UW - Med/CV Flashcards
What does signs of CHF in a young female patient w/ vascular risk factors most likely indicate?
Viral Myocarditis - often from Coxsackie B virus
What is a major thrombotic complication from cardiac catheterizations and what can develop?
Atheroembolism from chol plaques, stroke, diffuse showering in peripheral circulation, intestinal ischemia, GI bleed, pancreatitis, acute renal injury, blue toe syndrome (cyanosis over toes), livedo reticularis, gangrene, ulcers
What is the best treatment to reverse alcoholic dilated cardiomyopahty?
Abstinence from alcohol
What is the utility of digitalis in CHF and why?
Best for systolic dysfunction w/ RVR due to atrial flutter/afib
Positive ionotropic effect and negative dromotropic (slowing AV conduction)
What are paroxysmal supraventricular tachycardias (pSVT)? How do you manage it?
SVTs w/ abrupt on/offset (pts may have palpitations, dizzy, SOB, presyncope/syncope, chest pain)
Adenosine or Vagal maneuvers -> temporarily slow conduction via AV node, may unmask hidden P waves in pts w/ atrial flutter/afib
How do you distinguish sinus tachycardia from PSVT?
Sinus Tach = normal P wave morphology and relationship w/ QRS complex
PSVT = P waves usually “buried” w/in or seen just after QRS complex
What are the clinical features of abd aortic aneurysm?
Old men, atherosclerosis, smoking history, pulsatile abdominal mass
What is the MoA of adenosine and dipyridamole?
Coronary vasodilators
What are the clinical features of renal artery stenosis?
Atherosclerosis, secondary HTN, abd bruit
What is the utility of lidocaine for cardiac abnormalities? Risks?
Control complex forms of ventricular arrhythmias (VTach), in patients w/ acute coronary syndrome. Decreases frequency of VPBs and diminishes risk of V-Fib
Can also cause Asystole
What treatment is preferred in RVR in hyperthyroidism related A-fib?
Propranalol (resistant to cardiac glycosides)
What does the CHADS2 score assess?
Need for anticoagulation in aFib
C = CHF, H = HTN, A = age > 75, D = Diabetes mellitus, S = Prior stroke/TIA (2 pts, all others 1)
What may acute MR/AR lead to? What happens to RV preload in these conditions?
Elevated LV end diastolic pressure (LVEDP, LV filling pressures) which reflects back to LA and pulm veins causing signs of CHF
RV preload unaffected or down b/c of reduced effective forward flow
How do you identify 1st degree AV block and what is the management for it?
- Slowed conduction through AV -> prolonged PR interval
- Most w/ normal QRS duration require no further evaluation unless associated w/ severe bradycardic symptoms (syncope)
- AV block w/ prolonged QRS associated w/ delay below AV nodes in bundle branches, can advance to 2nd degree or complete block and require electrophysiological testing
What should be closely monitored in patients on Amiodarone and who should not get it?
- Can cause severe Pulm toxicity (chronic interstitial pneumonitis, organizing pneumonia, ARDS) avoid in preexisting lung disease
- Monitor PFTs
What is the drug of choice for a-fib w/ RVR?
Verapamil and Digoxin as second line
What is the most common location of ectopic foci that can cause a-fib? Why does this occur (anatomically) and how can you treat?
Pulmonary veins, Cardiac tissue (mocardial sleeves) extend into PVs and normally fxn like sphincters to reduce reflux of blood into PVs during atrial systole
Tx: Catheter based radiofrequency ablation can disrupt this connection
What electrical disturbance can lead to sinus tachycardia? Atrial flutter?
- SA node discharge rate of 100-180 b/min
- Reentrant circuit around tricuspid annulus, w/ slowing of impulse through cavotricuspid isthmus –> rapid sawtooth flutter waves
What are the steps to manage beta blocker overdose/toxicity?
- Secure airway, give isotonic fluid boluses and IV atropine for initial Tx of HoTN and Bradycardia
- If refractory/profound HoTN, give IV Glucagon (increases intracellular levels of cAMP)
- IV calcium, vasopressors (NE, Epi), high dose insulin/glucose, and IV lipid emulsion tx can also be used
What can be used effectively to treat betablocker/ca channel blocker toxicity and why?
IV glucagon -> increases intracellular levels of cAMP
What is the effect of dobutamine?
Ionotropic agent that can cause significant vasodilation (hypotension)
What Tx is useful in patients w/ wide QRS or ventricular arrhythmia from TCA toxicity and why?
Sodium bicarbonate - sodium load will alleviate depressant action on myocardial sodium channels (TCAs inhibit fast Na channels His-Purk system/myocardium)
What are the alpha2-adrenergic agonist medications and their uses?
Clonidine, methyldopa which treat HTN; and dexmedetomidine for sedation in ICU/OR
What are non-cardiac/pulm causes of A-Fib?
Obestiy, Endocrine (Hypothyroid, diabetes), Alcohol abuse, Drugs (amphetamine, cocaine, theophylline)
What should be on the differential for fever, polyarthralgias, and pustular rash?
