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129 Cards in this Set
- Front
- Back
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Dilated cardiomyopathy can be caused by which two drugs? |
Adriamycin and Cobalt |
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Which drug classes are used to treat dilated cardiomyopathy? (5) |
ACEi beta-blockers (cautiously - DO NOT USE with low EF) Diuretics Digoxin (second line - favored as an adjunct) Anticoagulants |
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What should be avoided in dilated CM? |
CCB (unless absolutely necessary for rate control) |
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What is used to treat hypertrophic cardiomyopathy? (6) What is the function of each tx? |
1) Beta-blockers - initial drug in sx pts 2) CCB (verapamil) - Prolongs diastole, longer filling time, negative inotropes, reduces stroke force 3) Disopyramide - adjunct negative iontrope 3) Dual chamber Pacemaker - alters septal activation 4) Septal myotomy or non-surgical septal ablation with alcohol 5) Thromboembolism/Endocarditis prophylaxis |
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What should be avoided in pts with HCM? (4) |
Digoxin, beta-agonists, nitrates, exercise
These increase HR, ventricles have less time to fill, low blood flow/EF, can result in sudden death |
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What is the treatment for a hemodynamically unstable, severely hypotensive, pt with first episode, sudden onset A-fib? What if this fails?
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Immediate Electrical DC cardioversion
Initial shock: 100-200 J in synchrony with the R wave. If fails, attempt 360 J. If this fails, IV ibutilide (1 mg over 10 min, repeat prn) |
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What is the preferred pharmological treatment for a hemodynamically stable pt with A-fib? |
Beta-blockers: preferred agent in myocardial infaction/ischemia related A-fib = - Metoprolol (5 mg IV bolus then follow up doses), OR - Esmolol (o.5 mg-0.2 mg/kg/min)
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What is the preferred pharmological treatment for a hemodynamically stable pt with A-fib if beta-blockers are CI? |
CCB = Diltiazem (20 mg bolus, repeat q 15 min) OR Verapamil (5-10 mg IV over 2-3 min, repeat at 30 min)
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What is another option for a hemodynamically stable pt with a-fib that is slow to control rate and may be inadequate? |
Digoxin - less risky but less successful (0.5 mg IV over 30 min) |
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What is a useful adjunct to rate control of A-fib that is incomplete with other agents or cardioversion is in the near future? |
Amiodarone |
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Pt has been stable with A-fib for a 48 hrs but now is having worsening sx of dyspnea but is otherwise stable. What should you do? |
First perform TEE to rule out thrombus formation. Anticoagulate with warfarin for 3-4 weeks until INR 2-3. Then use electrical DC cardioversion. |
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What else can you try if electrical DC cardioversion fails or use for maintanence therapy of A-fib? (5) |
Pharmacologic cardioversion - Ibutilide, dofetilide (risk of torsades), propafenone, flecanide, sotalol |
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What are the different ways to convert atrial flutter into normal sinus rhythm? (4) |
1) IV class III antiarrhythmic - Ibutilide (1-2 mg) 2) Electrocardioversion - 25-50 J 3) Catheter ablation (highly successful/preferred approach to recurrent typical a-flutter) 4) Amiodarone or dofetilide are the antiarrhythmics of choice if rate cannot be controlled |
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What is the most common arrhythmia associated with digoxin toxicity? |
2:1 block |
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What is the first step in managing a pt with paroxysmal supraventricular tachycardia? |
Increase the vagal tone via vagal maneuvers, stretching arms/body, lower head btw knees, coughing, splashing cold water on face, breath holding, physicians can attempt unilateral carotid massage with continuous ECG monitoring (used well in combination with digitalis, adenosine, or a CCB) |
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First line drug to terminate PSVT? When should you be cautious? |
IV adenosine (6 mg bolus, then 12 mg bolus after 1-2 min, then 12 mg bolus) Well tolerated, blocks electrical current through node Caution in pts with reactive airway disease - bronchospasm Caution with elderly pts increased chest discomfort |
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What other drug can be used for PSVT? When should you be cautious? |
CCB - induces AV block - Verapamil (2.5 mg IV bolus, 2.5-5 mg q 1-3 min) - Diltiazem (0.25 mg/kg/2 min, 0.35 mg/kg) - less hypotension/myocardial depression
Caution with CCB in pts with heart failure Avoid verapamil if arrhythmia is ventricular in origin |
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What is the third line option for PSVT? |
Short acting beta-blockers - Esmolol (500 mcg/kg IV over 1 min) or Metoprolol (5 mg bolus q 5 min) |
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What if PSVT is mediated by an accessory pathway? How do you treat? |
