Cardio from Prep Book Flashcards
Name the NYHA classification: no limitation of physical activity, ordinary physical activity does not cause fatigue, dyspnea, or anginal pain
Class I
Name the NYHA classification: marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes symptoms
Class III
Name the NYHA classification: Slight limitation of physical activity, ordinary physical activity results in sx
II
Name the NYHA classification: Unable to engage in any physical activity w/o discomfort; sx may be present even at rest
IV
___________ may be related to reduced CO, paroxysmal cardiac dysrhythmias, low blood volume, meds, and various endocrine/metabolic disorders
Postural hypotension
Postural hypotension is > ______mmHg drop in SBP b/t supine and sitting and/or standing measurements
20
What can exacerbate HTN?
excessive ETOH, smoking, lack of exercise, polycythemia, NSAIDs, low K intake
What are causes of secondary HTN?
sleep apnea, estrogen, pheochromocytoma, coarctation of aorta, pseudotumor cerebri, parenchymal renal disease, renal artery stenosis, chronic steroid therapy, Cushing’s, thyroid/parathyroid disease, primary hyperaldosteronism, pregnancy
Stage 1 HTN
SBP 140-159
DBP 90-99
PreHTN
SBP 120-139
DBP 80-99
Stage 2 HTN
SBP >160
DBP >100
What is a hypertensive urgency?
reflects BP that must be reduced w/in hours; SBP>220, DBP >125
What is hypertensive emergency?
Reflects BP that must be reduced w/in 1 hour to prevent progression to end-organ damage or death; DBP >130; optic disc edema indicates end organ damage; complications include HTN encephalopathy, nephropathy, intracranial hemorrhage, aortic dissection, preeclampsia, eclampsia, pulmonary edema, unstable angina, MI
What is malignant HTN?
Elevated BP associated with papilledema and encephalopathy or nephropathy; if untreated, progressive renal failure occurs
End organ damage in untreated HTN
HF, RF, stroke, dementia, aortic dissection, atherosclerosis, retinal hemorrhage
What will EKG show for HTN?
LVH or HF; strain failure if poor prognosis
HTN Treatment
DASH diet, diuretics, Beta blockers, ACEI, ARB, CCB, Renin inhibitor
When should loop diuretics be used?
Only in those with renal dysfunction and when close electrolyte monitoring is assured
What is the initial HTN DOC for diabetics?
ACEI
What HTN drug is used for men with symptomatic prostatic hyperplasia?
alpha adrenergic antagonists
What is preferred agent to treat hypertensive urgencies or emergencies?
sodium nitroprusside
CHF results from changes in 1 of what 3 areas
contractile ability of heart muscle
preload and afterload of ventricle
heart rate
Characteristics of left sided heart failure
exertional dyspnea plus nonproductive cough, fatigue, orthopnea, paroxysmal noctural dyspnea, basilar rales, gallops, exercise intolerance
Characteristics of right sided heart failure
Distended neck veins, tender or nontender hepatic congestion, N, dependent pitting edema, hepatomegaly, edema
Cardiac PE signs of CHF
Parasternal lift, enlarged apical impulse, diminished first heart sound, S3 gallop
What is a common nightime sx of CHF?
nocturia
CXR of CHF
cardiomegaly and b/l or right sided pulmonary effusions, perivascular or interstitial edema (Kerley B lines), venous dilation, alveolar fluid
What lab may be elevated with heart failure?
BNP
Treatment of CHF
stress reduction, aerobic exercise, low sodium, diuretic
Initial therapy: thiazide (or loop diuretic) + ACEI
What is the most common cause of cardiac related death and disability?
Atherosclerotic heart disease
What is an important marker of atherosclerosis?
C-reactive protein
Treatment of atherosclerosis
Smoking cessation; exercise, dietary modifications, treatment of dyslipidemias
What is the usual cause of ischemic heart disease?
atherosclerotic narrowing
Risk factors of ishemic heart disease
male, age, low estrogen, smoking, Fhx, HTN, DM, abdominal obesity, inactivity, dyslipidemias, increase ETOH, low intake of fruits/veggies
What is stable angina?
exacerbated by physical activity and is relieved by rest
What is variant angina (or Prinzmetal’s)?
