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Family Medicine EOR > Cardiovascular > Flashcards

Cardiovascular Flashcards

Focus: Diagnosis, Clinical Therapeutics, Intervention

1
Q

What symptoms warrant order for EKG?

A

exercise intolerance, fatigue, dizzy spells, HA, nausea, palpitations, chest pain, SOB, syncope

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2
Q

Arrhythmias: sick sinus syndrome and EKG findings (3)

A

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)

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3
Q

Tx for symptomatic sick sinus syndrome?

A

Permanent pacemaker

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4
Q

Arrhythmias: AV block 1st, 2nd, and 3rd and EKG findings (3)

A

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

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5
Q

When do you provide treatment for AV blocks?
TOC?

A

Mobitz 2 and 3rd degree AV block
TOC: permanent pacemaker

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6
Q

Stable v-tach tx?

A

IV amiodarone

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7
Q

What does RBBB look like on EKG?

A
  1. Wide QRS
  2. V1, V6: MarroW
    “rSR’ pattern with abnormal ST/T wave in V1 or V2”
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7
Q

Polymorphic v tach tx?

A

IV magnesium

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8
Q

Complete vs incomplete BBB?

A

*QRS width
QRS 120+ = complete BBB
QRS 110-120 = incomplete BBB

note: incomplete BBB is also known as fascicular blocks

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8
Q

What electrolyte abnormalities have the potential to cause torsades?

A

Hypokalemia, Hypomagnasemia, Hypocalcemia

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9
Q

An EKG with axis deviation means?

What if right axis?
What if left axis?

A

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

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9
Q

Treatment for torsades?

A

IV magnesium sulfate

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10
Q

Tx of bundle branch block?

A

Permanent pacemaker only if symptomatic

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10
Q

Potential causes of DCM?

A

Myocarditis
CAD/ischemia
Alcohol, cocaine, amph (thiamine deficiency)
Endocrine (thyroid, pheo, cushings)
Autoimmune/inflammatory (SLE, RA, sarcoidosis)

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11
Q

What does premature atrial contraction look like on EKG?

A
  1. Premature/early beat after a normal QRS
  2. The P wave has a different morphology that you can sometimes see a pattern of throughout the EKG
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11
Q

Dilated cardiomyopathy: patho, sx, dx, tx

A

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

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12
Q

What does premature ventricular contraction look like on EKG?

A
  1. Premature/early QRS after a normal QRS
  2. The QRS doesn’t have a p wave in front and is wide, telling you it’s coming from the ventricle
  3. There will be a slight pause after the abnormal beat because the normal sinus beat stays on pace with itself
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12
Q

Restrictive Cardiomyopathy: patho, sx, dx, tx

A

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)

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13
Q

A premature atrial contraction (PAC) can turn into?

A

A-fib or a-flutter

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13
Q

Hypertrophic cardiomyopathy: patho, sx, dx, tx?

A

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)

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14
Q

A premature ventricular contraction (PVC) can turn into ____ if there are 3+ in a row

A

Non-sustained vtach

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14
Q

Most common causes of restrictive cardiomyopathy (3)?

A

Amyloidosis, Sarcoidosis, Hemochromatisis

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15
Q

Tx of a-flutter and a-fib in unstable pt?

A

always synchronized cardioversion if unstable

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15
Q

Endocarditis: mc bacteria and mc valve, sx

A

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)

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16
Q

Tx of a-flutter in stable patients?

A

1a: vagal maneuver or

Adenosine only given in monomorphic and regular

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16
Q

Who is most at risk for endocarditis?

Dx labs and definitive dx?

A

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)

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17
Q

Definitive treatment for refractory a-flutter or a-fib?

A

Radiofrequency ablation + long-term anticoagulation

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17
Q

Empiric tx of valve endocarditis?
Native valve replacement
Prosthetic valve replacement

A

NVE - Vanc + ceftri/cefepime
PVE - Vanc + gentamicin + cefepime

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18
Q

Step-wise approach to patients newly diagnosed with a-fib? (6)

A
  1. Find the cause: Get ECHO to assess the valves, stress test, Holter monitor; Get labs (TSH and free T4, electolytes, CBC, glucose/A1C)
  2. Use the CHADVASc score to see if they need an anticoag: Start on anticoag therapy (DOACs: apixaban or dabigatran); if valve disease give warfarin
  3. Rate control for acute episodes or persistent-asymptomatic patients (BB or NON-DHP CCB)
  4. Rhythm control in persistent symptomatic patients (AMIODARONE)
  5. Follow-up every 3-6mo if on anti-arrhythmics
  6. Catheter ablation if nothing works
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18
Q

Targeted tx of MSSA endocarditis?

