Cardiology - 13% Flashcards
Atrial Fibrillation Anticoagulation
CHA2DS2VASc + Anticoag Meds
Atrial thrombi form after 48 hr of AF, usu in L atrial appendage
CHA2DS2VASc >/= 2
- CHF
- Hypertension
- Age > 75yo = 2pts
- Age 65-74 yo
- DM
- Stroke, TIA, Thrombus = 2 pts
- Sex - Female
- Vasc dz
Score 0 - ASA 81 - 325 mg daily
Score 1 - ASA or Anticoag
Score 2+ - Anticoag
Warfarin (Coumadin)
- PT and INR - 2-3 is therapeutic
- bridge with Heparin or Enoxaparin for 3-5 d
- Hepatic metabolism CYP2C9
- Enhance Warfarin - Fluconazole, amiodarone, sulfamethoxazole, grapefruit juice, etoh
- Reversal with Vit K and FFP
DOACs
- Dabigatran (direct thrombin), Rivaroxaban, Apixaban, Edoxaban
- Immediate action
- no routine lab monitor
- Adjust for renal insufficiency
- Dabigatran reversal - Idarucizumab
- Xa inhibitor rev - Andexanet alpha
Atrial Fibrillation
Eti, Sxs, Dx, Tx
Irregularly Irregular rhythm - SVT
MCC - mitral valve stenosis, hyperthyroidism
3 types
- Paroxysmal - AF terminates spont or win 7d
- Persistent - AF > 7d and need pharm or DCCV to terminate
- Permanent - AF remains despite mult interventions and attempts to regain SR
Sxs:
- Stable AF - SOB, Chest Pain, Dizziness, Fatigue
- Unstable AF - CHF, hypotension, unctrl angina
Dx:
- EKG - Irregular irreg rhythm, No discernable P waves, Atrial rate >300bpm, variable and irreg QRS
- Labs - CBC, BNP, DDimer, Cardiac enzymes, TSH
- Echo - valvular, tachy med CMO
Atrial Fibrillation
Treatment
Rate control - BB (metop, Esmolol), **CCB (Diltiazem, Verapamil) - slow condution through AV node, or digoxin (for CHF or hypotension)
Rhythm Control - Direct current CV,antiarrhythmic meds
-
Amiodarone (class 3 K+ blocker) - prolong QT, check liver and TSH/T4,
- blue/gray skin pigment, ocular toxicity (halo vision), interstitial lung dz (Rountine PFT)
-
Sotalol - Class 3 - prolong QT
- avoid in CHF, asthma, renal
- Flecainide, Propafenone - Class 1C Na ch - pill in pocket
Treatment Algorithm
- Unstable - DCCV
- Stable
- <48 h
- DCCV or
- Rate Control/anticoag = 3 wks before come back for DCCV or antiarrhythmics
- >48 h -
- Rate control/anticoag
- TEE - no clot, then DCCV
- <48 h
NSTEMI/STEMI
Treatment
Reperfusion is KEY - done w/in 12 hrs of onset
Immediate Tx in ED
- ASA 325mg
- Nitroglycerine subling 0.4mg x3 q5m (no for RV infarc)
- O2 if <90%
- Morphine - avoid if hypotensive, if pain is not relieved with 3 NTG
After stabilization:
- BB (metoprolol, atenolol preferred)
- hold if CHF (decr contractility at first)
- Statin
- ACEI/ARBS - pril - if on LV dysfunction
- prevent ventricular remodeling
- decr mortality
PCI
- best within 90 mins
- TOC in cardiogenic shock - hypotensive in setting of MI
- > thrombolytics
Thrombolytics/Fibrinolytics
- use if PCI is not available
- new EKG ST elev, LBBB
-
time onset of sxs <12 hr
- Alteplase (tPa) - activates plasminogen to destroy clots
- Streptokinase - less effective than tPa, less chance of ICH
Maintenance
- Antiplatelet therapy
- Aspirin - inhibits plt activation and aggregation via COX1
- P2Y12 inhibitor - 5-7 d washout
- Plavix/clopidegrol,
- Ticagrelo/Brilinta - quicker onset, cant use higher then ASA 100 mg
- Prasugrel (avoid if hx TIA/CVA or >75yo)
- Anticoagulant therapy
- Unfrc Heparin - binds to antithrombin
- LMWH - better for DM
- Anti-ischemic therapy
- BB - decr symp drive
- Nitrates - venodilation
- CCB - verapamil/diltiazem - decr contractility
STEMI
ACS
Coronary Artery Disease
Sxs:
- CP, L arm pain, N/V, dyspnea, diaphoresis
Leads
- V1, V2, V3, V4- Anterior → LAD
- V1, V2 - Septal
- I, aVL, V5, V6 - Lateral → Circumflex
- II, III, aVF - inferior → RCA
Dx
- ST elevation >/= 1 mm in at least 2 anatomically contiguous leads + reciprocal changes in opposite leads
- A NEW LBBB = STEMI
- Ele Trop > 0.08
- Appears 3-12 hrs
- Peaks 24-48 h
- Lasts 5-14 days
- Ele CK-MB
- Appears 3-12 hrs
- Peaks 24 h
- Lasts 2-3 days
Unstable Angina & NSTEMI
ACS
Coronary Artery Disease
Previously stable & predictable => more freq and intense
new onset or severe or worsening angina, occurs at rest
Dx -
- EKG - ST depr or T w inv
- Normal CKMB and trop = UNSTABLE ANGINA
- Abn Trop = NSTEMI**
