CARDIO HIGH NOTES BLOCK I Flashcards
What are the cardinal S/s of CVD
Dyspnea Pain Syncope Edema Palpitations Fatigue Claudication Fatigue
What does Vindicates stand for
Vascular Infection Neoplastic Drugs/ Degenerative Inflammatory/ Idiopathic Congenital Autoimmune Trauma Endocrine/ Enviromental Something else/ Psychological
What is the earliest and most common S/s of HDz
Dyspnea
Think ischemia, HF, Arrhythmia
How does classic cardiac chest pain present
Angina, retrosteranal left anterior “crushing” chest pain w/ squeezing, tightness, or pressure.
What is Diamond Criteria
Substernal pain
Worse with exertion
relieved by NG
3/3= typical 2/3= Atypical 0-1/3= Non Anginal
What does OMI MONA BASH C
O2, MONITOR, IV
Morphine, O2, NTG, Aspirin
Beta Blockers, ACE, Statin, Heparin
Clopidogrel
How does Claudication present
Pain, burning feelings, in the legs or buttocks when walking
Shiny Hairless blotch foot skin that may get sores
Leg is pale when raised and red when lowered
Impotence in men
Leg pain at night
What are MAjor ASCVD events
Recent ACS within 12 months History of MI He of Ischemic Stroke Symptomatic PVD Claudication is ABI < 0,85 Previous revascularization or amputation
What are the Risk Fx for HDz
Age > 65 yrs Familial High cholesterol Prior Bypass or PCI DM HTN CKD ( GFR 15-59) Smocking LDL-C above 100 despite statins
How does acute pericarditis present on EKG
Diffuse ST elevations with PR depressions in majority of leads
AVR has PR elevation and ST depression
Sympathetic nerves innervate which parts of the heart
Sa Node
Atria
AV node
And Ventricles
Parasympathetic nerves innervate which parts of the heart
Sa node
Atria
AV node
NO innervation of the Ventricles
What is the major determinant force of cardiac contraction
Concentration of Calcium within the cytosol
How do calcium flucutaions effect cardiac contraction
Mechanisms that raise intracellular Ca++ concentration enhance force development, whereas factors that lower Ca++ concentration reduce the contractile force.
Absent X waves correspond to..
Tricuspid regurgitation
Prominent V waves correspond to …
Severe Tricuspid regurgitation
Prominent Y descent waves relate to..
Constrictive pericarditis, or restrictive cardiomyopathy
Tricuspid regurgitations
Or ASD
Blunted Y descent waves relate to
Cardiac Tamp.
RV ischemia
Or Tricuspid stenosis
What is Kussmals sign
Kussmaul’s Sign:
Physical exam finding
-Ordinarily the JVP falls with inspiration due to reduced pressure in the expanding thoracic cavity.
- Kussmaul’s sign is the observation of a JVP that rises with inspiration.
- The differential diagnosis generally associated with Kussmaul sign is constrictive pericarditis, as well as with restrictive cardiomyopathy
What is hepato-jugular reflex
Physical exam technique by which the JVP is observed while pressure is firmly applied to the right upper quadrant, primarily used in patients with subacute right-sided heart failure and/or passive hepatic congestion
High JVP means..
Right heart HF, Tricuspid Regurgitation
Tamp.
Low JVP Means
Dehydration Bleeding out ( Hypovolemic)
Prominent A waves mean
RVH or tricuspid stenosis
Prominent v waves mean
Tricuspid Regurgitation
Prominent y waves mean
Constrictive pericarditis
What are the fundamental contractile units of the heart
Myocardial cells containing myofibirls made of sarcomeres
What does valvular regurgitation lead to
Volume overload
What does vulvular stenosis lead to
Pressure overload
Murmurs: Harsh/ rumble sound think ..
