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SmPc IMC Flashcards

1
Q

What does the definition of Cardiomyopathy broadly mean?

Define the three types and general issue of each

A

Heart Muscle Dz

Dilated: large, weak ventricles

Hypertrophic: large, thickened heart muscle

Restrictive: stiff ventricle

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2
Q

How may a Pt w/ dilated cardiomyopathy present to clinic

What MedHx can be there

What may be found on PE

What could be seen on CXR?

A

Older w/ SoB, worse in PM

HTN, ETOH abuse

Pan-systolic murmur radiating to axilla
Apex beat,
Normal breath sounds,
S3 gallop

CXR: enlarged LV shadow

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3
Q

What is the MC type of cardiomyopathy

What process usually causes this MC

A

Dilated

Process/Event/Trauma damages myocardium leading to decreased ventricular contraction and LV dilation

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4
Q

What are possible etiologies of Dilated Cardiomyopathy

1/3 of cases will be d/t ?

A 
GP-CEVICHE
Genetic
Post-partum
Chemo
Endocrine d/o
Viral infections
Ischemic: MI CADz Arrythmia
Cocaine
Heavy metals
ETOH abuse

Inherited

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5
Q

How is Dilated Cardiomyopathy Dx

What will be seen on EKG

What can be seen on CXR

A

Echo- most definitive; shows dilation and dysfunction

Nonspecific ST/T changes

Balloon like heart- cardiomegaly/pulm congestion

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6
Q

How is Dilated Cardiomyopathy Tx

Why is the ABCD mnemonic used for Tx

What medication is used to increase cardiac contractility

A

BB + ACEI+ Loop

Anti-Coag
ACEI
BB
CCBs
Diuretic/Digoxin

Digitalis

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7
Q

Extreme cases of Dilated Cardiomyopathy may need ? for Tx

What part of the heart becomes hypertrophied during HOCM

Where is this murmur heard and what makes it worse?

A

Transplant, LVAD

Septum, impedes into LV outflow tract during systole

LLSB mid-systolic
Worse w/ contractility (Valsalva, standing)

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8
Q

How will HOCM present

How is this condition passed down genetically

What can this condition be confused w/ and how is it differentiated?

A

Young athlete w/ +FamHx of sudden death/syncopal episodes

Autosomal dominant

Athletic heart- won’t have diastolic dysfunction

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9
Q

What will be seen on PE during HOCM

How is this condition Dx

What would be seen on an EKG?

A

Bifid pulse
S4 gallop

Echo- LVH w/ thick septum, small LV and diastolic dysfunction

LVH and non-specific ST/T-wave changes

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10
Q

How is HOCM Tx

What needs to be avoided during Tx

What medication is contraindicated during Tx?

A
  • Metoprolol and/or Verapamil- dec contractility/HR to dec outflow obstruction
  • ICD implant consideration
  • No high intensity athletics
  • Surgical/alcohol ablation of hypertrophy section

Nitrates, or any drug that decreases preload (diuretic, ACEI, ARBs)

Digoxin- increases force of contraction and increase obstruction

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11
Q

Define Restrictive Cardiomyopathy

What are the etiologies of this condition

A

Right HF w/ Hx of infiltrative process

Ca- radiation/chemo
Hemochromatosis
Fibrosis
Amyloidosis
Sarcoidosis
Scleroderma
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12
Q

What abnormals may be seen on PE of Restrictive Cardiomyopathy

What would be seen on Echo

What would an EKG show

What would CXR show

A

P-HTN
Large atria
Early diastolic filling

Normal LVEF, dilated atria, hypertrophied myocardium

Non-specific abnormals:
ST/T-wave abnormalities
Low voltage

Pulm vascular congestion
Normal heart size

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13
Q

If a Dx is still uncertain after Echo/EKG, what is the next step?

Although not necessary for Dx, what result would be seen if catheterization is done?

Since this condition’s Tx is focused at the underlying cause, what management step can be taken w/ caution

A

MRI- abnormal cardiac textures

High atrial pressures

Diuretics if +edema/pulmonary congestion- caution, don’t lower preload

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14
Q

What type of murmur does ASD create?

