MTB 2 CK - Cardio Flashcards
Normal splitting
S1 A2|P2 during inhalation (drop in intrathoracic pressure, increased venous return, longer pulmonary ejection time)
Wide splitting
S1 A2| |P2
Conditions that delay RV emptying (pulmonic stenosis, RBBB)
Exaggeration of normal
Fixed splitting
S1 A2| |P2
Seen in ASD (increased RV filling). Always there, similar to wide splitting…
Paradoxical splitting
S1 P2| |A2
Delayed LV emptying (aortic stenosis, LBBB)
P2 occurs before A2 which is abnormal.
On inhalation, P2 is prolonged, moves closer to A2, can be no splitting
(Maneuver and effect)
- Inhalation
- Exhalation
- Hand grip
- Valsalva
- Rapid squatting
- Increased right heart sounds
- Increased left heart sounds
- (increased SVR) Increased intensity of MR, AR, VSD, MVP murmurs (all things where flow is going backwards); decreases intensity of AS, HCOM (less fluid moving forwards to make a big sound)
- (decreased venous return/preload increases LV outflow obstruction) increases intensity of MVP and HCOM
- (increases venous return/preload) decreases HCOM
GI disorders associated with chest pain (4)
Ulcer disease
Cholelithiasis
Duodenitis
Gastritis
Around what age do the protective effects of estrogen wear off for women?
55-60yo
Pro ischemic pain qualities
soreness, dullness, squeezing, pressure-like pain
Anti-ischemic pain qualities
sharp, knifelike, lasting a few seconds
Fever + chest pain suggests
PE or pneumonia
Office chest pain days to weeks. Cardiac enzymes?
No
Office chest pain minutes to hours. Cardiac enzymes?
Yes
maximum HR equation
220-age
What if you can’t read the EKG? What test do you order
Thallium or sestamibi uptake scan.
Echo
Remember the difference in ischemia and infarction!
!
Holter monitor does not detect
ischemia (don’t do it for chest pain!!)
Holter monitor does detect
arrhythmia
Chronic angina meds (3)
Aspirin
B-blocker
Nitroglycerin
When to give Clopidogrel (CAD)
if aspirin intolerant (allergy)
w/ recent angioplasty w/ stenting
Prasugrel: don’t give to patients >75yo due to
risk of hemorrhagic stroke
Give ticlopidine if (CAD)
allergic to aspirin and clopidogrel (but not bc of bleeding!)
Ticlopidine adverse effects
neutropenia, TTP
When to give statins for CAD
LDL >100
What do you need to check regularly in a patient on a statin?
AST/ALT
Liver dysfunction MC adverse effect
Niacin adverse effects
glucose, uric acid, itchy
fibric acid adverse effects
myositis with statins
ezetimibe adverse effects
well tolerated but useless
CCB in CAD
may increase mortality by raising HR
When to use CCB in CAD
- Severe asthma
- Prinzmetal angina
- Cocaine-induced angina (B-blocker CI)
Adverse effects of CCB
- Edema
- Constipation
- Heart block (rare)
PCI vs. med mgmt in chronic angina
medical mgmt is better
Don’t use PCI for…
stable patients
Heart sound associated with acute coronary syndrome
S4
Kussmaul sign
increase in JVP on inhalation
–constrictive pericarditis, restrictive cardiomyopathy
continuous machine like murmur
PDA
Which is worse MI in V2-V4 or MI in II, III, aVF?
V2-V4–this is anterior wall. Higher mortality than inferior wall (II, III, aVF)
Pathologic potential of first degree AV block?
Very little
Should you treat PVCs?
Nope
Leads V1 and V2 should be read…
backwards (ST elevation is actually depression and depression is actually elevation) because they are posterior leads
O2, NG, aspirin, morphine–which to give first in acute MI?
Aspirin. The only one that lowers mortality
What is the earliest cardiac enzymes become elevated?
4hr
Myoglobin onset
1-4hr
Myoglobin duration
1-2d
CK-MB onset
4-6hr
CK-MB duration
1-2d
Troponin onset
4-6hr
Troponin duration
10-14d
2 problems with troponin levels
- cannot detect reinfarction during window of elevation
2. if patient has renal insufficiency can have false positive troponins (renally excreted)
How do we detect reinfarction w/in a few days of first?
CK-MB
MCC of death after recent MI
ventricular arrhythmia
PCI vs thrombolytics in ACS
PCI
Warfarin in ACS
NOT USED. used for clots in venous side of circulation. no use in coronary disease
Heparin in ACS
usually given at the time of PCI but discontinued long term
Which is better, immediate thrombolytics or delayed angioplasty?
