Cardiology Flashcards
Opening
Snap - MS
Click - MVP
Closure
S1
S2
Loud S1
MS
Short PR (WPW)
Tachycardia
Thyrotoxicosis
Soft S1
MR
Long PR
inc’d LVEDP
S2 inspiration
A2 - AV closess first
P2 - PV closes last -> physiologist split
S2 expiration
both valves close at same time
S2 split inc’d
closese earlier - MR, VSD
Closes later PS, pulm HTN (loud P2) RBBB
Fixed S2 split
ASD
paradoxical S2 split
AS, HTN, LBBB
S3
inc'd flow chronic MR CHF TR, PDA BENIGN IN KIDS pregnancy
Inspiration
MORE BLOOD IN R HEART
S4
Decreased compliance Acute MR HOCM LVH AS Ischemia
Pericardial friction rub
Superficial scratch sound best heard when pt upright leaning forward and deep breath in pericarditis
Pericardial knock
constrictive pericarditis - sharp early diastolic sound (early 3rd sound)
Physioligc during expiration
Single S2
HTN/AS/LBBB
Paradoxical S2 split
ASD
Fixed split
Calcified AS
Single S2 (soft A2)
HTN
Loud A2
Pulm HTN
Loud P2
Physiologist split
A2 before P2
Pulsus tardus
slowly rising pulse
AS
Pulsus bisferients
rapid upstroke - bifid/trifid
HCM
Pulsus alternans
one heart snd normal, one abn severe HF cardiac tamponade SVC obstruction Pulm obstruction
Hyperkinetic
High output state
PDA
Thyrotoxicosis
Hypokinetic
Low output states
Kusmal
deep breath more blood into R heart - taemponade - R septum bulges into LV, dec’d BP on inspiration, JVP bulges
Auscultation
R IInd IC space (Aortic Area)
AS
AI
Left II IC Space (Pulm area)
PS, PR, AI, PDA
LLSB (Tricuspid area)
TS, TR
ASD, VSD
HOCM
Apex (Mitral Area)
MS
MR
AR
Palpation
Left parasternal area
Hyperdynamic implse (inc’d RV volume (ASD or TR)
Sustained L parasternal heave - RVH, (MS, pHTN, PS)
Apical area Hyperdynamic impulse Inc'd LV vol (Hyprthyroid, Anemia, preimary MR, AR with nl EF, PDA VSD) Susptained Apex lift/impulse LVH (HTN, Dil CM) IHD, AR with low EF Bifid/trifid apical impulse - HOCM
AV Valve Holosystolic murmur
MR, MR, VSD
V valves Mid systolic murmur
AS, PS
AV Valves Late systolic murmur
MVP - mid systolic click
Diastolic mumur
All in-flow to ventricles creates diastolic murmurs
AV valves Mid diastolic murmur
MS, TS
AV valve - late diastolic murmur, mid systolic plop
Arial Myxoma - > surgery
V valves Early diastolic murmur
AR, PR
Continuous murmur
PDA
Pt with fixed split 2nd heart sound and mid systolic -diastolic rumble dx?
ASD
Inspiration
inc’d flow to R side of heart, all R sided murmurs increase
Expiration
Inc’d flow to L side of heart - all L sided murmurs increase
Inc’d flow INCREASES all murmurs EXCEPT
HOCM/MVP (decrease)
Inc’d flow
Sitting, squatting, leg raising
Dec’d flow
Standing, Valsalva
Handgrip
increases afterload, increases flow to murmurs that flow backward (AI, MR, VSD)
What happens to murmur during handgrip or phenylephrine
Handgrip inc’d afterload, LV cavit size inc’s so ALL murmurs increase including MR
Except: dec’s HOCM, MVP, AS
What happens to murmurs with amyl nitrate use
Decreaes afterload, so its easy for blood to be pushed into systemic cir, LV cavity decreased MR dec's MVP inc's HOCM inc's AS inc's
What happens to murmur post PVC
PVC=inc’d volume, dec’d afterload
HOCM/AS increase
MVP dec’s
What happens to blood that returns to heart during valsalva maneuver
Increases intrathoracic pressure and DEcreases blood return to heart
Kussmaul’s sign
Neck vins DISTENTION on INSPIRATION
constrictive pericarditis
cardiac tamoponade
RV infarct
Application of pressure in the RUQ causes engorged Right jugular vein - rapidly improved upon release of pressure - indicates…
Increased jugular venous pressure
inspiration
inc’d R side murmurs
Dec’d L side murmurs
Expiration
inc’d L side murmurs
Dec’s R sided murmurs
Standing/valsalva
Inc’d HOCM, MVP
Dec’d all other murmurs
Squatting/Sitting
Dec’d HOCM, MVP
Inc’d All other murmurs
Hand grip
Dec’d HOCM, AS, MVP
Inc’d MR, MVP
Post PVC
Inc’d HOCM, AS
Dec’d MVP
AS
inc’d standing, valsalva, post-PVC
dec’d with handgrip
MR
inc’d standing, valsalva
Dec’d Post=PVC, handgrip
MVP
Dec’d standing, valsalva, post-PVC
Inc’d with handgrip
HOCM
Dec’d Standing, valsalva, handgrip
Inc’d Post-PVC
16yo pw routine checkup - PE reveals a murmur at LSB radiating thru pre-cordium - no change with valsalva or respiration - exam LVH dx?
VSD
RCA
inferior
II, III aVF
Posterior V1, V2 (early R wave progression)
RV -> V3R-V4R (no nitrates - IVF + atropine if HR dec)
LAD
Anterioseptal V2-4
Anterior V3-5
Cirumflex
Apicolateral V5-6
Circumflex branch (OM1) or LAD branch (diag)
High lateral
I, aVL
Pt h/o CP EKG stress reveals depression in lateral leads - nuclear iaging reveals anteroseptal ischemia
High grade LAD stenosis
48yo F exertional CP, stress done - stopped in 50 min from CP and ST dep V4-6
High grade LAD stenosis
Epidemiology
900,000 deaths/yr
1/3 from CAD
smoking doubles risk
INc’d LDL and total chol risk factor
1% dec LDL = 2-3% ec risk of CAD
Every 1mm dec in BP - 2-3 % dec in r/o MI
Death rates with heart dz MORE in females
Risk factors for atherosclerosis
Modifiable HLD tob Psychocsocial stressors DM HTN Obesity Etoh Physical activity Diet low in fruits/vegies
Unmodifiable:
Age
Male
Family h/o premature CAD (LP (a))
Pt no meds - wants advice on dec’ing CAD risk - smoker, HTN, LDL 100 wtd?
