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PLE REVIEWER > IM Cardio > Flashcards

IM Cardio Flashcards

1
Q

Initial diagnostic tests for chronic coronary syndrome

A

Ecg

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2
Q

Pharmacologic agent for stress test used for Chronic coronary syndrome

A

DAD
Dobutamine
Adenosine
Dipyridamole

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3
Q

Definitive test for chronic coronary syndrome

A

Coronary angiography

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4
Q

First line and second line intervention for chronic coronary syndrome

A

1st line : BBB, CCB

2nd line: long acting nitrates, ivabradine, nicorandil, trimetazidine

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5
Q

Drugs for prevention of event in CCS and their MOA (4)

A

Aspirin - cox 1 inhi
Clopidogrel - p2y12 inhi
Statin - HMGcoA reductase inhi
ACEi /ARB - RAAS inhi

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6
Q

Drugs for relief of angina

A

Bb - decrease hr,
Ccb - vasodi, dec PVR, nodal inhi ( for nondihydropyrines)
Nitrate - venous vasodilator, coronary arteriolar dilator
Ivabradine - sinus node lf channel inhi
Nicorandril - stimulates k adenosine triphosphate
Trimetazidine - 3 ketoacyl coA inhi, anti ischemic metabolic modulator

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7
Q

Indicatios for CORONARY ARTERY BYPASS GRAFT SURGERY

A

left main coronary artery disease
3 vessel + LVEF <50% or diabetes
2 vessel including Left descending coronary artery

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8
Q

Indication for Percutaneous Coronary Intervention

A

Single vessel disease

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9
Q

Definitive management CCS

A

PCI percutaneous coronary intervention

Coronary Arteru Bypass Graft surgery

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10
Q

Sudden onset cheat pain, increasing in intensity , associated with diaphoresis, shortness of breath
Usually lasting for more than 30 mins and does not relieved with reat, nitroglycerin or meds

A

ACS acute coronary syndrome

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11
Q

Diagnostic procedure of choice for ACS

A

12L ECG

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12
Q

Heart wall affected when ecg findings are seen on

1) v1-v2
2) v3-v4
3) v5-v6
4) II, III AVF
5) I AVL

A

1) septal - LAD
2) anterior- LAD
3) Lateral - Lcx
4) Inferior wall - 80 RCA, 10 lcx, 10 both
5) high Lateral - Lcx

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13
Q

Effect of

1) james reflex
2) bezold jarish reflex

A
  1. James - high HR, BP

2. bezold Jarish - decrease HR. BP

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14
Q

Criteria for STE ACS

For NSTE ACS

A

STE ACS (infarct)
V1-V6 : 1mm elevation / 1 small box
I avL, II III avF : 5mm elevation /5 small box

NONSTE ACS -(ischemia)
ANY 2 contigous LEADS
ST DEPRESSION 1mm/1small box
T wave inversion 5mm/5small box

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15
Q

Antiplatelet therapy

A 
Aspirin 120-325
Clopidogrel 300-600 the 75 OD
Prasugrel 60mg then 10 0D /5mg OD
Ticagrelor 180 mg then 90mgBID
Cilostazol 100mg BID
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16
Q

Adjunctive therapy

A

Acei arbs : captopril 25mg thenn75 1/4 tab q8
Bb : metoprolol 50mg 1/2 tab q6
Statin : atorvastatin 40-80 mg OD / rosuvastatin 20-40mg OD
Heparin- target PTt 2x control / enoxaparin 1mg/kg q12
Nitrates : ISDN /NITROGLYCERIN
Lactulose
PPI

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17
Q

Management for
STE ACS
NSTE ACS

A

Ste acs
Urgernt revascularization
pci

nste acs
Primarily medical
Unless there are presence of riak factora
1) refrac chest pain
2) persistent ST Elevation
3) ventricular tachycardia
4) hemodynamic instability
5) signs of heart failure
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18
Q

