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Cardiology


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Unstable Angina Def
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Angina at rest > 20 min, New onset angina, Increase frequency Negative troponin

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Cardiology - Details

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Unstable Angina Def
Angina at rest > 20 min, New onset angina, Increase frequency Negative troponin
NSTEMI Def
Sx of MI with positive troponin, neg EKG No Fibrinolytics Treat with PCI within 2 hours of presentation.
Treatment of UA/NSTEMI
ASA 162-325 mg chewable ASAP , Clopidrogel 300 mg load followed by 75 mg for up to 12 months, Glycoprotein IIb/IIIa ( eptifibatide or tirofiban), Anticoagulation with either UFH, LMWH ( Enoxaparin) , Bivalirudin, or Fondaparinux.
STEMI Treatment
PCI if can be done in < 90 min and Sx < 12 hours, or Fibrinolytic tPA if > 2 hours from PCI facility. t-pa in conjunction with DAPT, Anticoagulation, and BB.
Fibrinolytic Contraindications
Intracranial hemorrhage, IC AVM, neoplasm, stroke/6mo, head trauma/3mo, Aoritic dissection, surgery/2 wk/ active bleeding.
CABG Indications
L main dz, 3 vessel + DM/ low EF, 2 vessel + prox LAD + DM/ low EF : DC Plavix 5 days before CABG. ASA ok to continue
EST indications
Symptomatic, Intermediate risk and can exercise. Men > 40, women> 50, Preop for vascular surgery or transplant with symptoms.
Def Positive Stress Test
Symptoms with exercise, Drop in BP > 10 or BP elevation > 250/115, ST elevation 1 mm or ST depression 2 mm.
ACS Treatment
Morphine: only for unacceptable pain, Oxygen only if O2 sat < 90, NTG SL x 3 IV to hold for SBP< 90, HR < 50 or > 100, ASA 325 chew, ACE, Statin, GPI , Anticoagulation, DAPT
Fondaparinux indication
ACS, VTE, DVT: Similar to LMWH, Indirect inhibitor of factor xa, injectable SQ once daily dose, No monitoring or platelet interaction , no reversal agent.
NSTEMI Ischemia Strategy
DAPT, Anticoagulant: UFH or Enoxaparin or Fondaparinux
NSTEMI Early invasive strategy
DAPT, Anticoagulate ( UFH/Enoxaparin/Fondaparinux/Bivalirudin), GPI for high risk Eptifibatide or Tirofiban
Primary prevention ASA
No bleeding risk ( HASbled), life expectancy > 10 yr, 50-60: ASCVD risk > 10%, 60-70: Individual decision, > 50 with DM: ASCVD > 10% + one risk factor ( HTN, FHx, smoking)
Stable CAD treatment
ASA 81 mg, Statin mod/high dose, ACE, Antianginal( 1. BB,2. CCB, 3. Nitrate, 4. Ranolazine, life style factors.
Nuclear Stress test: Indications
Resting ST abnormality, LBBB, WPW, LVH, Paced Rhythm, Dig, Obese or COPD and can't exercise.
Nuclear stress test positive
ST depression > 2mm or > 1 mm in > 5 leads, VT, Low BP, Angina, < 4 mets, 1 large defect, > 2 reversible defects, increase lung uptake : Any of these will go on to angiography
Risk assessment screening test
CRP > 2, CA Calcification > 300 , ABI < 0.9 If Elevated ASCVD > 7.5 councel re: BP , Chold, Wt, lifestyle. Coronary CTA: anatomical test for plaque burden. Look at graft post CABG and help risk stratify, Calcium scan: Help determine if asymptomatic intermediate risk needs statin to stabilize plaque. Do not repeat.
Lipid treatment guideline
1. ASCVD < 75 y.o - high intensity statin, > 75 yo - low intensity, 2. Severe LDL > 190 in 20-75 - max tolerated statin, 3. DM > 40 - mod intensity, DM > 40 with 10 yr risk > 20% - high intensity statin, 4. Adults > 40-75 with ASCVD risk > 7.5% - moderate intensity statin.
