Cardiology Flashcards
pathology of myocardial infarction
occlusion of a coronary vessel
patient presentation of myocardial infarction
chest pain that is worse with exertion, better with rest, relieved with nitrates in a hypertensive, diabetic, dyslipidemic smoker, who is old
diagnosis of myocardial infarction
ST segment changes = STEMI
biomarker elevation = NSTEMI
Stress test = CAD
Coronary angiogram = best test
treatment of myocardial infarction
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)
risk factors and goals for myocardial infarction
HTN = <140/90 Diabetes = A1c < 7.0 Smoking = cessation dyslipidemia = LDL <100, better <70; HDL > 40, better > 60 age = women >55, men >45
story of MI
left-sided/substernal
worse with exertion
better with rest
physical exam of MI
nonpositional
nonpleuritic
nontender (not reproducible)
Pain, relief, trops, ST changes in stable angina
Pain = exercise
relief = rest + nitrates
trops = negative
ST changes = none
Pain, relief, trops, ST changes in unstable angina
pain = @ rest
relief = none
trops = negative
ST changes = none
Pain, relief, trops, ST changes in NSTEMI
pain = @ rest
relief = none
trops = elevated
ST changes = none
Pain, relief, trops, ST changes in STEMI
pain = @ rest
relief = none
trops = increased
ST changes = elevated
ACUTE treatment options in MI
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
door to balloon time in MI
90 mins
chronic treatment options in MI
ß blocker = <140/90, HR <70 ACE-i = BP <140/90 Aspirin = antiplatelet Clopidogrel = antiplatelet Statins = LDL < 100 (prefer <70)
imaging in MI
EKG = test of choice, no baseline abnormality Echo = EKG abnormality, no CABG Nuclear = CABG, Baseline Wall defects, LBBB
stress test
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
complications of MI
RV failure = right-sided EKG, NO NITRATES
aneurysm = diagnosed by echo
arrhythmia = vtach/vfib - ventricular ectopy from dying cells; Brady/blocks - AV nodal dysfunction
left sided heart failure
pulmonary edema, shortness of breath, crackles, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea
S3
right sided heart failure
JVD, peripheral edema, abdominal pain
systolic heart failure
floppy (ischemic/chronic), leaky (valves), or dead (ischemic)
depressed ejection fraction
poor forward flow
diastolic heart failure
stiff ventricle, unable to fill
pericardium (tamponade, constrictive pericarditis)
restrictive or hypertrophic cardiomyopathy
NYHA classifications of heart failure
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
diagnostic choices for heart failure
cxr ekg bnp 2d echo nuclear angiogram, LV gram angiogram, coronaries
cxr in heart failure
large heart, generally useless
ekg in heart failure
old ischemia, generally useless
bnp in heart failure
if elevated, likely heart failure, but cannot discern left/right, diastolic/systolic
2d echo in heart failure
test of choice
gives much information including EF and diastolic failure, valve lesions
nuclear imaging in heart failure
gives EF and reversible ischemia
angiogram, LV gram in heart failure
gold standard, invasive, generally not needed
angiogram, coronaries
determine CAD state: ischemic cardiomyopathy vs. not
treatments everyone in heart failure gets
ß-blocker, ACE-i
salt restriction <2g NaCl
fluid restrict <2L H2O
treatments in ischemic heart failure
add aspirin, add statin
treatment if EF <35%
must be >/= NYHA III
AICD
treatment in NYHA stage I
ß blocker + ACE-i
treatment in NYHA stage II
BB + ACE-i
loop diuretics
treatment in NYHA stage III
BB + ACE
loop diuretics
hydralazine/isosorbide dinitrate, spironolactone
treatment in NYHA stage IV
BB + ACE
loop diuretics
hydralazine/isosorbide dinitrate, spironolactone
pressors
path of congestive heart failure
systolic vs diastolic
right vs left
ischemic vs non-ischemic
patient in congestive heart failure
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, peripheral edema, crackles, jvd
diagnosis in CHF
1st: BNP
then: 2D echo = trans thoracic echo
Best: LV ventriculogram
treatment in CHF
systolic: NYHA stage
Diastolic: control BB
grade I murmur
S1, S2 > murmur (murmur is softer)
grade II murmur
S1, S2 = murmur (murmur is equal)
grade III murmur
S1, S2 < murmur (murmur is louder)
grade IV murmur
palpable thrill
grade V murmur
1/2 stethoscope off chest, still audible
grade VI murmur
no stethoscope is needed
