Cardio: Exam 3 (Tsu)

Determine if the following statements describe Vtach or Vfib or both.

Torsades is a form of this rhythm.

This is the more life-threatening rhythm.

Can have a regular or irregular rhythm.

Usually occurs due to irritable ventricular foci.

Torsades is a form of this rhythm: Vtach

This is the more life-threatening rhythm: Vfib

Can have a regular or irregular rhythm: Vtach

Usually occurs due to irritable ventricular foci: Both

What are the possible causes of ventricular arrhytmias and cardiac arrest?

How do you manage the 5 T’s?

How do you manage the 5 H’s?

YU is a 56 year old female who is recovering in the hospital after hip surgery. Overnight, her cardiac rhythm changes from sinus tachycardia to ventricular tachycardia to asystole. Her BP is dropping to 70/50 mm Hg and she has no detectable pulses. What are the steps to treatment for YU?

A. Cpr, shock, cpr, meds

B. Cpr, meds, shock, cpr

C. Meds, cpr, meds

D. Cpr, meds, cpr

D:

1. Always start w/ CPR

2. Epinephrine ASAP

3. CPR 2 min

3. Which statement is accurate about YU? (Select all that apply)

A. If the patient has return of spontaneous circulation, targeted temperature management should be started

B. If the patient only has peripheral IV line, we should give higher doses of medications C. This rhythm could have been caused by acidosis, hypovolemia, or a pulmonary embolism

D. If the patient has a wide complex rhythm, we could use procainamide

A. If the patient has return of spontaneous circulation, targeted temperature management should be started

B. If the patient only has peripheral IV line, we should give higher doses of medications

• Medication doses are the same for peripheral or central

C. This rhythm could have been caused by acidosis, hypovolemia, or a pulmonary embolism

D. If the patient has a wide complex rhythm, we could use procainamide

• Procainamide is not indicated for asystole

4. Which of the following are steps in treating pulseless electrical activity? (Select all that apply)

A. Shock B. CPR C. Administer amiodarone D. Administer epinephrine E. Check pulses

A. Shock

B. CPR

C. Administer amiodarone

D. Administer epinephrine

E. Check pulses

Elevated levels of _ increases risk of seizures

Lidocaine

5. Which statement is accurate regarding bradycardia?

A. Intraosseous administration is preferred over intravenous administration

B. Atropine stimulates the beta-1 receptors in the myocardium

C. A pacemaker should be implanted if the heart rate is less than 60 bpm

D. Dopamine at intermediate (or medium) doses can be used if the patient is symptomatic

A. Intraosseous administration is preferred over intravenous administration

B. Atropine stimulates the beta-1 receptors in the myocardium

• AchR antagonist

C. A pacemaker should be implanted if the heart rate is less than 60 bpm

• Only use if symptomatic

D. Dopamine at intermediate (or medium) doses can be used if the patient is symptomatic

6. Which of the following is a reversible cause of cardiac arrest?

A. Pulmonary embolism B. Hyperglycemia C. Alkalosis D. Hypertension

A. Pulmonary embolism

7. Which statement is accurate regarding ventricular arrhythmias?

A. Pulseless electrical activity is a shockable cardiac arrest rhythm.

B. Chest compressions should be performed in cycles of 100 compressions and 2 breaths.

C. Procainamide and amiodarone can be used to treat wide-complex stable tachycardia. D. Adenosine should be infused over 1-2 minutes to avoid hypotension.

A. Pulseless electrical activity is a shockable cardiac arrest rhythm.

B. Chest compressions should be performed in cycles of 100 compressions and 2 breaths.

• 30 compressions, 2 breaths

C. Procainamide and amiodarone can be used to treat wide-complex stable tachycardia. D. Adenosine should be infused over 1-2 minutes to avoid hypotension.

• Half-life <10 seconds → adminster as RAPID iv push

Which medication is used in pulseless electrical activity?

A. Epinephrine B. Amiodarone C. Sotalol D. Lidocaine

A:

Only Epinephrine is used for non-shockable rhythms

What medications are used for cardiac arrest?