Diagnostic to distinguish STE vs Nste

A

Cardiac biomarkers

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19
Q

Typical ECG of NSTE

A

ST depression, T wave inversion, transient ST elevation

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20
Q

1st cardiac marker to be elevated
Specific sensitive and preferred markers for myocardial necrosis
This only stays elevated foe 1-2days
1-2weeis elevation
Best to detect a reinfarction a few days after the initial infarction

A

1) myoglobin
2) troponin
3) ckmb
4) troponin
5) ck mb

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21
Q

TIMI RISK SCORE FOR NSTE ACS

A 
*1 point each category
Age more than or equal to 65 
More than or equal to 3CAD risk factors
Known CAD (50%stenosis)
Aspirin use within past 7 days
Severe angina in last 24hrs
Elevated cardiac markers
St deviation >0.5mm
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22
Q

High risk score for TIMI

Treatment for oatient having high risk TIMI

A

> / = 3 points (13% mortality)
Early invasive strategy followingbtreatment with anti ischemic and antithrombotic agents, angiography is carried out within 48 hours followed by PCI or CABG

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23
Q

Standard anti ischemic therapy

A 
Bed rest
Supplemental o2 if o2 sat is less than 94
Nirtates and sublingual IV *
Beta blockers *
CCB * 
Ace arb*
Morphine 2-5 mg IV
HIGH intensity statins : atorvastatin 40 - 80mg or rosuvastatin 20-40 mg

*contraindicated if ot has SBp of less than 90mmhg or more than 30mmgh from. Baseline

Bb and CCB are contraindicated if patient have pr interval of more than 0.24 sec or with high gradeAV BLOCK IN THE ABSENCE of pacemaker

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24
Q

Pathophy of STEMI

A

Rupture of plaque

25
Q

Txt for v. Fib

A

SCREAM

Shock
Asynchronous cardioversion or defib 360j monophasic
Biphasic 200j

Cpr

Epinephrine 1mg every 3 - 5 mins
AMiodarone 200 mg IV bolus

26
Q

Most common arrhythmia associated with STEMI

A

V. Fib

27
Q

1) Most common cause of OUT HOSPITAL death from STEMI
2) most common cause of IN HOSPITAL death from STEMI
2) what will you suspect if the patient develops or presents with new murmur
4) if the the patient develops pain radiating to either trapezius muscle, what does disease entity the patient have

A

1) Vfib
2) pump failure
3) free or septal wall rupture and acute mitral regurgitation
4) pericarditis

28
Q

Scoring used for ST SEGMENT ELEVATION MI

A

Killip Scoring
Class 1 - no rales or signs of pulmo congestion
Normal bp
Class 2 - moderate heart failure, bibasal rales
Normal BP
S3 gallop
Tachypnea or signs of right sided CHF ( venous and hepatic congestion

Class 3 - severe heart failure, mid basal rales and pulmo edema
Normal BP
S3 and S4
Class 4 - shock with SBP < 90 mmhg and evidence of peripheral vasoconstriction
Peripheral cyanosis
Mental confusion and oliguria

29
Q

Management for STEMI

A

General approach for STEMI
1) referfusion therapy ( primary goal of management) via thrombolysis or PCI within 12 hours
2) pharmacologic approach same with NSTEMI
For inferiror wall STEMI IN THE ABSENSES OF RV INFARCTION : BB are contraindicated
If with RV INFARCTION : BB and nitrates are contraindicated

30
Q

How to determine the presence of RV INFARCT

A

right ECG V3-V6R

31
Q

First Medical Contact time to device attachment in patients seen in PCI CAPABLE HOSPITAL
FMC- Device time for patients seen in NON Pci capable hospital
If the FMC - Device time for the patient above cannot be meet, what is the best next step

A
32
Q

This is the preferred therapy for patients with EARLY PRESENTATION < 3 HRS of ONSET of symptoms, invasive therapy is not available, and if there is delay to invasive therapy (prolonged transport and fmc-d > 120 mins

IF FMC-D time is = 120 mins, high riak STEMI ( cardiogenic ahock killip >/= 3), contraindications with fibrinolytic, late presentation (symptom onset >3 hours), diagnosis of STEMI is in doubt

