Cardiology 2 (step up son) Flashcards
What are the two valvular diseases that cause crescendo-decrescendo systolic ejection murmurs?
Aortic stenosis (2nd R intercostal space --> neck) Pulmonic stenosis (2nd-3rd L interspace)
What two valvular diseases cause holosystolic murmurs?
Mitral regurgitation (apex --> axilla) Tricuspid regurgitation (LLSB --> RLSB)
What valvular disease causes a late systolic murmur?
MVP (apex –> axilla)
What two valvular diseases cause early diastolic murmurs?
Aortic regurgitation (left sternum) Pulmonic regurgitation (upper left sternum)
What valvular disease causes a mid/late diastolic murmur?
Mitral stenosis (apex)
What can cause aortic stenosis?
Congenital defect*
Rheumatic Heart Disease
Calcification in the old
Tertiary syphilis
What symptoms can be associated with aortic stenosis?
Chest pain
Dyspnea on exertion
Syncope*
Besides the typical systolic crescendo-decrescendo murmur, what else is often found on exam of aortic stenosis?
Weak S2
Weak, prolonged pulse
Valsalva DECREASES murmur
What can cause mitral regurgitation?
MVP Rheumatic heart disease* Papillary muscle dysfunction Endocarditis LV dilation
What symptoms are associated with mitral regurgitation?
Often asymptomatic Palpitations DoE Orthopnea Paroxysmal nocturnal dyspnea
Besides the expected holosystolic murmur, what else is often seen on exam of mitral regurgitation?
S3
Widely split S2
Midsystolic click
What are treatments for mitral regurgitation?
Vasodilator if symptomatic
Prophylactic abx for increased infection risk
Prophylactic anticoagulation
Surgical repair in severe or acute cases
What symptoms are associated with aortic regurgitation?
Initially asymptomatic
DoE
Chest pain
Orthopnea
Besides the typical diastolic decrescendo murmur, what else can be found on exam of aortic regurgitation?
Bounding pulses
Late diastolic rumble (Austin-Flint murmur)
Capillary pulsations in nail beds (Quinicke sign)
What causes mitral stenosis?
Rheumatic heart disease
What symptoms can be associated with mitral stenosis?
Initially asymptomatic (10yrs) DoE Orthopnea PND Peripheral edema Hepatomegaly
What is found on exam of mitral stenosis?
Opening snap after S2
Diastolic rumble
Loud S1
The murmur associated with aortic stenosis decreases with the valsalva maneuver. Which heart defect’s murmur increases with the valsalva maneuver?
HOCM
How can restrictive cardiomyopathy be differentiated from constrictive pericarditis?
CT or MRI
The three types of cardiomyopathies are hypertrophic, dilated, and restrictive. Which of these causes both systolic and diastolic dysfunction?
Hypertrophic…ventricular hypertrophy and thickened septum cause decreased filling and LV outflow obstruction
The three types of cardiomyopathies are hypertrophic, dilated, and restrictive. Which one causes diastolic dysfunction?
Restrictive…decreased heart compliance
The three types of cardiomyopathies are hypertrophic, dilated, and restrictive. Which one causes only systolic dysfunction?
Dilated…ventricular dilation
What causes HOCM?
Congenital…autosomal dominant
What causes dilated cardiomyopathy?
Idiopathic* Alcohol, cocaine, beriberi Coxsackie B, HIV Hemochromatosis Doxorubicin Pregnancy Ischemic heart disease Chagas disease
So in the prompt the patient has obvious signs of HF and the only time the patient had ever been sick before was 10-30 years prior in one of the the other Americas or Mexico. What does this patient have? What could have caused it?
Dilated cardiomyopathy secondary to Chagas disease
A patient comes in and they have hyperpigmented skin, diabetic symptoms, smaller nuts (in a guy…obviously), and HF symptoms. What do the patient have? What could have caused it? How can it be treated?
Dilated cardiomyopathy secondary to hemochromatosis…treat with phlebotomy
What causes restrictive cardiomyopathy?
Sarcoidosis
Amyloidosis
What are the symptoms of HOCM?
Syncope, dyspnea, palpitations, chest pain
WORSE WITH EXERTION
What are the symptoms of dilated cardiomyopathy?
Similar to CHF and bi-valvular regurgitation
What are the symptoms of restrictive cardiomyopathy?
Similar to CHF with right-sided symptoms
What is found on exam with HOCM?
S4 and systolic murmur
Sustained apical impulse
ECG may show arrhythmia, LVH, or abnormal Q waves
What is found on exam of dilated cardiomyopathy?
S3, systolic and diastolic murmurs
ECG may show ST and T wave changes, weak QRS, tachycardia, LBBB
What is found on exam of restrictive cardiomyopathy?
Ascites
JVD
How is restrictive cardiomyopathy diagnosed?
Biopsy
What is seen on x-ray of HOCM? How is it diagnosed?
Boot-shaped heart
Echo
What is seen on x-ray of dilated cardiomyopathy? How is it diagnosed?
Balloon-like heart
Echo
How is HOCM treated?
Beta-blocker
CCB
Pacemaker
Partial septal excision
How is dilated cardiomyopathy treated?
Stop alcohol or cocaine Diuretics ACEI Beta-blockers Anticoagulation
How is restrictive cardiomyopathy treated?
Treat underlying cause
Palliative treatment for heart failure
Exertion exacerbates HOCM symptoms. What relieves thses symptoms?
Squatting
What is the most common cardiomyopathy?
