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Cardiovascular Flashcards

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1
Q 
Angina 
Path and Risk factors:
Pt:
Dx:
Tx:
A

Path: ischemia w/ myocardial oxygen demand > oxygen supply
Risks-> CAD, family hx, old age, HTN, HLD, DM, CKD, smoking

Pt:
Stable angina: Chest discomfort precipitate by activity but sx abate after activity
Unstable angina: sx at rest or a change in usual sx pattern
+/- SOB, NA, diaphoresis, dizziness, fatigue

Dx:
EKG: J point or ST segment depression, normal
Stress Test-> exercise, nuclear, ECHO

Tx:
Lifestyle modifications
Beta Blockers
CCB
Nitrates
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2
Q 
Aortic Stenosis 
Path:
Pt:
Dx:
Tx:
A

Path: Congenital (>70 y/o)-> MC degenerative calcification, Bicuspid aortic valve
LV outflow obstruction-> fixed CO; Inc afterload-> LVH

Pt: Angina, syncope, CHF, dyspnea
Older patient hx of DM, HTN

Dx: Systolic ejection crescendo-decrescendo murmur @ RUSB; radiates to carotid arteries
Pulsus parvus et tardus-> weak; delayed pulse
S4 if LVH
Narrow pulse pressure
LV heave due to LVH
Paradoxically split S2 (if severe)

Tx: Aortic valve replacement
Severe AS is dependent on preload: Avoid exertion, ventilators & negative inotropes (CCB, BB)

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3
Q 
Mitral Stenosis 
Path:
Pt:
Dx:
Tx:
A

Path: Obstruction of flow from LA to LV -> LA enlargement and inc LA pressure-> pulm HTN, Rheumatic heart disease

Pt: 
R sided heart failure
Pulmonary HTN-> hemoptysis 
A-fib
Mitral facies-> flushed cheeks 
Dx: 
Diastolic rumble @ apex in L lateral decubitus +/- opening snap; no radiation
Pulse usually dec intensity 
LA enlargement 
Prominent S1 (closing snap)

Tx:
Valvotomy in young pts -> rheumatic dz is cause, static & valve orifice <1cm
Repair preferred over replacement

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4
Q 
Aortic Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Back flow from aorta to LV-> LV volume overload
Rheumatic disease, HTN, endocarditis, Marfan, Syphilis, Ankylosing spondylitis

Pt:
L sided heart failure

Dx:
Diastolic decrescendo blowing @ LUSB radiates along L-sternal border
-Inc w/ handgrip
-Dec w/ nitrate
Austin flint murmur: mid-late diastolic rumble @ apex
Bounding pulses-> inc. SV
Wide pulse pressure
Pulsus bisferiens-> if combined with AS + AR
Water hammer pulse

Tx:
Vasodilators-> dec afterload increases forward flow
Surgery-> acute or static AR or dec LV <55% (need hyperdynamic ventricle to maintain CO)

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5
Q 
Mitral Valve Prolapse
Path:
Pt:
Dx:
Tx:
A

Path: Myxomatous degeneration of mitral valve-> floppy, redundant valve
Abnormal movement of 1 or both leaflets across valve during systole
MC young women, benign condition
Connective tissue disease-> Marfan, Ehlers-Danlos

Pt: Most asx
Autonomic dysfunction: Chest pain, panic attacks, Arrhythmias causing palpitations, Syncope, dizziness, fatigue
Sx associated w/ MR progression: Fatigue, dyspnea, CHF, Stroke, endocarditis, PVCs

Dx:
Mid to late systolic ejection click @ apex; dec venous return (valsalva, standing, inspiration) -> earlier click (inc. prolapse) and longer murmurs duration
+/- mid-late systolic murmur
Narrow AP diameter
Low body weight, Hypotension, scoliosis, pectus excavatum

Tx:
Reassurance-> good prognosis in asx pts or mild sx
BB for autonomic dysfunction

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6
Q 
Mitral Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Backflow from LV to LA-> LV volume overload-> dec. CO
Mitral Valve prolapse MC
Rheumatic, endocarditis, ischemia (ruptured papillary muscle/chordae tendinae post MI)

