Diseases of the Myocardium, Acquired Flashcards by Marisa Siegel

What class of medication should you avoid in cocaine toxicity

Beta blockers

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Cocaine intoxication clinically presents as a

Cocaine intoxication clinically presents as a sympathomimetic toxidrome that includes tachycardia, hypertension, diaphoresis, chest pain, and mydriasis. Patients may also have hyperthermia and cardiac dysrhythmias.

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Cocaine works by

Cocaine exerts its affects by stimulating and blocking reuptake of multiple neurotransmitters (dopamine, epinephrine, norepinephrine, and serotonin). Although many receptors are activated, the most profound effect is the adrenergic stimulation caused by norepinephrine and epinephrine, resulting in vasoconstriction, increased myocardial contractility, increased myocardial oxygen demand, and increased heart rate.

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Cocaine-related chest pain ensues as a result of

Cocaine-related chest pain ensues as a result of coronary vasospasm and ischemia due to increased myocardial oxygen demand.

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Cocaine-related chest pain is most effectively managed through

benzodiazepines, which will decrease the oxygen demand and sympathetic effects

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Should you give aspirin in cocaine induced chest pain

Aspirin should be administered as well since cocaine induces platelet aggregation

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Beta-blockers are generally recommended to be avoided in cocaine-related chest pain due to

Beta-blockers are generally recommended to be avoided in cocaine-related chest pain due to the unopposed alpha stimulation that can lead to increased cardiac ischemia. Concern that it can lead to worsening vasoconstriction.

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Cocaine effects

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True or false: preexistent cardiovascular disease is a prerequisite for cocaine-related myocardial ischemia.

False

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Rapid Review: Cocaine Intoxication

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Myocarditis

Myocarditis occurs when there is inflammation and necrosis of the myocardium. This typically occurs after an infection and can present with fever, chills, and chest pain. The diagnosis is more likely in a young patient. ECG may demonstrate nonspecific ST segment changes, T wave inversions, and QT prolongation. Echocardiography can demonstrate global hypokinesis. Troponins will be elevated given the damage to the cardiac myocytes. Other tests can include an erythrocyte sedimentation rate or C-reactive protein, serum viral titers, and a cardiovascular MRI. An endomyocardial biopsy is the gold standard to confirm the diagnosis, although it is rarely done. The prognosis is variable in myocarditis, and sudden death is possible even in young and previously healthy patients. The treatment of myocarditis is supportive care, with heart failure medications and antidysrhythmics as needed.

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Myocarditis Chart

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What is the treatment of pericardial tamponade in a hemodynamically unstable patient?

Pericardiocentesis.

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Rapid Review: Myocarditis

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What is the biggest risk factor for the development of a left ventricular aneurysm?

Left anterior descending coronary artery infarction

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Left ventricular aneurysm

Left ventricular aneurysm formation is a potential complication following a myocardial infarction. Occurring in up to 15% of patients after myocardial infarction, it is characterized by a thinned, focal area of the myocardium and is four times as likely to involve the anterior or apical walls than the inferior or posterior walls. On echocardiogram, the involved segment will appear to paradoxically balloon outward during systole. Electrocardiographic findings include persistent ST segment elevation in the distribution of the recent myocardial infarction. Those at greatest risk for the development of a left ventricular aneurysm include patients with complete occlusion of the left anterior descending artery, delayed or incomplete reperfusion, and absence of collateralization. Treatment of left ventricular aneurysm includes afterload reduction, usually with an angiotensin-converting enzyme inhibitor, and anticoagulation, if there is evidence of significant left ventricular dysfunction or thrombus formation.

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Left ventricular aneurysm Chart

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Rapid Review: Left ventricular aneurysm

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What are the three main complications related to development of a left ventricular aneurysm?

Heart failure, dysrhythmias, and thromboembolic disease.

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The use of nitrates is contraindicated in patients who also take

sildenafil

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Sildenafil is an

inhibitor of cyclic guanosine monophosphate specific phosphodiesterase type 5. It leads to an increased release of nitric oxide, resulting in smooth muscle relaxation and vasodilation

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Sildenafil is commonly used to treat

Erectile dysfunction

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Which electrolyte is increased with hydrochlorothiazide use?