- high risk - L heart cath
- low risk - echo, noninvasive test
Tx
- progression to MI if untreated
- Nitroglycerin and morphine
- Stress test - if cath or revasc necessary
Anaphylactic Shock
food allergy, insect stinc, iodinated contrast, blood transfusion
Mediated IgE ab response => release of mast cells => loss of vascular tone & incr cap permeability => HYPOTENSION
Sxs
- bronchospasm, angioedema, urticaria, rash, profuse rhinorrhea,
- N/V, tachycardia
Tx
- Epinephrine - IM 1:1000 autoinjector 0.3mg/injection for adult patients
- IV Epi
- antihistamines
- CS
- IV Fluids/volume
Aortic Aneursym/Dissection
Vascular Disease
Tear through all three layers of artery (intima, adventia, media) w/ blood pooling
RF - atherosclerotic, HTN, HLD, smoking*
Sxs:
- tearing chest pain; r->back
- hypotensive, tachycardic, tachypnea
- Cool extremities
- diaphoretic
- back/flank pain when unruptured
Dx:
- Screen with US for any M > 65yo who have smoked >100cigs/lifetime
- different BP in R and L UE
- CXR - first line - widened mediastinum
- CT*** - gold
- Trop/BNP r/o MI
- EKG
Tx:
- Thoracic Aorta
- Type A - Ascending Aorta => Immediate Surgery
-
Type B - Descending/Abdominal => HTNsive mgmt to prevent progression
- <3cm = observe
- 3-5.5 = CT q 6 mos surveillance
- >5.5 = Surgery - stent to reinforce aorta
- Long term management
- BB - control HR/HTN, DM
- at least 6 mos anticoag with Warfarin or DOAC
Aortic Regurgitation
Valvular Disease
Congenital bicuspid valve, Dilated aortic root, Aortic dissection; Marfan’s syndrome (large diameter), Syphilis/Lupus
Sxs:
- Syncope, SOB, CHF, pulm edema
- blowing, decrescrendo DIASTOLIC murmur
- widen pulse pressure (180/50), Corrigan/water hammer pulse, bounding femoral
- RUSB 2nd ICS
- Murmur is louder with increase venous return (squatting)
Dx:
- Echocardiogram - TEE is better
Tx:
- Aortic Valve replacement
Aortic Stenosis
Valvular Disease
Usu d/t atherosclerotic dz, stiffened AV; congenital AS, bicuspid AS
Sxs:
- Dizziness, syncope w/ exertion - not enough blood going to body
- angina, SOB
- delayed carotid upstroke
Dx:
- RUSB 2nd ICS
- Harsh crescendo-decrescendo murmur (louder with squatting)
- Radiates to Carotids
Tx:
- Balloon valvuloplasty temporary
- Total AV Replacement
Arterial Occlusion or Thrombosis
Vascular Disease
Recent injury, clot in med/small artery vessel d/t A Fib
MC in anterior calf or forearm
Sxs: 6Ps
- Pain
- Pallor
- Pulselessless
- Poikilothermia - loss of heat
- Paresthesias
- Paralysis
Dx:
- Doppler US for blood flow
Tx:
- Surgical Emergency - angioplasty, stent or embolectomy
- Anticoag - Heparin or LMWH
Printzmetal Angina
Coronary Artery Disease
vasospasm - smooth m contractions
Eti - Worse with Triptans, ergotamine, cocaine, smoking, > 50yo, F
non-exertional CP
cyclical - usu in the morning
Dx:
- EKG - ST or T waves elevations, Inverted U waves
- Normal trop and CKMB
Tx - CCBs
Stable Angina
Coronary Artery Disease
Angina brought on by exertion, emotional upset - relieved w/ stress in a few mins (<15mins)
Sxs
- Levine’s sign
- tightness, pressure
- indigestion/burning r-> L chest or mid sternum, jaw, shoulder
Dx
- EKG usu normal w/ temporary ST depression, T wave depression or inv
- neg trops
-
Stress test - exercise or pharmological (adenosine or Persantine)
- hold negative chronotropics (HR - BB, CCB, digoxin) morning of Stress test
- Coronary angio - gold std***
Tx
- ASA - antiplatelets (inhibits COX1)
- BB - neg chronotropic - Decr HR, decr O2 demands
- avoid if SBP <100, HR < 60
- CCB - decr BP and vasospasms
- Nitrates - vasodilate, decr pre/afterload, dilate coronaries;
- decr cardiac O2 (ask about Viagra, cialis - hypotension)
- Ranolazine (Ranexa) - no affect on HR and BP
- Statin- decr LDL
Cardiac Tamponade
Traumatic/Infectious Heart Condition
fluid compromises refilling - collapsed R ventricle (weakest wall) and impairs CO
Sxs:
- Pulsus paradoxus - > 10 mmHg decrease in systolic when pt inspires
- Tachycardia, Tachypnea
- Narrow pulse pressure (180/130)
- Kussmaul’s sign - rise in JVP on inspiration
-
Beck’s Triad***
- JVD
- Muffled heart sounds
- Hypotension
Dx
