(Nisha) cardiology p92-99

Question 1

Rapid onset of fluid accumulating in the lungs

Answer 1

Pulmonary edema

Question 2

Presentation of Pulmonary edema

Answer 2

Acute onset SOB with rales, JVD, s3 gallop, edema, orthopnea, may be ascites, enlargement of the liver or spleen

Question 3

Diagnostic tests of pulmonary edema

Answer 3

BNP (if SOB etiology is unclear, normal excludes pulmonary edema)
Chest X Ray (enlarged pulmonary veins)
Oximetry/ABG (initial stage of dz, respiratory alkalosis)
EKG (most important test acutely)
Echo (done in all patients to determine if the dynfxn is diastolic or systolic)

Question 4

What do you do if atrial fib, atrial flutter or vtach is the cause of pulmonary edema?

Answer 4

Rapid, synchronized cardioversion in order to restore systole and return the atrial contribution to cardiac output

Question 5

How much does atrial systole contribute to cardiac output?

Answer 5

10-20%

Question 6

In dilated cardiomyopathy, decreased EF, and valvular heart disease….Atrial contribution to CO is ?

Answer 6

40-50%

Question 7

Acute pulmonary edema from arrythmia is treated with ?

Answer 7

Cardioversion

Question 8

Treatment of Pulmonary edema? Preload reduction?

Answer 8

Oxygen, loop diuretics (furosemide, bumetinide, ethacrynic acid), morphines, nitrates, nesiritide

Question 9

A 73-year-old white man with type 2 diabetes mellitus, hypertension, coronary artery disease is admitted with increasing shortness of breath and lower-extremity edema. A brain natriuretic peptide level is 1000 pg/ml. His medications include glyburide, aspirin, atorvastatin and enalapril. He is allergic to sulfonamides. On physical examination, he has bilateral crepitations more in the right chest. Extremity examination reveals 3+ edema bilaterally. An electrocardiogram reveals changes consistent with left venricular hypertrophy but no evidence of acute ischemia. Cardiac enzymes are negative. A chest x-ray reveals bilateral pulmonary edema. Pulse oximetry reveals a saturation of 89% on room air. The patient is started on oxygen by nasal cannula. Which of the following is the most appropriate next step in management?

A) Intubation
B) Intravenous Furosemide
C) Bilevel Positive Airway pressure (BIPAP)
D) Intravenous Ethacrynic acid
E) Cardiac catheterization.

Answer 9

D. Ethacrynic acid is a nonsulfa loop diuretic

All loop diuretics are associated with ototoxicity.

Question 10

If SOB in acute setting patient with pulmonary edema does not respond with preload reduction, what can you do?

Answer 10

Dobutamine - positive inotrophic agent.

can also use Amrinone, Milrinone

Question 11

Will digoxin be effective in patient with pulmonary edema that presents in an acute setting?

Answer 11

NO. Digoxin takes several weeks to be effective.

Question 12

Tx of Pulmonary edema. Afterload reduction?

Answer 12

Ace inhibitors and ARBS, used in discharge in all patients with systolic dysfxn and low EF

Question 13

What drugs can reduce afterload in an acute setting?

Answer 13

Nitroprusside and IV hydralazine

Question 14

Rheumatic fever leads to what kind of murmur?

Answer 14

Mitral stenosis

Question 15

What heart murmur in heard in aging?

Answer 15

Aortic stenosis

Question 16

Regurgitant heart disease is most commonly in ?

Answer 16

HTN and IHD

Question 17

Lesions on the right side of heart increase with?

Answer 17

Inhalation, due to increased venous return

Question 18

Lesions on the left side of heart increase with ?

Answer 18

Exhalation, squeezes blood out of lungs and into left side of heart

Question 19

Best initial test for valvular heart disease

Answer 19

Echocardiogram, TEE

Question 20

Most accurate test

Answer 20

Catheterization

Question 21

Treatment of valvular heart disease

Answer 21

All benefit from diuretics due to fluid overload in the lungs

Question 22

How to tx mitral stenosis?

Answer 22

Dilated with balloon

Question 23

How to tx aortic stenosis?

Answer 23

surgical removal

Question 24

How to tx regurgitant lesions?

Answer 24

Vasodilator therapy with ACE inhib, ARBS, nifedipine, hydralazine…Surgery if heart dilates too much

Question 25

How do you assess ventricular size ?

Answer 25

End systolic diameter and EF

Question 26

Mitral stenosis is most often caused by

Answer 26

RF

Question 27

Do you treat mitral stenosis that is asymptomatic?

Answer 27

No

Question 28

Mitral stenosis is most often found in young, pregnant or immigrant patients. True or false?

Answer 28

True. Immigrants because they come from a geographic region where acute rheumatic fever is still common.

Question 29

What is the presentation of Mitral Stenosis?

Answer 29

SOB, CHF, dysphagia (LA pressing on esophagus), hoarseness (LA pressing on laryngeal nerve), A fibb and stroke, hemopytsis

Question 30

A diastolic murmur with an opening snap is heard…what is the murmur?

Answer 30

Mitral stenosis

Question 31

Diagnostic test for mitral stenosis?

Answer 31

Echo (TEE) - initial
Catherization - accurate
EKG (atrial rhythm disturbance, particularly a fibb) LA hypertrophy shows up as - biphasic P wave in leads V1 and V2
Chest Xray - straightening of the left heart border, elevation of the left main stem bronchus, second bubble behind the heart

Question 32

Treatment of Mitral Stenosis?

Answer 32

1. Diuretics and sodium restriction when fluid overload is present in the lungs
2. Balloon valvuloplasty done with a catheter
3. Valve replacement only when a catheter procedure
4. Warfarin for AF to an INR 2-3
5. Rate control of atrial fibrillation with digoxin, beta blockers, or diltiazem/verapril