Cardio Flashcards
What imaging used to follow AAA?
Abdominal U/S - facilitates measurement of aneurysm size, show presence of thrombus, etc.
Cause of angina in pts with aortic stenosis
Increased myocardial O2 demand.
Aortic Stenosis - large ventricle - more demand
Aortic Dissection:
Sx: CP radiating to the back + HTN
- AR murmur
- weak/absent peripheral pulses
- systolic BP > 20 diff btwn arms
- CXR shows widened mediastinum
RF:
- Marfan’s
- HTN
- cocaine
Dx:
- Chest CT with contrast
- TEE (esp if Cr not normal or has contrast allergy)
Tx:
Beta-blockers!
Type A: ascending aorta = medical + surgical
Type B: descending aorta = medical only.
Right Ventricular MI: Features and Tx
- EKG: II, III, aVF
- Symptoms of MI: Chest pain, diaphoresis, dypsnea
- Hypotension (due to dec. L heart filling)
- Distended jugular veins with clear lung fields** (bc R side)
Tx:
- IVF because need increased RV preload
- same as others except..
Avoid:
- nitrates, diuretics, opioids - which decrease preload.
Aortic Dissection Sequelae
Tearing chest pain radiating to the back
Sequelae: dissection can extend into
- carotid a -> stroke
- renal a -> acute renal fail
- aortic valve -> aortic regurg
- sympathetic ganglion -> horner’s
- pericardium -> cardiac tamponade
- arm vessels -> diff in blood pressure btwn arms
- mesenteric -> abd pain
Cardiac Tamponade
Beck’s Triad:
- Hypotension
- Increased JVP
- Muffled Heart sounds
- Pulsus Paradoxus (>10 dec in systolic BP inspiration)
- Positive hepatojugular reflex
(Lungs are clear)
Echo: pericardial effusion
EKG: electrical alternans: varying amplitude of the QRS complexes
Sx due to decreased LV preload!
- intrapericardial pressure increases - restricts venous return to the heart - lowers R and LV preload - dec CO
Acute Pericarditis
sharp, pleuritic chest pain that can radiate to left arm/shoulder
can cause effusion, cardiac tamponade
usually due to virus
Isolated Systolic HTN in elderly is caused by?
Rigidity of the arterial wall -> systolic HTN, widened pulse pressure
Tx: bc risk of cardio disease
- low dose thiazide
- ACEi
- CCB
Constrictive Pericarditis
Causes: TB (endemic areas) Viral Radiation Cardiac surgery
Sx: impairs ventricular filling - major cause of RHF.
Dec CO = Fatigue, dypsnea on exertion
Venous overload = JVP, ascites, pedal edema
Kassmaul’s sign (paradoxical rise in JVP on inspiration)
Pulsus Paradoxus
Pericardial knock after S2 (mid-diastolic sound)
Hepatojugular reflex
CXR: pericardial Ca++
EKG: afib or low voltage QRS
JVP - prominent x and y descents
Patients initially diagnosed with HTN should have what basic workup?
UA, U p/c
BMP
Lipid
EKG
Hereditary Hemochromatosis
Skin: Hyperpigmentation - Bronze Diabetes
MSK: arthralgias, arthropathy, chondrocalcinosis
GI: elevated hepatic enzymes w hepatomegaly -> cirrhosis -> HCC
Endo: DM, hypogonadism, hypothyroidism
Cardiac: Restrictive or Dilated cardiomyopathy; cardiac conduction abnl - sick sinus syndrome
Infections: increased susceptibility to listeria, vibrio, yersinia
AAA vs. Renal artery stenosis - sounds
AAA: HTN, smoker
- pulsatile abd mass
- systolic bruit may be heard
RAS: HTN
- systolic-diastolic bruit
Troponin vs. CK-MB
Troponin T: more sensitive, but stays elevated for 10d
CK-MB: normalizes in 1-2d, good for assessing coronary re=occlusion/recurrent MI
Prinzmetal’s Angina (variant angina)
CP bc of coronary vasospasm
- occurs at NIGHT
- TRANSIENT ST elevation/EKG changes
Tx:
- stop smoking!
