MTB and important from FA 4 Flashcards
mcc of CHF
hypertension
All diagnosis of dyspnea except CHF will lack
orthopnea/ paroxysmal nocturnal dyspnea
S3 gallop
the best initial and the most accurate test for Ejection fraction
best initial: Transthoracic echo
most accurate: Multiple-gated acquisition scan (MUGA) (nuclear ventriculography) –> doxorubicin
Transesophangeal as a test (TEE) - accurate at / role in CHF
the most accurate in evaluating heart valve function and diameter
not necessary for evaluating CHF
test used to determine etiology of CHF - endomycoardial biopsy - etiology of CHF
- rarely done
- exclude infiltrative disease such as sarcoid or amyloid when other sites for biopsy inconclusive
- most accurate test for some infections
systolic dysfunction - medication
- ACEi (or receptor blockers)
- Beta blockers
- Spironolactone
- Diuretics
- Digoxin
- Nitrates
- Hydralazine
- Implantable defibralator
- Transplantation
systolic dysfunction - ACEi (or receptor blockers)
ALL patients with systolic dysfunction at any stage of the disease
beneficial effects with ANY drug in the class
systolic dysfunction - beta blockers - which drugs exactly
- Metoprolol (β1)
- Bisoprolol (β2)
- Carvedilol (non-specific beta blocker with also α1 receptor blocking activity)
systolic dysfunction - spironolactone efective?
in NYHA 3 + 4
Devices for CHF treatment
2 other treatments taht are associated with mortality benefit in CHF:
- Implantable defibrillator
- Biventricular pacemaker
CHF - Implantable defibrillator
for those with ischemic cardiomyopathy and EF below 35
CHF - Biventricular pacemaker
- dialted cardiomyopathy and EF less than 35 and a wide QRS above 120 mls who have persistent symptoms
- resychronizes the heart when there is a conduction defect
systolic HF - transplantation
when maximal medical therapy and possible the biventricular pacemaker fail to control symptoms of CHF, then the only alternative is this
systolic CHF - CCB
nor benefits. some can actually raise mortality
Diastolic dysfunction - treatment
- the management here is not as clear as in the systolic
- b-blockers have clear benefits
- digoxin and spironolactone has no benefit and should not used
- diuretics to control symptoms
- unclear benefit for ACEi and ARBs and hydralazine
pulm edema - treatment (preload reduction)
- O2
- Loop diuretics (such as furosemide or bumetanide)
- Morphine
- Nitrates
- Nesiritide can be used as a part of therapy, but it is not clear that it works better than standard agents (and no proven mortality benefit)
pulm edema - treatment (positive inotropic agents)
- Dobutamine when they don’t respond to therapy acutely with preload reduction
- amrinone and milrinone (phosphodiesterase inhibitors) that preform the same role
pulm edema - afterload reduction medication
in acute setting: nitropruside or IV hydralazine
regurgitant disease is most commonly caused by …
- hypertension
- ischemic heart disease
LEADS TO DILATION
valvular heart disease - best initial test (explain)
- best initial: ECHO
- Transesophageal echo is both more sensitive and more specific than transthoracic echo
valvular heart disease - catheterization
most precise measurement of valvular diameter, as well as the exact pressure gradient across the valve
stenotic valvular heart disease - treatment
- diuretics
- mitral stenosis is dilated with a balloon, aortic needs surgical removal
regurgitant valvular heart disease - treatment
- diuretics
- vasodilator therapy with (ACEi, nifedipine, hydralazine)
- surgical replacement before heart dilates
assessment of ventricular size is based on
- the end systolic diameter
2. EF
MS - critical narrowing?
