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USMLE2 Medicine 07

Cardiology 1

3 big categories for ddx of CP 1. nonCVD, 2. CVD, 3. Pulm
Non-CVD ddx of CP (5) CHUGG: 1. Costochondritis, 2. Hiatal hernia, 3. Ulcer peptic, 4. GERD, 5. Gallbladder dz
CVD ddx of CP (6) MI DaaM ASs PiMs. 1. MI, 2. Dissecting aortic aneurysm, 3. Mitral valve prolapse, 4. Aortic stenosis, 5. Percarditis, 6. Myocarditis
Pulm ddx of CP (3) 3 P's of pulm. PE, Pulm HTN, PTX.
Chest Pain exacerbated with inspiration, reproduced with chest wall palpitation costochondritis
CP with reflux of food, relief with antacids hiatal hernia
CP with acid reflux, relief with antacids GERD
Epigastric pain worse 3 h after eating Peptic ulcer
CP with RUQ pain and tenderness gallbladder disease
severe CP, more than 20 min duration MI
CP with systolic ejection murmur aortic stenosis
CP that is vague and mild Myocarditis
CP that is sharp, pain worse with lying down and relieved by sitting up Pericarditis
CP that is sharp, tearing, often occurs in the back dissecting aortic aneurysm
transient CP with mid-systolic click murmur, young female, no CVD risk factors MVP
CP with tachypnea, cough, pleuritic pain, hemoptysis PE
CP with signs of RV failure Pulm HTN
sudden onset of CP and dyspnea, unequal BS PTX
things to ask about CP Time: Onset, Sudden/Acute, Duration, Frequency, Progression. Pain: Location, Quality, Radiation, Severity, Better/Worse (exertion, food). Associated sx's. (nausea, vomiting, diaphoresis, taste of metal/acid, cough, SOB)
Chest tightness, heaviness, or pressure stable angina and ACS
sharp or knife-like pain that the pt can pinpoint (exact area) less likely ischemia or infarction
pain >20-30 min MI more likely
CP relieved by NTG within a few minutes c/w transient ischemia or esophageal spasm
CP that worsens with NTG GERD
woman comes into ER with SOB and fatigue, mild CP consider atypical ACS sx's
CP, tachy, tachypnea consider PE
if check BP in both arms in pt with CP and there is a difference >20mmHg likely aortic dissection
Wide physiologic splitting of S2 (splitting wider with inspiration) and CP RBBB or RV infarction
Paradoxical splitting of S2 (splitting wider with expiration) and CP LBBB or anterior/lateral infarction
New S4 and CP angina or infarction
New S3 and CP CHF
pts with aortic dissection can get what type of valve pathology? aortic regurg
pts with angina or infarction can get what type of valve pathology? mitral regurg 2/2 papillary muscle dysfunction
absent lung sounds or unequal breath sounds and CP PTX
CP with no pedal pulses consider Aortic dissection
unilateral leg swelling and CP DVT --> PE
When does CK-MB become detectable, peak, and normalize? detectable 4-6 hrs after onset of ischemia, peaks in 12-24 hrs, normalizes in 2-3 days
nl CK-MB, elevated trop minor myocardial damage
elevations in both CK-MB and trop acute MI
When do trops normalize up to two weeks after ischemic event
loss of lung volume or unilateral decrease in vascular markings on CXR PE
CP that is sharp, tearing, severe, radiating to back aortic dissection
CP with widened mediastinum on CXR aortic dissection
how to dx aortic dissection CT or MRI chest
dyspnea, tachycardia, hypoxemia with pleuritic CP PE
EKG with SI, Q3, inverted T3 PE
dx PE spiral chest CT with contrast
CP preceded by viral illness; sharp, positional CP, nl CK-MB pericarditis
CP improves with sitting up pericarditis
pericardial rub pericarditis
EKG with diffuse ST elevation without evolution of Q waves pericarditis
tx for pericarditis anti-inflammatory agents
CP preceded by viral illness; vague and mild CP, elevated CK-MB myocarditis
CP worse with lying down GERD
CP initiated with cold liquids, better with NTG esophageal spasm
abrupt onset sharp pleuritic CP and SOB. PTX
pleuritic CP, friction rub, other repiratory sx's pleuritis
what is ischemic heart disease caused by? atherosclerosis --> decreased blood flow
how many years after quitting smoking does smoker's risk of MI reduced to that of non-smokers two years, regardless of how long or how much person smoked.
