CV Flashcards
MI in mensturating woman
VIRTUALLY NEVER
MI in mensturating woman
VIRTUALLY NEVER
chest pain– must find out if they have
RISK FACTORS FOR CAD
most likely to benefit cardiac outcome
REGULAR EXERCISE
tai chi and yoga with CV effects
NOT PROVEN yet, difficult in measuring relaxation
who dies from heart disease
WOMEN die more from heart disease than men
nb fam hx for cv risk factor
must be hx of PREMATURE cad
and FIRST DEGREE RELATIVE
worst risk factor for CAD
DM
most common risk factor for CAD
HTN
premature age of CAD men
premature age of CAD women
most dangerous lipid profile for a patient
elevated LDL
tx TAKO-TSUBO
ACE inhibs
Beta blockers
NO REVASC— since no problem with coronary vessels
tx TAKO-TSUBO
ACE inhibs
Beta blockers
NO REVASC— since no problem with coronary vessels
chest pain– must find out if they have
RISK FACTORS FOR CAD
most likely to benefit cardiac outcome
REGULAR EXERCISE
tai chi and yoga with CV effects
NOT PROVEN yet, difficult in measuring relaxation
who dies from heart disease
WOMEN die more from heart disease than men
nb fam hx for cv risk factor
must be hx of PREMATURE cad
and FIRST DEGREE RELATIVE
worst risk factor for CAD
DM
most common risk factor for CAD
HTN
premature age of CAD men
premature age of CAD women
most dangerous lipid profile for a patient
elevated LDL
PC: postmenopausal woman
son died in war
ballooning of LV and LV dyskinesia
chest pain
TAKO-TSUBO cardiomyopathy:
massive catecholamine discharge from stressful event (divorce, financial issues, earthquake, lightning, hypoglycaemia)
tx TAKO-TSUBO
ACE inhibs
Beta blockers
NO REVASC— since no problem with coronary vessels
elevated homocysteine as rf for CAD
FALSE
elevated CRP as rf for CAD
FALSE
infection with chlamydia as rf for CAD
FALSE
immediate benefit if remove which CAD rf
STOP SMOKING
description for cardiac/ischemic chest pain
DULL or SORE
SQUEEZING or pressure like
UNLIKELY description of ischaemic pain
sharp (knifelike) or pointlike
lasts for a few seconds
NOT
- tender
- positional
- pleuritic
chest wall tenderness
costochondritis
costochondritis most accurate test
physical exam
chest pain radiating to back, unequal bp between arms
AD
AD most accurate test
CXR with widened mediastinum confirmation of AD, chest: - CT - MRI - TEE
chest pain worse with lying flat, better when sitting up, young person (
pericarditis
2 factors nb for ETT
- cannot read EKG, ie. its not diagnostic
2. patient can exercise: get heart rate above 85% of maximum
chest pain + bad taste, cough, hoarseness
GERD
best test for GERD
response to PPI’s
aluminum and magnesium hdroxide
viscous lidocaine
chest pain
cough
sputum
haemoptysis
PNEUMONIA
SUDDEN SOB and chest pain
tachycardia
hypoxia
PE
chest pain thats sharp
pleuritic pain
tracheal deviation
pneumothorax
best test pneumothorax
CXR
NONspecific symptoms seen in MANY causes of chest pain
nausea fever SOB sweating anxiety
BEST INTIAL TEST for all forms of chest pain
EKG
office based ambulatory setting EKG
likely to be normal, but CANNOT go on to other forms of testing until EKG is done
acute chest pain in office/ clinic setting, next best answer
TRANSFER TO EMERGENCY DEPARTMENT
acute chest pain in emergency department, next best step
ENZYMES
when to do exercise tolerance testing
UNCLEAR cause of chest pain
2 factors nb for ETT
- you can read EKG
2. patient can exercise: get heart rate above 85% of maximum
maximum heart rate
