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PANCE Review > Cardiology II > Flashcards

Cardiology II Flashcards

1
Q

cardiac valvular disease - causes and dx

A

issue with valves of heart - can either be stenosis or regurgitation (i.e. insufficiency) due to “floppy” valve

historically, rheumatic dx
now, atherosclerosis

Dx Test: ECHO!!

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2
Q

mitral valve prolapse - what do you hear on auscultation

A

midsystolic click

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3
Q

aortic stenosis - sxs

A

dyspnea, angina, syncope w/ exertion
- LV failure and hypertrophy (displaced PMI)

Murmur: systolic ejection murmur, harsh and loud
- have pt lean forward

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4
Q

aortic stenosis - dx

A

doppler ECHO (test of choice)

EKG: LVH
CXR: cardiomegaly, calcified valve

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5
Q

aortic stenosis - tx

A

valve replacement has great results

- must do if following triad of HF, angina, or syncope

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6
Q

aortic regurgitation - sxs and cause

A

dyspnea on exertion
PE: head-bobbling and pulsating nail beds
- WIDE PULSE PRESSURE (high systolic and low diastolic)
- also see LVH since blood flowing back into LV

cause: can see in Marfan’s due to aortic root problem

Murmur: high pitched, blowing diastolic murmur

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7
Q

aortic regurgitation - dx

A

ECHO - test of choice

EKG and CXR: LVH

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8
Q

aortic regurgitation - tx

A

acute regurg (following invasive endocarditis) - immediate surgery

chronic regurg:

  • ARBs and ACE-I reduce sxs
  • valve replacement eventually
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9
Q

mitral stenosis - sxs

A

orthopnea, proximal nocturnal dyspnea, exertion dyspnea
- initial sxs often with onset of A-fib or pregnancy

Murmur: mid-diastolic, low-pitched rumble

  • OPENING SNAP (HINT-MS/OS)
  • loudest in L lateral position (use bell)
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10
Q

mitral stenosis - dx

A

ECHO - see “hockey stick shape of anterior leaflet of mitral valve

EKG: atrial findings, including A-Fib

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11
Q

mitral stenosis - tx

A

often asymptomatic
- follow
if have A-Fib - treat A-Fib
- anti-coag

possibly valve repair or replacement

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12
Q

mitral regurgitation - progression

A

initially can see increased pre-load and reduced afterload

eventually, LV enlarges, weekend, and EF drops = left-sided heart failure

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13
Q

mitral regurgitation - sxs

A

gradually progressing dyspnea and fatigue over many years

Murmur: harsh, blowing, holo-systolic murmur best heard at apex radiating to left axilla

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14
Q

mitral regurgitation - dx

A

ECHO and TEE (trans-esophageal)

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15
Q

mitral regurgitation - tx

A

sxs manage: vasodilators, ACE-I

surgery for intolerable sxs or EF<60%

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16
Q

mitral valve prolapse (MVP) - sxs

A

common - found in thin, young females and goes away with age

usually, asymptomatic, but can present as young women with non-specific chest pain, dyspnea, fatigue, palpitations

Murmur:

  • mid-systolic click
  • murmur increases with standing or valsalva
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17
Q

mitral valve prolapse (MVP) - dx

A

clinically diagnosed; ECHO confirms

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18
Q

mitral valve prolapse (MVP) - tx

A

beta-blockers for hyperadrenergic state (young women)
SSRI

surgical repair is option, but not common

NOTE: no ABX prophylaxis needed

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19
Q

tricuspid stenosis - sxs

A

uncommon

rt-sided heart failure
- hepatomegaly, ascites, dependent edema

elevated JVP (giant a wave)

Murmur: diastolic, rumbling murmur

  • best heard at left, lower sternal border
  • increases with inspiration
  • use bell
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20
Q

tricuspid stenosis - dx and tx

A

ECHO - best

EKG: right-sided issues (rt atrial enlargement, rt ventricular hypertrophy)

Tx:

  • diuretics (tx right HF sxs)
  • bioprosthetic valve is tx of choice
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21
Q

tricuspid regurgitation - causes and sxs

A

iatrogenic: pacemaker lead placement

tricuspid valve prolapse, plaque, collagen inflammatory dz, tricuspid endocarditis

sxs: right-sided sxs (high JVP

Murmur: blowing, holosystolic

  • best heard at left, lower sternal border
  • increases with inspiration
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22
Q

tricuspid regurgitation - dx and tx

A

Dx: ECHO

Tx:

  • minor regurg = diuretics help
  • valve replacement if needed
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23
Q

pulmonic stenosis - sxs

A

frequently asymptomatic

  • gradual increase in dyspnea w/ exertion, CP, syncope
  • right-sided sxs: JVP

Murmur: harsh, loud, systolic murmur

  • best heard at 2nd/3rd left sternal border
  • DECREASES w/ inspiration
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24
Q

pulmonic stenosis - dx and tx

A

Dx: ECHO
- EKG: right sided problems

Tx:

  • tx predisposing conditions (rt sided HF)
  • valve replacement if needed
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25
Q

pulmonary regurgitation - cause and sxs

A

causes: most are 2nd to pulmonary HTN
- trivial amounts of PR can be normal variant

Murmur: low-pitched, diastolic murmur

  • best heard at 3rd/4th left sternal border
  • loud, split S2

NOTE: if w/ pulmonary HTN, called a GRAHAM-STEELL murmur
- increases w/ inspiration and diminished w/ valsalva

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26
Q

pulmonary regurgitation - dx and tx

A

Dx: ECHO

Tx:

  • treat pulmonary HTN first
  • surgical replacement
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27
Q

management of prosthetic valves

A

ALL mechanical valves required anti-coagulation

  • Coumadin and/or ASA
  • INR maintained at 2-2.5

Note:

  • Stop Coumadin 3 days prior to elective surgery; re-start 24 hrs after
  • Heparin used as bridge therapy
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28
Q

stable angina / angina pectoris - definition and PE findings

A

chest pain that is:

  • precipitated by stress/exertion
  • relieved rapidly be rest/nitrates

PE:

  • normal, non-specific
  • can find HTN, DM, hyperlipidemia, PAD
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29
Q

Tietze syndrome

A

inflammation at chondrocostal junction

  • mimics cardiac chest pain
  • tell apart by tenderness with chest palpation
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30
Q

cardiac markers

A

Proteins released by dead cardiac cells

Troponins I and T

  • preferred
  • detect in 3-6 hrs; peak in 12-24 hrs; normalize in 2 weeks (so not good for 2nd MI)
  • prognostic value: higher levels = more injury

CK-MB

  • detect in 4-6 hrs, peak 12-24 hrs, normalize in 2-3 days (so good for 2nd MI)
  • no prognostic value
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31
Q

stable angina - findings on EKG

A

many resting EKGs are normal
Classic:
- ST depression that resolves after pain subsides
- T wave flattening or inversion
- RARELY ST elevation due to coronary spasm (aka Prinzmetal’s)

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32
Q

stable angina - most useful test in evaluation

A

exercise stress test

Note: can also do pharmacological stress test

  • Meds: dobutamine, adenosine, dipyridamole
  • stimulate exercise and or vasodilator vessels

Note: can also do nuclear stress test or stress ECHO

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33
Q

stable angina - definitive diagnosis

A

coronary angiogram

  • diagnoses CAD
  • is diagnostic and curative at same time since clogged vessels are opened up if found
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34
Q

stable angina - treatment

A

Nitroglycerin

  • sublingual in 1-2 min; also long-acting
  • decreases vascular tone, pre-load, after-load, and O2 demand
  • SE: H/A, nausea, dec. BP

Revascularization / percutaneous coronary intervention (aka stent)

  • enter through vessel
  • note: need to be on anti-coag for at least 1 year

Surgery (CABG)

  • used with multi-vessel dz
  • use artery or vein form other area
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35
Q

Prinzmetal (variant) angina

A

results from coronary artery vasospasm (w/ or w/o coronary disease

  • chest pain w/o usually precipitating factors (often 1st this in morning, F>M)
  • may be induced by cocaine
  • associated with arrhythmia
  • EKG: shows ST elevation
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36
Q

unstable angina - definition and EKG

A

chest pain that occurs:

  • at rest
  • not relieved by nitroglycerine

Presents as unstable angina, ST-elevation (STEMI) or non ST-elevation
- May be a myocardial infarction!!

