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340 Cards in this Set

  • Front
  • Back
What is the most common chronic illness in America?
What is the nation's leading cause of disability or death due to stroke, heart attack, heart failure, & kidney failure?
The relationship between BP & risk of cardiovascular dz events is?
Continuous, consistent & independent of other risk factors.
The higher the BP the greater the chance of?
MI, Heart failure, CVA, & Kidney dz.
What are the benefits of lower BP?
35-40% reduction in CVA incidence.
20-25% reduction in MI
>50% reduction in heart failure.
Blood Pressure =
Cardiovascular Output X Peripherial Vascular Resistance.
What is Essential Hypertension?
(primary htn)
No identifiable cause
95% of cases
Onset 25-50yrs
Essential HTN Risk Factors;
Genetic factors, Environmental factors (diet, especially ↑ salt intake), Sympathetic nervous system hyperactivity, Problems w/renin-angiotensin system, Defect in excretion of Na, ↑ intracellular Ca.
Essential HTN Exacerbating Factors;
Obesity, Na intake, Alcohol, Cigarette smoking, Sedentary lifestyle, Polycythemia, NSAID, ↓ K intake.
Cause of secondary HTN is identified how?
By hx, px or lab studies.
Identifieable causes of secondary HTN;
Sleep apnea, Drug induced or drug related, Chronic kidney dz, Renal vascular dz, Primary hyperaldosteronism, Cushing's syndrome, Chronic steroid therapy, Pheochromocytoma, Corarctation of aorta, Thyroid or parathyroid dz, Pregnancy.
What is Pheochromocytoma?
A tumor derived from neural crest cells of the sympathetic nervous system that is responsible for about 0.1% to 2% of all cases of hypertension.
What is hyperaldosteronism?
The excessive production of aldosterone by the adrenal gland.
What is Cushing's syndrome?
S/Sx that result from prolonged exposure to excessive glucocorticoid hormones,a side effect of the pharmacological use of steroids.
What is Corarctation of aorta?
A narrowing of the aorta between the upper-body artery branches and the branches to the lower body. This blockage can increase blood pressure in your arms and head, reduce pressure in your legs and seriously strain your heart. Aortic valve abnormalities often accompany coarctation.
What is Malignant HTN?
HTN that rises very quickly & is very high 210/120, it is a hypertensive crisis.
What are the 3 objectives in evaluation of a pt w/HTN?
1. Asses lifestyle & identify other CV risk factors.
2. Reveal identifiable causes of HTN.
3. Assess for end organ damage (complications of HTN)
What are the CV risk factors?
HTN, Cigarette smoking, Obesity, Sedentary lifestyle, Dyslipidemia, DM, Age (>55men, >65 women), Family hx.
HTN causes what complitions on the heart?
Left ventricular hypertrophy, hrt failure.
Coronary artery dz, angina or MI.
HTN causes what complitions on the Brain?
HTN causes what complitions?
Chronic kidney dz,
Peripheral arterial dz, claudication.
What are the symptoms of essential HTN?
usually asymptomatic, HTN found on routine exam.
May present w/sx that are 2ndary to the complications of untx HTN, CP, dyspnea, unilateral weakness, or paraplegia, vision ▲s.
What are the sx of secondary HTN?
Depends on identifiable cause.
Pheochromocytoma-sxs associated w/↑ norepinephrine (palpitations, anxiety, perspiration, tremor).
CHD may develop angina or CHF.
Primary hyperalsosteronism-muscular weakness, polyuria, nocturia.
What is polyuria?
Excessive secretion and discharge of urine.
What are the sx of hypertensive encephalopathy?
Pulsating HA, behind eyes, AM.
Visual disturbances
Dizziness, Nausea, Vomitting
What are the signs of HTN?
Elevated BP
Retina ▲s
Heart & artery ▲s
HTN classification is based on?
≥ 2 BP readings, ≥ 2 office visits, Supine, Standing & sitting, Both arms, legs if pulses diminished or delayed, pt seated quietly for 5 min, seated w/feet on floor & arm supported @ hrt level, appropriate cuff size.
What retinal ▲s are sometimes evident w/HTN?
Arterial narrowing
Copper wiring or silver wiring appearance
Exudates, hemorrhages
What are the heart & artery ▲s w/HTN?
LV heave or displaced, diffuse apical pulse due to LVH.
Systolic ejection murmur due to calcific aortic valve, rerely associated A1 murmur.
S4 gallop 2ndary to poor conpliance of LV
What do you look for during PE of a pt w/HTN regarding pulses?
Absent or markedly reduced or delayed femoral pulses (hypertensive pt <30.
Check pulses to R/O aortic dissection.
Auscultate abdomen for bruits to R/O renal artery stenosis.
What is aortic dissection?
A potentially life-threatening condition in which there is bleeding into and along the wall of the aorta.
What are you looking for when ordering Labs for a pt w/HTN?
Minimal lab, CBC (anemia), UA (↑ proteins, renal inscf), Serum analysis (K, Na, creatinine, glucose, uric acid, electrolyte imbalance), Lipid profile, EKG. *The younger the pt & the more severe the HTN the more extensive the work up*
What are you looking for when ordering Labs for a pt w/secondary HTN?
