1
Q
Define stable angina
A
transient, episodic chest discomfort resulting from myocardial ischemia
2
Q
Outline CCS classification for angina
A
Class I = no angina with ordinary physical activity
Class II = minimal limitation of normal activity as angina occurs with exertion or emotional stress
Class III = severe limitation of ordinary physical activity as angina occurs with exertion under normal physical conditions
Class IV = inability to perform any physical activity without discomfort as anginal symptoms occur at rest or with minimal physical exertion
3
Q
Define unstable angina
A
- angina that is new onset or occurring at rest or with minimal exertion
- worsening from a previously stable pain pattern, increased frequency or duration of attacks, resistance to previously effective medications, or provocation with decreasing levels of exertion or stress
4
Q
Define rest angina
A
angina occurring at rest, lasting longer than 20 minutes, and occurring within 1 week of presentation
5
Q
Define Prinzmetal (variant) angina
A
- coronary artery vasospasm at rest with minimal fixed coronary artery lesions
- relieved by exercise or NTG
- ECG reveals STE and is impossible to discern from plaque rupture–related STEMI clinically and electrocardiographically.
6
Q
Define myocardial INJURY
A
- elevated troponin with at least one value above the 99th percentile upper reference limit
- injury is considered acute if rise or fall of the troponin values
7
Q
Define myocardial INFARCTION
A
- elevated troponin above the 99th percentile upper reference limit
WITH one of:
- Symptoms of myocardial ischemia
- EKG abnormalities:
(New ST segment and/or T wave changes, or new pathologic Q waves) - Imaging evidence of loss of viable myocardium or regional wall motion abnormality consistent with ischemic cause
- Angiographic or autopsy evidence of coronary thrombus
8
Q
Outline 5 types of AMI
A
TYPE 1
- spontaneous MI from a primary coronary event, such as plaque erosion rupture, erosion, fissuring, or dissection with accompanying thrombus formation and vasospasm
- represents true ACS event.
TYPE 2
- MI 2/2 ischemia caused by increased oxygen demand or decreased supply, as seen in coronary artery spasm, coronary embolism, severe anemia, compromising arrhythmias, or significant systemic hypotension
TYPE 3
- sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia
- accompanied by presumably new STE or new LBBB pattern
- Fresh coronary thrombus is noted via angiography or autopsy
- death occurs before troponin drawn
TYPE 4
- MI 2/2 coronary instrumentation (PCI)
- Pts with normal baseline troponin get elevated troponin indicative of periprocedural myocardial necrosis
- Trop >3x the 99%ile URL = PCI-related MI
- stent thrombosis also in type 4
TYPE 5
- MI 2/2 CABG
- Pts with normal baseline troponin get elevated troponin indicative of periprocedural myocardial necrosis
- Trop >5x the 99%ile URL = CABG-related MI + any of the following:
- New pathologic Q waves or new LBBB
- Angiographically documented new graft or native coronary artery occlusion
- Imaging evidence of new loss of viable myocardium
9
Q
Define NSTEMI
A
- presence of chest pain or other anginal equivalent complaint
- abnormal ECG (lacking STE)
- elevated troponin
10
Q
Define STEMI
A
- presence of chest pain or other anginal equivalent complaint
- abnormal ECG with STE
- elevated serum troponin
11
Q
Define CAD
A
thickening and obstruction of coronary vessel arterial lumen by atherosclerotic plaques
12
Q
List 4 advantages of EMS dx of STEMI
A
1) earlier detection of STEMI
2) ability to select patient destination based on availability of PCI
3) hospital-based preparation prior to patient arrival
4) more rapid initiation of hospital-based reperfusion therapy, either fibrinolysis or PCI
13
Q
Compare & contrast anginal pain vs non-anginal pain, based on:
Type of pain
Duration
Onset
Location
Reproducibility
Associated symptoms
Palpation of chest wall
A
14
Q
List associated symptoms with angina
A
dyspnea (most common)
nausea
vomiting
diaphoresis
weakness
dizziness
excessive fatigue
anxiety
- ‘heartburn’
- ‘indigestion’
*if no chest pain but known CAD, they are anginal equivalent symptoms
15
Q
List 12 DDx for Chest Pain
A
- AMI
- Unstable angina
- Stable angina
- Prinzmetal angina
- Pericarditis
- Myocardial contusion
- Pulmonary contusion
- PNA
- PE
- PTX
- Pulmonary hypertension
- Pleurisy
- Aortic dissection
- Boerhaave syndrome
- GERD
- PUD
- Gastritis
- Esophagitis
- Esophageal spasm
- Mallory-Weiss syndrome
- Cholecystitis
- Biliary colic
- Pancreatitis
- Herpes zoster
- MSK pain
16
Q
List 10 risk factors for atypical (no chest pain) presentation of ACS
A
- DM
- older age
- female
- non-White
- dementia
- no prior MI
- no prior hypercholesterolemia
- no fam hx CAD
- prev hx CHF
- prev stroke
17
Q
List 6 traditional + 3 additional risk factors for ACS
A
Age
Tobacco smoking
HTN
DM
DLD
Fam hx of AMI at age <50 yr
Elevated BMI
Artificial or Early Menopause
Cocaine use
18
Q
List 4 medical dxs that are less common risk factors for CAD
A
APLAS
RA
HIV
SLE
19
Q
List 12 Early Complications of AMI
A
- Bradydysrhythmia
- AV blocks
- Tachydysrhythmia
- Sinus tachycardia
- AFib
- VF
- VT
- Cardiogenic shock
- LV free wall rupture
- Interventricular septum rupture
- Papillary muscle rupture w/ acute MVR
- Infarct-related pericarditis (early)
- Stroke
- Pseudoaneurysm of femoral artery after cannulization in PCI
20
Q
Define Cardiogenic Shock
A
end-organ hypoperfusion resulting from decreased cardiac output unresponsive to restoration of adequate preload
- systemic hTN
- low CO
- elevated filling pressures
- increased SVR
21
Q
List 5 risk factors for Cardiogenic Shock in pts with AMI
A
- large infarctions
- prior MI
- low EF on presentation (<35%)
- older age
- diabetes mellitus
22
Q
List clinical features of Dressler syndrome
A
- 1 week to several mos after MI
- fever
- malaise
- pleuro-pericardial pain
- rub on cardiac auscultation
- elevated ESR
- elevated leukocytes
- PR segment depression
- ST changes
23
Q
List etiologies of stroke in AMI
A
Ischemic, Thromboembolic and Hemorrhagic (from meds)
- embolization from LV mural thrombus with decreased EF
- embolization from LA appendage with Afib
- hypercoagulability with concomitant carotid arterial disease
- hemorrhagic stroke with fibrinolytics
24
Q
List 10 DDx of STE in pts with chest pain
A
- Acute MI
- Acute pericarditis
- LVH
- LV aneurysm
- Ventricular paced rhythm
- Benign early repolarization
- Normal variant
- Osborn J wave of hypothermia
- Hyperkalemia
- Brugada syndrome
- PE
- Acute cerebral hemorrhage
- Prinzmetal angina
- Takotsubo cardiomyopathy
- Postelectrical cardioversion
25
Outline ECG findings consistent with STEMI
New STE > 1mm in at least 2 contiguous leads except for leads V2 & V3
- 1.5mm+ in Females
- 2.5mm+ in Males <40yrs
- 2mm+ Males >40yrs
26
List 6 DDx for tall T waves on EKG
Acute MI
HyperK
Benign early repolarization
LVH
LBBB
Acute pericarditis
27
List 10 DDx for STD on EKG
- Myocardial infarction (NSTEMI or STEMI reciprocal change)
- Subendocardial ischemia (UA)
- Repolarization abnormality of LVH
- Bundle branch block
- Ventricular paced rhythm
- Digoxin effect
- HyperK
- HypoK
- PE
- ICH
- Myocarditis
- Rate-related STD
- Postcardioversion of tachydysrhythmias
- PTX
28
List 4 examples of STD in ACS
1) NSTEMI
2) preceding STE in STEMI
3) reflect a mirror image of STE in (V8-9) posterior MI when in V1 to V3
4) represent reciprocal STD in STEMI
29
Describe Wellens syndrome
= Ischemic T wave inversions in V2-3
- Hx recent chest pain, with sign of impending PROXIMAL LAD re-occlusion
Type A = Biphasic T wave
Type B = Deep symmetrical TWI
May also have isoelectric or minimally elevated (<1mm) ST, and lack precordial Q waves
30
List 10 DDx of TWI on EKG
- ACS
- ventricular hypertrophy
- bundle branch block
- ventricular paced rhythm
- myocarditis
- pericarditis
- PE
- PTX
- WPW
- CVA
- hypoK
- GI disorders
- hyperventilation
- persistent juvenile T wave pattern
- normal variants
31
Outline Regional ST Segment Changes in Acute Myocardial Infarction
32
What does STE in aVR represent?
Occlusion of Lt MAIN
Can also be:
- proximal LAD
- LCX
- RCA
- diffuse ischemia 2/2 hypoperfusion
33
Diagnosis?
Anterior STEMI
34
Diagnosis?
Anterolateral STEMI
35
Diagnosis?
Lt main CA occlusion
36
Describe de Winter syndrome
= Prominent T waves w/ J point depression
- STD in precordial leads + STE in aVR
= Anterior STEMI equivalent
37
Diagnosis?
de Winter T waves
w/ STE in aVR
= Anterior STEMI equivalent
38
Diagnosis?
Wellens sign
Type I and II
= impending Proximal LAD occlusion
39
Diagnosis?
Anterolateral STEMI
STE in leads V1 to V4 (ant) + leads I, aVL, V5-6 (lat)
= proximal LAD lesion
40
Diagnosis?
High Lateral STEMI
- STE in I and aVL
- STD can be in III, aVF, V1
= LCA or D1 lesion
41
Diagnosis?
Inferior STEMI
42
In an Inferior STEMI, what do changes in leads other than aVF, II and III represent?
STE in II, III, aVF
+ STD in aVL and/or I = RCA lesion
+ STE in V1, and STE III > II = RV infarction
43
List 3 possible culprit CAs that result in Posterior MIs
RCA
RCA posterior descending branch
LCX
44
List 4 findings in leads V1-3 that suggest Posterior MI
1) Horizontal STD
2) Upright T wave
3) Tall, wide R wave
4) R wave amplitude–to–S wave amplitude ratio >1
45
Diagnosis?
Inferior STEMI with RV infarct
- STE in VR3-6
46
List 6 EKG features of Benign early repolarization (BER)
1) STE (usually <2mm in precordial & <0.5mm in limb)
2) upward concavity of initial portion of ST segment
3) notching of terminal portion of QRS complex at J point (J pt elevation <3.5mm)
4) symmetric concordant T waves of large amplitude
5) diffuse STE on ECG
6) relative temporal stability
47
Diagnosis?
BER
- upwardly concave STE in V4-6
- T waves relatively large
- Subtle irregularity of J point V5 and V6 (arrows)
48
Diagnosis?
Pericarditis
49
List 4 classic features of pericarditis on EKG
1) sinus tachycardia
2) diffuse, concave upward STE
3) PR depression (best seen in lead II)
4) PR elevation in aVR
50
Define Left ventricular aneurysm (LVA)
focal area of myocardium paradoxically bulges outward during systole
- usually anterior
51
List 5 EKG features of LV aneurysm
1) STE in V1-6 and I and aVL (anterior leads)
2) STE concave or convex
3) Q waves present
4) T wave amplitude : QRS amplitude <0.36
5) No reciprocal ST changes
52
List classic EKG findings of LBBB
1) QRS complex width > 120 msec
2) absence of Q wave in lead V6
3) broad monophasic R wave in leads V5 , V6, I, and aVL
4) discordant ST segment–T wave changes in leads V1 to V3 (simulating acute myocardial infarction), I, and aVL
*rule of appropriate discordance
53
Diagnosis?
LBBB
w/ 1' AVB
54
Outline Sgarbossa criteria for AMI in LBBB
A) STE >1mm that is concordant with QRS complex
B) STD >1mm in V1, V2, or V3
OLD C) STE >5mm that is discordant with QRS complex
Modified Sgarbossa D) Ratio of discordant ST to S wave amplitude >25%
55
Outline Sgarbossa criteria for AMI in ventricular paced rhythms
Essentially the same as for LBBB, using old criteria, not modified
1) STE >5mm that is discordant with QRS complex
2) STE >1mm that is concordant with QRS complex
3) STD >1mm in V1, V2, or V3
56
Diagnosis?
Lateral STEMI in a V-paced patient
*concordant ST segment elevation in leads I and aVL
57
Diagnosis?
LVH with repolarization abnormality
aka LVH strain
58
What EKG feature in LVH with repolarization abnormality is reassuring, as opposed to worrisome for AMI?
