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Med 1 > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Risk factors for CAD (7)

A

DM; Hyperlipidemia(LDL45, W >55
Family Hx

minor - obesity, sedentary, stress, alcohol

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2
Q

Poor EF in CAD is

A

<50%

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3
Q

Vessel that is worse to have fixed atherosclerotic lesions?

A

Left main coronary

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4
Q

Symptoms of Stable Angina

A

Chest pain lasting <10-15 min; heaviness, prssure, squeezing tightness, NOT sharp/stabbing
Exertion related
Relived w/ rest/nitro
No ∆ w/ breathing or position

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5
Q

Metabolic syndrome includes (6)

A

hypercholesterolemia, hypertriglyceridemia, impaired glucose, DM, hyperuricemia, HTN

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6
Q

1st test w. chest pain

A

ECG

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7
Q

Indications for stress ECG

A

Confirm angina
Eval response to therapy
ID CAD pts w/ high risk

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8
Q

Stress test 75% sens if able to reach what factor?

Calculated how?

A

85% of max HR

0.85 x (220-age)

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9
Q

Positive signs on stress test

f/u?

A

ST depression, HF, ventricular arrythmia, hypotension, chest pain

(+) => cardiac catheterization

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10
Q

Stress echo looks for

A

wall motion abnormalites, LV size/function, valve disease,

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11
Q

Pharacologic stress test

A

IV adenosine, dipyridamole,
(cause coronary vasodialtion)

dobutamine(increases oxygen demand w/ higher HR, BO and contractility)

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12
Q

thallium 201 in ischemia used to see what?

A

stress myocardial perfussion, determines reversibility of ischemia and rescued from PCI, cABG

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13
Q

Silent ischemia detected by what

A

Holter monitor - Contunous over 24-72hrs

eval arrythmias, HR variability, ICD need

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14
Q

Definitive Test for CAD is

A

Cardiac catheterization -> CORONARY ANGIOGRAPHY often w. PCI (angioplasty)

Stenosis of 70% symptoms

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15
Q

Who gets CABG?

A

Severe CAD: 3 vessel disease w/ 70% stenosis or LAD or Left Main >50% stenosis or L ventricular dysfunction

Cardiogenic shock post MI? Complications w. PCI? ventrical arrythmia?

Revascularization does NOT reduce MI but improves symptoms

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16
Q

Medical Therapy in CAD( 3)

A

ASA- decrease morbidity

Beta blockers (atenolol, metoprolol) - reduce frequency

CCB - coronary vasodialation and after load reduction, secondary Tx, not routine

ACE I - if CHF

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17
Q

Percutaneous Coronary Intervention indications

Complication:

A

1.2.3 vessel disease, vent arrhythmia, new mitral regard, hemodynamic unstable

Rate of MI equivalent w/ CABG but have more reverse procedures
Best for proximal lesions

Restenosis - 40% in 6 months

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18
Q

Dif between Unstable and Stable Angina

A

oxygen demands the same but supply is decreased

possible total occlusioin

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19
Q

Acute coronary syndrome is

A

clinical manifestation of atherosclerotic plaque rupture and coronary occlusion -> unstable angina, STEMI or NSTEMI

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20
Q

Symptoms of unstable angina(3)

A

Chronic angina w/ increase frequency, duration, intensity

New onset that is severe and worse

Angina at rest

NO enzymes (troponin of CK-MB), may have St changes

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21
Q

Rx for Unstable Angina (6)

A 
ASA*
Clopidogrel (also)
Beta Blockers*
LMWH (2 days min)
Nitrates*
Oxygen

Maybe Glycoprotein IIb/IIIa inhib (abciximab, tirofiban)

Maybe Morphine

Mg and K replace

Statin after as well*

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22
Q

Thrombolytics in MI Risk Score (TIMI) (7)

A

risk of death and ischemia in untable angina and NSTMI

(+1):
 for Age >65;
 >3 risk factors;  
Known CAD (stenosis >50%);
 >2 episodes angina in 24hrs
ASA in past 7 days
Elv enzymes
ST change >0.5mm

risk of cardiac event is: 0-1=5%, 2=8%, 3=13%, 4=40%, 5=26%, 6-7 =41%

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23
Q

Variant/Prinxmetals Angina is?

Dx w/?

A

transient coronary vasospasm w/ fixed lesion

Occurs at rest, classically at night
See STEMI

Angiography w/ IV ergonovine definitive

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24
Q

Rx in Variant angina (2)

A

CCB and nitrates

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25
Q

Mortality of MI is?

A

30%, half before the hospital

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26
Q

4 categories of MI response

A

Pain - substernal, crushing (>30min), radiates to neck, jaw, arms, back (L); no Nitro response

Asymptomatic (1/3)

Dypnes, diaphoresis, weak, N/V, impending doom, syncope

Sudden death - V fib

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27
Q

ECG MI changes (5)

A 
Peaked T waves early
ST elevation - transmural
Q wave - seen late
T wave inversion - sensitive but not specific
ST depression subendocaridal
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28
Q 
Location of infarct:
Anterior
Posterior
lateral 
Inferior
A

Anterior: STEMI in V1-V4; Q waves late

Lateral: Lead I and aVL

Inferior: STEMI in II, III and aVF

Posterior: NSTEMI in V1 and V2 and Upright prom T waves in V1 and 2

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29
Q

Time line and use for 2 cardiac enzymes

A

Troponin - specific, rise in 3-5hrs, 24hr peak, normal 5-14 days; follow q8h for 24hrs

CK-MB - rise 4-8hrs, normal in 24-48hrs, Total CK and CK-MB measured - good to eval new chest pain peri MI

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30
Q

Reduce mortality in MI - Rx (3)

A

Beta blockers
ASA
Ace Inhibitors

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31
Q

beta blocker that reduces mortality w/ post MI LV dysfunction

A

carvediol

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32
Q

Rx for MI medical(8)

4 long lasting

A

ASA- mortality and maintenance*
Beta blockers - mortality and maintenance*
Ace I - mortality and maintenance*
Statins - mortality and maintenance*

Oxygen - limit ischemia
Nitrates - symptoms, lower preload
Morphine - analgesia, venodialation
LMWH - no mortality, prevents progression

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33
Q

Revascularization is good if early how early w/ thrombilytics vs PCI vs CABG

A

PCI if <90min or contraindications to thrombolytics
Stent - Clopidogrel + ASA 30 days, for 12 months total Clopidogrel