• Epinephrine

• Amioadarone

• Lidocaine

• Vasopressin

Epinephrine Dosing: Cardiac Arrest

1mg Q 3-5 minutes

Amiodarone Dosing: Cardiac Arrest

300 mg bolus, then 150 mg

What are adjunctive ACLS medications and when are they used?

Magnesium → Torsades de Pointes

Sodium Bicarbonate → If acidosis

Thrombolytics → If concern for MI or pulmonary embolism

Lidocaine Dosing: Cardiac Arrest

1-1.5 mg/kg, then 0.5-0.75

Which statement is most accurate regarding medications used in ACLS? Correct the incorrect statements.

A. Epinephrine is used to decrease the fibrillation threshold

B. Vasopressin use is no longer recommended routinely

C. Amiodarone dosing is 1mg every 3-5 mins

D. Sodium bicarbonate should be given to all pts to prevent acidosis

A. Epinephrine is used to decrease the fibrillation threshold

• Epinephrine is used to increase coronary and cerebral perfusion pressures, increases vasoconstriction

• Amiodarone and Lidocaine are used to increase the fibrilation threshold

B. Vasopressin use is no longer recommended routinely

C. Amiodarone dosing is 1mg every 3-5 mins

• Epinephrine dosing: 1mg q 3-5 min

• Amiodarone dosing: 300 mg bolus, then 150 mg

D. Sodium bicarbonate should be given to all pts to prevent acidosis

• Used as an adjunctive med if they ALREADY have acidosis, not used for prevention

All meds for cardiac arrest should be administered by _

Rapid IV push

Which statement is accurate? Correct the incorrect statements.

A. Endotracheal medication dosing is 1:1 with IV dosing

B. Intraosseous route is only indicated for certain ACLS medications

C. Targeted temperature management is indicated to preserve cardiac function

D. During targeted temperature management, patients are cooled for 5-7 days

E. Common complications of targeted temperature management include arrhythmias and infection

A. Endotracheal medication dosing is 1:1 with IV dosing

• Intraosseous dosing: 1 (IV):1 (IO)

• Endotracheal dosing is 1 (IV): 2-2.5 (Endotrecheal)

B. Intraosseous route is only indicated for certain ACLS medications

• Endotracheal

• Intraosseous can be used for all ACLS drugs

• Intraosseous can be used for all ACLS drugs

C. Targeted temperature management is indicated to preserve cardiac function

• Cerebral function

D. During targeted temperature management, patients are cooled for 5-7 days

• 12-24 hours

E. Common complications of targeted temperature management include arrhythmias and infection

What are A.E of targeted temperature management?

• Arrhythmias

• Electrolyte disorders

• Hyperglycemia

• Decreased drug clearance

• Coagulation disorders

• Infections

• Shivering

What medications are used for bradycardia?

• Atropine

• Epinephrine

• Dopamine

You are helping to manage a patient who is becoming bradycardic with a heart rate in the 40s. She is now hypotensive and is becoming slightly mentally altered with slurred speech.

How should we manage this patient? Why?

Which medication is first line for this patient?

If this medication is ineffective, what are the next steps?

1. Start medications since symptomatic

2. First line: Atropine 1 mg bous

3. Repeat Atropine, consider Epinephrine or Dopamine

What medications are used for stable tachycardia?

• Adenosine

• Procainamide

• Amiodarone

Rapid IV administration of Amiodarone can cause _ and _

Hypotension

Bradycardia

You are on patient rounds when the team sees the patient develop the rhythm below, which is a wide complex ventricular tachycardia. The patient appears to be slightly agitated and restless. BP = 142/86, HR 120, RR 26. Should we treat this patient with medications? Provide rationale. Which of the following medications would be reasonable for this patient?

