Cardiovascular Flashcards
ECG for LBBB
QRS > 120ms
In V1: deep S and no R
In I, V5, V6: tall R
ECG for RBBB
QRS > 120ms
In V1: qR or R
In I, V5, V6: S
3 consecutive changes in ECG when acute ischemia
1- T inversion
2- ST changes
3- Q wave (>40ms or >1/3 of QRS amplitude)
Poor R wave progression in precordial waves
ECG for RA and LA enlargement
RA: amplitude of P > 2.5mm in II
LA: width of P > 120ms in II or terminal negative deflection in V1 (> 1mm and > 40ms)
ECG for RVH and LVH
RVH: right-axis deviation, R > 7mm in V1
LVH: S in V1 + R in V5 or V6 > 35mm
Pulsus paradoxus
Pulsus alternans
Pulsus parvus et tardus
Paradoxus: pericardial tamponade, obstructive lung diseases, tension pneumothorax, foreign body inhalation.
Alternans: cardial tamponade, impaired LV systolic function.
Parvus et tardus: aortic stenosis
Management options for AFib
A: Anticoagulate
B: Beta-blockers (rate control)
C: Cardiovert/CCB
D: Digoxin (if refractory)
Estimate stroke risk in AFib + ttt
CHA2DS2-VASc ≥2
CHF (1) HTN (1) Age ≥ 75 (2) Diabetes (1) Stroke or TIA history (2) Vascular disease (1) Age 65-74 (1) Sex category (female = 1)
3 steps after diagnosis of WPW on ECG
Advice against vigorous physical activity
Procainamide for arrhythmias
Electrophysiology study
Sinus bradycardia (etiologies + ttt)
Normal response to conditioning, SN dysfunction, excess B-blockers/CCB
None (if asymptomatic), Atropine, Pacemaker (if severe)
AV block (etiologies + ttt)
1st: ass w/ ↑ vagal tone, B- or CCB; PR >200ms; no ttt
2nd + Mob I: digox/B-/CCB, ↑ vagal tone, right coro ischemia/infarction; PR lengthening then drop; stop drug, Atropine
2nd + Mob II: fibrotic ds of conduction (MI); dropped beat; pacemaker
3rd: no A-V communication; pacemaker
Sick sinus syndrome (etiologies + ttt)
Multifocal atrial tachycardia
SSS: Intermittent SupraV tachy+brady arrhythmias
ttt: Pacemaker
MAT: multiple atrial pacemakers/reentrant paths/COPD, hypoxemia (≥3 diff P waves)
ttt: underlying cause, Verapamil/B-, suppress pacemakers
Sinus tachycardia (etiologies + ttt)
Normal response to pain/exo/fear, hyperthyroidism, volume contraction, infection, PE
ttt underlying cause
AFib (etiologies + ttt)
Acute: pulmonary ds, ischemia, rheumatic heart ds, anemia, atrial myxoma, thyrotoxicosis, ethanol, sepsis
Chronic: HTN, CHF
ttt chronic: Rate control (B-/CCB/Digoxin) + Anticoag Warfarin (CHA2DS2-VASc ≥2)
ttt unstable or <2d: cardiovert
ttt >2d or unclear: TEE to r/o atrial clot
Atrial flutter (etiologies + ttt)
“sawtooth” P waves
240-320 bpm in atria and 150bpm in ventricles
ttt chronic: Rate control (B-/CCB/Digoxin) + Anticoag Warfarin (CHA2DS2-VASc ≥2)
ttt unstable or <2d: cardiovert
ttt >2d or unclear: TEE to r/o atrial clot
AVNRT (etiologies + ttt)
AVRT (etiologies + ttt)
AVNRT: reentry in AV node (A+V depol simultaneously); 150-250 bpm (P buried in QRS)
ttt: carotid massage/Valsalva/adenosine (stop it), cardiovert if unstable
AVRT: ectopic connection of A+V causes reentry (ex: WPW); P after QRS
ttt: carotid massage/Valsalva/adenosine (stop it), cardiovert if unstable
Paroxysmal atrial tachycardia (etiologies + ttt)
Ectopic pacemaker in A
>100 bpm; P before QRS but unusual axis
ttt: adenosine (unmask A activity by slowing rate)
