Mumurs And Valve Disease and Anti Arrhythmia Drugs Flashcards
What are 4 common symptoms of Valve disease and which one is most common?
Dyspnea on exertion (most common), angina, syncope and palpitations.
As far as etiology, what are the 3 most common conditions encountered today and what valve problem does it lead to?
- Degenerative process like calcification. Just happens with age. Aortic calcification.
- Myxomatous degeneration in Mitral Valve Prolapse
- Congenital issues like bicuspid aortic valve.
What 3 things are we thinking as to the patho behind a valve issue?
Pressure overload, volume overload, or a specific disease process like an infection or heart failure.
What is the jones major criteria for RHD?
J: joints involved O: myOcarditis N: Nodules that are subcutaneous E: Erythema marginatum S: Syndenhams Chorea
What are the minor criteria for RHD? What is the mnemonic?
C: CRP increased A: Arthralgia F: Fever E: Elevated ESR and ASO titer or anti DNAse B P: Prolonged PR A: medical history of rhumatism L: leukocytosis
What is the criteria to diagnose RHD?
2 major criteria or
1 major and 2 minor
RF is virtually the only cause of what?
Acquired MS
5 common symptoms of a patient with Mitral Stenosis?
Exertional Dyspnea, Fatigue with low CO, cough orthopnea, PHT and RHF with edema.
What age does the typical patient with MS present with?
4th decade
What is the syndrome associated with MS and explain whats going on?
Ortner syndrome. Hoarseness because of compression of the left recurrent laryngeal nerve.
3 physical exam findings for MS?
Malar rash or blue face
Increased s1
Opening snap after s2.
How do we describe what we hear when listening to a MS murmur?
Low frequency that starts at the opening snap and decreases in volume. During diastole. Starts back up again right before S1 during atrial contraction.
What is the best way to hear the MS murmur?
Use bell, have patient lay left lateral decubitus position and listen at the apex.
When do you use anticoagulant for MS?
If there is Afib. Don’t want to have an embolism.
What is the most common etiology of chronic MR?
MVP, so myxomatous degeneration
3 common causes of Acute MR?
Rupture of Chordae tendinae, rupture of pap muscle, or IE.
Big picture, what is the problem going on with acute MR?
Got to think forwards and backwards. LA pressure is jacked up and then there isn’t enough blood getting through the heart to pump for the body.
What is going on with the symptoms of MR?
Can be asymptomatic for years, but then you can appreciate LA dilation and backing up to the right side of heart.
What kind of murmur is MR?
Holosystolic
Where is MR best heart and what part of the stethoscope is used?
Apex and diaphragm
Where does MR murmur radiate?
Left axilla
What happens to s1 during MR murmur?
Decreased or normal
When do cardiac troponin levels increase, when do they hit peak levels after MI, how long are they typically elevated for?
They elevate in 4-6 hours and peak at 8-12 hours. 5-7 days.
What are the same levels for CK-MB?
Rise in 4-8 hours, peak at 24 hours and return in 48-72 hours.
3 symptoms of MVP?
Asymptomatic to arrhythmias, chest pain, and syncope
What type of murmur is MVP?
Systolic
What is a state you can find your patient in with MVP?
Hyper adrenergic state because of anxiety or palpitations
What is a “click” and why would you have a systolic click with MVP?
A click is abnormal closure of a valve, so you would have a systolic click with MVP because the valves, which prolapsed during systole, are closing.
Top 3 causes of AS?
Calcification due to age, Rheumatic, and radiation scarring
4 symptoms of AS?
Exertional dyspnea, angina, syncope and CHF.
What happens with pulse pressure, SV, and systolic pressure in a patient with AS?
Pulse pressure becomes more narrow, SV and systolic pressure decrease.
What’s going on with pulses and AS?
Either have parvis pulses which are weka and decreased due to CO drop or tarsus pulses which are delayed and decreased as you go up the carotid.
What kind of murmur is AS and where do you best hear it and where can it radiate to?
Harsh systolic murmur. Right 2nd intercostal space. Radiates into carotid.
What is the gallavardin phenomenon?
Murmur radiates to the apex like MR
2 causes of acute AR?
IE and dissection
5 causes of chronic AR?
Syphilis, calcification, aortic dilation, ankylosing spondylitis, RF
What is the main pathophysiology of AR?
Volume overload starting in left side of heart and working backwards.
What type of murmur is AR and where is it best heard?
Diastolic murmur at left 3rd ICS
What syndrome can TS be associated with?
Carcinoid
What is identification of TS in jugular venous pressure?
Prominent A wave.
What type of murmur is TS and what is the sign associated with it?
Diastolic murmur. Corvallos sign. Murmur increases with inspiration and decreases with expiration.
TR is associated with what marker in the JVP waveform?
Prominent V wave.
What type of murmur is TR?
Holosystolic
Where can we best hear Pulmonary Stenosis and where does it radiate to?
2-3 Left ICS and radiates to left shoulder and clavicle
Most cases of PR are due to what, what type of murmur is PR and where do we best hear the murmur?
Pulmonary HTN. Diastolic. 2nd LSB.
What are the 4 continuous murmurs?
PDA that is machine like, AV fistula, ASD with super high LA pressure, and coarctation
What are the 4 families of drugs to treat arrhythmias?
Sodium channel blockers, beta blockers, potassium channel blockers, cardioactive calcium blockers.
What 3 cardiac cells/tissues have fast action potentials?
Ventricles, atrial muscle cells, purkinje fibers
What two tissues/cells have slow action potentials?
SA node and AV node.
What two channels are establishing resting membrane potential or restores the membrane potential?
Sodium potassium pump and sodium/calcium exchanger.
What are the two channels responsible for pacemaker action potential depolarization initially and what activates the channels?
Funny or leaky sodium and potassium channels. Both coming in. Hyper polarization activates them.
What channel continues the depolarization after the leaky/funny channels?
Transient calcium channels
What ion and channel is responsible for phase 0 of the pacemaker action potential?
Calcium. Slow L type (long acting)
What are the 3 main factors determining the firing rate or automaticity of the pacemaker cells?
Slope of phase 4 which will increase or decrease rate, threshold potential level, resting potential
What are the specific type of activation and inactivation gates?
M and h
What is meant by class 1 drugs being state dependent blockers?
They don’t mess around with channels at rest, just activated or inactivated. This means they aren’t messing with normal firing tissue, just high frequency.
MOA of Class 1A drugs?
Selective for blocking open or activated sodium channels which leads to a slower upstroke of sodium influx phase 0 or slower spontaneous of phase 4.
What are the 3 effects of class 1a drugs?
Slows conduction velocity, prolongs action potential duration, and prolongs QRS and Qt.
What type of cells will be targeted by class 1a drugs?
Ectopic pacemaker cells with faster rhythms.
What else do class 1a drugs block?
Potassium channels
Class 1A drugs dissociate with what type of kinetics?
Intermediate
Procainamide is used to treat what arrhythmia by directly working where in the heart?
V tach by directly depressing the SA and AV node
3 adverse effects of procainamide?
Qt prolongation, tornadoes de pointes, and too much inhibition
2 uses for quinidine?
Sustained ventricular arrhythmia and sometimes to restore atrial rhythm in Afib or flutter.
Quinidine adverse effects on heart?
Qt prolongation, torsades de pointes, and excessive conduction inhibition
What is disopyramide used for and what is the big time adverse effect?
Ventricular arrhythmias. Potent antimuscarinic effect
MOA for class 1b drugs and what are their kinetics?
Selectively block sodium channels of inactivated or depolarize sodium channels. Dissociate with fast kinetics.
What do they not do that is different from class 1a drugs?
These guys do not block potasssium channels at all so they do not prolong the action potential
What is lidocaine used for?
Ventricular tachycardia and arrhythmias associated with MI.
2 indications for mexiletine?
Ventricular arrhythmias and chronic pain due to diabetic neuropathy and nerve injury
MOA for class 1c drugs and what are their dissociation kinetics?
Selectively block open sodium channels and has slow dissociation kinetics
What about class 1c’s effect on potassium channels?
Can block some
2 indications of flecainide?
Supraventricular arrhythmias and sustained V tach or other life threatening ventricular arrhythmias.
Who do we not give flecainide to?
Patients with pre existing ventricular issues.
What is the drug to drug interaction to remember for propafenone?
Don’t combine with cyp2d6 or cyp3a4 inhibitors
What is the MOA for beta blockers and what is the result?
Block funny channels and L type calcium channels resulting in decreased slope and increased threshold. HR down and AV conductance down.
4 clinical indications for beta blockers?
Tachycardia due to sympathetic activity, Afib and flutter, AV reentrant, and arrhythmias associated with MI.
What is the big deal with Esmolol and how is it used?
Super short acting so it is used IV and for emergent situations or surgeries.
Which potassium channels are open during resting state?
Inward rectifying
What is the purpose of potassium channels with the action potential, 2 things?
Repolarize the cell. Makes possible the refractory period so we limit action potential duration
MOA for class 3 drugs and what 3 effects?
Block potassium channels. Increase action potential duration, qt interval, and prolong the refractory period.
2 indications for amiodarone?
Ventricular arrhythmias and atrial fibrillation
2 drug to drug interactions for amiodarone?
Rifampin, a cyp3a4 inducer, or cimetidine, a cyp3a4 inhibitor.
4 adverse effects of amiodarone?
Av block, bradycardia, fatal pulmonary fibrosis and hepatitis
What is unique about sotalol and what are the 2 clinical indications?
It is a class 2 and 3. Life threatening ventricular arrhythmia and a fib.
MOA of dofetilide? What unique identifier to remember about it. 2 clinical indications for it?
Pure potassium blocker. Blocks the delayed rectifier channel. Cleared by the kidneys so need to make sure person has good renal clearance. Persistent A fib, heart failure and CAD.
MOA of Ibutilide? How is it cleared and administered? Use? Adverse effect, 1?
Blocks delayed fast potassium rectifier. IV and by liver. Convert a fib and flutter to normal sinus rhythm. Big time QT prolongation.
MOA for class 4 drugs and what 3 effects?
Blocks activated and inactivated L type calcium channels. Decrease slope, increase l type threshold and prolong refractory period.
What 2 effects does verapamil and diltiazem have on the heart rate?
Slow SA node depolarization and prolong the action potential and time through AV node.
Clinical use of verapamil and diltiazem, 2 things?
Prevention of paroxysmal SVT and rate control in a flutter and fib.
Adverse effect of verapamil?
Constipation
MOA for adenosine acting as an anti arrhythmia drug?
Increases potassium current and inhibits calcium and funny currents which leads to hyper-polarization and inhibition of action potentials in slow cells.
Clinical use of adenosine?
Convert paraoxysmal SVT back to sinus rhythm
2 adverse effects of using adenosine?
Shortness of breath and bronchoconstriction
