cardiac Flashcards
1st degree AV block - ecg change
consistent, prolonged PR interval >0.2 d/t AV node delay
1st degree av - pres
most asx unless other conditions
1st degree AV - management
d/c medications that contribute to AV node blockade: adenosine, BB, CCB, digoxin
-observe
2nd degree AV - ecg
type 1: wenkebach - progressive prolongation of PR leading to dropped QRS d/t AV node dz
type 2: mobitz - same PR w/ randomly dropped QRE d/t his-purkinje fiber dz
2nd degree AVB - prese
most asx ,some can have syncope / dizziness / CP / palpiations w/ assoc conditions
2nd degree AVB - management
type 1 - same as 1st degree
type 2 - REQUIRES PACEMAKER - OFTEN PROGRESSES TO COMPLETE HEART BLOCK!
3rd degree AVB - ecg
AV dissociation - no correlation b/n P and QRS w/ ventricular rate b/n 25-40
3rd degree AVB - pres
dizzy, syncope, confusion, dyspnea, chest pain, SCD
3rd degree AVB - workup
- CBC and CMP - r/o infection, metabolic disturbance
- CXR
- echo
- ecg
3rd degree management
REQUIRES PACEMAKER!
-discontinue AV blockers - may need IVF, vasopressors for OD CCB and BB
mitral regurgitation- pathophys
acute: a/w endocarditis or rupture leading to rapid LA filling w/o time to compensate –> pulmonary edema, reduced CO w/ hypotension and shock
chronic: gradual dilation of LA and LV with LV dysfunction leading to pulmonary hypertension
Mitral regurgitation - causes
acute: endocarditis, papillary muscle / chordae tendinae rupture
chronic: MVP, cardiomyopathy, rheumatic fever, marfans
Mitral regurg - pres
acute: abrupt onset CHF and shock - dyspnea, thready pulses, orthopnea, peripheral vasoconstriction
chronic: dyspnea on exertion, PND, orthopnea, fatigue, palpitations / AFib
Mitral regurg - murmur
holosytolic at apex, radiating to axilla
mitral regurg - PE
displaced PMI, holosystolic murmur, JVD, edema,ascites, s3
mitral regurg - dx
echo - definitive
cxr: dilated Left heart / cardiomegaly, pulmonary congestion
mitral regurg - tx
acute: emergent! ABCs, intraortic balloon pump, MV repair
chronic: afterload reduction w/ vasodilators and diuretics
-w/ asx: mild - monitor clinically q 1 yr
mod - clinically and echo q 1 yr
severe: clinical and echo q 6-12 mo
mitral stenosis - causes
1 RHEUMATIC HEART DISEASE! - causes fibrosis and scarring and thus narrowing of valve d/t cross reactivity to strep antigen
mitral stenosis - sx
- worse w/ anything that increase blood flow across mitral valve i.e. exercise, tachycardia
- often asx until <2.5 cm - sx d/t pulmonary congestions - dyspnea on exertion, orthopnea, PND, fatigue, palpitations
- adv dz: pulm HTN, RHF sx, hemoptysis and hoarseness (irritated recurrent laryngeal nerve), dysphagia
mitral stenosis - pathology
- increase LA pressure, dilation and pulmonary HTN
- can cause afib!
mitral stenosis murmur
diastolic decrescendo low rumbling at apex, increasing w/ inspiration
mitral stenosis PE
- loud S1 (hallmark!!) w/ diastolic murmur, RHF sx
- mitral facies
mitral stenosis dx
ecg: atrial enlargement, RAD d/t RVH, a fib
echo: dx - mild d/t LA enlargement
mitral stenosis tx
meds: tx afib - CANNOT USE X INHIBITORS MUST USE WARFARIN!
diuretics for pulmonary congestion, BB or CCB for tachycardia
-abx w/ h/o rheumatic: PCN IM> PO take continuously
-if sx: balloon valvotomy and mitral vave surgery when severe
most common arrythmia w/ digoxin
paroxysmal atrial tach w/ 2:1 block
multifocal atrial tachycardia is a/w…
CHRONIC LUNG DZ…COPD!`
MAT traits
rate >100, 3 different p waves w/ variable PR and RR intervals
difference b/n MAT and wondering pacemaker…
MAT rate >100, wondering pacemaker 60-100
MAT dx
- ecg
2. vagal manuever / adenosine doesnt cause av block (because coming from different foci)
MAT treatment
w/ LV function preserved: BB, CCB, digoxin, amiodarone, flecanide, propafenone
w/ LV dysf: digoxin, diltiazem, amiodarone
paroxysmal SVT - patho
2 mech:
- most common: AV nodal reentry - 2 pathways w/in AV node
- orthodromic / accessory pathway - “concealed bypass tract”
paroxysmal SVT ecg
> 100 w/o P waves for reentry, may see w/ accessorry pathway
NARROW QRS COMPLEX!