Pheochromocytoma-Urinary or plasma catecholamines, VMA, metanephrines, (urine).
Primary aldosteronism-serum K (low w/out diuretic).
Primary renal dz-Urinalysis (proteinuria, cylindruria, microhematuria w/out nitrogen.
What are you looking for when ordering a EKG for a pt w/HTN?
Evidence of LVH
What are you looking for when ordering a Echo for a pt w/HTN?
Not routinely used to evaluate HTN.
Useful to evaluate LVH.
Primarily used for pts w/clinical S/Sx of cardiac dz or hrt failure.
Is a CXR necessary in uncomplicated HTN?
Not usually
What is the cure for primary HTN?
It has no cure.
Tx does modify its course.
What are the goals of tx of HTN?
Reduce CV & renal morbidity & mortality.
Target BP ≤ 140/90
≤ 130/80 pts w/DM
What is the action of diuretics when used for HTN?
They reduce the volume of fluid in the body.
They cause the kidneys to excrete more Na in urine (the Na takes w/it H2O from the blood)
Less volume of blood pushing through arteries & less pressure on artery walls.
Name the types of Medications used for HTN;
Diuretics, ACE inhibitors, Angiotensin II receptor blockers (ARB), Calcium channel blockers, Alpha Blockers,
What is the action of ACE inhibitors when used for HTN?
They prevent the body from producing angiotensin I.
What is the action of Angiotension II receptor blockers (ARB) when used for HTN?
Block the action of angiotensin II, compared w/ACE inhibitors, which block the formation of angiotensin I.
ARBs don't affect bradykinin.
What is bradykinin?
A plasma kinin
What is kinin?
Polypeptides that are capable of influencing smooth muscle contraction; inducing hypotension; increasing the blood flow and permeability of small blood capillaries; and inciting pain.
What is the action of Calcium channel blockers when used for HTN?
They affect the muscle cells around arteries. The muscle cells contain passages in the membranes called Ca channels. When Ca flows into them, muscle cells contract & arteries narrow. Ca antagonists block the channels & prevent Ca from getting into muscle cells.
What is the action of Alpha blockers when used for HTN?
They ↓ BR by preventing the nervous system from stimulating muscles in the walls of smaller arteries. So they don't constrict as much.
They also diminish the effect norepinephrine & epinephrine has on constriction of the blood vessels.
What is the action of Central Acting Antihypertensives when used for HTN?
They prevent the brain from sending signals to speed up the hrt rate or constrict blood vessels. They work on the Brain.
If a pt is on a single antihypertensive & their BP is >20/10mmHg above goal, what should be done?
Start a 2nd med or combination med.
What would be the best 2nd med?
Diuretics, they enhance the effectiveness of other antihypertensive drugs. (They are more affordable & are underused.)
When choosing the right antihypertensive what should be considered?
Other medical conditions
Simplicity of regimen
What is a good med to prescribe for HTN if the pt has stable angina?
Beta Blocker or Calcium Channel Blocker
(add other drugs as needed for BP control)
What is a good med to prescribe for HTN if the pt has Unstable angina or MI?
Beta Blocker (reduces the risk of 2nd MI) w/ACE inhibitor.
What is a good med to prescribe for HTN if the pt has DM?
Combo of 2 or more drugs usually needed. Thiazide diuretic, ACE inhibitor, ARBs, BB, CCBs. All reduce the risk of stroke in diabetics.
*ACE/ARBs protect kidneys & + affect progression of diabetic nephropathy.
What is a good med to prescribe for HTN if the pt has Chronic Kidney Dz?
Goal is to slow deterioration of renal function. Aggressive tx, usually 3 or more drugs.
ACE/ARBs, loop diuretics.
What is a good med to prescribe for HTN if the pt has CV dz?
Decrease recurrent stroke w/ACE inhibitor & thiazide diuretic.
What is a good med to prescribe for HTN if the pt is African-American?
Reduced BP response w/monotherapy.
Increased risk of ACE I, induced angioedema.
What is a good med to prescribe for HTN if the pt has Left ventricular hypertrophy?
Regression of LVH occurs w/aggressive tx.
Use all classes of druges except direct vasodilators, hydralazine & minoxidil.
What HTN medications should not be given to African-American pts?
ACE inhibitors (risk of angioedema)
What HTN medications should not be given to pts w/LVH?
Direct vasodilators; hydralazine & minoxidil.
What ▲s need to be made when prescribing meds for HTN if the pt is elderly?
>2/3 of indivduals >65, Population w/lowest rate of BP control, tx same as for general pop, Diuretics work well & are tolerated well, start w/lower doses, tx isolated systoloic HTN w/diuretics.
What should I remember when tx women for HTN?
OC may ↑ BP, risk of developing HTN ↑ w/duration on OC.
Pregnancy-Methyldopa, BB, & vasodilators preferred.
ARBs, ACE I contraindicated in sexually active or pregnant women.
What other favorable effects do Thiazide diuretics have?
Slow development of osteoporsis.
What other favorable effects do Beta Blockers have?
