Jack's Cardiololgy Flashcards
Define Orthostatic Hypotension?
-a decrease in systolic BP of 20 mm Hg or a decrease in diastolic BP of 10 mm Hg when going from lying to sitting or sitting to standing
Why is orthostatic hypotension a problem with elderly?
-syncope and especially falls
You have a 75 y.o. male with orthostatic hypotension. In addition when evaluating him his heart rate increases more than 15 beats per minute when he stands from a sitting position. What does this indicate?
-indicates that the problem is probably low blood volume
How do you tx a patient with orthostatic hypotension?
-tx the underlying cause ie. fluids for depletion, check PB meds
An elderly patient presents with exertional dyspnea and can’t walk more than a block without SOB. He also says he occationally wakes up at night with dyspnea. He describes a chronic nonproductive cough. What is the likely Dx?
-CHF
An elderly patient’s wife says he stops breathing when he naps in the afternoon. What is this called?
-Cheyne-Stokes breathing
How do you assess Jugular Venous Distension (JVD) ?
- sit the patient at 45 degrees
- jugular vein pulsation higher than 4 cms above the sternal angle is considered to be elevated venous pressure
A displaced apical impulse can be seen in CHF. Describe how to find this on PE?
-found on the midclavicualr line in the 5th intercostal space
A positive Hepatojugular Reflex may be seen in CHF. How do you check for this on PE?
- patient sitting at 45 degrees
- pressure is applied to the abdomen for 1 min and if the neck vein height increases by 3 cm the test is positive
What are the x-ray findings of CHF ?
- cardiomegaly : boot or water bottle heart
- pleural effusion : ground glass, fluid build up in pleural space
- Kerley B lines : short parallel lines at the lung perifpery near the bases
- Batwing or Butterfly shadow-enlarged hila or alveolar edema
What lab values might be positive in CHF ?
-Beta natriuretic peptide (BNP) : is a good indicator of CHF however it may not be as specific in patients who are old or have COPD
What meds do you use for CHF?
- thiazide diuretic for long term tx along with a ACEI
- loop diuretic with for acute situation tx
What PE, and other studies do you do for atherosclerosis?
- PE : listen for bruit
- U/S Doppler for blood flow
- Ankle Brachial Index
- Angiogram/Heart cath
A 47 y.o. male presents without c/o and you notice yellow crust on the skin of his eyelids (Xanthomas). What might this be an indication of?
-Dyslipedemia, but over half of the people with them have a normal lipid profile
When should you begin screening patients for dyslipidemia?
-35 for men and 45 for women
What are the numbers for total cholesterol?
- Optimal < 200
- Borderline 200 -239
- High > 240
What are the numbers for HDL cholesterol?
-Low 60
What are the numbers for LDL cholesterol?
- Optimal < 100
- Near Optimal 100-129
- Borderline high 130-159
- High >160
What are the number for Triglycerides?
- Normal <150
- Borderline 150-199
- High 200-499
What are the nonpharmacological tx for dyslipidemia?
- wt reduction
- reduce dietary fat to 30% and saturated fat to <10%
- Mediterranean diet
- increase aerobic exercise
How do statins work?
-lnhibit rate limiting step in cholesterol production
Most common side effect of statins?
-myositis
Ways to lower cholesterol in postmenopausal women include?
-estrogen replacement helps lower LDL and raise HDL
Name 2 Bile acid binding resins for lowering cholesterol?
- Cholestyramine
- Colestipol
Name 2 Fibric acid derivatives for lowering cholesterol?
- Gemfibrozil
- Fenofibrate
Chest pain brought on by physical activity and relieved with rest and usually resolves in 30 minutes is what?
-Stable Angina
Increasing chest pain that occurs at rest or with exercise is what?
-Unstable Angina/non ST elevation MI
Chest pain that lasts longer than 3 minutes and is not affected by activity is what?
