Clin Med Exam 1 Flashcards
1
Q
EKG
ELECTROcardiography
A
machine detects the electrical activity of the heart
2
Q
Test for Acute Chest Pain
A
EKG
3
Q
Telemetry
A
Continuous EKG monitoring in inpatient setting
4
Q
When to do Telemetry
A
Hospital admission for CP or possible ACS-Acute Coronary Syndrome
5
Q
Cardiac regulatory protein that controls the calcium-mediated Actin-Myosin interaction
regulates muscle contraction
A
Troponin
6
Q
CTn-I
A
only in the heart
7
Q
CTn-T
A
in heart and skeletal muscle
8
Q
High sensitivity cardiac troponin
A
preferred, cardiac specific
9
Q
Troponin
A
preferred method of dx and prognosis in Acute MI
more sensitive and specific than CK-MB
10
Q
Troponin is increased in
A
trauma, surgery, inflammation, and infection
“biomarker of cardiac injury”
11
Q
CK
A
isoenzyme in a bunch of tissues: heart, brain, and skeletal muscle
12
Q
CK-MB
A
more specific for cardiac injury than regular CK (not as much as trop)
any form of heart damage can increase CK-MB (ischemia, trauma, surgery, inflammation, infection)
13
Q
How long does elevated CK last
A
36-48 hours
14
Q
How long does elevated Troponin last
A
up to 14 days
15
Q
CK and Trop details
A
Onset 3-12 hrs after injury
Peak 18-24 hrs after injury
16
Q
ECHOcardiography (movie)
A
US of heart
crystal probe- transmit high frequency sound pulse into tissue
some of sound waves reflect back to probe and are picked up by machine displaying a 2D image on the monitor
17
Q
TransTHORACIC echo
A
evaluate cardiac Anatomy and Function
18
Q
Indications for TransTHORACIC echo
A
evaluate Wall Motion
calculate Ejection Fraction/Systolic Fx
Evaluate Valve Structure and Fx
19
Q
TransESOPHAGEAL echo
A
reveals Posterior cardiac structures
Can detect:
Clots
Valvular pathology (vegetations in endocarditis)
20
Q
Contraindications of TransESOPHOGeal echo
A
AMS, compromised cardio-resp status, recent or active esoph tear or hemorrhage, coagulopathies, thrombocytopenia, esoph stricture
21
Q
inadequate oxygen supply
A
hypOperfusion
22
Q
3 types of stress test
A
EKG stress test
Nuclear stress test
Stress echo
23
Q
Indications for Cardiac Stress Test
A
Exertional CP
CHD with new/worsening sx
Newly dx heart failure or cardiomyopathy
24
Q
Contraindications to all forms of stress testing
A
Acute MI w/in 48 hr Unstable/uncontrolled angina, cardiac arrhythmia (a-fib) severe, sx aortic stenosis uncontrolled heart failure or HTN severe pulm HTN acute aortic dissection acutely ill
25
Exercise EKG stress test, pt exercises to achieve
Target HR
Symptoms
Time limit
26
During Exercise EKG stress test, clinician looks for
EKG changes
Increased HR
Symptom development
27
Big difference with stress echo
more specific and can localize ischemia
28
Nuclear stress test
Radioactive tracer: Technetium-99m agents (or Thallium)
concentrate in areas of myocardium with adequate blood flow and living cells
29
Nuclear stress test
perfusion defect seen in areas of hypoperfusion
Take rest images, then add med and retake images
30
Vasodilators used in Nuclear Stress Test
Adenosine
| Dipyridamole
31
Ionotropes used in Nuclear Stress Test
Dobutamine (increases HR and contractility)
32
Nuclear stress test
Gamma-ray detection camera scans at rest and after stress
33
When to do Nuclear Stress Test?
