Ischemic Heart Disease:

What is the MCC of death in US? CAD

Ages for fam history to be a risk factor? Premature
CAD
Female relative less than 65
Male relative less than 55
After what age does CAD happen? Men > 45; Women
> 55
Why do women get it later? Estrogen protective effect
What is most dangerous risk for CAD? DM
What is the most COMMON risk for CAD? Hypertension
Best management in patient with chest pain due to
GERD?
PPI, check amylase & lipase levels
Abdo sonogram for gallstones
5 Ps assd with Pleuritic (resp) chest pain?
PE, Pneumonia, Pleuritis, Pericarditis,
Pneumothorax
Chest pain lasts atleast how long to be ischemic? 1530 mins
S3 gallop= Dilated LV (rapid LV filling in diastole)
in fluid overload states: CHF, MR
S4 gallop= LV hypertrophy (atrial systole into stiff LV)
When ischemic chest pain pt presents, do you give tx
first or EKG?
Tx first: 2 antiplatelets (ASPIRIN + grel),
Heparin
Then EKG, cardiac enzymes
Nitrates, Oxygen, Morphine
BB, ACE/ARB (low EF), Statins (high LDL)
Ranolazine (persistant pain)
Most accurate test for ischemic chest pain?
Cardiac enzymes: troponin or CKMB
Which enzyme will rise first? Myoglobin
What to do when chest pain is not acute & EKG +
enzymes dont tell you dx?
Stress test/exercise EKG (most sensitive test
for CAD) (exercise tolerance test) (220-age)
o Abnormal = (reversible ischemia
seen), do Angiography
o Normal = discharge on BB, ACE, statin,
aspirin
Which patients cant take stress test?
COPD
Amputation/ lower extremity ulcer
Weakness, previous stroke
Dementia
Obesity
What to do in these patients that cant stress test?
Chemical stress test
Dipyridamole/Adenosine Thallium stress test
o Cant do in asthma/copd
Dobutamine echo stress test
Sestamibi stress test (for obese ppl)
When EKG not readable/cant do it?
LBBB, LVH
Digoxin use, Pacemaker
ST nonspecific changes
What to do in patients with unreadable EKG? Nuclear
Stress test
Exercise thallium test

Exercise Echo (shows ventricle hypokinesia =

infarction)

What is a fixed defect on a stress test?

Scar from previous infarction (defect
unchanged between exercise and rest)
P2Y12 antagonists: block aggregation of platelets by
inhibiting ADP induced activation of P2Y12 receptor.
Why do thrombolytics have to be given fast?
Activate plasminogenplasmin
Plasmin breaks fibrin strands to D dimers the
first couple hours BEFORE they get stabilized
by factor 13
Always lower mortality?
Aspirin,
Heparin (LMWH>IV unfractionated)
Angioplasty(pci),
Defibrillators,
BB, Statin, Grels,
Sometimes lower mortality?
ACEI/ARB (if EF is low= CHF, systolic prob)
Thrombolytics (only in STEMI or new LBBB
within 12 hrs)
Gp2b/3a inhibitors (only in NSTEMI)
Which drugs lower mortality but are not time
dependent?
Beta blockers (decrease arrhythmia MCC of
death)
ACE/ARB (only in systolic or LV dysfunction=
low EF)
Statins (if LDL > 100 in CAD, >70 if DM too)
Which drugs decrease pain but no mortality benefit?
Morphine
Oxygen (only if hypoxia in patient)
Nitrates
**add RANOLAZINE if pain persists
When do you give Prasugrel, Clopidogrel, Ticagrelor in
chest pain?
Aspirin allergy
Add to aspirin in acute MI (use Prasugrel if
angioplasty needed)
When to use CCB?
Asthma (no BB used)
Cocaine induced chest pain
Coronary vasospasm/Prinzmetals angina
When is a pacemaker used for acute MI?
Complications of MI
o 3rd degree/complete AV block (with
atropine)
o Mobitiz type II 2nd degree AV block
o Symptomatic bradycardia (if atropine
doesnt resolve)
o New LBBB
When do you give patient lidocaine or amiodarone?
Vtach or Vfib
What 2 things lower mortality in STEMI (st elevation)?

Angioplasty/PCI : intraluminal ballon dilation &

stent place
o
(within 90 mins of coming)
Thrombolytics
o (w/i 12 hrs of pain + 30 min of arrival)

How long to wait till can have sex after MI?

2-6 weeks (if normal post MI stress test)
d/d Management between STEMI and NSTEMI?
STEMI: PCI or Thrombolytics
NSTEMI: PCI + Gp2a/3b inhibitors (eptifibatide,
tirofiban, abciximab)
**do not give thrombolytics in NSTEMI**

Complications of MI:

all have hypotension

When dx is with Echo?

