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161 Cards in this Set
- Front
- Back
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What is the simplest test for dx of angina?
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stress ecg
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What is the definitive test for assesing severity of CAD?
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coronary angiography
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If you have a constant PR interval where 1 or more beats fail to conduct, what kind of AV block is that?
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2nd degree AV block - Mobitz 2
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Which do nitrates affect: afterload or preload
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predominantly preload and some afterload
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What does hydralazine affect: afterload or preload
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afterload
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What is a common cause of multifocal atrial tachycardia?
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COPD, sepsis, CHF
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If CP lasts >30 min. and is unrelieved by NTG, what is it?
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acute MI
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What kind of ECG findings for Prinzmetal's angina?
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transient ST changes
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What is DOC for Prinzmetal's angina?
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CCB
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What are characteristics of left sided heart failure?
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pulmonary congestion (dyspnea, orthopnea)
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What are characteristics of right sided heart failure?
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edema, congestive hepatomegaly and systemic venous distention
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What is MC cause of right sided heart failure?
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Left sided heart failure
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Define hypertensive emergency.
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diastolic pressure >120 with end organ failure (encephalopathy, cardiac, and renal)
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What heart defect is characterized by a mid-systolic click and a crescendo murmur.
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mitral valve prolapse
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What dysrhythmia has a heart rate between 150 and 250 bpm?
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supraventricular tachycardia
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What are the ECG findings of hypokalemia?
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flattened t-waves
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What are the ECG findings of hyperkalemia?
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diffuse peaked t-waves
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What is the scale for measuring heart murmurs?
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Levine
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What are the most common side effects of beta blockers?
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fatigue
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What drugs are contraindicated when treating hypertension in DM patients?
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thiazide diuretics
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What heart condition shows a "water bottle" sillouette on CXR?
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pericarditis
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What is the most common cause of angina
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atherosclerotic coronary artery disease
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Describe the murmur of aortic stenosis
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mid systolic ejection murmur (harsh and blowing) that radiates to the carotids and can be heard over the aortic area (s4 may be heard)
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Describe the murmur of mitral valve prolapse.
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midsystolic click that is heard best at the apex. Enhanced by valsalva maneuver and decreased by squatting
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Describe the murmur of mitral valve regurgitation.
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blowing murmur best heard at the apex and radiates to axilla. can be enhanced by occluding the brachial artery
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Describe the murmur of pulmonary stenosis.
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crescendo-decrescendo best heard at pulmonic area. harsh quality with radiation to neck or back. intensifies with deep inspiration
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Describe the murmur of ventricular septal defects.
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Holosystolic murmur heard best over tricuspid area with radiation to right lower sternal border.
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Describe the murmur of atrial septal defect.
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mid-systolic flow murmur heard best over pulmonic area and may radiate to back
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Name the cyanotic heart defects.
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tetrology of fallot, transposition of great vessels, tricuspid atresia
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Name the acyanotic heart defects.
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ventricular septal defect, atrial septal defect, patent ductus arteriosus
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Describe the murmur of aortic regurgitation.
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1. early midsystolic flow best heard over right sternal border with radiation to neck. All this due to large volume of blood ejected rapidly during systole (because left ventricle is extremely overloaded).
2. blowing decrescendo heard best in 3rd left ICS with radiation to left sternal border. All this due to retrograde flow into left ventricle 3. Austin Flint Murmur - soft, rumbling, low-pitched late diastolic murmur heard best at the apex due to functional mitral valve stenosis male predominant |
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Describe the murmer of mitral stenosis.
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Appears .08 sec. after s2 and is heralded by "opening snap". Holosystolic, low pitched, decrescendo, and rumbling best heard at the apex with patient in left lateral decubitus position
female predominant |
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Name the conditions that cause diastolic murmurs
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mitral stenosis, aortic regurgitation
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Name the defects that cause systolic murmurs
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atrial septal defect, ventricular septal defect, pulmonary stenosis, mitral regurgitation, mitral valve prolapse, aortic stenosis, aortic regurgitation (sometimes)
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What defect causes fixed splitting of s2?
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atrial septal defect
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How do you treat an asymptomatic atrial septal defect?
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no treatment required unless patient becomes symptomatic
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Define acute heart failure
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sudden reduction in cardiac performance, resulting in: acute pulmonary edema, hypotension with or without peripheral edema
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What are causes of acute heart failure?
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infection, arrhythmias, ischemia, physical, environmental and emotional excesses, pulmonary embolism, anemia, thyrotoxicosis, pregnancy, infective endocarditis, closed chest trauma, rupture of papillary muscle
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What are SSx of acute heart failure?
