PANCE Prep- Cardiology Flashcards
1
Q
What meds should you avoid in WPW and why?
A
AV nodal blockers (ABCD)
- Adenosine
- BB
- CCB
- Digoxin
*AV nodal blockade may cause preferential conduction through the fast (preexcitation) pathway–> worsening of the tachyarrhythmia
2
Q
Describe the normal intervals
PR:
QRS:
QT:
A
PR: 3-5 small boxes (0.12-0.2sec)
QRS: <3 small boxes (<0.12 sec)
QT: 7.5-11 small boxes (0.3-0.44 sec)
3
Q
Describe the sympathetic NS control of the heart
A
Hormones Epi and NE cause
- increased excitability
- increased force of contraction
- increased SA node discharge rate (increase HR)
*Epi and dobutamine are sympathomimetics (stimulate the SNS)
4
Q
Describe the parasympathetic NS control of the heart
A
Hormone acetylcholine (regulated by the vagus nerve) causes:
- decreased excitability
- decreased force of contraction
- decreased SA node discharge rate (decrease HR)
- Vagal stimulation or vagal maneuvers slow down the HR
- Conversely, anticholinergic drugs increase the HR
5
Q
How do you determine LBBB or RBBB
A
LBBB:
- Wide QRS >0.12sec
- Broad, slurred/bunny ears bumps R in V5,6
- Deep S wave in V1
- ST elevation in V1-V3
RBBB:
- Wide QRS >0.12sec
- RsR’ in V1, V2
- Wide S wave in V6
6
Q
Describe the leads involved and artery involved for the area of infarction:
Anterior wall
A
V1-V4 (V3,4*)–Q waves/ ST elevation
LAD artery or LCA
7
Q
Describe the leads involved and artery involved for the area of infarction:
Septal
A
V1 and V2– Q waves/ ST elevation
Proximal LAD
8
Q
Describe the leads involved and artery involved for the area of infarction:
Lateral wall
A
I, aVL, V5, V6– Q waves/ ST elevation
Left circumflex artery
9
Q
Describe the leads involved and artery involved for the area of infarction:
inferior
A
II, III, aVF– Q waves/ ST elevation
RCA
10
Q
Describe the leads involved and artery involved for the area of infarction:
Posterior Wall
A
V1-V2 ST Depression**
RCA or LCX
11
Q
What is a normal QRS axis
A
- 30 to +90 degrees
* look at leads I and aVF
12
Q
in NSR, P waves are positive/upright in leads:___ and neg in leads: ___
A
Positive P: I, II, aVF
Negative P: aVR
13
Q
Heart rate typically ___ during inspiration
A
Increases in inspiration
decreases in expiration
14
Q
What is sick sinus syndrome
A
Brady-tachy syndrome
- Combination of sinus arrest w/ alternating pparoxysms of atrial tachyarrhythmias and bradyarrhythmias
- commonly caused by SA node disease and corrective cardiac surgery
15
Q
Management of Sick Sinus Syndrome
A
- Permanent pacemaker if symptomatic (dual chamber pacing usually preferred over ventricular pacing).
- *if brady alternating with ventricular tachycardia–> permanent pacemaker w/ automatic implantable cardioverter-defibrillator (AICD)
16
Q
___ is the most helpful in determining the presence of AV conduction blocks
A
PR interval
17
Q
Describe 1st, 2nd type 1 and 2, and 3rd degree AV blocks
A
1st: Fixed, prolonged PRI (>0.2sec) and QRS followed by every P
2nd Type I (Wenckebach): Progressive PRI lengthening then DROPPED QRS
2nd Type II (Mobitz II): Fixed prolonged PRI then DROPPED QRS
3rd: AV dissociation: P waves NOT related to QRS, all P waves NOT followed by QRS = decreased Cardiac output
18
Q
What is the management of 1st, 2nd type 1 and 2, and 3rd degree AV blocks
A
1st: none, observe (may progress)
2nd type I (Wenckebach):
- Symptomatic: ATROPINE, epi +/- pacemaker
- Asymptomatic: observe +/- cardiac consult
2nd type II: ATROPINE OR TEMP. PACING, (progression to 3rd degree is common so PPM is definitive tx)
3rd:
- Acute/symptomatic: temporary pacing–> PPM
- Definitive tx: PPM
19
Q
Describe the appearance of Aflutter and rate
A
- “saw tooth” waves
2. Rate: 250-350bpm (no P waves but is usually REGULAR)
20
Q
Management of Atrial flutter
A
- Stable: Vagal, BB, or CCB
- Unstable: Direct current synchronized cardioversion
- Definitive tx: Radiofrequency ablation
*Anticoagulation use is similar to afib
21
Q
___ is the most common chronic arrhythmia
A
atrial fibrillation
*most patients are asymptomatic
22
Q
Why are people with atrial fibrillation at increase risk for stroke?
