Cardiology

What is the most common risk factor for Coronary Artery Disease?

Hypertension

What is the worst risk factor for Coronary Artery Disease?

Diabetes

Correction of which of the following leads to the greatest immediate improvement in Coronary Artery Disease?

Stopping Smoking

Prior to what age must Mom or Dad have CAD in order for it to count towards Family History of CAD?

55 for Dad

65 for Mom

What is the most common physical exam finding of someone having a heart attack?

Normal Physical Exam

Chest pain relieved by rest?

Angina

What could be some associated symptoms if someone is having and Inferior Wall MI?

Bradycardia, hypotension, dizziness or fainting because the heart is resting on the diaphragm, Vagally innervated, which causes slowing of heart rate: Jarish-Beez reflex.

Name three things ischemic heart pain is NOT:

Pleuritic, Positional or Tender

What is an S4 gallop indicative of?

Left Ventricular Hypertrophy, atrial systole into a stiff or non compliant left ventricle

What might a wide S2 split (P2 even more delayed than normal beyond A2) be indicative of?

RBBB or Right ventricular infarction, pulmonary HTN or Pulmonary Stenosis

What might a paradoxically split S2 sound (P2 before A2) be indicative of?

LBBB or Left ventricular infarction, HTN or AS

A patient comes with hypertension for the past 20 years what is the most common physical finding and what will you do differently based on this finding?

S4 heart sound from LVH and a stiff ventricle.

Nothing, treat HTN anyway

What is an S3 gallop indicative of?

Fluid overload, CHF, the sound is made by blood SPLASHING into a pool of blood standing in the heart.

What must be done differently in light of an S3 gallop?

Increase meds! Increase Diuretic, ACE Inhibitor, or Beta Blockers!!! Do not let ppl go home with that.

Best initial test for a patient with chest pain.

EKG, reguardless of change with position, pleuritic, tenderness....

How long does it take Troponins/ CKMB to begin to elevate?

4 hours minimum, peaks at 12 (Might not become positive until 12)

How long are thrombolytics indicated for after the onset of chest pain?

Up to 12 hours

What are Acute Coronary Syndromes?

Unstable angina, NSTEMI or STEMI

When Can Thrombolytics be used for a patient undergoing and MI?

Only for STEMIs and up to 12 hours after onset of chest pain

How much ST elevation is needed before it can be counted as significant?

1 mm or more in 2+ leads

What is the biomarker for a NEW MI after a recent MI?

CK-MB because they only last for 3-4 days, whereas Troponins can last for 1 to 2 weeks

Leads II, III and AVF elevation corresponds to...

Inferior wall infarct

What is the federal standard time frame for giving someone thrombolytics of they come with chest pain?

THIRTY MINUTES tho they have mortality benefit for up to 12 hours

What can cause a false elevation of troponins?

Renal Failure patients, polymyositis, dermatomyositis

Most common cause of non-ischemic chest pain?

GI things, esp GERD, then peptic ulcers

Most common cause of epigastric pain?

Non-ulcer dyspepsia

What are the three presenting symptoms of Aortic Stenosis?

Syncope, CHF and Angina

What is the most common presenting symptom of AS?

Angina

Worst prognosis symptom of AS?

CHF

What positional changes alleviate or exacerbate pericarditis?

Worse with lying flat (stretches pericardium) , better with leaning forward

What is the classic location of the pain of someone undergoing aortic dissection?

Radiates to the back IN BETWEEN the scapula

What are associated symptoms of Mitral Valve Prolapse?

Pain ( no one knows why there is pain), Panic, palpitations, esp seen in females in their 40's

Most common cause of hemoptysis in the US?

Bronchitis

Suspected Aortic Dissection, what is the best initial test?

CXR to look for widened mediastinum

What is the most accurate test to check for Aortic Dissection?

Angiogram, putting a catheter into the heart

What are three tests that can be done after an initial chest x-ray is done in a suspected Aortic Dissection?

