EH 2 Flashcards
CHF with decreased EF (<55%)
systolic heart failure
*** causes of systolic heart failure
viral, ETOH, cocaine, Chagas, idiopathic (essentially, heart becomes ischemic and then dilated)
What is the EF is diastolic or preserved EF heart failure?
> 55%
*** Causes of diastolic heart failure
HTN, amyloidosis, hemachromatosis
*** CHF treatment
ACEi, bb, spironolactone, furosemide, digoxin
*** ACEi role in CHF
prevents heart remodeling by blocking aldo
*** BB role in CHF
prevents remodeling by blocking epi/norepi
Furosemide role in CHF
improve sx (SOB, crackles, edema)
Digoxin role in CHF
Decrease sxs and hospitilization
*** Which two CHF meds improve survival
ACEi and BB
Does digoxin improve survival in those with CHF?
NO
heart > 50% AP diameter, cephalization, Kerly B lines, interstitial edema
CHF
*** thickened peri-tracheal stripe and splayed carina bifurcation
LA enlargement (severe mitral stenosis) or CA with mediastinal pathology
Can mitral stenosis cause LA enlargement?
YES
complications of cocaine use
aortic dissection, cranial hemorrhage, acute MI
first 3 things to do in cardiac arrest
CPR, oxgen, and assess rhythm
*** When to shock cardiac arrest?
v fib or pulseless v tachycardia
*** Do you defibrillate or shock patients in PEA or asystole?
NO - use continuous CPR or epinephrine for vasopressor
*** Ortne syndrome
when mitral stenosis becomes SO severe that LA enlarges and begins to compress surrounding structures, specifically the laryngeal nerve resulting in hoarse voice
*** dyspnea, orthopnea, PND, hemoptysis, voice hoarseness, mid-diastolic rumble with opening snap, predisposes to a fib with resultant thromboemboli
MS
Why dyspnea, orthopnea, PND and hemoptysis in severe MS?
increased left atrial pressures results in increased pulmonary pressure and thus pulmonary vascular congestion
*** low amounts of which electrolytes can result in torsades?
low K, Mg, Ca
*** first line tx for torsades
mag sulfate
when to use adenosine
tx of paroxysmal SVT
*** use this for tx symptomatic bradycardia or AV block
atropine
months after MI with CHF-like sx, EKG with persistent ST elevations and deep Q waves, echo with thinned, dyskinetic myocardial wall
left ventricular aneurysm
can someone get dilated cardiomyopathy (systolic HF) secondary to viral myocarditis?
YES
hypokinesis of inferior wall of heart
inferior MI (RCA, II III and avF)
*** mid diastolic click, opening snap, left atrial hypertrophy
MS
ST pattern in anterolateral infarction (left main, LAD +LCx)
elevated in I, aVL, V2-V6 and depressed in II, III and avF
if EKG confirms MI, do you need cardiac enzymes?
Nope
rheumatic fever
MS
why a fib in MS
causes left atria to dilate, which stretches fibers and disrupts normal conduction resulting in afib
taring chest pain radiating to back in setting of severe HTN
aortic dissection
*** restrictive cardiomyopathy, proteinuria, easy bruising, neuropathy, hepatomegaly, macroglossia
amyloidosis
fixed splitting S2
ASD
pulsus paradoxus
tamponade
bounding pulses
AR
pulsus parvus et tardus
AS
*** tx of chronic stable angina
BB, CCB, nitrates, ranolazine
role of nitrates in angina tx
decrease preload
*** two first line rx for chronic stable angina
BB and nondihydropyridine CCB (amlodipine, nifedipine)
how do BB (metoprolol, atenolol) and non-dihydropyridine CCB (amlodipine, nifedipine) work to relieve sx of angina
decrease myocardial contractility and HR, resulting in lower oxygen demand of heart
*** physical exam findings of chronic severe MR
displaced apical impulse, holosystolic murmur, third heart sounds, afib 2/2 atrial enlargement
isolated systolic HTN
result of decreased elasticity or increased stiffness of arterial walls
ddx for exertional dyspnea
ventricular arrhythmias (MI) and outflow obstruction (AS, HCOM)
delayed and diminished carotid pulse
pulsus parvus et tardus of AS
continuous murmur at the left interscapular area due to turbulent flow across
coarctation of the aorta
prominent capillary pulsations in the fingertips or nail beds
AR, finding due to widened pulse pressure
> 10 change in SBP with inspiration
pulsus paradoxus of cardiac tamponade
tx of complete AV disassociation/3rd degree AV block
cardiac pacing, prevents asystole
decreased CO, increased SVR, increased LVEDV
CHF
Can LV systolic dysfunction result in LV dilation and MR?
