Cardiology Flashcards
1
Q
Risk factors for CAD (7)
A
DM; Hyperlipidemia(LDL45, W >55
Family Hx
minor - obesity, sedentary, stress, alcohol
2
Q
Poor EF in CAD is
A
<50%
3
Q
Vessel that is worse to have fixed atherosclerotic lesions?
A
Left main coronary
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
5
Q
Metabolic syndrome includes (6)
A
hypercholesterolemia, hypertriglyceridemia, impaired glucose, DM, hyperuricemia, HTN
6
Q
1st test w. chest pain
A
ECG
7
Q
Indications for stress ECG
A
Confirm angina
Eval response to therapy
ID CAD pts w/ high risk
8
Q
Stress test 75% sens if able to reach what factor?
Calculated how?
A
85% of max HR
0.85 x (220-age)
9
Q
Positive signs on stress test
f/u?
A
ST depression, HF, ventricular arrythmia, hypotension, chest pain
(+) => cardiac catheterization
10
Q
Stress echo looks for
A
wall motion abnormalites, LV size/function, valve disease,
11
Q
Pharacologic stress test
A
IV adenosine, dipyridamole,
(cause coronary vasodialtion)
dobutamine(increases oxygen demand w/ higher HR, BO and contractility)
12
Q
thallium 201 in ischemia used to see what?
A
stress myocardial perfussion, determines reversibility of ischemia and rescued from PCI, cABG
13
Q
Silent ischemia detected by what
A
Holter monitor - Contunous over 24-72hrs
eval arrythmias, HR variability, ICD need
14
Q
Definitive Test for CAD is
A
Cardiac catheterization -> CORONARY ANGIOGRAPHY often w. PCI (angioplasty)
Stenosis of 70% symptoms
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
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
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
18
Q
Dif between Unstable and Stable Angina
A
oxygen demands the same but supply is decreased
possible total occlusioin
19
Q
Acute coronary syndrome is
A
clinical manifestation of atherosclerotic plaque rupture and coronary occlusion -> unstable angina, STEMI or NSTEMI
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
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*
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%
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
24
Q
Rx in Variant angina (2)
A
CCB and nitrates
25
Mortality of MI is?
30%, half before the hospital
26
4 categories of MI response
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
27
ECG MI changes (5)
```
Peaked T waves early
ST elevation - transmural
Q wave - seen late
T wave inversion - sensitive but not specific
ST depression subendocaridal
```
28
```
Location of infarct:
Anterior
Posterior
lateral
Inferior
```
*******************
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
29
Time line and use for 2 cardiac enzymes
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
30
Reduce mortality in MI - Rx (3)
Beta blockers
ASA
Ace Inhibitors
31
beta blocker that reduces mortality w/ post MI LV dysfunction
carvediol
32
Rx for MI medical(8)
4 long lasting
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
33
Revascularization is good if early how early w/ thrombilytics vs PCI vs CABG
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
34
Complications of MI(9)
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
35
Contraindications of thrombolytics in MI(5)
truama, prior stroke, recent surgery, Dissecting aortic aneurism, active bleeding
36
Chest Pain Ddx (6systems)
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
37
Chest pain tests (4)
ECG
enzymes
CXR
PE w/up?
38
Causes attributed High Output HF (8) in underlying disease
```
Chronic anemia
pregnancy
hyperthyroidism
AV fistula
wet beriberi (B1)
Pages disease of bone
Mitral regurg
Aortic insuficency
```
39
Systolic dysfunction
| -> HF (3+)
HTN** -> cardiomyopathy
valvular disease
myocarditis
Less: EtOH, radiation, hemochromatosis, thyrois
40
Diastolic dysfunction -> HF (3+)
Impaired ventricular filling (stiff or impaired relaxing)
HTN** -> hypertrophy
Valve (AS, AR, MS)
Restrictive cardiomyopathy(amyloidosis, sarcoid, hemochromatosis)
41
Difficulty breathing recumbant
L Heart failure - orthopnea
42
only 1-2 hrs of sleep 2/2 SOB
L heart failure
Paroxysmal nocturnal dyspnea
43
nocturnal cough - nonproductive
L heart failure, worse laying down
44
S3 -
Venricular gallop heard at apex
rapid filling phase (slosh-----ing-ing)
normal in kids
45
S4
atrial systole hittins a stiff wall
A-stiff ----heart
46
NYHA Classification (4) for HF
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
47
CHF on Xray
Cardiomegaly
Kerley B lines
interstial markings
pleual effustion
48
Test for diastolic vs systolic HF
Echo - Determine EF
EF>40% are diastolic dysfunction while <40% is systolic dysfunction
49
Enzyme released in CHF
BNP >150 suggestive and helps dif SOB from COPD vs. CHF
50
Rx in CHF(5)
Which help w/ morbidity and mortality
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
51
Spiranolactone alt in CHF Tx?
