MTB 3 - Cardio Flashcards
Worst risk factor for CAD
DM
Most common risk factor for CAD
HTN
Risk Factors for CAD
DM, tobacco, HTN, hyperlipidemia, 1st degree family member with premature CAD, Men >45 & Women > 55
Correcting which risk factor shows greatest improvement with CAD?
smoking cessation
50% 1 year, 90% 2 years after smoking
Ischemic Pain
dull or sore
squeezing or pressure-like
Non-ischemic pain
Sharp or point-like
lasts for a few seconds
Changes with respiratoin (pleuritic), position, touch/tenderness
Chest Wall Tenderness
Costochondritis
Do PE
Radiation to back, unequal BP in arms
Aortic Dissection
chest x-ray-widened mediastinum
chest CT, MRI, or TEE confirms Dx
Pain worsens with lying flat, better when sitting up
Pericarditis
EKG with ST-elevation everywhere, PR depression
Epigastric discomfort, pain better when eating
Duodenal ulcer disease
Endoscopy
Bad taste, cough, hoarseness
GERD
Response to PPIs; Alumium hydroxide and Mg hydroxide, viscous lidocaine
Cough, sputum, hemoptysis
Pneumonia
CXR
Sudden-onset SOB, tachy, hypoxia
PE (can have fever)
Spiral CT*, V/Q scan
Sharp, pleuritic pain, tracheal deviation
Pneumothorax
CXR
Best initial test for chest pain
EKG
EKG not diagnostic and etiology of chest pain unclear-next step
stress test
Mortality lowering drugs with chronic angina
1) Aspirin-(clopidogrel used in apsirin intolerant pts or new stented pts)
2) Beta blockers-B1 spec. metoprolol
3) Nitroglycerin
Statin AE
Elevated transaminases (AST/ALT) do liver fxn tests Myositis
Niacin AE
Pruritis (+histamine)
elevation glucose and uric acid level
Fibric Acid derivatives (gemfibrozil) AE
increase risk myositis with statins
Cholestyramine AE
flatus, abd cramping
Ezetimibe AE
well tolerated, add to statins, not very useful
ACS confirmed on EKG, next step
Aspirin-shown to decrease mortality
clopidogrel is aspirin intolerant or if pt has stent already
ACS confirmed, aspirin given, next step
Angioplasty (90 min door time)>thrombolytics
Thrombolytics only used if angioplasty not available, in STEMIs, or new LBBB
NSTEMI-use heparin instead
contraindications to thrombolytics
1) hx major bleeding to brain/bowel
2) recent surgery-2 wks
3) severe HTN-180/110
4) nonhemorrhagic stroke in last 6 months
Indication for tPA (thrombolytics) in MI
only beneficial with STEMI
Indication for heparin in MI
best for NSTEMI (LMWH)
Indication for GP IIb/IIIa inhibitors in MI
best for NSTEMI and undergoing PCI and stenting
Post MI routine meds on d/c
1) Aspirin 2) Beta blockers (metoprolol) 3) Statins 4) ACEi
CHF Systolic vs Diastolic
Systolic- low EF, dilation of heart, or diastolic dysfxn.
can’t get blood out
Diastolic- inability of heart to relax and receive blood
EF is preserved, can be increased
Top causes of systolic CHF
HTN #1, MI, cardiomyopathy, valve disease-(95%)
-all can lead to dilated cardiomyopathy
Other causes of systolic CHF
alcohol, postviral idiopathic myocarditis, radiation, doxorubicin, Chagas (other infxns), Hemochromatosis (restrictive too), Thyroid dx, Peripartum cardiomyopathy, Thiamine deficiency
Sxs CHF
#1- SOB/dyspnea upon exertion orthopnea, peripheral edema, rales, JVD, paroxysmal nocturnal dyspnea, S3 gallop (fluid overload)
Dyspnea, sudden onset, clear lungs
PE
Dyspnea, sudden onset, wheezing, increased expiratory phase
asthma
Dyspnea, slower, fever, sputum, unilateral rales/rhonchi
Pneumonia
Dyspnea, decreased breath sounds unilaterally, tracheal deviation
Pneumothorax
Dyspnea, circumoral numbness, caffeine use, hx anxiety
panic attack
Dyspnea, pallor, gradual over days to weeks
anemia
Dyspean, pulsus paradoxus, decreased heart sounds, JVD
tamponade
Dyspnea, palitation, syncope
arrhythmia of any kind
Dyspnea, dullness to percussion at bases
pleural effusion
Dyspnea, long smoking history, barrel chest
COPD
Dyspnea, recent anesthetic use, brown blood no improved with O2, clear lungs, cyanosis
methemoglinemia
tx: methylene blue
Dyspnea, burning building or car, wood-burning stove, suicide attempt
carbon monoxide poisoning
tx: 100% O2 hyperbaric chamber
Tx Systolic CHF
ACEi/ARB, Beta blockers (decrease mortality), Spironolactone (blocks aldosterone), Diuretics (tx sxs), Digoxin (tx sxs)
Mortality benefitting Rxs in CHF
ACEi/ARBs, Beta blockers, Spironolactone, Hydralazine/Nitrates, implantable defib (
Tx diastolic CHF
Beta blockers*, Diuretics
Uncertain-ACEi, ARBs, and hydralazine
Don’t use in diastolic CHF
Digoxin and spironolactone
Rheumatic fever MC a/w
mitral stenosis
valvular lesions that increase/worsen with inhalation
right side-tricuspid and pulmonic
