| 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 is the stroke risk for A fib? | 5%/year |
| 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 murmur is AR | Diastolic |
| What causes AR | Congenital bicuspid valve, RF, marfan, syphillis and giant cell arteritis. |
