Cardiovascular Exam 1 Cards Flashcards
(214 cards)
1
Q
Diagnostic criteria for hypertension
A
Two or more accurate seated BP readings during two or more outpatient visits
UNLESS there is a hypertensive emergency (end organ damage)
2
Q
Normal blood pressure
A
Under 120 AND under 80
3
Q
Elevated blood pressure
A
120-129 AND under 80
4
Q
Stage 1 hypertension
A
130-139 OR 80-89
5
Q
Stage 2 hypertension
A
Over 140 OR over 90
6
Q
Primary/Essential hypertension
A
Multifactorial or uncertain etiology
7
Q
Secondary hypertension
A
Definable cause to HTN
8
Q
Coarctation of the aorta
A
Aorta is pinched after leaving the heart
9
Q
Hypertensive patterns in patients under 50
A
Systolic and diastolic rise
Hormonal or sleep apnea
10
Q
Hypertensive patterns in patients over 60
A
Systolic rises without diastolic rise due to arterial stiffness
11
Q
Isolated systolic hypertension
A
SBP over 140 with DBP under 90
Older patients or young athletic males
12
Q
Which blood pressure number tends to be more important
A
Systolic for older patients
Diastolic for younger patients
13
Q
White coat hypertension
A
over 140/90 in office but normal at home
Use long term monitoring and ensure they are getting accurate home measurements
14
Q
Which is more concerning, narrow or wide pulse pressure?
A
Narrow pulse pressure
15
Q
Masked hypertension
A
Normal in office but abnormal at home
Often a result of alcohol, tobacco or caffeine consumption
16
Q
Pseudohypertension
A
Calcification of blood vessels in the elderly results in a false elevation
Reason for caution in treating hypertension in the elderly
May present with high reading and hypotensive sx
17
Q
Blood pressure equation
A
Cardiac output X Systemic vascular resistance
18
Q
5 things that can cause HTN
A
Hyperactive SNS
RAAS defect
Defective natriuresis
Abnormal CV or renal development
Elevated intracellular calcium or sodium
19
Q
3 goals in evaluating a hypertensive patient
A
Look for end-organ damage (bruits, etc)
Determine presence of CV risk factors (lipids, lifestyle, etc.)
Evaluate for underlying secondary causes of HTN
20
Q
6 parameters of an IDEAL blood pressure
A
CAUSED
Cuff on bear arm
Arm at heart level
Uncrossed legs
Support feet and back
Empty bladder
Don’t talk
21
Q
Ideal method for taking BP
A
both arms, two times, spaced 1-2 minutes apart
Automatic may not work in A fib patients
22
Q
Ambulatory BP monitoring
A
Monitor checks BP automatically at intervals - must be worn
23
Q
4 meds that can cause hypertension
A
Contraceptives
NSAIDs
Amphetamines
Licorice
24
Q
Historical findings that suggest end organ damage
A
Neuro dysfunction
Heart failure
CAD
PAD
25
Optic signs of HTN damage
Hemorrhages, exudates, papilledema
26
Significance of abdominal bruits with HTN
Renal artery stenosis
27
Signs of aortic coarctation
Diminished pulses, rib bruits
28
5 labs to consider with hypertension
UA, BMP, EKG, Lipids, TSH
29
Cardiac sign of hypertensive pathology on an EKG
Left ventricular hypertrophy
Can improve with BP management
May also see heaves or gallops
30
2 vascular complications of HTN
Atherosclerosis and aortic aneurism/disection
31
Weight reduction effect of HTM
5-20mmHg reduction per 10kg weight loss
32
DASH diet effect on HTN
8-14 mmHg reduction
33
3 other lifestyle modifications for HTN
Alcohol reduction 2-4mmHg
Physical activity 4-9mmHg
Sodium restriction 1-8mmHg
34
Management recommendations for prehypertensive
Non-pharm therapy with reevaluation in 3-6 months
35
Management recommendation for Stage 1 hypertension
Begin pharm is 10 year ASCVD risk is abov 10%
36
Management recommendation for stage 2 hypertension
Begin pharm and non-pharm treatment
37
Target BP for all HTN patients
Under 130/80
38
Best HTN meds for african americans
CCB or Thiazides
39
2 compelling indications for aldosterone agonists
Heart failure and post MI
40
2 compelling indications for CCBs
High coronary disease risk
DM
41
3 compelling indications for ARB use
Heart failure
DM
CKD
42
2 situations where beta blocker might not be advised
CKD
Stroke prevention
43
2 situations where a diuretic for HTN might not be advised
Post MI
CKD
44
2 medication classes that interact with BP meds
