Cardio 10 Flashcards
What is the treatment for Aortic coarctation⁉️
Balloon angioplasty plus or minus stent placement, surgery
What are the diagnostic studies done aortic coarctation⁉️
ECG showing left ventricular hypertrophy, chest x-ray showing notching, echocardiograph which is diagnostic confirmation
What is the etiology of Coarctation of the aorta⁉️
Congenital, acquired in rare cases such as Takayasu arteritis
What are the clinical features for coarctation of the aorta?
Upper extremities are well-developed and hypertensive may result in epistaxis and headaches; lower extremities are underdeveloped may result in claudication; brachial femoral pulse delay, systolic or continuous murmur in left interscapular area
What electrolyte imbalance parallels the severity of congestive heart failure?
Hyponatremia
What is the independent predictor of adverse clinical outcomes for congestive heart failure?
Low sodium levels
What murmur is heard in intraventricular hypertrophy⁉️
Crescendo decrescendo systolic murmur along the left sternal border=> without radiation to the carotid arteries
What can syncope be secondary to?
Secondary to arrhythmia, ischemia, ventricular baroreceptor response that inappropriately causes vasodilation, hypertrophy cardiomyopathy
What is the most effective intervention for high blood pressure in overweight patients?
Weight control and dash diet
What is the DASH diet⁉️
Low sodium intake, moderation of alcohol intake, regular moderate exercise, and smoke cessation
What is the action of norepinephrine and what are its applications?
a1>a2
Hypotension and septic shock
What are the adverse effects norepinephrine-induced vasospasm can have on patients with decreased blood flow?
Vasoconstriction in the setting of decrease blood low can result in ischemia and he crosses of distal fingers and toes, similar phenomenon may occur the intestines (mesenteric ischemia) or kidneys (acute Renal failure)
Why may the ejection fraction in a patient discharge echocardiogram appear normal after and anterior wall myocardial infarction?
Ejection fraction is initially preserved after MI however remodeling will occur weeks to months after
What is Blue toe syndrome⁉️
Cholesterol and Emboli can occur in patients with atherosclerosis and can affect digits, Symmetrical involvement of all digits are unusual
What patients can get superior vena cava syndrome? How does it affect arterial flow?
Lung cancer thrombi and fibrosing mediastinitis, can cause upper extremity edema. Arterial blood flow is preserved and no ischemia can result
When should ACE inhibitors be given to myocardial infarction patient?
24 hours after MI
Why is aspirin given to patients after myocardial infarction?
To prevent the reoccurrence of coronary artery blockage
Isosorbide Dinitrate is given to which patients?
Used to prevent angina chest pain, can be given to patients with chronic symptoms of stable angina
Which one is favored in post MI patients, aspirin or warfarin⁉️
Antiplatelet agents (Aspirin) over anticoagulation (Warfarin)
What does ventricular remodeling lead to?
Dilation or hypertrophy of the ventricle
What are the drugs shown to improve long-term survival in patients with left ventricular systolic dysfunction⁉️
Beta blockers, ACE inhibitors, ATII blockers, ARBs, Bidil (AA patients)
What is the definition of persistent HF symptoms?
Despite the use of ACEi and BBs=> LV EF <40, with recent STEMI and symptomatic HF
What does Digoxin use in HF LV systolic dysfunction patient reduce⁉️
Reduces the rate of hospitalization but has not been proven to improve overall mortality
CHADS-VASc Is utilized to identify what⁉️ what’s the score that warrants treatment?
Patients who are at greatest risk of Thromboembolic complications and Would benefit from anti-thrombotic therapy; 4 max score is 9
What are the uses for Spirolactone?
Moderate to severe systolic congestive heart failure or, ascites from cirrhosis
What are the patients presentation that are consistent with A fib?
Irregularity irregular heart rate, and worsening Fatigue
What are the treatment issues that need to be addressed in patients with new onset AF⁉️
Rhythm and rate control and systemic embolization prevention
Why should serum electrolytes be measured in patients who take loop diuretics?
Because common side effects include hypokalemia and hypomagnesema=> can lead to ventricular Tachycardia and can also potentiate decide effects of Digoxin which may include arrhythmias such as recurrent VT
What is S3 sound a sign of?
increased cardiac filling pressure
Can cyanosis be seen in CHF patients?
