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445 Cards in this Set

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How to calculate Rate based on ECG using # of boxes
1=300, 2=150, 3=100, 4=75, 5=60, 6=50, 7=30 (i.e. if a QRS every 3 boxes, rate is 100 bpm); 1 big box = 0.2s & 1 small box = 0.04s
How to calculate Rate based on ECG using the whole strip
total number of QRSs x6
Normal sinus heart rate.
60-100 bpm
Define bradycardia.
heart rate <60 bpm
Define tachycardia
heart rate >100 bpm
Define sinus rhythm.
P before every QRS and QRS for every P
Rhythm regulated by the atria is at what rate?
60-80 bpm
Rhythm regulated at the AV junction is at what rate?
40-60 bpm
Rhythm regulated by ventricular septum or other ventricular cells is at what rate?
20-40 bpm
QRS width in PAC.
narrow
QRS width in PVC
wide
Normal Axis via Rule of Thumbs
Left thumb up for positive Lead I and Right thumb up for positive Lead II (there are variations to leads used)
Left Axis Deviation via Rule of Thumbs
Left thumb up for positive Lead I and Right thumb down for down for negative Lead II (there are variations to leads used)
Right Axis Deviation via Rule of Thumbs
Left thumb down for down for negative Lead I and Right thumb up for positive Lead II (there are variations to leads used)
Normal PR interval.
120-200 msec (< 1 big box)
Normal QRS width
<100 msec (about 2 small boxes)
PR interval greater than 200 msec (more than 1 big box).
AV block
Name the 2 types of secondary AV block.
mobitz I and motbitz II
Mobitz II pattern on ECG (AKA secondary AV block type 2).
PR interval remains the same, but occasional dropped beat. Measure it!
Mobitz I pattern on ECG (AKA Wenckebach or secondary AV block type 1).
PR interval "marches out" (increases in length for each subsequent conduction) until QRS is dropped. Measure it!
Third degree AV block pattern on ECG.
interval between P waves not associated with interval between QRSs.
ECG shows no association between p's and qrs's.
3rd degree (complete) heart block.
Bundle branch blocks show what variation in qrs?
Wide (>120 ms)
What will V1 be missing in LBBB?
There will be no R wave.
RBBB will have what variation in I, V5, & V6?
Wide s wave.
WiLLiam MaRRoW mnemonic to distinguish RBBB vs. LBBB:
Left: W shape (positive qrs) in V1-V2; M shape (rabbit ears) in V3-V6.
Right: M shape in V1-V2; W shape in V3-V6.
Millisecond definition of Long QT syndrome.
QTc >440 ms
Long QT syndrome (congenital disorder) predisposes to what arrhythmia?
Ventricular tachyarrhythmia
ST elevation in I & aVL and V5-V6: where is the MI?
Lateral
st ELEVATION in V1 & V2: where is the MI?
Septal
ST elevation in V3 & V4: where is the MI?
Anterior
ST elevation only in V5 & V6: where is the MI?
Apical
ST elevation in II, III, and aVF: where is the MI?
Inferior
st DEPRESSION in V1 & V2: where is the MI?
Posterior
What is poor R-wave progression?
R wave should get progressively positive from V1 to V4. If not, it is "poor" progression.
A "significant" (pathologic) Q-wave is how long?
>40 msec (or more than 1/3 of the QRS amplitude)
Right Atrial Enlargement evidence in lead II:
Tall p-wave (>2.5 mm)
Left Atrial Enlargement evidence in lead II:
Long p-wave (>120 ms)
First thought if R&S waves are so large they overlap.
Left Ventricle Hypertrophy (LVH)
LVH Cornell criteria.
R in aVL + S in V3 >28mm (men), or >20mm (women)
LVH Sokolow-Lyon criteria.
S in V1 + R in V5 or V6 >35 mm.
Tall R wave in V1 (longer than 7mm).
Think Right Ventricle Hypertrophy (RVH).
JVD hieght definition.
>7cm above sternal angle
What is Kussmauls' sign?
increase in JVP with inspiration
Classic aortic stenosis murmur description.
systolic, crescendo-decrescendo
aortic stenosis murmur can radiate where?
carotids
Classic mitral regurgitation murmur description.
holosystolic, blowing
Classic mitral valve prolapse murmur description.
midsystolic click
Classic aortic regurgitation (insufficiency) murmur description.
Diastolic, early decrescendo murmur
Mitral stenosis murmur description.
diastolic, low-pitched rumbling, plus or minus a late crescendo
What are the 2 gallop sounds?
S3 or S4
S3 can be normal in what patients?
young or PREGNANT
S3 may indicate what pathology of the ventricle?
dilated cardiomyopathy (floppy ventricle)
When is S3 in relation to S1 and S2?
just after S2
When is S4 in relation to S1 and S2?
just before S1
Which valve may S3 indicate has pathology?
Mitral
S4 can be normal in what patients?
young or ATHLETES
What pathology is classically associated with an S4 heart sound?
stiff ventricle (diastolic dysfunction)
Pulmonary edema is caused directly by:
increased left atrial pressure (left heart failure)
Usually the first noticed sign of right heart failure.
lower extremity edema (peripheral edema)
Right wrist pulse stronger than femoral pulse.
coarcation of the aorta
What palpation physical exam finding for compensated aortic regurgitation?
increased peripheral pulse strength
Patent Ductus Arteriosis has what pulse finding?
increased strength of peripheral pulse
Periphearl Artery Disease physical exam pulse finding.
diminished pulses
What is pulsus peridoxus?
decreased systolic BP (decreased pulse strength) with inspiration
Classic pulse finding in pericardial tamponade.
pulsus paradoxus
What is it called when pulse varies in strength between beats.
