CV Flashcards
List your DANGER SIGNALS
Acute MI AAA (Dissecting Abdominal Aortic Aneurysm) CHF Bacterial Endocarditis
DS-Acute MI Classic Case
- Mid age or older male c/o midsternal chest pain that feels like heavy pressure on chest. Pain a/w numbness and/or tingling in the left jaw and the left arm. Pt diaphoretic with cool, clammy skin.
- Women p/w nonspecific symptoms such as dyspnea, fatigue, back pain and nausea.
DS-AAA Classic Case
- Elderly white male c/o PULSATING type sensation in abdomen and or LBP.
- With impending rupture, sudden onset of severe chest and LBP that steadily becomes SHARP and EXCRUCIATING.
- pt with HTN and Smokers are at higher risk.
DS-CHF Classic Case
- Elderly pt c/o acute or gradual dyspnea, fatigue, DRY cough, and swollen feets and cankles.
- pt has sudden or gradual increase in weight
- Lung exam will reveal crackles on both the lunch bases (bibasilar crackles) along with an S3 heart sound.
- Hx preexisting CAD, prior MI, or previous episode of CHF is possible. - This pt is usually taking diuretics, digoxin, and antihypertensives.
DS-Bacterial Endocarditis Classic case
- Pt presents with fever, chills, and malaise a/w NEW murmur and the abrupt onset of CHF
- Associated skin findings are found mostly on the fingers, hands, and toes/feet.
- Subungal hemorrhages (splinter hemorrhages on nailbed), petechiae on palate, painful violet colored nodes on fingers or feet (OSLER NODES). - Tender red spots on palms/soles (JANEWAY LESIONS)
Mneumonic for remembering valves
MOTIVATED APPLES
AV Valves
Mitral and Tricuspid
SemiLunar Valves
Aortic and Pulmonic
S1
“LUB” SYSTOLE
-Closure of the AV valves (MT)
S2
“DUB” DIASTOLE
-CLosure of the semilunar valves (Aortic/Pulmonic)
S3
- CHF or heart failure
- occurs during early diastole
- ventricular gallop
- sounds like kentucky
- always considered abnl if occurs after age 35
- this may be normal in some kids or young adults if there are no s/s of heart or valvular disease
S4
- caused by increased resistane due to STIFF left ventricle
- usually indicates LVH; considered normal in some elderly
- sounds like tenesee
- best heard at apex or apical area (mitral area) using the bell of the steth
Summation Gallop
- Pathologic finding
- all heart sounds are present from S1-S4 and sounds like a galloping horse
Bell
- Low tones such as the extra heart sounds (S3 or S4) sounds
- Mitral Stenosis
Diaphragm
- Mid to High pitch tones such as LUNG sounds
- MR which is SYSTOLIC
- AS which is SYSTOLIC
Benign Split S2
- Best heard over pulmonic area (2nd ICD left side of sternum)
- Due to splitting of the aortic and pulmonic components; - Its only normal if it appears during inspiration and disappears at expiration
Benign S4 in Elderly
- Some healthy elderly pt have S4 (late diastolic) heart sound aka “atrial kick” (the atria have to squeeze harder to overcome resistance of a stiff left ventricle)
Heart Mumurs. its all about…
Timing (systole or diastole)
and
Location (aortic or mital)
Systolic Murmurs Mneum
MR. AS
Diastolic Murmur Mneum
MS. AR
DARMS
Auscultatory Areas
Mitral and Aortic
Mitral Area
- AKA Apical area or Apex
- 5th left ICS midclavicular
Aortic Area
-2nd ICS to the right side of the upper border of the sternum at the base of the heart
Systolic MR. ASH.
- Occur during S1 or as a HOLOsytolic, PANsystolic, early systolic, late systolic, or midsystolic murmurs.
- compared to diastolic murmurs, these are LOUDER and can radiate to the neck or axillae
- Mitral Regurg
- Aortic Stenosis
Mitral Regurgitation
- PANsystolic (or HOLOsystolic) murmur
- heard best at the apex of the heart
- radiates to the axilla
- LOUD blowing and HIGH pitched murmur
Aortic Stenosis
MIDsystolic ejection murmur
- best heard at the second ICS at right side sternum
- radiates to the neck
- harsh and noisy murmur (diaphragm)
- These pt should avoid physical overexertion, as there is increased risk of sudden death…Really? just euthanize me
- Valve replacement candidates
Diastolic murmurs are always indicative of
-Heart disease, unlike systolic murmurs
Diastolic: MS. ART
Mitral Stenosis
- LOW pitched diastolic rumbling murmur
- Heard best at the apex of heart
- AKA “Opening Snap” (use bell)
Diastolic: MS. ART
Aortic Regurgitation
- High pitched diastolic murmur
- Best heard at the second ICS at right of the sternum
- High pitched blowing murmur (use diaphragm)
ACS
ACUTE CORONARY SYNDROME: An ischemic chest pain syndrome usually associated with coronary artery plaque rupture. Encompasses STEMI, NSTEMI, and UA.
