Cardiovascular Flashcards
Focus: Diagnosis, Clinical Therapeutics, Intervention
What symptoms warrant order for EKG?
exercise intolerance, fatigue, dizzy spells, HA, nausea, palpitations, chest pain, SOB, syncope
Arrhythmias: sick sinus syndrome and EKG findings (3)
SA node doesn’t create consistent AP
Can be:
-random or alternating sinus bradycardia/tachycardia (tachy-brady syndrome)
-random sinus pause or arrests >3seconds
-exit blocks (p wave to p wave shortens then a pause)
Tx for symptomatic sick sinus syndrome?
Permanent pacemaker
Arrhythmias: AV block 1st, 2nd, and 3rd and EKG findings (3)
1st: stable prolonged PR >200ms
2nd type 1: longer, longer, dropped QRS
2nd type 2: stable normal PR, then dropped QRS
3rd: p waves don’t agree with QRS
When do you provide treatment for AV blocks?
TOC?
Mobitz 2 and 3rd degree AV block
TOC: permanent pacemaker
Stable v-tach tx?
IV amiodarone
What does RBBB look like on EKG?
- Wide QRS
- V1, V6: MarroW
“rSR’ pattern with abnormal ST/T wave in V1 or V2”
Polymorphic v tach tx?
IV magnesium
Complete vs incomplete BBB?
*QRS width
QRS 120+ = complete BBB
QRS 110-120 = incomplete BBB
note: incomplete BBB is also known as fascicular blocks
What electrolyte abnormalities have the potential to cause torsades?
Hypokalemia, Hypomagnasemia, Hypocalcemia
An EKG with axis deviation means?
What if right axis?
What if left axis?
Could mean
-leads on wrong
-hypertrophy
-ischemia
-conduction issue
*Conduction specifically think
Fascicular branch block:
Right axis deviation = Posterior fascicular block
Left axis deviation = Anterior fascicular block
Treatment for torsades?
IV magnesium sulfate
Tx of bundle branch block?
Permanent pacemaker only if symptomatic
Potential causes of DCM?
Myocarditis
CAD/ischemia
Alcohol, cocaine, amph (thiamine deficiency)
Endocrine (thyroid, pheo, cushings)
Autoimmune/inflammatory (SLE, RA, sarcoidosis)
What does premature atrial contraction look like on EKG?
- Premature/early beat after a normal QRS
- The P wave has a different morphology that you can sometimes see a pattern of throughout the EKG
Dilated cardiomyopathy: patho, sx, dx, tx
patho - inability to eject blood during systole due to extremely dilated left ventricle
sx - fluid retention/edema, HoTN, S3 gallop, cp on exertion, extertional SOB, fatigue, pulm congestion, cough, JVD
dx - ECHO
tx - BB (-olol), ACEi (-pril), diuretics
What does premature ventricular contraction look like on EKG?
- Premature/early QRS after a normal QRS
- The QRS doesn’t have a p wave in front and is wide, telling you it’s coming from the ventricle
- There will be a slight pause after the abnormal beat because the normal sinus beat stays on pace with itself
Restrictive Cardiomyopathy: patho, sx, dx, tx
Patho - fibrosis of the ventricle causing poor filling during diastole
sx - edema, JVD, ascites, hepatomegaly (r-sided), SOB, fatigue, Kussmaul’s sign (JVP w/ insp)
dx - ECHO
tx - BB (-olol)
A premature atrial contraction (PAC) can turn into?
A-fib or a-flutter
Hypertrophic cardiomyopathy: patho, sx, dx, tx?
Patho - hypertrophy of ventricle d/t high demand, leads to poor filling during diastole
sx - harsh systolic murmur that relieves with squatting, exertional cp/SOB
dx - ECHO
tx - BB (-olol), CCB (-pine)
A premature ventricular contraction (PVC) can turn into ____ if there are 3+ in a row
Non-sustained vtach
Most common causes of restrictive cardiomyopathy (3)?
