Cardiology part 4 Flashcards
Antiplatelet therapy after Coronary Stenting
x
trx
x
what is the recommended duration of therapy antiplatelet therapy after coronary stenting?
- DAPT (dual antiplatelet therapy=aspirin + P2Y12 receptor blocker) for minimum of 6-12 months after Bare Metal stent or Drug eluting stent placement
- DAPT for minimum of 4 weeks in select patients after BMS
- Continue DAPT for a total of 30 months if pos
what is perioperative management of antiplatelet therapy after coronary stenting if elective surgery?
defer surgery until after minimum DAPT duration
what is perioperative management of antiplatelet therapy after coronary stenting if urgent surgery?
continue P2Y12 receptor blocker or hold for shortest duration possible
what is perioperative management of antiplatelet therapy after coronary stenting if high risk of severe surgical bleeding?
continue aspirin unless high risk of severe surgical bleeding
Trastuzumab
x
side effects
x
what are the side effects of trastuzumab?
cardiotoxicity
what is the incidence of cardiotoxicity?
5% with trastuzumab monotherapy, but it is 25% with trastuzumab combined with anthracycline (eg doxorubicin) and cyclophosphamide.
MOA
x
how does trastuzumab work?
monoclonal Ab that targets HER2
managment
x
what is the management of trastuzumab only cardiotoxicity?
reversible
what is the management of chronic anthracycline + trastuzumab cardiotoxicity?
not reversible because dose related due to myocyte necrosis , destruction, and replacement of fibrous tissue
when should you hold trastuzumab?
- if CHF develops
- if LVEF decreases by >=16% from baseline, or by 10-15% from baseline to below the lower limits of normal
Statin induced Myopathy
x
risk
x
what are the risks that lead to statin induced myopathy?
prolonged vigorous excercise
management
x
what are the indications for discontinuation of statin therapy?
Asyx patients with CK > 10 x Upper Limit of Normal
if the elevation of CK is temporally related to excercise, then what should you do?
recheck CK levels and restart atorvastatin if the levels have normalized
RBC transfusion
x
indications
x
what are the general indications for RBC transfusion?
Hgb <7g/dL
when would transfusion be appropriate for Hgb of 7-8?
cardiac surgery, oncology patients in trx, CHF
when would transfusion be appropriate for Hgb of 8-10?
- syx anemia,
- ongoing bleeding
- ACS
- noncardiac surgery
if Hgb >10, would you ever transfuse?
nope not generally
Heart Auscultation
x
where do you hear the aortic valve best?
2nd ICS to the right of sternal border
where do you hear the pulmonic valve best?
2nd ICS to the left of sternal border
where do you hear Erbs point ?
3rd ICS to the left of sternal border
where do you hear Tricuspic Valve best?
5th ICS to the lower left of sternal border
where do you hear Mtiral valve Best?
apex, PMI and 5th intercostal space at mid clavicular line
Antithrombotic Therapy in Patients with mechanical Heart Valves
x
risk
x
what are the risks of throomboembolism in patients per year with mechanical prosthetic valves with no anticoag vs with aspirin vs with warfarin?
no anticoag: 4%
w aspirin: 2%
w warfarin: <1%
who has higher risk of stroke mitral mechanical valves or aortic valve prosthesis?
mitral valve have twic the risk of stroke
risk
x
what are considered risk factors/comorbidities in those with artificial valves?
Atrial fibrillation, severe left ventricular dysfunction EF <=30%, prior thromboembolism, presence of hypercoagulable state
management
x
what are current guidelines for INR for patients with aortic valve replacements and no risk factors (i.e. no a fib, severe left ventricular dysfunction EF <=30%, prior thromboembolism, presence of hypercoagulable state)?
INR of 2-3 using aspirin and warfarin
what is the goal warfarin INR if patients have mitral valve replacement, aortic valve replacement with presence of risk factors, in the first 3 months after aortic valve replacement?
INR of 2.5 to 3.5 using aspirin and warfarin
in patient who can’t take warfarin, how much aspirin do you give?
75-325mg/day
in all patients who have aortic or mitral valve replacements, how much aspirin do you give in addition to warfarin?
