Quick cards Flashcards
(112 cards)
1
Q
Any change in carotid upstroke/pulse has to do with?
A
Aortic valve
Similarly anything that radiates to carotids = AORTIC VALVE
2
Q
“Fixed splitting of S2”
A
= ASD
bc blood going thru defect & coming bacd around & causing valve to close slightly slower
3
Q
S3 = ?
A
Volume overload -
Occurs during increased passive filling (increase preload)
CHF
4
Q
S4 = ?
A
Occurs in stiff, noncompliant ventricle during atrial kick
= (atrial squeeze right at end of diastole to get rest of blood from atria –> ventricles)
5
Q
S1 = ?
A
AV valve closure
Mitral
Tricuspid
6
Q
S2 = ?
A
Semilunar valves closing
Aortic
Pulmonic
7
Q
Physiologic splitting of S2 = ?
A
Delay in aortic valve closure in YOUNG active healthy person w/ large inspiration
8
Q
Paradoxical splitting
A
ABNORMAL
Delay in aortic valve closure w/ large exhalation in young active = HOCM!!!
9
Q
Fixed splitting
A
Delayed consistently w/ every beat in a L-R shunt (ASD)
10
Q
MR. ASTR - PS - mnemonic that’s helpful for what?
A
These are the murmurs that are all systolic - if they give you a systolic murmur and a location, then you know what it’s from immediately
If they give you a diastolic murmur and a location, switch it from REGURG –> STENOSIS or vice versa but with same valve!!!
MR-TR - should be closed during systole b/c so backflow = REGURG
AS-PS - open during systolic so systolic murmurs a/w these valves = STENOSIS
11
Q
Any valve disorder that causes or results in enlargement of either atria will lead to?
A
Afib
12
Q
Any valve disorder that causes increased fluid in either ventricle will lead to?
A
Dilated CMP and HFrEF
13
Q
Any valve disorder which causes increased pressure in either ventricle (stenotic aortic or pulmonic valve) will cause?
A
LVH and lead to HFpEF at first and then HFrEF later if not treated
14
Q
Calcified (stenotic) aortic valve by age 40…(so young?)..you’re thinking?
A
Bicuspid aortic valve - taking bigger pressure hit over longer period of time = AS at much younger age than normal
15
Q
Systolic murmur
HARSH, loud
Radiates to neck
Slow, rising, prolonged carotid pulse
+syncopal episode walking up stairs
A
AORTIC STENOSIS
Anything radiating to carotids/neck = aortic
Anything that affects carotid upstroke = aortic issue
Systolic w/ aortic features (MR. ASTR-PS) = aortic stenosis
16
Q
Aortic murmurs in general are?
A
Harsh, loud
High-pitched
17
Q
Mitral murmurs in general are?
A
Low-pitched
18
Q
Aortic stenosis = which structural cardiac issues over time?
A
LVH, LAE, LAD on EKG
19
Q
AS = CP - ?
A
AS = SAD
Syncope (on exertion)
Angina
Dyspnea (on exertion)
Fatigue
Weakness
20
Q
Loud harsh systolic murmur w/ exertional angina
A
Aortic stenosis
not an MI
21
Q
Regurgitation = ? volume or pressure overload in general
A
Volume overload = S3
22
Q
Stenosis = ? in general
A
Pressure overload = ventricular remodeling = stiffening of tissue = S4
Pressure overload = concentric LVH
Similar pathology as seen in LVH due to increase pressure 2/2 hypertension - so can think of that as an example
23
Q
Signs of aortic regurg
A
AR = Al roker = WIDE pulse pressure signs
DIASTOLIC, HIGH-pitched, at BASE, wide pulse pressure, S3 common
Regurg = volume overload = ventricular remodeling = LVH (cardiomegaly) - tolerated well for many years
MR. ASTR-PS = systolic so if at base and diastolic = opposite = AR
24
Q
Which maneuvers increase venous return (therefore increasing all murmurs except MVP, HOCM)
A
Squatting Laying down (legs up)
25
Which maneuvers decease venous return? (therefore decreasing all murmurs except HOCM, MVP)
Valsalva
| Standing
26
Inspiration does what?
