Ch_1 - Cardiology Flashcards
1
Q
Starting with III. ARRHYTHMIAS
A
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2
Q
The most important issue for anyone admitted with an arrhythmia is ….?
A
…hemodynamic stability
3
Q
What is hemodynamic instability? [4]
A
- Hypotensive (SBP < 90)
- Dyspnea
- Altered mental status/confusion d/t inadequate perfusion.
- Chest pain
4
Q
Mnemonic for hemodynamic instability
A
things are LOW – low BP, Shortness (low) of breath, low mentation and the oddball – chest pain.
5
Q
What must you, as the medical student, do when you find a pt who is hemodynamically unstable?
A
- Call your resident!
- Recheck BP
- Normal saline is REQUIRED
- Repeat EKG
6
Q
T/F Palpitations are very non-specific
A
True
7
Q
T/F Patient w/ palpitations has no disease at all 50% of the time.
A
True
8
Q
What must you do first if your patient has palpitations?
A
EKG!
9
Q
Pt with palpitations gets an EKG and it is normal. Next step?
A
Outpatient - Holter monitor
Inpatient - Telemetry
10
Q
T/F Pt with palpitations should not be medicated if no objective pathology is found.
A
True
11
Q
What must you exclude in a patient with palpitations? [3]
A
- Thyroid disease
- Alcohol excess (can cause transient episodes of afib)
- Excessive caffeine intake
12
Q
T/F The testing and treatment are essentially the same for a-fib and a-flutter
A
True
13
Q
What is the classic presentation of a pt with afib/aflutter? [5]
A
- Palpitations of fluttering of the chest
- Lightheaded
- “Racing” heart
- LOC is rare, but possible
- Chest pain in SOME.
14
Q
T/F loss of consciousness is possible with atrial fibrillation.
A
True, but it is rare.
15
Q
Your patient has atrial fibrillation. What questions of the patient would your resident/attending most likely ask you in regards to the afib? [6]
A
Basically, their PMH and diagnostic studies.
- Hypertension (most common)
- CHF or cardiomyopathy of any kind
- Thyroid dz
- Alcohol or cocaine use
- Rheumatic fever, particularly of immigrants
- Previous EKG/Holter/ECHO
16
Q
What is the most important feature of a-fib on physical exam?
A
irregularly irregular rhythm.
17
Q
What is a wrong way to measure heart rate in patient with afib?
A
By palpating the radial pulse.
18
Q
Why is palpating the radial pulse a bad way to measure heart rate in afib patient?
A
All beats are not transmitted sufficiently and may not be felt at the radial pulse b/c the heart is only partially full during a number of beats.
19
Q
What SBP is necessary to feel a radial pulse?
A
SBP > 90 mm Hg. Weak contractions will not transmit.
20
Q
What does an EKG show for afib? [3]
A
- absent P waves
- QRS < 100 msec
- Irregularly irregular rhythm based on RR intervals.
May also see fibrillatory waves.
21
Q
For what patients would a Holter monitor be used?
A
outpatients
22
Q
For what patients would telemetry be used?
A
inpatients
23
Q
Afib pts would get CK-MB and/or troponin ordered for who?
A
patients with acute episodes of rapid rate.
24
Q
Afib pts would get ECHO when?
A
EVERYONE, if not done in last 6 months.
25
Why do an ECHO on afib pt? [2]
1. Detect valve dz (may have led to afib)
| 2. Look for clots (if present --> anticoagulate)
26
T/F Valvular disease that leads to afib/aflutter needs warfarin in many cases
True
27
Would you do a stress test in an afib pt?
Maybe. They are sometimes useful.
28
An atrial arrhythmia is generally caused by...
...dilated atrium.
29
T/F Ischemia is a frequent cause of atrial arrythmias
False, the cause is generally dilation (eg, volume expansion from heart failure causes dilation)
30
What is the first step in the management of afib/aflutter?
slowing the RATE.
31
What is the heart rate goal in afib/aflutter?
HR< 100-110/min
32
What are the 2 best therapies for afib/aflutter?
1. Metoprolol: 5 mg IV q5 minutes for 3 doses. Then start PO 50 mg bid. Max 200 bid.
2. Diltiazem: 0.25 mg/kg with a second IV dose of 0.35 mg/kg. Then start PO 30 mg qid. Max 120 mg qid.
33
How long does it usually take for Metoprolol and Diltiazem to control the rate?
Within 30 min.
34
If one of these (Metoprolol, Diltiazem) doesn't work and SBP is >90-100 mm Hg, you can do what?
add the other med (ie, if Metoprolol was given alone and BP is over 90, then you can add diltiazem).
35
What is the brand name for metoprolol?
Lopressor
36
What is the brand name for diltiazem?
Cardizem
37
If SBP is low or borderline (ie, < 90), what drug can be used to control the rate in an afib/aflutter pt?
Digoxin
38
Why is digoxin not the first choice in controlling the rate in stable afib/aflutter pts?
b/c it's not good in controlling the HR on exertion.
39
T/F In hospital settings (ie, controlled environment), digoxin is very useful in controlling the rate when afib/aflutter is rapid and BP is low.
True
40
T/F Digoxin is faster than CCBs or BBs in controlling heart rate
False, it is slower acting.
41
T/F Digoxin can raise the BP when the rate of an afib/aflutter pt is controlled.
True! Probably b/c it increases contractility.
42
Dose of digoxin for afib/aflutter pts who have SBP < 90 mm Hg.
0.25 mg IV q 2 hours. PO q 6 hours.
43
Patients with afib/aflutter with SBP< 90 can get digoxin to control the HR. Most pts can be controlled with how many mg?
1-1.15 mg (Dose: 0.25 mg IV q 2 hours) - so in about 8 hours. Notice how this is much slower than with CCB or BB (where pts are controlled within 30 min).
44
What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?
200 bid
45
What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?
120 qid
46
200 bid (Jeopardy)
What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?
47
120 qid
What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?
48
What are other meds in addition to Metoprolol/Diltiazem/Digoxin that can be used for rate control of rapid atrial arrhythmias?
1. CCB: Verapamil
2. BBs: Esmolol (B1), Propranolol (B1, B2), Atenolol (B1)
note: Metoprolol is also B1 blocker.
49
T/F Afib/aflutter pt - Routine cardioversion to sinus RHYTHM is correct.
False, it is NOT correct, routinely.
50
T/F It is correct to slow the RATE with BB, CCB, and occasionally with digoxin.
True
51
When can you urgently cardiovert an afib/aflutter patient?
hemodynamically unstable pt.
52
What are the 2 ways to cardiovert patients into sinus rhythm?
chemically with drugs and electric shock
53
Why would chemical cardioversion with drugs like amiodarone, procainamide, propafenone, or dofetilide not done for afib/aflutter pts?
Most pts will not stay in sinus rhythm with the meds. Also, these meds can cause arrhythmias such as Torsades de pointes, especially with dofetilide and ibutilide.
54
The AFFIRM trial showed what?
AFFIRM = Atrial Fibrillation Follow-up Investigation of Rhythm Management
showed that RATE CONTROL is superior to rhythm control in treatment of afib.
55
Prior to electrically cardioverting a hemodynamically stable afib pt, what must you do?
an ECHO (usually TTE and then TEE if TTE is negative) to look for clots. Shocking with a clot present may cause emboli.
