IM Cardio Flashcards
A-fib
EKG of A-fib
narrow QRS complex
no P wave
chaotic activity of atria
irregular R-R intervals
4 types of a-fib
- Paroxysmal: <7days
- Persistent: >7days, requires termination
- Permanent: AF > 1 yr
- Lone: any of the above w/o evidence of hrt dz
Mgmt of stable a-fib rate control
B-Blockers: metoprolol
CCB: Diltiazem
Digoxin: pts w/hypotension or CHF
Options for A-fib rhythm control
DCC: direct current cardioversion (synchronized cardioversion)
When would you use DCC over pharm tx?
AF <48hrs
OR
post 3-4 wks of anticoag & TEE showing no atrial thrombi
OR
If you dont want to use DCC: **start IV Heparin, cardiovert w/in 24hrs & anticoag for 4 wks**
Pharma rhythm control meds
IFSA
Ibutilide
Flecainide
Sotalol
Amiodarone
“IFSA”
Main focus of A-fib meds
control Heart rate
reduce clotting
Other tx options for a-fib
Pacemaker
RF ablation(Av node ablation): maze–> need pacemaker with this
CHA2DS2-VASc Criteria topics
Congestive Hrt failure
HTN
Age >75y/o
DM
Stroke, TIA, Thrombosis
Vascular Dz: prior MI, aortic plaque, peripheral art dz
Age 65-74
Sex F
Which 2 categories of CHA2DS2-VASc Criteria have 2 points?
Age >75 y/old
Stroke, TIA, thrombus
tx for greater than or equal to 2 on CHAD2DS2-VASc criteria
mod-high risk = chronic anticoag
anti-coag agents used for a-fib
NOAC: lower rates of major bleeding, dec. risk of ischemic stroke, do not need to check INR
Ex: Dabigatran, “abans”
Warfarin indications: severe CKD, CI to NOAC (HIV pts), monitor INR goal of 2-3
Dual A-platelet therapy: ASA + clopidogrel –> only ise if pts annot be tx with anti-coag.
Class I Angina Pectoris
angina with unusually strenuous activity
no limitations on activity
Class II Angina Pectoris
W/prolonged/rigorous activity
slight limitation of physical activity
Class II Angina Pectoris
angina with usual daily activity
Marked limitation of Phys. activity
Class IV Angina Pectoris
angina at rest
unable to carry out any physical activity
stable angina
relieved by rest /nitroglycerine
unstable angina
more frequent sxs, increasing sxs, present at rest
Any new onset murmur w/fever is…
infective endocarditis
IVDA w/endocarditis will affect which valve and what bacteria?
staph aureus tricuspid
non IVDAs will affect which valve and what bacteria is it?
strep viridans and mitral valve
What 3 things do you see in infective endocarditis?
- Roths spots: hemorrhage in the retina with a white center
- Janeway lesions: arise from infected microemboli
- Osler Nodes: small tender subcutaneous nodules on digits
what is the INITIAL study for infective endocarditis?
TTE
what is the diagnostic method of choice for infective endocarditis?
echocardiography
infective endo tx
IV PCN and ceftriaxone
leading cause of mitral valve stenosis and valve replacement
rheumatic heart dz
Major Jones criteria
carditis
polyarthritis
chorea, subcutaneous nodules, erythema marginatum
minor jones criteria
fever
arthralgia
elevated ESR
ASO titer test
pts with rheumatic heart may develop what?
a fib
cpx of aortic stenosis
right 2nd ICS radiates to carotids and down to border of apex
syncope
dyspnea
angina on exertion
CHF
dx of PAD
A-B Index
doppler US
angiography (if surg required)
what is ABI?
ratio of systolic ankle BP/brachial systolic BP
if <0.9 = PAD
tx of PAD
anti-platelets
if severe: stent placement
ABI <0.9 indicates what?
ABI < 0.4 indicates what?
< 0.9 = > 50% stenosis
<0.4 = ischemia
can present with lower extremity edema, varicosities, increased pigmentation, and venous stasis ulcers
Venous Insuff
normal range of ABI
0.91–1.3
MCC of PAD
atherosclerotic disease
gold standard for PAD
If limb is threatened - contrast arteriography
PE: cool extremity with absent or diminished pulses
What dz
PAD
classic triad of AS
chest pain, dyspnea, and syncope
crescendo descrescendo
systolic ejection murmur
delayed/diminished carotid pulses
paaradoxically split S2
narrow pulse pressure
Associated with what dz?
Aortic Stenosis
Complaining of sudden “ripping” or “tearing” CP radiating to back
CXR will show widened mediastinum
Diagnosis is made by CT or transesophageal echocardiogram (TEE)
Treatment is reduce BP, surgery
What dz?
aortic dissection
What populations are recommended to start screening for Lipid disorders?
