Cardiovascular Flashcards
What are common reasons for Chest Pain
MI: Dull, Aching, Pressure, Tightness, Squeezing. Usually noted with exercise, stress from cold exposure or meals, resolve once inciting even is over
Unstable Angina: Sx may occur at rest
Hypertrophy of Ventricles such as with aortic stenosis or hypertrophic cardiomypathy: Results in ischemic pain
Pericarditis: Pain usually greater when spine and upright
Aortic Dissection: Abrupt onset of tearing pain that radiates to back
Pleuritic chest pain: Not ischemic
Pain with palpation indicative of musculoskeletal origin
Dyspnea on exertion results from what
Elevated left atrial and pulmonary venous pressure or from hypoxia
Dyspnea can be indication of what
Heart Disease
Pulmonary Disease
What can Heart Disease dyspnea be differentiated from Pulmonary Disease dyspnea
BNP which can dx HF
What is Orthopnea
Dyspnea that occurs in recumbency and results from increase in central blood volume when supine
What can Orthopnea be an indication of
Pulmonary Disease
Obseity
What is Paroxysmal Nocturnal Dyspnea
SOB occurring abruptly 30 minutes to 4 hours after going to bed, relieved after 10-20 minutes by sitting up or standing
Usually specific to cardiac disease
What are Palpitations
Awareness of the heartbeat
What do Palpitations refelct
Increased cardiac or stroke output
May be due to increased stroke volume from cardiac abnormalities
What is Cardiogenic Syncope
Results from bradyarrhythmias, very rapid supraventricular rhythms or ventricular tachycardia or fibrillation
Usually occurs at rest
What else can cause Cardiogenic Syncope
Aortic Stenosis
Hypertrophic Cardiomypathy
What is the NYHA classification system (Class I - Class V)
Class I: No limitation of physical activity
Class Ii: Ordinary physical activity results in sx
Class III: Comfortable at rest, less than ordinary activity causes sx
Class IV: Unable to engage in physical actiity without discomfort. Sx may present even at rest
Class V: Atypical sx, occur at rest or with exertion
What are the ACC/AHA Stages (Stage A - Stage D)
Stage A: High risk for heart failure but not structural heart disease
Stage B: Structural HD but no sx
Stage C: Structural HD with current or prior sx
Stage D: Refractory HF requiring device or special intervention
What is Paroxysmal Supraventricular Tachycardia
Frequently associated with palpitations Abrupt onset/offset Rapid, regular rhythm (140-280 bmp) Most commonly seen in young adults Rarely causes syncope Usually see narrow QRS complex Often responds to vagal maneuvers, AV nodal blockers or adenosine
Sx of SVT
Asymptomatic
Palpitations
Some have chest pain, SOB, diaphoresis, syncope
Dx of SVT
EKG: Rapid beat of 140-280 bmp, regular.
Tx of SVT
Most resolve spontaenously
Valsalva, Carotid Sinus Massage, Facial contact with cold water
Adenosine is first line med
If Adenosine fails, use CCB like Verapamil and diltiazem
Beta-Blockers like Esmolol, Propranolol, Metoprolol
If hemodynamically unstable: Cardioversion
What are preventative measures for SVT
Catheter Ablation
CCB: Diltiazem and Verapamil which block AV node
What is Wolff-Parkinson-White Syndrome
Supraventricular Tachycardia due to an accessory AV pathway (Preexcitation Syndrome)
These are specifically through Kent bundles
Sx of Wolff-Parkinson-White Syndrome
Palpitations
Syncope
Rapid, Regular Rhythm
Dx of Wolff-Parkinson-White Syndrome
EKG: Short PR interval with Delta Wave
Tx of Wolff-Parkinson-White Syndrome
Catheter Ablation
What is Atrial Fibrillation
Most common chronic arrhythmia
Irregularly irregular rhythm
Often associated with palpitations or fatigue
What is the concern with Atrial Fibrillation
Can lead to LV dysfunction, HF, or MI
Thrombus formation due to stasis in atria that can embolize to cerebral circulation (stroke)