PVCs (etiologies + ttt)
WPW (etiologies + ttt)
PVCs: ectopic beats from V; ass w/ hypoxia, e- abnl, hyperthyroidism; wide QRS w/o P
ttt: underlying cause; B- if symptomatic
WPW: abnl path A to V; delta wave + wide QRS + short PR
ttt: observation if asymptomatic
VT (etiologies + ttt)
VF (etiologies + ttt)
VT: ass w/ CAD, MI, structural heart ds; < 30sec or > 30sec; ≥3 consec PVCs, regular rapid wide QRS
ttt: cardiovert if unstable, antiarrhythmics
VF: ass w/ CAD, structural heart ds, cardiac arrest; erratic wide complexes; no BP no pulse
ttt: immediate defibrillation and ACLS
Torsades de pointes (etiologies + ttt)
Ass w/ long QT, medications, hypokalemia, cong deafness, alcoholism
Polymorphous QRS, VT 150-250 bpm
ttt: magnesium then cardiovert if unstable, correct hypoK, stop medication
NYHA classification of CHF
I: no activity limitation, asymptomatic w/ Nl activity
II: slight activity limitation, comfortable w/ rest + mild exertion
III: marked activity limitation, comfortable only at rest
IV: discomfort w/ any activity, symptoms also at rest
Acute CHF management
L: Lasix (furosemide) M: Morphine N: Nitrates O: Oxygen P: Position (upright)
Acute systolic dysfunction ttt
Chronic systolic dysfunction ttt
Acute: loop diuretics, ACEIs/ARBs, avoid B- when decompensated, ttt underlying cause
Chronic: lifestyle (↓ salt/fluid), B- and ACEIs/ARBs (↓ mortality), avoid CCB, diuretics (loop), low-dose spironolactone (↓ mortality), ASA and statin if cause is prior MI, ICD if EF < 35%, LVAD or cardiac transplant if refractory
Nonsystolic dysfunction ttt
Diuretics
Rate and BP control: B-, ACEIs/ARBs, or CCBs
(No digox)
Dilated CM
Hypertrophic CM
Restrictive CM
Dilated: impaired contractility, LVsizeED ↑↑, LVsizeES ↑↑, EF ↓↓, wall thickness ↓
Hypertrophic: impaired relaxation, LVsizeED ↓, LVsizeES ↓↓, EF ↑/Nl, wall thickness ↑↑
Restrictive: impaired elasticity, LVsizeED ↑, LVsizeES ↑, EF ↓/Nl, wall thickness ↑
Dilated CM
Idiopathic (#1) or 2* (many causes esp. ischemia, long HTN)
Gradual CHF, JVD, S3/S4, MR/TR
Echo for dg
ttt: underlying cause (infection, endocrino, alcohol, …) and the CHF (lifestyle, meds, ICD)
Hypertrophic CM
HOCM (AD), HTN, Ao stenosis
Systolic ejection cresc-decresc murmur that ↑ w/ ↓ preload and ↓ w/ ↑ preload; S4
Echo for dg
LVH (on ECG), MR than LA enlarged
ttt: B- (#1), CCB (#2); surgery for HOCM + avoid intense exo
Restrictive CM
2* to infiltrative ds, scarring, fibrosis
Right HF > Left HF
Echo for dg
LBBB (on ECG)
ttt: palliative; diuretics if overload, vasodilators to ↓ filling P*
CAD (RF, dg, ttt)
CAD = Angina pectoris (subst chest pain 2* to myoc ischemia w/ stress/exertion and ↓ w/ rest/nitrates) and Prinzmetal (ST elev w/o cardiac enzymes)
DM, fam Hx of premature CAD (M<55, F<65), Smoking, Dyslip, abdo obesity, HTN, age (M>45, F>55), male
ECG then stress test for dg
ttt: if stable angina ASA, B-, nitrogl, ↓RF
ASA + B- reduce mortality
ACS
Unstable angina (pain is new, accelerating, at rest) maybe ST changes, no enzymes NSTEMI (+ Trop I and CKMB)
ttt: ASA, O2, IV nitrogl, IV morphine, B- (if hemod stable)
Admission (serial card enz to r/o MI)
TIMI score for UA/NSTEMI (if ≥3 enoxaparin (not hep), GPIIbIIIa inhib and early angiography)
ACS (cont.)
