Cardiovascular Flashcards
Normal HR
60-100 bpm
Right axis deviation causes (4)
Right ventricular hypertrophy
Anterolateral MI
Left Posterior Hemiblock
(also consider PE)
Left Axis deviation causes (4)
Ventricular tachycardia
Inferior myocardial infarction
Left ventricular hypertrophy
Left anterior hemiblock
Jervell and Lange-Nielsen syndrome
Long QT syndrome due to a defect in K channel conduction.
Associated with sensorineural deafness
Treat with Beta blockers and pacemaker
Left bundle branch block
WiLLiaM
V1= W QRS pattern V6= M QRS pattern
Acute MI
Right bundle branch block
MaRRoW
V1= M QRS pattern V6= W QRS pattern
Rabbit ears (M Shaped) in V1
Right atrial abnormality
P pulmonale
causes Peaked P waves
> 2.5 mm in lead II
Left atrial abnormality
P mitrale
Mitrale causes M shaped P waves
P wave width in Lead II is > 120 sec
Notched P waves
Right sided murmurs do what
Increased with inspiration
Left sided murmurs do what
Increased with expiration
JVD measurement
> 4 cm above sternal angle
Kussmaul sign
Increase in jugular venous pressure (JVP) with inspiration
Seen in constrictive pericarditis
An early decrescendo murmur
Aortic regurgitation
A mid to late low pitched murmur
Mitral stenosis
S3 gallop
Rapid ventricular filling due to fluid overload
A sign of fluid overload
Heart failure, mitral valve disease
Normal in young and pregnancy
S4 gallop
Stiff noncompliant ventricle
A sign of decreased compliance
Hypertension, aortic stenosis, diastolic dysfunction,
Hear a “plop” while listening to chest
Atrial myxoma
Can develop systemic embolization from breakoff of tumor leading to stroke
Tx: Resection
Wolff-Parkinson White
Tx
Abnormal fast accessory conduction pathway from atria to ventricle (Bundle of kent)
Delta wave with widened QRS complex and shortened PR interval
Advise against vigorous activity
Procainamide for arrhythmias
Calcium channel blockers are contraindicated
Management for atrial fibrillation (4)
ABCD
Anticoagulate
B-blockers to control rate
Cardiovert/calcium channel blockers
Digoxin (in refractory cases)
Collapsing (“waterhammer”) peripheral pulse
Aortic incompetence
AV malformation
Patent ductus arteriosus
thyrotoxicosis
Severe anemia
Pulsus paradoxus
Decrease in systolic blood pressure >10 Hg with inspiration
Cardiac tamponade
Pericardial constriction
Tension pneumothorax
Foreign body in airway
Pulsus alternans
Alternating weak and strong pulses
Cardiomyopathy
Impaired left ventricular systolic function
Jerky peripheral pulses
Hypertrophic obstructive cardiomyopathy
Pulsus bisferiens
Bifid pulse/ twice beating
Aortic regurgitation
Combined aortic stenosis and aortic regurgitation
Hypertrophic obstructive cardiomyopathy
What can be used to increase heart rate
Atropine
Causes of arrthymias
Beta blockers
CCB
No P waves
Variable and irregular QRS response
- Tx
Atrial fibrillation
Tx: Beta blockers, CCB or digoxin
Anticoagualtion w/ warfarin
Causes Atrial fibrillation
PIRATES
Pulmonary disease Ischemia Rheumatic heart disease Anemia/ Atrial myxoma Thyrotoxicosis Ethanol Sepsis
Estimate stroke risk in atrial fibrillation
CHA(2)DS(2)-VASc
CHF (1 point) HTN (1 point) Age >= 75 (2points) Diabets (1 point) Stroke or TIA history (2 points)
Vascular disease (1 pt) Age 65-74 (1 pt) Sex Category (female) 1 point
Ventricular tachycardia tx
Amiodarone
Lidocaine
Procainamide
(If stable)
Ventricular fibrillation tx
no pulse
Electrical defibrillation
CXR findings for CHF diagnosis (5)
ABCDE
Alveolar edema (Bat's wings) Kerley B lines (interstitial edema) Cardiomegaly Dilated prominent upper lobe vessels Effusion (pleural)
How to diagnose CHF
Echocardiogram ( tarnsthoracic echocardiogram)
Left sided CHF symptoms ( 6)
Dyspnea predominates Left sided S3/S4 gallop Bilateral basilar rales Pleural effusions Pulmonary edema Orthopnea, paroxysmal nocturnal dyspnea
Right sided CHF symptoms (6)
Fluid retention predominates Right sided S3/S4 gallop JVD Hepatojugular reflux Peripheral edema Hepatomegaly, ascites
Acute CHF management (5)
LMNOP
Lasix (furosemide) Morphine NItrates Oxygen Position (sit upright)
CHF management
Loop diuretics
ACEI or ARBS w/ loops
Beta blockers (avoid when decompensated) but started once euvolemic
Loop diuretics (4)
SE (6)
Furosemide
Ethacrynic acid
Bumetanide
Torsemide
SE: ototoxicity Hypokalemia Hypocalcemia Hyeruricemia Dehydration Gout
Thiazide diuretics (3)
SE (6)
Hydrochlorothiazide
Chlorothiazide
Chlorthalidone
SE: Hypokalemic metabolic alkalosis Hyponatremia HYperGLUC (hyperglycemia, hyperlipidemia, hyperuricemia, hyperCalcemia)
K sparing agents (4)
SE (3)
Exception
Spironolactone
Eplerenone
Triamterene
Amiloride
SE:
Hyperkalemia
Gynecomastia
Sexual dysfunction
Eplerenone does not have antiandrogenic effects that lead to gynecomastia
Carbonic anhydrase inhibitors
SE (4)
Acetazolamide
SE: Hyperchloremic metabolic acidosis Neuropathy NH3 toxicity Sulfa allergy
Osmotic agents
SE (2)
CI (2)
Mannitol
SE:
Pulmonary edema
Dehydration
CI:
Anuria
CHF
Acute decompensated heart failure tx
Inotropic agents (dobutamine) reduces left ventricular end systolic volume for symptomatic improvement
When to place cardiac defibrillator
EF < 35%
When to place pacemaker
EF < 35
Dilated cardiomyopathy
Widened QRS complex with persistent symptoms
Diuretic taht looses alcium
Loops lose calicum
Thiazides take in
College man passes out playing basketball, ECG shows slurred upstroke of QRS
