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131 Cards in this Set
- Front
- Back
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What is lack of oxygen due to inadequate perfusion?
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ischemia
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3 biochemical effects of ischemia?
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1. FA's can't be oxidized
2. inc. lactate 3. dec. pH (metabolic acidosis) |
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What is the most common cause of ischemia?
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atherosclerosis
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What % blockage or stenosis is considered clinically significant?
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75-80%
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Top 5 risk factors for atherosclerosis in descending order?
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1. hyperlipidemia (inc. LDL)
2. smoking 3. HTN 4. DM 5. physical inactivity (friedlander)/obesity (johnston) |
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5 characteristics of metabolic syndrome (X)?
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insulin resistance, HTN, high TG/low HDL, hyperuricemia, hypercoagulable
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What % of US adults have metabolic syndrome?
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25%... yikes
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BMI ranges for desirable wt., overwt., and obese?
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desirable- 21-24, overwt.- 24-29, obese- 29 +
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What is the target amt. of physical activity to reduce risk for CAD, etc.?
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45-60 min. moderate intensity 5-7 x/week
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What 4 factors control MVO2 (mycoardial oxygen consumption?
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HR, afterload, contractility, & wall tension
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pathognomonic sign for angina?
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levine's sign (substernal, clinched fist)
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Cardiac pt. w/ pain radiating to the neck. First suspicion?
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angina until proven otherwise
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duration of stable angina?
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usually 15-20 minutes
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Pt. comes in and says they have dyspnea on exertion. You suspect anginal equivalent. what is happening pathologically?
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eleveate LV filling pressure (inc. LV-EDV) that leads to pulmonary edema
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Evaluate pt. w/ stable angina for possible CAD. What can you do? What can you do for unstable angina?
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stable: stress test is possible. unstable: no stress test, cath lab instead
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What drugs are the frontline of angina/CAD therapy?
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nitrates
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Pt. comes to the ED w/ symptoms of ACS. What is the protocol of treatment?
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morphine, oxygen, nitroglycerine, and aspirin (MONA)
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Beta-blockers control what two major determinants of myocardial oxygen demand?
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HR and BP
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What are characteristics of STEMI?
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(transmural) complete occlusion, ST elevation > 1mm in 2 or more contiguous limb leads or >2 mm in 2 or more contiguous precordial leads
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What are characteristics NSTEMI?
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(subendocardial) partial or transient occlusion; spontaneous revascularization
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What is the DOC for refractory chest pain?
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morphine sulfate (4 mg IV)
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What are the conraindications for treatment w/ beta-blockers?
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severe sinus brady (<40), 2nd or 3rd degree AV block (other blocks ok), decompensated HF, hypoentions, reactive airway diesease, cocaine-induced MI
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When is TLT therapy beneficial?
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Most beneficial if given in first few hours after onset of symptoms for STEMI or LBBB.
NO benefit w/ NSTEMI |
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Pt. presents w/ ischemic pain at rest w/ ST elevation. You suspect spasm as underlying problem. What is the Dx and Rx for it?
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Dx: Prinzmetal's variant angina
Rx: nitrates and CCB |
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In the first few hours of MI, what is the most common cause of death?
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a fatal arrhythmia
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What is the rise, peak, and duration of T1 associated w/ MI?
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Rises 3 hours
Peak 12-24 hours Duration 7-11 days |
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What is the rise, peak, and duration of CKMB associated w/ MI?
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Rises 4 hours
Peak in 12-24 hours Duration 2-3 days |
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How do you treat ventricular dysfunction as a potential mechanical complication of MI?
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ACE-inhibitors (prevents remodeling)
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What is the key treatment for pericarditis?
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ASA
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A post MI (1-2 months ago) pt. presents w/ chest fever, malaise, elevated sed rate and WBC, but cardiac enzymes are ok.
What is the Dx and Rx? |
Dx: Dressler's syndrome (due to inflammatory/immunologic reaction)
Rx: ASA |
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In term of diagnostic tests in cardiology, what is the most commonly ordered test?
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Assessment of LV function
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Why is ECG not "diagnostic" for angina?
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50% of pts w/ angina have a normal ECG
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Stress testing serves as a screening for what population?
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certain pop. of pts. for CAD
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True or False. Pt. has a "negative" stress test. CAD can be excluded in the diff. diagnosis.
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false. While it does not exclude it, it makes the likelihood of 3 vessel or left main CAD unlikely.
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What (in general) indicates a "positive stress test"?
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ST segment depression of 1 mm below baseline and lasting 0.08 sec.