A. Dopamine

B. Magnesium

C. Atenolol

D. Procainamide

Yes, treat to further prevent progression into Vfib

A. Dopamine → Increases HR, used for bradycardia. Pt. has tachycardia

B. Magnesium → Used for prolonged QT/torsades de pointes

C. Atenolol → Used for narrow complex, pt. has wide complex

D. Procainamide

A 67 year old male is on the telemetry floor, and suddenly converts from sinus tachycardia to a wide complex ventricular tachycardia (VT). While he is hemodynamically stable, his VT is sustained and is polymorphic, and you notice his QTc interval is 550 msec. Which therapy would be the best choice for this pt?

A. Procainamide B. Adenosine C. Amiodarone D. Magnesium E. No therapy is needed

A. Procainamide

B. Adenosine

C. Amiodarone

D. Magnesium → D/T the patient prolonged QTc = torsades

E. No therapy is needed

2. What is accurate about meds used when the pt. has cardiac rhythm changes from sinus tachycardia to ventricular tachycardia to asystole. and BP is dropping to 70/50 mm Hg and she has no detectable pulses?

A. Only treat the patient if they are showing symptoms

B. Amiodarone will help lower fibrillation threshold

C. Atropine is the first medication that should be used

D. Epinephrine affects both beta and alpha receptors

A. Only treat the patient if they are showing symptoms

• Treatment should begin immediately in asystole

B. Amiodarone will help lower fibrillation threshold

• Increase

C. Atropine is the first medication that should be used

• Atropine is indicated for bradycardia

D. Epinephrine affects both beta and alpha receptors

If stable tachycardia is emergent or non-emergent, you should:

Emergent: cardioversion or adenosine

Non-emergent: Monitor and consult cardiologist, consider medications

Determine whether each statement describes A fib (AF) or A flutter.

1. Originates from a single ectopic focus in atrium

2. Rhythm is described as “regularly irregular”

3. No discernable p waves

1. Originates from a single ectopic focus in atrium

• Aflutter

2. Rhythm is described as “regularly irregular”

• Aflutter

• Afib - “irregularly irregular”

3. No discernable p waves

• Afib

What is the CHA2DS2VASC Score?

What are the antithrombotic therapy recommendations for the following risk categories?

RB is a 74 year old, 70kg female who presents to the hospital with new symptoms of cardioembolic stroke, and is diagnosed with new AF.

• PMH: hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction 2010, GI bleed 2012

• SH: 1-2 glasses of wine/night, quit smoking 17 years ago

• Vitals: BP 140/86 mmHg, HR 80 bpm, RR 20

• Labs: Scr 0.8, AST/ALT WNL, electrolytes WNL, H/H 9.9/29.8, HgbA1c 7.2

• Current medications: aspirin 81mg PO daily, carvedilol 12.5mg PO BID, simvastatin 40mg PO at bedtime, metformin 500mg PO BID

• Assess RB’s risk of stroke. Determine if RB should be treated with anticoagulation.

RB’s stroke: 7 (Female (1), 74 (1), stroke (2), hypertension (1), MI (1), diabetes (1)

• Yes, bc/ her CHADVASC score is >3

Which of the following is the best recommendation for anticoagulation for RB?

A. Increase aspirin to 325mg PO daily

B. Start warfarin 10mg PO daily, titrate to INR 2-3

C. Start rivaroxaban 15mg PO BID x 21 days, then 20mg daily

D. Start edoxaban 60mg PO daily and enoxaparin 70mg SC BID

E. Start apixaban 5mg PO BID

A. Increase aspirin to 325mg PO daily

• Anticoags!

B. Start warfarin 10mg PO daily, titrate to INR 2-3

• For VTE, do 10 mg for 2 doses then adjust after that - DO NOT DO DAILY WITH NO CHANGE.

• Warfarin could be used but it’s just too high of a dose for the pt. → If it was 5mg, this could be a reasonable option

C. Start rivaroxaban 15mg PO BID x 21 days, then 20mg daily

• Dosing for VTE

D. Start edoxaban 60mg PO daily and enoxaparin 70mg SC BID

• Never do edoxaban and enoxaparin at the same time - double anticoags

E. Start apixaban 5mg PO BID

What drugs are for rate control?

