Cardiology II Flashcards

1
Q

cardiac valvular disease - causes and dx

A

issue with valves of heart - can either be stenosis or regurgitation (i.e. insufficiency) due to “floppy” valve

historically, rheumatic dx
now, atherosclerosis

Dx Test: ECHO!!

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2
Q

mitral valve prolapse - what do you hear on auscultation

A

midsystolic click

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3
Q

aortic stenosis - sxs

A

dyspnea, angina, syncope w/ exertion
- LV failure and hypertrophy (displaced PMI)

Murmur: systolic ejection murmur, harsh and loud
- have pt lean forward

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4
Q

aortic stenosis - dx

A

doppler ECHO (test of choice)

EKG: LVH
CXR: cardiomegaly, calcified valve

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5
Q

aortic stenosis - tx

A

valve replacement has great results

- must do if following triad of HF, angina, or syncope

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6
Q

aortic regurgitation - sxs and cause

A

dyspnea on exertion
PE: head-bobbling and pulsating nail beds
- WIDE PULSE PRESSURE (high systolic and low diastolic)
- also see LVH since blood flowing back into LV

cause: can see in Marfan’s due to aortic root problem

Murmur: high pitched, blowing diastolic murmur

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7
Q

aortic regurgitation - dx

A

ECHO - test of choice

EKG and CXR: LVH

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8
Q

aortic regurgitation - tx

A

acute regurg (following invasive endocarditis) - immediate surgery

chronic regurg:

  • ARBs and ACE-I reduce sxs
  • valve replacement eventually
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9
Q

mitral stenosis - sxs

A

orthopnea, proximal nocturnal dyspnea, exertion dyspnea
- initial sxs often with onset of A-fib or pregnancy

Murmur: mid-diastolic, low-pitched rumble

  • OPENING SNAP (HINT-MS/OS)
  • loudest in L lateral position (use bell)
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10
Q

mitral stenosis - dx

A

ECHO - see “hockey stick shape of anterior leaflet of mitral valve

EKG: atrial findings, including A-Fib

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11
Q

mitral stenosis - tx

A

often asymptomatic
- follow
if have A-Fib - treat A-Fib
- anti-coag

possibly valve repair or replacement

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12
Q

mitral regurgitation - progression

A

initially can see increased pre-load and reduced afterload

eventually, LV enlarges, weekend, and EF drops = left-sided heart failure

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13
Q

mitral regurgitation - sxs

A

gradually progressing dyspnea and fatigue over many years

Murmur: harsh, blowing, holo-systolic murmur best heard at apex radiating to left axilla

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14
Q

mitral regurgitation - dx

A

ECHO and TEE (trans-esophageal)

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15
Q

mitral regurgitation - tx

A

sxs manage: vasodilators, ACE-I

surgery for intolerable sxs or EF<60%

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16
Q

mitral valve prolapse (MVP) - sxs

A

common - found in thin, young females and goes away with age

usually, asymptomatic, but can present as young women with non-specific chest pain, dyspnea, fatigue, palpitations

Murmur:

  • mid-systolic click
  • murmur increases with standing or valsalva
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17
Q

mitral valve prolapse (MVP) - dx

A

clinically diagnosed; ECHO confirms

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18
Q

mitral valve prolapse (MVP) - tx

A

beta-blockers for hyperadrenergic state (young women)
SSRI

surgical repair is option, but not common

NOTE: no ABX prophylaxis needed

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19
Q

tricuspid stenosis - sxs

A

uncommon

rt-sided heart failure
- hepatomegaly, ascites, dependent edema

elevated JVP (giant a wave)

Murmur: diastolic, rumbling murmur

  • best heard at left, lower sternal border
  • increases with inspiration
  • use bell
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20
Q

tricuspid stenosis - dx and tx

A

ECHO - best

EKG: right-sided issues (rt atrial enlargement, rt ventricular hypertrophy)

Tx:

  • diuretics (tx right HF sxs)
  • bioprosthetic valve is tx of choice
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21
Q

tricuspid regurgitation - causes and sxs

A

iatrogenic: pacemaker lead placement

tricuspid valve prolapse, plaque, collagen inflammatory dz, tricuspid endocarditis

sxs: right-sided sxs (high JVP

Murmur: blowing, holosystolic

  • best heard at left, lower sternal border
  • increases with inspiration
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22
Q

tricuspid regurgitation - dx and tx

A

Dx: ECHO

Tx:

  • minor regurg = diuretics help
  • valve replacement if needed
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23
Q

pulmonic stenosis - sxs

A

frequently asymptomatic

  • gradual increase in dyspnea w/ exertion, CP, syncope
  • right-sided sxs: JVP

Murmur: harsh, loud, systolic murmur

  • best heard at 2nd/3rd left sternal border
  • DECREASES w/ inspiration
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24
Q

pulmonic stenosis - dx and tx

A

Dx: ECHO
- EKG: right sided problems

Tx:

  • tx predisposing conditions (rt sided HF)
  • valve replacement if needed
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25
pulmonary regurgitation - cause and sxs
causes: most are 2nd to pulmonary HTN - trivial amounts of PR can be normal variant Murmur: low-pitched, diastolic murmur - best heard at 3rd/4th left sternal border - loud, split S2 NOTE: if w/ pulmonary HTN, called a GRAHAM-STEELL murmur - increases w/ inspiration and diminished w/ valsalva
26
pulmonary regurgitation - dx and tx
Dx: ECHO Tx: - treat pulmonary HTN first - surgical replacement
27
management of prosthetic valves
ALL mechanical valves required anti-coagulation - Coumadin and/or ASA - INR maintained at 2-2.5 Note: - Stop Coumadin 3 days prior to elective surgery; re-start 24 hrs after - Heparin used as bridge therapy
28
stable angina / angina pectoris - definition and PE findings
chest pain that is: - precipitated by stress/exertion - relieved rapidly be rest/nitrates PE: - normal, non-specific - can find HTN, DM, hyperlipidemia, PAD
29
Tietze syndrome
inflammation at chondrocostal junction - mimics cardiac chest pain - tell apart by tenderness with chest palpation
30
cardiac markers
Proteins released by dead cardiac cells Troponins I and T - preferred - detect in 3-6 hrs; peak in 12-24 hrs; normalize in 2 weeks (so not good for 2nd MI) - prognostic value: higher levels = more injury CK-MB - detect in 4-6 hrs, peak 12-24 hrs, normalize in 2-3 days (so good for 2nd MI) - no prognostic value
31
stable angina - findings on EKG
many resting EKGs are normal Classic: - ST depression that resolves after pain subsides - T wave flattening or inversion - RARELY ST elevation due to coronary spasm (aka Prinzmetal's)
32
stable angina - most useful test in evaluation
exercise stress test Note: can also do pharmacological stress test - Meds: dobutamine, adenosine, dipyridamole - stimulate exercise and or vasodilator vessels Note: can also do nuclear stress test or stress ECHO
33
stable angina - definitive diagnosis
coronary angiogram - diagnoses CAD - is diagnostic and curative at same time since clogged vessels are opened up if found
34
stable angina - treatment
Nitroglycerin - sublingual in 1-2 min; also long-acting - decreases vascular tone, pre-load, after-load, and O2 demand - SE: H/A, nausea, dec. BP Revascularization / percutaneous coronary intervention (aka stent) - enter through vessel - note: need to be on anti-coag for at least 1 year Surgery (CABG) - used with multi-vessel dz - use artery or vein form other area
35
Prinzmetal (variant) angina
results from coronary artery vasospasm (w/ or w/o coronary disease - chest pain w/o usually precipitating factors (often 1st this in morning, F>M) - may be induced by cocaine - associated with arrhythmia - EKG: shows ST elevation