1. Cardiogenic shock
Dx: Echo & Swan ganz catheter (right
heart)
Tx: ACEI, urgent revascularization
2.

3.

New onset murmur + pulm congestion

Valve rupture (usually causes MR at apex
radiating to axilla)
2-7 days post infarction
Tx: ACEI, nitroprusside, intra aortic balloon
pump (bridge to surgery)
Septal rupture (Ventricular septal rupture
heard at lower left sternal border)
(Right heart catheter (higher O2 saturation
in RV compared to RA)
Tx: ACEI, nitroprusside, urgent surgery
Myocardial free wall rupture (causes
Tamponade)
sudden loss of pulse (PEA) + clear
lungs
Tx: pericardiocentesis + cardiac repair

4. Mural thrombi/Aneurysm
Tx: Heparin + Warfarin
When dx is with EKG?
BRADYCARDIA:
5. Sinus brady (very common) (SA node less
blood flow)
Tx: atropine, pacemaker (if still
symptoms)
6. Complete heart block (3* AV block)
(cannon A waves- atrial systole against closed
tricuspid from unsynchronization)
bounding JVP into neck
tx: atropine + pacemaker BOTH
TACHYCARDIA:
7. RV infarcation ( clear lungs)
Dx: EKG (right ventricular leadso most specific finding: ST elevation
R4)
Tx: high volume fluid loading (nitro
worsens filling)
8. Pulseless Vtach/Vfib
Tx: Electric shock/debrillation/cardioversion

9.

Reinfarction (new rales/ sudden onset pulm

edema)
esp with Ant/Inf wall MI
Dx: EKG & CKMB
Tx: angioplasty
MCC of ED after MI? Anxiety (if drug induced then BB)
(tx patient with sildenafil but STOP NITRATES)
-patient can exercise/sex if post MI stress test
is norm
RCA supplies: RV, AV node, Inf wall (so all assd with
each other)
inf wall MI
complete heart block (3* AV block)
RV infarction
New systolic murmur 5-7 days s/p? Papillary Muscle rupture
Acute severe hypotension? Ventricular FREE WALL rupture
Persistent ST elevation ~1mo later + systolic MR murmur?
Ventricular WALL aneurysm
5-10wks later pleuritic CP, low grade temp? Dresslers syndrome.
(autoimmune pericarditis) Tx w/ NSAIDs and aspirin.
Intra Aortic Balloon Pump (IABP): tx acute pump fail in
operating room
-bridge to surgery for 1-2 days

Tako-Tsubo Cardiomyopathy (postmenopausal

women, emotional trigger, chest pain, sudden death)
Echo: LV ballooning
Best tx? BB & ACEi (no revascularization
since normal coronary arteries)
How much does smoking cessation decrease CAD risk?
Within 1 year 50% RR
Within 2 years 90% RR
Other causes of chest pain, most accurate dx tests?
Costochondritis= physical exam
Aortic Dissection, Pneumothorax, Pneumonia = CXR
Pericarditis= EKG
Duodenal ulcer= Endoscopy (pain better w/ eating)
GERD= PPI response
Pulmonary Embolus= Spiral CT, V/Q scan
Worse prognostic factor in chest pain? SOB
Fever in which chest pains? PE or Pneumonia
If vague w/ hx of viral infxn and murmur ?? myocarditis
If occurs at rest, worse at night, few CAD risk factors
and migraine headaches, w/ transient ST elevation
during episodes??
-Prinzmetals angina ( Dx w/ ergonovine stim test. Tx
w/ CCB or nitrates
--------------------------------------------------------------------------

Valves
Best initial dx test for valvular function & wall motion?
Echocardiography (order TTE first, but TEE
more accurate)
Most accurate test for valve lesions?
catheterization/angiography
Right side lesions lounder with inhalation (tricuspid,
pulmonary)
Left side lesions louder with expiration

Mitral stenosis: dysphagia, hoarseness, A

fibrillation/stroke
LA hypertrophy:
o EKG: biphasic P wave in V1/2
o CXR: second bubble (double density)
behind heart, high left bronchus,
straight left heart border
Rheumatic fever (immigrant or pregnant)
Lounder intensity S1 at apex with opening snap
in S2
How to know severity of MS?
Open snap is earlier in diastole (closer to s2)
Can lead to RV heave & loud P2 sound (pulm
HTN)
Aortic Stenosis: chest pain; radiates to carotids
LV hypertrophy: LV heave
o EKG: S wave in V1, R wave in V5
How to tx stenotic lesions?
If asymptomatic nothing
If SymptomaticDiuretics or Anatomic repair
o (MS= balloon valvuloplasty even in
preggo)
o (AS= surgical valve replacement if
pressure gradient > 50 or area > 1cm)
MS extra tx: Warfarin + Rate control
(Dig,BB,CCB) for A fib

