TEST 1 Flashcards
initial testing
-conduction- EKG, holter, loop
-HTN- 12 lead, bloods- kidneys, thyroid, lipids (CAD)
-urine- pheochromocytoma, aldosteronism
PSVT, AF, A FLUTTER
-PSVT: MC
-atrial, multifocal, junctional
-caffeine + alc
-ischemic heart ds
-post MI
-bear down -> adenosine or amiodarone (wide) -> cardioversion if unstable
-prevent with beta blocks and CCB
-AFIB:
-alc + withdrawl
-ischemic heart ds
-mitral stenosis
-cardiomyopathy
-AFLUTTER:
-COPD*
-cardiomyopathy
-atrial septal defect
-same tx as afib
-Ablation can be done for all
CHA2Ds2VASc and HASBLED, warfarin
-CHAD
-CHF, DM, HTN, vascular disease- 1 point
->65 - 1 point
->75- 2 points
-past stroke- 2 point
-female- + 1
-0- none or ASA, 1- ASA or full, 2+- full
-HASBLED
-HTN- uncontrolled
-abnormal liver or renal function
-stroke
-bleeding
-elderly
-drugs or alc
-WARFARIN
-blocks vitamin K
-reverse with vitamin K and FFP
-direct oral anticoag- renal impairment
VT, VF, arrest
-VT:
-MC- coronary artery disease after MI
-cardiomyopathy
-VF:
-MC- ischemic heart disease
-ACLC- defib -> epi -> defib -> epi -> amiodarone
-AICD
-cardiac arrest:
-MC coronary artery disease
-low Mg and K
VT tx
-pulseless tx- ACLS
-stable sustained- synchronized cardioversion + antiarrhythmic
-unstable sustained- synchronized cardioversion
-nonsustained-beta blocker therapy
-treating underlying cause:
-myocardial ischemia- catheter
-cardiomyopathy- echo
-electrolytes
-medication
sick sinus syndrome, BBB, AV block
-sick sinus syndrome
-myocardial scarring
-d/c med if its causing it
-tx- pacemaker
-BBB- 3 small boxes .12
-tx underlying cause
-RBBB- right pressure
-LBBB- myocardial scarring- LAD*
-tx- r/o underlying disease
-AV block:
-age
-coronary artery disease MI
-secondary diseases
hypertension: goal and tx guidelines
-2ndary- renal, coarction of aorta, endocrine
-goal- <140/90 -> DM <130/80
-diuretics
-renal comorbid- ACE or ARB
-CAD- beta blocker + ACE or ARB
-HF- beta blocker, ACE or ARB, diuretic
HTN medications
-ARB (sartan)- vasodilation, decrease preload/after load
-ACE (pril)- hyperkalemia, cough, angioedema, renal
-beta blocker
-CCB- peripheral edema, lightheadedness
-DHP- vasodilate - amlodipine
-nonDHP- contraction - verapamil
-alpha blockers- vasodilate -> orthostatic hypotension*
meds to avoid with comorbidities
-end stage chronic kidney disease / hyperkalemia /angioedema - ACE and ARB
-hyponatremia- diuretics
-asthma- beta blocker
-gout- thiazide and loop diuretics
-angioedema- ACE
-2nd/3rd degree heart block- beta blockers, nonDHP CCB
HTN urgency vs emergency
-urgency- >180/>120 without end organ damage
-gradual decrease in MAP -> beta blocker, CCB, ACE
-emergency- >220/>120 with end organ damage
-papilledema, unstable angina, MI, CHF…
-usually caused by 2ndary things or noncompliance
-ASAP tx- reduce MAP by 25% in 1-2 hours -> can leads to ischemic CVA
-IV: esmolol, labetalol, nitroglycerine
hypotension / orthostatic
-<90/<60
-vasodilation? -> alpha blockers
-cough to increase preload
-orthostatic hypo- decrease 20/10
-med tx- fludrocortisone or midodrine
cardiogenic shock
-systolic BP <90 with urine output <20ml/hr
-caused by acute MI** and other cardiac emergency events
-tx: ABCs (2 large bore needles, central line arterial line) -> vasopressors (dopamine, norepinephrine)
-balloon pump, ecmo, underlying cause:
-Acute MI- aspirin, heparin, nitrates
-coronary angiogram
-bypass, stent
-cardiac tamponade- pericardiocentesis
-arrythmia- ACLC
heart failure
-high output- compensation -> anemia, hemochromatosis, pagets, pregnancy, thyrotoxicosis, AV fistula
