Cardiovascular Flashcards
Patients with ________ and _______ are treated to the same values of hypertension
Diabetes
Hypertension
Patients > 60 y/o are treated when systolic pressure over _____ or diastolic over _____ unless they have diabetes or CKD
150
90
Stage 1 hypertension
Systolic 140-159
Diastolic 90-100
Stage 2 hypertension
Systolic > 160
Diastolic > 100
Who should undergo evaluation for secondary hypertension?
- Severe or resistant hypertension (not responsive to at least 3 medications, one of which must include a diuretic)
- Age < 30 who are otherwise healthy
- Malignant or very rapidly occurring HTN
Abdominal bruit with hypertension
Renal artery stenosis
Hypokalemia and hypernatremia. Increased aldosterone:renin ratio and plasma aldosterone over 15 with hypertension
Hyperaldosteronism
Hypertension with elevated creatinine
Primary kidney disease
Acute episodes of hypertension with headache, palpitations and sweating
Pheochromocytoma
Hypertension in a child. BP high in upper extremities vs lower extremities with diminished femoral pulses
Coarctation of the aorta
Routine labs ordered with hypertension (6)
- UA
- Urine micro albumin
- EKG
- CBC
- BMP
- Lipid panel
First step treatment for hypertension
Initiate lifestyle recommendations such as weight loss, DASH diet, smoking cessation, moderate alcohol use, decrease sodium consumption and exercise
Second step treatment for hypertension if first step is unhelpful
Diuretic - hydrochlorothiazide, chlorthalidone
ACE/ARB or amlodipine
Treatment of stage 2 hypertension
2 medications
One is typically diuretic
Treatment for HTN for pts with diabetes or CKD
ACE / ARB
Treatment for HTN for pts with CHF/ischemia/CAD
Beta blocker
ACE / ARB
Treatment for HTN for pts with angina
Beta blocker
CCB
Treatment for HTN for pts with BPH
Alpha blocker
Treatment for HTN for pts with hyperthyroidism
Beta blockers
Treatment for HTN for pts raynaud’s syndrome
CCB
Treatment for HTN for pts with migraine
Beta blocker or CCB
Treatment for HTN for pts with osteoporosis
Thiazide diuretics
Resistant hypertension is defined as:
Hypertension that is not responsive to at least 3 medications, one of which must include a diuretic
Acute coronary syndrome encompasses:
Unstable angina
NSTEMI
STEMI
Chest pain that is new, worsening (occurs sooner, lasts longer, doesn’t respond to medication) or at rest
Unstable angina
Coronary artery disease risks factors
- Diabetes
- Hypertension (most common)
- Smoking
- Hyperlipidemia
- Obesity
- Age (males > 45, females > 55)
- Family history
All pts with ____ present the same: chest pain (squeezing, pressure, substernal), shortness of breath, N/V, diaphoresis
ACS
_________ is a very specific predictor of ACS (ST segment elevation)
Diaphoresis
Left main coronary artery is divided into:
- LAD (left anterior descending)
2. Left circumflex artery
_____ supplies the anterior and inferior portion of the left ventricle with oxygen
LAD
_______ supplies SA node in 40% of people, the AV node (10%), left atrium, and the lateral/posterior aspects of the left ventricle with oxygen
Left circumflex artery
The right main coronary artery is divided into
- Right marginal artery
2. Posterior descending artery
Supplies right ventricle, right atrium, SA node (60% of people), and AV (90% with people) with oxygen
Right marginal artery
Supplies inferior portion of left ventricle, posteromedial papillary muscle, and septum with oxygen
Posterior descending artery
Do not want to give nitrates in the event of a:
Right sided MI
Right sided MIs occur in about ____% of pts with an inferior MI
40%
First test to be ordered for coronary symptoms
ECG
Shows on leads II, III, and aVF
Inferior MI
Shows on leads V1-V4
Anterior MI
Shows on leads I, aVL, and V5-V6
Lateral MI
Unstable and NSTEMI will have signs of ischemia on ECG, such as:
ST depression
T wave inversion
The EKG should be repeated every __________ if ACS is suspected, as initial EKG may be normal
10 minutes
A new left bundle branch block should be treated as an ___________
Infarction
Q waves are specific for __________ but are a late change
Necrosis
Cardiac enzymes
Myoglobin
CK-MB
Troponins (preferred)
Most pts with negative enzymes can have an MI excluded by __________, but for high risk pts, should continue serial labs for _________ hours
8 hours
12-24 hours
Reinfarction is diagnosed if troponin increases over _______
20%
Unstable angina will not have an elevation in:
Cardiac enzymes
Initially, unstable angina and NSTEMI will present identically, as it takes time for:
Cardiac enzymes to rise
All pts presenting with ACs should immediately be given:
Morphine Nitrates Aspirin (chewed) Oxygen (only if hypoxic) All pts should also get a loading dose of a P2Y12 drug (clopidogrel, ticagrelor)
Nitrates in ACS pts should be avoided if pt is on:
Phosphodiesterase-5 inhibitors
Will cause hypotension
If pts have inferior MI, avoid ________, as it will causes severe drop in BP. Instead, give these pts ________
Nitrates
Fluid
All pts with ACS (after acute attack) should receive:
Beta blocker (metoprolol or atenolol)
ACE
Statin (atorvastatin)
Should get these immediately if no CI exists and be discharged with these
Everyone with a STEMI, NSTEMI and unstable angina should get:
Heparin
______ is preferred to thrombolytics. Must be done within 90 minutes of arrival.
PCI
If PCI unavailable or unable to get to center in 90 minutes, give thrombolytics
TIMI Risk Score
Determines whether pt needed revascularization performed within 24-48 hours or whether medical therapy is needed (pt must be asymptomatic)
Most common cause of death within first few days after an MI is _________________
Ventricular tachycardia/fibrillation
Therefore, continuous rhythm monitoring is required
Should PVCs be treated?
No
Autoimmune mediated pericarditis. Pts present with pericarditis, fever, malaise, and leukocytosis 2-10 weeks post MI. Give aspirin
Dressler syndrome
Post STEMI/NSTEMI pts should be put on _______________ for one year
Dual antiplatelet therapy
P2Y12 receptor blocker and aspirin
Presentation is that of angina in the legs (leg pain with exertion and relieved with rest). Lower extremities may show pallor, ulcerations, diminished pulses, and hair loss
Peripheral vascular disease
Diagnosis of peripheral vascular disease
ABI - positive if ratio is < 0.9
All pts with peripheral vascular disease should receive, however first step is a:
Aspirin
Supervised 12 week exercise regimen
Long PR interval > 0.2 seconds. Treatment?
First degree heart block
No treatment
PR progressively lengthens until it fails to produce a QRS complex. Treatment?
Mobitz I / Wenckebach
No tx until pt is symptomatic.
place pacemaker if sx are present. Atropine if unstable
Patient will have continuously dropped QRS complex, however, there won’t be lengthening of the PR interval. Treatment?
Mobitz II
Pacemaker to prevent progression to 3rd degree
Signal from atria does not reach ventricle. P waves are independent from the QRS complex. Treatment?
Third degree heart block
Pacemaker - may be fatal
Wide QRS, RSR pattern in leads V1/V2/V3, S wave wider than R wave in leads 1 and V6. Treatment?
Right Bundle Branch Block
Asymptomatic does not need tx
Symptomatic: pacemaker
Wide QRS, notched R wave in leads I/aVL/V5/V6. Treatment?
Left Bundle Branch Block
Must be treated as an MI if new
Patients will present with abrupt onset of palpitations and the EKG will show complex tachycardia. QRS absorbs p waves. Treatment?
Paroxysmal Supraventricular Tachycardia
If hemodynamic instability exists: cardiovert
If stable: vagal maneuvers - valsalva or carotid massage
If this does not work: adenosine - then CCB or BB
Congenital disorder that has abnormal cardiac tissue connecting the atria to the ventricles - leads to an accessory pathway, and in turn, leads to preexcitation
Wolff-Parkinson-White-Syndrome
When pts are in sinus rhythm, EKG will have delta wave, widened QRS, short PR interval
Wolff-Parkinson-White-Syndrome
Most accurate test for Wolff-Parkinson-White-Syndrome
EPS (electrophysiology studies)
However, not necessary for diagnosis
Treatment for Wolff-Parkinson-White-Syndrome
If asymptomatic, you can observe
If symptomatic - treat with amiodarone or procainamide
Ablation is curative
EKG will show alternating bradycardia and tachycardia, sinus arrest without an appropriate escape rhythm, and an inappropriate response to stress. Treatment?
