Cardiology - MTB Flashcards
0
Q
A 48 y.o woman comes to the office wth chest pain that has been occuring for the past several weeks. Not reliably related to exertion. She is comfortable now. Pain sometimes associated with nausea. No SOB. and pain does not radiate beyonf chest. She has no PMH. What is most likely diagnosis?
A
GERD
1
Q
Coronary artery disease
A
- aka atherosclerotic disease
- ischemic heart disease
2
Q
Risk factors for CAD
A
- Diabetes mellitus
- Tobacco smoking
- HTN
- Hyperlipidemia
- Family hx of premature coronary arery disease
- Age above 45 in men and above 55 in women
3
Q
Worst risk factor for CAD
A
Diabetes mellitus
4
Q
Premature coronary heart disease
A
- male relative under 55
- female relative under 65
5
Q
Postmenopausal woman develops chest pain immediately on hearing news of her son’s death in war. She develops acute chest pain , dyspnea, ST segment elevation in V2 - V4 on ECG. Elevated levels of troponin confirm an acute MI. Coronary angiography is normal including absence of vasospasm with provocative testing. ECG reveals apical LV “ballooning”. Mechanism of this disorder?
A
- massive catecholamine discharge
6
Q
Tako-Tsubo cardiomyopathy
A
- often occurs in postmenopausal women s/p emotionally stressful event
- manage w/ Beta blockers and ACE inhibitors
7
Q
Most dangerous risk factors in terms of risk or CAD?
A
Elevated LDL
8
Q
Correcting which risk factor for CAD will result in the most immediate benefit for the patient?
A
Smoking cessation
9
Q
Chest pain described as dull / “sore” and/or squeezing or pressure-like
A
ischemic pain
- sharp (“knifelike”) or pointlike
- lasts for a few seconds
10
Q
Chest pain that excludes ischemic pain
A
- changes with respiration (pleuritic)
- changes with position of the body
- changes with touch of the chest wall (tenderness)
** if patient answers yes to the previous questions, likely NOT ischemic
11
Q
Most common cause of chest pain
A
Gastrointestinal disorders
12
Q
Patient describes chest wall tenderness. Most likely diagnosis?
A
Costochrondritis
13
Q
Most accurate test for costochondritis
A
Physical exam
14
Q
Patient describes chest pain that radiates to the back, unequal blood pressure between arms. Most likely diagnosis?
A
Aortic dissection
15
Q
Most accurate test for aortic dissection
A
CXR
w/ widened mediastinum
- chest CT, MRI, or TEE confirms the disease
16
Q
Young Pt (< 40) c/o chest pain worse with lying flat, better when sitting up. Likely diagnosis?
A
Pericarditis
17
Q
Most accurate test for pericarditis
A
Electrocardiogram with ST elevation every where
PR depression
18
Q
Pt describes epigastric discomfort, pain better when eating. Likely diagnosis?
A
Duodenal ulcer disease
19
Q
Most accurate test for chest pain
A
Endoscopy
20
Q
Pt describes chest pain with bad tatse, cough, hoarsness
A
Gastroesophageal reflux
21
Q
Most accurate test for GERD
A
Response to PPIs;
- alumnium hydroxide and magnesium hydroxide
- viscous lidocaine
22
Q
Pt describes chest pain with cough, sputum, and hemoptysis. Likely diagnosis?
A
Pneumonia
23
Q
Most accurate test for pneumonia
A
CXR
24
Patient describes chest pain with sudden onset SOB, tacycardia, and hypoxia.
Pulmonary embolus
25
Most accurate test for pulmonary embolus
- spiral CT
| - V/Q scan
26
Pt complains chest pain with sharp, pleuritic pain, and tracheal deviation. Likely diagnosis?
Pneumothorax
27
Most accurate test for pneumothorax
Chest X-ray
28
Worst prognostic significance for chest pain
Shortness of breath
29
Best initial test for chest pain
Electrocardiogram (EKG)`
| - in office setting, the EKG is normal most of time but cannot progress to other testing without this test
30
If patient has acute chest pain in an office/ambulatory setting, what is the next best step to evaluate chest pain?
Transfer to ER
| - DON'T ANSWER CARDIAC ENZYMES!!
31
If patient has chest pain in office/clinic for days to weeks, are cardiac enzymes appropriate?
No enzymes
32
If patient has chest pain in emergency department for minutes to hours, are cardiac enzymes appropriate?
Yes enzymes,
| after an EKG is performed
33
When the etiology of chest pain is not clear, what is the best tool for evaluation of chest pain?
Exercise tolerance testing (ETT)
34
What are the two best factors for ETT
1. You can read the EKG
| 2. The patient can exercise (gets heart rate > 85% of maximum)
35
Maximum heart rate
220 - age of patient
36
Best way to detect ischemia on EKG
ST segment depression
37
If you cannot read EKG because of baseline EKG abnormality, what are the 2 best ways to detect ischemia w/o EKG?
- Nuclear isotope uptake: thallium or sestamibi
| - Echocardiographic detection of wall abnormalities
38
Reasons for baseline EKG abnormalities
- Left bundle branch block
- Left ventricular hypertrophy
- Pacemaker use
- Effect of digoxin
39
Thallium testing for detection of cardiac ischemia
Normal myocardium will pick up thallium
- if myocardium is alive and perfused, thallium will be picked by Na/K ATPase
- if myocardium is abnormal, thallium has decreased uptake
40
Echocardiogram for detection of cardiac ischemia
Normal myocardium will move on contraction
| - abnormal heart has decreased wall motion (dyskinesis, akinesis, or hypokinesis)
41
Ischemia vs infarction
ischemia: decreased perfusion that is detected by REVERSAL of thallium uptake or wall motion that returns to normal after rest period
42
If patient is unable to exercise to detect cardiac ischemia with exercise tolerance testing, what is the best method of detecting cardiac ischemia?
Pharm testing
- Persantine (dipyramidole) or adenosine in combination with thallium or nuclear isotopes
- Dobutamine in combination with echocardiogram
43
How does dobutamine work to detect cardiac ischemia
Dobutamine will increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities on ech
44
Coronary Angiography
- used to detect anatomic location of coronary artery disease
- use to determine whether narrowing should be best dealt with by surgery, angiography, or methods of revascularization
45
Most accurate test for detecting coronary artery disease
Angiography
46
Arterial stenosis
- insignificant when less than 50%
| - surgically correctable when > 70%
47
Holter monitoring
- continuous ambulatory EKG monitor that records rhythm
- used for 24 - 72 hrs
- mainly detects rhythm disorders (a-fib, a-glutter, PVCs)
- does not detect ischemia and not for evaluating ST segment
48
48 y.o woman comes to office w/ chest pain that has been occurring over the last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of pain is retrosternal. She has no hypertension and the EKG is normal. What is the next best step?