Vasospasm at rest, with preservation of exercise capacity
What is unstable angina?
Increasing pattern of pain in previously stable patients. Less responsive to meds, lasts longer, occurs at rest or with less exertion
What is it called when a patient has a clenched fist over their sternum and clenched teeth when describing chest pain? Seen in ischemia patients
Levine’s sign
If angina pectoris lasts longer than 30 minutes what does it suggest?
unstable angina, MI, or another dx
_______ is relieved by sublingual or spray nitroglycerin
Acute Anginal attacks
During an exercise test, an ST segment depression of 1mm is considered a positive test for what?
ischemic heart disease
What is first line therapy for chronic angina?
Beta blockers
Conditions classified simply as ST-elevated or non-ST elevated events rather than unstable angina, q-wave infarction, or non-q wave infarction
ACS
Causes of MI
prolonged myocardial ischemia, prolonged vasospasm, reduced myocardial blood flow, excessive metabolic demand, embolic occlusion, vasculitis, aortitis, coronary artery dissection, cocaine use
Who are more likely to present atypically with MI?
Elderly, women, diabetics
Patient develops increasingly severe, prolonged (>30min) anterior CP at rest, usually during early morning hours
MI
Other common symptoms of MI
diaphoresis, weakness, anxiety, restlessness, light-headedness, syncope, cough, dyspnea, orthopnea, N/V, abdominal bloating
What is Dressler’s syndrome? (post-Mi syndrome)
pericarditis, fever, leukocytosis, pericardial or pleural effusion; usually 1-2 weeks post-MI
What serial cardiac enzymes are elevated in MI?
creatine kinase, troponin T, and troponin I
MRI with gadolinium contrast is one of the most sensitive tests to quantify the extent of _______
infarction
What should all patients with suspected ACS receive?
IV fluids, oxygen, nitroglycerin, pain management
If a patient with ACS WITHOUT STEMI what should they get?
antiplatelets (ASA and clopidrogel);
Anticoagulant (heparin, enoxaparin, fondoparinux, bivalriduin)
What is the drug that is started in most patients with ACS?
Beta Blockers
Patients with ACS and acute STEMI tx
ASA and clopidrogel = immediately; Within 90 minutes, coronary angiography, primary PCI; Within 3 hours, thrombolytic therapy (alteplase, reteplase, tenecteplase)
What are absolute C/I to thrombolytic therapy?
previous hemorrhagic stroke, any stroke in last year, known intracranial neoplasm, active internal bleeding, suspected aortic dissection
_____ types of congential heart anomalies are R–> L shunt
Cyanotic (Tetralogy of Fallot, Pulmonary atresia, hypoplastic left heart syndrome, transposition of great vessels)
_____ types of congential heart anomalies are L–> R shunt
Noncyanotic (ASD, VSD, AV septal defect, PDA, Coarctation of aorta)
Occurs with an intact ventricular septum; pulmonary valve is closed; an open atrial septal opening and PDA are present
Pulmonary atresia
Subaortic septal defect, right ventricular outflow obstruction, overriding aorta, right ventricular hypertrophy
Tetralogy of Fallot
What is the most common ASD?
ostium secundum
Due to incomplete fusion of endocardial cushions; common in Down syndrome
AV septal defect
Failure to close or delay in closure of the channel bypassing the lungs, which allows placental gas exchange during the fetal state
PDA
What are the most frequent causes of mitral and aortic valve disorders
congenital defects
What are the common sx’s of valvular disorders?
Dyspnea, fatigue, decreased exercise tolerance
Thin females with minor chest wall deformities, midsystolic clicks, late systolic murmur
mitral valve prolapse
Is ECG useful in diagnosing valvular disorders?