Wolff-Parkinson white syndrome
Dilated Cardiomyopathies
Abnormality
Left ventricular cavity size (end diastole)
Left ventricular cavity size (end diastole)
EF
Wall thickness
Impaired contractility
Large Increased Left ventricular cavity size (end diastole)
Large Increased Left ventricular cavity size (end diastole)
Decreased EF
Wall thickness decreased
Balloon like heart
Hypertrophic Cardiomyopathies
Abnormality
Left ventricular cavity size (end diastole)
Left ventricular cavity size (end diastole)
EF
Wall thickness
Impaired relaxation
Decreased Left ventricular cavity size (end diastole)
Large Decreased Left ventricular cavity size (end diastole)
Increased or normal EF
Wall thickness largely increased
Tx: BB/CCB
Restrictive Cardiomyopathies
Abnormality
Left ventricular cavity size (end diastole)
Left ventricular cavity size (end diastole)
EF
Wall thickness
Impaired elasticity
Decreased Left ventricular cavity size (end diastole)
Decreased Left ventricular cavity size (end diastole)
Normal EF
Wall thickness increased
Caused by: amyloidosis, sarcoidosis, hemochromatosis)
Harsh systolic ejection crescendo-decrescendo murmur in the lower left sternal edge that increases with decrease in preload (valsalva, standing) and decreases in increase in preload ( passive leg raise)
Tx
Hypertrophic cardiomyopathy
Abnormal mitral leaflet motion= systolic anterior motion of mitral valve
Anterior motion of mitral valve leaflets toward the interventricular septum
Beta blockers (initial therapy) Non-dihydropyridine CCB
CI: Digoxin and spironolactone
Prinzmetal angina
Young women
Early morning at rest
TX: CCB with or without nitrates
TIMI Risk score for Unstable Angina/ NSTEMI
Age >= 65 (1pt)
Three or more CAD risk factors (1 pt)
[ Premature fm hx, DM, smoking, HTN, Increased cholesterol, PAD, abdominal aortic aneurysm]
Known CAD; stenosis > 50% (1 pt)
ASA use in past 7 days (1 pt)
Severe angina (1 pt)
[Two or more episodes within 24 hours]
ST deviation >= 0.5 mm (1 pt)
+ cardiac marker (1 pt)
> = 3 pts benefit more from enoxaparin (vs unfractionate heparin), glycoprotein IIB/II inhibitors (abciximad, tirofiban, eptifibatide) and early angiography
TX MI
MOANing Big from MI (MONA-B)
Morphine Oxygen ASA+ Additional second antiplatelet agent (NSTEMI) [Prasugrel or ticagrelor] Nitrates B-blockers
IV morphine w/ IV metoclopramide
Heart failure: avoid beta blockers (give ACEI)
Enoxaparin
Low molecular weight heparin
STEMI ECG changes
1) Peaked T waves
2) ST segment elevation
3) Q waves
4) T wave inversion
5) ST segment normalization
6) T wave normalization over several hours to days
Cardiac enzymes
Troponin most sensitive
3-12 hrs to rise (troponin and CK-MB)
Troponin peaks 24-48
CKMB peaks 24 hrs
ST segment elevated leads II, III, aVF
Inferior MI
RCA
PDA
LCX
Avoid nitrates and diuretics due to risk for severe hypotension (preload dependent)
ST segment elevations V1-V4
Anterior MI
LAD
Diagonal branches
St segment elevations Leads I, AVI, V5-V6
Lateral MI
LCA
Diagonal
ST segment depression in V1-V3
ST elevation in leads I and aVL
or
ST depression in leads I and aVL
Posterior MI
LCX
RCA
ST elevation in leads I and aVL= LCX
ST depression in leads I and aVL= RCA
Contraindications to thrombolysis (5)
- Previous intracranial hemorrhage or major GI bleed
- Recent major trauma/ surgery/ head injury
- Ischemic stroke within the last 6 months
- Severe HTN (>180/110)
- Known bleeding disorder
Timeline of complications post MI
First day: Heart failure
2-4 days: arrhythmia, pericarditis
5-10 days:
1) left ventricular wall rupture (acute pericardial tamponade causing electrical alternans, pulseless electrical activity, JVD)
2) papillary muscle rupture (severe mitral regurgitation, pulmonary edema)
3) Septal rupture (lower left sternal border murmur, increased O2 saturation in the right ventricle)
weeks to months: ventricular aneurysm (CHF, arrhythmia, persistent ST segment elevation, mitral regurg, thrombus formation)
Post MI
2-4 weeks
Fever, pericarditis
pleural effusion
Leukocytosis
Increased ESR
Dressler syndrome
Dyslipidemia
LDL > 130 mg/dL or
HDL < 40 mg/dL
HMG-COA reductase inhibitors (5)
Effects of lipids
SE (3)
Atorvastin Simvastatin Lovastatin Pravastin Rosuvastatin
Decrease LDL
Decrease Triglycerides
SE:
Elevated LFT
Myositis
Warfarin potentiation
Lipoprotein lipase stimulators (fibrates)
Effects of lipids
SE (5)
Gemfibrozil
Decrease triglycerides
Increase HDL
SE: GI upset Cholelithiasis Myositis (esp in combo w/ statin) Increased LFT Pancreatitis
Cholesterol absorption inhibitors
Effects of lipids
SE (3)
Ezetimibe
Decrease LDL
SE:
Diarrhea
Abdominal pain
Can cause angioedema
Niacin
Effects of lipids
SE (5)
Decrease LDL
Increased HDL
Skin flushing (can be prevented w/ ASA, due to increase in prostaglandins) Paresthesias Pruritus GI upset Increased LFTs
Bile acid resins (3)
Effects of lipids
SE (5)
Cholestyramine
Colestipol
Colesevelam
Decrease LDL
SE Constipation GI upset LFT Abnormalities Myalgias Can decrease absorption of other drugs from small intestine
Proprotein convertase subtilisin/ kexin type 9 (PSCK9) inhibitors (2)
Effects of lipids
SE (4)
Evolocumab
Alirocumab (injectable 2-4 weeks)
Decrease Decrease LDL
Injection site swelling
Rash
Muscle/ limb pain
Backache
HTN non african american tx
ACEI/ ARB
Thiazide
CCB
HTN african american tx
Thiazide
CCB
HTN w/ CKD tx
ACEI/ ARB
HTN
1) uncomplicated
2) CHF
3) Diabetes
4) Post MI