220 MINUS patients age
determining ischaemic when cannot read the EKG/ baseline EKG abnormalities
- Thallium or sestamibi scan
2. ECHO– wall motion abormalities
baseline EKG abnormalities causes
- LBBB
- LVH
- pacemaker use
- effect of digoxin
normal myocardium with Thallium
INCREASED UPTAKE of thallium
abnormal myocardium with Thallium
DECREASED UPTAKE of thallium
ECHO for baseline EKG abnormaltiies
decreased wall motion
dyskinesia/akinesia/hypokinesia
ischaemia reversible or irreversible
REVERSIBLE
infarction reversible or irreversible
IRREVERSIBLE
alternatives to exercise in stress testing
NOTE they are of equal sensitivity and specificity
- persantine= dipyridamole or adenosine in combo with thallium or sestamibi
- dobutamine + ECHO
avoid with agent for stress testing in asthmatic patients
DIPYRIDAMOLE
exercise thallium same as
exercise ECHO
dipyridamole thallium same as
dobutamine ECHO
PC: man with atypical chest pain has normal nuclear uptake in his myocardium at rest. with exercise, decreased uptake in inferior wall. two hours after exercise, nuclear isotope returns to normal. NEXT BEST STEP
CORONARY ANGIOGRAPHY– because already know this patient has reversible ischaemic, it’s 100% specific for coronary disease
NOT dobutamine ECHO because only done when NOT SURE of the cause
coronary angiography determines…
bypass SURGERY vs. bypass ANGIOPLASTY
most accurate method of detecting CAD
angiography
stenosis
INSIGNIFICANT
surgically correctable disease % stenosis
70% stenosis
goal of LDL
- PAD
- Carotid disease (NOT stroke)
- Aortic vessel disease
- stroke
- DM
do you do ETT in ACS patients currently having pain?
NO because the diagnosis is already clear
[remember don’t put the patients on the treadmill to exercise/ stress heart– if they are CURRENTLY having chest pain]
meds that lower chronic angina mortality (not ACS)
“BAN”
beta blockers
aspirin
nitroglycerin
best= B + A
propanolol use in cardiology
NO– B/C NON-specific
acute coronary syndrome tx
ASPIRIN + 1 other anti platelet
- clopidogrel
- prasugrel
- ticagreolar
NB use of clopidogrel
aspirin intolerance
NB use of prasugrel
antiplatelet in those undergoing
ANGIOPLASTY and STENTING
dangerous in patients>775 since risk of hemorrhagic stroke
what drug if intolerant to aspirin and clopidogrel
truly intolerant, not because bleeding
TICLOPIDINE
side effects of ticlodipine
neutropenia and ttp
CAD use of ACE/ARBs
LOW EF (systolic dysfunction)-- BEST MORTALITY BENEFIT REGURGITANT valvular disease
BIG 3 SE’s of CCBs
- edema
- constipation
- heart block (rarely)
what drugs if systolic dysfunction CAD
ACEinhibitors or
hydralazine
(both directly decrease mortality)
goal level for LDL in CAD
goal of LDL
- PAD
- Carotid disease (NOT stroke)
- Aortic vessel disease
- stroke
- DM
ACS associated with point of maximal impulse
NOOOOOO— because no specific physical findings in ACS
PMI:
- LVH
- DCM
NB monitoring for patients on statins
AST, ALT even without symptoms
DON’T DO CPK ROUTINELY (only done if have symptoms)
give to all CAD patients regardless of lipid levels
STATINS
NB effect of statins on endothelial lining
ANTIOXIDANT effect on endothelial lining
if full lipid control is not achieved with statins alone, add….
NIACIN
gemfibrozil + statins
increase myositis risk
ezetimibe
no better than placebo in terms of clinical endpoints
but yes definitely lowers LDL, but of no clinical benefit
well tolerated and nearly useless!
