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USMLE2 Medicine 07
Cardiology 1
| Question | Answer |
|---|---|
| 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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