Cardiology

Cardiovascular disease

Stable angina – pain occurs with exercise relieves with rest, improves with rest, next thing is Stress Test, EKG, Echo, nuclear perfusion study

Echo or nuclear perfusion study if that person has abnormality on EKG

Positive stress test anything that shows ST depression, hypotension or pain

Echo wall abnormality

Nuclear perfusion decreased uptake of nuclear isotope

Unable to exercise – pharmacologic stress test exercise or adenosine

Correct answer is exercise stress test using EKG, abnormal EKG that masks the result of stress EKG

Echo or nuclear perfusion

Can’t exercise – wheel chair bound, osteoporosis, contraindication to exercise test – pharmacologic

Pharmacologic test on EKG, Echo, or nuclear perfusion

Stress – Exercise, chemical

Test – EKG, Echo, nuclear perfusion

Definitive way to diagnose coronary artery disease is through angiography

Stress test, angiography is invasive

First test is EKG

First line treatment for stable angina – nitrates, aspirin, beta blockers

Unstable

MONA C BASH – morphine, oxygen, nitrates, aspirin, clopidogrel, beta blockers, ace inhibitors, statin, heparin

Unstable angina – worsening or evolving occurs at rest, no cardiac biomarkers (no troponin) unstable angina with troponin elevations

Unstable angina becomes NSTEMI if there are troponins

STEMI – troponins with EKG

Chest pain – rule out ACS acute coronary syndrome – unstable angina, NSTEMI, or STEMI

Chest pain want to rule that out

EKG and cardiac enzymes, cardiac enzymes take a while to come in

With the EKG look to see if this is STEMI or not

If this is STEMI, to diagnose stemi don’t need cardiac enzymes 1 milimeter st elevations and two continuous leads or a new left bundle branch block considered STEMI don’t need enzymes go straight to cath lab

EKG but no ST elevations, but have characteristic chest pain, want to do serial troponins and EKGs to see if evolving or changing

Unstable angina or NSTEMI

If troponins come back elevated troponins – NSTEMI

Non ST elevation MI

No troponins after serial troponins, stays low unstable angina, conditions satisfied where chest pain has been evolving recently and getting worse and chest pain at rest, 

unstable angina or NSTEMI apply TIMI score 0-2 get stress test, 3 or more this person will go to cath

chest pain with unstable vitals suspect MI go straight to cath lab

main indications for cabg – three vessel disease or proximal left anterior descending disease with 70% stenosis

prinzmetal angina – coronary vasospasm – aniography with methylergonivine or succinylcholine see ST elevation, painful episodes, calcium channel blockers or nitrates

use TPA if no access to PCI center

inferior MI, myocardial infarction of inferior wall leads 2/3 AVF exception don’t give nitrates or morphine, right ventricular MI, heart has problem pumping blood to the left side of the heart, will exacerbate hypotension, inferior wall MI want to give fluids. Inferior wall MI because the right coronary artery supplies blood to the SA node, sinus bradycardia can cause cardiogenic shock can give dobutamine beta 1 agonist in the case of inferior MI this is due to injury to the SA node so want to give atropine

drugs that reduce mortality in MI are aspirin, beta blockers, and ace inhibitors

Nitrates work in two ways, predominant decreases preload, venodilator decreases stress on myocardium decreasing excess blood, secondary effect dilates coronary arteries

First and second degree heart block 

First degree and Mobitz one no treatment. Mobitz two and complete heart block pacemaker

Dressler syndrome autoimmune pericarditis two weeks after MI, post MI two weeks with fever and symptoms of pericarditis and leukocytosis treat with aspirin

Other pericarditis – viral pericarditis – NSAIDs

Dressler pericarditis – aspirin

Restrictive cardiomyopathy PUPPY LEASH

Osis – hemochromatosis, amyloidosis, sarcoidosis

Diastolic heart failure with reduced ejection fraction, due to deposits in the myocardium

Granulomas, iron deposits in the myocardium, restrictive cardiomyopathy.

Hemochromatosis – bronze diabetes, iron overload, elevated liver disease, diabetes, dark skin

Amyloid – proteinuria, deposits in kidneys and joints

Sarcoidosis – heart and lung – bilateral adenopathy dry cough, uveitis, erythema nodosum, restrictive cardiomyopathy

Three CHF drugs BAMS RN beta blockers, ace inhibitors, MRA mineralocorticoids, spironolactone, SGLT2 inhibitor

Three drugs Ace inhibitoirs, beta blockers, third aspirin

Metformin first line for t2dm contraindicated in renal disease and CHF because it can cause metabolic acidosis

Acute decompensation of CHF you want to treat with no LIT – nitrates, oxygen, loop diuretics, inotropes, positioning no LIP

Loop diuretic furosemide

Supraventricular tachycardia  verse ventricular tachycardia

SVT – narrow QRST QRST stable adenosine, unstable cardioversion

VT – wide bizarre qrs complexes – amiodarone, unstable cardioversion

Vfib and pulseless VTACH.- defibrillation

Asystole Pea EKG shows any rhythm, when you feel pulse don’t feel, treat with CPR. 