Pt:
Acute: Pulmonary edema, Dyspnea
Chronic: A-fib, CHF, May have pulmonary HTN (less often than mitral stenosis)

Dx:
Blowing holosystolic murmurs @ apex radiates to axilla
-Inc with handgrip, left lateral decubitus
-dec. w/ nitrate
Pulse may have brisk upstroke-> due to hyperdynamic ventricle from inc. preload and dec. afterload
Widely split S2

Tx:
Vasodilators: dec. afterload inc forward flow (ACEi)
Surgery: vale repair preferred vs valve replacement

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7
Q

Tricuspid Regurgitation
Dx:
Tx:

A

Dx: Holosystolic blowing high-pitched murmur @ subxiphoid area (L mid sternal border)
-Little-no murmur radiation
-Inc murmur intensity w/ inc venous return (squatting, inspiration)
Carvallo’s sign: increased murmur intensity w/ inspiration (due to inc right sided blood flow during inspiration
- Helps distinguish TR from MR
- +/- pulsatile liver

Tx:
Medical: diuretics (for volume overload and congestion)
If LV dysfunction-> standard HF therapy
Surgical: suggested for pts w/ severe TR despite medical therapy
Repair > replacement

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8
Q

Tricuspid Stenosis
Path:
Dx:
Tx:

A

Path: Blood backs up into RA -> inc RA enlargement -> right-sided heart failure

Dx: Mid-diastolic murmurs @ left lower sternal border (4th ICS). Low frequency
Inc intensity of murmur: inc venous return (squatting, laying down, leg raising, inspiration)
Opening snap: usually occurs later than the opening snap of mitral stenosis

Tx:
Medical: decrease RA volume overload w/ diuretics and Na+ restriction
Surgical: commisurotomy or replacement if right heart failure or dec CO

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9
Q 
Pulmonic Regurgitation 
Path:
Pt:
Dx:
Tx:
A

Path: Pulmonary HTN, tetralogy of fallot, endocarditis, rheumatic heart disease
Retrograde blood flow from pulmonary artery into RV-> right sided volume overload

Pt:
Most clinically insignificant
If sx-> right sided heart failure

Dx:
Graham Steell murmur: brief decrescendo early diastolic murmur @ LUSB (2nd L ICS) w/ full inspiration
-Inc murmur w/ inc venous return (squatting, supine, inspiration)
-Dec murmur w/ dec venous return (Valsalva, standing, expiration)

Tx:
No tx needed in most
Almost always congenital

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10
Q 
Pulmonic Stenosis
Path:
Pt:
Dx:
Tx:
A

Path: RV outflow obstruction of blood

Pt:
Almost alway congenital and disease of the young (congenital rubella syndrome)

Dx:
Harsh mid systolic ejection crescendo-decrescendo murmur (maximal @ LUSB) radiate to neck
-Murmur inc w/ inspiration; the longer the murmur duration = inc stenosis
-Signs of r-sided heart failure
-Systolic ejection click (often buried in S1) may precede the murmur (click increases w/ expiration) wide, split S2 (delayed P2) +/-S4

Tx:
Balloon valvuloplasty

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11
Q

What is pulsus alternans?

A

S1: mitral and tricuspid valve closure

S2: aortic and pulmonary valve closure

S3: in early diastole

  • during rapid ventricular filling phase
  • large amount of blood striking a very compliant LV
  • normal in children, pregnant women

S4: “atrial kick”

  • late diastole
  • blood flowing against noncompliant LV
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12
Q 
Angina 
Path:
Pt:
Dx:
Tx:
A

Path: ischemia w/ myocardial oxygen demand > oxygen supply
Risks-> CAD, family hx, old age, HTN, HLD, DM, CKD, smoking

Pt:
Stable angina: Chest discomfort precipitate by activity but sx abate after activity
Unstable angina: sx at rest or a change in usual sx pattern
+/- SOB, NA, diaphoresis, dizziness, fatigue

Dx: EKG: J point or ST segment depression, normal, Stress Test

Tx:
Lifestyle modifications
Beta Blockers
CCB
Nitrates
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13
Q

Sinus bradycardia

tx:

A

Tx:
Atropin if pt sx
Epi or transcutaneous pacing if unresponsive to atropine

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14
Q

2nd degree heart block- Mobitz I/ Wenckebach
EKG:
Tx:

A

EKG:
Progressive PRI lengthening -> dropped QRS

Tx:
Symptomatic: atropine; Epi +/- pacemaker
Asx: observation

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15
Q

2nd degree heart block- Mobitz II
EKG:
Tx:

A

EKG:
Constant/prolonged PRI-> dropped QRS

Tx:
Atropine or temporary pacing
Progression to 3rd degree AV block common so permanent pacemaker is definitive tx

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16
Q

3rd degree AV block
EKG:
Tx:

A

EKG:
P wave not related to QRS
All p waves not followed by QRS-> dec CO

Tx:
Acute/symptomatic: temporary pacing-> permanent pacemaker
Definitive tx: permanent pacemaker

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17
Q

A-flutter

Tx:

A 
Tx:
Stable: vagal, BB or CCB
Unstable: synchronized cardioversion
Definitive: radiofrequency ablation 
Anticoagulation use similar to a-fib (CHADSVAS-2 score)
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18
Q

Determine need for anticoagulation

A 
CHA2DS2-VAS-2 score
CHF... 1
HTN... 1
Age >/=75... 2
DM... 1
S: stroke, TIA, thrombus... 2
Vascular disease (prior MI, aortic plaque, PAD)... 1
Age 65-75 yr... 1
Sex (female)... 1

> /=2: moderate to high risk-> chronic oral anticoagulation recommended

1 = low risk: based on clinical judgement, consideration of risk to benefit assessment and discussion with patient. anticoagulation may be recommended in some cases

0=very low risk

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19
Q

A-fib

Tx:

A

Stable:
Rate Control
-Non-dihydropyridines CCB: diltiazem/verapamil
-BB: metoprolol (caution in reactive airway disease)
-Digoxin: hypotension + CHF
Rhythm Control
-Synchronized cardioversion
-AF present <48hrs
-3-4w after anticoagulation or TEE shows no atrial thrombi
-Start IV heparin, cardiovert within 24hrs and anticoagulate for 4w
-Pharm: ibutilidie, flecainide, sotalol, amiodarone
-Radiofrequency ablation-> permanent pacemaker

Unstable: cardioversion

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20
Q

SVT

Tx:T

A

Tx:
Vagal maneuvers
Adenosine
Cardioversion

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21
Q

RBBB EKG

A

wide S wave in lead I and V6

RSR’ pattern in lead VI

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22
Q

LBBB EKG

A

large R wave in lead I

Large QS or rS in lead V1

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23
Q

Vtach

Tx:

A

Tx: Determine hemodynamic stability

Stable: procainamide; sotalol (2nd line)

Unstable: Synchronized cardioversion

Pulseless: defibrillation

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24
Q

Wolff-Parkinson-White Syndrome
Path:
EKG:
Tx:

A

Path:
Accessory bundle pathway -> bundle of Kent
Premature depolarization of ventricles by bypassing the AV node