- Prinzmetal’s Angina, or variant angina
- this is caused by vasospasm of the coronary arteries
Elderly male presents with chest pain and a Clenched fist held over his heart?
-Levine’s Sign
Immediate tx for new patient presenting with angina includes what meds?
- sublingual nitroglycerin or isosorbide (emergently)
- these should provide immediate relief
Drugs for long term tx of angina include?
- long acting nitrates
- beta blockers
- calcium channel blockers
- blood thiners, asa, clopidogrel (Plavix)
Most common cause of an MI?
-thrombic event at the site of preexisting plaque causing complete blockage of an artery
7 days after an MI a 65 y.o. male develops pericarditis, fever, leukocytosis, pericardial effusion and a pleural effusion. What is the Dx?
-Dressler Syndrome, post myocardial infarction syndrome
What 3 labs do you order for looking at cardiac enzymes if MI is suspected?
- Myoglobin
- cardiac troponin I, and troponin K
- CK-MB
Which cardiac enzyme is elevated first in an MI?
-Myoglobin, it elevates in first 1-3 hours and peaks 6-7 hours, normal in 24 hours
How quickly do cardiac enzymes troponin I and K elevate after an MI?
-elevate in 2-24 hours, peak at 24 hours, N in 2 weeks
When do troponin I and K normalize after an MI?
-return to normal in 2 weeks
How quickly does CK-MB elevate after an MI?
-elevate in 3-12 hours and peak at 24 hours
When does CK-MB normalize after an MI?
-72 hours
What is the usual progression on an EKG for an MI?
-progression from peaked T waves to ST segment elevation to Q waves to T wave inversion
Leads II, III and aVF show what location of an MI?
-inferior MI
Leads V1 and V2 show what location of an MI?
-posterior MI
Leads V1 and V2 show what location of an MI?
-anteroseptal
Leads V1, V2 and V3 show what location of an MI?
-anterior
Leads V4, V5 and V6 would show what location for an MI?
-anterolateral
What % of deaths from MI occur before the patient reaches the hospital?
-50%
What OTC counter med should be given immediately is MI is suspected?
-325 mg of ASA
What oral prescription med should be be given asap is MI is suspected?
-clopidogrel (Plavix) 300 mg oral once as loading dose
then titrate down to 75 mg/day
What 2 meds are given for MI for angina tx?
- nitoglycerin
- morphine for pain control if nitroglycerin is ineffective
Describe heparin vs enoxaparin for tx of MI in the ER?
- enoxaparin is more effective than heparin
- significant reduction in death from MI at day 30
When is t-PA given with an MI?
-most effective if given the first three hours
How long do you give to t-PA with an MI?
-tx to 12 hours after onset of sx (10% mortality reduction)
What EKG finding would make you give t-PA ?
-ST elevation would warrant reperfusion (clot busting drugs, fibrinolytic meds)
When do you give streptokinase for MI?
-you don’t, it’s not available any more in the USA
70 y.o. presents with MI Sx and ST elevation. He had a stroke 6 months ago. Do you give t-PA?
-no, it is contraindicated in strokes within 1 year
67 y.o. female with cranial neoplasm presents with Sx of MI and ST segment elevation on EKG. Do you give t-PA?
-no, contraindicated in cranial neoplasms
50 y.o. male wt lifter presents to ER with Sx of MI and ST elevations on EKG. He had a concussion 2 weeks ago. Do you give t-PA?
-no, contraindicated in recent head trauma
47 y.o. presents to ER with Sx of MI and ST elevations on EKG. He is being treated for a peptic ulcer. Do you give t-PA
-no contraindicated in internal bleeding
81 y.o. presents to ER with Sx of MI and ST elevations on EKG and is known to have aortic dissection. Do you give t-PA?
-no, contraindicated in aortic dissection
For Tx an MI how soon should cardiac catherization and stunting be performed?
-door to balloon time < 90 min
What types of contraindications to tx with t-PA are BP > 180/110, intracerebral pathology, and trauma within 2 wks of MI?
