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Clinical Medicine I, Part III
occupational disorders, pulm emergencies, cv testing, ecg, cad/acute coronary syndromes, dyslipidemia, NSTEMI/STEMI, Arterial/Venous vascular diseases, HTN
153
Medical
Graduate
02/20/2010

Additional Medical Flashcards

 


 

Cards

Term

OCCUPATIONAL DISORDERS

2/2/10

Definition
Term
4 occupational stressors
Definition

1) chemical hazards: excessive airborne concentrations of vapors, gases, solids, dusts

2) Physical hazards: electromagntic/ionizing radiation, noise, vibration, temp extremes

3) ergonomic hazards: improperly designed tools/work areas

4) biological hazards: insects, molds, fungi, bacteria

Term
3 routes of entry of occupational hazards into the body
Definition

1) inhalation via lungs

2) ingestion (eg. eating at lab space)

3) absorption via skin

Term

4 reasons to get occupational hx:

 

Definition

1) disease etiology

2) evaluate toxic materials/extenet of exposure

3) recognise unusual patterns of illness

4) evaluate new chemicals introduced into industrial setting

Term
3 reasons when an exposure hx should be obtained...
Definition

1) possible exposure

2) atypical disease presentation

3) disease unresponsive to tx

Term
Ask every pt these 5 occupational exposure screening questions
Definition

1) type of work

2) health problem related to work?

3) sx differ btwn work and home?

4) current and past exposure: chem, dust, metal, radiation, noise, repetitive work

5) similar sx with co-workers?

Term
ROS/SH of occupation Hx (2)
Definition

GYN: miscarriages, stillbirths, prior pregnancies, difficulty conceiving, change in libido, change in menses

 

ALCOHOL: confounding factor in pts with suspected toxic exposure

Term

PULMONARY EMERGENCIES

2/4/10

Definition
Term
Initial Assessment for Resp Distress (6)
Definition

1) RR

2) Accessory Muscles

3) O2 Saturation

4) Tidal volume

5) Color

6) Diaphoresis on forehead/back of neck

Term

nml RR adult, baby

 

nml pulse ox - rm air, copd, if # not reliable do...

 

cap refill nm

 

P CO2 nml values,

 

Definition

nml RR adult 10-20 rpm, baby >60 rpm

 

nml pulse ox - >92% rm air, copd 90%, if # not reliable do...ABG

 

cap refill nml  <2 sec

 

ABG: PCO2 nml 35-40%, COPD 55%

Term

Lung exam findings

 

1) silent chest

2) crackles

3) dullness to percussion in one area

Definition

1) silent chest: emphysema & bad in asthma

2) crackles: fluid buildup: CHF, infiltrate, tumor, blood

3) dullness to percussion in one area

Term

management of respiratory distress?

 

1) What is the most important issue

2) pt position

3) use what 2 drugs?

4) what helps COPD pts

Definition

1) O2 sat, keep up with nebulizer

2) upright

3) tx steroids and IV ABX (leviquin) if fever present

4) CPAP: device to deliver continuous positive pressure to keep alveoli open.

Term

Respiratory Failure

 

1) PO2 and P CO2 numbers by definition

2) numbers may not be functional in what pts?

3) what procedure must you do?

Definition

1) PO2=50-60 mmHg

PCO2=50 mmHg or greater

 

2) COPD

 

3) ET tube

Term

5 yr old pt presents to ER on a winter night with barking cough that gets better with cold air and worse at night, low grade fever.

 

Dx and Tx

Definition

Dx: Croup (6ms-6yrs)

 

Tx: steroids: racemic epinephrine (nebulizer).

tylenol+codeine+decadron (0.5mg/kg)= cough suppresent, treats, fever, decr inflamm

Term

Bacterial Tracheitis

 

1) common age affected

2) tx

Definition

1) 5-10 yrs

2) IV ABX, steroids, nebulizers, admission

Term

Adult presents to ER with fever and hot potato voice with drooling and difficulty swallowing.  Pt resides in tripod position.

 

Dx and Tx

Definition

dx: epiglottitis (mostly adults b/c prevented by H influenzae vaccines in children now)

 

tx: IV ANX, steroids, ENT involvement, admission

Term
2 abcesses that cause respiratory emergencies:
Definition

retropharyngeal &

peritonsillar (young adults post GABHS)

Term

Allergic rxn that involves face, tongue, eyes.

 

dx, questions that should be asked, tx

Definition

dx: angioedema

 

q: look for allergen: PCN, foods, environment

 

tx: diphenhydramine (IM), H2, blockers, steroids

Term

more than 2 or 3 ribs on one side of chest that are broken in two places.  Causes paradoxical breathing: inhale= injured part goes IN instead of OUT.  Can restrict breathing.  Due to trauma (car accidents with banging against steering wheel).

 

Definition
Flail Chest
Term

pt presents to ER with dyspnea.  Has low O2 sats, CXR hyperaeration, cyanosis , sentence dyspnea, accessory muscle use, tachycardia, tachypnea

 

Dx and tx

Definition

Status Asthmaticus

 

OR

 

Severe Asthma

 

tx: B2 agonists, steroids, IV fluid, intubation to prevent ARDS

Term

In a COPD exacerbation, check ABG for....

 

tx:? (what is last resort?)

Definition

CO2 retention

 

tx: steroids, b2 agonists, ABX (if infxn present), IV fluids, INTUBATION last resort

Term

This condition has no typical presentation.

 

Sometimes there is unexplained tachycardia, tachypnea, pleuretic chest pain (pain on inspiration), dyspnea

 

dx:

labs:

tx:

Definition

dx: PE: causes: immolization, recent surgery, pregancy, malignancy, lower extremity fracture, hypercoagulopathy

 

labs: bilat ultrasounds, V/Q, spiral CT angiogram, D dimer*

*D dimer high in pregnancy

 

tx: moderate PE= LMW heparin.  large PE= thrombolysis (risky!)...but this type of PE may put pt into shock, need to treat ASAP.

Long term coumadin  post PE.

Term
In a pregnant pt, you order a D-dimer.  What should be noted...
Definition

D dimer usually high in pregnant pt, don´t assume clot/PE.  Get a CT, even if in 3rd trimester.

 

PE most common in 2nd and 3rd trimesters.

Term

Life threatening lung failure caused by sepsis, major trauma, or inhalation of toxic fumes.

