Cardiovascular Flashcards
ACE inhibitor (function and examples)
Stops conversion of angiotensin 1 to angiotensin 2
Lisniopril
Elanapril
ARBs
Angiotensin II receptor blockers (ARBs)
Losartan
Irbestartan
Calcium Channel Blockers - Dihydropyridines
Relax blood vessels, which decreases vascular resistance and blood pressure
Potent vasodilator – used for reducing heart rate and reducing heart irritability)
- Amlodipine
- Nifedipine
- Nicardipine
Calcium Channel Blockers - Non-Dihydropyridines
Less potent vasodilator, depressive effect on cardiac conduction and contractility
Cardizem
Diltiazem
verapamil
Side effects of CCBs
Constipation and peripheral edema
Beta blockers
Used for heart rate control
Coreg (alpha and beta blocker, good for HF. Reduces contractility and relaxes blood vessels
Metoprolol: Beta one selective
Loop diuretics
Most potent, cause loss of all electrolytes.
Furosemide
Thiazide diuretics
Weaker than loop diuretics but retain calcium and loss of other electrolytes.
Hydrochlorothiazide
Potassium sparing diuretics
Increase potassium levels in serum, decrease sodium.
Spironolactone
Hypertension according to JNCB
140/90
Normal BP
120/80
Elevated BP
120-129/80
Stage 1 hypertension
130-139/80-90
Stage 2 Hypertension
140/90 or above
Systolic heart failure
Failure of the myocardium to effectively contract
Diastolic heart failure
Failure of the heart to effectively relax
HFrEF
Ejection fraction <40%
NY Heart Association Subjective Heart Failure levels
- No symptoms
- Symptoms with exertion but not ADLs
- Symptoms with ADLs
- Feel terrible (rales, edema, weight gain, fluid overload, pulmonary congestion)
HFpEF
Ejection fraction >40%
Symptoms of HF
SOB
Fatigue
Exertional dyspnea
Diependent and pulmonary edema
Low activity tolerance
Abdominal bleeding
Orthopnea
Causes of HF
Ischemic heart disease
Valve disease
MI
Cardiomyopathy
Treatment for HF
- ACE/ARB
- ARB/ARNI
- Beta blocker
- Nitrites plus hydralazine
- Fluid and salt restriction
- Daily weights
Goal of HF treatment
- Minimize exacerbation/hospitalization
- Maintain/optimize current functional status and medication regimen
Gold standard treatment for ASCVD
Statins
High intensity statins include..
Atorvastatin - 40-80mg
Rosuvastatin 20-40mg
Most common side effect of statins
Myalgia
CoQ10 can help reduce achiness
Most severe and life threatening complication of statins
Rhabdomylosis
Therapy track for statins
Statins (can’t get to goal) –> ezetimibe (zetia) –> proven angiographic disease then refer to cardiology for higher level of medication injectable biweekly highly expensive medication (PCSK9 medication – or for familial homozygous hyperlipidemia
Aortic Stenosis - s/s
Blood can’t get out of heart.
- Syncope or near syncope (due to reduced flow to the brain)
- HF symptoms (SOB, fatigue, orthopnea,)
- Echo and carotid US
- High frequency murmur (during systole – trying to get through a small hole)
Systolic, harsh, blowing murmur at the second right intercostal space that radiates to the neck
Aortic Regurgitation
Causes backflow
- HF symptoms (SOB, fatigue, orthopnea,)
- diastole
Mitral stenosis
Blood can’t get out
- HF symptoms (SOB, fatigue, orthopnea,)
- Radiate laterally, left chest wall
- Low frequency murmur (diastolic while the heart is relaxed and trying to fill back up)
Mitral regurgitation
Causes backflow
- HF symptoms (SOB, fatigue, orthopnea,)
- Heard during systole
What does aortic stenosis sound like?
a high-pitched, rough, and low-pitched systolic murmur that has a crescendo-decrescendo configuration, or “diamond shape”.
It’s usually heard best at the second intercostal space in the right upper sternal border, and it can radiate to the neck and carotid arteries.
SYSTOLIC
What does aortic regurgitation sound like?
a blowing, high-pitched diastolic murmur that is decrescendo in nature.
It is best heard at the left lower sternal border, and is most audible when the patient leans forward and holds their breath at the end of an exhalation
DIASTOLIC
Sound of mitral regurgitation
high-pitched and “blowing,” and is best heard at the apex of the heart with the patient in a left lateral decubitus position.
SYSTOLIC
Sound of mitral stenosis
A sharp click or snap that occurs after the second heart sound (S2) when the mitral valve opens forcefully
A decrescendo-crescendo murmur that occurs after the opening snap and lasts until mid-diastole.
DIASTOLIC
Acute triad of ruptured AAA
acute abdominal pain, abdominal distention and hemodynamic instability.
Cause of AAA
HTN, smoking, congenital disorder
Chest aortic aneurysms
Stanford A (ascending before the left subclavian branch)
* Very dangerous, if dissects near cardiac arteries then death
Stanford B (descending after the left subclavian)
* Less dangerous, more chronic management
How many months of therapy minimum for DVT/PE?
