Cardiovascular Flashcards
History
A. family
1. MI (when, who, which side), high BP, AS
B. tobacco, alcohol, recreational drug use
- alcohol decreases platelet aggregation, red wine has flavonoids from grape skins — same with dark beer
- cocaine use can cause coronary spasm, can cause an MI at any point of use
C. physical activity
D. stress - *what do you do for relaxation?
E. increased BP
F. Ht disease
1. rheumatic fever (from strep — antibodies can lodge in mitral valve), Ht murmurs
G. chest pain
1. OPQRST
2. do they have *pressure — immediate referral, squeezing
a. clenched fist in center of sternum
3. worse with exertion, better with rest
4. radiation commonly to left jaw, neck, shoulder, arm — but not always, for women can be epigastric discomfort and back pain
H. chest pressure, tightness, heaviness
I. dyspnea
1. orthopnea - difficulty breathing in different positions, esp lying down, pattern of heart failure (fluid building in lung)
2. paroxysmal nocturnal dyspnea (PND)
3. dry cough
4. leg edema
BPA and BPS — found in most babies’ serum
in adults, we know that BPA is a factor in hypertension
J. palpitations 1. perception of Ht action (awareness of your heart’s action, “do you ever feel like you miss a beat?”) K. rapid or irregular Ht beat L. lightheadedness (from standing up too quickly it’s most likely state of hydration), fainting (do they actually pass out - syncope), weakness, fatigue M. circulation 1. cold hands or feet 2. leg cramps 3. phlebitis 4. varicose veins N. past EKG
Physical Exam
A. vital signs
1. BP: 120/80 a. CO - systole b. peripheral resistance - diastole c. elastic recoil of aorta and large arteries d. blood volume e. blood viscosity - sort of a cutting edge way of looking at hypertension, difficult because viscosity changes immediately once pulled 2. HR: 60 – 100 3. RR: 12 – 20 (9 – 16) 4. T (temperature)
B. peripheral pulses
1. rate, symmetry, bruits (turbulent sound - want to hear in carotids) 2. radial, carotid, femoral “I’m going to palpate your abdomen then reach down a little more to feel your pulse”, popliteal UB 40 - may or may not feel, posterior tibial Kid 3, dorsalis pedis St 42 - want to palpate esp in patients with diabetes - Note in exam 0-4; 0 - don’t feel it, 4 - felt very strong
C. jugular venous pressure
1. competency and compliance of right Ht
2. patient at 45O
3. see venous column - waves - in internal jugular vein; behind SCM
a. N just below clavicles
4. briefly elevated by pressure of hand on abdomen
a. hepatojugular reflux
5. should return to N in a few seconds even with continued pressure on abdomen
6. if not - cardiomyopathy, Ht failure, right ventricular problem
D. inspection
1. patient should lie for remainder of examination
2. tangential lighting to detect pulsations
E. palpation
1. orderly a. aortic, pulmonic, tricuspid, mitral, epigastric 2. thrills a. loud murmurs - when did they occur in the space, how loudly, blowing, musical, sharp? b. vibrations - use ball of hand 3. pulsations a. pads of fingers b. apical - PMI i. 5th ICS midclavicular line - St 18, sometimes referred to as the Great Luo of the St c. epigastric i. aortic width
F. auscultation
1. possibly the most demanding skill 2. lungs first - congestion, rubs 3. orderly a. aortic, pulmonic, tricuspid, mitral b. reflection of heart sounds i. . aortic - R 2nd ICS close to sternum ii. . pulmonic - L 2nd ICS close to sternum iii. tricuspid - L 5th ICS close to sternum iv. mitral - L 5th ICS midclavicular line 4. 1st sound - S1 a. intensity, pitch, duration, timing, splitting 5. 2nd sound - S2 a. as above b. breathe through nose c. inspiratory splitting 6. systole a. extra sounds, murmurs i. timing, intensity, pitch 7. diastole a. extra sounds, murmurs 8. for all murmurs, listen for the following characteristics a. duration b. timing i. early, mid, late c. location i. interspace ii. # cm from midline d. radiation e. intensity i. grades 1-6 f. pitch i. high, medium, low g. quality i. blowing, rumbling, harsh, musical 9. use diaphragm then bell
Laboratory
A. Lipids
1. triglycerides (TG, TC - total cholesterol: HDL, LDL) 2. cholesterol a. HDL, LDL, apolipoproteins 3. homocysteine 4. CRP - Highly sensitive CRP, similar to sed rate (inflammation) — hsCRP is enzyme form of this for cardiovascular, some say this is the most important test to do
B. cardiac enzymes
1. CK - Creatine Kinase — muscle (iso)enzyme also elevated in dermatomyositis; damage to the heart muscle, LDH -lactate dehydrogenase
C. specialized testing depending on presumptive diagnosis
- troponin level can tell you whether you are having an MI (together with EKG?)
