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Emergency Medicine > Cardiovascular > Flashcards

Cardiovascular Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What are common reasons for Chest Pain

A

MI: Dull, Aching, Pressure, Tightness, Squeezing. Usually noted with exercise, stress from cold exposure or meals, resolve once inciting even is over
Unstable Angina: Sx may occur at rest
Hypertrophy of Ventricles such as with aortic stenosis or hypertrophic cardiomypathy: Results in ischemic pain
Pericarditis: Pain usually greater when spine and upright
Aortic Dissection: Abrupt onset of tearing pain that radiates to back
Pleuritic chest pain: Not ischemic
Pain with palpation indicative of musculoskeletal origin

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2
Q

Dyspnea on exertion results from what

A

Elevated left atrial and pulmonary venous pressure or from hypoxia

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3
Q

Dyspnea can be indication of what

A

Heart Disease

Pulmonary Disease

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4
Q

What can Heart Disease dyspnea be differentiated from Pulmonary Disease dyspnea

A

BNP which can dx HF

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5
Q

What is Orthopnea

A

Dyspnea that occurs in recumbency and results from increase in central blood volume when supine

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6
Q

What can Orthopnea be an indication of

A

Pulmonary Disease

Obseity

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7
Q

What is Paroxysmal Nocturnal Dyspnea

A

SOB occurring abruptly 30 minutes to 4 hours after going to bed, relieved after 10-20 minutes by sitting up or standing
Usually specific to cardiac disease

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8
Q

What are Palpitations

A

Awareness of the heartbeat

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9
Q

What do Palpitations refelct

A

Increased cardiac or stroke output

May be due to increased stroke volume from cardiac abnormalities

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10
Q

What is Cardiogenic Syncope

A

Results from bradyarrhythmias, very rapid supraventricular rhythms or ventricular tachycardia or fibrillation
Usually occurs at rest

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11
Q

What else can cause Cardiogenic Syncope

A

Aortic Stenosis

Hypertrophic Cardiomypathy

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12
Q

What is the NYHA classification system (Class I - Class V)

A

Class I: No limitation of physical activity
Class Ii: Ordinary physical activity results in sx
Class III: Comfortable at rest, less than ordinary activity causes sx
Class IV: Unable to engage in physical actiity without discomfort. Sx may present even at rest
Class V: Atypical sx, occur at rest or with exertion

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13
Q

What are the ACC/AHA Stages (Stage A - Stage D)

A

Stage A: High risk for heart failure but not structural heart disease
Stage B: Structural HD but no sx
Stage C: Structural HD with current or prior sx
Stage D: Refractory HF requiring device or special intervention

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14
Q

What is Paroxysmal Supraventricular Tachycardia

A 
Frequently associated with palpitations
Abrupt onset/offset
Rapid, regular rhythm (140-280 bmp)
Most commonly seen in young adults
Rarely causes syncope
Usually see narrow QRS complex
Often responds to vagal maneuvers, AV nodal blockers or adenosine
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15
Q

Sx of SVT

A

Asymptomatic
Palpitations
Some have chest pain, SOB, diaphoresis, syncope

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16
Q

Dx of SVT

A

EKG: Rapid beat of 140-280 bmp, regular.

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17
Q

Tx of SVT

A

Most resolve spontaenously
Valsalva, Carotid Sinus Massage, Facial contact with cold water
Adenosine is first line med
If Adenosine fails, use CCB like Verapamil and diltiazem
Beta-Blockers like Esmolol, Propranolol, Metoprolol
If hemodynamically unstable: Cardioversion

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18
Q

What are preventative measures for SVT

A

Catheter Ablation

CCB: Diltiazem and Verapamil which block AV node

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19
Q

What is Wolff-Parkinson-White Syndrome

A

Supraventricular Tachycardia due to an accessory AV pathway (Preexcitation Syndrome)
These are specifically through Kent bundles

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20
Q

Sx of Wolff-Parkinson-White Syndrome

A

Palpitations
Syncope
Rapid, Regular Rhythm

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21
Q

Dx of Wolff-Parkinson-White Syndrome

A

EKG: Short PR interval with Delta Wave

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22
Q

Tx of Wolff-Parkinson-White Syndrome

A

Catheter Ablation

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23
Q

What is Atrial Fibrillation

A

Most common chronic arrhythmia
Irregularly irregular rhythm
Often associated with palpitations or fatigue

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24
Q

What is the concern with Atrial Fibrillation

A

Can lead to LV dysfunction, HF, or MI

Thrombus formation due to stasis in atria that can embolize to cerebral circulation (stroke)

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25
Q

Sx of Atrial Fibrillation

A

Asymptomatic

Palpitations

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26
Q

Dx of Atrial Fibrillation

A

EKG: Erratic, disorganized atrial activity between discrete QRS complexes occurring in an irregularly pattern

