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Clinical features of Stable Angina

>Substernal pressure/tightness (less than 15 mins).
>Worse w/ exertion (inc. heart O2 demand).
>Better w/ rest or nitroglycerin


Diagnostic tests for Stable Angina

>ECG stress test: ST depression, hypotension, heart failure, ventricular arrhythmia
> Stress echocardiography: detects wall motion abnormalities
>Pharma stress test: IV adenosine or dipyridamole; dobutamine.


When do we use cardiac catheterization for a patient with stable angina? What is it used to determine?

>If the ECG stress test or Stress echocardiogram is (+).
>determines specific dx, location of lesion, severity of stenosis --> if we should do PCI or CABG and where.
*CABG if stenosis >70%, 3-vessel dse, or Left main coronary artery dse.


Pharma treatment for Stable angina

>Aspirin (or clopidogrel): all CAD pts; dec. morbidity, dec. MI risk.
>B-blockers: dec. freq. of coronary events.
>Nitrates: general vasodilation relieves angina.


Diagnostic tests for Unstable angina

>Immediate ECG to rule out MI.
>No cardiac enzymes present (vs. NSTEMI).
>cardiac catheterization w/ angiogram


Pharma treatment for Unstable angina

>Aspirin, Clopidogrel: take together do dec. MI incidence.
>LMW Heparin: prevent clot progression.
>Statins: for all CAD cases, regardless of LDL levels.
>Nitrates, morphine.


Clinical features of MI

>Substernal pressure, maybe radiating to neck, jaw, arms, back.
>No response to nitroglycerin; lasts >30 mins.
>Possible epigastric discomfort.
>Sudden cardiac death due to V-fib.
>N/V, diaphoresis, sense of impending doom, dyspnea.


Diagnostic tests for MI

>ECG: ST elevation (STEMI) or depression (NSTEMI); Q waves, peaked T waves.
>Cardiac enzymes (vs. USA): Troponin I, T; CK-MB (re-infarction).


Dx test results for USA vs. NSTEMI vs. STEMI

>USA: (+) ECG abnormalities, (-) cardiac enzymes.
>NSTEMI: (-) ST elevation, (+) cardiac enzymes.
>STEMI: (+) ST elevation, (+) cardiac enzymes


Pharma treatment for MI

>Supplemental O2 and analgesics (nitrates, morphine --> Beware of hypotension).
>Aspirin, B-blockers, ACEi: maintenance therapy; dec. mortality.
>Statins: also maintenance.


When do you do Revascularization for a patient w/ MI (esp. STEMI)?

>If caught w/in 3 hrs of arrival, begin fibrinolysis, then do PCI w/in 24 hrs of pain onset.
>If caught late or contraindicated for fibrinolysis, do PCI immediately.
>Do CABG if >12 hrs from pain onset or PCI fails.


Clinical features of Congestive heart failure

>Fatigue, diaphoresis, cool extremities.
>Dyspnea due to pulmo congestion.
>Paroxysmal nocturnal dyspnea.
>Peripheral edema.
>Jugular venous distension.


Features of Systolic vs. Diastolic failure in CHF

>Systolic: impaired contractility, normal relaxation and filling, dec. EF; eccentric LV hypertrophy, LV enlargement.
>Diastolic: impaired ventricular filling, lost compliance, stiff ventricle; normal EF, concentric hypertrophy, no LV enlargement.


Diagnostic tests for CHF

>CXR: cardiomegaly, Kerly B lines, pleural effusion.
>Echocardiogram: systolic vs. diastolic failure; estimates EF; chamber dilation or hypertrophy.
>ECG only if suspect systolic failure --> possible AFib or sudden decompensation in known CHF pts.


How may BNP levels be helpful in diagnosing CHF cases?

BNP is released from ventricles in response to ventricular volume expansion or pressure overload. Elevated BNP may indicate decompensated CHF.
>CHF vs. COPD as cause of dyspnea.
>Specific but not sensitive.


Pharma treatment for CHF (systolic failure)

>Loop diuretics, ACEi; B-blockers once stable or response suboptimal -- standard treatment.
>Spironolactone: systolic failure only; inc. diuretic effect; dec. mortality.
>Dobutamine: systolic failure only; helps contractility; acute exacerbations (hospital).
>Digitalis: systolic failure only; if w/ persisting sx, severe CHF, AFib


How do you differentiate the effects of the class I antiarrhythmic subclasses?

