Cardiovascular Flashcards by Alice Richards

classification of bacterial endocarditis

acute
subacute

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25 yo F w. hx IVDU - previous tx for osteomyelitis - febrile with new systolic murmur best heart at left sternal border

bacterial endocarditis

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what valve do you think of w. bacterial endocarditis:
IVDU
non IVDU

IVDU: tricuspid
non IVDU: mitral

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pathogen associated w. acute bacterial endocarditis and drug users:

pathogen associated w. subacute bacterial endocarditis:

acute/IVDU: staph aureus
subacute: strep viridans

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duke’s criteria

2 major
1 major, 3 minor
5 minor

major:
cultures x 2
positive echo findings
new regurgitant murmur

minor:
risk factor
fever 100.5
immunologic signs
positive culture x 1
positive echo not meeting major criteria

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vascular phenomena associated w. bacterial endocarditis

splinter hemorrhages
janeway lesions

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immunologic phenomena associated w. bacterial endocarditis

osler node
roth spots

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what does from jane stand for

classic signs of endocarditis:

fever
roth spots
osler nodes
murmur
janeway lesions
anemia
nail bed hemorrhage
emboli

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what are these

osler nodes: ouchy nodules

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what are these

janeway lesions: painless macules

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what are these

splinter hemorrhages

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what are these

roth spots

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tx for bacterial endocarditis

empiric:
prosthetic valve:

empiric: IV vanco OR ampicillin/sulbactam PLUS aminoglycoside

prosthetic valve: add rifampin

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prophylactic tx for bacterial endocarditis for high risk pt’s pre procedure

amoxicillin

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what is this showing

clubbing

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chest pain/discomfort/heaviness/ pressure/squeezing/tightness that is increased w. exertion or emotion

stable angina

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stable angina is relieved w.

rest
nitro

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stress test findings of stable angina

-reversible wall motion abnormalities
-ST depressions > 1mm

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definitive dx for angina

angiography

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tx for angina

bb
nitro
angioplasty
bypass

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previously stable/predictable sx of angina that become more frequent/intense/present at rest

unstable angina

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tx for unstable angina

-IV, O2 monitor
-nitro, morphine
-ASA, bb +/- LMWH
-stress test when stable

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4 rf for angina

smoking
overweight/obese
DM
HTN

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coronary artery vasospasms NOT associated w. clot

prinzmetal variant angina

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#1 rf for prinzmetal angina

**1. smoking** also cocaine

3 EKG findings of prinzmetal angina

U waves ST elevation T wave abnormalities

t/f: prinzmetal angina is associated w. preservation of exercise capacity

tx for acute prinzmetal angina

-stress test w. myocardial perfusion imaging or CTA -nitro -ASA, statins, thrombolytics

tx for chronic prinzmetal angina

amlodipine long acting nitrates

what med is contraindicated for prinzmetal angina bc it may exacerbate vasospasms

2 common complaints w. arrhythmias

SOB CP

atrial arrhythmias

PAC a fib a flutter PSVT: accessory pathway vs AVNR

extra beats from the atria

PAC

upper atrial chambers beat out of rhythm **multiple atria foci**

a fib

atria w. a single foci having **multiple p waves before a QRS**

a flutter

regular, fast arrhythmia btw 160-220 bpm begins/ends suddently originates in atria

PSVT

additional electrical conduction pathway btw 2 parts of the heart

PSVT: accessory pathway tacycardia

mc type of accessory pathway tachycardia

WPW

2 EKG findings associated w. WPW

shortened PR interval < .20 delta wave

mc type of PSVT

AVNR (AV nodal reentrant) tachy

HR associated w. AVNR

100-250 bpm

EKG finding of AVNR

late p waves that may be hidden w.in QRS

ventricular arrhythmias

PVCs v tach v fib

early, wide, bizarre QRS no p wave

PVCs

regular, fast, wide QRS structural heart disease increased risk of sudden death

v tach

-quivering ventricles that do not contract in a coordinated way -erratic rhythm w. no discernable waves

v fib

tx for narrow, tachy arrhythmias

rate control: adenosine bb ccb procainamide cardoversion

tx for wide, tachy arrhythmias

amiodarone cardioversion

45 yo M presents after MVA - conscious, responsive; chest wall ecchymosis, symmetrical breath sounds; unremarkable cardiac/abd exams - several broken ribs -placed on IV/O2/monitor - 2 hr later: tachy, hypotensive, elevated JVP, distant heart sounds, cool extremities, delayed cap refill

cardiac tamponade

buildup of fluid btw pericardial sac and the heart -> heart constricted

cardiac tamponade

classification of cardiac tamponade

acute slow onset

causes of acute onset cardiac tamponade: causes of slow onset cardiac tamponade:

acute: trauma, MI, aortic dissection, pericardial effusion slow onset: cancer, chronic inflammation, uremic pericarditis, hypothyroidism, connective tissue dz