Epleronone for gynectomastia
52
Digitoxality - 3 systems
GI: N/V, anorexia
Cardiac - ectopic beats, AV block, Afib
CNS: disorientation
53
Contra indicated in CHF (3)
Metformin -lactic acidosis
Thiazolidinediones - fluid retention
NSAIDs
54
ICD goes to who?
HF Pt
40 days post MI w/ EF <35% and class II or III
55
Cardiac resynch device goes to who? Biventricular pacemaker.
HF Pt
40 days post MI w/ EF 120
56
5yr mortality in CHF
50%
57
Diastolic Dysfunction CHF differs use: (3)
Beta blockers, diuretics, maybe ACE
NO: digoxin or spiranolactone
58
Acute decompensated HF is
Acute dyspnea w/ elv L filling pressures w/or w/o pulm edema
DDx: PE, Asthma, pneumonia
59
Rx for Acute decompensated HF
Oxygen
Diuretics for volume overload and congestive
Low Na
Nitrates w/o hyotension
Admission
60
PAC is?
Causes?
premature arial complex - see abnormal P waves
adrenergic excess, drugs, alcohol tobacco, electrolyte, ischemia, infection
61
Rx for PAC
none- monitor and maybe a beta blocker
62
PVC is?
Causes
premature ventricular complex
Occur w/ or w/o structural heart disease- hypoxia, electrolyte, stimulants, caffeine, meds
63
Wide isolated QRS, lower than normal, compensatory beat
PVC
P wave not seen, burred in QRS
64
When to w/u PVC?
frequent and recurrent PVC w/ underlying heart disease
order ECG to think about an ICD
65
Bigeminy vs trigeminy
Sinus beat followed by PCV
2 sinus beats followed by PVC
66
Irregular rapid ventricular rate >400bpm, ventricle AV slows to 75-175
A fib
67
Causes of Afib (9)
```
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
```
68
Symptoms of A fib
Fatigue, SOB, racing heart, dizzy, angina, syncope, irregular irregular pulse, blood stasis
69
Acute Afib if hemodynamically unstable Rx
electrocardiovert
70
Cardioversion
Used when?
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
71
Defibrillate
Used when?
Shock not in snc w/ QRS,
Convert dysrythmia to normal sinus
Used in V fib, VT w/o pulse
72
Acute A fib Rx in hemodynamically stable
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
73
Skip 3-4 wk wait time w/ anticoagulation post cardiovert by doing what?
Use a TEE to look for a clot.
Still need 4 wks after of anticoag
74
Chronic A Fib Rx?
Rate control w/ beta blocker or diltiazem
| Anticoag w/ warvarin
75
Causes of A flutter (3)
```
heart disease (HF*, rheumatic heart, CAD)
COPD
Atrial septal defect
```
76
Treatment for A flutter
Same as A fib
77
Multifocal Atrial Tachy occurs w/ whom
people w/ severe pulm disease - COPD
78
Morphology of Multifocal atrial Tachy? (3 things)
Variable P morphologies,
- need 3 dif P wav morphology
Variable PR interval
Variable R to R
79
Wandering atrial pacemaker
Same as Multifocal atrial tacky (dif P wave origins) but slower (60-100)
80
Rx for Multifocal atrial tachy?
Oxygen and ventilation improvement
- if LV fine use CCB, BB, digoxin, amiodarone, IV flecainise, IV propafenone
- NO LV- digoxin, diltazem, amiodarone
NO cardiovert
81
Paroxysmal Supraventricular Tachy
2 types
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
82
Causes of paroxysmal supraventrocular tachy (PSVT) (6)
```
ischemic heart disease
Digoxin tox
AV nore reentry
Atrial flutter
AV reciprocating tachy
Excessive caffeine or EtOH
```
83
Rx for Paroxysmal Supraventricular Tachy (4)
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
84
Sfx of adenosine
HA, flushing, chest pain, SOB, Nausea
85
Prevent PSVT? (2)
Pharm: digoxin*, verapamil, beta blockers
Radio frequency catheter ablation of AV node or accessory
86
Wolf Parkinson White Syndrome due to?
accessory conduction - causes premature ventricular excitation, lacks AV delay
-> Paroxysmal tachy and reentry pathways
87
Delta wave and short PR interval seen in?
