Cardio Block 3 Flashcards
What are the RFs for DVT?
What are the most common findings?
Hx of DVT Current CA Stasis x 6hrs Endothelium injury Thrombophilia
Calf pain, Edema, Warmth, Palpable cord
What two tests are sufficient to positively Dx DVT?
When can a DVT be ruled in/out?
D-Dimer
Compression US
In: Mod/High probability, Pos compression US
Out: Low probability, Neg D-Dimer
What are the acquired/inherited risk factors of DVTs?
Persistent: age, CA, antiphosphoidal Abs, Hx of DVT/PE
Transient: recent surgery/trauma, pregnant, OCP/Hormones, imobile
Inherited: antithrombin 3 deficiency, Protein C/S
Factor 5 Leiden
Prothrombin gene mutaiton
When is a D-Dimer for DVT not recommended?
What blood work up result is considered after a DVT has been Dx’d?
Pretest probability is intermediate/high
Factor 5 levels
What is the gray zone of DVT Dx?
What is done to finalize the Dx?
Neg US
High probability
CT/MR venography w/ repeat US when D-Dimer is 500ng or higher
What are 5 thrombophilic disorders?
What PE finding is indicative of DVT but unreliable?
OCPs Hormone replacement Antiphospholpid Ab syndrome Protein C/S deficiency Hyperhormocysteinemia Factor 5 Leiden
Homan Sign- pain w/ foot dorsiflexion
What is the Gold Standard of DVT Dx?
What are the 3 parts of Virchows triad
US
Stasis
Hypercoagulability
Trauma
What Tx med can’t be used in pregnant PTs w/ DVTs?
Define AAA
Warfarin, LMWH (Enoxaparin) is preferred
Infrarenal aortic diameter of 3cm or more
What are the RFs for AAA?
What is the underlying pathology?
FamHx Syphillis Men (Caucasian) Atherosclerosis Smoking HTN
Oxidative stress
Aortic wall inflammation
Proteolytic degradation of elastin/collagen
When is US screening for AAA conducted?
When are they surgical?
Men 65-75 w/ smoking Hx of at least 100 cigarettes
5.5cm or more
Growth of 0.6-0.8cm over 6mon
When are AAAs monitored for growth?
What are they monitored w/?
<5.5cm or growth 0.6cm or less per year
Cereal US
What size of AAAs don’t/need screening?
When do these PT need to be referred to vascular specialist?
<3cm, no testing
3-4: Q12mon
4-4.5: Q6mon
> 4.5cm
What can be done for PTs w/ AAAs in attempt to reduce their rupture/surgery likelihood?
Aortic dissection involves what 2 events?
Tobacco cessation
BP control
LDL <70
PO BB
Intimal tear
Hemorrhagic extravasation into intima-media space
Aortic dissections are characterized by ? pain and the development of ?
What is the first and second line medical therapy given to these PTs after rupture?
Ripping/tearing
AI murmur
IV Labetolol, Esmolol
Nitroprusside
What are three genetic d/os that can cause protein abnormalities leading to aortic dissection?
How can dissections be viewed for Dx?
Polycystic kidney- polycystin
Marfans- fibrillin
Ehlers- type 3 procollagen
CT- stable
TEE- unstable
What type of shunt is an ASD?
When are most of these Dx’d?
L to R
5th decade
Over time, a large enough ASD can lead to what five issues
What is the classic findings of these w/ auscultation?
Pulmonary overcirculation PHTN Eisenmenger R to L shunting Cyanosis
Wide fixed, split S2
ASDs done affect ? heart structure?
What is the most common and 3 other types of ASD?
Coronary artery
Ostium secundum- incomplete adhesion of flap and septum
Ostium primum
Sinus venosus
Coronary sinus septal defect
What is the most common cyanotic congenital heart dz in childhood?
What are the four parts of this d/o?
Tetrology of Fallot
PV stenosis- ejection murmur
RVH
VSD, no change w/ respiration
Over riding aorta
What PE finding is characteristic of Tetrology of Fallot?
What makes the Tet spells worse or better?
Loud systolic ejection murmur
CXR of boot shaped heart
R sided aortic arch
Worse: worsened pulmonary outflow obstruction
Better: inc systemic vascular resistance
Where does coarctation of the aorta occur?
How can this be identified on PE?
Acyanotic narrowing of descending aorta at origin of ductus arteriosus
Dec femoral pulse
Brachial HTN
Systolic ejection at apex
“3 sign” aortic knob on CXR
What does a VSD sound like?
This is considered acyanotic alone but can be seen in ?
Harsh murmur louder w/ smaller defects
Tetrology
Transportation of arteries
What causes a PT to become cyanotic from a VSD?
What syndrome is defined by PHTN and cyanosis from pulmonary vascular obstruction secondary to large R to L shunt?
