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Emergency Medicine > Cardiology > Flashcards

Cardiology Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Endocarditis

eti, sxs

A

MC Native Valve infx - Mitral - Strep viridans, S aureus, Enterococcus

IVDU - S aureus in tricuspid; Prosthetic - S. aureus or fungal if w/in 2 mos of implantation

Sxs:

  • Fever,
  • non spec sx - dyspnea, CP
  • Murmur
  • Janeway lesions - painless macules on palms and soles
  • Roth spots - retinal hemorrhages w/ pale centers
  • Petechiae
  • Splinter hemorrhages
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2
Q

Endocarditis

dx, tx

A

Modified Duke Criteria

Major

  • bacteremia 2+ blood culture
  • Echo w/ evidence of vegetation
  • Newly dx valvular regurgitation

Minor

  • RFs - IVDU, indwelling cath, weird valvular morphology
  • Fever > 38C or 100.4F
  • Vasc or embolic phenomena - Janeway lesions
  • Immunologic phenom - Osler nodes (ouch), Roth spots, acute GMN
  • Positive blood cultures not meeting major criteria

Tx

  • Acute/Native Valve
    • Nafcillin + Gentamicin; Vanco if MRSA+
  • Subacute (HACEK organisms)
    • Pencillin or Ampicillin + Gentamicin
    • Vanco if MRSA+
  • Prosthetic valve
    • Vanco+Gentamicin + Rifampin (For S aureus)
  • Fungal
    • Ampho B for 6-8 wks
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3
Q

Stable Angina

A

Angina brought on by physical activity, emotional upset - relieved w/ stress in a few mins (<30mins)

Levine’s sign

Dx

  • EKG w/ temporary ST depression, T wave depression or inv
  • Stress test - exercise or pharmological with adenosine or dipyridamole
  • Coronary angio - gold std***
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4
Q

Printzmetal Angina

A

vasospasm - smooth m contractions

Eti - cocaine, smoking, > 50yo, F

non-exertional CP

cyclical - usu in the morning

Dx:

  • EKG - ST or T waves elevations, Inverted U waves
  • Normal trop and CKMB

Tx - CCBs

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5
Q

Unstable Angina

A

Previously stable & predictable => more freq and intense

new onset or severe or worsening angina, occurs at rest

Dx -

  • EKG - ST depr or T w inv
  • Normal CKMB and trop

Tx

  • progression to MI if untreated
  • Nitroglycerin and morphine
  • Stress test - if cath or revasc necessary
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6
Q

NSTEMI

A

prolonged crushing CP; more severe and wider radiation; R->L arm or upper back

Dx

  • EKG w/ ST depr or T wave inv
  • Elevated Trop or CKMB or BNP
  • Cardiac Cath to determine tx
    • PCI or CABG
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7
Q

STEMI

A

Leads

  • V1, V2, V3, V4- Anterior → LAD
  • V1, V2 - Septal
  • I, aVL, V5, V6 - Lateral → Circumflex
  • II, III, aVF - inferior → RCA

A NEW LBBB = STEMI

Dx

  • ST elevation >/= 1 mm in at least 2 anatomically contiguous leads + reciprocal changes in opposite leads
  • Ele Trop > 0.08
    • Appears 3-12 hrs
    • Peaks 24-48 h
    • Lasts 5-14 days
  • Ele CK-MB
    • Appears 3-12 hrs
    • Peaks 24 h
    • Lasts 2-3 days
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8
Q

NSTEMI/STEMI

Treatment

A

Reperfusion is KEY - done w/in 12 hrs of onset

Immediate Tx in ED

  1. Morphine
  2. O2
  3. ASA 325mg
  4. Nitroglycerine subling x3 q5m
  5. BB
  6. Statin
  7. ACEI/ARBS

PCI

  • best within 3 hrs
  • > thrombolytics

Thrombolytics/Fibrinolytics

  • use if PCI is not available
  • Alteplase (tPa) - activates plasminogen to destroy clots
  • Streptokinase - less effective than tPa, less chance of ICH

Maintenance

  • Antiplatelet therapy
    • Aspirin - inhibits plt activation and aggregation
    • P2Y12 inhibitor - Plavix/clopidegrol, Ticagrelor, Prasugrel
  • Anticoag
    • Unfrc Heparin - binds to antithrombin
    • LMWH - better for DM
  • Anti-ischemic therapy
    • BB - decr symp drive
    • Nitrates - venodilation
    • CCB - verapamil/diltiazem - decr contractility
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9
Q