Exercise tolerance testing
49
Medications that lower mortality in setting of chronic angina
- Aspirin
- Beta blockers
- Nitroglycerin
50
Route of nitroglycerin in chronic angina
Orally or a transdermal patch
51
Route of nitroglycerin in acute coronary syndromes
Sublingual, paste, and IV forms of nitroglycerine
52
Clopidogrel
- aspirin intolerance (e.g. allergy)
- recent angioplasty with stenting
- rarely used with TTP
53
Prasugrel
- thienopyridine medication in same clas as clopidogrel and ticlopidine
- antiplatelet medication best used for angioplasty ad stenting
54
Ticlopidine
- antiplatelet med in rare patient intolerant of both aspirin and clopidogrel
- should not be used if aspirin/clopidogrel intolerance is bleeding
- can cause neutropenia and TTP
55
Ranolazine
- additional therapy for angina refractory or persistent through treatment
56
ACE inhibitors / ARBS: Indications
- low systolic ejection raction/ systolic dysfunction (best mortality beneift)
- regurgitant valvular disease
57
Most common side effect of ACE inhibitors
Cough
58
64 y/o man is placed on lisinopril as part of managing CAD in association with ejection fraction of 24% and symptoms of breathlessness. Although he sometimes has rales on lung exam, the patient is asymptomatic today. PE should minimal edema of lower extremities. Blood tests reveal an elevated level of K that is present on a repeat measurement. EKG is unchanged. What's the best way to manage this patient
Switch from lisinopril to hydralazine and nitrates
- Lisinopril also cause hyperkalemia due to inhibition of aldosterone
- hydralazine will decrease afterload a arterial vasodilator
59
Why should hydralazine be used with nitrates in systolic dysfunction?
Hydralazine in an arterial vasodilator that decreases afterload
- used w/ nitrates to dilate coronary arteries so that blood isn't stolen away from coronary perfusion when afterload is decreased w/ hydrazalines
60
Lipid Management in CAD
Patients use statins w/ CAD with an LDL above 100 mg/dL
61
Aside from CAD, other conditions in which lipids should be controlled to < 100 mg/dL
- Peripheral artery disease (PAD)
- Carotid disease (not stroke)
- Aortic disease ( the artery, not the valve)
- Diabetes mellitus
62
Most common adverse effect of statins
Liver dysfunction
| - elevation of transaminases
63
Why are statins considered to have some mortality benefit?
Statins have antioxidant effect on endothelial lining of coronary arteries
64
Niacin
- used to lower lipid levels
- associated w/ glucose intolerance, elevation of uric avid level and itchiness due histalimine rlease
- excellent ADDITION to statins if full lipid control not achieved with statins alone
65
Gemfibrozil
- fibric acids lower triglyceride levels more than statins however, less mortality benefit than statins
- caution using with statins due to increased risk of myositis
66
Cholestyramine
- bile acid sequestrant but often has interactions with other drugs in gut by blocking their absorption
- associated with uncomfortabe GI complaints such as constipation and flatus
67
Ezetimibe
- lowers LDL level w/o any evidence of actual benefit to patient
- no better than placebo in terms of endpoints (e.g. MI, stroke or death)
68
Statin: adverse effect
- elevations of transaminases (liver fxn tests)
| - myositis
69
Niacin: adverse effect
- elevation in glucose and uric acid level
| - pruritis
70
Fibric acid derivatives: adverse effect
- increased risk of myositis when combined with statins
71
Cholestyramine: adverse effect
Flatus and abdominal discomfort
72
Ezetimibe: adverse effect
- well tolerated and nearly useless
73
Dihydropyridine calcium channel blockers
- Nifedipine
- Nitrenipine
- Nicardipine
- Nimodipine
74
Dihydropyridine calciums affect mortality of CAD patients in which way?
They INCREASE mortality in patients with CAD b/c they raise heart rate
- the increased HR will increase myocardial oxygen consumption
75
Which calcium channel blockers are used in CAD?
Verapamil
| Diltiazem
76
Indications for use of CCB in CAD
- Severe asthma precluding use of B-blockers
- Prinzmetal variant angina
- Cocaine induced chest pain (B-blockers are contraindicated)
- Inability to control pain w/ maximal medical therapy
77
Calcium channel blockers: Adverse effects
- Edema
- Constipation (verapamil most often)
- Heart block (rare)
78
Which diagnostic test is best to evaluate patient for revascularization?
- Angiography to determine whether patient needs CABG or angioplasty
79
Indications for coronary artery bypass grafting (CABG)
- Three vessels > 70% stenosis in each vessel
- Left main coronary artery occlusion
- Two-vessel disease in a patient with diabetes
- Persistent symptoms despite maximal medical therapy
80
Pts that benefit the most from CABG
- patients with EF < 35%
81
Which grafted veins are used for CABG
- Internal mammary artery grafts last 10 yrs before occlusion
- Saphenous vein grafts remain patent reliably for 5 years
82
Percutanous coronary intevention
- aka angioplasty
- best therapy for acute coronary syndromes esp those with ST segment elevation
- does not provide clear mortality benefit for stable CAD patients
83
Maximal medical therapy in stable CAD
- ASpirin
- Beta Blockers
- ACEis / ARBs
- Statin
84
70 y.o F comes to ED w/ crushing substernal chest pain for the last hr. The pain radiates to her left artm and is associated with anxiety, diaphoresis, and nausea. She describes the pain as "sore" and "dull" and clenches her fist in front of her chest/ She has a hx of hyperension What is most likely to be found in this patient?
S4 gallop b/c ishemia leading to noncompliance of left ventricle
85
Kussmaul sign
- increase in JVP on inhalation
- often associated with constrictive pericarditis or restrictive cardiomyopathy
- "scratchy" sound in pericardial friction rub
86
Dressler synrome
- complication of myocardial infarction that occurs several days after MI and is much rarer than simpler ventricular iscemia
87
Patent ductus arteriosus (PDA)
- continuous "machinery" murmur t
88
Displaced point of maximal impulse (PMI)
- characteristic of left ventricular hypertrophy as well as dilated cardiomyopathy
- anatomic abnormality that can't occur with an acute coronary syndrome
89
70 y.o F comes to the emergency department w/ crushing substernal chest pain for the last hr. Which of the following EKG findings would be associated with the prognosis?
ST elevations in V2 - V4
- corresponds to the anterior wall of the left ventricle
- signifies an acute myocardial infarction
90
Premature ventricular complexes (PVCS)
- should not be treated
- associated with an acute infarction
- treatment of PVCs only worsens outcome
91
70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hour. An EKG shows ST segment elevation in V-2. What is the most appropriate next step of management in this patient?
Aspirin
- lowers mortality and important to administer as quickly as possible
- initiate therapy before moving patien to the ICU
92
70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hr. An EKG shows ST segment elevation in leads V2 - V4. Aspirin has been given to the patient to chew. What is the most appropriate next step in management?
Angioplasty is associated with greatest mortality benefit
93
Pt c/o chest pain, when to do an EKG
- immediately at onset of pain
| - ST elevation progresses to Q waves over several days to a week
94
Myoglobin
- becomes abnormal 1-4 hrs
| - duration of myoglobin elevation is 1-2 days
95
CK-MB
- becomes abnormal 4-6 hrs
| - duration of elevated CK-MB for 1-2 days
96
Troponin
- becomes abnormal in 4-6 hrs
| - duration of elevated troponin is 10-14 hrs
97
Difficulty of using troponin levels in detection of myocardial infarctions
- Troponin can't distinguish btwn reinfarction occurring several days after 1st event
- Renal insufficiency can result in false positive tests since troponin is excreted via kidneys
98
If pt c/o of new chest pain within a few days of first cardiac event, how do you manage this condition?
