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CPR 2 Exam 1 > Clinical Cardiac Part 4 > Flashcards

Clinical Cardiac Part 4 Flashcards

1
Q

What is syncope?

A

Transient, self-limited loss of consciousness due to cerebral hypoperfusion

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2
Q

What are the characteristics of syncope?

A

Rapid onset
Brief duration
Recovery is spontaneous and complete

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3
Q

What are the three categories of syncope?

A

1) Neurally mediated
2) Cardiac
3) Orthostatic hypotension

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4
Q

What is the time frame for neurally mediated syncope?

A

Transient

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5
Q

What is the time frame for orthostatic hypotension?

A

Chronic

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6
Q

What are the subtypes of neurally mediated syncope?

A

Vasovagal syncope
Carotid sinus syndrome (reflex)
Situational syncope (reflex)

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7
Q

What is cardiac syncope?

A

Due to arrhythmias -> structural cardiac disease that cause a decrease in cardiac output

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8
Q

What are the subtypes of orthostatic hypotension?

A

Initial (immediate)
Classic
Delayed
Neurogenic

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9
Q

What are examples of syncope mimics?

A

Seizures
Sleep disturbance (cataplexy or narcolepsy)
Trauma (head injury)
Metabolic (hypoglycemia, acute intoxications)
Psychogenic/pseudo-syncome

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10
Q

What is the trimodal incidence of first syncopal episode?

A

20
60
80

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11
Q

What is the most common type of syncope?

A

Neurally mediated

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12
Q

What type of syncope occurs with change in position?

A

Orthostatic hypotension

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13
Q

What type of syncope occurs primary when the patient is supine?

A

Cardiac syncope

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14
Q

What type of syncope happens when a patient has fatigue, nausea, or vomiting after?

A

Neurally mediated syncope (vasovagal)

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15
Q

What type of syncope occurs when a patient is coughing, pooping, eating, laughing, or urinating?

A

Neurally mediated syncope (situational)

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16
Q

What type of syncope occurs when a patient has emotional distress, fear, pain, prolonged standing, warm, or crowded area?

A

Neurally mediated syncope (vasovagal)

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17
Q

What type of syncope occurs with exertion?

A

Cardiac syncope (arrhythmia, structural heart disease)

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18
Q

What type of syncope occurs with head movement, shaving, or tight collar?

A

Neurally mediated syncope (carotid sinus)

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19
Q

What are short term risk factors for syncope?

A 
Male sex
Old
Palpitations
Exertional syncope
HF
Structural heart disease
CAD
Trauma
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20
Q

What are long term risk factors for syncope?

A

Male sex
Old
Absence of nausea/vomiting preceding syncopal event
VA

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21
Q

What does the San Francisco Syncope Rule predict?

A

Serious outcomes at 7 days in patients presenting with syncope or near syncope

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22
Q

What are the aspects of the San Francisco Syncope Rule?

A 
Congestive heart failure history
Hematocrit < 30%
EKG abnormal (EKG changes, no sinus rhythm)
SOB symptoms
Systolic BP < 90 mmHg
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23
Q

What is the equation for cardiac output?

A

Rate x Stroke Volume

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24
Q

Where is blood pooled when we are standing and what does that result in?

A

Legs

Decreased venous return

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25
Q

Decreased return to the heart activates what?

A

Sympathetic nervous system

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26
Q

What are the orthostatic intolerance symptoms with neurally mediated syncope?

A

Dizziness
Lightheadedness
Fatigue

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27
Q

What are the autonomic activation symptoms in neurally mediated syncope?

A 
Diaphoresis
Pallor
Palpitations
Nausea
Hyperventillation
Yawning
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28
Q

What happens to the eyes in neurally mediated syncope?

A

Remain open and deviate upwards
Pupils dilated
Roving eye movement may occurs

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29
Q

Does urinary incontinence happen with neurally mediate syncope?

A

Maybe

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30
Q

Does fecal incontinence happen with neurally meditated syncope?

A

No

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31
Q

Does post-episode confusion happen with neurally mediated syncope?

A

No

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32
Q

What is the prodrome for neurally mediated syncope?

