CV Flashcards
Heart rate on ecg
300/# of large boxes between two consecutive qrs complexes
Thumb rule for axis on ekg
If both leads I and II are positive (qrs up), axis is normal
If lead I is up and lead II is down, they have LEFT each other (left axis deviation)
If lead I is down and lead II is up, they are heading RIGHT for each other (right axis deviation)
Each large box on ecg represents ___ seconds and ms
0.2seconds
200ms
Each small box on ekg represents how many Seconds/milliseconds
0.04 s
40 ms
Pr interval is usually between how many msec
120 and 200 (3-5 little boxes)
Pr interval is how long in av block
> 200ms
Qrs interval is usually how many ms? Which two patterns have a wider qrs
Normally <12ms
Lbbb and rbbb
Normal qtc interval
<440 ms
In normal ekg, r waves ___ in size compared to S waves between leads __ and __
Increase
V1 and v5
Poor r wave progression in precordial leads is a nonspecific sign of
Ischemia
How to detect right atrial enlargement on ekg?
P wave in lead II > 2.5mm
How to detect left atrial enlargement on ekg?
P wave width in lead II is >120ms, or terminal negative deflection in v1 is >1mm in amplitude and >40msec in duration
Lv hypertrophy on ekg
Amplitude of s in v1 + r in v5 or v6 is >35mm
Rv hypertrophy on ekg
Right axis deviation and r wave in v1>7mm
One big box on ekg is how many mm
Five
What is hepatojugular reflux
Distention of neck veins upon applying pressure to liver
Hepatojugular reflux is seen in what conditions
Heart failure or pulmonary htn
What is kussmaul sign
Increase in jugular venous pressure with inspiration
Kussmaul sign is seen in what two conditions
Cardiac tamponade and constrictive pericarditis
Systolic murmurs
A dashing cis (sys) mister
Aortic stenosis
Mitral regurg
Also mvp and flow murmurs
Describe mitral regurg
Holosystolic murmur that radiates to the axilla
Describe mitral valve prolapse
Midsystolic click and then systolic murmur
Diastolic murmur types
Aortic regurg
Mitral stenosis
A daring missus, a disreputable diastolic damsel
Are diastolic murmurs normal or abnormal
Always abnormal
What is pulsus paradoxus
Decrease in systolic bp with inspiration
What is pulsus alternans? What is it seen in
Alternating weak and strong pulses
Seen in cardiac tamponade
What is pulsus parvus Et tardus? What is it seen in
Weak and delayed pulse
Seen in aortic stenosis
Management options for atrial fibrillation
Anticoagulate
B blockers
Cardiovert/ca channel blocker
Digoxin (refractory)
Chads vasc score estimates
Stroke risk in afib pts
Anticoagulate for a Chad’s vasc score of __ or above
2
What does Chad’s vasc stand for
Chf Htn Age >75 Diabetes Stroke or tia hx Vasc diseAse Age 65-74 Sex category (female)
Sinus bradycardia Is under how many bpm
60
In first degree av block, pr interval is >
200ms
Second degree av block is also called
Mobitz type I/wenckebach
Or
Mobitz type II
Define 2nd deg av block mobitz I
Progressive pr lengthening until a drppped beat occurs
Drugs that can cause second deg av block mobitz I
Digoxin
B blockers
Ccbs
Define mobitz II
Unexpected dropped beats without change in pr interval
Cause of mobitz II
Fibrotic dz of conduction system or MI
Tx of mobitz II
Pacemaker
Tx of mobitz I
Atropine as needed
Define third deg av block. Tx?
No electrical communication between Atria and ventricles
Tx-pacemaker
Define sick sinus/yacht Brady syndrome
Intermittent supraventricular tachy and Bradyarrhythmias
Most common indication for pacemaker
Sick sinus/tachy Brady syndrome
Sinus tachy is above
100 bpm
For chronic afib, rate control with
B blockers
Ccbs
Digoxin
For chronic afib, anticoagulate with
Warfarin
For unstable/chronic afib,
Cardiovert if onset <2 days
If >2 days or unclear duration,get a tee to rule out atrial clot
Etiology of aflutter
Circular movement of electrical activity around the atrium at rate of 300X per minute
Etiology of avnrt
Reentry circuit in av node that depolarizes atrium and ventricle nearly simultaneously
Rate in avnrt
150-200
P wave in avnrt
Often buried in qrs or shortly after
Etiology of avrt
Ectopic connection between Atria and ventricle that causes a reentry circuit
Example: wpw
Etiology of paroxysmal atrial tachy
Rapid ectopic pacemaker in atrium (not sinus node)
How to unmask underlying atrial activity in paroxysmal atrial tachy
Adenosine
Define systolic dysfunction
Ef <50% and increased lv end diastolic volumes
Systolic dysfunction is caused by
Inadequate lv contractility it increased afterload
Bnp levels in chf
> 500pg/ml
Creatinine in chf
Sometimes high
Sodium levels in chf
Low in later stages
Class III chf
Limitation of activity. Comfort only at rest.
