cardiology 1: General Flashcards
define the x-ray findings
define x-ray findings lateral view
Describe the sign?
this is the scimitar sign, which is a curvilinear opacity in the right lower lung field due to associated lung hypoplasia. It is an anomalous pulmonary vein
Describe the cxr finding
This is pericardial effusion, “water bottle” sign.
what are teh two types of cardiac stress tests?
exercise tolerance test and stress imaging test
what are the groups that you should not perform an exercise tolerance test?
- unable to achieve 85% of age-predicated max HR
- patients with baseline ECG abnormalities
what is the definition of a positive Exercise tolerance test?
- flat or down-sloping ST-segment depression >1mm and 80ms after J-point in 3 consecutive beats.
- ST depression does not correlate with anatomic location unlike ST elevation
what are the absolute indications for termination of ETT? (7)
- ST elevation >1mm in leads without q waves from prior MI excluding aVR, aVL, and V1
- the decrease in SBP >10mm Hg when accompanied by other evidence of ischemia or hypoperfusion
- moderate to severe angina
- CNS symptoms
- Sustained 2/3rd AV block
- Signs of poor perfusion (cyanosis/pallor)
- serious arrhythmia
what are the stress imaging studies you can do?
stress echo and myocardial perfusion imaging (MPI)
what is the general sensitivity/specificity of ETT?
60% sensitive, 70% specific
when are stress imaging tests done instead of ETT?
cannot exercise or ECG changes at rest
why is exercise tolerance tests not used in patietns that have pacemakers or LBBB?
produces false-positive left ventricular anteroseptal perfusion defects
what agents are used in cardiac imaging studies? How do they work?
- Dobutamine acts as an inotropic/chronotropic and acts similarly as exercise
- Vasodilatation increases blood flow but does not increase heart rate. They increase blood flow to normal vessels while doing no change to stenotic vessels. Thus, steal blood from stenotic vessels causing perfusion defects as seen on EKG.
what are the specific agents used for vasodilatation in cardiac stress testing?
Adenosine, dipyramadole, and regadenoson (nonselective A2 receptor activator)
what agent can you use for chemical stress test in patient w/history of bronchospasm?
dobutamine. Regadenoson has less effect.
when are exercise stress echo and MPI indicated instead of ETT? (5)
what cardiac test is indicated for patients with paced ventricular rhythm?
MPI with vasodilators
when do you use cardiopulmonary exercise testing?
- patients with systolic heart failure
- pre-transplant assessment
- unexplained exertional dyspnea
what are the requirements prior to doing a coronary Computed tomographic angiography?
when do you choose CTA diagnostic test? when should you not use this test?
- symptomatic patients who are at intermediate risk for CAD after initial risk stratification.
- Patient with congenital coronary anomalies
- It should not be used in asymptomatic patients or symptomatic patients with low/high probability for CAD.
- Usefulness is reduced patients with pronounced coronary calcification
why do you use Coronary computed angiogrpahy in intermediate CAD risk?
high negative predictive value in excluding significant CAD
what is coronary artery calcium scoring?
- use to scan for atherosclerosis and does not use IV contrast
- Used to further risk stratification in asymptomatic, intermediate-risk patients
- CAC score 0 is low
- CAC score>400 indicates 3 fold risk for CAD
what is a cardiac MRI used for?
can be used for everything but the mainstay is infiltrative diseases, post-MI tissue viability
what is PCWP?
dampened LA pressure that reflects LV-EDP, which reflects LV-EDV
what are normal Right atrial, right ventricular and pcwp pressures?
In what conditions does PCWP elevate?
in what conditions are diastolic pressures equal in all 4 chambers?
pericardial tamponade and constrictive pericarditis
what is pulsus paradoxus?
- decreased pulse amplitude with inspiration seen as absence of korotkoff sounds during inspiration
- Can be observed clinically bu auscultating BP and listening for exaggeration of normal inspiratory decrease in SBP>10mm Hg
- you can heart a heart beat but not a feel a pulse during inspiration
when do you see pulsus paradoxus?
- cardiac tamponade
- constrictive pericarditis
- asthma
- tension pneumothorax
what is pulsus bisferiens?
bifid with 2 systolic peaks during cardiac cycle
when do you see pulsus bisferiens?
