Flashcards in Day 7.1 Cardio Deck (131):
4 drugs used to treat tinea capitis or pubis
Lindane (but it's neurotoxic)
Organism in animal urine
Hanta virus (rat/mouse urine)
Drug w best effect on:
Raises HDL: Niacin
Lowers LDL: Statins (HMG coA reductase inhib)
Lowers TGs: Fibrates (2nd- omega3 FA)
Murmur: mitral/tricuspid regurg (MR/TR)
Heard from S1 all the way to S2.
Holocystic, high-pitched "blowing murmur"
Mitral: loudest at apex, radiates to axilla
Enhanced by things that increase TPR (squatting, hand grip) or by increased LA return (expiration)
Tricuspid: loudest at tricuspid area, radiates to right sternal border
Enhanced by maneuvers that increase RA return (inspiration)
What are the causes of mitral and tricuspid regurg?
ischemic heart dz
mitral valve prolapse
Murmur: Aortic stenosis
B/t ejection click and S2 (ejection click is shortly after S1)
Crescendo-decrescendo systolic ejection murmur after ejection click. (ED is d/t abrupt halting of valve leaflets)
LV prs >> aortic prs during systole
Radiates to carotids/apex
Heard in aortic area
"Pulsus parvus et tardus"- pulses are weak compared to heart sounds. Can lead to syncope.
Causes of aortic stenosis
Age-related calcific aortic stenosis
Bicuspid aortic valve
Heard from S1 all the way to S2
Holocystolic, harsh sounding murmur
Loudest at tricuspid area
Murmur: mitral prolapse
From mid-systolic click to S2. (MC is halfway thru S1 and S2)
Late systolic crecendo murmur w midsystolic click. (MC is due to sudden tensing of chordae tendineae)
Most frequent valvular lesion
Loudest at S2 (bc crescendos up to it)
Can predispose to infective endocarditis (only if there is mitral regurg assoc w it. give abx before dental procedures)
Enhanced by maneuvers that increase TPR (squatting, hand grip)
What can cause mitral prolapse?
Murmur: Aortic regurg
Starts at S2
Immediate high-pitched "blowing" diastolic murmur
Wide pulse prs when chronic
Can px w bounding pulses and head throbbing
Cause of aortic regurg
Aortic root dilation (syphilis, Marfan's)
Bicuspid aortic valve (but this is more characteristic of stenosis, not regurg)
Murmur: mitral stenosis
After the Opening Snap (which is even after S2)
Follows opening snap (OS d/t tension of chordae tendineae)
Delayed rumbling late diastolic murmur
LA prs >> LV prs during diastole
Enhanced by maneuvers that increase LA return- expiration (vs split S2 sound, which is enhanced by INspiration)
What can cause mitral stenosis?
Often secondary to rheumatic fever
Chronic MS can result in LA dilation
Continuous- from S1 to S2 and beyond, but most at S2
Continuous machinery-like murmur
Loudest at S2
What murmur can be heard best at the tricuspid area?
What murmurs are enhanced when TPR is increased?
What murmur is enhanced when LA return is increased?
What murmurs can be d/t Rheumatic Fever?
What murmurs are loudest at S2?
What are the diastolic murmurs? (After S2)
Mitral stenosis (late, after OS)
PDA is continuous, so can hear in both diastole and systole
What are the systolic murmurs? (B/t S1 and S2)
Aortic stenosis (after EC)
Mitral prolapse (late, after MC)
What sounds are d/t sudden tensing of chordae tendineae?
Midsystolic click (systole)
Opening snap (diastole)
What do S1 and S2 heart sounds represent?
S1 = Mitral valve closure
S2 = Aortic valve closure
Between them is systole (contraction)
What murmurs can be best heard at the aortic area?
Aortic valve sclerosis
What murmurs can be best heard at the Left Sternal Border?
What murmurs can be best heard at the pulmonic area?
Systolic ejection murmur:
Flow murmur (eg ASD)
What murmurs can be best heard at the mitral area?
Systolic: mitral regurg
Diastolic: mitral stenosis
Systolic murmur at left sternal border
Systolic ejection murmur at pulmonic area
Flow murmur (ASD)
Diastolic murmur at tricuspid area
Diastolic murmur at mitral area
Systolic murmur at aortic area
Aortic valve sclerosis
Diastolic murmur at left sternal border
Pansystolic murmur at tricuspid area
Systolic murmur at mitral area
Px of ASD murmur
Commonly presents as pulmonary flow murmur (increased flow thru pulm valve) plus a diastolic rumble (d/t increased flow across tricuspid).
