Cardiology Flashcards
Exercise stress test can not be performed
Meds: digitalis, BB, CCB, Amiodarone Aortic Stenosis (absolute contraindication)
Must use imaging for: LBBB LVH with strain pattern WPW Pacemaker
Kerly B lines
Signs of fluid accumulation in lungs with high blood pressure
Pharmacologic stress test indications
Unable to exercise
Aortic Stenosis
Dobutamine-substitution for exercise
Adenosine-vasodilator
Can only dilate “healthy” vessels, causes a “steal effect”
RCA inervates
R ventricle, R atrium, SA node, AV node, INFERIOR wall of L ventricle
Leads II, III and AVF
LAD inervates
septum, ANTERIOR wall of L ventricle
Leads V1-V4
Circumflex inervates
Lateral wall L ventricle
Leads V5, V6, I, aVL
Prinzmetal angina
Resting angina (midnight-8AM) Caused by focal coronary artery spasm
Treatment: CCB, stop smoking
Acute Coronary Syndrome:
Unstable Angina
NSTEMI
STEMI
UNSTABLE ANGINA: chest pain (change from normal), neg Troponin
MSTEMI: chest pain + Ischemic EKG changes (ST depression or T wave inversion), increase in cardiac enzymes. Do stress echo.
Plavix or Heparin (no Thrombolysis)
STEMI: infarct (complete occlusion), ST elevation in 2 consecutive leads.
Right to cath lab (don’t wait for Troponin). PCI within 90 min or Thrombolysis
Treatment: MONAB
Post MI complications
Myocardial rupture: new holosystolic murmur. Acute MR (papillary muscle rupture) or VSD
Cardiogenic shock/CHF
Thromboembolism
Pericardial disease: pericarditis, Dressler’s Syndrome
Abnormal heart sounds
S3= volume overload (CHF)
S4=pressure overload (longstanding HTN, LVH, acute
Murmur Locations
RUSB: Aortic Stenosis LUSB: Pulmonic murmurs Erb's Point(LSB): Aortic Insufficiency, HCM Tricuspid: TS, TR, ASD, VSD Mitral/Apex: MS, MR
Murmur Pitch
Low Pitch (bell of stethoscope)- MS, TS
Murmur Radiation
Neck/Carotid=Aortic Stenosis
Back/Axilla=Mitral Regurg
Aortic Stenosis
Sx: exertional angina, syncope dyspnea
PE: CHF, narrow pulse pressure, S4 )LVH), sustained PMI
Murmur: crescendo-decrescendo SEM radiating to R clavicle and carotid heard best at RUSB
Ejection click
Rx: avoid exertion, valve replacement
Avoid nitrates, ACE, all vasodilators
Aortic Insufficiency/ Regurg
Odd pulses
Stress Test: Hypotension with exercise
Rx: treat CHF, vasodilators to reduce afterload
Mitral Stenosis
Etiology: Rheumatic Heart Disease
Sx: DOE, Orthoptera, fatigue, palpitations, peripheral edema
PE: AFib, parastatal lift, crackles
Murmur: mid diastolic RUMBLE heard at apex in LLD position, LOUD S1
Opening snap
Mitral Regurg
Etiology: acute-post MI complication
Chronic- MVP
Murmur: holosystolic at apex radiating to back/axilla with an APICAL THRILL
Mitral Valve Prolapse
Sx: short lived stabbing chest pain, anxiety, palpitations, fatigue
Heart sound: mid-systolic click
Hypertrophic Cardiomyopathy
ECH: LVH in young person, Q waves in V5, V6, I, aVL
Echo: asymmetric hypertrophy of septum
Ex: Exercise restriction & BB
Other Murmurs
Tricuspid Regurg: infective endocarditis in IV drug user
Pulmonic Stenosis: congenital, pediatric. Young child with dyspnea
PDA: continuous/ Machinery, LE cyanosis
Acute Pericarditis
Most common pathogen: coxsackie
Most common bacterial pathogen= TB
Autoimmune: SLE, RA (female)
Triad of pleuritic chest pain + FRICTION RUB + EKG changes
Pain worse laying flat, better sitting up
EKG: global ST elevation, notched QRS, PR segment depression, tachycardia
Rx: NSAIDS, high dose ASA
DO NOT use steroids ( more complications)
Complications: pericardial effusion, tamponade, chronic pericarditis
Cardiac Tamponade
Triad
Pathognomonic signs
Treatment
Effusion large enough to collapse right heart
BECK’s TRIAD: hypotension, JVD, muffled heart tones
Pathognomic: Pulsus parodoxus (drop in systolic BP with inspiration) and electrical alternans (EKG)
Ex: immediate pericardiocentesis (echo guided)
Heart Failure
5 years mortality rate=50%
Stage A=at risk (pre HF)
Stage B=asymptomatic
Stage C= Symptomatic
Stage D= Marked sxs at rest (end stage)
Heart Failure
Defective pumping mechanism results in accumulation and redistribution of fluids.