which drug increases mortality in patients with CAD
CCB’s– since raise heart rates– reflex tachycardia with nifedipine
DO NOT USE CCBs in CAD
only times when can use CCBs in CAD
- SEVERE asthmatic
- prinzmetal
- cocaine
- failed aspirin and beta blocker medical tx
BIG 3 SE’s of CCBs
- edema
- constipation
- heart block (rarely)
few circumstances, in which CABG lowers mortality
VERY SEVERE DISEASE 1. THREE vessels at least 70% stenosis 2. L MAIN coronary artery occlusion [3. 2 vessels in DM patient [4. persistent symptoms despite maximal medical tx
duration of graft length before occlusion
internal mammary= 10 years
saphenous vein= 5 years
BEST TX FOR ACS
PCI = angioplasty
ACS associated with point of maximal impulse
NOOOOOO— because no specific physical findings in ACS
PMI:
- LVH
- DCM
ST elevation in leads II, III, aVF
acute MI inferior wall
mortality with IWMI
DOOR TO BALLOON TIME
90 minutes
PR interval >200 milliseconds
first degree AV block– little pathologic potential
ST elevation in leads V2-V4
Anterior Wall MI
premature ventricular contractions
aw later development of more severe arrhythmias
no additional tx if NORMAL K, Mg
ST depression in leads V1 and V2
posterior wall mI; low mortality
RBBB vs LBBB
RBBB= benign LBBB= pathologic
treatment of PVCs
DO NOT TREAT
TX WORSENS OUTCOME
FIRST MGMT OF ACS
ASPIRIN– since it lowers mortality (more important than morphine, oxygen and nitroglycerin– however these are all administered)
NB rules in mgmt of ACS
START TX ASAP and do testing
BEFORE move to ICU
on step 2 CK should you ever consult with another dr?
NO– DO IT YOURSELF
ONLY 2 things that decrease mortality in ACS– and must be prioritized first
- ASPIRIN
2. PCI/angioplasty
mgmt of reinfarction
- EKG– check new ST abnormality
- check CK-MB
CK-MB BETTER at detecting reinfarction
ACS angioplasty or thrombolytics?
ANGIOPLASTY– better with survival/mortality, less bleeding, less complications of MI develop
DOOR TO BALLOON TIME
90 minutes
complications of PCI
- RUPTURE coronary artery when inflate the balloon
- RESTENOSIS (thrombosis) of vessel after angioplasty
- HAEMATOMA- at entry site into artery
most NB in decreasing risk of restenosis of coronary artery after PIC?
placement of drug-eluting stent– paclitaxel, sirolimus
4 ABSOLUTE contraindications to thrombolytics
- major bleed in bowel (BLACK-MELENA, not brown), and brain (ANY type of bleed)
- recent surgery (in last 2 weeks)
- severe HTN (above 180/110)
- non-haemorragic stroke in last 6 months
Door to needle time
30 minutes
who should get beta blockers in ACS
EVERYONE,
BUT NOT dependent on time
first line treatment for NSTEMI (stable)
LMWH, clopidogrel or enoxaparin
obviously because want to prevent the clot from growing and FULLY occluding the coronary arteries
GP2b/3a inhibitors
abciximab
tirofiban
eptifibatide
use of GP2b/3a inhibitors
ANGIOPLASTY and STENTING and NONSTEMI
only use for thrombolytics in MI
STEMI not for nstemi
SPECIFICALLY which type of heparin is best for NSTEMI
LMWH
not unfractionated heparin in terms of mortality benefit
NSTEMI that is not getting better with LMWH tx
- persistent pain
- S3 gallop or CHF developing
- worse EKG changes or sustained ventricular tachycardia
- rising troponin levels
post-MI stress test
done for EVERYONE prior to discharge UNLESS SYMPTOMATIC (since immediately need angiography)
deciding whether need angiography or not
intra-aortic balloon pump
BRIDGE to surgery for valve replacement or transplant for 24-48hrs after rupture of valve or septum post-MI
dipyridamole in coronary artery disease
NEVER NEVER NEVER NEVER NEVER
ACE inhibitors are best for which type of wall infarct
ANTERIOR wall infract, since most likely to develop systolic dysfunction
bradycardia and canon A waves post-MI
third degree AV block
bradycardia and NO canon A waves post-MI