Sx of Atrial Fibrillation
Asymptomatic
Palpitations
Dx of Atrial Fibrillation
EKG: Erratic, disorganized atrial activity between discrete QRS complexes occurring in an irregularly pattern
Tx of Atrial Fibrillation for hemodynamically unstable patient
Hospitalization
IV Beta Blockers (Esmolol, Propranolol, Metoprolol) and IV
CCB (Diltiazem and Verapamil) for rate control
Cardioversion if patient in shock or severe hypotension, pulmonary edema, ongoing MI or ischemia
Tx of Atrial Fibrillation for hemodynamically stable patient
Rate control and anticoagulation
Rate Control: Beta-Blocker or CCB
Anticoagulation: Warfarin, ASA
If cardioversion is planned, anticoagulation must ben given for 3-4 weeks prior
What is Atrial Flutter
Regular Heart Rhythm Often Tachycardic (100-150) Palpitations, Fatigue Sawtooth pattern on EKG Often seen with COPD or structural HD
Tx of Atrial Flutter
Ventricular rate control: Beta-Blocker or CCB
Chronic: Catheter Ablation is definitive
What is Ventricular Tachycardia
Fast, Wide QRS complex
Associated with structural heart disease
Associated with syncope
What defines Ventricular Tachycardia
3 or more consecutive ventricular premature beats
Sx of Ventricular Tachycardia
Asymptomatic
Syncope
Dx of Ventricular Tachycardia
Wide QRS
Hypokalemia
Hypomagnesemia
Tx of Ventricular Tachycardia
Beta-Blocker
What is a complication of Ventricular Tachycardia and what is its treatment
Torsades de Pointes
QRS morphology twists around the baseline
May occur in hypokalemia, hypomagneseia
Tx: IV Magnesium
What is Ventricular Fibrillation
Disorganized electrical activity in the ventricles
Tx for Ventricular Fibrillation
Defibrillation + CPR
What is a Ventricular Premature Beat (PVC)
Isolated beats originating from ventricular tissue
Sudden death occurs in presence of organic heart disease
Sx of PVCs
Skipped beat
Palpitations
Dx of PVCs
EKG: Wide QRS that differ in morphology, usually not preceded by P-wave
Tx of PVCs
If no cardiac disease: No tx needed
Beta-Blockers on CCB are 1st line
Catheter ablation for sx patients who don’t respond to medication
What is a First Degree AV Block
Tx
Constant prolonged PR interval
Every P-wave is followed by QRS
Tx: None
What is a Second Degree AV Block, Type I (Mobitz I/Wenckebach)
Progressively elongated PR intervals until a QRS is eventually dropped
Tx: Atropine, Epinephrine, Pacemaker if symptomatic
What is a Second Degree AV Block, Type II (Mobitz II)
Constant PR Interval until a QRS is eventually dropped
Tx: Permanent Pacemaker
What is a Third Degree AV Block
P-waves don’t relate to QRS
AV Dissociation
Tx: Permanent Pacemaker
What is Sick Sinus Syndrome
Applied to patients with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia
Often caused by medications like digitalis, CCB, Beta-Blocker, Antiarrhythmics
Sx of Sick Sinus Syndrome
Asymptomatic
Syncope, dizziness, confusion, palpitations, HF, angina
Tx of Sick Sinus Syndrome
Permanent pacing if sx
What leads to LV failure
Systolic or diastolic dysfunction
Results in low CO and congestion, including dyspea
What leads to RV failure
LV failure leads to RV failure
Sx of fluid overload
What is the definition of Hypertension
At least 2 elevated BP readings on 2 different visits
Systolic >140 or Diastolic >90
What is primary Hypertension
Due to Idiopathic etiology
Usually strong family history
What is secondary HTN
Due to underlying, identifiable and correctable cause
Most commonly due to Renal Artery Stenosis, Primary Hyperaldosteronism, Coarctation ofAorta, Pheochromoctyoma
What are complications for HTN
CAD, HF, MI, LVH, TIA, Stroke, Renal Stenosis and Sclerosis, Retinal Hemorrhage, Blindness, Retinopathy
Sx of HTN
Papilledema: Advanced stage of malignant HTN
