Cardiology Flashcards
(43 cards)
1
Q
Endocarditis
eti, sxs
A
MC Native Valve infx - Mitral - Strep viridans, S aureus, Enterococcus
IVDU - S aureus in tricuspid; Prosthetic - S. aureus or fungal if w/in 2 mos of implantation
Sxs:
- Fever,
- non spec sx - dyspnea, CP
- Murmur
- Janeway lesions - painless macules on palms and soles
- Roth spots - retinal hemorrhages w/ pale centers
- Petechiae
- Splinter hemorrhages
2
Q
Endocarditis
dx, tx
A
Modified Duke Criteria
Major
- bacteremia 2+ blood culture
- Echo w/ evidence of vegetation
- Newly dx valvular regurgitation
Minor
- RFs - IVDU, indwelling cath, weird valvular morphology
- Fever > 38C or 100.4F
- Vasc or embolic phenomena - Janeway lesions
- Immunologic phenom - Osler nodes (ouch), Roth spots, acute GMN
- Positive blood cultures not meeting major criteria
Tx
- Acute/Native Valve
- Nafcillin + Gentamicin; Vanco if MRSA+
- Subacute (HACEK organisms)
- Pencillin or Ampicillin + Gentamicin
- Vanco if MRSA+
- Prosthetic valve
- Vanco+Gentamicin + Rifampin (For S aureus)
- Fungal
- Ampho B for 6-8 wks
3
Q
Stable Angina
A
Angina brought on by physical activity, emotional upset - relieved w/ stress in a few mins (<30mins)
Levine’s sign
Dx
- EKG w/ temporary ST depression, T wave depression or inv
- Stress test - exercise or pharmological with adenosine or dipyridamole
- Coronary angio - gold std***
4
Q
Printzmetal Angina
A
vasospasm - smooth m contractions
Eti - cocaine, smoking, > 50yo, F
non-exertional CP
cyclical - usu in the morning
Dx:
- EKG - ST or T waves elevations, Inverted U waves
- Normal trop and CKMB
Tx - CCBs
5
Q
Unstable Angina
A
Previously stable & predictable => more freq and intense
new onset or severe or worsening angina, occurs at rest
Dx -
- EKG - ST depr or T w inv
- Normal CKMB and trop
Tx
- progression to MI if untreated
- Nitroglycerin and morphine
- Stress test - if cath or revasc necessary
6
Q
NSTEMI
A
prolonged crushing CP; more severe and wider radiation; R->L arm or upper back
Dx
- EKG w/ ST depr or T wave inv
- Elevated Trop or CKMB or BNP
- Cardiac Cath to determine tx
- PCI or CABG
7
Q
STEMI
A
Leads
- V1, V2, V3, V4- Anterior → LAD
- V1, V2 - Septal
- I, aVL, V5, V6 - Lateral → Circumflex
- II, III, aVF - inferior → RCA
A NEW LBBB = STEMI
Dx
- ST elevation >/= 1 mm in at least 2 anatomically contiguous leads + reciprocal changes in opposite leads
- Ele Trop > 0.08
- Appears 3-12 hrs
- Peaks 24-48 h
- Lasts 5-14 days
- Ele CK-MB
- Appears 3-12 hrs
- Peaks 24 h
- Lasts 2-3 days
8
Q
NSTEMI/STEMI
Treatment
A
Reperfusion is KEY - done w/in 12 hrs of onset
Immediate Tx in ED
- Morphine
- O2
- ASA 325mg
- Nitroglycerine subling x3 q5m
- BB
- Statin
- ACEI/ARBS
PCI
- best within 3 hrs
- > thrombolytics
Thrombolytics/Fibrinolytics
- use if PCI is not available
- Alteplase (tPa) - activates plasminogen to destroy clots
- Streptokinase - less effective than tPa, less chance of ICH
Maintenance
- Antiplatelet therapy
- Aspirin - inhibits plt activation and aggregation
- P2Y12 inhibitor - Plavix/clopidegrol, Ticagrelor, Prasugrel
- Anticoag
- Unfrc Heparin - binds to antithrombin
- LMWH - better for DM
- Anti-ischemic therapy
- BB - decr symp drive
- Nitrates - venodilation
- CCB - verapamil/diltiazem - decr contractility
9
Q
Pericarditis
A
idiopathic or viral - restrictive pressure on heart
Sxs:
- Dyspnea, fatigue, weakness
