4 May (cardiac) Flashcards
Young female has signs of CHF a few weeks after a viral infection. What disease process? Echo findings?
Likely viral myocarditis leading to dilated cardiomyopathy and eventual biventricular failure with reduced ejection fraction. Echo show dilated ventricles with diffuse hypokinesia and reduced EF.
What viruses cause dilated cardiomyopathy?
Coxsackie A and B HHV-6 Parvovirus B19 Adenovirus Enterovirus
What are the causes of dilated cardiomyopathy?
Genetic mutation Myocarditis Alcohol abuse Drugs like doxorubicin Pregnancy Hemochromatosis
When is eccentric hypertrophy seen in the heart?
Due to long term volume overload, often from a leaky valve causing regurgitation.
How is dilated cardiomyopathy managed?
Supportive, managing the CHF symptoms
What is normal value for bicarbonate?
22-28
What is normal value for BUN?
7-18
What is normal value for creatinine?
0.6-1.2
What is normal calcium level?
8.4-10.2
What is a low-pitched early diastolic heart sound?
S3
What is a heart complication of meth use?
Cardiomyopathy and eventually heart failure
Dobutamine MOA and use
Beta-1 agonist having a positive inotropic and chronotropic effect on the heart
Used in CHF associated with LV systolic failure and cardiogenic shock to help increase the EF and improve sx
What effect do beta-2 receptors have on vasculature?
Slight vasodilator effect
How do the following affect preload and afterload? Valsalva, Standing rapidly, Nitro, Hand grip, Squat, Passive leg raise
Valsalva: dec preload Standing: dec preload Nitro: dec preload Hand grip: inc afterload Squat: increase preload and afterload Passive leg raise: inc preload
Clinical features of hypertrophic cardiomyopathy. What is heard on auscultation?
Exertional dyspnea, chest pain, fatigue, palpitations, presyncope, syncope
Crescendo-decrescendo systolic murmur at left border changing appropriately with maneuvers. Gets louder with less blood in the heart.
What are the two structural abnormalities in HCM that lead to the systolic murmur?
Hypertrophic septal wall leading to obstruction of the aortic valve and abnormal motion of the mitral valve. The valve has anterior systolic motion towards the septum making the outflow obstruction worse.
Pt presents with Sx of CHF and EKG shows low voltage and diminished QRS amplitude. Heart biopsy shows endomyocardial fibrosis with eosinophilic infiltrate and eosinophilia. What is this condition? What are other causes of this cardiomyopathy?
This is Loeffler syndrome causing restrictive cardiomyopathy
Other causes: amyloidosis, sarcoidosis, endocardial fibroelastosis in children
What are the symptoms of cyanide toxicity from Nitroprusside?
Altered mental status, lactic acidosis, seizure, coma
Describe the progression of alcohol withdrawal syndrome
6-24hr: Mild withdrawal, anxiety, insomnia, tremors, diaphoresis, palpitations, gi upset, intact orientation
12-24hr: seizures (single or multiple generalized tonic-clonic)
12-24hr: Alcoholic hallucinosis (tactile, visual, auditory), intact orienation and stable vitals
48-96hr: delerium tremens (confusion, agitation, fever, tachycardia, htn, diaphoresis, hallucinations)
In HTN emergencies, how fast should the BP be lowered? What happens if go too fast?
10-20% in the first hour
5-15% over the following 23 hours
Too fast results in cerebral ischemia because it does not have time to react to the decreasing BP.
What are the primary effects of hyperkalemia?
muscle weakness or paralysis, cardiac conduction abnormalities and arrhythmias
Not associated with altered mental status or seizures
Rank the effectiveness of non-drug treatments for HTN
1) weight loss in obese patients (5-20 mmHG)
2) DASH diet in all patients (8-14)
3) Exercise 30 minutes, 5-6xweek (4-9)
4) Limit salt intake (2-8)
5) Limit alcohol intake (2-4)
What is the DASH diet?
