Part 16 Flashcards
Why do post menopausal women have an increased risk of CAD?
Estrogen plays a role in increasing HDL levels and because it is absent post menopause it changes the female’s risks to that of male equivalents
HS-CRP vs CRP
High sensitivity CRP is a test that allows for detection of markers in lower grade conc than CRP and is theorized to be a better predictor of MI than CRP as a result, both are nonspecific inflammatory markers that can be present regardless of MI
Precipitating factors for acute myocardial infarction (5) and what is the most common of them?
- Physical stress (30%)
- Post surgical (5%)
- sleep (10%)
- emotional stress (20%)
- rest (NO precipitating factor, 50%)***
Peak hours for acute myocardial infarction and why?
early morning, thought to be tied to circadian rhythm and increase in sympathetic activity following waking
What are the common causes of chest pain? (5)
- MI
- Aortic dissection
- PE
- esophageal rupture
- pneumothorax
The hallmark of a previous acute myocardial infarction is development of what on an EKG?
…Q wave in leads corresponding to region of the heart (for example lead II, III and AVF)
3 separate cardiac enzymes tests (name the specific one) need to be done 6-12 hours apart to definitively rule out ____
troponin T, Myocardial Infarction
Type I MI
Caused by acute atherothrombotic coronary artery disease usually precipitated by atherosclerotic plaque disruption
Type 2 MI
Consequent to mismatch between o2 supply and demand due to things other than a plaque such as coronary dissection, vasospasm, embolism (a non-plaque one), microvascular dysfunction, or increased demand with or without underlying CAD
Type 3 MI
Undiagnosed MI resulting in death before any obtaining of biomarker values to determine type otherwise
Type 4a MI
MI associated with percutaneous coronary intervention (PCI)
Type 4b MI
Subcategory of percutaneous coronary intervention related MI due to stent or scaffold thrombosis
Type 5 MI
MI related to coronary artery bipass graft
Inferior wall MI (right ventricle infarct due to occlusion of posterior descending artery) triad of presentation
- JVD increasing on inspiration (kussmaul’s sign)
- Hypotension
- Clear lung fields upon auscultation
Triad of acute MI presentation
- prolonged chest pain >30 min
- ST elevation >2 consecutive leads
- Positive cardiac enzyme test
Sublingual nitroglycerine for acute MI can be delivered only if SBP is greater than…
…90mmHg
Percutaneous coronary intervention needs to be completed within ___ min for patients transported to PCI capable hospital
90 min
Absolute contraindications of thrombolysis in acute myocardial infarction (4)
- active internal bleeding
- intracranial neoplasm or recent head trauma
- pregnancy
- history of CVA
Indications for CABG for acute myocardial infarction (2)
- 3 vessels disease
- left main disease
Some post MI complications (4)
- sinus tachycardia
- recurrent ischemia
- pericarditis
- Dressler’s syndrome
Dressler’s syndrome
2ndary pericarditis to MI characterized by malaise, fever, and pericardial pain
Key distinguishing finding to determine between RV infarct and HF
-The lungs are clear upon auscultation in RV infarct despite the increased JVD and hypotension, while the lungs are not clear sounding in HF
You can give any patient with acute angina, NSTEMI or STEMI these 3 drugs except in hypotensive RV infarcts where ___ (which one of them?) is contraindicated
- nitroglycerin
- aspirin chewable
- B blocker
-NITROGLYCERIN
2 Medications for 1 year following placement of drug eluding stent
- aspirin daily
- plavix
4 medications for 1 month following bare metal stent placement
- ACEI or ARB
- B blocker
- Statin
- Sublingual Nitroglycerin as needed
Unstable angina will have ___ cardiac biomarkers while STEMI and Non-STEMI will have ___ ones.
Negative, positive
Management of AMI in ER list (13 steps!)