Imaging
- radiology
- PA, lateral
2. size, shape, lung vasculature
Imaging
- echocardiography
- (can tell a whole lot about the heart, look at chambers walls, valves, and motion, can look at color of it and see blood) — 65-70% of blood into aorta (EF - ejection fraction)
1. diagnostic ultrasound
2. valvular disease
3. cardiac chambers
4. congenital Ht disease
5. coronary artery disease
6. cardiomyopathy
7. cardiac masses
8. pericardial effusion
9. aortic disease
Imaging
- ultra-fast CT scan
- a lot of X-rays all at once, series of images; ultra fast because heart moves, can see calcification in coronary vessels
1. coronary vessels - doesn’t tell you anything about function and blood flow, oxygenation, just calcification
- mostly do EKG, X-rays, echocardiogram, calcium scoring, usually in that order — then move to other tests
Imaging
- MRI
- vessels
- masses
- other structures with contrast agents, ECG
Special Studies
- electrocardiogram
- record of Ht electrical activity
- no exam of a cardiac patient is complete without a chest x-ray and an ECG
- standard 12 lead
- exercise ECG (stress test, treadmill test)
a. stress echocardiogram
b. myocardial perfusion scintigraphy
i. radionuclide imaging
ii. technetium (thallium) scan - Rapid Interpretation of EKG’s by Dubin - book
Special Studies
- angiocardiography
- visualization of chambers, vessels by x-ray after injection of contrast material
- can do this anywhere e.g. peripheral vessels
Special Studies
- venography
- cardiac catheterization
- cannulation
- Doppler ultrasonography
- plethysmography
C. venography 1. visualization of chambers, vessels by x-ray after injection of contrast material D. cardiac catheterization 1. diagnosis and therapy E. cannulation 1. arterial and venous 2. monitoring, measurements F. doppler ultrasonography - pregnant women ultrasounds, sound of heartbeat bouncing off surrounding blood flow 1. blood flow G. plethysmography 1. peripheral venous blood flow
Emergencies
4
A. chest pain discomfort
1. severe with SOB - immediate ER referral
2. complex
a. any acute chest pain needs primary evaluation
B. aneurysm
1. dilation of a blood vessel, especially aorta or peripheral artery
2. pain
3. specific testing - physical, imaging
4. immediate ER referral if suspected
5. danger is from rupture
The
C. myocardial infarction (MI)
1. ischemic myocardial necrosis from sudden reduction in coronary blood flow
2. deep, substernal pain
3. restless, anxious, pale
4. thready pulse
5. die of ventricular fibrillation before reaching hospital
6. EKG, cardiac enzymes
7. call 911
a. need rapid dx and tx
b. 50% of deaths from MI occur within 3-4 hours of onset of clinical syndrome
D. deep vein thrombosis (DVT)
1. not emergency but needs evaluation and monitoring as soon as possible
2. possible pulmonary embolism - fibrillation, then person dies
Atherosclerosis
- definition
- etiology
A. the presence of irregularly distributed lipid deposits in arterial intima
1. the arterial wall becomes thickened and loses elasticity
2. arteriosclerosis is general term for any process that causes the above to occur
a. commonly called hardening of the arteries
B. leading cause of morbidity and mortality in US & West
1. AS Ht disease and stroke #1 killer
2. 33% of all deaths
C. between 35-44, 6x > in white men than white women
D. increase in postmenopausal women to match men
- estrogen, used to be thought that estrogen protected the heart
E. etiology
1. age
2. male gender
3. family hx of early AS
- know if someone in the family died early from MI
4. elevated TC or LDL; elevated TC/HDL ratio
5. decreased HDL
6. cigarette smoking
7. DM - diabetes
8. hypertension
- risk of stroke and MI
9. other potential etiologies
a. low or excess alcohol intake
- because of what it does to the liver, studies showing people who drink no alcohol at greater risk than people who drink some
b. Chlamydia pneumoniae
c. increased CRP ?