 

Mech: alveoli inflammed, fill with fluid, and collapse...no gas exchange.

Definition
ARDS
Term

Symptoms & Signs
Dyspnea, tachypnea, cyanosis, obvious distress
CXR fluid in alveolar space of both lungs

ABGs--severe hypoxemia

 

dx and tx?

Definition

dx: ARDS

 

tx: mechanical ventilation, tx of underlying cause

Term
lung parencyma collapse, separation of parietal and visceral pleurae, no shift of mediastium, no shift of diaphragm
Definition
simple pneumothorax
Term
progressive accumulation of air under pressure within pleural cavity, mediastinal shift and compression of contralateral lung
Definition
tension pneumothorax
Term

tx of ....
1)   Small pneumothoraces
2) Moderate and Large pneumothoraces
3) Tension pneumothoraces

Definition

1) Monitor for progression/resolution with repeat CXRs

 

2) Need chest tube for gradual decompression

 

3) Require  immediate needle decompression followed by chest tube placement

Term

CARDIOVASCULAR TESTING

2/9/10

Definition
Term

Non invasive technique that utilizes high frequency ultrasound( 2.0 to 7.0 MHz) to evaluate structural, functional and hemodynamic status of the  cardiovascular system in real time

Definition
echocardiology
Term

2-d echo pictures are obtained using 4 standard transducer positions...

 

Pt positions...

 

 

Definition

1) parasternal (L sternal border)

2)apical (L, midclav line)

3)subcostal

4) suprasternal

 

L lat decub: for parasternal & apical views

supine: subcostal & suprasternal views

Term
measuring the tricuspid regurg can allow you to calculate estimated....
Definition
pulm artery pressures (nml 4-12mmHg)
Term

a benign cardiac tumor that is usually attached by stalk to interatrial spetum, usually moves with blood flow or might completely prolapse into LV during diastole (mimics mitral stenosis w/ diastolic rumble)

 

what is this and how can it be seen?

Definition
myxoma: echocardiogram
Term
24 hr ECG lead system to evaluate palpitations, sycope, ischemia, detect freq & severity of rhythm disturbances
Definition
Holter Cardiac monitor
Term
used to evaluate sustained palpitations
Definition
cardiac event monitor
Term

A nuclear scan that evaluates the pumping function of the ventricles. Quantitatively evaluates LV ej fraction (esp pre and post chemo tx).

 

Indications: LV assessment, ej frac, wall motion abnmlities, LV aneurysm detection, cardio toxicity eval

 

Definition
multiple gated acquisition (MUGA)
Term

Can calculate LVEF and RVEF
Bolus injection of the radioisotope
Images obtained during the  initial pass of the radiotracer

 

Definition
First Pass Studies
Term

-HR and BP response
-Arrhythmia
-Signs/Sx’s of Stress Intolerance (cyanosis)
-ST-T changes
-Workload achieved

....parameters to evaluate during what test?
*contrandications of this test?
*sensitivity
*what HR is test diagnostic?

 

Definition

Stress Test

 

Contraindications:  recent signif ECG changes, unstable angina, uncontrolled arryhthmias, heart blocks, acute CHF, severe AS, suspected PE/DVT, acute infection, uncontrolled DM

 

sensitivity 65-75%

 

dx: 85% of age predicted max HR (220-age)

Term
Stress testing improvements for motion and uptake(2)
Definition

motion: stress echo. Do this resting and with exercise.

 

uptake: stress nuclear, isotope lights up in walls where it is uptaked in 1hr.  No allergic rxns to T201 isotope (attached to RBCs).  Do this resting and with exercise.

Term
Persatine and Dobutatme are used for what cardiac test?
Definition

Pharmacologic Stress testing

 

persatine + isotope in nuclear stress test*

dobutamine in stress echo

 

*contraindicated in COPD, bronchospastic pts, tx with theophylline.

Term
this delineates coronary anatomy after a positive stress test.  also indicated to investigate chest pain etiology, hemodynamics of heart, and shunt/valvular disease evaluation.
Definition
cardiac catheterization.
Term

Cardiac Catheterization

 

1) catheters administered via...

 

2) can inject.... (what do you do if there is an allergy?)

Definition

1) R femoral artery

 

2) can inject dye (give steroid before if known allergy to dye)

Term

PTCA (percut transluminal coronary angiography) is used to evaluate.....

 

 

PCI (percut intervention) is used to evaluate.....(2)

 

**what are these two things?

Definition

PTCA: coronary artery stenosis

 

PCI: renal/carotid artery stenosis

 

 

**angiography

Term
what is used to map/ablate arrhythmias and for pacemaker evaluations?
Definition
EPS: electrophysiology
Term
This test produces high quality still and moving pics of the heart and great vessels.
Definition
MRI
Term
This test uses non-invasive means to measure coronary Ca, which provides an estimate of the extent of coronary plaque burden.
Definition
EBCT (electron bean CT) for coronary artery scanning.
Term

Cardiac Enzyme:

 

highest levels found in skeletal muscle.  Also in myocardium and brain tissue.

 

elevated 2-4hrs post-MI

Peaks at 24-36 hrs

returns to nml in 3 days

 

what enzyme and list 3 types.

Definition

CPK mb: creatine phosphokinase

 

CPK nm = skeetal muscle

CPK bb = brain tissue

CPK mb= cardiac

Term
SGOT
Definition
serum glutamic ocalacetic transaminase : cardiac enzyme no longer used.
Term

Cardiac Enzyme:

 

found in cardiac and skeletal muscle, but this assay is cardiac specific.

incr levels with cardiac ischemia/MI.

 

rises within 3hrs of injury

continously released for 5-10 post injury

peaks @ 20x nml level

remains elevated for up to 2 wks.

 

What is this?  Is it more sensitive than what enzyme, in what sense?

Definition

Troponin I

 

More senstive than CPK-MB b/c just low levels of troponin I determine necrosis.

Term

substance secreted from ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops or worsens.

