Cardiovascular Flashcards

Question

Peripheral Artery Disease (PAD)

Answer 1

- Arteries that supply the limbs narrows, thereby reducing blood flow and perfusion Risk factors: - Hyperlipidemia, smoking, hypertension and diabetes Presentation: - Extremity ulceration - Arterial: Over toe joints, over the bones prominence of the malleoli, the anterior shin, or at the base of the heel. - Venous: Malleoli (above the bony prominence), and also over the posterior calf. - Neuropathic: Pressure points of the foot (plantar surface of the foot over the metatarsal heads and the heel) - Claudication: Reproducible discomfort of a defined group of muscles that is caused by exercise and relieved with rest. - Can occur with buttock, hip, thigh, calf, foot pain (alone or in combination) - Buttock and hip: Aortoiliac occlusion - Thigh: Aortoiliac or common femoral artery occlusion - Calf: Superficial femoral or popliteal artery Diagnosis: - An ankle-brachial systolic pressure index (ABI) of <0.90 has a high degree of sensitivity and specificity for a diagnosis of PAD

Answer 2

- Conservative measures: - Reducing cardiovascular risk factors - Reducing smoking - Exercise therapy - Pharmacological therapy: - Naftidrofuryl - Cilostzol - Surgical repair

Answer 3

- Heart cannot pump blood efficiently, or only at the cost of high filling pressures - Most commonly acute HF is due to dysfunction of the left ventricle Classified by Ejection Fraction - HF with a LVEF <40% is known as HF with reduced EF (HFrEF) - HF with LVEF of 41-49% is HF with mid-range EF (HFmrEF) - HF with LVEF >50% may be cause by HF with preserved EF (HFpEF) or cardiomyopathy Risk factors: - Ischemia or infarction, uncontrolled hypertension, new onset or uncontrolled atrial fibrillation, excessive tachycardia, pulmonary embolism, uncontrolled diabetes, thyroid dysfunction and substance abuse. Presentation: - Classic symptoms: Dyspnea, fatigue, edema - Additional symptoms: exercise intolerance, unintentional weight loss, recurrent ventricular arrhythmias, hypotension and sign of inadequate perfusion.

Answer 4

Class 1: Patients with cardiac disease but WITHOUT limitations during ordinary physical activity Class 2: Patients with cardiac disease and with SLIGHT limitations. Normal activity causes some fatigue and dyspnea, however patient is comfortable at rest. Class 3: Patients with cardiac disease and with MARKED limitations. These patients are comfortable ONLY at rest and less than normal activity causes dyspnea Class 4: Patients with cardiac disease and who experience symptoms if ANY physical activity occurs. Symptoms may also occur at REST.

Answer 5

- There is no gold standard for the diagnosis instead it is based on collection data to support the diagnosis Tests used to support the diagnosis: - History and physical exam - Echocardiogram, ECG, natriuretic peptide levels and a chest radiograph - Echo to assess cardiac dysfunction and identify possible cause - ECG to rule out arrhythmias, infarction - A normal ECG essentially rules out left sided heart failure - Natriuretic Peptide levels may be normal in patients with HF who have preserved ejection fraction and therefore it can be used to support a diagnosis of Hf. - Cardiomegaly, pleural effusion, Kerley B Lines Treatment: - Combination therapy: - Angiotensin Blocker (Angiotensin receptor blocker neprilysin inhibitor, or ACE inhibitor or ARB) - Preferably sacubitril-Valsartan - Beta Blocker - Preferably metoprolol, carvedilol or bisoprolol - Mineralcorticoid receptor antagonist - Preferably eplerenone rather than spironolactone - SGLT2 Inhibitor - Preferably dapagliflozin or empagliflozin - HF With fluid overload - Requires diuretic - Example of loops diuretics: Furosemide, Torsemide, or Bumetanide - Effects are dose dependent and include: - Diuresis - Ototoxicty (typically occurs with large doses given IV)

Answer 6

- Irregularly irregular ventricular rhythm and the absence of distinct P waves Presentation: - Palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, reduced exercise capacity, increased urination or mild dyspnea. Management: - Long term rate control: - Beta blocker - Non-Dihydropyridine CCB - Digoxin - Narrow therapeutic range: between 0.8 - 2 - Toxicity: Arrhythmias, gastrointestinal symptoms, confusion and vision changes. - Oral anticoagulants: - Direct oral anticoagulants - Examples: Direct thrombin inhibitor dabigatran (Pradaxa) and the direct factor Xa inhibitors Rivaroxaban (xarelto) and Apixaban (Eliquis) - Do not use in patients with severe kidney disease, pregnancy and with patients who have mechanical prosthetic heart valves. - Vitamin K antagonist (warfarin) - Use in patients with a mechanical heart valve - Warfarin for a prosthetic heart valve: 2.5-3.5 - Warfarin for Afib: 2.0-3.0

