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Fundamentals of Medicine: Cardiology > Treatments > Flashcards

Treatments Flashcards

1
Q

Pulmonary Valve Stenosis - Dysplastic

A

usually requires surgical treatment (commissurotomy or pulmonary valve replacement)

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2
Q

Pulmonary Valve Stenosis - Domed

A

percutaneous balloon valvuloplasty

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3
Q

Coarctation of the Aorta

A

resection and surgical repair of coarctation or cardiac catheterization with possible angioplasty or percutaneous balloon dilation and stent of coarctation
o in patients with a pressure gradient > 20 mm Hg (measured with echocardiography/Doppler)

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4
Q

Atrial Septal Defect

A

pulmonary vasodilators or surgical repair (pericardial or prosthetic patch; percutaneous transcatheter device closure), depending on size of defect

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5
Q

Patent Foramen Ovale

A

most patients do not require treatment

unexplained neurological event
 low risk – aspirin
 high risk – warfarin

percutaneous closure if patient cannot take anticoagulants or if PFO > 25 mm

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6
Q

Ventricular Septal Defect

A

pulmonary vasodilators for hypertension and surgical closure

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7
Q

Tetralogy of Fallot

A

surgical correction is definitive before the age of 1

requires endocarditis prophylaxis for procedures

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8
Q

Patent Ductus Arteriosus

A

indomethacin closes PDA (treats premature infants for first 10-14 days of life) by inhibiting prostaglandin, which keeps PDA open in the womb

cardiac catheterization (becoming treatment of choice)

surgical ligation (standard treatment) – must beware of hitting the laryngeal nerve

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9
Q

Mitral Stenosis

A

intervention indicated for symptoms (edema, decline in ability to exercise), atrial fibrillation, or evidence of pulmonary hypertension

percutaneous balloon valvuloplasty is treatment of choice

mitral commissurotomy/valvuloplasty or valve replacement provide long-term relief, but are rare

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10
Q

Acute Mitral Regurgitation

A

threat the cause and life-threatening symptoms: MI (O2, analgesics, nitrates), Infections (antibiotics), Pulmonary Congestion (diuretics), Atrial Fibrillation (beta-blockers, calcium channel blockers, and digitalis therapy)

Afterload Reducing Agents - ACE inhibitors and nitrates

Intra-aortic balloon counterpulsation should be considered if hemodynamically unstable

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11
Q

Chronic Mitral Regurgitation

A

treat prior to development of pulmonary hypertension

surgical mitral valve repair or replacement

percutatneous mitraclip valve repair

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12
Q

Mitral Valve Prolapse

A

surgical repair/replacement of the mitral valve is recommended for patients with moderate to severe MR and left ventricular enlargement

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13
Q

Aortic Stenosis

A

surgery typically indicated for symptoms

surgical risk is typically low even in the very elderly percutaneous valve replacement may be an option for high surgical risk patients

surgery considered for asymptomatic patients with severe aortic stenosis (mean gradient greater than 55 mm Hg) or when undergoing heart surgery for other reasons (eg, coronary artery bypass grafting [CABG])

Beta Blockers to help slow heart rate and improve coronary flow

anticoagulation for mechanical valve replacements

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14
Q

Acute Aortic Regurgitation

A

acute aortic regurgitation requires immediate surgery with valve replacement

requires airway management

administer positive inotorpes (increase force of muscular contraction) and vasodilators as needed

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15
Q

Chronic Aortic Regurgitation

A

afterload reduction with ACE inhibitors, calcium channel blockers, or nitrates

surgery once symptoms emerge or if there is evidence of LV failure

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16
Q

ACE inhibitors

A

relax blood vessels

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17
Q

Calcium Channel Blockers

A

relax and widen blood vessels

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18
Q

Nitrates

A

vasodilators used to treat angina

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19
Q

Tricuspid Stenosis

A

reduce fluid congestion: diuretics for fluid overload + salt restriction

bowel edema: torsemide and bumetanide

ascites (fluid in the peritoneal cavity) and liver engorgement: aldosterone inhibitors

treat arrhythmias with medical therapy

valve replacement is the preferred treatment (Bioprosthetic valve preferred); often along with mitral valve replacement

