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86 Cards in this Set
- Front
- Back
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Calcium Channel Blockers - classify
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Classify - Dihydropyridine (pines) – amlodipine and nefedipine (Norvasc and Adalat) – relax cardiac and smooth muscle. Non- Dihydropyridine – Diltiazem and Verapamil – same as above and inhibits AV and SA nodes
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Mechanism of action of Calcium Channel Blockers
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Dihydropyridine – inhibit Ca++ influx into cardiac and smooth muscle cells, relaxing vessels and the heart . Non- Dihydropyridine - same properties as above, plus inhibits AV node and SA node to lesser extent
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Uses of Calcium Channel Blockers.
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Uses - Dihydropyridine (pines) – HTN, Migraine prevention. Non-Dihydropyridine – Angina, PSVT, Atrial Fib/ Flutter
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Name 3 side effects of calcium channel blockers.
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Hypotension, leg edema and
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Describe the symptoms, ecg features and management of PSVT
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Asymptomatic, usually young male with palpitations. Regular sinus tachycardia 150-180bpm. Vagal manoevres, adenosine 6mg x2 then 12mg.
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Describe the symptoms, key features and management of Pulmonary Hypertension
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Management – Sildenafil, Prostacyclin or Bosantin
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Describe how endothelial cell relaxation and constriction is medicated , how the various treatments work on this system and the connection to Pulmonary Hypertension.
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2 parallel cycles – endothelin vs. NO, Prostacyclin vs. Thromboxane. Relaxation – mediated by NO and prostacyclin – Sildenafil increases NO concentration, Prostacyclin works against thromboxane to relax endothelial cells. Constriction – Endothelin and Thromboxane
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How should niacin be taken, most common side effect and how to minimize it?
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Take at night with some lifh food, most common side effect is flushing, can couterqct it in those that have it by taking ASA 325mg 30 minutes prior to niacin.
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How should you manage hypertension in heart block syndromes such as a Mobitz Type 2 Wenkeback?
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NEVER give Non-Dihydropyridin (diltiazem and verapamil)), Beta-Blocker or Digoxin. Consider ACEi, ARB, HCTZ
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How should niacin be taken, most common side effect and how to minimize it?
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Take at night with some lifh food, most common side effect is flushing, can couterqct it in those that have it by taking ASA 325mg 30 minutes prior to niacin.
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What is the role of High-sensitivity C-reactive protein in relation to CAD?
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High-sensitivity C-reactive protein may be clinically useful in identifying individuals who are at higher risk for CAD than that predicted by a global risk assessment, in particular in patients with abdominal obesity or a calculated 10-year risk between 10% and 20%. A high-sensitivity C-reactive protein level of less than 1.0 mg/L indicates low risk for cardiovascular disease, between 1.0 mg/L to 3.0 mg/L indicates moderate risk and more than 3.0 mg/L indicates high risk. High risk patients should have their LDL aggressively lowered to below 2, ideally 1.5.
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Give 4 treatment options for an elevated LDL.
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Atorvastatin/Lipitor 10 mg - 80 mg, Rosuvastatin/Crestor 10 mg - 40 mg, Simvastatin/Zocor 10 mg - 80 mg, Ezetimibe 10 mg, Bezafibrate 400 mg, Fenofibrate 100 mg, Niaspan 0.5 g - 2 g
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Give 3 side effects of losartan and ARBs. Give a standard dose for CHF and evidence supporting use.
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Hypotension, hyperkalemia and and renal impairment. HEAAL STUDY Lancet 2009 shows that 150mg od reduces mortality in NYHA 2-4 in those intolerant to ACEi and should be titrate up to this dose unless side effects supersede.
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Give 4 side effects of ACEi
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Hypotension, hyperkalemia, renal impairment and cough is most common.
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What coagulation factors does Warfarin effect?
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Factors 2, 7, 9 & 10
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What factors does INR reflect?
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Factor 7 only
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What factors does dabigatran affect?
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Works on the final common pathway, factor 2
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what options do you have for rate control in A Dib?
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1. Beta blocker unless low BP or bradycardia, 2. Diltiazem but need to watch renal function 3. Digoxin I 3rd choice.
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what drugs should be stopped with heart block?
