Cardio 2 Flashcards
What is pericardiectomy?
“Pericardial stripping” most effect surgical procedure for managing large pericardial effusions.
Pulsus paradoxus is defined as a decline of greater than _______ in (sys/dias)_________pressure during inspiration.
10-12 mmHg
systolic pressure
Weak pulse during inspiration
What causes secondary myocarditis?
Non viral pathogens, meds, chemicals,
SYSTEMIC LUPUS
What is the BPM for sinus bradycardia?
<60 bpm.
A patient presents with an ABI of 0.4 and is symptomatic of PAD, what should you do?
REFER ASAP!! Emergent.
A patient present with Ventricular Tachycardia, but is determined to be chronic and sustained, what would you do next?
Treat cause.
Consider chemical or electrical cardioversion
Three main steps for treating rheumatic fever.
Bed rest
Penicillin
Anti-inflammatory agents
Pharm treatment of LONG QT?
Beta Blockers.
Mexilitine
Disorder of ventricular depolarization resulting in a LONG QT interval
LONG QT SYNDROME
What does a high dose of dopamine do?
Peripheral vasoconstriction. >10 mcg/kg/min
True or False: electrical cardioversion restores sinus rhythm in 75-90% of patients
True.
It is an initial shock of 100-200 Joules in synchrony with the R wave. If unsuccessful, juice it up to 360 Joules
What is the most common cause of Acute Endocarditis?
Staph aureus
Atrial flutter is commonly associated with________
COPD!
What is the vasopressor of choice for anaphylaxis?
Epinephrine
Patients with PVD usually have coexisting _____________disease.
Coronary Artery
Acute inflammatory pericarditis is usually _____________in duration.
Less than 2 weeks
Are statins helpful in HF?
No benefit has been shown.
What is a bacterial or fungal infection of the valvular or endocardial surface of the heart?
Acute/Subacute Endocarditis
What is obstructive shock?
Obstruction to the outflow due to impaired cardiac filling and excessive afterload.
Antiarrhytmics maintain sinus rhythm in about ________% of patients.
50
Nerves and Lange-Nielsen Syndrome is associated with ________ syndrome.
LONG QT
What might you see on a chest x-ray with dilated cardiomyopathy?
Enlarged LEFT VENTRICULAR shadow
For a patient with PAD, pain in the calf, and reduced popliteal and pedal pulses, where might the level of obstruction be?
Femoral or popliteal
What happens to mitral valves during dilated cardiomyopathy?
Regurgitation.
Will hear holosystolic murmur.
What might you see on an ECG with Wolf-Parkinson-White? (Antidromic)
Abnormally long QRS.
DELTA wave
Short PR
200-300 bpm
What is the treatment for ACUTE Ventricular tachycardia?
THIS IS A CODE!!
Cardioversion/ VT algorithm meds
More than 3 consecutive PVCs (WIDE QRS!)
Ventricular Tachycardia
The junctional rhythm rate is usually______________bpm
35-60
What are common symptoms of pericardial effusion?
Chest pain.
Syncope and light-headed
Palpitations
Cough
What is happening to the heart in hypertrophic cardiomyopathy?
Myocardium concentrically hypertrophied leading to:
THICKENED and STIFF ventricle.
Can’t FILL-DIASTOLIC HEART FAILURE.
What is the definitive therapy for cardiac tamponade?
Removal of pericardial fluid.
What are the two main key points for diagnosing heart failure?
History and Physical Examination
________is an anti-arrhythmic used to treat atrial______ and atrial________ in patients with heart failure.
Digoxin
Flutter
Fibrillation
What might you see on a chest x-ray with heart failure?
“Kerley B lines” (fluid in lungs)
Enlarged heart
What is the Venturi effect?
Building muscle in inner septum in LV pushes up against valve walls and increases afterload. (Blood forced through small opening).
CRESCENDO-DECRESCENDO murmur.
Many patients with Multifocal Atrial Tachycardia have ________ _________.
Severe COPD.
We know A fib causes a 5 fold increase in stroke risk, but what other conditions are we concerned about?
Heart failure, dementia, increased risk of death
Also precipitates hypotension, myocardial ischemia, or other myocardial dysfunction
What causes dilated cardiomyopathy?
Generally Idiopathic.
Genetic Mutation
Infection
Alcohol Abuse-STRONGLY RELATED!
What is the ejection fraction of heart failure with “reduced ejection fraction” (or systolic heart failure)?
< or = to 40%
Second line meds for AVNRT.
Diltiazem
Beta Blockers
*slow down the AV node
What are extrinsic causes of sinus node dysfunction?
Drugs, hypothyroidism, electrolyte abnormalities, autonomic dysfunction.
Ischemic ulceration of toes, secondary to local trauma that does not heal, is suggestive of _________disease.
Peripheral Vascular
In which kind of heart failure have effective therapies been identified?
Reduced Ejection Fraction (Systolic HF)
What is restrictive cardiomyopathy?
Muscles in heart are stiff and less compliant. Can’t stretch.
Less blood can fill into ventricle-less can pump out.
HEART FAILURE. (Diastolic)
ECG of Supraventricular Tachycardia
NARROW QRS
Regular
P wave embedded
NOT atrial fib.
What are some symptoms of PVCs?
Skipped beat
Dizziness
More frequent AT REST
Go away with EXERTION
What is the traditional definition of systolic BP in hypotension?
90 or less
What drug might cause bradycardia?
Digoxin
CCBs and BBs
What tests should you do if PVCs are frequent and/ or hemodynamically symptomatic?
Evaluate with:
ECHO
STRESS TESTING
+/- Electrophysiology evaluation
Trigger of AVNRT
Caffeine
In diagnosing shock you may see elevated __________concentrations of higher than _____mmol/L
Lactic Acid (b/c of inadequate 02 delivery)
2
Examples of WIDE REGULAR TACHYCARDIA.
