Cardiovascular Flashcards
To Know The CardioVascular System In the First Aid Book.
Normal Heart Rate
60 - 100 bpm
Heart Rate < 60 bpm is?
Bradycardia
Heart Rate > 100 bpm is?
Tachycardia
Rhythm, look for what on tracing?
P before every QRS and QRS after every P
Axis: Normal
Upright (positive) QRS in leads I and II
Left Axis Deviation
Upright (positive) QRS in lead I
&
Downward (negative) QRS in Lead II
Right Axis Deviation
Downward QRS in lead I
&
Upright QRS in lead II
What is “unstable” in a patient?
Chest Pain
SOB
Hypotension
Confusion (brain not perfusing)
Characteristics of “Stable Angina”
Tightness Heaviness Pressure Sore Dull Squeeze
Inferior Wall Ischemia presents?
Presents with Vagal Reflexes
Bradycardia Hypotension Dizzy Faint Sweating
Less Likely to be Ischemic or Infarct with characteristics like?
Sharp / knife like pain, easily pinpointed
Pain reproduced on palpation
Or
Change in position
Tender
Respiratory changes
True Infarct has a time that lasts longer than?
Pain lasts > 20 - 30 min
Transient Ischemia
Or
Esophageal Spasms
Relieved by Nitro
GERD (Worse with Nitro)
To Distinguish between LBBB and RBBB
WiLLiaM MaRRoW:
W patter: of QRS in V1-V2 and M pattern of QRS in V3-V6 for LBBB
M pattern: of QRS in V1-V2 and W pattern of QRS in V3-V6 for RBBB
Infarction
ST is elevated or depressed?
T-wave is?
ST Elevation
T wave inversion
Systolic Murmurs:
Aortic Stenosis
Mitral Regurgitation
Mitral Valve Prolapse
Flow Murmur
AS- Harsh Systolic ejection murmur
- radiation to carotids
MR- Holosystolic murmur
- radiation to axillae or carotids
MVP- Midsystolic Click or Late Systolic Click
Flow Murmur- Common, no disease
Diastolic Murmurs:
Aortic Regurgitation
Mitral Stenosis
AR- Early decrescendo murmur
MS- Mid to late, low pitched murmur
Difference of 20 mmHg in Arms with B.P. suggests what?
Aortic Disection
Gallops:
S3
S4
S3- Volume Issue
- Dilated cardiomyopathy (Floppy ventricle) - Mitral Valve Disease - Estrogen effect in early females (normal)
S4- Stiff Ventricle
- HTN - Diastolic dysfunction (stiff ventricle) - Aortic Stenosis
Edema, what are causes?
Pulmonary
Peripheral
Pulmonary: Left heart Failure
Peripheral: Right heart failure
: Hypoalbuminemia and drugs
: Hepatic Disease
Pulsus Paradoxus
(decreased systolic B.P. with inspiration)
Pericardial tamponade Asthma COPD Tension Pneumothorax Foreign body in airway
Pulsus Alternans
(alternating weak and strong pulse)
Cardiac tamponade
impaired left ventricular systolic function
Poor prognosis
Pulsus Parvus et Tardus
(weak and delayed pulse)
Aortic Stenosis
Management of Atrial Fibrillation
ABCD
Anti-Coagulate
Beta Blockers to control rate
Cardiovert / Calcium Channel Blockers
Digoxin
Definition of CHF
Inability of the heart to pump enough blood to maintain luid and metabolic homeostasis
CHF Drugs that Increase Mortality
ACE-I / ARBS ACE-I + Diuretic Beta Blocker Vasodilator Spironolactone
Acute Atrial Fibrillation Causes (7)
Chronic Atrial Fibrillation Causes (2)
PIRATES:
- Pulmonary Disease
- Ischemia
- Rheumatic Heart Disease
- Anemia / Atrial Myxoma
- Thyrotoxicosis
- Ethanol
- Sepsis
Chronic:
- HTN
- CHF
Atrial Flutter has what type of EKG Appearance?
Sawtooth
Atrial Flutter has a bpm rate of how much?
240 - 320 bpm
Treatment of Atrial Flutter?
