PA test Cardiology

What are the "Big 6" in regards to risk factors for CAD?

FSH DAD

F - Family Hx of premature CAD/MI (M < 45; F < 55)

S - Smoking (Cigarettes)

H - HTN, Homocysteine levels elevated

D - DM/Metabolic syndrome

A - Age (M: > 45; F: > 55)

D - Dyslipidemia - Elevated LDL; Low HDL

What is the normal ejection fraction? What is the ejection fraction value that corresponds to increased mortality?

Normal = > 50%

<50% is associated w/ mortality

What vessel corresponds to a poor prognosis in regards to CAD?

LAD - b/c it covers 2/3 of the heart

What type of CAD is being described: CP that lasts < 10/15 min that is described as heaviness/pressure that is brought on by exertion, and relieved by rest or NTG?

A. Unstable Angina

B. Stable Angina

C. Prinzmetal's Angina

B. Stable Angina

What diagnostic procedures can be used as a screening tool for CAD?

Exercise stress ECHO/EKG

What is the GOLD STANDARD diagnostic procedure for CAD?

Coronary Angiography

The coronary cath looks at what? Coronary angiography looks at what?

Cath --> determining a cardiac diagnosis

Angiography --> presence and severity of CAD; looks at delineating coronary anatomy

What procedures can be used with "reversible" ischemia?

CABG and PTCA

If a patient is unable to exercise, what procedure can you use as a screening test for CAD?

Pharmacological Stress Test w/ IV adenosine, dipyramidole, dobutamine

What device can be used to detect silent ischemia and silent arrhythmias not assable by an in office EKG?

Holter Monitor

What are the components of metabolic syndrome?

hypercholesterolemia

hypertriglyceridemia

impaired glucose tolerance

diabetes

hyperuricemia

HTN

What is a nonpharmacological treatment that can be used for the tx of CAD?

TLC - EXERCISE is crucial and DIET modification (decrease fat, cholesterol)

What pharmacological therapies are first line for all CAD patients?

TLC, Aspirin, BB, Nitrates

(2nd line: add CCB)

What is the TOC is severe CAD?

CABG

The pathophysiology of stable vs unstable angina?

Stable: due to increased demand

Unstable: reduced resting coronary flow

What three patient profiles can be diagnosed with unstable angina (USA)?

1) Pts with chronic angina with increasing freq, duration, and intensity of CP

2) Pts with new-onset angina that is severe or worsening

3) Patients w/ ANGINA AT REST

What diagnostic procedures should be utilitzed for USA?

Higher risk for AE w/ Stress test sooo....

1) Stablize w/ medical management before stress test

or

2) undergo cardiac cath initially

What management should be taken with USA?

Admit w/ IV access and O2

Medical Management: "HANG"

Heparin (LMWH)

Aspirin

NTG - FIRST LINE THERAPY

Glycoprotein IIb/IIa

+

BB - FIRST LINE THERAPY

+

Cardiac Cath

After acute event, what tx are used for USA?

Aspirin, BB, nitrates

What form of angina is characterized by "transient coronary vasospasm", the episodes occur at rest, and ass w/ ventricular dysfunction?

A. Stable Angina

B. Unstable Angina

C. Prinzmetal's Angina

C. Prinzmetal's Angina

What is the HALLMARK of prinzmetal's angina?

transient S-T ELEVATION on ECG during chest pain, which respresents transmural ischemia

What is the DEFINITVE TEST for prinzmetal's angina?

CORONARY ANGIOGRAPHY - displays coronary vasopasm when the pt is given "IV ERGONOVINE"

What management can be used for prinzmetal's angina?

Nitrates, CCB

What is the MOST COMMON CAUSE of a MI?

Acute Coronary Thrombosis

Remember time is muscle w/ an MI

o 20-40 min: irreversible cell damage

o 3-6 hours: necrosis

MI is associated with 30% mortality, 1/2 of the deaths are (pre/post) hospital?

Pre

What are the clinical features of a MI?