Quit smoking
ACS
ST elev -> Q wave MI - TPA or PCI
NSTEMI - w+CE - ASA, plavix +- IIb/IIIa
no CE (U/A) - no TPA - hep gtt, ASA, plavix
Workup for suspected CAD - middle aged woman pw chest pain, chest discomfort or atypical CP - wtd?
EKG - if normal stress test (exc if can walk)
If pt with COPD then
Dobutamine stress (no adneosine, dyprimadole)
45yo F vague CP on exertion - EKG normal - exc stress non-sp changes - wtd?
Exc stress with imaging
If can’t walk - or non-sp ST chagnes with LBBB, LAHB, repolariz change then persantine/thallium study
Which can under EKG stress?
RBB (not LBBB or paced)
Pt with peripheral vascular dz scheduled for bypass surgery - wheezing on exam - HTN controlled to 150.90 from 170/110
Dob stress test (can’t use adenosine or dipyridamole with wheezing)
Who gets gated pool studies or MUGA scan
IN pt to dtermine LVEF and WMA (dec’d LVEF poor prognostic factor on MUGA
When NOT to do stress test
U/A
AS with sx
45yo DM2 with CP, EKG neg - test LEAST likely to be accurate is…
Exercise stress test
Obese woman with atypical CP undergoes EST - stops test after 5 min due to fatigue, no CP, HR inc’d by 50%, no EKG chagnes wtd?
Adenosine stress or stress echo
When is EST positive
Flat or down sloping ST depressions>1mm & longer than 0.08s
If ST elevated then high grade stenosis
When do you stop a stress test
ST dep >2mm
SBP dec >15mm Hg
VT
Chest pain/SOB
Poor prognostic factors on stress test
>2mm ST depression Persistant ST dep 5 min post excercise Fall in BP > 15mmHg ST elev Vent ectopy/VT global ischemic changes
Who gets cardiac cath/angiogram
Presence of poor prognostic factor on stress test
Post infarct angina
U/A on med tx still with sx or ST dep or troponin +
Unstable Angina
New onset severe angina < 2 months
Angina at rest
Recent inc’d freq
Post infarct angina
Pt with angina controlled on BB, ASA, nitrates pw inc’d freq and now chest pain lasting > 30 min -> EKG ST dep II, III, aVF - most likley mechanism for CP
Atherosclerotic plque with intermittent rupture and thomobolysis
Pt h/o chornic angina controlled on ASA, nitrates with inc freq angina wtd?
Add BB
Pt now on ASA, nitrates (with 12 hr nitrate free interval) and BB with inc’d freq angina
Check CBC for anemia
Check for infxn (in’d HR-> ischemia)
Abv pt with low Hg and EKG with ST dep - PRBC tx’d wtd?
Coronary angiogram
Pt on ASA, nitrates, BB, statin, Hg normal - no signs infxn or stress with increasing episodes angion a on exertion - angiogram MV dz not amenable to revascularization - wtd?
Ranoxazine (ranexa)
Antiplts
ASA - thromboxane
Plavix ADP
GB IIb/IIIa
Pt with CP, ST depression present
Welen’s syndrome -> persistent twi on EKG - cath lab
LMWH + GP IIb/IIIa + Plavix + ASA
If angina or ST depression perissts with or without troponin (+)
Cardiac cath
Pt stopped ASA 2 months ago 2/2 PUD - started on PPI now pw CP wtd?
start ASA
45yo M non-smoker, no DM pw new onset CP more than 1/2 hr duration while shoveling snow - no EKG changes in ER wtd?
Admit pt to chest pain unit
If CE neg, no ekg chages o/n -> stress test
65yo M woke up early AM with severe retrosernal CP x 40min, sweating, diaphoresis - EKG ST dep, Twi, started on ASA, IV nitrates BB, LMWH gpIIb/IIIa inhib - anginal pain resolves - 24 hrs later ST dep still persists
Dx: silent ischemia
Cardiac Cath pt
-> if angioplasty/PCI done - would decrease recurrent ischemia at 6 months (not reduce MI freq)
Multislice CT helpful to evaluate CP in what group of pts
Exclude dx in LOW risk patients
Exertiona dyspnea w/o chest pain in a pt may represent and anginal equivalent in absenseof pulm dz - mc seen in…
DM
Women
Elderly
Post CABG
Pathogenesis of SOB
Ischemia-> inc’d LVEDP-> Pulmonary edema
Dx: Empiric NTG or stress test or radionuclide studies
65yo with murmur MR during excercise and disappers post exc - S4 + echo shows mild hypkinesisa and EF 60% etio?
Ischemic
46yo M CP lasting 15 min - resolved in ED - HR/BP ok, no ST elev - deep Twi 1-4 - wellen’s sign wtd?
Check echo, cath
The followin gare true in pts with DM
CAD lesions are proximal
CABG better tha PTCA in pt with CAD
DM patients more likely to have silent ischemia
Among DM - more women athan men die of CAD
DM more prone to CAD than non-DM
Pt pw CP, EKG neg - Thalimum stress with reversible ischemia, cath neg dx?
microvascular angina
Tx: CCB, BB, nitrates
Elderly man with h/o syncope - EKG on prsenation normal - feels dizzy after dinner - ST dep in II, III aVF - EKG after 15 min normal dx?
Post prandial ischemia
tx: cardiac cath
Least likely to cuase ST elevation is?
Unstable angina
Transmural MI, LV aneursym post MI, acute pericarditis, Prinzmetals angina ll aan cause ST elev
Young man brought to ER with severe CP - EKG shows ST elev and MI dx - caused by which drug?