What causes a non-cyanotic ASD

What is the MC type of non-cyanotic ASD

A

ULSB systolic rumble w/ wide, fixed, split S-2 during in/expiration

Foramen ovale fails to close

Ostium Secundum- defect in middle of septum (primum occurs in lower atrial septum)

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15
Q

Other than a murmur, what else may be noted on PE during an ASD exam

What is the best method to Dx this condition

How is this condition Tx Sx and definitively

A

Failure to thrive

Placing catheter through shunt

Sxs: Diuretics ACEI Digoxin
Def: surgical closure

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16
Q

How does a PDA defect present

What type of murmur is heard

Normally, this structure is kept open d/t ?

A

Young infant w/ red/pink UE and blue LE

Machinery-like of LSB at pulmonic space late in systole make loud S2

Prostaglandin E-2- why NSAIDs Tx condition and c/i in pregnancy

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17
Q

How is PDA Dx

How is it Tx

What type of murmur does VSA create

A

Echo

Indomethacin

Holosystolic at LLSB w/out radiating into axila

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18
Q

? is the MC pathologic murmur found in childhood

How is this MC Dx

How is this Tx

A

VSD

Echo

If not self-resolving by age 6- surgery

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19
Q

What systemic issue is often present w/ CAAortas?

What key PE finding may be noted in teen/early adulthood exams?

What type of murmur may be appreciated

A

HTN- kidneys can’t sense normal pressures

Normal UE pressure,
Dec LE pressures

Ejection murmur at aortic area, radiates to axilla/back

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20
Q

What anatomical defect is present in half of Coarctation of Aorta cases

These pts are at increased risk for ? issue

What are the 3 methods to Dx this condition

A

Bicuspid valve

Cerebral berry aneurysm

1st- echo
EKG- LVH
CXR- rib notching, Figure-3 sign

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21
Q

How is Coarctation of Aortas Tx

What are the 4 issues seen in Tetralogy of Fallot

How does this condition present

A

Prostaglandin- E1s
Surgery- balloon dilation

Pulm stenosis
RVH
Over riding aorta
VSD

Difficult feeding
Failure to thrive
LoC w/ crying

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22
Q

What type of murmur is head during TOFallot

What will be seen on CXRs

? RF places Pts at risk for Stable Angina w/ Pts that have atherosclerosis

A

Crescendo-decrescendo, holosystolic murmur at LSB and radiates to back

Boot shaped heart

DM

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23
Q

Pts w/ classic Sxs of aninga need ? test as the most widely used test to Dx ischemic heart Dz

Define Stable Angina

What would be seen on EKG

A

Nuclear stress test

Precordial discomfort/pressure that is predictably relieved by rest/nitro and worse w/ activity

ST depression during episodes, can be normal; Flat/inverse T-waves

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24
Q

How is Stable Angina Dx

What is the definitive method to Dx

How is this condition Tx

A

Exercise stress test- most useful/effective non-invasive test; ST depression 1mm= Dx

