Cardiology - CAD, infective, CHF, myopathy, HTN Flashcards
1
Q
Define Preload?
A
this is from the left atrium contracting, thus pushing blood into the LV and causing to stretch and have a stronger contraction
2
Q
Define Afterload?
A
another way of saying BP, or pressure that holds the aortic valve closed (generally the systolic number) - resistance against which the heart contracts
3
Q
Define Contractility?
A
strength of LV muscle
4
Q
What drug increases contractility?
A
digoxin
5
Q
What drug reduces contractility?
A
verapamil (blocks Ca++)
6
Q
Define Systole?
A
blood leaves the LV to body
7
Q
Define diastole?
A
Ventricle fills (passive and active)
8
Q
Normal Ejection Fraction is what %?
A
55%
9
Q
Ejection Fraction of post MI?
A
25%
10
Q
What is coronary artery disease?
A
inflammatory process involving the arteries in the body. Starts with deposition of lipids (causes inflammation and narrowing), constant remodeling
11
Q
What are non-modifiable risk factors for CAD?
A
age, sex, genetic, ethnicity
12
Q
What are modifiable risk factors for CAD?
A
high cholesterol, HTN, DM, smoking, obesity, physical inactivity, ETOH, stress
13
Q
What are some key preventions for CAD?
A
DASH diet exercise proper weight control DM, HTN, cholesterol stop smoking
14
Q
Atypical Presentation of CAD…Elderly, DM, women?
A
Elderly - syncope
DM - silent ischemia (no pain), SOB
Women - often mistaken for abdominal pain
15
Q
Examples of non-cardiac pain?
A
pleuritic pain (sharp related to respiratory movement); lower abdomen, localized with one finger; reproduced by movement or palpation; constant pain lasting for days
16
Q
Typical MI signs and symptoms?
A
substernal chest pain/pressure crushing radiation to neck or left arm grey color diaphoresis anxiety feeling impending doom HTN, hypotension
17
Q
Atypical MI signs and symptoms?
A
nausea, epigastric pain, back pain, fatigue, no symptoms
18
Q
What is Acute Coronary Syndrome (3)?
A
- CHEST PAIN consistent with cardiac cause of pain
- EKG changes consistent with ischemia (ST elevation, depression, flipped T wave)
- elevated cardiac enzymes
(ranges from unstable angina to MI {NSTEMI/STEMI})
19
Q
Define Stable Angina?
A
patient with predicable pattern of angina with activities
- exertional CP is relieved by rest or 2 nitroglycerin tablets
- get stress test
20
Q
Define Unstable Angina?
A
new chest pain due to partial occlusion of coronary artery lasting <30 min
-get cardiac cath
21
Q
Treatment for Stable Angina?
A
ACEI, BB, ASA, Nitroglycerin sublingual, Statin
22
Q
Prinzmetal or Variant Angina… define and treatment?
A
Wakes from sleep or occurs at rest
-ST elevations during active vasospasm (if no vasospasm they can exert themselves and no CP)
TX = CCB
23
Q
What is the most sensitive cardiac enzyme?
A
Troponin T (detected for 3 days)
24
Q
Describe Chest Pain story suggestive of MI?
A
>30 min pressure, heavy, band like or squeezing levine sign (make fist over sternum) worse with exertion radiate to jaw or left arm (associated = SOB, nausea, diaphoresis)
25
Treatment for NSTEMI?
1. antiplatelet (aspirin, clopidogrel)
2. anticoag (unfractionated heparin, enoxaprin, fondoparinux)
3. BB (if no contraindications - heart failure, bradycardia, heart block) = then give CCB
{MONA B CASHPAD, elective cardiac cath}
26
Treatment for STEMI?
1. Aspirin
2. clopidogrel
3. IMMEDIATE (90 min) CATH - coronary angiography
4. thrombolytic (alteplase, reteplase)
{MONA B CASHPAD + urgent cardiac cath}
27
What are contraindications for thrombolytics?
previous hemorrhagic stroke, any stoke in last year, intracranial neoplasm, active internal bleed, suspect aortic dissection
trauma within 2-4 weeks, bleeding, major surgery within 3 weeks, pregnancy, PUD, anticoagulants, BP >180/110
28
What does MONA B CASHPAD stand for?
