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