Amyloidosis, Sarcoidosis, Hemochromatisis
Tx of a-flutter and a-fib in unstable pt?
always synchronized cardioversion if unstable
Endocarditis: mc bacteria and mc valve, sx
MCC - staph, most commonly mitral valve, tricuspid if IVDU
Sx - fever chills weight loss, cp/murmur, hand/feet rash (petechiae), osler nodes/janeway lesion, splinter hemorrhages, Roth spots (fundoscopy)
Tx of a-flutter in stable patients?
1a: vagal maneuver or
Adenosine only given in monomorphic and regular
Who is most at risk for endocarditis?
Dx labs and definitive dx?
IVDU, mechanical valve or valve disorder, male >60, poor dentition/abscess, rheumatic heart disease
dx labs - BLOOD CULTURE x3 from separate sites before getting abx started; REPEAT q24-48 until bacteria is cleared
other - CBC (WBC, platelets, left shift leukocytosis), BMP (Na, K, Mg, Ca), BNP, CRP?ESR, RF, anemia
dx imaging - ECHO (transthoracic ECHO within 12 of presentation with REPEAT after abx)
Definitive treatment for refractory a-flutter or a-fib?
Radiofrequency ablation + long-term anticoagulation
Empiric tx of valve endocarditis?
Native valve replacement
Prosthetic valve replacement
NVE - Vanc + ceftri/cefepime
PVE - Vanc + gentamicin + cefepime
Step-wise approach to patients newly diagnosed with a-fib? (6)
- Find the cause: Get ECHO to assess the valves, stress test, Holter monitor; Get labs (TSH and free T4, electolytes, CBC, glucose/A1C)
- Use the CHADVASc score to see if they need an anticoag: Start on anticoag therapy (DOACs: apixaban or dabigatran); if valve disease give warfarin
- Rate control for acute episodes or persistent-asymptomatic patients (BB or NON-DHP CCB)
- Rhythm control in persistent symptomatic patients (AMIODARONE)
- Follow-up every 3-6mo if on anti-arrhythmics
- Catheter ablation if nothing works
Targeted tx of MSSA endocarditis?
NVE - nafcillin or cefazolin
PVE - nafcillin/cefazolin/vanc + rifampin + gentamicin
What does CHA2DS2-VASc score tell you?
What # is positive?
Tells you if an a-fib patient is indicated for anticoag therapy –> giving anticoag is not benign, increases bleeding risk
Men 1+ = give
Women 2+ = give
Targeted tx of MRSA endocarditis?
NVE - Vanc
PVE - Vanc + rifampin
A patient with LEFT bundle branch block calls for further eval bc LBBB occurs from what 4 etiologies?
CAD, HTN heart disease, Aortic valve disease, Cardiomyopathy
Targeted tx of enterococci endocarditis?
Ampicillin or pen G + ceftriaxonw
Pen-resistant - vanc
AVNRT looks like what on EKG?
TOC?
- HR 120-200
- P wave buried in QRS
Targeted tx of HACEK (gram neg) endocarditits?
Ceftriaxone
What arrhythmia can cause head or neck pulsations?
AVNRT
Targeted tx of ESBL endocarditis?
Carbapenem
CHF
Most common paroxysmal supraventricular tachycardia?
AVNRT
Which medication should NOT be used in patients with CHF?
CCBs (reduces pumping ability), NSAIDs (fluid retention)
Most common arrhythmia?
A-fib
Leading cause of mortality in the US?
CAD
TOC for AVNRT?
Valsalva, carotid massage
IV adenosine
definitive if refractory: catheter ablation
CAD consists of what disease subcategories?
Ischemic heart disease - chronic ischemia that could be stable angina pectoris, unstable angina, NSTEMI, STEMI
Acute coronary syndrome - an acute symptomatic episode of ischemic heart –> unstable angina, NSTEMI, or STEMI
AVRT EKG findings?
