Lecture 3 - Cardiac Flashcards
1
Q
What is the treatment for myocarditis?
A
steroids
and heart transplant
2
Q
Where do most aortic aneurysms occur?
A
abdomen
typically do not cause pain
3
Q
What causes pain during a pneumothorax?
A
damage to the pleura
4
Q
When does PNA cause chest pain?
A
once the infection advances to the lining of the lung
5
Q
Where on the bone is there sensory innervation?
A
only at the periosteum
6
Q
Who are we more worried about in regards to bone fracture, a 16 year old or a 50 year old?
A
The 50 year old
more likely to be pathologic
7
Q
Which chest pain can you NOT miss?
A
PNA MI PE ACS Dissection
8
Q
What are the official vs not official cardiac risk factors?
A
Cardiac RF: HTN Cholesterol DM Family Hx (really only if they have familial hypercholesterolemia) Tobacco
Non-official: sedentary lifestyle obesity prior MI age
9
Q
Right sided heart failure can manifest how?
A
peripheral edema
10
Q
What is one of the most common reasons for decreased breath sounds?
A
broken ribs
the pt is avoiding breathing in all the way
11
Q
What tests will you order for chest pain?
A
EKG (first and best)
Troponin
Chest Xray
12
Q
D - Dimer
A
tests when a clot is being broken down by the body
it is a good test for aortic dissection because the blood trapped in the false lumen is clotting
13
Q
BNP
A
test that can help differentiate between CHF and COPD
14
Q
What is the gold standard for dx dissection?
A
CT scan with contrast
15
Q
Who should get a D-dimer?
A
pts in low risk with a 15% pre-test probability AND sxs less than 72 hours (mature clots come back negative)
16
Q
Who are we worried about with aortic dissection?
A
Marfan’s Syndrome: tall, lanky arms and legs, bluish tinge to sclera, high arched palate
17
Q
If esophageal spasm manifests similarly to chest pain and is even released by nitro, how can you differentiate this from MI?
A
troponin
18
Q
What causes esophageal rupture?
A
vomiting (not coughing) really hard
you may even see pink dots on cheeks from where they’ve ruptured blood vessels on their face
19
Q
What is the initial presentation of ischemic heart disease?
A
Stable angina
20
Q
What is the underlying pathology behind stable angina?
A
Atherosclerosis — end result of an inflammatory process instigated by endothelial disruption
Stable angina is limited flow from progressive athersoclerotic narrowing of epicardial vessels
21
Q
What are the s/s of stable angina?
A
Persistent, exertional chest discomfort
Relief with rest or nitro
22
Q
Unstable angina?
A
Sxs are accelerating (increasing in frequency, duration, intensity) or occur at rest
23
Q
What is the treatment for stable ischemic heart disease?
A
Nitro
Beta blocker (or BBC if contraindications for BB)
Daily ASA (or clopidogrel if ASA CI)
Lifestyle modifications
24
Q
NSTEMI
A
Intermittent occlusion/pre-profusion
Unlike STEMI which complete occlusion of coronary blood flow
+ cardiac enzymes in both STEMI and NSTEMI (not found in unstable angina)
25
How is STEMI dx?
Clinical intuition + EKG
Move quickly to treatment —> time is muscle
26
What is the treatment for an NSTEMI?
PCI within 72 hours of symptom onset (more urgent than emergent)
27
What is the treatment for angina?
Oxygen and IV saline
If they are stable you can observe them, contact their PCP (most often stable angina pts do not present to the ED), and send them home
```
Unstable: (getting admitted)
Oxygen NC
Aspirin (Chew)
Heparin
Nitro
BB (esmolol)
```
CCB only have a place in Prizmetal angina
28
How can you tell which leads belong to which area of the heart?
Big I, lil I, Ass up, All down
L S. L
I L. S. L
I. I. A. A
29
What is the gold standard for dx MI?
Troponin
30
What is the goal of “door to balloon time”?
90 minutes to PTCA (percutaneous transluminal coronary angioplasty)
If that is unavailable then 30minutes to fibrinolysis
31
What are thrombolysis agents that are used for MI treatment when cath lab is not available?
Tissue plasminogen activator
Streptokinase
Tenecteplase
32
What supportive therapy is given to pts with MI in the ED?
MONA
Morphine (helps with pain and lowers BP, decreasing afterload)
Oxygen (NC only if <90% or respiratory distress)
Nitro (decrease afterload and preload
ASA (aspirin)
+/- statin therapy (helps decrease inflammation)
+/- ACEI
33
What does the morphine part of MONA do?
Reduce afterload
34
For MI pt, when do you not want to do MONA?
Don’t give nitro (we dont want to decrease pre-load) for pts with a right (RCA) occlusion
35
When do we not give nitro?
