Cardiovascular Flashcards
1
Q
endocarditis etiology, RF, and sxs
A
- MC native valve infection (strep viridans, staph aureus, enterococci)
- IVDU: staph aureus, tricuspid
- Prosthetic valve: staph aureus, gram neg or fungi
- most pts have underlying regurgitant defect providing a nidus
- sxs: fever, nonspecific sxs (dyspnea, cough, CP, arthralgias, back or flank pain, GI complaints)
- signs: stable murmur (90%), palatal, conjunctival, or subungal petechiae, splinter hemorrhages, pallor, splenomegaly
- diagnostic signs:
- osler nodes (painful, violaceous, raised lesions on fingers, toes, feet)
- janeway lesions (painless red lesions on palms/soles of feet)
- roth spots (exudative lesions in retina)
2
Q
endocarditis dx and tx
A
- dx: 3 sets of blood cultures at least 1h apart, before starting abx
- echo: required to make dx and identify involved valves (vegetation)
- tx: empiric abx cover staph, strep, enterococci
- native valve: vanco alone or + cefazolin
- Ill pts w/ HF: gentamicin plus cefepime and vanco
- aortic valve replacement if refractory or abscess (funcal infxn)
- prophylaxis: abx recommended before invasive dental work or surgical procedures: prosthetic valves, previous IE, some congenital heart dzs (transposition, tetrology), acquired valve disorders, HCM, cardiac transplant pts with valvulopathy
- ALL OF THE ABOVE GET AMOX 1 hr before procedure (clarith or azith if PCN allergy)
3
Q
Modified duke criteria
A
- For detecting endocarditis
- must have one of the following criteria:
- 2 major
- 1 major and 3 minor
- 5 minor
- Major:
- two pos blood cultures of typical causative microorganism
- echo showing new valve regurg
- Minor:
- predisposing factor
- fever >100.4
- vascular phenomena (embolic dz or pulm infarct)
- immunologic phenomena (glomeruloneph, osler nodes, roth spots)
- blood cuture not meeting major criteria
coronary artery vasospasm (Prinzmetal variant) etiology, RF, sxs
- etiology: smooth muscle constriction (spasm) of the coronary artery w/out obstruction - leads to MI, ventricular arrhythmias, sudden death
- known triggers: hyperventilation, cocaine, tobacco use, provocative agents (acetylcholine, ergonovine, histamine, serotonin)
- Nitric oxide deficiency: increased activity of potent vasoconstrictors and stimulators of smooth muscle proliferation
- 50yo, females
- sxs: nonexertional chest pain similar to unstable angina
- normal exercise tolerance
- pain is cyclical (most occur in morning hours, no correlaiton to cardiac workload)
4
Q
Prinzmetal angina dx and tx
A
- dx: EKG (ST segment or Twave abnormalities)
- Cardiac enzyme: normal troponin, CK-MB
- Check Mg level, CBC, CMP, lipid panel
- tx: stress testing with myocardial perfusion imaging or coronary angiography
- pharmacotherapy (SL, topical, or IV nitrates (initial), antiplatelet, thrombolytics, statins, BB
- once dx made, CCB and long-acting nitrates used for long term prophylaxis (amlodipine)
5
Q
pharm tx of ACS/chest pain (angina)
A
- Clopidogrel: reduces incidence of MI in pts with USA compared with ASA alone
- LMWH: continue for at least 2d; PTT not followed
- UFH: PTT 2-2.5x normal if using UFH
- start pt with USA or NSTEMI with high LDL on statin
6
Q
Unstable angina
A
- O2 demand unchanged, supply decreased, secondary to low resting coronary flow
- sxs: chronic angina increasing in frequency, duration, or intensity of pain OR
- new onset angina that is severe and worsening OR
- angina at rest
- dx: EKG shows ST segment or Twave abnl
- cardiac enzymes show normal troponin and CK-MB