Useful in tx of atrial arrhythmias (afib)
Essential tremor
What other favorable effects do Calcium Channel Blockers have?
Useful in tx of some arrhythmias.
Useful in tx of Reynaud's syndrome.
Nephroprotective if DM pts are unable to tolerate ACE or ARB.
Thiazide diuretics should be avoided in pts with?
Gout, hyponatremia.
Beta blockers should be avoided in pts with?
2nd or 3rd degree HB.
Restrictive airway dz.
ACE inhibitors & ARBs should be avoided in which pts?
Sexually active or pregnant women.
What are the Adverse effects of Diuretics?
ED, Rash, Weakness, HA, GI disturbances, ↓ in K+ NA+ & Mg+, ↑ risk of gout, In combination w/ACE can cause hyperkalemia.
What are the Adverse effects of Beta Blockers?
Bronchospasm, Fatigue, Insomnia, Mask sx of hypoglycemia, ↑ in hrt block.
What are the Adverse effects of ACE inhibitors?
Cough, Hypotension, Dizziness, Hyperkalemia, Angioedema, Rash, Contrindicated in Pregnancy.
What are the Adverse effects of Angiotensin II receptor blockers?
Hyperkalemia, Renal dysfunction, Rare angioedema, Contrindicated in Pregnancy.
What are the Adverse effects of Calcium Channel Blockers?
Edema, HA, Bradycardia, GI disturbances, Dizziness, Palpitations.
What are the Adverse effects of Alpha Blockers?
Syncope w/1st dose, RHB, HA, Dizziness, Palpitations, Orthostatic hypotension, ED, Urinary incontinence.
What are the Adverse effects of Central Agonists?
Orthostatic hypotension, Impotence, Drowsiness, Sedation, Dry mouth, Constipation.
Rebound HTN may occur even p gradula withdrawl.
What are the Adverse effects of Peripheral adrenergic inhibitors?
Stuffy nose, Diarrhea, Heartburn, Depression, Nightmares, Insomnia, Orthostatic dizziness, Weakness.
What are the Adverse effects of Blood Vessel Dilators?
HS, Nasal congestion, Palpitations, Joint Pain, Hirsutism, Thrombocytopenia.
What is resistant HTN?
Failure to reach goal BP in pts who are adhering to full doses of an appropriate 3 drug regimen which includes a diuretic.
What are some drug-induced causes of resistant HTN?
Nonadherence, Inadequate dose, Inappropriate combo, NSAID, Cocaine, amphetamines or other ellicit drugs, Decongestants, OC, Adrenal steroids, Cyclosporine, Erythropoietin, Licorice, OTC dietary supplements & meds (ephedra, ma haung, bitter orange).
What emergant conditions can HTN cause?
Hypertensive encehalopathy, Acute LV failure, Pulmonary edema, Eclampsia, Severe htn w/ angina, MI, Aortic dissection.
What Drugs should be used to tx hypertensive emergencies?
IV vasodilators
IV diuretics
IV adrenergic inhibitors
Follow up & monitoring the HTN pt?
Monthly f/u & adujustment of meds until BP goal reached.
More often if comorbid conditions (hrt failure, DM)
K & creatinine 1-2 X year.
Stable BP f/u q 3-6mos
What is Angina?
Clinical syndrome due to myocardial ischemia characterized by precordial discomfort of pressure, typically precipitated by exertion & relieved by rest or subligual nitroglycerin.
What is the Etiology of Angina?
Coronary obstruction or Dzs that increase cardiac work.
Angina what causes Coronary obstruction?
Angina what dzs ↑ cardiac work?
Calcific aortic stenosis
Aortic regurgitation
Hypertrophic subaortic stenosis
What is the Pathophysiology of Angina?
Cardiac demand for O2 exceeds the coronary arteries ability to supply O2. Coronary sinus blood pH falls, lactate production ↑, EKG ▲s, ↓ cardiac performance → sx (CHF, dyspnea, angina)
What are the S/Sx of Angina?
Vague ache, Severe intense crushing sensation, Usually felt beneath sternum, May radiate to; L arm, fingers, jaw, back, throat & teeth, occ to R arm, Pain seldom occurs at the cardiac apex, Predictable, Relieved by rest or nitro.
What usually triggers angina sx?
Px activity, it lasts a few minutes & subsides w/rest, is worse when exertion follows a meal, or cold weather.
Angina PE;
During attacks; hrt rate ↑, BP ↑, hrt sounds become distant & apical pulse is more diffuse, 4th hrt sound is common.
If angina sx wake a pt from sleep it is called?
Nocturnal angina
A increase in the frequency of angina sx is called?
Cresendo angina
Angina sx occuring spontaneously at rest are called?
Angina decubitus
Angina sx are usually constant for a pt any ▲ in pattern should be?
Considered seriously.
It is a abnormal sign & should be aggressivly investigated & tx.
Angina in a pt w/a normal coronary anteriogram is called?
Syndrome X
Angina Clincal Dx;
CP brought on by exertion relieved by rest.
Reversible EKG ▲s (ST depression)
Sublingual nitro
What procedures should be ordered for Angina?