Stenosis
Murmurs: blowing sound think…
Regurgitation
What is the s1 sound
Normal closure of the MITRAL and TRICUSPID valves
What is the s2 sound
NML closure of the AORTIC and PULMONIC valves
Which heart sound is in sync with the carotid pulse
S1
What heart sound is the onset of systole
S1
What three things can cause S1 to be louder
Shortened PR interval
Mild Mitral Stenosis
High Cardiac output states
(Excercise or Tachy HR)
What can cause diminished S1 sounds
AV blocks
Mitral regurgitation
Severe Mitral stenosis
Stiff left ventricle
What sound is at the onset of Diastole
S2
What are two common causes of widened split of S2
RBBB and Pulm stenosis
What is the cause of S2 splitting
ASD
What two things cause Paradoxical splitting of S2
LBBB and Aortic stenosis
When does S3 occur and why does it occur
During Diastole
( ventricular gallop)
Can be NML in children
in adults in indicated volume overload ( CHF or mitral/ tricuspid regurgitation)
When is S4 heard and what does it mean
Late in diastole, atria contracting against a stiff non compliant ventricle
“Atrial gallop”
Means pressure overload
Heard best in L Lat Decubitus
Associated most with HTN
Physiological Split of s2 is accentuated how
During inspiration
Paradoxical splitting of S2 is accentuated how
audible separation of A2and P2duringexpirationthat fuses into a single sound oninspiration, the opposite of the normal situation.
What is the most common cause of paradoxical splitting of S2
LBBB
What is the 1st step for a patient with Dyspnea or Chest pain
O2
Monitor
IV
What is the most common cause of R HF
L HF
How does anemia effect HR and BP
Increases both HR and BP
Clubbing of the nail is a sign of
HF, Chronic Lung Dz or Liver Dz
What is pulse pressure and what is considered NML
Systolic - diastolic
40 is NML
Increased Pulse pressures indicate
Aortic regurgitation
Or increases in SV or Inotropy
Narrow pulse pressures indicate
Hypovolemia, severe LVF or mitral stenosis
What Dz is associated with Pulsus tardus
Aortic Stenosis
Pulsus bisferiens is associated with what Dz
Aortic Regurgitation
And HOCM
What Dz is associated with Pulsus altérnans
Severe HF
What Dz is associated with Pulsus paradoxus
Cardiac Tamp SVC obstruction Pulm Obstruction ( COPD, PE)
Hyperkinetic pulses are associated with what Dz
High output states ( PDA, Thryotoxicosis, anemia, fever)
“High volume, bounding pulse”
Hypokinetic pulses are associated with what Dz
Low output states ( SHOCK)
Abnormal exaggeration (>10 mm Hg) of the normal decrease in systolic blood pressure during inspiration is called and indiactes what
Pulsus Paradoxus
Seen in cardiac tamponade, constrictive pericarditis, restrictive cardiomyopathy, hypotensive shock, severe obstructive pulmonary disease, large pulmonary embolism
A thrill corresponds to what grade murmur
Grade IV to VI
Heaves or Lifts indicate
HF
What three things cause Early Sys Ejection murmur
AS, PS, and Pulm HTN
What causes a mid systolic ejection sound
Mitral valve prolapse
OS is
MS
Mitral Stenosis is best heard in what position
Left Lateral Recumbent
What tumor sounds like mitral stenosis
Left Atrial Myxoma
What does a pericardial knock mean
Severe constrictive pericarditis
Where does Aortic stenosis radiate to
The neck
Where does aortic stenosis radiate to
Axilla
What are the three holosystolic murmurs
VSD, Tricuspid and Mitral regurgitation
Increase in venous return (squatting) increases the sound of all murmurs except which two
HOCM and Mitral valve Prolapse
Increasing after load (hand grip) accentuates which murmurs
AR, MR, and VSD
Hand grip ( increasing after load) diminishes which murmurs
AS MS MVP and HOCM
What effect does Amy NItrate have on Murmurs
Increases Stenotic murmurs and decreases regurgitation murmurs
In the role of Cardiac, what is NSAIDs used for
Pericarditis
What is the PET scan used for
Profusion and myocardial viability
What is the MUGA (SPECT) used for
Assessment of Left Vent function
assesses myocardial perfusion, Left Ventricular ejection fraction, and regional wall motion by injected technetium-99m-labeled red blood cells (i.e., Sestamibi or other labeled 99mTc agents)
What is the medication for pharm stress testing
Regadenoson
What is the injection used during PET to detect profusion
