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1
Q

What does pulsus parvus et tardus indicate?

A

Severe aortic stenosis (AS)

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2
Q

What characterizes an anacrotic pulse?

A

Slow, notched, or interrupted upstroke with shrill or shudder

Indicates aortic stenosis (AS)

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3
Q

What is Corrigan’s pulse?

A

Water-hammer pulse with a sharp rise and rapid fall-off

Indicates chronic severe aortic regurgitation (AR)

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4
Q

What does a bifid or bisferiens pulse indicate?

A

Two systolic peaks

Indicates advanced aortic regurgitation (AR), hypertrophic obstructive cardiomyopathy (HOCM), or intra-aortic balloon counterpulsation (IABP) with a second pulse being diastolic

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5
Q

What is pulsus paradoxus?

A

A drop in systolic blood pressure (SBP) > 10 mmHg with inspiration

Indicates cardiac tamponade, massive pulmonary thromboembolism (PTE), hemorrhagic shock, severe COPD, or tension pneumothorax

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6
Q

What does pulsus alternans indicate?

A

Beat-to-beat variability of pulse amplitude

Indicates severe left ventricular (LV) systolic dysfunction

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7
Q

What is the thrill location associated with mitral regurgitation (MR)?

A

Cardiac apex

Thrills are vibrations felt on the chest wall due to turbulent blood flow.

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8
Q

Where is the thrill from aortic stenosis (AS) located?

A

From the precordium to the right side of the neck

AS causes specific patterns of blood flow turbulence leading to this sensation.

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9
Q

What is the thrill location associated with pulmonic stenosis?

A

From the precordium to the left side of the neck

Pulmonic stenosis results in characteristic vibrations on the chest wall.

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10
Q

Where is the thrill from a ventricular septal defect (VSD) typically felt?

A

Third and fourth intercostal spaces near the left sternal border

VSD creates a significant left-to-right shunt that produces notable thrills.

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11
Q

What conditions are associated with a loud S1?

A
  • Early phases of rheumatic mitral stenosis (MS)
  • Hyperkinetic circulatory states
  • Short PR intervals

A loud S1 indicates increased pressure or rapid closure of the mitral valve.

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12
Q

What causes a soft S1?

A
  • Later stages of mitral stenosis (rigid/calcified leaflets)
  • Beta-blocker use
  • Long PR interval
  • Left ventricular dysfunction

A soft S1 may indicate decreased pressure or delayed closure of the mitral valve.

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13
Q

What conditions can lead to reduced S1 and S2?

A
  • Mechanical ventilation
  • COPD
  • Obesity
  • Pneumothorax
  • Pericardial effusion

These conditions can dampen heart sounds due to various physiological factors.

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14
Q

What does a normal or widened S1 indicate?

A

Complete right bundle branch block (RBBB), young patients

Normal or widened S1 suggests a variation in electrical conduction affecting heart sounds.

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15
Q

What does reversed S1 indicate?

A
  • Severe mitral stenosis
  • Left bundle branch block (LBBB)
  • Left atrial myxoma
  • Wide: RBBB

Reversed S1 often points to significant cardiac pathology.

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16
Q

What is normal or physiologic splitting of S2?

A

Increase during inspiration, decrease during expiration

This is a normal finding due to changes in intrathoracic pressure affecting valve closure timing.

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17
Q

What conditions are associated with a widened split S2?

A
  • Right bundle branch block (RBBB)
  • Severe mitral regurgitation

A widened split S2 indicates delayed closure of the pulmonic valve relative to the aortic valve.

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18
Q

What does a narrow or absent split S2 indicate?

A

Pulmonary arterial hypertension

This finding suggests increased pressure in the pulmonary circulation affecting valve closure timing.

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19
Q

What is fixed splitting of S2 associated with?

A

Secundum atrial septal defect

Fixed splitting is a characteristic finding in certain congenital heart defects.

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20
Q

What conditions are associated with reversed or paradoxical splitting of S2?

A
  • LBBB
  • Right ventricular pacing
  • Severe aortic stenosis
  • Hypertrophic obstructive cardiomyopathy (HOCM)
  • Acute myocardial infarction (AMI)

Reversed splitting occurs when the aortic valve closes later than the pulmonic valve.

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21
Q

What are the therapeutic goals in HFpEF?

A

Improve symptoms and exercise tolerance

This includes lifestyle changes, control of congestion, stabilizing heart rhythm, BP control, and managing comorbidities.

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22
Q

List some lifestyle changes that can help manage HFpEF.

A
  • Dietary modifications
  • Regular physical activity
  • Weight management
  • Smoking cessation
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23
Q

What comorbidities should be managed in HFpEF to prevent disease progression?

Study These Flashcards
A
  • Obesity
  • Obstructive lung disease
  • OSA
  • Diabetes/insulin resistance
  • Anemia
  • Iron deficiency
  • Chronic kidney disease (CKD)
24
Q

What neurohormonal antagonists show no benefit in HFpEF?