Concern for reinfarction
1. Perform an EKG to detect NEW ST segment abnormalities
2. Check CK-MB levels
* * after two days, the CK-MB levels should have returned to normal
3. Transfer to ICU if new infarction
99
Most common cause of death in first several days of MI
Ventricular arrhythmia (v-tach, v-fib)
100
ST segment elevation myocardial infarction (STEMI)
- best initially managed with aspirin (orally or chewed).
| - clopidogrel can be used an alternative to aspirin if there is an allergy
101
Angioplasty vs Thromobolytics
Angioplasty is superior to thrombolytics b/c
- Survival and mortality benefit
- Fewer hemorrhagic complications
- Likelihood of developing MI complicatins (less arrhythmia, less CHF, fewer septal ruptures, few episodes of tampanade)
102
PCI
- standard of care is expected to be performed within 90 minutes of patient arriving in ED with chest pain
103
Complications of PCI
- Rupture of coronary artery on inflation of the balloon
- Restenosis (thrombosis) of the vessel after angioplasty
- Hematoma at the site of entry into artery
104
Which of the following is most important in decreasing the risk of restenosis of the coronary artery after PCI?
Placement of drug eluting stent (paclitazel, siroliums)
| - inhibit the local T cell response which reduces rate of sternosis
105
Absolute contraindications to thrombolytics
- Major bleeding into the bowel (melena) or brain (any type of CNS bleeding)
- Recent surgery (within the last 2 weeks)
- Severe hypertension (above 180/110)
- Nonhemorrhagic stroke within the last 6 months
106
Pt comes to a small rural hospital w/o catherization lab. The patient has chest pain and ST segment elevation. What is the most appropriate next step in the management of the patient?
Administer thrombolytics now
- better than angioplasty delayed by several hrs
- mortality benefit of thombolytics extend to 12 hrs
107
Best initial therapy for acute coronary syndrome?
Asprin
| - best used for everyone
108
Indication for clopidogrel in ACS
- when aspirin not tolerated, those undergoing angioplasty and stenting
109
Indication for Beta blockers in ACS
- used in everyone
| - effect is not dependent on time - starting anytime during admission
110
Indication for ACE inhibitors and ARB in ACS
- used in everyone
| - benefits those with ejection fraction < 35%
111
Indication for statins in ACS
- used in everyone
| - benefits those with LDL > 100 mg/ dL
112
Indication for oxygen and nitrates in ACS
- used everyone
| - no clear mortality benefit
113
Indication for heparin in ACS
- after thrombolytics / PCI to prevent restenosis
| initial therapy with ST depression and other non- STEMI events (unstable angina)
114
Indication for calcium channel blockers in ACS
- when beta blockers can't be used
- cocaine induced pain
- Prinzmetal variant or vasospastic variant angina
115
Most dangerous risk factors in terms of risk or CAD?
Elevated LDL
116
Man comes to the emergency department w/ chest pain for the last hr that is crushing in quality and does not change w/ respiration or position of his body. EKG shows ST segment depression in leads V2 - V4. Aspirin has been given. What is the most appropriate next step in management?
Heparin
- heparin will prevent clot formation in coronary arteries but does not dissolve already formed clots
- there is no ST ELEVATION, no benefit of thrombolytics
117
Glycoprotein IIb/IIIa Inhibitors (Abciximab, Tirofiban, Eptifibitide)
- used in ACS in those are to undergo angioplasty and stenting
- inhibit the aggregation of plateletss.
- led to reduction in mortality in those w/ ST depression, particularly in patients whose troponin or CK-MB levels
- not useful in acute STEMIs separate from angioplasty and stenting
118
tPA (thrombolytics) best used in which patients?
- ST elevation MI patients
119
Heparin is best used in which patients?
- non-STEMI patients
120
Glycoprotein IIa/IIIb inhibitors are best in used in which patients?
non-STEMO patients and those undergoing angioplasty and stenting
121
If in non-STEMI ACS, when all meds have been given, and patient has persistent pain, S3 gallop or CHF develop, worse EKG changes or SVT, rising troponin levels. Next step?
Urgent angiography and possible angioplasty
122
Complications of acute MI
- Bradycardia
- Tachycardia
- Tamponade/Free wall rupture
- Ventricular tachycardia/ventricular fibrillation
- Valve/septal rupture
123
Sinus bradycardia in setting of MI
- common w/ MI if vascular insufficiency of the SA node
124
3rd degree (complete) AV block
- will have CANNON A WAVES
| - obtain EKG to distinguish 3rd degree AV block vs sinus bradycardia
125
Cannon A waves
- produced by atrial systole against closed tricuspid valve
- tricuspid valve is closed b/c essence of 3rd degree block is that atria and valves are contracting separate
- JVD is bouncing up into the neck
126
Right ventricular infarction
- associated w/ new inferior wall MI and clear lungs
| - diagnosed by flipping EKG from usual left side to right side of chest
127
R coronary artery supplies
- RV
- AV node
- inferior wall of heart
128
R ventricular infarction: treatment
- High volume fluid replacement
| - avoid nitroglycerin to RV infarctions which markedly worsen cardiac filling
129
Tamponade/free wall rupture s/p MI
- takes several days s/p infarction for wall to scar and weakens enough to rupture
- look for sudden loss of pulse
- lungs are clear and is cause of pulseless electrical activity
130
Tamponade/Free Wall Rupture: Diagnosis
- emergency echocardiography
131
Ventricular Tachycardia/Ventricular Fibrillation s/p MI
- can cause sudden
- must use EKG to distinguish v-tachycardia and v-fibrillaiotn
- both treated w/ cardiovarsion/defibrillation
132
Septal rupture/Valve rupture s/p MI
- new onset of murmur and pulmonary congestion
133
Ventricular septal rupture best heard where?
- can be seen s/p MI
| - best heart at LLSB
134
Mitral regurgitation
- can occur s/p MI
| - best heard at apex w/ radiation to axilla
135
Most accurate test to detect valve rupture and septal rupture
- Echocardiogram
136
Septal rupture
- look for increase in oxygen saturation as you go from right atrium to right ventricle
137
Intraaortic balloon pump
- used when there is acute pump failure from anatomic problem that can be fixed in OR
- contracts and relazes w/ natural heartbeat
- helps give a "push forward to the blood"
138
Reinfarction or extension of infarction
- patient often presents w/ either inferior or anterior infarction
- look for reoccurrence of pain, new rales on exam, bump up CK-MB and even suddent onset of pulmonary edema
139
Reinfarction or extension of infarction
- repeat EKG
- retreat w/ angioplasty and sometimes thrombolytics in addition to usual meds (aspirin, metoprolol, nitrates, ACE, statins)
140
Aneurysm/ Mural Thrombus
- detected with echocadiogramy
| - treated w/ heparin followed by warfarin
141
Pt s/p MI presents w bradycardia and cannon A waves. Likely dx?
3rd degree AV block
142
Pt s/p MI presents w/ bradycardia. No cannon A waves on EKG. Likely dx?
Sinus bradycardia
143
Pt s/p MI w/ PMH of inferior wall MI, clear lungs, tachycardia, hypotension w/ nitroglycerin. Likely dx?
RV infarction
144
Pt s/p MI with new murmur, rales/congestion. Likely dx?
Valve rupture
145
Pt s/p MI with new murmur, increase in oxygen saturation on entering the right ventricle. Likely dx?
Septal rupture
146
Pt s/p MI with loss of pulse, need EKG to answer question. Likely diagnosis
Ventricular fibrillation
147
Before patient w/ MI is discharged. Which test should be done?
Stress test
- to determine if angiography is needed
- angiogrpay determines need for revascularization
148
Meds needed for postinfarction patients
Every MI patient should go home:
- Aspirin
- Beta blockers (metoprolol)
- Statins
- ACE inhibitors
149
ACE inhibitors are best used for which type of MI patients?