-all are relative contraindications
What types of contraindications to Tx with t-PA are major surgery within the last 2 weeks, CPR lasting more than 10 min, pregnancy, and current use of coumadin for tx of MI?
-all are relative contraindications
What lipid medication might you prescribe for a guy with triglycerides >400 ?
- Fibrates: Gemfibrozil (Lopid) or Fenofibrate (Tricor)
- they lower TG by 20-50%
What is the major side effects of Fibrates (Gemfibrozil or Fenofibrate) ?
-Cholelithiasis (gallstones)
A 56 y.o. male presents and lipids are checked and his HDL’s are low? What might you prescribe?
- Niacin
- may increase HDL’s 25-35%
65 y.o. female presents with increased lipids, his LDL’s are markedly elevated. What might you prescribe?
- Statins
- lower LDL’s 20-55%
A 29 y.o. female presents with increased lipids. What would you prescribe?
- Bile Acid Binding Resins (cholestramine, choleserelam, colestipol)
- is the only safe lipid medication for use in pregnancy
A 27 year old presents with elevated trigylcerides. What might you prescribe?
-Omega 3 (fish oils / lovaza )
After an MI or with CVA patients what lipid med do you prescribe?
-Statins
With low HDL’s prescribe what lipid lowering med?
-Niacin
For high triglycerides prescribe what lipid lowering meds?
- Niacin
- Fibrates
For Men <35 and pre-menopausal women what is the most important factor in tx hyperlipidemia?
-Theraputic Lifestyle Changes
- decrease saturated and trans-fats - restrict diet cholesterol to <200mg/d - increase soluble fiber - fish oil supplements - wt reduction - increase physical activity - increase fruits / vegetables
Which lipid med does not cause liver enzyme elevation?
-Bile acid binding resins
When do you D/C bile acid binding resins if liver enzymes are elevated?
-d/c if ALT > 3x normal
All but this lipid lowering med may cause myopathy?
-bile acid binding resins
When do you d/c lipid med if myopathy is noted?
-d/c or lower dose if CPK rises or consider changing meds
What is the term for inflammation of the cardiac tissue?
-Endocarditis
What usually causes Endocarditis?
-most commonly occurs with damaged or prosthetic heart valves
What heart condition can damaged or prosthetic heart valves lead to?
-Endocarditis
What bacteria etiology most commonly cause endocarditis?
- strep viridans
- staph aureus
- enterococci
What are the 4 predisposing factors for Endocarditis?
- damaged or prosthetic heart valves
- bacteria infection to heart valves
- post op valve replacement
- procedures or other events that introduce bacteria into the circulatory system
A 56 y.o. is post op 4 weeks heart valve replacement and now has endocarditis? What bugs would cause this?
- this infection in common in the first 2 mo post op
- staph aureus, Fungi, and Gram-negative bacteria are usually the cause
What other events can introduce bacteria into the blood circulation and cause endocarditis?
- dental work
- IV drug use, staph aureus due to needle contamination
- central line placement
- surgery on infected tissue–foot wounds
- tonsillectomy/adnenoidectomy–upper resp procedures
- GI procedures
- urinary procedures
With what Sx would a patient with endocarditis present?
-non specifc sx, fever/chills, fatigue, loss of appetite, joint pain ect.
What are the PE findings for Endocarditis?
- new or changed murmer
- **Janeway lesions : nontender macular lesions usually on the pads of the fingers and toes
- petichia
Nontender, macular lesions on the palms and soles ?
- Janeway lesions***
- specific to endocarditis
- caused by septic emboli coming off the heart valves
56 y.o. male presents with c/o fever/chills, fatigue, and loss of appetite. He is 3 wks post op valve surgery (or is known to have mitral valve stenosis). What do you suspect and what lab/studies are you going to order?
