Step Up To Medicine - Cardio Flashcards
CAD have have what clinical presentation?
Asymptomatic Stable angina pectoris USA pectoris MI (NSTEMI, STEMI) Sudden cardiac death
LDL goal in pts w CAD?
<100
Describe typical anginal chest pain?
Substernal
Worse w exertion
Better w rest/nitro
Best test for chest pain
ECG
When should you use a stress test (stable angina)
Confirm dx of angina
Eval response of therapy
ID high risk pts
When is a stress test considered positive?
ST depression
Chest pain
HOTN
Arrhythmias
Standard of care for stable angina?
ASA
B-blocker
Nitrates (chest pain)
SE of nitrates?
HA
Orthostatic HOTN
Tolerance
Syncope
COURAGE trial?
No difference between PCI (bare metal) or max medical management for stable angina
PCI sciency name
Angioplasty
What is acute coronary syndrome?
Clnical manafestation of athersclerotic plaque rupture and coronary occlusion
Usually refers to USA, NSTEMI, STEMI
What does stress test identify?
- hint this is a limitation
Flow limiting high-grade lesions
- thus can miss an MI (its an acute rupture of plaque)
How to differentiate USA and MI?
Presentation is the same, you must look at cardiac markers and EKG findings
Essence trial?
Found that enoxaparin was greater than heparin for
- risk of death
- recurrent angina
- less need for PCI
When is fibrinolysis useful?
Only in STEMI when you cant get to PCI
- not used for USA
CARE trial?
Pt w hx of MI who took statin
- death reduced 24%
- stroke reduced 31%
- CABAGE reduced 27%
Suspect MI if combination of?
Substernal chest pain >30 min and Diaphoresis strongly suggest MI
Who doesnt get Nitro?
Right ventricular infarct
- inferior ECG changes
- HOTN
- elevated JVP
- hepatomegaly
- clear lungs
Its preload dependent - they will experience cardiovascular collapse
Which is worse STEMI or NSTEMI?
STEMI = infact 75% of time NSTEMI = infarct 25% of time
How are troponins monitored?
Q 8 hrs x 3 samples
- higher peak and longer enzymes are high more sever the myocardial injury is
- worse prognosis
Only agents shown to reduce mortality in MI pts?
ASA
B-blocker
ACEI
CAPRICORN trial?
The b-blocker carvediol reduces risk of death in post MI LV dysfunction
Meds indicated for MI?
O2 Nitro B-blocker ASA Morphine ACEI IV heparin
Best test if pt developes recurrent chest pain while in the hospital (for their MI)
CK-MB is the most helpful
Heparin is for STEMI and NSTEMI, when do you not use it?
Stable angina
If pt is treated conservatively for UA/NSTEMI, then need what before discharge?
stress test to see if they need angiography (cath)
MI pts have elevated risk for?
Stroke (during the next 5 yrs)
- the lower the EF and older thept - Higher risk of stroke
MCC of death following MI?
Ventricular arrhythmia
- Vtach
- VFib
Post MI all pts need to go home with?
ASA
B-blocker
statin
ACEI
If you suspect cardiac pain you should give?
Nytro and asa
MCC of noncardiac chest pain?
GI d/o
Non cardiac pain that may respond to nitro?
Esophagela spasm
- still unlikely
If pain changes w respiration rate (pleuritic), body position, or TTP to chest wall?
cardiac cause is highly unlikely
Pt has chronic stable angina and presents w symptoms of USA you should?
ECG and troponin
Give ASA
IV heparin
Which presents first, systolic or diastolic dysfunction?
Usually its simultaneous
Tests to order for new CHF?
cxr ECG Troponin - r/o MI CBC - anemia Echo - r/o pericardial effusion
Common treatable cause of CHF?
HTN - goal is to reduce preload and afterload
RALES trial?
Showed spironolactone reduces morbidity and mortality in pts w class III, IV HF - CI in renal failure
Things to monitor in CHF pt?
Weight (water gain) Exercise tolerance Lab values: - electrolytes - potassium - BUN - creatinine - serum digoxin
Standard tx for CHF?
Loop diuretic
ACEI
B-blocker
Maybes:
- digoxin
- hydralazine/nitrate
- spironolactone
MCC of death in CHF?
Sudden death from ventricular arrhythmias
- ischemia provokes ventricular arrhythmias
COMET trial?
Carvediol best B-blocker for CHF
Meds that do and do not lower mortality in systolic HF’?
Do reduce mortality
- ACEI/ARB
- B-blocker
- Spironolactone (aldosterone agonists)
- Hydralazine+nitrate
do not (symptoms only)q
- loop diuretics
- digoxin
Signs of digoxin toxicity?
GI: N/V, anorexia
Cardiac: ectropic (ventricular) beats, AV block, AFib
CNS: visual disturbances, disorientation
What drug plays no role in CHF?
CCB - may rause mortality
However i f you need more control of other shit (HTN) you can use
- amlodipine
- felodipine
5 yr mortality for CHF pts?
50%
CAST I and CAST II trial?
Antiarrhythmic drugs to suppress PVCs after MI increase death
Types of PVC’s?
couplet - 2 in a row
Bigeminy - sinus beat followed by PVC
Trigeminy - 2 sinus beats followed by PVC
Pts in Afib w underlying heart disease have?