Cocaine
tx: PCI
Cardiac enzymes
Troponin - + 3-6hrs after MI
Peak 10-25hrs
Normal 5-15 days
CPK-MB + 3-8hr
Peak 10-36hrs
Normal 3 days
LDH + 8 to 18hrs
Peaks 2-3 days
Returns to normal 6-10 days
Myoglboin - 0-85= normal
inc’d immediately peaks in 1-4 hrs and normal in 24 hrs
Pt with CP, ST elv trop elevated - s/p TPA ST resolve - CP resolved - next blood draw trop more elevated wtd?
Nothing - pt who reperfused have faster peak and higher peak of trop than pt NOT perfused
Pt pw CP and ST elev - PTCA done next day has CP best marker?
Myoglobin (peaks 1-4 hrs, normal 24 hrs)
65yo M aw PNA to MICU on IV abx - EKG NSR - trop 1.3 wtd?
Echo
Low level trop see in
CHF, critial illness, LVH, coronary vasopalsm, pulm embolism, CKD
Pt pw chest pain and low BP - you suspect RV infarct - next dx step?
R EKG - V3R-V4R
Acute MI
Q wave MI and non-Q wave MI both similar long term survival
Always admit pt with new onset classic CP - relieved by SL nitro even if pt young or EKG normal
PTCA better than TPA
thrombolytics NOT given for non-Q wave MI - instead give gpIIb/IIIa inhibitors just like for U/A and ST depression
INdications for thrombolysis
Chest pain typical for infarction > 30 min with LBBB
ST elev 1mm in two continguous leads
2hrs away from PTCA center and NOT in shock
Contraindication for TPA
Absolute Prev hmorrhagic stroke Other CVA events < 1 yr IC neoplasm Active internal bleed
Relative CVA> 1 yr recent internal bleed or major trauma < 2-4 wks BP>180/110 Pregnancy Active PUD
Indications for PTCA (PCI or angioplasty)
Acute ST elev MI ST elevation with CP > 12hrs MI with shock and Pt is < 75yr STEMI post CABG pts If tPA contraindicated
Plavix
Thienopyridine ADP Plt inhibitor
Pt with MI allergic to ASA -> use plavix
Pt going for PTCA needs plavix
Pt goign for CABG - NO PLAVIX
When is CABG better than PTCA
Left Main dz
3 vessel dz with dec’d LVEF
two vessel dz with prox LAD and decreased EF
DM with CAD
Pt with CAD s/p PTCA with stent palcement - what meds on d/c
ASA + Plavix
60yo pt undergoes CABG - couple months later he is doing fine but has problems keep ing accounts occasionally
Dx: neurocognitive defect
Pt with retrosternal CP>1, diaphoretic -> EKG LBBB, ST elev in ant leads - old EKG not availabe to compaire - CK and trop pending wtd?
Cath lab
Pt with Chest pain, ST elev ant leads - s/p tPA with BP of 90/60 - 2hrs later ST elev in lateral leads BP drops to 80 pt SOB - no new murmurs - CXR pulm edema wtd?
Cath - IABP-> PIC
If allergic to ASA then desensitization
Elderly pt with IWMI gets tPA - pt becomes hypotensive and HR 38 wtd?
atropine
HR 74, BP stable, pt confused, both puils dilated - dx?
ANtichoinergic delierum
Pt with 14hrs CP, taken antacids without relief - EKG with ST elevatins in anterior leads - BP 140/80 - given ASA to chew - IV nitrates, IV BB and IV morphine - closest PTCA at least 1 hr away wtd?
Transfer for PTCA
60yo pw CP AWMI to small community hospital - nearest PTCA 2 hours away wtd?
TPA then tx for PTCA
Pt aw MI - 3 day slater Cp relieved with NTG wtd?
Cath
Pt has cath - 2 days later pain in R groin - exam with erythematous and pulsatile mass wtd?
US r/o pseduoaneurysm
Pt with MI - 9 days later with persistent CP, worse on deep breath - pericardial friction rub - CXR with effusion - EKG diffuse ST elevation with concatvity upwards
Dressler’s syndrome - secondary pericarditis
Indomethacin, ASA
Factors shownto improve survival in MI
PTCA thrombolytic therapy after Q wave MI BB ASA ACE in EF < 35%
Pt with CP, ST elev in II, III, avF all are true
ACEi improve survival
BB imporove survival
statins improve survival
(CCB DO NOT improve survival)
Pt p/w CP - AWMI tx’d in CCU wihtout complciations EF 30%, on D/C what meds
ASA, plavix, BB, ACEi, warfarin 3-6 months, Statin, ICD 40 days later - if high risk for VT then wear lifevest
65yo with angina CVABG 2ya HR BP ok, no DM, EF normal wtd to reduce chance of another cardiac event
ACEi (ramipril)
Pt had MI, stabilized - few months later stress tes ab - underwent cath - 70% Cx - started on ASA - what will inc survival?
Statin (NOT CABG or PTCA)
Complications of MI (arrythmia)
48hrs
VT (scar tissue -> need amiodarone-> ICD
NSVT
Complication of MI (ruptures)
Papillary muscle rupture -> Acute MR
Septal rupture -> Acute VSD
Free wall rupture -> Tamponade
Ventucular arrythmias during acute MI
Ventricular ectopy or NSVT during AMI should NOT be treated
VT/VFib occuring within 24 hrs of MI are independent risk factors for in house mortality BUT not risk for subsequent mortality from arrhthmia fter d/c
These DO NOT NEED long term antiarrhythmic therapy
Pt pw CP - EKG shows MI tx’d with tPA, heparin, nitrates, BB, ACEi - w/in 24 hrs pt has NSVT <30s wtd?
Observe
Mechanism of reperfusion arrhythmias?
Triggered activity; change in cardiac frequency due to accumulated Ca+
Reperfusion arrythmia
If unstable (dec’d BP, CP) - DCCV
If stable - amiodarone
wtd next - cath
Pt with NSVT reverts to SR and is otherwise uneventful - 5 days later pt ready for d/c does pt require long hterm anti arrythmic?
No
Pt with VT or VF 48hrs afte rMI - no evidence of reinfarction wtd?
tx VTACH
Vtach/VF 48 hrs after MI or more - independent risk factor for mortality after d/c - after acute tx wtd?
ICD
Pt has 2 discharges from ICD in 2 months wtd?
start amiodarone
Pt with ICD on amiodarone still getting shocks 4 months later wtd?
