MKSAP 5 Flashcards
50 y/o 2 hour episode of epigastric discomfort and dyspnea during exercise that is relieved by rest. Now pain free. Antacids give parital relief. No fever, chills, n/v, diaphoresis. Diagnosis?
ANGINA PECTORIS: Ischemic cardiac pain has predictable relation to exercise and relief with rest or nitroglycerin. Most patients with PUD do not have pain at diagnosis.
Trreatment of right ventricular MI with hemodynamic abnormalities?
NORMAL SALINE INFUSION: RV contractility is reduced resulting in higher RV diastolic pressure, lower RV systolic pressure and reduced preload. Mecahnism is: Increases gradient of pressure from RA to LA to maintain filling of LV. Nitro and B-blocker are co
Classic triad of right ventricular MI?
Hypotension, Clear lung fields, elevated estimated central venous pressure. Most predictive finding is ST-segment elevation on right-sided precordial lead V4R. Likely RCA
Most common cause of marked bradycardia?
Third degree block - complete absence of conduction of atrial impulses to the ventricle.
Mobitz type I second-degree AV block is characterized by:
Progressive prolongation of the PR interval until a dropped beat occurs. Intermittent failure of AV conduction
Mobitz type II second degree block is characterized by:
regularly dropped beat, ie nonconducted P wave every second or thrid beat w/o progressive prolongation of the PR interval. PATHOLOGIC. 2:1. Anatomic site almost always below AV node, frequently associated with BBB
Treatment of chronic stable angina.
TREAT CHRONIC STABLE ANGINA WITH WORSENING SYMPTOMS WITH INCREASED DOSAGE OF A BB. Use antianginal agents (BB, CCB, nitrates) and vascular-protective therapy (ASA, ACE, statins). Beta blocker dose should be titrated to achieve a resting HR of approximatel
MOA and use of Ranolazine
Rx chronic stable angina. Only used in addition to baseline therapy with a BB, CCB, long-acting nitrate. Inhibits late phase of inward sodium channel (late I Na) in ischemic cardiac myocytes reduce intracellular sodium and reduces calcium influx via Na-Ca
What physical exam findings would you look for if you suspect a PE?
Chest pain and dyspnia with asymmetric leg edema, elevated central venous pressure, tachypnea, tachycardia
Exercise electrocardiographic stress testing is the primary approach to the diagnosis of:
CAD in patients who can exercise and have normal resting ECGs.
Rx for chronic stable angina?
Aspirin (reduces risk of stroke, MI, SCD, vascular death by 33%), ACE (20% reduced mortality), Statins (25-30%) and maintain LDL <100 mg/dL for patients with CAD. Nitroglycerin. (Carvedilol, lisinopril, simvastatin, nitro.)
Next step in patient with CAD that remains highly symptomatic despite optimal medical therapy
CORONARY ANGIOGRAPHY is indicated in patients with chronic stable angina who experience lifestyle-limiting angina despite optimal medical therapy.
Presence of a new systolic murmur and respiratory distress several days after an acute MI
Ventricular septal rupture or mitral regugitation
First degree AV block
PR > 0.2 sec, associated with soft S1, associated with acute reversible conditions ie inferior MI, RF, digitalis intoxicatin
Clinical triad of hypotension, clear lung fields, and jugular venous distension.
RIGHT VENTRICULAR INFARCTION occurs in 20% of patients with an inferior wall STEMI. RIght sided ECG shows ST-elevation in leads V3R and V4R.
Rx for right ventricular infarction
Restore blood flow to RV: Thrombolytic therapy, primary percutaneous coronary intervention, aggressive volume loading with IV NS, dopamine or dobutamine if hypotension persists.
A ventricular septal defect following an ST-elevation MI results in what? How could you confirm?
Hypotension, respiratory distress, new systolic murmur, and a palpable thrill. occurs in 0.1% STEMI 2-7 days after MI. Echocardiography to confirm.
Sinoatrial node dysfunction
ALso called sick sinus syndrome, Comprises a collectin of pathologic findings (sinus arrest, sinus exit block, sinus bradycardia) that result in bradycardia. CC: Dizziness, sinus bradycardia, rates between 40-50/min with 2 symptomatic sinus pauses of 3-5
CHAD2 score
Congestive HF, Hypertension, Age >75, Diabetes, Stroke or TIA(2 points for stroke/TIA). Risk is 18%. Warfarin with target INR 2-3 reduces stroke risk by 62% compared to 19% on aspirin. Use warfarin if score 3+ or h/o stroke.
How should you treat Atriall fibrillation.