Class IV chf
Symptoms present at rest
Class I chf
No limitation of activity
Acute chf pulmonary congestion management
Lmnop Lasix Morphine Nitrates Oxygen Position (upright)
B blockers should be ___ during decompensated chf
Avoided
Why avoid ccbs in chf
Can worsen edema
B Blockers and arbs in chf help
Help prevent remodeling of heart and decrease mortality
Low dose spironolactone does what for chf pts
Decrease mortality risk
Loops ___ calcium, thiazides ___
Loose
Take in
In nonsystolic dysfunction, ventricle has either
Impaired active relaxation or impaired passive filling
If you send a guy out after chf exacerbation on lasix and bblocker, what else should you add
Acei
Potassium levels with loops
Cause hypokalemia
Thiazides cause hyper__
Gluc Glycemia Lipidemia Uricemia Calcemia
Side effects of spironolactone
Hyperkalemia
Gynecomastia
Sex dysfunction
S3 signifies
Rapid ventricular filling in setting of fluid overload
S4 gallop signifies
Stiff non compliant ventricle and increased atrial kick
S4 May be associated with
Hypertrophic cardiomyopathy
Key pe finding in hocm
Systolic ejection crescendo-decrescendo murmur that increased with decreased preload (valsalva, standing) and decreases with increased preload (passive leg raise)
Tx of hocm
B blockers for symptomatic relief, ccbs second line
What is angina pectoris
Substernal chest pain secondary to ischemia
Prinzmetal angina is caused by
Vasospasm of coronary vessels
Prinzmetal angina classically affects
Young women at rest in early morning
St elevation in absence of cardiac enzyme elevation
Prinzmetal angina
Tx of stable angina
Asa
B blockers
Nitroglycerin
Ck comes down _ days after mi, tropinin comes down after _ days
Two
4-5
Inferior mi involves what coronary vessels
Rca/pda
Anterior mi involves what coronary vessels
Lad
Lateral mi involves what coronary vessels
Lca
Ecg changes in inferior mi
St elevation in leads II, III, aVF
Ekg changes in anterior mi
St elevation in leads v1-v4
Ekg changes in lateral mi
St elevation in leads I, aVL, and v5-v6
In ___ Wall mis, avoid nitrates due to
Inferior
Risk of severe hypotension
Post mi complications: first day
Heart failure
Post mi complications: 2-4 days
Arrhythmia, pericarditis
Post mi complications: 5-10 days
Lv Wall rupture, papillary muscles rupture
Post mi complications: weeks to months
Ventricular aneurysm
What is dressler syndrome
Autoimmune process 2-10 weeks post mi, presents with fever, pericarditis, pleural effusion, leykocytosis, elevated esr
Start getting lipid levels at age
35
Effect on lipid profile:
Gemfibrozil
Low triglycerides
High hdl
Effect on lipid profile:
Ezetimibe
Lowers ldl
Effect on lipid profile:
Niacin
Elevated hdl
Lowers ldl
Effect on lipid profile: choles tyramine
Lowers ldl
Side effect of statins
Myositis
Side effect of niacin
Skin flushing
Tx of primary htn
Abcd Aceis/arbs B blockers Ccbs Diuretics (thiazides)
Ekg findings on pericarditis
Diffuse st segment elevation and pr segment depressions
Beck triad of cardiac tamponade
Jvd
Hypotension
Distant heart sounds
Electrical alternans is diagnostic of
Large pericardial effusion
Aortic aneurysms are most commonly associated with
Atherosclerosis
> 90% of aortic aneurysms originate below the
Renal arteries
Who to screen for aaa and how
Men 65-75 with hx of smoking at any point, once by ultrasound
Blowing diastolic murmur is likely
Aortic regurg
You see head bob with which murmur
Aortic regurg
Virchow triad
Risk factors for dvt:
Venous stasis
Endothelial trauma
Hypercoag states
What is homans sign
Calf tenderness with passive foot dorsiflexion
Inflammation from surgical cardiac intervention can lead to
Pericarditis, pericardial effusion, cardiac tamponade
Why in a normal fetus is the r v bigger than the lv
In fetus blood is shunted away from lungs through pda, so systemi circulation relies primarily on rv
Newborns have what on ekg
R axis deviation due to larger rv
Ekg findings in tricuspid valve atresia
Left axis deviation and peaked p waves
Small or absent r waves in precordial leads
