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Flashcards in Cardio Deck (169):
1

Valvular Heart Disease

because we didnt get enough in path...

2

What wave corresponds with an increase in atrial pressure?

A wave

3

What is the C wave?

Upward bulging of mitral valve into left atrium may produce a C wave early in systole

4

What is the V wave?

Atrial volume increases during ventricular systole due to passive filling from pulmonary veins

5

Normal mitral valve sounds?

  • Opening sound
    • Absent
  • Closing sound
    • production of S1 as a byproduct of mitral valve closure

6

Most common cause of valvular LV inflow obstruction?

Rheumatic mitral stenosis

7

What occurs to the Mitral valve in MV stenosis?

  • Diffuse fibrous thickening of leaflets
    • +/- calcification
  • Fusion of commissures
  • Thickened fused chordae
  • Greatest obstruction at apex
  • Aschoff nodules

8

What occurs to the left atrium and left ventricle in mitral stenosis?

  • Atrium
    • Enlarged, hypertrophied
    • Mural thrombi
      • especially if there is A. fib
  • Ventricle
    • normal or smaller sized

9

What is the normal size of mitral valve orfice? Mild MS? Severe MS?

  • Normal: 4-6cm
  • Mild MS: 2cm
  • Severe MS: 1cm

10

What happens to LV diastolic pressure in MS? LA?

  • LV diastolic pressure = normal
  • LA pressure = increased

11

In MS what happens to the pulmonary artery pressure?

Cardiac output?

  • PAP
    • Normal
    • Later it increases because the LA pressure is pushing backwards on the pulmonary system
  • CO
    • Normal
    • Later decreases in decompensation

12

In the normal heart when there is an increase in flow what happens to the pressure gradient? What occurs in mitral stenosis

  • Normal heart
    • Large increase Q = little increase pressure gradient
  • MS
    • Small increase in Q = large increase in pressure gradient

13

Signs/Symptoms of MS?

  • Dyspnea/Orthopnea/PND
    • related to increased pulm. venous pressure
    • accentuated by increased BF across stenotic MV
  • Acute pulmonary edema
  • Hemoptysis
    • due to elevated pulm. venous pressure

14

What happens as a result of pulmonary HTN?

  • Cor pulmonale
  • Fatigue
  • Lower extremity edema, ascites
  • hepatic failure

15

What is Ortner's syndrome?

In pulmonary hypertension when the pulmonary artery compresses the left recurrent laryngeal nerve resulting in hoarseness

16

What occurs to the point of maximal impulse in MS?

PMI is normal or decreased because the LV is smaller

17

Where/when would you have RV heave?

Occurs with pulmonary HTN along the parasternal border

18

Auscultation findings in mitral stenosis?

  • Loud S1
  • Onset of murmur after S2 (diastolic murmur)
    • HALLMARK**
  • Low pitched decrescendo murmur
  • Opening snap

A image thumb
19

Nonrheumatic causes of mitral stenosis?

  • Congenital
    • single papillary muscle
  • Active infective endocarditis
  • Annular calcification
  • Cor triatriatum
    • congenital membrane sparating LA into 2 separate chambers
  • Neoplasm

20

Mitral regurgitation: What causes abnormalities of the valve leaflets?

  • Rheumatic heart disease
  • Floppy mitral valve
    • most common
  • IE

21

In mitral regurg. what obnomalities of the mitral anulus can occur?

  • Calcification
    • normal aging (degenerative)
    • associated with hypertension, aortic stenosis
    • chronic hypercalcemia
  • Dilation
    • LV (cardiomyopathy/ischemic disease)
    • Marfans

22

What can occur to the chordae tendinae to cause mitral regurg?

  • Elongation
    • marfans
  • Rupture
    • idopathic
    • trauma
    • IE

23

What can occur to the papillary muscles in order to cause mitral regurg?

  • Malalignment
    • LV dilation
    • Hypertrophic obstructive cardiomyopathy
  • Dysfunction
    • ischemia
    • infiltrative - amyloid/sarcoid/neoplasm

24

How does the heart compensate for mitral regurgitation? What occurs to change the structure?