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27
Q

Tx of Atrial Fibrillation for hemodynamically unstable patient

A

Hospitalization
IV Beta Blockers (Esmolol, Propranolol, Metoprolol) and IV
CCB (Diltiazem and Verapamil) for rate control
Cardioversion if patient in shock or severe hypotension, pulmonary edema, ongoing MI or ischemia

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28
Q

Tx of Atrial Fibrillation for hemodynamically stable patient

A

Rate control and anticoagulation
Rate Control: Beta-Blocker or CCB
Anticoagulation: Warfarin, ASA
If cardioversion is planned, anticoagulation must ben given for 3-4 weeks prior

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29
Q

What is Atrial Flutter

A 
Regular Heart Rhythm
Often Tachycardic (100-150)
Palpitations, Fatigue
Sawtooth pattern on EKG
Often seen with COPD or structural HD
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30
Q

Tx of Atrial Flutter

A

Ventricular rate control: Beta-Blocker or CCB

Chronic: Catheter Ablation is definitive

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31
Q

What is Ventricular Tachycardia

A

Fast, Wide QRS complex
Associated with structural heart disease
Associated with syncope

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32
Q

What defines Ventricular Tachycardia

A

3 or more consecutive ventricular premature beats

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33
Q

Sx of Ventricular Tachycardia

A

Asymptomatic

Syncope

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34
Q

Dx of Ventricular Tachycardia

A

Wide QRS
Hypokalemia
Hypomagnesemia

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35
Q

Tx of Ventricular Tachycardia

A

Beta-Blocker

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36
Q

What is a complication of Ventricular Tachycardia and what is its treatment

A

Torsades de Pointes
QRS morphology twists around the baseline
May occur in hypokalemia, hypomagneseia
Tx: IV Magnesium

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37
Q

What is Ventricular Fibrillation

A

Disorganized electrical activity in the ventricles

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38
Q

Tx for Ventricular Fibrillation

A

Defibrillation + CPR

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39
Q

What is a Ventricular Premature Beat (PVC)

A

Isolated beats originating from ventricular tissue

Sudden death occurs in presence of organic heart disease

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40
Q

Sx of PVCs

A

Skipped beat

Palpitations

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41
Q

Dx of PVCs

A

EKG: Wide QRS that differ in morphology, usually not preceded by P-wave

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42
Q

Tx of PVCs

A

If no cardiac disease: No tx needed
Beta-Blockers on CCB are 1st line
Catheter ablation for sx patients who don’t respond to medication

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43
Q

What is a First Degree AV Block

Tx

A

Constant prolonged PR interval
Every P-wave is followed by QRS
Tx: None

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44
Q

What is a Second Degree AV Block, Type I (Mobitz I/Wenckebach)

A

Progressively elongated PR intervals until a QRS is eventually dropped
Tx: Atropine, Epinephrine, Pacemaker if symptomatic

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45
Q

What is a Second Degree AV Block, Type II (Mobitz II)

A

Constant PR Interval until a QRS is eventually dropped

Tx: Permanent Pacemaker

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46
Q

What is a Third Degree AV Block

A

P-waves don’t relate to QRS
AV Dissociation
Tx: Permanent Pacemaker

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47
Q

What is Sick Sinus Syndrome

A

Applied to patients with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia
Often caused by medications like digitalis, CCB, Beta-Blocker, Antiarrhythmics

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48
Q

Sx of Sick Sinus Syndrome

A

Asymptomatic

Syncope, dizziness, confusion, palpitations, HF, angina

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49
Q

Tx of Sick Sinus Syndrome

A

Permanent pacing if sx

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50
Q

What leads to LV failure

A

Systolic or diastolic dysfunction

Results in low CO and congestion, including dyspea

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51
Q

What leads to RV failure

A

LV failure leads to RV failure

Sx of fluid overload

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52
Q

What is the definition of Hypertension

A

At least 2 elevated BP readings on 2 different visits

Systolic >140 or Diastolic >90

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53
Q

What is primary Hypertension

A

Due to Idiopathic etiology

Usually strong family history

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54
Q

What is secondary HTN

A

Due to underlying, identifiable and correctable cause

Most commonly due to Renal Artery Stenosis, Primary Hyperaldosteronism, Coarctation ofAorta, Pheochromoctyoma

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55
Q

What are complications for HTN

A

CAD, HF, MI, LVH, TIA, Stroke, Renal Stenosis and Sclerosis, Retinal Hemorrhage, Blindness, Retinopathy

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56
Q

Sx of HTN

A

Papilledema: Advanced stage of malignant HTN

Striae, Carotid Bruits, JVD, Polycystic kidneys, bruits over renal artery, decreased femoral pulses

