CARDS: BW Medicine + THS review Flashcards
1
Q
Pt presents with hypotension, tachy, JVD, no pulsus paradoxus -Dx?
A
R ventricular infarct
tx = vigorous fluid resuscitation, do not give nitro
2
Q
Next test to rule out cardiac pathology after EKG?
A
troponins q8 x3
3
Q
Elevations in what leads for LAD STEMI?
A
V1-V4
4
Q
Elevations in what leads for L Circ STEMI
A
I, aVL, V4-V6
5
Q
Elevations in what leads for RCA STEMI
A
II, III, aVF
6
Q
Elevations in what leads for R vent STEMI
A
v4 on right side
7
Q
NSTEMI next test after elevated trops?
A
coronary angiography w/in 48 hours
8
Q
when do CABG after PCI?
A
L main disease 3 vessel disease 2 vessel disease in a diabetic >70% occlusion pain despite max medical tx or post-infection angina
9
Q
Medical Tx for MI
A
morphine oxygen Nitrates ASA/Clopidogrel Beta blocker
10
Q
Discharge Meds STEMI?
A
ASA (+ plavix 9-12 months if stent)
b blocker
ACE if CHF or LV dysfunction
statin
11
Q
No ST Elevation and normal cardiac enzymes x3, next step?
A
dx unstable angina
exercise EKG aka stress test
12
Q
When can’t you do a stress test? what do instead?
A
old LBBB, baseline ST elevation or on Digoxin
do echo instead
13
Q
When use a chemical stress test?
A
pt cannot ambulate but needs a stress test
14
Q
What is a positive stress test?
A
chest pain reproduced
ST depression
hypotension
–> cath lab
15
Q
What are the major risk factors for CAD?
A
Diabetes Smoking HTN Hypercholesterolemia Fhx Age >45 M >55 F HDL<40 chronic renal failure
16
Q
What is the #1 preventable risk factor for CAD
A
smoking
17
Q
Who often do not have classic MI sx?
A
elderly and DM
18
Q
EKG changes for unstable angina?
A
ST depression or T-wave inversions
19
Q
Tx for angina
A
sublingual nitro
3 doses q3-5 min intervals
20
Q
Chronic prevention of angina tx
A
isordil (long acting nitrate)
beta blocker (decrease myocardial O2 consumption)
ASA to prevent platelet aggregation in atherosclerotic plaque
quit smoking
improve lipid levels
21
Q
NSTEMI vs. unstable angina
A
- NSTEMI pain often lasts >20 min without resolving and may only partially respond or not respond to nitroglycerin
- EKG similar to unstable angina (ST depression or T-wave inversions)
- DO see elevated cardiac enzymes
22
Q
Tx of NSTEMI
A
ASA O2 Beta blocker Sublingual nitro PRN LMWH GPIIB-IIA antagonist if enzymes positive of ST dperssions >1mm
23
Q
etiology of STEMI
A
infarct usually 2/2 acute plaque rupture causing thrombosis in an atherosclerotic vessel
24
Q
How soon do you have to give tPA and heparin for thrombolysis of an MI?
A
6 hrs of infarct
25
second line for thrombolysis of MI
streptokinase
26
what drugs are proven to decrease mortality s/p MI?
asa and b-blockers
27
what are the EKG changes in Prinzmetals?
ST elevation
28
how differentiate prinzmetals from STEMI?
transient ST elevation, troponins typically negative
29
tx for prinzmetals
vasodilators (nitroglycerin or calcium blocker) and catheterization because vasospasm often occurs at the site of an atherosclerotic lesion in the coronaries
30
MCC of death s/p MI?
arrythmia
31
new systolic murmur 5-7 d s/p MI?
regurg from papillary muscle rupture
32
acute severe hypotension s/p MI
free wall rupture
33
step up in O2 conc from RA to RV s/p MI?
free wall rupture
34
persistent ST elevation 1 month later + systolic MR murmur?
ventricular wall aneurysm
35
"cannon a waves" s/p MI?
blood bound up to next
| AV dissociation, V-Fib or 3rd degree heart block
36
5-10 weeks s/p MI pleurtic CP, low grade temp?
Dressler's
37
young healthy pt with diffuse ST elevation
pericarditis
38
Chest pain worse with inspiration, better with leaning forward, friction rub dx?
pericarditis
39
tx for pericarditis
NSAIDs
40
chest pain worse with palpation
costochondritis
41
new murmur and history of virus
myocarditis
42
pain occurs at rest, worse at night, woman with migraines
prinzmetal's
43
what can cause hemopericardium?
trauma, metastatic CA, viral or bacterial infections
44
what is pulsus paradoxus?
