Cardiovascular Flashcards
Peripheral artery disease Path: Pt: Dx: Tx:
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
Peripheral artery disease which vessel is affected?
intermittent claudication in buttock, hip, groin
aortic bifurcation
common iliac
Peripheral artery disease which vessel is affected?
intermittent claudication in thigh/upper calf
femoral artery or branches
Peripheral artery disease which vessel is affected?
intermittent claudication in lower calf, ankle, foot
popliteal artery
Peripheral artery disease which vessel is affected?
intermittent claudication in foot
tibial and peroneal arteries
Aortic Stenosis Path: Pt: Dx: Tx:
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)
Mitral Stenosis Path: Pt: Dx: Tx:
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
Aortic Regurgitation Path: Pt: Dx: Tx:
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)
Mitral Valve Prolapse Path: Pt: Dx: Tx:
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
Mitral Regurgitation Path: Pt: Dx: Tx:
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
Tricuspid Regurgitation
Dx:
Tx:
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
Tricuspid Stenosis
Path:
Dx:
Tx:
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
Pulmonic Regurgitation Path: Pt: Dx: Tx:
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
Pulmonic Stenosis Path: Pt: Dx: Tx:
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
What is pulsus alternans?
Alternating strong and weak pulse beats in the arterial pulse waveform, indicating left ventricular systolic dysfunction
Heart sounds: S1 S2 S3 S4
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
Angina Path: Pt: Dx: Tx:
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
Sinus bradycardia
tx:
Tx:
Atropin if pt sx
Epi or transcutaneous pacing if unresponsive to atropine
2nd degree heart block- Mobitz I/ Wenckebach
EKG:
Tx:
EKG:
Progressive PRI lengthening -> dropped QRS
Tx:
Symptomatic: atropine; Epi +/- pacemaker
Asx: observation
2nd degree heart block- Mobitz II
EKG:
Tx:
EKG:
Constant/prolonged PRI-> dropped QRS
Tx:
Atropine or temporary pacing
Progression to 3rd degree AV block common so permanent pacemaker is definitive tx
3rd degree AV block
EKG:
Tx:
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
A-flutter
Tx:
Tx: Stable: vagal, BB or CCB Unstable: synchronized cardioversion Definitive: radiofrequency ablation Anticoagulation use similar to a-fib (CHADSVAS-2 score)
Determine need for anticoagulation
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
A-fib
Tx:
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
SVT
Tx:
Tx:
Vagal maneuvers
Adenosine
Cardioversion
RBBB EKG
wide S wave in lead I and V6
RSR’ pattern in lead VI
LBBB EKG
large R wave in lead I
Large QS or rS in lead V1
Vtach
Tx:
Tx: Determine hemodynamic stability
Stable: procainamide; sotalol (2nd line)
Unstable: Synchronized cardioversion
Pulseless: defibrillation
Wolff-Parkinson-White Syndrome
Path:
EKG:
Tx:
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
Wellens Syndrome
Path:
EKG:
Tx:
Path:
Critical stenosis of proximal left anterior descending coronary artery (LAD)
EKG:
large, inverted T wave in leads V2 and V3
Tx: Cath Lab!
Brugada Syndrome
Path:
EKG:
Path: Hereditary
EKG
Right BBB-like pattern w/ ST elevation in leads V1-V3
Coronary artery disease
Path:
Risk factors:
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
Non-ST segment elevation acute MI Path: Pt: Dx: Tx:
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
ST segment elevation acute MI Path: Pt: Dx: Tx:
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
Anterior wall MI
EKG:
Coronary vessel:
EKG: V1-V4
Coronary vessel: left anterior descending (LAD)
Inferior wall MI
EKG:
Coronary vessel:
EKG: II, III, aVF
Coronary vessel:
right coronary artery (RCA) (70%+)
left circumflex (LCx)
Lateral wall MI
EKG:
Coronary vessel:
EKG: I, aVL, V5, V6
Coronary vessel:
left circumflex (LCx)
diagonal of left anterior descending
Posterior wall MI
EKG:
Coronary vessel:
EKG: ST depression V1-V4, elevation in V8-V9
Coronary vessel: posterior descending artery (PAD)
Endocarditis Path: Pt: Dx: Tx:
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
Modified Duke Criteria
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
Abx prophylaxis for endocarditis
Cardiac conditions
Procedures
Regimens
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
Hyperlipidemia Tx Lowering LDL Lowering triglycerides Increasing HDL Type II DM
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)