- AR
- HCM
what is pulsus alterans?
varying pulse pressure with a regular pulse rate
when do you see pulsus alterans?
any cause pf decreased systolic function that leads to decreased stroke volume
what is pulsus parvus et tardus? condition seen?
- parvus = low amplitude
- tardus - slow upswing
- aortic stenosis
what is and where do you see branchiofemoral delay?
this is femoral pulse occurring after brachial pulse
see this in coarctation of the aorta
what does standing do to valve murmurs?
- decrease right and left cardiac filling and cause the sound of most murmurs to decrease
- increase murmurs of MVP and HCM
what does strain phase of valsalva do to cardiac murmurs?
- decrease right and left cardiac filling and cause the sound of most murmurs to decrease
- increase murmurs of MVP and HCM
what does squatting do to cardiac murmurs?
- increase cardiac volume
- increase volume and after load
- increase intensity of all murmurs except MVP and HCM
what does lying down or supine passive straight leg raise?
- increase cardiac volume
- increase volume and after load
- increase intensity of all murmurs except MVP and HCM
what does sustained handgrip do?
- boosts SVR and LV volume
- decreases murmurs of HCM and aortic stenosis
what maneuever can you do to distinguish HCM and MVP?
handgrip prolongs murmur of MVP due to earlier prolapse of MV.
what maneuver can you use to differentiate between AS and MVP?
- AS murmur decreases
- MVP murmur increases in duration
what does inspiration/expiration do to heart murmurs?
inspiration increases right-sided sounds
Expiration increases left-sided sounds.
S1 is caused by?
closing of mitral and tricuspid valves
S1 is decreased when?
- prolonged PR interval
- Mitral regurgitation
- acute aortic regurgitation (Increased LV pressure causes early LV closure)
- severely calcified mitral valve
S1 intensity is increased when?
- (mitral valve slams shut)
- short PR interval
- mitral stenosis
- hyperdynamic ventricular function
what is S2 caused by?
closing by the aortic and pulmonic valves (A2 then P2)
why do you have a physiologic split?
- this is when P2 occurs after A2
- Caused by the increased volume of blood in the RV prolonged RV systole, delays closure of the pulmonic valve.
- Disappears during expiration
what is a persistent/wide split S2? causes?
- vary with respiration but does not disappear on expiration
- anything that cause delay or prolonged contraction of the right ventricle
- pulmonic stenosis, PE, RBBB,
what is the classic presentation of a fixed split S2?
also see patient with systolic ejection murmur, ASD, and pulmonary vascular congestion on CXR
what is paradoxical split S2?
- P2 occurs before A2
- hear split with expiration instead of inspiration
what conditions do you see paradoxical split S2?
- LBBB
- pacemaker beat from RV
what does a S3 indicate?
indicates end of rapid ventricular filling
what conditions do you see a S3?
kids, patients with poor LV dysfunction.
what is S4?
- ventricular filling during atrial contraction
- hear it in patients with decreased ventricular compliance
- ischemic heart disease, aortic stenosis, HCM,
what pathological conditions do you not hear a S4?
- atrial fibrillation
- mitral stenosis (ventricular inflow obstruction)
when do you see large right sided v waves?
- ventricular septal rupture
- Tricuspid regurgitaiton
when do you left sided v waves?
severe MR
what do you see with constrictive pericarditis?
rapid x and y descents
what do you see with tamponade?
rapid x descent only
what do you see with mitral stenosis?
large, left sided a-waves
when do you see cannon a waves?
anything with AV disassociation (times when atrium is contracting gainst a close TV)
when do you see a slow y descent?
delayed atrial emptying as in from tricuspid stenosis
what waveforms are seen during diastole?
- A wave (atrium contracting, tricuspid valve open)
- Y descent (atrium emptying, tricuspid open)
what wave forms are seen during systole?
- C notch
- X descent (atrium relaxing then filling, tricuspid closed)
- V wave (atrium tense and full, tricuspid close)
what waveforms do you see in pulmonary HTN?
elevated A and V waves
what waveforms are seen in tricuspid regurgitation?
large V waves
what waveforms do you see with tricuspid stenosis?
slow y descent
what waveforms do you see with restrictive cardiomyopathy?
rapid x and y descents
what waveforms do you see with RV infarction?
elevated A and V wave
what waveforms do you see with ASD?
large V waves and rapid y descent
when should you suspect secondary HTN?
