Cardiac 2024 Flashcards
MI, AV blocks, congenital abnormalities, BBB, percarditis, ...
Afib and Aflutter med tx
BB, CCB(diltiazem, verapamil).
Also for Afib- digoxin for allergy to BB and CCB
EKG for afib and aflutter
sawtooth for flutter. smaller sawtooth in afib.
1,2,3 degree heart blocks
1st: prolonged PR interval(>200), every p has a qrs
2nd: dropped qrs
Mobitz 1: prog lengthening PR w/ dropped qrs
Mobitz 2: same length PR w/ occ dropped qrs
3rd: AV dissociation
Causes can be from fibrosis, increased vagal tone, drugs, CAD, nml variant, mitral valve surgeries,
* delay in conduction thru AV node
*poss electrolyte imbalance causes are what
1st degree AV block
hypokalemia and hypomagnesiumia
1st degree AV block symptoms? What is a big risk of having this? tx?
Asymptomatic usually. 3 x risk for Afib, pacemaker if over 300 PR interval and symptomatic
Wenkebach tx
Mobitz 1; usually no tx. Atropine for bradycardia and hypotension, maybe pacing.
Causes can be from increased vagal tone, drugs, nml variant, mitral valve surgeries, MI, HYPERkalemia
mobitz 1, wenkeabach
4 types of afib
- Paroxysmal: self terminating in 7 days, usually 24 hrs, +/- recurrent
- Persistent: fails to self terminate, lasts > 7 days. Requires termination.
- Permanent: persistent AF > 1 year- refractory to cardioversion.
- Lone: Paroxysmal, persistent, or permanent w/out evidence of heart disease.
symptoms in unstable afib
due to hypoperfusion: HYPOtension, altered mental status, refractory CP
tx for unstable afib and aflutter
direct synchronized cardioversion
AV nodal blocking agents
BB, digoxin, CCB
bradycardia related decreased perfusion symptoms
fatigue, dizziness, CP, syncope
-think second degree heart block, mobitz type 1 Wenckebach
TX for symptomatic wenckebach, what if it is persistent?
tx for mobitz type 2
atropine; pacemaker;
type 2: atropine or temp pacing. Progression to type 3 is common so permanent pacemaker is definitive.
AV block commonly at bundle of HIS
mobitz type 2
AV block rarely seen in patients w/out structural heart disease: myocardial ischemia, myocardial fibrosis, myocarditits(LYME), endocarditis
mobitz type 2
avoid atropine in what heart block
it can precipitate 3rd degree heart block
No atrial impulses reach ventricles leading to escape rhythm. More P waves then QRS complexes
3rd degree heart block
causes of 3rd degree heart block
INFERIOR wall infarction, AV node blocking agents, degeneration of conduction system
which AV block often symptomatic? symptoms?
3rd degree. syncope, fatigue, CP, death
tx of 3rd degree heart block
maybe dopamine or adrenaline.
For sure pacemaker
Valves most affected in endocarditis
M>A>T>P
except IV drug use: tricuspid
describe acute bacterial endocarditis
infection of normal valves with virulent organism (eg S. aureus)
describe subacute bacterial endocarditis
indolent infection of abnormal valves with less virulent organism (eg s viridans)
organisms with IV drug related endocarditis
most commonly s aureus(especially MRSA), pseudomonas, candida
describe prosthetic valve endocarditis
early(within 60 days): staph epidermis most common.
late: resembles native valve endocarditis.