Rarely, only if there is marked hypoperfusion ( hypotension, cold clammy hands)
When can wheezing be heard⁉️
Heard as a sign of bronchial constriction in patients with asthma and COPD exacerbation, sometimes be heard in patients with CHF exacerbation due to bronchial wall edema
What is prohormone proBNP?
Cleavage produces a biologically active BNP and an inert N-terminal proBNP
What correlates to the severity of CHF? What is its negative predictive value?
Elevated levels of circulating BNP or NT – pro BNP correlate with severity of LV systolic dysfunction; normal levels have a very high negative predictive value for CHF as the cause of dyspnea
How is the third heart sound best heard⁉️
Best heard over to cardiac Apex in the left lateral decubitus position
What are the congenital causes of symptomatic AVF(arteriovenous fistula)⁉️acquired?
Patent ductus arteriosus, angiomas, pulmonary AVF, CNS AVF; trauma, iatrogenic from femoral catheterization, cancer, Atherosclerosis forming aortocaval fistula, Trauma
How can high output heart failure result from tramatic injury?
Right thigh injury causing symptomatic arteriovenous fistula of the popliteal or aortic artery at the site of injury
What is AVF and how are Cardiac output, Cardiac preload and systemic vascular resistance affected⁉️
Abnormal connection between arterial and venous systems that bypass the capillary beds. Shutting of large amount of blood to fistula decreases systemic vascular resistance, increases cardiac preload and increases cardiac output
What are some of the clinical signs of AVF?
Widen pulse pressure, strong peripheral arterial pulsation (brisk carotid upstroke), systolic flow murmur, tachycardia, flushed extremities
How can AVF cause cardiac failure⁉️
Compensatory increase in heart rate and stroke volume in order to meet oxygen requirements in peripheral tissues.=> normal heart is able to increase stroke volume and a cardiac output but eventually will cause cardiac failure
What are the other causes of high output cardiac failure?
Thyrotoxicosis, paget disease, anemia, thiamine deficiency
What is the preferred test to diagnose AVF in extremity⁉️
Doppler ultrasonography; surgical therapy is indicated for a large AVF
How can Atherosclerosis lead to AVF⁉️
Aortocaval fistula
What is heart failure that results in normal or high cardiac output⁉️
High output heart failure, because circulation is unable to meet oxygen demand of peripheral tissues
What gives a hint that arrhythmia is the cause of syncope?
History of structural heart disease (mitral regurg or MI) with frequent ectopic beats
What are the lifestyle changes that are necessary for hypertension?
Weight loss reduce under 25 BMI, dash diet high fruits and vegetables low fat, exercise 30 minutes five days out of week, dietary sodium less than 3g a day, alcohol intake two drinks in men one for women, smoking cessation
What medication enhances natriuresis, decreases serum ATII, and decreases aldosterone production⁉️
Direct renin inhibitor or Ace inhibitors
What organ produces angiotensinogen?
Liver
What stimulates the Juxtaglomerular apparatus to produce renin⁉️
Beta-1 sympathetic stimulation and low blood flow to the kidney
What can cause low blood flow to the Kidney?
Hypotension renal artery stenosis or diuretic use
What do the angiotensin II receptor type I do⁉️
On the vascular bed they constrict causing hypertension, on the adrenal cortex they produce Aldosterone
What does renin?
Cleave angiotensinogen into angiotensin I
What are the signs of cardiac Tamponade?
Hypotension, tachycardia, distended juggler vein, pulses paradoxes, sudden onset of severe tearing chest pain radiating to the back (of the cause is aortic dissection)=> may cause syncope
What are the affects of nitrates and how does it cause anti-anginal effects?
Nitrates cause systemic vasodilation and coronary vasodilation. Systemic venodilation causes decrease in preload and wall stress
How can nitrates worsen in Angina? How can this be prevented?
Nitrates do not have an direct effect on heart rate however the fall of in blood pressure can result in reflex tachycardia which may increase myocardial oxygen demand and worsen angina; this can be prevented by concomitant use of beta blockers
How does nitrates affect afterload and preload⁉️
The decrease and afterload occurs in much less degree then the decrease in preload
What are the secondary causes of hypertension?
