2018 Cardiovascular Disease 14% - lipid 2% Flashcards
Opening snap? = click? =
Snap - MS Click - MVP
Closure of valves makes what heart sound?
S1 S2
Loud S1
MS Short PR (WPW) Tachycardia Thyrotoxicosis
Soft S1
MR Long PR inc’d LVEDP
S2 inspiration
A2 - AV closess first P2 - PV closes last -> physiologist split
S2 expiration
both valves close at same time
S2 split inc’d
closese earlier - MR, VSD Closes later PS, pulm HTN (loud P2) RBBB
Fixed S2 split
ASD
paradoxical S2 split
AS, HTN, LBBB
S3
inc’d flow chronic MR CHF TR, PDA BENIGN IN KIDS/pregnancy restrictive cardiomyopathy
Inspiration
MORE BLOOD IN R HEART
S4
Decreased compliance Acute MR HOCM LVH AS Ischemia
Pericardial friction rub
Superficial scratch sound best heard when pt upright leaning forward and deep breath in pericarditis
Pericardial knock
constrictive pericarditis - sharp early diastolic sound (early 3rd sound)
Physioligc during expiration
Single S2
HTN/AS/LBBB
Paradoxical S2 split
ASD
Fixed split
Calcified AS
Single S2 (soft A2)
HTN
Loud A2
Pulm HTN
Loud P2
Physiologist split
A2 before P2
Pulsus tardus
slowly rising pulse –> AS #2 murmur radiates to the carotids. #3 crescendo-decrescendo
Pulsus bisferiens
- rapid upstroke, no radiation 2. bifid/trifid impulse HOCM. #3. early systolic murmur (incr. w/ exertion)
Pulsus alternans
one heart snd normal, one abnormal severe HF
Hyperkinetic
High output state PDA Thyrotoxicosis
Hypokinetic
Low output states
Auscultation areas?
- R 2nd ICS (Aortic Area) - AS, AI 2. Left 2nd ICS (Pulm area) - PS, PR, AI, - PDA (left 3rd ICS 3. LLSB (Tricuspid area) - TS, TR - ASD, VSD - HOCM 4. Apex (Mitral Area) - MS - MR - AR
Palpation areas?
Left parasternal area 1. Hyperdynamic implse (inc’d RV volume (ASD or TR) 2. Sustained L parasternal heave - (incr. pressure) RVH, (MS, pHTN, PS) Apical area 1. Hyperdynamic impulse - Inc’d LV vol (Hyprthyroid, Anemia, preimary MR, AR with nl EF, PDA VSD) 2. Susptained Apex lift/impulse (incr. pressure) - LVH (HTN, Dil CM) - IHD, AR with low EF - Bifid/trifid apical impulse - HOCM
AV Valve Holosystolic murmur
MR, MR, VSD
V valves Mid systolic murmur
AS, PS
AV Valves Late systolic murmur
MVP - mid systolic click (secundum asd)
Diastolic mumur
All in-flow to ventricles creates diastolic murmurs
AV valves Mid diastolic murmur
MS, TS (-ASD)
AV valve - late diastolic murmur, mid systolic plop
Arial Myxoma - > surgery
V valves Early diastolic murmur
AR, PR
Continuous murmur
PDA
Pt with fixed split 2nd heart sound and mid-diastolic rumble dx?
ASD
What happens to murmur w/ Inspiration
inc’d flow to R side of heart, all R sided murmurs increase
What happens to murmur w/ Expiration
Inc’d flow to L side of heart - all L sided murmurs increase EXCEPT HOCM &MVP DECREASE
Increased volume, increases murmurs except in
HOCM/MVP (decrease)
What positions cause increased volume return to heart?
Sitting, squatting, leg raising
What positions cause decreased volume return to the heart?
Standing, Valsalva
Handgrip
increases afterload, increases flow to murmurs that flow backward (AI, MR, VSD)
What happens to murmur during handgrip or phenylephrine? MR? MVP? HOCM?
- Handgrip increases afterload, LV cavit size increases so … volume increases. MR –> increases MVP —> duration of murmuer decreases, intensity incr HOCM –> decr murmur ALL murmurs increase including MR Except: dec’s HOCM, MVP, AS
What happens to murmurs with amyl nitrate use? MVP? HOCM? AS? MR?
Decreaes afterload, so its easy for blood to be pushed into systemic cir, LV cavity decreased so… volume decr MVP –> duration of murmur increases, intensity decr. HOCM –> incr murmur AS –> incr murmur MR –> decr murmur
What happens to murmur post PVC? HOCM? MVP? AS murmur?
post PVC volume potentiation and decreased afterload –> rapid emptying. Volume decr. HOCM –> murmur incr MVP –> duration of murmur incr., intensity decr AS murmurs –> murmur will incr
What happens to blood that returns to heart during valsalva maneuver
Increases intrathoracic pressure and DEcreases blood return to heart
Kussmaul’s sign
Neck vins DISTENTION on INSPIRATION constrictive pericarditis cardiac tamoponade RV infarct
Application of pressure in the RUQ causes engorged Right jugular vein - rapidly improved upon release of pressure - indicates…
Increased jugular venous pressure
murmurs on inspiration increased in?
inc’d R side murmurs
Murmur of AS is best heard on
expiration. any L-sided murmurs will incr w/ expir except HOCM and MVP
Which maneuver will distinguish HOCM vs AS?
valsalva. incr. w/ HOCM, decr w/ AS
Standing/Valsalva
decr. volume Dec’d in: MR, AS, intensity MVP incr in : HOCM, duration MVP
Hand grip
incr volume Dec’d : HOCM, AS, intensity MVP incr.: MR, duration MVP
Post PVC
decr. volume Inc’d : HOCM, duration MVP, AS Dec’d : MR, intensity MVP
16yo pw routine checkup - PE reveals a murmur at LSB radiating thru precordium - no change with valsalva or respiration - ekg mild LVH dx?
VSD MC murmur at LLSB
RCA
inferior –> II, III aVF Posterior –> V1, V2 (early R wave progression) ** RV –> V3R-V4R Right sided EKG(no nitrates - IVF + atropine if HR dec)
LAD
Anterioseptal V2-4 Anterior V3-5 antical-lateral V5-6
Circumflex
Apical- lateral V5-6
Circumflex branch (OM1) or LAD branch (diag)
High lateral I, aVL
Pt h/o CP EKG stress reveals depression in lateral leads - nuclear iaging reveals anteroseptal ischemia
High grade LAD stenosis
48yo F exertional CP, stress done - stopped in 50 min from CP and ST dep V4-6
High grade LAD stenosis
Epidemiology
900,000 deaths/yr 1/3 from CAD smoking doubles risk INc’d LDL and total chol risk factor 1% dec LDL = 2-3% ec risk of CAD Every 1mm dec in BP - 2-3 % dec in r/o MI Death rates with heart dz MORE in females
Risk factors for atherosclerosis
Modifiable HLD tobacco Psychocsocial stressors DM HTN Obesity Etoh Physical activity Diet low in fruits/vegies Unmodifiable: Age Male Family h/o premature CAD (LP (a))
Pt no meds - wants advice on dec’ing CAD risk - smoker, HTN, LDL 100 wtd?