A

NVE - nafcillin or cefazolin
PVE - nafcillin/cefazolin/vanc + rifampin + gentamicin

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19
Q

What does CHA2DS2-VASc score tell you?

What # is positive?

A

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

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19
Q

Targeted tx of MRSA endocarditis?

A

NVE - Vanc
PVE - Vanc + rifampin

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20
Q

A patient with LEFT bundle branch block calls for further eval bc LBBB occurs from what 4 etiologies?

A

CAD, HTN heart disease, Aortic valve disease, Cardiomyopathy

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20
Q

Targeted tx of enterococci endocarditis?

A

Ampicillin or pen G + ceftriaxonw
Pen-resistant - vanc

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21
Q

AVNRT looks like what on EKG?
TOC?

A
  1. HR 120-200
  2. P wave buried in QRS
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21
Q

Targeted tx of HACEK (gram neg) endocarditits?

A

Ceftriaxone

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22
Q

What arrhythmia can cause head or neck pulsations?

A

AVNRT

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22
Q

Targeted tx of ESBL endocarditis?

A

Carbapenem

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23
Q

CHF

A
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23
Q

Most common paroxysmal supraventricular tachycardia?

A

AVNRT

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24
Q

Which medication should NOT be used in patients with CHF?

A

CCBs (reduces pumping ability), NSAIDs (fluid retention)

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24
Q

Most common arrhythmia?

A

A-fib

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25
Q

Leading cause of mortality in the US?

A

CAD

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25
Q

TOC for AVNRT?

A

Valsalva, carotid massage
IV adenosine
definitive if refractory: catheter ablation

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26
Q

CAD consists of what disease subcategories?

A

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

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26
Q

AVRT EKG findings?

A
  1. retrograde p wave after the QRS in orthodromic
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27
Q

The largest independent risk factor for ACS?

A

Diabetes - a patient with DM has same risk as someone with a hx of heart attack

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27
Q

Wolfe Parkinson White EKG findings?

A
  1. delta wave
  2. short PR <120ms
  3. wide QRS >110
  4. +/- inverted t wave
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28
Q

Modifiable risk factor for CAD that yields immediate risk reduction?

A

Smoking - TELL YOUR PATIENTS TO STOP SMOKING

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28
Q

Wandering atrial pacemaker EKG finding?

A

irregularly irregular rhythm w/ varying PR intervals
-3+ distinct p wave morphologies
-HR is 100-

*same thing as MAT but MAT is tachycardia

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29
Q

When is DAPT therapy indicated in a CAD patient?

A

Recent ACS, especially if stent was placed. Continue treatment for AT LEAST 1 year

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29
Q

What arrhythmia is HIGHLY associated with COPD?

TOC?

A

multifocal atrial tachycardia

TOC: non-DHP CCB (verapamil) or BB (metoprolol tartrate)

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30
Q

All patients with CAD should be placed on what #1 medications?

A

*Beta blocker - lowers mortality
ACEi - lowers mortality & stroke risk
Statin - lowers mortality

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30
Q

Sudden cardiac death or sleeping cardiac death is most commonly associated with which arrhythmia?

Most common in what population?

A

Brugada syndrome: psuedo-RBBB + persistent ST segment elevation in V1-V2

MC: asian men

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31
Q

What findings are expected on EKG in stable angina/NSTEMI?

A

T wave flattening, peaked t wave
T wave inversion
ST depression

31
Q

1 treatment for polymorphic vtach with wide QRS

A

IV magnesium

32
Q

Stable angina: dx and steps in intervention and therapy

A

Dx:
IN HOSPITAL
inconclusive EKG
normal troponin, cardiac enzymes
**angiography

OUT OF HOSPITAL
Exercise stress test (ST depression >1mm)
stress ECHO
myocardial perfusion scintigraphy

32
Q

TOC for torsades?

A

IV magnesium sulfate

33
Q

Sublingual nitro is contraindicated in patients with?

A

History of inferior/right-sided wall MI or hx of elevated ICP

34
Q

First line tx for preventing angina in stable angina pts?

A

Beta blocker
Second line: nitroglycerin (fast-acting nitrate), isosorbide mononitrate (long-acting nitrate)

35
Q

In patients with stable angina, when is revascularization indicated?

A

Left main stenosis >50%
Any other stenosis >70%
Triple-vessel stenosis
Pharm therapy inadequate

36
Q

Prinzmetal angina is defined as?

