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Family Medicine Rotation > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q 
Peripheral artery disease
Path:
Pt:
Dx:
Tx:
A

Path: atherosclerotic disease of the lower extremities

Pt: intermittent claudication, resting leg pain
PE: decreased/absent pulses, bruits, dec cap refill, cool limbs, shiny skin, hair loss, pale w/ dependent rubor

Dx:
(GS) contrast angiography
ABI <0.9
duplex U/S
hand held doppler

Tx:
Plt inhibitor: cilostazol, ASA, clopidogrel
revascularization surgery

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2
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in buttock, hip, groin

A

aortic bifurcation

common iliac

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3
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in thigh/upper calf

A

femoral artery or branches

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4
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in lower calf, ankle, foot

A

popliteal artery

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5
Q

Peripheral artery disease which vessel is affected?

intermittent claudication in foot

A

tibial and peroneal arteries

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6
Q 
Aortic Stenosis 
Path:
Pt:
Dx:
Tx:
A

Path: Congenital (>70 y/o)-> MC degenerative calcification, Bicuspid aortic valve
LV outflow obstruction-> fixed CO; Inc afterload-> LVH

Pt: Angina, syncope, CHF, dyspnea
Older patient hx of DM, HTN

Dx: Systolic ejection crescendo-decrescendo murmur @ RUSB; radiates to carotid arteries
Pulsus parvus et tardus-> weak; delayed pulse
S4 if LVH
Narrow pulse pressure
LV heave due to LVH
Paradoxically split S2 (if severe)

Tx: Aortic valve replacement
Severe AS is dependent on preload: Avoid exertion, ventilators & negative inotropes (CCB, BB)

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7
Q 
Mitral Stenosis 
Path:
Pt:
Dx:
Tx:
A

Path: Obstruction of flow from LA to LV -> LA enlargement and inc LA pressure-> pulm HTN, Rheumatic heart disease

Pt: 
R sided heart failure
Pulmonary HTN-> hemoptysis 
A-fib
Mitral facies-> flushed cheeks 
Dx: 
Diastolic rumble @ apex in L lateral decubitus +/- opening snap; no radiation
Pulse usually dec intensity 
LA enlargement 
Prominent S1 (closing snap)

Tx:
Valvotomy in young pts -> rheumatic dz is cause, static & valve orifice <1cm
Repair preferred over replacement

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8
Q 
Aortic Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Back flow from aorta to LV-> LV volume overload
Rheumatic disease, HTN, endocarditis, Marfan, Syphilis, Ankylosing spondylitis

Pt:
L sided heart failure

Dx:
Diastolic decrescendo blowing @ LUSB radiates along L-sternal border
-Inc w/ handgrip
-Dec w/ nitrate
Austin flint murmur: mid-late diastolic rumble @ apex
Bounding pulses-> inc. SV
Wide pulse pressure
Pulsus bisferiens-> if combined with AS + AR
Water hammer pulse

Tx:
Vasodilators-> dec afterload increases forward flow
Surgery-> acute or static AR or dec LV <55% (need hyperdynamic ventricle to maintain CO)

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9
Q 
Mitral Valve Prolapse
Path:
Pt:
Dx:
Tx:
A

Path: Myxomatous degeneration of mitral valve-> floppy, redundant valve
Abnormal movement of 1 or both leaflets across valve during systole
MC young women, benign condition
Connective tissue disease-> Marfan, Ehlers-Danlos

Pt: Most asx
Autonomic dysfunction: Chest pain, panic attacks, Arrhythmias causing palpitations, Syncope, dizziness, fatigue
Sx associated w/ MR progression: Fatigue, dyspnea, CHF, Stroke, endocarditis, PVCs

Dx:
Mid to late systolic ejection click @ apex; dec venous return (valsalva, standing, inspiration) -> earlier click (inc. prolapse) and longer murmurs duration
+/- mid-late systolic murmur
Narrow AP diameter
Low body weight, Hypotension, scoliosis, pectus excavatum

Tx:
Reassurance-> good prognosis in asx pts or mild sx
BB for autonomic dysfunction

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10
Q 
Mitral Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Backflow from LV to LA-> LV volume overload-> dec. CO
Mitral Valve prolapse MC
Rheumatic, endocarditis, ischemia (ruptured papillary muscle/chordae tendinae post MI)