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57
Q

Tx of HTN

A

Goal is <140/90
If Diabetic, goal is <130/80
Lifestyle modifications first: weight loss, dash diet, exercise, limit alcohol
Diuretics: Initial therapy (HCTZ, Chlorthalidone, Furosemide, Spironolactone, Amiloride)
Ace-I: HTN especially with DM, nephropathy, CHF
CCB: HTN, Angina, Raynaud’s
Beta-Blockers: HTN, Angina

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58
Q

What is a Hypertensive Urgency

A

BP >220/120 without end-organ damage

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59
Q

Tx of HTN Urgency

A

Decreased BP by 25% in first 24-48 hours using PO agents

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60
Q

What is Hypertensive Emergency

A

BP>220/120 with end-organ damage

End-Organ Damage: Encephalopathy, Stroke, ACS, HF, Aortic Dissection, AKI, Proteinuria, Hematuria,

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61
Q

Tx of HTN Emergency

A

Decreased BP by 10% in the 1st hour and an additional 15% next 2-3 hours using IV agents

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62
Q

What is Cardiogenic Shock

A

Results from heart failure with inadequate tissue perfusion

Evidence of tissue hypoxia due to decreased cardiac output with adequate intravascular volume

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63
Q

What causes Cardiogenic Shock

A

Cardiac disease such as MI, myocarditis, valvular dysfunction, Cardiomyopathy

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64
Q

Tx of Cardiogenic Shock

A

Oxygen
Isotonic fluids, but avoid aggressive IV fluids
Inotropic support: Dobutamine, Epinephrine, Amrinone
Treat underlying cause: MI

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65
Q

What is the body’s normal response to avoid Orthostatic Hypotension

A

Vasoconstriction occurs when someone goes from a laying down to sitting or sitting to upright posture which compensates for the abrupt decrease in venous return

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66
Q

What are causes of Orthostatic Hypotension

A

Diabetics with autonomic neuropathy
Blood loss or Hypovolemia
Vasodilators, diuretics and adrenergic-blocking medications

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67
Q

What is Heart Failure

A

The inability of the heart to pump sufficient blood to meet the metabolic demands of the body at normal filling pressures

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68
Q

What is the most common cause of Heart Failure

A

Coronary Artery Disease

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69
Q

What happens with Left sided heart failure

A

Low cardiac output and elevated pulmonary venous pressure

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70
Q

Sx of left sided HF

A

Dyspnea
Initially exertional dyspnea then orthopnea
Pulmonary Congestion: Rhonchi, nonproductive cough

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71
Q

What happens with right sided HF

A

Left sided HF leads to right sided HF

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72
Q

Sx of right sided HF

A

Fluid retention
Elevated JVD, Peripheral Edema
GI/Hepatic Congestion

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73
Q

Dx of HF

A

Echocardiogram is 1st: Can determine Ejection Fraction
CXR: May see pleural effusions, Kerley B Lines
BNP: Results from volume overload

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74
Q

What are the 2 drugs that all patients with HF should be on

A

ACE-I and Diuretics

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75
Q

What is 1st line treatment for HF

A

ACE-I

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76
Q

What are the drugs that decrease mortality in HF

A

ACE-I, ARB, Beta-Blockers, Hydralazine + Nitrates, Spironolactone, Amiloride, Dopamine

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77
Q

What are the drugs that help with sx in HF

A

Diuretics, Digoxin

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78
Q

What drugs should HF patients be on

A

ACE-I + Diuretic at first then eventually add a Beta-Blocker

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79
Q

What is indicated in a patient with HF with EF <35%

A

Implantable Cardioverter Defibrillator

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80
Q

What is CHF

A

Decompensated HF with worsening of baseline sx characterized by pulmonary congestion

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81
Q

Sx of CHF

A

Worsening dyspnea, rales, pink frothy sputum

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82
Q

What do see on CXR with CHF

A

Cephalization of flow: Increased pulmonary venous pressure

Kerley B Lines

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83
Q

Tx of CHF

A 
LMNOP
Lasix
Morphine
Nitrates
Oxygen
Position (place upright to decrease venous return
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84
Q

What is Acute Pericarditis

A

Acute inflammation of pericardium

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85
Q

What are the P’s of Acute Pericarditis

A

Persistent, Pleuritic, Postural pain and Pericardial friction rub

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86
Q

What are causes of Acute Pericarditis

A

Viral: Coxsackie and Echovirus, Adenovirus
Neoplastic
Dressler’s Syndrome (Pericarditis 2-5 days after an MI)

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87
Q

Sx of Acute Pericarditis

A

Pleuritic chest pain relieved with leaning forward
Radiates to trapezius, back, neck, shoulder, arm
Pericardial Friction Rub

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88
Q

Dx of Acute Pericarditis

A

EKG: See ST elevations in precordial leads (concave up in V1-V6) and PR depressions
Echo: Look for effusions or tamponade

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89
Q

Tx of Acute Pericarditis

A

ASA or NSAIDS for 7-14 days
Colchicine is 2nd line
Corticosteroids if >48 hours or refractory