3 months
For idiopathic with recurrence may need lifelong therapy
Virchow’s triad
High risk for a thrombotic event.
o Venous statis
o Hypercoagulability
o Endothelial injury
Clinical findings for PAD
o Pale, waxy, hairless less, achiness, intermittent claudication (work throught e pain to help encourage angiogenesis – development of new blood vessels)
o Pain with ambulation that improves with rest
How is PAD diagnosed?
Diagnose in clinic with ankle brachial index (BP arm vs BP ankle, less than .9 is diagnostic for PAD)
Diagnosis must be confirmed with angiography.
Treatment for PAD
- Stents or bypass of occluded vessels
- Antiplatelets (clopidogrel, aspirin…)
- Statins for lipid management
- Smoking cessation
- Management of comorbid conditions (DM)
- Daily ambulation/exercise therapy
Pericardial effusion
Fluid around the heart inside the pericardium
o Limits compression and filling
o Echo to diagnose
S/S of pericardial effusion
- Narrowed pulse pressure
- Tachycardia
- JVD
- Muffled heart tones
- Atrial fibrillation/aflutter/sinus tach
Causes of pericardial effusion
- Viral pericarditis
- Post trauma
- Dressler syndrome (after cardiac surgery, stent, surgery)
- Thyroid dysfunction (myxedema coma)
Treatment for pericardial effusion
Address underlying cause (malignancy, hypothyroidism, hypocoagulable state, trauma)
Pericardiocentesis
Medications
* Colchicine
* NSAIDS
* Steroids may be considered by not first line
What does AF look like on an EKG?
o Irregularly irregular rhythm w/o P waves
Treatment for AF
rate and rhythm control
What does Atrial Flutter look like on an EKG?
Sawtooth pattern
S/s of A flutter and Afib
Acute onset fatigue, dizziness, nausea, palpitations, rapid irregular pulse
Anticoagulation bridging
Needed for 5-6 days after starting warfarin until the dose becomes therapeutic. Usually done with lovenox or heparin. Stop when INR is over 2.
STEMI
- EKG changes plus enzyme elevation
- Exposure of tunica media which attracts platelets which builds a clot (increasing thrombus) that blocks the artery
- 90 minutes or less into the ED
Non-STEMI
- No EKG changes only enzyme elevation
- Elevated troponin (4-6 hours)
- Elevated creatinine kinase
EKG changes with an MI
- ST elevation –> acute injury
- T wave inversion –> ischemia
- Pathological q wave –> old irreversible MI (with ST elevation then current MI)
- Wide QRS complex – contractions not at same time, may need pacer
EKG leads with MI
I SEE ALL LEADS
Lead changes can tell you where the infarct is
- Inferior (2,3 AVF)
- Septal (V1-2)
- Anterior (V3-4)
- Lateral (v5-6)
MONA for chest pain
Morphine
Oxygen
Nitroglycerin
Aspirin
Catelcholamines
Catecholamines increase heart rate, blood pressure, breathing rate, muscle strength, and mental alertness.
- Dopamine
- Dobutamine
- Norepinephrine
- Epinephrine
Vasodilators
- Nitroglycerine
- Nicardipine
- Nitroprusside
Coronary angiogram
- Direct vascular access with visualization of the endovascular anatomy
- May include angioplasty and stenting (primary coronary intervention)
What pathogen causes bacterial endocarditis most often? What is it treated with?
Stapholoccoal aureus
Treat with amoxicillin
S/S of bacterial endocarditis
Fever
Chills
New murmur
anorexia
weight loss
splinter hemorrhage to nail beds
petechate on palate
non-tender spots to hands and soles
Systolic Heart Sounds (S1)
MOTIVATED
M - mitral
T - tricuspid
AV - atrioventricular
Diastolic Heart Sounds (S2)
APPLES
A - aortic
P - pulmonic
S - semilunar
S3 gallop
Indicative of HF or CHF
Sounds like “kentucky”
Always abnormal after age 40
S4 gallop
Indicative of increased resistance due to stiff left ventricle
Best heard at apex
Sounds like “tenessee”
S2 split
Splitting of aortic and pulmonic components
How to assess murmurs?
- Is it happening during systole or diastole?
- What is the location of the murmur (aortic, pulmonic, erbs point…)
Systolic Murmurs
MR PASS
Mitral regurgitation
Physiologic
Aortic Stenosis
Diastolic murmurs
MS ARD
Mitral stenosis
Aortic regurgitation
Usually indicates heart disease
What does mitral regurgitation sound like?
Soft low pitched decrescendo
Best heart at apex
What does aortic stenosis sound like?
Harsh and noisy.
Best heard at 2nd ICS L sternum
What does aortic regurgitation sound like?
High pitched diastolic murmur. Best heard at 2nd intercostal space L sternum.
What does mitral stenosis sound like?
Low pitched and rumbling. Best heard at apex.
