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step 2 ck > CARDIOVASCULAR > Flashcards

CARDIOVASCULAR Flashcards

1
Q

what is the indication for sodium bicarbonate therapy in TCA overdose?

A

QRS >100msec

risk for ventricular arrythmia and seizures

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2
Q

what is the worst risk factor for CAD?

what is the most common?

A

worst is diabetes mellitus

MC is HTN

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3
Q

premature coronary disease is defined as
male under…
female under…

is family history a risk factor for CAD?

A

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

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4
Q

which value in the lipid panel is the most dangerous to a patient in terms of risk for CAD?

A

a HIGH LDL

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5
Q

tako-tsubo cardiomyopathy

presentation?
tx?

A

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)

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6
Q

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
A

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%

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7
Q

chest pain that is reproducible to palpation =

A

chostochondritis

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8
Q

chest pain worse w lying flat, better sitting up + ekg with overall ST elevations

A

pericarditis

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9
Q

best initial test for all forms of chest pain?

A

ekg

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10
Q

in the office/ambulatory setting, if a patient comes in with chest pain, what is the next steps?

A

ekg –> transfer to ED –> cardiac enzymes

DO NOT GET ENZYMES IN OFFICE SETTING

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11
Q

if patient with chest pain cannot exercise for stress test, what are other options?

which to use in asthmatics?

A

dipyridamole thallium test (decreased uptake of thallium)
or
dobutamine echo (wall motion abnormalities)

use dobutamine in asthmatics since dipyridamole can cause bronchospasm

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12
Q

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
A

coronary angiography (catheterization) to know anatomy to determine whether patient needs bypass or angioplasty

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13
Q

what does coronary angiography determine?

A

who gets bypass surgery vs who gets angioplasty
(detects location of CAD)

most accurate way to detect CAD!

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14
Q

what % of CAD stenosis requires surgery?

A

stenosis of at least 70%

<50% is insignificant

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15
Q

in chest pain, if patient has baseline EKG abnormalities, what is the next test you do?

A

stress echocardiogram or nuclear stress test

since ekg cant be read properly

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16
Q

do not do a exercise stress test if patient currently has…

A

chest pain

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17
Q

what medications will decrease mortality in chronic angina (CAD)?

A

aspirin
beta blockers
nitroglycerin

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18
Q

what form of nitroglycerin do you use for acute angina? for chronic?

A

oral or transdermal for chronic

sublingual, paste of IV in acute

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19
Q

what medication should acute coronary syndrome pt receive upon arrival to ED?

A

2 antiplatelet agents

aspirin + clopidogrel, prasugrel, or ticagrelor

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20
Q

what med has best mortality benefit on patients with low ejection fraction?

A

ace inhibitor

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21
Q

side effects of ace inhibitors?

A 
cough
hyperkalemia (aldosterone usually excretes K)
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22
Q

what do you switch to if patient on ace inhibitor gets hyperkalemia?

A

hydralazine and nitrates

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23
Q

best med to lower LDL?

goal?

A

hmg coa reductase inhibitors (statins!)

less than 100

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24
Q

med with clear mortality benefit in hyperlipidemia?

A

statins

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25
Q

common side effect of statins?

A

liver dysfunction

get baseline AST/ALT!

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26
Q 
other lipid lowering agents:
1 niacin
2 gemfibrozil
3 cholestyramine
4 ezetimibe
A

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

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27
Q

delta wave on ekg means what?

A

WPW (accessory A-V pathway)

delta wave is a slurred upsloping of the QRS

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28
Q

recommended AAA screening?

A

men 65-75 who have smoked cigarettes should get a 1 time abdominal ultrasound

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29
Q 
adverse effects of lipid medications:
1 statins?
2 niacin?
3 fibric acid derivatives (gemfibrozil)?
4 cholestyramine?
5 ezetimibe?
A

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

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30
Q

which ca channel blockers have been shown to lower mortality in CAD?

A

none!

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31
Q

which ca channel blockers do NOT increase heart rate?

A

verapamil and diltiazem

**used in patient with severe asthma who cannot use beta blockers

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32
Q

adverse effects of ca channel blockers?

A

edema
constipation
heart block *rare

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33
Q

4 situations where CABG lowers mortality?

A

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
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34
Q

kussmaul sign

A

increase in JVP on inhalation

associated withc onstrictive pericarditis

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35
Q

what does a triphasic scratchy sound indication?