A
The ineffective quivering of the atria may cause thrombi (clots) to form, which can embolize and cause ischemic strokes
23
Q
Describe the 4 different types of Afib
A
- Paroxysmal: self terminating w/in 7 days (usually <24hrs) +/- recurrent
- Persistent: fails to self terminate, lasts >7 days (requires termination via medical or electrical)
- Permanent: persistent AF >1yr (refractory to cardioversion or cardioversion never tried)
- Lone: paroxysmal, persistent or permanent w/o evidence of heart disease
24
Q
Management of Stable AFib
A
- Rate control (usually preferred as initial management of symptomatic AF over rhythm control)
- BB: Metoprolol (cautious use in those w/ reactive airway dz**)
- CCB: Diltiazem*, verapamil (non-dihydropyridines)
- Digoxin: +/- use in elderly, **Preferred for rate control in pts w/ hypotension or CHF (not generally used in active patients) - Rhythm control
- Direct current synchronized cardioversion (DCC):
- Pharmacologic: Ibutilide, Flecainide, Sotalol, Amiodarone
- Radiofrequency ablation: PPM, cath-based ablation or surgical MAZE procedure
25
Direct current (synchronized) cardioversion (DCC) can be done for AFib if:
1. AF present >48 hrs OR
2. After 3-4 weeks of anticoagulation and a transesophageal echocardiogram (TEE) shows no atrial thrombi OR
3. Start IV heparin, cardiovert w/in 24 hrs and anticoagulation for 4 weeks
26
Management of unstable Afib
Direct current synchronized cardioversion (DCC)
27
All patients with non-valvular Afib should undergo what two things:
1. assessment of the risk of embolization via CHAD2DS2-VASc or CHADS2
* shown to reduce embolic risk by 70%
2. Determination benefits vs risks of anticoagulation via clinical judgment and discussion w/ patient
28
Describe the CHA2DS2-VASc Scoring Criteria for afib
1. CHF: 1
2. HTN: 1
3. Age 75 or older: 2
4. DM: 1
5. S: Stroke, TIA, thrombus hx: 2
6. V: Vascular dz (prior MI, aortic plaque, PAD): 1
7. A: Age 65-74: 1
8. S: Sex: female: 1
-2 or more= moderate to high risk= chronic oral anticoag. recommended
-1= low risk= consider risks/benefits
0= very low risk= no anticoag. needed
29
Describe types of anticoagulant agents
1. Non-vitamin K antagonist oral anticoagulants (NOAC): usually now preferred over warfarin in most cases due to similar or lower rates of major bleedig and less DDI and less drug monitoring
- Dabigatran: direct thrombin inhibitor
- Rivaroxaban, Apixaban, Edoxaban: factor Xa inhibitors
2. Warfarin
3. Dual Antiplatelet therapy: ASA + clopidogrel (anticoagulant monotherapy is superior to dual antiplatelet therapy)
30
What are Factor Xa inhibitors?
What are direct thrombin inhibitors?
Describe their MOA
Factor Xa inhibitors: Rivaroxaban (Xarelto), Apixiban (Eliquis), Edoxaban (Savaysa)--> selectively binds to antithrombin III)
Direct thrombin inhibitors: Dabigatran (Pradaxa)--> binds and inhibits thrombin
31
What are three contraindications to NOAC? (non-vitamin K antagonist oral anticoagulants)
1. Severe chronic kidney disease
2. HIV pts on potease inhibitor-based therapy
3. on CP450 inducing antiepileptic meds such as carbamazepine, phenytoin
32
What describe rate, rhythm, and EKG appearance for (p)SVT?