Positively charged rubidium- 82 or nitrogen 13
What is the injection used in PET to asses myocardial viability
Positively charged fluorine-18-2-deoxyglucose
What is the 1st non invasive rhythm assessment ordered in pts with frequent daily S/s like palpaciones or unexplained syncope
Holter Monitor
What are the postive findings in a cardiac stress test
Ischemic ECG findings within 3 minutes of exercise or persist 5 min after stopping exercise
ST Depression > 2mm
Systolic pressure decreases during exercise
high grade ventricular arrhythmias develop
Pt unable to exercise for at least 2 min because of cardiopulmonary limitations
Where would tricuspid regurgitation radiate to
right side of the chest
Aortic and Pulm regurgitation are best heard where
At Erbs point
Diastolic Murmurs
What systolic murmur is heard at erbs point
HOCM murmur
Which grade murmurs will have a thrill
Grades IV and above
What murmur is classically a decrescendo murmu
Early Diastolic murmur of aortic regurgitation
What murmur is classically a Crescendo-decrescendo “diamond shaped” murmur
Aortic Stenosis
Where are stills murmurs heard and what do they indicate
Best heard w/ the bell at the L lower sternal border as a crescendo-decrescendo sound in adolescent pts
No therapy is needed as it is not pathological
Indicates increase cardiac output or inotropy in children
What happens to stills murmurs when the pt is upright
Less preload and flow when upright causes the murmur to disappear
What distinguishes VSD murmur from Tricupsid or mitral regurgitation
It does not increases with inspiration or radiate to the axial
Is head at the tricuspid area/ LLSB
When is Aortic regurgitation best heard vs Pulm regurgitation
Leaning forward and exhaling for aortic
Leaning forward and inhaling
Where are Austin flint murmurs best heard
Associated with severe aortic regurgitation and best heard at the 5th ICS Midclavicular line
Constant boring pain in the chest indicates..
Esophageal rupture or pericarditis
Does PE present with a fever
YES
What is the most common presentation for a pt with PE
Tachycardia, sudden onset of Dyspnea
Hearing murmurs at the aortic area should make you think of
Aortic problems./ dissection or MI
Tachycardia with non specific ST changes, Sometime Right Heart strain sign indiactes
PE, sometime S1Q3T3 as well
Right axis deviation is a hint to
Right heart problems like PE
Diffuse ST elevations with PR depression indicates
Pericarditis
For low risk PE order=
High risk=
Low risk D Dimer ‘
High risk Contrast CT
What is the causative agent for Rheumatic fever
Strep A pharyngitis
What is jones Criteria for Rheumatic Fever
Migratory poly arthritis Pancarditis SubQQ nodules Erythema marginatum Sydenham chorea
Rheumatic fever occurs most in what age pts
5-15 years old
What is the Tx approach to Rheumatic fever
Anti-inflammatory medication
Prophylaxis with PCN
What is the Dx criteria for Rheumatic fever with Jones Criteria
2 Major or 1 major 2 minor
MAJOR- J: Joints O: Carditis/ Murmur N: Nodules E: Erthyema marginatum S: Sydenham chorea
Minor- Arthlagias w/out arthritis Fever 101 to 104 Elevated ESR or CRP Prolonged PR Intervals Rapid Strep
What valves are most effected by Rheumatic Fever/ Rhematic HDz
Mitral valve stenosis in number 1
Aortic Valve Dz is second
What is the 5 step clinical approach
Determine anatomy Understand impact of medical history Form DDx Sick Vs non sick triage Life threats 1st
What is the equivalent to angina in the legs
Claudication
What does Vindicates stand for
Vascular Infectious Neoplastic Drugs/ Degenerative Inflammatory/ idiopathic Congenital Autoimmune Trauma Endocrine/ Environmental Something Else/ Psychological
Administration of O2 should start at an SPO2 of ____
94 or below
Start with NC 2-4 L/ Titrate to 99 %
What effect does increasing the HOB angle do to preload (Orthopnea)
Elevation decreases preload and s/s of heart failure
Pts with pericarditis can find relief in what anatomical position
Sitting up and leaning forward , as a pt with with ACS will not find relief by doing this
What is the IV morphine regiment for UA/ STEMI
2-4 mg IV PRN, may repeat dose of 2-8 mg q 5-15 min Intervals
What is the nitro dose for UA/ STEMI
0.3-0.6 sublingual q5min PRN