90
Q

What is a Pericardial Effusion

A

Increased fluid in the pericardial space

91
Q

What causes Pericardial Effusions

A

Pericarditis, Infection, Radiation Therapy, Dialysis, Collagen Vascular Disease

92
Q

Sx of Pericardial Effusions

A

Distant Heart Sounds

93
Q

Dx of Pericardial Effusions

A

EKG: Low voltage QRS complexes, Electric Alternans (QRS that differ in size regarding tall/short peaks)
Echo: Increased pericardial fluid
CXR: Cardiomegaly

94
Q

Tx of Pericardial Effusions

A

Observation if small

Pericardiocentesis if tamponade or large effusion

95
Q

What is Pericardial Tamponade

A

Pericardial effusions that causes significant pressure on the heart and results in restriction of ventricular filling and therefore decreased CO

96
Q

Sx of Pericardial Tamponade

A

Beck’s Triad: Distant heart sounds, Increased JVP, Systemic Hypotension
Pulsus Paradoxus: >10mmHG systolic BP DROP with inspiration
Dyspnea, Fatigue, Peripheral Edema, Hypotension

97
Q

Dx of Pericardial Tamponade

A

Echo: See effusions and diastolic collapse of cardiac chambers

98
Q

Tx of Pericardial Tamponade

A

Pericardiocentesis

99
Q

What is Constrictive Pericarditis

A

Thickened, fibrotic, calcified pericardium that restricts ventricular diastolic filling
Leads to increased venous return and decreased stroke volume and decreased CO

100
Q

Sx of Constrictive Pericarditis

A

Dyspnea
Right sided HF signs (Increased JVD, peripheral edema, N/V)
Kussmaul’s Sign: JVD during inspiration
Pericardial Knock

101
Q

Dx of Constrictive Pericarditis

A

Echo: Pericardial thickening
CXR: Pericardial Calcification

102
Q

Tx of Constrictive Pericarditis

A

Pericardiectomy

Diuretics for sx

103
Q

What is Myocarditis

A

Inflammation of the heart muscle

104
Q

What are common causes of Myocarditis

A

Viral: Enterovirus like Coxsackie B and Echovirus
Rickettsial
Systemic Lupus, Rheumatic Fever

105
Q

Sx of Myocarditis

A

Viral Prodome: Fever, Myalgias, Malaise
HF symptoms: Dyspnea, Syncope, Tachypnea, Tachycardia
Pericarditis Simultaneously

106
Q

Dx of Myocarditis

What is the gold standard

A

Endomyocardial Biopsy is gold standard: SEe infiltrations of lymphocytes with myocardial necrosis
CXR: Cardiomegaly
CK-MB and Troponin
Echo: Ventricular dysfunction, Pericardial effusion

107
Q

Tx of Myocarditis

A 
Supportive
CHF tx (Diuretics, ACE-I, Dopamine)
108
Q

What is Cardiomyopathy

A

Disease of the heart muscle associated with cardiac dysfunction in the absence of heart disease

109
Q

What is Dilated Cardiomyopathy

A

Systolic Dysfunction leads to ventricular dilation

110
Q

What causes Dilated Cardiomyopathy

A

Idiopathic
Viral (Coxsackie B, Echovirus), Parvovirus B-19
Alcohol Abuse
Infiltrative

111
Q

Sx of Dilated Cardiomyopathy

A

HF sx

Embolic Events: Arrhythmias, Chest Pain

112
Q

Dx of Dilated Cardiomyopathy

A

Echo: See LV dilation, Large venticular chamber, Reduced EF
CXR: Cardiomegaly, Pulmonary edema, pleural effusions

113
Q

Tx of Dilated Cardiomyopathy

A

HF Tx: ACE-I, Diuretics, Digoxin, Beta Blockers

114
Q

What is Restrictive Cardiomyopathy

A

STIFF Ventricles
Imparied diastolic function with preserved contractility
Ventricular rigidity impedes ventricular filling

115
Q

What causes Restrictive Cardiomypathy

A

Infiltrative Diseases such as amyloidosis, sarcoidosis

116
Q

Sx of Restrictive Cardiomyopathy

A

Right sided HF sx

Kussmaul’s Sign (JVP increases with inspiration)

117
Q

Dx of Restrictive Cardiomyopathy

A

Echo: Ventricles nondilated with normal wall thickness, Dilated of both atrium, Diastolic dysfunction with normal systolic function
CXR: Enlarged Atrium, normal ventricular chamber size

118
Q

Tx of Restrictive Cardiomyopathy

A

Symptomatic (diuretics, vasodilators)

119
Q

What is Hypertrophic Cardiomyopathy

A

Inherited genetic disorder of inappropriate LV or RV hypertrophy (especially septal)

120
Q

How does Hypertrophic Cardiomyopathy leads to sx

A

Septum is hypertrophic and the systolic anterior motion of mitral valve is displaced