- HR >100
- Regular rhythm with narrow QRS
- P waves hard to discern due to rapid rate
33
Describe the 2 main types of pSVT
1. AVNRT: AV nodal reentry tachycardia: 2 pathways both within the AV node (slow and fast) **MC TYPE
2. AVRT: AV Reciprocating tachycardia: 1 pathway within the AV node and a second accessory pathway OUTSIDE the AV node ex. WPW and LGL
34
Describe the conduction patterns that result in Narrow complex tachycardia and wide complex tachycardia
Narrow complex tachy: Orthodromic (95%): Impulse goes down the normal AV node pathway first and returns via the accessory pathway in circles, perpetuating the rhythm
Wide complex tachy: Antidromic (5%): Impulse goes down the accessory pathway first and returns to the atria via the normal pathway (mimics VT)
35
Management of Stable Narrow Complex SVT vs Stable Wide complex SVT
Narrow Complex SVT:
1. Vagal maneuvers (vagus nerve stimulation releases acetylcholine = decrease HR)
2. Adenosine 1st line medical tx for SVT (terminates 90% of narrow complex SVT) **may cause bronchospasm for those w/ asthma/COPD
3. AV nodal blockers: BB or CCB
Wide Complex SVT:
1. Antiarrhythmics: ex. Amiodarone or Procainamide if WPW
36
Tx of unstable SVT (wide or narrow complex) and what is the definitive tx of SVT
1. direct current synchronized cardioversion
Definitive: Radiofrequency ablation
37
What rhythm?
- HR <100 and
- 3 or more P wave morphologies
Wandering atrial pacemaker: multiple ectopic atrial foci generated impulses that are conducted to the ventricles
38
What rhythm?
- HR >100 and
- 3 or more p wave morphologies
Multifocal atrial tachycardia
| *same as WAP but HR is >100
39
Multifocal Atrial Tachycardia (MAT) is commonly associated with ___ and is difficult to tx but usually use: ___
Severe COPD
Tx: CCB (Verapamil) or BB if LV fxn presereved
40
What 3 EKG findings are associated w/ WPW and what is WPW
1. Delta wave (slurred QRS upstroke)
2. Wide QRS (>0.12sec)
3. Short PRI
*accessory pathway (bundle of Kent) pre-excites the ventricles--> a type of of AVRT
41
Management of
- Stable WPW
- Unstable WPW
- Definitive management
1. Vagal maneuver
2. Antiarrhythmics ex. Class IA: Procainamide preferred***, amiodarone, flecainide
3. Avoid the use of AV nodal blockers (ABCD) in WPW****
Unstable: direct current synchronized cardioversion
Definitive: radiofrequency ablation
42
What Rhythm?
- Regular rhythm
- P waves inverted (negative) if present in leads where they are normally positive (I, II, aVF) or are not seen
- Classical associated w a narrow QRS
AV junctional dysrhythmias
*AV node/junction becomes the dominant pacemaker of the heart
43
MC rhythm seen w/ digitalis toxicity
AV junctional dysrhythmia
44
What are the 3 types of AV junctional dysrhythmias
1. Junctional rhythm: HR 40-60,
2. Accelerated Junctional: HR 60-100
3. Junctional tachycardia: HR >100
45
- Wide, bizarre QRS occurring earlier than expected.