36
unstable angina - definition and EKG
chest pain that occurs: - at rest - not relieved by nitroglycerine Presents as unstable angina, ST-elevation (STEMI) or non ST-elevation - May be a myocardial infarction!! Results of CK-MG and Troponins help to determine if acute MI
37
acute STEMI - Treatment
1. immediate coronary angiography with PCI (percutaneous coronary intervention) 2. PTCA (balloon) and stenting - #1 today 3. CABG surgery using artery or vein from other area of body - in severe cases
38
congenital heart disease - adults
rare | Most live into adulthood
39
atrial septal defect (ASD)
most occur from patent foramen ovale Hx: - most asymptomatic with small/medium shunt - over 30 y/o w/ large shunt - dyspnea, CP - over 50 y/o w/ large shunt - atrial arrhythmia (A-Fib), rt. ventricular failure
40
loudness of murmurs
louder the shunt = smaller the opening - with stenosis = more severe - with ASD and VSD - less severe
41
atrial septal defect - murmur quality
systolic ejection murmur widely split and FIXED S2 (lub, d-dub) located at left 2nd/3rd interspace (aka pulmonic area)
42
atrial septal defect - EKG and CXR
EKG: RBBB, RAD, RVH CXR: dilated pulmonary arteries and increased vascularity - enlarged RA and RV (blog is shunting to right side)
43
ASD - dx, tx, and caution
Dx: ECHO Tx: - small shunts - observe - large shunts - surgical repair BEWARD: emboli leading to stroke/TIA
44
coarctation of aorta - definition
narrowing of aorta past great vessels - this is why carotid and UE pulses are normal and LE pulses are delayed Note: cause of 2nd HTN in young Note: bicuspid aortic valve in 50-80% of pts - inc. risk of cerebral berry aneurysm
45
coarctation of aorta - sxs and PE
usually asymptomatic until LV heart failure - may have HTN as young - may have CVA (due to emboli) PE: - absent femoral pulses - HTN in arms but normal or low in LE
46
coarctation of aorta - dx and prognosis
ECHO - diagnostic EKG: LVH CXR: - aortic shadow "3 sign" which is the notch that narrows aorta - notching of ribs due to inc. blood flow If have cardiac failure, prognosis is poor - surgery is curative - untreated adults die by 50 y/o (aortic rupture, CVA, aortic dissection)
47
patent ductus arteriosus (PDA) - definition
failure in closure of embryonic ductus resulting in persistent shunt connecting left pulmonary artery to aorta - PDA is treated in neonates w/ indomethacin - large shunts can cause pulmonary HTN (Eisenmenger's physiology)
48
patent ductus arteriosus (PDA) - sxs and PE
asymptomatic until develop HF or pulmonary HTN PE: - widened pulse pressure (low DPB) - harsh, continuous MACHINERY-like murmur at left 2nd ICS - large shunts = toes cyanotic or blue
49
tetralogy of fallot - classic features (4) and CXR
1. ventricular-septal defect 2. right ventricular hypertrophy 3. pulmonary stenosis 4. overriding/dilated aorta Note: right-sided aortic arch is common (25%) CXR: "boot shaped heart"
50
ventricular septal defect (VSD) - general info
most close in childhood results in L to R shunt presentation depends on size of shunt
51
ventricular septal defect (VSD) - sxs and PE
Sxs: usually asymptomatic, large shunts cause HF PE: - loud, harsh, holosystolic murmur along L sternal borner (3rd/4th ICS) - systolic thrill common (grades IV-VI) - cyanosis in late stages
52
abdominal aortic aneurysm (AAA) - general info
``` 90% original below renal arteries aortic diameter >3cm (normal=2cm) rarely rupture until >5cm most asymptomatic M:F = 4:1 ```
53
AAA - sxs
often found incidentally since anymptomatic - pulsatile mass palpable on PE - associated with LE occlusive disease of vessels Rupture: severe abd/low back pain, pulsatile mass, hypotension
