M2 Cardiology Key Facts - Week 3 Flashcards
Shock - Definition
Low tissue perfusion leads to cellular hypoxia and energy defect - usually with hypotension - compensation can delay hypotension onset.
Two Major Class of Shock (3 Types Each)
Low CO Shock - Cardiogenic, Obstructive, Hypovolemic
Disruptive - Low Resistance Shock - Sepsis, Neurogenesis, Anaphalaxis
Two Major Compensation Mechanisms for low CO Shock
Baroreceptors - Detect low BP - Decrease signal, decreases their parasymp stimulation + symp inhibition - Symp. Dominates - Increases CO and Vasoconstriction
RAAS - Low Kidney Perfusion - Activates Renin - AI - AII - Aldosterone - Vasoconstriction + Fluid Retention
Responses to Low CO Shock (Universal) - 3
1) Increased Vasoconstriction - Cold/Clammy
2) Metabolic Acidosis
3) Tachypnea
Cardiogenic Shock - Causes (4) + Major Signs/Symptoms (3)
Causes
1) #1 = Acute MI > 40% of Ventricle
2) Cardiomyopathy
3) Valve Disease
4) CHF
Major Symptoms - Pump Failure = Pulm. Overload
1) Pulm. Congestion with Rales/Wheezes + S3 and maybe S4
2) If RCA MI - Mitral Regurgitation
3) Cold/Clammy
4) JVD
Hypovolemic Shock - Causes (3) + Major Signs/Symptoms (3)
Causes - Loss of Volume/Plasma
1) Trauma/Surgery
2) GI Fluid Loss - Choleara
3) Plasma Loss via Burn Injury
Major Symptoms - Decreased Preload
1) Weak Thready Pulse + Narrow Pulse Pressure + Tachycardia
2) Weak/Cold/Clammy
Obstructive Shock - Causes (2) + Major Signs/Symptoms (3)
Causes - Restricted Venous Return
1) Cardiac Tamponade
2) Pneumothorax
Major Symptoms - Decreased Preload
Tamponade (4)
Becks Triad = Hypotension + Muffled Heart Sounds + JVD
Pneumothorax (2)
Trachea deviated to opposite side of pneumothorax + JVD + Absent breathe sounds
Hypovolemic vs. Cardiogenic Shock
Both Low CO - Hypovolemia has no lung/JVD Signs
Septic vs. Hypovolemic Shock
Septic has normal skin color because there is no vasoconstriction
Neurogenic Shock vs. Anaphylactic Shock
Neurogenic - Loss of Symp. Tone after SCI
Anaphylactic - Histime and Prsotagladin Vasodilation
Septic Shock - Causes (2) + Major Signs/Symptoms (3)
Causes Bacteria signals (LPS etc.) induce massive vasodilation via NO with inability for CO to compensate
Major Symptoms
1) Hypotension less responsive to vasopressors (NE is best)
2) Reduced peripheral oxygen extraction
3) Not Cold/Clammy
Hypovolemic Shock vs. Obstructive
Obstructive with JVD vs. No JVD in Hypovolemic
Infectious Endocarditis - Common Causes (3)
1) 80% = Staph or Strep
2) Strep Viridans = Most Common Sub-Acute Cause
3) Staph Aureus = Most Common Acute Cause - IV Drug Users + Tricuspid
S. Aureus Endocarditis - 3 Keys
1) Acute Onset
2) IV Drug User
3) Tricuspid Involvement
Common Valves Infected by Endocarditis (3)
All Regurgitationn Murmurs
1) Aortic - 60%
2) Mitral - 35%
3) Tricuspid (S. Aureus IV Drug User)
S. Viridans Endocarditis - 2 Keys
1) Sub-Acute (Most Common)
2) Requires predisposed valve (e.g. via Rheumatic Fever or Artificial Valve)
Major Endocarditis Findings (6)
1) New Regurgitation Murmur
2) Unremitting Fever
3) Nail Bed Splinter
4) Roth Spot (Eye)
5) Janeway Lesions - Painless - Palm/Sole
6) Osler Nodes - Painful Fingertip Nodules
Olser Nodes vs. Janeway Lesions
Painful Fingertip Nodules vs. Painless on Palm
Peripheral Arterial Occlusive Disease - Basics and Comparison to CAD
Intermittent Claudication - Stable Angina
Rest Pain - Unstable Angina
Ischemic Limb - NSTEMI/STEMI
Peripheral Arterial Occlusive Disease - Most Common Causes (2) + Most Common Symptom (1)
Causes - Atherosclerosis + Emboli
Finding - Poor Healing Wounds (Low O2 Perfusion
Key for Intermittent Claudication (3) vs. Spinal Stenosis (3)
IC = Reproducible + No Discomfort when standing + relieved by rest
Spinal Stenosis - Variable + Discomfort with standing + Relieved when flexing the spine via sitting