Quit smoking
ACS
ST elev -> Q wave MI - TPA or PCI NSTEMI - w/ +trops –> ASA, plavix +- IIb/IIIa UA, - trops –>no TPA - hep gtt, ASA, plavix
Workup for suspected CAD - middle aged woman pw chest pain, chest discomfort or atypical CP - wtd?
EKG - if normal –> stress test (exc if can walk)
If pt with COPD then
Dobutamine stress echo (no adneosine, dyprimadole)
45yo F vague CP on exertion - EKG normal - exc stress non-sp changes - wtd?
Exc stress with imaging If can’t walk - or non-sp ST chagnes with LBBB, LAHB, repolariz change then persantine/thallium study
Which can under EKG stress?
RBBB (not LBBB or paced)
Pt with peripheral vascular dz scheduled for bypass surgery - wheezing on exam - HTN controlled to 150/90 from 170/110
Dob stress test (can’t use adenosine or dipyridamole with wheezing)
Who gets gated pool studies or MUGA scan
IN pt to dtermine LVEF and wall motion abnorm (dec’d LVEF poor prognostic factor on MUGA
When NOT to do stress test
unstable angina AS with sx
45yo DM2 with CP, EKG neg - test LEAST likely to be accurate is…
Exercise stress test
Obese woman with atypical CP undergoes EST - stops test after 5 min due to fatigue, no CP, HR inc’d by 50%, no EKG chagnes wtd?
suboptimal Adenosine stress or stress echo
When is exercise stress test considered positive
- Flat or down sloping ST depressions>1mm & longer than 0.08s - If ST elevated then high grade stenosis
When do you stop a stress test
- ST dep >2mm - SBP dec >15mm Hg - VT - Chest pain/SOB (anginal equiv in elderly, DM, female)
Poor prognostic factors on stress test
>2mm ST depression Persistant ST dep 5 min post excercise Fall in BP > 15mmHg ST elev Vent ectopy/VT global ischemic changes
Who gets cardiac cath/angiogram
Presence of poor prognostic factor on stress test Post infarct angina U/A on med tx still with sx or ST dep or troponin +
Unstable Angina
- New onset severe angina < 2 months - Angina at rest - Recent inc’d freq - Post infarct angina
Pt with angina controlled on BB, ASA, nitrates pw inc’d freq and now chest pain lasting > 30 min -> EKG ST dep II, III, aVF - most likley mechanism for CP
Atherosclerotic plque with intermittent rupture and thomobolysis
Pt h/o chronic angina controlled on ASA, nitrates with inc freq angina wtd?
Add BB
Pt on ASA, nitrates (with 12 hr nitrate free interval) and max BB with inc’d freq angina? after walking 2 blocks. HR 55?
Check CBC for anemia. Check for infxn (in’d HR-> ischemia) –> PCI
Pt on ASA, nitrates, BB, statin, Hg normal - no signs infxn or stress with increasing episodes angion a on exertion - angiogram MV dz not amenable to revascularization - wtd?
Ranoxazine (ranexa) decr freq of anginal episodes and improved exercise tolerance
Antiplts
ASA - thromboxane Plavix ADP GB IIb/IIIa
Pt with CP, ST depression biphasic anteroseptal leads present
Welen’s syndrome -> persistent twi on EKG - cath lab LMWH + GP IIb/IIIa + Plavix + ASA
If angina or ST depression persists with or without troponin (+)
Cardiac cath
Pt stopped ASA 2 months ago 2/2 PUD - started on PPI now pw CP wtd?
start ASA
45yo M non-smoker, no DM pw new onset CP more than 1/2 hr duration while shoveling snow - no EKG changes in ER wtd?
Admit pt to chest pain unit If cardiac enzymes neg, no ekg changes -> stress test
65yo M woke up early AM with severe retrosernal CP x 40min, sweating, diaphoresis - EKG ST dep, Twi, started on ASA, IV nitrates BB, LMWH gpIIb/IIIa inhib - anginal pain resolves - 24 hrs later ST dep still persists
Dx: silent ischemia Cardiac Cath pt -> if angioplasty/PCI done - would decrease recurrent ischemia at 6 months (not reduce MI freq)
Multislice CT helpful to evaluate CP in what group of pts
Exclude dx in LOW risk patients
Exertiona dyspnea w/o chest pain in a pt may represent and anginal equivalent in absenseof pulm dz - mc seen in…
DM Women (esp. post menopausal) Elderly Post CABG
Pathogenesis of SOB
Ischemia-> inc’d LVEDP-> Pulmonary edema Dx: Empiric NTG or stress test or radionuclide studies
65yo with murmur MR during excercise and disappers post exc - S4 + echo shows mild hypkinesisa and EF 60% etio?
Ischemic
46yo M CP lasting 15 min - resolved in ED - HR/BP ok, No STE, only deep TWI V1-4… this represents..
myocardial ischemia –> Wellens syndrome (LAD TWI synd) wtd? –> angiogram
The following are true in pts with DM
CAD lesions are proximal CABG better tha PTCA in pt with CAD DM patients more likely to have silent ischemia Among DM - more women athan men die of CAD DM more prone to CAD than non-DM
Pt pw CP, EKG neg - Thalimum stress with reversible ischemia, cath neg dx?
microvascular angina Tx: CCB, BB and nitrates
Elderly man with h/o syncope - EKG on prsenation normal - feels dizzy after dinner - ST dep in II, III aVF - EKG after 15 min normal dx?
Post prandial ischemia tx: cardiac cath
Cause of STE? Causes Least likely to cause ST elevation is?
Transmural MI LV aneursym post MI Acute pericarditis Prinzmetals angina Takotsubo CM least likely : unstable angina
Young man brought to ER with severe CP - EKG shows ST elev and MI dx - caused by which drug?
Cocaine tx: PCI
Cardiac enzymes
- Troponin: + 3-6hrs after MI, Peak 10-25hrs, Normal 5-15 days 2. CPK-MB: + 3-8hr, Peak 10-36hrs, Normal 3 days 3. LDH: + 8 to 18hrs, Peaks 2-3 days, Returns to normal 6-10 days 4. Myoglboin: - 0-85= normal inc’d immediately peaks in 1-4 hrs and normal in 24 hrs
Pt with CP, ST elv trop elevated - s/p TPA ST resolve - CP resolved - next blood draw trop more elevated wtd?
Nothing - pt who reperfused have faster peak and higher peak of trop than pt NOT perfused
Pt pw CP and ST elev - PTCA done next day has CP best marker?
Myoglobin (peaks 1-4 hrs, normal 24 hrs)
65yo M aw PNA to MICU on IV abx - EKG NSR - trop 1.3 wtd?
Echo Low level trop see in CHF, critial illness, LVH, HOCM, coronary vasopalsm, pulm embolism, CKD
Pt pw chest pain and low BP - you suspect RV infarct - next dx step?