Grading of heart murmurs
1 - very soft, only heard in optimal conditions
2 - mild-moderately loud
3 - Loud, easily heard
4 - Loud with THRILL present (first hear thrill)
5 - Very loud heard with edge of stethoscope off the chest
6 - can be heard with stethoscope off the chest, palpable thrill
Treatment for endocarditis
Amoxicillin (2g PO x1 for prophylaxis)
Irregularly irregular rhythm with no visible P waves on EKG is what diagnosis?
AF
ST elevation in V2-4 with tombstone pattern on EKG is what diagnosis?
Anterior wall MI
Jagged irregular QRS complex on EKG is what diagnosis?
Ventricular tachycardia
Variation in the P-P interval, which is the time between consecutive P waves. In sinus arrhythmia, the P-P interval varies by more than 120 milliseconds, increasing and decreasing with breathing is what diagnosis if seen on EKG?
Sinus arrhythmia
First line therapy for non-valvular arrhythmias?
DOACs
How to start a patient on warfarin
- 5mg (or 2.5 if patient over 70)
- Check INR every 2-3 days until therapeutic twice, then monitor every 4 weeks
- Bridge with lovenox or low molecular weight heparin
First line therapy for patients with prosthetic heart valves?
Warfarin
INR goal for patient with AF
2-3
INR goal for patient with synthetic heart valves
2.5-3.5
Screening guidelines for individuals at high risk for hyperlipidemia
Screen males age 25-35, screen females age 30-35
Screening for individuals at low risk of hyperlipidemia
Screen males starting age 35 and females starting age 45
Total cholesterol
<200
Borderline high cholesterol level
201-239
High cholesterol level
> 240
HDL
> 40 in men
50 in women
LDL
<100
LDL goal for patients with heart disease or diabetes
<70
Triglycerids
<150
What medications increase triglycerides?
Estrogen
Diuretics
Isotrentinoin
Beta blockers
Lifestyle modifications for high triglycerides
Decrease sugar and carb intake, avoid alcohol, low fat diet, fist with omega 3, exercise
Triglycerides over what level are high risk for developing acute pancreatitis?
500
Focus on reducing LDL which will bring triglycerides down as well.
Diets that improve cholesterol levels
Mediterranean diet and DASH diet
Hypertensive crisis
BP 180+/120+ with end organ damage
Retinal findings with hypertensive retinopathy
- AV nicking
- Copper/silver wire arterioles
Retinal findings for diabetic retinopathy
Neovascularization
Cotton wool spots
Microaneurysms
Pappiledema
Swelling of the optic disc due to elevated intracranial pressure (ICP).
Thiazide diuretics and side effects
Inhibit NaCl reabsorption in the kidneys.
Side effects:
- hyperglycemia, hyperuricemia, hypertryglyceridemia, hypercholesterolemia
- hypo K, Mg, Na
Loop diuretics
Inhibit Na, Cl and K pump in the loop of henle.
Loss of K, Na, and Mg.
Aldosterone receptor agonists side effects
Spironolactone
Gynecomastia, galactorrhea, hyperkalemia, erectile dysfunction, GI effects
Thiazide diuretics and osteoporosis
Slow calcium loss from bone. Prescribe for patients with hypertension and osteopenia or osteoporosis.
Cardioselective beta blockers
Atenolol, metroprolol, bisoprolol
Non-cardioselective beta blockers
Propranolol, timolol pindalol
Meds that are both alpha and beta blockers
Coreg and labetalol
Alpha blockers
Used for HTN and BPH only
- terazosin
- doxazosin
- tamsulosin
Sound of mitral valve prolapse
Midsystolic, non-ejection click with late systolic or holosystolic murmur
preferred treatment for HFrEF
Carvedilol
Best place to hear s3 heart sound
mitral area
most common causes of infective endocarditis are…
staphylococci, streptococci, and enterococci.
Diagnostics for AAA
- Asymptomatic - US
- Symptomatic but stable - CT
- Symptomatic unstable - FAST
First action for a patient with newly discovered AF
Order a stat transthoracic (2D) echocardiogram and prepare the patient for trasnport to the closest appropriate hospital for inpatient evaluation
An example of secondary prevention for a diagnosis of coronary artery disease includes what?
Coronary artery bypass grafting
Treatment for stage C heart failure
Furosemide (Lasix), lisinopril (Zestril), carvedilol (Coreg)
Which of the following agents would NOT be useful in reducing pulmonary edema in a patient with cardiogenic shock?
Phenylephrine
Phenylephrine is an afterload increasing agent and would likely exacerbate worsening of pulmonary edema in a heart with cardiogenic shock.
Your patient presents with bradycardia, severe nausea, and substernal pain. STEMI was identified on the EKG. Which region of the heart is most likely involved?
Inferior Wall
The inferior wall, fed by the right coronary artery is commonly associated with these symptoms. Remember right equals rate as it is the blood supply for the SA and AV nodes in most patients.
Dyspepsia is common in RCA territory injury due to vagal stimulation not typical of other areas.