- The T wave is in the opposite direction of the QRS usually
- Associated w a compensatory pause
PVC
*no tx usually needed
46
Ventricular tachycardia is considered:
3 or more consecutive PVCs at a rate >100bpm
| -Sustained VT= lasting 30 or more seconds
47
___ is a common predisposing condition for VT
Prolonged QT interval
48
Torsades De Pointes is most commonly due to ___
hypomagnesemia, hypokalemia
49
Management of the following VTs:
1. Stable sustained VT
2. Unstable VT w/ a pulse
3. Pulseless VT
4. Torsades de pointes:
1. Stable sustained VT: Antiarrhythmics (amiodarone, lidocaine)
2. Unstable VT w/ a pulse: Synchronized cardioversion
3. Pulseless VT: defibrillation (unsynchronized cardioversion) + CPR (tx as VF)
4. Torsades de pointes: IV magnesium
50
Management of VF
Unsynchronized cardioversion (defibrillation) + CPR
51
Management of PEA (pulseless electrical activity) or asystole
1. CPR
2. Epi
3. Checks for "shockable" rhythms every 2 min
52
```
Causes of increased jugular pressure
Increased JVP + ____ = ____
1. + Crackles/rales
2. + Normal pulmonary exam
3. + decreased breath sounds
```
1. + Crackles/rales: CHF
2. + Normal pulmonary exam: Pericardial (tamponade or constrictive pericarditis)
3. + decreased breath sounds: Tension pneumothorax
53
3 EKG signs of LVH w/ LV strain
1. ST elevation in right precordial leads (V1-V3)
2. Increase voltage
3. Asymmetric ST depressions and T wave inversions in the lateral leads (I, aVL, V5, V6)
54
Describe Brugada Syndrome EKG patterns
1. RBBB (often incomplete) in V1-V3
2. ST elevation V1-V3 (often downsloping)
3. T wave inversion in V1 and V2
4. +/- S wave in lateral leads (I, aVL, V5, V6)
55
Brugada Syndrome is
1. MC in ___
2. Associated with ___
3. Often caused by: ___
4. Management includes: ___
1. MC in Asian Males
2. Associated w/ syncope and sudden cardiac death from ventricular arrhythmias
3. Often caused by genetic disorder
4. Managed w/ AICD to prevent death from VF
56
Kussmaul's sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by
1. severe right-sided heart failure;
2. constrictive pericarditis or
3. right ventricular infarction.
57
A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of
distended neck veins- Cardiac compression will manifest with distended neck veins and cold clammy skin
58
What test is done to detect ventricular wall dysfunction
Cardiac nuclear scanning
59
PT-INR is a reflection of the ___ pathway clotting system. Coumadin interferes with Vitamin K synthesis which is needed in the manufacture of factors ___ which are part of that clotting pathway
extrinsic and common
factors II, VII, IX, X
2,7,9,10 (1972- Extrinsic)
60
What antiarrhythmic drugs can be associated with hyper- or hypothyroidism following long-term use?
amiodarone
61
What hypertensive emergency drugs has the potential for developing cyanide toxicity?
Sodium nitroprusside metabolization results in cyanide ion production. It can be treated with sodium thiosulfite, which combines with the cyanide ion to form thiocyanate, which is nontoxic
62
What beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors?
Metoprolol
63
What is the EKG manifestation of cardiac end-organ damage due to hypertension?
LVH
64
Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of __
3 years.
65
How do vagal maneuvers and carotid massage decrease HR in tachycarrhythmias?
baroreceptors sense increase carotid artery pressure--> reflexive decrease in HR
66
What is the equation for cardiac output
CO= SV X HR
67
What is pulsus paradoxus and when is it seen?
>10mmHg decline in SB with inspiration (palpable peripheral pulses disappear w/ inspiration)
EX: Cardiac tamponade and tension pneumothorax
68
Cautious use w/ IV nitro and morphine with what types of MIs and why?
