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Medicine > CARDS: BW Medicine + THS review > Flashcards

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

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2
Q

Next test to rule out cardiac pathology after EKG?

A

troponins q8 x3

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3
Q

Elevations in what leads for LAD STEMI?

A

V1-V4

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4
Q

Elevations in what leads for L Circ STEMI

A

I, aVL, V4-V6

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5
Q

Elevations in what leads for RCA STEMI

A

II, III, aVF

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6
Q

Elevations in what leads for R vent STEMI

A

v4 on right side

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7
Q

NSTEMI next test after elevated trops?

A

coronary angiography w/in 48 hours

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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
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9
Q

Medical Tx for MI

A 
morphine
oxygen
Nitrates
ASA/Clopidogrel
Beta blocker
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10
Q

Discharge Meds STEMI?

A

ASA (+ plavix 9-12 months if stent)
b blocker
ACE if CHF or LV dysfunction
statin

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11
Q

No ST Elevation and normal cardiac enzymes x3, next step?

A

dx unstable angina

exercise EKG aka stress test

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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

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13
Q

When use a chemical stress test?

A

pt cannot ambulate but needs a stress test

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14
Q

What is a positive stress test?

A

chest pain reproduced
ST depression
hypotension
–> cath lab

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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
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16
Q

What is the #1 preventable risk factor for CAD

A

smoking

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17
Q

Who often do not have classic MI sx?

A

elderly and DM

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18
Q

EKG changes for unstable angina?

A

ST depression or T-wave inversions

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19
Q

Tx for angina

A

sublingual nitro

3 doses q3-5 min intervals

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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

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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
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22
Q

Tx of NSTEMI

A 
ASA
O2
Beta blocker
Sublingual nitro PRN
LMWH
GPIIB-IIA antagonist if enzymes positive of ST dperssions >1mm
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23
Q

etiology of STEMI

A

infarct usually 2/2 acute plaque rupture causing thrombosis in an atherosclerotic vessel

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24
Q

How soon do you have to give tPA and heparin for thrombolysis of an MI?

A

6 hrs of infarct

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25
Q

second line for thrombolysis of MI

A

streptokinase

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26
Q

what drugs are proven to decrease mortality s/p MI?

A

asa and b-blockers

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27
Q

what are the EKG changes in Prinzmetals?

A

ST elevation

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28
Q

how differentiate prinzmetals from STEMI?

A

transient ST elevation, troponins typically negative

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29
Q

tx for prinzmetals

A

vasodilators (nitroglycerin or calcium blocker) and catheterization because vasospasm often occurs at the site of an atherosclerotic lesion in the coronaries

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30
Q

MCC of death s/p MI?

A

arrythmia

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31
Q

new systolic murmur 5-7 d s/p MI?

A

regurg from papillary muscle rupture

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32
Q

acute severe hypotension s/p MI

A

free wall rupture

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33
Q

step up in O2 conc from RA to RV s/p MI?

A

free wall rupture

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34
Q

persistent ST elevation 1 month later + systolic MR murmur?

A

ventricular wall aneurysm

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35
Q

“cannon a waves” s/p MI?

A

blood bound up to next

AV dissociation, V-Fib or 3rd degree heart block

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36
Q

5-10 weeks s/p MI pleurtic CP, low grade temp?

A

Dressler’s

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37
Q

young healthy pt with diffuse ST elevation

A

pericarditis

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38
Q

Chest pain worse with inspiration, better with leaning forward, friction rub dx?

A

pericarditis

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39
Q

tx for pericarditis

A

NSAIDs

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40
Q

chest pain worse with palpation

A

costochondritis

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41
Q

new murmur and history of virus

A

myocarditis

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42
Q

pain occurs at rest, worse at night, woman with migraines

A

prinzmetal’s

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43
Q

what can cause hemopericardium?

A

trauma, metastatic CA, viral or bacterial infections

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44
Q

what is pulsus paradoxus?

A

> 10mmHg fall in BP during normal inspiration

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45
Q

EKG findings on pericarditis

A

electrical alternans, beat to beat alternating height of QRS

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46
Q

Causes of pericarditis?