IV procainamide may terminate Risk of increased rate, usually given after CCB or beta-blocker |
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Pt is having an episode of PSVT and is unstable. What is the next step? What should you be cautious of? |
Synchronized electrical cardioversion - 100 J Do not use in cases of digitalis toxicity |
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What is used to prevent further episodes of PSVT? List some other drug options? |
Radiofrequency ablation is preferred over antiarrhythmic drugs
Drugs include: BB, non-di CCB (diltiazem or verapamil), Class IC drugs: flecainide, profaenone (pts without structural heart dz), class III agents: sotalol or amiodarone (pts with structural heart dz) |
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Treatment of premature beats (PVCs, PACs) |
Asx: no treatment Sx: beta-blocker, ICD placement (PVCs) |
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What is the treatment for a patient with acute ventricular tachycardia w/ hypotension, heart failure, or MI? |
Synchronized DC cardioversion with 100-360 J |
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What is the treatment for a pt with acute VT who is stable and tolerating the rhythm? (4)
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1) Amiodarone 150 mg slow IV bolus over 10 min
2) Lidocaine 1 mg/kg IV bolus injection 3) IV procainamide 20 mg/min IV +/- Magnesium 1-2 g IV 4) Ventricular overdrive pacing |
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What is the treatment for chronic recurrent symptomatic/sustained VT? (2)
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1) Pts with sign. LV dysfxn = Implantable defibrillator
2) Pts without LV dysfxn = Amiodarone + Beta-blocker (other options: AV nodal blockers, catheter ablation) |
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What is the treatment for nonsustained ventricular tachycardia? |
1) Pt w/o heart disease = no tx needed 2) Pt w/ structural heart dz or reduced LV EF = Beta-blockers (best in CAD pts w/ sign. LV sys. dysfxn <35-40%) 3) Pt with inducible VT via electrophysiologic teasting = implantable defibrillator |
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What is the treatment of a patient with sudden onset of ventricular fibrillation? |
Immediate unsynchronized DC cardioversion, CPR, Epinephrine 1 mg IV bolus q 3-5 min, Shock again, may try amiodarone IV |
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What is the treatment for a pt with torsades de pointes? |
1-2 g IV magnesium sulfate in 100 mL D5W administered over 1-2 minutes (q 4 hrs) (Amiodarone proven somewhat effective) |
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What is the definitive treatment of atrial septal defect? |
Surgery - including simple stitching, patching with Dacron or a pericardial patch, percutanous closure with Dacron umbrellas. |
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Moderately loud systolic ejection murmur over 2nd/3rd ICS parasternally, widely "fixed" split of S2, a mid-diastolic rumbling at LLSB can also be heard, Prominent RV and PA pulsations. |
Atrial septal defect (ASD) (murmur due to increased flow through pulmonary valve) |
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Continuous murmur heard superiorly and midline in the back or over left anterior chest. May also hear a systolic ejection murmur heard posteriorly. |
Coarctation of the aorta (may also hear AR/AS murmur due to 50% having an associated bicuspid aortic valve) |
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A Turner syndrome pt presents with absent and weak femoral pulses. You perform an echo which reveals a gradient of >20 mmHg and evidence of significant collateral blood vessels. How would you treat this pt? |
1) Prostaglandins can temporarily open the PDA decreasing pressure in the aorta, if needed
2) Resection of the coarctation site, endovascular stenting, or balloon-expandable covered stents aortoplasty. |
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A 2 week old infant presents with excessive sweating during feeding but is acyanotic. You listen to the chest and you hear a continuous rough "machinery" murmur in late systole. The murmur is best heard in the left 1st/2nd interspaces at the left sternal border. A thrill is also notable. What is the most likely diagnosis? |
Patent ductus arteriosus (PDA) |
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An infant has PDA but does not have evidence of pulmonary vascular disease. How would you treat? |
1) Indomethacin can be attempted 2) Surgical ligation or percutaneous placement of coil or duct occluder device |
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An infant has PDA and evidence of Eisenmenger physiology. How would you treat this patient? |
Do not correct surgically, Indomethacin is indicated for closure. |
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Within minutes of delivery, an infant begins having cyanotic episodes with crying spells. You listen to the chest and hear a persistent pulmonary outflow cres-decres murmur at the LUSB, a right-sided gallop, and a VSD murmur. What is the most likely diagnosis? How is this initially treated? |
Dx: Tetralogy of fallot
Tx: Blalock-Taussig shunt (allows increased pulmonary blood flow by attaching one of the subclavian arteries to the pulmonary artery)