YES
is MR heard as a holosystolic murmur at the apex with radiation to the axilla?
YES
what to do with pt whose triglycerides are > 1000
fibrates, fish oil, abstinence from alcohol –> GOAL IS TO PREVENT PANCREATITIS
*** triglycerides 150-500
lifestyle modification (wt loss, exercise, alcohol decrease) and manage CVD risk (statin)
name two fibrate medications used for triglyceride lowering
gemifibrozil, fenofibrate
does niacin + statin lead to SE?
YES, mostly GI
murmur made louder upon standing and valsalva, AD inheritance
HOCM
Why outflow obstruction in HCOM?
contact between the mitral valve and the thickened septum during systole
myxomatous degeneration of the mitral valve and/or chordae tendineae
MV prolapse
dilation of MV annulus
dilated cariomyopathy or ischemic cardiomyopathy leading to MR
pleuritic chest pain, dyspnea, tachycardia
worry about PE
30 y/o woman presents with atypical CP, should she be evaluated for CAD?
NO
*** how does dobutamine work in decompensated HF?
as an INOTROPE, improves heart contractility by binding to beta-1 receptors
when to hospitalize HTN?
severe with end organ damage (AMS, retinal hemorrhage etc)
who should be screened for secondary causes of HTN?
if resistant HTN (3 or more meds and not controlled) and young < 30 non-obese, non-black patients
treatment of WpW patient who presents with stable a fib
procainamide
*** what do these meds have in common: digoxin, bb, ccb, adenosine
AV node blockers (do not use in WpW patients)
prolonged standing, pallor, sinus bradycardia with arrest, passing out
vasovagal syncope
progressive edema, ascites, elevated JVP, pericardial knock (mid-diastolic sound), pericardial calicifications on CXR
constrictive pericarditis
nephrotic range proteinuria
> 3.5 g/day
*** pulmonary HTN, dilated RV, TR
cor pulmonale
what is cor pulmonale
RV failure as a result of pulmonary HTN due to severe lung disease, pulmonary vascular disease or OSA
old man with HTN who has sudden severe “tearing” pain that radiates to the back
aortic disease - disseciton, intramural hematoma
what does ST elevation turn into?
T wave inversion
can diffuse T wave inversions be seen in someone with pericarditis?
yes, as evolution of ischemic changes
recent catheterization, now mottling of LE skin, and labs with elevated creatine, eosinophils, and low complement
cholesterol emboli
*** physical exam findings suggestive of severe AS
pulsus parvus and tardus
mid to late peaking systolic murmur
quiet S2 as valve becomes too stiff to shut quickly
why is S2 soft in severe AS
S2 is due to sudden AV closure, with severe AS the aortic valve is stiff and slow to close
how does the murmur of mild-moderate AS differ from that of severe AS?
mild-mod = early-peaking systolic murmur severe = late-peaking
how severe is AS if pt has exertional presyncope and delayed carotid upstroke
SEVERE - would expect late-peaking systolic murmur with a soft S2
what conditions produce S3 heart sound
severe MR, chronic aortic reguritation, HF, high CO states like thyrotoxicosis or pregnancy
*** plasma aldo: renin > 20:1, hypokalemia, resistant HTN
primary hyper-aldosteronism
how does tension pneumothorax lead to hypotension?
obstructs the vena cava and thus blood flow return to RA
is PCWP and CI low in pneumothorax?
YES
can MI lead to cardiogenic shock?
YES
narrow complex tachycardia, hemodynamic instability with hypotension and poor perfusion
unstable SVT = provide synchronized cardioversion
inferior leads
II, III, avF (RCA)
inferior infarction
RCA, primarily affects R ventricle
pt comes in with CP and vomiting, found to have ST elevations in II, III, and avF - what DON’T you give them?
nitroglycerin - can worsen hypotension
are pt with inferior infarct preload dependent and need fluids in addition to MI tx?
YES
MI treatment regimen
Oxygen if <90% PCI within 90 minutes of medical contact Nitrates (cautious with RV infarction) Antiplatelet (ASA + clopidogrel) Anticag (heparin, warfarin) BB Statin
*** ascites, peripheral edema, hepatomeagly, splenomegaly
portal hypertension
