Cardiovascular Disease Flashcards
what are the pharmacologic stress tests available
dobutamine echo, dobutamine nuclear perfusion, vasodilator nuclear perfusion (adenosine, dipyrimadole, regadenoson), PET/CT
first line therapy in patients with stable angina
Aspirin (or clopidogrel on ASA intolerante pts), BB, Statin
Indications for thrombolytics (streptokinase, alteplase, reteplase, tenecteplase) in STEMI cases
if STEMI symptom onset within 12 hr-24 hr prior to presentation and PCI not available within 120 mins of first medical contact
absolute contraindications to thrombolytic therapy for STEMI
any previous intracerebral hemorrhage, known cerebrovascular lesion (AVM), ischemic stroke w/in 3 months, suspected aortic dissection, active bleeding or bleeding diathesis,, significant closed head or facial trauma within 3 months
Contraindications of BB in ACS
evidence of cardiogenic shock, heart failure on presentation, bradycardia, PR>240ms or heart block
nitrates during ACS contraindicated in patients who had received ______ within 24-48 hrs
PDE5 inhibitors such as sildenafil
TIMI score for Non-STE ACS
age >65, >3 traditional CAD risk factors (HTN, Cholesterolemia, DM, current smoker, family hx of CAD), documented CAD >50% stenosis, ST segment deviation, >2 anginal episodes in 24 hrs, ASA use w/in 1 week, elevated cardiac biomarkers
TIMI risk score and corresponding invasive v. ischemia guided treatment
TIMI score 0-2 -> ischemia guided tx
TIMI score 3-4 -> delayed invasive tx (24-72 hrs)
TIMI score 5-7 -> early invasive tx (within 24 hrs)
care after ACS
low dose ASA indefinitely, Statin indefinitely, DAPT for a year; BB and ACEI indefinitely in those with LV dysfunction
Avoid NSAIDs if possible due to increased CV risk associated with these drugs
Cardiac X syndrome
frequent cause of chest pain syndromes in women and present without traditional risk factors for CAD. most common theory: microvascular dysfunction.
Tx with BB, CCB and nitrates
seen in patients with chronic inflammatory dieases or neuromuscular disease with elevated Troponin T (present in skeletal muscles) but cardiac Troponin I is wnl.
Aspirin is recommended as ______prevention in all patients with ______ and CAD
secondary; diabetes
True or False: tight glycemic control reduces microvascular complications but does not reduce risk for MI
true
treatment for symptomatic bradycardia and hemodynamic distress
atropine first; if ineffective, dopamine or epinephrine infusion until transcutaneous pacing or temporary pacing wire placed;
Temporary pacing indicated in those with hemodynamically unstable bradycardia
In hemodynamically stable, permanent pacing indications are?
- symptomatic bradycardia without reversible cause
- asymptomatic brady with pauses >3 seconds in sinus rhythm or heart rate <40
- afib with pauses of 5 secs or longer
- alternating Bundle branch block
- asymptomatic complete heart block or Mobitz Type 2 second degree heart block
wide complex tachycardia
qrs>120ms; QRS either all pos or neg in precordial leads
multifocal atrial tachycardia
irregular rhythm, p wave shape varies, atrial rate >100; seen with Chronic COPD and can be seen with digitalis toxicity in patients with heart disease
wandering pacemaker
p wave shape varies as pacameker center moves within atria, irregular rhythm, atrial rate <100
afib
continuous rapid firing of multiple atrial automaticity foci; no single impulse depolarizes both of the atria completely, so no P waves; occasional random atrial depolarization reaches the AV node -> irregular ventricular rhythm
escape beat/rhythm…atrial, junctional and ventricular
SA node misses one cycle (sufficient pause for an atrial/junctional/ ventricular automaticity focus to escape overdrive suppression –> escape beat).
atrial escape beat: pause, then different p wave with associated QRS, rate 60-80
junctional escape beat: pause, QRS complex with no p waves, rate 40-60 or if retrograde atrial depolarization, then inverted p wave after the QRS
ventricular escape beat: pause, enormous QRS complex; rate 20-40
PVC
PVC depolarize only the ventricles, not the SA node; originate suddenly in an irritable ventricular automaticity focus and produces giant ventricular complex ; irritable usually because of hypoxia;
how many runs of PVCs equals a run of VT
3 or more
definition of sustained VT
VT lasting >30 secs
inherited arrhythmia syndrome
long QT syndrome, short QT syndrome, Brugada syndrome, early repolarization syndrome, catecholaminergic polymorphic VT, HCM
Long QT syndrome
men QTc>440, women QTc>460; can progress to torsades-> Vfib;
tx: BB as first line therapy
but if recurrent events (syncope or VT) or refractory to BB tx, then ICD placement
Short QT syndrome
QTC<340ms; inherited, ADominant;
can present with atrial or ventricular arrhythmias (afib or VT)
at VERY high risk of SCD
Tx: ICD in ALL patients
Brugada syndrome
R precordial ECG changes (V1 - V3, concave or linear downsloping ST segment +/- RBBB)
M>W; Asians
arrhythmias more common at night during sleep
Tx: ICD
early repolarization syndrome
should strongly suspect in patients with unexplained VF arrest, particularly when provoked during exercise.