when to investigate a murmur
any diastolic murmur
any systolic murmur >/= 3/6 (more than II)
how to investigate murmur
2D echo to evaluate all murmurs
path of mitral stenosis
rheumatic heart disease, stenosis of valve
decreased forward flow during DIASTOLE
atrial stretch
patient with mitral stenosis
Afib with CHF symptoms
opening snap
diastolic decrescendo murmur
diagnosis of mitral stenosis
echo
treatment of mitral stenosis
balloon valvotomy
valve replacement
path of aortic stenosis
calcification, sclerosis of outflow from ventricle
patient with aortic stenosis
old men with atherosclerosis
shortness of breath, syncope, chest pain
crescendo-decrescendo murmur
2nd ICS, R sternal border
diagnosis of aortic stenosis
echo
treatment of aortic stenosis
valve replacement
balloon doesn’t work
follow up for aortic stenosis
CABG assessment if replacing valves
what to think if young person with aortic stenosis
bicuspid aortic valve
path of MVP
congenital defect
patient with MVP
women, especially pregnant
sounds like mitral regard, opening snap
diagnosis of MVP
echo
treatment of MVP
valve replacement
path of mitral regurgitation
acute = infarction, infection, ruptured papillary muscle, chordae tendinae chronic = prolapse, ischemia
patient with mitral regurg
acute = fulminant CHF, hypoxemia, hypotension Chronic = AFib, exertional dyspnea, HOLOSYSTOLIC murmur, radiating to the axilla
diagnosis of mitral regurg
echo
treatment of mitral regurg
valve replacement
path of aortic regurg/insufficiency
ischemia, infection, dissection
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
diagnosis of aortic regurg
echo
treatment of aortic regurg
valve replacement
intra-aortic balloon pump
path of hypertrophic cardiomyopathy
sarcomere defect
pt with HOCM
sudden cardiac death
dyspnea, syncope with exertion
young patient
diagnosis of HCOM
echo
treatment of HOCM
avoid exercise/dehydration
ß-blockade
myotomy
path of dilated cardiomyopathy
decrease contractility
virus, EtOH, ischemia, chemo
pt with dilated cardiomyopathy
systolic CHF: orthopnea, PND, DOE, crackles, dyspnea, JVD
dx of dilated cardiomyopathy
echo = dilated
tx of dilated cardiomyopathy
CHF: BB, ACE-i, diuretics
avoid/stop etoh
avoid/stop chemo
transplant
path of HOCM
genetics, sarcomeres
pt with HOCM
murmur = aortic stenosis
young athletes - sudden cardiac death, syncope, dyspnea on exertion
what increases most murmurs?
leg raise/squat
what decreases most murmurs?
valsalva
what increase HOCM and MVP murmurs?
valsalva
what decreases HOCM and MVP murmurs?
leg raise/squat
why is the mech of murmur different in HOCM and MVP?
increased blood = fill heart more = less obstruction from hypertrophy or valve
dx of HOCM
echo = asymmetric hypertrophy
tx of HOCM
avoid dehydration avoid exercise BB = CCB (rate control) etoh ablation, myectomy AICD if increased risk of death transplant
path of concentric hypertrophic cardiomyopathy
HTN
pt with concentric hypertrophic cardiomyopathy
diastolic CHF
dx of concentric hypertrophic cardiomyopathy
echo = concentric hypertrophy
tx of concentric hypertrophic cardiomyopathy
DIA CHF - avoid dehydration - BB = CCB (Rate) - control BP transplant
path of restrictive cardiomyopathy
amyloid, sarcoid, hemachromatosis, cancer, and fibrosis
pt with restrictive cardiomyopathy
DIA CHF
amyloid -> neuropathy
sarcoid -> pulmonary disease
hema -> cirrhosis, bronze diabetes, CHF
dx of restrictive cardiomyopathy
echo = restrictive
amyloid -> fat pad biopsy
sarcoid -> cardiac MRI -> biopsy
hema -> ferritin -> genetics
tx of restrictive cardiomyopathy
DIA CHF - BB = CHF gentle diuresis transplant underlying disease
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
path of pericarditis
viral, uremia
pt with pericarditis
chest pain = pleuritic and positional
dx of pericarditis
1st: EKG shows PR depressions, diffuse ST elevations
best: MRI
tx of pericarditis
NSAIDs + colchicine
NSAIDs - c/I CKD, thrombocytopenia, PUD
colchicine - c/I diarrhea
no longer use steroids
f/u of pericarditis
increase recurrence after steroids
hemodialysis for uremia
path of pericardial effusion
pericarditis
pt with pericardial effusion
pericarditis
dx of pericardial effusion
echo = effusion
tx of pericardial effusion
pericardial window
path of pericardial tamponade
RV cannot fill
pt with pericardial tamponade
JVD + hypotension + decrease heart sounds (Beck’s triad)