paroxysmal SVT causes
- ischemic heart dz
- nodal reentry, accessory pathway
- digoxin
- caffeine, ETOH
- a flutter w/ rvr
paroxysmal svt acute tx
- vagal manuevers
- adenosine (se: headache, flushing, nausea, sob, chest pain)
- verpamil, esmolol, digoxin
- cardioversin if refractory / unstable
paroxsymal svt prophylaxis
- digoxin most common
- verapamil, BB
* ablation w/ recurrent symptomatic episodes
PAC - causes
adrenergic excess, alcohol, drugs, tobacco, electrolyte disturbance, ischemia
PAC - ecg
change in p wave morphology, narrow QRS, pause
PAC - tx
- most asx, w/ sx can give BB
* benign in normal heart, may be precursor to ischemia in w/ structural abnl
PVC - causes
hypoxia, electrolyte abnl, stimulants / caffeine, meds, structural dz
PVC - ecg
early beat w/ no p wave, wide QRS,
couplet: 2 successive
bigeminy: every other
trigeminy: every third
PVC - workup
w/ frequent / recurrent, espeically with structural heart disease need workup b/c at inc risk sudden death - order electrophysiologic study
PVC - TX
if sx (palpiations, dizzy) - BB w/ recurrent + structural dz may need ICD
young patient w/ pleuritic chest pain, worse w/ lying down and improved when sitting, leaning forward. was sick 1 week ago….suggests
ACUTE PERICARDITIS
hallmark signs pericarditis
- pericardial friction rub (best heard seated, leaning forward at lower LSB)
- pleuritic, positional chest pain (improved seated, leaning forward)
- diffuse ST elevation and PR depression
- pericardial effusion
acute pericarditis causes
- idiopathic (often postviral) - majority of cases
- viral - esp COXSCAHIEIRUS
- acute mi - w/in 24 hr
acute pericarditis ecg changes
4 stages:
- diffuse ST elevation and PR depression
- normalization of ST and PR
- diffuse T wave inversion
- normalization of T waves
acute pericarditis workup
- ECG
- echo w/ signs of effusion - get TEE
- labs: cbc (leukocytosis), elevated ESR, CRP
- CXR - r/o pulmonary process
acute pericarditis tx
uncomplicated:
- NSAIDS: ibuprofen 600 mg tid or indomethacin 50 mg tid - taper q 1-2 weeks
- ASA - preferred w/ recent MI 750-1000 mg tid, then to bid then qd
- colchicine - adjunt to nsaids
- corticosteroids - for CT dz / refractory to nsaids
* most resolve 1-3 weeks
indications for surgery w/ acute pericarditis
pericardiocentesis if:
- cardiac tamponade
- purulent / tuberculous / neoplastic effusions
- do pericardial biopsy w/ recurrent effusions
constrictive pericarditis - background
rigid, fibrotic pericardial sac that impairs LATE diastolic filling (in tamponade all of filling is impaired)
constrictive pericarditis causes
-most idiopathic or viral
constrictive pericarditis pres
2 main:
- fluid overload - JVD, ascites, hepatomegaly, edema
- decreased cardiac output - fatigue, dyspnea on exertion, palpitations, dec exercise tolerance
constrictive pericarditis - PE
- **JVD w/ Kussmaul sign (no decreased in JVD w/ inspiration)
- pericardial knock: a/w rapid decline in ventricular filling
- edema
constrictive pericarditis - workup
- ECG - nonspecific, may have afib
- echo - increased thickness w/ decreased late diastolic filling
* *3. CT / MRI - best to show increased thickness and calcification - cath - shows equal diastolic pressures and rapid y descent in ventricular pressure (sq root sign) when filling stops
constrictive pericarditis tx
- aimed at underlying cause
- diuretics w/ overload
* admit w/ fever, large effusion, tamponade, refractory
- watch for coagulopathies, immunocompromised
contraindication w/ pericarditis
DON’T GIVE HEPARIN AND DON’T DO EXERCISE STRESS TEST!!! RISK OF HEMORRHAGE!
