CARDIOVASCULAR Flashcards
what is the indication for sodium bicarbonate therapy in TCA overdose?
QRS >100msec
risk for ventricular arrythmia and seizures
what is the worst risk factor for CAD?
what is the most common?
worst is diabetes mellitus
MC is HTN
premature coronary disease is defined as
male under…
female under…
is family history a risk factor for CAD?
male under 55
female under 65
only a risk factor if family member was PREMATURE and FIRST DEGREE (sibling or parent) – so it is not a positive family history risk factor if the family member was OLD
which value in the lipid panel is the most dangerous to a patient in terms of risk for CAD?
a HIGH LDL
tako-tsubo cardiomyopathy
presentation?
tx?
acute myocardial damage in postmenopausal women after a stressful/emotional event which causes catecholamine discharge and left ventricular ballooning/dyskinesis
tx is with B blockers and ACEi
**revascularization will not work because coronary arteries are NORMAL (not CAD)
correcting which of the following risk factors for CAD will result in the most immediate benefit for the patient?
DM tobacco smoking HTN HLD weight loss
tobacco smoking
smoking cessation results in the greatest immediate improvement in outcomes for CAD – within 1 year, risk of CAD decreases by half; within 2 years, decreases by 90%
chest pain that is reproducible to palpation =
chostochondritis
chest pain worse w lying flat, better sitting up + ekg with overall ST elevations
pericarditis
best initial test for all forms of chest pain?
ekg
in the office/ambulatory setting, if a patient comes in with chest pain, what is the next steps?
ekg –> transfer to ED –> cardiac enzymes
DO NOT GET ENZYMES IN OFFICE SETTING
if patient with chest pain cannot exercise for stress test, what are other options?
which to use in asthmatics?
dipyridamole thallium test (decreased uptake of thallium)
or
dobutamine echo (wall motion abnormalities)
use dobutamine in asthmatics since dipyridamole can cause bronchospasm
patient has normal nuclear uptake at rest but decreased with exercise., which returns to normal 2 hrs after exercise. what is next intervention?
coronary angiography bypass surgery PCI (angioplasty) dobutamine echo nothing
coronary angiography (catheterization) to know anatomy to determine whether patient needs bypass or angioplasty
what does coronary angiography determine?
who gets bypass surgery vs who gets angioplasty
(detects location of CAD)
most accurate way to detect CAD!
what % of CAD stenosis requires surgery?
stenosis of at least 70%
<50% is insignificant
in chest pain, if patient has baseline EKG abnormalities, what is the next test you do?
stress echocardiogram or nuclear stress test
since ekg cant be read properly
do not do a exercise stress test if patient currently has…
chest pain
what medications will decrease mortality in chronic angina (CAD)?
aspirin
beta blockers
nitroglycerin
what form of nitroglycerin do you use for acute angina? for chronic?
oral or transdermal for chronic
sublingual, paste of IV in acute
what medication should acute coronary syndrome pt receive upon arrival to ED?
2 antiplatelet agents
aspirin + clopidogrel, prasugrel, or ticagrelor
what med has best mortality benefit on patients with low ejection fraction?
ace inhibitor
side effects of ace inhibitors?
cough hyperkalemia (aldosterone usually excretes K)
what do you switch to if patient on ace inhibitor gets hyperkalemia?
hydralazine and nitrates
best med to lower LDL?
goal?
hmg coa reductase inhibitors (statins!)
less than 100
med with clear mortality benefit in hyperlipidemia?
statins
common side effect of statins?
liver dysfunction
get baseline AST/ALT!
other lipid lowering agents: 1 niacin 2 gemfibrozil 3 cholestyramine 4 ezetimibe
1 - will raise HDL
2 - will lower TGs
**increased risk of myositis when statins + gemfibrozil
3 - bile acid sequestrant which decreases absorption
***uncomfortable GI constipation/flatus
4 - lowers LDL WITHOUT ANY ACTUAL HEALTH BENEFIT
** only use these when statins alone cannot control LDL
delta wave on ekg means what?