Coronary angiography

Bypass surgery
ACEI/BB/CCBs
Nitrates
Angioplasty
ASA
Statins
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25
# Define NSTEMI What type of EKG changes may be seen What type of infarct can cause this presentation
Myocardial necrosis w/: +troponin/CK But w/out: ST elevation, Q-waves ST depression T-wave inversion Subendocardial infarct
26
What does the typical workup for NSTEMI include What cardiac marker is most sensitive and what time frames does it follow What other two markers can be used, but less often, and what time lines do they follow
CXR CBC/CMP BNP EKG Troponin I Troponin: Appears 2-4hrs Peaks 12-24hrs Lasts 7-10days CK/MB: Appear: 4-6hrs Peak: 12-24hrs Normal: 48-72hrs Mb: Appear: 1-4hrs Peak: 12hrs Baseline: 24hrs
27
How are NSTEMIs Tx
``` BBs ASA Reperfusion- PCI Clop Heparin ACEI NTG Statin ```
28
# Define STEMI How are these worked up
Myocardial necrosis w/: +troponin/CK AND ST elevation/Q-wave CXR CBC/CMP BNP EKG Troponin I
29
What EKG findings indicated the location of an MI
Anterior: 1, aVL, V2-6 Inferior: 2,3,aVF Lateral: ST elevation 1, aVL, 5-6 w/ reciprocal changes in 3, aVF Posterior: ST depression V1-3
30
How are STEMIs Tx
ASA/Clop at once PCI <90min Thrombolytics <180min if PCI unavailable ``` BBs ASA Reperfusion- PCI Clop Heparin ACEI NTG Statin ```
31
What are the absolute c/i for performing fibrolytic therapy for STEMI Tx What absolutes don't include ? ongoing issue
``` Prior intracranial hemorrhage Cerebral vascular lesion Malignant intracranial neoplasm Ischemic stroke <3mon Suspected aortic dissection Active bleeding/diathesis ``` Menses
32
How does LV failure present How does RV failure present
SOB Fatigue w/ exertion SoB S3 Crackles Displaced to left apical impulse SoB Ankle swelling JVD Hepatojugular reflex Hepatomegaly Lung will be CTA
33
HF is a syndrome of ? Left sided Systolic HF is d/t ? How is this form of HF Tx How is an acute worsening of this type of HF Tx
Ventricular dysfunction- dilated w/ EF <40% Rapid ventricular filling during early diastole causing S3 ``` ACEI + BB _ Loop O2, ACEI D/c BB Start Nitro Double IV diuretic ```
34
How is a Diastolic left HF identified on PE What causes this condition/form of HF This form is common in Pts w/ ? MedHx
Diastolic S4 w/ normal EF Hypertrophic thick wall of LV w/ impaired relaxation HTN
35
How is Diastolic L-HF Tx What two forms of Tx are avoided How are acute exacerbation Tx
ACEI BB/CCB No diuretic if stable chronic failure Digoxin ``` Same as Systolic LFH: ACE IV Loop Nitro O2 ```
36
What causes RV right sided HF What is the MC cause of R-HF What is the Gold standard method for Dx and how is this Tx
Pulm-HTN Left sided HF R sided heart cath Tx: underlying condition
37
What causes High Output Cardiac Failure What Sx will appear first but then the Pt will progress into ? How is this form Tx
Inc metabolic demand: Hyperthyroid Anemia, severe BeriBeri/THiamine deficient Tachy leading to systolic failure Llike HF and acute CHF; Tx underlying condition
38
What is the best method to Dx CHF What is the most important determinant in the prognosis
Echo EF Norm 55-60 <35: inc mortality, place defib
39
What are the 4 classes of NYHA HF
1: no limitations on activity 2: slight limitations; ordinary activity leads to fatigue, palpitations, dyspnea, angina but conformable at rest 3: marked limitations of activity; less than ordinary activity leads to palpitations, dyspnea, angina but are comfortable at rest 4: unable to carry out activity w/out discomfort but also have Sxs at rest that worse w/ any activity
40
When Tx S/D-HF, what part of the Tx needs to be used ASAP and why What 3 specific drugs are used in Tx
ACEI: dec comorbidity and mortality Beta-1 selective: Bisoprolol Metoprolol succinate Carvedilol
41
Aortic regurg
Early blowing, decrescendo diastolic murmur at LSB Pt sits, leans fwd and exhales Diaphragm at Erbs
42
MS
Split S1 after opening snap at apex Rumble loudest at beginning of diastole heard best LSB/apex Pt position: supine, left side down w/ bell on mitral position
