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Internal Medicine - MTW - Fischer > Ch_1 - Cardiology > Flashcards

Ch_1 - Cardiology Flashcards

1
Q

Starting with III. ARRHYTHMIAS

A

blank

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2
Q

The most important issue for anyone admitted with an arrhythmia is ….?

A

…hemodynamic stability

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3
Q

What is hemodynamic instability? [4]

A
  1. Hypotensive (SBP < 90)
  2. Dyspnea
  3. Altered mental status/confusion d/t inadequate perfusion.
  4. Chest pain
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4
Q

Mnemonic for hemodynamic instability

A

things are LOW – low BP, Shortness (low) of breath, low mentation and the oddball – chest pain.

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5
Q

What must you, as the medical student, do when you find a pt who is hemodynamically unstable?

A
  1. Call your resident!
  2. Recheck BP
  3. Normal saline is REQUIRED
  4. Repeat EKG
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6
Q

T/F Palpitations are very non-specific

A

True

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7
Q

T/F Patient w/ palpitations has no disease at all 50% of the time.

A

True

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8
Q

What must you do first if your patient has palpitations?

A

EKG!

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9
Q

Pt with palpitations gets an EKG and it is normal. Next step?

A

Outpatient - Holter monitor

Inpatient - Telemetry

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10
Q

T/F Pt with palpitations should not be medicated if no objective pathology is found.

A

True

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11
Q

What must you exclude in a patient with palpitations? [3]

A
  1. Thyroid disease
  2. Alcohol excess (can cause transient episodes of afib)
  3. Excessive caffeine intake
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12
Q

T/F The testing and treatment are essentially the same for a-fib and a-flutter

A

True

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13
Q

What is the classic presentation of a pt with afib/aflutter? [5]

A
  1. Palpitations of fluttering of the chest
  2. Lightheaded
  3. “Racing” heart
  4. LOC is rare, but possible
  5. Chest pain in SOME.
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14
Q

T/F loss of consciousness is possible with atrial fibrillation.

A

True, but it is rare.

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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.

  1. Hypertension (most common)
  2. CHF or cardiomyopathy of any kind
  3. Thyroid dz
  4. Alcohol or cocaine use
  5. Rheumatic fever, particularly of immigrants
  6. Previous EKG/Holter/ECHO
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16
Q

What is the most important feature of a-fib on physical exam?

A

irregularly irregular rhythm.

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17
Q

What is a wrong way to measure heart rate in patient with afib?

A

By palpating the radial pulse.

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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.

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19
Q

What SBP is necessary to feel a radial pulse?

A

SBP > 90 mm Hg. Weak contractions will not transmit.

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20
Q

What does an EKG show for afib? [3]

A
  1. absent P waves
  2. QRS < 100 msec
  3. Irregularly irregular rhythm based on RR intervals.

May also see fibrillatory waves.

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21
Q

For what patients would a Holter monitor be used?

A

outpatients

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22
Q

For what patients would telemetry be used?

A

inpatients

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23
Q

Afib pts would get CK-MB and/or troponin ordered for who?

A

patients with acute episodes of rapid rate.

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24
Q

Afib pts would get ECHO when?

A

EVERYONE, if not done in last 6 months.

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25
Q

Why do an ECHO on afib pt? [2]

A
  1. Detect valve dz (may have led to afib)

2. Look for clots (if present –> anticoagulate)

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26
Q

T/F Valvular disease that leads to afib/aflutter needs warfarin in many cases

A

True

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27
Q

Would you do a stress test in an afib pt?

A

Maybe. They are sometimes useful.

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28
Q

An atrial arrhythmia is generally caused by…

A

…dilated atrium.

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29
Q

T/F Ischemia is a frequent cause of atrial arrythmias

A

False, the cause is generally dilation (eg, volume expansion from heart failure causes dilation)

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30
Q

What is the first step in the management of afib/aflutter?

A

slowing the RATE.

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31
Q

What is the heart rate goal in afib/aflutter?

A

HR< 100-110/min

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32
Q

What are the 2 best therapies for afib/aflutter?

A
  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.
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33
Q

How long does it usually take for Metoprolol and Diltiazem to control the rate?

A

Within 30 min.

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34
Q

If one of these (Metoprolol, Diltiazem) doesn’t work and SBP is >90-100 mm Hg, you can do what?

A

add the other med (ie, if Metoprolol was given alone and BP is over 90, then you can add diltiazem).

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35
Q

What is the brand name for metoprolol?

A

Lopressor

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36
Q

What is the brand name for diltiazem?

A

Cardizem

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37
Q

If SBP is low or borderline (ie, < 90), what drug can be used to control the rate in an afib/aflutter pt?

A

Digoxin

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38
Q

Why is digoxin not the first choice in controlling the rate in stable afib/aflutter pts?

A

b/c it’s not good in controlling the HR on exertion.

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39
Q

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.

A

True

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40
Q

T/F Digoxin is faster than CCBs or BBs in controlling heart rate

A

False, it is slower acting.

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41
Q

T/F Digoxin can raise the BP when the rate of an afib/aflutter pt is controlled.

A

True! Probably b/c it increases contractility.

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42
Q

Dose of digoxin for afib/aflutter pts who have SBP < 90 mm Hg.

A

0.25 mg IV q 2 hours. PO q 6 hours.

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43
Q

Patients with afib/aflutter with SBP< 90 can get digoxin to control the HR. Most pts can be controlled with how many mg?

A

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).

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44
Q

What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?

A

200 bid

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45
Q

What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?

A

120 qid

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46
Q

200 bid (Jeopardy)

A

What is the maximum dose of Metoprolol that can be given to afib/aflutter patient for rate control?

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47
Q

120 qid

A

What is the maximum dose of Diltiazem that can be given to afib/aflutter patient for rate control?

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48
Q

What are other meds in addition to Metoprolol/Diltiazem/Digoxin that can be used for rate control of rapid atrial arrhythmias?

A
  1. CCB: Verapamil
  2. BBs: Esmolol (B1), Propranolol (B1, B2), Atenolol (B1)

note: Metoprolol is also B1 blocker.

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49
Q

T/F Afib/aflutter pt - Routine cardioversion to sinus RHYTHM is correct.

A

False, it is NOT correct, routinely.

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50
Q

T/F It is correct to slow the RATE with BB, CCB, and occasionally with digoxin.

A

True

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51
Q

When can you urgently cardiovert an afib/aflutter patient?

A

hemodynamically unstable pt.

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52
Q

What are the 2 ways to cardiovert patients into sinus rhythm?

A

chemically with drugs and electric shock

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53
Q

Why would chemical cardioversion with drugs like amiodarone, procainamide, propafenone, or dofetilide not done for afib/aflutter pts?

A

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.

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54
Q

The AFFIRM trial showed what?

A

AFFIRM = Atrial Fibrillation Follow-up Investigation of Rhythm Management
showed that RATE CONTROL is superior to rhythm control in treatment of afib.

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55
Q

Prior to electrically cardioverting a hemodynamically stable afib pt, what must you do?

A

an ECHO (usually TTE and then TEE if TTE is negative) to look for clots. Shocking with a clot present may cause emboli.

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56
Q

Patient with afib has a TEE positive for a clot in the heart. Next best step?

A

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.