d. high levels of small, dense LDL
- low density lipoproteins (some large molecules, some small and dense — more atherogenic)
e. high lp(a) - lipoprotein a (combo of small LDL and lipoprotein a?) ___ will lower lp a but only a little, *ADD carnotine to dramatically lower
f. hyperhomocysteinemia
g. hyperinsulinemia
h. hypertriglyceridemia
i. obesity, metabolic syndrome
- atherogenic dyslipidemia, elevated blood pressure, elevated blood glucose, prothrombitic state, proinflammatory state
j. low intake of fruits and vegetables
k. sedentary lifestyle
l. personality: type A, depressive, anxious, socioeconomic
m. renal insufficiency
n. prothrombotic
Atherosclerosis
- signs and symptoms
- none until critical level of stenosis
- sx from decreased blood flow to an area
a. thrombosis, embolism, aneurysm, CVA, MI
Atherosclerosis
- labs
- serum lipids
a. triglycerides (TG ≤ 150), cholesterol, HDL, LDL
- TC (total cholesterol - HDL+LDL+VLDL) ≤ 200; HDL ≥ 40, LDL (some say 130 or below, some say for everyone its ok 160 or below — have to take into account all other pieces), most VLDL levels what around 25-30
- always look at labs for people who present with metabolic syndrome
- Type 4 hypolipidemia often overlooked, what Joe has
b. apolipoprotein A & B
- apolipotrotein a - should be between 96-176
- apolipoprotein b - 43 - 128
- #s not important, ratio A/B is
- the higher the ratio the better, 1:1 ok, 2:1 fantastic, 1:2 bad — will give you idea of how atherogenic vessels are - lipoprotein (a) - will be on highly sensitive panel,
- red yeast rice, carnotine help lower - (ns)CRP
- < 3
4. homocysteine
5. thrombocytes
Atherosclerosis
- imaging
- doppler ultrasonography - watch and hear blood flow through vessel
- angiography
TX —
- prevention
- diet
- story of carbohydrate hyperlipidemia?