Striae, Carotid Bruits, JVD, Polycystic kidneys, bruits over renal artery, decreased femoral pulses
Tx of HTN
Goal is <140/90
If Diabetic, goal is <130/80
Lifestyle modifications first: weight loss, dash diet, exercise, limit alcohol
Diuretics: Initial therapy (HCTZ, Chlorthalidone, Furosemide, Spironolactone, Amiloride)
Ace-I: HTN especially with DM, nephropathy, CHF
CCB: HTN, Angina, Raynaud’s
Beta-Blockers: HTN, Angina
What is a Hypertensive Urgency
BP >220/120 without end-organ damage
Tx of HTN Urgency
Decreased BP by 25% in first 24-48 hours using PO agents
What is Hypertensive Emergency
BP>220/120 with end-organ damage
End-Organ Damage: Encephalopathy, Stroke, ACS, HF, Aortic Dissection, AKI, Proteinuria, Hematuria,
Tx of HTN Emergency
Decreased BP by 10% in the 1st hour and an additional 15% next 2-3 hours using IV agents
What is Cardiogenic Shock
Results from heart failure with inadequate tissue perfusion
Evidence of tissue hypoxia due to decreased cardiac output with adequate intravascular volume
What causes Cardiogenic Shock
Cardiac disease such as MI, myocarditis, valvular dysfunction, Cardiomyopathy
Tx of Cardiogenic Shock
Oxygen
Isotonic fluids, but avoid aggressive IV fluids
Inotropic support: Dobutamine, Epinephrine, Amrinone
Treat underlying cause: MI
What is the body’s normal response to avoid Orthostatic Hypotension
Vasoconstriction occurs when someone goes from a laying down to sitting or sitting to upright posture which compensates for the abrupt decrease in venous return
What are causes of Orthostatic Hypotension
Diabetics with autonomic neuropathy
Blood loss or Hypovolemia
Vasodilators, diuretics and adrenergic-blocking medications
What is Heart Failure
The inability of the heart to pump sufficient blood to meet the metabolic demands of the body at normal filling pressures
What is the most common cause of Heart Failure
Coronary Artery Disease
What happens with Left sided heart failure
Low cardiac output and elevated pulmonary venous pressure
Sx of left sided HF
Dyspnea
Initially exertional dyspnea then orthopnea
Pulmonary Congestion: Rhonchi, nonproductive cough
What happens with right sided HF
Left sided HF leads to right sided HF
Sx of right sided HF
Fluid retention
Elevated JVD, Peripheral Edema
GI/Hepatic Congestion
Dx of HF
Echocardiogram is 1st: Can determine Ejection Fraction
CXR: May see pleural effusions, Kerley B Lines
BNP: Results from volume overload
What are the 2 drugs that all patients with HF should be on
ACE-I and Diuretics
What is 1st line treatment for HF
ACE-I
What are the drugs that decrease mortality in HF
ACE-I, ARB, Beta-Blockers, Hydralazine + Nitrates, Spironolactone, Amiloride, Dopamine
What are the drugs that help with sx in HF
Diuretics, Digoxin
What drugs should HF patients be on
ACE-I + Diuretic at first then eventually add a Beta-Blocker
What is indicated in a patient with HF with EF <35%
Implantable Cardioverter Defibrillator
What is CHF
Decompensated HF with worsening of baseline sx characterized by pulmonary congestion
Sx of CHF
Worsening dyspnea, rales, pink frothy sputum
What do see on CXR with CHF
Cephalization of flow: Increased pulmonary venous pressure
Kerley B Lines
Tx of CHF
LMNOP Lasix Morphine Nitrates Oxygen Position (place upright to decrease venous return
What is Acute Pericarditis
Acute inflammation of pericardium
What are the P’s of Acute Pericarditis
Persistent, Pleuritic, Postural pain and Pericardial friction rub
What are causes of Acute Pericarditis
Viral: Coxsackie and Echovirus, Adenovirus
Neoplastic
Dressler’s Syndrome (Pericarditis 2-5 days after an MI)
Sx of Acute Pericarditis
Pleuritic chest pain relieved with leaning forward
Radiates to trapezius, back, neck, shoulder, arm
Pericardial Friction Rub
Dx of Acute Pericarditis
EKG: See ST elevations in precordial leads (concave up in V1-V6) and PR depressions
