Cardiology part 3 Flashcards
VSD
x
PE
x
what type of murmur would you hear?
holosystolic murmur with maximal intensity over the left third and fourth intercostal spaces, accompanied by a palpable thrill
pathophys
x
why do you see a step up in oxygen saturation in VSD?
left to right shunt allows for mixiing of oxygenated blood from the left ventricle with deoxygengated blood in the right ventricle
Coarctation of the aorta
x
PE
x
what type of exam findings are classic?
delay in brachial to femoral pulse
PDA
x
PE
x
what type of exam findings are seen with Patent Ductus Arteriosus?
continuous murmur heart best in the left infraclavicular area
Acute Right Ventricular MI (RVMI)
x
Dx
x
what does EKG show for RVMI?
ST elevation in leads II, III, aVF
Syx
x
what are teh symptoms of RVMI?
hypotension, shock, JVD, CTAB, lightheadedness, dizziness, diaphoretic and extremities cold
management
x
what is the management of RVMI?
-similar to acute MI with dual antiplatelets, statins, anticoag therapy, use beta blockers (slow HR) adn CCB(decrease contractility) with caution -Emergent reperfusion with thrombolytics or primary percutaneous coronary intervention if indicated (Id
what drugs should be avoided in RVMI? why?
avoid preload lowering drugs like nitrates, diuretics, and opioids
what should patients with hypotension and normal or low JVD be treated with ?
IV fluids (facilitates preload and LV filling)
what is the intial ionotropic agent used in persistent hypotension from RVMI?
dopamine (dobutamine at higher doses can decrease peripheral vascular resistance at higher doses and worsen hypotension)
Diagnostic Evaluation of Suspected Stable CAD
x
syx
x
for patients >80 y.o. , what are the symptoms that they can present that are anginal other than chest pain?
SOB, lightheadedness, fatigue
algorithm
x
first part to algorithm?
you start with symptoms(CP with exertion, dyspnea on exertion, etc) and risk factors (DM, Smoking, HTN) suggest stable CAD
next step after you start with symptoms and risk factors suggest stable CAD, is to do what?
determine if person is able to excercise or unable to excercise
if able to excercise, then what test do you do?
excercise EKG / stress testing
if unable to excercise , then what test do you do?
pharmacologic stress testing (dobutamine stress echo, myocardial perfusion imaging)
if either stress test is negative, what do you do?
no significant CAD, goal is risk factor reduction
if either stress test is positive, what do you do?
CAD present, medical management +/- Coronary Angiography (high risk patients) with revascularization via stent or CABG
if a patient has a negative stress test (exertion >=85% of max HR) with no significant EKG changes, what does that denote?
<1 % risk of cardiovascular event within the next year
In patients with known CAD excercise or pharmacological stress testing with radionuclide myocardial perfusion imaging (thallium or technetium-99m) is useful for confirming the the dx. What are the meds given for stress testing?
adenosine and dipyridamole, act by producing coronary vasodilation and increasing the coronary flow rate and velocity. In normal coronary vessels the resulting vasodilation increases blood flow, however in areas of severe stenosis there is already compensatory microvascular dilation at rest to maintain normal blood flow, so no further flow occurs and that flow defect is detected by radionuclide imaging studies.
trx
x
what is trx for stable CAD?
medical therapy: aspirin, high rade intensity statin (eg atorvastatin, rosuvastatin), and a beta blocker optimize cardiovascular risk factors (smoking cessation, BP control, glucose control)
factors to consider with excercise stress testing that lead to increased risk of adverse cardiovascular events
x
what clinical variables are assoicated with increased risk of adverse cardiovascular events?
-poor excercise capacity -excercise induced angina at low workload -fall in systolic blood pressure from baseline -chronotropic incompetence
what EKG variables are available associated with increased risk of adverse cardiovascular events?
- >1mm ST depression(flat or downsloping) -ST depression at low workload -ST elevation in leads without Q waves -ventricular arrythmias
Coronary Vessel Localization to Ventricle Defect on Perfusion imaging
x
if the perfusion defect is in the lateral wall of the left ventricle, which artery is the culprit?
LCx artery (which runs laterally in the left atrioventricular groove to supply the lateral and posterolateral parts of the left ventricle)
if the perfusion defect is in the anterior wall of the left ventricle, which artery is the culprit?
LAD ( which runs along the anterior interventricular groove and supplies the anterior wall fo the left ventricle)
if the perfusion defect is in the inferoposterior walls of the left ventricle and right ventricle, which artery is the culprit?
RCA (which runs in the right AV groove)
Acute Chest Pain (Angina)
x
dx
x
the absence of what features helps rule out ACS?
