Step Up to medicine - Cardiovascular Flashcards
stable angina pectoris is due to __________ narrowing of _________ vessels
fixed
atherosclerotic
what are the top 5 risk factors for stable angina pectoris
DM HLD HTN Cigarette smoking age FHx
what are the two prognostic indicators for CAD
Left ventricular function
vessels involved
which of the vessels involved in CAD purports the worst prognosiss
left main
T/F multiple vessel disease is worse that single vessel
T
T/F ischemic pain changes with changes in body positioning and breathing
F ( does not change with these changes, these would indicate a different pathology for the pain)
Any combination of Hypercholesterolemia
Hypertriglyceridemia impaired glucose tolerance
diabetes hyperuricemia
HTN
Key underlying factor is insulin resistance
Metabolic syndrome X
exertional angina with normal coronary arteriogram
exercise testing and nuclear imaging show evidence of myocardial ischemia
syndrome X
T/F physical exam in patients with CAD is often normal
T
what is the typical outcome of resting ecg in patients with stable angina
normal
Q waves present on resting ECG indicate
prior MI
how does the diagnosis of angina change with presence of ST elevations or segmeental changes
unstable
useful test for patients with an intermediate pretest probability of CAD based upon age gender and symptoms
stress test
quick and dirty method for finding a persons maximum HR
220 - age
patients with a positive stress test should undergo
cardiac cath
what is the parameter by which a stress test is considered postive
ST segment depression
ventricular arrhythmia
hypotension
stress test is 75% sensitive if patients can complete what task during the test
increase HR to 85% maximum
when is the echo performed in stress echo
after exercise
patients with a positive stress echo should undergo
cardiac cath
what cardiac pathology does not allow radioactive testing in cardiac workup
left bundle branch block
what should be done in cardiac workup if patient cannot exercise
pharmacologic testing
how do IV adenosine and dipyramidole work with pharmacologic testing
cause coronary vasodilation which means that the vessels supplying ischemic portions of the heart are already maximally dilated therefore the shunting of blood to the areas of the heart in which the vessels still have vasodilatory capacity will lead to ischemic changes in the vessels that supply ischemic portions of the heart
how does dobutamine work in pharmacologic testing in cardiac workup
increases HR, strength of contraction, increases BP
can be useful for detecting silent ischemic, arrhythmias, heart rate variability and assess pacemaker/ ICD function
holter monitoring
useful testing for unexplained dizziness and syncope if cardiovascular cause suspected
holter monitoring
definitive test for CAD
cardiac catheterization
most accurate test for detecting CAD
cardiac angiography
if CAD is severe typically with three vessel disease what should be done
surgical (CABG) repair
what medication is commonly employed in lowering cholesterol and decrease risk for CAD
statins (HMG CoA reductase inhibitors)
what types of fats should be avoided in patients with CAD
saturated
what medical therapy is indicated for all patients with CAD
aspirin
first line therapy that has been shown to decrease the number of coronary events in patients with CAD
beta blocker
relieve angina by reducing preload myocardial O2 demand
VERY COMMON
nitrates
medical therapy that induces coronary vasodilation and afterload reduction
calcium channel blockers
If CHF is present in patients with CAD then what two medications can be added on to the typical therapeutic options of aspirin beta blockers and CCbs
diuretics and ACE inhibitors
Mild disease
normal EF
mild angina
single vessel
what should be done in terms of management on top of aspirin therapy
beta blockers and nitrates
consider CCBs if symptoms persist
normal EF moderate angina and two vessel disease
coronary angiography to assess for revascularization
decreased EF
severe angina
three vessel of left main or LAD disease
angiography to consider CABG
T/F oxygen demand is increased in unstable agina
F (only the supply is diminished)
significant because it indicates stenosis that has enlarged via throbosis hemorrhage or plaque rupture