Thrombolytics - best w/in 6hrs, up to 24hrs (alteplase)

CABG if mechanical complications of MI, cariogenic shock, life threatening ventricular arrhythmia, failure of PCI - NEVER stable angina

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34
Q

Complications of MI(9)

A

CHF; Arrhythmia - all types; Free wall rupture - w/in2wks, usually 1-4d; Septum rupture - 1/in 10days; Papillary muscle rupture - MR; Vent pseudoaneurysm incomplete wall rupture; Vent aneurism - V tachy; Acute pericarditis- give ASA, NO NSAIDS or steroids; Dresslers - ASA or inbuprofen, pleuritis wks to months after

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35
Q

Contraindications of thrombolytics in MI(5)

A

truama, prior stroke, recent surgery, Dissecting aortic aneurism, active bleeding

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36
Q

Chest Pain Ddx (6systems)

A
  1. Heart - MI, aortic dissection, pericarditis, angina 2. Pulmonary - PE, pneumothorax, pleuritis, pneumonia, 3. GI - GERD, esophageal spasm, PEP, esophageal rupture 4. Chest wall- costochondritis, strain, fxr, herpes zoster, thoracic outlet syndrome 5. Psychiatric- panic attack, anxiety, somatization 6. Cocaine
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37
Q

Chest pain tests (4)

A

ECG
enzymes
CXR
PE w/up?

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38
Q

Causes attributed High Output HF (8) in underlying disease

A 
Chronic anemia
pregnancy
hyperthyroidism
AV fistula
wet beriberi (B1)
Pages disease of bone
Mitral regurg
Aortic insuficency
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39
Q

Systolic dysfunction

-> HF (3+)

A

HTN** -> cardiomyopathy
valvular disease
myocarditis

Less: EtOH, radiation, hemochromatosis, thyrois

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40
Q

Diastolic dysfunction -> HF (3+)

A

Impaired ventricular filling (stiff or impaired relaxing)

HTN** -> hypertrophy
Valve (AS, AR, MS)
Restrictive cardiomyopathy(amyloidosis, sarcoid, hemochromatosis)

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41
Q

Difficulty breathing recumbant

A

L Heart failure - orthopnea

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42
Q

only 1-2 hrs of sleep 2/2 SOB

A

L heart failure

Paroxysmal nocturnal dyspnea

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43
Q

nocturnal cough - nonproductive

A

L heart failure, worse laying down

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44
Q

S3 -

A

Venricular gallop heard at apex

rapid filling phase (slosh—–ing-ing)
normal in kids

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45
Q

S4

A

atrial systole hittins a stiff wall

A-stiff —-heart

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46
Q

NYHA Classification (4) for HF

A

1- no symptoms, Vigorus - sport
2- Symptoms w/ exertion (flight of stairs)
3 - symptoms w/ mild exertion(walk across a room)
4. symptoms at rest

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47
Q

CHF on Xray

A

Cardiomegaly
Kerley B lines
interstial markings
pleual effustion

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48
Q

Test for diastolic vs systolic HF

A

Echo - Determine EF

EF>40% are diastolic dysfunction while <40% is systolic dysfunction

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49
Q

Enzyme released in CHF

A

BNP >150 suggestive and helps dif SOB from COPD vs. CHF

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50
Q

Rx in CHF(5)

Which help w/ morbidity and mortality

A

Ace Inhib/ARB* 1st - venous and arterial dilation

Beta Blockers* - slows remodeling, lowers oxygen demand, ischemia protection Class II-III, (metoprolol, bipropolol, carvediol)

Spiranolactone* - aldosterone antagonist, (class III and IV) -

Dieuretics - symptomatic- loop vs thiazide - Hydralazine has some mortality

Digitalis - EF<40% and low BP

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51
Q

Spiranolactone alt in CHF Tx?

A

Epleronone for gynectomastia

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52
Q

Digitoxality - 3 systems

A

GI: N/V, anorexia
Cardiac - ectopic beats, AV block, Afib
CNS: disorientation

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53
Q

Contra indicated in CHF (3)

A

Metformin -lactic acidosis
Thiazolidinediones - fluid retention
NSAIDs

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54
Q

ICD goes to who?

A

HF Pt

40 days post MI w/ EF <35% and class II or III

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55
Q

Cardiac resynch device goes to who? Biventricular pacemaker.

A

HF Pt

40 days post MI w/ EF 120

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56
Q

5yr mortality in CHF

A

50%

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57
Q

Diastolic Dysfunction CHF differs use: (3)

A

Beta blockers, diuretics, maybe ACE

NO: digoxin or spiranolactone

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58
Q

Acute decompensated HF is

A

Acute dyspnea w/ elv L filling pressures w/or w/o pulm edema

DDx: PE, Asthma, pneumonia

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59
Q

Rx for Acute decompensated HF

A

Oxygen
Diuretics for volume overload and congestive
Low Na
Nitrates w/o hyotension

Admission

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60
Q

PAC is?

Causes?

A

premature arial complex - see abnormal P waves

adrenergic excess, drugs, alcohol tobacco, electrolyte, ischemia, infection

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61
Q

Rx for PAC

A

none- monitor and maybe a beta blocker

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62
Q

PVC is?

Causes

A

premature ventricular complex

Occur w/ or w/o structural heart disease- hypoxia, electrolyte, stimulants, caffeine, meds

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63
Q

Wide isolated QRS, lower than normal, compensatory beat

A

PVC

P wave not seen, burred in QRS

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64
Q

When to w/u PVC?

A

frequent and recurrent PVC w/ underlying heart disease

order ECG to think about an ICD

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65
Q

Bigeminy vs trigeminy

A

Sinus beat followed by PCV

2 sinus beats followed by PVC

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66
Q

Irregular rapid ventricular rate >400bpm, ventricle AV slows to 75-175

A

A fib

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67
Q

Causes of Afib (9)

A 
Heart disease (CAD, MI, HTN, mitral valve),  
Pericarditis and truama
pulm disease (PE)
Hyper/hypo thyroidism
Systemic Illness (sepsis)
Stress(postop)
Holiday Heart
Sick Sinus
Pheochomocytoma
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68
Q

Symptoms of A fib

A

Fatigue, SOB, racing heart, dizzy, angina, syncope, irregular irregular pulse, blood stasis

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69
Q

Acute Afib if hemodynamically unstable Rx

A

electrocardiovert

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70
Q

Cardioversion

Used when?