Increases preload = all right sided murmurs = louder, L-sided murmurs quieter
27
Exhalation does what?
Increases venous return to left side = all L-sided murmurs louder& right sided murmurs quieter
**Why L-sided murmurs are best heard after maximal expiration
28
MS ==>
MS = diastolic opening snap / diastolic rumble - heard best at APEX, radiates to axilla - low-pitched = use bell
MS. DOSSA - laying on left side - slut - got strep - rheumatic fever
Rheumatic fever = MCC
Pulm edema, hoarseness, cough, LAE, afib:
So much pressure backed up into LA b/c can't get thru stenotic valve - so it backs up into pulm - so get pulmonary symptoms & get hoarseness b/c l recurrent pharyngeal nerve gets stretched out
29
MR etiologies - acute vs chronic
Acute:
Infective endocarditis
Chordae tendinae rupture
Papillary mu ischemia/infarction
Chronic:
MC form - can be asx for years or forever
Marfan's syndrome
Rheumatic, congenital, MVP
30
Acute MR
NO LA enlargement - blood just backs up due to huge sudden volume overload
Remember blood coming from lungs into LA -> LV
So if Mitral valve not working, blood backs up into..? LUNGS = ACUTE PULMONARY EDEMA
31
Chronic MR
Blood flows back from LV to LA during systole = volume overload = prominent S3
LA will become enlarged
LV will dilate to accomodate
Results in dilated heart failure (EF < 40%) =
Afib
DOE
Fatigue
32
Chronic MR management
Yearly Echo
| Cards referral if > mild
33
MVP = ? murmur? CP?
MVP = MSC (mid-systolic click)
Up to 10% of females 2/2 floppy valve
ASX in most - found incidentally
CP = palpitations, CP, dyspnea, fatigue
34
MVP management
If murmur, send to cards
Bb for palps
SSRI's for anxiety
MV repair
35
Tricuspid stenosis = ?
RAE, RVH --> right HF = dependent edema, hepatometaly, ascites (fluid backs up to body if RHF)
Holosystolic murmur along LLSB, increases w/ inspiration
(inspiration = increased preload = all R-sided murmurs get louder)
Valve replacement
36
Left heart failure, fluid backs up to?
BODY - systemic
LIVER -portosystemic
LEFT side = blood coming from LUNGS
RIGHT side = blood coming from BODY
37
Stenotic mitral valve, fluid backs up to?
Left atria
Then lungs
LEFT side = blood coming from LUNGS
RIGHT side = blood coming from BODY
38
Who gets abx ppx with dental procedures?
Prosthetic cardiac valves
Previous infective endocarditis
Congenital anomalies - shunts, unrepaired cyanotic heart disease
39
Controlling sx in HFrEF
Reduce cardiac workload:
Dec afterload! (control HTN)
Reduce preload: (control excessive fluid!!)
- Diet, diuretics, vasodilators
Increase contractility (+inotropes)
40
Which med is given to improve QOL in the later stages of CHF?
Digoxin = positive cardiac inotrope
Does NOT PROLONG life, makes QOL better - makes heart pump harder so decreases sx but heart might poop out sooner
Also + inotrope = milrinone
In cardiogenic shock - can use pressors = IV + inotropes = Epi, NE, dobutamine, and dopamine
41
Vasodilator drugs
CCB
Alpha-1 blockers
Hydralazine
Minoxodil
Nitropress
42
What is BiDil? Who should get it?
BiDil = medication for AA w/ HF
BiDil = isosorbid dinitrate + hydralazine = dec BP & dec vascular resistance
43
Nitrates are used for?