- blood cultures x 3 at least one hour apart from each other
- this is suspicious for endocarditis
56 y.o. male presents with c/o fever/chills, fatigue, and loss of appetite. He is 3 wks post op valve surgery (or is known to have mitral valve stenosis). What do you suspect and what lab/studies are you going to order?
- blood cultures x 3 at least one hour apart from each other
- cbc
- C reactive protein
- sed rate
- possible echo/transesophageal–may affected heart valve
What are the two Major criteria (Duke Criteria) for Dx of endocarditis?
- two positive blood cultures that typically cause endocarditis (staph aueus, fungi, gram neg bacteria)
- Positive echo findings
- new regurg
- abscess
- oscillating mass
What is Pericarditis?
-inflammation of the pericardium (the double layer membrane that contains the heart)
List 7 common causes for Pericarditis
1 viral infection ***most common cause
-echovirus, coxsackie, flu, HIV
2 Bacterial infections (rare, but follows resp infectin)
3 Post MI--Dressler Syndrome
4 Post cardiac surgery
5 Radiation
6 Autoimmune
7 Kidney failureList 7 common causes for Pericarditis
1 *** viral infection ***most common cause
-echovirus, coxsackie, flu, HIV
2 Bacterial infections (rare, but follows resp infectin)
3 Post MI--Dressler Syndrome
4 Post cardiac surgery
5 Radiation
6 Autoimmune
7 Kidney failureSx of Pericarditis.
- pleuritic chest pain, worse with deap breath or lying down
- Dyspnea
- diaphoresis
- fever
- dry cough
- may look very ill
What are the PE findings of pericarditis?
- pericardial friction rub
- CBC with elevated WBC’s
- ST-segment changes
What are the tx for pericarditis?
1) -tx the infection–antibiotics etc.
- antifungals
- dialysis
2) high doses of nsaids
3) colchicine along with nsaids for initial tx, or for chronic
4) corticosteroids if nsaids are not effective
5) pericardiocentesis
6) pericardiotomy
sick guy, fever and chills, dyspnea, diaphoresis, and pericardial friction rub on PE. Dx?
-viral pericarditis
3 wks post MI guy comes in with chills, fever, dyspnea, pleuritic chest pain worse with deap inspiration. Pericardial friction rub on PE. Dx?
-pericarditis, Dressler Syndrome
Gal is post cardiac surgery 2 mo, with fever and chills, dyspnea, chest pain worse with lying down and a dry cough. Has pericardial friction rub on PE. Dx?
-pericarditis
Smoker has had chest radiation for cancer Tx 2 wks ago. Presents with fever, chest pain worse with deep breath, diaphoresis, looks very ill. Has pericardial friction rub on PE. Dx?
-pericarditis
kidney failure patient presents with chest pain worse with lying down, fever, dyspnea, diaphoresis and dry cough. Has pericardial friction rub on PE. Dx?
-pericarditis
How does a pericardial effusion and tamponade usually occur?
-a person has a pericarditis which leads to a pericardial effusion which leads to a cardiac tamponade
What is an increased fluid within the pericardium?
-pericardial effusion
What is the term for when the pressure from a pericardial effusion constricts the heart to a point where it begins to affect cardiac output?
-cardiac tamponade
List the common causes for a pericardial effusion?
- pericarditis (most often)*
- CHF
- myxedema
- tuberculosis
- trauma
69 y.o. male with a know Hx of heart failure presents to ER with chest pain, pressure in his chest, dyspnea and dry cough. PE shows Paradoxical pulse pressures, Water Bottle heart on CXR, and Electrical Alternans on EKG. What is the Dx and Tx?
-pericardial effusion
- Tx : tx underlying cause
- small effusions can be watched
- pericardiocentesis may be required
- pericardiectomy
Jaw claudication =
-Giant cell arteritis/ Temporal Arteritis
Which of the following is used for diagnosing endocarditis according to the Duke criteria?