PE of endocarditis around body
- Persistent fever
- new onset murmur or worsening of an existing murmur
S: splinter hemmorhages
O: Osler nodes (hands/feet) painful
R: roth spots (eye)
J: Janeway lesions (hands/feet/ashtray)
3 biggest causes of endocarditis
IV drugs/needles, valve replacement surg, dental visits
6 organisms of endocarditis
staph aureus
strep viridans
staph epidermis
enterococcus
HACEK
strep bovis
describe staph aureus in endocarditis
most common cause of acute endocarditis, rapidly progressive, affects NORMAL valves. also common in pts with IV drug use (esp MRSA)
describe strept viridans in endocarditis
most common cause of subacute infective endocarditis; affects DAMAGED valves. part of oral flora(dental procedures)
describe staph epidermis in endocarditis
most common in early prostetic valve endocarditis, especially within 60 days of the procedure
describe enterococcus in endocarditis
seen especially in men over 50 years old with recent history of GI or genitourinary procedure
describe HACEK in endocarditis
Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella, Enterococci; all gram neg and hard to culture. Suspect these in endocarditis and neg blood cultures
describe strep bovis in endocarditis
especially in patients with colon cancer or UC
endocarditis blood cultures
3 sets at least 1 hour apart;
labs: leukocytosis, anemia(microchromic, normocytic), increased ESR/rheumatoid factor
left vs right sided emboli from heart
left to other organs(brain, kidney, spleen, heart)
right to lungs
imaging for endocarditis
Get TTE first (transesophageal echocardiogram more sensitive than TTE)
endocarditis, DUKE criteria
2 major OR 1 major with 3 minor, OR 5 minor
describe major criteria (DUKE)
- sustained bacteremia with 2 pos blood cultures by organism known to cause endocarditis
- endocardial involvement: + echo and new valvular regurgitation(AR or MR)
describe minor criteria (DUKE)
- predisposing condition
- fevers>38 degrees or 100.4
- vascular and embolic phenomena(janeway, septic arterial or pulmonary emboli, ICH)
- immunologic phenomena: oslers nodes, roth spots, +RF, acute glomerulonephritis
- blood culture not meeting major criteria
- echo not meeting major criteria (worsening existing murmur)
refractory CHF, persisent or refractory infection, invasive infection, prostetic valve, recurrent systemic emboli, fungal infections
indications for surgery for endocarditis
empiric endocarditis tx: native valve
- anti staph PCN: (nafcillin, oxacillin) plus ceftriaxone 4-6 weeks or gentamycin (aminoglycocides only 2 weeks)
- vanco if needed due to allergy
empiric endocarditis tx: prosthetic valve
vanco plus gentamicin plus rifampin
empiric endocarditis tx: fungal
amphotericin B for 6-8 weeks, often will need surgery
great gram positive coverage
PCN and Vanco
great gram neg coverage
gentamicin, ceftriaxone
Prophylaxis for which procedures to prevent endocarditis
dental, respiratory, and procedures involving infected skin/musculoskeletal tissues
Prophylaxis medications to prevent endocarditis
amox 2 gms 30-60 min before procedure
clinda 600 mg if PCN allergic
Macrolides or cephalexin are other options
4 things to ask if bradycardic pulse
Hypotension, AMS, refractory CP, acute heart failure
bradycardic med tx and exception
atropine 1st line; next is epi infusion or dopamine infusion, pacing
**exception is 3rd heart block- must pace then permanent pacemaker
When left side of the heart malfunctions, what happens?
blood will get backed up in the lungs, you get SOB, body does not get O2 rich blood to the body(fatigue), kidneys getting too little blood(doesn’t make enough urine causing fluid build up in the body[legs]
When right side of the heart malfunctions, what happens?
blood gets backed up from tissues in the body[swelling in feet/LL], sluggish flow of blood and heart failure can lead to blood clots forming in heart, leading to clots in brain to cause a stroke OR clots in legs can travel to lungs
what is a cardiac arrest?
Heart has stopped pumping blood effectively due to an electrical issue, brain not getting enough O2, person unconscious, may not be breathing or breathing abnormally
Beck’s triad
B E C
B: big jugular vein distention
E: extreme low BP (hypotension) C: can’t hear heart sounds, distant muffled heart sounds
**Cardiac tamponade
5 initial symptoms of hypoxemia
restless & confusion, dizziness (syncope), fatigue, SOB, tachycardia
first sign of decreased cardiac output
tachycardia
pulses paradoxes
think cardiac tamponade;
systolic drop by 10mmhg upon respiration;
pulse pressure gets closer due to heart being compressed (systolic minus diastolic)
what tests to get for cardiac tamponade?
** echo: pericardial effusion and diastolic collapse of cardiac chambers (swinging heart)
1st, EKG: short and uneven qrs complexes , electrical alternans
- cardiac cath shows all pressures in chambers to be equal
- EKG: short and uneven qrs complexes , electrical alternans
cardiac tamponade
cardiac tamponade 6 symptoms
dyspnea, fatigue, peripheral edema, shock, reflex tachycardia, cool extremities
dyspnea, fatigue, peripheral edema, shock, reflex tachycardia, cool extremities
cardiac tamponade symptoms
Normal inspiration causes ___ pressure and pulls ___ into the___, the ___ ventricle ____, and this ______ affect left heart volume at all.
negative, pulls blood in the heart, the right ventricle expands and this does not affect left heart volume.
In tamponade, extra volume pushes ______ to the left and causing 3 things
interventricular septum to the left,
1. less left ventricular diastolic volume
2. lower stroke volume
3. lower systolic BP during inspiration
In tamponade, what happens to the atria
The atria can’t distend enough to accomodate VENOUS blood so blood backs up and you see JVP
electrical alternans
QRS complexes have different heights, think tamponade
What is cardiogenic shock?