121
Q

Sx of Hypertrophic Cardiomyopathy

A 
Dyspnea
Angina
Syncope
Arrhythmias, Palpitations
Sudden Cardiac Death
Murmur: Harsh Systolic Crescendo-Decrescendo heard at LUSB
122
Q

How is the murmur in Hypertrophic Cardiomyopathy INCREASED

A

Decreased Venous Return

Valsalva and Standing

123
Q

How is the murmur in Hypertrophic Cardiomyopathy DECREASED

A

Increase Venous Return
Squatting, Lying Down
Increasing Venous Return leads to pushing the septum towards the left side of the heart which leads to closure of the aortic valve outflow, therefore decreasing murmur sound

124
Q

Dx of Hypertrophic Cardiomyopathy

A

Echo: Asymmetric wall thickness
EKG: LVH

125
Q

Tx of Hypertrophic Cardiomyopathy

A 
Beta-Blockers are 1st line
Myomectomy
Alcohol septal ablation
Avoid strenuous activity and dehydration
May need Implantable Cardio Defibrillator as these patients are likely to die from arrhythmias
126
Q

What is Rheumatic Fever

A

An acute autoimmune inflammatory multi-systemic illness affecting kids 4-15 yrs old
Usually post-Strep infection (Group A Beta-Hemolytic Strep aka Strep. Pyogens)

127
Q

What are complications that can happen with Rheumatic Fever

A

Mitral Valve Disease

128
Q

What is the name of the diagnostic criteria for Rheumatic Fever

A

Jones Criteria

129
Q

Dx for Rheumatic Fever

A 
Recent Strep + 2 Major
Recent Strep + 1 Major + 2 Minor
Major
-J: Joints, Migratory Polyarthritis
-O: Active Carditis
-N: Nodules, Subcutaneous Nodules
-E: Erythema Marginatum
-S: Sydenham's Chorea

Minor
-Fever, Arthrlagias, Increased ESR/CRP/Leukocytosis, EKG with prolonged PR intervals

130
Q

Tx for Rheumatic Fever

A

Penicillin G

ASA for 2-6 weeks with taper or Corticosteroids in severe cases

131
Q

What are maneuvers to INCREASE murmurs

A

Squatting, Leg Raises, Laying down
-ALL murmurs are increased with these maneuvers EXCEPT Hypertrophic Cardiomyopathy
Inspiration increases venous return on right side of heart
Expiration increases venous return on left side of heart

132
Q

What are maneuvers to DECREASE murmurs

A

Valsalva/Standing
-All murmurs are decreased with these maneuvers EXCEPT Hypertrophic Cardiomyopathy
Expiration decreases venous return on right side of heart
Inspiration decreases venous return on left side

133
Q 
What are the features of the Aortic Stenosis
Pathophysiology
Etiology
Sx
Murmur Sound
Radiation
Pulse
Tx
A

Pathophysiology: LV outflow obstruction leads to fixed CO
Etiology: Degeneration, Congenital, Rheumatic Disease
Sx: Angina, Syncope, CHF
Murmur Sound: Systolic ejection crescendo-decresendo at RUSB
Radiation: Carotid Arteries
Pulse: Pulsus Parvus (weak delayed pulse)
Tx: Aortic valve replacement when symptomatic

134
Q 
What are the features of Mitral Regurgitation
Pathophysiology
Etiology
Sx
Murmur Sound
Radiation
Pulse
Tx
A

Pathophysiology: Backflow from LV into LA
Etiology: MVP, Ischemia
Sx: Dyspnea, Pulmonary Edema
Murmur Sound: Blowing Holosystolic Murmurs at Apex
Radiation: Axilla
Pulse: Brisk Upstroke
Tx: Vasodilators (ACE-I), Valve repair preferred

135
Q 
What are the features of Mitral Valve Prolapse
Pathophysiology
Etiology
Sx
Murmur Sound
Radiation
Pulse
Tx
A

Pathophysiology: Floppy, Redundant Valve
Etiology: Younge Women
Sx: Asymptomatic, Autonomic dysfunction (chest pain, panic attcks, arrhythmias)
Murmur Sound: Midsystolic Ejection Click at apex
Radiation: N/A
Pulse: N/A
Tx: Reassurance, Beta Blockers if symptomatic

136
Q 
What are the features of Aortic Regurgitation
Pathophysiology
Etiology
Sx
Murmur Sound
Radiation
Pulse
Tx
A

Pathophysiology: Backflow from Aorta to LV
Etiology: Rhumatic disease, HTN, Endocarditis
Sx: Left Sided HF
Murmur Sound: Diastolic Decrescendo Blowing at LUSB
Radiation: Left Sternal Border
Pulse: Bounding pulses, Wide pulse pressure
Tx: Vasodilators, Surgery if symptomatic