What happens to tricuspid valve in tricuspid valve atresia
It’s absent
What happens to rv in tricuspid valve atresia
It’s hypoplastic
Complete av canal defect is associated with what syndrome
Downs
Primary problem in ebsteins anomaly
Malformed tricuspid valve into right ventricle
Ekg findings in ebsteins anomaly
Tall p waves and right axis deviation on ecg
Truncus arteriosus is strongly associated with ___ syndrome
Digeorge
What is truncus arteriosus
Single blood vessel (truncus arteriosus) comes out of the right and left ventricles instead of the normal two vessels (aorta and pulm artery)
What remodeling can occur in heart after mi
Dilation of lv and thinning of ventricular walls
What meds can limit ventricular remodeling following MI
Aceis
Can hyperthyroid cause afib with rvr
Yep
Tx of tachycardia and afib in hyperthyroidism
Beta blockers
Propranolol also decreases conversion of t4 to t3 in peripheral tissues
How does adenosine work?
Induced transient block at av node
When is adenosine used
Often in pts with svt in whom the dx is unclear
Why do you get a decrescendo diastolic murmur in aortic dissection
Due to aortic regurg due to proximal extension of dissection into aortic valvular annulus
Why might you get elevated creatinine in aortic dissection
Due to distal extension into renal arteries
Heart failure with preserved lv ejection fraction is also known as
Lv diastolic dysfunction
___ stenosis is found in 45% of pts with severe htn and 30% of pts with pad
Renal artery
Continuous abdominal bruit is suggestive of
Renovascular diseAse
__ is associated with rib notching on X-ray
Coarctation of aorta
Due to enlarged collateral intercostal vessels
Direct current cardio version is indicated with ___ whereas defibrillation is indicated with __
Persistent tachyarrhythmia causing clinical instability (eg afib)-synchronized with qrs
Unsynchronized, used in vfib
Proteinuria, hepatomegaly, restrictive cardiomyopathy, peripheral neuropathy, waxy thick skin and easy bruising. What am I?
Amyloidosis
Amyloidosis can cause what heart pathology
R sided heart failure
Mitral valve leaflet motion in hocm
Systolic anterior motion towards iv septum
Dilated mitral valve annulus is seen in pts with
Dilated cardiomyopathy or ischemic cardiomyopathy
Recent uri followed by sudden onset of cardiac failure in otherwise healthy pt is suggestive of
Dilated cardiomyopathy likely secondary to acute viral myocarditis
Viral or idiopathic myocarditis is most commonly seen with what virus
Coxsackie b
Tx of vfib
Immediate defibrillation
First step in acute limb ischemia from arterial occlusion
Echo because most come from lv thrombi
Pulm side effect of amiodarone
Chronic interstitial pneumonitis
Treatment of claudication (non emergent)
Low dose aspirin
Statin
Exercise
Can asthma and copd cause pulsus paradoxus
Yes
Aortic regurg prevents or causes pulsus paradoxus
Prevents- causes increase in lv end diastolic pressure. That precludes iv septum from shifting towards lv cavity during inspiration
What abnormal heart sound can be heard in pts during acute mi
S4 due to lv stiffening and dysfunction
Premature atrial complexes are largely
Benign
Premature ventricular complexes in presence of st elevation may indicate
Reentrant ventricular arrhythmia secondary to mi
Ekg findings in aortic coarctation
Consistent with lv hypertrophy (high voltage qrs complexes, lateral st segment depression, lateral t wave inversion)
Pulsatile groin mass below the inguinal ligament is likely a
Femoral artery aneurysm
Anterior thigh pain with a femoral artery aneurysm is due to
Compression of the femoral nerve that runs lateral to the artery
First and second most common peripheral artery aneurysms
First: popliteal aneurysm
Second: femoral artery aneurysm
Effect on preload: valsalva
Decreased
Effect on preload: abrupt standing from sitting or supine position
Decrease
Effect on preload: nitroglycerin administration
Decreased
Effect on preload: squatting
Increased
Effect on preload: passive leg raise
Increased
Effect on afterload: sustained hand grip
Increased