-A normal EKG rules out STEMI -Negative serial trop levels rule out non-STEMI -absence of extertional CP that gradually worsens over a period of months (crescendo angina), associated symptoms (eg dyspnea, diaphoresis), and EKG abnormalities suggesting i
what is an appropriate test for assessing risk of CAD in stable angina?
stress EKG (pharmacological with adenosine MPI or dobutamine echo if unable to excercise)
risk
x
what are risk factors for CAD?
age, male sex, fam hx of CAD
define
x
classic angina is defined as:
-typical location (eg substernal), quality and duration -provoked by excercise or emotional stress -relieved by rest or nitroglycerin
atypical angina is defined as :
2 of the 3 characteristics of classic angina
non anginal CP is defined as :
<2 of the 3 characterisitcs of classic angina
Acute Limb Ischemia (ALI)
x
definition
x
what is the definition of ALI?
sudden decrease in limb perfusion and is most often caused by acute arterial occlusion due to systemic embolism from a cardiac source (eg Afib, LV thrombus, or septic emboli from infective endocarditis)
syx
x
what are the classic 6 syx of acute ischemia?
6P’s: pain, pallor, paresthesia, pulselessness, poikilothermia, and paralysis
trx
x
all patients with clinical signs and syx of ALI should receive what?
anticoag (IV heparin bolus followed by continuous heparin infusion)
patients with an immediately threatened extremity are at increased risk for what irreversible mynoecrosis within how many hours?
4-6 hours, should have emergency surgical revascularization
clinical features of acute limb ischemia
x
viable limb
x
in viable limb (no tissue loss), do you have pain?
mild
in viable limb (no tissue loss), do you have sensory/motor deficit?
none
in viable limb (no tissue loss), do you have intact cap refill?
intact
in viable limb (no tissue loss), do you have arterial dopplers?
audible
in viable limb (no tissue loss), do you have venous dopplers?
audible
in viable limb (no tissue loss), what is the management?
catheter-based or surgical revascularization
imaging choice for viable limb?
duplex U/S, CT angio , MR-A
threatened limb (risk of tissue loss)
x
in threatened limb (risk of tissue loss), do you have pain?
severe
in threatened limb (risk of tissue loss), do you have sensory/motor deficit?
mild/partial
in threatened limb (risk of tissue loss), do you have intact cap refill?
dealyed
in threatened limb (risk of tissue loss), do you have arterial dopplers?
inaudible
in threatened limb (risk of tissue loss), do you have venous dopplers?
audible
in threatened limb (risk of tissue loss), what is the management?
emergency surgical revascularization
nonviable limb (permanent tissue damage)
x
in nonviable limb (permanent tissue damage), do you have pain?
variable
in threatened limb (permanent tissue damage), do you have sensory/motor deficit?
severe/complete
in threatened limb (permanent tissue damage), do you have intact cap refill?
absent
in threatened limb (permanent tissue damage), do you have arterial dopplers?
inaudible
in threatened limb (permanent tissue damage), do you have venous dopplers?
inaudible
in threatened limb (permanent tissue damage), what is the management?
amputation
Prior Myocardial Infarction (MI)
x
dx
x
what does EKG show for prior MI?
Q waves and Twave inversions in contiguous leads (i.e. II, III, aVF)
what are other EKG findings of previous anterior MI?
deep Q waves in leads V1-V4 typicallly indicate previous anterior MI
syx
x
what are the symptoms of prior MI?
new excercise intolerance and SOB due to subsequent left ventricular systolic dysfunction
trx
x
what are appropriate secondary preventions of CAD?
beta blocker, high intensity statin, anti platelet therapy, ACEi or ARB
ICD therapy placements (indications for implantable cardioverter defibrillator placement)
x
indications for placement to prevent SCD
x
what are primary indications for implantable cardioverter-defibrillator placement to prevent SCD?
-prior MI and LVEF <=30% -NYHA class II or III syx and LVEF <=35%
what are secondary indications for implantable cardioverter-defibrillator placement to prevent SCD?
-prior VF or unstable VT without reversible cause -prior sustained VT with underlying cardiomyopathy
indications for ICD placement in HCM patients
x
what are pirmary indications for ICD for HCM?
-family hx of SCD -Syncope(recurrent and/or associated with exertion) -nonsustained VT on Holter Monitoring -Hypotensive blood pressure response to excercise -extreme LVH (>3cm maximum septal wall thickness)
what are secondary indications for ICD for HCM?
-survivors of cardiac arrest -sustained spontaneous ventricular arrythmias
indications for biventricular pacing in sinus rhythm
x
criteria for biventricular pacing
x
what is the criteria for biventricular pacing in sinus rhythm?
-LVEF <35% -NYHA class II, III, or IV heart failure symptoms (essentaily the presence of any symptoms) -LBBB with QRS >150ms
