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CPR II Exam 1 > Week 3 Clinical Medicine: Valvular Heart Disease/HF, Heart Murmurs, and Syncope/Chronic Hypertension > Flashcards

Week 3 Clinical Medicine: Valvular Heart Disease/HF, Heart Murmurs, and Syncope/Chronic Hypertension Flashcards

1
Q

What overload do stenosis and regurgitation cause and how does the heart compensate?

A

Stenosis: causes PRESSURE overload
- causes hypertrophy

Regurgitation: causes VOLUME overload
- causes dilation

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2
Q

Murmur Grading: what does each level indicate?

  1. +1
  2. +2
  3. +3
  4. +4
  5. +5
  6. +6
A
  1. barely audible
  2. faint, soft
  3. louder, easily heard

1-3 have NO detectable THRILLS

  1. very loud, palpable thrill
  2. stethoscope barely touching chest, thrill
  3. hear without stethoscope; palpable thrill
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3
Q

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

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
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4
Q

Mitral Valve Prolapse

What is it and how is it treated?

A
  • one or both leaflets prolapse into left atrium
  • more common in WOMEN; murmur inc. with Valsalva or standing
  • reassure or Beta Blockers if symptomatic
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5
Q

Tricuspid Regurgitation

What does it sound like and where is it heard?

What is seen on jugular venous pulse?

A
  • blowing, systolic murmur at 4th ICS LSB
  • inc. with INSPIRATION (Carvallo sign)
  • prominent V WAVE on jugular venous pulse
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6
Q

Aortic Stenosis

What is it caused by and what does it lead to?

What are its 3 cardinal symptoms? (D/A/S)

A
  • due to degenerative calcifications; bicuspid Aortic Valve
  • cause PRESSURE OVERLOAD and LVH

CS: dyspnea on exertion, angina, syncope

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7
Q

Aortic Stenosis

What does it sound like and where?

What is seen on ECG?

A
  • harsh crescendo-decrescendo @ 2nd ICS RSB, radiates to sternal notch and carotids

ECG: down sloping of ST segment - T wave

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8
Q

Where are these Systolic murmurs heard:

  1. Pulmonic Stenosis (what condition is it associated with)
  2. Ventricular Septal Defect (VSD)
  3. Atrial Septal Defect (ASD)
A
  1. crescendo-decrescendo @ 2nd ICS LSB, radiates to left clavicle
    • associated with Tetralogy of Fallot
  2. holosystolic murmur, LLSB with thrill
    • murmur inc. with handgrip
  3. upper LSB with S2 splitting
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9
Q

Mitral Stenosis

What causes it and what are its symptoms?

Where is it heard and what is seen on ECG?

A
  • 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.

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10
Q

Tricuspid Stenosis

What causes it and where is it heard?

What is seen on jugular venous pulse and ECG?

A
  • due to Rheumatic Disease
  • LSB murmur inc. during inspiration (Carvallo)
  • prominent A wave on in Jugular vein

ECG: Right atrial enlargement

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11
Q

Aortic Regurgitation

What are 2 acute causes and 2 chronic causes?

What does it lead to?

A

Acute: infective endocarditis, aortic dissection

Chronic: calcific degeneration, bicuspid aortic valve

  • causes volume overload and left ventricular hypertrophy (LHF)
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12
Q

Aortic Regurgitation

What does it sound like and where is it heard?

What are DeMusset, Quincke’s, Traube, and Duroziez’s Signs?

A
  • 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)

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13
Q

Pulmonary Regurgitation

What does it sound like and where?

What is it associated with?

A
  • decrescendo murmur at 2nd ICS LSB

- associated with pulmonary hypertension; inc. P2 sound

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14
Q

What is the difference between HFpEF and HFrEF?

What are the cardinal clinical symptoms?

A

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

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15
Q

What Lab tests and imaging are more frequently used to diagnose HFrEF?

A

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

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16
Q

What are the objectives of treating HFrEF and HFpEF?

How are both of these conditions treated?

A

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

17
Q

What are diagnostic imaging findings of Cor Pulmonale using EKG and CXR?

How should pts. with Cor Pulmonale be treated?

A

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

18
Q

What is Syncope and what are its 3 categories?

A
  • 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
19
Q

What is the Criteria used for Syncope decision making?