- retrograde p wave after the QRS in orthodromic
The largest independent risk factor for ACS?
Diabetes - a patient with DM has same risk as someone with a hx of heart attack
Wolfe Parkinson White EKG findings?
- delta wave
- short PR <120ms
- wide QRS >110
- +/- inverted t wave
Modifiable risk factor for CAD that yields immediate risk reduction?
Smoking - TELL YOUR PATIENTS TO STOP SMOKING
Wandering atrial pacemaker EKG finding?
irregularly irregular rhythm w/ varying PR intervals
-3+ distinct p wave morphologies
-HR is 100-
*same thing as MAT but MAT is tachycardia
When is DAPT therapy indicated in a CAD patient?
Recent ACS, especially if stent was placed. Continue treatment for AT LEAST 1 year
What arrhythmia is HIGHLY associated with COPD?
TOC?
multifocal atrial tachycardia
TOC: non-DHP CCB (verapamil) or BB (metoprolol tartrate)
All patients with CAD should be placed on what #1 medications?
*Beta blocker - lowers mortality
ACEi - lowers mortality & stroke risk
Statin - lowers mortality
Sudden cardiac death or sleeping cardiac death is most commonly associated with which arrhythmia?
Most common in what population?
Brugada syndrome: psuedo-RBBB + persistent ST segment elevation in V1-V2
MC: asian men
What findings are expected on EKG in stable angina/NSTEMI?
T wave flattening, peaked t wave
T wave inversion
ST depression
1 treatment for polymorphic vtach with wide QRS
IV magnesium
Stable angina: dx and steps in intervention and therapy
Dx:
IN HOSPITAL
inconclusive EKG
normal troponin, cardiac enzymes
**angiography
OUT OF HOSPITAL
Exercise stress test (ST depression >1mm)
stress ECHO
myocardial perfusion scintigraphy
TOC for torsades?
IV magnesium sulfate
Sublingual nitro is contraindicated in patients with?
History of inferior/right-sided wall MI or hx of elevated ICP
First line tx for preventing angina in stable angina pts?
Beta blocker
Second line: nitroglycerin (fast-acting nitrate), isosorbide mononitrate (long-acting nitrate)
In patients with stable angina, when is revascularization indicated?
Left main stenosis >50%
Any other stenosis >70%
Triple-vessel stenosis
Pharm therapy inadequate
Prinzmetal angina is defined as?
Angina caused by random vasospasms
Cocaine or amphetamines, is a major cause of vasospastic angina in otherwise healthy individuals
Prinzmetal angina is unique from ischemic angina in what ways
Rapidly responsive to nitrates
Chest pain at rest
No history of CAD
Drug triggers often a cause
If suspicion of prinzmetal angina, what diagnostic criteria is used?
COVADIS
-nitrate-responsive
-transient EKG changes
-angiograph shows spasms with “>90% constriction”
TOC for prinzmetal angina?
CCBs: diltiazem, amlodipine
*focus = preventing vasospasm
AVOID non-selective BB (propanolol)
Ranolazine is a secondary option in patients with chronic chest pain who can’t take BB. But it should NEVER be given to what patients?
Prolonged QT!
What are the characteristics of a right-sided MI? Why is this important to watch out for?
HoTN, JVD, Clear lung fields
Inferior MI on EKG
Important bc pharm management is different: no nitrates, volume load to improve preload
2 possible EKG findings in STEMI
- ST elevation >1mm in 2 contiguous leads
- LBBB or new q wave
Which leads are the inferior leads?
Lead II, III and aVF
Which leads are the anterior leads?
V3, V4
Which leads are the septal leads?
V1, V2
Which leads are the lateral leads?
Lead I, aVL, V5, V6
What are the 3 cardiac biomarkers in ACS eval?
troponin
Creatine kinase (CK-MB)
Myoglobin
Troponins expected changes and monitoring in ACS?