• BB

• Non-DHP CCBs

• Digoxin

What drugs are for AF w/ rapid ventricular response?

• IV non-DHP CCBs

• IV BBs

• IV Digoxin

• IV Amiodarone

What is used for AF w/ rapid ventricular response if the patient is hemodynamically unstable?

Cardioversion

TM is a 78 year old male who is presenting with fatigue, dizziness, and syncope. He is currently on metoprolol succinate 50mg daily succinate for rate control. His home BP log shows that his HRs are 80-90s, and his BP readings are 100-110s/60-70s. How should we adjust TM’s rate control therapy?

A. Increase metoprolol to goal HR 60-80

B. Decrease metoprolol, start diltiazem 120mg ER daily

C. Decrease metoprolol, start digoxin 0.125 mg daily

D. Discontinue metoprolol

A. Increase metoprolol to goal HR 60-80

• Will worsen hypotension

B. Decrease metoprolol, start diltiazem 120mg ER daily

• Dilitiazem decrease HR and B.P

C. Decrease metoprolol, start digoxin 0.125 mg daily

• Digoxin will decrease H.R but NOT B.P → might also help w/ CO + H.F

D. Discontinue metoprolol

• If D/C metoprolol → HR will go back up

Rate vs. Rhythm control strategy

• Rhythm control strategy: Cardioversion then antiarrhythmic drugs to maintain NSR

• Rate control strategy: Rate-control medications (BBs, Non-DHP CCBs, Digoxin)

What is the goal resting H.R?

<100-110 BPM

Warfarin (Comaudin) dosing

Dosing varies, usually 1-10 mg daily

Dabagitran (Pradaxa) dosing: AF and VTE

150 mg PO BID

Rivaroxaban (Xarelto) dosing: AF and VTE

AF: 20 mg PO daily

VTE: 15 mg PO BID x 3 weeks, then 20 mg PO daily

Apixaban (Eliquis) dosing: AF and VTE

AF: 5 mg PO BID

VTE: 10 mg PO BID x 1 week, then 5 mg PO BID

Edoxaban (Sayvasa) dosing: AF and VTE

AF and VTE: 60 mg PO daily

What are other AADs for pharmacological cardioversion?

• Amiodarone

• Dofetilide

• Ibutilide (IV formulation only)

• Flecainide

• Propafenone

What are AADs for maintenance of normal sinus rhythm? Which one is the most effective?

• Amiodarone (Cordarone, Pacerone) → Most effective

• Dronedarone (Multaq

• Dofetilide (Tikosyn)

• Sotalol (Betapace AF)

• Flecainide (Tambocor)

• Propafenone (Rythmol)

WE is a 56 year old male who presents to the hospital with new AF with RVR. He states that his symptoms have been on-and-off for last week, and he came to the hospital since he is feeling more dizziness and nauseated. His BP is 88/58 mmHg and HR 132 bpm.

• Is emergent cardioversion an option for WE?

• Which echo modality should be used to visualize his left atrium?

• Is elective cardioversion an option?

• Based on his medical chart, you find his CHADS2-VASc score = 6. What recommendation do you have for his antithrombotic therapy (include dosing)?

1. Yes, hemodynamically unstable <90 BP but concern about duration of symptoms

2. TEE

3. Yes, can wait 3-4 weeks as outpatient. Need some other way to control his symptoms now. Would need anticoags for >3 weeks so no need for TEE

4. Needs long term full anticoagulation. (Options are Warfarin INR 2-3, Pradaxa 150mg BID, Xarelto 20mg daily, Eliquis 5 mg daily, or Sayvasa 60 mg)

Which statements are accurate regarding amiodarone therapy? Select all that apply.

A. It can cause renal fibrosis with prolonged use

B. Drug interactions occur with substrates of CYP 3A4 and PgP

C. PFTs and LFTs should be monitored at baseline

D. Amiodarone’s effects can persist for years

A. It can cause renal fibrosis with prolonged use

• Pulmonary fibrosis

B. Drug interactions occur with substrates of CYP 3A4 and PgP

C. PFTs and LFTs should be monitored at baseline

D. Amiodarone’s effects can persist for years

• Months

What is Dronedarone’s BBW?