Men greater than or equal to 35
Men 20-35 yrs at inc. risk for coronary heart dz
women greater than or equal to 45 at inc. risk for CAD
women 20-45 yrs old at inc, risk for CAD
Causes of mitral stenosis
rheumatic heart dz
atrial myxoma
mitral stenosis murmur
low pitched, rumbling diastolic apical murmur (LRDA)
Loud S1 & opening snap
acute mitral regurg causes
endocarditis, myocardial infartion, trauma
chronic mitral regurg causes
rheumatic heart dz
mitral regurg murmur
loud holosystolic heard best at apex, with radiation to base
mitral valve prolapse cause
congenital
mitral valve prolapse murmur
early to mid systolic click with late systolic mumur heard best at left lateral heart border
aortic stenosis cause
calcific valve degeneration
bicuspid aortic valve
aortic stenosis murmur
crescendo-decrescendo systolic murmur radiating to neck
acute aortic regurg cause
endocarditits, aortic dissection
chronic aortic regurg cause
rheumatic heart disease, bicuspid aortic valve
aortic regurg murmur
high pitched, blowing, diastolic murmur heard best at left sternal border (HBD)
what is the most commonly associated complication of mitral valve stenosis?
A FIB
What meds lower TGLs the best?
FIBRATES: gemfibrozil, fenofibrate
Can you use gemfibrozil in pts with biliary dz?
NO
Xanthomas
Tendinous xanthomas
Corneal arcus
CPx of what dz?
hypertriglyceridemia
What are the 1st line antihyeprtensives for AA?
thiazide type diuretics
Dx of HTN
elevated BP greater on 2 or more reading on 2 or more different visits
greater or equal to 140/90
When should you suspect 2ry hypertension?
if BP is refreactory to anti-HTN drugs or severely elevated
what signifiies an adv stage of malignant HTN?
papilledema
Grades of Retinopathy
- arterial narrowing
- A-V nicking
- 1 + 2 and hemorrhages + soft exudates
- papilledema
main side effects of HCTZ
hypercalcemia
hyperuricemia
hyperglycemia
**avoid in pts with gout & DM**
main SES of loop diuretics (furosemide, bumetanide)
hypokalemia
hyperglycemia
metabolic alkalosis
ototoxicity
_** avoid in pts with sulfa allergy**_
main SES of K+ sparing diuretics (spironolactone, amiloride, eplerenone)
hyperkalemia
gynecomastia with spironolcatone
SES of ACE-I (prils)
1st dose hypotensio, azotemia/renal insuff
hyperkalemia
cough & angioedema (inc bradykinin)
hyperuricemia
_**avoid in preggo pts**_
Hypertensive Urgency
Inc. BP + NO acute end organ damage
Hypertensive Urgency Mgmt
Captopril
Clonidine (short term use)
Hypertensive Emergency
inc. BP + acute end organ damage**
>180/>120
HTN emergency Mgmt
use IV agents
When to not use IV agents:
- acute phase of an ischemic stroke
- acute aortic dissection
Neurologic hypertensive emergency
nicardipine/clevidipine/labetolol
CV hypertensive emergency
Esmolol/Labetolol
Nitroglycerin/BB (ACS)
Nitro/Furosemide (acute heart failure)
Four groups that benefit from statins
- patients with ASCVD,
- patients with LDL levels greater than or equal to 190 mg/dL,
- patients aged 40-75 years with DM and an LDL level of 70-189 mg/dL,
- patients with an LDL level of 70-189 mg/dL and a 10-year ASCVD risk of greater than or equal to 7.5%
What 2 choices are 1st line tx for AA for HTN?
HCTZ & CCB
Indications for ARB for HTN
pts not able to tolerate BB/ACEI
indication for non-dihydropyridine (verapamil,diltiazem) use in HTN
HTN w/a-fib
What should you use for a pt with HTN + BPH?
alpha 1 blockers (zosins)
What is the main SES of Alpha 1 blockers?
1st dose syncope
Best HTN med for a fib
BB or CCB (non-D)
best med for HTN + angina
BB, CCB
Best meds for HTN + post-MI
BB, ACE
HTN + systolic HF
best HTN meds?
ACE, ARB, BB, diuretics
Best HTN meds ?
HTN + DM/CKD
ACE, ARB
Best HTN for pt w/isolated systolic HTN in elderly
Diuretics
best HTN med for pt w/OP
Thiazides
Best HTN med for pts with BPH
A-blockers (zosins)
Best HTN meds for young, caucasian males
thiazides –> ACE/ARB –> BB
Best HTN med for pt w/gout
CCB or Losartan (only ARB allowed)
What is considered HTN in pregnancy?
acute onset of BP 160/110 for > 15 mins
Best meds to increase HDL
Niacin
Which Hyperlipidemia meds should be used in T2DM?
fibrates, statins
What hyperlipidemia med should be avoided in T2DM?
Niacin
Optimal cholesterol levels
LDL <100
Total chol <200
HDL >60
Main SES of niacin
flushing
HA
warm sensation
pruiritis
hyperuricemia
hyperglycemia
main SE of statins
hepatitis
Which cholesterol meds are safe in pregnancy?
bile acid sequestrants:
Cholestyramine
Colestipol
Colesevelam
SES of bile acid sequestrants
GI: inc. LFTs
inc. TGL