Unstable Angina
UNSTABLE ANGINA: An acute coronary syndrome in which chest pain is of new onset, increasing severity, or occurs at rest, and cardiac biomarkers are not elevated.
NSTEMI
NON-ST ELEVATION MYOCARDIAL INFARCTION: An acute coronary syndrome in which cardiac biomarkers are eventually elevated but which lacks new ST elevation on ECG.
STEMI
ST ELEVATION MYOCARDIAL INFARCTION: An acute coronary syndrome in which significant ST elevation is found in two or more contiguous ECG leads. It is typically associated with epicardial coronary artery occlusion and transmural infarction, resulting in myocardial cell death evidenced by Q waves if perfusion is not soon restored.
Key ECG Findings in ACS
STEMI: indications for immediate reperfusion therapy
ST elevation >1 mV (1 mm) in two contiguous leads and <12 h since pain onset
Left bundle-branch block not known to be old with a history suggestive of acute MI
ST elevations in posterior leads (V7, V8, and V9) or ST depression in V1-V3 with a prominent R wave and upright T-wave suggestive of posterior STEMI
Typical ECG findings in NSTEMI and UA
Horizontal ST-segment depression
ECG findings change in accord with symptoms
Deep T-wave inversions
Therapies Proven Benefit for MI
Aspirin (162 mg, chewed immediately, then continued daily for life)
PCI (angioplasty or stenting the blocked artery)
Thrombolysis (if primary PCI not available; most regimens require heparin therapy)
β-blockers (immediate IV use and started orally within 24 hours; if no contraindications then continued daily)
ACE (started within 1-3 days and continued for life)
STATIN Cholesterol-lowering drugs (started within 1-3 days and continued daily for life)
Enoxaparin (dosage given prior to thrombolysis or PCI, for patients <75 years of age)
Clopidogrel (75 mg daily with or without reperfusion therapy)
Potential Complications from Acute MI
VFIB
VTACH
HBlock
RV Infarction
FWR Free wall rupture
Ventricular aneurysm
Hemorrhage secondary to therapy
Cardiogenic pulmonary edema
Ventricular septal defect
Cardiogenic shock
Mitral regurgitation
Pericarditis
Thromboembolism
Anterior MI
A new systolic murmur may be heard if cardiogenic pulmonary edema is caused by papillary muscle dysfunction and acute mitral regurgitation. Right ventricular infarction from an inferior MI usually presents as hypotension without pulmonary congestion. Treatment is aggressive volume loading. Nitroglycerine will decrease preload and must be avoided in patients with right ventricular infarction.
Late complications of MI that tend to occur several hours to days after presentation include left ventricular free wall rupture causing tamponade, ventricular septal defect, pericarditis, left ventricular aneurysm, and thromboembolism. Finally, iatrogenic complications of MI therapy can occur. Heparin and antiplatelet therapies lead to significant bleeding in up to 10% of patients. Intracranial hemorrhage occurs in 0.5% to 0.7% of patients who receive thrombolytics for STEMI. These bleeds are usually fatal.
Left ventricular dysfunction that occurs with anterior MI usually causes pulmonary edema or cardiogenic shock. Signs of cardiogenic shock range from frank hypotension to indicators of impaired perfusion such as cool moist skin, oliguria, and confusion. Treatment includes emergent PCI, pressor agents, and, if necessary, an intra-aortic balloon pump.
