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51 Cards in this Set
- Front
- Back
Stable Angina Pectoris
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Coronary ischemia due to imbalance between blood supply and oxygen demand due to fixed atherosclerotic lesions in arteries
*Occurs with INCREASED OXYGEN DEMAND |
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Risk factors for Stable Angina Pectoris
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1) DM
2) Hyperlipidemia - elevated LDL 3) HTN 4) Cigarette smoking 5) Age 6) Low HDL 7) Hyperhomocysteinemia |
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Normal cardiac ejection fraction
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>50%
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Clinical features of stable angina
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1) Chest pain or substernal pressure lasting less than 10-15 minutes
2) Brought on by exertion or emotion 3) Relieved with rest or nitroglycerin |
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Diagnosis of coronary artery disease
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1) Resting EKG
2) Stress EKG / Stress Echocardiogram 3) Pharmacologic stress test (if unable to exercise) 4) Holter monitoring (ambulatory EKG) 5) Cardiac catheterization with coronary angiography *If stress studies +, proceed to catheterization |
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Metabolic Syndrome X
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Obesity, plus any 2 of the following:
1) Hypercholesterolemia 2) Hypertriglyceridemia 3) DM 4) Hyperuricemia 5) HTN |
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Stress test considered positive with any of these findings...
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1) S-T segment depression
2) Chest pain 3) HYPOtension 4) Significant arrhytmias |
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Syndrome X
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Exertional angina with NORMAL coronary arteriogram
Exercise testing and nuclear imaging show evidence of MI *Excellent prognosis |
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Medications used for pharmacologic stress test
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1) IV adenosine
2) Dipyramidole 3) Dobutamine *Adenosine and Dypyramidole cause generalized coronary vasodilation *Dobutamine increases myocardial oxygen demand (HR, BP, contractility) |
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Treatment of CAD
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1) Risk factor modification
2) Medical therapy (aspirin, beta-blockers, nitrates, Ca2+ channel blockers, ACEI [for CHF]) 3) Revascularization (PTCA or CABG) |
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Coronary artery disease: Severe disease
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1) Decreased ejection fraction (EF)
2) Three-vessel disease 3) Left main or LAD disease |
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Indications of Percutaneous Transluminal Coronary Angioplasty (PTCA)
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Indicated with one- or two-vessel disease (proximal lesions)
*Restenosis occurs in 40% within 6 months --> rate reduced with stent placment |
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Unstable Angina Pectoris (USA)
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Coronary artery blood supply is decreased secondary to reduced resting coronary flow
**Oxygen demand is unchanged --> Indicates stenosis that enlarged via thrombosis, hemorrhage, or plaque rupture** |
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Characteristics of USA
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1) Chronic angina with increasing frequency, duration, or intensity of chest pain
2) New-onset angina that is severe and worsening 3) Angina at rest |
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First-line therapy for USA
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1) Beta-blockers
2) Nitrates *Aspirin, Low-molecular-weight heparin (LMWH), and Glycoprotein IIb/IIIa inhibitors helpful adjuncts |
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Variant (Prinzmetal's) Angina
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Transient coronary vasospasm accompanied by fixed atherosclerotic lesion
Angina at rest, associated with ventricular dysrhythmias *Transient S-T segment elevation |
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Coronary angiogram of variant angina
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Displays coronary vasospasm
*Pt given Ergonovine (to provoke chest pain) |
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Treatment of variant angina
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1) Calcium channel blockers
2) Nitrates |
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Myocardial Infarction (MI)
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Necrosis of myocardium resulting from interruption of blood supply
Usually due to acute coronary thrombosis *30% mortality rate |
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Clinical features of MI
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1) Chest pain (substernal "crushing" pressure) that radiates to jaw, neck, arm on left side
2) May be asymptomatic 3) Dyspnea, Diaphoresis, Weakness / Fatigue, N/V, Syncope, Sense of impending doom 4) Sudden Cardiac Death (V-fib) |
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EKG markers for ischemia/infarction
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1) Peaked T waves
2) S-T segment elevation (transmural injury) 3) Q waves 4) T wave inversion |
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Categories of cardiac infarcts
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1) ST segment elevation - transmural (entire thickness of wall)
2) Non-ST segment elevation - subendocardial (inner one third to one half of wall) *Types differentiated by cardiac enzymes |
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Cardiac enzymes
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1) Creatine kinase-MB (CK-MB) - increases within 4-8 hrs of MI; returns to normal in 2-3 days
2) Troponins (I&T) - increases within 3-5 hrs; returns to normal in 5 -14 days *Troponins are most important markers of MI |
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Medical therapy shown to reduce mortality after MI
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1) Aspirin - inhibtis platelet aggregation on top of thrombus
2) Beta-blockers - blocks contractility and reduces afterload 3) ACE Inhibitors *Statins, Nitrates, Morphine, Heparin & Oxygen used also |
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Complications of MI
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1) Pump failure (CHF)
2) Arrhythmias 3) Recurrent infarction 4) Mechanical complications (rupture of free wall, interventricular septum, papillary muscle, etc) 5) Acute pericarditis 6) Dressler's Syndrome |