sinus bradycardia
clear chest and new inferior wall MI
RV infarct
don’t give what if RV infarct
Nitroglycerates– since cause hypotension
SUDDEN loss of pulse with jugulovenous distension
tamponade
DIAGNOSIS V.FIB
EKG
tx v/tach
electric cardioversion/ defib
PCI ASAP
new murmur post-MI in LLSB
septal rupture
oxygen sats in RA = 72% and 85% in RV
septal rupture
prophylactic antiarrhythmics post-MI
DON'T DO IT!!!!!!!!!!!!!!!!! even if have frequent PVC's and ectopy don't use: - amiodarone - flecainide - any rhythm controller
sexual issues post-infarction
- NO nitrates and sildenafil
- erectile dysfunction most commonly from ANXIETY, however if med associated–most commonly= beta blockers
- do NOT need to wait to have sex (or normal exercise, given that post-MI stress test was normal)
most common cause of admission to the hospital in the US
Congestive heart failure
SOB brown blood and cyanosis, not improved with oxygen and clear lungs
methhaemoglobinaemia
burning wood stove in winter
carbon monixde poisoning
MOST important test in chf
ECHO
TEE or transthoracic ECHO best for CHF
transthoracic best, but TEE MOST accurate test (but often not needed)
MOST accurate test in CHF
MUGA= nuclear ventriculography
multiple gated acquisition scan
most accurate because evaluates WALL MOTION abnormalities
when to use MUGA ….
patient receiving doxorubicin
ACE inhibitors and ARBs in tx of systolic dysfunction CHF
ALL PATIENTS,
benefits seen with ANY drug in combo
when to answer ARBs >ACE inhibitors CHF
when the patient has cough from ACE inhibitor
which beta blockers to use for CHF (Recall don’t use acutely)
- metoprolol and bisoprolol= beta 1
- carvedilol= non-specific
MCC death from CHF
ischaemia–> arhythmia–> sudden death
decrease mortality in CHF drugs
- spironolactone and eplrenone
[anti-androgenic, and NOT anti-androgenic] - hydralazine + nitrates (systolic dysfunction)
- ACEinhibitors/ ARBS
- beta blockers
loops and spironolactone not given at diuretic effect in ACUTE MGMT CHF
do NOT lower mortality
NO benefit in mortality CHF systolic dysfunction
- loops (and spironolactone at non-diuretic levels)
2. digoxin/ positive inotropes
BENEFIT mortality in CHF systolic dysfunction
- spironolactone/ eplerenone
- implantable defbrillator
- biventricular pacemaker
- hydralazine + nitrates (systolic dysfunction)
- ACE inhibitors/ ARBs
- beta blockers
when to give implantable defibrillator
- ischaemic cardiomyopathy
- EF
when to give biventricular pacemaker
- dilated cardiomyopathy
- EF 120ms
should you give warfarin if there is no clot in the heart?
NOOOOO
CCB’s in heart failure
NO clear benefit in systolic dysfunction
some can actually RAISE MORTALITY
clearly beneficial diastolic dysfunction CHF
beta blockers
diuretics
clearly NOT beneficial diastolic dysfunction CHF
spironolactone
digoxine
uncertain beneficial diastolic dysfunction CHF
ACE inhibitors
ARBs
hydralazine
tx of acute pulmonary oedema from arrhythmia
CARDIOVERSION ASAP!!!!
nesiritide on mortality
NO PROVEN BENEFIT and
NOT PROVEN BETTER than standard agents for acute pulmonary edema
dobutamine in acute pulmonary edema
if failed LMNOP
digoxin in acute pulmonary edema
NOOOOO
treatment of acute pulmonary oedema with heparin but NO CLOT
NOOOOOOO NEVER
INITIAL diagnostic test for valvular heart disease
TEE: transesophageal ECHO
most accurate test for vaulter heart disease
catheterization
surgery with MS
dilated with a balloon
treatment of regurgitant lesions
VASODILATORS:
- ACE inhibitors, ARBs
- nifedipine
- hydralazine
with valvular heart disease and heart dilates XS from regurgitant—-
CANNOT correct the decrease in systolic function
thus will end up needing to replace the valve
assessment of ventricular size
based on end-SYSTOLIC diameter and EF
prophylaxis antibiotics in valvular disease
ONLY IF….