Wolf parkinson white
narrow GRS also
88
V Tach def?
2 types?
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
89
Causes of V tach (6)
```
CAD w/ prior MI*
Active ischemia, hypotension
Cardiomyopathies
Congenital defexts
Prolonged QT
Drug tox
```
90
Torsades de pointes def
Rapid polymorphic VT
-> Vfib
91
Risk of Long QT?(4)
TCAs, anticholinergics, electrolyte abnormalities, ischemia
92
Treatment for Torsades?
IV magnesium
93
V tach symptoms(4+)
palpitations, dypsnea, lightheaded, angina, syncope
Sudden cardiac death
Cardio shock signs
Asymptomatic if slow
94
Canon A waves
seen in V tach when the atria try to contract on contracting ventricles
95
ECG of V tach
Wide(>0.12s) and bizarre QRS
- monomorphic v polymorphic
P wave washed
NO response to vagal or adenosine
96
Rx for sustained V tach
Hemodynamically stable and BP>90 = Pharm: IV Amiodarone, IV procainamide, IV sotalol
Unstable - Immediate cardioversion -> IV amiodarone
ICD unless EF is normal
97
Rx for non sustained V tach
if no heart disease, DO NOT treat
If heart disease- get an ECG, if shows inducible sustained VT, give ICD
Pharm is 2nd line
98
V fib def
Multiple foci in ventricles -> chaotic quivering, begin usually w/ VT
ECG= no p waves, no qrs
99
Recurrence rate of V fib depends on?
Proximity of MI
- spontaneous = high rate (30%) give amiodarone pox
-Peri MI = low risk (1-2%), watch
100
Cardiac arrest
sudden loss of cardiac output, potentially reversible if circulation restored
101
Sudden cardiac death
unexpected death in one hr, Not reversible like cardiac arrest
102
Causes of V Fib (3)
Ischemic Heart*
Antiarrythmic drugs(torsades)
A fib w/ RVR
103
V fib Rx?
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
104
Sinus Bradycardia =
Causes (4)
<45
ischemia, vagal tone, antiarrythmics, athlete
105
Rx for bradycardia
Atropine, blocks vagal stim. cardiac pace maker?
106
Sick sinus rhythm def
Symptoms (5)
persistent spontaneous sinus brady
dizzy, confusion, syncope, fatigue, CHF
107
1st degree AV block
PR >0.20
QRS after each P
Benign
108
2nd degree AV block
| Mobitz I
Progressive PR interval increase and eventual drop of QRS
Benign - weinckeboch
109
Who gets a pacemaker? (4)
sick sinus,
Symptomatic Bradycardia
Mobitz Type II
3rd degree block
110
Mobitz type II
P wave fails suddenly, progresses to complete heart block
Block in His purkinje
111
3rd degree block
Absence of conduction, Regular P wave does not correlate w/ QRS
AV dissociation, 25-45 BPM
112
Dilated Cardiomyopathy def and prognosis
Most common CM
Dysfunction of LV contractility 2/2 insult
many die w/in 5 yrs
113
Causes of dilated cardiomyopathy (11)
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
114
Symptoms of dilated cardiomyopathy (5)
1. L/R CHF
2. S3/S4 murmurs
3. Cardiomegaly
4. Coexisting arrythmia
5. Sudden death
115
Rx Dialated Cardiomyopathy
1. Tx CHF w/ diuretics, digoxin, vasodialators, cardiac transplant
2. Remove offending agent
3. Anticoag?
116
Hypertrophic Cardiomyopathy def?
Cause?
diastolic dysfunction 2/2 stiff hypertrophied ventricles -> elv filling pressures; may have outflow obstruction w/ hypertorphy
Autosomal dom trait usually. Can be spontaneous.
