Cardio 1

Front 1

What is stable angina due to? What is coronary ischemia due to?

Back 1

i)due to fixed narrowing of vessels due to atherosclerosis. ii)Due to imbalance b/w blood supply and O2 demand->inadequate perfusion.

Front 2

What are the clinical presentations of CAD? x5

Back 2

i)asymptomatic ii)stable angina pectoris iii)USA iv)MI v)sudden death

Front 3

What are some risk factors for stable angina? x5

Back 3

i)DM ii)High LDL iii)low HDL iv)homocysteinemia v)m>45; w>55

Front 4

What are the prognostic indicators of CAD? x3

Back 4

i)LV function (EF): <50% means bad ii)vessel: L MCA: poor b/c 2/3 of heart. iii)>1 vessel involved

Front 5

when to use a stress EKG?

Back 5

i)confirm angina DX ii)evaluate response of therapy iii)ID pts w/CAD who may have high risk of ACS

Front 6

what are clinical features of stable angina?

Back 6

i)pressure, squeezing, heaviness CP ii)brought on by exertion or emotion iii)relieved by nitro

Front 7

What are the diagnostic modalities for stable angina? x5

Back 7

i)1st: EKG-> ii)if +, exercise stress test or iii)pharm stress test iv)Holter monitoring: ambulatory EKG in silent ischemia. v)cardiac cath w/coronary angiography: if +stress test

Front 8

What is normal EKG in stable angina, and what are 2 other situations?

Back 8

i)nl: no changes ii)if Q wave: prior MI iii)If ST or T wave during CP, treat as if unstable angina

Front 9

What is Syndrome X?

Back 9

exertional angina w/nl coronary arteriogram (no stenosis at cardiac cath). ii)see evidence of MI. iii)excellent PX

Front 10

What is a + stress test? x4 What do you do if +?

Back 10

i)ST depression:subendocardial ischemia ii)CP iii)arrythmias iv)hypotension. Need cardiac cath

Front 11

What are the types of the stress test? x3

Back 11

i)stress EKG ii)stress echo: exercise induced ischemia seen in wall motion abnl not present at rest. Often favored over stress EKG (ischemia, LV size/fcn, valvular dz seen). iii)nuclear perfusion imaging: enhances info from stress test. Viable myocardial cells extract radioisotope from blood, so if no uptake, then no blood flow to area of mycardium. Need to figure out reversible areas vs irreversible b/c can use PTCA or CABG

Front 12

What are the drugs in pharm stress test and how do they cause stress?

Back 12

i)adenosine and dipyramidole: cause entire system to vasodilate, and since dz'd ones are maximally dilated at rest, they get less flow. ii)dobutamine: incr HR, BP, contractility

Front 13

What are the 4 parts to the treatment plan in SAP

Back 13

i)risk factor modification ii)medical therapy iii)revasc iv)management decisions

Front 14

what are some risk factor modification methods for CHD? x3

Back 14

i)smoking: cuts CHD risk by 1/2. ii)diabetes: more eff on microvasc iii)diet: decrease sat fat and chol

Front 15

what are the main drugs used in CAD? x5

Back 15

i)ASA: decreases morbidity (decr risk of MI) ii)B block: block symp stim of heart (decr HR, BP, and contractility). They decr freq of coronary events. iii)nitrates: decr preload. iv)CCB: afterload reduction and coronary vasodilation. Secondary treatment to B block or nitrates. v)CHF present: ACE or diuretic

Front 16

what is the management of stable angina?

Back 16

i)risk mod and ASA in all ii)B block and nitrates for mild. Possible CCB. iii)moderate dz: 2 vessel dz, mod angina: coronary angiography (PTCA or CABG?) iii)Severe: decr EF, severe angina, LMCA or 3 vessels do angio and CABG

Front 17

What is ACS?

Back 17

plaque rupture and occlusion. Used for USA and MI

Front 18

Pathophysiology of USA?

Back 18

Due to decreased coronary flow at rest: O2 demand is unchanged. It is due to stenosis that has enlarged via thrombosis, hemorrhage or plaque rupture

Front 19

Definition of the patient that has USA? x3

Back 19

i)pts w/chronic angina w/incr freq, duration, or intensity of CP. ii)pts w/new onset angina that is severe and worsening iii)pts w/angina at rest

Front 20

How to DX USA?

Back 20

(sim to stable angina). i)R/o MI ii)stabilize w/meds b/4 stress test or just do cardiac cath initially if high prob (TIMI)

Front 21

How to treat USA?