- CXR - water shapped, jug shaped heart, > 50% of mediastinum
- EKG - electrical alternans
Tx -
- give fluids for volume expansion to tx hypotension
- pericardiocentesis immediately
- Pericardiectomy - window
Cardiogenic Shock
Eti - Acute MI, ventricular arrhythemias, Heart block, Valvular HD, BB/CCB overdose
Pump failure - depressed CO = hypoperfusion = kidney, resp, lliver failure
Sxs
- Hypotensive
- Tachy
- S3 gallop
- cool, clammy, pale, ashen skin, oliguria, pulm edema (fluid backing up)
Dx - ICU monitor w/ Swan gaz cath, monitor CO and index
Tx
- vasopressor - norepi, dopamine,
- Inotropes - (help incr contractility) = Dobutamine, Milrinone
- Intraortic pump
Congestive Heart Failure
eti, sxs, dx
Left Sided HF
- Volume overload - S3
- Dyspnea, SOB, exertional fatigue, Orthopnea, PND
- Enlarged or displaced apical pulse dt LVH
Right Sided HF
- Edema, wt gain, JVD, HJR,
- Hepatomegaly, RUQ pain, RV heave
Dx:
- CXR - Kerley B lines, Pulm effusion/edema
- Labs - CBC, TSH (high output), BNP, BUN/Cr, BNP
- if HyperK - avoid ACE-I
- Echocardiogram* - assess fx
-
NYHA
- Class I - Risk but no symp
- Class II - risk with vigorous activity
- Class III - sxs w/ ADLs or min activity
- Clas IV - sxs at rest
Congestive Heart Failure
systolic vs diastolic
High CO failure - high demands for blood circ - thyroid storm, beriberi (B1 thiamine deficiency), Paget’s Dz of bone, AV Fistula, etc
Low CO failure = 1. Systolic Dysfunction 2. Diastolic Dysfunction
Systolic Dysfunction - decr contractility, CO - LVEF < 50%
- Valvular dz
- Ischemic CMO
- Dilated CMO - viral, etoh, postpartum, chemo-induced Doxorubicin
Diastolic Dysfunction - impaired ability of hear to relax - LVEF >50%
- restrictive CMO amyloidosis, sacroidosis
- HOCM
- HTN
Congestive Heart Failure
treatment
Sxs control, reduce cardiac workload - treat HTN, control fluids (2L fluid restriction)
-
Loop Diuretics - Furosemide, Torsemide
- reduce NaCl abs = free water excretion
- monitor K, Mg, Na
- SE - ototoxic sulfa allergy
- need K supplement
-
ACE-I or ARBS - statins, sartans
- prevent remodeling of heart = lowers mortality
- decr preload and afterload - 1st line for systolic dysfx
- monitor Cr - renal dysfx => may cause hyperK
-
BB - Carvedilol, Metop-succinate XL, Bisoprolol
- prolongs survival, incr LVEF
- control rate, prevents arrhythmias
-
Mineralocorticoid (Aldosterone) Receptor Antagonist - Spironolactone
- Aldosterone - contributes to cardiac hypertrophy and fibrosis
- decr fluid retention
- monitor K for hyperK - check labs 3-4 d*, few wks after ( cant use if K>5)
- SE - gynecomastia
-
ICD - risk of VT and VF
- if Acute MI EF <30%
- Class II or II and EF <35% w/ sxs
Right Bundle Branch Block
Conduction Disorders
Conduction comes from L ventricle so widened QRS
V1 - R-R’, V2 (bunny ears), V3
RBBB in asymptomatic - fine
new RBBB + CP = occlusion in L anterior descending artery
new RBBB + dyspnea = Pulm embolism, myocarditis
First Degree Atrioventricular Block
Conduction Disorders
constant prolonged PR Intvl = > 200 msec or 0.2
no tx necessary, monitor
Second Degree Atrioventricular Block
Type I
Conduction Disorders
Mobitz 1 - Wenckebach
progressively lengthening PR interval until P wave drops, PR then resets
r/o hyperK or digoxin toxicity
Tx:
- none if asymp
- Atropine, epinephrine, +/- pacemaker
Second Degree Atrioventricular Block
Type II
Conduction Disorders
PR interval constant until P wave drops randomly
Tx:
- Atropine
- Temporary pacing
- Permanent pacemaker definitive
- progression to 3rd degree high
Third Degree Atrioventricular Block
Conduction Disorder
No relationship btwn P and QRS - atrial and ventricles are firing separately. All P waves not followed by QRS = Decr CO
Sxs:
- Syncope, Dizziness, acute HF, hypotension, cannon A wave
Tx:
- Permanent Pacemaker
Atrial Flutter
Conduction Disorders
Atrial focus of ~250-350 bpm
Sxs:
- SOB, dizziness, fatigue
Dx:
- EKG - Saw tooth pattern, regular rhythm
- Atrial rate 240-320bpm
- Ventricular 150bpm
Tx:
- Rate control BB, CCB, Digoxin*
- Anticoag if CHAD Vasc >/=2
- Warfarin or DOAC
Left Bundle Branch Block
Conduction Disorders
