Cards Flashcards
GI disorders assc with chest pain
- duodenitis
- cholelithiasis
- ulcers
- gastritis
Worst risk factor for CAD? Most common?
Worst- DM
MC- HTN
Age assc with CAD in men vs women?
45 men 55 women
this is why lipids at 35 and 45
Most dangerous portion of lipid profile
high LDL (more impactful than obesity itself)
When is fam hx CAD relevant?
FIRST DEGREE, EARLY MI (65 woman, 55 male)
“Tako Tsubo”/ Broken heart syndrome pathogenesis and key findings
catechol surg; ballooning of LV
Which lifestyle change has the most immediate effect on CAD risk
smoking cessation
What pains are abnormal for ACS?
sharp/stabbing/ knifelike
Chest pain worst when lying flat is ___? How to dx?
Pericarditis
EKG (Diffuse STE, PRD)
Epigastric pain worst BETTER WITH FOOD
duodenal ulcer
Chest pain with fever =
PE or PNA
Max heart rate
220- age patient
Appearance of CAD on nuclear scan?
decreased thallium uptake
Reversible ischemia present on stress NBS
angiography –> plasty/ surgery
*NOTE YOU CAN DO NOTHING ABOUT FIXED LESIONS!
Options for stress tests
1) Exercise + EKG
2) Exercise + Thallium or Echo (for abnl EKG)
3) Diypridamole + Thallium or Dobutamine + echo (for intability to exercise)
To correct stenosis must be at least ____%
70%
Medications for stable CAD?
BBer * ASA* ACEi Statin NG PRN
*lower mortality
ASA should be used in all stable CAD/angina…
When should second antiplatelet agent (ie clopidogrel) be added?
- Acute ACS
- Recent Stenting
- In place of ASA if intolerant
When should ACEi be used?
- Low EF/Systolic Dysfunction
- Valvular Regurg
When to use statins?
All CAD patients on statins, get LDL at least below 100
Also use for CAD equivalents (Stroke, carotid disease, PAD, DM, aortic disease)
Also use for hyperlidipemia
ADRs of statins + which is MC?
- # 1: transamintitis
- myositis
- CPK ^
- rhabdo
Why is statin therapy superior to others?
largest mortality decrease, antioxidant effect on endothelial lining of arteries
Niacin ADRs
flushing, glucose/uric acid ^^
Fibrate ADRs
increased risk myositis when added to statins
Colestyramine ADRs
- flatulence/bloating
- can decrease absorption of other meds
Ezetimibe ADRs
actually well tolerated but doesn’t work worth a shit
Effect of CCBs on mortality in CAD?
actually increases due to reflex tachycardia so do not routinely use
ADRs of CCBs
edema
constipation
heart block
Indications for CABG
- 3 vessel disease
- 2 vessel disease +DM
- Left Main occlusion
- Persistent symptoms despite max therapy
Which veins are used for bypass? how long do they last?
IMA- 10 years
Saphenous- 5 years
Why is S4 heard in ACS?
Ischemia –> noncompliant left ventricle
MI location with highest mortality rate?
anterior wall (V2-4)
Increased JVD on inhalation is _____ sign?
When is it seen?
Kussmal
Constrictive pericarditis
Triphasic scratchy sound is _____ assc with ____
friction rub, pericarditis
A decrease in BP more than 10mg on inspiration is _____ assc with _____.
pulsus paradoxus; tamponade
Drug that is most important to give immediately in ACS to lower mortality (while activating cath lab)
ASA
Which management should always be “NBS” in ACS?
whatever lowers mortality
How long from MI does it take for troponin to rise?
4- 6 hours
Appropriate door to balloon time? Door to needle? (thrombolytics)
90 mins; 30 mins
What best prevents restenosis following angioplasty?
drug eluting stent
Contraindications to thrombolytics?
What to do if pt has these?
