FINAL Flashcards
aortic stenosis/regurgitation
-catheter- eval if valve or wall not getting enough blood
-STENOSIS-
-absent S2
-parvus et targus (diminish carotid pulse)
-pericardial thrill
-REGURGITATION-
-murmur increased with hand griping, leaning forward, or sitting
-corrigan’s pulse- bounding due to increase SV
-austin flint murmur- low pitch rumbling
-if severe -> heard at apex
-TX- HF tx or valve replacement if < 1cm for stenosis
-replace for regurgitation if asymptomatic or symptomatic with LV decompensation
mitral stenosis/regurgitation/prolapse
-STENOSIS
-dyspnea, hemoptysis
-LHF and RHF
-afib -> tx- warfarin
-anticoag, valve replacement, HF tx
-REGURGITATION
-radiation to axilla
-repair- preserve LV function, lower risk of endocarditis, less thrombotic events
-PROLAPSE
-palpitations
tricuspid stenosis/regurgitation
-STENOSIS-
-rheumatic, carcinoid, endocarditis, congenital, ebstein
-abdominal distention
-REGURGITATION
-pulmonary HTN, COPD
-IV drugs- staph
-radiations to xiphoid
pulmonic stenosis/regurgitation
-STENOSIS-
-tetrology of fallot- overriding aorta, RV outflow obstruction, ventricular septal defect, RV hypertrophy
-radiates to left shoulder
-REGURGITATION-
-congenital, pulm HTN
-graham steel murmur- high pitch decrescendo early diastolic murmur
septal defects
-atrial- systolic ejection murmur at 2nd LICS
-ventricular- systolic murmur at LLSB
-ventricular symptoms depends on size
-PFO- paradoxical embolism
murmurs
-aortic stenosis- crescendo decrescendo systolic murmur
-aortic regurgitation- low pitch decrescendo diastolic murmur
-mitral stenosis- low pitch diastolic murmur with opening snap
-mitral regurgitation- holosystolic murmur
-mitral prolapse- mid systolic click
-tricuspid stenosis- mid diastolic murmur
-tricuspid regurgitation- holosystolic murmur
-pulmonic stenosis- mid systolic murmur
-pulmonic regurgitation- high pitch early decrescendo diastolic murmur
valve prophylaxis
-congenital defects
-prior endocarditis
-prosthetic valve
-repaired congenital defect within first 6 months
-prophylax with amox 30-60 mins prior
-if allergic -> cephlaxin, clindamycin, azithromycin
-prior to dentist, respiratory, infected skin, muscle surgery
reversal agents
-beta blocker- glucagon
-warfarin- vit E, FFP
-heparin- protamine
-digoxin- digoxin immune Fab (digibind)
PAD
-AORTA/ILIAC
-2/3 asymptomatic
-weak pulses -> bruit over aorta, iliac or femoral
-leriches syndrome- impotence, claudication, decrease femoral pulse
-ABI, CTA, MRI
-walking, statin, aspirin, PDE inhibitors, angioplasty, stent, bypass- axillo-femoral
-FEMORAL/POPLITEAL
-10 years after aortioiliac
-at abductor magnus
-blanching, atrophic, loss of hair, thinning of skin, ulcers, gangrene
-ABI, doppler, CTA, MRI
-walking, statin, aspirin, PDE inhibitors, angioplasty, stent, bypass- femoral popliteal
-thromboendartectomy
-TIBIAL/PEDAL
-diabetics
-may have absent claudication
-cold, atrophic, hairless, blanch
-ABI <.4, digital subtraction angiography
-2-3 weeks with no healing -> revascularization
-bypass- distal tibial pedal
-amputation
acute arterial occlusion of limb
-sudden onset -> emboli
-pain, pallor, pulseless, poikilothermia, parathesias, paralysis
-livedo reticularis- lacy mottled vascular pattern
-doppler- low flow
-no time for CT or MRI
-revascularize within 3 hours ideally -> by 6 its irreversible
-IV heparin
-TPA
-thromboembolectomy
occlusive cerebrovascular disease
-TIA- reversible with reestablished collateral flow
-amaurosis fugax- unilateral blindness
-carotid artery bruit- loudest mid neck
-dx- duplex ultrasound, MRA, CTA
-CHECK FOR AFIB
-tx-
-CVA management
->60% stenosed -> carotid endartectomy -> angioplasty/stenting
-F/U with US
visceral artery insufficiency
-pain after eating (post-prandial)