5) CKD
6) BPH
7) Isolated systolic HTN
8) Pregnancy
1) uncomplicated: Diuretics, CCB, ACEI
2) CHF: Diuretic, Beta blocker, ACEI, ARB, Aldosterone antagonist
3) Diabetes: Diuretics, ACEIs, ARBs, CCBs
4) Post MI: Beta blocker, ACEI, ARB, Aldosterone antagonist
5) CKD: ACEI, ARBs
6) BPH: Diuretics, alpha adrenergic blockers
7) Isolated systolic HTN: Diuretics, ACEIs, CCB (dihydropyridines)
8) Pregnancy: Methyldopa, beta blockers (labetalol), hydralazine
BP > 180/120
Hypertensive crises
IV medications: labetalol, nitropruside, nicardipine)
Pericardial calcifications seen on CXR suggest
Constrictive pericarditis due to chronic fibrosis and calcification of the pericardium
Cardiac tamponade tx
Aggressive volume expansion with IV fluids
Urgent pericardiocentesis
Ascending aortic aneurysm vs descending aortic aneurysm
Ascending
- think cystic medial necrosis or connective tissue disease
Descending aortic aneurysm
- think atherosclerosis
Rapid onset of pulmonary congestion, cardiogenic shock and severe dyspnea
Acute aortic regurgitation
[ From infective endocarditis, aortic dissection, chest trauma, MI]
Uncomfortable heart pounding when laying on left side
Aortic regurgition (chronic)
Aortic regurgitation
PE (6)
Tx
PE:
1) Early blowing diastolic murmur at the left sternal border
2) Mid-diastolic rumble (austin flint murmur)
3) Midsystolic apical murmur
Head bob with heart beat
Water hammer pulse (corrigan sign)
Duroziez sign (femoral bruit)
Tx: Vasodilator therapy (dihydropyridine or ACEI)
Opening snap and mid diastolic murmur at the apex
Pulmonary edema
Tx
Mitral valve stenosis
Tx: Antiarrhythmics (Beta blockers, digoxin, CCB) and warfarin
Aortic dissection due to
Aortic aneurysm due to
Dissection: HTN
Aneurysm: atherosclerosis
Common site of aortic dissection
Above the aortic valve and distal to the left subclavian artery
Hypotension
Severe tearing abdominal pain that radiates to the back
Aortic aneurysm
Tx: <5 cm monitor
>5.5 (abdominal) surgery
> 6 cm (thoracic) surgery
Sudden tearing/ ripping pain in the anterior chest with or without radiation fo the back
Hypertensive
Diagnose?
Aortic dissection
Anterior chest pain ( ascending) Back pain (descending)
If stable: CT angiography
Unstable: TEE
Screening AAA
men 65-75 who ever smoked
Aortic dissection types
Type A: ascending aortia and may progress to involve the arch and thoracoabdominal aorta
[More common]
Type B: descending thoracic or thoracoabdominal aorta distal to the left subclavian artery without involvement of the ascending aorta
[Can be managed medically, IV beta blockers (labetalol) before starting vasodilators (nitroprusside)
Imaging for DVT
Tx DVT
Doppler Ultrasound
TX: LMWH or IV unfractionated heparin followed by PO warfarin for 3-6 months
Imaging for PE
Tx PE
Spiral CT or V/Q scan
TX: LMWH or IV unfractionated heparin followed by PO warfarin for 3-6 months
Calf claudication=
Buttock claudication=
Buttock claudication+ impotence=
Calf claudication= femoral disease
Buttock claudication= iliac disease
Buttock claudication+ impotence= Leriche syndrome (aortoiliac occlusive disease)
Cough
Progressive dyspnea
Orthopnea
Atrial fibrillation with rapid ventricular response
Immigrated to US from India
Recurrent sore throat as child
Cough, Progressive dyspnea, orthopnea= pulmonary edema with rapid decompensation due to development of new atrial fibrillation
Recurrent sore throat= rheumatic heart disease
Mitral stenosis is diagnosis
[Rheumatic mitral stenosis can become symptomatic w/ pregnancy]
Elevated jugular venous pressure
Hepatomegaly
Ascites
Peripheral edema
Constrictive pericarditis
Peripartum cardiomyopathy (PPCM)
Rapid onset of systolic heart failure
Fatigue
Dyspnea
Cough
Pedal edema
at > 36 weeks
80 y.o Purulent ulcer Hypotension Tachycardic Tachypnea Lethargy Confusion
Septic shock
1) Decreased systemic vascular resistance (reduced afterload) due to peripheral vasodilation
2) Decreased pulmonary capillary wedge pressure (left atrial pressure) due to capillary leakage, which causes decreased preload
3) Elevated mixed venous oxygen saturation due to hyperdynamic circulation with an inability of tissues to adequately extract oxygen
Types of shock
Central venous pressure (right sided preload)
PCWP (left sided preload)
Cardiac index (LV output)
SVR (afterload)
SvO2
Hypovolemic
- mass hemorrhage
Low CVP, PCWP, CI, SvO2
High SVR
Cardiogenic shock
- decreased cardiac contractility
High CVP, PCWP, SVR
Low CI, SvO2
Obstructive shock - increased intrapericardial pressure - pulmonary artery embolism High: CVP, SVR Low: PCWP, CI, SvO2
Distributive - septic shock - neurogenic shock High: CI, SvO2 Low: CVP, PCWP, SVR
See screen shot
Biphasic stridor in child that improves with extension
Vascular ring
Orthostatic hypotension caused by
Decreased baroreceptor responsiveness
Insufficient constriction of blood vessels in the lower extremities on standing
21 y.o dizziness and palpitations
Provoked by fatigue or strong emotions
Can stop episode by squatting or taking a deep breath
Hypotension
Cool extremities
Regular narrow complex tachycardia
What to do
Supraventricular tachycardia (SVT)
Causes hemodynamic instability (hypotension, cool extremities)
Tx: Cardioversion
Diagnosing aortic dissection
Hemodynamically stable patients= CT angiography
If Renal insuffiency= tranesophageal echocardiography (diabetes)
Why is K high in CHF