Morphine, oxygen, nitroglycerin, aspirin
BB
CCB, ACEI, Statin, Heparin (stemi) or Lovenox (nstemi/angina), plavix, amiodarone, dopamine/dobutamine/diuretics
29
4 Key BB?
Metoprolol - use if EF >40
Carvedilol - use if EF <40%
Esmolol - rate control agent
Labetalol - HTN drug of choice
30
When do you use amiodarone... ADR?
for VT/VF or any arrhythmia
ADR: pulmonary HTN, elevated LFT, hypo/hyperthyroid, iodine allergy
Get PFT, LFT, thyroid before starting
31
What are cardiac catheterization criteria?
- within 90 minutes of arrival
- access via femoral or brachial artery
- bare metal (plavix for 30 days)
- drug eluting (plavix x1 year)
32
What do you do if cardiac catheterization is not available within 90 minutes?
thrombolytics
or meets criteria: persistent ST elevation + chest pain; hypotension, CHF, arrhythmia - VT/VF
33
What are indications for thrombolytic therapy?
- symptoms of MI
- ST elevation >0.1mV on 2 leads
- onset of symptoms within 12 hrs
- can't have PCI within 90 minutes or prolonged transport (>1 hr to facility)
34
pleuritic chest pain (with inspiration - sharp/stabbing), relieved by sitting upright and forward, friction rub, diffuse ST elevation
Pericarditis
35
What is #1 cause of pericarditis?
Viral infection
36
What is Dressler's Syndrome?
Pericarditis after an acute MI
37
Pericarditis Treatment?
if hemodynamic compromise = pericardiocentesis
-NSAID or Steroid
if bacterial (usually viral) - may require ABX
38
What chest pain usually lasts <3 minutes, exacerbated by physical activity, relieved by rest?
Angina Pectoris - stable
39
Severe tearing sensation, radiates to back, most severe pain is at onset, male
involves only intima layer
Aortic dissection
- Type A = ascending (65%)
- Type B = descending (35%)
40
Risk Factors for Aortic Dissection?
pregnancy, cocaine, chronic HTN, bicuspid aortic valve, aortic coarctation, giant cell arteritis, CT disease, marina's syndrome, ehler's-danlos syndrome
41
Gold Standard for Aortic Dissection?
Aortic Angiography
-CT is generally first choice
42
Treatment for Aortic Dissection?
- lower BP (nicardipine, esmolol, labetalol, nitroprusside)
- Type A = surgical management
- Type B = medically first, maybe surgery
43
ADR of nitroprusside?
may cause cyanide toxicity, leading to AMS and high anion gap acidosis
44
abrupt onset of severe pain unrelieved by position change, back pain/pulsatile mass/hypotenstion
>60
involves 3 layers
Aortic Aneurysm
45
Diagnosis for Aortic Aneurysm?
```
Ultrasound (first line)
CT angio (for preop eval)
```
46
Risk factors for AA?
tobacco abuse, atherosclerosis, HTN, COPD
47
Treatment for AAA?
- observation up to 5.4cm
| - surgery if >5.4 or change in 0.5cm in 6 months or 1cm in 1 year
48
Name the triad -
1. Distant heart sounds
2. distended jugular veins
3. decreased arterial pressure
Beck's Triad - pericardial tamponade
49
tachycardia, tachypnea, narrow pulse pressure, pulses paradoxus.... test...diagnosis?
order Echo (gold standard)
- EKG = electrical alternans
- CXR = huge globular heart
diagnosis = pericardial tamponade
50
Treatment for Pericardial Tamponade?
Pericardiocentesis (urgent)
| {can send fluid}
51
Present with petechiae, splinter hemorrhages, Janeway lesions, Osler's nodes, Roth spots...HIGH FEVER
(stroke + fever)
Endocarditis
52
Duke Criteria?
Endocarditis
Major: + blood culture + echo for vegetation, no regard murmur
Minor: predisposing factor, fever, vascular phenomena (embolic disease/pulmonary infarction), immunologic phenomena (glomerulonephritis/osler/roth),
53
Common pathogen for Endocarditis?
IV drug user/acute = staphyloccus aureus
(involve tricuspid valve with IV drug user)
Subacute = strep viridans
54
Endocarditis Treatment?
ABX: amoxicillin or vancyo + ceftrixone
prophylaxis = before dental or surgical procedures with prosthetic valves = amoxicillin
often require valve surgery (replacement)
55
Jones Criteria?
post Beta-hemolytic streptococcal infection (acute rheumatic fever)
56
Jones Major and minor criteria?