If SBP is <90
Inferior infarct pattern
Use of viagara/sildenafil in last 24 hours
36
What is the dose of ASA that should first be chewed by the pt having an MI?
325mg followed by a daily dose of 81mg
37
What is the goal of anticoagulation therapy?
Limitation of thrombin
Achieved by attacking various portions of the coagulation cascase
38
What role do statins play in ACS?
Should be given to every pt with ACS regardless of their lipid levels
Should be started on day of presentation and continued indefinitely
It:
- stableizes plaques
- reverses endothelial dysfunction
- decreases thrombogenicity
- anti-inflammatory
39
Beta blockers use in the setting of ACS?
Negative inotropic properties
Positive effects on remodeling
Reduction of myocardial oxygen demand in the acute setting
40
What is the difference between NSTEMI and STEMI in regards to treatment?
STEMI has to go to the cath lab right away
NSTEMI will EVENTUALLY go to the cath lab (24-48 hours)
41
How does PCI (cath lab) work?
Access via radial or femoral artery
Catheter advanced to aorta and coronaries via fluoroscopy
42
If a pt with ACS begins to show signs of heart failure and have a heart murmur, what type of valve problem is this?
Acute mitral regurgitation
43
Loud, harsh mid-systolic murmur primarily localized to the RUSB and projecting to the carotids
Aortic stenosis
44
How do pts with aortic stenosis present?
Dyspnea
Syncope
Angina with exertion
Harsh systolic murmur
Left ventricular hypertrophy
45
What is the treatment for aortic stenosis?
Eventually valve replacement
Admit with syncope, cardiac chest pain, CHF, arrythmias
Treatment in the ED is really focused on what NOT to do since these pts have a fixed cardiac output
NOT:
Nitrates/diuretics: exacerbate sxs by reducing pre-load
BB: reduce inotropes —> exacerbate sxs (basically decrease contractility)
CCBs: reduce in afterload —> lead to deminished outflow
46
Which murmur might you see with endocarditis?
Aortic regurgitation (diastolic murmur)
47
Aortic regurgitation
Incompetence of aortic valve leading to reduction in cardiac output —> heart failure
Acute:
Endocarditis
Retrograde dissection
Chronic:
Bicuspid valve (MC in US)
Rheumatic heart disease (MC in world)
Infective endocarditis
48
Soft, high pitched, early diastolic decrescendo murmur localized to 3rd intercostal space on the left (Erbs point)
Aortic regurg
Accentuated at end expiration with pt sitting up and leaning forward
49
What is the mainstay of treatment for aortic regurg in the ER?
Check for underlying infection (endocarditis can be a major cause)
Control HTN to alleviate pressure
NOT:
BB - may prolong diastole and lead to increased regurg
50
What causes acute aortic regurg?
```
Infective endocarditis
Aortic dissection (retrograde)
```
Traumatic deceleration injury
51
What is the pathophysiology behind chronic aortic regurg?
Left ventricle dilates to accommodate the regurgitant volume while maintaining cardiac output. Increasing end-diastolic volume (pre-load) is the primary hemodynamic compensation for aortic regurg —> eventually this fails leading to CHF
52
How do pts with aortic regurg present?
Pts present late in disease
May complain of uncomfortable awareness of their heart beat or palpitations, especially in bed, for years before exertional sxs develop
As ventricle fails, sxs of left sided and then right sided heart failure develop
53
With which valvular disease do you see widened pulse pressure?
Aortic regurg
54
Mitral stenosis
W > M
Rheumatic fever (autoimmune attack on the heart in response to strep infection)
Decreased left ventricle filling
Marked atrial enlargment and elevated atrial pressures
Leads to pulmonary hypertension and right sided heart failure
Sxs: exertional dyspnea and cough progressing to sxs of CHF and then right sided heart failure
Hemoptysis
55
What are the sxs of someone with mitral stenosis?
Dyspnea on exertion (d/t pulmonary HTN)
Right heart failure
Elevated jugular venous pressure
Narrow pulse pressure
Diastolic opening snap
Low pitch rumble
56
What is the treatment for mitral stenosis?
BB/CCB: increase diastolic filling time to augment cardiac output
Warfarin for A. Fib
Balloon vulvuoplasty
57
What is the most common valvular disease in US?
Mitral regurgitation
58
What are the sxs of mitral regurg?
Acute
-often associated with ischemia
-occur with chordal rupture
Sxs are abrupt onset and associated with FLASH PULMONARY EDEMA
Chronic:
Progressive dyspnea
A. Fib
Worsening heart failure
59
What is the treatment for someone with mitral regurg?
