Step 3- Cardiology

Jaimie Shah
Flashcards by Jaimie Shah, updated more than 1 year ago
Jaimie Shah
Created by Jaimie Shah over 7 years ago
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Step 3 cards Flashcards on Step 3- Cardiology, created by Jaimie Shah on 08/09/2013.

Resource summary

Question Answer
RF for CAD DM, HTN, Tobacco use, HLD, PAD, Obesity, inactivity, Family Hx
Significant family history for CAD young patient and family with HD female < 65 and male relatives <55
define pleuritic pain and what are the causes? PE, PNA, Pleuritis, Pericarditis, Pneumothorax
what causes positional changes in pain? Pericarditis
Chest pain on palpation? Costochondritis
ischemic HD diagnosis and tx if asked what to do first with diagnosis check an EKG...if just asked what to do first and given choice of tx v. dx test and it is clear ischemia choose treatment first
Most accurate test for ischemic HD? CK-MB and trop, but first intial test is EKG that tells you to give ASA first
Cardiac and muscle enzymes CKMB and trop rise 3-6hrs after start of CP, CKMB stays for 1-2d and check for reinfarct; trop will dissapear in 1-2wk; Mgb elelvates FIRST 1-4 hrs after CP start
When do we do a chemical stress test? Patients who can't exercise to a target HR o >85% max, COPD, Amputation, Deconditioning, Weakness, prior stroke, LE ulcer, Dementia, Obesity
When do I do a stress echo? EKG unreliable for ischemia: LBBB, Digoxin use, Pacer in place, LVH, Any baseline abn in EKG of the ST segment
Define ACS Causes of acute chest pain, can be with exercise or rest, Can cause ST elevation or depression or normal EKG, based on hx of CP with features that suggest ischemia
Treatment of ACS ASA (oral)-lowers mortality, Nitrates and Morphine but they have no mortality effect, O2 but no benefit if pt not hypoxic; clopidogrel is added in acute MI
Thrombolytics and primary angioplasty and mortality they lower mortality in STEMI but it is dependent on time. (PCI done in 90 min on arrival shows improvement to mortality; no benefit if done in stable angina over medical therapy)
When do you do urgent angioplasty? if it asks for the single greatest efficacy in lowering mortality in STEMI, and the question includes contraindication to use of thrombolytics
When to give thrombolytics? CP for <12hrs and has STEMI in at least 2 leads, a new LBBB; needs to be given within 30mins of arrival to ER with pain
Do BB lower mortality and when is the best time to given them in relation to episode of CP? They do lower mortality but timinig of administration is not critical
what type of patients do ACE/ARBs lower mortality? Should be given to all patients with an ACS but they only lower mortality if there is left ventricular dys or systolic dys
Which medications given in ACS will lower mortality? ASA, Thrombolytics, Primary angioplasty, Metoprolol, statins, plavix
Which ACS medications lower mortality in certain conditions? ACE/ARBs lower mortality with a low ejection fraction
Which ACS medications do not lower mortality? O2, Morphine, Nitrates, CCB, Lidocaine, Amiodarone
When should plavix be used? with ACS, an ASA allergy, patient to get angioplasty, acute infarction ; Ticlodipine can cause neutropenia and Prasugrel has greater efficacy than plavix but more bleed risk
When in ACS do we use CCB instead? patient has intolerance to BB like asthma, there is cocaine induced chest pain, there is coronary vasospasm/Prinzmetal's angina
When is a pacemaker the answer for acute MI? 3rd degree heart block, Mobitz 2 heart block, bifasicular block, new LBBB, symptomatic brady
when is lidocaine or amiodarone needed in acute MI? when there is VT/VF, not given for prevention of arrythmias
Cardiogenic shock basics Is a complication of Acute MI; dx: ECHO, swan; tx: ACE, urgent revascularization
Valve rupture basics Complication of Acute MI; dx with ECHO; tx: ACE, nitroprusside, intra aortic balloon pump as a bridge to surgery
Septal rupture basics Complication of Acute MI; Dx: ECHO, R heart cath showing diff in blood saturation; tx: ACE, nitroprusside and urgent surgery
Myocardial wall rupture basics Complications of acute MI; Dx: ECHO; Tx: pericardiocentesis, urgent cardiac repair
Sinus brady basics Can be a complication of MI; dx: EKG; tx: atropine and pacer if symptomatic
Complete heart block basics Can be a complication of acute MI; tx: EKG, canon A waves; dx: atropine and if symptoms may need a pacer
RV infarct basics can be a complication of Acute MI; dx: EKG; tx: fluid overloading
How long does patient wait to have sex after an MI? 2-6 weeks
