Cardiovascular (15%) Flashcards
AFib is described as an ______ ______ rhythm with (narrow/wide) QRS
Irregularly irregular
narrow
What will not be observed on a pt’s EKG with AFib?
P waves
What is the ventricular rate of a pt with AFib?
80-140 bpm, rarely >170
What is the most common chronic arrythmia?
AFib
Most patients with AFib are (asymptomatic/symptomatic)
Asymptomatic
In a pt with AFib, what sequela do we worry most about?
Thrombus formation, which can embolize and cause ischemic strokes
What is Ashman’s phenomenon?
What dz process is it associated with?
Occasional aberrantly conducted beats (wide QRS) after short R-R cycles
AFib
Is Afib more common in men or women? White or black patients?
Men
White
What are the 4 types of AFib?
Describe each.
Paroxysmal: self-terminating w/in 7 days (usually <24 hrs); ±Recurrent
Persistent: fails to self-terminate, lasts >7 days; Requires termination (medical or electrical)
Permanent: persistent AF >1 year (refractory to cardioversion or cardioversion never tried)
Lone: paroxysmal, persistent or permanent w/o evidence of heart dz
What is recommended tx for a pt with STABLE AFib?
Examples of medications?
Rate Control: preferred as initial managmenet in sx AFib pts over rhythm control
BB, CCB, Digoxin
Rhythm Control: Direct current (synchronized) cardioversion is preferred over Rx rhythm control {AFib present <48 hrs, after 3-4 wks of anticoag and TE echo w/o atrial thrombi}
Pharm rhythm control: Ibutilide, Flecainide, Sotalol, Amiodarone
Readiofrequency ablation, paermanent pacemaker
What is recommended tx for pts with UNSTABLE AFib?
Direct current (synchronized) cardioversion {DCC}
Is anticoagulation recommended for pts with AFib?
YES
What is the CHA2DS2-VASc score and why is it used?
Used for determining risk of embolization and need for anticoag
Congestive Heart Failure
Hypertension
A2ge >= 75 y/o
S2troke, TIA, thrombus
Vascular dz
Age 65-74 y/o
Sex (female)
- Maximum score = 9*
- >= 2: moderate-high risk, chronic oral anticoag recommended*
- 1: low risk, anticoag sometimes recommended*
- 0: very low risk, no anticoag needed*
What are some examples of Non vitamin K antagonist oral anticoagulants (NOAC)?
Dabigatran: direct thrombin inhibitor (binds to and inhibits thrombin)
Rivaroxaban, Apixaban, Edoxaban: Factor Xa inhibitors (selectively bind to antithrombin III)
What is the goal for INR in pts on Warafrin?
2-3
Is anticoagulant monotherapy or dual therapy superior?
monotherapy
Dual should be reserved for pts who cannot be treated with anticoagulation (for reasons OTHER than bleeding risk)
What medications can cause Long QT syndrome?
Macrolides
TCAs
What are some clinical manifestations in a pt with Long QT syndrome?
recurrent syncope, ventricular arryhtmias, and sudden cardiac death
What is the definitive management of congenital long QT syndrome?
Automatic implantable cardiodefibrilator (AICD)
_______ abnormalities may cause a pt to develop Long QT syndrome
Electrolyte
In a pt with paroxysmal aupraventricular tachycardia, their HR will be ______
They will have a (irregular/regular) rhythm with (narrow/wide) QRS complexes
____ waves are hard to discern d/t the rapid rate
>100 bpm
regular
narrow
P waves
What are the two main pathways of paroxysmal supraventricular tachycardia?
Which is MC?
Describe each.
AV Nodal Reentry Tachycardia (AVNRT): 2 pathways both w/in the AV node (slow and fast), MC
AV Reciprocating Tachycarida (AVRT): 1 pathway w/in the AV node and a 2nd accessory pathway OUTSIDE the AV node
What are two examples of AV Reciprocating Tachycaridas (AVRT)?
Wolff-Parkinson-White (WPW)
Lown-Ganong-Levine (LGL) Syndrome
What are the two types of conduction patterns that may be seen in a pt with paroxysmal supraventricular tachycardia?
Which is MC?
Describe each.
Which one leads to narrow vs wide complex tachycardia?
Orthodromic (95%): impulse goes nown the normal AV node pathway first and returns via the accessory pathway in circles, perpetuating the rhythm –> narrow complex tachycardia
Antidromic (5%): impulse goes down the accessory pathway first and returns to the atria via the normal pathway –> wide complex tachycardia (mimics ventricular tachycardia)
What is the 1st line tx for SVT?