Blood flow across the actual ASD does NOT cause a murmur bc there is no prs gradient.
The murmur later progresses to a louder diastolic murmur of pulmonic regurg, from dilation of the pulmonary artery
What valves should be open during diastole?
Diastolic filling- so mitral and tricuspid should be open. Therefore stenosis of these valves will make a diastolic murmur.
What valves should be closed during diastole?
Diastolic filling- aortic and pulm valves should be closed. If there is aortic or pulm regurg, will hear a murmur.
What valve should be open during systole?
Systolic contraction: aortic and pulmonic valves should be open (at the end of systole)
So aortic or pulm stenosis will cause a systolic murmur
What valves should be closed during systole?
Mitral and Tricuspid. So if have mitral or tricuspid regurg, will cause a systolic murmur.
When are all of the valves closed?
Isovolumetric contraction (Early systole)
Isovolumetric relaxation (Early diastole)
Best heard w pt in left lateral decubitous position (on left side)?
Left-sided S3 and S4 heart sounds.
Most common causes of aortic stenosis
Congenital bicuspid valve (doesn't px until >40yo)
Chronic rheumatic valve dz
Less common, but still causes:
Congenital unicuspid valve
Syphilis (tree-barking of aorta- can cause stenosis or regurg)
VSD and tricuspid regurg sound the same. In what pts is it likely to be VSD? to be tricuspid regurg?
IV drug user: tricuspid regurg
What does holosystolic mean?
Blood is flowing through valves during all of systole (S1 to S2), including during isovolumetric contraction at the beginning (when there should be no flow)
How do you open/close a PDA?
Close: NSAIDs (indomethicin)
Signs of R-sided heart failure
Peripheral / lower extremity edema
Signs of L-sided heart failure
Pulmonic congestion / edema
Dyspnea on exertion
Paroxysmal nocturnal dyspnea
Signs/sympt of bacterial endocarditis
Fever (most common sympt)
Roth's spots (round white spots on retina surrounded by hemorrhage)
Osler's nodes (tender raised lesions on finger/toe pads)
New murmur (caused by valvular dmg)
Janeway lesions (sml erythematous lesions on palm or sole)
Spinter hemorrhages on nail bed
Bacterial FROM JANE:
Nail-bed hemorrhages (splinter)
What valves are usu involved in bacterial endocarditis?
Mitral valve most frequently
Tricuspid valve in IV drug users (don't tri drugs)- assoc w S. aureus, Pseudomonas, Candida
Complications of bacterial endocarditis
R-sided (tricuspid) emboli -->PE
L-sided (mitral) emboli --> Stroke
Organisms causing bacterial endocarditis
Acute is caused by S. aureus (high virulence)
See lg vegetations on valves that were fine before. Rapid onset.
Subacute is caused by viridans strep (low virulence)
Smlr vegetations, seen on congentially abn or diseased valves (not good valves). More insidious onset. Can occur after dental procedures- so give abx before!
Enterococci (VRE esp bad, bc can't give vanco)
Coag-neg Staph (S. epidermiditis)
IV drug users: S. aureus, Pseudomonas, Candida, S. epidermiditis
Colon cancer pts: S. bovis
Pts w prosthetic valves: S. epidermitidis
Culture-neg: HACEK organisms
Occurs secondary to malignancy or hyper-coag state (marantic / thrombolyic endocarditis)
How to dx bacterial endocarditis
multiple blood cultures
What are the HACEK organisms?
These cause culture-negative endocarditis
What is Libman-Sacks endocarditis?
Verrucous (wart-like), sterile vegetations
Occur on both sides of valve.
Most often benign; can be assoc w mitral regurg and (less common) mitral stenosis
The most common heart manefestation of SLE!
SLE causes LSE
What is endocarditis?
Inflammation of the inner layer of the heart- the endocardium
Usu involves the valves
Can also involve other structures- IV septum, chordae tendonae, mural endocardium, intracardiac devices
What are vegetations?
