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Clinical Lecture Series 1 > Chest Pain and A.fib TBL > Flashcards

Chest Pain and A.fib TBL Flashcards

1
Q

How is the wells clinical prediction for pulmonary embolism interpreted?

A

Greater than six points: high-risk 2 to 6 points: moderate risk
less than two points: low risk

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2
Q

What is responsible for 40% of ER chest pain visits?

A

Musculoskeletal conditions and chest wall pain

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3
Q

List the top 3 causes of chest pain in primary care setting in order

A

Chest wall pain, reflux esophagitis, costochondritis

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4
Q

What are the four best independent predictors of musculoskeletal (versus cardiac or pulmonary) chest pain?

A

Absence of cough, stinging pain, pain that is reproducible on palpation, localized muscle tension

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5
Q

Which electrocardiogram findings can be used to predict acute MI?

A

ST elevation, new left bundle branch block, Q waves, hyperacute T waves

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6
Q

List key predictors of acute MI in patients with nearly normal ECG findings

A

Male sex,
older than 60,
pressure type pain,
pain radiating to arm, shoulder, neck or jaw

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7
Q

What five factors are used to predict patients whose chest pain is caused by CAD?

A 
Age 55 or older in men, 65 or older in women 
Known CAD or CVD
Pain not reproducible by palpation 
Pain worse during exercise 
Patient assumes pain is cardiogenic
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8
Q

How is risk calculated in clinical decision rule for determining chest pain caused by CAD?

A

Each variable worth 1 point
0 to 1 points: low risk
2 to 3 points: moderate risk
4 to 5 points: high-risk

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9
Q

What should you do for a patient with chest pain with low risk of MI?

A

Evaluate for non-cardiac causes

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10
Q

What should you do for a patient with chest pain at moderate risk for MI?

A

Order ECG to look for findings consistent with ischemic heart disease, and if positive give oxygen aspirin and transport to emergency department

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11
Q

What should you do for a patient with chest pain at high risk for MI?

A

Order ECG, give oxygen and aspirin and transport to emergency department

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12
Q

What should be done if moderate risk chest pain patient has normal ECG or nonspecific ST waves?

A

Order troponin testing, get eval by cardiologist and stress testing

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13
Q

What four components of an ECG indicate MI?

A

ST segment changes, new onset left bundle branch block, presence of Q waves, and new onset T-wave inversions

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14
Q

What should the initial approach to patient with chest pain be?

A

Always consider a cardiac etiology first

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15
Q

How does the presence of comorbidities (like diabetes, smoking, hyperlipidemia, hypertension) affect prediction of ACS in patients older than 40?

A

They are only weak predictors but should be included in initial assessment

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16
Q

Which seven factors are used to predict pulmonary embolism?

A

Clinical symptoms of DVT, other diagnoses less likely, tachycardia, immobilization within the past four weeks, previous DVT or PE, hemoptysis, malignancy

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17
Q

State the clinical triad of pericarditis

A

Pleuritic chest pain, pericardial friction rub, diffuse ECG ST T-wave changes

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18
Q

What is the best predictor of heart failure in clinical setting?

A

History of heart failure or acute MI

most present with dyspnea on exertion

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19
Q

Which three symptoms are present in 97% of those diagnosed with PE?

A

Dyspnea, tachycardia, and chest pain

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20
Q

Which symptoms are common in Thoracic aortic dissection?

A

Pain radiating to back, pulse differential in upper extremities

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21
Q

What is the CHADS method of identifying patients at increased risk of stroke?

A

Congestive heart failure, hypertension, age over 75, diabetes mellitus, previous stroke

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22
Q

Which patients is adjusted-dose warfarin recommended for?

A

All patients with non-valvular a fib who are at high risk of stroke and for some who are at moderate risk

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23
Q

Which patients is antiplatelet therapy with aspirin recommended for?

A

Patients with a fib at low risk of stroke and for some patients at moderate risk

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24
Q

What medication should be given to high-risk stroke patients with a fib and contraindications to anticoagulants?

A

Dual antiplatelet therapy with Plavix (clopidogrel) and aspirin

25
Q

What therapy should be given to patients with history of ischemic stroke to have a fib?

A

Vitamin K antagonists

26
Q

What combination of medicine carries a similar hemorrhagic risk to warfarin and should therefore be avoided in patients with history of stroke?

A

Clopidogrel and aspirin

27
Q

When is dabigatran prescribed?

A

Patients with a fib and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve, renal failure, or liver disease

28
Q

When is Rivaroxaban prescribed?

A

To prevent strokes in patients with a fib though no AHA recommendations exist

29
Q

What are two major problems with dabigatran, Rivaroxaban, and apixaban?