A 
Abdominal pain
Diaphoresis
Nausea
Blurred vision
Dizziness
Lightheadedness
Vertigo
Slow pulse
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33
Q

What is the definition of orthostatic hypotension?

A

Reduction in systolic BP of > 20 mmHg or diastolic > 10 mmHg within 3 minutes of standing

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34
Q

What are the symptoms with orthostatic hypotension?

A 
Light-headedness
Dizziness
Presyncope with sudden postural change
Generalized weakness
Fatigue
Cognitive slowing
Leg buckling
Headache
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35
Q

Is syncope preceded by warning symptoms in orthostatic hypotension?

A

Yes

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36
Q

What is the most concerning type of syncope?

A

Cardiac syncope

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37
Q

Is syncope preceded by warning symptoms in cardiac syncope?

A

No

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38
Q

What is the one symptom associated with cardiac syncope?

A

Palpitations

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39
Q

What history is a risk factor for cardiac syncope?

A

Family history of sudden death

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40
Q

What is the best approach for a patient with syncope?

A

Detailed history

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41
Q

What are the key elements of history taking in syncope?

A

LOC attributable to syncope?
Is there a history of CV disease?
Are there clinical features to suggest a specific cause of syncope?

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42
Q

What causes 5-15% of syncope cases?

A

Medications (do medication reconcilitation)

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43
Q

What can meds cause in terms of syncope?

A

Orthostatic hypotension
Sedation
Symptomatic bradycardia
QT interval prolongation

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44
Q

What should be focused on for the PE in syncope?

A

Vital signs
Cardiovascular
Neuro examination
Orthostatic vitals (BP and pulse)

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45
Q

Any ECG abnormality or change from baseline increases the risk of arrhythmia or death within how long from a syncopal event?

A

One year

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46
Q

What labs should be order for syncope?

A

CBC
CMP
BNP
Troponin

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47
Q

What should not be done in cases of syncope without focal neurologic findings or head injury?

A

CT
MRI
Carotid artery imaging

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48
Q

What should be done if you suspect neurogenic syncope?

A

Autonomic evaluation

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49
Q

What should be done if you suspect reflex neurally mediated syncope?

A

Tilt-table testing

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50
Q

What should be done if you suspect cardiac syncope?

A

Cardiac monitoring

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51
Q

What is tilt-table testing good for?

A

Suspected VVS
Suspected delayed OH
Distinguished convulsive syncope from epilepsy
Establish diagnosis of pseudosyncope

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52
Q

Patients with exertional syncope you order what?

A

Stress testing

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53
Q

Patients with syncope and suspected structural heart diagnosis you order what?

A

TTE

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54
Q

Patients with syncope and suspected arrhythmia you order what?

A

EPS (electric physiologic study)

55
Q

What are the four different types of cardiac monitors?

A

1) Holter
2) Event monitor
3) External loop recorder
4) Internal monitor

56
Q

When is a holter monitor used?

A

Symptoms recur within 24-72 hours

57
Q

What is a holter monitor?

A

Portable, continuous correlation with diary

58
Q

What is an event monitor?

A

Patient-activated via analog phone to station

59
Q

When is an event monitor used?

A

Symptoms recur within 2-6 weeks

60
Q

What is an external loop recorder?

A

Continuous, patient activated or auto triggered, get data around event too, via cell phone

61
Q

When is external loop recorder used?

A

Symptoms recur within 2-6 weeks

62
Q

What is an internal monitor?

A

SubQ, battery lasts 2-3 years, triggered by patient or family

63
Q

When is a internal monitor used?

A

Recurrent, infrequent, unexplained syncope of suspected arrhythmic origin

64
Q

When do you manage syncope outpatient?

A

Presumed neurally mediated

Cardiac syncope but not serious medical condition

65
Q

When do you manage syncope with observation?

A 
Age > 50
Hx of cardiac disease
Functioning cardiac device
Abnormal ECG
Family history of sudden cardiac death
Symptoms do not point to neurally mediated syncope
66
Q

What do you manage syncope with admission?

A 
Major cardiac arrhythmia
Serious CV condition (cardiac ischemia, aortic stenosis, heart failure, pulmonary embolism, hypertrophic cardiomyopathy)
Anemia
Major trauma
Persistent abnormal vital signs
67
Q

What is the treatment for neurally mediated syncope?

