Clin Med Exam 5 Flashcards
(186 cards)
1
Q
Pericarditis causes
A
Infectious/viral is the most common
Inflammation of pericardium, often occurs in the presence of MI
2
Q
Acute pericarditis clinical findings
A
Chest pain- sharp, stabbing
Pain relieved by leaning forward
Intermitten fever, builds over a few days
Dyspnea
3
Q
Acute pericarditis physicical exam
A
Possible pericardial effusion
Pericardial friction rub- expiration
4
Q
Acute pericarditis EKG
A
Concave up ST elevation, PR segment depression
5
Q
Constrictive pericarditis
A
Long term, chronic
Inflammation becomes thickened, fibrotic, adheres to pericardium
Restricts motion of ventricles, reduces diastolic filling
6
Q
Constrictive pericarditis clinical findings
A
Dyspnea Fatigue Orthopnea Chronic edema Weakness
Jugular venous distension, ascites, pleural effusion
7
Q
Constrictive pericarditis clinical findings/diagnosis
A
Distant or muffled heart sounds
Elevated jugular venous pressure
Pericardial knock
Kussmaul sign (increased systemic venous pressure during inspiration)
8
Q
Pericardial effusion clinical findings
A
Pain, dyspnea cough, N/V, fatigue, malaise
Dressler syndrome- fever, chest pain, pericardial friction rub
9
Q
Pericardial effusion physical exam
A
Signs of shock or right heart failure (tachycardia, hypotension)
Pericardial friction rub
Low grade fever
10
Q
EKG findings on pericardial effusion
A
Electrical alternans- pathognomonic
11
Q
Cardiac tamponade
A
Decreased cardiac output from impaired ventricular filling due to the pericardial fluid
12
Q
For cardiac tamponade, the prognosis depends…
A
Size and speed of effusion
13
Q
Cardiac tamponade clinical findings
A
Becks triad- hypotension, JVD, muffled heart sounds
Pulsus paradoxus
Low voltage QRS
14
Q
Biggest differentiation between musculoskeletal causes of chest pain and cardiac causes
A
Palpable tenderness
15
Q
Most common cause of musculoskeletal chest pain
A
Costochondritis
16
Q
Dilated cardiomyopathy clinical findings
A
Palpitations
Fatigues
Dyspnea
Arrhythmias
Holosystolic murmur, regurgitation
Lower SV
17
Q
Dilated mardiomyopathy causes
A
Alcohol abuse is most common!!
Also peripartum cardiomyopathy, infection, genetics
18
Q
Dilated cardiomyopathy treatment
A
LVAD
19
Q
Restrictive cardiomyopathy causes
A
Amyloidosis, sarcoidosis, radiation of heart tissue, anything fibrosing the tissue
20
Q
Restrictive cardiomyopathy clinical findings and diagnosis
A
Less blood filling the ventricle, causing diastolic herat failure
Dyspnea, distant heart sounds, exercise intolerance
21
Q
Hypertrophic cardiomyopathy clinically
A
Interventricular septum grows larger, decreased stroke volume
Diastolic herat failure
Crescendo decrescendo murmur
22
Q
Cause of HOCM
A
Autosomal dominant inherited
23
Q
HOCM contraindication
A
Digoxin
24
Q
What is the most common cause of death in young athletes?
A
HOCM
25
Takotsubo
Acute cardiac syndrome aka broken heart syndrome, presents like ACS
LV apical ballooning
26
Infective endocarditis general
Infection of heart valves or endothelium
Valvular disease is an important precursor- jet effects disrupt endothelium
Bacteremia prerequisite
27
Endocarditis microbiology
Staph and strep
HACEK
28
What is the most common cause of acute endocarditis?
Staph aureus
29
Bacteremia with strep bovis is strongly associated with...