Echo: Look for effusions or tamponade
Tx of Acute Pericarditis
ASA or NSAIDS for 7-14 days
Colchicine is 2nd line
Corticosteroids if >48 hours or refractory
What is a Pericardial Effusion
Increased fluid in the pericardial space
What causes Pericardial Effusions
Pericarditis, Infection, Radiation Therapy, Dialysis, Collagen Vascular Disease
Sx of Pericardial Effusions
Distant Heart Sounds
Dx of Pericardial Effusions
EKG: Low voltage QRS complexes, Electric Alternans (QRS that differ in size regarding tall/short peaks)
Echo: Increased pericardial fluid
CXR: Cardiomegaly
Tx of Pericardial Effusions
Observation if small
Pericardiocentesis if tamponade or large effusion
What is Pericardial Tamponade
Pericardial effusions that causes significant pressure on the heart and results in restriction of ventricular filling and therefore decreased CO
Sx of Pericardial Tamponade
Beck’s Triad: Distant heart sounds, Increased JVP, Systemic Hypotension
Pulsus Paradoxus: >10mmHG systolic BP DROP with inspiration
Dyspnea, Fatigue, Peripheral Edema, Hypotension
Dx of Pericardial Tamponade
Echo: See effusions and diastolic collapse of cardiac chambers
Tx of Pericardial Tamponade
Pericardiocentesis
What is Constrictive Pericarditis
Thickened, fibrotic, calcified pericardium that restricts ventricular diastolic filling
Leads to increased venous return and decreased stroke volume and decreased CO
Sx of Constrictive Pericarditis
Dyspnea
Right sided HF signs (Increased JVD, peripheral edema, N/V)
Kussmaul’s Sign: JVD during inspiration
Pericardial Knock
Dx of Constrictive Pericarditis
Echo: Pericardial thickening
CXR: Pericardial Calcification
Tx of Constrictive Pericarditis
Pericardiectomy
Diuretics for sx
What is Myocarditis
Inflammation of the heart muscle
What are common causes of Myocarditis
Viral: Enterovirus like Coxsackie B and Echovirus
Rickettsial
Systemic Lupus, Rheumatic Fever
Sx of Myocarditis
Viral Prodome: Fever, Myalgias, Malaise
HF symptoms: Dyspnea, Syncope, Tachypnea, Tachycardia
Pericarditis Simultaneously
Dx of Myocarditis
What is the gold standard
Endomyocardial Biopsy is gold standard: SEe infiltrations of lymphocytes with myocardial necrosis
CXR: Cardiomegaly
CK-MB and Troponin
Echo: Ventricular dysfunction, Pericardial effusion
Tx of Myocarditis
Supportive CHF tx (Diuretics, ACE-I, Dopamine)
What is Cardiomyopathy
Disease of the heart muscle associated with cardiac dysfunction in the absence of heart disease
What is Dilated Cardiomyopathy
Systolic Dysfunction leads to ventricular dilation
What causes Dilated Cardiomyopathy
Idiopathic
Viral (Coxsackie B, Echovirus), Parvovirus B-19
Alcohol Abuse
Infiltrative
Sx of Dilated Cardiomyopathy
HF sx
Embolic Events: Arrhythmias, Chest Pain
Dx of Dilated Cardiomyopathy
Echo: See LV dilation, Large venticular chamber, Reduced EF
CXR: Cardiomegaly, Pulmonary edema, pleural effusions
Tx of Dilated Cardiomyopathy
HF Tx: ACE-I, Diuretics, Digoxin, Beta Blockers
What is Restrictive Cardiomyopathy
STIFF Ventricles
Imparied diastolic function with preserved contractility
Ventricular rigidity impedes ventricular filling
What causes Restrictive Cardiomypathy
Infiltrative Diseases such as amyloidosis, sarcoidosis
Sx of Restrictive Cardiomyopathy
Right sided HF sx
Kussmaul’s Sign (JVP increases with inspiration)
Dx of Restrictive Cardiomyopathy
Echo: Ventricles nondilated with normal wall thickness, Dilated of both atrium, Diastolic dysfunction with normal systolic function
CXR: Enlarged Atrium, normal ventricular chamber size
Tx of Restrictive Cardiomyopathy
Symptomatic (diuretics, vasodilators)
What is Hypertrophic Cardiomyopathy
Inherited genetic disorder of inappropriate LV or RV hypertrophy (especially septal)
How does Hypertrophic Cardiomyopathy leads to sx