  • LV dilates to increase forward SV
    • Increased LVEDV
  • LA enlarged to to increased BV
  • Systolic LV function normal (until late)

25

In MR what happens to LA pressure? Pulm artery pressure? CO?

  • LA pressure
    • Normal
    • Increases later (large V waves)
  • PAP/CO
    • Normal
    • Increase later

26

Complications of MR?

  • A. fib
    • chronic LA dilation
  • IE
  • Pulm htn and cor pulmonale
    • edema
    • hepatomegaly

27

What occurs to the point of maximal impulse in MR?

 

Displaced and hyperdynamic

28

Auscultation findings in MR?

  • Diminished S1
  • Holosystolic murur
    • best heard at apex
  • S3
  • Variably present:
    • split S2
    • mid-diastolic murmur

A image thumb
29

Valvular causes of LV outflow obstruction? (were in the aortic valve now just FYIIII)

  • Congenital
    • most common
  • Rheumatic
  • Degenerative

30

Most common subvalvular causes of LV outflow obstruction?

Hypertrophic cardiomyopathy

31

Congenital and acquired causes of aortic stenosis?

  • Congenital
    • unicuspid (severe)
    • Bicuspid: progressive fibrosis or calcification
  • Acquired
    • Rheumatic 
      • MV involvement too
    • Hypercholesterolemia
    • Endocarditis

32

Second most common congenital anomaly?

Bicuspid aortic valve: turbulent flow --> fibrosis and calcification over time

33

What happens to the aorta in rheumatic fever?

  • Commisural fusion
  • Often regurgitation
  • MV must be affected as well

34

What is degenerative acquired aortic stenosis?

  • Senile wear and tear
  • Calcific deposition
  • Calcification of MV anulus, and coronaries

35

Anatomical changes to LV in Aortic stenosis?

  • LV hypertrophy
    • Large LA-AA pressure gradient

36

Aortic stenosis:

Opening size? Pressure change? CO? Pulmonary arterial pressure?

  • Opening size <.75cm>
  • Change in pressure >50mmhg
  • CO
    • normal
    • decreased later
  • PAP
    • increase

37

Aortic stenosis:

LV systolic pressure?

LV diastolic pressure?

  • LV systolic pressure
    • extremely increased
  • LV diastolic pressure
    • increased

38

Symptoms of aortic stenosis?

  • Angina
    • due to increased o2 demand (LVH)
  • Syncope
    • often orthostatic or exertional
    • decreased cerebral perfusion
    • arrhythmias
  • Dyspnea
    • orthopnea, PND, CHF
    • venous hypertension

39

Aortic stenosis prognosis?

May be asymptomatic for many years but once symptoms develop --> poor prognosis with potential for sudden death

40

Aortic stenosis:

What happens to the peripheral pulse?

Cardiac palpation?

  • Peripheral pulse
    • slow rise, low volume
  • Cardiac palpation
    • Palpable a-wave
    • systolic thriss in aortic area
    • sustained lift (LVH)

41

Auscultation in aortic stenosis?

  • Prominent S4 gallop
  • Paradoxical splitting of S2
    • severe AS or decreased LV function
  • Aortic ejection sound
  • Systolic murmur
    • heard at the base of the heart
    • Radiation to the carotids
    • Decreases with LV failure
    • Rasping sound
    • Length of murmur is correlated with severity

A image thumb
42

Causes of cusp abnormality leading to aortic regurgitation?

  • Bacterial endocarditis
  • Rheumatic disease
  • Degenerative
  • Congenital
    • bicuspid

43

causes of Aortic root dilation leading to aortic regurg?

  • Marfans
  • idiopathic
  • Ehlers-danlos
  • Pseudoxanthoma elasticum
  • Chronic systemic hypertension

44

Tell me whatcha know about marfans?

  • AD
  • Musculoskeletal
    • long limbs, lax joints, high palate, pectus deformity
  • Lens deformity
  • ASCENDING AORTIC ANEURYSM 

45

Causes of aortic root distortion leading to reurg?