Intermittent Claudication Pain + Associated Vessel (2)
Calf Pain - Superficial Femoral = Most Common
Thigh + Buttock with Erectile Dysfunction - Aortoiliac Area
Acute Limb Ischemia - 5 P’s
1) Pain
2) Pulseless
3) Paresthesias
4) Paralysis
5) Poiklytothermia (Feels Cold)
Most Common Cause = Emboli
Most Common Location = Femoral Artery Bifurcation
Major Symptoms of Claudication (6)
1) Bruits (Renal, Femoral, Illiac
2) Decreased Distal Pulse
3) Decreased ABI (Ankle-Brachial Index) - Normal > 1 because of gravity
4) Atrophy of Calf Muscle
5) Thin Shinny Skin
6) Depedent Rubor - Redness that goes away on knee lifting
3 Major Class of Heart Failure
Systolic - Reduced EF - Increased Afterload or Decreased Contractility
Diastolic - Preserve EF - Decreased Preload /Impaired Filling
Right Heart Failure
Systolic Heart Failure Causes (5)
Reduced Contractility
1) MI/Ischemia
2) Chronic Valve Overload Valve Disease (Regurgitation) - Aortic or Mitral
3) Dilated Cardiomyopathy
Increased Afterload
Chronic HTN
Aortic Stenosis
Diastolic Heart Failure Causes (4)
Reduced Filling
1) LVH - Stiff LV
2) Restrictive Cardiomyopathy
3) Cardiac Tamponade
4) Pericardial Constriction
Right Heart Failure Causes (4)
1 = Left HF
Isolated Right HF - Pulm. Issue COPD Chronic Chroncitis Smoking Primary Pulm. HTN (PE + Right MI)
Compensation for CHF - Low Perfusion Pressure Response (4)
1) Increase RAAS - Volume Overload + Cardiac Remodeling
2) Increase Contracility (Symp. via Baroreceptors)
3) Increase ADH
All good at first but make it worse later - Volume Overload + high SVR
Symptoms of Left Heart Failure (3)
1) Dyspnea (Pulm. Congestion)
2) Orthopnea/PND
3) Fatigue (Low Perfusion
Symptoms of Right Heart Failure (2)
1) Peripherial Edema
2) Right Upper Quadrant Pain
Exam Findings in Left Heart Failure (5)
1) Symp Stim - Diaphoresis + Tachycardia + Tachypnea
2) Pulmonary Rales
3) S3 Sound - Abnormal Filling of a Dilated Chamber (Systolic Failure)
4) S4 Sound - Forceful contraction against a stiff LV (Diastolic Failure)
5) Elevated BNP Peptide
Exam Findings In Right Heart Failure (6)
1) Peripherial Edema
2) Ascities
3) JVD
4) Hepatomegaly
5) Palpable Parasternal RV Heave
6) Right S3/4 with Tricuspid Regurgitation
Key Pearl - Dilated (2) vs. Hypertrophic (3) vs. Restrictive (3) Cardiomyopathy
Dilated
1) Problem with Preload
2) Linked with Mitral/Tricuspid Regurgitation
Hypertrophic
1) Problem with Afterload
2) Key pathology = disarray of myofibers on histopathology
3) Can cause functional aortic stenosis + LV septum enlargement
Restrictive
1) Problem with Expansion
2) ECG with diminished QRS = Key Finding
3) FIbrosis of Endocardium
Pathophysiology - Dilated (3) vs. Hypertrophic (2) vs. Restrictive (2) Cardiomyopathy
Dilated
1) Systolic Dysfunction of ventricles bilateraly leading to CHF
2) Eccentric - Myocytes added in series
3) Loss of Ejection Fraction - Systolic Failure
Hypertrophic
1) Diastolic Dysfunction - Impaired relaxation leads to low filling volume due to high compliance
2) Concentric - Myocytes added in parallel
Restrictive
1) Stiff LV with impaired relaxation and filling
2) Preserved Ejection Fraction - Diastolic Failure
Common Causes - Dilated (5) vs. Hypertrophic (2) vs. Restrictive (3) Cardiomyopathy
Dilated
1) Alcohol
2) Coxsackie A + B
3) Cocaine
4) Pregnancy
5) Genetics (Beri-Beri)
Hypertrophic
1) Genetics
2) High Afterload (HTN/Aortic Stenosis
Restrictive
1) Amyloidosis
2) Hematochromatosis
3) Scleroderma
Major Symptoms - Dilated (4) vs. Hypertrophic (3) vs. Restrictive (2) Cardiomyopathy
Dilated
1) Left HF - Dyspnea + Orthopnea + PND
Hypertrophic
1) Like Angina - Dyspnea on Exertion + Syncope
Restrictive
1) Dyspnea on Exertion + Fatigue
Major Exam Findings - Dilated (4) vs. Hypertrophic (3) vs. Restrictive (2) Cardiomyopathy
Dilated