3 d's of cardiac tamponade

distant heart sounds distended jugular veins decreased arterial pressure

beck's triad

hypotn muffled heart sounds elevated JVD

classic PE finding associated w. tamponade

pulsus paradoxus: drop 10 mmHg in SBP on inspiration narrow pulse pressure

EKG finding associated w. tamponade

electrical alternans: low voltage QRS's that alternate in height

what is this showing

water bottle/canteen shaped heart -> tamponade

tx for tamponade

pericardiocentesis

5 causes of acute CP

pericarditis ACS pulmonary embolism pneumothorax thoracic aneurysm/dissection

pericarditis is relieved by

sitting leaning forward

mc symptom of PE

dyspnea

best initial test for PE

spiral CT

3 PE findings of PTX

decreased tactile fremitus hyperresonance diminished breath sounds

severe, tearing, ripping, knife-like CP radiating to the back

thoracic aneurysm/dissection

typical work up for acute CP

ekg troponin bnp cxr cbc/cmp

ESR is helpful in evaluating what cause of acute CP

pericarditis

imaging for thoracic aneurysm

CT aortogram

what are the 7 conduction disorders

a fib a flutter SVT BBB v tach vfib premature beats

irregularly irregular rhythm with disorganized and irregular atrial activations, absence of p waves

a fib

regular, sawtooth pattern narrow QRS

a flutter

narrow complex tachycardia no discernible p waves

SVT

3 or more consecutive VPB's wide QRS tachyarrhythmia

v tach

erratic rhythm no discernable waves

v fib

3 types of premature beats

PVC PAC PJC

early wide bizarre QRS no p waves

PVC

abnormally shaped P wave

PAC

narrow QRS no p wave or inverted p wave

PJC

R R' in V4-V6

LBBB

R R' in V1-V3

RBBB

what is this showing

afib

what is this showing

a flutter

what is this showing

SVT

what is this showing

v tach

what is this showing

v fib

what is this showing

PVC

what is this showing

PAC

what are these showing

PJC

what is this showing

LBBB

what is this showing

RBBB

3 types of coronary heart dz

NSTEMI STEMI angina

troponin/CK elevation in the absence of acute ST elevation or Q waves

NSTEMI

NSTEMI's are _ infarcts

subendocardial *coronary artery not completely blocked*

what EKG findings may be present with an NSTEMI

ST depression T wave inversion

3 cardiac markers useful in evaluation of NSTEMI

troponin CK/CK-MB myoglobin (Mb)

most sensitive and specific cardiac marker

troponin

troponin appears at _ hr peaks at _ hr and lasts for _ days

appears: 2-4 hr peaks: 12-24 hr lasts: 7-10 days

CK/CK-MB appears at _ hr peaks at _ hr and normalizes w.in _ days

appears: 4-6 hr peaks: 12-24 hr normalizes: 48-72 hr

myoglobin appears at _ hr peaks at _ hr and normalizes w.in _ hr

appears: 1-4 hr peaks: 12 hr normalizes: 24 hr

tx for NSTEMI

bb nitro ASA/clopidigrel heparin ACEI statins reperfusion

t/f: reperfusion for NSTEMI's are less time sensitive than for STEMI's

what cardiac markers will be elevated with a STEMI

troponin 1 OR troponin T CK

STEMIs are characterized by ST elevations and/or _ waves

Q waves

immediate tx for STEMI

ASA clopidigrel

CTA and reperfusion should be done w.in _ minutes of STEMI onset

_ should be done within _ hours of STEMI onset if PCI is not available

thrombolytic therapy w.in 3 hr

6 absolute contraindications for fibrinolytic therapy with STEMI

prior ICH structural cerebral vascular lesion malignant intracranial neoplasm ischemic stroke w.in 3 months suspected aortic dissection active bleeding/bleeding diathesis (excluding menses)