EKG, Exercise Stress EKG, Coronary angiography (dignificant @ 70% obstruction, Visualize wall movement) , Echo (Assess anatomy) , Radionuclited venticulography, Single photon emission CT.
What are some of the D/Dx for Angina?
GI (PUD, HH, gallbladder dz)
Chest wall Dz (Constrochondritis, seperation, pleurisy)
What is the prognosis of angina?
Unstable angina, MI, Sudden death syndrome, L main CA high risk, Poorer the ejection fraction , poorer the prognosis, Age.
What is the tx of Angina?
Reduce risk factors, Short acting Nitroglycerin, Long acting Nitrates, Beta blockers, Ca Blockers, Antiplatelets, Angioplasty, CABG.
What are important risk factors to reduce in a pt w/Angina?
Reduce LDL
Angina Tx with Short Acting Nitroglycerin;
Smooth muscle relaxer & vasodilator, Lowers SBP & dilates veins (peripherally), 1q 5min X3, usually onset in 1-2min (store away from light)
What is the most effective drug for acute attack of angina?
Short acting nitroglycerin
Angina Tx with Long acting Nitrates;
Oral & cutaneous preparations, Isosorbide dinitrate 10-20 mg qid, Isosorbide monoitrate longer action, Nitro ointment use during the day, remove @ night to avoid tolerance.
Angina Tx with Beta Blockers;
Block sympathetic stimulation, ↓ systolic pressure, hrt rake contractility & CO → ↓ O2 demand, ↑ threshold for Vfib, ↑ exercise tolerance.
Angina Tx with Ca Channel Blockers;
Vasodilators, tx angina, HTN, & coronary artery spasm, neg chronotropic & inotropic effects.
Angina Tx with Antiplatelets;
ASA (inhibits cycloosygenase & platelet aggregation 80-325 mg qd)
Plavix (clopidogrel)
Ticlide (ticlopidine)
Angina Tx with Angioplasty;
Dilate obstructed arteries, Stents.
Angina Tx with CABG;
<5% perioperative MI, <1% mortality, 85% of pts have complete or dramatic improvement of sx.
Define Unstable Angina;
Angina characterized by a progressive ↑ in anginal sx, new onstet of rest or nocturnal angina, or onset of prolonged angina.
What is unstable angina precipitated by?
An acute ↑ in coronary obstruction due to rupture of the fibrous plaque covering a atheroma w/platelet adhesion.
Unstable Angina S/Sx;
Pain is intense & lasts longer than stable angina, brought on by less exertion, occurs @ rest.
Unstable Angina Prognosis;
30% of pts have a MI in 3mos, Sudden death is less common, it is a medical emergancy.
What is the Tx for unstable angina?
IV Heparin, ASA (plavix or ticlid), Beta blockers (reduces work of hrt), Tx underlying problems (HTN, anemia), Bedrest, O2, Nitrates, Ca channel Blockers, (Thrombolytic drugs are not indicated), Balloon pump, Angioplasty or CABG.
What is Prinzmetals Angina?
(variant angina)
Angina that is 2ndary to lg vessel spasm & is characterized by discomfort @ rest & by ST elevation during attack.
Prinzmetals Angina Etiology;
Pts usually have obstruction in coronary artery, Spasm occurs w/in 1cm of obstruction.
Prinzmetals Angina EKG findings?
Ventricular arrhythmias, ST elevation during attack, EKG normal or stable abnormal patterns.
Prinzmetals Angina S/Sx?
Episodes occur regularly @ certain times of day, & @ rest.
Prinzmetals Angina Prognosis;
5yr survival rate is 89-97%
Prinzmetals Angina Tx;
Ca Channel Blockers
What is endocarditis?
Microbial infection of the endocardium.
What are the characteristics of endocarditis?
Fever, Hrt murmurs, Petchiae, Anemia, Embolic phenomea & endocardial vegetations.
What damage do endocardial vegetations cause?
Valvular obstruction or imcompetence, Myocardial abscess or mycotic aneurysm.
Epidemalogy of endocarditis?
♂ twice as often as ♀, Median age 50, R sided more common than L, (IV drug abuse, Central lines), 10-15% nosocomial associated w/cardiac surgery or other invasive procedures, 30% elderly (thickened stiff calcified valves)
What microbes are responsible for Acute Bacterial Endocarditis?
Usually Staph aureus, Sometimes; Group A hemolytic strep, Pneumococcus, Gonococcus, Less virulen organisms if immunocompromised.
What microbes are responsible for Sub-Acute Bacterial Endocarditis?
Usually Streptococcal species, Sometimes; Microaerophillic, Anaerobic streptococci, Non-entrococcal Group D, Enterococci.
Sub-acute endocarditis often develops on the valves after?
Asymptomatic bacteremias (gums, GU, GI)
What % of pts develop Prostethetic Valvular Endocarditis 1yr after valve replacement?
0.5% each year thereafter
(aortic more common than mitral & Porcine less common than other prostethetic valves)
What ae the organisms that cause early onset Prostethetic Valvular Endocarditis?
<2 mos, Very high mortality
S. epidermidis, diphthroids, coliform bacilli, candida species, aspergillus species.
What are the organisms that cause late onset Prostethetic Valvular Endocarditis?