Infective endocarditis, disseminated gonococcal infection (DGI)
What is Kussmaul’s Sign?
Lack of the typical inspiratory decline in CVP
What therapies are required in Prinzmetal (variant) angina? What should be avoided
- Eliminate risk factors like smoking
- Pharm: Calcium channel blockers (Diltiazem, Verapamil, or Dihydropyridines) or nitrates (Promote vasodilation and prevent vasoconstriction)
-Avoid nonselective beta blockers (B2-R inhibition can worsen coronary vasospasm) and aspirin (prostacyclin inhibition, promotes vasospasm)
What are the CV/pulm clinical features of Marfan’s syndrome?
CV: Aortic dilation, regurgitation, or dissection, MVP
Pulm: Apical blebs -> Pneumothorax
What findings may be associated w/ aortic regurgitation in Marfan’s syndrome?
-Aortic root dilation/dissection -> AR -> Early decrescendo diastolic murmur, best along L sternal border (3/4 space) with patient sitting up, leaning forward and holding breath after full expiration
What is Holt-Oram syndrome and what heart sounds may it be associated w/?
ASD -> wide and fixed splitting of S2
Associated w/ upper limb defects (radius and carpal bones)
What heart sounds are associated w/ mitral stenosis? MVP?
MS: Opening snap in early diastole, loud S1, mid-diastolic murmur from turbulent flow across AV valves
MVP: Mid to late systolic murmur
What is pulsus parvus et tardus and what is it associated w/?
Arterial pulse w/ decreased amplitutde and delayed peak, commonly seen in severe aortic stenosis
What artery distribution is involved in anterior and posterior MIs? ECG leads involved?
Anterior - LAD, STEs in some or all of V1-V6
Posterior - LCX or RCA, STDs in V1-3; also STDs in 1 & aVL (RCA); or STEs in 1 & aVL (LCX)
What artery distribution is involved in inferior, lateral, RV MIs? ECG leads involved?
Inferior - RCA or LCX, STEs in II, III, aVF
Lateral - LCX, diagonal, STEs in 1, aVL, V5, V6; STDs in II, III, aVF
RV (0.5 of inferior) - RCA, STEs in V4-V6R
What electrophysiology complication can result from RCA occlusion?
AV block (mobitz 2) -> sinus brady from increased vagal tone(decreased blood to SA node) - in 90%
What should be done first in a middle aged patient w/ burning epigastric pain on exertion?
Concerning for Ischemic heart disease –> check exercise EKG
What are two endocrine/autoimmune risk factors for CAD?
SLE and chronic steroid use -> accelerate atherosclerosis
What is the most likely cause of CHF symptoms in a young person?
Dilated cardiomyopathy secondary to acute viral myocarditis (Coxsackie B virus infection most common; also parvoB19, HHV6, adenovirus, enterovirus)
How can you differentiate between the murmur in HOCM vs. AS? Associated symptoms?
HOCM: crescendo-decrescendo systolic murmur along L sternal border w/o carotid radiation (interventricular septal hypertrophy) –> Syncope, dyspnea, chest pain, young person
AS: crescendo-decrescendo systolic murmur at right sternal border radiating to carotids -> syncope dyspnea, older person
What cardiac finding can be associated w/ fever and hypoxemia?
Hyperkinetic state –> systolic murmur
What are the 3 major cardiac sources of arterial emboli?
- Left ventricular thrombus (especially following anterior wall MI)
- Left atrial thrombus (A-fib)
- Aortic atherosclerosis
What are patients w/ large anterior STEMIs at greatest risk for? What is the workup for them?
- LV thrombus and anteroapical aneurysm formation
- If signs of systemic embolization -> ischemia; immediate anticoagulation, vascular surgery consult, TTE to screen for thrombus
What can help patients w/ Torsades de pointes?
Magnesium Sulfate
What clinical features are consistent w/ aortic dissection?
- severe, sharp tearing, chest, neck or back pain
- > 20mmHg difference in BPs between arms
- Mediastinal widening on CXR
- Syncope, hx of HTN,
What are the indications for emergency pericardiocentesis?
Patients w/ pericardial effusion and cardiac tamponade w/ hemodynamic instability or cardiogenic shock
What are premature ventricular complexes (PVCs) and how can you identify them on EKG?
Wide QRS (>120msec), bizarre morphology, compensatory pause -Seen in normal patients but most often in cardiac pathology especially post MI
What are the main risks of AAA expansion and rupture?
Large diameter, increased rate of expansion, current cigarette smoking
What EKG signs are consistent w/ A-fib + RVR? What therapy should be used in stable patients?
Irregularly irregular, w/ narrow complex tachycardia, no organized P waves
Tx: Diltiazem, beta blockers, digoxin
How do you treat paroxysmal SVTs and why?
Adenosine - slows AV node conduction interrupting re-entrant pathway and terminating PSVT
What is lidocaine primarily used to treat?
Ventricular arrythmias (especially post MI tissue/hypoxic tissue)
What is the murmur heard w/ MVP?
