Cardiovascular Flashcards
Blood Flow through the Heart
- Superior Vena Cava
- Right Atrium
- Tricuspid Valve
- RV
- Pulmonic Vavle
- Pulmonary Artery
- Lungs
- Pulmonary Veins
- Left Atrium
- Mitral Valve
- LV
- Aortic Valve
- Aorta
- Body
Heart Sound and Anatomical Locations
S1 = Mitral/Tricuspid (AV) valve closure
S2 = Aortic/Pulmonic (Semilunar) Valve closure
Systole = Period between S1-S2
Diastole = Period between S2-S1
S3 Ken-Tuck-Y, increased fluid states (CHF, pregnancy)
*Leading abnormal heart sound in CHF
S4 Ten-Ne_SSee, stiff ventricular wall (MI, LVH, Chronic HTN)
Valvular Dz
Mitral Stenosis: Loud S1 murmur, mid-diastolic, apical crescendo
Mitral Regurg: S3 with systolic murmur at 5th ICS MCL (apex), may radiate to base or left axilla, musical, blowing or high pitched
Aortic Stenosis: Systolic, blowing, rough, harsh murmur at 2nd ICS, *usually radiates to neck*
Aortic Regurgitation: Diastolic, blowing murmur at 2nd left ICS
Mitral
Regurg
Pulmonic Mr. Pass
Aortic
Stenosis
Systolic Murmurs
When? Beginning is Systolic, end is diastolic
Where? Mid-chest, 5th ICS = Mitral
Upper Chest= Aortic
Murmur Grades
I: Barely audible
II: Audible but faint
III: Moderately loud, easily heard, No thrill
IV: Loud, associated with + thrill
V: Very loud, heard with one corner of stethescope off chest
VI: Loudest, from the doorway
*III=no thrill, IV=thrill
Heart Failure Types
Cardiac Output is insufficent to meet metabolic needs of body
Types:
Systolic: Inability to contract reuslts in decreased CO
-(inotrope, dig)
Diastolic: Inability to relax and fill results in decreased CO
-(Dilator to help relax)
Acute- (L) abrupt onset usually follows MI or valve rupture
Chronic (R) develops as result of inadequate compensatory mechanisms over time to improve cardiac output
Cardiac Definitions
Preload: Filling pressure of the heart at the end of diastole
Afterload: Pressure against which the heart must work to eject blood during systole
Contractility: Strength and vigor of heart’s contraction during systole
Cardiac Index: Volume of blood pumped by the heart based on BSA per minute (L/min)
- Greater the preload, the greater will be the volume of blood in the heart at the end of diastole*
- Lower the afterload, the more blood the heart will eject with each contraction*
NYHA Functional Classification of HF
I: No limitations
II Slight limitation with physical activity but comfortable at rest
III: Marked limitation of physical activity but comfortable at rest
IV: Severe, inability to carry out any physical activity without symptoms, symptoms noted at rest
Left Heart Failure (Acute)
- Dyspnea at rest
- Coarse rales all lung fields
- Wheezing, frothy cough
- Appears generally healthy except with acute exacerbation
- S3 gallop
- Mitral regurg murmur (systolic, loudest at apex)
*Left failure =Lung
Right Heart Failure (Chronic)
- JVD
- Hepatosplenomegaly
- Dependent peripheral edema, result of increased capillary hydrostatic pressure
- PND
- Chronically ill appearance
- Diffuse chest wall heave
- Displaced PMI
- Abdominal fullness
- Fatigue on exertion
- S3 and/or S4
HF Diagnostics
- BMP
- BNP
- U/A
- CXR: Pulm edema, Kerley’s lines (squiggly lines suggest pulm edema), effusions
- Echo: Contraction/relaxation, valvular function, EF
- ECG: may show underlying problem, acute MI, dysrthymia
- PFT’s for wheezing during exercise
- ABG: may show hypoxemia or hypocapnia
HF Management Out-Patient
Non-Pharm
- Sodium restriction (leading reason for decompensation is failure to comply with this!)