56
Patient with afib has a TEE positive for a clot in the heart. Next best step?
Anticoagulation with warfarin for at least 3-4 weeks before cardioversion and 4 weeks after cardioversion.
If TEE was negative, start IV heparin and perform CV within 24 hrs. Post-CV anticoagulation for 4 weeks still required.
57
When is cardioversion performed for afib?
After rate control if patient is YOUNG and has an otherwise anatomically normal heart.
58
T/F Afib patient with dilated left atrium or significant valve dz is unlikely to stay in sinus rhythm even after cardioversion.
True.
59
When is anticoagulation NOT indicated for an afib patient?
If the afib is "new" -- ie, started < 48 hours ago.
60
If there is a significant risk for stroke in an afib patient, what should the pt get?
Anticoagulation therapy (eg, warfarin)
61
How do we quantify risk for stroke in afib pt to know whether pt should receive anticoagulation therapy?
CHADS2 score
62
What does CHADS2 stand for?
```
C - dilated Cardiomyopathy
H - HTN
A - old Age (>75)
D - DM
S - prior Stroke or TIA is clear indication
```
63
When CHADS score is 0-1, next step?
ASA or
ASA and Plavix (Clopidogrel)
Note: this is controversial -- ask attending
64
CHADS 2+
anticoagulate with Warfarin, Dabigatran, or Rivaroxaban.
65
What lab parameter must be monitored with warfarin use?
INR -- keep b/w 2-3 -- problematic and takes several days to achieve.
66
Is there a need to use heparin to bridge to warfarin for afib patients?
Depends:
| If clot is present, then yes. But usually/otherwise, not needed. Why? b/c heparin causes bleeding and thrombocytopenia.
67
T/F Rivaroxaban and Dabigatran don't have to be monitored by INR
True, and that's awesome for us and the patient!
68
T/F Rivaroxaban and Dabigatran are like warfarin in that they take several days to become therapeutic
False, they are therapeutic on the same day you start.
69
T/F Rivaroxaban and Dabigatran cannot be reversed.
True. Warfarin can with PCC, FFP, Vit K...
70
What is the eficacy of rivaroxaban and dabigatran as compared with warfarin?
at least as effective or even better.
71
In afib, what is the ATRIAL rate (about)?
~400 bpm
72
In afib, what is the VENTRICULAR rate? why is it lower than the atrial rate?
b/w 75-175 b/c most atrial impulses are blocked by the AVN.
73
What are the causes of Afib?
1. Heart dz (CAD, MI, HTN, mitral valve dz)
2. Pericarditis, pericardial trauma (eg, surgery)
3. Pulmonary dz (including PE)
4. Thyroid dz (hyper/hypo)
5. Systemic illness (eg, sepsis, malignancy, DM)
6. Stress (eg, postop)
7. Excess alcohol ("Holiday heart syndrome")
8. Sick sinus syndrome
9. Pheochromocytoma.
74
Clinical features of afib?
1. Asymtomamtic
2. fatigue, exertional dyspnea
3. palps, dizzy, angina, syncope
4. irregularly irregular pulse
5. blood stasis --> intramural thrombi --> emboli to brain --> TIA or stroke sx
75
Tx: Acute Afib in hemodynamically unstable pt
Immediate electrical cardioversion to sinus rhythm.
76
Three main goals of afib/aflutter management
1. control ventricular rate.
2. restore NSR.
3. Assess need for anticoagulation.
77
Rate control in afib goal?
60-100 bpm
78
What drug is preferred for rate control?
BB > CCB
79
If LV systolic dysfxn is present, consider what drugs?
Digoxin or Amiodarone (useful in rhythm control)
80
After rate control of afib, what is next step?
convert to sinus rhythm via cardioversion if patient is a candidate for cardioversion.
81
What are the candidates for cardioversion? [3]
1. hemodynamically unstable
2. worsening sx
3. first ever case of afib (<48 hrs)
82
What is risk of cerebrovascular accident (CVA) in patient with "lone afib" (ie, absence of cardiovascular risk factors or underlying heart dz)?
1% per year
83
What is risk of cerebrovascular accident (CVA) in patient with afib + underlying heart dz?
4% per year
84
I. INTRODUCTION
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85
Chest pain
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86
How many pts coming into the ED actually have an MI?
<10%
87
What qs must be asked if pt has chest pain?
OLDCARTS
1. When did pain start?
2. Does it get better/worse with change in position or breathing?
3. How long does it last?
4. Did anything make it better or worse? (eg, rest/exertion)
5. What is the "quality" of the pain? (eg, sharp vs. dull, squeezing vs. pinpoint)
6. Radiate?
7. Use any meds?
88
To evaluate for chest pain, consider these 3 things
1. Is pain cardiac?
2. Does pain change with bodily position or respiration?
3. Is there chest wall tenderness?
89
If pain changes with position or respiration or there is chest wall tenderness, what is the percentage that the pain is ischemic?
~5% - very low!
90
T/F "Yes" to pain on exertion (eg, walking or climbing stairs) means the pain is very likely to be ischemic
True
91
T/F "No" to pain on exertion (eg, walking or climbing stairs) means the pain is very unlikely to be ischemic
False, it is inconclusive.
92
If patient has chest pain, should an EKG be done?
Yes!
93
If chest pain is cardiac in nature, what meds should be given?
```
Chewable ASA
Nitroglycerin (NTG)
Statin
BB (metoprolol 25 mg PO bid)
Possibly ACEI
No O2 unless hypoxic.
```
94
T/F In cases of chest pain, you should always get the old EKG
True!
95
EKG shows ST depression. Next step in management?
LMW Heparin
96
EKG shows ST elevation. Next step in management?
Get Cardiology immediately so they can do Angioplasty or thrombolytics.
97
Diabetes can cause what kind of MI?
"Silent" MI (painless)
98
Case #1
Patient has pleuritic chest pain that changes with respiration. Pt has fever, cough, sputum, SOB.
MLDx?
Mx?
MLDx = PNA
Mx: CXR, Oximeter, ABG
99
Case #2
Pt has pleuritic CP. Sharp, SOB, sudden onset.
MLDx?
Mx?
MLDx = Pneumothorax or PE
Mx = CXR, Oximeter, ABG
CTA for PE
100
Case #3
Pt has pleuritic CP. It is positional and is relieved when sitting up.
MLDx?
Mx?
MLDx - Pericarditis
Mx - EKG and NSAIDs.
101
Case #4
Pt has tearing CP that radiates to back. CXR shows wide mediastinum.
MLD?
Mx?
MLDx - Aortic dissection
| Mx - CTA, MRA, TEE
102
Case #5
Pt with chest point tenderness.
MLDx?
Mx?
MLDx = Costochondritis
No test necessary. May use NSAIDs to relieve pain.
103
Case #6
Pt with burning epigastric pain, bad taste in mouth.
MLDx?
Mx?
MLD = GERD
Mx = improves with liquid antacids/PPIs
104
Important things to do when pt is hypotensive (SBP<90): [4]
1. Repeat BP manually. Don't use automatic machine
2. Position pt with feet up and head down.
3. Call resident immediately.
4. Give FLUIDS: bolus of 250-500 ml NS over 15-30 min.
105
T/F Hypotension is the number 1 condition in which correction with fluids is more important than getting a specific diagnosis.