Heart’s fault that pt is in shock.
inadequate tissue perfusion causing low cardiac output with increased systemic vascular resistance. Often systolic in nature.
difference between cardiogenic shock and hypovolemic shock
cardiogenic produces increased respiratory effort/distress, hypovolemic does not.
3 main Causes of cardiogenic shock
MI, heart failure(CHF), lethal rhythm
signs in cardiogenic shock
hypoTN, rales(blood backed up in lungs), JVD(heart failure), increased RR, decreased sp02(hypoxia)
myocarditis, valve dysfunction, congenital heart ds, cardiomyopathy, arrhythmias, MI
etiologies of cardiogenic shock
hypoTN, rales, JVD, increased RR, decreased sp02
signs in cardiogenic shock
symptoms in cardiogenic shock
CP, dyspnea, cold extremities with delayed capillary refill
increased pulmonary capillary wedge pressure(>15mmHg)
cardiogenic shock
cardiogenic shock and pulmonary capillary wedge pressure
increased pulmonary capillary wedge pressure(>15mmHg)
Vaso constriction or dilation in cardiogenic shock
vasoconstriction- increased SVR
Which shock do you do not give large amounts of fluid
cardiogenic shock
Tx of cardiogenic shock
O2, ISOtonic fluids(avoid aggressive IV fluid tx); inotropic support to increase myocardial contractility and CO:
1. dobutamine: positive inotrope
2. epi: positive inotrope and vasoconstrictor
3. Amrinone: may be used if refractory, positive inotrope
intraaortic balloon pump support
describe these meds:
- dobutamine
- epi
- Amrinone
- dobutamine: positive inotrope
- epi: positive inotrope and vasoconstrictor
- Amrinone: may be used if refractory, positive inotrope
Foramen Ovale
Shunts 2/3 of oxygenated blood from right atrium directly into the left atrium. Remaining 1/3 passes into right ventricle. Most of the remaining 1/3 goes through the right ventricle and gets pumped into the pulm artery.
ductus arteriosus
shunts blood from the pulm artery directly into the aorta(systemic circulation), bypassing fetal lungs
as baby takes its first breath, what happens
left side pressure becomes > right side pressure, promoting closure of openings
prostaglandins and PDA and ductus arteriosus
- to close PDA, give a prostaglandin inhibitor (IV indomethacin or Ibuprofen)
- To keep ductus arteriosus open, administer a prostaglandin
Left to right congenital heart disease
most common
- VSD, most common
- ASD
- PDA
Eisenmenger syndrome
lt to right shunt eventually develops into a right to left shunt
4 types of VSD
- perimembranous, most common, hole in LV outflow tract near tricuspid
- muscular: swiss cheese pattern
- inlet(posterior): located posterior to septal leaflet of tricuspid valve
- supracristal(outlet): beneath pulmonic valve. May have aortic valve insuffiency.
symptoms of moderate VSD
excessive sweating or fatigue, especially during feeds, lack of adequate growth, frequent respiratory infections
excessive sweating or fatigue, especially during feeds, lack of adequate growth, frequent respiratory infections
symptoms of moderate VSD
symptoms of large VSD
severe sx. No pressure differences between ventricles.
High pitch harsh holosystolic murmur best heard at LL sternal border.
May be associated with a thrill or diastolic rumble at the mitral area
VSD
VSD heart sound
High pitch harsh holosystolic murmur best heard at LL sternal border.
May be associated with a thrill or diastolic rumble at the mitral area
smaller VSDs heart sound
usually louder and associated with more palpable thrills then larger ones
testing for VSD
echo preferred over cath.
ECG and CXR in VSD
ECG: LVH.
CXR: may be nml, show left atrial enlargement or RVH.
When to repair large VSD
at 2 years to prevent pulm HTN
4 types of ASD, most common
- ostium secundum 80%
- ostium primum(assoc with mitral valve abn)
- sinus venosus
- coronary sinus
- ostium secundum 80%
- ostium primum(assoc with mitral valve abn)
- sinus venosus
- coronary sinus
ASD
- perimembranous, most common, hole in LV outflow tract near tricuspid
- muscular: swiss cheese pattern
- inlet(posterior): located posterior to septal leaflet of tricuspid valve
- supracristal(outlet): beneath pulmonic valve. May have aortic valve insuffiency.