>10mmHg fall in BP during normal inspiration
45
EKG findings on pericarditis
electrical alternans, beat to beat alternating height of QRS
46
Causes of pericarditis?
infection: bacterial, viral, fungal
| generalized serositis 2/2 RA, SLE, scleroderma, uremia
47
treatment for pericarditis
viral: NSAIDs
bacterial/fungal: antimicrobials
thickened pericardium: pericardectomy
48
Progressive prolongationg of the PR interval followed by a dropped beat
Mobitz type 1 or wenkebach
49
Cannon a waves, regular p-p interval and regular r-r interval but not associated
3rd degree heart block
50
varying pr interval with 3 or more morphologically distinct p waves in the same lead
MFAT
| multifocal atrial tachycardia
51
wide QRS, fast
V tach
| 3 or more consecutive beats with QRS 120 bpm
52
how treat V tach if stable vs unstable
unstable: shock
stable: lidocaine or amiodarone
53
short PR interval followed by a QRS >120 ms with a slurred initial deflection representing early ventricular activation via the bundle of kent
WPW
54
tx WPW
procainamide
55
what do you NOT give for WPW
anything that slows AV conduction
| b-blockers, digoxing, ca channel blockers (dilt, verapamil)
56
regular rhythm with a ventricular rate 125-150 and an atrial rate of 250-300
atrial flutter
57
tx for a flutter unstable vs, stable
unstable: shock
stable: beta blockers and digoxin
58
prolonged QT interval leading to undulating rotation of QRS complex around the EKG baseline in a pt with low Mg and low K, lithium or TCA OD
torsades
59
regular rhythm with a rate between 150-220 sudden onset dizziness/palpitations
supraventricular tachycardia
60
first line tx for SVT
```
carotid massage (kids shove face in ice water)
(adenosine if want med)
```
61
EKG in pt with renal failure, crush injury, burn victim with peaked T waves, widened QRS, short QT and prolonged PR
hyperkalemia
62
undulating baseline, low voltage, alternate beat variation in direction on EKG
cardiac tamponade
| this is electrical alternans
63
undulating baseline, no p-waves, irregular R-R in pt who is hyperthyroid, dizziness or CHF with valve dz
A Fib
64
nml PR interval
<0.2 ms which is 5 small boxes
65
what is a Q wave
initial downward deflection
66
Tx A Fib
beta blockers
digoxin
ca-channel blockers (verapamil and diltiazem)
cardioversion
67
what drugs use to cardiovert afib?
IV procainamide 1st line
| sotalol or amiodarome
68
when do you anticoagulate before cardioversion in pts with A Fib?
if A Fib > 24 hrs, anticoagulate with warfarin for 3 weeks to prevent embolization during procedure
69
How determine if a pt with A Fib needs anticoagulation?
```
CHADS score
1 pt for CHF, HTN, AGE > 75, or diabetes
2 points for stroke or TIA
>2 pts warfarin
>1 ASA or warfarin
0 - ASA
```
70
why can medically slowing A flutter be dangerous?
can increase nodal conduction and result in an increased ventricular rate
71
Tx for A Flutter?
slow vent rate with diltiazem or beta blockers
AVOID procainamide which can result in increased ventricular rate as the atrial rate slows
*use digozin for pts with CHF or decreased EF
*anticoagulate for 3 weeks before cardioversion
72
Who typically gets MFAT?
COPDers
73
Tx for MFAT?
verapamil, also treat underlying condition
74
Tx for SVT?
Depends on etiology:
- correct electrolyte imbalance, vent rate control (digoxin, CCB, BB, adenosine)
- carotid massage in pts with paroxysmal SVT
* *Adenosine breasks >90% of SVT (this can also be used as a diagnostic test)
75
sustained v tach definition
>30 seconds
76
tx v tach
if hypotensive and no pulse --> defibrillate and treat as v fib
asx and not hypotensive--> amiodarone or lidocaine that can convert rhythm
77
V fib tx
electric countershock (second line is amiodarone or lidocaine)
78
Main sx of L sided CHF
exertional dyspnea, orthopnea and paroxsysmal nocturnal dyspnea, S3 gallop
79
Sx of R sided CHF
JVD, depdendent edema, hepatic congestion with transaminitis, fatigue, weight loss, cyanosis
80
Tx of CHF
ACEi or ARB
beta blocker
diuretics (loop or K sparing)
**if can't do ACE do a combo of hydral and isosorbide dinitrate
81
when do you NOT start Beta blockers in a CHF patient?
when they are in active failure because that can worsen failure
82
Digoxin effect in CHF?
decreases hospitalizations and improves sx
83
Why be wary of giving loop diuretic to a pt on digoxin?
because in presence of hypokalemia, digoxin can reach toxic levels
84
Sx of Digoxin toxicity?