Colon cancer
Colonoscopy is indicated for these patients
30
Endocarditis signs/symptoms
Fever
Murmur that is new/changing
Metastatic infection, emboli, immune phenomenon
31
Skin findings of endocarditis
Petechia/hemorrhage
(Palate, conjunctival, ungal)
Janeway lesions- painless red lesions on palms/soles
Osler nodes- painful, raised lesions on hands and feet
32
Roth spots
Endocarditis sign- exudative retinal lesions
33
Duke criteria endocarditis
2 major
1 major and 3 minor
0 major and 5 minor
34
Abscess and endocarditis
Perivalvular abscess is an important complication of IE
Reduced rate of cure
35
Prosthetic valve endocarditis
Rare but bad
TEE is diagnostic test of choice
36
Rheumatic fever
5-15 years age
Systemic immune process that is a sequela to GABHS
ASO titers to confirm
Mitral valve attacked in 75-80% of cases
37
Jones criteria rheumatic fever
Two major criteria
| One major two minor
38
Major jones criteria for rheumatic fever
Carditis
Erythema marginatum and subq nodules
Sydenham chorea
Polyarthritis
39
Myocarditis general
Inflammation of heart muscle
Post viral
40
Hist. Changes of myocarditis
Inflammation and necrosis
41
Gold standard of myocarditis
Endomyocardial bx
42
Myocarditis presentation
SOB
DOE
Chest pain
VOLUME OVERLOAD
Aneurysms
43
EKG and CXR findings for myocarditis
EKG- ventricular ectopy
CXR- pulmonary venous congestion
44
Severe myocarditis
Left Ventricular assist devices
Impella (short term replacement of pump function)
Then total artificial heart and heart transplant
45
Frank starling effect
SV rises as end diastolic volume increases
46
Systolic dysfunction in heart failure
Decreased contractility, flattens frank starling curve
47
Diastolic dysfunction
Due to stiffened myocardium
Less compliant ventricle, requires more work from the atria to fill the ventricle
48
Pre/afterload dysfunction
Preload- end diastolic volume/pressure
Failing heart increases preload
Afterload- arterial pressure/systemic vasc resistance
Increased afterload in HF
49
Broad systolic HF description
HF with reduced left ventricle ejection fraction
50
Broad classification of diastolic heart failure
Heart failure with present ejection fraction
Abnormal diastolic dysfunction
51
Why does NE increase in heart failure and what does it say?
Compensating for the decreased pulse pressure and renal perfusion
Poor prognostic sign in HF
52
RAAS in HF
Increases to increase renal perfusion
ACEIs and ARBs are essential in HF
Increases vasoconstriction and retains fluid and acts like the patient is underperfused, but they are volume OVERLOADED
53
General heart failure symptoms
```
Fatigue
Dyspnea (most common sx)
Exercise intolerance
Nocturnal
Cachexia
```
54
Right heart failure symptoms
Fluid retention- JVD
Dependent edema
HSM, ascites
Fluid backing up into the systemic system
55
Left heart failure symptoms
Dyspnea- pink frothy sputum/pulmonary edema
Orthopnea
Paroxysmal nocturnal dyspnea
56
Most common cause of RHF?
LHF
Failing LV, blood backs up into LV then pulmonary system then increases the afterload of RV
57
Exam findings for HF are...
