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Cardiology Flashcards

1
Q

bradycardia algorithm

A

UNSTABLE or symptomatic:

  • hypotension
  • AMS
  • refractory chest pain
  • acute heart failure
  • -> ATROPINE 1ST LINE
  • if ineffective: epinephrine infusion, dopamine infusion, transcutaneous pacing

*exception to unstable/symptomatic rule = IF 3RD DEGREE HEART BLOCK OR AV DISSOCIATION –> TRANSCUTANEOUS PACING 1ST LINE and PERMANENT PACEMAKER AS DEFINITIVE

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2
Q

tachycardia algorithm

A

UNSTABLE:

  • hypotension
  • AMS
  • refractory chest pain
  • acute heart failure

–> SYNCHRONIZED CARDIOVERSION
(if regular, narrow QRS complex, may consider adenosine)

STABLE:
-WIDE QRS (12+ sec) –> AMIODARONE (antiarrhythmic) or lidocaine, procainamide + cardicac consult

-NO WIDE QRS = vagal maneuvers, ADENOSINE (if regular and narrow QRS), BETA-BLOCKER OR CCB

  • EXCEPTIONS:
  • ATRIAL FLUTTER –> BETA BLOCKER OR CCB 1ST LINE
  • ATRIAL FIBRILLATION –> BETA BLOCKER OR CCB 1ST LINE
  • WOLFF-PARKINSON-WHITE –> PROCAINAMIDE PREFERRED (or amiodarone), avoid av nodal blockers (adenosine, bb, ccb, digoxin)
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3
Q

sympathetic control of heart

A

Sympathomimetics: EPI and NOREPI cause:

  • increased excitability
  • increased force of contraction
  • increased SA node discharge rate (inc HR)
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4
Q

parasympathetic control of heart

A

ACETYLCHOLINE (regulated by vagus nerve) causes:

  • decreased excitability
  • decreased force of contraction
  • decreased SA node discharge rate (dec HR)
  • VAGAL STIMULATION OR VAGAL MANEUVERS = SLOW DOWN HEART RATE
  • anticholinergics block the action of acetylcholine (thus increase heart rate - atropine)
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5
Q

atrial fibrillation

A

Etiologies:
cardiac dz, ischemia, pulmonary dz, infection, electrolyte imbalance, endocrine/neurologic disorders, age, genetics, hemodynamic stress, meds, drug or alcohol use

Types:

  • Paroxysmal - self-terminating w/in 7 days (usually <24h)
  • Persistent - fails to self-terminate, lasts >7d, requires termination (medical or electrical)
  • Permanent - persistent >1y (refractory to cardioversion)
  • Lone: paroxysmal, persistent or permanent w/out evidence of heart disease

-tx:

STABLE:

RATE CONTROL: preferred initial management

  • BETA-BLOCKERS - metoprolol - careful w/ rx airway dz
  • CCB - DILTIAZEM, verapamil (nondihydropyridines)
  • DIGOXIN used in elderly - PREFERRED FOR PT W/ HYPOTN OR CHF

RHYTHM CONTROL: younger pt w/ lone a-fib

  • Direct Current (synchronized) Cardioversion (if AF present for <48 hours or after 3-4 wks of antigoagulation and a TEE shows thrombi)
  • Pharmacologic Control - ibutilide, flecainide, sotalol, amiodarone
  • Radiofrequency Ablation - permanent pacemaker

UNSTABLE –> DIRECT CURRENT (SYNCH) CARDIOVERT

ANTICOAGULATION: all pt w/ nonvalvular a-fib should:

  • ASSESSMENT OF RISK OF EMBOLI (CHA2DS2-VASc)
  • DETERMINE BENEFITS V RISK OF ANTICOAGULATION
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6
Q

CHA2DS2 - VASc Criteria

A

(anti-coag risk stratification in nonvalvular a-fib)
2+ = moderate to high risk - chronic oral anti-coag rec

congestive heart failure - 1
hypertension - 1
age 75+ - 2
diabetes - 1
stroke, tia, thrombus - 2
vascular disease (prior mi, aortic plaque, pad) - 1
age 65-74 - 1
sex female - 1
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7
Q

anticoagulation agents

A

Non-vitamin K antagonist oral anticoags (NOAC)

  • usually preferred over warfarin in most cases
  • DABIGATRAN (direct thrombin inhib)
  • RIVAROXABAN, APIXABAN, EDOXABAN (factor Xa inhibitors)

Warfarin

  • Ind: preferred for severe ckd, if c/i to NOAC (hiv pt on protease inhib tx, carbamazepine, phenytoin), cost issues
  • INR GOAL 2-3

Dual antiplatelet therapy

  • ASA + CLOPIDOGREL
  • monotherapy > dual therapy
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8
Q

baroreceptors

A

-sense changes in arterial pressure (carotid artery stretch) and changes in aortic arch

VAGAL MANEUVERS (CAROTID MASSAGE) DEC HR
-inc carotid pressure --> reflexive decrease in hr (due to inc in vagal stimulation)
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9
Q

autoregulation

A
  • process by which blood flow remains constant in an organ despite changing arterial pressures (perfusion) to the organ
  • IN HEART, LOCAL VASODILATORS ARE NITRIC OXIDE, OXYGEN AND ADENOSINE
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10
Q

CO = HR x SV

A
  • CO on left side is different than on right side

- normal physiologic variation = DURING INSPIRATION, LEFT SIDE STROKE VOLUME DECREASES

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11
Q

renin-angiotensin-aldoserone system

A

regulates bp and water (fluid) balance
-activated w/ decrease in sbp

dec arterial BP –> kidney releases RENIN –> converts angiotensinogen to angiotensin I –> angio-converting enzyme in lungs convert ACE I to ACE II =

  • inc aldosterone = inc Na retention
  • inc ADH = inc H2O retention
  • vasoconstriction = inc BP
  • inc sympathetic tone = inc BP
  • TOO MUCH RENIN = INC BP
  • HYPERALDOSTERONISM ASSOCI W/ INC BP AND HYPOK (aldosterone enhances renal K excretion and Na retention)
  • ACEi block effects of angiotensin II, leading to dec BP
  • inhibit aldosterone, may have hyperK
  • potentiate vasodilators (bradykinin) may devo cough
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12
Q

angiogram

A

GOLD STANDARD / definitive dx for:

  • coronary artery dz
  • peripheral arterial dz
  • renal artery stenosis
  • abdominal aortic aneurysms
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13
Q

exercise stress testing

A

Treadmill Test
-Bruce Protocol: + if ST depressions, exercise-induced htn or hypotn, arrhythmias, sx or hr abnormalities

Radionuclide Myocardial Perfusion Imaging (MPI)

  • either SPECT or PET
  • benefits: localizes regions of ischemia
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14
Q

pharmacologic stress test

A

Vasodilators w/ MPI: ADENOSINE OR DIPYRIDAMOLE

  • coronary vasodilators of normal (but not dz) arteries
  • ind: pt w/ baseline ECG abnormalities
  • localizes region of ischemia
  • C/I IN BRONCHOSPASTIC DZ (asthma and copd), 2/3rd degree heart block or sick sinus syndrome
  • AVOID VASOCONSTRICTORS 24 HR BEFORE (caffeine)
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15
Q

stress echo

A

LOCALIZES REGIONS OF ISCHEMIA, depicts wall motion abnormalities, visualizes stx/fx of heart