(1) intense substernal CP - "crushing" or "elephant on chest"

(2) Radiation to neck, jaw, arms, or back - MOST COMMON on LEFT side

(3) Some experience epigastric discomfort (make sure to r/o w/ GERD sx)

(4) Dyspnea

(5)diaphoresis

(6)weakness, fatigue

(7) N/V, sense of impending doom

(8) syncope

What patient population can have an asx or atypical MIs?

(1) post-op

(2) DM

(3) Elderly

(4) Women

In the case of a MI w/ sudden cardiac death, what is the MOST COMMON CAUSE?

V. Fib

What are the characteristic EKG findings for a MI?

Peaked T waves - occur EARLY and may be missed

ST Elevation (STEMI) - TRANSMURAL MI - diagnostic of an acute infarct

Q Waves - evidence of NECROSIS (SPECIFIC) - usually seen LATE, not acutely

T wave inversion - sensitive NOT specific

ST Depression (NSTEMI) - SUBENDOCARDIAL injury

(NSTEMI/STEMI) is larger and more devestating to the patient's health?

STEMI

NSTEM tends to be smaller than a STEMI and presents similar to USA, how can you differentiate the two?

Cardiac Enzymes

What is the GOLD STANDARD for MI diagnosis?

CARDIAC ENZYMES (<-- Per Stepup to Medicine)

ANGIOGRAPHY (<-- Per Ovalle)

What cardiac enzyme increases w/in 4-8 hour - peaks at 24 hours - and returns to nl at 48-72 hours?

CK-MB (best when measured 24-36 hours)

Measure @ admission - every 8 hours for first 24 hours

What is the MOST IMPORTANT cardiac enzyme?

Troponin (I&T) <-- greater sensitivity and specificity than CK-MB

Increase w/in 3-5 hours - peak at 24-48 hours - return to nl at 5-14 days

Obtain levels on admission - every 8 hours for 24 hours

Troponin (I/T) is falsely elevated in patients w/ renal failure?

Troponin I

What is the initial treatment of an MI upon admission?

MONA - Morphine, Oxygen, Nitro, Aspirin

What is the acute management for a RCA infarction?

IV NL Saline + MOA (Morphine, O2, ASA)

NITRO IS C/I IN A RIGHT SIDED MI

What is the acute management for a NSTEMI/Non-Q wave MI?

MONA (THROMBOLYTICS ARE C/I)

BB/CCB/STENT

What are the indications for stents and thrombolytics?

CP 30-6 hours: ST elevation of 1mm or greater in 2 leads in STEMI --> use thrombolytics

o CP < 30 min → STENT in STEMI/NSTEMI

o CP > 6 hours - risk to benefit ratio in STEMI

NEVER USE USE THROMBOLYTICS IN NSTEMI***

TPA - most expensive and most effective

Streptokinase: least expensive an less effective

Explain the presentation for a cocaine induced MI? What is the MOST COMMON CAUSE of death?

o Tachycardia, HTN, vascular constriction

o Sudden death due to V.Fib

What is initiated in all patients with an MI to prevent the progreessio of thrombus, however has NOT been shown to decrease mortality?

LMWH (enoxaparin)

What drugs are used post-MI for maintance therapy?

ASA - decreases mortality - prevents platelet aggregation to prevent thrombosis formation

BB - decreases mortality - decreases HR/Contractility/afterload

ACEi - initiate w/in hours of hospitalization if no c/i - been shown to decrease mortality - esp important in DIABETICS

Statins - reduce risk of other coronary events

What is the MOST COMMON CAUSE of inpatient mortality post-MI?

Pump Failure (CHF)

Mild: tx w/ ACEi and Diuretic

Severe: can lead to cardiogenic shock - hemodynamic monitoring

If a pt is post MI w/ a second or third degree heart block, what is the appropriate treatment measures if it is an anterior MI? Inferior MI?

Anterior MI: pacemaker (temp then permanent) - worse prognosis

Inferior MI: atropine IV, if not controlled then temporary pacement (better prognosis)

How can a physician know if a patient is having a recurrent infaraction?

repeat ST-Elevation on EKG post 24 hours of the MI

In a papillary muscle infact, what is the common resulting murmur and what is the management

MR

ECHO - Emergeny MV replacement - afterload reduction w/ nitroprusside or intra-aortic balloon pump.