L ventricle will depolarize from impulses from R ventricle - partially or completely outside conduction system = Widened QRS
- Completely LBBB > 0.12 seconds
- Incomplete LBBB < 0.12 secs but can develop into complete
Signifies Ischemia and structural heart disease
Premature Atrial Contractions
Conduction Disorders
ectopic focus but still impulse goes through AV and bundle of His so normal QRS complex
P wave morphology depends on where ectopic beat is - close to SA node = normal looking P wave, otherwise, it is wider
If impulse is close to AV node, atria depolarize opposite direction = retrograde P wave
Next beat has longer interval
Tx - none, BB, CCB
Premature Ventricular Contractions
Conduction Disorders
Ectopic beat from ventricular foci - wide QRS complex >0.12s + opposite deflection
not a/w P wave
Sxs - palpitations
Tx - BBs and other anti-arrhythmics
Sinus Arrhythmias
Conduction Disorders
Irregular patterns in rate of NSR
- Respiratory or phasic
- normal - decreases w/ age
- Inspiration - increase sinus rate (inhibits vagal tone)
- Expiration - rate declines
- Nonrespiratory or nonphasic
- not related to respiratory cycle
- d/t normal, diseased heart or digitalis intoxication
- Nonrespiratory, ventriculophasic sinus arrhythmias
- 3d AV block
- intermittent differences in PP intvls
Sick Sinus Syndrome
Conduction Disorders
Dysfunction of Sinus node’s automaticity and impulse generation
EKG:
- sinus rhythm with resting HR of 60bpm
- Sinus pause < 3s
- Sinus arrest > 3 s
- tachy-brady alterations
MC in elderly
Worse with digitalis, CCB, BB, antiarrhythmic
Tx - permanent pacemaker
Torsades de Pointes
Conduction Disorders
Sudden cardiac arrest
a/w palps, dizziness, syncope
EKG - polymorphic V Tach
either from HypoK or HypoMg
rate btwn 150-250
Either cease spontaneously or degenerate into VFib
Tx- IV Magnesium
Cardiovert if unstable
Ventricular Fibrillation
Conduction Disorders
Uncoordinated quivering of ventricle w/ no useful contractions
No P waves, QRS Complexes, or T waves,
Rate 150-500 bpm
pulseless
Tx:
- Severe hypotension or LOC = Sync Cardioversion
-
Pulseless V Tach = Defib and CPR
- 1mg IV bolus epi, q 3-5 mins
- Defib 30-50sec
- Refract V Fib - IV Amiodarone
- Implantable Defib
Ventricular Tachycardia
Conduction Disorders
a/w CAD, MI, Structural Heart Dz
Three or more consecutive Ventricular Premature Beats
Regular rhythm - Wide and regular >120, wide QRS >0.12
Tx:
- Cardioversion if unstable
- Stable → IV amiodarone
- Unstable w/ pulse → sync cardioversion
- VT no pulse → Defib
- Evential ICD placement
- Non-sustained VT
- No heart diz or asymp - no tx
- Heart dz, recent MI - electrophysiology study
Dilated Cardiomyopathy
Systolic dysfunction => ventricular dilation => decreased contractial function => reduced CO
Eti:
- MC in 20-60yo, M, idiopathic 50%
- viral myocarditis - Enteroviruses (Coxsackie B), Chagaz dz
- Toxic - etoh abse, cocaine, doxorubicin, radiation
Sxs:
- systolic HF - fatigue, DOE
- mitral or tricuspid regurg
- lateral displaced PMI
- S3 if
Dx:
- CXR - enlarged heart, pulm edema, pleural effusion
- Echo - LV dilation, decr EF, regional or global LV hypokinesis
Tx:
- HF Tx - ACEI, diuretics, BBS, Digoxin, NA restrictionn
- ICD if EF < 30-35%
DDx
- Takotsubo CMO - broken heart syndrome, apical L ventricular ballooning d/t catecholamine surge
Endocarditis
dx, tx
Traumatic/Infectious Heart Condition
Modified Duke Criteria
Major
- bacteremia 2+ blood culture
- Echo w/ evidence of vegetation
- Newly dx valvular regurgitation
Minor
- RFs - IVDU, indwelling cath, weird valvular morphology
- Fever > 38C or 100.4F
- Vasc or embolic phenomena - Janeway lesions
- Immunologic phenom - Osler nodes (ouch), Roth spots, acute GMN
- Positive blood cultures not meeting major criteria
Tx
- Acute/Native Valve
- Nafcillin + Gentamicin; Vanco if MRSA+
- Subacute (HACEK organisms)
- Pencillin or Ampicillin + Gentamicin
- Vanco if MRSA+
- Prosthetic valve
- Vanco+Gentamicin + Rifampin (For S aureus)
- Fungal
- Ampho B for 6-8 wks
Endocarditis
eti, sxs
Traumatic/Infectious Heart Condition
MC Native Valve infx - Mitral - Strep viridans, S aureus, Enterococcus