Results of CK-MG and Troponins help to determine if acute MI

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37
Q

acute STEMI - Treatment

A
  1. immediate coronary angiography with PCI (percutaneous coronary intervention)
  2. PTCA (balloon) and stenting
    - #1 today
  3. CABG surgery using artery or vein from other area of body
    - in severe cases
38
Q

congenital heart disease - adults

A

rare

Most live into adulthood

39
Q

atrial septal defect (ASD)

A

most occur from patent foramen ovale

Hx:

  • most asymptomatic with small/medium shunt
  • over 30 y/o w/ large shunt - dyspnea, CP
  • over 50 y/o w/ large shunt - atrial arrhythmia (A-Fib), rt. ventricular failure
40
Q

loudness of murmurs

A

louder the shunt = smaller the opening

  • with stenosis = more severe
  • with ASD and VSD - less severe
41
Q

atrial septal defect - murmur quality

A

systolic ejection murmur
widely split and FIXED S2 (lub, d-dub)

located at left 2nd/3rd interspace (aka pulmonic area)

42
Q

atrial septal defect - EKG and CXR

A

EKG: RBBB, RAD, RVH
CXR: dilated pulmonary arteries and increased vascularity
- enlarged RA and RV (blog is shunting to right side)

43
Q

ASD - dx, tx, and caution

A

Dx: ECHO
Tx:
- small shunts - observe
- large shunts - surgical repair

BEWARD: emboli leading to stroke/TIA

44
Q

coarctation of aorta - definition

A

narrowing of aorta past great vessels
- this is why carotid and UE pulses are normal and LE pulses are delayed

Note: cause of 2nd HTN in young

Note: bicuspid aortic valve in 50-80% of pts
- inc. risk of cerebral berry aneurysm

45
Q

coarctation of aorta - sxs and PE

A

usually asymptomatic until LV heart failure

  • may have HTN as young
  • may have CVA (due to emboli)

PE:

  • absent femoral pulses
  • HTN in arms but normal or low in LE
46
Q

coarctation of aorta - dx and prognosis

A

ECHO - diagnostic

EKG: LVH
CXR:
- aortic shadow “3 sign” which is the notch that narrows aorta
- notching of ribs due to inc. blood flow

If have cardiac failure, prognosis is poor

  • surgery is curative
  • untreated adults die by 50 y/o (aortic rupture, CVA, aortic dissection)
47
Q

patent ductus arteriosus (PDA) - definition

A

failure in closure of embryonic ductus resulting in persistent shunt connecting left pulmonary artery to aorta

  • PDA is treated in neonates w/ indomethacin
  • large shunts can cause pulmonary HTN (Eisenmenger’s physiology)
48
Q

patent ductus arteriosus (PDA) - sxs and PE

A

asymptomatic until develop HF or pulmonary HTN

PE:

  • widened pulse pressure (low DPB)
  • harsh, continuous MACHINERY-like murmur at left 2nd ICS
  • large shunts = toes cyanotic or blue
49
Q

tetralogy of fallot - classic features (4) and CXR

A
  1. ventricular-septal defect
  2. right ventricular hypertrophy
  3. pulmonary stenosis
  4. overriding/dilated aorta

Note: right-sided aortic arch is common (25%)

CXR: “boot shaped heart”

50
Q

ventricular septal defect (VSD) - general info

A

most close in childhood
results in L to R shunt

presentation depends on size of shunt

51
Q

ventricular septal defect (VSD) - sxs and PE

A

Sxs: usually asymptomatic, large shunts cause HF

PE:

  • loud, harsh, holosystolic murmur along L sternal borner (3rd/4th ICS)
  • systolic thrill common (grades IV-VI)
  • cyanosis in late stages
52
Q

abdominal aortic aneurysm (AAA) - general info

A 
90% original below renal arteries
aortic diameter >3cm (normal=2cm)
rarely rupture until >5cm
most asymptomatic
M:F = 4:1
53
Q

AAA - sxs

A

often found incidentally since anymptomatic

  • pulsatile mass palpable on PE
  • associated with LE occlusive disease of vessels

Rupture: severe abd/low back pain, pulsatile mass, hypotension

54
Q

AAA - dx and tx

A

abdominal U/S

Tx:

  • beta-blocker if monitoring
  • surgical correction if healthy
55
Q

aortic dissection - definition and risks

A

CATASTROPHE!!
- 90% mortality and 3 months

intimal tear creates a false lumen b/t media and adventitia

occurs in thoracic aortic (higher than AAA)
- types A and B

Risks: HTN (80%), Marfan’s pregnancy, bicuspid aortic valve

56
Q

aortic dissection - sxs

A

sudden, excruciating ripping pain in chest or upper back

  • HTN at presentation
  • peripheral pulses and BP diminished or unequal
57
Q

aortic dissection - dx

A

CT (abd/chest) is best study

CXR: widened mediastinum

58
Q

aortic dissection - tx

A

STAT:

  • BP control
  • beta blockade (labetalol) to reduce LV EF
  • IV Nitroprusside to lower BR
  • Pain relief with morphine
  • SURGERY
59
Q

3 ways an artery can be blocked - emboli, thrombi, trauma

- what at 3 areas on PE

A

thrombi: clot forms at location due to damage

emboli: traveling clot
- most arise from heart (e.g. A-fib)

trauma: injury

PE:
- circulation (pulses), motor, sensory

60
Q

acute ischemia - 6 “P’s”

A

blockage due to arterial clot in periphery

pain
paresthesias (early)
pallor
pulselessness
poikilothermia (varying temps)
paralysis
61
Q

arterial embolism/thrombosis - dx

A

doppler (U/S): of affected area will show distal to blockage little to no blood flow

62
Q

arterial embolism - tx and complications

A

heparin IV
t-PA via catheter (thin blood)
emergent embolectomy via balloon catheter

Complications:

  • metabolic acidosis, hyper K+, cardiac arrest
  • foot drop (loss of motor fx)
  • compartment syndrome (excrutiating pain)
63
Q

arterial thrombosis - causes and risk factors

A

commonly from chronic, atherosclerotic occlusive disease

- smoking, polycythemia, dehydration, hyper coagulable states

64
Q

arterial thrombosis - sxs

A

intermittent claudication (severe, cramp-like pain w/ exercise); absent or weak distal pulses

65
Q

arterial thrombosis - dx

A

ankle-brachial index (ABI): compares BP in ankle and arm
- <0.9 positive

CT/MR angiogram prior to surgery to determine location

66
Q

arterial thrombosis - tx

A

mild:

  • reduce risk factors (smoking)
  • cilostazol (anti-platelet drug)
  • endovascular repairs (angioplasty and stents)
  • surgical interventions (bypass grafts)
  • thromboendarterectomy: remove plaque (common in femoral artery)
67
Q

arterail occlusion (carotid) - sxs, dx, tx

A

carotid stenosis = 25% strokes

  • TIA: complete resolution of sxs in <24hrs
  • CVA: no resolution of sxs in 24 hrs

sxs: sudden weakness, aphasia, vision loss
dx: U/S, MRA/CTA

tx:
- medical (small occlusion): ASA and clopidogrel
- surgical: heparin and CEA (remove occlusion from carotid) or angioplasty/stenting via percutaneous route

68
Q

carotid artery dissection - classic triad and tx

A
  1. CVA or TIA
  2. Unilateral neck pain or severe H/A
  3. Horner’s syndrome (miosis - pinpoint pupils; ptosis - drooping eyelid)

Tx: drug therapy (Coumadin) then surgery

69
Q

arterial occlusions - common sites, imagine and treatment

A

Sites:

  • intestinal ischemia (chronic or acute)
  • ischemic colitis
  • renal artery stenosis (2ndary cause of HTN)
  • acute UE limb ischemia
  • mesenteric vascular insufficiency

Imaging: CTA or MRA

Treatment: vessels bypass, angioplasty, stenting

70
Q

peripheral arterial disease (PAD) - definition and risks

A

chronic condition; lower extremities effected by atherosclerotic disease

Risks: male, age, DM, HTN, smoking

highly associated with CVA and CAD (plaques can be everywhere)

71
Q

PAD treatment

A

identify and control risk factors: exercise, smoking cessation, lipid lowering

Cilostazol or ASA

endovascular techniques

  • bypass grafts
  • amputation when no longer circulation
72
Q

giant cell (temporal) arteritis and polymyalgia rheumatica - general info

A

same disease in different locations
- affects medium and large vessels

GCA: affects above the neck (temporal artery)
PMR: affects below the neck

Age > 50 (mean = 79 y/o)