R to L shunt
PHTN
Dyspnea
Eisenmenger syndrome (irreversible)
Peripheral artery dz can represent atheroscletoic disease w/in the aortoilliac system and is then called?
How does classic claudicaton present?
Leriche syndrome- thigh, butt, hip pain w/ ED
Replicated w/ exercise
Relieved w/ rest
What is the most common site for claudication from peripheral artery dz?
What derm changes can be seen on PE?
Calf
Cool, shiny skin w/ dec hair
What is a late PE finding of peripheral artery dz?
What measurement can be taken for Dx purposes?
Resting pain
Ankle brachial index
<0.9= >50% stenosis
<0.4= ischemia
Pregnant PTs w/ DVTs are usually Tx how?
Although controversal and not recommended, how can these PTs LMWH levels be monitored?
Therapeutic anticoag x 6mon
6wks post-partum
Anti-Xa
UFH use requires what lab monitoring?
PTs w/ Coarctation and have the PDA closed may present w/ ?
aPTT
Circulatory failure
Shock
In many PTs, coarctation of the aorta occurs ?
What feature does this anomaly allow?
Juxtaductal, adjacent to PDA
Widens juxtaducta area of aorta so blood can flow forwards from LV
What are the 3 types of coarctation?
Preductal- narrowing proximal to ductus arteriosus, seen in Turners.
Ductal- narrowing at insertion of ductus arteriosus, appears when ducts closes.
Postductal- narrowing distal to ductus arteriosus and most common in adults
What medication can be used to maintain the patency of a ductus arteriosus?
What is the etiology of acquired cases of aortic coarctation?
Alprostadil, prostaglandin E1
Takayasu arteritis
PTs w/ Turners and coarctation generally develop what two compensation mechanisms due to the coarctation?
What are the classic PE findings?
LVH, collateral flow around lesion
Systolic HTN
Diminished/delayed femoral pulses
How do adults/older kids w/ aortic coarctation present in clinic?
What are the initial diagnostic studies conducted?
Chest pain
Cold extremities
Claudication
Continuous murmur over L anterior chest or L midline back
EKG, CXR, Echo
In most PTs w/ coarctation, how is the Dx established?
What further test will adults possibly need?
Echo w/ doppler
MRI/CT
What are 3 common complications of aortic coarctation who don’t have surgical correction?
Adults w/ unrepaired coarctation are at increased risk for what other vascular d/os?
Accelerated CAD
Dissection
Stroke
HF
Intracranial aneurysm
What is the genetic map of Tuners?
What genetic cardiac differences do Turners present w/?
45,XO
Bicuspid aorta
Coarctation
How does coarctation appear on EKG?
What surgical procedure corrects this?
LVH- Scott Criteria +35mm
Balloon angioplasty
Stent placement
Surgical correction
What is Well’s Criteria for PE?
What is the PT has a Hx of DVTs?
CIB LTS SPC AD Cancer Immobile Bedridden x 3days/major surgery in past 4wks Leg tender/swelling >3cm Pitting edema Collateral veins Alternative Dx (-2pts) Low= 0 Med= 1-2 High= 3 or more
Given 1pt
DVT likely= 2 or more pts
DVT unlikely= 1 or less
What is the preferred Dx modality for PTs w/ suspected PE?
What is the next best test if PTs kidney can’t handle contrast?
CT angiogram of chest
D-Dimer- not needed if mod/high probability exists
Define DeBakey Type 2 dissection?
What is NOT a RF for AAA
Dissection in only ascending aorta
Female gender
What systemic Dz may actually be protective against AAA?
If PT receives PGE-1 infusion for PDA maintenance, what are common s/e and two things needed on stand by?
DM
Apnea Prophylactically intubate HOTN Hyperpyrexia FPP Anti-seizure meds
What medication is used to close PDAs in premature infants?
What PO anti-coagulants can be used for PTs w/ A-fib?
Indomethacin (prostaglandin inhibitor) or Ibuprofen
Direct thrombin inhibitor
Factor Xa inhibitor
What is the most serious complication that can arise from A-Fib?
What diameter do vessels need to be for veins to be classifed as varicose?
Thromboembolism
> 3mm
What is the CHA2DS2VASc criteria?
Peripheral artery dz is associated with 3 RFs?
CHF HTN Age >75 DM Stroke
Vascular Dz Age 65-74 Sex, female
Smoking, DM, Age
Atherosclerosis
What are c/i to lower limb vericose vein ablation therapy?
How are vericose veins dx and how are they Tx?
Pregnancy Thromboembolism Mod/Sev peripheral artery dz Joint dz affecting mobility Congenital venous abnormality
Duplex US
Compression/elevation
What is the most common systemic vasculitis in the US?