EKG:
Delta waves-> wide QRS
Shortened PR interval

Tx: Radiofrequency ablation

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25
Wellens Syndrome Path: EKG: Tx:
Path: Critical stenosis of proximal left anterior descending coronary artery (LAD) EKG: large, inverted T wave in leads V2 and V3 Tx: Cath Lab!
26
Brugada Syndrome Path: EKG:
Path: Hereditary EKG Right BBB-like pattern w/ ST elevation in leads V1-V3
27
``` Non-ST segment elevation acute MI Path: Pt: Dx: Tx: ```
Path: Acute reduction in blood flow, incomplete occlusion w/ cardiac enzymes Pt: Angina at rest >20 mins Dx: Troponin elevation EKG: ST depression Tx: ASA, O2, heparin, BB, nitrates, stress tests, cardiac cath
28
``` ST segment elevation acute MI Path: Pt: Dx: Tx: ```
Path: Thrombus formation causing blockage of coronary vessel Pt: Chest tightness/pressure radiates to arms or neck ``` Dx: Labs Elevated troponin I or troponin T and CK EKG ST segment elevations >1mm in >2 contiguous leads ``` Tx: PCI (gold standard) Thrombolytic therapy ASA
29
Anterior wall MI EKG: Coronary vessel:
EKG: V1-V4 | Coronary vessel: left anterior descending (LAD)
30
Inferior wall MI EKG: Coronary vessel:
EKG: II, III, aVF Coronary vessel: right coronary artery (RCA) (70%+) left circumflex (LCx)
31
Lateral wall MI EKG: Coronary vessel:
EKG: I, aVL, V5, V6 Coronary vessel: left circumflex (LCx) diagonal of left anterior descending
32
Posterior wall MI EKG: Coronary vessel:
EKG: ST depression V1-V4, elevation in V8-V9 | Coronary vessel: posterior descending artery (PAD)
33
``` Hyperlipidemia Tx Lowering LDL Lowering triglycerides Increasing HDL Type II DM ```
Lowering LDL: - Statins - Bile acid sequestrants - Ezetimibe (zetia) - PCSK9 inhibitor-> repatha (evolocumab), praluent (alirocumab) Lowering triglycerides: - Fibrates - Omega-3 fatty acids-> lovaza, vascepa, epanova - PCSK9 inhibitor-> repatha (evolocumab), praluent (alirocumab) Increasing HDL: - Niacin, niaspan, slo niacin - exercise Type II DM: -Fibrates -Statins (niacin may cause hyperglycemia)
34
``` Dilated cardiomyopathy Path: Pt: Dx: Tx: ```
Path: dec contractility virus, EtOH, ischemia, chemo Pt: systolic CHF-> orthopnea, DOE, crackles, dyspnea, JVD Dx: Echo-> Dilated Tx: CHF Ace-i, BB, Diuretics avoid EtOH/chemo transplant
35
``` Restrictive cardiomyopathy Path: Pt: Dx: Tx: ```
Path: amyloid, sarcoid, hemachromatosis, cancer, fibrosis Pt: diastolic CHF amyloid-> neuropathy Sarcoid-> pulmonary dz Hemachromatosis-> cirrhosis, DM, CHF Dx: echo-> restrictive, marked dilation of both atria amyloid-> fat pad bx sarcoid -> cardiac MRI -> bx hemachromatosis-> ferritin -> genetics ``` Tx: Diastolic HF BB=CCB gentle diuresis transplant underlying dz ```
36
``` Hypertrophic obstructive cardiomyopathy Path: Pt: Dx: Tx: ```
Path: genetics, sarcomeres Pt: murmur = aortic stenosis young athletes-> sudden cardiac death, syncope, DOE Dx: Echo = Asymmetric ``` Tx: avoid dehydration, exercise BB = CCB EtOH ablation, myectomy AICD for inc risk of death transplant ```
37
``` Concentric hypertrophic cardiomyopathy Path: Pt: Dx: Tx: ```
Path: HTN Pt: Diastolic CHF Dx: ECHO = concentric ``` Tx: Diastolic CHF avoid dehydration CCB = BB control BP transplant ```
38
``` Coronary Artery disease Path: Pt: Dx: Tx: ```
``` Path: Atherosclerosis Coronary artery vasospam Aortic stenosis/aortic regurgitation Pulm HTN Severe systemic HTN Hypertrophic cardiomyopathy ``` ``` Pt: pectoris angina Risk factors: DM Cigarette smoking HLD HTN Males Age >45 men, >55 women Family hx ``` ``` Dx: EKG: -ST depression -LVH -Resting EKG normal in 50% Wave inversion, non specific ST changes, poor r wave progression, t wave pseudo normalization ``` ``` Stress test: Stress EKG + with: -ST depressions -hypotension/hypertension -Arrhythmias -Symptoms Myocardial perfusion imaging stress (exercise or pharmacologic) -Indicated for patients with abnormal baseline EKGs to localize regions of ischemia Stress ECHO (exercise of pharmacologic) Cardiac MRI Coronary angiography: GOLD STANDARD ``` Tx: Revascularization: -PTCA (percutaneous transluminal coronary angioplasty) -CABG (coronary artery bypass graft) Medical: - Nitroglycerin - Beta blockers - CCB - ASA