R EKG - V3R-V4R
Acute MI
Q wave MI and non-Q wave MI both similar long term survival - Always admit pt with new onset classic CP - relieved by SL nitro even if pt young or EKG normal - thrombolytics NOT given for NSTEMI
INdications for thrombolysis
- Chest pain typical for infarction > 30 min with LBBB - STE 1mm in two continguous leads - < 12 hr post MI - < 2hrs away from PTCA center and NOT in shock
Contraindication for TPA
Absolute - Prev hmorrhagic stroke - Other CVA events < 1 yr - IC neoplasm - Active internal bleed Relative - CVA > 1 yr - recent internal bleed or major trauma < 2-4 wks - BP>180/110 - Pregnancy - Active PUD
Indications for PTCA (PCI or angioplasty)
- Acute ST elev MI - ST elevation with CP > 12hrs - MI with shock and Pt is< 2hrs away from PCI center & < 75yr - STEMI post CABG pts - If tPA contraindicated
Plavix
Thienopyridine ADP Plt inhibitor Pt with MI allergic to ASA -> use plavix Pt going for PTCA needs plavix Pt goign for CABG - NO PLAVIX
When is CABG better than PCI?
- Left Main dz - 3 vessel dz with dec’d LVEF - two vessel dz with prox LAD and decreased LVEF <35 - DM with CAD
Pt with CAD s/p PCI with stent placement - what meds on d/c
ASA + Plavix for at least 6 months
60 yo pt undergoes CABG - couple months later he is doing fine but has problems keep ing accounts occasionally.
Dx: neurocognitive defect
Pt with retrosternal CP>1, diaphoretic -> EKG LBBB, ST elev in ant leads - old EKG not availabe to compaire - CK and trop pending wtd?
Cath lab
Pt with Chest pain, STE ant leads - s/p tPA with BP of 90/60 - 2 hrs later STE in lateral leads BP drops to 80 pt SOB - no new murmurs - CXR pulm edema wtd?
Cath - IABP-> PCI If allergic to ASA then desensitization
Elderly pt with IWMI gets tPA - pt becomes hypotensive and HR 38 wtd?
IV atropine first
HR 74, BP stable, pt confused, both puils dilated - dx?
ANtichoinergic delirium
Pt with 14hrs CP, taken antacids without relief - EKG with STE in anterior leads - BP 140/80 - given ASA to chew - IV nitrates, IV BB and IV morphine - closest PCI center at least 1 hr away wtd?
Transfer & do PCI
60 yo p/w CP AWMI to small community hospital. found to have AWMI- nearest tertiary center is 2 hours away wtd?
tPA then transfer for PCI
Pt aw MI - 3 days later Cp relieved with NTG wtd?
Cath
Pt has cath - 2 days later pain in R groin - exam with erythematous and pulsatile mass wtd?
US r/o pseduoaneurysm
Pt with MI - 9 days later with persistent CP, worse on deep breath - pericardial friction rub - CXR with effusion - EKG diffuse ST elevation with concatvity upwards
Dressler’s syndrome - secondary pericarditis tx: ASA high dose 6-8grams/day
Factors shownto improve survival in MI
PCI thrombolytic therapy after Q wave MI BB ASA ACEI stop smoking statins ICD (40days later) cardiac rehab
Pt p/w CP - AWMI tx’d in CCU w/o complications, EF 30%, on D/C what meds
- ASA - plavix - BB - ACEI, - statin - ICD ( 40 days later - if high risk for VT then wear lifevest)
Pt had MI, stabilized - few months later. stress test abnormal - underwent cath - 70% stenosis LCx- started on ASA - what will incr long term survival?
start Statin (NOT CABG or PTCA)
Complications of MI (arrythmia)
< 48hrs: - VT (runs: observe. no incr mort. sustained=ischemic: stable –> IV lidocaine/amio. unstable: cardioversion) then back to cath lab. - NSVT - Blocks >48hrs: - VT (scar tisssue –> ICD maybe in 3months - NSVT
Complication of MI (mechanical ruptures)
- Papillary muscle rupture -> Acute MR - Septal rupture -> Acute VSD - Free wall rupture -> Tamponade
Ventucular arrythmias during acute MI
Ventricular ectopy or NSVT during AMI should NOT be treated VT/VFib occuring within 24 hrs of MI are independent risk factors for in house mortality BUT not risk for subsequent mortality from arrhthmia after d/c These DO NOT NEED long term antiarrhythmic therapy
Pt pw CP - EKG shows MI tx’d with tPA, heparin, nitrates, BB, ACEi - w/in 24 hrs pt has NSVT <30s wtd?
Observe
Mechanism of reperfusion arrhythmias?
Triggered activity; change in cardiac frequency due to accumulated Ca+
Pt with NSVT reverts to SR and is otherwise uneventful - 5 days later pt ready for d/c does pt require long hterm anti arrythmic?
No
Pt with VT or VF 48hrs afte rMI - no evidence of reinfarction wtd?
tx VTACH
Vtach/VF 48 hrs after MI or more - independent risk factor for mortality after d/c - after acute tx wtd?
ICD *
Pt has 2 discharges from ICD in 2 months wtd?
start amiodarone
Pt with ICD on amiodarone still getting shocks 4 months later wtd?
RF catheter ablation
Pt with MI refractive VT wtd?
adequate O2 and correct electrolytes Tx with amiodarone
Post MI surgery
elective surgeries at least 6 months post MI (risk of reinfarction highest first 3 months post MI)
Middle aged man clutches chest c/o severe CP - EKG diffuse STE with concavity up and PR depression wtd?
NSAIDs for pericarditis Best med for ppx - colchicine
If pt w/ pericarditis, has CXR showing cardiomegaly or has JVD or pulsus paradoxis. Best test to confirm dx?
echo r/o tamponade/effusion
Pt post CABG or AVR 4 yars ago with inc SOB for 3 months +JVD 9cm, hepatomegaly adn pedal edema, EKG and CXR normal - dx?
Pericarditis
MCC CHF
Ischemia>dilated CM>HTN, valvular dz, congential HDz *Always r/o ischemia in pt with new onset CHF and sudden decompensation in stable CHF MC precipitant of decompensation in CHF -> inc’d salt intake
CHF Systolic dysfxn
problem = dec’d contractility inc’d LVEDP dec’d LVEF Echo - dilated Tx: 1. ACEI, 2. BB - diuretics for sx: (Loop/ 3. spironolactone) - Digoxin - Hydralazine + nitrate** decr mort. if cant tolerate ACEI and in black pts. - ICD/CRT
CHF Diastolic dysfxn
dec’d relaxation inc’d LVEDP NORMAL EF Echo: hypertrophy, early restrictive filling, E/e’ > 15 Tx: - Candesartan (good elderly & setting of systolic as well) - ACEI - BB - CCB (long acting) - Diuretics
What BNP is specific for acute CHF?
<100: no chf > 500: definate CHF
Elevated BNP seen in…
LHF 2/2 diastolic dysfxn LHF 22/ systolic dysfxn RHF 2/2 COPD RHF 2/2 PE
60yo F eval for 3 month SOB on exertion, no CP, pmhx HTN DM2, HLD for which she takes meds.. wtd?
TTE check LV fxn/WM
Echo with inf wall hypokinesis and EF 40% best managment?
Cath (not dob stress echo)
50yo M pw inc’d SOB 3 days - pmhs HTN, BMI 40, JVP 14, b/l crackles and S3 heard, b/l pitting edema, BNP 160 - management?
IV lasix
BNP monitoring shows what?