SNRIs - elevate BP
NSAIDs - Compete for receptors
45
When should meds be taken in relation to BP readings and why
Before because we need to know if the med is making a difference
46
Non-DHP CCBs
Verapamil and Diltaezem - act on heart
47
DHP CCBs
Work on periphery and can cause edema
48
Pharmacologic BP reduction rule of thumb
10mmHg reduction per agent used
49
Electrolyte to watch with ACEI/ARB therapy
Potassium
50
Difference between hypertensive urgency and emergency
Urgency has no symptoms of organ failure
51
Threshold for hypertensive urgency/emergency
Over 180/ and or over 120
52
Imaging for renal artery stenosis
Duplex venous ultrasound
53
2 non biological etiologies to consider for hypertensive crises
Non-compliance with meds
Illicit drugs
54
Management for hypertensive urgency
Treat PO in office
Can give - Clonidine, Captopril, Metoprolol tartrate, Hydralazine to stabilize short term
55
MOA of clonidine
Central sympatholytic
56
What does a drastic shift in kidney function after ACEI/ARB induction mean
Renal artery stenosis
57
Why might a beta blocker be useful to include for hypertensive urgency
Prevention of reflex tachycardia
58
Management of hypertensive emergency (180/120+ with end organ damage)
IV and inpatient treatment
Lower BP by no more than 25% in first two hours
Target BP is 160/100 over next 2-6 hours
59
Management of hypertensive emergency with ischemic stroke
SBP 180-200 with slow reduction
60
Management of hypertensive emergency with hemmorhagic stroke
Target SBP under 140
61
Management of hypertensive emergency with aortic dissection
Goal SBP under 120
62
Management of hypertensive emergency with MI
Anticoagulation and nitroglycerin - no BP goal
63
First two agents usually used in hypertensive emergency
Beta blockers and CCBs
64
5 first line drugs for a hypertensive emergency
Nicardipine - May percipitate MI
Clevidipine - Contraindicated in soy/egg allergies
Labetolol - Avoid in LV systolic dysfunction
Esmolol - Avoid in LV systolic dysfunction
Fenoldopam - May protect kidneys
65
4 second line hypertensive emergency treatment options
Enalaprilat - ACEI can cause hypotension
Furosemide - Loop diuretic, use with vasodilator
Nitroglycerin - Used with MI, can become tolerant
Nitroprusside - Not commonly used due to cyanide toxicity potential
66
Abnormal blood pressure for pregnancy
Greater than 140/90
67
Diagnostic for HTN during pregnancy
2 elevated reading four ours apart
68
3 acute BP meds used for hypertension management in pregnancy
NEVER USE AN ACEI or ARB
Labetolol, Hydralazine, Nifedipine
69
3 chronic HTN meds used in pregnancy
Labetolol, Nifedipine, Methyldopa
70
Target pregnancy BP
130-150/80-100
71
Definition of resistant hypertension
Does not respond to a 3 drug regimen that includes a diuretic
Often due to non-compliance
72
Treatment for resistant hypertension
Referral to nephrology is often the best choice
73
Hypotension
Usually a BP under 90/60
Treat the symptoms not the number
74
BP reading of too small cuff
HIGH
75
BP reading of too large cuff
LOW
76
Three things that determine arterial pressure
Cardiac output
Venous pressure
Systemic vascular resistance
77
4 skin signs of hypotension
Pallor, DIaphoresis, Cool and Clammy, Prolonged capillary refill
78
2 potential etiologies of orthostatic hypotension
Impairment of autonomic reflexes
Volume depletion
79
Systolic and diastolic drop of orthostatic hypotension
20mmHg SBP
10mmHg DPB
80
6 medications that can cause orthostatic hypotension
Alpha 1 agonists (-zosin)
Antihypertensives
Diuretics
PD-5 inhibitors (-fil)
Antidepressants (TCA, MAOI)
Opiods
81
Test for orthostatic hypotension
Bedside tilt or table tilt test
Strat to table, tilt, take BP
Can give nitroglycerin if no symptoms
82
When might we see symptoms for orthostatic hypotension
Either immediately or within 2-5 minutes
83
Non-pharm interventions for orthostatic hypotension
Compression stockings
Hydration
Tensing leg muscles when standing
Avoid exertion in hot weather
Getting up slowly
84
2 pharmalogical treatments for orthostatic hypotension
Fludricortisone
Midodrine
85
Side effect of hypotension medications
Supine hypertension - elevate HOB
