cv leik Flashcards
incidental finding on CXR, may show widend mediastinam and obliteration of the aortic knob
thoracic aortic dissection
apical impulse
5th ics mid clavicular line left sternal border
LVH (severe) and cardiomyopathy can displace more than 3cm, it is larger and more prominent
3rd trimester preggers S3 during preggers is OK, located slightly up on the left side of the chest
de ox blood path
sean is a total victor passes prominantly
Superiror vena cava Inferior vena cava Atrium Tricuspid Vent Pulmonic Pulm artery
ox blood path
after my vistory aspireing always
pulm veins from lungs then
Atrium Mitral Vent Aortic valve Aorta
motivated apples
Mitral Aortic
Tricuspid pulmonic
AV valves semilunar
S1 systole Motivated
lub
closure of mitral and tricuspid valves
(AV valves have 3 leaflets
S2 diastole apples
dub
closure of aortic and pulmonic valves
two leafs
S3 sound
equals heart failure
early diastole also called ventricular gallup or
S3 gallup
kentuky
always abnormal if after 35 cept preggers, can be normal in kids
The third heart sound is caused by a sudden deceleration of blood flow into the left ventricle from the left atrium
s4 heart sound
increased resistance from stiff left ventricle usually indicates LVH
can be normal in some elderly
late diastole
atrial gallop
sounds like tennessee
BEST HEARD AT THE APEX OR APICAL AREA USING THE BELL OF THE STETHESCOPE
bell is for
low tones like extra heart sounds
mitral stenosis
diaphragm is for
mid to high pitich such as lung sounds
Mitral regurg
aortic stenosis
benign variants
split S2- PULMONIC AREA 2nd ICS appears at inspiration dissapears at experiation
s4 in elderly- if no S and S of heart or valve disease, it can be normal
Systolic murmurs
Mitral Regurg
Aortic Stenosis
Systolic murmurs
diastolic murmurs
Mitral
Stenosis
Aortic
Regurg
Diastole
mitral area
lower anatomically
apex, or apical area
5 ICS 8-9 cm form the midsternal line slightly medial to the midclavicular line
PMI or apical pulse is here
Aortic area
up top
2nd ACS at the BASE (anatomically higher)
S1 murmurs MR Ass
holosystolic, pan systolic, early mid or late systolic,
louder and radiate up to the neck
Mitral regurg
pan or holosystolic murmur
HEARD at the APEX 5th ICS
Radiates to axillia
LOUD BLOWING and high pithced (use diaphragm)
Aortic Stenosis
midsystolic ejection murmur
2nd ics R sternal border (careful with this one)
HARSH NOISY MURMUR, diaphragm
MS ard Diasotlic
diastolic murmurs are always bad
S2 MS-
low pitched- bell
heard best at apex 5th ics
also called “opening snap”
MS ARD
aortic regurg
high pitched diastolic
2nd ics RSB
high pitched blowing murmur - diaphragm
murmur grade
1
2
3
1 barely able to hear, can do only under p=optimal conditions
- mild to mod loud murmur
- loud murmur easily heard once the stethiscope is placed on chest
murmur grade
4
5
6
4 louder than three FIRST TIME THRILL IS PRESENT (think palpable murmur)
5 very loud murmur more obvious thrill, can hear with edge of scope off chest
- thrill is easily palpated, can hear with scope off chest
radiats to axila
mitral regurg
radiats to the neck
aortic stenosis
parox AF
terminates within 7 days but usually less than 24 hours, generally asymoptomatic
AF CC and treatment
fluttering heart, hypotension, pre or near syncopy,
tx is based on pt type and risk factors for stroke
CHADS VASC
0 is low 2 or more needs AC C-CHF H-HTN A age over 75 D- DM S- stroke or tia V- vascular disease A- 65-74 years S- female gender (higher risk)
AF labs after EKG
TSH, lytes, rena panel, BNP to R/O HF dig level if on digoxin 0.5-2 digibind for elevated
eccho to evaluate for valve problems that increase risk of stroke
if parox consider
24hr holter monitor
lifestyle for afib
avoid stims, caffeine, nicotine, decongestants and booze in some pts
AF - new
refer to cards
can cardiovert if stable in first 48 hours
or seek rate control
Rate control meds AF
BB
calcium channel blockers
Norvasc (amlodipine) Plendil (felodipine) DynaCirc (isradipine) Cardene (nicardipine) Procardia XL, Adalat (nifedipine) Cardizem, Dilacor, Tiazac, Diltia XL (diltiazem) Sular (Nisoldipine) Isoptin, Calan, Verelan, Covera-HS (verapamil)
or dig cardiac glycosides.
AF antiarythmics
amiodarone (cordarone) black box for pulmonary or liver damage, simvastatin with amio can cause rhabdo
Af anticoagulation
coumadin- vitamin K agonist only one reccomend for liver failure pt
baseline labs for coumadin
prothrombin time is 9.5-13.5 seconds.