True
106
T/F treat low BP first and diagnose later.
True
107
DDx of hypotension [8]
1. Dehydration
2. Sepsis
3. MI
4. Arrhythmia
5. Drug s/e
6. Orthostasis
7. Anaphylaxis
8. PE
There are many others!
108
Initial clues of dehydration?
High BUN:Creatinine ratio (>15-20:1)
109
Confirm dehydration how?
Low Urine Na+ (500 mOsm/L)
110
Initial clues of sepsis?
Leukocytosis
| Fever
111
Confirm sepsis?
blood cultures
112
Initial clues of MI causing cardiogenic shock?
Rales
S3
JVD on exam
113
Confirming MI/Cardiogenic shock
CXR
ECHO
High BUN
Troponin
114
Initial clues of arrhythmia?
Palpitations
| Syncope
115
Confirm arrhythmia?
EKG
116
What drugs commonly cause/predispose to hypotension?
BB, CCB; confirm with Medication Hx
117
Initial clues of orthostasis?
BP normalizes lying flat
118
How to diagnose orthostasis?
tilt-table test
119
initial clues of anaphylaxis?
Foods (seafood, crab, lobster, milk); insect bite; drug rxn
120
confirm anaphylaxis how?
Allergy Hx
| Elevated Eosinophils
121
initial clues of PE?
sudden SOB
| recent surgery
122
confirm PE with?
CTA
123
pt with hypotension. You want to start an antiplatelet agent. What should you consider prior to starting tx?
Bleeding risk
If pt is currently bleeding, these drugs are CI!
124
What are commonly prescribed anti-platelet agents?
ASA, Clopidogrel, Prasugrel, Ticagrelor.
If pt is currently bleeding, these drugs are CI!
125
pt with hypotension. You want to start heparin or enoxaparin. What should you consider prior to starting tx?
Bleeding risk. If pt is currently bleeding, these drugs are CI!
126
pt with hypotension. You want to start ASA. What should you consider prior to starting tx?
Allergy.
ASA is CI if pt has allergy.
127
pt with hypotension. You want to start BB agent. What should you consider prior to starting tx?
Check for Low BP, severe asthma, COPD.
B1B is not necessarily CI, but should be avoided if possible.
128
pt with hypotension. You want to start NTG. What should you consider prior to starting tx?
pt is hypotensive, NTG is CI!
129
pt w/ hypotension. You want to give them a statin. When should you not do this?
Liver dysfxn, Myositis
130
When should you not give ACEI?
patient has cough
| Hyperkalemic
131
When should you avoid ARB, Spironolactone, Eplerenone?
Hyperkalemia
132
When should you avoid spironolactone?
Gynecomastia, Hyperkalemia
133
Patient has heme-positive brown stool. Can he be given an anti-platelet agent such as ASA, Plavix, Effient, ticagrelor or heparin?
If that's the ONLY finding, then it's OK to give.
134
Intro Part 3: ACS
blank
135
What is the most important part of ACS management?
getting a good History!!!
136
Aren't elevated Troponin and CK-MB and EKG important too?
Yes, but less so than Hx b/c they take 3-4 hours to elevate.
137
T/F Enzymes are usually normal when first test is done, even when ischemic event occurs.
True!
138
If Hx = ACS but EKG =/= ACS, should you treat it as if it's ACS?
YES!
139
T/F ACS = Hx + EKG
True
140
From Hx, what clues tell you that the pain is ischemic?
1. Substernal
2. Pain on exertion
3. Lasts 15-30 min
4. Doesn't change w/ position, respiration, or palpation
5. Dull, squeezing, pressure
141
What are the 3 different types of Acute Coronary Syndromes?
Unstable angina
NSTEMI
STEMI
142
From Hx, what clues tell you the pain is NOT ischemic?
1. Left or right sided
2. Worsens OR improves with position or breathing
3. Sharp (knife like)
4. Stabbing or point-like
5. Few seconds in duration
6. Continuous for hours and hours or 1-2 days
143
What is the worst and most dangerous risk factor for ACS?
Diabetes Mellitus
144
What is the most commonly found risk factor?
HTN
145
What is the relevance of FH in ACS?
only significant if it's PREMATURE in relative (<65 in female)
146
What are the common RFs of ACS?
1. DM
2. HTN
3. Tobacco use
4. Hypercholesterolemia
5. Premature dz in 1st-degree relative (parents, siblings)
147
Why are RFs of ACS important in Mx?
Because if Hx/EKG/Enzymes is equivocal, then RFs are used.
148
PEx of ACS pt?
MCC finding -- Absence of findings.
May find S3 Ventricular gallop and/or S4 atrial gallop, or rales.
149
T/F One EKG is good enough in the assessment of ACS
False! Make sure to do a repeat EKG. Also, make sure to compare to any previous EKGs pt had.
150
What are the different tests for ACS?
1. Troponin
2. CK-MB
3. Mgb
4. Cath
5. BNP
6. Stress test
7. ECHO
8. Telemetry
151
Troponin begins to rise...
at 3-4 hours
152
Max sensitivity to Troponin is at....?
12-18 hours
153
Troponin stays positive for..
1-2 weeks after event
154
Negative first troponin excludes disease?
No! It excludes nothing
155
Positive troponin suggests...
MI
156
False positive troponin increase is seen with?
Renal failure, CHF
157
CK-MB begins to rise...
at 3-4 hours
158
Max Sn for CK-MB?
12-18 hrs
159
CK-MB lasts...
1-2 days
160
Negative first CK-MB excludes...
nothing
161
Positive CK-MB...
suggests MI
162
CK-MB is best test for...
detecting re-infarction
163
Myoglobin rises at...
1-4 hours
164
T/F Myoglobin is very specific for MI
False
165
Mgb can exclude MI...
if negative test at 4 hours
166
If clear Hx of ACS and abnormal EKG, next step is?
Cath. If those 2 are unclear, then stress test.
167
Max medical therapy for ACS pt but pain continues. Next step?
Cath
168
Pt w/ possible ACS has SOB but etiology is unclear. Test?
BNP
169
Normal BNP...
excludes CHF
170
abnormal BNP...
is non-specific
171
When Hx and EKG are not clear, next step?
Stress test
172
What are you looking for in a stress test?
Reversible ischemia is the main thing to look for.
173
If stress test is abnormal, next step?
Cath
174
ECHO looks for?
Wall and valve motion
| Estimates EF
175
Normal wall motion on ECHO...
excludes MI
176
High troponin with normal wall motion means what?
false positive troponin (eg, Renal failure)
177
What is telemetry?
Inpatient continuous EKG monitoring
178
T/F All ACS pts need telemetry.
True
179
When should a stress test NOT be done (although it is algorithmically indicated)?
If patient is in pain!
180
T/F Cath = Angiography
True
181
Which instances of ACS is Cath indicated?
1. STEMI
2. ST depression with persistent CP despite ASA, Plavix, Hep, Lopressor, and Nitrates
3. ST depression with recurrent CP
4. Recurrent episodes of ischemic-type CP with normal EKG
5. Reversible ischemia on stress test.
182
All pts with ACS shouldreceive these meds (6)
1. ASA 2+ tab, each 81 mg
2. Metoprolol 25 mg bid
3. NTG
4. ACEI
5. Statin
6. Morphine during pain.
183
Patient with chest pain + EKG with ST depression or T wave inversion + elevated troponins = ???