less than 1 cm2
MS - main indication for treatment
presence of symptoms
no much point on asymptomatic
MS - pregnancy
- pregnancy is associated with 50% increase in plasma volume which must traverse a narrow valve
- during delivery, contraction of the uterus can squeeze as much as 500 ml extra of blood into the central circulation (inducing pregnancy related cardiomyopathy
MS - presentation (beside dyspnea and CHF which is in every valvular disease)
- Dysphagia (LA presses esophagaus)
- hoarseness (LA presses laryngeal nerve
- AF
- hemoptysis
MS - EKG
- atrial rhythm disturbances (AF is very common)
2. LA hypertrophy (biphasic P wave in V1 and V1)
MS - chest x-ray
LA hypertrophy:
- straightening of the left heart border
- elevation of the left main-stem bronchus
- second bubble behind the heart
MS - treatment
- diuretics and sodium restriction when fluid overload is present in the lungs
- ballon valvuloplasty done with catheter
- valve replacement only when a catheter procdure cannot be done
- Warfarin for AF (target INR:2-3)
- Rate control of aAF (digoxin, β-blockers, diltiazem/verapamil)
aortic stenosis - presentation
- angina (mc presentation)
- syncope
- CHF (poorest prognosis with 2 year average survival)
aortic stenosis - EKG
LV hypertrophy : S in V1 + R in V5 greater than 35 millimeters
aortic stenosis - treatment
- valve replacement is the only truly effective therapy for AS
- diuretics can be used to decrease CHF, but patients do not tolerate volume depletion very well
- ballon valvuloplasty is not routinely done for AS
MR - treatment
- vasodilators
- Digoxin and diuretics
- valve replacement
MR - valve replacement
When LVESD is above 40 mm or EF drops below 60%
–> surgical valve repair or replacement
AR - physical findings (not the murmur)
- wide pulse pressure
- water-hammer (wide,dounding) pulse
- Quincke pulse (puslations in the nail)
- Hill sign (BP in legs as much as 50 above arm)
- head bobbing (de Musset sign)
AR - treatment
- vasodilators
- digoxin and diuretics (little benefit)
- Valve replacement or repair
AR - valve replacement
- EF less than 55 or LVESD greater than 55
- Repairing the valve means tightening the ends of the valve with sutures
cardiomyopathy - best initial
Echo
Dilated cardiomyopathy - treatment
- Dilated cardiomyopathy has the greatest number of medications to lower mortality (ACEi, β-blockers, spironolactone)
- diuretics and digoxin to control symptoms
- if QRS is wide (more than 120), a biventricular pacemaker (improve symptoms + survival)
- Automated implantable cardioverter/defibrillator has moratlity benefit in some patients
differences between Hypertrophic cardiomyopathy and other forms of cardiomyopathy
- S4 gallop
2. Fewer signs of Right HF
hypertrophic obstructive cardiomyopathy - diagnostic test
- Echo is the best initial (septum is 1.5 times the thickness of the posterior wall)
- Catheterization is the most accurate test to determine precise gradients of pressure across the chamber
HOCM - specific therapy
implantable defibrillators should be used in any HCOM patient with syncope
ablation of the septum should frist be tried with a catheter placing absolute alcohol in the muscle causing small infractions. If symptoms persist, sugical mymectomy removing part of the septum is the ultimate therapy.
HOCM - EKG
septal Q waves in the inferior and lateral leads are common (they are not in MI)
Restrictive cardiomyopathy - definition
it combines the worst aspects of both dilated and hypertrophic cardiomyopathy. The heart neither contracts nor relaxes normally because it is infiltrated with substances creating immobility (esp DIASTOLIC DYSFUNCTION, systolic later)
restrictive cardiomyopathy - treatment
treat the underlying cause
diuretics may relieve some of the pulm hypertension the the RHF symptoms
there is no clear therapy
mitral stenosis - (1) handgrip vs (2) amyl nitrate effects
no effects
amyl nitrate is a vasodilator –> decreases afterload
pericarditis - treatment
- treat the underling cause
- Colchicine decreases recurrences
pericardial tamponate - diangosis
EGG: electrical alterans (different heights of QRS)
Chest x-ray: enlarged shadow expands in both directions (globular heart)
Echo: RA and RV collapse
R heart catheterization: equalization of pressures in diastole
constrictive pericarditis - diagnostic tests
- the best initial test is chest x-ray that shows calcification and fibrosis
- CT and MRI are both accurate, but would not done if a chest x-ray were not done first
- Echo is often necessary to exlude RV hypertrophy or cardiomyopathy (in constrictive pericarditis the myocardium moves normally)
constrictive pericarditis - treatment
- diuretics: used 1st to decompress the filling of the heart and relieve edema and organomegaly
2, surgical removal of the pericardium
Routine screening for PAD
No since there is no mortality benefit to obtain
peripheral artery disease (PAD) - presentation
- leg pain in the calves on exertion, relieved by rest
- it can occurs when walking up or down hills
- if severe: loss of hair follicels, sweat and sebaceous glands
- the skin becomes smooth and skiny
peripheral artery disease (PAD) - treatment
- best initial treatment: aspirin, stop smoking, cilostazol (cilostazol is the single most effective medication)
- surgery is done to bypass if medical therapies fail.
