Cardiology Flashcards
Discuss the causes of left heart failure
Systolic Dysfunction
- Impaired Contractility
- coronary artery disease
- MI
- Valvular Disease
- mitral regurgitation
- aortic regurgitation
- Dilated Cardiomyopathy
- Increased afterload
- aortic stenosis
- hypertension
Diastolic Dysfunction
- impaired diastolic filling
- left ventricular hypertrophy
- restrictive cardiomyopathy
- myocardial fibrosis
- transient myocardial ischemia
- pericardial constriction or tamponadeDiscuss the causes of right heart failure
Cardiac Causes - left sided heart failure - pulmonic valve stenosis - right ventricular infarction Lung Diseases - COPD - Interstitial lung disease - ARDS - infection Pulmonary Vascular Disease - pulmonary embolism - primary pulmonary hypertension
Discuss the definitions for heart failure
Definitions
- Forward Failure
- inability to pump blood forward at sufficient rate leading to low cardiac output - Backward Failure
- heart able to pump at sufficient rate only if cardiac filling pressure is abnormally high, volume overload - Systolic dysfunction
- unable to contract blood efficiently due to impaired contractility or increased afterload
- decreased ejection fraction - Diastolic dysfunction
- unable to fill due to decreased compliance
Discuss the compensation for heart failure
Compensation
- increase preload
- incomplete chamber emptying resulting in decreased stroke volume -> increase end diastolic volume -> increase stroke volume and end diastolic pressure -> volume overload - Neuro-hormonal axis
- increased sympathetic activity by increased contractility, HR and vasoconstriction
- increased renin-angiotensin system which increase BP, increase venous return, and increase aldosterone leading to Na retention and increased circulating volume and venous return
- increase ADH which increase aldosterone
Discuss the presentation and investigations for heart failure
Presentation
- FACES
- fatigue
- activities limited, exercise intolerance
- chest congestion
- edema including ascites and peripheral edema
- SOB including orthopnea, paroxysmal nocturnal dyspnea
Investigations
- CBC, electrolytes, BUN/creatinine, LFT
- B-type natriueretic peptide (BNP)
- CXR
- ECG
Diagnosis
- normal BNP rules out heart failure
- left systolic dysfunction with LVEF <40%
Discuss the New York Heart Association (NYHA) classification
Class 1 - no symptoms - perform ordinary activity without limitations - have structural heart disease but no symptoms Class 2 - mild symptoms of dyspnea, fatigue with moderate exertion - occasional swelling of ankles - no symptoms at rest Class 3 - symptoms with minimal exertion - limitation to activity - comfortable only at rest Class 4 - symptms at rest
Discuss the management for systolic heart failure
Prevention
- dyslipidemia, diabetes, hypertension, smoking
Loop Diuretics
- treat volume overload
- furosemide 20-40mg OD-BID
ACE inhibitor + Beta Blocker
- symptomatic or LVEF <40%
- ACEi
- Captopril start at 6.25mg PO TID to 50mg PO TID
- Enalapril start at 2.5mg PO BID to 20mg PO BID
- Lisinopril start 5mg PO BID to 40mg PO BID
- ARBs
- Candesartan 4mg PO to 32mg PO
- Beta Blocker
- Carvedilol start at 3.125mg PO BID to 25-50mg PO BID
- Bisoprolol start at 1.25mg PO OD to 5-10mg PO OD
- Metoprolol start at 12.5mg PO OD to 200mg PO OD
Aldosterone Antagonist
- NYHA III/IV
- Spironolactone 12.5mg PO OD to 50mg PO OD
Digoxin, Nitrate, Hydralazine
- NYHA III/IV
- digoxin improve symptom and reduce hospitalization
Combined Diuretics
- NYHA III/IV
- thiazide
Implantable Cardioverter Defibrillator
- LVEF <30%
Cardiac Resynchronization Therapy
- QRS >120ms
Heart Transplant
- refractory to above treatments
Discuss the exacerbating factors for congestive heart failure
Increased Metabolic Demands - infection - anemia - hyperthyroidism - pregnancy Increased Circulating Volume - excessive sodium diet - excessive fluid administration - renal failure Increased Afterload - uncontrolled hypertension - pulmonary embolism Impaired Contractility - Myocardial ischemia - excessive alcohol Medication Incompliance Bradycardia
