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Flashcards in Other Deck (47):
1

Define hypertensive emergency

SBP great 180 and DBP greater than 120
plus end organ damage
Neurologic, cardiac, renal, retinal

2

Define hypertensive urgency

SBP great 180 and DBP greater than 120
but no end organ damage

3

Lipid guidelines

Statin use for 10 year life time risk from risk calculator
Treat:
- DM 40-75
- 21 yo or more with LDL >190mg/dL
- With cardiovascular disease

4

Dilated cardiomyopathy

Path: decreased contractility
Eti: viral or idiopathic
Symp: Orthpnea, PND, DOE, crackles, edema
Dx: echo
Tx: same as CHF: BB, ACE, diuretic
- transplant

5

Hypertrophic cardiomyopathy

Path: Long standing HTN leads to concentric hypertrophy
Dx: Echo
Tx: Diastolic CHF
- avoid dehyrdation, BB or CCB

6

Restrictive cardiomyopathy

Path; Amyloid, Sarcoid, Hema ChromaT
Pt: diastolic CHF
Dx: Echo
Tx: Diastolic CHF
- BB or CCB, gentle diuresis

7

What is cardioversion and when do you use it?

CI?

Application of electricity to terminate a still perfusing arrhythmia to allow NSR to restart.
- VT with a pulse who are HD unstable, SVT, a flutter, afib
CI: a fib of unknown time frame (can throw a clot) without anticoagulation, NSR.

8

What is defibrillation and when do you use it?

CI?

Electricity to depolarize the muscle to coordinated contractions. Usually applied to an attempt to terminate a nonperfusing rhythm.
Indications: VF and pulseless VT.
CI: A pulse, person is awake.NSR. Asystole.

9

MC Etiology of acute myocardial infarction

Atherosclerotic disease of epicardial arteries (CAD)

10

Signs and symptoms of acute myocardial infarction?

Sub-sternal chest pain
Associated symptoms of N/V, diaphoresis, dyspnea, lightheadedness, syncope and palpitations
- radiation to arm, neck or jaw
- think non classic symptoms in females, DM, advanced age
- Presence of new murmur bad sign

11

Workup for acute myocardial infarction

ECG
- TIMI score: estimates morality for patients with unstable angina/NSTEMI
- HEART score: used in ED (predicts 6 wk risk of major adverse cardiac event)
- Troponins
- BNP (more for heart failure)

12

Treatment of MI

MONA
morphine
O2
nitroglycerin
aspirin
PCI window: 90 minutes door to PCI

13

ST-segment elevations in V1 -V3

Anteroseptal

14

ST-segment elevations in V1-V4

Anterior

15

ST-segment elevations in V1-V6 and aVL

anteriolateral

16

ST-segment elevations in I and aVL

lateral

17

ST-segment elevations in II, III, aVF

inferior

18

ST-segment elevations in II, III, aVF, V5-V6

inferolateral

19

ST-segment depression in V1

posterior

20

Etiology of heart failure

ischemia,
systemic HTN
cardiac dysthrythmias
valvular dysfunction
cardiomyopathies
myocarditis

21

S/s of heart failure

SOB, edema, fatigue
- exercise intolerance, fluid retention

22

Types of HF

Systolic: reduced EF (<50%), ventricle has difficulty ejecting blood, increased intracardiac volume

Diastolic: preserved EF: impaired ventricular relaxation. Left ventricle has difficulty receiving blood.

23

Work up for HF

No single diagnostic test
- Extra heart sounds
- CXR: pulmonary venous congestion, cardiomegaly, interstitial edema (curly b lines)
- Biomarkers: BNP trends = HF
- ECHO: is the best test

24

Etiology of acute bacterial endocarditis, risk factors

Pathogens:

- Structural heart disease: Mitra valve prolapse: common predisoposing cardiac lesion.
- Prosthetic heart valves
- Poor dentition or dental infection
- Injection drug use
- Presence of intravascular device.

Pathogens: Staph A, strep, enterococci

25

S/s of acute bacterial endocarditis

fever, chills, weakness, dyspnea, heart murmur, cough
Skin manifestations: petechiae, splinter hemorrhages
- Janeway lesions (small hem on soles of hands and feet)
- Osler nodes (small tender sub! nodules on pads of fingers and toes)
- Roth spots
- hypotension

26

Work up for endocarditis

Specific criteria?

CBC, CMP, coags, blood cultures before starting abx.

Dukes criteria: (2 major or 1 major + 3 minor)
Major: blood culture, evidence on echo, new valvular regurg.
Minor: predisposing heart condition (IVDU), fever, vascular phenomena, microbiologic evidence.

