Cardiology #3 Flashcards
Mitral Valve Prolapse Murmur
Mid-late systolic ejection click best heard at apex.
- Standing and Valsalva make click earlier
- Squatting and supine make click delayed
Mitral Regurgitation Murmur
Blowing holosystolic murmur heard at apex with radiation to axilla
MCC of mitral regurgitation in the US
Mitral Valve Prolapse
What are some common complications of cardiac catheterization?
- Hematoma/Retroperitoneal Bleeding
- AV Fistula
- Dissection
- Myocardial Infarction
- Infection
- Allergic Reaction to Contrast Dye
Treatment for anterior and lateral wall MI
- MONA
- Heparin, BB, Clopidogrel
Treatment for Inferior or Posterior Wall MI
- Aspirin/Heparin, IVF, Oxygen, Clopidogrel
- Avoid Nitroglycerin and Morphine in these types
What is Dressler Syndrome?
-Post-MI Pericarditis
MCC of Heart Failure
CAD
Mechanism of action of Ace Inhibitors
- Decreased preload, decreased afterload, decreased aldosterone production
- Decreases ventricular remodeling
What do all Ace Inhibitors end with?
- Pril
- Lisinopril, Captopril, Enalapril, Quinapril
Ace inhibitors are first-line therapy for heart failure. (Most effective singular medication for mortality benefit.) What are the common adverse effects of Ace Inhibitors?
- Hyperkalemia
- Angioedema
- Cough
HAC
True or False: Ace Inhibitors are not safe in pregnancy?
True
They should be avoided in pregnancy, hypotension, renal insufficiency, and bilateral renal artery stenosis.
What medications should be used first in African Americans with hypertension?
-Hydralazine + Nitrates
Diuretics and CCB
Regarding lipid medications:
- Best meds to lower elevated LDL levels: ______
- Best meds to lower elevated triglycerides: _____
- Best meds to increase HDL: ______
- With type II DM: ______, ______
Statins
Fibrates
Niacin
Statins, Fibrates
What are five times a statin should be started?
1) Patients with DM between 40-75
2) People > 21 with LDL > 190
3) Any patient with any form of atherosclerotic CVD
4) Patients < 19 with familial hypercholesterolemia
5) Patients 40-75 with no CVD but 7.5% risk for stroke within 10 years
Mechanism of action of statins
-Inhibit the rate-limiting step in hepatic cholesterol synthesis via inhibition of enzyme HMG-CoA reductase
Adverse effects of statins
- Muscle damage (myalgias, rhabdomyolysis)
- Increased liver function tests
- Hepatitis (MC)
- GI symptoms
- Diabetes mellitus
Side effects of Niacin
- Flushing, warm sensation, pruritus (give NSAIDs or Aspirin beforehand)
- Hyperglycemia (take with meals)
What are 4 cardiac conditions that are indications for endocarditis prophylaxis?
- Prosthetic heart valves
- Heart repairs using prosthetic material (not including stents)
- Prior history of endocarditis
- Congenital heart disease
What is given as prophylaxis for dental or respiratory procedures against endocarditis?
- Amoxicillin 2g 30-60 min before procedure
- Clindamycin 600 mg if PCN allergy
What is the treatment for Dressler Syndrome?
Aspirin or Colchicine
Amyl Nitrate ________ and, therefore, murmurs like AR and MR are decreased with amyl nitrate
Decreases afterload
Describe the murmur for Aortic Regurgitation
Diastolic blowing decrescendo murmur best heard at the LUSB
Unique symptoms/signs of widened pulse pressure in AR/AI
- Water Hammer Pulse: swift upstroke and rapid fall of radial pulse accentuated with wrist elevation
- Hill’s Sign: Popliteal artery systolic pressure > brachial artery by 60 mmHg (MOST SENSITIVE)
- De Mussett’s Sign: Head bobbing with each heartbeat
- Quincke’s Pulse: Visible fingernail bed pulsations with light compression of fingernail bed
What is the definitive diagnostic for Aortic Regurgitation?
Cardiac catheterization
Treatment for AR/AI
Medical therapy: afterload reduction (ACEi, ARB, Hydralazine)
Surgical therapy: definitive management
MC type of Aortic Dissection
-Ascending = high mortality
Risk Factors for Aortic Dissection
- HYPERTENSION (MOST IMPORTANT)
- Age > 50
- Marfan Syndrome
- Men
- Pregnancy
- Turner Syndrome
Symptoms of Aortic Dissection
- Chest Pain: sudden onset of severe, tearing, ripping chest/upper back pain radiating between scapula
- Unequal blood pressure in both arms
- Decreased peripheral pulses
- New onset of aortic regurgitation
Diagnostics for Aortic Dissection
- CT angiogram and TEE (MC first-line imaging)
- CXR: widened mediastinum
Treatment for both types of Aortic Dissection
- Surgical: Proximal/Ascending
- Medical: Descending/Distal. Nonselective BB (Labetalol) with Sodium Nitroprusside if needed
What is Leriche’s Syndrome in regards to PAD?
Claudication + Impotence + Decreased femoral pulses
Treatment for PAD
- Exercise (fixed distance walking)
- Smoking cessation (greatest benefit)
- Foot care
- Cilostazol most effective medical therapy
- Revascularization: Percutaneous transluminal angioplasty, bypass grafts
With an acute arterial occlusion, this is a vascular emergency. What type of occlusion is the most common?
Thrombotic occlusion in superficial femoral or popliteal artery
Symptoms of acute arterial occlusion
- Paresthesias
- Pain
- pallor
- Pulselessness
- Poikilothermia
- Paralysis
Workup for acute arterial occlusion
- Bedside arterial doppler to assess for pulses
- CT angiography (quicker)
What is the mainstay of treatment for acute arterial occlusion?
Reperfusion: surgical bypass, surgical or catheter based thromboembolectomy
-Supportive: pain control, fluid resuscitation, unfractionated Heparin
With a DVT, what are the symptoms?
- Unilateral swelling and edema of lower extremity > 3 cm (most specific)
- Calf pain and tenderness
- Homan sign: deep calf pain with foot dorsiflexion while squeezing the calf
First-line imaging for DVT
-Venous Duplex US
However, the definitive diagnostic for DVT is
Contrast venography
-Invasive, difficult to perform, and rarely used though
When can a D-dimer exclude a DVT
-Negative D-dimer with a low-risk for DVT can exclude DVT as the diagnosis
Management of DVT
- Anticoagulation: first line
- IVC filter: if recurrent, stable patients whom anticoagulation is contraindicated, or right ventricular dysfunction with enlarged RV on echo
What are the anticoagulation options for patients with a DVT
1) LMWH + Warfarin
2) LMWH + Dabigatran/Edoxaban
3) Monotherapy: Rivaroxaban or Apixaban
In pregnancy, what is the preferred anticoagulation for patients with a DVT?
LMWH as initial and long-term therapy
LMWH potentiates antithrombin III. Explain this.
Works more on factor Xa than thrombin (Factor IIa)
Contraindications of LMWH
- Renal failure
- Thrombocytopenia
For Peripheral Venous Disease, what does the leg pain feel like?
- Worse with leg dependency, standing, prolonged sitting
- Improved with walking, elevation of leg
- Cyanotic leg with dependency
Where are ulcers associated with peripheral venous disease located?
Medial malleolus, uneven ulcer margins
For Peripheral arterial disease, what does the leg pain feel like?
- Better with leg dependency, rest
- Worse with walking, elevation of leg, cold
- Redness leg with dependency
- Dependent rubor and cyanotic leg with elevation
Where are ulcers associated with PAD located?
Lateral malleolus, clean margins