Ultimately surgery
Can help with decrease remodeling with BB and afterload reduction
60
Previously healthy person presents to the ED with pulmonary edema
Be thinking acute mitral regurg
61
Holosystolic murmur
Mitral regurg
62
Aortic dissection
Precipitated by tear of vascular intima
HTN biggest RF
Excrutiating/ “tearing” pain with abrupt onset and marked distress
Decresendo
Pain located to chest or back/abdomin depending on location
HTN
Pulse variance or BP differential (difference in BP between right and left arm)
Mediastinal widening on xray
Tx: strict BP control with BB, fluid support, surgery
63
Mediastinal widening on chest x-ray
Aortic dissection
Also you will see:
Abrupt onset of tearing pain in chest or abdomen
Variance in BP or pulse between arms
64
What is the treatment for aortic dissection?
BB —> control that BP
Fluids
Surgery
65
What size aneurysm is dx for aortic aneurysm?
>4cm
66
At what cm do pts with aortic aneurysms get surgery?
5.5cm or greater
67
Ascending vs descending aortic aneurysm
Ascending = before ligamentum arteriosum
Descending = distal to ligamentum arterisoum
68
Pericarditis
Non=specific inflammation of the pericardial sac surrounding the heart
Typically viral etiology (HIV, TB, neoplasia, autoimmune)
Acute vs recurrent vs effusive
Often see systemic signs of inflammation/infection
URI prodrome common
95% present with acute, sharp/pleuritic pain
Worse when laying flat, relieved when leaning forward
Pericardial friction rub
Muffled heart sounds
Pulsus paradoxus
Diffuse ST elevations
Echo - assess for effusion
Tx: NSAIDs
Colchicine
Glucocorticoids (Prednisone) —> only for refractory cases
69
Presentation of pericarditis?
Often see systemic signs of inflammation/infection
URI prodrome common
95% present with acute, sharp/pleuritic pain
Worse when laying flat, relieved when leaning forward
Pericardial friction rub
Muffled heart sounds
Pulsus paradoxus
Diffuse ST elevations
Echo - assess for effusion
70
What is the treatment for pericarditis?
NSAIDs
Colchicine
71
Pericardial tamponade
Ventricular compromise d/t effusion around the heart
Rate of fluid accumulation rather than volume is predictor of severity
Commonly caused by trauma
Becks triad:
Neck vein distention
Hypotension
Muffled heart sounds
Kussmauls sign (increased JVD with inspiration)
EKG: electrical alternans
Tx: pericadiocenteiss
Dobutamine
Admit to ICU
72
Becks Traid
Seen with pericardial tamponade
Muffled heart sounds
Hypotension
JVD
73
Kussmaul sign
Increase JVD with inspriation
| Seen with tamponade
74
Electrical alternans
Seen on EKG for cardiac tamponade
75
How do you treat HTN in pregnancy?
Labetolol (first line)
Nifedipine
Methyldopa
76
How do you treat HTN in DM?
ACEI/ARB, CCB, diuretic
77
Sxs of HTN emergency
```
Dydpnea
Chest pain
HA
Dizziness
Neurological deficit
```
Flash edema is common initial presentation
78
HTN emergency
In general, MAP reduction of 25% in the first 2 hours
Then target 160/100 gradually over 6 hours
Labatelol (BB first line therapy)
Nicardpine
79
What is the treatment for acute pulmonary edema?
Nitroprusside with loop diuretic
80
What is the treatment acute aortic dissection?
Nitroprusside + metoprolol
81
When do we admit syncope pts?
CHF hx
Ventricular arrythmias
Valvular disease
Abnormal ECG
82
Treatment for CHF in the ED focuses on?
Symptom stabilization and referral to ultimate care
```
Based on presentation
Wet and cold
Wet and warm
Dry and cold
Dry and warm
```
83
Treatment for wet and cold CHF?
Dobutamine (inotropic support to help with decongestion)
Or dapamine or milrinone
84
What is the most dangerous zone to be in for CHF pts?
Dry and cold
(Poor perfusion even at optimal hemodynamics
Pts need mechanical support or transplant
85
What is the treatment for bradycardic rhythms?
Atropine to improve rate
If unstable: transcutaneous pacing
Always look for reversible causes
Ultimate management is with pacemaker
86
Treatment for tachy arrhythmias?
Unstable: shock
Stable: consider adenosine or vagal
87
Afib vs aflutter on EKG?
Afib is irregularly irregular
Aflutter is usually regular (organized atrial activity increases suspicion of flutter)
88
What is the treatment for afib and aflutter in a stable pt?
Rate control vis CCB or BB
Unstable: cardioversion (ONLY IF SXS ARE LESS THAN hours)
Anticoagulation is based on risk calculation with CHADSVASC score
89
V Tach
MEDICAL EMERGENCY
Cardioversion
Rhythm control —> amiodarone
90
What imaging provides the highest yield when assessing someone for aortic dissection?
CT