IVDU - S aureus in tricuspid; Prosthetic - S. aureus or fungal if w/in 2 mos of implantation
Sxs:
- Fever,
- non spec sx - dyspnea, CP
- Murmur
- Janeway lesions - painless macules on palms and soles
- Roth spots - retinal hemorrhages w/ pale centers
- Petechiae
- Splinter hemorrhages
Primary Hypertension
Diagnostic Criteria
start screening at 18yo
Primary HTN resting systolic BP >= 130 or diastolic BP >/= 80 on at least two readings, on at least two separate visits with no identifiable cause
Sxs
- Fundoscopy - AV nicking in retinal a., Retinal hemorrhages, papilledema, cotton wool spots
- LVH - displaced apical pulse
Dx
ACC/AHA Guidelines
- Normal - < 120/80
- Elevated - 120-129 / < 80 mmHg
- Stage 1 - 130-139 or 80-89 mmHg
- Stage2 - >/= 140 mm Hg or >= 90 mm Hg
JNC-8 Guidelines
- Gen pop, age < 60yo = BP < 140/90 mmHg
- Gen pop, age > 60yo = BP < 150/90 mmHg
- Pts w/ DM or CKD (regardless of age) = < 140/90 mmHg
Primary Hypertension
Medications
LSM - Weight reduction, DASH diet, Decrease Na intake, no etoh, aerobic exercise
For Gen pop and all DM
- Non-black - Thiazide diuretic, or ACEI/ARB, or CCB or combo
- Black - Initiate Thiazide diuretic or CCB alone or in combo
- low renin state***
Chronic Kidney dz
- ACE I or ARB
- careful if >75 with CKD risk of hyperK
Thiazide Diuretics
-
‘Chlorthalidone, HCTZ, chlorothiazide’
- Blocks Na and Cl reabs
- Good for osteoporosis - incr Ca reabs
- Good for AA pts, careful with gout or hypercholesteremia
- Full anti-HTN effects 12 wks
- SE - hypokalemia, sulfa allergies, gout and DM
CCBs
-
Dihydropyridine - ‘dipine’
- ‘Amlodipine, nifedipine’
- No effect on cardiac contractility & conduction
- Effective in elderly
-
Non-dihydropyridine - ‘verapamil” & ‘diltiazem’
- Vasodilator
- Affects contractility and conduction; avoid in HFrEF
- Monitor for arrhythmias
ACE - ‘pril’
-
‘Lisinopril, catopril, enalapril, ramipril’
- Systolic HF, prior MI, CKD Renal protective - preferred for DM
- SEs - Bradykinin - cough; incr risk of angioedema, hyperkalemia
- C/i preggo
ARB - ‘sartan’
-
‘Losartan, irbesartan, valsartan’
- same as above
- NO cough
- Should not be used with ACE
- c/i preggo
BB
- Acute MI, angina, migrain pervention, hyperthyroid, migraine, tremor
- SE - impotence, postural hypotension, bradycard, depression
- wean to stop over 1-2 wks
Mineralocorticoid Receptor antagonist
- “Spironolactone, Eplerenone”
- antagonist aldosterone at distal convoluted renal tubule = incr NaCl and water excretion
- for CHF and acute MI w/ low EF
- careful with Hyper K - do not start if K > 5
Others
- Central acting a adrenergic agonist “clonidine”
- Direct arterial dilators “hydralazine, minoxidil”
- Pregnancy - acute - labetalol, hydralazine
- Chronic - labetalol, nifedipine,
- methyldopa (check LFT, cause hepatits, hemolytic anemia)
Hypertensive Urgency and Emergencies
Urgency
SBP >180 or > 120 w/ no evidence of end organ damage
No need to emergently lower BP
Goal = lower BP by 25% over 24 hrs = outpatient
Emergency
>220 or > 130
Accelerated HTN - BP w/ target organ damage - CP, SOB, blurred vision
Malignant HTN - elevated BP a/w papilledema and other signs of EOD
Decr BP < 25% over 1 hr
Tx
- ICU admission
- Sodium Nitroprusside for HTN Emergency - watch for cyanide toxicity
- Nicardipine - just BP, not HR
- Hydralazine in eclampsia
- Nipride for pheo crisis
- Clonidine for HTN urgency
Hyperlipidemia
Eti, screening guidelines
Normal Values
- Primary (familial) HLD or hypercholesterolemia - overproduction or defective clearance of TG
- Secondary Hypercholesterolemia - 2/2 obesity, DM*, htn, smoking, sedentary, CKD
Sxs
- Xanthelasmas - lipid deposits on eyelids
- Xanthelomas - tendenous, with familial hypercholesterolemia
Dx - Fasting lipid profile
- LDL <100
- HDL >60 mg/dL
- Total Cholesterol < 200 mg/dL
- Triglyceride < 150
Screening - >7.5% 10 year ACSVD
- Pts w/ high CVD risk (HTN, DM, tobacco, FH heart dx)
- Males start at 25-30 yo
- Females at 30-35 yo
- Pts w/ lower CV risk
- Males start at 35 yo
- Females start at 45 yo
Hyperlipidemia
Medications
Hyperlipidemia 2018 guidelines
- any clinical ASVD, stroke, TIA, PAD
- LDL > 190
- Diabetic 40-75, mod intensity; if > 7.5% then higher intensity