- Obtain history
- perform physical exam
- order diagnostic tests such as EKG, chest xray and echocardiogram
- supplemental O2 as necessary
- Morphine administration for pain control
- 2 IV lines
- chewable aspirin or plavix if allergic
- Sublingual nitroglycerine
- Potentially IV nitroglycerine if no relief
- IV B blocker metoprolol 5mg every 2-5 min for 3 doses
- statins
- ACE inhibitors
- Consider percutaneous coronary intervention, CABG, or thrombolytics
Takesubo’s cardiomyopathy and treatment options
- Mimic’s acute coronary syndrome, characterized by left ventricular apical ballooning, presents with absence of angiographically significant coronary artery stenosis and is typically precipitated by acute emotional distress (also known as broken heart syndrome)
- Treated with ACE inhibitors, B blockers, aspirin and a statin
Heart failure caused by systolic dysfunction is also known as…
….heart failure with reduced ejection fraction (HFREF)
Systolic dysfunction has a _____ and ___ventricle while diastolic has a ____ and ___ ventricle
dilated and floppy, stiff and inflexible
Ejection fraction to diagnose left heart failure must be less than…
Less than 40%
Most common cause of systolic heart failure
Ischemic cardiomyopathy following an acute MI
Most common cause of diastolic heart failure
Longstanding uncontrolled hypertension leading to LV hypertrophy
Natriuretic peptides normal functions and levels in systolic dysfunction heart failure (generally)
Counterbalance RAAS by causing vasodilation (BNP) and increase Na+ excretion (and therefore H2O volume as well), levels will be elevated in heart failure
Cardiorenal syndrome
Comorbidity due to the low cardiac output associated with systolic dysfunction heart failure causing renal hypoperfusion resulting in renal failure (patients with heart failure often go into renal failure)
Hepatojugular reflex
Distension of neck veins precipitated by placing firm pressure over the liver, distension greater than 3cm is diagnostic for systolic heart failure
Leading disease state cause of right ventricular failure
Left ventricular failure (fluid backs up from left ventricles to lungs to right ventricle causing increased pressure on it)
Common cause of 2ndary** right sided only ventricular failure
pulmonary fibrosis from things such as COPD (cor pulmonale)
Functional classification of heart failure and the 4 classes
Relates to syptoms of everyday activities and QOL
Class 1 - no limitation
Class 2 - slight limitation of physical activity
Class 3 - comfortable only at rest
Class 4 - symptomatic even at rest
BNP testing can show false positive elevation indicative of heart failure in these 3 other conditions
- pulmonary disease
- PE
- renal impairment
S3 cause and what type of heart failure is it heard with?
- Increased sloshing reverberating against dilated left ventricular wall, not always pathology
- More common in a systolic heart failure
S4 cause and what type of heart failure is it heard with?
- Blood being forced into a stiff non-compliant ventricle, almost always pathology
- more common in a diastolic heart failure
Kerley B lines
Occur on a chest xray indicating fluid buildup in lower lobes of the lungs often in LV heart failure
Systolic dysfunction HF has what contraindicated drug class?
