Cardiology Flashcards by Veena Katikineni

systolic murmur that is heard in apex, radiates to axilla and increases with grip maneuver and decreases with valsalva

mitral regurgitation

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sounds heard with acute mitral regurg

soft decrescendo systolic murmur
decreased S1
presence of S4

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four MCC of acute heart failure

papillary muscle rupture
infective endocarditis
rupture of chordae tendinae
chest wall trauma with compromise of valvular apparatus

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CF in Ehlers Danlos

pes planus
scoliosis
thin, velvety, fragile skin (cigarette paper)
easy bruisability
past hx of hernias and MVP

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cocaine related chest pain - tx.

tx early with BDZs

-avoid beta blockers (to avoid causing coronary vasospasm)

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Tx. persistent HTN after cocaine use

phentolamine

- also decreases coronary vasospasm
alt. nitroglycerin, nitroprusside

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valve dz in an immigrant or a pregnant person

mitral stenosis

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valve dz in Turner’s syndrome pt with coarctation of the aorta

bicuspid aortic valve

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valve dz in pt presenting with palpitations, atypical chest pain not with exertion

MVP

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systolic murmurs

AS
MVP
MR
HOCM

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diastolic murmurs

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all right sided murmurs increase in intensity with…

inhalation

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all left sided murmurs increase in intensity with…

exhalation

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effect of squatting and lifting legs in the air on heart

return blood to heart therefore, increase venous return to the heart

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effect of Valsalve maneuver and standing up on the heart….

decrease venous return to the heart

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which murmurs get louder with squatting and leg raise

all right sided murmurs

AS, AR, MS, MR

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which murmurs get softer with squatting and leg raise

MVP
HOCM
- these murmurs INCREASE with valsalva

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which murmurs increase in loudness with valsalva/standing

HOCM

MVP

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Effect of handgrip on heart and which murmurs does it make louder?

increases afterload
Worsens VSD, AR and MR murmur
Improves/softens MVP and HOCM

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effect of amyl nitrate on heart and murmurs

decreases afterload
softens, AR and MR
worsens MVP and HOCM (increases the obstruction and degree of prolapse)

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effect of amylnitrate and handgrip on murmur of AS

handgrip actually makes AS murmur softer –> creates less of a gradient between LV and aorta. Amyl nitrate increases the gradient and thus, increases murmur of AS

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any murmur that improves with amyl nitrate will improve with tx with what med?

ACEI

murmurs: AR, MR, VSD

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best initial test for valve lesions (1)

most accurate test for valve lesions (2)

echo (TTE –> TEE)
left heart catheterization
- also order EKG and CXR on ccs

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best treatment for regurgitant lesions

vasodilator therapy - ACEI or ARBs, nifedipine

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in which murmurs is diuretic therapy indicated

if murmur improves with valsalva (decreased venous return) --> AS, AR, MS, MR, VSD

crescendo-descrescendo systolic murmur, heard best at 2nd intercostal space, radiates to carotid arteries, delayed carotid upstroke

how do you assess severity of AS?

measure pressure gradient across valve Normal < 30 Moderate 30-70 Severe > 70 mmHg

best initial therapy for AS (1) | treatment of choice for AS (2)

1. diuretics | 2. valve replacement

diastolic descrescendo murmur heard best at left sternal border

clinical findings unique to AR

Quinke's pulse - pulsations in fingernails Corrigan's pulse - bounding pulses Musset's sign: head bobbing up and down with each pulse Duroziez's sign - murmur heard over femoral artery Hill sign - BP gradient high in lower extremities

Tx. aortic regurg

1. ACE, ARBs and nifedipine - best initial 2. add furosemide 3. surgery if EF < 55%

diastolic rumble murmur with opening snap, best heard at cardiac apex, S1 louder than S2

mitral stenosis

unique clinical findings in MS

dysphagia and hoarseness due to pressure of LA pressing on esophagus and recurrent laryngeal nerve (Ortner's syndrome) atrial fibrillation mitral facies - pinkish-purple patches on cheeks

