CV 2 Flashcards
A female presents to the ED with chest and upper abdominal pain that started 40 minutes ago and rates it as an 8/10. It has not responded to antacids. The pain is aching, does not radiates, and no vomiting. She has no SOB & mentions a similar episode for 10 minutes earlier today. What diagnosis?
MI
What do you see on this ECG? What is it most consistent with?
ST depression (that’s greater than 1mm); T wave inversion in V5 & V6
Most consistent with Myocardial Ischemia
What is the major difference between UA & NSTEMI?
NSTEMI there are abnormal cardiac markers (troponins) that indicate cell necrosis.
With UA, no cell necrosis has occurred (yet)
What is the pathology behind UA or NSTEMI?
Complex coronary lesions, stenosis with plaque rupture, hemorrhage, or thrombus
What happens if you miss the diagnosis of an UA or an NSTEMI?
UA has a high risk of developing an MI
NSTEMI will progress to a larger MI/death
What are the major symptoms of UA or NSTEMI?
Substernal chest pain/discomfort at rest, that lasts longer than 10 minutes
What might you see on PE with UA or NSTEMI?
S4 gallop is common! Variables changes in LV function
So, what’s the criteria to diagnose NSTEMI?
ONE value (serial markers every 6-8 hours) >99th percentile of upper reference limit
* Classic curve of troponins: Starts slightly elevated, peaks, and comes back down
*Remember values that are elevated but not quite in the 99th percentile, you should be suspicious of (troponin should never be elevated)
What’s the one type of patient who might give you a false positive on troponins?
Those with chronic renal failure
What are some of the risk factors to UA or NSTEMI?
Older than 65
Prior coronary stenosis
ST seg deviation
2 or more angina episodes in prior 24 hours
You have a patient you are concerned has UA or NSTEMI, but their first biomarkers are negative, ECG is normal, what do you do?
Continuous monitoring, serial ECG’s, and serial troponins
If absolutely everything came back stone cold normal for 24 hours, what do you do with your patient who you were concerned about UA or NSTEMI?
Stress test/imaging
Your patient that you thought had an MI but was normal for 24 hours just had a stress test done and it came back positive for ischemia – what do you do? What if it had come back negative?
Positive à Cath lab (possible revascularization)
Negative à Discharge
Let’s say the patient you’re concerned about an MI has ST depression, positive troponins and still has chest pain – what do you do?
NTG (3 in the ED)
ASA (chew 325mg)
Start oral beta-blocker
Can add CCB
**SINCE THERE ARE ELEVATED TROPONINS ITS AN NSTEMI SOOOOO ADD:
Full Anticoag (LMWH)
Prasugrel or Trcagrelor
For our patient that has a NSTEMI, we have started her on all the appropriate meds, what do we do next?
Most NSTEMI’s should be considered for revascularization
What factors would favor revascularization?
Recurrent angina/ischemia, elevated troponins, ST depression on ECG, Develop CHF or EF (that’s less than .40), sustained VTach
A woman presents with 7 day history of 3/10 chest discomfort and SOB. She describes it as fullness. She has had increasing fatigue, but today she is very fatigued with increasing SOB at rest – what diagnosis?
Pericardial effusion (with possible tamponade)
What would we see on PE with pericardial effusion with compression – tamponade?
JVD, soft heart sounds but clear lungs, hypotensive –> varying BP’s
What do you see on this ECG?
Low voltage (in both limb and precordial leads) with flat T waves
When we see low voltage on ECG & we are concerned about pericardial effusion what diagnostic test must we order? What would we see?
Echo – RA/RV collapse in early diastole
Thus we would have to re-evaluate the BP to see if a drop of >10mmHg in systolic BP occurs with INSPIRATION
*If so, that indicates PULSUS PARADOXUS à CARDIAC TAMPONADE
What is cardiac tamponade?
Pericardial effusion elevates to a pressure causing compression of the heart.
Leads to progressive limitation of diastolic filling & is FATAL if not recognized and aggressively treated
What 3 things are often associated with tamponade, what are they known as?
Beck’s triad = decline in arterial pressure,
elevation of systemic venous pressure, and quiet heart
If we give someone with tamponade a small amount of IV fluid what would we expect to happen?