117
Symptoms/Signs of Hypertrophied heart
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
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
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
Dx of hypertrophied Cardiomyopathy
Echocardio
Clinical Dx and FHx
120
Rx for hypertophied CM
asymptomatic need NONE, avoid strenuous exercise
Symptoms: beta blockers, CCB(verapamil), diuretics if retaining, Surgery (myomectomy)
121
Restrictive Cardiomyopathy - 3 things to note
1. infiltrative disease -> impaired diastolic ventricular filling 2/2 low compliance
2. Systolic dysfunction is variable, usually advance disease
3. Less common
122
Causes of restrictive Cardiomyopathy (7)
Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, carcinoid, chemotherapy, idiopathic
123
Symptoms of Restrictive CM (2)
Elv filling pressures-> dyspnea and exercise intollerance
R side signs and symptoms
124
Diagnose Restrictive CM- 3 things
1. Echo - thick myocardium, RA and LA size increase
2. ECG low voltage, arrhythmia
3. Biopsy may be diagnostic
125
Rx for Restrictive Cardiomyopathy
Tx the cause!
Hemochromatosis- phlebotomy, deferoxamine
Sarcoidosis- glucosteriods
Amyloidosis - none
Digoxin for systolic dysfunction (except amyloidosis)
Diuretics and vasodilators cautiously
126
Causes of Myocarditis (5)
```
Virus- coxsackie, parvo B19, HSV6
Bacteria- Group A strep rheumatic fever, Lyme, mycoplama
SLE
MEds
Idiopathic
```
127
Symptoms of myocarditis (7)
asymptomatic or...
| fatigue, fever, chest pain, pericarditis, CHF, arrythmia, death
128
Classic myocarditis Pt and diagnosis clues
See a young male w/ ESR and cardiac enzymes
129
causes of Pericarditis - MANY
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
Complication sof pericarditis (2)
pericardial effusion
| Cardiac tamponode
131
Acute pericarditis symptoms (4)
chest pain (pleuritic and positional),
friction rub,
ECG change- diffuse ST elv and PR depression
pericardial effusion
132
Rx for pericarditis (4)
self limited to 2-6 wks usually
Tx cause if known
NSAIDs*, maybe cochicine
glucocorticoids 2nd line
133
Constrictive pericarditis
fibrous scarring of pericardium -< rigid and thickening
2/2 post viral? uremia, radiation, TB, chonic pericardial effusion, surgery
134
Key pathophys of constrictive pericarditis
diastolic dysfunction -
| early diastolic -> rapid fill, late diastolic -> halted
135
2 presentations of constrictive pericardits
Symptoms of fluid overload - edema, ascites, pleural effusions
diminshed CO - dyspnea, fatigue, cachexia
or both
136
Signs of Constricitve pericarditis (5)
```
JVD - prom
kussmal's sign: JVD FAILS to fall w/ breath
pericardial knock- stopped filling
Ascities
Edema
```
137
Diagnose Ponstricitve pericardities (4)
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
Pericardial effusion causes
CHF, cirrhosis, nephrotic syndrome
retain salt and water, concern w/ tamponode if rapid
139
Exam of pericardial effusion (4)
muffled Heart sounds, soft PMI, dull L Lung base, friction rub?
140
Diagnose pericardial effusion?
Echo, shows little as 20mL, see "water bottle" appearance
141
Tx for pericardial effusion
Depends on hemodynamic stability -
- NO pericardiocentesis until Cardiac tamponade
- small repeat echo 1-2 wks
142
Cardiac Tamponade Def
High RATE of accumulation of pericardial fluid -
Mechanically impairs diastolic filling and have elv and equalization of filling pressures
IMPAIRED ventricular filling
143
Causes of Cardiac Tamponade(4)
Penetrating trauma to thorax (stabbed)
Iatrogenic (central line, pacemaker, pericardiocentesis)
Pericarditis
Post MI free wall rupture
144
Pulsus paridoxus
seen in tamponade
| decrease in atrial pressure during inspiration , pulse strong on expiration
145
Signs of Cardiac tamponade (6)
JVD, narrow pulse pressure, Pulsus paradoxes, muffled heart sounds, tachy and hypotensive
146
Test for cardiac tamponode
Echo
CXR may show enlargement of silhouette w/ >250mL
ECG - electrical alternans (moving)
147
Mitral stenosis cause?
rheumatic heart disease, many forget rheumatic fever
Asymptomatic until area reduced to 1.5cm (squared4-5cm normally
148
Signs/Symptoms of Mitral stenosis
Murmur?
exertional dypsnea, ortopnea, palpiations, angina, hemoptysis (elv LA pressure->rupture), thromboembolism (a fib)
Murmur, open snap ->LOW PITCH DIASTOLIC RUMBLE, loud S1 follows
149
Mitral stenosis Dx test
Echo* - LA enlarged, narrow fish mouth orifice
CXR shows LA enlargement
150
Mitral Stenosis Tx
Medical (4)
Surgical
Rx: diuretics (pulm and edema)
Beta blockers (low CO and HR)
Inflective endocarditis ppx
Warfarin?