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57
Q

When is cardioversion performed for afib?

A

After rate control if patient is YOUNG and has an otherwise anatomically normal heart.

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58
Q

T/F Afib patient with dilated left atrium or significant valve dz is unlikely to stay in sinus rhythm even after cardioversion.

A

True.

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59
Q

When is anticoagulation NOT indicated for an afib patient?

A

If the afib is “new” – ie, started < 48 hours ago.

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60
Q

If there is a significant risk for stroke in an afib patient, what should the pt get?

A

Anticoagulation therapy (eg, warfarin)

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61
Q

How do we quantify risk for stroke in afib pt to know whether pt should receive anticoagulation therapy?

A

CHADS2 score

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62
Q

What does CHADS2 stand for?

A 
C - dilated Cardiomyopathy
H - HTN
A - old Age (>75)
D - DM
S - prior Stroke or TIA is clear indication
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63
Q

When CHADS score is 0-1, next step?

A

ASA or
ASA and Plavix (Clopidogrel)
Note: this is controversial – ask attending

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64
Q

CHADS 2+

A

anticoagulate with Warfarin, Dabigatran, or Rivaroxaban.

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65
Q

What lab parameter must be monitored with warfarin use?

A

INR – keep b/w 2-3 – problematic and takes several days to achieve.

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66
Q

Is there a need to use heparin to bridge to warfarin for afib patients?

A

Depends:

If clot is present, then yes. But usually/otherwise, not needed. Why? b/c heparin causes bleeding and thrombocytopenia.

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67
Q

T/F Rivaroxaban and Dabigatran don’t have to be monitored by INR

A

True, and that’s awesome for us and the patient!

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68
Q

T/F Rivaroxaban and Dabigatran are like warfarin in that they take several days to become therapeutic

A

False, they are therapeutic on the same day you start.

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69
Q

T/F Rivaroxaban and Dabigatran cannot be reversed.

A

True. Warfarin can with PCC, FFP, Vit K…

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70
Q

What is the eficacy of rivaroxaban and dabigatran as compared with warfarin?

A

at least as effective or even better.

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71
Q

In afib, what is the ATRIAL rate (about)?

A

~400 bpm

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72
Q

In afib, what is the VENTRICULAR rate? why is it lower than the atrial rate?

A

b/w 75-175 b/c most atrial impulses are blocked by the AVN.

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73
Q

What are the causes of Afib?

A
  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.
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74
Q

Clinical features of afib?

A
  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
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75
Q

Tx: Acute Afib in hemodynamically unstable pt

A

Immediate electrical cardioversion to sinus rhythm.

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76
Q

Three main goals of afib/aflutter management

A
  1. control ventricular rate.
  2. restore NSR.
  3. Assess need for anticoagulation.
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77
Q

Rate control in afib goal?

A

60-100 bpm

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78
Q

What drug is preferred for rate control?

A

BB > CCB

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79
Q

If LV systolic dysfxn is present, consider what drugs?

A

Digoxin or Amiodarone (useful in rhythm control)

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80
Q

After rate control of afib, what is next step?

A

convert to sinus rhythm via cardioversion if patient is a candidate for cardioversion.

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81
Q

What are the candidates for cardioversion? [3]

A
  1. hemodynamically unstable
  2. worsening sx
  3. first ever case of afib (<48 hrs)
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82
Q

What is risk of cerebrovascular accident (CVA) in patient with “lone afib” (ie, absence of cardiovascular risk factors or underlying heart dz)?

A

1% per year

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83
Q

What is risk of cerebrovascular accident (CVA) in patient with afib + underlying heart dz?

A

4% per year

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84
Q

I. INTRODUCTION

A

blank

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85
Q

Chest pain

A

blank

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86
Q

How many pts coming into the ED actually have an MI?

A

<10%

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87
Q

What qs must be asked if pt has chest pain?

A

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?
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88
Q

To evaluate for chest pain, consider these 3 things

A
  1. Is pain cardiac?
  2. Does pain change with bodily position or respiration?
  3. Is there chest wall tenderness?
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89
Q

If pain changes with position or respiration or there is chest wall tenderness, what is the percentage that the pain is ischemic?

A

~5% - very low!

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90
Q

T/F “Yes” to pain on exertion (eg, walking or climbing stairs) means the pain is very likely to be ischemic

A

True

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91
Q

T/F “No” to pain on exertion (eg, walking or climbing stairs) means the pain is very unlikely to be ischemic

A

False, it is inconclusive.

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92
Q

If patient has chest pain, should an EKG be done?

A

Yes!

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93
Q

If chest pain is cardiac in nature, what meds should be given?

A 
Chewable ASA
Nitroglycerin (NTG)
Statin
BB (metoprolol 25 mg PO bid)
Possibly ACEI
No O2 unless hypoxic.
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94
Q

T/F In cases of chest pain, you should always get the old EKG

A

True!

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95
Q

EKG shows ST depression. Next step in management?

A

LMW Heparin

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96
Q

EKG shows ST elevation. Next step in management?

A

Get Cardiology immediately so they can do Angioplasty or thrombolytics.

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97
Q

Diabetes can cause what kind of MI?

A

“Silent” MI (painless)

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98
Q

Case #1
Patient has pleuritic chest pain that changes with respiration. Pt has fever, cough, sputum, SOB.
MLDx?
Mx?

A

MLDx = PNA

Mx: CXR, Oximeter, ABG

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99
Q

Case #2
Pt has pleuritic CP. Sharp, SOB, sudden onset.
MLDx?
Mx?

A

MLDx = Pneumothorax or PE

Mx = CXR, Oximeter, ABG
CTA for PE

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100
Q

Case #3
Pt has pleuritic CP. It is positional and is relieved when sitting up.
MLDx?
Mx?

A

MLDx - Pericarditis

Mx - EKG and NSAIDs.

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101
Q

Case #4
Pt has tearing CP that radiates to back. CXR shows wide mediastinum.
MLD?
Mx?

A

MLDx - Aortic dissection

Mx - CTA, MRA, TEE

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102
Q

Case #5
Pt with chest point tenderness.
MLDx?
Mx?

A

MLDx = Costochondritis

No test necessary. May use NSAIDs to relieve pain.

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103
Q

Case #6
Pt with burning epigastric pain, bad taste in mouth.
MLDx?
Mx?

A

MLD = GERD

Mx = improves with liquid antacids/PPIs

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104
Q

Important things to do when pt is hypotensive (SBP<90): [4]

A
  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.
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105
Q

T/F Hypotension is the number 1 condition in which correction with fluids is more important than getting a specific diagnosis.

A

True

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106
Q

T/F treat low BP first and diagnose later.

A

True

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107
Q

DDx of hypotension [8]

A
  1. Dehydration
  2. Sepsis
  3. MI
  4. Arrhythmia
  5. Drug s/e
  6. Orthostasis
  7. Anaphylaxis
  8. PE
    There are many others!
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108
Q

Initial clues of dehydration?

A

High BUN:Creatinine ratio (>15-20:1)

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109
Q

Confirm dehydration how?

A

Low Urine Na+ (500 mOsm/L)

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110
Q

Initial clues of sepsis?

A

Leukocytosis

Fever

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111
Q

Confirm sepsis?