• Increased risk of death with decompensated HF or permanent AF

What monitoring does Sotalol require? What condition should it be avoided in?

Monitor:

• Renal function

• QT prolongation

Avoid in:

• Systolic HF

What monitoring does Dofetilide require? What condition is at the highest risk for?

• Renal function

• QT interval

• DDIs (Verapamil, HCTZ, cimetidine, ketoconazole, prochlorperazine, trimethoprim, any other drug that prolongs QT interval)

High risk for:

• Torsades de Pointes

How often should Amiodarone’s baseline tests be monitored afterwards?

Thyroid function tests, EKG, liver function tests: Baseline and every 6 months

Baseline and PRN: Eye exam, pulmonary function tests

The medical team wants to start an anti-arrhythmic for the patient. Which antiarrhythmic would be the best choice for HH?

A. Amiodarone B. Sotalol C. Dronedarone D. Dofetilide E. Atenolol

C. Dronedarone

1. Do they have prior MI or significant heart disease? No → Look to the left chart!

2. Dofetilide → Choose when no options are available, requires so much monitoring (renal function, QT interval, DDIs)

3. Atenolol controls rate control → we need rhythm control for Afib

Which statement regarding AADs for maintenance of NSR is most accurate?

A. Sotalol and dronedarone are first-line options for HF patients

B. Flecainide and propafenone should not be used in structural heart disease

C. Amiodarone is the first-line AAD for pts with and without structural heart disease

D. Lidocaine is a second line option

Which statement regarding AADs for maintenance of NSR is most accurate?

A. Sotalol and dronedarone are first-line options for HF patients

• Amiodarone and dofetilide are 1st line options for H.F pts

B. Flecainide and propafenone should not be used in structural heart disease

C. Amiodarone is the first-line AAD for pts with and without structural heart disease

• For those with structural heart disease

D. Lidocaine is a second line option

• Lidocaine is for ventricular arrhythmias NOT atrial arrhythmias

Which statement regarding Sotalol use for AF is most accurate?

A. It can be used for both pharmacological cardioversion and maintenance of NSR

B. Monitoring parameters include HR, BP, and LFTs

C. It can cause QT prolongation leading to TdP

D. Its main mechanism in AF is for rate control

A. It can be used for both pharmacological cardioversion and maintenance of NSR

• Only maintenance of NSR, not pharmacological cardioversion

B. Monitoring parameters include HR, BP, and LFTs

• Renal function & QT prolongation

C. It can cause QT prolongation leading to TdP

D. Its main mechanism in AF is for rate control

• Rhythm control in Afib

What are catherer ablation indications?

• If anti-arrhythmic medications are ineffective, contraindicated, or not tolerated

• First-line in younger pts with few comorbidities to improve symptoms and prevent AF progression

Pulmonary vein isolation vs AV node ablation

Pulmonary vein isolation:

• Can be curative for AF symptoms

• Anticoagulation based on risk assessment

AV node ablation

• Permanent pacemaker

• AF persists → Continue anticoagulation

Which matches the medication to its corresponding adverse effect?

A. Amiodarone and renal dysfunction B. Dronedarone and pulmonary fibrosis C. Dofetilide and hepatitis D. Sotalol and QT prolongation

D

Digoxin (Lanoxin) Dosing

0.125-0.5 mg daily

Balloon valvulopasty is commonly used for _

Mitral stenosis

Balloon valvuloplasty requires pre-procedural _ to rule out thrombus formation

TEE

Young patient → Mechanical

Risk factors for bleeding → Bioprosthetic

Refuses/C/I to anticoag → Bioprosthetic

Which DOACs can be used in valvular disease? What is it contraindicated in?

• Dabigatran

• Rivaroxaban

• Apixaban

• Edoxaban

C/I w/ mechanical heart valves

A 30 year-old female requires mitral valve replacement for severe mitral valve prolapse. Which statement regarding valve replacement is most accurate for this patient?