Max 3 doses witching 15 min
What are the cardinal S/s of ACS
Chest pain Dyspnea Palpitations Syncope Edema
Non pitting edema is a a sign of
Lymphedema
A pt with a shiny hairless blotchy skin on the foot or leg, and the leg is pale when elevated and red when lowered is a sign of
Claudication, Vasucalar Dz
what is the greatest modifiable risk factor for ACS/ HDz
Smoking
What is metabolic syndrome
HTN medication or HTN Hypertryglyceridema HDL less than 50 Fasting Glucose greater than 100 (DM) Fat Waist
What are the age cut off numbers for traditional RSK factors for CAD
Men 45 women 55
First degree relative at 55 for men
And 65 for women
How should you interpret the following CAC scores
CAC=O
CAC 1-99
CAC 100 or over
O= Decrease RSK of CVD, no statin required
1-99= favors statin, especially if older than 55
100= Statin therapy required
What is the alarm number for a CRP in CVD
Greater than 2 mg/L
What lipoprotein A number is alarming for CVD
Greater than 50 with a FMHx
Normal value is 10mg/dl
How is ApoF testing conducted and what is the alarm value
Testing is reserved for pts with High Triglycerides >200 mg/dl
Alarm= > 130 mg/L
A ApoB of 130 = a LDL of…
Greater than 160 ( RSK for CVD)
An ABI of less than 0.9 indicates
Occlusive arterial Dz
Low QRS volatage, Friction Rub, Becks triad, and pulsus paradoxus are all signs of..
Pericardial effusion
What nerves modulate electrical impulses and conduction to the SA and AV nodes
VAgal efferent fibers
The SNS inervates the heart via what receptors
B1
JVP waveforms reflect pressure in what cardiac structure
Right atrium
How are a waves in AFIB
Absent
JVP that increases with inspiration is called what and indicates?
Kussmal sign, indicates; Pericarditits or restrictive cardiomyopathy’s
What is the S1 sound
NML closure of the Mitral and tricuspid Valves ( AV valves)
What is the S2 sound
NML closure of the Aoritc and Pukmonic valves ( semilunar valves)
Ejection Clicks indicate
Aortic or pulm stenosis, or dilation of the aortic root or plan artery
Mid to late clicks indicate
Mitral or Tricuspid valve prolapses
Openings snap is
Mitral stenosis
IN adults what does the low pitch S3 sound indicate
HF or Volume overload
What does the low pitched S4 sound indicate
Reduced Vent Compliance
What 2 conditions cause a wide split of S2
RBBBB and Pulm Stenosis
What causes a Fixed S2 split
ASD
What causes a paradoxical splitting of S2
LBBB or Aortic Stenosis
Is S3 a diastolic or Systolic sound
Diastolic, its rapid filling of the ventricles
What position is S4 best heard in
Left lateral decub
Chronic HTN leads to what pathological heart sound
S4 ( atrial gallop)
What is the primary means of establishing a specific Dx
Physical examination
What is the normal pulse pressure
40 mmHG ( Sys-Dias)
Pulses should Always be examined for what 5 criteria
Rate Rhythm Strength Contour Symmetry
The diacritic notch correlates to what valve closing
The aortic valve
A slow rising pulse, aka pulsus tardus indicates what Dz
Aortic Stenosis
A bi or triffid pulse ( Pulsus Bisferines) incidactes what Dz
Severe Heart Failure
Pulsus paradoxus (change in pulse pressure/amplitude with inspiration) indicates what Dz
Cardiac Tamp SVC Obstruction Pulm Obstruction ( PE/ COPD)
Hyperkinetic pulses indicate what Dz
PDA, Thyrotoxicosis, Anemia, fever
How does the apical pulse differentiate with Volume Overload vs pressure overload
Volume: Hyperdynamic Apical pulse (S3)
Pressure: Sustained Apical pulse (S4)
Pericardial Knock indicated what Dz
Constrictive pericarditis
Where does the VSD murmur radiate to and what causes it to increase or decrease
Murmur intensity does not increase with inspiration or radiate to the axilla, which distinguishes it from tricuspid and mitral regurgitation, respectively.
Non specific ST changes, w/ Right axis deviation should think..
PE
What does HEART stand for in the HEART score
History ECG AGE RSK Fxs Troponins
What are the primary indications for CT in Cardiac PTs
1) aortic aneurysm or dissection suspected and 2) differentiating diseases of the pericardium
What are electron beam CRT scanners main use
To evaluate pericardial Dz and Cardiac tumors
Metallosis, amyloidosis, and sarcoidosis are best seen with what kind of imaging study?