```
MAJOR:
Joints (polyarthritis)
O-carditis
N-nodules, subcutaneous
E-erhythema marginatum
S-sydenham's chorea
```
MINOR:
arthralgia, fever, lab elevated ESR/CRP, ekg prolong PR
57
Treatment for Acute Rheumatic Fever?
- bed rest
- salicylates = reduce fever, joint pain
- IM penicillin (allergic = erythromycin)
prevention = early treatment of streptococcal pharyngitis.
Benzathine penicillin q4 weeks
58
How do you diagnose heart failure?
echocardiogram = determine size and function of chambers, monitors ejection fraction (<40 = BAD) normal 60-70.
59
Define congestive heart failure...
syndrome = dyspnea, abnormal retention of water and sodium
| dyspnea & edema
60
What are the 4 main types of heart failure?
1. Left heart - systolic s3
2. Left heart - diastolic s4
3. Right heart - pulm HTN
4. high output cardiac failure - metabolic demand
61
What heart failure -
exertional dyspnea + nonproductive cough, fatigue, orthopnea, paroxysmal nocturnal dyspnea, basilar rales, gallops, exercise intolerance
Left-sided (LUNG)
62
What heart failure ....
| distended neck veins (JVD), hepatic congestion, nausea, pitting edema, edema & hepatomegaly?
Right-sided (often caused by left-side)
right (liver)
63
What lab value is often elevated in heart failure?
BNP >100
-also test CK-MB, troponins
64
Describe a chest xray for CHF?
- alveolar infiltrates (bat wing)
- pulm veonus redistribution
- kerley B lines (horizontal)
- peribronchial cuffing
- pleural effusion
- cardiomegaly
65
Treatment for Systolic Left-sided heart failure?
ACEI
| Loop Diuretic
66
JVD with clear lung fields is what type of heart failure?
Right-sided heart failure
67
Treatment for congestive heart failure goal?
Focus on decreasing prelude with Lasix (furosemide), morphine sulfate, nitrate, oxygen
68
What does inotrope do?
alter muscle contractions
69
What does chronotrope do?
alter heart rate
70
What are the 3 types of cardiomyopathies?
- Dilated (congestive) = 95%
- Hypertrophic
- Restrictive
71
What heart failure presents like dilated cardiomyopathy?
systolic heart failure - s3 and low EF
dyspnea!! s3 gallop, rales, increased jugular venous pressure
72
What are dilated cardiomyopathies associated with?
reduced strength of ventricular contraction = dilation of LV
73
Causes of dilated cardiomyopathy?
- Ischemia (CAD, cocaine, arrhythmia)
- Viral (hep c)
- Toxins (etoh, chemotherapy)
- genetic (takotsubo)
- idiopathic
74
Treatment for dilated cardiomyopathy?
(just like systolic HF)
- BB, loop diuretic, ACEI
- abstinence from alcohol
- treat underlying disease
75
Lab for dilated cardiomyopathy?
ECG = nonspecific ST and T changes,
chest xray = cardiomegaly, pulm congestion
Echo and catheterization = LV dilation and dysfunction, high diastolic pressure, low CO
76
What heart failure is hypertrophic cardiomyopathy related to?
Diastolic heart failure - s4 and thick stiff ventricle
77
Cause of sudden cardiac death in young patients (<30)?
hypertrophic cardiomyopathy
78
Cause of hypertrophic cardiomyopathy?
Genetics!
| -asian descent
79
Patient presents with dyspnea, angina, syncope, arrhythmias, sudden death, sustained point of maximal impulse, loud s4, JVP with "a" wave
Hypertrophic cardiomyopathy
80
Echo shows what for hypertrophic cardiomyopathy?
LVH and/or thickened septum
81
Treatment for hypertrophic cardiomyopathy?
- BB or CCB
- diuretic
- surgery
- screen entire family!
82
What heart failure should you think of with restrictive cardiomyopathy?
diastolic - s4 and thick stiff ventricle.
83
Cause of restrictive cardiomyopathy?
fibrosis or infiltration
| collagen-defect disease (amyloidosis, radiation, posted changes, diabetes, endomyocardial fibrosis)
84
What heart failure should you think of with constrictive cardiomyopathy?
right heart failure (RV weak and fail first)
- fatigue
- dyspnea
- body swelling
- elevated JVP
- ascites
- peripheral edema
85
Causes of constrictive cardiomyopathy?
radiation, TB, infection, recurrent pericarditis
86
What are the classification of HTN?