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dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cheyne-stokes respiration, cerebral symptoms - altered mental status due to decreased cerebral perfusion, nocturia
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What are physical exam findings of acute heart failure?
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systolic hypotension - cool, diaphoretic extremities, cyanosis of lips and nail beds, sinus tachycardia; reduced pulse pressure, JVD, positive abdominojugular reflex, pulsus alternans, pulmonary rales, hydrothorax, jaundice
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How do you diagnose acute heart failure?
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ECG, CXR, echo with doppler flow studies, BNP, Framingham criteria
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What BNP level is diagnostic of acute heart failure?
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>200 pg/mL
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Is BNP elevated in dyspnea due to lung disease?
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no
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What labs are used to diagnose acute heart failure?
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BNP, Troponin T & I, CRP, uric acid, cardiac enzymes (to r/o MI), UA (albuminuria, high sp. gravity, low sodium), CBC, CMP. In selected patients - eval. for DM, dyslipidemia, and thyroid abnormalities.
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What is the "gold standard" for assesing left ventricular mass and volume?
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MRI
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What are the two primary hemodynamic determinants of acute heart failure?
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elevated left ventricular filling pressures and decreased cardiac output
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What are the Tx goals for acute heart failure?
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hemodynamic stabilization, identify and treat underlying causes, prevent disease progression and relapse
**hopital admission almost always required - often in ICU |
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What are pharmacologic Tx of acute heart failure?
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IV loop diuretics 20-400 mg/d
IV vasodilators inotropic agents - used when vasodilators and diuretics are not helpful (last choice) vasoconstrictors - reserved for true emergencies only |
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What are mechanical and surgical interventions for acute heart failure?
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intraaortic balloon counterpulsation, LVAD, cardiac transplant
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What are common arrhythmias associated with acute heart failure?
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PVC, asymptomatic v-tach, v-fib
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How do you treat arrhythmias associated with acute heart failure?
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correct electrolyte and acid base disturbance
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How do you treat pulmonary edema?
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Oxygen therapy (PPV if supplemental o2 is inadequate -->intubation and mechanical ventilation if PPV is inadequate), reduce preload
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What are choices for reducing preload when treating pulmonary edema?
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Lasix .5-1.0 mg/kg, sublingual NTG .4mg q 5 min. x 3 if ineffective-->IV Nitroprusside, morphine, ACEi, inotropic agents, digitalis, intraaortic counterpulsation followed by surgery, AV sequential pacemaker
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Discuss systolic vs. diastolic heart failure.
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systolic - inability of ventricle to contract normally-->inadequate CO-->EF<40%
diastolic - inability of ventricle to relax and fill normally-->elevated filling pressures-->EF>50% **often coexist |
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Discuss low output vs. high output heart failure.
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low output - CO at rest = <2.2L/min
high output - CO = >3.5L/min |
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Discuss left sided vs. right sided heart failure.
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Left sided - pulmonary congestion (dyspnea, orthopnea)
Right sided - edema, congestive hepatomegaly and systemic venous distention |
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What are SSx of chronic heart failure?
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dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue and weakness, abdominal Sx, cerebral Sx, nocturia
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What are physical exam findings of chronic heart failure?
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pulmonary rales with or without expiratory wheeze, lower extremity edema, pleural effusion, ascites, congestive hepatomegaly, JVD, elevated diastolic arterial pressure, depression, sexual dysfunction, LATE and SEVERE: pulsus alternans, diminished pulse pressure, jaundice, decreased urine output, cardiac cachexia
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What are the major criteria for diagnosis of chronic heart failure?
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paroxysmal nocturnal dyspnea, neck vein distention, rales, cardiomegaly, acute pulmonary edema, s3 gallop, increased venous pressure, positive hepatojugular reflux
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what are the minor criteria for Dx of chronic heart failure?
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extremity edema, night cough, dyspnea on exertion, hepatomegaly, pleural effusion, vital capacity reduced by one-third of normal, tachycardia
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What are labs used for Dx of chronic heart failure?
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ECG, BNP, UA, CMP
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What are imaging studies used to Dx chronic heart failure?
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CXR and echo with doppler flow studies
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Describe the classification for heart failure - briefly.
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A - at risk; no sx or structural abnormalities
B - structural disease without sx C - structural disease with prior or current sx D - refractory HF requiring specialized interventions |
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Describe Tx approach to heart failure.