- Rest/activity balance
- Weight reduction
- others
Pharm:
- ACE inhibitor: pril
- Diuretics: Thiazide, loop
- Anticoagulation for AF
In-Patient Management of Acute Pulmonary Edema
- O2 while awating ABG’s
- Sitting or semi-Fowler position
- Morphine 2-4mg IVP, MR 20-30 min PRN, stop if hypercapnea occurs
- Furosemide 40mg IVP, MR in 10 min if no response
- If severe bronchospasm occurs, inhaled simpathomimetics (albuterol, terbutaline)
- If severe, afterload and preload reduction with nitroprusside, dyfralazine or others
- If CI remains low, dobutamine 2.5-20 mcg/kg/min (helps pump with increased CO, BP, HR, improves blood flow, decreases peripheral vascular resistance)
- If SBP <100, Dopamine 5-20mcg/kg/min
HTN
Sustained elevation of SBP >140 or DBP > 90 at least 3 times on two different occasions
2 Types:
- Primary/Essential: 95% of all cases, onset <55 years of age
- Secondary: 5% of all cases, secondary to other known causes such as estrogen use, renal dz, pregnancy, endocrine disorders, * renal artery stenosis* (leading cause of secondary)
Exacerbating factors:
- Smoking, obesity, excessive alcohol intake, use of NSAIDS, others
HTN Signs/Symptoms
- Often silent killer
- Elevated BP
- Severe HTN*sub-occipital pulsating HA, early in morning and resolving throught the day*
- *Epistaxis* in adult of no known reason
- Dizziness/Lightheadedness
- *S4 r/t hypertrophy
HTN Diagnostics
- In uncomplicated HTN, labs usually WNL
Diagnostics to r/o:
- Renal Vascular Dz
- CXR if cardiomegaly suspected
- Plasma aldosterone level to r/o aldosteronism
- AM/PM cortisol level to r/o Cushings
U/A, CBC, BMP, Ca+, phos, uric acid, cholesterol, trigylcerides
ECG
PA and Lat CXR
JNC 7 Classifications
Normal <120 AND <80
Pre-HTN 120-139 OR 80-89
Stage I 140-159 OR 90-99
Stage II >160 OR >100
JNC 7 HTN Management- Non-Pharm
Life style changes:
Wight reduction
low sodium diet
avoid/reduce alcohol intake
relaxation/stress management
Exercise 30 min/day, most days week
JNC 7 HTN Management- Pharm
Stage I (SBP 140-159 or DBP 90-99)
- Without compelling indications: thiazide diuretic, consider ACE/ARB, BB, CCB
Stage II (SBP >160 or DBP > 100)
- 2 drug combination: thaizide type AND ACE or ARB, or CCB, or BB
With compelling indications:
- HF: thiazide, BB, ACE, ARB, Aldosterone antagonist (spironolactone, elpirinone)
- Post MI: BB, ACE, Aldosterone antagonist
- High CVD risk: Thiazide, BB, ACE, CCB
- CKD: ACE, ARB
- Recurrent stroke prevention: Thiazide, ACE
*Goal=SBP<130/80 for pt’s with DM or CKD
*
Other HTN Pharm Considerations
Beta Bockers: effective for migraines and angina, in combination iwth diuretics, monitor for wheezing
- (metoprolol, propranolol, atenolol, nadolol (corgard), acebutolol (sectral)
CCB: Effective for Caucasians, not 1st line, monotherapy if BB contraindicated, effective for AF, ATach, migraine or DM
- Dilt, verapamil (calan), amlodipine (Norvasc), nicardipine (Cardene), felodipine(plendil)
Diuretics: Effective for AA, elderly with isolated HTN, CHF (Lasix)
ACE “Pril”: Caucasians <65, **durg of choice in DM**, watch for cough and bronchospasm (in HF switch to ARB)
- Captopril (Capoten), enalapril (Vasotec), benazepril (Lotensin), ramipril (Altace)
1. Adrenergic Inhibitors (Central/eripheral, alpha blocker) - No standard of care for these, use as adjunct therapy
- Clonidine (catapress), methyldopa (aldomet), guanethidine (Ismelin), guanadrel (hylorel), prazosin (mini-press), doxazosin (cardura), labetalol (Normodyne/Trandate), carvedilol (coreg)
ARB: well tolerated
- Used for HTN, HFm preventing kidney damage in pts with DM or HTN
- Most serious SE’s are: kidney failure, liver failure, allergic reactions, angioedema, decreased WBC