Dec’d mortality in pt <75yo
Pt pw exc intolerance and DOE - exm JVD 10cm, few basal rales, S3+ - pt dx with CHF CE and trop normal - pt tx’d with diuretics and gts better - TTE shows EF 35% . what to proscribe at time of d/c
ACEI
In pt with new onset CHF - Cr up from 1.1 to 2 and potassium inc’d from 4 to 5.6 after starting ACEI.. wtd?
D/C ACEI, start hydralazine + nitrates
PT with CHF on lisinpril 5mg and lasix 40mg dialy pw continued fatigue, JVD 12cm, scatter rales, pitting edema , best management?
Maximize lisinopril - start IV lasix) (no diff between bolus vs infusion)
When to start BB in decompensated CHF
ONce volume overload corrected, start low dose BB and titrate up
When to f/u patient as outpt after d/c for acute decompensated CHF
F/u Appt in 1 week (not 2) decreased mortality wth early post dc monitoring
If CHF is taking lisinopril 10mg qd. what to add next?
carvedilol
Two months later pt on lasix 40mg, KCl supp, lisinopril 10 and coreg 25 bid NYHA III, EF 35% K is 5.2. waht do you start next?
D/C K supp and start low dose spironolactone
Pt on spironolactone at inc’d risk for what?
HyperK+ (potassium sparing diuretic)
Pt on spironolactone p/w L only breast enlargement 6 months later
Biospy (if unilateral)
CHF pt on lasix, coreg, spironolactone, lipitor prsents 6 months later with BILATERAL breast enlargment
D/C spironolactone ad start Eplerenone If can’t afford Eplerenone -> start amiloride
58yo F pw CHF taking lasix 20, lisinopril 5, liptor 20, coreg 6.125, spironolactone and ASA - JVP 12cm - lung with mid lung crackles, +S3, pedal edema b/l, EKG QRS 0.13 - started on IV lasix - best management?
Optimize medical therapy for CHF (all meds low doses and is overloaded now)
1 wk later, pt that was on suboptimal therapy now on lisinopril 30, lipitor 40, coreg 25, spironolactone 25, lasix now up to 60, asa 81 - JVP 10, lungs still with bibasilar cracksl S3+ EKG QRS 0.13 EF 35 % - beset mangement?
Start Metolazone 30min prior to lasix
3 months later - pt who was optimized for CHF with lasix 60mg qD, metolazone, coreg 25mg BID, lisinopril 40mg, sprionlactone 25mg and ASA 81. p/w f/u - Echo still 35%, QRS 0.13s. best managment for pt?
Start ICD with cardiac resynchroization tx optimize meds with at least three months before ICD placement
76yo F c/o progressive SOB x 2 months - pmhx HTN, bibasilar crackles S1,S2 no murmurs 1+ pittin gedema - EF 65% with LVH best management?
CANDESARTAN (+diuretics)
Apart from HTN which conditions will you get inc’d LV mass?
DM, Obesity
Which pt’s have higer incidence of Heart failure wih prserved EF (HFpEF)
Women age > 75 with systolic HTN
Poor prognostic factors for CHF
S3 Hyponatremia PCWP >12, norm 4-12 PAP >50, norm 10-20 Peak O2 uptake < 14 ml/Kg
Drug that improve mortality in CHF
ACEI ARB Succubutril is angiotensin-r - neprilysin inhib (ARNI) Spironolactone (low dose) (for NYHA III/IV Hydralazine + nitrates BB
What drugs DO NOT improve survival in CHF
Digoxin (improves fxn capacity and decreases hospitalizations) CCB Lasix
55yo F brouht to ED onset of severe SSCP x 2 days - inc’d with breathing - recently lost custody of her grandchild - JVP normal HR 120 lungs clear with summation gallop. trop 36, EKG 1mm ST elev V1-4 - echo anter and lateral wall hypokinesis with EF 35% ballooning of LV - cath shows NO CORONARY OBSTRUCTIN dx?
Takotsubo’s cardiomyopathy
Can you use ACEI in asx pt with LV dysfxn?
Yes
ACE used for all following
Sclerodermal renal crisis post acute MI CHF DM with microalbuminuria HTN with S4 Viral myocarditis IgA nephropath chemo induced NICM NOT WITH PREGNANCY
SE ACEI…
Cough 2/2 bradykinin First dose syncope Angioedmea/laryngela edema Dec’d constriction of efferent arterioles - renal failure in marginal patients OR, increased vasodilation of efferent w hypoperfusion of glomerulus. GFR will decr slightly Neutropenia
What drugs NOT to use in CHF pts
NSAIDs Glitazones insulin sensitizing agents CCB Cilostazol metformin in advanced CHF
Combination of ACEi and ARB shown what?
Less proteinuria WORSE renal outcomes
70yo F pw pulm edema, two earlier episodes - responds well to IV lasix - HTN hx with 160/95 - LUngs clear, systolic murmur II/VI at apex-> axill a - echo mild LVH EF 60% etio?
CAD
65yo F new onset CHF loud S4 soft S3, JVD 12, basal crackes - EKG BBB echo EF 25% - started on iv lasix, iv acei sx improve. most appropriate next test?
coronary angio
Joint commision core measures for CHF
D/C instructions Use of ACEi or ARB Document EF Smoking cessation counseling Flu shot
Dilated CM
Etio Etoh/peripartum/doxorubicin Ischemia Hemochormatosis Tx: Similar to systolic dysfuction In severe CHF inotropic agents such as dobutamine
Hypertropic CM
Diastolic dysfxn Aut dom 30%
4% mortality/yr
Sudden syncope/death after vigorous excercise
Sudden death most frequent in familial form in young patient
CP/dypnea also occurs
Carotid and peripheral pulses with brisk upstroke, BISFERIENTS pulse
Early systoic murmur at LLSB inc’d with dec’d flow (standing, valsalva (Symmetric hypertrophy=athletes heart)
Etio = Asymm hypertrophy of left ventricle –> HOCM**
(symm hypertrophy of LV = athletes heart**)
Dx: Echo
Tx:
- BB, metoprolol improve sx
- CCB for CP
- defibrillator, Septal myotomy
one run of NSVT = ICD
Do HOCM pts need endocardiitis ppx?
NO
Poor progrnostic factors in HOCM
VT
Age < 30
septal thickness > 3cm
Syncope
Failure to inc BP by 20mmHg upon excerise
Familial form and
fhx of sudden death
T/F about HCM 18yo basketball player with suddne death after vigorous play - autopsy hyperrophied IV septum
T
T/F about HCM pt p./w syncope, dypena or CP
T
Ventricular Tach on holter monitor inc’d risk of sudden death - these pts need ICD
T
T/F about HCM Murmur inc’d on standing, valsalva and decreases with handshake and sitting
T
An asyx 18yo wants to join soccer team at PE reveals ejection murmur and brisk carotid upsstorke - echo 16mm thickened upper portion of IV septum - wtd?
No high intensity sports
Can do boweling
If the Pt has VT OR has one run of NSVT on holter & fhx of sudden death then ICD**
Aortic Stenosis.. p/w? s/sx?
