Clin Med Exam 1 Flashcards
EKG
ELECTROcardiography
machine detects the electrical activity of the heart
Test for Acute Chest Pain
EKG
Telemetry
Continuous EKG monitoring in inpatient setting
When to do Telemetry
Hospital admission for CP or possible ACS-Acute Coronary Syndrome
Cardiac regulatory protein that controls the calcium-mediated Actin-Myosin interaction
regulates muscle contraction
Troponin
CTn-I
only in the heart
CTn-T
in heart and skeletal muscle
High sensitivity cardiac troponin
preferred, cardiac specific
Troponin
preferred method of dx and prognosis in Acute MI
more sensitive and specific than CK-MB
Troponin is increased in
trauma, surgery, inflammation, and infection
“biomarker of cardiac injury”
CK
isoenzyme in a bunch of tissues: heart, brain, and skeletal muscle
CK-MB
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)
How long does elevated CK last
36-48 hours
How long does elevated Troponin last
up to 14 days
CK and Trop details
Onset 3-12 hrs after injury
Peak 18-24 hrs after injury
ECHOcardiography (movie)
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
TransTHORACIC echo
evaluate cardiac Anatomy and Function
Indications for TransTHORACIC echo
evaluate Wall Motion
calculate Ejection Fraction/Systolic Fx
Evaluate Valve Structure and Fx
TransESOPHAGEAL echo
reveals Posterior cardiac structures
Can detect:
Clots
Valvular pathology (vegetations in endocarditis)
Contraindications of TransESOPHOGeal echo
AMS, compromised cardio-resp status, recent or active esoph tear or hemorrhage, coagulopathies, thrombocytopenia, esoph stricture
inadequate oxygen supply
hypOperfusion
3 types of stress test
EKG stress test
Nuclear stress test
Stress echo
Indications for Cardiac Stress Test
Exertional CP
CHD with new/worsening sx
Newly dx heart failure or cardiomyopathy
Contraindications to all forms of stress testing
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
Exercise EKG stress test, pt exercises to achieve
Target HR
Symptoms
Time limit
During Exercise EKG stress test, clinician looks for
EKG changes
Increased HR
Symptom development
Big difference with stress echo
more specific and can localize ischemia
Nuclear stress test
Radioactive tracer: Technetium-99m agents (or Thallium)
concentrate in areas of myocardium with adequate blood flow and living cells
Nuclear stress test
perfusion defect seen in areas of hypoperfusion
Take rest images, then add med and retake images
Vasodilators used in Nuclear Stress Test
Adenosine
Dipyridamole
Ionotropes used in Nuclear Stress Test
Dobutamine (increases HR and contractility)
Nuclear stress test
Gamma-ray detection camera scans at rest and after stress
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
Stress echo (movie)
More focused on development of WALL MOTION abnormality with stress/exercise
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
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
Avoid stress echo (movie) in pts with
A-Fib or LBBB
Holter monitor
continuous recording, on for the whole duration of 24-48 hr
keep sx diary
Indications for Holter monitor
Evaluation of syncope PALPITATIONS Rhythm recording HR variability ST segment monitoring
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
Implantable cardiac monitor
SubQ, records up to 3 years
automatically activated to programmed criteria
pt can also prompt device to record
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
Fingertrip monitor
instant, portable EKG at home without clinician assistance
Indication for Fingertip monitor
MONITORING ARRHYTHMIAS such as A-Fib
EKG and HR can be synced to smartphone or computer
CT scan
combo of x ray images to produce cross-sectional images “slices” of specific areas
CCTA (coronary CT angiography)
Pt given IV CONTRAST and then CT scan of heart to evaluate for coronary artery occlusion
Coronary CT Calcium scan
NO contrast