- 40-75y LDL 70-189
- Risk 5-20% = mod intensity
- >/=20% = high
- FH ASCVD, ele CRP, smoke, Ca score > 100
HMG-CoA Reductase Inhibitors - “Statins”
“Atorvastatin 40-80, Rosuvastatin 20-40”
- decrease LDL, Reduce infl of plaques, lower Trigs, incr HDL
- check LFTs and CPK before starting statin
- SEs - anorexia, wt loss, aches, myalgias, C/I preggo
-
Myopathy r/o rhabdo - c/i prior muscle symptoms, myalgias (weakness, stiffness) - check CPK, need IV reh2o for renal failure
- Avoid w/ fibrates, macrolides (clarith/erythr), amiodarone, verapamil, protease inhibitors, antifungals, grapefruit juice
PCSK9 Inhibitor
-
Evolocumab/Repatha, Alirocumab/Praluent
- Liver cells to remove LDL
- good for patients who cant tolerate statins
- once a month, 2x/wk injection
- Hypercholesteremia
Bile acid sequestrants
- “cholestyramine, colestipol, coleselevam”
- Binds w/ bile acid in intestines, mainly for familial hypercholestremia
- Dont use if fasting TG > 300
- SE - lots of GI issues
- C/i - bowel obstruction, hypertriglyceridemia induced pancreatitis
- Inhibits abs of warfarin, digoxin, propanolol, thyroid hormones
Ezetimibe (Zetia)
- Inhibits gut absorption of cholesterol; reduce LDL > 20%
- add to statin to help decr LDL
Hypertriglyceridemia
Excerbation of uncontrolled DM, obesity, sedentary
Sxs
- Asymp until TG > 1000-2000 - incr risk of pancreatitis
- Midepigastric pain (chest/back) - TTP
- Dyspnea
Tx
- LSM - low fat/carbs, exercise, limit etoh
- Fibrates - Gemfibrozil, Fenofibrate - decr LDL, incr HDL
- do not use it with statin - incr risk myositis and rhabdo
Hypertrophic Obstructive Cardiomyopathy
Hereditary - Autosomal Dom, early MI death, young athletes
Hypertrophied Ventricular septum = Impaired ventricular relaxation/filling
Sxs:
- Dyspnea, Angina, Syncope - esp during exertion
- Sudden cardiac death - due to V fib
- S4“a-stiff-wall” if outflow obstruction present
- Harsh cres-decres murmur at LLSB
- murmur increases intensity with Valsalva or standing - reduced LV volume/preload increases obstruction
Dx:
- Echo - asymmetrc wall thickeys > 15mm, small LV chamber size
- EKG - LVH, atrial enlargement
- CXR - cardiomegaly
Tx:
- Counseling - avoid dehydration and extreme exertion/exercise
- BB - first line, CCB
- Avoid Digoxin (incr contractility), Nitrates and diuretics (decr’s LV volume)
- Surgical - myectomy - definitive if refrc to medical tx
- ICD For high risk
Hypovolemic Shock
Eti
- Nonhemorrhagic - deh2o, burns, pancreatitis
- Hemorrhagic - trauma, ruptured ectopic, GI bleed
Sxs
- weak pulse, oliguria
- hypotension, tachycard, AMS
Tx
- Nonhemorrhagic - rapid volume repletion - 2L of 0.9% NS or LR
- UO for effectiveness - 30mL / hr
- watch for hyperchloremic acidosis - HA, confused
- Hemorrhagic shock = PRBCs
- keep Hgb >7 g/dl
- Vasopressor only after volume replaced
Mitral Regurgitation
Valvular Disease
Widened mitral valv = Mitral valve prolapse, dilated CMO, ischemic HD
backward flow into LA
Sxs:
- Signs of pulm congestion - pulm effusion, edema
- dyspnea, PND, orthopnea
- 4th ICS, midclavicular
- _holosystolic apical murmur, blowing, r-> axilla****_
Dx:
- TTE echocardiogram
Tx
- Diuretics
- antihypertensive
- MV replacement
Mitral Stenosis
Valvular Disease
MCC Rheumatic fever (aka GABHS); stiffened mitral valves
Sxs:
- decrease CO, CHF, Afib common
- 4th ICS, midclavicular
- low pitched, DIASTOLIC rumble murmur
- opening snap
Dx:
- Echocardiogram
Tx:
- MVR
- diuretics for mild-mod
Mitral Valve Prolapse
Valvular Disease
Sxs
- Mid to late systolic click
- worse with standing and Valsalva maneuvers
- Panic attacks, palps, young females
Dx
- exam + echocardiogram
Tx
- BB - propanolol
- aerobic exercise
- Hydration, caffeine
- Mitral valve repair
Obstructive Shock
Eti - physical obstruction - PTE, Cardiac tamponade, tension PTX
Tx - relieve obstruction, volume
Atrioventricular Nodal Reentry Tachycardia
Paroxysmal Supraventricular Tachycardia
SVT with abrupt onset and offset
Any tachyarrhythmias arising from above Bundle of His
Reentry circuit in or near AV node - electrical impulse travel in circular pattern => heart beats fast and regular
