Cardiac Flashcards
Where is the right ventricle best heard?
Sternum
Where is the left ventricle heard?
5th ICS Midclavicuar line- at PMI
Atrioventricular valves?
Mitral & tricuspid
The mitral valve separates what chambers?
Left atria and ventricles
The tricuspid valve separates what chambers
Right atria and ventricles
Semi lunar valves?
Aortic and pulmonic- separate ventricles from major vessels
S1 involves closing of what valves? What part of cardiac cycle?
Mitral and tricuspid- systole
S2 involves closing of what valves- and what part of cardiac cycle?
Closing of pulmonic and aortic/ semilunar valves- diastole
What heart sound makes “Kentucky”?
S3. Ventricular gallop
What HS makes “Tennessee”?
S4
What extra HS suggests——— Heart Failure? &. LVH?
HF= S3
LVH= S4
What grade murmur do you begin to feel a thrill?
Grade 4 or higher
Name this murmur-loudest at the 2nd ICS R sterna border, systolic, radiating to the neck
Aortic stenosis
Name this murmur- loudest at 5th ICS Mid clavic, systolic, radiating to axilla
Mitral regurgitation
Diastolic murmurs?
ARMS- Aortic Regurgitate & Mitral Stenosis
Systolic Murmurs (3)
MR Peyton Manning AS MVP:
Mitral Regurgitation Physiologic Murmur
Aortic Stenosis
Mitral Valve Prolapse
1 side effect of amlodepine?
Lower extremity edema- dose related
Name 2 non DHP Calcium Channel Blockers
Verapamil & Diltiazem
Name 2 DHP CCB’s?
Amlodipine & Nifedipine
Who do you not want to give CCB’s too?
Heart failure
Why do we not give NSAIDs to folks with renal disease
Inhibits Rena prostaglandin production which normally promote renal artery dilation = decreased renal perfusion
NSAID’s cause Na retention = fluid overload
Which of the following drug classes Increase Serum K+ vs Decrease Serum K+?
ACE/ARB Vs. HCTZ
Increase K+ = ARBs
Decrease K+ = HCTZ
What are 2 causes of elevated triglycerides?
Alcohol & elevated BG
Increased Trigs + low HDL = ?
Insulin insensitivity
What time do you advise people to take their CCB? Statins? HCTZ? ACE/ARBs?
CCB+ Statins = at hs
HCTS + ARBs/ACE = am
Key ECG features of SVT
Peaked, narrow QRS (<120 ms) & P waves
Causes of paroxysmal SVT? 2 disease, 4 ingestants
Wolf Parkinson’s white
Digitalis toxicity
Alcohol
Caffeine
Hyperthyroid
Drugs ie. cocaine
Pulses paradoxes - features & how to measure
-Apical pulse can be heard but radial pulses not palpable
- systolic pressure drop >10 mmHg with inspiration
- check BP- listen for when heart sounds first heard and then disappear during inspiration- note measurement
- then note when heart sounds no longer pause during inspiration- note measurement
- if difference between measurements > 10 mmHg
- Causes- impaired diastolic filling ie. pericardial effusion/ tamponade
Goal INR when antigoagulating
2-3
What minimum CHA2DS2- VASC score indicates need for anticoagulant?
2
Lettuce, Brussels sprouts, kale, spinach, collards, mustard greens - these foods are all high in what?
Vitamin K
Be cautious with Warfarin
Pt on warfarin has an INR between 4.01-4.99- what do you advise for dosing?
Hold one dose
How long does it take for Warfarin to change INR?
May take 3 days
Stage 1 hypertension values
Systolic 140-159
Diastolic 90-99
Stage 2 hypertension
Syst- >160
Diast - >100
Pre- HTN parameters
Syst- 120-139
Diast- 80-89
Examples of micro vascular damage 2nd to HTN (eyes and kidneys)
Arteriovenous junction nicking on fundoscopic exam
Microalbuminurua & proteinuria
Examples of macro vascular damage 2nd to HTN
CAD/ PVD
TIA’s
What is the cause of these Fundoscopic exam findings- Copper and silver wire arterioles + arteriovenous nicking
Hypertensive retinopathy
What causes the following fundoscopic exam findings- Neovascularizarion + cotton wall spots + microaneurism
Diabetic retinopathy
Adverse affects of thiazides
3 hyper + 3 hypo
Hyper- uric acid, calcium, glucose, triglycerides
Hypo- potassium, sodium, magnesium
ACE inhib adverse effects
Dry cough
Angioedema
Postural hypotension- resolves with time
Hyperkalemia ** caution when combo with spiro
Who not to give an ACE
Blacks + ppl with renal artery stenosis
What hypertensive patients can be initially treated with mono therapy?