Anticoagulation and rate Control
Cardiovert according to AF criteria
CHAD2 Score
CHAD2 VASc
C- CHF (1) H- HTN (1) A- Age (1) D- DM (1) S2- Stroke or TIA (2) ------------------------- Total = 6
V- Vascular (1) A- Age (1) Sc- Sex (1) ---------------- CHAD2 VASc = 9
Atrial Fibrillation use the CHAD2 score to estimate risk of Stroke then treat accordingly
What is the treatments?
- Anticoagulate if >48 hours (prevent CVA)
- Rate Control (CCB, BB, Digoxin, Amiodarone)
or
- Initiate Cardioversion if <48 hours
- Cardiovert if Transesophageal echo (TEE) shows no Left Atrial Clot
- Cardiovert after 3 - 6 weeks of warfarin treatment with INR 2 -3
Ventricular Tachycardia (VT) Treatment
Cardioversion and Antiarrhythmics (Amiodarone, Lidocaine, Procainamide)
Ventricular Fibrillation (VF) Treatment
Syncope, absence of blood pressure, pulselessness
Immediate electrial cardioversion and ACLS protocol
Torsades De Pointes Treatment
- Correct HypoKalemia
- Withdrawl offending drugs
- Give Magnesium Initally
- Cardiovert if unstable
New York Heart Association Classificaiton of CHF
(NYHA Classifcation of CHF)
4 classes
1- No limit on activity; no symptoms with normal activity
2- Slight limitation of activity, comfortable at rest or with mild exertion
- Marked limitation of activity, comfortable only at rest
4- Confined to complete bed rest or chair, physical activity brings on discomfort, symptoms present at rest
Left Sided CHF Symptoms (5)
Left sided S3/S4 gallop Bilateral Basilar Rales Pleural Effusions Pulmonary Edema Orthopnea, Paroxysmal Nocturnal dyspnea
Right Sided CHF Symptoms (5)
Right-sided S3/S4 gallop JVD Hepatojugular reflex Peripheral Edema Hepatomegaly, Ascites
Stage Classification and Treatment of CHF (4)
A- Patients at high risk of developing CHF
Treatment- Manage risk factors (HTN, Smoking, Hyperlipidemia, obesity, exercise, alcohol)
- ACE-I
B- Structural Heart Disease (MI, Valve Disease), with no symptoms of CHF
Treat- ACE-I, BB
C- Structural Heart Disease with symtoms of CHF (SOB, fatigue, decrease exercise)
Treat- Diuretics, ACE-I, BB, Digitalis, Salt Restrict
D- Marked symtoms of CHF at rest
Treat- Mechanical assist, Heart Transplant, IV inotropic drugs, Hospice
Systolic Dysfunction is defined at what?
Ejection Fraction <50% and Increased Left Ventricular End-Diastolic Volumes
CHF Diagnosis
CHF is Clinical Syndrome
CXR: Cardiomegaly
Pleural Effusions
Vascular Plumpness
Prominent Hila
Echo- Decrease Ejection Fraction
Ventricular dilation
Lab Abnor- BNP >500
Increase Cr
Decrease Sodium
Acute CHF Managment
LMNOP
Lasix Morphine Nitrates Oxygen Position (Upright)
Acute Treatment of CHF
- Correct underlying cause (MI, Drugs, Alcohol, Thyroid and Valvular Disease)
- Diurese aggressively with loop and thiazide
- Give ACE-I
Do the LMNOP
Chronic CHF Treatment
Control Comorbid Conditions (DM, HTNm Obesity) limit sodium and fluid
- Long term BB + ACE-I
- Daily ASA and Statin
- Chronic diuretic
- Low Dose Spironolactone
- Anticoagulate with history of AF
Hypertrophic Cardiomyopathy
What is it?