INR below 1.1
aptt 30-40sec
platelet count 150,000 to 450,000
initial dose for coum-
5mg but frail or elderly above 70 take 2.5
full effect takes a few days 2-3
check INR- every 2-3 days untill theraputic for 2 consecutive checks
then weekly untill stable at between 2-3
then every 4 weeks when stable
for non vavlular AF consider
direct thrombin inibitors - xarelto, eliquis, no INR or diet restrictions
90% of warafin deaths are caused by
intracerebral hemmorhage
INR goal with a prostetic valve
2.5-3.5
INR less than 5 or 5-9 with no bleed
5-no vitamin K , sip next dose/adjust baseline dose, recheck once or twice a week while adjusting
5-9 hold one or 2 doses with 1 to 2.5mg of vitamin K monitor INR and lower maintnece dose of coum
WPW (more common in kids) delta wave Paroxsysmal SVT- peaked QRS with P waves CC and TX
like a-fib but with p waves, HR like 150 or 250
can be caused by dig tox, etoh, hyperthyroid, caffeine, drugs
EKG, if unstable may need cardioversion
vagal maneuvers
pulsus paradoxus
apical pulse can be heard but radial pulse cant be palpated, mesured with BP cuff and sterthoscope, imapired diastolic filling cause drop of sustolic pressure of more than 10mmhg
pulm cause- asthma or emphysema- increased positive pressure
cardiac- tamponade, pericarditis, effusion
anterior wall mi
Reciprocal ST segment depression in the inferior leads (II, III and aVF
st elevation in 3-4
BP measurement
manual is preferred- 2 or ore readings seperated by at least 2 mins should be averaged per visit
higher number determins BP stage
any change in PVR or CO has corrosponding effect on BP
Primary or essential HTN
most often asymptomatic
Normal
pre
1
2
normal less then 120 and 80
pre less than 120-139 and 80-89
1 less than 140-159 and 90-99
2 less than 160 or 100
angiotensin 1 to angiotensin 2
increases vasoconstriction and BP
younger pts have higher renin levels than elderly
Sympathetic Stim
epinephrin secretion causes tacchy and vasoconstriction
preggers and BP
SVR is LOWER from hormones, sys and diastolic decrease during 1st and 2nd trimester
secondary HTN, 3 types
Renal: renal artery stenosis- polycystic kidney, or CKD (more common in young)
Endocrine: HYPERthyroid, HYPERaldosteronism, Pheocromocytoma (middle age)
Other- OSA, coarctation of aorta,
Malignant HTN
severe HTN iwth end organ damage, retinal hemmorhage, pailledema, acute renal failure and sever HA
coartation of Aorta
BP in arms is higher than legs
check fem and radial at same time, fem is delayed
Avoid ace (prils) and arb (sartan) with epigastric bruit or flank bruit indicating renal artery stenosis
with chronic kidney disease
main BP goal 60 and under
less than 140 and 90
main BP goal over 60 no DM or CKD
150/90
AA treatment to get to less than 140/90
thiazide diurtetic and CCB’s or “PINE” drugs alone or in combo
non AA to get to less than 140/90
thiazide dirutic and acei (prils) (except DM or CKD)
CKD 18 years and older- less than 140/90
ACEI (prils) or ARB (sartans)
DM 18 years and older less than 140 and 90
ACEI (prils) or ARB (sartans)
HTN emergency
diastolic BP greater than 120, with end organ damage, NV think increased ICP,
isolated systolic HTN in elderly
loss of recoil in artery- increasing PVR
wide pulse pressure
for frail or with sever orthostatic hypotension if older than 60 its ok to be up to 150 systolic
low dose hctc
and long acting ccb-
orthostatic hypo
less active autonomic nervous system activity
slower drug metabolism in liver ‘
first line therapy for HTN, lipids, and type 2 dm
lifestyle changes stop smoking, lose weight sodium below 2.4 g less than 2,400 mg fatty fish 3 times a week less than 10z and 05 oz of booze per day
normal BMI
18.5-24.9
DASH diet
for pre and HTN, high K, Mg, CA, low red meat and processed food, more whole grain and legume, more fish and poultry
calcium
low fat dairy
K
potatoes, most fruits and veggies,
mag
dried beans, whole grains and nuts
omega 3
anchovy, krill, salmon, flax seed
exercise lowers
LD overll cholesterol and BP
exercise plan
4 session per week
40 mins
thiazides work by
chlortalidone- hygrotin
indpamide- lozil
changin how kidneys handle sodium, upping urine output
favorable efffect on osteopenia perosis- slow demineralization
all contain sulfa, avoid in allergy
SE are HYPER-
glycemia
uricemia- wathc for gout
cholesterol check panel
HYPO
K watch iwth dig
na
mag
Loop diuretics work by
inhibiting the sodium, potassium, chloride pump of the kidney in the loop of henley
possibly alter excretion of lithium and saliclyates
K sparring Aldosterone receptor antagonist diuretics
spironolactone aldactone
epelrenone inspira
increase elimination of water,
used in hirstuism, precosious puberty and htn
avoid with Ace-i (prils)
avoid in
DM 2with microalbuminemia
serum creat greater than 2
serum K over 5.5