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20
Q

Mild Tricuspid Regurgitation

A

manage with diuretics

monitor with regular echocardiography

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21
Q

Severe Tricuspid Regurgitation

A

reduce fluid congestion: diuretics for fluid overload + salt restriction

bowel edema: torsemide and bumetanide

ascites (fluid in the peritoneal cavity) and liver engorgement: aldosterone inhibitors

treat arrhythmias with medical therapy

Annuloplasty (retains patient’s own tissues); valve replacement when this cannot happen

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22
Q

Pulmonary Valve Regurgitation

A

Rarely needs specific therapy other than treatment of primary cause: pulmonary hypertension, carcinoid (bioprosthetic valve replacement), Tetralogy of Fallot Repair (bioprosthetic valve replacement)

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23
Q

Hypertension

A

thiazide diuretics (best for African Americans and obese) reduce plasma volume initially, then reduce peripheral vascular resistance long-term

long-acting Calcium Channel Blockers cause peripheral vasodilation

ACE Inhibitors or ARB (NOT BOTH); ACE Inhibitors are first-line for patients with HF, symptomatic LV dysfunction, STEMI/NSTEMI, diabetes, systolic dysfunction, proteinuric chronic kidney disease

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24
Q

Hypertensive Emergency

A

captopril, oral clonidine or hydralazine, or nitrates

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25
Q

Dislipidemia

A

healthy lifestyle

assumed to be taking low dose aspiring and treatment for co-morbid conditions

statins for patients with
o previously diagnosed atherosclerotic cardiovascular disease
o LDL cholesterol over 190 mg/dL
o diabetes, LDL over 70, age 40-75
o calculated 10-year CV risk 7.5% or greater, age 40-75

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26
Q

Metabolic Syndrome

A

optimal management of blood pressure, blood sugars, and lipids; weight management

27
Q

Chronic Stable Angina Acute Treatment

A

Sublingual Nitroglycerin

cause=es decreased myocardial oxygen demand by producing systemic vasodilation

acts in 1-2 minutes and can be repeated at 3-5 minute intervals; if pain is not relieved or improving after 5 minutes, call 911

28
Q

Chronic Stable Angina Initial Therapy

A

Beta Blockers

inhibits sympathetic stimulation of the heart, reducing heart rate and contractility

the only medication that has demonstrated to prolong life in patients with CAD

29
Q

Chronic Stable Angina First-Line Therapy

A

Ranolazine

relieves ischemia by reducing myocardial cellular sodium and calcium overload via inhibition of late sodium current of the cardiac action potential

no affect on HR and BP

30
Q

All patients with Chronic Stable Angina should be on:

A

a beta-blocker, a statin, ranolazine (first-line), and aspirin

31
Q

Unstable Angina

A 
antiplatelet agents
lipid-lowering statin agents
cardiovascular antiplatelet agents
beta blockers
anticoagulants
thrombin inhibitors
nitrates
ACE inhibitors

long-term medications: beta-blockers, ASA (aspirin), ACE inhibitor, and statin

32
Q

Unstable Angina Invasive Approach

A

invasive approach may require Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG)
o Patients with unacceptable symptoms despite medical therapy to its tolerable limits.
o Patients with left main coronary artery stenosis greater than 50% with or without symptoms.
o Patients with three-vessel disease with LV dysfunction (EF less than 50% or previous transmural infarction).
o Patients with unstable angina who after symptom control by medical therapy continue to exhibit ischemia on exercise testing or monitoring.
o Post-myocardial infarction patients with continuing angina or severe ischemia on noninvasive testing.