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A - treat HTN, smoking cessation, treat lipid d/o, lifestyle modifications
B - all A measures + B-blocker C - all A and B measures + diuretic, digitalis (in systolic HF), spironalactone, <2g Na diet D - all A, B, and C measures, < 1g Na diet, mechanical assist devices, heart transplant, continuous IV inotropic infusions for palliation, hospice care |
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How do you treat severe A-fib?
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cardioversion
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What is first line Tx for SVT?
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adenosine or CCB
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How do you treat A-fib.
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B-blockers and CCB
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How do you treat sustained ventricular tachycardia?
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cardioversion and lidocaine
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How do you treat ventricular fibrillation?
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defibrillation and lidocaine
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How do you treat Torsades de Pointe?
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Magnesium Sulfate
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How do you treat chronic heart failure?
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1. thiazides except refractory HF and severe pulmonary edema (use loops)
1. ACEi - at all stages unless CI (use ARB's) 2. B-blockers in Stage C - start low and go slow 3. Digoxin 4. Ventricular resynchronization 5. management of arrhythmias 6. anticoagulation |
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What are monitoring parameters for chronic heart failure?
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serial BNP measurements, daily weight, pt education, supervised outpt care
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What is the most common sustained tachyarrhythmia?
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atrial fibrillation
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Define atrial fibrillation.
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disorganized atrial activity without effective atrial contraction
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What is the mechanism of a-fib?
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multiple reentrant impulses through the atria create continuous electrical activity or "wavelets"
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Discuss tx approach to a-fib.
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If a risk factor or precipitating illness is present -->treat that first
If new onset and severely compromised patient -->electrical cardioversion is tx of choice Absence of severe cardiovascular compromise -->pharmacological therapy is initial tx of choice |
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Once normal sinus rhythm is restored, how do you prevent reccurance of a-fib?
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antiarrhythmics - procainamide, amiodorone, etc.
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How do you convert to a normal sinus rhythm during a-fib?
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cardioversion and/or quinidine, flecainide, ibutilide
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What are risk factors for SVT
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family hx of preexcitation, digitalis intoxication, hyperthyroidism, adrenergic drugs, pregnancy, hypokalemia
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What is Tx for SVT?
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carotid massage
adenosine cardioversion ablation (except in SNART) |
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How do you prevent reccurance of SVT?
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b-blockers, CCB, digoxin
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How do you treat WPW?
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TOC is radio frequency catheter ablation
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How do all antiarrhythmic drugs work?
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altering ion fluxes within excitable tissues in the myocardium
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What is the most common sustained tachyarrhythmia?
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atrial fibrillation
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What is the mechanism of atrial fibrillation?
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multiple reentrant impulses through the atria create continuous electrical activity
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In a stable patient wih atrial fibrillation, what is the first diagnostic approach?
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obtain ecg - compare with ecg recorded during normal sinus rhythm
JVP will have no A waves, the arterial pulse will vary in amplitude, and the first heart sound will vary in intensity |
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What are some labs that you might order if the clinical presentation warrants them in a patient with atrial fibrillation?
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TSH, BAC, electrolytes, ABG
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What arrhythmia are the following ecg findings associated with?
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no discernible P waves
rate = 350-600 beats/min irregular and rapid ventricular rate |
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If a patient presents with new onset atrial fibrillation and is severely compromised, what is the tx of choice?
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cardioversion
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How do you control heart rate in a patient with new onset atrial fibrillation?
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IV Diltiazem, IV B-blocker, digoxin, or some combination
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If a patient remains in atrial fibrillation after attempts at pharmacologic rate control, what drug to you give next?
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IV unfractionated or subq Low Molecular Weight Heparin
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You have just started you patient with atrial fibrillation on heparin therapy. You have determined that the duration of a-fib. has been <48 hrs, and they have no clinically significant left ventricular dysfunction, mitral valve disease, or previous embolism. What is your next step in tx?
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IV ibutilide; or oral propafenone or flecainide; or oral quinidine; or direct current shock
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If you are unsure how long a patient has been in atrial fibrillation, is it ok to perform cardioversion?
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no. If >48 hrs or duration is unknown or patient has a high risk of embolism, you must perform TEE guided cardioversion OR anticoagulate for 3 weeks followed by direct cardioversion, with or without concommitant antiarrhythmic drugs
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Once a normal sinus rhythm is restored and maintained from atrial fibrillation, what is f/u therapy?
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Warfarin x 6-12 weeks and assesment of need for long term antithrombotic therapy
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If cardioversion fails to restore normal sinus rhythm or there is an early recurrance of atrial fibrillation, what is next step?
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long term antithrombotic therapy and rate control or repeated direct current cardioversion with new antiarrhythmic drug
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When is ablation therapy an option for atrial fibrillation?
