Missed Cardiology Qs

1. Tearing chest pain with mid-scapular radiation in an elderly patient with known atherosclerosis and hypertension carries a high index of suspicion for Type III aortic dissection.

Summary of DeBakey Classification of Aortic Dissection:

Type I: Dissection of ascending and descending thoracic aorta

Type II: Dissection of ascending aorta

Type III: Dissection of descending aorta

2. Treatment for acute right ventricular infarction includes fluids to increase pre-load and thus increase cardiac output.
1. Cardiac catheterization may be needed if less invasive treatment does not work but it is not the initial step
2. The diagnosis is right ventricular infarction caused by occlusion of the right coronary artery (RCA). Hypotension and jugular venous distention that worsens with inhalation (Kussmaul sign) are signs of right ventricular infarction. ST elevations in leads II, III and aVF indicate acute ischemia in the inferior left ventricular wall which is also associated with occlusion of the RCA.
3. Thiazide diuretics precipitate gouty attacks and can cause hypercalcemia, hyponatremia and hypokalemia, as well as many additional unwanted side effects.
4. Mobitz Type II second-degree AV block occurs when there is a constant PR interval followed by a dropped QRS complex.
1. Use a transcutaneous pacemaker for all patients with second-degree type II AV block and third-degree block.
5. Electrical therapy is reserved for unstable patients. Epinephrine is used for cardiac arrest arrhythmias (asystole, PEA, VF, VT). Atropine is used for bradyarrhythmias (symptomatic bradycardia). Adenosine is specifically used for stable SVT.
1. Supraventricular tachycardia is initially treated with vagal maneuvers, such as asking the patient to bear down or carotid massage, if the patient is awake and stable. The next course in management is adenosine because it drastically slows conduction through the AV node.
6. The differential diagnosis for syncope is big but the two main systems to focus on are neurological and cardiovascular. This patient has a heart rate of 40 indicating that a bradyarrhythmia is the most likely cause. This can be confirmed with an electrocardiogram (ECG).
1. A thorough history is important, especially asking about medications, but an ECG will confirm an arrhythmia
7. Atrial fibrillation with rapid ventricular response can be initially managed with diltiazem.
1. The ECG shown is atrial fibrillation with rapid ventricular response and treatment is aimed at rate control. The medications of choice are calcium channel blockers or beta blockers.
2. Procainamide is used for atrial fibrillation with Wolff-Parkinson-White syndrome, where AV nodal blocking agents like calcium channel blockers should be avoided.
3. Cardioversion is used for unstable patients. Hemodynamic instability means systolic blood pressure < 90, chest pain, shortness of breath, or confusion.
4. Digoxin can be used adjunctively but is less effective for rate control than calcium channel blockers or beta blockers.
8. Alcoholic dilated cardiomyopathy can cause a pre-excitation syndrome that may be observed as delta waves on the ECG.
1. Alcoholic dilated cardiomyopathy can cause a pre-excitation syndrome that may be observed as delta waves on the ECG.
9. Intravenous heparin is indicated for a patient evolving from stable to unstable angina
1. Antithrombotic therapy with intravenous heparin is indicated, along with additional antiplatelet therapy such as clopidogrel. Subcutaneous administration of low-molecular-weight-heparin (such as enoxaparin) is another possible treatment.
10. Hypertensive emergencies are associated with elevated blood pressures, usually > 179/119 mm Hg. Other clinical manifestations include: retinal hemorrhages and exudates, papilledema, malignant nephrosclerosis (leading to ARF, hematuria, and proteinuria,) and neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar infarcts, or hypertensive encephalopathy.
1. The initial aim of treatment is to rapidly lower the diastolic pressure to 100-105 mm Hg within two-six hours. The blood pressure should not be dropped by more than 25% of the presenting value. Medications that can be used to achieve this include: nitroprusside, nicardipine, clevidipine, labetalol, fenoldopam.
2. If you do not have rapid access to parenteral medications, sublingual or liquid nifedipine and sublingual captopril can be used.
3. Clonidine and hydrochlorothiazide have no role in the management of acute hypertensive emergencies.
4. unlike hypertensive emergency, there is no proven benefit from rapid reduction of blood pressure in patients with hypertensive urgency. The goal of management of hypertensive urgency is to lower the blood pressure to <160/100 mm Hg over several hour to days.
11. Hyperkalemia is associated with peaked T-waves on ECG.
1. The only choice that is associated with hyperkalemia is ACE-inhibitors. These drugs block the formation of angiotensin thus decreasing the secretion of aldosterone. This can lead to elevated potassium.
2. Calcium reverses the effects of potassium on the membrane potential and is the most rapid way to correct arrhythmia associated with hyperkalemia.
12. it would be very unlikely for a patient with WPW to develop any type of AV block.
13. ECG findings with digoxin toxicity include prolonged PR intervals, depressed (scooped) ST segments, and alterations in T wave morphology.
14. The first line of treatment for pulmonary hypertension due to congestive heart failure is loop diuretics, nitrates and morphine.
1. Echocardiogram will be needed to evaluate the ejection fraction but it is not the first step when there is respiratory distress from pulmonary hypertension
15. A baseline ECG should always be ordered first in the work-up of a cardiac patient. Although other modalities may be warranted, it is usually the ECG that should be ordered first.
16. Mitral regurgitation increases on expiration, is holosystolic, and increases with handgrip maneuver.
17. Use of the Framingham criteria (eight major and seven minor) is one method by which to organize the signs and symptoms of congestive heart failure (CHF). (diagnosis of CHF by this method, at least one major and two minor criteria are required).
1. Major criteria include
1. paroxysmal nocturnal dyspnea,
2. neck vein distention,
3. rales,
4. cardiomegaly,
5. acute pulmonary edema,
6. auscultation of an S3 gallop,
7. increased venous pressure, and a
8. positive hepatojugular reflux.
2. Minor criteria include
1. extremity edema,
2. night cough,
3. dyspnea on exertion,
4. hepatosplenomegaly,
5. pleural effusion,
6. vital capacity reduced by one-third from normal, and
7. tachycardia of 120 or more beats per minute.
3. weight loss of 4.5 kg or more during the course of therapy may be considered as a major or minor criterion.
18. The most common symptoms of digoxin toxicity are GI distress, blurry vision and arrhythmia. Hypokalemia can enhance digoxin toxicity.
1. Heart block (as seen with the prolonged PR interval) is a common side-effect of digoxin which usually does not cause any trouble.
2. Hypokalemia and renal failure can enhance digoxin toxicity.
19. Mitral stenosis is the most common valvular disease caused by rheumatic heart disease and is characterized by a loud S1, along with a mid-diastolic rumble at the cardiac apex.
20. Hypovolemic Shock: ↓ CO, ↓ PCWP, ↑ PVR

Cardiogenic Shock: ↓ CO, ↑ PCWP, ↑ PVR

Septic Shock: ↑ CO, ↓ PCWP, ↓ PVR