 

 

the level increases when heart failure develops/worsens:

give values of

-no CHF

-Suggestive of HF

-mild, mod, & severe HF

Definition

BNB B type natriuretic peptide

 

BNP increases in blood when HF develops and worsens

 

<100 pg/mL = no CHF

100-300= suggestive

300 mild

600 mod

>900 severe

 

 

Term
increased levels of this thiol are associated with increased risk of CAD ,PVD, CVA, venous thromboembolism.
Definition
homocysteine (cholesterol testing)
Term

ECG Timing

 

large box (sec)

small box (sec)

HR (measured interval btwn adjacent complexes)

Definition

 

large box= 0.2 sec (200msec)

small box = 0.04 sec (40msec)

 

HR = 300/# large boxes =

300, 150, 100, 75, 60, 50, 43

<3 large boxes=tachycardia

>5 large boxes=bradycardia

Term

ECG

 

1) SA node firing (atrial depolatization)

2) AV node firing through bundle of his and purkinje fibers (ventricular depolarization)

3) time for impulse to go from SA to AV node

4)repolarization of ventricles

5) rarely seen repolarization of atria

5) time btwn  depolarizing and repolarizing

Definition

P WAVE: SA node firing (atrial depolatization)

 

PR INTERVAL: time for impulse to go from SA to AV node

 

QRS COMPLEX: AV node firing through bundle of his and purkinje fibers (ventricular depolarization)

 

ST SEGMENT: time btwn  depolarizing and repolarizing

 

T WAVE:repolarization of ventricles

 

U WAVE:rarely seen, repolarization of atria

[image]

Term

NSR: normal sinus rhythm

 

paced at....

conducts down....

variation with....

Definition

 (paced @ SA NODE)

 

60-100 bpm, regular

 

conducts down normal pathways

 

can have variation with breathing

Term

ECG INTERPRETATION: THE BASICS

2/9/2010

Definition
Term
3 ECG indications
Definition

1) cardiac disease pt

2) screen for occult cardiac abmlty; ensure absence of acute disease

3) baseline pic of heart

Term

Heart electrical conduction system

(state path from SA to myocardial cell innervation)

Definition
SA node>internodal tract/bachmann's bundle>AV node>bundle of His>L/R bundle branches>purkinje fibers=myocardial cell contraction.
Term
3 types of cells in heart
Definition

1) pacemaker

2) electrical conducting cells

3) myocardial

Term

MYOCARDIAL CELLS

The major part of the heart tissue, these cells contain an abundance of _____ and ______
Responsible for repeatedly ______ and _______, thereby delivering blood to the rest of the body
When a wave of depolarization hits the myocardial cell, ________ is released within the cell, causing the cell to contract (_______________ Coupling)

Definition
The major part of the heart tissue, these cells contain an abundance of actin and myosin
Responsible for repeatedly contracting and relaxing, thereby delivering blood to the rest of the body
When a wave of depolarization hits the myocardial cell, calcium is released within the cell, causing the cell to contract (Excitation-Contraction Coupling)
Term

Myocardial cells:

1) intracellular has incr conc of....

2) extracellular has incr conc of.....

3) where is the greater positive charge located?

4) net charge of cell @ rest, what must enter cell for contraction

Definition

1) intracellular has incr conc of K+

2) extracellular has incr conc of Na+, Ca++

3) greater positive charge is extracellular

4) net charge= negative @ rest.  Influx of Na+ begins contraction.

Term

•__________ is propagated from cell to cell, producing a wave that can be transmitted across the entire heart.  What type of charge comes into cell during this process?  Inflection on ECG = ?
When a this wave is complete, cardiac cells cells are restored to their resting state in a process called __________, where cells regain ______ charge.

 

Definition

Depolarization is propagated from cell to cell, producing a wave that can be transmitted across the entire heart.  Positive charge comes into cell (Na+).  Pos inflection on ECG.
When a wave of depolarization is complete, cardiac cells cells are restored to their resting state in a process called repolarization, where cells regain negative charge.
Term

ECG basic components:


1) Deflection from baseline that represents a cardiac event


2) Specific portion of the complex as represented on ECG, joins 2 waves

3) Distance, measured as time, between two cardiac events

 

Definition

1) Wave: Deflection from baseline that represents a cardiac event
2) Segment: Specific portion of the complex as represented on ECG, joins 2 waves
3) Interval: Distance, measured as time, between two cardiac events, containing segment and at least 1 wave.

 

Term
In hyperkalemia, T wave is....
Definition
peaked
Term

Q wave:

 

1) significant Q wave is defined by (2)....indicates(1)...

 

2) insignificant Q wave commonly found in leads (3).....due to.....

Definition

 

1) significant Q wave is defined by

t 0.03 seconds

OR

Amplitude1/3 of R wave amp.

Indicates MI over involved region.

 

2) insignificant Q wave commonly found in leads I, aVL, & V6, due to septal innervatio (¨septal Qs¨)

Term

Normal time intervals:

 

1) PR interval

2) QRS duration

3) QT interval.  Prolonged indicates...

Definition

 

P-R Interval: 0.12-0.20 seconds
QRS Duration: 0.06-0.10 seconds
Q-T Interval: varies with heart rate, usually 1/2 of R-R interval.  Prolonged= life-threatening arrhythmias.

[image]

Term

PR segment: what length is pathologic?

 

ST segment: what is representative of myocardial injury or infarction?

Definition

PR segment:   >0.8mm

 

ST segment:elevation

Term
Point where ST segment begins is called....
Definition
J point
Term

Conventional  ECG

name all the leads: limb and chest leads and what plane they are in, and location on chest (picture it, I put a picture on the other side).

 

 

Definition

 

Limb/extremity leads:

coronal plane - hexaxial system (leads 30º apart)


-Bipolar standard limbs: I, II, III

-unipolar limb leads: aVR (R arm), aVL (L arm), aVF (L leg)

 

Chest/Precordial Leads:

transverse plane - precordial system

- V1, V2, V3, V4, V5, V6

 

[image]

 

 

 

Term

Standard format for most ECGs:

 

1) picture of lead order on ECG printout

2) Each lead= ? seconds

3) Full ECG is how many seconds

4) boxes and time (1 sec, big, small boxes)

5) Ht (1mV, mm, small boxes, big boxes)

Definition

Standard format for most ECGs:

1) picture

[image]

 

2) Each lead= 3 sec

 

3) Full ECG = 12 sec

 

4) 1 sec=5 big boxes (0.20 sec each) =25 small boxes (0.04sec each)

 

5) Ht (1mV=10mm=2 big boxes=10 small boxes)

Term

Clinical ECG Lead Groups:

1) inferior wall

2) lateral wall

3) anterior wall

4) septal wall

5) odd ball

Definition

[image]

odd ball is aVR (R arm)

 

 

FYI reference for table above:

[image]

Term

ECG: HR calculation by counting thick lines:

 

**how many thick lines defines tachy/bradycardia

Definition

find R wave that begins on thick line, count the thick lines up to the next R wave in this order:

 

HR: 300, 150, 100, 75, 60, 50

 

<3 big boxes=tachycardia (HR>100)

>5 big boxes=bradycardia (HR<60)

 

[image]

 

Term
3 irregularly irregular ECG rhythms
Definition

Atrial fibrillation

wandering atrial pacemaker

multifocal atrial tachycardia

Term

P waves

 

1) indicate  _____ or _____ compenent

2) 2 causes of un-identical P waves (abnml)

3) # of p waves: #QRS waves >1....(abnml number suggests)...