a. whole foods
i. vegetables, fruits, whole grains, nuts, seeds, legumes
ii. fish, olive oil, onions, garlic
- Mediterranean diet
iii. moderate use of eggs, alcohol, organic free ranged beef, chicken, turkey
- free range beef (and grass fed) seems to have better omega 3 level than salmon
b. Ornish, Pritikin, or modified Atkins diets in some cases
c. avoid: refined sugar, refined grains, over-cooked food, fried foods, trans fatty acids, chlorinated water
- chlorine is oxidizing agent, we are trying to avoid oxidization
- eggs, scrambled the worst (have exposed them to light, heat, and oxygen) — changing the cholesterol (soft boiled, poached, hard boiled best way to eat them) - EPA: 2-3 gm/d - from salmon (eat the gray matter between flesh and skin, where all the good fats are
- vit. C: 2-10 gm/d
- Mg: 300-600 mg/d - many say most important for cardiovascular health, any form (citrate most absorbable form, but one study said all easily absorbable, could use mg oxide etc)
- niacin: time release 500-1200mg/d
- folic acid (2.5 mg/d), vit. B6 (25 mg/d), vit. B12 (250 mcg/d)
- Cr - 200-1,000 mcg/d - Chromium raises HDL levels (200 considered normal dose, 1000 megadose)
- pantethine - 1200 mg/d - amino acid, lower total cholesterol and tryglycerides, $$, take with food, make sure you’re taking enough
- carnitine - 3 gm/d - amino acid, same as above
- exercise - essential
a. 30-60 minutes of moderate activity daily - meditation
- avoid tobacco use
Hypertension
- definition, stats
- etiology
A. elevation of systolic and/or diastolic BP
1. normal: <120 and <80
2. elevated: 120-129 and <80
2. stage 1 hypertension: 130-139 or 80-89
3. stage 2 hypertension: > or = 140 or > or = 90
B. increase with age - in West
1. 2/3 of people over 65
2. 90% risk of developing HTN if normal at 55
3. apparently no age related hypertension in non industrialized areas
4. hypertension increases dramatically when move to developed area
C. incidence
1. more in blacks - 32% of adults - than whites - 23% of adults
a. 50% all males and 60% all females over age 65 in U.S. if both isolated systolic and diastolic
2. 85-95% primary (essential) - unknown etiology
- Joe totally disagrees
3. 5-10% secondary to renal disease - rare that people get Kidneys checked with hypertension, 10% is significant
4. 1-2% other curable conditions
ETIOLOGY
- CO x TPR
- primary
a. blood volume
b. increased CO
c. increased peripheral vascular resistance - more important
d. sympathetic nervous system stimulation
e. renin-angiotensin-aldosterone - secondary
a. renal disease
b. pheochromocytoma
c. Cushing’s syndrome - hyperfunction, adrenal excess, excess cortisol
(Adson’s is hypofunction)
d. hypo or hyperthyroid
e. coarctation of aorta
f. oral contraceptives
g. corticosteroids
h. cocaine
i. licorice - causes sodium retention —> edema
- licorice in small amounts causing pseudosterone? effect, …
- If BP increases with new formula, suspect licorice
j. alcohol abuse
k. cigarette smoking
l. excess sodium intake
Hypertension
- signs and symptoms
- asx until complications develop - like atherosclerosis
- dizziness, HA, flushed face, fatigue, epistaxis, anxiety
- complications
a. left ventricular failure
b. AS Ht disease
c. retinal diseases
d. CVA
e. renal failure
Hypertension
- dx
- measure twice (once sitting, once standing) on three separate occasions and take the average of the three readings (in a couple of weeks?) — over 120/80 = hypertension
- exclude secondary causes
Hypertension
- prognosis
- untreated have risk for left ventricular failure, MI, CVA, renal failure
- **most important risk factor for stroke
- one of 3 most important for CAD coronary artery disease(cigarette smoking, dyslipidemia)
- CAD most common cause of death for hypertensives
- mortality related to systolic, morbidity - how ill are you
TX —
- similar to AS, especially diet
- Na restriction to 1500 mg/d, about 1/2 tsp/day
- avoid food sensitivities
- weight loss** very clear that this drops hypertension the most
- start with eating smaller portions - exercise
- meditation
- stress reduction
- potassium, especially dietary - some people sub potassium salt for sodium salt, sufficient (unless person taking ACE inhibitor — don’t want to give too much potassium)