TEE, MRA, CT angiogram

What are 5 things that can cause Pleuritic pain?

Pleuritis, PE, Pericaditis, pneumonia, pneumothorax

Scan of choice for a PE in a pregnant woman?

V/Q scan

Most accurate test to diagnose PE?

Angiogram

Best initial test to get in suspected PE?

Spiral CT

What is the most specific EKG finding in pericarditis?

PR segment depression. Diffuse ST elevation also occurs but is less specific.

Best initial therapy for someone with Pericarditis?

Begin NSAID therapy.

A patient who had positional, pleuritic chest pain 2 days ago was started on NSAIDS and returns to the ER without relief. What now?

Start steroids.

Most common cause of Myocarditis in the US?

Viral illness, high association with Coxsackie B virus. Chagas disease is most common cause in SOUTH AMERICA, not US.

What is the most specific test to verify myocarditis?

Biopsy

Are breath sounds absent in all Pneumothoraces?

No, only TENSION pneumos.

What is the treatment for pleuritis?

NSAIDS....Inflammation of the pleura. Viral infection. Usually from underlying lung infection

What are the three components that determine oxygen supply to the heart?

Cardiac output, Percent O2 saturation, low Hb/HCT.

Why does ischemia occur after a plaque rupture?

Rupture clot actives platelets, which adhere to the rupture site and clog the blood vessels. Fibrinogen forms fibrin to cover the clot and the clot is stabilized by factor XIII. TPA must be given to activate plasminogen BEFORE Factor XIII works.

You have CAD, what should your LDL be?

Less than 100

You have CAD and Diabetes, what should your LDL be?

Less than 70

What is the BP goal of a patient with Renal failure? Diabetes?

130/80

Most common risk factor for CAD?

Hypertension

What part of the lipid panel is most affected by exercise?

HDL goes up

A fat slob stops smoking...What part of the lipid panel is more affected?

HDL...goes up

What lifestyle modification is most likely to decrease hypertension?

Wt loss... for each Kg lost, there is a decrease in 1 mmHg

What are the CAD equivalents?

CAD, PAD, Aortic Disease, Diabetes, Carotid disease, LDL should be less than 100

At what age does gender not play a role in likelihood of MI?

Between 65-70... After than women are at the same risk as men.

Classic story for ischemic heart disease and a negative EKG...what is done next?

Stress test

What is considered a positive stress test?

ST segment depression.... 2mm or more

OR

Hypotension, decrease of 10 mm Hg in systolic pressure

What three things can qualify Angina as Unstable?

NEW

WORSE

Occurs at REST

ST elevation is indicative of...

Infarction

ST depression is indicative of...

Ischemia

How can you tell if someone can exercise sufficiently for a stress test?

They can achieve 85% of their maximum heart rate, which is 220 minus their age

Contraindications to Exercise stress test?

Suspected cardiac instability

Pt unable to walk

Baseline EKG abnormalities such as LBBB which makes test difficult to interpret

What tests can be done if Exercise stress test in contraindicated?

Dipyridamole or persantine thallium chemical stress tests, OR Dobutamine ECHO. Positive test will show decreased thallium uptake (because it looks like K+ to the heart and should be taken up) OR decreased wall motion.

What do you want to see on a Nuclear stress test?

Thallium that is NOT taken up during exercise but is taken up at rest....Means reversible ischemia, which can be bypassed or reperfused

What are the two indications to do a CABG?

3 vessel disease or Left main artery disease.

ORRRRR

2-vessel disease in a DIABETIC

What is done if a positive stress test leads to an angiogram and 1 or 2 vessel disease is noted?

Stent placement after angioplasty.

What actions will lower mortality in a patient with Chest pain?

ASPIRIN*

BB*

Statins if LDL is greater than 100

CLOPIDOGREL if you cannot take Aspirin

Besides Diabetes and CAD, who else should have an LDL less than 70?

