Cardiology Flashcards
Right BBB
Delays R ventricular depolarization - right begins when LV is almost fully depolarizaed
Criteria:
- widened QRS (0.12) in any lead
- V1 or V2 w/RSR’ (rabbit ears) and T wave inversion
Dx:
- complete: all criteria
- incomplete: narrow QRS w/RSR’
Left BBB
Delayed LV depolarization
Criteria:
- widened QRS (0.12) in any lead
- V6 had broad and/or notched R wave (slurring)
Dx:
- ECG diagnosis of MI cannot be made reliably w/LBBB
- treat new LBBB like MI
L anterior fascicular block
Conduction rerouted through L posterior fascicle to inferior heart
Retrograde depolarization from L posterior fascicle - depolarization starts inferior and progresses superior, R to L
Criteria:
- L axis deviation (-30 to 90) w/no other causes of LAD
- QRS, ST, and T normal
L posterior fascicular block
Conduction rerouted through L anterior fascicle to inferior heart
Depolarization starts superior to inferior, L to R
Criteria:
- R axis deviation with no other causes
- QRS, ST, T normal
Bifascicular block
L anterior or posterior fascicular block + a RBBB
PVCs
MC ventricular arrhythmia*
- wide QRS among regular QRS, followed by compensatory pause
- often occurs in normal hearts
Concern:
- > 3 in a row (Vtach)
- frequent, increased risk for progression to Vtach
- nonsustained or sustained (>30s)
- multifocal (different morphologies)
- PVCs falling on T wave = R on T phenomenon
- PVCs during/after MI = a lot of injured tissue
Premature junctional beat
no or inverted p-wave w/normal QRS
amplitude may be different
Essential HTN general
Et: age, AA, familial
CV RF: HTN, smoking, obesity, physical inactivity, dyslipidemia, DM, microalbuminuria (or GRF<60), age, Fhx of premature CVD
Consequence: end-stage organ damage
- atherosclerosis, stroke, CHF, renal failure, vision loss, brain damage, metabolic syndrome
Primary prevention
- diet: dec alcohol, sodium, increase fruit/veggie, low fat/red meat
- exercise, wt loss
- assess RF and comorbidities
Assess EOD:
- UA: proteinuria, microalbuminuria
- blood glucose: metabolic syndrome, DM
- Hct: anemia, CKD
- Lipid panel
- BMP: kidney
- ECG: LVH, LAE, arrhythmias
- TSH: hyperthyroidism
PE: fundoscopy, carotids, heart sounds, PMI, peripheral pulse, edema, crackles
Essential HTN dx/tx
Dx
- 2+ measured BP readings on 2+ office visits (7d to 2mo apart)
- pt w/EOD on first occurrence, do not wait to diagnose
- check BP outside of clinic as well, ambulatory monitoring
- yearly repeat on labs, especially BMP for electrolyte abnormalities if on a med*
Mgmt:
- BP, cholesterol, blood sugar, smoking, diet, weight, exercise
- DASH Diet: fruits, veggies, low-fat dairy, reduced saturated and total fat, reduced sodium, dec alcohol, high K and Ca
Goal: dec <140/90 w/in 1 month
Meds:
- TZD: hypoK, hyperuricemia, Dec mortality
- ACE: hyperK, Inc BUN/Scr, angioedema, chronic cough
- DHP-CCB: peripheral edema, use long-acting (short-acting can increase r/o MI)
- BB: labetalol w/pregnancy
AA: thiazide (HCTZ) or CCB (amlodipine)
CKD: ACE or ARB
Second line:
- spironolactone
- alpha blockers
- direct vasodilators (hydralazine)
- central alpha-adrenergic AG (clonidine, methyldopa)
- renin inhibitor (aliskiren)
Secondary HTN
Causes:
- RAS, DM**
- Adrenal: Cushing’s, pheochromocytoma
- Stress: anxiety, pain, white coat
- Meds: OCPs, steroids, NSAIDs, cyclosporine, ephedrine, stimulants, MAOI, cocaine/meth
- Other: pregnancy, aortic coarctation, OSA*
Sxs: BP not responding to medication or increased creatinine w/initiation of lisinopril
Additional dx: echo, ambulatory BP, urine microalbumin, plasma renin activity, urine catecholamines, renovascular doppler U/S, angiogram
Tx underlying cause
Stable angina pectoris
Ischemic heart disease:
- insufficient O2 supply to cardiac muscle (MC atherosclerosis)
- MC cause of CV death/disability
RF: smoking, dyslipidemia, HTN, FH, sedentary, overweight, DM, stress/depression, alcohol
