(Nisha) cardiology p92-99 Flashcards
Rapid onset of fluid accumulating in the lungs
Pulmonary edema
Presentation of Pulmonary edema
Acute onset SOB with rales, JVD, s3 gallop, edema, orthopnea, may be ascites, enlargement of the liver or spleen
Diagnostic tests of pulmonary edema
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)
What do you do if atrial fib, atrial flutter or vtach is the cause of pulmonary edema?
Rapid, synchronized cardioversion in order to restore systole and return the atrial contribution to cardiac output
How much does atrial systole contribute to cardiac output?
10-20%
In dilated cardiomyopathy, decreased EF, and valvular heart disease….Atrial contribution to CO is ?
40-50%
Acute pulmonary edema from arrythmia is treated with ?
Cardioversion
Treatment of Pulmonary edema? Preload reduction?
Oxygen, loop diuretics (furosemide, bumetinide, ethacrynic acid), morphines, nitrates, nesiritide
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.
D. Ethacrynic acid is a nonsulfa loop diuretic
All loop diuretics are associated with ototoxicity.
If SOB in acute setting patient with pulmonary edema does not respond with preload reduction, what can you do?
Dobutamine - positive inotrophic agent.
can also use Amrinone, Milrinone
Will digoxin be effective in patient with pulmonary edema that presents in an acute setting?
NO. Digoxin takes several weeks to be effective.
Tx of Pulmonary edema. Afterload reduction?
Ace inhibitors and ARBS, used in discharge in all patients with systolic dysfxn and low EF
What drugs can reduce afterload in an acute setting?
Nitroprusside and IV hydralazine
Rheumatic fever leads to what kind of murmur?
Mitral stenosis
What heart murmur in heard in aging?
Aortic stenosis
Regurgitant heart disease is most commonly in ?
HTN and IHD
Lesions on the right side of heart increase with?
Inhalation, due to increased venous return
Lesions on the left side of heart increase with ?
Exhalation, squeezes blood out of lungs and into left side of heart
Best initial test for valvular heart disease
Echocardiogram, TEE
Most accurate test
Catheterization
Treatment of valvular heart disease
All benefit from diuretics due to fluid overload in the lungs
How to tx mitral stenosis?
Dilated with balloon
How to tx aortic stenosis?
surgical removal
How to tx regurgitant lesions?
Vasodilator therapy with ACE inhib, ARBS, nifedipine, hydralazine…Surgery if heart dilates too much
How do you assess ventricular size ?
End systolic diameter and EF
Mitral stenosis is most often caused by
RF
Do you treat mitral stenosis that is asymptomatic?
No
Mitral stenosis is most often found in young, pregnant or immigrant patients. True or false?
True. Immigrants because they come from a geographic region where acute rheumatic fever is still common.
What is the presentation of Mitral Stenosis?
SOB, CHF, dysphagia (LA pressing on esophagus), hoarseness (LA pressing on laryngeal nerve), A fibb and stroke, hemopytsis
A diastolic murmur with an opening snap is heard…what is the murmur?
Mitral stenosis
Diagnostic test for mitral stenosis?
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
Treatment of Mitral Stenosis?
- Diuretics and sodium restriction when fluid overload is present in the lungs
- Balloon valvuloplasty done with a catheter
- Valve replacement only when a catheter procedure
- Warfarin for AF to an INR 2-3
- Rate control of atrial fibrillation with digoxin, beta blockers, or diltiazem/verapril