MRI
Are Marfans pt would best benefit from what kind of cardiac imagining
MRI
What are the indications for Echocardiograms
Valvular lesions, Ventricualr assessment
CAD
Cardiomyopathy
Pericardial Dz
What is the bubble study
simultaneous venous saline agitation in order to identify an intracardiac shunt in a TTE
What are the absolute contras to stress tests
Recent STEMI < 2 days
High risk ACS ( perform coronary angiogram)
Active Heart Failure (decompensated)
Active endocarditis
Severe Aortic Stenosis, Symptomatic HOCM
Acute myocarditis or pericarditis
Physical disability that precludes safe and adequate testing
What is the Duke Treadmill criteria
Duke Treadmill Score = Minutes of Exercise (Bruce protocol) - (5xmax ST deviation in mm)-(4xexercise angina)
What is Regadenoson
An adenosine receptor agonist used in the SPECT scan , (VASODILATOR)
What probability of CAD is a pt with typical angina (male over 40 or female over 60)
W/ DM, smoker, or hyperlipidemia
HIGH RISK take straight to catch lab or admit
What probability of CAD is a pt with typical angina ( younger than 40 male or 60 female)
Intermediate risk, Order a stress test
Reliable stress test results require that the pt reach what level of the predicted maximum HR
85 percent
How do you calculate a duke treadmill score
Minutes of exercise- (5x max ST deviation in mm)- (4x exercise angina)
What are the markedly postive findings of a cardiac stress test
Ischemic ECG findings within 3 minutes of exercise or persist 5 min after stopping exercise
ST Depression > 2mm
Systolic pressure decreases during exercise
high grade ventricular arrhythmias develop
Pt unable to exercise for at least 2 min because of cardiopulmonary limitations
What are the 5 major Jones Criteria for Rheumatic Fever
Migratory Poly Arthritis Pancarditis SubQ nodules Erthyema marginatum Sydenham chorea
What does the JONES neumoníc stand for
Joint ( migratory) O- Carditis N- nodules E- Erthyema marginatum S- Sydenham Chorea
What is the causative agent of Rhematic Fever
Group A strep including pharyngitis assoc w/ scarlet fever
Rheumatic fever leads to Rhuematic HDz which effects which valves the most
Mitral VAlve the most
Second is Aoritc Vavle
What does the HEARTFAILED neuronic stand for
Hypertension Endocarditis Anemia Rheumatic Heart Thyrotoxicosis Failure to take meds Arrhythmia Infection/ Ishcemia/ infarct Lung Problems Endocrine Dietary indiscretion
A pt with Progressive Dyspnea on exertion and hemoptysis likely has what valvular heart Dz
Mitral stenosis
On palpitations of the pericordium, a Right ventricular heave suggests
Mitral stenosis
A patient with Severe MS ( MVA< 1.5 cm) symptomatic stage D a pliable valve, no clots, and a <2+ MR are candidates for what Tx of Rhumenatic Heart MS
Percutaneous Mitral balloon
Commissurotomy
IF they have severe HF symptoms and are a surgical candidate then they get MV surgery
What is the TX approach for a pt with VHD and Afib
IF the have Rhematic MS then Long term Vitmain K antagonist ( HEPARIN)
A PT that presents with a new murmur and fever you should suspect
Endocarditis
Also may present with Janeway lesions
Non infective endocarditis can be caused by..