Sxs
- substernal CP aggravated by exertion or emotional stress; relief with rest or nitrates
- well-defined, predictable and unchanged*
Dx:
- ECG normal, may see Q wave, nonspecific ST-T changes, LVH or BBB
- cardiac enzymes
- CBC, FLP, FBG
- stress test, coronary angio
Mgmt:
- pt ed on when to seek help; inc exercise; heart healthy diet; moderate alcohol; wt loss; stop smoking; manage comorbidities
- daily ASA 81mg*
- ACE if HTN, DM, EF<40%, CKD
- SQ NG for acute sxs relief, q5 min x3, then call EMS
Nitro: Dec afterload, lower O2 demand, dilates coronary arteries
- don’t give if hypotension
BB: angina sxs, old MI, EF <40% to help prevent angina episodes
Revascularization indicated for pt not managed on medical therapy*
Giant Cell Arteritis
Large vessel vasculitis affecting vessels arising from aortic arch
- patchy pattern, granulomas
MC vasculitis in adults, MC in women
- average age: 70y
Complication: permanent blindness if ophthalmic artery is involved
- high risk for thoracic aortic aneurysm
Sxs:
- temporal HA, visual disturbance, scalp tenderness, jaw claudication*
- constitutional: fever*
- possible sudden monocular vision loss
- CN, peripheral neuropathies, dementia
- MI
- polymyalgia rheumatica*: symmetrical pain, stiffness in shoulder/pelvic girdle muscles for >1mo in pt >50y w/inc ESR & rapid response to steroids
Dx: markedly elevated ESR, CRP*
- N/N anemia, normal WBC
- multinucleated giant cells, histocytes, and CD4 T cells
- Gold standard** = temporal artery biopsy**
Criteria: age of onset > 50y, new HA, temporal artery abnormality, increased ESR, abnormal artery bx
Mgmt: Prednisone* until symptoms resolve (2-4wk)
- urgent referral if dx is suspected
- start low dose aspirin at dx as well
Phlebitis / Thrombophlebitis
Superficial* venous stasis / thrombosis leading to venous inflammation
- inflammation d/t small thrombus formation in vein cause partial/complete occlusion
- usually short term w/out complications; may occur spontaneously after trauma
RF: Virchow’s triad (venous stasis, vascular injury, hypercoaguability)
Sxs:
- dull pain, erythema, induration of vein
- NOT a DVT
- sxs usually go away 1-2wk, hardness of vein may remain much longer
Dx: compression U/S
- 25% have underlying DVT
Mgmt: LMWH for 45d if >5cm
- reduce discomfort and swelling
- support stockings, elevation of affected extremity, warm compress
Varicose veins
Dilated, elongated, tortuous, SQ veins 3mm or greater
- MC: greater saphenous
RF: age, obesity, FH, prolonged standing, pregnancy, smoking, sedentary, childbirth, trauma, DVT, female sex
Sxs: spider veins, dermatitis, edema, ulcers, pain, cellulitis
- venous stasis ulcers: MC over medial malleolus*
- dilated veins, edema, lipodermatosclerosis (fibrosing dermatitis of SQ tissue), ulceration*
- other: heaviness/ache, dry skin, tightness, skin irritation, muscle cramps, itching
Dx: venous duplex U/S to r/o DVT
- determine valve function and reflux
Mgmt:
- reduce discomfort and swelling, stockings, elevation, warm compression*
- sxs: typically require 3mo of conservative treatment prior to more therapy
E.g.
- sclerotherapy
- RFA
- laser ablation
- vein stripping
Venous insufficiency
Veins have difficulty sending blood back to the heart from the periphery d/t loss of wall tension**
- typically LE
RF: old age, obesity, prolonged standing, childbirth, trauma, DVT, FH
Causes: venous HTN, obstruction to flow, valve dysfunction, failure of venous pump
Sxs: spider veins, varicose veins
- venous stasis dermatitis: sloughing of skin, cyanosis, shiny appearance
- edema worse w/dependency
- stasis ulcers (atrophied skin)
- pain worse w/menstrual cycle or pregnancy
- cellulitis, phlebitis
Mgmt: elevation of legs, compression stockings, avoid prolonged standing*
- treat stasis dermatitis w/hydrocortisone cream, wet compress
- treat stasis ulcers w/compression boots or skin grafting
