Cardio Flashcards
Acute Rheumatic Fever definition, causes, sx, dx, tx
*acute autoimmune inflammatory multi-systemic illness mainly affecting children 5-15yrs
PATHO:
*symptomatic or asymptomatic infectious w/ group A strep stimulates antibody production to host tissues & damages organs directly
*the infection usually precedes the onset or rheumatic fever by 2-6wks
sx
Polyarthritis
*2 or more joints affected or migratory (lower 🡪 upper)
*medium/large joints MC affected (knees, hips, wrists, elbows, shoulders)
*heat, redness, swelling, & severe joint pain must be present
*usually lasts 3-4wks
Active carditis
*can affect valves (esp. mitral/aortic), myocardium (myocarditis), &/or pericardium (pericarditis)
*carditis confers great morbidity & mortality
Sydenham’s Chorea: “Saint Vitus Dance” may occur 1-8mo after initial infection
*sudden involuntary, jerky, non-rhythmic purposeless movements esp. involving the head/arms
Erythema marginatum: often accompanies carditis
*macular, erythematous, non-pruritic annular rash w/ rounded, sharply demarcated borders (may have central clearing)
*MC seen on trunk/extremities (not on face)
Subcutaneous nodules: rare
*seen over joints (extensor surfaces), scalp, & spinal column
Other findings: abdominal pain, facial tics/grimaces, epistaxis
dx
JONES CRITERIA: 2 major OR 1 major + 2 minor
MAJOR CRITERIA:
*J – Joint (migratory polyarthritis)
*O – Oh my heart (active carditis)
*N – Nodules (subcutaneous)
*E – Erythema marginatum
*S – Sydenham’s chorea
MINOR CRITERIA:
Clinical
*fever (≥101.3F)
*arthralgia (joint pain)
Laboratory
*↑ ESR, CRP, leukocytosis
*EKG: prolonged PR interval
PLUS supportive evidence of a recent group A strep infection
*(+) throat culture for GAS or
*rapid streptococcal antigen or
*elevated/↑ streptococcal Ab titers (e.g., antideoxynuclease B or antistreptolysin O)
tx
Anti-inflammatory:
*Aspirin (2-6wks w/ taper) +/- corticosteroids
Penicillin G
*erythromycin if PCN-allergy
Complications:
*rheumatic valvular disease (MC mitral/aortic)
Hypertrophic Cardiomyopathy
definition, sx, dx, tx
*Autosomal dominant genetic disorder of inappropriate LV &/or RV hypertrophy w/ diastolic dysfunction
*Subaortic outflow obstruction due to asymmetrical septal hypertrophy & systolic anterior motion of the mitral valve
The obstruction worsens w/:
*↑ contractility (exercise, Digoxin, beta agonists)
*↓ LV volume (dehydration, decreased venous return, Valsalva maneuver)
sx
*dyspnea MC symptom
*fatigue, angina, syncope, dizziness, arrhythmias
*sudden cardiac death
PE: harsh systolic murmur best heart at LLSB
↑ intensity:
*↓ venous return (Valsalva, standing)
*amyl nitrate (decreased afterload)
↓ intensity:
*↑ venous return (squatting, supine, leg raise)
*handgrip (increased afterload)
*may have loud S4, mitral regurgitation, or pulsus biferiens
dx
Echo
*asymmetric ventricular wall thickness (especially septal)
*systolic anterior motion of the mitral valve
*small LV chamber size
EKG:
*LVH
tx
*BBs, CCBs, disopyramide
*myomectomy, alcohol septal ablation
*pts should avoid dehydration, extreme exertion, & exercise; cautious use of digoxin, nitrates, & diuretics
Atrial Septal Defect definition, sx, dx, tx
Abnormal opening in the atrial septum between the right & left atrium
PATHO: allows for a LEFT 🡪 RIGHT shunt (noncyanotic)
Types:
*Ostium Secundum MC type
*Ostium Primum (associated w/ mitral valve abnormalities)
*Sinus Venosus, Coronary Sinus
2nd MCC of CHD (VSD MC)
sx
*usually asymptomatic until >30yrs
Infants & young children:
*recurrent respiratory infection
*failure to thrive
*exertional dyspnea
Adolescents & young adults:
*exertional dyspnea, easy fatigability
*palpitations, atrial arrhythmias
*syncope, heart failure
May develop paradoxical emboli (stroke from venous clots) or dysrhythmias later in life
PE:
*systolic ejection crescendo-decrescendo murmur
-pulmonic area (LUSB)
*wide fixed split S2 that does not vary w/ respirations
*loud S1, hyperdynamic right ventricle
dx