86
Class of midodrine
Alpha-1 adrenergic agonist
87
Postural orthostatic tachycardia syndrome
Form of orthostatic intolerance where the resonse to standing is an increased heart rate MC in young females
88
Diagnostic criteria for POTS
Correlation of symptoms (syncope, brain fog, etc.) with HR increase of 30-40 bpm or 120+ within ten minutes of standing
NO DROP IN BP
89
Gold standard diagnostic for POTS
Table Tilt test
90
Non-pharm treatment for POTS
Increased salt and water intake
Avoidance of exacerbating factors
Lower extremity exercise and compression stockings
91
Pharm treatment for POTS
Fludricortisone, Midodrine
Beta Blockers
May use SSRI or SNRI but rare
Improved sx after 1-2 years
92
3 potential triggers for POTS
Large heavy meals, Heat, Alcohol
93
MCC of cardiogenic shock
Acute MI, 50% mortality
94
Classic presentation of cardiogenic shock
Peripheral vasoconstriction and tachycardia
95
5 step vicious cycle of cardiac injury
Ischemia of coronary artery
Myocardial injury/death
Decreased CO
Hypotension
Decreased coronary perfusion
96
S1
MV and TV closing
97
S2
Aortic and Pulmonic valves closing
98
Aortic post
Second intercostal space right sternal border
99
Pulmonic post
Second intercostal space, left sternal border
100
Erb's point
third intercostal space, left sternal border
101
Tricuspid post
Fourth/Fifth intercostal space left stenal border
102
Mitral post
Fifth intercostal space, mid clavicular line
103
Proper heart listening position
HOB at 30 degrees, if they are straight up and it's quiet - sit up and breath OUT
104
Changes in heart sounds with expiration
More blood in the left heart
105
Difference in heart standing v. squatting
Harsher noise with standing because heart has to work harder. Decrease intensity of AS
106
Ejection click
Hear the opening of an AV valve - immediately follows S1
107
Opening snap
Opening of mitral valve
108
S3
Kentucky gallup
Early diastole (dull)
Physiologic in kids pathologic in older
We hear the ventricle FILLING
109
S4
Tennessee gallop
Late diastole
Due to increased resistance to filling of ventricle
110
Comparison of S1 to S2
S1 is softer at the base but louder at the apex
111
Split S1
May be normal if mitral and tricuspid
Abnormal in RBBB or PVC
112
Physiologic splitting
Breathing in increases a split b/c more pressure in the right heart
113
Holosystolic
All of systole
114
Holosystolic
High to low pressure chamber through a valve that should be closed
Regurgitation/ VSD
115
Midsystolic murmur
Not always pathologic
Innocent if it disappears during systole
Pathologic - harsh with stenotic valves
mid systolic click w/ hyperthyroidism
116
Diastolic murmers
Usually pathologic
May not hear a closing sound
117
Venous hum
Louder in diastole than systole
Humming above the clavicle
Pressure on vein decreases hum
118
Pericardial friction rub sound
Rubbing noise
119
PDA sound
Harsh radiating to the clavicle less loud in diastole
120
Transesophageal echo
Better view of posterior side of the heart
Use if a TT Echo is not working well enough
121
Stenosis sound
Harder click
122
Regurgitation sound
Whoosh (may not hear the valve close)
123
6 stages of valvular heart disease
A-C - Murmer with NO symnptoms
C2 - LV dysfunction
D-Symptomatic
124
Mid - Systolic murmur with LVH
Radiating to the carotids
Harsh Sound
May also hear some regurgitation
Aortic stenosis
125
Symptoms of aortic stenosis
Exertional chest pain
Syncope
(Can't get enough blood out - also dilates blood vessels)
126
Source of displaced PMI in aortic stenosis
LVH
127
Meds for a mechanical heart valve
Warfarin and 81mg ASA - lifelong
Plavix 6 months and ASA forever for TAVI
128
Cause of aortic regrugitation
Can be marfans syndrome or a cause of Aortic stenosis
129
Symptoms of Aortic regurgitation
Chest pain etc. from blood backing upp and not getting to the body
130
Holo-diastolic murmur
With S3 and S4 gallops
2nd and 4th left intercostal spaces
Aortic regurgitation murmur
131
Why widened pulse pressure with Aortic regurgitation
Heart tries really hard to get that blood out to the system
132
Austin flint murmur
With Aortic regurg
133
Acute aortic regurgitation
Trauma etc.