Renal parenchymal disease, renal vascular disease, primary aldosteronism, pheochromocytoma, Cushing syndrome, hypothyroidism, primary hyperparathyroidism, coarctation of the aorta
What are the clinical features of primary hyperparathyroidism as being the secondary causes hypertension?
Hypercalcemia (polyuria and polydipsia), kidney stones, neuropsychiatric presentations (confusion depression and psychosis)
What is the definition of exertional heat stroke?
Temperature >40 C
Encephalopathy
Dehydration hypotension Tachycardia are common. Systemic effects can also occur
What is serotonin syndrome?
Associated with significant hypertension, typically seen in patients taking SSRIs, malignant hyperthermia is usually triggered by extreme exertion or anesthetic agent. Muscular rigidity it’s associated
What is supra valvular aortic stenosis?
Congenital left ventricular outflow obstruction due to discrete or diffuse narrowing of ascending aorta. Causes systolic murmur and that’s similar to aortic valve stenosis
Where is the murmur heard in supra valvular stenosis as opposed to valvular AS?
Best heard in first right intercostal space, higher than where valvular AS is heard
What are the clinical features of supravalvular aortic stenosis?
Unequal carotid pulses, differential blood pressure in upper extremities, high-pressure In ascending aorta and palpable thrill (high-pressure) in suprasternal notch. Presents as substernal pressure-like pain when exercise with no associated symptoms. May have a murmur as a child, loud midsystolic murmur Heard in first right intercostal space
How can Supravalvular AS lead to angina symptoms during exercise⁉️
This condition may develop with left ventricular hypertrophy over time and also concurrent coronary artery stenosis can cause an increase in oxygen demand during exercise and lead to sub in a cardio or myocardial ischemia
How can an anomalous RCA cause anginal symptoms?
The coronary artery can course between the aortic root and the main pulmonary trunk and can become compressed during exercise leading to anginal symptoms
What are the peripheral manifestations of infective endocarditis, lung manifestations, what valve is more associated with part HF?
Splinter hemorrhage, janeway lesions; septic pulmonary emboli, heart failure more common in aortic valve involvement
What are the clinical presentations for fibromuscular dysplasia⁉️
90% women, internal corded artery stenosis, renal artery stenosis
How can internal carded artery stenosis manifest in symptoms?
Transient ischemic attack, stroke, pulsatile tinnitis , recurrent headaches
What are the symptoms associated with renal artery stenosis?
Secondary hypertension, flank pain
What can be found in the PE in a patient who has Fibromuscular dysplasia⁉️
Subauricular systolic bruit, abdominal bruit
How are patients with Fibromuscular dysplasia diagnosed?
Imaging (duplex US, CTA, MRA) catheter-based angiography
What is the treatment for fibromuscular dysplasia?
Antihypertensive (ACEi or ARBs 1st line), PTA percutaneous transluminal angioplasty or surgery
Symptoms of Digoxin toxicity?
Cardiac arrhythmias G.I. anorexia nausea vomiting abdominal pain Neurologic General fatigue confusion weakness color vision alterations
Addition of what drug can cause Digoxin toxicity⁉️
Amiodarone verapamil quinidine and propafenone; must decrease the dose of the Digoxin by 25 to 50% when initiating these drugs with close monitoring of levels weekly for several weeks. Loop diuretics can cause hyperkalemia and hypomagnesiumia=> potentiate the effects of Digoxin
What is the greatest predictors for abdominal aortic aneurysm expansion and rupture?
Large aneurysm diameter, rapid rate expansion and current cigarette smoking
What are the indications for operative or endovascular repair of aneurysms?
Size greater than 5.5 cm, rapid rate of expansion greater than .5 in six months, presence of symptoms (abdominal back flank pain, limb ischemia) regardless of aneurysm size
What are the risk factors for abdominal aortic aneurysm’s?
Older than 60, cigarette smoking, family history, white race, atherosclerosis
What are the risk factors for aortic dissection⁉️
Hypertension most common, Marfan syndrome, cocaine use
What are the clinical features for aortic dissection⁉️
Severe sharp tearing chest pain or back pain, pain maybe felt anteriorly as well as neck and in between shoulder blades. >20 mmHg variation systolic blood pressure between arms
What are complications of aortic dissection?