  • Ankylosing spondylitis
  • Syphilis
  • Rheumatoid disease

46

Causes of loss of commissureal support leading to aortic regurgitation?

  • Aortic dissection
  • Aortitis
    • inflammatory, syphilis
  • VSD

47

What is aortic dissection? What is it associated with?

  • Intimal tearing allowing propagation of blood between intima and media
  • Associations:
    • HTN
    • marfans
    • pregnancy
    • bicuspid aortic valve

48

What is Cor bovinum?

LV volume overload (happens in aortic regurg)

49

Aortic regurgitation:

Pulse pressure?

Cardiac output?

LVEDP?

  • Increase pulse pressure
  • Normal CO until late
  • LVEDP normal, late increase

50

Symptoms of aortic regurgitation?

  • Exertional dyspnea
  • orthopnea
  • PND
  • Angina
    • due to low BP

51

Findings on physical exam of aortic regurgitation?

  • DeMusset's sign
    • head bob in synchrony with beating heart
  • Corrigan's pulse: bounding and forceful
  • Traube's sign - s/d sounds over femoral artery
  • Muller's sign - systolic pulsation of uvula
  • Quincke's sign - capillary pulse in nailbed
  • Wide pulse pressure

52

Auscultation of aortic regurg?

  • S1 may be split
  • Systolic ejection sound murmur
    • blood flows backwards in diastole
  • S3 gallop may be present
  • High frequency diastolic murmur ("blow")
    • Decrescendo pattern
    • Immediately after A2
  • Mid-late diastolic apical rumble

53

Most common cause of tricuspid stenosis?

Functional result?

  • Rheumatic disease
    • Always in association with concomitant MV
    • Minimal calcification
  • Functional result: inability of RA to empty leading to systemic venous congestion

54

Triscuspid stenosis symptoms and signs?

  • Orthopnea, PND = UNUSUAL
  • RARE pulmonary edema
  • Fatigue
  • Weakness
  • Abdominal discomfort
    • due to congestion in the liver
    • ascites possible

55

What occurs to the jugular venous pressure in tricuspid stenosis?

  • "giant" A waves
  • Slow Y descent

56

Auscultation findings in Tricuspid stenosis?

  • Opening snap
  • Diastolic murmur at the lower left stenal border
  • Both OS and murmur increase with inspiration

57

Causes of tricuspid regurgitation?

  • Rheumatic
  • IE
  • Ebsteins anomoly: congenital
    • septal and posterior leaflets displaced towards RV apex
  • Carcinoid valve disease
    • dilation of valve ring secondary to RVF or pulm HTN
  • Floppy (prolapse)
  • RV infarct

58

Most common cause of pure tricuspid regurg?

  • Anatomically normal 
  • Dilation of RV and tricuspid anulus
    • PHTN
    • RV diastolic HTN
      • dilated cardiomyopathy
      • RVF

59

Tricuspid regurgitation:

RA pressure?

RV diastolic pressure?

Pulmonary artery systolic pressure?

  • RA pressure increases
    • Large V wave with prominent Y descent
  • RV dp increases
  • PAP
    • <40mmHg suggest primary valve etiology
    • <60mmHg suggests either 1 or 2ndary

60

Signs/Symptoms of Tricuspid valve regurg?

  • Progressive fatigue
  • anorexia
  • painful congestive hepatomegaly, ascites, edema
  • Throbbing pulsations in neck
  • A. fib is common
  • JVD
  • jaundice

61

Triscuspid Regurgitation auscultation signs?

  • S3 gallop
    • increases with inspiration
  • Holosystolic murmur
    • lower left sternal border
    • increases with inspiration (carvallo's sign)

62

Coronary Heart Disease

63

Role of cytokines in atherosclerosis?

A image thumb
64

What are the coronary equivalents?

  • Diabetes
  • Framingham risk score >20%
    • takes into account smoking, lipids, cholesterold, physical activity etc..
  • Aortic atherosclerosis
  • Peripheral vascular disease with ABI (ankle brachial index) ratio of <0.9

65

Steps in the development of atherosclerosis?

