Medicine 2 Flashcards
An 84 yr old comes with sxs of CHF. Has hx of MI a year ago. BP is 144/82 PR- 98, cardiac catheterization would show
- cardiac index
- systemic vascular resistance
- LVEDV
The pt has CHF due to LV systolic dysfunction (MI hx-ischemic CMP)
- cardiac index-⬇️
- systemic vascular resistance -⬆️
- LVEDV-⬆️
- as the cardiac contractility decreases the SVR is increased to maintain CO.
A 65 yr old woman comes with chest pain. Yesterday she was told she has early stage colon cancer. ECG reveals sinus tachycardia with deep symmetric T wave inversion in leads V2-V4. Coronary angiography shows no obstructive coronary aa disease. The most likely dx is?
Stress induced (takotsubo) CMP, AKA broken heart 💔 syndrome
- usually in postmenopausal woman; physical or emotional stress; microvascular spasm with consequent ischemia n impaired contraction. The LV dysfunction is characteristically segmental- mid n apical hypokinesis n basilar hyperkinesis (balloon shape) on echo resembling an octopus trap (takotsubo in Japanese)
- Rx is supportive, resolves on its own within several weeks
Pharmacologic stress testing in angina - drugs used? Mechanism?
Adinosine, dipyramidol
- adinosine causes coronary vasodilation. There is a several fold augmentation of blood flow in non-obstructed coronary aas, blood flow in stenosed aa is also increased but to a much lesser extent➡️detectable reduction in radioactive isotope uptake in areas supplied by stenotic aas.(ischemic defect on myocardial perfusion imaging
A pt suddenly develops chest pain , diaphoresis, dizziness n becomes unresponsive shortly afterwards. His coworkers perform CPR n regains consciousness. In the ER, ECG shows normal sinus rhythm, ST elevation in leads V1-3. Mechanism of his syncopal episode?
Reentrant ventricular arrhythmia.
- ventricular arrhythmias r common in the immediate post MI period
- V. Fib is the commonest underlying arrhythmia for SCD post MI
- onset of MI- arrhythmia occurring within 10min are called immediate/phase 1 ventricular arrhythmias. -reentry is the mechanism.
- 10-60min- delayed or phase 1b- abnormal automaticity is the mechanism
A man is diagnosed to have a paroxysmal atrial fibrillation( with no structural abnormalities) and started on a drug therapy. 2 weeks later, on a treadmill test, heart rate is increased from 75 to 165 and QRS duration increases from 0.09 to 0.13
Which medications are most likely responsible?
Class lC antiarrhythmics eg flacainide, propafenone.
- occasionally used in Afib with structurally normal hearts.
- they have the slowest rate of binding n dissociation from the sodium channel receptor. Under normal conditions these drugs do not cause any significant QRS or QT prolongation. But in faster heart rate the drugs have less time to dissociate ➡️higher number of blocked channels➡️progressive decrease in conduction n widening of QRS. This is known as use dependence.
Atrial fibrillation in Wolff-Parkinson-White syndrome is treated with?
Drugs contraindicated?
- if unstable- cardioversion
Stable- procainamide or ibutilide.
-AV blocking agents such as b blockers, CCB, digoxin, adinosine r contraindicated as they may increase conduction through the accessory pathway
A 64 yr old man presents with sxs n signs of right heart failure. He had mitral valve repair surgery 12 yrs ago. A mid diastolic sound is heard on auscultation. X-ray- normal heart size, spotty calcification along the left heart border. Echocardiography- ejection fraction of 65%, mild mitral regurgitation. Dx?
Constructive pericarditis
- prior cardiac surgery, irradiation therapy, TB, malignancy, uremia are common antecedents.
- rt heart failure, mid diastolic sound (pericardial knock), calcification on CXR r characteristic.
A 29 yr old had epistaxis 2 weeks back which required nasal packing. His BP was 170/110 and today, 180/112. He has occasional headache and fatigue. No other sxs or abnormal physical findings. ECG shows normal sinus rhythm, high voltage QRS complex, downsloping ST segment depression , T wave inversion in leads V5 n V6
Most likely Dx is?
Aortic coarctation
The ECG finding is consistent with LV hypertrophy which is not expected with essential hypertension under the age of 40. A cause of secondary hypertension should b sought.
- usually present with asymptomatic htn but can also have epistaxis, headache, lower extremity claudication
A relatively specific ECG finding for digitalis toxicity is?
Atrial tachycardia with AV block.
Due to increased ectopy n increased vagal tone
Sensitive Vs specific p/e n laboratory findings in CHF
Sensitive- BNP levels
Specific- clinical signs eg. Bilateral lung crackles, S3, ⬆️JVP…- their absence shouldn’t b used to rule out CHF
A 72 yr old man comes with chest pain for the past 6months that is brought on by exercise, lasts 2-3min n subsides with rest. He has HTN, hyperlipidemia, smoking hx. Echo shows LA dilation, mild concentric LV hypertrophy, calcified aortic valve with restricted opening, with estimated valve area of 1.6cm2
The most likely cause of his sxs is?
Coronary aa disease (CAD)
- AS is a common cause of angina and also syncope n HF. However, sxs do not typically occur until the stenosis becomes severe, usually <1cm2 valve area
CHF, concentric LV hypertrophy with preserved injection fraction in the absence of hypertension hx, proteinuria, increased bleeding tendency…
Most likely cause is?
Amyloidosis
Carotid aa stenosis Mx
-what kind of intervention? Indications?
Carotid endarterectomy ( preferred over carotid aa stenting)
- indications
🚩symptomatic-70-99%stenosis
🚩asymptomatic-80-99% - as some evidences suggest. <80% are medically treated.
- all pts should be medically treated.
A pt with inferior wall MI has holosystolic murmur at the apex.
What happens to the left ventricular filling pressure?
Increases!
- apical holosystolic murmur is indicative of MR which can develop as a complication of MI➡️increased LVEDV
A 25 yr old woman comes with transient vision loss in the right eye. Past medical hx is unremarkable. BP-164/103, PR- 77 bruit below the right mandibular angle. Serum Cr-0.9, K-3.5
Plasma renin activity- high, plasma aldosterone concentration/plasma renin activity ratio-10
-most likely Dx?
- the best next step in the mx is?
-fibromuscular dysplasia- abnormal cell development in the arterial wall➡️vessel stenosis
Her Transient vision loss(amaurosis fugax), young age(usually 15-50), carotid bruit are suggestive.
- commonly involved vessels- renal, carotid, vertebral.
-renal aa involvement ➡️RAAS activation➡️hypertension. Aldosterone/renin~10 (<20) indicates secondary hyperaldoseronism.
-Dx- CT ANGIOGRAPHY of the abdomen, or duplex U/S