Pulsus alternans
Where do you classically find pulsus parvus et tardus (weak and delayed pulse)?
aortic stenosis
ABCD management of Atrial Fibrillation
Anticoagulate, Beta-blocker, Cardiovert/Ca Channel blocerk, Digoxin
How slow is "bradycardia"?
<60 bpm
Bradycardia can be normal in what population?
athletes
Beta-Blocker over dosing will have what effect on heart rate?
slow (brady)
Calcium Channel blocker (CCB) over dosing will have what effect on heart rate?
slow (brady)
vagal stimulation does what to the heart rate?
slows (brady)
2 common drug classes that cause first degree AV-block.
Beta blocker, or CCB
Increased PR interval with NO dropped beats.
first degree heart block
3 drug causes of Wenckebach (Second degree AV block-Mobitz 1).
Beta-blocker, Calcium Channel Blocker (CCB), and digoxin.
Symptoms Wenckebach (Second degree AV block-Mobitz 1)
usually assymptomatic
Symptoms of Mobitz II AV-block.
occasional syncope
Which second degree AV-block is more likely to progress to complete AV-block (third degree): Mobitz I or Mobitz II?
Mobitz II.
Treatment for Wenckebach block not caused by drugs.
Atropine or Pacemaker
Treatment in symptomatic bradycardia
Atropine (or pacemaker in severe cases)
What is Wenckebach?
second degree AV-block type 1 (Mobitz I)
What is Mobitz I?
second degree AV-block type 1 (Wenckebach)
First step in management of Mobitz I.
Check for medication induced causes.
Treatment of Mobitz II.
pacemaker
Treatment of third degree heart block.
pacemaker
Treatment for 1st degree heart block (increased PR interval)?
no treatment necessary
symptoms of third degree heart block
hypotension, dizziness, syncope
What is a cannon A wave?
pressure wave in the jugular veins with contracting atria
Classic etiology of a cannon A wave?
third degree (complete) AV block
ECG findings in sinoatrial (SA) conduction disease diagnoses what?
AV block
Treatment for Tachy-Brady Syndrome (a type of Sinus Sick Syndrome).
Pacemaker
HEARTFAILED mnemonic for Congestive Heart Failure etiologies.
HTN
Endocrine
Anemia
Rheumatic Heart Disease
Toxins
Failure to take Meds
Arrhythmia
Infection
Lung (pulmonary embolism)
Electrolytes
Diet (sodium)
inability of the heart to pump enough blood to meet bodies needs
Congestive Heart Failure
3 heart pathologies that are risk factors for CHF:
CAD, valve disease, cardiomyopathy
Common endocrine abnormality which can cause tachycardia.
hyperthyroidism
Dehydration findings on exam: heart, skin, mouth.
tachycardia, poor skin turgor, dry mucous membranes
3 "Normal" causes of tachycardia.
Exercise, fear, pain.
Suspect this in patient with leg swelling and now tachycardic.
Pulmonary Embolism
SIRS criteria
3Ts and 1 W:
Temperature elevated
Tachycardic
Tachypneic
WBC abnormal (<4 or >12)
Causes of Acute Atrial Fibrillation (mnemonic PIRATES)
Pulmonary disease
Ischemia
Rheumatic heart disease
Anemai/Atrial myxoma
Thyrotoxicosis
Ethanol
Sepsis
2 common causes of Chronic Atrial fibrillation.
HTN, CHF
Pulse is irregularly irregular. Diagnosis?
Atrial Fibrillation
ABCD treatment of Atrial Fibrillation (not just the rate control).
Anticoagulate
Beta Blocker
Cardiovert
Digoxin
2 rules before cardioverting a stable patient in Atrial Fibrillation.
<48 hours of sx and don't suspect stroke
If over 48 hours of sx in Atrial Fibrillation, when to initiate cardioversion (2 options).
After TEE shows no clot OR after 3 weeks of adequate Coumadin tx.
INR goal in Atrial Fibrillation
2-3
Anticoagulation in Atrial Fibrillation if In-Patient.
Heparin bridge to Coumadin.
Anticoagulation in Atrial Fibrillation if Out-Patient.
Coumadin
Rate control options in Atrial Fibrillation (name 4 drugs).
Beta Blocker
Calcium Channel Blocker
Digoxin
Amiodarone
When to cardiovert an unstable patient with Atrial Fibrillation.
immediately
Sawtooth p-waves on ecg is called what?
Atrial Flutter
What is the rate of Atrial FLUTTER?
240-320 (remember 300) times per minute or 1 "sawtooth" per big box.
What is the pathophysiologic mechanism for Atrial FLUTTER?
1) circular electrical activity around the atrium
2) varying degrees of heart block
Treatment of Atrial FLUTTER?
Treat like AFib: antiocoagulate and rate control
2 diagnostic criteria for Multifocal Atrial Tachycardia (MAT) on ecg.
1) tachycardia (>100bpm)
2) 3 or more unique p-wave forms in one lead for 1 strip (6 seconds).
Treatment for Multifocal Atrial Tachycardia (MAT)?
treat the underlying disorder. rate control is not very effective.