  • LDL is oxidized and transported to the media
  • Breaks down the internal elastic lamina
  • Macrophages are activated
  • Smooth muscle cells migrate and proliferate in the media
  • Foam cells develop
  • Cellular apoptosis occurs
  • Neovascularization of the plaques via the vasa vasorum

66

What is in the fatty streak? What occurs in advanced lesions?

  • Fatty streak
    • lipid laden monocytes, macrophages, and t-lymphocytes
  • Advanced lesions
    • There is fibrous cap development
    • Core easily becomes necrotic

67

Atherosclerosis timeline

Just cool to look at 

A image thumb
68

What ratio determines the integrity of the lesion?

Ratio between synthesis and breakdown. Increased breakdown leads to a weaker, more unstable, plaque

69

What can cause plaque rupture?

  • Decreased collagen synthesis
  • Increased collagen breakdown
  • Smooth muscle apoptosis

70

What leads to plaque erosion?

  • Increased endothelial cell apoptosis
  • Basement membrane breakdown

71

Erosion is likely to cause? What populations are most affected?

  • Sudden cardiac death > acute coronary syndrome
  • Older women > younger women
  • Younger men > older men

72

Increased expression of what leads to thrombosis?

  • Tissue factor
  • Fibrinogen
  • Plasminogen activator inhibitor

73

Relationship between amount of stenosis and likelihood of MI?

None. The quality of the plaque plays the most important role

74

Healthy vs. dysfunctional vascular endothelium?

  • Healthy
    • dilation, growth inhibition, antithrombic, antiinflammatory, anti-oxidation
  • Dysfunctional
    • constriction, growth promotion, prothrombic, proinflammatory, and pro-oxidation

75

Endothelial dependence on Adenosine? NO?

  • Coronary response to increased demand
  • Adenosine
    • not endothelium dependent
    • potent vasodilator
  • NO
    • endothelium dependence

76

Characteristics of plaques prone to rupture?

 

Initial response of the vessel?

  • Characteristics
    • thin fibrous cap
    • lipid, macrophage rich
    • smooth muscle poor/apoptosis
    • remodeling of the artery
    • adventitial inflammation
    • neovascularization
  • Initial response
    • stretching and growth to preserve the lumen

77

What is the fractional flow reserve?

•FFR = Flow Dilated / Flow Initial

•FFR = Pressure Dilated / Pressure Initial
 

78

Consequence/complication of coronary artery disease?

  • Angina
    • Stable/unstable
  • MI
    • NSTEMI/STEMI
  • LV dysfunction
    • ischemica causes diastolic dysfunction first
  • HF
  • Myocardial stunning, hibernation, and necrosis

79

What is myocardial stunning?

Brief period of myocardial ischemia resulting in prolonged myocardial dysfunction with gradual return

80

What is myocardial hibernation?

Impaired LV function secondary to reduced coronary BF that can be resored toward normal by revascularization

81

Ways to evaluate Angina Pectoris?

  • ECG
  • TM with nuclear imaging
  • Catheterization
  • Intravascular ultrasound
  • Fractional flow reserve

82

In angina, what is prognosis dependent upon?

Prognosis is dependent upon left ventricular function and amount of myocardium at risk from ischemia

83

In unstable angina and an NSTEMI MI how does micronecrosis occur?

Surface of thrombus associated with plaque rupture is covered with activated platelets which are sheared off by blood flow and occlude distal beds causing regions of micronecrosis

84

What are the three "A"s of platelet function?

  • Adhesion: platelet GP1B receptor
  • Activation: TXA2, serotonin, ADP, fibrinogen etc
  • Aggregation: crosslinking of platelets by fibrinogen or VWF

85

Diagnosis of a STEMI?

  • Ischemic chest pain
  • Characteristic ECG changes
  • Elevated cardiac markers
  • ST Elevation in 2+ contiguous leads

86

Peripheral Arterial Disease

this was the easiest lecture. he better ask super easy questions!

87

What is Peripheral arterial Disease (PAD) the most common cause of?

Atherosclerosis of the peripheral arteries is the most common cause of symptomatic obstruction in the peripheral arterial tree

88

What is the difference between incidence and prevalence?