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When the patient has recurrent or sustained a-fib with poor rate control or sx related to the irregular rhythm
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What drugs can you use to prevent reccurance of atrial fibrillation?
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procainamide, flecainide, propafenone, sotalol, dofetilide, amiodarone
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What criteria do you use when choosing an anti-arrhythmic drug to prevent recurrance of atrial fibrillation?
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LV EF<45% and/or CHF - amiodarone or dofetilide.
CAD, normal EF, no CHF - sotalol, amiodarone, dofetilide HTN - flecainide no structural heart disease - first choice: flecainide second choice: sotalol or amiodarone |
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What is the anticoagulant of choice in patients <65 y.o. with no cardiovascular risk factors?
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aspirin
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What is the anticoagulant of choice in patients with known cardiovascular risk factors and all patients >75 y.o.?
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warfarin
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what are risk factors for SVT?
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FHx, digitalis intoxication, hyperthyroidism, adrenergic drugs, hypokalemia, pregnancy
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What is the mechanism responsible for most cases of PSVT?
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reentry
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What triggers AVNRT?
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premature atrial impulses
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What triggers AVRT?
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atrial or ventricular premature beats
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What are common presenting sx of SVT?
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palpitations, dizziness, SOB, chest discomfort, syncope
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What labs need to be ordered in a patient presenting with SVT?
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cardiac enzymes (in patients at risk for MI and who present with HF, hypotension, pulmonary edema, or angina), serum electrolytes, CBC, digoxin level (in patients taking Digoxin)
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How do you treat AVNRT and AVRT in patients without hypotension?
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1. vagal maneuvers
2. adenosine 12mg IV (1st) 3. B-blockers (2nd) 4. temp. pacemaker 5. digitalis glycosides (not for acute therapy) |
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How do you treat AVNRT and AVRT in patients with hypotension and/or severe ischemia?
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synchronized cardioversion
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How do you prevent recurrance of AVNRT or AVRT?
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ablation of AV node, anti-arrhythmic agents (B-blockers, CCB, or digoxin are 1st line tx)
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Why is catheter ablation less successful in SANRT?
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because multiple foci may be present
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How do you control ventricular response in patients with Nonreentrant automatic atrial tachycardia?
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B-blockers, CCB, digoxin, catheter ablation
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What is tx for WPW?
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B-blockers or CCB - to slow conduction and increase refractoriness of AV node
catheter ablation - tx of choice |
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What drugs are contraindicated in patients with WPW and atrial fibrillation?
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digitalis or IV verapamil
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What is the most common cause of nonparoxysmal junctional tachycardia?
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digitalis therapy
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What procedure should NOT be performed on patients with nonparoxysmal junctional tachycardia?
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cardioversion
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What should you suspect in patients who present with what appears to be slightly irregular and very rapid ventricular tachycardia?
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WPW with AF
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What is another name for accelerated idioventricular rhythm?
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slow ventricular tachycardia
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T or F. Most episodes of VF begin with VT.
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True
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You are comparing two ecg's, one from a tachycardic episode and one from a normal sinus rhythm. Which condition do you expect will show a difference in QRS morphology?
-Ventricular tachycardia or -paroxysmal supraventricular tachycardia |
ventricular tachycardia
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Will carotid sinus massage or other vagal maneuvers affect ventricular tachycardia?
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no
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What labs need to be ordered in a pt with VT?
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K, Mg, Ca
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How do you treat a stable patient without hemodynamic compromise suffering from VT?
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IV amiodarone 5-10mg/kg load over 20 min. then 1g in 24 hrs
OR IV procainamide 40-50mg/min to total of 10-20mg/kg FOLLOWED BY: oral 500-1000mg q6h (SR form) |
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How do you treat Torsades de Pointes?
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atrial and ventricular overdrive pacind AND Mg sulfate 2-4g IV
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How do you treat congenital prolonged QT syndrome?
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B-blockers are mainstay. When these fail, use ICD with B-blocker
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How do you treat polymorphic VT assoc. with normal QT interval if it is due to "R on T"?
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Class I or Class III antiarrhythmics (procainamide or amiodarone)
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How do you treat polymorphic VT assoc. with normal QT interval if it is due to acute severe ischemia?
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abolition of ischemia (revascularization)
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How do you treat polymorphic VT assoc. with normal QT interval if it is due to short coupled VPC's during exercise or other catecholamine states?
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ICD
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When and how do you treat accelerated idioventricular rhythm?
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only in setting of hemodynamic compromise - atropine
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What are indications for radiofrequency ablation in VT patients?