WPW (accessory A-V pathway)
delta wave is a slurred upsloping of the QRS
recommended AAA screening?
men 65-75 who have smoked cigarettes should get a 1 time abdominal ultrasound
adverse effects of lipid medications: 1 statins? 2 niacin? 3 fibric acid derivatives (gemfibrozil)? 4 cholestyramine? 5 ezetimibe?
1 elevated LFTs, myositis
2 elevated glucose and uric acid (gout), pruritis
3 increased risk of myositis when added to statin
4 flatus and cramping
5 no s/e, but useless med
which ca channel blockers have been shown to lower mortality in CAD?
none!
which ca channel blockers do NOT increase heart rate?
verapamil and diltiazem
**used in patient with severe asthma who cannot use beta blockers
adverse effects of ca channel blockers?
edema
constipation
heart block *rare
4 situations where CABG lowers mortality?
severe disease such as:
- 3 vessels dz with 70+% stenosis in each
- left main coronary artery occlusion
- 2 vessel disease in a diabetic
- persistent sx despite max medical therapy
kussmaul sign
increase in JVP on inhalation
associated withc onstrictive pericarditis
what does a triphasic scratchy sound indication?
pericardial friction rub (pericarditis)
dressler syndrome
pericarditis several days to weeks after an MI
ST elevation in leads II, III, and aVF
acute MI of the inferior wall
PR interval >200 ms…….
first degree AV block (requires no tx when isolated)
ST elevation in leads V2-V4
acute MI of the anterior wall of LV
PVCs present…..what next
check magnesium and potassium
if e- are normal, no tx required
***treatment of PVCs only worsens the outcome
ST depression in leads V1 and V2
posterior wall MI
reading V1 and V2 are opposite of the others; depression here equals elevation elsewhere
first step in a patient with chest pain in ED after the EKG..
ASPIRIN!
(clopidogrel if patient cant take aspirin)
lowers mortality in ACS and must be given asap
do not choose ck-mb, troponins(enzyme tests normal in first 4 hrs), morphine, oxygen, or nitro…they can all be done after!
after aspirin, in ACS angioplasty should be NEXT if you must choose best option
troponin versus CKMB in their timing postMI
which is used for reinfarction detection?
they both rise after 4-6 hours
ck-mb normalizes after 1-2 days
trops normalize after 10-14 days
use ekg + ck-mb to check reinfarction
most common cause of death in the first few days after an MI?
v tach or v fib
door to balloon time is under __ minutes
(angioplasty/PCI)
PCI is more or less superior to thombolytics?
door to needle time (for thrombolytics)?
90 minutes within arriving to the ED with chest pain
more superior
under 30 minutes for thrombolytics (within 12 hours of onset)
what is the most important consideration in decreasing the risk of restenosis of coronary artery after PCI?
placement of a drug-eluting stent (paclitaxel, sirolimus)
this will decrease the local T cell response and reduce the rate of restenosis (<10% versus 15-30% with bare metal stent)
absolute contraindications to thrombolytics?
major GI (melena not just occult+) or brain bleeding
recent surgery in past 2 weeks
severe htn (>180/110)
nonhemorrhagic stroke in last 6 months
man in ED with chest pain for past hr, EKG shows ST depressions in V2-V4, aspirin has been given, what is next step?
low weight molecular heparin
to prevent cot from forming in coronary arteries (does not dissolve clots that already formed)
there is no benefit of thrombolytic(tPA) therapy when patient has ACS and NO ST elevations
abciximab
a gp2b/3a inhibitor (inhibit platelet aggregation)
used in ACS for those undergoing PCI/angioplasting
heparin is best for ___ MI
tPA (thrombolytics) is best for ____ MI
NSTEMI
STEMI
LMWH vs unfractionated heparin
which is superior in terms of mortality benefit
LMWH
cannon A waves + bradycardia
bounding jvp up into the neck (atrial systole against a closed tricuspid) = A and V are out of coordination
3rd degree complete AV block
tx: atropine –> pacemaker if atropine is ineffective
right coronary artery supplies….