- Sharp, pleuritic substernal CP => relieved by sitting upright or leaning forward
- Friction rub
- edema
Dx
- ele WBC
- Diffuse ST seg elevations - EKG
Tx
- NSAIDs or Aspirin x 7-14d
- Colchicine 2nd line
- CS if sxs > 48 or refractory
10
Q
Pericardial Effusion
A
2/2 to pericarditis, uremia, cardiac truam
Sxs:
- painful or painless, depending on rate of effusion
- cough
- dyspnea
- pressure
Dx
- EKG - electrical alternans, non-spec T wave changes, low QRS voltage
- Echo - fluid surrounding heart
Tx
- Observe is small
- Pericardiocentesis if + tamponade or large effusion
11
Q
Cardiac Tamponade
A
fluid compromises refilling - collapsed R ventricle (weakest wall) and impairs CO
Sxs:
- Pulsus paradoxus - > 10 mmHg decrease in systolic when pt inspires
- Tachycardia, Tachypnea
- Narrow pulse pressure (180/130)
-
Beck’s Triad***
- JVD
- Muffled heart sounds
- Hypotension
Tx - pericardiocentesis immediately
12
Q
Peripheral Artery/Vascular Disease
A
MCC atherosclerosis
Sxs:
- Intermittent claudication on lower leg pain, relieved by rest
- Develops to pain at rest
- weak femoral or distal (popliteal/TP/DP) pulses
- Aortic, iliac, or femoral bruit present
- Skin changes
- shiny
- atrophic
- loss of hair
- be wary of acute arterial occlusion - 6Ps
Dx
- Doppler US - eval
- ABI - BP in upper and lower extremities
- <0.9 = severe disease
- normal is >1.2
- Angiography - gold std
- stenotic sites
Tx
- smoking cessation
- control HTN, DM2, HLD
- Aspirin/ plavix
- stenting if stenosis > 70%
- Cilostazol - relieve w/ walking
13
Q
Dilated Cardiomyopathy
A
Systolic dysfunction => ventricular dilation => decreased contractial function => reduced CO
Eti:
- MC in 20-60yo, M, idiopathic 50%
- viral myocarditis - Enteroviruses (Coxsackie B), Chagaz dz
- Toxic - etoh abse, cocaine, doxorubicin, radiation
Sxs:
- systolic HF - fatigue, DOE
- mitral or tricuspid regurg
- lateral displaced PMI
- S3 if
Dx:
- CXR - enlarged heart, pulm edema, pleural effusion
- Echo - LV dilation, decr EF, regional or global LV hypokinesis
Tx:
- HF Tx - ACEI, diuretics, BBS, Digoxin, NA restrictionn
- ICD if EF < 30-35%
DDx
- Takotsubo CMO - broken heart syndrome, apical L ventricular ballooning d/t catecholamine surge
14
Q
Hypertrophic Cardiomyopathy
A
Hereditary - Autosomal Dom, early MI death, young athletes
Hypertrophied Ventricular septum = Impaired ventricular relaxation/filling
Sxs:
- Dyspnea, Angina, Syncope - esp during exertion
- Sudden cardiac death - due to V fib
- S4 if outflow obstruction present
- Harsh cres-decres murmur at LLSB
- incr murmur intensity with decreased venous return (Valsalva or standing)
Dx:
- Echo - asymmetrc wall thickeys > 15mm, small LV chamber size
- EKG - LVH, atrial enlargement
- CXR - cardiomegaly
Tx:
- Counseling - avoid dehydration and extreme exertion/exercise
- BB - first line, CCB
- Avoid Digoxin (incr contractility), Nitrates and diuretics (decr’s LV volume)
- Surgical - myomectomy - definitive if refrc to medical tx
- ICD For high risk
*
15
Q
Restrictive Cardiomyopathy
A
Impaired diastolic relaxation - stiff ventricles decreases filling
Eti - infiltrative diseases - Amyloidosis MCC, Sarcoidosis, hemachromatosis, scleroderma, chemo, XRT
Sxs:
- RS HF more common
- Kussmaul’s sign - JVP incr with inspiration, Hepatomegaly, perip edema
Dx:
- Echo - usual normal systolic contraction
- Speckled appearance - infiltrative disorder
Tx:
- Na restriction, caution diuretics