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Beta blockers, digoxin and verpamil.
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Name 3 side effects of ACEi and how long does it take for the symptoms?
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Angioedema - often within 1st month but can occur after a year. Manifests with lip, tongue and throat swelling. Cough - most common complaint
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what is the difference between amiodarone and dronedarone regarding maintaining sinus rhythm and side effects?
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Dronedarone is slightly better maintaining normal sinus rhythm, however 70% will return to a fib within a year. Thus if a CHADs score of two or more still needs warfarin even if they return to sinus rhythm. Dronedarone does result in lower hospitalization and mortality. Amiodarone causes thyroid dysfunction, liver fibrosis and lun fibrosis which are serious complications. Dronedarone causes bradycardia and a rise in creatinine.
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what GFR would be a concern for contrast media and how can you protect against it?
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Below 30 is high risk. Give mucomist (acetylcystein) 600mg po bid the day before and day of the IV dye procedure such as cardiac cat, keep patient well hydrated and use low osmolality contrast.
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how much doe the average BP med decrease BP?
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They all decrease it by 8-10mmHg
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A person has a BP of 150/90. What choice of meds would you use?
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they need to drop by 20mmHg. Use a combo such as Atacand Plus (candasartan and HCTZ)
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what trial showed the effects of atenolol and losartan in lvh and what were the findings?
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LIFE TRIAL - Both have equal effects on blood pressure and inhibit continued hypertrophy but losartan had significant effects on mortality and strokes MI, CHF.
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when does a persantine cardiolyte perfusion test come back normal?
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When there is no stenosis in any vessels or... When all the vessels have significant stenosis - be very careful because you can have a normal test and a massive MI the next day.
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3 side effects of amlodipine norvasc?
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Leg edema, hypotension
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describe your approach to ECGs.
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What is a prolonged PR interval? Name 1 condition and one drug that cause it
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name 3 clinical and 3 lab findings from starting a statin.
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Clinical - myalgias, fatgue and brown urine. Lab - increased CPK, Cr, myoglobinuria, hyperkalemia
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name 3 causes of ST elevation.
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STEMI, Pericarditis, Ventriular aneurysm
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Name 3 causes of ST depression.
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STEMI if in Inferior Leads, Ischemia, Ventricular hypertrophy, hypokalemia and hypomagnesemia, subarachnoid hemorrhage
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name 3 side effects of amiodarone and 1 food to avoid.
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Pulmonary fibrosis, thyroid dysfunction, liver fibrosis, photosensitivity
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what monitoring should be done with amiodarone?
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Yearly CXR to monitor for pulmonary fibrosis and TSH for drug induced hypothyroidism.
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which drugs should you avoid grapefruit while taking?
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Lipitor, Zocor, erythromycin
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what is the killip class and how is it used?
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Used on ward for post-MI to classify grade of failure. Use only stethoscope to classify. Class 1 no crackles. Class 2 crackles at bases. Class 3 crackles up to upper lobes. Class 4 decreased BP.
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how can you cover a pt. with a dye allergy when doing an angiogram?
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Give prednisone 60mg the night before twice then the morning of and hydrocortisone 150mg load with benadryl 50mg. Then take home prednisone and benadryl.
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what do diffuse T waves indicate?
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Recent MI or myocarditis.
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Describe what you will see in the 1st, 2nd and 3rd degree conduction blocks:
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1st degree - Prolonged PR interval >120 ms (3 boxes). 2nd degree - Mobitz Type 1 – wenkeback. (PR longer until dropped). Mobitz Type 2 (Regularly non-conducted eg. 1:2). 3rd degree - Complete dissociation
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what are the Canadian LDL targets
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Aim for a 50% reduction in most. High Risk (>1 risk factor) <1.8. Moderate Risk <2.8. Average person <3.3
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Give 4 first and second line treatments for elevated LDL cholesterol and 3 side effects for each.
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First Line = Statin – Lipitor, Crestor. Second Line = Generic Niacin or Niaspan – 1 good study evidence. Max out statin first. Ezetrol - not very effective.
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What is atherosclerosis and how does it occur?
