MTB CardioPulm Flashcards
________ women virtually never have MIs
Menstruating
Risk Factors for CAD
1) worst RF
2) most common RF
3) most immediate effect if changed RF
4) FH RF details
1) DM
2) HTN
3) smoking cessation
4) FIRST DEGREE relatives with premature CAD events (male
Most dangerous HLD risk factor
Elevated LDL
Post menopausal woman with chest pain upon hearing news of her son’s death. + ST elevation on EKG.
1) diagnosis?
2) echo results?
3) angiography results?
4) management?
1) Tako-Tsubo Cardiomyopathy
2) Echo will show apical ballooning
3) Normal angiography
4) B-blockers and ACE-Inhibitors (no revascularization!)
Worst prognostic indicator in patient with ‘chest pain’?
Shortness of breath
Chest Pain - best initial test?
EKG
Indications for EKG Exercise Stress Test
Etiology of chest pain is unclear - EKG non-diagnostic - trying to determine if there is Ischemia
Unsure if patient’s chest pain is ischemic events but there are underlining ST segment abnormalities (left bundle branch block, left ventricular hypertrophy, pacemaker use)
What test?
Exercise thallium or exercise echo
Unsure if patient has ischemic heart disease but they cannot exercise…what test?
Dipyridamole thallium or dobutamine echo
Dipyridamole cannot be used in…
Asthmatics because may provoke bronchospasm
What percentage stenosis calls for stent/CABG consideration?
70%
CABG indications
1) 3 vessel disease
2) 2 vessel disease in a diabetic
3) left main artery stenosis
Angina medications that actually lower mortality.
Beta blockers
ACE inhibitors
Nitroglycerin
What forms of nitroglycerin used in stable angina vs acute coronary syndrome
Angina: oral, transdermal patch
ACS: sublingual, paste, IV
________ women virtually never have MIs
Menstruating
Risk Factors for CAD
1) worst RF
2) most common RF
3) most immediate effect if changed RF
4) FH RF details
1) DM
2) HTN
3) smoking cessation
4) FIRST DEGREE relatives with premature CAD events (male
Most dangerous HLD risk factor
Elevated LDL
Post menopausal woman with chest pain upon hearing news of her son’s death. + ST elevation on EKG.
1) diagnosis?
2) echo results?
3) angiography results?
4) management?
1) Tako-Tsubo Cardiomyopathy
2) Echo will show apical ballooning
3) Normal angiography
4) B-blockers and ACE-Inhibitors (no revascularization!)
Worst prognostic indicator in patient with ‘chest pain’?
Shortness of breath
Chest Pain - best initial test?
EKG
Indications for EKG Exercise Stress Test
Etiology of chest pain is unclear - EKG non-diagnostic - trying to determine if there is Ischemia
Unsure if patient’s chest pain is ischemic events but there are underlining ST segment abnormalities (left bundle branch block, left ventricular hypertrophy, pacemaker use)
What test?
Exercise thallium or exercise echo
Unsure if patient has ischemic heart disease but they cannot exercise…what test?
Dipyridamole thallium or dobutamine echo
Dipyridamole cannot be used in…
Asthmatics because may provoke bronchospasm
What percentage stenosis calls for stent/CABG consideration?
70%
CABG indications
1) 3 vessel disease
2) 2 vessel disease in a diabetic
3) left main artery stenosis
Angina medications that actually lower mortality.
Beta blockers (esp B blocker + aspirin)
ACE inhibitors
Nitroglycerin
What forms of nitroglycerin used in stable angina vs acute coronary syndrome
Angina: oral, transdermal patch
ACS: sublingual, paste, IV
Indications for anti-platelet medications
Acute coronary syndrome
Recent angioplasty with stunting (use namely prasugrel and ticagrelor)
Ticlopidine- what is it used for and side effects
Anti-platelet medication
Neutropenia and TTP
Patient just had STEMI 2 weeks ago and is on all recommended ACS medications…suddenly develops fever and bruise-like lesions on abdomen and studies show normocytic anemia, thrombocytopenia, and renal failure. What test to confirm diagnosis? What happened?
Blood smear will show schistocytes
TTP from ticlopidine or clopidogrel
Ranolazine - used for?
Persistent or refractory cases of angina
Systolic dysfunction - drug that has best mortality benefit?
Side effects?
Best second line medication?
ACE inhibitors/ARBs best for low ejection fraction and/or regurgitant valvular disease
Side effects: cough, hyperkalemia
2nd line: hydralazine (decreases after load via arterial vasodilation) with nitrates (allow coronary dilation as well so blood doesn’t travel path of least resistance and leave them empty)
Most common statin side effect
Elevated liver enzymes
Triglyceride lowering medication and its side effect
Fibrates
Myositis
Medication that raises HDL and its side effects
Niacin
High uric acid, flushing, itchiness, glucose intolerance
Which lipid lowering drug has best mortality benefit and why? Its side effects?
Statins: antioxidant effect on endothelial lining in addition to LDL lowering effect
Side effects: liver damage, myositis, Rhabdomyolysis
CAD Indications and adverse effects of CCBs
Indication: verapamil and diltiazem can be used in CAD with sever asthma that cannot use beta blockers; prinzmetal angina; chest pain caused by cocaine use
Side effects: edema, constipation (esp verapamil), rarely heart block
CABG grafts and how long they typically last
Internal mammary artery - 10 years
Great saphenous vein - 5 years
Patient presents who has history of stable angina and is on all proper medications. Asks why he can’t have a stent put in to prevent the MI if we already know his arteries are clogging up…what do u say?
Maximum medical therapy (beta blocker, ACE inhibitor, statin, and aspirin) has proven to be equal to or of greater effect than PCI in stable angina.
Lead changes associates with: anterior wall MI, inferior wall MI, posterior wall MI
AWMI: St elevation in V2-V4 MOST DANGEROUSLY left main
IWMI: St elevation in II, III, aVf
PWMI: St depression in V1-V2
What do you give first in ACS? Best effect on mortality…
Aspirin
….then angiography/angioplasty
What test is first to show result and what test is last to show result for ACS?
1) EKG changes
2) myoglobin
3) CK-MB
4) Troponins
Myoglobin and CK-MB are also first to leave the system…good for re-infarction tests
Patient has creatinine of 2.4 and BUN of 40, and troponins are positive, what is next step in management?
Check other tests (EKG, CK-MB) because troponins are excreted through the kidneys and therefore run high in renal failure.
Concerned for reinfarction…first and second step in management?
1) EKG to look for new changes
2) CK-MB
Standard of care for PCI is “door to balloon” time in…
90 minutes
Do drug-eluting stents change morbidity of disease process? If so, how?
Yes, decrease the rate of re-infarction/re-stenosis by inhibiting T-cell response (sirolimus and paclitaxel)
Indications for thrombolytics
Contraindication for thrombolytics
If the hospital does not have capabilities to perform PCI and within 12 hours of chest pain
Contrindications: hemorrhagic stroke EVER, ischemic stroke in last 6 months, surgery in last 2 weeks, severe hypertension (>180/110)
Patient presents with crushing chest pain for 1 hour and EKG shows ST depressions- what is first and second step in management?
1) aspirin
2) low molecular weight heparin - want to prevent clot from progressing further
What is eptifabatide?
Glycoproteins IIb/IIIa inhibitor
What is tirofiban?
A glycoprotein IIb/IIa inhibitor
Indication for glycoprotein IIb/IIIa inhibitors in ACS?
In unstable angina…especially when enzymes come back showing nonSTEMI…decreases mortality
Which is better in terms of mortality for ACS - LMWH or unfractionated heparin?
LMWH
DONT WORRY!
“I can do ALL things in Christ Who strengthens me”
Stay focused…on Your Beloved
“…in all your ways, submit to Him, and He will make your way straight…” Proverbs
Don’t be afraid…
“So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen you and help you; I will uphold you with my righteous right hand.” Isaiah 41:10
Patient presents with crushing chest pain, JVD, but lungs are clear…what to avoid giving?
No nitrates! Give high volume fluid replacement.
Patient has an MI and 5 days later presents with pulmonary congestion and new onset murmur…what happened? What is first step in management?
Valvular or septal rupture
Intra-aortic balloon pump to bridge to surgery
Erectile dysfunction after MI - what is the most likely reason?
Probably from anxiety
Must consider if beta blockers are contributing though
Dyspnea + circumolar numbness
Anxiety attack
Chocolate/Brown blood + dyspnea
Methemoglobinemia
CHF picture, first best test?
TTE
Most accurate test for ejection fraction
Indication?
MUGA or nuclear ventriculogram
Use when precision is necessary - like when dosing doxorubicin in chemotherapy
Does spironalactone have a role in CHF treatment?
Yes, systolic dysfunction type…CHF stage III/IV - proven mortality benefit
How does spironalactone work in CHF?
Does not have anti-diuretic effect, but helps in its inhibition of aldosterone
Patient has history of MI, long history of CAD, presents with peripheral edema, JVD, pulmonary congestion…ejection fraction is found to be below 35%
Next step in management ?
Implantable defibrillator
Patient has history of MI, long history of CAD, presents with peripheral edema, JVD, pulmonary congestion…ejection fraction is found to be below 35%
QRS complex is above 120 milliseconds
Symptomatic even at maximal medical therapy with ACE inhibitors, diuretics, beta blocker…
Next step in management ?
Biventricular pacemaker
Patient presents with acute pulmonary edema possibly secondary to CHF with systolic dysfunction, what is best first step in medical management?
IV furosemide
Most common valvular defect in rheumatic fever?
Mitral stenosis, but any defect can result
Why does exhaling exaggerate L sided murmurs?
Increase pulmonary venous return from lungs to heart
When to do TTE vs TEE?
TTE: CHF evaluation initially…to get rough measurement of ejection fraction
TEE: for valvular disease, better picture and more accurate for dilatation measurements
Immigrant + murmur
Mitral stenosis
Pregnant + new heart murmur
Mitral stenosis (50% plasma increase)
Young patient + diastolic murmur
Mitral stenosis
Diastolic murmur + dysphagia/hoarseness/hemoptysis
Mitral stenosis
QUICK!! Diastolic murmur could be…
AR
MS
Diastolic murmur + Marfan
Aortic regurgitation
Diastolic murmur + seronegative spondy
Aortic regurg
Diastolic murmur + syphilis
AR
Murmur + quincke pulse
Quincke pulse = pulsation sin nail beds
AR
Murmur + hill sign
Hill sign: BP in legs higher than in arms
AR
Murmur + de Musset sign
De Musset sign: head bobbing
AR
Systolic murmur + Marfan
MVP
What murmurs get better with expiration and why?
MVP and HOCM
Because they get better when there is more blood filling the heart, and expiration increases pulmonary vein return flow from the lungs to the heart
Indication for endocarditis prophylaxis? (4)
Prosthetic valve
Prior endocarditis
Cardiac transplant patient with valve dz
Dental work with blood
Treatment for aortic stenosis
Valve replacement
Treatment for aortic regurgitation
ACE inhibitors/ARB
Treatment for mitral stenosis
Valvuloplasty
Treatment for mitral regurgitation
ACE inhibitors
ARBs
Treatment for Mitral valve prolapse
Beta blockers if asymptomatic
Valve repair
Patient recently traveled from South America + esophageal problem + CHF picture
Chagas disease (causes achalasia and dilated cardiomyopathy)
6 causes of dilated cardiomyopathy
Alcohol Ischemia Chagas' disease Radiation Postviral myocarditis Toxins- eg doxorubicin
Systolic anterior motion of mitral valve
HOCM
How to treat HOCM?
Beta blockers
Verapamil/diltiazem
Implantable defibrillators for syncope patients
Septum ablation with alcohol…then myomectomy if still symptoms persist
ST elevation everywhere + depressed PR interval
Diagnosis and treatment
Pericarditis
(If no underlying etiology that is treatable)
NSAIDs and Colchicine
Cardinal tamponade treatment
Pericardiocentesis
IV fluids to prevent heart collapse
Hole or “window” if recurrent
Constrictive pericarditis XRay findings
Calcification over heart
Kussmaul sign - Dx?
JVP increases on inhalation
Constrictive pericarditis or severe restrictive cardiomyopathy
ABI difference to indication peripheral vascular disease
ABI
Treatment for peripheral artery disease
Stop smoking
Aspirin
Cilostazol- most effective medication
What is cilostazol? Indication?
Peripheral artery disease tx
Phosphodiesterase inhibitor
Treatment for aortic dissection?
Beta blocker, nitroprusside, surgical correction (BP control is most important)
Screening for AAA?
Men over 65 who have ever smoked with ultrasound
Worst 2 cardiac complication in pregnancy? How do they harm?
1) Peripartum Cardiomyopathy: antibodies made against myocardium - presents after delivery - treat like dilated cardiomyopathy
2) eisenmenger syndrome: already exists a left-to-right shunt (VSD), increase in plasma causes pulmonary hypertension to worsen quickly - causing a right-to-left shunt (cyanotic disease)