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MCC of in-hospital mortality post MI
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Pump failure (CHF)
*Mild: Tx with ACEI or diuretic *Severe: Invasive hemodynamic monitoring |
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Management of 2nd degree (type 2) or 3rd degree AV block in setting of anterior MI
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Emergent placement of temporary pacemaker, followed by placement of permanent pacemaker
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Free wall rupture post MI
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Occurs during first 2 weeks
90% mortality via hemopericardium and tamponade Treated with hemodynamic stabilization, pericardiocentesis, and surgical repair |
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Valvular dysfunction caused by papillary muscle rupture
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Mitral Regurgitation
*Valve replacement necessary |
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Ventricular Pseudoaneurysm
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Incomplete free wall rupture
*Surgical emergency --> leads to free wall rupture |
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Treatment of post-MI acute pericarditis
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Aspirin
*NSAIDS and corticosteroids contraindicated |
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Dressler's Syndrome
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Fever, malaise, pericarditis, leukocytosis, and pleuritis occurring weeks to months after MI
*Aspirin is most effective therapy |
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Differential Diagnosis of Chest Pain: Heart
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1) MI
2) Angina 3) Pericarditis 4) Aortic dissection |
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Differential Diagnosis of Chest Pain: Lungs
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1) Pleuritis
2) Pulmonary embolism 3) Pneumothorax 4) Pneumonia 5) Status asthmaticus |
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Differential Diagnosis of Chest Pain: GI
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1) GERD
2) Diffuse esophageal spasm 3) Peptic ulcer disease 4) Esophageal rupture |
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Differential Diagnosis of Chest Pain: Chest Wall
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1) Costochondritis
2) Muscle strain 3) Rib fracture 4) Herpes zoster 5) Thoracic outlet syndrome |
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Differential Diagnosis of Chest Pain: Psychiatric / Drugs
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1) Panic attacks
2) Anxiety 3) Somatization *Cocaine use can cause angina |
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Systolic dysfunction in Congestive Heart Failure (CHF)
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1) Impaired contractility
2) Cardiomyopathy 3) Myocarditis |
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Diastolic dysfunction in CHF
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1) HTN leading to hypertrophy (MCC)
2) Valvular diseases 3) Restrictive cardiomyopathy (i.e., amyloidosis, sarcoidosis, hemochromatosis) |
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Clinical features of CHF
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1) Dyspnea
2) Orthopnea 3) Paroxysmal nocturnal dyspnea 4) Nonproductive nocturnal cough 5) Confusion and memory impairment (inadequate brain perfusion) 6) Diaphoresis and cool extremities at rest |
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Orthopnea
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Difficulty breathing in recumbent position
*Due to increased distribution of blood to the pulmonary circulation when laying down |
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Paroxysmal Nocturnal Dyspnea (PND)
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Awakening after 1 -2 hours of sleep due to acute shortness of breath
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Signs of left-sided heart failure
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1) Displaced PMI
2) S3 gallop (best heard at apex with bell of stethoscope) 3) S4 gallop 4) Crackles / rales at lung bases 5) Dullness to percussion and decreased vocal fremitus (pleural effusion) 6) Increased intensity of pulomonic component of 2nd heart sound (left upper sternal border) |
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Signs/symptoms of right-sided heart failure
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1) Peripheral pitting edema
2) Jugular venous distention 3) Nocturia (due to increased venous return w/ leg elevation 4) Hepatomegaly/hepatojugular reflex 5) Ascites 6) Right ventricular heave |
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Diagnosis of CHF
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1) CXR
2) EKG 3) Stress testing 4) Cardiac catheterization 5) Echo (EF, r/o pericardial effusion) 6) Radionuclide ventriculography w/ technetium-99m |
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New York Heart Association (NYHA) Classification of CHF
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Class I: Symptoms w/ vigorous activity; asymptomatic at rest
Class II: Symptoms w/ prolonged or moderate exertion; slight limitation of activities Class III: Symptoms w/ usual daily activities; markedly limitation Class IV: Symptoms at rest; incapacitating |
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Possible CXR findings in CHF
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1) Cardiomegaly
2) Kerley B lines - short horizontal lines near periphery of lung 3) Prominent interstitial markings 4) Pleural effusion |
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Treatment options for CHF
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1) Salt restriction (>4g /day)
2) Diuretics (symptomatic relief) 3) ACEI 4) Angiotensin II receptor blockers 5) Digitalis (+ inotropic agent; EF<30%) *Hydralazine & Isosorbide dinitrates used in patients who cannot tolerate ACEI 6) |
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Signs of digoxin toxicity
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1) GI: n/v, anorexia
2) Cardiac: AV block. AFib, ectopic ventricular beats 3) CNS: visual disturbances, disorientation |
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Carvedilol
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Non-selective beta blocker/alpha-1 blocker
Used in tx of CHF *Better improvement than Metoprolol |
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Useful in differentiating between dyspnea caused by CHF and COPD
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B-type natriuretic peptide (BNP)
*Released from cardiac ventricles in response to volume expansion and pressure overload |