- you need 2 major criteria, or
- one major and three minor criteria, or
- 5 minor criteria
A 68 y.o. male presents to the ER with c/o of fever, fatigue and loss of appetite. While taking his Hx his wife tells you that the had to have some heart surgery about a year ago, but doesn’t know exactly what they did. PE shows a slight murmur.
-obtain blood cultures (for possible endocarditis)
What are the 6 P’s of arterial occlusion?
- pain
- pallor
- pulselessness
- paresthesias
- poikilothermia
- paralysis
Describe the Ankle Brachial index?
1-1.2 is normal,
Define Aneurysm.
-widening or ballooning of a section of an artery due to weakness in the wall of the blood vessel
What is the location of the most common aneurysm?
-abdominal aortic aneurysm, below the renal vessels and usually involving the bifurcation
What risk factors contribute to atherosclerosis which can damage blood vessels and lead to aneurysms?
- CAD
- smoking
- HTN
- Hyperlipidemia
What congenital conditions can lead to weakness of the lining of the blood vessels and contribute to aneurysms?
- Marfan’s
- Ehler’s Danlos type IV
Are most patients with aneurysms symptomatic?
-no, most with aneurysms are asymptomatic
A patient presents with c/o a tearing pain radiating to the back must be worked up for what condition?
-rupture aortic aneurysm
A patient presents with c/o abdominal pain and radiating to the back (substernal) must be worked up for what condition?
-aortic aneurysm
A patient presents with a pulsatile mass in his abdomen. The best study to comfirm your Dx is what?
U/S is the best study for abdominal aneurysms
For suspected thoracic aneurysms what is the best study to order?
-aortography may be necessary for dx
The Tx for abdominal aortic aneurysms is what ?
-surgery, open or endovascular techniques
Giant Cell Arteritis is also known as what?
-Temporal Arteritis
A patient presents with c/o pain in his jaw while chewing, and when he stops chewing it lets up. What are you suspicious of and how do you work this up?
-jaw pain while chewing is called jaw claudication and is consistant with Giant Cell or temporal arteritis
- you need lab blood work, liver function tests because Alk phos will be elevated, C-reactive protein will be elevated, sed rate will be elevated and platelets may be low
- Biopsy of the temporal artery is the gold standard for Dx
What its the tx for Giant Cell Arteritis/Temporal Arteritis?
- high dose prednisone 40-60 mg po daily for 1-2 months followed by tapering over the period of 1-2 years
- asa 81 mg, will help reduce the risk of stroke and blindness
Terms for Peripheral Arterial Disease include?
- peripheral vascular disease
- peripheral vascular disorder
68 y.o. presents with c/o numbness, tingling, and ulcers, and erectile dysfunction. PE shows weakened pulses, paresthesia, and skin ulcers. What do you do for further study?
-You suspect claudication from peripheral arterial disease so do a Ankle Brachial Index
Old guy comes in with leg pain, pale leg skin, no pulse, paresthesia, cold skin (poikilothermia), and can’t move his foot (paralysis). What is the Dx? What is the Tx?
- Occlusion, peripheral arterial disease
- Tx is endovascular stenting and angioplasty, or bypass grafting,
What are tx’s for peripheral arterial disease?
- 81 mg asa per day
- lifestyle modifications and progressive exercise
- surgery
Inflammation of a vein?
-phlebitis
Inflammation of a vein as a result of a blood clot?
-thrombophlebitis, the most common cause of phlebitis
Some risks for DVT that you don’t always think about include?
- oral contraceptives, esp with smokers
- family hx
- pregnancy, post natal period
- cancer
What is the Gold Standard test for Dx of DVT?
-U/S doppler
What does a D-dimer test tell you about a DVT?
- this test looks for fibrin degradation products
- if it is negative there is no DVT, it can be positive for many reason so a positive dx for DVT you still need the doppler
The dosage for Lovenox for DVT prevention is what ?