Definition

 

1) indicate  atrial or supraventricular compenent

 

2) 2 causes of un-identical P waves (abnml):

-additional pacemaker firing

-superimposistion

 

3) # of p waves> #QRS waves... (this is abnml, should be =)... suggests AV nodal block

Term

QRS complex

 

1) narrow indicates...

2) wide indicates...

3) un-/grouping can determine...(2)

4) dropped beats occur in ...(2)

Definition

1) narrow indicates supraventricular rhythms

 

2) wide indicates impulses transmitted by direct cell-cell contact

 

3) AV nodal block or recurrent premature complexes

 

4) Dropped beats: AV nodal block OR sinus arrest

Term

CAD AND ACUTE CORONARY ARTERY SYNDROMES

2/12/10

Definition
Term
Top 6 Chest Pin causes
Definition

1) MI

2) Thoracic Aortic Dissection

3) PE

4) Pneumonia

5) Pneumothorax

6) Boerhaave's Syndrome: esophageal perforation due to vomitting.

Term

MI

1) miss rate increases with...(gender, age, pain)

2) classic HPI...unrelieved by...

3) ECG (taken within how many minutes of pain onset?, ST, Q, T, arrythmia)

4) what % of MI come with normal ECG?

Definition

1) miss rate in dx of MI associated with significant morbidity/mortalities.  Increased missed rate in women, age<50y/o, SOB complaints, no pain (50% of 80 year olds), or pain in uncommon locations (neck, throat, wrist).

 

2) severe squeezing >30min w/ radiation to jaw, L arm, neck, unrelevied by nitroglycerin/rest. *This is not always the case.* Assoc sx: diaphoresis, N/V, fatigue.

 

3) ECG:

ST elevation

Q waves= appears 12-36 hrs after damage

T waves Hyperacute or Flipped

Possible Arrythmias

 

4) 10% MIs have normal ECG

 

Term
What diagnostic test would you use if you suspect PE, Aortic Dissection, Cardiac Tamponade, or to evaluate Ca blockages in coronary arteries?
Definition
CT scanners
Term

ACS (acute coronary syndrome) epidemiology:

 

1) % that have STEMI?

(STEMI= ST elevated MI)

 

2) % that have UA/NSTEMI?

(UA=unstable angina, NSTEMI= non-ST elevated MI)

...of these pts, what % have elevated troponin

(troponin=evidence of myocardial necrosis)

Definition

1) 25% that have STEMI

(STEMI= ST elevated MI)

 

2) 75% that have UA/NSTEMI?

(UA=unstable angina, NSTEMI= non-ST elevated MI)

...of these pts, 40-60% have elevated Troponin levels.

 


**FYI: The cardiac troponins T & I...

   - released within 4–6 hours of MI

   - remain elevated for up to 2 weeks

   - nearly complete tissue specificity

   - preferred markers for asssessing myocardial damage

 


Term

Angina (definition: Angina pectoris is severe chest pain due to ischemia):

 

1) cardiac pain secondary to...

 

2) etiology

 

3) 3 types of angina:

a) Stable: plaque, pain location/quality/precipation/palliative factor/duration?

b) Unstable: plaque, pain onset/duration/Hx.  3 other causes with same clinical presentation.

c) Prinzmetal's Angina: cause. 

 

 

Definition

1) Angina is cardiac pain secondary to cardiac ischemia*.

 

2) Angina etiology is caused by atherosclerosis (atheroma (fatty plaque) formation in arterial BVs)

 

3a) Stable Angina (thick fibrous arterial plaque cap).  Deep/squeezing/heavy chest pain anywhere btwn mandible and umbilicus.   Precipitated by exertion/emotional upset.  Alleviated by rest within 1-2 min.  Duration= 2-30min.

 

3b) Unstable Angina (UA): (thin plaque cap that can rupture, causing UA/MI.  Pain not associated w/exertion.  Increasing freq/duration/severity/pattern of previous ischemic symptoms.

Other causes with same clinical presentation:

-Recurrent isch 4-6 wks post PCI**/CABG***

-recurrent pulm edema

 

3c) Prinzmetal's Angina: angina (cardiac chest pain) at rest that occurs in cycles. It is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than by atherosclerosis

 

 

FYIs:

*Cardiac Ischemia=defieciency of blood to myocardial cells.  Supply is not equal to demand.

  • Ischemia > 20min may lead to irreversible damage (MI).   
  • Some diseases increase myocardial oxygen consumption (MVO2) to such a point that compensatory mechanisms fail and the heart cells become ischemic (imbalance between supply and demand).

**PCI= Percutaneous Coronary Intervention: balloons, stents, angioplasty, atheroectomy, thrombectomy, etc.


***Coronary artery bypass surgery (CABG) relieves angina and reduces the risk of death from CAD. Arteries or veins from elsewhere in the body are graftedcoronary arteries to bypass atheroscleroticnarrowings and improve the blood supply to the coronary circulation supplying the myocardium . This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. 

Term

Pt presents to ER with chest pain, & you dx ACS (acute coronary syndrome).  You do the standard procedure: IV, O2 mask, Heart Monitor, CXR (unremarkable), Hx, PE with vitals/pulse Ox, and ECG...

 

1) if ECG shows ST elevation, what are two diagnosies?

 

2) if ECG shows no ST elevation, what are 2 possibilities (which is majority and which is minority, and what distinguishes the two)?

Definition

1) ST elev:

Q wave MI (QwMI)= majority

non Q wave MI (NQMI) = minority.

