Cardiology Flashcards
What are the complications of infective endocarditis?
Cardiac: valvular insufficiency (common cause of death), perivalvular abscess, conduction abnormalities, mycotic aneurysm
Neurologic: embolic stroke, cerebral hemorrhage, brain abscess, acute encephalopathy or meningoencephalitis
Renal: renal infarction, glomerulonephritis, drug induced acute interstitial nephritis from therapy
MSK: vertebral osteomyelitis, septic arthritis, MSK abscess
NO chronic diarrhea or flushing.
What is the most common cause of mitral regurgitation?
Mitral valve prolapse, which occurs due to myxomatous degeneration of the mitral valve leaflet and chordae; causes a mid-systolic click followed by a mid-to-late systolic murmur
What is the relationship between peripheral artery disease and cardiovascular disease?
CVD is the major cause of morbidity and mortality in pts with PAD.
Only 1-2% of pts with PAD progress to develop critical limb ischemia with risk of limb amputation.
What are clues to renovascular disease/renal artery stenosis?
HTN related sxs:
-resistant HTN (uncontrolled despite 3-drug regimen -one being a diuretic)
-malignant HTN (w/end organ damage)
-onset of severe HTN (>180.120) after 55
-severe HTN w/ diffuse atherosclerosis
-recurrent flash pulmonary edema w/ severe HTN
Supportive evidence: physical exam (asymmetric renal size >1.5cm, abdominal bruit*), labs (unexplained rise in serum creatinine >30% after starting ACE inhibitors or ARBS, imaging results (asymmetric kidney size/unexplained atrophic kidney)
Dx: renal duplex doppler u/s, CT angio, or MR angiography
What is sudden cardiac death?
Pt w/ prior MI complicated by LV systolic dysfunction w/ ejection fractioin <30% are at increased risk of sudden cardiac death due to ventricular arrhythmia (ie ventricular tachycardia, ventricular fibrillation)
ICD indicated in pts who fail medical therapy
What is the most important predisposing risk factor for aortic dissection?
Systemic hypertension in older pts (>60)
Marfan’s in younger pts (<40)
Tx: IV beta blockers (labetalol, propranolol, esmolol) - decrease HR, SBP, and LV contractility
Hydralazine + nitroprusside can cause reflex sympathetic stimulation w/ consequent rises in HR, LV contractility, and aortic wall stress which might propagate aortic dissection.
What is the 4th heart sound?
Due to left atrial kick against stiff LV
Low frequency sound heard at the end of diastole just before S1 that is commonly associated with LVH from prolonged hypertension
Often heard during the acute phase of MI due to LV stiffening and dysfunction induced by MI
Seen in : decreased LV compliance - hypertensive heart diseae, aortic stenosis, HOCM, acute phase of MI
What is vasospastic angina?
Pathogenesis: hyper-reactivity of coronary smooth muscle
Clinical presentation: young pts (<50), smoking (minimal other CAD risk factors), recurrent chest discomfort (occurs at rest or during sleep, spontaneous resolution <15m)
Dx: ambulatory ECG - ST elevation, coronary angio - No CAD
Tx: ccb (preventive), sublingual nitro (abortive)
ASA should be avoided b/c it can inhibit prostacyclin production and worsen coronary vasospasm
What is non-cardiac chest pain suggestive of esophageal origin?
Prolonged episodes lasting more than an hour, postprandial symptoms, associated heartburn or dysphagia, and relief of pain by anti-reflux therapy
What is the relationship between aspirin, beta blockers, and asthma?
Aspirin and beta blockers are common medications that can trigger bronchoconstriction in patients with asthma.
What is fibromuscular dysplasia?
Pts to screen: women age <50 w/ 1 of the following - severe or resistent HTN, onset of HTN before age 35, sudden increase in BP from baseline, increase in cr >0.5-1 after starting ACE inhibitor or ARB and w/o significant effect on blood pressure, systolic -diastolic epigastric bruit
Presentation: resistent HTN, sxs of brain ischemia, carotid or vertebral artery involvement (HA, pulsatile tinnitus, dizziness)
Dx and f/u: ct angio, duplex us, BP and cr f/u, renal us q6-12mo
What is the association between AR and LV volume?
In severe, chronic AR, the LV responds to volume overload with eccentric hypertrophy to increase both LV compliance and contractility, allowing for an increase in SV to maintain CO.
This allows for a temporary asymptomatic period.
