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Tako-Tsubo cardiomyopathy
- Acute myocardial damage following stressful event (deaths, earthquakes, hypoglycemia)
- Most often in postmenopausal women, normal coronaries
- Leads to ballooning and LV dyskinesis
- Manage with bblockers and ACEi
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Maximum heart rate
220-age
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Dipyridamole aka and contraindication
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Stress tests with equal sensitivity and specificity
- Exercise thallium=Excerise Echo
- Dipyridamole thallium=Dobutamine Echo
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Meds which lower mortality in chronic angina
- ASA
- Bblocker
- Nitroglycerin - oral or patch
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Clopidogrel indications
- Chronic angina with ASA allergy
- Recent stenting
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Prasugrel
- Thienopyridine
- Antiplatelet for those undergoing angioplasty and stenting
- dangerous in >75yo bc of stroke
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Ticlopidine
- For intolerant to both ASA and clopidogrel
- Antiplatelet
- Cuases neutropenia
- Ranolazine
- Additional tx for angina if refractory
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ACEi cardiac indications with mortality benefit, sides and alternative
- Low EF/systolic dysfunction
- Regurgitant valvular disease
- Cough, hyperK. Hydralazine with nitrates
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CAD equivalents
- Peripheral artery disease
- Carotid disease
- Aortic artery disease
- DM
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Niacin: use, sides
- To raise HDL after on statin with exercise and tobacco cessation
- Glc intolerance, inc uric acid, itchiness
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Gemfibrozil: use, sides
- Lower TG more than statin but not as much mortality benefit
- inc risk of myositis if combined with statins
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Cholestyramine: sides
Interactions with other drugs, constipation, flatus
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Ezetimibe: use, sides
- Lowers LDL with no proven benefit
- well tolerated
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CCB use in CAD, which ones, sides
- -Severe asthma so cant take bblocker
- prinzmetal angina
- cocaine induced angina (bblockers are contraindicated)
- -Verapamil and diltiazem since do not inc heart rate
- -Edema, constipation, rare heart block
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CABG indications, time to occlusion
- 70% in 3 vessels
- Left main
- 2 vessels + DM
- Persistent on medical tx
- -Saphenous vein, 5yrs. internal mammary 10yrs
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Pulsus paradoxus
- dec in BP of >10 on inhalation
- assoc with cardiac tamponade
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Kussmaul sign
- Inc in JVD on inhalation
- assoc with constrictive pericarditis or restrictive cardiomyopathy
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Wall MI leads and mortality rates
- inferior (II, III, aVF): 5%
- anterior (V2-4): 35%
- posterior (V1,2 depression): low
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ACS meds with whether mortality benefit
- Benefit: ASA (do first)
- Statins, ACEi, Bblockers - timing doesnt matter
- no mortality benefit: Morphine, O2, nitroglycerin
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Cardiac enzyme timings
- Troponin: 4-6hrs to 10-14days
- CK-MB: 4-6hrs to 1-2days
- Myoglobin 1-4 hrs to 1-2 days
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Most common cause of death in first days after MI
Ventricular arrhythmia
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Angioplasty vs thrombolytics in ACS
- Angioplasty has inc mortality benefit, fewer hemorrhages, and less MI complications. Perform within 90 minutes
- Complications of angioplasty are rupture, restenosis, and hemaotma at entry site
- Thrombolytics should be within 30min in rural places
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Restenosis rates 6 months post PCI
- No stent: 35%
- Metal stent 20%
- Drug eluting: 10% - paclitaxel or sirolimus, Tcell inhibitors)
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Contraindications to thrombolytics
- Bowel or brain bleeding
- Surgery within 2 weeks
- BP>180/110
- Nonhemorrhagic stroke within 6mo
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Glycoprotein IIb/IIIa inhibitors
- Abciximab, tirofiban, eptifibitide
- ST depression of angioplasty and stenting get benifit
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nSTEMI tx
- ASA then LMWheparin first
- bblocker, nitrate, GPIIb/IIIa
- no thrombolytic
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STEMI tx
- ASA first
- then angioplasty
- Also bblocker and nitrates
- If no angioplasty, thrombolytic and heparin
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Cannon A waves
- Atrial systole against closed tricuspid valve in 3rd degree heart block post MI
- Bounding JVD wave
- Tx with atropine then pacemaker
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RCA supply, EKG, tx of infarct
- -RV
- AV node
- Inferior wall
- -V4 elevation in flipped EKG
- -Needs high volume fluid replacement and avoidance of nitroglycerin
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PostMI meds to go home on and sex
- ASA
- Metoprolol
- Statin
- ACEi
- Bblockers and mostly anxiety cause erectile disfunction. If symptom free or normal postMI stress test, can have sex
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CHF causes
- Infarction
- Cardiomyopathy incl from HTN
- Valve
- Etoh
- Postviral myocarditis
- Radiation
- Adriamycin/doxorubicin
- Chagas
- Hemochromatosis
- Thyroid
- Peripartum
- Thiamine deficiency
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Tests for EF
- Initial: TTE
- Accurate: Multiple gated acquisition scan or nuclear ventriculography
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Systolic CHF tx (mortality benefit*)
- *ACEi - if cough give ARB, if hyperK give hydralazine and nitroglycerin
- *Bblockers- metoprolol, bisoprolol, carvedilol. Used for chronic to prevent sudden death from arrhythmias
- *Spironolactone - for class III and IV
- Diuretics - loop
- Digoxin - no mortality benefit, dec hospitalizations and symptoms
- *Defibrillator - if <35% EF and ischemic cardiomyopathy
- Biventricular pacemaker - if <35% EF and dilated cardiomyopathy and wide QRS
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Spironolactone alternative
- eplerenone
- no gynecomastia
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Diastolic CHF tx
- Bblockers
- Diuretics
- Not: digoxin, spironolactone
- Uncertain: ACEi, ARB, hydralazine
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Acute pulmonary edema tx
- O2
- Loop diuretic
- Morphine
- Nitrates
- Nesiritide is unclear (IV atrial natriuretic peptide)
- Then dobutamine, amrinone, or milrinone for positive inotropy
- Nitroprusside and IV hydralazine for afterload reduction
- D/c: ACEi
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