This Dz almost never presents before ? age
GCA
50y/o
How do PTs w/ GCA present?
How is it Tx?
Amaurosis Fugax
Claudication in jaw
HA
No vision loss- pred
Vision loss- Methylpred
What PO anti-coag is similar to Warfarin but doesn’t require monitoring?
Define Kussmaul sign
Dabigatran
Inc of CVP rather than decrease from R sided HF
Kussmaul signs are frequently seen in PTs w/ ? two issues
Periodic BP measurements should be a part of routine preventative health assessments starting at age ?
Constrictive pericarditis
RV infarction
3y/o
What is the most appropriate initial medication for Diabetics w/ HTN?
What is the most common cause of Secondary HTN?
ACEI
Renal parenchymal Dz
HCM is characterized by ?
What movement reduces/increases AS?
Medium pitch, mid-systolic murmur decreasing w/ squatting/inc w/ straining
Dec w/ Straining
Inc w/ Squatting
How is MR characterized?
What is this type of murmur rarely associated w/?
Blowing systolic murmur radiating to axilla
Syncope
How is PS characterized?
Acute MI frequently presents w/ what 2 Sxs and rarely w/ what 2?
Widely split S2
Not changed w/ maneuvers
Frequent: Chest pain, SoB
Rare: Fever, Myalgia
Restrictive pericarditis is most commonly from ? and shows ? on Echo
What study is useful for establishing Dx/pathway of complex arrhythmias including SVT?
Amyloidosis
Impaired diastolic
Electrophysiology
Thiazide diuretics are most likely to cause ? E+ disturbance?
What medication needs to be avoided in PTs w/ WPW?
Hypokalemia
Digoxin/CCBs- dec refractory, inc AV node refractory causing faster ventricular rates
What are two findings seen in central retinal artery occlusions?
What is seen in chronic HTN PTs?
Cherry red fovea
Boxcar segmentation
AV nicking
What is the first finding that can indicate worsening CHF?
What is the major predisposing risk factor to the development of A-Fib?
Inc in weight during daily checks
MS
What drugs are most likely to cause a Lupus-like reactions and pericarditis?
What are examples of causes of high output HF?
Procainimide Hydralazine Methyldopa Isoniazid Phenytoin
Reduced systemic vascular resisitance in: Thyrotoxicosis Animia Pregnancy BeriBeri Pagets Dz AV malformation
What is the most common cause of acute arterial occlusion in the upper extremities in adults over 40y/o?
PTs w/ Marfans frequently/rarely have what 2 cardiac conditions?
Thoracic outlet syndrome
Common: MVP, AR
Rare: RAE, PS, VSDs
What are the major criteria for the Dx of Marfans?
What are the absolute c/i to giving thrombolytic therapies?
Ectopia lentis
Aortic root dilation
Aortic dissection
Hermorrhagic stroke Stroke in past 1yrs Intracranial neoplasm Internal bleeding, actively Suspected dissection
How is renal artery stenosis identified?
How does primary aldosteronism affect E+ balances?
Abnormal radionuclide uptake in affected kidney
High Na
Low K
What is the only E+ loss that effects Digoxin metabolism?
Revascularization of the Left Main artery is indicated when stenosis is greater than ?
K loss
50%
What type of ventricular arrhythmia leads to death?
What is the TOC for these PTs?
VT
Inplanted Defib
What type of physiological cahnge/shift can predispose Pts to skin ulcers?
Leaking fibrinogen/GF into interstitial space
Leukocyte aggregation/activation
Loss of cutaneous lymphatic network
What is the definitive Tx to correct MR from papillary muscle rupture?
What PT population has the highest risk for HTN?
MV replacement
Black, non-hispanic
AHA recommends what PTs receive ABX prophylaxis?
PTs w/ prosthetic MV or AV should keep INR between ?
Prosthetic heart valves
Heart transplant w/ valve dz
Un/repaired cyanotic CHD
MV: 2.5-3.5
AV: 2-3
What heart measurement is an indirect measurement of the left atria filling pressure?
What is a classic finding of cardiac tamponade?
Pulmonary capillary wedge pressure
Pulsus paradoxus
What is the last in sequence of events to occur in peripheral artery dz?
What Sx usually precedes this finding?
Arterial ulcers, usually in feet/areas of pressure
Claudication
When do venous ulcerations typically develop?
What is the most common location for these to develop?
Secondary to venous incompetence/chronic edema
Medial ankle
What trifecta leads to diabetic ulcers?
HPV is commonly associated with ? but not ?
Atheroscleorsis
Arterial insufficiency
Diabetic neuropathy
Venereal warts
Myocarditis
What 2 viruses are most commonly associated with myocarditis?
What two are most likely to cause pericarditis?
Coxsacie
Echovirus
Coxsackie
CMV
How does LVH present on EKG?