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VT in absence of structural heart disease
drug resistant or drug intolerant VT In patients with structural heart disease: bundle branch reentrant VT or sustained monomorphic VT and an ICD who receives multiple shocks despite drug therapy |
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What two rhythm strip features are virtually pathognomic of VT?
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fusion beats and capture beats
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What did the cardia arrhythmia suppression trial suggest?
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many antiarrhythmic drugs may significantly increase mortality compared to placebo
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How do all antiarrhythmic drugs work?
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altering ion fluxes within excitable tissues in the myocardium - esp. Na, Ca, and K
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What is the name of the classification system for anti arrhthmic drugs?
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Singh-Vaughan Williams Classification
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What is the mechanism of class I antiarrhythmics? What are some examples?
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block sodium channels - also further classified based on their potency for Na channel blockage and their affect on repolarization
IA - high potency SCB's, prolong repolarization Ex: quinidine, procainamide, disopyramide IB - low potency SCB's, shorten repolarization Ex: lidocaine, tocainide, phenytoin IC - most potent SCB's, little effect on repolarization Ex: flecainide, propafenone, encainide |
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What is the mechanism of Class II antiarrhythmics? Examples?
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B-blockers
Ex: propranolol, esmolol |
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What is the mechanism of Class III antiarrhythmics? Examples?
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prolong repolarization by blocking outward potassium conductance
Ex: amiodarone, bretylium, ibutilide |
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What is the mechanism of class IV antiarrhythmics? Examples?
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CCB's
Ex: verapamil, diltiazem, bepridil |
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What are the drugs that fall in the "misc" class of antiarrhythmics?
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digoxin, adenosine, magnesium
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What is a proarrhythmia?
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a drug induced arrhythmia
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What class of antiarrhythmics is associated with Torsades de Pointe?
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Class III (potassium channel blockers)
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Who is at a higer risk for developing a CAST proarrhythmia?
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patients taking encainide or flecainide with underlying sustained v-tach, CAD, and/or LVEF<40%
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What is the result of sodium channel blockage in the heart?
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slows rate and amplitude of depolarization, reduces cell excitability, reduces conduciton velocity
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What represents the major ion flux during depolarization?
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calcium entry through L type channels
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What must be considered before beginning any antiarrhythmic drug?
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1. eliminate any factors that might predispose a patient to an arrhythmia
2. firm dx before beginning therapy, baseline ecg to monitor tx efficacy |
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What are monitoring parameters for antiarrhythmics?
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monitoring for efficacy and side effects
monitor plasma concentrations of the drug including free and protein bound |
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What antiarrhythmic drug has the lowest incidence of toxicity?
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lidocaine
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T or F. The severity of aortic stenosis can be judged by the intensity and duration of the murmur that accompanies it.
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True
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When are females at a greater risk for developing ischemic heart disease?
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after menopause
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What are anginal equivalents?
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sx of myocardial ischemia other than angina - dyspnea, nausea, fatigue, faintness
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What are the four classes of angina? (canadian)
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I. no limitations of physical activity
II. slight limitations of ordinary activity III. marked limitations of physical activity IV. inability to carry on any physical activity and sx may be present at rest |
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What is Class I tx for angina?
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I. ASA, B-blockers, sublingual NTG, lower lipids, lifestyle modifications
If B-blockers are CI, use CCB's as 1st line OR you can use them together to control sx |
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What is Class IIa tx for angina?
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Plavix (when ASA is CI), long acting nondihydropyradine CCB's - 1st line, add long acting B-blockers and nitrates for sx as needed
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What is the most effective form of NTG for acute relief?
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sublingual
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What are ideal levels for the following: total cholesterol, LDL, HDL
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Total cholesterol <200
LDL <100 HDL >40 |
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What drugs are best for decreasing triglycerides and increasing HDL?
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Niacin or fibrates
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What are contraindications of B-blockers?
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asthma, AV conduction block, and heart failure
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When do you choose a CCB to treat angina?
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when pt does not respond to B-blockers and nitrates alone (can be used in combination)
when B-blockers are contraindicated in patients with Prinzmetal's angina or symptomatic PAD |
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Which CCB CAN be combined with B-blockers?
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diltiazem
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Which CCB is useful in treating angina and HTN?
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amlodipine, nicardipine, isradipine, nifedipine, and felodipine
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Can IHD pts use NSAIDS?
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should be avoided due to increased risk of MI. If necessary, use lowest dose for shortest time
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If a pt with a hx of MI lowers his cholesterol levels and stops smoking, how much has he decreased his risk of coronary death?
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one third
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