39
``` Endocarditis Path: Pt: Dx: Tx: ```
Path: Acute: S. Aureus, MRSA-> IV drug users Subacute: S. Viridians-> oral flora infection Pt: Fever, anorexia, weight loss, fatigue, EKG conduction abnormalities Dx: Modified Duke Criteria 2 major 1 major + 3 minor 5 minor Tx: - Acute/IVDU: vanc + cefepime - Subacute: Vanc + amp/ceftriaxone/cipro - Surgery if refractory CHF, persistent/refractory infection, invasive infection, prosthetic valve, recurrent systemic emboli, fungal infections
40
Modified Duke Criteria
Major *Sustained bacteria: 2+ blood cultures by organic known to cause endocarditis *Endocardio involvement ...+ echo: vegetation, abscess, valve perforation, prosthetic dehiscence ...New valvular regurgitation: aortic or mitral ``` Minor *predisposing condition: abnormal valves, IVDU, indwelling catheters *Fever >38 (100.4) *Vascular and embolic phenomena ...Janeway lesions ...septic arterial/pulmonary embolic ...intracranial hemorrhage *Immunologic phenomena ...Osler's nodes, roth spots ...+RF ...acute glomerulonephritis *+blood culture not meeting major criteria * +echo not meeting major criteria-> worsening of existing murmur ```
41
Abx prophylaxis for endocarditis Cardiac conditions Procedures Regimens
Cardiac conditions: - Prosthetic heart valves - Heart repairs using prosthetic material (not stents) - Prior hx of endocarditis - Congenital heart disease - Cardiac valvulopathy in a transplanted heart Procedures: - Dental: manipulation of gums, roots of teeth, oral mucosa perforation - Respiratory: surgery on respiratory mucosa, rigid bronchoscopy - Procedures involving infected skin/musculoskeletal tissues (including I&D) Regimens - Amox 2g 30-60mins before procedure - Clinda if PCN allergy No longer recommended for GI/GU procedures or most types of valvular heart disease (MV prolapse, bicuspid aortic valve, acquired MV, AV disease, hypertrophic cardiomyopathy
42
Systolic ejection crescendo-decrescendo murmur @ RUSB; radiates to carotid arteries
Aortic stenosis
43
Diastolic rumble @ apex in L lateral decubitus +/- opening snap; no radiation
Mitral stenosis
44
Diastolic decrescendo blowing @ LUSB radiates along L-sternal border
Aortic regurgitation
45
Mid to late systolic ejection click @ apex
Mitral valve prolapse
46
Blowing holosystolic murmurs @ apex radiates to axilla
Mitral regurgitation
47
Holosystolic blowing high-pitched murmur @ subxiphoid area
Tricuspid regurgitation
48
Mid-diastolic murmurs @ left lower sternal border (4th ICS)
Tricuspid stenosis
49
Early diastolic murmur @ LUSB (2nd L ICS) w/ full inspiration
Pulmonary regurgitation
50
Harsh mid systolic ejection crescendo-decrescendo murmur (maximal @ LUSB) radiate to neck, murmur increases w/ inspiration
Pulmonary stenosis
51
HTN dx: tx:
Dx: Elevated BP >/= 2 readings on >/= 2 different visits If initial average of 2+ readings is >160/100 Normal: <120 / <80 Elevated: 120-129 / <80 Stage 1: 130-130 / 80-89 Stage 2: >/=140 / >/=90 ``` Tx: Lifestyle modifications Thiazide/thiazide type diuretic ACEi ARB CCB ``` DM, CKD: ACEi, ARB African American: CCB, thiazide type diuretic
52
``` Non-ST segment elevation acute MI Path: Pt: Dx: Tx: ```
Path: Acute reduction in blood flow, incomplete occlusion w/ cardiac enzymes Pt: Angina at rest >20 mins Dx: Troponin elevation EKG: ST depression Tx: ASA, O2, heparin, BB, nitrates, stress tests, cardiac cath