A. A bioprosthetic valve will last longer than a prosthetic (mechanical) valve B. Her goal INR would be 2.5 – 3.5 if she received a prosthetic (mechanical) valve

C. A prosthetic/mechanical valve would be better if she would like to have children in the future

D. If she receives a bioprosthetic bovine valve, she should be on aspirin and clopidogrel therapy

A. A bioprosthetic valve will last longer than a prosthetic (mechanical) valve

B. Her goal INR would be 2.5 – 3.5 if she received a prosthetic (mechanical) valve

C. A prosthetic/mechanical valve would be better if she would like to have children in the future

• Bioprosthetic

D. If she receives a bioprosthetic bovine valve, she should be on aspirin and clopidogrel therapy

• Clopidogrel only if receiving transcatheter implantation, for bioprosthetic aortic valve

A 55 year-old male receives a mechanical mitral valve and mechanical aortic valve. His past medical history includes previous DVT and asthma. In addition to therapeutic heparin, which of the following anti-thrombotic regimens would be most appropriate?

A. Aspirin 81mg and warfarin to goal INR 2 - 3

B. Aspirin 81mg and warfarin to goal INR 2.5-3.5

C. Warfarin to goal INR 2 – 3

D. Warfarin to goal INR 2.5 – 3.5

B.

Mechanical Aortic Valve: Warfarin with INR 2 – 3 indefinitely

Mechanical Mitral Valve: Warfarin with INR 2.5 – 3.5 indefinitely

• Bridge with IV UFH or SC LMWH if INR subtherapeutic

• Add aspirin 50 – 100mg/day if additional risk factors for thromboembolism (atrial fibrillation, low EF, older age, history of TE)

A 78 year-old female presents with severe mitral stenosis. Her past medical history includes atrial fibrillation (stopped warfarin due to intracranial hemorrhage), HTN, and diabetes. Which of the following statements about this patient is most accurate?

A. Her mitral stenosis is likely due to rheumatic heart disease

B. A bioprosthetic valve will last >20 years in this pt

C. The best option for valve replacement would be a mechanical mitral valve

D. If the patient receives a bioprosthetic valve, she can use apixaban instead of warfarin

A

D. If the patient receives a bioprosthetic valve, she can use apixaban instead of warfarin

• DOACs C/I in mechanical heart valves

A 75-year old patient has severe aortic stenosis, and is considering valve replacement. Which of the following statements is most accurate?

A. If she receives a valve by transcatheter procedure, she should be on warfarin and clopidogrel

B. She needs to be on warfarin whether she receives a mechanical or bioprosthetic valve

C. If she receives a mechanical valve, she will need to be on warfarin lifelong with a goal INR of 2-3

A. If she receives a valve by transcatheter procedure, she should be on warfarin and clopidogrel

• Aspirin and clopidogrel

B. She needs to be on warfarin whether she receives a mechanical or bioprosthetic valve

• Bioprosthetic aortic: No warfarin required

C. If she receives a mechanical valve, she will need to be on warfarin lifelong with a goal INR of 2-3

The goal of shock is to achieve and maintain a mean arterial pressure >_ mmHg

65

Which accurately describes shock due to massive blood loss after a trauma?

A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive

Describe what the etiologies of the other types of shocks.

A. Cardiogenic

• H.F

• Valve dysfunction

B. Obstructive

• Pulmonary embolism

• Tamponade

C. Hypovolemic

• + Fluid Loss

D. Distributive

• Anaphylaxis

• Sepsis

Epinephrine receptor activity and physiologic effect

A1, B1, B2 agonist

• Vasoconstriction

• Increased inotropic/chronotrophic activity

Norepinephrine (Levophed) receptor activity and physiologic effect

A1 agonist, secondarily B1 agonist

• Vasoconstriction

• Increased inotropic / chronotropic activity

Dopamine receptor activity and physiologic effect

D, B1, A1 agonist (depending on dosing)

• Increased renal blood flow (low dose)

• Increased inotropic/chronotropic activity (medium dose)

• Vasoconstriction (high dose)

Phenylephrine (Neo-Synephrine) receptor activity and physiologic effect

A1 Agonist

• Vasoconstriction

_ is used as an adjunctive agent to norepinephrine in sepsis (not as monotherapy_). Physiologic effect is _.