  • DOBUTAMINE - sympathomimetic, stims B-mediated inc hr/contractility (positive inotrope/chronotrope) that inc myocardial O2 demand and provokes ischemia
  • ind: pt w/ c/i to vasodilators or w/ recent vasoconstrictor use
  • C/I: sustained ventricular arrhythmias, severe aortic stenosis, mod-sev htn (>180), aortic dissection, pt on B-blocker

Exercise Stress Echo - another option

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16
Q

coronary artery disease

A

INADEQUATE TISSUE PERFUSION / ISCHEMIA

  • due to imbalance btw dec coronary blood supply and inc demand
  • ATHEROSCLEROSIS MC CAUSE, vasospasm, aoritc stenosis/aortic regurge, pulm htn, severe htn, hypertrophic cardiomyopathy
  • RF: DIABETES (WORST), CIGARETTE SMOKING, HYPERLIPIDEMIA, HTN, MALES, AGE (>45 MEN, >55 W), FAMILY HX

Pathophysio:

  • FATTY STREAK FORMATION - LIPID DEPOSITION IN WBC –> smooth muscle proliferation
  • formation of early plaque: LDL enters endothemlium in fatty streak and oxidized, attracts macrophages to ingest LDL and become foam cells, attract more macrophages, fibroblasts, inflam cells
  • formation of fibrous (mature) plaque: proliferating smooth muscle cells and connective tissue becomes incorporated into plaque, FIBROUS CAP results in narrowing of lumen +/-calcification to stabilize

-MYCARDIAL ISCHEMIA: narrowing of lumen reduces blood flow in conditions of increased demand = ischemia
>70% reduction when pt are symptomatic

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17
Q

angina pectoris

A

SUBSTERNAL CHEST PAIN BROUGHT ON BY EXERTION

Class 1: only w/ unusually strenuous activity
Class 2: w/ prolonged or rigorous activity, slight limitation
Class 3: w/ usual daily activity, marked limitation
Class 4: angina at rest

-sx:
HISTORY IMPORTANT
-CHEST PAIN: substernal, poorly localized, exertional
-radiation: ARM (esp ulnar surfaces of forearm and hand), TEETH, LOWER JAW, back, epigastrium or shoulders
-SHORT DURATION <30 MIN (often 1-5 min)
-LEVINE’S SIGN - clenched fist over chest
-pain relieved w/ rest or nitroglycerin (predictable)

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18
Q

diagnosis of ischemic heart disease

A

Workup: ECG initial, STRESS TEST, ANGIOGRAPHY IS GOLD STANDARD

ECG
-ST DEPRESSION = CLASSIC (horizontal or downslope)
-RESTING ECG NORMAL IN 50%
+/- T wave inversion/nonspp ST changes
-presence of left ventricular hypertrophy assoc w/ inc adverse outcome

STRESS TEST - most useful non-invasive screen tool
Treadmill Test
-Bruce Protocol: + if ST depressions, exercise-induced htn or hypotn, arrhythmias, sx or hr abnormalities

Radionuclide Myocardial Perfusion Imaging (MPI)

  • Ind: PT W/ BASELINE ECG ABNORMAL –> LOCALIZE
  • ADENOSINE OR DIPYRIDAMOLE (dilate normal arteries, not diseased ones) - used if pt can’t tolerate exercise
  • C/I: ASTHMATICS

Stress Echo
LOCALIZES REGIONS OF ISCHEMIA, depicts wall motion abnormalities, visualizes stx/fx of heart

CORONARY ANGIOGRAPHY

  • DEFINITIVE DX / GOLD STANDARD
  • defines location and extent of CAD
  • Ind:
  • confirm/exclude CAD in pt w/ symptoms
  • confirm/exclude CAD in pt w/ negative noninvasive tests
  • pt who may need revascularization (PTCA or CABG)
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19
Q

percutaneous transluminal coronary angioplasty PTCA

A

Indications:

  • 1 or 2 VESSEL DISEASE NOT INVOLVING LEFT MAIN CORONARY ARTERY AND WHEN VENTRICULAR FX IS NORMAL/NEAR NORMAL
  • restenosis occurs in 30% w/in 3 months after PTCA so restenosis can be reduced w/ stents

Stents:

  • provide safety net and reduces restenosis rates
  • some stents have drug-eluting properties
  • ASA + CLOPIDOGREL effective in preventing stent thrombosis
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20
Q

coronary artery bypass graft CABG

A

Indications:
-LEFT MAIN CORONARY ARTERY DISEASE, SYMPTOMATIC OR CRITICAL STENOTIC (>70%)
3-VESSEL DISEASE or decreased left ventricular EJECTION FRACTION <40%

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21
Q

medical management of angina

A

NITROGLYCERIN (NITRATES)

  • inc O2 and dilation (blood flow), reduces coronary vasospasm, decreased preload by venodilation
  • sublingual most effective
  • if no relief w/ 1st dose, give 2nd/3rd q5 minutes - no relief suspect ACS
  • can be used prophylactically (5 min before activity)
  • deteriorates w/ moisture, light, air
  • SE: ha, flush, tolerance, hypotn, peripheral edema, TACHYPHYLAXIS (nitrate-free period for 8r)
  • C/I: SBP <90, RV INFARCT, SILDENAFIL (OTHER PDE-5)

BETA-BLOCKERS
-inc O2 by prolonging coronary artery filling time (diastole), reduces O2 requirements during stress (negative chrono/inotrope)
IND: 1ST LINE MANAGEMENT FOR CHORONIC

CA CHANNEL BLOCKERS
-prevents/terminates ischemia induced by vasospasm (dilates), decreased contractility, heart rate, afterload
IND: pt who can’t use BB, PRINZMETAL ANGINA

ASPIRIN

  • prevents platelet activation/aggregation
  • doesn’t address supply/demand, but prevents progression, reduces risk of thrombosis
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22
Q

classic outpatient chronic (stable) angina regimen

A

daily ASA
sublingual nitroglycerin prn
daily BB and STATIN

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23
Q

acute coronary syndrome (ACS)

A

SX OF ACUTE MYOCARDIAL ISCHEMIA 2RY TO ACUTE PLAQUE RUPTURE AND VARYING DEGREES OF CORONARY ARTERY THROMBOSIS (OCCLUSION)
-Includes: UNSTABLE ANGINA, NSTEMI AND STEMI

Unstable Angina

  • angina that is new, crescendo, or at rest >30 min (90% occlusion can cause sx at rest)
  • thrombosis: subtotal occlusion
  • ECG: ST DEPRESSION and/or T-wave inversions
  • cardiac enzymes: NEG

NSTEMI

  • angina that is new, crescendo, or at rest >30 min (90% occlusion can cause sx at rest)
  • thrombosis: subtotal occlusion
  • ECG: ST DEPRESSION and/or T-wave inversions
  • cardiac enzymes: POS (cell death)

STEMI

  • angina that is new, crescendo, or at rest >30 min (90% occlusion can cause sx at rest)
  • thrombosis: TOTAL occlusion
  • ECG: ST ELEVATIONS
  • cardiac enzymes: POS

etiologies:

  • ATHEROSCLEROSIS (MC CAUSE) –> PLAQUE RUPTURE
  • CORONARY ARTERY VASOSPASM: cocaine, variant (prinzmetal angina)

symptoms:

  • angina pain (>30 min), not relieved w/ rest or nitro
  • SYMPATHETIC STIMULATION - tachy/palp, n/v, dizzy
  • silent MI - about 25%, esp women, elderly, dm, obese
  • PE usually normal +/- S4

diagnostic:
-ECG
-CARDIAC MARKERS - STD 3 SETS q8
-troponin most sensitive and specific
CK/CK-MB: appears 4-6 h, peaks 12-24 h, returns 3-4 d
TROP I + T: appears 4-8 h, peaks 12-24 h, returns 7-10 d
*trop may be falsely elevated in pt w/ renal failure, advanced HF, acute PE, CVA