53
``` ST segment elevation acute MI Path: Pt: Dx: Tx: ```
Path: Thrombus formation causing blockage of coronary vessel Pt: Chest tightness/pressure radiates to arms or neck ``` Dx: Labs Elevated troponin I or troponin T and CK EKG ST segment elevations >1mm in >2 contiguous leads ``` Tx: PCI (gold standard) Thrombolytic therapy ASA
54
Anterior wall MI EKG: Coronary vessel:
EKG: V1-V4 | Coronary vessel: left anterior descending (LAD)
55
Inferior wall MI EKG: Coronary vessel:
EKG: II, III, aVF Coronary vessel: right coronary artery (RCA) (70%+) left circumflex (LCx)
56
Lateral wall MI EKG: Coronary vessel:
EKG: I, aVL, V5, V6 Coronary vessel: left circumflex (LCx) diagonal of left anterior descending
57
Posterior wall MI EKG: Coronary vessel:
EKG: ST depression V1-V4, elevation in V8-V9 | Coronary vessel: posterior descending artery (PAD)
58
Cardiac biomarkers
Troponin: Highest sensitivity and specificity - Time detectable from onset: 3-12 hrs - Peak: 24-48 hrs - Return to baseline: 5-14 days CK-MB - Time detectable from onset: 3-12 hrs - Peak: 24 hrs - Return to baseline: 48-72 hrs - Useful for dx of re-infarction Myoglobin - First to appear, first to peak, first to decline - Lacks specificity
59
Right ventricular infarct Pt: EKG: Tx:
Pt: hypotension, JVD, clear lungs EKG: elevation in II, III, aVF Tx: Aggressive fluid resuscitation with NS bolus -preload dependent Dopamine/dobutamine if hypotension persists after fluid resuscitation Avoid meds that lower - Preload-> nitroglycerin, morphine - HR-> beta blockers
60
``` Myocarditis Path: Pt: Dx: Tx: ```
Path: inflammation of heart muscle Myocellular damage-> myocardial necrosis and dysfunction -> +/- HF -Infectious: viral-> enteroviruses (coxsackie), bacterial-> rickettsial -Toxic: Scorpion envenomation, Diphtheria toxins -Autoimmune: SLE. Rheumatic fever -Systemic : Uremia , Hypothyroidism -Medications: Clozapine Pt: Viral prodrome: fever, myalgia, malaise-> for several days-> HF sx Dyspnea @ rest, exercise intolerance, syncope, tachypnea, tachycardia, hepatomegaly S3 +/- S4 Dx: -CXR: cardiomegaly (dilated cardiomyopathy) -EKG: Non-specific: sinus tach (MC), Pericarditis: precordial ST elevations + PR depression , Pericardial effusion: alternans -Cardiac Enzymes: +CK-MB and troponin (distinguish myocarditis from chronic dilated cardiomyopathy) -ECHO: ventricular dysfunction -Other: Inc ESR -Endomyocardial biopsy: GOLD STANDARD Infiltration of lymphocytes w/ myocardial tissue necrosis Tx: Supportive, standard systolic HF tx: diuretics ACEi inotropic drugs if severe: dopamine, dobutamine, milrinone
61
``` Pericarditis Path: Pt: Dx: Tx: ```
Path: Fibrinous inflammation of pericardium Idiopathic Viral-> enteroviruses, coxsackie and echovirus Dressler syndrome-> post-MI pericarditis ``` Pt: Chest pain Pleuritic-> sharp; worse w inspiration Persistent Postural-> worse when supine and relieved by sitting/leaning forward Pericardial friction rub Best heard at end expiration while upright and leaning forward Fever usually present ``` Dx: EKG: diffuse ST elevations in precordial leads and associated PR depressions ECHO assess for complications Tx: ASA or NSAIDs x7-14 days Colchicine 2nd line +/- corticosteroids if sx >48hrs and refractory to 1st line meds Complications: Effusion Tamponade
62
``` Peripheral artery disease Path: Pt: Dx: Tx: ```
Path: atherosclerotic disease of the lower extremities Pt: intermittent claudication, resting leg pain PE: decreased/absent pulses, bruits, dec cap refill, cool limbs, shiny skin, hair loss, pale w/ dependent rubor ``` Dx: (GS) contrast angiography ABI <0.9 duplex U/S hand held doppler ``` Tx: Plt inhibitor: cilostazol, ASA, clopidogrel revascularization surgery