Back 21

i)admit and give IV and O2. Give nitrates and morphine for pain. ii)meds: ASA; B-Block; LMWH w/PTT 2-2.5 if nl Heparin; nitrates; GP2b/3a inhibitors (abciximab) iii)cardiac cath/revasc if no response to med therapy or if EKG has ischemia after 48 hrs on stress test. iv)post acute treatment: a)ASA, B block, nitrates; b)decr risk factors: esp statin; consider folic acid: good for endothelium and as antiox

Front 22

What is variant angina?

Back 22

i)transient coronary vasospasm that is accompanied by atherosclerotic lesion but can be in normals. ii)Get angina at rest and ass'd w/ventricular dysrhythmias iii)ST elevation: transmural.

Front 23

How to DX Prinzmetal's? how to treat?

Back 23

i)coronary angiography: vasospasm w/ergonovine. ii)vasodilate: CCBs and nitrates

Front 24

What is MI due to?

Back 24

i)necrosis of myocardium b/c of interuppted blood supply (thrombotic occlusion of coronary previously narrowed by athero).

Front 25

What is mortality in MI?

Back 25

i)30%. ii)1/2 are prehospital

Front 26

What are the clinical features of MI?

Back 26

i)CP: radiates to back, neck, jaw, arms ii)some have epigastric discomfort. (substernal CP lasting >30 min w/diaphoresis=usually MI) iii)can be asympto: old, DM, postop, women. iv)SCD due to VFib. v)other sxs: dysp, N/V, syncope, impending doom

Front 27

How to DX MI?

Back 27

i)EKG ii)cardiac enzymes: CKMB and Troponin I and T

Front 28

i)What are markers for EKG changes in MI?

Back 28

i)a)Peaked T waves early b)ST seg elevation: transmural c)Q waves: necrosis, seen late d)T wave inversion e)ST segment depression: subendocardial injury

Front 29

What are categories of infarcts in MI?

Back 29

i)ST segment elevation infarct: transmural; larger. ii)Non ST segment elevation infarct: subendocard (inner 1/3 to 1/2 of wall); smaller; presents like USA but cardiac enzymes differentiates

Front 30

What are the diff cardiac enzymes; What is there pattern; how to manage and when to get the tests?

Back 30

i)CKMB: gold std. incr w/in 4-8 and returns 48-72 w/peak at 24; measure at admission and q8 hrs. ii)Troponins (I and T): incr 3-5 hrs; returns 5-14 days w/peak at 24-48; better sn/sp; obtain at admission and q 8 hrs; falsely incr w/renal failure

Front 31

W/cardiac enzymes, when is injury more severe and worse prognosis?

Back 31

higher the peak and longer enzyme levels remain elevated

Front 32

What drugs have been shown to decr mortality in MI?

Back 32

i)ASA ii)B block iii)ACE-I

Front 33

How do you treat MI?

Back 33

i)admit to CCU and do IV access w/O2 and analgesics. ii)med TX iii)Revasc: earliness is more imp than type of reperfusion (tPA vs PTCA) iv)rehab:exercise and risk factor reduction; reduces sxs and prolongs survival

Front 34

What meds do you use for MI?

Back 34

i)ASA ii)B block: decr afterload iii)ACE-I: w/in hrs of admit iv)statins: maintenance; v)heparin: no decr in mortality but prevents thrombus progression (+IV, morphine, and O2)

Front 35

What are the complications of MI? x5

Back 35

i)CHF:mild case treat medically; severe may lead to cardiogenic shock ii)arrhythmia iii)rupture iv)pericarditis v)recurrent MI: CK MB used; and if repeat ST elevation w/in 1st 24 hrs, think recurrent infarct.

Front 36

What type of arrhythmias may result from MI? (x10)Treatments?

Back 36

i)Premature ventricular contractions (PVCs), sinus bradycardia, accelerated idioventricular rhythm, 1st and 2nd degree AV block: observe ii)A-fib iii)VT: cardioversion if unstable; antiarrhythmics (amio) if stable. iv)Vfib: defib/CPR v)PVST vi)sinus tach: treat cause (pain pills, ASA for fever). vii)asystole: defib for VFib if unclear; if clear, then pacemaker. viii)2nd/3rd degree AV block: ant MI needs pacemaker; inf MI can use atropine unless conduction not restored

Front 37

What are the types of mechanical complications for MI x3? What are the sequelae, and when do they occur?