non dihydropyridine ca2+ channel blockers (potential to act on heart)
2 Devices indicated for patients with LV Ejection Fraction of <30%
- Implantable cardioverter defibrillator
- Biventricular pacemaker (cardiac resyncronization therapy)
Steven Johnson syndrome
A rare serious immune complex mediated hypersensitivity condition of skin and mucus membranes that begins with flu like symptoms and progresses to a severe rash as a reaction to medication such as bactrim
Lentigo
Pigmented indented macule (diff from freckle) often a result of localized proliferation of melanocytes in the epidermis, need to be monitored for changes that could indicate malignancy
Actinic keratosis
An occupational related pattern of discrete dry scaley lesions on areas exposed to sun, flesh colored
Melasma
Area of dark pigmentation mostly seen on a woman’s face, influencing factors are typically hormonal female changes
Vitiligo
Complete absence of melanocytes, thus developing white patches on skin from immune mediated pathogenesis against melanocytes
Piebaldism
Rare autosomal dominant congenital disorder of melanocyte developemnt that results in patches of white skin and hair
Hypopigmented patches on central face with greasy scale can be identified as usually being…
…seborrheic dermatitis
Open comedones vs closed comedones
Black headed pimples come from open comedones resulting from oxidation darkening the color, while white heads come from closed comedones
Bonzoyl peroxide for acne treatment mech of action
-antibacterial thru oxidizing activity on proteins of P. acnes, and comedolytic to treat mild to moderate acne
Topical retinoids (vit A derivatives) for acne treatment mech of action and contraindication
-normalizes desquamation of folicular epithelium preventing formation of new comedones and clearing existing ones
-pregnancy
Oral retinoids (accutane) for acne treatment mech of action
-reserved for severe or nodulocystic acne, acts as an analogue to vit. A and is a teratogen and pregnancy category X
Placing a patient on oral retinoids requires that they undergo a…
…risk management program
Hidradenitis suppurativa
Chronic suppurative subcutaneous process that occurs in areas of skin to skin contact (often in groin, axilla, parianal region) where follicle occlusion and sweating create abscesses that are not infectious, take a long time to diagnose
4 main subtypes of rosacea
-erythematotelangiectatic rosacea -papulopustular rosacea -phymatous -ocular
How do you distinguish papulopustular rosacea with acne vulgaris?
A lack of comedomes in papulopustular rosacea
Beau’s lines
Transverse depressions that result from temporary interruption of proximal nail matrix often due to trauma unless presenting in multiple digits, depth of depression indicates extend of damage and width longitudinally indicates duration of insult, grows out with the nail itself
Leukonychia
White opaque discoloration on nails that can either present punctate (spot that moves with growth due to trauma), striate (mee’s lines) (transverse parallel lines that migrate distally) or diffuse (spread evenly over the nail)
Striate or Mee’s lines leukonychia can be a sign in these 2 pathologies
-heavy metal poisoning -chemotherapy
Muehrcke’s lines
Transverse pale lines in the vascular nail beds that do not move with nail growth and are grooveless, due to decreased protein synthesis indicative of systemic disease such as nephrotic syndrome or hypoalbuminemia
The most common type of onychomycosis is distal subungual onychomycosis caused by the dermatophyte…
…trichophyton rubrum
Why do we need to confirm a fungus presence before beginning oral antifungal treatment? How do we confirm a fungus?
-antifungals are hard on the liver and take a long treatment course -Fungus culture is preferred but can also do KOH exam or biopsy nail clippings
1st, 2nd, and 3rd choices for distal subungual onychomycosis treatment
-terbinafine -fluconazole -itraconazole
White bulb at end of hair indicates it was in the ___ phase, while no bulb indicates it was in the ___ phase
Telogen (arrest) anagen (growth)
Kerion
A fungal infectious cause of hair loss with distinct roundness that distinguishes it
Female pattern baldness
Diffuse baldness starting centrally and going out to the sides
Telogen effluvium
Sudden loss of large amounts of hair from premature conversion from anagen to telogen state, often due to diet, hormonal variation, drugs, stress, or pregnancy
Alopecia Areata
Autoimmune disease that impacts young patients resulting in complete hair loss with the hallmark finding of exclamation point hairs
Androgenic alopecia treatment (3)
-5a reductase inhibitor (lower testosterone) -Topical minoxidil -hair transplant
Pull test for alopecia
No shower for 24 hrs then 60 hairs pulled from scalp gently, removal of 6 or more hairs is positive result and indicates active shedding
Cone of light orientation on the tympanic membrane
Lies anteriorally
Presenting symptoms of otitis externa (5) (one big one!)