Is coarctation cyanotic or acyanotic?
Tall R in Lead 1, aVL
Deep S waves
Poor R wave progression
Scotts criteria- 35mm
Acyanotic
What is the NYHA HF classifications?
What is the College of Cardiology staging crtieria?
1: ASx
2: Sx w/ normal activity
3: Asy only at rest
4: Sxs at rest
A: high risk, no Sx/Dz
B: Dz w/out Sxs
C: Dz w/ Sxs
D: refractory heart failure
What medication could be given to PTs w/ coarctation and HTN?
How would COPD w/ cardiac strain present on EKG?
ARB- protects kidneys
Tall R waves
Deep S waves
RAD
Tall P waves
What is a normal pulmonary artery systolic pressure value?
Define Cor Pulmonale
25mmGH
HF secondary to lung Dz
Lung Dzs are a cause of ? sided HF
What strong CCBs are used in PTs w/ Raynauds?
R
Verapamil
Diltiazem
How does an atrial myxoma present?
What heart issue does this mimic?
Inducible diastolic murmur w/ bending over, disappears w/ sitting up
MS
Loud P2 is always indicative of ?
What are the 5 categories of PHTN?
PHTN
1: idiopathic, CT Dz, CHD, pulmonary arterial HTN
2: result of L sided HDz
3: lung dz/dec O2
4: occlusion of pulmonary vasculature
5: unclear mechanism
Which categories of PHTN can be Tx with meds?
What has to be done prior to conducting CT angiogram, what is the f/u exam if PT is ineligible for this?
1 and 4
CrCl/BUN
VQ scan
PHTN causes ? looking feature seen on pulmonary angiography?
What meds are used to treat PHTN?
“Pruned tree” vasculature
Endolthelium blockers- prevents dilation
Prostacyclin- causes dilation
PD-5 inhibs- Sildenafanil (viagra/cialis)
Sildenafil can’t be used within 24hrs of ?
What are two risks of femur Fx?
Nitro
Fat embolism
Blood loss
Sympathetic responses to the CV system travel through ? vertebral structures?
Contusions of the heart are Tx like?
From medulla to T1-5
Myocarditis
What would the troponin levels be if they’re from a PE etiology?
What drugs are used for triglyceride lowering therapy?
1-10
Fibrate- Gemfibrozil
Diabetics w/ HTN should be put on one of what two ACEIs?
PTs that are cold/clammy, confused, HOTN, and tachy have ? type of shock?
Enalapril
Lisinopril
Cardiogenic
What would be two hallmark findings of a PT suffering from anterior wall MI?
What would be seen if they were having an inferior wall MI?
Tachy, HOTN
Brady, HOTN
What drug is used in intubated PTs that are suffering from HOTN?
What is the best way to monitor cardiogenic shock resuscitation?
What drug can be added to inc one of these monitored indicators?
Dobutamine
Ins and Outs, especially outs
NorEpi
What is the most common cause of the development of a prominent S4?
What type of genetic issue is HOCM that usually causes mutations in the development of ?
HTN
Autosomal dominant
Myocardial contractile apparatus
What are the only two holosystolic, blowing murmurs over the sternum w/out radiation?
What drug is given to PTs Dx’d w/ MRSA IE?
TR, VSD
VSD won’t change w/ inspiration
IV Vancomycin
What microbe is the most common cause of IE in the US?
What is given to PTs as a endocarditis prophylaxis prior to dental procedures?
Strep Viridians
Amoxocillin
What is the most likely Dx for PTs w/ wide pulse pressure?
AVRT= ?
AR
WPW
What type of lesion is Hypoplastic Left heart Syndrome?
What would be heard on PE?
Cyanotic, no LV
Loud P2
Hyperactive precordium from large RV
What drug can be used to keep PDA open in PTs w/ Hypoplastic Left Heart Syndrome?
What can be given to inc their BP?
Alprostadil older than 12mon surgery repair
Dopamine
Normally, PDA connects ? to ?
What treatment needs to be avoided in PDA PTs?
Aorta
Pulmonary artery
O2
What EKG abnormality is associated w/ ADS?
ASDs smaller than ? close sponataneously
RBBB- rabbit ears
<8mm
What is the most common cardiac congenital abnormality in adults?
What is the most common one in infants?
ASD- acyanotic
VSD, membranous
What are the 4 types of VSDs?
VSDs that don’t are Sx and cause CHF receive ? med?
Membranous
Muscular
AV canal
Outlet septum
Furosemide
What is the most common cardiac issue seen in Down’s?
Define Hyperoxia test
A-V Canal
ABG is drawn
>200g- Cardiac Dz unlikely
50-150- mixing lesion (truncus, tricuspid atresia)
<50- two circuits w/ mixing
What are the two cyanotic lesions that will be on the test?