A

FIBRINOLYSIS / THROMBOLYSIS

INVASIVE THERAPY

32
Q

This is the preferred therapy for patients with EARLY PRESENTATION < 3 HRS of ONSET of symptoms, invasive therapy is not available, and if there is delay to invasive therapy (prolonged transport and fmc-d > 120 mins

IF FMC-D time is = 120 mins, high riak STEMI ( cardiogenic ahock killip >/= 3), contraindications with fibrinolytic, late presentation (symptom onset >3 hours), diagnosis of STEMI is in doubt

A

FIBRINOLYSIS / THROMBOLYSIS

INVASIVE THERAPY

33
Q

Clear contraindications for Thrombolysis

A

MANS C

MARKED Hypertension SBP >180 mmhg and or DBP >110 mmhg
Activw internal bleeding
Non hemorrhagic stroke
Suspicion of Aortic Dissection
Cerebrovascular hemorrhage anytime
34
Q

Clear contraindications for Thrombolysis

A

MANS C

MARKED Hypertension SBP >180 mmhg and or DBP >110 mmhg
Activw internal bleeding
Non hemorrhagic stroke
Suspicion of Aortic Dissection
Cerebrovascular hemorrhage anytime
35
Q

Relative contraindicationa for thrombosis

A

CR PP HHF KA

Current use of anticoagulants
Recent (<2 weeks) invasive or surgical procedure

Pregancy
Prolonged (> 10 min) invasive or surgical procedure

Hemorrhagic ophthalmic conditiona
Hx of severe hypertension that is currently adequately controlled
For streptokinas : if agent had been recieved within the preceeding 5 days to 2 years

Known bleeding diasthesis
Active PUD

36
Q

Lab parameters/procedue that will direct the management of ACS

A

12 L ECG

37
Q

Feature that will lead you to proceed with urgent coronary angiogram possible angioplasty

A

Hypotension reuiring vasopressor support

38
Q

Contraindicated in Patients with inferior wall STEMI W/O RV INFARCT

WITH RV INFRACT

A

BB metoprolol

BB + nitroglycerin

39
Q

Mc cause of in hospital death after STEMI

A

Pump failure

40
Q

Heard when AV VALVE CLOSES (mitral and tricuspid valve)

Heard when SEMILUNAR VALVE CLOSES

Heard heart sound that is due rapid flow of blood from atria into ventricles

Due to late systolic filling of ventricle due to atrial contraction

Patholgic in ADULT , normal in children

Heardvin ventricular hypertrophy

A 
S1
S2
S3
S4
S3
41
Q

Increased intensity of S1 is due to what condition

Softer S1 is due to what conditions

S2 increases during
S2 decreases during

S2 is best heard when

A

Increased s1 : early stage of MS, hyperkinetic states
Softer s1: late stage MS, cobtractile dysfunction
S2 increases during inspiration
S2 decreases during expiration

Best heard in supine condition 2nd LICS

42
Q

Murmur that increases with inspiration
Murmur that increases with expiration

Murmur that increases with valsalva maneuver
Murmur that decreases with valsalva maneuver

Murmur that increases with squatting
Decreases with squatting

                   Increases with standing 
                    Decreases with standing
A

Respiration
Increased IN INSPIRATION : RIGHT SIDED MURMUR
TS, TR, PS, PR (TPRI)

LOUDER IN EXPIRATION.    : LEFT SIDED MURMUR
                                                        AS, AR, MS, MR  (MALE)

Valsalva
Increased : HOCM, MVP
Decreased :

SQUATTING (passive leg raising)
increased:
Decreased : HOCM, VMVP

Standing
Increased : Hocm, mvp
Decreased: as, ar, ms, mr, vsd

43
Q

Manifestation : syncope angina dyspnea, heart failure
PE: diamond shaped crescendo descresendo midsystolic murmur at 2nd ICS R sternal border, weak and delayed pulse (pulsus parvus et tardus)
Best initial test
TOC