  • Prevalence
    • # with the disease/ # of people in the population
  • Incidence
    • measure of the probability of occurrence of a given medical condition in a population within a specified period of time

89

Two main risk factors to peripheral artery disease?

  • Diabetes
  • Smoking
  • ***Definitely know

90

What is PAD tell you about what is happening with the rest of the body?

Peripheral artery disease is a surrogate marker for vascular disease elsewhere: stroke/heart disease.

 

PAD likely wont kill you, the stroke or MI may

91

When does the 5 year risk of limb loss go up?

SIGNIFICANTLY goes up for a diabetic patient

Nondiabetic risk: 5%

Diabetic risk: 25%

92

What is claudication?

"Angina" of the lower legs. Can walk. Cramps. Pain. Patient does better with rest. This is all exertional related. Highly unlikely that you will lose your legs (again, unless diabetic)

93

Claudication is commonly misdiagnosed as what?

Arthritis

94

What are some obvious and unique signs of PAD?

  • Shiny skin
  • Hair loss

95

What are you checking for in the physical exam for PAD?

  • Hair loss on distal limbs
  • Edema/tenderness
  • Pulses
  • Check both pressures in the upper extremity
  • Check for bruits
    • abdominal
      • renal art. stenosis/mesenteric stenosis/ iliac disease/aneurysm
    • Remoral

96

Non-invasive tests for PAD?

  • ABI
  • Exercise test
  • Segmental pressures
  • MRA
  • CTA

97

What is Amaurosis fugax?

Sudden loss of vision in the eye that does come back. This is usually a sign of artery disease

98

Ankle-Brachial Index:

Normal?

Moderate?

Severe?

  • Normal
    • 0.95-1.05
  • Moderate
    • .55-.9
  • Severe 
    • <0.4 with critical limb ischemia

99

Change in the doppler waveform in PAD?

Normal is triphasic but can be --> biphasic --> monophasic --> flat flow (or even reversal) in severe PAD

100

What is Leriche syndrome?

Atheroma of distal aorta and eventually occlusion; however, due to slow nature of the occlusion the body has generated collaterals to compensate. Doesnt lead to bone loss

101

Risks of CTA?

Radiation

Renal necrotozicity

Less technology dependency

102

Main thing to keep in mind when treating PAD?

MUST treat the underlying cause

(stop smoking, control diabetes, exercise etc)

103

Medical treatment options for PAD?

  • Risk factor modification
  • Exercise therapy
  • Drug therapy

104

Physical Diagnosis

105

Difference between central and peripheral cyanosis?

  • Central
    • entire circulation involved: face/lips/exposed tissue
  • Peripheral
    • environmental exposure/stasis to extremities
    • more local

106

What is pulse pressure? Difference between narrow and wide?

  • PP = SBP-DBP
    • reflects compliance of the cardiovascular system
  • Narrow: <20mmHg
    • low C.O
  • Wide: >100mmHg
    • high C.O.
    • Decreased TPR and increased arterial stiffness

107

What is paradoxical pulse? What does it indicate if it is high?

  • Paradoxical pulse is the decrease in SBP with inspiration
  • >15mmHg is an important sign of pericardial disease and cardiac tamponade

108

What is Pulses alternans?

Beat to beat variation in intensity or amplitude of the arterial pulse: indicative of CHF

109

Where is venous pulse reflected?

What are the pulse waves?

  • Venous pulse is reflected in the jugular veins
    • distended in recumbant position
    • Normal <7cmH2O
  • Pulse waves
    • A wave - atrial contraction
    • X descent - atrial relaxation
    • V wave - peak of atrial filling
    • Y descent - atrial emptying

110

What is SI?

  • Onset of systole/QRS complex
  • Closure of the mitral/tricuspid valves
  • Heard near the apex of the heart

111

What is SII?

  • End of systole 
  • Closure of aortic and pulmonary valves
  • Normally split on inspiration and single on expiration

112

What is wide splitting in SII?

  • Right bundle branch block
    • reversed splitting; wider on expiration
  • Left bundle branch block
    • severe aortic stenosis and htn

113

In what situation would you ALWAYS hear a split SII?