ECHO – best test to make dx
EKG: incomplete RBBB
*Crochetage sign (notching of the peak of the R wave in the inferior leads)
CXR:
*cardiomegaly
*↑ cardiovascular markings
Cardiac catherization – definitive *rarely needed
tx
Small ASD <5mm:
*observation – most spontaneously close in 1st year of life
Surgical correction: >1cm or symptomatic
*usually between 2-4yrs of age
*percutaneous transcatheter closure
*surgical intervention
Patent Ductus Arteriosus definition, sx, dx, tx
Persistent communication between the descending thoracic aorta & main pulmonary artery after birth
LEFT 🡪 RIGHT shunt (noncyanotic)
Risk Factors:
*prematurity
*female (2x more common)
*fetal hypoxia
*Rubella infection in 1st TM
PATHO: continued prostaglandin E1 production & lower arterial oxygen content promoted patency
sx
*frequent lower respiratory tract infections
*pulmonary congestion, infective endocarditis
Eisenmenger Syndrome: pulmonary HTN & cyanotic heart disease occurring when a L🡪R shunt switches & becomes a R🡪L shunt (cyanotic)
*cyanotic lower extremities (cyanosis & clubbing of the feet)
PE:
*continuous machine-like murmur
-loudest at pulmonic area (LUSB)
*wide pulse pressure (bounding peripheral pulses)
*loud S2
dx
ECHO – best initial test
EKG: LVH, left atrial enlargement
CXR: normal or cardiomegaly
Cardiac catheterization – definitive *rarely done
tx
NSAIDs (IV indomethacin) first line to close a PDA in infants (PG inhibitor)
No closure w/ indomethacin 🡪 surgical
*percutaneous catheter occlusion
*surgical ligation
*best if done before 1-3yrs old
Coarctation of the Aorta definition, sx, dx, tx
Congenital narrowing of the aortic lumen at the distal or descending aorta; 2x MC in males
*associated w/ bicuspid aortic valve (70%), mitral valve defects, patent ductus arteriosus, Turner syndrome
PATHO:
*narrowing of the aorta MC at the insertion of the ductus arteriosus distal to the origin of the left subclavian vein results in HTN in the arteries proximal to the lesion (e.g., primary arteries supplying the UE) w/ relative hypotension in the LE
*over time, the body compensates by developing collaterals around the coarctation (e.g., intercostal arteries)
Types:
*Post-Ductal (adult type): narrowing occurs distal to the ductus arteriosum
*Pre-Ductal (infantile type): narrowing occurs proximal to the ductus arteriosum
sx
May range from asymptomatic to HF or shock after birth w/ closure of the patent ductus arteriosus
Secondary HTN*
Bilateral claudication, DOE, syncope
Neonatal presentation: FTT, poor feeding 1-2wks after birth
PE:
*systolic BP in UE > than in LE
*delayed/weak femoral pulses
*systolic murmur radiating to the back, scapula, or chest
dx
Echo: confirmatory (narrowing of the aorta)
CXR: posterior rib notching (due to increased intercostal artery collateral flow), 3 sign (narrowed aorta looks like the notch of the number 3)
EKG: LVH
Angiograph: gold standard
tx
Corrective surgery or transcatheter-based intervention
- balloon angioplasty w/ or w/o stent placement
PG E1 (alprostadil) preoperatively to stabilize the condition
- maintains a patent ductus arteriosus, reducing sxs & improves the LE blood flow
Tetralogy of Fallot definition, sx, dx, tx
Constellation of 1) RV outflow obstruction (pulmonary stenosis) 2) RVH 3) large unrestrictive VSD & 4) overriding aorta
MC cyanotic congenital heart disease (RIGHT 🡪 LEFT shunt)
Risk Factors:
*genetics, environmental factors
*associated w/ chromosome 22 deletion
sx
Infancy:
*cyanosis (blue baby syndrome)
Older children:
*exertional dyspnea, cyanosis that worsens w/ age
*Tet spells – cyanosis relieved w/ squatting
PE:
*harsh systolic murmur @ left mid-upper sternal border (VSD)
*right ventricular heave
*digital clubbing, cyanosis
dx
ECHO – test of choice
CXR: boot-shaped heart (prominent right ventricle)
EKG: RVH, right atrial enlargement
tx
*surgical repair (performed ideally in first 4-12mo of life)
*prostaglandin infusion prior to repair to maintain a patent ductus arteriosus (improves circulation)