-MC- low output -> cardiomyopathy, valve stenosis
-systolic- MC CAD
-diastolic- MC left hypertrophy from chronic HTN -> restrictive cardiomyopathy
-left vs right
CHF dx and classification
-BNP
-imaging- cardiomegaly, B lines, effusions, echo, stress test (ischemia), angiogram -> EKG not really
-classify based on symps and tx based on EF
-Class 1 (normal), 2 (slight limit), 3 (marked limit), 4 (symp at rest)
heart failure tx
-diuretics -> loop, thiazide, aldosterone antagonist
-ACE or ARB if ACE contraindicated
-beta blockers
-digoxin- not first line
-sacubitril vasartan - neprilysin inhibitor -> increase BNP - for systolic HF
-ICDs- <35% EF
-LVADs- bridge to transplant
dilated and restrictive cardiomyopathy
-MC- dilated:
-HF symptoms
-alcohol
-CAD
-restrictive:
-collagen -> less relaxation -> bad filling
-right HF symptoms
-EKG low amplitude
-endomyocardial bx
-tx underlying cause
-HF tx
-defib- AICD
-cardiac transplant
hypertrophic cardiomyopathy
-hypertrophic obstructive cardiomyopathy (HOCM)- blockage of flow
-sudden death in people younger than 30*
-dyspnea, chest pain, palpitation
-systolic ejection murmur at lower left sternal border -> increase with valsalva and standing -> decrease with squatting and laying down
-increase carotid pulse
-echo- DX of choice
-tx- avoid exercise
-beta blockers or CCB
-septal myomectomy
-alcohol septal ablation
-aicd
cardiovascular disease
-Lipid deposition -> fibrosis -> calcification -> plaque formation
-peripheral arterial disease
-carotid -> stroke
-cerebral -> CVA, TIA
-coronary- ischemic heart disease
-tobacco and DM
metabolic syndrome
-3 or more:
-triglycerides >150
-HDL <40 (men), <50 (women)
-fasting glucose > 110
-abdominal obesity
-HTN
-family hx of CAD
-obesity
hyperlipidemia
-Mixed hyperlipidemia
-Hypercholesterolemia- genetic
-Hypertriglyceridemia- pancreatitis
-asymptomatic
-xanthoma
fasting lipid panel goals
-Cholesterol < 200 mg/dL
-Triglycerides < 150 mg/dL - more short term
-LDL < 100 mg/dL:
-< 70 for pt with DM, CAD
-Most important for CAD risk*
-HDL > 40 mg/dL men, > 50 mg/dL women -> Protective factor
hyperlipidemia: statins (HMG-CoA reductase inhibitor)
-statins
-inhibits HMG-CoA reductase -> inhibits cholesterol synthesis
-CAD- NEEDS STATIN -> most potent to lower LDL
-smooths
-ADR:
-rhabdo
-myalgia, arthraliga
-high ALT/AST -> check every 3 months
other hyperlipidemia tx
-PSK9 inibitors: mabs ->
-lower LDL
-hypercholesterolemia and CAD
-headache, diarrhea, URI
-niaotinic acid:
-lower triglycerides and increase HDL
-flushing, itch, N/V, skin on fire
-fenofibrates:
-gemfibrozil
-lowers triglycerides
-GI upset
-bile acid binding resins:
-cholestyramine
-lowers LDL -> not triglyceride
-last resort drug
-GI side effect
angina pectoris
-low perfusion of myocardium
-MC- coronary artery disease
-dissection, vasospasm (cocaine + prinzmetals)
-typical (men) vs atypical (women, old, DM, immunocompromised):
-jaw, back of right shoulder
-radiates to right or both arms and back
-stable vs unstable:
-stable:
-<3 mins
-predictable
-relieved with sublingual nitroglycerin
-unstable:
-grouped with acute coronary syndrome
-indicated stenosis that has enlarged
-less response to nitroglycerin
-1 or more:
-angina at rest
-new onset of angina
-increasing pain in stable pts
prinzmetal angina
-vasospasm at rest- exercise capacity preserved
-female > men*
-75% with atherosclerotic lesion*
-cocaine use, early morning
-ST elevation but troponins are neg
-resolved with meds bc its just a spasm
CAD dx
-EKG- normal in 25% -> ST depressions (nonspecific)
-stress test- at least 2 leads ST depression -> + test