What are 3 others that will be distractors?
Transposition
Tetralogy
Truncus arterious
Tricuspid atresia
Anomalous pulmonary venous
What is the timeline from Dx to fixing of transposition of the vessels or death will occur?
How do you ID transposition on an x-ray?
6hrs
“Egg on a string” w/ Pt being cyanotic
Kids w/ tricuspid atresia usually also have ?
RV failure is also associated w/ ? finding on PE?
VSD
Heave
What is the whole issue of Tetralogy?
What is the condition called if an ASD is added to the tetrology?
PS
Pentology of Fallot
How does uremic pericarditis present?
How is it Tx?
High Cr/BUN
EKG- ST elevation, PR depression in multiple
Dialysis
PT w/ HOTN/Tachy is in ? shock
PT w/ HOTN/Brady is in ? shock
Cardiac
Neurogenic
Where does PHTN show on EKG?
What changes this to Cor Pulmonale
Large P-waves on Lead 2
Edema
JVD
Loud P2
Why would a 30 year old PT who smokes already have COPD?
What needs to be looked for on PE for obstructive sleep apnea?
Alpha-1 trypsin Dz
Mallampati score of 3 1- complete visualization of soft palate 2- complete visualization of uvula 3*- visualization of only base of uvula 4- soft palate not visible at all Polysomnograpy
PT experiencing pain around an IV site w/ not streaks/heat has a ?
How is it Tx?
Thrombophlebitis
Warm compression
NSAIDs
Where are acute thrombo embolisms created and thrown from?
PT w/ CTA showing numerous PEs would be classified as ?
A-fib, Left atria
Group 4
Restrictive pericarditis will have ? EF and is usually caused by ?
How does Takosubo’s look on Echo?
Preserved
Sarcoidosis
Apical ballooning
How do you Dx Rheumatic heart Dz?
PT w/ calf pain when walking can have an expected ankle brachial index below ?
JONES J- large O- carditis N- nodules E- erythema marginatum S- synchorea
0.9
PT w/ low brachial ankle index needs to have ? issue r/o
Examining new born who is cyanotic, palpation of the chest produces heave, what needs to be done for ? issue
CAD
Bring knees to chest
Tetrology
PT w/ CA, abdominal ascites, significant LE edema, no change of JVP w/ inspiration. CXR reveals calcified ring around heart is ?
What is the most important initial therapy for vericose veins?
Constrictive pericarditis
Compression
What is the difference in available studies for PTs w/ suspected dissections?
All STEMI PTs get ?
HTN- CT
HOTN- no scans
Caths
What drug is most associated w/ causing TR?
What other cardiac anomaly is associated w/ TR?
Lithium
Epstein anomaly
PT w/ brachial index of 1 and claudication needs to have what 2 steps done for Tx?
Statin
Low ABI= Exercise stress test to rule CAD in/out
An vessel needs to be stenosis _% in order to be symptomatic?
What drug is used for, and only for, peripheral artery dz?
71%
Pletal (Cilostazol)
Vasodilator
BNP will be artificially low for what two issues?
PT w/ bilateral claudication in thighs/calf/feet will most likely have occlusion in what area?
Body fat
Pericarditis
Thighs: abdomen
Calf: popliteal
Feet: tibial artery
What is the criteria for using Dobutamine?
What are the most common causes of cardiogenic, neurogenic, hypovolemic shock and criteria?
HOTN
Cardiogenic shock
Exhausted all other options
Volemic- fluid
How does pericarditis present on EKG?
What drugs do are used to Tx and prevent reoccurence?
Diffuse ST elevation (+1mm)
PR depression
Concave ST upslope
Pathognomonic for pericarditis
Tx: NSAID (Indomethacin) if viral
Prevent: Colchicine
ASA if acute/Dressler’s
Steroids- refractory to NSAID, Colchicine, ASA (anaphylactic reaction to ASA= straight to steroid)
What is the sequence of changes seen on EKG during a MI?
What happens with a prolonged QT interval?
Hyper acute T waves
ST depression
ST elevation
Q wave development
Torsades
What leads are high lat? What leads are inferior? What leads are septal? What leads are anterior? What leads are lateral?
1, aVL- diagonal 2, 3, aVF (RCA) V1, V2- (LAD), posterior= RCA V3, V4- LAD V5, V6 (LCX)
What is more common, NSTEMI or STEMI?
What are 3 things that can cause an ST depression?
NSTEMI- 70% of MIs in US
Digoxin
Ischemia
Hypo-K
Inferior MI in 2, 3, aVF will have reciprocal changes where?
What is the next step after these are confirmed?
1, aVL
R sided EKG
What two medications can be given during brady/instable PTs?
What is the TOC for confirming/Dx dilated cardiomyopathy?