High risk of embolization and hemodynamic compromise (death)
Treatment of Afib and Aflutter?
Control ventricular rate
Restore NSR
Assess need for anticoagulation
AFFIRM trial?
Rate control is superior to rhythm control in treatment of Afib
differentiating source of arrhythmias by QRS?A
Narrow QRS: above level of AV node
Wide QRS: outside normal conduction system
- Supraventricular
- HIS-purkinge systems
S/e of adenosine?
- HA
- Flushing
- SOB
- Chest pressure
- Nausea
What causes 75% of cardiac arrest?
Vtac
VFib
Torsades de points?
Rapid polymorphic VT
Causes - prolonged QT interval
- congenital QT
- TCA
- anticholinergics
- electrolytes
- ischemia
Tx: iv magnesium and fix prob
When is PVC and VT especially worrisome?
Pt w underlying heart disease
- LV dysfunction
Risk of Sudden Death
If a pt has wide QRS tachycardia you should suspect?
VT
Best treatment for pt w underlying heart disease and non sustained VT?
Implantable defibrillator
Difference between cardiac arrest and SCD?
Cardiac arrest
- sudden loss of cardiac output,
- potentially reversible
Sudden cardiac death
- unexpected death w/in 1 hr of symptom onset
Can drugs convert VFib?
Not alone
- need defib, CPR and epi
Does defib work for asystole?
Nope they need CPR and Epi
What is PEA?
Pulseless electrical activity
- monitor shows stuff but no pulse found
Which heart blocks requrie pacemaker?
Second degree mobitz type II
Third degree
Standing, valsalva and leg raise diminish all murmurs except?
MVP Hypertrophic cardiomyopathy (HCM)
Cardinal manifestations of acute pericarditis?
Chest pain Pericardial friction rub ECG changes - ST elevation - PR depression Pericardial effusion
Constrictive pericarditis causes what diastolic dysfunction?
Early diastole - rapid filling
Late diastole - halted filling
If a pt has signs of cirrhosis- ascities, hepatomegaly and distended neck veins you should r/o what?
Constrictive pericarditis
Untreated pericarditis progresses to?
Worsening Co and hepatic and/or renal failure
They need surgery
TOC for pericardial effusion and cardiac tamponade?
Echo
Rapid pericardial effusion can lead to?
Cardiac tamponade
What does cardiac tamponade do to cardiac pressures?
All 4 chambers pressure equalize during diastole
Beck triad is a sign of?
Cardiac tamponad
What is beck triad?
HOTN
Muffled heart sounds
JVD
Symptomatic AS pts need?
Valve replacement
- 1/4 die in 3 yrs w/o surgery
Management of AS?
Asymptomatic - nothing
Symptomatic - surgery
Physical findings of aortic insufficiency? (Weird ones)
De Musset sign: head bobbing
Muller sign: uvula bobs
Duroziez sign: Pistol shot sound heard over femoral arteries
Key signs of mitral valve prolapse?
Systolic click
Mid systolic rumbling murmur - increase w standing and valsalva
- decreases w squatting
Always suspect endocarditis in pts w?
New heart murmur and Unexplained fever/bacteriema
Best test for diagnosis of endocarditis?
TEE - better than trans thoracic
Prognosis for infective endocarditis?
Almost always fatal
Coarctation of the aorta in women is often associated w?
Turner syndrome
Leading cause of death in adults w PDA?
Heart failure
Infective endocarditis
Pulmonary pressures in adults w PDA?
Usually normal
Short active BP lowering med?
Hydralazine
Types of meds for Hypertensive emergency vs urgency?
Emergency - IV drugs
Urgency - PO drugs
Types of aortic dissection and treatments
Type A - involves the ascending - surgery
Type B - descending only - medical
Why is it important to r/o aortic dissection in suspected MI pts?
Because thrombolytics used to treat MI are often fatal for aortic dissection pts
Preferred tests for acute aortic dissection?
TEE - unstable pts
CT - stable pts
What is leriche syndrome?
Atheromatous occlusion of distal aorta just above the bifurcation - Bilateral claudication, impotence and absent/diminished femoral pulses
How to differentate location of peripheral vascular disease?
Femoral or popliteal - calf claudication
Aortic - buttock and hip claudication
When are ABI not accurate?
DM pts - often have calcified incompressible vessels
Why do only 1/2 of DVT pts have classic findings?
Superficial venous system is patent the classic findings (erythema, pain, cords) dont occur b/c the blood drains from those patent veins
Of those pts w classic DVT findings how many have DVT?
50%
Preferred heparin?
LMWH
- longer 1/2 life
- given outpatient
- no need for PTT levels
- more $$$
many pts w DVT develop what?
CVI - 80%
If you see superficial thrombophlebitis in different locations over a short time you need to worry about?
Migratory superficial thrombophlebitis
- trousseau syndrome
S/s common in all forms of shock?
HOTN
Oliguria
Tachycardia
AMS
Only shock with elevated jugular venous pulse?
Cardiogenic shock
W hypovolemic shock, when do the compensatory measures start to fail?
20-25% blood loss
Best method for monitor shock treatment?
Urine output
Skin finding w septic shock and hypovolemic shock?
septic: Severe peripheral vasodilation (flushing, warm skin)
Hypovolemic: peripheral vasoconstriction (cool, clammy skin)
MCC of death in ICU?
Septic shock