90% specific but not very sensitive
58
HF exam findings
Mild
Dyspnea
Variable HR
BP normal to high early on, then low in late HF
59
Neck exam findings in HF
JVD
| Hepatojugular reflux
60
Pulmonary exam findings HF
Rales/crackles
| Pleural effusion
61
Cardiac exam findings HF
Displaced or prolonged or enlarged PMI
Parasternal lift
S3 (suggests systolic dysfunction)
S4
Murmurs
62
Abdomen exam HF
HSM
| Jaundice (sublingual first)
63
Extremities exam HF
Cool to touch
Cyanosis
Edema (pitting, dependent)
Untied shoes
64
High output heart failure
Symptoms of heart failure but increased cardiac output
Eventually will progress to low output HF
65
Chronic HF
Gradual onset and progressive signs
Generally remains stable
66
Flash pulmonary edema description
Dramatic presentation of acute, decompensated HF
Increased LV pressure, rapid fluid accumulation in alveoli
67
Flash pulmonary edema presentation
Severe cough
Dyspnea- pink frothy sputum
Tachypnea
68
Pulmonary venous HTN CXR findings
Increased pulmonary veins
| Cephalization
69
CXR interstitial edema findings
Interstitial infiltrates
| Kerley B lines (short, parallel lines at periphery)
70
Brain natriuretic peptide
Released in response to ventricular stretch
Helpful in volume overload
Need to know baseline BNP
71
NYHA classes
1- asymptomatic
2- asymptomatic at rest, symptoms with walking up a couple of blocks or flights of stairs
3- asymptomatic at rest, symptoms with walking up 1 flight of stairs
4- symptomatic at rest
72
NYHA classes major points
Widely used, class can change and even quickly
Somewhat subjective
73
ACCF/AHA guidelines
A- at high risk for HF but no structural disease or sx
B- structural heart disease without signs/sx of heart failure
C- structural heart disease with prior or current sx of HF
D- refractory HF requiring specialized interventions
74
Right to left shunt
Bypasses pulmonary circulation
Cyanosis
75
Left to right shunt
Increased pulmonary circulation
No cyanosis
Can cause right heart failure from the volume overload
76
Eisenmenger syndrome
Prolonged left to right shunt causing pulmonary hypertension, then the right ventricle pressure exceeds the left
The shunt reverses, and the left ventricle ejects more deoxygenated blood
Very bad
77
Ventricular septal defect
Failure of any component of ventricular septum to develop fully
Symptoms depend on size and pulmonary vascular resistance
78
VSD exam
Loud, pansystolic murmur
Increased flow through the lungs
Left to right shunt
79
Atrial septal defect (types_
Primum- inferior
Secundum- superior
Sinus venosus defect- around inlet of vena cava, develops into SA node
Left to right shunt
80
ASD findings
Rarely symptomatic due to low pressure system
Soft systolic ejection murmur, fixed s2 splitting
81
Patent ductus arteriosus general
Allows blood to flow from the pulmonary artery into the aorta
Left to right shunt with pulmonary hypertension
82
PDA and NSAIDs
Prostaglandins keep the ductus open during pregnancy- which is why pregnant women cannot take NSAIDs while they are pregnant
Closure can be induced by NSAIDs
83
Endocardial cushion defect
ASD, VSD, and A-V valve malformations
Left to right shunting
AV valvular insufficiency
CHF, pulmonary hypertension
Needs surgical repair
84
Pulmonary stenosis
DOE, fatigue, right herat failure if severe
85
Aortic stenosis
Post stenotic dilation of aorta, LVH as well
Severe stenosis is fatigue, syncope
Systolic ejection murmur
86
Coarctation of the aorta
Narrowing of aortic lumen, generally near the ductus
PDA reduces symptoms in these patients!