- CCB, nitrates - vasodilate
AVOID - nonselective beta blockers and aspirin - vasoconstricts
Like other vasospastic disorders: Raynaud’s, migranes
Afib in WPW should be treated with:
Hemodynamically unstable -> Cardioversion!
Stable -> Rhythm control with Procainamide
Avoid AV nodal blockers: beta blockers, CCB, digoxin, adenosine -> bc increases conduction thru the abberrant pathway
Acute MR develops after MI due to ?
Papillary muscle displacement - 2-7d after MI
- leads to increased LV filling pressures -> pulm edema, CHF.
What antiarrhythmic prolongs QRS interval when HR increases?
Class IC antiarrhythmic - Flecainide
- when HR increases, stays bound to the Na channel longer bc less time to dissociate - prolongs QRS interval
HOCM
Sx:
exertional dypsnea, CP, fatigue, palpitations, syncope
sudden death in athletes
Murmur:
harsh cresendo-descrendo murmur - apex, LLB
INCREASE with DEC PRELOAD
(valsalva, abrupt standing)
DECREASE with INC AFTERLOAD (handgrip, squat)
vs aortic stenosis: dec with dec preload..
EKG: LVH - tall R in aVL, deep S in V3
Patho: AD - mutation in cardiac myocyte contractility or sarcomere proteins - interventricular septal hypertrophy - abnormal mitral leaflet motion
Tx: HOCM primarily causes diastolic HF
- Beta-blockers: increase diastole
- CCB: same
What antiarrhythmic causes lung damage?
Amiodarone:
- Pulm tox - chronic interstitial pneumonitis - depends on total cumulative dose *
- Thyroid - Hypo > hyper *
- Hepatotoxicity - elevated transaminases, hepatitis *
- Cardiac: sinus brady, heart blood, risk of torsades
- Ocular: Corneal deposits
- Skin: blue gray skin change
- Neurologic: peripheral neuropathy
Aortic Stenosis - indications for surgery
Murmur: Harsh systolic murmur R sternal border Radiates to carotids Pulsus Tardus et parvus S4 - LVH
Aortic Valve Replacement:
- SAD: syncope, angina, dypsnea
- severe AS undergoing CABG/other valve surgery
- severe AS asymptomatic, but poor LV function
Exertional Heat Stroke
T > 104 + CNS or organ damage
Tx: rapid cooling with ice-water immersion
VS:
- Serotonin syndrome/Malignant Hyperthermia - has muscle rigidity
- Non-exertional heat stroke - elderly people; evaporative cooling as tx instead.
HTN emergency definition
HTN URGENCY
- Severe HTN (usually > 180/120) but no sx
HTN EMERGENCY - Severe HTN w. SX!
- Malignant HTN - with papilledema, retinal hemorrhages or exudates
- HTN encephalopathy - cerebral edema, non-localizing neurologic signs/sx
Why don’t we use lidocaine to prevent the development of vfib in acute MI?
Increases risk of asystole.
What cause of restrictive cardiomyopathy is reversible?
Hemachromatosis - phlebotomy
Restrictive cardiomyopathy
- sarcoid, amyloid, hemachromatosis
- diastolic dysfxn - symmetric thickening of ventricles
- RHF > LHF but both can occur.
Drugs that improve mortality in CHF:
ACEi ARB Beta-blockers Spironolactone (Aspirin if due to CAD)
NOT:
Digoxin
Loop diuretics
Mechanical Complications 3-7d after MI
- MR - papillary muscle rupture - look for murmur!
- LV free wall rupture
- Interventricular septum rupture
All can cause hypotension.
Look at pic.
Side effect of CCB
peripheral edema - due to dilation of peripheral vessels
addition of ACEi (postcapillary venous dilation) can help reduce this.
Treatment of Pulm HTN
Depends on CAUSE: (durh!)