RF catheter ablation
Pt with MI refractive VT wtd?
O2 and correct electrolytes
Tx with amiodarone
Post MI surgery
elective surgeries at least 6 months post MI (risk of reinfarction highest first 3 months post MI)
Middle aged man clutches chest c/o severe CP - EKG diffuse ST elev with concavity up and PR depression wtd?
NSAIDs for pericarditis
Best med for ppx - colchicine
If pt’s CXR (pericarditis) shows cardiomegaly or has JVD o rpulsus paradoxis wtd?
echo r/o tamponade/effusion
Constrictive pericarditis
Rigid pericardium - impaired cardiac filling
Cl features - gradual onset dypnea, fatigue, ascites, Kussmauls sign +
Sharp early diastolic snd following S2 (early S3)
JVP - > inc’d with prominent x and y descent (Sqrt sign)
EKG normal
CXR - 50% show pericardial calcification
Echo - thickened pericardium =- early diastolic filling of ventricles and pressures >15 adn within 5mm of each other
Swan - RA=RV=PAP=PCWP
tx: pericardial stripping
Risk factors for contrictive pericarditis
Post cardiotomy (CABG/AVR)
INfections Viral, TB, fungal
Radiation exposure to chest in past
Most sensitive test to measure pericardial thickness
MRI
Pt post CABG or AVR 4 yars ago with inc SOB for 3 months +JVD 9cm, hepatomegaly adn pedal edema, EKG and CXR normal - dx?
Pericarditis
T/F in pericarditis JVP inc’d on inspiration
T
T/F in pericarditis pericardial knock also knowna as sharp early 3rd heard snd can be heard
T
T/F in pericarditis Echo can reveal pericardial thikening
T
T/F in pericarditis CXR can show pericardial calcification
T
T/F in pericarditis Treatment is surgical streipping
T
T/F in pericarditis MRI is most sensitive to detect thickness of pericardium
T
MCC CHF
Ischemia>dilated CM>HTN, valvular dz, congential HDz
Always r/o ischemia in pt with new onset CHF and sudden decompensation in stable CHF
MC precipitant of decompensation in CHF -> inc’d salt intake
CHF Systolic dysfxn
dec'd contractility inc'd LVEDP dec'd LVEF Echo - dilated Tx: ACEi, BB, ACEi diuretics (Loop/spironolactone) Digoxin Hydralazine + nitrate ICD/CRT
CHF Diastolic dysfxn
dec'd relaxation inc'd LVEDP NORMAL EF Hypertrophy on echo Tx: Candesartan BB, CCB (long acting) Diuretics
BNP
inc’d in CHF
100-250 - significant LV dysfxn with compensated congestion
250-500 - CHF with both systolic and diastolic dysfxn
500-1000 decompenstaed CHF
>1000 - severe CHF
Elevated BNP seen in…
LHF 2/2 diastolic dysfxn
LHF 22/ systolic dysfxn
RHF 2/2 COPD
RHF 2/2 PE
60yo F eval for 3 month SOB on exertion, no CP, pmhx HTN DM2, HLD - takes meds wtd?
TTE check LV fxn/WM
Echo with inf wall hypokinesis and EF 40% best managment?
Cath (not dob stress echo)
50yo M pw inc’d SOB 3 days - pmhs HTN, BMI 40, JVP 14, b/l crackles and S3 heard, b/l pitting edema, BNP 160 - management?
IV lasix
BNP monitoring shows what?
Dec’d mortality in pt <75yo
Pt pw exc intolerance and DOE - exm JVD 10cm, few basal rales, S3+ - pt dx with CHF
CE and trop normal - pt tx’d with diuretics and gts better - TTE shows EF 35% wtd at d/c
ACEi
In pt with new onset CHF - Cr up and K inc’d from 4 to 5.6 after starting ACEi wtd?
D/C ACEi
start hydralazine
PT with CHF on lisinpril 5mg and lasix 40mg dialy pw continued fatigue, JVD 12cm, scatter rales, pitting edema - wtd?
Maximize lisinopril - start IV lasix) (no diff between bolus vs infusion)
When to start BB in decompensated CHF
ONce volume overload corrected, start low dose BB and titrate up
When to f/u patient as outpt after d/c for acute decompensated CHF
F/u Appt in 1 week (not 2)
If CHF pt on lasix and lisinopril what to add next?
carvediolol
Two months later pt on lasix, KCl supp, lisiopril 10 and coreg 25 bid NYHA III, EF 35% wtd?
D/C K supp and start low dose spironolactone
Pt on spironolactone at inc’d risk for what?
HyperK+ (potassium sparing diuretic)
Pt on spironolactone pw L only breast enlargement 6 months later
Biospy (if unilateral)
CHF pt on lasix, coreg, spironolactone, lipitor prsents 6 months later with BILATERAL breast enlargment
D/C spironolactone ad start Eplerenone
If can’t afford Eplerenone -> start amiloride
58yo F pw CHF taking lasix 20, lisinopril 5, liptor 20, coreg 6.125, spironolactone and ASA - JVP 12cm - lung with mid lung crackles, +S3, pedal edema b/l, EKG QRS 0.13 - started on IV lasix - best management?
Optimize medical therapy for CHF (all meds low doses and is overloaded now)
1 wk later, pt that was on suboptimal therapy now on lisinopril 30, lipitor 40, coreg 25, spironolactone 25, lasix now up to 60, asa 81 - JVP 10, lungs still with bibasilar cracksl S3+ EKG QRS 0.13 EF 35 % - beset mangement?
Start Metolazone 30min prior to lasix
9 months later - pt who was optimized for CHF with lasix, metolazone, coreg, lipiotr sprionlactone and asa for f/u - Echo still 35%, QRS 0.13 -
Start ICD with cardiac resynchroization tx
54yo M CHF - echo reveals ejection fraction 35% - what target BP will prevent any coronary event in pt?
BP < 120/80
76yo F c/o progressive SOB x 2 months - pmhx HTN, bibasilar crackles S1,S2 no murmurs 1+ pittin gedema - EF 65% with LVH best management?
CANDESARTAN (+diuretics)
Apart from HTN which conditions will you get inc’d LV mass?