BB
avoid abrupt discontinue with chronic use
works by decreasing vasomotor activity
inhibits renin and norepinephrine realease
contraindicated in asthma, COPD, emphysema,
2nd degree block weinkie and mobits II ( normal but extra pr)
3rd degree block
b1 receptors are
cardiac
b2 receptors are
lungs and peripheral vasculature
dont use propanalol for HTN because of
short half life
CCBs pine endings
blocks voltage gated CA in cardiac smooth muscle, and the nlood vessels, resutls in systemic vasodialation
nondihydropyridines
verapimil- calan sr
caridzem
depress the muscle of the heart (inotropic effect
dihydropyridines
nefidipin- procardia
amlodipine norvasc
felodipine plendil
slow the rate (chronotropic effect
drug of choice in DM or CKD
ACEI (pril) ARB (sartan) prevent conversion of angiotensin less vasoconstriction
ACEI (pril) ARB (sartan) dont use
mod to sever kidney disease especially renal artery stenosis
High K side effect of this class so effect will be worse
Alpha 1 blockers- alph adrenergic (zosin)
teraosin (hytrin) htn and BPH use in this group
tamulosin (flomax) htn only
potent vasodilarors - cause dizzyness, give at bedtime and titrate up
1st dose orthostasis is common with ARBS (sartan) severe hypotension and tacchy
CHF cutoff
systolic is less than 40 HFrEF
diastolic EF is over 40 HFpEF
CHF left ventricular failure
crackles, dull to precussion, rales on lower lobes
R and L failure- paroxysmal nocturnal dypsnea, orthopnea, nocturnal non productive cough, wheezing (cardiac asthma) HTN
CHF R ventricular failure
JVD- normal is 4cm or less
large spleen, liver, anorexia, nausea, and ab pain,
LE edema, cool skin
R and L failure- paroxysmal nocturnal dypsnea, orthopnea, nocturnal non productive cough, wheezing (cardiac asthma) HTN
CHF CXR
increased heart size, interstitial or alveolar edema
Kerley B lines
BNP
echo with doppler flow for ef
daily weights
CHF diruetic
20 or up to 320 of lasix initially
CHF stable HF with reduced EF and HTN
Start ACEI (prils) or ARB (sartans) plus BB, and others limit salt
CHF stage
1 no limitations
2 ordinary activity results in fatigue- exertional dypsnea
3 MARKED LIMITATION in activity
4 PRESENT AT REST, with or without activity
CHF lifestyle mod
weight loss, smokingg cessation, no ETOH
Restrict sodium 2-3g daily
fluid restrict 1.5-2L daily
DVT 3 categories
stasis: travel, more than 3hours of inactivity
inherited coag disorders: factor C or leiden
increased coag due to external factors: oral contraceptivs or bone frx etc
DVT classic case
gradual onset of LE swelling painful swollen LE that is red and warm.
hep gtt then coum for 3-6 months first episode
recurrant dvt or elderly may have lifelong anticoag
superficial vs DVT
no swelling in superficial
treatment is nsaid
warm compress, elevate
PAD cc
older, smoking, HLD, worsoning pain on ambulation instantly relieved by rest atrophic skin changes, may get gangrene
ABI score
0.9-1.3 is normal, less than 0.9 is PAD
Systolic BP of arm (brachial) and ankle with cuff and ultrasound after supine for 10mins,
done for each leg
SBP of foot is divided by arm
PAD treatment
pentoxifylline pletal- watch fro grapefruit juice, dig, and priolosec if taken together,
bypass
reynauds
females mostly
avoid caffine, stop smoking
do not use vasoconstrictors and non selective beta blockers
endo
tender red spots on the hands -janes
tender violet colored nodules on fingers or toes (oslers)
Give amox 2g po one hour before for (or clinda with allergy
dental procedures that (previous history of infective endo)
valve- any time u are screwing with the resprityoy tract
MVP, cc
treat
S2 click” followed by systolic murmur, female, fatigue palpitations, orthostatic hypo made worse by excertion
can have sunken chest or marfans,
asymtomatic- no treatment
mvp with palp- BB avoide cafinne and
holter monitor for detecting significan arrythmias
HLD screen at age then
over 40 screen
preexisting HLD
start at 20 then Q5
over 40 its Q2-3
preexisting HLD is annually
total cholesterol ranges
normal: less than 200
borderline- 200-239
High over 240
HDL C goals
men over 40 women over 50
statin or niacin are good at increasing HDL
LDL goals
optimal is less than 100
Less than 130for pts with fewer than 2 risk factors
greater than 190 is Very high
Triglycerides
less than 150 is normal
pancretitis concenr over 1000
treatment plan for lipids
lifestyle
reduce salt
lower LDL first
21-75 with ASCVD
lower LDL by 50%
lipitor atorvastatin
rosuvastatin crestor
21 with LDL over 190 but no ASCVD
lower LDL by 50%
lipitor atorvastatin
rosuvastatin crestor
over 75 with ASCVD
moderated lower LDL by 30-50
zocor-simvastatin
pravastatin- pravachol
lovastatin-mevacor
rhabdo triad
muscle pain, weakness, and dark urne
CK is at least 500K
urine has myoglobin and protein up to 45%