LVH results in Impaireded left ventricular relaxation and filling
involves the interventricular septum, leading to left ventricular outflow tract obstruction and impaired ejection of blood
Congenital Form (Hypertropic Obstructive Cardiomyopathy: HOCM) in Autosomal Dominant)
Most common cause of sudden death in children
Diagnosis of HOCM
Echo- shows asymmetrically thickened left ventricular wall and dynamic obstuction of blood flow
ECG- may show LVH
CXR- may reveal left atrial enlargement
Treatment of HOCM
Initial- BB for symptom relief
2nd line- CCB
Restrictive Cardiomyopathy
Defined as Decreased Elastic of myocardium
Leads to impaired diastolic filling but has normal EF
Caused- Infiltrative disease (Amyloidosis, Sarcoidosis, Hemochromatosis) or by scarring
History or Restrictive Cardiomyopathy
Left sided and right side heart failure
Symtoms of Right sided heart failure predominate (JVD, Peripheral edema)
Diagnosis and Treatment of Restrictive Cardiomyopathy
Echo- Key test
reveals rapid early filling with normal EF
ECG- frequently shows LBBB
Treatment- Limited and Pallative
- Diuretics for fluid overload
- Vasodilators to decease filling
pressure
Dilated Cardiomyopathy
Most common
Left ventricular dilation Systolic Dysfunction (Low EF)
both must be present
Most cases idiopathic
2nd cause- Alcohol, myocarditis, Drugs, Endocrinopathies, Infections (Coxsackie, Chags), nutrition (Beriberi) and most common are HTN and Ischemia
History of Dilated Cardiomyopathy
Gradual symtoms of CHF
Exam shows:
- displacement of Left Venticular impulse
- JVD
- S3/S4 gallop
- Mitral / Tricuspid Regurg
Diagnosis of Dilated Cardiomyopathy
Echo- Diagnostic
EKG- non-specific St-T changes
- Low volte QRS - LBBB
CXR- Enlarged balloon-like heart
- Pulmonary congestion
Treatment of Dilated Cardiomyopathy
Address underlying issues (Alcohol, endocrine)
- Treat CHF symptoms:
- Diuretics
Prevent disease pregression:
- ACE-I
- BB
- Aldosterone Antagonists
Consider ICD if EF <35%
Coronary Artery Disease (CAD)
Manifestations
Stable and Unstable Angina SOB Dyspnea on Exertion Arrhythmias MI Heart Failure Sudden Death
Angina Pectoris
Prinzmetal’s (Variant)
Substernal Chest Pain secondary to Myocardial Ischemia (O2 supply and demand mismatch)
Prinzmetal’s- mimics Angina Pectoris but is caused by vasospasms of coronary vessels.
Affects young women at rest in early morning
- ST-Elevation in absence of Cardiac Enzyme elevation
Angina Pectoris:
Diagnosis
- Rule out: Pulmonary, GI and Cardiac causes
- Women and diabetic classically experience “silent” ischemic events. Keep Suspicous high
- St segment change with stress test is diagnostic of CAD
Angina Pectoris:
Treatment
Acute
Chronic
Acute Symptoms: (MONA)
- ASA
- 02
- Nitro IV
- IV Morphine
- Consider IV BB
Chronic:
- Nitrates
- ASA
- BB (CCB are second line)
Initiate risk reduction:
- Smoking
- Cholesterol
- HTN
Unstable Angina / Non-Elevation MI (NSTEMI)
Unstable Angina Description
Unstable Angina- chest pain that is
- New Onset
- Accelerating
- Occurs at rest
NSTEMI
- Elevation of:
- Troponin I
- Troponin T
- CK-MB
Unstable Angina / NSTEMI
Diagnosis
Pt should be risk stratified by TIMI (Thrombosis in Myocardial Infarction Study)
- Unstable Angina doesn’t have elevated cardiac Markers, but ST changes seen on EKG
- NSTEMI- serial cardiac enzymes and EKG
Unstable Angina / NSTEMI
Tx same as for Stable Angina
- Clopidogrel
- Unfractionated Heparin or Enoxaparin
- Glycoprotein IIB/IIIA
TIMI >3
- Troponin elevation or St changed >1mm
- Given Heparin
- Angiography
- Revascularization
TIMI
- AGE (>65)- 1
- > 3 CAD risk factors (Family, DM, Smoke, HTN)- 1
- Known CAD (stenosis >50%) - 1
- ASA use in past 7 days- 1
Presentation
- Severe Angina >2 episodes in 24hr- 1