DM, Obesity
Which pt’s have higer incidence of Heart failure wih prserved EF (HFPEF)
Women age > 75 with systolic HTN
Poor prognostic factors for CHF
S3 Hyponatremia PCWP >12 PAP >50 Peak O2 uptake < 14ml/Kg
Drug that improve mortality in CHF
ACEi ARB Spiroolactone (for NYHA III/IV Hydralazine+nitrates BB
What drugs DO NOT improve survival in CHF
Digoxin (improves fxn capacity and decreases hospitalizations)
CCB
Lasix
55yo F brouht to ED onset of severe SSCP x 2 days - inc’d with breathing - recently lost custody of her grandchild - JVP normal HR 120 lungs clear trop 36, EKG 1mm ST elev V1-4 - echo anter and lateral wall hypokinesis with EF 35% ballooning of LV - cath shows NO CORONARY OBSTRUCTIN dx?
Takotsubo’s cardiomyopathy
Can you use ACEI in asx pt with LV dysfxn?
Yes
ACE used for all following
Sclerodermal renal crisis post acute MI CHF DM with microalbuminuria HTN with S4 Viral myocarditis IgA nephropath NOT WITH PREGNANCY
In pt taking ACEi least likely to follow
Serum Ca+
Do need to f/u BP, K, Cr
S/E ACEi
Cough 2/2 bradykinin First dose syncope Angioedmea/laryngela edema Dec'd consstriction of efferent arterioles - renal failure in marginal patients Neutropenia
What drugs NOT to use in CHF pts
NSAIDs
Glitazones
CCB
Cilostazol
Combination of ACEi and ARB shown what?
Less proteinuria
WORSE renal outcomes
70yo F pw pulm edema, two earlier episodes - responds well to IV lasix - HTN hx with 160/95 - LUngs clear, systolic murmur II/VI at apex-> axill a - echo mild LVH EF 60% etio?
CAD
65yo F new onset CHF loud S4 soft S3, JVD 12, basal crackes - EKG BBB echo EF 25% - started on iv laxi, iv ace sx improve next test?
cath
-if 3 vessel dz? -> CABG
Joint commision core measures for CHF
D/C instructions Use of ACEi or AR Document EF Smoking cessation counseling Flu shot
Dilated CM
Etio Etoh/peripartum/doxorubicin Ischemia Hemochormatosis Tx: Similar to systolic dysfuction In severe CHF inotropic agents such as dobutamine
Restrictive cardiomyopathy (Diastolic dysfxn)
Secondary to Fibrosis or
Amyloid - thickened septum refractile on echo - normal systolic fxn
Diastolic dysfxn (early restrictive filling)
Hemochormatosis
CHF/arrhythmias
Endomyocardial fibrosis
Hypertropic CM
Diastolic dysfxn
Aut dom 30%
4% mortality/yr
Sudden syncope/death after vigorous excercise
Sudden death most frequent in familial form in young patient
CP/dypnea also occurs
Carotid and peripheral pulses with brisk upstroke, BISFERIENTS pulse
Early systoic murmura t LLSB inc’d with dec’d flow (standing, valsalva
(Symmetric hypertrophy=athletes heart)
Etio Asymm hypertrophy of LV = HOCM
Dx: Echo
Tx: BB improve sx
CCB for CP
ICD/Septal myotomy
Do HOCM pts need endocardiitis ppx?
NO
Poor progrnostic factors in HOCM
VT Age 3cm Syncope Failure to inc BP by 20mm upon excerise Familial form and fhx of sudden death
T/F about HCM 18yo basketball player with suddne death after vigorous play - autopsy hyperrophied IV septum
T
T/F about HCM pt p./w syncope, dypena or CP
T
Ventricular Tach on holter monitor inc’d risk of sudden death - these pts need ICD
T
T/F about HCM Murmur inc’d on standing, valsalva and decreases with handshake and sitting
T
An asyx 18yo wants to join soccer team at PE reveals ejection murmur and brisk carotid upsstorke - echo 16mm thickened upper portion of IV septum - wtd?
No high intensity sports
Can do boweling
tx: sx - CP - BB, long acting CCB
if no response - AV seq pacing or sugical myotomy
If Pt VT or NSVT on holter and fhx sudden death then ICD
Aortic Stenossi
MC valvular dz in adults
pw
Sncope - left untreated time to death 3 years
CP - left untreated time to death 3 years
CHF left untreated time to death < 2 years
Signs: Pulsus tardus - systolic crescendo-decrescendo murmura t Right sternal border rad to carotid
Delayed and slow carotid upstroke
Signs of severe AS
S4, paradoxical split S2, late peaking murmur Echo with gradient >50, valve <0.5cm sq
WTD in asx AS pt
f/u serial echos
WTD if progressive deterioration with sx
Replace valve
75yo AS gradient 80 and syncope - falls has hip fx after fall
replace valve first
If poor EF then
Balloon valvuloplasty prior to hip surgery
If pt has asx AS and hip fx with echo gradient 0.5 then wtd?
Swan during surgery
AS pt going for surgical valve replacement wtd prior?
Cath
What is seen in pt with AS
LVH
AV malformation with GI bleed related to?
AS
Aortic Reguritation
Presents w/ dyspnea (backed up blood)
Early diastolic murmur at Left sternal border
Sever cases with AUSTIN FLINT MURMUR (mid diastolic murmur like MS)
AR tx:
Tx: Even with severe AR, Asx and EF>50% then according to LV dimentions
ES 55, ED >75 -> Surgery
IF EF<50 with sx then DO SURGERY!
Austin flint murmur
AR Jet hits MV open leaflets mid diastolic murmur like MS
25yo F with AR EF 60% wants to get pregnant - what to expect?
Normal Vaginal Deivery
Best candidate for sildenafil is
Pt with AR adn preserved LVEF (better than AS or pt with angina)
Mitral stenosis
Middle aged woman born in china/india with dyspnea, hemoptysis - on exam loud S1, Loud P2, opening snap - mid diastolic rumble (decrescendo at apex - Swan PCWP 18, PAP 80/34, RAP 15 - CXR cardiomegaly - straighteing of left heart border
Dx: Mitral stenosis
COmplciation - dilation of LA -> Afib -> thromboembolism and CHF
Tx: If valve
The reason for using diltiazem or BB in mitral stenosis
inc diastolic filing time
Pt with III/VI holosystolic murmur at apex->axilla asx or mild diziness echo sev MR BP/HR ok EF 50% LV 72mm diastolic, 51 mm systole wtd?