NSTEMI
184
(possible) NSTEMI treatment?
```
ASA
Plavix, Prasugrel, or ticagrelor
LMW Hep (eg, Enoxaparin 1mg/kg bid) subQ
Evaluate for Angio (cath)
Place on telemetry or ICU
```
185
Should treatment of possible NSTEMI start before enzyme results return?
YES!
| Hx + EKG = ACS
186
In NSTEMI, where would you most likely expect T-wave inversions?
Inferior leads (II, III, aVF)
187
Clopidogrel must be given to which subset of ACS pts?
all pts undergoing PCI w/ stent placement and those undergoing fibrinolytic tx.
188
Pt with STEMI. Tx?
ASA, plavix (or equivalent - prasugrel, ticagrelor)
| Thrombolytics or Angioplasty for PCI
189
Which medication should not be used in STEMI?
Heparin
190
When cardio is doing an angioplasty stent w/ PCI, what meds may be used?
GpIIb/IIIa inhibitor such as Eptifibatide or abciximab.
191
Define Takotsubo CM
sudden ventricular dysfxn from overwhelming emotions. May stimulate MI w/ anterior wall STEMI
192
When would you know for sure whether a pt has Takotsubo CM or Prinzmetal angina?
after Angio
193
Conditions that can cause ST elevations unrelated to acute MI? [5]
1. Early repolarization (benign)
2. Hyperkalemia
3. Pericarditis
4. CM
5. Prinzmetal's variant angina (spasm causes temporary transmural ischemia?)
194
CCBs may be beneficial in [3]
1. chest pain assoc w/ cocaine abuse
2. Intolerance to BBs (eg, asthma)
3. Variant/Prinzmetal's angina
195
Serious complications of MI? [4]
1. Arrhythmia
2. Wall/valve rupture
3. Hypotension
4. Pericarditis
196
In first 2-3 days after MI, what is the most serious MI complication?
Arrhythmia
197
Management of PVCs?
None, don't treat!
198
Key features of 3rd deg AVB
Bradycardia
| Canon A waves
199
Treatment of 3rd deg AVB?
Atropine first if Sx
| Pacemaker later in all
200
Key features of Sinus Bradycardia
bradycardia w/o canon A waves
201
Treatment of bradycardia
Atropine if Sx!
| Pacemaker only if Sx persist
202
Key features of tamponade/wall rupture?
Sudden loss of pulse, (distended neck veins)
203
Tamponade/wall rupture Tx?
Needle thoracocentesis
| Surgery
204
Key features of RV infarction
Inferior wall MI in Hx, clear lungs, tachycardia
205
Tx of RV infarction
Fluids
206
Valve rupture key features?
new murmur, rales/congestion
207
Tx of valve rupture
Surgery, some need balloon pump
208
Key features of septal rupture
New murmur
| increase in O2 sat on entering RV
209
Tx of septal rupture
Surgery, some need balloon pump
210
Key features of Vfib
loss of pulse
| need EKG
211
Tx of Vfib
Unsynchronized cardioversion
212
What is max HR?
220 - Age = Max HR
213
When doing a stress test, what should the HR be to properly assess heart function via EKG or ECHO?
80-85% of max HR.
214
What is 80% of max HR for 70 y/o patient?
(220 - 70)0.80 = 0.8x150 = 120 bpm
215
If pt has LBBB and you want to do a stress test. What kind is preferred?
Chemical stress test w/ Dipyrimadole thallium or Dobutamine stress ECHO
216
T/F LVH, LBBB, Pacemaker, and Digoxin make EKG reading difficult.
True, so need a stress test.
217
Different types of stress tests?
```
Exercise stress ECHO
Nuclear stress test
Dipyrimadole thallium
Adenosine thaliium
Dobutamine ECHO
TEsts have equal SN and Sp
```
218
Define "reversible" defect on Angio
defect in perfusion with exercise, but not seen at rest.
219
Why do an Angio?
To determine who should undergo bypass surgery.
220
Stenosis of __% in a vessel is "significant"
>70%
221
Management of 1- or 2-vessel dz
medical management and possible angioplasty, which may decrease Sx compared w/ meds, but there is no clear mortality benefit w/ the use of angioplasty in chronic stable angina.
222
Management of 3-vessel dz w/ LV dysfxn or Left Main Coronary dz
CABG surgery
223
Which drugs lower mortality in CAD?
ASA +/- Clopidogrel, Prasugrel, Ticagrelor
BB (Metoprolol, Nebivolol)
Statins to LDL goal < 100 mg/dL
ACEI if EF < 40%
224
Pt w/ CAD. Give statin. What is LDL goal?
<100 mg/dL
225
Pt w/ CAD. Give ACEI when?
If EF < 40%
226
Pt w/ chronic stable angina. Tx?
ASA alone
227
Pt w/ chronic stable angina with persistent pain.
ASA + long-acting NTG
228
What is ranolazine?
Na+ channel blocker used in refractory angina.
229
What drug is used in refractory angina?
Ranolazine (Na channel blocker)
230
CAD + LDL > 100 == ??
Statin
231
When is a CAD pt given statins
everyone with CAD (in real life) is given Statins
232
Most common a/e of statins?
1) increased LFTs (AST/ALT) in 2-3% of patients
| 2) Myositis in <1% of pts.
233
Pt on statin presents with LFTs 3-5x upper limit of normal. Next step?
Stop the med.
234
What are the other circustances when you want to get an LDL < 100 mg/dL (i.e., start a statin)
1) PAD
2) Diabetes
3) Aortic disease
4) Carotid disease
235
II. CHF
blank
236
What are the MC precipitants of acute pulmonary edema? [7]
1. Ischemia
2. Any arrhythmia
3. Non-adherence
4. Infection
5. Salty food diet
6. Iatrogenic fluid overload
7. Hypertensive crisis
237
CP of acute pulmonary edema?
sudden onset of SOB worse when supine and relieved when sitting upright
238
Physical exam of Acute pulm edema?
1. Rales
2. S3 ventricular gallop
3. JVD
4. Peripheral edema
5. Tachycardia
6. Diaphoresis and Nausea
239
If sx/sy of acute pulm edema are present, what is next best step?
1. OXYGEN
2. Elevate head of bed
3. Call resident
4. Attach Oximeter
5. Make sure ABG is done.
6. Connect to telemetry
240
Diagnostic tests for Acute Pulmonary Edema?
1. EKG -- to r/o arrhythmia and ischemia
2. CXR - congestion/vascular fluid overload, effusions, cardiomegaly
3. BNP
4. Troponin/CK-MB
241
How can BNP be useful in pt w/ acute pulm edema?
If Hx/Px and CXR are not clear, BNP can help diagnose CHF b/c normal BNP will exclude APE.
242
Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
Rales
Auscultation
CXR
BNP
243
Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
S3 ventricular gallop
EKG changes?
CXR
BNP
Troponin/CKMB
244
Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
JVD, peripheral edema
CXR?
| BNP
245
BUN:Creatinine ratio in CHF
CHF --> pre-renal azotemia --> increase reabsorption --> increase BUN:Cr (>20:1)
246
Na content in plasma in CHF
Hyponatremia
247
CHF pt with Hypokalemia and metabolic alkalosis. Why?
chronic Diuretic use
| Lasix is not K+ sparing and contraction alkalosis occurs with depleted volume.
