Cardiovascular Flashcards
1
Q
acute rheumatic fever
A
- supporting RF: previous + throat culture or RAT (66%), elevated or rising strep antibody titer
- complications: mitral stenosis
- sxs: major criteria (polyarthritis, carditis, chorea, erythema marginatum - red pathces with central clearing, subcut nodules)
- minor criteria: fever, arthralgia, elevated CRP or ESR, prolonged PR interval (mitral regurg)
- dx: throat cx or RAT, ASO titer: establishes recent strep infxn
- dx criteria: 2 major or 1 major and 2 minor
- tx: PO aspirin, PCN IM, prednison
- prophylaxis: PCN G
2
Q
kawasaki dz
A
- primarily in kids 6mo-4y, unkown etiology, vasculitis can lead to aneurysms
- sxs: fever >5d + any 4 of the following:
- bilateral conjunctivitis, red mucous membranes (red, cracked lips), swelling of hands/feet with red palms and soles, transverse grooves on nails, polymorphous rash, cervical nodes >1.5 cm
- signs: strawberry tongue, red lips, injected throat, conjunctivitis, peeling rash - fingers and toes
- dx: CBC (anemia, WBC <15k, platelet >450K), albumin <3, inc AST, urine >10 WBC, ASO titer and strep = neg, echocardiogram
- tx: ASA for thrombosis prophylaxis, immune globulin (IVIG) in first 10d, plasmapheresis, corticosteroids
- complications: coronary artery aneurysms, polymorphous exanthema, arteritis
3
Q
syncope
A
- loss of consciousness/postural tone secondary to acute dec in cerebral blood flow; rapid recovery of consciousness without resuscitation
- almost 20% pts with syncope have primary dx of mood, anxiety, or substance abuse disorder (MC = panic disorder)
- differential: siezure, cardiac (arrhythmias, obstruction blood flow, massive MI), vasovagal (MCC, emotional stress, pain, fear, extreme fatigue, claustrophobic; tilt table reproduces sxs), orthostatic hypotension (sudden standing or prolonged standing, +tilt table), cerebrovasc dz, hypoglyc, etc.
- eval: hx, physical, EKG for all pts, CBC, CMP, Holter monitor, tilt-table, CT or EEG, echo, prolactin levels
4
Q
hypertrophic cardiomyopathy etiology, RF, sxs
A
- most: autosomal dominant trait, 60-70% caused by mutation in sarcomere gene; +fhx
- left ventricular hyptrophy leading to LV outflow obstruction, diastolic dysfn, MI, and mitral regurg
- MC presentation: HF with resultant DOE (90% of sxatic pts)
- MC location: inc wall thickness in basal ant septum in continuity with ant free wall
- CRESCENDO DECRESCENDO murmu
- differentiate from aortic stenosis by having pt perform routine maneuvers and position changes
- sxs: infants - lethargy, rapid breathing, difficulty feeding
- signs: S4, systolic murmur LLSB, radiates to axilla and base, left ventricular lift, bisferious pulse (carotid pulse with 2 upstrokes), prominent “a” wave in neck veins
- murmur louder with standing and valsalva
- murmur quieter with sitting, hand grip
- associated: palpable/loud S4, LV heave
5
Q
hypertrophic cardiomyopathy dx and tx
A
- dx: EKG (first line), LVH with RAE; left axis deviation
- TTE: unexplained LV wall thickness >15mm (diagnostic); systolic ant motion (SAM) of mitral valve or hyperdynamic LV
- exercise stress testing (test for ischemia and arrhythmias), cardiac MR (CMR) imaging, cardiac cath, genetic testing
- tx: asx = no tx indicated; negative inotropic monotx (BB or nonhydropyridine [verapamil]), surg reserved for pts with class III/IV HF
- health maintenance: prohibit strenuous activities, endocarditis prophylaxis not recommended
- inc risk of death from sickle cell, HF, stroke
6
Q
ventricular septal defect etiology, RF, sxs
A
- results in L-R shunt, most common congenital anomaly; occurs in 50% pts with CHD
- MC loc: perimembranous (just beneath aortic valve, behind septal leafet of tricuspid valve)
- Causes: down syndrome, DiGeorge, FAS, DM
- sxs: ACYANOTIC OR CYANOTIC BASED ON SIZE
- neonatal: isolated syst. mumur; HF sxs = tachypnea, inc WOB, poor weight gain, FTT< diaphoresis with feeding
- small: asxatic
- mod-large: DOE, recurrent URI, HF sxs, FTT, poor weight gain
- signs: tachypnea, increased WOB, rales, grunts, retractions, diaphoresis, pallor, hepatomegaly
- Murmur: grade 2-3, harsh, high pitched, or blowing, HOLOSYSTOLIC, heard best LLSB, diffuse radiation, louder with isometric handgrip, quieter with valsalva
- associated: pulm HTN and eisenmenger syndrome = cyanosis and bidirectional shunt
7
Q
VSD dx and tx
A
- clinical dx: EKG shows biventricular hypertrophy, CXR shows cardiomeg, inc pulm vasc, enlarged LA, LV, and pulm artery, TTE = confirmatory (loc and size of defect, direction of flow), cath rarely utilized
- complications: endocarditis, aortic regurg, subaortic stenosis, RV outflow tract obstruction, atrial shunting
- tx: asx and small = delay tx, 75% close spont in first 2y of life
- HF sxs: nutritional support, diuretics (furosemide), surg repair (direct patch closure via median sternotomy), transcath closure
- prognosis: if surg not performed in first year of life, inc risk irreversible pulm vasc dz especially in children with down syndrome
- health maint: all IMZ UTD including PNA and flu, RSV proph if <1y
8
Q
tetrology of fallot etiology, sxs, dx
A
- R-L shunt, blue baby syndrome, 7-10% of children, M=F, most common cyanotic CHD
- anatomic features: VSD, overriding aorta, pulmonic/subpulmonic stenosis, RVH, crescendo-decrescendo murmur primarily dt RV outflow obstruction
- sxs: exertional dysp
- signs: cyanosis worse with age, tet spells, irritability or agitation, tachypnea
- murmur: harsh, holosystolic ejection best heard at LUSB, radiates to back
- louder with acidosis, stress, infxn, exercise, B agonists, dehydration, closure of ductus arteriosus, posture
- quieter with squatting (increases SVR)
- murmur: harsh, holosystolic ejection best heard at LUSB, radiates to back
- associated: click with single loud S2, palpable RV lift, systolic thrill at LSB
9
Q
tetrology of fallot dx and tx
A
- dx: EKG shows RAD, RVH; CXR shows boot-shaped heart (triad = egg on a string, inc pulm congestion, mild cardiomegaly), TTE, cardiac cath
- tx: IV PGE-1 to prevent ductal closure, allowing pulm flow until surg repair
- tet spells: knee-chest position (inc SVR moves blood from RV to pulm circ), surgery (palliative shunts, intracardiac repair by 1y of age)
- prognosis: associated PDA increases survival
- health maintenance: endocarditis abx proph for all pts with unrepaired cyanotic CHD, preg not recommended in unrepaired TOF
10
Q
atrial septal defect etiology, RF, sxs
A
- hole in atrial septum or patent foramen ovale, inc flow across pulm valve owing to RV volume overload from L-R atrial shunting
- ostium secundum (75%): openings without tissue flap
- often undetected until adulthood, very subtle findings, crescendo-decrescendo murmur
- sxs: acyanotic - mostly asx until 30yo
- infants/children: hx recurrent URI, FTT, exertional dysp
- adults/adolescents: exertional dysp, fatigue, palps, syncope, MC presenting sx = atrial arrhythmias
- murmur: soft mid-systolic ejection murmur, heard best over LUSB, doesnt radiate, fixed, widely split S2 (unchanged with insp) dt inc RV volume and delayed closure of pulm valve; early mid-systolic rumble, associated with loud S1
11
Q
ASD dx and tx
A
- dx: prenatal US can diagnose in fetus 18-22wk, must be confirmed by postnatal echo
- clinical dx: EKG = normal or RAD +/- RVH (incomplete RBBB), CXR = dilation of right atrium, ventricle, and pulm arteries, cardiomegaly, TTE, MRI, cardiac cath (GOLD STANDARD TO MEASURE Qp/Qs)
- tx: small (<6mm diameter) 40-80% close spont by 2y, moderate (6-8mm) percut closure, median sternotomy, or thoracotomy
- indications for repair
12
Q
patent ductus arteriosus etiology, RF, sxs
A
- normally DA connects main pulm artery and the aorta during development, diverting blood away from lungs, kept open by low arterial O2 and circulating PGE2 produced by the placenta
