Em Test 1: Penney Cardio; Kct

Front 1

What should be included in the differential for ischemic heart disease presenting as chest pain?

Back 1

1. Unstable angina
2. Acute MI
3. Pulmonary Embolism
4. Aortic Dissection
5. Pneumothorax
6. Aortic Aneurysm

Front 2

Chest wall tenderness presents in what % of people w/ ischemic heart pain?

Back 2

5%

Front 3

Describe the symptoms of ischemic heart disease and the location & radiation of the pain.

Back 3

Sx's: diaphoresis, nausea,
dyspnea, palpitations, syncope;
Location & radiation: substernal, radiates to neck, shoulder (L or R-more commonly L), back, epigastrium.

Front 4

**What are some risk factors for ischemic heart disease?

Back 4

family history, smoking, HTN, DM, elevated cholesterol, male sex (but females are on the rise), obesity, cocaine, type A personality.

Front 5

On a PE, what signs would indicate cardiac abnoralities?

Back 5

-Vitals: tachycardia, HTN
-Cardiac exam:
-->NEW S4-noncompetent ventricle
-->NEW S3-congestive heart failure
-->NEW murmur: papillary muscle dysfxn or rupture
-->Interventricular septal rupture
-->New friction rub=pericardial inflamamtion

Front 6

What evaluation and diagnostic studies should be done on a patient w/ chest pain/ischemic heart disease?

Back 6

-ECG; abnl in <1/2 of pts in ED w/ ischemic CP; Can be abnl w/ pericarditis, myocarditis, aortic dissection, electrolyte abnormalities, & cardiac hypertrophy;
-CXR: helpful to evaluate aortic dissection or pulmonary dz.
-Evaluate heart size: will tell you cardiothoracic ration.
(get an old EKG to compare to new findings)

Front 7

Describe the changes in the cardiac enzymes in ischemic heart disease.***

Back 7

-Myoglobin + early in 1/2-2 hrs but nonspecific (b/c can inc just from putting in IV or IM injections but also goes up w/ MI)
-Troponin (#1 test now! nl < .05) + in 2-6 hrs & specific for cardiac injury.
-CPK MB (#2): + 3-8 hrs, less specific than troponin.
-Enzymes + only w/ infarction & myocardial cell death
-Nl w/ ischemic heart dz or angina. Can be nl early even in MI and + w/ myocarditis, myositis, renal failure.

Front 8

Define angina.

Back 8

Myocardiac oxygen demand exceeds supply

Front 9

What are the 2 classifications of ischemic chest pain?

Back 9

A: dec oxygen supply, obstruction of coronary supply from atherosclerotic lesions (everyone has some!) or arterial spasm, systemic hypotension (if you have a dec in BP & you're pursuing oxygen supply,it can lead to MI), severe anemia (don't have O2 carrying capacity in blood).
B: Inc oxygen demand, tachycardia, systemic HTN (if your afterload has inc and yourheart is trying to pump against that), inc contractility of drugs.

Front 10

What usually occurs on an EKG indicating an MI?

Back 10

ST wave elevation

Front 11

What are the 3 types of acute coronary syndrome?

Back 11

1) ST segment MI
2) Non ST segment MI
3) Unstable angina

Front 12

Describe what a complex atheroma looks like when examining a coronary artery.

Back 12

Calcification, thrombosis, hemorrhage. (Calcification can make a coronary angioplasty difficult)

Front 13

What are the symptoms of unstable angina.

Back 13

Pain new onset, at rest, or crescendo pattern (inc frequency or w/ less exertion); 40% infarction w/in 90 days

Front 14

What are the 8 types of treatment for unstable angina?

Back 14

1. Aspirin
2. Heparin (LMWH)
3. Nitrates
4. Beta blockers
5. Calcium Channel Blockers
6. Glycoprotein IIb/IIIa inhibitor
7. Clopidogrel (plavix)
8. ACE inhibitor: helps remodeling of heart.

Front 15

What is the mechanism of aspirin?

Back 15

Inhibits cyclo-oxygenase & dec thromboxane A2 (1st line of treatment), decreases platelet aggregation---1st line treatment!

Front 16

What is the mechanism of low molecular weight heparin?

Back 16

Inhibits coagulation; its simpler to administer, monitor, & effective.

Front 17

What is the fxn of Nitrates?

Back 17

-Systemic and coronary vasodilation;
-Inc collateral flow, dec wall tension.

Front 18

What is the fxn of beta blockers?

Back 18

-reduction in heart flow & contractility reduces myocardial oxygen demand.
-decreases dysrhythmias.
-may inc risk of CHF & heart block.

Front 19

What is the fxn of Ca channel blockers?

Back 19

decreases contractility, little evidence decreases mortality in ischemia.

Front 20

When should Glycoprotein IIb/IIIa inhibitor IV be used?

Back 20

Pre-catheterization, otherwise not given routinely. Oral may inc mortality, IV may be beneficial.

Front 21

What is the mechanism of Clopidogrel (plavix)?

Back 21

-blocks adenopsine diphosphate receptor, inhibits platelet activation & aggregation; combo therapy w/ aspirin reduces risk of adverse cardiac events esp in pts undergoing percutaneous coronary intervention so they don't occlude coronary artery.

Front 22

What is the fxn of an ACE inhibitor?

Back 22

-helps remodeling of heart.
-administer w/in first 24 hrs.
-reduces mortality & incidence of CHF.

Front 23

What is Prinzmetal's (Variant) Angina? When does the pain occur? What relieves the pain?

Back 23

-spasm of coronary artery.
-transient lg ST elevation
-2/3 have non-significant fixed coronary lesions
-Usually occur @ rest, may result in acute MI.
-Usually relieved w/ nitrates (to try to reverse them but don't let them leave b/c you don't know if they have coronary vascular dz)

Front 24

What are the symptoms of acute myocardial infarction? This is secondary to what?

Back 24

-sx's similar to unstable angina except more prolonged.
-usually secondary to atherosclerotic plaque causing thrombosis.

Front 25

Describe the treatments for Acute Myocardial Infarction.

Back 25

-Goal preservation of heart muscle-->pick this up b/c tx's can reserve this.
-20-25% loss causes CHF, 34-40% cardiogenic shock.
-re-open coronary artery to preserve myocardium
1. Thrombolysis vs
2. Angioplasty.
-PTCA better outcome & fewer complications w/ experienced angiographers in busy centers.
-benefit of PTCA (Percutaneous Coronary Angioplasty) lost w/ timy delay: open up coronary arteries mechanically.

Front 26

In which 2 conditions is it common to get significant narrowing of distal portion of coronary artery?

Back 26

DM or Familial Hypercholesterolemia.

Front 27

What is the #1 complication of an MI?

Back 27

dysrhythmia.

Front 28

What do normal myocardial fibers looks like?

Back 28

Central nuclei & syncytial arrangement of fibers, some have pink intercalated discs.

Front 29

How do you determine what type of surgical procedure should be done in a patient w/ severe atherosclerosis?

Back 29

Pre-operative catheterization is done.

Front 30

In an artery where is the atherosclerosis worse?

Back 30

proximal-where arterial blood flow is more turbulent.

Front 31

An aneurysm in the heart (formed from healing post infarction)predisposes to what?

Back 31

Mural thrombosis. The aneurysm is non-contractile tissue that reduces stroke volume & strains remaining myocardium.

Front 32

What are the 3 types of thrombolytic agents?

Back 32

1. tissue plasminogen activators (tPA)
2. Urokinase
3. Streptokinase
(comparable early in infections, tPA may be more efficacious in some groups & less side effects.

Front 33

What are the contraindications to using thrombolytic agents?***

Back 33

1. Recent major surgery (<10d)
2. Recent GI bleed
3. Recent trauma
4. HTN (BP>180/110)
5. Pericarditis
6. Clotting abnormalities
7. Prior receipt of streptokinase (only tPA)-foreign protein (previous neurosurgery, previous stroke)

Front 34

What does a Q wave on EKG indicate?

Back 34

sign of MI in past.

Front 35

What on an EKG indicates death of a tissue?

Back 35

T wave inversions & Q waves.

Front 36

How do endocardial and transmural injuries differ on an EKG?

Back 36

-endocardial injury: ST depression;
-transmural injury: ST elevation (>1mm in 2 leads)-->this is an indication for thrombolytic;

Front 37

Do Q waves always develop post MI?

Back 37

No, depending on size & location of ischemia, Q waves may not develop (non-Q wave infarctions)

Front 38

What is the earliest change post MI?

Back 38

peaked or 'hyper-acute' T waves.

Front 39

In an inferior wall MI, you should be cautious of giving a patient what?

Back 39

-pt may be volume dependent for cardiac output.
-caution w/ nitrates or vasodilators esp if assoc R ventricular infarction (diagnose by right sided leads V3R and V4R)

Front 40

What does a posterior wall MI show on EKG?

Back 40

-Large R wave in VI and V2 w/ ST depression, also may place posterior leads.

Front 41

What is probably the cause of nearly all out-of-hospital mortality from an acute MI?

Back 41

arrhythmias, nearly any rhythm can occur, treat like any other dysrhythmia.

Front 42

**What is an accelerated idioventricular rhythm? How do you treat it?

Back 42

-occurs primarily in setting of acute MI;
-resembles VT except slow rate (40-90/min)
-usually transient & self-limited NOT requiring therapy-->treatment may result in ASYSTOLE!

Front 43

Is most CHF R ventricular, L ventricular, or biventricular?

Back 43

biventricular

Front 44

Most R ventricular failure is secondary to what?

Back 44

Left failure.

Front 45

What are the signs & sx's of R ventricular failure?

Back 45

JVD (jugular venous distention), dependent edema, liver congestion

Front 46

What are the causes of R ventricular failure?

Back 46

-Mitral stenosis/regurgiations
-Pulmonary HTN (-->R ventricular P)
-pulmonary stenosis/regurgiation
-Cardiomyopathy-can involve R & L ventricular walls
-R ventricular infarction
(portal

Front 47

What are the signs & sx's of L ventricular failure?

Back 47

-Pulmonary edema (you hear rhales, wet sounds)
-Orthopnea (ask pts how many pillows they use to sleep)
-Paroxysmal nocturnal dyspnea
(wake up in middle of night gasping)
-Pulsus alterans (BP varies w/ inspiration & expiration)
-S3 gallop

Front 48

What are the causes of L ventricular failure?

Back 48

1. Mitral regurgitation
2. Systemic HTN
3. Aortic stenosis/regurgitation
4. Cardiomyopathy (on both sides, dz of muscle itself)
5. Left ventricular infarction

Front 49

What are the causes of high output CHF?

Back 49

Hyperthyroidism, Septic shock, Beri Beri (thiamine deficiency), AV fistula, Severe Paget's dz, severe anemia, pregnancy.

Front 50

What are the causes of low output CHF? What happens to the Starling curve?

Back 50

-acute decompensation w/ minor stress dietary, tachydysrhythmia, infection, hypoxia, meds or lack of meds, ischemia, pulmonary embolism.
-Starling curve: exceeds capacity of inc filling pressures to inc CO.

Front 51

What diagnostic testing is done for CHF?**

Back 51

1. CXR: Cardiomegaly, Cephalization (venous distribution), Kerley B lines (lymphatic vessels--help to drain back up of fluid on periphery of lung), interstitial peri-hilar infiltrates, Pleural effusion (R>L). X ray may identify other cause of SOB.
2. ECG: useful if etiology is acute ischemia or prior infarction, usually non-specific.
3. B-naturetic peptide (BNP): elevated in CHF value, may reflex severity of dz., useful to discriminate COPD & pulm dz from CHF.

Front 52

What is the tx for CHF?

Back 52

-oxygen,
-inotropic agents (dobutamine, amrinone),
-reduced filling pressures (reduce pre-load)-->diuretics (lasix), nitrates, morphine (vasodilates), sitting upright (b/c short of breath), Nesiritide (BNP)(really good drug, calming, allows urination, no breathing problems, very justifying drug); Inc outflow (reduced after-load)-->nitrates, nitroprusside (or other anti-HTN) given IV, titratable, but light senstivie so needs to be covered from light.

Front 53

Why should you not overaggressively treat HTN?

Back 53

Can lead to stroke or renal failure

Front 54

What is asymptomatic HTN? How should you treat it?

Back 54

-Diastolic <130-140, no sx's, no signs of end organ injury;
-Education, follow-up w/in 1week, initiation of outpatient therapy;

Front 55

How do you define a hypertensive emergency?

Back 55

Elevation of DBP>130 w/ systemic complication or problem (but don't really go by numbers)

Front 56

What are some examples of hypertensive emergencies?***

Back 56

1. Hypertensive encephalopathy
2. Intracerebral hemorrhage
3. Left ventricular failure or cardiac ischemia.
4. Aortic dissection
5. Malignant HTN, papilledema, seizure, confusion, coma.
6. Eclampsia
7. Renal failure

Front 57

Define hypertensive urgency (Grey zone). How should you treat it?

Back 57

-Asymptomatic pts w/ severe or recently inc BP
-No sign of any end organ acute injury.
-Diastolic >130-140 mm Hg
-BP should be gradually reduced over 24 hrs

Front 58

How would you tx someone w/ a hypertensive emergency?

Back 58

-reduce DMP by 30% in 1st hour (but not below 90-100). Normalize BP over next 8-24 hrs.
-IV meds preferable (quickly titratable)

Front 59

What are the sx's of hypertensive encephalopathy? How would you tx it?