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Atherosclerosis is a disease of large and medium-sized muscular arteries and is characterized by endothelial dysfunction, vascular inflammation, and the buildup of lipids, cholesterol, calcium, and cellular debris within the intima of the vessel wall. This buildup results in plaque formation, vascular remodeling, acute and chronic luminal obstruction, abnormalities of blood flow, and diminished oxygen supply to target organs.
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Describe the steps in the development of atherosclerotic plaques.
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The "response-to-injury" theory is most widely accepted. Endothelial injury causes vascular inflammation and a fibroproliferative response ensues. Probable causes of endothelial injury include oxidized low-density lipoprotein (LDL) cholesterol; infectious agents; toxins, including the byproducts of cigarette smoking; hyperglycemia; and hyperhomocystinemia. Circulating monocytes infiltrate the intima of the vessel wall, and these tissue macrophages act as scavenger cells, taking up LDL cholesterol and forming the characteristic foam cell of early atherosclerosis. These activated macrophages produce numerous factors that are injurious to the endothelium.
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What is hyperhomocystineimia?
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An inherited disorder of one of several pathways involved in the synthesis of vitamin B12. Deficiencies in diet exacerbate the condition, resulting in the buildup of toxic metabolites. This can lead to insults to vessels of many sizes. The results can include CAD, PVD, stoke, MI and ACS, and miscarriages.
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Define a STEMI
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Positive Troponin, no ST elevation
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Define unstable angina ACS
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UA – Unstable Angina is new onset or evolving changing angina with negative Troponin, no ST elevation
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How should UA Unstable Angina be managed?
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All STEMI meds except Ramipril and Plavix. ASA 160mg chewed, then 81mg od, Metoprolol 5mg IV push, then bid. Enoxaparin 40mg IV, then weight based now and od. Morphine prn. Oxygen prn. Nitrates SL prn. Atorvastatin 40mg po od. Follow with Exercise test and angiography
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How should STEMI and NSTEMI be managed?
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Urgent PCI – door to balloon <90min. tPA if PCI >90 min. Many contraindications. ASA 160mg chewed, then 81mg od, Clopidogrel 300mg once, then 75 mg od, Metoprolol 5mg IV push, then bid. Enoxaparin 40mg IV, then weight based now and od. Morphine prn. Oxygen prn. Nitrates SL prn. Atorvastatin 40mg po od. Ramipril 2.5mg po od
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What is a Q wave and when is it pathological?
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Q waves are formed from the retrograde depolarization of the septum from left to right as the impulse travels down the purkinje fibers. Q waves are pathological when they are greater than 1 small square and evolve after an insult.
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How do statins work, what is their role in disease management and give 2 side effects.
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The HMG-CoA reductase inhibitors inhibit the rate-limiting step of cholesterol synthesis in the liver. HMG-CoA reductase inhibitors are effective in lowering the serum total cholesterol, LDL cholesterol, and triglyceride levels and in raising the serum HDL cholesterol level, and they have a low incidence of adverse effects, the most common being hepatotoxicity and myopathy.
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What is the evidence suggesting is the best 2nd line treatment for statin resistant LDL cholesterol?
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Niacin significantly reduced LDL cholesterol and TG. Ezetimibe group showed a decrease of LDL cholesterol levels by 19.2% to 66 mg/dL (1.7 mmol/L) (P <0.001). Ezetimibe did not increase HDL cholesterol (HDL levels were actually reduced), but it did reduce triglycerides. Niacin had greater efficacy regarding the change in mean carotid intima–media thickness over 14 months compared with ezetimibe (P =0.003), leading to significant reduction of both mean (P =0.001) and maximal carotid intima–media thickness. Niacin is currently recommended as second line treatment after maximizing a statin.
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What is the main side effect of niacin?
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Flushing, some people like, some hate it. It can be treated with ASA 325mg 30 minutes prior to niacin.
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What are the Clinical indications and contraindications to PCI/Coronary Angioplasty?