248
T/F ECHO is needed in the acute management of acute pulmonary edema
False. Initial therapy is not altered whether CHF is systolic or diastolic.
249
Treatment of APE?
1. O2, elevated head of bed
2. LASIX IV q 20-30 min until urine is produced
3. Strict I/O monitoring to make sure there's response
4. NTG (paste, IV, or sublingual)
5. Morphine 2-4 mg IV
250
If no furosemide was previously used, how should it be given?
Start with 10 mg, then 20 mg, then 40 mg, then 80 mg via IV push.
251
If furosemide was previously used, how should it be given?
Start with usual IV dose. Ex: If pt had taken 40 mg bid, then give 40 mg IV, then 80 mg, then 160 mg q 20-30 min until urine is produced.
252
Refractory cases of pulm edema are treated with?
Hemodialysis
253
Who should be sent to the ICU?
1. Those where O2, diuretics, nitrates, and morphine don't control the Dyspnea
2. Those w/ SBP < 90 mmHG, making diuretics difficult
3. Acute MI or ventricular arrhythmia pts.
254
T/F Acutely ill patients should be given BBs
False
255
What are the positive inotropes used in the ICU for pts in CHF?
Dobutamine, Imamrinone, Milrinone.
256
If CHF pt is sick enough for the ICU, who should you get?
Cardiology
257
T/F CPAP/BiPAP might be necessary in CHF pt.
True
258
What is Nesiritide?
IV Atrial Natriuretic peptide
259
What is the IV ANP drug called?
Nesiritide
260
Pt with CHF is in ICU. He was given O2, diuretics, nitrates, morphine, dobutamine, and put on CPAP. Still hypoxic. Next best step?
Intubate!
261
In outpatient clinic, what clinical signs point you to pulmonary edema?
Dyspnea, Peripheral edema, and Rales.
There's no EKG, CXR, ABG!
262
Pt with CHF needs which diagnostic test after acute phase is over?
ECHO
263
ECHO tells us about...
EF
Systolic vs Diastolic dysfxn
Valvular dysfxn
264
Pt with CHF. What important findings can you look for on EKG?
1. Q waves - sx of old infarct
2. LVH: S wave in V1 and R wave in V5 > 35 mm
3. Afib or aflutter
265
CHF therapy depends on what?
Systolic vs. Diastolic failure (determine by ECHO)
266
T/F Systolic dysfxn is sometimes used interchangeably w/ Dilated CM
T
267
What is systolic dysfxn?
Heart can relax (diastole) but cannot contract well.
| Diastolic failure is opposite.
268
What are the treatment options for Systolic dysfxn?
1. ACEI
2. BB
3. Spironolactone
4. Diuretics and Digoxin
5. Biventricular Pacemaker
6. Automatic implantable cardioverter defibrillator (AICD)
7. Hydralazine + Nitrates
269
T/F All ACEI are equal in efficacy
True
270
T/F ARBs are an alternative to ACEI and the #1 use for ARB is if pt has cough with ACEI
True
271
What are the commonly prescribed BBs for CHF (Systolic dysfxn)
Metoprolol, Carvedilol, Bisoprolol
272
When is spironolactone recommended?
used only in advanced stage Class III or IV CHF.
273
What is Class III/IV CHF?
Sx w/ minimum exertion or at rest
274
a/e of Spironolactone?
Gynecomastia
| Hyperkalemia (K+ sparing)
275
Which aldosterone antagonist does not cause gynecomastia?
Eplerenone -- it still can, but less so than Spironolactone
276
T/F Diuretics have a mortality benefit
False, but are useful in pts w/ fluid overload
277
T/F Digoxin has a mortality benefit
False, but decreases sx in those ill despite other treatments
278
How is a biventricular pacemaker useful?
lowers mortality if there's Systolic dysfxn and there's a QRS>120 ms. The BVP "resynchronizes" the ventricles so they beat more efficiently together.
279
When is an AICD appropriate?
It lowers mortality in those w/ Persistently low EF despite maximal medical therapy.
280
https://icd.ices.on.ca/Portals/0/images/cvml_0077a_ICD-res1.jpg
ICD
281
http://my.clevelandclinic.org/PublishingImages/heart/bivpm.jpg
Biventricular pacemaker
282
Pt is unable to take ACEI or ARB. Persistent hyperkalemia is the reason. Next best step to control systolic dysfxn?
Hydralazine and Nitrates.
283
Are there any medications or devices proven to lower mortality in diastolic dysfunction pts?
No
284
What is the standard of care for Diastolic dysfunction?
Beta blockers: Metoprolol, Carvedilol, Bisoprolol
| Diuretics
285
T/F ACEI are beneficial in Diastolic dysfxn pts
False
286
T/F Hypertensive Crisis = hypertensive emergency
T
287
Define Hypertensive emergency
severe HTN w/ end-organ damage
288
Sx of hypertensive emergency
End-organ damage sx:
1. CNS: Confusion
2. Heart: CP
3. Lung: SOB, CHF
4. Eye: blurry vision
5. Renal insufficiency
289
Managing htn emergency
```
IV anti-HTN meds:
Labetalol (a1, B1, B2- blocker)
Enalaprilat
OR
Nitroprusside
```
290
Pt seen in ED with HTN emergency. He is given Enalaprilat. Later patient says he feels dizzy and gets a stroke. How could this have been avoided?
Make sure not to lower BP > 25% in first few hours to prevent a stroke.
291
Define Cardiomyopathy
any cardiac muscular disorder that impairs the function of either contraction or relaxation.
292
T/F In cardiomyopathy, EF is always low
False, it can be high or low
293
T/F In most cases of CM the patient feels SOB, which worsens on exertion and improves w/ rest. Rales and peripheral edema can be present,
True and true
294
CM pt will show what on CXR ?
congestion or pulmonary vascular redistribution
295
What 2 tests are technically more accurate for the EF?
1. Nuclear ventriculogram (MUGA)
2. Left heart cath
Neither test is routinely done, but they are more accurate than ECHO.
296
Systolic dysfxn = ___1___ CM = relaxes _2_ / contraction _3_
1. Dilated
2. relaxes OK
3. contraction Poor
297
Diastolic dysfxn = ___1___ CM = relaxes _2_ / contraction _3_
1. Hypertrophic
2, Poorly
3. Well
298
define restrictive Cm
neither contracts or relaxes well.
299
Causes of restrictive CM
1. Sarcoidosis
2. Amyloidosis
3. Hemochromatosis
4. Endomyocardial Fibrosis
5. Cancer.
300
Treatment of Dilated CM
Same as Tx for systolic dysfxn:
| BB, ACEI/ARB (Hydralazine+Nitrates), Spironolactone/Eplerenone, Diuretics
301
Treatment of Hypertrophic CM
Same Tx as Diastolic dysfxn
BB
Diuretics
302
Tx of Restrictive CM
Correct underlying cause
303
What is HOCM?
Hypertrophic Obstructive CM:
Idiopathic/genetic w/ an abnormal shape to the septum of the heart that leads to a physical obstruction to the outflow of blood.
304
How is HOCM and hypertrophic CM similar from a treatment standpoint?
Beta-blockers
305
What increases the outflow tract obstruction in HOCM?