Better prognosis
Streptocossus species; S. epidermidis (can be resistant in early infections, suspectible in late infections)
Diphtheroids, Gram neg Rods; Haemophillus species, actinobacillus, actinomycetemcomitans, cardiobacterum hominis.
Right sided endocarditis usually invoves which valve?
What are some causes of Right sided endocarditis?
IV drug abuse
Central line infections (facilitate the infection, damage the endocardium)
Organisms from the skin (S. aureus, candida species, colifom bacilli)
What are the S/Sx of Prostethetic Valve Endocarditis?
*R sided infections respond better to ABX than L sided infections* Septic phlebitis, Fever, Pleurisy, Hemoptysis, Septic pulmonary infarction, Tricuspid regurgitation.
What is the pathology of endocarditis?
Nidus, Sterili fibrin-platelet vegetation, Tissue factor is released by damaged epithelium, microorganisms colonize vegetation, covered by layer of fibrin & platelets (prevent access by neutrophils, immunoglobulin, permits pathogens to resist host defenses) W/out tx dz progresses & is fatal.
What is Nidus?
A nestlike structure, Focus of infection.
What is the progression of acute valve dysfunction in endocarditis?
Heart failure, excerbation of underlying heart dz.
What is the progression of embolization of vegetations in endocarditis?
Infarction, mycotic aneurysm, septic shock, renal failure.
What are the affected valves in order of frequency?
What are the predosposing factors of endocarditis?
*Abnormal structure attracts vegetation* Congenital defects, rheumatic valvular dz, mural thrombi, arterovenous fistulas, ventricular-septal defects, pt ductus-arteriosus, bicuspid or calcific aortic valves, mitral valve prolapse, idiopathic hypertrophic sub-aortic stenosis, prostetic valves.
What are the S/Sx of Subacute bacterial endocarditis?
Insidious onset, May mimic other systemic petchiael illnesses. Low grade fever, night sweats, fatigability, malaise, wt loss, valvular insufficiency (murmur), chills, arthralgias, emboli (CVA, MI, flank pain, hematuria, abd pain, acute arterial insufficiency in extremities)
Endocarditis PE;
Oslers nodes (painful erythematous nodules on distal digits), Splinter hemorrhages under nails, Hemorrhagic retinal lesions; Roth spots (round/oval lesions w/sm white centers). Prolonged infection (splenomegally clubbing fingers), Hematuria & Proteinuria (embolic infarction of the kidneys, diffuse glomerulonephritis, immune complex deposition)
What % of pts w/endocarditis exhibit CNS involvement & what are the S/Sx?
35%, TIA, Toxic encephalopathy (brain abscess), Subarachnoid hemmorrhage (ruptured mycotic aneurysm), Purulent meningitis in ABE
What are the S/Sx of Acute Bacterial Endocarditis?
Similar to those of SBE, course is more rapid, high fever, toxic appearance, rapid valvular destruction, valve ring abscesses, septic emboli, obvious source of infection, septic shock.
What are the S/Sx of Prostetic Valve Endocarditis?
S/Sx of SBE & ABE, valve ring abscesses, obstructing vegetations, myocardial abscesses, mycotic aneurysms (valve obstruction, dehiscence, cardiac conduction disturbances).
What is dehiscence?
A bursting open, as of a graafian follicle or a wound, esp. a surgical abdominal wound.
What are the conditions of pts that are at high risk for endocarditis?
Hx of cardiac valvular hrt dz, hx of cardiac valve replacement, recent invasive medical procedure (TURP), dental work, illicit drug use.
What is the most constant finding of pts w/endocarditis?
Fever & heart murmur (15% of pts may not initally have fever or murmur)
What tests should be ran w/anyone w/suspected septicemia, fever & murmur?
Blood cultures; 3-5 samples over 24hrs, 20-30ml q sample, 2 sets drawn 20mins apart (can take 24hrs-5days for most common organisms, can require 3-4wks of incubation for certain organisms)
If endocarditis is suspected what could negative blood cultures indicate?
Suppression; poor antimicrobial therapy, organisms that do not grow in routine lab culture media, a D/Dx (nonbacterial thrombotic endocarditis, atrial myxoma, vasculitis)
What other lab work could be ran for a pt w/suspected endocarditis?
Normocytic, normochromic anemia, Elevated ESR, Neutrophila, ↑Immunoglobulins, Circulating immune compleses, Rheumatoid factor.
What will echographic studies find if a pt has endocarditis?
Vegetations in 60-80%
What is the prognosis of untx endocarditis?
Always fatal
What is the mortality of treated endocarditis based on?
Pts age, Pts condition, Severity of underlying dz, Site of infection (R sided responds better than L), Susceptibility of microorganisms to ABX, Complications.
What is the expected mortality of Endocarditis w/the viridians streptococcus?
W/out major complictions, <10%
What is the expected mortality of Endocarditis w/the viridians aspergillus?
100% after bioprosthetic valve surgery.
Poor prognosis of endocarditis is associated with?