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Indications- STEMI, NSTEMI, Unstable angina and Unstable Angina. Contraindications - Significant comorbidities (relative contraindication)
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Each of the following has been shown to improve mortality in heart failure patients except: a) Beta blocker b) ACEI c) Loop diuretic d) Aldosterone antagonist e) Nitrate
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c) Loop diuretic
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Each of the following is a potential component of the management of both STEMI and UA/NSTEMI except: a) PCI b) ASA c) Clopidogrel d) Beta blocker e) Fibrinolysis
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e) fibrinolysis
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Which of the following is not an absolute contraindication to exercise ECG stress testing? a) Acute aortic dissection b) Acute MI within 2 days c) Unstable angina not stabilized by medical therapy d) Asymptomatic Aortic stenosis e) Symptomatic heart failure not controlled by therapy
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d) Asymptomatic Aortic stenosis
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e) none of the above
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Each of the following is an ECG feature of acute MI except: a) U wave b) T wave inversion c) ST depression d) New LBBB e) Tall "hyperacute" T waves
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a) U wave
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Which of the following is not a mechanism for atrial fibrillation affecting cardiac function: a) Decreased time for diastolic filling b) Decreased ventricular compliance c) Irregular ventricular response d) Loss of atrial contraction e) Decreased time for coronary perfusion
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b) decreased ventricular compliance
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Dressler's syndrome refers to: a) Migratory superficial thrombophlebitis b) The clinical features of myocarditis c) Delayed pericarditis post MI d) A preexcitation syndrome similar to WPW e) Cardiac myxoma
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c) Delayed pericarditis post MI
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Each of the following is a cause of left axis deviation except: a) Left anterior hemiblock b) Inferior MI c) WPW d) RV pacing e) LBBB
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e) LBBB
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Each of the following in and of itself is a potential indication for AAA repair except: a) Rate of enlargement 1.0 cm/yr b) Comorbid HTN, COPD and smoking c) Size = 5.5 cm in a male d) Size = 5.5 cm in a female e) Ruptured aneurysm
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b) Comorbid HTN, COPD and smoking
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10) The subendothelium is the most vulnerable segment of the heart from an ischemic standpoint. The major reason for this is: a) The highest oxygen utilization is in the subendocardium b) Coronary flow to the subendocardium occurs almost completely during diastole whereas other regions receive some flow during systole as well c) The subendocardium has a diminished aerobic capacity d) There is less potential for collateralization to the subendocardium e) The ratio of capillary to myocyte is less in the subendocardium than in other regions
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b) Coronary flow to the subendocardium occurs almost completely during diastole whereas other regions receive some flow during systole as well
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11) Impaired coronary flow reserve is associated with each of the following conditions EXCEPT: a) Severe aortic stenosis b) Severe systemic hypertension with left ventricular hypertrophy c) Severe mitral stenosis in the presence of atrial fibrillation d) A totally occluded coronary artery but with excellent collateral supply from the contralateral (i.e. opposite) coronary artery e) An isolated 30% diameter stenosis of a coronary arter
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e) An isolated 30% diameter stenosis of a coronary artery
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12) Which of the following would NOT be part of your plan for the treatment of acute ventricular fibrillation? a) Electrical defibrillation b) Lidocaine c) Epinephrine d) Amiodarone e) Manganese
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e) Manganese
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Which of the following is not an aggravating factor of congestive heart failure? a) Hypertension b) Thyrotoxicosis c) Alcohol d) Inactivity e) Arrhythmia
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d) inactivity
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Endocarditis in an I.V. drug user: a) Is equally prevalent to that of the normal population b) Transthoracic Echocardiography is highly sensitive in diagnosing c) Is typically caused by S. pneumoniae d) Is typically found on the tricuspid valve e) Is typically found on the aortic valve, producing a systolic ejection murmur
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d) Is typically found on the tricuspid valve
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Nitroglycerin administered sublingually may contribute to the relief of myocardial ischemic pain by each of the following mechanisms EXCEPT: a) Coronary vasodilation b) Decreased venous pooling resulting in increased cardiac preload c) Reduced systemic vascular resistance d) Reduced ventricular volume
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b) Decreased venous pooling resulting in increased cardiac preload
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16) A 48 year-old male is brought to the ED with CPR being administered. The ECG shows electrical activity present but you cannot palpate a carotid pulse. Which of the following is not on the differential for pulseless electrical activity? a) Alkalosis b) Hypokalemia c) Cardiac tamponade d) Hypothermia e) Tension pneumothorax