Mass of platelets, fibrin, microcolonies of microorganisms, and inflammatory cells
Subacute (viridians) vegetations can also have a center of granulomatous tsu which can calcify/fibrose.
Which lesions of endocarditis are painful? non-painful?
Painful = Osler's nodes on finger/toe pads
Non-painful = Janeway lesions on palms/soles
What are the features of Hypovolemic/Cardiogenic shock?
Hypovol/Cardiogenic = LOW-output failure
Increased TPR (afterload)
Cold, clammy pt
Septic = HIGH-output failure
Decreased TPR (decreased afterload)
Dilated arterioles, high mixed venous prs
SVR & CO, plus Rx in Hypovolemic shock
SVR and CO both increase
Rx = IV fluid and blood
Causes of hypovolemic shock
Blood loss d/t trauma (gunshot, MVA, stabbing)
SVR & CO plus Rx in Heart failure (cardiogenic shock)
CO is decreased bc heart is failing, so have a compensatory increase in SVR
Rx = LMNOPP
SVR & CO plus Rx in sepsis/anaphylaxis
Massive vasodilation - decreased SVR
Compensatory increase in CO
Rx Abx, IV fluids (plus NE if needed)
SVR & CO plus Rx in neurogenic shock
E.g. Spinal cord injury, TBI
This means there is not good communication b/t body and brain, so nothing works:
SVR and CO are both decreased
Rx IV fluids. For SC injury give high dose corticosteroids
Causes of cardiogenic shock
Arrhythmias (V-tach, esp V-fib)
Sympt of Rheumatic heart dz
Valve dmg (vegetation and fibrosis)
Red-hot joints (migratory polyarthritis
Subcutaneous nodules (Aschoff bodies)
St. Vitus' dance (chorea)
JONES (O = s cells (activiated histiocytes)
Elevated ASO titers
Aschoff body - granuloma w giant cells
What is Rheumatic heart dz?
Pharyngeal infection w S. pyogenes Gp A strep (beta-hemolytic), which leads to dz
Early deaths are d/t myocarditis
Late results: rheumatic heart dz (affects heart valves mitral > aortic >> tricuspid)
Early lesion - mitral valve prolapse
Late lesion- mitral stenosis
NOT bacterial. It is immune-mediated (type II HPS). There are Ab to M protein.
Pathognomonic for rheumatic heart dz!
It's a granuloma w giant cells in the middle of myocyte cells (heart muscle).
Area of fibrinous necrosis, surrounded by mono-nuclear lymphocytes and multinucleated giant cells.
T/F Rheumatic dz of the heart is d/t bacterial infection.
False. It's auto-immune
But: It is the consequence of S. pyogenes infection.
Compression of heart by fluid in pericardium (eg blood, effusion), which squeezes the heart and t/f causes decreased CO.
Bc there is prs from the outside all around, all 4 chambers equalize in prs (the diastolic prs)
Findings in cardiac tamponade
increased venous prs (JVD)
distant heart sounds (have to hear them through the fluid)
increased HR (to make up for the decreased CO)
EKG: electrical alternans (QRS has beat-to-beat variations in amplitude- sometimes tall, sometimes short, medium, etc)
What is pulsus paradoxis?
Exaggerated decrease in amplitude (loudness) of pulse during inspiration.
So when pt breaths in, systolic BP drops a lot (>10mmHg).
Seen in severe cardiac tamponade, asthma, obstructive sleep apnea, croup (things w exaggerated inspiration)
What are the types of pericarditis?
Serious (SLE, Rheum Arthritis, viral infection, uremia)
Fibrinous (Uremia, MI-dressler's synd, Rheum Fever)
Hemorrhagic (TB, malignancy-melanoma)
What are the findings in pericarditis?
Distant heart sounds
EKG chgs- ST segmt elevation in MULTIPLE leads (vs MI- only in a few specific leads, dep on MI location)
Kussmaul's sign (JVD w inspiration)
It can get better w/o scarring, or it can cause chronic adhesive or chronic constrictive pericarditis
Heart dz caused by syphilis
Tertiary (3) syphilis dmgs the vaso vasorum of the aorta, causing dilation of the aorta and the valve ring (root of the aorta)
Tree-barking: can see calcification of aortic root and ascending aortic arch.
Can result in aneurysm of the ascending aorta or the aortic arch; aortic valve incompetence
What is Kussmaul's sign/pulse?