No
Murmur heard in 2nd-4th left intercostal space; radiates to apex and RSB; Grade 1-3; High pitch, blowing; Better heard when patient sits and leans forward on full exhalation; murmur is systolic and diastolic decrescendo
Aortic regurg
Murmur heard at apex with little or no radiation; Grade 1-4; Low pitch; Can be heard better in left lateral position on full exhalation; S1 accentuated; opening snap follows S2; Mid-diastolic
Mitral Stenosis
Murmur heard at apex that radiates to left axilla; murmur is soft to loud and is medium to high pitch; blowing; S2 often decreased; Pansystolic
Mitral Regurg
Murmur found in 2nd Right intercostal space that radiates to neck and LSB; It is loud with a THRILL; Medium pitch and harsh; Can be heard better if patient is sitting and leaning forward; Midsystolic
Aortic Stenosis
With aortic valve disorders, CXR may show?
left sided atrial enlargement, ventricular hypertrophy
With mitral valve disorders, CXR may show?
atrial enlargement
What are the only definitive methods for identifying structural and functional abnormalities of the heart?
Echocardiography, cardiac catheterization
In all cases of tricuspid and pulmonic valve disorders, right sided pressure overload leads to ?
right-sided cardiomegaly, systemic venous congestion, right-sided heart failure
How do patients with tricuspid and pulmonic valve disorders typically present?
Exercise intolerance
How to treat tricuspid and pulmonic valve disorders ?
Sodium restrction and diuretics to decrease fluid volume and right atrial filling pressures
Murmur at LLSB that is holosystolic and radiating to right sternum and xiphoid area; Variable intensity; Pitch/Quality is medium and blowing; Increases slightly with inspiration; JVP often elevated; Pansystolic
Tricuspid regurg
Pulmonic Stenosis Murmur: Location Radiation Intensity Pitch/Quality Associated findings Timing
Heard: 2-3rd left intercostal space, midsystolic crescendo-decrescendo murmur; Radiations to left shoulder and neck; Intensity soft to loud; Pitch/Quality: Medium/harsh; Early pulmonic ejection sound common; Timing: systolic
What are risk factors for developing an arrhythmia?
electrolyte abnormalities, hormonal imbalances, hypoxia, drug effects, MI
Heart Rate <60bpm; normal in athletes, usually represents SA node pathology, increased risk for ectopic rhythms
Sinus Bradycardia
HR >100bpm occurs with fever, exercise, pain, emotion, shock, thyrotoxicosis, anemia, HF, use of many drugs
Sinus Tachycardia
What is the most common paroxysmal tachycardia?
Paroxysmal supraventricular tachycardia
What class of antiarrhythmic drug includes beta blockers that slow AV conduction?; esmolol, propranolol, metoprolol
Class II
What class of antiarrhythmic drug includes drugs that slow calcium channel blockers?; verapamil, diltiazem
Class IV
Digoxin and Adenosine are in what class?
Class V
This drug slows the conduction time through the AV node and interrupts reentry pathways
Adenosine
This drug directs action on cardiac muscles and indirect action on cardiovascular system via ANS
Digoxin
What class of antiarrhythmics prolongs action potential?; amiodarone, sotalol, dofetilide, ibutilide
Class III
What class of antiarrhythmics blocks sodium channels? They also depress phase 0 depolarization, slow conduction, and prolong repolarization. Quinidine, procainamide, disopyramide, moricizine
Class Ia
What class of antiarrhythmics shortens depolarization?; lidocaine, mexiletine
Class IIB
What class of antiarrhythmics depress phase 0 repolarization and slows conduction?; flecainide, propafenone
Class Ic
What is the most common chronic arrhythmia?
A fib
Who does A flutter typically occur in?
COPD, CHF, ASD, CAD
What mechanical measures can be used to interrupt acute PSVT?
Valsalva maneuver, coughing, breath holding, stretching, putting head b/t knees, applying cold water to face, U/L carotid sinus massage
What is treatment of choice for chronic A flutter?
amiodarone, dofetilide
Three or more consecutive ventricular premature beats
V tach
What is Brugada’s syndrome?
Syncope, v fib, sudden death common in Asians and men
What is preferred pharmacologic interventions for acute V tach?
lidocaine, procainamide, amiodarone
When is implantable defibrillator indicated?
Chronic recurrent sustained V tach w/o reversible causes, congenital long QT syndrome, Brugada’s syndrome
Often occurs in elderly; usually asymptomatic, but may have syncope, dizziness, confusion, heart failure, palpitations, angina; can be exacerbated by digitalis, CCB, BB, sympatholytic agents, antiarrhythmic drugs
Sick Sinus syndrome
How do you treat sick sinus syndrome?
permanent pacing
What are the most common type of cardiomyopathy?