abiciximab has great benefit in STEMI (t/f) False
Medications used in stable angina? ASA and metoprolol both provide mortality benefit; Nitrates provide symptomatic relief but no mortality benefit; ACE/ARB used in stable cases if there is CHF, systolic dys, and low EF; plavix if ASA not tolterated; statins (do not do angiography to start any of the meds but do if you consider CABG)
what is the difference between saphenous vein graft and internal mammary artery graft? Vein graft starts to occlude in 5 years and artery graft starts to occlude in 10 years; no difference in the meds needed to be taken
what are the indications of CABG? three coronary vessels with > 70% stenosis; Left main coronary artery stenosis > 70% stenosis
what are the CAD equivalents? DM, PAD, Aortic disease, Carotid disease
LDL goal in patient with CAD? LDL<100
LDL goal in patients with DM and CAD LDL<70
Other risk factors for LDL management? tobacco use, HTN +/- BP meds, low HDL, Family hx of early CAD (female rel<65 and male rel<55), and age (male >45, female>55)
SE of statins? liver toxicity and rhabdo; check LFTs routinely and if more than 2-3x ULN then d/c medication of if elevated this much dont start the medication
review calculating LDL goals review calculating LDL goals
Most COMMON cause of ED after MI? Anxiety more than BB
Test that should be ordered for Pulm edema and CHF on CCS? CXR, EKG, Pulse ox +/- ABG, and ECHO (order all at same time but if you see pulm edema and asked what to do next just give lasix, o2 and nitrates cuz it is a clinical diagnosis first)
When to use Digoxin? to slow afib, do not use in pulm edema
Most patients with pulm edema do well with preload reduction (lasix, o2, nitrates, morphine) but if on CCS they cont have SOB after these meds what do you give? Dobutamine Amrinone, Milrinone (ionotropes or increase contractility but don't change mortality)
Acute pulm edema assoc with new onset VT with a pulse, afib, aflutter,SVT what is the best therapy? falls under unstable tachy algorithim so needs Synchronized cardioversion
Hemodynamic changes seen on R heart cath secondary to pulm edema decreased CO, increased SVR, increased wedge pressure, and increased Right atrial pressure
what should all patients with pulm edema now stabalized have done? ECHO to determine if this is systolic or diastolic failure
What is the further management of chronic systolic CHF? ACE/ARB (Show a decrease in mortality), metoprolol/carvedilol (lower mortality), Spironolactone (lower mortality in advanced dz and give if pt originally presented with pulm edema), Diuretics, Digoxin (decreases symps and freq of hospitalization, no mortality change)
What is the further management of diastolic CHF? Metoprolol/Carvedilol, diuretics; be careful of overuse
when and why do we put a implantable defibrilator/cardioverter in patients? place in patients with DCM, and EF below 35% persists because the most common cause of death in CHF is sudden death from arrythmia
when is a biventricular pacer the answer in CHF? there is a decrease mortality seen in patients with severe CHF and QRS duration >120ms
When do we use coumadin in CHF patients? there is no routine use in CHF no matter how low the EF in the abscence of clot or chronic afib
what is an absolute contraindication for BB use? symptomatic Bradycardia (not PAD, Asthma, Emphysema, and diabetes)
Valvular disease in young female in general population MVP
valvular heart disease in healthy young athlete HOCM
Valvular HD in a pregnant woman or immigrant MS
Valvular HD in turner's syndrome and with coarctation of aorta Bicuspid aortic valve
Valvular HD with palpitations, atypical chest pain not with exertion MVP
Systolic murmurs AS, MR, MVP, HOCM
diastolic murmurs AR and MS
What increases intensity of right sided murmurs inhalation (stenosis and reurg of tricuspid and pulmonic lesions)
What increases intensity of Left sided murmurs exhalation (mitral and aortic valve lesions)
What does squatting and lifting the legs do or blood return to the heart? increases venous return to the heart
what does valsalva and standing up do to venous return to the heart decreases venous return to the heart
How does valsalva decrease venous return it increases intrathoracic pressure so venous return to the heart decreases
which murmurs increase in intensity with squatting and leg raise AS, AR, MS, MR, VSD
which murmurs decrease in intensity with squatting and leg raise HOCM and MVP
which murmurs decrease in intensity with standing and Valsalva AS, AR, MS, MR, VSD