Ventricular Tachycardia
SVT with aberrant conduction
AVRT with antidromic conduction
__________is the most effective diuretic in the treatment of heart failure.
Furosemide
What is the most commonly infected valve in endocarditis?
Mitral
Tricuspid in IV drug users
PVC’s usually go away during__________.
Exertion
___________is the cytokines that mediates septic shock.
TNF-alpha
This type of shock occurs when the intramuscular volume is depleted relative to the vascular capacity as a result of blood loss or dehydration.
Hypovolemic Shock.
How does long standing hypertension lead to heart failure?
Arterial pressure makes it harder to pump blood into systolic circulation, to compensate the left ventricle hypertrophies (to contract with more force), which increases muscle mass leading to greater 02 demand.
The coronaries are squeezed, which reduces 02 saturation of ventricles. More Demand and Less Supply!
Muscles have weaker contractions. Leading to heart failure.
Pitting edema can be a sign of________sided heart failure.
Right
What are Class III antiarrhythmics?
Potassium channel blockers
What happens to walls of myocardium in dilated cardiomyopathy?
Get thin and weak.
Weak contractions-lower stroke volume
Biventricular congestive heart failure.
What is the accessory pathway in WOLF-Parkinson-White Syndrome?
Bundle of KENT
Is hypertrophic cardiomyopathy a systolic or diastolic heart failure?
Diastolic
____________heart failure is abnormal cardiac relaxation, stiffness, or filling.
Diastolic
Ventricular rupture can cause ________________shock.
Cardiogenic
What might you find on the feet of patients with endocarditis?
Osler nodes: tender subcutaneous nodules found on the distal pads of the digits.
What is the most common type of cardiomyopathy?
Dilated
Two major signs of pericardial effusion.
Pericardial friction rub
Pulses paradoxes
What causes Rheumatic Fever?
Autoimmune inflammatory response that develops 2-3 weeks after a PHARYNGEAL group A beta-hemolytic streptococcal infection.
What are the minor jones criteria for diagnosis of rheumatic fever?
Fever.
Polyarthralgias (inflammation of joints, morning stiffness)
Reversible prolonged PR interval
Elevated ESR or CRP (erthryocyte sedimentation and C-reaction protein)-detect inflammation in the body
What is the accumulation of too much fluid in the double-layered, sac like structure around the heart?
Pericardial Effusion
What is the targeting resting heart rate for Afib?
<80bpm
What happens to the pulse pressure in cardiogenic shock?
Decreases.
Management of SIck Sinus Syndrome
ATROPINE
Bicuspid aortic valves, rheumatic fever, IV drug use, and sclerotic aortic valves are risk factors for___________.
Endocarditis
Long PR interval, LONGER, EVEN LOOOONGER…dropped.
Second Degree AV Block Mobitz Type I (Wenckebach)
Rhythm arising from the AV junction.
Junctional Rhythms
Bradycardia with P wave ALWAYS followed by QRS. (multiple options)
Sinus brady
First degree AV
Sinus pause/arrest
What is the cornerstone of therapy for PAD?
Lifestyle Management!
Smoking
Diabetes
Walking program
What happens during squatting with hypertrophic cardiomyopathy?
Systemic Vascular Resistance Increases-Making it harder to eject blood (inc. afterload).
This INCREASES BLOOD IN VENTRICLE, making it LESS obstructed.
Murmur LESS INTENSE.
What should all patients with cardiac tamponade receive?
O2
Volume expansion with blood plasma.
Bed Rest with leg elevation (increase venous return).
What is the criterion standard for confirming group A streptococcal infection?
Positive Throat Culture.
Can also have a Rapid Strep or ASO
How do you treat all hemodynamically unstable AV blocks?
ATROPINE! (increases firing of SA node)
Treat cause
What happens to the PR interval in rheumatic fever?
Prolonged
A reduced ejection fraction, increased end diastolic volume, and decreased contractility are signs of ________cardiac dysfunction.
Systolic
Anaphylactic shock is a type of __________shock.
Distributive
What is the ejection fraction of “Diastolic heart failure” or Preserved Ejection Fraction?
> or = to 50%
What are AV nodal blocking agents used to manage Afib?
Beta Blockers
CCBs
Digoxin-when combined with above.
What is exercise testing used for?
Detection of ischemic heart disease.
Risk stratification.
An abnormal pattern of breathing, deeper and faster followed by decrease and a temporary stop.
Cheyne Stokes
Diastolic heart failure is more common in (men/women)________
Women
Diltiazem is what kind of drug? What is used to treat?
CCB
High BP and angina
*relaxes blood vessels in the heart, so it doesn’t have to work as hard
What category of AFib terminates spontaneously or for a duration of time after intervention that happen with variable frequency?
Paroxysmal
Symptoms of acute pericarditis.
Palpitations
Low-grade intermittent fever
Shortness of breath.
Cough
Dysphasia
____________shock is characterized by loss of vascular tone.
Distributive
What is third spacing?
When too much fluid moves from the blood vessels in the interstitial space-the nonfunctional area between cells. Can cause edema, reduced cardiac output, and hypotension.
What’s a major difference in neurogenic claudication and intermittent vascular claudication?
Pain triggered by unsupported standing;relieved by leaning on something “shopping cart sign” (neurogenic claudication)
_______sided heart failure is associated with paroxysmal nocturnal dyspnea.
Left
What is the goal of rate control treatment of A fib?
Symptom management and prevention of tachycardia-mediated cardiomyopathy
What are the causes of sinus bradycardia?
Increased vagal influence on the normal pacemaker.
Physical fitness.
Meds: Beta Blockers
The rate of ventricular tachycardia is _________bpm
> 120 (Typically 160-240). RAPID!