J point elevation >1mm in lateral and inferior leads in a patient with VF/cardiac arrest
Tx: ICD
class I recommendation for ICD placement as secondary prevention
sustained VT (>30secs) or cardiac arrest without reversible cause
what are the indications for ICD placement as primary prevention
HF with EF
Cardiac resynchronization therapy (biventricular pacing) indicated in which patients
HF with EF < or = 35%, NYHA class II to IV symptoms despite guideline directed medical therapy, sinus rhythm, LBBB with QRS >150ms or greater
most common cause of severe aortic stenosis
degeneration of aortic valve
definition of severe aortic stenosis
small valve area <1.0 cm2 and either high peaking velocity (>4m/s) or high mean gradient (>40mm Hg).
Indications for Aortic valve replacement
1) symptomatic patients (dyspnea, angina, presyncope/syncope)
2) LV dysfunction (Ef<50%) in asymptomatic patient
3) concomitant cardiac surgical procedure (such as simultaneous CABG or ascending aorta surgery)
considered in asymptomatic patients with abnormal results on supervised exercise testing: poor exercise tolerance, abnormal EG changes or hypotension during testing
TAVR indications
Trileaflet aortic stenosis who are at intermediate to high surgical risk and those who dont have severe concomitant aortic regurgitation
characteristic physical finding of severe aortic stenosis
late peaking systolic murmur, diminished/absent S2, weak/delayed carotid upstroke
characteristic aortic stenosis murmur
mid-systolic, crescendo-descrescendo; at RUSB; radiates to neck (carotids) or apex
characteristic aortic regurgitation murmur
diastolic; decrescendo; at LLSB (3rd intercostal space?)
parvus et tardus
pulses weaker than compared to heart sounds; a/w aortic stenosis
characteristic mitral stenosis murmur
diastolic, decrescendo; at apex no radiation
loud opening snap;late rumble
characteristic mitral regurgitation murmur
systolic murumr/holosystolic murmur at apex with radiation to axilla or back
characteristic tricuspid stenosis murmur
diastolic, at LLSB with no radiation
characteristic tricuspid regurgitation murmur
holosystolic at LLSB
characteristic pulmonic stenosis murmur
systolic, crescendo - decrecendo; LUSB
characteristic pulmomic regurgitation murmur
diastolic at LLSB
most common cause of aortic stenosis
valve degeneration; other causes: rheumatic disease and chest radiation (mantle therapy for non Hodgkin lymphoma)
rheumatic disease involves which valves
mitral valve in isolation
rheumatic aortic valve disease never occurs without mitral valve involvement.
how does aortic stenosis lead to heart failure
it results in chronic pressure overload of LV -> concentric LV hypertophy and myocardial interstitial fibrosis. Diastolic dysfunction follows with eventual systolic heart failure and pulmonary congestion
severe aortic stenosis definition and murmur
late peaking systolic murmur, diminished or absent aortic component of S2 and delay in carotid upstroke (pulsus tardus) with pulsus parvus (due to low cardiac output)
mean gradient>40mm Hg, AVA <1.0 cm2, Vmax>4m/s
dobutamine echo or invasive hemodynamic study to distinguish between true aortic stenosis and pseudostenosis indicated when?
2 subsets of patients with severe aortic stenosis might have small valve are and low velocity/gradient:
1) patients with severe LV dysfunction and low CO
2) patients preserved LV dysfunction and paradoxical low-flow, low gradient aortic stenosis
causes of chronic aortic regurgitation
ascending aortic dilation, valve abnormalities due to bicuspid disease, calcific degeneration, rheumatic involvement or chest radiation
causes of acute aortic regurgitation
endocarditis, blunt chest trauma, iatrogenic (balloon aortic valvuloplasty) and aortic dissection
physical findings of chronic aortic regurgitation
dyspnea, bounding peripheral pulses due to large stroke volume and LV dilatation; displacement of LV apex, diastolic decrescendo murmur along RUSB (if root pathology), LUSB (if valvular path)
physical findings of acute aortic regurgitation
abrupt onset of volume overload is not tolerated well and can present with acute heart failure or cardiogenic shock, +/- bounding pulse
management of acute aortic regurgitation
if due to aortic dissection: surgical emergency
for other acute causes, surgical indication depends on symptoms, hemodynamic stability
management of chronic aortic regurgitation
indications for surgery with OPEN aortic valve REPLACEMENT:
- symptomatic patients with LV EF<50%
- patients undergoing other cardiac surgery
- significant LV dysfunction
medical therapy for chronic aortic regurgitation
with dihydropyridine CCB (nifedipine, amlodipine), ACEI or ARBs in those with AR with HTN
if no HTN, then medical tx for symptomatic patients who are not surgical candidates
what type of lesion does bicuspid aortic valve lead to and during what decade of life?
predisposes to early degeneration –> aortic stenosis mostly
progresses to severe disease during 5th or 6th decade of life
management of bicuspid aortic valve disease
follows recommendation for predominant valve lesion (aortic stenosis or regurgitation) and severity of valvular disease
leading cause of mitral stenosis
rheumatic heart disease, W>M
symptoms of mitral stenosis
arise from low cardiac output (fatigue), pulmonary congestion (dyspnea) and pulmonary hypertension with R sided HF (lower extremity edema).
severe mitral stenosis definition
mitral valve area 15cm2 or less, MV gradient 5-10 mmHg at normal heart rate.
management of significant rheumatic mitral stenosis
percutaneous balloon mitral commissurotomy (PBMC)
indications for Percutaneous balloon mitral commissurotomy
symptomatic patients with severe mitral stenosis
asymptomatic patients with critical mitral stenosis when valve area <1.0 cm2
patients with mitral stenosis are at incerased risk for what? and whats the tx for it?