Percutaneous balloon valvuplasty
NO Rx if asymptomatic
151
Aortic Stenosis complication
Causes (3)
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
Symptoms/signs of Aortic Stenosis
Murmur?
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
Tx aortic stenosis
asymptomatic - none
| symptomatic - surgery
154
Diagnose aortic stenosis
Echo* - LVH, immobile valve
Cardiac Cath definitive - valve gradient and valve area (before surgery)
CXR - calcified
155
Causes of aortic regurgitation
4 acute
2 chronic
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
De mussels sign
head bobbing w/ Aortic insufficiency
157
Mullers sign
uvula bobs w/ aortic insufficiency
158
Duroziez sgn
pistol shot sound over femoral arteries
159
Symptoms of aortic insufficiency
Murmur
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
Diagnose Aortic regurg
Echo* - LV size, function,
CXR- LVH, dialated aorta
ECH LVH
161
Tx for aortic regurg -
Conservative if stable - low salt, diuretics, VASODIALAIS, after load reduction
Surgery definative( LV dysfunction)
Acute AR (post mi) medical emergency
162
Mitral regurg Acutely due to? (3)
Endocarditis (S aureous), Papillary muscle rupture, Chordae tendinae ruptures
Quick shift to increase LA pressure and decreased forward flow -> hypotensionand shock
163
Mitral Regurg Chronic due to 4?
Mitral valve prolapse
Rheumatic fever
Marfan's syndrome
Cardiomyopathy
Gradual fill -> dilation and eventual LV dysfunction, Pulm HTN
164
Symptoms and Signs of mitral regurgitation
Murmur
Dyspnea, orthopnea, Palpitations, pulm edema
Holosystoloc murmur at apex(starts w/ s1)
Often Afib, diminished S1, wide S2
165
Diagnosis of mitral regurg
CXR - cardiomyopathy, dialated LV, pulm edema
| Echo* - ME dialated LA and LV
166
Tx for mitral regurg
After load reduction w/ vasodilators if symptomatic
Anticoag>
IABP bridge to surger
Surgical valve repair/replace
167
Causes of Tricuspid regurg (5)
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
Clinical features of Tricuspid regurg (4)
Mumur
Asymptomatic unless RHF/puln HTN!!!
RVF,
Pulsitile Liver!!
, AFib present
Blowing holosystolic murmur- greater w/ inspiration, less w/expiration and valsalva
169
Diagnose Tricuspid regurg w/
Echo - ID's
EKG - RV and RA enlarged
170
Mitral valve prolapse more common in
marfans, osteogenesis imperfecta and ehlers Danlos
most common MR in developed countries
171
Signs of MVP - mitral valve prolapse
systolic clicks,
midsystolic rumble that increase w/ standing and valsalva (smaller LV chamber)
decreases with squatting(increases LV chamber)
172
Diagnose MVP
echo,
173
Bug causing rheumatic heart disease
strep pharyngitis. group A
174
Most common valve abnormality in rheumatic fever
MS, also aortic or tricuspid
175
Major(5) and minor(6) criteria for rheumatic fever
2 M vs 1M and 1m vs 2m
Major: JONES
migratory polyarthritis, cardiac involved, subq nodes, Erythema marginatum, Chorea
Minor: fever, ESR, polyarthralgia, Hx of, PR interval, prior strep infection
176
Tx of rheumatic fever
PPX
Acutely
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
Monitor Rx for acute rheumatic fever w/
C peptide
178
New heart murmur and unexplained fever always suspect
endocarditis
179
Acute endocarditis caused by?
Fatal in?
Staph aureous on NORMAL heart valves
fatal in 6 wks
180
Subacute endocarditis caused by?
Fatal in?
Strep viridans and enterococcus on DAMGED valves
fatal in >6 wks
181
Native valve endocarditis caused by (3 groups)
Strep viridans- most common
Staph aures and epidemnus and enterococci
HACEK
182
HACEK organisms are?