Pre-excitation syndromes involves a ________accessory pathway.
Congenital
In Left sided heart failure blood gets backed up in the________
Lungs
What is the main goal in management of hypovolemic shock?
Restore volume lost.
Hemorrhagic shock>blood substitutes
Non hemorrhagic shock>isotonic crystalloid in IL increments.
This medication may improve pain and walking distance in patients with PAD
Cilostazol
In term of the CHADS VASc score, what is >2 mean?
High risk, anticoagulation.
What is the initial test of choice for acute pericarditis?
ECHO (but shows limited view of pericardium)
What should be performed on all patients with suspected purple tissue pericarditis?
Pericardiocentesis (fluid analysis and culture)
What is the most common chronic arrhythmia?
Afib
Ventricular tachycardia is ______ or more consecutive ventricular beats
3
Anaphylaxis is caused by type I, _________mediated hypersensitivity response.
IgE
What might you find in a blood test in myocarditis?
Elevated Troponin and Creatine Kinase levels.
How does percutaneous balloon pericardiotomy work?
Creates a pleura-pericardial direct communication, allowing for drainage of fluid into the pleural space.
The most common viral cause of myocarditis is________.
Coxsackie B.
1 in 4 people over ____ years old can expect to develop Afib in their lifetime
40
What are causes of nontraumatic hemorrhagic hypovolemic shock?
GI bleed
AAA rupture
Ectopic pregnancy rupture
In septic shock, the primary insult is due to systemic vasodilation and therefore an (inc/dec) ______in afterload.
Decrease
What is the NORMAL vertical height of the external jugular vein pulsation?
<3cm above the sternal angle.
Upon physical exam you notice a JVD and peripheral edema, with an irregular and rapid pulse.
Afib.
How do you treat PVCs?
Not much you can do.
HEALTHY LIFESTYLE CHANGES.
MAYBE use Beta-blockers or Calcium Channel Ablation
Ventricular tachycardia has a ________QRS complex
Wide
What is a normal hearts ejection fraction?
Around 55-65%
In terms of CHADS VASc score, what does 1 mean?
moderate risk, anticoagulant, ASA or no therapy.
What is the HR for SIRS?
> 90
Afib causes a ______fold increase risk of stroke.
5
Why do you do a CT or MRI for acute pericarditis?
Rule out any extra cardiac disease.
How do you treat NONSUSTAINED CHRONIC VT?
CORRECT UNDERLYING CAUSE
CONTROL RATE AND DECREASE RECURRENCE W/ Beta Blockers and Calcium Channel Blockers
Radio frequency ablation if refractory
Pacemaker
Not a true block, more of a delayed or slowed AV conduction.
First Degree AV Block
What med could use to manage bradycardia?
Atropine
Ejection fraction is usually (is/is not)________preserved in diastolic heart failure. Why?
IS
ABNORMAL CARDIAC FILLING (not contractility) Less blood overall getting pumped into body, but not less % that is actually in the heart.
Someone suddenly dies waking up to a new alarm clock. What causes this?
Long QT syndrome
______ and _______diuretics both decrease preload on the heart but are not associated with improved survival in patients with congestive heart failure.
Loop and Thiazides
Common symptom of AVNRT.
Faint-lose adequate BP to perfuse to brain. SOB and chest pain.
What are Class I antiarrhythmics?
Fast Sodium Channel Blockers
What is something really important to not miss in sinus tachycardia?
BLOOD CLOTS IN LUNGS!!
Thought to be either an ESCAPE RHYTHM b/c other pacemakers aren’t working OR due to INCREASED AUTOMATICITY.
Accelerated idioventricular rhythm
What kind of heart sound does pericarditis make?
Leather rubbing on leather. Scratching or grating.
Most common cause of palpitations in patients with structurally normal heart beats.
AVNRT
EKG of ventricular tachycardia has ________QRS and BPM of ______
WIDE QRS (more than 3 PVC)
>
Can’t ID a P wave
What is an inflammation of the heart muscle caused by an acute viral infection or a post viral immune response?
Myocarditis
What does atropine do?
Increases the firing of the SA node and conduction through the AV.
Opposes actions of vagus nerves
What meds do you use to treat CONGENITAL long QT syndrome?
Beta Blockers
Mexiletine (sodium channel blocker)
What is hypertrophic cardiomyopathy?
Asymmetric thickening of walls of bottom 1/2 of heart with disorganization.
What do you do if there is an escape rhythm in accelerated idioventricular rhythm?
Treatment contraindicated since it’s the ONLY THING KEEPING THE HEART GOING.
Is hypertrophic cardiomyopathy autosomal dominant or recessive?
Dominant
What is the main genetic mutation causes LQTS?
LQT1 (40 to 55%)
If Wenckebach is symptomatic and hemodynamically unstable, what might you do?
ATROPINE!
Temporary Cardiac pacing.
(If stable, just monitor with pads)
Signs of hypovolemic shock.
Tachycardia.
Hypo
Oliguria
Pale Skin
What is the target ambulatory rate for Afib?
<100 bpm
For a patient with PAD, if pain is found in the calf, thigh or hip, where might the level of obstruction be?
Aorta or Iliac
What is the pathophysiology of ventricular tachycardia?
REENTRANT DYSRHYTHMIA
SECONDARY TO OR A COMPLICATION OF SOMETHING ELSE.
- ischemia
- dilated cardiomyopathy
- chronic coronary disease
- many more.
What is the best treatment for long term control of a recurrent or very symptomatic PVC?
Electrophysiological studies and catheter ablation.
Anaphylactic shock is a type of ____________shock.
Distributive
How does increased pulmonary blood pressure effect the right side of the heart?
Right Side has to pump harder, which can lead to hypertrophy and ultimately failure.