Discuss the warm vs cold and dry vs wet presentation of heart failure exacerbation
Warm vs Cold where cold have - skin cool - sleepy/obtunded - renal failure, hyponatremia - hypotension, narrow pulse pressure Dry vs Wet where wet have - distended, elevated JVP - orthopnea, PND - ascited, lower leg edema
Discuss the treatment for cold heart failure
Inotrope to Increase CO
- dopamine
- dobutamine
- Milrinone
Discuss the treatment for wet heart failure
LMNOP
- Lasix
- 40-500mg IV until euvolemic based on normal JVP, no peripheral edema or pulmonary edema
- age + BUN for lasix dose - Morphine
- decrease anxiety and decrease preload by venodilation
- 2-4mg IV - Nitrate
- decrease preload - Oxygen
- titrate to O2 >92% - Position and Positive Pressure Ventilation
- position upright to help breathing
- CPAP/BiPAP to decrease preload
- used for respiratory distress, severe hypoxia, or altered LOC
Discuss the normal ECG values and calibration
Normal Values - HR 60-100 - QRS Axis: -30 - +90 - PR Interval: 120-200ms - QRS Duration: <100ms - QTc Interval: 350-450ms Calibration - small square = 1mm = 40ms = 0.1mV - large sqaure = 5mm = 200ms = 0.5mV
Discuss when to initiate rate vs rhythm control for atrial fibrillation
Rate Control - persistent atrial fibrillation - less symptomatic - age >65 - hypertension - no history of CHF - failure with rhythm control Rhythm Control - paroxysmal atrial fibrillation - new atrial fibrillation - more symptomatic - age <65 - no hypertension - CHF exacerbated by AF - failure with rate control
Discuss first line medications for rate and rhythm control
Rate Control - target <100 bpm - BB or CCD - digoxin Rhythm Control - electrical cardioversion if unstable - propafenone - fleicainide - amiodarone 100-200mg OD - catheter ablation
Discuss anticoagulation for atrial fibrillation
CHADS2 - Congestive Heart Failure - Hypertension - Age >75 - Diabetes - Stroke/TIA prior (2 points) Severity - 0: ASA 81-325mg OD - 1: dabigitran or warfarin (INR 2-3) or ASA 81-325mg OD - 2-6: dabigitran or warfarin (INR 2-3)
Discuss the cause, symptoms and findings of mitral stenosis
Cause - rheumatic heart disease Symptoms - left-sided heart failure Findings - Loud S1 - Opening snap - diastolic rumble, loudest in left lateral decubitus
Discuss the cause, symptoms and findings of mitral regurgitation
Causes
- Acute:
- endocarditis
- ruptured chordae
- papillary muscle dysfunction
- Chronic
- rheumatic
- mitral prolapse
- calcified annulus
- dilated LV
Symptoms
- pulmonary edema
- left sided HF
- fatigue
Findings
- holosystolic murmur at apea
- murmur worse with clenching fistsDiscuss the cause, symptoms and findings of aortic stenosis
Causes - degenerative calcifications - congenital - rheumatic Symptoms - chest pain - syncope - dyspnea with exertion Findings - delayed upstroke and decrease volume at carotid - suprasternal thrill - Soft A2 - systolic ejection type murmur
Discuss the cause, symptoms and findings of aortic regurgitation
Causes - congenital (bicuspid valve) - endocarditis - rheumatic - aortic root dilatation Symptoms - dyspnea on exertion - chest pain Findings - wide pulse pressure - bounding pulses - early diastolic decresendo murmur (heard best at expiration, with patient leaning forward)
Discuss some of the complications from myocardial infarction
Free Wall Rupture
- tearing of ventricle or atrial wall resulting in hemorrhage into pericardium
- occur 3-5 days post MI
- immediate death
Ventricle Septal Rupture
- rupture in septum resulting in flow from left to right ventricle
- new pan-systolic murmur, cardiogenic shock, palpable thrill over sternal border
- urgent cardiac surger
Ventricular Aneurysm
- outward bulging of heart chamber due to weakened and thinned ventricular wall
- dyskinetic and displaced apex
- result in embolism, mitral regurgitation, ventricular arrhythmia
Papillary muscle Ischemia/Rupture
- mitral regurgitation, heart failure, pan-systolic murmur
- urgent cardiac surgery
Pericarditis
- inflammation immediately after MI or due to autoimmune >1 month post MI