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*not sure on this one*
How do you calculate target HR? |
(220 - age) *85%
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What are the 6 most common indications for a stress test?
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T or F. False positives/negatives on stress test are extremely rare.
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False. 15% overall.
(Incidence of false positive test is increased in asymptomatic men less than 40 y/o or in pre-menopausal women with no risk factors) |
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What things can cause a false positive on stress testing?
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Quinidine, digitalis, BBB, vent. hypertrophy, resting ST seg. changes, hypokalemia, WPW, MVP, hypervent., anemia, aortic stenosis/insufficiency
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What are some absolute contraindications to stress testing?
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If you're extra smart, what are some relative contraindications to stress testing?
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What sorts of things can point to an adverse prognosis from stress testing?
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When is pharmacological stress testing indicated/useful?
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Pt.s who can't exercise.
LBBB, pacemaker |
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What drugs can be used for stress testing?
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Adenosine (short half-life, don't use in COPD/asthmatics) and Dobutamine (inc. HR, contractility)
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What is the most widely used imaging technology in cardiology? When is it used?
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echocardiography used in acute MI, aneurysms, pericardial effusions, and LV thrombus
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What are the basic methods employed in the echocardiogram?
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M mode, 2-D, and doppler/color doppler
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What does 2-D echocardiography do?
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assess chamber sizes, wall motion, valves, pericardium, global and RWMA
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What does doppler/color doppler ECHO do?
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allows measurements of blood velocities across valves
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When should you order a TEE?
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when you want high resolution imaging of posterior heart structures (LA, MV, aorta).
useful for aortic and source of emboli |
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What is the gold standard for anatomy/physiology of the heart?
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cardiac catheterization
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What are the basic methods employed in cardiac catheterization-contrast angiography?
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85% performed via femoral route
inject contrast agent into cardiac chambers and coronaries visualize w/ x-rays |
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What are the indications for cath?
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What are the contraindication for cardiac cath?
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What is more accurate for diagnosis of CAD than a stress ECG?
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nuclear perfusion imaging (80-90% sensitive and specific)
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What are the 2 basic techniques of radionucleotide imaging?
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labeling RBCS's w/ isotope to asses endocardial motion and perfusion tracers
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Basics of myocardial perfusion imaging?
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Use radioisotopes (tech 99, thallium, or sestamibi) that get taken up by myocytes according to blood flow (images taken at rest and after exercise)
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Which radioisotope is a K+ analog and is useful for viability study?
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Thallium (2 day study)
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A normal myocardial perfusion scan is highly predictive of what?
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the absence of significant CAD and a low risk of subsequent cardiac death
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What are 3 indications for nuclear stress testing?
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1. high prob. of a false positive on treadmill exercise test
2. exercise ekg not interpretable (BBB, pacemaker, ST-T abnormal) 3. S/P revascularization procedures |
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What can be analyzed with a cardio MRI?
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assess LV size, function, muscle mass, pericardial abnormalities, and cardiac amyloid
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What cardiac imaging modality measures calcium content of coronaries w/ coronary calcium score?
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electron beam computed tomography (EBCT)
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What is the basic mechanism responsible for ischemia in angina?
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oxygen supply (CA flow) doesn't meet oxygen demand (exercise, excitement, LVH from AS, etc)
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What are the 3 general disturbances of ischemia and some examples of them?
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1. Mechanical (HF, angina, akinesis)
2. biochemical (can't ox. FA's, inc. lactate, metabolic acidosis) 3. electrical (inv. T wave, ST elevation/depression, VT, VF) |
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8 risk factors for CAD?
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hyperlipidemia, smoking, HTN, DM, obesity (not to friedlander), physical inactivity, age/gender, family hx
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Lipid level goals for pt.s w/ prior events?
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LDL < 70 mg/dl
HDL >65 TG < 150 T-C < 200 |
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What is the Diff Dx for angina?
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chest wall syndrome
intercostal neuritis PUD chronic cholecystitis esophageal spasm GERD pneumothorax, PE, pneumonia |
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Definition of anginal equivalent?
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ischemia, but described as dyspnea, fatigue, faintness (women usually)
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What conditions can mimic angina in the absence of CAD?
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AS/AI, pulmonary HTN, and hypertrophic cardiomyopathy
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What are 2 poor prognostic signs from a cardiac cath?
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1. inc. LVEDP
2. reduced EF |
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What drug should you give to ACS pt.s for whom cath and PCI is planned?
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platelet glycoprotein inhibitors
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What drugs are indicated in stable angina pts (when they see you)? unstable angina?
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antiplatelets (e.g. clopidogrel), can combine w/ ASA for UA
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Two biggest go-to treatments for symptomatic CAD in the ED?
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nitrates and beta blockers (they were bolded on his slides so...)
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What are three medical conditions under the umbrella of ACS?
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STEMI, Non-STEMI, UA
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What are some characteristics of stable angina?
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Predictable; pain, pressure, etc. brought on by exertion, emotion fear, etc.
Usually relieved by NTG and rest |
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What are some characteristics of unstable angina (UA)?
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inc. severity and freq. of pain
More intense, lasts longer SOB Nausea & diaphoresis Occurs AT REST or new onset pain Brought on my MINIMAL exertion May NOT be relieved by NTG |
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True or False. 1st ECG is diagnostic in the majority of pts. w/ acute MI.
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False. 1st is non-diagnostic in 50% (usually need serial ECG's and enzymes)
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What are the four general goals of treatment of acute MI?
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1. anti-platelets (ASA, clopidogrel)
2. Anticoags (heparin) 3. Chemical dissolution (lytics) 4. Mechanical disruption (PCI/angioplasty) |
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You suspect an MI. Trop I and CKMB are up, but no Q waves or ST elevation on ECG. What's your diagnosis?
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NSTEMI
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What are the timeline goals for intervention when pt. comes to ED in w/ STEMI?
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ECG in 10 minutes
IV/clot buster in 30 minutes Cath lab in 90 minutes... correct me if i got that wrong |
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2 routine interventions in early management of ACS?
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1. relieve chest pain (NTG 0.4 mg SL)
2. anti-platelets (ASA or clopidogrel) |
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T or F. 50% of inf. Mi also have RV MI.
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True... according to my written in notes
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Giant drug regimen for UA/NSTEMI (may be indistinguishable)?
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Morphine sufat
Oxygen (2 liters nasal canula) Beta blocker (sans contraindication) ASA/clopper (coplidogrel) ACE or ARB IV heparin Platelet gylocoprotein inhibitors (Ab, Ep, and Tiro; useful in high risk patient) call me in the morning (I have no idea which of these drugs he specified for which condition, but ... oh well) |
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How quickly do you want to get MI pt. on TLT?
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w/in 30 min.
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T or F. Survival benefit is lost or negligible if TLT is delayed greater than 12 hours.
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True (and no benefit w/ NSTEMI)
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What 2 interventions apply only to a STEMI?
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TLT and PCI/angioplasty
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Rare but potentially fatal side effect of TLT?
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intracranial hemhorrage
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What time of day to MI's most often occur?
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6 am to noon (50% of deaths occur before hospital presentation)
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Post MI pt. has non-sustained VT w/ PVC's (> 3 PVCs but less than 30 sec). What should you do?
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Monitor K and Mg. consider beta blocker.
This is NOT associated w/ increased mortality |
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Post MI pt. has sustained VT (> 30 sec. or w/ hemedynamic compromise). What should you do?
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If unstable: cardioversion/Defib.
If stable: amiodarone & precainamide (and lidocaine) |
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Tx for VT/VF?
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Defib. immediately
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Ant. MI is associated (usually) w/ what arrhythmia? Inf. MI?
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ant: tachy
Infl: brady |
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What is AIVR?
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accelerated idioventricular rhythm: 60-100 HR; after TLT at time of reperfusion. it's benign
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1st degree and Mobitz I AV block is complication of what type of MI (usually)?
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Inferior MI
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Mobitz II block is associated w/ what type of MI?
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anterior MI... may progress to 3rd degree
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Post MI pt. presents w/ unstable SVT. What should you do?
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synchronized shock (1/3 of acute MI pt.s get SVTs)
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After an MI, what is the most important determinant of prognosis?
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LV dysfunction
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What are the functional classifications of mechanical complications of MI (Killip)?
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• Class I – no signs of pulmonary congestion
• Class II – moderate HF – crackles, S3, tachypnea; moderate RHF with hepatic congestion • Class III – severe HF – pulmonary edema • Class IV – cardiogenic shock – systolic < 90 peripheral vasoconstrictor, cyanosis, confusion, oliguria |
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How can you Rx the mechanical complications of MI?
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diuretics (pulmonary congestion)
ACE-inhibitors beta-blockers Nitrates |
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If a post-MI pt. is hypotensive but has clear lungs, what do you consider them?
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confusing... jk. consider them hypovolemic first
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What are some causes of post-MI cardiogenic shock?