75-100mg/day
Approach to Adult Cardiac Arrest
x
Approach to Adult Cardiac Arrest
x
Step 1 of cardiac arrest is?
start CPR, give oxygen and attach monitor/defibrillator
Step 2 are assess rhythm and decide if it is either ____ or ____
VF/pulseless VT or PEA/Asystole
if VF/Pulseless VT, then what do you do?
defibrillator shock
if VF/Pulseless VT, then what do you do after you defibrillator shock?
CPR x 2min, airway, IV/IO access, epinephrine every 3-5 minutes.
if PEA/Asystole, then what do you do ?
CPR x 2min, airway, IV/IO access, epinephrine every 3-5 minutes, so no shock needed.
After CPR x 2min, airway, IV/IO access, epinephrine every 3-5 minutes, what do you do?
pulse and rhythm check every 2 min, treat reversible causes
what do you after checking pulse and rhythm check?
identify if shockable rhythm (VF/pulseless VT) or unshockable rhythm (PEA/Asystole)
what should you always remember to do instead of giving epi on the third shockable rhythm?
give amiodarone
Adult Tachycardia Algorithm (with pulse)- ACLS
x
what is the first steps of ACLS with pulse?
identify and treat underlying cause:
- maintain patent airway; assist breathing if needed
- oxygen
- cardiac monitor to identify rhythm; monitor blood pressure and oximetry
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and the answer is yes, what is the next step?
- synchronized cardioversion,
- if regular narrow complex, consider adenosine
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and the answer is no, what is the next step?
ask if the QRS is >0.12 seconds
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and there is prolonged QRS, what is the next step?
IV access, 12 lead EKG, give adenosine if regular and monomorphic, consider antiarrhythmic infusion, consider exper consultation
if you ask yourself is there persistent tachyarrythmia causing hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure, and the QRS is not prolonged, what is the next step?
IV access, 12 lead EKG, vagal maneuvers, adenosine (if regular rhythm), beta blocker or CCB, consider exper consultation
PEA/Asystole
x
define
x
what does PEA mean?
refers to an organized cardiac rhythm (eg sinus bradycardia, atrial fibrillation) that is unable to generate sufficient cardiac output to create a measurable blood pressure or palpable pulse
cause
x
what is the underlying cause typically?
severe hypovolemia, massive PE, markedly impaired left ventricular contractility
risk
x
what is a risk for PEA and asystole?
lightning injury, rhabdomyloyslsis w renal failure,
managment
x
what is the management of Asystole ?
chest compressions while giving vasopressors (epi or vasopressin) and identifying and treating reversible causes
complications
x
what is a complication of PEA?
asystole (complete absence of organized cardiac electrical activity
reversible causes
x
what are reversible causes of Asystole/PEA?
5 H’s: Hypovolemia, Hypoxia, Hydrogen ions (acidosis), hypokalemia or hyperkalemia, hypothermia
5T’s: Tension Pneumo, Tamponade cardia, Toxins (narcotics, BDZs), Thrombosis (Pulmonary or Coronary), Trauma
Narrow Complex Tachycardias
x
Trx
x
what is treatment for Narrow Complex Tachycardias that is HD stable?
adenosine
what is treatment for Narrow Complex Tachycardias that is HD unstable?
synchronize cardioversion
Types
x
what are types of Narrow Complex Tachycardias ?
SVT’s (i.e. Afib with RVR)
what are various types of SVT?
AVNRT (atrioventricular nodal reentrant tachycardia), Sinus tachy, AV reentrant tachycardia (AVRT), Afib, and A flutter
define
x
what are the components of SVT arrhythmias?
- mostly narrow QRS complex tachcyardia.
- usually there are no regular P waves as they are buried in the QRS complexes, but retrograde P wave can occur.
- retrograde P waves : seen in the beginning or end of a QRS complex when the atria and ventricles a
Abdominal Aortic Aneurysm (AAA)
x
Anatomy
x
what is the anatomy of AAA?
most commonly affects infrarenal aorta (>=3cm)
Risks
x
what are the risks of AAA?
smoking (highest risk), male sex, older, white ethnicity, family hx of AAA, atherosclerotic disease
Screening
x
what is the screening of AAA?
abd ultrasound in men age 65-75 y.o. who have ever smoked
symptoms
x
what are the syx of AAA?