MC valvular dz in adults
p/w
- syncope, left untreated time to death 3 years
- CP - left untreated time to death 3 years
- CHF left untreated time to death < 2 years
Signs:
- Pulsus tardus - systolic crescendo-decrescendo murmur at Right sternal border, radiating to carotids
- Delayed and slow carotid upstroke
Signs of severe AS
- S4,
- paradoxical split S2,
- late peaking murmur
- Echo with gradient >40, AVA < 1 cm2
WTD in an asymptomatic AS pt w/ mild disease?
echo Q 3-5 years
WTD in an asymptomatic AS patient with moderate disease?
Echo Q 1-2 years
WTD in an asymptomatic AS patient with severe disease?
echo q 6-12 months
75 yo w/ AS gradient 80 and syncope, has hip fx after fall. wtd?
Replace valve first.
if patient has very poor EF –> TAVR
Compared to surgery the complications with TAVR are….
increased.
- vascular complications
- strokes
- heart blocks
AS pt going for surgical valve replacement wtd prior?
coronary angiogram
What is seen in pt with AS
LVH
AV malformation with GI bleed related to?
AS
heydes?
Aortic Reguritation
- Presents w/ dyspnea (backed up blood)
- Early diastolic murmur at Left sternal border
- Severe cases with AUSTIN FLINT MURMUR (mid diastolic murmur like MS)
AR tx:
Tx:
Even with severe AR, Asx and EF>50% then according to LV dimentions
- End-systolic dimension: < 40mm. End-distolic dimension: < 60. CHF rate = 0. wtd. –> echo in 12 months
- End-systolic dimension: 40-50 mm. End-distolic dimension: 60-70. CHF rate = 6%. wtd. –> echo in 12 months
- End-systolic dimension: 50-55 mm. End-distolic dimension: 70-75. CHF rate = 19%. wtd. –> echo in 3-6 months
- End-systolic dimension: >55 mm. End-distolic dimension: >75. wtd. –> surgery
Surgery IF EF<50 with sx
Austin flint murmur
AR Jet hits MV open leaflets mid diastolic murmur like MS
25yo F with AR EF 60% wants to get pregnant - what to expect?
Normal Vaginal Deivery
Best candidate for sildenafil is
Pt with AR and preserved LVEF
(better than AS or pt with angina)
Mitral stenosis Middle aged woman born in china/india with dyspnea, hemoptysis - on exam loud S1, Loud P2, opening snap - mid diastolic rumble (decrescendo at apex)
- Swan PCWP 18, PAP 80/34, RAP 15
- CXR cardiomegaly - straightening of left heart border
dx?
Dx: Mitral stenosis
Complication = dilation of LA -> Afib -> thromboembolism and CHF
Tx: If valve < 1.3cm2, then valvuloplasty
The reason for using diltiazem or BB in mitral stenosis
inc diastolic filling time
Pt with III/VI holosystolic murmur at apex , radiating to axilla. Pt is asx or mild dizziness. BP 130/84. HR: 86/min. echo = sev MR , EF 50%
LV 72mm diastolic (norm=37-57mm),
51 mm systole (norm=28-44mm).
approp mngment?
Surgery , MV repair decreased long term complications and post op mortality.
Sx even tho asympt, when:
- LV systolic dysfunction. i.e. < 60% OR
- pulm HTN
- atrial fibrillation
- Symptoms
Pt h/o aortic aneurysm schedule for surgery gtting stress test - recent EKG, PFTs CXR normal - during stress test has ST dep in lat leads and 2/6 systolic murmur at apex - 5 min later no murmur dx?
Ischemic MR
ASD
- Secundum defect 70% (no need for abx ppx)
- Fixed split S2 (pulm valve clsoes later than aortic valve
- Parasternal impulse, prom ‘a’ and ‘v’ wave - mid systolic murmur at Left sternal border
- EKG with RV strain and partial RBBB
When closure
If L-> R shunt >1.7:1
What if pt ASD asx and L-> R shunt >2:1
Surgery
What if R-> L shunt (Eisenmenger’s syndrome)
NO SURGERY - denotes onset of pulm HTN
What is the best long term management for Atrial septal aneursym ?
nothing.
No ASA, No warfarin, no need to resect
PFO
- incomplete fusion of septum primum
- Bubble study for dx - 1 bubble /beat in LA (Hepatopulm syndrome 1 bubble every 4th beat)
Secundum ASD
- Incomplete covering of foramen ovale by septum primum
- Ideal candidate for percutanous closure
MVP
Primum ASD
- Septum primum does not connect to endocardial cushion
MVR
VSD
- common in children
- systolic murmur at LLSB -> precordium
- Split 2nd heart sound (not fixed)
- No endocarditis ppx unless w/in 6 months of surgery
- If L-> shunt >1.7:1 then Do surgery
PDA
- Crescendo-descrecendo continuous murmur left parasternal area (Lt 3rd ICS) - Soft S3
- Percutaneous closure helps at all ages
- No abx ppx before high risk procedures needed
Coarctation of Aorta
- most common assoc congen. cardiac abnormality –> 70% w bicuspid valve
- Delayed femoral-brachial pulse or absent femoral puulse Early systolic murmur
- Persistent HTN after surgical correction
- BP higher in upper than LE
- CXR rib notching 22/2 collateral vessels (“3” sign)
- No need for abx ppx
Marfan’s syndrome
- Decrased strength and dilation of aorta with aortic regurgitation and dissection
- Monitor yearly echos, If >4.5cm - Echo q6month
- 5.5cm or greater - repair
- Prevention of dissection = BB –> + losartan
Pt with marfan’s has echo q6month. you have explained 2 yrs ago, that repair should be done if it reaches 5.5cms. current echo reveals aorta of 5.3cms and you discuss the possibility for repair now and patient says he will wait another 6 months and see … wtd?
explain pt should consider repair now and the possibility of dissection in mean time
Eisenmenger’s syndrome
R-> L shunt
most common presentation of eisenmenger’s = Cyanosis of mucous membranes
HTN
Systolic BP>disastolic BP as CVD risk factor
Pt normal BP, after age 18 Screen for HTN how often?
q2yr
what systolic bp is preferred for a pt with HTN according to SPRINT trial?
SBP < 120 mmHg
Diastolic HF more common in…
Women > 75 with systolic HTN
Isolated systolic HTN in elderly tx?
Thiazide diuretic 12.5-25 daily
Mild to mod HTN
Thiazide/chorothalaidone
HTN with LVH (S4+)
ACEi
HTN with renal insuff
ACEi
HTN with ischemic HDz
BB, CCB
HTN with DM/proteinuria
ACEi
HTN with CHF
ACEi, Diuretics, Carveilol
HTN post MI
BB, ACEi
HTN with gout
Losartan (ARB)
HTN with pregnancy
Labetolol, Methyldopa, hydralazine NO ACEi
Thiazide s/e
Hyper Ca+ Hyper uricemia Hypo K+ Hyponatremia Inc’d dig and lithium levels, pancreatitis, psoriasis
Does Angiotensin II blocker induce cough?
NO
Pt on HCTZ 25 daily BP still high wtd?
Restric fluid and salt
Pt HTN on HCTZ 25 daily - BP 160-148 Exam S4+ wtd?
add ACEi
18yo F 170/105 wtd?