Normal: 160/100
87
Causes of 2ndary HTN?
sleep apnea, estrogen use, pheochromocytoma, aortic coarctation, pseudo tumor cerebri, renal disease, renal artery stenosis, steroids, cushing syndrome, thyroid/parathyroid, aldosteronism
pregnancy
88
Causes of drug induced HTN?
NSAID, steroid, pseudoephedrine, cyclosporine, tacrolimus, OCP, cocaine, amphetamines, licorice, chinese ephedra
89
What should you look for on physical exam for a patient with HTN?
retinopathy, peripheral artery disease, nephropathy, LVH - cardiomyopathy, TIA/Stroke/Dementia
-renal artery bruits, thryomegaly, moon face/striae/buffalo hump, flank pain/fluid overload, snoring/apnea
90
Genetic predisposition for HTN?
black, male, age, smokers
91
BP goals:
<130/80
92
Labs associated with HTN?
EKG = LV hypertrophy or heart failure
chest xray = ventricular hypertrophy (NOT NECESSARY)
BMP, TFT, Cortisol, UA
Echo and Renal doppler
93
Major Cardiovascular Disease risk factors?
obesity, dyslipidemia, SM, smoking, decreased physical activity, GFR <60, micro albuminuria, FHx
94
Essential diagnostic criterion for HTN?
BP >140/90 on 3 separate occasions (2 visits)
95
First line treatment for HTN?
lifestyle
- then thiazide
- may consider ACEI, ARB, BB, CCB
96
Hypertensive URGENCY?
-reflect BP that must be reduced within HOURS (no end-organ damage)
->220/125
-treated with parenteral agents (but don't decrease BP to rapidly = cause cerebral ischemia)
= IV sodium nitroprusside (same as emergency)
=clonidine, captopril, nifedipine
97
Hypertensive EMERGENCY?
-reflect BP that must be reduced within 1 HOUR to prevent progression of end-organ damage (papilledema) or death
>180/120 + end organ dysfunction
(elevated BP + encephalopathy, nephropathy, intracranial hemorrhage, aortic dissection, pulmonary edema, unstable angina, MI)
98
Define Orthostatic Hypotension?
<20 systolic or 10 diastolic BP 2-5 minutes after changing from supine to standing
99
Causes of postural hypotension?
reduced CO, dysrhythmia, low blood volume, meds, endocrine/metabolic
100
ACEI (mechanism, ADR, CI):
| Lisinopril; captopril
mechanism: vasodilate, decrease volume, decrease angiotensin II production
First line: DM or Kidney disease
ADR: cough, angioedema, hyperkalemia
CI: renal artery stenosis, pregnancy
101
ARB (mechanism, ADR, CI)
| losartan, valsartan
Mechanism: vasodilate
ADR: dizziness, angioedema, hyperkalemia
-lorsartan = gout (lowers uric acid)
CI: Renal artery stenosis, pregnancy
102
Aldosterone ant. (mechanism, ADR, CI)
| spironolactone
Mechanism: decrease volume
ADr: hyperkalemia
CI: renal artery stenosis, pregnancy
103
BB (mechanism, ADR, CI)
atenolol
metoprolol
Mechanism: decrease HR and CO (rate and contractility)
ADR: decrease HR, fatigue, depression, sexual dysfunction
CI: asthma, low HR, 2-3 heart block
104
CCB (mechanism, ADR, CI)
verapamil
nifedipine
amlodipine
diltiazem
Mechanism: vasodilate, decrease rate
ADR: edema, HA
CI: low HR, SSS, blocks
105
```
Thiazide Diuretics (mechanism, ADR, CI)
HCTZ (thiazide)
```
Loop (furosemide) = only if renal dysfunction
Mechanism: decrease volume, increase urinary sodium excretion
ADR: hypokalemia, increased uric acid, urinary frequency, cramps
CI: gout, DM, pregnancy
106
Drug for HTN in pregnancy?
hydralazine (vasodilator)
107
what meds should be avoided in individuals with coronary spasm
non-selective beta blockers and sumatriptan
108
Presents with exercise induced angina pectoris, syncope, sudden cardiac death in kids.
anaomalous coronary artery
109
what labs does niacin raise?
plasma glucoe and serum uric acid values
110
what can be given to minimize flushign with niacin
aspirin or ibuprofen before dosing
111
meds to give for ST elevation for someone who has ingested cocaine
nitrates and verapamil