Assess for calcium deposits in the coronary arteries and therefore risk of MI
Cardiac CT useful for
Evaluating Thoracic aorta and Pericardium which are less mobile
Major applications for Cardiac CT
Detect Aortic dissection (major one)
Detect Coronary Artery calcium
Indications for Cardiac CT
Stable angina
Acute Coronary Syndrome
AORTIC DISSECTION (main one)
Contraindications to Cardiac CT
Allergic to contrast dye
Severe Renal insufficiency
Cardiac MRI
Assess Functional and Tissue properties of heart
Indications
used AFTER evaluation with 1st line testing, such as echo
For complicated and advanced dz patients
Cardiac MRI Indications
Myocardial, valvular, pericardial dz
cardiac tumor
coronary artery dz
myocardial perfusion (w gadolinium contrast) during adenosine stress
Contraindications for cardiac MRI
Metal or electrical implants, devices, or foreign bodies
Cardiac cath/coronary angiography
Gold standard for diagnosing CAD
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
Statins
lower LDL
Adverse: Liver toxic, myopathy, drug interactins
If myositis (Rhabdo), discontinue and check CK level
Fibrate
lower Triglycerides (main use)
Do NOT use with statin- increased risk of toxicity
Niacin
lower LDL, raise HDL
Adverse: Flushing
Check LFT, caution use with Statin
Bile Acid Sequestrant
lower LDL
SAFE in pregnancy
synergistic w Statin
Adverse: Can INCREASE Triglycerides, GI side effects
Ezetamibe
lower LDL, statin add-on
BUT, dont use with statin in liver dz
PCSK9 Inhib
lower LDL, statin add on
expensive injections
Drugs to use with Statins
Bile acid sequestrant
Ezetimibe (as long as no liver dz)
PCSK9 Inhibitor
Not recommended to use with Statins
Nicotinic Acid
Fibric Acid
(N and F Acid)
Bile Acid is ok to use w/Statin
Cholesterol
<200 desirable
240 high risk
Triglycerides
<150 desirable
200-499 high risk
HDL
60 desirable
<35 high risk
LDL
60-130 desirable
160-189 high risk
Bile Acid Sequestrant aka Resins
bind bile acid in intestine, lower LDL, synergistic w/Statin
safe during pregnancy!
Risk of increasing Trig
Nicotinic Acid
lower LDL and increase HDL
Flushing and pruritus side effect
Fibric Acid
main use: Lowering Triglycerides
can also increase HDL
Drugs that can affect Warfarin use
Bile Acid Sequestrant (adverse effect)
Fibric Acid Derivative (relative contraindication)
Statin Benefit Group #1 (secondary prevention, preventing recurrence)
Individuals with Atherosclerotic Cardiovascular Dz (ASCVD)
- Acute coronary syndrome
- Hx MI
- Symptomatic PAD
- Stroke or TIA
Statin Benefit Group #2
those with LDL >/ 190
Statin Benefit Group #3
those w DM 40-75 YO
WITH
LDL >/ 70
Statin Benefit Group #4
those w/o ASCVD or DM but with LDL 70-189
AND
estimated 10-yr ASCVD risk >/ 7.5%
Tool to estimate ASCVD risk
Pooled Cohort Eq’ns
1st line med for Acute Angina
Nitroglycerin (short acting, decreased preload)
1st line med for Chronic Angina
Beta blocker (long acting, decreased afterload)
Decreasing O2 meds that decrease AFTERload
Beta blockers and CCB-calcium channel blocker
Decreasing O2 med that decreases PREload
Nitrate
Use this when pts dont respond to Nitrates or Beta blockers
CCB
Meds that both decrease oxygen demand AND increase oxygen supply
Nitrates
CCBs
Dilated Cardiomyopathy-CDM
Idiopathic
S3 gallop
Gold standard for diagnosing Infectious DCM
Endomyocardial biopsy
Peripartum DCM Risk Factors
>30 African American hx precampslia Maternal cocaine >4 wks use of Oral Tocolytic
Presentation of Peripartum DCM
36 wks-5 months postpartum
Dyspnea, PND, pedal edema, cough, hemoptysis
Diagnosis of Peripartum DCM
Increased BNP
Echo EF <45
Alcoholic DCM
about 6 drinks per day for 5-10 yrs
Tachycardia mediated DCM
130-200 bpm sustained rapid ventricular rates
Echo of Dilated Cardiomyopathy will show:
Dilated ventricle(s), reduced LV systolic function (decreased EF)
1st line med for Dilated Cardiomyopathy
ACE- Inhibitors
What do ACE-I do?