R-sided (inferior and posterior MIs)
-Bc right side is more dependent on preload and SV to maintain CO and nitro and morphine decreases preload
69
SE of ACE inhibitors and why
1. can cause hyperkalemia bc they inhibit aldosterone which typically increases K+ excretion
2. Cough or angioedema bc they potentiate other vasodilators (ex. bradykinin)
*ARBs (angiotensin II receptor blockers) block the receptor for AGII but don't cause angioedema or cough
70
7 Risk factors for CAD
1. DM (worst)
2. Cig smoking (most important modifiable)
3. Hyperlipidemia
4. HTN
5. Age (M >45, F>55)
6. FHX 1st degree relative
7. Men
71
Describe the pathophysiology of atherosclerosis
1. Fatty streak formation: lipid deposition in WBC--> smooth muscle proliferation (forms streaks)
2. LDL enters endothelium in the fatty streaks and LDL becomes oxidized which attracts other WBCs
3. proliferating smooth muscle cells and CT makes "fibrous cap" and arterial lumen narrowing +/- calcification (stabilized plaque)
72
Arterial lumen is typically ____% narrowed when a patient becomes symptomatic to myocardial ischemia w/ exertion and ____% narrowed when symptomatic at rest
70% or more narrowed w/ exertion
>90% at rest
73
What is angina pectoris
substernal CP usually brought on by exertion (inadequate tissue perfusion due to decrease coronary blood supply and increased demand)
74
Describe common features of cardiac CP in stable angina
substernal, poorly localized, exertional, radiates to arm, teeth, lower jaw, back, typically UNDER 30 min, relieved w/ nitro or rest
**diaphoresis, numbess, N/V, fatigue
75
Resting EKG is normal in __% of patients with stable angina
50%
76
When is PTCA indicated for management of angina
1-2 vessel disease in nondiabetics NOT involving Left main CA and in whom LV fxn is normal/near normal
*restenosis is prevented with stents w/ drug-eluting properties
77
Indications for CABG
1. Left main coronary artery stenosis
2. Symptomatic or critical stenotic 3-vessel disease (>70% stenosis), 2 vessel disease in DM
3. Decreased LV EF <40%
78
What is the pharmacologic management of stable (chronic) angina
(and their MOA)
1. PRN Nitrates (increases O2 supply, reduces coronary spasm, and decreases demand by decreased preload venodilation)
2. BB (increase O2 supply by prolonging coronary artery filling times/diastolic time, and decreased O2 demand) **1st line
3. Statin
4. ASA (prevents platelet activation/aggregation by inhibiting cyclooxygenase--> decreased thromboxane A2 and inhibit prostaglandins)
Typical Regimen: ASA + SL nitro PRN + BB + statin
**CCB if BB can't be used or in prinzmetal angina: increase O2 supply and prevents ischemia induced coronary vasospasm
79
4 SE of Nitrates
And 3 contraindications to nitrates
1. HA
2. flushing
3. hypotension
4. tachyphylaxis after 24 hrs
CI: SBP <90, RV infarction, Use of sildenafil and other PDE-5 inhibitors
80
What medication is the 1st line drug for chronic management in stable (chronic) angina
Beta blockers - reduces mortality, symptoms and prevents ischemic occurrences)
81
What BB are cardioselective (B1) and what ones are nonselective?
Selective (B1): Metoprolol and Atenolol
Nonselective: Propranolol, Nadolol
82
What medication is indicated for prinzmetal angina?
CCB
| nondihydropyridines: Diltiazem or verapamil (long acing)
83
Who are most likely to suffer from a "Silent or atypical MI". what are usually the presenting sxs?
1. women
2. Elderly
3. Diabetics
4. obese
sx: abdominal pain, jaw pain, dyspnea w/o CP
84
STEMI is defined as:
ST elevations 1mm or more in 2 or more anatomically contiguous leads +/- reciprocal changes in opposite leads
**New LBBB is considered STEMI equivalent
85
Cardiac markers for MI include:
-Standard is usually __ sets every ___
-describe when these markers appear, peak and return to baseline
1. Troponin- most sensitive and specific**
-appear 4-8hr
-peaks: 12-24hr
-Returns to baseline: 7-10 days
2. CK/CK-MB
-appear 4-6hr
-peaks: 12-24hr
-Returns to baseline: 3-4days
3. Myoglobin
-appear 4-8 hr
-peaks: 12-24 hr
returns to baseline 1 day
*3 sets q8hrs
86
Management of unstable angina or NSTEMI
1). MONA= chewable ASA, NTG, oxygen (at least 4L) +
obtain cardiac markers and EKG
**morphine ONLY if NTG not relieving pain or pt on PDE5 inhibitor
2) . If EKG shows ST depressions and/or T wave inversions: know its UA or NSTEMI
3) . - cardiac enzymes = UA, + cardiac enzymes = NSTEMI
4) .Start Antithrombotic therapy: HEPARIN (LMWH or UFH)
* *consider plavix (ADP inhibitors) or GP IIb/IIIa inhibitors
5) . Then consider adjunctive anti-ischemic
* **BB
6). assess TIMI risk score (estimates mortality for these pts)
87
Compare the MOA of
- Unfractionated heparin:
- LMWH (enoxaparin):
- Fondaparinux:
Heparin (UFHLMWH): inhibits thrombin by activating antithrombin III and inhibits factor Xa
- (LMWH more specific to Factor Xa than UFH)
-Fondaparinux: direct factor Xa inhibitors (binds to and enhances antithrombin)- no direct effects on thrombin
88
Management of STEMI
1) . MONA: morphine, oxygen, nitro, ASA (NO NTG or MORPHINE IN INFERIOR/POST MI) + EKG and cardiac enzymes
* *Morphine only given if pain not relieved by NTG or pt on PDE5 inhibitor
2). EKG shows ST elevation
3) . Give Antithrombotics: Heparin (LMWH or UFH)
* *consider plavix or GP IIb/IIIa
4). Consider adjunctive therapy: BB
5) . REPERFUSION (most important) w/in 12 hrs of sxs onset (PCI or thrombolytics w/ rTPA)
* *DOOR TO PCI <90 mins, DOOR TO FIBRINOLYTICS , 30 mins
6). long term: ACEIs (slows the progression of CHF by decreasing ventricular remodeling)
89
PCI is best w/in ___ hours of sx onset
3 hours (esp c/n 90min)
- Door to thrombolyics: w/in 30 min
- Door to PCI: w/in 90 mins (+/- 30min)
90
Management of Cocaine-induced MI
CCB = treatment of choice
+ ASA, NTG, O2, Heparin, anxiolytics
*AVOID BB bc of unopposed alpha vasoconstriction/vasospasm
91
What is Dressler Syndrome
1. post MI pericarditis
2. + fever
3. + pulmonary infiltrates
92
What is variant (prinzmetal) angina and how is it diagnosed?
sxs such as rest angina due to coronary artery spasm w/ transient ST elevations (usually w/o MI)
- CP usually nonexertional, often at rest
- DX: EKG +/- transient ST elevations
* angiography vasospasm w/ IV Ergonovine administration
*Sx and ST elevations resolve w/ CCB* or nitro
93
What is the drug of choice to tx variant (prinzmetal) angina?
CCB* and nitro PRN
| **NO BB**
94
What is cocaine induced CP/MI?
coronary artery vasospasm due to cocaine/s activation of sympathetic nervous system and alpha-1 receptors causing vasoconstriction of arteries
***MI can occur if vasoconstriction is prolonged
95
Most common cause of CHF
CAD
96
What is the chief adverse effect of thiazide diuretics?
-hypokalemia**
Also causes
-hyponatremia
-retention of Ca++
97
___ is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium.
Patent ductus arteriosus
98
___ leads to enlargement of the left atrium, which is the major predisposing risk factor for the development of atrial fibrillation.
Mitral stenosis
99
__ and __ are the most common drugs that may cause a lupus-like eruption.
Procainamide and hydralazine
100
Which electrolyte abnormality is associated with an increase in the risk for digoxin toxicity?
hypokalemia
*Decreased concentration of potassium results in the increased activity of cardiac glycosides by increasing tissue binding and decreasing renal excretion of digoxin. Potassium loss is the only significant electrolyte abnormality that significantly affects digoxin metabolism.
101
___ is characterized by a holosystolic murmur at the lower left sternal border.
Ventricular septal defect
102
___ is characterized by a systolic thrill at the left sternal border with a systolic ejection murmur that may or may not have an associated systolic click.
Tetralogy of Fallot
103
__ is associated with a systolic ejection click or a short systolic murmur at the left sternal border.
Coarctation of the aorta
104
An electrocardiogram (ECG) shows a sinus rhythm with varying T wave heights, axis changes every other beat and a wandering baseline. Which of the following is most likely the diagnosis?
Pericardial effusion
* electrical alternans`
105
Who is most at risk for developing primary HTN
Black non-Hispanic adults have the highest risk of hypertension.
106
What is the optimal INR for a patient with a mechanical mitral valve prosthesis on warfarin (Coumadin)?