A

Shock synchronized to QRS complex- Stops shock given during T wave which may lead to A fib

Used in Afib, flutter, VT w/ pulse, SVT

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71
Q

Defibrillate

Used when?

A

Shock not in snc w/ QRS,

Convert dysrythmia to normal sinus

Used in V fib, VT w/o pulse

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72
Q

Acute A fib Rx in hemodynamically stable

A

Rate control - target 60-100bpm w/ beta blockers

LV systolic dysfunction use dig or amiodarone

Electrical cardiovert to sinus -Chemical (ibutilide, procainamide, flecaninide, sotalol, amiodarone)

Anticoag - >48hrs or unknown -3wks before +4wks post cardioversion

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73
Q

Skip 3-4 wk wait time w/ anticoagulation post cardiovert by doing what?

A

Use a TEE to look for a clot.

Still need 4 wks after of anticoag

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74
Q

Chronic A Fib Rx?

A

Rate control w/ beta blocker or diltiazem

Anticoag w/ warvarin

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75
Q

Causes of A flutter (3)

A 
heart disease (HF*, rheumatic heart, CAD)
COPD
Atrial septal defect
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76
Q

Treatment for A flutter

A

Same as A fib

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77
Q

Multifocal Atrial Tachy occurs w/ whom

A

people w/ severe pulm disease - COPD

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78
Q

Morphology of Multifocal atrial Tachy? (3 things)

A

Variable P morphologies,
- need 3 dif P wav morphology
Variable PR interval
Variable R to R

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79
Q

Wandering atrial pacemaker

A

Same as Multifocal atrial tacky (dif P wave origins) but slower (60-100)

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80
Q

Rx for Multifocal atrial tachy?

A

Oxygen and ventilation improvement

  • if LV fine use CCB, BB, digoxin, amiodarone, IV flecainise, IV propafenone
  • NO LV- digoxin, diltazem, amiodarone

NO cardiovert

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81
Q

Paroxysmal Supraventricular Tachy

2 types

A

AV nodal reentrant - where 2 paths w/in the node, most common nidus (PAC initiate)

orthodondromic AV reentrant tachy - accessory pathway (PAC and PVC initiate)

BOTH have narrow QRS

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82
Q

Causes of paroxysmal supraventrocular tachy (PSVT) (6)

A 
ischemic heart disease
Digoxin tox
AV nore reentry
Atrial flutter
AV reciprocating tachy
Excessive caffeine or EtOH
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83
Q

Rx for Paroxysmal Supraventricular Tachy (4)

A

Vagal manuevers/valsalva, carotid sinus massage/breath holding

IV adenosine* - slows nodal activity
IV verapamil/ esmolol/digoxin if LV function preserved

DC cardioversion if above NOT effective

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84
Q

Sfx of adenosine

A

HA, flushing, chest pain, SOB, Nausea

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85
Q

Prevent PSVT? (2)

A

Pharm: digoxin*, verapamil, beta blockers

Radio frequency catheter ablation of AV node or accessory

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86
Q

Wolf Parkinson White Syndrome due to?

A

accessory conduction - causes premature ventricular excitation, lacks AV delay

-> Paroxysmal tachy and reentry pathways

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87
Q

Delta wave and short PR interval seen in?

A

Wolf parkinson white

narrow GRS also

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88
Q

V Tach def?

2 types?

A

3+ PVCs in a row at 100-250 bpm

Sinus P has no effect

sustained: longer 30s, seen in marked hemodynamic compromise
nonsustained: usually asymptomatic, evaluate for cause

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89
Q

Causes of V tach (6)

A 
CAD w/ prior MI*
Active ischemia, hypotension
Cardiomyopathies
Congenital defexts
Prolonged QT
Drug tox
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90
Q

Torsades de pointes def

A

Rapid polymorphic VT

-> Vfib

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91
Q

Risk of Long QT?(4)

A

TCAs, anticholinergics, electrolyte abnormalities, ischemia

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92
Q

Treatment for Torsades?

A

IV magnesium

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93
Q

V tach symptoms(4+)

A

palpitations, dypsnea, lightheaded, angina, syncope

Sudden cardiac death

Cardio shock signs

Asymptomatic if slow

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94
Q

Canon A waves

A

seen in V tach when the atria try to contract on contracting ventricles

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95
Q

ECG of V tach

A

Wide(>0.12s) and bizarre QRS
- monomorphic v polymorphic

P wave washed

NO response to vagal or adenosine

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96
Q

Rx for sustained V tach

A

Hemodynamically stable and BP>90 = Pharm: IV Amiodarone, IV procainamide, IV sotalol

Unstable - Immediate cardioversion -> IV amiodarone

ICD unless EF is normal

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97
Q

Rx for non sustained V tach

A

if no heart disease, DO NOT treat

If heart disease- get an ECG, if shows inducible sustained VT, give ICD

Pharm is 2nd line

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98
Q

V fib def

A

Multiple foci in ventricles -> chaotic quivering, begin usually w/ VT

ECG= no p waves, no qrs

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99
Q

Recurrence rate of V fib depends on?

A

Proximity of MI
- spontaneous = high rate (30%) give amiodarone pox

-Peri MI = low risk (1-2%), watch

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100
Q

Cardiac arrest

A

sudden loss of cardiac output, potentially reversible if circulation restored

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101
Q

Sudden cardiac death

A

unexpected death in one hr, Not reversible like cardiac arrest

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102
Q

Causes of V Fib (3)

A

Ischemic Heart*
Antiarrythmic drugs(torsades)
A fib w/ RVR

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103
Q

V fib Rx?

A

Defibrillate and CPR

  • 3 shocks initially, then CPR
  • Epi (1mg IV initial then q3-5min)
  • defib again 30-60s after 1st epi

Refractory: IV amiodarone -> shock

If success - IV antuarythmic (amiodarone), Implant defib

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104
Q

Sinus Bradycardia =

Causes (4)

A

<45

ischemia, vagal tone, antiarrythmics, athlete

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105
Q

Rx for bradycardia

A

Atropine, blocks vagal stim. cardiac pace maker?