- treat underlying disorders
16
Q
Atrial Fibrillation
Conduction Disorders
A
Irregularly Irregular rhythm - SVT
MCC - mitral valve stenosis, hyperthyroidism
Sxs:
- SOB, Chest Pain, Dizziness, Fatigue
- Irregular pulse
Dx:
- EKG - Irregular irreg rhythm
- Atrial rate >140bpm
- No discernable P waves
- variable and irreg QRS
Tx:
- Rate control - BB, CCB, or digoxin (for CHF or hypotension)
- anticoag - warfarin or DOACs if CHADsVASc >/= 2
- CHF
- HTN
- > 75yo
- Stroke, TIA, Thrombus
- Vasc dz
- Female
- Unstable AF or new onset AF < 2 d - cardiovert
- > 2 days get TEE To r/o clot
17
Q
Atrial Flutter
Conduction Disorders
A
Atrial focus of ~300 bpm
Sxs:
- SOB, dizziness, fatigue
Dx:
- EKG - Saw tooth pattern, regular rhythm
- Atrial rate 240-320bpm
- Ventricular 150bpm
Tx:
- Rate control BB, CCB, Digoxin*
- Anticoag if CHAD Vasc >/=2
- Warfarin or DOAC
18
Q
First Degree Atrioventricular Block
Conduction Disorders
A
constant prolonged PR Intvl = > 200 msec or 0.2
no tx necessary, monitor
19
Q
Second Degree Atrioventricular Block
Type I
Conduction Disorders
A
Mobitz 1 - Wenckebach
progressively lengthening PR interval until P wave drops, PR then resets
Tx:
- none if asymp
- Atropine, epinephrine, +/- pacemaker
20
Q
Second Degree Atrioventricular Block
Type II
Conduction Disorders
A
PR interval constant until P wave drops randomly
Tx:
- Atropine
- Temporary pacing
- Permanent pacemaker definitive
- progression to 3rd degree high
21
Q
Third Degree Atrioventricular Block
Conduction Disorder
A
No relationship btwn P and QRS - atrial and ventricles are firing separately. All P waves not followed by QRS = Decr CO
Sxs:
- Syncope, Dizziness, acute HF, hypotension, cannon A wave
Tx:
- Permanent Pacemaker
22
Q
Left Bundle Branch Block
Conduction Disorders
A
L ventricle will depolarize from impulses from R ventricle - partially or completely outside conduction system = Widened QRS
- Completely LBBB > 0.12 seconds
- Incomplete LBBB < 0.12 secs but can develop into complete
Signifies Ischemia and structural heart disease
23
Q
Right Bundle Branch Block
Conduction Disorders
A
Conduction comes from L ventricle so widened QRS
RBBB in asymptomatic - fine
new RBBB + CP = occlusion in L anterior descending artery
new RBBB + dyspnea = Pulm embolism
24
Q
Atrioventricular Nodal Reentry Tachycardia
Paroxysmal Supraventricular Tachycardia
A
SVT with abrupt onset and offset
Any tachyarrhythmias arising from above Bundle of His
Reentry circuit in or near AV node - electrical impulse travel in circular pattern => heart beats fast and regular
Sxs:
- Palps, SOB, Angina, Syncope, Lightheadedness
Dx
- EKG rate at 150-250 bpm
- P wave buried in QRS or after
- Holter monitor to catch eps
Tx:
- Cardiovert if hemodynamically unstable
- Vagal maneuvers
- Adenosine**
25
**Wolf Parkinson White**
Paroxysmal Supraventricular Tachycardia
Presence of abn accessory pathway (**Bundle of Kent fibers**) btwn atria and ventricles
Sxs:
* Palps, dyspnea, dizziness, rarely cardiac death
Dx:
* EKG - shorted PR intvl, widened QRS, **delta waves**
Tx:
* observed if asymp
* Acute tx - **Procainamide\*\***
* Radio freq ablation is curative
26
**Premature Ventricular Contractions**
Conduction Disorders
Ectopic beat from ventricular foci - wide QRS complex \>0.12s
not a/w P wave
Sxs - palpitations
Tx underlying cause, BBs and other anti-arrhythmics
27
**Premature Atrial Contractions**
Conduction Disorders