A

infection: bacterial, viral, fungal

generalized serositis 2/2 RA, SLE, scleroderma, uremia

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47
Q

treatment for pericarditis

A

viral: NSAIDs
bacterial/fungal: antimicrobials
thickened pericardium: pericardectomy

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48
Q

Progressive prolongationg of the PR interval followed by a dropped beat

A

Mobitz type 1 or wenkebach

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49
Q

Cannon a waves, regular p-p interval and regular r-r interval but not associated

A

3rd degree heart block

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50
Q

varying pr interval with 3 or more morphologically distinct p waves in the same lead

A

MFAT

multifocal atrial tachycardia

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51
Q

wide QRS, fast

A

V tach

3 or more consecutive beats with QRS 120 bpm

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52
Q

how treat V tach if stable vs unstable

A

unstable: shock
stable: lidocaine or amiodarone

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53
Q

short PR interval followed by a QRS >120 ms with a slurred initial deflection representing early ventricular activation via the bundle of kent

A

WPW

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54
Q

tx WPW

A

procainamide

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55
Q

what do you NOT give for WPW

A

anything that slows AV conduction

b-blockers, digoxing, ca channel blockers (dilt, verapamil)

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56
Q

regular rhythm with a ventricular rate 125-150 and an atrial rate of 250-300

A

atrial flutter

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57
Q

tx for a flutter unstable vs, stable

A

unstable: shock
stable: beta blockers and digoxin

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58
Q

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

A

torsades

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59
Q

regular rhythm with a rate between 150-220 sudden onset dizziness/palpitations

A

supraventricular tachycardia

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60
Q

first line tx for SVT

A 
carotid massage (kids shove face in ice water)
(adenosine if want med)
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61
Q

EKG in pt with renal failure, crush injury, burn victim with peaked T waves, widened QRS, short QT and prolonged PR

A

hyperkalemia

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62
Q

undulating baseline, low voltage, alternate beat variation in direction on EKG

A

cardiac tamponade

this is electrical alternans

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63
Q

undulating baseline, no p-waves, irregular R-R in pt who is hyperthyroid, dizziness or CHF with valve dz

A

A Fib

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64
Q

nml PR interval

A

<0.2 ms which is 5 small boxes

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65
Q

what is a Q wave

A

initial downward deflection

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66
Q

Tx A Fib

A

beta blockers
digoxin
ca-channel blockers (verapamil and diltiazem)
cardioversion

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67
Q

what drugs use to cardiovert afib?

A

IV procainamide 1st line

sotalol or amiodarome

68
Q

when do you anticoagulate before cardioversion in pts with A Fib?

A

if A Fib > 24 hrs, anticoagulate with warfarin for 3 weeks to prevent embolization during procedure

69
Q

How determine if a pt with A Fib needs anticoagulation?

A 
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
Q

why can medically slowing A flutter be dangerous?

A

can increase nodal conduction and result in an increased ventricular rate

71
Q

Tx for A Flutter?

A

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
Q

Who typically gets MFAT?

A

COPDers

73
Q

Tx for MFAT?

A

verapamil, also treat underlying condition

74
Q

Tx for SVT?

A

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
Q

sustained v tach definition

A

> 30 seconds

76
Q

tx v tach

A

if hypotensive and no pulse –> defibrillate and treat as v fib
asx and not hypotensive–> amiodarone or lidocaine that can convert rhythm

77
Q

V fib tx

A

electric countershock (second line is amiodarone or lidocaine)

78
Q

Main sx of L sided CHF

A

exertional dyspnea, orthopnea and paroxsysmal nocturnal dyspnea, S3 gallop

79
Q

Sx of R sided CHF

A

JVD, depdendent edema, hepatic congestion with transaminitis, fatigue, weight loss, cyanosis

80
Q

Tx of CHF

A

ACEi or ARB
beta blocker
diuretics (loop or K sparing)
**if can’t do ACE do a combo of hydral and isosorbide dinitrate

81
Q

when do you NOT start Beta blockers in a CHF patient?

A

when they are in active failure because that can worsen failure

82
Q

Digoxin effect in CHF?

A

decreases hospitalizations and improves sx

83
Q

Why be wary of giving loop diuretic to a pt on digoxin?

A

because in presence of hypokalemia, digoxin can reach toxic levels

84
Q

Sx of Digoxin toxicity?

A

SVT with AV block and yellow vision

85
Q

How treat digoxin toxicity?