Hrt failure, Extreme age, Aortic or multiple valve involvemtnt, lg vegetations, polymicrobial bacteremia, antimicrobial resistance, delay in initiating therapy, prosthetic valve infections, mycotic aneurysms, valve ring abscess, major embolic events.
In what pts is antimicrobial prophylaxis (for endocarditis) recommended in?
Pts w/walvular hrt dz or other predisposition to infective endocarditis.
What (endocarditis) prophylaxis is recomended for pts having dental procedures?
Viridians sp; Amoxicillin 2gm.
PCN allergic; Clindamycin, Cephalexin, Azithromycin.
What (endocarditis) prophylaxis is recomended for pts w/GI & GU infections?
Enterococcus sp; Ampicillin 2gm & Gentamicin 1.5mg/kg .5hr before surgery.
2 additional doses of Amp or Amox q 8hr.
What (endocarditis) prophylaxis is recomended for pts having Cardiac valvular surgery?
S. aureus, S. epidermidis;
Ancef 1gm @ induction,
Gentamicin if in hospital 48 prior to surg,
Continue until chest tubes are removed.
What does successful tx of endocarditis require?
Maintence of high serum levels of an effective antibiotic (for 4-6wks), Surgical management of mechanical complications & resistant organisms.
What pathogens of endocarditis is PCN used to tx?
Streptococci including the viridans, Microaerophilic & anaerrobic strepococci, Nonenterococcal group D strep.
How should PCN be administered for endocarditis?
PCN G 12-18MU/day, IV contiuously or q 8hrs x 4wks.
Add gentamicin 1mg/kg (up to 80mg)q 8hrs will ↓tx to 2wks. PCN allergic; Ceftriaxone, Vancomycin.
What is the tx of endocarditis w/PCN resistant strains or low susceptibility?
PCN or Vancomycin w/aminoglycoside, 40% enterococcal strain resistance of streptomycin-use gentamicin unless documented resistance.
What is the tx for neumococcal or group A streptococcal infective endocarditis?
Pen G 10-20MU/day IV x 4wks, S. aureus produce B-lactamse-tx w/penicillinase resistant PCN (oxacillin or nafcillin 2gm IV q8hrs for 4-6wks), if resistant, tx w/vancomycin.
What is the tx for S. epidermidis infective endocarditis w/prosthetic valves?
Treat like S. aureus, Oxacillin or nafcillin & rifapin 300mg q 8hrs, & gentamicin 6-8wks, or use Vanco insted of oxacillin or nafcillin if resistant.
What is the surgical tx for endocarditis?
Fix the valve, debride or replace the valve to eliminate infection, especially in early PVE, ABX before surgery.
What is the course of endocarditis after initian of tx?
Feel better in 3-7days, Staph infection responds more slowly, risk valve rupture up to 1yr p successful therapy, relapse possible w/in 4wks, Re-occurence of sx 6wks p successful tx in pt w/out prostetic valves is considered new infection (not relapse)
What is non-infectious endocarditis?
Formation of sterile platelet & fibrin thrombi on cardiac valves & adjacent endocardium in response to trauma, local turbulence, circulating immune compleses, vasculitis hypercoaguable states.
What is the etiology of non-infectious endocarditis?
Bicuspid valves, Catheters bassing through valves may injure them (platelets & frbrin form @ the site of injury).
What should always be suspected when chronically ill pts develop sx suggestive of arterial embolism?
Non-infectious endocarditis
What is found @ autopsy of 40% of pts w/SLE?
Lesions on one or more valves.
What is the tx of non-infectious endocarditis?
Anticoagultaion, Elimination of predisposing factors.
What is the prognosis of pts w/non-infectious endocarditis?
Poor given the underlying seriousness of the predisposing conditions.
What is the surgical tx of non-infectious endocarditis?
Excision of abnormal bodies, Correction of valve insufficiencies.
What is pericarditis?
Inflammation of the pericardium which may be acute or chronic & may result in pericardial effusion.
What bacterial pathogens can cause pericarditis?
Staph sp,
Strep sp,
What viruses can cause pericarditis?
What dz are suspectible to pericarditis?
Neoplasms, Connective tissue disorders (RA, SLE, Scleroderma), Metabolic disorders (Uremia, kidney failure)
What is Dressler's syndrome?
Pericarditis secondary to MI.
What is chronic idiopathic constrictive pericarditis?
It follows a dz that causes acute pericarditis; RA, Ca, radiation.
What cardiac traumas are common causes of pericarditis?
Cardiac surgery, postpericardiotomy (CABG), Catheters that penetrate the pericardium (angiography, TPN)
What are the causes of chronic effusive pericarditis?
Idiopathic, fungi, Ca, TB
What is Idiopathic?
Pertaining to illnesses whose cause is either uncertain or as yet undetermined.
What is the etiology of fungal pericarditis?
Accomapanies some systemic dzs; RA, SLE, Scleroderma, Uremia, (compromised immune system)
What is the etiology of Metastatic neoplasm pericarditis?
Lg pericardia effusion, AIDS; TB, Fungi, Viral (Kaposi's sarcoma)
What is the etiology of pyogenic pericarditis?
Uncommon, infective endocarditis, pneumonia, septicemia, penetrating trauma
What may cause subacute chronic pericarditis?
