CARDIO Flashcards
what are the 4 components of the Tetralogy of fallot
- right ventricle hypertrophy
- pulmonic stenosis
- Ventral Septal Defect
- Overriding aorta
What is a continuous machinery murmur
Pateten Ductus Arterious (PDA)
classic description of mitral stenosis
Mid-diastolic rumble or
Crescendo-decrescendo
What type of past medical history will a patient with mitral stenosis have
Rheumatic Fever
description of aortic insufficiency?
eccentric early diastolic murmur
S3 heart sound should make you think?
Fluid Overload like CHF
S4 heart sound should make you think
pressure overload such a LVH or stunned Myocardium from an MI
what murmurs are systolic
Mr AsTr Mitral Regurgitation Aortic Stenosis Tricuspid regurgitation Pulmonic Stenosis
what murmurs are diastolic
Mitral Stenosis
Aortic Regurgitation
Tricuspid Stenosis
Pulmonic Regurgitation
where does aortic murmurs radiate to
carotids and is high pitched
where does mitral murmurs radiate to?
axilla and is low pitched and rumbling
how does squatting affect blood flow
increases venous return
what does rising from a squatting position do
decreased flow
what does valsalva maneuver do
increase intra abdominal pressure decreases flow
what does hand gripping do
increases pressure in the aortic root
what are the two main causes of aortic stenosis
congenital bicuspid value (usually in a young person)
Calcific ( patient >65 yo with HTN,HYPchol, Smoking)
Aortic Stenosis symptoms(SAD)
syncope
angina
DOE
Aortic stenosis signs
harsh loud murmur at the base that radiates to the carotids
LVH
diffuse LV impulse
Aortic Regurgitation causes
Infective endocarditis
thoracic aortic aneurysm
congenital valve anomaly
rheumatic fever
Aortic regurg signs
diastolic murmur at the base
widened pulse pressure
water hammer pulse (big radial pulse
Most common etiology of Mitral Stenosis
Rheumatic Fever
affects females more than males
Elevated LA pressure
Murmur can become apparent during pregnancy
Mitral stenosis symptoms
Dyspnea Orthopnea Pulmonary Edema Angina Hemoptysis Hoarsness
Mitral stenosis signs
diastolic rumble with opening snap
heard best at the apex and radiates into the axilla
a fib or flutter
medical treatment of mitral stenosis
Afib anticoagulation and dig
surgical valvuloplasty
commussurotomy
replacement
what are osler nodes
they are painful raised bumps on the hands and feet and associated with infective endocarditis
what are janeway lesions
are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis
what is the most common cardiomyopathy?
dilated cardiomyopathy
Etiology of dilated cardiomyopathy
Genetic
Viral myocarditis
Alcoholism
Postpartum
dilated cardiomyopathy signs and symptoms
weakness SOB Peripheral Edema Crackles S3 JVD
what is the most common cause of right sided heart failure
left sided heart failure
what are the classic CXR finding of dilated cardiomyopathy
large heart
kerley B lines
dilated cardiomyopathy work up
ECG non specific
ECO is most useful will tell you ejection fraction, valve function wall motion
the treatment of Dilated cardiomyopathy
try to find reversible cause
treat CHF and dysrhythmias
Anticoagulation
restrictive cardiomyopathy etiology
it is a diastolic dysfunction so there is trouble with the filling caused by radiation, fibrosis or amlydosis which results in a small heart
hypertrophic cardiomyopathy
heart muscle is too big and assymetric where the septum grows bigger and eventually causes blockage of blood out through aortic valve.
This usually causes exercise induces syncope
how to bring out a hypertrophic cardiomyopathy
if you valsalva it causes the heart to fill with less blood causing the wall to collapse a little making the opening to the aortic valve smaller and producing more turbulence
a handgrip murmur will accentuate which murmurs
aortic regurgitation or insufficiency
mitral regurgitation or insufficiency
VSD
hand grip maneuver will decrease which murmurs
aortic stenosis
hypertrophic cardiomyopathy
mitral valve prolapse
valsalva will decrease which murmurs
aortic stenosis
pulmonic stenosis
tricuspid regurgitation
valsalva will increase which murmurs
MVP and hypertrophic cardiomyopathy
treatment for hypertrophic cardiomyopathy
avoid exertion
avoid inoptropes
beta blockers slows contraction and speed of contraction
AICD for ventricular arrhythmias
what is the treatment for dilated cardiomyopathy?
remove offending agent
diuretics, vasodilators, nitrates
cardiac transplant
anticoagulate because they are at high risk of embolization
how to treat restrictive cardiomyopathies
Hemochromatosis- phlebotomy or deferoxamine
Sarcoidosis- glucocorticoids
Amlyoydosis-no treatment
Use diuretics and vasodilators for pulmonary and peripheral edema
what is the most common reason for Heart Failure
atherosclerosis which leads to Ischemic heart disease
what tests should you order with a patient with new onset CHF
CXR ECG Cardiac Enzymes CBC (anemia) ECHO
what is the treatment of systolic dysfunction in HF?