VSD
ASD symptoms occur when usually
around 30 years old
symptoms of ASD in infants and young children
recurrent resp infection, failure to thrive, exertional dyspnea
recurrent resp infection, failure to thrive, exertional dyspnea
symptoms of ASD in infants and young children
symptoms of ASD in adolescents and young adults
exertional dyspnea, easy fatigability, palpitations, atrial arrhythmias, syncope, heart failure
paradoxical emboli
stroke from venous clots, think ASD
exertional dyspnea, easy fatigability, palpitations, atrial arrhythmias, syncope, heart failure
symptoms of ASD in adolescents and young adults
murmur with ASD
systolic murmur best heard at left sternal border; fixed S2 splitting
systolic murmur best heard at left sternal border, fixed S2 splitting
ASD
crochetage sign
notching of peak of r wave in inferior leads, think ASD
ECG in ASD
incomplete RBBB. echo best test.
PDA located where
descending thoracic aorta and main pulm artery
PDA closes when
2-3 weeks
PDA common in who
premature births
How does blood move in a PDA
from aorta shunted to pulmonary vasculature
cyanosis lower half of body
eismengers syndrome in PDA
Symptoms in PDA; murmur
usually asymptomatic.
continuous machine like murmur loud at pulmonic area(left upper sternal border); wide pulse pressures(bounding peripheral pulses), loud S2
usually asymptomatic.
continuous machine like murmur loud at pulmonic area(left upper sternal border); wide pulse pressures(bounding peripheral pulses), loud S2
PDA
child has poor feeding, wt loss, frequent lower resp tract infections, pulm congestion, infective endocarditis
PDA
PDA if they are symptomatic
child has poor feeding, wt loss, frequent lower resp tract infections, pulm congestion, infective endocarditis
prostaglandins can keep what open
PDA
EKG in PDA
LVH, left atrial enlargement.
echo best test
R to L shunts
- Tet of fallot(most common cyanotic shunt)
4 abn of tet of fallot
- RV outflow obstruction
- RVH
- large unrestrictive VSD
4.OVERIDING AORTA
Cyanosis at birth
tet of fallot
older kid symptoms of tet of fallot
exertional dyspnea, cyanosis worsens with age
tet spells
tet spells
agitation, cyanosis, rapid shallow breathing from hypoxemia- blood bypassing lungs and entering aorta;
squatting decreases right to left shunting, improving oxygenation
in infants, relieved by putting knees to chest
tet of fallot murmur
harsh systolic murmur at left mid to upper sternal border(VSD), right ventricular heave
harsh systolic murmur at left mid to upper sternal border(VSD), right ventricular heave
tet of fallot
boot shaped heart on CXR
tet of fallot
echo best test.
transposition of great arteries definition
Discordance b/t aorta and pulm trunk (the aorta arises from the RV and the pulm trunk arises from the LV
What is the most common cyanotic heart disease presenting in the neonatal period(dextro)?
transposition of great arteries
Dextro-TGA
Dextro-TGA: most common. Aorta arises from the RV and the pulm artery from the LV, leading to 2 parallel circuits. The systemic circuit sends systemic deoxygenated blood back to the systemic circulation. The pulm circuit sends oxygenated pulm venous blood back to the lungs. Prior to surgical correction, survival is dependent upon the presence of shunts b/t right and left circulation.
Levo-TGA
Levo-TGA: cyanotic. Rt atrium sends blood to the morphologic LV, which is on the right side physically. This morphologic LV sends blood to the pulm system. The LA sends blood to morphologic RV located on the left side. The morphologic RV sends blood to the systemic circulation.
symptoms of TGA
severe cyanosis and tachypnea within the first 30 days of life not affected by exertion or the use of oxygen.
Egg on a string on CXR
TGA
ECG and CXR TGA
ECG: nml or rt axis deviation or RVH.
CXR: egg on a string
gold standard for TGA
cardiac cath; echo primary means of diagnosis.
Hallmarks of congenital heart disease.
- 70% have bicuspid aortic valve
- continuous machine like murmur, loudest where
- boot shaped heart on cxr
- widely fixed, split S2, does it vary with respirations?
- Bounding pulses, wide pulse pressure
- COA
- PDA, pulmonic
- Tet of fallot
- ASD, no
- PDA
Hallmarks of congenital heart disease.
- rib notching on cxr, “3”sign
- Systolic ejection murmur, heard best at pulmonic area
- MC cyanotic heart disease overall
- Suspect in a child with 2 year HTN, bilateral LE claudication
- May develop stroke due to paradoxical emboli
- COA
- ASD
- Tet of fallot
- COA
- ASD