A

Angina caused by random vasospasms

Cocaine or amphetamines, is a major cause of vasospastic angina in otherwise healthy individuals

37
Q

Prinzmetal angina is unique from ischemic angina in what ways

A

Rapidly responsive to nitrates
Chest pain at rest
No history of CAD
Drug triggers often a cause

38
Q

If suspicion of prinzmetal angina, what diagnostic criteria is used?

A

COVADIS
-nitrate-responsive
-transient EKG changes
-angiograph shows spasms with “>90% constriction”

39
Q

TOC for prinzmetal angina?

A

CCBs: diltiazem, amlodipine
*focus = preventing vasospasm

AVOID non-selective BB (propanolol)

40
Q

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?

A

Prolonged QT!

41
Q

What are the characteristics of a right-sided MI? Why is this important to watch out for?

A

HoTN, JVD, Clear lung fields
Inferior MI on EKG

Important bc pharm management is different: no nitrates, volume load to improve preload

42
Q

2 possible EKG findings in STEMI

A
  1. ST elevation >1mm in 2 contiguous leads
  2. LBBB or new q wave
43
Q

Which leads are the inferior leads?

A

Lead II, III and aVF

44
Q

Which leads are the anterior leads?

A

V3, V4

45
Q

Which leads are the septal leads?

A

V1, V2

46
Q

Which leads are the lateral leads?

A

Lead I, aVL, V5, V6

47
Q

What are the 3 cardiac biomarkers in ACS eval?

A

troponin
Creatine kinase (CK-MB)
Myoglobin

48
Q

Troponins expected changes and monitoring in ACS?

A
  1. Rise 2-3hrs
  2. Peak 24hrs
  3. normalize 7-10 days
49
Q

Door to PCI?

A

90 minutes, an hour and half

50
Q

Algorithm that assesses need for PCI in patients with UA or NSTEMI?

A

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

51
Q

ALL patients discharged with UA/NSTEMI/STEMI require what combo medications?

A
  1. DAPT: P2Y12 + ASA 81mg
  2. BB + ACEi + statin
52
Q

Fibrinolysis is indicated when PCI can’t be performed within?

fibrinolysis includes what meds?

A

120 min

*-plase
alteplase, reteplase, tenecteplase

53
Q

Endocarditis

A
54
Q

What is the LDL goal for hyperlipidemia

A

LDL <130

55
Q

Aside from diabetes, what are secondary causes of hyperlipidemia?

What drugs could cause HLD?

A

Alcohol, cigarettes
CKD
Hypothyroid
Cirrhosis/liver disease
Estrogen, steroids, thiazides, BB

56
Q

Required diagnosis for metabolic syndrome includes?

A

3 out of 5:
Trig 150+
HDL <40 M, <50W
Waist circum 40+ M, 35+ W
HBP
Fasting BG 100+

57
Q

Normal total cholesterol?

A

<200 mg/dL

58
Q

What triglyceride level is indicated for treatment with trig-lowering meds?

What meds are trig-lowering?

A

Trig >300
**fibrates (fenofibrate, gemfibrozil)
Omega-3

59
Q

Statins can be initiated with lone LDL abnormality of?

A

LDL 190+

60
Q

LDL-lowering goal for high intensity statin?

A

50% or more from baseline

61
Q

High intensity statins include?

A

Atorvastatin 40-80
Rosuvastatin 20-40

62
Q

Moderate intensity statins include?

A

Atorvastatin 10-20
Rosuvastatin 5-10
Simvastatin 20-40
Pravastatin 40-80
Lovastatin 40

63
Q

What labs are monitored/how often on patients on statin therapy?

A

Baseline CK & aminotransferase
Repeat lipids every 4-12 weeks, then monitor once a year

64
Q

Key ADRs for statins?
Key CI?

A

Muscle damage (myalghia, myositis, rhabdo)

Increased LFTs

CI: active liver disease or elevated LFTs or PG/breastfeeding

65
Q

A cholesterol-lowering med that is safe in pregnancy and used to treat pruritis associated with biliary obstruction?

A

Cholestyramine (bile acid sequestrant)

66
Q

What lipid-lowering med can RAISE triglycerides and is CI in severely elevated trigs?

A

Bile acid sequestrants (Cholestyramine, colestipol, colesvelam)

67
Q

Stage 1 HTN

A

130/80+

68
Q

Stage 2 HTN

A

140/90

69
Q

HTN crisis vs HTN urgency

A

HTN crisis/urgency: >180/120

HTN emergency: > or end-organ failure

70
Q

DASH diet: Na and K intake?