Haemophilis, Actinobacillus, Cardiobacterium, Eikenella, Kingella
183
<60 days of surgery and prosthetic valve concern due to
Staph epidermis> aureus endocarditis
184
>60 days of surgery posthetic valve concern due to
Strep viridans
185
Endocarditis in IV drug users see
staph aureous on tricuspid valve
186
Imaging in endocardits
TEE
187
Dukes Criteria for endocarditis diagnosis
2major
6 minor
(2M, 1M and 3m, or 5m)
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
Rx for endocarditis
what if (-) cultures but still suspicious
IV abx for 4-6 wks
Empircle Rx of penicillin or vance + aminoglycoside
189
Nonbacterial thrombotic endocarditis (marantic)- associated w?
METS CA (20%)
Vegetation can embolize, maybe use heparin
190
Found vegitation on both sides of valve
involving the aortic valve
What is disease and underlying condition
Nonbacterial verrucous endocarditis (Libman sacks) -
SLE
191
Atrial septal defect types (3)
Ostium secundum = 80%- central portion of intertribal septum
Ostium primum - low septum
Sinus venous defcts - high in septim
192
Symptoms of ASD
Asymptomatic till 40
Exercise intolerance, dyspnea, fatigue
mild systolic ejection murmur in pulmonary area
193
Wide fixed split S2 and diastolic flow rumble
ASD
Heard near tricuspid valve
194
Eisenmengers disease
complication of ASD
| irreversible pulm HTN leads reversal of shunt, HF and cyanosis
195
Complications of ASD
```
Pulm HTN - after 20, common >40
Eisenmenger disease
RHF
Atrial arrythmia (Afib)
Stoke -paradoxical emboli or afib
```
196
Most common congenital cardiac malformation
VSD
197
Harsh blowing holosystolic murmur at 4th L intercostal
VSD
decreases w/ vassal and handgrip
198
Coarctation of aorta may in woman can be associated w/?
Turners syndrome
199
Midsystolic murmur over the back w/ HA, cold extremities and claudication w. exercise
Coartaction of aorta
Deleayed femoral pulses vs radial
200
Coarctation Dx w/
ECG - LVH
| CWR- notched ribs and Figure 3 indentation of aorta
201
Complications of coarctation (4)
Severe HTN, rupture of cerebral aneurisms, Infective endocarditis, Aortic dissection
202
2 leading causes of death w/ patent ductus arteriosus?
HF
| endocarditis
203
Patent ductus arteriousus associated w/ (3)
rubella
high altitude
premature birth
204
Wide pulse pressure and bounding peripheral pulses, Loud P2, LVH, RVH 2/2 pulm htn
PDA
machinery murmur
205
Diagnosis PDA w?
CXR - increased pulm vascular markings, dilated pull artery, enlarged cardiac silhouette
Echo
206
Rx for severe PDA w/ pulm HTN or R-L shunt
do NOT correct PDA
if pulm disease absent, correct
207
Use for closure of PDA at birth
Indomethacin
PGE2 keeps it open
208
Tetralogy of Fallot (4)
VSD
RV hypertrophy
Pulmonary stenosis
overiding aorta
209
Tet spells
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
Diagnose tetrology of fallot
Echo
EKG may show large RA ond RV
211
Boot shaped heart on CXR in a kid
Tetralogy of ballot w. RVH
212
Hypertensive emergency definition
Systolic >180 and/or diastolic >110in addition to end organ damage - immediate Rx
w/o damage -> end organ urgency - 24 hrs to Rx
213
End organ damage in HTN emergency (5 systems)
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
Causes of HTN Emergency -11
```
Noncompliance on HTN meds
Cushings
Drugs (Cocaine, LSD, meth)
Eclampsia
Hyperaldosteronism
Vasculitis
Alcohol withdrawal
Pheo
Noncompliant dialysis
Renal Artery Stenosis
polycystic kidney disease
```
215
Posterior Reversible encephalopathy Syndrome (PRES)
seen in HTN emergency - overwhelms outrage of cerebral vessels
HA, AMS, visual changes, seizures
-Posterior Cerebral White matter edema on radiographs (MRI)
216
Tx of hypertensive emergency
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
TS HTN urgency
lowered w/in 24 hrs w/ oral agents
218
Aortic dissection risks (6)
```
long standing HTN **
cocaine
trauma
Marfans/Ehlers danlos
Bicuspid valve
Corartation
3rd trimester pregnancy
```
219
Type A vs Type B Aortic dissection
A - proximal - ascending aorta
| B - distal - limited to decending post subclavian
220
tearing/ripping chest pain abruptly w/ diaphoresis. Pulse or BP asymmetry, aortic regurgiation, neurobstruction (carotid involvement)
Aortic dissection
221
To Dx aortic dissection order
TEE or CT
CXR shows widened mediastinum
222
Rx for Aortic dissection -
Type A vs Type B
All get Beta Blockers and IV sodium nitro IMMEDIATLY
Type A - surgical
Type B - Medical mgmt - w/ morphine or dilaudid
223
Location of most AAA
between renal arteries and iliac bifurcation
224
Common age for AA
65-70
Rare before 50
M>W
225
Causes of AAA(3)
multifactorial - athersclerotic plaque
Truama/htn/vasulitis/smoking
Syphilis/connective tissue disorders
226
Findings of AAA
```
Pain?