Septum is hypertrophic and the systolic anterior motion of mitral valve is displaced
Sx of Hypertrophic Cardiomyopathy
Dyspnea Angina Syncope Arrhythmias, Palpitations Sudden Cardiac Death Murmur: Harsh Systolic Crescendo-Decrescendo heard at LUSB
How is the murmur in Hypertrophic Cardiomyopathy INCREASED
Decreased Venous Return
Valsalva and Standing
How is the murmur in Hypertrophic Cardiomyopathy DECREASED
Increase Venous Return
Squatting, Lying Down
Increasing Venous Return leads to pushing the septum towards the left side of the heart which leads to closure of the aortic valve outflow, therefore decreasing murmur sound
Dx of Hypertrophic Cardiomyopathy
Echo: Asymmetric wall thickness
EKG: LVH
Tx of Hypertrophic Cardiomyopathy
Beta-Blockers are 1st line Myomectomy Alcohol septal ablation Avoid strenuous activity and dehydration May need Implantable Cardio Defibrillator as these patients are likely to die from arrhythmias
What is Rheumatic Fever
An acute autoimmune inflammatory multi-systemic illness affecting kids 4-15 yrs old
Usually post-Strep infection (Group A Beta-Hemolytic Strep aka Strep. Pyogens)
What are complications that can happen with Rheumatic Fever
Mitral Valve Disease
What is the name of the diagnostic criteria for Rheumatic Fever
Jones Criteria
Dx for Rheumatic Fever
Recent Strep + 2 Major Recent Strep + 1 Major + 2 Minor Major -J: Joints, Migratory Polyarthritis -O: Active Carditis -N: Nodules, Subcutaneous Nodules -E: Erythema Marginatum -S: Sydenham's Chorea
Minor
-Fever, Arthrlagias, Increased ESR/CRP/Leukocytosis, EKG with prolonged PR intervals
Tx for Rheumatic Fever
Penicillin G
ASA for 2-6 weeks with taper or Corticosteroids in severe cases
What are maneuvers to INCREASE murmurs
Squatting, Leg Raises, Laying down
-ALL murmurs are increased with these maneuvers EXCEPT Hypertrophic Cardiomyopathy
Inspiration increases venous return on right side of heart
Expiration increases venous return on left side of heart
What are maneuvers to DECREASE murmurs
Valsalva/Standing
-All murmurs are decreased with these maneuvers EXCEPT Hypertrophic Cardiomyopathy
Expiration decreases venous return on right side of heart
Inspiration decreases venous return on left side
What are the features of the Aortic Stenosis Pathophysiology Etiology Sx Murmur Sound Radiation Pulse Tx
Pathophysiology: LV outflow obstruction leads to fixed CO
Etiology: Degeneration, Congenital, Rheumatic Disease
Sx: Angina, Syncope, CHF
Murmur Sound: Systolic ejection crescendo-decresendo at RUSB
Radiation: Carotid Arteries
Pulse: Pulsus Parvus (weak delayed pulse)
Tx: Aortic valve replacement when symptomatic
What are the features of Mitral Regurgitation Pathophysiology Etiology Sx Murmur Sound Radiation Pulse Tx
Pathophysiology: Backflow from LV into LA
Etiology: MVP, Ischemia
Sx: Dyspnea, Pulmonary Edema
Murmur Sound: Blowing Holosystolic Murmurs at Apex
Radiation: Axilla
Pulse: Brisk Upstroke
Tx: Vasodilators (ACE-I), Valve repair preferred
What are the features of Mitral Valve Prolapse Pathophysiology Etiology Sx Murmur Sound Radiation Pulse Tx
Pathophysiology: Floppy, Redundant Valve
Etiology: Younge Women
Sx: Asymptomatic, Autonomic dysfunction (chest pain, panic attcks, arrhythmias)
Murmur Sound: Midsystolic Ejection Click at apex
Radiation: N/A
Pulse: N/A
Tx: Reassurance, Beta Blockers if symptomatic
What are the features of Aortic Regurgitation Pathophysiology Etiology Sx Murmur Sound Radiation Pulse Tx
Pathophysiology: Backflow from Aorta to LV
Etiology: Rhumatic disease, HTN, Endocarditis
Sx: Left Sided HF
Murmur Sound: Diastolic Decrescendo Blowing at LUSB
Radiation: Left Sternal Border
Pulse: Bounding pulses, Wide pulse pressure
Tx: Vasodilators, Surgery if symptomatic