 

 

2) No ST elev:

NSTEMI = must have elevated blood markers (Trop, CK-mB).

UA

 

Term

During myocardial necrosis (from an ostructed coronary artery), why is a

very narrow zone of myocardium immediately beneath the endocardium is spared from necrosis?

Definition

necrosis because it can be oxygenated by diffusion from the ventricle.

Term

What 2 cardiac blood markers are released at a similar initial release time (within 2-4 hours of chest pain onset)?

 

When are they tested?

Which is more sensitive/specific?

Which is best for a late diagnosis of MI?

 

 

Definition

troponin I & T 

-test usually ordered with a suspected MI at presentation to ER (only suggestive of MI)

- test repeated 6-12 hours later (for def dx).

-Troponin values can remain high for 1–2 weeks post-MI.

-Very sensitive and specific: The test is not affected by damage to other muscles.

 

 

CK-MB can usually be elevated in MI pts about 3-4 hours after onset of chest pain.

-peaks in 18-24 hours

-levels return to normal within 72 hours.

 


Term

TIMI (thrombolysis in MI) RISK SCORE:

the higher the number, the greater the risk of complications/death.

 

1) to predict the benifit of.....

 

2) What TIMI score do you use PCA?  (do you even know what PCA is?)

 

3) TIMI SCORE of 0 to 2, what is the next test to perform?

Definition

1) to predict the benifit of early invasive strategies for UA/NSTEMI.

 

2) PCA (percutanous coronary intervention= angioplasty) used in management of med/high risk UA/NSTEMI (TIMI >3).  PCA includes balloon angiography (w/ or w/o stent), Atherectomy, Thromboectomy.

 

3) TIMI 0-2= low risk. Stress test.  If high risk stress test, do coronary arteriography.  If not high risk, tx with statins, ACEi.

Term

Pt presents with sudden onset of sharp chest pain.  Pain is relieved by leaning forward while sitting upright.  Pt is febrile.  Rub heard on physical exam.

 

Dx & definition

Etiology

Dx labs

f/u test

OTC tx & tx goal

Definition

Pericarditis


definition: fluid accum btwn parietal and visceral pericardium.  Inflammation as well.

 

Etiology: viral, bacterial , fungal ,malignancy, drugs, uremia.

 

Labs:CXR

 

f/u: echo

 

tx: NSAIDS, goal: look for the cause

Term

Who can go home with chest pain?

 

1) age

2) risk factors

3) enzymes

Definition

1) <35 y/o

2) minimal risk factors

3) repeat cardiac enzymes in 4-6 hrs to ensure NO elevated levels of troponin of CK-mb

Term

DYSLIPIDEMIA

2/12/10

Definition
Term

*FYI CARD*

*Don´'t need to memorize, just helpful for this lecture*

 

LIPID PROFILES: don't even try to guess, just flip

Definition

Why?

- To determine risk of CHD (coronary heart disease). 

- Good indicators of likeliness of MI or CVA.

 

What the lipid profile includes:

-TC         Total Chol

-HDL-C    High Density Lipoprotein Chol

-LDL-C     Low Density Lipoprotein Chol

-TG          Triglycerides

...extended profile...

-VLDL-C   very low density lipoprotein chol

-non-HDL-C

 

When?  *know this for test*

-Screening begins @ 20y/o q. 5yrs (possibly just chol test, not full lipid profile).

-Screening begins EARLIER with +FH, DM; HTN, obesity.

 

Optimal Values:

  • total cholesterol: <200 mg/dL.
  • HDL-C: >40 mg/dL (women) & >50 mg/dL (men).
  • LDL-C: <100 mg/dL.
  • TG: <150 mg/dL.

Calculated Values:

  • VLDL-C = TG/5 (estimated).  High levels associated with incr risk of CHD & CVA.
  • Non-HDL-C = TC - HDL-C = (calculated).  Represents atherogenic cholesterol.  Used to assess risk of CVD.
Term

Lipoproteins:

 

1) Composition: core, outer layer, surface molecules

2) general role

 

Types (low to high density):

a) carry TGs from intestines

b)carry trialglycerol from liver to adipose tissue

c) not detectable in blood

d) carry cholesterol from liver to cells, "bad cholesterol"

e) collect chol from tissues, & return it to liver,  "good cholesterol"

Definition

1) Core: TGs and chol esters carried internally, shielded from the water by the phospholipid monolayer.

Outer layer/Surface Molecules: hydrophilic polarizedphospholipids, free chol, and apolipoproteins directed outward.


2) Role:  Transport lipids (mainly TGs and cholesterol esters) and fat-soluble vitamins to/from body tissues

 

Types (low to high density): *memorize those in red*

a) Chylomicrons: carry TGs from intestines

b) VLDL: carry trialglycerol from liver to adipose tissue

c) IDL: not detectable in blood

d) LDL: carry cholesterol from liver to cells, "bad cholesterol"

e) HDL: collect chol from tissues, & return it to liver,  "good cholesterol"

Term

Responsible for the interaction b/w cell surface lipases and the lipoprotein receptors necessary for lipid catabolism. Required for the assembly and structure of lipoproteins

 

Definition
Apolipoproteins (on surface of lipoproteins).
Term

-Pathogenesis: oxidized LDL/lipid particle uptake by vascular endothelium by macrophages→(+) feedback loop via chemotactic factors→atheroma (“plaque”) formation.

 

Definition
Atherosclerosis
Term

Atheroma ¨plaque¨formation:

 

a) Describe (endothelial injury) to (rapid increase of collagen, lipid/debris, & smooth muscle) in stages

 

b) What stage is a fatty streak (early stages of atheroma) formed?

Definition

Endothelial Injury (HTN, tobacco, homocysteine, etc.)