- mostly asyx,
- may have abd, back or flank pain
- lower limb ischemia and/or thromboembolism
- rupture often presents with Abd distention and shock
management
x
what is the management of AAA?
- smoking cessation is key!
- aspirin and statin therapy
when is elective repair recommnded for?
- Large (>=5.5 cm) aneurysms
- rapidly enlarging aneurysms (>= 0.5cm in 6 months)
- AAA associated with PAD or aneurysm
follow up imaging
x
what is follow up imaging for AAA?
medium artery (4-5.4cm): U/S q 6-12 months smaller: U/S q 2-3 years
risks of rupture
x
what are the three biggest risk factors for aneurysmal ruptures?
large diameter (20% risk in aneurysms >6cm), rate of expansion (>0.5 cm in 6 months), and current cigarette smoking
Cardiovascular Effects of Cocaine Intoxication
x
pathophys
x
what are the pathophysiology of cardiovascular effects of cocaine intoxication?
HTN and Tachy, coronary vasoconstriction, increased platelet activity and thrombus formation
syx
x
what are syx of cocaine intox?
CP in the middle of chest and upper sternal area,nausea, mild occipital headache
complications
x
what are the complications of cocaine intoxication?
MI or infrarct, aortic dissection, neurologic ischemia or stroke
trx
x
what is the initial mangement treatement goals of MI due to cocaine intox?
reduction of myocardial oxygen demand and improvment in myocardial oxygen supply
what is the initial treatment for cocaine intoxication in persistent CP with minimal EKG changes ?
-BDZ (reduce sympathetic outflow) and nitroglycerin (alleviates HTN and MI)
what is the second line treatment for persistent chest pain with minimal EKG changes in the setting of cocaine intoxication?
CCBs
what is the treatment for persistent HTN in the setting of cocaine intoxication?
phentolamine (alpha receptor antagonist)
if ST elevation persists in setting of cocaine intox, what is appropriate next step?
aspirin then PCI (cocain that encourage thrombus formation and cause thrombotic occlusion of coronary arteries) even in young patients.
if there is an MI due to cocaine intox, what do you do?
PCI
when are fibrinolytics (eg alteplase) recommended?
only in patients with STEMI for whom PCI cannot be performed within 2 hours of first medical contact
complications
x
what are the complications of cardiovascular effects of cocain intox?
acute aortic dissection of the ascending aorta
acute aortic dissection of the ascending aorta
x
syx
x
what are syx of aortic dissection of the ascending aorta?
new neuro findings of right sided weakness, severe, sharp, tearing CP or Back Pain
risk
x
what are the risks associated iwth aortic dissections?
HTN (Most common), marfan sydnrome, cocaine use
PE
x
what are the physical exam findings of aortic dissection?
> 20mmHg variation in SBP between arms
complications
x
what are the complications of aortic dissection?
stroke (carotid arteries), acute aortic regurg (aortic valves), horner syndrome (superior cervical sympathetic ganglion), acute MI (coronary artery), pericardial effusion/cardiac tamponade (pericardial cavity), hemothorax (pleural cavity), LE weakness or ischemia (spinal or common iliac arteries), abd pain (mesenteric artery)
dx
x
what is the dx imaging needed for acute dissection of the ascending aorta?
CT angiography
pathophys
x
how do focal neuro deficits deficits occur?
carotid artery involvement (eg obstruction by intimal flap, extension of dissection into carotids) leading to cerebral ischemia
Detection of Left to Right Shunt by Oximetry
x
dx
x
what is the best measure of oxygenation saturation changes between atria and ventricles?
right and left heart cath
location of shunt
x
what are the three most common locations of potential shunts?
atrial, ventricular , and great vessels
causes of specific shunts
x
if you’re in the level of the atria and you have step up in O2 % saturation from superior/inferior vena cava to right atrium, what are the possible causes?
- ASD
- Partial anomalous pulm venous drainage
- Ruptured sinus of valsalva
- VSD with tricuspid regurg
- coronary fistula to right atrium
if you’re in the level of the ventricle and you have step up in O2 % saturation from right atrium to right ventricle, what are the possible causes?
- VSD
- PDA with pulm regurg
- coronary fistual to right ventricle
if you’re in the level of the great vessels and you have step up in O2 % saturation from right ventricle to pulm artery, what are the possible causes?
- PDA
- Aorto-pulmonary window