87
Coarctation of the aorta findings
Baby- poor feeding, resp. Distress, shock
Older- exertional leg discomfort, epistaxis, upper extremity HTN
Systolic ejection murmur
**BP/oximetry screening of multiple extremities
88
Tetralogy of Fallot
VSD
Pulmonary stenosis
Overriding aorta
RVH
89
Tetralogy of Fallot findings
Hypoxic "tet" spells
Squat to increase venous return, cyanotic
90
Transposition of great arteries
Reversal of pulmonary artery and aorta
Desaturated blood returns to right heart and is sent through the aorta to the systemic system
Death occurs rapidly
91
Transposition of great arteries findings
CXR- egg on a string
Hyperdynamic herat
Quiet tachypnea
92
Tricuspid atresia
Absent tricuspid valve
Hypoplastic RV
Requires PDA or VSD to perfuse pulmonary artery and ASD needed to allow blood flow to left heart
93
Tricuspid atresia findings
Surgery is essential, prostaglandins given to maintain ductus until surgery
94
Truncus arteriosus
Truncus does not separate into aorta and pulmonary arteries
Variable cyanosis
Needs surgical repair
95
Total anomalous pulmonary venous return
Pulmonary veins drain into right atrium, no oxygenated blood goes to the right heart
Obstruction- severe cyanosis
Surgery essential
96
Hypoplastic left heart syndrome
Cyanotic disease
Failure of development of mitral or aortic valve/aortic arch
Small left ventricle
Urgent surgery needed
97
Patent foramen ovale
Foramen ovale does not close, allows for right to left shunting
Increased left heart pressure should close it usually
Often clinically silent
98
Patent foramen ovale findings
```
Maybe:
Stroke
Migraine
Hypoxia
Risk of atrial fib
Decompression illness with air embolism
Dyspnea and decreased o2 saturation when upright
```
99
Ruling out valvular heart disease- diagnostic approach to a murmur
Careful H&P
EKG to verify rhythm
CXR to rule out pulmonary issues
Echo with doppler flow to visualize blood flow
100
Best diagnostic for valvular disorders?
Echo
101
What are the majority of mitral stenosis cases caused by?
Rheumatic fever
More common with multiple infections and multiple bouts of rheumatic fever
102
Mitral stenosis auscultation findings
Opening snap following s2
Localized diastolic murmur (if disease is farther along)
Best heart at apex
103
Systemic effects of mitral stenosis
Long asymptomatic phase
Right heart failure and low cardiac output
Sudden increase in HR causing pulmonary HTN/edema
104
Mechanical prosthetic valves
Last 30-50 years
Can cause endocarditis, paravalvular leaks
**most importantly, thrombosis. Need to be anticoagulated for life
105
Bioprosthetic valves
Last 5-10 years
Anticoagulation not needed
106
When do you use a bioprosthetic valve?
Anticoag CI or not desired
Desire to be pregnant
>70 year old patients
107
When do you use a mechanical valve?
Patients less than 60 years old that can be anticoagulated
Re operation is dangerous
108
Mitral regurgitation auscultation
Pansystolic murmur best heard at apex, radiating to the axilla
109
Mitral regurgitation systemic findings
LV enlargement (reflects severity/chronicity)
Chronic dz can be asymptomatic
Afterload reduction is helpful
110
What is going on in the heart because of mitral regurgitation?
Increased preload, but decreased afterload
Enlarged left ventricle
Increased ejection fraction
Acute- pulmonary edema
Chronic- LA/V enlargement
111
What can chronic mitral regurg cause?
Valvular atrial fibrillation
112
Mitral valve prolapse general
Usually females
Can see arrhythmias
Asymptomatic or SOB, fatigued, palpitations
113
Auscultation mitral valve prolapse
Mid systolic click
Murmur (could be absent or late/pansystolic, which is severe)
114
How does valsalve effect mitral valve prolapse?
Increased murmur (if there is one) because of the decreased venous return
115
What are skeletal/collagen disorders seen with mitral valve prolapse?
Pectus excavatum, scoliosis/straight back
Marfan, ehlers-danlos
116
Symptoms for tricuspid stenosis
Right heart failure
JVD with a giant "a wave" (aka resistance to R atrial emptying)
117
Auscultating tricuspid stenosis
Diastolic rumble at LLSB
118
Tricuspid stenosis EKG/CXR findings
EKG- RA enlargement
CXR- cardiomegaly with normal PA size
119
What valve is preferred to replace tricuspid stenotic valve?