A

blood cultures

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112
Q

Initial clues of MI causing cardiogenic shock?

A

Rales
S3
JVD on exam

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113
Q

Confirming MI/Cardiogenic shock

A

CXR
ECHO
High BUN
Troponin

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114
Q

Initial clues of arrhythmia?

A

Palpitations

Syncope

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115
Q

Confirm arrhythmia?

A

EKG

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116
Q

What drugs commonly cause/predispose to hypotension?

A

BB, CCB; confirm with Medication Hx

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117
Q

Initial clues of orthostasis?

A

BP normalizes lying flat

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118
Q

How to diagnose orthostasis?

A

tilt-table test

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119
Q

initial clues of anaphylaxis?

A

Foods (seafood, crab, lobster, milk); insect bite; drug rxn

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120
Q

confirm anaphylaxis how?

A

Allergy Hx

Elevated Eosinophils

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121
Q

initial clues of PE?

A

sudden SOB

recent surgery

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122
Q

confirm PE with?

A

CTA

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123
Q

pt with hypotension. You want to start an antiplatelet agent. What should you consider prior to starting tx?

A

Bleeding risk

If pt is currently bleeding, these drugs are CI!

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124
Q

What are commonly prescribed anti-platelet agents?

A

ASA, Clopidogrel, Prasugrel, Ticagrelor.

If pt is currently bleeding, these drugs are CI!

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125
Q

pt with hypotension. You want to start heparin or enoxaparin. What should you consider prior to starting tx?

A

Bleeding risk. If pt is currently bleeding, these drugs are CI!

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126
Q

pt with hypotension. You want to start ASA. What should you consider prior to starting tx?

A

Allergy.

ASA is CI if pt has allergy.

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127
Q

pt with hypotension. You want to start BB agent. What should you consider prior to starting tx?

A

Check for Low BP, severe asthma, COPD.

B1B is not necessarily CI, but should be avoided if possible.

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128
Q

pt with hypotension. You want to start NTG. What should you consider prior to starting tx?

A

pt is hypotensive, NTG is CI!

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129
Q

pt w/ hypotension. You want to give them a statin. When should you not do this?

A

Liver dysfxn, Myositis

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130
Q

When should you not give ACEI?

A

patient has cough

Hyperkalemic

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131
Q

When should you avoid ARB, Spironolactone, Eplerenone?

A

Hyperkalemia

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132
Q

When should you avoid spironolactone?

A

Gynecomastia, Hyperkalemia

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133
Q

Patient has heme-positive brown stool. Can he be given an anti-platelet agent such as ASA, Plavix, Effient, ticagrelor or heparin?

A

If that’s the ONLY finding, then it’s OK to give.

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134
Q

Intro Part 3: ACS

A

blank

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135
Q

What is the most important part of ACS management?

A

getting a good History!!!

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136
Q

Aren’t elevated Troponin and CK-MB and EKG important too?

A

Yes, but less so than Hx b/c they take 3-4 hours to elevate.

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137
Q

T/F Enzymes are usually normal when first test is done, even when ischemic event occurs.

A

True!

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138
Q

If Hx = ACS but EKG =/= ACS, should you treat it as if it’s ACS?

A

YES!

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139
Q

T/F ACS = Hx + EKG

A

True

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140
Q

From Hx, what clues tell you that the pain is ischemic?

A
  1. Substernal
  2. Pain on exertion
  3. Lasts 15-30 min
  4. Doesn’t change w/ position, respiration, or palpation
  5. Dull, squeezing, pressure
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141
Q

What are the 3 different types of Acute Coronary Syndromes?

A

Unstable angina
NSTEMI
STEMI

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142
Q

From Hx, what clues tell you the pain is NOT ischemic?

A
  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
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143
Q

What is the worst and most dangerous risk factor for ACS?

A

Diabetes Mellitus

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144
Q

What is the most commonly found risk factor?

A

HTN

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145
Q

What is the relevance of FH in ACS?

A

only significant if it’s PREMATURE in relative (<65 in female)

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146
Q

What are the common RFs of ACS?

A
  1. DM
  2. HTN
  3. Tobacco use
  4. Hypercholesterolemia
  5. Premature dz in 1st-degree relative (parents, siblings)
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147
Q

Why are RFs of ACS important in Mx?

A

Because if Hx/EKG/Enzymes is equivocal, then RFs are used.

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148
Q

PEx of ACS pt?

A

MCC finding – Absence of findings.

May find S3 Ventricular gallop and/or S4 atrial gallop, or rales.

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149
Q

T/F One EKG is good enough in the assessment of ACS

A

False! Make sure to do a repeat EKG. Also, make sure to compare to any previous EKGs pt had.

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150
Q

What are the different tests for ACS?

A
  1. Troponin
  2. CK-MB
  3. Mgb
  4. Cath
  5. BNP
  6. Stress test
  7. ECHO
  8. Telemetry
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151
Q

Troponin begins to rise…

A

at 3-4 hours

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152
Q

Max sensitivity to Troponin is at….?

A

12-18 hours

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153
Q

Troponin stays positive for..

A

1-2 weeks after event

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154
Q

Negative first troponin excludes disease?

A

No! It excludes nothing

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155
Q

Positive troponin suggests…

A

MI

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156
Q

False positive troponin increase is seen with?

A

Renal failure, CHF

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157
Q

CK-MB begins to rise…

A

at 3-4 hours

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158
Q

Max Sn for CK-MB?

A

12-18 hrs

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159
Q

CK-MB lasts…

A

1-2 days

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160
Q

Negative first CK-MB excludes…

A

nothing

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161
Q

Positive CK-MB…

A

suggests MI

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162
Q

CK-MB is best test for…

A

detecting re-infarction

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163
Q

Myoglobin rises at…

A

1-4 hours

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164
Q

T/F Myoglobin is very specific for MI

A

False

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165
Q

Mgb can exclude MI…

A

if negative test at 4 hours

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166
Q

If clear Hx of ACS and abnormal EKG, next step is?

A

Cath. If those 2 are unclear, then stress test.

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167
Q

Max medical therapy for ACS pt but pain continues. Next step?

A

Cath

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168
Q

Pt w/ possible ACS has SOB but etiology is unclear. Test?

A

BNP

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169
Q

Normal BNP…

A

excludes CHF

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170
Q

abnormal BNP…

A

is non-specific

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171
Q

When Hx and EKG are not clear, next step?

A

Stress test

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172
Q

What are you looking for in a stress test?

A

Reversible ischemia is the main thing to look for.

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173
Q

If stress test is abnormal, next step?

A

Cath

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174
Q

ECHO looks for?

A

Wall and valve motion

Estimates EF

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175
Q

Normal wall motion on ECHO…

A

excludes MI

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176
Q

High troponin with normal wall motion means what?

A

false positive troponin (eg, Renal failure)

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177
Q

What is telemetry?

A

Inpatient continuous EKG monitoring

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178
Q

T/F All ACS pts need telemetry.

A

True

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179
Q

When should a stress test NOT be done (although it is algorithmically indicated)?

A

If patient is in pain!

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180
Q

T/F Cath = Angiography

A

True

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181
Q

Which instances of ACS is Cath indicated?