ECG shows 3 unique wave forms in a COPD patient with hypoxemia. Diagnose the rhythm.
Multifocal Atrial Tachycardia (MAT)
Wandering Atrial Pacemaker ECG definition.
variable p-wave morphology; normal rate (>100bpm=MAT)
When to cardiovert an unstable patient with an arrhythmia?
Immediately
Arrhythmia symptoms (for gross location think head, chest, heart, lungs; doing a catholic sign of the cross.)
syncope/lightheadedness/dizziness
angina/chest pain
palpitations
shortness of breath
Medical treatment for re-entry tachycardias.
Adenosine.
2 non-medication treatments to try for re-entry tachycardias.
carotid massage and/or valsalva
P-wave vs. the QRS-wave in Atrioventricular NODAL Reentry Tachycardia (AVNRT) vs. Atrioventricular Reciprocating Tachycardia (AVRT)?
AVNRT: P-wave BURIED IN the QRS-wave
AVRT: P-wave often comes AFTER the QRS-wave
Premature Ventricular Contraction appearance on ECG?
wide QRS with compensatory pause
3 known causes of PVCs
hypoxia, electrolyte abnormalities, hyperthyroidism
Treatment for VFib.
Immediate electrical cardioversion and ACLS chest compression protocol.
3 general types of Superventricular Tachycardia (SVT)s by location of origin?
SA, Atria, AV
1st line therapy for symptomatic PVCs.
Beta Blocker
Electrical orgin of a PVC.
Ventricular.
Why immediately cardiovert a Ventricular Tachycardia (VT)?
It often progresses to VFib.
On ECG: wide QRS complexes (consistent and repeating), regular rhythm, rapid rate, with AV dissociation. Diagnosis?
Ventricular Tachycardia (VT)
Electrolyte abnormality often associated with Torsades de pointes.
Hypokalemia.
Sudden onset, very rapid rate with variable QRS shapes on ECG often associated with long QT syndrome.
Torsades de pointes.
Can try infusion of this element to treat Torsades de pointes.
Mg
Chronic shortness of breath, fatigue, exacerbated by exercise. What heart disease is in the differential?
CHF
Diabetic patient with hypertension. 1st line for HTN?
ACEI
Non-treatable risk factors of heart disease (four).
Age>65
Male
Family History
Black
Treatable diseases that are risk factors of heart disease (four).
HTN
Obesity
HLD
DM
Treatable behaviors that are risk factors of heart disease (four).
Smoking
over-eating/poor diet
innactivity/lack of exercise
alcohol abuse
Treatment for CHF without symptoms.
Diet
Exercise
& treat risk factors!
Treatment for CFH pts with known structural disease but little to no symptoms.
ACEI and Beta Blocker
When to consider adding diruretic to CHF treatment regimen.
SOB or fatigue
A specific diet modification for CHF patients.
Sodium restriction
When to consider adding Digitalis to CHF treatment regimen.
ACEI, Beta Blocker, and Diuretic fail to control or can't be used.
When is it indicated to NOT anticoagulate an AFib patient?
<65 years and zero CHADS2 risk factors for stroke.
CHADS2 risk for stroke for AFib patients.
CHF (+1)
HTN (+1)
Age>75 (+1)
DM (+1)
Sx previously of TIA/stroke (+2)
S3 gallop is a sound created by . . .
the end of diastolic rapid ventricular filling; the sound is turbulence in the setting of fluid overload.
S4 gallop is a sound created by . . .
turbulent blood hitting a stiff ventricle
Location of the pressure that we call the "preload."
fluid of a full ventricle
Location of the pressure that we call the "afterload."
fluid in aorta
AHA Stage A Congestive Heart Failure.
1) has risk factors for CHF
2) no symptoms
AHA Stage B Congestive Heart Failure.
1) known structural heart disease (e.g. MI)
2) no symptoms
AHA Stage C Congestive Heart Failure.
1) heart disease
2) symptomatic (SOB, fatigue, etc.)
AHA Stage D Congestive Heart Failure.
1) marked symptoms 2) at rest 3) despite maximal medical therapy
Left sided heart failure: lung exam finding.
bilateral basilar rales (crackles in lower lobes)
JVD occurs in which type of heart failure?
Right sided.
Pleural effusions, pulmonary edema, orthopnea, paroxysmal nocturnal dyspnea. Which side is the heart failure?
Left.
Hepatojugular reflex, hepatomegaly, ascites. Which side is the heart failure?
Right.
Cardiomegaly on CXR in CHF: what is the dysfunction?
Systolic dysfunction
Restrictive/Hypertrophic Cardiomyopathy and LVH.can cause CHF through what mechanism?
Diastolic dysfunction
Dilated cardiomyopathy or valvular heart disease can cause heart failure through what mechanism?
Systolic dysfunction
PMI abnormality in Dilated Cardiomyopathy.
displaced
PMI abnormality in Left Ventricular Hypertrophy
sustained
Patient with congestive heart failure due to diastolic dysfunction now has decreasing ejection fraction. What does this mean?
There is now some systolic dysfunction.
First symptom of CHF.
exertional dyspnea
What is the most common cause of right sided heart failure?
left sided heart failure.
How does inadequate left ventricular contractility and increased afterload show up on Echo reads?
Decreased ejection fraction (<50) and ventricular dilation.
What level of BNP is specific for CHF?