Both Lifestyle and Pharmacological
1. Life style modifications: sodium reduction (less than 4g/day) weight loss smoking cessation restrict alcohol use exercise 2. Diuretics to provide volume overload relief Furosemide, HCTZ, 3.Spironolactone 4.ACE 5.ARBs 6.B-blockers
how to treat mild CHF which encompasses NHYA classes 1-2
sodium restriction and physical activity
loop diuretic
ACE- first line agent
how to treat mild to moderate CHF NYHA 2-3
Loop diuretic and ACE
Add B-blocker if response to standard treatment is suboptimal
how to treat moderate to severe CHF NYHA 3-4
add digoxin to loop and ACE
Digoxin does not improve mortality
how to treat diastolic heart failure
patients are treated symptomatically
B-blockers
Diuretics
NO DIG OR SPRINOLACTONE
premature atrial complexes
p waves with different morphology
Usually asymptomatic and requires no treatment but if symptomatic beta-blockers maybe helpful
what should be done with patients who have frequent PVCs and heart disease
they are at increased risk of death from an arrhythmia so order an Electrophysiology study
Atrial Fib causes
CAD, MI, HTN mitral valve disease Pericarditis or pericardial trauma Hyper or Hypothyroidism Sepsis, Malignancy Stress Alcoholic Sick Sinus Pheochromo
Clinical features of A Fib.
Fatigue
DOE
Palpitations, dizziness, angina, or syncope
Irregularly irregular pulse
what is the diagnostic dukes criteria for endocarditis
2 major
1 major 3 minor
or 5 minor
what is the major criteria for dukes criteria
- positive blood culture for endocarditis ( Haemophilus, actinobacillis, cardiobacterium, Eikenlla, kingella, (HACEK), staph aureus)
- Echo with intracardiac mass on valve or supporting structures
what is dukes minor criteria
- predisposing heart condition or IV drug use
- temp >38C or 100.4
- Vascular phenomenon Arterial emboli, pulmonary emboli, conjunctival hemorrhages or janeway lesions
- osler nodes, roth spots gomerlular nephritis, rheumatoid factor
- positive blood cultures that do not meet strict definition of major criteria
hypertensive urgency is defined as?
> 180/>120 in asymptomatic patients
what is malignant hypertension
hypertensive emergency with papilledema with or without endorgan damage
usually have diastolic bp above 120
what is the treatment for malignant HTN
25% reduction in Mean Arterial Pressure in first few hour and gradually decline over 24hours with the exception of Aortic Dissection where you need to get BP down ASASP
what agents are used to reduce BP in Malignant HTN
IV labetolol, sodium nitroprusside, nicardipine, nitroglycerin
what is shock
inadequate delivery of oxygen to the tissues.
severe cardiovascular failure from poor blood flow or inadequate distributive flow
Involves release of catecholamines, renin, ADH, glucagon, cortisol
what are the clinical feature of shock
low BP Tachycardia Peripheral hypoperfusion Altered mental status oliguria
what are the causes of SHOCK
sepsis hypovolemia obstructive causes cardiac Kortisol distributive
treatment for septic shock
ABC
identify sources, cultures and ABx
treatment for hypovolemia
causes GI bleed, ruptures AAA or trauma or plasma loss
ABC,IVF, control source and transfuse
obstructive causes for shock
Cardiac tamponade Tension Pneumo Atrial myxoma Obstructive valve dz Aortic dissection massive pulmonary emboli
what is the treatment for obstructive causes of shock
ABC, bedside ultrasound, CXR, CT
what are the cardiac causes of shock
MI
Dysrhythmia
HF
Valve disease
treatment of cardiac shock
ABC, ECG, monitor, thrombolytics, catheterization
diagnosis for acute rheumatic fever requires what?
two major criteria or one major and two minor
what are the major criteria for rheumatic fever (5)
- Migratory polyarthritis
- Erythema marginatum
- Cardiac involvement (pericarditis, CHF, valve dz)
- Chorea
- Subcutaneous nodules
what are the minor criteria for rheumatic fever (6)
- Fever
- elevated ESR
- Polyarthralgias
- Prior Hx of rehumatic heart Dz
- Prolonged PR interval
- Evidence of preceding strep infection
Rheumatic heart disease is caused by?
streptococcal pharyngitis (group A strep)
what is the most common valvular abnormality of rheumatic heart disease?
mitral stenosis but they can have aortic or tricuspid involvement
how is rheumatic fever treated?
penicillin for strep pharyngitis
add NSAID with acute rheumatic fever
what is the most common cause of acute endocarditis?