aortic dissection - treatment
the most important is to control the blood pressure:
1. beta blockers
2. nitroprusside
3. surgical correction
beta blockers will decrease the shearing forces that are worsening the dissection –> must be started before nitroprusside to protect against reflex tachycardia (which will worsen shearing forces)
who must be checked (screening) aortic aneurysm and when and how (and management)
men who ever smoked above 65 with US
the worst form of heart disease in pregnancy is …
peripartum cardiomyopathy with persistent ventricular dysfunction –> if becomes pregnant again she has VERY HIGH change of markedly worsening of her cardiac function
peripartum cardiomyopathy - mechanism
it is unknown why there are antibodies made against the myocardium in some pregant women. The LV dysfunction is often reversible and short term
If the LV does not improve, then the person must undergo cardiac transplantation
peripartum cardiomyopathy - treatment
the medical therapy is the same as dilated cardiomyopathy :
- ACEi (because is after delivery)
- beta-blockers
- spironolactone
- diuretics
- digoxin
HF with preserved EF - spironolactone
- not decreased mortality
- reduced hospitalisation rate
- indication in peripheral edema and lung congestion
diagnosis of hypercholesteremia requires
total cholesterol of > 200 mg/dL on two occasions.
Systemic glucocorticoid for pericarditis
pericarditis associated with connective tissue diseases and in patients with recurrent pericarditis refractory to treatment with NSAIDs.
The first ECG sign of an ST-segment elevation MI can be
hyperacute T waves
BP with increasing age
- systolic blood pressure increases
- diastolic blood pressure decreases
- pulse pressure increases.
…… are recommended in patients with newly diagnosed hypertension before initiating therapy.
Measurements of blood glucose, potassium, calcium, creatinine, hematocrit; urinalysis; and lipoprotein profile
statin in young people
A patient 21 years of age or older that presents with an LDL-C of 190mg/dL or higher should be started on statin therapy.
after starting lisinopril
lab test –> no acute rise in creatinine or the development of hyperkalemia
contraindications of PCI include
- intracranial hemorrhage
- ischemic strokes within preceeding 3 months
- signs and symptoms of aortic dissection.
hypertensive emergency - initial management
- target diastolic blood pressure of 100-105 mm Hg within 2-6 hours
- initial fall in the mean arterial pressure should not exceed 25% of the presenting value.
MI criteria
- at least 1 mm segment elevation in at least 2 contiguous limb leads
- 2mmm elevation in 2 continguous precordial limbs
- New LBBB
drug that is contraindicated in patients with dilated cardiomyopathy and why
NSAID
worsen afterload by inhibiting prostagladin synthesis and by counteracting the benefits of ACEi
traumatic thoracic aortic injury - The gold standards for diagnosis
CT angiography (in stable patients) and TEE (preferred for hemodynamically unstable patients).
renal Fibromuscular dysplasia - Treatment of choice is
percutaneous transluminal angioplasty.
….. are appropriate methods of treating pericarditis in a patient refractory to oral medications.
Balloon pericardiotomy, prolonged pericardial catheter drainage, surgical pericardiectomy, and intrapericardial sclerosing therapy
