Laflamme- Chapter 9 (Miscellaneous) Flashcards
1
Q
What are the 6 components of the RCRI?
A
CAD CHF CVD IDDM Cr > 176 Intrathoracic, intraperitoneal or vascular surgery
2
Q
What is high risk on RCRI?
A
3 or more points = high risk (9%)
3
Q
What % of troponin elevation is Type 1 MI post surgery?
A
5%
4
Q
How to reprogram pacemakers during OR? ICD?
A
- PPM: VOO or DOO
- ICD: Deactivate tachyarrhythmia therapies or magnet during the operation
5
Q
What % of all CAD deaths can be attributed to smoking?
A
30%
6
Q
What is benefit of CV reduction after smoking cessation?
A
Similar to non smokers after 5 years of smoking cessation
7
Q
What do lipoproteins do?
A
-transport TG and cholesterol in the blood
8
Q
What are chylomicrons?
A
Large nonatherogenic lipoproteins transporting TG from the GI tract
9
Q
What is VLDL?
A
Large nonatherogenic lipoproteins transporting TG from the liver (apo B100)
10
Q
What is LDL?
A
Atherogenic lipoproteins responsible for atherosclerosis, mainly contain cholesterol, apoB100
11
Q
How is LDL calculated?
A
Total cholesterol - HDL - (0.45 x TG)
*only if TG < 4.5 mmol/L
12
Q
What is HDL?
A
Antitherogenic properties, contains apolipoprotein AoA1
13
Q
How does hypertriglyceridemia result in more LDL?
A
TG enriched LDL -> Formation of smaller and denser LDL due to modification by hepatic lipase -> dense, atherogenic LDL
14
Q
What are 12 populations to screen for dyslipidemia?
A
Male > 40
Female > 50
DM
HTN
Smoking
BMI > 27
CrCL < 60
Atherosclerosis
ED
Family history of premature CAD or dyslipidemia
ED
HIV
15
Q
What are 8 causes of decreased HDL?
A
Smoking
Obesity
Sedentary lifestyle
DM
CRF
HyperTG
Steroids
Cyclosporine
16
Q
What is inheritance of FH?
A
-LDL R receptor mutation, AD, 1/1000
17
Q
3 physical exam findings of FH?
A
Xanthelasmas
Senile arcus
Tendinous xanthomas
18
Q
What is familial dysbetalipoproteinemia?
A
-Homozygote for ApoE2 (less effective binding to hepatic receptors)
19
Q
Two physical exam findings of Familial Dysbetalipoproteinemia?
A
-Tuberous xanthomas, Palmar xanthomas
20
Q
Biochemical evidence of Dysbetalipoproteinemia?
A
ApoB/TC ratio < 0.15
21
Q
Three inherited causes of decreased HDL?
A
- Apo A1 deficiency
- Tangiers Disease
- Familial LCAT deficiency
22
Q
What to consider Familial combined hyperlipidemia?
A
- Apo B > 120 mg/dl
- TG > 1.5 mmol/l
- History of premature CAD
23
Q
when to start fenofibrate for hypertriglyceridemia? (2)
A
- TG > 10
- Pancreatitis
24
Q
How do statins work?
A
- HMG Coa reductase inhibitor which reduces the intracellular cholesterol synthesis and increased expression of LDL receptor
- Pleotropic and antinflammatory response
25
Name two Bile acid sequestrants and how much do they lower LDL by
-Colestipol or Colesevalam, reduced LDL by 15-30%
26
How does Ezetimibe work and how much does it reduce LDL by?
- 20%
| - Interferes with NPC1-L1 protein of intestinal epithelial cells
27
Only lipid lowering therapy that increased HDL?
-Niacin
28
What are 4 sideeffects of Niacin?
-Flushing, Hyperuricemia, Hyperglycemia, Gastritis
29
What are 7 causes for statin intolerance/myalgias?
Hypothyroidism
Renal failure
Liver disease
PMR
Steroid use
Vitamin D deficiency
Primary muscle disease
30
What 7 risk factors for statin myopathy?
- statin dose
- drug interactions
- > 75 years old
- Renal failure
- Liver disease
- Alcohol use
- Pre-existing myopathy
31
When should you be worried about statin s/e based on AST/ALT and CK?
3x, 5x
32
How to approach statin toxicity (ALT/AST + CK)
-DC statin, consider DDx, monitor until normalization, reintroduce at a lower dose of less potent statin (Pravastatin, Fluvastatin) or QoD dosing
33
What if statin s/e doesn't meet criteria to DC based on AST/ALT or CK?
-Continue treatment and check again in 6 weeks. If stable than resume.
34
Three ways to diagnose HTN in the office?
- 180/110 mmhg x 1
- 160/100 mmhg x 3
- 140/90 mmhg x 5
35
ABPM cut offs for HTN diagnosis?
- Daytime > 135/85
- 24 hour SBP > 130/80
- Night time BP should drop by 10%
36
Home BP monitoring cut off?
> 135/85
37
Work up for renovascular disease?
-Doppler renal arteries, MRA, CTA
38
Work up for Primary hyperaldo?