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106
Q

Sick sinus rhythm def

Symptoms (5)

A

persistent spontaneous sinus brady

dizzy, confusion, syncope, fatigue, CHF

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107
Q

1st degree AV block

A

PR >0.20

QRS after each P
Benign

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108
Q

2nd degree AV block

Mobitz I

A

Progressive PR interval increase and eventual drop of QRS

Benign - weinckeboch

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109
Q

Who gets a pacemaker? (4)

A

sick sinus,
Symptomatic Bradycardia
Mobitz Type II
3rd degree block

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110
Q

Mobitz type II

A

P wave fails suddenly, progresses to complete heart block

Block in His purkinje

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111
Q

3rd degree block

A

Absence of conduction, Regular P wave does not correlate w/ QRS

AV dissociation, 25-45 BPM

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112
Q

Dilated Cardiomyopathy def and prognosis

A

Most common CM

Dysfunction of LV contractility 2/2 insult

many die w/in 5 yrs

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113
Q

Causes of dilated cardiomyopathy (11)

A

50% idiopathic

CAD* w/ prior MI; Toxic (alcohol, doxyrubicin); Metabolic (low thiamine, selenium, phos; uremia); Infection (viral, chagas, Lyme, HIV); Thyroid (hyper/hypo); Peripartum; Collagen vascular (SLE, scleroderma); uncontrolled Tachy; catecholamine (pheo, cocaine); familial

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114
Q

Symptoms of dilated cardiomyopathy (5)

A
  1. L/R CHF
  2. S3/S4 murmurs
  3. Cardiomegaly
  4. Coexisting arrythmia
  5. Sudden death
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115
Q

Rx Dialated Cardiomyopathy

A
  1. Tx CHF w/ diuretics, digoxin, vasodialators, cardiac transplant
  2. Remove offending agent
  3. Anticoag?
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116
Q

Hypertrophic Cardiomyopathy def?

Cause?

A

diastolic dysfunction 2/2 stiff hypertrophied ventricles -> elv filling pressures; may have outflow obstruction w/ hypertorphy

Autosomal dom trait usually. Can be spontaneous.

117
Q

Symptoms/Signs of Hypertrophied heart

A

dypsnea, angina, syncope w/ vasalva, palpitations, arrythmia (high pressure), cardiac failure, sudden death

sustained PMI, loud S4, rapid increase in carotid pulse w/ 2 upstrokes, systolic ejection murmur (decreases w/ squat/lying 2/2 less outflow obstruction - increases w/ valsalva and standing)

118
Q

systolic murmur that increases w/ valsalva and standing and decreased w/ sustained hand grip (increased systemic resistance lows gradient across aortic valve) and squatting/lying down

A

think of Cardiac hypertrophy and outflow obstruction

normally standing etc.. moves decrease intensity of all murmurs w/ decrease L vent volume

normally Squat increases intensity of all murmur

119
Q

Dx of hypertrophied Cardiomyopathy

A

Echocardio

Clinical Dx and FHx

120
Q

Rx for hypertophied CM

A

asymptomatic need NONE, avoid strenuous exercise

Symptoms: beta blockers, CCB(verapamil), diuretics if retaining, Surgery (myomectomy)

121
Q

Restrictive Cardiomyopathy - 3 things to note

A
  1. infiltrative disease -> impaired diastolic ventricular filling 2/2 low compliance
  2. Systolic dysfunction is variable, usually advance disease
  3. Less common
122
Q

Causes of restrictive Cardiomyopathy (7)

A

Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, carcinoid, chemotherapy, idiopathic

123
Q

Symptoms of Restrictive CM (2)

A

Elv filling pressures-> dyspnea and exercise intollerance

R side signs and symptoms

124
Q

Diagnose Restrictive CM- 3 things

A
  1. Echo - thick myocardium, RA and LA size increase
  2. ECG low voltage, arrhythmia
  3. Biopsy may be diagnostic
125
Q

Rx for Restrictive Cardiomyopathy

A

Tx the cause!

Hemochromatosis- phlebotomy, deferoxamine
Sarcoidosis- glucosteriods
Amyloidosis - none

Digoxin for systolic dysfunction (except amyloidosis)

Diuretics and vasodilators cautiously

126
Q

Causes of Myocarditis (5)

A 
Virus- coxsackie, parvo B19, HSV6
Bacteria- Group A strep rheumatic fever, Lyme, mycoplama
SLE
MEds
Idiopathic
127
Q

Symptoms of myocarditis (7)

A

asymptomatic or…

fatigue, fever, chest pain, pericarditis, CHF, arrythmia, death

128
Q

Classic myocarditis Pt and diagnosis clues

A

See a young male w/ ESR and cardiac enzymes

129
Q

causes of Pericarditis - MANY

A

Idiopathic- postviral

Infectious - viral (coxsackie echoviris, adenovirus, EBV, infuenza, Hep A/B, bacterial, fungal, toxo

Acute MI; Uremia; Collagen vascular disease (SLE scleroderma); neoplasm, drug induced SLE (hydrazine, procainamide); Post MI (dressers), surged, amyloidosis, radiation, trauma

130
Q

Complication sof pericarditis (2)

A

pericardial effusion

Cardiac tamponode

131
Q

Acute pericarditis symptoms (4)

A

chest pain (pleuritic and positional),
friction rub,
ECG change- diffuse ST elv and PR depression
pericardial effusion

132
Q

Rx for pericarditis (4)

A

self limited to 2-6 wks usually
Tx cause if known
NSAIDs*, maybe cochicine
glucocorticoids 2nd line

133
Q

Constrictive pericarditis

A

fibrous scarring of pericardium -< rigid and thickening

2/2 post viral? uremia, radiation, TB, chonic pericardial effusion, surgery

134
Q

Key pathophys of constrictive pericarditis

A

diastolic dysfunction -

early diastolic -> rapid fill, late diastolic -> halted

135
Q

2 presentations of constrictive pericardits

A

Symptoms of fluid overload - edema, ascites, pleural effusions

diminshed CO - dyspnea, fatigue, cachexia

or both

136
Q

Signs of Constricitve pericarditis (5)

A 
JVD - prom
kussmal's sign: JVD FAILS to fall w/ breath
pericardial knock- stopped filling
Ascities
Edema
137
Q

Diagnose Ponstricitve pericardities (4)

A

ECG- Atrial fib advances, low qrs, T flattening

Echo*- increased pericardial thickness, sharp halt in vent filling

CT/MRI thickening/calcification

Cardiac Cath- elv and equal pressure of all chambers - rapid y descent

138
Q

Pericardial effusion causes

A

CHF, cirrhosis, nephrotic syndrome

retain salt and water, concern w/ tamponode if rapid

139
Q

Exam of pericardial effusion (4)

A

muffled Heart sounds, soft PMI, dull L Lung base, friction rub?