Non bacterial thrombi
Systemic Lupus
Pancreatic adenocarcinoma
How are Oslers Nodes different than Janeway lesions
Oslers nodes are painful and caused bu bacterial AG-Ab complexes
Janeways are non tender and caused by thrombic emboli
What is the criteria to Dx endocarditis
2 major Dukes
1 major and 3 minor dukes
Or 5 minor dukes criteria
What are the major dukes criteria
Blood cultures (positive) Echocardiogram
What are the 5 minor Dukes criteria for endocarditis
Cardiac lesion/ PHx of IV drug use
Fever
Evidence of septic emboli
( Janeway lesions, Pulm Infarcts, Conjunctival Hemorrhages)
Auto immune conditions
(Glomerulonephritis, Oslers nodes, Roths spots, Rhuematoid)
Serological evidence
When inspecting for endocarditis ( valvular) when would you go straight to TEE
In pts with prosthesis valves, implantable cardiac devices, prior valve ABNMLS, obese or have chest wall deformities
What is the most common affected valves of endocarditis
Mitral (most) or bicuspid aortic valves
In a pt with endocarditis and IV drug use what is the most common effected valve
Tricuspid
In a pt with Endocarditis caused by Viridians strep or Strep Sanguiins what is the most likely causes (dental procedures)
Older pts with native valve dz develop endocarditis after dental procedures
Endocarditis from Staph Epi effects what valves the most
Prosthetic valves ( Dirty IV)
Endocarditis from genital urinary catheretiers is caused by what agent
Group D Enerococcal Endocarditis
Pseudomonas/ Candida (IV drug use) effects what valves most during endocarditis
Tricuspid Valves
Patients with Q fever and endocarditis most likely got it from what
Coxiella Burnetti ( Sheep, COWS, Goats)
Streptococcus Gallolyticus endure endocarditis is associated with what type of cancer
Colorectal cancer (needs colonoscopy screening)
BArtonella endcuced endocarditis ( Cat infection) effects what valves most
Tricuspid Valves
What bacteria is associated with Endocarditis, old people and dental procedures
Viridans strep
Pts with endocarditis that have vegetation’s greater than 10mm, abcesses, severe valve damage, Dehiscence, heartfauliure or Recurrent septic emboli are candidates for..
Surgery
HRpEF is equal to
60% and greater
HRrEF is equal to
40% and less
What is the relationship between left ventricular dysfunction and BNP
Its more specific to LV Dysfunction in HEART Failure States
Aldosterone has what effect
Increases Na retention in exhcannge for potassium (increases fluid level)
Angiotensin II has what effect
Leads to Peripheral vasoconstriction
What is PRO BNP used to discriminate against
Cardiogenic vs non cardiogenic pulmonary edema
What are the cutoff values for PRO BNP for cardiogenic pulm edema in 50 yo, 50-75 yo, and older than 75 yo
50 and younger : 450 pg/nl;
50-75: 900
Older than 75: 1800
What is eccentric hypertrophy
Increased ventricular chamber radius and wall thickness
What is concentric hypertrophy
Increases wall thickness without proportional chamber dilation
A pt with Dyspnea, orthopnea, nocturnal Dyspnea and fatigue, Diaphoretic, Tachypnea and Tachycardia, Pulmonary Rales and a S3/S4 gallop is what sided HF
Left Sided
A pt with peripheral edema, JVP, RUQ discomfort, Hepatic enlargement, Ascites is what sided HF
Right Sided
HIGH YEILD NUEMONIC
HEARTFAILED
HTN Endocarditis Anemia Rhuematic HDz Thyrotoxicosis Failure to take meds Arrhythmias Infection/ MI, Ishcemia Lung Problems ( COPD, PE, Pneumo) Endocrine D/o Dietary indiscreción
S3 is pathological for what
HF in adults
What are the top three causes of HFrEF
CAD, Valvulr D/o, HTN
What is Framingham Criteria
Dx made with 2 major or 1 major 2 minor criteria
MAJOR: Acute Pulm Edema Cardiomeg Hepatojux reflex JVD Orthopnea or Nocturanl Rales S3
Minor: Ankle Edema Dyspnea Heptmeg Nocturnal cough Pleural Effusion Tachycardia
S3 vs S4 is common with which form of cardiomyopathies
S3 dilated
S4 Hypertrophioc Cardiomypthies
High output HF is associated with what S/s
Tachycardia
What are the #1 and #2 most common Causes of sudden cardiac death
Cardiomyopathy is the 2nd most common cause of sudden death
(** Ischemic heart disease is #1**)
What cancer drug can cause Cardiomyopthy
Doxicirubicin
Pts with dilated cardiomyopathies are most likey to die from what abnormalities
Arrhythmic D/o ( VTACH, VFIB)
Cossackie B virus is heavily associated with…
Myocarditis and Pericarditis
An EKG with LVH/ LAD, prominent q waves in II, III, and AvF, I AVL, V5-V6, and septal Qs
Hypertrophioc Cardiomyopathy
What is the 1st line Tx for HCM
BB and alternative CCB (Verapamil) and Amioderone
Myomectomy,
PTs with EF less than 35 and with 1 year prognosis, 40 days after MI, should get..