dyspnea on exertion should make you think of what 2 etiologies

CVD respiratory duh

6 cardiac causes of dyspnea on exertion

coronary heart dz CHF myocarditis pericarditis MI ACS

8 respiratory causes of dyspnea on exertion

asthma COPD PNA pulmonary HTN obesity/kyphosis/scoliosis ILD drugs psychogenic

2 drugs that cause dyspnea on exertion

MTX amiodarone

hematologic cause of dyspnea on exertion

anemia

edema should make you think of what 3 etiologies

**heart** **liver** **kidneys** *pump failure vs fluid back up* also consider: pregnancy drugs travel

main underlying cause of edema

Na retention

tx for edema (4)

reduce Na lasix compression socks elevation

2 meds that cause peripheral edema

CCB alpha 1 blockers (ex doxazosin)

4 mc causes of HF

CAD HTN MI DM

pathology of HF

LV remodeling -> dilation -> thinning -> mitral valve incompetence -> RV remodeling

sx of HF

exertional dyspnea -> dyspnea at rest chronic non productive cough fatigue paroxysmal nocturnal dyspnea night cough nocturia

symptom indicative of late HF

orthopnea

PE findings of HF (6)

cheyne stokes breathing LE edema rales (same-same crackles) S3/S4 JVP > 8 cm cold extremeties/cyanosis hepatomegaly/ascites/jaundice

S4 indicates _ HF

diastolic

S3 indicates _ HF

systolic

which type of HF is associated w. reduced ejection fraction

systolic

mechanism responsible for S3 in systolic HF

rapid ventricular refilling during early systole

ejection fraction is usuall normal w. _ HF

diastolic

3 causes of elevated BNP

advanced age renal impairment HF

what pt pop might have low BNP despite HF

obese

what is this showing

kerley lines -> CHF

best test to diagnose and evaluate HF

echo

NY HF classification

class I (<5%): no limitation of physical activity class II (10-15%): slight limitation of activity, comfortable at rest class III (20-25%): marked limitation in physical activity, comfortable at rest class IV (34-40%): discomfort prohibits physical activity, sx of HF or anginal syndrome at rest

tx for systolic HF (HFrEF)

ACEI bb lasix

tx for diastolic failure (HFpEF)

ACEI bb OR ccb

_ should not be used in stable chronic HFpEF (diastolic)

diuretics

what 2 drugs used in HF reduces preload O2

nitrates

what drug used in HF reduces preload

morphine

5 factors associated w. poor prognosis in CHF

CKD DM lower LVEF severe sx old age

3 types of hypertensive emergency

**emergency:** >180/120 w. impending/progressing end organ damage **urgency:** >180/120 w.o end organ damage **malignant:** DBP > 140

malignant HTN is associated w. what 3 sx

papilledema encephalopathy nephropathy

tx for the different types of HTN emergencies

**emergency:** sodium nitroprusside **urgency:** clonidine **malignant:** hydralazine

2 types of hypotensive emergency

hypotension cardiogenic shock

3 common causes of cardiogenic shock

acute MI CHF cardiac tamponade

5 PE findings of cardiogenic shock

SBP < 90 AMS cyanosis cool extremeties crackles

capillary wedge pressure > _ is indicative of cardiogenic shock

tx for cardiogenic shock (3)

fluids pressors (dopamine) treat underlying cause

orthostatic hypotn parameters

2-5 min after a change from supine to standing: SBP drop > 20 DBP drop > 10 pulse increase > 15

2 common causes of orthostatic hypotn

DM autonomic dysfxn meds

test if you suspect orthostatic hypotn due to DM autonomic dysfxn

tilt table

PE finding of orthostatic hypotn due to low blood volume

HR > 15 bpm

what do you think of first when you see orthopnea in the emergency setting

pulmonary edema

3 causes of orthopnea

cardiac pulmonary obesity

3 cardiac causes of orthopnea

CHF MI arrhythmias (afib)

3 direct causes of pulmonary orthopnea

COPD cor pulmonale pulmonary HTN

2 indirect causes of pulmonary orthopnea

kidney failure liver failure *backed up fluid in lungs*

ABG finding of orthopnea

large A-a gradient

pathology behind obesity related orthopnea

belly fat pushed up into the chest when lying down

ddx for palpitations (lots!)