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a) Alkalosis
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Which of the following is not a surgically correctable cause of hypertension? a) Aortic coarctation b) Renal artery atherosclerosis c) Pheochromocytoma d) Primary hyperaldosteronism (Conn syndrome) e) None of the above
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e) None of the above
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Which of the following findings is inconsistent with cardiac tamponade? a) Hypotension b) Pulsus paradoxus c) Kussmaul sign d) Jugular venous distension e) Muffled heart sounds
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c) Kussmaul sign
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Which of the following is the most common cardiac manifestation of systemic lupus erythematosus? a) Myocarditis b) Pericarditis c) Myocardial infarction d) Mitral valve prolapse
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b) Pericarditis
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Which of the following is false regarding the clinical findings of significant aortic stenosis? a) Cresendo-decresendo systolic murmur with left ventricular hypertrophy b) Diminished or absent S2 c) Severe cases cause paradoxical splitting d) Parvus-et-tardus carotid upstroke e) Radiates to axilla
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e) Radiates to axilla
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21) All of the following are signs of increasing severity of AS except: a) Late peaking of murmur b) Diminished or absent S2 c) Radiation to carotids d) Increased apical carotid delay e) Lack of brachio-radial delay
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e) Lack of brachio-radial delay
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All of the following can lead to elevation of Troponin except? a) Myocarditis b) Hypothyroidism c) Pulmonary embolism d) Subarachnoid haemorrhage e) Extreme exercise
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b) Hypothyroidism
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All of the following are causes for low voltage on a 12-lead ECG except? a) Hypokalemia b) Pericardial effusion c) Thick chest wall, barrel chest, COPD, or obesity d) Generalized edema e) Hypothyroidism with myxedema
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a) Hypokalemia
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All of the following are causes of left axis deviation (LAD) on ECG except? a) Inferior myocardial infarction b) WPW / pre-excitation / bypass tract c) Hyperkalemia d) Mechanical shift: Expiration, high diaphragm from pregnancy, ascites, abdominal tumors, etc. e) Aortic stenosis
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e) Aortic stenosis
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All of the following are the causes of right axis deviation (RAD) on ECG except? a) Right ventricular hypertrophy b) Right bundle branch block c) Lateral infarction d) Hypercalcemia e) WPW / Preexcitation / Bypass tract
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d) Hypercalcemia
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All of the following are criteria for the CHADS2 score for assessing the risk for stroke among patients with atrial fibrillation except? a) Heart Failure b) High blood pressure c) History of smoking d) Over 75 years old e) Diabetes mellitus
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c) History of smoking
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27) When wide complex tachycardia is seen on an ECG, all of the following signs and symptoms suggest ventricular tachycardia (VT) rather than supraventricular tachycardia (SVT) except? a) Carotid massage and adenosine terminate the arrhythmia b) Cannon A waves present on physical exam c) History of CAD and previous MI d) Capture or fusion beats e) AV dissociation
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a) Carotid massage and adenosine terminate the arrhythmia
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All of the following are causes of prolonged QT interval except: a) Coronary artery disease b) Hypercalcemia c) Sotolol d) Tricyclic antidepressants e) Hypothermia
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b) Hypercalcemia - hypocalcemia causes prolonged QT
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What does an S4 heart sound mean? Cause?
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It is the sound of blood rushing into a stiff ventricle. Causes include LVH, HTN, ischemia (90% of pts. W angina symptoms will have an S4).
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What did the RALES trial find?
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That spirololactone significantly decreased mortality in NYHA class III-IV
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What did the JUPITER trial find?
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JUPITER trial found that CRP was a good measure of inflammation and correlated well with CAD and that a CRP >2 correlated with an increased short term risk of ACS events. It also demonstrated that Crestor 10-20mg was very effective at reducing the progress or even halting atherosclerotic plaques.
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What did the HOPE trial find?
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HOPE showed that ACEi ramipril added to Crestor and ASA significantly reduced mortality in patients with one or more risk factors for CAD and ACS events
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a 50 year old male presents with exertional angina and a strong family history of CAD. Name 3 tests you woul order in the clinic and 5 meds you would start.
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Tests - ECG, stress test and angiogram +/- echo. Rx - Ramipril 5mg qhs, metoprolol 25mg bid, crestor 20mg, ASA, maybe plavix 75mg, nitro patch 0.2-0.4mg prn.
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