-4 mg subcutaneous per day or 30 mg Bid po, and 81 mg asa per day
What is the tx for DVT dx by dopler?
- heparin
- warfarin
- lovenox
- filter for the inferior vena cava
- thrombolysis
- thrombectomy
55 y.o. female presents with c/o painful leg veins and fatigue and aching of her lower extremities. PE shows dilated and tortuous veins (saphenous vein) which are tender (but don’t have to be tender). What is the dx, how do you tx?
-dx is varicose veins
- avoid standing for long periods of time
- elevate legs when possible
- graduated elastic stockings
- vein stripping
- sclerotherapy
What is the term for weakend vessel walls and incompetent valves in the lower extremity?
-chronic venous insufficiency
67 y.o. female presents with c/o skin color changes (darkening) of her legs and painful skin ulcerations. What is the dx and tx?
-chronic venous insufficiency
tx : avoid standing for long periods
elevate legs when possible
graduated elastic stockings
heat
ambulatory exercise
Sx of lower extremity hyperpigmentation, shinny skin, atrophic, dermatitis, and painful ulcerations are consistant with what disorder?
-Chronic Venous Insufficiency
Electrical Alternans is pathognomonic for what?
-pericardial effusion
Pericardial friction rub should make you think of what Dx?
-pericardial effusion
What is the basic physiology of cyanotic congenital heart disorders?
- right to left shunting
- deoxyngenated blood returning from the body bypasses the lungs altogether and is recirculated
Tetralogy of Fallot involves what 4 defects?
- ventricular septal defect
- right ventricular hypertrophy (ventricle has to work against the outflow issues
- right ventricular outflow obstruction (think pulm stenosis)
- overriding aorta (attaches to both right and left ventricles)
Traditionally what is the “tet” spell of Tetralogy of Fallot?
-these kids would spells would include extreme hypoxia, cyanosis, syncope and hyperapnea.
What are the PE and study findings of Tetralogy of Fallot?
- a crescendo-decrescendo holosystolic mumur along the left sternal border and radiating to the back
- CXR shows classic boot shaped heart due to RV hypertrophy and No interstitial lung findings
- Echo for DX
What is pulmonary atresia and how is it tx?
-the pulmonary valve is closed and tx is surgery
What is Hypoplasitc Left Heart Syndrome?
- small and undeveloped left ventricle and aorta
- so the right side of the heart pumps blood though a patent ductus arteriosus
- Tx with surgery
What is a Patent Ductus Arteriosus?
- the ductus arteriosus is a blood vessel which connects the pulmonary artery to the aorta. In utero this allows most of the blood to bypass the lungs
- patent means it’s open or not obstructed
- the ductus arteriosus should close at birth
What are the Sx of PDA (patent ductus arteriosus)?
- signs of left ventricular failure
- pulmonary hypertension
What is the PE findings for patent ductus arteriosus?
- Machine like Murmur
- Thrill is common
- wide pulse pressure
- Normal EKG
- Echo is Normal
- MRI/CT/cardiac cath best to visualize the shunt
How do you tx the baby with PDA (patent ductus arteriosus?
- NSAIDS may close shunt, they inhibit prostaglandin production and prostaglandins are responsible for keeping the shunt open
- a small shunt will go undetected until later in life with CHF
- Surgical correction
What is Coarctation of the Aorta?
-narrowing of the aorta
What are the Sx of Coarctation of the Aorta?
- failure to thrive
- chest pain
- lightheadedness
- shortness of breath
- heart failure in an infant
- HTN
What are the PE findings for coarctation of the aorta?
- delayed or weak femoral pulse
- Harsh systolic murmur heard in the back
- hypertension in the upper extremities and hypotension in the lower exremities
How is coarctation of the aorta Dx?
-Echo
How is coarctation of the aorta Tx?