A

Increase central blood volume and cardiac output
Reassurance
Avoidance of triggers
Plasma volume expansion with fluid/salt
Physical counterpressure maneuvers of limbs (leg crossing or handgrip)

68
Q

What is the treatment for orthostatic hypotension?

A 
Remove reversible causes
Patient education on standing up
Compression stockings
Counterpressure maneuvers
Expanded intravascular volume by increasing dietary fluid and salt
69
Q

What drugs treat orthostatic hypotension?

A

Midodrine

Fludrocortisine

70
Q

What is the treatment for cardiac syncope in patients with a suspected arrhythmic etiology?

A

EPS

71
Q

What is the treatment for bradyarrhythmias?

A

Cardiac pacing for sinus node disease and AV block

72
Q

What is the treatment for tachyarrhythmias?

A

Ablation
Antiarrythmic drugs
Cardioverter-defibrillators

73
Q

HTN doubles the risk of what?

A

Cardiovascular disease

74
Q

What are modifiable risk factors in HTN?

A 
Smoking
DM
Dyslipidemia
Obesity
Low fitness
Unhealthy diet
75
Q

What are relatively fixed risk factors in HTN?

A 
Chronic kidney disease
Family history
Increased age
Low socioeconomic/educational status
Male sex
Sleep apnea
Psychosocial stress
76
Q

What is the most common cause of death in patients with HTN?

A

Structural/functional adaptations of HTN leading to LVH, HF, atherosclerotic CAD, microvascular disease, cardiac arrhythmias, A. fib

77
Q

What are brain consequences of HTN?

A

Stroke
Impaired cognition/dementia
HTN-encephalopathy

78
Q

What are kidney consequences of HTN?

A

Renal injury

End stage renal disease

79
Q

What are peripheral arteries consequences of HTN?

A

Peripheral artery disease

80
Q

What is primary HTN?

A

No specific underlying disorder

81
Q

What is secondary HTN?

A

Elevated BP with specific underlying disorder

82
Q

What is asymptomatic severe HTN?

A

> 180/110 without end organ damage

83
Q

What is a hypertensive emergency?

A

Severe BP elevation >180/110 with end organ damage

84
Q

What is elevated BP?

A

120-129/<80

85
Q

What is stage 1 hypertension?

A

130-139/80-89

86
Q

What is stage 2 hypertension?

A

> 140/90

87
Q

How do you diagnose HTN?

A

Average of greater than two reading on greater than two occasions

88
Q

How do you diagnose HTN in children?

A

SBP > 95% for age, sex, and height

Pre-HTN: 90-95%

89
Q

How do you diagnose HTN in pregnant women?

A

SBP > 140 OR DBP > 90

90
Q

What should you ask in women regarding HTN?

A

Did you have HTN when you were pregnant

91
Q

When do you take BP in the office?

A

After patient has sat quietly for 5 minutes

92
Q

What do you look for in HEENT exam for HTN?

A

Retinopathy

93
Q

What do you look for in neck exam for HTN?

A

Carotid bruit

94
Q

What do you look for in CV exam for HTN?

A

Rate
Rhythm
Murmur

95
Q

What do you look for in lung exam for HTN?

A

Rales

Effusions

96
Q

What do you look for in abdominal exam for HTN?

A

Aortic dilation

Bruit

97
Q

What do you look for in extremities for HTN?

A

Edema

Quality of femoral/pedal pulses

98
Q

What do you order if you suspect HTN?

A 
CBC
CMP
Lipid panel
TSH
UA
EKG
99
Q

How do you treat someone with normal BP?

A

Promote lifestyle habits

100
Q

How do you treat someone with elevated BP?

A

Non-pharmacologically

101
Q

How do you treat someone with stage 2 hypertension?

A

Non-pharmacological therapy
BP-lowering medication (two from two different classes)
Reassess in one month

102
Q

How do you treat someone with stage 1 HTN and a greater than 10% risk of cardiovascular event in 10 years?

A

Non-pharmacological therapy
BP-lowering medication
Reassess in one month

103
Q

How do you treat someone with stage 1 HTN and without a risk for a cardiovascular event in 10 years?