2.5-3.5
107
Coronary artery perfusion occurs primarily during __
diastole
108
Pulmonary capillary wedge pressure indirectly measures which of the following?
left atrial filling pressure
109
Causes of left sided heart failure
1. CAD **
2. HTN**
3. Valvular dz
4. cardiomyopathies
110
Causes of Right sided heart failure
1. Left sided heart failure**
2. Pulmonary dz** (COPD, PHTN)
3. Mitral stenosis
111
What is the difference btwn systolic and diastolic HF
Systolic: decreased EF +/- S3 gallop. (MC form)
Diastolic: normal EF +/- S4 gallop = forced atrial contraction into a stiff ventricle (associated w/ normal cardiac size)
112
Causes of systolic HF
1. Post MI
2. dilated cardiomyopathy
3. myocarditis
113
Causes of diastolic HF
1. HTN
2. LVH
3. Elderly
4. Valvular dz
5. cardiomyopathies
6. Constrictive pericarditis
114
Compare and contrast diastolic and systolic HF
Diastolic: NORMAL/increased EF, THICK ventriular walls, SMALL LV chamber, +S4
(thick and stiff)
Systolic: DECREASED EF, THIN venticular walls, DILATED LV chamber, S3
115
Describe the NY Heart Association Functional Class of Heart Failure
Class I: No sx or physical limitations
Class II: Mild sx (dyspnea or angina), slight limitation
Class III: sx w/ limitation w/ activity, comfortable at rest
Class IV: sx at rest w/ severe limitations
116
Describe the pathophysiology of heart failure
Initial insult leads to **Increased Afterload, increased preload and/or decreased contractility (heart tries to compensate for a short term)
Compensation includes:
1. SNS activation
2. Myocyte hypertrophy/remodeling
3. RAAS activation: fluid overload, ventricular remodeling/hypertrophy===> CHF
117
Clinical Manifestations of Left sided HF
* *Increase pulmonary venous pressure from fluid backing up into the lungs
1. Dyspnea (MC SX)
2. Pulmonary congestions (rales, rhonchi)
3. Pink frothy sputum w/ nonproductive cough
4. HTN
5. Cheyne-Stokes breathing (deepr faster w/ gradual decrease and peroids of apnea)
6. S3 (SHF) or S4 (DHF)
7. Increased adrenergic activation (dusky, pale, diaphoresis)
118
MC cause of transudative pleural effusions
CHF (left sided)
119
Clinical manifestations of right sided HF
* *Increase systemic venous pressure--> signs of systemic fluid retention
1. Peripheral edema
2. Increased JVP/jugular venous distention
3. GI/Hepatic congestion- hepatosplenomegaly, anorexia
120
How do you diagnose HF
1. Echo** (measures LV function and EF)
2. CXR: esp. for congestive HF
3. Increased BNP: ventricles release BNP during volume overload
121
What is the most important determinant of prognosis for HF
EF
122
What is a normal and abnormal EF
Normal: 55-60%
| EF less than 35%: increased mortality, Needs a cardioverter defibrillator in place to reduce mortality
123
What is the initial management of HF
1. ACEI (1st line in HF) + diuretic (for sx)
2. Add BB
3. Add Hydralazine + NTG
4. Digoxin (add earlier if Afib)
*ACEI>BB best 2 drugs for decreased mortality
124
Lifestyle changes to help manage HF
1. Salt restriction <2g/d
2. Fluid restriction <2L/d
3. exercise
4. smoking cessation
125
HF meds to decrease afterload
* vasodilators
1. ACEI
2. ARBs
3. BB
4. Hydralazine + Nitrates combo
126
SE of ACEI
1. hypotension
2. Renal insufficiency
3. hyperkalemia
4. cough and angioedema (due to increased bradykinin)
*CI in pregnancy
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HF meds that decrease preload
1. Diuretics
2. HCTZ
3. Metolazone
128
What are loop diuretics
1. furosemide
2. bumetanide
3. torsemide
129
What type of diuretic is most effective tx for sx for mild-moderate CHF
loop diuretics
130
SE of loop diuretics
1. volume depletion
2. hypOkalemia
3. hypOcalcemia
4. hypOnatremia
5. HYPERglycemia
6. HYPERuricemia
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SE of potassium sparing diuretics
1. HYPERkalemia
| 2. gynecomastia w/ spironolactone
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___ diuretic is associated w/ decreased mortality and added in severe CHF
spironolactone
133
Positive inotropes HF meds
(sympathomimetics)
1. Digoxin
2. Dobutamine
3. Dopamine
134
When is digoxin indicated
HF with Afib
| *decrease hospitalizations and sx but NO mortality benefit w/ digoxin**