137
Q 
What are the features of Mitral Stenosis
Pathophysiology
Etiology
Sx
Murmur Sound
Radiation
Pulse
Tx
A

Pathophysiology: Obstruction of flow from LA to LV, Pulmonary HTN
Etiology: Rehumatic Heart Disease
Sx: Right Sided HF, Pulmonary HTN, Atrial Fibrillation
Murmur Sound: Diastolic Rumble at Apex
Radiation: None
Pulse: Reduced intensity
Tx: Valvotomy in young patients

138
Q

What is Angina

A

Substernal chest pain that is often brought on by exertion

139
Q

What causes Angina

A

CAD
Coronary Artery Spasms
Cardiomyopathy

140
Q

What are Risk Factors for Angina

A

DM, Hyperlipidemia, Smoking, HTN, Family hx of CAD

141
Q

Sx of Angina

A

Substernal chest pain, may radiate to arm, lower jaw, back, shoulder
Lasts <30 minutes
Relieved by NTG
Caused by Fixed coronary artery stenosis
Dyspnea, Nausea, Vomiting, Diaphoresis or numbness

142
Q

Dx of Angina

Gold Standard

A

Coronary Angiogram is gold standard
EKG: See ST depression with exertion, T-Wave Invesions
Stress Test: Best screening tool

143
Q

When is PTCA indicated

A

1 or 2 vessels that don’t involve the Left Coronary Artery + Normal or near normal EF

144
Q

When is a CABG indicated

A

Left Main Coronary Artery Disease
Sx 3 vessel disease
Left Ventricular EF < 40%

145
Q

What are indications for Nitrates (NTG) and how does it work

A

Angina
Can give up to 3 doses, if need more than 3 doses suspect CAD
Increased blood supply, decrease demand by decreasing cardiac work and decreasing preload

146
Q

What are indications for beta blockers in Angina/CAD and how does it work

A

1st line for chronic management
Increased myocardial blood supply
Decreases demand by reducing myocardial o2 requirements during exercise/stress

147
Q

What are indications for CCB in Angina/CAD and how does it work

A

Increases myocardial blood supply

Effective at terminating coronary vasospasms by increasing coronary vasodilation and prolonging filling time

148
Q

What are indications for ASA and how does it work

A

Plays a role in slowing or stopping the progression of stable angina to CAD
Prevents platelet activation/aggregation

149
Q

What are the categories of Acute Coronary Syndrome

A

Unstable Angina, NSTEMI, and STEMI

150
Q

What causes ACS

A

Acute plaque rupture and coronary artery thrombosis

Coronary artery vasospasms

151
Q

What are risk factors for ACS

A

DM, males, age, HTN, Hyperlipidemia, family hx, smoking, obesity

152
Q

Sx of Acute Coronary Syndrome

A

Retrosternal chest pain that is not relieved with rest or NTG
May radiate to arms, neck, back, shoulders, epigastrium, lower jaw
Anxiety, diaphoresis, tachycardia, N/V, Palpitations, Dizziness

153
Q

Dx of ACS

A

EKG

  • Unstable Angina/NSTEMI: T-wave inversion/ST depression
  • STEMI: ST elevations
154
Q

What does the location of the ST Elevations/Depression tell you about the location of the MI

A 
V1-V4: Anterior Wall/Septal
I, aVL, V5, V6: Lateral Wall
I, aVL, V4, V5, V6: Anterolateral
II, III, aVF: Inferior
ST Depressions at V1-V2: Inferior
155
Q

What are 2 cardiac markers to measure MI

A

Troponin

CK/CK-MB

156
Q

What are indications for ASA use during an MI

A

Prevents platelet aggregation, used to stop or slow progression
Everyone should be on ASA

157
Q

What are indications for Unfractionated Heparin for MI

A

Give if history of ACS, EKG changes or positive cardiac markers

158
Q

What are indications for Low Molecular Weight Heparin for MI

A

Give if history of ACS, EKG changes or positive cardiac markers
This is better than UFH because LMWH has longer half life and don’t need to monitor PTT

159
Q

What are indications for Plavix (Clopidogrel) in an MI

A

Useful for initial tx in people with allergy to ASA

160
Q

What are additional therapies used in an MI

A 
Morphine: Relieves pain and anxiety
O: Oxygen
N: Nitrates
A: ASA
B: Beta Blockers
A: Ace-Inhibitors
S: Statins
H: Heparin
161
Q