- tx: admit to unit with continuous cardiac monitoring, establish IV access, O2, pain control with NTG and morphine
- ASA, clopidogrel, BB (first line), LMWH, replace electrolytes, if response to med tx - stress test to determine if catheterization/revascularization necessary
- reduce RF: stop smoking, weight loss, tx DM/HTN/HLD
- heparin
- NOT BENEFICIAL: thrombolytics and CCB
7
Q
NSTEMI and STEMI etiology, RF, sxs
A
- NSTEMI: caused by severely narrowed artery that is not 100% blocked
- STEMI: caused by 100% blockage of a coronary artery, necrosis of myocardium (thrombotic occlusion), asx in 1/3 of pts
- sxs: CP (intense, substernal, crushing), radiation to neck, jaw, arms, back, left side, similar to angina pectoris but more severe and lasts longer, pain doesnt respond to NTG, epigastric, SOB, sweating, nausea, vomiting, weakness fatigue, syncope
8
Q
NSTEMI and STEMI dx and tx
A
- dx:
- NSTEMI: EKG shows pathologic Q waves, elevated trop and CK-MB
- STEMI: EKG shows peaked T-waves, ST elevation, Q waves, T wave inversion
- in both, monitor BP/HR, cardiac enzymes
- tx: admit to ccu, establish IV access, O2, NTG/morphine
- MONA: morphine, O2, nitrates, ASA
- BB, ACE, heparin, statin
- prognosis: 30% mortality rate
9
Q
dressler syndrome
A
- post-MI syndrome occurs 1-2 wk post-MI
- sxs: fever, malaise
- complications: pericarditis, pleuritis
- dx: CBC shows leukocytosis
- tx: ASA (first line), ibuprofen
10
Q
Dyspnea on exertion
A
- breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity
- clues to need for an urgent eval inclue HR >120, resp rate >30, pulse ox <90%, accessory m use, difficulty speaking full sentences, stridor, asymmetric breath sounds or percussion, diffuse crackes, diaphoresis, cyanosis
- CV causes = AMI, HF, cardiac tamponade
- Resp causes = bronchospasm, PE, PTX, pulm infxn, upper airway obstruction
- workup in emergent setting for acute dyspnea: EKG and CXR, cardiac biomarkers, US, BNP, D-dimer, ABG/VBG, CO2 monitoring, chest CT or VQ scan, peak flow and PFTs
- management: O2, IV access, EKG and uplse ox, airway managment
11
Q
stable angina etiology, RF, sxs
A
- etiology: fixed atherosclerosis narrowing arteries
- O2 supply < )2 demand
- major RF: DM (worst), HLDL (high LDL), HTN (most common), smoking, age (m>45, w>55), FHx premature CAD or MI in 1st degree relative, low HDL
- minor RF: obesity, sedentary, stress, ETOH
- sxs: CP or substernal pressure (lasts <10-15m, heaviness, pressure, squeezing, tightness, rarely sharp), gradual onset pain, increases with exertion or emotion, relieved with rest or NTG
- Levine sign: clenched fist over sternum and clenched teeth when describing CP
12
Q
stable angina dx and tx
A
- dx: EKG - normal, Q-waves (prior MI)
- cardiac stress test
- tx: sublingual NTG - IV NTG
- coronary angiography: if severely sxatic despite medical tx
- prognosis: depends on LVEF: <50% = increased mortality
- vessels involved: left main = poor prognosis, 2-3 vessels total = worst prognosis
13
Q
Pericardial effusion
A
- secondary to pericarditis, uremia, or cardiac trauma: restrictive pressure on the heart
- sxs: painful or painless, cough and dyspnea, atypical chest discomfort, dizziness (low BP), palps
- signs: periph edema, distant heart sounds
- complications: as effusion increases, CO and BP dec, falling to critical levels (tamponade)
- dx: CXR or echo determine extent of effusion or calcification (inc pericardial fluid, cardiomeg), EKG shows nonspec T wave changes, low QRS voltage (alternans)
- tx: pericardiocentesis to relieve fluid accumulation; if recurrent, surgery with a pericardial window
14
Q
cardiac tamponade