Back 59

Sx's: HEADACHE!, N, V, confusion, seizure, focal neuro deficits, papilledema or coma.
-Nl cerebral vascular autoregulation is lost.
-Lower BP gradually-->1) nitroprusside, 2) labetalol, 3) nicardipine.

Front 60

What are the sx's of an intracerebral hemorrhage?

Back 60

-HA, N, V, confusion, seizure, focal neuro deficits, papilledema, coma.
-tx severe HTN gradually

Front 61

Which is tolerated better: mild-moderate HTN or Hypotension?

Back 61

HTN

Front 62

Whats the most common place for an intracerebral hemorrhage?

Back 62

-60% ICH-basal ganglia in location, 20% infratentorial (18% cerebellum, 2% brainstem)
[ie if its supratentorial-->its in basal ganglia; if in infratentorial-->its in cerebellum

Front 63

If someone has an intracerebral hemorrhage, do you want to decrease their blood pressure?

Back 63

NO--you need for your BP to cover for ICP.

Front 64

Why are there often bleeds at the lenticular striate arteries?

Back 64

b/c they're at right angles to anterior & middle cerebral arteries.

Front 65

In an ischemic CVA, how can the HTN be treated?

Back 65

gradual reduction!

Front 66

What is considered the 'angina of blood pressure'?

Back 66

Malignant HTN-Hypertensive emergency!

Front 67

What are the characteristics of Malignant HTN?

Back 67

Accelerated HTN, papilledema, renal dysfxn (azothemia, proteinuria, red cells)

Front 68

In Cardiac ischemia or CHF, what happens to the myocardial oxygen demands and the cardiac output?

Back 68

Myocardial oxygen demands inc, cardiac output decreases due to high afterload.

Front 69

What are the sx's of cardiac ischemia or CHF?

Back 69

-chest pain, shortness of breath, bipedal edema

Front 70

What is the tx for cardiac ischemia or CHF?

Back 70

nitroglycerin, morphine, diuretics.

Front 71

What are some causes of catecholamine excess?

Back 71

MAO inhibitors, pheochromocytomas, clonidine withdrawal, stimulant drug ingestion, alcohol withdrawal

Front 72

10% of those w/ alcohol withdrawal get what emergency

Back 72

delirium tremens;

Front 73

What should be avoided to prevent catecholamine excess?

Back 73

Avoid beta blockers alone (unopposed alpha receptor stimulation may lead to inc BP)

Front 74

What is the tx of an aortic dissection?

Back 74

-Needs AGGRESSIVE lowering of BP w/ beta blockers & nitroprusside or w/ labetalol (has alpha & beta blockage)
-Dec SBP to 90-100 (as tolerate to dec stress on intimal flap)

Front 75

What is the difference b/w an aneurysm and an aortic dissection?

Back 75

Aneurysm: involves all layers vs Aortic dissection which involves only intima.

Front 76

What is an aortic dissection?

Back 76

-Intimal tear in artery lining that allows blood to leak into media of artery wall.
-Lining of artery separates from wall, dissection of lining propagates proximally & distally.
-Aortic dissection is NOT an aneursym. (aneurysm is balloon like dilatation of all layers of artery)

Front 77

What are the risk factors for an aortic dissection?

Back 77

atherosclerosis, age>50 y/o, males, HTN (70-90% of all pts), connective tissue d/o (Marfans/ Ehlers Danlos--type III collagen deficiency), Hyperdynamic states (pregnancy, hyperthyroidism, cocaine), trauma, congenital dz (bicuspid aortic valve, coarctation), prosthetic aortic valve.

Front 78

What is the prognosis of someone who has an aortic dissection?

Back 78

-most don't die immediately
-most have time to seek medical care as dissection propagates
-Mortality: 28% in 24 hrs
-50% in 48 hrs
-90% in 3 months

Front 79

What are the 2 classifications for aortic dissections?

Back 79

1. Debakey: Type I-ascending & descending aorta involved, Type II, ascending aorta only, Type III-descending aorta only.
2. Stanford:Type A: involves ascending aorta (includes Debakey type II), type B: involves only descending aorta.

Front 80

What are the sx's of someone w/ an aortic dissection?

Back 80

This condition EVOLVES as condition progresses, migrates depending on where dissection is going on.
-Pain=most common presenting sx (70-90%)
-starts abruptly, excrutiating & maximal at onset
-Migrates as dissection flap propagates
-may be located in back, epigastrium, chest upper back, mid back, lower back, flank, legs;
-others sx's occur as aortic branch vessels are occluded by intimal flap
-CVA (Carotid vessels)
-Paraplegia (spinal artery)
-Cold, pulseless extremity
-CHF, CP, Pulmonary edema (coronary artery)
-Abdominal pain (mesenteric arteries)
-Flank pain & hematuria (renal artery)
-Syncope

Front 81

What are the clinical findings of someone w/ an aortic dissection?