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24
Q

management of unstable angina or NSTEMI

A

2 Parts:

  1. ANTITHROMBOTIC TX
    - ASA (antiplatelet)
    - CLOPDOGREL (antiplatelet)
    - UNFRACTIONATED HEPARIN (anticoag)
    - LOW MOLECULAR WEIGHT HEPARIN (ENOXAPRAIN / LOVENOX) (anticoag)
    - fondaparinux (anticoag)
  2. ADJUNCTIVE THERAPY
    - B-BLOCKERS - metoprolol
    - Nitrates - dec sx, doesn’t dec mortality
    - Morphine - pain and venodilation, dec preload
    - CCB - DOC in VASOSPASTIC DISORDER (cocaine, prinzmental/variant angina)
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25
Q

management of STEMI

A

3 Parts:

  1. REPERFUSION TX (MOST IMPORTANT)
    - done w/in 12 hours of sx onset

PERCUTANEOUS CORONARY INTERVENTION (PCI)

  • best w/in 3H OF SX (esp w/in 90 min)
  • better than thrombolytics

THROMBOLYTIC (FIBRINOLYTIC) THERAPY

  • use if PCI not option
  • ALEPLASE (rTPA) - dissolves clot, RISK REBLEED
  • STREPTOKINASE - least chance of intracranial bleed
  1. ANTITHROMBOTICS
    - ASA
    - HEPARIN
    - Glycoprotein
  2. ADJUNCTIVE THERAPY
    - B-BLOCKERS - dec wall tension
    - ACE INHIBITORS - slows progress of CHF, dec ventricular remodeling
    - Nitrates
    - Morphine
    - Additional: K + Mg replete, STATINS, monitor BP, glucose
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26
Q

thrombolytic/fibrinolysis contraindications in ACS

A

Absolute:

  • PREVIOUS INTRACRANIAL HEMORRHAGE
  • NON-HEMORRHAGIC STROKE W/IN 6 MONTHS OR CLOSED HEAD/FACIAL TRAUMA W/IN 3 MONTHS
  • intracranial neoplasm, aneurysm, AVM
  • active internal bleeding
  • suspected aortic dissection

Relative:

  • SBP > 180 on presentation
  • INR >2 or known bleeding diathesis
  • trauma/major surgery in last 2 weeks
  • recent internal bleed w/in 2 weeks
  • prior streptokinase exposure, pregnancy
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27
Q

heart failure

A

MC CAUSE IS CORONARY ARTERY DISEASE

LEFT: MC CAUSE CAD + HTN, valvular dz, cardiomyopathies

RIGHT: MC CAUSE IS L-SIDED HF, PULMONARY DZ (copd, pulm htn), mitral stenosis

SYSTOLIC: 
-DEC EJECTION FRACTION 
\+/- S3 GALLOP
-THIN VENTRICLE WALLS
-DILATED LV CHAMBER
-MC FORM OF HF
-etiologies: post-MI, dilated cardiomyopathy, myocarditis (can be acute)
DIASTOLIC: 
-NORMAL EJECTION FRACTION 
\+/- S4 GALLOP
-THICK VENTRICLE WALLS, SMALL LV CHAMBER
-assoc w/ normal heart size
-etiologies: HTN, left ventricular hypertrophy, elderly, vlave disease, cardiomyopathies, constrictive pericarditis
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28
Q

heart failure cont…

A

Initial insult leads to INC AFTERLOAD, INC PRELOAD OR DEC CONTRACTILITY –> compensations over time lead to deterioration:

  • sympathetic nervous system activation
  • myocyte hypertrophy/remodeling
  • RAAS activation (fluid overload, ventricular remodeling/hypertrophy)

-sx:

LEFT:

  • INC PULMONARY VENOUS PRESSURE FROM FLUID BACKING UP INTO LUNGS
  • DYSPNEA MC
  • PULMONARY CONGESTION/EDEMA: rales, rhonchi, nonproductive cough, pink frothy sputum, wheezing (CHF MC CAUSE OF TRANSUDATIVE PLEURAL EFFUSIONS)
  • HYPERTENSION, CHEYNE-STOKES BREATHING, cyanosis
  • Increased adrenergic activation - pale skin, sweat, tachy, poor perfusion

RIGHT:

  • INC SYSTEMIC VENOUS PRESSURE –> SIGNS OF SYSTEMIC FLUID RETENTION
  • PERIPHERAL EDEMA
  • JUGULAR VENOUS DISTENTION
  • GI/HEPATIC CONGESTION: n/v, hepatosplenomegaly, ruq tenderness, anorexia

-dx:
ECHO MOST USEFUL TEST (EF IMPORTANT FOR PROGNOSIS)
-normal EF = 55-60%
-EF <35% = inc mortality –> defibrilator placement

CXR - especially for congestive heart failure
-KERLEY B LINES, CARDIOMEGALY, PLEURAL EFFUSIONS, PULM EDEMA

BNP - MAY ID CHF AS CAUSE OF DYSPNEA IN ER

  • indicates severity and prognosis
  • ventricles release BNP during volume overload (congestive hf)
  • BNP >100 = CHF likely
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29
Q

heart failure treatment

A

Initial: ACEI (+ DIURETIC for symptoms)
-ACEI > BB - best 2 drugs for decreased mortality

Meds that decrease mortality:
ACEI, ARB, BB, NITRATES + HYDRALAZINE, SPIRONOLACTONE

Outpatient Regimen:
ACE + DIURETIC –> ADD B-BLOCKER
+/- hydralazine + nitrates, digoxin

IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IN PT W/ EF <35%

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30
Q

congestive (decompensated) heart failure

A

CHF: acute decompensated hf w/ worsening of baseline sx, pulmonary congestion

CXR:

  • CEPHALIZATION = inc vascular flow to apices bc of inc pulmonary venous pressure, occurs w/ wedge pressures 12-18mmHg
  • cephalization –> kerley b lines –> batwing appearance –> pulmonary edema

TX:

  • LMNOP: lasix, morphine, nitrates, oxygen, position (upright for dec venous return)
  • lasix removes fluids and relieves sx
  • morphine reduces preload, reduces strain
  • nitrates reduce preload and afterload
31
Q

acute pericarditis

A

Acute: ACUTE FIBRINOUS INFLAMMATION OF PERICARDIUM, may cause an effusion
Serous: non-infectious (RA, SLE)

Etiologies: MC ARE IDiOPATHIC (maybe viral related) AND VIRAL (ESP ENTEROVIRUSES: COXSACKIE AND ECHOVIRUS), dressler syndrome, autoimmune, uremia, bacterial, drugs: procainamide, INH, hydralazine

  • sx:
  • CHEST PAIN: PLEURITIC (sharp and worse w/ inspiration), PERSISTENT AND POSTURAL (worse supine and relived w/ sitting/leaning forward)
  • FEVER
  • PERICARDIAL FRICTION RUB - best heard at end expiration while upright and leaning forward
  • dx:
  • ECG: DIFFUSE ST ELEVATIONS IN PRECORDIAL LEADS AND PR DEPRESSIONS
  • ECHO: used to assess for complications of acute (effusions, tamponade); isolated pericarditis –> normal

-tx:
-ANTI-INFLAMMATORIES: ASA or NSAIDS x 7-14d, colchicine 2nd line
+/- CORTICO if sx >48h and refractory

