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111 Cards in this Set
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A patient comes to the ER with chest pain. The pain also occurs in the epigastric area and is associated with a sore throat, a bad metallic taste in the mouth and a cough. What do your recommend?
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PPI
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An alcoholic patient comes to the ER with chest pain. There is nausea and vomiting and epigastric tenderness. What do you recommend?
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amylase and lipase levels
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A patient comes to the ER with chest pain. There is right upper quadrant tenderness and mild fever. What do you recommend?
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abdominal sonogram for gallstones
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56 yo man comes in after an episode of chest pain. This was his first episode of pain and he has no risk factors. In the ER, he had a normal EKG and a normal CK-MB and was released the next day. Further managment?
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Stress test
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63 yo woman is in your office for the evaluation of an abnormal stress test that shows an area of reversible ischemia. She has no risk factors for CAD. What is the most accurate diagnostic test, next step in managment?
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angiography, best test for reversible ischemia. Fixed defect, from before and after is a scar and does not need a angio. Coronary bypass is only the answer if angio has been done. Echo will evaluate the valve function or ventricular wall motion.
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A patient admitted 5 days ago for MI has a new episode of chest pain. Which of the is the most specific method of establishing the diagnosis of a new infarct.
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CK-MB returns to normal in 2-3 days.
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72 yo male comes to ER having had chest pain for the last hour. His initial EKG shows ST segment elevation in leads V2-V4. Aspirin has been given. What will most benefit this patient?
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angioplasty
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Patients wife comes to take the patient home after an MI and asks how long they should wait before they have sex. What do you tell her?
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no waiting necessary, duration nor intensity of exsertion is sufficient to provoke ischemia
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54 yo history of DM and HTN comes to ER with crushing, substernal chest pain that radiates to his left arm. The pain has been on and off for several hours, wiht this last episoe being 30 min in duration. He has had chest pain on exertion before, but this is the first time it has developed at rest. The EKG is normal. Aspirin, Ox and nitrates have been given. Troponin is elevated. What will most likely benefit this pt?
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Low molecular weight heparin is the only one shown to produce lower mortalitiy, other good choice is GPIIb/IIIa inhibitors (eptifibatide, tirofiban, abciximab) or angioplasty/PCI. Thrombolitics do not lower mortality unles there is ST elevation or a new LBBB.
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When do you use thrombolytics?
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ST segment elevation or new LBBB within 12 hours of the onset of chest pain
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ACE and ARBs both cause what?
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hyperkalemia
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CAD risk facors
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DM - PAD - AORTIC DZ - CAROTID DZ
HTN Tobacco hyperlipidemia Obesity Inactivity Family history AGE (65/55) |
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ankle brachial radial index
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<0.8 PVD
<0.4 Ischemic. next step do doppler. tx asprin and pentoxifylline |
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Pleuritic pain, changes with respirations
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PE, Pneumo, Pleuritis, Pericarditis, Pneumonia
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Positional pain, changes with bodily postition
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Pericarditis
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Tenderness, pain on palpation
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Costochondritis
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CAD presentation
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does not change with body position/respiration, not associated with chest wall tenderness. Dull pain, lasting 15-30min, occuring on exertion, in a substernal location, radiating to jaw/arm.
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Ph E: S3 gallop
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dilated left venticle
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Ph E: S4 gallop
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left venticular hypertrophy
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Ph E: CV
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jugulovenous distention, holosystolic murmur of mitral regurgitation
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Ph E: Chest
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rales suggestive of CHF
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Ph E: extremities
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edema
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Ph E: general
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distressed, SOB, clutching chest
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CE, which will rise first and which is best for recurrent MI?
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CK will rise first, CK-MB only elevated 1-2 days, Troponin stays up for 1-2 weeks.
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Medication stress test?
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COPD, amputation, deconditioning, weakness/previous stroke, LE ulcer, dementia, obesity
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Exercise stress test?
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LBBB, digoxin use, pacemaker in place, left ventricular hypertrophy, baseline abnormality of ST segment of the EKG.
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Sestamibi nuclear stress test?
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Obese and large breast
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Definition of ACS?