Sxs:
- Palps, SOB, Angina, Syncope, Lightheadedness
Dx
- EKG rate at 150-250 bpm
- P wave buried in QRS or after
- Holter monitor to catch eps
Tx:
- Cardiovert if hemodynamically unstable
- Vagal maneuvers
- Adenosine**
Wolf Parkinson White
Paroxysmal Supraventricular Tachycardia
Presence of abn accessory pathway (Bundle of Kent fibers) btwn atria and ventricles
Type of orthodromic AVRT
Sxs:
- Palps, dyspnea, dizziness, rarely cardiac death
Dx:
- EKG - shorted PR intvl, widened QRS, delta waves
Tx:
- observed if asymp
- Acute tx - Procainamide**
- Radio freq ablation is curative
Atrial Septal Defect
Congenital Heart Disease
opening in atrial septum; L => R shunt
2nd MC congenital HD
Sxs
- Asymp until 30yo
- >30yo present w/ dyspnea, and CP
- >50yo present w/ atrial arrhythmias - A fib and RVF
Dx
- PE - widely split and fixed S2 into A2
- systolic ejection murmur at 2nd-3rd LICS
- Echo - definitive**
Tx
- Small, centrally located ASD - close spontaneously < 3mm
- Mod to large ASD = Transcatheter closure or surgical repair btwn 2-6 yo
Coarctation of the Aorta
Congenital Heart Disease
Narrowing of aorta; MC below origin of L subclavian Artery
Sxs:
- Higher BP in arms than legs (> 20 mmHg difference)
- Decr pulses in legs, bounding pulses in arms
- Bicuspid AV in 50-70% of pts
Dx
- Radial-femoral pulse delay
- EKG w/ LVH
- CXR - notching of ribs, figure 3
- Echo, CT or MRI - definitive
Tx
- Balloon angioplasty w/ stent placement or surgical correction
- Prostaglandin E1 - to keep PDA open
Patent Ductus Arteriosus
Congenital Heart Disease
Connection btwn aorta and pulm artery after birth (from ductus arteriosus connection that failed to close); L =>R shunt
Sxs
- FTT, poor feeding, tachycardia, tachypnea
Dx
- Harsh, continuous machinery murmur at 2nd ICS LUSB
- Widened pulse pressure w/ low DSP
- Echo*
Tx
- Indomethacin for premature babies
- Surgical or catheter connection
Tetralogy of Fallot
Congenital Heart Disease
Only Cyanotic CHD - Defect that causes deficient O2 flow out of heart and into body
Four Main Characteristics
- RV outflow obstruction aka Pulmonary stenosis
- R ventricular hypertrophy
- Overriding aorta
- Ventricular septal defect
Sxs
- Tet spells - hypercyanotic eps during crying or feeding, relieved with squatting
Dx
- Echo - gold
- CXR - boot shaped heart
Tx
- Surgery w/in 1st year of life
- Prostaglandin E1 - keep PDA open
Ventricular Septal Defect
Congenital Heart Disease
MC CHD in childhood;
Opening in ventricular septum - shunt btwn ventricles, L→ R shunt
Sxs
- Child tires easily, can’t keep up with children
- Loud pitch harsh, holosystolic murmur
Dx
- Echo
- EKG - mod to severe VSD shows LVH
Tx
- Surgical closure
Pericardial Effusion
Traumatic/Infectious Heart Condition
2/2 to pericarditis, uremia, cardiac truam
Sxs:
- painful or painless, depending on rate of effusion
- cough
- dyspnea
- pressure
Dx
- EKG - electrical alternans, non-spec T wave changes, low QRS voltage
- Echo - fluid surrounding heart
Tx
- Observe is small
- Pericardiocentesis if + tamponade or large effusion
Pericarditis
Traumatic/Infectious Heart Condition
idiopathic or viral - restrictive pressure on heart
echovirus, coxsackie, HIV, TB
Sxs:
- Dyspnea, fatigue, weakness
- Sharp, pleuritic substernal CP => relieved by sitting upright or leaning forward
- Friction rub
- pericardial knock
Dx
- ele WBC
- EKG
- Diffuse ST seg elevations - concave (smiley)
- PR depression
- J point notching
Tx
- NSAIDs or Aspirin x 7-14d
- Colchicine 2nd line
- avoid CS - recurrent pericarditis
Peripheral Arterial Disease
Vascular Disease
MCC Atherosclertoic Dz - important risk factor for CV and cerebrovascular M&M
Sxs:
- intermittent claudication - foot or lower leg pain - relieved by rest
- As condition develops, pain at rest develops
- Femoral or distal pulses weak or absent
- Aortic, iliac or femoral bruit may be present
- Skin changes - loss of hair, shiny atrophic skin, pallor w/ dependent rubor
- Severe, chronic = numbness, tingling, ischemic ulceration
Dx:
- ABI - upper and lower extremities
- 0.9-1.2 = normal
- <0.9 = PAD
- <0.4 = severe disease