Anterior wall infarctions b/c of high likelihood of developing systolic dysfunction
150
Clopidogrel
- used for those intolerant of aspirin or post-stenting
151
ARBS
- used for MI patients with cough on ACE inhibitor
152
Prophylactic antiarrhythmic medications
- don't use amiodarone, flecainide or any rhythm controlleing med to prevent development of v-tach
153
Sexual issues postinfarction
1. Don't combine nitrates w/ sildenafil
2. Erectile dysfunction (usually from anxiety)
3. Pt doesn't have to wait after an MI to begin sexual activity
4. If post-MI stress test is normal, pt can engage in exercise program
154
Congestive Heart Failure
- dysfunction of heart as pump of blood
- dyspnea is most common function
- can be due to either systolic or diastolic dysfunction
155
Diastolic dysfunction
- inability of heart to "relax" and receive blood
| - ejection fraction is preserved and sometimes even above normal
156
Most common causes of systolic dysfunction (3)
1. Infarction
2. Cardiomyopathy (2/2 HTN)
3. Valve disease
157
Less common causes of systolic dysfunction
- Alcohol
- post viral myocarditis
- Doxorubicin use
- Chagas disease
- Hemochromatosis
158
CHF: presentation
- dyspnea
- pulmonary edema, in worst form
- orthopnea (worse when lying flat, relieved when sitting up)
- Rales on lung exam
- JVD
- paroxysmal nocturnal dyspnea (sudden worsening at night)
- S3 gallop
159
Pt presents with sudden onset dyspnea with clear lungs. Likely dx?
Pulmonary embolus
160
Pt presents w/ sudden onset dyspnea, wheexing, increased expiratory phase. Likely dx?
Asthma
161
Pt presents w/ slower onset dyspnea, sputum, unilateral rales/rhonci
Pneumonia
162
Pt presents w/ dyspnea, circumoral numbness, caffeine use, hx of anxiety. Likely dx?
Panic attack
163
Pt presents w/ pallor, gradual onset dyspnea over days to weeks. Likely dx?
Anemia
164
Pt presents w/ dyspnea, pulsus paradoxus, decreased heart sounds, JVD. Likely dx?
Tamponade
165
Pt presents w/ dyspnea, palpitations, syncope. Likely dx?
Arrhythmia of almost any kind
166
Pt presents w/ dyspnea, dullness to percussion at bases. Likely dx?
Pleural effusion
167
Pt presents w/ dyspnea, long smoking hx, barrel chest. Likely dx?
COPD
168
Pt presents w/ dyspnea, recent anesthetic use, brown blood not improved w. oxygen, clear lungs on auscultation, cyanosis. Likely dx?
Methemoglobinemia
169
Pt presents w/ dyspnea, burning building or car, wood burning stove in winder, suicide attempt. Likely dx?
Carbon monoxide poisoning
170
Most important test in CHF
Echocardiography
171
Best initial test to evaluate ejection fraction
Transthoracic echo
172
Most accurate test to evaluate ejection fraction
MUGA or nuclear vetriculography
173
When is nuclear ventriculography used to evaluate ejection fraction
- necessary when precision is needed
| - example if giving doxorubicin for chemo but need to ensure maximum treatment w/o cardiomyopathy
174
BNP level is used t evaluate
- acute SOB with unclear etiology
| - normal BNP excludes CHG
175
Best test to detemine CHF 2/2 MI or heart block
EKG
176
Best test to determine CHF 2/2 dilated cardiomyopathy
CXR
177
Best test to determine CHF 2/2 paroxysmal arrhythmias
Holter monitoring
178
Best test to determine precise valve diameter
Cardiac catherization
179
Best test to determine CHF 2/2 abnormal thyroid levels (high or low)
Thyrid function tests (T4/TSH)
180
Best test that distinguishes CHF from ARDS
Swan Ganz right heart catherization
181
Systolic Dysfunction (Low Ejection Fraction): Test
- ACE inhibitors
- Beta Blockers
- Spironolactone
- Diuretics
- Digoxin
182
Specific B-blockers beneficial in systolic dysfunction
- Metoprolol (specific B-1 antagonists)
- Bisoprolol (specific B-1 antagonists)
- Carvedilol (nonspecific B-blocker w/ alpha blocker)
183
Why B-blockers (carvedilol, metoprolol, bisoprolol) are beneficial in systolic dysfunction
- Antiischemic effect
- Decrease in HR leading to decreased oxygen consumption
- antiarrhythmic effect
184
Most common cause of death from CHF
- Arrhythmia/sudden death
185
Spironolactone
- beneficial b/c it inhibits effects of aldosterone
| - effective in later stages of CHF (stages III and IV)
186
Spironolactone: adverse effects
- Hyperkalemia
| - Gynecomastia
187
Eplerone
- alternative to spironolactone
- inhibits aldosterone
- doesnt have antiandrogen effects that leads to gynecomastia
188
Pt w/ CHF who develops gynecomastia?
Switch from spironolactone to eplerone
189
Indications for diuretics in CHF
- initial therapy in CHF w/ low ejection fraction
| - often loop diuretic with ACEi/ARB
190
Digoxin
- doesn't lower mortality in CHF
| - used to control symptoms of dyspnea and will decrease frequency of hospitalixations
191
74 y/o A-A man w/ hx of dilatered cardiomyopathy 2/2 o MI in past is seen in office. He is asymptomatic and is maintained on lisinopril, furosemide, metoprolol aspirin, and digoxin. Lab tests reveal elevated K level. EKG is unchanged. Best management?
Switch from lisinopril to hydralazine and nitroglycerin
192
Non pharm treatments that have mortality benefit in CHF
1. Implantable defribrillator: used in for EF < 35% and ischemic cardiomyopathy
2. Biventricular pacemaker: used in dilated cardiomopathy and ejection fraction < 35% and a wide QRS > 120ms
193
Drugs w/ mortality benefit in CHF
- ACEi/ARBS
- Spironolactone or eplerone
- Beta blockers
- Hydralazine/nitrates
- Implantable defibrillator
194
Diastolic Dysfunction (CHF w/ preserved EF)
- B-blockers are beneficial
| - Diuretics are used to control symptoms of fluid overload
195
HOCM (hypertrophic obstructive cardiomyopathy)
- congenital disease w/ asymmetrically enlarged (hypertrophic) septum leading to an obstruction of LV outflow tract
* diuretics are contraindicated b/c they increase obstruction**
196
Pulmonary edema
- most severe form ofCHF
| - rapid onset of fluid accumulating in lungs
197
Pulmonary edema: presentation
- Rales
- JVD
- S3 gallop
- Edema
- Orthopnea
198
Pulmonary edema: diagnostic tests
- BNP is etiology of dyspnea is unclear
- CXR shows vascular congestion with filling of blood vessels towards the head
- Respiratory alkalosis on ABG
- EKG
- Echo
199
Best test to do in acute pulmonary edema
EKG
| ** if pt has arrhythmia (a-fib, a-flutter, or v-tach) best thing to do is rapid cardioversion
200
Correcting which risk factor for CAD will result in the most immediate benefit for the patient?
Smoking cessation
201
Chest pain described as dull / "sore" and/or squeezing or pressure-like
ischemic pain
- sharp ("knifelike") or pointlike
- lasts for a few seconds
202
Chest pain that excludes ischemic pain
1. changes with respiration (pleuritic)
2. changes with position of the body
3. changes with touch of the chest wall (tenderness)
** if patient answers yes to the previous questions, likely NOT ischemic
203
Most common cause of chest pain
Gastrointestinal disorders
204
Patient describes chest wall tenderness. Most likely diagnosis?