Vasodilation- reduce afterload on the heart
Reduce BP
Beta blockers
decrease oxygen demand from the heart
Digoxin
(+) ionotrope, use if person fails to respond to other treatment
Digoxin
used in A-fib, fatigue, dyspnea
When to use Anti-coag for Dilated Cardiomyopathy
If A-fib present,
Ejection Fraction <30
hx of clot
presence of mural clot
Histological hallmark of Hypertrophic Cardiomyopathy
myocyte hypertrophy and disarray, interstitial fibrosis
Factors that WORSEN LVOT in Hypertrophic Cardiomyopathy
Tachycardia Hypovolemia Standing, Vasalva (+) Ionotrops Diuretics Vasodilators
S4 gallop found in
Hypertrophic Cardiomyopathy
How to increase murmur heard with Hypertrophic Cardiomyopathy
Vasalva and Standing
How to decrease murmur heard with Hypertrophic Cardiomyopathy
Squat and Isometric hand grip
Echo of Hypertrophic Cardiomyopathy shows:
Increased LV thickness: >/15 mm is diagnostic
Stress/Exercise Echo for someone with Hypertrophic Cardiomyopathy
Risk stratify
Assess LVOT
Preferred Meds to treat Hypertrophic Cardiomyopathy
Beta blockers
Calcium channel blockers (Nd)
both are (-) ionotropes
Surgery for Hypertrophic Cardiomyopathy
if someone has sx of LVOT obstruction and isnt responding to Meds
3 surgeries for Hypertrophic Cardiomyopathy
Surgical septal myectomy
EtOH ablation
Mitral valve surgery
Restrictive Cardiomyopathy
Non dilated rigid ventricles
Diastolic issue (restrictie filling)
Ejection fraction in Restrictive Cardiomyopathy?
Preserved!!
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
Restrictive cardiomyopathy
the least common cardiomyopathy
Amyloidosis is the most common cause
Restrictive Cardiomyopathy presentation
will have “Right Heart Failure” like sx
Restrictive Cardiomyopathy
S3 gallop
JVP
Kussmaul’s sign
Cardiac Amyloidosis (cause of RCM)
Elevated JVP
Hepatomegaly
Ascites
Peri-orbital purpura
Echo of Cardiac Amyloidosis
Increased ventricular wall thickness with diastolic dysfunction
later Right diastolic dysfx develops
Definititive dx of Cardiac Amyloidosis
Endomyocardial biopsy
Echo of Restrictive Cardiomyopathy will show:
Atrial enlargement!!
Normal/small ventricle cavity
(amyloid can cause wall to thicken)
Normal Ejection fraction, BUT abnormal filling
Cardiac MRI for RCM
chamber size, wall thickness, infilatraion, inflamation, fibrosis
The only 2 pathologies that Cardiac MRI is mentioned for
Restrictive Cardiomyopathy and Takitbutso Cardiomyopathy
TCM Takibutso
Left venricular Systolic AND Diastolic dysfx (tansient)
EKG of TCM
STE and TWI
At d/c, what meds do you Rx to someone with Takitsubo?
ASA, Beta blocker, ACE-I until LV fully recovers
4 criteria to diagnose someone with Tabotsubo
- transient wall abnormalities of left ventricle
- no CAD or plaque rupture
- new EKG abn
- absence of Pheo or Myocarditis
Chylomicrons
carry dietary lipids
VLDL
carry triglycerides
LDL
carry cholesterol
Both inherited types of hypercholesterolemia
Familial (one gene)
Polygenic (many, obviously)
Treat with statin
Secondary hyperlipid (non lipid etiology)
less common than inherited
Screen for hyperlipid
9-11 YO
again at 17-21 YO
Plane xanthomas
chol filled soft yellow plaques
can be familial or secondary cause
Tuberous xanthomas
yellow-orange nodules often over knees and elbows
can also be tendinous
assoc w FAMILIAL
Tuberous xanthomas
elbows, knees
FAMILIAL
Eruptive xanthoma
small red-yellow papules
Elevated TRIGLYCERIDES
may indicate Familial
Statins
inhibit HMG-CoA reductase, rate limiting in cholesterol synthesis
Statins
Rhabdo, liver toxic
give at bedtime
Contra-indications to Statins
Acute Liver dz
Pregnancy
Caution when using a Statin
and other CYP3A4 inhibitors
Med to lower triglycerides
Fibric Acid
Med that has a risk of raising triglycerides
Bile Acid
Statins
Lower LDL
Fibrates
Decrease triglycerides
Niacin
Raise HDL, lower LDL
Bile acid
lower LDL BUT be careful can raise triglycerides.
Safe in pregnancy.
can use with statin
Statin add-on
Bile acid
Ezetamibe
PCSK9
1st line Med for Acute Angina
Nitro (a preload reducer)
1st line Med for Chronic Angina
Beta blocker (an afterload reducer)