CNS/GI bleed, surg last two weeks, stroke last 6months, BP 180/110
*Transfer for angioplasty even if will be more than 90 mins
When are GPIIB/IIIA inhibitors used?
abciximab, tirofiban, eptifibatide
stenting; NSTEMI not STEMI
When is heparin used in ACS?
NSTEMI
Drugs given in case of NSTEMI
1-2) ASA, antiplatelet
3) BBer
4) Nitrate, morphine, O2
5-6) Heparin, GPIIBIIIAI
Drugs given in case of STEMI
1) ASA, Statin
2) BBer
3) Thrombolytics –> heparin or stenting
4) statin
5) morphine, nitrates, o2
Clue to right ventricular infarct?
Inferior MI’s (leads II,III,avf)
Clear lungs
STE in RV4
Special treatment for RVI
no nitro
extra fluids
How does 3AV block assc with MI present?
cannon A waves
symptomatic bradycardia
Presentation of tamponade/wall rupture post MI
sudden loss of pulse, JVD
several days after the original MI
Presentation of valve or septal rupture post MI?
How to dx?
new onset murmur
pulm congestion
need echo
Purpose of intraaortic balloon pump
bridges to surg in anatomic lesion… 24-48 hours
Management of post MI mural thrombus
heparin –> warfarin
Testing prior to discharge from hospital for MI patient
stress –> angiography if needed
BBer typically used postMI
metoprolol
When to use prophylactic antiarrythmics
don’t… that’s stupid.
Causes of ED post MI
anxiety, BBer
In which CHF type is ejection fraction preserved?
diastolic
3 MCC CHF
MI
cardiomyopathy
valve disease
Difference between asthma exacerbation and PE
lungs clear in PE
Circumoral numbness and chest pain is assc with?
panic attack
S3 sound? S4
S3 Ken-tuc-KY
S4 TEN-ne-see
Why to do CBC in case of CHF
R/O anemia as a cause
Meds for systolic heart failure
ACE/ARB
BBer
Diuretics
Dig PRN Spironolactone (class III, IV)
BBers that are appropriate for CHF
metoprolol (B1)
bisoprolol (B1)
carvedilol (a1, B1)
Most common cause of death from CHF
arrhythmia
Alternative to ACEi in case of hyperkalemia
hydral + nitrate
What drugs have mortality benefit in systolic dysfunction
ACEi BBer Spironolactone Defibrillator hydral, nitrates in AA
When is an implantable defibrillator appropriate for CHF
ischemic cardiomyopathy
EF less than 35%
When is a biventricular pacer appropriate treatment for CHF
EF under 35%
QRS more than 120 ms
Only two drugs that are clearly beneficial in diastolic heart failure
BBer
diuretics
Drugs that are harmful in diastolic heart failure
Dig
spiro
Heart sound assc with pulmonary edema
S3
Metabolic changes assc with CHFE
until very severe, respiratory alkalosis due to severe hyperventilation
Management of acute pulm edema
- ->EKG, if arrhythmia (ie afib or flutter)-cardiovert
- -> no arrhythmia, diuretics
all: echo +O2/morphine/nitrates but do above first
Why is dig not helpful in acute setting?
takes effect weeks after starting
Causes of regurgitant heart disease
ischemic heart disease
hypertension
Which murmurs increase with inhalation
right sided
Treatment of stenotic valvular disease
mitral- balloon
aortic- replace
Treatment of regurgitant disease
vasodilators –> if end systolic diameter ^^ need to replace before its too late, also replace if acute
Unique features (symptoms) of mitral stenosis
- afib
- hoarseness/dysphagia from big LA
- hemoptysis
Mitral stenosis
murmur and EKG findings
- biphasic P wave in leads V1-2 (m wave)
- diastolic, opening snap
Two causes AS
congenital bicuspid valve
aging- calcification
What decreases the intensity of AS murmur
standing, Valsalva
worse with handgrip, squatting
Acute causes of mitral regurg or aortic regurg
- MI (pap muscle rupture)
- endocarditis
Murmur of MR
holosystolic
Appropriate vasodilators for regurgitant valve disease
ACE/ ARBs best
Syndromes/ diseases assc with aortic regurg (4)
- marfans
- ank spon
- reiter
- syphilis
Unique symptoms of AR murmur
head bob
pulsating finger nails
high pressure in legs
wide pulse pressure
Symptoms of MVP
palpitations, panic attack
Murmur of MVP
midsytolic click –> MR murmur
Most murmurs are ______ with standing. ____ and _____ are _____ with standing.