Pericarditis

A

idiopathic or viral - restrictive pressure on heart

Sxs:

  • Dyspnea, fatigue, weakness
  • Sharp, pleuritic substernal CP => relieved by sitting upright or leaning forward
  • Friction rub
  • edema

Dx

  • ele WBC
  • Diffuse ST seg elevations - EKG

Tx

  • NSAIDs or Aspirin x 7-14d
  • Colchicine 2nd line
  • CS if sxs > 48 or refractory
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10
Q

Pericardial Effusion

A

2/2 to pericarditis, uremia, cardiac truam

Sxs:

  • painful or painless, depending on rate of effusion
  • cough
  • dyspnea
  • pressure

Dx

  • EKG - electrical alternans, non-spec T wave changes, low QRS voltage
  • Echo - fluid surrounding heart

Tx

  • Observe is small
  • Pericardiocentesis if + tamponade or large effusion
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11
Q

Cardiac Tamponade

A

fluid compromises refilling - collapsed R ventricle (weakest wall) and impairs CO

Sxs:

  • Pulsus paradoxus - > 10 mmHg decrease in systolic when pt inspires
  • Tachycardia, Tachypnea
  • Narrow pulse pressure (180/130)
  • Beck’s Triad***
    • ​JVD
    • Muffled heart sounds
    • Hypotension

Tx - pericardiocentesis immediately

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12
Q

Peripheral Artery/Vascular Disease

A

MCC atherosclerosis

Sxs:

  • Intermittent claudication on lower leg pain, relieved by rest
  • Develops to pain at rest
  • weak femoral or distal (popliteal/TP/DP) pulses
  • Aortic, iliac, or femoral bruit present
  • Skin changes
    • shiny
    • atrophic
    • loss of hair
  • be wary of acute arterial occlusion - 6Ps

Dx

  • Doppler US - eval
  • ABI - BP in upper and lower extremities
    • <0.9 = severe disease
    • normal is >1.2
  • Angiography - gold std
    • stenotic sites

Tx

  • smoking cessation
  • control HTN, DM2, HLD
  • Aspirin/ plavix
  • stenting if stenosis > 70%
  • Cilostazol - relieve w/ walking
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13
Q

Dilated Cardiomyopathy

A

Systolic dysfunction => ventricular dilation => decreased contractial function => reduced CO

Eti:

  • MC in 20-60yo, M, idiopathic 50%
  • viral myocarditis - Enteroviruses (Coxsackie B), Chagaz dz
  • Toxic - etoh abse, cocaine, doxorubicin, radiation

Sxs:

  • systolic HF - fatigue, DOE
  • mitral or tricuspid regurg
  • lateral displaced PMI
  • S3 if

Dx:

  • CXR - enlarged heart, pulm edema, pleural effusion
  • Echo - LV dilation, decr EF, regional or global LV hypokinesis

Tx:

  • HF Tx - ACEI, diuretics, BBS, Digoxin, NA restrictionn
  • ICD if EF < 30-35%

DDx

  • Takotsubo CMO - broken heart syndrome, apical L ventricular ballooning d/t catecholamine surge
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14
Q

Hypertrophic Cardiomyopathy

A

Hereditary - Autosomal Dom, early MI death, young athletes

Hypertrophied Ventricular septum = Impaired ventricular relaxation/filling

Sxs:

  • Dyspnea, Angina, Syncope - esp during exertion
  • Sudden cardiac death - due to V fib
  • S4 if outflow obstruction present
  • Harsh cres-decres murmur at LLSB
    • incr murmur intensity with decreased venous return (Valsalva or standing)

Dx:

  • Echo - asymmetrc wall thickeys > 15mm, small LV chamber size
  • EKG - LVH, atrial enlargement
  • CXR - cardiomegaly

Tx:

  • Counseling - avoid dehydration and extreme exertion/exercise
  • BB - first line, CCB
  • Avoid Digoxin (incr contractility), Nitrates and diuretics (decr’s LV volume)
  • Surgical - myomectomy - definitive if refrc to medical tx
  • ICD For high risk
    *
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15
Q

Restrictive Cardiomyopathy

A

Impaired diastolic relaxation - stiff ventricles decreases filling

Eti - infiltrative diseases - Amyloidosis MCC, Sarcoidosis, hemachromatosis, scleroderma, chemo, XRT

Sxs:

  • RS HF more common
  • Kussmaul’s sign - JVP incr with inspiration, Hepatomegaly, perip edema

Dx:

  • Echo - usual normal systolic contraction
  • Speckled appearance - infiltrative disorder

Tx:

  • Na restriction, caution diuretics
  • treat underlying disorders
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16
Q

Atrial Fibrillation

Conduction Disorders

A

Irregularly Irregular rhythm - SVT

MCC - mitral valve stenosis, hyperthyroidism

Sxs:

  • SOB, Chest Pain, Dizziness, Fatigue
  • Irregular pulse

Dx:

  • EKG - Irregular irreg rhythm
  • Atrial rate >140bpm
  • No discernable P waves
  • variable and irreg QRS

Tx:

  • Rate control - BB, CCB, or digoxin (for CHF or hypotension)
  • anticoag - warfarin or DOACs if CHADsVASc >/= 2
    • CHF
    • HTN
    • > 75yo
    • Stroke, TIA, Thrombus
    • Vasc dz
    • Female
  • Unstable AF or new onset AF < 2 d - cardiovert
  • > 2 days get TEE To r/o clot
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17
Q

Atrial Flutter

Conduction Disorders

A

Atrial focus of ~300 bpm

Sxs:

  • SOB, dizziness, fatigue

Dx:

  • EKG - Saw tooth pattern, regular rhythm
  • Atrial rate 240-320bpm
  • Ventricular 150bpm

Tx:

  • Rate control BB, CCB, Digoxin*
  • Anticoag if CHAD Vasc >/=2
    • Warfarin or DOAC
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18
Q

First Degree Atrioventricular Block

Conduction Disorders

A

constant prolonged PR Intvl = > 200 msec or 0.2

no tx necessary, monitor

19
Q

Second Degree Atrioventricular Block

Type I

Conduction Disorders

A

Mobitz 1 - Wenckebach

progressively lengthening PR interval until P wave drops, PR then resets

Tx:

  • none if asymp
  • Atropine, epinephrine, +/- pacemaker
20
Q

Second Degree Atrioventricular Block

Type II

Conduction Disorders

A

PR interval constant until P wave drops randomly

Tx:

  • Atropine
  • Temporary pacing
  • Permanent pacemaker definitive
  • progression to 3rd degree high
21
Q

Third Degree Atrioventricular Block

Conduction Disorder

A

No relationship btwn P and QRS - atrial and ventricles are firing separately. All P waves not followed by QRS = Decr CO

Sxs:

  • Syncope, Dizziness, acute HF, hypotension, cannon A wave

Tx:

  • Permanent Pacemaker
22
Q

Left Bundle Branch Block

Conduction Disorders

A

L ventricle will depolarize from impulses from R ventricle - partially or completely outside conduction system = Widened QRS

  • Completely LBBB > 0.12 seconds
  • Incomplete LBBB < 0.12 secs but can develop into complete

Signifies Ischemia and structural heart disease

23
Q

Right Bundle Branch Block

Conduction Disorders

A

Conduction comes from L ventricle so widened QRS

RBBB in asymptomatic - fine

new RBBB + CP = occlusion in L anterior descending artery

new RBBB + dyspnea = Pulm embolism

24
Q

Atrioventricular Nodal Reentry Tachycardia

Paroxysmal Supraventricular Tachycardia

A

SVT with abrupt onset and offset

Any tachyarrhythmias arising from above Bundle of His

Reentry circuit in or near AV node - electrical impulse travel in circular pattern => heart beats fast and regular

Sxs:

  • Palps, SOB, Angina, Syncope, Lightheadedness

Dx

  • EKG rate at 150-250 bpm
  • P wave buried in QRS or after
  • Holter monitor to catch eps

Tx:

  • Cardiovert if hemodynamically unstable
  • Vagal maneuvers
  • Adenosine**
25
Q

Wolf Parkinson White

Paroxysmal Supraventricular Tachycardia

A

Presence of abn accessory pathway (Bundle of Kent fibers) btwn atria and ventricles

Sxs:

  • Palps, dyspnea, dizziness, rarely cardiac death

Dx:

  • EKG - shorted PR intvl, widened QRS, delta waves

Tx:

  • observed if asymp
  • Acute tx - Procainamide**
  • Radio freq ablation is curative
26
Q

Premature Ventricular Contractions

Conduction Disorders

A

Ectopic beat from ventricular foci - wide QRS complex >0.12s

not a/w P wave

Sxs - palpitations

Tx underlying cause, BBs and other anti-arrhythmics

27
Q

Premature Atrial Contractions

Conduction Disorders

A

ectopic focus but still impulse goes through AV and bundle of His so normal QRS complex