Mirtal Regurg: radiates to axilla; HTN, endocarditis,

MI
-

Palpable LV heave
causes of MR + Marfans, Cystic
medial necrosis, Inflam disorders (ankylosing spondy,
reiters), Syphilis
Quincke pulse: in fingernails
Corrigans pulse: waterhammer pulse
Mussets sign: head bobbing
Duroziezs sign: femoral artery murmur
Hill sign: higher BP in lower extremities

Aortic Regurg:

Tricuspid Regurg:
-

Large C-V wave

Usually due to rheumatic disease or IV endo

How to tx Regurgitant lesions?

Vasodilators ACEi/ARB, nifedipine,
hydralazine (decrease afterload & DELAY
PROGRESSION)
Surgical replacement
o MR if LVESD more than 40mm ; or EF
less than 60%
o AR if LVESD more 55mm ; or EF less
than 55%
Valve replacement:
BioSynthetic valves (bovine, porcine) replace
10 yrs; no warfarin need
Mechanical valves 15-20yrs; NEED
WARFARIN

MVP:
-

chest pain, palpitations, panic attack,

can lead to MR
Tx MVP: beta blockers if symptomatic

How to measure degree of L to R shunt in VSD?

catherization
How to tx VSD? Mild defects dont need repair
When to repair an ASD? When shunt ratio more than
1.5;1. (with catheter or percutaneous)

Valsalva and Standing: decrease VR

Decrease all valvular murmurs and VSD
Vice versa HOCM, MVP
Squatting & Leg raising: increase VR
Increase all valvular murmurs and VSD
Vice versa
Handgrip: increases afterload
Increases AR/MR & VSD murmurs (more
backward flow)
Decreases HOCM, MVP, AS (MS not affected)
Amyl Nitrate
(vasodilator)/dehydration/diuretics/tachycardia:
decreases afterload
Decreases AR/MR & VSD
Increases HOCM, MVP, AS
**if Amyl nitrate makes murmur better/less= give
ACEi**
Which murmurs heard at LOWER LEFT STERNAL
BORDER?
AR, TS/TR, VSD
S2 splitting
Paradoxical (a2 delay): LBBB, LVH, HTN, AS
Wide (p2 delay): RBBB, RVH, pulm HTN, PS
Holosystolic murmur w/ late diastolic rumble in kiddos? VSD
Rumbling diastolic murmur w/ opening snap, LAE and A-fib? MS
Blowing diastolic murmur with widened pulse pressure and eponym
parade? AR

CHF (SOB=dyspnea on exertion)(s3)

-

Orthopnea (when laying flat; beter with

sitting/standing)
Rales on lung exam
JVD
Sudden wakening at night (paroxysmal
nocturnal dyspnea)
Can lead to pulm edema, ascites, liver/spleen
largement
MCC of CHF? Hypertension (hypertropic
cardiomyopathy)
MCC of hospital admission in US? CHF
Most imp/initial test in CHF? Echo (TTE) (to d/d systolic
or diastolic prob by EF)
Most accurate test to check EF in CHF? MUGA (multiple
gated acquisition scan) or Nuclear Ventriculography
Tests to determine etiology of CHF?
EKG (MI, heart block)
CXR (DCM)
Holter monitor (paroxysmal Arrythmias)
Catherization (valve size; septal probs)
CBC (anemia)
T4/TSH (hypo/hyperthyroidism both)

Endomyocardial biopsy (for RCM)

Swan Ganz catheter (to d/d CHF from ARDS)
What can dx CHF when SOB etiology not clear? BNP
levels (normal excludes CHF)
Best initial tx cardiomyopathies + CHF? with diuretics
A patient comes in with shortness of breath cardiac
or pulmonary? If you suspect PE (history of cancer,
surgery or lots of butt sitting) ? give HEPARIN!
Check O2 sats give O2 if <90% saturation
If signs/sxs of pneumonia? get a CXR
If murmur present or history of CHF? get echo to
check ejection fraction
For acute pulmonary edema? give nitrates, lasix and
morphine
If young w/ sxs of CHF w/ prior hx of viral infx?
consider myocarditis (Coxsackie B).
If pt is young and no cardiomegaly on CXR? consider
Primary pHTN

DCM: systolic dysfunction

-

Alcohol (REVERSIBLE stop the booze)