- Increased plasma aldoserone/renin ratio
- Suppression test with salt load
- Adrenal CT scan or MRI
- Adrenal vein catheterization
39
Work up for Cushings?
- Urinary cortisol
- Suppression test (1mg dexamethasone)
- CT scan adrenals
40
Work up for Pheochromocytoma?
-Plasma metanephrines, urine meta, CT scan or MRI
41
Why might elderly patients have NIBP lower than arterial monitoring?
-Secondary to rigid arteries that are not compressed by the cuff
42
How does Metformin work? How much does it reduce Hba1c by?
- decreases hepatic glucose synthesis
| - decrease by 0.8%
43
Sulfonylureas?
- Stimulates insulin secretion by the pancreas
| - 0.7%
44
GLP1 agonist
- Increase insulin secretion, decreases glucagon secretion
| - 1%
45
DPP4 inhibitors
Inhibits the breakdown of GLP1
-0.6%
46
SGLT2 inhibitor
-Decrease glucose reabsorption by the renal proximal tubule
47
4 classes of diabetes meds that have CV benefit?
- Metformin: Benefit on the risk of MI and mortality in obese patients (UKPDS)
- Sulfonylureas: as above
- Liraglutide: LEADER trial
- SGLT2 inhibitor: Empa
48
Name a two diabetes medications that carry CV harm?
- TZDs (HF)
| - Saxaglipitin (HF)
49
What is the affect of exercise aerobic exercise on HTN, DSL, Obesity, DM?
HTN: 3/2mmhg
DSL: HDL up by 0.06, decrease TG
Obesity: decrease 7kg
Diabetes: Hba1c 0.8%
50
What two CV disease populations have mortality benefit from exercise?
- LVEF < 35% (HF action)
| - CAD
51
What is class 1 and 2 obesity?
1) BMI 30-35
| 2) BMI 35-40
52
6 CV benefits of weight loss?
- decreased BP
- Improved lipid profile
- DM
- OSA
- Inflammatory state
- Improves endothelial function
53
Waist circumference targets?
102 cm < M, 88 cm < F
54
what should weight loss target be over 3-6 months?
5%
55
When should drug treatment be started for obesity?
-Failure of non drug therapy for 6 months with BMI > 30 or >27
56
When should bariatric surgery be considered?
-Class III obesity or Class II with comorbidities
57
What three diets supported by evidence?
DASH diet
Mediterranean diet
AHA diet
58
What is definition of OSA?
Absence of airflow for >10 seconds despite active ventilatory efforts
59
What is severe AHI?
Severe AHI > 30
60
Driving restriction post STEMI?
1 month Private vehicle
3 month commercial vehicle
61
Driving- NSTEMI?
Depends on WMA. If WMA, same as STEMI
If no WMA:
- Private: 48h post PCI, 7 days if PCI
- Commercial: 7 days post PCI, 30 days if no PCI
62
Driving- Elective PCI
Private: 48h post PCI
Commercial: 7 days post PCI
63
Driving- CABG
Same as STEMI
64
LMCA disease
No private driving if > 70%
No commercial driving if > 50%
65
Driving- VF/VT?
No reversible cause:
Private: 6 months
Commercial: Never
66
Stable Sustained VT if LVEF > 30%? If < 30%
Private: 4 weeks, 3 months
Commercial: 3 months, never
67
Driving restriction if Symptomatic SSS, Mobitz II, CHB, Alternating LBBB or RBBB
No driving
68
Driving- PPM implant?
Private: 1 week post implantation
Commercial: 1 month post implantation
69
ICD? Primary prevention
Private: 4 weeks
Commercial: Never
70
ICD- Secondary prevention
Private: 6 months no therapy
Commercial: never
71
ICD: Secondary prevention but no VT with LOC
1 week + interval associated with VT
Commercial: never
72
EP study?
- Private: 48h
| - Commercial: 1 week
73
1 episode vagal syncope, recurrent < 12 months?
- Private: no restriction, 1 week
| - Commercial: 1 week, 12 months
74
Syncope treated with pacemaker?
1 week, 12 months
75
Unexplained syncope 1 episode, recurrent < 12 months
Private: 1 week, 3 months
Commercial: 12 months, 12 months
76
NYHA 1 or II, III, IV
1 or 2: none
III: None, never
IV: never
77
Heart transplant
Private: ok to drive 6 weeks out with NYHA 1 or 2
Commercial: 6 months, LVEF >35%, no ischemia
78
LVAD
- Private: 2 months, NYHA I-III
| - Commercial: Never
79
HCM
- No LOC
| - Wall thickness < 30, no syncope, No NSVT, No fmaily history of sudden death, no decreased BP on ecercise
80
When can you fly post MI?
6-8 weeks
81
When can you fly post ICD
1 month post ICD therapy associated with presyncope or syncope
82
What patients need to fly with O2?