Future surgical tx may include: VSD closure, resection of infundibular muscle, outflow tract patch, pulmonary valve replacement
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Pt presents with a loud, harsh holosystolic murmur over the left 3rd/4th ICS along the left sternum. A systolic thrill is also heard. What is the most likely diagnosis? |
Ventricular septal defect (VSD) (small) |
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What is the different treatments for pts with VSD? |
1) Surgical closure or percutaneous closure is indicated with a L->R shunt >2.0 and reasonable if the gradient is >1.5. Heart failure and IE are other reasons for closure
2) Tx of pulm HTN depends on response to vasodilation with nitric oxide. + response = CCB - 1st line - response = phosphodiesterase inhib. (sildenafil or tadalafil) or endothelin receptor blockers (bosentan or ambrisentan) with increased sx = prostacyclin analogs (epoprostenol, iloprost, beraprost, treprotinal)
Long time anticoagulation & supplemental oxygen also should be considered |
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What drug classes may contribute to worsening heart failure? (4)
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CCB (verapamil or diltiazem)
Antiarrhythmic drugs NSAIDs Thiazolidinediones |
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What is the initial treatment for a patient with congestive heart failure who is symptomatic (dyspnea, orthopnea, PND etc) and has reduced LV EF? |
Combination of: 1) Diuretic - Thiazides (HCT 25-100 mg, metolazone 2.5-5 mg, chlorthalidone 25-50 mg) better than loop but ineffective if GFR < 30-40 mL/min - Loop diuretics - less control over HTN, but useful in severe CHF (furosemide 20-320 mg, bumetanide 1-8 mg, torsemide 20-200 mg)
2) ACE inhibitor - captopril 50 mg TID, or enalapril 10 g BID, or lisinopril 20 mg SE: hypotension, dizziness, cough Monitor K+ level and kidney fxn |
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Common side effects of diuretics? (4)
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Hypokalemia, intravascular vol. depletion, prerenal azotemia, skin rashes
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What is a useful adjunct to loop diuretics or thiazides in CHF? What added benefit is there? What is a SE? |
K+ sparing agents: spironolactone, triamterene, amiloride
Spironolactone and eplerenone help to inhibit aldosterone which is increased in CHF
Risk of hyperkalemia is increased especially in combination with ACEi |
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What is part of the foundation of care of chronic heart failure that has significant life saving benefits including improving EF and reducing LV size/mass? |
Beta-blockers: - Cavedilol 3.125 mg BID (nonselective) - Bisoprolol 1.25 mg daily - Metoprolol succinate 12.5 mg daily
All titrated up - better tolerated |
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Pt with CHF remains symptomatic even while taking diuretics and an ACEi. What is indicated at this time? |
Digoxin - (Digitalis glycosides) - No proven benefit besides sx relief - withdrawal can worsen heart failure, result in hospitalizations, and reduced exercise tolerance - 0.125 mg 3x a week up to 0.5 mg daily |
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What drugs can increase digoxin levels in the blood up to 100%? |
Amiodarone, quinidine, propafenone, verapamil |
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What are some SE of digoxin? (4)
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May induce ventricuar arrhythmias (esp. with hypokalemia or myocardial ischemia is present)
Others include: anorexia, HA, blurry/yellow vision |
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Are nitrates useful in pts with heart failure? |
Not as much as first line therapies such as ACEi. Isosorbide dinitrate 20-80 mg oral TID has proved effective in small studies, relieves SOB but ineffective in advanced heart failure due to little effect on CO. Pt on nitrates can develop a tolerance Nesiritide is an alternative which improved CO |
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What is the impact of CCB on patients with CHF? |
1st gen. CCB may accelerate progression of CHF These are ONLY USED to treat associated HTN or angina - Amplodipine is the drug of choice |
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What are some other treatment modalities to think about in CHF? (5)
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1) Anti-coag - only for pt w/ a-fib, prior MIs, or mobile LV thrombi
2) Implantable cardioverter defibrillators 3) Biventricular pacing (resynchronization) - proven beneficial - incr. EF, improve exercise tolerance, reduction of death/hosp. in mod-severe HF pts 4) Coronary revascularization 5) Cardiac transplant - now widely used |
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What are the non-pharm treatments for essential hypertension? |
Lifestyle modification, DASH diet, Calcium & Potassium supplements, Smoking cessation |
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What is the effect of thiazide diuretics on essential hypertension? Which of these diuretics is better for 24 hr long term control? |
Decrease plasma volume, over time - reduction of peripheral vascular resistance.