Caution for use in pts with what comorbidity?
Adenosine
pts with asthma or COPD = may cause bronchospasm
For pts with Stable narrow complex PSVT, _______ maneuvers may help to decrease HR.
Explain the pathophysiology
Vagal maneuvers
vagus nerve stimulation releases acetylcholine which in turn decreases HR
AV Nodal blockers such as _____ or _____ may be used in pts with stable narrow complex PSVT
BB
CCB
What pharmacologic tx is recommended for pts with stable wide complex PSVT?
What if WPW is suspected?
Antiarrhythmics i.e. Amiodarone
Procainamide if WPW is suspected
If a pt has unstable PSVT, what is the recommended tx?
Direct current (synchronized) cardioversion
What is considered definitive managment for a pt with PSVT?
Radiofrequency ablation
What condition is described below:
Multiple ectopic atrial foci generate impulses that are conducted to the ventricles
What is the expected HR in a pt w/ this condition?
How many P wave morphologies?
Wandering atrial pacemaker
HR: <100 bpm
>= 3 P wave morphologies
Multifocal atrial tachycardia is considered to be the same as wandering atrial pacemaker, except for what?
What condition is MAT usually associated with?
MAT is difficult to tx, but what medications may be helpful?
HR > 100 bpm
Classically associated with severe COPD
CCB (Verapamil) or BB if LV fxn is preserved
___________ is a condition where there is an accessory pathway (bundle of Kent) that pre-excites the ventricles, leading to a slurred wide QRS
Wolff Parkinson White
What findings will be seen on EKG of a pt with WPW?
DELTA WAVES (slurred QRS upstrokes)
Wide QRS >0.12 seconds
Short PR interval
What is recommended tx for a pt with STABLE WPW?
What to avoid? Acronym to remember?
Vagal manuevers (valsalva, carotid massage if no carotid bruits present)
Antiarrhythmics (Class 1A: Procainamide preferred, Amiodarone, Flecainide, Ibutilide)
Avoid the use of AV nodal blockers, as this may lead to worsening of the tachyarrhythmia
_ABCD_ = _A_denosine, _B_eta Blockers, _C_alcium Channel Blockers, _D_igoxin
What is the recommended 1st line tx for a pt with UNSTABLE WPW?
Direct current (synchronized) cardioversion
What is the definitive management for a pt with WPW?
Radiofrequency ablation
Lown-Ganong-Levine Syndrome is characterized by a (short/long) PR interval with a (narrow/normal/wide) QRS complex
short PR interval
normal QRS complex
What node becomes the dominant pacemaker of the heart in AV junctional rhythms?
AV node ;)
The most common rhythm seen with digitalis toxicity and myocarditis is ______
AV junctional dysrhythmia
In an AV junctional dysrhythmia, the P waves are usually (negative/positive) in leads where they are normally (negative/positive), or are ______
negative (inverted)
positive (I, II, aVF)
absent
Junctional Rhythm: heart rate is usually ____-____ bpm (reflecting the intrinsic rate of the AV junction)
Accelerated Junctional: heart rate is ____-____bpm
Junctional Tachycardia: heart rate is _____ bpm
Junctional: 40-60 bpm
Accelerated Junctional: 60 - 100 bpm
Junctional Tachycardia: >100 bpm
(Ventricular/Atrial) dysrhythmias are frequently unpredictable, unstable and potentially lethal because stroke volume and coronary flow are compromised
Ventricular
Ventricular dysrhythmias are associated with (narrow/wide), _____ QRS complexes
wide
bizarre
With a premature ventricular contraction (PVC), the ____ wave is in the opposite direction of the QRS usually
T wave
Most ventricular arrythmias occur after a _____
PVC
What tx is recommended for PVCs?
no tx usually needed
What condition is described below?
a cardiac rhythm in which each normal beat is followed by an abnormal one
Ventricular bigeminy
Torsades De Pointes is most commonly due to ________, and _________.
Its appearance on EKG is often described as ….
Hypomagnesemia, hypokalemia
“Party streamer” (ventricular tachycardia that twists arounf baseline)
Management for stable sustained VT?
Unstable VT with pulse?
VT (no pulse)?
Torsades de pointes?
Stable sustained VT: Antiarrhythmics (Amiodarone, Lidocaine, Procainamide)
Unstable VT w/ a pulse: Synchronized cardioversion
VT (no pulse): Defibrillation (unsynchronized cardioversion) + CPR (tx as VFib)
Torsades de pointes: IV Magnesium, correct electrolyte abnormalities
Appearance of VFib on EKG?