54
AAA - dx and tx
abdominal U/S Tx: - beta-blocker if monitoring - surgical correction if healthy
55
aortic dissection - definition and risks
CATASTROPHE!! - 90% mortality and 3 months intimal tear creates a false lumen b/t media and adventitia occurs in thoracic aortic (higher than AAA) - types A and B Risks: HTN (80%), Marfan's pregnancy, bicuspid aortic valve
56
aortic dissection - sxs
sudden, excruciating ripping pain in chest or upper back - HTN at presentation - peripheral pulses and BP diminished or unequal
57
aortic dissection - dx
CT (abd/chest) is best study CXR: widened mediastinum
58
aortic dissection - tx
STAT: - BP control - beta blockade (labetalol) to reduce LV EF - IV Nitroprusside to lower BR - Pain relief with morphine - SURGERY
59
3 ways an artery can be blocked - emboli, thrombi, trauma | - what at 3 areas on PE
thrombi: clot forms at location due to damage emboli: traveling clot - most arise from heart (e.g. A-fib) trauma: injury PE: - circulation (pulses), motor, sensory
60
acute ischemia - 6 "P's"
blockage due to arterial clot in periphery ``` pain paresthesias (early) pallor pulselessness poikilothermia (varying temps) paralysis ```
61
arterial embolism/thrombosis - dx
doppler (U/S): of affected area will show distal to blockage little to no blood flow
62
arterial embolism - tx and complications
heparin IV t-PA via catheter (thin blood) emergent embolectomy via balloon catheter Complications: - metabolic acidosis, hyper K+, cardiac arrest - foot drop (loss of motor fx) - compartment syndrome (excrutiating pain)
63
arterial thrombosis - causes and risk factors
commonly from chronic, atherosclerotic occlusive disease | - smoking, polycythemia, dehydration, hyper coagulable states
64
arterial thrombosis - sxs
intermittent claudication (severe, cramp-like pain w/ exercise); absent or weak distal pulses
65
arterial thrombosis - dx
ankle-brachial index (ABI): compares BP in ankle and arm - <0.9 positive CT/MR angiogram prior to surgery to determine location
66
arterial thrombosis - tx
mild: - reduce risk factors (smoking) - cilostazol (anti-platelet drug) - endovascular repairs (angioplasty and stents) - surgical interventions (bypass grafts) - thromboendarterectomy: remove plaque (common in femoral artery)
67
arterail occlusion (carotid) - sxs, dx, tx
carotid stenosis = 25% strokes - TIA: complete resolution of sxs in <24hrs - CVA: no resolution of sxs in 24 hrs sxs: sudden weakness, aphasia, vision loss dx: U/S, MRA/CTA tx: - medical (small occlusion): ASA and clopidogrel - surgical: heparin and CEA (remove occlusion from carotid) or angioplasty/stenting via percutaneous route
68
carotid artery dissection - classic triad and tx
1. CVA or TIA 2. Unilateral neck pain or severe H/A 3. Horner's syndrome (miosis - pinpoint pupils; ptosis - drooping eyelid) Tx: drug therapy (Coumadin) then surgery
69
arterial occlusions - common sites, imagine and treatment
Sites: - intestinal ischemia (chronic or acute) - ischemic colitis - renal artery stenosis (2ndary cause of HTN) - acute UE limb ischemia - mesenteric vascular insufficiency Imaging: CTA or MRA Treatment: vessels bypass, angioplasty, stenting
70
peripheral arterial disease (PAD) - definition and risks
chronic condition; lower extremities effected by atherosclerotic disease Risks: male, age, DM, HTN, smoking highly associated with CVA and CAD (plaques can be everywhere)
71
PAD treatment
identify and control risk factors: exercise, smoking cessation, lipid lowering Cilostazol or ASA endovascular techniques - bypass grafts - amputation when no longer circulation
72
giant cell (temporal) arteritis and polymyalgia rheumatica - general info
