Pgs 1 - 24 Flashcards
Cardiovascular Medicine
Typical Angina includes:
Substernal chest pain with exertion and relief with rest or nitroglycerin
Atypical Symptoms:
Exertional dyspnea, fatigue, nausea and vomiting
Signs of cardiac ischemia include:
New MR murmur and S3 and S4 gallops
ST-elevation equivalents
New LBBB or Posterior MI (tall R waves and ST depressions in V1 - V3
In patients with unstable angina/NSTEMI, immediate angiography is indicated if any of the following are present:
Hemodynamic instabillity Heart Failure Recurrent rest angina despite therapy New or worsening MR murmur Sustained VT
TIMI Risk score 0 - 2
Low Risk
TIMI Risk Score 3 - 7
Intermediate to high risk
TIMI low risk management
Begin Aspirin, B-blocker, nitrates, heparin, statin, clopidogrel.
Predischarge stress test and angiography if testing reveals significant myocardial ischemia
TIMI intermediate to high risk management
Begin Aspirin, B-blocker, nitrates, heparin, statin, clopidogrel, and early angiography
Cardiac catheterization is indicated for patients with the following post-MI stress test results:
Exercise-induced ST-segment depression or elevation
Inability to achieve 5 METs during testing
Inability to increase SBP by 10 - 30 mm Hg
Inability to exercise (arthritis)
Other causes of ST-segment elevation:
Acute pericarditis LV aneurysm Takotsubo (stress) cardiomyopathy Coronary vasospasm (prinzmetal angina) Acute Stroke Normal variant
Relative contraindication to thrombolytic agents?
BP > 180/110 mm Hg on presentation
CABG is indicated acutely for STEMI in the presence of?
Thrombolytic PCI failure or mechanical complications (papillary muscle rupture, VSD, free wall rupture).
Patients with right ventricular/posterior infarction may present with?
Hypotension or may develop hypotension following administration of nitroglycerin or morphine.
Signs and symptoms of right ventricular/posterior infarction?
JVD with clear lungs, hypotension, tachycardia
Most predictive ECG finding in right ventricular/posterior infarction?
St-segment elevation on right-sided ECG lead V4R
Initial management of patients with right ventricular/posterior infarction?
IV fluids
Patients with papillary muscle rupture and VSD should be stabilized with an?
Intra-aortic balloon pump, afterload reduction with sodium nitroprusside, and diuretics followed by emergency surgical intervention.
ICDs are also indicated in post-MI patients meeting all of the following criteria:
> 40 days since MI
LVEF < or = to 35% and NYHA functional class II or III or LVEF < or = to 30% and NYHA functional class I
> 3 months since PCI or CABG
ACEI or ARB is indicated post MI at time of discharge in patients with?
LV systolic dysfunction, hypertension, diabetes, or kidney disease
Stable angina pectoris is defined as
Stable anginal symptoms of at least 2 months duration precipitated by exertion or stress and relieved by rest
In patients with chronic stable angina, stress testing is most useful in patients with?
An intermediate pretest probability of CAD (>10% or <90%)
Pretest probability is based on?
Patients age, sex, and symptoms; risk factors for CAD; and ECG findings
Indications for Exercise ECG with myocardial perfusion imaging or exercise ECHO?
Patients who can Exercise Pre-excitation (WPW) Pattern > 1 mm ST depression Previous CABG or PCI LBBB LV hypertrophy Digoxin use
Select coronary angiography for patients with high pretest probability of disease or:
LV dysfunction
Class III or IV angina despite therapy
Highly positive stress or imaging test
High pretest probability of left main or three-vessel CAD (a Duke treadmill score < or = to - 11)
Uncertain diagnosis after noninvasive testing
History of surviving sudden cardiac death
Suspected coronary spasm
CCB use in patients with chronic stable angina
Are first line therapy for patients with absolute contraindications to B-blockers.
In the setting of continued angina despite optimal doses of B-blockers and nitrates, CCBs can be added.
Avoid short acting CCB
Are Nitrates as effective as CCBs and BBs in reducing Angina?
Yes
Prevent nitrate tachyphylaxis by:
Establishing a nitrate-free period of 8 - 12 hrs per day (typically overnight), during which nitrates are not used.
When should Ranolazine be considered in patients with chronic stable angina?
Patients who remain symptomatic despite optimal doses of BB, CCB, and nitrates
ACEI is a cardioprotective drug that:
reduces cardiovascular and all-cause mortality in patients with diabetes, hypertension, CKD, LVEF < or = to 40%, HF, or a history of MI.
NHYA Class I
Structural disease but no symptoms
NYHA Class II
Symptomatic; slight limitation of physical activity
NYHA Class III
Symptomatic; marked limitation of physical activity
NYHA Class IV
Inability to perfom any physical activity without symptoms
Summarize the BNP level
BNP > 400 is compatible with HF
BNP < 100 effectively excludes HF as a cause of acute dyspnea
Endomyocardial biopsy in testing for HF is rarely indicated but can assist in the diagnosis of
Giant cell myocarditis, amyloidosis, Hemochromatosis
What may falsely elevate the BNP?
Kidney failure, older age, female sex
What reduces the BNP?
Obesity
When is Hydralazine plus nitrates used in treatment of HFrEF?
Given in addition to standard therapy for NYHA class III-IV and EF < 40% in black and select nonblack patients (low output syndrome, hypertension) to reduce mortality.
For patients who cannot tolerate ACEI or ARBS
When are aldosterone antagonists used in treatment of HFrEF?
NYHA class III - IV HF to reduce mortality
When is digitalis used in treatment of HFrEF?
Predominantly in patients who continue to experience symptoms despite guideline-directed medical therapy
When is Ivabradine used in treatment of HFrEF?
EF < or = to 35% who are in sinus rhythme with a HR > or = to 70/min
When is Valsartan-sacubitril used in treatment of HFrEF?
Substitute for an ACEI or ARB in HFrEF (NYHA class II or III) in patients who have tolerated ACEI or ARB therapy
When is ICD placement used in treatment of HFrEF?
For ischemic and nonischemic cardiomyopathy in patients with and EF < 35% and NYHA functional class II - III or with an EF < 30% and NYHA functional class I
For NYHA class II - III symptoms
Cardiac resynchronization therapy used in treatment of HFrEF?
For NYHA class II - IV, LVEF < 35%, and LBBB with QRS duration > 150 ms
Dilated cardiomyopathy is characterized by?
Dilation and reduced function of one or both ventricles manifesting as HF, arrhythmias and sudden death.
Most common cause of dilated cardiomyopathy?
Idiopathic dilated cardiomyopathy (50%)
Treatment for dilated cardiomyopathy?
Reversal of the underlying cause (alcohol, drug, tachycardia-mediated cardiomyopathies)
Standard medical therapy for HF