new heart murmur and fever suggests…
INFECTIVE ENDOCARDITIS!
infective endocarditis pathogens
acute: staph aureus
subacute: strep viridans (alpha-hemolytic)
native value: most d/t strep viridans, then staph and enterococci
prosthetic valve: early (win 60 days) staph epidermidis > aureus, then late (>60 d) strep
IV drug users: staph aureus affecting TRICUSPID VALVE
presentation - infective endocarditis
fever, malaise, fatigue weight loss, CVA / TIA sx
splinter hemorrhages, roth spots
janeway lesions: nontender hemorrhagic lesions on palms / soles
oslers nodes: TENDER raised red lesions on hands / feet
sx of CVA (increased embolic risk!!!)
diagnosis infective endocarditis
dukes criteria! 2 major or 1 major w/ 3 minor or 5 minor
major: visual vegetation / abscess on valve or displacement of prostehtic valve, new murmur / valve regurg, positive blood cultures x 2 for causative org
minor: PE findings, fever, vascular changes, predisposing heart conditions, positive culture
* *want TEE for echo
infective endocarditis tx
start antibiotics AFTER 3 blood cultures, do empiric tx first x 4-6 weeks
native valve: unasyn / augmentin + gentamycin
PCN allergy: vanco + gentamycin + cipro
prosthetic (<12 mo since surgery): vanco + gentamycin + rifampin
-prophylactic antibiotics for oral, gi/gu surgeries
most common valve affected
MITRAL VALVE!! MVP is predisposing!
prognosis
almost all fatal if untreated!
complications: heart failure and CVA d/t emboli
patient w/ acute onset searing chest pain radiating to back w/ long-standing h/o HTN…
AORTIC DISSECTION!
types of aortic dissection
Type A: proximal to subclavian - involves ascending aorta
Type B: distal to subclavian - involves descening aorta
aortic dissection causes
1 HTN (70%)
in non-hypertensive, think CT dz - Ehlers
danlos and marfan
trauma, 3rd tri prego
aortic coarctation, bicuspid aortic valve
aortic dissection pres
- acute onset stabbing / tearing / searing chest pain, radiates to abdomen, back, scapula
- prox most a/w chest pain
- distal most a/w back / interscapular pain
- most hypertensive
- diaphoretic
- asymm pulses/ bp in UE
- neuro changes, LE weakness / paralysis
aortic dissection diagnosis
best CT! chest and abdomen!
TEE good for unstable, but rarely done
CXR - wide mediastinum (>8mm)
angiography shows extent of dissection
aortic dissection tx
MUST IMMEDIATELY LOWER BLOOD PRESSURE - ALWAYS GIVE IV BB 1ST! to decrease wall tension
-esmolol - good for bradycardia and asthmatic b/c short-acting (book / test answer)
-labetolol 20 mg over 2 min, then 40-80 mg over 10 prn or 2 mg/min infusion
-propranolol
-most often won’t get BP down enough…give IV nitroprusside (book answer - dont give b/c get cyanide poisoning!! cyanide is byproduct) …GIVE NICARDIPINE!
**goal BP: SBP 100-120
*avoid hydralazine! increases wall stress
Type A - surgical emergency!
Type B - medical management, do surgery w/ refractory symptoms or signs of malperfusion i.e. gut, kidney
aortic dissection - maintenance
need BB for blood pressure control and annual CT to monitor false lumen - if equal / greater than 6 need surgery
70 y/o w/ acute onset back pain x 1 hr. hx smoking, CAD, HTN. on exam, hr 116 and pulse 80/76 w/ pulsatile mass…what happened and test?
rupture AAA!!!! do CT!
whats a AAA?
dilation in aorta twice its normal size or larger.
RF: smoking, HTN, family hx, increased age (>55 men and > 70 women)
AAA pres
most asx
testing for AAA…
screen >65 men w/ hx smoking w/ abdominal u/s!
u/s cannot detect rupture!! do CT!! (see retroperitoneal blood!)
indications for repair…
- size 5 cm or larger
- symptomatic
- rapidly enlarging
- do open or endovascular repair
t wave inversion and wide q waves on ecg suggests…
ACUTE MI!!
-w/o q waves = ischemia
anti-htnsive meds to avoid in pt w/ hx nephrolithiasis…
loops! increase urinary calcium excretion! not good w/ ho calcium oxalate kidney stones
28 y/o AA male w/ dyspnea, mild substernal chest pain. S4 gallop w/ murmur best hear at LLSB, decreases w/ squatting and asymmetric LVH - septum twice as thick…dx and treatment…
HYPERTROPHIC CARDIOMYOPATHY!
