Cardiology Flashcards
Cardiomegaly - how does heart enlarge in CHF
first laterally and then inferiorly - get PMI at 5th ICS , lt anterior axillary line (instead of typical mid-clavicular line)
exertional dyspnea
SOB on exertion - hint to possibly cardiac pathology
paroxysmal noctural dyspnea
must get up out of bed due to SOB
orthopnea
must sit up - SOB with lying down
dyspnea at rest
sign of worsening cardiac pathology
syncope/pre-syncope/dizzy
results from decreased cerebral blood flow
- may be due to arrhythmia, low BP, low cardiac output
- test with BP, EKG, holter monitor, tilt-table test (r/o vasovagal response)
cough - hints to cardiac origin
usually dry or non-productive
seen in HF and ACE-inhibitor medication use
blood pressure - orthostatic changes
when systolic BP drops >20mm when standing = positive for orthostasis
pulse pressure
difference b/t systolic and diastolic
- widened = larger stroke volume
- narrow = smaller stroke volume
pulse grading
1-4; 2 = normal
bifed / bisferiens pulse
beating 2 x in systole (hypertrophic obstructive cardiomyopathy and aoritc regurgitation)
dicrotic pulse
exaggerated; early diastolic wave seen in heart failure
pulses alternans
alternating strong/weak pulse force seen in HF
paradoxical pulse
> 10mm Hg drop in systolic BP during inspiration in obstructive lung dz and cardiac tamponade
jugular venous pulsations
provides info about central venous pressures and RIGHT-heart function
hepatic jugular reflux (HJR)
when press on liver see a >1cm increase in jugular venous pressure
- seen in HF
first heart sound - S1
“Lub” - results from closing of mitral and tricuspid valves
- loud in mitral stenosis
second heart sound - S2
“dub” - closure of aortic and pulmonic valves
- split with inspiration - physiologic S2 (normal)
third heart sound - S3
early, rapid LV filling (normal in young)
associated with LV overload conditions - HF
fourth heart sound - S4
results from vigorous atrial contraction into a resistant/still LV
- heard with lt ventricular hypertrophy 9HF) or MI
- NEVER hear in atrial fibrillation (b/c no contraction of atria)
mid-systolic click
found in mitral valve prolapse
opening snap
found in mitral stenosis
systolic murmurs
most common
Found in normal heart sounds, aortic stenosis, pulmonic stenosis
innocent flow murmurs
early systolic
80% kids
pregnant females
decreased with sitting up
diastolic murmurs
almost always pathology
most common is high-pitched = pulmonic regurg, aortic regurg
HINT: diastolic “rumble” = mitral stenosis
continuous murmur
heard through systole and diastole
patent ductus arteriosus = most common (“machinery like”)
electrocardiogram (ECG)
12-lead ECG - diagnostic study looking for electricity in heart
Holter monitor = 24 hour ECG
ECHO - echocardiogram
U/S of heart: good for anatomy and structural problems (any valve issue)
- can see blood flow
tilt-table test
often used to R/O vasovagal response as cause of syncope
- test autonomic nervous system functioning
- used before more invasive testing is performed
stress testing - types
exercise stress test: detects ischemia, CAD, cardiac response to exercise
nuclear stress test: if need to see more detail of what is going on in heart - use w/ LBBB or ? results from XST
- thallium
pharmacologic/ chemical: is someone cannot exercise
chemicals used in pharmacologic stress tests
adenosine
dipyridamole
dobutamine
lexiscan
contraindications to stress test
severe aortic stenosis
fresh MI
EP studies - electrophysiologic
used to detect and treat rhythm disorders (looks at electrical flow of heart)
- performed in cath lab
- certain identified arrhythmias (WPW, SVT, A-fib, VT) are treated pharmacologically or with radio-frequency ablation or cryotherapy
cardiac catheterization (coronary angiography)
best used to evaluate and treat CAD
- coronary angiography (visualize vessels)
- angioplasty (PTCA aka “balloon”)
- angioplasty with stent placement
hypertension - basics
office BP > or = 140/90
- must have 2 measurments
most common condition in primary care
JNC 8 criteria
hypertension - pathophysiology
RAAS mechanism/natriuretic hormone
vasoconstriction at level of arterioles
- leads to electrolyte disturbance
hypertension - definition (pre, stage I, stage II)
normal: <120 AND <80
prehypertension: 120-139 OR 80-89
Stage I HTN: 140-159 OR 90-99
Stage II HTN: >160 OR >100
hypertension - classification (primary, secondary, resistant)
essential/primary
- most common (90%)
- cause unknown
- incurable (controlled w/ lifestyle mod and meds)
secondary/identifiable
- less common (<10%)
- most common cause: chronic renal dz
- other cases: pheochromocytoma, coarctation of aorta, OSA, meds
resistant/pseudoresistant
- uncontrolled on 3 meds
- controlled on 4 meds
primary HTN - exacerbating factors
environmental: salt, obesity
others: tobacco, ETOH, sedentary, polycythemia vera (high HGB, HCT), NSAIDS, low K+, metabolic syndrome (DM)
HTN - most common sxs
headache
HTN - physical exam
retinopathy: hemorrhages, cotton wool spots, AV nicking
neck: bruits, JVD, thyroid enlarge
CV exam: lt vent heave, aortic regurg, presystolic S4 gallop
ABD exam: abd bruits, aortic pulsations
PV exam: loss of peripheral pulses (atherosclerosis), radial-femoral delay (coarctation)
red flags for secondary HTN causes
HTN starts early (<25 y/o) w/o FH
HTN first develops >50
previously controlled HTN, now refractory
HTN resistant for 3+ meds
secondary HTN - most common cause
chronic renal disease
- screening tests: BUN/Cr, U/A, microalbuminuria
- Dx: renal U/S
- tx: BP control and/or dialysis
most common TREATABLE cause of HTN
aldosteronism - usually caused by an aldosterone-producing adenoma
Presents at age 30-50 with HTN and hypokalemia
secondary HTN - renovascular dz
1-2% HTN causes
- artherosclerosis (85%)
- fibromuscular dysplasia (25% - F)
Presents:
- b/f age 20 and after age 50
- HTN resistent to 3+ drugs
- bruits, peripheral artherosclerosis
secondary HTN - Cushing’s Syndrome
hypercortisolism
Presents: truncal obesity, striae, acne, hyperpigmented skin, moon facies and buffalo hump
Labs: glucose (hyperglycemia), hypokalemia
Dx: 24 hr free cortisol
secondary HTN - pheochromocytoma
rare catecholamine secreting tumor from adrenal medulla
- causes vasoconstriction and inc. cardiac output
Presentation: pulsatile headache, palpitations, diaphoresis
Dx: plasma metanephrine test
secondary HTN - coarctation of aorta
narrowing of aorta
Presents: young pt with HTN and delayed femoral pulses
Dx: Echo
CXR: see figure 3 sign of aortic arch