What are moderate intensity statins?
Atorvastatin 10 mg/d, Fluvastatin 40 mg bid, Simvastatin 20 mg/d Harmful if exceed > 40 mg/d.
What is high intensity statin?
Atorvastatin 40-80 mg/d, Rosuvastatin 20 mg/d.
How do you treat statin myalgia
Look for interacting drugs, Check CPK, . 10 stop med, lower statin dose or give it 1-2x/wk, Check ALT yearly.
What are secondary causes of elevate lipids?
DM, ETOH, Thyroid, obesity and drugs ( HCTZ)
What type of murmur is MR and what causes it?
Systolic murmur, caused by MVP and RF
How do you manage MR?
Look for sx: dyspnea, fatigue. Monitor yearly echo, Referr for surgery if abnormal LV size or function, pulmonary HTN, or new onset A fib.
What type of murmur is MS
Diastolic with open snap, caused mostly by RF
How do you manage MS?
If symptomatic with diuretics and rate control. Prone to A fib and pulmonary HTN,. Referr to surgery when valve are is < 1.3
Who need antibiotic prophylaxis for Infective Endocarditis?
1. prosthetic valve, 2. Previous IE, 3. Heart transplant, 4. Congenital HD
Which heart block do you pace?
Symptomatic ones. Mobitz type 2 and 3rd degree. If unstable give atropine. Look for reversible causes.
How do you treat hemodynamically unstable bradycardia?
HR < 50 with confusion, angina, dyspnea : Give Atropine 0.5mg IV Q 3-5 min If not better temporary transcutaneous pacer. Sadate if conscious. Give Dopamine for low BP and Dobutamine for CHF.
What are some of the reversible causes for bradycardia?
Medication: BB, Clonidine, Acetylcholine, sedatives, opioids, cimetidine, Dig, CCB, Amiodarone, lithium, Acute MI, OSA, Increase valsalva, Increased ICP, infection and hypothyroid.
What are some of the causes of A fib?
MVP, CAD, COPD, Cardiomyopathy, hypothyroid, ETOH, Cocaine, nicotine, caffeine, OSA
What is the workup of Afib?
EKG, Echo, CBC, thyroid, chempanel PT/INR
How do you treat A fib?
Rate control with metoprolol or carvedilol or a CCB. Goal to keep HR < 80 at rest and < 110 with activity.
When would you choose rhythm control for Afib?
Pt with CHF, Young athlete with normal heart. Referer for catheter ablation around the pulmonic veins
How do you decide who needs anticoagulation in a fib?
Cha2ds2-vasc score CHF(1), HTN(1), Age > 75 (2) , DM (1), Stroke (2), Vascular dz ( 1) female (1) Score > 2 man or > 3 women, anticoagulate.
What do anticoagulants do you use in Afib.?
Warfarin for valvular Afib with INR goals 2-3. NOAC
What are the NOAC
1. Apixaba (Eliquis) bid OK with CKD 2. Dabigatan - reversible direct thrombin inhibitor, 3. Rivaroxaban - reversible factor xa inhibitor once a day.
When do you cardiovert Afib?
Unstable, WPQ, Ongoing ischemia Cardiovert with 200 J If Cardioversion is elective you need anticoagulation 4 wk pre and post.
AAA who to screen and how to manage
Screen > 65 smokers Monitor > 3cm, Referr > 4.5 cm, and surgery for > 5.5 cm
Which murmurs do you echo?
All diastolic and all > grade 3.
AS what type of murmur is it?
Systolic at RUSB decreasing with valsalva
What causes AS?
Bicuspid valve, RF, Calcification
How do you manage AS
Referr for symptomatic or Valve are < 1 cm2. ( Normal 3-4 cm2) Anticoagulate to keep INR 2.5-3.5
Bicuspid Aortic valve
Systolic murmur with opening click, Most common CHD, Associated with coarctation and AAA
What causes AR
Congenital bicuspid valve, RF, marfan, syphillis and giant cell arteritis.