32
Q

pericardial effusion

A

INCREASED FLUID IN THE PERICARDIAL SPACE
-caused by pericarditis, malignancy, infx, radiation, dialysis/uremia, collagen vascular dz

  • sx:
  • DISTANT/MUFFLED HEART SOUNDS
  • dx:
  • ECG: low voltage QRS complex, electric alternans
  • ECHO: inc pericardial fluid
  • CXR: cardiomegaly

-tx:
-observe is small and no evidence of tamponade
+/-PERICARDIOCENTESIS IF TAMPONADE OR LARGE

33
Q

pericardial tamponade

A

PERICARDIAL EFFUSION CAUSING SIGNIFICANT PRESSURE ON HEART –> RESTRICTS VENTRICULAR FILLING –> DECREASED OUTPUT

  • sx:
  • BECK’S TRIAD: DISTANT/MUFFLED HEART SOUNDS, INC JVP, SYSTEMIC HYPOTENSION
  • PULSUS PARADOXUS (>10mmHG decrease w/ inspiration)
  • dyspnea, fatigue, peripheral edema, shock
  • dx:
  • ECHO: effusion + diastolic collapse of cardiac chambers (due to fluid pressure > chamber pressure)
  • tx:
  • PERICADIOCENTESIS (IMMEDIATE)
34
Q

constrictive pericarditis

A

THICKENED, FIBROTIC, CALCIFIED PERICARDIUM (FROM CHRONIC PERICARDITIS AND INFLAM)
-RESTRICTS VENTRRICLAR DIASTOLIC FILLING = inc venous pressure, dec cardiac output

  • sx:
  • DYSPNEA MC, fatigue, orthopnea
  • RIGHT-SIDE HF SIGNS: jvd, peripheral edema, n/v, hepatojugular reflux
  • KUSSMAU’LS SIGN: INC JVD W/ RESPIRATION
  • PERICARDIAL KNOCK - HIGH PITCHED 3RD HEART SOUND d/t sudden cessation of ventricular filling from inelastic pericardium
  • dx:
  • ECHO: pericardial thickening
  • CXR: pericardial calcification, normal size or inc

-ddx: restrictive cardiomyopathy

  • tx:
  • PERICARIECTOMY DEFINITIVE, diuretics for sx
35
Q

myocarditis

A

INFLAMMATION OF HEART MUSCLE

  • MC DUE TO VIRAL INFX (or post-viral immune rx)
  • myocellular damage –> myocardial necrosis –> HF
  • Viral: ENTEROVIRUSES (ESP COXSACKIE B) MC, adenovirus, parvo19, hhv6, ebv, hiv, vzv
  • Toxic: scorpion, diptheria toxins
  • Autoimm: SLE, RH fever, RA, kawasaki, UC
  • Meds: CLOZAPINE, methyldopa, abx, isoniazid

-sx:
-VIRAL PRODROME –> HF SX
-dyspnea at reast, syncope, tachypnea, tachy, impaired systolic fx (S3)
-GI: MEGACOLON
+/-CONCURRENT PERICARDITIS: fever, pain, rub, effusion

-dx:
-CXR: CARDIOMEGALY (DILATED)
-ECG: sinus tachy
+CK-MB + TROPONIN, INC ESR
-ECHO: VENTRICULAR DYSFUNCTION
**BIOPSY GOLD STANDARD (infiltration of lymphs)

  • tx:
  • supportive, standard hf tx: diuretics, ACEI, inotropes if severe (dopamine, dobutamine, milrinone)
36
Q

dilated cardiomyopathy

A

95% OF CARDIOMYOPATHIES

  • SYSTOLIC DYSFX –> VENTRICULAR DILATION –> DILATED, WEAK HEART
  • 20-60y, MC MEN
  • IDIOPATHIC 50%
  • VIRAL: ENTEROVIRUSES (COXSACKIE B, ECHO), PB19, CHAGAS, lyme
  • TOXIC: ALCOHOL ABUSE, COCAINE
  • PREGNANCY, autoimmune
  • sx:
  • HEART FAILURE SX: +S3, fatigue, chf
  • embolic events, arrhythmias
  • dx:
  • ECHO: LEFT VENTRICULAR DILATION, DEC EF, LEFT VENTRICLE HYPKINESIS
  • CXR: CARDIOMEGALY
  • tx:
  • standard: ACEI, DIURETICS, BB, DIGOXIN, NA RESTRICT
37
Q

restrictive cardiomyopathy

A

1% of cardiomyopathies
-IMPAIRED DIASTOLIC FX W/ RELATIVELY PRESERVED CONTRACITLITY; VENTRICULAR RIGIDITY IMPEDES VENTRICULAR FILLING

-INFILTRATIVE DZ: AMYLOIDOSIS MC CUASE, SARCOID

  • sx:
  • RIGHT-SIDED FAILURE SX MORE COMMON
  • KUSSMAULS SIGN (JVP INC W/ INSPIRATION)
  • dx:
  • CXR: normal vent, enlarged atria
  • ECG: low voltage, +/- arrhythmias
  • ECHO: VENTRICLES NONDILATED W/ NORMAL WALL THICKNESS, MARKED DILATION IN BOTH ATRIA, DIASTOLIC DYSFX
  • tx:
  • treat underlying disorder, symptomatic
38
Q

hypertrophic cardiomyopathy

A

4% of cardiomyopathies
-INHERITED DISORDER OF INAPPROPRIATE LV OR RV

  • SUBAORTIC OUTFLOW OBSTX narrowed LV outflow 2ry to HYPERTROPHIED SEPTUM
  • diastolic dysfunction –> IMPAIRED VENTRICULAR RELAXATION/FILLING
  • sx:
  • often asymptomatic, first sx may be SUDDEN DEATH during intense exertion due to VENT FIBRILLATION
  • DYSPNEA MC 90% INITIAL
  • ANGINA, syncope, ARRHYTHMIAS
  • HARSH SYSTOLIC CRESCENDO=DECRESCENDO MURMUR
  • decrease intensity w/ inc venous return (squat, supine)
  • increase intensity w/ dec venous return (valsalva, stand)
  • dx:
  • ECHO: ASYMMETRIC WALL THICKNESS, SYSTOLIC ANTERIOR MOTION OF MITRAL VALVE
  • ECG: LEFT VENTRICLE HYPERTROPHY
  • tx:
  • early detection, ICD PLACEMENT
  • AVOID DEHYDRATION AND EXTREME EXERTION
  • BB 1ST LINE, caution w/ digoxin, nitrates and diuretics
  • MYOMECTOMY to remove hypertrophied septum
  • ALCOHOL SEPTUM ABLATION (alt to sx)
39
Q

rheumatic fever

A

ACUTE AUTOIMMUNE INFLAMMATORY MULTI-SYSTEM ILLNESS
-MAINLY CHILDREN 5-15y, strep infx 2-6 wks prior

-RHEUMATIC VALVE DZ: MITRAL 75%, AORTIC 25%

JONES CRITERIA (2 MAJOR; 1 MAJOR + 2 MINOR)

  • JOINT - MIGRATORY POLYARTHRITIS, MED/LAR MC
  • oh my heart - ACTIVE CARDITIS - mitral and aortic valves
  • NODULES - SUBCUTANEOUS over joints, scalp, spine
  • ERYTHEMA MARGINATUM - macular, red, annular
  • SYDENHAM’S CHOREA - invol movement, jerky, purposeless

MINOR: 101.3+ fever, arthralgia, inc ESR, CRP, leukocytosis, prolonged PR interval