Lt precordial leads (V4-6 +/- I and aVL) show evidence of a repolarization abnormality (strain pattern) = STD and asymmetrical TWI
Reassuring when:
Rt precordial leads (V1-3) show mirror image = STE and tall T waves
59
List 4 situations where you should order additional EKG leads (Rt or posterior)
1) ST changes (D or E) in V1-3, in an isolated lead OR in more than one
2) equivocal STE in inferior (II, III, aVF) or lateral (I, aVL) limb leads, OR both
3) all inferior STEMIs
4) hypotension in setting of ACS
60
List 10 DDx for elevated troponin outside of ACS
- myocarditis
- pericarditis
- CHF
- LVH
- nonpenetrating cardiac trauma
- extreme physical exertion
- renal insufficiency
- multiple trauma
- PE
- sepsis
- multi-organ failure
61
List 8 DDx for false-positive Exercise Stress Tests
- Aortic stenosis or insufficiency
- Hypertrophic cardiomyopathy
- HTN
- AV fistula
- Anemia
- Hemoglobinopathies
- Low cardiac output states
- COPD
- Digitalis toxic states
- LVH
- Hyperventilation
- MV prolapse
- RBBB or LBBB
62
List 5 Pros & 4 Cons to PoCUS Echo in the ED for ACS w/u
PRO
- Readily accessible, portable
- Inexpensive
- Safe, noninvasive
- Detection of wall motion abnormalities
- Identification of non-ischemic causes of symptoms
CON
- Operator and interpreter dependent
- Limited sensitivity in small areas of myocardial injury
- Limited visual windows in 10% of patients
- Inability to distinguish acute & chronic wall motion abnormalities
63
Name 2 imaging techniques other than angiogram that can assess CAD
Nuclear perfusion MIBI scan
Coronary CTA
64
What is the purpose of HEART score?
assist in the identification of low-risk patients, suitable for ED discharge after a limited evaluation.
- accurate in predicting short-term risk of MACE, defined as AMI, need for PCI or CABG, and death within 6 weeks of the index ED visit
65
Outline the HEART scoring system
Total HEART Score: risk category & recommended management strategy
0–3: low risk, potential candidate for early discharge
4–6: moderate risk, potential candidate for observation & further evaluation
7–10: high risk, candidate for urgent or emergent intervention
66
Outline HEART Pathway, and what is its benefit over HEART Score
HEART Pathway uses combo of HEART score + serial troponin @ 0 & 3hr
*Higher sensitivity + Greater NPV for MACE than HEART score alone
67
List 3 main 'phases' of an ED assessment of a pt with chest pain/suspected ACS
1) STEMI recognition
- first 10 mins
2) ACS rule-out
- 30 mins - 6hrs
3) CAD consideration
- >6hrs
68
List 4 ED disposition pathways during consideration of significant CAD
- ED d/c, no further outpt eval needed
- Outpt f/u with PCP or cardiologist
- Continued ED or obs unit eval +/- cardio consult
- Admit w/ continued diagnostic eval
69
Outline 5 phases of pathophysiology of ACS
1) Endothelial damage thru plaque disruption, irregular luminal lesions, and shear injury
2) PLT aggregation
3) Thrombus formation = partial or total lumen occlusion
4) CA vasospasm
5) Reperfusion injury 2/2 oxygen free radicals, Ca2+, and neutrophils
70
Outline time to treatment goals in STEMI
PCI under 90 mins from arrival
Fibrinolytics under 30 mins after arrival
71
What are the 4 Ds in STEMI care?
Door (events before arrival at the ED)
Data (obtaining the ECG)
Decision (arriving at STEMI dx and deciding on tx)
Drug (administer fibrinolytic OR pass angioplasty catheter across culprit lesion in PCI)
72
List drugs given as part of acute ACS care in the ED
- O2 when sats <94%
- Nitroglycerin when SBP >90, for chest pain, HTN, pulm edema
- Opioids for chest pain
- BBs for signif HTN, refractory tachydysrhythmias
- ASA for any ACS suspect
- P2Y-12 receptor inhibitors (Clopidogrel/Ticalgrelor) for ACS pts
- Antithrombins for ACS pts
73
List 4 types of anti-thrombins
1) unfractionated heparin
2) low-molecular-weight heparin
3) direct thrombin inhibitors
4) factor Xa inhibitors
74
List 4 clinical ACS features for when to start unfrac heparin
- recurrent or persistent chest pain
- AMI
- positive serum marker
- dynamic ECG
75
What is standard ACS dosing for heparin?
Bolus 60units/kg IV
- max 4000units
Infusion 12units/kg/hr IV
76
Which type of anti-thrombin is preferred in STEMI and NSTEMI?
STEMI - immediate PCI = UFH
NSTEMI - PCI in >24hrs = LMWH
ex) enoxaparin
77
What is enoxaparin dosing?
Enoxaparin 1mg/kg subcut q12h
or q24h if GFR <30
78
List 3 contraindications to heparins
1) allergy
2) active ongoing hemorrhage
3) predisposition to hemorrhage
79
When should fondaparinux be used in ACS?
for NSTEMI and STEMI pts who are NOT undergoing PCI
80
List eligibility criteria for fibrinolytic tx in ACS
1) New STE > 1mm in 2+ contiguous leads except for leads V2 & V3
- 1.5mm+ in Females
- 2.5mm+ in Males <40yrs
- 2mm+ Males >40yrs
2) Any age, but >75yr = higher risk
3) Tx w/in 12hrs of STEMI onset
4) BP <200/120
5) NO active diabetic hemorrhagic retinopathy
6) CPR <10min and NO extensive chest wall trauma in cardiac arrest
7) NO hx of TIA/CVA
- relative contra to ischemic
- abs contra to hemorrhagic
8) Major surgery >3wks
Recent internal bleeding >4wks,
Brain/Spine sx >2mos
Head/Face trauma >3mos
81
List 5 benefits of early PCI over fibrinolytics
- increased number of eligible patients
- lower risk of intracranial bleeding
- significantly higher initial reperfusion rate
- earlier definition of overall coronary anatomy with rapid triage to surgical intervention
- risk stratification allowing safe early hospital discharge
82
If fibrinolytics "fail" to stop chest pain or stop STE, what tx should occur next?
Rescue PCI > > > 2nd dose fibrinolytics
83
If pt presents to a non-PCI hospital
AND
presentation is <2hr symptom onset, what tx should be considered?
Immediate fibrinolysis
OR
PCI if time to transfer is <60mins
84
If pt presents to a non-PCI hospital
AND
presentation is btwn 2-3hr symptom onset, what tx should be considered?
Immediate fibrinolysis
OR
PCI if time to transfer is 60-120mins
85
If pt presents to a non-PCI hospital
AND
presentation is btwn 3-12hr symptom onset, what tx should be considered?
Transfer to PCI
if time to transfer <120mins
86
In STEMI pts with cardiogenic shock, what reperfusion tx is preferred?
PCI or emergenct CABG > > > fibrinolytics
87
List 9 features unfavourable to resuscitation in OHCA
1) Unwitnessed arrest
2) Initial nonshockable rhythm
3) No bystander interventions
4) Prolonged arrest time >30 mins
5) Ongoing CPR at ED arrival
6) Abnormal serum studies (pH < 7.20, lactate > 7)
7) Age >85 yrs
8) ESRD
9) Noncardiogenic cause of arrest
88
Outline tx for pt with stable or resolved chest pain, normal to minimally abnormal EKG, and (-) troponin
ASA 364mg (or 162mg)
- non-EC
89
Outline tx for pt with NSTEMI
ASA 364mg
NTG
Clopidogrel or Ticagrelor
Heparin or other AC
90
Outline tx for pt with STEMI
ASA 364mg
NTG
Opioids
Clopidogrel or Ticagrelor
Heparin or other AC
Consider PCI, fibrinolytics, or CABG
91
List 5 features of pts with undx'd ACS who are inappropriately discharged from the ED
Younger
Women
Non-White
Non-chest pain presentations
EKG w/out acute ischemia
92
Any regular new-onset, symptomatic, wide-complex tachycardia should be assumed to be...?
Ventricular Tachycardia
93
Any tachycardia >225-250 bpm, regardless of QRS morphology, should be considered what...?
Accessory Pathway Syndrome
94
List meds that should be avoided in accessory pathway syndromes
any nodal blocking agent
95
List 2 clinical states that increase and decrease the sinus rate produced by the SA node
INCREASE
- hyperthermia
- sympathetic stimulation
- low-absent parasympathetic tone
DECREASE
- hypothermia
- vagal stimulation
96
Label where each electrical event in the heart occurs
1) SA node fires
2) Atrial depolarization = P wave
3) AV node transmits = PR
4) Ventricular depolarization = QRS
97
Where do accessory pathways occur?
Conduction tissue outside of AV node
= bypass tract btwn atria and ventriceles
98
What do Class I anti-arrhythmics do?
= Fast Na Channel Blockers
- slow conduction thru atria, AV node, His-Purkinje system
- suppress accessory paths
99
List 3 Class IA Antidysrhythmics
**Procainamide**
Quinidine
Disopyramide
100
List 2 (or 4) Class IB Antidysrhythmics
**Lidocaine**
Phenytoin
Tocainide
Mexiletine
101
List 2 Class IC Antidysrhythmics
Flecainide
Propafenone (shares properties w/ class IA, BBs & CCBs)
102
What do Class II anti-arrhythmics do?
Beta adrenergic antagonists
- depress SA node automaticity
- slow AV node
103
List 2 (or 8) Class II Antidysrhythmics
**Esmolol**
**Metoprolol**
Propranolol
Atenolol
Carvedilol
Timolol
Nadolol
Bisoprolol
104
What do Class III anti-arrhythmics do?
= K channel blockers
- prolong QT
- anti-fibrillatory
- prolong action potential and refractory period
105
List 4 Class III Antidysrhythmics
Amiodarone
Ibutilide
Dronedarone
Sotalol
106
What do Class IV anti-arrhythmics do?
= Ca channel blockers
- slow conduction thru AV node
- peripheral vasodilation
107
List 2 Class IV Antidysrhythmics
Diltiazdem
Verapamil
* Non-dihydropyridines
108
Name the preferred tx for Wolff Parkinson White
Procainamide
20-30mg/min IV
109
List 1 CV risk of procainamide
hypotension
110
List 1 CV risk of lidocaine
asystole in AMI
111
List 1 CV risk of Class IC agents (flecainide & propafenone)
prodysrhythmias
= new dysrhythmias
112
List contraindications to beta blocker use
- advanced CHF
- 3rd trimester pregnancy
- pre-existing bradycardia
- pre-existing hTN
- AVB >1'
113
Compare & Contrast Beta1 & Beta2 receptors by:
- location
- stimulation effect
- antagonism effect
114
Name 1 Beta1 cardioselective agent used in ED,
+ dosing
Esmolol
500 mcg/kg IV bolus
50 mcg/kg/min IV (titratable)
115
Name the 1st line tx for VT
Amiodarone
116
List 5 drugs that have their pharmacokinetics altered by amiodarone, resulting in INCREASED doses
warfarin
phenytoin
digoxin
procainamide
flecainide
117
List adverse acute (3) & long-term (5) effects of amiodarone
ACUTE
- Hypotension
- Bradycardia
- Negative contractility
LONG TERM
Common Effects
- Corneal deposits
- Photosensitivity
- GI intolerance
Less Common Effects
- Bradycardia
- Prodysrhythmic effect
- Heart failure
- Hyperthyroidism
- Hypothyroidism
- Pulmonary toxicity, fibrosis
- Blue-green skin discolouration
118
List 2 uses for Ibutilide (Corvert)
IV Cardioversion of Aflutter + Afib
must be on CCRM
119
Outline dosing of Diltiazem
0.25-0.35mg/kg IV bolus over 2 mins
5-15mg/hr IV infusion afterwards
60-90mg IR PO
120
Outline dosing of Veramapil
0.1mg/kg IV bolus over 2 mins
Then repeat with 1.5x previous dose q10min
121
Outline action of adenosine
Abrupt slowing of AV conduction in anterograde and retrograde pathways
122
List 10 side effects of adenosine
flushing
dyspnea
chest pressure
nausea
headache
dizziness
transient bradycardia or heart block
sense of impending doom
hypotension
transient asystole
123
List 3 CV effects of digoxin
- positive inotropy
- slows AV conduction
- enhanced automaticity
124
List 5 common and 5 less common adverse effects of digoxin
COMMON
- GI intolerance
(n/v/d, abdo pain, anorexia)
- Fatigue
- Drowsiness
- Headache
- Depression
- Apathy
LESS COMMON
- Psychosis
- Heart block
- Increased ectopy
- Combined block and ectopy (multifocal atrial tachycardia with block or complete atrioventricular block with accelerated junctional rhythm)
- VTach
- Visual colour disturbances
125
List 5 biochemical imbalances that affect digoxin and aggravate side effects
hypoK
hyperCa
hypoMg
inc catecholamines
acid-base disturbances
126
Outline mechanism of action of Isoproterenol, and its effects and dosing
Beta1+2 AGONIST
- prevent acquired TdP in BB overdose
- speeds SA and AV
- enhances contractility
1-2 mcg IV bolus
2-10 mcg/min IV infusion
(titrated)
127
Name most important mgmt for unstable pts with a dysrhythmia
Electrical therapy
- shock if fast
- pacing if slow
128
List 5 causes of pseudodysrhythmias
Loose leads
Muscle contraction
Shivering
Tremors
Other movements
129
List DDx causing sinus bradycardia
Athletes
Young people with high resting vagal tone
Inferior MI
Hypothermia
Hypoxia
BBs
CCBs
Sick sinus syndrome
Autonomic mediated syncope
Hemoperitoneum
130
Diagnosis?
Sinus bradycardia
131
Diagnosis?
Sinus arrhythmia
132
What will you see on EKG with SA exit block?
Dropped Ps in regularly occurring patterns (2:1, 3:1, 4:1)
- failure of impulse conduction out of SA node
133
What can you see on EKG with sinus arrest?
No Ps and ventricular escape rhythm
134
List medical conditions associated with sick sinus syndrome
Older adult
Infiltrative cardiomyopathies
Connective tissue disease
Certain drugs
135
Outline long term tx from tachy-brady syndrome
PPM + pharmacotherapy for Afib
136
Compare & Contrast Type I & II 2deg AVB by:
- clinical situations
- anatomy
- EKG features
Response to atropine & carotid massage
137
List 6 causes of grouped impulses on EKG
1) Wenckebach mechanism (usually at AV node, but can occur elsewhere)
2) Sinoatrial exit block
3) Atrial tachycardia or flutter with alternating conduction
4) Frequent extrasystoles
5) Non-conducted atrial trigemini
6) Concealed or interpolated extrasystoles
138
Diagnosis?