(I.e. Chronic lung diseases)
Patients with ________disease can present with continuous rest pain that is prominent at night (relieved by standing).
Peripheral vascular
What is the most common pathophysiology of a PVC?
Reentrant circuit, which is typically secondary to a healed MI.
________________heart failure is a dysfunction resulting in cardiac contractile function.
Systolic
What are the 3 categories of Afib and their defining characteristics?
Paroxysmal-terminates spontaneously
Persistent >7 days
Chronic-no treatment to restore.
What are important pieces of patient history with AV block?
Lyme disease
History of heart disease
Cardiac procedures
Level of fitness
What is the most common cause of left sided heart failure?
RIGHT SIDED HF. (Wants you to realize that they are both connected, and both back up systems in the body. )
Beta-blockers are recommended in all stages of (acute/chronic)______heart failure.
Chronic
Incidence of PVC increase with:
AGE
CV disease
Electrolyte abnormalities (K+, Mg++, Ca++)
Pharmacological Rx options for ACQUIRED LONG QT syndrome.
Magnesium Sulfate
Isoproterenol
Lidocaine
Phenytoin
Sodium bicarbonate
HR of Junctional Tachycardia
100-120
What are three methods for removing pericardial fluid?
1) emergency subxiphoid percutaneous drainage
2) pericardiocentesis
3) Percutaneous balloon pericardiotomy
What are pathological causes of sinus tachycardia?
Alcohol withdrawal
Anemia
Heart failure
Hypokalemia
These rhythms arise from the AV junction and disrupt the atrial pacemaking.
Junctional Rhythms
What is the body temp criteria for SIRS?
Higher than 100.4 or lower than 96.8
Hypertrophic cardiomyopathy causes up to _______of cardiac deaths in young athletes.
1/3
Does chest pain in pericarditis get worse when lying down or sitting forward?
Lying down
Rate of AVNRT
140-280, regular
HR of accelerated Junctional Rhythm
80-100
In hypovolemia afterload is___________.
Increased.
What chemicals might you use to treat SUSTAINED CHRONIC VT?
AMIODARONE
LIDOCAINE
_________is a drug that affects the renin-angiotensin-aldosterone system. It limits cardiac remodeling in heart failure.
Spiranolactone
During HF, you may see ________limb lead voltage.
Low
What are nonpharmacologic treatments for CONGENITAL QT syndrome?
Permanent dual chamber PACEMAKER
IMPLANTABLE CARIDIOVERTER-DEFRIBILLATOR
What is a first line med for AVNRT?
IV adenosine-slows conduction in AV node
What is the rate control Tx of Afib
Beta blockers and calcium channel blockers to block the AV node.
Maybe Digoxin (needs extra monitoring)
What is “holiday heart” usually?
Afib.
The heart failure in which the heart is SQUEEZING hard enough, but not FILLING hard enough.
Diastolic Heart Failure (or preserved ejection fraction)
How does a massive pulmonary embolism cause obstructive shock?
Increases RV afterload.
What is the most common cause of palpitations in patients with structurally normal heart beats?
AVNRT
What is end-diastolic volume?
The volume of blood right before systole.
Synonymous with preload. (Which is the STRETCH of cardiac cells prior to contraction).
What it the BPM for sinus tachycardia?
> 100
Young athletes have a _______x higher risk of death from sudden cardiac arrest than non-athletes
3
What heart sound is usually associated with hypertrophic cardiomyopathy?
S4 (or S3)
Compliance with________treatment is essential to preventing acute rheumatic fever.
Strep throat.
What causes symptoms in neurogenic shock?
Loss of SYMPATHETIC branch of the autonomic nervous system (largely T5-L2). The parasympathetic branch’s effects dominate.
BRADYCARDIA!
What test should you do with patients with lower extremity exertional pain?
ABI (ankle-brachial index).
In septic shock, the skin is ____________.
Warm and Dry.
What are the major JONES criteria for Rheumatic fever?
Carditis
Erythema marginatum
Subcutaneous nodules
Joint Pain/Swelling
Name 3 causes of left-sided heart failure.
Ischemic heart disease.
Long-standing hypertension
Dilated Cardiomyopathy
A fast heart bead from a signal above the ventricles.
Supraventricular Tachycardia
How do you treat acute VT?
AN ACLS/CODE SCENARIO!
Cardioversion and VT algorithm meds
Causes of Junctional Rhythms
Myocarditis.
CAD
Digitalis Toxicity
How would manage a junctional rhythm?
ATROPINE!!
Treat underlying cause
Pacemaker
What is happens to the heart walls in hypertrophic cardiomyopathy?
Walls are thick and heavy.
Hypercontractile
Asymmetrical muscle growth
Less FILLING-LESS PUMPED
LEFT VENTRICLE
A patient presents with anorexia, nausea, early satiety, and abdominal fullness, what kind of heart failure might you suspect and why?
Right Sided Heart Failure (peripheral congestion, body system getting back up with fluid because blood not able to flow into Right Side of heart).
What is the leading cause of sudden cardiac arrest/death in young athletes?
Hypertrophic Cardiomyopathy
What is pulse pressure?
The difference between the systolic and diastolic pressure readings.
What is a major complication of pericarditis and pericardial effusion?
Cardiac Tamponade-Life threatening!!
What relieves chest pain associated with acute pericarditis?
Leaning forward while seated.
SIGNS and SYMPTOMS of LONG QT SYNDROME.
- asymptomatic
- syncope
- apparent seizures
- sudden cardiac arrest
What is the primary reason we give vasopressors in hypovolemic shock management?
To restore BP until fluid resuscitation can take place. A temporary method.
When would you use rhythm control to manage Afib?
When difficult to rate control.
Younger.
Triggered from Acute illness.
Following restoring fluid balance and increasing MAP through vasopressors what is the next step in managing septic shock?
Antibiotics
Tachycardia-Brady syndrome.
Sick sinus syndrome: drugs, meds, toxins.
How would you treat chronic nonsustained ventricular tachycardia?
Beta Blockers or CCBS
Radio frequency ablation if refractory.
Possibly defribrillator/pacemaker
If a younger person presents with new onset A fib, what should you also test for?
Hyperthyroidism
What is the initial test of choice for carotid atherosclerosis?
Duplex Ultrasonography
Neurogenic shock is usually caused by a traumatic _________injury.
Spinal Cord
Above the T6 thoracic vertebra
What happened to the central venous pressure in hypovolemic shock?
Low.
Cardiac output is _______in hypovolemia.
Decreased
With right sided heart failure blood gets backed up into the _______ which leads to __________congestion.
Body.
Systemic Vein
When ventricles have become the pacemaker of the heart.
Ventricular Escape Rhythm.
“DYING HEART”
When treating A fib with antiarrhythmics, what is Class I?
Fast Sodium Channel Blockers
What tests might you do for a frequent PVC?
Echo
Stress
+/- electrophysiology evaluation
_________is the most common cause of cardiogenic shock.
MI
You suspect A fib, what diagnostics would you order?
- Echocardiogram
- Ambulatory rhythm monitoring for pts who have very erratic Sx presentation
- Metabolic profile, thyroid panel
Treatment for Junctional Rhythm.
Not much. TREAT UNDERLYING CAUSE
An S3 during INSPIRATION is indicative of______sided heart failure.
Right.
What are the signs and symptoms of accelerated idioventricular rhythm?
A WIDE RANGE! (Often occurs in post-MI settings)
Afterload_________in cardiogenic shock.
Increases.
What is hepatomegaly and what kind of heart failure is associated with it?
Fluid build up in liver.
Right
What are the A fib Tx options for rhythm control?
Cardioversion
Antiarrhthymics (either short term with a loading dose, or long term)
Ablation
JVD’s are a sign of_______sided heart failure.
Right
When does accelerated idioventricular rhythm most often occur?
POST-MI setting
What is important to be aware of in regards to LONG QT syndrome?
Can be genetic, but INCOMPLETE PENETRANCE. CAN SUDDENLY SHOW UP.
_________is a hormone secreted by the ventricles that can be used as a screening test for heart failure.
BNP (Brain Natriuretic Peptide)
When examining the foot of a patient with PAD, what might you find?
Delayed capillary refill
Loss of hair, thin skin, brittle nails
Cool
Dependent rubor (purple feet)
Arterial ulcers (critical)
What might you see on a chest radiography with acute pericarditis?
Normal (may show cardiomegaly).
What is Beck’s Triad?
Hypotension.
Muffled Heart Sounds
JVD
Junctional Rhythm ECG
Retrograde p waves.
36-60bpm
The heart failure in which the heart is FILLING enough, but not SQUEEZING enough.
Systolic Heart Failure or “REDUCED EJECTION FRACTION”
Isolated early beats that arise from ECTOPIC focus in the atria.
Premature Atrial Complex
What are some major complications with acute pericarditis?
Cardiac Tamponade
Pericardial Effusion
Recurrence in 15-32% of patients
Constrictive Pericarditis
When the atria and ventricles are beating independently.
3rd Degree Complete AV Block
What are A fib symptoms caused by?
Decreased cardiac output (decreased diastolic filling and decreased ventricular conractibility)
The peripheries are (cool/warm)______in a patient with cardiogenic shock.
Cool
What might you see on an ECG in restrictive cardiomyopathy?
Low-amplitude QRS
How do you manage all hemodynamically stable AV blocks?
Monitor, be ready with pads
Pericardial disease can cause ______________shock.
Obstructive
Pericardial tamponade. Constrictive pericarditis
Peripheral vascular disease is diagnosed if the ankle-brachial index is less than_______
0.9
WIDE IRREGULAR TACHYCARDIAs
Ventricular Fibrillation
Polymorphic Ventricular Tachycardia
Torsades de Pointes
WPW with Afib
Black athletes have an increased risk with a ____x rate of sudden cardiac death than white athletes
3
Septic shock is a subclass of ________shock.
Distributive
_______shock is a condition in which decreased blood flow in the smallest blood vessels results in inadequate blood supply to the body’s tissues.
Distributive.
What are causes of traumatic hemorrhagic hypovolemic shock?
Loss of blood from injury.
Hemothorax
Hemoperitoneum
Fracture (femur, pelvis)
What are the major characteristics of cardiac tamponade?
Elevated intrapericardial pressure that RESTRICTS venous return and ventricular filling.
What are 3 categories of right sided heart failure?
Decreased RV contractility.
Increased RV pressure (from increased resistance)
RV volume overload (tricuspid regurgitation).
How do you treat SUSTAINED CHRONIC VT?
Sustained
- correct underlying cause
- depending on stability: chemical cardioversion, electrical cardioversion
What happens in a valsalva maneuver or standing with hypertrophic cardiomyopathy?
Venous return decreases (decreased PRELOAD).
OBSTRUCTION GETS LARGER.
Murmur INCREASES
Classic description of Afib.
Irregularly irregular rate and rhythm.
How would you treated acquired Long QT?
MAGNESIUM SULFATE!!
Is hypertrophic cardiomyopathy diastolic or systolic dysfunction?
Diastolic
What test is necessary when initiating therapy for heart failure with diuretics and/or ACE/ARBs?
CMP-get baseline evaluation of electrolytes and creatinine.
When ventricles are going too fast and “driving the ship”?
Ventricular Tachycardia
The impulse comes from the AV node and spreads to atria and ventricles. The P waves are absent
Junctional Rhythm
In hypovolemic shock the initial BP may be stable, why is this?
Compensatory vasoconstriction may maintain BP.
A fib is rarely threatening, so what is the biggest reason we treat it?
Because it causes a 5 fold increase in stroke risk
What is the most common cause of endocarditis from dental procedures?
Strep Viridans (amoxicillin, one dose, administered before the procedure)
P waves in Afib.
Absent.
A patient presents with fatigue, shortness of breath, and orthopnea, what kind of heart failure might you suspect and why?
Left Sided Heart Failure (pulmonary system is getting backed up).
What happens to the pulse pressure in hypovolemic shock?
Narrows.
_________cardiomyopathy is a form of cardiac disease in which the ventricles are too stiff to contract adequately.
Restrictive (leads to diastolic heart failure)
What does SIRS stand for?
Systemic Inflammatory Response System
Tachypnea, Tachycardia, hypotension, and high WBC are suggestive of ________shock.
Septic
How is clinical impact determined in pericardial effusion?
The SPEED of fluid accumulation.
Myocarditis often follows what?
Upper Respiratory Infection
For a patient with PAD with severe pain in the forefoot relieved by dependency, pain/numbness in the foot with walking, where might the level of obstruction be?
Tibial or pedal
When do PVCs “go away”?
With exertion.
The divisions of chronic ventricular tachycardia are _________ and _____________
Sustained.
Nonsustained VT (<30 sec)
What is the most common cause of supraventricular tachycardia?
WOLF-Parkinson_white syndrome.
How do you treat accelerated idioventricular rhythm?
USUALLY NOTHING.
Should you use AV blocking meds in Afib?
NO! Can increase conduction via accessory pathway.
What might you find on an ECG for myocarditis?
Saddle shaped ST elevations.
T-wave inversion
What is the primary management of neurogenic shock?
Correction of persistent hypotension with vasopressors and inotropes
What is the treatment of choice in acute coronary syndrome?
Reperfusion percutaneous coronary intervention (angioplasty-restores blood flow in the blocked artery).
Pericarditis is characterized by___________,______________, and____________.
Chest pain.
Pericardial friction rub.
Serial ECG changes
Volume losses of over 15% of the total intramuscular volume result in ___________and progressive tissue ________.
Hypotension.
Hypoxia
What causes AVNRT?
Fast heart beat.
Electrical signal looping back on its self.
Causes atrial and ventricular contraction.
In LONG QT SYNDROME:
QTC>________msec in men
QTC>________msec in women
440
460
_________is leg pain when walking which resolves with rest.
Claudication
What is the most common cause of septic shock in hospitalized patients?
Infection with gram-positive or gram-negative organisms. Distributive Shock
Signs and symptoms of ACUTE VT.
-can be asymptomatic w/palpitations.
NORM: some degree of hemodynamics compromise
- syncope
- shortness of breath
- chest pain
- cardiac arrest
- shock
- death
A STEP AWAY FROM VFIB
Treatment of Torsades de Pointes
IV Magnesium!!
What happens to the heart rate and venous pressure in cardiac tamponade?
Rise. (Heart trying to get blood out).
Coronary atherosclerosis is the most common cause of_________________
Left Sided Heart Failure (damage to myocardium, blood not getting to heart tissue, heart unable to work).
Name 3 differential diagnosis’ for acute pericarditis.
Acute Gastritis
Angina Pectoris
Myocardial Infarction
(Many more)
What might you see on the ECG in cardiac tamponade?
Alternation of QRS. Swinging of heart.
What happens to systolic BP in late HF?
Decreased.
_________is a distributive type of shock resulting in hypotension, occasionally with a slowed heart rate, that is attributed to the disruption of autonomic pathways within the spinal cord.
Neurogenic shock. (Can occur after damage to central nervous system, such as a spinal cord injury).
What is a WIDE COMPLEX RHYTHM, rate of 60-120 bpm?
Accelerated idioventricular rhythm
What should you consider in patients complaining of stomach pain (greater than signs presented) and weight loss?
Mesenteric ischemia
Are PVCs more common in men or women?
Men
All drugs that have been shown to decrease mortality in heart failure have been shown to do so by affecting remodeling which is due to increased _________stimulation and decreased (hormone)_____________production.
Sympathetic.
Aldosterone
Prolonged PR interval. Everything else normal.
First Degree AV block
How do you treat atrial flutter
Antiarrhythmics
Sinus arrhythmia results in irregular ________rate
Ventricular
What is the atrial rate in atrial flutter?
250-350bpm
How do you treat neurogenic shock?
IV fluids and Vasopressors.
When treating A fib with antiarrhythmics, what is Class II?
Beta Blockers
What can cause non hemorrhagic hypovolemic shock?
Burns.
Vomiting/diarrhea/dehydration
Hyperosmolar states (diabetic keoacidosis)
Third spacing (ascites, pancreatitis)
What are Class II antiarrhythmics?
Beta Blockers
You see sawtooth in II, III, and aVF.
Atrial Flutter
What is pericardiocentesis?
Echo guided needle drainage used in diagnosing and treating pericardial effusion.
What might cause rheumatic fever?
Episode of untreated Group A Streptococcal Pharyngitis
What happens to the stroke volume and arterial pulse pressure in cardiac tamponade?
Fall. Too much pressure.
How do pulmonary arterioles respond to hypoxia?
They constrict, which raises Pulmonary BP. (Caused by chronic lung disease)
AV Block Cause
Increased vagal tone
Fibrosis of conduction system
Ischemic Heart disease
Congenital
Drugs
You hear rales and crackles during auscultation, what may this indicate?
Congestive Heart Failure
Describe the two pathways within the AV node.
Slow-conducts slowly, short refractory.
Fast-conducts rapidly, long refractory.
What medication may be used to treat multifocal atrial tachycardia?
Verapamil
Tension pneumothorax limits ______(l/r) ventricular filling by obstruction of __________return.
Right
Venous
What is the diagnostic tool of choice with cardiac tamponade?
ECHO!
Nonpharm treatment of Long QT
Permanent dual chamber pacemaker
Left cardiac sympathetic enervation
Implantable defibrillator.
Who is more likely to get AVNRT?
Women 3:1
Following Cardioversion: Afib recurs in ___________of patients at 3 months and___________after 12 months.
40-60%
60-80%
Does everyone experience symptoms with Afib?
Absent in 1/3
What would you find on exam with a patient with A fib?
Irregular and rapid pulse.
Maybe a murmur, gallop, JVD or peripheral edema.
What is the traditional Mean Arterial Pressure in hypotension?
60-65
What should be avoided when treating cardiac tamponade?
Positive-pressure mechanical ventilation. Decrease venous return and aggravate signs and symptoms of tamponade.
What is the most common chronic arrhythmia?
A fib
What arrhythmia presents with an absence of P waves?
A fib
You see erratic, disorganized atrial activity between discrete QRS complexes in an irregular pattern on an EKG, what condition is this likely to be? Irregular irregularity
A fib
What category of Afib would include failed treatment to restore or maintain sinus rhythm that is now just an effort to treat rate and symptoms?
Chronic/Permanent
True or false: if a pt undergoes a successful cardioversion, they will never have A fib again.
False.
In 3 mos, it will recur in 40-60% of pts
In 12 mos, it will recur in 60-80% of pts
If Nonsustained Chronic VT is sustained what might you use to treat it?
Radio frequency ablation
Accelerated idioventricular rhythm is a _______complex rhythm, rate of __________
WIDE
60-120 bpm
SUPER NARROW QRS complex, WITHOUT p-waves.
Junctional Rhythm
________heart failure results from the ventricles unable to adequately FILL with blood.
Diastolic
An S3 on expiration is indicative of _________sided heart failure.
LEFT
The cause of __________is reflex changes in the effect of vagal input on the normal pacemaker.
Sinus arrythmia
What is the main ECG characteristic of a premature atrial complex?
P wave usually different in contour from normal P wave.
What is caused by a combo of congenital accessory pathways leading to tachycardia (formed during development of heart)?
Wolff-Parkinson-White
What are you REALLY concerned about in regards to Afib?
STROKES! Twice as likely to be fatal!
If no cause for PVC is found, what meds could you give?
BBs or CCBs
What work up might you order for Junctional Rhythm?
Electrolytes
TSH
EKG
Blood work for AV block
Electrolytes
TSH
Tension pneumothorax is a type of ____________shock.
Obstructive
What happens to cardiac output (or the stroke volume) in hypovolemic shock?
Reduced.
JVP is ______ and CVP is _________in cardiogenic shock.
Elevated.
Elevated.
What does a low dose of dopamine do in terms of shock management?
Increases HR and contractility (gets more blood into the body)
Preload is ________ in cardiogenic shock.
Increased.
What causes oliguria in hypovolemia?
Antidiuretic hormone is released. Body is trying to retain what fluid it can.
What causes bradycardia in neurogenic shock?
Unopposed vagal activity. (Exacerbated by hypoxia)
Acute inflammatory pericarditis is most common in ________-
Males <50 y/o
In acute pericarditis chest pain is worse with ______, ________,________,and _________.
Inspiration.
Lying flat
Swallowing
Body movement
How do you treat acute pericarditis?
Restrict activity.
TREAT CAUSE!
If no pericardial effusion-stable patients with viral may be discharged.
What are major risk factors for endocarditis?
Rheumatic
Bicuspid Aortic Valves
Calcification or sclerotic aortic valves
Tetralogy of Fallot
Intravenous drug use.
What is the typically antibiotic used to treat endocarditis?
Penicillin
What medication is strongly contraindicated for hypertrophic cardiomyopathy?
Digoxin
Increases contraction force, which increases the obstruction
Intermittent claudication, absent pulses, and dry skin are all signs of ______________ disease.
Peripheral Vascular
Pharm treatments for PAD.
Platelet inhibitors
STATIN! (High-intensity)
Pharm adjuncts for smoking cessation
What are surgical interventions for PAD?
Angioplasty
Bypass procedures
How do ACE inhibitors improve blood flow?
Dilate blood vessels.
What causes Afib?
Heart Failure
Diabetes
High BP
Hyperthyroidism
Age
Heart Disease
Symptoms of CHRONIC VT
Sustained Palpitations (shortness of breath, presyncope/syncope)
Nonsustained: Asymptomatic or syncope
Cardiac output is __________in cardiogenic shock.
Decreased.
What should you do if you see a wide irregular QRS?
Be worried! Get pads on!!
Why would you want to decrease aldosterone production when treating heart failure?
When dysregulated, it increases water in the kidneys, which can increase BP and blood volume, adding more work on the heart.
How do you treat ventricular escape rhythm?
Pacemaker
ATROPINE
Treat cause
What is the resting target heart rate when treating Afib with rate control? Ambulatory target heart rate?
<80
<100
*Rate control meds can be difficult to tolerate, so sometimes aim is <100 overall
What happens to the diastolic pressure in hypovolemic shock?
Elevated.
In acute pericarditis, erythrocytes sedimentation rate is usually_______.
Elevated
EKG of VT
BIG WIDE QRS, pretty uniform in a lead. CAN’T ID a P WAVE
_________are the most common cause of acute pericarditis.
Viruses
What are the four types of shock?
Hypovolemic
Cardiogenic
Obstructive
Distributive
“Ventricles are driving the ship!”
Ventricular Tachycardia. BAD!!
When would you choose to treat rhythm control over rate control with AFib?
A pt still has symptoms despite treating rate.
Rate control has been difficult or not well tolerated.