Drugs: Adriamycin, radiation, doxorubicin
Chagas disease
Postviral myocarditis (coxsackie B)
Previous MI
o MI DCM Regurge CHF

HCM: diastolic dysfunction (norm EF);

S4 gallop
Diatolic drugs (BB and diuretics)
HOCM/IHSS: thick ventricular septum
systolic Ant motion (SAM) of mitral valve (LV
outflow obstruction)
septal Q waves in Inf/Lateral leads
worsened by anything that increases HR (ex:
exercise, dehydration, diuretics)
worsened by anything that decreases LV
chamber size (ex: diuretics, vasodilators)
o HOCM tx? Beta blockers only! NO
DIURETICS
o HOCM w/ syncope tx? Implantable
Defibrillator
o Ablation of septum
o HOCM last resort tx? Surgical
myomectomy
Best initial tx for HCM/HOCM? Beta blockers

RCM:

kussmauls sign (increase JVP on inhalation),

right heart failure signs (ascites, liver/spleen large),
Pulm HTN (increase wedge pressure)
Sarcoidosis, Amyloidosis, Scleroderma
Hemochromatosis (REVERSIBLE w/
phlebotomy)
Cancer
Myocardial fibrosis
Endomyocardial fibrosis
Glycogen storage diseases
Most accurate dx test RCM? Endomyocardial biopsy
Special RCM characteristics?
Cardiac catherization= x and y decent
EKG= low voltage
Echo= in Amyloidosis with speckled pattern on
Echo)
RCM tx: underlying cause + diuretics

What is the worst manisfestation of CHF?

Pulmonary edema (rales/crepitations, s3,
orthopnea, SOB)
(CXR= cephalization of blood flow towards
head)
Best initial tx for ACUTE pulmonary edema in CHF?
DECREASE PRELOAD
IV Furosemide or Bumetinide (loop diuretic)
Nitrates & Morphine (venodilators)
Oxygen + sit upright
What tests to order at SAME TIME as initial tx?
CXR (pulm congestion, effusion, cardiomegaly)
EKG (tachycardia, arrhythmia)
Oximeter (hypoxia & resp alkalosis frm
Hyperventilation)
Echo (to d/d systolic or diastolic)
What drug to use when initial tx doesnt help by 30-60
mins? DECREASE AFTERLOAD with Positive inotropes
Dobutamine
PhosphoDiEsterase inhibitors
(inamRinone, milRinone, Amrinone)
What to use of Dobutamine doesnt work? IV
Hydralazine & nitro
If patient feels hypotension after Dobutamine? Give
Dopamine
Pulmonary edema + Arrhythmia tx? Synchronized
cardioversion (fastest way to fix)
(Unsynchronized only used in Vfib and Vtach
without a pulse)
Which
-

things lower mortality in CHF/cardiomyopathies?

ACEI/ARB
BB (metoprolol, carve, bisoprolol)
Spironolactone/Eplerenone (in severe CHF)
o (d/d statins in chest pain)
Implantable Defibrillator
o (if EF less than 35%)
Biventricular pacemaker (Cardiac
Resynchronization therapy)
o (if EF less than 35 & QRS more than
120msec)

** if cough: switch ACEi ARB

**if hyperkalemia: switch ACEi/ARB hydralazine +
nitrate
What is mechanism of resp alkalosis in Pulmonary
edema?
Fluid overload hypoxia in body
hyperventilationdecreased pCO2resp
alkalosis
Which drugs to use in Systolic dysfunction (low EF) (ex:
DCM)?
Digoxin, Diuretics
Spironolactone/Eplerenone, BB, ACEi/ARB
Which drugs to use in Diastolic dysfunction (ex: HCM)?
Diuretic & BB
If drugs & pacemakers dont help CHF? Cardiac
transplant

Pericardial disease:

Pericarditis (any prob NEAR heart can

cause this)
-

MCC is viral Coxsackie B

MC connective tissue cause? SLE
o (others= Wegners, goodpasture, RA,
Polyarteritis nodosa, etc)
Friction rub; sharp PLEURITIC pain (more with
breathing)
Positional pain (better w/ sitting up)
Best initial test: EKG (diffuse ST elevation; PR
depression in lead 2
Best initial tx: NSAIDS (indomethacin, aspirin,
ibuprofen, naproxen)
if symptoms persist prednisone
Recurrence px? Colchicine