which murmurs increase in intensity with standing and valsalva HOCM and MVP
How does handgrip affect murmurs it increases afterload, does the opposite of what ACE inhibitors do; increases intensitry of AR, VSD and MR as afterload reduction will increase flow to the aorta (with handgrip blood flow backs up into the heart)
How does Amyl nitrate effect murmurs? it causes vasodilation so decreases afterload so it decreases intensity of AR and MR
How does Handgrip effect MVP and HOCM lessens murmurs of MVP and HOCM (murmurs decrease when LV is more full)
How does Amyl effect MVP and HOCM It increases ventricular emptying so worsens murmurs of MVP and HOCM
How does hand grip effects AS Softens the murmur, it wont allow blood to flow past the valve and if it doesnt flow then there is no murmur
How does amyl nitrate effect AS it decreases afterload and increases the pressure gradient between LV and aorta so makes the murmur louder
Amyl nitrate and Handgrip effect on MS negligible effect
where is AS best heard Second R intercostal space and radiates to the carotid arteries (crescendo-decrescendo)
Where are pulmonic murmurs heard best second left intercostal space
Where best to hear AR, tricuspid Murmurs, and VSD heard best at lower left sternal border
where is MR heard the best heard best at apex and radiates into axilla (5th intercostal space below Left nipple)
Murmur intensity scoring 1: only heard with special maneuvers; 2+3:majority of murmurs; 4+5: palable thrill; 5+6: heard with stethescope partially off chest; 6: stethescope not needed to hear
Dx tests of murmurs Best initial test is ECHO, most accurate test is L heart cath; on CCS add EKG and CXR when evaluating a murmur
Treatment of Regurgitant lesions vasodilator therapy with ACE, ARBs, nifedipine (afterload reduction slows progression of murmurs)
Treatment of stenotic lesions best treated with anatomic repair and diuetics can be used to decrease pulm vascular congestion
If valsalva improves the mumur due to decreased venous return what medication is indicated Diuretics
If amyl nitrate improves the murmur by decreasing afterload what medication is indicated ACE/ARB
AS dx tests the best initial test is TTE and more accurate is TEE; L heart cath is most accurate (nl grad across the valve is 30; mod disease 30-70; severe disease>70); EKG and CXR will show LVH
Valve replacement in AS Biprosthetic valves will last avg of 10yrs and dont need comadin; Mechanical valves dont need replacement but do require coumadin
Causes of AR HTN, rheumatic HD, endocarditis, cystic medial necrosis, Marfan's, AS and reactive arthritis (usu presents with SOB and fatigue)
special PE findings in AR Quincke pulse- atrial or capillary pulsations in fingernails; Corrigan pulse- high bounding pulses; Musset's sign- head bob up and down with each pulse; Duroziez sign- murmur heard over femoral artery; Hill's sign- BP gradient higher in lower ext
Tx AR ACE/ARB, nifedipine, loops; do surgery if EF less than 55% or LVED diameter >55mm- do surgery even if no symptoms
MS causes and presentation Rheumatic HD, immigrant population and common in preg women due to increased plasma vol; Dysphagia, hoarseness, Afib leading to stroke
Murmur of MS diastolic rumble after opening snap (extra sound in diastole) and S1 louder as MS worsens the opening snap moves closer to S2
CXR in MS LAenlargement, straightening of the L heart border and elevation of the L mainstem bronchus, double density cardiac silohette
Tx of MS Diuretics and surgery (preg not a contraindication to surgery)
MR murmur holosystolic murmur that obscures S1 and S2, S3 gallop is often present (indicates vol overload and can be normal in patients under 30)
MR treatment ACE/ARB, nifedipine, loops, surgery if LFEF less than 60% or if LVED volume>40mm --do surgery even if asymptomatic
VSD basics holosystolic murmur at left lower sternal border; larger defect can present with SOB; Dx test is ECHO but cath is used precisely to determine L to R shunting; +/- surgery
ASD basics large defects lead to SOB or signs of RV failure with SOB and parasternal heave; assoc with fixed split S2; Dx is ECHO; Catheter device best treatment and repair needed if shunt ratio exceeds 1.5 to 1
fixed split A2 ASD
Paradoxical, A2 delayed LBBB, AS, LVH, HTN
Widened S2, delayed P2 RBBB, PS, RVH, Pulm HTN
DCM dx best initial test is ECHO and MUGA is most accurate method to determine EF
Causes and tx of DCM Ischemia, alcohol, adriamycin, radiation, chaga's diseae; tx same in all CM just like CHF--ACE/ARB, BB, spironolactone, Digoxin (decrease symps not mortality)