2nd deg AVB, type I
"Wenkebech"
139
In escape rhythms, what rates tell you if the pacemaker is above or below the bundle of His?
Above His
- narrow QRS @ 45-60bpm
At or Below His
- wide QRS @ 30-45bpm
140
Diagnosis?
3rd deg AVB
"complete"
141
What specific dysrhythmia is classically associated with digoxin toxicity?
"Regularized AFib"
fibrillatory atrial waves are accompanied by a slow and regular ventricular response
142
List 2 tick-borne illnesses that can cause 3rd deg AVB
Lyme disease
Chagas disease
143
List DDx for causes of PACs on EKG
Benign
Catecholamine excess
Myocardial ischemia
Heart failure
Hyperthyroidism
Metabolic abnormality
144
Compare & Contrast PACs and PVCs
145
List 10 causes of PVCs and VTach
Acute or previous myocardial infarction or ischemia
Hypokalemia
Hypoxemia
Ischemic heart disease
Valvular disease
Catecholamine excess
Other drug intoxications (especially cyclic antidepressants)
Idiopathic causes
Digoxin toxicity
Hypomagnesemia
Hypercapnia
Class I antidysrhythmic agents
Ethanol
Myocardial contusion
Cardiomyopathy
Acidosis
Alkalosis
Methylxanthine toxicity
146
What tachyarrythmia is usually seen in pulmonary disease (like COPD) ?
Multifocal Atrial Tachycardia
147
List 5 causes of Completely Irregular (Chaotic) Rhythms
Atrial fibrillation
Atrial tachycardia or flutter with varying conduction
Multifocal atrial tachycardia
Multiple extrasystoles
Wandering pacemaker (usually atrial)
Parasystole
148
What is pathology is suggestive in Afib RVR with HR >200?
Accessory pathway
ex) WPW
149
List 10 Causes of Atrial Fibrillation
Hypertensive heart disease
Cardiomyopathy
Ischemic heart disease
Valvular disease (especially mitral)
Congestive heart failure
Pericarditis
Hyperthyroidism
Sick sinus syndrome
Myocardial contusion
Acute ethanol intoxication (holiday heart syndrome)
Idiopathic
Cardiac surgery
Catecholamine excess
Pulmonary embolism
Sepsis
Cardiac tamponade
Accessory pathway (Wolff-Parkinson-White) syndrome
150
In Afib, who can be electrically cardioverted?
New onset <48h
Afib pts on therapeutic AC
DO NOT shock Afib >48h with NO AC
= inc embolization risk
151
List 5 pharmacologic options for conversion of Afib/Flutter
1) Procainamide 30-50 mg/min IV
- up to a total dose of 18–20 mg/kg
- or 12 mg/kg in pts w/ CHF
OR
2) Amiodarone 150mg IV over 10-15 mins
- followed by 22 or 44mg/hr IV infusion
OR
3) Ibutilide 0.02 mg/kg IV, over 10–15 min
- conversion usually w/in 20 min
OR
4) Propafenone 600 mg PO
- contraindicated in structural heart disease or ischemia
OR
5) Flecainide 300mg PO
- contraindicated in structural heart disease or ischemia
152
List 8 risk factors for developing Afib
Advancing age
Male sex
HTN
HFrEF
Valvular heart disease
Overt thyroid disease
OSA
Obesity
Excessive alcohol
Congenital heart disease (ex early repair of ASD)
153
Outline CHADS2-65 algorithm for choosing oral AC in Afib
154
Outline CHA2DS2-VASc score for choosing oral AC in Afib
CHF - 1
HTN - 1
Age equal or >75 - 2
DM - 1
Stroke - 2
Vascular dz (MI, PAD, aortic plaque) - 1
Age 65-74 - 1
Sex female - 1
Score 0 = no AC
Score 1 = OAC considered
Score 2+ = OAC recommended
155
Outline HAS-BLED score for Afib pts taking AC
* 1-Year risk of major bleeding
* Score =/>3 is HIGH RISK
HYPERTENSION =1
- uncontrolled, SBP >160
ABNORMAL Renal & Liver Fnc = 1 each
- Dialysis, transplant, Cr >200
- Cirrhosis
- Bili >2x normal
- AST/ALT/ALP >3x normal
STROKE = 1
- any hx
BLEEDING = 1
- hx major bleed or predisposition to bleed
LABILE INR = 1
- unstable or high INR
ELDERLY = 1
- age >65yr
DRINKS & DRUGS = 1 each
- >8 drinks/wk
- bleeding meds (anti-PLT, NSAIDs)
156
When considering electrical cardioversion in AFib, when is it safe?
157
List 3 classic EKG features of WPW
(at rest)
Short PR <120ms
QRS >100ms
Slurred upstroke on QRS "Delta Wave"
158
Diagnosis?
WPW
159
List 5 Diseases Associated With Wolff-Parkinson-White Syndrome
Idiopathic
Cardiomyopathy (especially hypertrophic)
Transposition of great vessels
Endocardial fibroelastosis
Mitral valve prolapse
Tricuspid atresia
Ebstein disease (low TV)
160
List 1 difference between orthodromic and antidromic accessory pathways
Orthodromic "normal anterograde"
= narrow QRS, not as fast
Antidromic
= wide QRS, rates up to 220
* NO NODAL BLOCKING AGENTS, as risk VFib
- procainamide safe
161
List the 4 Brugada Criteria for diagnosing Vtach vs SVT w/ aberrancy
*Any YES, equals VT
1) Absence of any RS complexes in the precordial leads?
2) RS duration greater than 100 msec in one precoredial lead?
(2.5 lil boxes measured from beginning of R to deepest part of S wave)
3) AV dissociation?
(best seen in inferior leads & V1-2)
4) Specific VT morphologic criteria in both V1-2 and V6?
162
Define non-sustained VTach
short episode <30s
163
List 3 meds for cardioversion of VTach
1st Line:
Amiodarone 150-300mg IV over 20min
2nd Line:
Procainamide 30-50mg/min IV, up to 18mg/kg
3rd Line:
Lidocaine 1.0-1.5mg/kg IV, up to 3mg/kg, then infusion
164
List 3 clinical criteria for Torsades de Pointes
1) Ventricular rate >200 bpm
2 Undulating QRS axis, with polarity of complexes appearing to shift about baseline
3) Paroxysms <90sec
165
List 15 Acquired Causes of Prolonged QT Syndromes That Produce Torsades de Pointes
Pause-Dependent (Acquired):
- Class IA dysrhythmics
- Class IC dysrhythmics
- Haloperidol
- TCAs
- Macrolides
- Organophospahtes
- Antihistamines
- Antifungals
- Antiepileptics
- Antiemetics
- HypoK
- HypoMg
- HypoCa
- Starvation
- Low protein
- Severe bradycardia or AVB
- Hypothyroidism
- Contrast injection
- CVA
- Myocardial ischemia
Adrenergic-Dependent (Tachycardia-Prompted):
- SAH
- Radical neck dissection
- Carotid endarterectomy
- Truncal vagotomy
166
List 4 Congenital Causes of Prolonged QT Syndromes That Produce Torsades de Pointes
Adrenergic-Dependent (Tachycardia-Prompted):
- Mitral Valve Prolapse
- Sporadic
- Romano-Ward syndrome
- Jervell and Lange-Nielsen syndrome
167
List 4 ways to treat and prevent acquired TdP
1) MgSO4 1-2g IV bolus
2) Isoproterenol (beta adrenergic stim)
3) Overdrive pacing to 100-120bpm
4) Electrical cardioversion
168
What is Brugada Syndrome?
Ventricular dysrhythmia triggering syncope or sudden cardiac death, in absence of structural heart disease
Inherited disorder of sodium channels
169
Describe appearance of Brugada EKG pattern
Downward Coved
or Humped Saddleback
STE in V1-3
Can look like RBBB
Increased PR or QRS intervals
Transient or elicited with exertion
170
Define aortic dissection
tear of intimal layer of aortic wall
171
Outline Stanford classification of aortic dissections
Type A = ascending aorta with or without descending involvement
Type B = descending aorta commencing distal to the left subclavian artery
172
List 10 risk factors for aortic dissection
- HTN
- Cardiac sx
- AVR
- Aortic aneurysm
- previous aortic dissection
- Marfan syndrome
- atherosclerosis
- fam hx of thoracic aortic dz +/- genetic dz
- bicuspid AV
- coarctation of aortia
- bovine type aortic arch
- syphilis
- crack/cocaine use
- weight lifting
- peripartum period
- deceleration trauma
- Turner syndrome
- Ehlers Danlos type 4
- fluoroquinolone use
173
List s/s of aortic dissection, other than pain
- syncope
- dyspnea
- CVA
- spinal cord compromise
- asymmetric pulse deficits
- dysrhythmia
- pericardial tamponade
174
Outline Aortic Dissection Detection risk score
High Risk Conditions:
- Marfan
- FamHx of aortic dz
- Known AV dz
- REcent aortic manipulation
- Known TAA
High-Risk Pain Features:
chest, back, or abdo pain
- abrupt onset
- severe intensity
- ripping or tearing
High-Risk Exam Features:
- pulse deficit
- SBP differential
- Focal neuro deficit (w pain)
- AI murmur (new w pain)
- hTN or Shock
Score of 1+ = 95% sensitivity
175
List DDx for Aortic Dissection
MI
PE
CVA
Mesenteric ischemia
Renal artery aneurysm
Lumbar spinal disc dz
176
List 4 diagnostic imaging tests for aortic dissection
CTA
Conventional angiography
MRA
TEE
177
List medications and dosing for minimizing aortic dissection extension
Esmolol 0.5mg/kg over 1 min, then 50 mcg/kg/min IV inf
*max 300mcg/kg/min
- need bolus of 0.5mg/kg IV with each dose increase
Labetalol 10-20 mg IV q10min
*or 0.5-2mg/min IV inf
Metoprolol 2.5-5mg IV q5min
Nitroprusside 0.25-0.5mcg/kg/min IV inf
*max 10mcg/kg/min
Enalaprilat 1.25mg IV over 5 min
*repeat up to 5mg over 6hr
Diltiazem 10-20mg IV x1
then 5mg/hr IV inf
*max 15mg/hr
Veramapil 5mg IV over 5min
then 5-10mg IV q15min
178
List 2 vasopressors to use in aortic dissection
Norepinephrine
Phenylephrine
179
What are HR, MAP and BP goals in aortic dissection?
HR <60bpm
SBP 100-120
180
If pt with aortic dissection goes hypotensive, and found to have tamponade, how should this be evacuated?