What are the 3 parts to approach a STEMI

A

Reperfusion, Antithrombotic Therapy, Adjunctive Therapy

162
Q

What is included in Reperfusion Therapy in a STEMI

A

PCI or Thrombolytics

Thrombolytics: Alteplase (rTPA), Streptokinase

163
Q

What are Antithrombotic Therapies in a STEMI

A

ASA, UFH/LMWH/GP IIb/IIIa Inhibitors

164
Q

What are Adjunctive Therapies in a STEMI

A 
Beta-Blockers
Ace-I
Nitrates
Morphine
Statin Therapy
165
Q

What adjunctive therapies in a STEMI reduce mortality vs. control symptoms

A

Reduce MortalitY: Beta-Blockers, Ace-I

Symptoms: Nitrates, Morphines

166
Q

What are 2 common Coronary Vasospasm Disorders

A

Prinzemetal’s Angina

Cocaine Induced MI

167
Q

What is Prinzemetal’s Angina

A

Coronary spasms that lead to transient ST elevations

168
Q

Sx of Prinzemetal’s Angina

A

Chest pain at rest, usually in the mornings with hyperventilation

169
Q

Dx of Prinzemetal’s Angina

A

EKG: Transiet ST Elevations which resolve with CCB and NTG
Angiography: No fixed stenotic lesions

170
Q

Tx of Prinzemetal’s Angina

A

CCB is 1st line

Nitrates as needed

171
Q

What is Cocaine Induced MI

A

Coronary spasms
Cocaine activates the sympathetic nervous system and alpha-1 receptors which lead to vasoconstriction of the coronary arteries

172
Q

Dx of Cocaine Induced MI

A

EKG: Transient ST elevations that may induce an MI if prolonged

173
Q

Tx of Cocaine Induced MI

A

CCB and Nitrates to reverse vasospasms
ASA, Heparin, Benzodiazepines
No beta-blockers because they increase the risk of vasospasms (unopposed alpha-1 constriction)

174
Q

What is Infective Endocarditis

A

Infeciton of the endothelium/valves secondary to colonization during bacterial infection

175
Q

What is the most common valve involved in Infective Endocarditis

A

Mitral Valve

176
Q 
What are the pathogens involved with the different types of Endocarditis/Valve Involvement
Normal Valves
Abnormal Valves
Prosthetic Valves
IV Drug Users
A

Normal Valves: Strep Viridans (oral flora), Staph Aureus
Abnormal Valves: Strep Viridans
Prosthetic Valves: Staph Epidermis
IV Drug Users: Staph Auerus

177
Q

Sx of Infective Endocarditis

A

Fever
Janeway Lesions: Painless erythematous macules on palms/soles
Roth Spots: Retinal Hemorrhage with plae center
Osler’s Nodes: Tender nodules on pads of digits
Splinter Hemorrhages

178
Q

Dx of Infective Endocarditis

A

Modified Duke Criteria: 2 major, or 1 major+ 3 minor, or 5 minor
-Major: 2 positive blood cultures, Positive Echo
Minor
-Minor: Predisposing condition, fever, vascular and embolic phenomena, Immunologic phenomena, Positive blood culture with atypical pathogen, positive echo

179
Q

Tx of Infective Endocarditis

A

Native Normal Valve: Nafcillin + Gentamicin for 4-6 weeks (vancomycin if PCN allergy)
Native Abnormal Valves: Penicillin/Ampicillin + Gentamicin (Vancomycin if PCN allergy)
Prosthetic Valve: Vancomycin + Gentamycin + Rifampin
Fungal: Amphotericin B, Caspofungin

180
Q

What is Peripheral Artery Disease

A

Atherosclerotic disease of the lower extremities

181
Q

Sx of PAD

A

Intermittent claudication
Reproducible pain/discomfort in LE brought on by exercise/walking and relieved with rest
Resting leg pain indicates severe disease
Gangrene
Lateral Malleolar Ulcers
Atrophic skin changes (muscle atrophy, thin/shiny skin, hair loss, thick nails)
Decreased or absent pulses, reduced capillary refill

182
Q

Dx of PAD

A

Arteriograph is gold standard
Ankle-Brachial Index
Duplex B mode ultrasound

183
Q

Tx of PAD

A

Platelet Inhibitors: Cilostazol, ASA, Plaix
Revascularization: Angioplasty, Bypass graft, Endarteretomy
Exercise, reduced risk factors(HTN, DM, Lipid)
Amputation if gangrene
Acute Arterial Occlusion: Haperin for embolism, Thrombolytics if thrombus

184
Q

What is an Abdominal Aortic Anuerysm

A

Focal dilation of the aorta

185
Q

Risk factors Abdominal Aortic Aneurysm

A

Atherosclerosis
Age >60yrs
Smoking
Caucasians, Males

186
Q

Sx of AAA

A

Asymptomatic until rupture
Rupture: Severe back or abdominal pain with syncope or hypotension
Tender Pulsatile abdominal mass
Ripping chest pain

187
Q

Dx of AAA

A

CT Scan is test of choice
Angiogram is gold standard
Abdominal Ultrasound

188
Q

Tx of AAA

A 
3-4cm: US every year
4-4.5cm: US every 6 months
>4.5cm: Vascular surgeon referral
>5.5cm: Immediate surgical repair
Beta-Blockers reduce shearing forcers
189
Q

