Cardio: MI, angina, endocarditis, ASD

Question 1

What is the pathophysiology of stable angina?

Answer 1

Fixed atherosclerotic lesion that narrow major coronary arteries. Imbalance btw blood supply and O2 demand leading to inadequate perfusion.

Question 2

What are the risk factors for ischemic HD?

Answer 2

• DM
• Hyperlipidemia
• Low levels of HDL
• Family history
• Smoking
• Age, men >45 women >55
• Obesity/lifestyle
• Excessive alcohol use
• Stress

Question 3

Clinical features of stable angina

Answer 3

• Chest/substernal pressure/pain/heaviness/tightness
• Gradual in onset
• Brought on by increased myocardial demand: excertion, emotion
• Releived w/ rest og nitroglycerin
• Does not change w/ breathing or change in body position

Question 4

How to DX stable angina?

Answer 4

1) Physical exam usually normal
2) Resting ECG: Q waves/normal/ ST, T abnormalities during pain
3) Stress test: ECG and echo
4) Pharmacologic stress test if patient cannot exercise
5) Holter monitoring: ambulatory ECG
6) Cardiac catheterization w/ coronary angiography = definite test for CAD

Question 5

Tx for stable angina

Answer 5

1) Risk factor modification
2) Drugs: Aspirin + B-blockers + nitrates (+ Ca-channel blockers). If CHF: ACEi’s
3) Revascularization for high-risk patients ( >70% of left main occluded)

Question 6

What is variant (prinzmetal) angina?
Clinical?
Tx

Answer 6

• Transient coronary vasospasm, usually accompanied by a fixed atherosclerotic lesion
• Happen at night and at rest
• Associated w/ ventricular dysrhythmias
• ST elevation during pain
• Ca-channel blockers, nitrates

Question 7

What is unstable angina?

Answer 7

Enlarged stenosis, chronic angina w/ increse in frequency/duration/intensity, new onset angina that is severe and worsening, patients w/ angina at rest

Question 8

Dx of unstable angina

Answer 8

1) Exclude MI
2) Stabilize medically before stress test
Like angina:
3) Stress test: ECG and echo
4) Pharmacologic stress test if patient cannot exercise
5) Holter monitoring: ambulatory ECG
6) Cardiac catheterization w/ coronary angiography = definite test for CAD

Question 9

Tx of unstable angina

Answer 9

1) Hospital admission w/ scope: O2, Iv access, pain control w/ nitrates and morphine
2) Agressive medical treatment- as MI w/o fibrinolysis
Aspirin, clopidogrel, bblockers, LMWH, abciximab/tirofiban
3) Cardiac catheterization/revascularization
4) After acute phase: continue aspirin, bblockers, nitrates, reduce risk factors

Question 10

What is an MI ?

Answer 10

Necrosis of myocardium as a result of an interruption of blood supply

Question 11

What is the mortality rate for MI?

Answer 11

30%

Question 12

What kind of patient typically gets an MI?

Answer 12

Patients w/

• Angina
• Risk factors of CAD
• Arrhythmia history

Question 13

What is the characteristic chest pain in MI?

Answer 13

• Substernal pressure (crushing elephant on chest)
• Similar to angina but more severe and do not respond to nitroglycerin
• Radiation to neck/jaw/arms/back of the left side

Question 14

What other symptoms than pain might be present during a MI?

Answer 14

• Dyspnea
• Diaphoresis(sweating)
• Weakness/fatigue
• Syncope
• N/V
• Sense of impending doom

Question 15

How to Dx a MI?

Answer 15

1) ECG: peaked T waves, St- segment elevation, Q-waves, T wave inversion, ST-segment depression
2) Cardiac enzymes: troponins, CK-MB

Question 16

Tx of MI

Answer 16

1) Hospital admission: O2, nitrates, morphine
2) Meds: aspirin, bblockers, ACEi’s, statins, heparin(?)
3) Revascularization: thrombolysis (alteplase), PCI, CABG

Question 17

What is the complications after MI?

Answer 17

• Pump failure: HF, cardiogenic shock
• Arrhythmias
• Recurrent infarct: Dx often difficult
• Mechanical injury: rupture of wall/ septum / papillary muscle, ventricular aneurysm
• Acute pericarditis
• Dressler syndrome

Question 18

What is endocarditis?