Insert catheter under US guidance
Remove 5-10cc at a time
Goal SBP 80-90
181
List 4 clinical features of cardiac tamponade
(1 + Beck's triad)
Dyspnea
+
1) Distended neck veins
2) Hypotension
3) Muffled heart sounds
182
List 5 clinical s/s of dilated cardiomyopathy
Dyspnea (exertion or supine)
Chest pain
Peripheral edema
Dysrhythmias
Syncope
Sudden death
183
List 10 causes of dilated cardiomyopathy
- Ischemic heart disease/CAD
- Alcohol
- Cocaine
- Methamphetamines
- Chemotherapy
- Hemochromatosis
- Pseudoephedrine
- Ephedra
- Phenothiazines
- Lithium
- Anabolic steroids
- Clozapine
- Hydroxychloroquine
184
List 6 tx for a dilated cardiomyopathies
- diuretics (lasix)
- vasodilators (nitroglycerine)
- ACEi/ARBs
- BBs
- Biventricular pacing
- ICD
185
List 8 clinical s/s of HOCM
SOBOE
Orthopnea
Peripheral edema
Syncope
Chest pain
Palpitations
Afib
VTach
Sudden death
186
List 3 physical exam findings in HOCM
- Displaced Lt precordial impulse
- Strong peripheral pulses
- Harsh midsystolic grade 3-4 murmur btwn LLSB & apex
187
List 5 DDx for HOCM
Valvular disease
VSD
MV prolapse
PulmHTN
CAD
188
List 8 common EKG findings in HOCM
- Afib
- VTach
- LVH
- ST changes
- TWI
- Lt atrial enlargement
- Abnormal Q waves
- Diminished or Absent R waves in lateral leads
189
List 4 echo findings of HOCM
- asymmetrical LVH
- LVOT narrowing
- small LV cavity
- reduced septal motion
190
List tx for HOCM in ED
Afib
- Dilt or Esmolol
- Electrical cardioversion
- anticoagulate
- amiodarone
Hypotension
- IVF
- Phenylephrine
191
List 8 causes of Restrictive Cardiomyopathy
- Amyloidosis
- Sarcoidosis
- Hemochromatosis
- Scleroderma
- Neoplastic cardiac infiltration
- Glycogen storage disorders
- Fabry disease
- Gaucher disease
- Mutations related to myocardial muscle proteins
192
List 7 clinical s/s of restrictive cardiomyopathy
Dyspnea
SOBOE
Pulmonary congestion
Elevated CVP
Peripheral edema
Pulmonary edema
S3 + S4 gallops
193
List 6 risk factors for peripartum cardiomyopathy
African ancestry
Preeclampsia
Advanced maternal age
Tocolytic use
Twins
Obesity
Cocaine use
194
List 6 DDx for peripartum cardiomyopathy
Preeclampisa
MI
Coronary artery dissection
PE
PNA
Dysrhythmia
195
List safe afterload reduction meds in pregnancy
Hydralazine
Labetalol
196
List 20 causes of Takotsubo Syndrome
Achalasia
Addison disease
Anaphylaxis
Anesthesia
Asthma
Chemotherapy
Closed head injury
Depression
Diarrhea
Diving
Emotional stress
Foley catheter insertion
Hanging
Hypoglycemia
Inferior vena cava clot
Lightning strike
Multiple trauma
Myocardial infarction (MI)
Near drowning
Opioid withdrawal
Pancreatitis
Pheochromocytoma
Pneumopericardium
Pregnancy
Scorpion envenomation
Seizures
Sepsis
Sexual intercourse
Stress testing
Subarachnoid hemorrhage
Surgery or medical procedures
Thrombotic thrombocytopenic purpura
Thyrotoxicosis
Transient ischemic attack
Tricyclic overdose
Vomiting
197
List 5 risk factors for Takotsubo syndrome
Female
Age >60
Emotional stress
Smoking
Alcohol abuse
Anxiety
Hyperlipidemia
198
List vasopressor of choice in Takotsubo syndrome
Phenylephrine
199
Outline pathologic finding in Arrhythmogenic Right Ventricular Cardiomyopathy
- Genetic disorder
- Fibrofatty replacement of myocardium
- Diffuse myocardial atrophy (in RV most)
- Get ventricular dysrhythmias then systolic dysfnc
200
Name hallmark EKG finding in ARVC/ARVD
(Arrhythmogenic Right Ventricular Cardiomyopathy)
Epsilon waves
- Small deflection (“blip” or “wiggle”) buried in end of QRS complex
- Best seen in V1-V2
- Caused by post-excitation of myocytes in the right ventricle
201
List 3 cardiac channelopathies
Long QT syndrome
Short QT syndrome
Brugada syndrome
202
List 20 Infectious Causes of Myocarditis
Adenovirus
Chagas disease
Chlamydia
Coxsackie B virus
Cytomegalovirus
Epstein-Barr virus
H1N1 virus
Hepatitis A
Hepatitis B
Hepatitis C
Human herpesvirus 6
Influenza A
Influenza B
Legionella
Lymphocytic choriomeningitis virus
Mononucleosis
Mumps
Mycoplasma
Parainfluenza
Parvovirus 19
Rabies
Rubeola
Rubella
SARS-COV-2
Streptococcus
Toxoplasma gondii
Varicella zoster
203
List 3 stages of myocarditis
1) ACUTE
- cytotoxicity and focal necrosis
2) SUBACUTE
- increase in humoral factors leading to autoimmune injury
3) CHRONIC
- diffuse myocardial fibrosis and cardiac dysfunction may lead to DCM
204
List 4 complications of myocarditis
- Ventricular dysrhythmias
- Lt ventricular aneurysm
- CHF
- DCM
205
List problem pathogen in Chagas disease
Protozoan by insect vector
Trypanosoma cruzi
206
List 4 non-cardiac findings of Chagas disease
Fever
Hepatic enlargement
Splenic enlargement
Unilateral periorbital edema
207
List 5 cardiac findings of Chagas disease
- angina-like chest pain
- dysrhythmias
- embolic episodes
- heart failure
- conduction abnormalities
- multifocal PVCs
- syncope
208
List 5 EKG findings in Chagas disease
VTach
STE
TWI
Increased PR
Increased QRS
209
List treatment for Chagas disease based on age
2-12yrs:
Benznidazole 5 mg/kg/day divided q12h x60d
12-17yrs:
Nifurtimox 15 mg/kg/day divided TID or QID
18yrs+:
Nifurtimox 10 mg/kg/day divided TID or QID
210
List 5 cardiac causes of sudden death (young & old ppl)
- Myocarditis
- Congenital abnormalities
- HOCM
- Channelopathies
- Anomalous coronary artery circulation
- CAD
211
List 15 causes of pericarditis
Infectious:
- Bacterial
- TB
- Fungal
- Parasite
- Viral
Post-Injury:
- Blunt trauma
- Penetrating trauma
- Medication
- MI
- Radiation
- Surgery
- Iatrogenic after procedure like PPM/ICD placement
Systemic diseases:
- Amyloidosis
- Sarcoidosis
- Metastatic tumour
- RA
- Scleroderma
- SLE
- Sjogren syndrome
- GCA
- Ankylosing spondylitis
- Behcet's disease
- Polyarteritis
- Uremia
Primary tumours
Aortic dissection
212
List features of pericarditis chest pain
Sharp
Pleuritic
Waxes/wanes
Varies with position
Retrosternal
213
List DDx for Pericarditis
MI
PNA
GERD
PE
214
List 4 diagnostic features of pericarditis
Chest pain
Pericardial rub
STE on EKG
New pericardial effusion
*Not all mandatory
215
List EKG stages of pericarditis
1) Diffuse STE (concave) and reciprocal STD
- +/- PR depression
2) ST and PR normalizes, T wave flattening
3) Deep TWI
4) Normal EKG, +/- persistent TWI
216
Diagnosis?
Pericarditis
217
List treatment options w/ doses for Pericarditis
First Line (choose one):
- Ibuprofen 600mg PO QID x10d
- Indomethacin 25mg PO TID x10d
- ASA 650mg PO TID x10d
Second Line:
- If above not improving in 7d, try
Naproxen 250mg PO BID x7d more
- If cannot take NSAIDs, try
Prednisone 0.2-0.5mg/kg/day PO x5d
May Add:
- Colchicine x3-6mos
- 0.5-0.6mg/kg PO BID if >70kg
- 0.5-0.6mg/kg PO OD if <70kg
218
List indications for admission with pericarditis
- hemodynamic instability
- dx uncertainty with ACS
- Temp >38
- Large effusion
- Failure of first round tx
219
List one most common cause of cardiac tamponade
Uremic pericarditis
220
List treatments for Uremic Pericarditis
- Intensive dialysis
- Indomethacin 25 mg PO TID
- May need drainage
- Prednisone 50mg PO OD
- Intra-pericaridal inj of steroids
221
List 6 clinical features of early post-MI pericarditis
- 2-4 days after MI
- Low grade fever
- Transient friction rub
- More dysrhythmias & HF
- Indicator of greater myocardial damage & worse outcome
- Txd with ASA
222
List 8 clinical features of delayed post-MI pericarditis (Dresslers)
- 2-8 weeks after MI
- Fever
- Pleuritis
- Leukocytosis
- Friction rub
- New pericardial or pleural effusion on CXR
- Increased risk of hemorrhage (while on AC)
- Txd with Ibuprofen 600 mg QID or Indomethacin 25 mg TID
223
List 2 medical problems other than post-MI that can get Dressler syndrome
PE
Post-pericardiotomy
224
List 2 cancers in which post-radiation pericarditis can occur
Breast Ca
Lymphoma
225
List 5 specific infectious causes of pericarditis
- Rickettsia conorii (Mediterranean spotted fever)
- Mycoplasma pneumoniae
- Nocardia asteroides
- Chlamydia trachomatis
- Epstein-Barr virus
- CMV
- Haemophilus actinomycetemcomitans
- Coccidioidomycosis
- Tuberculosis
226
List 6 most common causes of pericardial effusion
- viral pericarditis
- idiopathic pericarditis
- malignancy
- uremia
- trauma
- radiation therapy
227
List 4 mechanisms that produce purulent pericarditis
1) spread from adjacent infxn (PNA, empyema)
2) hematogenous spread
3) direct inoculation (trauma, surgery)
4) spread from intra-cardiac source
228
List 3 causes of purulent pericarditis
Streptococcus sp
Staphylococcus sp
Candida sp
229
List 6 clinical s/s of constrictive pericarditis
- Rt sided HF
- Dyspnea
- Fatigue
- Weight gain
- Hempatomegaly
- Marked pitting LE edema
- Pericardial knock in early diastole
- Low voltage EKG
- Atrial dysrhythmias
230
Outline 3 stages necessary for cardiac tamponade to develop
1) fluid filling the recesses of parietal pericardium
2) fluid accumulating faster than rate of parietal pericardium’s ability to stretch
3) fluid accumulation that exceeds body’s ability to increase blood volume to support RV filling pressure
231
List 7 causes of cardiac tamponade
- penetrating trauma
- malignancy
- infection
- idiopathic
- iatrogenic
- post acute-MI (like cardiac wall rupture)
- uremic
232
List 8 DDx for cardiac tamponade
Small pericardial effusion
MI
Pericarditis
Cardiomegaly
Dilated CMP
Jugular venous distension
SVC syndrome
HF
233
Diagnosis?
Electrical alternans = Cardiac tamponade
234
List 5 causes of Pneumopericardium
- Pericardial-pleural fistula
- Upper GI- pericardial fistula
- Bronchial carcinoma
- Idiopathic
- Asthma
- Labour
- Barotrauma from PPV
- Valsalva
- Weightlifting
235
What is CONTRAINDICATED in aortic insufficiency
Intra-aortic balloon pump
236
List 5 predictors of poor outcomes in infective endocarditis
Older age
Co-morbidities
S. aureus infxn
HF
Perivalvular extension
237
List 7 High-Risk Populations & Predisposing Conditions for Infectious Endocarditis
Prior history of endocarditis
Congenital heart disease (cyanotic lesions mostly)
IVDU
Prosthetic heart valve
Intracardiac device (PPM, ICD)
Hemodialysis
Recent hospitalization with central or long-term intravenous access
Nursing home residents
Rheumatic valvular disease
238
List 10 common pathogens causing IE
- MSSA
- MRSA
- Streptococcus viridans
- Streptococcus bovis
- Enterococcus faecalis
- HACEK gram negatives
- Coxiella burnetii
- Brucella sp
- Bartonella sp
- Candida sp
- Aspergillus sp
239
List the 5 fastidious gram-negatives that can cause IE
= HACEK
- Haemophilus spp
- Aggregatibacter actinomycetemcomitans
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella kingae
240
Outline Duke diagnostic criteria for "definite endocarditis"
2 Major
or
1 Major + 3 Minor
or
5 Minor
241
Outline Duke diagnostic criteria for "possible endocarditis"
1 Major + 1-2 Minor
or
3 Minor
242
List MAJOR Duke criteria for IE
1) Positive BCx
= 2 sets (+) with typical pathogens:
- Staphylococcus aureus
- Viridans streptococci species of Streptococcus bovis
- Enterococcus species
- HACEK group
OR
= Persistent (+) BCx with typical organism for IE
OR
= 1x BCx (+) or Serology (+) for Coxielli burnetii
2) Echo evidence of Endocardial Involvement
- Pendulum-like vegetation on valve endocardium
- Paravalvular abscess
- Prosthetic valve dehiscence
- New valvular regurgitation
243
List MINOR Duke criteria for IE
1) Predisposition
= predisposing heart condition or IVDU
2) Fever >38°C
3) Vascular phenomena
- arterial emboli
- septic pulmonary infarcts
- mycotic aneurysm
- conjunctival hemorrhages
- Janeway lesions
4) Immunologic phenomena
- glomerulonephritis
- Osler’s nodes
- Roth’s spots
- (+) Rheumatoid Factor
5) Microbiologic evidence
= (+) BCx not meeting Major Criteria
6) Echo findings
= consistent w/ IE but do not meet Major Criteria
244
List most common presenting symptom of IE
Fever
245
List 6 clinical syndromes of IE
Mild and nonspecific febrile illness
Acute heart failure
Focal neurological deficit from septic cerebral embolus
Altered mental status
Axial spine pain from osteomyelitis
Pneumonia from septic pulmonary emboli
246
List 8 clinical findings of IE
Heart murmur
Splinter hemorrhages
Cardiac device pocket inflammation
Janeway lesions, Osler’s nodes
Roth spots
Splenomegaly
Anemia
Glomerulonephritis
247
List 6 Indications for Surgical Treatment for Infective Endocarditis
Aortic or Mitral insufficiency w/ Ventricular Failure
Valve perforation or rupture
Perivalvular extension, abscess, fistula, or associated heart block
Prosthetic valve dehiscence
>10mm vegetation on anterior mitral leaflet
Recurrent embolization or persistent bacteremia on therapy
248
List initial IV ABX tx for possible IE
Vancomycin 20-35 mg/kg IV loading dose,
then 15-20 mg/kg IV q8-12h
CTX 2g IV q24h
249
List 3 types of pts that would need ppx abx for IE, before undergoing the procedure (like dental work)
- Prior IE
- Congenital heart disease
- Presence of prosthetic valve
250
Which valve is most commonly affected by rheumatic fever?
Mitral valve
- causes MV regurgitation
251
Outline MAJOR and MINOR Jones Criteria for Diagnosis of Acute Rheumatic Fever,
& how many of each do you need for Dx?
Strep Infxn
PLUS
2 Major
or
1 Major + 2 Minor
MAJOR:
"JONES"
- Joints = Polyarthritis
- O = <3 = Carditis
- Nodules, subcutaneous
- Erythema marginatum
- Syndenham chorea
MINOR:
- Fever
- Arthralgias
- Elevated ESR
- Elevated CRP
- Prolonged PR
Evidence of Preceding Streptococcal Infection:
- (+) Throat Cx for Group A beta-hemolytic Streptococci
OR
- (+) rapid streptococcal antigen test
OR
- Elevated or rising Streptococcal antibody titer (antistreptolysin O)
252
List 3 causes of mitral stenosis
Rheumatic heart disease
Mitral annular calcification
Congenital
253
List most common complication of mitral stenosis
Afib
254
What are 2 mgmt steps in acute presentation of mitral stenosis?
