Day 7.1 Cardio Flashcards
4 drugs used to treat tinea capitis or pubis
Pyrmethrin
Pyrethin
Lindane (but it’s neurotoxic)
Melathium
Organism in animal urine
Leptospira Hanta virus (rat/mouse urine)
Drug w best effect on:
HDL
LDL
TGs
Raises HDL: Niacin
Lowers LDL: Statins (HMG coA reductase inhib)
Lowers TGs: Fibrates (2nd- omega3 FA)
Murmur: mitral/tricuspid regurg (MR/TR)
Heard from S1 all the way to S2.
Holocystic, high-pitched “blowing murmur”
Mitral: loudest at apex, radiates to axilla
Enhanced by things that increase TPR (squatting, hand grip) or by increased LA return (expiration)
Tricuspid: loudest at tricuspid area, radiates to right sternal border
Enhanced by maneuvers that increase RA return (inspiration)
What are the causes of mitral and tricuspid regurg?
MR: ischemic heart dz mitral valve prolapse LV dilation rheumatic fever endocarditis
TR:
RV dilation
Endocarditis
Rheumatic fever
Murmur: Aortic stenosis
B/t ejection click and S2 (ejection click is shortly after S1)
Crescendo-decrescendo systolic ejection murmur after ejection click. (ED is d/t abrupt halting of valve leaflets)
LV prs»_space; aortic prs during systole
Radiates to carotids/apex
Heard in aortic area
“Pulsus parvus et tardus”- pulses are weak compared to heart sounds. Can lead to syncope.
Causes of aortic stenosis
Age-related calcific aortic stenosis
Bicuspid aortic valve
Murmur: VSD
Heard from S1 all the way to S2
Holocystolic, harsh sounding murmur
Loudest at tricuspid area
Murmur: mitral prolapse
From mid-systolic click to S2. (MC is halfway thru S1 and S2)
Late systolic crecendo murmur w midsystolic click. (MC is due to sudden tensing of chordae tendineae)
Most frequent valvular lesion
Loudest at S2 (bc crescendos up to it)
Usu benign
Can predispose to infective endocarditis (only if there is mitral regurg assoc w it. give abx before dental procedures)
Enhanced by maneuvers that increase TPR (squatting, hand grip)
What can cause mitral prolapse?
Myxomatous degeneration
Rheumatic fever
Chordae rupture
Murmur: Aortic regurg
Starts at S2
Immediate high-pitched “blowing” diastolic murmur
Wide pulse prs when chronic
Can px w bounding pulses and head throbbing
Cause of aortic regurg
Aortic root dilation (syphilis, Marfan’s)
Bicuspid aortic valve (but this is more characteristic of stenosis, not regurg)
Rheumatic fever
Murmur: mitral stenosis
After the Opening Snap (which is even after S2)
Follows opening snap (OS d/t tension of chordae tendineae)
Delayed rumbling late diastolic murmur
LA prs»_space; LV prs during diastole
Enhanced by maneuvers that increase LA return- expiration (vs split S2 sound, which is enhanced by INspiration)
What can cause mitral stenosis?
Often secondary to rheumatic fever
Chronic MS can result in LA dilation
Murmur: PDA
Continuous- from S1 to S2 and beyond, but most at S2
Continuous machinery-like murmur
Loudest at S2
What murmur can be heard best at the tricuspid area?
Pan-systolic:
Tricuspid regurg
VSD
Diastolic:
Tricuspid stenosis
ASD
What murmurs are enhanced when TPR is increased?
Mitral regurg
Mitral prolapse
What murmur is enhanced when LA return is increased?
Mitral regurg
Mitral stenosis
What murmurs can be d/t Rheumatic Fever?
Mitral regurg Mitral stenosis Aortic regurg Aortic stenosis Tricuspid regurg Mitral prolapse
What murmurs are loudest at S2?
Mitral prolapse
PDA
What are the diastolic murmurs? (After S2)
Aortic regurg
Mitral stenosis (late, after OS)
PDA is continuous, so can hear in both diastole and systole
What are the systolic murmurs? (B/t S1 and S2)
Mitral regurg Tricuspid regurg VSD PDA (continuous) Aortic stenosis (after EC) Mitral prolapse (late, after MC)
What sounds are d/t sudden tensing of chordae tendineae?