Less than 20mmhg/10mmhg above target bp
Systolic heart failure
Reduced EF/ HFrEF <40%
Diastolic heart failure
Preserved EF- >40%
Humans sign
Pain in lower leg with Dorsiflexion- low sensitivity for DVT
NYHA class 2 symptomolgy
Ordinary physical activity results in fatigue, exertions dyspnea
Risk factors for DVT
Stasis >3h
Coagulation disorders
Increased coagulation ie- birth control, pregnancy, fractures, trauma, surgery, malignancy
1st line med for patients with stable HF
ACE/ ARB
Preferred medication for isolated systolic hypertension in elderly
Low dose thiazides like or CCB
ACE and ARB are used in what 3 conditions
Diabetes, CKD, Heart Failure
Raynauds colours and treatment
Red, blue, white
CCB- nifedipine/ amlodipine
Oslers nodes + Jane way lesions +subungual hemorrhages
Infective endocarditis
ARB side effects
Hyperkalemia
Calcium channel blockers adverse effects
Peripheral edema, bradycardia, hyperprolactinemia, dizziness/lightheaded- usually resolves
Beta Blocker adverse effects
Bronchospasm, bradycardia, fatigue, sexual dysfunction
Effects of blocking Beta 2 receptors x 8
- & 2. Mild vasoconstriction of skeletal muscle and brain vessels
- Bronchoconstrictions
- Decreased production of aqueous humour- decreased intraoccular pressure
- Increased GI motility
- Decreased glucose release in liver
- Decreased glucagon release in pancreas
- Increased serum triglycerides
Affects of blocking beta 1 receptors
Decreased HR & contractile strength of heart
Decreased renin production in kidneys
Lipid screening guidelines
- Fasting lipid profile starting at 20yrs every 5 yrs
- > 40yrs, screen q 2-3yrs
- Pre-existing hyperlipidemia- screen annually or more
Triglycerides >1000 is high risk of what?
Acute pancreatitis
If Trigs > 500 what treatment is recommended?
Give a fibrate or niacin or high-dose fish oil (lovaza)
Once’s trigs are under control- switch to target LDL
Causes of elevated triglycerides
Metabolic syndrome/ diabetes
Familial hypertriglyceridemia
Alcohol abuse
Hyperthyroidism
Kidney disease
Medications ie. anabolic steroids, acutane
Encourage use of ———- fibre in hyperlipidemia to help lower LDL’s
Soluble fibre- ie. fruits and veggies
True or false- low HDL alone, with normal LDL is a risk factors for heart disease
TRUE- low = <40mg/dL
If taking statins- avoid what 5 things?
- Grapefruit juice
- Fibrates
- Antifungals
- Macrolides
- Amiodarone
Combination regiments of fibrates, statins, niacin and/or ezetimibe are ——
Not recommended and increase risk of rhabdomyolysis
Who to avoid fibrates in?
Renal disease
Side effects of niacin?
Flushing, itching, tingling, hepatotoxicity
Take small doses until tolerated
Cholestyramine is an example of what med?
Who is it used for?
Bile acid sequesterant
Work in small intestine to interfere with fat absorption
Used in ppl who do not tolerate statins, niacin, fibrates
Triad of rhabdomyolysis?
- Muscle pain
- Weakness
- Dark urine - myoglobinuria
1st line tx for hyperlipidemia? And exception?
Lifestyle mod - unless has ASCVD or equivalent ie. CAD, HTN
High intensity statin medications and dosing
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
Who gets high intensity statin? X 3
21-75 + ASCVD
Adult with LDL > 190mg/dL
10 yr ASCVD > 7.5%
Metabolic syndrome diagnostic criteria
- Abdo obesity - W- >35inches M- >40 inches
- Hypertension
- Hyperlipdemia- elevated fasting plasma glucose (>100) / elevated trigs/ decreased HDL
Overweight BMI?
> 27 - lifestyle modifications
Abdominal aortic aneurysm screening?
Men
65-75 yrs
Any smoking hx
1 x abdominal duplex ultrasound
Hx of aortic aneurism- what antibiotics would be avoided?
Fluroqinalones- “floxacin”
Also with hx tendon rupture