Cardiac Pathology Flashcards
what does the presentation of equivocal pain characterized as if a pt denies any true chest pain?
not pain in the chest -> can be localized to shoulder or jaw
-not relieved w/ rest & is persistent
why does radiation of chest pain occur and where in the body does it typically radiate?
They have the same dermatomes of the spinal cord that innervate the heart
- arm
- lower jaw/neck
- chest
- upper abdominal area
____ is used to distinguish STEMI from NSTEMI when troponin is elevated in a pt
EKG
___ to the heart that results in irreversible muscle damage
prolonged ischemia
what differential diagnoses should be considered for patients w/ chest pain that are not cardiac related?
• Pulmonary conditions > PTX > PE • MSK condition > rib fx > pleurisy • GERD • Cholecystitis > ask pt if pain is worse w/ fatty foods • Anxiety
what is a possible finding in pulmonary exam for a pt that you suspect MI?
rales
- left side of heart has an issue because blood flow backs up from lungs
what is a possible finding on cardiac exam for a pt that you suspect MI?
New/worsening murmurs
S3
for a pt that presents to the ED and you suspect an MI, what might their vitals be?
hypotension
tachycardia
what is the hallmark diagnostic used to determine if a patent is having a MI?
EKG
_____ is a chest discomfort that occurs when myocardial oxygen demand exceeds oxygen supply. this is a ____ myocardial ischemia
angina pectoris
-temporary
what are risk factors assoc. w/ incidence of MI?
- Smoking
- Age > 65
- DM & age > 50
- Cholesterol
- HTN
- Family History
angina pectoris (is/is not) considered one of the acute coronary syndromes
is
True or false: angina pectoris presents with the same symptoms, risk factors, exam findings as a MI.
True
what should be ordered to r/o ischemia/infarct in a pt w/ angina pectoris when the EKG and trop are both negative?
stress imaging
what makes angina pectoris atypical from a pt that has chest pain and MI is evident on EKG?
angina pectoris is more gradual
*** significant exertional component
in systolic heart failure, there is (decreased/increased) myocardial contractility
decreased
if there is an increase in pre-load, a pt w/ systolic failure most likely has valvular ______
regurgitation
common conditions that a pt w/ systolic heart failure which causes increased afterload include:
chronic HTN
aortic stenosis
in diastolic heart failure, there is abnormal _____ of the Left Ventricle or Right Ventricle
filling
in diastolic heart failure, there is ____ myocardial relaxation of the heart & the chamber becomes _______
impaired
non-compliant
what risk factors are associated with CHF?
- Age: >65 year old
- History of HTN
- coronary artery disease
- myocardial infarction
- Smoking
- Diabetes
- Obesity
symptoms such as edema, pain from hepatic congestion, & abdominal discomfort due to distension from ascites are related to _____ heart failure
right sided
symptoms such as dyspnea & orthopnea are seen in _____ heart failure due to _______
left sided
-excessive fluid accumulation
the most common symptoms that a pt w/ acute right sided heart failure has are:
leg swelling/edema
the most common symptoms that a pt w/ acute left sided heart failure will have are:
dyspnea
cough
wheezing
what are non-systemic differential diagnoses that should be considered when working up a pt for CHF?
deconditioning- prolonged bed rest sleep apnea depression drug side effects cirrhosis
what non cardiac differential diagnoses should be considered when working up a pt for CHF?
>> pulmonic disorders -COPD -asthma >> venous thrombosis -swelling will be acute >> venous insufficiency -look for chronic discoloration >> renal disease -can affect sodium retention
what would the vitals be for a pt presenting with acute CHF?
uncontrolled HTN > 140/90
HR either tachy or brady
tachypnea
JVD is a finding on exam that is seen in patients with _____ failure
right sided
S3 is an abnormal heart sound that is heard early in diastole and is more common in ____ heart failure
systolic
-Related to increased preload and increased afterload
what insufficiencies are related to S3?
valvular regurgitation
- mitral
- aortic
___ (heart sound) is related to an abnormal filling of non-compliant ventricles and is most common in ___ heart failure
S4
-diastolic
where is hepatojugular reflex seen on exam and if positive, what can it indicate?
abdomen
evaluates for fluid overload -> right ventricle cannot accommodate an increased venous return
what pathologies are associated with a positive hepatojugular reflex?
- Constrictive pericarditis
- Right ventricular failure
- Tricuspid regurgitation
when evaluating for hepatojugular reflex, the patient should be ___ and you should palpate the ___ of the abdomen while evaluating for baseline ____
supine at 30-45 degrees
RUQ (at least 15 seconds - 1 min)
JVD > 3cm
what diagnostics should be ordered when suspecting CHF in a patient and why?