Overwhelming wall stress eventually leads to symptomatic, decompensated heart failure.
What is beta blocker poisoning?
Beta adrenergic agonists - cause bronchoDILATION
Dobutamine is an inotropic agent that can cause significant vasodilation and worsen hypotenson. Not recommended in this setting.
Presents with bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock.
Tx: IV fluids and atropine are 1st line; IV glucagon if there is profound or refractory hypotension
Glucagon also used to treat ccb toxicity as well
What is heart failure with preserved ejection fraction (HFpEF)?
Form of diastolic heart failure; Common cause of decompensated heart failure.
Causes: LV diastolic dysfunction, valvular disease (AS/AR, MS/MR; impaired myocardial relaxation or increased LV wall stiffness (decreased compliance), leading to increased LVEDP, which is transmitted to LA and pulmonary veins and capillaries
Presentation: exertional dyspnea, orthopnea, bibasilar rales, LE edema, normal EF on echocardiography
Tx: ctrl BP and HR, address afib and myocardial iscihemia, treat volume overload w/ diuretics, exercise training/cardiac rehabilitation
Where does high output heart failure occur?
Severe anemia, hyperthyroidism, beriberi, Paget disease, and arteriovenous fistulas
What is alcoholic cardiomyopathy?
Diagnosis of exclusion in patients with dilated cardiomyopathy and history of alcohol abuse.
Presentation: dyspnea, 3rd heart sounds, bibasilar crackles, low ejection fraction
Tx: complete abstinence from alcohol use associated with improvement or normalization of LV function over time
What is HOCM?
Presentation: syncope, dyspnea, and chest pain
Due to interventricular septal hypertrophy
Primary mitral valve abnormality is presence of systolic anterior motion of mitral valve leading to anterior motion of mitral valve leaflets toward the interventricular septum
Contact b/n mitral valve and thickened septum during systole leads to LVOT obstruction
Dx: crescendo-decresendo systolic murmur along L sternal border w/o carotid radiation
Tx: BB (atenolol, metoprolol) or CCBs (verapamil)
What is a premature ventricular contraction?
QRS duration >.12s, bizarre morphology not resembling any conduction abnormality (eg BBB), T wave in opposite direction of QRS axis, compensatory pause
Tx: (for frequent symptomatic PVCs) escalating doses of BBs (metoprolol) or CCBs are 1st line
What is the indication for placement of an automatic implantable cardioverter-defibrillator (AICD)?
Recommended for primary prevention of sudden cardiac death due to ventricular arrhythmias (eg ventricular tachycardia) in pts with a LVEF =35 (and those with prior MI and LVEF <= 30.
What is situational syncope?
A form of reflex or neurally mediated syncope associated with specific triggers (eg micturition, defecation, cough)
These triggers cause an alteration in the autonomic response and can precipitate a predominant cardioinhibitory, vasodepressor, or mixed response.
-increased PNS: bradycardia, AV block, asystole
-decreased SNS: vasodilatioin, hypotension, or syncope
What is CHF due to LV systolic dysfunction?
Characterized by decreased cardiac output/index, increaed systemic vascular resistance (SVR), and an increase in LVEDV.
What does angiotensin II do?
Vasoconstriction of both the afferent and efferent glomerular arterioles, leading to an increase in renal vascular resistance and a net decrease in renal blood flow.
Preferential vasoconstriction of efferent renal arterioles, which increases intraglomerular pressure in attempt to maintain adequate GFR
Direct stimulation of Na resorption in the proximal tubules and increased secretion of aldosterone from the adrenal glands, which promotes further Na resorption in the cortical collecting tubule. Leads to decreased Na delivery to distal tubule and increase in extracellular fluid volume
What is aortic stenosis?
Common cause of angina, syncope, and HF - but these are rare until symptoms become severe
Mild to severe: early peaking systolic murmur
Severe: valve area <1cm squared
Severe AS restricts SV and leads to low pulse pressure (<25)
-delayed (slow rising) and diminished (weak) carotid pulse (“pulses parvus and tardus”),
-presence of single and soft S2,
-mid-to-late peaking systolic murmur w/ maximal intensity at 2nd ICS radiating to the carotids
What is cardiac tamponade?