CHD risk equivalents Risk for CHD inc when you drive Car to the PAD in Framingham. CHD, symptomatic CARotid artery disease, peripheral artery disease, AAA, DM, Framingham risk >20%.
Cardiac risk factors SHOT of D-CAF. Cholesterol, Tobacco, HTN, Obesity (metabolic syndrome), DM, Fam Hx (1st degree relative m<55, f<65), Age >65, Sex - men.
CV events increase at what BP? 110/75
estrogen and ischemic heart disease protective effect. this is why pre-menopausal women have lower risk than men, although post-menopause risk equalizes
stable angina ischemic myocardium (increased demand or decreased supply)
substernal pressure 5-15 min after exertion, radiation to jaw/neck/shoulders/arms stable angina
anginal equivalent sense of dread, weakness, breathlessness
ST segment elevation on EKG with CP consider Prinzmetal
Exercise treadmill test most useful when? when considering causes of chronic CP and stable angina
When is exercise treadmill test positive when >2mm ST segment depressions OR when drop >10mmHg in SBP
The earlier ECG/angina appears in stress testing.... ...the more significant they are
What can exercise stress test tell you about cardiac pt? 1. severity of IHD, 2. effectiveness of treatment (done post-tx), 3. functional capacity
Two drugs used during chemical stress test persantine or dobutamine
if pt has BBB and needs stress testing, what should be done? difficult to interpret in someone with BBB so should do nuclear stress test instead
stress testing in asymptomatic young woman shows 1mm ST depression false positive test
exercise testing in known CAD very high false-negative rate!
Stress testing that is not affected by baseline ECG abnormalities nuclear stress testing
what test to use in people who can't exercise? dobutamine (causes tachycardia and mimics pt heart when running)
4 drugs those with stable angina should be taking daily SNAB. statin and ASA, B-blockers, and nitrates
HLP goals LDL <100, HDL>40, TG<150
LDL goal for very high CVD risk LDL<70
do statins reduce mortality in pts with CVD risk? yes. first line med, clear mortality benefit.
what if pt is intolerant of one statin? try another statin in different dosing
who gets a CABG? 1. left main disease, 2. 3-vessel disease and LV dysfunction, 3. pts with sx's despite meds or those with severe side effects of meds
CABG most efficacious in whom? DM pts
ACS includes what? unstable angina, STEMI, NSTEMI
what causes ACS? coronary vessel atherosclerotic obstruction with superimposed thrombotic occlusion
when to use thrombolytic therapy? STEMI only. contraindicated in NSTEMI and unstable angina (UA)
angina of increasing severity, frequency, duration unstable angina
angina at rest unstable angina
angina showing increased resistance to nitrates unstable angina
high risk features for pts with UA/NSTEMI SBP<90 (hemodynamic instability), SVT, syncope, LV ejection fraction <40%, prior PTCA or CABG, DM, CKD
what drug is indicated in almost all pts with possible ACS ASA
to whom should you not give clopidogrel? pts who need emergency procedure such as CABG (widespread ST segment depression and hemodynamic instability)
what drug should be given >6h before cardiac catheterization? clopidogrel
clopidogrel is what kind of drug anti-plt
If pt on clopidogrel but is now scheduled for CABG d/c clopidogrel at least 5d before CABG
If pt on clopidogrel, what is the preferred anti-coagulat to use in conjunction? Heparin
how long should ACS pt be on Anti-thrombin therapy (UF heparin, subQ enoxaparin) until cath or 48-72 h
GP2b/3a inhibitors. who is it good for? tirofiban, eptifibatide. Good for high-risk pts in whom an invasive strategy is planned. Tirobfiban esp good for pts with DM.