most- decrease with standing and Valsalva
MVP and HOCM- WORSE with standing and Valsalva, better with squatting
MVP treatment
BBer if symptomatic
Dilated and Hypertoropic Cardiomyopathy are treated with _____.
diuretics … NOT HOCM though!
Dilated cardiomyopathy is treated with?
see systolic CHF
ACE, BBer, Diuretic, +/-spiro/dig
In addition to MI/ischemia what are some of the weirdo causes of dilated cardiomyopathy
- alcohol
- virus, Chagas
- rads, doxo
Special PE finding assc with Hypertrophic Cardiomyopathy
S4 (stiff ventricle)
What is far and away the most common cause of HCM?
HTN
What worsens hOcm
ACE/ARB, dig, hydral, stress and high HR
Best initial therapy for both HCOM and HCOM
BBer
____ are helpful in HCM but harmful in HCOM.
diuretics
Treatment for diastolic/hypertrhopic cardiomyopathy
bber, diuretics
Treatment for systolic/ dilated heart failure
bber, ace, diuretics +/- spiro and dig
Specific therapies for HOCM
implantable defibrillator if syncope
ablation of septum/ myometctomy
EKG findings with HOCM
inferior and lateral Q waves
and LVH
Restrictive cardiomyopathy is ____ + ____
dilated + hypertrophic CM
Causes of restrictive cardiomyopathy
- hemochromatosis
- sarcoid
- amyloid
- fibrosis/ scleroderma
Common PE finding with restrictive CM
Kussmal (JVD with inspiration)
Treatment of restrictive CM
only diuretics may help. no other clear treatment.
Maneuvers that decrease MVP and HOCM
squatting
handgrip
leg reaise
Maneuvers that increase MVP and HOCM
standing
Valsalva
Standing and Valsalva are = to what medication
diuretics; less blood helps everything except MVP and HOCM
What valvular disease follows trends of HOCM/ MVP in case of only handgrip/amyl nitrate
AS
What murmurs are increased by amyl nitrate?
MVP, HOCM, AS
because empties left ventricle
Amyl nitrate is equal to
ACE/ ARB (which treat regurgitant lesions by decreasing blood amount!)
Handgrip = ____ blood. Amyl nitrate = _____ blood.
hangrip more. amyl less.
less better for regurgitation
more better for MVP, HOCM, AS
Three pericardial diseases that are closely linked
pericarditis, tamponade, constrictive pericarditis
MC infection causing periocarditis? Most common CT disorder?
virus–coxsackie; lupus
EKG finding in pericarditis
diffuse STE and PRD
*PRD more specific
What decreases recurrence of pericarditis?
colchicine, but NSAIDs treat acutely.
Can give both.
Risk assc with pericarditis
tamponade
PE finding most likely assc with tamponade?
pulsus paradoxus. BP down 10 with inspiration
also JVD, low bp, tachy, clear lungs because no blood to lungs
Best dx tool for tamponade
echo
EKG finding in tampoande
electrical alternans
Constrictive pericarditis- best PE clues x2 + dx
“knock” + ^^JVD when INHALING (Kussmal); calcification on xray
Treatment of constrictive pericarditis
diuretics –> surgery
Clue to spinal stenosis
worse when walking downhill
Most effective medication for treating PAD
cilostazol
Best test for dissection
Initial test for dissection
best- angio
initial- cxr
Who to screen for AAA
men who ever smoked above age 65
Treatment of aortic dissection:
BBer
Nitroprusside
Surgery
Treatment of peripartum cardiomyopathy
same as dilated/systolic therapy