ectopic focus but still impulse goes through AV and bundle of His so normal QRS complex
## Footnote
P wave morphology depends on where ectopic beat is - close to SA node = normal looking P wave, otherwise, it is wider
If impulse is close to AV node, atria depolarize opposite direction = **retrograde P wave**
Next beat has longer interval
28
**Sick Sinus Syndrome**
Conduction Disorders
Dysfunction of Sinus node's automaticity and impulse generation
EKG:
* sinus rhythm with resting HR of 60bpm
* Sinus pause \< 3s
* Sinus arrest \> 3 s
* tachy-brady alterations
MC in elderly
Worse with digitalis, CCB, BB, antiarrhythmic
Tx - permanent pacemaker
29
**Sinus Arrhythmias**
Conduction Disorders
Irregular patterns in rate of NSR
1. Respiratory or phasic
* normal - decreases w/ age
* Inspiration - increase sinus rate (inhibits vagal tone)
* Expiration - rate declines
2. Nonrespiratory or nonphasic
* not related to respiratory cycle
* d/t normal, diseased heart or digitalis intoxication
3. Nonrespiratory, ventriculophasic sinus arrhythmias
* 3d AV block
* intermittent differences in PP intvls
30
**Torsades de Pointes**
Conduction Disorders
Sudden cardiac arrest
a/w palps, dizziness, syncope
EKG - polymorphic V Tach
either from HypoK or HypoMg
rate btwn 150-250
Either cease spontaneously or degenerate into VFib
Tx- **IV Magnesium**
Cardiovert if unstable
31
**Ventricular Tachycardia**
Conduction Disorders
a/w CAD, MI, Structural Heart Dz
Three or more consecutive Ventricular Premature Beats
Regular rhythm - Wide and regular
Tx:
* Cardioversion if unstable
* Sustained VT
* Stable → IV amiodarone
* Unstable w/ pulse → sync cardioversion
* VT no pulse → Defib
* Evential ICD placement
* Non-sustained VT
* No heart diz or asymp - no tx
* Heart dz, recent MI - electrophysiology study
32
**Ventricular Fibrillation**
Conduction Disorders
Uncoordinated quivering of ventricle w/ no useful contractions
No P waves, QRS Complexes, or T waves,
Rate 150-500 bpm
Tx:
* Severe hypotension or LOC = Sync Cardioversion
* _Pulseless V Tach_ = **Defib and CPR**
* 1mg IV bolus epi, q 3-5 mins
* Defib 30-50sec
* Refract V Fib - **IV Amiodarone**
* **Implantable Defib**
33
Aortic Stenosis
Usu d/t atherosclerotic dz, stiffened AV; **congenital bicuspid**
Sxs:
* Dizziness, syncope w/ exertion - not enough blood going to body
* angina, SOB
* delayed carotid upstroke
Dx:
* RUSB 2nd ICS
* **Harsh cres-decrs** murmur (louder with squatting)
* **Radiates to Carotids**
Tx:
* Balloon valvuloplasty temporary
* Total AV Replacement
34
Aortic Regurgitation
Congenital bicuspid valve, Marfan's syndrome (large diameter)
Sxs:
* Syncope, SOB, dyspnea, CHF, pulm edema
* widen pulse pressure (180/50), Corrigan/water hammer pulse
* RUSB 2nd ICS
* Murmur is louder with increase venous return (squatting)
* **blowing, decresc DIASTOLIC murmur**
Dx:
* Echocardiogram - TEE is better
Tx:
* TAVR
35
Mitral Stenosis
MCC Rheumatic fever (aka GABHS); stiffened mitral valves
Sxs:
* decrease CO, CHF, Afib common
* 4th ICS, midclavicular
* **low pitched, DIASTOLIC murmur**
* **opening snap**
Dx:
* Echocardiogram
Tx:
* MVR
* diuretics
36
Mitral Regurgitation
Widened mitral valv = Mitral valve prolapse, ischemic HD
backward flow into LA
Sxs:
* Signs of pulm congestion - pulm effusion, edema
* dyspnea, SOB, PND, orthopnea
* 4th ICS, midclavicular
* **holosystolic murmur, blowing, r-\> axilla\*\*\*\***