What is its CHESS mneumonic?

A

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
20
Q

Presentation of:

  1. Neurally-mediate Syncope
  2. Orthostatic Hypotension
  3. Cardiac Syncope
A
  1. orthostatic intolerance, autonomic activation
    • diaphoresis, pallor, hyperventilation, yawning
    • eyes open, deviate up; roving movements
    • urinary incontinence
  2. reduced SBP > 20 mmHg or DBP > 10 mmHg within 3 minutes of standing
    • light-headedness w/sudden postural change
    • preceded by warning symptoms
  3. Cardiac
    • appears suddenly with few warnings
    • exercise or supine preceded by palpitations
21
Q

What are these devices and which pts. should get them:

  1. Holter
  2. Event Monitor
  3. External Loop Recorder
  4. Internal Monitor
A

used for pts with CV abnormalities

  1. portable, continuous - pt w/symptoms in 24-72 hrs
  2. pt.-activated, analog phone - pt. symp in 2-6 wks
  3. continuous, get data around events - 2-6 wks
  4. SubQ, pt. controlled - recurrent, infrequent syncope
22
Q

Syncope Treatments:

  1. Neurally-mediated
  2. Orthostatic Hypotension
  3. Cardiac
A
  1. inc. central blood volume and CO
    • reassurance, avoidance of triggers
    • physical counterpressure of limbs (leg cross)
  2. remove reversibles; pt. education/compress stocking
    • counterpressure maneuvers; inc. Na/H2O
  3. EPS –> pts. with arrhythmic etiology ONLY
    • treat underlying tachycardia/bradycardia
23
Q

What is the difference between:

  1. Primary Hypertension
  2. Secondary Hypertension
  3. Hypertensive Urgency
  4. Hypertensive Emergency
A
  1. elevated BP with NO underlying disorders
  2. elevated BP with specific underlying disorder
  3. BP > 180/110 without end organ symptoms
  4. BP > 180/110 WITH end organ symptoms
24
Q

What are the ranges for:

  1. Normal BP
  2. Elevated BP
  3. Stage 1 Hypertension
  4. Stage 2 Hypertension

What are HTN ranges for children and pregnant women?

A
  1. < 120/80 mmHg
  2. 120-129/<80 mmHg
  3. 130-139/80-89 mmHg
  4. > 140/90 mmHg

Kids: HTN - SBP >95th%ile, Pre-HTN - 90-95%ile
PW: HTN - SBP > 140 and DBP > 90

usually asymptomatic = MEASURE BP

25
Q

What 6 tests should be gotten for pts. suspected of hypertension?

A

CBC, CMP, lipid panel, TSH, UA, EKG

26
Q

What 3 pt populations are automatically placed in high-risk category for hypertension?

A
  • pts with DM, CKD, age > 65 yo
27
Q

What are the first-line drugs for Hypertension Treatment?

What drugs are better for African American pts. vs Caucasian pts?

A

RAAS inhibitors, CCBs, thiazide diuretics

AA: CCBs or diuretics
C: ACEi/ARBs

28
Q

Which drugs are used to treat these hypertension comorbidities:

  1. DM2
  2. CHD/CHF
  3. BPH
  4. A Fib.
A
  1. ACEi/ARBs
  2. ACEi/ARBs and Beta-blockers
  3. Alpha-blockers
  4. CCBs (non-dihydropiridines) or Beta-blockers
29
Q

Hypertensive Urgency (Asymptomatic Severe HTN)

How should it be treated?

What are the two most common symptoms of end organ damage?

A
  • 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

30
Q

What drugs should be used for treatment of these areas during HTN Emergency?

  1. General
  2. Brain (C/N/F/N)
  3. Heart (N/C/M/E) or (N/N)
  4. Vascular (E)
  5. Kidney (F)
A
  1. lower MAP gradually: 10-20% 1st hr, 5-15% in nxt 24 hrs
  2. HTN encephalopathy
    • Clevidipene, nicardipine, fenoldapam, nitroprusside
  3. Acute HF - nitroprusside and nitroglycerin
    • ACS - nicardipene, clevidipene, metoprolol, esmolol
  4. esmolol (IV beta blockers)
  5. fenoldapam (does NOT worsen renal function)

CPR II Exam 1 (15 decks)

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