What are the features of Mitral Stenosis Pathophysiology Etiology Sx Murmur Sound Radiation Pulse Tx
Pathophysiology: Obstruction of flow from LA to LV, Pulmonary HTN
Etiology: Rehumatic Heart Disease
Sx: Right Sided HF, Pulmonary HTN, Atrial Fibrillation
Murmur Sound: Diastolic Rumble at Apex
Radiation: None
Pulse: Reduced intensity
Tx: Valvotomy in young patients
What is Angina
Substernal chest pain that is often brought on by exertion
What causes Angina
CAD
Coronary Artery Spasms
Cardiomyopathy
What are Risk Factors for Angina
DM, Hyperlipidemia, Smoking, HTN, Family hx of CAD
Sx of Angina
Substernal chest pain, may radiate to arm, lower jaw, back, shoulder
Lasts <30 minutes
Relieved by NTG
Caused by Fixed coronary artery stenosis
Dyspnea, Nausea, Vomiting, Diaphoresis or numbness
Dx of Angina
Gold Standard
Coronary Angiogram is gold standard
EKG: See ST depression with exertion, T-Wave Invesions
Stress Test: Best screening tool
When is PTCA indicated
1 or 2 vessels that don’t involve the Left Coronary Artery + Normal or near normal EF
When is a CABG indicated
Left Main Coronary Artery Disease
Sx 3 vessel disease
Left Ventricular EF < 40%
What are indications for Nitrates (NTG) and how does it work
Angina
Can give up to 3 doses, if need more than 3 doses suspect CAD
Increased blood supply, decrease demand by decreasing cardiac work and decreasing preload
What are indications for beta blockers in Angina/CAD and how does it work
1st line for chronic management
Increased myocardial blood supply
Decreases demand by reducing myocardial o2 requirements during exercise/stress
What are indications for CCB in Angina/CAD and how does it work
Increases myocardial blood supply
Effective at terminating coronary vasospasms by increasing coronary vasodilation and prolonging filling time
What are indications for ASA and how does it work
Plays a role in slowing or stopping the progression of stable angina to CAD
Prevents platelet activation/aggregation
What are the categories of Acute Coronary Syndrome
Unstable Angina, NSTEMI, and STEMI
What causes ACS
Acute plaque rupture and coronary artery thrombosis
Coronary artery vasospasms
What are risk factors for ACS
DM, males, age, HTN, Hyperlipidemia, family hx, smoking, obesity
Sx of Acute Coronary Syndrome
Retrosternal chest pain that is not relieved with rest or NTG
May radiate to arms, neck, back, shoulders, epigastrium, lower jaw
Anxiety, diaphoresis, tachycardia, N/V, Palpitations, Dizziness
Dx of ACS
EKG
- Unstable Angina/NSTEMI: T-wave inversion/ST depression
- STEMI: ST elevations
What does the location of the ST Elevations/Depression tell you about the location of the MI
V1-V4: Anterior Wall/Septal I, aVL, V5, V6: Lateral Wall I, aVL, V4, V5, V6: Anterolateral II, III, aVF: Inferior ST Depressions at V1-V2: Inferior
What are 2 cardiac markers to measure MI
Troponin
CK/CK-MB
What are indications for ASA use during an MI
Prevents platelet aggregation, used to stop or slow progression
Everyone should be on ASA
What are indications for Unfractionated Heparin for MI
Give if history of ACS, EKG changes or positive cardiac markers
What are indications for Low Molecular Weight Heparin for MI
Give if history of ACS, EKG changes or positive cardiac markers
This is better than UFH because LMWH has longer half life and don’t need to monitor PTT
What are indications for Plavix (Clopidogrel) in an MI
Useful for initial tx in people with allergy to ASA
What are additional therapies used in an MI
Morphine: Relieves pain and anxiety O: Oxygen N: Nitrates A: ASA B: Beta Blockers A: Ace-Inhibitors S: Statins H: Heparin
What are the 3 parts to approach a STEMI
Reperfusion, Antithrombotic Therapy, Adjunctive Therapy
What is included in Reperfusion Therapy in a STEMI
PCI or Thrombolytics