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history of chest pain with features suggestive of ischemic disease
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Treatment of ACS
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1) ASPIRIN reduce mortality by 25% for acute MI and 50% in unstable angina which may become NSTEMI 2)Oxygen, nitrates and morphine. Prasugrel or clopidogrel is added to aspirin for all patients with acute MI.
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Patient within 90 minutes of arrival to ER with STEMI
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1) angioplasty/PCI- greatest efficacy in reducing mortality 2) thrombolytics if angio cannot be performed. (always check for contraindications to thrombolytics)
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Indication for thrombolytics?
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chest pain for <12 hours and has a ST segment elevation in 2 or more leads. A new LBBB. Should be given within 30 min of patients arrival to ER.
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what do you give next?
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BB... ACEI/ARBs- only lower mortality if there is left vent dysfunction or systolic dysfunction. Get a lipid profile and start HMG CoA reductase inhibitors. Statins to all patients
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when do you give clopidogrel/prasugrel?
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aspirin allergy, angioplasty or stent, acute MI.
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when do you choose Ca channel blockers?
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BB intolerance, asthma, coccaine induced chest pain, coronary vasospasms/ prinzmetal's angina
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when is pacemaker the choice?
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3' AV block, Mobitz II 2' block, bifasicular block, new LBBB, symptomatic bradycardia
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when is lidocaine or amiodarone the choice?
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only with ventricular tachycardia or ventricular fibrillation. NOTE: do not give anti arryhythmic to prevent ventricular arrhythmias.
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Complications of MI
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always hypotension
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cardiogenic shock, diagnostic test? treatment?
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echo or swan ganz (rt heart) catheter, tx ACEI and urgent revascularization
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valve rupture, diagnostic test? treatment?
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echo, ACEI, nitroprusside, intraortic balloon pump as a bridge to surgery
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septal rupture, diagnostic test? treatment?
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echo, rt heart catheter showing a step up in saturation from the rt atrium to the rt ventricle. ACEI, nitroprusside, urgent surgery
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myocardial wall rupture? diagnostic test? treatment?
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echo, pericardiocentesis, urgent cardiac repair
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sinus bradycardia, diagnostic test? treatment?
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EKG, atropine, followed by pacemaker if there is still symptoms
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third degree heart block, diagnostic test? treatment?
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EKG, canon 'a' waves, atropine and pacemaker even if symptoms resolve
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rt ventricular infarction, diagnostic test? treatment?
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rt venticular leads on EKG and fluid loading
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post MI discharge
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aspirin, BB, statin and ACEI
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NSTEMI management
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no thrombolytic use, heparin used routinely, glycoprotien IIb/IIIa inhibitors
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Difference between saphenous venous graft vs internal mammary artery?
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IMA will remain open 10yrs
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Indications for CABG
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3 vessel with >70% stenosis or Left Main Coronary Artery stenosis >70%
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CAD equivalents
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DM, PVD, Aortic Dz, Carotid Dz
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ACS with LDL >130
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START STATIN
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goal LDL with CAD
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<100
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Most important reason for using statin?
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MORTALITY BENEFIT
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When is the goal of therapy of LDL <70?
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CAD and DM
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Most common reason for erectile dysfunction after infaction?
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Anxiety
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Erectile dysfunction treated with sildenafil. What must you avoid?
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Nitrates
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63 year old woman comes to ER with acute, severe shortness of breath; rales on lung exam; S3 gallop; and orthopnea. Next step?
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MON and furosemide
Morphine, O2, Nitrates and Lasix |
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Difference between saphenous venous graft vs internal mammary artery?
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IMA will remain open 10yrs
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Additional tests that need to be ordered along with treatment?
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CXray, EKG, Oximeter/ABG and Echocardiogram
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Patient continues short of breath. Further management?
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Positive Inotropic Agents:
Dobutamine, Amrinone Milrinone |
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80 year old woman is admitted to the ICU fo acute pulmonary edema. She has rales to the apices and jugulovneous distention. EKG shows ventricular tachy. Best therapy?