33
Q

Prinzmetal Angina

A

avoid precipitants is top priority, such as smoking or cocaine

avoidance of triggers, nitrates for acute episodes, and long-term nitrates and calcium channel blockers prophylactically

coronary stenting for medically resistant vasospasms

34
Q

NSTEMI

A

bed rest with continuous ECG monitoring for ST-segment deviation and cardiac arrhythmias4

Anti-ischemic Therapy: nitrates, beta-blockers, oxygen if needed

Antithrombotic Therapy: Antiplatelet Drugs (aspirin, clopidogrel or prasugrel, ticagrelor) and Anticoagulant Drugs (heparin, bivalirudin, fondaparinux)

Highly variable and potentially life-threatening course; most will be managed with Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG) – if cardiac markers are found to be elevated or ST-T wave changes are viewed on the ECG; occurs within 48 hours of presentation

35
Q

MI Prehospital Care

A

o Intravenous access
o Supplemental oxygen if oxygen saturation is less than 90% via pulse oximetry
o Immediate administration of aspirin
o Nitroglycerin for active chest pain, given sublingually or by spray
o Telemetry and prehospital ECG, if available

36
Q

MI ED Therapy

A

o On arrival, all patients should have a 12-lead ECG performed immediately.
o If aspirin has not been given, then 162–325 mg of aspirin should be administered.
o Patients should have continuous cardiac ECG monitoring and two separate intravenous lines.
o Sublingual nitroglycerin and intravenous morphine should be administered for pain.
o Oxygen saturation should be monitored noninvasively; supplemental oxygen if needed.
o A portable chest radiograph should be ordered but should not delay reperfusion.
o Echocardiography may be considered if the diagnosis of MI remains in doubt.
o Oral β-blockers should be administered to all patients, unless there is a contraindication.
o An anticoagulant should be administered to all patients unless a contraindication exists. In patients with ST elevation who receive fibrinolytics, 48 hours of anticoagulant should be administered

37
Q

MI Reperfusion Therapy

A

o Patients with medical care within 12–24 hours of symptom onset are considered for reperfusion.
o Fibrinolysis or Percutaneous Coronary Intervention (PCI)
o Both strategies improve patency of the infarct-related artery, reduce infarct size, and lower mortality rates.
o The goal of reperfusion therapies is a door-to-needle time of 30 minutes (for fibrinolysis) and a door-to-balloon inflation time of less than 90 minutes (for PCI).
o PCI has been shown to be superior to fibrinolysis when it is performed without significant delay by experienced clinicians in experienced centers.
o Fibrinolysis should be reserved for chest pain patients in the first 1 to 3 hours of symptoms; after 3 hours PCI is the preferred treatment.
o Following reperfusion, all patients benefit from early administration of a P2Y12 inhibitor in addition to aspirin (clopidogrel, prasugrel, or ticagrelor).

38
Q

What is the most important immediate therapy for patients with a MI?

A

aspirin

39
Q

Heart Failure with Reduced Ejection Fraction/ Systolic

A
  • Beta Blockers
  • ACEI
  • ARNI
  • Hydralazine plus Nitrate
  • Aldosterone Antagonists.
  • Diuretics and Digoxin for symptom relief
40
Q

Heart Failure with preserved Ejection Fraction/ Diastolic

A

• There is limited direct evidence to support a specific drug regimen to treat HFpEF.
• Control fluid overload with diuretics
• Treat hypertension
o Mineralocorticoid receptor antagonist in patients with HFpEF who can be appropriately monitored.
o ACEI, ARBs, CCBs, and beta blockers are used as need to treat hypertension but lack proven efficacy to alter clinical outcomes in HFpEF.
• Statins might be of benefit in patients with HFpEF.
• Prevent rapid heart rates
o Restoration and maintenance of sinus rhythm is preferred to rate control in atrial fibrillation