Surgery for mitral regurgitation: Repair>Replacement Asx - LV systomic dysfxn (EF<60) Pulm HTN afib Symptoms
Pt h/o aortic aneurysm schedule for surgery gtting stress test - recent EKG, PFTs CXR normal - during stress test has ST dep in lat leads and 2/6 systolic murmur at apex - 5 min later no murmur dx?
Ischemic MR
ASD
Secundum defect 70% (no need for abx ppx)
Fixed S2 (pulm valve clsoes later than aortic valve
Parasternal impulse, prom a and v wave - mid systolic murmur at Left sternal border
EKG with RV strain and partial RBBB
When closure
If L-> R shunt >1.7:1
What if pt ASD asx and L-> shunt >2:1
Surgery
What if R-> L shunt (Eisenmenger’s syndrome)
NO SURGERY - denotes onset of pulm HTN
Atrial septal aneursym management
No ASA, No warfarin, no need to resect
PFO
incomplete fusion of septum primum
Bubble study for dx - 1 bubble /beat in LA
(Hepatopulm syndrome 1 bubble every 4th beat)
Secundum ASD
Incomplete covering of foramen ovale by septum primum
Ideal candidate for percutanous closure
Primum ASD
Septum primum does not connect to endocardial cushion
VSD
common in children systoic murmur at LLSB -> precordium Split 2nd heart sound (not fixed) No endocarditis ppx unless w/in 6 months of surgery If L-> shunt >1.7:1 then Do surgery
PDA
Crescendo-descrecendo continuous murmur left parasternal area (Lt 3rd ICS) - Soft S3
Surgery helps at all ages
No abx pps needed
35yo Asx man for routine physical - brisk carotid upstrokes and ejection click followed by stystolic ejection murmur at base of heart, also II/VI diastolic murmur at LSB wtd?
Echo -
mild dilation of LV wtd?
nifedipine/ACEi revent further dilation and systolic dysfxn
Coarctation of Aorta
Aw bicuspid AV
Delayed femoral-brachial pulse or absent femoral puulse
Early systolic murmur
Persistent HTN after surgical correction
BP higher in upper than LE
CXR rib notching 22/2 collateral vessels (“3” sign)
No need for abx ppx
Marfan’s syndrome
Decrased strength and dilation of aorta with aortic regurgitation and dissection Monitor yearly echos If >4.5cm - Echo q6month 5.5cm or greater - repair Prevention of dissection - BB
Pt with marfan’s has echo q6month - current echo 5.3cm - pt wants to wait
explain pt should consider repair now and the possibility of dissection in mean time
Eisenmenger’s syndrome
R-> L shunt
Cl ft - Cyanosis of mucous membranes
HTN
Systolic BP>disastolic BP as CVD risk factor
HTN screenings
Pt normal BP after age 18
Screen for HTN q2yr
What systoic BP aim for in elderly
SBP < 150
Diastolic HF more common in…
Women > 75 with systolic HTN
Isolated systolic HTN in elderly tx?
Thiazide diuretic 12.5-25 daily
Mild to mod HTN
Thiazide/chorothalaidone
HTN with LVH (S4+)
ACEi
HTN with renal insuff
ACEi
HTN with ischemic HDz
BB, CCB
HTN with DM/proteinuria
ACEi
HTN with CHF
ACEi, Diuretics, Carveilol
HTN post MI
BB, ACEi
HTN with gout
Losartan (ARB)
HTN with pregnancy
Labetolol, Methyldopa, hydralazine
NO ACEi
Thiazide s/e
Hyper Ca+ Hyper uricemia Hypo K+ Hyponatremia Inc'd dig and lithium levels
Does Angiotensin II blocker induce cough?
NO
Pt on HCTZ 25 daily BP still high wtd?
Restric fluid and salt
Pt HTN on HCTZ 25 daily - BP 160-148 Exam S4+ wtd?
add ACEi
Ma huang (ephedra) causes
HTN
18yo F 170/105 wtd?
Urine tox first
21yo Pt CP, cocaine + 160/100 wtdD?
benzo, nitrate, ASA
Prevent CP - no cocaine, CCB
Thoracic aneuysm
CP rad-> back Acute AR murmur Widened mediastinum Surgery if >6cm and asx OR symptoms at any size or dissections
Abdominal aneurysm
Interscapular pain
Surgery >5cm and asx
or Sx’s at any size
Dissecting AAA treat medically first with BB and nitroprusside if pain persists then surgery
68yo M ddmittened for urgent repair of 7.5cm AAA pt with DM and inc’d cholesterol - fhx MI at 57 next step?
No further testing
AAA screening
Anytime smoker age 65-75 - AAA US screening noce in MEN ONLY
No screening in women
73yo chrnoic smoker with family hx AAA has neg abd US for AAA wtd?
No additional US needed
73yo ex soker no fhx of AAA has small aneursym on US wtd?
Repeat US in 6 months
60yo M h/o CAD severe CP-<> back 190/100 HR 90 decresenco murmur dx?