Sudden
EMERGENT because hemodynamic instability
134
S/S of cardiogenic shock
Weak
Pale
Cold extremities
Low pitched early diastolic murmur
135
Treatment for Acute aortic regrug
Echo
Beta blockers
Diuretics
Vasodilators
136
Mitral stenosis
Most common in women who have had rheumatic fever
Left atrial enlargement
137
s/s of mitral stenosis
A fib
Hockey stick deformity
Irregular pulse
Hemoptysis from pulm edema
Hoarse voice (atrium compressing
138
Low pitched diastolic murmur at the apex of the heart
S2 Opening snap with mid diastolic murmur
Mitral stenosis
Bell in left lateral decubitus
139
Mid systolic click meaning
Mitral valve prolapse
140
Indication for percutaneous baloon valvuloplasty
No emboli, or not needed to last for very long
141
MI that leads to mitral regurg
Posteior wall MI
142
Holosystolic murmur radiating to the axilla and back
May hear mid-systolic click
Mitral regurg murmur
143
Why does acute regurg cause cardiogenic shock
The atria don't have time to dilate to compensate for the back flow - blood goes to the lungs!!
144
Mitral valve prolapse
Usually in young women
Valves don't line up
May cause regurg
145
Standing vs. Squatting and murmurs
Standing makes the heart work harder, hear MVP click sooner
146
Valves of S1
Aortic and pulmonic
147
Valves of S2
Tricuspid and Mitral
148
Expected s/s of tricuspid stenosis
Diastolic murmur w/ opening snap
JVD
Ascites with liver pulsation with atrial contraction
149
Difference between mitral and tricuspid stenosis
Tricuspid should present with increased sound with inspiration
150
Management of tricuspid stenosis
Loop diuretics are best
Add an aldosterone antagonist of liver congestion and ascites are present
151
MCC of tricuspid regurgitation/RV dilation
Pulmonary hypertension
152
How can tricuspid stenosis lead to LVH
Left ventricle tries harder because it is not getting enough blood
153
Management of tricuspid regurgitation
Repair or replacement - only need anticoagulation if a-fib is present
154
Presentation of tricuspid regurg
Signs of right heart failure (JVD, ascites, etc.)
High pitched pansystolic murmur to the left sternal border
Accentuated by inspiration
155
Pulmonic stenosis
Usually a congenital defect
Noonan and Trisomy 13
Results in RVH
156
Presentation of pulmonic stenosis
Systolic ejection murmur at the left upper sternal border (pulmonic post) radiating to the left shoulder
RV lift of precordium
Louder with expiration
157
Management of pulmonic stenosis
Valvuloplasty or surgery if 36-64mmHg with symptoms or 64+ with or without for the gradient
158
Cause of pulmonic regurg
Typically due to dilation of the PV annulus secondary to pulmonary hypertension
159
Presentation of pulmonic regurg
Diastolic murmur with ahigh pitched blowing quality at the second left intercostal space
160
MCC of pulmonary HTN
Left heart failure
161
Non-echo diagnostics for pulmonic regurg
MRI or CT to give an idea of the size of the pulmonary artery - excludes other causes of pulmonary hypertension
162
Mechanical valve warfarin therapy requirement
INR of 2.5-3.5
163
Non-mechanical heart valve therapy requirement
ASA 81 mg may be sufficient
164
Pathophysiology of rheumatic heart disease
Starts with a group A beta hemolytic strep infection followed by pancarditis
165
Hostologic finding of rheumatic fever
Aschoff bodies with verrucous lesions on the leaflet edge
166
JONES criteria for rheumatic fever - MAJOR
Joints - polyarthritis
Carditis (heart looks like an O)
Nodules
Erythema marginatum
Sydenham chorea (S looks like it's dancing)
167
Minor JONES criteria for rheumatic fever
Arthralgia
Prolonged PR
Fever
Elevated ESR/CRP
168
Diagnostic criteria for rheumatic heart disease
2 major JONES crit
or 1 Major and 2 minor with evidence of recent strep infection
Needs to be a documented case
169
Erythema marginatum
Bulls eye rashes but all over body
170
What qualifies as a documented case of strep for RHD
Throat culture growing GABHS
OR
Elevated anti-streptolysin O titers
171
Treatment for RHD
Salicylates for fever/arthritis
PCN for strep infection
PCN or erythromycin for 10 year prophylaxis (be mindful of compliance
172
Something that must happen for endocaritis
Valve must be damaged, and bacteria must be introduced into blood stream
173
Aspect of personal hygeine related to infective endocarditis
ORAL Hygeine
174
cardiac vulnerability in IV drug users
Right heart because bacteria goes there first from blood stream
175
Most common organism for native valve endocarditis
S. aureus
176
Risk factors for infectious endocarditis
any malformation of the valve etc.