What is the name of the "postmyocardial infarction syndrome" that is immunologically based and consists of fever, malaise, pericarditis, leukocytosis, and pleuritis occuring weeks to months post-MI?

Dresslers Syndrome

TOC = ASA

Name the leads and corresponding artery for which ST-Elevation/Depression can be seen for the following infarctions:

Anterior MI?

Lateral MI?

Inferior MI?

Posterior MI?

Anterior: V1-V4 - LAD

Lateral: I, avL, V5, V6 - Circumflex

Inferior: II, III, avF - RCA

Posterior Large R wave in V1/V2 - RCA

What MI location is the MOST COMMON?

Anterior - LAD

In CHF there is systolic and diastolic dysfunction...what are they defined by and what is the MOST COMMON CAUSE of each?

Defined by Ejection fraction

Systolic: <50% or decreased EF

MCC - post MI

Other: DCM/Myocarditis

Diastolic: Nl/increased EF

MCC = HTN leading to myocardial hypertrophy

Other: AS, MS, AR, RCM/HCM

What are the sx of left-sided heart failure?

What is the MCC of left-sided HF?

Left sided heart failure - dyspnea, orthopnea, paraxoysmal noctural dyspnea, nocturnal cought (nonproductive)

Adv CHF - confusion and memory impairment

NYHA Class IV - diaphoresis and cool extremeities at rest

MCC = CAD/HTN

What are the signs of left sided heart failure?

Dislaced PMI to the left

Pathologic S3 (ventricular gallop) - S4 can be present

Crackles/rales at lung bases (pulmonary edema, moderate severity of left ventricular HF)

Dullness to percusssion and decreased tactile fremitus of lower lung feilds

increased pulmonic component of heart sounds indicates pulmonary HTN

What are the S&S of right sided heart failure?

What is the MCC?

Peripheral Pitting Edema (secondary to venous insuff)

Nocturia (due to increased venous return from leg elevation)

MCC = Left sided HF or Cor pulmonale (pure)

JVD

Hepatomegaly/Hepatojugular reflex

Ascites

Right ventricular heave

Name the NYHA described..."symptoms occur w/ vigorous activities, such as playing a sport, pts are nearly asymptomatic?

A. I

B. II

C. III

D. IV

A. I

Name the NYHA described..."symptoms occur w/ prolonged or moderate exertion, such as climbing a flight of stairs or carrying heavy packages. Slight limitation in activity"?

A. I

B. II

C. III

D. IV

B. II

Name the NYHA described...."symptoms occurs w/ usual activities of daily living, such as walking across the room or getting dressed. Marketedly Limited"?

A. I

B. II

C. III

D. IV

C. III

Name the NYHA described...."symptoms occur at rest. Incapacitating.?

A. I

B. II

C. III

D. IV

D. IV

What are the CXR findings for CHF?

Cardiomegaly

KERLY B LINES

Prominent interstitial markings

Pleural Effusion

What is the INITIAL TEST OF CHOICE/GOLD STD for CHF?

Echo

What is very important about the ECHO and CHF?

It measures EJECTION FRACTION

<40% = systolic dysfunction (MOST COMMON)

>40% = diastolic dysfunction

What can be used to precisely measure the EF and left ventricular function?

Radionucleotide ventriculography using technetium-99m

What lab is pathognomic for CHF?

Elevated BNP

What is the acute tx for CHF?

LMNOP

L - Lasics

M - Morphine

N - Nitro

O - O2

P - Position

What is the initial LT treatment for mild CHF (I/II)?

Mild restriction of sodium intake (<4 g Na+)

Physical activity

Loop Diuretic

ACEi

Loop and ACEi are the FIRST LINE TREATMENTS

What is the initial LT treatment for mild-mod CHF (II/III)?

Start w/ a loop diuretic and ACEi

Add a Beta Blocker if moderate disease is present.

What is the initial LT treatment for moderate-severe CHF (III/IV)

Add Dig to loop and ACEi

Can add Dig at anytime for systolic dysfunction

In patient with Class IV sx who are still symptomatic despite the previously mentioned treatment, what can you add?

spironolactone

What are the S&S of Dig toxicity?