Classification of HTN
JNC7 Classification of HypertensionClass
Systolic BP (mm Hg) Diastolic BP (mm Hg)
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
Stage 2 ≥160 o r≥100
Hypertensive Emergency
Hypertensive emergency is an acute elevation of blood pressure (≥180/120 mm Hg) associated with end-organ damage; the targeted end organs include the brain, heart, aorta, kidneys, or eyes
The key is to seek acute end organ involvement
Target End Organs
brain,
heart,
aorta,
kidneys,
eyes
Brain
- ischemic brain damage
- Hemorrhagic stroke CVA
Heart/Aorta
- ECG changes in acute MI
- Diastolic murmur in AA
- Aortic dissection
Kidneys
- Acute Renal Failure: Elevated serum creatinine confirms the diagnosis, and urinary sediment is also abnormal
- HELLP: Pre-eclampsia is associated with hypertension, peripheral edema, and proteinuria. These patients may also develop hemolysis, elevated liver enzyme levels, and low platelet counts (HELLP syndrome)
Eyes
- Papilledema (encephelopathy)
- Hypertensive retinopathy: Scattered flame (splinter) hemorrhages and cotton-wool spots
Common Antihypertensive Agents in HTN EMERGENCY
Sam Needs Cheese w/her L E F E H
Sodium nitroprusside
Nitroglycerin
Nicardipine
Labetalol
Esmolol
Fenoldopam
Enalaprilat
Hydralazine
Tx of Hypertensive Emergencies by Diagnosis:
AORTIC DISSECTION
Goal is to:
-Reduce shear forces by ↓ BP and PR; lower SBP to 100–120 mm Hg or lower SBP to <140 mm Hg23; ↓ PR <60 beats/min.
-Measure BP in both arms and treat higher BP
Labetalol, IV continuous infusion
or esmolol IV bolus, then continuous infusion
Respiratory distress in COPD, asthma patients; test dose of esmolol recommended, switch to diltiazem if esmolol intolerant.
Always use β-blocker prior to vasodilators!!!
Nicardipine IV continuous infusion (after β-blocker)
Nitroprusside continuous infusion (after β-blocker); nitroprusside alone increases wall stress from reflex tachycardia; cyanide and thiocyanate toxicity in patients with reduced renal function or therapy >24–48 h
ALDOSTERONE RECEPTOR ANTAGONIST DIURETICS
Action:
- antagonizes the action of aldosterone. increases elimination of water in kidneys and conserves potassium
- AKA mineralcorticoid receptor antagonists
Indications:
- HTN, Heart failure, hirsuitism, precocious puberty
- Avoid combining with K sparing diuretics, ACE, or K supps
Side Effects: gynecomastia, hyperkalemia, GI (vomitting, diarrhea, stomach cramps), ED, postmenopausal bleeding
Ex: SPIRINOLACTONE, EPLERENONE
Loop Duretics
Action:
Inhibit Na K Cl pump of the kidney in the loop of Henle
Side Effects:
- Electrolyte imbalance
- Hypokalemia (potentiates dig tox, increased risk of arrythmia) torsades
- Hyponatremia (hold diuertic, restrict water intake, replace K lost)
- Hypomagnesemia
Contraindications:
-Sensitivity
Ex: Furosemide, Bumetanide
ALPHA 1 BLOCKER/AGONIST
- AKA alpha adrenergic blockers “zosin” A potent vasodilator. Give at bedtime at very low dose and titrate up, SE dizziness and hypotension.
- Not first line med unless pt is a male with HTN and BPH
- Alpha blockers relax smooth muscle found on bladder neck and prostate glad and relieve obstructive voiding symptoms such as weak urianry stream, urgency, and nocturia.
Ex: Terazosin used for HTN and BPH, or Tamsulosin used for BPH only
THIAZIDES and women
Women with HTN and osteopenia/osteoporosis shoud recieve thiazides
thiazides help bone loss by slowing down calium loss from the bone and stimulating osteoclasts
AHF Clinical Presentation
- The symptom with the highest sensitivity for diagnosis is DOE
- The most specific symptoms are paroxysmal nocturnal dyspnea, orthopnea, and edema.
- On exam, an S3 has the highest LR+ for acute heart failure
- Abdominojugular reflux and JVD are the only other two physical examination findings
AHF PE-LEFT
Left Ventricular Failure (Diminished ventricular systolic empyting)
- Crackles, babasilar rales (rales on lower lobes of the lungs), cough, dyspnea, decreased breath sounds, dullness to percusion
- Paraxosymal nocturnal dyspnea, orthopnea, nocturnal nonprodcutive cough, wheezing (cardiac asthma)
MVP Classic Case
- Adult tall and thin FEMALE pt c/o fatigue, palpitations, and lightheadedness (orthostatic hypotension) that is aggravated by heavy exertion. May be asymptomatic.
- A/w pectus excavatum, hypermobility of the joints, arm span greater than height (r/o marfans syndrome)