Short systolic murmur heard best at apex, disappears w/ squatting (because increase preload -> increased in ventricular size/volume, delay in prolapse w/ late click)
What is the murmur heard w/ VSD?
Loud holosystolic murmur w/ max intensity over 3/4 L intercostal space (greater murmur intensity w/ squatting)
What are the indications for starting statins? What else can statins help w/ aside from lowering LDL?
ACS, MI, Stable/unstable angina, Stroke/TIA/PAD, LDL >190, Age 40-75 w/ diabetes, 10 year ASVCD risk >7.5%
Basically everything… better than all other lipid lowering agents (also helps w/ triglycerides so use as long as trigs
What is the murmur heard w/ AR and what PE signs would the patient present with?
- Early diastolic murmur (mild AR) & holodiastolic murmur (severe AR)
- Bounding or “water hammer” pulses (from increased stroke volume -> abrupt rise in SBP then regurgitation in diastole causes low DBP and collapse of peripheral arteries)
What heart failure is associated w/ alcohol use?
Alcohol related HD (Alcohol cardiomyopathy) -> Dilated cardiomyopathy w/ LV cavity dilation and impaired LV systolic fxn
What is the indication for treating a patient w/ Norepinephrine?
Severe HoTN, and shock (e.g. septic shock)
What cardiac complication necessitates treatment w/ Atropine? What if this doesn’t work?
- Bradyarrhythmia, to improve both HoTN and sinus bradycardia
- IV epi, dopamine, or transcutaneous pacing
What heart/lung sounds are associated w/ viral myocarditis?
Audible S3 and bibasilar rales
When do you hear an S4 heart sound?
Decreased LV compliance (HTN dz, AS, hypertrophic cardiomyopathy, acute phase of MI)
What are signs of viral pericardial effusion?
Recent URI, early cardiac tamponade, elevated JVP, dyspnea (clear lung fields), XRay shows water bottle sign
What is the best medication to treat primary raynaud’s phenomenon?
Avoid aggravating factors (cold, emotional stress) and dihydropyridine calcium channel blockers (Nifedipine, Amlodipine)
What is the effect of alcohol on blood pressure?
> 2 drinks per day or binge drinking (>5 drinks in a row) are associated w/ HTN
What are the signs of pericarditis on EKG? How do you treat this post MI (i.e. from Dressler’s syndrome)? what should you avoid?
- ST elevations in all leads but aVR which has reciprocal ST depressions
- NSAIDs (inflammatory process)
- Avoid anticoagulants which could cause hemorrhagic pericardial effusion
What is a major complication of giant cell arteritis and how can you monitor for it?
Aortic aneurysm-> frequent chest XRays
How much epi is used for anaphylaxis? Cardiac arrest?
Ana - 0.3mg
Arrest - 1mg
What cardiac complication is associated w/ pregnancy and what is the prognosis?
Peripartum cardiomyopathy
-50% recover, but future pregnancies have high mortality and increased myocardial damage
What heart sounds are associated w/ VSD? Free wall rupture?
VSD - Loud holosystolic murmur
Free wall rup - Hemopericardium, mechanical electrical dissociation (decreased sounds w/ tamponade)
What are the requirements to diagnose stress (takotsubo) cardiomyopathy?
(1) ST-segment elevation, (2) transient wall motion abnormalities of the apex and mid ventricle, (3) the absence of obstructive coronary artery disease, and (4) absence of other causes of transient left ventricular dysfunction, such as recent head trauma or myocarditis
What is the late presentation of aortic coarctation? How can you confirm?
- Asymptomatic HTN most commonly
- CP, claudication, HA, epistaxis, heart failure, aortic dissection in severe cases
- B/l BP measurement of LE and UE (brachial/femoral index by palpation of pulse)
What effect does reducing BMI have on blood pressure>
SBP decreases by 5-20 per 10 kg weight loss (most effective non-Rx measure in overweight pts)
What can increase patient susceptibility to digoxin toxicity?
Hypokalemia from loop diuretic use
What is the presentation for Buerger’s disease?
distal extremity ischemia/ulcers/gangrene, after DM, hypercoagulable disorders and autoimmune disease are ruled out
What is the workup for suspected secondary raynaud’s phenomenon?
CBC/BMP, urinalysis, ANA/RF, ESR and C3/C4 levels
What heart sound may be heard after acute MI and what is the cause?
Abnormal S4 (atrial gallop) due to ischemia induced myocardial dysfunction, immediately after atrial contraction as blood is forced into stiff ventricle
What are the effects of hemochromatosis on the heart?
Dilated/restrictive cardiomyopathy and conduction defects (sick sinus syndrome)
Which patient populations may benefit from Ab ultrasound for AAA?
Men 65-75 w/ past history of smoking should get 1 time scan
How do patients w/ septic shock present (from hemodynamic standpoint)?
HoTN, Tachycardic, Low PCWP, High Mixed venous O2
What are the hemodynamic features of hypotensive shock?
SVR increases to maintain perfusion, MvO2 low because low perfusion and high O2 extraction, reduced preload and reduced CO