  • tx:
  • ANTI-INFLAM: ASA +/- CORTICO in severe or cardio
  • PCN G (or erythromycin)
40
Q

heart sounds

A

SYSTOLE
S1: AV VALVES CLOSE (M + T) - beginning of systole
S2: SEMILUNAR VALVES CLOSE (A + P) - end of systole

DIASTOLE
S3: RAPID “PASSIVE” VENTRICULAR FILING
S4: ATRIAL CONTRACTION INTO VENTRICLES

41
Q

aortic stenosis

A

SYSTOLIC “EJECTION” CRESCENDO-DECRESCENDO

  • LV outflow obstruction –> fixed CO
  • increased afterload –> LVH
  • DEGENERATION 70+ y/o
  • CONGENITAL <70 y/o
  • rheumatic dz
  • sx:
  • ANGINA, SYNCOPE, CHF
  • radiate to CAROTID ARTERIES
  • weak, delayed pulse, narrow pulse pressure
  • LV heave due to lvh
  • tx:
  • AORTIC VALVE REPLACEMENT
  • severe is preload dependent –> avoid exertion, venodilators and negative inotropes (BB, CCB)
42
Q

mitral stenosis

A

OPENING SNAP AND DIASTOLIC RUMBLE AT APEX

  • obstx of outflow from LA to LV –> LA enlargement and inc pressure –> pulm HTN
  • RHEUMATIC HEART DISEASE MC CAUSE!
  • sx:
  • R-SIDED HEART FAILURE
  • PULM HTN
  • ATRIAL FIBRILLATION
  • mitral facies - flushed cheeks
  • no radiation
  • reduced pulse intensity
  • left atrial enlargement
  • tx:
  • VALVOTOMY IN YOUNG PT
  • repair preferred over replacement
43
Q

aortic regurgitation

A

DIASTOLIC DECRESCENDO BLOWING AT LUSB
+/- AUSTIN FLINT MURMUR (mid-late diastolic rumble)

  • backflow from aorta to LV -> LV volume overload
  • rheumatic disease, htn
  • endocarditis, MARFAN
  • syphilis, ankylosing spondylitis
  • sx:
  • LEFT SIDED HEART FAILURE
  • RADIATES ALONG LEFT STERNAL BORDER
  • BOUNDING PULSES - WIDE PULSE PRESSURE
  • tx:
  • VASODILATORS (dec afterload increases forward flow)
  • surgery
44
Q

mitral regurgitation

A

BLOWING HOLOSYSTOLIC MURMUR AT APEX

  • backflow from LV into LA –> LV volume overload –> dec CO
  • MVP MC CAUSE
  • rheumatic, endocarditis, ischemia
  • sx:
  • pulmonary edema, DYSPNEA
  • chronic: a-fib, CHF, pulmonary htn
  • RADIATES TO AXILLA
  • tx:
  • VASODILATORS - dec afterload increases forward flow (ACEI)
  • SURGERY: VALVE REPAIR > REPLACEMENT
45
Q

mitral valve prolapse

A

MID-LATE SYSTOLIC EJECTION CLICK

  • myxomatous degneration ofmitral valve
  • MC IN YOUNG WOMEN
  • connective tissue dz: marfans, ehrlos danlos
  • sx:
  • MOST ASYMPTOMATIC
  • autonomic dysfx: chest pain, panic attacks, arrhythmias
  • w/ progression: fatigue, dizzy, CHF
  • stroke, endocarditis, PVCs
  • narrow AP diameter, thin, hypotn, scoliosis
  • tx:
  • REASSURANCE IN ASYMPTOMATIC PT W/ MILD SX
  • B-BLOCKERS FOR AUTONOMIC DYSFX
46
Q

murmur maneuvers

A

INSPIRATION INCREASES ALL R-SIDED MURMURS

EXPIRATION INCREASES ALL L-SIDED MURMURS

SITING FORWARD INCREASES AR/AS

LEFT LATERAL DECUBITUS INCREASES MR, MS

DECREASED VENOUS RETURN (VALSALVA, STANDING) DECREASES ALL MURMURS (except hypertrophic cardiomyopathy and earlier ejection click of mvp)

INCREASED VENOUS RETURN (SQUAT, LEG RAISE, LYING DOWN) INCREASES ALL MURMURS (except murmur of hypertrophic cardiomyopathy and delayed ejection click of mvp)

47
Q

hypertension

A
  • PRIMARY 95% - idiopathic, onset 25-55, fam hx
  • SECONDARY - suspect if refractory to htn meds or severely elevated, RENAL MC, FIBROMUSCULAR DYSPLASIA MC IN YOUNG, ATHEROSCLEROSIS IN ELDERLY
  • Endocrine: 1ry hyperaldosteronism, pheochromocytoma, cushing’s
  • coarctation of aorta (upper > lower), sleep apnea, etoh, ocps, cox-2 inhib

Complications:

  • CARDIO: CAD, HF, MI, LVH, aortic dissection, AA, PVD
  • NEURO: TIA, CVA, encephalopathy
  • RENAL: renal stynosis and sclerosis, HTN –> ESRD
  • OPTIC: retinal hemorrhage, blindness, retinopathy
  • sx:
  • FUNDO:
  • grade I: arterial narrowing
  • grade II: A-V nicking
  • grade III: hemorrhages and soft exudates
  • grade IV: PAPILLEDEMA (MALIGNANT HTN)
  • Skin: ureimic (ckd), striae (cushings)
  • Neck: carotid bruits, jugular vein exam
  • Abd: pheochromocytoma, polycysticKD, renal bruits, dilation of aorta, trunchal obesity
  • Arterial pulses: decreased or absent femoral (pvd), bp upper>lower (coarctation), edema (chf, ckd)
  • tx:
  • GOAL <140/90 IN GEN POP, DM OR CKD
  • <150/90 if 60+
  • lifestyle mod: wl, low sodium, exercise, limit etoh
  • meds
48
Q

treat uncomplicated HTN

A 
Initial in uncomplicated and non AA, any of folllowing:
THIAZIDE DIURETICS
ACE INHIB
ARBs
CCBs
49
Q

treat HTN w/ comorbidities

A

a-fib (rate control) –> BB or CCB (non-dihyd)

angina –> BB, CCB

post-MI –> BB, ACEi

systolic HF –> ACEi, ARB, BB, diuretics

DM, CKD –> ACEi, arb

isolated HTN in elderly –> diuretics +/- CCB

osteoporosis –> thiazides

BPH –> a-blockers

AA non-diabetic –> thiazides, CCB

young, caucasian male –> thiazides –> ACEi/ARB –> BB

gout –> CCB, LOSARTAN ONLY ARB THAT DOESN’T CAUSE HYPERURICEMIA

50
Q

hypertensive urgency

A

INC BP W/OUT END ORGAN DAMAGE

-tx: DEC BP BY 25% OVER 24-48 HRS W/ ORAL AGENTS

CLONIDINE - REBOUND HTN IF DC'D ABRUPTLY
CAPTOPRIL
furosemide
labetalol
nicardipine
51
Q

hypertensive emergency

A

INC BP W/ ACUTE END ORGAN DAMAGE

Neuro: encephalopathy, hemorrhagic or ischemic stroke, seizure
-perform neuro exam, may need CT to r/o stroke

Cardio: ACS, aortic dissection, acute hf, pulm edema
-ECG, CXR to r/o dissection, CK-MB, troponin

Renal: aki –> proteinuria, hematuria (glom-neph)
-UA, may need chemistries to look for BUN/Cr

Retinal: MALIGNANT THN, GRADE IV RETINOPATHY, may present w/ blurred vision

tx:

  • DECREASE BP BY NO MORE THAN 25% W/IN FIRST HOUR AND ADDITIONAL 5-15% OVER NEXT 23 HOURS USING IV AGENTS
  • DIURETICS?
  • 2 exceptions:
  • ACUTE PHASE OF ISCHEMIC STROKE –> not lowered unless >195/110 in pt who are candidates for thrombolytic or >220/120 if not candidate for thrombolytics
  • ACUTE AORTIC DISSECTION –> bp rapidly reduced to 100-120 w/in 20 min
52
Q

hypertensive emergencies - treatment

A

HTN encephalopathy –> NICARDIPINE OR LABETALOL
-must r/o stroke, often presents w/ confustion, ha, n/v

hemorrhagic or ischemic stroke –> NICARDIPINE OR LABETALOL

  • avoid cerebral hypoperfusion if ischemic
  • only lower if >220/120 in pt who are not candidates for thrombolytic or >185/110 if candidate for thrombolytics

aortic dissection –> ESMOLOL, LABETALOL, nicardipine, sodium nitroprusside

acute coronary syndrome –> NITROGLYCERIN, BB
-nitro not used if suspected right ventricular infarct or viagra w/in 24-48h

acute heart failure –> NITROGLYCERIN, FUROSIMIDE
-avoid hydralazine and BB

renal –> FENOLDOPAM

53
Q

hyperlipidemia

A

etiologies:
Hypercholesterolemia: hypothyroid, pregnancy, kidney fail
Hypertrigs: DM, ETOH, obesity, steroids, estrogen

  • sx:
  • hypertriglyceridemia may cause pancreatitis
  • may devo xanthomas (achilles) or xanthelasma (plaques on eye lids)

SCREEN:

  • adults 20 to 79 w/out CVD –> reasonable to assess RF every 4-6 yrs to calculate 10-yr CVD risk
  • low risk: initiate at 35 for M, 45 for F
  • higher risk: >1 RF (htn, smoking, fam hx) initiate at 20-25 for M, 30-35 for F

INITIATE STATIN: determined by 10 yr + lifetime risk calc

  1. Pt w/ DM between 40 and 75 yo
  2. Pt w/out CVD ages 40 to 75 yo and >7.5% 10 year risk
  3. 21+ yo with LDL = 190+
  4. Any pt w/ any form of clinical atherosclerotic CVD
  • tx:
  • Best for LDL –> STATIN, bile acid sequestrants
  • Best for TRIGS –> FIBRATES, niacin
  • Best for HDL –> NIACIN, fibrates
  • TYPE II DM –> fibrates, statins (niacin may cause hyperglycemia)
54
Q

infective endocarditis

A
  • infection of. endothelium/valves 2ry to colonization
  • MITRAL VALVE MC (m > a > t > p)
  • TRICUSPID VALVE MC IN IV DRUG USERS

Types:
ACUTE: infection of normal valves w/ virulent organism
-STAPH AUREUS MC

SUBACUTE: indolent infection of abnormal valves w/ less virulent organism
-STREP VIRIDANS MC, ORAL FLORA AS SOURCE

IV DRUG USER:
-STAPH AUREUS MC, ESP MRSA, pseudomonas, candida

PROSTHETIC VALVE:

  • w/in 60 days –> STAPH EPI MC
  • late –> resembles native valve endocarditis

*ENTEROCOCCI MC MEN 50Y W/ HISTORY OF GI/GU PROCEDURES, others: fungi, yeast, gnr

  • sx:
  • FEVER 80-80%, anorexia, weight loss, fatigue
  • ECG CONDUCTION ABNORMALITIES
  • JANEWAY LESIONS - red, painless on palms/soles
  • ROTH SPOTS - retinal hemorrhages w/ pale center
  • PETECHIAE - conjunctiva, palate
  • OSLER’S NODES - tender nodules on pads of digits
  • SPLINTER HEMORRHAGES of proximal nail bed, clubbing, hepatosplenomegaly
  • dx:
  • BLOOD CULTURES - 3 SETS 1 HR APART
  • ECG - prone to arrhythmias
  • ECHO - TTE first
  • LABS: CBC (leukocytosis, anemia - normo), ESR, RhF
55
Q

Duke criteria for infective endocarditis

A 
2 Major 
OR 
1 Major and 3 Minor 
OR 
5 Minor

Major:

  • SUSTAINED BACTEREMIA - 2+ BC by org known to cause
  • ENDOCARDIAL INVOLVEMENT: positive ECHO (vegetation, abscess, valve perforation, etc) OR NEW VALVULAR REGURGITATION

Minor:

  • PREDISPOSING CONDITION (abnormal valves, IV drug user, indwelling catheter)
  • FEVER
  • VASCULAR + EMBOLIC PHENOMENA: Janeway lesions, emboli, ICH
  • IMMUNOLOGIC PHENOMENA: Osler’s nodes, Roth spots, +RhF, acute glomerulonephritis
  • Positive BC (doesn’t meet major criteria)
  • Positive ECHO (doesn’t meet major criteria - worsen murmur)
56
Q

management for infective endocarditis

A

VANC FOR GRAM +, GENT FOR GRAM -

Acute = NAFCILLIN + GENTAMICIN 4-6WKS; VANC + GENTAMICIN (if suspected mrsa or pcn allergic)

Subacute = PCN OR AMP + GENTAMICIN; VANC IN IVDA

Prosthetic = VANC + GENT + RIFAMPIN (for s.aureus)

Fungal = AMPHO B

*DURATION USUALLY 4-6 WKS, AMINOGLYCOSIDES ONLY FOR 2 WKS

57
Q

endocarditis prophylaxis indications

A

Cardiac Conditions:

  1. prosthetic heart valves
  2. heart repairs w/ prosthetic material
  3. prior history of endocarditis
  4. congenital heart disease
  5. cardiac valvulopathy in a transplanted heart
    - NOT for GI/GU problems, NOT for most valve dz

Procedures:

  1. DENTAL, involving manipulation of gums, roots of teeth, oral mucosa perf
  2. RESPIRATORY, surgery on respiratory mucosa, rigid bronchoscopy
  3. PROCEDURES INVOLVING INFECTED SKIN/MSK TISSUE (including I+D)

Regimens:
AMOX 2g 30-60 min before procedure
CLINDA if pcn allergic

58
Q

nonbacterial verrucous endocarditis (Libman-Sacks endocarditis)

A

small, wary, sterile vegetations on both sides of leaflets that can be a source of embolization

  • SEEN W/ SLE
  • may need anti-coag
59
Q

peripheral arterial disease

A

atherosclerotic disease of lower extremities

  • sx:
  • INTERMITTENT CLAUDICATION MC - reproducible pain/discomfort in lower extremity brought on by exercise/walking and relived w/ rest
  • sx distal to lesion (artery affected)
  • RESTING LEG PAIN = advanced disease
  • ACUTE ARTERIAL EMBOLISM - paresthesias, pain, pallor, pulselessness, paralysis, poikilothermia
  • GANGRENE - wet = ulcers; dry = mummification
  • Skin: atrophic changes, thin, shiny, hair loss, thick nails, cool limbs
  • Color: pale on elevation, dusky red w/ dependency, cyanosis, LATERAL MALLEOLAR ULCERS

-dx:
-ANKLE-BRACHIAL INDEX = pos if ABI <0.90 (.5 severe)
normal ABI = 1-1.2
-ARTERIOGRAPHY GOLD STANDARD
-Duplex B ultrasound, HANDHELD DOPPLER