Likely vascular congestion (pulmonary edema)
- diuretics
Likely Afib
- rate control
255
List 5 causes of PRIMARY mitral regurgitation
- Degenerative disease
- Rheumatic heart disease
- IE
- MV prolapse in CTD
- Acute papillary muscle rupture
256
List 2 causes of SECONDARY mitral regurgitation
- LVH
- Cardiomyopathies
257
List presenting s/s of acute mitral regurgitation
* True cardiac emergency
- severe dyspnea
- acute pulmonary edema on CXR
- cardiogenic shock
- harsh, high pitched midsystolic murmur
- MR jet on echo
258
Outline stabilization tx for acute MR
- IV nitrates, diuretics and NIPPV for pulmonary edema
- NE +/- Dobutamine for hTN and cardiogenic shock
- +/- IABP if persistently hTN
259
List 2 disorders that may have associated MV prolapse
Marfan
Ehlers-Danlos
* any CTD
260
List 3 causes of aortic stenosis
Bicuspid valve
Rheumatic heart disease
Calcific degeneration
261
List 3 mgmt/tx steps for decompensated aortic stenosis
- judicious IVF resuscitation
- rate control/restore sinus rhythm
- phenylephrine is 1st line vasopressor
262
List 5 processes/disorders that affect the aortic root
- Idiopathic root dilation (Ectasia)
- CTD
- Syphilis
- Aortic aneurysm
- Aortic dissection
263
List 4 causes of aortic valve leaflet abnormalities, that can lead to AR
- calcific degeneration
- congenital bicuspid valve
- infectious endocarditis
- RHD
264
List 2 major complications of acute aortic regurgitation
Severe respiratory distress
Cardiogenic shock
265
List 10 causes of Wide Pulse Pressure
- Advanced Age
- Pregnancy
- Well‐Conditioned Athletes
- Atherosclerosis
- CHRONIC Aortic Regurgitation
- Arteriovenous Fistula
- Wet Beriberi (thiamine deficiency)
- Distributive Shock
- Elevated Intracranial Pressure
- Hyperthyroidism/Thyrotoxicosis
266
List 7 classic physical exam findings of chronic aortic regurgitation
- wide pulse pressure
- high pitched, blowing, DIASTOLIC murmur @ LLSB
- Austin-Flint murmur
- water hammer/Corrigan's pulse
- head-bobbing/Musset's sign
- nail bed pulsations/Quincke's sign
- femoral artery bruit/Duroziez's sign
267
List 2 medical stabilization tx's for acute aortic regurgitation
- Short acting vasodilators (nitroprusside, nicardipine)
- Diuretics
268
List 5 causes of Prosthetic Valve Complications
Structural failure
Valve thrombosis
Systemic embolization
Hemolysis
Endocarditis
269
List 2 mgmt options for prosthetic valve thromboses
Fibrinolytic therapy
Surgery
270
List 3 IV ABX for tx of prosthetic valve endocarditis
Vancomycin
PLUS Gentamycin +Rifampin for definitive therapy in Staphylococcal PVE
271
Name most useful diagnostic test for identifying lung congestion due to acute heart failure
8-point lung ultrasound B-line scan
* more sensitive than CXR, higher PPV than BNP
272
Compare & Contrast Vascular and Cardiac phenotypes of acute heart failure
Vascular
- functional CV issue
- "reversible"
- increased vascular tone and fluid shifts
- abrupt onset
- likely HTN
- less likely hypervolemic
- good response to IV nitroglycerin
- better outcomes
Cardiac
- structural CV issue
- "irreversible"
- myocardial dz, ischemia, and multiorgan interactions (CRS)
- indolent progression
- likely hypervolemic
- response to IV diuretics
- worse outcomes
273
Name first line approach for respiratory distress in acute HF
NIPPV
274
List 3 main components of the clinical syndrome of heart failure
1) Structural or Functional CV abnormalities
2) Elevated intracardiac pressures or Depressed CO 2/2 abnormalities
3) Resultant S/S 2/2 above
- dyspnea, edema, fatigue, exertional intolerance, etc
275
List 3 most common presenting signs/symptoms of acute HF in the ED (in order)
1. Dyspnea
2. Edema/swelling
3. Fatigue
276
Name the primary issue in systolic and diastolic dysfunction, in regards to HF
Systolic Dysfunction
= Decreased Inotropy
Diastolic Dysfunction
= Impaired Relaxation
277
List risk factors for heart failure
Advancing age
Obesity
HTN
DM
Smoking
DLD
Low SES
Ischemic heart disease
278
Outline 2 equations for Cardiac Output
CO = HR x SV
CO = HR x EDV X EF
= (chronotropy x lusitropy x inotropy)
279
List Common and Important DDx for Acute HF
PNA
COPDe
Asthma Exacerbation
ACS
Unstable tachy- or brady-arrhythmia
ARDS
Aspiration pneumonitis
Severe anemia (w/ exertional dyspnea & fatigue)
Acute renal failure w/ fluid overload (CRS type 3)
Severe metabolic acidosis (presenting as resp distress)
Acute Toxidrome (presenting as respiratory distress)
Noncardiac Peripheral Edema
Cirrhosis
Peripheral Venous Insufficiency
Nephrotic Syndrome
PE
PTX
COVID-19
280
List 3 findings on CXR consistent with acute HF
Pulmonary edema
Cephalization
Kerley B lines
281
List 8 common causes of elevated BNP that are not acute HF
PE
COPD
PNA
CKD
HTN
PulmHTN
AFib
Advanced age
282
List stabilization meds in vascular-type acute HF, when SBP >140
1) Nitroglycerin 0.4mg SL x1-5 doses
If SBP >160-180:
2) Nitroglycerin 1-2mg IV push q3-5min (up to 10x)
3) Nitroglycerin 0.3-0.5mcg/kg/min IV infusion
+/- Enalaprilat IV boluses
+/- IV Diuretics
283
List stabilization meds in cardiac-type acute HF, with cardiogenic shock, and when SBP <90
1) NE infusion
2) 250-500cc IV boluses
3) Consider 2nd line agent:
- Dobutamine
- Epinephrine
- Milrinone
+/- Mechanical support
284
List stabilization meds in cardiac-type acute HF, when SBP 90-140
IV Diuretics!
1) Furosemide 40-240mg IV with repeats prn
2) Metolazone 2.5-5mg PO
3) Acetazolamide 250-500mg PO
4) Chlorothiazide 0.5-1g IV
285
List 5 low risk factors for pts with acute HF who could likely be d/c'd home after tx
- SBP >160 w/out HTN emergency
- Few co-morbidities
- Normal troponin
- Renal and hepatic fnc unchanged from baseline
- High diuretic efficiency in ED
286
List 11 Class I Indications for Permanent Pacing in Adults
1. Symptoms 2/2 to SA node dysfunction
2. Symptomatic SA node dysfnc or AVB 2/2 GDMT w/ no alternative tx available and must continue
3. Permanent AFib + Symptomatic bradycardia
4. Symptomatic AVB 2/2 known reversible cause (Lyme disease or drug toxicity) w/out resolution despite appropriate tx of underlying cause
5. Acquired 2' AVB Mobitz type II, High-grade AVB, or 3' AVB not 2/2 reversible or physiologic causes, regardless of symptoms
6. Neuromuscular dz w/ conduction d/o (muscular dystrophy, Kearns-Sayre syndrome, etc.) w/ evidence 2' or 3' AVB, regardless of symptoms, w/ survival >1yr
7. Syncope + BBB w/ HV interval >70 ms or Infra-nodal block
8. Alternating bundle branch block
9. Post-Op SA node dysfnc or AVB w/ persistent symptoms or hemodynamic instability, after CABG, sx for AFib, Valvular sx or replacement
10. Adult congenital heart dz + Symptomatic SA node dysfnc, chronotropic incompetence, symptomatic brady from AVB, mean daytime HR <50 bpm, complex ventricular ectopy, or ventricular dysfunction
11. 2' AVB Mobitz type 2, High-grade AVB, 3' AVB, or Alternating BBB after MI (following waiting period)
287
What is EF cutoff for recommendation of a CRT-D in HF pts?
Strongly recommend CRT for systolic HF w/ LVEF <35% + LBBB
288
Outline the 5 Letter Pacemaker Code
289
List 3 common pacemaker settings
VVI
DDD
DVI
290
List 6 risk factors for pacemaker infection
- CKD
- COPD
- Chronic steroid use
- DM
- Malignancy
- Advanced age
291
List 2+ abx options for pacemaker site infection
To cover Staph:
Vanco IV
OR Daptomycin IV
If risk of Pseudomonas or hemodynamic instability:
ADD PipTazo
OR Cefepime
292
List 3 complications of PPM and ICD implantations
Site infection
Venous thrombosis
Venous stenosis
293
List 9 complications of existing pacemakers
- Pacemaker Syndrome
- Coronary sinus perforation
- Coronary sinus dissection
- Cardiac tamponade
- Failure to Capture
- Undersensing
- Oversensing
- Battery failure
- Runaway pacemaker
294
Describe "pacemaker syndrome"
After single-chamber PPM implantation, pt develops symptoms of HF
- result of AV and VV dyssynchrony w/ increases in JV and PV pressures
295
List 3 general PPM malfunctions
Failure to capture
Failure to sense
Failure to pace
296
List 10 causes of PPM malfunction
Failure to Capture:
- Lead disconnection, break, or displacement
- Exit block
- Battery depletion
Undersensing:
- Lead displacement
- Lead fracture
- Inadequate endocardial lead contact
- Low-voltage intracardiac P waves and QRS complexes
Oversensing:
- Sensing extracardiac signals: myopotentials
- T wave sensing
Inappropriate Rate:
- Battery depletion
- Ventriculoatrial conduction with Pacemaker-Mediated Tachycardia
- 1:1 response to Atrial Dysrhythmias
297
List 2 EKG findings consistent with PPM failure to capture
- Complete absence of pacemaker spikes
- Spikes not followed by stimulus induced complex
298
Define exit block
failure of an adequate stimulus to depolarize the paced chamber
299
List 4 causes of exit block, via changes in endocardium in contact with pacing lead
- ischemia
- infarction
- hyperK
- use of class III anti-arrhythmics that affect ventricular depol (amiodarone)
300
Define under-sensing
Failure of PPM to sense the heart's intrinsic or native electrical activity
- appearance of pacer spikes occurring earlier in the cardiac cycle than expected, with or without a paced complex afterwards
301
Define over-sensing
PPM detects electrical activity not associated with appropriate cardiac contraction
- may be sensing myopotentials or T waves as P waves
302
Describe runaway pacemaker
"Endless loop tachycardia" can result
- can get ventricular to atrial conduction, and retrograde atrial depolarization
- which then conducts down to ventricular depolarization
- can get things like Aflutter, waves get sensed and create further "tachycardia loop"
- PPM will still not go higher than the set upper limit
Need magnet to convert PPM to fixed rate and terminates tachyarrhythmia
303
List 6 Class I Indications for ICD Therapy
1. Ischemic heart disease + sudden cardiac arrest 2/2 VF or VT or stable sustained VT, not caused by transient or reversible event & meaningful survival expected > 1yr
2. Ischemic heart disease + unexplained syncope that has induced sustained monomorphic VT during EP study & meaningful survival expected > 1yr
3. Depressed LV fnc >40 days post-MI + >90 days post-revascularization + persistent HF symptoms if meaningful survival expected > 1yr
4. Nonsustained VT 2/2 prior MI w/ depressed Lt-sided systolic function + inducible VT or VF during EP study if meaningful survival expected > 1yr
5. Non-ischemic cardiomyopathy + depressed LV function if meaningful survival expected > 1yr
6. Sudden cardiac arrest or sustained ventricular arrhythmias from:
- NICM
- ARVD
- HOCM
- Cardiac Sarcoidosis
- Neuromuscular d/o's
- Cardiac Channelopathies
- High-risk patients w/ symptomatic Long QT syndrome failing BB tx
- Catecholaminergic polymorphic VTach failing BB tx
- Brugada syndrome
- Early repolarization
- Short QT syndrome
- Idiopathic polymorphic VTach
- Congenital heart disease
304
Describe Anti-Tachycardia Pacing (ATP)
A feature of ICD-PPM that delivers brief paced rhythm at a very high rate that interrupts the VT reentrant circuit and restores NSR
305
List 3 Presenting Symptoms of ICD Malfunction
1) Increase or abrupt change in shock frequency
- Increased frequency of VF or VT (ischemia, electrolyte disorder, drug effect)
- Displacement or break in ventricular lead
- Recurrent nonsustained VT
- Sensing + shock of SVTs
- Oversensing T waves
- Sensing non-cardiac signals
2) Syncope, near-syncope, dizziness
- Recurrent VT w/ low shock strength (lead problem, change in defibrillation threshold)
- Hemodynamically significant SVTs
- Inadequate backup pacing for bradyarrhythmias (spontaneous or drug induced)
3) Cardiac arrest
- True ICD malfunction
- VF that failed to respond to programmed shock parameters
306
List 4 potential causes for a single ICD shock
- acute cardiac ischemia
- worsening of chronic CHF
- new-onset HF
- electrolyte abnormalities
307
If an ICD is delivering inappropriate shocks, what should you do?
Put a magnet on it to deactivate the defibrillation
308
When treating a pt with an ICD who is in cardiac arrest, where should transthoracic pads be placed?
Sternal electrode pad should be placed in parasternal location >10 cm from the ICD subcutaneous pouch
309
Describe how an IABP works
- Placed in descending aorta
- Inflates during diastole to augment diastolic filling pressure.