P wave morphology depends on where ectopic beat is - close to SA node = normal looking P wave, otherwise, it is wider

If impulse is close to AV node, atria depolarize opposite direction = retrograde P wave

Next beat has longer interval

28
Q

Sick Sinus Syndrome

Conduction Disorders

A

Dysfunction of Sinus node’s automaticity and impulse generation

EKG:

  • sinus rhythm with resting HR of 60bpm
  • Sinus pause < 3s
  • Sinus arrest > 3 s
  • tachy-brady alterations

MC in elderly

Worse with digitalis, CCB, BB, antiarrhythmic

Tx - permanent pacemaker

29
Q

Sinus Arrhythmias

Conduction Disorders

A

Irregular patterns in rate of NSR

  1. Respiratory or phasic
    • normal - decreases w/ age
    • Inspiration - increase sinus rate (inhibits vagal tone)
    • Expiration - rate declines
  2. Nonrespiratory or nonphasic
    • not related to respiratory cycle
    • d/t normal, diseased heart or digitalis intoxication
  3. Nonrespiratory, ventriculophasic sinus arrhythmias
    • 3d AV block
    • intermittent differences in PP intvls
30
Q

Torsades de Pointes

Conduction Disorders

A

Sudden cardiac arrest

a/w palps, dizziness, syncope

EKG - polymorphic V Tach

either from HypoK or HypoMg

rate btwn 150-250

Either cease spontaneously or degenerate into VFib

Tx- IV Magnesium

Cardiovert if unstable

31
Q

Ventricular Tachycardia

Conduction Disorders

A

a/w CAD, MI, Structural Heart Dz

Three or more consecutive Ventricular Premature Beats

Regular rhythm - Wide and regular

Tx:

  • Cardioversion if unstable
    • Sustained VT
    • Stable → IV amiodarone
    • Unstable w/ pulse → sync cardioversion
    • VT no pulse → Defib
    • Evential ICD placement
  • Non-sustained VT
    • No heart diz or asymp - no tx
    • Heart dz, recent MI - electrophysiology study
32
Q

Ventricular Fibrillation

Conduction Disorders

A

Uncoordinated quivering of ventricle w/ no useful contractions

No P waves, QRS Complexes, or T waves,

Rate 150-500 bpm

Tx:

  • Severe hypotension or LOC = Sync Cardioversion
  • Pulseless V Tach = Defib and CPR
    • 1mg IV bolus epi, q 3-5 mins
    • Defib 30-50sec
    • Refract V Fib - IV Amiodarone
  • Implantable Defib
33
Q

Aortic Stenosis

A

Usu d/t atherosclerotic dz, stiffened AV; congenital bicuspid

Sxs:

  • Dizziness, syncope w/ exertion - not enough blood going to body
  • angina, SOB
  • delayed carotid upstroke

Dx:

  • RUSB 2nd ICS
  • Harsh cres-decrs murmur (louder with squatting)
  • Radiates to Carotids

Tx:

  • Balloon valvuloplasty temporary
  • Total AV Replacement
34
Q

Aortic Regurgitation

A

Congenital bicuspid valve, Marfan’s syndrome (large diameter)

Sxs:

  • Syncope, SOB, dyspnea, CHF, pulm edema
  • widen pulse pressure (180/50), Corrigan/water hammer pulse
  • RUSB 2nd ICS
  • Murmur is louder with increase venous return (squatting)
  • blowing, decresc DIASTOLIC murmur

Dx:

  • Echocardiogram - TEE is better

Tx:

  • TAVR
35
Q

Mitral Stenosis

A

MCC Rheumatic fever (aka GABHS); stiffened mitral valves

Sxs:

  • decrease CO, CHF, Afib common
  • 4th ICS, midclavicular
  • low pitched, DIASTOLIC murmur
  • opening snap

Dx:

  • Echocardiogram

Tx:

  • MVR
  • diuretics
36
Q

Mitral Regurgitation

A

Widened mitral valv = Mitral valve prolapse, ischemic HD

backward flow into LA

Sxs:

  • Signs of pulm congestion - pulm effusion, edema
  • dyspnea, SOB, PND, orthopnea
  • 4th ICS, midclavicular
  • holosystolic murmur, blowing, r-> axilla****

Dx:

  • TTE echocardiogram

Tx

  • MV replacement
  • Diuretics
  • antihypertensive
37
Q

Aortic Aneursym/Dissection

A

Tear through all three layers of artery (intima, adventia, media) w/ blood pooling

RF - atherosclerotic, HTN, HLD, smoking*

Sxs:

  • tearing chest pain; r->back
  • hypotensive, tachycardic, tachypnea
  • Cool extremities
  • diaphoretic
  • back/flank pain when unruptured

Dx:

  • different BP in R and L UE
  • CXR - first line - enlarged silhouette
  • CT*** - gold
  • Trop/BNP r/o MI
  • EKG

Tx:

  • Thoracic Aorta
    • Type A - Ascending Aorta => Immediate Surgery
    • Type B - Descending/Abdominal => HTNsive mgmt to prevent progression
      • <3cm = observe
      • 3-5.5 = CT q 6 mos surveillance
      • >5.5 = Surgery - stent to reinforce aorta
  • Long term management
    • BB - control HR/HTN, DM
    • at least 6 mos anticoag with Warfarin or DOAC
38
Q

Arterial Occlusion or Thrombosis

A

Recent injury, clot in med/small artery vessel afib

MC in anterior calf or forearm

Sxs: 6Ps

  • Pain
  • Pallor
  • Pulselessless
  • Poikilothermia - loss of heat
  • Paresthesias
  • Pressure?

Dx:

  • Doppler US for blood flow

Tx:

  • Surgical Emergency - angioplasty, stent or embolectomy
  • Anticoag - Heparine or LMWH
39
Q

Phlebitis

A

Inflammation of vein, usu d/t injury aka need stick

Sxs:

  • pain, erythema at site
  • vein feels hardened

Dx:

  • Venous duplex US - noncompressible vein

Tx:

  • NSAIDs
  • elevation
  • compression stockings
40
Q

Hypertensive Urgency and Emergencies

A

Urgency

SBP >180/120 w/ no evidence of end organ damage

No need to emergently lower BP

Goal = lower BP by 25% over 24 hrs = outpatient

Emergency

>220/130

Accelerated HTN - BP w/ target organ damage

Malignant HTN - elevated BP a/w papilledema and other signs of EOD

Sxs:

  • CP, dyspnea, HA, blurred vision

Tx

  • ICU
  • Nitroprusside
  • IV labetalol
  • Nicardipine
41
Q

Heart Failure

systolic vs diastolic

A

High CO failure - high demands for blood circ - thyroid storm, berri berri etc

Low CO failure = 1. Systolic Dysfunction 2. Diastolic Dysfunction

Systolic Dysfunction - decr contractility, CO

  • Valvular dz
  • Ischemic CMO
  • Dilated CMO

Diastolic Dysfunction - impaired ability of hear to relax

  • restrictive CMO
  • HOCM
  • HTN
42
Q

Congestive Heart Failure

eti, sxs, dx

A

Left Sided HF

  • Volume overload - S3
  • Dyspnea, SOB, exertional fatigue, Orthopnea, PND

Right Sided HF

  • Edema, JVD,
  • Hepatomegaly, HJR, wt gain

Dx:

  • CXR - Kerley B lines, Pulm effusion/edema
  • Labs - CBC, TSH (high output), BNP, BUN/Cr
  • Echocardiogram* -assess fx
    • NYHA
      • Class I - Risk but no symp
      • Class II - risk and sxs
      • Class III - sxs w/ ADLs or mini activity
      • Clas IV - sxs at rest
43
Q

Congestive Heart Failure

treatment

A

Sxs control, reduce cardiac workload, control fluids

  1. Loop Diuretics - Furosemide, Torsemide
    • reduce NaCl abs = free water excretion
    • monitor K, Mg, Na
    • ototoxic sulfa allergy
  2. ACE-I or ARBS - statins, sartans
    • prevent remodeling of heart = lowers mortality
    • decr preload and afterload
    • monitor Cr - renal dysfx
  3. BB - Carvedilol, Metop, Bisoprolol
    • prolongs survival, incr LVEF
    • control rate, prevents arrhythmias
  4. Aldosterone Receptor Antagonist - Spironolactone
    • ​​decr fluid retention
    • monitor K for hyperK - check labs 3-4 d, few wks after
    • gynecomastia
  5. ICD
    • ​​if Acute MI EF <30%
    • Class II or II and EF <35% w/ sxs

Emergency Medicine (13 decks)

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