Thrombolytics: Alteplase (rTPA), Streptokinase
What are Antithrombotic Therapies in a STEMI
ASA, UFH/LMWH/GP IIb/IIIa Inhibitors
What are Adjunctive Therapies in a STEMI
Beta-Blockers Ace-I Nitrates Morphine Statin Therapy
What adjunctive therapies in a STEMI reduce mortality vs. control symptoms
Reduce MortalitY: Beta-Blockers, Ace-I
Symptoms: Nitrates, Morphines
What are 2 common Coronary Vasospasm Disorders
Prinzemetal’s Angina
Cocaine Induced MI
What is Prinzemetal’s Angina
Coronary spasms that lead to transient ST elevations
Sx of Prinzemetal’s Angina
Chest pain at rest, usually in the mornings with hyperventilation
Dx of Prinzemetal’s Angina
EKG: Transiet ST Elevations which resolve with CCB and NTG
Angiography: No fixed stenotic lesions
Tx of Prinzemetal’s Angina
CCB is 1st line
Nitrates as needed
What is Cocaine Induced MI
Coronary spasms
Cocaine activates the sympathetic nervous system and alpha-1 receptors which lead to vasoconstriction of the coronary arteries
Dx of Cocaine Induced MI
EKG: Transient ST elevations that may induce an MI if prolonged
Tx of Cocaine Induced MI
CCB and Nitrates to reverse vasospasms
ASA, Heparin, Benzodiazepines
No beta-blockers because they increase the risk of vasospasms (unopposed alpha-1 constriction)
What is Infective Endocarditis
Infeciton of the endothelium/valves secondary to colonization during bacterial infection
What is the most common valve involved in Infective Endocarditis
Mitral Valve
What are the pathogens involved with the different types of Endocarditis/Valve Involvement Normal Valves Abnormal Valves Prosthetic Valves IV Drug Users
Normal Valves: Strep Viridans (oral flora), Staph Aureus
Abnormal Valves: Strep Viridans
Prosthetic Valves: Staph Epidermis
IV Drug Users: Staph Auerus
Sx of Infective Endocarditis
Fever
Janeway Lesions: Painless erythematous macules on palms/soles
Roth Spots: Retinal Hemorrhage with plae center
Osler’s Nodes: Tender nodules on pads of digits
Splinter Hemorrhages
Dx of Infective Endocarditis
Modified Duke Criteria: 2 major, or 1 major+ 3 minor, or 5 minor
-Major: 2 positive blood cultures, Positive Echo
Minor
-Minor: Predisposing condition, fever, vascular and embolic phenomena, Immunologic phenomena, Positive blood culture with atypical pathogen, positive echo
Tx of Infective Endocarditis
Native Normal Valve: Nafcillin + Gentamicin for 4-6 weeks (vancomycin if PCN allergy)
Native Abnormal Valves: Penicillin/Ampicillin + Gentamicin (Vancomycin if PCN allergy)
Prosthetic Valve: Vancomycin + Gentamycin + Rifampin
Fungal: Amphotericin B, Caspofungin
What is Peripheral Artery Disease
Atherosclerotic disease of the lower extremities
Sx of PAD
Intermittent claudication
Reproducible pain/discomfort in LE brought on by exercise/walking and relieved with rest
Resting leg pain indicates severe disease
Gangrene
Lateral Malleolar Ulcers
Atrophic skin changes (muscle atrophy, thin/shiny skin, hair loss, thick nails)
Decreased or absent pulses, reduced capillary refill
Dx of PAD
Arteriograph is gold standard
Ankle-Brachial Index
Duplex B mode ultrasound
Tx of PAD
Platelet Inhibitors: Cilostazol, ASA, Plaix
Revascularization: Angioplasty, Bypass graft, Endarteretomy
Exercise, reduced risk factors(HTN, DM, Lipid)
Amputation if gangrene
Acute Arterial Occlusion: Haperin for embolism, Thrombolytics if thrombus
What is an Abdominal Aortic Anuerysm
Focal dilation of the aorta
Risk factors Abdominal Aortic Aneurysm
Atherosclerosis
Age >60yrs
Smoking
Caucasians, Males
Sx of AAA
Asymptomatic until rupture
Rupture: Severe back or abdominal pain with syncope or hypotension
Tender Pulsatile abdominal mass
Ripping chest pain
Dx of AAA
CT Scan is test of choice
Angiogram is gold standard
Abdominal Ultrasound
Tx of AAA