Study These Flashcards
A
  • ARBs
  • ACE inhibitors
  • Beta-blockers
  • Digoxin
  • Nitrates
25
What is the benefit of Sacubitril-Valsartan (ARNI) in HFpEF?
Possibly beneficial, especially among patients with lower ejection fraction (EF) ## Footnote This medication has shown promise in improving outcomes in certain HFpEF patients.
26
Which novel targets have shown potential benefits in HFpEF?
* Empagliflozin * Dapagliflozin ## Footnote These are SGLT2 inhibitors that may reduce the risk of cardiovascular death and hospitalization for heart failure.
27
When is the use of a pulmonary artery catheter in ADHF recommended?
Only under specific conditions: * Low output heart failure or cardiogenic shock requiring vasopressors or mechanical support * Resistant or refractory to diuresis * Combined cardiorenal dysfunction * Known or suspected pulmonary arterial hypertension
28
What parameters are associated with worse outcomes in ADHF?
* BUN >43 mg/dL * SBP <115 mmHg * Serum creatinine >2.75 mg/dL * Elevated cardiac markers (Natriuretic peptide, troponin)
29
True or False: The use of a pulmonary artery catheter is recommended for all patients with ADHF.
False ## Footnote It is only recommended in specific cases as outlined.
30
Fill in the blank: Empagliflozin and Dapagliflozin are types of _______.
[SGLT2 inhibitors]
31
typical ADHF tx
Normotensive - diuresis (volume overload) HPNsive - vasodilators (not volume overloaded)
32
Pulmonary edema ADHF tx
VOOD Vasodilators Opiates O2 and NIV Diuretics
33
RF for sudden death in HCM
History of cardiac arrest or spontaneous sustained ventricular tachycardia Syncope Family history of sudden cardiac death Spontaneous nonsustained ventricular tachycardia LV thickness >30 mm Abnormal blood pressure response to exercise
34
What is an early complaint in aortic regurgitation (AR)?
Uncomfortable awareness of the heartbeat, especially when lying down.
35
What is the first symptom of diminished cardiac reserve in AR?
Exertional dyspnea.
36
What is Corrigan's pulse?
Rapidly rising 'water-hammer' pulse that collapses suddenly as arterial pressure falls rapidly during late systole and diastole.
37
What is Quincke's pulse?
Capillary pulsations, with alternate flushing and paling of the skin at the root of the nail while pressure is applied to the tip of the nail.
38
What is Traube's sign?
Booming 'pistol-shot' sound over the femoral arteries.
39
What is Duroziez's sign?
To-and-fro murmur audible with light compression of the femoral artery.
40
What causes widened arterial pulse pressure in AR?
Due to decreased systolic blood pressure (SBP) and decreased diastolic blood pressure (DBP).
41
What is Carvallo's sign?
Pansystolic murmur at left sternal border of a functional TR accentuated by inspiration and diminished during forced expiration or with Valsalva maneuver ## Footnote TR stands for tricuspid regurgitation.
42
Describe the Graham Steell murmur.
High-pitched, diastolic, decrescendo blowing murmur along the left sternal border resulting from dilatation of the pulmonary valve ring ## Footnote Occurs in patients with mitral valve disease and severe pulmonary hypertension.
43
How does inspiration affect Carvallo's sign?
It accentuates the murmur ## Footnote This is characteristic of functional tricuspid regurgitation.
44
What happens to Carvallo's sign during forced expiration?
It is diminished ## Footnote This change can also occur with the Valsalva maneuver.
45
What type of murmur is the Graham Steell murmur?
Diastolic, decrescendo blowing murmur ## Footnote High-pitched in nature.
46
What condition is associated with the Graham Steell murmur?
Mitral valve disease and severe pulmonary hypertension ## Footnote It results from the dilatation of the pulmonary valve ring.
47
Features of acute pericarditis
Chest pain Friction rub ECG changes Pericardial effusion
48
What settings is stress testing considered in?
Uncertainty with IHD diagnosis, assessing functional capacity of patients, assessing adequacy of treatment program for IHD, markedly abnormal calcium score on EBCT.
49
When should an exercise stress test be stopped?
(+) Chest discomfort, severe SOB, dizziness, severe fatigue, ST-segment depressed > 0.2 mV (>2mm), t SBP >10 mmHg, (+) ventricular tachyarrhythmia.
50
What is the ischemic ST-segment response?
Flat or downsloping depression of the ST segment >0.1 mV below baseline and lasting longer than 0.08 s.
51
What are the contraindications to exercise stress testing?
Rest angina ≤ 48 h, unstable rhythm, severe aortic stenosis, acute myocarditis, uncontrolled HF, severe pulmonary HTN, active lE.
52
dm Management
Guidelines for Ongoing, Comprehensive Medical Care for Patients with Diabetes Individualized glycemic goal and therapeutic plan Self-monitoring at individualized frequency of blood glucose (capillary/meter) or interstitial glucose (continuous glucose monitoring) HbAlc testing (2-4 times/year) Lifestyle management in the care of diabetes, including: Diabetes-self-management education and support Nutrition therapy Physical activity Psychosocial care, including evaluation for depression, anxiety Manage or treat diabetes-relevant conditions, including: Blood pressure (2-4 times quarterly) Lipids (1-2 times/year) Consider antiplatelet therapy with low dose aspirin Overall Principles Goals of therapy: (1) eliminate symptoms related to hyperglycemia, (2) reduce or eliminate long-term microvascular and macrovascular complications of DM, (3) achieve as normal a lifestyle as possible DM symptoms usually resolve when plasma glucose is <11.1 mmol/L (200 mg/dL), thus focus on achieving the second and third goals econd and third goals tate on f diabetes during NOTE: C-peptide levels are unable to completely distinguish T1 form T2 DM, as many individuals with type 1 DM retain some C-peptide production • Islet cell antibodies at the time of DM onset: may be useful if the type of DM is not clear Detection, prevention, or management of diabetes- related complications, including: Diabetes-related eye examination (annual or biannual) Diabetes-related foot examination (1-2 times/year by provider; daily by patient) Diabetes-related neuropathy examination (annual) Diabetes-related kidney disease testing (annual) Influenza/pneumococcal/hepatitis B immunizations
53
54
Traditional RF in CKD
HPN DM Dyslipidemia Hypervolemia Sympathetic overactivity Hyperhomocystinemia
55
Non traditional/CKD related RF
Anemia Hyperphosphatemia HyperPTH Inc FGF23 SLeep apnea Systemic inflammation

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