N/V Anorexia

Cardiac: ectopic ventricular beats, AV block, Afib

CNS: green/yellow vision, disorientation

What are the characteristic findings for PACs? What management would you recommend?

EKG: early p-waves that differ in morphology from the normal sinus P-wave - QRS is normal

Management: can occur in healthy individuals and some patients can be asx so they do not require treatement

If palpatations - prescribe BB

What are the EKG findings for PVCs? Tx?

Wide, Bizzare QRS complexes followed by compensatory pause are seen; a P-wave is not usually seen because it is buried within the wide QRS complex.

Increased Incidence w/ Age

>10 PVC/hour --> Pathologic

Exercise should improve PVCs, if not then pathologic

Tx: Symptomatic - BB

Pts w/ repetitive PVCs are at increased risk for what?

Sudden Death by V. Fib (Esp when >10/hour)

Define the following terms in regards to PVCs:

Couplet?

Bigeminy?

Trigeminy?

Couplet: two successive PVCs

Bigeminy: Sinus beat followed by a PVC

Trigeminy: sinus beat followed by two PVCs

What EKG finding is defined as "irregularly irregular"?

A. Fib (Atrial rate is > 400 and vent rate is 75-175)

MOST COMMON ARRYTHMIA

Pts with A. Fib are at increased risk for what?

thromboembolism and hemodynamic compromise

What is "holiday heart syndrome"?

A. Fib caused by excessive alcohol intake

What are the clinical features of A. Fib?

Fatigue and Exertional Dyspnea

Palpitations, dizziness, angina, or syncope

Irregular, irregular pulse

Blood stasis leads to formation of intramural thrombi, which can embolize to the brain

Absense of an "A Wave" in JVP measurement.

In a hemodynamically unstable patient in A. Fib what manaement would you take?

Immediate electrical cardioversion to sinus rhythm

In regards to A. Fib and rate control, what is the target rate? Perferred Tx?

60-100 bpm

CCB - Perferred Tx (Alt: BB)

In a hemodynamically stable patient, what management steps should you take?

Rate Control w/ CCB

Duration of A.Fib <48 hours --> Cardioversion

Duration of A.Fib > 48 hours --> Anticoagulate x 3 weeks w/ Warfarin (INR 2-3) then cardiovert

or

Duration of A.Fib > 48 hours --> get a TEE --> If thrombosis in left atrium then anticoagulate x 3 weeks and then cardiovert; If no thrombis in left atrium then cardiovert immediatly.

Explain the CHADS score for A. Fib?

Used to assess patients risk and when to anticoagulate w/ "Warfarin" verus "electric shock"

DO NOT ANTIVERT PATIENTS WITH HIGH RISK! (CHAD SCORE >/= 2+

ALWAYS ANTICOAGULATE CHADS 2+ PATIENT

Criteria for CHADS Score - BQ

Congestive Heart Failure (1 point)

Hypertension (1 point)

Age over 75 years (1 point)

Diabetes Mellitus (1 point)

Stroke or TIA history (2 points)

Mitral Stenosis or prosthetic heart valve carry similar risk and also indicate Warfarin

Interpretation

CHADS Score >2 (CVA risk >5% per year): Warfarin with goal INR 2.0 to 3.0

CHADS Score 1 (CVA risk >4% per year): Warfarin or Aspirin

CHADS Score 0: Aspirin 81 to 325 mg daily

*NEW ONSET A.FIB W/ NO PRIOR DOCUMENTATION - CARDIOVERT**

What is the MOST COMMON CAUSE of A. Flutter?

COPD = MCC

Other: rheumatic heart disease, CAD, CHF, ASD

What is the EKG findings for A. Flutter?

Pathogneumonic - "saw-tooth" flutter waves best seen in II/III/avF

Rate will be 250-350

What is the MCC of multifocal atrial tachycardia?

COPD

How can you diagnose multifocal atrial tachycardia?

three different P-wave morphologies are required to make an accurate diagnosis

Rate is 100-200

Can also be diagnosed w/ vagal maneuvars or adenosine to slow AV block

*Note that a wandering pacemaker is similiar but the rate is <100*

Explain orthodromic and antidromic AVRT.