JVD with inspiration
Caused by decreased capacity of RIGHT ventricle
Common in constrictive pericarditis (not v much in tamponade)
How is pulsus paradoxus different from Kussmaul's?
PParadox has to do w decreased systolic BP on inspiration. It is decreased capacity of LV (vs Kussmaul's which is RV)
And it occurs in cardiac tamponade (vs Kussmauls, which occurs in pericarditis).
Most common primary cardiac tumor in adults
90% are in atria (mostly LA)
Ball-valve obstruction in LA assoc w multiple syncopal episodes.
Most freq primary cardiac tumor in kids
Assoc w tuberous sclerosis
Most common heart tumor
Metastases - melanoma, lymphoma
Chest pain, dyspnea, tachycardia, tachypnea in..
IV drug user
IVDU: Bacterial endocarditis (maybe bacterial embolism --> PE)
MVA pt: Tension pneumothorax
Post-op: Pulm embolism (esp if pt is also confused)
Immediate Rx for bacterial endocarditis
give IV vanco
then later give specific Abx dep on what culture shows
Diffuse myocardial inflam w necrosis and mononuclear cells
Chest pain + course rubbing heart sounds in pt w Creatinine 5.0
ST elevations in all EKG leads
Disordered growth of myocytes
EKG shows electrical alternans
Decrsd blood flow to skin d/t arteriolar vasospasm
Caused by cold temp, emotional distress
Fingers and toes turn blue/white
Sml vessel dz
Can be secondary to:
MCTD (mixed CT dz)
Rx for Raynaud's
Sildenafil (ED- but great vasodilator)
Renal dz + lung dz
Wegener's granulomatosis or Goodpasture's syndrome
Differentiate bc Wegener's has upper airway dz, Goodpasture's doesn't
Perforation of nasal septum- cause
Triad for Wegener's granulomatosis
Focal necrotizing vasculitis (sml vessles)
Necrotizing granulomas in lung/upper airway (hard palate, soft palate, oropharynx, nasopharynx)
So basically a lot of inflam that necrotizes.
Symptoms of Wegener's granulomatosis
Perf of nasal septum
Lab findings in Wegener's granulomatosis
CXR might show lg nodular densities
Hematuria and red cell casts
Rx for Wegener's granulomatosis
Cyclophosphamide and corticosteroids
(this is also the Rx for polyarteritis nodosa)
What 3 things are p-ANCA positive?
Microscopic poly angitis
Primary pauci-immune crescentic glomerular nephritis
What is microscopic polyangitis?
Like Wegeners (inflam, necrosis- lungs, kidneys), but does NOT have granulomas.
What is primary pauci-immune crescentic glomerulonephritis?
Vasculitis limited to kidney
Pauce-immune = paucity of Ab
What is Churgg-Strauss syndrome?
Granulomatous vasculitis w eosinophilia(!)
Px: asthma, sinusitis, skin lesions, and peripheral neuropathy (foot/wrist drop)
Can also involve heart, GI, kidneys
"vasculitis in a young asthmatic"
Things that cause eosinophilia
Atopy (predisposition to HPS rxns)
Congenital vascular disorder that affects capillaries. (sml vessels)
Causes port wine stain (nevus fammeus) at opthalmic division of trigeminal nerve on face;
Ipsilateral angiomatosis (intracerebral AVM)
Lower extremity palpable purpura (butt and legs)
Arthralgia (knees esp)
Abd pain (intestinal hemorrhage, melena)
Most commone form of childhood systemic vasculitis.
IgA immune complexes
Assoc w IgA nephropathy (nephrotic, nephritic synd)
aka thromboangiitis obliterans
Heavy smoker(!) with
idiopathic, segmental, thrombosing vasculitis of sml and medium periph arteries and veins
Sympt: intermittent claudication, superficial nodular phlebitis, cold sensitivity (reynaud's phenomenon), severe pain in affected part
Can lead to gangrene and auto-amputation of digits
RX: stop smoking!
T/F medium-vessel dz causes thrombosis/infarction of arteries
aka mucocutaneous lymph node syndrome
Asian infants/children w acute, self-limiting necrotizing vasculitis
Sympt: fever, conjunctivitis, chg in lips/oral mucosa (strawberry tongue, lips cracking), lymphadenitis, peeling palms/fingers/toes (desquamative skin rash)
May develop coronary aneurysms- really dangerous bc a) can rupture and heart won't be perfused or b) the widening pools blood and causes thrombosis- so heart won't be perfused.