Costochrondritis
205
Most accurate test for costochondritis
Physical exam
206
Patient describes chest pain that radiates to the back, unequal blood pressure between arms. Most likely diagnosis?
Aortic dissection
207
Most accurate test for aortic dissection
CXR
w/ widened mediastinum
- chest CT, MRI, or TEE confirms the disease
208
Young Pt (< 40) c/o chest pain worse with lying flat, better when sitting up. Likely diagnosis?
Pericarditis
209
Most accurate test for pericarditis
Electrocardiogram with ST elevation every where
| PR depression
210
Pt describes epigastric discomfort, pain better when eating. Likely diagnosis?
Duodenal ulcer disease
211
Most accurate test for chest pain
Endoscopy
212
Pt describes chest pain with bad tatse, cough, hoarsness
Gastroesophageal reflux
213
Most accurate test for GERD
Response to PPIs;
- alumnium hydroxide and magnesium hydroxide
- viscous lidocaine
214
Pt describes chest pain with cough, sputum, and hemoptysis. Likely diagnosis?
Pneumonia
215
Most accurate test for pneumonia
CXR
216
Patient describes chest pain with sudden onset SOB, tacycardia, and hypoxia.
Pulmonary embolus
217
Most accurate test for pulmonary embolus
- spiral CT
| - V/Q scan
218
Pt complains chest pain with sharp, pleuritic pain, and tracheal deviation. Likely diagnosis?
Pneumothorax
219
Most accurate test for pneumothorax
Chest X-ray
220
Worst prognostic significance for chest pain
Shortness of breath
221
Best initial test for chest pain
Electrocardiogram (EKG)`
| - in office setting, the EKG is normal most of time but cannot progress to other testing without this test
222
If patient has acute chest pain in an office/ambulatory setting, what is the next best step to evaluate chest pain?
Transfer to ER
| - DON'T ANSWER CARDIAC ENZYMES!!
223
If patient has chest pain in office/clinic for days to weeks, are cardiac enzymes appropriate?
No enzymes
224
If patient has chest pain in emergency department for minutes to hours, are cardiac enzymes appropriate?
Yes enzymes,
| after an EKG is performed
225
When the etiology of chest pain is not clear, what is the best tool for evaluation of chest pain?
Exercise tolerance testing (ETT)
226
What are the two best factors for ETT
1. You can read the EKG
| 2. The patient can exercise (gets heart rate > 85% of maximum)
227
Maximum heart rate
220 - age of patient
228
Best way to detect ischemia on EKG
ST segment depression
229
If you cannot read EKG because of baseline EKG abnormality, what are the 2 best ways to detect ischemia w/o EKG?
- Nuclear isotope uptake: thallium or sestamibi
| - Echocardiographic detection of wall abnormalities
230
Reasons for baseline EKG abnormalities
- Left bundle branch block
- Left ventricular hypertrophy
- Pacemaker use
- Effect of digoxin
231
Thallium testing for detection of cardiac ischemia
Normal myocardium will pick up thallium
- if myocardium is alive and perfused, thallium will be picked by Na/K ATPase
- if myocardium is abnormal, thallium has decreased uptake
232
Echocardiogram for detection of cardiac ischemia
Normal myocardium will move on contraction
| - abnormal heart has decreased wall motion (dyskinesis, akinesis, or hypokinesis)
233
Ischemia vs infarction
ischemia: decreased perfusion that is detected by REVERSAL of thallium uptake or wall motion that returns to normal after rest period
234
If patient is unable to exercise to detect cardiac ischemia with exercise tolerance testing, what is the best method of detecting cardiac ischemia?
Pharm testing
- Persantine (dipyramidole) or adenosine in combination with thallium or nuclear isotopes
- Dobutamine in combination with echocardiogram
235
How does dobutamine work to detect cardiac ischemia
Dobutamine will increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities on ech
236
Coronary Angiography
- used to detect anatomic location of coronary artery disease
- use to determine whether narrowing should be best dealt with by surgery, angiography, or methods of revascularization
237
Most accurate test for detecting coronary artery disease
Angiography
238
Arterial stenosis
- insignificant when less than 50%
| - surgically correctable when > 70%
239
Holter monitoring
- continuous ambulatory EKG monitor that records rhythm
- used for 24 - 72 hrs
- mainly detects rhythm disorders (a-fib, a-glutter, PVCs)
- does not detect ischemia and not for evaluating ST segment
240
48 y.o woman comes to office w/ chest pain that has been occurring over the last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of pain is retrosternal. She has no hypertension and the EKG is normal. What is the next best step?
Exercise tolerance testing
241
Medications that lower mortality in setting of chronic angina
- Aspirin
- Beta blockers
- Nitroglycerin
242
Route of nitroglycerin in chronic angina
Orally or a transdermal patch
243
Route of nitroglycerin in acute coronary syndromes
Sublingual, paste, and IV forms of nitroglycerine
244
Clopidogrel
- aspirin intolerance (e.g. allergy)
- recent angioplasty with stenting
- rarely used with TTP
245
Prasugrel
- thienopyridine medication in same clas as clopidogrel and ticlopidine
- antiplatelet medication best used for angioplasty ad stenting
246
Ticlopidine
- antiplatelet med in rare patient intolerant of both aspirin and clopidogrel
- should not be used if aspirin/clopidogrel intolerance is bleeding
- can cause neutropenia and TTP
247
Ranolazine
- additional therapy for angina refractory or persistent through treatment
248
ACE inhibitors / ARBS: Indications
- low systolic ejection raction/ systolic dysfunction (best mortality beneift)
- regurgitant valvular disease
249
Most common side effect of ACE inhibitors
Cough
250
64 y/o man is placed on lisinopril as part of managing CAD in association with ejection fraction of 24% and symptoms of breathlessness. Although he sometimes has rales on lung exam, the patient is asymptomatic today. PE should minimal edema of lower extremities. Blood tests reveal an elevated level of K that is present on a repeat measurement. EKG is unchanged. What's the best way to manage this patient
Switch from lisinopril to hydralazine and nitrates
- Lisinopril also cause hyperkalemia due to inhibition of aldosterone
- hydralazine will decrease afterload a arterial vasodilator
251
Why should hydralazine be used with nitrates in systolic dysfunction?
Hydralazine in an arterial vasodilator that decreases afterload
- used w/ nitrates to dilate coronary arteries so that blood isn't stolen away from coronary perfusion when afterload is decreased w/ hydrazalines
252
Lipid Management in CAD
Patients use statins w/ CAD with an LDL above 100 mg/dL
253
Aside from CAD, other conditions in which lipids should be controlled to < 100 mg/dL
- Peripheral artery disease (PAD)
- Carotid disease (not stroke)
- Aortic disease ( the artery, not the valve)
- Diabetes mellitus
254
Most common adverse effect of statins
Liver dysfunction
| - elevation of transaminases
255
Why are statins considered to have some mortality benefit?