- Deflates during systole, and may decrease LV afterload and augment CO by 0.5-1L/min
310
List 1 complication of IABP
Thrombocytopenia
311
Describe LVAD placements
Supports CO via mechanical pump that draws blood from an inflow cannula in LV and pumps it into ascending aorta via an outflow cannula.
312
List 3 ways to measure BP in a pt with a nonpulsatile flow VAD
- manual BP cuff
- Doppler probe
- arterial cannulation
313
List complications of Mechanical Circulatory Support Devices
Thrombotic:
- pump thrombosis
- ischemic CVA
- limb ischemia
- intestinal ischemia
Bleeding:
- Hemolysis
- ICH
- GI bleeding
- epistaxis
- MSK hematomas
Infection:
- PNA
- UTI
- endocarditis
- SSTI
Mechanical
- preload (hypovolemia, hemorrhage, RV failure, dysrhythmia)
- pump (thrombosis, power source)
- afterload (sepsis)
314
Outline Common Intracorporeal VAD Alarms
315
Outline ER mgmt of a VAD patient presenting as stable or unstable
316
Define true HTN emergency
presence of acute target organ damage (TOD)
317
List 6 examples of hypertensive emergency
Ischemic stroke
Hemorrhagic stroke
MI
Acute HF
Aortic Dissection
Pre-eclampsia
318
Outline stages of HTN, as per the ACC/AHA 2017
Normal = SBP <120 AND DBP <80
Elevated BP = SBP 120-129 OR DBP <80
Stage I HTN = SBP 130-139 OR DBP 80-89
Stage II HTN = SBP > 140 OR DBP >90
319
What is the cut off for diagnosis of HTN?
>130/80
320
What is the best way to evaluate a pt for HTN?
Ambulatory BP measurement for 24hr
321
Define and outline mgmt for Hypertensive Emergency
= Evidence of acute target organ damage
- Tx with IV anti-HTN meds
322
Define and outline mgmt for Poorly Controlled Chronic HTN
= patients with established HTN are found to have elevated BP without specific attributable symptoms or evidence of acute TOD.
- Consider initiation/titration of chronic PO anti-HTN meds
- Refer to PCP
323
Define and outline mgmt for Elevated BP w/out Prior Hx of HTN
- No tx necessary
- Refer to PCP
324
List 15 Causes of Secondary HTN
VASCULAR:
- Artherosclerosis
- Coarctation of aorta
PULMONARY:
- OSA
RENAL:
- Chronic pyelonephritis
- Diabetic nephropathy
- Nephritic syndrome
- Nephrotic syndrome
- PCKD
- Renal artery stenosis
ENDOCRINE:
- Cushing's syndrome
- Hyperaldosteronism (unexplained hypoK)
- OCP use
- Pheochromocytoma
- Thyroid dz
- Parathyroid dz
TOXIC & METABOLIC:
- Chronic EtOH abuse
- Sympathomimetic drug use
- Tyramine-containing foods
325
List clinical clues for a dx of Renal Artery Stenosis
- HTN onset before the age of 30 years or after 55 years
- Abdominal bruit
- Refractory HTN control
- Recurrent pulmonary edema
- Unexplained renal failure
326
Outline RAAS and how it affects BP
1. Renin released by kidney in response to decreased renal perfusion and presence of Na in the distal tubule
2. Renin cleaves Angiotensin I from its precursor Angiotensinogen
3. Angiotensin I is converted to Angiotensin II by Angiotensin-Converting Enzyme (ACE)
4. Angiotensin II binds to Angiotensin II Type I Receptors (AT1R)
5. Results in:
- arterial vasoconstriction
- aldosterone release
- increased Na reabsorption
- increased sympathetic outflow
- release of ADH/vasopressin
327
List 10 HTN Emergencies
Heart
- Acute HF
- ACS
Brain
- Acute ischemic stroke
- Spontaneous ICH
- Hypertensive encephalopathy
Kidney
- Acute renal risk
- Acute kidney injury
Vascular
- Aortic dissection
Other
- Eclampsia
- Acute hypertensive retinopathy
328
List 8 clinical features of hypertensive encephalopathy
- markedly elevated BP
- diffuse vasogenic cerebral edema
- severe HA
- vomiting
- altered mental status
- seizures
- coma
- blurred vision
- papilledema
- retinopathy
- +/- small hemorrhages on CT
329
List 5 causes of PRES (posterior reversible encephalopathy syndrome)
HTN
Kidney dz
Malignancy
Cytotoxic therapy
Autoimmune dz
330
List 5 clinical features of PRES (posterior reversible encephalopathy syndrome)
"Posterior cerebral impairment"
- reversible by tx'ing underlying cause
- visual changes
- HA
- altered mental status
- seizures
- white matter edema in the posterior parietal-temporal-occipital regions on MRI brain
331
List 3 DDx for elevated BP in the ED
1) True hypertensive emergencies (acute heart failure, ischemic stroke, pre-eclampsia)
2) Elevated BP 2/2 pain, anxiety, transient physiological conditions, and medications
3) Inaccurate measurement
332
Outline equation for MAP
MAP = (CO × SVR) + CVP
SVR = afterload
CVP = preload
333
List Adrenergic Inhibitors used for IV tx of HTN, and their hemodynamic effects
Alpha-1 blockers:
- Phentolamine (inc CO, dec SVR, inc CVP)
Beta-1 blockers:
- Esmolol & Metoprolol (dec CO, +/- SVR & CVP)
Mixed A-1-B1 blockers:
- Labetalol (dec CO, dec SVP, +/- CVP)
334
List an ACEi used for IV tx of HTN, and its hemodynamic effects
Enalaprilat
(dec SVR, +/- CO & CVP)
335
List CCBs used for IV tx of HTN, and their hemodynamic effects
Dihydropyridine:
- Nicardipine (inc CO, dec SVR, +/- CVP)
Non-Dihydropyridine:
- Diltiazem & Veramapil (dec CO, dec SVR, +/- CVP)
336
List a Direct-acting vasodilator used for IV tx of HTN, and its hemodynamic effects
Hydralazine
(inc CO, dec SVR, +/- CVP)
337
List Nitric Oxide donors used for IV tx of HTN, and their hemodynamic effects
Sodium Nitroprusside & Nitroglycerin & ISDN
(inc CO, dec SVR, dec CVP)
338
Outline dosing of common IV anti-HTN meds:
- Phentolamine
- Esmolol
- Metoprolol
- Labetalol
- Enalaprilat
- Nicardipine
- Diltiazem
- Veramapil
- Hydralazine
- Furosemide
- Nitroprusside
- Nitroglycerin
Phentolamine
- Bolus 5–15mg IV q5min
- Inf 0.2–0.5 mg/min IV
Esmolol
- Bolus 500–1000 mcg/kg IV × 1
- Inf 50–300 mcg/kg/min IV
Metoprolol
- Bolus 5mg IV q5min
Labetalol
- Bolus 20-80mg IV q10min
- Inf 1-2 mg/min IV
Enalaprilat
- Bolus 0.625–1.25mg IV q15min
- Inf 1-2mg/hr IV
Nicardipine
- Inf 5-15 mg/hr IV
Diltiazem
- Bolus 0.25-0.35 mg/kg IV q15min
- Inf 5-15 mg/hr IV
Veramapil
- Bolus 2.5-5mg IV q15min
Hydralazine
- Bolus 5-20mg IV q30min
Furosemide
- Bolus 40-240mg IV q12h
- Inf 10-40 mg/hr IV
Nitroprusside
- Inf 0.25-10 mcg/kg/min IV
Nitroglycerin
- Bolus 1-2mg IV q5min
- Inf 5-200 mcg/min IV
339
Outline the general optimal tx and BP goals in HTN emergencies
In Hr 1 - max reduction of MAP by 20-25%
In Hrs 2-6 - goal BP 160/100
* to prevent acute changes in cerebral blood flow
340
Outline goals of tx in ACS as a hypertensive emergency, and what anti-HTN meds you would use
- Diminish cardiac workload
- Improve coronary artery perfusion
1. Nitroglycerin
2. Metoprolol, Labetalol
341
Outline goals of tx in Acute HF as a hypertensive emergency, and what anti-HTN meds you would use
- Diminish cardiac workload
- Reduce impedance to forward flow
1. Nitroglycerin, Furosemide
2. Enalaprilat
342
Outline goals of tx in Aortic Dissection as a hypertensive emergency, and what anti-HTN meds you would use
- Reduce shear force
- Reduce dP/dt (change in pressure/change in time)
1. Esmolol + Nitroprusside
2. Labetalol
Goal SBP <110, HR <60
*Avoid BBs if aortic regurg is present
343
Outline goals of tx in AKI as a hypertensive emergency, and what anti-HTN meds you would use
- Decrease pressure in renal parenchyma and glomerular apparatus
1. Nicardipine
2. Labetalol
344
Outline goals of tx in a Sympathetic Crisis as a hypertensive emergency, and what anti-HTN meds you would use
- Reduce Alpha-1 adrenergic receptor–mediated vasoconstriction
1. Phentolamine
2. Nitroglycerin
*Benzos first-line when sympathetic crisis 2/2 cocaine or amphetamines
*Beta-blocker monotherapy is relatively contraindicated
345
Which pts should avoid getting an NO (nitric oxide) donor med, like nitroglycerin or nitroprusside?
Pts who have taken a PDE5i (sildenafil or tadalafil) in the last 24-48hrs.
= profound hypotension
346
What toxicity risk comes with nitroprusside administration?
Cyanide toxicity
347
Outline approach to initiating anti-HTN meds in pts with chronic poorly controlled HTN
348
List triad of ruptured AAA
Abdo/back/flank pain
Hypotension
Pulsatile mass
349
Name diagnositc imaging test of choice for evaluating for suspected ruptured AAA in a stable pt
Abdominal CT scan
- IV contrast not essential in emergencies
350
Define false/pseudoaneurysm of the aorta
- collection of flowing blood that communicates with arterial lumen but not enclosed by normal vessel wall
- is contained only by adventitia or surrounding soft tissue
351
List 2 ways an aortic pseudoaneurysm can occur
1. defect in arterial wall
2. leaking anastomosis after AAA repair
352
Name most common area for an AAA
Infrarenal
353
What diameter of abdominal aorta defines AAA?
3cm or more
354
List 5 risk factors for AAA
1. Male
2. 65yr+
3. CAD
4. Occlusive PVD
5. Being a brother of pt with AAA
355
List 5 etiologies of AAA
1. Degenerative aneurysm
2. Infection
3. Trauma
4. CTD
5. Arteritis
356
Where do AAAs most commonly rupture into?
Retroperitoneum
357
List the 3 features of 'blue toe syndrome'
- Livedo reticularis
- 1+ cool, painful, cyanotic toes
- Palpable pedal pulses
*highly suggestive of proximal source of microemboli
358
Define primary and secondary aortoenteric fistula (AEF)
Primary = unrepaired AAA erodes into the gastrointestinal tract
- (commonly 3rd-4th part of duodenum)
Secondary = communication between the site of previous aortic surgery and the gastrointestinal tract
- (late complication of AAA repair)
359
List clinical features of an AortoCaval (aorta to IVC) Fistula
- abdominal bruit
- abdominal palpable thrill
- 'high output CHF' = dyspnea, JVD, pulm edema
- dilated superficial veins in LE
- microscopic hematuria
- rectal bleeding
- cool, diminished pulses to LE
- renal insufficiency
360
List 10 DDx for Ruptured AAAs, otherwise known as the 'common misdiagnoses'
Renal colic
Acute abdomen
Pancreatitis
Intestinal ischemia
Diverticulitis
Cholecystitis
Appendicitis
Perforated viscus
Bowel obstruction
Musculoskeletal back pain
Acute myocardial infarction
361
What diagnostic imaging test is 100% sensitive for detecting AAAs?
Ultrasound
362
What diagnostic imaging test is nearly 100% sensitive for detecting retroperitoneal hemorrhage associated with ruptured AAAs?
CT
363
In a hypotensive pt with a suspected ruptured AAA, what target of permissive hypotension is ok?
SBP 70-90
Correct only to prevent end organ damage effects
364
State door to intervention time for urgent/emergent mgmt of a ruptured AAA
<90min
365
List 7 late complications of AAA repair
1) Graft infection
2) Aortoenteric fistula
3) Anastomotic aneurysm/pseudoaneurysm formation
4) Graft migration
5) Graft stenosis
6) Graft thrombosis
7) Structural failure of the graft
366
Outline types of endoleaks after AAA repair
Type I = separation of proximal or distal end of graft from aortic wall
Type II = back-bleeding into sac from branch vessels
Type III = leakage between modular components of graft
Type IV = leak thru fabric itself
Type V = sac enlarges w/out identifiable leak = endotension
367
Outline the Raynaud triphasic attack
Digits turn pale, blue, then red.
368
List 3 layers of an artery
tunica intima
tunica media
tunica adventitia
369
List 8 pathophysiologic processes occurring in the peripheral arterial vascular system
1) Atherosclerosis*
2) Aneurysm
3) Embolism
4) Thrombosis*
5) Inflammation
6) Trauma
7) Vasospasm
8) Arteriovenous fistula
*two most common cases of disease
370
List 4 causes of arterial thromboembolism
MI
Mitral stenosis
Rheumatic HD
AFib
371
Outline Laplace's law
tension (lateral pressure) in the wall of a hollow viscus varies directly with its radius
tension = pressure × radius
372
List 5 clinical symptoms of arterial aneurysms
1) Rupture with subsequent hemorrhage
2) Impingement on adjacent structures
3) Occlusion of a vessel by either direct pressure or mural thrombus formation
4) Embolism from mural thrombus
5) A pulsatile mass
373
List the primary cause of arteritis
Non-infectious systemic necrotizing vasculitis
374
List 3 causes of infectious arteritis
Septicemia
IVDU
IE
375
Which bleeds more, partial or complete transection of an artery?