Low distal sodium and water delivery in CHF —> reduced potassium excretion and subsequent hyperkalemia
Brain natriuretic peptide (BNP)
hormone released from ventricular myocytes in response to high ventricular filling pressures and wall stress in patients
CHF
CHF signs (5)
Progressive dyspnea
Fatigue
Elevated BNP
Third heart sound
Peripheral edema
Exertional dyspnea
Orthopnea
Nocturnal cough
Hemoptysis
Emigrated from cambodia 2 years ago
Palpitations and irregular heart rate
Rheumatic heart disease
Mitral stenosis
Risk of development of atrial fibrillation —> left atrial thrombus —> systemic thromboembolic complications (stroke)
Syncope while working in garden
HTN
Tachycardia
Widening of mediastinum
Small pericardial effusion
Acute aortic dissection
Type A (ascending aorta) into pericardial space
CT angiography
Leg apain
Hx Afib
Smoker
Mottled skin that is cool
Pulses not palpable
Medication to prevent this
Embolism of a left atrial thrombus
Anticoagulation therapy
Apixaban: non-vit K antagonist oral anticoagulant (NOAC) directly inhibits factor Xa
[Apixaban, dabigatran, rivaroxaban, edoxaban]
Aspirin and clopidogrel less effective
Harsh crescendo decrescendo systolic ejection murmur over the left upper sternal border
Pulmonary stenosis
Tetralogy of fallot
Ring of calcification around the heart
Tuberculosis
Initial stabilization of acute ST elevated MI
MONA-B
Oxygen Aspirin PSY12 inhibitor (clopidogrel) Nitrates Beta blocker Statin Anticoagulation
If persistent pain, HTN or heart failure= IV nitroglycerin
If persistent severe pain= IV morphine
If unstable sinus bradycardia= IV atropine
If Pulmonary edema= IV furosemide
[If pulmonary edema dont give beta blocker]
Right lung biopsy develop=
Chest pain
Hypotension
Severe dyspnea
Low cardiac index
High PCWP
Cardiogenic shock
= Acute MI
Maneuvers that increase preload or afterload
Squatting
Leg raise
Hand grip
Supine
Maneuvers that decrease preload
Valsalva
Abrupt standing
Syncope while peeing
Situational (postmicturition) syncope
Form of vasovagal syncope (neurally mediated)
Triggers: Micturition, defecation, cough
Cardioinhibitory response
Patient on digoxin
New medication added
Anorexia
Nausea
Generalized weakness now
- Also seen features (2)
Drug interaction w/ amiodarone
Digoxin toxicity
Can lead to color vision changes
Atrial tachycardia with AV block
From Asia
Febrile illness a year ago, with pain and swelling in knees and wrists given NSAIDS
Holosystolic murmur at apex radiates to left axilla
Mitral regurgitation
Tx
Rheumatic heart disease
High risk for recurrence
Need antibiotic therapy
Should receive prophylaxis IM benzathine pencillin G every 4 weeks to prevent recurrence
On medication for A fib
Treadmill exercise test
Heart rate dramatically increases and QRS complex increases
What medication
Class I antiarrhythmic drugs that block sodium channels by inhibiting initial depolarization phase
Flecainide
Propafenone
When patient has faster heart rate drug has less time to dissociate from sodium channels—> higher number blocked channels —> progressive decrease in impulse conduction and widening of QRS complex
“Use dependence”
Amlodipine
Dihydropyridine CCB
[no QRS effect]
Verapamil
Diltiazem
CCB
Prolong refractory period of AV node and increase PR interval
Uncontrolled HTN
Progessive dyspnea
Lower extremity swelling
JVD
Prominent V waves
Holosystolic murmur at left lower sternal border
Decompensated left sided heart failure
Tricuspid regurgitation
Secondary TR results from right ventricular cavity enlargement from chronic right sided volume/pressure overload (right sided heart failure)
Left sided heart failure causes right sided
RV enlargement causes tricuspid annular dilation
Prominent V waves are highly specific for TR
Rumbling diastolic murmur at left lower sternal border
no JVP
Prominent A wave
Fusion of tricuspid valve commissures
[Rheumatic heart disease]
Tricuspid stenosis
Chest pain given medications aspirin, clopidogrel, LMWH, metoprolol, and lisinopril
Hx: Allergic rhinitis
Eczema
Second day: acute onset dyspnea with wheezing and prolonged expieration
Bronchoconstriction
Undiagnosed asthma that was exacerbated by aspirin
25 y.o
Transient vision loss in right eye
Elevated blood pressure
Bruit below right mandibular angle
High plasma renin
Grandmother stroke at 50
- Name
- MOA
Fibromuscular dysplasia (FMD)
Transient monoocular vision loss is consistent with amaurosis fugax
Emboli from severe ipsilateral carotid stenosis cause cause ischemia of optic nerve
FMD: noninflammatory and nonatherosclerotic condition caused by abnormal cell developemnt in the arterial wall —> vessel stenosis, aneurysm or dissection
Commonly: renal, carotid and vertebral arteries
Headache
Pulsatile tinnitus
Dizziness
Transient ischemic attack
Stroke
Amaurosis fugax
Dx: CT angiography of abdomen or duplex U/S
FMD decreases perfusion to kidneys which increases both renin and aldosterone levels
Preventive medication for anginal episodes
How does it work
Beta blockers (first line)
Decreased myocardial contractility and decrease in HR
Coronary artery vasodilation medication
Dihydropyridine calcium channel blockers
Amlodipine
Felodipine
They increase myocardial oxygen supply by vasodilation and reduce myocardial oxygen demand through systemic arterial vasodilation and reduction of afterload
Decreases cardiac afterload
Dihydropyridine calcium channel blockers
Amlodipine
Felodipine