-acute- emboli
-chronic- atherosclerosis, CHF, hypotension
-usually multiple occlusions due to collateral blood supply to intestines
-ischemic colitis- IMA intestinal mucosa will slough off
-dx- high WBC, lactic acidosis, hypotension, abdominal distention
-CT with contrast, US, colonoscopy for ischemic signs
-tx:
-acute- surgical exploration
-chronic- angioplasty/stent
-ischemic- establish collateral circulation -> if perforation -> resect
thromboangitis obliterans
-buerger disease
-inflammation and thrombotic process of distal arteries and sometimes veins
-vasculitis due to smoking
-male, younger
-DX- MRA or invasive angiography
-tx- stop smoking
aortic aneurysm
->3cm- AAA, >5 risk of rupture, >5.5 rupture
-below the renal arteries
-screen men 65-75, and women with 1st degree relative
-DX- abdominal US, CT for measurement and location
-if approaching 5cm -> 6 month US f/u
-approaching 5.5cm -> CTA to define anatomy for repair
-<4cm -> US every year
-TX-
->5.5cm or rapid expansion (.5cm in 6 months)
-no tx if <2 year life expectancy
-graft
thoracic aortic aneurysm
-mostly asymptomatic
-back and neck pain, dyspnea, stridor, cough, hoarse, distended neck veins
-50-60 yo
-CXR- widened mediastinum
-CT
->6cm -> repair
-surgical or endovascular
-RISK FOR PARAPLEGIA- vertebral artery loss
peripheral artery aneurysm
-asymptomatic until acute emergency
-emboli
-mostly popliteal, mostly bilateral -> 1/2 also have AAA
-pulsatile mass
-US, MRA, CTA
-screen for AAA
-surgical repair -> bypass
aortic dissection
-searing chest pain -> radiates to back, abdomen, or neck
-HTN
-syncope, hemiplegia, paralysis of lower limbs, ischemia, renal insufficiency
-diminished pulse -> unequal
-MRA -> gold standard
-CXR- widened mediastinum
-CT
-da bakey 1,stanford type A- whole thing
-type 2, stanford type A- only ascending aorta
-type 3 stanford type B- only descending and lower
-tx-
-type A- surgery
-type B- meds
superficial venous thrombophlebitis
-partial or complete occlusion of vein and inflammatory changes
-induration, red, tender
-usually at site of recent IV -> Staph
-spontaneous or site of varicose vein
-CAN BE CAUSED BY SYSTEMIC HYPERCOAGULOPATHY IN ABDOMINAL CANCER
-tx- heat and NSAIDS, antibiotics for infection
chronic venous insufficiency
-low of wall tension -> stasis -> assoc with DVT, leg injury, varicose veins
-hemosiderian deposits -> dark skin
-pitting edema
-itching
-dull pain
-ulcers -> medial malleolous
-arterial insufficiency- lateral malleolous
-shiny, thin, atrophic
-tx- elevation, movement, compression
-surgery- ligation or stripping
SVC obstruction
-worse with bending over and laying down
-CT for dx
DVT
-virchows triad- stasis, hypercoagulability, vascular injury
-duplex US- def dx?
-D-dimer
-suspicious -> CTA and VQ scan
-compression devices for bedridden pts
-heparin
-novel anticoagulants
acute mesenteric vein occlusion
-more uncommon than arterial occlusive
-evidence of hypercoagulable state
-pain after eating
-clotted off part of portal circulation
-Risk Factors:
-Paroxsymal nocturnal hemoglobinuria, Protein C, Protein S, Antithrombin deficiencies or JAK2 mutation
-Thrombolysis is mainstay therapy
-Aggressive long-term anticoagulation
jones criteria
MAJOR
-carditis
-subcutaneous nodules
-erythema marginatum
-chorea
-polyarthritis (monoarthritis for high risk)
MINOR
-fever
-polyarthralgia (monoarthralgia for high risk)
-prolonged PR interval (1st degree heart block)
-ESR > 60 (30 for high risk), CRP >3
-2 MAJOR or 1 MAJOR 2 MINOR
endocarditis organisms (including non infectious)
-ACUTE- septic
-strep pneumoniae
-strep pyogenes
-staph aureus
-neisseria gonorrhea
-SUBACUTE-
-strep bovis- colon cancer
-entercoccus- GI/GU surgery
-staph epidermis- prosthetic valve