Partial
376
List 3 reasons for delayed hemorrhage from a completely transected artery
- Relaxation of arterial spasm
- Liquefaction of the thrombus
- Displacement of the thrombus by arterial pressure
377
List 5 vasospastic disorders
* Presence of ischemic symptoms and absence of tissue loss
- Raynaud disease
- Raynaud phenomenon
- Livedo reticularis
- Acrocyanosis
- Erythromelalgia
378
List 4 factors that increase the likelihood of atherosclerosis
cigarette smoking
diabetes
hypercholesterolemia
hypertension
379
Describe Buerger sign for severe advanced peripheral ischemia
Pt supine, legs elevated to 45deg = Pallor = vascular insufficiency
Pt sitting, legs hanging down = Hyperemic = dependent rubor after 1 min down
380
Outline ABI and degrees of arterial insufficiency
Ankle SBP / Brachial SBP
>90% = Normal
70-90% = Mild arterial insufficiency
50-70% = Moderate
<50% = Severe
381
List 5 skin and cutaneous manifestations of vasculitides
Palpable purpura
Macules
Papules
Vesicles
Bullae
Subcut nodules
Ulcers
Urticaria
Usually in dependent areas
382
List diagnostic imaging tests to evaluate for peripheral arterial occlusive disease
- Colour-coded Doppler angiography
- Contrast angiography
- CT angiography
- MR angiography
383
List 3 indications for emergency angiography
1) acute arterial embolus or thrombosis if clinical diagnosis is uncertain
2) consideration of emergency vascular bypass grafting
3) characterization of vascular abnormality before emergency surgical correction
384
List 7 mgmt options for arterial thromboembolism
- Heparin infusion (80u/kg IV bolus + 18u/kg/hr IV inf)
- Intra-arterial fibrinolytics
- Fogarty catheter thrombectomy
- Balloon angioplasty
- Transluminal angioplasty with intravascular stent placement
- Vascular grafting
- HBOT
385
List 7 relative contraindications to heparin infusion
- Recent NSx <2 wks
- Major surgery <48 hrs
- Childbirth <24 hrs
- Known bleeding diathesis
- Thrombocytopenia
- Potentially hemorrhagic lesion
- Active bleeding
386
List risk factors for arteriosclerosis obliterans
cigarette smoking
DLD
HTN
387
List 2 types of pain in chronic aortic insufficiency
Intermittent claudication
Ischemic pain at rest
388
List 4 physical exam findings of the foot that indicate chronic arterial insufficiency
1. absence of hair growth on dorsum of feet
2. skin atrophy
3. absent pulses
4. nail deformities
389
List 3 physical exam findings of the foot that indicate chronic venous insufficiency
1. edema
2. prominent superficial veins
3. stasis dermatitis
390
List 5 DDx of a LE ulcer
- Chronic arterial insufficiency
- Chronic venous insufficiency
- Diabetic foot ulcers
- Hypertensive ulcers
- Vasculitis
- IV drug injection sites
- Malignancy related ulcers
391
List 3 risk factors for Buerger Disease aka Thromboangiitis Obliterans
Men
Age 20-40
Smokers
392
List 5 clinical criteria for Buerger Disease aka Thromboangiitis Obliterans
1) a history of smoking
2) onset < age 50
3) infrapopliteal arterial occlusive lesions
4) either upper limb involvement or phlebitis migrans
5) absence of atherosclerotic risk factors other than smoking
393
In which age groups are Arteriosclerosis Obliterans & Thromboangiitis Obliterans most common?
AO in age >50yrs
TO in age <50yrs
394
List 5 Ps seen in acute arterial occlusion
Pain
Pallor
Pulselessness
Paresthesias
Paralysis
395
Diagnosis?
Phlegmasia cerulea dolens
Massive iliofemoral DVT
396
List 5 DDx for an acute arterial occlusion of a LE
- Phlegmasia cerulea dolens
- aortic dissection
- transverse myelitis
- spinal SAH
- hypovolemia
397
At what time frame does likelihood of an ischemic limb being salvaged decrease?
After 4hrs
398
Differentiate an Embolus from a Thrombus in an extremity
399
List the 5 diagnostic criteria for Raynaud disease
1) episodes are precipitated by cold or emotion
2) symptoms are bilateral
3) gangrene is absent or is minimal and confined to skin
4) no disease or condition that could cause a secondary Raynaud phenomenon is present
5) symptoms have been occurring for at least 2 years
400
List 3 types of thoracic outlet syndrome
Neurologic
Venous
Arterial
401
Name most reliable screening test for thoracic outlet syndrome
Elevated Arm Stress Test
= EAST
402
List 6 DDx for thoracic outlet syndrome
- herniated cervical disk
- cervical spondylitis
- spinal cord tumor
- ulnar nerve compression at elbow
- carpal tunnel syndrome
- orthopedic shoulder problems
- trauma
- postural palsy
- angina pectoris
- DM neuropathy
- MS
403
What are the treatments for distal vs proximal superficial vein thrombophlebitis?
Distal = NSAIDs + warm compress
Proximal = AC
404
DVTs distal to what region can be safely treated as an outpt?
DVT distal to iliofemoral region
405
List 7 DDx for DVT
- Venous insufficiency
- Cellulitis
- Muscle or tendon injury
- Baker cyst (including ruptured synovial membrane)
- Hematoma
- Arterial insufficiency and claudication
- Asymmetrical edema (CHF or liver disease)
406
Outline Wells Score for DVT
C3P(3)O R2D2
LOW risk <2
HIGH risk ≥3
* Everything +1, except DDx -2
- Calf swelling 3+cm larger than asymptomatic side (measured 10cm below tibial tuberosity)
- Cancer active (tx'd w/in <6 mos or currently palliative tx)
- Collateral superficial veins (nonvaricose)
- Pitting edema confined to symptomatic leg
- Previously documented DVT
- Pain & tenderness along deep venous system
- Oedema of entire leg
- Recent immobilization of LEs (plaster, paralysis, paresis)
- Recently bedridden (≥3 days or major surgery <12 wks req'ing regional or GA)
-Different dx at least as likely as DVT = (-2)!
407
List 10 Factors Other Than VTE With (+) D-Dimers
- Female sex
- Advanced age
- Black or African American race
- Cocaine use
- Immobility (general, limb, or neurologic)
- Hemoptysis
- Hemodialysis
- Malignancy (active)
- RA
- SLE
- Sickle cell disease
- Pregnancy and postpartum state
- Recent surgery <1 month
408
Outline mechanism of action of Norepinephrine
Predominantly a1 agonism
Some B1 agonism
Minimal B2 activity
Increases SVR, therefore increases CO
409
Outline mechanism of action of Dopamine
a1 + B1 + Dopaminergic agonism
* Dose dependent
410
List 3 common side effects of dopamine infusion use
- Persistent tachycardia
- Decreased PaO2
- Increased pulmonary artery occlusion
411
Outline mechanism of action of Epinephrine
Mixed a + B agonism
Increased O2 consumption
Increased systemic lactate levels (short term)
Decreased splanchnic blood flow
412
Outline mechanism of action of Phenylephrine
Only a1 agonism
Increases SVR
No sig change to CO
Reflex bradycardia
413
Outline mechanism of action of Dobutamine
a + B agonism
As Cardiac Index increases, HR increases
* Dose dependent
Decreased sphlanchnic blood flow
Decreased SVR
414
What BP difference in the UEs is suggestive of subclavian steal syndrome?
>40mmHg difference between arms
415
Outline general D-Dimer cut-offs
'Abnormal' threshold is 500ug/L FEU or 250ug/L DDU
If Age >50, age adjusted cutoff:
FEU = Age x 10
DDU = Age x 5
416
Outline U/S types for DVT
(-) Whole leg U/S can r/o DVT
(-) 3-point compression U/S in pts w/ LOW pre-test probability r/o DVT
Otherwise should have repeat U/S in 7d if higher pre-test probability (or pos D-Dimer)
417
Outline Anticoagulation options for Initial Tx of DVT or PE
UF Heparin 80u/kg IV, then 18u/kg/h IV inf
Dalteparin 200u/kg subcut q24h
Enoxaparin 1mg/kg subcut q12h
Apixaban 10mg PO q12h x7d, then 5mg PO q12h
Rivaroxaban 15mg PO q12h
418
List 5 contraindications to DOAC use for VTE
- Pregnancy
- Severe renal failure
- Liver failure
- APLAS
- High-risk PE
Use LMWH or UFH
419
Briefly list reversal agents for common anticoagulants
Heparin
- Protamine sulfate
Warfarin
- FFP
- PCC
- Vitamin K
Dabigatran
- Idarucizumab
Rivaroxaban, Apixaban
- Andexanet alfa
420
List 6 clinical features of post-thrombotic syndrome after DVT
- pain
- paresthesia
- burning sensation
- induration
- swelling
- discolouration
- ulceration of leg
- varicose veins
421
Outline 5 Absolute & 6 Relative Contraindications to Anticoagulation (in general)
ABSOLUTE:
- Active bleeding into critical organ or uncontrolled site
- Severe bleeding diathesis
- Recent, planned, or emergency HIGH-bleeding-risk surgery/procedure
- Recent major trauma
- Recent intracranial, spinal or ocular hemorrhage
RELATIVE:
- Hx of major GIB
- Intracranial or spinal tumours
- Previous bleeding into a tumour
- Large AAA w/ concurrent severe HTN
- Stable aortic dissection
- Recent, planned, or emergent LOW-bleeding-risk surgery/procedure
422
Outline the VTE-BLEED Score
Active cancer = 2
Age =/>60 = 1.5
Anemia = 1.5
Hx of bleeding = 1.5
Renal dysfnc = 1.5
Male w/ uncontrolled HTN = 1
<2 = 0.5% risk of major bleeding w/ AC in VTE
>2 = 2% risk of major bleeding w/ AC in VTE
423
Outline mgmt of a Superficial Vein Thrombophlebitis, including involvement of the Greater Saphenous Vein
Distal superficial vein thrombophlebitis = NSAIDs + warm compresses
- can repeat U/S in 7d
Proximal involving greater saphenous vein = Therapeutic dose AC x30d
424
Outline 5 factors that favour full anticoagulation in pts w/ isolated calf-vein DVTs
- ongoing thrombotic risk (active cancer, immobility)
- severe symptoms
- DVT longer than 5 cm
- DVT close to proximal veins
- Hx of prior VTE
425
Describe Paget-Schroetter syndrome
= Effort DVT
- UE DVT, especially axillary-subclavian vein
- in dominant arm of relatively young, physically active, patients
- form of thoracic outlet syndrome, 2/2 compression of venous structures by hypertrophied scalene muscles or cervical rib
426
How long should an UE DVT be tx'd for?
at least 3mos of AC
427
Name 1st and 2nd most common SYMPTOMS of PE
Number 1 = Dyspnea
Number 2 = Chest pain
428
List clinical s/s of pts w/ PE just prior to cardiac arrest
HR > SBP (shock index >1)
Overt respiratory distress
Syncope or Seizure-like activity
Significant anxiety
Or slow agonal heart rhythms 2/2 ischemia of AV node
429
Outline most common heart rhythm/ECG finding in pts in cardiac arrest 2/2 PE
PEA w/ >20 depolarizations/min
W/out palpable pulse
430
List most common VITAL SIGN abnormality in PE
Tachycardia
431
Name single most important predictor of PE mortality
Hypotension
SBP <90
432
Name the only physical exam finding that reliably increases the probability of a PE diagnosis
Evidence of DVT
- unilateral leg asymmetry, unilateral edema, or tenderness along a deep vein
433
List 12 DDx of PE
PNA
ACS
Aortic dissection
Pericarditis
Pleural effusion
Pericardial effusion
Pulm HTN
PTX
Acute decomp. CHF
Asthma
COPD
GERD
Dyspepsia
MSK pain
434
Diagnosis?
Pt dyspneic, chest pain, tachycardic
Hampton's hump
= pulmonary infarction 2/2 PE
- pleural-based, wedge-shaped infiltrate
435
List 9 common ECG changes of PE
Sinus tachycardia
- number one most common
Symmetric TWI in V1-4 (ant leads)
+/- inf leads II, III, aVF
- most specific
Incomplete or Complete RBBB
Right axis deviation
McGinn-White S1Q3T3 pattern
- not sensitive or specific
STE/STD
Atrial tachydysrhythmias
Right atrial enlargement (P pulmonale) – peaked P wave in lead II
Dominant R wave in V1
436
What is the S1Q3T3 ECG pattern?
