Step Up- CVD Flashcards
Features of stable angina
Brought on by exertion
lessened by rest
does not change with position
lasts less than 15 min
pressure, heaviness, squeezing
Exertional angina with clean cath. Dx? What will nuclear stress test show?
Syndrome x
Nuclear stress test will show ischemia
How does adenosine work in a cardiac stress test?
Because diseased vessels are already maximally dilated, dilation of other vessels caruses shunting of bloodflow away from diseased vessel.
Main indications for CABG?
3 vessel disease with >70% stenosis in each
Left main disease with >50% stenosis
LV dysfunction
Characteristics of unstable angina
angina at rest
chronic angina with increasing frequency, duration or intensity
New onset angina that is worsening
How to differentiate unstable angina and NSTEMI
Cardiac enzymes
(beacuase both lack ECG changes)
Tx of Unstable angina/NSTEMI
- Aspirin (clopidegrel shown to be superior in CURE trial)
- B Blocker
- LMWH for at least 2 days (enoxaparin is best)
- Nitrates
- O2 if hypoxic
- Morphine
- Replace electrolytes
- Schedule cardiac cath
Classic time for prinzmetal angina to occur?
-At night
How does a RV infarct present?
- Inferior ECG changes
- Hypotension
- Elevated jugular venous pressure
- hepatomegaly
- CLEAR lungs
Earliest ECG change in MI?
Peaking T waves
Which cardiac enzymes are the first to rise? Last to return to normal?
- Troponin I and T increase within 3-5hr and peak at 24-48
- CK-MB peaks first at about 24
- Trp I and T stay longer– 7-10 days
Which Tx for MI has been shown to reduce mortality?
- Aspirin (or eq. antiplatelet)
- B Blocker
- ACE inhibitor
Antiplatelet therapy for ppl who receieve a stent (bare metal and drug eluting)?
- at least 6mo with bare metal
- at least 12mo with drug eluting
Dual antiplatelet with aspirin and clopidogrel
Pt with complete heart block, likely locations of MI? Which is worse?
Anterior or inferior
Anterior has worse prognosis
A re-elevation in this enzyme is more specific for re-infarction dur to its rapid return to basseline…
CK-Mb
Ventricular free wall rupture generally occurs within this time frame following MI…
First 14 days
Septal rupture occurs within this time frame…
10 days
Treatment of acute pericarditis following MI?
Aspirin (should already be on)
NSAIDs and corticosteroids are contraindicated! (prevents myocardial scar formation)
Patient 3 months post MI with fever, malaise, pericarditis, pleuritis, and leukocytosis…Dx?
Dressler syndrome–autoimmune phenomenon following MI
Tx- aspirin or ibuprofen
Causes of high output cardiac failure
- Think: anything that causes the heart to have to work harder to meet the oxygen and metabolic needs
- chronic anemia, pregnancy, hyperthyroidism, AV fistula, wet beriberi, paget disease of bone, mitral regurg, aortic insuffciency
A patient with stable angina presents with new onset chest pain that will not relieve with rest. What are the first steps to management of this patient?
- ECG and cardiac enzymes
- give aspirin
- begin IV heparin or LMWH
Causes of systolic heart failure
- Ischemic heart disease
- cardiomyopathy (hypertensive)
- myocarditis
- Less common things like radiation, hemochromatosis, thyroid dz)
Casues of diastolic dysfunction
- HTN leading to LVH (most common)
- valvular disease
- Restrictive cardiomyopathy (sarcoid, amyloid, hemochomatosis)
Cause of S3 gallop
rapid filling into a noncomplaint LV
Cause of S4
atrial systole ejected into a non-compliant, stiff LV
-TEN-nes-see
Do diuretics reduce mortality in CHF?
NO
Symtomatic relief
-Spironolactone is shown to prolong survival in select patients
Initial combination treatment of choice in CHF…
ACEi with a diuretic and beta blocker
What drug is shown to reduce mortality and prolong survival in CHF?
ACEi
Digitalis is indicated in which patients with CHF?
Those with EF <40% and who are symtomatic
Patient with CHF presents with nausea, vomiting, AV block and disorientation…
Dig tox
Which patient population is at highest risk for developing multifocal atrial tach?
Those with severe pulmonary disease
What is the difference between MAT and wandering atrial pacemaker?