They are anti-anginal agents- for PPX and treatemnt
NTG - SL tab, patch, ointment - used to treat acute CHF/angina, MI --> paste you can rub off! - Caution can cause hypotension
Isosorbid dinitrate - for AA w/ CHF or PO tab for angina
Nitrates MOA - get converted to nitrous oxide = smooth muscle relaxation & vasodilation =
Dec preload
Dec afterload
Nitrates C/I in inferior MI (preload dependent) and hypotension
Note: PDE-5 inhibitors (sildenafil, tadalafil) work on same pathway to cause vasodilation! Used in P. aa. HTN. Not used w/ nitrates = severe hypotension
44
Initial management stable afib
RATE CONTROL
BB (metoprolol)
CCB (Diltiazem)
Dig in CHF/Hypotension
45
Preferred agent for rate control in Afib if elderly with significant comorbid conditions of CHF or severe hypotension?
Digoxin
= + cardiac inotrope
Improves LVEF, reduces hospitalizations for CHF but NO IMPROVEMENT IN MORTALITY
For standard CHF tx - still use ACEI + BB + DIURETIC
46
Which drug reduces # hospitalizations in CHF?
Digoxin
47
Standard maintenance management of CHF
ACEI
BB
Diuretic
48
Stable afib: After rate control what are other considerations?
Rhythm control - use direct synchronized cardioversion most commonly - can do if:
Afib < 48 hrs, anticoagulated 3-4 weeks & TEE shows no clots in LA
IF UNSTABLE CARDIOVERT RIGHT AWAY
Or can use anti-arrhythmic agent (amiodarone, ibutilide, flecainide etc)
49
CHA2DS2-VASc components?
```
CHF
HTN
Age > or equal to 75 - 2pt
DM
Stroke, TIA, thrombus - 2pt
```
Vascular dz (MI, PAD)
Age > or equal to 65-74
Sex (female 1 pt)
Total of 9 points max
> or equal to 2 = moderate to high risk of clot - chronic oral anti-coag recommended
1 = low risk = based on clinical judgement - benefit vs risk
0 = low risk - no anticoagulation
50
Drugs that prolong QT...why prolonged QT is dangerous? How prolonged QT can present clinically?
```
Drugs:
Macrolides
Fluoroquinolones
TCAs
First gen antipsychotics
Anti-arrhythmics (amio) --> GET EKG BEFORE STARTING
```
ELECTROLYTE ABNL can also prolong QT!!! AKA Hypocalcemia, hypo-Mg2+, hypo-K+
Presents clinically as recurrent syncope - get electrolytes & EKG...or can present as SCD in otherwise young healthy b/c can be congenital
Can lead to torsades - polymorphic ventricular tachycardia that leads to vfib --> death
51
Two types of SVT
AV nodal reentry tachycardia (AVNRT) --> two pathways WITHIN node = MC type
Extra pathways = extra impulses sent to ventricles
AV reciprocating tachycardia (AVRT) = less common, MORE dangerous - accessory pathway OUTSIDE AV node = WPW
**Often preceded by a PAC that kicks it on --> SVT is frequently fast on, fast off
52
Orthodromic AVNRT, AVRT = ? wide or narrow? Stable or unstable? Tx?
Can to orthodromic (normal direction thru AV Node) ==> leads to STABLE, NARROW complex SVT
Tx: Vagal maneuvers, Adenosine
53
Antidromic AVNRT, AVRT = wide or narrow QRS? Stable or unstable?
WIDE QRS (going wrong direction thru AV node)
Usually less stable but if pt is doing okay (HD stable), can try meds first --> NO ADENOSINE, need an anti-arrhythmic (Look at ALCS algorithm)
Tx: Amiodarone
**If suspect WPW, then PROCAINAMIDE = tx
54
WPW = what on EKG?
Delta wave = wide QRS
Upward slope of QRS
Short PR interval
55
MAT a/w what dz? definitoin = what?
Multifocal atrial tachycardia = rate > 100, > 3 p wave morphologies
A/w SEVERE COPD
56
Unstable SVT or unstable WPW
Direct synchronized cardioversion
If stable and WPW - use procainamide
57
Which drugs must you avoid in WPW?
AV nodal blockers - ABCD
Adenosine
Beta blockers
CCB
Digoxin
These are avoided b/c they can cause preferential conduction through the fast (pre-excitation) pathway = worsening of the tachy-arrhythmia
58
Causes of increased JVP
JVP & crackles = CHF
JVP & normal pulm exam = tamponade or constrictive pericarditis
JVP & decrease breath sounds = tension PTX
59
Young asian male w/ sudden cardiac syncope = ?
