If indetermediate, consider:
- Coronary Artery Calcium score greater than 300 or greater than 75% for age
- C-reactive protein level (hsCRP) above 2 mg/L
- Ankle-brachial index below 0.90
- LDL cholesterol level 160 mg/dL
- Family history
- HIGH intensity statin for LDL > 190 regardless of risk
Abdominal Aortic Aneurysm - CORRECT ANSWER -<4cm low risk, US every 2-3 years
4cm-5.4cm need 6-12 month monitoring
Over 5.5cm = SURGERY
HIGH RISK surgery so need cardiac evaluation with AT LEAST chemical stress test if
sedentary and angio if indicated...elective procedure so if myocardium at risk, DEFER
surgery
If symptomatic over 5cm in men or 4.5cm in women = SURGERY
- Cholesterol atheroemboli are high risk after any vascular procedures esp those with
comorbidities
- differentiate from renal embolization which is due to A fib and can present like
pyelonephritis (but with increased LDH)
Abdominal compartment syndrome - CORRECT ANSWER -- oliguria or increasing
serum creatinine levels who have had abdominal surgery, who have received massive
fluid resuscitation, who have a tense abdomen, or who have liver or pancreatic disease
with ascites
- measure abdominal pressure or bladder pressure for diagnosis
- treatment is surgical decompression
Pregnant patients should be off for ONE MONTH before conceiving
Acquired cystic kidney disease (ACKD) - CORRECT ANSWER -- no family history
- small kidneys, cysts in the renal parenchyma
- once ESRD, patient at significantly increased risk of renal cell carcinoma
Acromegaly - CORRECT ANSWER -- Tx: transsphenoidal pituitary surgery for removal
of adenoma
- might not completely remove tumor but surgery can effectively debulk the tumor and
preserve vision in addition to significantly decreasing GH secretion as measured by
IGF-1 levels
- radiation therapy afterward may continue to work on the tumor if symptoms don't
improve with surgery
Acute Liver Failure - CORRECT ANSWER -- non alcoholic, non acetaminophen
induced, non infectious: N-acetylcysteine IV is beneficial as we wait for transplace,
REGARDLESS of tylenol use or not!! wtf!!
Acute MI - CORRECT ANSWER -- Can be complicated with Ventricular Septal Defect.
- VSD manifests as hemodynamic compromise in the setting of a new holosystolic
murmur AT LEFT STERNAL BORDER 3 to 7 days after an initial myocardial infarction.
Patient has symptoms of CARDIOGENIC SHOCK, SYNCOPE and CHF, echo showing
left to right blood flow. Emergency condition requiring EMERGENT SURGERY
, - if chest pain and new LBBB or 3rd degree block, go straight to cath
- if over 50 and typical angina presentation, then GREATER THAN 90% chance of CAD
- can be complicated with papillary muscle rupture and acute mitral regurg requiring
EMERGENT SURGERY
- no syncope reported and murmur usually at apex, though it can also be left sternal too
-___-
- Patient's who we start on medical therapy can have adverse effects, for example BB
can lead to heart block so monitor and titrate dose
- as we await cath, start antiplatelet therapy and heparin
- please note, Bivalirudin is an anticoagulant that can be in place of Heparin :-<
- please note, in NSTEMI, Ticagrelor is preferred over Plavix for DAPT
- please note, in NSTEMI, Prasugrel can ONLY be used if initiated AT THE TIME of PCI
- If stable then sudden chest pain, think RV infarct with acute right HF. Patient cannot
perfuse left heart and ultimately rest of the body...these patients are PRELOAD
dependent in order to keep cardiac output up. PCWP is LOW, but PA and RA is high
- Biventricular failure you get low CO but high PCWP high RA. INOTROPIC
dependence
- Fibrin specific tPA preferred over streptokinase if available and PCI is not able to be
performed
- MENSES is NOT a contraindication for tpA
- New LBBB can mask ST elevation so if evidence of LBBB go for PCI or tPA if unable
- no tPA if CVA within 3 months
NTEMI
- Ticagrelor is preferred over Plavix for DAPT
- urgent PCI within 24 hours if new ST depression w
Acute renal failure - CORRECT ANSWER -- if hyperkalemia and EKG changes:
1) Calcium Gluconate
2) Insulin and d50
3) Dialysis
- rhabdo can even cause ARF
PRERENAL AZOTEMIA
- common with NSAIDS
- improved w fluids
- hyaline casts
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