- Common SE’s cough, hyperkalemia, low BP, dizziness, HA, drowsiness, diarrhea, abnormal taste, rash
- Candesartan (Atacand), eprosarta (Teveten), irbesartan (Avapro), telmisartan (Micardis), valsartan (Diovan), losartan (Cozaar)
*Use as few meds as needed at lowest dose to get to desired goal*
JNC 8 Tx Threshholds
No classifications
Tx Threshholds
- Do not tx adult <60 until reach 140 OR 90, then tx to <140AND 90
- Tx adults >60 once >150 AND/OR 90, tx to <150 and 90
JNC 8 Important Recs
- CKD in Non-AA, thiazide type diuretic, CCB, ACE or ARB
- In AA= thiazide diuretic CCB, Grade B
- Tx goal: return in one month F/U, then increase drug or add drug
- Do NOT use ACE and ARB together
- Refer to specialist if 3 or more drugs are needed
Lifestyle changes:
- Restrict sodium, DASH diet, weight loss
- Increase to 40 min exercise most days
- Stress management planning
- Reduce or eliminate alcohol <2 drinks for men, < 1 for women daily
- Smoking cessation
- Watch lytes: K, Mag, Ca+
JNC 8 Common Pharm
Thiazide type diuretic-*1st line*
ACE “pril” cause vasodilation, block sodium water retention, watch for cough
ARB “sartan” - reserved for those with ACE intolerance
BB
CCB
Aldosterone antagonists/Central blockers/Alpha antagonists
Special considerations
*neither age nor gender affects agent responsiveness
HTN Urgency
SBP>180 or DBP >110 without target organ damage
Require BP reduction within hours to days
MAy be associated with HA, epistaxis, anxiety
- Upper level stage 2 HTN
- HTN with disc edema
- Progressive target organ complications
- Severe peri-operative HTN
Management
- Oral therapy such as clonidine, captopril, nifedipine, loop diuretics
- Rarely needs parenteral tx (don’t overtx pt)
HTN Emergency
Rare situations that require immediate (w/in 1 hr) BP reduction to prevent or limit end organ damage
Generally SBP> 180/ DBP >120 with target organ dysfunction
*Initial tx goal to reduce MAP by no more than 25% w/in 2 hrs*
- **Malignant HTN: fundoscopic changes include flame shaped retinal hemorrhage, soft exudates and **papilledema (swelling of optic disc with blurred margins)
- HTN encephalopathy
- Intracranial hemorrhage
- Unstable angine
- Acute MI
- Acute LV failure with pulmonary edema
- Dissecting aortic aneurysm
- Ecclampsia
Management:
- If requiring IV agents, critical care bed, invasive arterial pressure monitoring
- Sodium nitroprusside (Nipride) is a potent vasodilator, *drug of choice*, IV at .25 to 10 mcg/kg/min
**AVOID rapid, severe drops in BP as cerebral infarction may occur**
Pressure should be lowered acutely to SBP 160-180 range then gradually with oral therapy over a period of days!
Angina
Decreased blood flow thru vessel=>ischemia
Types:
- Stable: (classic or chronic) Exertional-nost common
- Prinzmetal’s: Occurs at various times, including rest (coronary vasospams=>influx of Ca+, tx with CCB)
- Unstable (pre-infarction, rest or crescendo, coronary syndromes)
- Microvascular (Metabolic syndrome)
Angina Signs/symptoms
- Chest discomfort lasting several minutes
- Exertional precipitated by activity, subsides with rest
- NTG shortens or prevents attacks
Exam findings:
- Signs of peripheral areterial dz
- Levine’s sign=Clenched fist (squeeze vs elephant sitting/MI)
- Transient S4 not uncommon during angina
Angina Diagnostics
- ECG may be normal with down sloping of ST segment or T wave peak or inversion during attack
- Exercise ECG
- Serum lipids-biggest contributor to cardiac dz
- Coronary angio *definitive diagnostic procedure but not indicated solely for diagnosis
Total cholesterol target
<200
Triglycerides Target
<150
HDL Target
>40 Male
>50 Female
LDL Target Healthy persons
<100 mg/dL
LDL Target for Pt’s with Cardiac Dz OR DM
<70
ASCVD risk
Pooled cohort equation for 10 yr risk