Back 81

HTN, tachycardia, clammy, diaphoretic, unequal pulses (>20 mm Hg) rarely occurs, aortic insuffiency murmur, tamponade (muffled heart sound)

Front 82

What is the differential diagnosis of an aortic dissection?

Back 82

Acute MI, pulmonary embolism, abdominal aortic aneurysm, stroke, CVGA, systemic embolic disease

Front 83

________ occurs when inner lining of aorta tears & blood flow dissects b/w layers of aortic wall, it bursts into pericardium.

Back 83

Aortic dissection

Front 84

If a tear progresses down to and occludes coronary artery, what do you have?

Back 84

MI

Front 85

If a valve disrupts aortic valve producing acute valvular insufficiency, what condition do you get?

Back 85

CHF

Front 86

***What should be seen on an X-ray indicating an aortic dissection?

Back 86

1) widened mediastinum
2) Aortic border >5mm beyond calcific intimal shadow
3) blurred aortic knob
4) pleural apical cap
5) pleural effusion

Front 87

Besides the X-ray what are some other imaging modalities are diagnosing aortic dissection?

Back 87

-no labs
-EKG: to rule out MI but dissection can lead to MI if it goes down to coronaries;
-Transesophageal Echo: sensitivity & specificity approach 100%, visualizes pericardium & aortic valve, only real disadvantage: requires special equipment & trained operators (often not in hospital)

Front 88

What is the disadvantage of using an MRI to view an aortic dissection since its specificity and sensitivity approach 100%?

Back 88

needs long time to scan

Front 89

What are the adv and disadv of using a CT scan for aortic dissection?

Back 89

ADV: sensi & specificty of 95-98%, can help ID other causes for chest pain, readily available.
DISADV: can't do in ED, doesn't reveal aortic regurgitation or coronary artery involvement.

Front 90

What are the adv and disadv of using an aortography for an aortic dissection?

Back 90

used to be thought of as 'gold standard';
disadv: invasive, specialized personnel, contrast media allergies, can't be performed in ED

Front 91

What is the tx for someone w/ aortic dissection?

Back 91

TREAT QUICKLY!
-Control of BP & rate of change of pulse P w/ each beat (dP/dT)
-Beta blocker + Nitroprusside or labetalol
-Goal: reduce systolic to 90-100 mm Hg. Hypotension managed w/ fluid or blood products but don't want to overburden heart.
-Long term tx: surgical management

Front 92

What is the difference in the surgical mortality in someone w/ a type A vs type B aortic dissection?

Back 92

type A (involves ASC aorta) surgical tx lowest mortality.
type B (invovles Desc Aorta) surgical mortality exceeds medical management mortality.
-minimal invasive grafts.

Front 93

What is an aortic aneurysm? It may lead to what?

Back 93

deterioration of elastic fibers in aorta leads to localized stretching & dilatation of all 3 layers of aorta;
-may lead to aortic rupture-->can kill your patient. Rupture risk inc w/ size of aneurysm

Front 94

Where are the majority of aortic aneurysms located?

Back 94

abdominal and intra-renal

Front 95

What are the risk factors for an aortic aneurysm?

Back 95

advanced age, males, HTN, smoking, hx of atherosclerotic dz, fam hx of aortic aneurysm.

Front 96

How does pt w/ aortic aneurysm present? may radiate to what?

Back 96

sudden onset of severe abdominal, chest, back or flank pain.May radiate to groin. Syncope from pain or blood loss w/ rupture. May be dull in nature & radiate to groin or legs.

Front 97

Diagnosis of aortic aneurysm often confused w/ what?

Back 97

renal stone or musculoskeletal pain (mimics sciatic or kidney stone)

Front 98

how much does an aoric aneurysm grow/yr?

Back 98

once its stretched >3cm, it grows by 4mm/yr

Front 99

What will be found on PE of pts w/ aortic aneurysm?

Back 99

pulsatile mass palpable in 3/4 of pts, may not be palpable if pt hypotensive, small aneurysm, fat pt; unequal pulses, less than 1/2 are hypotensive,

Front 100

What imaging technique is used in 100% of detection of aneurysms but can't detect if aneurysm has ruptured or leaked

Back 100

ultrasound (this CAN be done by CT)

Front 101

What imaging technique is superior to CT for detecting and evaluating aneurysms but it takes too long?

Back 101

MRI