What is the tx for VFib?
Coarse ventricular fibrillation
Unsynchronized cardioversion (defibrillation) + CPR
Describe pulseless electrical activity and its management
Organized rhythm seen on a monitor but pt has no palpable pulse
Management: CPR + epinephrine + check for shockable rhythm every 2 minutes
What is the tx for asytole?
What is the appearance on an EKG?
Same as PEA: CPR, epi, check for shockable rhythm every 2 minutes
What is ischemia?
Inadequate tissue perfusion
What is the most common cause of coronary artery disease?
Atherosclerosis
What are possible etiologies of CAD?
Atherosclerosis (MC), coronary artery vasospasm, aortic stenosis, aortic regurgitation, pulmonary HTN, severe systemic HTN, hypertrophic cardiomyopathy
What is the worst risk factor for CAD?
What is the most important modifiable risk factor for CAD?
What are other RF for CAD?
Worst: DM
Modifiable: Cigarette smoking
HLD, HTN, male, age, FHx, obesity, hyperhomocysteinemia, increased CRP
What are the first step in the development of an atherosclerotic plaque?
Fatty streaks
lipid deposition in the WBCs which leads to smooth muscle proliferation
Usually, ____% lumen reduction is when pts become symptomatic in CAD
>= 70%
What are the 4 classes of angina pectoris?
Describe each.
I. Angina only with unusually strenuous activity, no limitations of activity
II. Angina with more prolonged or rigorous activity, slight limitation of physical activity
III. Angina with usual daily activity, marked limitation of physical activity
IV. Angina at rest, often unable to carry out any physical activity
Describe the sx experienced by a pt with angina pectoris
(location, localization, exertional or nonexertional, duration, relieved with, precipitated by)
substernal CP that is poorly localized, non pleuritic, exertional
Readiation to the arm (esp. ulnar surfaces of the forearm and hand), teeth, lower jaw, back, epigastrium
usually short in duration (<30 min, typically 1-5 min)
Pain relieved with: rest of NTG (predictable pattern)
Pain precipitated by exertion/anxiety
What is Levine’s sign and what condition is it associated with?
Clenched fist over chest
Angina pectoris
What are three examples of anginal equivalents?
Dyspnea, Epigastric pain, Shoulder pain
instead of the classic chest pain
During an episode of angina pectoris, a pt may have what signs/sx on PE?
Often normal, but may present with:
+/- S4 gallop
+/- signs of left ventricular failure (S3, pulmonary edema)
Evidence of HLD (xanthelasma)
In the workup of a pt with angina pectoris, what should be initially performed?
After that?
What is considered gold standard?
ECG often initial test
Stress test after initial ECG
Angiography is gold standard
What is the classic finding on ECG for a pt with angina pectoris?
A resting ECG will be normal in what % of pts with stable angina?
The presence of _______ hypertrophy is associated with increased adverse outcome.
ST depression (especially horizontal or downsloping)
Resting ECG is NORMAL in 50% of pts with stable angina
left ventricular hypertrophy
What is the most noninvasive screening tool used in pts with angina pectoris?
What would be considered a positive result?
Stress testing
ST depressions, hypotension/hypertension, arrythmias and/or sx
________ is used to localize regions of ischemia in a pt with baseline ECG abnormalities, and gives more information than an ECG
__________ are used in pts unable to tolerate exercise
These are contraindicated in patients who have ______
Myocardial Perfusion Imaging Stress
Pharmacologic agents (Adenosine or Dipyridamole)
Asthma
A stress echocardiogram assesses (left/right) ventricular function, in conjunction with ____(drug)____, a positive inotrope/chronotrope that increases myocardial O2 demand and provokes ischemia
Left ventricular
Dobutamine
A ________ is performed with dobutmaine infucion, can assess perfusion and wall motion abnormalities, and may be used as an alternative to a stress test
Cardiac MRI
What are the two options for revascularization techniques for the definitive management of angina?
Percutaneous transluminal cornoary angioplasty (PTCA)
Coronary Artery Bypass Graft (CABG)
What is the indication for undergoing PTCA?
Placement of what can reduce restenosis?
1 or 2 vessel disease not involving the left main coronary artery and in whom ventricular function is normal/near normal
Stents
What medication combination is considered effective for prevention of coronary stent thrombosis?
ASA + Clopidogrel (Plavix)
What are the indications for CABG?
left main coronary artery dz, symptomatic or critical stenotic (>70%) 3-vessel dz or decreased left ventricular EF <40%
What are 4 examples of medications that can be used for the medical management of angina?
