board review cards Flashcards
rare syncope associated with palpitations.
frequency of sx determines choice
-wearable loop recorder– useful for palpitations accompanied by syncope/presyncope or short-lived episodes that may not be captured by patient triggered recorder.
-if sx spaced out in time-needs implantable loop recorder (2-3y)
patient with palpitations and WPW. Next best management
EP study– EPS+ablate the pathway. no ICD.
if asymptomatic with incidental WPW – exercise stress test. If they develop pre-excitation, then need EP study due to high risk of progression. if delta wave disappears it is reasssuring.
symptomatic with frequent PVCs (>20% burden) and bigeminy. EF drops to 40% from normal despite BB therapy.
note: no ischemia on cardiac MR.
PVC ablation for non-ischemic PVCs.
tx 1st line: BB/CCB
if persistent sx of LV dysfunction–> PVC ablation
PVCs can cause sx and cardiomyopathy if >10% PVC burden.
STEMI s/p PCI
following PCI–develops cannon a waves, otherwise asymptomatic and has accelerated idioventricular rhythm. vitals fine. next step.
observe.
No P waves, ventricular rhythm with rate 60-100. transient in 1st 24h after reperfusion.
grade 1/6 decrescendo diastolic murmur heard best over apex.
when and how to evaluate a murmur
always get eval when:
-diastolic murmur
-systolic 3/6 or greater
-holosystolic
-late systolic (MVP)
-symptomatic
get TTE
when not to evaluate a murmur
- no sx
- soft
- short but not diastolic
- systolic
- S1 and S2 normal
- standing or sitting (no positional component)
must meet all 6- reassure
management of HCM
stop diuretics
management of HCM
stop diuretics/avoid hypovolemia
start BB/CCB for negative inotropic effect
avoid vasodilators (such as ACEi) – worsen pressure gradient
consider:
-surgery for treatment refractory sx
-ICD for SCD prevention (not for sx)
murmurs with valsalva
decreases venous return
murmurs with valsalva/sit to stand
decrease VR
murmurs with stand to squat
increase VR/increase preload, increase AL
hand grip
ie, increases vascular resistance
increase LV afterload
AS
decrease with standing/valsalva, decrease handgrip, increase with squatting
HCM
increase with standing/valsalva and handgrip and decrease with squatting
MVP
increase with standing/valsalva
decrease with handgrip and squatting
ICD indications in HCM
prior hx of cardiac arrest or sustained VT.
Do not do this if no concerning sx, family hx, or LV wall thickness >30mm or recent unexplained syncope.
hx of rheumatic fever
severe MR with sx
hx of GI bleeding
can do medical therapy with afterload reduction for symptoms early on but ultimately needs bioprosthetic MV replacement
severe MR
indications for surgery
-symptomatic (class II-IV)
-LVEF <60% or LVESD >40mm
-asymptomatic who can get it done at an experienced center
repair v replacement
repairable valve has no calcification in leaflet and no calcium in annulus. Do not pick if calcium is listed in stem.
Bioprosthetic v mechanical
-bio – recommended in patients >70 or any age for whom AC is contraindicated, cannot be managed appropriately, or not desired by patient.
-mechanical - younger (<50), or those who have other indication for AC already.
-Age 50-70 – shared decision making
AS in asymptomatic 68yo - management
AV area 0.8cm
mean gradient of 44mmHg
EF 55%
peak gradient of 53mmHg
f/u ECHO in 6-12 months as asymptomatic
severe AS criteria
-AVA <1cm
-peak velocity >4m/s
-mean gradient >40
-absent A2 and late peaking murmur
Surgery performed when
-sx by hx or with exercise-testing
-LVEF>50%
-at the time of other cardiac surgery, eg if getting aortic aneurysm repaired
If not met with severe AS – f/u in 6-12 months for sx
surveillance for bicuspid AV
Get CT chest for full thoracic aorta eval once bicuspid AV diagnosed
f/u after diagnosis:
-ECHO if adequate windows. If not – get CT or MRI
bAV with only mild AS without ascending aortic aneurysm – TTE every 3-5 yr
bAV and asc aortic aneurysm >4,5cm – annual TTE
more frequent if changes in sx or pregnancy – risk of increased aortic dilation and dissection in late pregnancy or postpartum.
AR
diastolic decrescendo murmur at end-expiration when leaning forward.
widened pulse pressure, bounding carotid and peripheral pulses.
Austin flint murmur – low pitched mid to late diastolic rumble heard best at apex and ass with severe AR caused by AR jet abutting LV endocardium.
MS
opening snap, low-pitched, mid-diastolic murmur
hx of rheumatic fever
acute dCHF management in HFpEF
HFpEF
-treat underlying factors – HTN, afib/flutter, OSA, overweight, no role for mortality reducing Rxs.