If due to LV dysfunction = Loop diuretic, ACEi
If idiopathic and symptomatic = endothelin-R antagonist (bosentan); PDE5 inhibitors (slidenfil); Prostanoids.
AAA
Sx: initially asymptomatic, found incidentally
RF: SMOKING, old age, fhx, athero
Risks for rupture:
- smoking
- large diameter
- rapid rate of expansion
Indications for Repair:
- > 5.5 cm
- rapid rate expansion (0.5cm/6 mo or 1cm/1yr)
- symptoms - abd/back/flank pain; limb ischemia.
Screening: one time Abd US
Smokers or former smokers 65-75
Afib due to hyperthyroidism should be treated with?
beta-blocker!
- rhythm control AND diminishes sx of hyperthyroid
Treatment of Angina
Antianginal:
- Beta blocker - 1st line
- dec. myocardial contractility, HR
- improves survival in MI - CCB - add on or alternative
- peripheral and coronary vasodilation - Nitrates
- short for acute setting
- long for chronic
Initial stabilization of STEMI
- O2
- Aspirin
- Clopidogrel
- Nitrate
- Beta blocker
- Statin
- Anticoag
- > persistent HTN or pain - NO
- > persistent pain - morphine
- > persistent brady - atropine
- > pulm edema - furosemide
PTCA within 90 minutes!
Thrombolysis if PTCA not within 120 min.
Paroxysmal SupraVentricular Tachycardia
NARROW QRS complex TACHY
- retrograde p waves
- constant RR intervals
Abrupt onset/offset
AVNRT, AVRT, atrial tachy, junctional tachy
Tx:
- If hemodynamically stable -> VAGAL or ADENOSINE -> slow conduction thru AV node
- can unmask p waves in a flutter/tachy
- terminate AV node dependent arrhythmias - AVNRT
Ventricular Tachycardia
WIDE QRS complex TACHY
+ Fusion beats
+ AV dissociation
Tx: If unstable (hypotension, resp distress, AMS) -> Cardiovert
If stable, IV amiodarone first line
- can also give lidocaine
Note: Loop diuretics - hypoK and hypoMg which can cause ventricular tachy
Digoxin Side effects
GI: nausea, vomiting, diarrhea, dec appetite
CNS: confusion, weakness,
Cards: atrial tachy with AV block
Vision: scotomata, color change
Note:
- hypoK from diuretics increases risk for tox
- amiodarone can increase serum levels of dig
Aortic Regurg
Descrendo early diastolic murmur
- LSB 3-4th intercostal (due to valvular disease)
- RSB (aortic root disease)
- sometimes can only be heard if pt sits up, full expiration, firm pressure with stethoscope
Other signs:
- widened pulse pressure
- “water hammer” pulse
- “pounding heart” - due to increase in LVEDV
Causes:
- young, developed country = bicuspid aortic valve, aortic root dilation (marfan’s, syphillis)
- underdeveloped = rheumatic heart disease
Mitral Stenosis
Murmur:
Loud S1 + mid diastolic rumbling
Sx: MS -> LA pressure -> Pulm congestion
Pulm congestion (exertional dyspnea, nocturnal cough)
HEMOPTYSIS**
Afib (bc LA dilation)
Emboli (due to Afib)
Cause:
- Undeveloped - Rheumatic fever!!
Recent URI and acute cardiac failure in young patient?
Dilated Cardiomyopathy - Viral myocarditis
- dilated ventricles with diffuse hypokinesia (systolic dysfunction)
- Tx: supportive.
Concentric hypertrophy - due to chronic pressure overload
Eccentric hypertrophy - due to chronic volume overload
Asymmetric septal hypertrophy - HOCM
Acute limb ischemia after MI - management?