Chlorthalidone is better than HCT for 24 hour blood pressure control |
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Are loop diuretics as effective as thiazide diuretics? When are these used? |
No, these lead to electrolyte and vol. depletion more readily than thiazides. They also have short durations of action. They are used in pts with kidney dysfunction. |
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What demographics is thiazide diuretics more effective? |
Blacks, elderly, obese, smokers |
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What side effects do thiazide diuretics have on elderly women? |
Loss of bone mineral content resulting in increased risk for osteoporosis |
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What are the side effects of thiazide diuretics? (5) |
Electrolyte abnormalities: Hypokalemia, hypomag, hypercalcemia, hyponatremia
Increase in uric acid - potentially leading to gout
Increase in LDLs and TGs
Rash, ED |
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What is the MOA for beta-blockers in essential hypertension? |
Decrease heart rate and cardiac output, decrease renin |
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What is the demographic that benefits most from beta-blockers? (4)
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Younger white patients with elevated renin activity
Pts with cardiovascular disease due to cardioprotective nature of beta-blockers. This includes pts with angina, prior MI, CHF. Also benefits pts with migraines and anxiety |
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What are some side effects of beta-blockers? |
Exacerbate bronchospasm in asthmatics/COPD, AV conduction depression, nasal congestion, Rayaud phenomenon, CNS effects: nightmares, excitement, depression, fatigure, lethargy, ED. |
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In the treatment of pheochromocytoma, what is the rule for using beta-blockers? |
Beta-blockers should not be administered until a-blockade has been established. If not unopposed strictor a-adrenergic receptor activation will result in worsening hypertension |
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What is a renin inhibitor that was recently approved by the FDA for mono or combo therapy for essential hypertension? |
Aliskiren |
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What is the MOA of ACE inhibitors? |
Inhibition of the RAAS system, inhibit bradykinin degradation, stimulate vasodilating prostaglandins, reduce sympathetic nervous sys. activity |
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What demographic are ACEi more effective? Which are they less effective? |
Younger white patients
Less effective in blacks and older pts |
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When are ACE inhibitors the drugs of choice? |
Type I DM, Type 2 DM, non-diabetic kidney disease, Congestive heart failure or pts with reduced ejection fraction |
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What are the side effects of ACEi? (5)
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Severe hypotension or acute renal failure in bilateral artery stenosis, hyperkalemia in diabetics or the elderly, chronic dry cough, skin rash, angioedema
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What are the benefits of using an ARB over an ACE? |
ARBs do not cause a cough, less likely to have skin rashes or angioedema |
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When are adosterone receptor antagonists used? What are some kinds? What demographic are they effective in? What are some side effects (3)? |
Used in tx of resistent hypertension, spironolactone and eplerenone, effective in blacks
SE: Spironolactone = breast pain, gynecomastia Both can cause hyperkalemia |
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What is the MOA of CCB in essential hypertension? |
Peripheral vasodilation with less reflex tachycardia and fluid retention than other vasodilators |
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What demographics do CCB benefit most? |
All demographics, all grades of hypertension Preferred over BB or ACEi in blacks and older pts |
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When should you be cautious when using CCB? |
Be cautious when combining with beta-blockers due to the ability to depress AV conduction and SA node automaticity and contractility
Also in pts with cardiac dysfxn (except amlodipine is safe in severe heart failure) |
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What are the common SE of CCB? (5)
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HA, peripheral edema, bradycardia, constipation (verapamil in elderly), dihy CCB may produce more vasodilation (nifedipine, nicardipine, isradipine, felodipine, nisoldipine, amlodipine)
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What are the other options for essential HTN treatment? |
1) a-adrenoceptor antagonists (prazosin, terazosin etc) 2) CNS acting drugs - methyldopa (SE: hepatitis, hem. anemia), clonidine, guanabenz, guanfacine) (SE: sedation, fatigue, dry mouth, postural hypotension, ED) 3) Arteriolar dilators - hydralazine, minoxidil SE: reflex tachycardia, incr. myocard. contractility, HA, palpitations, used in HTN resistence |
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What is the SE of hydralazine? (2) minoxidil? (2)
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Hydralazine = GI disturbances, lupus-like syndrome
Minoxidil = hirsutism, fluid retention |
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What drug should be part of initial HTN management in diabetics? |
ACE inhibitors (+ diuretic, CCB, or BB) |
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Which HTN drugs are more effective in young, white persons? (2)
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ACEi/ARBs or B-blockers
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Which HTN drugs are more effective in older black individuals? |
CCB and thiazide diuretics |
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What drug should be part of initial management of pt with chronic kidney disease? |
ACEi or ARB |
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What should be considered in pts with resistent hypertension? |
Aldosterone receptor blockers - spironolactone or eplerenone |
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What is the rule for reducing hypertensive emergencies? What drug should be avoided due to unpredictable nature? |
Reduce pressure by no more than 25% within min or 1-2 hrs. Then lower to >160/100 mmHg within 2-6 hrs. Reduce risk of coronary, cerebral, or renal ischemia.