Length of systole versus diastole?

  • Persistant splitting in ASD
    • RV pumps 3x as LV
  • Systole is shorter than diastole
    • SAME as diastole with increased HR (exercise)

114

What is SIII? Difference between children and adults?

  • SIII = Filling sound in early diastole due to rapid filling of the ventricle
    • Occurs immediately after SII
    • Listen at the apex
  • Normal in children
  • Pathological in adults
    • CHF
    • Increased LVEDV
    • Ventricular gallop

115

What is SIV? Cause?

  • Ventricular filling sound in late diastole due to atrial contraction
    • Heard right before SI at the apex
  • Due to cardiomyopathy or hypertension
  • Poor ventricular compliance with hypertrophy
    • not necessarily increased volume
  • Either ventricle is involved
  • "atrial sound or gallop" (although it originates in the ventricle)

116

What is the ejection click? Cause?

  • Ejection click is created during early systole in the aortic or pulmonic valves
    • Heard at the left sternal border right after SI
      • almost sounds like "double SI"
  • This is due to either of these valves being stenotic

117

What is a systolic click? vs Opening snap?

  • Both occur at the apex
  • Systolic click
    • mitral/tricuspid valve prolapse
    • often accompanied by late systolic murmur
  • Opening snap
    • Mitral/tricuspid valve stenosis
      • Same as SIII timing

118

What is a holosystolic murmur and what causes it?

  • Extends from SI to SII
  • Caused my mitral/tricuspid regurgitation of VSD

A image thumb
119

What is a midsystolic murmur? Causes?

  • Ejection murmur that begins after SI and ends before SII
  • Pulmonic or aortic stenosis
    • Pulmonic: common in kids and in high output states
    • Aortic: sclerosis at the base of the valve and hypertension

A image thumb
120

What is an early diastolic murmur caused by?

  • High pressure gradient right after SII
  • Aortic or pulmonic regurgitation
  • "blowing or soft"

A image thumb
121

Characteristics of mid-diastolic murmurs? Causes?

  • Low frequency due to turburlent flow over mitral or tricuspid valves; lower pressure gradients
  • Due to mitral or tricuspid stenosis/regurg, VSD, or ASD

A image thumb
122

What is a continuous murmur? Two main types?

  • Extend directly from systole into diastole although not necessarily continuously present
  • A-V shunt
    • PDA, coronary artery fistula, Pulmonary A-V fistula
  • Narrowed artery
    • coarctation of aorta and pulmonary artery stenosis

123

Components of a pericardial friction rub? (i typed rum initially - liquor on my mind?)

  • Pre systole
  • Systolic
  • Early diastole

A image thumb
124

Features of a functional systolic murmur?

  • short duration
  • early to mid systole
  • Left sternal border sound with normal SII
  • Decreased intensity on standing
  • Remainder of exam is normal

125

How is aortic stenosis categorized?

  • Delayed/weak carotid pulse = 5
  • Decreased/absent A2 = 3
  • Late murmur at R upper sternal border = 2
  • Calcification on chest film = 4

 

  • 0-6 = Not significant
  • 7-9 = intermediate
  • 10+ = moderate to severe

126

Diagnostic Methods

I HATEEE TESTING CRIZZAP

127

Five finger approache includes?

  1. History
  2. Physical
  3. ECG
  4. Lab tests
  5. Imaging

128

Role of the CK enzymes?

Basic blood panels taken?

  • Makes ADP
  • Basic blood panel
    • CBC
    • BMP
    • Liver panel

129

Targeted blood panels?

  • Cardiac enzymes
    • Old: CPK, MB; myoglobin
    • New: troponin
  • BNP
  • Lipids

130

Significance of elevated troponin?

  • Evidence of tissue injury
  • Demand - ischemia
    • mismatch of supply and demand

131

What is BNP? Sensitivity versus specificity?