Answer 18

Inf. of the endocardial surface, usually involving the cusps of the valves

Question 19

Classification of endocarditis

Answer 19

• Acute: S. aureus most common, normal heart valve, if untreated-fatal in <6w
• Subacute: S.viridans/enterococcus, damaged heart valve, if untreated >6w to cause death

Question 20

What organisms cause endocarditis in native valve?

Answer 20

• S. virridans most common
• Staph spieces and enterococci
• HACEK: haemophilus, actinobacillus, cardiobacterium, eikenella, kingella

Question 21

What organisms cause endocarditis in prosthetic valve?

Answer 21

• Staph epidermidis (early onset)

- Strep (late onset)

Question 22

What organisms typically cause endocarditis in IV drug users?

Answer 22

• Right sided
• S. aureus
• Other: enterococci, Strep, candida, gram negs (pseudomonas)

Question 23

What are the complications of endocarditis?

Answer 23

• Cardiac failure
• Myocardial abscess
• Various solid organ damage from emboli
• Glomerulonephritis

Question 24

What do you need to do to DX endocarditis?

Answer 24

Use DUKE clinical criteria

• 2 major
• 1 major + 3 minor
• 5 minor

Question 25

What are the major duke clinical criteria?

Answer 25

- Sustained bacteremia | - Endocardial involvement: new valvular regurgitation

Question 26

What are the minor duke clinical criteria?

Answer 26

- Predisposing condition - Fever - Vascular phenomena: emboli, aneurysm, hemorrhage, Janeway lesion - Immune phenomena: GN, Osler nodes, Roth spots, RF - Positive blood culture: not meeting major criteria - Positive echo: not meeting major criteria

Question 27

What are the treatment of endocarditis?

Answer 27

- Parenteral AB's based on culture for 4-6 w | - If neg culture but high suspicion: empirical Tx w/ penicillin/vancomycin + aminoglycoside

Question 28

What are the cardiac indications for prophylaxis of endocarditis?

Answer 28

- Prosthetic heart valves - History of inf. endocarditis - Congenital HD: unrepaired cyanotic, repaired w/ prosthetic material - Cardiac transplant w/ valvulopathy

Question 29

What are the qualifying procedures requiring prophylaxis for endocarditis?

Answer 29

- Dental procedures - Involving biopsy/incision of resp. mucosa - Procedure involving inf. skin/skeletal muscle

Question 30

What is Marantic endocarditis?

Answer 30

- Also called nonbacterial thrombotic endocarditis - Associated w/ metastatic cancer - Sterile deposits of fibrin and plot form on the closure line of valve leaflets - Vegetations may embolize to the brain

Question 31

What is Libman-Sacks endocarditis?

Answer 31

- Also called nonbacterial verrucous endocarditis - Involves aortic valve in SLE - Regurg murmurs - May embolize

Question 32

What are the 3 types of ASD?

Answer 32

- Ostium secundum: most common, central portion - Ostium primum: low in septum - Sinus venosus: high in septum

Question 33

What is the pathophysiology of ASD?

Answer 33

- O2 rich blood from LA -> RA -> increase RH output and pulm. flow - Increase work og RH -> shunt size increase -> RA and RV dilatation w/ pulm-to-systemic flow ratio > 1,5:1 - Pulm. HT is a serious sequela

Question 34

What is the clinical features of ASD?

Answer 34

- Often asymptomatic until middle-aged (40y) - After this symptoms may start - Exercise intolerance, dyspnea on exertion, fatigue - Mild systolic ejection murmur at pulm. area - Fixed split S2 - Diastolic flow "rumble" mumur over tricuspid valve

Question 35

How to Dx ASD?

Answer 35

1) TEE : "bubble study" 2) CXR: large pulm. arteries and markings 3) ECG: RBBB, right axis deviation, atrial abnormalities

Question 36

What are the complications of ASD?

Answer 36

- Pulm. HT - Eisenmenger disease: fainting seplls, thromboembolism, hypovolemia, hemoptysis, preeclampsia - Right HF - Atrial arrhythmias - Stroke (paradoxical emboli/afib)