They increase myocardial oxygen supply by vasodilation and reduce myocardial oxygen demand through systemic arterial vasodilation and reduction of afterload
Decreases cardiac preload
Nitrates
Dilation of venous capacitance vessels and reduction of cardiac preload
Tachycardia resolved with cold water immersion
Pasroxysmal supraventricular tachycardia
AV nodal reentrant tachycardia
Carotid sinus massage Cold water immersion Valsalva Eyeball pressure - Increase parasympathetic tone —> temporary slowing conduction of AV node
A fib treatment
Diltazem
Beta blockers
SOB
Abdominal distension
Chemotherapy 18 years ago
JVD
Positive fluid wave
Hepatomegaly
Pitting edema
Constrictive pericarditis
Complication of radiation therapy
Pericardial thickening & calcification
Inelastic pericardium
Portal vein thrombosis/ compression
Decompensated cirrhosis
Hypercoagulable states
NOT JVP
Arteriovenous fistula
Afterload
Preload
Cardiac index
Forms an enlarged vein
Fistula allows a portion of blood to bypass the high resistancce of the systemic arterioles , systemic vascular resistance (SVR) is decreased (decreased afterload)
Blood through fistula returns to right atrium more quickly—> increased venous return (increased preload)
Both increased venous return and decreased SVR contribute to increased cardiac output
Risk: high-output heart failure
(Increased cardiac preload)
Aortic regurg w/ dilated left ventricle why no symptoms
Increased left ventricular compliance
AR causes
Increase LV preload
Increased SV (due to increased preload)
Increase in ventricular contractility
Cardiac output sustained
Total peripheral resistance (TPR) remains unchanged
[TPR increases once decompensation begins]
Substernal chest pain
HTN
Diverticular bleed 2 years ago
Cardiac catheterization performed
Heparin drip
Develops weakness, back pain, SOB, nausea, abdominal discomfort
Flat neck veins
Hypotension
Tachycardia
Retroperitoneal hematoma
Non-contrast CT scan
Chest pain from cocaine tx
IV diazepam
Digeorge findings
Low set ears
Micrognathia
Cleft palate
No thymus
Truncus arteriosus
Hypocalcemia/ Hypoparathyroidism
Horseshoe kidney
Turner syndrome
MOA nitroglycerin
Decreased left ventricular wall stress
Systemic vasodilation and decreased preload —> decrease in left ventricular end diastolic and end systolic volume —> reduction in left ventricular systolic wall stress
1) Lowers preload
2) Lowers left ventricular end diastolic volume
3) Reduces wall stress
Statins MOA
Inhibit HMG-CoA reductase
RL enzyme needed to convert HMG-CoA to mevalonate
Decrease hepatic cholesterol activates cellular signals that increase the number of LDL receptors
[Inhibition of intracellular synthesis pathway]
1) Cell surface receptor blockage
2) Extracellular enzyme blockage
3) Inhibition of intracellular synthesis pathway
1) Cell surface receptor blockage= beta blockers
2) Extracellular enzyme blockage= ACEI
3) Inhibition of intracellular synthesis pathways= Statins
Mitral valve prolapse change with squatting
Disappears
Just like HCM
[Other murmurs get louder]
Syncopal events triggered by emotion
Vasovagal syncope
Tx: Counterpressure maneuver education
Progressive dyspnea
Lower extremity edema
JVD
Ascites
Concentric Left ventricular hypertrophy
Non dilated LV cavity
Restrictive cardiomyopathy
Holosystolic murmur at left lower sternal border with diastolic rumble over the cardiac apex
Poor feeding
Ventricular septal defect
Harsh systolic ejection murmur at left upper sternal border
Tetralogy of Fallot
Young
Smoking
Recurrent chest discomfort at rest or when sleeping
Tx
Vasospastic angina
CCB
- diltiazem
- amlodipine, felodipine
(preventive)
Sublingual nitroglycerin (abortive)
80 y.o man putting on shirt and tie and passing out
Carotid hypersensitivity syncope
Baroreceptor hypersensitivity
Syncope w/ exertion
LV outflow obstruction
Leg cramping
Peripheral pulses decreased in left leg
ABI 0.65 in left and 1.1 in right
Next step
Atherosclerotic cardiovascular disease
Peripheral artery disease
Tx: Supervised graded exercise program
Low dose aspirin
Statin therapy
Hemodynamics in heart failure
Contractility Cardiac output Compensatory SVR Afterload
Decrease contractility —> decrease cardiac output —> Compensatory neurohormonal activation —> increase systemic vascular resistance —> Increase afterload —> Decrease contractility
Calf pain after artery embolectomy
Burning sensation in posterior aspect of leg
Swollen
Tense
Exquisitely tender
Pain worse w/ dorsiflexion
Shiny and cool to touch
Patient cant move toes
Compartment syndrome
Cold 2 weeks ago
Progressive SOB
Swelling of feet
Decompensated heart failure from viral myocarditis
—> Dilated cardiomyopathy
Dilated ventricular chambers and diffuse hypokinesis of the ventricular walls
Acute coronary syndrome with low risk for aortic dissection give what medication
Aspirin
Light headedness past month
Syncopal episode
HX HTN
Left ventricular hypertrophy
Ejection fraction 55%
Cardiogenic syncope
Bradyarrhythmia
Respiratory variation in systolic blood pressure
Pulsus paradoxus
Cardiac tamponade
Informed consent
1) Patient diagnosis
2) Risk and benefits of both proposed tx and tx alternatives
3) Risk of refusing treatment
QRS that varies in height
Electrical alternans
Cardiac tamponade
Pericardiocentesis
HTN cause to consider
Oral contraceptives
Small face and jaw
No skin creases on palmar aspect
Overlapping fingers
Cardiovascular abnormalities?