A

pericardial friction rub (pericarditis)

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36
Q

dressler syndrome

A

pericarditis several days to weeks after an MI

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37
Q

ST elevation in leads II, III, and aVF

A

acute MI of the inferior wall

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38
Q

PR interval >200 ms…….

A

first degree AV block (requires no tx when isolated)

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39
Q

ST elevation in leads V2-V4

A

acute MI of the anterior wall of LV

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40
Q

PVCs present…..what next

A

check magnesium and potassium
if e- are normal, no tx required

***treatment of PVCs only worsens the outcome

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41
Q

ST depression in leads V1 and V2

A

posterior wall MI

reading V1 and V2 are opposite of the others; depression here equals elevation elsewhere

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42
Q

first step in a patient with chest pain in ED after the EKG..

A

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

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43
Q

troponin versus CKMB in their timing postMI

which is used for reinfarction detection?

A

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

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44
Q

most common cause of death in the first few days after an MI?

A

v tach or v fib

45
Q

door to balloon time is under __ minutes
(angioplasty/PCI)

PCI is more or less superior to thombolytics?

door to needle time (for thrombolytics)?

A

90 minutes within arriving to the ED with chest pain

more superior

under 30 minutes for thrombolytics (within 12 hours of onset)

46
Q

what is the most important consideration in decreasing the risk of restenosis of coronary artery after PCI?

A

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)

47
Q

absolute contraindications to thrombolytics?

A

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

48
Q

man in ED with chest pain for past hr, EKG shows ST depressions in V2-V4, aspirin has been given, what is next step?

A

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

49
Q

abciximab

A

a gp2b/3a inhibitor (inhibit platelet aggregation)

used in ACS for those undergoing PCI/angioplasting

50
Q

heparin is best for ___ MI

tPA (thrombolytics) is best for ____ MI

A

NSTEMI

STEMI

51
Q

LMWH vs unfractionated heparin

which is superior in terms of mortality benefit

A

LMWH

52
Q

cannon A waves + bradycardia

A

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

53
Q

right coronary artery supplies….

A

right ventricle
AV node
inferior wall of heart

54
Q

treatment for right ventricular infarction

A

high volume fluid replacement

no nitroglycerin since it worsens filling

55
Q

sudden loss of pulse/pulseless electrical activity several days after MI

A

free wall rupture!

tx: emergent pericardiocentesis on the way to the OR!

56
Q

treatment for v fib or v tach?

A

cardioversion/shock

57
Q

a step up in oxygen saturation from the right atrium to the right ventricle indicates….

most accurate test for dx?

A

valve or septal rupture

presents with new onset murmur and pulmonary congestion

echocardiogram for both valve and septal ruptures

58
Q

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

A 
1 - 3rd degree AV block
2 - tamponade/free wall rupture
3 - RV infarction
4 - valve rupture
5 - septal rupture
6 - ventricular fibrillaton
59
Q

all post-MI patients should go home on these meds

A

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
60
Q

prophylactic antiarrythmics ___mortality

A

increase!!

do not give prophylactic antiarrythmics like amiodarone, flecainide etc

61
Q

can a patient have sex after an MI?

A

yes if they are symptom free and post MI stress test is normal

62
Q

s3 versus s4

A

s3 is right after S2

s4 is right before S1

63
Q

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

A 
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
64
Q

what is the best initial test for ejection fraction/chf?

which is more accurate: TTE, TEE?

A

TTE

TEE

65
Q

which three beta blockers are the only ones with proven benefit for low ejection fraction CHF?

A

metoprolol (beta 1 spec)
bisoprolol (beta 1 spec)
carvedilol (nonspecific B with alpha 1 blocking)

66
Q

meds given for low ejection fraction CHF?

A

B blocker
ACEi/Arb
spironolactone (inhibits aldosterone)
diuretics (lower sx, do NOT lower mortality)
digoxin (lower sc, DOes NOT lower mortality, DOES decrease hospitalizations)

67
Q

mc cause of death from CHF?

A

arrythmia/sudden death

68
Q

what is management of a chf patient who develops gynecomastia?

A

switch spironolactone to eplerenone

69
Q

adverse effects of spironolactone?

A

gynecomastia

hyperkalemia

70
Q

II, III, aVF MI…dont give….

A

nitrates

71
Q

do beta blockers, diruetics, spironolatone, and digoxin have benefits in diastolic dysfunction chf?

A

beta blockers and diuretics YES

digoxin and spironolactone NO

72
Q

diuretics or indicated or contraindicated in HOCM?