Dilated cardiomyopathy
What are causes of dilated cardiomyopathy?
genetic abnormalities, excessive ETOH, postpartum state, chemo toxicity, endocrinopathies, myocarditis
What is Takotsubo cardiomyopathy?
Occurs after major catecholamine discharge and is an apical left ventricular ballooning with sx indistinguishable from acute MI
Results from fibrosis or infiltration of ventricular wall b/c of collagen-defect disease, most commonly amyloidosis, radiation, postop changes, diabetes, endomyocardial fibrossi
Restrictive cardiomyopathy
Dilated cardiomyopathy sx/PE
Left or biventricular congestive failure; most common presentation is dyspnea; S3 gallop, rales, increased JVP
Hypertrophic cardiomyopathy s/sx
Dyspnea and angina; syncope and arrhythmias; sudden death may be initial presentation
Hypertrophic cardiomyopathy PE
sustained PMI, loud S4 gallop, variable systolic murmur, bisferiens carotid pulse, JVP with prominent “a” wave
Restrictive cardiomyopathy s/sx
Decreased exercise tolerance; in advanced dz: right sided congestive failure; pulmonary HTN
Tx of dilated cardiomyopathies
Abstinence of ETOH, underlying disease tx
Tx of hypertrophic cardiomyopathies
BB or CCB; surgical or nonsurgical ablation of hypertrophic septum possibly; dual chamber pacing, implantable defibrillators, mitral valve replacement may be indicated
What may help pts with restrictive cardiomyopathies?
Diuretics
Occurs as result of infx, autoimmune or connective tissue disease, neoplasms, RT, chemo, cardiac surgery, myxedema, TB
Pericarditis
Cardiac tamponade occurs when _____ compromises cardiac filling and impairs CO
Fluid
What is primary presenting sx of acute pericarditis?
pleuritic substernal radiating CP relieved by sitting upright and leaning forward; friction rub characteristic
Presents with slowly progressive dyspnea, fatigue, weakness, edema, hepatomegaly, ascites
Constrictive pericarditis
Presents with tachycardia, tachypnea, narrow pulse pressure, pulsus paradoxus
Cardiac tamponade
What organisms typically cause infective endocarditis?
Staph. aureus (most common in IV drug users), Group D strep, enterococci, HACEK organisms
Presentation of infective endocarditis
Fever, nonspecific sx (cough, dyspnea, arthralgias, back/flank pain, GI complaints); stable murmur
What classic features of infective endocarditis occurs in 25%?
Palatal, conjunctival, subungual petechiae, splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots
How do you diagnose infective endocarditis?
3 sets of blood cultures at least 1 hour apart preferable before starting ABX
CXR on infective endocarditis
underlying cardiac abnormality or reveal pulmonary infiltrates if right side of heart is involved
_______ criteria are used to establish DX of infective endocarditis
Duke criteria
What is the common ABX for infective endocarditis?
Vancomycin + ceftriaxone
A systemic immune response occuring usually 2-3 weeks following a Beta hemolytic strep pharyngitis infection
Rheumatic fever
_______ criteria are used to establish DX of rheumatic fever
Jones (Need 2 major or 1 major and 1 minor)
What are the major Jones criteria for RF?
Carditis, erythema marginatum, subQ nodules, chorea, polyarthritis
What are minor Jones criteria for RF?
Fever, polyarthralgias, reversible prolongation of PR interval, rapid ESR, C-reactive protein
Common age range of RF
5-15y/o
What valve is most affected in RF?
Mitral
Recommended tx of RF
Strict bed rest, salicylates, corticosteroids, IM penicillin for strep infix, prevention (early tx of strep pharyngitis)
Lower leg pain with exercise (relieved by rest), weak or absent femoral/distal pulses; possible aortic, iliac, femoral bruit; if severe: numbness, tingling, ischemic ulcers (leads to gangrene);
PAD
What is Leriche’s syndrome?
ED when PAD in iliac artery disease
In PAD, extremity occlusion results in the 6 Ps. What are they?
pain, pallor, pulselessness, paresthesias, poikilothermia, paralysis
An ABI of <____ indicates significant PAD
0.9
What is main drug tx of PAD?