Early cases due to large pericardial effusion
Presentation: recent URI, dyspnea, elevated JVP, clear lung fields
Diminished heart sounds + Inability to palpate point of maximal apical impulse = pericardial effusion; decrease in SBP>10 w/ inspiration = pulsus paradoxus
Beck’s triad: hypotension, elevated JVP, muffled heart sounds
Does not cause dramatic hypoxia
Sxs are due to an exaggerated shift of the interventricular septum toward the LV cavitiy, which reduces LV preload, stroke volume, and cardiac output.
Imaging: enlarged, globular cardiac silhouette (water bottle heart shape)
CXR: enlarged and globular cardiac silhouette (water bottle heart), clear lungs
Unable to palpate the point of maximal impulse due to large pericardial effusion
Pericardial metastasis common in lung cancer and lymphoma, rare in colon cancer
B/c R-sided heart chambers are principally affected, the lungs remain clear and there is usually no evidence of pulmonary edema (eg, orthopnea, crackles on lung auscultation)
What is uremic pericarditis?
Occurs in 6-10% of renal failure patients, typically in those w/ BUN >60mg/dl
Most pts doe not present with classic electrocardiogram changes of pericarditis (eg diffuse ST segment elevations)
Tx: hemodialysis leads to rapid resolution of chest pain and reduces size of any associated pericardial effusion
What is chronic venous insufficiency?
A common cause of LE edema.
Presentation: varicose veins, skin discoloration, and medial skin ulceration, pitting edema is most common PE finding
Initial treatment: conservative measures w/ leg elevation, exercise, and compression stockings
What is the indication for an exercise stress ECG?
It is recommended as an initial stress test for diagnosis and risk stratification of most pts with suspected stable ischemic heart disease.
Coronary angiography is performed in pts with high-risk findings on initial stress testing.
What is dilated cardiomyopathy?
Hx of URI followed by sudden onset of cardiac failure
Etiology: coxsackievirus B, parvovirus B19, HSV6, adenovirus, enterovirus
Dx: echocardiogram - dilated ventricles with diffuse hypokinesia resulting in low EF (ie systolic dysfunction)
Tx: supportive
What is cardiac sarcoidosis?
A disease of noncaseating granuloma infiltration of the myocardium.
Can result in serious arrhythmia (complete AV block*), cardiomyopathies, heart failure, and sudden cardiac death
What is the 3rd heart sound?
Due to inflow from LA striking blood already in the LV causing reverberation of blood between LV walls.
A low frequency diastolic sound heard just after S2 that is associated with LV failure.
IV diuretics provide symptomatic benefits to patients with decompensated heart failure.
Can be seen in viral myocarditis (+ pulmonary vascular congestion)
What is aortic regurgitation?
Due to aortic root dilation or congenital bicuspid valve
Produces early diastolic decrescendo murmur
It leads to increased LV end diastolic volume due to leakage of blood from the aorta back in the LV.
Presentation: wide pulse pressure, “water hammer” pulse - rapid, abrupt upstroke followed by rapid collapse of the peripheral pulse, and LV enlargement
L lateral decubitus position brings the newly enlarged LV closer to the chest wall and causes pounding sensation and increased awareness of the heartbeat
What is a diastolic murmur?
Diastolic and continuous murmurs are usually due to an underlying pathologic cause. Presence should prompt further evaluation w/ a transthoracic echocardiogram.
Midsystolic murmurs in otherwise young, asymptomatic adults are usually benign and do not require further evaluation.
What is atrial fibrillation?
Commonly caused by ectopic foci w/in the pulmonary veins.
Tx: radiofrequency ablation in the PVs
What is atrial flutter?
Commonly involves a reentrant circuit around the tricuspid annulus.
What is atrioventricular nodal reentry tachycardia?
Results from a reentrant circuit formed by 2 separate conducting pathways within the AV node.
What is peripartum cardiomyopathy?
An uncommon cause of dilated cardiomyopathy characterized by the development of heart failure during the last month of pregnancy (>36w) or w/in 5 months following delivery.
Rapid onset systolic HF (dyspnea, cough, pedal edema)
A fib with rapid ventricular rate is relatively rare in PPCM.
What has the greatest sensitivity for diagnosing heart failure?
An elevated plasma BNP level has high sensitivity (>90%) for the diagnosis of CHF.
What does acute limb ischemia after an MI suggest?
An arterial thrombus from the LV.
[Acute limb ischemia: Arterial occlusion due to: embolus from cardiac source (LA thrombus due to a fib; LV thrombus following MI), infective endocarditis (septic emboli), thrombus from prosthetic valves]
What is the presentation of a venous thromboembolism?