- younger than 50 open surgical repair
- older than 5 stenting is often best option
A month old presents with parents and appears fussy. You take blood pressures in all 4 extremities and note that thye
-coarctation of the aorta
A month old presents with parents and appears fussy. You take blood pressures in all 4 extremities and note that they are inconsistent and he has decreased femoral pulses.
-coarctation of the aorta
A month old presents with parents and appears fussy. You take blood pressures in all 4 extremities and note that they are inconsistent and he has decreased femoral pulses. What is the Dx and what do you do next?
- coarctation of the aorta
- send to cardiologist for Echo and surgical tx
An older child or adult presents with hypertension. PE shows decreased femoral pulses when palpating them simultaineously and there is 20mmHg BP difference lower in the lower extremities. EKG show LVH. What is the Dx and Tx?
-coarctation of the aorta
An older child or adult presents with hypertension. PE shows decreased femoral pulses when palpating them simultaineously and there is 20mmHg BP difference lower in the lower extremities. EKG show LVH. What is the Dx and Tx?
- coarctation of the aorta
- refer for echo and tx (older pts may do fine with stents)
Describe the physiology and the how an Atrial Septal Defect occurs?
- this is an opening between the left and right atrium
- either the foramen ovale does not close or is too large to close
- this creates a left to right shunt or sometimes a right to left shunt of blood
What are the PE findings in an Atrial Septal Defect?
-systolic ejection murmur in the 2nd and 3rd intercostal spaces, sometimes with a mid systolic rumble
What are the PE findings in an Atrial Septal Defect?
- systolic ejection murmur in the 2nd and 3rd intercostal spaces, sometimes with a mid systolic rumble
- CXR shows enlarged right heart and large pulmonary arteries
- EKG shows RV hypertrophy and Rt bundle branch block
What give the definitive Dx for Atrial Septal Defect? And how do you Tx?
-Echo is DX
- Tx : a small shunt may need no surgery
- surgical closure for large defects
A infant FEMALE presents for routine exam (or a Down’s baby or fetal alc baby) and you hear a widely split second heart sound, a soft ejection murmer on the left upper sternal border, and a diastolic rumble over the left sternum (due to the increased flow of blood through the tricuspid valve with a large shunt). What is the Dx?
-Atrial Septal Defect
- patients are 2:1 female
- seen often in Down’s syndrome
- seen in fetal alc syndrome
List the Duke 5 minor criteria for Dx of endocarditis.
- any predisposing factors (valve problems, dental work)
- fever
- embolic events
- Janeway lesions*****
- petichia
- spinter hemorrhages on fingernails
- Immunologic event
- glomerulonephritis
- Osler nodes
- Positive blood culture but not one of the common bugs
What is the preventive Tx for cardiac valve problems that might cause endocarditis?
-prophylactic antibiotics for dental or surgical procedures
When and how do you tx endocarditis?
- tx with empiric antibiotics after first positive blood culture
- tx 4-6 wks with IV antibiotics
- Surgical tx for valve replacement or debride abscess or infected material
Antibiotic Tx for endocarditis for Strep infection (most people)?
-Pen G or cephtriaxone
Empiric Antibiotic Tx for endocarditis for Strep infection for endocarditis (most people)?
-Pen G or cephtriaxone
Emperic Tx for endocardiis for endocarditis for IV drug users?
-Nafcillin or Oxacillin or Vanc
Which HTN meds are best to use with HF?
- ACE-I
- BB
- ARB”s
- aldosterone blockers
- Loop Diuretics
What HTN meds are best to use in Diabetes or with chronic kidney disease?
- ACE-I
- ARB
- Thiazide diuretics
- BB
- CCB’s
What is the HTN Tx goal for diabetics or those with chronic kidney disease?
What is the goal of HTN Tx for Cerebrolvascular disease?
-around 160/100
Which HTN meds should be avoided in pregnant or sexually active girls?
-ACI-I and ARB’s
When do you use an Aldosterone Antagonist?
-HF and post MI
For Stable Angina how do you tx?