>As Na-channel blockers, they dec. phase 0 depolarization, and thus dec. conduction velocity throughout atria and ventricles -- IC>IA>IB.
>As potential K-channel blockers, they can affect phase 3 repolarization, and thus APD and ERP -- IA (strong; inc. APD, ERP)>IC (no effect)>IB (weak; dec. APD, ERP).


What is the dysfunction found in Dilated cardiomyopathy? What are possible causes?

>An insult that impairs LV contractility (systolic dysfunction).
>Ischemia (CAD w/ prior MI), Alcohol, Doxorubicin, Chagas dse, SLE, catecholamine-induced (cocaine), Pregancy.


What clinical features may be found in Dilated cardiomyopathy?

>SSx of CHF (LHF, RHF ssx).
>S3, S4.
>Mitral, tricuspid insufficiency.
>Arrhythmia (AFib).
>Possible sudden death.


What does the echocardiogram look like for Dilated cardiomyopathy? Hypertrophic cardiomyopathy? Restrictive cardiomyopathy?

>Dilated: dilated walls, eccentric hypertrophy.
>Hypertrophic: asymmetric wall thickening (LV > RV), w/ outflow obstruction due to thick IV septum.
>Restrictive: thick myocardium, rapid diastolic filling; inc. RA/LA size, normal RV/LV.


How do you treat a patient w/ dilated cardiomyopathy?

>Similar to CHF: Diuretics, vasodilators, digoxin.
>Anticoagulation if at risk of embolization.
>Longterm: ACEi, B-blockers, Spironolactone if necessary
*Vasodilation + dec. HR and contractility allows for improved SV due to dec. SBP.


What is the dysfunction found in Restrictive cardiomyopathy? What are possible causes?

>impaired ventricular compliance (diastolic dysfunction) due to infiltration of the myocardium -- problems filling and contracting; dec. RA compliance
>Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, chemotherapy, radiation.


What are the clinical features of Restrictive cardiomyopathy?

>Dyspnea and exercise intolerance due to inc. filling pressures.
>Right-sided ssx, inc. JVP.
>Pulmo edema, peripheral edema.


What is particular about the ECG of a patient w/ Restrictive cardiomyopathy?

>Low voltages (low amplitude) or conduction abnormalities.
>Patient may develop AFib.


How do you treat a patient w/ Restrictive cardiomyopathy?

>Treat underlying disorders.
>Diuretics and vasodilators used w/ caution (for pulmo and peripheral edema) -- dec. preload may compromise CO.
>B-blockers, CCBs -- inc. filling, inc. CO.


What is the dysfunction found in Hypertrophic cardiomyopathy? What are possible causes?

>A stiff, hypertrophied ventricle causing diastolic dysfunction
>Asymmetric hypertrophy of IV septum can cause dynamic outflow obstruction.
>AD inheritance causes obstructive type; chronic untreated HTN can cause non-obstructive type.


What are the clinical features of Hypertrophic cardiomyopathy?

>Syncope on exertion (MC).
>Chest pain, palpitations.
> Arrhythmias due to inc. atrial pressures.
>Sudden death, often in young athletes (first manifestation).
>Loud S4.
>Systolic ejection murmur (similar to AS murmur) -- inc. w/ squatting, sustained handgrip; dec. w/ Valsalva, standing.


How do you treat a patient w/ Hypertrophic cardiomyopathy?

>Avoid strenuous exercise.
>B-blockers -- inc. duration in diastole (improve diastolic filling, dec. HR).
>Myomectomy for severe cases.


What drugs should be avoided in pts w/ hypertrophic cardiomyopathy?

>(+) inotropes: digoxin, dobutamine.
>B-agonists, Nitrates, ACEi.
*Also avoid hypovolemia, tachycardia, arrhythmia, Valsalva (heavy lifting).


Steps for identifying a murmur.

>Is there a murmur?
>When is it? (systole vs. diastole)
>Where is it?
>Which valve does it involve?
>After all that, what's the murmur?


What are the symptoms found in Mitral stenosis?

>Pulmo edema -- SOB, dyspnea, fatigue, hemoptysis.
>Hoarseness due to enlarged LA compressing the left recurrent laryngeal nerve.
>Emboli formation.


What are the signs of Mitral stenosis? What does the echocardiogram look like?