Orthodromic AVRT (MORE COMMON):

Narrow Complex tachycardia in which the wave of depol travels down the aVnode and retrograde up the accessory pathway (narrow QRS - bypass going down normal conduction pathways) - Retrograde

Antidromic AVRT (LESS COMMON):

Wide Complex tachycardia in which wave of depol travels down the accessory pathway and retrograde up the AV node (The wider the QRS the farther the conduction is from the std conduction pathways and it is slower) - Anterograde

What is the treatment for AVRT?

Vagal Maneuvars

IV Adenosine = TOC

Prevention: DIG = TOC

Recurrent/Symptomatic = radiofreqencu catheter abalation of either the AV node or accessory tract

Explain WPW and the Tx?

Accessory pathways between the atrium and ventricle may occasionally be seen

MOST COMMON is 'bundle of Kent' seen in Wolff-Parkinson-White syndrome

SHORTENED PR INTERVAL AND A "DELTA WAVE" caused by early excitation of the ventricle via the accessory pathway.

TX: Radiofreqency catheter abalation

What is the arrhythmia that is defined as *"rapid and repetitive firing of 3+ PVCs in a row, at a rate of 150 - 250 bpm?

A. A. Fib

B. V. Fib

C. Trigeminy

D. V. Tach

D. V. Tach

What is the MOST COMMON CAUSE of V. Tach?

CAD w/ Prior MI = MCC

OTher: active ichemia, hypotsn, CM, CHD, prolonged QT syndrome, drug toxicity

Define sustained V.Tach. What are the associated risks?

Sustained VT lasts longer than 30 secondas and is almost always symptomatic!

Ass w/ MI/Hypotsn

Can be a life-treatening arrhythmia and can lead to V. Fib :0

Define non-sustained VT.

VT that lasts less than 30 seconds - brief, asx

Worse prognosis when CAD/LV dysfunction are present.

What are the clinical features of VT?

l. Palpitations, dyspnea, lightheadedness, angina, impaired consciousness (syncope or near-syncope)

2. May present with sudden cardiac death

3. Signs of cardiogenic shock may be present.

4. May be asymptomatic if rate is slow

5. Physical findings include cannon a waves in the neck (secondary to AV dissociation,

which results in atrial contraction during ventricular contraction) and an Sl that varies in intensity.

Name the EKG findings that are characteristic of VT.

Pathogneuomic = WIDE AND BIZARRE QRS COMPLEXES

QRS can be monomorphic or polymorphic

MONOMORPHIC - all QRS complexes are identical

POLYMORPHIC - the QRS complexes are different - beat to beat variation

How can you differentiate VT from PVST?

Unlike PVST, VT DOES NOT respond to vagal maneuvars or adenosine

What phenomenon is described as follows... ABERRANT VENTRICULAR CONDUCTION DUE TO A CHANGE IN QRS CYCLE LENGTH. Describes a particular type of wide complex tachycardia that is often seen in atrial fibrillation. It is more often misinterpreted as a premature ventricular complex.

ASHMAN'S PHENOMENON

What is the management option for hemodynamically stable sustained VT pts w/ SBP of > 90?

New ACLS says IV Amiodarone, IV procaimamide, or IV sotaolol

What is the management option for a non-hemodynamically stable sustained VT pt?

BOX TRUMPS PILL

IMMEDIATE synchronous DC cardioversion

Follow w/ Amiodarone to maintain sinus rhythm

As a general rule, what form of management should be given to all patient who are dx w/ sustained VT?

ICD

Exception - EF is normal, then you can consider amiodarone

In regards to VT as a whole what is the FIRST LINE THERAPY?

ICD

Amiodarone is considered the BEST 2ND LINE TX

Describe the patho behind V. Fib?

Multiple foci in the ventricles fire rapidly, leading to chaotic quivering of the ventricles and NO CO.

Reoccurance is high if unrelate to an MI and has a worse prognosis --> Pt will need a ICD/Amiodarone

Fatal if untreated can result in "SUDDEN CARDIAC DEATH"