- age<30
- drug resistant HTN
- people who develop uncontrolled HTN that was previously well controlled
physical exam finding that suggests renal vascular HTN?
systolic abdominal bruit without a diastolic bruit
primary hyperaldosteronism basic script?
hypertension patient with hypokalemia and low renin
which common cardiac medications prolong survival post - MI?
- beta blockers
- carvedilol
- ACe/ARB
- Epleronone
which common cardiac medications prolong survival in HF?
- Beta blockers
- carvedilol
- nitrates (with hydralazine)
- Ace/ARb
- spirinolactone
- Epleronone
what is a dromotrope?
affects the speed of the electrical impulses (SA node to purkinjie fibers)
what is a inotrope?
affects the strength of contraction (ability to squeeze)
what is chronotropic?
affects the heart rate
what time of day does the highest incidence of spontaneous ischemic cardiac events occur?
circadian pattern with the highest incidence in the early morning hours.
what type of cardiac medication is digoxin?
negative chronotropic and negative domotropic
what type of cardiac medication are beta blockers?
negative inotropic
negative chronotropic
negative domotropic
anti-anginal
prolongs survival post - MI
prolongs survival in HF
Only coreg is a vasodilator
generally, non-dihydropiridine CCB is what type of cardiac medication?
- these are verapamidl and diltiazem
- negative inotrope
- negative chronotrope
- negative dromotrope
- vasodilator
- antianginal
- vasodilator
- does not prolong survival
generally, dihydropidine CCB is what type of cardiac medication?
- These are nifedipine, amlodipine
- negative inotrope
- no chrono/dromotropic effects
- vasodilator
- anti-anginal
- only amlodipine prolongs survival in DCM
what type cardiac medication is ACE/ARB?
- vasodilator
- prolongs survival post mi and hF
what type of cardiac medication do nitrates do?
vasodilator
anti-anginal
prolongs survival in HF with hydralazine
what causes resting ST segment elevation?
- acute MI
- pericarditis
- LV aneurysm
- LBBB
- LVH
- ventricular pacing
- benign early repolarization
define hibernating myocardium?
- chronically underperfused myocardium without irreversible myocyte injury
- when perfusion restored to normal, contractility should return to normal
define reperfusion injury?
- severely ischemic myocardium is reperfused after 1 hour
- causes further irreversible microvascular damage and myocardial cell damage
define stunned myocardium?
- result of acute ischemic
- from time to reperfusion, takes 7-10 days for the ventricular function to return to normal
what does ST-segment elevation suggest on an exercise ECG test?
suggest spasms of the coronary arteries
what are the main drugs to treat angina?
- beta-blockers and nitrates are staples
- CCB can also help by decreasing coronary artery vasodilation, peripheral vasodilation, and negative chronotropic effect.
which patient would benefit from ranexa?
- maximal standard therapy or substitute for beta-blockers
- inhibits late sodium current in cardiac myocytes reducing sodium and calcium overload that follows ischemia
- improves myocardial relaxation and reduces LV diastolic stiffness, enhancing myocardial contractility and perfusion
which antianginal drugs decrease preload?
nitrates decrease preload>afterload,
which antianginals decrease afterload?
- nitrates
- beta blockers
- CCB
wat anti-anginal drugs do you NOT give to a patient with RV infarct?
Nitrates because acute preload reduction can cause severe decompensation
what drugs decrease preload in general?
- nitroglycerin
- ACE/ARB
- Morphine
- Aldosterone blockers
which drugs decrease afterload?
- nitroprusside
- milironine
- CCB (pines)
- ACE.ARB
which drugs decrease heart rate?
- beta blockers
- CCB
- Digoxin
- adenosine
- antiarrhythmics
what 3 components make up SV?
- preload
- afterload
- contractility
what are the two pathologies of thoracic aortic aneurysms?
when is surgery indicated for chronic thoracic aortic aneurysms?
how to manage AAA?
what is coarctation of the aorta?