Statins have antioxidant effect on endothelial lining of coronary arteries
256
Niacin
- used to lower lipid levels
- associated w/ glucose intolerance, elevation of uric avid level and itchiness due histalimine rlease
- excellent ADDITION to statins if full lipid control not achieved with statins alone
257
Gemfibrozil
- fibric acids lower triglyceride levels more than statins however, less mortality benefit than statins
- caution using with statins due to increased risk of myositis
258
Cholestyramine
- bile acid sequestrant but often has interactions with other drugs in gut by blocking their absorption
- associated with uncomfortabe GI complaints such as constipation and flatus
259
Ezetimibe
- lowers LDL level w/o any evidence of actual benefit to patient
- no better than placebo in terms of endpoints (e.g. MI, stroke or death)
260
Statin: adverse effect
- elevations of transaminases (liver fxn tests)
| - myositis
261
Niacin: adverse effect
- elevation in glucose and uric acid level
| - pruritis
262
Fibric acid derivatives: adverse effect
- increased risk of myositis when combined with statins
263
Cholestyramine: adverse effect
Flatus and abdominal discomfort
264
Ezetimibe: adverse effect
- well tolerated and nearly useless
265
Dihydropyridine calcium channel blockers
- Nifedipine
- Nitrenipine
- Nicardipine
- Nimodipine
266
Dihydropyridine calciums affect mortality of CAD patients in which way?
They INCREASE mortality in patients with CAD b/c they raise heart rate
- the increased HR will increase myocardial oxygen consumption
267
Which calcium channel blockers are used in CAD?
Verapamil
| Diltiazem
268
Indications for use of CCB in CAD
- Severe asthma precluding use of B-blockers
- Prinzmetal variant angina
- Cocaine induced chest pain (B-blockers are contraindicated)
- Inability to control pain w/ maximal medical therapy
269
Calcium channel blockers: Adverse effects
- Edema
- Constipation (verapamil most often)
- Heart block (rare)
270
Which diagnostic test is best to evaluate patient for revascularization?
- Angiography to determine whether patient needs CABG or angioplasty
271
Indications for coronary artery bypass grafting (CABG)
- Three vessels > 70% stenosis in each vessel
- Left main coronary artery occlusion
- Two-vessel disease in a patient with diabetes
- Persistent symptoms despite maximal medical therapy
272
Pts that benefit the most from CABG
- patients with EF < 35%
273
Which grafted veins are used for CABG
- Internal mammary artery grafts last 10 yrs before occlusion
- Saphenous vein grafts remain patent reliably for 5 years
274
Percutanous coronary intevention
- aka angioplasty
- best therapy for acute coronary syndromes esp those with ST segment elevation
- does not provide clear mortality benefit for stable CAD patients
275
Maximal medical therapy in stable CAD
- ASpirin
- Beta Blockers
- ACEis / ARBs
- Statin
276
70 y.o F comes to ED w/ crushing substernal chest pain for the last hr. The pain radiates to her left artm and is associated with anxiety, diaphoresis, and nausea. She describes the pain as "sore" and "dull" and clenches her fist in front of her chest/ She has a hx of hyperension What is most likely to be found in this patient?
S4 gallop b/c ishemia leading to noncompliance of left ventricle
277
Kussmaul sign
- increase in JVP on inhalation
- often associated with constrictive pericarditis or restrictive cardiomyopathy
- "scratchy" sound in pericardial friction rub
278
Dressler synrome
- complication of myocardial infarction that occurs several days after MI and is much rarer than simpler ventricular iscemia
279
Patent ductus arteriosus (PDA)
- continuous "machinery" murmur t
280
Displaced point of maximal impulse (PMI)
- characteristic of left ventricular hypertrophy as well as dilated cardiomyopathy
- anatomic abnormality that can't occur with an acute coronary syndrome
281
70 y.o F comes to the emergency department w/ crushing substernal chest pain for the last hr. Which of the following EKG findings would be associated with the prognosis?
ST elevations in V2 - V4
- corresponds to the anterior wall of the left ventricle
- signifies an acute myocardial infarction
282
Premature ventricular complexes (PVCS)
- should not be treated
- associated with an acute infarction
- treatment of PVCs only worsens outcome
283
70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hour. An EKG shows ST segment elevation in V-2. What is the most appropriate next step of management in this patient?
Aspirin
- lowers mortality and important to administer as quickly as possible
- initiate therapy before moving patien to the ICU
284
70 y/o F comes to the emergency department w/ crushing substernal chest pain for the last hr. An EKG shows ST segment elevation in leads V2 - V4. Aspirin has been given to the patient to chew. What is the most appropriate next step in management?
Angioplasty is associated with greatest mortality benefit
285
Pt c/o chest pain, when to do an EKG
- immediately at onset of pain
| - ST elevation progresses to Q waves over several days to a week
286
Myoglobin
- becomes abnormal 1-4 hrs
| - duration of myoglobin elevation is 1-2 days
287
CK-MB
- becomes abnormal 4-6 hrs
| - duration of elevated CK-MB for 1-2 days
288
Troponin
- becomes abnormal in 4-6 hrs
| - duration of elevated troponin is 10-14 hrs
289
Difficulty of using troponin levels in detection of myocardial infarctions
- Troponin can't distinguish btwn reinfarction occurring several days after 1st event
- Renal insufficiency can result in false positive tests since troponin is excreted via kidneys
290
If pt c/o of new chest pain within a few days of first cardiac event, how do you manage this condition?
Concern for reinfarction
1. Perform an EKG to detect NEW ST segment abnormalities
2. Check CK-MB levels
* * after two days, the CK-MB levels should have returned to normal
3. Transfer to ICU if new infarction
291
Most common cause of death in first several days of MI
Ventricular arrhythmia (v-tach, v-fib)
292
ST segment elevation myocardial infarction (STEMI)
- best initially managed with aspirin (orally or chewed).
| - clopidogrel can be used an alternative to aspirin if there is an allergy
293
Angioplasty vs Thromobolytics
Angioplasty is superior to thrombolytics b/c
- Survival and mortality benefit
- Fewer hemorrhagic complications
- Likelihood of developing MI complicatins (less arrhythmia, less CHF, fewer septal ruptures, few episodes of tampanade)
294
PCI
- standard of care is expected to be performed within 90 minutes of patient arriving in ED with chest pain
295
Complications of PCI
- Rupture of coronary artery on inflation of the balloon
- Restenosis (thrombosis) of the vessel after angioplasty
- Hematoma at the site of entry into artery
296
Which of the following is most important in decreasing the risk of restenosis of the coronary artery after PCI?
Placement of drug eluting stent (paclitazel, siroliums)
| - inhibit the local T cell response which reduces rate of sternosis
297
Absolute contraindications to thrombolytics
- Major bleeding into the bowel (melena) or brain (any type of CNS bleeding)
- Recent surgery (within the last 2 weeks)
- Severe hypertension (above 180/110)
- Nonhemorrhagic stroke within the last 6 months
298
Pt comes to a small rural hospital w/o catherization lab. The patient has chest pain and ST segment elevation. What is the most appropriate next step in the management of the patient?
Administer thrombolytics now
- better than angioplasty delayed by several hrs
- mortality benefit of thombolytics extend to 12 hrs
299
Best initial therapy for acute coronary syndrome?
Asprin
| - best used for everyone
300
Indication for clopidogrel in ACS
- when aspirin not tolerated, those undergoing angioplasty and stenting
301
Indication for Beta blockers in ACS
- used in everyone
| - effect is not dependent on time - starting anytime during admission
302
Indication for ACE inhibitors and ARB in ACS
- used in everyone
| - benefits those with ejection fraction < 35%
303
Indication for statins in ACS
- used in everyone
| - benefits those with LDL > 100 mg/ dL
304
Indication for oxygen and nitrates in ACS
- used everyone
| - no clear mortality benefit
305
Indication for heparin in ACS
- after thrombolytics / PCI to prevent restenosis
| initial therapy with ST depression and other non- STEMI events (unstable angina)
306
Indication for calcium channel blockers in ACS
- when beta blockers can't be used
- cocaine induced pain
- Prinzmetal variant or vasospastic variant angina
308
Man comes to the emergency department w/ chest pain for the last hr that is crushing in quality and does not change w/ respiration or position of his body. EKG shows ST segment depression in leads V2 - V4. Aspirin has been given. What is the most appropriate next step in management?