- Ear pain
- Pruritus
- Discharge
- Hearing loss
- Tragus tenderness**
Ear wick
Dropping topical antibiotics on a cloth used when delivery of the topical antibiotic is blocked or difficult to reach, acts as a folded up cloth to stick deep in the ear to reach the deep part of the external auditory canal
If a child has artificial ostomy in tympanic membrane (for recurrent ottitis media)***, you can treat otitis media from then on with…
…cipro or ofloxacin otic drops as it goes thru the open tubes to the infection
Neurofibromatosis definition and 3 types
A genetic condition that causes tumors to form in the brain, spinal cord, and nerves
Type 1 - causes skin changes and deformed bones. It usually starts in childhood,sometimes the symptoms are present at birth
Type 2 - causes hearing loss, ringing in the ears, and poor balance. Symptoms often start in the teen years
Type 3 - Schwannomatosis causes intense pain. It is the rarest type.
Ramsay Hunt’s syndrome (Herpes zoster oticus)
Invasion of 8th nerve ganglia and ganglion of facial nerve by the herpes zoster virus causing severe ear pain, hearing loss, vertigo, vesicles in the auditory canal and auricle, paralysis of the facial nerve, taste perception, hearing, and lacrimation
90% of otitis externa is one of these 2 causative agents
- p. aeruginosa
- staph aureus
Hearing pathway
External ear Ear drum Ossicles Oval window (Vestibulocochlear apparatus - vestibule and cochlea) Cochlea (fluid filled) Hair cells (ending at round window) Cochlear nerve Brainstem
Epiglottic vallecula
Depression behind root of tongue at floor of oropharynx where saliva is held until initiation of the swallowing reflex, an important landmark in intubation, space between tongue and epiglottis
Stensens duct
The duct emptying the parotid salivary gland, enters the buccal mucosa opposite the 2nd molar and sees facial nerve passing thru this gland
Wharton’s duct
The duct of the submandibular glands located at the floor of the mouth, with a portion of lingual, facial, and hypoglossal nerves lying deep to this gland
Clinical findings of allergic rhinitis (3)
- Allergic shiners
- allergic salute/transverse nasal crease
- pale boggy mucosa sometimes with cobblstoning
Easy way to differentiate leaking CSF from mucus
Glucose strip
Implantable cardiac monitor
Implanted on upper chest wall subcutaneously, hand held device activator placed over device to mark and save rhythms before, during, and after event, new models can automatically send transmission to physician
White on an echocardiogram represents ____ and black represents ___
muscle, lumen
Cardiac stress testing and 2 ways to enhance the study
Goal is to evaluate perfusion/function of myocardium at times of stress (exercise induced or pharmacologically induced) that can evaluate exercise intolerance or rhythm abnormalities, can evaluate for ST segment changes, BP response, maximum achieved predicted HR
-enhanced with imaging studies such as echocardiogram or nuclear imaging
Pharmacological alternatives to treadmill for stress testing (3)
- Dobutamine
- Adenosine
- Persantine
Dobutamine stress testing function
Prominent inoropic and less prominent chronotropic effects on myocardium that increases heart rate, blood pressure, and contractility closely simulating exercise, up titrated as infusion to achieve max acheived predicted HR
Adenosine stress testing function
Coronary vasodilator that decreases blood pressure but has no effect on HR, can cause transient heart block or induce bronchospasm, can accurately assess CAD in patients unable to exercise and is relatively safe with side effects that can be rapidly reversed
Nuclear stress test (perfusion imaging)
Involves nuclear isotope with an affinity for the heart is injected, ischemic areas will have decreased uptake and infarcted will have none, highly sensitive for coronary artery disease as it directly measures PERFUSION
Cardiac catheterization
Angiogram that allows for location of stenosis or aneurysm in blood vessels, allows to assess hemodynamics, pressure in heart and lungs, biopsy, and identify congenital heart defects
Cardiac MRI
Examines size of heart chambers and thickness of the wall and other anatomy, determines extent of damage caused by heart attack or progressive heart disease, detects plaque buildup, assesses a patients recovery following treatment
Cardiac CT angiogram
Uses CT and IV contrast to obtain 3D images of heart and great vessels, enable visualization of plaque or ca2+ deposits on artery walls, noninvasive method to detect blockages
Most common congenital abnormality of heart, what does this predispose patients to?