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Synchonized Cardioversion
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Synchronized Cardioversion
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Atrial Fibrillation
Flutter Supra Vent Tachy |
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Unsynchronized Cardioversion
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V Fib
Ventricular Tachycardia without a pulse |
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Sustained V Tach that is hemodynamically stable
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Lidocaine, Amiodarone or Procainamide
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When is Nesiritide the answer?
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It is a synthenic version of atrial natriuretic peptide that is used for acute pulmonary edema as part of preload reduction.
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When is BNP level the answer?
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Nonspecific, Used to establish the diagnosis of CHF in patient who is short of breath. Normal BNP excludes CHF.
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Cardiac Output Decreased
SVR Increased Wedge Pressure Increased Right Atrial Pressure Increased |
Pulmonary Edema
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Cardiac Output Decreased
SVR Increased Wedge Pressure Decreased Right Atrial P Decreased |
Hypovolemic Shock - Dehydration
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Cardiac Output Increased
SVR Decreased Wedge Pressure Decreased Right Atrial Pres Decreased |
Septic Shock
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Cardiac Output Decreased
SVR Increased Wedge Pressure Decreased Right Atrial Pressure Increased |
Pulmonary Hyptertension
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Chronic Management CHF with EF <45%
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1-ACEI and BBlocker
2-Spirinolactone (presents with CHF) 3- Diuretic and Digoxin (no dec mortality may decrease number of hospital stays) |
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Chronic Management CHF with EF 45-55%
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BBlocker
Diuretic AVOID DIG AND SPIRONOLACTONE |
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69 year old man is seen in office for further management of this CHF. Currently, has no symptoms and good exercise tolerance. Has been on Lisinipril, Metoprolol, Spironolactone, and Furosemide for the last 6 months. EF is 23%. Most likely to benefit from?
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Implanted Cardioverter/Defribrillator
EF <35% that persists, prevent arrythmias |
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When is a biventricular pacemaker the answer for CHF?
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severe congestive failure and a QRS duration > 130msec
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Warfarin for the answer for CHF?
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never, unless there is a clot or atrial fib
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Which of following is an absolute contrainindication to the use of bblockers?
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Symptomatic Bradycardia
Mortality benefit outweighs asthma, emphysema or PVD |
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Murmurs
RiGHT |
INSPIRATION increase -
Tricuspid (stenosis/regurge) Pulmonic Valve |
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Murmurs
LeFT |
EXHALATION increase -
Mitral and Aortic |
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Increased blood return to heart?
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Squating, Leg Raise
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Decrease blood return to heart?
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Standing, Valsalva
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Increased blood return,
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Increases:
Aortic and Mitral and VSD DECREASE: HOCM and Mitral Valve Prolapse |
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Decreased blood return
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OPPOSITE as above
Decrease Aortic/Mitral/VSD Increase HOCM MVP |
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Handgrip
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worsens AR and MR and VSD
improves HOCM/MVP TREAT WITH SPIRONOLACTONE |
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Amyl Nitrate
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Improves AR and MR
worsens HOCM/MVP |
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Most accurate test for valvular lesion?
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left heart catheterization
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Chest pain that is sharp and brief, gets worse with respirations, relieved by sitting up and leaning forward.
Physical? Diagnosis and Tx? |
PERICARDITIS
FRICTION RUB (no pulsus parodox, tenderness, edema or kussmaul, neg JVD) normal BP. EKG - ST seg elevation in all leads. PR depression (pathognomonic) NSAIDS, advance 2 days if pain persists add prednisone and recheck in 2 days. |
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Shortness of breath, hypotension, jugular venous distention.
PE: clear lungs, dec bp on inhalation >10mmHg. Diagnosis? Tx? |
PERICARDIAL TAMPONADE - AVOID DIURETICS
EKG: electrical alternans variation in height of ekg's Echo-diastolic colapse of rt atrium and rt ventricle. RT heart cath equaliztion of pressures. Will need pericardiocentesis, or window (long term) |
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chronic right heart failure
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Edema, JVD, Hepatosplenomegaly, Ascites
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Chronic R-HF with inc JVP on inhalation and a extra diastolic sound. Diagnosis? Tx?
