Cards Flashcards
What is the worst risk factor for CAD?
What is the most common risk factor for CAD?
DM
HTN
What is the relationship between family history and CAD?
First degree relatives carry a risk
Premature CAD carries a risk (males
What lipid marker is the greatest concern for CAD risk
Elevated LDL
What is Tako Tsubo CM?
What is it caused by?
Post menopausal women experience a massive catecholamine surge and have LV ballooning
Due to sudden stress
What are 2 characteristics of ischemic pain?
What are 5 characteristics of non-ischemic pain?
Dull/sore, squeeze/pressure
Sharp, couple seconds, pleuritic, positional, tender
What is the initial test for chest pain?
What is the next step in an office?
What is the next step in a hospital?
EKG
Transfer to ED
CK MB + Tropinin
What is the maximum heart rate?
220-age
When should you stress test someone?
Etiology of chest pain is uncertain + EKG is nondiagnostic
What are 2 tests for when you cannot read an EKG because of a baseline abnormality?
Nuclear isotope uptake (thallium or sestamibi)
Echo detection of wall motion abnormalities
What is a medication for stress testing that should be avoided in asthmatics and why?
What should you use instead?
Dipyridamole causes bronchospasm
Dobutamine with an Echo
What is the next step in a patient with a positive stress test for ischemia?
Who gets a stent vs a CABG?
Coronary angiography (most accurate detector of CAD) Stent for 1-2 vessels, CABG for 3+ or 2 in DM
When do you use Holter monitoring?
Rhythm evaluation
What antiplatelet meds should an ACS patient receive immediately upon arrival?
ASA + Clopedigrel or Prasugrel or Ticagrelor (P/T if being stented)
What is ticlopidine and who gets it?
Platelet inhibitor in patients intolerant of ASA and clopidogrel
Causes neutropenia + TTP
What patients receive ranolazine?
Angina patients refractory to other treatments
What has the best mortality benefit to Low EF CHF?
ACEi/ARBs
What do you combine with hydralazine and why?
Nitrates –> dilate coronary As so blood is not stolen away when after load is decreased
What is the most common adverse affect of statins?
Liver dysfunction
What are the adverse effects of Niacin?
Any positives?
Increased glucose, increase Uric acid, pruritus
Increased HDL
What are the adverse effects of Fibrates?
Any positives?
Myositis risk with statins
Lower TGs
What are the adverse effects of cholestyramine?
Significant interactions with other meds, flatus/cramping
What are the adverse effects of Ezetimibe?
It is useless (though it does lower LDL)
What is the association of Ca Channel blockers and CAD?
Who are the exceptions and what drugs?
May increase mortality (reflex tach)
Verapamil/Dilt –> severe asthma pts who can’t use BBlockers, prinzmetal angina, Cochin induced chest pain
When does CABG lower mortality?
3 vessels of >70% stenosis
L Main occlusion
2 vessels + DM
Persistent Sx despite max medical therapy
How long do the 2 types of graft last in a CABG?
Mammary A: 10 years
Saphenous V: 5 years
What heart sound is associated with ACS and why?
S4 gallop
Ischemia causes LV noncompliance
What is kussmaul sign and what is it associated with?
Increased JVD on inhalation
Constrictive pericarditis > restrictive CM
What is a displaced PMI characteristic of?
LVH
EKG finding of anterior wall MI
ST elevation in V2-V4
EKG finding of the inferior wall
ST elevation in II, III, aVF
EKG finding of 1st degree AV block
PR >200mSec
EKG findings of posterior wall MI
ST depression in V1 and V2
What is the first drug to administer in an acute MI patient because it lowers mortality?
What are the next 3 drugs?
ASA
Morphine + O2 + Nitroglycerin
What are 3 drugs given to MI patients that are not time sensitive?
Metoprolol
ACEi
Station
What disease can cause a false positive troponin and why?
Renal insufficiency
Troponin excreted by the kidney
What are the 2 steps for a patient who has a suspected reinfarction a few days after their MI
1) EKG
2) CKMB
* 3) transfer to ICU
How much time should elapse to giving PCI in an MI?
How is restenosis prevented?
90 minutes
Drug eluding stent (Paclitaxel, Sirolimus)
When is heparin useful with regards to ACS?
ST depression and other NSTEMI events
When are Cannon A waves seen?
What are they?
3rd degree AV block
Atrial systole against the tricuspid valve (which is closed)
How is symptomatic Brady treated?
1) atropine –> pacemaker if necessary
What are the findings in RV in fact?
What is most specific?
How do you treat these?
What do you avoid?
Tachy
ST elevation in V4
High volume fluid replacement
Nitroglycerin (worsens cardiac filling)
What are 3 clues of post MI valve or septal rupture?
Step up in O2 SATs from RA to RV
New onset mitral regurg murmur
Pulmonary congestion
When is an intraaortic balloon pump used?
Bridge to valve replacement for
What are 2 diagnoses if there is a sudden loss of pulse with JVD?
Tamponade
Wall rupture
What are the meds that a post infarct patient goes home with?
ASA
Metoprolol
Statin
ACEi
What 3 diseases cause >95% of Systolic dysfunction CHF
Infarct
CM
Valve disease
What heart sound is associated with CHF
S3 gallop
What is the most important test in CHF (also initial)?
What is the most accurate test for CHF?
TTE
MUGA
What can you use a Swan Ganz catheter to distinguish?
CHF and ARDS
What thyroid disorders can cause CHF?
Both high and low ;)
What is the most common cause of death from CHF?