-stress test can be done with SPECT, nuclear, pharm use if unstable
-echo- wall abnormalities, EF
-cardiac catheterization (angiography) -> DEF DX (high timi/grace score)
CAD/stable angina medication tx
-1. 1st line for stable angina- beta blocker (increase O2)-> DO NOT USE FOR PRINZMETAL
-2. 2nd line- CCB non-DHP -> FIRST LINE FOR PRINZMETAL
-3. nitrates-
-angina persisting with monotherapy
-nitroglycerin- episodic
-isosorbide and hydralazine- long acting
-SE- flushing, orthostatic hypotension
-late Na channel blocker- ranolazine
CAD/angina revascularization tx
-balloon angioplasty
-drug eluding stents -> 12 months need aspirin and clopidogrel (antiplatelet)
-bare metal stents -> 1 month of dual antiplatelet therapy (DAPT)
-bypass (CABG):
-triple vessel ds with >70% stenosis of each vessel
-left main coronary disease > 50% stenosis
-YOU CAN NEVER PUT A STENT IN LEFT MAIN CORONARY unless the other option is death
acute coronary syndrome
-1. unstable angina
-2. NSTEMI -> partial thickness necrosis
-3. STEMI- full thickness necrosis
myocardial infarction
-MC cause is thrombosis
-ruptured plaque -> thrombus -> occlusion
-MC in atypical symptom pts -> atypical chest pain, fatigue, weakness, abd pain, sweating
-hyper or hypotension
-inferior wall MI -> bradycardia/heart block
-pathological Q waves - infarction- remodeling (past the 90 min mark)
NSTEMI
-nstemi and unstable angina -> ST depression or T wave inversions
-positive cardiac enzymes
-unstable angina- neg enzymes but the EKG shows depressions
cardiac enzymes
-gold standard dx of MI
-+ in STEMI and NSTEMI
-release with necrosis
-3 sets every 6 hrs
-Troponin T and I most specific*
-Increases 4-8 hours
-Peaks 12-24 hours
-Normalizes 5 to 14 days
-CK-MB:
-Increases 4-6 hours
-Peaks in 12-24 hours
-Normalizes 48-72 hours
-Myoglobin:
-Increases 1-4 hours
-Peaks 4-6 hours
-Normalizes in 24 hours
MI with corresponding artery
-Inferior MI- right coronary artery
-posterior MI- posterior descending artery
-septal MI- left anterior descending
-anterior MI- left anterior descending
-lateral MI- left anterior descending or circumflex
MI tx: MONAB
-Morphine- pain
-Oxygen
-Nitroglycerine (NTG)
-Aspirin -> use adenosine diphosphate inhibitor (antiplatelet) if allergic (clopidogrel, ticlopidine, prasugrel) -> caution if CABG in 7 days
-Beta blocker
-Statins- reduce further events (CAD)
-Unfractionated heparin or low molecular weight heparin (LMWH)
-unfractionated- less thrombus and fibrin
-LMWH- inactive factor Xa
ASAP REPERFUSION…
MI reperfusion
-ASAP
-angioplasty OR thrombolytics
-PCI > thrombolysis
-cath within 90 mins*
-Drug eluding stent (DES) and Bare mental stents (BMS) with DAPT
-thrombolytic within 30 mins
-tissue plasminogen activators (alteplase, reteplase, teneceplase) -> Dissolves clot by activating tissue plasminogen
-CONTRAINIDICATIONS:
-hemorrhagic CVA
-CVA within past year
-intracranial neoplasm
-active internal bleeding
-sus aortic dissection
-trauma or major surgery < 2 weeks
-RELATIVE CONTRAINDICATIONS:
-trauma past 2-4 weeks
-major surgery in past 3 weeks
-BP >180/110
-prolonged traumatic CPR
-recent internal bleeding
-diabetic retinopathy
-pregnancy
-PUD
-current use of anticoag
unstable angina management
-TIMI and GRACE scale
-low score -> conservative:
-antiplatelet
-anticoagulation
-high score -> invasive
-cardiac angiogram/plasty
cocaine induced MI
-vasospasm
-constriction of coronary arteries
-dx- EKG-> stemi, + troponins, + Utox
-tx-
-CCB and nitrates
-ASA and heparin/LMWH until CAD ruled out
-NO beta blockers due to risk of vasospasm
-aspirin/antiplatelet
-statin
-beta blocker? CCB?