Atropine/Isoproterenol
Trans thoracic echo
What are the 3 types of restrictive cardiomyopathy?
What will be seen on CXR and how is it Dx?
Amyloidosis
Sacroidosis
Hemchromatosis
Normal x-ray
Biopsy
What can be given to PTs w/ sarcoidosis induced cardiomyopathy?
What is the most and second most common location for hypertrophy to occur in HCM?
Steroids
Septum
LV
What will be seen on CXR of HCM?
What is the TOC for Dx?
Normal heart
Doppler Echo
What 3 things are avoided in PTs w/ HCM?
What can be used?
Digoxin
Dilators
Exertion
CCBs, BBs, amiodarone for arrhythmias
Improve diastolic function
Normal sinus rhythm has upright P-waves in what leads?
What is a normal sinus, junctional and ventricular rate?
1, 2, 3, aVF
Sinus: 60+
Junction: 40-60
Ventricle: 20-40
How do you figure out max tachy rate?
What is a common cause of tachy, narrow complex rhythms?
220-age
Hypovolemia
How is A-Fib Tx?
How is A-flutter Tx?
Vagal, Adenosine, CCB/BB, conversion
A1 meds- Procainamide/Quinidine
Amiodarone
Conversion
What med is used for Torsades if the Qc is normal?
What is used if the QTc is prolonged?
Lidocaine
Mg Sulfate
Sequence of drugs for wide complex V-Tach
When are PDAs necessary for life?
Procainamide
Amiodarone
Lidocaine
Tetrology
Transposition of vessels
What do different BNP levels mean”
What is the sequence of Tx of HF?
<1000: unlikely decompensated CHF
>500: likely decompensated
100-500: uncertain
Ventilation
Tx dysrhthmias
Reduce PL- nitro, loop, morphine
Reduce AL- nitro, ACEI, prussie
What are the 3 parts of HF?
Inc PL
Inc AL
Dec contractility
JNC8 BP goals
60+ <150/90
59- <140/90
DM/CKD: <140/90
White: Thiazide, ACEI/ARB, CCB
Black: Thiazide, CCB
CKD: ACEI/ARB
What causes 95% of HTN?
What are the causes of Secondary HTN?
Essential HTN- no identifiable cause
Renal/VascularDz Obstructive sleep apnea Pheo Estrogen Steroids Drugs Coarctation- kids* Cushings Hyperaldosteronism
What are the first two meds given for HTN control?
What is the last resort?
ACEI- first in CKD/DM
CCB- amlodipine
BB
DOC for neurologic HTN
DOC for dissections
Nicardipine/Clevidipine
Labetalol
Esmolol
Nitroprusside
Metoprolol
DOC for acute MI HTN
DOC for acute HF
Nitro
Esmolol
Metoprolol
Nitro
Furosemide
Nitroprusside
DOC for renal HTN
DOC for pregnancy HTN
Nicardipine/Clevidipine
Labetolol
Fenoldopam
Hydralazine
Labetolol
Mg sulfate- pre/eclampsia
What does the acronym SHOCKD mean
What is the Metabolic Syndrome
Causes of shock Sepsis Hypovolemia Obstructive Cardiac Kortisol Distributive
Inc risk for atheroscleortic Dz, having 3 of: Obesity TG >150 HDL <40/<50 in female Fastin glucose >110 HTN- BP >140/90
Old person exercising and has syncope is most likely due to ?
What if they’re young?
AS
WPW, HCM
What 4 systemic factors increase Metabolic Syndrome risks for dz?
Time for rise, peak and normal for myoglobin, CK-MB and troponin
Lupus RA HIV CKD
M: 1-3h, 6-8h, 12-18h
C: 3-6h, 18-24hr, 48-72hr
T: 4-6h, 18-24h, 7-10day
Difference Type A/B dissection
Chart on
A= proximal/ascending aorta, surgery B= distal aorta, medical therapy
Pg 64
What Txs are given to PTs w/ venous thrombosis?
When is a D-Dimer ordered?
LMWH, Coumadin
Low risk DVT
Mod/High= US
Rheumatic fever is associated with ? valve issue?
Define Austin Flint murmur
MS
Early diastolic decrescendo from AR
Wide PP, hypoperfusion (HOTN)
Thick LV on CXR
What does IVDA do to the TV?
What drug is added for IE from a Gram Neg organism but can’t be given alone?
TS
Gentamicin
What’s the difference of areas affected between myocarditis and pericarditis?
What is Beck’s Triad?
Myo: transmural
Per: only pericardium
Tamponade:
Muffled sounds
JVD
HOTN
ASD is common w/ ? type of block?
VSD is common w/ ? type of block?
RBBB (rabbit ears)
Fixed split S2
Mid systolic ejection murmur
LBBB (Deep S in V1, High R in V6)
Constant machinery
What microbe is likely to cause pericarditis in ImmComp PTs around the world?