VSD
Trisomy 18 Edwards syndrome
27 y.o with bouts of dyspnea on exertion
Ejection type Systolic murmur at lower left sternal border that decreases when squatting
Inheritence?
Hypertrophic cardiomyopathy
Autosomal dominant
Dark purple legs
Palable pulses
Chronic stasis dermatitis due to venous insufficiency
Get Venous doppler U/S
Methamphetamine on heart
Given IV medication taht acts primarily stimulating beta 1 adrenergic receptors, what is the MOA
Decompensated heart failure
Hypotension
Cool extremities
Low cardiac output state
Dobutamine acts on Beta-1 receptors—> increased production of cAMP in cardiac myocytes —> enhanced calcium mediated binding of actin-myosin to troponin C —>
Increased myocardial contractility (positive inotropic effect)
HR is increased via calcium channel activation (positive chronotropic effect)
Increased myocardial contractility —> ejection of higher volume of blood which results in —> decreased left ventricular end systolic volume
Adverse effect of pacemaker
Tricuspid regurgitation
Result in right sided heart failure
Pulsation in neck when lies down
Holosystolic murmur at left lower sternal border
T wave inversions in V1-V4, Troponin normal
Next step
NSTEMI
1) Antiplatelet agents (aspirin, clopidogrel or aspirin and ticagrelor)
2) Anticoagulant therapy (unfractioned heparin, enoxaparin, bivalirudin)
3) Beta blockers (reduce myocardial oxygen demand)
4) Nitrates (reduce oxygen demand and relieve ischemic pain)
5) High intensity statins (stabilize plaques and lower risk of recurrent ACS)
Coronary angiogram 5 days ago
Now nausea and abdominal pain
Painless mottling of skin in feet
Cholesterol emboli
Medication used w/ Beta blocker and ACE I to reduce mortality in MI
Eplerenone
Spironolactone
Mineralocorticoid receptor antagonists (MRA)
BLock deleterious effects of aldosterone on the heart
Irregular pulse
No P waves
What will resolve ventricular function
Afib
Rate or rhythm control
Dyspnea
Paroxysmal nocturnal dyspnea
Bibasilar crackles
Hypoxemia
- Name
- Due to
- Tx
Pulmonary edema
Acute decompensated heart failure
Tx IV diuresis
Oxygen supplementation
Noninvasive ventilation
Afib originates where
Pulmonary veins is most frequent location for ectopic foci that cause AF
Atrial flutter location
Tx
Reentrant circuit around the tricuspid annulus
Anticoagulation (rivaroxaban, apixaban)
18 y.o
During expiration that is an extra high pitched sound heard after S1
Systolic crescendo-decrescendo murmur at left upper sternal border
S2 split throughout the respiratory cycle and splitting increases with inspiration
Pulmonic stenosis
Ejection click= high pitch sound after S1 best heard during expiration
Uveitis 6 months ago
Bradycardia
2:1 AV block and left bundle branch block
Bilateral midfield lung opacities
Sarcoidosis
Patient < 55 with unexplained second or third degree heart lbock
Sarcoidosis
Fourth heart sound due to
Long standing HTN
High amplitude jugular venous pulsations that are seen intermittently at irregular intervals
Wide complex tachycardia
Atrioventricular dissociation
Ventricular tachycardia
Cannon A waves: intermittent prominent waves caused by surge in jugular venous pressure —> atrioventricular dissociation
Side effect of Amlodipine
CCB
Peripheral edema
A fib medication that needs pulmonary fxn testing
Amiodarone
Pulmonary function and thyroid tests
Muffled heart sounds results in
A. Decreased cardiac contractility
B. Decreased left ventricular preload
C. Increased right ventricular compliance
D. Left ventircular outflow obstruction
E. Pulmonary HTN
B. Decreased left ventricular preload
Increase intrapericardial pressure restricts venous return to the heart and lowers right and left ventricular filling
Decrease preload
Decrease Stroke volume
Decrease cardiac output
Decreases right ventricular compliance and shifts interventricular septum toward the left ventircular cavity
Patient given niacin
1 week later generalized pruritus and flushing
Prostaglandin related reaction
Know SE of niacin
Niacin induced peripheral vasodilation
9 days of fever
Previous 10 day amoxicillin for streptococcus pharyngitis
No vaccines
Rash on trunk —> extemities
Cervical lymph node palpated
Erythematous strawberry tongue
Kawasaki disease
Next step get echo to check for coronary artery aneurysms
Benign murmurs
Early or mid-systolic
Grade I or II that decrease with standing and Valsalva maneuver
Low pitched
Muscial
Squaky tone
High pitched at LUSB
Chest pain, Sharp localized to anterior chest. Exacerbated by deep breathing
Six weeks ago have CABG
Normal wound
100.4 F
144/78
pulse 99/min
Tachycardia nonspecific ST changes
Leukocytosis
Small pericardial effusion
- Name
- MOA
- TX (3)
Dressler syndrome
Immune medicated inflammation
NSAIDS + colchicine
Self limited disease
Trauma
Hypotension
Tachycardia
JVD
Cardiac tamponade
Papillary muscle rupture vs interventricular septum rupture vs free wall rupture
Papillary muscle rupture
- 3-4 days
- RCA
- Severe pulmonary edema
- New holosystolic murmur (mitral regurgitation) with flail leaflet
Interventricular septum rupture
- 3-5 days
- LAD or RCA
- Chest pain
- New holosystolic murmur
- Biventricular failure
- Shock
Free wall rupture
- 5 days to 2 wks
- LAD
- Chest pain
- Shock
- Distant heart sounds
Tx Wide complex tachycardia
Sustained monomorphic ventricular tachycardia
Amiodarone
Hypovolemic shock
CO
PCWP
SVR
Blood pressure
Blood pressure decreases
Loss volume leads to decrease in preload and pulmonary capillary wedge pressure
Consequent decrease in preload—> decrease cardiac output (CO) and BP
Stimulates sympathetic NS which increases HR and peripheral vasoconstriction —> Increase in systemic vascular resistance
Decrescendo early diastolic murmur at left sternal border
Patient leaning forward
Aortic regurgitation
Bicuspid aortic valve
HTN Depression Poor sleep Headaches Muscle weakness
Kidney stones
Hypercalcemia
Hyperparathyroidism
Spontaneous or easily provoked hypokalemia
HTN
Primary aldosteronism
Recent catheterization
Vague abdominal pain
Tender in periumbilical area
Bluish discoloration of right great toe and all toes of left foot
Mottling of leg
Atheroembolism (cholesterol embolism)
What should be given to diabetic over age 40
Statin
Sudden cardiac arrest
Ventricular fibrillation
Reentrant ventricular arrhythmias
Kussmaul
JVD
RV failure
STEMI with right ventricular myocardial infarction (acute inferior wall MI)
Left side
Early diastolic heart sound followed by diastolic rumble
Hemodynamic findings
Pulm A Sys pressure
Pulm A dis pressure
LV diastolic pressure
Mitral stenosis
Rheumatic heart disease
Restricted diastolic filling of LV —> increase left atrial pressure —> left atrial dilation—> increase pulm artery pressure (systolic and diastolic)
Early diastolic sound followed by mid-diastolic murmur
Seen on Echo?