XR findings in MS

LA enlargement with flattened left heart border | dilated pulm vessels

EKG findings in MS

broad, notched P waves | RVH: tall R in V1 and V2

Tx. mitral stenosis

diuretics most effective = balloon valvuloplasty if pregnant - do not hesitate to perform valvuloplasty

holosystolic murmus that obscures both S1 and S2, heard best at apex that radiates to axilla, S3 gallop often present

mitral regurg

S3 gallop

assoc. with fluid overload states, such as CHF or MR

Tx. mitral regurg

1. ACE, ARBs and nifedipine - best initial 2. add furosemide 3. surgery if if LVEF < 60% or LVED > 40 mm

holosystolic murmur at the LLSB that worsens with exhalation, squatting and leg raise

VSD

murmur assoc with ASD

fixed splitting of S2

Tx. ASD

percutaneous or catheter devices | - repair indicated when the shunt ratio exceeds 1.5:1

causes of wide splitting of S2 with delayed P2

RBBB PS RVH pulm HTN

causes of paradoxical splitting of S2 with A2 delayed

LBBB AS LVH HTN

best initial test for cardiomyopathy

ECHO

most accurate method for determining EF

MUGA | nuclear ventriculography

Tx. dilated cardiomyopathy

ACEi/ARBs BB spironolactone

S4 gallop

sign of LVH and decreased compliance or stiffness of the ventricle

Tx. HCM

beta blockers | diuretics

Dx. findings in restrictive evaluation

cardiac cath --> rapid x and y descent EKG --> low voltage echo = mainstay of diagnosis single most accurate dx test: endomyocardial biopsy

best initial test for pericarditis

EKG --> diffuse ST elevation, PR depression

best initial therapy for pericarditis

NSAID | if the pain persists for > 2 days, add prenisone orally

CF in pericardial tamponade

``` SOB hypotension JVD pulsus paradoxus EKG: electrical alternans ```

most accurate diagnostic test for tamponade

echo --> diastolic collapse of RA and RV

results of right heart cath in tamponade

equalization of all pressures in the heart during diastole

best initial therapy for tamponade

pericardiocentesis

unique features of constrictive pericarditis

sx of chronic RHF -> JVD, hepatomeg, ascites, edema Kussmaul's sign: JVD with inspiration pericardial knock

best initial therapy for constrictive pericarditis

diuretics

most effective therapy for constrictive pericarditis

pericardial stripping

pt presents with severe chest pain that radiates to the back. on exam,he is hypertensive with BP are greater in the right arm vs left arm - dx? best initial test? most accurate test?

Dx. thoracic dissection initial test: CXR shows widening mediastinum best test: CT angio = TEE = MRA

first steps in management if you suspect pt with thoracic dissection

``` 1) start BB get EKG, CXR --> CT angio or TEE or MRA 2) nitroprusside to control BP 3) place in ICU 4) get surgery consult ```

best initial test for PAD

ankle brachial index | normal should be > 0.9

best initial therapy for PAD

1. aspirin or clopidogrel (most effective) 2. ACEI 3. supervised exercise program 4. cilastazol - only if severe symptoms 5. lipid control with statins

pentoxyfylline

marginally effective therapy for PAD, used only if cilostazol is ineffective

for CCS, tests to order once A-fib is found

1. ECHO 2. TFTs 3. electrolytes: K+, Mg, Ca 4. troponin or CK MB

Tx. unstable pt with A-fib

synchronized cardioversion | - without any TEE or anticoagulation

Tx. stable pt with A-fib

1. slow HR with BB (metoprolol or esmolol) or CCB (diltiazem) 2. anticoagulation with warfarin (INR 2-3) or dabigatran

CHADS

``` CHF HTN Age > 75 Diabetes Stroke/TIA (2) - score > 2 warrants warfarin if score < 2, can tx with aspirin ```

causes of multifocal atrial tachycardia

secondary to hypoxia (COPD), hypokalemia, hypomag, coronary/valvular dz, meds (theophylline, aminophylline, isoproterenol)

Tx. MAT

correct underlying cause | if that does not work --> CCBs (verapamil)

best initial therapy for unstable pts with SVT

synchronized cardioversion

best initial therapy for stable pts with SVT

Vagal maneuvers | - if vagal maneuvers do not work --> IV adenosine

best long term management of SVT

radiofrequency catheter ablation

pt with history of SVT is treated with a CCB which worsens his/her symptoms - dx?

WPW

best initial therapy if pt is described as being in SVT or VT from WPW

procainamide

therapy options for pt who is hemodynamically stable in VT

amiodarone lidocaine procainamide Mg

acquired QT prolongation

hypomagnesemia hypokalemia meds - macrolides, antihistamines, psychotropic drugs