Warmth, erythema, swelling, and tenderness.
What is an abdominal aortic aneurysm?
Dx: preverterbral aortic calcifications on XR
Confirm with an abdominal CT scan
In pts w/ HD instability and signs and sxs consistent w/ an abdominal aortic aneursym (AAA) but w/o a known hx, a focused bedside u/s should be performed.
A CT scan is helpful in symptomatic pts who are stable, while those who are unstable w/ a known history of AAA should undergo emergent repair.
What is exertional syncope?
Portends underlying pathologic cause including ventricular arrhythmias (due to MI) and outflow tract obstruction (eg aortic stenosis, HOCM)
Presents with dyspnea on exertion, fatigue
What is subclavian steal syndrome?
Due to severe atherosclerosis of the L subclavian artery proximal to origin of vertebral artery; leads to reversal of blood flow in ipsilateral vertebral artery
L more commonly affect than the R
Presentation: ischemia in affected UE, vertebrobasilar ischemia (dizziness, ataxia, dysequilibrium)
Lower brachial SBP (>15mm Hg) in affected arm, systolic bruit in supraclavicular fossa on affected side; 4th heart sound due to LVH from systemic HTN
Dx: Dopper u/s or MRA
Tx: statins, smoking cessation, stent placement
What is wound dehiscence after CABG?
Common complication.
Presentation: sternal wound drainage
Soft tissue dehiscence occurs when superfical tissues (skin, muscle) separate. No signs of sternal instability or systemic illness. Local wound care/debridement with primary closure is indicated.
Sternal dehiscence occurs w/ separation of edges of approx. sternum, may occur w/ or w/o soft tissue dehiscence; sternal instability + nonunion = “clicking” or “rocking” on sternal palpitation. surgical emergency requiring sternal rewiring to prevent cardiac trauma
Dx: chest and sternal imaging
What is amyloid cardiomyopathy?
Should be suspected in pts w/ unexplained CHF, proteinuria, and LVH in the absence of hx of HTN.
Presentation: proteinuria (>300mg/d), nephrotic syndrome (>3.5g/d), waxy skin, anemia, easy bruising w/ ecchymosis, early satiety, enlarged tongue, peripheral or autonomic neuropathy
Increased ventricular wall thickness w/ normal or nondilated LV cavity
What is nitroprusside?
Parenteral vasodilator w/ quick onset and offset of action
Metabolized to nitric oxide and cyanide ions
Cyanide toxicity occurs in pts receiving prolonged infusion or higher doses of nitroprusside, most common in pts w/ renal insufficiency
Presentation: altered mental status, lactic acidosis, seizures, and coma
What is a PDA murmur?
Continuous flow murmur
Mildly accentuated peripheral pulses can occur
What are the murmurs of tetralogy of fallot?
Pulmonary stenosis leads to harsh, crescendo-decrescendo systolic ejection murmur over LUSB
RVH
Over-riding aorta: single S2 due to normal aortic and inaudible pulmonary component
VSD
Medical tx shown to improve morbidity + mortality in pts w/ known coronary artery disease.
ACE-i/ARBs
Aldosterone antagonists (spironolactone, eplerenone)
Beta blockers
Aspirin + p2y12 receptor blockers (clopidogrel, prasugrel, ticagrelor)
Statins
Perivalvular abscess.
Development of AV block in pt w/ infective endocarditis should raise suspicion for perivalvular abscess extending into adjacent cardiac conduction tissues.
Aortic valve endocarditis is assoc. w/ an increased risk of periannular extension of endocarditis.
Viridans group streptococci infectious endocarditis treatment.
Highly susceptible to pencillin and should be treated w/ IV aqueous penicillin G or IV ceftriaxone for 4 weeks.
Oral abx are not recommended.
Risk of systemic thromboembolism.
Warfarin or non-vit. K antagonist oral anticoagulants (eg apixaban, dabigatran, rivaroxaban) should be used to reduce the risk of systemic thromboembolism in pts w/ a fib and moderate to high risk of thromboembolic events (CHADVASC score >2).
Interventricular septum rupture.
Occurs 3-5d after an acute MI
Presentation: sudden onset cardiogenic shock w/ sudden onset hypotension, biventricular failure, VSD-new harsh holosystolic murmur w/ palpable thrill at the L sternal border
Does not cause rapid decompensation