- MONA
- morphine
- oxygen
- nitroglycerine
- aspiring
To prevent further Stable Angina attacks how do you tx?
- beta blockers, prolong life*
- aspirin*
- CCB’s, and only amlodipin/norvasc
52 y.o. female presents to ER at 8 a.m. with chest pain. She has done nothing physically this morning. She has had this in the past but not severe enough to present to ER. EKG shows ST-segment elevation.What is the Dx and tx?
-Prinzmetal angina (variant)
- Tx is Calcium channel blockers
- Nitrates
Sx in the morning and ST-segment elevation and a female are the keys here*
What is the Tx for MI in the ER?
-MONA + Betablockers
+/- Plavix, heparin, IIb/IIa inhibitors (Integreilin)
- cardiac cath lab : angioplasty +/- stent
- coronary artery bypass surg / TMLR
- Thombolytics
What does STEMI stand for?
-ST elevation myocardial infarction
55 y.o. male with chest pain for 15 min presents to ER. He was shoveling snow when sx began. He has negative troponin and an EKG shows T wave flattening and ST depression. What is the Dx and what test does he need next?
- Stable Angina
- Tx with MONA and Nitroglycerine, then
- needs a Coronary Angiography (Gold Standard)
55 y.o. male presents with chest pain. These now are occurring when he is resting. What studies are needed?
Toponin I &T best for early detection
EKG
54 y.o. male presents with chest pain. How do you Dx for MI?
-at least on one biomarker elevated with evidence of ischemia & one of the following
- sx of ischemia
- EKG changes of new ischemia
- New Q waves
- imaging evidence of loss of viable myocardium or new wall motion abnormality
V1 -V2 lead changes
-MI Septal wall, LAD -septals arteries
V1 -V4 lead changes
-Anterior wall MI, Left anterior defending artery
V1 -V6 lead changes
-LAD -Diagonals
V1 -V6 lead changes
-Anterolateral wall MI, LAD MI -Diagonals
I, AVL (V5 - V6 ) lead changes
-Lateral wall MI, Circumflex Artery
II, III, aVF lead changes
-Inferior wall MI, RCA /PDA Arteries
Patient presents with syncope and angina. PE shows a diastolic murmer, high pitched **decrescendo blowing murmur** heard along the left sternal border best heard sitting and leaning forward. ****Austin Flint Murmer, with low pitched diastolic rumble is noted. Wide pulse pressure is noted. Hill’s sign is noted (systolic BP > 30 mmHg in legs compared to arms. What do you suspect and what do you order and how do you tx?
- EKG : shows LV hypertrophy
- Echo : measures abnl diastolic flow
- Tx : Surgery
- Meds : diuretics, ACE-I, betablockers
Auscultation shows mid-stystolic click
-Mitral Regurgitation
Tx of Mitral Regurgitation (mid-systolic click)
-beta blockers or surgery
Holosystolic murmur that radiates to the axilla and is frequently accompanied by a thrill?
-Mitral Regurgitation
Surgical Tx of Mitral Regurgitation?
-Valve Repair annular band or ring is usually sewn iin to maintain shape, anticoagulant x 3 mo
- Valve Replacement should be performed before the ejection fraction falls below 60%
- tissue valve vs mechanical valve
When Tx Acute Coronary Syndrome (ACS)–heart attack -what medication do you use for a low blood pressure?
-dopamine
When Tx Acute Coronary Syndrome (ACS)–heart attack, what medication do you use for cariogenic shock?
-dobutamine
When Tx Acute Coronary Syndrome (ACS)–heart attack, what medication should you give if the patient also has CHF?
-diuretic
The C A D in MONA CASHPAD, tell me when the C A D meds are used (only used when they have these conditions).
C, use CCB only when they have A fib
A, use amioterone only when they have V tachy, or V fib
D, dopamine for low blood pressure only
dobutamine for cardiogenic shock only
diuretics for CHF only