-candida albicans- IV drugs
-strep viridans- dental
-libman-sacks endocarditis- lupus- granulomatis -> mitral or aortic
-marantic endocarditis- metastatic
duke criteria
-2 major, 1 major with 3 minor, or 5 minor
-possible dx- 1 major with 1 minor or 3 minor
-MAJOR
-2 + blood cultures
-TTE echo- vegetations, abscess
-auscultation of new regurgitation
-MINOR
-heart condition or IV drug use
-fever
-vascular- jane way, emboli, septic pulmonary infarct, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage
-immune- osler, glomerulonephritis, roth, rheumatoid factor
-1 + blood culture or serologic evidence
endocarditis dx and tx
-dx- TEE
-tx-
-2 broad spectrum IV antibiotics -> until infectious cause identified
-SURGERY INDICATIONS:
-prosthetic valve
-HF
-pts refractory to medical therapy
-abscess formation
-conduction disturbance
myocarditis
-primary- viral
-secondary- toxin, meds, drugs, chemo, radiation, inflammatory ds
-HF/shock symptoms
-pericardial friction rub
-dx- echo, MRI, bx
-tx-
-aggressive support if shock
-HF symptoms: ACE, beta blocker
-treat underlying cause
acute pericarditis
-< 2 weeks
-can lead to effusion
-dx- EKG with ST elevations, sharp pain worse while supine, auscultation
-kussmaul sign- increase JVD on inspiration
-echo
-CT or MRI if neoplasm
-tx-
-less activity
-NSAIDS
-colchicine
-dresslers- ASA + colchicine
-uremia- dialysis
acute pericarditis causes
-autoimmune- lupus, RA
-uremia- dialysis
-viral illness
-lymes
-dresslers syndrome
-rheumatic fever
-cardiac procedures
-hemorrhage
-constrictive- radiation, tb
pericardial effusion/tamponade
-tamponde- >15mmHg -> RV collapse
-JVD- collapse of IVC, SVC, RV
-beck triad- muffled heart sounds, hypotension, JVD
-tachycardia
-pulsus paradoxus- decrease BP >10 during inhalation
-dx- EKG (low voltage and electrical alternans)
-US/echo- fluid, RV collaspe
-tx
-no hemodynamic compromise -> monitor (echo) and volume expansion -> bolus
-procedural- percutaneous pericardiocentesis (tap)
-surgical: trauma, purulent, pts with coagulopathy or need for bx
-surgical with window- trauma with hole, chronic effusions, pts who decompensate
PSVT, AF, A FLUTTER
-PSVT: MC AV node reentry
-atrial, multifocal, junctional
-caffeine + alc
-ischemic heart ds
-post MI
-bear down -> adenosine or amiodarone (wide) -> cardioversion if unstable
-prevent with beta blockers and CCB
-AFIB:
-alc + withdrawl
-ischemic heart ds
-mitral stenosis
-cardiomyopathy
-AFLUTTER:
-COPD*
-cardiomyopathy
-atrial septal defect
-same tx as afib
-Ablation can be done for all
afib tx
-<48 hrs -> synchronized cardioversion
->48hrs -> anticoagulation + rate control for 3 weeks
-beta blockers, CCB, digoxin
-TEE- high risk
-ablation
-CHADSVASC:
-CHF
-Age 65-75 (1 point), >75 (2 points)
-DM
-prior stroke- 2 points
-vascular disease- CAD, PAD
-HTN
-female- +1
-0- ASA, none
-1- ASA or full anticoagulation
->2- full anticoagulation
things that increase and decrease INR
Decreasing INR:
-Leafy green vegetables: spinach, broccoli, brussels sprouts
-Phenytoin, phenobarbitol
-St. Jonhs wart- OTC
-Increasing INR:
-Alcohol
-Antibiotics: quinolones, amoxicillin, metronidazole
-Steroids
-Amiodarone
-if INR Is too high -> risk bleeding event
HASBLED
-HTN (uncontrolled)
-abnormal liver or renal
-stroke
-bleeding (past major event) (labile INR)
-elderly
-drugs or alcohol
ventricular tachy tx
-pulseless tx- ACLS
-stable sustained- synchronized cardioversion + antiarrhythmic
-unstable sustained- synchronized cardioversion
-nonsustained-beta blocker therapy
-treating underlying cause:
-myocardial ischemia- catheter
-cardiomyopathy- echo
-electrolytes
-medication
-torsades- magnesium -> synchronized cardioversion if there is pulse
ventricular fib tx
-ischemic heart disease
-defib
-CPR