First line CPR for supraventricular tachycardia before adenosine is vagal carotid massage

Torsades de points can lead to v-fib treat with IV magnesium stabilizescardiac membranes

Constrictive pericarditis – idiopathic fibrous scarring replacing pericardial space, chest x ray, calcifications caused by TB or lupus

 

Caused by TB or lupus can present similarly to restrictive cardiomyopathy equal diastolic pressures in all chambers, biatrial enlargement

Treatment pericardiectomy

Acute pericarditis – main causes coxsackie virus treat with nsaid

Dressler – aspirin nsaid, Ekg diffuse ST elevations, improved with leaning forward

Beck’s triad – hypotension, JVD, muffled heart sounds, pulsus paradoxus, inspire increases filling to the right ventricle causes interventricular septum to bow over to the left side, which decreases the left ventricular preload, stroke volume is decreased and systolic pressure will drop greater than 10, Pulsus paradoxus systolic dropping more than 10

Stroke volume is decreased

Systolic pressure drops greater than 10

Systolic pressure dropping by greater than 10 upon inspiration

Electrical alternans big and small heart is swinging within the pericardial fluid, which distorts the qrs measurements, low voltage QRS and kussmaul signs, when you inhale, jugular venous distension increases. Cardiac tamponade, filling of right ventricular is harder, venous blood overflows faster

Mitral stenosis – rheumatic fever or rheumatic heart disease

Aortic stenosis- left ventricular hypertrophy, dilated cardiomyopathy, htn or AS get angina because of decreased perfusion to coronary arteries, syncope decreased perfusion to brain, left ventricular hypertrophy increased afterload, dilated cardiomyopathy from chronicity, soft S2, valve doesn’t move well. Definitive diagnosis cardiac catheter or echo to measure diameter < 1 centimeter or any symptoms angina, syncope, CHF treat with valve replacement

Tricuspid valve – IVDU or carcinoid, too much serotonin bronchospasm, flushing, diarrhea, right sided heart murmurs

Holosytolic murmur – mitral regurg, tricuspid regurg, VSD

Infective endocarditis – fever, leukocytosis, new onset murmur, blood culture, treat empirically with vancomycin and aminoglycoside

Hypertensive emergency 180 / 120 is IV hydralazine nitroprusside or labetalol, emergency evidence of end organ damage encephalopathy, acute kidney injury, liver injury

Hypertensive urgency blood pressure > 180 over 120 no end organ damage, emergency IV, urgency oral medications

Subarachnoid hemorrhage worst headache CT head without contrast, noncon dry ct, lumbar puncture, positive xanthochromia bilirubin in csf

Aortic dissection substernal chest pain tearing and radiating to the back

 

Type A proximal to left subclavian

A goes to surgery

B beta blockers to treat

Diagnose with CT angiogram or TEE transesophageal echo

CT imaging check patient’s kidneys kidney disease contraindicated to do CT

Contrast nephropathy spasming of afferent arteriole leading to worsened kidney injury

Peripheral vascular disease peripheral artery disease risk factor is smoking to diagnose, ankle brachial index, differences of blood pressures of ankle to the arm

Ratio of ankle to arm is less than 0.9 is disease < 0.4 severe disease pain at rest as well

Peripheral artery disease claudication in legs while walking feel pain in legs and improves with rest, stable angina of legs similar mechanism as chronic mesenteric ischemia

Clots acute limb ischemia synonymous with myocardial infarction ratio between 0.4 and 0.9 stages of peripheral vascular disease first line treatment is exercise program

Problems at rest ratio <0.4 stent or bypass. Acute limb ischemia – thrombosis that cuts off circulation in legs distal cuts cold and pulseless then you want to treat with heparin or embolectomy

Peripheral vascular disease leriche syndrome satherosclerosis proximal to aortic bifruction before iliac arteries, bilateral leg pain, impotence and buttock pain, subvariation of same thing

 

IVC filter placed if contraindicated to heparin or warfarin or failed therapy

PE acute sudden onset of tachypnea, tachycardia, hypoxemia sharp chest pain give heparin before CT angio

Heparin ct angiogram

Best next step pick heparin before CT angiogram

LMWH contraindicated in renal disease

Venous insufficiency medial malleolus ulcer sign of venous insufficiency contrasted to other similar presentations such as CHF

Cardiogenic shock inotrope such as dobutamine

Septic shock IV antibiotics + IV fluids and vasopressors

Neurogenic shock – everything down cardiac output, heart rate down, TPR is down WP down, JVD down treat with IV fliuds