  • tx:
  • PLATELET INHIBITORS - CILOSTAZOL, aspirin, clopidogrel
  • REVASCULARIXATION - percutaneous transluminal angioplasty, fem-pop bypass, endarterectomy
  • Supportive: EXERCISE, foot care
  • Heparin for acute embolism
60
Q

abdominal aortic aneurysm

A

Focal dilation of aortic diameter at least 1-1.5x diameter at renal arteries
>3cm generally aneurismal
-MC OCCURS INFRARENALLY
-RF: ATHEROSCLEROSIS MC, age >60, smoking, males (5x), caucasian, hyperlipidemia, connective tissue dz, htn

-sx:
-ASYMPTOMATIC until rupture, incidental finding
-ACUTE LEAKAGE/RUPTURE: OLDER MALE >60, SEVERE BACK/ABD PAIN, SYNCOPE OR HYPOTN, TENDER, PULSATILE ABD MASS
+flank ecchymosis, unilateral groin/hip pain
>5cm = inc rupture risk

  • dx:
  • ABD US: initial study of choice, used to monitor
  • CT: test of choice for thoracic and eval known AAA
  • ANGIOGRAPHY GOLD STANDARD
  • MRI/MRA
  • abdominal xray - may show calcified aorta

-tx:
-SURGICAL REPAIR DEFINITIVE
>5.5 cm or >0.5 cm expansion in 6 mo –> IMMED SX
>4.5 cm –> vascular referral
4-4.5 cm –> monitor US q 6 mo
3-4 cm –> monitor US yearly
-B-BLOCKERS REDUCE SHEARING FORCES, DEC EXPANSION AND RUPTURE RISK

61
Q

aortic dissection

A

TEAR IN INNERMOST LAYER OF AORTA (INTIMA)

  • 65% ASCENDING (near aortic arch or left subclavian), 20% descending
  • ASCENDING = HIGH MORTALITY
  • RF: HTN (most important), AGE 50-60y, men, vasculitis, trauma, TURNER’s or MARFAN syndrome
  • sx:
  • CHEST PAIN (96%) MC - SUDDEN, SEVERE, TEARING, CHEST AND UPPER BACK
  • n/v, sweating
  • DECREASED PERIPERHAL PULSES (radial, carotid, femoral), VARIATION IN PULSE >20mmHg
  • HTN, ACUTE NEW-ONSET AORTIC REGURGITATION
  • dx:
  • CT W/ CONTRAST
  • MRI ANGIOGPARHY GOLD STANDARD
  • TEE (maybe initially to eval pt esp if hemodynamically unstable)
  • CXR - widening of mediastinum classic (60-90%)
  • tx:
  • SURGICAL - ACUTE PROXIMAL, ACUTE DISTAL, WITH COMPLICATIONS
  • MEDICAL - DESCENDING W/OUT COMPLICATIONS
  • ESMOLOL, LABETALOL 1ST LINE, sbp 100-120 and pulse <60 achieved in 20 min
  • sodium nitroprusside added if needed
62
Q

thromboangitis obliterans (Buerger’s Disease)

A

NONARHEROSCLEROTIC INFLAMMATORY DISEASE OF SMALL AND MEDIUM ARTERIES AND VEINS

  • STRONGLY ASSOC W/ TOBACCO - suspect in young smokers/tobacco w/ distal extremity ischemia/ulcers or gangrene of digits
  • MC YOUNG MEN
  • sx: TRIAD
  • SUPERFICIAL MIGRATORY THROMBOPHLEBITIS - large, red, tender superficial veins causing nodules that follow venous distribution
  • DISTAL EXTREMITY ISCHEMIA - claudication and finger/toe ischemia mc, paresthesias, ischemic ulcers or gangrene
  • RAYNAUD’S - reversible vasospasm-induced tricolor
  • dx:
  • AORTOGRPAHY GOLD STD: segmental, occlusive lesions of small/med vessels with CORKSCREW COLLATERALS
  • ABNORMAL ALLEN TEST - tests patency of radial and ulnar arteries (dec patency and delayed reperfusion)
  • tx:
  • TOBACCO CESSATION - ONLY DEFINITIVE
  • wound care
  • CCBs for Raynauds (dihydropyridines)
  • Iloprost
63
Q

peripheral venous disease

A

SUPERFICIAL: greater/lesser saphenous veins
DEEP: accompanies major arteries, carries 90% of venous return and well supported
PERFORATING: communicate btw superficial and deep

THROMBOPHLEBITIS: inflam of vein caused by blood clot
-superficial thrombophlebitis and DVT

VIRCHOWS TRIAD: pt w/ thrombi may have combo of factors:
INTIMAL DAMAGE - trauma, infx, inflam
STASIS - prolonged sitting >4 h
HYPERCOAGUABILITY - factor V leiden, C or S deficient, OCP, malignancy, pregnancy

64
Q

superficial thrombophlebitis

A

inflam and/or thrombus of superfical vein

  • MC ASSOC W/ IV, TRAUMA, PREGNANCY, VARICOSE
  • usually benign, self-limited

TROUSSEAU’S SYNDROME - MIGRATORY THROMBOPHLEBITIS IS ASSOC W/ MALIGNANCY

  • sx:
  • LOCAL PHLEBITIS - tender, pain, induration, edema, red, +/- palpable cord
  • dx:
  • VENOUS DUPLEX ULTRASOUND: noncompressible vein
  • tx:
  • SUPPORTIVE: elevate, warm compress, NSAIDs, compression stockings
  • SEPTIC: IV PCN + AMINOGLYCOSIDE (suspect if F)
  • vein ligation/excision if extensive varicose veins or persistent
65
Q

deep venous thrombosis

A
  • MOST ORIGINATE IN CALF
  • CONSEQUENCE –> PULMONARY EMBOLISM (50%)
  • RF: VIRCHOW’S TRIAD: STASIS, ENDOTHELIAL DAMAGE, HYPERCOAGUABILITY

-sx:
-UNILATERAL SWELLING OF LOWER EXTREMITY
>3 cm most specific sign of DVT
-CALF PAIN/TENDERNESS, phlebitis

-dx:
-VENOUS DUPLEX ULTRASOUND FIRST LINE - non-compressible echogenicity, altered flow
-D-DIMER: negative can rule out, positive doesn’t confirm
(false pos in pregnancy, liver dz, inflam, malig, trauma)
-VENOGRAPHY GOLD STANDARD: filling defect

  • tx:
  • PREVENT PE
  • ANTICOAG THERAPY: HEPARIN –> WARFARIN
  • IVC FILTER: pt w/ contraindications or failed anticoag

1st Episode w/ reversible or time-limiting RF for VTE –> TX FOR AT LEAST 3 MO
1st Episode of IDIOPATHIC (no malig) –> TX LONG-TERM
Pregnancy –> LMWH preferred as initial and long term
Malignancy –> LMWH as initial long-term

66
Q

varicose veins

A

-seen esp w/ inc estrogen: OCPs, pregnancy

  • sx:
  • dilated, tortuous, often asymptomatic
  • dull ache or pressure worse w/ long standing and relieved w/ elevation
  • venous stasis ulcers: severe result in skin ulcers
  • visual inspection of leg in dependent position
  • tx:
  • leg elevation, compression stockings, avoid prolonged standing
  • sclerotherapy, radiofrequency or laser ablation
67
Q

chronic venous insufficiency

A

etiology: MC AFTER SUPERFICIAL THROMBOPHLEBITIS, AFTER DVT OR TRAUMA TO AFFECTED LEG

  • sx:
  • LEG PAIN, burn, ache, fatigue, heavy leg (worse w/ prolonged sitting/stand, foot dependency; better w/ elevation and walking)
  • leg edema
  • STASIS DERMATITIS: eczema rash, itch, scale, weeping erosions w/ crusting +/- cellulitis
  • BROWNISH HYPERPIGMENTATION
  • VENOUS STASIS ULCERS - ESP MEDIAL MALLEOLUS
  • dx:
  • TERNDELENBURG TEST
  • ULTRASOUND
  • tx:
  • COMPRESSION SOCKS MAINSTAY, ELEVATION, avoid long periods standing or sitting, exercise regularly
  • ulcer management
  • venous valve transplant
68
Q

postural (orthostatic) hypotension

A

pathophysio:

  • impaired autonomic reflexes or reduced intravascular vol
  • meds: anti-HTN, vasodilators, diuretics, narcotics, antipsychotics, antidepressants, etoh consumption
  • neuro: diabetic autonomic neuropathy, parkinson’s, G-B

-sx:
+/- weak pulse, cool extremities, tachy, hypoTN, tachypnea

  • dx:
  • w/in 2-5 min of quiet standing (after 5 min supine) there is EITHER:
  • FALL IN SYSTOLIC BP >20 mmHg
  • fall in diastolic BP >10 mmHg with changes in position
  • pulse rate normally rises with standing, if not, may be autonomic dysfunction
  • if 2ry to hypovolemia, may have increase of pulse rate >15 bpm
  • tx:
  • tx underlying disease, remove offending meds, support BP, salt, fluids, exercise, stockings, caffeine
  • pharm: fludrocortisone, midodrine
69
Q

atrial myxoma

A

mc primary cardiac tumor in adults (rare)
-90% in atria, seen on echo

  • sx:
  • non-specific, flu-like sx, fever, palpitations, may embolize
  • low-pitched diastolic murmur that changes character w/ changing body positions
70
Q

circulatory shock

A

INADEQUATE ORGAN PERFUSION AND TISSUE OXYGENATION, OFTEN ASSOC W/ HYPOTN
-Shock: low cardiac output OR low systemic vascular resistance

4 Main Types:
HYPOVOLEMIC - loss of blood or fluid volume
CARDIOGENIC - primary myocardial dysfunction (dec CO)
OBSTRUCTIVE - intrinsic or extrinsic obstx to circulation
DISTRIBUTIVE - maldistribution of blood flow

Pathophys:

  • INADEQUATE TISSUE PERFUSION –> metabolic acidosis
  • AUTONOMIC NS ACTIVATION –> to vasoconstrict and inc CO (norepi, dopamine + cortisol release), RAAS active
  • SYSTEMIC EFFECTS OF SHOCK –> ATP depletion –> cellular dysfx, cell swell and death, METABOLIC ACIDOSIS (anaerobic metabolism by-product lactic acidosis)
  • sx:
  • acutely ill, ams, decreased peripheral pulses, tachy, skin cool, low bp
  • DBC, BMP, lactate, coag studies, cultures, ABG
  • Management: ABCDE
  • Airway - may need intubation
  • Breathing - vent and sedation decreases work to breath
  • Circulation - isotonic crystalloids (NS, LR)
  • Delivery of O2 - monitor lactate
  • Endpoint of Resuscitation - urine output 0.5ml/kg/hr, CVP 8-12mmHg, MAP 65-90mmHg, central venous O2 >70%
71
Q

hypovolemic shock

A

Hemorrhagic or Non-blood fluid loss (vomit, obstx, burns, dka)
-loss of blood or volume –> inc heart rate, vasoconstrict, hypoTN, dec CO

  • sx:
  • tachy, hypoTN, oliguria or anuria
  • PALE, COOL, DRY SKIN/EXTREMITIES, SLOW CAP REFIL >2 SEC, DEC TURGOR, DRY MUCOUS MEMBRANES
  • BAD = NO URINE OUTPUT
  • doesn’t affect respiratory effort/distress
  • dx:
  • HALLMARK: VASOCONSTRICTION, HYPOTN, DEC CO AND DEC PULMONARY CAP PRESSURE
  • CBC (inc hgb/hct)
  • decreased CVP (central venous pressure)/PCWP (wedge)
  • tx:
  • ABCDE’s, insert 2 large bore IV lines or central
  • VOLUME RESUSCITATION CRYSTALLOIDS (NS OR LR)
  • control bleeding, +/- packed RBC
  • prevent hypothermia, tx coagulopathies
72
Q

cardiogenic shock

A

PRIMARY CARDIAC/MYOCARDIAL DYSFUNCTION –> inadequate tissue perfusion –> dec CO w/ inc SVR (systemic vasc resistance)

  • often produces increased respiratory effort/distress
  • CARDIAC DZ: MI, infarct, myocarditis, valve dysfunction
  • dx:
  • HYPOTN in presence of INC PULM CAPILLARY WEDGE PRESSURE (>15mmHg)
  • VASOCONSTRICTION (INC SVR), DEC CARDIAC OUTPUT
  • tx:
  • O2, ISOTONIC FLUIDS (AVOID AGGRESSIVE)
  • INOTROPIC SUPPORT (dobutamine, epi, amrinone)
  • treat underlying cause
73
Q

obstructive shock

A

OBSTRUCTION OF BLOOD FLOW DUE TO PHYSICAL OBSTRUCTION OF HEART OR GREAT VESSELS
-intrinsic or extrinsic - inc external pressure on heart dec ability to pump blood

Etiologies:

  • MASSIVE PULM EMBOLISM
  • PERICARDIAL TAMPONADE
  • TENSION PNEUMOTHORAX
  • AORTIC DISSECTION
  • tx:
  • O2, isotonic fluids, inotropic support (dobutamine, epi)
  • Treat underlying cause:
  • PE –> heparin, thrombolytics
  • Tamponade –> pericardiocentesis
  • Tension Pneumo –> needle decompression
  • Proximal AA dissections usually need sx
74
Q

distributive shock

A

EXCESS VASODILATION AND ALTERED DISTRIBUTION OF BLOOD FLOW (inc venous capacity) with shunting of BF from vital organs to non-vital tissues

SX: DEC CO, DEC SVR, DEC PCWP
-IMPORTANT EXCEPTION IS EARLY SEPTIC SHOCK - ASSOC W/ INC CO AND DEC SVR SO WARM EXTREMITIES

Types:

SEPTIC SHOCK - MC

  • systemic inflammatory response to infective organisms
  • sx: HYPOTN, WIDE PULSE PRESSURE, WARM FLUSHED EXTREMITIES (INC CO)
  • SEPSIS CRITERIA + REFRACTORY HYPOTN
  • tx: IV abx, IV fluids NS/LR, vasopressors

ANAPHYLACTIC SHOCK

  • IgE-MEDIATED SYSTEMIC HYPERSENSITIVITY RX
  • sx: itching, hives, angioedema –> resp distress, stridor, hoarseness, lump in throat
  • tx: EPI, manage airway w/ antihistamines, observe 4-6hr

NEUROGENIC SHOCK

  • DUE TO ACUTE SPINAL CORD INJURY, regional anesthesia
  • autonomic ns blockade –> unopposed inc vagal tone –> BRADYCARDIA AND HYPOTN
  • sx: warm skin, normal/dec HR, dec SVR, hypovolemia, WIDE PULSE PRESSURE
  • tx: fluids, pressors, +/-corticosteroids

ENDOCRINE SHOCK

  • ADRENAL INSUFFICIENCY (ADDISONIAN CRISIS)
  • tx: HYDROCORTISONE 100 MG IV (most don’t respond to fluids and pressors)

Concepts / Lists (16 decks)

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