1st line for symptomatic is adrenergic blockers = BETA BLOCKERS b/c decrease diastolic dysf and hr (dec o2 demand): metoprolol w/ target HR 50-60, propranol, atenolol
-septal myotomy = gold std w/ refractory to meds, dual vent pacing is less effective; minimal aerobics and AVOID DIGITALIS!
NITRATES CONTRAINDICATED!!!
week old baby boy w/ VSD w/ dyspnea, tachycardia and poor weight gain…tx…
1st line: digoxin, diuretics and afterload reduction to reduce pulmonary congestion!
2nd line: w/ failed medical tx or large VSD do surgical closure
-observe only if asx
fundoscopic findings and causes…
- cotton wool spots
- drusen
- microaneurysm
- macular star
- deep retinal hemorrhages
- cotton wool - HTN (nerve fiber infarcts)
- drusen - ARMD
- microaneurysm - diabetic retinopathy
- macular star - malignant HTN
- diabetes
what type of shock worsens w/ IVF administration?
CARDIOGENIC!!! pump failure leads to loss of 15-20% of CO - treat first w/ VASOPRESSORS OR INOTROPIC AGENTS!!! fluids worsen condition
whats treatment for neonate w/ machine gun murmur?
INDOMETHACIN! baby has patent ductus arteriosus - NSAIDS close PDA!
trousseau’s syndrome
migratory thrombophlebitis and involvement of superficial veins at unusual sites and is assoc w/ malignancy - esp adenocarcinoma
-tx w/ HEPARIN until malignancy gone. warfarin is INEFFECTIVE!
benefit of spironolactone in pt w/ mi
blocks aldosterone-mediated ventricular remodeling!
silent MI common in…?
elderly diabetic!
common pres: dyspnea and weakness!! changes in mental status, arrythmias, hypotension
ischemic pain at rest and worse at night w/ transient ST elevation…
PRINZMETAL ANGINA!!!
key diagnostic hallmark of prinzmetal angina???
coronary vasospasm on coronary angiography!
prinzmetal angina tx?
-nitrates, CCB
CHF framingham diagnosis requirements…
1 major and 2 minor sx
CHF framingham major criteria
- acute pulmonary edema
- S3
- neck vein distension
- JVD
- PND
- pos hepatojugular reflux
- rales
- cardiomegaly
CHF framingham minor criteria
- extremity edema
- night cough
- D on E
- hepatomegaly
- pleural effusion
- decreased vital capacity by 1/3
- HR 120 or more
- 4.5 kg weight loss or more over 5 days of treatment
postpartum cardiomyopathy…
- must be in 3trd trimester or w/in 6 mo of delivery
- 1/2 recover (mortality of 10-20%)
- same treatment as CHF, no ACE-I
- *avoid future pregnancies!
J point (osborn wave) seen w/ ?
hypothermia!
dyspnea on exertion, palpitations, hemoptysis w/ low pitched diastolic rumble at apex….
mitral stenosis! most d/t rheumatic dz!
-increased s1 and opening snap common
holosystolic murmur at mid LSB?
VSD!
marfan w/ wide pp, high pitched blowing diastolic murmur w/ water hammer pulse…
AR!
-no treatment needed unless sig MR or arrythmia!
holosystolic murmur at LSB that increases w/ inspiration…
TR!
pulsus paradoxus?
drop in systolic BP >10 in inspiration! a/w cardiac tamponade!!!
patient w/ bp 250/150, lethargic, headache w/ visual disturbance and mental status changes w/ hx asthma…tx?
malignant htn!
- nitroprusside infusion (nitroglycerin alt)
- no BB in asthmatic!
signs of cor pulmonale on ECG..
RAE: tall P in II, III, AvF
RVH: tall R in v1-3, deep S in v6 w/ st changes
tx for SVT
- vagal
- adenosine 6 then 12
- verapamil 2.5 then 5
* cardiovert if unstable
teen w/ fever, arthritis, nodule on extensor tender and pink rash w/ central clearing and increased ESR…dx?
rheumatic!
-test for antistreptolysin o titer!
high risk conditions that need abx prophylaxis…
- marfan
- coarctation
- pda
- prosthetic valves
paradoxical split s2
- normal: widened of s2 d/t increased blood flow to heart in inspiration
- paradoxical: narrowing of split d/t delay of left ventricular conduction
* LBBB, MI, AS, HTN
