Cardiovascular (15%) Flashcards
Pericarditis
- Inflammation of pericardium
- Usually d/t infection (non-infectious causes include post-MI, autoimmune, uremia)
- Characterized by non-radiating, sharp, stabbing, knife-like chest pain over PMI
- Friction rub may be present
- 12-lead ECG may show global concave ST elevation
- Pain relieved by leaning forward
- Treatment – NSAIDs for mild; corticosteroids for severe
Endocarditis
- Inflammation of endocardium
- Caused by bacteria (Staph. Aureus) or fungi
- Increased risk in patients with valve disease and those with increased risk of pathogen introduction
- Changing cardiac murmur is diagnostically significant
- Physical exam typically shows a septic patient
- Other findings – Osler’s nodes (painful nodules on distal fingers), Janeway lesions (macules on palms and soles), splinter hemorrhages
- Treatment – Gram+ coverage (Vanco + Gentamicin)
Myocarditis
- Inflammation of the myocardium
- Usually caused by viruses, but can also be from bacteria and other causes
- Chest pain, fever, sweats, recent flu-like symptoms or recent URI
- Supportive therapy for s/s of acute HF – diuretics, nitro, ACE-I, inotropes
- Avoid NSAIDs in acute phase
Coronary Artery Disease (CAD)
- Develops d/t several factors including endothelial damage and infiltration of fatty deposits
- Management centers around decreasing myocardial workload or increasing oxygen supply
Stable Angina
- Earliest stages of clinically significant CAD
- Symptoms occur with activity and end with rest and/or nitrates
- No cardiac enzyme elevation, rarely see EKG changes
- Treatment – prophylactic therapy (lower lipids, nitrates, ASA, lifestyle modification)
Unstable Angina
- Partial coronary thrombosis
- Symptoms with activity and/or rest and isn’t easily relieved with rest or nitrates (< 30 minutes)
- No cardiac enzyme elevation, may have ST depression
- Treatment – nitrates, beta blockers, morphine, oxygen, aspirin 16-324 mg once then 81 mg daily, ADP receptor blocker (clopidogrel, ticareglor), heparin therapy (if admitted), cardiology consult
NSTEMI
- Subtotal coronary thrombosis with partial thickness infarction
- Symptoms with activity and/or rest and isn’t easily relieved with rest or nitrates (> 30 minutes)
- Cardiac enzyme elevation, ST depression
- Treatment – nitrates, beta blockers, morphine, oxygen, aspirin 16-324 mg once then 81 mg daily, ADP receptor blocker (clopidogrel, ticareglor), heparin therapy (if admitted), cardiology consult
STEMI
- Total coronary thrombosis with full thickness infarction
- Symptoms at rest, not improved with rest, may improve with nitrates
- Cardiac enzyme elevation, ST elevations
- Treatment – ASA 325 mg once, nitrates, beta blockers, antiplatelet, heparin therapy, cardiac catheterization/PCI or fibrinolysis (if delayed PCI)
TIMI Scoring for UA/NSTEMI
- 0-2: low risk
* 3-7: high risk
Cardiac interventions - Fibrinolysis
- Symptoms > 15 minutes but < 12 hours
- Goal (if presenting to PCI facility) door to balloon < 90 minutes
- Goal (if presenting to non-PCI facility) door to balloon < 120 minutes
- Absolute contraindications – hx of cerebrovascular event (ICH, intracranial tumor, aneurysm), non-hemorrhagic stroke or head trauma < 3 months ago, cranial or spinal trauma < 2 months ago, known bleeding disorder, active internal bleeding
Cardiac Tamponade
Accumulation of fluid in the pericardial space
Emergency!