Midsystolic click (systole) Opening snap (diastole)
What do S1 and S2 heart sounds represent?
S1 = Mitral valve closure
S2 = Aortic valve closure
Between them is systole (contraction)
What murmurs can be best heard at the aortic area?
Systolic murmurs:
Aortic stenosis
Flow murmur
Aortic valve sclerosis
What murmurs can be best heard at the Left Sternal Border?
Diastolic murmur: Aortic regurg Pulmonic regurg Systolic murmur: Hypertrophic cardiomyopathy
What murmurs can be best heard at the pulmonic area?
Systolic ejection murmur:
Pulmonic stenosis
Flow murmur (eg ASD)
What murmurs can be best heard at the mitral area?
Systolic: mitral regurg
Diastolic: mitral stenosis
Systolic murmur at left sternal border
Hypertrophic cardiomyopathy
Systolic ejection murmur at pulmonic area
Pulmonic stenosis Flow murmur (ASD)
Diastolic murmur at tricuspid area
Tricuspid stenosis
ASD
Diastolic murmur at mitral area
Mitral stenosis
Systolic murmur at aortic area
Aortic stenosis
Flow murmur
Aortic valve sclerosis
Diastolic murmur at left sternal border
Aortic regurg
Pulmonic regurg
Pansystolic murmur at tricuspid area
Tricuspid regurg
VSD
Systolic murmur at mitral area
Mitral regurg
Px of ASD murmur
Commonly presents as pulmonary flow murmur (increased flow thru pulm valve) plus a diastolic rumble (d/t increased flow across tricuspid).
Blood flow across the actual ASD does NOT cause a murmur bc there is no prs gradient.
The murmur later progresses to a louder diastolic murmur of pulmonic regurg, from dilation of the pulmonary artery
What valves should be open during diastole?
Diastolic filling- so mitral and tricuspid should be open. Therefore stenosis of these valves will make a diastolic murmur.
What valves should be closed during diastole?
Diastolic filling- aortic and pulm valves should be closed. If there is aortic or pulm regurg, will hear a murmur.
What valve should be open during systole?
Systolic contraction: aortic and pulmonic valves should be open (at the end of systole)
So aortic or pulm stenosis will cause a systolic murmur
What valves should be closed during systole?
Mitral and Tricuspid. So if have mitral or tricuspid regurg, will cause a systolic murmur.
When are all of the valves closed?
Isovolumetric contraction (Early systole) Isovolumetric relaxation (Early diastole)
Best heard w pt in left lateral decubitous position (on left side)?
Mitral regurg
Mitral stenosis
Left-sided S3 and S4 heart sounds.
Most common causes of aortic stenosis
Congenital bicuspid valve (doesn’t px until >40yo)
Senile calcification
Chronic rheumatic valve dz
Less common, but still causes:
Congenital unicuspid valve
Syphilis (tree-barking of aorta- can cause stenosis or regurg)
VSD and tricuspid regurg sound the same. In what pts is it likely to be VSD? to be tricuspid regurg?
VSD: newborns
IV drug user: tricuspid regurg
What does holosystolic mean?
Blood is flowing through valves during all of systole (S1 to S2), including during isovolumetric contraction at the beginning (when there should be no flow)
How do you open/close a PDA?
Open: prostaglandins
Close: NSAIDs (indomethicin)
Signs of R-sided heart failure
Peripheral / lower extremity edema
Hepatosplenomegaly
Signs of L-sided heart failure
Pulmonic congestion / edema
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Signs/sympt of bacterial endocarditis
Fever (most common sympt)
Roth’s spots (round white spots on retina surrounded by hemorrhage)
Osler’s nodes (tender raised lesions on finger/toe pads)
New murmur (caused by valvular dmg)
Janeway lesions (sml erythematous lesions on palm or sole)
Anemia
Spinter hemorrhages on nail bed
Bacterial FROM JANE: Fever Roth's spots Osler's nodes Murmur Janeway lesions Anemia Nail-bed hemorrhages (splinter) Emboli
What valves are usu involved in bacterial endocarditis?