Answer 7

- CHF: 1 point - HTN: 1 point - 75 years and older: 2 points - Diabetes: 1 point - History of stroke/TIA: 2 points - Vascular disease (prior MI, PAD, aortic plaque): 2 point - Age 65 to 74 years: 1 point - Female gender: 1 point - Max score: 9 - Oral anticoagulants recommended: - Males with 2 or more points - Females with 3 or more points

Answer 8

Sound caused by turbulent blood flow that is heard loudest at the point of origin Intensity Grade: - Grade I: The faintest audible murmur heard - Grade II: Soft murmur that is readily detectable - Grade III: Murmur louder than grade II but without a palpable thrill - Grade IV: Loud murmur WITH a palpable thrill - Grade V: Very loud murmur, audible with the stethoscope lightly placed not the chest and a palpable thrill - Grade VI: Loudest murmur, audible with the stethoscope off the chest and a palpable thrill Treatment: - An Echocardiogram should be done on all patients with a cardiac murmur, that have not already been diagnosed and evaluated with an Echo or for anyone who is symptomatic. REMEMBER: For/4 the thrill of it — Grave IV has a palpable thrill Aortic area: 2nd ICS, right of the sternum Pulmonic area: 2nd ICS, left of the sternum Tricuspid area: 4th and 5th ICS, left of the sternum Mitral area: Located at the apex (bottom), 5th ICS

Answer 9

Starts with or after S1 and terminates before or at S2 - Systolic murmurs are seen in approximately 60% of patients of which 90% have a normal Echo Examples: - Mitral Regurgitation: Holosystolic murmur that is classified as high pitched and is best heard with the diaphragm of the stethoscope with the patient lying in the left lateral decubitus position. - Holosystolic murmur: Begins with the first heart sound and extends to or through the heard sound. - May radiate to left axilla. - Aortic sclerosis or stenosis: Causes a mid systolic murmur that is best heard at the right 2nd ICS - May radiate to the carotid (neck) - Mitral Valve prolapse: Mot common cause of late systolic murmur and is best heard wit the diaphragm of the stethoscope over or just medial to the cardiac apex. - Most common cause of MVP is a “floppy valve” also referred to as Barlow’s Syndrome. - Tricuspid Regurgitation (rare): Best heard with the diaphragm of the stethoscope along the left lower sternal border. - Increases with inspiration which is also known as Carvallo’s Sign. - Midsystolic ejection murmur (typically benign) - Ventricular septal defect

Answer 10

Almost always pathological and they occur at S2 or after and end before S1 Examples: - Mitral stenosis: Best hear with the bell of the stethoscope with the patient in the left lateral decubitus position - Mid diastolic murmur that has a rumbling quality - Pulmonic Regurgitation: Findings are based on the severity - Begins early in diastole and is typically best heard over the left 2nd and 3rd ICS - Aortic Regurgitation: Decrescendo murmur that is best heard wit the diaphragm of the stethoscope at the right 2nd ICS - High frequency and “blowing” effect - May be musical in quality and cause a “diastolic whoop” - May be more audible if the patient leans forward and hold their breath after a complete expiration - Tricuspid Stenosis: Most often inaudible and discovered accidentally on an Echo - Most commonly associated with rheumatic etiology

Answer 11

DIASTOLIC Murmurs M: Mitral S: Stensosi A: Aortic R: Regurgitation D: Diastolic SYSTOLIC Murmurs M: Mitral R: Regurgitation P: Physiologic A: Aortic S: Stenosis S: Systolic

Answer 12

An infection of one or more heart valves Risk factor: - Heart valve disease - Mechanical heart valve - Device such as a pacemaker - Immunocompromised patients - Person who use IV drugs Presentation: - Systemic symptoms - Fever, sweat or chills, body aches - Other symptoms - Janeway Lesions: Hemorrhagic macules found on the palms of the hand and sole of the feet that are not painful - Splinter hemorrhages: Small blood clots that appear as streaks under the nail plate - Osler nodes: Tender lesions on the finger pads and toe pads - Murmur: detected in approximately 85% of patients with IE