SmPc IMC Flashcards
What does the definition of Cardiomyopathy broadly mean?
Define the three types and general issue of each
Heart Muscle Dz
Dilated: large, weak ventricles
Hypertrophic: large, thickened heart muscle
Restrictive: stiff ventricle
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?
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
What is the MC type of cardiomyopathy
What process usually causes this MC
Dilated
Process/Event/Trauma damages myocardium leading to decreased ventricular contraction and LV dilation
What are possible etiologies of Dilated Cardiomyopathy
1/3 of cases will be d/t ?
GP-CEVICHE Genetic Post-partum Chemo Endocrine d/o Viral infections Ischemic: MI CADz Arrythmia Cocaine Heavy metals ETOH abuse
Inherited
How is Dilated Cardiomyopathy Dx
What will be seen on EKG
What can be seen on CXR
Echo- most definitive; shows dilation and dysfunction
Nonspecific ST/T changes
Balloon like heart- cardiomegaly/pulm congestion
How is Dilated Cardiomyopathy Tx
Why is the ABCD mnemonic used for Tx
What medication is used to increase cardiac contractility
BB + ACEI+ Loop
Anti-Coag ACEI BB CCBs Diuretic/Digoxin
Digitalis
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?
Transplant, LVAD
Septum, impedes into LV outflow tract during systole
LLSB mid-systolic
Worse w/ contractility (Valsalva, standing)
How will HOCM present
How is this condition passed down genetically
What can this condition be confused w/ and how is it differentiated?
Young athlete w/ +FamHx of sudden death/syncopal episodes
Autosomal dominant
Athletic heart- won’t have diastolic dysfunction
What will be seen on PE during HOCM
How is this condition Dx
What would be seen on an EKG?
Bifid pulse
S4 gallop
Echo- LVH w/ thick septum, small LV and diastolic dysfunction
LVH and non-specific ST/T-wave changes
How is HOCM Tx
What needs to be avoided during Tx
What medication is contraindicated during Tx?
- 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
Define Restrictive Cardiomyopathy
What are the etiologies of this condition
Right HF w/ Hx of infiltrative process
Ca- radiation/chemo Hemochromatosis Fibrosis Amyloidosis Sarcoidosis Scleroderma
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
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
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
MRI- abnormal cardiac textures
High atrial pressures
Diuretics if +edema/pulmonary congestion- caution, don’t lower preload
What type of murmur does ASD create?
What causes a non-cyanotic ASD
What is the MC type of non-cyanotic ASD
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)
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
Failure to thrive
Placing catheter through shunt
Sxs: Diuretics ACEI Digoxin
Def: surgical closure
How does a PDA defect present
What type of murmur is heard
Normally, this structure is kept open d/t ?
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
How is PDA Dx
How is it Tx
What type of murmur does VSA create
Echo
Indomethacin
Holosystolic at LLSB w/out radiating into axila
? is the MC pathologic murmur found in childhood
How is this MC Dx
How is this Tx
VSD
Echo
If not self-resolving by age 6- surgery
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
HTN- kidneys can’t sense normal pressures
Normal UE pressure,
Dec LE pressures
Ejection murmur at aortic area, radiates to axilla/back
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
Bicuspid valve
Cerebral berry aneurysm
1st- echo
EKG- LVH
CXR- rib notching, Figure-3 sign
How is Coarctation of Aortas Tx
What are the 4 issues seen in Tetralogy of Fallot
How does this condition present
Prostaglandin- E1s
Surgery- balloon dilation
Pulm stenosis
RVH
Over riding aorta
VSD
Difficult feeding
Failure to thrive
LoC w/ crying
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
Crescendo-decrescendo, holosystolic murmur at LSB and radiates to back
Boot shaped heart
DM
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
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
How is Stable Angina Dx
What is the definitive method to Dx
How is this condition Tx
Exercise stress test- most useful/effective non-invasive test; ST depression 1mm= Dx
Coronary angiography
Bypass surgery ACEI/BB/CCBs Nitrates Angioplasty ASA Statins
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
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
How are NSTEMIs Tx
BBs ASA Reperfusion- PCI Clop Heparin ACEI NTG Statin
Define STEMI
How are these worked up
Myocardial necrosis w/: +troponin/CK AND
ST elevation/Q-wave
CXR CBC/CMP
BNP EKG Troponin I
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
How are STEMIs Tx
ASA/Clop at once
PCI <90min
Thrombolytics <180min if PCI unavailable
BBs ASA Reperfusion- PCI Clop Heparin ACEI NTG Statin
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
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
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
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
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
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
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
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
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
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
Aortic regurg
Early blowing, decrescendo diastolic murmur at LSB
Pt sits, leans fwd and exhales
Diaphragm at Erbs
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
Pulm Regurg
High pitch decrescendo murmur at LUSB
Inc w/ inspiration
Pt sits, leans fwd
Diaphragm on pulmonic
TS
Diastolic rumble best heard at LLSB/xiphoid
Pt supine w/ bell at Tricuspid position
? 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
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
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
HCM
Med-pitched mid-systolic murmur; dec w/ squat, inc w/ strain
Pt supine w/ diaphragm over mitral
MVP
Mid-systolic click
Pt supine w/ diaphragm over mitral position
MR
Blowing holosystolic murmur at apex/mitral w/ split S2 and radiates to axilla
Pt supine w/ diaphragm on mitral/apex location
TR
Hx rheumatic fever
Blowing holosystolic murmur on LSB; inc w/ valsalva and inspiration
EKG: afib
Pt supine w/ diaphragm over tricuspid position
VSD
Loud, harsh holosystolic murmur at LLSB w/out axila radiation
Wide, fixed S2
Pt supine w/ diaphragm over tricuspid
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 >
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
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
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
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
S/e of using Spironolactone for antihypertensive therapy
S/e of CCBs
What two CCBs are rate controlling
HyperK
Edema
Verapamil/Diltiazem
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
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
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
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
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
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
What class drug can accidentally cause HTn Urgency
How does occur
MAOI
Eating wrong at Holiday buffets: cheese sausage wine
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
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
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
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
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
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
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
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
? 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
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
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
What are the major and minor criteria needed for Dx infectious endocarditis
Major:
Minor:
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
What is used for infective endocarditis prophylaxis
2g Amoxicillin 60min or less before procedures