Prophylaxis for bacterial endocarditis
Kawasaki Syndrome “Mucocutaneous Lymph Node Syndrome” definition, sx, dx, tx
Medium & small vessel necrotizing vasculitis including the coronary arteries
PATHO: thought to be an unidentified respiratory agent or viral pathogen w/ a propensity towards vascular tissue
Risk Factors:
*children (esp. <5yrs)
*boys, Asians (highest risk)
sx
Warm + CREAM = fever >5d + 4/5:
C – conjunctivitis
R – rash (erythematous or morbilliform or macular)
E – extremity changes:
*edema
*erythema or desquamation of the palms & soles
*Beau’s lines: transverse nail grooves
*arthritis
A – adenopathy (cervical)
M – mucositis
*strawberry tongue, lip swelling, fissures
*pharyngeal erythema
dx
Labs: nonspecific
*elevated WBC & platelet count
*anemia
*↑ ESR & CRP
*sterile pyuria
ECHO & EKG 🡪 look for complications
Complications: coronary vessel arteritis
*coronary artery aneurysm
*myocardial infarction
*pericarditis
*myocarditis
tx
IV immunoglobulin + aspirin for fever, joint pain, & prevention of cardiac complications
Syncope definition, reflex, orthostatic, cardiac
Loss of Consciousness (LOC): a cognitive state of loss of awareness of self & situation w/ an inability to response to stimuli
Transient Loss of Consciousness (TLOC): rapid onset, self-limited LOC w/ complete recovery
Presyncope (near-syncope): prodromal symptoms of syncope (e.g., lightheadedness, N/V, diaphoresis, blurry vision)
Syncope: transient, self-limited LOC caused by transient, self-terminating, inadequate nutrient flow to the brain
Reflex Syncope (neurally-mediated): neural reflexes inappropriately modify HR & BP
▪︎Vasovagal syncope (VVS):
» emotional stress (e.g., fear/pain, sight of blood)
» orthostatic stress (e.g., prolonged standing, usually in a warm environment)
▪︎Situational syncope: coughing, swallowing, micturition/defecation
▪︎Carotid sinus syndrome/syncope (CSS): occurs w/ pressure on carotid sinus d/t carotid sinus hypersensitivity (CSH)
» ⊕ = HR (ventricular) pause ≥3s &/or SBP ⇣ ≥50mmHg when pressure applied
Orthostatic (postural) Hypotension (OH): SBP ⇣ ≥20mmHg or DBP ⇣ ≥10mmHg w/ upright posture
▪︎Medication-related: antidepressants (e.g., TCAs, phenothiazine APs), antihypertensive agents (e.g., β/⍺ blockers,
hydralazine, ACEI), vasodilators (e.g., CCBs, nitrates), opiates, bromocriptine
▪︎Volume depletion: inadequate fluid intake, excessive loss (e.g., sweating, hemorrhage), vomiting/diarrhea
▪︎Autonomic failure
» Primary: pure autonomic failure, multiple system atrophy, Parkinson
» Secondary: diabetes, amyloidosis, spinal cord injuries, autoimmune neuropathy (Guillain-Barré)
Cardiac:
▪︎Arrhythmias: tachyarrhythmias (e.g., VTACH, SVT), bradyarrhythmias (e.g., AV block, prolonged sinus pause)
▪︎Structural disease: severe aortic stenosis, HCM, cardiac tamponade, atrial myxoma
▪︎Cardiopulmonary/vascular: pulmonary embolism, acute MI/ischemia, severe pulmonary HTN, aortic dissection
Ventricular Septal Defect (VSD) definition, sx, dx, tx
Hole in the ventricular septum; usually associated w/ a LEFT 🡪 RIGHT shunt (noncyanotic)
MC type of congenital heart disease in childhood
Small to moderate associated w/ a LEFT 🡪 RIGHT shunt; large (unrestricted) defects may eventually develop a RIGHT 🡪 LEFT shunt (Eisenmenger syndrome)
Types:
*Perimembranous: MC – hole in LV outflow tract near the tricuspid valve
*Muscular: usually multiple holes in a “swiss cheese” pattern
*Inlet (posterior): located posterior to the septal leaflet of the tricuspid valve
*Supracristal (outlet): beneath the pulmonic valve; may have aortic valve insufficiency
sx
Small (restrictive):
*asymptomatic or mild sxs
*normal pressure differences between the ventricles are maintained
*usually asymptomatic at birth & develop sxs after a few weeks
Moderate:
*excessive sweating or fatigue, esp. during feeds
*lack of adequate growth
*frequent respiratory infections
Larger (unrestricted):
*severe sxs
*no pressure differences between the ventricles