Aortic dissection
Dx: TEE - or CT scan wo contrast if no TEE available
then tx with BB, IV nitropruside THEN surgery
A loose fitting/large fitting BP cuff will …
UNDERestimate BP
Small/tight cuff will…
OVER estimate BP
Porcine valve
No A/C
Prosthetic valve
Needs A/C
Valvuloplasty
Tricuspid stenosis, pulm stenosis, mitral stenosis
Temporary in Aortic stenosis
TEE needed for…
prostethic valve endocarditis
Desceding aortic aneurysm
Left atrial thrombus
PFO
Afib
atria fibrillating, no p waves
some imprulse conducted and cnotract ventricles - irregularly irregular ventricular response
Narrow QRS except with abberant conduction
New onset afib
w/in 48hrs
Paroxysmal afib
terminates spontaneously
Chronic
always in afib
Slow ventricular response in afib
BB
CCB
Digoxin
Convert to NSR
Amiodarone Ibutilide (prolongs QT) Quinidine Procainagmide Dofetilide (prolonges QT) Electrical cardioversion Dronedarone (ony med shown to decrease hospitazation -> avoid in pt with EF<35%)
Risk factors for afib
High risk -Prev stroke TIA or Embolism Mitral stenosis Prosthetic heart valve
Moderate Risk factors Heart failure HTN Age>75 LVEF<35% DM
Weaker risk factors Female Age 65-74 CAD Thyrotoxicosis
Afib tx
No risk factors - ASA 81
one mod risk factor ASA81 daily or wafarin INR 2-3
Any high risk factor or >1 mod risk factor - warfarin INR 2-3
CHAD Vasc
Vasc dz 1 point
Age 65-75 1 point
Sc=female=1 point
Heart dz with one major contraindication to warfarin
tx with ASA
Afib with wide compplex tachy
WPW tx with procainamide NO DIG NO BB NO CCB -> vfib
62yo pw palpiations EKG afib HR 100/min - started on BB - echo with no vavluar abnormalies and normal wall thickeness - BP 140/84 wtd?
ASA 81 (no risk factors)
76yo pt HTN pw palpitations - HR 110 HR 110, started on BB
Warfarin (one mod risk factor - HTN)
65yo afib h/o TIA in past
Warfarin (one high risk factor)
start on 5mg daily
Pt chronic afib on warfarin going for MINOR surgery
continue warfarin
Pt with chronic afib on warfarin going for major surgery wtd?
If CHAD score 2 or less -> D/C warfarin 5 days prior no bridge
If CHAD score 3 or higher -> D/C warfarin 5 day sprior and bridge with:
1. LMWH twice daily and last dose 24 hrs prior to surgery OR
2. LMWH once daily last dose 1/2 morning of procedure
On day of surgery pt INR 1.6 wtd?
Clear for surgery
Rate control and A/C in afib compared to DCCV show to ?
Decrease stroke
Decrease hospitalizations
Pt with chronic afib refractory to med tx or can’t tolerate meds wtd?
AVJ ablation with PPM
needs AC? - YES - atria still fibrillating
Young adult recurrent afib refractory to medical tx or can’t tolerate meds
Afib ablation - pulm vein isolation
Elderly pt pw weakness on L side body - EKG shows afib IV heparin started weakness resolves - carotid dopper hows L ICA >70% best tx?
warfarin + heparin bridge
Afib rate control goal
<110 (resting)
48yo M pw acute onset periumbilical pain - afib with RVR 130 bpm wtd?
arteriography r/o sequella afib emboli
Pt wtih afib tx’ing with diltirazem - rate control - echo structurally normal heart - pt comes back with inc’d sx palpitations - holter shows many episodes of afib where he had sx wtd?
Add BB
What drug will bring afib into NSR
ibutilide
Aflutter
macro re-entrant circuit - EPS for RFA
Atrial flutter rate 250-300
Usually 2:1 block HR 125-175
Etio Cardiac or pulm dz - can have WPW
First slow AV conduction BB, dilt then cardiovert with amiodarone/quinidine
Low energy DCCV or atrial pacing can also be done
Recurrent flutter - EPS/RFA
32yo F MS sudden palpitation - 150/min and regular - carotid massage slowed rate but then returned to 150 when stopped - dx?
Aflutter
MCC SVT
AVNRT 70%
Tx: carotid massage
Adenosine 6->
If wheezing then CCB
Orthodromic reentrant tachycarida
accessory pathway
EPS/RFA
down AVN, up accessory pathway - narrow complex
Tx: AVN blockers, vagal maneurvers
Antidromic re-entrant tachycardia
Accessory pathway
Down accessory pathway, up AVN
Wide complex
Treat like VT with procainamide or cardioversion
22yo palpitations pounding sensation in neck for several years - now worse - gets slightly dizzy at times - sx occur without warning while restig - when she breathes slowly and deeply palpiations resolve on own - EKG normal dx?
Paroxysmal SVT
WPW
Impulse via accessory pathway reach ventricle earlier than AV node -> delta wave, shortened PR on EKG
WPW can pw Afib, aflutter and vfib
DO EPS if aw any arrhythmia or unexplained syncope
Never tx wide complex tachy with BB, CCB or digoxin
Pt has SVT and respods to carotid sinus massage - pt asks how to prevent future episodes
teach vagal maneuvers
25yo palpitations, gradual onset - during episodes sinus tach 140 notes - asx EKG normal - echo normal - pt dx with inappropriate sinus tach wtd?
start BB
Youn athlete on routine physical found to have EKG with WPW, asx - can he play basketball?
YES
Pt pw palpitaitons, EKG Afib or SVT - after BB feels bette rand repeat EKG shows shortened PR - wtd?
EPS/ablation of errant tract
Pt pw wide complex tachycardia HR 200 QRS 0.14 pt has h/o WPW - unable to decide if is SVT with aberration or VTach - you woudl tx this patient with ?
Procainamide
Multifocal Atrial Tachycardia
Three or more distinct morphological types of "p" waves Seen in COPD, result of theophylline use Tx: Oxygen, Mg, inhaled bronchodilators 2nd: CCB NO DIGOXIN
PVCs
3 or more PVCs = NSVT
30 S of NSVT = sustained VT
Pt with muultiple PVCs wtd?
Look for organic heart dz - echo, stress, gated pool studies
If heart dz negative, asx - NO TX
If heart dz neg but symptoms -> BB
If heard dz postiive with LOW LVEF -> ICD
Sustained VTach - ICD
45yo healthy man who excercises everyday and asymptomatic, is going for elective major surgery - EKG reveals multiple PVCs wtd?