Medications that increase myocardial blood supply and decrease demand
NTG (oral, spray, patch)
BB (cardioselective: metoprolol, atenolol; nonselective: propranolol, nadolol)
CCB (nondihydropyridines: diltiazem, verapamil)
ASA
What calss of medications is indicated for use in patients with prinzmetal angina?
Nondihydropyridine CCB (Diltiazem and Verapamil)
What class of medications are 1st line for chronic management of angina?
BB
NTG should not be used in patients with SBP <___mmHg, pts with ______ infarction, or if they are also taking medications such as ______
CI in: SBP <90 mmHg, RV infarction, Sildenafil (and other PDE-5 Inhibitors)
What is the MOA of ASA?
Prevents platelet activation/aggregation by inhibiting cyclooxygenase
–> decreasing thromboxane A2 and inhibiting prostaglandins
What is the classic pharmacologic outpatient regimen for patients with angina?
Daily ASA, SL NTG prn, daily BB and statin
If a pt presents with c/o CP, what emergent conditions should be on your differential? (x6+)
What tests/labs/studies would be appropriate to order in a pt c/o CP?
MI
PE (CT Angiogram)
Esophageal rupture (CXR)
Tension PTX (CXR)
Aortic dissection (CT aorta w/ contrast)
Cardiac Tamponade
Orders: CXR, EKG, Cardiac Enzymes, CBC, CMP, Coags
What is the most common cause of heart failure?
CAD
_____ _____ is the inability of the heart to pump sufficient blood to meet the metabolic demands of the body at normal filling pressures
Heart Failure
What are the most common causes of left sided heart failure?
CAD and HTN
other causes include valvular disease and cardiomyopathies
What is the most common cause of right sided heart failure?
Left sided failure
Pulmonary dz (COPD, pulmonary HTN) mitral stenosis
Is systolic or diastolic the more common form of heart failure?
Systolic
Systolic heart failure is characterized by a (decreased/normal/increased) ejection fraction, a (S3/S4) gallop, and is commonly seen in pts post -_____, with _____, and _____.
decreased EF
+/- S3 gallop
post-MI, with dilated cardiomyopathy, and myocarditis
Diastolic heart failure is characterized by a (decreased/normal/increased) ejection fraction, a (S3/S4) gallop, and is associated with a (small/normal/large) cardiac size, and is commonly seen in pts with _____, (left/right) ventricular hypertrophy, and in what population?
normal/increased EF
+/- S4 gallop = forced atrial contraction into a stiff ventricle
Normal cardiac size
HTN, left ventricular hypertrophy, in the elderly
What is the difference between high and low output heart failure?
High output HF occurs when the metabolic demands of the body exceeds normal cardiac function (ex: thyrotoxicosis, wet beriberi, severe anemia, AV shunting, and Paget’s dz of the bone)
Low output HF is an inherent problem of myocardial contraction, ischemia, and chronic HTN
Acute heart failure is largely (systolic/diastolic) and can occur during what three pathophysiological events?
Systolic
HTN crisis, acute MI, papillary muscle rupture
Chronic heart failure is typically seen in patients with ______ cardiomyopathy or _____ dz
dilated cardiomyopathy or valvular dz
Describe the NYHA functional classes of Heart Failure
Class I: No sx, no limitation during ordinary physical activity
Class II: Mild sx (dyspnea and/or angina), slight limitation during ordinary activity
Class III: Sx cause marked limitation in activity (even with minimal exertion) comfortable only at rest
Class IV: Sx even while at rest, severe limitations and inability to carry out physical activity
Leading up to heart failure, the initial insult results in (decreased/increased) afterload, (decreased/increased) preload, and/or (decreased/increased) contractility.
The injured heart then tries to make short term compensations that over time promote CV deterioration–compensations include what three things?
Increased afterload
Increased preload and/or decreased contractility
Compensations include:
- Sympathetic NS activation
- Myocyte hypertrophy/remodeling
- RAAS activation(fluid overload, ventricular remodeling/hypertrophy leading to CHF)
(Left/Right) sided heart failure leads to (decreased/increased) pulmonary venous pressure from fluid backing up into the lungs
Left
Increased
(Left/Right) sided heart failure leads to (decreased/increased) systemic venous pressure, which leads to signs of systemic fluid retention
Right
Increased
What are some classic clinical manifestations of Left sided heart failure?