  • Brain Natriuretic peptide secreted by myocytes secondary to stretching
    • increases natriuresis
  • Very sensitive - rules out HF but does not diagnose it
  • NOT specific: elevated in pulmonary disease, RF, shock, cirrhosis... etc

132

Relationship between troponin level and possible causes

  • Below 1 - multiple causes, mild effects 
    • .001 = normal
  • 10 = medium sized MI or severe myocarditis
  • 100mg/L - large MI

133

5 major lipoproteins? (this is REVIEW)

ApoA1 and ApoB = ?

  • Chylomicrons, VLDL, LDL, HDL, IDL
  • Apo A1 = component of HDL
  • Apo B = component of non-HDL

 

All merkers for atherosclerosis/plaques/calcifications

134

Uses of ECG? Normal heart vector?

  • Ecg
    • Screening, diagnosis, monitoring
  • Normal heart vector = +60

135

EKG of premature atrial contraction?

A image thumb
136

EKG of premature ventricular contraction?

A image thumb
137

EKG of atrial flutter?

Atrial fibrillation?

Ventricular tachycardia?

A image thumb
138

EKG of v. fib, left bundle branch block? right bundle branch block?

A image thumb
139

Different types of ECG monitors?

  • Ambulatory
    • portable and worn for varied lengths of time
    • three leads
  • Holter
    • 24hr/48hr/2wk monitors
    • Continuously records and when returned the data is downloaded
  • Event monitor
    • longer term with daily auto transmission
    • will also detect tachy/brady episodes
  • Loop recorders
    • subcutaneously over the heart
    • auto detects arrhythmias

140

What is baye's theorem?

  • When prevalence is low - higher risk of false +
  • When prevalence is high - higher risk of false -
  • Predictive power is best in patients with intermediate prevalence
    • higher the workload the better the prognosis
    • lower workload predicts poor prognosis

141

Treadmill testing:

Goal?

Double product?

Best predictor of ischemia?

  • Goal
    • Goal: Maximum exercise capacity to increase sensitivity 
  • Double product – peak BP x peak HR - indication of the energy demand of the heart and energy consumption of the heart. >20,000 is good
  • The best predictor of ischemia is horizontal to downsloping ST depression of  ≥1 mm (80 milliseconds past J-point).

142

Indications for pharmacologic stress testing?

Types of testing?

  • Indication: cant exercise, pacemaker, aortic aneurysm, abnormal EKG, poorly controlled HTN, COPD
  • Coronary vasodilators (adenosine)
    • Perfusion worsens when you dilate non-stenosed coronaries versus stenosed
  • Inotropes (dobutamine)
    • Increases stress and myocardial O2 demand --> ischemia in stenosed patient

143

Three types of nuclear imaging and uses?

  • Thallium - 201
    • Na/K pump to enter myocytes for viability testing
  • Technetium
    • Stress testing and eval of LV function
  • PET scan with Rubidium
    • Used for viability

View the PET images for normal/inferior ischemia/anterior ischemia in ppt?

144

What does ultrasound use for imaging?

  • High frequency sound wave to discern images, function, and direction of BF
  • Audible sound = 20kHz; US = 2-5 MHz
  • Use of doppler

145

Different ultrasound views?

Transthoracic
•Apical (A) 4 chamber
•Parasternal
•Short axis
•A – 2 Chamber 

 

Can also be done transesophageally to visualize
 

A image thumb
146

Use of contrast echo?


•To evaluate for shunts – agitated saline
•To enhance endocardial borders – echogenic microspheres
 

147

Use of intracardiac ultrasound?

What is a stress echo?


•Used during structural heart disease procedures.

  ASD closure
•A.fib ablations

 

Stress echo = standard stress test then imaging

148

CT cardiac applications?

•Coronary arteries anatomy and morphology
•Coronary artery calcium score
•Cardiac anatomy – Pericardial disease; Masses
•Coronary plaque characterization
•Congenital Heart disease
•Postop. Evaluation (CABG)
•Electrophysiology
•Newer – Perfusion and Fractional flow reserve.
•Aortic evaluation – aneurysms, dissections
 

149

Signs/Symptoms of cardiac disease

150

Causes of dyspnea?

