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What are the three cardiac killers that we have to rule out first thing?
Acute MI, aortic dissection, PE
How do you diagnose stable angina?
Stress test
How does an acute MI frequently present in women?
Fatigue, dyspepsia, vague abdominal pain, jaw/arm pain
What is defined as "classic" chest pain?
Substernal, pressure, heaviness, sitting on chest
What type of angina is > 30 min, crushing, SOB, predictable with exertion?
Stable
What type of angina is seen in DM, elderly, females?
Atypical
Which type of angina is seen in young females and is due to coronary vasospasms without high grade stenosis?
Variant/prinzmetal/spastic
What are the three types of ACS?
Unstable angina, NSTEMI, STEMI
How do you treat unstable angina?
Heparin, nitroglycerin, and GP IIb/IIa inhibitors
What are the clinical manifestations of MI (need ⅔ to diagnose)?
ACS chest pain, ECG injury, increased cardiac enzymes
What is the mechanical treatment for a STEMI?
PCI (door to balloon in 90 minutes)
What is the pharm treatment for STEMI if PCI is unavailable?
tPA (door to needle in 30 minutes)
If a PCI/stent is contraindicated, how do you treat a STEMI?
CABG
When is a PCI/stent contraindicated?
Severe left main or proximal LAD disease, failed stent placement
If a pt with a STEMI is in the ED, what things need to be done?
ECG, CXR, telemetry, 2 large-bore IVs, maintain O2, platelet inhibition (ASA), heparin or LMWH
What does THROMBINS stand for and what is it used for?
Thienopyridine (like clopidogrel)
Heparin
RAAS (ARN or ACE)
O2
Morphine
BB
Intervention (stent/CABG)
Nitrates
Statin
Salicylate (ASA)
Used for acute MI tx
What anticoagulant is preferred for angina and NSTEMIs?
Lovenox
What anticoagulant is preferred for STEMI?
Heparin
What do you prescribe after an acute event?
ASA for life, DAPT, BB, ACE-I, Statins
No signs of HF is what Killip class?
I
Rales or crackles, S3, JVD is what killip class?
II
Acute pulmonary edema is what killip class?
III
Cardiogenic shock, SBP <90, low CO is what killip class?
IV
What is killip classification used for?
Quantifies severity of heart failure in NSTEMI and predicts 30 day mortality
What is indicated when there is destruction of the critical region of impulse propagation (this eliminates the arrhythmia)?
RF catheter ablation
Electrical impulses delivered by electrodes to the heart to regulate rhythm?
Pacemaker
Treats patients at risk for sudden cardiac death due to v-fib?
AICD (automated implantable cardioverter-defibrillator)
How do you treat sinus brady?
Treat underlying cause
Atropine if symptomatic and severe
Pacemaker if unresponsive to atropine
How do you treat sick sinus syndrome?
Correct underlying cause
Pacemaker if normal EF
AICD if reduced EF
How do you treat sinus tachy?
Treat underlying cause
How do you treat acute unstable WPW?
Synchronized cardioversion
How do you treat afib + WPW?
Amiodarone or procainamide
What is the long term treatment for WPW?
RF ablation
What is the first line treatment for HR control in afib?
Diltiazem
What is the first line for afib?
DOACs (apixaban, dabigatran, edoxaban, rivaroxaban)
What do you use to treat afib with an artificial valve?
Warfarin
If you have a refractory cause of afib, how do you treat it?
Ablation
What is the first line treatment for SVT?
Vagal maneuvers (bear down, carotid massage, face in ice water)
What is the second line (pharmological tx) for SVT?
Adenosine
How do you treat severe PVCs?
Empiric BBs
How do you treat torsades de points?
IV mag sulfate
If unstable defibrillate!
How do you treat v-fib?
Immediate defibrillation
How do you treat stable vtach?
Amiodorone or procainamide
How do you treat unstable vtach?
Synch cardiovert
How do you treat pulseless vtach?
Defibrillator, CPR, amiodarone, EPi
How do you treat 2nd degree type I heart block?
Transcutaneous pacing, atropine
How do you treat 2nd degree type II heart block?
Transcutaneous pacing
Hemodynamically unstable - temporary transvenous pacing wire
How do you treat 3rd degree heart block?
Dual chamber PPM
What are the class IA antiarrhythmics?
Quinidine, procainamide, disopyramide
What class of antiarrhythmics prolong the QT interval (could cause torsades)?
IA
Which antiarrhythmic causes lupus like syndrome?
Procainamide (IA)
What are the class IB antiarrhythmics?
Lidocaine, tocainide, mexiletine, diphenylhydantoin
Which antiarrhythmic do you use for digitalis induced arrhythmias?