Dietary Approaches to Stop Htn
Lots of fruits, vegetables, legumes, low-fat dairy, low saturated and total fat
Effect of cigarettes on BP
Transient increase in BP during use
Overall might slightly decrease BP
Not a significant factor when counseling pt on steps to reduce BP, but healthy overall to stop.
What are the primary presentations of Chagas disease? Where is Chagas disease endemic? Name of the pathogen?
Megacolon/Megesophagus (by destroying the nerves that control them) and heart disease leading to CHF through unknown mechanism Endemic in latin America Trypanosoma cruzi (protozoal parasite)
What should be suspected if creatinine jumps in a patient after starting an ACEI or ARB and there is little effect on the BP?
Think of renal artery stenosis. This is caused by fibromuscular dysplasia in young women.
Describe amaurosis fugax
Transient monocular vision loss that can be caused by many things including atherosclerosis, vasospasm, nerve issues, hypoperfusion, hyperviscosity of blood, angle-closure glaucoma, giant cell arteritis
What is fibromuscular dysplasia?
Abnormal thickening of arterial wall that is non-atherosclerotic, and non-inflammatory, but is caused by abnormal cell development leading to stenosis, aneurysm, dissection. Can involve all arteries, but most commonly renal, carotid, and vertebral arteries. Usually in women 15-50. Can also affect the iliac, subclavian and visceral arteries. Complications are HTN from renal involvement, and TIA, amaurosis fugax, stroke, HA, pulsatile tinnitus, dizziness from carotid or vertebral involvement
How can an aldosterone/renin ratio be useful?
Ratio helps to differentiate between renal and adrenal causes of renin or aldosterone abnormalities. If the kidneys are driving this, then renin and aldosterone will both be high with a lower ratio under 20. If there is a disorder in the adrenal glands leading to release of aldosterone, then the aldosterone/renin ratio will be high (over 20) because the aldosterone will suppress the release of renin. Disorders include adrenal hyperplasia and adenoma.
What is a dexamethasone suppression test used for?
Diagnosing cushing’s syndrome
What are the classic symptoms of pheochromocytoma?
Headache, palpitations, sweating, HTN
From the release of too much norepinephrine
Name selective and non-selective beta blockers
Nonselective (beta-1&2): propranolol, nadolol, sotalol, timolol
Selective (beta-1): metoprolol, atenolol, nebivolol, bisoprolol
Is aspirin ok with patients with asthma??
Aspirin is a common trigger for bronchoconstriction in patients with asthma
When can beta blockers be used in asthma?
The selective blockers can be used safely in mild-moderate asthma, though care should always be taken when giving a beta blocker
What is Amiodarone used for and when should it not be used?
Often used for ventricular arrhythmias and also to maintain a sinus rhythm in a-fib.
Should not use when hemodynamically unstable as this can worsen the hypotension and delay effective intervention by cardioversion.
Why are ACEI’s given within 24 hours after MI?
Post MI, cardiac remodeling takes place which can thin the walls and lead to aneurysm or rupture. ACEI’s help to prevent this remodeling.
What is required for a Dx of malignant HTN?
This is a subtype of HTN emergency
Includes retinal hemorrhages, exudate, papilledema
Define HTN emergency
Sever HTN associated with malignant HTN or HTN encephalopathy (cerebral edema leading to HA, nausea, vomiting, general CNS Sx of cunfusion, agitation, seizure, coma.
What is the clinical manifestation of anaphylaxis?
Previous exposure to antigen sensitizes them to the offending agent. Subsequent exposure causes massive IgE mediated release of histamine and other molecules from mast cells and basophils.
Vasodilation leads to hypotension and tachycardia and poor organ perfusion.
Upper airway edema leads to airway obstruction.
Bronchoconstriction and edema leads to narrowing of the airways and dyspnea.
Increased vascular permeability leads to flushing, wheal formation, and edema generally. Histamine causes pruritus and erythematous rash.
What are the clinical manifestations of fat embolism and what is the timeline for presentation?
