Cardiovascular Flashcards
1
Q
Valvular Heart Dz
A
-
Aortic sclerosis
- Thickening of the aortic leaflets
- Causes a systolic murmur similar to that of aortic stenosis
-
Aortic stenosis
- Syncope, CHF, or fatigue
- Age + endoscopic techniques = contraindications to surgical repair
-
Mitral regurgitation
- May cause heart failure or death
- Tx = surgical
2
Q
Coronary Heart Dz
A
- Ischemic heart dz very common in elderly but frequently presents atypically
- SOB or fatigue, weakness, or confusion rather than w/ chest pain or tightness
- Elderly patients are more likely to have severe or 3-vessel coronary disease
- Cardiac enzymes may not rise as much or may be difficult to interpret secondary to renal disease
- TIMI score and risk stratification
- Useful to assess the risk of death & ischemic events in patients w/ UA or NSTEMI
- 1 point each
- Age ≥65y
- ≥3 CAD risk factors (FHx, HTN, Chol, smoker, DM)
- Known CAD (stenosis >50%)
- ASA use in past 7 days
- Recent (<24h) severe angina
- Cardiac markers
- ST elevation 0.5mm
- Score ≥3 = high risk
3
Q
Angina Pectoris
A
- dyspnea, fatigue, diaphoresis, nausea, or syncope without chest pain
- Presenting sxs in elderly:
- Classical
- Present: CP, sxs related to exertion and relieved by rest
- Often present: pain radiating to jaw or arm, sweating, dyspnea, fatigue
- Atypical: syncope or presyncope
- Atypical:
- Present: sxs related to exertion and relieved by rest
- Often only sx: dyspnea
- May be only sx: fatigue, syncope or presyncope
- Absent: CP, pain radiating to jaw or arm, sweating
- Classical
- Ddx: ischemic CV dz, GI dz, musculoskeletal dz, pulm dz, psych
- Dx: troponin, CK, MBCK, ECG, BNP, echo, US of GB, esophagram, UGD, LFTs, CK, aldolase, CRP, puls ox, CBC, stress test, echo, coronary angio
4
Q
Diagnosis of Angina
A
-
EKG = initial test; and then Stress test
- EKG à ST depression (especially horizontal or downsloping) = classic finding
- Resting EKG normal in 50% of pts
- Stress test à most useful noninvasive screening tool
- Positive if = ST depressions, hypotension/hypertension, arrhythmias
- Myocardial perfusion imaging stress à w/ thallium or technetium
- Done in pts w/ baseline EKG abnormalities
- Adenosine or Dipyridamole – used in pts unable to tolerate exercise
- Coronary vasodilators of normal (but not diseased arteries)
- CI = asthmatics (causes bronchospasm)
- Stress Echo à assesses LV function, valvular dz, pts w/ pathologic Q waves
- Dobutamine (positive inotrope/chronotrope) = increases myocardial O2 demand and provokes ischemia
-
GOLD STANDARD = Angiography
- Defines location and extent of CAD
5
Q
Managment of Angina
A
-
Nitroglycerin = increases myocardial blood supply, reduces coronary vasospasm
- If no relief with 1st dose à give 2nd/3rd q5 minutes
- SE = HA, flushing, hypotension, tachyphylaxis after 24h
- CI = SBP <90; RV infarction, use of PDE-inhibitors
-
Beta blockers = increases myocardial blood supply and decreases demand (negative chronotrope/inotrope)
- 1st line drug for chronic management
- Cardioselective (B1) = Metoprolol, Atenolol
- Nonselective = Propranolol, Nadolol
-
Calcium channel blockers = increases myocardial blood supply and decreases demand
- Indications à used in patients unable to use beta blockers; Prinzmetal angina
- Aspirin = prevents platelet activation/aggregation
- Classic outpatient regimen = ASA + Nitroglycerin PRN + Beta blocker + Statin
- DEFINITIVE MANAGEMENT
-
PTCA (Percutaneous transluminal coronary angioplasty)
- 1 or 2 vessel dz NOT involving the LMCA and in whom ventricular fxn is normal/near normal
- CABG (Coronary artery bypass graft)
-
PTCA (Percutaneous transluminal coronary angioplasty)
6
Q
Myocardial Infarction
A
- Classified as acute coronary syndrome with unstable angina
- If pt has sxs of unstable angina, pt should be admitted to ICU, cardio consult, labs (CBC, BMP, thyroid, ECG, myocardial enzymes, CXR)
- Tx: ASA, nitrates (IV or PO), and BB
- After stabilization, ACEi should be given to pts with DM
- Echo and coronary arteriography almost always indicated
- If LVEF dec, then ACE should be started
- If pt cannot be admitted to hospital with capability of performing angioplasty, streptokinase is appropriate (if within 12 hrs of sx onset)