Pt has abnormal resting EKG (rendering it useless)
Assess areas of ischemia
Location and size of injured muscle after MI
Dx Coronary artery stenosis
Evaluate how grafted vessels work after bypass surgery
34
Stress echo (movie)
More focused on development of WALL MOTION abnormality with stress/exercise
35
Stress echo (movie)
Peak stress images obtained once pt reaches 85% predicted HR
Exercise (treadmill) OR
Dobutamine (increase contractility) used to get pt to 85% predicted HR
36
Indications for stress echo (movie)
remember this is focused more on wall motion
Known of suspected CAD
Evaluation of CP, SOB, DOE
Evaluate valvular abnormalities
Pre-op risk assessment
37
Avoid stress echo (movie) in pts with
A-Fib or LBBB
38
Holter monitor
continuous recording, on for the whole duration of 24-48 hr
| keep sx diary
39
Indications for Holter monitor
```
Evaluation of syncope
PALPITATIONS
Rhythm recording
HR variability
ST segment monitoring
```
40
Event monitor
NOT continuous, only turns on if an "event" is experienced
worn for 30-60 days
pt must activate device (button) to capture previous 2-5 min and few subsequent min
signal then transmitted to interpreting center for eval
41
Implantable cardiac monitor
SubQ, records up to 3 years
automatically activated to programmed criteria
pt can also prompt device to record
42
Indications for Implantable cardiac monitor
```
Infrequent sx (remember this can record up to 3 yr)
Suspected arrhythmia but non-invasive testing has been negative or inconclusive
```
43
Fingertrip monitor
instant, portable EKG at home without clinician assistance
44
Indication for Fingertip monitor
MONITORING ARRHYTHMIAS such as A-Fib
EKG and HR can be synced to smartphone or computer
45
CT scan
combo of x ray images to produce cross-sectional images "slices" of specific areas
46
CCTA (coronary CT angiography)
Pt given IV CONTRAST and then CT scan of heart to evaluate for coronary artery occlusion
47
Coronary CT Calcium scan
NO contrast
| Assess for calcium deposits in the coronary arteries and therefore risk of MI
48
Cardiac CT useful for
Evaluating Thoracic aorta and Pericardium which are less mobile
49
Major applications for Cardiac CT
Detect Aortic dissection (major one)
| Detect Coronary Artery calcium
50
Indications for Cardiac CT
Stable angina
Acute Coronary Syndrome
AORTIC DISSECTION (main one)
51
Contraindications to Cardiac CT
Allergic to contrast dye
| Severe Renal insufficiency
52
Cardiac MRI
Assess Functional and Tissue properties of heart
53
Indications
used AFTER evaluation with 1st line testing, such as echo
For complicated and advanced dz patients
54
Cardiac MRI Indications
Myocardial, valvular, pericardial dz
cardiac tumor
coronary artery dz
myocardial perfusion (w gadolinium contrast) during adenosine stress
55
Contraindications for cardiac MRI
Metal or electrical implants, devices, or foreign bodies
56
Cardiac cath/coronary angiography
Gold standard for diagnosing CAD
57
Indications for cardiac cath/coronary angiography
Known/suspected CAD***
```
also,
unstable angina
angina and + stress test
history of MI w/EKG change
Post-resusc from cardiac arrest
atypical CP
b4 valve surgery
```
58
Statins
lower LDL
Adverse: Liver toxic, myopathy, drug interactins
If myositis (Rhabdo), discontinue and check CK level
59
Fibrate
lower Triglycerides (main use)
Do NOT use with statin- increased risk of toxicity
60
Niacin
lower LDL, raise HDL
Adverse: Flushing
Check LFT, caution use with Statin
61
Bile Acid Sequestrant
lower LDL
SAFE in pregnancy
synergistic w Statin
Adverse: Can INCREASE Triglycerides, GI side effects
62
Ezetamibe
lower LDL, statin add-on
BUT, dont use with statin in liver dz
63
PCSK9 Inhib
lower LDL, statin add on
| expensive injections
64
Drugs to use with Statins
Bile acid sequestrant
Ezetimibe (as long as no liver dz)
PCSK9 Inhibitor
65
Not recommended to use with Statins
Nicotinic Acid
Fibric Acid
(N and F Acid)
Bile Acid is ok to use w/Statin
66
Cholesterol
<200 desirable
240 high risk
67
Triglycerides
<150 desirable
200-499 high risk
68
HDL
60 desirable
<35 high risk
69
LDL
60-130 desirable
160-189 high risk
70
Bile Acid Sequestrant aka Resins
bind bile acid in intestine, lower LDL, synergistic w/Statin
safe during pregnancy!