- great leafies, mushrooms, potatoes (esp skin), bananas, parsley… - Ca/Mg: 1,000mg/500mg
- CoQ10 200 mg/d (100 baseline, 200 better results)
- vit. D - may or may not be helpful
- heavy metal treatment
- drug tx
a. diuretics - standard drug treatment starts with this (Hydrochloric Thiozide)
b. beta-blockers - problem is that they lower heart rate, lower blood pressure — get very cold and fatigued easily
- metoprolol
c. Ca channel blockers
d. angiotensin converting enzyme inhibitor
- ACE inhibitors better, least side effect profile - dry cough common SE, often nothing you can do about it
e. Cacao - 1 sq inch, once a day, at least 85% cacao
- can find many lists online for what to do for hypertension, not much research
Coronary Artery Disease
- definition
- etiology
A. impairment of blood flow in the coronary arteries, decrease of blood flow
1. AS in vessels surrounding Ht
2. coronary artery spasm
B. complications are angina pectoris, MI
C. angina pectoris
1. chest discomfort or pressure due to myocardial ischemia brought on by exertion and relieved by rest or sublingual nitroglycerin
- sometimes radiates (more common to left), straight through to the back, right side
- “feels like a truck on my chest”, clenching fist
D. 1/3 of all deaths in developed countries
Coronary Artery Disease
- signs and symptoms
- variable discomfort
a. from a vague ache to an intense crushing sensation - substernal
- radiation to left shoulder and down inside of left arm to fingers
- also radiates to back, throat, jaw, teeth
- worse with physical activity, better with rest
- worse if exertion after a meal or in cold weather
- frequency varies
- sx characteristic for each individual
a. any change in pattern is serious and may indicate an impending MI – unstable angina – 30% have MI within 3 months of onset
- “I’ve had this chest pain but it’s different all of the sudden” — immediate ER visit - often no sns
- may have increased HR & BP during attack
Coronary Artery Disease
- dx
- clinical, based on classic pattern
2. better with nitroglycerin
Coronary Artery Disease
- testing
- ECG
- CT scan
- exercise testing
a. stress ECG
b. myocardial perfusion scintigraphy - coronary arteriography
Coronary Artery Disease
- prognosis
- unstable angina, MI biggest risk
- age, extent of coronary disease, severity, vent function major influences on prognosis
- left main coronary artery lesions worst
- # coronary vessels involved
TX —
- diet similar to AS
- smoking cessation
- weight loss
- exercise - want to keep moving, keep pushing, can grow new vessels, can perfuse myocardium better
- Mg
- arginine 1gm tid - increase in nitric oxide, causes vasodilation
- tx HTN, dyslipidemia, DM
- IV chelation therapy
- drug tx
a. sublingual nitroglycerin for tx and prophylaxis
b. beta blockers
c. Ca channel blockers
d. angioplasty
- problem with stents is that you will be on Rx for life, plus blood thinners
- rupture possible, re-stenosis
e. coronary arterial bypass surgery - CABG procedure
- sternum wired together, tremendous back pain, pts often complain about lower extremity pain from incisions
f. Elation therapy - using EDTA + minerals to do IV treatments
- EDTA latches onto calcium and wears down plaque
Myocardial Infarction
- definition
- epidemiology
A. ischemic myocardial necrosis due to abrupt decrease in coronary blood flow — typically not occlusion, *rupture
B. greater than 90% have thrombus that occludes artery that supplies affected myocardium
C. cocaine users - coronary artery spasm, MI
D. epidemiology
1. 1.5 million in US yearly
2. 500,000 deaths
a. half before reaching hospital
E. acute rupture of thrombus
1. greater than 50% have thrombotic vessel occlusion less than 40%
MI
- signs and symptoms
- 2/3 experience prodromal sx for days or weeks before MI
- worsening angina
- SOB
- fatigue
- 1st acute MI sx
a. deep substernal visceral pain - pressure or aching - often radiating to back, jaw, or left arm - 20% acute MI silent
- restless, anxious, diaphoretic
- cyanosis with cool skin
- thready pulse, arrhythmia
- muffled heart sounds
MI
- lab
- ECG
- troponins
- increased ESR & WBC in 12 hours due to tissue necrosis
- CK-MB inc within 6 hrs
a. increase for 48 hrs - LDH