Avoid sublingual or oral fast acting nifedipine |
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What are the different agents for treating hypertensive emergencies/urgencies? (7)
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1) Nitroprusside sodium - IV, lowers BP within seconds (with BB for aortic dissection)
2) Nitroglycerin - IV acute ischemic syndromes only 3) Labetalol - Most potent b- and a- blocker, used in pregnancy, avoid in CHF 4) Esmolol - SVT pts, used only if concerned for severe adverse reaction to BB 5) Hydralazine - less predictable, used for pregnancy and children 6) Clonidine - Oral 0.2 mg, lowers BP over a couple hours, rebound HTN after stopping 7) Captopril - 12.5-25 mg oral, lowers BP in 15-30 min. May result in excessive hypotension |
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Pt presents with the complaint of chest pain during exercise and one time passed out. You listen to this pts chest and you hear a harsh cres-decres. systolic ejection murmur at the R 2nd ICS radiating into the neck. You are able to palpate a LV heave/thrill. What is this pts most likely diagnosis? What is the preferred treatment? |
Aortic stenosis
Tx: Valve replacement is preferred (bovine >> porcine valves >>> mechanical (need anticoag))
Percutaneous valvuloplasty still has a minor role in young adolescent pts The Ross procedure - using pulm valve for aortic valve is still also used in young pts
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Pt presents with recent fatigue and difficulty sleeping at night. You listen to the chest and hear a high pitch diastolic blowing murmur at the 2nd-4th ICS area. You also note that the PMI is displaced down/left. You also note that his capillary beds of his fingers are flashing. You ask the pt if he ever had a history of infectious endocarditis and he says "Yes! I did about 3 years ago". What is the most likely diagnosis? |
Aortic regurgitation |
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What type of treatment should asymptomatic pts get with aortic regurgitation? What is preferred in Marfan's pts? |
Afterload reduction is recommended for pts with a systolic BP of >140 mmHg. This can be done with Beta-blockers, ACEi, and ARBs.
ACEi or ARBs are preferred in Marfan's because they reduce aortic stiffness
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What is the ultimate treatment for pts with aortic regurgitation? When is it indicated? |
Surgical replacement of the aortic valve with either homograft or bioprothetic valves + root replacement if needed.
Indicated: ECHO shows EF < 55%, LV end systolic dimension >5.0 cm (Marfan's root = >4.5) |
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A 32 y/o pregnant female presents to the office with complaints of shortness of breath with walking and a productive cough. You listen to her chest and hear a low-pitched diastolic rumble with an opening snap following S2 at the apex. You ask the patient to roll onto her left lateral side and you note you hear the murmur even better. What is the most likely diagnosis? What arrhythmia would you expect to find on ECG? |
Mitral stenosis - hx of rheumatic fever Atrial fibrillation occurs in 50-80% of pts
"Oh snap! MS. Rheumatic Fever is A-fibber" |
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What is the preferred treatment for mitral stenosis? |
Once pts are symptomatic = percutaneous balloon valvuloplasty is preferred even in pregnancy
open mitral commissurotomy - rare now
valve replacement is indicated when stenosis and regurg are present and the echo score is >8-10 |
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Pt presents with shortness of breath with exercising. Pt does have a prior history of myocardial infarction. You listen to his chest which reveals a medium pitch holosystolic blowing murmur at the apex which radiates to the left axilla. You also note a hyperdynamic LV impulse and a prominent 3rd heart sound. What is the most likely diagnosis? |
Mitral Regurgitation |
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What is the preferred treatment for pts with mitral regurgitation? When is each indicated? |
Surgical repair or replacement of the valve is indicated in acute cases, (caused by MI, endocarditis, or ruptured cordae tendinae), symptomatic pts, and asx with EF <60% or LV dilation >4.0 cm on ECHO
Asymptomatic pts - vasodilators may help such as beta blockers
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Pt is a young female who presents for a routine physical exam. You listen to the chest and note that she has a mid-systolic click followed by a late systolic murmur. You have her stand up which increases the sound of the murmur. You also note that she has moderate scholiosis in her back. What is the most likely diagnosis? How do you treat? |
Mitral valve prolapse Tx: Beta-blockers at low doses for arrhythmias or hyperdyanmic state of the heart, otherwise mitral valve repair>> replacement, earlier is proven better than later. |