Etiology – blunt/penetrating chest trauma, s/p cardiac surgery or cath., pericarditis, acute MI, infection
Symptoms – Beck’s triad (elevated JVP, hypotension, distant/muffled heart tones), signs of shock, narrowing pulse pressure, tachycardia
Diagnostics – TTE
Treatment – IVF to maintain preload, O2, inotrope, mainstay = percutaneous or open pericardiocentesis
Dilated Cardiomyopathy
- Ventricular chamber enlargement causes progressive dilation leading to overstretching and failure
- Symptoms – gradual heart failure – fatigue, DOE, dyspnea, orthopnea, edema, weight gain
- Management – heart failure management (rest, daily weight, Na restriction, diuretics, ACE INHIBITORS (-PRILs), beta blockers
Hypertrophic Cardiomyopathy
- Increased LV wall thickness which restricts ventricular filling leading to diastolic HF
- Symptoms – dyspnea (most common), syncope, palpitations, orthopnea, dizziness, sudden cardiac death
- TTE is diagnostic
- Management – restrain from highly strenuous activity, BETA BLOCKERS (METOPROLOL IS 1ST LINE), ICD
Restrictive Cardiomyopathy
- Rigid ventricular walls causing impaired diastolic filling and diastolic HF
- Can be caused by amyloidosis or sarcoidosis
- Symptoms – gradually worsening SOB, fatigue, weakness, chest pain, right-sided HF s/s
- Management – treat cause (if known – amyloidosis or sarcoidosis), nitrates, beta-blockers (carvedilol), inotropes (digoxin)
Dyslipidemia Causes - primary vs. secondary
- Primary – familial hypercholesterolemia
* Secondary – SEDENTARY LIFESTYLE with excessive intake of fats and cholesterol
Dyslipidemia Screening
• ACCE recommends screening all adults 20-44 years every 5 years, 45-65 every 1-2 years, 65+ years annually
Dyslipidemia Treatment
- Lifestyle recommendations – weight reduction, DASH diet, Na restriction, physical activity, moderate consumption of alcohol
- Statin therapy – initiate high-intensity statin (can down-titrate of not tolerated (atorvastatin 40-80 mg or rosuvastatin 20-40 mg)
- Contraindications to high-intensity statin therapy – age > 80, impaired renal function, frailty, multiple comorbidities
Left-sided vs. Right-sided Heart Failure
- Left – involves left ventricle, pulmonary symptoms are most common (i.e., SOB, DOE, pulmonary edema, etc.)
- Right – involves right ventricle, systemic symptoms are most common (i.e., hepatosplenomegaly, edema, etc.)
Systolic vs. Diastolic Heart Failure
- Systolic – decreased forcefulness of contraction, decreased EF
- Diastolic – inability of full relaxation, normal EF
Assessing degree of congestion and adequacy of perfusion in HF (cold vs. warm; wet vs. dry)
No congestion, good perfusion: warm & dry
– outpatient treatment
No congestion, poor perfusion: cold & dry
– inpatient, inotropes
Congestion, good pefusion: warm & wet
– inpatient, diuresis
Congestion, poor perfusion: cold & wet
– ICU, diuresis, inotropes, and/or vasodilators
Treatment for Congestion in HF
- “LMNOP”
- Lasix – give IV at 1-2.5x total daily PO dose
- Morphine – for refractory symptoms, SOB
- Nitrates – vasodilation
- Oxygen – consider non-invasive mechanical ventilation
- Position – upright with legs over side of the bed
Treatment for Poor Perfusion in HF
- IV vasodilators – nitro
- Inotropes – dobutamine, Milrinone
- Mechanical circulatory support – IABP (inflates in diastole and deflates in systole, decreases O2 demand and increases coronary perfusion), LVAD (bridge to recovery or transplant)
ACC/AHA Stages of HF
- Can only progress down
- Stage A – high risk of HF without structural changes or presence of symptoms
- Stage B – structural changes but no s/s of HF
- Stage C – structural changes with s/s of HF
- Stage D – refractory HF
NYHA Symptom Classification of HF
- Can move up or down
- Class I – no limitation on activity
- Class II – slight physical limitation, comfortable at rest, normal activity causes symptoms
- Class III – marked physical limitation, comfortable at rest, less than normal activity causes symptoms
- Class IV – unable to perform any activity without symptoms, symptoms present at rest
Hypertension
Elevated BP is 120-129/<80
• No pharmacologic therapy, reassess BP in 3-6 months
HTN is ≥ 140/≥90
• Non-pharmacologic therapy and BP-lowering meds, reassess BP in 1 month
• Consider initiating 2 first-line agents of different classes: thiazide diuretics (HCTZ), CCBs (amlodipine, diltiazem), and ACE (-pril) or ARB (-sartan)