What is an Aortic Dissection

A

Tear in the innermost layer of the aorta

190
Q

Risk Factors for Aortic Dissection

A

HTN, Age, Vasculitis, Collagen Disorder (Marfans)

191
Q

Sx of Aortic Dissection

A

Chest pain, sudden onset of severe tearing or ripping chest pain/back pain
Decreased peripheral pulses (variation between left and right arm)
HTN

192
Q

Dx of Aortic Dissection

A

MRI Angiography: Gold Standard
CXR: Widening of mediastinum
CT scan with contrast is test of choice
Trans Esophageal Echocardiograph

193
Q

Tx of Aortic Dissection

A

Surgical if ascending

Beta-Blockers (Labetalol) with Sodium Nitroprusside if descending

194
Q

What is Giant Cell Arteritis

A

A vasculitis seen with Temporal or Cranial Arteries

195
Q

What should associate with Gian Cell Arteritis

A

Polymyalgia Rheumatica

196
Q

What causes Giant Cell Arteritis

A

Autoimmune, viral infection, vasculitis

197
Q

Sx of Giant Cell Arteritis

A

Headache, Scalp Tenderness, Jaw claudication with mastication, acute vision disturbances, fatigue, weight loss

198
Q

Dx of Giant Cell Arteritis

A

Biopsy is definitive: See Mononuclear lypmhocyte infiltration, multinucleated giant cells
Increased ESR and CRP

199
Q

Tx of Giant Cell Arteritis

A

High Dose Corticosteroids

Methotrexate

200
Q

What is the biggest concern with Giant Cell Arteritis

A

Can lead to blindness

201
Q

What is Thromboangiitis Obliterans

A

Nonathersclerotic inflammatory disease of small and medium arteries and veins

202
Q

What is Thromboangiitis Obliterans strongly associated with

A

Smoking

203
Q

Sx of Thromboangiitis Obliterans

A

Superficial Migratory Thrombophlebitis: Tender nodules that follow venous distribution
Claudication of ditis/toes
Raynaud’s Phenomenon

204
Q

Dx of Thromboangiitis Obliterans

A

Aortography: Nonatherosclerotic, segmental occlusive lesions of small/medium vessels with corkscrew collaterals

205
Q

Tx of Thromboangiitis Obliterans

A

Stop Smoking is definitive
Would care
CCB for Raynaud’s (Nifedipine, Nicardipine, Amlodipine)

206
Q

What is Superficial Thrombophlebitis

A

Inflammation of the superficial vein or thromus

207
Q

What is Superficial Thrombophlebitis commonly associated with

A

IV cathetrization, trauma, pregnancy and varicose veins

208
Q

Sx of Superficial Thrombophlebitis

A

Local Phlebitis: Tenderness, pain, inducration, edema, erythema along the course of the superfical vein, palpable cord

209
Q

Dx of Superficial Thrombophlebitis

A

Ultrasound: Non-compressible vein with clot and vein thickening

210
Q

Tx of Superficial Thrombophlebitis

A

Supportive: Elevation, warm compresses, NSAIDS, compression stockings

211
Q

How do you develop a DVT

A

Virchow’s Triad: Venous Stasis, Endothelial Damage, Hypercoagulability

212
Q

Sx of DVT

A

Unilateral swelling/edema of the LE
Calf Pain/Tenderness
Phlebitis: Local warmth, erythema, palpable cord

213
Q

Dx of DVT

A

Venous Duplex Ultrasoud
D-Dimer
Venograph is gold standard

214
Q

Tx of DVT

A

Anticoagulation: UH, LMH, Warfarin

IVC Filter for people with contraindications or who fail anticoagulation

215
Q

What are Varicose Veins

A

Dilated, Tortuous Superficial veins

216
Q

Who gets Varicose Veins

A

OCP, Pregnancy, Prolonged Standing, Obesity

217
Q

Sx of Varicose Veins

A

Tortuous Veins
Dull ache or pressure, worse with prolonged standing and relieved with elevation
Venous Stasis Ulcer

218
Q

Tx of Varicose Veisn

A

Leg elevation, compression stockings

Sclerotherapy

219
Q

What is Chronic Venous Insufficiency

A

Vascular incompetency of either deep or superficial veins

220
Q

Sx of Chronic Venous Insufficiency

A

Leg pain: Burning, aching, Throbbing, cramping
Leg Edema
Stasis Dermatitis: Eczematous rash, itching, scaling
Brownish Hyperpigmentation
Medial Malleolus Ulcer
Atrophie Blnache

221
Q

Dx of Chronic Venous Insufficiency

A

Ankle/branchial index

Ultrasound

222
Q

Tx of Chronic Venous Insufficiency

A

Compression: Leg elevation, compression stockings

Ulcer tx: Wet to dry dressing, skin grafting, hyperbaric oxygen

Emergency Medicine (6 decks)

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