-ACLS- defib -> epi -> defib -> epi
-amiodarone IV- 24 - 28 hrs following conversion
-ischemic eval
-AICD placement
sick sinus syndrome, BBB, AV block
-sick sinus syndrome
-myocardial scarring
-d/c med if its causing it
-tx- pacemaker
-BBB- 3 small boxes .12
-tx underlying cause
-RBBB- right pressure
-LBBB- myocardial scarring/ischemia- LAD*
-tx- r/o underlying disease
-AV block:
-age
-coronary artery disease MI
-secondary diseases
HTN: goals and tx, dx
-2ndary- renal, coarction of aorta, endocrine
-goal- <140/90 -> DM <130/80
-diuretics
-renal comorbid- ACE or ARB
-CAD- beta blocker + ACE or ARB
-HF- beta blocker, ACE or ARB, diuretic
-dx- EKG (LV hypertrophy), labs, urine
HTN meds
-ACE (pril)- vasodilation, hyperkalemia, cough, angioedema, renal
-ARB (sartan)- vasodilation, decrease preload/after load
-beta blocker
-CCB- peripheral edema, lightheadedness
-DHP- vasodilate - amlodipine
-nonDHP- contraction - verapamil
-alpha blockers- vasodilate -> orthostatic hypotension*
-diuretics- hypokalemia, hypotension
HTN urgency vs emergency
-urgency- >180/>120 without end organ damage
-gradual decrease in MAP -> beta blocker, CCB, ACE
-emergency- >220/>120 with end organ damage
-papilledema, unstable angina, MI, CHF…
-usually caused by 2ndary things or noncompliance
-ASAP tx- reduce MAP by 25% in 1-2 hours -> can lead to ischemic CVA
-IV: esmolol, labetalol, nitroglycerine
hypotension/orthostatic
-<90/<60
-vasodilation? -> alpha blockers
-cough to increase preload
-orthostatic hypo- decrease 20/10
-med tx- fludrocortisone or midodrine
cardiogenic shock
-systolic BP <90 with urine output <20ml/hr
-caused by acute MI** and other cardiac emergency events
-tx: ABCs (2 large bore needles, central line arterial line) -> vasopressors (dopamine, norepinephrine)
-balloon pump, ecmo, underlying cause:
-Acute MI- aspirin, heparin, nitrates
-coronary angiogram
-bypass, stent
-cardiac tamponade- pericardiocentesis
-arrythmia- ACLC
heart failure
-high output- compensation -> anemia, hemochromatosis, pagets, pregnancy, thyrotoxicosis, AV fistula
-MC- low output -> cardiomyopathy, valve stenosis
-systolic- MC CAD - EF < 45%
-diastolic- MC left hypertrophy from chronic HTN -> restrictive cardiomyopathy
-diastolic preserves LVEF- impaired filling
-left vs right
CHF dx and classification
-BNP
-imaging- cardiomegaly, B lines, effusions, echo*, stress test (ischemia), angiogram -> EKG not really
-classify based on symps and tx based on EF
-Class 1 (normal), 2 (slight limit), 3 (marked limit), 4 (symp at rest)
HF tx
-diuretics -> loop, thiazide, aldosterone antagonist (add on)
-ACE or ARB if ACE contraindicated*
-beta blockers
-digoxin- not first line
-sacubitril vasartan (encresto) - neprilysin inhibitor -> increase BNP - for systolic HF
-ICDs- <35% EF
-LVADs- bridge to transplant
dilated and restrictive cardiomyopathy
-MC- dilated: systolic
-HF symptoms
-alcohol
-CAD*
-S3 and S4
-sudden death
-restrictive (diastolic):
-collagen -> less relaxation -> bad filling
-right HF symptoms
-EKG low amplitude
-endomyocardial bx
-tx underlying cause
-HF tx
-defib- AICD
-cardiac transplant
hypertrophic cardiomyopathy
-systolic ejection murmur at lower left sternal border -> increase with valsalva and standing -> decrease with squatting and laying down
-increase carotid pulse
-echo- DX of choice
-tx- avoid exercise
-beta blockers or CCB
-septal myomectomy
-alcohol septal ablation
-aicd
CAD risks
-tobacco, HTN, DM
-metabolic syndrome:
-3 of more of the following!!!:
-Triglycerides > 150 mg/dL
-HDL < 40 mg/dL men, <50 mg/dL women
-Fasting blood glucose > 110mg/dL
-Abdominal obesity
-HTN
-Family history of coronary artery disease
-Obesity
hyperlipidemia
-Mixed hyperlipidemia
-Hypercholesterolemia- genetic
-Hypertriglyceridemia- pancreatitis