63
Peripheral artery disease which vessel is affected? | intermittent claudication in buttock, hip, groin
aortic bifurcation | common iliac
64
Peripheral artery disease which vessel is affected? | intermittent claudication in thigh/upper calf
femoral artery or branches
65
Peripheral artery disease which vessel is affected? | intermittent claudication in lower calf, ankle, foot
popliteal artery
66
Peripheral artery disease which vessel is affected? | intermittent claudication in foot
tibial and peroneal arteries
67
``` Rheumatic Fever Path: Dx: Tx: Complications: ```
Path: Acute autoimmune inflammatory multi-systemic illness; MC affect 5-15yr Infection with GABHS (Strep pyogenes) stimulated antibody production to host tissues and damages organs directly; Infection usually precedes rheumatic fever by 2-6w Dx: Jones Criteria 2 major OR 1 major + 2 minor AND evidence of recent GAS infection Major: -Joint-> migratory polyarthritis 2+ joints affected or migratory (lower to upper), Heat, redness, swelling, severe joint tenderness must be present -Oh my heart-> active carditis, Valves-> mitral/aortic, Myocardium, Pericardium -Nodules-> subcutaneous, Rare finding, Seen over joint (extensor surface), scalp and spinal column -Erythema marginatum : macular, erythematous, non-pruritic annular rash w/ rounded, sharply demarcated borders (may have central clearing), MC seen on trunk and extremities -Sydenham’s chorea: Sudden involuntary jerky, non-rhythmic, purposeless movements especially involving head/arms ``` Minor: Clinical -Fever >101.3/38.5 -Arthralgia Laboratory Inc. acute phase reactant -ESR -CRP -Leukocytosis ECG: prolonged PR interval ``` Evidence of recent group A streptococcal infection + throat cultures Rapid antigen detection tests elevated/increasing streptococcal antibody titers (ASO) Tx: Anti-inflammatory: ASA 2-6w taper +/- corticosteroids in severe cases and carditis Penicillin G (Erythromycin is PCN allergy) Complications: Rheumatic valvular disease - Mitral 75-80% - Aortic 30% - Tricuspid and pulmonic 5%
68
``` Aortic dissection Path: Pt: Dx: Tx: ```
Path: Risk factor-> HTN, advanced age, connective tissue dz (marfan, Ehlers-Danlos) ``` Pt: Older, usually male CC: sudden “ripping/tearing” CP radiating to back PE asymmetric pulses/BP CXR-> widened mediastinum Bimodal peak <40 yrs w/ connective tissue disorder >50 yrs w/ chronic HTN ``` Dx: CT angio (goldstandard) TEE-> used in unstable pt ``` Tx: Reduce BP w/ negative inotropes Short-acting beta-blockers first line -Labetalol -Esmolol -Propranolol CCB (if BB contraindicated) ``` Persistent HTN Vasodilators -Nitroprusside -Nicardipine Hypotensive-> Fluid resuscitation: Crystalloids Surgery Typically Standard type A and complicated type B Uncomplicated type B manage medically Stanford type A: involves Ascending aorta Stanford type B: involves only descending aorta
69
``` Aortic aneurysm Path: Pt: Dx: Tx: Screening: ```
Path: Focal dilation of aortic diameter at least 1-1.5x measured at renal arteries >3cm MC infrarenally Risk factors-> atherosclerosis, age>60, smoking, males, HLD, connective tissue disorder (marfan’s), syphilis, HTN Pt: Most Asx >60yr old male, severe back/abdominal pain, syncope, hypotension Tender, pulsatile abdominal mass +/- flank ecchymosis ``` Dx: Abdominal U/S CT scan-> test of choice Angiography-> gold standard MRI/MRA Abdominal radiograph ``` ``` Tx: BB Surgical repair-> endovascular stent graft or open repair Asx repair: -AAA grows >/= 5.5cm -Grows > 0.6-0.8 cm in 6m ``` Screening: Abd U/S in males aged 65-75 who have ever smoked

Internal Medicine (10 decks)

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