MAT has rate >100
Most common arrythmia associated with dig toxicity?
paroxysmal atrial tachycardia with 2:1 block
Should NSVT be evaluated? Why?
Yes becuase it can indicate LV dysfunction and or Ischemia
PR interval >0.20s with QRS following each P
First degree AV block
Progressive lengthening of the PR interval until a P wave fails to conduct
Mobitz Type 1
Second degree type 1 block
Wenckebach
P randomly does not conduct and sometimes occurs in patterns
Second degree type II
Mobitz II
BAD– can degenerate into complete block
Clinical features of dilated cardiomyopathy
S3, S4
mitral or tricuspid insufficiency
Cardiomegaly
Arrythmias
Clinical signs of HOCOM with: valsalva, hand grip, squat, lying down, leg raise, standing…
Valsalva, standing, decreased venous return, arterial dilators and BP drugs- worsens
Lying down, hand grip, squatting- gets better
Anything that decrease EDLVP will increase the dynamic obstruction
Carotid pulse in a person with HOCOM
Bisferious
Fist line drug in Tx and prevention of progression of HOCOM
B-blocker
Low voltages on ECG with speckled appearence on echo
amyloidosis
Young male with elevated ESR, trending cardiac markers, and previous URI
myocarditis– tx is supportive
What are the common viral causes of acute pericarditis?
Coxsackievirus
Echovirus
adenovirus
EBV
Influensza
What is a cause of pericarditis associated with kidney disease?
Uremia
Pain of pericarditis is relieved by…
Sitting forward
Mainstay of treatment of acute pericarditis?
NSAIDs
Cholchicine
What is kussmaul sign? How does it relate to constrictive percarditis?
Occurs when JVD fails to decrease during inspiration.
Caused by resitriced filling of the heart during diastole.
What is pulsus paradoxus?
Exagerated decreased of pulse strength during inspiration.
>10mmHg
Cardiac tamponade
Opening snap followed by a low pitch diastolic rumble
Mitral stenosis
Tx of acute mitral regurg?
Afterload reduction with vasodilators
What happens to MVP murmur when standing of valsalva?
How about squatting?
Standing and valsalva– increases due to LV reduction in size
Squatting– decreases due to increase in LV size
Criteria for rhematic heart disease (major)?
J- joints: migratory polyarthritis
O- Heart (shape)
N- Subcutaneous nodules
E- Erythema marginatum
S- Sydenham corea
Organism most commonly causing infection to native valve
S. viridans
and HACEK group
Most common cause of prosthetic valve endocarditis
S. epidermidis more commonly that S. aureus (except IVDA)
Duke criteria for endocarditis
Major: Sustained bacteremia, New regurgitant valve
Minor: Predisposition, fever, vascular phenomenon, immune phenomena, + blood culture, +echo
Aortic valve with small warty vegitations on them in patient with SLE
Libeman-sacks enodcarditis
Large pulmonary arteries and + bubble study
ASD
Most common cardiac defect?
VSD
Harsh, blowing systolic mumur heard at 4th intercostal decreasing with valsalva and handgrip…
VSD
Congenital disease associated with coarctation of aorta?
Turner syndrome
This maintains a ductus areteriosus
Prostaglandin and low O2 tension
Drug that closes PDA? Drug that keeps open? Why keep open?
Close: Indomethacin
Open: Misoprostol (Transposition of great vessels)
PRES Syndrome
Posterior reversible encephalopathy syndrome
- Hypertensive patient with cerebral edema
- Due to loss of autoregulation of cerebral vascularture
How much to lower BP in HTN emergency in first 1-2hr?
no more than 25%
Type A v type B aortic dissection…
Type A- Proximal
Type B- Distal to subclavian A.
Goal in Tx of aortic dissection?
Lower BP and give B-blocker
Bilateral leg pain, impotence, and absent lower extremity pulses…
Leriche’s syndrome
occlusion of the distal aorta just above iliac bifurcation
PDE inhibitor used in PAD to reduce claudication
Cilostazol
phlegmasia cerula dolens
post DVT, severe leg edema and vascular compromise occurs
Appropriate PTT and aPTT for DVT on heparin
PTT 1.5 to 2x the aPTT
Non-cyanotic congenital heart lesions
ASD
PDA
VSD
“The 3 D’s”