Complications of GP2b/3a inhibitors bleeding and TCP (dec plts) - should be monitored in first 24h
drugs for initial ACS management MONA B. Morphine, O2, NTG, ASA, B blocker.
Drug to give DM pt with possible ACS insulin for tight glycemic control
Pt with NSTEMI and high risk features should get what? early cath within 48h for revascularization
Indications for cardiac cath 1. pain/ischemia refractory to medical therapy, 2. high-risk features on exercise testing
EKG criteria for STEMI 1. persistent ST-segment elevation of >1mm in two contiguous leads, 2. ST-segment elevation of >2mm in two contiguous chest leads, 3. New LBBB pattern
Pts with STEMI should get what in what timeframe cardiac cath or fibrinolytic therapy within 12 h of onset of ischemic sx's
inferior EKG leads, what artery is involved? II, III, aVF. R coronary
anteroseptal EKG leads, what artery is involved? V1-V3, LAD
anterior EKG leads, what artery is involved? V2-V4, LAD
lateral EKG leads, what artery is involved? I, aVL, V4-V6; LAD or circumflex
posterior EKG leads, what artery is involved? V1-V2; posterior descending
EKG changes in Posterior Descending infarct V1-V2 with 1. tall broad initial R wave, 2. tall upright T wave; associated with inferior or lateral MI
EKG characteristics of a STEMI immediately after onset of sx's STE, hyperacute T waves (tall peaked in leads where the infarct is)
for STEMI pt, when do the hyperacute T waves disappear 6-24 h
for STEMI pt, when does the STE disappear 1-6wks
for STEMI pt, how long does it take q-waves to show up on EKG 1 to several days
for STEMI pt, how long until T wave inversions show up? when will they disappear 6-24h --> months to years to disappear
formula for cardiac output CO = HR x SV (stroke vol)
what's the cardiac index? CI = CO/(body surface area). relates heart performance to the size of the individual. If <1.8, consider cardiogenic shock.
Acute MI Class 1 (Clinical Finding, CI, and PCWP) No pulm congestion or hypoperfusion. CI > 2.2 (heart still pumping well), PCWP <15 (LV doing ok, no backup into lungs).
Acute MI Class 2 (Clinical Finding, CI, and PCWP) Pulm congestion only. CI > 2.2 (heart still pumping well), PCWP >15 (LV pressures high, + backup into lungs).
Acute MI Class 3 (Clinical Finding, CI, and PCWP) Peripheral hypoperfusion only. CI < 2.2 (heart not pumping well), PCWP <15 (LV doing ok, no backup into lungs).
Acute MI Class 4 (Clinical Finding, CI, and PCWP) Peripheral hypoperfusio AND pulm congestion. CI < 2.2 (heart not pumping well), PCWP >15 (LV pressures high, + backup into lungs).
If pt undergoing STEMI, what to do to reperfuse heart? percutaneous coronary intervention (PCI/cardiac cath) - best if within 12 h of onset of sx's - OR thrombolytic therapy. If getting to a PCI facility takes >90min, start thrombolytics.
what is the ideal time from first medical encouter to PCI 90min
Name two thrombolytics streptokinase and tPA (lyses the clot)
what kind of infarction benefits most from thrombolysis anterior infarction
Who in terms of EKG findings gets greatest benefit from thrombolysis? STEMI (>1mm in two contiguous leads or new LBBB with sx <12h
What thrombolysis tx should a pt get if he's already received streptokinase once in the last 12 months? a different thrombolytic because people could have persistance of Abs against streptokinase, which would reduce effectiveness of the tx.