- St deviation >0.5mm - 1
- Cardiac Marker - 1
Risk Score = 0-7
Score >3 = Enoxaparin and Angiography
ST-Elevation MI (STEMI)
Definition
St- Elevation and Cardiac Enzyme release secondary to prolonged cardiac ischemia and necosis
STEMI Hx
Acute onset substernal chest pain
Described as:
- pressure or tightness
- radiates to left arm, next, jaw
Associated symptoms
- Diaphoresis
- SOB
- Lightheaded
- Anxiety
- N/V
- Syncope
Physical
- Arrhythmias
- Mitral Regurg (rupture papillary muscle
- Hypotension
- CHF new (rales, S3 gallop)
Best predictor of survival - left ventricular EF
STEMI Diagnosis
ST Elevation
New LBBB
ST Depression in leads V1-V2 means infarction of posterior wall
T wave inversions
peak T waves
Cardiac Enzymes
- Troponin I (most sensitive)
- CK-MB (specific)
STEMI Tx
Six Meds Consider:
- ASA
- BB
- Clopidorgrel
- Morphine
- Nitrates
- O2
Emergent Angiography and PCI
Indications for CABA
DUST
Depressed ventricular Function
Unable to do PCI
Stenosis of left main coronary artery
Triple vessel disease
Complications of STEMI
Arrhythmia most common
Dressler’s happen 2-10 weeks Post MI
Timeline of complications: 1st day- Heart failure 2-4- arrhythmias 5-10- left ventricular wall rupture Weeks-Months- Ventricular aneurysms
HyperCholesterolemia
Total Cholesterol >200 mg/dL
LDL >130 mg/dL
Triglycerides >500 mg/dL
HDL <40 mg/dL
Risk factors for CAD
Hypercholesterolemia Hx
Most have no signs or symptoms
Extremely high triglycerides or LDL levels may have
- Xanthomas (nodules in skin over the tendons
- Xanthelasmas (yellow fatty deposits in the skin around the eyes)
- Lipemia Retinalis (creamy appearance of retinal vessels)
Hypercholesterolemia Dx
Fasting lipid profile >20 years old
Repeat every 5 years
Total Serum Cholesterol >200 mg/dL on 2 occasions is diagnostic
Dyslipidemia
LDL >130
HDL <200 is diagnostic of dyslipidemia
Hypercholesterolemia Tx
1st intervention- Diet / Exercise for 12 weeks
Then do Statins
HTN Definition
Systolic >140
Diastolic >90
based on 3 measurements separated in time
Diabetic HTN range
<130/80
Essental HTN Dx
Conduct:
- Cardio
- Neuro
- Ophthalmologic
- Abdominal exams
Obtain:
- UA
- BUN/CR
- Electrolytes
To assess organ problems
HTN Tx
ABCD
ACE-I / ARBS
BB
CCB
Diuretics
Causes of 2 HTN
CHAPS
Cushings Hyperaldosteronism (Conns) Aortic Coarctation Pheochromocytoma Stenosis of Renal Arteries
HTN Emergencies
> 200
IV Meds:
- Labetalol
- Nitroprusside
- Nicardipine
Goal is to lower no more than 25% over first 2 hours to prevent cerebral hypoperfusion
Pericarditis
Pain sharper and worse when lying down (due to stretch on pericardium)
Pain worsens with inspiration
Relieved when sitting up
Pericarditis
Looks on EKG and Tx
PR Depression
Treat- Start NSAIDS then give steroids if no better in 2 days
Pericarditis Diagnosis
CXR, EKG and Echo to rule out MI
EKG changes include ST segment Elevation
PR depressions
T wave inversion
Cardiac Tamponade
Excess fluid in the pericardial sac
compromises ventricular filling and decrease cardiac output
Risk factors for Cardiac Tamponade
Pericarditis Malignancy SLE TB Trauma (Stab wound medial to the left nipple)
Cardiac Tamponade
What is Becks Triad
JVD
Hypotension
Distant Heart Sounds
What Causes Pericarditis
CARDIAC RIND
Collagen Disease Aortic Disection Radiation Drugs Infections Acute Renal Failure Cardiac (MI) Rheumatic Fever Injury Neoplasms Dressler Syndrome
Treatment of Tamponade
Aggressive Volume Expansion with IV fluid
Pericardiocentesis (aspirate will be non clotting blood)
Decomprensation may warrent balloon pericardiotomy and pericardial window
Aortic Aneurysms
Associated wit Atherosclerosis
Most Abdominal
> 90% originate below renal arteries
Aortic Aneurysm HX
Risk factors?
