Cardio Primary Care
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- How does HR effect hemodynamic status
- Faster rate decreases diastolic filling, lose atrial kick which decreases CO and BP
- How does acidosis effect the heart
- Makes it irritable causing PVCs
- Which electrolyte (K+, Ca++, or Mg+) stabilizes the cell membrane
- Magnesium
- What portions of the heart does the right coronary artery feed
- Right atrium and rt. ventricle, anterior and posterior wall of left ventricle, SA and AV node
- What portions of the heart does the left anterior descending artery feed
- Anterior and part of lateral surface of left ventricle, majority of right bundle branch and portions of left bundle branch
- What portions of the heart does the left circumflex artery feed
- Left atrium and portion of left ventricle, SA and AV node
- How do you treat post surgical sinus bradycardia
- Atropine
- What causes sinus arrythmia
- Increases with inspiration decreases with expiration. Should disappear on breath holding if not may may digitalis toxicity
- What is the treatment for sinus arrest
- Atropine, Isoproterenol, Pacemaker
- What are some EKG signs of a wandering atrial pacemaker
- PR interval stays the same but P wave changes
- How do you treat MAT
- CCB, BB, Amiodarone
- What are the causes of Premature Atrial Contractions
- Emotional stress, alcohol, tobacco, hyperthyroidism, cocaine. Patient may indicate they can feel it.
- What is the treatment for atrial tachycardia
- Oxygen, vagal maneuvers, CCB-Verapamil
- How do you treat PSVT
- Adenosine, Vagal maneuvers
- How do you treat A-flutter
- If asymptomatic use CCB, if symptomatic numb with Versaid then cardiovert at 25-50 joules
- How do you treat A-fib
- Cardiovert, CCB and give heparin and coumadin to prevent clot formation
- How do you recognize a premature AV junctional beat on an EKG
- Rhythm will be regular with a premature beat that has an inverted P wave before the QRS or a P wave after the QRS
- Under what heart condition might you see junctional escape beats
- Inferior wall MI in which right coronary artery is plugged which feeds SA and AV node.
- How would you treat a junctional escape beat
- Depending on symptoms - Atropine and possible transcutaneous pacing
- What causes accelerated junctional rhythm/junctional tachycardia
- Increased automaticity at bundle of HIS node which send wave impulse back thru atria causing retrograde P wave
- How do you recognize and treat ventricular escape beats/idoventricular rhythm
- Recognize by wide QRS and slow rate. Don't use lidocaine (suppresses). Use atropine or transcutaneous pacing
- What are some causes of PVCs
- Meds, Alchohol, Caffeine, Cocaine, Stress, Exercise, MI, Ischemia, Acid-Base Imbalance
- How do you treat PVCs
- Most don't require meds. If due to MI, provide pain relief, oxygen, correct acid-base imbalances
- What is the difference between monomorphic and polymorphic Vent. Tach
- Monomorphic - QRS's look the same and result from CAD with ischemia. Polymorphic - QRSs look different and result from long QT syndrome (an electrical problem)
- What is the treatment for Ventricular Tachycardia
- Stable but symptomatic - oxygen and drugs to slow rhythm; Unstable - cardiovert
- How do you treat accelerated idioventricular rhythm
- Atropine or transcutaneous pacing
- How do you treat Wenkebach
- Only if symptomatic use atropine
- How do you treat Mobitz Type II
- If symptomatic - transcutaneous pacing until pacemaker installed
- What are some signs and symptoms of chronic stable angina
- Pressure, burning, stabbing ache below sternum radiating to left face and arm with ST segment depression and possibly S4 and mitral regurg.
- How would you treat chronic stable angina
- Sublingual NTG, BB, Antiplatelets (ASA, Plavix), and Lipid lowering drugs
- What are some catheter based treatment options for chronic stable angina
- Percutaneous Coronary Intervention (PCI), Balloon Percutaneous Transluminal Coronary Angioplasty (PCTA)-restenosis rate of 30-40%, Stents (lower restenosis rate 20-30%, coated with antiplatelet)
- What veins are used for coronary artery bypass graft
- Saphenous vein or internal mammary artery
- What might be the cause of prinzmetal angina or coronary artery spasm
- Dysfunctional endothelian or hypersensitive smooth muscle (can evoke with acetylcholine)
- What type of drugs are used in chemical stress tests
- Dobudamine and positive inotropes (Adenosine)
- How can you differentiate between an MI and unstable angina ischemia
- MI shows cardiac enzymes, ischemia does not
- An ECHO shows dyskinesia during an acute coronary syndrome, what does this mean
- Irritable non-synchronized beating of the heart. The ECHO can also evaluate clots and fluid.