>500
Why get an ECG in CHF patient with acute symptoms (2 diseases)?
could be AF or MI.
Why treat CHF patients with a diuretics?
symptomatic relief only (no mortality benefit); if co-morbid L ventricular systolic dysfunction, Spiranolactone may decrease mortality.
First line class of diuretic in CHF.
Loop diuretics (e.g. Furosemide)
What causes chronic cough in CHF patient?
pulmonary edema (Left sided)
What are cheyne-stokes respirations?
Episodes of crescendo/decrescendo, deep/fast breathing alternating with apneic periods.
Bumetanide and Torsemide are what class of diuretics?
Loop Diuretics.
An osmotic diuretic.
Mannitol
Electrolyte abnormality caused by Spiranolactone.
Hyperkalemia (it's a Potassium sparing diuretic)
Hypocalcemia can be caused by what class of diuretics?
Loop Loses calcium.
What type of diuretic is ototoxic?
Loop diuretics
What is the mechanism by which Spiranolactone can cause gynecomastia, hirsuitism, or sexual dysfunction?
aldosterone receptor antagonist
What is the first line diuretic for mild hyperkalemia?
Furosemide, a Loop diruetic
This diuretic is contraindicated in CHF or anuria.
Mannitol
This diuretic decreases Calcium excretion and can cause hypercalcemia.
Thiazides
CHF or DM patient on ACEI has a dry, chronic cough. What do you do?
Switch to an ARB
Furosemide overdose exam findings
dehydrated and hypotensive
When an ACEI is indicated for a CHF patient.
Anyone who can tolerate them. If ACE cough, give an ARB.
When to start a Beta Blocker (e.g. Carvedilol) in a patient with acute decompensated CHF.
once the patient is euvolemic
ACEI + Beta Blocker prevents what in MI or CHF patients.
neurohormonal remodeling of the heart.
Most important management patients with mild CHF.
control co-morbid conditions (e.g. DM, HTN, obesity), and limit dietary sodium.
CHF patient with comorbid ischemia. Treatment?
Daily aspirin and statin to prevent further ischemic events.
CHF with EF less than 30 plus CAD. Treatment?
ICD (implantable biventricular cardiac defibrillator)
LMNOP mnemonic for acute exacerbations of CHF.
Lasix
Morphine
Nitrates
Oxygen
Position
CHF refractory to maximal medical therapy. Last resort treatment?
mech. left ventricular assist device or cardiac transplantation
decreased ventricular compliance with normal systolic function defines what?
Diastolic Dysfunction
First line agents for Diastolic Dysfunction.
Diuretics
Beta Blockers, ACEIs, ARBS, or CCBs, for what purpose in patient with Diastolic Dysfunction?
BP and rate control.
3 types of cardiomyopathies.
Dilated, Hypertrophic, and Restrictive
The most common type of cardiomyopathies of the 3 types.
Dilated.
How to confirm diagnosis of dilated cardiomyopathy.
low ECF (systolic dysfunction) and left ventricular dilation
2 most common causes of Secondary Dilated Cardiomyopathy
Ischemia or Long-Standing HTN
What is the most common cause of dilated cardiomyopathy?
Idiopathic
What social history is important in finding an etiology of dilated cardiomyopathy?
alcohol or cocaine
Coxsackievirus can be associated with what heart disease?
Dilated Cardiomyopathy.
Most common cause of death in patients with Acromegaly (like Andre the Giant).
Cardiomyopathy induced heart failure.
Gallop associated with Dilated Cardiomyopathy (Systolic Dysfunction)?
S3
Endocrine test to order when suspecting dilated cardiomyopathy.
TSH
Diagnostic test for cardiomyopathy.
Echo
Which block is common in dilated cardiomyopathy?
LBBB
Major physiologic abnormality in Dilated Cardiomyopathy?
Impaired contractility
Major physiologic abnormality in Hypertrophic Cardiomyopathy?
Impaired relaxation of the left ventricle (diastolic dysfunction)
Major physiologic abnormality in Restrictive Cardiomyopathy?
Impaired elasticity
Left ventricular cavity size in Hypertrophic Cardiomyopathy.
Small (wall hypertrophy)
Ejection Fraction (EF) in Dilated Cardiomyopathy.
Low (systolic dysfunction)
Wall thickness in Hypertrophic Cardiomyopathy.
Thick (LVH)
Which Cardiomyopathies are diastolic dysfunction?
Hypertrophic and Restrictive. (Dilated=systolic dysfnct)
History of sx in dilated cardiomyopathy.
gradual onset of CHF symptoms
Classic ECG finding in Dilated Cardiomyopathy.
non-specific ST-T changes
CXR shows enlarged, balloon-like heart and pulmonary congestion. Diagnosis?
Dilated Cardiomyopathy/CHF
Treatment for Dilated Cardiomyopathy induced heart failure.
Treat the CHF.
Most common cause of sudden death in a young, healthy athlete.
Hypertrophic Cardiomyopathy.
Congenital Hypertrophophic Obstructive Cardiomyopathy (HOCM) shows what inheritance pattern?
autosomal-dominant
How to differentiate murmur of Hypertrophic Stenosis from (Valvular) Aortic Stenosis.
HCM murmur will increase with valsalva (decreased preload). Also, HCM murmur will not radiate to carotids.
Usual location of hypertrophy in Hypertrophic Cardiomyopathy.
Interventricular Septum
Gallop associated with Hypertrophic Cardiomyopathy.