Common with long bone fractures like the femur
Common Sx are dyspnea, focal neurological deficits, confusion, seizures, and petechial rash
Sx usually don’t present until 12-24 hours after injury
What kind of rash is associated with toxic shock syndrome?
Erythematous and desquamating
What are the common side effects of high dose niacin to treat hypertriglyceridemia? What can help prevent this?
Flushing and pruritus happen from drug induced release of histamine and PG’s that lead to peripheral vasodilation. This can be prevented by taking low dose aspirin 30 minutes before taking niacin because it is PG mediated and ASA inhibits production of PG’s.
How is aortic dissection confirmed or diagnosed?
CT angio in stable patients without kidney disease
MR angio in stable patients with no kidney disease
TEE in unstable patients and those with renal insufficiency
How is aortic dissection treated?
Type A is a surgical emergency
Type B can be managed medically
Beta blockers can decrease systolic pressure
Anticoagulation is contraindicated because of risk of bleeding
Causes of secondary HTN
Renal parenchymal disease Renal vascular disease Primary aldosteronism Pheochromocytoma Cushing syndrome Hypothyroidism Primary hyperparathyroidism Coarctation of the aorta
What are the commonly affected organs/glands in multiple endocrine neoplasias?
Often involves hyperparathyroidism of some kind and pheochromocytoma
Whenever either of these is found, MEN should be considered and investigated.
Symptoms of hyperparathyroidism
Muscle weakness, frequent kidney stones, GI problems, bone pain, neuropsychiatric sx, hypercalcemia
“bones, stones, abd moans, psych groans”
Can cause HTN, arrhythmias, calcification of valves,
Patient presents with sx of CHF but does not have reasonable explanation for it. Also has asymptomatic proteinuria. EKG show reduced voltage. Echo shows diastolic dysfunction with concentric thickening of walls with normal ventricular dimensions. Diagnosis? Other classic signs and symptoms of this disease?
Amyloidosis
Primary (AL Type) or secondary to chronic inflammatory conditions (AA Type)
Deposition of amyloid (Proteins) in extracellular space of organs throughout the body.
Common symptoms and signs: proteinuria, easy bruising, waxy skin, macroglossia, hepatomegaly, peripheral and autonomic neuropathy
Cardiac amyloidosis causes CHF diastolic dysfunction and the features listed on front of card
Diagnosed with tissue biopsy of abd fat pad or elsewhere showing protein deposits
Describe hemochromatosis
Iron overload due to extra absorption in the GI tract
Iron accumulates in heart, liver, skin, pancreas, joints, pituitary. Causes CHF, cirrhosis, discolored skin, DM, arthritis, infertility, depression, impotence, lack of energy, abdominal pain, memory fog, hypogonadism
Usually onset in males in 20’s-30’s and females 10-15 years after they stop having periods for whatever reason
Describe sarcoidosis
Granulomatous disease of unknown origin. Immune clusters form classically in bases of lungs causing hylar LAD, enlarge lymph nodes in neck and elsewhere, skin lesions
Less commonly affects the heart, liver, brain
Can have erythema nodosum
Findings making this likely are enlarged lymph nodes bilaterally at base of lungs, high blood calcium with normal parathyroid levels, elevated ACE in the blood.
Typically resolves spontaneously, but severe cases may require immune modulation
More common in Scandinavian countries, women, and blacks between age 20-50
What are the most common causes of aortic regurgitation?
In developing countries it is rheumatic heart disease
In developed countries it is root dilation or bicuspid valve
How is stable angina medically managed?
Beta blockers are first line because they reduce the O2 demand of the heart by decreasing rate and contractility
Calcium channel blockers are alternative first line and work by similar mechanism
Other calcium channel blockers can be used because they dilate coronary arteries to provide more O2, and they reduce afterload
Nitrates are also used, for chronic management long-acting nitrates are used like isosorbide mononitrate. These reduce preload by dilating capacitance veins
What are the primary causes of cardiac emboli?
AFib
Post MI
Infective endocarditis
Prosthetic valve
What are the three primary causes of acute limb ischemia?
Arterial embolus
Arterial thrombus
Trauma