STEMI (ST elevation and + card enz)
LV EF best predictor of survival
Atypical/silent MI (women, DM, elderly, post-heart transpl)
ttt: morphine, O2, ASA, nitrates (not if inf MI), clopidogrel, B- (not if shock/HF, instead ACEI but not if hypoTN)
PCI in 90 min
If >90min + no CI for thrombolysis + within 3h, tPA/reteplase/streptokinase
Coronary arteries and MI
Inferior MI: RCA/PDA (II, III, aVF)
Anterior MI: LAD/diagonal (V1-V4)
Lateral MI: LCA (I, aVL, V5, V6)
Posterior MI: Cx/PDA (V7-V9)
Long-term ttt and complications of STEMI
Long ttt: ASA, ACEIs, B-, high-dose statins (LDL<100), clopidogrel (if PCI) + modify RF (exo, diet, tobacco)
Arrhythmias (#1 + #1 death)
HF (d1), arrhythmia/pericarditis (d2-4), LV wall rupture/tamponade/papill M rupture + MR (d5-10), V aneurysm/thrombus (wks-months)
Dressler (2-10 wks)
Dyslipidemia (RF for CAD, etiologies, dg)
Total cholest > 200 mg/dL, LDL > 130, Tg > 150, HDL < 40
Obesity, DM, alcoholism, hypothyroidism, nephrotic sd, hepatic ds, Cushing sd, OCP, high-dose diuretics, familial hypercholest.
If high Tg or LDL: xanthomas, xanthelasmas, lipemia retinalis
Dg: lipid test for >35yo or ≥20yo w/ CAD RF. Repeat every ≤5y acc to levels
ttt of dyslipidemia
First, 12-wk trial diet + exo if no known atheroscl vasc ds.
High-intensity statin (↓ LDL >50%): Hx of CAD/CVA/PAD, LDL 70-189 w/o DM w/ ≥7.5% 10yR, LDL 70-189 w/ DM w/ ≥7.5% 10yR, LDL ≥190
Moderate-intensity statin (↓ LDL 30-50%): LDL 70-189 w/o DM w/ 5-7.5% 10yR, LDL 70-189 w/ DM w/ ≤7.5% 10yR
No statin: LDL 70-189 w/o DM w/ ≤5% 10yR
Hypertension (def, RF, dg)
<60yo: SBP > 140 and/or DBP > 90 (x3 separate measures)
≥60yo w/o CKD/DM: SBP > 150 and/or DBP >90
RF: faml Hx of HTN/heart ds, high-Na diet, smoking, obesity, black, age
Dg: urinalysis, BUN/creatinine, e-, possible 2* causes (Cushing sd, Hyperaldo/Conn, Ao coarctation, Pheo, Stenosis of renal arteries)
ttt of hypertension
Lifestyle modif (↓ weight, exo, diet, ↓ alcohol and salt)
Diuretics/CCB/ACEIs/B- reduce mortality in uncompl HTN
Periodic testing for end-organ damage: renal, cardiac, ocular, cerebral
Hypertensive emergencies (def, ttt)
BP > 180/120 lead to end-organ damage (AKI, MI, Ao dissection, encephalopathy)
HTN urgency: mild to mod sympt, no end-org dam. Oral ttt (B-, ACEI) w/ gradual lowering in 24-48h
HTN emergency: end-org dam (intracran hge, papilledema, pulm edema, …). IV ttt (labetalol, nitroprusside, nicardipine) w/ lowering of ≤25% in 2h
Pericarditis (etiologies, dg)
Collagen vascular ds, Ao dissection, radiation, drugs, infections, AKF, MI, rheumatic fever, injury, neoplasms, Dressler sd
Pain worse in supine and w/ inspiration (so pt stays sitting + bend forward)
CXR, ECG, echo to r/o MI/pneumonia
ECG (diffuse ST elevation, PR depression)
ttt of pericarditis
CS/immunosupp for SLE Dialysis for uremia ASA for post-MI (no CS) ASA/NSAIDs for viral pericarditis If asymptom, monitor If tamponade, pericardiocentesis w/ continuous drainage
Tamponade (RF, dg, ttt)
Excess fluid leading to compromised LV filling/CO
RF: pericarditis, malignancy, SLE, TB, trauma
Beck triad (JVD, hypoTN, distant heart sounds), pulsus paradoxus, Kussmaul sign
Echo, CXR, ECG (electrical alternans is dg)