- after birth, DA normally constricts and obliterates after 10-15hrs as arterial O2 increases and PGE2 dec turning into ligamentum arteriosum after 2-3wks
- RF: prematurity, perinatal distress, or hypoxia (dec PVR sooner) - delays closure; rubella, birth at high alt
- F>M 2:1, in PDA the DA fails to completely close postnatally, differentiate from other continuous murmurs based on location and quality, crescendo-decrescendo murmur
- infant/child sxs: acyanotic, asx unless pulm HTN or LVF results, poor feeding and weight loss, frequent URIs or pulm congestion
- infant/child signs: HF (FTT, poor feeding, resp distress, sweating), SOB, easy fatigability
- murmur: continuous, rough, machinery, late systolic, heard best at LUSB, associated LV thrill, multiple clicks throughout murmur
- associated: wide pulse pressure, bounding peripheral pulses
13
Q
patent ductus arteriosus dx and tx
A
- dx: EKG shows BVH, LAE; CXR shows prominent aortic knob along LUSB; cardiomegaly, inc pulmonary vasculature; enlarged LV and LA
- TTE is confirmatory: + ductus arteriosus, retrograde flow in pulm artery; Cardiac catheter shows pulm HTN, MRI
- tx: PGE or COX inhibitor (NSAIDs, IV indomethacin or ibuprofen - ineffective in older children)
- med mngmt for infants with HF: digoxin and diuretics; stabilize until candidates for device or sugrical ligation; if asx, observe until large enough for surg
- surg: for term neonates and older infants >5kg, repair before age 1y (surg ligation = VATS), preferred if preterm (percutaneous occlusion)
- indications for surg repair: significant L-R shunting, L sided volume overload, reversible PAH, hx of endocarditis
- health maintenance: no endocarditis proph required except eisenmenger syndrome, device closure or surg ligation w prosthetics, device closure or ligation and residual defect at site of repair
- usually closes 48h after berth
14
Q
coarctation of the aorta etiology, RF, sxs
A
- M>F 3:1
- MC: ligamentum anteriosum
- associated: turner syndrome, DM, bicuspid aortic valve, discrete or long segment narrowing adjacent to left subclav, systemic collaterals develop
- malformation originating in L side of heart (prox to dist), narrowing of descending thoracic aorta from transverse arch to iliac bifurcation
- sxs: acyanotic or cyanotic (if severe or large PDA)
- infants: HF sxs or shock, FTT, poor feeding
- signs: pale, irritable, diaphoretic, dyspneic, absent femoral pulses, HM
- young children: HTN, new murmur, underdeveloped lower extremities
- signs: HTN in upper extrems, systolic pressure gradient >10mmHg between R arm and leg, weak/absent or delayed fem pulse
- infants: HF sxs or shock, FTT, poor feeding
- Murmur: continuous systolic ejection click over L infraclavicular region heard best on back between scapulae, radiates to LUSB and L scap, associated with S4 gallop
- complications: dissection, aortic rupture, HTN, CHF, endocarditis, stroke
15
Q
coarctation of the aorta dx and tx
A
- dx: clinical dx, EKG shows LVH, CXR shows cardiomeg +/- pulm vasc markings, rib notching, echo is confirmatory and shows reduced and delayed syst amplitude with persistent flow during diastole; discrete area of narrowing within lumen of proximal descending thoracic aorta, CV MRI/CT (defines loc and severity, recommended in all adults with CoA), cardiac cath, barium swallow (three or E sign)
- associated (adults): HA, epistaxis, heart failure, aortic dissection
- tx: infants at higher risk for HR and death when DA closes - continuous IV PGE-1 (alprostadil) to maintain patent ductus arteriosus until surg, dopamine or dobutamine to inc contractility in HF, supportive care (correct MA< hypogly, resp failure, anemia)
- adults: indication for stent placement (coarc gradient >20mmHg or <20 with anatomic imaging of severe narrowing and radiologic evidence of increased collateral flow
- prognosis: unoperated mean survival rate of adults = 35y
- complications: recoarctation, aneurysm formation, femoral occlusion