A
  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.
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182
Q

All pts with ACS shouldreceive these meds (6)

A
  1. ASA 2+ tab, each 81 mg
  2. Metoprolol 25 mg bid
  3. NTG
  4. ACEI
  5. Statin
  6. Morphine during pain.
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183
Q

Patient with chest pain + EKG with ST depression or T wave inversion + elevated troponins = ???

A

NSTEMI

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184
Q

(possible) NSTEMI treatment?

A 
ASA
Plavix, Prasugrel, or ticagrelor
LMW Hep (eg, Enoxaparin 1mg/kg bid) subQ
Evaluate for Angio (cath)
Place on telemetry or ICU
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185
Q

Should treatment of possible NSTEMI start before enzyme results return?

A

YES!

Hx + EKG = ACS

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186
Q

In NSTEMI, where would you most likely expect T-wave inversions?

A

Inferior leads (II, III, aVF)

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187
Q

Clopidogrel must be given to which subset of ACS pts?

A

all pts undergoing PCI w/ stent placement and those undergoing fibrinolytic tx.

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188
Q

Pt with STEMI. Tx?

A

ASA, plavix (or equivalent - prasugrel, ticagrelor)

Thrombolytics or Angioplasty for PCI

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189
Q

Which medication should not be used in STEMI?

A

Heparin

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190
Q

When cardio is doing an angioplasty stent w/ PCI, what meds may be used?

A

GpIIb/IIIa inhibitor such as Eptifibatide or abciximab.

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191
Q

Define Takotsubo CM

A

sudden ventricular dysfxn from overwhelming emotions. May stimulate MI w/ anterior wall STEMI

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192
Q

When would you know for sure whether a pt has Takotsubo CM or Prinzmetal angina?

A

after Angio

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193
Q

Conditions that can cause ST elevations unrelated to acute MI? [5]

A
  1. Early repolarization (benign)
  2. Hyperkalemia
  3. Pericarditis
  4. CM
  5. Prinzmetal’s variant angina (spasm causes temporary transmural ischemia?)
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194
Q

CCBs may be beneficial in [3]

A
  1. chest pain assoc w/ cocaine abuse
  2. Intolerance to BBs (eg, asthma)
  3. Variant/Prinzmetal’s angina
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195
Q

Serious complications of MI? [4]

A
  1. Arrhythmia
  2. Wall/valve rupture
  3. Hypotension
  4. Pericarditis
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196
Q

In first 2-3 days after MI, what is the most serious MI complication?

A

Arrhythmia

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197
Q

Management of PVCs?

A

None, don’t treat!

198
Q

Key features of 3rd deg AVB

A

Bradycardia

Canon A waves

199
Q

Treatment of 3rd deg AVB?

A

Atropine first if Sx

Pacemaker later in all

200
Q

Key features of Sinus Bradycardia

A

bradycardia w/o canon A waves

201
Q

Treatment of bradycardia

A

Atropine if Sx!

Pacemaker only if Sx persist

202
Q

Key features of tamponade/wall rupture?

A

Sudden loss of pulse, (distended neck veins)

203
Q

Tamponade/wall rupture Tx?

A

Needle thoracocentesis

Surgery

204
Q

Key features of RV infarction

A

Inferior wall MI in Hx, clear lungs, tachycardia

205
Q

Tx of RV infarction

206
Q

Valve rupture key features?

A

new murmur, rales/congestion

207
Q

Tx of valve rupture

A

Surgery, some need balloon pump

208
Q

Key features of septal rupture

A

New murmur

increase in O2 sat on entering RV

209
Q

Tx of septal rupture

A

Surgery, some need balloon pump

210
Q

Key features of Vfib

A

loss of pulse

need EKG

211
Q

Tx of Vfib

A

Unsynchronized cardioversion

212
Q

What is max HR?

A

220 - Age = Max HR

213
Q

When doing a stress test, what should the HR be to properly assess heart function via EKG or ECHO?

A

80-85% of max HR.

214
Q

What is 80% of max HR for 70 y/o patient?

A

(220 - 70)0.80 = 0.8x150 = 120 bpm

215
Q

If pt has LBBB and you want to do a stress test. What kind is preferred?

A

Chemical stress test w/ Dipyrimadole thallium or Dobutamine stress ECHO

216
Q

T/F LVH, LBBB, Pacemaker, and Digoxin make EKG reading difficult.

A

True, so need a stress test.

217
Q

Different types of stress tests?

A 
Exercise stress ECHO
Nuclear stress test
Dipyrimadole thallium
Adenosine thaliium
Dobutamine ECHO
TEsts have equal SN and Sp
218
Q

Define “reversible” defect on Angio

A

defect in perfusion with exercise, but not seen at rest.

219
Q

Why do an Angio?

A

To determine who should undergo bypass surgery.

220
Q

Stenosis of __% in a vessel is “significant”

221
Q

Management of 1- or 2-vessel dz

A

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
Q

Management of 3-vessel dz w/ LV dysfxn or Left Main Coronary dz

A

CABG surgery

223
Q

Which drugs lower mortality in CAD?

A

ASA +/- Clopidogrel, Prasugrel, Ticagrelor
BB (Metoprolol, Nebivolol)
Statins to LDL goal < 100 mg/dL
ACEI if EF < 40%

224
Q

Pt w/ CAD. Give statin. What is LDL goal?

A

<100 mg/dL

225
Q

Pt w/ CAD. Give ACEI when?

A

If EF < 40%

226
Q

Pt w/ chronic stable angina. Tx?

227
Q

Pt w/ chronic stable angina with persistent pain.

A

ASA + long-acting NTG

228
Q

What is ranolazine?

A

Na+ channel blocker used in refractory angina.

229
Q

What drug is used in refractory angina?

A

Ranolazine (Na channel blocker)

230
Q

CAD + LDL > 100 == ??

231
Q

When is a CAD pt given statins

A

everyone with CAD (in real life) is given Statins

232
Q

Most common a/e of statins?

A

1) increased LFTs (AST/ALT) in 2-3% of patients

2) Myositis in <1% of pts.

233
Q

Pt on statin presents with LFTs 3-5x upper limit of normal. Next step?

A

Stop the med.

234
Q

What are the other circustances when you want to get an LDL < 100 mg/dL (i.e., start a statin)

A

1) PAD
2) Diabetes
3) Aortic disease
4) Carotid disease

235
Q

II. CHF

236
Q

What are the MC precipitants of acute pulmonary edema? [7]

A
  1. Ischemia
  2. Any arrhythmia
  3. Non-adherence
  4. Infection
  5. Salty food diet
  6. Iatrogenic fluid overload
  7. Hypertensive crisis
237
Q

CP of acute pulmonary edema?

A

sudden onset of SOB worse when supine and relieved when sitting upright

238
Q

Physical exam of Acute pulm edema?

A
  1. Rales
  2. S3 ventricular gallop
  3. JVD
  4. Peripheral edema
  5. Tachycardia
  6. Diaphoresis and Nausea
239
Q

If sx/sy of acute pulm edema are present, what is next best step?

A
  1. OXYGEN
  2. Elevate head of bed
  3. Call resident
  4. Attach Oximeter
  5. Make sure ABG is done.
  6. Connect to telemetry
240
Q

Diagnostic tests for Acute Pulmonary Edema?