SVT with AV block and yellow vision
85
How treat digoxin toxicity?
Fab fragments, correct underlying K deficit
86
Sx of restrictive cardiomyopathy
pulmonary HTN, S4, decreased QRS voltage due to diastolic dz
87
causes of dilated cardiomyopathy
ischemic
infectious: Chagas, Coxsackie, HIV
metabolic
drugs (alcohol, doxorubicin, AZT)
88
Causes of restrictive cardiomyopathy
```
Amyloidosis
scleroderma
hemochromatosis
glycogen storage dz
sarcoidosis
```
89
tx dilated cardiomyopathy
stop offending agent
| tx ~ CHF
90
tx hypertrophic CHF
implantable defibrillator to prevent sudden death from arrhythmia
91
Tx restrictive cardiomyopathy
tx underlying dz if possible
92
HTN urgency criteria
>200/110 without evidence of end-organ damage
93
Tx HTN urgency
BP meds to slowly reduce BP over days, doesn't need hospital
94
HTN emergency criteria
severe HTN with evidence of end-organ compromise (encephalopathy, renal failure, CHF)--> AMS, papilledema, focal neuro sx, chest pain, MAHA)
95
Tx HTN emergency?
IV drip of nitroprusside or nitroglycerin do NOT lower BP by >25% in first hour or pt may stroke
96
Causes of 2o HTN? Cardio? Renal? Endocrine? Drug
Cardio: AR, aortic coarctation
Renal: glomerular dz, RAS 2/2 atherosclerosis (old men) or fibromuscular dysplasia (young women)
Endocrine: Cushing's, Conn's--> HTN with hypokalemia, Pheo, Hyperthyroidism
Drugs: OCPs, glucocorticoids, phenylephrine, NSAIDs
97
1st line HTN drug if s/p MI
BB and ACE
98
HTn drug if osteoporotic
thiazide (decrease Ca excretion)
99
HTN drug if prostatic
alpha blockers: tx for HTN and BPH
100
HTN drug if pregnant
alpha-methyldopa
101
when use Minoxidil for HTN
only if severe and refractory
| have to combine with BB to prevent reflex tachycardia and diuretic to counteract edema
102
when use CLonidine for HTN
refractory HTN in renal pts or those in withdrawal
103
contraindication to ACE
pregnancy (teratogen), RAS (causes acute renal failure), creatinine >1.5
104
contraindication to K-sparing diuretics
creatinine >1.5
105
contraindication to diuretics
gout (can cause hyperuricemia)
106
contraindication to diltiazem or verapamil
CHF (depresses contractility)
107
late systolic murmur with a midsystolic click
MVP
108
What can cause MR?
```
severe MVP
rheumatic fever
papillarly muscle dysfunction (often 2/2 MI)
endocarditis
Marfan's
```
109
Tx MR
ACEi
vasodialtors
diuretics
consider surgery in severe disease
110
MS causes
usually 2/2 prior rheumatic fever
111
Sx of MS
```
dyspnea
orthopnea
hemoptysis
pulm edema
A Fib
```
112
Tx MS
beta blocker (slow HR to allow flow across valve)
digitalis
anticoagulants to prevent embolus
surgical valve replacement for uncontrollable dz
113
AR causes
```
endocarditis
rheumatic fever
ventricular septal defects
congenital bicuspid aorta
3o syphilis
aortic dissection
Marfan's
trauma
```
114
Water Hammar pulse
wide pulse pressure seen in AR
115
Traube's sign
pistol shot bruit over femoral pulse in AR
116
Corrigan's pulse
unusually large carotid pulsations
117
Quincke's sign
pulsatile blanching and reddening of fingernails upon light pressure
118
de Musset's sign
head bobbing caused by carotid pulsations in AR
119
Muller's sign
pulsatile bobbing of the uvula in AR
120
Duroziez's sign
to and fro murmur over femoral artery heard best with mild pressure applied to artery in AR
121
diastolic rumble and opening snap
MS
122
how elicit MVP
valsalva--> click earlier in systole, prolonged murmur
123
high pitched apical blowing holosystolic murmur radiating to axilla
MR
124
diastolic rumble
TS
125
murmur louder with inspiration
TS
126
pulsus parvus et tardus
AS
| peripheral pulses are weak and late comapred to heart sounds, systolic thrill second interspace
127
blowing early diastolic murmur
AR
128
apical diastolic rumble with no opening snap
AR
129
Tx for AR
decrease afterload wtih ACEi or vasodilators
| consiser valve replacement if refractory to drugs or fulminant
130
causes of AS
congenital
rheumatic fever
mild degenerative calcs = AS that is a normal part of aging
131
Sx of AS
syncope, angina, exertional dyspnea
132
what meds do you want to be careful with in patients with AS
beta blockers, vasodilators and ACEi becasue the peripheral vasculature is maximally constricted to maintain BP so these agents can push pts into shock
133
what is hypertrophic cardiomyopathy
when septal wall impinges on anterior leaflet during systole which obstructs outflow. valsalva decreases the obstruction and results in increased flow across the valve and a louder murmur
134
diastolic rumble, increasingly loud with inspiration
tricuspid stenosis
135
holosystolic murmur louder with inspiration, jugular and hepatic pulsations
tricuspid regurgitation
136
what adults get pulmonary stenosis
carcinoid syndrome
137
Graham Steel murmur
diastolic murmur at the L sternal border, mimicks AR murmur
138
Tx for Tricuspid stenosis or pulm stenosis
balloon valvuloplasty, surgery is rare
139
MCC endocarditis
S. aureus
140
Subacute endocarditis bugs
```
insidious onset, sx less severe
strep viridans
strep
enterococcus
HACEK
```
141
what causes marantic endocarditis?
