Cardiovascular disorders Flashcards by Ashley Atwood

What are the indications for cardioversion?

Indications for synchronized electrical cardioversion include the following:

–Supraventricular tachycardia

–Atrial fibrillation

–Atrial flutter

–Ventricular tachycardia

–Any patient with reentrant tachycardia with narrow or wide QRS complex who is unstable (eg, chest pain, pulmonary edema, hypotension)

Medscape

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What are contraindications for cardioversion?

–Known digitalis toxicity–associated tachycardia

–Multifocal atrial tachycardia

–Patients with atrial fibrillation who are not anticoagulated should not undergo cardioversion without a TEE that can assess the presence of left atrial thrombus

Medscape

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What are indications for defibrillation?

Indications for defibrillation include the following:

–Pulseless ventricular tachycardia (VT)

–Ventricular fibrillation (VF)

–Cardiac arrest due to or resulting in VF

Medscape

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What are contraindications for defibrillation?

Awake, responsive patient

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What is this?

Digitalis toxicity

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What is this?

A: hypercalcemia

B: hypocalcemia

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What is this?

Hyperkalemia

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What is this?

Hypokalemia

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What is this?

Wolff Parkinson White

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What is this?

Pericarditis

–ST elevation with entire T wave above baseline

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–IVDU

–fever

–valve vegetations seen on TTE

–septic emboli in lungs or brain seen on CT

–get blood cultures

Is this endocarditis, pericarditis, or myocarditis?

endocarditis

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–audible rub

–pain worse supine, improves if sitting up leaning forward

–diffuse ST elevations seen on EKG

Is this endocarditis, pericarditis, or myocarditis?

pericarditis

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–often follows URI

–need a biopsy to diagnose

–Echocardiogram documents cardiomegaly and contractile dysfunction

Is this endocarditis, pericarditis, or myocarditis?

myocarditis

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What is the top bug that causes endocarditis?

S. aureus

purple book 6-12

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After S. aureus, what is the most common bug in endocarditis for

–native valve

–prosthetic valve

Native valve: S. viridans

Prosthetic valve: S. epidermidis

purple book 6-12

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What is the treatment regimen for infective endocarditis?

Acute, native valve: vanco

Subacute, native valve: ceftriaxone

Prosthetic valve: vanco + gent + ceph

purple book 6-13

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What are the etiologies of pericarditis?

–90% idiopathic (presumed to be viral)

–metastatic neoplasms

–autoimmune

–uremia

–acute STEMI

–radiation

purple book 1-25

What is the treatment of pericarditis?

NSAIDs +/- colchicine

Steroids

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What are the signs and symptoms of cardiac tamponade?

cardiogenic shock (hypotension, fatigue) without pulmonary edema
pulsus paradoxus (large decrease in SBP on inspiration)
dyspnea
increased cardiac silhouette on CXR
effusion seen on TTE

purple book 1-26

What is the treatment regimen for cardiac tamponade?

PERICARDIOCENTESIS

But also:

Volume (but not too much, since that will worsen tamponade due to overfilling)
Positive inotropes e.g. dobutamine
Avoid vasoconstrictors

What is the NYHA Functional classification system for heart failure?

Class I (Mild)

No limitation of physical activity.

Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea.

Class II (Mild)

Slight limitation of physical activity.

Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Class III (Moderate)

Marked limitation of physical activity.

Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Class IV (Severe)

Unable to carry out any physical activity without discomfort.

Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

What are the symptoms of congestive heart failure (right and left)?

Left: dyspnea, orthopnea, PND

Right: peripheral edema, RUQ discomfort, bloating, satiety

purple book 1-14

What are the physical exam findings of CHF?

–increased JVP

–hepatojugular reflux

–S3

–rales, dullness in lung bases 2/2 pleural effusion

–peripheral edema

purple book 1-14

What are the treatments for acute decompensated heart failure?

Warm & dry: outpatient

Warm & wet: diuresis

Cold & dry: inotropes

Cold & wet: diuresis, inotropes, +/- vasodilators

purple book 1-15

What are the pharmacologic and non-pharmacologic measures that should be taken to prevent venous thromboembolism in hospitalized patients?