A
  1. EKG – to r/o arrhythmia and ischemia
  2. CXR - congestion/vascular fluid overload, effusions, cardiomegaly
  3. BNP
  4. Troponin/CK-MB
241
Q

How can BNP be useful in pt w/ acute pulm edema?

A

If Hx/Px and CXR are not clear, BNP can help diagnose CHF b/c normal BNP will exclude APE.

242
Q

Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
Rales

A

Auscultation
CXR
BNP

243
Q

Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
S3 ventricular gallop

A

EKG changes?
CXR
BNP
Troponin/CKMB

244
Q

Match the following Sx of Acute pulmonary edema with appropriate diagnostic test:
JVD, peripheral edema

245
Q

BUN:Creatinine ratio in CHF

A

CHF –> pre-renal azotemia –> increase reabsorption –> increase BUN:Cr (>20:1)

246
Q

Na content in plasma in CHF

A

Hyponatremia

247
Q

CHF pt with Hypokalemia and metabolic alkalosis. Why?

A

chronic Diuretic use

Lasix is not K+ sparing and contraction alkalosis occurs with depleted volume.

248
Q

T/F ECHO is needed in the acute management of acute pulmonary edema

A

False. Initial therapy is not altered whether CHF is systolic or diastolic.

249
Q

Treatment of APE?

A
  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
Q

If no furosemide was previously used, how should it be given?

A

Start with 10 mg, then 20 mg, then 40 mg, then 80 mg via IV push.

251
Q

If furosemide was previously used, how should it be given?

A

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
Q

Refractory cases of pulm edema are treated with?

A

Hemodialysis

253
Q

Who should be sent to the ICU?

A
  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
Q

T/F Acutely ill patients should be given BBs

255
Q

What are the positive inotropes used in the ICU for pts in CHF?

A

Dobutamine, Imamrinone, Milrinone.

256
Q

If CHF pt is sick enough for the ICU, who should you get?

A

Cardiology

257
Q

T/F CPAP/BiPAP might be necessary in CHF pt.

258
Q

What is Nesiritide?

A

IV Atrial Natriuretic peptide

259
Q

What is the IV ANP drug called?

A

Nesiritide

260
Q

Pt with CHF is in ICU. He was given O2, diuretics, nitrates, morphine, dobutamine, and put on CPAP. Still hypoxic. Next best step?

261
Q

In outpatient clinic, what clinical signs point you to pulmonary edema?

A

Dyspnea, Peripheral edema, and Rales.

There’s no EKG, CXR, ABG!

262
Q

Pt with CHF needs which diagnostic test after acute phase is over?

263
Q

ECHO tells us about…

A

EF
Systolic vs Diastolic dysfxn
Valvular dysfxn

264
Q

Pt with CHF. What important findings can you look for on EKG?

A
  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
Q

CHF therapy depends on what?

A

Systolic vs. Diastolic failure (determine by ECHO)

266
Q

T/F Systolic dysfxn is sometimes used interchangeably w/ Dilated CM

267
Q

What is systolic dysfxn?

A

Heart can relax (diastole) but cannot contract well.

Diastolic failure is opposite.

268
Q

What are the treatment options for Systolic dysfxn?

A
  1. ACEI
  2. BB
  3. Spironolactone
  4. Diuretics and Digoxin
  5. Biventricular Pacemaker
  6. Automatic implantable cardioverter defibrillator (AICD)
  7. Hydralazine + Nitrates
269
Q

T/F All ACEI are equal in efficacy

270
Q

T/F ARBs are an alternative to ACEI and the #1 use for ARB is if pt has cough with ACEI

271
Q

What are the commonly prescribed BBs for CHF (Systolic dysfxn)

A

Metoprolol, Carvedilol, Bisoprolol

272
Q

When is spironolactone recommended?

A

used only in advanced stage Class III or IV CHF.

273
Q

What is Class III/IV CHF?

A

Sx w/ minimum exertion or at rest

274
Q

a/e of Spironolactone?

A

Gynecomastia

Hyperkalemia (K+ sparing)

275
Q

Which aldosterone antagonist does not cause gynecomastia?

A

Eplerenone – it still can, but less so than Spironolactone

276
Q

T/F Diuretics have a mortality benefit

A

False, but are useful in pts w/ fluid overload

277
Q

T/F Digoxin has a mortality benefit

A

False, but decreases sx in those ill despite other treatments

278
Q

How is a biventricular pacemaker useful?

A

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
Q

When is an AICD appropriate?

A

It lowers mortality in those w/ Persistently low EF despite maximal medical therapy.

280
Q

https://icd.ices.on.ca/Portals/0/images/cvml_0077a_ICD-res1.jpg

281
Q

http://my.clevelandclinic.org/PublishingImages/heart/bivpm.jpg

A

Biventricular pacemaker

282
Q

Pt is unable to take ACEI or ARB. Persistent hyperkalemia is the reason. Next best step to control systolic dysfxn?

A

Hydralazine and Nitrates.

283
Q

Are there any medications or devices proven to lower mortality in diastolic dysfunction pts?

284
Q

What is the standard of care for Diastolic dysfunction?

A

Beta blockers: Metoprolol, Carvedilol, Bisoprolol

Diuretics

285
Q

T/F ACEI are beneficial in Diastolic dysfxn pts

286
Q

T/F Hypertensive Crisis = hypertensive emergency

287
Q

Define Hypertensive emergency

A

severe HTN w/ end-organ damage

288
Q

Sx of hypertensive emergency

A

End-organ damage sx:

  1. CNS: Confusion
  2. Heart: CP
  3. Lung: SOB, CHF
  4. Eye: blurry vision
  5. Renal insufficiency
289
Q

Managing htn emergency

A 
IV anti-HTN meds:
Labetalol (a1, B1, B2- blocker)
Enalaprilat
OR
Nitroprusside
290
Q

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?

A

Make sure not to lower BP > 25% in first few hours to prevent a stroke.

291
Q

Define Cardiomyopathy

A

any cardiac muscular disorder that impairs the function of either contraction or relaxation.

292
Q

T/F In cardiomyopathy, EF is always low

A

False, it can be high or low

293
Q

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,

A

True and true

294
Q

CM pt will show what on CXR ?

A

congestion or pulmonary vascular redistribution

295
Q

What 2 tests are technically more accurate for the EF?

A
  1. Nuclear ventriculogram (MUGA)
  2. Left heart cath

Neither test is routinely done, but they are more accurate than ECHO.

296
Q

Systolic dysfxn = ___1___ CM = relaxes 2 / contraction 3

A
  1. Dilated
  2. relaxes OK
  3. contraction Poor
297
Q

Diastolic dysfxn = ___1___ CM = relaxes 2 / contraction 3

A
  1. Hypertrophic
    2, Poorly
  2. Well
298
Q

define restrictive Cm

A

neither contracts or relaxes well.

299
Q

Causes of restrictive CM

A
  1. Sarcoidosis
  2. Amyloidosis
  3. Hemochromatosis
  4. Endomyocardial Fibrosis
  5. Cancer.
300
Q

Treatment of Dilated CM

A

Same as Tx for systolic dysfxn:

BB, ACEI/ARB (Hydralazine+Nitrates), Spironolactone/Eplerenone, Diuretics

301
Q

Treatment of Hypertrophic CM

A

Same Tx as Diastolic dysfxn
BB
Diuretics

302
Q

Tx of Restrictive CM

A

Correct underlying cause

303
Q

What is HOCM?