Bicuspid aortic valve, aortic aneurysm
arcus senilis
A finding on physical exam where the outer iris has whitish gray clouding around the periphery often composed of cholesterol deposits
Why does physiologic splitting of S2 occur?
-The pressure from inflation of the lungs and depression of the diaphragm causes external pressure on vena cava to decrease resulting in it widening and sucking in more blood to the right heart delaying closure of the pulmonic valve after the aortic valve (a2 before p2)
5 steps in assessing a murmur
- Determine where it is heard best
- explain what type it sounds like
- perform valsalva: have patient clench to decrease venous return to better isolate the sound (less blood moves in and out of heart)
- perform handgrip: increase pressure (afterload) which will increase aortic pressure (less blood going out so more blood remains in heart to regurgitate
- leg lift/squatting to increase venous return to right side of heart (more blood comes in and out of heart)
Hypertrophic obstructive cardiomyopathy and pathonomonic sign
Genetic disorder with autosomal dominance that can cause sudden cardiac death in youthful athletes most often with potential to later in life result in atrial fib and other arrhythmias
-valsalva causing increased sound
Acute pericarditis pain is worsened upon ___ and ____
inspiration, laying in recumbant position
Parvus et tartus pulse
Delayed and weak pulse
Corrigan’s pulse
Rapid upstroke and collapse of the carotid artery pulse pathognomonic for aortic insufficiency
Quinke’s sign
Pulsation of capillary bed in nails during capillary refill indicative of aortic insufficiency
Valsalva should ___ aortic stenosis, ___ HOCM, ___mitral and tricuspid regurg
Decrease, increase, decrease
Handgrip should ___ aortic stenosis, ___ HOCM, and ___ mitral regurg
Decrease, decrease, increase
Leg lift/squatting should ___ aortic stenosis, ____ HOCM, ___mitral regurg and tricuspid regurg
Increase, decrease, increase
3 symptoms of aortic stenosis
-syncope
-angina (coronary steal syndrome, blood not coming back during diastole)
-dyspnea
(SAD)
Acquired Aortic Stenosis prognosis and treatment (3)
-good until symptoms develop (then 3 year mortality is 50%)
-Treatment is artificial valve replacement (bioprosthetic or mechanical) or TAVR
or balloon valvuloplasty in extreme cases
Mussett’s sign
Slight head bobbing rare but occasionally seen in end stage valvular diseases
Classic triad of signs for mitral stenosis
- right bundle branch block
- right axis deviation
- biatrial enlargement
Mitral regurgitation physical exam findings (3)
- holosystolic murmur (heard everywhere)
- S1 and S2 obliterated
- PMI laterally displaced
Acquired mitral regurgitation prognosis and treatment (3)
- prognosis is VERY poor when signs develop
- afterload reduction pharmacological drugs, surgical repair of mitral valve or replacement
Aortic valve disease ___, mitral valve disease ___ because ____
replace, repair, chordae tendinae preservation
Epstein anomaly
Congenital defect where tricuspid valve is displaced apically otward bottom of right ventricle so right atrial becomes significantly larger, often associated with ASD
Tetralogy of Fallot
-VSD that overrides the aorta resulting in pulmonary valve narrowing and thickening of the right ventricle**
Rheumatic fever most often affects this valve
Mitral
Gradation of heart murmurs and what grade is consistent with pathological heart disease
1 - very faint, may not be heard in all positions
2 - quiet but heard immediately
3 - moderately loud
(anything below here is pathologic for heart dz)
4 - loud with palpable thrill
5 (systolic only) - loud with thrill may be heard when stethoscope is partially off chest
6 (systolic only) - very loud with thrill may be heard with stethoscope completely off chest
Cooing dove murmur is always associated with…
Still’s murmur
Innocent murmurs characteristics (5)
- grad I-III only
- no clicks
- brief duration, never solely diastolic
- echo will be normal
- no associated pathological findings
Aortic stenosis murmur
