3) Cardiology (Part 2) Flashcards
Neck signs of heart failure
- Elevated jugular venous distension
Lung signs of heart failure
- Pulmonary crackles (rales)
- Wheezing (cardiac wheezes)
Heart signs of heart failure
- S3 (s4 may be present in the case of decreased LV compliance)
Abdomen signs of heart failure
- May have ascites
- Hepatomegaly
Extremity signs of heart failure
- Lower extremity edema
CXR findings in CHF
- Cardiomegaly
- Vascular redistribution (redistribution of flow to apices)
- Pulmonary venous congestion
- Kerley B lines
- Pleural effusions
Kerley B lines
- Reflect chronic elevation of LA pressure
- Chronic thickening of intralobular septa from edema
Laboratory tests in heart failure
- Elevated B-Type Natriuretic Peptide/Brain Natriuretic Peptide (BNP)
- Used in combination with clinical evaluation to distinguish dyspnea from HF from other causes
Best diagnostic test
- Echocardiogram
- 2D echocardiogram with doppler flow studies
What to look for in echocardiogram
- Ejection Fraction
- Structural abnormalities of the left ventricle
- Abnormalities of the myocardium
- Valvular heart disease
- Abnormalities of the pericardium
Types of heart failure
- HF with preserved Ejection Fraction (formerly known as Diastolic Dysfunction)
- HF with diminished Ejection Fraction (formerly known as Systolic Dysfunction)
- Mixed systolic/diastolic
HFpEF diagnosis includes
- Clinical signs or symptoms of HF
- Evidence of preserved or normal LVEF
- Evidence of abnormal LV diastolic dysfunction that can be determined by Doppler echocardiography or cardiac catheterization
Etiologies of diastolic dysfunction
- Marked LVH
- Diabetes mellitus
- Restrictive cardiomyopathies
- Hypertrophic cardiomyopathy with or without obstruction
Marked LVH
- HTN
- Advanced Aortic Stenosis (AS)
Restrictive cardiomyopathies
- Amyloidosis
- Sarcoidosis
- Hemochromotosis
Hypertrophic cardiomyopathy with or without obstruction Tx
- Beta blockers are first line
Diagnosis of HF w/ preserved EF
- Echocardiogram is a valuable study for DX
- Contractility is preserved and ejection fraction is usually normal
- Concentric hypertrophy on echo Inwardly directed ventricular hypertrophy
Tx for (HFpEF)
- Manage volume overload w/ diuretics
- Treat BP w/ guideline-directed medical therapy such as ACE inhibitors
New updates for Tx of class I HFpEF
- Attain SBP <130 mm Hg in patients with HFpEF and persistent hypertension after management of volume overload
New updates for Tx of class IIa HFpEF
- Use of aldosterone antagonists in appropriately selected patients with HFpEF (with EF ≥45%, elevated BNP or HF admission within 1 year, estimated glomerular filtration rate >30 and creatinine <2.5 mg/dl, potassium <5.0 mEq /L), to decrease hospitalizations
HFrEF definition
- HF and EF ≤40%
Etiologie sof systolic dysfunction
- Most common = ischemia: coronary Heart Disease (CAD)
- Valvular Heart disease (AS, AR, MR)
- HTN
- Non-ischemic Dilated Cardiomyopathies
Non-ischemic dilated cardiomyopathies
- Peripartum
- Various infections (mostly viral) –> myocarditis
- Toxins: Alcohol, cocaine, Doxorubicin (Adriamycin)
- HIV
- Rheumatologic conditions: ie scleroderma
- Nutritional deficiencies: ie Beriberi
- Other causes
Primary goals and management of HF
- Improve symptoms & quality of life
- Avoid/reduce hospitalizations
- Slow or Reverse disease progression
- Decrease mortality
General measures of improving HF
- Dietary sodium restriction
- Daily weights
- Physical activity to prevent deconditioning
Dietary sodium restriction
- Improves diuresis
- Prevents volume overload
Daily weights
- Monitor volume status
Physical activity to prevent deconditioning
- No heavy labor or intensive sports
- Avoid in acute exacerbations or myocarditis
2016 additional guidelines for systolic failure with reduced EF
- Loop diuretics (Lasix, furosemide)
- Relieve volume overload
Chronic medications that reduce mortality
- ACE inhibitor (preferred) OR ARB (if intolerant to ACE-I 2/2 cough or angioedema) OR angiotensin receptor–neprilysin inhibitor (ARNI)
- Evidence based beta blockers
- Aldosterone antagonists
Evidence-based beta blockers
- Bisoprolol
- Carvedilol
- Sustained release metoprolol succinate
Aldosterone antagonists
- Spironolactone
- Eplerenone
Hydralazine + long acting nitrate used for
- Patients with moderate-severe symptoms on ACE-I, bblockers, and diuretics (Especially African Americans)
- An alternative to those who cannot take ACE Inhibitors
Sinoatrial node modulator Ivabradine (Corlanor) can benefit patients with
- Symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) who:
- Are receiving guideline directed evaluation and management, including a beta blocker at maximum tolerated dose
- Who are in sinus rhythm with a heart rate of 70 bpm or greater at rest
Rheumatic fever
- Consequence of infection with group A b-hemolytic streptococci
- Late sequelae includes valvular disease: Mitral >Aortic > Tricuspid
Rheumatic fever Tx
- Course of Penicillin for streptococcal infection
- Aspirin for arthralgia
- Treat HF with standard medications (ACE-I, diuretics, etc.)