S4
What ECG finding is often found with Hypertrophic Cardiomyopathy?
LVH (overlapping S&R waves in V-V6)
2 most common causes of LVH.
HTN and Aortic Stenosis
Echo findings in Hypertrophic Cardiomyopathy?
asymmetric LVH and changing outflow obstruction
Medical treatment for symptomatic Hypertrophic Cardiomyopathy.
Beta Blocker
Behavior changes in kids with Hypertrophic Cardiomyopathy
Avoid competitive sports and rigorous exercise.
Hemochromatosis can cause what type of cardiomyopathy?
Restrictive
Amyloid and Sarcoid can cause what type of cardiomyopathy?
Restrictive
Radiation can cause what type of cardiomyopathy?
Restrictive
Infections such as HIV, Chagas' disease and some parasites can cause what type of cardiomyopathy?
Dilated
Wet Berberi can be associated with what type of cardiomyopathy?
Dilated
2nd line medical treatment for Hypertrophic Cardiopathy (if can't do Beta Blockers)?
CCBs
Predominant symptoms of Restrictive Cardiomyopathy.
Right sided Heart Failure: JVD and peripheral edema
Cardiac biopsy shows infiltration. What is the cardiomyopathy?
Restrictive
Heart transplants often must be considered because this type of cardiomyopathy is so difficult to treat.
Restrictive
Which is worse: Apple obesity or Pear obesity?
Apple AKA Central AKA Abdominal obesity is worse that thigh/butt obesity
Prinzmetal's Angina is caused by what pathophysiology?
vasospasm of coronary vessels.
Young woman often has substernal chest pain at rest in the morning. Found to have ST elevation, but normal troponins. Diagnosis?
Prinzmetal's Angina
What is the physiology of Ischemia?
Not enough oxygen for the tissue's demand.
Definition of Angina Pectoris.
Substernal chest pain secondary to myocardial ischemia.
Classic triad of Angina symptoms (stable).
1) Substernal chest pain
2) Provoked by exertion
3) Relieved by rest (or nitro)
Levine's sign
fist on chest: often described as pressure (e.g. "elephant on chest") rather than pain
Suspect abnormal presentation for MI in what patients?
Women, Elderly pts with AMS, Post-heart transplant pts, or Diabetic pts
Things to check for on physical exam to suggest atherosclerosis as the cause of chest pain.
carotid and peripheral bruits, HTN
Indications for Exercise Stress Test.
symptomatic with some risk of CAD
Indications for testing an asymptomatic patient with Exercise Stress Test.
No absolute indications; can consider in pilots and bus drivers, or patients with high risk for CAD.
Medical treatment for acute stable or unstable angina (MONA-B).
Morphine - IV
Oxygen
Nitroglycerin
Aspirin
Beta Blocker
Medical treatment for chronic stable angina.
Daily Aspirin and Beta Blocker, plus PRN Nitroglycerin
Second line agent (if Beta Blockers are contraindicated) for treatment in chronic heart disease.
a nondihydropyridine CCB (Diltiazem or Verapamil)
3 independent criteria for unstable angina.
new pain
worsening pain
pain at rest
Elevated troponin and CK-MB without ST-elevations. Diagnosis?
NSTEMI
How to diagnose NSTEMI.
Serial cardiac enzymes (positive) and ECG (negative).
Low risk patient has Unstable Angina without elevation of cardiac enzymes or ECG changes. Next 2 tests in work-up?
Stress Test and Echo
What is the cut off time for clinic vs. ER referral for Unstable Angina?
Symptoms in the last 2 days goes to ER.
High risk Chest Pain characteristics that will prompt ER referral instead of a clinic appointment (go through OPQRST-A).
O >20 minutes
P pain at rest
Q typical triad
R right arm/jaw
S severe
T <2 days
A SOB or LOC
2 STAT tests for patient in the ER with acute unstable angina.
Troponin and ECG
When to order BNP and CXR in patient with unstable angina.
if Heart Failure sx
ECG change besides ST changes that may indicate acute MI.
New LBBB
When NOT to give Beta Blocker in acute angina.
If CHF suspected.
ST depression in these leads indicates Posterior Infarction.
V1-V2
What is the best predictor of survival after MI?
left ventricular EF
Troponin vs. CK-MB: which is the better test?
Troponin most sensitive and specific.
Diffuse ST-Elevation (across all leads).
Pericarditis
If ACS suspected in patient with Angina, add these 2 drugs in addition to Aspirin.
Clopidogrel and Enoxaparin
When to add GP IIb/IIa inhibitor in patient with ACS.
If planning angiography/PCI. Especially if there will be a delay.
PCI vs. CABG: which has more complications?
CABG
PCI vs. CABG: which patients are more likely to require repeat procedures?
PCI
Why test CK-MB as well when testing Troponin?
CK-MB can help in timing of MI onset
Why test CRP as well when testing troponin?
CRP helps with risk stratification, especially long term.
What makes an ACS patient "high risk" and therefore in need of the Invasive Strategy? (3 independent criteria)
TIMI risk score (TRS) 3 or more, positive Troponin, or positive ECG.
What is the door-to-balloon time preferred when performing PCI on an ACS patient?
<90min.
When is thrombolysis with tPA or Streptokinase the preferred treatment over PCI (in ACS)?
If time to PCI >90 minutes after sx onset AND sx have been present for less than 3 hours.