1) Pulmonary Crackles/Weeze
2) S3/4
3) Right Heart Signs - JVD + Peripheral Edema
Hypertrophic
1) S4 + Systolic Murmur (if Aortic Stenosis Present)
2) Possibly Mitral Regurgitation
Restrictive
1) Mostly Right Side Signs - JVD + Hepatomegaly
3 Major Disorders Linked to Congenital Heart Defects
VSD - Fetal Alcohol Syndrome
ASD - Osium Primum = Down’s Syndrome
Coartaction of the Aorta - Turner’s Syndrome
ASD - Key Associations (3)
1) Murmur - Fixed Split S2 - LA/RA Balance Pressures
2) Primum Associated with Downs + Valve Disease
3) Secondum = More Common
VSD - Key Associations (3)
1) Murmur - LLSB = Holosystolic
2) Associated with Fetal Alcohol Syndrome
3) Early VSD Closing = Stem Cells
Tetraology of Fallot - Key Associations (4)
1) Cynosis development based on degree of pulmonic stenosis
2) - 4 Components - VSD + Overriding Aorta + Pulmonic Stenosis + RV Hypertrophy
3) Boot Shaped Heart on CXR
4) Mid-pitched coarse systolic murmur LUSB Radiating to the Chest
Small Slit Left Heart - Syndrome + Pathology
Hypoplastic Left Heart Syndrome
PFO Shunts the blood back and PDA keeps you alive (basically blood goes from pulm circulation back to RA from LA and then into circulation via PDA
PDA - Key Features
1) Continuous Machine Like Murmur
2) Increases Risk of Infection
3) Closed by Prostaglandin Drop + High O2 at Birth - Kept open by prostaglandin inhibitor indomethacin
Bicuspid Aortic Valve - Associated Predispositions (2) + Associated Pathology (5)
Syndromes that Predispose to Bicuspid
Marfan
Ehler-Danlos
Assocaited Pathology Aortic Regurgitation Aortic Stenosis Aortic Endocarditis AAA Aortic Dissection
Aortic Dissection - Risk Factors (7)
1) Smoking
2) Hylaine Atherosclerosis of Vaso Vasorum
3) Pregnancy
4) Cocaine
5) Chronic HTN
6) Marfan
7) Ehlers-Danlos
Aortic Dissection - Classifications (2) + Second Most Common Site
1) - Sanford A - Ascending Aorta Involved
2) - Sanford B - No Ascending Aorta Involved
Second Most Common Site - Distal to Left-Subclavain - Trauma = Ligamentum Arteriosus Tear
Aortic Dissection - Exam Findings (2) + Secondary Pathology (3)
Findings
1) HTN + Murmur/Aortic Regurgitation
2) Perfusion Deficit
Secondary Pathology
1) Cardiac Tamponade
2) MI
3) Renal Artery Occlusion
Thoracic Aortic Aneurysm - Congenital Causes (3) + Acquired Causes (2)
Congenital
1) Marfan
2) Ehlers-Danlos
3) Bicuspid Aortic Valve
Acquired
1) Smoking
2) Tertiary Syphilis (Endartaritis)
3)
Thoracic Aortic Aneurysm - Major Complications (3)
1) Dilated Root
2) Aortic Regurgitation
3) Mediastinum Compress
Abdominal Aortic Aneurysm Rupture Symptoms
Beck’s Triad
1) Flank Pain
2) Hypotension
3) Pulsatile Mass (Still)
4) Shock - More likely in the setting of acute abdominal pain vs. sepsis
Acute Pericarditis - Causes (7)
1) Cocksackie
2) Enterovirus
3) MI (Acute + Autoimmune)
4) Trauma
5) TB
6) Procainamide
7) Hydralazine
Acute Pericarditis - Signs/Symptoms (3)
1) Pericardial Pain - Worse on inspiration - better leaning forward/expiration
2) Pericardial Friction Rub
3) ECG Changes - Diffuse ST Elevation
Acute Pericardial Effusion - Causes (3)
Trauma, Acute MI with Rupture, Aortic Dissection
Acute Pericardial Effusion - Findings (6)
1) Soft Heart Sounds
2) Reduced Intensity of Pericardial Rub
3) ECG - Electric Alterans - QRS with alternating amplitudes
4) Dysphagia
5) Dyspnia
6) Hoarseness
Cardiac Tamponade - Signs + Symptoms (6)
Beck’s Triad
1) Hypotension
2) Muffled Heart Sounds
3) Elevated JVP
4) Pulsus Paradoxus
5) Pulm. Rales
6) Less y Ascent on JVP Tracing
Constrictive Pericarditis - Signs + Symptoms (5)
1) Pericardial Knock
2) Reduced CO (Hypotension)
3) Right HF Mimic - Hepatosplenomegaly + Ascities much worse than expected based on peripherial edema
4) Kausmall’s Sign - Elevated JVP on Inspirtation (normall not the case)
5) Exaggerated y wave on JVP