Pt:
Acute: Pulmonary edema, Dyspnea
Chronic: A-fib, CHF, May have pulmonary HTN (less often than mitral stenosis)

Dx:
Blowing holosystolic murmurs @ apex radiates to axilla
-Inc with handgrip, left lateral decubitus
-dec. w/ nitrate
Pulse may have brisk upstroke-> due to hyperdynamic ventricle from inc. preload and dec. afterload
Widely split S2

Tx:
Vasodilators: dec. afterload inc forward flow (ACEi)
Surgery: vale repair preferred vs valve replacement

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11
Q

Tricuspid Regurgitation
Dx:
Tx:

A

Dx: Holosystolic blowing high-pitched murmur @ subxiphoid area (L mid sternal border)
-Little-no murmur radiation
-Inc murmur intensity w/ inc venous return (squatting, inspiration)
Carvallo’s sign: increased murmur intensity w/ inspiration (due to inc right sided blood flow during inspiration
- Helps distinguish TR from MR
- +/- pulsatile liver

Tx:
Medical: diuretics (for volume overload and congestion)
If LV dysfunction-> standard HF therapy
Surgical: suggested for pts w/ severe TR despite medical therapy
Repair > replacement

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12
Q

Tricuspid Stenosis
Path:
Dx:
Tx:

A

Path: Blood backs up into RA -> inc RA enlargement -> right-sided heart failure

Dx: Mid-diastolic murmurs @ left lower sternal border (4th ICS). Low frequency
Inc intensity of murmur: inc venous return (squatting, laying down, leg raising, inspiration)
Opening snap: usually occurs later than the opening snap of mitral stenosis

Tx:
Medical: decrease RA volume overload w/ diuretics and Na+ restriction
Surgical: commisurotomy or replacement if right heart failure or dec CO

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13
Q 
Pulmonic Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Pulmonary HTN, tetralogy of fallot, endocarditis, rheumatic heart disease
Retrograde blood flow from pulmonary artery into RV-> right sided volume overload

Pt:
Most clinically insignificant
If sx-> right sided heart failure

Dx:
Graham Steell murmur: brief decrescendo early diastolic murmur @ LUSB (2nd L ICS) w/ full inspiration
-Inc murmur w/ inc venous return (squatting, supine, inspiration)
-Dec murmur w/ dec venous return (Valsalva, standing, expiration)

Tx:
No tx needed in most
Almost always congenital

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14
Q 
Pulmonic Stenosis
Path:
Pt:
Dx:
Tx:
A

Path: RV outflow obstruction of blood

Pt:
Almost alway congenital and disease of the young (congenital rubella syndrome)

Dx:
Harsh mid systolic ejection crescendo-decrescendo murmur (maximal @ LUSB) radiate to neck
-Murmur inc w/ inspiration; the longer the murmur duration = inc stenosis
-Signs of r-sided heart failure
-Systolic ejection click (often buried in S1) may precede the murmur (click increases w/ expiration) wide, split S2 (delayed P2) +/-S4

Tx:
Balloon valvuloplasty

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15
Q

What is pulsus alternans?

A

Alternating strong and weak pulse beats in the arterial pulse waveform, indicating left ventricular systolic dysfunction

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16
Q 
Heart sounds:
S1
S2
S3
S4
A

S1: mitral and tricuspid valve closure

S2: aortic and pulmonary valve closure

S3: in early diastole

  • during rapid ventricular filling phase
  • large amount of blood striking a very compliant LV
  • normal in children, pregnant women

S4: “atrial kick”

  • late diastole
  • blood flowing against noncompliant LV
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17
Q 
Angina 
Path:
Pt:
Dx:
Tx:
A

Path: ischemia w/ myocardial oxygen demand > oxygen supply
Risks-> CAD, family hx, old age, HTN, HLD, DM, CKD, smoking

Pt:
Stable angina: Chest discomfort precipitate by activity but sx abate after activity
Unstable angina: sx at rest or a change in usual sx pattern
+/- SOB, NA, diaphoresis, dizziness, fatigue

Dx: EKG: J point or ST segment depression, normal, Stress Test

Tx:
Lifestyle modifications
Beta Blockers
CCB
Nitrates
18
Q

Sinus bradycardia

tx:

A

Tx:
Atropin if pt sx
Epi or transcutaneous pacing if unresponsive to atropine

19
Q

2nd degree heart block- Mobitz I/ Wenckebach
EKG:
Tx:

A

EKG:
Progressive PRI lengthening -> dropped QRS

Tx:
Symptomatic: atropine; Epi +/- pacemaker
Asx: observation

20
Q

2nd degree heart block- Mobitz II
EKG:
Tx:

A

EKG:
Constant/prolonged PRI-> dropped QRS

Tx:
Atropine or temporary pacing
Progression to 3rd degree AV block common so permanent pacemaker is definitive tx

21
Q

3rd degree AV block
EKG:
Tx:

A

EKG:
P wave not related to QRS
All p waves not followed by QRS-> dec CO

Tx:
Acute/symptomatic: temporary pacing-> permanent pacemaker
Definitive tx: permanent pacemaker

22
Q

A-flutter

Tx:

A 
Tx:
Stable: vagal, BB or CCB
Unstable: synchronized cardioversion
Definitive: radiofrequency ablation 
Anticoagulation use similar to a-fib (CHADSVAS-2 score)
23
Q

Determine need for anticoagulation

A 
CHA2DS2-VAS-2 score
CHF... 1
HTN... 1
Age >/=75... 2
DM... 1
S: stroke, TIA, thrombus... 2
Vascular disease (prior MI, aortic plaque, PAD)... 1
Age 65-75 yr... 1
Sex (female)... 1

> /=2: moderate to high risk-> chronic oral anticoagulation recommended

1 = low risk: based on clinical judgement, consideration of risk to benefit assessment and discussion with patient. anticoagulation may be recommended in some cases

0=very low risk

24
Q

A-fib

Tx:

A

Tx:

Stable:
Rate Control
-Non-dihydropyridines CCB: diltiazem/verapamil
-BB: metoprolol (caution in reactive airway disease)
-Digoxin: hypotension + CHF
Rhythm Control
-Synchronized cardioversion
-AF present <48hrs
-3-4w after anticoagulation or TEE shows no atrial thrombi
-Start IV heparin, cardiovert within 24hrs and anticoagulate for 4w
-Pharm: ibutilidie, flecainide, sotalol, amiodarone
-Radiofrequency ablation-> permanent pacemaker

Unstable: cardioversion

25
Q

SVT

Tx:

A

Tx:
Vagal maneuvers
Adenosine
Cardioversion

26
Q

RBBB EKG

A

wide S wave in lead I and V6

RSR’ pattern in lead VI

27
Q

LBBB EKG

A

large R wave in lead I

Large QS or rS in lead V1

28
Q

Vtach

Tx:

A

Tx: Determine hemodynamic stability

Stable: procainamide; sotalol (2nd line)

Unstable: Synchronized cardioversion

Pulseless: defibrillation

29
Q

Wolff-Parkinson-White Syndrome
Path:
EKG:
Tx:

A

Path:
Accessory bundle pathway -> bundle of Kent
Premature depolarization of ventricles by bypassing the AV node

EKG:
Delta waves-> wide QRS
Shortened PR interval

Tx: Radiofrequency ablation

30
Q

Wellens Syndrome
Path:
EKG:
Tx:

A

Path:
Critical stenosis of proximal left anterior descending coronary artery (LAD)

EKG:
large, inverted T wave in leads V2 and V3

Tx: Cath Lab!

31
Q

Brugada Syndrome
Path:
EKG:

A

Path: Hereditary

EKG
Right BBB-like pattern w/ ST elevation in leads V1-V3

32
Q

Coronary artery disease
Path:
Risk factors:

A 
Path:
Atherosclerosis
Coronary artery vasospasm
Aortic stenosis/aortic regurgitation
Pulm HTN
Severe systemic HTN
Hypertrophic cardiomyopathy 
Risk factors:
DM
Cigarette smoking
HLD
HTN
Males
Age >45 men, >55 women
Family hx
33
Q 
Non-ST segment elevation acute MI
Path:
Pt:
Dx:
Tx:
A