S wave in Lead 1
Q wave in Lead 3
T wave inversion in Lead 3
437
List CXR findings of PE
Hampton's hump
Westermark sign
Palla sign
Pleural effusion
Raised hemidiaphragm w/ basal atelectasis
438
Outline Wells Score for PE risk
Low risk <2
Intermed 2-6
High risk >6
PE most likely dx = 3
Clinical signs of DVT = 3
Prev PE or DVT = 1.5
HR >100 = 1.5
Recent Surg or Immobilization w/in 4wks = 1.5
Hemoptysis = 1
Cancer active (tx'd w/in <6 mos or currently palliative tx) = 1
439
Outline Revised Geneva Score for PE risk
Low risk <4
Intermed 4-10
High risk >10
HR:
- <75 = 0
- 75-94 = 3
- >95 = 5
Pain on palpation + U/L edema of leg = 4
Prev PE or DVT = 3
Unilateral leg pain = 3
Recent Surg or Immobilization w/in 4wks = 2
Cancer active (tx'd w/in <12 mos or currently palliative tx) = 2
Hemoptysis = 2
Age >65yr = 1
440
Outline Hestia Score for Outpt Tx of PE
* basically anything that would reasonably require a pt to be admitted, or cause concern for their safety at home
* like PERC, having 1pt means have to stay in hospital
Hemodynamically unstable (HR >100, SBP <100, need ICU)
Thrombolysis or Embolectomy needed
Active bleeding or high risk for bleeding (recent CVA, GIB, Sx, PLT<75, uncontrolled HTN)
>24hr on suppO2 req'd for SaO2 >90%
PE dx'd while on AC
>24hr severe pain needing IV analgesia
Medical or Social reason for admission >24 hr (infxn, cancer, no support)
Cr clearance <30 mL/min
Severe liver impairment
Pregnant
Documented Hx of HIT
441
Outline PERC rule for PE r/o
*Any point means NOT low risk, cannot r/o, need other risk score
"HAD CLOTS"
Hormone use
Age >50
DVT/PE hx
Coughing blood
Leg swelling U/L
O2 <95%
Tachycardia HR >100
Surgery/Trauma <4wk
442
Outline YEARS algorithm for PE
* validated in pregnancy
* if pregnant w/ signs of DVT, get U/S first. If abnormal = tx w/ AC. If U/S normal, move to usual 3 Q's
3 Q's:
1. PE most likely dx?
2. Clinical signs of DVT?
3. Hemoptysis?
Score = 0, use D-Dimer cutoff of 1000 FEU
Score 1+, use D-Dimer cutoff of 500 FEU
>500 or >1000 gets CTPA
<500 or <1000 gets R/O PE
443
List 5 independent risk factors associated w/ clinical deterioration after PE dx
ED hTN
Hypoxemia
Prior CAD
Residual DVT
Rt heart strain on echo
444
Define MASSIVE (High Risk) PE, and list next steps
= Hemodynamically UNSTABLE!
- SBP <90 x15min (not caused by dysrhythmia or other etiology)
- Drop baseline SBP by 40
- Req vasopressors
- Profound bradycardia HR <40
1. Initiate AC
- (heparin if thrombolysis or thromboembolectomy planned)
2. Activate PERT
3. Thrombolysis or thromboembolectomy unless contraindicated
4. Admission to ICU
445
Define SUBMASSIVE (Intermediate Risk) PE, and list next steps
= Hemodynamically STABLE w/ any of the following:
- RV dysfnc on Echo or CTPA
- Troponin (+)
- BNP/NT-pro-BNP (+)
1. Initiate AC
- DOAC or heparin
2. Activate PERT
3. Thrombolysis or thromboembolectomy in minority of cases
4. Admission to monitored bed or ICU
446
Define Low Risk PE, and list next steps
= Hemodynamically STABLE
- NO RV dysfnc
- Troponin (-)
1. Initiate AC
- DOAC preferred
2. Determine safety for Outpt Tx & F/u
- negative Hestia criteria
3. Optional admission to inpatient service or observation unit
447
List 8 U/S findings of PE
- Normal
- RV dilatation
- Hypokinesis of intraventricular septum
- Bowing of intraventricular septum towards LV
- Visualized thrombus in Rt heart
- Dilated & fixed IVC
- Tricuspid regurgitation
- McConnell's sign
448
Define RV dysfunction as seen on CT for PE
RV:LV >1
449
Outline 12 Absolute & 14 Relative Contraindications to Thrombolysis in PE
ABSOLUTE:
- GIB w/in prev 30d
- Active hemorrhage (intraperitoneal, retroperitoneal, pulmonary, uterine, bladder, or nose
- Head trauma causing LoC w/in prev 7d
- ANY Hx hemorrhagic stroke
- Ischemic stroke w/in past 1yr
- Hx intraocular hemorrhage
- Known or suspected intracranial metastasis
- Liver failure w/ INR >1.7
- Surgery involving opening of chest cavity, peritoneum, skull, or spinal canal w/in prev 14d
- Subacute bacterial endocarditis under tx
- Pregnancy
- Large pericardial effusion
RELATIVE:
- Age >75yr
- Dementia
- Surgery btwn 30-60d ago
- Any prior CVA
- TIA in last 30d
- Any hx GIB
- Concurrent use of clopidogrel
- INR >1.7 from warfarin
- Hx of hematuria
- Any metastatic cancer
- Recent fracture
- Recent fall w/ head strike
- Recent dental extraction
- Recent orthopedic surgery
450
Outline systemic thrombolysis dosing, including full and low dose options
rtPA (Alteplase)
- Full 100mg IV over 2hr
- or 50mg IV x1, then additional 50mg IV 15min later
- Low 25-50mg IV over 2hr
TNK (Tenecteplase)
- IV bolus over 5-10sec
- <60 kg: 30mg (6000u)
60 – <70 kg: 35mg (7000u)
70 – <80 kg: 40mg (8000u)
80 – <90 kg: 45mg (9000u)
≥90 kg: 50mg (10,000u)
451
When is it appropriate NOT to anticoagulate a pt w/ a PE?
- isolated subsegmental PE
- no DVT on B/L LE U/S
- no Rt heart dysfnc
- no ongoing major risk for thrombosis (active malignancy, cast immobilization)
452
Outline thrombolytic dosing in cardiac arrest 2/2 PE
tPA 50mg IV or TNK 50mg IV
- Then continue CPR for at least 60min to circulate meds
453
Name clinical features w/ highest & lowest perioperative mortality related to pts undergoing surgical embolectomy for PE
Highest mortality = Require CPR before surgery
Lowest mortality = IVC filter placed before surgery
454
List 4 mgmt options for PEs other than systemic thrombolysis
- IVC filter
- Catheter directed thrombolysis
- Surgical embolectomy
- ECMO
455
List causes of false negative troponin and false positive troponin (6 each)
FALSE NEGATIVE:
- Analysis malfunction
- Hemolysis
- Hyperbilirubinemia
- Lipemia
- Biotin consumption
- Cardiac troponin autoAbs
FALSE POSITIVE:
- Analysis malfunction
- Hemolysis
- Elevated ALP
- Rheumatoid factor
- Heterophile Abs
- Fibrin interference
456
List patient factors that favour rate vs rhythm control in AFib (3 each)
Rate control favoured
- Multiple comorbidities
- Large atrial enlargement
- Longstanding AF
Rhythm control favoured
- Young age
- Symptomatic AF
- Persistent HF despite rate control
- Difficulty maintaining rate control
457
Define syncope
Sudden, spontaneous loss of consciousness & postural tone
W/ rapid, complete, and spontaneous recovery
458
What is the cause of syncope?
Transient global cerebral hypoperfusion
459
List 3 general causes of syncope
Cardiac
Reflex
Orthostatic
460
Name one test all patients with syncope should have
12 lead EKG
461
List 10 Cardiac Diagnoses Associated With Syncope
Dysrhythmias:
- Tachydysrhythmias
- Bradydysrhythmias
Structural:
- HOCM
- Aortic stenosis
- Severe pulmonic stenosis
- Acute MI
- Cardiac masses (atrial myxoma)
- Pericardial tamponade
- Prosthetic valve dysfnc
- Ventricular assist device (VAD) dysfnc
Cardio-Pulmonary:
- Acute aortic dissection
- PE
- Pulm HTN
- Acute MI
462
List 3 causes of reflex syncope (neurocardiogenic)
Vasovagal syncope
- intense fear, emotion, anxiety, or pain, being in a warm, crowded place, prolonged standing, noxious stimuli
Carotid sinus syndrome
- carotid sinus hypersensitivity, >3s or >50mmHg decrease in SBP, upon stimulation
Situational syncope
- urination, defecation, recent or overeating, coughing, sneezing, swallowing, laughing, breath holding, or post-exercise
463
Define orthostatic syncope
Postural hTN
Dec in SBP >20
Dec in DBP >10
- W/in 3 min of standing
464
List 12 Dysrhythmias Potentially Associated With Syncope
AV Block
- Mobitz type II second degree
- Third degree (complete)
Sinus pause >3s
Sick sinus syndrome
Persistent sinus bradycardia <40
Ventricular tachyarrhythmias
- Monomorphic VT
- Polymorphic VT (Torsades de pointes)
- VFib
Supraventricular tachyarrhythmias
- AFlutter
- AFib
- AVNRT
- AVRT
Alternating Lt and Rt BBB
Pacemaker or automatic ICD malfunction w/ cardiac pauses
465
List 9 DDx w/ ECG Abnormalities Potentially Associated w/ Syncope
Signs = AMI
- STE and STD
- TWI
- New BBB
- New abnormal Qs
Pre-excitation
= WPW
Long QT interval
= Congenital or Acquired long QT syndrome
Short QT interval
= Short QT syndrome
RBBB w/ STE in V1–V3
= Brugada syndrome
TWI in V1-3 + Epsilon waves
= Arrhythmogenic RV cardiomyopathy
LVH, dagger Q waves, deep TWI
= HOCM
Low voltages or Electrical alternans
= Pericardial effusion
RV strain pattern
= PE
466
List 10 Syncope Mimics
Seizure/epilepsy
Hypoglycemia
Hypoxemia
Fall
Concussion
Intoxication
- Ethanol
- Opiates
- Carbon monoxide
Vertebrobasilar TIA
Cataplexy
Drop attacks
Psychogenic pseudo-syncope
467
List 20 Medications Associated w/ Orthostatic hTN
BBs
CCBs
Nitrates
Hydralazine
ACEi
ARBs
Sildenafil
Tadalafil
HCTZ
Furosemide
Clonidine
Methyldopa
Amiodarone
Flecainide
Procainamide
Sotalol
Carbamazepine
Phenytoin
Olanzapine
Risperidone
Levodopa
Pramipexole
Barbiturates
Benzos
MAOIs
SSRIs
Trazodone
TCAs
Opiates
Diphenhydramine
Donepezil
EtOH
Digitalis
Vincristine
Bromocriptine
468
List 12 Life-Threatening Critical Dx associated w/ Syncope
MI
Life-threatening dysrhythmias
Acute aortic dissection
Critical aortic stenosis
HOCM
Pericardial tamponade
Ruptured AAA
Massive PE
SAH
Toxic-Metabolic derangements
Severe hypovolemia or hemorrhage
Ruptured ectopic pregnancy
Sepsis
469
List 15 Cardiovascular System–Mediated Causes of Syncope
Outflow Obstruction:
- Mitral Stenosis
- Aortic stenosis
- Pulmonic stenosis
- HOCM
- Atrial myxoma
- PE
- PHTN
- Cardiac tamponade
- Congenital heart disease
Reduced Cardiac Output:
- SVT
- VTach
- VFib
- WPW
- Torsades de pointes
- Sinus node disease
- 2' & 3' AVB
- Prolonged QT syndrome
- Brugada syndrome
- PPM malfunction
- ICD malfunction
Other Cardiovascular Disease
- Aortic dissection
- MI
- Cardiomyopathy
470
List 6 DDx of Syncope caused by Focal Hypoperfusion of CNS Structures
- Cerebrovascular disease
- Hyperventilation
- Subclavian steal
- SAH
- Basilar artery migraine
- Cerebral syncope
471
List 10 DDx of Syncope caused by CNS Dysfunction w/ Normal Cerebral Perfusion
Hypoglycemia
Hypoxemia & Asphyxiation
Seizure
Narcolepsy
Psychogenic
- Anxiety disorder
- Conversion disorder
- Somatization disorder
- Panic disorder
- Breath-holding spells
Intoxication
- Medications
- Carbon monoxide
472
List 7 short-term risk factors for guiding mgmt and disposition of pts w/ syncope
1. Older age
2. Male
3. FamHx of early sudden death <50yrs
4. Syncope w/out prodrome
5. Exertional syncope
6. Syncope while in supine position
7. Palpitations before syncope
473
Outline 9 criteria of Canadian Syncope Risk Score
SCORE
-2 = Very Low Risk
-1-0 = Low Risk
1-3 = Medium Risk
>3 = High Risk
Predisposition to vasovagal syncope
= −1
Hx heart disease
= +1
Any SBP reading <90 or >180 in the ED
= +2
Troponin >99th percentile for normal population
= +2
Abnormal QRS axis <−30' or >110'
= +1
Prolonged QRS >130ms
= +1
Prolonged QTc >480ms
= +2
ED Dx of vasovagal syncope
= −2
ED Dx of cardiac syncope
= +2
474
Outline 5 components of FAINT Score for Syncope
Hx of HF +1
Hx of cardiac arrhythmia +1
Initial abnormal 12-lead ECG +1
Elevated NT proBNP >125 pg/mL +2
Elevated troponin >19 ng/L +1
475
List 5 DDx of Pleuritic Chest Pain
Esophageal rupture
PTX
Cholecystitis
Pericarditis
Myocarditis
Rosen's 10th
flashcards
Decks in class (23)
# Cards
-
Toxicology346
-
General3
-
Electrolytes, Metabolism, Endocrine, & Rheum197
-
Pediatrics207
-
GI258
-
Ortho394
-
Infectious Disease389
-
Trauma312
-
Psych89
-
Enviro313
-
Cardiovascular475
-
Respiratory157
-
Neuro418
-
Ophtho139
-
OBGYN + Urology316
-
Nephro24
-
Heme/Onc168
-
Dermatology116
-
Resuscitation146
-
Head & Neck94
-
Bonus Chapters107
-
Special Populations & Geriatrics49
-
Hard Stuff/High Yield93