Feeling of fullness
pulsitile mass on exam
Grey Turner's sign - bruising on back/flanks
Cullen sign -bruising around umbilicus
```
227
Ruptured AAA finding(3)
Abdominal pain
Hypotension
palpable pusitile abdominal mass
CV collapse, syncope, N/V
emergency laporatomy
228
Dx of AAA?
US* - location and size
CT - longer and only in hemodynamic stable
229
Size of aneurism to have surgery
>5cm
230
Atheromatous occlusion of distal aorta just above the bifurcation -> impotence and loss of femoral pulses
leriche syndrome
231
Eval of PVD
HTN/carotid bruits?/AAA
lower legs for color change, ulcers, atrophy, loss of hair
Superficial femoral most common, popliteal, aortoilia occlusive
232
Risks of PVD? (3)
Smoking*
CAD/HL/HTN
DM
233
pain of legs especially at night think of
PVD
Hangs feet over the side of the bed to help
234
False ABIs in which Pts?
calcified arteries - especially DM, be warry
235
Dx of PVD (3)
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
ischemic toes, absent dorsal pulses, muscular atrophy decreased hair growth, thick toe nails
PVD
237
Tx of PVD?
```
Stop smoking
Exercise
Foot care
Atherosclerotic risk reduction
avoid extreme temp
ASA?
Cilostazol (PDE inhibitor)
```
Surgery: (severe_ Angioplasty surgical bypass
238
Sources of acute arterial occlusion
Heart -85% (a fib**, post mi, endocarditis, myxoma)
aneurysm
plaques
239
6 Ps of arterial occlusion
```
Pain
Pallor
Polar-cold
paraysis
Parestheisas
Pulseless
```
240
Dx of Arterial occlusion
Arteriogram
ECG for MI, A fib
Echo for eval of valves/clot.mi
241
Tx of arterial occlusion acutely
Have 6hrs for ischemia
anticoag w/ IV heparin
Surgical embolectomy
Maybe thrombolytis
Risk compartment syndrome
242
Cholesterol embolization syndorme
See?
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
Mycotic aneurysm
damage of aortic wall 2/2 infection
blood cultures +
244
Leutic heart
Syphilitic aortitis,
men in 4th -5th decade,
Aneurysm of aortic arch w/ retrograde extension
IV penicillin and surgery
245
DVT risk factors (10)
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
Classic DVT findings(4)
pain and swelling(better w/ elevation)
Humans sign (pain dorsiflexion)
palpable cord
DVT
247
DVT test
Doppler and US**
Venography (calf veins)
Plethysmogrphy(electrical impuse)
D dimer- r/o
248
postthrombotic syndrome -chronic venous stasis
half of Pts w/ DVTs
| residual venous obstruction and valv incompetence->ambulatory HTN
249
Phelgmasia cerula dolens
SEVERE DVT - compromises arterial flow -> thrombectomy
250
DVT Tx (3)
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
Ambulatory venous HTN
in chronic venous insufficency post DVT 2/2 increased pressure
- > extravasation of plasma proteins and RBCs -> subQ->
- brawny induration, pigmentation
252
Venous ulcers develop where?
medially from the insttep to above the ankle over incompetent vein
253
Venous ulcer vs arterial insufficiency
Venous - less painful and rapidly recur, get better w/ elevation
Arterial get better with hanging
254
Tx of Venous ulcers
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
superficial thrombophlebitis in dif locations over short period of time think of?
migratory superficial thrombophlebitis 2/2 malignancy - (pancreas)
256
Superficial thrmbophelbitis occurs 2/2
Upper ext?