EKG: r/o ischemia, arrhythmias, low voltage • Cardiac enzymes • CBC • Metabolic panel • LFTs • BNP
pericarditis causes irritation to the _____ adjacent to the pericardium
parietal pleura
a pt suspected to have pericarditis will have ____ or ____ chest pain
precordial
retrosternal
if a pt is suspected to have pericarditis, their pain is ___ with breathing, changing positions (such as laying), coughing, swallowing
worse
pericardial irritation is caused by ______
infectious etiology
if a pt presents w/ retrosternal chest pain and is sitting forward when you first evaluate them, what should you suspect? why are they in this position?
pericarditis
-pain improves leaning forward d/t intrathoracic pressure
what is an underlying cause of pericarditis?
autoimmune
HIV
pericarditis has been noted to have some increased incidents with ____ patients and ____ chest pain admissions
hospitalized
-non-ischemic
what differential diagnoses should be considered when working up a pt w/ suspected pericarditis?
- Acute coronary syndrome
- Aortic dissection
- Costochondritis
- Pericardial tamponade
- Gastritis
- GERD
a ___ on cardiac exam is a superficial scratchy and squeaky sound that can wax and wane in intensity
pericardial friction rub
True or false: A pericardial friction rub auscultated on exam is diagnostic in assessing for pericarditis.
False
-not 100% diagnostic, only a possibility
True or false: Adventitious breath sounds are heard on exam in a pt w/ suspected pericarditis.
False
-pt will not want to take deep breaths d/t intensification of pain
what is the hallmark sign in evaluating diagnostics that is an indication of pericarditis?
widespread ST changes
what are the 4 findings that are c/w pericarditis? how many of these findings must a pt have to diagnose pericarditis?
2 of the 4
- Sharp, pleuritic chest pain that improves when leaning forward
- Pericardial friction rub
- Diffuse ST wave changes
- New or worsening pericardial effusion
____ is an accumulation of pericardial fluid under pressure
pericardial tamponade
how does pericarditis differ from pericardial tamponade?
pericarditis involves the inflammation of the pericardial sac itself
____ is impeded by an external force when a pt has pericardial tamponade
cardiac filling
what happens to the pericardium when reserve volume is exceeded?
the pericardium stiffens
-> prevents heart from filling & dilating in diastole
patients that have ____ or have been _____ are at risk for developing pericardial tamponade
cancers (neoplastic disease)
-recently hospitalized
subacute symptoms of pericardial tamponade are ____ in onset and consist of ____
longer in onset- dyspnea, chest discomfort or fullness, peripheral edema, fatigue
an acute onset of chest pain, tachypnea, & dyspnea less than ____ hour(s) is suspicious for pericardial tamponade and can be _____
2
-life threatening
____ is an abnormally large decrease in systolic blood pressure (>10 mmHg) on inspiration seen in patients with pericardial tamponade
pulses paradoxus
what symptoms are seen in Beck’s triad which are specific to pericardial tamponade?
• low arterial blood pressure -narrow pulse pressure -d/t limited stroke volume • dilated neck veins -JVD • muffled heart sounds - S1 & S2 are not heard well d/t fluid accumulation
why is JVD seen in patients with pericardial tamponade?
increased pressure in R atrium -> limitation of heart filling -> back up of fluid due to lack of ventricles expanding
»_space; fluid overload
what differential diagnoses should be considered when suspecting pericardial tamponade?
ACS
pulmonary embolism
CXR findings of patients with suspected pericardial tamponade will appear to have __. why does this happen?
cardiomegaly
-sac of fluid causes increased portion of heart
what are EKG findings associated with pericardial tamponade?
Low voltage EKG
PR depression
_____ diagnosis is crucial for patients with suspected aortic dissection.
Early & accurate
aortic dissection is the ____ within the layers of the aortic wall
splitting
rupture of the dissection into the pericardium can precipitate _____
cardiac tamponade
acute dissection into the aortic valvular annulus can lead to severe _____. this will increase ___ in the left ventricle.
aortic regurgitation
-afterload
obstruction of the coronary artery ostia with an aortic dissection can lead to _____
myocardial infarction
if an aortic dissection involves an abdominal aortic branch vessel, what organs can be affected and what is the severity?
kidneys
|»_space; end-organ failure
what genetic disorders are related to aortic dissection?
Marfan syndrome
-Ehlers-Danlos syndrome
*connective tissue disorders
what antibiotic is associated with incidence of aortic dissection?