Brugada syndrome
EKG: RBBB & ST elevations (downsloping) in V1-V2
60
Why is digoxin good for rate control in people with hypotension or CHF?
Because it is a positive inotrope (inc contractility) but a negative chronotrope (dec rate)
61
First line chronic management angina
Beta blocker
Reduces mortality
Decreases sx
Prevents ischemic occurrences
62
Tx Prinzmental angina
CCB
Prevents/terminates ischemia induced by coronary vasospasm
63
Why do we use nitoglycerin in angina?
Nitro - SL
Reduces coronary vasospasm
Decreases demand/cardiac workload by dec preload
Increases myocardial blood supply - increased collateral blood flow to iischemic myocardium, coronary artery vasodilation
64
Both DHPs and Non-DHPs cause peripheral dilation - which group have direct effects on the heart as well?
Non-DHPs - Diltiazem, verapamil
Think Non-DHPs = Non-selective - affect heart (negative chorno/dromo/inotrope) and peripheral blood vessels
Therefore caution in CHF, in combination w/ BB (do same thing, different mech), pre-existing AV block= WORSE
65
Medication regimen chronic stable angina
Nitro SL PRN
Beta-blocker (FIRST LINE)
ASA
66
Tx NTEMI/STEMI caused by cocaine (coronary artery vasospasm)
BETA BLOCKERS CONTRAINDICATED (usually part of first line management in acute and
67
When are BB contraindicated in acute management of NSTEMI/STEMI?
Severe bradycardia (<50) - inferior / RV might present w/ this
```
Hypotension (SBP <90)
Decompensated CHF
Heart block (2nd-3rd deg)
Cardiogenic shock
Cocain-induced MI
Severe asthma/COPD
```
68
Medications unstable angina/ NSTEMI
MONA +
Clopidogrel
(caution if CABG planned)
UFH
(dec mortality - add in pt w/ EKG change or + cardiac biomarkers)
Beta-blocker
(CCB in pt who cannot have Bb)
Nitrate (no dec in mortality, dec anginal sx)
69
R ventricular (inferior wall) MI - DO NOT give??
Nitrates
Caution w/ morphine too
Causes unsafe drop in preload
Give IV fluids to keep preload up
70
Management STEMI
MONA + EKG (w/in 10 imn) + troponin
Heparin
Consider clopidogrel
Beta blocker
ACEI
PCI = most important (w/in 90 min)
71
Complications of MI
```
Arrhythmias (Vfib)
Ventricular aneurysm/rupture
Cardiogenic shock
Papillary muscle dysfunction
Heart failure
LV wall rupture
```
Post-MI pericarditis (dressler syndrome)
72
Signs left-sided HF
Pulmonary edema = chronic nonproductive cough (or pink frothy), dyspnea (MC symptom)
PE: S3, rales, rhonchi
73
Signs right-sided HF
Fluid backs up into systemic sx = JVD, LE pitting edema, hepatic congestion (hepatomegaly) + hepatogugular reflex
74
Management acute decompenstated HF
LMNOP
```
Lasix
Morphine +/-
Nitrates
Oxygen
Position
```
+ Inotropic support if severe!