ICD
What are the major IND for ICD placement
Unexplained syncope
LV wall thickness greater than 30 mm
Or non sustained VTACH
Apple green biference is hallmark for
Amyloidosis, and Restricitive Cardiomyopathy
What is a aldosterone antagonist
Spirinolactone (Potassium Keeping) diuretics
useful in Stage C HFrEF pts with good CrCL and Adequate K+
Pts in Stage C HFrEF on a ACEI or ARB with no Contra to ARB or Sacubitril what is the Standard HF treatment
ARNI (Sacrubitril + Valsartran)
A black pt in Stage C HFrEF gets what meds
Nissoprusside
A pt with Stage C HFeRF with a EF less than 35, 1 year survival and 40 days post MI is a candidate for what intervention
ICD
A pt with LVEF less than 35%, NSR and LBBB is a candidate for what intervention
CRT (Pacing)
A Group 1 pulm HTN pt due to scleroderma presents with what 5 conditions
Calcinosis Raynauds Syndrome Esophageal Dysmotility Sclerodactily Telangiectasia
What is an infection to the endocardia surface, that particularly impacts prosethitc valves, damaged native valves, and native valves.
Endocarditis
What are the two types of endocarditis
Infectious and non infectious
What are the RSK Fxs for infective endocarditis
Dental Surgery, Wounds IV Drug use IV Catheters Immunocomp pts Valvular or congenital HDz Previous Hx of endocarditis, pacemaker, or prosethic valve
What are the conditions that promote non infectious endocarditis
Hypercoag states ( Cancer, pregnancy)
Ag-Ab complex ( systemic lupus)
A pt with a fever and a new heart murmur presents with Septic emboli or type III hypersensitivity reaction (Ag-Ab complex, aka lupus).. what is the heart condition that should be suspected
Endocarditis
Endocarditis of the left valves in the heart, can create septic emboli that can lead to
Stroke
Endocarditis of the right valves of the heart can create septic emboli that can lead to
PE
Describe splinter hemorrhages and what are they a S/s of
Splinter hemorrhages are longitudinal red brow hemorrhages under the nail that look like splinters
It is a S/s of septic embolus from Endocarditis
Describe Janeway lesions and what are they a S/s of
Jane way lesions are NON TENDER, small macular or nodular lesions of the palms or toes
They are a S/s of septic emboli from endocarditis
Septic emboli from endocarditis can effect the eyes how..
Conjunctival hemorragias
How will infective endocarditis present on an EKG
Heart Blocks Conduction Delays (effecting the valves) Isolated prolonged PR Intervals
Can also present with Cardiac ischemia from septic emboli in the coronary circulation
What is the first branch off the aorta
Coronary circulation
Bacterial Ag-Ab complexes from infectious endocarditis can effect the skin, the kidney, and the eyes in what three specific ways
Skin: Oslers nodes - PAINFUL tender lumps on the fingers or toes. They are red-purple, raised, and often with a pale center.
Kidneys: Glomerulonephritis
Eyes: Roths Spots- seen most commonly in acute bacterial endocarditis. A red spot caused by a hemorrhage, with a characteristic pale white center.
Describe an Oslers Node
Osler nodes are red-purple, slightly raised, tender lumps, often with a pale center.
Pain often precedes thedevelopmentof the visiblelesionby up to 24 hours.
They are typically found on the fingers and/or toes.
Explain Roths spots
A Roth spot, seen most commonly in acute bacterial endocarditis is a red spot (caused by hemorrhage) with a characteristic pale white center.
This white center usually representsfibrin-platelet plugs
Duke criteria is specific to what Dz process
Endocarditis
- Cardiac lesions or Hx of Rec. Drug use
- Fever
- Evidence of Septic Emboli
- Autoimmune Conditions (Ag-Ab complexes)
- Serological Evidence
There are what criteria
5 minor Dukes Criteria
In endocarditis, how many sets of blood cultures need to be collected
3
1 aerobic, 1 anaerobic, 1 fungi
How will endocarditis present on Echocardiography
Presents with valvular vegetations,
Valular regurgitation, MVP, or stenosis.
When would transesophageal echo be done first as opposed to transthoracic ?
