Cardiology Flashcards
Substernal poorly localized exertional chest pain that is short in duration and resolves with rest or nitro
Pain may radiate to arm, teeth, or jaw
Diaphoresis
Stable angina
Levine’s sign
fist over heart
Classes of angina
Class I: strenuous activity
Class II: more prolonged or rigorous activity, slight limitation of physical activity
Class III: daily activity, marked limitation of physical activity
Class IV: angina at rest
Acute coronary syndrome diagnosis?
EKG = initial test of choice
Cardiac enzymes: CK/CK-MB, troponin
Coronary angiography = GOLD STANDARD
Stable angina tx?
Daily aspirin, beta blockers, nitro, and statin
Angina that is new in onset, occurs at rest, or lasts > 30 minutes; not relieved by nitro
Unstable angina (acute coronary syndrome)
Tx of angina, UA, or NSTEMI?
Nitro, aspirin, beta blockers, heparin, statin, ACEI
STEMI tx?
Nitro, aspirin, beta blockers, ACEI
+ REPROFUSION: PCI within 90 min, if not available within 120 min fibrinolytics within 30 min (TPA- Alteplase)
When should you avoid nitro and morphine in ACS?
Inferior wall MI
What type of MI does V1-V4 involvement indicate?
Anterior/septal (LAD)
What type of MI does I, aVL, V5-V6 involvement indicate?
Lateral (LCA)
What type of MI does II, III, aVF involvement indicate?
Inferior (RCA)
What are the systolic murmurs?
Mitral regurgitation Tricuspid regurgitation Mitral valve prolapse Aortic stenosis Pulmonary stenosis
What are the diastolic murmurs?
Tricuspid stenosis
Mitral stenosis
Pulmonary regurgitation
Aortic regurgitation
Harsh systolic crescendo-decrescendo murmur best heard at the right sternal border
Prominent S4
Radiates to carotid
Aortic stenosis
Blowing diastolic decrescendo murmur best heard at the left sternal border
Aortic regurgitation
MCC of rheumatic heart disease?
Mitral stenosis
Rumbling mid-diastolic murmur with a prominent S1 and opening snap best heard at the apex
Mitral stenosis
Mid-late systolic ejection click best heard at the apex
MVP
What causes an earlier and later click in MVP?
Earlier click: Valsalva, standing
Delayed click: leaning forward, squatting, supine
What is the MCC of mitral regurgitation in the US?
MVP
Blowing holosystolic murmur best heard at the apex
Radiates to the axilla
Mitral regurgitation
Mid-diastolic murmur best heard at LLSB
Increased intensity: inspiration
Tricuspid stenosis
Blowing holosystolic murmur best heard at the left sternal border
Increased intensity: inspiration
Tricuspid regurgitation
Always congenital
Harsh mid-systolic crescendo-decrescendo murmur beast heard at left sternal border
Increased intensity: inspiration
Radiates to the neck
Pulmonic stenosis
Always congenital
Graham-Steel murmur: brief decrescendo early diastolic murmur best heard at LUSB
Increased intensity: inspiration
Pulmonic regurgitation
Constant prolonged PR interval (>.20s), all P waves followed by QRS complexes
1st degree AV block
Progressive PR interval lengthening followed by dropped QRS complex
2nd degree AV block type 1
Constant prolonged PR interval and dropped QRS complexes
2nd degree AV block type 2
AV dissociation; regular P-P intervals and regular R-R interval, but they are not related to each other
3rd degree AV block
Sawtooth atrial waves, no discernable P waves
Tx?
Atrial flutter
Stable: vagal maneuvers, ΒB or CCB
Unstable: direct current synchronized cardioversion
Irregularly irregular rhythm, no discernable P waves
Atrial fibrillation
A. fib tx?
Stable: rate control (ΒB or CCB)
Unstable: Direct current synchronized cardioversion
If present for more than 48 hrs, anticoagulate for 21 days prior to cardioversion
Long- term
Anticoagulation based on CHA2DS2-vasc score: Warfarin, Dabigatran, Apixaban, Rivaroxaban
Rate control (BB, CCB, Digoxin, Amiodarone)
*Avoid CCBs in HF
Regular, narrow-complex tachycardia, no discernable P waves (MC)
Regular wide-complex tachycardia
Paroxysmal Supraventricular Tachycardia (PSVT)
Paroxysmal Supraventricular Tachycardia tx?
Stable (narrow-complex): vagal maneuvers, Adenosine
Stable (wide-complex): Amiodarone
Unstable: Direct current synchronized cardioversion
Definitive: radiofrequency catheter ablation
Delta wave (slurred QRS upstroke), shortened PR interval, wide QRS complexes
Wolff-Parkinson-White (WPW)
Wolff-Parkinson-White (WPW) tx?
Stable: Procainamide
Unstable: Direct current synchronized cardioversion
Definitive: radiofrequency catheter ablation
Inverted or absent P wavesAV Junction Dysrhythmias
AV Junction Dysrhythmias
Wide bizarre QRS occurring earlier than expected; T waves in the opposite direction of the QRS complexes; associated w/ compensatory pause
Premature Ventricular Complexes (PVC)
Regular wide complex tachycardia with no discernable P waves
Sustained VT = duration of 30+ sec
Monomorphic vs polymorphic based on QRS morphology
Ventricular Tachycardia
Variant of polymorphic VT (Bow tie appearance)
Tx?
Torsades de pointes
IV magnesium
VT tx?
Stable: Amiodarone
Unstable (with pulse): Direct current synchronized cardioversion
No pulse: Defibrillation + CPR
Erratic pattern of electrical impulses, no discernable P waves
Defibrillation + CPR
Organized rhythm but no pulse
TX?