- Rise 2-3hrs
- Peak 24hrs
- normalize 7-10 days
Door to PCI?
90 minutes, an hour and half
Algorithm that assesses need for PCI in patients with UA or NSTEMI?
TIMI score 3 or more:
age, CAD risk, known CAD, ASA use in last 7d, 2+ episodes of angina within 24hrs, EKG ST changes 0.5+, positive cardiac biomarkers
ALL patients discharged with UA/NSTEMI/STEMI require what combo medications?
- DAPT: P2Y12 + ASA 81mg
- BB + ACEi + statin
Fibrinolysis is indicated when PCI can’t be performed within?
fibrinolysis includes what meds?
120 min
*-plase
alteplase, reteplase, tenecteplase
Endocarditis
What is the LDL goal for hyperlipidemia
LDL <130
Aside from diabetes, what are secondary causes of hyperlipidemia?
What drugs could cause HLD?
Alcohol, cigarettes
CKD
Hypothyroid
Cirrhosis/liver disease
Estrogen, steroids, thiazides, BB
Required diagnosis for metabolic syndrome includes?
3 out of 5:
Trig 150+
HDL <40 M, <50W
Waist circum 40+ M, 35+ W
HBP
Fasting BG 100+
Normal total cholesterol?
<200 mg/dL
What triglyceride level is indicated for treatment with trig-lowering meds?
What meds are trig-lowering?
Trig >300
**fibrates (fenofibrate, gemfibrozil)
Omega-3
Statins can be initiated with lone LDL abnormality of?
LDL 190+
LDL-lowering goal for high intensity statin?
50% or more from baseline
High intensity statins include?
Atorvastatin 40-80
Rosuvastatin 20-40
Moderate intensity statins include?
Atorvastatin 10-20
Rosuvastatin 5-10
Simvastatin 20-40
Pravastatin 40-80
Lovastatin 40
What labs are monitored/how often on patients on statin therapy?
Baseline CK & aminotransferase
Repeat lipids every 4-12 weeks, then monitor once a year
Key ADRs for statins?
Key CI?
Muscle damage (myalghia, myositis, rhabdo)
Increased LFTs
CI: active liver disease or elevated LFTs or PG/breastfeeding
A cholesterol-lowering med that is safe in pregnancy and used to treat pruritis associated with biliary obstruction?
Cholestyramine (bile acid sequestrant)
What lipid-lowering med can RAISE triglycerides and is CI in severely elevated trigs?
Bile acid sequestrants (Cholestyramine, colestipol, colesvelam)
Stage 1 HTN
130/80+
Stage 2 HTN
140/90
HTN crisis vs HTN urgency
HTN crisis/urgency: >180/120
HTN emergency: > or end-organ failure
DASH diet: Na and K intake?
Na 1500-mg/d
K 3.5-5g/d
What two scenarios warrant initiation of pharm tx for HTN rather than waiting for BP readings?
- 130/80 + comorbidities or age
- 140/90+
When is combo therapy indicated for HTN?
> 20/10 above goal of <130/80
DOC for AA with HTN?
CCB: -pine rather than ACEi -pril
How long do you wait to increase dose of BP medicine?
1mo of new med then increase dose if still not at goal; use clinical judgement if still elevated despite compliance
What medication is contraindicated with gout?
Thiazides. Be mindful of patients with HTN, check med list
HTN urgency tx?
Lower BP by?
Lower BP slowly over hours to days with CLONIDINE or CAPTOPRIL
**max 25% lowering over first 2-4 hours, then aim for <160/110 over 2-6 hrs
Which antihypertensive is given in HTN urgency with aortic dissection?
IV BB (esmolol or labetolol) + vasodilator Sodium nitro
In ischemic stroke, BP should only be lowered at a BP of?