HIV pts; TB bacilli & fungi
What are the types of chronic pericarditis?
Serous, Chylous, Fibrous, Adhesive, Hemorrhagic (effusive), Purulent, Calcific.
What is the pathophysiology of Fibrous chronic pericarditis?
(remodeling) Follow infection or trauma, Accompany connective tissue dz, patchy, extensive, calcific deposits, Constriction +/- hemodynamic effects (elevation of systemic venous & hepatic venous pressure, leading to cardiac cirrhosis.
What is the pathophysiology of Effusive chronic pericarditis?
Compression may limit L ventricular filling during diastole (LVEDP, preload), Gradual effusions (pericardium may stretch to accommodate, no sx), ↑congestion (dependent edema & ascites) R sided hrt failure.
What EKG ▲s may be seen w/chronic pericarditis?
Low QRS voltages, Nonspecific T wave ▲s, 25% A-fib/flutter if constrictive.
What may be seen on a CXR of a pt w/chronic pericarditis?
Calcified pericardium on Lateral CXR.
What to you look for on a CT if you suspect chronic pericarditis?
>5mm thickening
What may be heard on PE of a pt w/chronic pericarditis?
Pericardial knock (early diastolic sound, best heard on inspiration), Pulses Paradoxus.
What are the DDx for chronic Pericarditis?
AMI, Restrictive cardiomyopathy, Valvular dz, Cirrhosis of liver.
What is the tx for chronic pericarditis?
Tx of underlying cause, Bed rest, Salt restriction, Diuretic (↓preload so hrt dosen't have to work as hard), Digoxin prn (arrhythmias, vent systolic dysfunction), pericardial resection, Ca-Sclerosis drugs (help stop fluid production)
In what % of pts does acute pericarditis that is associated w/MI occur?
Early 10-15%, Late (usually occurs w/in 10days-2mos, Dressler's syndrome 10-3%)
In what % of pts does acute pericarditis that is associated w/cardiac surgery occur?
Postpericardiotomy syndrome occurs in 10-15% of pts.
What are the Sx of acute pericarditis?
CP (dull, sharp, precordial, substernal, radiating to neck or shoulders, mild to severe), Dyspnea, Fever.
What are the S/sx of cardiac tamponade?
Rising ventricular diastolic pressure, rising atrial, pulmonary, & venous pressure, falling stroke volume & cardiac put (declining pulse pressure, cardiogenic shock), Dyspnea, Orthopnea, Pulsus patadoxus.
What EKG ▲s are commonly found in acute pericarditis?
ST elevation in most leads, ST segments w/out reciprocal ▲s (vx AMI), No Q waves, T waves flatten & invert, Except AVr, Occurs p normalization of ST segments, w/effusion QRS voltage typically ↓
Describe the sxs of pain w/acute pericarditis?
Sharp or dull, precordial or substernal, aggravated by thoracic motion relieved by sitting up & leaning forward.
What are other sx of acute pericarditis?
Tachypnea, Nonproductive cough, Fever, rigors, Pleural effusion.
What are the D/Dx of acute pericarditis?
Pleuritic pain, AMI, Pulmonary infarction.
What is the tx of acute pericarditis?
Treat underlying problem, treat any bacterial or mycotic infections, tx sxs w/ASA, NSAIDS, Short course steroids, Analgesics, Avoid anticoagulants (could cause hemopericardium)
What is the tx for pericardial effusion?
Pericardialcentesis, Subxiphoid approach, monitor to know if hrt is touched.
What are the risks of pericardialcentesis?
Coronary artery laceration, AMI, Tamponade, Death, (should be preformed by cardiologist)
What is Rheumatic Fever?
Nonsuppurative acute inflammatory complication of Group A strep infections characterized mainly by arthritis, chorea, or carditis appearing alone or in combination w/residual hrt dz as a possibel sequela of the carditis.
What is the etiology of Rheumatic Fever?
Group A strep infection (lowincome, malnutrition, overcrowed living conditions), incidence 0.1-3% in untx pts w/mild or asymptomatic infections, incidence 50% of those untx w/hx of RF & strep pharyngitis.
What is the cardiac involvement of Rheumatic Fever?
Interstitial valvulitis, valvular edema, thickening & fusion & destruction of leaflets, fused or thickened chordae tendineae, regurgitation & stenosis.
What are the 5 major manifestations of Rheumatic Fever?
Migratory polyarthritis, Chorea, Carditis, Subcutaneous nodules, Erythema marginatum.
Rheumatic Fever What is the Jones criteria?
(manifestations) Evidence of recent group A strep infection (scarlet fever, +throat culture or ↑antistreptolysin O), Fever, Athralgia, Prior hx of RF, ↑ESR or CRP, ↑WBC, Prolonged PR.
What is the tx of mild carditis in Rheumatic Fever?
ASA or NSAID, Corticosteroid therapy.
What is the tx of severe carditis in Rheumatic Fever?
Steroids PO(0.5-2mg/kg/qd) or IV & ASA, PCN, Diuresis (↓ preload), Afterload ↓(vasodialate vessels on L side) ACE inhibitors, Beta Blockers, Surgery (valve repair or replacement)
What are the major components to systolic heart function?