73
Q

giant cell (temporal) arteritis - sxs

A

H/A, jaw claudication (pain with chewing), scalp tenderness, visual sxs
- BLINDNESS may result if ophthalmic artery affected

NOTE: elderly with fever and normal white count

74
Q

giant cell (temporal) arteritis - dx and tx

A

ESR is high (> 50)
dx: biopsy of temporal artery
Tx: urgent prednisone (60mg/day x 1 mo w/ taper)
- to prevent blindness

75
Q

polymyalgia rheumatica - sxs

A

pain and stiffness of shoulders/pelvis
fever, malaise, weight loss

Labs: anemia, elevated ESR

Tx: Prednisone (10-20mg)
- if no improvement in 72 hours, reconsider dx

76
Q

phlebitis / thrombophlebitis - general information

A

inflammation of superficial veins (long saphenous in LE most common)
- due to IVs and PICC lines

Risks: varicosity, pregnancy or postpartum, trauma
- associated with occult DVT in 20% cases

77
Q

phlebitis / thrombophlebitis - sxs

A

dull pain, redness and tenderness in linear distribution (vs. cellulitis which would be round)
- NO edema (since not deep vein)

chills and fever suggest septic cause (IV)

78
Q

phlebitis / thrombophlebitis - tx

A

NSAIDs, heat, elevation (7-10 days)

  • encourage ambulation
  • vein excision if complications
  • septic causes (S. aureus) require heparin and ABX (vancomycin)
79
Q

deep vein thrombophlebitis (DVT) - general info and risks

A

virchow triad: stasis, vascular injury, hypercoagulability

Risks: CHF, recent surgery or trauma, neoplasia, OC use (estrogen), sedentary, clotting abnormalities (factor V Leiden, protein C or S dsyfxn)

Complication: Pulmonary Embolism

80
Q

Virchow’s triad

A

For DVT:

  1. stasis
  2. vascular injury
  3. hypercoagulability
81
Q

deep vein thrombophlebitis (DVT) - sxs

A

heavy legs, dull ache, tightness, calf/leg pain with walking

Slight edema
Homan’s sign: only 50% positive

82
Q

deep vein thrombophlebitis (DVT) - dx and prevention

A

Venous U/S: diagnostic!

Prevention:

  • early ambulation, compression stockings, foot board
  • prophylax with anti-coagulation: LMWheparin, warfarin, vena cava filter
83
Q

chronic venous insufficiency - sxs

A

chronic elevation in venous pressure

  • history of phlebitis, DVT, leg injury
  • ankle edema early sign
  • late signs: itching, brawny stasis, pigmentation, dermatitis, varicosities, ulceration (painless)
84
Q

chronic venous insufficiency - tx

A

leg elevation, compression stockings, exercises

- care for ulcerations and wounds (wet compresses, ABX)

85
Q

varicose veins - general info

A

dilated, tortuous superficial veins in lE

  • incompetent venous valves
  • can be unilateral

Risk factors: female, pregnant, FH, h/o phlebitis
- greater saphenous vein most common

86
Q

varicose veins - sxs and tx

A

dull, achy, heaviness, fatigue in LE

tx: stockings, exercise, elevate legs
- surgery

87
Q

rheumatic fever

A

disease that can occur post GAS infection

JONES criteria (5 major):

  • migratory polyarthritis
  • carditis
  • Sydenham’s chora
  • subcutaneous nodules
  • erythema marginatum

Minor:

  • fever
  • arthralgia
  • acute phase reactants: CPR, ESR, leukocytosis
  • prolonged PR interval
88
Q

LDL goals

A

<160: no risk factors
<130: 2 risk factors (smoke, HTN, age over 45 (M) and 55 (F), FH)
<100: DM and CAD

89
Q

CHADS2VASC

A

used to estimate risk of stroke in patients with A-Fib

female: 1
CHF: 1
HTN: 1
Prior stroke, TIA, systemic embolism: 1
Vascular dz (CAD, MI, PAD): 1
Age > 75: 2
Age 65-74: 1
90
Q

endocarditis - causative organisms

A

Strep Viridans: most common overall
Strep Bovi: common in cancer
Staph epidermitisl: common in prosthetic valves
Staph aureas: common in IV drug use
HACEK: associated with endocarditis and neg blood cultures

Note: HACEK = haemophilus, asctinobaccillus, cardiobacterium, eikenella, kingella

PANCE Review (16 decks)

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