Sick sinus syndrome
Pacemaker
Treatment for ventricular tachycardia
Unstable - cardiovert
Stable - amiodarone, lidocaine, or procainamide
Treatment for torsades de pointes
Magnesium sulfate
If magnesium doesn’t work, cardiac pacing is offered
Treatment for ventricullar fibrillation
ACLS: defibrillation, CPR, epinephrine, and amiodarone
Infection of the endocardial surface of the heart, which extends to the heart valves
Endocarditis
Risk factors for endocarditis
Valvular heart disease Congenital heart disease Prosthetic heart valves Immunosuppression Age > 60 y/o Injection drug users
Most common etiology of endocarditis in native valves
Streptococci viridans
Most common etiology of endocarditis in those who are injection drug users
Staphylococcus aureus
Most common etiology of endocarditis in those with prosthetic valve endocarditis
Staphylococcus epidermidis
Fever, anorexia, weight loss, fatigue, ECG conduction abnormalities
Endocarditis
Painless erythematous macules on the palms and soles
Janeway Lesions
Endocarditis
Retinal hemorrhages with pale centers. Petechiae (conjunctiva and palate)
Roth spots
Endocarditis
Tender nodules on the pads of the digits
Osler’s Nodes
Endocarditis
Splinter hemorrhages of proximal nail bed, clubbing, hepatosplenomegaly
Endocarditis
Diagnostic studies for endocarditis
- Blood cultures - before abx initiation - 3 sets at least 1 hour apart if pt is stable
- ECG
- Echo
- Labs - leukocytosis, anemia, increased ESR, rheumatoid factor
Major Duke Criteria
Sustained bacteremia (2 + blood cultures) Endocardial involvement - on echo New aortic or mitral regurg
Minor Duke Criteria
Predisposing condition Fever Janeay lesions, etc. \+ blood culture \+ echo not meeting major criteria
Clinical criteria for infective endocarditis based on criteria
2 major or
1 major + 3 minor or
5 minor
Indications for surgery with endocarditis
Refractory CHF Persistent or refractory infxn Invasive infection Prosthetic valve Recurrent systemic emboli Fungal infxns
Management of endocarditis (acute)
Nafcillin + Gentamicin OR vanco + gentamicin
Management of endocarditis (prosthetic valve)
Vancomycin + gentamicin + rifampin
Management of endocarditis (fungal)
Amphotericin B
Screening for hyperlipidemia not high risk
Males >35 y/o
Females > 45 y/o
If high risk, screen 10 years earlier
Treament for hyperlipidemia
- Lifestyle modifications
2. Statins
Pts with triglyceride levels > 500 should be started on:
Niacin, fish oil or a fibrate
Myocardial ischemia secondary to exertion (increased oxygen demand)
Stable angina
Presents with chest discomfort (squeezing/pressure/substernal) with exertion that is relieved by rest and/or nitroglycerin. Does not occur at rest
Stable angina
_____ will be normal in stable angina
ECG
Cardiac enzymes
Treatment for stable angina
Lifestyle modifications
Control hypertension, diabetes, hyperlipidemia
All pts are treated with statin, aspirin, beta blocker
Most common cause of systolic congestive heart failure
Coronary artery disease
Most common cause of diastolic congestive heart failure
HTN
In diastolic dysfunction, ejection fraction is: _______. In systolic dysfunction, ejection fraction is: _______
Normal
Less than < 50%
Fatigue, SOB, orthopnea (SOB upon lying), PnD, chronic cough, pedal edema, JVD, S3 gallop, S4 gallop
Congestive heart failure
S3 gallop is seen with ______ heart failure
Systolic
S4 gallop is seen with ________ heart failure
Diastolic
Crackles, orthopnea and PND are seen more with _________ heart dysfunction
Left sided
JVD, hepatojugular reflux, pedal edema, ascites are seen more with _______ heart dysfunction
Right sided
Diagnosis of congestive heart failure
- Clinical
- Echo w/ ejection fraction
- ECG
- CXR
- Stress testing
Treatment for diastolic dysfunction
Manage sx and treat comorbid conditions. No medications proven
Treatment for systolic dysfunction
ACE/ARBs
BB
Never give _____ during an acute exacerbation of CHF and also be careful with ____
BB
CCB
Most acute exacerbations of CHF present with:
Acute pulmonary edema
Treatment of acute exacerbation of CHF
LMNOP loop diuretic morphine nitrates oxygen position (head up)
Definitive diagnosis for all valvular disease is reached with:
Echocardiogram
Most symptoms of valvular disease are similar to that of CHF:
SOB and chest discomfort
Holosystolic murmurs:
Mitral regurgitation
Tricuspid regurgitation
VSD
Increases sound of all murmurs, except mitral valve prolapse and HOCM (decreases)
Squatting
Leg raise
Handgrip
Systolic crescendo-decrescendo murmur heart best at the second right intercostal space - radiates to the neck
Aortic stenosis
Heard best at the left upper sternal border with an ejection click
Pulmonic Stenosis
Holosystolic murmur heard best over the apex that radiates to the axilla
Mitral regurgitation
Mid systolic click with a possible late systolic murmur
Mitral valve prolapse
Holosystolic murmur heard best at the left mid sternal border
Tricuspid regurgitation
Decrescendo murmur with a blowing quality heard best at the left sternal border
Aortic regurgitation
Decrescendo murmur
Pulmonic regurgitation
Low pitch rumble heard best at the apex
Mitral stenosis
Heard best at the 4th intercostal space at the left lower sternal border
Tricuspid stenosis