Heparin, LMWH, fondaparinux, enoxaparin NOT warfarin NOT aspirin ~~~ YES Intermittent pneumatic compression devices NO real evidence for compression stockings UpToDate

What is the Wells Criteria scoring system for DVT probability?

--Paralysis, paresis or recent orthopedic casting of lower extremity (1 point) --Recently bedridden (more than 3 days) or major surgery within past 4 weeks (1 point) --Localized tenderness in deep vein system (1 point) --Swelling of entire leg (1 point) --Calf swelling 3 cm greater than other leg (measured 10 cm below the tibial tuberosity) (1 point) --Pitting edema greater in the symptomatic leg (1 point) --Collateral non varicose superficial veins (1 point) --Active cancer or cancer treated within 6 months (1 point) --Alternative diagnosis more likely than DVT (Baker's cyst, cellulitis, muscle damage, superficial venous thrombosis, post phlebitic syndrome, inguinal lymphadenopathy, external venous compression) (-2 points) Scoring: 3-8 Points: High probability of DVT 1-2 Points: Moderate probability - 2-0 Points: Low Probability * UpToDate*

What are the diagnostic steps for suspected DVT?

1. Wells score 2. D-dimer (sensitive, not specific - rules out if neg but if pos, don't know why, need more testing) 3. Ultrasound

How do you best prevent development of pressure ulcers in hospitalized patients?

1. Identify patients at risk 2. Turn Q2 hours 3. Position properly (elevate HOB, use pillows between knees, etc.) 4. Choose proper surface (mattress, pneumatic mattress, etc.) 5. Minimize moisture (i.e. from incontinence) 6. Proper nutrition 7. Proper skin care (moisturizing, etc.) 8. Minimize immobility 9. Educate staff, have protocols in place

What are the 3 main classifications of cardiomyopathy?

Dilated Hypertrophic Restricted (plus Takotsubo)

72 yo woman whose husband passed away suddenly last week presents with s/s of acute anterior MI but upon cardiac catheterization/imaging only LV apical ballooning is found. What is it?

Takotsubo, or stress cardiomyopathy Usually complete recovery --postmenopausal women --after major catecholamine discharge

Caused by mutations in sarcomeric contractile protein genes and transmitted as an autosomal dominant trait with incomplete penetrance. What type of cardiomyopathy?

Hypertrophic

Characterized by dilatation and impaired contraction of one or both ventricles. The dilatation often becomes severe and is invariably accompanied by an increase in total cardiac mass (hypertrophy). Affected patients have impaired systolic function and may or may not develop overt heart failure. What type of cardiomyopathy?

Dilated

Characterized by nondilated ventricles with impaired ventricular filling. Hypertrophy is typically absent, although infiltrative disease (such as amyloidosis) and storage disease (such as Fabry disease) may cause an increase in LV wall thickness. Systolic function usually remains normal, at least early in the disease. What type of cardiomyopathy?

Restrictive

You want to evaluate the heart chambers, check heart wall motion, evaluate LV volume & function, and check the valve leaflets for vegetations. What imaging modality will you choose? CT, MRI, PET, TTE/TEE, EKG, cardiac cath

TTE/TEE

You want to evaluate your patient for suspected AAA. What imaging modality will you use?

CT or MRI

You want to assess the tissue viability of your patient's heart. What imaging modality will you use?

PET/nuclear imaging

You want to assess your patient for pericardial disease and myocardial disease. What imaging modality will you use?

MRI

You want to visualize as much of the coronary arteries and anatomy of your patient as you can, and check for stenoses. What imaging modality will you use?

You want to measure the hemodynamics of your patient's heart, as well as do some coronary angiography. What imaging modality will you use?

cardiac catheterization

What are the indications for implantable pacemaker?

* Sinus node dysfunction (sick sinus syndrome) * Acquired AV block in adults * After acute myocardial infarction * After cardiac transplantation * Pacing to prevent tachycardia * Patients with congenital heart disease *Medscape*

What are the indications for implantable defibrillator?

* Idiopathic VT/VF * **Congenital long QT** syndrome * Prior MI with LV ejection fraction \< 30% * Syncope with structural heart disease * High-risk patients with **Hypertrophic Cardiomyopathy** * High-risk patients with **Brugada** syndrome ## Footnote *UpToDate*