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What is the most common cause of tricuspid stenosis? U.S? |
Rheumatic heart disease Carcinoid disease in the U.S. |
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Pt presents with a diastolic medium pitch rumble along the lower left sternal border which increases with inspiration and squatting. What is the most likely diagnosis? How do you treat? (3)
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Tricuspid stenosis Tx: 1) Loop diuretics esp. Torsemide >> furosemide (better absorption in the gut) 2) Aldosterone inhibitors 3) Tricuspid valve (bioprosthetic) replacement preferred |
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Pt presents to the office with a medium pitch blowing holosystolic murmur at the left sternal border. The murmur increases with inspiration and radiates the the xiphoid. There is an additional S3 present. What is the most likely diagnosis? What is the treatment? |
Tricuspid regurgitation
Tx: Well managed with diuretics if mild, loop diuretics such as furosemide or torsemide (better), thiazide diuretics may be added
Surgical tx is indicated at the same time as other valvular repairs such as for mitral valve replacement, if there is a defect that can not be repaired then replacement is warranted with a bioprothetic valve (no need for anticoag unless assoc. afib) |
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Pt presents with a loud, harsh systolic ejection murmur at the 2nd left ICS that radiates to the left shoulder. There is also a ejection click that decreases with inspiration and a delayed S2. The pt also has a palpable parasternal lift. What is the most likely diagnosis? What is appropriate treatment? |
Pulmonic stenosis (congenital, domed valve, or dysplastic valve)
Tx: Mild = normal life/no intervention
Pts who are symptomatic (domed valve) or have a mean gradient of >40 mmHg or peak gradient of >60 mmHg = Percutaneous balloon valvuloplasty is the treatment of choice/highly successful
Surgical commissurotomy, or valve replacement can also be done with a dysplastic valve or severe additional regurg |
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Pt presents with a faint, high-pitch blowing murmur at the left 2nd-3rd ICS that increases with inspiration and diminishes with valsalva. The S2 heart sound is widely split. What is the most likely diagonsis? What is the appropriate treatment? |
Pulmonic regurgitation (mcc pulm. HTN)
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What is the treatment for rheumatic fever? (4) |
1) Strict bed rest until temp is normal 2) Salicylates like ASA reduce fever, jt pain, swelling 3) Benzathine PCN 1.2 million units IM, or 600,000 units IM daily for 10 days, Alternative: Erythromycin 4) Corticosteroids - rapid improvement of jt sx |
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What is prophylaxis for recurrent rheumatic fever? |
Benzathine PCN G 1.2 mil units IM q 4 weeks (Oral is less reliable, sulfadiazine, erythromycin, azithromycin, or cephalosporin - if pt not allergic to PCN) |
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What is the empiric treatment for infectious endocarditis? |
1) Empiric = Vancomycin 1 g q 12hrs IV + Ceftriaxone 2 g q 24 hrs
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What is the treatment for S. viridans infectious endocarditis? (4) |
1) PCN G IV q 4 hrs for 4 weeks 2) PCN G + Gentamycin 1 mg/kg IV q 8 hrs for only 2 weeks 3) Ceftriaxone 2 g once daily IM for 4 weeks (better for home therapy) 4) PCN allx = Vancomycin 15 mg/kg IV q 12 hrs for 4 weeks |
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What is the treatment for S. aureus infectious endocarditis? MRSA? |
1) Nafcillin or oxacillin 1.5-2 g IV q 4 hrs for 6 weeks (preferred therapy) 2) PCN allx = Cefazolin 2 g IV q 8 hrs OR Vanco 30 mg/kg/d IV divided into 2 or 3 doses 3) MRSA = vanco (preferred) |
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What is the treatments for acute pericarditis (6)? |
Mainly symptomatic relief most spontaneously resolve 1) Salicylates/ASA/indomethacin 2) Corticosteroids if unresponsive (taper) 3) Immunosuppression if resistent to tx with methotrexate or cyclophosphamide 4) Pericardial stripping 5) Pericardial window/partial pericardiectomy - subxiphoid or video assisted thoracic surg. if tamponade (tetracycline may be admin.) 6) Colchicine may be required for years and is superior to CS |
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Pt presents with tachycardia, tachypnea, and a 10 mmHg decline in systolic BP during inspiration. The ECG revealed nonspecific T wave changes and low QRS voltage. Listening to the chest you hear muffled heart sounds. What is the most likely diagnosis? What is the treatment? |
Pericardial effusion/tamponade
Tx: 1) JVP/serial ECHOs for monitoring 2) Tamponade = pericardiocentesis via pericardial window - considered a medical emergency |