Clear for surgery
Ventricular tachycardia
3 or more consequential PVC Diff dx: SVT with aberrancy WPW LBBB
VT more likely if
QRS>0.14 LADev Fusion beats Capture beats Prsense of organic heard dz Cannon A Concordance of QRS in precordial leads Rate>100
30yo AA pt to ER with palpitations - found to be in arrhythmia adn hypotensive - defib twice and IV med is started - exam cervial axillary and epitrocheal LN ++
Dx: Sarcoidosis
Prolonged QT interval
Quinidine Disopyramide Methadone Azithro Procainagmide Hypokalmeia, hypo Mg+ Pentamidine Erythromycin Phenothiazine TCA, moxifloxacin Ariprazole
Torsade de points
tx: D/C offending drug
Overdrive pacing
Mg SO4
MCC sudden cardiac death
ishemia
What dec’d short term mortality in pt with vfib
Defibrillation
What is most effective timing of defib
CPR then defib
Pt with Vfib collapse in ER - defib x 2 but short while later vfib twice more wtd next?
epinephrine
check electrolytes
amiodarone
Best managment in pt with fhx sudden cardiac death
ICD
Indications for ICD
Sudden cardiac death VT or Vfib EF<35% with CHF irrespectie of etio NICM - 3 monthas fter med therapy ICM - 40 days after MI HOCM with NSVT and fhx SCD
21yo F wakened by alarm clock and minutes later has syncope - EKG prolongued QT and TWi - hx might be helpful is?
fhx sudden cardiac death
60yo F c/o recurrent excercise idued palpitations with near syncoep - pt fhx near syncope in mother and daughter - EKG QTc 460, EF 55% next step?
BB therapy (sotolol)
42yo Asian man with sudden cardiac arrest - EKG Vfib - defib’d successfull - EKG now ST elev in V1-3 and asx - pt fhx father dying at age 40 dx?
Brugada syndorme
tx: ICD
Pt with h/o dizziness passing out for few sesonds - h/o palpitations
Holter montior (continuous loop recorder)
Pt with palpitations 2-15 minutes - NO SYNCOPE
Event monitor - press button to start
First deg AVB
conduction impulse to ventricles delayed PR>0.2 intranodal block with benign process NO NEED FOR PPM (if suspecting endocarditis -> may have new 1st deg AVB)
2nd deg AVB type I (mobitz I/wenkebach)
prolonguing PR till dropped QRS
no need for PPM unless very low HR or HD problems
Pt with inf wall MI had PCI now stable - 3 days later tele shows 2nd deg AVB type I 50bpm no sx - wtd?
Close monitoring as outpt
reduce BB dose
Block in AVN
2nd deg AV block type II
PR prolonged but constant with sudden drop QRS
If 2/2 IWMI/RV MI usually transient and doesn’t required PPM (may need atropine or TVP)
If 2/2 AWMI - more extensive damage - may need PPM
Infranodal block
3rd deg AVB
atria and ventricles beathing at own rate - cannon A waves on JVP
PPM needed
Acute MI with new bifasciular block -> high risk for progression to CHB
Indications for PPM
2nd deg Mobitz II 3rd deg AVB Pause dep VT sinus nodes dysfxn - HR3s, Mobitz II AVB with bifasciular block, post op AVB CHF with prolonged QRS - use bivi ppm
75yo M intermittent palpitations denies SOB or syncope - pt on BB and ACEi for HTN - EKG NSR 66bpm - holter with HR 35-106 during day
PPM (need for tachy brady to tx palpitaitons)
80yo for regular checkup found to have HR 45 - holter shows rate max 55, drops to 38 during night at one point - no sx
reassurance NO PPM
65yo F SOB on exertion CHF EF 22% on nitrates, BB, ACEi, spironolactone and dogxoin QRS>0.12 what else to decrease sx?
BIVICD
Junctional rhythm
Junctional tachycardia Vrate 70-130 p wave may be inverted - buried beneath QRS or following QRS Etio: Dig toxicity IWMI Myocarditis Post cardiac surgery
Sinus bradycardia
HR<60
Hypothermia
Hypothyroid
Sick Sinus syndrome
SA node problem causing bradycardia, block, arrest or tachy-brady syndrome
No need for EPS -> directly to PPM
Tx: PPM if:
1. Symptomatic
2. Tx of tachyarrhythmias causing significant bradycardia
Digoxin
inc’d vagal tone
Wt loss
anemia
AVN block -> Jnc rhthym -> regularized afib -> dig tox
Digoxin effect
Scooped ST segment No tx (not dig toxicity)
Anti arrhythmic drugs
ClassI decrease upslope of action potential
Ia: Disopyramide, Quinidine, Procainamide (Double quarter Pounder)
Ib: Lidocaine, Tocainide, Mexiletine, Phenytoin (Letuce Tomato, mayo)
Ic: Flecanide, Propafenone (Fries Please)
Class II: decreases synpathetic activity
Beta Blockeers
Class III: prolongs action potential
Amiodarone, Sotolol, Bretylium
Class IV: CCB
Others: Adenosine: slows AV conduction
Digoxin
Toxicity of Antiarrhythmics
Quinidine -> prolongues QT, dec’d plts
Procainamide -> Drug induced lupus (anti-histone)
Lidocaine -> seizures
Amiodarone -> Pulm fibrosis, hypo/hyperthyroid, COrneal deposits
LAenlargement EKG
M shaped pwave (MS)
RAEnlargment
Tall p wave
RVH
R wave V1, RADev
RBBB
R, R’ V1-2
LBBB
R R’ I, aVL, V6
Digoxin: Normal level <1ng/mL
Toxcity - anorexia/wt loss
Regularized afib - weight loss
EKG Jnc Tachycardia, PAT with block, PVCs
Predisposing factors for dig toxicity
Low K
Low Mg
Low Renal Fxn
Low O2
Drugs tha tincrease Digoxin level
Quinidine Amiodarone Verapamil Spironolactone Chlorthalidone/HCTZ
Treament of Digoxin toxicity
Correct electrolytes BB Lidocine/phenytoin Digoxin binding antibodies - if pt with life threatening arrythmia NO QUINIDINE, NO PROCAINAMIDE
Pt with afib started on Digoxin - regularized afib on EKG wtd?
D/C Digoxin
Elderly pt with Cr 1.3 on lisinopril, glizpiide mirtazapien and digoxin 0.25/day with gradual wt loss wtd?
lower digoxin dose
Pt on digoxin and amiodarone is added wtd?
Decrease digoxin dose
78yo M SOB with Cr 1.5 on digoxin and warfarin - EKG HR 96 looks regular with regular with retrograde pwave
Dig toxcity - check electrolytes
pAT with block