Bioprosthetic, less risk of thrombosis
120
Tricuspid regurgitation causes
Valve defects
RV dilation from any cause
121
Tricuspid regurg signs/symptoms
Asymptomatic
R heart failure
Systolic murmur at LLSB
Obliteration of x descent in jugular pulse wave
122
Pulmonic stenosis general
Most commonly sen as congenital heart disease, can be valvular, supravalvular or subvalvular
123
Pulmonic stenosis symptoms
Often asymptomatic
Fatigue, DOE, right heart failure (if severe)
124
Pulmonic regurgitation causes
High pressure (pulmonary HTN)
Low pressure (valve disorders)
125
Which ventricle tolerates volume load better than pressure load?
Right ventricle
126
Signs for pulmonic regurgitation
Split s2, systolic click, right sided gallop, RV lift
Diastolic murmur, graham steel murmur
127
Aortic sclerosis general
Common in elderly
Atherosclerotic calcification of valve leaflets, **does not effect valve function
Gradual evolution to aortic stenosis
128
Aortic sclerosis signs
Maybe systolic murmur
Incidental echo finding
Irregular leaflet thickening
129
Aortic stenosis causes
Uni/bicuspid valve
| Degenerative/calcification
130
Which is the most common surgical valve lesion?
Aortic stenosis
131
Symptoms of aortic stenosis
Heart failure, angina, syncope (50% 3 year mortality)
LVH
Arrhythmia
132
Aortic stenosis exam findings
Systolic ejection murmur
Best heart at aortic area, transmitted to neck and apex with patient leaning forward
Maybe preceded by AV click
If severe, s2 split
133
Gallavardin phenomenon
Aortic stenosis
Musical murmur best heard at apex, maybe vibrations from the stenotic valve.
Handgrip increases arterial resistance and thus decreases the AS murmur
134
Aortic regurgitation common cause
Aortic root dz (marfan, aortic dissection)
135
Aortic regurg compensatory mechanisms
Left ventricular dilation increasing the stroke volume
If EF drops, time to replace the aortic valve
136
Aortic regurgitation symptoms
Usually chronic with no side effects aside from diastolic murmur
LV failure can arise and be sudden
LVH if chronic
137
Aortic regurgitation exam
High SV with rapid runoff, causing:
Wide pulse pressure
Water-hammer/corrigan pulse
Musset sign
Quincke pulse
138
Aortic regurgitation murmur
Systolic ejection murmur with increased SV
Diastolic murmur from the regurg
Austin flint murmur- rumbling apical diastolic murmur
139
When do you treat aortic regurg?
If symptoms, need surgery
140
What medications help aortic regurg?
Beta blockers to reduce afterload
ACEI to reduce aortic stiffness
141
What are the 4 major factors that determine myocardial work and therefore oxygen demand?
Heart rate
Systolic blood pressure
Myocardial wall tension/stress
Myocardial contractility
142
Right coronary artery perfuses mostly...
Lateral and inferior parts of the heart
143
Left coronary artery perfuses mostly...
The posterior aspect of the heart
144
Left anterior descending artery perfuses mostly...
The anterior aspect of the heart
145
Causes of angina:
1. Obstruction of coronary arteries
2. Structural cardiac abnormalities
3. Increased metabolic demands
4. Cardiac syndrome X
146
What is cardiac syndrome x?
Cause of angina
Angina like chest pain with exertion
ST depression on stress test
Normal coronary arteries without vasospasm
147
What are some hypermetabolic states?
```
Hyperthyroid
Anemia
Sepsis/infection
Trauma
Pregnancy
```
148
What is prinzmetal's angina?
Coronary vasoconstriction occuring as a result of spasm of the large coronary arteries
Spontaneously or from cold, stress, or drugs
Usually women <50, early morning chest pain waking them up, often associated with arrhythmias or conduction defects
149
What is the time frame for angina versus MI or unstable angina?
<30 minutes is angina
>30 minutes, consider unstable or MI
150
Low risk
<10%, watch and follow
151
Intermediate risk
10-90%, stress test
152
High risk
>90%, stress test or heart cath or something!
153
Silent ischemia
Most common manifestation of CHD
Common in diabetics, elderly, prior MI or revascularization procedures
154
After stress test, what dictates a worse prognosis?