clear lungs
pluses paradoxus > 10mmHg
dx of pericardial tamponade
echo
tx of pericardial tamponade
pericardiocentesis
f/u of pericardial tamponade
IVF in real life
path of constrictive pericarditis
pericarditis
pt with constrictive pericarditis
diastolic CHF
pericardial knock
dx of constrictive pericarditis
echo
tx of constrictive pericarditis
pericardiectomy
hypertension medications
CCB ACE ARB thiazide loop BB art-dilator veno-dilator spironolactone clonidine
side effect of CCB
peripheral edema
indication for CCB
JNC8, angina
side effect of ACE
increase K, cough, angioedema
indication for ACE
JNC8
side effect of ARB
increase K, no cough, no angioedema
indication for ARB
ACE-i intolerance
side effect of thiazide
decrease K, urinary symptoms, inc gout
indications of thiazide
GFR > 60
side effect of loop
decrease K, urinary symptoms
indication of loop
GFR < 60
BB side effect
decrease HR, hypertriglyceridemia, hyperglycemia
bb indications
CAD, CHF
art-dilator side effects
reflex tachycardia
art-dilator indications
CHF
veno-dilator side effects
c/I sildenafil = hypotension
veno-dilator indications
CHF
spironolactone side effects
increase K, gynecomastia
indications of spironolactone
CHF
clonidine side effect
rebound HTN
clonidine indications
never
normal BP
<120/80
stage I hypertension
140/90
stage II hypertension
160/100
diagnosis of hypertension
screen everyone
2 readings, 2 weeks, 2 visits
best: ambulatory monitoring
treatment for pre-hypertension
lifestyle modifications
treatment for stage I HTN
1 med
tx for stage II HTN
2 med
tx for HTN urgency
orals
HTN urgency
180/110
hypertensive emergency treatment
IV
hypertensive emergency
end organ damage
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)
path of cholesterol
need enough to make cells
too much makes plaques
plaques make atherosclerosis
pt with cholesterol
HDL is good
LDL is bad
Non-HDL cholesterol is what matters
dx of cholesterol
lipid panel
tx of cholesterol
diet and exercise
adherence
f/u cholesterol
statins, others
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)
high intensity statin
atorva 40, 80
rosuva 20, 40
moderate intensity statin
atorva 10, 20 rosuva 5, 10 simva 20, 40 prava 40, 80 lova 40
low intensity statin
simva 5, 10
prava 10, 20
lova 20
check lipids
q1y
check A1c
DM = q3mo
check CK
muscle soreness/myalgias
check LFTs
hepatitis
good effect of statin
decrease LDL, TG
bad effect of statin
myositis, increase LFT
good effect fibrates
decrease Tchol, increase HDL
bad effect of fibrates
myositis, increase LFT
good effect of ezetimibe
decrease LDL
bad effect of ezetimibe
diarrhea
good effect of bile acid resins
decrease LDL
bad effect of bile acid resins
diarrhea
good effect of niacins
increase HDL, decrease LDL
bad effect of niacins
flushing, pre-tx with aspirin to avoid
tx vfib
amiodarone
shock
tx vtach
amiodarone
shock
tx torsades
magnesium
shock
tx SVT
adenosine
shock
tx 1deg block
atropine
pace
tx 2deg block type 1
atropine
pace
tx 2deg block type 2
pace
tx 3deg block
pace
codes - no pulse
CPR
codes - shock delivered
CPR
codes - anything
CPR
all codes
epi
VT/VF codes
epi, amio
PEA, asystole
epi
path of afib with RVR
underlying stressor
ischemia, infection, structural heart
pt with afib with RVR
palpitations, asymptomatic
dx of afib with RVR
EKG
tx of afib with RVR
no heart failure: BB or CCB
heart failure: dig, amio
shock: shock
path of afib
PIRATES =
ischemia, infarction, structural heart
pt with afib
palpitations, asymptomatic
dx of afib
ekg
tx of afib
rate control = rhythm control
rhythm: cardiovert after TTE, TEE, one month of anticoagulation
rate: BB, CCB
rate: anticoagulant with CHADS2
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
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
pt with vasovagal syncope
prodrome
one of the pathologies
situational
dx of vasovagal syncope
tilt-table
tx of vasovagal syncope
ß blockers
path of orthostatic syncope
volume down = dehydration, diarrhea, diuresis, hemorrhage
autonomic nervous system = age, diabetes, Shy-Drager (Parkinson’s)
pt with orthostatic syncope
orthostats
dx of orthostatic syncope
orthostatics
tx of orthostatic syncope
rehydrate/transfuse
steroids if that fails
cautious standing in elderly
path of mechanical cardiac syncope
valvular or structural lesion = HCOM, saddle embolus, aortic stenosis, left atrial myxoma