Immediate thrombolytics
1, 2 tx for ST segment depression
- Aspirin
2. Heparin
Thrombolytics for ST depression ACS
No. no clot.
Utility of GP2B3A inhibitors
- -Not helpful in STEMI alone
- -Helpful in STEMI/ACS with angioplasty or stenting
- -Helpful in NSTEMI
Stable angina meds
…
Weight loss affects
BP
Exercise affects
HDL
Smoking affects
HDL
when is the only time tPA is beneficial?
STEMI
What is Heparin best for?
non-STEMI
All of the complications of MI can have this symptom
Hypotension.
Will not lead you towards one diagnosis
MI complication w/ cannon A wave
Third degree heart block
TX of bradycardia after MI
Atropine
Pacemaker prn
RV infarction–artery?
Right coronary artery
RV infarction exam finding
clear lungs
RV infarction, wall?
inferior
RV infarction dx
flip EKG leads, elevation in RV4
Right coronary artery supplies (3)
RIght ventricle
Inferior wall
AV node
TX of RVI
high-volume fluid replacement
Tx to avoid in RVI
nitroglycerin
Presentation of free wall rupture
tamponade
sudden loss of pulse/pulseless electrical activity
clear lungs
Vtach/Vfib tx
cardioversion/defibrillation
Valve/septal rupture presentation
New onset murmur
New onset pulmonary congestion
After MI if you have an increase in O2 sat between RA and RV
Septal rupture
Intraaortic balloon pump
Never a permanent device
Bridge to surgery for valve replacement or transplant for 24-48hr
For acute pump failure or anatomic problem that can be fixed in OR
Ventricular aneurysm tx
none needed
Ventricular mural thrombus tx
heparin then warfarin
Post-MI stress test
to determine residual ischemia, need for revascularization (angina)
Would do angiography next if +
Post-MI angiography
to determine need for revascularization w/ angioplasty or CABG
(don’t do if infarcted w/ dead myocardium, only if reversible)
Prophylactic anti-arrhythmics
DO NOT USE. INCREASE MORTALITY
Transthoracic vs transesophageal echo for CHF
Transthoracic
Utility of TEE
most accurate test to evaluate valve function and diameter
When is nuclear ventriculography the best test for CHF?
Rarely. When giving chemo (doxorubicin)
bNP
if normal, rules out CHF.
Do this if w/ acute SOA the etiology is not clear and can’t wait for an echo
Tests to determine ETIOLOGY (not diagnosis of) CHF
EKG–MI, heart block
CXR–dilated cardiomyopathy
Holter monitor–paroxysmal arrhythmias
Cardiac cath–Precise valve diameters, septal defects
CBC–Anemia
TSH–high and low levels can cause CHF
Endomyocardial biopsy–rarely done; sarcoid, amyloid, infections
Swan-Ganz catheter–distinguishes CHF from ARDS; not routinely done
Drugs that lower CHF mortality
ACE-I, B-blocker, Spironolactone
Hydralazine + Nitroglycerin
Implantable defibrillators
Tx of systolic CHF
ACE-I–everyone gets this
B-blocker–metoprolol, bisoprolol, carvedilol only
spironolactone–class III, IV
diuretics–loop, to control symptoms
digoxin–to control symptoms and decrease hospitalizations
hydralazine + NG–in substitution for ACE-I
CCB in systolic CHF
no benefit
+ inotropes in systolic CHF
no benefit
Routine anticoagulation w/ warfarin in CHF
never a right answer is there is no clot
TX of diastolic CHF
B-blockers–definitely
Diuretics–definitely
DO NOT USE–digoxin, spironolactone
Uncertain: ACE-I, ARB, hydralazine
Diuretics in HCOM?
No! will increase obstruction
Tests for pulmonary edema
BNP, CXR, ABG, EKG, Echo
These will help determine ETIOLOGY of pulmonary edema
most important acute test for pulmonary edema and why
EKG–an arrhythmia could be the etiology
Best initial therapy in pulmonary edema
- Diuretics
O2, morphine, nitrates, ACE-I
3 approaches of treating pulmonary edema
preload reduction, positive inotropes, afterload reduction
preload reduction therapy in pulmonary edema
diuretics, nitrates
+ inotropes in PEd
dobutamine, amnirone/milrinone
Used in acute setting (ICU) when unresponsive to preload reduction
afterload reduction in PEd
nitroprusside, hydralazine acutely
ACE-I long term if systolic dysfunction