Eisenmenger Syndrome:
*RIGHT 🡪 LEFT shunt (cyanotic) occurring w/ large (unrestricted) VSDs
PE:
*high-pitched harsh holosystolic murmur
-best heard at LLSB
*smaller VSDs are usually louder & associated w/ more palpable thrills than larger ones
*may be associated w/ a thrill or diastolic rumble at the mitral area
dx
ECHO – determines size & location
EKG:
*LVH in mild to moderate disease
*combined RVH + LVH (Katz-Wachtel phenomenon)
CXR: may be normal, show left atrial enlargement, or RVH
tx
Small, asymptomatic:
*observation *most close within 12mo
Patch closure: symptomatic infants or uncontrolled CHF, growth delay, recurrent respiratory infections
*large shunts repaired by 2yrs of age to prevent pulmonary HTN
Infective Endocarditis definition, patho, RF
Mitral > aortic > (mitral & aortic) > tricuspid
*IVDU = tricuspid
PATHO: endocardial injury 🡪 focal adherence of platelets & fibrin 🡪 microorganisms circulating in blood infect platelet-fibrin nidus
*mature vegetation is a collection of fibrin, platelets, leukocytes, RBC debris, & dense clusters of bacteria
RF: >60yo, male, IVDU, poor dentition/dental infection, valvular & congenital heart disease, history of IE, prosthetic valve, indwelling catheter, chronic hemodialysis, HIV⊕
Infective Endocarditis acute vs subacute vs native valve vs prosthetic valve pathogens
Acute: healthy hearts, rapidly progressive w/ high fevers, rigors, sepsis; S. aureus MCC
Subacute: pre-existing heart disease, non-specific symptoms, indolent; viridans streptococci MCC
Native Valve (NVE): S. aureus MCC, viridans strep, Enterococcus
*CoNS, S. bovis, HACEK, culture⊖
*S. bovis: colorectal lesions/carcinoma
*E. faecalis: GU/GI sources
Prosthetic Valve (PVE):
*<2mo: S. aureus, *CoNS, gram⊖ bacilli, Candida
*2-12mo: CoNS, S. aureus, streptococci, enterococci
*>12mo: streptococci & S. aureus, CoNS, enterococci
*CoNS: S. epidermis MC
IVDU: S. aureus MCC, unusual gram⊖, fungi
*tricuspid valve
Infective Endocarditis sx
MC S/SXS: FEVER, MURMURS
*chills, anorexia, weight loss, malaise, HA, *myalgias, arthralgias, night sweats
*abdominal pain, dyspnea, splenomegaly
*petechiae (palate, conjunctiva, extremities)
*splinter hemorrhages
Uncommon, but highly suggestive of IE:
*Janeway lesions: NONTENDER erythematous macules on palms/soles
*Osler nodes: TENDER nodules on finger/toe pads (“Osler, Ouch”)
*Roth spots: exudative, edematous, hemorrhagic lesions of retina w/ pale centers
Systemic complications at presentation:
*cardiac – valve regurgitation, HF
*neuro – embolic stroke, ICH, brain abscess
*septic arterial or pulmonary emboli
*vertebral osteomyelitis, septic arthritis
*glomerulonephritis (hematuria, proteinuria)
Infective Endocarditis dx
Labs: ↑ ESR, mild anemia, +RF, leukocytosis w/ left shift
*non-specific
EKG: +/- new or evolving conduction disease (1st/2nd degree AV block, BBB, complete heart block)
*consider perivalvular abscess if prolonged PR
CXR: evaluate for presence of septic pulmonary emboli, infiltrate (w/ or w/o cavitation), CHF
Blood cultures x3: different venipuncture sites, at least 1h between first & last, 3 sets ⊕>95% cases
*repeat q48-72h until clearance of bacteria
ECHO: ASAP (<12h after initial evaluation); TTE then TEE
*TTE insensitive in PVE, use TEE
*TEE superior for detecting complications (e.g., abscess, leaflet perforation, aortic pseudoaneurysm, fistula)
Infective Endocarditis tx
Empiric antibiotic therapy warranted for any patient w/ signs of clinical instability
Empiric Antibiotic Therapy (IV):
NVE: Vancomycin + Ceftriaxone x4-6wks
PVE: Vancomycin + Rifampin x6wks
+ Gentamicin for first 2wks
*persistent fever after 1wk suggests a septic embolic focus or inadequate coverage
*reappearance of fever after initial resolution suggests septic emboli or drug fever
Common Surgical Indications:
*refractory HF, myocardial abscess
*valvular obstruction or dysfunction
*perivalvular extension (new conduction dz)
*persistent bacteremia, fungal endocarditis
*recurrent emboli
