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Workup of a patient with suspected MI
- ECG
- CK-MB
- Troponin I
- Myoglobin (usually drawn every 8 hours, 3x)
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Management of a patient with MI
- 1. ECG monitoring
- 2. Oxygen
- 3. Morphine
- 4. Nitro
- 5. Beta blocker
- 6. Clopidogrel
- 7. LMWH
- 8. ACE inhibitor or ARB
- 9. Statin
REPERFUSION within 12 hours
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Causes of pericarditis
- Coxsackie virus (most common)
- TB
- Uremia
- Malignancy
- SLE
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Management of unstable angina
- 1. Oxygen
- 2. Aspirin
- 3. Nitro
- 4. Beta blocker
- 5. LMWH
- 6. GP IIb/IIIa inhibitor
- 7. ACE inhibitor or ARB
Emergency PTCA if pain does not resolve
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Late diastolic murmur, best heard at apex
Mitral stenosis
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Holosystolic murmur that radiates to axilla
Mitral regurg
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Harsh systolic ejection murmur best heard in aortic area that radiates to carotids
AS
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Early diastolic decrescendo murmur, best heard over apex
Aortic regurg
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Midsystolic click, late systolic murmur
Mitral prolapse
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What psychiatric condition is associated with mitral prolapse?
Panic disorder
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What antibiotic should be used for prophylaxis in patients with predisposing conditions to bacterial endocarditis?
Amoxicillin
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Conditions that predispose to DVT
- Recent surgery/immobility
- Malignancy
- Pregnancy
- OCPs
- DIC
- Coagulation disorder (e.g. factor V Leiden deficiency)
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What can recurrent superficial thrombophlebitis indicate?
Underlying malignancy (Trousseau syndrome)
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DVT management
- Start with IV LMWH or heparin
- Switch to warfarin, keep px on warfarin for 3-6 months
- Pneumatic compression stockings for patients at high risk for bleeding
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Management of PE
- Start LMWH or IV heparin, gradually switch the px to oral warfarin, for the next 3-6 months
- Greenfield filter for recurrent clots + contraindications to anticoagulation
- t-PA only for really massive emboli
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Major side effect of heparin
HIT, usually on day 3-7 (monitor CBC)
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How are the effects of heparin monitored?
- Unfractionated heparin--measure PTT
- LMWH--use anti-Xa to measure effect
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How can heparin be reversed?
Protamine
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Management of chronic CHF
- Na restriction
- ACE inhibitors (first line agents)
- Beta blockers
- Diuretics
- Spironolactone
- Digoxin (moderate to severe with low EF)
- Vasodilators
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Management of CHF exacerbation
- Oxygen
- Diuretics
- Inotropic agents (Digoxin, if px is stable, can also use dobutamine, dopamine, or amrinone)
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What can precipitate a CHF exacerbation?
- Medication non-compliance
- MI
- Severe HTN
- Arrhythmia
- Infection, fever
- PE
- Anemia
- Thyrotoxicosis
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Causes of dilated cardiomyopathy
- Chronic CAD or ischemia
- Alcohol abuse
- Myocarditis
- Doxorubicin
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Management of hypertrophic cardiomyopathy
Beta blockers or disopyramide
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Normal PR interval
0.12-0.2
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Management of A fib
- 1. Rate control--beta blocker or CCB
- 2. Ask if duration is more or less than 48 hours-
- If less than 48 hours: cardiovert (DC, amiodarone, or procainamide
- If more than 48 hours: do TEE to look for clots and then cardiovert, or anticoagulate for 3 weeks and then cardiovert
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Management of first degree heart block
- Leave it alone
- Don't give beta blockers or CCBs (slow conduction through AV node)
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Management of second degree heart block
- Mobitz I--pacemaker or atropine in symptomatic patients
- Mobitz II--pacemaker
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Management of WPW
- Control rhythm with procainamide or quinidine
- DON'T use digoxin or verapamil (they slow conduction through the AV node, which exacerbates the effect of the accessory pathway)
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Management of V tach
- Pulseless--defibrillation, epi, vasopressin, and amiodarone or lidocaine
- Pulse present--amiodarone + synchronized cardioversion
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Fixed split S2 + palpitations
ASD--most close on their own and are asymptomatic
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Teratology of Fallot
- Pulmonic stenosis
- RVH
- Overriding aorta
- VSD
Most common cyanotic congenital heart disease
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How often is cholesterol screened?
Total cholesterol and HDL every 5 years after a person turns 20
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What are goal LDL levels?
- If there are no CHD risk factors:
- LDL under 160 is normal
- Under 190 is medium risk
- Over 190 is high risk
- If there are 2 CAD risk factors:
- LDL under 100 is normal
- LDL under 130 is medium risk
- LDL over 130 is high risk
- If there is known CAD:
- Goal LDL is always under 100
If there is known CAD in a very high risk px (e.g. poorly controlled metabolic syndrome) the LDL goal is under 70
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What are the major risk factors for CAD?
- 1. Age over 45 in men, 55 in women
- 2. Family hx (MI in a man under 55 in a man or 65 in a woman)
- 3. Smoking
- 4. HTN
- 5. DM
- 6. Low HDL (under 40)
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How is LDL calculated?
LDL=total cholesterol - (HDL - TG/5)
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When should a patient with hypercholesterolemia be started on anti-lipid meds?
- LDL over 160 in a patient without CAD risk factors
- LDL over 100 in a patient with CAD risk factors
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What are first line lipid lowering meds?
- Statins--watch for MSK and hepatic toxicity
- Second line agents are niacin, ezetimibe (selectively inhibits cholesterol absorption), and cholestyramine
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