Endothelial Dysfunction (∆ permeability to leukocytes/monocytes, lipoproteins )

Smooth Muscle Emigration/Monocyte Activation

“Foam Cell” Formation (Monocyte and Smooth Muscle)

Proliferation of: Collagen, lipids/debris, Smooth Muscle

 

b) after smooth muscle emigration/monocyte activation

Term
5 major risk factors for CHD
Definition

1) cigs

2) HTN

3) FH of CHD in 1st degree relative

4) AGE (men>45, women>55)

5) HDL-C <40mg/dL

Term
Ischemic heart disease, CVA (ruptured aneurysm), and PVD are the top 3 complications for what disease?
Definition
Atherosclerosis
Term

Athersclerotic Lesions

 

1) Thin, flat yellow intimal discolorations that progressively enlarge

2) The accumulation of intracellular and extracellular lipids, proliferation of vascular smooth muscle cells, and formation of scar tissue 

3) Contains hemorrhage, ulceration, and scar tissue deposits
Definition

1) Fatty streaks

Thin, flat yellow intimal discolorations that progressively enlarge
2) Fibrous atheromatous plaque
The accumulation of intracellular and extracellular lipids, proliferation of vascular smooth muscle cells, and formation of scar tissue 
3) Complicated lesion
Contains hemorrhage, ulceration, and scar tissue deposits
Term

-Vessel narrowing & ischemia

-Sudden vessel obstruction

-Thromboemobli formation

-Aneurysm

 

are clinical manifestations of...

Definition
atherosclerosis
Term

Phenotype IIb (mutation of LDL receptor gene OR APL-B gene) and phenotype IV (mutation in LP lipase) are the most common....

 

which has greater atherogenic potential?

 

IIB has increased....

IV has increased....

Definition

familial hyperlipoproteinemias.

 

IIB>IV in atherogenic potential.

 

IIB= incr LDL, VLDL, TG, Chol

IV= incr VLDL, TG

Term
Xanthomas in the skin and tendons, commonly in achilles and eye, represent....
Definition
excessively high cholesterol (to the point where it is popping out of the skin!)
Term

Secondary Dyslipedemic Factors (6)

 

HeRe

HoMe

LiMe

 

Definition

HeRe

HoMe

LiMe

 

Hepatic

Renal

Hormonal

Metabolic

Lifestyle

Meds

Term

Therapy for Dyslipidemia:

 

a) Non-Pharmacologic

1) diet

2) lifestyle

3) natural products

 

b) Pharmacologic

MOA: name the agent

  • block rate-limiting step (mevalonic acid to cholesterol)
  • decreases hepatic VLDL synthesis
  • Increase LPL activity and decreases VLDL synthesis
  • Increase bile acid/cholesterol excretion and LDL receptors
  • Decreases intestinal cholesterol absorption
  • Decreases chylomicrom/VLDL synthesis

Definition


a) Non-Pharmacologic

1) diet: ↑fiber, ↓ETOH, ↓Fat (sat), CH2O (¿formaldehyde?  what the fuck is this?)

2) lifestyle: quit smoking, lose weight, exercise

3) natural products: plant sterols/stanols (psyllium, soy, chinese red yeast)

 

 

b) Pharmacologic

MOA:

Statins: block rate-limiting step (mevalonic acid to cholesterol)
Niacin (nicotinic acid): decreases hepatic VLDL synthesis
Fibrates (fibrinic acid deriv): Increase LPL activity and decreases VLDL synthesis
BAS (bile acid sequestrants): Increase bile acid/cholesterol excretion and LDL receptors
BATI (bile acid transport inhibitors): Decreases intestinal cholesterol absorption
OM3FAs (fish oil): Decreases chylomicrom/VLDL synthesis
Term

NSTEMI AND STEMI

2/12/10

Definition
Term

STEMI vs NSTEMI 

 

1) STEMI is due to...

tx mainstay is....

 

 

2) NSTEMI is due to...

tx is....(3)

 

3) what 2 drugs are given immediately to any MI pt?

Definition

1) STEMI = sudden thrombotic occlusion (complete block) of a coronary artery.

Tx: thrombolytic therapy.

 

2) NSTEMI = unstable plaque with aggregation of platelets (sudden narrowing).

Tx: anti platelet drugs (ASA, clopidogrel) and anticoagulants (heparin). B-blockers improve symptoms of cardiac ischemia in NSTEMI.

 

3) Immediately: NO and Aspirin

 

 

REVIEW:

NO (nitroglycerine) are nitrovasodilators

ASA & Clop are antiplatelets.

. B-blockers improve symptoms of cardiac ischemia in NSTEMI.

 

 

Term

STEMI:

 

ECG ST elevations are seen on what leads for the following MI locations:

  1. Septal Wall
  2. Anterior Wall
  3. Lateral Wall
  4. Inferior Wall (*what leads are reciprocal changes in?)
  5. Posterior Wall (*tricky trick, what happens to ST on anterior/posterior leads?)
  6. RV Infarct

What other ECG changes are seen as you move from ischemia to infarction of myocardium?

Definition
  1. Septal Wall: V1, V2
  2. Anterior Wall: V3, V4
  3. Lateral Wall: I, aVL, V5, V6
  4. Inferior Wall: II, III, aVF
    • Reciprocal Changes: I, aVL, V leads
  5. Posterior Wall:
    • ST depression-V1, V2, V3
    • ST elevation on posterior leads: V7, V8, V9
  6. RV Infarct: V3R, V4R, V5R, V6R

Other STEMI ECG changes:

  • Ischemia
    • ST depression
  • Infarction
    • ST elevation
    • significant Q wave (ht > than 1/3 R Wave Ht)
    • T wave inversion
Term

STEMI MANAGEMENT:

 

1) Inital Management (3)

 

2) Initial labs (4)

 

3) treat pain ASAP with...but have caution with these conditions (2)...    2nd line pain tx...but caution...

 

4) reprofusion therapy: goal time frame, method

 

5) antithrombin

 6) antiplatelet (2)

7) oral of this class drug is preferred over IV

8) these drugs lower LDL

 

9) AVOID!!!!

Definition

1) O2, IV access, continous cardiac monitoring

 

2) assess ABG, 2D echo, CXR, serial ECGs

 

3) Nitrates: caution in AS, RV infarction

2nd line: Morphine: possible increase in mortality

 

4) reperfusion within 2 hrs: PCI fibrinolysis

5) antithrombin - heparin

 6) antiplatelet (2) - ASA, clopidigrel

7) beta blockers: oral of this class drug is preferred over IV

8) Statins: lower LDL

 

9) AVOID: NSAIDS!!!, tobacco, hyperglycemia, CCB

Term

Conduction Disturbances (AV block)

Pericarditis (Dressler's*)

Heart Failure/LV dysfunction

LV free wall rupture

Ventral Septal Defect

Papillary muscle dysfunction

Dysrhythmias

Recurrent Angina

LV aneurysm (+/- thrombus)

 

....complications of what?