Dilated cardiomyopathy
A patient comes in with chest pain that feels better with leaning forward and reports having recently gotten over cold-like symptoms. What does this person have? What should be done? How should she be treated?
Viral pericarditis…ECG should be done to confirm and CXR should be done to check for effusion…if there is an effusion it should be drained, otherwise NSAIDs for symptoms…consider colchicine to prevent recurrence
A person had a positive mantoux and decided to start treatment for it. Some time later he comes in pleuritic chest pain that is better with leaning forward. What does this person have and what caused it? What is likely to be found on exam? What is likely to be found on ECG?
Isoniazid induced pericarditis
Friction rub can be heard with patient leaning forward Pulsus paradoxus (10+mmHg drop in BP with inspiration)
Diffuse ST elevations and PR depression
Besides a virus and isoniazid, what else can cause pericarditis?
TB SLE, uremia Neoplasm Hydralazine Dressler syndrome Radiation Recent heart surgery
A pericardiocentesis is done after an effusion is seen on CXR of a patient with pericarditis. The effusion is checked and found to have a specific gravity >1.020. What kind of effusion is this? What needs to be checked as the etiology of the pericarditis in this patient?
This is an EXUDATE (lots of proteins)
Neoplasm
Fribrotic
TB
What can happen if pericarditis secondary to radiation or heart surgery is not treated?
Chronic constrictive pericarditis
What causes the ‘constrictive’ part of chronic constrictive pericarditis?
Thickened pericardium (with possible calcification) decreases diastolic filling and CO
What are s/s of chronic constrictive pericarditis?
CHF symptoms (JVD [increased with inspiration = Kussmaul's sign], DoE, orthopnea, peripheral edema) A fib is common
A patient comes in for follow up to heart surgery after starting to have HF symptoms again. A cardiac catheterization is done that shows equal pressure in all chambers. What is likely to be seen on echo, CT, or MRI? What are the treatment options for this person?
Pericardial thickening and possibly calcifications…because this person has chronic constrictive pericarditis
NSAIDs, colchicine, corticosteroids
Surgical excision of pericardium…high mortality
A patient comes in with hypotension, distant heart sounds, and distended neck veins. What should be done? What would be seen on ECG?
This is Beck triad (cardiac tamponade) do a pericardiocentesis NOW
low voltage and sinus tach
A person in one of the other Americas presents with signs of achalasia and HF. What is the likely etiology? What is a kinda weird thing that could be found on chest auscultation?
Trypanosoma cruzi (Chagas disease) induced myocarditis
Diastolic murmur
Besides Chagas disease, what else can cause myocarditis?
Infection: viral (Coxsackie most common), bacterial, rickettsiae, fungal, parasitic
Drug toxicity (cancer drugs, penicillins, sulfonamides, cocaine, radiation)
Toxins
Endocrine abnormalities
A patient comes in that just looks awful: hot swollen joints…was this joint, now it’s that joint; fever; nodules on extensor surfaces; involuntary movements (Sydenham chorea); a painless rash (erythema marginatum). What does this patient have? How should this be treated?
This is acute rheumatoid fever…give NSAIDs for the joints, corticosteroids for severe carditis (pericarditis, myocarditis, valvulitis), and beta-lactam for infection
How is acute rheumatic disease diagnosed?
Jones criteria: recent strep + 2 major OR 1 major and 2 minor (JONES PEACE)
J- Joints (polyarthritis, hot/swollen joints)
O- shaped like a heart (carditis, valve damage)
N- Nodules (SQ on extensor surfaces)
E- Erythema marginatum (painless rash)
S- Sydenham chorea (flinching movement)
P- Previous rheumatic fever E- ECG with PR prolongation A- Arthralagias C- CRP and ESR elevated E- Elevated temperature
What is the likelihood of rheumatic heart disease after untreated strep infection?
3%…or just low should suffice
What is something to worry about with people with congenital heart defects, IV drug abuse, or prosthetic valves?
Endocarditis
Which bacteria particularly effect people with prosthetic valves?
Staph a or e
What are the Duke Criteria for diagnosing endocarditis?
Direct histologic evidence Positive gram stain from surgical debridement of abscess 2 Major 1 Major + 3 Minor 5 Minor
What are the Major Duke Criteria?
Serial blood cultures positive for organisms associated with infective endocarditis
Presence of vegetations or abscess on echo
Evidence of new onset valvular regurgitation
Blood culture positive for Coxiella burnetti
What are the Minor Duke Criteria?
Predisposing heart condition or IV drug use
Fever
Vascular phenomenon (arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions)
Immunologic phenomenon (glomerulonephritis, Osler nodes, Roth spots, positive rheumatoid factor)
Positive cultures not meeting requirements for major criteria, or serologic evidence of infection w/o positive culture
Which bugs typically cause acute infective endocarditis?
Staph a
Strep pneumo
Strep pyo
N. gono
Which bugs typically cause subacute infective endocarditis?
Strep viridans
Enterococcus
Fungi
Staph e
What are some bacteria that can cause endocarditis that won’t culture?
HACEK
H-Haemophilus A-Actinobacillus C-Cardiobacterium E-Eikenella K-Kingella
Patient comes in with symptoms that seem like endocarditis, but don’t quite meet criteria; and there is a history of SLE. What is the possible diagnosis?
Libman-Sacks Endocarditis
How is infective endocarditis treated?
Long-term abx (typically beta-lactam + aminoglycoside)
When should prophylactic abx be used to prevent infective endocarditis?
History of valvular damage
What are potential complications of endocarditis?
Septic embolization
Abscess formation