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What is Beck's triad? |
For cardiac tamponade, hypotension, muffled heart sounds, and JVD |
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What are the initial steps taken in a patient with a STEMI? |
1) ASA 162 mg/325 mg (chewable preferred) always, if ASA allergic - clopidogrel 600 mg or 300 mg loading dose, the combo of Clopidogrel and ASA may provide even better benefits without any major bleeding events 2) Oxygen and NG is given (unless right ventricular infarction) 3) PCI or thrombolytics are administered |
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What is the ultimate goal for a patient with STEMI when arriving to the hospital? |
Treat pts who seek medical attention within 12 hrs of the onset of symptoms with reperfusion therapy - coronary angiography and Primary PCI or thrombolytics |
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Which is better for treating STEMI, PCI or thrombolytics? |
PCI is preferred and superior to thrombolysis. Reduces mortality, lower risk of intracranial hemorrhage. Uses bare metal stents most commonly or bivalirudin or plt glycoprotein IIb/IIIa on the stents. Door to balloon should be <90 min |
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What time frame results in the greatest benefit of thrombolytics in pts with STEMI? |
Within 3 hours of symptom onset, results in a 50% reduction in mortality (after 12 hrs this is only 10%) |
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What are the 6 absolute contraindications for thrombolytic therapy? |
1) previous hemorrhagic stoke 2) any other stroke/CVA within 1 year 3) intracranial neoplasm 4) recent head trauma 5) active internal bleeding 6) suspected aortic dissection
HSIHIA |
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What are the relative contraindications for thrombolytic therapy? (12) |
1) BP >180/100 mmHg 2) Known bleeding diathesis 3) Trauma (minor head trauma) within 2-4 wks 4) Major surgery within 3 weeks 5) Prolonged (>10 min) or traumatic CPR 6) Internal bleeding w/in 2-4 weeks 7) Non-compressible vascular puncture 8) Active diabetic retinopathy 9) Pregnancy 10) Active PUD 11) Current use of anticoagulants 12) Hx of severe hypertension |
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What are the thrombolytic agents? |
1) Alteplase (t-PA) - naturally occurring plasminogen activator 2) Reteplase - recominant deletion mutant of t-PA, less fibrin specific, longer duration of action 3) Tenecteplase - genetically engineered substitution mutant of native t-PA, significantly less bleeding 4) Streptokinase - less effective, not used in the U.S., non-fibrin specific, induces hypotension, anaphylaxis can occur |
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What is continued after thrombolytic has been used for a pt with STEMI? |
1) ASA 2) IV heparin 60 units/kg bolus until 4000 units, then 12 units/kg/min to a max of 1000 units, then maintain aPTT btw 50-75 sec. for 48 hrs or until revascularization or hospital discharge 3) Warfarin therapy should initiate at some point and continue for 3 mo reduces emboli risk |
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What type of heparin are pts sent home with in post MI pts? |
LMWH such as enoxaparin or fondaparinux |
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How should pain be controlled in pts post MI? What should be avoided? |
1) Subling. NG - agent of choice for ischemic pain, reduces pulmonary congestion 2) Morphine sulfate 4-8 mg or meperidine 50-75 mg
Avoid NSAIDs (other than ASA) due to risk of myocardial rupture, HTN, HF, kidney injury |
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What should be started within the first 24 hrs of an MI? What is the benefit? |
Beta-blockers - decr. HR, decr. oxygen demand, decr. arrhythmias, decr. overall mortality (metoprolol, carvedilol, esmolol) |
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What additional agent has shown improved survival after a STEMI and greatly benefits pts with a EF < 40%? |
ACEi such as captopril, enalapril, or forsinopril (Or ARB - valsartan) |
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Do calcium channel blockers play a role in STEMIs? |
No. CCB have the potential to exacerbate ischemia and cause death from reflex tachycardia or myocardial depression |
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If thrombolytic/fibrolytic therapy only allows for 50% reperfusion in STEMI pts what should be done within 24 hrs? |
Coronary angioplast with PCI within 3-24 hrs of fibrinolytic tx showed improved outcomes |
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Can thrombolytics be used in NSTEMI? |
NO, do not use in non-STEMI |
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What is the treatment regimen for a pt with NSTEMI?(7)
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1) ASA 81-325 mg or clopidogrel