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LV failure, ventricular septal rupture, papillary muscle/chordae rupture, ventricular free wall rupture, RVF
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What are the hemodynamics and results of cardiogenic shock?
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dec. CO, dec. cardiac input (CI), inc. PCWP, dec. systolic BP
Result: vital organ hypoperfusion (confusion, oilguria, cool extremities) |
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What are the systolic and diastolic pathophysiological results of cardiogenic shock?
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Systolic: dec CO, SV, BP, coronary perfusion
Diastolic: inc. LVEDP, pulmonary congestion In common: ischemia, myocardial dysfunction, and death |
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What are the 6 common components for treatment of CS (cardiogenic shock)?
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1. invasive monitory (swanz-ganz) and ART line
2. oxygen (maybe vent. support) 3. correct the hypoxia/acidosis 4. vasopressors for hypotension.... maybe (NE, dopamine, dobutamine) 5. aortic counterpulsation (augment diastolic pressure & CO) 6. PCI or CABG |
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RCA supplies what two myocardial areas? Blockage can result in what mechanical complication of MI?
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RCA- inf. wall and RV
30-50% of inf. MI results in RV infarct... subsequent RVF |
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What would you see in a clinical exam of a pt. w/ post-MI RVF?
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hypotensive, clear lungs, inc. JVP, positive kussmaul, hepatomegalia, inc. paradoxical pulse
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What is the treatment for post-MI RVF?
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volume expansion (saline) to maintain RV preload
inotropic agent (dobutamine) avoid nitrates or vasodilators |
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What is the most commonly ruptured papillary muscle?
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posterior-medial
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What MI type is papillary muscle most associated with?
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inferior MI (then anterior)
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When is papillary muscle rupture most likely?
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3-5 days after inf MI
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Post-MI pt. presents w/ suddent onset of new, holosystolic murmur, MR, pulmonary edema, HF, and hypotension. What happened?
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papillary muscle rupture
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What are two Rx's for papillary muscle rupture?
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1. IABP
2. MV surgery (high mortality) |
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Post-MI (ant.) presents w/ loud holosytolic murmur w/ thrill on the LLSB. What happened?
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ventricular septal rupture
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How do you treat VSR?
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IABP, intotropic agents, vasodilator, and surgery
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Pt. had ant MI 4 days ago. Now has sudden loss of pulse (pulseless electrical activity), loss of BP, loss of consciousness, and tamponade. What happened?
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Free wall rupture (associated w/ ant. MI)
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What is the treatment for free wall rupture?
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pericardiocentesis (b/c of hemopericardium) and surgery
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What happens to chamber pressures w/ cardiac tamponade?
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equalize diastolic pressures
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When is an LV aneurysm most likely to occur after an MI?
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weeks/months after STEMI
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What is the treatment for LV aneurysm?
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anticoag if mural thrombus is identified
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3 days after a STEMI, pt. presents w/ CP, hurts to breathe, feels better leaning forward. What is happening? How do you treat it?
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pericarditis (may hear pericardial friction rub)
Treat w/ ASA |
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A pt. presents 1-2 months after MI w/ CP, fever, malaise, elevated ESR and WBC, but cardiac enzymes are normal. What is the diagnosis and how do you treat it?
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Dressler's syndrome (inflammatory/immunological reaction w/ pericarditis)
Tx- ASA |
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What can cause myocarditis in HIV patients?
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toxoplasmosis and mets from kaposi's sarcoma
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What conditions are associated w/ giant cell myocarditis?
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SLE, thyrotoxicosis, thymoma
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T or F. Corticosteroids are the mainstay of myocarditis treatment.
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False. steroids worsen myocyte damage
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What are characteristic of EKG's in pericarditis?
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wide-spread ST elevation (concave, convex in MI)
(Later) ST returns to normal and T inverts Voltage me be reduced PAC's, a-fib |
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What is ewarts sign?
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points to pericardial effusion.
area of dullness & tubular breath sounds at L scapula |
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What is the best test to detect pericardial effusion?
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echocardiogram... if large effusion, may see electrical alternans on ECG
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What is the most common cause of chronic pericardial effusion?
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TB (also seen in myxedema, neoplasms, SLE, RA)
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classic sign of chronic constrictive pericarditis?
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kussmauls sign
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What is the treatment for chronic constrictive pericarditis?
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pericardial resection
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What are the three (but actually 4) classic signs of Pericardial tamponade (becks triad)?
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1. dec. BP
2. Inc. JVP 3. muffled heart sounds 4. Dec. in systemic pressure w/ inspiration (paradoxical pulse) |
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What is the most common symptoms of tamponade?
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short of breath
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