Fluoroquinolone use
what is the age range for incidence of aortic dissection?
ages 60-80
what are risk factors for aortic dissection?
Male • Age: 60 – 80 years old •HTN • Bicuspid aortic valve • Prior history of aortic aneurysm • Aortic instrumentation and/or surgery • Coarctation of the aorta • Trauma • Pregnancy/Delivery
what kind of trauma can put patients at risk for an aortic dissection?
MVA
what is a hallmark symptom of an aortic dissection?
Ripping or tearing anterior/posterior chest pain radiating to the back/neck
what new heart murmur should lead you to suspect aortic dissection in a patient?
aortic regurgitation
-special auscultatory maneuver
on physical exam of a pt suspected to have an aortic dissection, what would the vital signs be?
hypotension in upper extremities
-pulse deficit
-abnl BP readings
»_space; SBP > 20mmHg when comparing upper extremities
what is the main diagnostic used to confirm aortic dissection?
widening of aortic silhouette
why should an EKG be ordered for a pt suspected to have aortic dissection?
helpful in distinguishing from Acute MI if negative.
*dissection can still lead to ischemia if it involves coronary artery ostia
what are the clinical triads in diagnosis of aortic dissection?
- Abrupt onset of thoracic or abdominal pain with a sharp, tearing, and/or ripping character
- variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20mmHg difference between the right and left arm)
- Mediastinal and/or aortic widening on chest radiograph
what is coarctation of the aorta & where does it occur in the body?
narrowing of the descending aorta
-typically located at the insertion of the ductus arteriosus
just distal to the left subclavian artery
what are risk factors for aortic coarctation?
- Male > female
- Bicupsid aortic valve (accounts for 30 – 40 % of cases)
- Turner’s syndrome
- Brain aneursym
in severe cases for infants found to have coarctation of the aorta, ___ will be found
CHF
infants with ___ can be asymptomatic with coarctation of the aorta
patent ductus arteriosus
what symptoms are common in coarctation of the aorta?
Claudication with activities
• Cold extremities
• HTN in upper extremities
> compare to BLE
what differential diagnoses should be considered when suspecting coarctation of the aorta?
- Obstructive peripheral arterial disease
- Aortic dissection
- Neonatal cardiac abnormality
____ pulse is absent or delayed in coarctation of the aorta.
femoral
these heart sounds from a bicuspid aortic valve are highly suspicious for coarctation of the aorta
ejection systolic click and a systolic ejection murmur
there is ____ SBP in the BLE compared with BUE. ___ artery to femoral pulse delay will also be present
reduced
-radial
what are the classic findings of CoA?
- systolic hypertension in the upper extremities
- diminished or delayed femoral pulses (brachial-femoral delay)
- low or unobtainable arterial blood pressure in the lower extremities
what should be ordered when suspecting CoA?
echocardiogram
CTA chest
what physical exam findings can be seen in patients with hypertrophic cardiomyopathy?
- fourth heart sound (d/t LV dysfunction)
- systolic murmur
- LV lift
what should be ordered when assessing for HCM?
- EKG
- ECHO
- Cardiac MRI (if ECHO is suboptimal)
- Holter monitor
- Stress testing
what echo finding will be seen in patients with HCM?
LV hypertrophy (LVH)
True or false: Most patients with hypertrophic cardiomyopathy are asymptomatic.
When is this detected?
true
-screening
if a pt w/ HCM is symptomatic, what can they present with?
- Fatigue
- Chest pain
- Syncope or near-syncope
- Palpitations
- Dyspnea (most common symptom)
hypertrophic cardiomyopathy is a ____ disorder that affects the ____ of the heart
autosomal dominant disorder
-contractility
depending on the affected site & extent of the cardiac hypertrophy, patients with HCM usually develop one or more of the following: myocardial infarction, mitral regurgitation, ________, & _________
- LV outflow obstruction
* Diastolic dysfunction
True or false: In patients with HCM, often no abnormalities detected.
True
what differentials should be considered when working up a pt with HCM?
- HTN
- Aortic stenosis
- Arrhythmias
- Anemia
when auscultating the lungs, there is evidence of crackles on exam. CXR shows pulmonary edema. what diagnosis. might this indicate?
left sided heart failure
when assessing the peripheral pulses, you should be evaluating for _____ & _____
strength
symmetry
abdominal bruits indicate turbulent flow in the ____, renal arteries, & possible the splenic artery
aorta
liver enlargement can indicate passive ____ on palpation of the abdomen which is consistent with ______ (disease)
congestion
-right sided heart failure