41
Q

Acute Heart Failure and Pulmonary Edema

A

o in pulmonary edema, have patient in sitting position with legs dangling over the side of the bed – facilitates respiration and reduces venous return
o morphine is highly effective in pulmonary edema
o IV Diuretics
o Nitrates
 reduce BP and LV filling pressures
o IV Nesiritide
 vasodilator that reduces ventricular filling pressures and improves cardiac output

42
Q

Heart Failure

A

ACEI, ARBs, Beta Blockers, Diuretics

43
Q

Sinus Bradycardia

A

none if asymptomatic

admit for monitoring if pacing is syncopal; stop medications which may be contributing

refer for pacemaker if recurrent/symptomatic/nor reversible cause

44
Q

AV Nodal Re-entry Tachycardia

A
  • May respond to vagal maneuvers
  • First-line medication is IV adenosine
  • Second-line medications are calcium channel blockers (verapamil, diltiazem) and beta blockers (esmolol, metoprolol)
  • Cardioversion (shock) if the patient is unstable and/or medications ineffective
  • Long-term treatment can include catheter ablation (first-line) or suppression with calcium channel blockers or beta blockers
45
Q

AVRT

A 
•	If hemodynamically stable:
o	Adenosine
o	Calcium channel blocker
•	If not hemodynamically stable:
o	Cardioversion
•	If AFib is present:
o	Do NOT use AV blocking maneuvers or medications, can increase conduction via the accessory pathway
o	Cardioversion vs other antiarrhythmics
•	Long-term: 
o	Catheter ablation is treatment of choice
46
Q

Atrial Fibrillation

A

Rate Control/AV Nodal Blocking Agents
o Beta-Blockers and Calcium Channel Blockers
o goal is >80 bpm at rest and >100 bpm ambulatory

Rhythm Control
o Preferred when
 Symptomatic despite rate control
 Are difficult to rate control
 Develop tachycardia-mediated cardiomyopathy
 Are younger
 Have a first episode or have Afib triggered by acute illness
 Hemodynamically unstable=urgent cardioversion
o Cardioversion
 restores sinus rhythm in 75-90% of patients
 initial shock 100-200 Joules, additional attempt 360 Joules
 Afib recurs in 40-60% of patients at 3 months, and in 60-80% of patients at 12 months
o Antiarrhythmics
 Class I Fast Sodium Channel Blockers
 Class II Beta Blockers
 Class III Potassium Channel Blockers
 Class IV Slow Calcium Channel Blockers
 Class V Variable Mechanism
o Ablation
 radiofrequency catheter ablation
 cryogenic freezing
 cauterizes short circuits that are causing Afib

47
Q

Atrial Flutter

A

ventricular rate control with antiarrhythmics

anticoagulation may be necessary due to increased stroke risk

48
Q

Premature Ventricular Contractions

A

underlying cause if there is one

no underlying cause, but bothersome: beta blockers or calcium channel blockers

if refractory may proceed to radiofrequency ablation

49
Q

Ventricular Tachycardia

A

Acute: This is an ACLS/Code scenario; Cardioversion and VT algorithm medications

Chronic:
Sustained: Correct underlying cause if possible (ischemia/infarction, metabolic derangement, medication toxicity); Depending on patient stability may either go to the ACLS algorithm; Chemical cardioversion with amiodarone, lidocaine, procainamide, or sotalol; or Electrical cardioversion

Nonsustained VT (NSVT): Correct underlying cause, Control rate and decrease recurrence with β-blockers or calcium channel blockers; Radiofrequency ablation if refractory (stubborn; resistant); If underlying heart disease is present, patients may end up with and Implantable Cardioverter Defibrillator (ICD) +/- Pacemaker

50
Q

Accelerated Idioventricular Rhythm

A

Often none, but careful monitoring.

If felt to be an escape rhythm, treatment is actually contraindicated since it’s the only thing keeping the heart going.

