Caridology Flashcards
Classic EKG findings for pericarditis
Diffuse ST elevation in most of the precordial leads, with PR depression in the same lead
Buzz word: mid-systolic click
Mitral valve prolapse
Harsh crescendo-decrescendo murmur that radiates to the carotids; heard best with patient leaning forward
Aortic Stenosis
Classic EKG finding in ischemic heart disease
ST depression
*normal resting EKG in 50%
Formation of an atherosclerotic plaque
1) fat streak formation from lipid deposition in white blood cell as
2) LDL+macrophages form foam cells
3) fibrous cap formation
MOA of nitroglycerin
1) decrease coronary vasospasm
2) decrease preload by vasodilation
- take sublingual q5 minutes up to 3 doses
- remember you need at least an 8 hr nitrate free period to prevent tachyphylaxis
Contraindications to Nitroglycerin
1) SBP<90
2) RV INFARCT
3) PDE-5 inhibitors
Classic outpatient regimens for chronic angina lector is
Aspirin, BB, statin, prn nitroglycerin
Coronary artery occlusion percentage that typically becomes symptomatic with exertion (stable angina)
70%
Coronary artery occlusion percentage that typically becomes symptomatic at rest (unstable angina)
90%
Sings of an inferior wall MI
Chest pain with bradycardia, possible S4
Dressler Syndrome
Post MI pericarditis+ fever+ pulmonary infiltrates
What is a normal ejection fraction?
55-60%
MC type of cardiomyopathy
Dilated Cardiomyopathy
Cause of dilated cardiomyopathy, including MC
- Viral myocarditis (MC) enterovirus such as Coxsackie B MC, then PB19, Chagas dz
- alcohol abuse
- idiopathic (50%)
- pregnancy
At what ejection fraction is an implantable defibrillator recommended due to the increased risk of arrhythmias?
<30-35%
Takotsubo Cardiomyopathy
Apical left ventricular ballooning following an event that causes a catecholamine surge
*”broken heart syndrome”
Kussmal’s sign
JVP increased with inspiration
*seen in restrictive cardiomyopathy
Echo finding a for restrictive cardiomyopathy
1) nondialated ventricles with normal wall tho knees (they are ridged, not hypertrophied )
2) marked dilation of both atria
3) diastolic dysfunction
Hypertrophic cardiomyopathy pathophysiology
1) diastolic dysfunction: impaired filling
2) sub aortic outflow obstruction: hypertrophied septum
3) systolic anterior motion of the mitral valve
Hypertensive urgency management
Decrease MAP by 25% over 24-48 hours using ORAL agents
- clonidine: central alpha agonist (rebound HTN If abruptly stopped)
- captopril: ACEI
What makes a split S2 physiologic?
It occurs with inspiration
In what conditions will we see a fixed, split S2?
Pulm. HTN
Mitral regurgitation
ASD
VSD
*a paradoxical split s2 May be seen in severe aortic stenosis
What does the S3 sound represent?
Passive atrial filling
What does the S4 sound represent? In what conditions is it pathologic?
Atrial contraction
-associated with HTN, LVH, Aortic stenosis
Is a harsh murmur indicative of stenosis or regurgitation?
Stenosis
Is a blowing murmur indicative of stenosis or regurgitation?
Regurgitation
Which murmurs occur during systole?
Aortic stenosis and mitral regurgitation
Which murmurs occurring during diastole?
Aortic regurge and mitral stenosis
*remember ARMS rest!!
What murmur radiates to the carotids
Aortic stenosis
Which murmur radiates to the axilla?
Mitral regurge
Which murmur radiates to the L upper sterna border
Aortic regurge
Murmurs on Which side of the heart are heard best with inspiration
RIGHT
Murmurs on Which side of the heart are heard best with expiration
LEFT
Presentation of symptomatic aortic stenosis
1) chest pain
2) syncope
3) CHF
4) dyspnea (MC)
Etiologies of aortic regurgitation
1) valve dz: rheumatic heart dz, endocarditis
2) aortic root dz: HTN, Marian, RA, SLE
Acute and chronic manifestations of aortic regurge
Acute: MI, aortic dissection, endocarditis , pulmonary edema
Chronic: CHF
Pulses in aortic regurgitation
BOUNDING with wide pulse pressures
*water hammer pulse
Medical therapy of aortic regurgitation
Afterload reduction with vasodilators such as ACEI, nifedipine, hydralazine
Rheumatic heart dz is the MC cause of which heart murmur?