- What events are taking place with an ST segment elevated MI
- Complete occlusion of an epicardial coronary artery that must be resolved in 3 hrs before a transmurial infarct develops
- What causes a "Stunned Myocardium"
- Coronary artery is occluded then reopened. During occlusion some areas may receive collateral circulation and there is transient periods of no muscular activity. If treated early, the heart can regain functional status
- What can cause an ischemia at a distance
- Occlusion in an artery at a bifurcation
- What occurs in the process of infarct remodeling
- Thinning, dilation and dyskinesis at area of infarct. Angiotensin II causes heart cells to undergo remodeling but they do not heal properly leading to CHF.
- What drugs can be used to stop the infarct remodeling process
- ACEI (help reduce afterload and tissue changes)
- What percentage of MI's are silent
- 25-30%. Elderly and Diabetics don't feel same symptoms until progressed to CHF
- Why would you not use NTG with a right side heart infarct
- Knock out SA node activity
- What percent of people die from denial of MI
- 50%
- Early reperfusion therapy decreases MI mortality by how much
- 27%. Give drug to dissolve blood clot
- When are thrombolytics contraindicated during an MI
- After 12 hours and without evidence of ischemia or pain or if the person has a bleeding condition
- List some complications resulting from an MI
- Cardiogenic shock, free wall rupture (2-14 days post MI)
- What tests should be run prior to hospital discharge
- ECHO (left ventricle status), treadmill stress test to determine ischemia, and EKG (to spot arrhythmias)
- What are the discharge medication for an MI patient
- ASA, Statin, BB, and ACEI
- What is a common side effect of statins
- Muscle aches
- What is a drug type that lowers the effectiveness of statins
- Abx
- Heart failure most commonly results from..
- Left ventricular impairment
- What factors characterize systolic dysfunction in Heart Failure
- Impaired contractility (MI, Ischemia (stiff ventricle), CAD, Volume overload (Mitral regurg and aortic regurg) and increased afterload (HTN and aortic stenosis)
- What factors characterize diastolic dysfunction in Heart Failure
- Impaired relaxation (LV hypertrophy, Hypertrophic cardiomyopathy, Restrictive Cardiomyopathy) and Obstruction to filling (mitral stenosis and pericarditis/tamponade)
- What are some factors that may precipitate symptoms of heart failure
- Factors that increase metabolic demand, afterload, preload and decrease contractility
- What causes the rales/crackles in the lungs with heart failure
- Fluid build up in alveolar spaces (alveoli snap open with each breath)
- What causes a white out on an lung x-ray with heart failure
- Once left atrial pressure exceeds 15mm/Hg pulmonary blood shifts upward (cephalization) to apex creating white out.
- What causes Kerly B-lines on lung x-ray with heart failure
- Accumulation of interstitial fluid that looks patchy on x-ray
- Describe the classifications of heart failure
- Class I (No physical limits), Class II (Dyspnea and fatigue with moderate activity), Class III (Dyspnea with minimal activity), Class IV (Severe limitations-symptoms at rest)
- What are the mortality rates with the different classification of heart failure
- Class I and II (50%), Class III and IV (70%)
- What lab test marker is a good indicator of CHF
- Beta Naturietic Peptide (BNP) - released from atria and ventricle in response to stretch-signals kidneys to dump fluid. Not effective because in CHF the kidneys are not receiving much blood flow.