Mitral valve most frequently
Tricuspid valve in IV drug users (don’t tri drugs)- assoc w S. aureus, Pseudomonas, Candida
Complications of bacterial endocarditis
chordae rupture glomerulonephritis suppurative pericarditis R-sided (tricuspid) emboli -->PE L-sided (mitral) emboli --> Stroke
Organisms causing bacterial endocarditis
Acute is caused by S. aureus (high virulence)
See lg vegetations on valves that were fine before. Rapid onset.
Subacute is caused by viridans strep (low virulence)
Smlr vegetations, seen on congentially abn or diseased valves (not good valves). More insidious onset. Can occur after dental procedures- so give abx before!
Enterococci (VRE esp bad, bc can’t give vanco)
Coag-neg Staph (S. epidermiditis)
IV drug users: S. aureus, Pseudomonas, Candida, S. epidermiditis
Colon cancer pts: S. bovis
Pts w prosthetic valves: S. epidermitidis
Culture-neg: HACEK organisms
Non-bacterial endocarditis
Occurs secondary to malignancy or hyper-coag state (marantic / thrombolyic endocarditis)
How to dx bacterial endocarditis
multiple blood cultures
What are the HACEK organisms?
Hemophilus Actinobacillus Cardiobacterium hominis Eikenella corrodens Kingella
These cause culture-negative endocarditis
What is Libman-Sacks endocarditis?
Verrucous (wart-like), sterile vegetations
Non-infective
Occur on both sides of valve.
Most often benign; can be assoc w mitral regurg and (less common) mitral stenosis
The most common heart manefestation of SLE!
SLE causes LSE
What is endocarditis?
Inflammation of the inner layer of the heart- the endocardium
Usu involves the valves
Can also involve other structures- IV septum, chordae tendonae, mural endocardium, intracardiac devices
What are vegetations?
Mass of platelets, fibrin, microcolonies of microorganisms, and inflammatory cells
Subacute (viridians) vegetations can also have a center of granulomatous tsu which can calcify/fibrose.
Which lesions of endocarditis are painful? non-painful?
Painful = Osler's nodes on finger/toe pads Non-painful = Janeway lesions on palms/soles
What are the features of Hypovolemic/Cardiogenic shock?
Septic shock?
Hypovol/Cardiogenic = LOW-output failure
Increased TPR (afterload)
Low CO
Cold, clammy pt
Septic = HIGH-output failure
Decreased TPR (decreased afterload)
Dilated arterioles, high mixed venous prs
Hot pt
SVR & CO, plus Rx in Hypovolemic shock
SVR and CO both increase
Rx = IV fluid and blood
Causes of hypovolemic shock
Blood loss d/t trauma (gunshot, MVA, stabbing)
Severe burns
SVR & CO plus Rx in Heart failure (cardiogenic shock)
CO is decreased bc heart is failing, so have a compensatory increase in SVR Rx = LMNOPP Loop/Lasix Morphine Nitrates O2 Pressors Positioning
SVR & CO plus Rx in sepsis/anaphylaxis
Massive vasodilation - decreased SVR
Compensatory increase in CO
Rx Abx, IV fluids (plus NE if needed)
SVR & CO plus Rx in neurogenic shock
E.g. Spinal cord injury, TBI
This means there is not good communication b/t body and brain, so nothing works:
SVR and CO are both decreased
Rx IV fluids. For SC injury give high dose corticosteroids
Causes of cardiogenic shock
Heart failure MI Arrhythmias (V-tach, esp V-fib) Tamponade Pulm embolism Tension pneumothorax Cardiac contusion
Sympt of Rheumatic heart dz
FEVERSS: Fever Erythema marginatum Valve dmg (vegetation and fibrosis) ESR increased Red-hot joints (migratory polyarthritis Subcutaneous nodules (Aschoff bodies) St. Vitus' dance (chorea)
OR
JONES (O = s cells (activiated histiocytes)
Elevated ASO titers
Aschoff body - granuloma w giant cells
What is Rheumatic heart dz?
Pharyngeal infection w S. pyogenes Gp A strep (beta-hemolytic), which leads to dz
Early deaths are d/t myocarditis
Late results: rheumatic heart dz (affects heart valves mitral > aortic»_space; tricuspid)
Early lesion - mitral valve prolapse
Late lesion- mitral stenosis
NOT bacterial. It is immune-mediated (type II HPS). There are Ab to M protein.