- Ideal time goals for acute MI management:
- EMT on scene: 8min
- If fibrinolysis – EMT to needle: 30min
- If angio – EMT to balloon: 60min
7
Q
Managment of NSTEMI
A
-
Anti-platelet drugs
- ASA
- Clopidogrel (Plavix) à good in pts w/ ASA allergy
- GpIIb/IIIa inhibitors
- Eptifibatide
- Tirofiban
- Abciximab
-
Anticoagulants
- Unfractionated heparin à binds to & potentiates antithrombin III’s ability to inactivated Factor Xa, inactivates thrombin
- LMWH à same MOA; S/E – thrombocytopenia
- Enoxaparin (Lovenox)
- Dalteparin (Fragmin)
-
Beta blockers – lowers myocardial O2 consumption
- CI à severe bradycardia, HoTN, decompensated CHF, 2nd/3rd heart block, cardiogenic shock, cocaine induced MI, severe asthma/COPD
- Nitrates – does not decrease mortality
- Morphine – venodilation à decreases preload
-
CCB – consider in pt’s that cannot tolerate beta blockers due to bronchospasm
- Drug of choice for prinzmetal angina
8
Q
Management of STEMI
A
- 3 part approach
-
Reperfusion therapy (Most important)
- PCI (Percutaneous Coronary Intervention) à best within 3h of sx onset (esp c/n 90 min)
- Thrombolytics
- Used if PCI is not an option/unable to get PCI early
- Alteplase (rTPA) à indications include STEMI; S/E = higher rebleed risk
- Streptokinase à least chance of ICB; S/E = tolerance develops; can only give it once
-
Antithrombotics
- ASA – lowers mortality by 20%; chewed for faster absorption
- Heparin
- Glycoprotein IIb/IIIa inhibitors
-
Adjunctive therapy
- Beta blockers à decreases wall tension, reduces incidence of V fib
- ACEi à slows progression of CHF during & after STEMI by decreases ventricular remodeling; S/E = angioedema & cough (due to increased bradykinin)
- Nitrates
- Morphine
-
Reperfusion therapy (Most important)
9
Q
Congestive Heart Failure
A
- MC reason for hospitalization in Medicare pts
- 5yr survival is less than 50%
- RF: asxatic LV systolic dysfn
- LFSD = LVEF <40%
- CHF = presence or evidence of fluid retention manifested by edema and congestion of veins of pulm and systemic circuits
- Dx: hx, PE, CXR, BNP (specific to ventricles, correlates with severity of CHF), JVD, S3 gallop
- Sxs:
- Classic: dyspnea, orthopnea, PND, periph edema, unexplained weight gain, weakness, poor exercise tolerance, abd pain, fatigue
- Atypical: chronic cough, insomnia, wt loss, nausea, nocturia, syncope
- Precipitating factors: DAMN IT
- Drugs (withdrawal from ACE, dig, BB, etc.), arrhythmias (brady, hrt block, tachy, AF), MIschemia, noncompliance (diet, fluid restriction, meds), IVF administration, Thyroid (hyper)
- Tx: Na restriction, exercise, loop diuretics (start low and follow Mg and K), ACEi, biventricular pacing or cardiac resynchronization tx
- Tx
- ACEI, Beta blockers, CCBs
- Diuretics should be used judiciously b/c of high probability of renal insufficiency as well as risk of dehydration and HoTN
- Pacemakers: optimize diastolic fxn in patients w/ refractory heart failure
10
Q
HTN
A
- Blacks of all ages are more likely to have HTN
- Mexican Americans are lower than both whites and blacks
- Linked to fnal issues such as impotence, renal fn, and vascular dementia
- HTN = ≥140/90 based on ≥3 readings on 3 separate occasions
- Hypertensive urgency: BP needs to be reduced over 24-48hrs and can be accomplished in outpt setting
- Hypertensive emergency requires parenteral drug tx usually in hospital or ER setting
- Small cuff may produce artificially high BP
- Pts older than 80yo should be treated if BP is greater than 150 à target = 140
- If >60y then goal is <150/90
- Should be treated aggressively unless side effects (like falls 2ndary to orthostatic HoTN) preclude lowering the SBP to recommended levels
- Renal artery stenosis is more common in the elderly
-
Thiazide diuretics = 1st line in systolic HTN
- SE = Dehydration, hyperuricemia, hyponatremia, hypokalemia
- Avoid centrally acting agents b/c of high risk of sedation, dry mouth, and depression
11
Q
Peripheral Vascular Dz
A
- Noninvasive imaging is dx text of choice
- Tx: antiplatelet agents, cholesterol lowing agents, percutaneous interventions, open surgical revascularization (gold standard)