Affects sml and medium vessels
Rx for Kawasaki dz
IV immunoglobulin (pooled Ab from population)
High dose aspirin- this is the only time you give it to kids (Reye's!)
Transmural vasculitis w fibrinoid necrosis.
HBV+ pt (30%) w non-specific sympt: fever, weight loss, malaise, abd pain, melena, headache, myalgia, HTN, neurologic dysfn, cutaneous eruptions
Findings and Rx for Polyarteritis nodosa
See multiple aneurysms and constricitons on arteriogram. (Lesions are of different ages)
Sml and med-vessel dz
Usu renal and visceral vessels (NOT pulm arteries)
Rx: corticosteroids and cyclophosphamide (same rx as wegener's, but wegener's is p-ANCA positive, this is not.)
pulseless dz- weak pulses in upper extremities.
Asian 40+ yo Female w granulomatous thickening of aortic arch and/or proximal great vessels. Assoc w increased ESR.
medium and large vessel dz.
Sympt: fever, arthritis, night sweats, myalgia, skin nodules, ocular disturbances, weak pulse in upper extremity.
Temporal arteritis (giant cell arteritis)
Most common vasculitis affecting med and lg arteries, usu branches of carotid artery.
Elderly females w focal, granulomatous inflam.
impaired vision (occlusion of opthalimic artery- can lead to irrev blindness.
TEMPoral arteritis has signs near TEMPles.
Can also hv hyperpigmt of temples, pronounced temporal artery, muscle wasting over temples, and poor perfusion of scalp
Findings and Rx in Temporal arteritis
Assoc w increased ESR
Half of pts have systemic involvement and polymyalgia rheumatica
Rx: high dose steriods (for over a year)
Pain and stiffness in shoulders, hips
Often w fever, malaise, weight loss
Does NOT cause muscular weakness- joints just hurt.
Pts 50+ years
Assoc w temporal arteritis (giant cell arteritis)
Findings: increased ESR, normal CK (not muscular)
Differential Dx for red lesions
Benign capillary hemangioma in infancy
Grows w child initially, then spontaneously regresses.
Benign capillary hemangioma in elderly
Does not regress
Freq increases w age
Polypoid capillary hemangioma that can ulcerate and bleed.
Assoc w trauma and pregnancy
Abn buildup of bld vessels in skin or organs
Cavernous lymphangioma of the neck.
Assoc w Turner's 45XO
Benign but painful, red-blue tumor under fingernails.
Arises from modified smooth musc cells of glomus body
Benign capillary skin papules found in AIDS pts.
Caused by Bartonella henselae infection
Freq mistaken as Kaposi's sarcoma
Highly lethal malignancy of the liver
Assoc w exposure to vinyl chloride, arsenic, and ThO2 (thorotrast) exposure
Lymphatic malignancy assoc w persistent lymphadema (e.g post- radical mastectomy)
Endothelial malignancy of the skin assoc w HHV-8 and HIV
Freq mistaken as bacillary angiomatosis.
Which vasculitis has...
Weak upper extremity pulses?
Occlusion of the opthalmic artery, which can cause blindness?
Perforation of the nasal septum?
Weak pulse = Takayasu
Opthal artery occlusion = Temporal arteritis
Nasal septum = Wegener's gran.
Which vasculitis features
Necrotizing granulomas of lung, and necrotizing glomerulonephritis?
Unlateral headache and jaw claudication?
Necrotizing immune-coomplex inflam of visceral/renal vessels?
Necrotizing lung, nephritis = Wegener's
Uni headache/Jaw = Temporal arteritis
Imm-complx in renal vessles = Polyarteritis Nodosa
Which vasculitis is common in...
Young male smokers?
Young asian women?
M smoker = Buerger's
Asian F = Takayasu
Asian baby = Kawasaki
Asthmatic = Churg-Strauss
Infants/kids, w coronary problems?
HBV = Polyarteritis nodosa
Coronary prob = Kawasaki
Most common = temporal arteritis
Most common brain tumor in adults?
Gliobastoma multiforme (also most deadly)