A

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
Q

How is HOCM and hypertrophic CM similar from a treatment standpoint?

A

Beta-blockers

305
Q

What increases the outflow tract obstruction in HOCM?

A

Anything that EMPTIES the ventricle

306
Q

What clinical symptoms is HOCM assoc with?

A

Syncope and rarely sudden cardiac death in healthy young athletes.

307
Q

What will you be asked on rounds in regards to HOCM?

A
  1. Episodes of lightheaded ness
  2. LOC
  3. CP
  4. Previous studies (EKG, ECHO).
308
Q

Random: 25 year old female with extensive smoking history with chest pain possibly due to CAD. Next best step?

A

Pregnancy test before any invasive procedures like a Cath!

309
Q

Physical findings of HOCM?

A
  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
Q

What is the initial test for HOCM?

311
Q

What would EKG show for HOCM?

A

Left axis deviation, pseudo Q waves in V1-V3, ventricular arrhythmias.

312
Q

What is the most accurate test for HOCM?

A

Left heart catheterization

313
Q

Treatment of HOCM

A

Beta blocker - Metoprolol - FIRST THERAPY

Implantable defibrillator (for syncope prevention).

314
Q

Which medication/state can worsen HOCM?

A

Diuretics (deplete volume)
ACEI/ARBs
Dehydration
Digoxin

315
Q

SVT clinical presentation?

A

Sudden onset of palps/racing heart that may lead to SOB.

316
Q

What is the approximate HR in SVT?

317
Q

What are the specific physical exam findings of SVT

A

There are none.

318
Q

T/F ischemia is a common cause of SVT

A

False, if you think a pt has an acute MI and you think that’s causing palps, question whether they have an SVT.

319
Q

SVT is often caused by…

A

An abnormal conduction pathway around the AVN

320
Q

What are the important clinical characteristics to consider for SVT?

A

Palpitations
Lightheadedness
Speed of onset of symptoms

321
Q

Diagnose SVT with?

322
Q

SVT shows what on EKG?

A

Rapid, narrow complex (<100 msec) tachycardia, usually around 160 bpm. No P waves, no fibrillation waves, no flutter waves.

323
Q

What unit should SVT pts be in?

A

Telemetry unit

324
Q

Why should an ECHO be done for SVT?

A

To r/o other pathology. Nothing specific for SVT.

325
Q

Are CK-MB and Troponin useful in SVT?

A

No, but they always seem to be done.

326
Q

Tx of SVT

A
  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
Q

How does WPW present on EKG?

A

SVT
SVT alternating w/ Vtach
Delta wave found incidentally

328
Q

What is a delta wave?

A

sign of conduction around AV node – early depolorization of ventricles.

329
Q

How does WPW present clinically?

A

Palpitations
Lightheaded
Occasionally w/ Syncope

330
Q

What is the PR interval in WPW?

A

SHORT (<0.12 s) d/t accessory conduction.

331
Q

On rounds, when going over the WPW pt, what will you be asked?

A

Previous EKG
Worsening sx or arrhythmia w/ use of Digoxin/CCB/BB
Previous cath or EP studies

332
Q

What is the most accurate test for WPW?

A

Electrophysiology (EP) study - cath into heart tests cardiac circuits.

333
Q

Treatment of WPW?

A
  1. Procainamide (DOC), Amiodarone, Flecainide, or Sotalol [use for SVT occurring at the moment]
  2. Radiofrequency catheter Ablation (permanent, long-term)
334
Q

T/F Most WPW pts are not having an arrhythmia at present moment.

335
Q

If WPW patient is not having an arrhythmia at the present moment, what is next best step?

A

Refer to EP study to identify the abnormal accessory conduction tract. Eliminate the tract immediately w/ ablation.

336
Q

Which drugs must be avoided in WPW?

A

AV nodal blocking agents - BB, CCB, Digoxin b/c these may accelerate the current going through the accessory path.

337
Q

Why does current go faster to the ventricles through the accessory path as opposed to the normal AV node path?

A

B/c there’s no AVN pause component!

338
Q

Which arrhythmia is associated w/ COPD or severe lung dz?

A

MAT (Multifocal Atrial Tachycardia)

339
Q

MAT on EKG?

A

At least 3 different P-wave morphologies, with variable PR and RR intervals and normal QRS width.

340
Q

Treatment of MAT?

A

Same as Afib/aflutter, but may want to avoid BB (b/c of COPD association).
May also Oxygenate and ventilate.

341
Q

Would you use electrical cardioversion for MAT?

A

No, it’s ineffective.

342
Q

All pts with Ventricular Fibrillation need to have…

A

CPR started immediately followed by an Unsynchronized cardioversion.

343
Q

CPR =??

A

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
Q

Vfib = __ + __ = Vtach w/o a pulse

A

CPR + electric unsynchronized shock

345
Q

T/F Lidocaine > Amiodarone for ACLS

A

False. opposite

346
Q

What is the sequential plan for V-fib?

A
  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
Q

T/F V-tach is always considered an extreme emergency

348
Q

Any sustained Vtach needs the following rapid response:

A
  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
Q

Normal QRS –??

350
Q

Wide QRS in Vtach –??

A

> 120 ms and reproducibly regular.

351
Q

What is sustained Vtach?

A

30 sec or more of VTach

352
Q

What is non-sustained Vtach?

A

<30 sec of Vtach pattern

353
Q

Which pts commonly get runs of nonsustained Vtach?

A

ICU
telemetry
ED w/ limited hemodynamic effects

354
Q

What are the 3 most important issues of Vtach on the wards?

A
  1. Is BP normal (SBP>90-100)?
  2. Are brain, heart, and lungs perfused?
  3. Is the VT continuing?
355
Q

What is the most common cause of Vtach?

A

Myocardial ischemia – so always check for Hx of MI!

356
Q

Vtach patient should get what checked?

A
  1. CK-MB, Troponin
  2. e- levels (K, Mg, Ca)
  3. Oxygen
  4. Medications pt is on
  5. EKG
357
Q

Any anti-arrhythmic except which class can cause arrhythmia?

A

Beta-blockers

358
Q

Low levels of which electrolytes can cause Vtach?

A

Low Mg

Low Ca

359
Q

Can low O2 cause Vtach?

360
Q

What levels of K+ (generally) can cause vtach?

A

High or low

361
Q

What illicit drug can cause Vtach?

362
Q

Ventricular tachycardia is possible d/t any CM. Which CM is most commonly associated w/ Vtach?

A

Dilated CM w/ low EF

363
Q

Unstable pts w/ Vtach need…

A

immediate SYNCHRONIZED cardioversion to sinus rhythm.

364
Q

Unstable = ?

A

SBP < 90, AMS, CP, and Dyspnea

365
Q

Stable patients w/ Vtach are treated with…

A

Mg + Anti-arrhythmic (Amiodarone, Lidocaine, or Procainamide).

366
Q

What is the most important issue with Bradycardia?

A

hemodynamic Stability

367
Q

If patient has pulse < 60, next step?

A

EKG for etiology

368
Q

Which bradycardias require no further Tx?