right ventricle
AV node
inferior wall of heart
treatment for right ventricular infarction
high volume fluid replacement
no nitroglycerin since it worsens filling
sudden loss of pulse/pulseless electrical activity several days after MI
free wall rupture!
tx: emergent pericardiocentesis on the way to the OR!
treatment for v fib or v tach?
cardioversion/shock
a step up in oxygen saturation from the right atrium to the right ventricle indicates….
most accurate test for dx?
valve or septal rupture
presents with new onset murmur and pulmonary congestion
echocardiogram for both valve and septal ruptures
name the post-MI complication?
1 - bradycardia and cannon A waves
2 - sudden loss of pulse, JVP
3 - inferior wall MI in hx, clear lungs, tachy, hypotension with nitro
4 - new murmur + rales/congestion
5 - new murmur + increasing oxygen sat from right atrium to ventricle
6 - loss of pulse, need EKG to answer dx
1 - 3rd degree AV block 2 - tamponade/free wall rupture 3 - RV infarction 4 - valve rupture 5 - septal rupture 6 - ventricular fibrillaton
all post-MI patients should go home on these meds
aspirin
B blocker (metoprolol = specific)
statins
ace inhibitor –> Acei are best for anterior wall infarctions because of the high likelihood of developing systolic dysfunction
- *clopidogrel or prasugrel IF intolerant of aspirin or post-stenting
- *ARB if intolerant of ACEi
prophylactic antiarrythmics ___mortality
increase!!
do not give prophylactic antiarrythmics like amiodarone, flecainide etc
can a patient have sex after an MI?
yes if they are symptom free and post MI stress test is normal
s3 versus s4
s3 is right after S2
s4 is right before S1
most likely dx for dyspnea:
1- sudden dyspnea + clear lungs
2- sudden dyspnea + wheezing and increased expiratory phase
3- slower onset, fever + sputum + unilateral rhonchi
4- decreased breath sounds unilaterally + tracheal deviation
5- circumoral numbness + caffeine use + hx of anxiety
6- pallor, gradual over days to weeks
7- pulsus paradoxus, decreased heart sounds, JVD
8- palpitations and syncope
9- dullness to percussion at bases
10- long smoking hx and barrel chest
11- recent anesthetic use, brown blood not improved with oxygen, clear lungs, cyanosis
12- burning building or car, wood burning stove, suicide attempt
1- PE 2- asthma 3- pneumonia 4- pneumothorax 5- panic attack 6- anemia 7- tamponade 8- arrythmia 9- pleural effusion 10- COPD 11- methemoglobinemia 12- Carbon monoxide poisoning
what is the best initial test for ejection fraction/chf?
which is more accurate: TTE, TEE?
TTE
TEE
which three beta blockers are the only ones with proven benefit for low ejection fraction CHF?
metoprolol (beta 1 spec)
bisoprolol (beta 1 spec)
carvedilol (nonspecific B with alpha 1 blocking)
meds given for low ejection fraction CHF?
B blocker
ACEi/Arb
spironolactone (inhibits aldosterone)
diuretics (lower sx, do NOT lower mortality)
digoxin (lower sc, DOes NOT lower mortality, DOES decrease hospitalizations)
mc cause of death from CHF?
arrythmia/sudden death
what is management of a chf patient who develops gynecomastia?
switch spironolactone to eplerenone
adverse effects of spironolactone?
gynecomastia
hyperkalemia
II, III, aVF MI…dont give….
nitrates
do beta blockers, diruetics, spironolatone, and digoxin have benefits in diastolic dysfunction chf?
beta blockers and diuretics YES
digoxin and spironolactone NO
diuretics or indicated or contraindicated in HOCM?
contraindicated
decrease V = increased obstruction by large septum
if there is pulmonary edema from an arrythmia, first step after ekg is…
cardioversion
patient comes in with jvd, sob, rr 38, rales and s3 gallop…best initial step?