A

Aortic stenosis
Transthoracic echocardiogram
Aortic valve replacement surgery

44
Q

Principal causes of AS

A

Congenital bicuspid valve with superimposed calcification
Calci of normal trileaflet valve
Rheumatic disease

45
Q

Murmur transmitted downward confusing with MR

Weak and delayed heart contraction

A

Galliverdin effect

Pulsus parvus et tardus

46
Q

Prognosis in pts with AS based on clin mani

A

Syncope : 3 years
Anginsa : 3 years
Dyspnea : 2 years
CHF : 1.5-2 years

47
Q

Mangement for AS

A 
Medical txt
    Avoid strenous physical activity
    Avoid dehydration and hypovolemia
    Tx comormid
     Statins may slow down progessiob of leaflet calci

Surg tx
Conventional surgical AVR :toc for low or intermediate risk
TAVI : for severe

48
Q

Clin mani : fatigue, hx of htn, dyspnea
Pe: high pitched blowing diastolic descrecendo murmur on the L STERNAL. BORDER AND widened pulse pressure, murmur that ia also heard in the femoral artery
Best initial test
Tx to be avoided

A

Aortic regurgitation
Transthoracic echocardiogram
Beta blockers

49
Q

Murmur that is heard over femoral artery when compressed

Murmur in severe AR

Jarring of entire body and bobbing motion of head

Bounding and forceful pulse rapidly increasing and subsequently collapsing

Capillary pulsation of root of nail

Booming pistol shot sound over femoral arteries

A

Duroziez sign

Austin flint murmur - rumbling sound

De musset sign

Water hammer or corrigans pulse

Quincke’s pulse

Traube sign

50
Q

Etiology of AR

Cln mani of acute AR
Chronic AR

A

Primary valve disease and aortic root disease

Acute AR : PULMO EDEMA and cardiogenic shock
Chronic AR: palpitations tachycardia exertional dyspnea, PND, cheat pain
High pitched diastolic murmur at left parasternal border
Austin flint murmur
Widened pulse

51
Q

Treatment of AR

A

Acute
Diuretics vasodilators
Avoid betablockers
Surgery : TOC necessary within 24hrs of diagnosis

Chronic AR
Ace inhi or ARB
Diuretics
Dihydropyridine CCB/BB
Surgery : aortic valve replacement
52
Q

Clin mani : hx of RF, dyspnea, palpitation, female
Pe : opening snap low pitched tumbling diastolic murmur at the apex
Most common cause
Earliest chest xray findings
Toc

A

Mitral stenosis
Rheumatic fever
Strajghtening of upper left border of cardiac silhouette
Percutaneous transmitral commissurotomy PTMC if there is no contraindications

53
Q

Hemodynamic hallmark of mitral stenosis

Most common presenting symptoms of MS

Functional tricuspid murmur

Manifestation in ECG

A

Abnormally elevated left av pressure gradient on 2d echo

Decreased exercise tolerance fatigue dyspnea

Carvallo sign

ECG : LA enlargement, RAD, RVH
CXR: straightening of the upper border of the cardiac silhoutte

54
Q

Most accurate approach to diagnosis and evaluation of MS

A

2d echo with doppler studies

55
Q

Characteristic anatomy seen inn2decho in MS

A

Leaflet thickening and restriction of opening caused by assymetric fusion of commisures resulting in DOMING of leaflets in diastole (hockey stick sign)

56
Q

Level of mitral stenosis

A

Normal 4-6cm2
Mild >1.5
Mod 1-1.5
Severe <1

57
Q

Management for ms

A

Diuretics
Slow hr : bb, digoxin, NDPH ca channel. Blocker (verapamil /diltiazem)
Warfarin if with onset of AF
percutaneous mitral valvr ballon valvotomy
Mitral valvr replacement surgery
Penicilline prophylaxis

58
Q

Beat initial tx for symptomatic patients with ms
Prophylacis given in patients with MS
Most effective treatment

A

Diuretics
Penicillin prophylaxis for group A B hemolytic streptococcal infection
Percutaneous mitral balloon valvotomy or vulvuloplasty

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