Pericardial tamponade
this)
-

(pericarditis can lead to

SOB, low BP (hypotension) + tachy, JVD

CLEAR LUNGS
Pulsus paradoxus (BP drops more than 10 on
inhale)
CXR: normal or globular big heart
EKG: Electrical Alternans (QRS complex height
alterations)
Right heart Catherization: shows equalization
of all pressures in diastole
accurate dx test: ECHO (diastolic collapse of RA &

Most
RV)
Best initial tx: Pericardiocentesis, IV fluids
Bloody tamponade tx? Emergent thoracotomy
Most effective long term tx: Pericardial window
placement
**DO NOT GIVE DIURETICS**

Constrictive Pericarditis (fibrosis +

calcification, chronic TB, )
-

RHF signs: edema, JVD, HSM, ascites

Pericardial knock:
(extra diastolic sound
from heart hitting calcified pericardium)
KUSSMAULS SIGN (also in RCM)
How to dx?
Best initial dx test? CXR: shows calcification/fibrosis
Most accurate test? CT and MRI: shows thick
pericardium
EKG: low voltage
Echo: myocardium moves normal in this
Best initial therapy? Diuretics
Most effective therapy? Pericardial Stripping (surgical
removal of pericardium)
-------------------------------------------------------------------------------------

Aortic Disease:
Aortic Dissection:
- Difference in BP in R & L arms
Best initial dx: CXR (shows wide mediastinum)
Most accurate dx test: angiography
Best initial tx: BB for reflex tachy (+ Nitroprusside to
control BP)

Most effective tx: surgical repair

**place patients in ICU and have surgical consult
there**

Abdominal Aortic Aneurysm:

When to screen for AAA? Smokers men over 65 w/
ULTRASOUND
When to repair an AAA with stent? If over 5cm
(monitor the rest)
--------------------------------------------------------------------------

Peripheral Artery Disease:

DM, high lipids,

smoking, HTN
Claudication (calf pain on EXERTION-walking
up/downhill)
Smooth shiny skin on calves (loss of hair/sweat
glands)
Loss of pulses in the feet
Best initial dx test? ABI (ankle branchial index) < 0.9
(>10% difference in arms and feet BP)
Normal ABI is more than 0.9
Most accurate dx test? Angiography
How to d/d PAD with Spinal Stenosis and Arterial
Embolus?
Spinal stenosis doesnt lose pulses in feet
Spinal stenosis pain is when walking
DOWNHILL
Arterial embolus is acute sudden loss of pulse
+ cold extremity (usually due to AS and A fib)
Best initial tx? Aspirin, ACEi, Exercise, Cilostazol,
Statins, stop smoke
Most effective tx? Cilostazol
Marginally effective tx: Pentoxifylline
If initial dont work then SURGICAL repair
Heart Disease in Preggo
Peripartum Cardiomyopathy (MOST dangerous in
preggo )
Antibodies in preggo girls myocardium AFTER
DELIVERY
LV dysfunction (reversible)
Repeat preggo is worse
Best initial tx? Systolic dysfunction drugs
Last resort? Cardiac transplant
Eisenmenger Syndrome (2nd most dangerous in preggo)
RL shunt from pulm HTN in VSD
----------------------------------------------------------------------Arrhythymias
Atrial fibrillation:
-palpitations + IRREGULAR pulse
(assd with HTN, ischemia, cardiomyopathy)
Initial test?
EKG
If EKG not clear?
Telemetry monitoring (inpatients)
Holter monitoring (outpatients)
Tests to do after A fib found on EKG?
Echo
TFT (T4, TSH)
Electrolytes (K, Mg, Ca)

 Troponin/CKMB
Tx in unstable patients?
Synchronized electrical cardioversion
Tx in stable patients?
rate control (to less than 100):
BB, CCB (if asthma), Digoxin (if borderline
hypotension)
anticoagulation:
CHADS
score
0-1
=
aspirin
(no
anticoagulant)
CHADS 2+ = warfarin, daBigaTran, RivaRoxaban,
Apixaban

Unstable patient definition?

systolic BP less than 90
congestive failure
confusion
chest pain
what is CHADS? scoring to indicate anticoagulant
use in A fib
C: CHF
H: hypertension
A: age more than 75
D: DM
S: stroke/ TIA (2 points)
d/d
between
Warfarin
and
the
Novel
Anticoagulants (NOACs:)?
NOACs work in a few hours
NOACs dont need INR monitoring

Oral

d/d Unsynchronized and synchronized

debrillation/cardioversion?
Unsynchronized: deliver electricity at ANY
POINT in cycle
o V fib, Pulseless Vtach
Synchronized: not during T wave (refractory
period)
Mechanism of Unsynchronized
Cardioversion/Defibrillation?
CPR
DEFIB
IV EPI or Vasopressin
DEFIB
IV Amiodarone or Lidocaine
DEFIB
CPR
How does V fib present?
Sudden death (loss of pulse)
Ventricular Tachy (VT):
Initial dx?
EKG (telemetry or holter monitor if EKG cant
detect)
Most accurate dx test?
Electrophysiologic studies
Tx in Stable patients?
Amiodarone
Lidocaine
Procainamide
Mg
Tx in Unstable patients ?