oximeter
echo
iv furosemide
metoprolol
iv furosemide
___ can be used in ICU acute setting if sob/pulm edema did not respond to preload reduction in order to increase contractility and decrease afterload
dobutamine (positive inotrope)
digoxin is also a + inotrope but takes weeks to take effect
mc valvular disease from rheumatic heart dz?
mitral stenosis
naturally inhalation will increase intensity of which two heart valve location? and exhalation will increase which two?
inhalation = right side increases (tricuspid and pulmonic)
exhalation = left side inreased return to heart from lungs (mitral and aortic)
valve disease
best initial test?
most accurate test?
best initial = echo (NOT xray)
most accurate = catheterization
only give endocarditis ppx with 2 scenarios…
prior endocarditis or valve has been replaced
critical narrowing of mitral stenosis is defined as
less than 1 cm squared of valve surface area
but tx still is based on presence of symptoms
what heart valve lesion can present with dysphagia and hoarseness?
mitral stenosis can cause LA enlargemend which can press on laryngeal nerve or esophagus
diastolic murmur after an opening snap
squatting and leg raising increase intensity
mitral stenosis
tx for mitral stenosis
balloon valvulosplasy –> valve procedure only if this fails
warfarin for a fib to an INR of 2-3
rate control with digoxin, b blocker, or diltiazem/verapamil
diruetics and Na restriction
2 causes of aortic stenosis
congenital bicuspid A valve
aging calcifications
tx for aortic stenosis?
valve replacement
not valvuloplasty
holosystolic murmur, obscuring s1 and s2, radiating to axilla
what happens w handgrip?
mitral regurg
worsens due to increased backward flow
handgrip _____ afterload
worsens what 2 murmurs?
increases
aortic and mitral regurg
best tx for mitral regurg?
ACEi or ARB (decrease rate of progression)
replace valve when LV end systolic diameter is >40 mm or ejection fractions is below 60%
diastolic derescendo murmur at LLSB , better w handgrip, worse with standing/valsalva, water hammer pulse or head bobbing
aortic regurg
when to replace aortic valve?
EF <55% or LVend sys diameter >55mm
valsalva and standing make MVP ___
handgrip and squatting make MVP ___
worse
better
2 mur murs that dont increase w expiration
MVP
HOcM
systolic anterior motion of the mitral valve and septal Q waves are classic for…
HOCM
best initial therapy for both HOCM and HCM
beta blockers
tx for HOCM patient with syncope?
implantable defibrillator +/- ablation of the septum –> myomectomy is sx persist
which to give in dilated vs hypertrophic cardiomyopathy?
beta blockers diuretics acei/arb spironolactone digoxin
hcm = betaB and diuretics
dilated = all 5
handgrip decreases ______
role in hocm?
LV emptying
it improves hocm by making the heart fuller which decreases the obstruction
diffuse st elevations?
whats the more specific finding?
pericarditis
PR segment depressions
colchicine role in pericarditis tx
it decreases recurrences!
best initial test for patient with smooth shiny leg skin and pain in calves on exertion?
best initial test for PAD is ABI (ankle brachial index)
normally they are equal (ration =1) or ankle is a little higher due to gravity
if ratio is <0.9, then disease is present
best initial tx for PAD?
aspirin
stop smoking
cilostazol (vasidilator; MOST effective drug for PAD)
best initial and most accurate tests for aortic dissection?
initial = CXR to look for widened mediastinum
most accurate = angiography
AAA repair is indicated when width > than???
5 cm
what is the worse cardiac disease in pregant woman?
peripartumc ardiomyopathy ( Ab made against myocardium)
second worst would be eisenmenger syndrome
eisenmenger syndrome
development of a right to left shunt from pulmonary htn
person has a VSD with a left to right shunt that reverses with significant pulm htn
best tx for pericarditis?
nsaids plus colchicine
the high intensity statins?
atorvastatin
resuvostatin
mc place for ectopic foci that cause a fib?
a flutter?
pulmonary veins
a flutter often due to circuit around the tricuspid annulus
what risk factor has strongest association with stoke
htn