140
Q

Diagnose pericardial effusion?

A

Echo, shows little as 20mL, see “water bottle” appearance

141
Q

Tx for pericardial effusion

A

Depends on hemodynamic stability -

  • NO pericardiocentesis until Cardiac tamponade
  • small repeat echo 1-2 wks
142
Q

Cardiac Tamponade Def

A

High RATE of accumulation of pericardial fluid -

Mechanically impairs diastolic filling and have elv and equalization of filling pressures

IMPAIRED ventricular filling

143
Q

Causes of Cardiac Tamponade(4)

A

Penetrating trauma to thorax (stabbed)
Iatrogenic (central line, pacemaker, pericardiocentesis)
Pericarditis
Post MI free wall rupture

144
Q

Pulsus paridoxus

A

seen in tamponade

decrease in atrial pressure during inspiration , pulse strong on expiration

145
Q

Signs of Cardiac tamponade (6)

A

JVD, narrow pulse pressure, Pulsus paradoxes, muffled heart sounds, tachy and hypotensive

146
Q

Test for cardiac tamponode

A

Echo

CXR may show enlargement of silhouette w/ >250mL

ECG - electrical alternans (moving)

147
Q

Mitral stenosis cause?

A

rheumatic heart disease, many forget rheumatic fever

Asymptomatic until area reduced to 1.5cm (squared4-5cm normally

148
Q

Signs/Symptoms of Mitral stenosis

Murmur?

A

exertional dypsnea, ortopnea, palpiations, angina, hemoptysis (elv LA pressure->rupture), thromboembolism (a fib)

Murmur, open snap ->LOW PITCH DIASTOLIC RUMBLE, loud S1 follows

149
Q

Mitral stenosis Dx test

A

Echo* - LA enlarged, narrow fish mouth orifice

CXR shows LA enlargement

150
Q

Mitral Stenosis Tx

Medical (4)
Surgical

A

Rx: diuretics (pulm and edema)
Beta blockers (low CO and HR)
Inflective endocarditis ppx
Warfarin?

Percutaneous balloon valvuplasty

NO Rx if asymptomatic

151
Q

Aortic Stenosis complication

Causes (3)

A

Symptoms mitral valve dysruption and MR

Calcified congenital bicuspid valves
Calcified tricuspid elderly valve
Rheumatic fever

poor prognosis w/ Angina(3yr), Syncope(2yr), HF (1.5yr)

152
Q

Symptoms/signs of Aortic Stenosis

Murmur?

A

Angina, syncope and HF(dyspnea, orthopnea)

Murmur - Harsh crescendo systolic murmur. Radiates to carotids,

Soft S2,
S4, precordial thrill
Parvus et tardus - delayed carotid upstrike

153
Q

Tx aortic stenosis

A

asymptomatic - none

symptomatic - surgery

154
Q

Diagnose aortic stenosis

A

Echo* - LVH, immobile valve

Cardiac Cath definitive - valve gradient and valve area (before surgery)

CXR - calcified

155
Q

Causes of aortic regurgitation

4 acute
2 chronic

A

A: infective endocardits,
Trauma,
aortic dissection,
itragenic post surgery

C: primary valve (rheumatic fever, bicuspid, Marfans, Ehlers Danlos, ankylosing spondylitis, SLE)
Aortic root disease (syphilis, osteogenesis imperfect, retirees, HTN)

156
Q

De mussels sign

A

head bobbing w/ Aortic insufficiency

157
Q

Mullers sign

A

uvula bobs w/ aortic insufficiency

158
Q

Duroziez sgn

A

pistol shot sound over femoral arteries

159
Q

Symptoms of aortic insufficiency

Murmur

A

Asymptomatic for yrs
Sypnea, orthopnea, palpations, Angina, Cyanosis

Wide pulse pressure, Corrigans(water hammer pulse)

Diastolic decrescendo murmur ((austin flint murmur) -> increased w/ sustained hand grip (increases SVR)

160
Q

Diagnose Aortic regurg

A

Echo* - LV size, function,

CXR- LVH, dialated aorta
ECH LVH

161
Q

Tx for aortic regurg -

A

Conservative if stable - low salt, diuretics, VASODIALAIS, after load reduction

Surgery definative( LV dysfunction)

Acute AR (post mi) medical emergency

162
Q

Mitral regurg Acutely due to? (3)

A

Endocarditis (S aureous), Papillary muscle rupture, Chordae tendinae ruptures

Quick shift to increase LA pressure and decreased forward flow -> hypotensionand shock

163
Q

Mitral Regurg Chronic due to 4?

A

Mitral valve prolapse
Rheumatic fever
Marfan’s syndrome
Cardiomyopathy

Gradual fill -> dilation and eventual LV dysfunction, Pulm HTN

164
Q

Symptoms and Signs of mitral regurgitation

Murmur

A

Dyspnea, orthopnea, Palpitations, pulm edema

Holosystoloc murmur at apex(starts w/ s1)

Often Afib, diminished S1, wide S2

165
Q

Diagnosis of mitral regurg

A

CXR - cardiomyopathy, dialated LV, pulm edema

Echo* - ME dialated LA and LV

166
Q

Tx for mitral regurg

A

After load reduction w/ vasodilators if symptomatic

Anticoag>

IABP bridge to surger

Surgical valve repair/replace

167
Q

Causes of Tricuspid regurg (5)

A

usually 2/2 RV dilation(LV failure, infra, Inferior wall mI); endocarditis (IV); rheumatic heart disease; Epsteins anomaly (displaced valve into RV); Other (carcinoid, SLE)

168
Q

Clinical features of Tricuspid regurg (4)

Mumur

A

Asymptomatic unless RHF/puln HTN!!!
RVF,
Pulsitile Liver!!
, AFib present

Blowing holosystolic murmur- greater w/ inspiration, less w/expiration and valsalva