ttt: abundant IV fluids, urgent pericardiocentesis
Aortic stenosis (etiologies, dg, ttt)
Elderly (unless uni/bicuspid AV)
Asymptom for years, then angina/syncope/CHF/death
Pulsus parvus et tardus, systolic murmur to carotids
Dg by echo
ttt: AV replacement
Aortic regurgitation (etiologies, dg, ttt)
Acute: rapid pulmonary congestion, shock, dyspnea
Chronic: slow progression of dyspnea
Blowing diastolic murmur, wide pulse pressure (head bob)
Dg by echo
ttt: vasodilator until severe, AV replacement
Mitral valve stenosis (etiologies, dg, ttt)
1 by rheumatic fever
Sympt: dyspnea, infective endocarditis, arrhythmias
Opening snap/mid-diastolic murmur at apex, pulm edema
Dg by echo
ttt: antiarrhythmics (B-/digox), mitral balloon valvotomy, MV replacement
Mitral valve regurgitation (etiologies, dg, ttt)
Rheumatic fever, chordae tendineae rupture after MI, infective endocarditis
Dyspnea, fatigue
Holosystolic murmur to axilla
Dg by echo
ttt: antiarrhythmics, nitrates/diuretics (↓ preload), MV replacement
Aortic aneurysm (RF, dg, ttt)
> 50% dilatation of the 3 layers, ass w/ atherosclerosis
Esp abdominal, >90% below renal art
Asympt, pulsatile abdo mass/bruits
RF: HTN, high cholest, vasc ds, fam Hx, smoking, male, age
Dg: screen all men 65-75yo w/ Hx of smoking by US, follow by US
ttt: monitor (asympt + <5cm), surgery (rapid, abdo >5.5cm, thor >6cm), emergent surgery (sympt, ruptured)
Aortic dissection (dg, ttt)
2* to HTN
Esp above AV + distal to subclavian art, 40-60yo, male
HyperTN/hypoTN (tamponade/bld loss), asymmetric pulses/BP
Dg: CT angiography (#1), MRA if contrast CI
Types: A (prox to left subclav), B (other)
ttt: manage BP/HR, B- before vasodilator, surgical emergency if asc Ao
Deep venous thrombosis (RF, dg, ttt)
Virchow triad (venous stasis, endothelial trauma, hypercoagulability)
Homans sign (calf tendern with dorsiflexion)
Dg: Doppler US
ttt: anticoagulation (IV heparin/subQ LMWH then PO warfarin for 3-6mo), IVC filter (if CI to anticoag), DVT prophyl (hospit ptts)
Peripheral arterial disease
Restriction of bld by atheroscl plaque Intermittent claudication (relieved by rest) then pain at rest, cold/numb/ulcerations in feet, ↓ pulse
Acute ischemia (emboli): Pain, Pallor, Paralysis, Pulse deficit, Paresthesias, Poikilothermia Chronic ischemia: muscle atrophy, pallor, cyanosis, hair loss, gangrene/necrosis
Peripheral arterial disease (dg, ttt)
Ankle-brachial index, Doppler US, arteriography for surgery
ttt: underlying condition (DM/smok), foot care, exo to form collateral art, ASA/cilostazol/thromboxane inh, angioplasty, surgery (bypass), amputation
Lymphedema (etiologies, dg, ttt)
Peripheral edema, chronic infection
2* to surgery/parasitic infection
Dg is clinical. R/o cardiac + metabolic disorders
ttt: exo/massage/pressure garments, G+ antibiotic prophyl
CI of diuretics
Syncope (etiologies, dg, ttt)
Cerebral hypoperfusion (2* to cardiac, neuro, other) [valvular, arrhythmias, PE, tamponade, Ao dissection, subarachnoid hge, ortho hypoTN, metabolic, vasovagal, psy, medications
Ask: age, triggers, prodromal symptoms, ass symptoms
Dg: dep on cause (ECG, Holter, echo, stress test, EEG, CT head, orthost BP, tilt test, glucose
ttt: the cause