Urine tox first
21yo Pt CP, cocaine + 160/100 wtdD?
benzo, nitrate, ASA Prevent CP - no cocaine, CCB
Thoracic aneuysm
- CP rad-> back
- Acute AR murmur
- Widened mediastinum
- Surgery if >6cm and asx OR
- symptoms at any size or dissections
Abdominal aneurysm
- Interscapular pain
- Surgery >5cm and asx or
- Sx’s at any size
- usually Dissecting AAA treat medically first with BB and nitroprusside if pain persists then surgery
68yo M ddmittened for urgent repair of 7.5cm AAA pt with DM and inc’d cholesterol - fhx MI at 57 next step?
No further testing
AAA screening
Anytime smoker age 65-75 - AAA US screening noce in MEN ONLY No screening in women
73yo chrnoic smoker with family hx AAA has neg abd US for AAA wtd?
No additional US needed
73yo ex soker no fhx of AAA has small aneursym on US wtd?
Repeat US
60yo M h/o CAD severe CP-<> back 190/100 HR 90 decresenco murmur dx?
Aortic dissection Dx: TEE - or CT scan wo contrast if no TEE available then tx with BB, IV nitropruside THEN surgery
A loose fitting/large fitting BP cuff will …
UNDERestimate BP
Small/tight cuff will…
OVER estimate BP
Porcine valve
No A/C
Prosthetic valve
Needs A/C PT INR 2.5-3.5. warfarin not noacs
Valvuloplasty
Tricuspid stenosis, pulm stenosis, mitral stenosis Temporary in Aortic stenosis
TEE needed for…
- prostethic valve endocarditis
- Descending aortic aneurysm
- Left atrial thrombus, PFO
Afib
- atria fibrillating, no ‘p’ waves
- some imprulse conducted to the ventricles giving rise to an irregularly irregular ventricular response
- Narrow QRS except with abberant conduction
- can present as
- new onset < 48hrs
- PAroxysmal (terminates spont.)
- Chronic > 48hrs
New onset afib
w/in 48hrs
Paroxysmal afib
terminates spontaneously
Chronic
always in afib
Slow ventricular response in afib
- BB
- CCB
- Digoxin
Convert to NSR
- Amiodarone
- Ibutilide (prolongs QT)
- Dofetilide (prolonges QT)
- Electrical cardioversion
- Dronedarone (ony med shown to decrease hospitazation -> avoid in pt with EF<35%)
Risk factors for afib
High risk -Prev stroke TIA or Embolism Mitral stenosis Prosthetic heart valve Moderate Risk factors Heart failure HTN Age>75 LVEF<35% DM Weaker risk factors Female Age 65-74 CAD Thyrotoxicosis
Afib tx
No risk factors - ASA 81 one mod risk factor ASA81 daily or wafarin INR 2-3 Any high risk factor or >1 mod risk factor - warfarin INR 2-3
CHAD Vasc
C-congestive HF or LV syst. dysfxn [1]
H-hypertension, BP > 140/90 consistently or on HTN meds [1]
A2-age >/= 75yrs [2]
D-diabetes mellitus [1]
S2-prior stroke, TIA, or DVT [2]
V-vascular dz (PAD,MI,aortic plaque) [1]
A-age 65-74 [1]
Sc-sex category, female [1]
~1% per point. score 1 = 0.6% @1yr. > 1 3% @1yr.
score >/= 2 –> AC
score =1, consider AC or ASA
Heart dz with one major contraindication to warfarin
tx with ASA
Afib with wide compplex tachy
WPW tx with procainamide NO DIG NO BB NO CCB -> vfib
62yo pw palpiations EKG afib HR 100/min - started on BB - echo with no vavluar abnormalies and normal wall thickeness - BP 140/84 wtd?
ASA 81 (no risk factors)
76yo pt HTN pw palpitations - HR 110 HR 110, started on BB
Warfarin (one mod risk factor - HTN)
65yo afib h/o TIA in past
Warfarin (one high risk factor) start on 5mg daily
Pt chronic afib on warfarin going for MINOR surgery
continue warfarin
Pt with chronic afib on warfarin going for major surgery wtd?
- If CHAD score 4 or less -> D/C warfarin 5 days prior, no need to bridge
- If CHAD score 5 or higher -> D/C warfarin 5 days prior and bridge with:
- LMWH twice daily and last dose 24 hrs prior to surgery OR
- LMWH once daily last dose 1/2 morning of procedure
On day of surgery pt INR 1.6 wtd?
Clear for surgery
Rate control and A/C in afib compared to DCCV show to ?
Decrease stroke Decrease hospitalizations
Pt with chronic afib refractory to med tx or can’t tolerate meds wtd?
AVJ ablation with PPM needs AC? - YES - atria still fibrillating
Young adult recurrent afib refractory to medical tx or can’t tolerate meds
circumferential pulmonary vein ablation
Elderly pt p/w weakness on L side body - EKG shows afib IV heparin given and weakness resolves - carotid dopper shows < 50% stenosis or right ICA & L ICA >70%. best tx at this time?
warfarin + heparin bridge
how to prevent rate related cardiomyopathy (CHF) in atrial fibrillation
control resting heart rate to <110 b/min
48yo M pw acute onset periumbilical pain - afib with RVR 130 bpm wtd?
arteriography r/o sequella afib emboli
heparin first, then tPA after.
acute mesenteric ischemia
Pt wtih afib tx’ing with diltirazem - rate control - echo structurally normal heart - pt comes back with inc’d sx palpitations - holter shows many episodes of afib where he had sx wtd?
Add BB
What drug will bring afib into NSR
ibutilide
Aflutter
- macro re-entrant circuit - EPS for RFA
- Atrial flutter rate 250-300/min
- Usually 1 in 2 flutter waves get through (2:1 block) ventricular rate 125-175 b/min.
- Etio: Cardiac or pulm dz - can have WPW
- Tx: First slow AV conduction BB, dilt then cardiovert with amiodarone/quinidine
- Low energy DCCV or atrial pacing can also be done
- Recurrent flutter - EPS/RFA
32yo F MS sudden palpitation - 150/min and regular - carotid massage slowed rate but then returned to 150 when stopped - dx?
Aflutter
MCC SVT
AVNRT 70% Tx: carotid massage Adenosine 6-> If wheezing then CCB
Orthodromic reentrant tachycarida
accessory pathway EPS/RFA down AVN, up accessory pathway - narrow complex Tx: AVN blockers, vagal maneurvers
Antidromic re-entrant tachycardia
Accessory pathway Down accessory pathway, up AVN Wide complex Treat like VT with procainamide or cardioversion
22yo palpitations pounding sensation in neck for several years - now worse - gets slightly dizzy at times - sx occur without warning while restig - when she breathes slowly and deeply palpiations resolve on own - EKG normal dx?
Paroxysmal SVT
WPW
Impulse via accessory pathway reach ventricle earlier than AV node -> delta wave, shortened PR on EKG WPW can pw Afib, aflutter and vfib DO EPS if aw any arrhythmia or unexplained syncope Never tx wide complex tachy with BB, CCB or digoxin
Pt has SVT and respods to carotid sinus massage - pt asks how to prevent future episodes
teach vagal maneuvers
25yo palpitations, gradual onset - during episodes sinus tach 140 notes - asx EKG normal - echo normal - pt dx with inappropriate sinus tach wtd?
start BB
Youn athlete on routine physical found to have EKG with WPW, asx - can he play basketball?