3-4cm: US every year 4-4.5cm: US every 6 months >4.5cm: Vascular surgeon referral >5.5cm: Immediate surgical repair Beta-Blockers reduce shearing forcers
What is an Aortic Dissection
Tear in the innermost layer of the aorta
Risk Factors for Aortic Dissection
HTN, Age, Vasculitis, Collagen Disorder (Marfans)
Sx of Aortic Dissection
Chest pain, sudden onset of severe tearing or ripping chest pain/back pain
Decreased peripheral pulses (variation between left and right arm)
HTN
Dx of Aortic Dissection
MRI Angiography: Gold Standard
CXR: Widening of mediastinum
CT scan with contrast is test of choice
Trans Esophageal Echocardiograph
Tx of Aortic Dissection
Surgical if ascending
Beta-Blockers (Labetalol) with Sodium Nitroprusside if descending
What is Giant Cell Arteritis
A vasculitis seen with Temporal or Cranial Arteries
What should associate with Gian Cell Arteritis
Polymyalgia Rheumatica
What causes Giant Cell Arteritis
Autoimmune, viral infection, vasculitis
Sx of Giant Cell Arteritis
Headache, Scalp Tenderness, Jaw claudication with mastication, acute vision disturbances, fatigue, weight loss
Dx of Giant Cell Arteritis
Biopsy is definitive: See Mononuclear lypmhocyte infiltration, multinucleated giant cells
Increased ESR and CRP
Tx of Giant Cell Arteritis
High Dose Corticosteroids
Methotrexate
What is the biggest concern with Giant Cell Arteritis
Can lead to blindness
What is Thromboangiitis Obliterans
Nonathersclerotic inflammatory disease of small and medium arteries and veins
What is Thromboangiitis Obliterans strongly associated with
Smoking
Sx of Thromboangiitis Obliterans
Superficial Migratory Thrombophlebitis: Tender nodules that follow venous distribution
Claudication of ditis/toes
Raynaud’s Phenomenon
Dx of Thromboangiitis Obliterans
Aortography: Nonatherosclerotic, segmental occlusive lesions of small/medium vessels with corkscrew collaterals
Tx of Thromboangiitis Obliterans
Stop Smoking is definitive
Would care
CCB for Raynaud’s (Nifedipine, Nicardipine, Amlodipine)
What is Superficial Thrombophlebitis
Inflammation of the superficial vein or thromus
What is Superficial Thrombophlebitis commonly associated with
IV cathetrization, trauma, pregnancy and varicose veins
Sx of Superficial Thrombophlebitis
Local Phlebitis: Tenderness, pain, inducration, edema, erythema along the course of the superfical vein, palpable cord
Dx of Superficial Thrombophlebitis
Ultrasound: Non-compressible vein with clot and vein thickening
Tx of Superficial Thrombophlebitis
Supportive: Elevation, warm compresses, NSAIDS, compression stockings
How do you develop a DVT
Virchow’s Triad: Venous Stasis, Endothelial Damage, Hypercoagulability
Sx of DVT
Unilateral swelling/edema of the LE
Calf Pain/Tenderness
Phlebitis: Local warmth, erythema, palpable cord
Dx of DVT
Venous Duplex Ultrasoud
D-Dimer
Venograph is gold standard
Tx of DVT
Anticoagulation: UH, LMH, Warfarin
IVC Filter for people with contraindications or who fail anticoagulation
What are Varicose Veins
Dilated, Tortuous Superficial veins
Who gets Varicose Veins
OCP, Pregnancy, Prolonged Standing, Obesity
Sx of Varicose Veins
Tortuous Veins
Dull ache or pressure, worse with prolonged standing and relieved with elevation
Venous Stasis Ulcer
Tx of Varicose Veisn
Leg elevation, compression stockings
Sclerotherapy
What is Chronic Venous Insufficiency
Vascular incompetency of either deep or superficial veins
Sx of Chronic Venous Insufficiency
Leg pain: Burning, aching, Throbbing, cramping
Leg Edema
Stasis Dermatitis: Eczematous rash, itching, scaling
Brownish Hyperpigmentation
Medial Malleolus Ulcer
Atrophie Blnache
Dx of Chronic Venous Insufficiency
Ankle/branchial index
Ultrasound
Tx of Chronic Venous Insufficiency
Compression: Leg elevation, compression stockings
Ulcer tx: Wet to dry dressing, skin grafting, hyperbaric oxygen