Effect on afterload: squatting
Increased
What congenital heart defect is common with trisomy 18 pts
Vsd
Can ocps cause hypertension
Yes
Three common etiologies of aortic regurg
Congenital bicuspid aortic valve
Postinflammatory (rheumatic heart dz, endocarditis)
Aortic root dilation (marfan, Syphillis)
Murmur of aortic regurg
Diastolic decrescendo murmur
Exertional dyspnea, pounding heart sensation, uncomfortably aware of heartbeat while laying on left side, and widened pulse pressure is likely due to
Chronic aortic regurg
Other than wt loss what is the most effective behavioral intervention to decrease bp
Dash diet
Spect scan: decreased uptake at rest and during exercise indicates
Scar tissue with decreased perfusion and cad
Spect scan: decreased tracer uptake with stress but normal uptake at rest indicates
Reversible defect, inducible ischemia and likely cad
Tx of inducible ischemia/likely cad
Antiplatelet therapy (aspirin) for prevention of mi
Tx of dressler syndrome
NSAIDs
Murmur in hocm
Crescendo-decrescendo systolic murmur along left sternal border without carotid radiation
Meds to withhold prior to cardiac stress testing
Beta blockers
Ccbs
Nitrates
Do you have to withhold aceis and arbs before cardiac stress testing
No
In acute mitral regurg post mi, there is ___ lv end diastolic pressure
Increased
Persistent st segment elevations and deep q waves in a pt with a previous mi
Ventricular aneurysm
Do you see htn and pulm edema with a post mi ventricular aneurysm
Yes
Do you see htn and pulm edema with a post mi pericarditis in dressler syndrome
No
Tx of post surgical mediastinitus
Drainage of pus in mediastinum, surgical debridement, prolonged abx therapy
In adults, s4 is an indicator of __ which could be due to what two things
Blood striking a Stiff left ventricle
Restrictive cardiomyopathy or lv hypertrophy from prolonged htn
Does synchronized cardio version help in a patient with pulseless electrical activity
No
If a baby is cyanotic, what kind of shunt do they have
Right to left
Tetralogy is associated with what syndrome
Downs
Four things of tetralogy?
Vsd
Overriding aorta
Pulm stenosis
Rv hypertrophy
Transposition in babies occurs when moms have
Diabetes (not gestational)
Pda is required for survival in what congenital heart defect
Transposition
How to keep pda open
Prostaglandin
Vsd is diagnosed before age
One
Vsd is associated with what syndrome
Downs
Multiphasic murmur May refer to
Pda
Cyanide poisoning causes what four things
Slac
Seizures
Lactic acidosis
Ams
Coma
What is mech of nitroprusside and why is it used?
Vasodilator with quick onset and offset. Commonly used for rapid blood pressure control in pts with hypertensive emergency.
Risk of using prolonged nitroprusside in pts with renal insuff
Cyanide poisoning
Decreased co in pts with decompensated chf leads to activation of ____ and increased secretion of ____
Raas
Adh
Increased ang II causes ___ renal blood flow due to ___ of afferent and efferent glomerular arterioles
Decrease
Vasoconstriction
Pe findings in transposition of great vessels
Single s2
+/- vsd murmur
Pe findings in tetralogy
Harsh pulmonic stenosis murmur, vsd murmur
Cxr of transposition of great vessels
Egg on a string appearance
Primary anti-ischemic effects of nitrates
They cause systemic vasodilation and decrease preload, which decreases left ventricular systolic Wall stress and decrease in oxygen demand
Is vasodilatory effect of nitrates on coronary vasculatre the reason they are beneficial
No
Septic shock causes ___ svr, ie ___ afterload
Decreased, reduced
Intermittent claudication due to pad is a strong predictor of future
Cv morbidity mortality
Do you have full peripheral pulses in coarctation of aorta
No, diminished distal. Get le claudication
How do vagal maneuvers fix paroxysmal supraventricular tachycardias (avnrt)
Increases parasympathetic tone in heart thus slowing conduction in av node and increasing av node refractory period, terminating avnrt
Aspirin provides anti___ therapy not anti___ therapy. Which do you need for a Chad’s vasc score above 2?