A

Na 1500-mg/d
K 3.5-5g/d

71
Q

What two scenarios warrant initiation of pharm tx for HTN rather than waiting for BP readings?

A
  1. 130/80 + comorbidities or age
  2. 140/90+
72
Q

When is combo therapy indicated for HTN?

A

> 20/10 above goal of <130/80

73
Q

DOC for AA with HTN?

A

CCB: -pine rather than ACEi -pril

74
Q

How long do you wait to increase dose of BP medicine?

A

1mo of new med then increase dose if still not at goal; use clinical judgement if still elevated despite compliance

75
Q

What medication is contraindicated with gout?

A

Thiazides. Be mindful of patients with HTN, check med list

76
Q

HTN urgency tx?
Lower BP by?

A

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

77
Q

Which antihypertensive is given in HTN urgency with aortic dissection?

A

IV BB (esmolol or labetolol) + vasodilator Sodium nitro

78
Q

In ischemic stroke, BP should only be lowered at a BP of?

A

220/120 - use labetolol or nicardipine, clevidipine

79
Q

Peripheral vascular disease: sx, **dx, tx

A

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

80
Q

Dx of aortic dissection?
Tx?

A

Dx: CTA/MRA, TEE
CXR: **widened mediastinum

Tx: labetolol and surgery

81
Q

Virchow’s Triad of DVT?

RF for a DVT (not including travel, recent sgx, hx of)

A

Stasis, vascular injury, hypercoagulable state

RF: HF, PG, oral contraceptives, HRT, smoker

82
Q

DVT tx?

A

DOACs: dabigatran (direct thrombin inh), rivaroxaban, apixaban, edoxaban (direct factor Xa inh)

83
Q

Diastolic murmurs include?

A

ARMS PRTS
Aortic regurg
Mitral stenosis
Pulmonic regurg
Tricuspid stenosis

84
Q

When is an S2 split concerning? Why?

A

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

85
Q

A fixed S2 split is characteristic of?

A

Atrial septal defect

86
Q

An ejection click is characteristic of?

A

Mitral valve prolapse

87
Q

An S3 means what? What is it characteristic of?

A

Vigorous LV filling - NORMAL if <40yo

Etiology - HF, CM

88
Q

What murmurs increase with inhale?

A

Right sided murmurs

89
Q

What murmurs increase with exhale?

A

Left-sided murmurs

90
Q

Most common valve disease?

A

Aortic stenosis

91
Q

Systolic crescendo-decrescendo murmur that intensifies with squatting

A

Aortic stenosis

92
Q

Harsh mid-sytolic crescendo-decrescendo murmur

A

Pulmonic stenosis

93
Q

Blowing holosystolic murmur, intensifies with expiration

A

Mitral regurg

94
Q

Blowing high-pitched holosystolic murmur, intensifies with inspiration

A

Tricuspid regurg

95
Q

The most common cause of mitral regurg?

A

Mitral valve prolapse

96
Q

Highest RF for MVP?

A

CT disorder - Ehlers-Danlos, Marfan, osteogenesis imperfecta

97
Q

Mid-late systolic ejection click murmur?

A

Mitral valve prolapse

98
Q

Tx for MVP?

A

Reassurance

Repair only if severe mitral regurg

99
Q

Diastolic blowing decrescendo murmur

A

Aortic regurg

100
Q

This murmur often presents with Water Hammer pulse, Corrigan’s pulse, **HILL’S SIGN, bounding pulse

A

Aortic regurg

101
Q

Diastolic brief early decrescendo murmur

A

Pulmonic regurg

102
Q

Mid-diastolic murmur associated with right-sided HF

A

tricuspid stenosis

103
Q

Rheumatic heart disease is almost always the cause of what murmur?

A

Mitral stenosis

104
Q

Low-pitched, mid-diastolic rumbling murmur

A

Mitral stenosis

105
Q

The JONES criteria is used to diagnose?

What does the major criteria include?
What does the minor criteria include?

A

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

106
Q

Tx of acute rheumatic fever?

A

ASA 2-6 weeks +/- corticosteroids

107
Q

Recent infection of ______________ is more likely to cause acute rheumatic fever?

A

Group A strep infection

108
Q

Tx for ortho HoTN?

A

Stop offending agents
First line = midodrine

109
Q

Aortic stenosis is most commonly caused by?

A

<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

110
Q

Calcification of the mitral valve leaflets (mitral stenosis) most commonly causes?

A

Rheumatic heart disease

111
Q

A patient with electrical alternans should raise suspicion for?

A

large pleural effusion

Family Medicine EOR (9 decks)

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