Carotid arteries (stroke), aortic valve (acute aortic regurgitation), superior cervical sympathetic ganglia (Horner’s syndrome), coronary artery (Acute MI/ischemia), Pericardial cavity (cardiac Tamponade), Pleural cavity (hemothorax), spinal, spinal or common iliac arteries (lower extremity weakness or ischemia), mesenteric artery (abdominal pain)
What is the most important predisposing factor for aortic dissection?
Hypertension
Pulsatile Nontender mass above the umbilicus is indicative of what? What’s the most appropriate diagnostic test?
Abdominal aortic aneurysm, abdominal ultrasound is 100% sensitive and specific for this condition
What is the benefit of using ultrasound or CT or MRI for diagnoses of abdominal aneurysm?
Ultrasound is relativity inexpensive and doesn’t require contrast administration
What are the causes of pulmonary hypertension⁉️
Atelectasis, Pulmonary congestion due to heart failure, pulmonary embolus or idiopathic
What is the definition of pulmonary hypertension⁉️
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of equal or greater 25 at rest (less than 20mmHg is normal)
What are the many causes of myocarditis?
Viral infections, autoimmune diseases rheumatoid arthritis or lupus, toxins, adverse reactions to medications
Viral myocarditis treatment?
Treat as you would with heart failure or pulmonary Edema medication, if doesn’t resolve then heart transplant maybe necessary. Temporary ventricular assist device if needed
What are the diagnostic test for viral myocarditis?
ECG nonspecific changes, echocardiogram 4-chamber dilation dilated cardiomyopathy, cardiac MRI enhancement of epicardium, biopsy lymphocytic infiltration and Viral genome
What are the clinical presentations for viral myocarditis?
Young adults younger than 60, viral prodrome (fever malaise myalgias), heart failure symptoms (liver may be enlarged), chest pain, sudden cardiac death
What is the ChadsVasc score for patients who have lone Afib?
Zero, Palpitations caused by a fib with rapid ventricular response that is converted to normal sinus rhythm and no other risk factors=> no additional therapy is needed
What does the Valsalva maneuver due to venous return?
Decreased venous return during strain and increase during relaxation
What does squatting do?
Increase venous return, increased afterload, increase regurgitant fraction
What increases regurgitate fraction?
Anything that increases afterload including squatting or handgrip
What maneuvers can increase murmurs heard in hypertrophic myocardial cardiomyopathy? Decrease sound?
Decreased venous return increases the murmur, increased afterload decreases the murmur
When can CCBs like amlodipine be added to myocardial infarction patients?
When hypertension is not completely controlled by ACEi and BBs
What is Ranolazine⁉️
Anti-anginal agent used in patients who have chronic exertional angina refractory to conventional medical therapy. Decreases diastolic wall tension and oxygen consumption
What is Tiotropium and when is it used?
Long acting anticholinergic medication, used for COPD maintenance and to reduce exacerbations
Heart rate may be negatively affected by the use of what asthma drug?
Beta-2 adrenergic agonist
What drug should be avoided in acute decompensated heart failure or do to systolic dysfunction (such as ventricular tachycardia)?
Beta blockers
What are the complications of Loop diuretics that can cause ventricular tachycardia?
Hypokalemia and hypomagnesemia cause vtach and potentiation of Digoxin that can also result in vtach
In arteriovenous with Shunting of the blood from arterial to the venous side, does what to the cardiac preload?
Increases cardiac preload, leads to cardiac failure because Unable to reach oxygen demand of peripheral tissues despite high or normal CO
What type of murmur can be heard in court Tatian of the aorta? Explain the polls findings and blood pressure?
Upper and lower extremity blood pressure differential, brachial femoral pulse delay; left intrascapular systolic or continuous murmur
Clinical factors in poor prognostic systolic heart failure⁉️
Hypotension, tachycardia, S3 Gallop, Moderate to severe mitral regurgitation, elevated JVP, low max oxygen consumption (Peak VO2)
What are poor prognostic laboratory findings in systolic heart failure her?