valvular lesions that increase/worsen with exhalation
left side-mitral and aortic
Mitral Stenosis Sxs
Diastolic murmur with opening snap
- squatting and leg raise (+VR) increase murmur
- CHF and SOB
- Dysphagia- LA pressing on esophagus
- Hoarseness-LA pressing on laryngeal nerve
- AFib and stroke
- Hemoptysis
Mitral Stenosis- CXR
straightening of left heart border
elevation of left main-stem bronchus
second bubble behind heart
Tx Mitral Stenosis
1) Balloon valvuloplasty
2) diuretics and sodium restriction with fluid in lungs
3) valve replacement if needed
4) warfarin for afib
5) rate control-dig, beta block, verap/dilt
Aortic Stenosis Sxs
systolic crescendo-decrescendo murmur Valsalva and Standing decrease murmur Handgrip also decrease murmur -Angina-#1 -Syncope -CHF
Aortic Stenosis-CXR
LVH >50% of transthoracic diameter
Mitral Stenosis- EKG
EKG-biphasic P-wave in V1, V2
Aortic Stenosis-EKG
S wave in V1, R wave in V5 > 35mm
Tx Aortic Stenosis
Valve replacement
Diuretics, but not always well tolerated
Mitral Regurgitation Sxs
pansystolic murmur, radiates to axilla
CHF, dyspnea
Mitral Regurg- hand grip, squatting, leg raise
all increase murmur
Tx Mitral Regurgitation
1) Vasodilators*-ACE or ARBs. decrease progresion
2) Dig and diuretics tx sxs
3) Valve replacement when heart starts to dilate
Aortic Regurg Sxs
diastolic decrescendo murmur Wide pule pressure Water-hammer pulse Quincke pulse (pulsations in nail bed) Hill sign (leg BP>>arm BP) Head bobbing (de Musset sign)
Aortic Regurg- Valsalva/standing, hand grip/squatting
Valsalva and standing- decrease murmur
Hand grip/squatting- increase murmur
Tx-Aortic Regurg
ACEi/ARBs or nifedipine-vasodilators to increase forward flow, decrease progression
Dig and diuretics little benefit
Surgery before dilates
Mitral Vale Prolapse Sxs
Different from other lesions-considered normal if aSxs midsystolic click Atypical chest pain Palpitations Panic attack
MVP- Valsalva/standing, Hand grip/Squatting
Valsalva/Standing- increase murmur (decrease VR)
Hand grip/Squatting- decrease murmur (increase afterload)
Tx- MVP
Beta blockers if symptomsatic
Valve repair/stitches
Endocarditis pxs not needed
Murmurs do not increase with expiration in?
HOCM and MVP
Cardiomyopathy Sxs
SOB, worse on exertion
Edema
Rales
JVD
Best test Cardiomyopathy
Echo-best and most accurate
CXR and EKG can also be done
Causes of dilated cardiomyopathy
1) MI/Ischemia
2) Alcohol
3) postviral myocarditis
4) Radiation
5) Toxins-doxorubicin
6) Chagas dx
Rxs lower mortality in dilated cardiomyopathy
1) ACEi/ARBs 2) metoprolol, carvedilol 3) Spironolactone
diuretics and dig for sxs
Tx in dilated cardiomyopathy wide widened QRS (>120ms)
biventricular pacemaker
HCM vs HOCM
HOCM sxs- 1) chest pain 2) syncope, dizzy 3) worse w/increase in HR (exercise, dehydration, diuretics) 4) sudden death in healthy athletes-rare
Initial Tx HCM and HOCM
Beta blockers
verapamil and disopyramide too, neg inotropes
Used in HCM, but not in HOCM
diuretics and ACEi
Causes of restrictive cardiomyopathy
1) Sacroidosis 2) Amyloidosis 3) Hemochromatosis 4) Endomyocardial fibrosis 5) Scleroderma
Sxs Restrictive Cardiomyopathy
Kussmaul sign-increase in JVD pressure (unique)
dyspnea with RH failure- ascites, edema, JVD, liver/spleen enlargement
Pericarditis EKG
ST segment elevation in all leads and PR segment depression
Hypotension, tachycardia, distended neck veins, clear lungs, pulsus paradoxus
Pericardial Tamponade
Electrical alternans (different height of QRS between beats)
Pericardial Tamponade
Tx Pericardial Tamponade
1) Pericardiocentesis, 2) IV fluids 3) pericardial window placed for recurrent cases
Contraindicated drug in pericardial tamponade
diuretics- will decrease the cardiac filling pressure and further collapse heart
Constrictive Pericarditis a/w
TB-MCC
calcification and fibrosis
Best test for peripheral artery disease
ankle-brachial index (ABI)
if difference in pressure is >10% then present
Initial Tx PAD
1) Aspirin, stop smoking, Cilostazol (single most effective) 2) Bypass surgery if Rxs not effective
Calcium Channel Blocker indications
Verapamil/Diltiazem 1) severe asthma (can't use beta-block) 2) Prinzmetal variant angina 3) cocaine-induced chest pain (beta-block CA) Rarely used in CAD
Adverse effects of CCBs
Edema, constipation (relax smooth muscle), Heart Block (rare)
maneuvers that increase preload
1) handgrip, 2) squat, 3) leg elevation, 4) lying down, 5)venoconstrictors
maneuvers that decrease preload
1) Valsalva 2) standing, 3) nitrates/venodilators