27

Treatment of endocarditis

Vanco good choice for most patients

28

Pericardial effusion
Eti
S/s
Workup: test of choice
Tx

Eti: usually injury or insult to the pericardium (anything that causes pericarditits) - often idiopathic
S/s: chestpain..., light headedness, syncope, palitations, cough, dyspnea
Becks triad: (pericardial tamponade): hypotension, JVD, muffled heart sounds
Test of choice: echo
Tx: NSAIDs, corticosteroids, anti-inflam(colchicine)

29

myocarditis
Eti:
s/s
Workup
Tx

Inflammatory infiltrate of the myocardium
Eti: viral (enterovirus (aka coxsackie), flu, EBV, hep B, hiv)
Classic patient is a young male
S/s: Viral prodrome (fever, myalgias, malaise), dyspnea at rest, exercise intolerance, tachypnea, tachycardia
Workup: CXR, ECG, cardiac enzymes, echo, esr, cbc
Tx: supportive, abx if fever

30

S3 heart sound
Sound:
Clinical significance?
Can it be normal?

Low frequency, early in diastole
Ventricular gallop, produced by a large amount of blood striking a very compliant left ventricle.
"Kentucky"
Dilated cardiomyopathy
S3 is not always abnormal, normal in young adults, kids pregnancy, athletes.

31

S4 heart sound
Sound:
Clinical significance?
Can it be normal?

Heard just before S1, atrial gallop
"Tennessee"
Low frequency heard best at apex of heart with patient in left lateral decubitus position.
Often signifies, diastolic heart failure, resulting from LV hypertrophy

32

Ruptured aortic aneurysms
Risk factors

Atherosclerosis
Advancing age
Hypertension
Smoking
connective tissue disease (marfans)

33

Ruptured aortic aneurysms
Pathogenesis

Elastin and collagen are dramatically reduced in the walls of the aneurysm. Combination of risk factors and force on the walls lead to dilation.

34

Ruptured aortic aneurysms
History

Most patients are asymptomatic
- may have dull constant abdominal, low back or flank pain.
- Symptoms usually indicate rupture
- hypotension, syncope
- If ruptured: often present with syncope, severe tearing abdominal pain that radiates to the back.

35

Ruptured aortic aneurysms
Physical exam findings
And workup

Pulsatile abdominal mass
Abdominal tenderness or bruits
Tachycardia, hypotension

W/u: US is the ideal test but not indicate if ruptured
Abdominal CT will demonstrate both aneurysm size and if ruptured.

36

Acute Aortic Dissections
Epidemiology

Most cases between 50-70 years old,
- younger age groups with conditions such as marfans
- 2x as common in men as women

37

Acute Aortic Dissections
Risk factors

Hypertension
Marfans, Ehlers-danlos
Bicuspid aortic valve
Coarctation of aorta
Inflammatory disease
Atherosclerosis
Smoking
Pregnancy

38

Acute Aortic Dissections
Pathogenesis

Defects in the intimal layer, allowing blood between the intimal and adventitia layers.

39

Acute Aortic Dissections
Types?

Type A: ascending aorta (DeBakey type 1 and 2)
Type B: involving the descending aorta

DeBakey:
Type 1: involves the ascending aorta, aortic arch, descending aorta.
Type 2: Confined to the ascending aorta
Type 3: Confined to the descending aorta distal to the left subclavian artery.

40

Acute Aortic Dissections
History

Sudden onset of tearing or ripping chest pain that radiates to the back between the scapula.
- Syncope
- Neurologic findings
- Hoarseness
- Dyspnea
- GI symptoms
- Flank or lumbar pain

41

Acute Aortic Dissections
Physical exam

Vs: hypertension or hypotension
Signs of shock: cool, diaphoretic skin, deceased consciousness
Cardiac exam: Aortic insufficiency (disection of aortic root)
- Pericardial friction rub, or muffled heart sounds
Pulmonary : Listen for rales, look for JVD
Neuro: look for deficits
Extremity: Check for differences of BP and pulses.

42

Acute Aortic Dissections
W/u

ECG: to rule out other sources of chest pain
CXR: Most common sign is WIDENED MEDIASTINUM
- obliteration of aortic knob, deviation of trachea or esophagus to right, left hemothorax.
CT is best
Aortography is still considered gold standard

43

Acute Aortic Dissections
Treatment

Patients who are hypotensive should get IV fluids and blood transfusions

Unstable patients: immediate vascular surgery consult

Hypertensive: control BP with Sodium nitro-prusside combined with beta blockers

44

Cardiac Tamponade
Etiology

MC: malignant diseases (30-60% of cases)
Uremia: 10-15%
Idiopathic pericarditis: 5-15%
Infectious diseases: 5-10%
Connective tissue disease: 2-6%
Dressler or postpericardiotomy syndrome 1-2%

45

Cardiac Tamponade
History:

Symptoms of pericarditits or effusion
Reflex tachycardia
Hypotension
Pulsus paradoxus (DBP dropped more than 10mmHg with inspiration)
Dyspnea at rest

46

Cardiac Tamponade
W/u

EGK: low voltage, ST segment elevation, PR segment depression, ELECTRICAL ALTERNANS
CXR
ECHO

47

Cardiac Tamponade
Treatment

With decompensation: emergent management
- O2
- Large IVs
- Fluids
- Dopamine
- pericardiocentesis or pericardial window