If ACS patient has sx over 3 hours at presentation, what is the preferred treatment?
PCI
In ACS, if PCI or CABG is not available, consider thrombolysis for how long?
some benefit remains if <12 hours of symptoms
If there is 3 vessel disease found in MI patient, what procedure is indicated after PCI?
CABG
Indications for CABG (mnemonic DUST).
Depressed ventricular fnct
Unable to perform PCI
Stenosis of L main Coronary a.
Triple vessel disease
How long to continue Clopidogrel after PCI.
4 weeks
3 long term medications after acute MI other than Aspirin (mnemonic "cover your BAceS").
Beta Blocker, Ace Inhibitor, Statin
If there is Left Main Coronary Artery disease in MI patient, what procedure is indicated after PCI?
CABG
If cannot give Beta Blockers, what is its 2nd line medical therapy (in ACS)?
ACEI or ARB
Overall most common complication after acute MI.
Arrhythmia
Most common cause of death after acute MI.
Arrhythmia
Most common complication post acute MI in the first 24 hours.
Heart failure
Most common complication post acute MI on day 2-4.
Arrhythmia
2 most common complications post acute MI on day 5-10.
Papillary muscle rupture (Mitral Regurg.) or Left ventricular wall rupture (and Tamponade)
over 10 days post MI, watch for complications especially with this certain pathology of the ventricle.
aneurysm
When is pericarditis most likely to occur post-MI?
2-4 days
Hypercholesterolemia definition: total cholesterol level.
>200
Hyperlipidemia definition: LDL level.
>130
Hyperlipidemia definition: triglyceride level.
>500
Dyslipidemia definition: HDL level.
<40
What is a Xanthoma?
fatty skin nodules over the tendons associated with Hyperlipidemia
Yellow patches of skin around eyes and on eyelids. Diagnosis?
Xanthelasmas caused by Hyperlipidemia (HLD)
Creamy appearance of retinal vessels caused by Hyperlipidemia (HLD).
Lipemia Retinalis
Screening for Hyperlipidemia. Begin? Frequency?
start at 20 y/o; q5 years
ATP III: LDL goal in Diabetics etc.
<100 (ATP IV may say <70)
What HDL level is considered a negative risk factor?
>60
ATP III: LDL goal in patients with NO risk factors.
<160
ATP III: LDL goal for patients with 2+ RFs.
<130
What age defines early CAD? (males and females)
Male <55, Female <65
What age is considered an independant RF for CAD? (males and females)
Male >45, Female >55
When can you to try diet and exercise to lower lipids.
If no known athersclerotic disease
How long to try diet and exercise to lower lipids?
12 weeks
2 Hyperlipidemia medications which raises HDL.
Niacin and Fibrates (Gemfibrozil)
1st line Lipid Lowering agent.
Statins
Mechanism of action of statins
HMG-CoA reductase inhibitor
Main side-effect of Cholestyramine, a bile-acid binder.
Constipation
Hyperlipidemia medication that causes facial flushing.
Niacin
Baseline blood test before beginning a statin.
Liver Function Tests
What is the mechanism by which Ezetimibe (Zetia) causes "floating" diarrhea?
decreases the absorption of cholesterol which creates the steathorrhea
What is the mechanism of the fibrates (Hyperlipidemia med)?
lipoprotein lipase stimulator
2 hyperlipidemia meds known to lower triglyceride levels.
Statins and Fibrates (Gemfibrozil)
Definition of Hypertension.
>140 syst or >90 diast.
Systolic lower limit definition of Pre-Hypertension
>120
Systolic definition of Stage 2 Hypertension.
>160
1st line treatment for Hypertension
Thiazide (HCTZ)
Stage 2 HTN usually requires 2 agents: usually what 2 drugs?
Thiazide+ACEI (HCTZ+Lisinopril)
Which of the following lifestyle changes effects BP the best? Na restriction, wt. loss, exercise, decreased EtOH consumption.
Wt. Loss (BP decrease is abt. 20)
Adequate exercise will decrease BP by how much?
abt. 10
BP goal for a diabetic.
<130/80
There is known benefit in CVE prophylaxis for lowering BP less than 120. What is the limiting factor on the goals set by JNC-7?
symptoms of Relative Hypotension
Why order baseline labs (UA, CBC, BMP) when HTN is diagnosed?
to assess end organ damage.
Cotton Wool Exudates as a sign of end-organ failure. Diagnosis?
Hypertensive Retinopathy
Hypertensive patient with CAD. What is the indicated medication/s?
ACEI (or ACEI+CCB)
Hypertensive patient with Stable Angina. What is the indicated medication/s?
Beta Blocker
Hypertensive patient post-MI. What is the indicated medication/s?
Beta Blocker and ACEI
Hypertensive patient with CHRONIC heart failure. What is the indicated medication/s?
ACEI or ARB and Beta Blocker; (likely be on a diuretic as well for edema)
Hypertensive patient with ACUTE/decompensated Heart Failure. What medication is contraindicated?
Beta Blocker
Hyptensive patient with DM. What is the indicated medication?
ACEI (or ARB)
Hypertensive patient with CKD. What is the indicated medication?
ACEI (or ARB)
Most common etiology for HTN.
Essential/Idiopathic (unknown)
Diet management of HTN secondary to Renal Parenchymal disease.
Salt and fluid restriction
Goal BP in patient with proteinuria (renal disease)?