- Recurrent attacks are common - Prophylaxis with Monthly Benzathine Penicillin IM should be continued for the first 5-10 years after infection
Infective endocarditis (IE)
- Infection of the endocardium
- Usually involves the valves and adjacent structures
- Caused by a wide variety of bacteria and fungi
Infective endocarditis is higher in patients with
- Underlying valvular heart diseases
- Intravenous drug abuse (IVDA)
Invasive procedures performed may cause
- Bloodstream infections
- May result in endocarditis (i.e. pacemaker endocarditis, IV catheters, surgical wounds)
IE signs and symptoms
- Fever
- Weight loss
- Skin lesions
- New murmur
Best diagnostic tests for IE
- Blood cultures x3 different sites (do NOT use IV)
- Echocardiogram (TEE is more sensitive than TTE)
Medical treatment of IE
- Various IV high potency antibiotic regimens are available (ie, vancomycin or Ceftriaxone plus gentamicin)
- All involve 4-8 wks of therapy
- Surgical Intervention of the valve for many patients
When surgically manipulating an actual infection (abscess, cellulitis, etc.) in a patient with a “high risk” for infective endocarditis
- Prosthetic cardiac valve disease
- Previous infective endocarditis
- Congenital heart disease (CHD)
- Cardiac transplantation with valvular defects
Congenital heart disease (CDH)
- Unrepaired cyanotic CHD
- Completely repaired CHD with prosthetic materials for 6mo, allowing endothelium formation
- Incompletely repaired CHD with residual defects at prosthetic patches or devices
American College of Foot and Ankle Surgeons’ Clinical Consensus Statement: Perioperative Prophylactic Antibiotic Use in Clean ElectiveFoot Surgery (2015)
- The panel reached consensus that antibiotic prophylaxis is appropriate in patients who may be at increased risk for infection including those with diabetes, those who are immunocompromised, and those at risk for endocarditis
- The panel noted that patient factors may more strongly drive the decision to use antibiotic prophylaxis than type of procedure performed
Diastolic murmurs (heard between s2 and s1) “ARMPITS”
- Aortic
- Regurgitation
- Mitral
- Stenosis
- Pulmonic
- Insufficiency (regurgitation)
- Tricuspid
- Stenosis
Systolic murmurs (heard between s1 and s2)
- Aortic stenosis
- Mitral regurgitation
- Pulmonic stenosis
- Tricuspid regurgitation
- Atrial Septal Defect
- Ventricular Septal Defect
- Hypertrophic cardiomyopathy
Continuous murmur (heard in Diastole and Systole)
- Patent Ductus Arteriosis
Aortic stenosis
- Most common acquired valve disease
- Systolic murmur that commonly radiates to the carotids
- Narrows over several years
- Severe stenosis may have a narrow pulse pressure, syncope, heart failure, or chest pain
Aortic regurgitation
- Diastolic murmur
- Caused by aortic root abnormalities or aortic valve abnormalities
- May be acute or chronic
- Have an increased cardiac output (due to increased end diastolic volume)
Mitral regurgitation
- Systolic murmur
- Ischemia/Infarction is an important cause (because the mitral valve has a specific blood supply)
- May be acute or chronic
- May cause atrial fibrillation
Mitral valve prolapse
- Mid-systolic click
- May progress to mitral regurgitation and have an associated systolic murmur
- Most common valve disorder in United states
Mitral stenosis
- Diastolic murmur
- Most common cause is Rheumatic Fever as a child
- May cause atrial fibrillation
Pulmonic stenosis
- Systolic murmur
- Rare – most cases are congenital
Pulmonary insufficiency (regurgitation)
- Diastolic murmur
- Most cases are due to pulmonary Hypertension and stress on the valve
Tricuspid regurgitation
- Systolic murmur
- Most cases are from pulmonary hypertension and stress on the valve
- Most common valve disorder involved in endocarditis from IV drug use
Tricuspid stenosis
- Diastolic murmur
- Very Rare
Atrial septal defect
- ASD is an opening in the atrial septum permitting free communication of blood between the atria.
- Left – Right shunt
- Systolic murmur with a wide, fixed-split s2
Ventricular septal defect (VSD)
- VSD is an opening in the ventricular septum permitting free communication of blood between the ventricles.
- Left to Right shunting of blood
- Systolic Murmur
- Most common defect in infancy/childhood
Patent ductus arteriosus
- Ductus arteriosus that never closed – blood shunts from the aorta to the pulmonary artery
- Continuous (heard in systole and diastole), “machinery,” “washing machine-like” murmur
Tetralogy of Fallot
- Most common cause of cyanosis in infancy/childhood
- Severity of cyanosis is related to the severity of right ventricular outflow tract obstruction
TOF: Hypercyanotic “tet” spell
- Decreased systemic vascular resistance (hot bath, fever, exercise) increases R-> L shunt, increasing cyanosis
- Agitation increases subpulmonic obstruction
- Life-threatening if untreated