Path: Acute reduction in blood flow, incomplete occlusion w/ cardiac enzymes

Pt: Angina at rest >20 mins

Dx:
Troponin elevation
EKG: ST depression

Tx:
ASA, O2, heparin, BB, nitrates, stress tests, cardiac cath

34
Q 
ST segment elevation acute MI
Path:
Pt:
Dx:
Tx:
A

Path: Thrombus formation causing blockage of coronary vessel

Pt: Chest tightness/pressure radiates to arms or neck

Dx: 
Labs
Elevated troponin I or troponin T and CK
EKG
ST segment elevations >1mm in >2 contiguous leads

Tx:
PCI (gold standard)
Thrombolytic therapy
ASA

35
Q

Anterior wall MI
EKG:
Coronary vessel:

A

EKG: V1-V4

Coronary vessel: left anterior descending (LAD)

36
Q

Inferior wall MI
EKG:
Coronary vessel:

A

EKG: II, III, aVF
Coronary vessel:
right coronary artery (RCA) (70%+)
left circumflex (LCx)

37
Q

Lateral wall MI
EKG:
Coronary vessel:

A

EKG: I, aVL, V5, V6
Coronary vessel:
left circumflex (LCx)
diagonal of left anterior descending

38
Q

Posterior wall MI
EKG:
Coronary vessel:

A

EKG: ST depression V1-V4, elevation in V8-V9

Coronary vessel: posterior descending artery (PAD)

39
Q 
Endocarditis
Path:
Pt:
Dx:
Tx:
A

Path:
Acute: S. Aureus, MRSA-> IV drug users
Subacute: S. Viridians-> oral flora infection

Pt: Fever, anorexia, weight loss, fatigue, EKG conduction abnormalities

Dx: Modified Duke Criteria
2 major
1 major + 3 minor
5 minor

Tx:

  • Acute/IVDU: vanc + cefepime
  • Subacute: Vanc + amp/ceftriaxone/cipro
  • Surgery if refractory CHF, persistent/refractory infection, invasive infection, prosthetic valve, recurrent systemic emboli, fungal infections
40
Q

Modified Duke Criteria

A

Major
*Sustained bacteria: 2+ blood cultures by organic known to cause endocarditis
*Endocardio involvement
…+ echo: vegetation, abscess, valve perforation, prosthetic dehiscence
…New valvular regurgitation: aortic or mitral

Minor 
*predisposing condition: abnormal valves, IVDU, indwelling catheters
*Fever >38 (100.4)
*Vascular and embolic phenomena
...Janeway lesions
...septic arterial/pulmonary embolic
...intracranial hemorrhage
*Immunologic phenomena
...Osler's nodes, roth spots
...+RF
...acute glomerulonephritis
*+blood culture not meeting major criteria
* +echo not meeting major criteria-> worsening of existing murmur
41
Q

Abx prophylaxis for endocarditis
Cardiac conditions
Procedures
Regimens

A

Cardiac conditions:

  • Prosthetic heart valves
  • Heart repairs using prosthetic material (not stents)
  • Prior hx of endocarditis
  • Congenital heart disease
  • Cardiac valvulopathy in a transplanted heart

Procedures:

  • Dental: manipulation of gums, roots of teeth, oral mucosa perforation
  • Respiratory: surgery on respiratory mucosa, rigid bronchoscopy
  • Procedures involving infected skin/musculoskeletal tissues (including I&D)

Regimens

  • Amox 2g 30-60mins before procedure
  • Clinda if PCN allergy

No longer recommended for GI/GU procedures or most types of valvular heart disease (MV prolapse, bicuspid aortic valve, acquired MV, AV disease, hypertrophic cardiomyopathy

42
Q 
Hyperlipidemia 
Tx
Lowering LDL
Lowering triglycerides
Increasing HDL
Type II DM
A

Lowering LDL:

  • Statins
  • Bile acid sequestrants
  • Ezetimibe (zetia)
  • PCSK9 inhibitor-> repatha (evolocumab), praluent (alirocumab)

Lowering triglycerides:

  • Fibrates
  • Omega-3 fatty acids-> lovaza, vascepa, epanova
  • PCSK9 inhibitor-> repatha (evolocumab), praluent (alirocumab)

Increasing HDL:

  • Niacin, niaspan, slo niacin
  • exercise

Type II DM:
-Fibrates
-Statins
(niacin may cause hyperglycemia)

Family Medicine Rotation (14 decks)

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