PANCE Flashcards
What do you give in narrow complex tachycardia and terminates 90% of SVTs?
adenosine
first line treatment in symptomatic sinus bradycardia
atropine
treatment for sick sinus syndrome
permanent pacemaker (PPM) with automatic implantable cardioverter defribillator (AICD)
management for A-flutter
vagal, CCB, b-blocker, DCC if unstable
radiofrequency ablation definitive tx*
what is included in the CHADS2 criteria?
congestive heart failure hypertension age >75 diabetes mellitus stroke, tia, thrombus (2 points)
high risk>2 –> warfarin
moderate: 1 –> warfarin or asa
what is wandering atrial pacemaker (WAP)? and what is Multifocal atrial tachycardia (MAT)?
WAP: HR <100 and >3 P wave morphologies
MAT if HR >100
what is MAT (multifocal atrial tachycardia) associated with?
severe COPD
what is a delta wave (slurred QRS upstrokc, wide QRS >0.12 sec) and short PRI associated with?
wolff-parkinson-white
-accessory pathway (Kent bundle) “pre-excites ventricle”
what is the treatment for WPW?
vagal maneuvers
antiarrhythmics (procainamide**, amiodorone)
what is torsades mc due to?
hypomagnesemia
ST elevation CONCAVE precordial leads
PR depressions seen in same leads with the ST elevations
NO reciprocal changes
EKG findings of acute pericarditis
what should you be cautious of using in an inferior (R-sided) MI?
nitroglycerin and morphine
why should you be cautious of using nitroglycerin and morphine in an inferior MI?
because they decrease preload and the R side is more dependent on preload (and stroke volume)
what is hyperadlosteronism associated with?
increased BP and hypokalemia
what is the most useful noninvasive test in evaluating patients with suspected coronary artery disease
stress test
risk factors for coronary artery disease
DM, hypoerlipidemia, smoking, HTN, males, age >65, family h/o CAD
EKG findings of CAD
ST depression* with exertion, T wave inversion, poor R wayve progression +/- normal (50%)
gold standard for cAD
coronary angiography
contraindication to pharmacologic stress testing
bronchospastic disease
contraindications for using nitroglycerin
SBP <90, RV infarction, use of viagra (sildenafil)
progression of an EKG in acute coronary syndrome
hyperacute (peaked ) T waves–> ST elevations –> Q waves –> T wave inversions
when does troponin peak and return to baseline?
peakes 12-24 hr, returns to baseline 7-10 days (appears 4-8 h)
side effect of enoxaparin (lovenox)
thrombocytopenia (obtain CBC prior to use)
what is clopidogrel?
plavix (ADP inhibitor) –> useful in initial tx of ACS in patients with ASA allergy
what is the MOA of betabolockers?
lowers myocardial O2 consumption, antiarrythmic effects
when are beta blockers contraindicated?
severe bradycardia (HR <50), hypotension, decompensated CHF, 2nd/3rd degree geart block, cardiogenic shock, cocain induced MI, severe asthma, COPD
when are beta blockers contraindicated in acute MI?
cocaine induced MI : use benzodiazepines bc b-blockers cause unopposed alpha vasoconstriction
what should yo ugive in a r ventricular (ninferior walle0 MI?
IV fluids for preload (cautious with IV nitrates and morphine use)
MC arrhythmia in MI
ventricular fibrillation
post MI pericarditis associated with fever and pulmonary infilltrates
dressler’s syndrome
chest pain usually at rest, not usually due to exertion
prinzmetal’s angina (coronary spasm –> transient ST elevations usually without MI)
diagnosis of pritzmetal’s angina
ECG shows transient ST elevations (symptoms and ST elevations rapidly resolve with CCB and nitro)
treatment: CCB
pathophys of cocaine induced MI
coronary artery spasm
absolute contraindications for thrombolytic use in ACS
any prior ICH, non-hemorrhagic stroke within 6 months or closed head/facial trauma within 3 months, intracranial neoplams, aneurysm, AVM, active internal bleeding, suspected aortic dissection
most common causes of L sided heart failure
coronary artery disease and hypertension
most common cause of r-sided heart failure
left sided heart failure
difference between systolic and diastolic HF
systolic: decreased EF associated with S3 gallop
diastolic: normal/increased EF associated with S4 gallop
MC symptom of L sided heart failure
dyspnea. initially exertional –> orthopnea and paroxysmal nocturnal dyspnea
pulmonary congestion/edema: rales, rhonchi, chronic nonproductive cough (commonly missed) esp with pink frothy sputum (surfactant)
MC cause of transudative pleural effusion
CHF
deeper faster breathing with gradual decrease and periods of apnea
cheyne stroke’s breathing (CHF PE)
clinical manifestions of R sided heart failure
peripheral edema, JVD, GI/hepatic congestion
most useful test to diagnose Heart failure
echo
most important determinant in heart failure prognosis
ejection fraction (normal 55-60)
unless contraindicated, what two drugs should every patient with Heart failure be on?