A

Fab fragments, correct underlying K deficit

86
Q

Sx of restrictive cardiomyopathy

A

pulmonary HTN, S4, decreased QRS voltage due to diastolic dz

87
Q

causes of dilated cardiomyopathy

A

ischemic
infectious: Chagas, Coxsackie, HIV
metabolic
drugs (alcohol, doxorubicin, AZT)

88
Q

Causes of restrictive cardiomyopathy

A 
Amyloidosis
scleroderma
hemochromatosis
glycogen storage dz
sarcoidosis
89
Q

tx dilated cardiomyopathy

A

stop offending agent

tx ~ CHF

90
Q

tx hypertrophic CHF

A

implantable defibrillator to prevent sudden death from arrhythmia

91
Q

Tx restrictive cardiomyopathy

A

tx underlying dz if possible

92
Q

HTN urgency criteria

A

> 200/110 without evidence of end-organ damage

93
Q

Tx HTN urgency

A

BP meds to slowly reduce BP over days, doesn’t need hospital

94
Q

HTN emergency criteria

A

severe HTN with evidence of end-organ compromise (encephalopathy, renal failure, CHF)–> AMS, papilledema, focal neuro sx, chest pain, MAHA)

95
Q

Tx HTN emergency?

A

IV drip of nitroprusside or nitroglycerin do NOT lower BP by >25% in first hour or pt may stroke

96
Q

Causes of 2o HTN? Cardio? Renal? Endocrine? Drug

A

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
Q

1st line HTN drug if s/p MI

A

BB and ACE

98
Q

HTn drug if osteoporotic

A

thiazide (decrease Ca excretion)

99
Q

HTN drug if prostatic

A

alpha blockers: tx for HTN and BPH

100
Q

HTN drug if pregnant

A

alpha-methyldopa

101
Q

when use Minoxidil for HTN

A

only if severe and refractory

have to combine with BB to prevent reflex tachycardia and diuretic to counteract edema

102
Q

when use CLonidine for HTN

A

refractory HTN in renal pts or those in withdrawal

103
Q

contraindication to ACE

A

pregnancy (teratogen), RAS (causes acute renal failure), creatinine >1.5

104
Q

contraindication to K-sparing diuretics

A

creatinine >1.5

105
Q

contraindication to diuretics

A

gout (can cause hyperuricemia)

106
Q

contraindication to diltiazem or verapamil

A

CHF (depresses contractility)

107
Q

late systolic murmur with a midsystolic click

A

MVP

108
Q

What can cause MR?

A 
severe MVP
rheumatic fever
papillarly muscle dysfunction (often 2/2 MI)
endocarditis
Marfan's
109
Q

Tx MR

A

ACEi
vasodialtors
diuretics
consider surgery in severe disease

110
Q

MS causes

A

usually 2/2 prior rheumatic fever

111
Q

Sx of MS

A 
dyspnea 
orthopnea
hemoptysis
pulm edema
A Fib
112
Q

Tx MS

A

beta blocker (slow HR to allow flow across valve)
digitalis
anticoagulants to prevent embolus
surgical valve replacement for uncontrollable dz

113
Q

AR causes

A 
endocarditis
rheumatic fever
ventricular septal defects
congenital bicuspid aorta
3o syphilis
aortic dissection
Marfan's
trauma
114
Q

Water Hammar pulse

A

wide pulse pressure seen in AR

115
Q

Traube’s sign

A

pistol shot bruit over femoral pulse in AR

116
Q

Corrigan’s pulse

A

unusually large carotid pulsations

117
Q

Quincke’s sign

A

pulsatile blanching and reddening of fingernails upon light pressure

118
Q

de Musset’s sign

A

head bobbing caused by carotid pulsations in AR

119
Q

Muller’s sign

A

pulsatile bobbing of the uvula in AR

120
Q

Duroziez’s sign

A

to and fro murmur over femoral artery heard best with mild pressure applied to artery in AR

121
Q

diastolic rumble and opening snap

A

MS

122
Q

how elicit MVP

A

valsalva–> click earlier in systole, prolonged murmur

123
Q

high pitched apical blowing holosystolic murmur radiating to axilla

A

MR

124
Q

diastolic rumble

A

TS

125
Q

murmur louder with inspiration

A

TS

126
Q

pulsus parvus et tardus

A

AS

peripheral pulses are weak and late comapred to heart sounds, systolic thrill second interspace