Risk of increasing Trig
71
Nicotinic Acid
lower LDL and increase HDL
Flushing and pruritus side effect
72
Fibric Acid
main use: Lowering Triglycerides
can also increase HDL
73
Drugs that can affect Warfarin use
Bile Acid Sequestrant (adverse effect)
Fibric Acid Derivative (relative contraindication)
74
Statin Benefit Group #1 (secondary prevention, preventing recurrence)
Individuals with Atherosclerotic Cardiovascular Dz (ASCVD)
- Acute coronary syndrome
- Hx MI
- Symptomatic PAD
- Stroke or TIA
75
Statin Benefit Group #2
those with LDL >/ 190
76
Statin Benefit Group #3
those w DM 40-75 YO
WITH
LDL >/ 70
77
Statin Benefit Group #4
those w/o ASCVD or DM but with LDL 70-189
AND
estimated 10-yr ASCVD risk >/ 7.5%
78
Tool to estimate ASCVD risk
Pooled Cohort Eq'ns
79
1st line med for Acute Angina
Nitroglycerin (short acting, decreased preload)
80
1st line med for Chronic Angina
Beta blocker (long acting, decreased afterload)
81
Decreasing O2 meds that decrease AFTERload
Beta blockers and CCB-calcium channel blocker
82
Decreasing O2 med that decreases PREload
Nitrate
83
Use this when pts dont respond to Nitrates or Beta blockers
CCB
84
Meds that both decrease oxygen demand AND increase oxygen supply
Nitrates
| CCBs
85
Dilated Cardiomyopathy-CDM
Idiopathic
| S3 gallop
86
Gold standard for diagnosing Infectious DCM
Endomyocardial biopsy
87
Peripartum DCM Risk Factors
```
>30
African American
hx precampslia
Maternal cocaine
>4 wks use of Oral Tocolytic
```
88
Presentation of Peripartum DCM
36 wks-5 months postpartum
Dyspnea, PND, pedal edema, cough, hemoptysis
89
Diagnosis of Peripartum DCM
Increased BNP
| Echo EF <45
90
Alcoholic DCM
about 6 drinks per day for 5-10 yrs
91
Tachycardia mediated DCM
130-200 bpm sustained rapid ventricular rates
92
Echo of Dilated Cardiomyopathy will show:
Dilated ventricle(s), reduced LV systolic function (decreased EF)
93
1st line med for Dilated Cardiomyopathy
ACE- Inhibitors
94
What do ACE-I do?
Vasodilation- reduce afterload on the heart
| Reduce BP
95
Beta blockers
decrease oxygen demand from the heart
96
Digoxin
(+) ionotrope, use if person fails to respond to other treatment
97
Digoxin
used in A-fib, fatigue, dyspnea
98
When to use Anti-coag for Dilated Cardiomyopathy
If A-fib present,
Ejection Fraction <30
hx of clot
presence of mural clot
99
Histological hallmark of Hypertrophic Cardiomyopathy
myocyte hypertrophy and disarray, interstitial fibrosis
100
Factors that WORSEN LVOT in Hypertrophic Cardiomyopathy
```
Tachycardia
Hypovolemia
Standing, Vasalva
(+) Ionotrops
Diuretics
Vasodilators
```
101
S4 gallop found in
Hypertrophic Cardiomyopathy
102
How to increase murmur heard with Hypertrophic Cardiomyopathy
Vasalva and Standing
103
How to decrease murmur heard with Hypertrophic Cardiomyopathy
Squat and Isometric hand grip
104
Echo of Hypertrophic Cardiomyopathy shows:
Increased LV thickness: >/15 mm is diagnostic
105
Stress/Exercise Echo for someone with Hypertrophic Cardiomyopathy
Risk stratify
| Assess LVOT
106
Preferred Meds to treat Hypertrophic Cardiomyopathy
Beta blockers
Calcium channel blockers (Nd)
both are (-) ionotropes
107
Surgery for Hypertrophic Cardiomyopathy
if someone has sx of LVOT obstruction and isnt responding to Meds
108
3 surgeries for Hypertrophic Cardiomyopathy
Surgical septal myectomy
EtOH ablation
Mitral valve surgery
109
Restrictive Cardiomyopathy
Non dilated rigid ventricles
Diastolic issue (restrictie filling)
110
Ejection fraction in Restrictive Cardiomyopathy?