METOPROLOL and WARFARIN: No survival advantige rate vs rhythm but for older patients (>70) rate associated with improved quality of life scores.
Primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of SCD in the setting of heart failure is:
LV EF <35%
Peripartum cardiomyopathy
HF with LVEF <45% diagnosed between 3 months before and 6 months after delivery in the absence of an identifiable cause.
Most appropriate diagnostic test forna patient with new-onset heart failure and angina? (Sx of typical angina substernal CP precipiated by exertion and relieved by rest) and exertional dyspnea, orthopnea (new-onset HF)
Evaluation with CARDIAC CATHETERIZATION and ANGIOGRAPHY if they are possible candidates for revascularization.
Purpose of BNP?
Differentiating acute HF from noncardiac causes of dyspnea. If 500 pg/mL likely HF.
Most appropriate diagnostic test for a patient with newly diagnosed or suspected heart failure?
ECHOCARDIOGRAM - to determine if failure is systolic vs diastolic and whether structureal or functional abnormalities may be causing (wall abnormalities, pericardial disease, valvular abnormality)
Standard treatment for patients with New York Heart Association class III or IV heart failure.
ACE, BB, spironolactone (30% reduction in mortality with spironolacone)
Maneuvers that increase the murmur of hypertrophic cardiomyopathy
Valsalva maneurver and squat-tostand: transiently decrease venous return, with septum and anterior mitral leaflet brought closer together. Turbulent flow and the murmur increase.
How is blood glucose managed in hospitalized patients with diabetes?
A basal-bolus insulin regimen consisting of a long-acting insulin and a rapid acting insulin analogue before meals is recommended.
How can you prevent hypoglycemia in a patient with DM?
Use one injection of basal Insulin GLARGINE and insulin LISPRO x 4 before each meal; basal and rapid-acting insulin analoges when dosed properly, reduce the risk of hypoglycemia.
Optimal basal insulin that are peakless and have 24 hour duration of action?
Insulin GLARGINE (lantus) and insulin DETEMIR, NPH does not, administered twice daily, acting 12-18 hours peaking 4 to 8 hours.
Ideal prandial insulins
Lispro, aspart, glulisine
Onset, duration of glargine
Onset 3-4 hours, Duration 24 hours, given at bedtime
Onset, duration of Human insulin lispro
15 minutes onset, 4 hours duration
How do you diagnose DKA?
Serum glucose, electrolytes, ketones, and ABGs. BG <15 meq/L and positive serum or urine ketone concentrations.
How do you treat Hyperglycemic hyperosmolar syndrome?
Identify underlying precipitating illness and restore plasma volume with IV FLUIDS!
Insulin used in DKA?
INSULIN DRIP
LDL-cholesterol goal varies depending on these 5 major CV risk factors
Smoking, HTN, older age (men 45, women 55), Low HDL, family history of coronary artery disease (male 55, female 65)
LDL-cholesterol goal for 0-1 risk factors
Below 160 mg/dL
When is fibrate therapy indicated?
> 200 mg/dL hypertiglyceridemia
When do you start a statin in a patient with no CV risk factors?
If LDL-cholesterol was above 190 mg/dL, ideal range is 160-190 if 0 risk factors.
LDL target in patients with DM
<100 mg/dL
LDL target in patient with a previous MI
<100 mg/dL
LDL goal in a patient with a TIA?
<100 mg/dL
M/C Cause of hypothyroidism? Do you need to confirm diagnosis?
Hashimoto disease, confirmation with measurement of TPO antibody is not necessary
Guidelines for evaluation of a thyroid nodule?
FNA for any nodule greater than 1 cm in diameter. Smaller nodules if cancer risk factors (male, h/o neck irradiation, fam hx esp medullary, rapid growth, hoarseness, extreme ages 60).
Sensitivity of FNA
90-95% Cancer risk of a thyroid nodule is 5-10% with incidence of thyroid nodules 4-7%
How should you manage hypothyroidism during pregnanacy? Why?
MONITOR TSH levels, standard T4 is not as accurate during pregnancy. Levothyroxine requirements may increase 30% to 50% during the first trimester of pregnancy. Estrogen increases TBG which binds free T4. Fetus depends on maternal thyroid hormone for firs
How do you treat Graves disease?
ATENOLOL and METHIMAZOLE. Methimazole has fewer side effects and results in quicker achievement of the euthyroid state than does propylthiouracil in patients with hyperthyroidism.
What is postpartum thyroiditis?
Occurs in 5% women within a few months of delivery, variant of painless thyroiditis; may have transient THYROTOXICOSIS (hyperthyroid), HYPOTHYROID or BOTH.