Synchronized cardioversion
Tx in pulseless patients?
Unsynchronized cardioversion
Torsades de Pointes:
-VT with undulating amplitude
tx? Same as VT but always add Mg
**Atrial Flutter has same tx as A fib**
(d/d Atrial flutter has REGULAR rhythm on EKG)
Multifocal Atrial Tachycardia: MAT (HR more than
100)
-atrial arrhthymia + COPD/emphysema
-polymorphic P waves (IRREGULAR chaotic
rhythym)
Initial tx for MAT?
Oxygen, then CCB (not BB)
SVT:
-palpitations + REGULAR pulse (ventricular rate
160-180)
(NOT assd with heart disease d/d A
fib)
Inital dx test?
EKG
If EKG not clear ?
telemetry or holter monitor
Initial tx for unstable patients?
Synchronized cardioversion
Initial tx for stable patients?
vagal maneuvers
o carotid sinus massage
o ice immersion of face
o valsalva maneuver
Next best tx if Vagal maneuvers dont work?
IV adenosine
Best long term management?
Radio-frequency catheter ablation
WPW (Wolff Parkinson-White):
-SVT alternating with VT
(SVT worsening after CCB or Digoxin)
Initial dx test ?
EKG (delta wave + short PR)
Most accurate test ?
Electro-Physiologic studies
Best initial tx?
Procainamide
Best long term management?
Radiofrequency catheter ablation

What are some initial tests ordered for syncope?

EKG
Enzymes (troponin/CKMB)
Echo (if murmur)
Heat CT (if head trauma, headache, seizure)
Oximeter
Chemistries (glucose, CBC)
What if dx of syncope is not clear?

Holter/Telemetry, Repeat enzymes

Urine/Blood toxicology screen

What if dx of syncope etiology (whether cardio or

neuro) not clear?
Tilt table testing (vasovagal/ neurocardiogenic
syncope)
Electrophysiological testing
What can cause GRADUAL syncope onset?
Toxic-metabolic
Hypoglycemia
Anemia
Hypoxia
What can cause SUDDEN syncope onset?
Gradual return to conscious= NEURO (order
head CT & EEG)
o Seizures
Sudden return to conscious= CARDIO (order
heart exam)
Abnorm Cardiac exam= Structural heart prob
Aortic/Mitral stenosis
HOCM
MVP
Normal Cardiac exam= Ventricular arrhythmia
Stroke/TIA of what part of brain can cause syncope?
Posterior circulation (not MCA)
Most important thing to exclude in syncope?
Cardiac cause (arrhythmia)(highest mortality)
d/d CHF and MI symptoms?
o SOB on exertion= CHF
Chest pain on exertion=CHF

Dont return BP to normal might

cause ischemic stroke/infarctions
Goal? BP by 25% in 2 hours

Hypertensive urgency: increased BP

without symptoms/end organ damage
- Tx: oral antihypertensive
Third degree heart block
- tx: IV atropine, followed by transvenous
pacing
Sick sinus syndrome: alternating
bradycardia with SVT (underlying a
fib/flutter)
Tx: pacemaker
Asymptomatic valvular murmur
- No tx needed (even if its due to
previous rheumatic fever)
A fib (irregularly irreg)
- Tx: beta blockers
o 2nd line: CCB, or digoxin
- tx unstable patient: defibrillation
Balloon valvuloplasty for Mitral stenosis
can be done in preggo women
- valve replacement is too dangerous
for baby and woman

Kaplan annotations: annotate BLOCK 48

Terazosin: alpha 1 antagonist

Bph + hyptertension

IABG: placed in descending thoracic

aorta for timed inflation and deflation
- Diastole: inflates to cause
increased diastolic BP increased
coronary artery and cerebral
perfusion
- Systole: deflates to decrease
systolic blood pressure reduces
work of heart to increase CO
Hypertensive emergency: increased BP
+ increased ICP (papilledema) + renal
failure (end organ damage)
- Tx: IV Na Nitroprusside
- Others: IV labetolol, nitroglycerin,
hydralazine