43
Pulm Regurg
High pitch decrescendo murmur at LUSB Inc w/ inspiration Pt sits, leans fwd Diaphragm on pulmonic
44
TS
Diastolic rumble best heard at LLSB/xiphoid Pt supine w/ bell at Tricuspid position
45
? are the MC types of heart murmurs What are the 3 types How are these MC differentiated from pansystolic murmurs
Mid-systolic ejection Pathologic: structural abnormalities (pansystolic) Physiologic: physiological alteration in body Innocent: no detectable abnormalities Gap between murmur and S2
46
AS
Late systolic ejection murmur at 2nd ICS, RSB that radiated to carotids/apex Dec w/ valsalva EKG shows LVH Pt sits, diaphragm on RUSB aortic position
47
PS
Harsh systolic murmur at 2/3rd ICS radiating to left shoulder Early systolic sound precedes murmur during expiration EKG: right axis deviation Wide split S2 Pt supine w/ bell at tricuspid locaiton
48
HCM
Med-pitched mid-systolic murmur; dec w/ squat, inc w/ strain Pt supine w/ diaphragm over mitral
49
MVP
Mid-systolic click Pt supine w/ diaphragm over mitral position
50
MR
Blowing holosystolic murmur at apex/mitral w/ split S2 and radiates to axilla Pt supine w/ diaphragm on mitral/apex location
51
TR
Hx rheumatic fever Blowing holosystolic murmur on LSB; inc w/ valsalva and inspiration EKG: afib Pt supine w/ diaphragm over tricuspid position
52
VSD
Loud, harsh holosystolic murmur at LLSB w/out axila radiation Wide, fixed S2 Pt supine w/ diaphragm over tricuspid
53
Primary HTN is defined as ?
SBP 130 or > DBP 80 or > On two readings during two different visits w/out obvious cause Norm: <120/80 and <80 Elevate: 120-29 and <80 Stage 1: 130-39 or 80-89 Stage 2: 140or> or 90 or >
54
What does the ACC/AHA define as a target blood pressure regardless of w/ or w/out comorbidity What are the JNC8 Tx targets
<130/80 <60y/o, even w/ DM/Kidney D/o: <140/90 >60y/o: <150/90
55
How is Primary HTN Tx
Normal: yearly eval Elevated: lifestyle change, re-eval 3-6mon ``` Stage 1: assess ASCVD risk <10%: lifestyle mod, reassess 3-6mon >10%, CVD, DM, CKD: lifestyle mod, 1 medication, re-eval 1mon Met goal: reassess 3-6mon Not met: different med/titrate Monthly f/u until goal reached ``` Stage 2: lifestyle mod w/ 2 medications, reassess 1mon Met goal: re-eval 3-6mon Not met: change med/titrate Monthly f/u until goal reached
56
How are Non-Black Pts, including those w/ DM Tx for Primary HTN How is Tx changed if they're at Stage 2 HTN How are black adults Tx and w/ ? goal in mind
ACEI or ARB CCB: Amlodipine Thz: Chlorthalidone/Indapamide 2 BP meds from different classes Two or more med (Thx and CCB) for target <130/80
57
When are CCBs c/i as an anti-hypertensive Why are ACEI/ARB c/i in diabetic HTN control When are ACEIs c/i When are BBs c/i during anti-hypertensive therapy
Angina pectoris Proteinuria Pregnancy DMs
58
S/e of using Spironolactone for antihypertensive therapy S/e of CCBs What two CCBs are rate controlling
HyperK Edema Verapamil/Diltiazem
59
A-blockers can be used to Tx HTN and ? simultaneously What are two possible s/e of using Hydralazine for antihypertensive therapy Criteria for a HTN emergency and the next step that determines Tx
BPH Lupus-like syndrome Pericarditis SBP >180 and/or DBP 120 or> End organ damage New/Worse/Progressive
60
Once an HTN emergency is admitted to ICU, what 3 conditions have to be r/o What is the Tx plan if these condition are or are not present
Aortic dissection Pre/Eclampsia Pheo crisis Are: SBP <140 w/in first hr Dec to <120 if dissecting Not: Max reduction 25% w/in first hour Then to 160/110-100 w/in 2-6hrs, Then to normal w/in 24hrs
61
Criteria for HTN urgency How are these PTs managed What Dx count as end organ damage for HTN Emergencies What doesn't count as an end organ damage
>180/120 w/out end organ damage Start on 2 PO drugs w/ close f/u ``` Encephalopathy Nephropathy ICH Aortic dissection Pulm Edema Unstable angina MI ``` Papilledema- HTN retinopathy
62