Arrhythmia leading to sudden death
What are 5 drugs classes used in low EF CHF and why?
ACEi/ARB: all
BBlocker (Metoprolol/Bisprolol/Carvedilol): all
Spironolactone: class 3+ –> Eplerenone if gynecomastia
Diuretics: initial Sx control
Digoxin: controls Sx but NO MORTALITY BENEFIT
What are 2 non medicine treatments for CHF with mortality benefit?
Defibrillator (ischemic CM + EF 120)
What is a good treatment in Preserved EF CHF?
What is bad?
Beta Blockers (diuretics if Sx but no HCM) Digoxin, Spironolactone
Initial therapy for acute pulmonary edema?
2 tests to do afterward?
IV Furosemide
EKG + ECHO
_____ _____ have basically never had MIs
Menstruating women
What is the most common valve disease of rheumatic fever?
Mitral stenosis
What valve disease is associated with aging?
Aortic stenosis
What side of the heart valvular lesions increase on inhalation? Why?
Right side –> increased venous return
What side of the heart lesions increase with exhaling? Why?
Left –> squeezes blood from the lungs into the heart
What is the best initial and accurate tests for valvular heart disease?
Initial: ECHO (TEE > TTE)
Accurate: catheterization
What do you look for to determine if a valve replacement will be helpful or not?
End diastolic volume (too large: will not be helpful)
What are 2 clues to mitral stenosis as the diagnosis?
Pregnancy (increased plasma V squeezing through stenosed valve)
Immigrant (not immunized)
What are 4 unique features of Mitral Stenosis?
Dysphagia (LA presses on esophagus)
Hoarseness (LA on laryngeal N)
Afib (+ stroke due to enormous LA)
Hemoptysis
What is the heart murmur of mitral stenosis? What changes it?
Diastolic right after opening snap
Squatting + leg raise increase intensity (increase V return)
What are the steps to treat mitral stenosis?
1) diuretics/Na restriction
2) balloon valvuloplasty –> valve replaced if needed
3) Warfarin for afib to 2-3
4) Rate control (dig/BBlock/CCB)
What is the most common and 2nd most common presentation of AS?
Angina > syncope
What is the murmur of AS?
Systolic crescendo decrescendo radiating to the carotid
Valsalva, Standing: soften by decreasing V return
Handgrip: soften by decreasing ejection of blood
What is the treatment for AS?
Valve replacement
What can cause mitral regurg?
How does it present?
Any reason for heart dilation
Holosystolic radiating to the axilla
Handgrip: Increases (increases afterload)
Squatting, leg raise: increase (increased V return)
What are some unique findings of Aortic Regurg?
What is the murmur?
Wide pulse P, Water Hammer bounding pulse, Pulsing nail bed, BP in legs 40mg>arm, head bobbing
Diastolic decrescendo in LLSB
Valsalva, Standing: improve
Handgrip: worsens (increases afterload by compressing arm As)
What is the most common presentation of MVP?
Nothing!
But also atypical chest pain, palpitations, panic attack
What is the murmur in MVP?
Midsystolic click
Valsalva, Standing: worsen MVP (decrease venous return)
Squatting, handgrip: improve murmur (increase LV size)
CM presentation?
Initial test?
Accurate test?
Treatment?
Shortness of breath
ECHO
ECHO
Diuretics
What 2 murmurs do not increase with expiration?
HCM
MVP
What valvular finding is classic for HOCM?
Systolic anterior motion of the mitral valve
What is the treatment of HCM and HOCM?
1) BBlock
2) negative ionotropes (Verapamil, Disopyramide)
3) Diuretics for HCM but NOT for HOCM
What is the best initial test of RCM?
Accurate?
ECHO
Endomyocardial biopsy
What is the result of standing suddenly?
open venous capacitance vessels in legs
What is the result of a valsalva?
1) increased intrathoracic P
2) decreased V return to R side of the heart
Which are the murmurs that improve with more blood?
MVP
HOCM
What happens with the handgrip?
1) Arm As are compressed
2) increased afterload because heart cannot empty
What does Amyl Nitrate do to murmurs?
1) direct A vasodilator
2) stimulates the effect of ACEis/ARBs
3) emptier LV
What is the treatment for idiopathic pericarditis?
NSAIDs + Colchicine (decrease recurrence)
What are signs of pericardial tamponade?
HypoTN
Tachy
Distended neck Vs
Clear lungs
What are 2 classic signs of constrictive pericarditis?
Kussmaul sign: increase in JVD on inhalation (should decrease)
Knock: heart fills to its maximum
What is the best initial test for constrictive pericarditis?
Accurate?
Additional?
CXR
CT/MRI (not needed if CXR done first)
ECHO
What is the classic symptom of PAD?
What is different in spinal stenosis?
Leg pain in the calves on exertion improving with rest
SS is worse walking down hills because you lean back
What is the best initial test for PAD?
Accurate?
ABI (
What are the treatments of PAD?
ASA
Smoking cessation
Cilostazol
What 3 things do you control in major vascular disease?
BP
LDL
What is the initial test for Aortic Dissection?
Accurate?
CXR
Angiography
What are 2 findings in aortic dissection?
Pain between the scapulae
Difference in BP between the arms
What are the treatment steps for aortic dissection?
1) BBlock
2) Nitroprusside (must BB first to prevent reflex tach)
3) surgery
Who is screened for AAA?
Men who ever smoked >65
What is the most dangerous heart disease in a pregnant woman?
Peripartum CM (reversible LV dysfunction usually but if not may need a heart transplant) Typically develops after pregnancy!