same disease in different locations - affects medium and large vessels GCA: affects above the neck (temporal artery) PMR: affects below the neck Age > 50 (mean = 79 y/o)
73
giant cell (temporal) arteritis - sxs
H/A, jaw claudication (pain with chewing), scalp tenderness, visual sxs - BLINDNESS may result if ophthalmic artery affected NOTE: elderly with fever and normal white count
74
giant cell (temporal) arteritis - dx and tx
ESR is high (> 50) dx: biopsy of temporal artery Tx: urgent prednisone (60mg/day x 1 mo w/ taper) - to prevent blindness
75
polymyalgia rheumatica - sxs
pain and stiffness of shoulders/pelvis fever, malaise, weight loss Labs: anemia, elevated ESR Tx: Prednisone (10-20mg) - if no improvement in 72 hours, reconsider dx
76
phlebitis / thrombophlebitis - general information
inflammation of superficial veins (long saphenous in LE most common) - due to IVs and PICC lines Risks: varicosity, pregnancy or postpartum, trauma - associated with occult DVT in 20% cases
77
phlebitis / thrombophlebitis - sxs
dull pain, redness and tenderness in linear distribution (vs. cellulitis which would be round) - NO edema (since not deep vein) chills and fever suggest septic cause (IV)
78
phlebitis / thrombophlebitis - tx
NSAIDs, heat, elevation (7-10 days) - encourage ambulation - vein excision if complications - septic causes (S. aureus) require heparin and ABX (vancomycin)
79
deep vein thrombophlebitis (DVT) - general info and risks
virchow triad: stasis, vascular injury, hypercoagulability Risks: CHF, recent surgery or trauma, neoplasia, OC use (estrogen), sedentary, clotting abnormalities (factor V Leiden, protein C or S dsyfxn) Complication: Pulmonary Embolism
80
Virchow's triad
For DVT: 1. stasis 2. vascular injury 3. hypercoagulability
81
deep vein thrombophlebitis (DVT) - sxs
heavy legs, dull ache, tightness, calf/leg pain with walking Slight edema Homan's sign: only 50% positive
82
deep vein thrombophlebitis (DVT) - dx and prevention
Venous U/S: diagnostic! Prevention: - early ambulation, compression stockings, foot board - prophylax with anti-coagulation: LMWheparin, warfarin, vena cava filter
83
chronic venous insufficiency - sxs
chronic elevation in venous pressure - history of phlebitis, DVT, leg injury - ankle edema early sign - late signs: itching, brawny stasis, pigmentation, dermatitis, varicosities, ulceration (painless)
84
chronic venous insufficiency - tx
leg elevation, compression stockings, exercises | - care for ulcerations and wounds (wet compresses, ABX)
85
varicose veins - general info
dilated, tortuous superficial veins in lE - incompetent venous valves - can be unilateral Risk factors: female, pregnant, FH, h/o phlebitis - greater saphenous vein most common
86
varicose veins - sxs and tx
dull, achy, heaviness, fatigue in LE tx: stockings, exercise, elevate legs - surgery
87
rheumatic fever
disease that can occur post GAS infection JONES criteria (5 major): - migratory polyarthritis - carditis - Sydenham's chora - subcutaneous nodules - erythema marginatum Minor: - fever - arthralgia - acute phase reactants: CPR, ESR, leukocytosis - prolonged PR interval
88
LDL goals
<160: no risk factors <130: 2 risk factors (smoke, HTN, age over 45 (M) and 55 (F), FH) <100: DM and CAD
89
CHADS2VASC
used to estimate risk of stroke in patients with A-Fib ``` female: 1 CHF: 1 HTN: 1 Prior stroke, TIA, systemic embolism: 1 Vascular dz (CAD, MI, PAD): 1 Age > 75: 2 Age 65-74: 1 ```
90
endocarditis - causative organisms
Strep Viridans: most common overall Strep Bovi: common in cancer Staph epidermitisl: common in prosthetic valves Staph aureas: common in IV drug use HACEK: associated with endocarditis and neg blood cultures Note: HACEK = haemophilus, asctinobaccillus, cardiobacterium, eikenella, kingella