Mitral stenosis
Clinical manifestations of mitral stenosis
1) pulmonary overload: dyspnea, hemoptysis
2) A fib! (Due to atrial enlargement)
3) right sided heart failure
4) mitral facies (flushed and pale)
5) ortner’s syndrome: HOARSENESS, enlarged L atria compresses recurrent laryngeal nerve
A prominent S1 and opening snap is found with what murmur
Mitral stenosis
What is the most common cause of mitral regurgitation?
Mitral valve prolapse
Management of mitral regurgitation
REPAIR PREFERRED OVER REPLACEMENT
MC epidemiology of mitral valve prolapse
Women 15-35
Presentation of mitral valve prolapse
1) autonomic s/s: anxiety, palpitation, syncope
2) progression s/s: PND, CHF
3) stoke
Mitral valve prolapse management
REASSURANCE
*only give B.B. if autonomic s/s
A mid-late systolic ejection click is associated with what murmur?
MVP
Pulmonic stenosis radiates where?
Neck
Xanthoma
Lipid plaques on the Achilles’ tendon and a result of hyperlipidemia
Xanthelasma
Lipid plaques on the eyelids as a result of hyperlipidemia
When do we begin screening for hyperlipidemia if they have no risk factors?
Makes=35
Females=46
When do we begin screening for hyperlipidemia if they have risk factors?
Males=20-25
Females
= 30-35
How do we determine when to treat hyperlipidemia ?
10 year cardiovascular risk calculator
What are the criteria for statin initiation ?
1) any CAD
2) 40-70y/o with DM
2) anyone over 21 with LDL >190
4) no heart dz, 40-75y/o with 7.5% risk of more
Best meds to lower Trigs
Fibrates
Best meds to increase HDL
Niacin
Niacin (Vit B3) MOA, SE
Increases HDL and delays production of LDL
-SE: flushing pruritus( give with ASA) , hyperuricemia (can cause GOUT) , hyperglycemia (carful in DM)
Statin MOA, SE
MOA: HMGcoA Reid tase inhibitors … decreases the production of LDL
SE: myositis, rhabdo, hepatitis
Fibrates MOA, SE
MOA: reduces hepatic triglyceride production
SE: myositis, increased LFTs, gallstones
Bile Acid Sequestrants MOA, SE
MOA: binds bile acids, removing LDL from the blood
SE: GI effects, increased triglycerides
Ezetimibe MOA, SE
MOA: inhibits intestinal cholesterol absorption
SE: increased LFTS
Management of acute endocarditis
Nafcillin + gentamicin x4-6 weeks
Management of subacute endocarditis
Penicillin or Ampicillin + Gentamicin
Management of endocarditis in a patient with a prosthetic valve
Vancomycin + Gentamicin + Rifampin
Who gets infective endocarditis prophylaxis?
1) dental, respiratory, open skin procedures with ….
- prosthetic valve
- prosthetic material
- hz of endocarditis
- congenital heart dz
What valve is MC involved in infective endocarditis?
Mitral
*tricuspid valve is found in IVDA
Acute bacterial endocarditis
No underlying heart dz, often S. aureus
Subacute bacterial endocarditis
Infection in a patient with abnormal valves
- often S. Viridans (oral flora)
Mc organism causing endocarditis in an IVDA
MRSA
MC organism causing endocarditis in a patient with a prosthetic valve
Staph. Epidermis
HACEK organisms of endocarditis
H- haemophilus A- actinobacillus C- cardiobacterium E- eikenella K- klingella
*gram negatives causing large vegetation’s and are difficult to culture
Clinical manifestations of endocarditis
FEVER, weight loss, fatigue
- Janeway lesions: painless macules on palms and soles
- Oslar nodes: painful nodules on pads of digits
- splinter hemorrhage
- Roth spots: retinal hemorrhage with pale center
- petechia
DUKE CRITERIA for infective endocarditis (major and minor)
MAJOR:
1) sustained bacteremia with organism know to cause IE
2) ECHO involvement
MINOR:
1) predisposing condition
2) fever
3) vascular/emboli: janeway leaions, PE
4) immunologic: osler’s nodes, Roth spots
5) blood culture not meeting major
6) echo not meeting major
need 2 major, 1 major + 3 minor, or 5 minor
MC cause of myocarditis
Enterovirus (Coxsackie)
- clozapine=MC drug cause
- SLE, rheumatic fever are common autoimmune causes
Presentation of myocarditis
Viral prod Rome followed by heart failure symptoms
Workup of myocarditis
Endoyocardial bx =GOLD STANDARD
CXR=cardiomegaly
Elevated cardiac enzymes
Myocarditis tx
Heart failure tx
What is rheumatic fever?