Absolute contraindications to thrombolytic therapy T-BIDS. 1. Trauma (face/head) in last 3 months, 2. Bleeding (active or diathesis), 3. ICH (prior intracranial hemorrhage), 4. Dissection (aortic, suspected), 5. Stroke (ischemic) in the last 3 months
Relative contraindications to thrombolytic therapy SCHUBS. 1. Surgery (major) within last 3 months, 2. CPR performed (traumatic or prolonged), 3. HTN (severe, poorly controlled), 4. Ulcer (peptic, active), 5. Bleeding (internal, in last month), 6. Stroke (ischemic ever)
what to do if pt presents >12 h after MI sx onset? if asx now and hemodynamically stable, no reperfusion (PCI or thrombolytics)
Someone undergoing PCI with a stent should receive what additional meds? ASA and clopidogrel +/- unfractionated heparin
If STEMI pt going to get emergency CABG, what med should they NOT get? clopidogrel
If pt to get fibrinolytics (tPA or streptokinase), what should they get in addition? clopidogrel (except if going to CABG emergently) +/- unfractionated heparin or enoxaparin (<75, no renal dz)
Clopidogrel should be discontinued with discontinuation of fibrinolytics. T or F? F. should be continued at least one month after fibrinolytic therapy.
Clopidogrel should be discontinued 9 to 12 months after stent implantation. T or F TRUE
if fibrinolysis, don't give what? GP 2b/3a inhibitors (tirofiban, eptifibatide, abciximab) --> excessive bleeding
treatments that decrease mortality in ischemic heart disease ABC'S. Statins, ASA, B-blockers. CABG in pts with 3-v disease and L main disease.
tx for bradycardia as complication of ACS atropine. if severe --> temp pacing.
if pt has angina post thrombolytics or PCI, what should next tx be? bypass surg
Dressler's syndrome pericarditis 2/2 damage to heart post ACS. persistent low-grade fever, pleuritic CP, pericardial friction rub, and /or a pericardial effusion. Sx occur usu 2 weeks post MI, but can be delayed for few months after infarction.
Tx of Dressler's Syndrome ASA and NSAIDs. If no response, then steroids.
Sudden cardiac death post ACS due to what? Most often due to arrhythmia.
RV infarction associated with what type of MI? accompanies 30% of inferior MI's
female pt with few CAD risk factors, angina at rest, CP sx's cluster in middle of the night, h/o migraines Prinzmetal's
how to dx Prinzmetal angina ergonovine during angiography --> triggers coronary spasm in susceptible pts
how to tx Prinzmetal angina CCP or nitrates (like esophageal spasm!)
What makes a pt high-risk for NSTEMI vs. UA? if they're chatty: CHATS. 1. CP at rest, 2. Hemodynamic instability, 3. Age, 4. Troponins elevated, 5. ST depression
Tx for UA or NSTEMI If UA or NSTEMI, use 3-legged gas to tx (BA CHAN GAS). B-blockers, ACEi if h/o LV failure and <48h, Clopidogrel, Heparin (enox), ASA, NTG, GP2a/3b, Angiography, Statins.
Tx for STEMI < 12h, can do <30 min to PCI Do PCI! PCI: AP AABS. Abxicimab before PCI, PCI, then ASA, ACEi, Bblocker, and Statin.
Tx for STEMI < 12h, can do 30-60 min to PCI If >3h with CP, then go straight to PCI. If CP sx's <3h, weigh tPA vs. PCI.
Tx for STEMI < 12h, >60 min to PCI only do PCI if 1. severe HF, 2. cardiogenic shock, 3. anterior MI, 4. >75yo, or 5. tPA contraindicated. Otherwise, tPA (reteplase or tenecteplase).
Tx for STEMI with tPA TCH AABS. tPA, followed by clopidogrel and heparin. PLUS ASA, ACEi, Bblockers, and Statin.
Emergent CABG when.... STEMI AND 1. failed PCI and now persistent pain or hemodynamic instability, 2. persistent ischemia refractory to medical tx
Cardiac D/C meds: AAABCCCDDEE. ASA/ACEi/Anti-anginal (NTG), B-blocker, Clopidogrel (9-12mo)/Cholesterol (statins)/Coumadin (warfarin if inc risk of thromboemb), DM control/Diet, Education/Exercise
PTCA percutaneous transluminal coronary angioplasty. Using angioplasty, get rid of blockages in coronary arteries with balloons, stents, or other methods.
Created by: christinapham



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