Anything that EMPTIES the ventricle
306
What clinical symptoms is HOCM assoc with?
Syncope and rarely sudden cardiac death in healthy young athletes.
307
What will you be asked on rounds in regards to HOCM?
1. Episodes of lightheaded ness
2. LOC
3. CP
4. Previous studies (EKG, ECHO).
308
Random: 25 year old female with extensive smoking history with chest pain possibly due to CAD. Next best step?
Pregnancy test before any invasive procedures like a Cath!
309
Physical findings of HOCM?
1. S4 atrial gallop
2. Systolic c-d murmur at LLSB
3. Murmur worse/louder with decreased preload (valsalva, standing)
4. Murmur better/softer with increased preload (squatting, leg raise)
310
What is the initial test for HOCM?
ECHO
311
What would EKG show for HOCM?
Left axis deviation, pseudo Q waves in V1-V3, ventricular arrhythmias.
312
What is the most accurate test for HOCM?
Left heart catheterization
313
Treatment of HOCM
Beta blocker - Metoprolol - FIRST THERAPY
Implantable defibrillator (for syncope prevention).
314
Which medication/state can worsen HOCM?
Diuretics (deplete volume)
ACEI/ARBs
Dehydration
Digoxin
315
SVT clinical presentation?
Sudden onset of palps/racing heart that may lead to SOB.
316
What is the approximate HR in SVT?
160/min
317
What are the specific physical exam findings of SVT
There are none.
318
T/F ischemia is a common cause of SVT
False, if you think a pt has an acute MI and you think that's causing palps, question whether they have an SVT.
319
SVT is often caused by...
An abnormal conduction pathway around the AVN
320
What are the important clinical characteristics to consider for SVT?
Palpitations
Lightheadedness
Speed of onset of symptoms
321
Diagnose SVT with?
EKG
322
SVT shows what on EKG?
Rapid, narrow complex (<100 msec) tachycardia, usually around 160 bpm. No P waves, no fibrillation waves, no flutter waves.
323
What unit should SVT pts be in?
Telemetry unit
324
Why should an ECHO be done for SVT?
To r/o other pathology. Nothing specific for SVT.
325
Are CK-MB and Troponin useful in SVT?
No, but they always seem to be done.
326
Tx of SVT
1. Vagal maneuvers: carotid massage, valsalva, gagging, and diving reflex
2. ADENOSINE
3. Metoprolol, or Diltiazem
4. Electrical cardioversion (for rare cases of hemodynamically unstable or non-responsive to other therapies).
327
How does WPW present on EKG?
SVT
SVT alternating w/ Vtach
Delta wave found incidentally
328
What is a delta wave?
sign of conduction around AV node -- early depolorization of ventricles.
329
How does WPW present clinically?
Palpitations
Lightheaded
Occasionally w/ Syncope
330
What is the PR interval in WPW?
SHORT (<0.12 s) d/t accessory conduction.
331
On rounds, when going over the WPW pt, what will you be asked?
Previous EKG
Worsening sx or arrhythmia w/ use of Digoxin/CCB/BB
Previous cath or EP studies
332
What is the most accurate test for WPW?
Electrophysiology (EP) study - cath into heart tests cardiac circuits.
333
Treatment of WPW?
1. Procainamide (DOC), Amiodarone, Flecainide, or Sotalol [use for SVT occurring at the moment]
2. Radiofrequency catheter Ablation (permanent, long-term)
334
T/F Most WPW pts are not having an arrhythmia at present moment.
True
335
If WPW patient is not having an arrhythmia at the present moment, what is next best step?
Refer to EP study to identify the abnormal accessory conduction tract. Eliminate the tract immediately w/ ablation.
336
Which drugs must be avoided in WPW?
AV nodal blocking agents - BB, CCB, Digoxin b/c these may accelerate the current going through the accessory path.
337
Why does current go faster to the ventricles through the accessory path as opposed to the normal AV node path?
B/c there's no AVN pause component!
338
Which arrhythmia is associated w/ COPD or severe lung dz?
MAT (Multifocal Atrial Tachycardia)
339
MAT on EKG?
At least 3 different P-wave morphologies, with variable PR and RR intervals and normal QRS width.
340
Treatment of MAT?
Same as Afib/aflutter, but may want to avoid BB (b/c of COPD association).
May also Oxygenate and ventilate.
341
Would you use electrical cardioversion for MAT?
No, it's ineffective.
342
All pts with Ventricular Fibrillation need to have...
CPR started immediately followed by an Unsynchronized cardioversion.
343
CPR =??
chest compressions at 100/min and respirations. 2 Ventilations per 30 compressions (30:2). No response --> Epi or Vasopressin and shock again while doing CPR.
344
Vfib = __ + __ = Vtach w/o a pulse
CPR + electric unsynchronized shock
345
T/F Lidocaine > Amiodarone for ACLS
False. opposite
346
What is the sequential plan for V-fib?
1. CPR
2. Unsynchronized shock
3. CPR
4. Epi (or ADH)
5. CPR
6. Shock again 2 min after 1st shock
7. CPR
8. Amiodarone (or lidocaine)
347
T/F V-tach is always considered an extreme emergency
True!
348
Any sustained Vtach needs the following rapid response:
1. Call resident
2. Check BP
3. If SBP < 90, give bolus of NS and activate "code" for emergency response (call for help)
4. Hook up continuous EKG
5. Check for CP, cnfusion, or SOB
6. Get a cardioverter/defibrillator INTO THE ROOM just in case.
349
Normal QRS --??
<100 ms
350
Wide QRS in Vtach --??
>120 ms and reproducibly regular.
351
What is sustained Vtach?
30 sec or more of VTach
352
What is non-sustained Vtach?
<30 sec of Vtach pattern
353
Which pts commonly get runs of nonsustained Vtach?
ICU
telemetry
ED w/ limited hemodynamic effects
354
What are the 3 most important issues of Vtach on the wards?
1. Is BP normal (SBP>90-100)?
2. Are brain, heart, and lungs perfused?
3. Is the VT continuing?
355
What is the most common cause of Vtach?
Myocardial ischemia -- so always check for Hx of MI!
356
Vtach patient should get what checked?
1. CK-MB, Troponin
2. e- levels (K, Mg, Ca)
3. Oxygen
4. Medications pt is on
5. EKG
357
Any anti-arrhythmic except which class can cause arrhythmia?
Beta-blockers
358
Low levels of which electrolytes can cause Vtach?
Low Mg
| Low Ca
359
Can low O2 cause Vtach?
yes
360
What levels of K+ (generally) can cause vtach?
High or low
361
What illicit drug can cause Vtach?
Cocaine
362
Ventricular tachycardia is possible d/t any CM. Which CM is most commonly associated w/ Vtach?
Dilated CM w/ low EF
363
Unstable pts w/ Vtach need...
immediate SYNCHRONIZED cardioversion to sinus rhythm.
364
Unstable = ?
SBP < 90, AMS, CP, and Dyspnea
365
Stable patients w/ Vtach are treated with...
Mg + Anti-arrhythmic (Amiodarone, Lidocaine, or Procainamide).
366
What is the most important issue with Bradycardia?
hemodynamic Stability
367
If patient has pulse < 60, next step?
EKG for etiology
368
Which bradycardias require no further Tx?
Sinus brady
First degree AV block
Mobits I second degree AV block
IF ASYMPTOMATIC!