>Opening snap ff. by diastolic rumble at apex (LLDP).
>Loud S1.
>Sx of RV failure in advanced cases.
>Echo: LA enlargement; thick, calcified MV; "fish mouth"-shaped orifice.


How do you treat a patient with Mitral stenosis?

Need to decrease preload.
>Na restriction.
>B-blockers -- dec. HR and CO.
>Surgery if severe disease.
>Treat AFib if present.


What are the signs found in Mitral regurgitation? What does the echocardiogram look like?

>CHF sx.
>S3; AFib, displaced PMI
>Holosystolic murmur at apex.
>Echo: dilated LA/LV, dec. LV function (if EF less than 60%, do surgery).


How do you treat a patient with Mitral regurgitation?

>Vasodilators (ACEi, Nitrates) if symptomatic -- dec. afterload.
>Anticoagulation if w/ AFib.
>MV replacement or repair.
>Emergent surgery if acute MR -- chordae tendinae rupture (post-MI); immediate echo and surgery.


What are the signs of Mitral valve prolapse?

>usually an incidental finding -- MC congenital valvular lesion.
>Most are asymptomatic; chest pain, palpitations, panic.
>Midsystolic click -- inc. w/ Valsalva, standing; dec. w/ squatting (dec. LV size, delays onset of murmur).


How do you treat a patient w/ Mitral valve prolapse?

>The condition is generally benign.
>B-blockers for chest pain.
>Surgery is rare.
>Antibiotic prophylaxis if w/ MR murmur.


What are the symptoms of Aortic stenosis?

>CHF sx: dysnpea, orthopnea, paroxysmal nocturnal dysnpea.
>Syncope upon exertion.


What are the signs of Aortic stenosis? What does the echocardiogram look like?

>Crescendo-decrescendo systolic murmur at RUSB; radiates to carotids.
>Paradoxical S2 split.
>Pulsus tardus et parvus.
>Echo: LVH, thick aortic valve; dilated aortic root.


How do you treat a patient with Aortic stenosis?

>Aortic valve replacement if orifice less than 0.8 cm2 or if symptomatic.
>Need antibiotic prophylaxis.


What are the signs of Aortic regurgitation? What does the echocardiogram look like?

>Diastolic decrescendo murmur (LSB) -- inc. w/ handgrip (inc. SVR).
>Widened pulse pressure; Bounding pulses; Head bobbing.
>Austin Flint murmur (low-pitched diastolic rumbling)
>Quincke's pulse.
>Echo: dilated aortic root and reverse blood flow; LVH; perform serially in chronic pts to assess need for surgery.


How do you treat a patient w/ Aortic regurgitation?

Need to dec. preload.
>Aortic valve replacement (EF less than 55%).
>Acute case -- emergency surgery (usually post MI; aortic dissection, aortic root dse, IE).


What are the clinical features of Tricuspid regurgitation?

>ssx of RHF/pulmo HTN
>Blowing holosystolic murmur at LLSB -- inc. w/ inspiration; dec. w/ expiration, Valsalva.
>Pulsatile liver.
>JVP: prominent V waves, rapid Y descent.
>Echo: assess degree of TR, measures pulmo pressures.


How do you treat a patient w/ Tricuspid regurgitation?

>Treat underlying etx (LVF, MI, cor pulmonale, RHD, tricuspid endocarditis).
>Surgery if w/o pulmo HTN.


What are the risk factors for Hypertension?

Sedentary lifestyle
Salt intake


How can HTN contribute to the development of heart failure/MI?

>inc. SVR -- inc. afterload -- LV hypertrophy and dilation -- LV dysfunction -- heart failure.
>HTN accelerates atherosclerosis -- inc. incidence of CAD, eventually leading to angina and MI.


What target organ damage can be caused by HTN?

>stroke, TIA.
>Peripheral arterial dse, AAA, aortic dissection.


How do you diagnose a patient for hypertension?

>inc. BP for 2-3 readings taken over one month (140/90).
>assess for possible causes to determine if secondary HTN: urinalysis, microalbuminemia, K, BUN, Crea, fasting glucose, lipid panel, ECG.


How do you manage HTN?

>Lifestyle changes.
>Thiazide diuretics (DOC).
>ACEi, ARBs - all diabetics (kidney protector).
>B-blockers - not for obstructive lung dse, heart block, depression.
>CCBs - arteriolar dilator.


What drugs would you give to treat HTN in a pregnant patient?