-heard over aortic area midsystolically often diminishing S2, increases when squatting, associated with ejection click, pulsus parvus et tardus
VSD murmur
Holosystolic heard best at tricuspid area, causes wide split of S2
VSD treatment options (5)
- If defect is small no treatment needed
- Endocarditis prophylaxis
- Increased caloric need
- Diuretics
- Usually close on own but might need surgical intervention if large
Atrial septal defect (ASD) definition
Congenital disorder caused by spontaneous malformation of the interartrial septum (closure of foramen ovale) from communication between atria resulting in left to right shunt with turbulent blood flow between atria leading to murmur, can be asymptomatic but progresses with age increasing risk of clot formation
Mitral valve prolapse is a ___ murmur heard at the ___
mid late systolic murmur (mid systolic non-ejection click occurring after carotid upstroke), apex (mitral area)
Carvallo’s sign
A pansystolic murmur that increases in intensity upon inspiration, clinical sign of tricuspid regurgitation*** and used to differentiate it from mitral regurg
Holding breath and leaning forward allows for better hearing of these 2 murmurs
- aortic regurgitation
- pericardial friction rub
Valsalva mech of action
- Increase in intrathoracic pressure from inspiration collapses Vena cavae, decreasing venous return
- Decreased stroke volume of left heart results causing reflex tachycardia
- Upon release increased venous return
- corresponding increased stroke volume from left heart causes brief spike in blood pressure
- reflex bradycardia lowers heart rate back to normal
- blood pressure returns to normal
Ventricular septal defect (VSD) definition
A left to right shunt due to congenital hole in the intraventricular septum
Most casees of mitral valve stenosis are caused by…
….rheumatic fever
Diastolic heart failure symptoms (5)
- dyspnea***
- pulmonary edema
- left sided heart failure symptoms
- Elevated BNP
- Evidence of increased ventricular wall thickness on echo
Physical exam finding of diastolic heart failure
S4
It is important not to use ____ in treating systolic heart failure, but can use them in diastolic heart failure
Non-hydropyridine Ca2+ channel blockers
Ischemic cardiomyopathy
A pseudocardiomyopathy that is the leading cause of heart failure in developed countries
List the true cardiomyopathies (4)
- dilated (ventricular dilation)
- hypertrophic (myocardial hypertrophy)
- Restrictive (impaired filling due to fibrosis)
- Arrhythmogenic right ventricular (uhh skip this)
Dilated cardiomyopathy
Most common true cardiomyopathy, characterized by dilation and impaired systolic function of right or left ventricle globally, 50% of cases unknown etiology, others include viral infection or familial inheritance
Restrictive cardiomyopathy
Restrictive ventricular filling and reduced diastolic volumes with normal or near normal wall thickness, uncommon in US and presents with diastolic dysfunction (poor prognosis)
Restrictive cardiomyopathy causes (3)
- amyloidosis
- sarcoidosis
- drug induced fibrosis
Vicious cycle of heart failure mech of action
- Cardiac lesion decreases cardiac performance
- Baroreceptor fails to be stimulated resulting in increased sympathetic response
- vasomotor response to constrict to increase pressure to perfuse various organs of the body
- Kidney’s juxtaglomerular cells activates RAAS system which causes vasoconstriction and fluid retention (aldosterone)
- workload of heart is increased (afterload and preload)
- increased workload causes myocardial cell structural damage
- further impaired decreased cardiac performance dropping cardiac output even more
- this stimulates causes failure to stimulate baroreceptors….
2 natriuretic peptides released by heart and their function
1) Atral natriuretic peptide - released in response to increased stretching of atrium to promote loss of Na+ and H2O into urine
2) B natriuretic peptide - Released in response to increases stretching of ventricles and promote arterial and venous dilation and increase GFR to kidney resulting in decreased systemic resistance and loss of Na+ and H2O in urine