Dressler’s can appear up to _wks after MIs
TB
12wks
What two drugs can cause pericarditis but w/out Lupus like syndrome?
What is the pathological process behind pericarditis?
Anthracycline antineoplastics (Doxorubicin, Daunorubicin) Minoxidil
Dilation, inc permeability, leukocyte exudation, fibrin deposit, inflammation, dec space
What type of pericarditis has the highest mortality of almost 50%?
What are 4 types of acute pericarditis?
Purulent
Serous- thin exudate
Serofibrinous- bread/butter
Suppurative- bacterial, inflammation
Hermorrhagic- TB, cancer
What medication is c/i during acute pericarditis?
How long does this med stay in circulation after d/c?
Warfarin
5 days
What are four things that can cause friction rubs on exam?
10% of PTs w/ pericarditis can present with a normal ?
Pericarditis
Tamponade
Myocarditis
Pleuritis
EKG
All pericarditis PTs get what three things?
What labs are ordered?
CXR, EKG, Echo
CBC, ESR/CRP, Enzymes
Fever= culture
PPD/HIV- if not done
ANA/RF- suspected rheumatoid d/o
Transition from effusion to tamponade occurs around __mL of fluid
What are three conditions that can cause pericardial effusion?
> 250mL
Inc permeability: hypothyroid
Inc hydrostatic press: CHF
Dec oncotic press: cirrhosis
How long after an MI can a free wall rupture occur and cause an effusion?
What does pericardial effusion do to JVP?
3-5 days
Inc w/ dominant x-descent
Hiccups longer than ? are pathological for ?
How do pericardial effusions look on EKG?
6wks
Effusion from irritation of phrenic nerve
Flat T, low voltage
What is the first Dx/TOC for pericardial effusions?
Pulsus paradoxis is more indicative of a ?
Echo
Tamponade
Pathophysiology of tamponades cause what two events?
What does a tamponade do to the JVP?
Inc atrial pressure, dec venous return
Inc ventricle pressure, dec diastolic filling
Loss of Y descent
What findings make you think of a tamponade from malignant effusion?
Tamponade w/out inflammatory signs
What is the difference in lab results for pericardial effusion from exudate or from transudate?
Ex: malignant, infection, CT d/o (external) SpecGrav >1.015 Protein >3 Serum/protein >0.5 Serum/LDH >0.6 Serum/glucose<1.0
Trans: hypothyroid uremia radiation trauma
Opposite of Exudate
How can you Tx cardiac tamponade?
What drug is used to prevent recurrence of constrictive pericarditis?
Inc fluids to stretch heart
Pericardiocentesis
Colchicine
Constrictive pericarditis mimics ?
What is the initial and definitive way to Dx?
R sided HF
TTE
Biopsy
CMR to determine constrictive vs restrictive
What PE findings would be seen in PTs w/ constrictive pericarditis?
How does this present on EKG/CXR?
Precordial knock before S3
EKG: ST/T-wave changes
Tachy, Low voltage, A-Fib
CXR: calcifications, minimale silhouette enlargement
What image is ordered to assess pericardial thickness?
What is ordered to differentiate effusion from scarring?
CT
MRI
What does cardiac cath allow for PTs w/ constrictive pericarditis?
What is the only effective Tx for severe/chronic cases?
Biopsy
Definitive distinction between constrictive/restrictive
Pericardectomy
All CA PTs are hyper-?
What is HF from pericarditis?
Coagulable
Myocarditis
The more ? a thrombus is, the more dangerous it is
Define Phlegmasia Cerulea dolens
Define Phlegmasa alba dolens
Proximal
PCD: cyanotic hue
PAD: pallor w/ edema
What labs are ordered for DVT work ups?
What test has the highest sensitivity/specificity for DVTs, but which one is 100% accurate?
PT and PTT CBC w/ platelet Renal/LFT UA D-dimer
Doppler US
Venography but invasive
Venous thromboembolism is ?+?
What is the Tx of choice of VTEs?
PE + DVT
LMWH* (Lovenox)
UFH (needs PTT monitoring)
Xa inhib- Fondaparinux*
PO Factor Xa inhib- Rivaroxaban
LMWH/Fonda use overlapped w/ Coumadin has to occur for at least ? days
When can you d/c one of the meds?
5 days, remains for 5 days after use
D/c LMWH/Fonda on day 5/6 if INR is in range for two days
What platelet level indicates HIT and need to stop heparin?
What are the only two issues with using Rivaroxaban?
<100K/microl
Similar to warfarin but,
BID dosing for 3wks then one/day (don’t give to forgetful/incompetent PTs, use Coumadin)
$
What is the reversal agent for Rivaroxaban?
Embolic strokes can only occur in the ?