Cilostazol
What are nonpharmacologic tx of PAD?
Stop smoking; progressive exercise
Risk factors of Varicose veins
Pregnancy, Fhx, prolonged sitting/standing, hx of phlebitis
What test differentiates saphenofemoral valve incompetence from perforator vein incompetence?
Brodie-Trendelenburg
Are lab studies necessary for varicose veins?
No
Tx of varicose veins
Graduated elastic stockings, leg elevation and exercise for sx, endovenous radiofrequency or laser ablation, compression sclerotherapy, surgical stripping
Partial or complete occlusion of vein and inflammatory changes
Thrombophlebitis
Virchow’s triad
stasis, vascular injury, hypercoagulability
Presents with dull pain, erythema, tenderness, induration of involved vein or with no sx; common in long saphenous vein; palpable cord
Superficial thrombophlebitis
Preferred study for DVT
Duplex US
What is most accurate method for definitive diagnosis of DVT?
venography
What is preferred pharmacologic tx of DVT?
LMWH; heparin followed by warfarin
Loss of wall tension in veins which results in stasis of venous blood and is associated with hx of DVT, leg injury, or varicose veins
Chronic venous insufficiency
Sx of chronic venous insufficiency
progressive edema starting at the ankle followed by skin and subQ changes; itching, dull pain w/ standing and pain with ulceration is common; skin is shiny,thin, atrophic with dark pigment changes and subQ induration
Stasis dermatitis tx
wet compresses, hydrocortisone cream; chronic dermatititis add zinc oxide with ichthammol and an antifungal cream
Causes of aortic aneurysm
Atherosclerosis (#1); syphillis, giant cell arteritis, vasculitis, trauma, Marfan’s syndrome, Ehlers-Danlos syndrome
Classic person with aortic aneurysm
Elderly male smoke with CAD, emphysema, renal impairment
Thoracic aortic aneurysms presentation
Substernal, back, neck pain; dyspnea, stridor, cough, dysphagia, hoarseness, sx of superior vena cava syndrome
Study of choice for abdominal aneurysms
abdominal US, followed by contrast enhanced CT
Tx for Aortic aneurysm
endovascular or open surgical repair
What are 2 impt features of aortic dissection?
unequal blood pressure between arms; widened mediastinum on CXR
Q waves in 2 or more leads means?
previous MI
ST depression >1mm means?
ischemia
ST elevation means?
acute MI or pericarditis (which will show involvement in all leads and PR depression)
LBBB means
suggests underlying heart disease (ischemia, HTN)
RBBB means
may indicate right heart strain (as in pulmonary embolus)
Substernal pressure, heaviness, burning, squeezing, or choking; rarely well localized
angina pectoris
Xanthomas may appear in what?
hyperlipidemia (fat build up under skin)
The __________ prediction model tallies point for the major known cardiac risk factors: age, gender, diabetes, smoking, LDL, HDL, BP
Framingham
When should you stop an exercise stress test?
Moderate to severe CP or dyspnea, dizziness, greater than 2mm ST segment depression, fall in SBP of >10mmHg (seen in ischemia), sustained ventricular tachycardia
What are causes of false ST depressions?
LBBB, LVH, WPW, digoxin use
Gold standard of diagnosing coronary artery disease
Coronary angiography
Treatment of Stable Angina (Acronym: ABCDE)
A: ASA, ACEI, antianginals B: BB and BP C: cholesterol and cigarettes D: diet and diabetes E: Education and exercise
Patients with CHD should have LDL of _______
<90
Are pathologic Q waves present in NSTEMI?
No
The evolution of the ECG during a STEMI
- T wave increases in amplitude (several minutes after vessel occlusion)
- ST-segment elevation (minutes to hours)
- Development of Q waves (hours to days)
- Resolution of ST segment elevation (hours to days)
What is Wellen’s sign?
deep inverted T waves in leads V1-V4 associated with severe disease in left anterior descending artery
TIMI Risk Score (7 point system for evaluating UA or NSTEMI) components
Age >65
At least 3 risk factors for coronary artery disease
Known coronary artery disease with at least 50% coronary stenosis
ST segment changes
At least 2 episodes of angina in past 24 hours
ASA used in past week
Elevated CK-MB or troponin