Differentiate between hypertensive crisis and malignant hypertension
Crisis
- asymptomatic hypertension >=210/130
Malignant Hypertension
- BP >180/110 with acute target ongoing organ damage
- hypertensive encephalopathy with papilledema
- acute ischemic stroke
- intracranial hemorrhage
- acute LV failure
- ACS
- Acute aortic dissection
- Acute Kidney Injury
- EclampsiaDiscuss the causes of malignant hypertension
Essential Hypertension Secondary Hypertension - renovascular - endocrine: hypo/hyperthyroid, hyperaldosteronism, pheochromocytoma - chronic kidney disease CNS - stroke - mass - epilepsy Vascular - aortic dissection Medication - MAOI - beta blocker withdrawal Substance - alcohol withdrawal - cocaine/amphetamine intoxication - pregnancy
Discuss the presentation and management of hypertensive crisis
Presentation
- blurred vision
- headache
- nausea/vomiting
- focal neurological deficit
- dyspnea
- angina
Investigations
- CBC, electrolytes, creatinine, BUN, glucose
- CXR
- ECG
- Urinalysis
- possible troponin or CT head if concerned
Management
- ABC
- Treat underlying cause
- Reduce blood pressure
- reduce MAP by 10-20% in first hour then by 25% gradually over next 23hr, target <170/110
- IV labetalol bolus 20mg followed by 20-80mg every 10 min for total dose of 300mg
- IV nitroprusside 0.25-0.5mcg/kg per minute increased to 8-10mcg/kg if needed
- Address target organ damage
- hypokalemia then PO KClDiscuss signs of secondary hypertension
- age of onset before puberty
- age <30 in non-obese and non-black with negative family history
- severe or resistant hypertension
- acute rise in BP in previously stable individual
- malignant or accelerated hypertension
Discuss Renal Artery Stenosis as secondary cause of hypertension
Risk Factors - Age >50 - other arthersclerotic disease - smoking Presentation - severe and refractory - asymmetric renal size - flank bruit - spontaneous hypokalemia - >30% increase in creatinine with ACE - flash pulmonary edema Diagnosis - Doppler ultrasound confirmed with CTA Management - percutaneous angioplasty with stent - ACEi for unilateral
Discuss hyperaldosteronism for cause of secondary hypertension
Definition - primary: increased adrenal aldosterone production - secondary: increase renin-angiotensin stimulating increased aldosterone production Primary Causes - adrenal adenoma (Conn) - bilateral idiopathy adrenal hyperplasia - familial hyperaldosteronism - aldosterone producing carcinoma Secondary Causes - renin-producing tumour - decreased renal perfusion Presentation - fatigue, weakness - metabolic abnormality: hypernatremia, hypokalemia, hypomagnesia, metabolic alkalosis Diagnosis - plasma aldosterone >400 - plasma aldosterone:renin ratio >140 in primary, normal in secondary Treatment - underlying cause - K sparing diuretic (spironolactone)
Discuss Cushing’s syndrome for secondary cause of hypertension
- increase glucorticoid in syndrome
- ACTH secreting pituitary adenoma increasing adrenal glucorticoid production in disease
ACTH Dependent - ACTH secreting pituitary tumour
- etopic ACTH secreting tumour
ACTH Independent - exogenous glucocorticoid use
- primary adrenocortical tumour
- alcoholism
Presentation - Facies: red cheeks, acne, moon face
- dorsal fat pad
- purple striae
- central obesity with thin arms/legs
- easy bruising
Diagnosis - 24hr urinary free cortisol 4x normal
- lack cortisol suppression with dexamethasone use
Management - treat underlying cause
- mitotane to reduce cortisol
Discuss pheochromocytoma as cause of secondary hypertension
- catelcholmine secreting adrenal tumour
- sporadic or familial with MEN2A, 2B, von Hippel-Lau, neurofibromatosis
Presentation - symptoms triggered by stress, exertion
- triad: episodic pounding headache, palpitation, diaphoresis
- tremor, anxiety, blurry vision
- orthostatic hypotension
Diagnosis - high urinary metanephrine and normetanephrine
Management - pre-operative preparation
- alpha blockade with phenoxybenzamine
- beta blockade with propranolol
- metyrosine to inhibit catelcholmine synthesis - surgical remove