BP will go up for a short period of time since CO is extremely Volume Sensitive
How do we treat cardiac tamponade?
Pericardiocentesis
A patient presents to the ED with severe SOB that awoke him abruptly from sleep. He denies any form of chest pain. He has a history of an MI 1 year ago and has not been compliant with his medications. His O2 sat is 90% and he is becoming more anxious with more difficulty breathing - what diagnosis?
acute pulmonary edema
What might you find on PE with acute pulmonary edema?
Crackles & rales
Apical holosystolic murmur (mitral regurg) & S3 gallop
JVD
What diagnostic test should you get with acute pulmonary edema?
ECG
CXR – vascular redistribution, alveolar edema in a “butterfly” pattern, with Kerly B lines
BNP – elevated (due to increased filling pressures)
How do we treat acute pulmonary edema?
This is a medical emergency!!!
Give O2!
Morphine sulfate (venodilator & reflex withdrawal of sympathetic NS)
IV diuretics
Nitrates (especially if elevated BP) to decrease preload
A patient presents to the ER with a racing heart and palpitations for the past 5 hours. He denies any SOB. On PE his BP 155/90 and his rhythm is irregular at 150bpm – what diagnosis?
Atrial Fibrillation
What do you see on this EKG?
Afib
In Afib, how might the pulses vary between over the heart and radial?
Radial will be less because the heart hasn’t filled enough to create an appropriate output
What is our first priority when we have a patient in AFib?
Assess hemodynamic stability (BP, P, and sxs)
If a patient is not stable and in Afib – what do you do?
Cardioversion
If a patient in stable and in Afib – what do you do next?
Echo – to look for underlying cardiac or pulmonary precipitating factors
Figure out how long it has been present for
Control their rate with Diltiazem
What happens if you learn the person’s Afib has been present for >48 hours?
You must fully anticoagulated for 3 weeks before cardioversion
If a patient has persistent/recurrent Afib how do you manage them?
Rhythm control (cardiovert + meds or ablation)
Rate control (leave in afib & anticoag)
What medication can you give for rapid conversion of recent onset Afib or Aflutter?
Ibutilide
A patient comes to the ED with severe HA & Nausea. She has also been confused. Hx of HTN & dyslipidemia but stopped all meds when she lost her job. She also smokes 2ppd. Her current BP is 230/130 – what diagnosis?
HTN Emergency!
What do you look for on PE with HTN Emergencies?
EYES! – Arteriolar narrowing, A/V nicking, disc margins & papilledema
What labs do you want to check with HTN Emergencies?
Kidney’s (UA for protein)
Along with CBC, INR, PTT, and Lytes
If a patient is asymptomatic with high BP – how would we treat them?
Do not require emergent Rx
BTW, what is considered high BP?
Greater than 200/110
What’s the difference between a HTN urgency & HTN Emergency?
Urgency = Lower BP within a few hours (no more than 25% within 2 hours)
Emergency = Lower BP within 1 hour (to avoid HTN encephalopathy, nephropathy)
What do we need to make sure of when we suspect a HTN urgency?
It’s not an MI
What meds are 1st line for HTN Emergencies?
Nicardipine or Clevipine
What other meds can you use of a htn emergency?
Labetolol, Esmolol, IV NTG
A patient brought in by EMS developed acute abdominal pain 25 minutes ago. Hx includes CHD, HTN, and PAD & he’s a heavy smoker. In route to the ED he becomes progressively hypotensive. He’s given fluids & his BP drops near 60mmHg (systolic) – what diagnosis are you thinking?
Aortic aneurysm
What could have been seen on PE for this patient long ago to prevent his current state of aortic aneurysm?
Pulsatile aortic mass in the stomach
What do we monitor AA’s with to make sure they’re not expanding too much?
Ultrasound
Who should be screened with an ultrasound for AAA’s?
Male smokers over 60 who…
- Have a family history of AAA
- Presence of PAD/atherosclerosis
- Presence of peripheral artery aneurysms
If a patient is asymptomatic when do we stent the aorta to prevent AAA?
Always do surgery if greater than 6.5cm
Probably surgery if greater than 5 cm