CAD and smokers or ACS patients

What are the LDL, HDL and Triglyceride goals for a hyperlipidemic Pt with CAD?

Changing which of them has greatest mortality benefit?

LDL less than 100

HDL greater than 40

Triglycerides less than 150

...

LDL

What things LOWER MORTALITY in CAD patients?

Aspirin, BB, TPA and Angioplasty, Clopidogrel

Statins if LDL is greater than 100

ACEs if ejection fraction is low

Heparin in UNstable or NSTEMI pts

How do you distinguish Unstable Angina from an NSTEMI?

Need CKMB or Troponins to be elevated for an NSTEMI. EKG can look the same.

What do you give to ACS patients?

Aspirin, Heparin, Beta blockers, morphine, oxygen, statins, nitrates.

High risk features of Unstable angina?

Repetitive or PROLONGED chest pain greater than 10 minutes

Elevated markers

Persistent EKG change

Hemodynamic instability

Name three glycoprotein IIb/IIIa inhibitors.

Tirofiban

Eptifibatide

Abciximab

When are glycoprotein IIb/IIIa inhibitors indicated?

In the worst patients who have gotten catheterized and need to prevent restenosing.

TPA products are indicated base on...

EKG changes, greater than1 mm rise in ST segment in 2 + leads... Troponins take too long to elevate.

The patient has ST elevations in leads V1-V3 what area is affected and what artery is getting hosed?

Anteroseptal, LAD

The patient has ST elevations in leads V2-V4 what area is affected and what artery is getting hosed?

Anterior, LAD

The patient has ST elevations in leads I, aVL, V4-V6 what area is affected and what artery is getting hosed?

Lateral, LAD or Circumflex

The patient has ST elevations in leads V1-V2 what area is affected and what artery is getting hosed?

Posterior, with tall, broad initial R-wave and usually occurs in association with inferior or lateral MI

The patient has ST elevations in leads II, III, aVF what area is affected and what artery is getting hosed?

Inferior, RCA

What are three contraindications to TPA?

Ischemic stroke within 3 months

Closed head injury or facial trauma within 3 months

Prior intracranial hemorrhage

Suspected aortic dissection

Within what time frame should you have a balloon in your heart if you have a STEMI after walking into the ER

90 Minutes

Of the Thrombolytics Streptokinase, alteplase, tenecteplase, rec-da-plase, which should not be given repeatedly?

Streptokinase, it is allergenic

Indication for thrombolytic therapy?

STEMI or New LBBB, which is indicative of an impending MI

What are the relative contraindications to thrombolytic therapy?

Major surgery within last 3 weeks

Prolonged CPR

Recent internal bleeding within last 4 weeks

BP of greater than 180/110

Ischemic stroke within 3 months

Primary indications for Clopidogrel?

Stenting (keep stent open longer than anything else)

Cannot tolerate aspirin

When should someone be Stress tested after an MI?

5-7 days later (submaximal Stress test)

Treatment plan for a pt with negative stress test 5-7 days later after MI?

Meds alone....Had an MI but the rest of your heart is fine

Treatment plan for a pt with a positive stress test 5-7 days after MI?

Catheterized

Discharge meds after ACS?

Aspirin

Clopidogrel if intolerant

Beta blocker indefinitely

ACE I and can stop after 6 weeks if EF is normal

Statins should be given and can be stopped if LDL is acceptable

Nitrates for pain

What is the number one cause of ED in a patient who is post MI?

Psychogenic, NOT BB related

How long does a patient have to wait post MI to have sex?

No waiting, it is much less stressful than a stress test

Do you treat bradyarrhythmias in a patient post MI?

Only if symptomatic

Do you treat premature beats in a patient post MI?

No

Will Supraventricular tachyarrhythmias kill you if you are post MI?

No, they will just annoy you, ventricular tachyarrhythmias will kill you.

Best treatment for symptomatic third degree heart block?

Atropine then pacer