<130/80
African American with hypertension. This cheap medication class is particularly effective in this population.
Diuretics
How often to follow up a patient with controlled Hypertension to screen for end-organ damage.
q3-6 months
Sleep disorder that is associated with Hypertension.
OSA
This hypertensive medication can actually accelerate kidney damage if there is bilateral renal artery stenosis.
ACEI
OR-CHAPS mneumonic for causes of secondary hypertension.
OCP use
Renal Parenchymal Disease
Cushings
Hyperaldosteronism (Conn's)
Aaortic Coarctation
Pheochromocytoma
S
Antihypertensive med to use in UNILATERAL renal artery stenosis.
ACEI
OB/GYN med class that can cause secondary hypertension.
OCPs
Abnormality associated with Turner's syndrome that causes secondary hypertension.
Coarctation of the Aorta
How to diagnose a pheochromocytoma.
urinary metanephrines/catecholamine levels
What do you give a patient with pheochromocytoma BEFORE surgery?
both alpha and beta blockers
episodes of panic attack symptoms + episodic headaches + HTN; what tumor?
pheochromocytoma
What does a pheochromocytoma secrete?
epinephrine and norepinephrine
Conn's syndrome is caused by elevated secretion of what hormone?
aldosterone
Hyperaldosteronism (Conn's Syndrome) triad.
HTN, hypokalemia, metabolic alkalosis
What is Cushing's DISEASE?
Pituitary gland tumor over produces ACTH which causes Cushing's Syndrome.
Cushing Syndrome is most often cause by . . .
exogenous steroids
How to treat HTN caused by Cushing's Disease.
Surgery
Most common cause of renal artery stenosis in YOUNGER patients (under 25).
fibromuscular dysplasia
Usual cause of renal artery stenosis in OLDER pateints (over 50).
atherosclerosis
Diagnosis of Malignant Hypertension, a form of Hypertensive Emergency, requires what eye exam finding?
Papilledema.
4 organs most commonly damaged by Hypertensive Emergencies.
Brain, Eyes, Heart, Kidneys
Based on expert opinion, what is the initial goal mean arterial pressure reduction for Hypertensive Emergency.
25% reduction
What is the difference between Hypertensive Emergency and Hypertensive Urgency?
By definition, Emergency involves end organ damage.
What is the blood pressure which defines Hypertensive Urgency?
>180/110
Hypertensive Urgency vs. Emergency: use PO or IV meds?
Urgency: PO (e.g. clonidine); Emergency: IV (e.g. labetalol)
HTN patient with osteoporosis. What is the indicated medication?
Thiazide diuretics (not Loop)
HTN patient with BPH. What is an indicated medication?
Alpha-1 adrenergics (e.g. prazosin or terazosin)
Hypertensive patient is now pregnant (Chronic HTN). What is the indicated anti-hypertensive?
Methyldopa
What is the mechanism of the ACEI cough?
increased Bradykinin levels
Severe Pre-Ecclampsia. What is the indicated anti-hypertensive?
Hydralazine or Labetalol
Mechanism of the anti-hypertensive Hydralazine.
vasodilator - dilates arteries
Asthma patient with HTN. What medication is contra-indicated?
Beta Blockers
Most common cause of Pericarditis (50%).
Infection
CARDIAC RIND mnemonic for causes of Pericarditis.
Collegen vascular dx (Lupus)
Aortic dissection
Radiation
Drugs
Infections
ARF (uremia)
Cardiac (MI)
Rheumatic Fever
Injury
Neoplasms
Dressler's syndrome
PERICarditis mnemonic for signs of Pericarditis.
Pulsus paradoxus
ECG changes
Rub
Increased JVP
Chest pain
What is the classic description of chest pain with pericarditis?
pleuritic, relieved by sitting forward
Squeaky leather, grating, rasping sound on heart exam. Diagnosis?
Pericarditis (Friction Rub)
What is pulsus paradoxus?
Decreased systolic BP by 10 during inspiration (evidenced by diminished pulse strength on exam)
Beck's triad for Cardiac Tamponade.
JVD, HoTN, Distant heart sounds
The "water-bottle" sign (effusion) around the heart on Echocardiogram suggests what diagnosis?
Pericarditis
Theurapeutic Pericardiocentesis is also used diagnostically in these 2 etiologies of Pericarditis.
Neoplasm or Infectious causes
What etiology of pericarditis will need dialysis for treatment?
uremia 2/2 renal failure
What is symptomatic treatment for viral pericarditis?
ASA and NSAIDS
Why distant heart sounds in Cardiac Tamponade?
effusion muffles sounds
What is Kussmaul's sign commonly found in Cardiac Tamponade?
JVD during inspiration
Electrical alterans (QRS amplitude varies beat to beat) is pathognomonic for what?
Cardiac Tamponade
Besides urgent pericardiocentesis, how do you manage Cardiac Tamponade?
Aggressive IVF
What is the most common cause of valve diseases all together?
mechanical degeneration
When to replace valve in patient with Aortic Stenosis.
only if symptomatic (angina or syncope or SOB)
How to get a definitive diagnosis for a heart murmur.
Echocardiogram
Nifedipine or Amlodipine or ACEI for patient waiting for valve replacement: what valve disease?
Aortic Regurgitation (Insufficiency)
CREAM mnemonic for causes of aortic regurgitation (insufficiency).