MC thing related to A fib is LA

enlargement
Acromegaly workup?
- Step 1: somatomedin C levels
- Step 2: oral glucose tolerance
tests
Aortic dissection aortic regurg
2* heart block TYPE 2 or 3* heart block:
- Both long term tx: pacemaker
- If symptomatic then give IV
atropine
o If ANY BRADYCARDIA is
symptomatic give IV atropine
#1 thing to give in pulm edema?
- 100% oxygen

2nd is loop diuretic, nitrates,

morphine (if does not work then
give IV dobutamine-decreases
afterload), (if dobutamine doesnt
work then give IV hydralazinehigher SE SLE like syndrome)
what if patient suddenly gets
hypotensive after dobutamine?
- Give dopamine (pressor &
increases afterload)
-

Cilostazol (PDE inhibitor): tx peripheral

claudication
- Contraindicated in heart failure
Isosorbide nitrate: is venodilator (does
not work on arteries)
Who is symptomatic in aortic stenosis?
- Aortic valve < 1cm & gradient
across valve >40
- Tx: aortic valve replacement
- No valvuloplasty in adults due to
high restenosis rate
- Can sometimes do valvuloplasty in
kids with congenital AS
HOCM- 1st step TTE (not TEE)
- holter monitor (to detect fatal
arrhythmias)
- when to do stress test in HOCM?
When chest pain or dyspnea (not
cns probs ex: syncope etc)
pulm hypertension: mean pulmonary
artery pressure > 25/10
- low DLCO
HOCM tx:
- asymptomatic: no tx
- symptomatic BB and CCB
- refractory: surgical myomectomy
PAN:
- routine screening ophthalmoscopy
- necrotic skin
changes/ulcers/purpura
- arteritis mesenteric or renal esp
RAS: cannot tolerate ACEi
SVTs: narrow complex on ECG
- SVTs include:
o A fib

A flutter
Sinus tachy
Multifocal atrial tachy
AV reentrant tachy (AVRT)
AV Nodal re entry
tachy(AVNRT)
- Vagal maneuvers decrease AV node
conduction carotid massage,
perirectal stimulation,
o 2nd line: adenosine
o 3rd line: BB, CCB, Digoxin
**WPW can become V fib if vagal
maneuvers used
o
o
o
o
o

Post MI complications:
signs of cardiac tamponade & RV infarct
are similar
- d/d RV infarct DOES NOT have
pulsus pardoxsus
- post MI valvular rupture or CHF
wud not have clear chest to
auscultation or clear lungs.
SHOCK (norm PCWP is 4-12)
Cardiogenic shock:
Low CO,
- tx: IV fluids (unless there is pulm
edema)
- tx if pulm edema too: inotropic
drugs (dobutamine & milrinone)
o 2nd line: NE or E
obstructive shock:
1. cardiac tamponade:
- if swan ganz done= shows equal
pressures in all chambers
2. pulmonary embolism
3. tension pneumothorax
hypovolemic shock: low PCWP and low
CO but HIGH SVR
Distributive shock: increased CO,
norm/low PCWP, very low SVR (low BP)
1. septic shock
2. neurogenic shock
in these, peripheral vasodilation
decreases blood flow to vital organs
spinal shock: after spinal cord injury
person has motor and sensory loss

in non acute Angina:

- step 1: EXERCISE treadmill stress
test (EKG)
o 2nd line: if EKG undiagnostic
then do:
Stress/exercise ECHO
or
Stress/exercise
THALLIUM
o when is ekg undiagnostic?
LBBB/LV hypertrophy
Pacemaker
Baseline EKG changes
Digoxin
WPW
Aortic stenosis: LV heave, diminished
carotid pulses
- Paradoxical S2 split
Cardiogenic syncope: decrease in HR
decrease in CO decrease in BP large
enuf to lose consciousness
Neurocardiogenic syncope: aka
Vasovagal syncope
- Loss of consciousness preceded by
prodrome of lightheaded,etc,
- Falling down helps increase blood
flow to brain and person wakes up
Jarish bezold reflex: apnea, brady,
hypotension
- Assd with: nicotine, serotonin,
snake venom, antihistamines,
halogenated Anesthetics,
biguanides, antihistamines
Neurogenic syncope: loss of sympathetic
tone
- Decrease BP, with no change in HR
In CHF, if loops, morphine, nitrates,
oxygen, head elevation dont work give
dobutamine.
When do you endotracheal intubation a
patient?
- Inability to oxygenate patient

o spO2 <90%
o PaO2 <55
Inability to ventilate patient
o Resp acidosis, AMS,
increasing pCO2
Patient unable to protect airway

SYMPTOMATIC Mitral regurg:

- Tx: decrease preload (loops),
decrease afterload (ACEi)
- Next step? Left heart
CATHERIZATION (for possible
angioplasty/bypass)
Acute coronary syndrome tx: oral
aspirin, sublingual nitrates, IV morphine
STEMI patient: ADD IV heparin, IV
nitrates clopidogrel, gp2b/3a inhibitors,
beta blockers
STEMI patient that cannot do angioplasty
- Tx: TpA instead (alteplase)
Warfarin with INR 3-4 with? Mechanical valves
Persistent DVTs, or recent hemorrhage/surgery? IVC
filter
Thigh & butt claudication, and Erectile dysfunction:
Leriche syndrome
Emergenct hypertension:
Drug of choice: IV Sodium nitroprusside
When signs of chest pain as well? IV
nitroglycerin
Clonidine: short acting sympathetic blocker
Central acting! alpha adrenergic stimulation
Abrupt cessation causes rebound HTN
Large atrial myxoma can cause mid diastolic rumble
(since blocks mitral valve)
Can embolize causing neuro deficits
Asymptomatic AS: tx serial echos + inquiry of
symptoms
Most specific test for any valvular prob? Catherization
Done if non invasive shit is inconclusive
First line to stabilize patient= IV fluids
2nd line : pressor support
RV infarct: tx: IV fluids since patient is preload
dependent
Normally start drugs for hypertension at 140 or 90
diastolic
if chronic renal failure, DM, CVS prob then start
drug at 130 or 80 diastolic
if CHF presentation not clear? Check BNP levels
if CHF obvious? Do echo

pericardial knock: .06-.12 secs after aortic valve closes

due to sudden cessation of ventricular filling
constrictive pericarditis: calcification of ant
pericicardium
abdominal bruit heard in Renal artery stenosis
(renovascular hypertension)
tx: angioplasty (after RAS is confirmed)
internal mammary artery Grafts are number one
choice, saphenous is next best choice.
Hypertension + DM, Chronic Kidney fail, Post MI, or
systolic CHF= use ACEi
Hypertension + Raynauds? Tx CCB
RBBB, pulmonary ejection murmur, + fixed S2 split?
ASD
A person with CHF is usually on Diuretics = Potassium
depletion
if this person is also taking Digoxin,
hypokalemia increases the chances for Digoxin
toxicity
MCC of A fib? Hypertension
can also be due to HYPERthyroidism
hyperthyroidism: increased risk of A fib, A flutter, &
Osteoporosis
when can you do Radioactive iodine ablation of
thyroid gland? Only when person is
asymptomatic (controlled with PTU and
methimazole for a couple weeks)
Subtotal thyroidectomy? For hyperthyroidism in 2nd
semester of preggo
If doing synchronized cardioversion in an Unstable
patient with A fib, then have to do ECHO first (to check
for LA clot that may embolize if normal rhythym
restored)
What is the first line therapy for HTN? Dietary
modifications and weight loss
first drug to use: thiazide (unless other
comorbidities)
first ECG finding in MI? hyperacute T waves (tall
positive T waves)
-

next: ST elevation
next: T wave inversion
next: ST back to normal
last: Q waves!!!!

Aortic dissection can cause MI (if dissects coronary

arteries)

ECG findings in PE? Usually right heart strain, ex:

RBBB, sinus tachy, right axis deviation, non specific
ST/T wave changes
first test to do in PE? ECHO (look for
hypokinesis & right heart strain)
confirm with? CT angiogram
Most significant factor that can reduce hypertension?
Weight reduction (by 5-20)
DASH diet? Increase fruits, veggies, low fat foods.
Can decrease BP by 14
Alcohol reduction only reduces BP by 4
WPW tx? First line is Procainamide
2nd line: amiodarone
definite tx? Radiofrequency catheter ablation
why are beta blockers contraindicated for WPW?
Blocks AV node, causing MORE conduction in the
abberant pathway.
adenosine: used for Regular narrow complex tachy
MC presention of HOCM? Dyspnea (SOB)
blocks Aortic valve (aortic stenosis murmur)
increased back pressure to lungs SOB
CABG if: main LCA is involved or PROXIMAL LAD > 70%
stenosis
Aortic stenosis: carotid pulse is brisk in upstroke &
bifid
in old ppl: due to calcification of norm valves
in middle aged: due to Bicuspid valves or
Aortic root dilation from chronic HTN
in developing countries/immigrants: rheumatic
fever
occasional palpitations in Premature atrial contractions
if no symptoms then no tx necessary
if hyperlipidemia patient tx is based on risk factors
HDL more than 60 then u can take off a risk
factor
Most effective therapy for hot flashes? Estrogen
Estrogen is NOT contraindicated in history of
endometrial hyperplasia