Hypertensive Urgency
- HTN with minimal or no acute target organ damage, can also be asymptomatic
- SBP > 180 mmHg and/or DBP > 120 mmHg
- Lower BP over a few hours with oral antihypertensives with goal to return BP to normal within 1-2 days
- Captopril 12.5-100 mg 3x daily, labetalol 200-800 mg 3x daily, clonidine 0.2 mg loading then 0.1 mg hourly
- Monitor for decreased urine output, increased creatinine, and decreased mental status – may indicate that the lower BPs aren’t tolerated by that BP has dropped to fast
Hypertensive Emergency
- HTN (of any degree) with acute target end organ damage and ischemia
- Neuro – encephalopathy, strokes, papilledema
- Cardio – acute coronary syndrome, HF, pulmonary edema, aortic dissection
- Renal – proteinuria, hematuria, acute renal failure
- Lower MAP by 25% within minutes to 2 hours with IV agents
- Consider arterial line monitoring
- Goal is DBP < 110 within 2-6 hours, as tolerated
- Nitroprusside 0.25-10 mcg/kg/min., labetalol 20-80 mg IVP, nicardipine 5-15 mg/hr, nitro 5-1000 mcg/min
- Monitor for decreased urine output, increased creatinine, and decreased mental status – may indicate that the lower BPs aren’t tolerated by that BP has dropped to fast
Adult Congenital Heart Diseases (ACHD)
- Most common birth defect
- Lifetime expert surveillance is needed
- Nearly all have some degree of HF (Grade A or NYHAC I or worse)
- Higher risk for endocarditis, thrombus formation, and premature degeneration and calcification of prosthetic materials
- Consult cardiology specialist
Murmurs - systolic vs. diastolic
Systolic - MR. ASS is MVP
– Mitral Regurg, Aortic Stenosis = Systolic is Mitral Valve Prolapse
– mitral regurg is classically holosystolic
Diastolic - MS. ARD
– Mitral stenosis, Aortic Regurg = Diastolic
Benign vs. Pathologic Murmurs
- Benign – no cardiac history, low grade, S1 and S2 intact, normal PMI, softens or disappears with supine to standing position change
- Pathologic – abnormal history, higher grade, S1 and S2 obliterated, PMI displaced, increases in intensity with supine to standing
- Consider pathologic if at least 1 criteria met; if pathologic, echo is next step
Postural Orthostatic Tachycardic Syndrome (POTS)
Lightheadedness, fainting, and a rapid increase in HR that comes on when standing up from a reclining or laying position
Diagnostics – tilt table test is gold standard for diagnosis
Treatment – POTS diet (drink fluids throughout the day, increase salt intake); physical therapy; combination of meds to retain Na (ex: fludrocortisone), beta blockers, and/or meds to improve constriction (ex: midodrine)
Peripheral Artery Disease (PAD)
o Intermittent claudication (exacerbated by exercise, relieved by rest)
o 6 Ps – pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
o Skin ulcerations – well defined, punched out appearance, painful
o Loss of hair over lower extremities, shiny skin, thin skin
o Ankle-Brachial Index (ABI) – systolic pressure of ankle divided by systolic pressure of arm; number > 0.9 is diagnostic of peripheral artery disease
o Management – smoking cessation, exercise, foot care, weight reduction, statin, beta blocker, antiplatelets
Chronic Venous Insufficiency
o Symptoms – dull ache in legs, leg swelling or tightness, hyperpigmentation
o Ulcerations – sloping, gradual edges, minimal pain, slough
o Management – elevate legs, compressive stockings, skin care, exercise, weight reduction
Aortic Dissection
o Occurs when a tear develops in the inner layer (tunica interna) of the aorta and blood dissects into the media
o Stanford classifications
Type A – upper ascending aorta, more common, emergency
Type B – lower descending aorta, acute < 14 days or chronic > 14 days
o Risk factors – HTN!, genetics (ex: common in Marfan’s syndrome), aortic coarctation, atherosclerosis
o Symptoms – acute “tearing” chest/back pain, pulse deficit/absent pulses, JVD, hypotension, tachycardia
o Clinical triad – abrupt onset of tearing back/chest pain, variation in pulse, mediastinal and/or aortic widening on CXR
o Type A management – immediate surgical intervention
o Type B management – stable is ICU for pain and HTN monitoring (labetalol); unstable is stenting and medication therapy
Aortic Aneurysm
o Most are asymptomatic until rupture!