A
- fluid compromises cardiac filling and impairs cardiac output
- signs: beck’s triad - biphasic scratching sound (muffled heart sounds), HoTN, JVD, tachycardia, tachypnea, Kussmaul’s sign, pulsus paradoxus
- dx: echo shows increased pericardial fluid, diastolic collapse of cardiac chambers, narrow pulse pressure
- tx: pericardiocentesis
15
Q
hypertensive urgency
A
- BP needs to be reduced within hours
- Persistently elevated higher than 220 systolic or 125 diastolic or accompanied complications without end-organ damage
- tx: oral agents: clonidine, captopril, nifedipine, labetolol
16
Q
Hypertensive emergency (malignant hypertension)
A
- elevated BP with papilledema or retinal hemorrhage and either encephalopathy or nephropathy, confusion, left ventricular failure, intravascular coagulation
- Difference: HTN emergency always has retinal papilledema and flame-shaped hemorrhages and exudates
- must be reduced within 1 h to prevent progression to end organ damage or death
- diagnostic criteria: persistently elevated higher than 220 systolic, diastolic >130
- Complications: encephalopathy, nephropathy, ICH, aortic dissection, pulmonary edema, unstable angina, MI, stroke
- on fundoscopic: retinal hemorrhages, exudates, papilledema
- Hallmark complication: fibrinoid necrosis of the arterioles in the kidney
- Tx: DONT REDUCE TOO RAPIDLY - can cause ischemia
- sodium nitroprusside (short acting, titratable, potential for thiocyanate and cyanide tox with prolonged use or renal/hep fail)
- labetalol (alpha and beta blocker) - preferred in dissection and ESRD
- Neuro emergencies:
- encephalopathy, stroke, ICH, SAH: labetalol, nicardipine, esmolol. AVOID nitroprusside and hydralazine
- reduce MAP 25% over 8h
- for MI us NTG or BB
- aortic dissection: use nitroprusside and BB
- Hydralazine during preg
- lower BP within first 24-48h by 25%
- 90% will die after 1-2y
- encephalopathy, stroke, ICH, SAH: labetalol, nicardipine, esmolol. AVOID nitroprusside and hydralazine
17
Q
congestive heart failure
A
- decompensated: evidence on PE or chest radiograph of pulm edema, audible 3rd heart sound or increased JVP
- Left ventricular failure: sxs of low cardiac output and congestion (SOB) dt systolic or diastolic dysfn
- R ventricular failure: sxs of fluid overload almost always dt LVF
- MCC systolif HF (reduced EF): ISCHEMIC CARDIOMYOPATHY (CAD with resultant MI an dloss of fning myocardium)
- systolic dysfn: difficulty with ventricular contraction
- diastolic dysfn: difficulty with ventricular relaxation; results from HTN and associated with aging; related to myocardial m. stiffness and LVH
- HF with preserved EF
18
Q
congestive heart failure etiology, RF, and sxs
A
-
MCC: CAD, HTN, DM
- LV remodeling: dilation, thinning, mitral valve incompetence, RV remodeling
- 75% have preexisting HTN
- MCC of transudative (extravascular fluid) pleural effusions
- mostly >65yo
- sxs:
- exertional dyspnea (SOB), then dyspnea with rest, chronic nonproductive cough, worse in recumbent position
- fatigue, orthopnea, night cough, relieved by sitting up or sleeping with additional pillows, paroxysmal nocturnal dyspnea, nocturia
- signs:
- cheyne-stokes breathing, edema (ankles, pretibial (cardinal)), RALES, additional heart sounds:
- S4 = diastolic HF (preserved EF)
- S3 = systolic HF (reduced EF) with volume overload - tachycardia, tachypnea
- jugular venous pressure >8cm
- cold extremities, cyanosis, hepatomegaly (ascites, jaundice, peripheral edema)
- cheyne-stokes breathing, edema (ankles, pretibial (cardinal)), RALES, additional heart sounds:
