Must Knows Flashcards
What does pulsus parvus et tardus indicate?
Severe aortic stenosis (AS)
What characterizes an anacrotic pulse?
Slow, notched, or interrupted upstroke with shrill or shudder
Indicates aortic stenosis (AS)
What is Corrigan’s pulse?
Water-hammer pulse with a sharp rise and rapid fall-off
Indicates chronic severe aortic regurgitation (AR)
What does a bifid or bisferiens pulse indicate?
Two systolic peaks
Indicates advanced aortic regurgitation (AR), hypertrophic obstructive cardiomyopathy (HOCM), or intra-aortic balloon counterpulsation (IABP) with a second pulse being diastolic
What is pulsus paradoxus?
A drop in systolic blood pressure (SBP) > 10 mmHg with inspiration
Indicates cardiac tamponade, massive pulmonary thromboembolism (PTE), hemorrhagic shock, severe COPD, or tension pneumothorax
What does pulsus alternans indicate?
Beat-to-beat variability of pulse amplitude
Indicates severe left ventricular (LV) systolic dysfunction
What is the thrill location associated with mitral regurgitation (MR)?
Cardiac apex
Thrills are vibrations felt on the chest wall due to turbulent blood flow.
Where is the thrill from aortic stenosis (AS) located?
From the precordium to the right side of the neck
AS causes specific patterns of blood flow turbulence leading to this sensation.
What is the thrill location associated with pulmonic stenosis?
From the precordium to the left side of the neck
Pulmonic stenosis results in characteristic vibrations on the chest wall.
Where is the thrill from a ventricular septal defect (VSD) typically felt?
Third and fourth intercostal spaces near the left sternal border
VSD creates a significant left-to-right shunt that produces notable thrills.
What conditions are associated with a loud S1?
- Early phases of rheumatic mitral stenosis (MS)
- Hyperkinetic circulatory states
- Short PR intervals
A loud S1 indicates increased pressure or rapid closure of the mitral valve.
What causes a soft S1?
- Later stages of mitral stenosis (rigid/calcified leaflets)
- Beta-blocker use
- Long PR interval
- Left ventricular dysfunction
A soft S1 may indicate decreased pressure or delayed closure of the mitral valve.
What conditions can lead to reduced S1 and S2?
- Mechanical ventilation
- COPD
- Obesity
- Pneumothorax
- Pericardial effusion
These conditions can dampen heart sounds due to various physiological factors.
What does a normal or widened S1 indicate?
Complete right bundle branch block (RBBB), young patients
Normal or widened S1 suggests a variation in electrical conduction affecting heart sounds.
What does reversed S1 indicate?
- Severe mitral stenosis
- Left bundle branch block (LBBB)
- Left atrial myxoma
- Wide: RBBB
Reversed S1 often points to significant cardiac pathology.
What is normal or physiologic splitting of S2?
Increase during inspiration, decrease during expiration
This is a normal finding due to changes in intrathoracic pressure affecting valve closure timing.
What conditions are associated with a widened split S2?
- Right bundle branch block (RBBB)
- Severe mitral regurgitation
A widened split S2 indicates delayed closure of the pulmonic valve relative to the aortic valve.
What does a narrow or absent split S2 indicate?
Pulmonary arterial hypertension
This finding suggests increased pressure in the pulmonary circulation affecting valve closure timing.
What is fixed splitting of S2 associated with?
Secundum atrial septal defect
Fixed splitting is a characteristic finding in certain congenital heart defects.
What conditions are associated with reversed or paradoxical splitting of S2?
- LBBB
- Right ventricular pacing
- Severe aortic stenosis
- Hypertrophic obstructive cardiomyopathy (HOCM)
- Acute myocardial infarction (AMI)
Reversed splitting occurs when the aortic valve closes later than the pulmonic valve.
What are the therapeutic goals in HFpEF?
Improve symptoms and exercise tolerance
This includes lifestyle changes, control of congestion, stabilizing heart rhythm, BP control, and managing comorbidities.
List some lifestyle changes that can help manage HFpEF.
- Dietary modifications
- Regular physical activity
- Weight management
- Smoking cessation
What comorbidities should be managed in HFpEF to prevent disease progression?
- Obesity
- Obstructive lung disease
- OSA
- Diabetes/insulin resistance
- Anemia
- Iron deficiency
- Chronic kidney disease (CKD)
What neurohormonal antagonists show no benefit in HFpEF?
- ARBs
- ACE inhibitors
- Beta-blockers
- Digoxin
- Nitrates
What is the benefit of Sacubitril-Valsartan (ARNI) in HFpEF?
Possibly beneficial, especially among patients with lower ejection fraction (EF)
This medication has shown promise in improving outcomes in certain HFpEF patients.
Which novel targets have shown potential benefits in HFpEF?
- Empagliflozin
- Dapagliflozin
These are SGLT2 inhibitors that may reduce the risk of cardiovascular death and hospitalization for heart failure.
When is the use of a pulmonary artery catheter in ADHF recommended?
Only under specific conditions:
* Low output heart failure or cardiogenic shock requiring vasopressors or mechanical support
* Resistant or refractory to diuresis
* Combined cardiorenal dysfunction
* Known or suspected pulmonary arterial hypertension
What parameters are associated with worse outcomes in ADHF?
- BUN >43 mg/dL
- SBP <115 mmHg
- Serum creatinine >2.75 mg/dL
- Elevated cardiac markers (Natriuretic peptide, troponin)
True or False: The use of a pulmonary artery catheter is recommended for all patients with ADHF.
