Week 3 Clinical Medicine: Valvular Heart Disease/HF, Heart Murmurs, and Syncope/Chronic Hypertension Flashcards
What overload do stenosis and regurgitation cause and how does the heart compensate?
Stenosis: causes PRESSURE overload
- causes hypertrophy
Regurgitation: causes VOLUME overload
- causes dilation
Murmur Grading: what does each level indicate?
- +1
- +2
- +3
- +4
- +5
- +6
- barely audible
- faint, soft
- louder, easily heard
1-3 have NO detectable THRILLS
- very loud, palpable thrill
- stethoscope barely touching chest, thrill
- hear without stethoscope; palpable thrill
Mitral Regurgitation
What are the 4 acute (IP/RC/IE/VO) and 2 chronic (VP/MD) causes of Mitral Regurgitation?
Where is it heard?
A: ischemic papillary muscles (2nd MC), ruptured chordae, infective endocarditis, volume overload
C: Mitral Valve Prolapse (MC) and myxomatous degen.
- systolic; blowing at apex; radiates to LEFT AXILLA
Mitral Valve Prolapse
What is it and how is it treated?
- one or both leaflets prolapse into left atrium
- more common in WOMEN; murmur inc. with Valsalva or standing
- reassure or Beta Blockers if symptomatic
Tricuspid Regurgitation
What does it sound like and where is it heard?
What is seen on jugular venous pulse?
- blowing, systolic murmur at 4th ICS LSB
- inc. with INSPIRATION (Carvallo sign)
- prominent V WAVE on jugular venous pulse
Aortic Stenosis
What is it caused by and what does it lead to?
What are its 3 cardinal symptoms? (D/A/S)
- due to degenerative calcifications; bicuspid Aortic Valve
- cause PRESSURE OVERLOAD and LVH
CS: dyspnea on exertion, angina, syncope
Aortic Stenosis
What does it sound like and where?
What is seen on ECG?
- harsh crescendo-decrescendo @ 2nd ICS RSB, radiates to sternal notch and carotids
ECG: down sloping of ST segment - T wave
Where are these Systolic murmurs heard:
- Pulmonic Stenosis (what condition is it associated with)
- Ventricular Septal Defect (VSD)
- Atrial Septal Defect (ASD)
- crescendo-decrescendo @ 2nd ICS LSB, radiates to left clavicle
- associated with Tetralogy of Fallot
- holosystolic murmur, LLSB with thrill
- murmur inc. with handgrip
- upper LSB with S2 splitting
Mitral Stenosis
What causes it and what are its symptoms?
Where is it heard and what is seen on ECG?
- due to Rheumatic HD (Group A strep), MAC, congenital
Sx: DOE, orthopnea, palpitations (Atrial Fibrillation)
- also Ortners Syndrome (L. Recurrent Laryngeal)
- Ortners = hoarseness
- low pitch rumbling at apex with opening snap
ECG: left atrial enlargement, right axis deviation, A Fib.
Tricuspid Stenosis
What causes it and where is it heard?
What is seen on jugular venous pulse and ECG?
- due to Rheumatic Disease
- LSB murmur inc. during inspiration (Carvallo)
- prominent A wave on in Jugular vein
ECG: Right atrial enlargement
Aortic Regurgitation
What are 2 acute causes and 2 chronic causes?
What does it lead to?
Acute: infective endocarditis, aortic dissection
Chronic: calcific degeneration, bicuspid aortic valve
- causes volume overload and left ventricular hypertrophy (LHF)
Aortic Regurgitation
What does it sound like and where is it heard?
What are DeMusset, Quincke’s, Traube, and Duroziez’s Signs?
- decrescendo murmur @ 3rd ICS LSB (mimics Mitral Stenosis) –> soft A2 w/WIDE PULSE PRESSURE
De: head bob w/beats
Q: capillary nail pulsations
T: “pistol shot” sound over femoral artery
Du: diastolic murmur over femoral A. w/bell compress.
Rx: dec. afterload (ACEI or ARB)
Pulmonary Regurgitation
What does it sound like and where?
What is it associated with?
- decrescendo murmur at 2nd ICS LSB
- associated with pulmonary hypertension; inc. P2 sound
What is the difference between HFpEF and HFrEF?
What are the cardinal clinical symptoms?
Preserved = LVEF > 50%
- ventricles hypertrophied
- EF normal, but less overall blood being pumped
Reduced = LVEF < 40% (50% of HF cases)
- ventricles dilated
- reduced EF, too much blood
CS: dyspnea and fatigue, with edema and rales
What Lab tests and imaging are more frequently used to diagnose HFrEF?
Labs: BNP and N-terminal-pro BNP
- pts. w/normal BNP & untreated = NO HF
- check Renal and Pulm = elevated BNP too!
Image: Echocardiogram!
- 2D TTE with suspected or known HF
What are the objectives of treating HFrEF and HFpEF?
How are both of these conditions treated?
Obj: improve symptoms, prevent remodeling, prevent hospital admission
HFrEF = ACEi and BB, add spirinolactone if still symptomatic w/LVEF < 35%
- use DIURETICS for symptom relief
- advanced? = HEART TRANSPLANT
- cardiac rehab and exercise programs too!