Vasopressin

Vasoconstriction

Which medication primarily increases BP by stimulating only α-receptors?

A. Norepinephrine B. Phenylephrine C. Epinephrine D. Dopamine

B.

What findings determine that EE is in shock?

What type of shock is it?

What is the initial management for shock in EE?

If this initial management is not effective, what should be started next?

1. SBP <90 and MAP <65 mm Hg

2. Distributive shock (Infection → Sepsis)

3. IV fluid boluses

4. Vasopressor → Norepinephrine is vasopressor of choice in sepsis

What is the general treatment for cardiogenic, obstructive, hypovolemic, distributive shock?

What are risk factors for ischemic heart disease?

What are the symptoms of the following IHDs: CAD, Chronic stable angina, ACS

How should we manage the IHDs?

Which of the following statements is most accurate regarding CV testing procedures?

A. EKGs are a non-invasive test used to determine presence of arrhythmias and cardiac function

B. An exercise stress test with nuclear imaging is considered last line due to risk of radiation

C. A cardiac catheterization procedure is best way to visualize the coronary arteries D. A trans-thoracic echocardiogram is an invasive test used to determine cardiac structural abnormalities

A. EKGs are a non-invasive test used to determine presence of arrhythmias and cardiac function

• Detects arrhythmias, conduction disturbances, myocardial ischemia

B. An exercise stress test with nuclear imaging is considered last line due to risk of radiation

• Not last line. Usually done before aardiac catheterization.

• Coronary artery calcium scoring has risks of radiation

C. A cardiac catheterization procedure is best way to visualize the coronary arteries

D. A trans-thoracic echocardiogram is an invasive test used to determine cardiac structural abnormalities

• Non-invasive

Purpose of coronary artery calcium scoring

Determines presence and extent of coronary calcification

What medications are used for chronic stable angina? What are other treatment recommendations?

• B-blockers

• CCB

• Nitrates

• Ranolazine

Risk factor reduction

Aspirin 81 mg indefinitely (Clopidogrel if aspirin C/I)

Anti-anginals

Interventional

• PCI

• CABG

Which statement regarding chronic stable angina is most accurate?

A. It is caused by a partially occlusive thrombus

B. It can be exacerbated by severe anemia

C. All pts should receive a cardiac catheterization

D. The double product equation (used to determine MVO2 ) is DP = HR x CO

A. It is caused by a partially occlusive thrombus

• Acute coronary syndrome

• Angina is usually due to imbalance of oxygen demand and supply

B. It can be exacerbated by severe anemia

C. All pts should receive a cardiac catheterization

• Invasive!

D. The double product equation (used to determine MVO2 ) is DP = HR x CO

• DP = HR X SBP

What drug class if first choice for chronic prophylaxis?

• B-Blockers

A 59 year old presents with new chest pain, and is diagnosed with chronic stable angina. Vitals: BP 148/92, HR 86, RR 18 Medications: aspirin 81mg daily, nitroglycerin 0.4mg SL PRN Which of the following is the most appropriate recommendation for this pt for prophylaxis of chest pain?

A. Lopressor 25mg BID

B. Inderal 10mg TID

C. Dilacor ER 120mg daily

D. Norvasc 50mg daily

A → Metoprolol, cardio-selective

1. We want BB

2. Want more cardio-selective

3. If C/I w/ BB → can use non-DHP CCBs

Long-acting nitrates indication

• Monotherapy only if BB or CCB C/I or intolerable

Nitroglycerin SL (Nitrostat)

0.4mg SL PRN

0.4 mg, under your tongue, 2 times, 5 mins apart

Original

24-48 hours

5-10 minutes

Avoid _ in prolonged QT interval