Acute autoimmune multi-system illness in 5-15y/o from a previous GABHS (group A. Beta-hemolytic strep, strep. Pyogenes) infection
JONES criteria for rheumatic fever
J- joint; polyarthritis O-oh my heart; carditis N- nodules ; sub Q on extensor surfaces E-erythema marginatum; macular, non-pruritic rash on the trunk and extremities S-Sydenham’s chorea; jerky movements
Rheumatic fever management
ASA +Pen G
MC presentation of peripheral arterial dz
Intermittent claudication
6 P’s of Acute arterial embolism
Palor, pain, pulselessness, poilkithermia, paresthesias, paralysis
Dx of PAD
ABI<0.9 (<0.4 is pain at rest)
Arteriography=GOLD STANDARD
Management of PAS
1) Platelet inhibitors: cilostazol (plital) ; ASA; plavix
2) Revascularization: PTA (percutaneous transluminal angioplasty) or fem-pop
3) supportive : foot care, exercise
What is trousseau’s syndrome?
Migratory thrombophlebitis associated with malignancy
Common causes of superficial thrombophlebitis
IV catheter (MC) , pregnancy, varicose veins , factor V Leiden
What is bronchiectasis ?
Irreversible bronchial dilation and inflammation causing bronchial collapse and impaired clearance of mucus
Clinical manifestations of bronchiectasis
1) recurrent lung infections
2) hemoptysis * MC cause of massive bronchiectasis
What is the most common cause of bronchiectasis in the US?
Cystic fibrosis *pseudomonas is the pathogen
What is the diagnostic study of choice for bronchiectasis?
High resolution CT of the chest!
*”tram-track” bronchial thickening
Antibiotic regimen for MAC caused bronchiectasis
Clarithromycin + ethambutol
Physical exam finding in pericardial effusion
Muffled heart sounds
What is electric alterans
Beat to beat shift in QRS amplitude on EKD coins in pericardial effusion
Becks triad of cardiac tamponade
1) muffled heart sounds
2) JVP
3) HYPOtension
Adults with unrepaired coarctation of the aorta are at increased risk for what other vascular disorder?
Intracranial aneurysm
What infectious etiology is associated with complete heart block?
Lyme Dz
What is the treatment for long QTc syndrome in a stable patient?
beta blockers such as metoprolol
What drugs can increase serum triglyceride concentration?
Estrogen replacement, tamoxifen, beta blockers, glucocorticoids, and human immunodeficiency virus (HIV) antiretroviral regimens.
Findings of a left bundle branch block on EKG
Wide QRS
Large R wave in lead I
Negative wave in VI
Findings of a right bundle branch block on EKG
Wide S wave in lead I
Triphasic QRS
What is the most common cause of heart failure
Coronary Artery Dz
Long term management of Angina vs long term medical management of HF
Angina=BB first line+ ASA
HF=ACE/ARB first line + diuretic
Kerley B lines indicate what diagnosis?
Congestive Heart failure
Treatment of acute pericarditis
ASA +NSAIDS, if greater than 48 hrs you can give corticosteroids
treatment of hypertrophic cardiomyopathy
ICD placement and start patient on BB
In what type of shock should you not administer large amounts of fluids
cardiogenic shock
Treatment of cariogenic shock
inotrope-dobutamine
fix the underlying cause..MI
Possible etiologies of obstructive shock
PE, tamponade, tension pneumothorax, aortic disection
these obstruct the blood flow from the heart or great vessels
Etiologies of distributive shock
- septic shock
- neurogenic shock
- anaphylactic shock
- endocrine shock
**these cause shunting of blood from vital organs to non-vital organs ; there is LOW SVR in this type of shock only
in what type of shock will you see BRADYCARDIA along with hypotension
neurogenic shock (type of distributive shock)
in what type of shock will you see increased pulmonary wedge pressures
cardiogenic shock
Medication treatment for orthostatic hypotension
- fludrocortisone
2. Midodrine (vasopressor)