- MC presentation is claudication
- Ddx: neurogenic claudication 2ndary to spinal stenosis, osteoarthritis of hip or knee
- Difference between neurogenic and vascular claudication: neurogenic has variable distance to onset, takes ≥15min to relieve pain
- Dx: DUS (noninvasive, reliable, accurate), CT (not sufficient by itself; contrasted angio must be used for accurate imaging), MRI (overestimates degree of stenosis and is expensive)
- MC d/t atherosclerosis
- LE atherosclerotic PAD initially asymptomatic but progresses to claudication, ischemia, and pain w/ exercise
- Clinical features
- Intermittent claudication, foot or lower leg pain w/ exercise that is relieved by rest
- Thigh or buttock pain w/ walking
-
Femoral and distal pulses will be weak or absent
- Aortic or iliac or femoral bruit may be present
- Skin changes = loss of hair, shiny atrophic skin, and pallor w/ dependent rubor
- Diagnosis
- Doppler ultrasound flow
- ABI (ankle-brachial index) à ≤0.9 indicates significant disease
- GOLD STANDARD = Angiography
- Management
- STOP tobacco use; control Diabetes, HTN, and hyperlipidemia
- B-blockers, ACEI, statins, progressive exercise, ASA and/or Plavix
- Cilostazol
- If all above fail, then revascularization using either endovascular or surgical techniques should be considered
12
Q
Varicose Veins
A
- Dilated, tortuous veins develop superficially in the lower extremities
- Particularly in the distribution of great saphenous vein
- May be asymptomatic or associated w/ aching and fatigue
- Chronic distal edema, abnormal pigmentation, fibrosis, atrophy, and skin ulceration may develop if severe
- Management
- Graduated elastic stockings
- Leg elevation and regular exercise
- Small venous ulcers heal w/ leg elevation and compression bandages
- Large ulcers may require compression boot dressing (Unna boot) or skin grafts
13
Q
Syncope
A
- A sudden, transient LOC not resulting from trauma
- Common causes = Arrhythmias, aortic stenosis, carotid sinus hypersensitivity, MI, hypoglycemia, orthostatic HoTN, postprandial HoTN, PE, vagal faint
- EKG, ambulatory monitoring (Holter), Echo, tilt-table test, possibly CT or MIR of the brain
- Management
- Varies w/ cause
14
Q
Atrial Fibrillation
A
- Increasingly common dysrhythmia
- RF: increasing age is strongest RF but DM< HTN, smoking, and ETOH inc risk of developing AF
- Sleep apnea increase AF risk fourfold
- Obesity inc AF risk in part through sleep apnea
- Can be a manifestation of hyperthyroid, cardiac amyloid, or other primary processes
- Atrial enlargement occurs with age à with each cm inc in LA dimension, risk of AF inc significantly
- Goal of tx: RATE CONTROL
- Target ventricular rate = 80-100bpm at rest
- Complications: CVA, CHF
- CHADS2 (CHF, HTN, Age ≥75, DM, prior Stroke or TIA [2pts]
- Irregularly irregular rhythm w/ narrow QRS; NO P WAVES
- Most patients are asymptomatic
- Ineffective quivering of the atria may cause clots to form and cause ischemic strokes
- Types
- Paroxysmal – self terminating within 7 days (usually <24h)
- Persistent – fails to self-terminate, >7 days
- Permanent – persistent AF >1 year
- Lone – paroxysmal, persistent or permanent w/o evidence of heart dz
- Management
- Stable
-
Rate control
- Beta blockers – Metoprolol, Esmolol
- CCB – Diltiazem
- Digoxin +/- used in the elderly
-
Rhythm control
- Synchronized cardioversion
- Amiodarone, Ibutilide, Flecainide, Sotalol
- Radiofrequency ablation – permanent pacemaker
-
Rate control
- Unstable à synchronized cardioversion
- Anticoagulation
- Stable
15
Q
Venous insufficiency
A
- Chronic venous insufficiency
- Loss of wall tension in veins à stasis of venous blood and often is associated w/ hx of DVT, leg injury, or varicose veins
- Clinical features
- Progressive edema starting at ankle
- Itching, dull pain w/ standing & pain w/ ulceration is common
- Skin is shiny, thin, and atrophic w/ dark pigmentary changes & subq induration
- Ulcers usually right above the ankle (stasis ulcer)
- Management
- Elevation of legs, avoidance of extended sitting or standing and compression hose
- Ulcerations may be treated w/ wet compresses, compression boots or stockings, and maybe skin grafting