Congenital
Rheumatic Fever
Endocarditis
Aortic Dissection
Marfans
Rheumatic Fever continues to be the most common cause of this valve disease despite decrease in incidence.
Mitral Valve Stenosis.
New Mitral Valve Regurgitation should prompt work up for what?
MI
Besides Mitral Stenosis, Mitral Regurgitation is often caused by this disease.
Rheumatic Fever
Treatment for Mitral valve disease is usually for symptoms caused by this abnormality.
arrhythmia
Definitive treatment for Mitral Stenosis in severe cases.
Valve replacement
Abdominal Aortic Aneurism (AAA) is associated with this pathology.
Atherosclerosis
more than 90% of Aortic Aneurisms are located where?
Abdomen (below renal arteries)
Pulsatile abdominal mass on exam. Diagnosis?
AAA
One time screening for men over 65 y/o who have ever smoked (w/ abdominal U/S) for this disease.
AAA
Ruptured Aortic Aneurism pain radiates where?
to back
Aortic Dissection is associated with this disease.
Hypertension
What size of AAA warrants surgical repair?
>5.5 cm
Follow AAA q6-12 months with serial Abdominal U/S if they are less than this size.
<5.5cm
When to screen males who have never smoked or females for AAA?
never
Most efficacious lifestyle change in preventing AAA rupture.
stop smoking
Sudden, tearing/ripping anterior chest pain radiating to interscapular back. Diagnosis?
ascending Aortic Dissection
Descending Aortic Dissection managment.
control BP and heart rate
Ascending Aorta Dissection treatment
emergent surgery
Consider this complication of Aortic Dissection if Hypotensive.
Pericardial Tamponade.
Virchows triad for DVT
Venous Stasis
Endothelial damage
Hypercoagulable states
Unilateral, deep leg pain and swelling. Diagnosis?
DVT
When to order D-Dimer.
When symptoms are indicative but patient risk factors are low for DVT or PE.
Anticoagulation for patient with DVT.
Heparin bridge to Warfarin
High risk DVT patient has contraindication to anticoagulation. Tx?
IVC filter
Prophylaxis for immobile hospital patient to prevent DVT/PE.
Enoxaparin
Pregnant woman with DVT. Treatment?
Enoxaparin
Patient with Aortic Dissection will have what variation in pulse and BP.
Asymmetric readings
Aortic Dissection can cause what heart murmur?
Aortic Regurgitation (Insufficiency)
Atherosclerotic plaque occluding blood supply to extremities. Diagnosis?
Peripheral Artery Disease (PAD)
Define intermittent claudication in PAD.
leg pain with walking and relieved by rest
Blue toe syndrome secondary to cholesterol atheroembolism is a known complication of what procedure?
CABG
With chronic severe PAD, what happens to the distal muscles?
from atrophy to gangrene/necrosis
1st step in evaluation of PAD severity.
Ankle-Brachial Index of Blood Pressure (ABI)
Diagnostic of choice when suspecting stenosis/occlusion from PAD.
Doppler U/S
What is the cut-off by Doppler U/S of ankle flow compared to brachial flow
ankle <90% of brachial = abnormal
Why avoid Beta Blockers in PAD?
Beta peripheral vasoconstriction
Medical therapy for PAD (other than Aspirin).
Cilostazol
Diabetics with PAD are especially prone to this complication.
ulcers
Surgery to consider before amputation of severe PAD.
Bypass
Treatment of PAD if medical treatment fails.
Angioplasty or Stent
Most common cause of lymphedema in the U.S.
surgery (e.g. mastectomy)
Most common cause of lymphedema in underdeveloped countries.
Filariasis parasites (e.g. Wucheria Bancrofti)
Congenital abnormalities in Milroy Disease causes this (usually lower extremity) abnormality bilaterally. Presents in childhood.
Lymphedema.
1st line treatment option for lymphedema secondary to surgery.
Pressure garments (Ted-Hose)
Monitor for this complication of chronic lymphedema.
cellulitis
Why does cardiac syncope need to be worked up even if the patient is currently assymptomatic.
1 year sudden cardiac death rate is 40%
Patient complains he passed out, reports he knew it was coming, and says he was confused afterward. Diagnosis?
Seizure
Most common cause of syncope.
Vasovagal (aka neurocardiogenic)
1st test to order when patient comes to ER reporting syncopal episode.
ECG
Syncope attributed to exertion on patient history. Next 2 orders in work-up (after ECG)?
Echo and Exercise Stress Test
Patient c/o syncope, now asymptomatic; no risk factors of heart disease. What test to order if this recurs?
tilt table
What is the cut-off age for automatic admit for work up after syncopal episode?
>60 y/o
Patient with syncopal episode has history of heart disease. What 2 tests to order?
Echo and Exercise tolerance test
Suspected cardiac source of syncope, but then got a negative work up. When do you consider Holter (ambulatory ECG)?
At 2nd syncopal episode, order holter.
Murmurs on heart exam in patient with history of syncope. Next 2 orders in work-up (besides ECG)?
Echo and Exercise Stress Test
DRIP-ABCDEFG-L mnemonic in CXR analysis.
Dumb stuff: right person? AP or PA? foreign bodies?
Rotation
Inspiration (7-8 ribs)
Penetration
Airway (midline?)
Bone
Cardiac Silhouette
Diaphragm
Effusions (costophrenic angle)
Free air (look under the heart)
Gotta get to the Lungs
Last: compare to previous CXRs