- PaO2 < 70mmhg
- CCS III/IV
- NYHA III/IV
- Cyanotic CHD
- PHT leading to right heart failure
83
8 CV consequences of HIV?
- Myocarditis
- DCM
- Accelerated athero
- Dyslipidemia
- CV tumor/mets
- Pericardial effusion
- Lipodystrophy
- Pulmonary Htn
84
Kawasaki CV manifestations? (8)
- Pericardial effusion
- Myocarditis
- MI
- Aortitis
- AR
- HF
- Arrhythmias
- Coronary Arteritis
85
5 CV manifestations of RA?
- Pericarditis
- Pericardial effusion
- Valvular lesions
- Aortitis
- Myocarditis
- Pulm HTN
86
Cv manifestations of SLE? (6)
- Libman sachs IE
- Pericardial disease
- Myocarditis
- PHTn
- Aortitis
- Congenital heart block
87
4 CV manifestations of Ank spond?
- Aortic root dilatation
- AR
- Accelerated CAD
- Blocks
88
5 CV manifestations of Scleroderma?
- PHtn
- DD
- Microvascular ischemia
- Htn/Crises
- Pericarditis
89
Indications for PPM in muscular dystrophies? (2)
- 3rd or 2nd degree heart blocks
| - any degree of heart block in patients with limb-girdle, steinert or kearns-sayre syndrome
90
What is inheritance of Becker and duchenne dystrophy?
X linked
91
What kind of CMO do muscular dystrophies cause?
-Dilated CMO with arrythmias and conduction system disease
92
ECG findings for duchenne? (4)
- increased R/S ratio V1
- Q wave in left precordials
- Short PR
- RVH
93
What are potential CV implications from trauma?
-Cardiac contusion
-Arrhythmias
-Tamponade/Effusion
-Free wall rupture
-VSR
-Ruptured Chordae
-Pap muscle rupture
(think of all mechanical complications of MI)
94
CV implications from electrocution? (5, alot of overlap)
Cardiac Arrest
Myocardial injury
Ischemia
Arrhyhtmias
Dysautonomias
95
How does cocaine work?
Inhibition of presynaptic reuptake of NE and Dopamine
96
8 ways to management beta blocker toxicity/overdose?
- Glucagon (reverse BB)
- IV calcium
- Vasopressors (Epi)
- High dose insulin and glucose
IV fat emulsion
- Sodium bicarbonate
- Pacemaker
- IABP/VAD
- IHD (to dialyse Atenolol, Nadolol, Sotalol, Acebutolol)
97
How to manage CCB overdose?
- IV calcium
- Glucagon
- High dose insulin/Glucose infusion
- Vasopressor
- IV fat emulsion
- VADs, PPM as needed
98
What are 4 extracardiac manifestations of Digoxin poisoning?
- Visual disturbance
- GI upset
- CNS ataxia/stroke symptoms
- Hypekalemia
99
What is MOA digoxin poisoning?
-Increased intracellular calcium leads to delayed after depolarizations, increased automaticity, increased vagal tone
100
ECG findings of Dig poisnong?
-U waves, scooped ST segments, Blocks, VT, Short QTc, T wave flattening
101
Management of Dig poisoning?
- ABC's MOVIE
- Correct Hypokalemia/Mg (potentiates arrhyhtmic MOA)
- Do not correct Hyper K (corrected by Digibind)
- Digibind Indications: Arrhythmias, ARF/LOC, HyperK > 5
102
What is Digibind dose?
- 10 vials for acute poisoning
| - Chronic poisoning: Number of vials = serum concentration x Patient's weight/ 100
103
What are 3 calcifications of Hyperparathyroidism?
- Short Qt
- Increased contractility
- Calcification of valves
104
What are 4 effects of hyperthyroidism?
- High output state/CMI
- Decreased systemic resistance
- Systolic Hypertension
- Tachycardia
- Vasospasm
105
What are 7 effects of hypothyroidism ?
- Low output state
- Increased systemic resistance
- Sinus bradycardia
- Diastolic hypertension
- Prolonged QT
- Pericardial effusion
- Hypertriglyceridemia
106
What are 5 effects of Pheochromocytoma?
- Hypertensive surges
- Concentric LVH
- Myocarditis
- CMO similar to Takotsubo
- Tachycardia
107
What are 3 ECG findings in Beckers/Duchenne dystrophy?
- Prominent R wave in V1 (Increased R/S ratio)
- Q waves in left precordial leads
- Short PR
108
What are three cardiac manifestations of Myathesthenia gravis?
-Myocarditis, arrhythmias, blocks
109
What are 5 manifestations for CNS catastrophe?
- ST changes
- TWI
- Long QT -> tdp
- Takotsubo CMO
- Acute pulmonary edema
110
5 mechanisms of MI with Cocaine use
- Increased demand
- Increased platelet aggregation -> Plaque rupture
- Coronary dissection
- Coronary vasospasm
- Accelerated CAD
111
What are 5 non coronary effects of cocaine use?
- Takotsubo CMO / DCM
- Arrythmias
- Aortic dissection
- Hypertensive surges -> LVH
- Myocarditis
112
What are 4 non cardiac implications in Beta blocker poisoning?
- Altered LOC
- Seizures
- Hypoglycemia
- Bronchospasm
113
What are 4 mechanisms of Digoxin induced arrhythmia?
- Delayed after depolarizations
- Increased Automaticity
- Increased Vagal tone
- Associated hyperkalemia