Digoxin - (HF + AFIB, dec hospitalizations but NO MORTALITY BENEFIT), dobutamine, dopamine etc
75
Long term management of CHF
1. ACEI
(FIRST LINE TX OF CHF) - dec mortality , prevents rehospitalization, reverses pathology by decreasing renin/SNS activation = dec ventricular remodeling
PLUS
2. Diuretic
(Most effective tx for SYMPTOMS caused by CHF - spironolactone also a/w dec mortality
Then add if needed:
+/- 3. Beta blocker
(dec mortality, added AFTER ACEI)
+ 4. Implantable cardioverter defibrillator in pt w/ EF < 35% (b/c they tolerate arrhythmias poorly)
76
Meds that decrease mortality in CHF
ACEI
Beta-blockers
Nitrates + Hydralazine (BIDIL)
Spironolactone
77
EKG changes pericarditis
| MCC pericarditis
MCC - idiopathic, after viral infection (ENTEROVIRUSES - coxackie, echo)
CP: PPPP - pleuritic, persistent, postural (worse supine, relieved leaning forward), Pericardial friction rub
EKG: DIFFUSE ST elevations in PRECORDIAL (V1-V6) leads & assocated PR DEPRESSIONS
78
EKG findings pericardial effusion
Low voltage QRS
| Electrical alternans
79
PE findings pericardial tamponade
Pulsus paradoxus
(exaggerated > 10mmHg dec in systolic blood pressure w/ inspiration - increased filling of R side of heart during inspiraiton dec left sided ventricular filling, leading to pulsus paradoxus)
+ Beck's triad
80
Beck's triad
Hypotension
JVD
Muffled heart sounds
Triad of pericardial tamponade!!!
81
Kussmaul's sign
Increased JVD during inspiration
```
Inspiration = increased filling of the R heart -->
r-I-ght = INc during INspiration
```
Rn disease where R heart cannot fill (constrictive pericarditis, restrictive CMP, R heart failure) = fluid backs up into jugulars b/c R heart cannot keep up
82
CP/PE constrictive pericarditis
```
Right sided heart failure signs:
Dyspnea
Kussmaul's sign
Inc JVD
Peripheral edema
Hepatojugular reflux
```
PERICARDIAL KNOCK
High-pitched 3rd heart sound due to sudden cessation of ventricular filling in early diastole from thickened inelastic pericardium - sounds like an S3
83
Myocarditis - MCC, CP/PE, Tx
MCC Infections - enteroviruses - COXSACKIE- Also Lyme, SLE, rheumatic fever - similar to pericarditis
Myocarditis = muscle is inflamed = HEART failure!!!! --> impaired systolic function (heart muscle is sick) =.....
CP/PE: DOE, S3, tachycardia, hepatomegaly
Dx:
CXR = CARDIOMEGALY 2/2 dilated CMP
+ TROPONIN - helps distinguish myocarditis from chronic dilated CMP
Echo - ventricular dysfunction
Endomyocardial bx = GOLD standard
Tx: supportive + standard HF tx (diuretic, ACEI, inotrope if severe)
84
Someone w/ viral prodrome (fever, myalgias, malaise) for several days who now comes in hypotensive, SOB, tachycardic, found to have hepatomegaly on exam
MYOCARDITIS - had coxackie B --> which infiltrated heart muscle & now has HEART FAILURE
May also have si/sx pericarditis concurrently
85
HOCM Murmur
Harsh systolic crescendo-decrescendo murmur best heard at LLSB (sounds similar to AS but in different location & patient population)
Tx: Beta blockers = first line medical therapy, surgical = definitive (reserved for severe)
86
Dx criteria rheumatic fever
Two Major OR one major + two minor
JONES = MAJOR
Joint (migratory arthralgias (LE-UE, LG)
Oh my heart! Active carditis - myo, valves (mit)
Nodules (subcutaneous) - over joints
Erythema marginatum - annular rash on trunk
Sydenham's chorea - jerky nonrhythmic mvmt
```
MINOR:
Fever
Arthralgia
Inc ESR/CRP
EKG prolonged PR interval
```
PLUS evidence of strep infection - rapid, cultures, ASO titer
Tx: Aspirin 2-6 weeks w/ taper + PCN G
87
HTN urgency
Lower BP by ~25% max over 24-48 hours using ORAL agents
```
Clonidine
Catopril
Furosemide
Labetalol
Nicardipine
```
Goal is to get < 160/100
88
HTN + OP
Thiazide diruetic
89
AA first line HTN
Thiazide
| not 2/2 RAAS, ACEI less effective
90
Aortic stenosis complications
= ASC
Angina
Syncope
CHF
91
HTN + Systolic HF
ACEI !!!