YES
Pt pw palpitaitons, EKG Afib or SVT - after BB feels bette rand repeat EKG shows shortened PR - wtd?
EPS/ablation of errant tract
Pt pw wide complex tachycardia HR 200 QRS 0.14 pt has h/o WPW - unable to decide if is SVT with aberration or VTach - you woudl tx this patient with ?
Procainamide
Multifocal Atrial Tachycardia
Three or more distinct morphological types of “p” waves Seen in COPD, result of theophylline use Tx: Oxygen, Mg, inhaled bronchodilators 2nd: CCB NO DIGOXIN
PVCs
3 or more PVCs = NSVT 30 S of NSVT = sustained VT
Pt with muultiple PVCs wtd?
Look for organic heart dz - echo, stress, gated pool studies If heart dz negative, asx - NO TX If heart dz neg but symptoms -> BB If heard dz postiive with LOW LVEF -> ICD Sustained VTach - ICD
45yo healthy man who excercises everyday and asymptomatic, is going for elective major surgery - EKG reveals multiple PVCs wtd?
Clear for surgery
Ventricular tachycardia
3 or more consequential PVC Diff dx: SVT with aberrancy WPW LBBB
VT more likely if
- AV dissociation
- QRS>0.14s
- LAD neg.
- Fusion beats
- Capture beats (normal conducted sinus beats interrupting wide complex tacycardia)
- Presense of organic heart dz
- Cannon ‘A’
- Concordance of QRS in precordial leads Rate>100
30yo AA pt to ER with palpitations - found to be in arrhythmia adn hypotensive - defib twice and IV med is started - exam cervial axillary and epitrocheal LN ++
Dx: Sarcoidosis
Prolonged QT interval
Quinidine Disopyramide Methadone Azithro Procainagmide Hypokalmeia, hypo Mg+ Pentamidine Erythromycin Phenothiazine TCA, moxifloxacin Ariprazole
Torsade de points
tx: D/C offending drug Overdrive pacing Mg SO4
MCC sudden cardiac death
ishemia
What dec’d short term mortality in pt with vfib
Defibrillation
What is most effective timing of defib
CPR then defib
Pt with Vfib collapse in ER - defib x 2 but short while later vfib twice more wtd next?
epinephrine check electrolytes amiodarone
Best managment in pt with fhx sudden cardiac death
ICD
Indications for ICD
- Sudden cardiac death VT or Vfib
- EF<35% with CHF irrespectie of etio
- NICM - 3 months fter med therapy
- ICM - 40 days after MI
- HOCM with NSVT and fhx SCD
21yo F wakened by alarm clock and minutes later has syncope - EKG prolongued QT and TWi - hx might be helpful is?
fhx sudden cardiac death
60yo F c/o recurrent excercise idued palpitations with near syncoep - pt fhx near syncope in mother and daughter - EKG QTc 460, EF 55% next step?
BB therapy (metoprolol, not sotalol)
42yo Asian man with sudden cardiac arrest - EKG Vfib - defib’d successfull - EKG now ST elev in V1-3 and asx - pt fhx father dying at age 40 dx?
Brugada syndorme tx: ICD
Pt with h/o dizziness passing out for few sesonds - h/o palpitations
Holter montior (continuous loop recorder)
Pt with palpitations 2-15 minutes - NO SYNCOPE
Event monitor - press button to start
First deg AVB
- conduction impulse to ventricles delayed
- PR>0.2
- intranodal block with benign process
- NO NEED FOR PPM (if suspecting endocarditis -> may have new 1st deg AVB)
2nd deg AVB type I (mobitz I/wenkebach)
progressively prolonging PR till dropped QRS no need for PPM unless very low HR or HD problems
ok to give low dose BB
Pt with inf wall MI had PCI now stable - 3 days later tele shows 2nd deg AVB type I, HR 50bpm no sx - wtd?
Close monitoring as outpt, reduce BB dose
2nd deg AV block type II
- PR prolonged but constant with sudden drop QRS
- If 2/2 IWMI/RV MI –> usually transient and doesn’t require pacing (may need atropine or TVP)
- If 2/2 AWMI –> more extensive damage –> may need PPM Infranodal block
3rd deg AVB
- atria and ventricles beathing at own rate - cannon A waves on JVP
- tx w/ PPM
- Acute MI with new bifasciular block -> high risk for progression to CHB
Indications for PPM
- 2nd deg Mobitz II
- 3rd deg AVB
- Pause dep VT
- sinus nodes dysfxn -
- HR<40s while awake,
- Mobitz II AVB with bifasciular block,
- post op AVB
CHF with prolonged QRS - use bivi ppm
75yo M intermittent palpitations denies SOB or syncope - pt on BB and ACEi for HTN - EKG NSR 66bpm - holter with HR 35-106 during day
PPM (need for tachy brady to tx palpitaitons)
80yo for regular checkup found to have HR 45 - holter shows rate max 55, drops to 38 during night at one point - no sx
reassurance NO PPM
65yo F SOB on exertion CHF EF 22% on nitrates, BB, ACEi, spironolactone and dogxoin QRS>0.15 w LBBB what else to decrease sx?
CRT-D
Junctional rhythm
- Junctional tachycardia
- Vrate 70-130
- ‘p’ wave may be inverted - buried beneath QRS or following QRS
- Etio: Dig toxicity IWMI Myocarditis Post cardiac surgery
Sinus bradycardia
HR<60 Hypothermia Hypothyroid
Sick Sinus syndrome
SA node problem causing bradycardia, block, arrest or tachy-brady syndrome No need for EPS -> directly to PPM Tx: PPM if: 1. Symptomatic 2. Tx of tachyarrhythmias causing significant bradycardia
Digoxin
inc’d vagal tone Wt loss anemia AVN block -> Jnc rhthym -> regularized afib -> dig tox
Digoxin effect
Scooped ST segment No tx (not dig toxicity)
Anti arrhythmic drugs
ClassI decrease upslope of action potential Ia: Disopyramide, Quinidine, Procainamide (Double quarter Pounder) Ib: Lidocaine, Tocainide, Mexiletine, Phenytoin (Letuce Tomato, mayo) Ic: Flecanide, Propafenone (Fries Please) Class II: decreases synpathetic activity Beta Blockeers Class III: prolongs action potential Amiodarone, Sotolol, Bretylium Class IV: CCB Others: Adenosine: slows AV conduction Digoxin
Toxicity of Antiarrhythmics
Quinidine -> prolongues QT, dec’d plts Procainamide -> Drug induced lupus (anti-histone) Lidocaine -> seizures Amiodarone -> Pulm fibrosis, hypo/hyperthyroid, COrneal deposits
LAenlargement EKG
M shaped pwave (MS)
RAEnlargment
Tall p wave
RVH
R wave V1, RADev
RBBB
R, R’ V1-2
LBBB
R R’ I, aVL, V6
Digoxin: Normal level <1ng/mL
Toxcity - anorexia/wt loss Regularized afib - weight loss EKG Jnc Tachycardia, PAT with block, PVCs
Predisposing factors for dig toxicity
Low K Low Mg Low Renal Fxn Low O2
Drugs tha tincrease Digoxin level
Quinidine Amiodarone Verapamil Spironolactone Chlorthalidone/HCTZ
Treament of Digoxin toxicity
Correct electrolytes BB Lidocine/phenytoin Digoxin binding antibodies - if pt with life threatening arrythmia NO QUINIDINE, NO PROCAINAMIDE
Pt with afib started on Digoxin - regularized afib on EKG wtd?