Diphenylhydantoin
Which antiarrhythmic causes 2nd degree blood dyscrasias?
Tocainide (IB)
Which class of antiarrhythmics are rarely used? What are they?
IC, flecainide, propafenone
Beta blockers are which antiarrhythmic class?
II
What are the class III antiarrhythmics?
Amiodarone, sotalol, bretylium tosylate, ibutilide, dofetilide
What are the side effects of amiodarone (amiterrible)?
Pulmonary toxicity
Thyroid abnormalities
Blue/gray hyperpigment
Which class of antiarrhythmics are the NDHP CCBs?
IV
What are the class V antiarrhythmics?
Adenosine, digoxin
What are some side effects of adenosine?
Transient SE, HA, chest pain, flushing, bronchoconstriction
What are some side effects of digoxin?
Neurotoxicity, GI, visual disturbances, arrhythmias, renal failure, hypokalemia
What is Cardarelli's sign?
Abnormal pulsation of the trachea (AAA)
What population needs to get an annual ultrasound to check for abdominal AA?
65-75 y/o male smokers
What are three risk factors for AAA?
CAD and HTN
Old male smokers
Hypercholesterolemia
At what measurement is there great risk of aortic rupture?
> 5.5 cm
What is the gold standard for diagnosis of AA?
CTA
What is the first line pharm treatment for aortic dissection?
IV BB
With aortic dissection repair surgery, the tear is resected and replaced with what?
Dacron graft
Severe tearing pain in the anterior chest is indicative of what?
Ascending aortic dissection
Severe tearing pain in the interscapular region is indicative of what?
Descending aortic dissection (acute pericardial tamponade is imminent)
What are the pulses like in PAD?
Absent/diminished
What is the recommended management for PAD?
Supervised exercise, ASA/clopidogrel, Cilostazol, Pentoxifylline
What are the 6 Ps of acute ischemia?
Pain, pallor, pulseless, paresthesias, paralysis, poiklothermia
What is defined as atheromatous disease of coronaries in the peripheries?
Arteriosclerotic obliterans
What is defined as NON-atheromatous intense inflammation followed by arterial and venous occlusive disease?
Thrombo-angitis Obliterans
What is also known as "Buerger's Disease?"
Thrombo-angitis Obliterans
This disease is associated with a triphasic color scheme?
Thromob-angitis Obliterans (white-blue-red)
What are the three types of arterial vasoplastic disorders?
Cold-sensitivity/Raynauds
Livedo reticularis
Acrocyanosis
How do you treat Raynauds?
CCBs, alpha blockers
Persistent cyanotic mottling of the skin, "fishnet" appearance?
Livedo reticularis
How do you treat vasculitis?
Steroids or immunosuppression
How do you treat varicose veins?
NSAIDs, sclerotherapy, compression socks, elevating legs, RF ablation, endovenous lasers, exercise, vein stripping (surgical)
Ulcers on the ends of the toes, top of the feet, and lateral ankle?
Arterial insufficiency
Ulcers on the medial parts of the lower legs?
Venous insufficiency
Ulcers with little drainage, little tissue granulation, necrotic, "punched out"
Arterial
Ulcers with drainage, granulation, irregular edges, shallow?
Venous
What are some S/S of left sided HF?
DOE, orthopnea, bibasilar rales, loud P2, S3 gallop
How do you treat acute HFrEF?
LMNOP
Lasix, morphine, nitrate, oxygen, position (upright)
How do you treat chronic HFrEF?
Fantastic 4!
MRA, BB, ARNI or ACE or ARB, SGLT2 inhibitor
What are some S/S of right sided HF?
Pitting edema, RUQ discomfort, JVD, hepatojugular reflex
What are the NYHA classes of HF?
I - asymptomatic
II - symptomatic with moderate exertion
III - symptomatic with mild exertion
IV - symptomatic at rest
What are the ACC/AHA HF stages?
A: high risk - CAD/HTN
B: structural dz - no symptoms
C: structural disease - symptoms
D: Refractory HF - interventions
In which cardiomyopathy is EF LOW?
Dilated
Which cardiomyopathy shows 4 chamber enlargement?
Dilated
What is the first line tx for dilated cardiomyopathy?
Treat HF (ACE/ARNI/MRA/BB)
What are some causes of dilated cardiomyopathy?
CAD/HT, alcoholic, perpartum
What type of dysfunction is dilated cardiomyopathy?
Systolic
How do you treat HOCM?
BBs and CCBs
PE findings in HOCM?
S4, EF normal or increased, LLSB murmur that increases w valsalva
Note 
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