HFpEF = use ONLY diuretics if NO Hypertension
- treat comorbidities
What are diagnostic imaging findings of Cor Pulmonale using EKG and CXR?
How should pts. with Cor Pulmonale be treated?
EKG: right axis deviation, RV hypertrophy
CXR: enlarged main central pulmonary arteries
Tx: keep SaO2 > 90%
- diuretics, fluid/Na restrictions
- IV inotropes while treating causes
possible palliative care since RHF is among strongest predictors for adverse outcomes for pts. with HF
What is Syncope and what are its 3 categories?
- transient, self-limited loss of consciousness due to cerebral hypoperfusion
Categories:
- Neurally-mediated (Transient; 45%) = REFLEX
- Cardiac (20%) = arrhythmias due to dec. CO
- Orthostatic (Chronic; 10%) = stand-up quickly
What is the Criteria used for Syncope decision making?
What is its CHESS mneumonic?
San Francisco Syncope Rule - predicts serious outcomes in 7 days in patients presenting with syncope
C - congestive heart failure history H - hematocrit < 30% E - EKG abnormality S - SOB symptoms S - systolic BP < 90 mmHg at triage
Presentation of:
- Neurally-mediate Syncope
- Orthostatic Hypotension
- Cardiac Syncope
- orthostatic intolerance, autonomic activation
- diaphoresis, pallor, hyperventilation, yawning
- eyes open, deviate up; roving movements
- urinary incontinence
- reduced SBP > 20 mmHg or DBP > 10 mmHg within 3 minutes of standing
- light-headedness w/sudden postural change
- preceded by warning symptoms
- Cardiac
- appears suddenly with few warnings
- exercise or supine preceded by palpitations
What are these devices and which pts. should get them:
- Holter
- Event Monitor
- External Loop Recorder
- Internal Monitor
used for pts with CV abnormalities
- portable, continuous - pt w/symptoms in 24-72 hrs
- pt.-activated, analog phone - pt. symp in 2-6 wks
- continuous, get data around events - 2-6 wks
- SubQ, pt. controlled - recurrent, infrequent syncope
Syncope Treatments:
- Neurally-mediated
- Orthostatic Hypotension
- Cardiac
- inc. central blood volume and CO
- reassurance, avoidance of triggers
- physical counterpressure of limbs (leg cross)
- remove reversibles; pt. education/compress stocking
- counterpressure maneuvers; inc. Na/H2O
- EPS –> pts. with arrhythmic etiology ONLY
- treat underlying tachycardia/bradycardia
What is the difference between:
- Primary Hypertension
- Secondary Hypertension
- Hypertensive Urgency
- Hypertensive Emergency
- elevated BP with NO underlying disorders
- elevated BP with specific underlying disorder
- BP > 180/110 without end organ symptoms
- BP > 180/110 WITH end organ symptoms
What are the ranges for:
- Normal BP
- Elevated BP
- Stage 1 Hypertension
- Stage 2 Hypertension
What are HTN ranges for children and pregnant women?
- < 120/80 mmHg
- 120-129/<80 mmHg
- 130-139/80-89 mmHg
- > 140/90 mmHg
Kids: HTN - SBP >95th%ile, Pre-HTN - 90-95%ile
PW: HTN - SBP > 140 and DBP > 90
usually asymptomatic = MEASURE BP
What 6 tests should be gotten for pts. suspected of hypertension?
CBC, CMP, lipid panel, TSH, UA, EKG
What 3 pt populations are automatically placed in high-risk category for hypertension?
- pts with DM, CKD, age > 65 yo
What are the first-line drugs for Hypertension Treatment?
What drugs are better for African American pts. vs Caucasian pts?
RAAS inhibitors, CCBs, thiazide diuretics
AA: CCBs or diuretics
C: ACEi/ARBs
Which drugs are used to treat these hypertension comorbidities:
- DM2
- CHD/CHF
- BPH
- A Fib.
- ACEi/ARBs
- ACEi/ARBs and Beta-blockers
- Alpha-blockers
- CCBs (non-dihydropiridines) or Beta-blockers
Hypertensive Urgency (Asymptomatic Severe HTN)
How should it be treated?
What are the two most common symptoms of end organ damage?
- no evidence that acute inpatient treatment improves outcome
GOAL: BP lowered gradually <160/100 mmHg but not acutely > 20-25% of MAP over several days to weeks
- intensify therapy every 2-4 wks
CS: cerebral infarction and pulmonary edema
What drugs should be used for treatment of these areas during HTN Emergency?
- General
- Brain (C/N/F/N)
- Heart (N/C/M/E) or (N/N)
- Vascular (E)
- Kidney (F)
- lower MAP gradually: 10-20% 1st hr, 5-15% in nxt 24 hrs
- HTN encephalopathy
- Clevidipene, nicardipine, fenoldapam, nitroprusside
- Acute HF - nitroprusside and nitroglycerin
- ACS - nicardipene, clevidipene, metoprolol, esmolol
- esmolol (IV beta blockers)
- fenoldapam (does NOT worsen renal function)