169
Q

Diagnose Tricuspid regurg w/

A

Echo - ID’s

EKG - RV and RA enlarged

170
Q

Mitral valve prolapse more common in

A

marfans, osteogenesis imperfecta and ehlers Danlos

most common MR in developed countries

171
Q

Signs of MVP - mitral valve prolapse

A

systolic clicks,
midsystolic rumble that increase w/ standing and valsalva (smaller LV chamber)

decreases with squatting(increases LV chamber)

172
Q

Diagnose MVP

A

echo,

173
Q

Bug causing rheumatic heart disease

A

strep pharyngitis. group A

174
Q

Most common valve abnormality in rheumatic fever

A

MS, also aortic or tricuspid

175
Q

Major(5) and minor(6) criteria for rheumatic fever

2 M vs 1M and 1m vs 2m

A

Major: JONES
migratory polyarthritis, cardiac involved, subq nodes, Erythema marginatum, Chorea

Minor: fever, ESR, polyarthralgia, Hx of, PR interval, prior strep infection

176
Q

Tx of rheumatic fever
PPX

Acutely

A

Treat strep pharyngitis w/ Erythromycin or penicillin to pervent

Acutely treat w/ NSAIDs-

HC of should get Abx pox w. erythromycin or amoxicillin for dental/gi/gu procedures

177
Q

Monitor Rx for acute rheumatic fever w/

A

C peptide

178
Q

New heart murmur and unexplained fever always suspect

A

endocarditis

179
Q

Acute endocarditis caused by?

Fatal in?

A

Staph aureous on NORMAL heart valves

fatal in 6 wks

180
Q

Subacute endocarditis caused by?

Fatal in?

A

Strep viridans and enterococcus on DAMGED valves

fatal in >6 wks

181
Q

Native valve endocarditis caused by (3 groups)

A

Strep viridans- most common

Staph aures and epidemnus and enterococci

HACEK

182
Q

HACEK organisms are?

A

Haemophilis, Actinobacillus, Cardiobacterium, Eikenella, Kingella

183
Q

<60 days of surgery and prosthetic valve concern due to

A

Staph epidermis> aureus endocarditis

184
Q

> 60 days of surgery posthetic valve concern due to

A

Strep viridans

185
Q

Endocarditis in IV drug users see

A

staph aureous on tricuspid valve

186
Q

Imaging in endocardits

A

TEE

187
Q

Dukes Criteria for endocarditis diagnosis
2major
6 minor
(2M, 1M and 3m, or 5m)

A

Major: Sustained bactermia; endocardial involvement (new valve regard, seen on TEE(

Minor: Predisposing condition, fever, vascular phenomena(janeway lesions, mycrotic aneurisms, emboli), immune phenomenon (glomerulonephritis, Oslers nodes, Roth spots), + blood cultures, + echo

188
Q

Rx for endocarditis

what if (-) cultures but still suspicious

A

IV abx for 4-6 wks

Empircle Rx of penicillin or vance + aminoglycoside

189
Q

Nonbacterial thrombotic endocarditis (marantic)- associated w?

A

METS CA (20%)

Vegetation can embolize, maybe use heparin

190
Q

Found vegitation on both sides of valve

involving the aortic valve

What is disease and underlying condition

A

Nonbacterial verrucous endocarditis (Libman sacks) -

SLE

191
Q

Atrial septal defect types (3)

A

Ostium secundum = 80%- central portion of intertribal septum

Ostium primum - low septum

Sinus venous defcts - high in septim

192
Q

Symptoms of ASD

A

Asymptomatic till 40

Exercise intolerance, dyspnea, fatigue

mild systolic ejection murmur in pulmonary area

193
Q

Wide fixed split S2 and diastolic flow rumble

A

ASD

Heard near tricuspid valve

194
Q

Eisenmengers disease

A

complication of ASD

irreversible pulm HTN leads reversal of shunt, HF and cyanosis

195
Q

Complications of ASD

A 
Pulm HTN - after 20, common >40
Eisenmenger disease
RHF
Atrial arrythmia (Afib)
 Stoke -paradoxical emboli or afib
196
Q

Most common congenital cardiac malformation

A

VSD

197
Q

Harsh blowing holosystolic murmur at 4th L intercostal

A

VSD

decreases w/ vassal and handgrip

198
Q

Coarctation of aorta may in woman can be associated w/?

A

Turners syndrome

199
Q

Midsystolic murmur over the back w/ HA, cold extremities and claudication w. exercise

A

Coartaction of aorta

Deleayed femoral pulses vs radial

200
Q

Coarctation Dx w/

A

ECG - LVH

CWR- notched ribs and Figure 3 indentation of aorta

201
Q

Complications of coarctation (4)

A

Severe HTN, rupture of cerebral aneurisms, Infective endocarditis, Aortic dissection

202
Q

2 leading causes of death w/ patent ductus arteriosus?

A

HF

endocarditis

203
Q

Patent ductus arteriousus associated w/ (3)

A

rubella
high altitude
premature birth

204
Q

Wide pulse pressure and bounding peripheral pulses, Loud P2, LVH, RVH 2/2 pulm htn

A

PDA

machinery murmur

205
Q

Diagnosis PDA w?

A

CXR - increased pulm vascular markings, dilated pull artery, enlarged cardiac silhouette

Echo

206
Q

Rx for severe PDA w/ pulm HTN or R-L shunt

A

do NOT correct PDA

if pulm disease absent, correct

207
Q

Use for closure of PDA at birth

A

Indomethacin

PGE2 keeps it open

208
Q

Tetralogy of Fallot (4)

A

VSD
RV hypertrophy
Pulmonary stenosis
overiding aorta

209
Q

Tet spells

A

squat after exertion to increase SVR which corrects L->R shunt and directs blood towards the stenotic pulm artery and lungs vs aorta

in tetrology of fallot

210
Q

Diagnose tetrology of fallot

A

Echo

EKG may show large RA ond RV

211
Q

Boot shaped heart on CXR in a kid

A

Tetralogy of ballot w. RVH

212
Q

Hypertensive emergency definition

A

Systolic >180 and/or diastolic >110in addition to end organ damage - immediate Rx

w/o damage -> end organ urgency - 24 hrs to Rx

213
Q

End organ damage in HTN emergency (5 systems)

A

Eyes - papilledema
CNS - AMS, intracranial hemorrhage, HTN encephalopathy
Kidneys-Renal failure, hematuria
Heart- unstable angina, MI, CHF w/pulm edema, aortic disseaction
Lungs- Pulm edema