o Risk factors – COPD, previous aneurysm repair, CAD, HTN, male
o Symptoms – asymptomatic (until rupture), back/flank/groin pain, n/v, abdominal pain, pulsing sensation in abdomen, progressive symptoms, shock symptoms
o Diagnostics – CTA (USPSTF =screen men 65-75 years old who have smoked)
o Management – consult vascular or cardiac surgery, BP control (beta blockers are first line – labetalol)
DVT
o Risk factors – PRIOR DVT, CANCER, immobility, post-op, major surgery, pregnancy or post-partum
o Virchow’s triad – inflammation, hypercoagulability, and endothelial injury
o Symptoms – pain, cramp, or “charley horse”, unilateral or bilateral swelling, redness, cyanosis
o Diagnostics – duplex is diagnostic; CT or MRI is not necessary; D-dimer is nonspecific (use only to rule out DVT)
o Wells Criteria Score:
≤ 0: low likihood of DVT
1-2: moderate likelihood of DVT
≥ 3: high likelihood of DVT
o Management – first line therapy is direct oral anticoagulation (rivaroxaban, dabigatran, apixaban) for 3 months if provoked or indefinitely if unprovoked
PE
o Risk factors – venous stasis, immobility, recent surgery, malignancy, hx of VTE
o Virchow’s triad – inflammation, hypercoagulability, and endothelial injury
o Symptoms – abrupt onset of chest pain, SOB, and hypoxia are classic symptoms
Other – anxious, wheezing, hemoptysis, tachypnea, diaphoretic
o Diagnostics – CTA (PE protocol)
o Management
Respiratory support
Hemodynamic support – cautious IVF (can overload RV), levophed, ECMO?
Anticoagulation
Reperfusion
Chronic phase – 3 months anticoagulation if provoked or indefinite anticoagulation if unprovoked (rivaroxaban, dabigatran, apixaban)
Intra-Aortic Balloon Pump (IABP)
- Inserted in femoral artery and sits in descending thoracic aorta
- Decreases afterload, decreases myocardial demand, increases coronary artery perfusion, enhances cardiac output
- Indications – low CO syndromes (ex: septic shock), LV overload, bridge to CABG or LVAD
Ventricular Assist Device (VAD)
- An electromechanical pump that is implanted to with assist with cardiac circulation
- Indications – destination therapy, bridge to transplant, bridge to recovery
- Contraindications – extreme BMI, RV UNABLE TO SUPPORT LV FLOWS
Extracorporeal Membrane Oxygenation (ECMO)
- Indications – cardiogenic shock, pulmonary HTN, PE with hemodynamic compromise, reversible respiratory failure (ARDS), cardiac arrest, bridge to decision (transplant or VAD)
- Contraindications – irreversible pulmonary or cardiac disease, > 65 years, metastatic malignancy, significant brain injury, terminal disease, inability to tolerate systemic anticoagulation
Heart Transplant
- Signs of rejection – most are asymptomatic, signs of left ventricular dysfunction (dyspnea, syncope, orthopnea), tachydysrhythmias
- Dilated cardiomyopathy is most frequent reason for heart transplant