2) unfr. heparin or LMWH (enoxaparin 1 mg/kg SQ q 12 hrs, fondaparinux 2.5 mg SQ once a day) less bleeding with fondaparinux 3) Glycoprotein IIb/IIIa receptor antagonists - for high risk pts with fluctuating ST-segment depression (Tirofiban, eptifibatide, abciximab) 4) Nitroglycerin -1st line for CP, SL or oral, IV NG if pain persists 5) Beta-blockers- titrate to BP 6) Statins - (atorvastatin 80 mg) improved outcome 7) Coronary angioplasty based on risk |
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Pt is a 50 y/o female who woke up in the early morning with severe chest pain. The pt states this has never happened before and has never had CP while exercising. The pt does smoke. ECG reveals ST elevation. How should this pt be treated? What should be avoided? |
Prinzmetal Variant angina 1) Coronary angiography should be performed to rule out any stenotic lesions 2) If none, coronary vasospasm responds well to nitrates and CCB (nifedipine, diltiazem, amlodipine) 3) Avoidance of precipitants such as cigarettes, avoid beta-blockers may exacerbate vasospasm |
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What is the difference in treatments of stable vs. unstable angina pectoris? |
Stable angina = responds to ASA and sublingual NG, beta-blockers can also be used, CCB - secondary choice
Unstable angina = ASA + Clopidogrel for 9-12 mo, beta-blockers, LMWH x 2 days (enoxaparin = DOC), nitrates, glycop. IIb/IIIa, treated as an MI except for fibrolytics |
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When is elective repair indicated in abdominal aortic aneurysms? |
Diameter of >5.5 cm or rapid expansion of >5 mm in 6 mo (1 cm in 12 mo) Or any pt with pain or tenderness |
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When is elective repair indicated in thoracic aortic aneurysms? |
Ascending = 5-6 cm (5 for Marfan's) Descending = 6-7 cm
Current Diameter > 6 cm are considered for repair
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How is aortic dissection treated medically? (4)
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Rapid reduction in systolic BP to 100-120 mmHg with a beta-blocker - Labetalol is preferred due to both a- and b- blockade which achieves rapid blood pressure control
Labetalol 20 mg IV over 2 min (add. dose 40-80 mg IV q 10 min max dose 300 mg) Esmolol can be used for pts with asthma or bradycardia Nitroprusside can be added if resistent Morphine sulfate can be used for pain |
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When is surgical intervention indicated in aortic dissection? |
Urgent surgery is required for all Type A dissections
Surgery is only indicated for Type B dissections if there is aortic branch compromise affecting renal, visceral, or extremity vessels. |
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What are the surgical treatments for varicose veins? |
- endovenous radiofrequency or laser ablation - greater saphenous vein stripping - Phelbectomy (less effective) - Sclerotherapy for small <4 mm veins |
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What is the treatment for phlebitis/thrombophlebitis? |
Local heat, NSAIDs, ligation/division (if progressing) Septic = S. aureus coverage broad spectrum abx Anticoag w/ heparin if indicated |
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Pt presents with head ache, scalp tenderness, jaw claudication and a history of polymyalgia rheumatica. What is the treatment? |
Prednisone 60 mg/day initiated immediately to prevent permanent blindness
Aspirin 81 mg may be added to therapy |
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What is the treatment for acute arterial occlusion of a limb? (3) |
Immediate revascularization 1) unfractionated heparin 5000-10,000 units IV 2) Catheter directed chemical thrombolysis with TPA (needs 24 hrs to work, need screening ECHO, and intact neuro of a pt) 3) Surgical embolectomy may be need for femoral, popliteal, and pedal vessels
(pretreat pt with sodium bicarb to prevent reperfusion syndrome where high levels of lactic acid and K+ are released into the system) |
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What is the treatment of a DVT? |
1) Initial treatment is with unfractionated heparin or LMWH (equal) - - Unfractionated heparin is preferred in pts with chronic kidney disease (GFR <30 mL/min) and those high risk of bleeding (post surgery) - - SQ Fondaparinux can also be used
2) Warfarin 5 mg daily started simultaneously and continues for 3 months (except in cancer related thrombus, they remain on LMWH) |
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What are some other drugs coming to the market for DVTs? |
1) Dabigatran - oral, noninferior to warfarin, used for atrial fibrillation 2) Rivaroxaban - oral direct factor Xa inhibitor approved in Europe and Canada
Benefits = predictable dose effects, minimal drug interactions, rapid onset of action, no need for lab monitoring |