214
Q

Causes of HTN Emergency -11

A 
Noncompliance on HTN meds
Cushings
Drugs (Cocaine, LSD, meth)
Eclampsia
Hyperaldosteronism
Vasculitis
Alcohol withdrawal
Pheo
Noncompliant dialysis
Renal Artery Stenosis
polycystic kidney disease
215
Q

Posterior Reversible encephalopathy Syndrome (PRES)

A

seen in HTN emergency - overwhelms outrage of cerebral vessels

HA, AMS, visual changes, seizures

-Posterior Cerebral White matter edema on radiographs (MRI)

216
Q

Tx of hypertensive emergency

A

Reduce MAP by 25% in 1-2 hrs

Severe (Diastolic>130)
IV hydralazine, esmolol, nitroprusside, labetalol, nitro

Less severe oral - catopril, labetalol, nifedipine, diazoxide

217
Q

TS HTN urgency

A

lowered w/in 24 hrs w/ oral agents

218
Q

Aortic dissection risks (6)

A 
long standing HTN **
cocaine
trauma
Marfans/Ehlers danlos
Bicuspid valve
Corartation
3rd trimester pregnancy
219
Q

Type A vs Type B Aortic dissection

A

A - proximal - ascending aorta

B - distal - limited to decending post subclavian

220
Q

tearing/ripping chest pain abruptly w/ diaphoresis. Pulse or BP asymmetry, aortic regurgiation, neurobstruction (carotid involvement)

A

Aortic dissection

221
Q

To Dx aortic dissection order

A

TEE or CT

CXR shows widened mediastinum

222
Q

Rx for Aortic dissection -

Type A vs Type B

A

All get Beta Blockers and IV sodium nitro IMMEDIATLY

Type A - surgical

Type B - Medical mgmt - w/ morphine or dilaudid

223
Q

Location of most AAA

A

between renal arteries and iliac bifurcation

224
Q

Common age for AA

A

65-70

Rare before 50

M>W

225
Q

Causes of AAA(3)

A

multifactorial - athersclerotic plaque

Truama/htn/vasulitis/smoking

Syphilis/connective tissue disorders

226
Q

Findings of AAA

A 
Pain?
Feeling of fullness
pulsitile mass on exam
Grey Turner's sign - bruising on back/flanks
Cullen sign -bruising around umbilicus
227
Q

Ruptured AAA finding(3)

A

Abdominal pain
Hypotension
palpable pusitile abdominal mass

CV collapse, syncope, N/V

emergency laporatomy

228
Q

Dx of AAA?

A

US* - location and size

CT - longer and only in hemodynamic stable

229
Q

Size of aneurism to have surgery

A

> 5cm

230
Q

Atheromatous occlusion of distal aorta just above the bifurcation -> impotence and loss of femoral pulses

A

leriche syndrome

231
Q

Eval of PVD

A

HTN/carotid bruits?/AAA

lower legs for color change, ulcers, atrophy, loss of hair

Superficial femoral most common, popliteal, aortoilia occlusive

232
Q

Risks of PVD? (3)

A

Smoking*
CAD/HL/HTN
DM

233
Q

pain of legs especially at night think of

A

PVD

Hangs feet over the side of the bed to help

234
Q

False ABIs in which Pts?

A

calcified arteries - especially DM, be warry

235
Q

Dx of PVD (3)

A

Ankle - brachial index (ABI) - systolic, Normal: 0.9-1.3

Claudication <0.4

Pulse volume recording - volume of blood per heart beat at dif sites

Arteriography - gold standard

236
Q

ischemic toes, absent dorsal pulses, muscular atrophy decreased hair growth, thick toe nails

A

PVD

237
Q

Tx of PVD?

A 
Stop smoking
Exercise
Foot care
Atherosclerotic risk reduction
avoid extreme temp
ASA?
Cilostazol (PDE inhibitor)

Surgery: (severe_ Angioplasty surgical bypass

238
Q

Sources of acute arterial occlusion

A

Heart -85% (a fib**, post mi, endocarditis, myxoma)
aneurysm
plaques

239
Q

6 Ps of arterial occlusion

A 
Pain
Pallor
Polar-cold
paraysis
Parestheisas
Pulseless
240
Q

Dx of Arterial occlusion

A

Arteriogram
ECG for MI, A fib
Echo for eval of valves/clot.mi

241
Q

Tx of arterial occlusion acutely

A

Have 6hrs for ischemia
anticoag w/ IV heparin

Surgical embolectomy

Maybe thrombolytis

Risk compartment syndrome

242
Q

Cholesterol embolization syndorme

See?

A

showers of cholesterol crystals (abdominal aorta, iliac, femoral)

Post surgery/arteriogram/thrombilytic therapu

small patches of ischemia (blue/black toes), renal insufficiency, abdominal pain (hyporprfused)

DONT anticoagulate!! get BP contril

243
Q

Mycotic aneurysm

A

damage of aortic wall 2/2 infection

blood cultures +

244
Q

Leutic heart

A

Syphilitic aortitis,
men in 4th -5th decade,

Aneurysm of aortic arch w/ retrograde extension

IV penicillin and surgery

245
Q

DVT risk factors (10)

A

Age>60; Malignancy; Prior Hx; Hereditary hypercoag(Factor V, protein C/S def, anti thromb III); immobilized; cardiac disease w/ CHF; Obesity; major surgery; Trauma; preganacy

246
Q

Classic DVT findings(4)

A

pain and swelling(better w/ elevation)
Humans sign (pain dorsiflexion)
palpable cord
DVT

247
Q

DVT test

A

Doppler and US**
Venography (calf veins)
Plethysmogrphy(electrical impuse)
D dimer- r/o

248
Q

postthrombotic syndrome -chronic venous stasis

A

half of Pts w/ DVTs

residual venous obstruction and valv incompetence->ambulatory HTN

249
Q

Phelgmasia cerula dolens

A

SEVERE DVT - compromises arterial flow -> thrombectomy

250
Q

DVT Tx (3)

A

Anticoag

  • heparin bolus w/ infusion to prevent propigation
  • Warfarin once aPTT therapeutic +48hrs (Warfarin for3-6months)

TPa - speeds up resolution, only for PEs, unstable, R HF and no contraindications

IVC filter for risks and containdications

251
Q

Ambulatory venous HTN

A

in chronic venous insufficency post DVT 2/2 increased pressure

  • > extravasation of plasma proteins and RBCs -> subQ->
  • brawny induration, pigmentation
252
Q

Venous ulcers develop where?