Aschoff body
Pathognomonic for rheumatic heart dz!
It’s a granuloma w giant cells in the middle of myocyte cells (heart muscle).
Area of fibrinous necrosis, surrounded by mono-nuclear lymphocytes and multinucleated giant cells.
T/F Rheumatic dz of the heart is d/t bacterial infection.
False. It’s auto-immune
But: It is the consequence of S. pyogenes infection.
Cardiac tamponade
Compression of heart by fluid in pericardium (eg blood, effusion), which squeezes the heart and t/f causes decreased CO.
Bc there is prs from the outside all around, all 4 chambers equalize in prs (the diastolic prs)
Findings in cardiac tamponade
hypotension
increased venous prs (JVD)
distant heart sounds (have to hear them through the fluid)
increased HR (to make up for the decreased CO)
Pulsus paradoxus
EKG: electrical alternans (QRS has beat-to-beat variations in amplitude- sometimes tall, sometimes short, medium, etc)
What is pulsus paradoxis?
Exaggerated decrease in amplitude (loudness) of pulse during inspiration.
So when pt breaths in, systolic BP drops a lot (>10mmHg).
Seen in severe cardiac tamponade, asthma, obstructive sleep apnea, croup (things w exaggerated inspiration)
What are the types of pericarditis?
Serious (SLE, Rheum Arthritis, viral infection, uremia)
Fibrinous (Uremia, MI-dressler’s synd, Rheum Fever)
Hemorrhagic (TB, malignancy-melanoma)
What are the findings in pericarditis?
Pericaridal pain Friction rub Pulsus paradoxus Distant heart sounds EKG chgs- ST segmt elevation in MULTIPLE leads (vs MI- only in a few specific leads, dep on MI location) Kussmaul's sign (JVD w inspiration)
It can get better w/o scarring, or it can cause chronic adhesive or chronic constrictive pericarditis
Heart dz caused by syphilis
Tertiary (3) syphilis dmgs the vaso vasorum of the aorta, causing dilation of the aorta and the valve ring (root of the aorta)
Tree-barking: can see calcification of aortic root and ascending aortic arch.
Can result in aneurysm of the ascending aorta or the aortic arch; aortic valve incompetence
What is Kussmaul’s sign/pulse?
JVD with inspiration
Caused by decreased capacity of RIGHT ventricle
Common in constrictive pericarditis (not v much in tamponade)
How is pulsus paradoxus different from Kussmaul’s?
PParadox has to do w decreased systolic BP on inspiration. It is decreased capacity of LV (vs Kussmaul’s which is RV)
And it occurs in cardiac tamponade (vs Kussmauls, which occurs in pericarditis).
Myxoma
Most common primary cardiac tumor in adults
90% are in atria (mostly LA)
HUGE BALL.
Ball-valve obstruction in LA assoc w multiple syncopal episodes.
Rhabdomyoma
Most freq primary cardiac tumor in kids
Assoc w tuberous sclerosis
Most common heart tumor
Metastases - melanoma, lymphoma
Chest pain, dyspnea, tachycardia, tachypnea in..
IV drug user
MVA pt
Post-op pt
IVDU: Bacterial endocarditis (maybe bacterial embolism –> PE)
MVA pt: Tension pneumothorax
Post-op: Pulm embolism (esp if pt is also confused)
Immediate Rx for bacterial endocarditis
Get culture
give IV vanco
then later give specific Abx dep on what culture shows
Diffuse myocardial inflam w necrosis and mononuclear cells
Myocarditis
Chest pain + course rubbing heart sounds in pt w Creatinine 5.0
Uremic pericarditis
ST elevations in all EKG leads
Pericarditis
Disordered growth of myocytes
Hypertrophic cardiomyopathy
EKG shows electrical alternans
Cardiac tamponade
Raynaud’s dz
Decrsd blood flow to skin d/t arteriolar vasospasm
Caused by cold temp, emotional distress
Fingers and toes turn blue/white
Sml vessel dz
Can be secondary to: MCTD (mixed CT dz) SLE CREST scleroderma Buerger's dz
Rx for Raynaud’s
Aspirin
Dihydropyridine CCBs
Sildenafil (ED- but great vasodilator)
Renal dz + lung dz
Wegener’s granulomatosis or Goodpasture’s syndrome
Differentiate bc Wegener’s has upper airway dz, Goodpasture’s doesn’t
Perforation of nasal septum- cause
Cocaine abuse
Wegener’s granulomatousis
Triad for Wegener’s granulomatosis
Focal necrotizing vasculitis (sml vessles)
Necrotizing granulomas in lung/upper airway (hard palate, soft palate, oropharynx, nasopharynx)
Necrotizing glomerulonephritis
So basically a lot of inflam that necrotizes.