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CONSTRICTIVE PERICARDITIS
Chest xray - calcifications EKG - low voltage CT and MRI- thickened pericardium Give Diuretics initially, will need surgical removal of pericardium. |
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Chest pain radiating to back btw the scapula, RIPPING.
PE? Diagnosis? Tx? |
AORTIC DISSECTION
difference in bp btw rt/lf initially chest xray- wide mediastinum get a CT angiogram GOAL CONTROL BP STAT: BBlocker and Nitroprusside EKG/Xray then, CT angio or TEE or MRA NEED SURGICAL CORRECTION - CONSULT |
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>65 year old male smoker comes to clinic
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abdominal aortic aneurysm
>5 surgical repair |
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Pain in calves on exertion. smooth shiny skin, loss of hair
PE? Dx? Tx? |
PERIPHERAL ARTERIAL DZ
claudication, ankel brachial index (NL >0.9; if >10-obstuction) get and angiography, best initial therapy Aspirin ACEI-bp cilostazol-antiplatelet (PDI) Statin-LDL<100 Exercise |
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continued pain at rest after treatment?
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signs of ischemia-
cont pain, gangrene surgical bypass |
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sudden onset LE pain presents with cold extremity?
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ACUTE ART EMBOLUS
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Pain worse with walking downhill and less walking uphill?
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SPINAL STENOSIS
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palpitations and irregular pulse? Diagnosis?
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ATRIAL FIBRILLATION
Telemety monitoring for Inpatient. Holter monitoring for Outpatient. Affib seen: Echo-clots/valve fx/Lt atrial size. Thyroid F Test Electrolytes - sK, sMg sCa Trop-I and CK-MB |
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Treatment?
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SBP <90, CHF, confusion, chest pain.
Unstable - synch electrical cardioversion. Stable - rate control (BBlocker, CaB, digoxin) anticoagulate with warfarin to target INR 2-3 |
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palpitation and regular rhythm irregular rate? Diagnosis?
Treatment? |
ATRIAL FLUTTER
Rate control |
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EKG: polymorphic p waves
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MULTIFOCAL ATRIAL TACHYCARDIA
AVOID BBLOCKERS |
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palpitations and tachycardia, occasional syncope
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regular rhythm with ventricular rate 160-180
get an EKG if not seen get Holter or Telemetry. Get a TTE once stable |
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supraventricular tachycardia alternating with ventricular tachycardia. Worsening SVT after the use of calcium channel blocker? Diagnosis? Treatment?
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WPW SYNDROME
delta wave on EKG, get electrophysiologic studies SVT/VT give Procainamide Long term tx: radiofrequency catheter ablation |
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Palpitations, syncope, chest pain or sudden death?
Diagnosis? |
VENTRICULAR TACHYCARDIA
EKG, telemetry most accurate is electrophysiologic studies |
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Treatment?
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Hemodynamically stable:
Amiodarone, Lidocaine, Procainamide, Mg Hemodynamically unstable: synchronized cardioversion |
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sudden death?
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V-FIB
EKG unsynchronized cardioversion!! |
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ventricular tachycardia with undulating amplitude?
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TORSADE DE POINTE
give MAGNESIUM then medical/electrical mgmt |
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sudden loss of consciousness?
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Cardiac vs Neurological
Exclude cardiac causes, 80% mortality from syncope |
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gradual loss of consciousness?
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Toxic-Metabolic
Hypoglycemia Drug/Intox Anemia Hypoxia |
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regaining consciousness?
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sudden - cardio (rhythms vs structural)
gradual - neuro (seizures) |
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Diagnostic testing?
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Cardio/Neuro examination
EKG Oximeter CBC Cardiac Enz Chemistries - glucose |
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murmur?
headache? fall-head trauma? siezure? |
Echo
CT head EEG |
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still unclear?
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Holter/telemetry
repeat CE Urine/Blood tox Tilt Table Electrophysiology |
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MOST IMPORTANT IN SYNCOPE?
TX? |
EXCLUDE CARDIAC CAUSE.
ventricular dysrhythmia implant cardioverter/defibrillator |