# Define Malignant HTN What is the drug of choice for Tx of HTN urgency What is the drug of choice for HTN emergencies What is the recommended drug combo for Tx of Malignant HTN
HTN Retinopathy; diastolic >140 w/ papilledema and either encephalopathy or nephropathy Clonidine- RxoC Sodium nitroprusside Clevidipine/Sodium nitroprusside
63
# Define Secondary HTN What are the red flags for secondary HTN This Dx needs to be suspected in ? presentation
SBP 130 or > DBP 80 or > Both w/ identifiable and correctable cause HTN <25y/o w/out FamHx HTN starting >50 Previously controlled, now refractory Refractory to antihypertensives
64
What is believed to be the MC cause of Secondary HTN If Pts HTN is newly Dx, what is the next step How is Secondary HTN Tx
Primary aldosteronism UA Spot albumin/Cr ratio EKG Cr K Na Fasting glucose Lipids TSH Underlying condition Tx w/ aim for BP treatment targets
65
What class drug can accidentally cause HTn Urgency How does occur
MAOI Eating wrong at Holiday buffets: cheese sausage wine
66
# Define Cardiogenic Shock What are the 3 MC causes What will be seen on PE
Impaired contractility and overall pump failure; heart can't generate enough output to sustain perfusion MI HF Tamponades JVD BP <90mm AMS
67
How is Cardiogenic Shock Dx How is this Tx
Echo: wedge pressure >15mm Fluids: 250-500ml NS w/ frequent auscultations Pressers: Dobutamine NorEpi Balloon pump
68
# Define O-HOTN If PT is diabetic, what is a common cause of this condition What test do they then need
Excessive drop of BP while upright SBP drop >20mm DBP drop 10mm Both 2-5min after supine to standing Autonomic dysfunction Tilt table test: HR >15 bpm= low volume
69
How is O-HOTN Dx What result suggests autonomic impairment as the cause What result suggests dec volume as the cause How is this Tx
BP/HR measured after 5min supine and 1-3min after standing HOTN w/out compensatory inc HR HR inc >100bpm or inc by >30bpm Fluids/Na intake Fludrocortisone/Midodrine
70
# Define Vasovagal HOTN How is this Dx What test can reproduce these Sxs
Paradoxical w/drawl of sympathetic stimulation replaced by parasympathetic/vagal activity causing dec BP/cerebral perfusion Hx PE Carotid massage EKG Upright tilt table test
71
Vasovagal HOTN can occur at anytime but if it first episode occurs after 40y/o, ? How is this Tx
Reluctant to make Dx Supine w/ legs elevated BBs Disopyramide Pacemaker
72
What type of lesions may be seen on the hands of Pts w/ infected cardiology Dxs What are the two MC microbes to cause infectious endocarditis What is the MC microbe to cause Acute/Subacute endocarditis, drug user endocarditis and valvular endocarditis
Janeway: painless Staph/Strep Acute: Staph A Sub: S Viridians Drug: Staph A Valve: Staph epidermis
73
What is the MC cause of fungal endocarditis What does this form usually cause to develop How is this Tx
Candidiasis: contaminated lines <2mon from valve replacement surgery Large vegetations Amphotericin B
74
? types of microbes cause vegetation to grow on native valves ? microbe is the MC cause of endocarditis How does this MC present
HACEK S veridians Late complication of valve replacement w/ small vegetations and emboli
75
What peripheral PE finding suggest infective endocarditis What neuro findings are consistant w/ this Dx
``` Splinter hemorrhages Osler nodes- painful on extremity Roth spot- retinal hemorrhage Janeway lesion Petichae: palate/conjunctiva Splenomegaly Hematuria ``` Visual loss Motor weakness Aphasia
76
How is infectious endocarditis Dx What labs are needed What frequency are these labs drawn
TEE: gold standard RF ESR CBC 3 sets, 1hr apart
77
What are the major and minor criteria needed for Dx infectious endocarditis
Major: Minor:
78
How is infectious endocarditis Tx based on etiology
Native valve and no IVDA: IV Ampicillin + Nafcillin + Gentamicin Prostethic valve: Vanc + Gentamicin + Rifampin IVDA: Nafcillin PCN allergy= Van substitute
79
What is used for infective endocarditis prophylaxis
2g Amoxicillin 60min or less before procedures

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