False
It is only recommended in specific cases as outlined.
Fill in the blank: Empagliflozin and Dapagliflozin are types of _______.
[SGLT2 inhibitors]
typical ADHF tx
Normotensive - diuresis (volume overload)
HPNsive - vasodilators (not volume overloaded)
Pulmonary edema ADHF tx
VOOD
Vasodilators
Opiates
O2 and NIV
Diuretics
RF for sudden death in HCM
History of cardiac arrest or spontaneous
sustained ventricular tachycardia
Syncope
Family history of sudden cardiac death
Spontaneous nonsustained ventricular tachycardia
LV thickness >30 mm
Abnormal blood pressure response to
exercise
What is an early complaint in aortic regurgitation (AR)?
Uncomfortable awareness of the heartbeat, especially when lying down.
What is the first symptom of diminished cardiac reserve in AR?
Exertional dyspnea.
What is Corrigan’s pulse?
Rapidly rising ‘water-hammer’ pulse that collapses suddenly as arterial pressure falls rapidly during late systole and diastole.
What is Quincke’s pulse?
Capillary pulsations, with alternate flushing and paling of the skin at the root of the nail while pressure is applied to the tip of the nail.
What is Traube’s sign?
Booming ‘pistol-shot’ sound over the femoral arteries.
What is Duroziez’s sign?
To-and-fro murmur audible with light compression of the femoral artery.
What causes widened arterial pulse pressure in AR?
Due to decreased systolic blood pressure (SBP) and decreased diastolic blood pressure (DBP).
What is Carvallo’s sign?
Pansystolic murmur at left sternal border of a functional TR accentuated by inspiration and diminished during forced expiration or with Valsalva maneuver
TR stands for tricuspid regurgitation.
Describe the Graham Steell murmur.
High-pitched, diastolic, decrescendo blowing murmur along the left sternal border resulting from dilatation of the pulmonary valve ring
Occurs in patients with mitral valve disease and severe pulmonary hypertension.
How does inspiration affect Carvallo’s sign?
It accentuates the murmur
This is characteristic of functional tricuspid regurgitation.
What happens to Carvallo’s sign during forced expiration?
It is diminished
This change can also occur with the Valsalva maneuver.
What type of murmur is the Graham Steell murmur?
Diastolic, decrescendo blowing murmur
High-pitched in nature.
What condition is associated with the Graham Steell murmur?
Mitral valve disease and severe pulmonary hypertension
It results from the dilatation of the pulmonary valve ring.
Features of acute pericarditis
Chest pain
Friction rub
ECG changes
Pericardial effusion
What settings is stress testing considered in?
Uncertainty with IHD diagnosis, assessing functional capacity of patients, assessing adequacy of treatment program for IHD, markedly abnormal calcium score on EBCT.
When should an exercise stress test be stopped?
(+) Chest discomfort, severe SOB, dizziness, severe fatigue, ST-segment depressed > 0.2 mV (>2mm), t SBP >10 mmHg, (+) ventricular tachyarrhythmia.
What is the ischemic ST-segment response?
Flat or downsloping depression of the ST segment >0.1 mV below baseline and lasting longer than 0.08 s.
What are the contraindications to exercise stress testing?
Rest angina ≤ 48 h, unstable rhythm, severe aortic stenosis, acute myocarditis, uncontrolled HF, severe pulmonary HTN, active lE.
dm Management
Guidelines for Ongoing, Comprehensive Medical Care for Patients with Diabetes
Individualized glycemic goal and therapeutic plan
Self-monitoring at individualized frequency of blood glucose
(capillary/meter) or interstitial glucose (continuous glucose monitoring)
HbAlc testing (2-4 times/year)
Lifestyle management in the care of diabetes, including:
Diabetes-self-management education and support
Nutrition therapy
Physical activity
Psychosocial care, including evaluation for depression, anxiety
Manage or treat diabetes-relevant conditions, including:
Blood pressure (2-4 times quarterly)
Lipids (1-2 times/year)
Consider antiplatelet therapy with low dose aspirin
Overall Principles
Goals of therapy: (1) eliminate symptoms related to
hyperglycemia, (2) reduce or eliminate long-term
microvascular and macrovascular complications of DM,
(3) achieve as normal a lifestyle as possible
DM symptoms usually resolve when plasma glucose is
<11.1 mmol/L (200 mg/dL), thus focus on achieving the
second and third goals
econd and third goals tate on
f diabetes during
NOTE: C-peptide levels are unable to
completely distinguish T1 form T2 DM, as
many individuals with type 1 DM retain
some C-peptide production
• Islet cell antibodies at the time of DM onset:
may be useful if the type of DM is not clear
Detection, prevention, or management of diabetes-
related complications, including:
Diabetes-related eye examination (annual or
biannual)
Diabetes-related foot examination (1-2
times/year by provider; daily by patient)
Diabetes-related neuropathy examination
(annual)
Diabetes-related kidney disease testing (annual)
Influenza/pneumococcal/hepatitis B immunizations
Traditional RF in CKD
HPN
DM
Dyslipidemia
Hypervolemia
Sympathetic overactivity
Hyperhomocystinemia
Non traditional/CKD related RF
Anemia
Hyperphosphatemia
HyperPTH
Inc FGF23
SLeep apnea
Systemic inflammation