RAAS:
Renal hypo perfusion causes release of renin-A-AI-AII
angiotensin II
Potent vasoconstrictor-causes increase in BP
Stimulates kidney to release aldosterone-mediates renal Na+ and H20 retention-increases arterial pressure-increase in BP
Heart Failure Signs
Dyspnea with minor activity, cyanotic, cold extremities, diaphoresis
Vitals: normal or tachy, hypotn, reduced pulse pressure
PE: crackles, dullness to percussion, exp wheeze/rhonchi, enlarged liver, edema
Key cardiac PE findings: Parasternal lift=pulmonary HTN Enlarged, sustained LV impulse Diminished S1 (impaired contractility) S3 gallop S4 (diastolic heart failure)
Cor Pulmonale
Prolonged HBP in pulmonary artery
If acute, think PE
If chronic, think COPD
Labored respiratory effort with retractions, hyperresonance, diminished breath sounds, wheeze, distant heart sounds
Dilated Cardiomyopathy
Most common
Poor EF, large heart, pulmonary congestion.
Thin, dysfunctional LV wall, LV dilation/dysfunction
Restrictive Cardiomyopathy
Pulmonary HTN, dyspnea Usually caused by Amyloidosis -sarcoidosis -scleroderma Right HF
Hypertrophic Cardiomyopathy
Early adulthood, athletes-sudden cardiac death
Heart Failure Prevention
Underlying causes, control Systolic HTN, prevent first MI
Initial rx= *diuretic+ ACE
Early addition of BB
Digitalis
Abdominal Aortic Aneurysm
>3cm diameter Typically involve bifurcation Rarely ruture until diameter > 5cm abdominal US Mid-abdominal pain radiating to back
Thoracic Aortic Aneurysm
Pressure on trachea/esophagus/SVC: dyspnea, stridor, cough, dysphasia
Stretching of laryngeal nerve: hoarseness
Study of choice= CT
Giant cell arteritis
Most frequently involves temp artery
50% also have polymyalgia rheumatica
Sxs: HA, scalp tenderness, amaurosis fugax, diplopia
ESR>50mm/h
Temporal artery bx =gold standard
Rx: prednisone 60 mg/d x 1 month before tapering
Screen for thoracic aneurysm
PAD
Aorto-iliac segment: extreme limb fatigue/weakness, weak/absent distal pulses, thigh/buttock pain
Femoral-popliteal: foot pain at rest, relieved by dependency Dependent rumor (purplish), legs blanch with elevation, distal atrophic changes
Tibial segment: thin skin on foot, hairless, cool, absent pulses
ABI
Virchow’s Triad
Venous stasis, vascular injury, hypercoagulanility
Increased risk of DVT
Main/serious complication is PE
DVT
Increased calf circumference by > 3cm Measured 10cm below tibial tuberosity Duplex US is study of choice Spiral CT chest to R/o PE Treatment: anti coagulation *LMWH or Lovenox Bridge to Warfarin for prolonged rx
Arterial Disease Pearls
Claudication Cool, thin, hairless skin Muscle atrophy Atrophic nails Ulcerations-painful, shallow, round, dry Gangrene
Venous Disease Pearls
Varicose ties Tough, thick, fibrous skin Hemosiderin deposits Pitting edema Stasis ulcerations: painless, large, irregular, wet, slow to heal
Lipid risk factors
Smoking
HTN
HDL 60
Metabolic Syndrome
Risk Factors: Waist circumference TG > 150 Low HDL Increased BP (>130/85) Fasting BG > 100
3+ risk factors or DM= Metabolic Syndrome
Lipid Treatment
Statins= DOC in most cases
Niacin-most effective for low HDL
Fibrates-DOC for high TG
Bile Acid Binders-pedis and Pregnancy (Welchol)
Supra ventricular Tachycardia
Regular narrow tachycardia Usually no P waves Commonly caused by congenital accessory pathway (AV node) Treatment= Vagal maneuvers Drug of choice= Adenosine Use CCB/BB following cardioversion
First Degree AV block
Long PR interval
Pathological causes: Acute rheumatic fever, Lyme carditis (hallmark), secondary syphilis
Second Degree AV Block Type I
Wenckebach
Varied PR interval (normal, long, longer, dropped)
Second Degree AV Block type II
Mobitz
Randomly dropped QRS complexes (extra P waves)
Treatment-stop new med
Pacemaker
Third Degree AV Block
PP interval and QRS intervals constant but not communicating
Treatment-pacemaker
V Fib
CPR
Defibrillated
Epinephrine followed by Amiodarone
V Tach
Sawtooth pattern
Treat stable pt with Amiodarone
Unstable pt with cardioversion
Torsades de Pointes
Sine wave pattern
Stop meds that prolong QT interval
Left Axis Deviation
Up in I, down in AVF
Causes: inferior wall MI
Right Axis Deviation
Down in I, up in AVF
Causes: RVH, COPD, ant/lay MI, PE
Normal variant in kids
Right BBB
Wide QRS
Bunny ears
Causes: RVH, PE, Ischemia
Left BBB
Wide QRS with ski slopes
Causes: HTN with LVH, AS, dilated cardiomyopathy, fibrosis, acute NI
Pericarditis
ST elevation in all leads
Ejection click
Aortic Stenosis
Opening Snap
Moral Stenosis
Mid-systolic click
MVP
Fixed split S2
ASD
Continuous/machinery
PDA