Pulseless Electrical Activity (PEA)
CPR + EPI, check for shockable rhythm every 2 min
Dyspnea (MC)
Angina, syncope, arrhythmia
Sudden cardiac death
Hypertrophic cardiomyopathy
How to dx cardiomyopathies?
Echo
Hypertrophic cardiomyopathy tx?
Beta-blockers = 1st line
CCB = 2nd line
Avoid dehydration, extreme exertion, exercise
Caution use of Digoxin, Nitrates, diuretics
Surgery
Septal myectomy
Alcohol septal ablation
Dyspnea Paroxysmal Nocturnal Dyspnea (PND) Pulmonary congestion: cough (blood-tinged sputum), crackles, wheezes Cyanosis Cheyne-stokes breathing
L sided HF
Peripheral edema JVD Ascites Weight gain Hepatosplenomegaly
R sided HF (MCC is L sided HF)
MC form of HF, commonly caused by MI, dilated cardiomyopathy
There are thin ventricular walls so they cannot pump as strongly to push blood out, hence reduced EF
May hear an S3
Systolic HF
Commonly caused by HTN, LVH, old age, constrictive pericarditis
Thick ventricular walls so difficult for the heart to fill with blood. However pumping capability is not impacted, hence preserved EF
May hear S4
Diastolic HF
CHF diagnosis?
BNP (>500 very likely)
Cardiac enzymes
EKG
CXR: cephalization, Kerley B lines, pleural effusion
Echo = GOLD STANDARD
CHF tx?
Wt loss, sodium <2g, fluids <2L
Daily weight monitoring
Loop Diuretics (furosimide)
ACEI/ARB (Check for hyperkalemia)
ΒB
Acute
LMNOP: Lasix, Morphine, O2, Nitrate, position
Avoid CCBs
Leg pain worse with dependency Improved with walking/elevation Normal pulses/temp Stasis dermatitis (itchy, eczematous rash and brownish/dark purple hyperpigmentation of the skin) Ulcers (medial malleolus) Dependent pitting edema
Chronic venous insufficiency
Chronic venous insufficiency dx?
Venous duplex US
Venography = GOLD STANDARD
Intermittent Claudication Intermittent claudication Worse with walking/elevation Improved with dependency/rest Decreased/absent pulses Decreased capillary refill Atrophic skin changes Ulcers (lateral malleolus) Pale with elevation, dependent rubor
ABI (positive if < 90)
ANGIOGRAPHY = GOLD STANDARD
Virchow’s triad
- Venous stasis
- Endothelial damage
- Hypercoagulability
(DVT)
Unilateral swelling of LE (> 2cm)
WARM skin & dusky cyanosis
Normal pulses
Homans sign: calf pain with dorsiflexion (unreliable)
DVT
DVT dx?
Venous duplex US = 1st line
Venography = GOLD STANDARD
What test is used to monitor LMWH?
PTT
What test is used to monitor warfarin?
PT/INR
LMWH antidote?
Warfarin antidote?
LMWH: protamine sulfate
Warfarin: VitK, FFP
HTN dx?
Diagnosis: 2+ elevated readings on 2+ different visits > 140/90
Pre-HTN: 120/139/80-89
Stage I: 140-159/90-99
Stage II: >160/100
Types of AAA?
Fusiform: circumferential dilatation of aortic wall
Saccular: outpouching of aortic wall (higher risk of rupture)
AAA dx?
Stable: CT w/ contrast
Unstable: bedside US
*Pts with known AAA who present w/ classic sx of rupture can be taken to the OR w/o preop imaging
AAA screening
One-time screening via abd US in men 65-75 who have ever smoked
5.5+ cm or > 0.5 cm growth in 6 mo immediate surgical repair
> 4.5 cm- surgery referral
4-4.5 cm- monitor; US q 6 mo
3-4 cm- monitor; US q year
Types of aortic dissection
Stanford Type A: Ascending aorta
Stanford Type B: Descending aorta
Aortic dissection dx
CXR: widened mediastinum
CT angiography: confirm dx, differentiate from ascending and descending
Aortic dissection tx
Ascending
BP control + emergent open surgical repair
Descending
Lower SBP to 100-120 and HR to <60 bpm w/in 20 min
BB (Labetalol) = first line
Can add Nitroprusside after HR is controlled
Pain control: morphine (pain & vasodilation)
Beck’s triad
- JVD
- Muffled heart sounds
- Hypotension
(cardiac tamponade)
Cardiac tamponade dx
EKG: low QRS voltage, electrical alternans
Echo = test of choice; effusion + diastolic collapse of cardiac chambers
MCC of pericardial effusion?
Pericarditis
Symptoms due to coronary vasospasm triggered by cold weather, exercise, hyperventilation
Chest pain at rest that is not exertional and not relieved by rest
Vasospastic angina (Variant, Prinzmetal)
Vasospastic angina (Variant, Prinzmetal) tx?
CCBs
Persistent fever New onset murmur Osler nodes Janeway lesions Splinter hemorrhages Roth spots
Endocarditis
What are Osler nodes?
Painful violaceous nodules on pads of digits and palms
What are Janeway lesions?
Painless erythematous macules on palms and soles
What are roth spots?
Retinal hemorrhages with pale centers
How to dx endocarditis?
Duke Criteria: 2 major OR 1 major + 3 minor OR 5 minor
Major
Bacteremia (2+ blood cultures)
Endocardial involvement on echo
New regurgitation murmur
Minor
Predisposing condition or IVDU
Fever (>100.4)
Vascular or embolic PNA (Janeway lesions)
Immunologic phenomena (Osler nodes, Roth spots, + RF, glomerulonephritis)
Blood culture not meeting major criteria
Worsening of existing heart murmur