A

Non-pharmacological therapy

Reassess in 3-6 months

104
Q

What do you check in patients after initiating them on HTN medication?

A

Assess electrolytes and renal function

105
Q

Who is automatically considered high risk when it comes to HTN?

A

Diabetes
Chronic kidney disease
Age > 65

106
Q

What is the risk calculator called?

A

ASCVD (atherosclerotic cardiovascular disease)

107
Q

What is goal BP for patients with known CVD or 10-year event risk of greater than > 10%?

A

<130/80

108
Q

What is the goal BP for patients with no clinical CVD and 10-year event risk less than 10%?

A

<130/80

109
Q

What is the goal BP of adults older than 65 who are ambulatory and not institutionalized?

A

<130

110
Q

What is the goal BP in adults older than 65 with comorbidities and limited life expectancy?

A

Individualized goal based on clinical judgement and patient preference (don’t want to drive BP too low)

111
Q

What is lifestyle management for HTN?

A 
Weight reduction (less than 25 BMI)
Dietary salt intake
Adapt DASH-type dietary
Moderation of alcohol consumption
Physical activity
Enhanced intake of potassium
112
Q

How much did the DASH diet lower BP?

A

-11.2 mmHg

113
Q

What are first line BP drugs for whites?

A

ACEi

ARBs

114
Q

What are first line BP drugs for blacks?

A

CCBs

Diuretics

115
Q

What are first line BP drugs for DM?

A

ACEi

ARB

116
Q

What are first line BP drugs for CHD or CHF?

A

ACEi
ARB
Beta-blockers

117
Q

What are first line BP drugs for BPH?

A

Alpha-blockers

118
Q

What are first line BP drugs for A fib?

A

CCBs (non-dihydropiridines)

Beta-blockers

119
Q

What to consider when choosing BP medications?

A 
Generics
Once daily dosing
Non-affected by food
Price
Combination pills
120
Q

What is the first choice within ACEis?

A

Lisinopril

121
Q

What is the first choice within ARBs?

A

Valsartan

122
Q

What is the first choice within thiazide/diuretics?

A

Chlorthalidone

123
Q

How do you reassess after starting BP medication?

A 
Detection of orthostasis
ID white coat effect
Document adherence
Monitor response
Reinforce importance of treatment and assistance in achieving BP target
124
Q

Is there evidence that acute inpatient treatment of severe asymmptomatic hypertension improves outcomes?

A

No

125
Q

What is the treatment for hypertensive urgency?

A

BP lowered gradually <160/100 but not acutely <20-25% of the MAP over several days to weeks
Intensify therapy every 2-4 weeks

126
Q

What are the symptoms of HTN emergency?

A

Agitation, delirium, stupor, seizures, nausea/vomiting
Focal weakness, numbness, dysarthria, aphasia
Visual disturbance, fresh flame hemorrhage, exudates, papilledema
Chest discomfort, palpitations
Acute severe back pain
Dyspnea
Cerebral infarction
Pulmonary edema

127
Q

What do you order if you suspect HTN emergency?

A 
EKG
CXR
UA
Serum electrolytes
Creatinine
Cardiac biomarkers
CT brain
128
Q

What are the general rules for treating HTN emergency?

A

Lower MAP gradually
10-20% 1st hours
5-15% over the next 24 hours

129
Q

How do you treat the brain in HTN emergency?

A

Differentiate stroke/trauma (tolerate higher BP) from HTN encephalopathy
Clevidipene, nicardipine, fenoldapam, nitroprusside

130
Q

How do you treat acute HF with HTN emergency?

A

Nitroprusside

Nitroglycerin (vasodilators, reduce preload)

131
Q

How do you treat acute coronary syndrome with HTN emergency?

A 
Nitroglycerin
Nicardipene
Clevidipene
Metoprolol
Esmolol (reduce myocardial O2 requirement)
132
Q

How do you treat the vasculature with HTN emergency?

A

Rapid lowering with IV esmolol

133
Q

How do you treat the kidney with HTN emergency?

A

Fenoldapam

134
Q

What percentage of patients in the US have resistant HTN?

A

15.3%

CPR 2 Exam 1 (20 decks)

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