Calcium (causing hypercalcemia).

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Erectile Dysfunction

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Rapid Review: PDE-5 Inhibitors

Which medication is the first line treatment for patients with acute decompensate heart failure

This patient presents with symptoms of acute decompensated heart failure and should be started on nitroglycerin therapy immediately. Patients present with shortness of breath, increased work of breathing, tachycardia, hypoxia, crackles on lung examination, and jugular venous distension. These patients experience acute worsening of left ventricular function and output secondary to a number of mechanisms including increased systemic vascular resistance. Therapy focuses on the reduction of preload to decrease the flow of blood into the lungs and afterload reduction to increase the effectiveness of the left ventricle. Both of these goals can be accomplished through the administration of nitroglycerin. At lower doses, nitroglycerin acts as a peripheral vasodilator and increases venous capacitance leading to decreased preload. At higher doses, nitroglycerin causes arterial vasodilation leading to decreased afterload. Because of its rapid onset of action, nitroglycerin is the first-line medication in patients with acute decompensated heart failure.

Rapid Review: Acute Decompensated Heart Failure

Nitrates chart

What life-threatening toxicity is associated with nitroprusside administration?

Cyanide toxicity.

Which medication has the greatest impact on reducing mortality in patients presenting with acute coronary syndrome?

Aspirin

Aspirin in ACS

Aspirin has been shown to have the greatest effect on reducing mortality in patients with acute coronary syndrome (ACS). Aspirin is an irreversible antiplatelet agent. It inactivates platelets for the life span of the platelet (8–10 days). Studies have demonstrated a 23% reduction in mortality for patients with acute myocardial infarction (AMI) who received aspirin but not thrombolytic therapy. Aspirin also works synergistically with thrombolytics (42% reduction in mortality). Overall, aspirin has a number needed to treat (to prevent death) of 42. Administration of aspirin (chewed and swallowed) is recommended in any patient with suspected ACS.

Which cardiac biomarker has the highest sensitivity and specificity?

Cardiac troponin

Initial Medical Therapy for ACS

Rapid Review: Ischemic Heart Disease

Which medication is contraindicated n an inferior STEMI

Nitroglycerin

Why is nitroglycerin contraindicated in an inferior MI

Patients with an inferior STEMI may have right ventricular infarct and be preload dependent. In a patient with an inferior STEMI, right ventricular infarct is suggested by the presence of ST elevation in lead III larger than that in lead II. A right ventricular infarct can be discovered by performing a right-sided ECG and looking for ST elevation in lead V4R. In these patients, a preload-reducing medication like nitroglycerin can lead to a precipitous drop in blood pressure.

Please interpret this EKG

A right ventricular infarct is suggested by the presence of ST elevation in lead III larger than that in lead II.

Right Ventricular Infarction Chart

Which coronary artery most commonly supplies the inferior wall with blood?

The right coronary artery.

Rapid Review: Inferior ST Elevation Myocardial Infarction

The Sgarbossa ST elevation myocardial infarction (STEMI) criteria

ECG predictors of myocardial infarction are used in the presence of a conduction delay like a left bundle branch block (LBBB). ST segment elevation of at least 1 mm that is concordant with the QRS complex in any lead meets one of the criteria for STEMI. Concordant means that the ST segment and QRS complex have the same direction. The two other criteria for STEMI include concordant ST segment depression of at least 1 mm in lead V1, V2, or V3 and ST segment elevation of at least 5 mm that is discordant with the QRS complex. However, this latter criterion is based on the original Sgarbossa criteria and has been replaced in the modified Sgarbossa criteria with excessive discordance, defined by an ST/S ratio > 0.25. The original Sgarbossa criteria assigned weighted scores to determine the likelihood of STEMI. However, in the modified Sgarbossa criteria, meeting any single criterion yields increased sensitivity without significant loss of specificity in the diagnosis of STEMI in the setting of a conduction delay.