A

Sinus brady
First degree AV block
Mobits I second degree AV block

IF ASYMPTOMATIC!

369
Q

Mobitz II and 3rd degree treatment?

A

Pacemaker required even if Asx!

If acute Sx…Atropine then Pacemaker

370
Q

Each large boc on EKG is how many seconds? milliseconds?

A

2 sec, 200 ms

371
Q

Over how many boxes will be considered bradycardia?

A

after 5 boxes. (300 – 150 – 100 – 75 –60…that’s 5)

372
Q

Why does pacemaker make it difficult to interpret ischemia?

A

Wide complex QRS and abnormal T-waves are present w/ pacer spikes

373
Q

Treatment of Unstable Bradycardia of any etiology?

A
  1. Atropine 0.5 -1.0 mg IV immediately (max 3 mg)
  2. Transcutaneous pacemaker
  3. Permanent Transvenous pm
374
Q

On EKG of atrial pacemaker, there may be 2 spikes. What are they?

A

The first pacer spike triggers the Atrium.

The second pacer spike triggers the Ventricle.

375
Q

What is sick sinus syndrome?

A

AKA “tachy-brady syndrome” - alternating fast and slow HR.

376
Q

If SSS pt has too slow of a rate (eg, pause > 3 s), tx?

377
Q

If SSS pt has too fast of a rate? Tx?

378
Q

What does the EKG show for Sick sinus syndrome?

A

Missing P waves, temporary Asystole-like picture, and restarting of P-waves spontaneously.

379
Q

Sx of SSS?

A

dizzy, confused, syncope, fatigue, CHF

380
Q

80-90% of the mortality with syncope is from ____ etiology?

A

cardiac and neurologic

381
Q

What are the most dangerous causes of syncope? [6]

A
  1. MI
  2. Ventricular arrhythmia
  3. Aortic Stenosis
  4. HOCM
  5. Seizure
  6. Brainstem stroke
382
Q

For almost any type of syncope, what is the inpatient evaluation? [5]

A
  1. EKG
  2. CK-MB, Troponin
  3. Telemetry
  4. ECHO
  5. O2, Glc, Na, and Ca level
383
Q

T/F In most cases, the cause of syncope will not be found

384
Q

For syncope, what is not your job, and what is?

A

Not your job to find a definite cause, but rather to find something that could be dangerous.

385
Q

HPI and PEx of Syncope must include?

A
  1. Was LOC sudden or gradual?
  2. Was recovery sudden or gradual?
  3. Any murmurs on exam?
386
Q

Most likely cause of sudden LOC?

A

Cardiac and neurologic causes (eg, MI, Seizures)

387
Q

Most likely cause of gradual LOC?

A

Toxi-metabolic causes: low Glc, Hypoxia, Drug OD

388
Q

Sudden regaining of consciousness usually points to a diagnosis of?

A

Cardiac cause: arrhythmia, MI, HOCM, or Aortic stenosis

389
Q

Gradual regaining of consciousness usually points to a diagnosis of?

A

Seizures, low glc, hypoxia, and drug OD

390
Q

If murmur is present, what is the cause of the syncope?

A

AS, MS, HOCM

391
Q

What is Bigeminy?

A

Every other beat is a PVC. Normal beats in between with narrow QRS (<100 ms). PVC with wide QRS.

392
Q

Does bigeminy need specific treatment?

393
Q

Can carotid disease cause syncope?

A

No! So no need to get carotid doppler!

394
Q

If you suspect a brainstem lesion causing syncope, what test should you get? And not get?

A

Do NOT get CT of head. Do get MRI. CT is useless.

395
Q

Should you get an EEG in syncope pt?

A

EEG would not help much…“low yield” test.

396
Q

If suspecting a cardiac cause of syncope, should you get an EKG?

A

Absolutely!

397
Q

If suspecting a cardiac cause of syncope, should you get an ECHO?

A

Depends…only if you hear a murmur. If no murmur, then ECHO is pretty useless.

398
Q

What can all forms of valve dz have in common?

A
  1. Dyspnea
  2. CHF
  3. Murmurs
  4. Edema
  5. Congenital or rheumatic fever
399
Q

Best initial test for valve dz?

400
Q

Most accurate test for valve dz?

A

Cath (can detect pressure difference)

401
Q

Should endocarditis prophylaxis be given to a pt with valve dz?

A

NO! Only if the valve was replaced.

402
Q

What decreases the intensity of mitral valve prolapse murmur?

A

increased venous return.

403
Q

What decreases the intensity of HOCM murmur?

A

increased venous return (more blood in ventricle = less obstruction)

404
Q

What actions can increase VR?

A

Raising legs passively

Squat from standing position

405
Q

What actions can decrease VR?

A

Standing

Valsalva

406
Q

What action can increase afterload?

407
Q

Handgrip can worsen ____ lesions.

A

Mitral and aortic regurge

408
Q

Handgrip may improve which murmur?

A

HOCM (keeps more blood in heart and decreases outflow obstruction).

409
Q

Aortic and Mitral Regurgitation can occur from any cause of _____ ______

A

dilated CM

410
Q

As heart dilates, the valve leaflets ___

411
Q

Cardiac dilation = ?

A

regurgitation

412
Q

Other than dilated CM, what are the other causes of regurtitant valve pathology?

A 
HTN
MI
Endocarditis
Myxomatous degeneration
Rare: Marfan's, Ehlers-Danlos, Ankylosing Spondylitis.
413
Q

T/F Most people with AR or MR are symptomatic

414
Q

When Sx, pts with MR/AR present w/ ?

A

Dyspnea, Rales, and Edema. Similar/Same as clinical presentation of Dilated CM.

415
Q

Murmur of AR is a _____ murmur heard best at____

A

diastolic decrescendo…………..Lower Left Sternal Border. Not in the “aortic area”!

416
Q

MR murmur is a _____ murmur type

A

pansystolic/holosystolic best heard at lower left heart border radiating to axilla.

417
Q

Both AR and MR become louder with ____

A

leg raise, handgrip, squatting [things that increase Venous Return and Afterload]

418
Q

Both AR and MR become softer with ____

A

Valsalva and standing…and ACEI/ARBs

decrease VR and Afterload

419
Q

Best test for AR/MR

420
Q

EKG of AR?

A

LVH — S wave in V1 and R wave in V5 > 35 mm

SV1 + RV5 > 35 mm = LVH

421
Q

CXR of MR and AR

A

Enlarged Left Atrium and Left Ventricle

422
Q

Initial therapy for AR/MR?

A

ACEI/ARBs or (Nifedipine?)

423
Q

Is there a need for Abx ppx before a dental procedure for AR or MR?

A

No, unless valve has been replaced.

424
Q

When is surgery (repair/replace) indicated for MR or AR?

A

When the EF drops or the Left Ventricular End-Systolic Diameter increases.

425
Q

Surgery indication for AR?

A

When EF < 50-55%
OR
LV End-Systolic Diameter (>50-55 mm) - about 2 inches

426
Q

Surgery indication for MR?

A

EF < 60%
OR
LV End-systolic Diameter > 45 mm

427
Q

Aortic stenosis triad?

A

Angina
CHF
Syncope

428
Q

Most common symptom of AS?

A

Angina

Not syncope!

429
Q

Symptom of AS –> Worst prognosis

A

CHF

Not syncope!