Back 37

i)free wall rupture: usually day 1-4 post-MI. leads to hemopericardium and tamponade. treat: stabilize, pericardiocentesis, SX repair. ii)IV septum rupture: 10 days post. treat: emergent surgery. iii)pap muscle rupture: produces MR; need echo immediately if suspect; treat: mitral valve replacement w/NaNitroprusside or IABP to decr afterload

Front 38

What is diff b/w ventricular pseudoaneurysm and ventricular aneurysm and what are they complications of?

Back 38

i)complication of MI. ii)pseudo: incomplete free wall rupture (contained by pericardium); due an echo and need surgery b/c becomes rupture. iii)aneurysm: no rupture but get v-tach; usually just meds given

Front 39

what are the 2 types of pericarditis and what are their cure?

Back 39

i)acute pericarditis: give ASA, NSAIDs and steroids contraind. ii)Dresslers: fever, malaise, pericarditis, leukocytosis. give ASA

Front 40

What are the groups for the DDX of CP

Back 40

i)heart, pericardium, vascular ii)pulmonary iii)GI iv)chest wall v)psych vi)cocaine: causes angina or MI

Front 41

what is DDX of heart causes of CP?

Back 41

i)3 kinds of angina ii)MI iii)pericarditis iv)dissection

Front 42

pulm causes of DDX of CP?

Back 42

i)pulm embolism (pain w/infarct). ii)pneumothorax iii)pleuritis iv)pneumonia v)status asthmaticus

Front 43

DDX of GI causes of CP?

Back 43

i)GERD ii)diffuse eso spas iii)PUD iv)eso rupture

Front 44

DDX of chest wall causes of CP?

Back 44

i)costochondritis ii)muscle strain iii)rib fracture iv)thoracic outlet syndrome v)herpes zoster

Front 45

What is approach to treating pt w/CP?

Back 45

i)r/o life threatening causes: MI, USA, dissect, PE, pneumothorax, rupture. ii)vitals iii)hx iv)PE v)tests: a)cardiac enzymes, b)EKG, c)CXR d)workup of PE if appropriate

Front 46

What do you do if chronic angina becomes USA

Back 46

i)EKG and enzymes ii)ASA iii)IV heparin

Front 47

Describe FS relationship in CHF

Back 47

i)Nl: increase preload->incr contractility/SV. at rest, no diff b/w CHF and nl. ii)exertion: increase preload w/o incr contractility.

Front 48

Diff b/w systolic and diastolic dysfcn?

Back 48

i)systolic: due to impaired contractility (decr EF); post MI, cardiomyopathy, myocarditis. ii)diastolic dysfcn: impaired relaxation or incr stiffness. Can see impaired relaxation on echo. Cause: HTN, valve dz, restrictive cardiomyopathy

Front 49

What are some symptom (x3) and signs (x5) of LHF:

Back 49

i)SX: nocturnal cough (nonprod) worse in recumbency; confusion and memory problem b/c of low brain perfusion; diaphoresis and cool ext at rest. ii)Signs: cardiomegaly->displaced PMI. S3: ken-tuck-Y (after S2). S3: rapid filling phase into stiff ventricle; at the apex. S4:a-kick into stiff ventricle. S4 b/4 S1 (TEN-nes-see); Left sternal border. crackles and rales at lung base. Pleural effusion (decr fremitus).

Front 50

Sxs and signs of RHF

Back 50

nocturia; rt ventricular heave.

Front 51

How do you DX CHF? x6

Back 51

i)CXR: cardiomegaly; Kerley B lines (lines near costophrenic angles due to pulm congestion b/c of dilation of pulm lymphatic vessels); interstitial markings; effusion. ii)echo: initial test for CHF! Can tell you if systolic or diastolic dysfcn; if CHF is pericardial, myocardial, valvular and estimates EF(imp). iii)EKG: for detection of chamber enlargement and if ischemic HD or prior MI. iv)radionuclide: precision for LV and RV EF (esp if echo suboptimal w/pulm dz). v)cardiac cath: clarifies cause of CHF if noninvasive results no good. can use angiograpy to exclude CAD as cause. vi)stress test

Front 52

How to treat systolic dysfcn?

Back 52

i)Na restrict ii)diuretics: no decr in mortality or improved px. lasix is best. iii)ACE-I: venous and arterial dilation to decr preload and afterload. ACE+diuretic should be initial treament. Ace reduce mortality; need to monitor BP, K, BIN, Cr. iv)B block: decrease mortality; slows tissue remodeling and given to stable patients only. v)digitalis: no improved mortality; need to check levels. Useful in bad EF, bad CHF, bad Afib. vi)hydralaine/isosorbide dinitrates: intolerable ACE-I. Improves CHF, but not as effective as ACE-I