  • cardiac/pulmonry disease
  • anemia
  • metabolic acidosis
  • obesity
  • poor physical condition
  • neuromuscular disease
  • psychogenic disorders

151

Different mechanisms for dyspnea?

  • diastolic abnormality
    • increased pulmonary venous pressure
  • Systolic abnormality
    • metabolic acidosis from anaerobic metabolism
  • exertional dyspnea
  • orthopnea, PND

152

Causes of chest pain?

  • cardiac
    • MI/angina
    • pulm htn
    • pericarditis
  • aortic dissection
  • pulmonary: embolus, pneumonia, pleuritis, pneumothorax
  • musculoskeletal
  • neurological
  • gastrointestinal
  • psychogenic: hyperventilation

153

Mechanisms of chest pain?

  • Angina
  • MI/dissection/PE/pericarditis

154

Symptoms of cardiac disease?

  • dyspnea
  • chest pain
  • edema 
  • fatigue (low CO)
  • palpitation 
  • syncope (due to decrease in global cerebral perfusion)

155

Risk factors for coronary heart disease?

  • Age
  • Gender
  • Hyperlipidemia
  • Hypertension
  • Family history
  • Diabetes 
  • Smoking

156

Leading cause of mortality in women?

Difference between women and men in this disease?

Leading cause is coronary artery disease

  • Presenting symptom is most commonly angina in women
    • Often atypical angina
  • Presenting symptom in men is most commonly MI
  • Sudden death is more common in men

157

What is metabolic syndrome?

  • Obesity: men and women BMI >30
  • Diabetes: men and women fasting blood sugar >110
  • Hypertension: men and women BP >135/85
  • Hyperlipidemia
    • both men and women triglycerides >150
    • HDL cholesterol
      • men <40
      • women <50

158

continuation of peripheral arterial disease I because i thought i was done but apppppppparently i was NAHT!

<3 choo! :D

159

What is thromboangiitis obliterans? Treatment?

  • Also known as buerger's disease
  • digital necrosis and can lead to loss of an extremity
  • starts with digital arteries and progresses
  • unsure of mechanism
  • ONLY treatment is to stop smoking

160

Causes of limb ischemia? How long to restore flow?

  • A. fib
  • AAA with mural thrombus
    • AAA?
  • Trauma
  • SBE
  • Popliteal aneurysm thrombosis
  • dissection
  • Only a 4-6 hour window to prevent death or irreversible damage to the limb

161

Six "P"s of acute limb ischemia presentation?

  1. Pain
  2. Pallor
  3. Pulselessness
  4. Poikilothermia
  5. Paresthesias
  6. Paralysis

162

What is subclavian steal syndrome?

  • Classically from LS stenosis or occlusion
  • Arm activity --> vasodilation in arm --> sets up a negative pressure gradient --> causes vertebral flow to reverse --> brainstem ischemia and syncope

163

How do you detect subclavian steal syndrome?

  • Symptoms
  • Pressure differential in arms
  • Ultrasound
  • Angiography

164

Signs/Symptoms of acute mesenteric ischemia?

  • Severe abdominal pain out of proportion to findings
  • Bloody stool
  • Dilated bowel with thickened walls
  • Progression to shock, sepsis, and death

165

Risk factors for acute mesenteric ischemia?

  • Being old
  • A. fib
  • Hypercoaguable states

166

Abdominal aortic aneurysm:

Association?

Diagnosis?

 

  • Association
    • smoking
    • family hx
  • Diagnosis
    • intense abdominal pain, pulsatile mass, hypotension, and shock
    • Follow with ultrasounds until size >5.5 cm

167

What is aortic dissection? Propagation?

  • Intimal damage that causes blood to go into the media and form a hematoma
  • Can dissect retrograde into pericardial space causing a tamponade
  • Can propagate anywhere:
    • CNS, viscera, pleural space

168

Aortic dissection signs/symptoms?

  • Sudden onset tearing pain
    • Pain radiates to the back
  • Associated with shock, stroke, acute aortic insufficiency, and ischemic gut

169

Diagnosis of aortic dissection?

  • Widened mediastinum on CXR
  • Pressure differential
  • Acute upper or lower extremity ischemia