Andexxa
Brain
Why is LMWH superior to UFH on inpatient settings?
What criteria must be met inorder for PTs w/ VTE to be Tx on outpatient basis?
Reduces mortality and bleeding risks
Stable/normal VS
Low bleeding risk
No severe renal insufficiency- normal Chem 7
System in place for LMWH use and monitoring
Surveilance/Tx of recurrent VTEs
What is the Chem panel set up and data inputs?
Na Cl BUN
K HCO3 Cr
At the end= Glucose
How long is Coumadin used when Tx DVTs?
When is an IVC filter used?
3-6mon
Anticoags are c/i
Recurrent embolism w/ anticoag therapy
Recurrent embolism w/ PHTN
Urgent surgery w/out time for anticoag
What is done for PTs suffering from a TIA?
What med has the highest effect on lowering TGs?
Give ASA, Dipyridamole
Admit to stroke unit
Fibrinates- Gemfibrozel
Strep infections lead to ? and will present w/ ? murmur
PT getting dental Tx and has to stop Warfarin, what is the next step?
MR- diastolic decrescendo murmur at apex
No bridging is necessary
Old PT w/ lower extremity skin changes and discomfort relieved w/ elevation will have what PE finding?
Fist Sx/complain of AS
LE edema
Dyspnea
Tx for V-Fib
What is the most common congenital heart Dz?
Defib
VSD
Who is classified as a medical PT and can be Tx for DVTs on outpatient basis?
Previous VTE
Ca
Immobility
Inherited/acquired hypercoag
What DVT prophylaxis drug can be taken PO w/out inc bleed risk?
Arterial thromboembolism will present w/ ? Sxs
Rivaroxaban
Pain
Paresthesis
Pallor
Absent pulses
Suppurative phlebitis w/ fevers and chills is called ?
Define Trousseau Syndrome
Suppurativel thrombophlebitis
Migratory superficial thrombophlebitis associated w/ adenocarcinomas
Most common location for superficial thrombophlebitis to occur?
What PT population gets lipodermatosclerosis?
Great saphenous vein
DM
What is the difference between pulse/no pulse in veins/arteries that are varicosed?
Varicose vein Tx is best with ?
Pulse= problem in vein
No pulse= problem in artery
Sclerotherapy
What is the most common vascular d/o
If vascular pain is better w/ walking then its ? where if it’s worse w/ walking then its ?
Chronic lower extremity venous dz
Better- vein
Worse- arteries
What can PTs w/ chronic venous insufficiency do to improve their Sxs?
What is pruritus in the LE indicative of?
Limb elevation
Walking
Chronic venous insufficiency
All PTs w/ chronic venous insufficiency/ulcers need to be on ? med
What causes lymphedema?
ASA
Primary: High protein content
Secondary: Filarisis (MC)
What is the only issue we’ve covered that has non-pitting edema?
What has to be avoided with this condition?
Lymphedema
Limb injury
What happens to untreated lymphedema?
What is Beurger’s Dz
Resistant to Tx due to subcutaneous fibrosis
Vascular Dz in chronic smoking involving both arteries and veins leading to foot claudication
Triad: ???
Thromboangitis obliterans
? heart murmur isn’t pathological in early life?
MOA of Gemfibrizil
Aortaenteric fisutal
Systolic
Activates lipoprotein lipase to increase VLDL clearance
MC seen on duodenum from AAA complication
What are the three processes leading to peripheral artery dz?
What causes plaque?
Structure changes
Lumen narrowing
Spasm
Tear, macrophages, foam cells
What is the time frame from arterial occlusion to surgical management?
What type of injury starts the peripheral artery disease etiology?
<6hrs or irreversible ischemia
Endothelial dysfunction
What PE finding would be seen if the popliteal artery is occluded 90%?
What questionnaire is used for peripheral artery disease screening?
Muscle atrophy
Ulcer
Edinburghs
What are the 6 Ps of PADzin order?
What is the time frame to correct it?
Pain Pallor Paresthesia Paralysis Poikilothermia Pulselessness
6hrs
Aortailiac occlusive dz
Common femoral artery
Butt hip thigh
Thigh and/or calf
Superficial femoral artery
Popliteal artery
Upper 2/3 calf
Lower 1/3 calf
What are the 4 acyanotic lesions?
What is the only type of ASD that does not have RAD?
ASD
PFO
VSD
PDA
Ostium primum- LAFB
What is the Dx test for ASD?
PTs w/ ASDs can’t do what recreational activity?
Echo- primary test for Dx
Bubble study
Scuba dive
Why do infants w/ VSD have failure to thrive?
If PT w/ VSD has a new diastolic murmur, what is it?
Large heart pressing on esophagus interferes w/ feeding
R to L shunt from increasing pulmonary pressure