Dx:
* TTE echocardiogram
Tx
* MV replacement
* Diuretics
* antihypertensive
37
Aortic Aneursym/Dissection
Tear through all three layers of artery (intima, adventia, media) w/ blood pooling
RF - atherosclerotic, HTN, HLD, smoking\*
Sxs:
* **tearing chest pain; r-\>back**
* hypotensive, tachycardic, tachypnea
* Cool extremities
* diaphoretic
* back/flank pain when unruptured
Dx:
* different BP in R and L UE
* CXR - first line - enlarged silhouette
* **CT\*\*\* - gold**
* Trop/BNP r/o MI
* EKG
Tx:
* Thoracic Aorta
* **Type A - Ascending Aorta** =\> Immediate Surgery
* **Type B - Descending/Abdominal** =\> HTNsive mgmt to prevent progression
* \<3cm = observe
* 3-5.5 = CT q 6 mos surveillance
* \>5.5 = Surgery - stent to reinforce aorta
* Long term management
* BB - control HR/HTN, DM
* at least 6 mos anticoag with Warfarin or DOAC
38
Arterial Occlusion or Thrombosis
Recent injury, clot in med/small artery vessel afib
MC in anterior calf or forearm
Sxs: 6Ps
* Pain
* Pallor
* Pulselessless
* Poikilothermia - loss of heat
* Paresthesias
* Pressure?
Dx:
* Doppler US for blood flow
Tx:
* Surgical Emergency - **angioplasty, stent or embolectomy**
* **Anticoag - Heparine or LMWH**
39
Phlebitis
Inflammation of vein, usu d/t injury aka need stick
Sxs:
* pain, erythema at site
* vein feels hardened
Dx:
* Venous duplex US - noncompressible vein
Tx:
* NSAIDs
* elevation
* compression stockings
40
Hypertensive Urgency and Emergencies
**_Urgency_**
SBP \>180/120 w/ no evidence of end organ damage
No need to emergently lower BP
Goal = lower BP by 25% over 24 hrs = outpatient
**_Emergency_**
\>220/130
Accelerated HTN - BP w/ target organ damage
Malignant HTN - elevated BP a/w papilledema and other signs of EOD
Sxs:
* CP, dyspnea, HA, blurred vision
Tx
* ICU
* Nitroprusside
* IV labetalol
* Nicardipine
41
**Heart Failure**
systolic vs diastolic
High CO failure - high demands for blood circ - thyroid storm, berri berri etc
Low CO failure = 1. Systolic Dysfunction 2. Diastolic Dysfunction
**Systolic Dysfunction** - decr contractility, CO
* Valvular dz
* Ischemic CMO
* Dilated CMO
**Diastolic Dysfunction** - impaired ability of hear to relax
* restrictive CMO
* HOCM
* HTN
42
**Congestive Heart Failure**
eti, sxs, dx
_Left Sided HF_
* Volume overload - S3
* Dyspnea, SOB, exertional fatigue, Orthopnea, PND
_Right Sided HF_
* Edema, JVD,
* Hepatomegaly, HJR, wt gain
Dx:
* CXR - Kerley B lines, Pulm effusion/edema
* Labs - CBC, TSH (high output), BNP, BUN/Cr
* **Echocardiogram\* -**assess fx
* NYHA
* Class I - Risk but no symp
* Class II - risk and sxs
* Class III - sxs w/ ADLs or mini activity
* Clas IV - sxs at rest
43
**Congestive Heart Failure**
treatment
Sxs control, reduce cardiac workload, control fluids
1. **_Loop Diuretics - Furosemide, Torsemide_**
* reduce NaCl abs = free water excretion
* monitor K, Mg, Na
* ototoxic sulfa allergy
2. **_ACE-I or ARBS - statins, sartans_**
* prevent remodeling of heart = **lowers mortality**
* decr preload and afterload
* monitor Cr - renal dysfx
3. **_BB - Carvedilol, Metop, Bisoprolol_**
* prolongs survival, incr LVEF
* control rate, prevents arrhythmias
4. **_Aldosterone Receptor Antagonist - Spironolactone_**
* ****decr fluid retention
* monitor K for hyperK - check labs 3-4 d, few wks after
* gynecomastia
5. **_ICD_**
* **__**if Acute MI EF \<30%
* Class II or II and EF \<35% w/ sxs
