Cardiology II Flashcards
cardiac valvular disease - causes and dx
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!!
mitral valve prolapse - what do you hear on auscultation
midsystolic click
aortic stenosis - sxs
dyspnea, angina, syncope w/ exertion
- LV failure and hypertrophy (displaced PMI)
Murmur: systolic ejection murmur, harsh and loud
- have pt lean forward
aortic stenosis - dx
doppler ECHO (test of choice)
EKG: LVH
CXR: cardiomegaly, calcified valve
aortic stenosis - tx
valve replacement has great results
- must do if following triad of HF, angina, or syncope
aortic regurgitation - sxs and cause
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
aortic regurgitation - dx
ECHO - test of choice
EKG and CXR: LVH
aortic regurgitation - tx
acute regurg (following invasive endocarditis) - immediate surgery
chronic regurg:
- ARBs and ACE-I reduce sxs
- valve replacement eventually
mitral stenosis - sxs
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)
mitral stenosis - dx
ECHO - see “hockey stick shape of anterior leaflet of mitral valve
EKG: atrial findings, including A-Fib
mitral stenosis - tx
often asymptomatic
- follow
if have A-Fib - treat A-Fib
- anti-coag
possibly valve repair or replacement
mitral regurgitation - progression
initially can see increased pre-load and reduced afterload
eventually, LV enlarges, weekend, and EF drops = left-sided heart failure
mitral regurgitation - sxs
gradually progressing dyspnea and fatigue over many years
Murmur: harsh, blowing, holo-systolic murmur best heard at apex radiating to left axilla
mitral regurgitation - dx
ECHO and TEE (trans-esophageal)
mitral regurgitation - tx
sxs manage: vasodilators, ACE-I
surgery for intolerable sxs or EF<60%
mitral valve prolapse (MVP) - sxs
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
mitral valve prolapse (MVP) - dx
clinically diagnosed; ECHO confirms
mitral valve prolapse (MVP) - tx
beta-blockers for hyperadrenergic state (young women)
SSRI
surgical repair is option, but not common
NOTE: no ABX prophylaxis needed
tricuspid stenosis - sxs
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
tricuspid stenosis - dx and tx
ECHO - best
EKG: right-sided issues (rt atrial enlargement, rt ventricular hypertrophy)
Tx:
- diuretics (tx right HF sxs)
- bioprosthetic valve is tx of choice
tricuspid regurgitation - causes and sxs
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
tricuspid regurgitation - dx and tx
Dx: ECHO
Tx:
- minor regurg = diuretics help
- valve replacement if needed
pulmonic stenosis - sxs
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
pulmonic stenosis - dx and tx
Dx: ECHO
- EKG: right sided problems
Tx:
- tx predisposing conditions (rt sided HF)
- valve replacement if needed
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
pulmonary regurgitation - dx and tx
Dx: ECHO
Tx:
- treat pulmonary HTN first
- surgical replacement
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
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
Tietze syndrome
inflammation at chondrocostal junction
- mimics cardiac chest pain
- tell apart by tenderness with chest palpation
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
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)
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
stable angina - definitive diagnosis
coronary angiogram
- diagnoses CAD
- is diagnostic and curative at same time since clogged vessels are opened up if found
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
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
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
acute STEMI - Treatment
- immediate coronary angiography with PCI (percutaneous coronary intervention)
- PTCA (balloon) and stenting
- #1 today - CABG surgery using artery or vein from other area of body
- in severe cases
congenital heart disease - adults
rare
Most live into adulthood
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
loudness of murmurs
louder the shunt = smaller the opening
- with stenosis = more severe
- with ASD and VSD - less severe
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)
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)
ASD - dx, tx, and caution
Dx: ECHO
Tx:
- small shunts - observe
- large shunts - surgical repair
BEWARD: emboli leading to stroke/TIA
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
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
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)
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)
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
tetralogy of fallot - classic features (4) and CXR
- ventricular-septal defect
- right ventricular hypertrophy
- pulmonary stenosis
- overriding/dilated aorta
Note: right-sided aortic arch is common (25%)
CXR: “boot shaped heart”
ventricular septal defect (VSD) - general info
most close in childhood
results in L to R shunt
presentation depends on size of shunt
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
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
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
AAA - dx and tx
abdominal U/S
Tx:
- beta-blocker if monitoring
- surgical correction if healthy
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
aortic dissection - sxs
sudden, excruciating ripping pain in chest or upper back
- HTN at presentation
- peripheral pulses and BP diminished or unequal
aortic dissection - dx
CT (abd/chest) is best study
CXR: widened mediastinum
aortic dissection - tx
STAT:
- BP control
- beta blockade (labetalol) to reduce LV EF
- IV Nitroprusside to lower BR
- Pain relief with morphine
- SURGERY
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
acute ischemia - 6 “P’s”
blockage due to arterial clot in periphery
pain paresthesias (early) pallor pulselessness poikilothermia (varying temps) paralysis
arterial embolism/thrombosis - dx
doppler (U/S): of affected area will show distal to blockage little to no blood flow
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)
arterial thrombosis - causes and risk factors
commonly from chronic, atherosclerotic occlusive disease
- smoking, polycythemia, dehydration, hyper coagulable states
arterial thrombosis - sxs
intermittent claudication (severe, cramp-like pain w/ exercise); absent or weak distal pulses
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
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)
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
carotid artery dissection - classic triad and tx
- CVA or TIA
- Unilateral neck pain or severe H/A
- Horner’s syndrome (miosis - pinpoint pupils; ptosis - drooping eyelid)
Tx: drug therapy (Coumadin) then surgery
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
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)
PAD treatment
identify and control risk factors: exercise, smoking cessation, lipid lowering
Cilostazol or ASA
endovascular techniques
- bypass grafts
- amputation when no longer circulation
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)
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
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
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
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
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)
phlebitis / thrombophlebitis - tx
NSAIDs, heat, elevation (7-10 days)
- encourage ambulation
- vein excision if complications
- septic causes (S. aureus) require heparin and ABX (vancomycin)
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
Virchow’s triad
For DVT:
- stasis
- vascular injury
- hypercoagulability
deep vein thrombophlebitis (DVT) - sxs
heavy legs, dull ache, tightness, calf/leg pain with walking
Slight edema
Homan’s sign: only 50% positive
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
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)
chronic venous insufficiency - tx
leg elevation, compression stockings, exercises
- care for ulcerations and wounds (wet compresses, ABX)
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
varicose veins - sxs and tx
dull, achy, heaviness, fatigue in LE
tx: stockings, exercise, elevate legs
- surgery
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
LDL goals
<160: no risk factors
<130: 2 risk factors (smoke, HTN, age over 45 (M) and 55 (F), FH)
<100: DM and CAD
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
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