The pt is younger
First episode or A fib is triggered by acute illness
They develop tachycardia-mediated cardiomyopathy
If there is an underlying heart disease present with nonsustained chronic VT what might you use to treat it?
Implantable Cardioverter Defibrillator (ICD) +/- Pacemaker
What is the most common cause of palpitations in a structurally normal heart?
Paroxysmal supraventricular tachycardia
What is POCUS?
Point of Care Ultrasound
Afib causes a______fold increase in risk of heart failure.
3
What is the antibiotic of choice for rheumatic fever?
Penicillin
A patient dies from cardiac arrest after being woken up from his loud alarm in the morning
Torsades de Pointes
What meds may be given for acute pericarditis?
Aspirin: 750-1000mg every 8 hrs, taper (or Ibuprofen)
Colchicine: .5-.6 mg for 3 mo
Arrythmias and dysrhythmias can cause______________shock
Cardiogenic
What are the SIRS criteria? ( in terms of RR and WBC)
Presence of 2 or more of the following:
- RR>20 or hyperventilation w/ arterial carbon dioxide tension <32mmgh
- abnormal white blood cell count
An EKG shows rates ranging from slow to extremely rapid, but irregular, what condition is this likely to be?
A fib
BP of bradycardia
<60
Risk factors for DVT
Many! Sitting > 4 hours, family history, over 60 years old, cancer & cancer treatment, polycythemia, overweight, smoking, pregnancy, OCP, serious illness, IV drug use. Genetic condition that results in resistance to activated C proteins -> Factor V Leiden mutation. And more!
Patient has painful, hot, red swollen area on left calf, which is >3 cm larger in circumference than right calf, they also just flew back from China on a 17 hour flight, what is likely diagnosis?
DVT
Best treatment for DVT
Prevention! with early ambulation, anticoagulation, intermittent compression devices, compression stockings, IVC filters, hydration.
Following a DVT, 50% of patients experience this condition that is characterized by pain, swelling, redness and sores in area of past DVT? What is treatment?
Post Thrombotic Syndrome
DVT treatments, or capsaicin or menthol cream can help
When should you refer a patient with suspected DVT?
Multiple or proximal thromboses, or in unusual places like renal, hepatic or cerebral veins. Or if they are really big!
First line treatment of DVT
Anticoagulants: start IV heparin and transition to oral warfarin taken for 3-6 months. Other anticoagulants are available also.
What is the main concern regarding DVT?
Pulmonary embolisms
Arterial aneurysms are ________the normal size.
> 1.5 x
If patient has a suspected DVT, what testing would you order?
D-dimer can rule out low probability, but Ultrasound performed by a tech is the definitive test.
Watch out for obese patients -> possible false negatives
What is the Virchow Triad?
3 factors that are important in the development of venous thrombosis:
- venous stasis
- activation of blood coagulation
- vein damage
Rudolf Virchow
Who should definitely be routinely screened for Abdominal Aortic Aneurysms (AAA)?
Men ages 65-75 who have ever smoked
Most detectable symptom of AAA?
Tearing back pain
Other Sx may include: trouble swallowing, chest pain, SOB, feeling of fullness or pain in abdomen, or feeling “heartbeat in abdomen”
Treatment of AAA?
If ruptured: stent/graft
If not ruptured and <5 cm, watch and evaluate every 6 months for growth, and treat w/ b-blockers, statins, lower BP and quit smoking. If >5 cm, send to surgeon for evaluation
Risk factors for AAA?
Male, smoker, white, cardio-pulmonary disease, being a large person, and 1st degree relative with AAA
The separation of the intimacy and media of a vessel that creates a false lumen which then tears and creates surging of blood into abdominal cavity is?
Aortic dissection
20% of pts will die before reaching the hospital. Hospital mortality is 30% for proximal dissection and 10% for distal. Hard to catch, fix or predict.
Arterial aneurysm in the lower leg
Peripheral artery aneurysm.
Half of people with these will also have aneurysmal abdominal aorta.
The vast majority of arterial aneurysms are found where?
Behind the popliteal.
What age greatly increases your risk of DVT?
> 60
What is the most common inherited cause of DVT in white populations?
Inherited blood-clotting disorder.
- resistance to activated protein C, natural anticoagulant
What are symptoms of DVT?
History of little movement.
Pain
Hot
Red
Swollen
Or NO symptoms
Pain in ______squeeze is a common exam finding in DVT.
calf
When is D-Dimer used in DVT diagnostics?
for ruling out low probability cases
What is the mainstay of therapy for DVT?
anticoagulation (prevent pulmonary embolism)
When to refer DVT?
Presence of large iliofemoral or IVC thrombosis.
Clots in unusual locations.
What are signs of post thrombotic syndrome?
Redness.
Discoloration
Sores/Ulcers
Skin breakdown
Swelling
Pain, ache, burning, itching
Most detectable symptom of AAA?
Tearing back pain- if ruptured
They are usually asymptomatic.
Other Sx may include: trouble swallowing, chest pain, SOB, feeling of fullness or pain in abdomen, or feeling “heartbeat in abdomen”
Treatment of AAA?
If ruptured: stent/graft
If not ruptured and <5 cm, watch and evaluate every 6 months for growth, and treat w/ b-blockers, statins, lower BP and quit smoking. If >5 cm, send to surgeon for evaluation. Elective repair (EVAR - endovascular aortic repair) is very effective
Arterial aneurysm in the lower leg
Peripheral artery aneurysm.
Half of people with these will also have aneurysmal abdominal aorta.
3 types of Thoracic Aortic Aneurysms?
Ascending aortic aneurysm, aortic arch aneurysm, or descending aortic aneurysm.
These account for 10% of aneurysms, but have an almost 100% mortality rate.
All have different treatments and approaches.