ACEI (decreases mortality, hospitalizations, and directly reverses the pathology by decreasing renin and sympathetic stimulation) and diuretic
MOA of ACEI in HF
decrease preload/afterload, decrease aldosterone production
side effects of ACEI
1st dose hypotension
azotemia/renal insufficiency
hyperkalemia
cough (often dry) and angioedema due to increased bradykinin**
contraindications to ACE
pregnancy
hypotension
ending for ACEI
“-pril”
what do beta blockers do for HF patients?
decrease mortality, increase EF and reduce ventricular size
drug that is most effective tx for symptoms of mild-moderate HF
diuretics
side effects of diuretics
hypOkalemia/calcemia/natremia, hyperglycemia, hyperuricemia
side effects of K sparking diuretics
hyperkalemia, gynecomastia
digoxin toxicity
digitalis effect on ECG: downsloping sagging ST segment, junctional rhythms, hypokalemia worsens toxicity**
what is treatment for patients with HF and an EF <35%
implantable cardioverter defibrillator
most common etiology of pericarditis
viral (enteroviruses: coxsackie and echovirus)
pericarditis 2-5 days s/p MI
dressler’s syndrome
EKG of pericarditis
diffuse ST elevations in precordial leads and associated PR depressions
treatment of pericarditis
aspirin or NSAIDs x 7-14 days + colchicine
exg with low voltage QRS complexes
large pleural effusion or tamponade
treatment of pericardial effusion
observation if small and no evidence of tamponade, treat underlying cause
+/- pericardiocentesis if tamponade, large effusion. pericardial window drainage if recurrent
pericardial effusion causing significant pressure on heart –> restriction of cardiac ventricular filling –> decreased CO
pericardial tamponade
what is beck’s triad
distant (muffled) heart sounds
elevated JVP
systemic hypotension
what will an echo show in pericardial tamponade?
diastolic collapse of cardiac chambers
treatment of pericardial tamponade
pericardiocentesis
most common etiologies of myocarditis
enterovirus (esp coxsacki B) mc cause and echovirus
bacterial: rickettsial (lyme dz, rocky mountain spotted fever, Q fever)
clinical manifestation of myocarditis
viral prodrome (fever, myalgias, malaise) x several days –> HF symptoms** (dyspnea @ rest, exercise intolerance, syncope, tachypnea, tachycardia) impaired systolic function
classic diagnostic study findings of myocarditis
cardiomegaly (dilated cardiomypathy)
gold standard in diagnosing myocarditis
endomyocardial biopsy
most common causes of dilated cardiomyopathy
idiopathic (50%): (viral probably the origin of idiopathic)
viral myocarditis : enterovirus MC
toxic: alcohol abuse, cocaine, anthracyclies (doxorubicin)** –> chemo drug
diagnostic studies for dilated cardiomyopathy
echocardiogram: left ventricular dilation **, large ventricular chamber, decreased ejection fraction, regional LV hypokinesis
apical left ventricular balooning following an event that causes a catecholamine surge (emotional stress, “broken heart syndrome”, surgery)
takotsubo cardiomypoathy
most common cause of restrictive cardiomyopathy
amyloidosis , followed by sarcoidosis
treament of HCMP
focus on early detection, medical managment, surgical and/or ICK placement**, counseling to avoid dehydration and extreme exertion/exercise very important !!
beta blockers (cautious use of digoxin, nitrates and diuretics)
myomectomy
alcohol septal ablation
when is rheumatic fever MC and in who?