Anticoagulation
Vascular Surgery
ECHO - to look for LV thrombus
AV block
If p is far from q, then you have a first degree
longer longer longer drop, then you have a wenkebach
if some ps just dont get thru, then you have a mobitz II
if ps and qs just dont agree, then you have a third degree
Location and Tx:
I and Mobitz I above AV node - benign, observe
Mobitz II and III below - pacemaker
PR interval prolonged = >5 small boxes
Normal QRS = 3 small boxes
Treatment Atrial Fibrillation
Hemodynamically unstable -> Cardiovert
Stable: eIther
- Rate control - beta blocker, diltiazem, digoxin
- Rhythm control - if unable to control HR, or continued symptoms.
Anticoagulation - warfarin or other anticoags
- CHA2DS2 VASc Scoring
CHF, HTN, Age > 75, DM, Stroke/TIA, Vascular disease (MI, PAD), Age 65-74, Sex Female
Score 0 = no anticoag
Score 1 = none/aspirin/oral
Score 2 or above = oral anticoag
Causes of ascending vs. descending Ao aneurysm
Ascending: cystic medial necrosis (age) or connective tissue disorders (marfan’s, ehlers-danlos)
Descending: atherosclerosis
Pericarditis
Diffuse ST segment elevation and PR depression
Pulsus Paradoxus
Fall >10 mmHg during inspiration.
- Cardiac tamponade
decrease in systolic BP when inspirate. Inspiration lowers intrathoracic pressure -> more preload into RV but uncompliant since tamponade -> shifts interventricular septum towards L -> decreased CO - Asthma, COPD.
exaggerated drop in intrathoracic pressure -> blood pools in pulm vasculature -> dec. LV preload.
Heparin Induced Thrombocytopenia
elevated PTT = heparin
Sx:
- *Thrombocytopenia OR >50% drop in plt count from baseline 5-10d after initiation of treatment
- *Thrombosis (arterial or venous)
Type I HIT: nonimmune, direct effect of heparin on plt activation within first 2 days - normalizes, and okay
Type II HIT:*
Antibodies to platelet factor 4 complexed with heparin
-> plt aggregation, thrombocytopenia, thrombosis (arterial or venous; such as limb ischemia/stroke)
-> *5-10 days after initiation of tx
Tx:
Stop heparin
Direct Thrombin/Factor Xa inhibitor
HTN + bilateral palpable masses
ADPKD
Frequent Epigastric Burning, brought on by exertion.
Get an exercise EKG if baseline EKG nl!
- Don’t just think GERD. Must keep ischemic cardiac pain on differential.
Asystole/Pulseless electrical activity vs. Defib vs. Cardioversion
Asystole/PEA = organized rhythm BUT NO PULSE
- CPR and epinephrine!
- Treat reversible causes
- Do it till get a shockable rhythm.
Reversible causes of asystole/PEA: 5H's: Hypovolemia Hypoxia Hydrogen (acidosis) Hypo or HyperKalemia Hypothermia
5T's Tension pneumothorax Tamponade Toxins (narcotics, benzos) Thrombosis (pulm or coronary) Trauma
Defibrillation = Vfib or pulseless VT
Cardioversion
- symptomatic or sustained monomorphic VT unresponsive to antiarrhythmics
- hemodynamically unstable afib
Symptoms of ATYPICAL presentation of CAD
Women
Elderly
Diabetics
Abdominal pain, Epigastric pain
Nausea, Vomiting
MUST EXCLUDE CARDIAC CAUSES!
What drugs can potentiate warfarin and increase risk of bleeding?
Acetaminophen
NSAIDS
Amiodarone
Antibiotics
What type of murmurs on auscultation need to be investigated?
Diastolic and Continuous murmurs!! => TTE
Bc organic causes more likely.
Note:
Midsystolic soft murmurs (grade 1-2) in asymptomatic young patient are usually benign
Lipid Lowering Therapy Guidelines:
STATINS:
HIGH = ator 40-80, rosuvas 20-40
MOD = ator 10-20, rosuvas 5-10, sim 20-40
- ATHEROSCLEROTIC disease - ACS, MI, stable or unstable angina, coronary or other arterial revascularization, Stroke, TIA, PAD
- Age = 75 = HIGH intensity statin
- Age > 75 = MOD intensity - LDL >/= 190 - HIGH intensity
- Diabetes (40-75)
- 10 year ASCVD risk >/= 7.5% = HIGH intensity
- 10 year ASCVD risk /= 7.5% = mod to high intensity
IVDU Infective Endocarditis associated with what murmur?