D/C Digoxin
Elderly pt with Cr 1.3 on lisinopril, glizpiide mirtazapien and digoxin 0.25/day with gradual wt loss wtd?
lower digoxin dose
Pt on digoxin and amiodarone is added wtd?
Decrease digoxin dose
78yo M SOB with Cr 1.5 on digoxin and warfarin - EKG HR 96 looks regular with regular with retrograde pwave
Dig toxcity - check electrolytes pAT with block
normal BP in setting of S4?
masked BP, therore home BP monitoring
Pulsus paradoxus
Decr. BP, JVP incr. w/ inspiration: cardiac tamponade SVC obstruction Pulm obstruction
PDA
apical –> V5-6
Pt w/ CP at night 5-15 min at rest. wtd?
- EKG –> ST-T changes? yes? do angiogram. if neg? do ambulatory EKG to see if vasospastic angina - EKG –> ST-T changes? no? do ambulatory EKG .. if positive then do angiogram.. if that is neg then vasospastic angina
21 yo pt w/ chest pain, cocaine positive in urine . BP 160/100. wtd?
1 benzo #2 nitrates #3 ASA prevent chest pain in the future with CCB
Pt w CAD s/p PCI w stent.. 3months later with low Hb , BRBPR and EKG reveals STD. PRBCs transfused, wtd?
colonoscopy
pt w/ stent placed 9 months ago on ASA + plavix presnets wtih GI bleed. wtd?
d/c plavix and contin asa at 81mg qD
Pt w/ CP 3hrs presents to the ER w/ STE in II,III, avF. troponin neg. wtd?
PCI
Pt w/ 3 hours of CP, presents to the ER with STE II,III,avF. Troponin neg. PCI not available.. mangmt?
PCI after 2 hours
Pt w/ CP for 3 hours presents w STE V2-4. Trop +. tPA was given w/in 30 min of arrival. Pt now w crackles in lungs and dyspnea. mangmt?
PCI asap
65 yo M w/ AWMI w/ BP 80/60. pt was put on IABP. nearest PCI center 2.5hrs away. wtd?
tPA & then trsnsfer to do PCI
Pt w/ MI is treated then develops sustained VT. wtd?
if unstable (CP or low BP) –> synchonized cardioversion, then amio/lidocaine* if QRS and T not seen –> defibrillation then amiodarone* if stable –> amiodarone/lidocaine.. wtd next ? cath*
Pt with CHF NYHAII on ACEI lisinopril 20mg PO BID, coreg 25mg BID, and spironolactone. He is mildly symptomatic. wtd?
–> switch from lisinopril to sacubril-valsartan. how? –> dc ACEI, wait 36hr washout period and then start sacubitril-valsartan entresto = decr mortality and hospitalization ACEI + entresto is CI
Constrictive pericarditis…
- rigid pericardium not allowing ventricles to expand
- post cardiotomy, viral, radiation
- sx: dyspnea, fatigue, ascites
- Increased Rt/Lft sided pressures
- Normal systolic function
- diastolic fxn : yes early restrictive filling E’ >12
- JVP bulge: equalization of diastolic pressures
- Positive square root/dip & plateau
- Heart sounds: knock aka early 3rd HS
- EKG : mostly normal
-murmurs less common
- BNP < 100
- CXR –> pericardial calcification
- atrial enlargement less common cardiomegally with biatrial enlargement
-MRI = thickened pericardium
- ECHO = bulging of septum to the left. Mitral annulus E’ > 12cm, respiratory variation 10-40%
Restrictive cardiomyopathy..
- rigid ventricle
- etio: amyloid, endocardial fibrosis, sarcoidosis
- sx: dyspnes, fatigue, ascites
- increased rt & left sided pressures
- normal systolic function
- diastolic fxn, early restrictive filling
- JVP bulge, equalization of diastolic pressures
- Squar root/dip & plateau
- Heart sounds: 3rd HS –> 4th HS early dz
- ekg: low voltage EKG, repolariz abnormalities, ST-T wave changes, AV conduction delays, afib, PACs
- BNP > 400
- CXR: cardiomegaly due to atrial enlargement
- atrial enlargement: cardiomegaly with Biatrial enlargement more common
- MRI: ventricular wall thickening, thickened septum, refractile
- ECHO: mitral annulus E’ < 8cm/sec. Resp variation < 10%
A 65 yo p/w dyspnea on exertion and fatigue for the past couple of months . pmhx of MI 5yrs ago w/ CABG. exam: bulging of JVP on inspiration. early diastolic sound on auscultation. pedal edema 1+. BP 130/80. on inspiration 124/74. EKG norm. BNP 80. ECHO = early restrictive filling with septum bulging to the left on inspiration.. dx
constrictive pericarditis
70 yo pt p/w dyspea on exertion and fatigue for the past several months. pmhx HTN. BP 140/80. Periorbital ecchymosis BL. JVP bulges on inspiration. S3 +. Trace pedal edema. petechiae over feet. Lungs clear. pansystolic murmur 2/6 at LSB. tender hepatomegaly. EKG = ST-T wave changes and 1st degree AV block. CXR = cardiomegaly. DX?
restrictive pericarditis
The best management for a pt with mitral stenosis with valve surface area < 1.5 sq cms and moderate MR?
mitral valve repair
HTN w/ systolic HTN in elderly woman
candesartan
HTN with aortic regurgitation
ACEI, ARB, dihydropyridine CCB
Frequency of AAA screening depends on size of the aneurysm.
<3 cms –>
3-3.4 cm –>
- 5 - 4.5 cm –>
- 5 - 5.5 cm –>
<3 cms –> 5 yrs
3-3.4 cm –> 3 yrs
- 5 - 4.5 cm –> 1 yr
- 5 - 5.5 cm –> 6 months
Drugs to maintain sinus rhythm in pts with afib.
NO STRUCTURAL HEART DISEASE..
- propafenone
- flecanide
Drugs to maintain sinus rhythm in pts with afib.
NO CAD and NO CHF
- sotalol
- amiodarone
- dronaderone
Drugs to maintain sinus rhythm in pts with afib.
NO CAD and with CHF
- amiodarone
82 yo woman trips and falls and becomes unresponsive for a few mins. PMGHx on non-valvular afib, w/ hx of TIA and HTN on warfarin and HCTZ. CT head shows soft tissue swelling but no fracture or bleed. wtd??
restart warfarin 2 wks later.
Which drug genotyping with VKORc1 +/- CYP2C9 has helped dosing for anticoagulation?
warfarin
First step in fast AVNRT is
carotid massage.
next step = adenosine 6mg IV
then 12mg IV
adenosine does not work in afib/flutter