Stap aureus
occurs on normal heart valves
what is the most common cause of subacute endocarditis?
Streptococcus viridans and enterococcus
occurs on damaged valves
what is the most common bacteria in native valve endocarditis?
Streptococcus viridans
what is the most common organism in IV drug use related endocarditis?
Staph aureus
most common valve affected is the tricuspid valve
when is endocarditis antibiotic prophylaxis required
patients with know valvular heart disease or prosthetic valves under go oral, GI or GU surgery
how is endocarditis treated
PCN+gentamicin for NVE
Naficillin+gentamicin for IV drug use
Vancomycin+gentamicin for MRSA
if prosthetic valve add rifampin
treatment is from 4-6weeks
what is the most common cause of pericarditis
infectious
It can also be caused by malignancy from lung and breast mets
drug induced from procainamide or hyddralizine
MI or Heart surgery
Autoimmune
Chemo
Pericarditis clinical features
sharp chest pain, pleuritic and positional better with leaning forward worse when laying supine
friction rub which increases when patient leans forward
tachycardia
ECG findings with pericarditis
ST elevation and PR depression
what is the treatment for pericarditis
high dose ASA or NSAIDS (naproxen or Ibuprofen) for 1-3 weeks
treat underlying infection
Cholchicine
what is becks triad
for pericardial tamponade
HYPOtension, JVD and muffled heart sounds
what is the best test for pericardial effusion
ECHO
ECG triad for pericardial tamponade
low voltage
tachycardia
QRS changes in size beat to beat
treatment for pericardial tamponade
pericardiocentesis vs pericardiotomy to drain fluid
predisposing factors for aortic dissection
Long standing HTN (70% of patients) Cocaine Trauma Marfans, ehlers danlo Bicuspid aortic valve coarctation of the aorta
what is a type A dissection?
involves the ascending aorta and moves towards the descending aorta
what is a type B dissection
limited to the descending aorta distal to the take off of the subclavian artery
what is the clinical presentation of an aortic dissection?
severe tearing,ripping,stabbing typically abrupt onset either in the anterior or back of chest. Diaphoresis most are HTN Pulse or BP asymmetry between limbs aortic regurg
How is a dissection diagnosed
CXR will show a widened mediastinum
TEE is a very high sensitivity and specificity
CT and MRI are both accurate
Aortic angio is invasive but best test to determine the extent of dissection for surgery
Treatment of aortic dissections
IV Betablockers to lower heart rate and diminish left ventricle ejection
IV nitroprusside to get bp below 120
For type A surgical management
TYPE B dissections
medical management first line drugs include IV beta blockers like labetalol, esmolol, propranolol
pain control with morphine or dilaudid
what are the clinical features of a AAA like
pay may or may not be present
pulsatile mass and throbbing
Grey turner sign which is ecchymoses on back and flanks
Cullen sign which is ecchymoses around umbilicus
what is the test of choice to evaluate AAA
Ultrasound
Can use CT but only indicated in stable patients
what is the treatment of a AAA
AAA >5cm in diameter or symptomatic surgical resection
AAA
general characteristics of PAD
superficial femoral artery is the most common site
risk factors are smoking by far the most common
CAD, Hyperlipidemia, HTN
PAD symptoms
intermittent claudication
rest pain, often awakens them at night. hanging foot over side of bed helps relieve pain
PAD signs
diminished or absent pulses, muscular atrophy, decreased hair growth, thick toenails, cool skin, pallor of elevation and dependent rubor
how is PAD diagnosed
ABI
Normal is .9-1.3
ABI>1.3 indicates noncompressible vessel which is severe disease
ABI
what is the treatment of PAD
STOP SMOKING exercise program foot care control HTN,weight, diabetes Aspirin along with clopidogrel Ciloztazol Surgery
what is virchows triad?
endothelial injury venous stasis and hypercoaguability for DVT
what are risk factors for DVT
age>60 malignancy prior HX of DVT,PE, or vericose veins Hypercoagulable state (factor V, protein c and s deficiency, antithrombin III def) cardiac disease Obesity, immobilization trauma surgery, pregnancy or estrogen use
what are the signs of DVT
lower extremity pain and swelling better with elevation
Homans signs
palpable cords
fever
how is a DVT diagnosed
Doppler and duplex ultrasound
venography
d-dimer
when should you use a d-dimer
has high sensitivity but low specificity can be used to rule our DVT when combined with doppler and clinical suspicion
what is the treatment for DVT
anticoagulation heparin bolus followed by a constant infusion and titrated to maintain the PTT of 1.5-2 times aptt
thrombolytic therapy
prophylatic inferior vena cava filter placement