When the pt is obese, has a chest wall deformity, has a prosethic valve, implanted cardiac device, or prior valve abnormalities
An older pt with native valve Dz ( endocarditis) post dental procedure is likely caused by what bacterial agent
Sterp Sanguinis or Viridans Strep
Endocarditis in IV drug abusers effects what valve? From what agents?
Tricuspid Valve
And if it’s Methicillin Senstitive ( MSSA) this its Staph, Aureus.
If its not Staph then its Psuedomonas or Candida
IV drug users are at risk of developing Endocardits from what agents
Staph Aureus (MSSA) Psuedomonas Candida
Endocardits acquired in the hospital or from surgery are likely caused by what agent
MRSA
What is the agent that is most likely to cause endocarditis in a prosthetic valve
Staph Epi.
Think dirty catheters, valve surgery, biofilm
A pt with a foley or post GI surgery is likely to develop Endocardits from what agent
Enterococcal ( Group D)
What pts are at most risk to developing endocarditis from Coxiella burnetti
Farmers (Cows, sheep, goats)
Immuno comp or preg pts
(These pts develop Q fever)
Q fever is associated with
Coxiella burnetti
Pts that develop Endocardits from Strep Gallolyticus, must also be screened from what associated conditions
Colorectal cancer ( need colonoscopies after endocarditis Tx)
What is the agent associated with endocarditis from a cat infection and what valve does it infect most
Bartonella and the tricuspid valve
What is the Tx approach to infective endocarditis
Suspected?
Dukes? (2 major? 1 Major 3 minor? 5 minor?)
Stable? What for cultures
Unstable?
-Then Tx 2-6 weeks
(Prevention is Amoxicillin/ Ampicillin 1 hr before procedures)
What is the protein in Rheumatic fever that looks/ mimics protiens on the myocardium, heart valves, joints, skin, and brain…
In short what is the protein that is the cause of Rhuematic fever turning into Rhuematic heart Dz
The M protiens on GROUP A sterp infections
Jones criteria is specific to what Heart Dz
JONES!!
Remember dukes is Endocarditis
What are the S/s of Rhuematic fever ( Aka jones criteria)
Migratory Polyarthritis Pancarditis SubQ nodules Erthyema Marginatum Sydenham Chorea
Chronic Rheumatic HDz presents with what valvular abnormalities
Regurgitation or stenosis of the Mitral or Aortic Valves
Does group A strep cause Endocarditis or Rhuematic Fever
RHeumatic Fever!!
What stage of VHD is symptomatic
Stage D
What stage of VHD meet criteria but are asymptomatic
Stage C
What stage is “ pts with progressive VHD yet asymptomatic”
Stage B
What stage of VHD is “at risk”
Stage A
What are stages A, B, C, and D of VHD
A; At risk B: Progressive (Mild to moderate severity, asymptomatic) C: Severe VHD, Aysmptomotis -C1: LV/RV compensated -C2: LV/RV decompensated D: symptomatic severe
MS leads to what major LV problems
LA dilation, Increased pressure in the LA and Increased pressure in the pulmonary vessels, which can lead to hemoptysis, and eventually Corpulmonale HF
What physical exam finding is indicative of MS
Right Vent Heave (with Pulm HTN), PMI may also be decreased
What atrial arrhythmia is associated with MS
A fib from a dilated L atria
This valve replacement requires life long Anticoagulant, last q-years, and has an audible click
Mechanical prosthetic valve
This valve replacement last 8-10 years, does not require anticoagulant, and has no audible click
Biological prosthetic valve
When would you do a Percutaneous Mitral balloon for RH mitral stenosis
A pt with Sever MS (MVA less tha 1.5 cm), Stage D VHD, has a pliable valve, with out clots, and Less than 2+ MR.
Tx approach for RHDz MS in a pt with Class D VHD, MVA less than 1.5cm, with a pliable valve, no clots and less than 2+ MR
PerC Mitral Ballon Commissure
When would a pt need MV surgery in RHDz MS
Severe MS (MVA less than 1.5 cm)
Stage D with out a Pliable Valve,
+presence of clots
And greater than 2+ MR
NYHA III-IV and is a surgical candidate
Tx A pt with VHD and AFib +RHDz s
Long Tterm VKA (Anticoagulant)
Pts with Afib require what medication
Anticoagulant