A

contraindicated

decrease V = increased obstruction by large septum

73
Q

if there is pulmonary edema from an arrythmia, first step after ekg is…

A

cardioversion

74
Q

patient comes in with jvd, sob, rr 38, rales and s3 gallop…best initial step?

oximeter
echo
iv furosemide
metoprolol

A

iv furosemide

75
Q

___ 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

A

dobutamine (positive inotrope)

digoxin is also a + inotrope but takes weeks to take effect

76
Q

mc valvular disease from rheumatic heart dz?

A

mitral stenosis

77
Q

naturally inhalation will increase intensity of which two heart valve location? and exhalation will increase which two?

A

inhalation = right side increases (tricuspid and pulmonic)

exhalation = left side inreased return to heart from lungs (mitral and aortic)

78
Q

valve disease

best initial test?
most accurate test?

A

best initial = echo (NOT xray)

most accurate = catheterization

79
Q

only give endocarditis ppx with 2 scenarios…

A

prior endocarditis or valve has been replaced

80
Q

critical narrowing of mitral stenosis is defined as

A

less than 1 cm squared of valve surface area

but tx still is based on presence of symptoms

81
Q

what heart valve lesion can present with dysphagia and hoarseness?

A

mitral stenosis can cause LA enlargemend which can press on laryngeal nerve or esophagus

82
Q

diastolic murmur after an opening snap

squatting and leg raising increase intensity

A

mitral stenosis

83
Q

tx for mitral stenosis

A

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

84
Q

2 causes of aortic stenosis

A

congenital bicuspid A valve

aging calcifications

85
Q

tx for aortic stenosis?

A

valve replacement

not valvuloplasty

86
Q

holosystolic murmur, obscuring s1 and s2, radiating to axilla

what happens w handgrip?

A

mitral regurg

worsens due to increased backward flow

87
Q

handgrip _____ afterload

worsens what 2 murmurs?

A

increases

aortic and mitral regurg

88
Q

best tx for mitral regurg?

A

ACEi or ARB (decrease rate of progression)

replace valve when LV end systolic diameter is >40 mm or ejection fractions is below 60%

89
Q

diastolic derescendo murmur at LLSB , better w handgrip, worse with standing/valsalva, water hammer pulse or head bobbing

A

aortic regurg

90
Q

when to replace aortic valve?

A

EF <55% or LVend sys diameter >55mm

91
Q

valsalva and standing make MVP ___

handgrip and squatting make MVP ___

A

worse

better

92
Q

2 mur murs that dont increase w expiration

A

MVP

HOcM

93
Q

systolic anterior motion of the mitral valve and septal Q waves are classic for…

A

HOCM

94
Q

best initial therapy for both HOCM and HCM

A

beta blockers

95
Q

tx for HOCM patient with syncope?

A

implantable defibrillator +/- ablation of the septum –> myomectomy is sx persist

96
Q

which to give in dilated vs hypertrophic cardiomyopathy?

beta blockers
diuretics
acei/arb
spironolactone
digoxin
A

hcm = betaB and diuretics

dilated = all 5

97
Q

handgrip decreases ______

role in hocm?

A

LV emptying

it improves hocm by making the heart fuller which decreases the obstruction

98
Q

diffuse st elevations?

whats the more specific finding?

A

pericarditis

PR segment depressions

99
Q

colchicine role in pericarditis tx

A

it decreases recurrences!

100
Q

best initial test for patient with smooth shiny leg skin and pain in calves on exertion?

A

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

101
Q

best initial tx for PAD?

A

aspirin
stop smoking
cilostazol (vasidilator; MOST effective drug for PAD)

102
Q

best initial and most accurate tests for aortic dissection?

A

initial = CXR to look for widened mediastinum

most accurate = angiography

103
Q

AAA repair is indicated when width > than???

A

5 cm

104
Q

what is the worse cardiac disease in pregant woman?

A

peripartumc ardiomyopathy ( Ab made against myocardium)

second worst would be eisenmenger syndrome

105
Q

eisenmenger syndrome

A

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

106
Q

best tx for pericarditis?

A

nsaids plus colchicine

107
Q

the high intensity statins?

A

atorvastatin

resuvostatin

108
Q

mc place for ectopic foci that cause a fib?

a flutter?

A

pulmonary veins

a flutter often due to circuit around the tricuspid annulus

109
Q

what risk factor has strongest association with stoke

A

htn

step 2 ck (16 decks)

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