A

medially from the insttep to above the ankle over incompetent vein

253
Q

Venous ulcer vs arterial insufficiency

A

Venous - less painful and rapidly recur, get better w/ elevation

Arterial get better with hanging

254
Q

Tx of Venous ulcers

A

Le elevation protects/avoid standing/ Heavyweight elastic socks

Wet -> dry alpine dressing (3x)
Unna boot changed every wk
(split thickness skin grafts, if not healed w/ ulna boot)

255
Q

superficial thrombophlebitis in dif locations over short period of time think of?

A

migratory superficial thrombophlebitis 2/2 malignancy - (pancreas)

256
Q

Superficial thrmbophelbitis occurs 2/2
Upper ext?

Lower Ext

A

upper 2/2 IV infusion

lower - varicose veins (great saphenous)

257
Q

Pain, tender, induration, erythema along vein

A

thrombophlebitis

NOT cellulitis of lymphangitis (widespread erythema)

258
Q

Tx superfical thromboembolits?

A

NO anticoag
mild analgesic (ASA) and activity
Severe (Pain/cellulitis) -> bed rest, elevation, hot compress
elastic stalkings, usually not Abx,

259
Q

Cardiac tumor etiology

A

0.1% primary (myxoma)

75% secondary

260
Q

Concern w/ atrial myxomas

A

benign but can embolize-> METS or valve dysfunction

261
Q

4 signs common to all SHOCK

A

hypotension
oliguria
tachycardia
AMS

Lactic acidosis as well

262
Q

underperfusion of tissue -

A

Shock

263
Q

Cardiogenic shock

CO
SVR
Pulm Capillary Wedge pressure

A

MI, Angina, heart disease
-JVD

CO - down
SVR - up
PCWP - Up!!!!

264
Q

Hypovolemic shock

CO
SVR
Pulm Capillary Wedge pressure

A

Trauma, GI bleed, Vomitting, diarrhea

CO - Down
SVR - UP
PCWP - down

265
Q

Neurogenic shock
CO
SVR
Pulm Capillary Wedge pressure

A

Spinal cord injury etc

CO - Down
SVR - Down
PCWB -Down

266
Q

Septic
CO
SVR
Pulm Capillary Wedge pressure

A

Fever and infection site

CO - UP!!
SVR - down
PCWB down

267
Q

Initial steps in shock (7)

A
  1. 2 large bore IV, central line and arterial line
  2. bolus of 500-1000mL NS
  3. Blood: CBC, lytes, renal funciton, PT/PTT
  4. ECG/CXR
  5. pulse ox
  6. vasopressors (dopamine NE)
  7. pulm arterial catheter?

Always ABCs

268
Q

Tx for each type of shock is usually fluids except in ?

A

Cardiac - sometime neuro

may need diuretics, Tx the cause: MI, pressers, after load reducing agents

269
Q

Cardiac shock defined

Causes (7)

A

RVF, myocardial diseas, Mech abnomalities

270
Q

altered senses, pale/cool skin, hypotensive and tachy think?

Also see?

A

Cardiac shock

engorged neck veins
Pulm congestion

271
Q

Dx of Cardiac shock

A

ECG-
Echo
hemodynamic monitoring (swan ganz)

272
Q

If CVP is low what shock is it most likely?

A

hypovolemic

lose 20-25% of volume and decompensate

273
Q

Intraaortic ballon pump is used in what?

A

used in failing heart
in thoracic aorta just distal to subclavian
help ventricular emptying by deflating just before systole (reduce after load) and increases coronary perfusion by inflating onset of diastole

-> increased myocardial oxygenation

274
Q 
See Drop in BP in what class of hypo volumetric shock?
  lost how much?
A

Class III = 30-40%

275
Q

See tachycardia after losing how much blood?

Class of hypo volumetric shick?

A

lost 20-30%

> 100 tachy

276
Q

Class I hypo volumetric signs

Lost how much blood?

A

10-15% lost

normal pulse and BP
CNS normal, normal urine output

277
Q

Class II hypo volumetric signs

lost how much blood

A

20-30%

Tachy but normal BP, decreased pulse pressure, delayed cap refill, Anxious w/ 20-30mL/hr urine output

278
Q

Class III hypo volumetric signs

Lost how much blood

A

30-40%

Tachy(120) AND BP drop,

marked tachypnea, confuses and Urine out drops to 20mL/hr

279
Q

Class IV hypo volumetric signs

Lost how much blood?

A

> 40%

Tachy (>140) and BP DROP

absent capillary refill, lethargic/coma

280
Q

Causes of hypo volumetric shock

A

Hemorrhage
- trauma, GI bleeds, retroperitoneal

Nonhemorrage
-vomitting, diarrhea, dehydration, burns, 3rd spacing

281
Q

SIRS -> sepsis -> septic shock -> MODS

What is SIRS?

A

2+ of:
Fever >38, 20 or pCO2 90 BPM
Increased WBC >12000, <4000

282
Q

SIRS becomes sepsis when?

Sepsis becomes septic shock when?

A

blood cultures are + and SIRS is present; Blood cultures - 2 sets from 2 sites, anaerobic and aerobic

Shock -Hypotension despite resusitation

283
Q

MODS?

A

Altered organ function in acutely ill patient leading to death

284
Q

Common causes of sepsis?

A

pneumonia, pyelonephritis, meningitis, abcess, cholangitis, cellulitis, peritonitis

285
Q

Warm extremities, CO is normal or increased, EF is decreased 2/2 reduction in contractility?

A

Septic shock

286
Q

TX of septic shock

A

ABx, surgical drainage?. Fluids, Pressors (dopamine 1st)

287
Q

Peripheral vasodialtion w/ decreased SVR?

Causes:

A

Neurogenic shock - failure of sympathetic nervous system to maintain tone

Spinal cord injury, severe head injury, spinal anesthesia, pharmacological block

288
Q

Warm perfused skin, Low/normal urine output, Bradycardia/hypotension, CO decreases w/ low SVR

A

Neurogenic shock

289
Q

Tx of neuro shock (4)

A

IV fluids **
vasoconstrictors
Suprine, trendelenburg position
Maintain body temp

Med 1 (11 decks)

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