Cardiololgy Flashcards
1
Q
Signs and Symptoms of Chronic Heart Failure:
A
- *Symptoms of Left-Sided Heart Failure**
1. Dyspnea: difficulty breathing secondary to pulmonary congestion/edema
2. Orthopnea: difficulty breathing in the recumbent position; relieved by elevation of the head with pillows
3. Paroxysmal nocturnal dyspnea (PND): awakening after 1 to 2 hours of sleep due to acute shortness of breath (SOB)
4. Nocturnal cough (nonproductive): worse in recumbent position (same pathophysiology as orthopnea)
5. Confusion and memory impairment occur in advanced CHF as a result of inadequate brain perfusion.
6. Diaphoresis and cool extremities at rest: occur in desperately ill patients (NYHA class IV) - *Symptoms/Signs of Right-Sided Heart Failure**
1. Peripheral pitting edema: pedal edema lacks specificity as an isolated finding. In the elderly, it is more likely to be secondary to venous insufficiency.
2. Nocturia: due to increased venous return with elevation of legs
3. Jugular venous distention (JVD)
4. Hepatomegaly/hepatojugular reflux
5. Ascites
6. Right ventricular heave
2
Q
Signs of Left-Sided Heart Failure:
A
- Displaced apex beat: also called PMI: it is displaced to the left due to cardiomegaly
- Pathologic S3: ventricular gallop;
a. Rapid filling phase “into” a noncompliant left ventricular chamber
b. May be normal finding in children; in adults, usually associated with CHF
c. May be difficult to hear, but is among the most specific signs of CHF
d. Heard best at apex with bell of stethoscope
e. The sequence in the cardiac cycle for S3: S3 follows S2 (ken-tuck-Y) - S4 gallop:
a. It is the sound of atrial systole as blood is ejected into a noncompliant, or stiff, left ventricular chamber
b. Heard best at left sternal border with bell of stethoscope
c. The sequence in the cardiac cycle for S4: S4 precedes S1 (TEN-nes-see) - Crackles/rales at lung bases:
a. Caused by fluid spilling into alveoli; indicates pulmonary edema
b. Rales heard over lung bases suggest at least moderate severity of left ventricular heart failure - Dullness to percussion and decreased tactile fremitus of lower lung fields caused by pleural effusion
- Increased intensity of pulmonic component of second heart sound indicates pulmonary HTN (heard over left upper sternal border).
3
Q
Treatment of Chronic Heart Failure, Beyond Drugs:
A
- Conservative
2. Procedural Interventions
4
Q
Treatment of Chronic Heart Failure, Beyond Drugs - Conservative:
A
- Symptomatic measures: oxygen in hospital, bedrest, elevate the head of bed
- Lifestyle measures:
a. Diet
b. Exercise: avoid heavy lifting and avoid temperature extreme
c. DM control
d. Smoking cessation
e. Decrease alcohol consumption
f. Patient education: daily weight
g. Sodium (2 grams/day) and fluid restriction: no salt substitutes
5
Q
Treatment of Chronic Heart Failure, Beyond Drugs - Procedural Interventions:
A
- Cardiac resynchronization therapy (CRT): symptomatic improvement with biventricular pacemaker
- ICD: mortality benefit in 1 o prevention of sudden cardiac death
- LVAD/RVAD
- Cardiac transplantation
6
Q
Treatment of Pulmonary Edema - Primary:
A
- Treat precipitating factors
- Furosemide: 40-500 mg IV
- Morphine: 2-4 mg IV- decreases anxiety and preload (venodilation)
- Nitroglycerin: topical /IV/SL
- Oxygen
- Positive airway pressure (CPAP/BiPAP): decreases preload and need for ventilation
- Position: sit patient up with legs hanging down unless patient is hypotensive
7
Q
Treatment of Pulmonary Edema - In ICU setting or failure the interventions above, try:
A
- Nitroprusside IV
- Hydralazine PO
- Sympathomimetics
- Dopamine
8
Q
Treatment of Pulmonary Edema - Others:
A
- Consider pulmonary artery catheter to monitor pulmonary capillary wedge pressure (PCWP) if patient is unstable or a cardiac etiology is uncertain (PCWP > 18 indicates likely cardiac etiology)
- Mechanical ventilation as needed
- Rarely used, but potentially life-saving measures:
a. Intra-aortic balloon pump (IABP)
b. Left or right ventricular assist device (LVAD/RVAD)
c. Cardiac transplant
9
Q
Non-modifiable risk factors of Coronary Artery Disease:
A
- Age
- Male (earlier), postmenopausal female
- Family history (FHx) of MI:
- First degree male relative <55
- First degree female relative < 65
10
Q
Modifiable risk factors of Coronary Artery Disease:
A
- Hyperlipidemia: ↑LDL; but also ↓HDL, hypercholesterolemia, cholesterol, hypertriglyceridemia
- Hypertension (HTN): increases at BP above 110/75 mm Hg. Systolic BP is as important as diastolic BP in terms of risk for ischemic heart disease, especially in older patients. Isolated HTN is now considered a major risk factor in coronary events.
- Diabetes mellitus (DM): considered an “IHD equivalent.” even when glucose levels are under control, diabetes greatly increases the risk of IHD. Almost 75% of patients with diabetes die of some form of cardiovascular disease.
- Cigarette smoking: 2x; risk in cigarette smokers’> cigars or pipes; secondhand smoke or passive smoking
- Metabolic syndrome (X):
- Obesity: especially if a lot is in the waist area
- Sedentary lifestyle
- Heavy alcohol intake
11
Q
Markers of Disease - risk factors of Coronary Artery Disease:
A
- Elevated lipoprotein (a)
- Hyperhomocysteinemia
- Elevated high-sensitivity C-reactive protein (hsCRP)
- Coronary artery calcification
- Fibrinogen
12
Q
Minor risk factors (less clear significance) of Coronary Artery Disease:
A
- obesity
- sedentary lifestyle (lack of physical activity)
- stress
- excess alcohol use
13
Q
Primary Prevention of Cardiovascular Diseases:
A
- healthy diet
- Smoking cessation
- Hypertension control
- Dyslipidemia control
- Physical activity
- Weight loss
- Glycemic control in diabetes
- Aspirin
- Alcohol (small amounts)
- The Framingham risk score
14
Q
The Framingham risk score:
A
is a gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual (10-year Risk):
- age
- gender
- total cholesterol
- HDL cholesterol
- smoker
- systolic blood pressure
15
Q
Ischemic Heart Disease - def:
A
IHD refers to an imbalance in coronary oxygen demand and supply resulting from insufficient blood flow.