- Arteriography- gold std - occlusion
Tx:
- Stop smoking
- Stent - only if short and proximal (femoral and < 0.3 cm); never stent otherwise
- Everything else = BYPASS
- Meds
- ASA
- Statin
- Cilostazol
- Exercise regimen
Pulmonic Stenosis
Valvular Disease
Congenital
Sxs
cyanosis at birth, fatigue, dyspnea
2nd LICS
JVD, RV hypertrophy heave
Restrictive Cardiomyopathy
Impaired diastolic relaxation - stiff ventricles decreases filling
Eti - infiltrative diseases - Amyloidosis MCC, Sarcoidosis, hemachromatosis, scleroderma, chemo, XRT
Sxs:
- RS HF more common
- Chest pain, dyspnea, edema, ascites
- Kussmaul’s sign - JVP incr with inspiration
Dx:
- Echo - usual normal systolic contraction
- Speckled appearance - infiltrative disorder
Tx:
- Na restriction, caution diuretics
- treat underlying disorders
- Poor prog
Septic Shock
Eti - bacterial - immune sys reaction = local vasodilation
Sxs
- confusion, hypoxemia, oliguria
- Hypotensive needing pressors (Norepi), tachy
Dx - ele plasma lactate (higher = sicker), leukos
Tx
- Broad spectrum abx w/in 1st hour = GOAL
- IV fluid hydration - 30mL/kg in first 3 hrs
- Vasopressors - Norepi, Vasopressin
Syncope - DDX
Reflex Syncope
- feels it coming on - lighthead, diaphoretic, pallor, N
- young adults
- Vasovagal or situational
Orthostatic Syncope
- elderly, dehydrated, gastroenteritis
- ETOH, Nitrates, BB, Antidepressants; Autonomic Dysfunction
- Tilt table test - systolic BP drop >20 w/ standing
- tx
- Fludrocortisone - mineralocorticoid - hang onto fluid.
- Midodrine - vasopressor activity
Cardiogenic Syncope
- no premonition - sudden hypotension
- arrhythmia or aortic/mitral stenosis, HOCM
Thrombophlebitis
Vascular Disease
Inflammation of superficial vein, usu d/t injury aka need stick
Sxs:
- pain, erythema at site
- vein feels hardened
Dx:
- Venous duplex US - noncompressible vein
Tx:
- NSAIDs
- elevation
- compression stockings
Tricuspid Regurgitation
Valvular Disease
Pulm htn, dilated RV, endocarditis, ebstein anomaly
Sxs
- JVD, ascites, perip edema
- high pitch pansystolic murmur, accentuated w/ inspiration
- LLSB
Tx
diuresis, severe TR, then VR
Varicose Vein
Vascular Disease
Dilated, tortuous superficial veins 2/2 defective valve structures; weak vein wall = incr intraluminal pressures, rev of venous flow (pooling)
Eti: Incr Estrogen = preg, stress of legs, prolonged standing, obesity
Sxs:
- Dilated, tortuous superficial veins
- dull ache or pressure w/ prolonged standing, relieved w/ elevation
Dx - clinical
Tx:
- Conservative - leg elevation, compression stockings, avoid prolonged standing
- Sclerotherapy, radiofreq or laser ablation
Venous Thrombosis - DVT
RF - smoking, preg, malignancy, OCPs, stationary
Sxs
- Virchow’s triad - stasis of blood flow, hypercoaguable state, vascular damage
- unilateral LE pain and swelling
Dx
- LE venous Doppler
- +D-Dimer
Tx
- Anticoag - Hep or Enoxaparin
- DOAC - anticoag for 3-6mos
- IVC Filter
Venous Ulcer Disease
Vascular Disease
Leg pain worse w/ dependency, standing/prolonged sitting
Improves w/ walking, elevation of leg; Cyanotic leg w/ dependency
Sxs:
-
ULCERS over medial malleolus* - ankle or knees
- (arterial ulcers are heels and toes)
- uneven ulcer margins
- Stasis dermatitis - eczematous rash, thickening of skin
- brownish pigmentation
- Pulses and temp usu normal
- Prominent edema common
Tx
- below-knee compression
- brisk walk
- Prognosis for this condition as poor
Secondary Hypertension
Secondary - d/t an identifiable cause
- HTN in esp in young or old
- stage 2 HTN
- abrupt onset
- Drug resistance
- clinical cause
Renal Vascular HTN - recurrent flash pulm edema, abd bruit
- Fibromuscular Dysplasia - young women
- tx balloon angioplasty
Pheochromocytoma - 4Ps - palpitations, htn, perspiration, pain headache
Primary Hyperaldosteronism
- retain water and Na - BP goes up
- hypoKalemia, order plasma adolesterone:plasma renin activity ratio
- tx - aldosterone antagonist - Eplerenone or Aldactone (Spironolactone)
SVT/PSVT
Sxs
- Regular >150 bpm
- no P waves
- no discernable PR intvl
- narrow QRS
- palps, dyspnea, CP, syncope
Tx
- Valsalva
- Carotid massage
- Adenosine 6mg then 12 mg
