderly
203
path of mechanical cardiac syncope
valvular or structural lesion = HCOM, saddle embolus, aortic stenosis, left atrial myxoma
204
pt with mechanical cardiac syncope
exertional syncope
205
dx of mechanical cardiac syncope
echo
206
tx of mechanical cardiac syncope
treat underlying mechanical disease
207
path of arrhythmia syncope
arrhythmia, too fast or too slow
208
pt with arrhythmia syncope
sudden onset, no prodrome
209
dx with arrhythmia syncope
EKG (usually negative)
Holter (24hr EKG)
event recorder (1mo)
210
tx of arrhythmia syncope
AICD or arrhythmia meds
211
path of neurogenic syncope
poor perfusion to the brain - posterior circulation
212
pt with neurogenic syncope
sudden onset, no prodrome
| focal neurologic deficit
213
dx of neurogenic syncope
CTA
214
tx of neurogenic syncope
medically manage
| stenting
215
CCB
amlodipine, felodipine
216
ACE
lisinopril, quinapril, benazepril
217
ARB
losartan, valsartan
218
thiazide
HCTZ, chlorthalidone
219
loop
furosemide
220
ß blocker
metoprolol, carvedilol, nebivolol
221
art dilator
hydralazine
222
veno-dilator
isosorbide dinitrite, mononitrate
223
Aldo antagonists
spironolactone
| eplerenone
224
secondary causes of HTN
```
hyperaldosteronism
hyperthyroid
hypercalcemia
aortic coarctation
renovascular
pheochromocytoma
cushing's
OSA
```
225
history of hyperaldosteronism (HTN)
refractory HTN or HTN and HypoK
226
history of hyperthyroid (HTN)
weight loss, sweating, heat intolerance, paliptaitons
227
work up for hyperaldosteronism
Aldo:renin >20
| CT pelvis
228
workup of hyperthyroid
TSH, free T4
229
history of aortic coarctation
```
children = warm arms, cold legs, claudication
adults = rib notching, BP differential in legs and arms
```
230
workup of aortic coarctation
cxr
| angiogram, CTA
231
history of renovascular HTN
DM or glomerulonephritis
young women = FMD
old guy = RAS
Renal bruit, hypoK
232
workup of renovascular HTN
CrCl
BMP
Aldo:renin <10
U/s renal artery
233
history of hypercalcemia
polyuria, AMS, moans, groans, bones, kidney stones
234
workup of hypercalcemia
free Ca
235
history of pheochromocytoma
pallor, palpitations, pain, perspiration, pressure
236
workup of pheochromocytomaa
24hr urinary metanephrines
| CT
237
history of Cushing's
diabetes, HTN, central obesity, moon facies
238
workup of Cushings'
low-dose dexa
ACTH level
high-dose dexa
239
history of OSA
obesity, daytime somnolence, improved with CPAP
240
workup of OSA
sleep study
241
PIRATES
mnemonic for new onset atrial fibrillation
Pulmonary disease - COPD, PE
Ischemia - ACS
Rheumatic heart disease - mitral stenosis
Anemia - high output failure, tachycardia/atrial myxoma
Thyrotoxicosis - tachycardia/Tox - cocaine
Ethanol/endocarditis
Sepsis/sick sinus syndrome
242
SVT
aberrent reentry that bypasses SA node
243
SVT rhythm
narrow (atrial), fast (tachycardia), and distinguished from sinus tachycardia by resting heart rate >150 + loss of p waves
244
tx svt
adenosine
245
ventricular tachycardia
wide complex and regular tachycardia
"tombstones"
no p waves, just QRS
246
tx v tach
Amiodarone or lidocaine
247
atrial fibrillation
narrow complex tachycardia, irregularly irregular, absent p waves
248
unstable new a fib treatment
shock
249
stable new a fib treatment
rate control with CCB or BB
| consider cardiovert if <48hrs
250
when to cardiovert a fib
<48 hrs OR >48hrs + negative TTE->TEE
251
when to tx a fib with warfarin
>48hrs, positive TTE-> TEE
252
sinus bradycardia
slow sinus rhythm
253
tx sinus brady
atropine
| if really bad, pacing
254
1st deg AV block
regularly prolonged PR interval
255
tx 1st deg AV block
atropine
pacing
nothing
256
2nd deg AV block type 1
constantly prolonging PR interval until QRS is dropped
257
tx 2nd deg AV block type 1
atropine
pace
nothing
258
2nd deg AV block type 2
normal PR interval but randomly drops QRS
259
tx 2nd deg AV block type 2
pace
260
3rd deg AV block
total AV node dissociation, p's march out, QRS march out
261
tx 3rd deg AV block
avoid atropine
| pace
262
idioventricular rhythm
rhythm without atrial activity
| looks like 3rd deg block without p waves
263
tx idioventricular rhythm
avoid atropine
| just pace
264
Cardiac arrest
VT/VF -> 2mins CPR + epinephrine -> shock -> 2mins CPR + Amiodarone -> 2mins CPR + epinephrine -> 2mins CPR + Amiodarone
PEA/asystole -> 2mins CPR + epi -> no shock -> 2mins CPR -> no shock -> 2mins CPR + epi -> 2mins CPR
265
ACLS: 1 - identify rhythm
1 - determine rate (tachycardia > 100, Brady <60)
2 - determine QRS width (wide >0.12msec & ventricular; narrow <0.12 & atrial)
3 - regular or irregular rhythm
266
ACLS: 2 - are there symptoms with arrhythmia?
no symptoms -> IVF, O2, monitor
| yes symptoms -> is pt stable?
267
ACLS: 3 - stable vs. unstable?
unstable: chest pain, SOB, AMS, or systolic <90 - use electricity
268
ACLS: 4 choose intervention
unstable: electricity
stable: medications
269
ACLS tx stable: fast + narrow
atrial
| adenosine
270
ACLS tx stable: fast + wide
ventricular
| amiodarone
271
ACLS tx stable: slow
atropine
272
ACLS tx stable: a fib/flutter
rate control = BB, CCB
273
tachycardia rhythms - atrial narrow
```
sinus tachycardia
SVT
multifocal atrial tachycardia
Afib
Aflutter
```
274
tachycardia rhythms - ventricular wide
Vtach
Vfib
Torsades
275
Brady rhythms - varying PR intervals
sinus Brady
1st deg AV block
2nd deg AV block
3rd deg AV block
276
Brady rhythms
junctional
| idioventricular