369
Mobitz II and 3rd degree treatment?
Pacemaker required even if Asx!
| If acute Sx...Atropine then Pacemaker
370
Each large boc on EKG is how many seconds? milliseconds?
2 sec, 200 ms
371
Over how many boxes will be considered bradycardia?
after 5 boxes. (300 -- 150 -- 100 -- 75 --60...that's 5)
372
Why does pacemaker make it difficult to interpret ischemia?
Wide complex QRS and abnormal T-waves are present w/ pacer spikes
373
Treatment of Unstable Bradycardia of any etiology?
1. Atropine 0.5 -1.0 mg IV immediately (max 3 mg)
2. Transcutaneous pacemaker
3. Permanent Transvenous pm
374
On EKG of atrial pacemaker, there may be 2 spikes. What are they?
The first pacer spike triggers the Atrium.
| The second pacer spike triggers the Ventricle.
375
What is sick sinus syndrome?
AKA "tachy-brady syndrome" - alternating fast and slow HR.
376
If SSS pt has too slow of a rate (eg, pause > 3 s), tx?
Pacemaker
377
If SSS pt has too fast of a rate? Tx?
BB
378
What does the EKG show for Sick sinus syndrome?
Missing P waves, temporary Asystole-like picture, and restarting of P-waves spontaneously.
379
Sx of SSS?
dizzy, confused, syncope, fatigue, CHF
380
80-90% of the mortality with syncope is from ____ etiology?
cardiac and neurologic
381
What are the most dangerous causes of syncope? [6]
1. MI
2. Ventricular arrhythmia
3. Aortic Stenosis
4. HOCM
5. Seizure
6. Brainstem stroke
382
For almost any type of syncope, what is the inpatient evaluation? [5]
1. EKG
2. CK-MB, Troponin
3. Telemetry
4. ECHO
5. O2, Glc, Na, and Ca level
383
T/F In most cases, the cause of syncope will not be found
True
384
For syncope, what is not your job, and what is?
Not your job to find a definite cause, but rather to find something that could be dangerous.
385
HPI and PEx of Syncope must include?
1. Was LOC sudden or gradual?
2. Was recovery sudden or gradual?
3. Any murmurs on exam?
386
Most likely cause of sudden LOC?
Cardiac and neurologic causes (eg, MI, Seizures)
387
Most likely cause of gradual LOC?
Toxi-metabolic causes: low Glc, Hypoxia, Drug OD
388
Sudden regaining of consciousness usually points to a diagnosis of?
Cardiac cause: arrhythmia, MI, HOCM, or Aortic stenosis
389
Gradual regaining of consciousness usually points to a diagnosis of?
Seizures, low glc, hypoxia, and drug OD
390
If murmur is present, what is the cause of the syncope?
AS, MS, HOCM
391
What is Bigeminy?
Every other beat is a PVC. Normal beats in between with narrow QRS (<100 ms). PVC with wide QRS.
392
Does bigeminy need specific treatment?
Nope
393
Can carotid disease cause syncope?
No! So no need to get carotid doppler!
394
If you suspect a brainstem lesion causing syncope, what test should you get? And not get?
Do NOT get CT of head. Do get MRI. CT is useless.
395
Should you get an EEG in syncope pt?
EEG would not help much..."low yield" test.
396
If suspecting a cardiac cause of syncope, should you get an EKG?
Absolutely!
397
If suspecting a cardiac cause of syncope, should you get an ECHO?
Depends...only if you hear a murmur. If no murmur, then ECHO is pretty useless.
398
What can all forms of valve dz have in common?
1. Dyspnea
2. CHF
3. Murmurs
4. Edema
5. Congenital or rheumatic fever
399
Best initial test for valve dz?
ECHO
400
Most accurate test for valve dz?
Cath (can detect pressure difference)
401
Should endocarditis prophylaxis be given to a pt with valve dz?
NO! Only if the valve was replaced.
402
What decreases the intensity of mitral valve prolapse murmur?
increased venous return.
403
What decreases the intensity of HOCM murmur?
increased venous return (more blood in ventricle = less obstruction)
404
What actions can increase VR?
Raising legs passively
| Squat from standing position
405
What actions can decrease VR?
Standing
| Valsalva
406
What action can increase afterload?
Handgrip
407
Handgrip can worsen ____ lesions.
Mitral and aortic regurge
408
Handgrip may improve which murmur?
HOCM (keeps more blood in heart and decreases outflow obstruction).
409
Aortic and Mitral Regurgitation can occur from any cause of _____ ______
dilated CM
410
As heart dilates, the valve leaflets ___
separate
411
Cardiac dilation = ?
regurgitation
412
Other than dilated CM, what are the other causes of regurtitant valve pathology?
```
HTN
MI
Endocarditis
Myxomatous degeneration
Rare: Marfan's, Ehlers-Danlos, Ankylosing Spondylitis.
```
413
T/F Most people with AR or MR are symptomatic
False
414
When Sx, pts with MR/AR present w/ ?
Dyspnea, Rales, and Edema. Similar/Same as clinical presentation of Dilated CM.
415
Murmur of AR is a _____ murmur heard best at____
diastolic decrescendo..............Lower Left Sternal Border. Not in the "aortic area"!
416
MR murmur is a _____ murmur type
pansystolic/holosystolic best heard at lower left heart border radiating to axilla.
417
Both AR and MR become louder with ____
leg raise, handgrip, squatting [things that increase Venous Return and Afterload]
418
Both AR and MR become softer with ____
Valsalva and standing...and ACEI/ARBs
| decrease VR and Afterload
419
Best test for AR/MR
ECHO
420
EKG of AR?
LVH --- S wave in V1 and R wave in V5 > 35 mm
SV1 + RV5 > 35 mm = LVH
421
CXR of MR and AR
Enlarged Left Atrium and Left Ventricle
422
Initial therapy for AR/MR?
ACEI/ARBs or (Nifedipine?)
423
Is there a need for Abx ppx before a dental procedure for AR or MR?
No, unless valve has been replaced.
424
When is surgery (repair/replace) indicated for MR or AR?
When the EF drops or the Left Ventricular End-Systolic Diameter increases.
425
Surgery indication for AR?
When EF < 50-55%
OR
LV End-Systolic Diameter (>50-55 mm) - about 2 inches
426
Surgery indication for MR?
EF < 60%
OR
LV End-systolic Diameter > 45 mm
427
Aortic stenosis triad?
Angina
CHF
Syncope
428
Most common symptom of AS?
Angina
Not syncope!
429
Symptom of AS --> Worst prognosis
CHF
Not syncope!
430
Why is angina so common in pts with AS?
1) co-existent CAD is very common in these pts
2) stenotic aortic valve is physically in the way of perfusing the coronaries
3) Resultant LVH compresses coronaries
4) micro-calcific emboli travel to coronaries (rare)
431
Diagnosis of AS?
ECHO
432
EKG change in AS?
severe LVH
recall: SV1 + RV5 > 35 mm
433
Why would stress tests and angiography be done in AS pts?
Angina!
Also, angio is good for diagnosing AS (looks at pressure Dx. Also, angio useful before surgical replacement of valve b/c bypass is frequently done at the same time.
434
Symptomatic AS pts - treated how?
"All" need surgical valve replacement (AVR)
435
What is done to patients with AS who are too ill to undergo valve replacement?