Mitral stenosis
Left atrial dilation
Pericarditis tx
NSAIDS
Fatigue Confusion Constipation Weight gain Dry skin
Medication that causes this
Hypothyroidism
Amiodarone
ABI
Peripheral artery disease
Afib tx
Warfarin
Scratchy sound at left sternal border before S1
Pericarditis
Tx: NSAID
Colchicine (ibuprofen)
Hyperextensible
Easy bruising, poor healing
Ehlers-Danlos
MVP
High sensitivity for Congestive heart failure
BNP
Diastolic dysfunction
Heart failure with preserved ejection fraction
Heart cant relax fast enough after each beat
Choking sensation Dry cough Palpitations Progressive SOB HTN Bibasilar crackles Afib Pitting edema normal EF
Medication associated with weight gain and worsening glucose tolerance
Beta adrenergic blockers
Regular Narrow complex tachycardia
Tx
Superventricular tachycardia
IV adenosine
Aortic Stenosis what you hear
late peaking crescendo-decrescendo systolic murmur
Soft single S2
Family Hx sudden death
QT interval prolong
Congenital sensorineural deafness
Tx:
Jervell and Lange-Niesen syndrome
AR
Risk of torsades de pointes
Tx: Beta blocker and pacemaker
Cor pulmonale
RV hypertrophy
Tricuspid regurgitation w/ right atrial enlargement
Elevated pulmonary artery systolic pressure
BP 165/75
Isolated systolic hypertension
MOA: increased stiffness or decreased elasticity
Pain in leg Numbness Palpitations in leg Hair is sparse Absent pulses of left, diminished on right Sensation to light touch decreased Weaker dorsiflexion
Acute limb ischemia
6 Ps Pain Pallor Paresthesia Pulselessness Poikilothermia (cool extremity) Paralysis (late)
Tx: Anticoagulation (heparin)
Thrombolysis vs surgery
Greatest impact on lowering HTN
Dietary modification to DASH diet
pharmacologic stress test
Adenosine
Coronary vasodilation and increased myocardial blood flow in non obstructed coronary arteries
Infective endocarditis with conduction abnormalities on ECG
Perivalvular abscess
INR mechanical valve
2-3
TX ventricular fibrillation
Defibrillation
MI 2 weeks ago
Persistant ST elevations
Ventricular aneurysm
Infective endocarditis finding
Tricupsid valve involvement
Holosystolic murmur increases with inspiration
MVP
Early diastolic murmur (Decrescendo)
HTN emergency
Given IV furosemide and nitroprusside
Next morning, Confused and agitated with tonic clonic seizures
Cyanide toxicity
Aortic dissection can progress to
Acute aortic regurgitation
[Aortic valve insufficiency]
Dont want to lay flat
Hypotension
pulmonary edema
Diastolic collapse with elevated right ventricular pressure
Cardiac tamponade
Dilated left ventricle with apical hypokinesis
Cardiogenic shock
Engorgement of the inferior vena cava
Cardiogenic shock
Right ventricular dilation and hypokinesis
Massive pulmonary embolism
Hx of aortic aneurysm what drugs to avoid
Fluroquinolones
- levofloxacin
- Moxifloxacin
- Ciprofloxacin
Antihypertensive for diabetic patient with proteinuria
ACE inhibitor
ARB
Drugs that slow heart rate
Beta blockers
Calcium channel blockers
Digoxin
Amiodarone
Systolic ejection murmur heard along lateral sternal border
Increases with Valsalva maneuver
Hypertrophic obstructive cardiomyopathy
Increases with decrease in preload
Diastolic decrescendo low pitched blowing murmur
Best heard sitting up
Increases with hand grip maneuver
Aortic insufficiency
Increases with increase in afterload
Systolic crescendo/decrescendo murmur
Increases with squatting
Aortic stenosis
Increase with increase in preload (squatting)
Holosystolic murmur that increases with hand grip
Mitral regurgitation
Increases with increase in after load
Diastolic mid to late low pitched murmur preceded by opening snap
Mitral stenosis
ECG for pericarditis
Low voltage
Diffuse ST segment elevations
Metabolic syndrome (6)
Abdominal obesity High triglycerides low HDL hypertension insulin resistance prothrombotic or proinflammatory states
Anterior wall MI
Inferior wall MI
Posterior wall MI
Septum MI
Anterior wall: LAD/ diagonal
Inferior wall: PDA
Posterior: left circumflex/ oblique, RCA/ Marginal
Septum: LAD/ diagonal
Reverses effects of heparin
Protamine
What parameter is effect by warfarin
Prothrombin time
Water bottle shaped heart
Pericardial effusion
Gradual prolongation of PR interval till dropped beat
Mobitz type II
Third degree or complete AV block
P waves are entirely unrelated to QRS complexes
PR intervals > 0.20 second
Constatn PR interval
First degree AV block
Displace apical impulse
Holosystolic murmur
Third heart sound
Chronic severe mitral regurgitation
Mitral valve prolapse more common in developed countires
Rheumatic heart disease causes what heart abnormalities
Mitral stenosis
MR
Aortic regurgitation
Tx asymptomatic bilateral carotid artery stenosis
Antiplatelet agent (aspirin)
Statin
Careful blood pressure control
When to do carotid endarterectomy
Symptomatic patients with high grade carotid stenosis > 70%
Worsening fatigue
Exertional dyspnea
Lower extremity swelling