R-sided more - Tricuspid Regurg (holosystolic murmur that increases with inspiration)
Septic emboli common.
S. aureus most common - Vanco empiric treatment.
Best Initial therapy for HTN for the following: CAD DMII BPH Depression/Asthma Hyperthyroid Osteoporosis
Initial: Thiazide, CCB, ACEi, ARB
CAD - BB, ACEi, ARB DMII - ACEi, ARB BPH - alpha blocker Depression/Asthma - NOT BB Hyperthyroid - BB Osteoporosis - Thiazide
Indications for Carotid Endarterectomy:
Carotid artery stenosis -> TIA
indications:
Symptomatic with 70-99% stenosis.
Consider in Males: Asymptomatic 60-99%
Prevention:
Aspirin, Antiplatelet agents, optimization of RF
Pericardial Effusion on CXR
CXR: “Water bottle” heart with clear lungs
Diminished heart sounds
PMI difficult to palpate.
Torsades - Treatment?
Torsade de Pointes
- polymorphic VTach
- due to congenital or acquired QT prolongation (fluconazole, moxifloxacin, hypoK)
Tx:
- if unstable -> defib
- stable -> Magnesium (works even if not hypomg)
Key Antiarrthymics
Adenosine: terminate PSVT
Amiodarone: atrial and ventricular tachy
Atropine: sinus bradycardia, AVNRT
Coronary Steal
Dipyridamole and Adenosine (coronary vasodilators):
- diseased vessels are already maximally dilated, so blood flow goes to ‘non-diseased areas
HOCM vs. AS
Cresendo-Descrendo Systolic murmur LLB
Both can cause syncope, dypsnea, CP
AS - radiates to the carotids, dec with dec preload
HOCM - increased with dec preload.
S4
Before S1 - right after atrial contraction as blood is forced into stiffened ventricle
Normal - healthy older adults
Abnormal
- Ventricular hypertrophy
- Acute MI
S3
After S2 - turbulent blood flow to ventricles due to increased volume
Normal - children, young adults, pregnancy
Abnormal
- restrictive cardiomyopathy
- high output states, HF
Most common paroxysmal tachycardia in people without structural heart disease?
PSVT - most commonly, mech is re-entry into AV node
Treat: Decreased conduction thru AV node
Manuevers
- Carotid sinus massage
- Valsalva manuever
- Breath holding
- Head immersion in cold water
Pharm:
- IV adenosine
- if unstable, DC cardiovert
New cardiac conduction abnormality in patients with infective endocarditis?
Perivalvular abscess extending into conduction pathways
Pt with palpitations and sx of CHF with Afib and evidence of systolic dysfxn on echo - how to treat to restore LV function?
Rate or Rhythm Control
Tachycardia-Mediated Cardiomyopathy
- chronic tachy causes LV dilation and myocardial dysfxn
What is the most common cause of sudden cardiac arrest in the immediate post-infarction period of acute MI?
Reentrant VENTRICULAR arrhythmias
Any ventricular arrhythmia can occur, but ventricular fibrillation is most common cause of sudden cardiac arrest.
If occurs within 10 minutes of acute MI - “immediate” or phase Ia ventricular arrhythmias = reentrant!
If occurs 10-60 min after, ‘delayed” or phase 1b arrhythmia - abnormal automaticity!