Platelet not coagulant. Need coagulant (warfarin, apixaban). Antiplatelet isn’t strong enough.
Middiastolic sound heard with constrictive pericarditis is also known as
Pericardial knock
Can you have hypoalbuminemia with constrictive pericarditis
Yes
What is cor pulmonale
Rv failure due to pulm htn
Mech of adenosine
Inhibits L type calcium channels, decreasing conduction velocity in av node. Used in termination of avnrt.
Htn has a ___ association with aaa
Weak
What behavior is associated with high rate of aneurysm expansion and rupture
Smoking
Tx for pts with wpw who develop afib with rapid ventricular rate
Cardioversion or antiarrhythmics such as procainimide
Why avoid av node blockers such as b blockers, ccbs, digoxin and adenosine In wpw pts with afib
Can cause increased conduction through accessory pathway
Inheritance of hocm
Autosomal dominant
Old man with acute onset of severe back pain, syncope, and hypotension is worrisome for
Abdominal aortic aneurysm rupture
If you have uremia + pericarditis what do you have? What is the treatment?
Uremic pericarditis, usually bun>60mg/dL
Tx is dialysis. Use NSAIDs if not responding to dialysis.
Mobitz type I is due to impaired conduction of
Av node
Confirm dx of cardiac tamponade
Urgent echo
Large amount of blood flowing through a fistula will __ svr, ___ preload and ___ co
Decrease
Increase
Increase
Brisk carotid upstroke also indicates
Strong peripheral arterial pulse
Can mitral stenosis present with dyspnea, orthopnea, pnd and hemoptysis
Yes
Can mitral stenosis present with hoarseness
Yes
Sx of digoxin tox
Arrhythmias, anorexia/n/v, color vision alterations, weakness and confusion
Amiodarone ___ levels of digoxin
Increases
Coarctation of aorta results from thickening of
Tunica media near junction of ductus arteriosus and aortic arch
First step in a pt with normal mental status after blunt abdo trauma
Focused bedside ultrasound
Which arrhythmia is most specific for digoxin toxicity
Atrial tachycardia with av block
Atrial tachycardia bpm? Aflutter bpm?
Tachy: 150-250
Flutter: 250-350
Pts who have delayed presentation of appendiceal rupture likely have
Appendiceal rupture with contained abscess
Valvular complication of aortic dissection
Retrograde extension of intimal tear to involve aortic valve and cause acute aortic regurgitation
How to screen for aaa
Abdo ultrasound
After mi pts should be on __ antiplatelet therapy consisting of __
Dual
Aspirin and p2y12 receptor blocker (eg clopidogrel)
What kind of murmur is associated with tricupsid regurg
Holosystolic murmur that increases in intensity with inspiration
Pts with persistent tachyarrhythmia causing hemodynamic instability should be managed with
Immediate synchronized cardioversion
Acute inferior and posterior wall mis are caused by occlusion of
Rca
Most common congenital heart defect in pts with downs
Complete av septal defect
Dobutamine mechanism
Adrenergic agonist with predominant activity on beta 1 receptors
What is dobutamine used for
Mgmt of severe heart failure associated with lv systolic dysfunction and cardiogenic shock
Dobutamine causes an increase in myocardial contractility which causes a __ in
Lv end systolic volume
Livedo reticularis and blue toe syndrome should make you suspect
Cholesterol embolization
How is angiotensin I converted to angiotensin II
Ace (from the lung) cleaves c terminal peptides on ang I
Acei blocks this
Pda is associated with congenital ___
Rubella
More than 2/3 of pts with coarctation of the aorta also have a
Bicuspid aortic valve
Bad complication of giant cell arteritis is ___. How do you screen?
Aortic aneurysms
Serial cxrs
Other than bradykinin cough, what is a side effect of aceis?
Angioedema (edema in face, mouth, lips, larynx)
If you get angioedema from acei what should be done
Stop acei immediately
> 90% of acute pes originate where
Proximal led/thigh (iliac, femoral, popliteal veins)
On cxr for transthoracic aortic aneurysm, you see what three things
Tracheal deviation
Widened mediastinum
Widened aorta