Afib
Anticoagulation with warfarin with goal INR of 2.0-3.0
warfarin tx is indicated in patients with mitral stenosis with hx of what?
afib, LA thrombus or systemic embolization
most common cause of CHRONIC primary mitral valve regurgitation
mitral valve prolapse
indications for surgery for chronic severe primary mitral valve regurgitation
symptomatic pts with EF>30%
- asymptomatic patients with VEF 30-60% or LV end diastolic diameter>40mm
- patients undergoing concomitant cardiac surgery
- asymptomatic patients with new onset Afib or pulmonary HTN (PASP>50mmHg)
surgical replacement or repair is preferred in patients with mitral valve regurgitation
surgical repair in all patients and paatients should be referred to surgical center with expertise with valve repair
management of chronic secondary mitral regurgitation
guideline directed medical therapy for ventricular dysfuncton; surgical repair or replacement benefits in chronic secondary mitral regurgitation are less certain;
but surgery beneficial if undergoing concomitant cardiac surgery
physical exam for chronic mitral regurgitation
blowing holosystolic murmur at apex
what is the medical therapy in acute severe mitral regurgitation (surgery is indicated promptly)
vasodilator therapy with titratable drug such as nitroprusside (decreases aortic impedance and mitral regurgitation, thereby improving cardiac output)
intra-aortic balloon pump can be used to decrease afterload and augment systemic and coronary perfusion pressures
management of patients who meet criteria for mitral valve repair but are not surgical candidates?
catheter based clip device
management of patients with significant tricuspid regurgitation
loop diuretics and aldosterone antagonists to improve symptoms
Tricuspid valve surgery for those with severe TR undergoing left sided valve surgery
goal INR for warfarin anticoagulation in mechanical aortic valve prosthesis
2.5 for those with no additional risk factors for thromboembolism (LV dysfunction, afib, hx of embolization, hypercoaguable disorder)
in those with risk factors for thromboembolism, target INR 3.0
whats the duration of oral AC with warfarin after mitral or aortic bioprosthesis
at least 3 months and as long as 6 months
mechanical valve prosthesis requires what type of AC and for how long
lifelong warfarin AC
are antiplatelets recommended with mechanical or bioprosthesis?
antiplatelets with aspirin is strongly recommended with mechanical prosthesis along with warfarin
when is yearly TTE recommended in patients with bioprosthetic valves?
starting at 10 years after surgery;
immediately after implantation, alll patients should have tte to document baseline hemodynamics and repeat evaluations based on signs/symptoms of prosthetic dysfunction
Infective Endocarditis prophylaxis, patients who are at risk
- hx of endocarditis
- prosthetic valves
- unrepaired cyanotic CHD
- repaired CHD using prosthetics in the first 6 months after procedure
- repaired CHD with residual defects
- heart transplant with valvular disease
IE high risk procedures requiring ppx
dental manipulation of gingival tissue or perforation of oral mucosa, resp procedure with biopsy or incision, GI/GU procedures with GI/GU ongoing infection, cardiac surgery
low risk procedures that do NOT require ppx
ERCP, GI procedres, GU procedres (prostatectomy catheter insertions), vaginal or C-section
IE ppx
denta/respiratory procedures:
oral: amoxicillin, cephalexin, clinda or azithromycin
IV: ampicillin, ceftriaxone, clinda
Gi/GU prodecures (enterococcus): amoxicillin, ampicillin, or vancomycin
Skin/musculoskeletal tissue ppx: (staph or strep): vancomycin or clindamycin for suspected MRSA
IE dx with Modified Duke criteria
- 2 major
- 1 major + 3 minor
- 5 minor
Major:
-2 +blood cultures, 12 hrs apart with typical organisms: viridans strep, strep bovis/gallolyticus, HACEK, staph aureus, CA enterococcus
Single positive culture for coxiella burnetti or IgG ab titer
- Evidence of endocardial involvement with +TTE showing intracardial mass/abscess or new partial dehiscence of prosthetic valve
- new valvular regurgitation
Minor:
- predisposing heart condition or IVDU
- fever
- vascular phenomenon (major arterial embolis, septic pulmonary infarcts, mycotic aneurysm, ICH, conjunctival hemorrages, janeway lesions)
- immunologic phenomenon: glomerulonephritis, osler nodes, roth spots, rheumatoid factor
- microbiologic evidence: +blood culture that does not meet major criteria