A

They have short half-lives, so patients who do not comply and missed doses may be at risk of thromboembolism
There are no antidotes to the drugs in cases of hemorrhage

30
Q

Which four antithrombotics are approved for prevention of first and recurrent stroke in patients with a fib?

A

Warfarin, apixaban, rivaroxaban, and dabigatran

31
Q

How is dosing determined for dabigatran?

A

Dabigatran-150 mg twice a day (or 75 mg twice a day if severe renal impairment-creatinine clearance of 15 to 30 mL per minute)

32
Q

How is dosing determined for Apixaban?

A

Apixaban – 5 mg twice a day (or 2.5 mg twice a day if patient has two or more of the following characteristics: 80 or older, 133 pounds or less, serum creatinine of 1.5 or greater)

33
Q

How is dosing determined for Rivaroxaban?

A

For patients with nonvalvular a fib at moderate to high risk of stroke, give 20 mg per day (or 15 mg per day if renal impairment-creatinine clearance of 15-50 mL per minute)
Do not use if creatinine clearance is less than 15 mL per minute

34
Q

Is it more important to control rate or rhythm in a fib patients?

A

Rate control is preferred but rhythm control is an option for patients whose rate control cannot be achieved or who have symptoms despite rate control

35
Q

What additional treatment is needed in addition to rate and rhythm control to prevent stroke?

A

Anticoagulation therapy (warfarin preferred over aspirin and clopidogrel)

36
Q

What is the current recommendation for rate control and a fib patients?

A

Rate of less than 80 bpm

37
Q

What are two surgical options for a fib treatment?

A

Disruption of abnormal conduction pathways in atria and obliteration of left atrial appendage

38
Q

What two mechanisms are associated with triggering and maintaining a fib?

A

Enhanced automaticity in depolarizing foci, and reentry involving one or more aberrant circuits

39
Q

What does chronic remodeling seen in a fib lead to?

A

Irreversible atrial enlargement

40
Q

Which type of a fib carries the highest risk of stroke?

A

Valvular a fib caused by structural changes in mitral valve or congenital heart disease

41
Q

Which a fib has the best prognosis and typically occurs in patients younger than 60 with no identifiable cause?

A

Lone a fib

42
Q

What are the most commonly reported symptoms of a fib?

A

Palpitations, dyspnea, fatigue, lightheadedness, chest pain

43
Q

What is used to diagnose a fib if ECG is nonspecific?

A

Holter monitor or cardiac event monitor

44
Q

What treatment should be given to patients who are unstable because of hypotension, ischemia, heart failure, or CV events?

A

Emergency electrical cardioversion

45
Q

List the two drugs used to control rate in a fib patients and state which is first-line agent

A

Beta blockers (first-line agent) and calcium channel blockers

46
Q

Why is digoxin no longer used for rate control in a fib?

A

It has little effect during exercise-slows ventricular rate mostly by enhancing vagal tone

47
Q

When should someone with a fib initiate anticoagulation (warfarin) therapy?

A

Three weeks before and four weeks after cardioversion

48
Q

List some medications commonly used for cardioversion

A

Ibutilide, Flecainide, dofetilide, sotalol, amiodarone

49
Q

Which medication used for cardioversion is a non-iodinated safer derivative of amiodarone?

A

Dronedarone

50
Q

Which cardioversion medications are preferred in patients with heart failure?

A

Amiodarone and dofetilide

51
Q

Which cardioversion medications are preferred in patients with preserved left ventricular systolic function?

A

Flecainide and propafenone

52
Q

What should the INR of a patient taking warfarin be?

A

2–3

53
Q

At what INR does the risk of stroke double?

A

1.8

54
Q

Who are at higher risk of thromboembolic events, men or women?

A

Women

55
Q

What CHADS score merits warfarin treatment?

A

2 or greater (moderate and high risk patients)

56
Q

What treatment should patients with a zero or one CHADS risk score undergo?

A

Aspirin 81 to 325 mg per day

57
Q

What factors are included to assess outpatient bleeding risk index in patients taking warfarin?

A

Older than 65, history of stroke, history of G.I. bleed, and one or more of the following: recent MI, severe anemia, diabetes, or renal impairment (each is one point)

58
Q

Where do the majority of thrombi form?

A

In the left atrial appendage

59
Q

When should an a fib patient be referred to cardiology?

A

Complex cardiac disease,
remains symptomatic on pharmacologic rate control, potential candidates for ablation or surgical treatment,
when they require a pacemaker or defibrillator

Clinical Lecture Series 1 (9 decks)

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