HOCM basics presents with SOB on exertion and S4 gallop (indicates LVH and decreased compliance); tx is BB and diuretics
RCM basics hx of sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial fibrosis, or glycogen storage disease; SOB is the presenting complaint and Kussmal's sign
RCM dx Cardiac cath and EKG shows low voltage; ECHO is mainstay diagnosis; Endomyocardial biopsy is most accurate diagnostic test
Pericardial disease Dx EKG best initial test with ST seg elevation in almost all leads and +/- PR seg depression
Tx of pericarditis NSAID and advance clock 1-2days if pain persists add perdnisone orally and advance 1-2 more days +/- colchicine
Presentation of Pericardial Tamponade SOB, hypotension and JVD, lung exam clear; pulss paradoxus present and can have electrical alternans
Tamponade Dx and Tx ECHO-diastolic collapse of RA and RV (less than 50ml can be there but no collapse should be seen); EKG shows electrical alternans; R heart cath shows equalization of pressures during diastole; tx: peicardiocentesis, window placement, do not use diuretics
Constrictive pericarditis presentation SOB and Chronic RHF S/S: Edema, JVD, hepatosplenomegaly, Ascites; unique s/s- kussmaul's sign, pericardial knock (extra diastolic sound)
Constrictive pericarditis dx CXR shows calcification, EKG shows low voltage, CT and MRI show thickened pericardium
tx of constrictive pericarditis initially diuretic, most effective is pericardial stripping
Dx of dissection of thoracic aorta best initial test is CXR, most accurate test is CT angio
Tx of aortic dissection (thorax) order BB and EKG and CXR on first seeing the patient; then either order CT angio, TEE, or MRA; order nitroprusside to control BP (these patients need ICU and Surgery consult)
AAA screening and screening tests screen men over age 65 who were smokers; it is first detected by US and repaired if over 5cm
Spinal stenosis presentation pain worse when walk downhill and less with walking uphill or while cycling or sitting; pulses and skin exam normal
Dx test for PAD initial test is ABI and most accurate test is angio
Tx of PAD ASA, ACE, exercise, cilostazol, statins; marginally effective Pentoxifylline; not effective CCB
if get a patient that presents with afib order the following EKG, Thyroid function, lytes, trop or CKMB
tx of afib (unstable) unstable patients need synced cardioversion, no TEE or anticoagulation (SBP<90, CHF, confusion or CP)
tx of afib (stable) slow Ventricular rate (BB, CCB, dig), then when at goal add warfarin if lasts more than 2 days
CHADS score (risk of stroke in patients with AFIB) CHF, HTN, AGE>75, DM, Stroke (2pts); score of 0-1 ASA and more than 2 anticoagulation
afib and aflutter treated the same way afib and aflutter treated the same way
when to use BB in afib or aflutter IHD, Migraines, Graves, Pheo (coreg)
when to use CCB in afib or aflutter Migraine or Asthma
when to use digoxin in afib and aflutter borderline HTN
Presentation of MAT assoc with COPD and emphysema with polymorphic P waves and HR>100, and irregular; Do not use BB
SVT presentation palpatations and tachy (160-180), not assoc with IHD and regular rhythm
tx of SVT (unstable) initially sync cardioversion
tx of SVT (stable) vagal maneuvers then try adenosine; best long term mgmt is ablation
WPW presentation SVT that can alternate with VT; worsening SVT after the use of CCB or digoxin
WPW dx EKG and most accurate is electrophys testing
what to give a patient is SVT or VT from WPW give Procainamide
best long term therapy for WPW ablation
VT presentation palpitation, syncope, CP or sudden death; still need EKG to see VT as possible cause of no pulse (tell its not PEA)
tx of VT (stable) Amio, Lidocaine, Procainamide, Mag
tx of VT (unstable) sync cardioversion
Vfib presentation sudden death; still need EKG to see vfib loss of pulse and that it's not PEA
Tx of Vfib always unsync cardioversion
Sudden LOC Cardiac or neuro (seizures)
Gradual LOC toxic-metabolic, Hypoglycemia, Drug tox/intoxication, Anemia, Hypoxia
sudden regain of consciousness cardiac, rhythm disorder v. structural disease
gradual regain of conciousness Neuro (seizures)
Cardiac exam after LOC if normal: vent arrythmia; if abnormal: structural disease (AS, HOCM, MS, MVP)
diagnostic tests with LOC cardiac and neuro exam, EKG, Chemistry, oximeter, CBC, trop (carotid dopplers not helpful in syncope)
if ventricular dysrhythmia causes syncope what does the patient need ICD placement
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