children 5-15 y, 2-3 weeks p symptomatic or asymptomatic strep pharyngitis
criteria for rheumatic fever
jones criteria
Major:
migratory polyarthritis (2 or more joints)
active carditis
syndenhajm’s chorea
subcutaneous nodules (rare, seen over joints)
erythema margitanum (macular, erythematous, non-pruritic anular rash with rounded, sharply demarkated edges)
minor:
fever( 101-104)
arthralgias
increase in acute phase reactants (ESR, CRP, leukocytosis)
PLUS: supporting evidence of a recent group A streptococcal infection
treatment of rheumatic fever
penicillin G drug of choice (or erythromycin if PCN allergic)
anti-inflammatory: ASA (2-6 weeks with taper)
CXR that shows “egg on a string”
transposition of the great vessels
what is carvallo’s sign?
increased murmur intensity with inspiration –> sign of tricuspid regurgitation
blowing holosystolic murmur @ apex with radiation to the axilla
mitral regurgitation
management of hypertensive emergency
decrease BP (MAP) by 10% first hour and an additional 15% next 2-3 hours using IV agents** -sodium nitroprusside
(different than hypertensive urgency- no end-organ damage- decrease by 25% 24-48 hours using PO agents)
what are the lipid guidelines for statin use?
- type 1 or 2 patients with DM between 40-75 years old
- people >21 with LDL levels greater than or equal to 190 Mg/dL
- people with cardiovascular disease
MC bacteria of subacute bacterial endocarditis
strep viridans - oral flora source of infection
MC bacteria of acute bacterial endocarditis and IVDA
staph aureus
clinical manifestations of endocarditis
fever (80-90%)
janeway lesions (painless erythematous macules on palms/soles)
osler nodes
roth spots, petechiae
splinter hemorrhages
diagnostic studies in suspected bacterial endocarditis
blood cultures (3 sets @ least 1 hour apart)
EKG (prone to arrythmias)
echo
labs: CBC - leukocytosis, anemia, elevated ESR/RF
criteria for endocarditis
duke criteria
treatment for infective endocarditis
Native valve acute bacterial endocarditis:
nafcillin + gentamicin x 4-6 weeks
vancomycin (if MRSA suspected or PCN allergic)
intermittent claudication(brought on by exercise and relieved with rest) is MC presentation of what?
PAD
diagnosis of PAD
ankle-brachial index (ABI), arteriography is gold standard (only done if revasulcarization is planned)
treatments of PAD
platelet inhibitos (cilostazole**) ASA Clopidogrel (plavix)
MC place for AAA
infrarenally
MC risk foactors for AAA development
atherosclerosis, age >60, smoking, males, caucasians
initial imaging study for patients with suspected AAA
abdominal ultrasound
test of choice for thoracic aneurysms
CT scan
drug that reduces shearing forces in AAA
beta blockers
most important predisposing factor of aortic dissection
hypertension, follwed by age (55-60 y)
variation in pulse (>20 MMHG difference) between R and L arm is indication of what?
aortic disection
diagnostic test for aortic dissection
CT scan test of choice
MRI angiography is gold standard
TEE if patient unstable
CXR shows widening of mediastinum
giant cell arteritis/temporal arteritis is same clinical spectrum as what?
polymyalgia rheumatica
clinical manifestations of giant cell arteritis
headache (unlateral, temporal, lancinating)
jaw claudication with mastication
acute vision distrubances : amaurosis fugax
diagnosis of giant cell arteritis
ESR > 100, elevated CRP
treatment of giant cell arteritis
high dose corticosteroids** (40-60 mg/day x 6 weeks)
-if suspected, start prednisone rather than wait for testing
headache, scalp tenderness, jaw claudication, fevers, visual loss
giant cell arteritis
nonatherosclerotic inflammatory disease of small and medium arteries and veins, strongly associated with tobacco, MC in young men 20-45
buerger disease
suspect in young smokers/tobacco users with distal extremity ischemia, ischemic digit ulcers and digital gangrene
buerger disease
beurger disease is also known as what?
thromboantiitis obliterans
what is trousseau’s sign?
migratory thrombophlebitis usually associated with malignancy or vasculitis
most specific sign of DVT
unilateral swelling/edema of lower extremity
treatment of DVT
heparin, LMWH –> warfarin x 3-6 months
skin findings of DVT
stasis dermatitis
skin findings of PAD
livedo reticularis
venous stasis ulcers are usually found where?
medial malleolus
treatment of cardiogenic shock
smaller amounts of fluid **only shock in which large amounts of fluids aren’t given)
inotropic support - dobutamine, epi, balloon pump
pathophys of cardiogenic shock
decreased CO, increased pulmonary capillary wedge pressure