Hyponatremia, BNP, Renal insufficiency
What are the Plumcrest not associated conditions in systolic heart failure her?
anemia, atrial fibrillation, diabetes mellitus
What causes decreased perfusion pressure in congestive heart failure? What does it results in?
Due to low cardiac output; decreased perfusion pressure at baroreceptors and Renal afferent arterioles lead to Neurohumoral activation with the release of renin and norepinephrine and secretion of ADH=> all promote free water retention and dilutional hyponatremia
What can be used in hyponatremia due to SIADH? What is the initial therapy for hyponatremia and CHF?
Salt tablets in addition to fluid restriction; restriction of water intake
What causes hyperkalemia in CHS?
Low distal sodium and water delivery leads to reduce potassium excretion and subsequent hyperkalemia
What is the difference between vasovagal and arrhythmic syncope?
Arrhythmia syncopal episode have no prodromal symptoms however vasovagal experience nausea, pallor, or diaphoresis and general fatigue prior to syncopal episode
What is orthostatic hypotension?
Postural hypotension associated with autonomic dysfunction. Refers to a drop in systolic BP >20 or diastolic >10 within 2-5 minutes of standing from a supine position
What is the common profile for a patient who has variant angina? What is the greatest risk factor?
Young female lacking cardiovascular risk factors who smokes, episode usually happens at night; smoking?
What drugs should be avoided in variant angina?
Nonselective beta blocker and beta-2 BBs because beta-2 receptor blockers can lead to worsening Cardiac vasospasm; aspirin should also be avoided because it causes prostacyclin which may also promote coronary vasospasm
What is the treatment for variant angina?
Eliminate risk factors such as smoking, pharmacologic therapy CCBs or nitrates
What is Digoxin typically used for⁉️
Increase contractility in patient with the CHF or rate control agent and patient with atrial fibrillation or Flutter
How does squatting affect mitral valve prolapse’s murmur?
Short systolic murmur at the cardiac Apex that disappears when squatting. Severe MR caused my MVP or other cause, squatting may increase murmur due to increase in afterload
What does the Valsalva maneuver do?
Decreased venous return during strain, increase during relaxation
What does decrease GFR promote? How does GFR change with age?
Promotes sodium retention and expansion of intravascular volume; Decreases with age
The dry cough and a patient who has mitral regurgitation indicative of?
Pulmonary congestion and Edema
What are the common clinical features of mitral regurgitation?
Exertional dyspnea, fatigue, atrial fib, and signs of heart failure
How would a patient with aortic dissection syncope present?
Acute Type A aortic dissection can extend into pericardial space causing hemopericardium and rapidly progressing to cardiac Tamponade and cardiogenic shock; chest and neck pain prior to syncopal episode
What is the initial diagnostic study done for hemodynamically stable patients with aortic dissection? What are the findings?
CT Angiography; revealing a intimal flap separating the true and false lumens
When is emergency pericardiocentesis indicated?
For patients with pericardial effusion and cardiac Tamponade with hemodynamic instability and or cardiogenic shock
How are beta blockers and anticoagulants used in aortic dissection?
Beta blockers are used to lower and systolic blood pressure, anticoagulant are contraindicated in these patients
What are the test that can be done for type a aortic dissection’s?
CT angiography if hemodynamically stable patient with no renal dysfunction, MR angiography time-consuming what cryers contrast should be avoided in patients with kidney disease to prevent nephrogenic systemic fibrosis, transesophageal echo preferred for unstable or Renal and sufficiency patients
What can cause atrioventricular conduction delay?
Slowed AV node conduction may be due to medications such as beta blockers or ischemic heart disease this will result in bradycardia
What are the features that are suggestive of seizures?
Trigger or stimuli such as lack of sleep emotional stress loud music flashing lights, presence of prodromal aura, head deviation, tongue laceration, prolonged posticteral phase with confusion and disorders
What is MVP syndrome?
Several nonspecific symptoms such as atypical chest pain dyspnea palpitations dizziness anxiety, Sharp left sternal pain, lasting seconds each episode, nonspecific ECG changes
What’s Primary hyperaldosterism ass with?
Secondary hypertension, hypokalemia, metabolic alkalosis, adrenal adenoma
What kind of tachycardia will would result in a patient who misises Digoxin and for furosemide?
Wide complex ventricular tachycardia