Symptoms of Wegener’s granulomatosis
Hemoptysis Hematuria Perf of nasal septum Chronic sinusitis Otitis media Mastoiditis Cough, Dyspnea
Lab findings in Wegener’s granulomatosis
c-ANCA (!!!)
CXR might show lg nodular densities
Hematuria and red cell casts
Rx for Wegener’s granulomatosis
Cyclophosphamide and corticosteroids
this is also the Rx for polyarteritis nodosa
What 3 things are p-ANCA positive?
Microscopic poly angitis
Primary pauci-immune crescentic glomerular nephritis
Churg-Strauss syndrome.
What is microscopic polyangitis?
Like Wegeners (inflam, necrosis- lungs, kidneys), but does NOT have granulomas. p-ANCA
What is primary pauci-immune crescentic glomerulonephritis?
Vasculitis limited to kidney
Pauce-immune = paucity of Ab
p-ANCA
mpo-ANCA
What is Churgg-Strauss syndrome?
Granulomatous vasculitis w eosinophilia(!)
Px: asthma, sinusitis, skin lesions, and peripheral neuropathy (foot/wrist drop)
Can also involve heart, GI, kidneys
p-ANCA
“vasculitis in a young asthmatic”
Things that cause eosinophilia
Atopy (predisposition to HPS rxns) Asthma Allergies Parasites Churg-Strauss
Sturge-Weber dz
Congenital vascular disorder that affects capillaries. (sml vessels)
Causes port wine stain (nevus fammeus) at opthalmic division of trigeminal nerve on face;
Ipsilateral angiomatosis (intracerebral AVM)
Seizures
Early-onset glaucoma
MR
Hemiplegia
Henoch-Schonlein purpura
Lower extremity palpable purpura (butt and legs)
Arthralgia (knees esp)
Abd pain (intestinal hemorrhage, melena)
Recent URI
Most commone form of childhood systemic vasculitis.
IgA immune complexes
Assoc w IgA nephropathy (nephrotic, nephritic synd)
Self-limiting
Buerger’s dz
aka thromboangiitis obliterans
Heavy smoker(!) with
idiopathic, segmental, thrombosing vasculitis of sml and medium periph arteries and veins
Sympt: intermittent claudication, superficial nodular phlebitis, cold sensitivity (reynaud’s phenomenon), severe pain in affected part
Can lead to gangrene and auto-amputation of digits
RX: stop smoking!
T/F medium-vessel dz causes thrombosis/infarction of arteries
True
Kawasaki dz
aka mucocutaneous lymph node syndrome
Asian infants/children w acute, self-limiting necrotizing vasculitis
Sympt: fever, conjunctivitis, chg in lips/oral mucosa (strawberry tongue, lips cracking), lymphadenitis, peeling palms/fingers/toes (desquamative skin rash)
May develop coronary aneurysms- really dangerous bc a) can rupture and heart won’t be perfused or b) the widening pools blood and causes thrombosis- so heart won’t be perfused.
Affects sml and medium vessels
Rx for Kawasaki dz
IV immunoglobulin (pooled Ab from population) High dose aspirin- this is the only time you give it to kids (Reye's!)
Polyarteritis nodosa
Transmural vasculitis w fibrinoid necrosis.
Is immune-mediated.
HBV+ pt (30%) w non-specific sympt: fever, weight loss, malaise, abd pain, melena, headache, myalgia, HTN, neurologic dysfn, cutaneous eruptions
Findings and Rx for Polyarteritis nodosa
HBV +
See multiple aneurysms and constricitons on arteriogram. (Lesions are of different ages)
Sml and med-vessel dz
Usu renal and visceral vessels (NOT pulm arteries)
Rx: corticosteroids and cyclophosphamide (same rx as wegener’s, but wegener’s is p-ANCA positive, this is not.)