Definition

STEMI complications

 

*FYI - Don´t memorize this.

Dressler's syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium (the outer lining of the heart). The syndrome consists of a persistent low-grade fever, chest pain (usually pleuritic in nature), a pericardial friction rub, and /or a pericardial effusion. The symptoms tend to occur after a few weeks or even months after infarction and tend to subside in a few days. An elevated ESR is an objective laboratory finding.

 

Term

Poor Prognosis factors for STEMI pts:

 

1) gender?

2) age?

3) PMH (3)

4) wall location of current MI

 

Definition

females

age>70

Hx: DM, prior angina/MI

Anterior Wall MI

Term

PERIPHERAL ARTERIAL DISEASE

2/16/10

Definition
Term
% of population age >55 with PAD (periph arterial disease) which are asymptomatic.  % with intermittent claudication.
Definition

50% asympto

40% claudication

Term

ABI evaluates...

(ankle brachial index)

 

ABI Values of....

1) an ischemic lesions unable to heal

2) ¨reasonable¨

3) healthy

 

**Sclerotic distal arteries give what kind ankle pressures?

Definition

ABI evaluates arterial disease.

 

1) an ischemic lesions unable to heal= 0.3

2) 0.6= ¨reasonable¨

3) 0.9-1.0= healthy

 

**Sclerotic distal arteries give false high ankle pressures

Term

Crtical stenosis is an ___% dropoff in arterial blood flow.  This is why PAD pts develop symptoms relatively ______ in the course of their disease.

 

 

Definition
Crtical stenosis is an 80% dropoff in arterial blood flow.  This is why PAD pts develop symptoms relatively late in the course of their disease.
Term
What is the functional limitation of PAD?
Definition
Intermittent Claudication: pain on exertion in the muscle (not joints), relieved by rest.  Reproducible by walking the same distance each time.
Term

State the locaton of claudication for each level of occlusion below:

 

1) aorta a

2) iliac a

3) s/f femoral a

Definition

 

1) aorta a...buttock

2) iliac a...hip & thigh

3) s/f femoral a....calf

Term
A 1 minute bedside evaluation of arterial flow to limb involves what 5 things?
Definition

pulse

color

temp

trophic changes

elevation/depency changes*

 

(*elev legs 45 seconds, look for blanching, than quickly place legs dependent.  After blanching, a very ischemic foot develops intense reddish blue on prolonged dependency.)

Term
atherosclerosis (esp in elderly), popliteal entrapment syndrome, and advential cysts all can cause....
Definition
popliteal artery occlusion
Term
What are 2 tests/maneuvers to perform an upper extremity arterial evaluation?
Definition

Allen test

 

Adson maneuver*

 

*a test for thoracic outlet narrowing (subclav a). It is performed with the patient sitting with hands on the thighs. The examiner palpates both radial pulses as the patient takes a deep breath and holds it while extending the neck and turning the head toward the affected side. If the radial pulse on the affected side is significantly diminished or there is numbness or tingling in the hand, the result is regarded as positive.

Term

Pulsed Doppler sound for the evaluation of....(2)

 

describe the quality of sound in good flow and low flow.

 

angle of probe

Definition

venous & arterial diseases

 

good= sharp, high pitch, biphasic (with respiration)

low flow (occlusion) = flat, low pitch, monophasic (with respiration)

 

probe @ 60º

 

 

 

 

Term

With proximal arterial stenosis (aorta, iliac, femoral), after exercise, ankle pressure and pulse volumes will be

 

increased or decreased?

Definition
markedly decreased.
Term

Meds for PAD.  State the class and therapeutic goal.

 

1) clopidogrel (what OTC is also in this class?)

 

2) cilostazol

Definition

1) antiplatelet: to reduce ischemic events:  It has no effect on the symptoms of atherosclerotic disorders but, rather, helps to prevent the acute complications associated with them.

 

**ASA is also good, cheap antiplatelet therapy

 

2) antiplatlet and vasodilator: indicated to improve PAD claudication symptoms by permitting greater blood perfusion of working muscle.

Term
Disabling claudication, non healing ischemic lesions, and ischemic rest pain are all indications for
Definition

invasive management of PAD.

 

(invasive= PTA = percutaneous transluminal angioplasty)

Term
Lower extremity graft material (3) in invasive treatment of PAD.
Definition

saphenous vein (reversed or in situ)

Synthetics: teflon

arm veins (not as good: cephalic and basilic)

Term

Sx include sudden onset of pain, coldness and pallor of lower extremity.  PE reveals no neuro deficit.  You fix the problem by Fogarty catheter embolectomy.

 

What was the dx?  and two possible causes?

Definition

Acute arterial occlusion

 

1) embolus from heart

2) thrombosis on top of chronic atherosclerosis

 

 

FYI***

Fogarty catheter

Introduced more than 30 years ago by Dr. Thomas J. Fogarty, these embolectomy catheters are indicated for the removal of fresh, soft emboli and thrombi from vessels in the arterial system.

Remains the leading choice for simple and rapid removal of emboli and thrombi from the arterial system.

Term

VENOUS DISEASES

2/16/10

Definition
Term

Veins:

 

Perforator (communicating veins) flow from...

 

Deep veins carry what % of venous return?

 

What is the primary deep veins of the thigh?

Definition

Perforator (communicating veins) flow from superficial to deep.

 

Deep veins carry what 80-85% of venous return.

 

Primary deep veins of the thigh: superficial femoral vein.

Term

Virchow's triad describes the three broad categories of factors that are thought to contribute to thrombosis

 

 

what are the 2 categories?

Definition
  • Hypercoagulability
  • Hemodynamic changes (stasis, turbulence)
  • Endothelial injury/dysfunction
Term
A unilateral swollen leg could be causeb by....(3)
Definition

venous insuff (chronic) = pitting edema

DVT = pitting edema

lymohedema

Term

this condition is characterized by local swelling, erythema, tender/indurated cord, possible fever/tachycardia/edema, with low risk of Pulm embolism.

 

Dx:

tx: (3 non-pharma)

subsudes in...

Definition

superficial thrombophlebitis

 

head, elevation, NSAIDS

 

1-2 weeks it goes away

Term

the symptoms of this condition include pitting edema, dull ache (worse on dependency), tenderness, warmth, dusky color, prominent s/f venous pattern, slight fever with tachycardia

 

what is this?

what non-specific test can be done in office?

what % are asymptomatic?

what is the major threat of this condition?