Age
sex
race
t chol
HDL chol
SBP
DM
Smkg
Angina Management
- Reduction of risk factors
- Manage diet
- Lower LDL
- Low dose ASA
- Common pharmacotherapy: Nitrates, BB, CCB
- Common pharmacotherapy for hypercholesterolemia: Statins, Niacin, Fibrates (gemfibrozil/Lopid)
MI
Contributes to leading cause of death in adults in US
“clot on plaque”
- Only 1/3 pts give hx of typical anginal pain
- Most MI’s occure at REST: pain is similar to angina but more severe
- NTG has little effect
MI Signs/Symptoms
- Cold sweats
- Syncope
- Impending doom
- Apprehension
- Light-headedness
- Dyspnea
- Cough
- N/V
MI Exam Findings
- Dysrhythmias
- S4 very common
- Wheezing
- Pulmonary crackles
- Low grade fever 1st 48 hrs
- Tachycardia
MI Diagnostics
ECG changes -almost 30% have no initial changes
- Peaked T waves, ST elevation, Q wave development (may not have Q waves in 30-50% MI’s)
- I,AVL, V5, V6- Left lateral wall
- II,III, AVF- Inferior wall
- V2-V4 Anterior wall
- AVR, V1-Right
Cardiac enzyme elevation above normal w/in 4-6hrs (trop-t, trop-I, CKMB), remain high 3 days to 3 weeks
Echo for wall motion, EF assessment
Leukocytosis 10-20 on 2nd day
MI Management
**Door to fibrinolytics-30 min, Door to cath lab-90 min**
- ASA 325 mg chew and swallow (decrease plt aggregation)
- NTG CL
- O2 therapy
- IV KVO- 3 PIV’s total
- 12 lead ECG and tele monitor
- Morphine 2-4mg IVP
- Furosemide for pulm edema 40mg IVP
- if no contraindication: metoprolol 5 mg IV x 3 doses at 2 min intervals, then 50 mg orally Q6 hrs starting 15 min after last IV dose
- ACE most beneficial when pts have failure or large infarction, otherwise should only be considered after fibrinolytics, ASA, BB and nitrates
- Heparin vs LMH (lovenox 1mg/kg)
- Monitor therapeutic coag values
Normal Coag Values
INR 0.8-1.2
ACT 70-120
aPTT 28-38 sec
PT 11-16 sec
pTT 60-90 sec
Therapeutic Coags
INR in MI: 2.5-3.5 x normal
INR Coumadin 2-3
ACT 150-190 or >300 sec post PTCA/Stent
aPTT, PT, pTT all 1.5-2.5 x normal
Indications for Pharm Revascularization
- Unrelieved chest pain >30 min and <6 hrs WITH:
- ST segment elevation >0.1 mV in 2 or more contiguous leads
Absolute contraindications: Active bleeding or risk thereof, including abnormal coag values (check plts as well- 150-400 normal)
Venous Thrombosis
Partial of complete occlusion of a vein by thrombus with secondary inflammation to wall of vessel, may be superficial or deep
Causes:
- Immobility
- Female
- Post-op
- Prolonged BR
- Oral contraceptives, esp smokers
- Hypercoagulability
Superficial Thrombosis
Sudden onset pain
Localized heat/erythema
Low grade temp
No labs needed
Management:
- Elevation
- Warm compress
- NSAIDS
- D/C oral contraceptives
DVT
Suden onset pain
Painor tenderness while walking
May present as dull ache or tightness
Physical exam:
- Edema distal to occlusion
- low grade temp
- Skin cool to touch
Management:
- BR with elevated extremity until tenderness subsides 7-14 days
- Walking gradually reintroduced
- Lovenox 1mg/kg Q 12 h OR
- Heparin infusion for 7-10 days
- Coumadin x 12 weeks
- Consultation when anti-coag therapy instituted
PVD
Atherosclerotic narrowing of lumen of arteries resulting indecreased blood supply to the extremities
Causes:
- Atherosclerosis
- similar risk factors as CAD
- Peak incidence 40-70 yrs
- Hyperlipidemia
- smkg
- DM
PVD Sign/Symptoms
Calf pain (claudication)
Cold/numbe extremities
Pain at rest
PVD Exam Findings
- Shiny/hairless skin
- dependent rubor
- Pallor when feet elevated
- Cyanosis
- Ulcerations
- Reduced pulses
PVD Diagnositics
- Doppler US
- ABI (ankle-brachial index)
- XR may show calcification
- Arteriography: most definitive test
PVD Management
- Stop smkg and all tobacco use