Actions of ATII (CHF -> RAAS activation -> ATII)
- vasoconstricts BOTH efferent and afferent - decreased renal blood flow
- BUT PREFERENTIAL vasoconstriction of EFFERENT renal arterioles - increases intraglomerular pressure to maintain adequate GFR
- direct stimulation of Na absorption in proximal tubules and increased aldo - increased in ECF, decreased Na delivery to distal tubule
Thiazide Diuretic Side Effects:
Electrolytes:
- HypoNa
- HypoK
- HyperCa
Metabolic:
- Hyperglycemia
- Increased LDL
- Increased TAG
Supraventricular Tachycardias and their locations
Afib: pulmonary veins
- absent p waves, fibrillatory waves, irregularly irregular RR intervals, narrow QRS
Aflutter: tricuspid annulus
- “sawtooth” flutter waves
AVNRT: reentrant circuit formed by 2 separate conducting pathways - one fast and other slow within AV node
- absent p waves or retrograde p waves, constant RR intervals, narrow QRS
AVRT/WPW: accessory AC bypass tract
- slurred upslowing p wave (delta wave), shortened PR interval, narrow QRS
What electrolyte change parallels severity of HF?
Hyponatremia!
Treatment: fluid restriction, ACEi, Loop
Arteriovenous Fistula
High-output cardiac failure
- shunts blood from arterial to venous side, increasing cardiac preload. Thou CO is increased, get HF because can’t meet O2 requirements of tissue
Signs:
- widened pulse pressure
- strong arterial pulses (brisk carotid upstroke)
- systolic flow murmur, tachycardia
- flushed extremities
- displaced PMI, LVH
Causes: Acquired: Trauma - knife/stab wound* Femoral cath Atherosclerosis - aortocaval fistula Cancer
Congenital
PDA
Angioma
Pulm or CNS AVF
2 months after acute MI, pt develops HF - what complication?
Ventricular Aneurysm
- late complication (5d - 3mo)
- EKG: persistent ST segment elevation after recent MI and deep Q waves in the same leads
- LV enlargement -> HR, refractory angina, ventricular arrhythmias, mural thrombus, annular dilation with MR.
VS. Papillary muscle rupture
- more acute 2-7d
- gives you severe MR + hypotension + pulm edema
VS. RV infarction
- inferior wall MI
- hypotension, elevated JVP, and clear lungs
VS. LV free wall rupture
- several hours - 2 wks
- cardiac tamponade and progresses rapidly to PEA, death
How does beta blocker overdose present? Treatment?
Beta Block overdose:
- hypotension *
- bradycardia *
- wheezing *
- hypoglycemia
- delirum, serizures
- cardiogenic shock
Treatment:
- IVF
- IV atropine
- IV glucagon *** - increases cAMP
MVP
most common cause of MR in developed countries
MVP due to myxomatous degeneration of the MV leaflets/chordae and causes mid-systolic click + mid-late systolic murmur
Chronic severe MR - holosystolic murmur, LA and LV enlargement -> CHF, afib
Lifestyle Modifications for HTN in order of efficacy
weight loss DASH exercise dec. Na intake dec. EtOH intake
Chagas Disease
Megacolon/Megaesophagus
CHF
Trypanosoma cruzi (protozoa) - endemic to Latin America.
What should be avoided in cocaine induced STEMI?
Beta-blockers - unopposed alpha agonist activity worsens vasospasm
How do nitrates work for anti-ischemic and anti-anginal effects?
Although they do vasodilate coronaries, primary effect is thru systemic venous venodilation -> lowers preload -> lowers LVEDV -> reduce wall stress and myocardial O2 demand.
Scleroderma renal crisis presents with what on peripheral blood smear?
Scleroderma renal crisis: increased vascular permeability, activation of coag cascade, increased renin
- acute renal failure - UA normal or mild proteinuria
- malignant HTN - headache, blurry vision, nausea
- microangiopathic hemolytic anemia, DIC (schistocytes)
Lipid Lowering Agents
LDL - Statins, Ezetimibe, Cholestyramine (bile acid sequestrants), NIacin
TAG - Fenofibrate/Gemfibrozil, Niacin
Antimicrobial PPX for endocarditis in dental procedures
Oral amoxicillin
Only those with:
- prosthetic valves
- prior hx of IE
- unrepaired congenital heart disease
(NOT isolated aortic or mitral valve disease)
Shock with WARM extremities
Distributive!