430
Q

Why is angina so common in pts with AS?

A

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
Q

Diagnosis of AS?

432
Q

EKG change in AS?

A

severe LVH

recall: SV1 + RV5 > 35 mm

433
Q

Why would stress tests and angiography be done in AS pts?

A

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
Q

Symptomatic AS pts - treated how?

A

“All” need surgical valve replacement (AVR)

435
Q

What is done to patients with AS who are too ill to undergo valve replacement?

A

Balloon valvuloplasty

436
Q

What is the role of ACEI/ARBs in AS?

A

Can worsen symptoms and don’t help

437
Q

When can diuretics be useful in pts with AS?

A

in cases of fluid overload. Note that pts with AS are very prone to volume depletion.

438
Q

Acute CHF + AS treated with?

A

Digoxin

No BB d/t acute CHF (decrease contractility not a good idea)

439
Q

Young immigrant + CHF – think about which valve problem>?

A

Mitral Stenosis

440
Q

young immigrant with rheumatic fever years ago and chronic mv scarring with MS may have what symptoms with MS?

A

Dysphagia
Hoarseness
Afib
Stroke at early age.

441
Q

MS can cause atrial __ which leads to ____ and pressure on the ______ and ______

A

atrial enlargement….Afib and pressure on the esophogus (dysphagia) and recurrent laryngeal nerve (hoarseness)

442
Q

EKG change on MS?

A

Left atrial enlargement = biphasic P wave in V1 and V2.

443
Q

CXR for MS?

A

Left atrial enlargement
“Double Bubble” extra density behind the heart
Pushing up the Left main stem bronchus
Straightening of left heart border.

444
Q

Best test for MS

A

TEE – fish mouth shape MV

445
Q

Most accurate test for MS

A

Left heart cath

446
Q

Tx of MS

A

Diuretics for fluid overload
Balloon valvuloplasty (MVR if fails)
Digoxin or BB for atrial arrhythmia control

447
Q

Role of endocarditis ppx for MS?

A

none unless replaced MV

448
Q

Most pts with MVP are (sx or asx)

449
Q

When MVP is Sx, what are the sx?

A

Palps

Atypical chest pain (not related to exertion and not relieved by rest)

450
Q

Describe murmur of MVP

A

Mid-systolic click followed by Late-systolic murmur of MR.

451
Q

MVP worsens with?

A

Valsalva and standing (decreased VR)

452
Q

MVP improved with?

A

Squatting and leg raise (increase VR)

453
Q

Dx of MVP?

454
Q

EKG of MVP?

455
Q

CXR of MVP?

456
Q

Treatment of MVP?

A

If Asx - nothing (no endocarditis PPX)

Sx (palps and CP) - BB

457
Q

Marfan syndrome may present with what valve abnormality?

A

Floppy mitral valve (MVP, MR) –> sudden cardiac death.

and Cystic medial necrosis–> Aortic dissection.

458
Q

Acute pericarditis CP?

A

CP that changes with position and respiration.

459
Q

Pain of acute pericarditis is better with? worse with?

A

better w/ sitting up

worse w/ lying down and inspiration

460
Q

Acute pericarditis on auscultation?

A

70-75% - nothing!

25-30% - friction rub

461
Q

Things to ask of /look for in patient suspected of pericarditis?

A
  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
Q

Most common class of infections that can cause pericarditis…

A

viruses!

any infection can do it though

463
Q

EKG of pericarditis

A

ST-elevations in all leads except aVR.

PR-segment depressions (more specific!)

464
Q

the lead that does not have ST elevations in acute pericarditis is usually lead ___?

465
Q

Tx pericarditis

A

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
Q

What is CP of Pericardial Tamponade?

A

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
Q

what is the relationship b/w heart rate and pericardial tamponade ?

A

tachycardia is present and when it isn’t tamponade is very unlikely.

468
Q

Pt with BP 85/30, HR 120, JVP 13, and decreased heart sounds. What is the MLDx? And what are the possible causes?

A

MLDx = Pericardial tamponade

infections (most viral), CT disorders, cancers, recent MI, uremia, chest trauma,

469
Q

What can pericadial tamponade look like on CXR?

A

pericardial effusion enlarges heart shadow in both left and right direction.

470
Q

ECHO of pericardial tamponade

A

effusion pressing on RIGHT side of heart with right atrial and ventricular DIASTOLIC collapse as FIRST SIGN.

471
Q

EKG shows low voltage….what are the possible causes?

A

Obesity, large breasts, COPD, pericardial tamponade

472
Q

EKG of pericardial tamponade may show low voltage and another interesting finding…

A

“electrical alterans” - variation in height of QRS complexes b/c heart “swims” in the fluid.

473
Q

Pt with pericardial tamponade gets Cath for whatever reason. What do you expect to see with diastolic pressures?

A

Equal pressures in ALL 4 chambers during diastole.

Note: cath rarely done

474
Q

Treatment of pericardial tamponade?

A

Fluids! – prevent and possibly reverse tamponade (push back)

Needle peri-cardiocentesis

Pericardial window placement.

475
Q

What is constrictive pericarditis due to?

A

Chronic pericardial INFECTION or INFLAMMATION leads to chronic thickening, fibrosis, and calcification of the pericardium.

476
Q

CP of constrictive pericarditis

A
  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
Q

What is Kussmaul’s sign?

A

inhalation –> paradoxical increase in JVP.

Normally inhalation –> increase VR –> decrease JVP.

478
Q

CXR of constrictive pericarditis?

A

fibrosis, thickening, and calcification of pericardium

479
Q

Chest CT/MRI of constrictive pericarditis?

A

fibrosis, thickening and calcification of pericardium in much better detail.

480
Q

ECHO comparison b/w pericardial tamponade and constrictive pericarditis

A

ECHO less useful in Constr peri b/c fluid level is normal and heart moves normally.

481
Q

Treatment of constrictive pericarditis?

A

Surgical removal is the only effective tx.

Diuretics and salt restriction (decrease R-sided HF sx) - sx relief only

482
Q

T/F PAD is angina of the calves…

483
Q

PAD CP?

A

Think stable angina

  1. Pain in legs relieved by REST
  2. decreased peripheral pulses
  3. smooth, shiny skin in severe cases.
484
Q

Risk factors of PAD?

A

HTN, DM, HLD, TOBACCO SMOKING!

485
Q

How can pain be better in PAD?

A

rest, dangling over edge of bed

486
Q

pain worse in PAD?

A

worse on ANY type of exertion

spinal stenosis is worse with walking DOWNHILL

487
Q

Diagnostic testing for PAD?

A
  1. ABI
  2. Dopplers of LE
  3. Angiography
488
Q

A normal person’s Ankle pressure will ____ arm (brachial) pressure when _____.

A

equal

lying flat

489
Q

When upright, ankle pressure is normally ____ than arm pressure

A

greater

thus, ABI 1.0-1.2 are NORMAL! - mind blown!

490
Q

If ankle pressure is lower than brachial pressure by more than ___ % (i.e. ABI ___), then we suspect _____???___

A

> 10%
ABI <0.9
obstruction to flow of blood in legs

491
Q

PAD Tx

A
  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

Internal Medicine - MTW - Fischer (11 decks)

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