177
MC causitive organisms for prosthetic valve infection
Staph and strep and enterococci later on
178
Clinical presentation of infectious endocarditis
CHF
Fever
Septic emboli
Petechiae
Splinter hemmorhages from emboli
179
Janeway lesions
PAINLESS - caused by vasculitis of endocarditis
180
Osler nodes
Painful - vasculitis of endocarditis
Peas under skin feel
181
Eye presentation of endocarditis infectious
Roth spots -like a bulls eye
182
Major DUKES criteria for infectious endocarditis
Positive blood culture
Evidence of involvement on an echo
New regurgitant murmur
183
Minor dukes criteria for infectious endocarditis
Predisposing heart condition
Vascular embolic phenomena (Janeway, etc.)
Single positive blood culture or evidence of active infection with a common organism
184
Definitive diagnosis of IE
2 major, 1 major 3 minor, or all 5 minor
185
Possible diagnosis of IE
1 major 1 minor or 3 minor
186
Management of infectious endocarditis
Antibiotic (PCN-G or Gentamycin or Vanc)
CHF management
Involve cardio and ID
187
Treatment for fungal IE
Amphotericin B - have to have surgery to CURE
188
Surgery for IE
Don't delay surgery to prolong abx therapy
Must if fungal
Chronic CHF
Spreading/Not improving
189
Dental care and IE
Will need dental care prophylaxis - get dentist on board
190
Prophylaxis for IE
In those with risk factors:
Amoxacillin first line or IV Ampicillin
Clinda or Keflex if allergic or Cephazolin IV
191
Patients who are at risk for IE from procedures
Prosthetic heart valves
Prior endocarditis
Cyanotic congenital heart disease
Cardiac transplant
192
Procedures for endocarditis prophylaxis
Dental procedures and cleanings
Respiratory tract procedures
Skin procedures - ie. abcess
NOT for GI procedures
193
Initial lab orders for IE
CBC and blood cultures
194
Most common etiology of pericarditis
Viral - cocksackie, flu, etc.
Can be from CKD, Hypothyroidism as well
Drug induced (chemo agents like doxyrubicin) also possible
195
Four principle diagnostic features of pericarditis
Chest pain
Pericardial friction rub
EKG changes
Pericardial effusion
196
EKG signs of pericarditis
Diffuse EKG changes - ST elevation and PR depression
197
Pleuritic chest pain
Worse with breathing and laying down; better with leaning forward
198
Diagnosis of Pericarditis
Viral panel
Cardiac enzymes
Echo
CBC, BMP, Thyroid
Inflammatory markers
Usually a clinical diagnosis though
199
Management of pericarditis
NSAIDs for pain and inflammation - ibuprofen (ASA if heart attack)
Corticosteroids to prevent recurrence
200
Admission criteria for pericarditis
Fever
Immune compromised
Tamponade
Subacute
Trauma
Myopericarditis
201
Pathognomic sign of cardiac tamponade
Alternations on an EKG
202
Kussmaul's sign
Indicative of cardiac tamponade - Increase in JVP on inspiration
203
Pulsus paradoxus
Sign of cardiac tamponade systolic BP falls 12+ mmHg during breathing
204
Cause of EKG variations in tamponade and what it is called
Heart is swinging in fluid - Electrical alternans
205
Initial test of choice for diagnosing a pericardial effusion
Echo -shows collapsed chambers
206
CXR of cardiac tamponade
May be normal, may have enlarged heart
207
Management for cardiac tamponade
Pericardiocentesis (diagnostic and therapeutic)
208
Analysis of pericardial fluid
RBCs
Protein,
Gram stain
LDH
209
Pericardial diodesis
Sclerosing of pericardium with chemicals to prevent fluid from re-accumulating
210
Pericardiotomy
Incise a window for drainage
211
Restrictive pericarditis
Caused by TB, radiation, surgeries
Inflammation leads to pericardial fibrosis
Fibrotic tissue makes it hard for heart to relax etc.
Like tamponade but more gradual
212
Presentation of restrictive pericarditis
Right heart failure (ascited/JVD)
Atrial fibrilation
213
Diagnosis of restrictive pericarditis
Imaging may show an enlarged pericardium
Cardiac catheterization is confirmatory
214
Management of restrictive pericarditis
Loop diuretics or aldosterone antagonist
May need a surgical incision for drainage