Preserved!!
111
Restrictive Cardiomyopathy does what to the Atria
cause them to Hypertrophy bc they are having to work much harder to pump blood into the ventricles
112
Restrictive cardiomyopathy
the least common cardiomyopathy
Amyloidosis is the most common cause
113
Restrictive Cardiomyopathy presentation
will have "Right Heart Failure" like sx
114
Restrictive Cardiomyopathy
S3 gallop
JVP
Kussmaul's sign
115
Cardiac Amyloidosis (cause of RCM)
Elevated JVP
Hepatomegaly
Ascites
Peri-orbital purpura
116
Echo of Cardiac Amyloidosis
Increased ventricular wall thickness with diastolic dysfunction
later Right diastolic dysfx develops
117
Definititive dx of Cardiac Amyloidosis
Endomyocardial biopsy
118
Echo of Restrictive Cardiomyopathy will show:
Atrial enlargement!!
Normal/small ventricle cavity
(amyloid can cause wall to thicken)
Normal Ejection fraction, BUT abnormal filling
119
Cardiac MRI for RCM
chamber size, wall thickness, infilatraion, inflamation, fibrosis
120
The only 2 pathologies that Cardiac MRI is mentioned for
Restrictive Cardiomyopathy and Takitbutso Cardiomyopathy
121
TCM Takibutso
Left venricular Systolic AND Diastolic dysfx (tansient)
122
EKG of TCM
STE and TWI
123
At d/c, what meds do you Rx to someone with Takitsubo?
ASA, Beta blocker, ACE-I until LV fully recovers
124
4 criteria to diagnose someone with Tabotsubo
1. transient wall abnormalities of left ventricle
2. no CAD or plaque rupture
3. new EKG abn
4. absence of Pheo or Myocarditis
125
Chylomicrons
carry dietary lipids
126
VLDL
carry triglycerides
127
LDL
carry cholesterol
128
Both inherited types of hypercholesterolemia
Familial (one gene)
Polygenic (many, obviously)
Treat with statin
129
Secondary hyperlipid (non lipid etiology)
less common than inherited
130
Screen for hyperlipid
9-11 YO
| again at 17-21 YO
131
Plane xanthomas
chol filled soft yellow plaques
can be familial or secondary cause
132
Tuberous xanthomas
yellow-orange nodules often over knees and elbows
can also be tendinous
assoc w FAMILIAL
133
Tuberous xanthomas
elbows, knees
| FAMILIAL
134
Eruptive xanthoma
small red-yellow papules
Elevated TRIGLYCERIDES
may indicate Familial
135
Statins
inhibit HMG-CoA reductase, rate limiting in cholesterol synthesis
136
Statins
Rhabdo, liver toxic
| give at bedtime
137
Contra-indications to Statins
Acute Liver dz
| Pregnancy
138
Caution when using a Statin
and other CYP3A4 inhibitors
139
Med to lower triglycerides
Fibric Acid
140
Med that has a risk of raising triglycerides
Bile Acid
141
Statins
Lower LDL
142
Fibrates
Decrease triglycerides
143
Niacin
Raise HDL, lower LDL
144
Bile acid
lower LDL BUT be careful can raise triglycerides.
Safe in pregnancy.
can use with statin
145
Statin add-on
Bile acid
Ezetamibe
PCSK9
146
1st line Med for Acute Angina
Nitro (a preload reducer)
147
1st line Med for Chronic Angina
Beta blocker (an afterload reducer)