>2mm depression at lower workload
Low HR
Hypotension during the test
155
Positive stress test?
>1 mm horizontal or downsloping ST segment depression 80 ms after J point
156
When do you use vasodilators for pharmacologic stress testing? What are the drugs?
Dipyridamole, adenosine
Avoid with bronchospastic dz, HOTN, high degree AV block
157
Synthetic catecholamine? When do you use it with pharm. stress testing?
Dobutamine
Preferred in stress echo
Avoid in ventricular arrhythmias, recent MI, aortic dissection, LV outflow tract obstruction
158
Scintigraphy
Myocardial nuclear perfusion imaging
Radionuclide uptake goes to areas of adequate** myocardial blood flow
Good for determining reversible damage or nonreversible infarct
159
Echo
Higher specificity, lower cost
Assesses cardiac anatomy and function
Wall motion abnormalities with increasing myocardial demand
160
CTA
Useful for low likelihood of significant CAD, non invasive
161
EBCT
Quantifies coronary artery calcification
Best for intermediate risk patients
162
Cardiac MRI
Used more for tissue diseases, like pericardium or neoplasm
163
Coronary angiography
Gold standard test to diagnose CAD
Used when noninvasive testing is inconclusive or severe CAD
164
Narrowing of >50%
Hemodynamically and clinically significant
165
Narrowing of >70%
Ischemia!
166
Coronary vasospasm diagnostics
IV ergonovine and ST segment elevation on an EKG
167
USPSTF ASA guidelines
low dose ASA for adults 50-59 with
>10% 10 year CVD risk
No risk for bleeding
Life expectancy of 10 years
Willing to take for 10 years
168
Treatment of stable, chronic angina
1st line- beta blockers!
Long acting nitrates
Ranolazine
CCBs (3rd line)
169
Acute coronary syndromes 3 presentations
1. Unstable angina
2. ST elevation MI
3. NSTEMI
170
ACS presentation vs. chronic stable angina
Similar symptoms as stable chronic angina, but occur at rest or with minimal exertion
More severe
NTG has little effect
171
Respiratory distress and edema indicating HF killip classification:
Class 1: absence of rales & S3
Class II: rales don't clear with coughing less than 1/3 of lung field or presence of S3
Class III: rales do not clear with coughing over >1/3 lung fields
Class IV: cardiogenic shock
172
NSTEMI diagnostics
Biomarkers of myocardial necrosis positive in addition to at least one of the following:
Ischemic symptoms
Q waves
Ischemic ST segment changes on EKG or imaging or coronary intervention
173
Cardiac enzymes and biomarkers timing
3 sets, measured at 6-8 hour intervals after the patients presentation
174
Which biomarkers is quickest to rise and when does it normalize?
CK-MB, normalizes in 24 hours
175
Which biomarker is latest to peak and how long will it stay elevated?
Troponin I & T, stay elevated for 5-7 days
176
Acute magement of STEMI
PCI or fibrinolytics
Dual antiplatelet therapy
Anticoagulation therapy
177
CABG
Patients with stable angina
Rarely performed in STEMI patients, unless failure of previous intervention, shock, or life threatening arrhythmia
178
After CABG prognosis
Mortality beneficit is most evident in first decade after surgery, then falls off
179
MI deaths
About half occur before arrival to ED
180
Neurally mediated syncope
Vasovagal
Situational
181
Orthostatic hypotension syncope
Hypovolemia
Medication
Underlying disease
182
Primary cardiac syncope
Structural
Arrhythmia
Decreased CO
183
What is the most important part in the evaluation of a syncopal patient?
History
184
Reassuring features of syncope
Prodrome of weakness, lightheadedness, diaphoresis, nausea
185
Non-reassuring features of syncope
Sudden onset
Prodrome of chest pain and/or palpitations
186
Physical exam of syncope
Assess for trauma, then look for causes