- Exercise (1hr per day, stopping during pain and resuming when pain stops to devlop collateral circulation)
- Pentoxifylline (Trental)
- Cilostazol (Pletal)
- Weight reduction as needed
- Manage DM and hyperlipidemia
- Angioplasty
- Bypass
- Amputation
Chronic Venous Insufficiency (CVI)
Impaired venous return d/t either destruction of valves, changes d/t deep thrombophlebitis, leg trauma, or sustained elevation of venous pressure
- More common in women than mes
- Genetic predisposition
- Hx of leg trauma, ?assoc with varicose veins
CVI Signs/ Symptoms
- Aching LE’s relieved by elevation
- Edema after prolonged standing
- Night cramps of LE’s
CVI Exam Findings
- Trophic changes with brownish discoloration
- Stasis leg ulcers
- Edema of LE’s
- Dermatitis
- Cool to touch
CVI Diagnostics
None specific to CVI dx
Testing to r/o edem r/t HF and other causes
CVI Management
- Bed rEst with legs elevated to diminish chronic edema
- Support hose
- Weight reduction as needed
- Treat dermatitis or ulcers
- Adute weeping dermatitis:
- WEt compress
- 0.5% hydrocortisone cream after compress
- systemic ATB only if active bacterial infection
Pericarditis
Inflammation of pericardium. HX imprtant to accurate dx!
Causes:
- Viruses *most common cause*
- Post MI
- Renal failure
- Neoplasm, TB, Septemia
- Endocarditis
- Collagen dz
- Drug/Trauma induced
- Idiopathic (viral)
Pericarditis Signs/ Symptoms
- Localized restrosternal/precordial CP, pleuritic in nature
- Pain increased by deep inspiration, swallowing, recumbent position
- Pain releived by sitting forward
- SOB secondary to pain with inspiration
Pericarditis Exam Findings
- Pericardial friction rub characteristically present
- Pleural friction rub may also be present
- Fever based on underlying cause
Pericarditis Diagnostics
- ST eleation in all leads
- Return of ST to WNL in few days followed by temp T wave inversion
- ESR elevation
- BC if suspected bacterial cause
- CBC to r/o infection or leukemia
- Echo confirms presence of pericardial fluid
- BMP
Pericarditis Management
- **NSAIDS are mainstay of Tx**
- Ibuprofen, Indomethicin
- Corticosteroids only when total failure of NSAIDS over several weeks with relapsing
- Dexamethasone may releive pain in few hours. Prednisone 60mg daily then tapered
- Codeine 15-60mg QID
- Monitor for tamponade
Endocarditis
Infection of the endothelial surface of the heart.
Usually affects the valves.
Infective endocarditits must be considered in all pts with heart murmur and FUO!
Causes:
Bacteria!!
Valvular heart dz, rheumatic, bicuspid aortic valve/mitral valve prolapse with significant regurg
Recent dental/mouth surgery
GU or Respiratory instrumentation
Congential heart dz
Prolonged IV or TPN
Burns
HD
Endocarditis Signs/ Symptoms
- Fever and malaise
- Night sweats and weight loss
- Sick feeling
Endocarditis Exam Findings
- Murmur, maybe absent in 30% pts
- Med to high fever
- Osler’s nodes: painful, red nodules in distal phalanges
- Petechie, purpura, pallor
- Splinter hemorrhage
- splenomegaly in 50%
- Janeway lesions-small painful macules on palms and soles
- Roth spots: small retinal infarcts, white encircled by hemorrhage
Endocarditis Diagnostics
- WBC normal or elevated, always left shift with bands
- Echo
- BC 3 at 3 sites
- ESR elevated
Endocarditis Management
Patients who aren’t acutely ill looking and have no signs of HF or major embolic events, ATB are preferably withheld until BC available
In all other pts, empiric ATB started:
- PCN G 2 million units IV q 4 H in combination with Gent
- Nafcillin 2 gm IV q 4 H
- Vanc MRSA
- Others
Heart failure causes physiologic changes in the body due to what process?
an increase in capillary hydrostatic pressure
Which murmur is associated with syncope?
Aortic stenosis