Bruising easily
Proteinuria
Smoker
JVD
Small pericardial effusion
Concentric thickening of the ventricular walls with diastolic dysfunction
Amyloidosis
Fatigue, exertional dyspena, lower extremity swelling in absence of pulmonary edema= right side heart failure
Manifestation of restrictive cardiomyopathy (thickened ventricular walls)
Bradycardia
AV block
Hypotension
Wheezing
Beta blocker overdose
Tx IV atropine
IV glucagon
Intense holosystolic murmur best heard at cardiac apex
Severe mitral regurgitation
S3 gallop
Sudden cessation of blood flow into a dilated LV
Atherosclerotic CV disease tx
High intensity statin therapy
Evaluation of HTN (4)
Chemistry panel (electrolytes and creatinine)
Hemoglobin/ hematocrit
Urinarlysis (to exclude hematuria and proteinuria)
ECG for LV hypertrophy or prior MI
Loud midsystolic murmur heard at first right intercostal space
Palpable thrill at suprasternal notch
Differential blood pressure between upper extremities
Supravalvular aortic stenosis
[Congenital left ventricular outflow tract obstruction]
Develop LV hypertrophy over time
—> Increased myocardial oxygen demand= pain
Systolic anterior motion of the mitral valve
Hypertrophic obstructive cardiomyopathy
Exertional angina Dyspnea Dizziness Presyncope Syncope
Systolic murmur with maximal intensity along the lower left sternal border
MI that result in LV systolic dysfunction
Resulted in thinned walls and evidence of scaring, dilated left ventricle
Eccentric hypertrophy
Due to ischemic heart disease
[Deleterious cardiac remodeling —> risk for fatal cardiac arrhythmia (ventricular tachycardia or fibrillation]
Cardiac remodeling driven by RAAS pathway
Prevented by ACE inhibitor
Tx Torsades de pointes
Stable: IV Magnesium sulfate
Unstable: defibrillation
Polymorphic ventricular tachycardia
Adenosine
Tx Paroxysmal supraventricular tachycardia
Amiodarone
Artrial and ventricular tachycardia
Atropine
Symptomatic sinus bradycardia
AV nodal block
Tx torsades de points with quinidine use
Sodium bicarbonate
Preventing pericarditis after MI
Early coronary reperfusion
[Minimizes myocardial necrosis]
Passing out while in crown or giving blood due to
See on ECG
Vasovagal syncope
Bradycardia and sinus arrest
32 y.o with HTN
Father dies suddenly at 54
BP 175/103
Bilateral nontender uper abdominal masses palpated
Hemoglobin elevated
ADPKD
Get abdominal US
NE used to tx
Severe hypotension and shock
HTN
Headaches
Fourth heart sound
Continuous murmur through out the thorax in multiple areas
Coarctation of the aorta
Erosions of the inferior costal surfaces
“Pounding” heart
150/45
Exertional SOB
Heart murmur?
Aortic regurgitation
Syncope when waking up to urinate
Due to
Peripheral vasodilation
37 y.o Weakness and dizziness
Two episodes of syncope
Vague mid-chest discomfort and left sided neck pain
Two ago had sore throat and dry cough
He has thready pulses over both radial arteries that disappear with deep inspiration
Cardiac tamponade
Due viral pericarditis
Pulsus paradoxus is a typical feature of pericardial tamponade, large decrease in systolic blood pressure on inspiration.
Loss of palpable radial pulse during inspiration
Afib
Weakness and slurred speech for 15-20 min
How to prevent future episodes
A. Amiodarone B. Aspirin C. Clopidogrel D. Long-acting nitrates E. Metoprolol succinate F. Rivaroxaban G. Strict blood glucose control
F. Rivaroxaban
Give warfarin or NOAC
Ventricular tachycardia tx
Amiodarone
Young patient
URI 2 weeks ago
Chest pain Arrhythmias Fatigue SOB Choking sensation when falling asleep
PMI displaced
Myocarditis —> Dilated cardiomyopathy
Atrial fibrillation
Unintentional WL
HTN
Best initial test?
TSH and free T4
Hyperthyroidism can cause both
Tx Atrial fibrillation
A. Quinidine B. Clonidine C. Metoprolol D. Hydroclorothiazide E. Amlodipine
C. Metoprolol
Increased left ventricular end diastolic pressure
Heart failure
Hypoxia
Hypotension
Tx of chest pain in MI
Venous dilation
Nitrates
[Not coronary artery dilation]
Soft murmur starts after the second heart sound and declines in intensity until disappearing suddenly before the first heart sound
Murmur heard along with left and right sternal borders
Accentuated when patient sits up, leans forward and puts hands in head
Aortic root dilation
Aortic regurgitation
Decrescendo diastolic murmur
59 y.o sudden onset of syncope
Twice in two hours while sitting
No confusion afterwards
Recent placed on Sotalol for sinus rhythm
Tx
Torsades de pointes
Ventricular Arrhythmia
Sotalol —> prolong QT —> torsades de pointes
Tx Magnesium sulfate
(Hypomagnesemia)
CHF put on loop diuretics
What other medication for long term outcomes
A. Amiodarone B. Amlodipine C. Atenolol D. Chlorthalidone E. Digoxin F. Diltiazem G. Metoprolol succinate H. Propafenone
Metoprolol succinate
[ACE-I, ARB, beta blockers, aldosterone antagonists]
Beta blockers
- Metoprolol succinate
- Carbedilol
- Bisoprolol