unstable angina
chronic angina with increasing frequency duration or intensity of chest pain
new onset that is severe and worsening
angina at rest
unstable angina
what is the only test that determines the difference between unstable angina and NSTEMI
cardiac enzymes
in what order should testing and management be carried out in patients with unstable angina
medically stabilize symptoms first before stress testing or angiography to assess for two/three vessel disease
patients with unstable angina should undergo what global management in terms of placement, nuts and bolts medical management
admission to hospital for continuous cardiac enzyme monitoring
establish IV access and give 2L fluids initially
give supplemental oxygen
control pain with nitrates and morphine
what is the aggressive medical management employed in a patient with unstable angina
supplemental oxygen IV fluid resuscitation beta blockers (if no contraindications) aspirin/clopidogrel LMWH nitrates K+ and Mg+ replacement (to avoid arrhythmia)
duration of aspirin and clopidogrel dual therapy in patients presenting with unstable angina
9 to 12 months
PERCENTAGE of patients that recover following initial aggressive medical management in the case of unstable angina
90%
what should be done in the management of a patient with USA that responds to initial medical management
stress ECG to assess need for catheerization
what is the immediate management in an individual that fails initial medical management in the setting of USA
immediately proceed to the cath lab
what is continued following acute treatment of USA
aspirin beta blockers and nitrate
what are the two beta blockers typically employed in the treatment of USA
metoprolol and atenolol
on top of continuing medical management what should be done in individuals with USA following acute treatment
reduce risk factors
smoking cessation
treat DM HTN HLD
t/F following USA a patient should be started on statin regardless of LDL level
T
transient ST segment elevation classically occuring at night associated with ventricular dysrhythmia
prinzmetal (variant) angina
what two medications are proven helpful with variant angina
CCBs and nitrates (those that vasodilate)
due to necrosis of myocardium as a result of an interruption of blood supply
MI
most cases of MI are due to
acute coronary thrombosis
mortality rate associated with MI
30%
what are the two medications that are utilized in the coronary angiography when looking for variant angina
ergonovine or acetylcholine
intense substernal pressure sensation
radiation to neck jaw arms back
pain typically unresponsive to nitro
epigastric discomfort
MI
T/F MI can be asymptomatic in up to one third of patients
T
painless infarcts or atypical MI more likely in these 4 demographics
women
postoperative
elderly
diabetics
less common symptoms of MI
dyspnea diaphoresis weakness fatigues nausea vomiting snese of impending doom syncope
very early sign of MI that is often missed
peaked T waves
ECG sign indivating transmural injury and diagnostic of acute infarct
ST segment elevation
evidence for necrosis usually seen late and typically absent acutely
Q waves
T/F T wave inversion is specific for MI
F (sensitive not specific)
ECG finding associated with subendocardial ischemia
ST segment depression
currently the diagnostic gold standard for MI versus USA
cardiac enzymes
time period over which troponins return to normal
5-14 days
when do troponins reach their peak
24-48 hours
what is the utility of CKMB enzymes
reinfarction measurement
PROVE IT TIMI 22 trial proved starting this agent should be part of maintenance therapy in MI management
statin (specifically atorvastatin 80mg)
what are the 7 agents that should be initiated in the acute treatment of MI
morphine oxygen nitrates aspirin ace inhibitor statin heparin
this ultimate treatment should be incorporated to the treatment of all patients being managed for acute MI
revascularization ASAP
what is the time period in which revascularization should be attempted in any patient presenting with acute MI
within 90 minutes
this outcome occurs with rupture of papillary muscle infarction ischemia
mitral regurg
length of time with which patients receiving a bare metal stent should be on dual platelet therapy
one month
how long should a patient be on dual platelet therapy following the placement of drug eluting stents
12 months
what is the most common cuase of inhospital mortality following MI
CHF
what is the treatment for PVCs following acute MI
conservative management (no need for antiarrhythmic agent)
what should be done in a stable patient that shows VTach that is sustained
IV amio
what should be done in an unstable patient that shows Vtach that is sustain
electrical cardioversion
what is the treatment for vfib following MI
immediate desynchronized defibrillation and CPR
sinus bradycardia management in the setting of acute MI
observation
if severe atropine may be helpful in increasing HR
asystole management in the setting of acute MI
elecrtrical defibrillation if thought to be 2/2 VFIB
transcutaneous pacing if asystole is clearly the cause
what is the typical cause for AV block in the setting of MI
infarction of the conduction tracts
second or third degree block has a terrible prognosis in the setting of what type of MI
anterior
what should be done in second or third degree heart block in the setting of anterior MI
temporary pacing (transcutaneous or transvenous)
initial management for heart block secondary to inferior MI
atropine
treatment for heart block 2/2 inferior MI that is refractory to initial treatment with atropine
pacemaker
T/F recurrent infarction is not as bad in prognosis as initial MIA
F (worse in both acute and long term prognosis)
catastrophic mechanical complication of MI that occurs within the first TWO WEEKS after MI
free wall rupture
usually within the first 1-4 days
what are the usual immediate complications of free wall rupture
hemopericardium and cardiac tamponade
what is the immediate treatment for free wall rupture
hemodynamic stabilization
pericardiocentesis
surgical repair
T/F interventricular septal rupture following MI is typically worse in prognosis than frree wall rupture
F (better prognostically)
what is the indication for interventricular septal rupture following MI
emergent surgery
time table for interventricular septal rupture following MI
within 10 days
new onset MR folloiwng MI cause
papillary muscle rupture
what is the immediate indication for new onset MR following MI
echo
what is the treatment for papillary muscle rupture
surgical (mitral valve replacement typically)
why are ventricular pseudoaneurysms considered surgical emergencies
tend to become free wall ruptures if left alone
acute pericarditis secondary to MI typically treated with
aspirin
what medications are contraindicated in the case of acute pericarditis following MI
NSAIDs
Immunologically based syndrome consisting of fever malaise pericarditis leukocytosis and pleuritis occuring weeks to months after an MI
dressler syndrome
what is the most effective therapy for dressler syndrome
aspirin
Ibuprofen is a good secondary choice
6 main causes/systems leading to chest pain
Cardiac Pulmonary GI Chest wall psychiatric cocaine
Heart pericardium vascular causes for chest pain
stable angina
USA
variant angina
MI
Pericarditis
Aortic dissection
Pulmonary causes for chest pain (3)
pulmonary embolism
PNA
status asthmaticus
GI causes for chest pain (4)
GERD
diffuse esophageal spasm
peptic ulcer disease
esophageal rupture
Chest wall causes for chest pain (5)
costochondritis muscle strain rib fracture herpes zoster thoracic outlet syndrome
3 main psych causes for chest pain
anxiety panic attacks somatization
3 tests that are obtained for practically all patients presenting with chest pain
ECG
troponins
chest xray
clinical syndrome resulting from the hearts inability to meet the body’s circulatory demands under normal physiologic conditions
CHF
what are the two most common causes for systolic CHF dysfunction
HTN and ischemia (MI)(
echocardiogram showing impaired relaxation of the left ventricle
diastolic dysfunction
which form of CHF is most common
systolic (HTN AND ISCHEMIA MUCH MORE COMMON PATHOLOGIES)
most common cause of diastolic CHF
HTN leading to hypertrophy of myocardium
aoritc stenosis mitral stenosis and aortic regurg cause what form of CHF
diastolic
dyspnea orthopnea paroxysmal nocturnal dyspnea nocturnal cough confusion and memory impairment in advanced forms diaphoresis and cool extremities at rest
CHF
difficulty breathing in the recumbent position relieved by elecation of the head with pillows
orthopnea
rapid filling phase into a noncompliant left ventricular chamber leads to what pathologic heart sound
S3
S3 heard best in what position
apex with the bell of the stethoscope
S3 occurs at what phase in the cardiac cycle
following S2
how to remember S3 S4 and their place in the cardiac cycle
4 is more than 3
tennessee has more letters than kentucky TEN-nes-see relates S4 prior to S1
ken-tuck-Y relates S3 following S2
crackles and rales at the bases of the lungs in CHF indicates what pathologic process
pulmonary edema 2/2 fluid spilling into the alveoli
dullness to percussion and decreased tactile fremitus of the lower lung fields is a sign of
pleural effusion
peripheral pitting edema nocturia JVD hepatomegaly ascites right ventricular heave
all signs of what sidded HF
rightr
T/F given enough time left sided HF will always lead to right sided HF
T
short horizontal lines near periphery of the lung near the costophrenic angles and indicate pulmonary congestion secondary to dilation of pulmonary lymphatic vessels
kerley B lines
prominent interstitial markings and pleural effusion a sign of what on CXR
CHF
what is the initial test of choice in suspected CHF
transthoracic echo
what is the importance of obtaining a TTE in the diagnosis of CHF
gives us the EF
cutoff for preserved left ventricular function in patients treated for CHF
> 40%
T/F ECG is often very helpful in CHF diagnosis
F (not particularly unless there is a component of MI or USA)
consider this test to rule out CAD as an underlying cause for CHF
coronary angiography
test used to assess dynamic response of HR heart rhythm and BP in the setting of CHF
stress testing
conservative management of systolic dysfunction of CHF
sodium restriction water restriction smoking cessation weight loss etoh decrease
most effective means of providing symptomatic relief to patients with moderate to severe CHF
recommended for patients with systolic failure and volume overload
diuretic
T/F diuretics improve mortality in patients with CHF
F (not been shown)
most potent diuretic that is usually used
lasix
lasix is what type of diuretic
loop
HCTZ is what type of diuretic
thiazide
T/F spironolactone has been shown to have survival benefits in patients with CHRF
T
spironolactone used in what types of CHF
advanced forms
which aldosterone antagonist does not cause gynecomastia
eplerenone
usual initial treatment for symptomatic CHF patients
ACE inhibitor and diuretic
T/F ACE inhibitors have reduced mortality benefit
T
CONSENSUS and SOLVD trials proved what point
ACE inhibitors reduce mortality in patients with CHF
T/F all patients with CHF should be on a ACE inhibitor regardless of symptomatology
T
ACE inhibitors should be started at a low dose to avoid
hypotension
patients that experience dry cough with ACE inhibitors can be switched to what type of medication
ARBs (-sartans)
beta blockers are shown to decrease mortality in CHF for what specific patient demographic
post MI CHF
stable patients with mild to moderate CHF should be given
beta blockers
what are the three beta blockers known to be safe in CHF
metoprolol
bisoprolol
carvedilol
useful agent in patients with EF <40%, severe CHF or severe Afib
digitalis
typically employed for patients with refractory symptoms despite being on diuretic ACE inhibitor and aldosterone antagonist
digitalis
two medications commonly employed in patients who cannot tolerate ACE inhibitors
hydralazine and isosorbide dinitrates
4 medication types that are contraindicated in CHF
metformin (can cause lethal lactic acidosis)
thiazolidinediones (fluid retention)
NSAIDs increase risk of CHF exacerbation
negative inotropic antiarrhythmics
what are the medications that reduce mortality in diastolic heart failure
none
what are the two devices that shown to reduce mortality in select patients
ICD prevents SCD
indicated for patients at least 40 days poist MI EF,35% and class II or III symptoms despite optimal medicla treatment
ICD
biventricular pacemaker in patients with QRS >120 ms
CRT
T/F most patients that meet criteria for CRT are also candidates for ICD and receive combined devices
T
last alternative if all else fails in CHF management
heart transplant
acute dyspnea associated with elevated left sided filling pressures with or without pulmonary edema
acute decompensated HF
what are the two most common causes for acute decomp HF
LH systolic or diastolic dysfunction
severe form of HF with rapid accumulation of fluid in the lungs
flash pulmonary edema
DIFFERENTIAL FOR RAPID RESPIRATORY DISTRESS
PULMONARY EMBOLISM ASTHMA pna AND FLASH PULMONARY EDEMA
diagnostic tests for an individual with flash pulmonary edema
chest xray ecg ABG BNP echo coronary angio (possibly)
what is the management of a patient with acute pulmonary (flash) edema
oxygenation and ventilation assistance
diuretics
dietary sodium restriction
nitrates
present in 50% of adults who undergo holter monitoring and mean nothing in a healthy heart
PACs
what is the treatment for asymptomatic PACs
usually just observation
what is the treatment for symptomatic PACs (palpitations)
beta blockers
causes for PVCs
hypoxia electrolyte abnormalities stimulants caffeine medications structural heart disease
why is the QRS wider in PVCs than with regular electrical activity of the heart
through the ventricular muscle and not the conduction pathways, therefore takes a longer time
patients with frequent repetitive PVCs and underlying heart disease are at increased risk for
sudden death (Vfib etc)
what test should be ordered in patients with PVCs and underlying structural or physiologic heart disease
electrophysiology test (may benefit from ICD)
multiple foci in the atria firing continuously in a chaotic pattern causing a totally irregular rapid ventricular rate
atrial fib
atrial rate in afib is usually over ______bpm but are blocked at the AV node so ventricular rate ranges between ___ and ____
400
75
175
T/F PVCs in patients with normal hearts is associated with increased mortality
T
what are the causes for afib (9) (double H triple S triple P E)
- Heart disease: CAD, MI, HTN, mitral valve disease
- Pericarditis and pericardial trauma (e.g., surgery)
- Pulmonary disease, including PE
- Hyperthyroidism or hypothyroidism
- Systemic illness (e.g., sepsis, malignancy
- Stress (e.g., postoperative)
- Excessive alcohol intake (“holiday heart syndrome”)
- Sick sinus syndrome
- Pheochromocytoma
acute hemodynamically unstable afib treatment
immediate cardioversion
acute afib in a hemodynamically stable patient
rate control (60-100bpm)
beta blockers
CCBs (alternatively)
delivery of a shock that is in synchrony with the QRS
cardioversion
delivery of shock that is NOT in conjunction with the QRS complex
defibrillation
if left ventricular dysfunction is present in the setting of afib
what two medications can be considered
amio or dig
three cases of cardioversion being appropriate in afib
hemodynamically unstable
those with worsening symptoms
those having their first ever case of AFib
what is the use of ibutilide procainamide flecainide sotalol or amiodarone in afib
pharmacologic conversion if electrical cardioversion is unfeasible or doesnt work
when should anticoagulation be employed in the setting of atrial fibrillation
present greater than 48 hours
what are the timing parameters for anticoagulation surrounding cardioversion
3 weeks before and 4 weeks afterwards
what is the INR goal in anticoagulation in patients with afib prior to and following cardioversion
2-3
what can be done (in theory) to avoid 3 weeks of anticoagulation prior to cardioversion in the case of afib)
TEE to image the left atrium for thrombus, if none, start IV heparin and perform cardioversion within 24 hours
T/F if the TEE route is carried out to expedite cardioversion, patients still need to be anticoagulated 4 weeks following cardioversion
T
what are the two agents typically used in the setting of chronic afib for rate control
beta blockers
CCBs
patients with lone afib or afib in the absence of any underlying heart disease or cardiovascular risk can take what medication
aspirin
patients with afib and underlying CVD or risk factors need what type of anticoagulation
warfarin
what is the most common cause for aflutter
heart failure
ECG exhibiting a saw tooth baseling with a QRS complex appearing after every second or third tooth
aflutter
flutter waves seen best in which lead
II III AvF (inferior leads)
how many different P wave morphologies are required to make the diagnosis of MAT
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