Takayasu’s arteritis
pulseless dz- weak pulses in upper extremities.
Asian 40+ yo Female w granulomatous thickening of aortic arch and/or proximal great vessels. Assoc w increased ESR.
medium and large vessel dz.
Sympt: fever, arthritis, night sweats, myalgia, skin nodules, ocular disturbances, weak pulse in upper extremity.
Temporal arteritis (giant cell arteritis)
Most common vasculitis affecting med and lg arteries, usu branches of carotid artery.
Elderly females w focal, granulomatous inflam.
Sympt:
unilateral headache
jaw claudication
impaired vision (occlusion of opthalimic artery- can lead to irrev blindness.
TEMPoral arteritis has signs near TEMPles.
Can also hv hyperpigmt of temples, pronounced temporal artery, muscle wasting over temples, and poor perfusion of scalp
Findings and Rx in Temporal arteritis
Assoc w increased ESR
Half of pts have systemic involvement and polymyalgia rheumatica
Rx: high dose steriods (for over a year)
Polymyalgia rhematica
Pain and stiffness in shoulders, hips
Often w fever, malaise, weight loss
Does NOT cause muscular weakness- joints just hurt.
Pts 50+ years
Assoc w temporal arteritis (giant cell arteritis)
Findings: increased ESR, normal CK (not muscular)
Rx: Prednisone
Differential Dx for red lesions
Strawberry hemangioma Cherry hemangioma Pyogenic granuloma Cystic hygroma Glomus tumor Bacillary angiomatosis Angiosarcoma Lymphangiosarcoma Kaposi's sarcoma
Strawberry hemangioma
Benign capillary hemangioma in infancy
Grows w child initially, then spontaneously regresses.
Cherry hemangioma
Benign capillary hemangioma in elderly
Does not regress
Freq increases w age
Pyrogenic granuloma
Polypoid capillary hemangioma that can ulcerate and bleed.
Assoc w trauma and pregnancy
Hemangioma
Benign tumor
Abn buildup of bld vessels in skin or organs
Cystic hygroma
Cavernous lymphangioma of the neck.
Assoc w Turner’s 45XO
Glomus tumor
Benign but painful, red-blue tumor under fingernails.
Arises from modified smooth musc cells of glomus body
Bacillary angiomatosis
Benign capillary skin papules found in AIDS pts.
Caused by Bartonella henselae infection
Freq mistaken as Kaposi’s sarcoma
Angiosarcoma
Highly lethal malignancy of the liver
Assoc w exposure to vinyl chloride, arsenic, and ThO2 (thorotrast) exposure
Lymphangiosarcoma
Lymphatic malignancy assoc w persistent lymphadema (e.g post- radical mastectomy)
Kaposi’s sarcoma
Endothelial malignancy of the skin assoc w HHV-8 and HIV
Freq mistaken as bacillary angiomatosis.
Which vasculitis has…
Weak upper extremity pulses?
Occlusion of the opthalmic artery, which can cause blindness?
Perforation of the nasal septum?
Weak pulse = Takayasu
Opthal artery occlusion = Temporal arteritis
Nasal septum = Wegener’s gran.
Which vasculitis features
Necrotizing granulomas of lung, and necrotizing glomerulonephritis?
Unlateral headache and jaw claudication?
Necrotizing immune-coomplex inflam of visceral/renal vessels?
Necrotizing lung, nephritis = Wegener’s
Uni headache/Jaw = Temporal arteritis
Imm-complx in renal vessles = Polyarteritis Nodosa
Which vasculitis is common in... Young male smokers? Young asian women? Asian babies? Young asthmatics?
M smoker = Buerger’s
Asian F = Takayasu
Asian baby = Kawasaki
Asthmatic = Churg-Strauss
Vasculitis in…
HBV+ pts?
Infants/kids, w coronary problems?
Most common?
HBV = Polyarteritis nodosa
Coronary prob = Kawasaki
Most common = temporal arteritis
Most common brain tumor in adults?
Gliobastoma multiforme (also most deadly)
Pregnant woman has normal BP but when lying down it drops. Why?
Compression of IVC
less preload, so less SV
If prego should lie on side.