Look for?
Usually asymptomatic
Risks- HTN
- Hypercholesterolimia
- Males > Females
Exam- Pulsitile abdominal mass or abdominal bruits
Diagnosis Aortic Aneurysms
Abdominal Ultrasound
Treatment of Aortic Aneurysms
Asymptomatic- Monitor lesions 5.5 cm Abdominal
>6cm thoracic
Surgery if ruptured
Aortic Dissection
Most commonly 2nd to HTN
Creates false Lumen (intima and adeventia) are affected not true rupture
Occurs at 40-60
M>F
Aortic Dissection HX
Sudden tearing / ripping pain in anterior chest in ascending dissection
Interscapular back pain in descending disection
Pt is typically HTN
Asymmetric pulses and B.P. measurments (20 mmHg difference between arms)
Aortic Dissection Dx
EKG
CXR- widening of the mediastinum, cardiomegaly or new left pleural effusion.
CT angiography is gold standard of imaging
TEE- provide details of thoracic aorta
Aortic Dissection Tx
Monitor and medically manage B.P. and HR necessary
Don’t give Thrombolytics
Dissection of Ascending Aorta- MEDICAL EMERGENCY
Dissection of DECENDING AORTA- Manage with B.P. and HR control
Deep Venous Thrombosis (DVT)
what is the Virchow’s Triad
Clot formation in the large veins of the extremities or pelvis
Virchow’s- Hemostasis, trauma, hypercoagulability
DVT Hx
Unilateral lower extremity pain, erythema and swelling
Homan’s Sign- Calf tenderness with passive foor dorsiflexion
DVT Dx
Doppler ultrasound
Spiral CT or V/Q scan- evaluate for pulmonary embolism
DVT Tx
IV unfractionated heparin
or
SQ low molecular weight heparin
followed by warfarin for 3-6 months
CONSIDER IVC Filter for contraindications to anticoagulation
Lymphedema
Disruption of lymphatic circulation results in peripheral edema and chronic infection of extremities
Complication of surgery or node dissection
Lymphedema Hx
PostMasectomy has upper extremity
Immigrants present with progressive swelling of lower extremities bilateraly
Children present progressive, bilateral swelling
Lymphedema Dx
Diagnosis is clinical
Rule out other causes of edema- Cardiac and Metabolic disorders
Lymphedema Tx
NO CURATIVE TX Exists
Diuretics are ineffective
Exercise, massage and pressure garments to mobilize and limit fluid may help
Peripheral Artery Disease
Occulsion of blood supply to the extremities by atherosclerotic plaque
Lower extremities are most commonly affected
PID Hx
Intermittent claudication (reproducible leg pain that occurs with walking and ALAYS relieved by rest)
Disease preogresses, pain occurs at rest and affect distal extremities
Foot ulcerations develop due to poor perfusion
FEMOROPOPLITEAL DISEASE- Calf Claudication, pulses below femoral artery absent
PID Dx
Measure Ankle and Brachial Systolic BP (Ankle-brachial index ((ABI)))
Normal ABI >1
Pain at rest occcurs with ABI<0.4
PID Tx
Control underlying conditions (smoke, dm)
Exercise best
Drugs:
ASA, cilostazol, thromboxane inhibits may improve symptoms
Angioplasty / stents have variable success rate
Amputation if conservation tx fails
Avoid BB in PID due to B2 mediated peripheral vasoconstriction
Syncope
Sudden temporary less of consciousness and postural tone secondary to cerebral hypoperfusion
Etiologies are either Cardiac or Non-Cardiac
Syncope
Cardiac reasons
Valvular lesions Arrhythmias Pulmonary Embolisms Cardiac Tamponade Aortic Dissection
Syncope
Non-Cardiac
Orthostatic / Hypovolemic Hyptotension Neurologic (TIA / Stroke) Metabolic Abnormalities Neurocardigenci syndromes (Vasovagal) Psychiatric
Syncope Dx
Depends on suspected etiology
Holter Monitor
Echocardiogram
Stress Test
Syncope Tx
Tailored to the etiology
Stable Angina
And Unstable Angina
Stable --------- EKG Negative Stress test + - ST depression Increase 02 demand Releaved by rest
Unstable ---------- New Worse pattern Pain @ rest