Heparin
- heparin will prevent clot formation in coronary arteries but does not dissolve already formed clots
- there is no ST ELEVATION, no benefit of thrombolytics
309
Glycoprotein IIb/IIIa Inhibitors (Abciximab, Tirofiban, Eptifibitide)
- used in ACS in those are to undergo angioplasty and stenting
- inhibit the aggregation of plateletss.
- led to reduction in mortality in those w/ ST depression, particularly in patients whose troponin or CK-MB levels
- not useful in acute STEMIs separate from angioplasty and stenting
310
tPA (thrombolytics) best used in which patients?
- ST elevation MI patients
311
Heparin is best used in which patients?
- non-STEMI patients
312
Glycoprotein IIa/IIIb inhibitors are best in used in which patients?
non-STEMO patients and those undergoing angioplasty and stenting
313
If in non-STEMI ACS, when all meds have been given, and patient has persistent pain, S3 gallop or CHF develop, worse EKG changes or SVT, rising troponin levels. Next step?
Urgent angiography and possible angioplasty
314
Complications of acute MI
- Bradycardia
- Tachycardia
- Tamponade/Free wall rupture
- Ventricular tachycardia/ventricular fibrillation
- Valve/septal rupture
315
Sinus bradycardia in setting of MI
- common w/ MI if vascular insufficiency of the SA node
316
3rd degree (complete) AV block
- will have CANNON A WAVES
| - obtain EKG to distinguish 3rd degree AV block vs sinus bradycardia
317
Cannon A waves
- produced by atrial systole against closed tricuspid valve
- tricuspid valve is closed b/c essence of 3rd degree block is that atria and valves are contracting separate
- JVD is bouncing up into the neck
318
Right ventricular infarction
- associated w/ new inferior wall MI and clear lungs
| - diagnosed by flipping EKG from usual left side to right side of chest
319
R coronary artery supplies
- RV
- AV node
- inferior wall of heart
320
R ventricular infarction: treatment
- High volume fluid replacement
| - avoid nitroglycerin to RV infarctions which markedly worsen cardiac filling
321
Tamponade/free wall rupture s/p MI
- takes several days s/p infarction for wall to scar and weakens enough to rupture
- look for sudden loss of pulse
- lungs are clear and is cause of pulseless electrical activity
322
Tamponade/Free Wall Rupture: Diagnosis
- emergency echocardiography
323
Ventricular Tachycardia/Ventricular Fibrillation s/p MI
- can cause sudden
- must use EKG to distinguish v-tachycardia and v-fibrillaiotn
- both treated w/ cardiovarsion/defibrillation
324
Septal rupture/Valve rupture s/p MI
- new onset of murmur and pulmonary congestion
325
Ventricular septal rupture best heard where?
- can be seen s/p MI
| - best heart at LLSB
326
Mitral regurgitation
- can occur s/p MI
| - best heard at apex w/ radiation to axilla
327
Most accurate test to detect valve rupture and septal rupture
- Echocardiogram
328
Septal rupture
- look for increase in oxygen saturation as you go from right atrium to right ventricle
329
Intraaortic balloon pump
- used when there is acute pump failure from anatomic problem that can be fixed in OR
- contracts and relazes w/ natural heartbeat
- helps give a "push forward to the blood"
330
Reinfarction or extension of infarction
- patient often presents w/ either inferior or anterior infarction
- look for reoccurrence of pain, new rales on exam, bump up CK-MB and even suddent onset of pulmonary edema
331
Reinfarction or extension of infarction
- repeat EKG
- retreat w/ angioplasty and sometimes thrombolytics in addition to usual meds (aspirin, metoprolol, nitrates, ACE, statins)
332
Aneurysm/ Mural Thrombus
- detected with echocadiogramy
| - treated w/ heparin followed by warfarin
333
Pt s/p MI presents w bradycardia and cannon A waves. Likely dx?
3rd degree AV block
334
Pt s/p MI presents w/ bradycardia. No cannon A waves on EKG. Likely dx?
Sinus bradycardia
335
Pt s/p MI w/ PMH of inferior wall MI, clear lungs, tachycardia, hypotension w/ nitroglycerin. Likely dx?
RV infarction
336
Pt s/p MI with new murmur, rales/congestion. Likely dx?
Valve rupture
337
Pt s/p MI with new murmur, increase in oxygen saturation on entering the right ventricle. Likely dx?
Septal rupture
338
Pt s/p MI with loss of pulse, need EKG to answer question. Likely diagnosis
Ventricular fibrillation
339
Before patient w/ MI is discharged. Which test should be done?
Stress test
- to determine if angiography is needed
- angiogrpay determines need for revascularization
340
Meds needed for postinfarction patients
Every MI patient should go home:
- Aspirin
- Beta blockers (metoprolol)
- Statins
- ACE inhibitors
341
ACE inhibitors are best used for which type of MI patients?
Anterior wall infarctions b/c of high likelihood of developing systolic dysfunction
342
Clopidogrel
- used for those intolerant of aspirin or post-stenting
343
ARBS
- used for MI patients with cough on ACE inhibitor
344
Prophylactic antiarrhythmic medications
- don't use amiodarone, flecainide or any rhythm controlleing med to prevent development of v-tach
345
Sexual issues postinfarction
1. Don't combine nitrates w/ sildenafil
2. Erectile dysfunction (usually from anxiety)
3. Pt doesn't have to wait after an MI to begin sexual activity
4. If post-MI stress test is normal, pt can engage in exercise program
346
Congestive Heart Failure
- dysfunction of heart as pump of blood
- dyspnea is most common function
- can be due to either systolic or diastolic dysfunction
347
Diastolic dysfunction
- inability of heart to "relax" and receive blood
| - ejection fraction is preserved and sometimes even above normal
348
Most common causes of systolic dysfunction (3)
1. Infarction
2. Cardiomyopathy (2/2 HTN)
3. Valve disease
349
Less common causes of systolic dysfunction
- Alcohol
- post viral myocarditis
- Doxorubicin use
- Chagas disease
- Hemochromatosis
350
CHF: presentation
- dyspnea
- pulmonary edema, in worst form
- orthopnea (worse when lying flat, relieved when sitting up)
- Rales on lung exam
- JVD
- paroxysmal nocturnal dyspnea (sudden worsening at night)
- S3 gallop
351
Pt presents with sudden onset dyspnea with clear lungs. Likely dx?
Pulmonary embolus
352
Pt presents w/ sudden onset dyspnea, wheexing, increased expiratory phase. Likely dx?
Asthma
353
Pt presents w/ slower onset dyspnea, sputum, unilateral rales/rhonci
Pneumonia
354
Pt presents w/ dyspnea, circumoral numbness, caffeine use, hx of anxiety. Likely dx?
Panic attack
355
Pt presents w/ pallor, gradual onset dyspnea over days to weeks. Likely dx?
Anemia
356
Pt presents w/ dyspnea, pulsus paradoxus, decreased heart sounds, JVD. Likely dx?
Tamponade
357
Pt presents w/ dyspnea, palpitations, syncope. Likely dx?