Lower Ext
upper 2/2 IV infusion
lower - varicose veins (great saphenous)
257
Pain, tender, induration, erythema along vein
thrombophlebitis
NOT cellulitis of lymphangitis (widespread erythema)
258
Tx superfical thromboembolits?
NO anticoag
mild analgesic (ASA) and activity
Severe (Pain/cellulitis) -> bed rest, elevation, hot compress
elastic stalkings, usually not Abx,
259
Cardiac tumor etiology
0.1% primary (myxoma)
| 75% secondary
260
Concern w/ atrial myxomas
benign but can embolize-> METS or valve dysfunction
261
4 signs common to all SHOCK
hypotension
oliguria
tachycardia
AMS
Lactic acidosis as well
262
underperfusion of tissue -
Shock
263
Cardiogenic shock
CO
SVR
Pulm Capillary Wedge pressure
MI, Angina, heart disease
-JVD
CO - down
SVR - up
PCWP - Up!!!!
264
Hypovolemic shock
CO
SVR
Pulm Capillary Wedge pressure
Trauma, GI bleed, Vomitting, diarrhea
CO - Down
SVR - UP
PCWP - down
265
Neurogenic shock
CO
SVR
Pulm Capillary Wedge pressure
Spinal cord injury etc
CO - Down
SVR - Down
PCWB -Down
266
Septic
CO
SVR
Pulm Capillary Wedge pressure
Fever and infection site
CO - UP!!
SVR - down
PCWB down
267
Initial steps in shock (7)
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
Tx for each type of shock is usually fluids except in ?
Cardiac - sometime neuro
may need diuretics, Tx the cause: MI, pressers, after load reducing agents
269
Cardiac shock defined
Causes (7)
RVF, myocardial diseas, Mech abnomalities
270
altered senses, pale/cool skin, hypotensive and tachy think?
Also see?
Cardiac shock
engorged neck veins
Pulm congestion
271
Dx of Cardiac shock
ECG-
Echo
hemodynamic monitoring (swan ganz)
272
If CVP is low what shock is it most likely?
hypovolemic
lose 20-25% of volume and decompensate
273
Intraaortic ballon pump is used in what?
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
```
See Drop in BP in what class of hypo volumetric shock?
lost how much?
```
Class III = 30-40%
275
See tachycardia after losing how much blood?
Class of hypo volumetric shick?
lost 20-30%
>100 tachy
276
Class I hypo volumetric signs
Lost how much blood?
10-15% lost
normal pulse and BP
CNS normal, normal urine output
277
Class II hypo volumetric signs
lost how much blood
20-30%
Tachy but normal BP, decreased pulse pressure, delayed cap refill, Anxious w/ 20-30mL/hr urine output
278
Class III hypo volumetric signs
Lost how much blood
30-40%
Tachy(120) AND BP drop,
marked tachypnea, confuses and Urine out drops to 20mL/hr
279
Class IV hypo volumetric signs
Lost how much blood?
>40%
Tachy (>140) and BP DROP
absent capillary refill, lethargic/coma
280
Causes of hypo volumetric shock
Hemorrhage
- trauma, GI bleeds, retroperitoneal
Nonhemorrage
-vomitting, diarrhea, dehydration, burns, 3rd spacing
281
SIRS -> sepsis -> septic shock -> MODS
What is SIRS?
2+ of:
Fever >38, 20 or pCO2 90 BPM
Increased WBC >12000, <4000
282
SIRS becomes sepsis when?
Sepsis becomes septic shock when?
blood cultures are + and SIRS is present; Blood cultures - 2 sets from 2 sites, anaerobic and aerobic
Shock -Hypotension despite resusitation
283
MODS?
Altered organ function in acutely ill patient leading to death
284
Common causes of sepsis?
pneumonia, pyelonephritis, meningitis, abcess, cholangitis, cellulitis, peritonitis
285
Warm extremities, CO is normal or increased, EF is decreased 2/2 reduction in contractility?
Septic shock
286
TX of septic shock
ABx, surgical drainage?. Fluids, Pressors (dopamine 1st)
287
Peripheral vasodialtion w/ decreased SVR?
Causes:
Neurogenic shock - failure of sympathetic nervous system to maintain tone
Spinal cord injury, severe head injury, spinal anesthesia, pharmacological block
288
Warm perfused skin, Low/normal urine output, Bradycardia/hypotension, CO decreases w/ low SVR
Neurogenic shock
289
Tx of neuro shock (4)
IV fluids **
vasoconstrictors
Suprine, trendelenburg position
Maintain body temp