- prosthetic valve
- hx of endocarditis
Mitral stenosis clues
PREGNANCY
IMMIGRANT
and YOUNG ADULTS
what 4 big things a/w MS
- haemoptysis
- dysphagia
- hoarseness
- A. FIB**** VERY COMMON
tx of MS
- diuretics and sodium restriction
- balloon valvuloplasty
- valve replacement
- warfarin for a fib, INR 2-3
- rate control: digoxin, beta blockers, diltiazem, verapamil
balloon valvuloplasty for AS
NOT routinely done, since the calcification= the problem, and putting in the balloon doesn’t help this problem
ONLY really done when can’t do surgery because patient is unstable or fragile
PC:
- atypical chest pain
- palpitations
- panic attack
3P’s of MVP
pain/palpitations/panic attack
need for catheterization in MVP
NOOOOOOOO, because don’t need to know if exact pressure gradient
NB ECHO finding in HOCM
SAM
HOCM vs. HCM
HCM– high bp, Y- ACEi, Y-diuretics
HOCM– genetic, N- ACEi, N- diuretics
don’t use which two drugs in hypertrophic cardiomyopathy
spironolactone and digoxin
EKG in HCM
non-specific ST and T wave changes
septal Q waves in inferior and lateral leads (NOT MI)
standing and valsalva = same effect as…
DIURETICS
amyl nitrate
direct arteriolar vasodilator
SIMULATES the effect of ACE inhibitors/ ARBs on the heart
ventricle size with handgrip and amyl nitrate
handgrip= FULLER left ventricle
amyl nitrate= ACE inhibitors= EMPTIER left ventricle
ACE inhibitor effect on MS
NO EFFECT,
thus amyl nitrate and handgrip, also no effect
inspiration effect on murmurs
INCREASES all heart sounds
valsalva and standing effect on murmurs
decreases most
INCREASES HOCM
EARLIER MVP
hand gripping effect on murmurs
INCREASES MR.AR.VSD
decreases HOCM
later MVP
squatting effect on murmurs
INCREASES AS
decreases HOCM
later MVP
NOTE– decreasing murmur intensity = same as
IMPROVING murmur
what drug to decrease recurrence of pericarditis?
COLCHICINE
what is the best pain relief in pericarditis?
NSAID and COLCHICINE
together
most APPROPRIATE diagnostic test in cardiac tamponade
ECHO
what MUST you do before catheterization in cardiac tamponade
ECHO
ECHO in cardiac tamponade:
COLLAPSE of RA + RV
Right heart catheterization in cardiac tamponade
EQUALIZATION of pressures in diastole
best initial test in constrictive pericarditis
CHEST X-RAY– shows calcification and fibrosis
initial treatment of constrictive pericarditis
DIURETICS (Decompresses the filling of the heart), later on can do surgery
pain worse in calves when walking DOWN hill
spinal stenosis (since leaning back)
single most effective medication in PAD
CILOSTAZOL
which drug does NOT HELP PAD
Calcium Channel Blockers
best initial diagnosis of aortic dissection
CXR– simple, and shows widening of mediastinum
MOST ACCURATE diagnosis of aortic dissection
CT angio= GOLD STANDARD
screening AAA
men
>65yo
smokers
surgical correction AAA
> 5cm
peripartum cardiomyopathy
occurs AFTER delivery
autoantibodies to myocardium
LV dysfunction often reversible
if worsening of LV function–> TRANSPLANT
tx OK with ACEi in peripartum cardiomyopathy
YES because occurs AFTER delivery
what happens when woman with hx of peripartum cardiomyopathy gets PREGNANT AGAIN
BIGGER surge of antibodies and
WORSENING of cardiac function
what cardiac functions worsen in pregnancy
peripartum cardiomyopathy
eisenmenger syndrome
[above 2 worsen more than MS]
syncope– suddenly, have heart disease, frequent ectopic beats, thiazides
arrhythmia
syncope– before get dizzy/weak/nauseous; EMOTIONAL trigger
vasovagal