Arrhythmia of almost any kind
358
Pt presents w/ dyspnea, dullness to percussion at bases. Likely dx?
Pleural effusion
359
Pt presents w/ dyspnea, long smoking hx, barrel chest. Likely dx?
COPD
360
Pt presents w/ dyspnea, recent anesthetic use, brown blood not improved w. oxygen, clear lungs on auscultation, cyanosis. Likely dx?
Methemoglobinemia
361
Pt presents w/ dyspnea, burning building or car, wood burning stove in winder, suicide attempt. Likely dx?
Carbon monoxide poisoning
362
Most important test in CHF
Echocardiography
363
Best initial test to evaluate ejection fraction
Transthoracic echo
364
Most accurate test to evaluate ejection fraction
MUGA or nuclear vetriculography
365
When is nuclear ventriculography used to evaluate ejection fraction
- necessary when precision is needed
| - example if giving doxorubicin for chemo but need to ensure maximum treatment w/o cardiomyopathy
366
BNP level is used t evaluate
- acute SOB with unclear etiology
| - normal BNP excludes CHG
367
Best test to detemine CHF 2/2 MI or heart block
EKG
368
Best test to determine CHF 2/2 dilated cardiomyopathy
CXR
369
Best test to determine CHF 2/2 paroxysmal arrhythmias
Holter monitoring
370
Best test to determine precise valve diameter
Cardiac catherization
371
Best test to determine CHF 2/2 abnormal thyroid levels (high or low)
Thyrid function tests (T4/TSH)
372
Best test that distinguishes CHF from ARDS
Swan Ganz right heart catherization
373
Systolic Dysfunction (Low Ejection Fraction): Test
- ACE inhibitors
- Beta Blockers
- Spironolactone
- Diuretics
- Digoxin
374
Specific B-blockers beneficial in systolic dysfunction
- Metoprolol (specific B-1 antagonists)
- Bisoprolol (specific B-1 antagonists)
- Carvedilol (nonspecific B-blocker w/ alpha blocker)
375
Why B-blockers (carvedilol, metoprolol, bisoprolol) are beneficial in systolic dysfunction
- Antiischemic effect
- Decrease in HR leading to decreased oxygen consumption
- antiarrhythmic effect
376
Most common cause of death from CHF
- Arrhythmia/sudden death
377
Spironolactone
- beneficial b/c it inhibits effects of aldosterone
| - effective in later stages of CHF (stages III and IV)
378
Spironolactone: adverse effects
- Hyperkalemia
| - Gynecomastia
379
Eplerone
- alternative to spironolactone
- inhibits aldosterone
- doesnt have antiandrogen effects that leads to gynecomastia
380
Pt w/ CHF who develops gynecomastia?
Switch from spironolactone to eplerone
381
Indications for diuretics in CHF
- initial therapy in CHF w/ low ejection fraction
| - often loop diuretic with ACEi/ARB
382
Digoxin
- doesn't lower mortality in CHF
| - used to control symptoms of dyspnea and will decrease frequency of hospitalixations
383
74 y/o A-A man w/ hx of dilatered cardiomyopathy 2/2 o MI in past is seen in office. He is asymptomatic and is maintained on lisinopril, furosemide, metoprolol aspirin, and digoxin. Lab tests reveal elevated K level. EKG is unchanged. Best management?
Switch from lisinopril to hydralazine and nitroglycerin
384
Non pharm treatments that have mortality benefit in CHF
1. Implantable defribrillator: used in for EF < 35% and ischemic cardiomyopathy
2. Biventricular pacemaker: used in dilated cardiomopathy and ejection fraction < 35% and a wide QRS > 120ms
385
Drugs w/ mortality benefit in CHF
- ACEi/ARBS
- Spironolactone or eplerone
- Beta blockers
- Hydralazine/nitrates
- Implantable defibrillator
386
Diastolic Dysfunction (CHF w/ preserved EF)
- B-blockers are beneficial
| - Diuretics are used to control symptoms of fluid overload
387
HOCM (hypertrophic obstructive cardiomyopathy)
- congenital disease w/ asymmetrically enlarged (hypertrophic) septum leading to an obstruction of LV outflow tract
* diuretics are contraindicated b/c they increase obstruction**
388
Pulmonary edema
- most severe form ofCHF
| - rapid onset of fluid accumulating in lungs
389
Pulmonary edema: presentation
- Rales
- JVD
- S3 gallop
- Edema
- Orthopnea
390
Pulmonary edema: diagnostic tests
- BNP is etiology of dyspnea is unclear
- CXR shows vascular congestion with filling of blood vessels towards the head
- Respiratory alkalosis on ABG
- EKG
- Echo
391
Best test to do in acute pulmonary edema
EKG
| ** if pt has arrhythmia (a-fib, a-flutter, or v-tach) best thing to do is rapid cardioversion
392
74 y.o F comes to the ED w/ acute onset SOB, RR of 38 bpm, S3 gallop, and JVD. What's the best initial step?
IV furosemide
| - acute management to remove large amts of fluid
393
CHF: Treatment
Initial therapy of pulmonary edema w/
- Oxygen
- Loop diuretics (e.g. furosemide or bumetanide)
- Morphine
- Nitrates
394
CHF: Treatment options
- Preload reduction ( w/ furosemide or bumetanide)
- Positive inotropic agents (e.g dobutamide)
- Afterload reduction (w/ ACEis / ARBs)
395
Positive ionotropes in setting of CHF
- Dobutamine
| - Amrinone and milrinone - phosphodiesterase inhibitors increase contractility and decrease afterload
396
Digoxin
positive ionotrope that increases contractility but does not have effect for several weeks
397
Afterload reduction in CHF
- Long term setting: ACEis/ ARBs
| - Acute setting: nitroprusside and IV hydralazine
398
Rheumatic fever
- associated with any form of valve disease
| - mitral stenosis is most common
399
Regurgitant valvular disease
- associated w. hypertension and ischemic heart disease
| - infarction automatically leads to regurgitation which leads to dilation
400
Right heart sided lesions: heart sounds
- tricuspid and pulmonic valves increase in intensity or loudness w/ inhalation
- inhalation will increase venous return to the heart
401
Left sided lesions (mitral valve and aortic valve): presentation
- increase w/ exhalation
| - exhalation will "squeeze" blood out of the lungs and into the left side of the heart
402
Best initial test for all valvular heart disease
Echocardiogram
| - TEE is most sensitive and specific than TTE
403
Most accurate test for valvular heart disease
Catherization
| - allows for precise measurement of valve diameter as well as exact pressure gradient across the valve
404
Mitral stenosis: treatment
- dilated w. a ballooon
405
Aortic stenosis: treatment
Surgical replacement of aortic valve
406
Regurgitant lesions: treatment
- respond best to vasodilator therapy w/ ACEi, ARBs, nifedipine, or hydralazine
- ** surgical replacement of regurgitant valves must be done before valve dilates too much **
407
Mitral stenosis
- often caused by rheumatic fever
| - critical narrowing by 1 cm ˆ2
408
Why should we worried about pregnant patients who emigrated from country w. high prevalence of rheumatic fever?
Pregnancy increases plasma by 50% which now must traverse narrow valve which can lead to pregnancy induced cardiomyopathy
409
Mitral stenosis: presentation
- dyspnea and CHF
- dysphagia (from dilated LA pressing on esophagus)
- hoarseness (LA pressing on laryngeal nerve)
- atrial fibrillation and stroke (from enlarged LA)
- hemoptysis
410
Mitral stenosis: physical findings
diastolic murmur (