| Diuretic
92
DM + HTN
ACEI
93
Aortic dissection - medical management
For DESCENDING
Esmolol
94
Best drug to increase HDL
Niacin
95
Best drug to decrease LDL
HmgCOa reductase inhibitors
| Statins
96
Best drug to decrease triglycerides
Fibrates
97
Duke criteria endocarditis
MAJOR:
Sustained bacteremia (2+ Bl Cx w/ organism known to cause endocarditis)
AND
Endocardial involvement (Echo = vegetations, NEW valvular regurgitation)
MINOR:
Predisposing condition (IVDA, abnl valve, indwelling catheter)
Fever (100.4)
Vascular & embolic phenomena
+ Bl cx not meeting major criteria
+ echo findings not meeting major (worsening of existing murmur)
TWO MAJOR or ONE major & THREE minor
Odd but can have + ESR/RF too...?
98
MCC subacute endocarditis
Indolent infection of ABnormal valve w/ less virulent organism
S. viridans
99
MC organism endocarditis prosthetic valve (PVE)
Staph epidermis if w/in 60 d of implant
| If late, same as acute endo (staph aureus)
100
Mainstay of PAD treatment
Cilostazol
Control other RF (DM, HTN, HLD)
101
When to repair AAA (prerupture)
>5.5 cm - immediate repair even if asx
102
Unique PE finding Aortic dissection
> 20 mmHg between left and right arm
Decreased peripheral pulses
Dx: CT scan w/ contrast = initial test of choice - MRI angiogram = gold standard
Tx: Esmolol if descending (type III/B) w/ target SBP 100-120 & pulse < 60 +/- sodium nitroprusside
If Type A, Type I/II - aka acute proximal = SURGERY
103
Signs coarctation of aorta
High UE BP
Low LE BP
A/w Bicuspid aortic valve
A/w TURNER syndrome - bicuspid valve looks like a T
104
Superficial thrombophlebitis
Thrombophlebitis = swelling/inflammation of a vein caused by a blood clot - superficial = superficial thrombophlebitis - deep = DVT
RF: Virchow's triad, IV cath, trauma, pregnancy, varicose veins
Tx: supportive management = MAINSTAY - extremity elevation, warm compresses, NSAIDs, elastic compression stockings
105
Etiologies cardiogenic shock
Massive PE
Pericardial tamponade
Tension PTX
Aortic dissection
Tx underlying cause!!!
106
SIRS criteria
HR > 90
RR > 20
Temp > 100.4
WBC > 12,000
Sepsis = SIRS + focus of infection (a/w inc lactate)))
Septic shock = Sepsis + refractory hypotension despite resuscitation
107
Neurogenic shock
Form of distributive shock (along w/ septic, anaphylactic, endocrine)
Hypotension WITHOUT reflex tachycardia --> AKA HYPOTENSION w/ BRADYCARDIA = weird!!!
108
4 findings TOF
1 of 5 cyanotic heart diseases
Pulmonary aa. stenosis =RVOF obs
Overriding aorta
RVH
VSD
= DOE, cyanosis worsens w/ age
"Tet-spells"= cyanotic spells relieved by inc venous return
109
Murmur of VSD
Non-cyanotic - L-->R shunt
= HHHH
Harsh, High-pitched, Holosystolic best heard at LLSB (think of where ventricles are & which way it's blowing L-->R)
110
PE of ASD
Left to right = NON-cyanotic (Lefties = good)
Systolic ejection crescendo-decrescendo murmur
ASD, AS, HOCM are all described as crescendo decrescendo - but all in DIFFERENT areas - ASD = pulmonic area, AS = aortic area (RUSB), HOCM = LLSB/Erb's point
111
PDA murmur/ CP
Loud harsh continuous machinery murmur heard at pulmonic area
Bounding pulses - like a hammer - everything aggressive in PDA
IV indomethacin = tx, surgical correction if fails before 1-3 years of age
112
Cyanotic congenital heart lesions
The 5 T's
Pulmonary atresia
Tricuspid atresia
KEEP PFO/PDA OPEN w/ prostaglandin until surgical correction