51
Q

Long QT Syndrome

A

Congenital: beta blockers and implantable cardioverter-defibrillator (nonpharmacologic)

Acquired: magnesium sulfate, isoproterenol, lidocaine, phenytoin, and sodium bicarbonate, or temporary pacing (nonpharmacologic)

52
Q

First Degree AV Block

A

no specific therapy if asymptomatic

Pacemaker may be considered if: Pacemaker syndrome: uncomfortable awareness of one’s heart beat because of the loss of atrioventricular synchrony; First degree AV block with concurrent neuromuscular disease.; Patients with a wide QRS complex in conjunction with prolongation of the PR interval

53
Q

Second Degree AV Block Motbitz Type I

A

Symptomatic and hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate

Symptomatic and hemodynamically unstable: atropine and temporary cardiac pacing

Mobitz type I and asymptomatic bradycardia not due to a reversible etiology: Permanent pacemaker is not indicated; Regularly follow-up, including a surface ECG, every 6 to 12 months.

Mobitz type I and symptomatic bradycardia not due to a reversible etiology: Permanent pacemaker

54
Q

Second Degree AV Block Mobitz Type II

A

treat underlying cause

Hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate

Hemodynamically unstable: atropine and temporary cardiac pacing

No reversible etiology: permanent pacemaker.

55
Q

Third Degree AV Block

A

Hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate

Unstable patients: atropine and temporary cardiac pacing.

Once hemodynamically stable, look for underlying reversible causes.

Once underlying reversible causes of heart block have been excluded, permanent pacing is usually indicated.

56
Q

Tachy-Brady Syndrome

A

Hemodynamically unstable: ACLS protocol with atropine, dopamine, or epinephrine as well as temporary cardiac pacing.

Hemodynamically stable: no urgent therapy but should be monitored with transcutaneous pacing pads in place in case they deteriorate The long-term management depends on the extent of symptoms and conduction abnormalities as well as the likelihood of recurrence or progression leading to subsequent problems.

Patients with bradycardia which is symptomatic: permanent pacemaker is not indicated; Follow with intermittent examinations.

57
Q

Torsades de Pointes

A

underlying cause

IV Magnesium (maybe Potassium); check troponins

Temporary Pacing

Isoproterenol

Permanent pacemaker may be necessary, especially for bradycardia dependent TdP

58
Q

Hypovolemic Shock

A

The goal is to restore the volume lost

Hemorrhagic shock use blood substitutes

Non hemorrhagic shock use isotonic crystalloid in 1L increments

Vasopressors are used only as a temporary method to restore BP until fluid resuscitation take place

59
Q

Cardiogenic Shock

A

The main goal is to improve myocardial function

Arrhythmia should be treated

Reperfusion percutaneous coronary intervention (PCI)/stent is the treatment of choice in acute coronary syndrome (ACS)

Inotropes (contractility - afterload) and vasopressors (vasoconstriction - preload)

60
Q

Obstructive Shock

A

The key is to identify and reverse the cause of the obstruction

Massive PE - IV thrombolytics

Pericardial Tamponade - pericardiocentesis via needle decompression

Tension pneumothorax - needle thoracostomy, finger thoracostomy, or tube thoracostomy

61
Q

Septic Shock

A

The initial approach to the patient with septic shock is the restoration and maintenance of adequate intravascular volume (CVP 8-12 mmHg)

Requires LARGE volumes of fluid for resuscitation (>2L) due to capillary leakage  warm fluids to avoid hypothermia and coagulopathy

Vasopressors to keep mean arterial pressure (MAP) above 65 mm Hg

Prompt institution of appropriate antibiotic

62
Q

Systemic Inflammatory Reponse

A

If septic, treat with appropriate antibiotics

Vasoactive drugs for refractory hypotension

Glucose control

Supplemental oxygen

Consultation for underlying causes/complications

63
Q

Neurogenic Shock

A

Primary management is the correction of persistent hypotension (despite fluid resuscitation) with vasopressors and inotropes

Fundamentals of Medicine: Cardiology (10 decks)

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