Balloon valvuloplasty
436
What is the role of ACEI/ARBs in AS?
Can worsen symptoms and don't help
437
When can diuretics be useful in pts with AS?
in cases of fluid overload. Note that pts with AS are very prone to volume depletion.
438
Acute CHF + AS treated with?
Digoxin
No BB d/t acute CHF (decrease contractility not a good idea)
439
Young immigrant + CHF -- think about which valve problem>?
Mitral Stenosis
440
young immigrant with rheumatic fever years ago and chronic mv scarring with MS may have what symptoms with MS?
Dysphagia
Hoarseness
Afib
Stroke at early age.
441
MS can cause atrial __ which leads to ____ and pressure on the ______ and ______
atrial enlargement....Afib and pressure on the esophogus (dysphagia) and recurrent laryngeal nerve (hoarseness)
442
EKG change on MS?
Left atrial enlargement = biphasic P wave in V1 and V2.
443
CXR for MS?
Left atrial enlargement
"Double Bubble" extra density behind the heart
Pushing up the Left main stem bronchus
Straightening of left heart border.
444
Best test for MS
TEE -- fish mouth shape MV
445
Most accurate test for MS
Left heart cath
446
Tx of MS
Diuretics for fluid overload
Balloon valvuloplasty (MVR if fails)
Digoxin or BB for atrial arrhythmia control
447
Role of endocarditis ppx for MS?
none unless replaced MV
448
Most pts with MVP are (sx or asx)
Asx
449
When MVP is Sx, what are the sx?
Palps
| Atypical chest pain (not related to exertion and not relieved by rest)
450
Describe murmur of MVP
Mid-systolic click followed by Late-systolic murmur of MR.
451
MVP worsens with?
Valsalva and standing (decreased VR)
452
MVP improved with?
Squatting and leg raise (increase VR)
453
Dx of MVP?
ECHO
454
EKG of MVP?
normal
455
CXR of MVP?
normal
456
Treatment of MVP?
If Asx - nothing (no endocarditis PPX)
| Sx (palps and CP) - BB
457
Marfan syndrome may present with what valve abnormality?
Floppy mitral valve (MVP, MR) --> sudden cardiac death.
and Cystic medial necrosis--> Aortic dissection.
458
Acute pericarditis CP?
CP that changes with position and respiration.
459
Pain of acute pericarditis is better with? worse with?
better w/ sitting up
| worse w/ lying down and inspiration
460
Acute pericarditis on auscultation?
70-75% - nothing!
| 25-30% - friction rub
461
Things to ask of /look for in patient suspected of pericarditis?
1. fever or recent infection (esp lungs)
2. renal failure (uremia)
3. Chest wall trauma/heart surgery
4. Conn tissue disorder (eg, Lupus)
5. Recent MI
6. Cancer of chest organs
462
Most common class of infections that can cause pericarditis...
viruses!
any infection can do it though
463
EKG of pericarditis
ST-elevations in all leads except aVR.
| PR-segment depressions (more specific!)
464
the lead that does not have ST elevations in acute pericarditis is usually lead ___?
aVR
465
Tx pericarditis
Tx underlying cause.
NSAIDs (ibuprofen, naproxen) for most cases. Colchicine can be added to NSAID to decrease recurrence.
If above doesn't work, Prednisone can be used.
466
What is CP of Pericardial Tamponade?
Hemodynamic dz that presents w/ SOB and lightheadedness from hypotension.
Hypotension
JVD with clear lung fields
Tachycardia
Pulsus paradoxus (decrease >10 SBP on inhalation)
Decreased and muffled heart sounds
467
what is the relationship b/w heart rate and pericardial tamponade ?
tachycardia is present and when it isn't tamponade is very unlikely.
468
Pt with BP 85/30, HR 120, JVP 13, and decreased heart sounds. What is the MLDx? And what are the possible causes?
MLDx = Pericardial tamponade
| infections (most viral), CT disorders, cancers, recent MI, uremia, chest trauma,
469
What can pericadial tamponade look like on CXR?
pericardial effusion enlarges heart shadow in both left and right direction.
470
ECHO of pericardial tamponade
effusion pressing on RIGHT side of heart with right atrial and ventricular DIASTOLIC collapse as FIRST SIGN.
471
EKG shows low voltage....what are the possible causes?
Obesity, large breasts, COPD, pericardial tamponade
472
EKG of pericardial tamponade may show low voltage and another interesting finding...
"electrical alterans" - variation in height of QRS complexes b/c heart "swims" in the fluid.
473
Pt with pericardial tamponade gets Cath for whatever reason. What do you expect to see with diastolic pressures?
Equal pressures in ALL 4 chambers during diastole.
| Note: cath rarely done
474
Treatment of pericardial tamponade?
Fluids! -- prevent and possibly reverse tamponade (push back)
Needle peri-cardiocentesis
Pericardial window placement.
475
What is constrictive pericarditis due to?
Chronic pericardial INFECTION or INFLAMMATION leads to chronic thickening, fibrosis, and calcification of the pericardium.
476
CP of constrictive pericarditis
1. Edema
2. JVD
3. Kussmaul's sign (paradoxical increase in JVP on inhalation)
4. Enlarged Liver and Spleen
5. Ascites
6. Pericardial "KNOCK" from filling of ventricle hitting fibrotic pericardium.
Note that 1-5 are Right sided HF signs and symptoms.
477
What is Kussmaul's sign?
inhalation --> paradoxical increase in JVP.
| Normally inhalation --> increase VR --> decrease JVP.
478
CXR of constrictive pericarditis?
fibrosis, thickening, and calcification of pericardium
479
Chest CT/MRI of constrictive pericarditis?
fibrosis, thickening and calcification of pericardium in much better detail.
480
ECHO comparison b/w pericardial tamponade and constrictive pericarditis
ECHO less useful in Constr peri b/c fluid level is normal and heart moves normally.
481
Treatment of constrictive pericarditis?
Surgical removal is the only effective tx.
| Diuretics and salt restriction (decrease R-sided HF sx) - sx relief only
482
T/F PAD is angina of the calves...
True
483
PAD CP?
Think stable angina
1. Pain in legs relieved by REST
2. decreased peripheral pulses
3. smooth, shiny skin in severe cases.
484
Risk factors of PAD?
HTN, DM, HLD, TOBACCO SMOKING!
485
How can pain be better in PAD?
rest, dangling over edge of bed
486
pain worse in PAD?
worse on ANY type of exertion
| spinal stenosis is worse with walking DOWNHILL
487
Diagnostic testing for PAD?
1. ABI
2. Dopplers of LE
3. Angiography
488
A normal person's Ankle pressure will ____ arm (brachial) pressure when _____.
equal
| lying flat
489
When upright, ankle pressure is normally ____ than arm pressure
greater
| thus, ABI 1.0-1.2 are NORMAL! - mind blown!
490
If ankle pressure is lower than brachial pressure by more than ___ % (i.e. ABI ___), then we suspect _____???___
>10%
ABI <0.9
obstruction to flow of blood in legs
491
PAD Tx
1. STOP SMOKING, STOP SMOKING, NOW
2. ASA (Plavix 2nd line)
3. Cilostazol
4. ACEI for HTN
5. Statins b/c PAD = ASCVD
6. Tight glc control