-asymptomatic
-xanthoma
other hyperlipidemia tx
-PSK9 inibitors: mabs ->
-lower LDL
-familial hypercholesterolemia and CAD
-headache, diarrhea, URI
-niaotinic acid:
-lower triglycerides and increase HDL
-flushing, itch, N/V, skin on fire
-fenofibrates:
-gemfibrozil
-lowers triglycerides
-GI upset
-bile acid binding resins:
-cholestyramine
-lowers LDL -> not triglyceride
-last resort drug
-GI side effect
angina pectoris
-low perfusion of myocardium
-MC- coronary artery disease
-dissection, vasospasm (cocaine + prinzmetals)
-typical (men) vs atypical (women, old, DM, immunocompromised):
-jaw, back of right shoulder
-radiates to right or both arms and back
-stable vs unstable:
-stable:
-<3 mins
-predictable
-relieved with sublingual nitroglycerin
-unstable:
-grouped with acute coronary syndrome
-indicated stenosis that has enlarged
-less response to nitroglycerin
-1 or more:
-angina at rest
-new onset of angina
-increasing pain in stable pts
prinzmetal angina
-MC in females
-75% with atherosclerotic lesion
-early morning
-exercise capacity reserved
-ST elevations with neg troponins
-tx- CCB, nitro -> just a vasospasm
-cocaine MI- ST elevation and + troponin => CCB, ASA and heparin until CAD is ruled out
CAD dx
-EKG- normal in 25% -> ST depressions (nonspecific)
-stress test- at least 2 leads ST depression -> + test
-stress test can be done with SPECT, nuclear, pharm use if unstable
-echo- wall abnormalities, EF
-cardiac catheterization (angiography) -> DEF DX (high timi/grace score)
CAD tx: meds and revascularization
-1. 1st line for stable angina- beta blocker (increase O2)-> DO NOT USE FOR PRINZMETAL
-2. 2nd line- CCB non-DHP -> FIRST LINE FOR PRINZMETAL
-3. nitrates-
-angina persisting with monotherapy
-nitroglycerin- episodic
-isosorbide and hydralazine- long acting
-SE- flushing, orthostatic hypotension
-cant gives to pts with ED
-balloon angioplasty
-drug eluding stents -> 12 months need aspirin and clopidogrel (antiplatelet)
-bare metal stents -> 1 month of dual antiplatelet therapy (DAPT)
-bypass (CABG):
-triple vessel ds with >70% stenosis of each vessel
-left main coronary disease > 50% stenosis
-YOU CAN NEVER PUT A STENT IN LEFT MAIN CORONARY unless the other option is death
acute coronary syndrome- sx and dx
-1. unstable angina- depressions and - troponins
-2. NSTEMI -> partial thickness necrosis - depressions and + troponins
-3. STEMI- full thickness necrosis - 2 elevations and + troponins
-MC cause of MI- thrombosis
-atypical chest pain
-hyper or hypotension
-dx:
-EKG
-3 sets of enzymes every 6 hours
MI tx
-Morphine- pain
-Oxygen
-Nitroglycerine (NTG)
-Aspirin -> use adenosine diphosphate inhibitor (antiplatelet) if allergic (clopidogrel, ticlopidine, prasugrel) -> caution if CABG in 7 days
-Beta blocker
-Statins- reduce further events (CAD)
-Unfractionated heparin or low molecular weight heparin (LMWH)
-unfractionated- less thrombus and fibrin
-LMWH- inactive factor Xa
ASAP REPERFUSION…
MI reperfusion
-PCI > thrombolysis
-door to cath = 90 mins
-DES (12 months) or BMS (1 month)
-thrombolysis:
-door to thrombolytic = 30 mins
-TPA- ateplase, reteplase, teneceplase
-absolute CI: Previous hemorrhagic CVA, CVA within the last year, Intracranial neoplasm, Active internal bleeding, Suspected aortic dissection, Suspected aortic dissection, Trauma or major surgery < 2 weeks, Active internal bleeding
-relative CI- trauma within 2-4 weeks, surgery within 3 weeks, HTN, internal bleeding, pregnant, PUD
unstable angina tx
-TIMI scale – Thrombolysis In Myocardial Infarction
-GRACE – Global Registry of Acute Coronary Events
-Low score = conservative treatment
-Antiplatelet therapy
-Anticoagulation therapy
-High score = invasive treatment -> Cardiac angiogram/angioplasty