135
What meds decrease mortality in HF
1. ACEI
2. ARBs
3. BB
4. Nitrates + hydralazine
5. spironolactone
136
___ meds are not generally sued in systolic HF
CCB
137
what is congestive heart failure
acute decompensated HF w/ worsening of baseline sx, pulmonary congestion
138
CXR findings of CHF
1. Cephalization of vessels
2. Kerley B lines (short linear markings at lung periphery)
3. Peribronchial cuffing
4. Cardiomegaly
5. Perihilar congestion
139
*Management of acute pulmonary edema/CHF
"LMNOP"
- Lasix (removes fluid and relieves sx)
- Morphine (decreases preload and heart strain)
- Nitrates (venodilator that reduces preload and afterload)
- Oxygen
- Position (upright to decrease venous return)
140
What is the use of echocardiogram in pericardititis
used to assess for complications of acute pericarditis (effusion or tamponade)
141
Tx of pericardial effusion
1. Observe if small and no evidence of tamponade
2. tx underlying cause
3. +/- pericardiocentesis if tamponade or large effusion
142
What is pulsus paradoxus
exaggerated>10mmHg decrease in systolic BP w/ inspiration and pulses decrease w/ inspiration
143
What is constrictive pericarditis
Thickened, fibrotic, calcified pericardium (from chronic pericarditits and inflammation) that restricts ventricular diastolic filling-> increases venous pressure and decreases stroke volume = decreased CO
144
Clinical manifestations of constrictive pericardititis
1. Dyspnea (MC SX)
2. Right sided HF sx (increased JVD, peripheral edema)
3. Kussmaul's sign* (increased JVD during inspiration)
4. pericardial knock*- high pitched 3rd heart sound due to sudden cessation of ventricular filling
145
Management of constrictive pericarditits
pericardiectomy is definitive tx*
| -diuretics may be used for symptomatic control
146
how to diagnose stable angina
clinical + testing
ECG: initial test of choice (normal in 50%, ST depression is classic finding)
stress testing: most important noninvasive test (stress ECG, stress echo, perfusion imaging)
coronary angiography is definitive (location and extent of CAD)
147
Stress ECG: indications, positive findings, limitations
indications: useful only if baseline EKG is normal
findings: ECG changes (ST depressions, T wave inversions) or reproduction of sxs
Limitations: does not locate the area of ischemia
148
stress ECHO: indications, how to perform, contraindications
indications: can be used if baseline EKG is abnormal, gives info based on location and extent of ischemia
can be done with exercise or positive inotrope med (dopamine or dobutamine)
contraindications to meds: severe LV outflow obstruction (aortic stenosis), ventricular arrhythmia, recent MI (1-3d), severe systemic HTN
149
myocardial perfusion imaging: indications , how to perform, contraindications
uses thallium or technetium for imaging
indications: useful if baseline ECG is abnormal, gives info regarding location and extent of ischemia
can be done with exercise or vasodilator med (adenosine or dipyridamole)
contraindications to meds: bronchospastic disease, hypotension, AV blocks
150
three indications to perform coronary cath
1) . confirm/exclude CAD in pts with CAD sxs
2) . confirm/exclude CAD in pts with negative noninvasive testing for CAD
3) . patients who may possibly need revascularization
151
when is aspirin used for primary prevention of atherosclerotic CV disease?
select patients aged 40-70 who are not at an increased risk of bleeding
152
difference between stable and unstable angina
UNSTABLE if:
1) . first occurrence of angina
2) . increase in anginal intensity (no longer relieved by rest or NTG)
3) . increase in frequency
153
what is triad of RV infarction?
increased JVP + clear lungs + positive Kussmaul sign (inc JVP with inspiration)
**inferior MI
154
what are q waves a sign of?
INFARCTED tissue
| *whereas ST depression or T wave inversions are signs of ischemia
155
what is the ECG progression of a STEMI?
1) . hyperacute T waves
2) . ST elevations
3) . q waves
156
how to treat pts who onset of chest pain sxs began over 12 hrs ago OR low TIMI without current chest pain
ASA (+/- Plavix for 9 months), statin, BB, ACEI, NTG PRN