- Why must caution be used with diuretics in treating right heart failure
- Don't want to drop volume so low that kidney are not perfused
- What is the treatment for left ventricular dyfunction
- Correct the underlying condition, give diuretics, limit salt and alcohol, use vasodilators and inotropics
- What is the treatment for right ventricular dysfunction
- Oxygen to relax pulmonary vessels and diuretics
- How does digoxin increase contractility in heart failure
- Keeps calcium inside the cell longer by inhibiting the sodium pump
- Why might a loops diuretic (Lasix) be better than Thiazide in heart failure treatment
- Thiazide needs normal renal function to work which may not be available in heart failure. Loops work at lower renal levels
- Why should the electrolytes be monitored in heart failure
- The use of diuretics can cause hypokalemia while kidney failure can cause a rise in potassium
- Name a commonly used inotropic drug for heart failure
- Digitalis glycosides (Digoxin)
- Name the 3 dosing levels of Dopamine (IV) B-andrenergic agonist
- Level I -2-5mcg increases renal blood flow, Level II - 5-10mcg increase rate and contraction of heart, Level III-10mcg+ increases systemic constriction via alpha1
- Why are inotropic drugs of limited value in diastolic dysfunction
- Inotropic drugs increase contractility, whereas diastolic dysfunction is a relaxation problem
- Name 2 venous dilators and there purpose in heart failure
- Nitrates and Morphine. Decrease preload stress
- How does Hydralazine help in heart failure
- Dilates arterioles decreasing afterload. Be careful of hypotension
- What function do ACEI serve in heart failure
- Dilate venous and arterioles and prevent cardiac remodeling
- What is the treatment for diastolic dyfunction
- Pericardectomy for constrictive pericarditis, correction of transient ischemia
- What are signs of acute pulmonary edema
- Tachypnea, cold clammy skin, coughing up frothy sputum
- What is the treatment for acute pulmonary edema
- Sit upright, morphine, lasix, NTG, possible positive inotrope, improve Oxygen saturation
- What forms of testing and monitoring is available for syncope
- Tilt table testing, Holter monitor, EKG
- What types of treatment are used for syncope
- Once cause is more understood, could use pacer, vasoconstrictors, BB or measures to prevent venous pooling
- How does kidney failure effect BP
- Without the kidneys regulating water BP skyrockets
- What is the BP goal in patients with HTN and Diabetes or Renal Disease
- <130/80
- What should you check albumin levels in diabetics
- Sugar pulls water into kidneys causing cell destruction which leaks protein out in urine
- What values classify pre-hypertension
- 130-139/80-89 (No drug treatment)
- What values classify Stage 1 hypertension
- 140-159/90-99 (Thiazide)
- What values classify Stage 2 hypertension
- >160/>100 (Thiazide plus another drug-ACEI, BB, CCB)
- What should you look for during a physical exam on a patient with HTN
- Check BP, Optic fundi (flame hemorrhages), Bruits in carotids and abdominal (renal area), Examine heart and lungs, Check for edema and pulses of upper and lower body
- What laboratory tests would you run on a patient with HTN
- EKG, Urinary albumin, Glucose, Hematocrit (if high, increases blood thickness, if low the heart increases to increase CO), Lipids, Electrolytes, Creatinine and GFR
- True or False. When combining drugs for HTN choose from the same class
- False. Never choose from the same class and always have one of the drugs be a diuretc
- True or False. Most people will need 2 drugs to control HTN
- True. Give first drug for 6-8weeks plus lifestyle changes then consider adding second drug. Plus have them monitor their BP at home and record values throughout the week.
- How do oral contraceptives effect BP
- Initial increase then come down. If don't come down, find alternative
- What organ systems are effected in a hypertensive emergency
- Brain initially constricts vessels in response to HTN then dilates which leads to seizures and coma, the optic disc swells cutting off blood supply causing visual loss and get headaches.
- What is the treatment for hypertensive emergency
- Admit to ICU, put in arterial line and administer Sodium Nitroprusside, also use NTG, Labetalol, Hydralazine
- What side effects exist with sodium nitroprusside
- Nitroprusside is metabolized to cyanide in RBC's so may need to infuse sodium nitrite or hydroxycobalamin to avoid toxicity
- How does a hypertensive emergency differ from a hypertensive urgency
- Emergency has organ damage and need for immediate lowering. Urgency does not have organ damage and can be lowered slowly over 24 hours with medications
- What situation may lead to hypertensive emergencies and urgencies
- Neglected HTN, Sudden stopping of meds (Clonidine, BB), Renovascular disease, Pheochromocytoma, Intercerebral or subarachnoid bleeding
- What is the pathophysiology of hypertensive emergencies and urgencies
- Vasospastic disorder with large increase in peripheral vascular resistance and over production of renin and angiotensin II which casues vessel wall necrosis in target organs
- How is resistant hypertension defined
- Failure to achieve BP goals in patient following 3 drug regimen that includes diuretic
- How do you manage resistant hypertension
- Rule out all secondary causes of hypertension and refer to specialist
- Where would you see an infarct if the Left Anterior Descending Artery was blocked
- Anterior wall of LV near apex, Anterior two-thirds of IV septum
- Where would you see an infarct if the Right Coronary artery was blocked
- Posterior wall of LV, Posterior one-third of IV septum
- Where would you see an infarct if the Left Circumflex artery was blocked
- Lateral wall of LV