CA seeding of heart valves during metastasis, poor px, mlaignant emboli can cause cerebral infarcts
142
MCC of culture neg endocarditis
Abx tx before drawing blood cultures
| OR: Q fever, Whipple's dz, Bartonella
143
prosthetic valve endocarditis bug?
staph aureus
144
Sx of endocarditis
fevers
splenomegaly
splinter hemorrhages
Ostelr's nodes (painful red nodes on digits)
roth spots: retinal hemorrhages with clear central areas
Janeway lesions: dark macules on palms and soles
conjunctival petechiae
brain/kidney/splenic abscess--> focal neruo sx, hematuria, ab or shoulder pain
145
tx for endocarditis
-prolonged Abx 4-6wks required (2wks if uncomplicated s viridans if give aminoglycosdes with beta lactams)
146
empiric tx endocarditis
- vancomycin for MRSA
- oxacillin for MSSA
- third gen cephalosporin for strep species
147
criteria for surgery for endocarditis
```
valve ring abscess
CHF from dysfunctional valve
multiple systemic emboli after Abx
difficult to treat bug
vegetation >1cm
```
148
Rheumatic Fever/Heart Dz: who?
5-15yo patients after group A strep infxn
149
Rheumatic Fever/Heart Dz: dx
JONES criteria + confirmation of prior strep ifxn
J - joints: migratory polyarthritis, responds to NSAIDs
O - carditis
N - nodules (subQ)
E - erythema marginatum (serpiginous skin rash)
S - syndenham's chorea (face, tongue, upper limb)
150
Jones minor criteria
fever, increased ESR, arthralgia, long EKG PR interval
151
Rheumatic Fever/Heart Dz: Tx?
PCN
152
Dukes Major criteria
1 blood cx growing common organisms
| 2 positive echo
153
Dukes Minor criteria
1. predisposing condition
2. fever >38
3. embolic dz
4. immunologic phenomenon
5. blood cx pos only 1 bottle or rare organism
154
What counts as pos Dukes criteria?
2 major or 1 maj and 3 minor or 5 minor
155
Midsystolic ejection murmur ddx
AS: crescendo decrescendo in second R space
PS: EKG shows RVH, second L space
any high flow sate, AR, A-S defect (fixed split s2), anemia, pregnancy, adolescence
156
Late systolic murmur ddx
AS: worse dz later peak
MVP: apical murmur
HTC: murmur louder with valsalva
157
Holosystolic murmur ddx
MR: radiates to axilla
V-S defect: diffuse across precordium
TR: louder with inspiration
158
Early diastolic murmur
AR: blowing aortic murmur
PR: Graham Steell murmur
159
Mid Diastolic murmur ddx
MS: opening snap, no change with inspiration
AR: apical, Austin flint murmur
As defect: fixed split S2
TS: louder with inspiration
160
Continuous murmur ddx
patent ductus: machinery, murmur loudest in back
Mammary souffle: harmless, heard in pregnancy due to increased flow in mammary artery
Aortic coarctation: upper and lower ext pulse discrepancy
AV fistula
161
Holosystolic murmur with late diastolic rumble in kids
VSD
162
Rumblind diastolic murmur with an opening snap, LAE and A-Fib
MS
163
Patient with SOB, next step
if suspect PE--> heparin
check O2 sats--> give O2 if low
pneumonia--> CXR
murmur of CHF--> echo to look at EF
acute pulm edema--> nitrates, lasix and morphine
young w/sxs of CHF and viral hx--. myocarditis (coxsackie B)
164
young pt with SOB
could be primary pulm HTN, want R heart cath
165
pulm HTN: what will wedge pressure be?
normal!
166
Reversible causes of CHF?
alcohol for dilated
| hemachromatosis for restrictive, reversible with iron overload