pt with mechanical cardiac syncope
exertional syncope
dx of mechanical cardiac syncope
echo
tx of mechanical cardiac syncope
treat underlying mechanical disease
path of arrhythmia syncope
arrhythmia, too fast or too slow
pt with arrhythmia syncope
sudden onset, no prodrome
dx with arrhythmia syncope
EKG (usually negative)
Holter (24hr EKG)
event recorder (1mo)
tx of arrhythmia syncope
AICD or arrhythmia meds
path of neurogenic syncope
poor perfusion to the brain - posterior circulation
pt with neurogenic syncope
sudden onset, no prodrome
focal neurologic deficit
dx of neurogenic syncope
CTA
tx of neurogenic syncope
medically manage
stenting
CCB
amlodipine, felodipine
ACE
lisinopril, quinapril, benazepril
ARB
losartan, valsartan
thiazide
HCTZ, chlorthalidone
loop
furosemide
ß blocker
metoprolol, carvedilol, nebivolol
art dilator
hydralazine
veno-dilator
isosorbide dinitrite, mononitrate
Aldo antagonists
spironolactone
eplerenone
secondary causes of HTN
hyperaldosteronism hyperthyroid hypercalcemia aortic coarctation renovascular pheochromocytoma cushing's OSA
history of hyperaldosteronism (HTN)
refractory HTN or HTN and HypoK
history of hyperthyroid (HTN)
weight loss, sweating, heat intolerance, paliptaitons
work up for hyperaldosteronism
Aldo:renin >20
CT pelvis
workup of hyperthyroid
TSH, free T4
history of aortic coarctation
children = warm arms, cold legs, claudication adults = rib notching, BP differential in legs and arms
workup of aortic coarctation
cxr
angiogram, CTA
history of renovascular HTN
DM or glomerulonephritis
young women = FMD
old guy = RAS
Renal bruit, hypoK
workup of renovascular HTN
CrCl
BMP
Aldo:renin <10
U/s renal artery
history of hypercalcemia
polyuria, AMS, moans, groans, bones, kidney stones
workup of hypercalcemia
free Ca
history of pheochromocytoma
pallor, palpitations, pain, perspiration, pressure
workup of pheochromocytomaa
24hr urinary metanephrines
CT
history of Cushing’s
diabetes, HTN, central obesity, moon facies
workup of Cushings’
low-dose dexa
ACTH level
high-dose dexa
history of OSA
obesity, daytime somnolence, improved with CPAP
workup of OSA
sleep study
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
SVT
aberrent reentry that bypasses SA node
SVT rhythm
narrow (atrial), fast (tachycardia), and distinguished from sinus tachycardia by resting heart rate >150 + loss of p waves
tx svt
adenosine
ventricular tachycardia
wide complex and regular tachycardia
“tombstones”
no p waves, just QRS
tx v tach
Amiodarone or lidocaine
atrial fibrillation
narrow complex tachycardia, irregularly irregular, absent p waves
unstable new a fib treatment
shock
stable new a fib treatment
rate control with CCB or BB
consider cardiovert if <48hrs
when to cardiovert a fib
<48 hrs OR >48hrs + negative TTE->TEE
when to tx a fib with warfarin
> 48hrs, positive TTE-> TEE
sinus bradycardia
slow sinus rhythm
tx sinus brady
atropine
if really bad, pacing
1st deg AV block
regularly prolonged PR interval
tx 1st deg AV block
atropine
pacing
nothing
2nd deg AV block type 1
constantly prolonging PR interval until QRS is dropped
tx 2nd deg AV block type 1
atropine
pace
nothing
2nd deg AV block type 2
normal PR interval but randomly drops QRS
tx 2nd deg AV block type 2
pace
3rd deg AV block
total AV node dissociation, p’s march out, QRS march out
tx 3rd deg AV block
avoid atropine
pace
idioventricular rhythm
rhythm without atrial activity
looks like 3rd deg block without p waves
tx idioventricular rhythm
avoid atropine
just pace
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
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
ACLS: 2 - are there symptoms with arrhythmia?
no symptoms -> IVF, O2, monitor
yes symptoms -> is pt stable?
ACLS: 3 - stable vs. unstable?
unstable: chest pain, SOB, AMS, or systolic <90 - use electricity
ACLS: 4 choose intervention
unstable: electricity
stable: medications
ACLS tx stable: fast + narrow
atrial
adenosine
ACLS tx stable: fast + wide
ventricular
amiodarone
ACLS tx stable: slow
atropine
ACLS tx stable: a fib/flutter
rate control = BB, CCB
tachycardia rhythms - atrial narrow
sinus tachycardia SVT multifocal atrial tachycardia Afib Aflutter
tachycardia rhythms - ventricular wide
Vtach
Vfib
Torsades
Brady rhythms - varying PR intervals
sinus Brady
1st deg AV block
2nd deg AV block
3rd deg AV block
Brady rhythms
junctional
idioventricular