anxiety lyte abnormalities hyperthyroidism ischemic heart dz stimulants meds pheochromocytoma hypoglycemia MVP afib WPW SSS PSVT

2 lyte abnormalities associated w. palpitations

hypokalemia hypomagnesemia

meds associated w. palpitations

bb ccb digoxin diuretics hydralazine minoxidil

64 yo f w. 5 weeks of intermittent SOB radiating from the shoulder to the chest - pain is worse w. inspiration and lying down, relieved by sitting forward - PE shows distant heart sounds - EKG shows low voltage QRS and electrical alternans

pericardial effusion

pericardial effusion is a complication of

pericarditis

PE finding of pericardial effusion

distant heart sounds

2 ekg findings of pericardial effusion

low voltage QRS electrical alternans

xray findings of pericardial effusion

water bottle heart

tx for pericardial effusion

pericardiocentesis

what is this showing

electrical alternans -> pericardial effusion

6 PE findings of PVD

lower extremity hair loss brittle nails pallor cyanosis claudication hypothermia ulcers

hallmark symptom associated w. PVD

intermittent claudication

ABI < _ indicates PVD

0.9

describe ulcers associated w. PVD (4)

pale to black well circumscribed painful lateral/distal

gs dx for PVD

arteriography

definitive tx for PVD

arterial bypass

pharm for PVD

antiplatelets: ASA, clopidigrel, cliostazol statins

transient LOC/postural tone 2/2 to acute decrease in cerebral blood flow

syncope

t/f: syncope is associated w. rapid recovery of consciousness w.o intervention

2 mc cause of syncope

vasovagal idiopathic

red flags for syncope (6)

during exertion multiple recurrences in short time murmur/structural heart dz old age significant injury during event fam hx unexpected deat/exertional syncope

types of syncope (5)

vasovagal cardiac orthostatic hypotn cerebral vascular dz noncardiogenic

neurocardiogenic syncope is same same

vasovagal

3 causes of cardiac syncope (5)

AV block SSS aortic stenosis HOCM massive MI

3 meds that can cause syncope

bb nitrates antiarrhythmic agents

work up for syncope

EEG glucose pulse ox tilt table rarely imaging

flowchart for syncope work up

valvular diseases Smarty PANCE wants us to know

aortic stenosis aortic regurgitation mitral stenosis mitral regurgitation

harsh systolic ejection crescendo-decrescendo murmur at right USB

aortic stenosis

aortic stenosis murmur radiates to the _ (2) and is heard best with _ (2)

radiates: neck/apex heard best: leaning forward/expiration

soft, early diastolic blowing murmur along LSB

aortic regurgitation

aortic regurgitation murmur is best heart with the patient

leaning forward/exhaling

what is erb's point what murmur does it make you think of

left third intercostal space close to the sternum mitral regurgitation

diastolic low pitched descrescendo rumbling murmur w. opening snap heart

mitral stenosis

mitral stenosis murmur is heard best at _ with the pt in _ position

apex lateral decubitus

holosystolic high pitched blowing murmur

mitral regurgitation

mitral regurgitation murmur is heard best at the _ and radiates to the _

apex axilla

heart sound associated w. mitral regurgitation

3 vascular dz's to know

aortic aneurysm/dissection arterial embolism/thrombosis phlebitis/thrombophlebitis

3 sx of aortic aneurysm

flank pain hypotn pulsatile abdominal mass

tx for aortic aneurysm based on size

> 5.5 cm OR expands > 0.6 cm/year: surgery > 3 cm: monitor annually > 4 cm: monitor q 6 mo

pharm for aortic aneurysm

sudden onset tearing CP between scapulas diminished pulses

aortic dissection

what is this showing

widened mediastinum -> aortic dissection

2 types of aortic dissection and tx for each

-ascending OR descending w. complications: emergent surgey -descending w.o complications: bb

6 p's of arterial emboli

pain pallor pulselessness paresthesia paralysis poikilothermia

2 common causes of thrombus formation

a fib mitral stenosis

gs for dx of embolism/thrombosis

angiography

tx for acute arterial embolism

IV heparin angioplasty graft endarterectomy

3 common causes of phlebitis/thrombophlebitis

trauma IV/PICC lines spontaneous

4 sx of phlebitis/thrombophlebitis

dull pain erythema induration of vein palpable cord

gs dx for thrombophlebitis

duplex US

tx for thrombophlebitis

NSAIDs warm compress