220/120 - use labetolol or nicardipine, clevidipine
Peripheral vascular disease: sx, **dx, tx
sx - arterial (heaviness, elevation with pale extremity, pain with exercise, ulcers are pale or necrotic)
dx - ankle-brachial US ABI 90 or less; ABI >1.4 is calcified; MR angiography is definitive and required for revasc
tx - STOP SMOKING, cilostazol, revasc
Dx of aortic dissection?
Tx?
Dx: CTA/MRA, TEE
CXR: **widened mediastinum
Tx: labetolol and surgery
Virchow’s Triad of DVT?
RF for a DVT (not including travel, recent sgx, hx of)
Stasis, vascular injury, hypercoagulable state
RF: HF, PG, oral contraceptives, HRT, smoker
DVT tx?
DOACs: dabigatran (direct thrombin inh), rivaroxaban, apixaban, edoxaban (direct factor Xa inh)
Diastolic murmurs include?
ARMS PRTS
Aortic regurg
Mitral stenosis
Pulmonic regurg
Tricuspid stenosis
When is an S2 split concerning? Why?
When heard on exhale or inhale and exhale (wide S2 split)
causes of exhale- aortic stenosis, LBBB
*An S2 split on exhale means the aortic valve has delayed closure
causes of both - pulmonic stenosis, RBBB, pulm HTN
A fixed S2 split is characteristic of?
Atrial septal defect
An ejection click is characteristic of?
Mitral valve prolapse
An S3 means what? What is it characteristic of?
Vigorous LV filling - NORMAL if <40yo
Etiology - HF, CM
What murmurs increase with inhale?
Right sided murmurs
What murmurs increase with exhale?
Left-sided murmurs
Most common valve disease?
Aortic stenosis
Systolic crescendo-decrescendo murmur that intensifies with squatting
Aortic stenosis
Harsh mid-sytolic crescendo-decrescendo murmur
Pulmonic stenosis
Blowing holosystolic murmur, intensifies with expiration
Mitral regurg
Blowing high-pitched holosystolic murmur, intensifies with inspiration
Tricuspid regurg
The most common cause of mitral regurg?
Mitral valve prolapse
Highest RF for MVP?
CT disorder - Ehlers-Danlos, Marfan, osteogenesis imperfecta
Mid-late systolic ejection click murmur?
Mitral valve prolapse
Tx for MVP?
Reassurance
Repair only if severe mitral regurg
Diastolic blowing decrescendo murmur
Aortic regurg
This murmur often presents with Water Hammer pulse, Corrigan’s pulse, **HILL’S SIGN, bounding pulse
Aortic regurg
Diastolic brief early decrescendo murmur
Pulmonic regurg
Mid-diastolic murmur associated with right-sided HF
tricuspid stenosis
Rheumatic heart disease is almost always the cause of what murmur?
Mitral stenosis
Low-pitched, mid-diastolic rumbling murmur
Mitral stenosis
The JONES criteria is used to diagnose?
What does the major criteria include?
What does the minor criteria include?
Acute rheumatic fever
Major criteria:
J - Joint (polyarthritis)
O - Oh my heart (active carditis/murmur)
N - Nodules (subq nodules)
E - erythema marginatum
S - St. Vitus Dance
*2 major = Acute rheumatic fever
Minor criteria:
Fever
Arthralgia
ESR, CRP, leukocytosis (elevated)
Prolonger PR on EKG
*1 major + 2 minor = Acute rheumatic fever
Tx of acute rheumatic fever?
ASA 2-6 weeks +/- corticosteroids
Recent infection of ______________ is more likely to cause acute rheumatic fever?
Group A strep infection
Tx for ortho HoTN?
Stop offending agents
First line = midodrine
Aortic stenosis is most commonly caused by?
<35yo: malformation of aortic valve, bi-leaflet leading to early calcification
> 35yo: normal tri-leaflet valve but calcification over time esp with DM or hyperlipidemia, smoking, HTN
Calcification of the mitral valve leaflets (mitral stenosis) most commonly causes?
Rheumatic heart disease
A patient with electrical alternans should raise suspicion for?
large pleural effusion