Sgarbossa Criteria

What is the time frame for urgent fibrinolysis in patients with ECG findings of ST elevation myocardial infarction who are not located in a percutaneous coronary intervention (PCI) center and are not able to meet PCI recommended goals?

30 Minutes

Rapid Review: Modified Sgarbossa Criteria

The most common ECG presentation of a posterior STEMI is to only see

the reciprocal changes in the anterior leads.

When horizontal ST depressions are seen in leads V1, V2, and V3 with upright T waves

a posterior ECG should promptly be performed to support the diagnosis

What treatment should be avoided in a right-sided myocardial infarction?

Nitroglycerin

Interpret the EKG, please

Posterior myocardial infarction

Rapid Review: ST Segment Elevation MI

Posterior MI Chart

Hypertrophic Cardiomyopathy Chart

Rapid Review: Hypertrophic Cardiomyopathy

Coronary Anatomy

Please Interpret this EKG

Anterolateral and inferior STEMI.

High Output vs Low Output Heart Failure

What physical exam finding is specific to high-output heart failure?

Bounding pulse with a quick upstroke and a wide pulse pressure.

Rapid Review: High Output Cardiac Failure

What gene mutation is most commonly associated with hypertrophic cardiomyopathy?

Beta-myosin heavy chain.

What is the interpretation of this EKG

Posterior STEMI

Posterior STEMI EKG

Higher Lateral STEMI

What is the most common complication of acute coronary syndrome?

Cardiac Dysrhythmia

What are the classic chest X-ray findings in heart failure?

Kerley B lines and cephalization of flow.

Rapid Review: Acute Decompensated Heart Failure

General Overview of Acute Decompensated Heart Failure

Please Interpret this EKG

Inferior MI

Preload Dependence

Rapid Review: Inferior STEMI

What medication used in the management of acute myocardial infarction activates antithrombin III and inactivates thrombin?

Heparin

What percentage of patients with cocaine chest pain are found to have myocardial injury?

Approximately 6

Treatment Options for Cocaine Induced Chest Pain

Rapid Review: Cocaine Associated Chest Pain

What is the next step in hemodynamic management in patients unresponsive to vasopressors?

Intraaortic Balloon Pump

Ionotropes and Vasopressors

Rapid Review: Cardiogenic Shock

The presence of pneumothorax is identified with which sign on ultrasound?

Lung Point Sign

B lines Ultrasound

B Lines Video Ultrasound

Rapid Review: Ultrasound Pulmonary Edema

What is the name for small, < 2 cm, horizontal lines representing edematous interlobular septa or lymphatic vessels seen in the lower zone periphery on a chest X-ray in patients with congestive heart failure?

Kerley B lines

What is a water hammer pulse?

Bounding pulse with quick upstroke and downstroke.

What respiratory intervention can significantly improve symptoms in acute pulmonary edema?

BiPAP

This CXR is concerning for

Pulmonary Edema

What laboratory test evaluates for a substance released by the ventricles in heart failure?

BNP

In an anterior wall ST elevation myocardial infarction, what decreases the rate of aneurysm development?

Time to revascularlization

Please Interpret this EKG

Concerning for Ventricular Aneurysm

In the setting of ST elevation myocardial infarction, what is the number needed to treat with aspirin to prevent one death

Types of Acute Coronary Syndromes

Rapid Review: Chest Pain

What is Brugada syndrome?

Brugada syndrome is a genetic sodium channelopathy that can result in lethal ventricular tachydysrhythmias

Please interpret this EKG

Hypertrophic Cardiomyopathy

Please interpret this EKG

Considered a STEMI equivalent seen with acute left anterior descending artery occlusion, this shows the de Winter pattern with ST depression and peaked T waves in the precordial leads.

Please interpret this EKG

Wellans Syndrome

Wellans Syndrome Chart

Rapid Review: Wellans Syndrome

Besides the history, ECG, age, risk factors, and troponin score, what are two other chest pain scoring tools that are highly sensitive for determining which chest pain patients are appropriate for early discharge from the emergency department?

The North American Chest Pain Rule and the ASPECT Rule.

Heart Score Chart