127
Q

blowing early diastolic murmur

A

AR

128
Q

apical diastolic rumble with no opening snap

A

AR

129
Q

Tx for AR

A

decrease afterload wtih ACEi or vasodilators

consiser valve replacement if refractory to drugs or fulminant

130
Q

causes of AS

A

congenital
rheumatic fever
mild degenerative calcs = AS that is a normal part of aging

131
Q

Sx of AS

A

syncope, angina, exertional dyspnea

132
Q

what meds do you want to be careful with in patients with AS

A

beta blockers, vasodilators and ACEi becasue the peripheral vasculature is maximally constricted to maintain BP so these agents can push pts into shock

133
Q

what is hypertrophic cardiomyopathy

A

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
Q

diastolic rumble, increasingly loud with inspiration

A

tricuspid stenosis

135
Q

holosystolic murmur louder with inspiration, jugular and hepatic pulsations

A

tricuspid regurgitation

136
Q

what adults get pulmonary stenosis

A

carcinoid syndrome

137
Q

Graham Steel murmur

A

diastolic murmur at the L sternal border, mimicks AR murmur

138
Q

Tx for Tricuspid stenosis or pulm stenosis

A

balloon valvuloplasty, surgery is rare

139
Q

MCC endocarditis

A

S. aureus

140
Q

Subacute endocarditis bugs

A 
insidious onset, sx less severe
strep viridans
strep
enterococcus
HACEK
141
Q

what causes marantic endocarditis?

A

CA seeding of heart valves during metastasis, poor px, mlaignant emboli can cause cerebral infarcts

142
Q

MCC of culture neg endocarditis

A

Abx tx before drawing blood cultures

OR: Q fever, Whipple’s dz, Bartonella

143
Q

prosthetic valve endocarditis bug?

A

staph aureus

144
Q

Sx of endocarditis

A

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
Q

tx for endocarditis

A

-prolonged Abx 4-6wks required (2wks if uncomplicated s viridans if give aminoglycosdes with beta lactams)

146
Q

empiric tx endocarditis

A
  • vancomycin for MRSA
  • oxacillin for MSSA
  • third gen cephalosporin for strep species
147
Q

criteria for surgery for endocarditis

A 
valve ring abscess
CHF from dysfunctional valve
multiple systemic emboli after Abx
difficult to treat bug 
vegetation >1cm
148
Q

Rheumatic Fever/Heart Dz: who?

A

5-15yo patients after group A strep infxn

149
Q

Rheumatic Fever/Heart Dz: dx

A

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
Q

Jones minor criteria

A

fever, increased ESR, arthralgia, long EKG PR interval

151
Q

Rheumatic Fever/Heart Dz: Tx?

A

PCN

152
Q

Dukes Major criteria

A

1 blood cx growing common organisms

2 positive echo

153
Q

Dukes Minor criteria

A
  1. predisposing condition
  2. fever >38
  3. embolic dz
  4. immunologic phenomenon
  5. blood cx pos only 1 bottle or rare organism
154
Q

What counts as pos Dukes criteria?

A

2 major or 1 maj and 3 minor or 5 minor

155
Q

Midsystolic ejection murmur ddx

A

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
Q

Late systolic murmur ddx

A

AS: worse dz later peak
MVP: apical murmur
HTC: murmur louder with valsalva

157
Q

Holosystolic murmur ddx

A

MR: radiates to axilla
V-S defect: diffuse across precordium
TR: louder with inspiration

158
Q

Early diastolic murmur

A

AR: blowing aortic murmur
PR: Graham Steell murmur

159
Q

Mid Diastolic murmur ddx

A

MS: opening snap, no change with inspiration
AR: apical, Austin flint murmur
As defect: fixed split S2
TS: louder with inspiration

160
Q

Continuous murmur ddx

A

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
Q

Holosystolic murmur with late diastolic rumble in kids

A

VSD

162
Q

Rumblind diastolic murmur with an opening snap, LAE and A-Fib

A

MS

163
Q

Patient with SOB, next step

A

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
Q

young pt with SOB

A

could be primary pulm HTN, want R heart cath

165
Q

pulm HTN: what will wedge pressure be?

A

normal!

166
Q

Reversible causes of CHF?

A

alcohol for dilated

hemachromatosis for restrictive, reversible with iron overload

Medicine (8 decks)

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