Dyspnea (most common sx), orthopnea, paroxysmal nocturnal dyspnea
Pulmonary congestion/edema: rales, rhonchi, chronic nonproductive cough, pink frothy sputum, transudative pleural effusions
PE: HTN, Cheyne-stokes breathing (deeper, faster breathing with gradual decrese and periods of apnea), S3, S4, lateral displaced PMI
Increased adrenergic activation: dusky pale skin, diaphoresis, sinus tachycardia, cold extremities, AMS
What are the classic signs and sx of a pt with right sided heart failure?
Peripheral edema
JVD
GI/hepatic congestion (anorexia, NV, RUQ TTP, hepatosplenomegaly, hepatojugular reflex)
What is the most useful test to dx a pt with heart failure?
What is the most important determinant of prognosis in a pt with heart failure?
Most useful: Echocardiogram
Most important determinant of prognosis: Ejection fraction
Noraml EF: 55-60%
What are the findings that will be seen on echo of a pt with systolic HF?
Diastolic HF?
Systolic HF: Decreased EF, thin ventricular walls, dilated LV chamber, (+) S3
Diastolic HF: Normal/Increased EF, thick ventricular walls, small LV chamber, (+) S4
A CXR is especially useful in the dx of what type of heart failure?
What will be seen?
Congestive HF
Cephalization of flow, Kerley B lines, Butterfly pattern, Cardiomegaly infiltrates, pleural effusions, pulmonary edema
Increased ______ may identify CHF as the cause for dyspnea in the ER
Increased B-type natriuretic peptide (BNP)
What part of the heart releases BNP during volume overload?
Ventricles
BNP of ______ is indicative of CHF
>100
Initial management of HF is ______ and a ______ for sx
The best two drugs to decrease HF associated mortality are:
ACE-I and diuretic for sx
ACE-I > BB are the best two drugs for decreasing mortality
What are the diet restrictions for a pt with HF?
Sodium restriction <2g/d
Fluid restriction <2L/day
exercise, smoking cessation
What is the 1st line medication for tx of HF?
ACE-I
What are some examples of medications that decrease afterload in patients with HF?
ACE-I (-pril)
ARB (-artan)
BB (-olol)
Hydralazine + Nitrates
What are some examples of medications that decrease preload in patients with HF?
Loop Diuretics (Furosemide, Bumetanide, Torsemide) may cause hypOkalemia/calcemia/natremia
Potassium Sparing Diuretics (Spironolactone, Eplerenone) may cause hypERkalemia
HCTZ may cause hypOnatremia/kalemia
Metolazone may cause hypOnatremia/kalemia
What are some examples of positive inotropic medications that can be used in the short term management of severe acute CHF?
Sympathomimetics (positive inotropes) –> Digoxin, Dobutamine, Dopamine
________ is synthetic BNP and is only used in ER or inpatient settings for pts with HF
Nesiritide
decreases RAAS activity and increases Na+ excretion
Medications that decrease mrotality in patients with HF include…
ACE-I
ARB
BB
Nitrates + Hydralazine
Spironolactone
Which medication is not generally used in pts with systolic HF, except in angina with HF or normal HF?
CCB
What is the outpatient regimen for HF?
ACE-I + Diuretic initially, then add BB; +/- hydralazine + NTG, Digoxin
An implantable cardioverter defibrillator should be placed in patients with EF of what?
Why?
<35%
they tolerate arrythmias poorly
What are two novel medications for systolic HF?
Ivabradine
Sacubitril-Valsartan (Entresto)
What condition is described below?
Acute decompensated HF with worsening of baseline sx, pulmonary congestion (worsening of dyspne, rales, pink frothy sputum, etc)
CHF
What are some examples of CXR findings in a pt with CHF?
Cephalization of flow –> Kerley B lines –> batwing/butterfly appearance –> pulmonary edema
Cephalization: increased vascular flow to the apices as a result of increased pulmonary venous pressure (pulmonary capillary wedge pressures of 12-18 mmHg; normal is 6-12 mmHg)
In CHF, Kerley B lines will be present on CXR when the pulmonary capillary wedge pressure is between _____ mmHg
Butterfly (batwing) appearance will be present when the PCWP is _____ mmHg
Kerley B: 18-25 mmHg
Butterfly (batwing): >25 mmHg
Management of acute pulmonary edema/CHF can be remembered with the acronym “LMNOP”, which stands for:
Lasix
Morphine
Nitrates
Oxygen
Position (place upright to decrease venous return)
What is the recommended course of management for a pt with diastolic HF?
heart rate control, BP control, and relief of ischemis (BB, ACE-I, CCB), and diuretics for volume overload