Definition

DVT

 

Homan's sign: dorsiflexion of foot with knee bent 90º induces calf pain.

 

50% asymptomatic

 

pulm embolism

Term

 

Venous duplex ultrasound is used in the diagnosis of....

Definition
DVT
Term

Treatment of DVT:

 

2 pharmas for the treatment of DVT

 

Therapy to dissolve the clot (indications?)

 

Invasive procedure used when anticoagultion does not work OR pt cannot be anticoagulated.

Definition

anticoagulants:

 

Low molecular weight heparin

warafin (COUMADIN)

 

Fibrinolytic therapy to dissolve the clot given directly to occluded site via catheter, indicated in moderate-severe DVT (Iliac, ilio-femoral, Mae Thurner syndrome).

 

IVC filters

Term
This condition is an associated of DVT with occult malignancy, DVT that is recurrent/resistant/migratory.
Definition
Trousseau's Syndrome
Term

DVT PROPHYLAXIS:

 

Elevation of leg, active leg exercises, compression stockings, and external pneumatic compression all help to decrease...

 

heparin, low dose coumadin help to...

Definition

stasis of venous blood flow.

 

alter hypercoagulable state (ASA doen´t really do anything for DVT).

Term
Brawny, non pitting edema (which may be ptting early on).  This involves superficial tissues rather than deep tissues.
Definition

Lymphedema

 

(Involves s/f tissues because 80% of lymphatics are superficial).

Term

Lymphedema:

 

Primary causes are...

 

Secondary causes (4)

Definition

1º: congential

 

2º: tumor, radiation, surgery, parasites

Term

Intermittent increased or unusual sensitivity to cold or emotional factors producing vasospasm with cold, pallor, pain in the hands and fingers.  this is exaggeration of a normal response. no arterial occlusion involved in primary type.

 

1º type must be present for ___ years without evidence of _______________.

Definition

Raynaud's phenomenon

 

1º type must be present for 2 years without evidence of underlying disease.

Term

HYPERTENSION

2/18/10

Definition
Term

Cardiovascular Mortality Risk ____________ With Each 20/10 mm Hg BP Increment


 

Definition

Cardiovascular Mortality Risk doubles With Each 20/10 mm Hg BP Increment

 

CV risk factors: smoking, dyslipidemia, DM, >60yrs, men, postmeno women, FH

Term

BP measurement

 

1) pt position

 

2) pt should not smoke or ingest caffeine for ____ min before measurement

 

3) measurement should begin ____ min after rest

 

4) how many readings should be averaged?

Definition

1) pt position: seated with back and arm supported

 

2) pt should not smoke or ingest caffeine for 30 min before measurement

 

3) measurement should begin 5 min after rest

 

4) 2 or more readings should be averaged

Term
When is BP lowest?
Definition
Morning
Term
What two methods of BP measurement often provide lower BP measurements than in the clinic?
Definition

Self measurement

 

Ambulatory measurement

Term

F/U recommendations based on initial BP measurements

 

1) <130/<85

2)130-139/85-89

3)140-159/ 90-99

4)160-179/100-109

5) >180/>110

Definition

1) <130/<85................recheck 2 yrs

2)130-139/85-89..........recheck 1 yr, lifestyle edu

3)140-159/ 90-99.........confirm 2 mnths, lifestyle edu

4)160-179/100-109......eval/refer within 1 mnth

5) >180/>110..............eval/refer within 7 days

Term
PE for HTN
Definition

blood pressure readings (2+), verify in contrlat arm

Ht, wt, waist circum

fundoscopic exam

neck

heart

lungs

abdomen

extremities

neurological

Term
Lab tests before initaiting HTN therapy (5)
Definition

urinalysis

CBC

blood chem

lipids

ECG

Term
Renal diseases, problems with adrenal cortex, cushings syndrome, hyperparathyroidism, and aortic coarctation are all identifiable causes of....
Definition
HTN
Term

The goal of HTN prevention and management is to reduce morbidity and mortality by the least intrusive means possible.  This may be accomplished by what 2 things:

Definition

1) maintaining BP <140/<90

2) controlling other cardiovascular risk factors

Term
Non pharma interventions for BP reduction (4)
Definition

exercise

low salt diet

reduce alcohol

potassium supplement

Term

7 CLASSES OF HTN DRUGS

¨AAA C DDD¨

Definition

ACEi

Adrenergic inhibitors (includes b blockers)

Ang II Receptor Blockers (ARBs)

Ca Antagonists (CCBs)

Direct Vasodilators

Diuretics (thiazide)

Direct Renin Inhibitors

Term
What is the main problem with controlling HTN with drugs?
Definition

Patient Compliance...

 

40% of pts stop within first 3 months

70% stop within 1 year

Term

Best drug class for treating Stg 1 HTN.

 

for Stg II HTN?

Definition

Stg I: Diuretics (thiazides)

 

Stg II: diuretic + ACEi, ARB, BB (b blocker), OR CCB

Term
2 drugs used in the treatment of emergency HTN
Definition
vasodilators + adrenergic inhibitors
Term

What HTN drugs are contraindicated for pregnancy?

 

What HTN drug is recommended for women during pregnancy?

Definition

contraindicated: ACEi, ARBs

 

Methydopa recommended

Term

HTN in the elderly, is systolic or Diastolic BP a better predictor of events?

 

1º HTN (idiosyncratic) is the most common cause, however, what identifiable cause of HTN should be considered in the elderly?

Definition

systolic

 

Renovascular HTN

Term

HTN medication to use in the following comorbid condition:

 

1) Cardiac Failure

2) Renal Disease

3) DM (4)

4) Chronic Airway Disease (incl Asthma): *C/I

5) Gout: don´t use...

 

 

 

 

Definition

1) Cardiac Failure: ACEi + digoxin/diuretics

2) Renal Disease: ACEi

3) DM: ACEi, a-blockers, CCB, low dose diuretics

4) Chronic Airway Disease (incl Asthma): ACEi (*NO B BLOCKERS!)

5) Gout: don´t use diuretics (hyperuricemia)

Term

Pts undergoing surgery...

 

surgery should be delayed until BP is less than...

 

if pt not on  prior drug therapy, treat with _______ before and after surgery.

Definition

<180/110

 

treat with b-blockers

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