HR, Contractile state of the myocardium, Preload (what is dumping into the heart), After load (the pressure against the L ventricle)
Systolic failure can be caused by?
Loss of contractility (MI), Excessive preload (valve imcompetence), Excessive afterload (HTN, valve stenosis)
Dystolic failure can be caused by?
Impaired filling due to non-complaint ventricle.
What is the classic sign of CHF?
Dyspnea on exertion
What makes the 1st heart sound, & where is it heard the loudest?
Closing of the mitral & tricuspid valves, @ the apex.
During what part of the cardiac cycle is the 1st heart sound heard?
What makes the 2nd heart sound, & where is it heard the loudest?
Closing of the aortic & pulmonic valves, @ the base.
During what part of the cardiac cycle is the 2nd heart sound heard?
End of ventricular systole beginning of diastole.
What type of splitting indicates dz, & what dzs does splitting of S2 indicate?
Fixed, ASD, Pulmonic stenosis/insufficiency, RBBB, Severe mitral insufficiency, Pulmonary HTN, VSD.
What does S3 sound like & what could be the cause?
Ken-tucky, low pitched, Pathologic, Rapid phase of ventricular filling, Caused by resistance to ventricular filling.
How is a S3 best heard?
@ apex, in L lateral decubitus.
What does S4 sound like & what could be the cause?
Ten-nes-see,(4,1 2), Stiff walls, MI, Pulmonary HTN, Heart failure, Hyperthyroidism (can occur on L or R side)
What can cause systolic & Diastolic murmurs?
Aortic stenosis, Pulmonary stenosis, Mitral regurgitation, Tricuspid regurgitation.
What are the grades for intensity of murmurs?
1.Just audible, 2.Quiet but readily audible, 3.Easily heard, 4.Loud, obvious w/thrill, 5.Very loud, heard over the pericardium & elsewhere in the body, 6.Heard w/out stethoscope.
What is aortic stenosis?
Narrowing of aortic outflow tract @ aortic valve, supravalvular or subvalvular levels causing obstruction from flow from LV to aorta (pressure gradient across obstruction >10mmHg)
What is the etiology of aortic stenosis?
Congenital or due to idiopathic calcification of abnormal or normal L vent valves.
What is the epidemology of aortic stenosis?
25% of pts >65yrs,
35% of pts >75yrs,
What are the S/sx of aortic stenosis?
Dyspnea on exertion, Syncope (can't ↑CO, arrhythmias, ↓cerebral perfusion), Angina (inadequate coronary artery supply d/t hypertrophy not necessarily CAD)
What is the condition of the valves of a pt w/aortic stenosis?
Narrowed, Thickened or Rough valve, Dilated aorta.
What would be found on PE of a pt w/aortic stenosis?
Systolic ejection murmur @ aortic area radiating to neck & apex (2nd ICS R of the sternum), Severe cases palpable LV heave or thrill), Weak aortic 2nd sound.
What would be found on a EKG of a pt w/aortic stenosis?
What would be found on a CXR of a pt w/aortic stenosis?
Normal or enlarged heart, Calcification of aorta.
What would be found on a Echo of a pt w/aortic stenosis?
Best for dx, Aortic valve calcification, LV thickness & function. Doppler to estimate aortic valve gradient.
What is the definitive procedure to dx aortic stenosis?
Cardiac Cath
What is the prognosis of a pt w/aortic stenosis?
Poor w/out replacement if pt has heart failure
What is the tx for aortic stenosis?
Surgery is not indicated for asymptomatic pts, coumadin for pts w/mechanical valves (mechanical valves have life time of 7-10yrs)
What is the Ross procedure?
Swith pulmonary valve to aortic position & bio-prosthesis in pulmonary position (extends the life of the bio-prosthetic valve)
What is Aortic regurgitation?
Imperfect closure of the aortic semilunar valve, Causes blood that has been ejected into the aorta to fall back into the left ventricle, It may produce volume overload of the ventricle and congestive heart failure.
What are some dzs associated w/Aortic regurgitation?
Marfan's syn, Ehler-Danlos (connective tissue disorder), Lupus, Rheumatic endocarditis.
What is found on PE of a pt w/Aortic regurgitation?
Blowing high pitched, descrescendo murmur along L sternal edge toward apex, heard best @ 4th ICS L of sternum, helps if pt leans forward in full expiration.
What are the S/Sx of Aortic regurgitation?
Diastolic murmur, Diastolic BP falls, LVH progresses, LV failure, Exertional dyspnea & fatigue most frequent sx, angina or atypical CP.
What is a water-hammer pulse?
A pulse with a powerful upstroke and then sudden disappearance; a hallmark of aortic regurgitation.
What is a Quincke's pulse?
Px finding in pts w/aortic regurgitation, visible capillary pulsation of nail beds when fingertip is pressed.
What is a Hill's sign?
(aortic regurg)Popliteal BP is higher than brachial BP by about 40mmHg, due to ↑ stroke may summate w/reflected wave from periphery.
What can be found on the CXR of a pt w/aortic regurgitation?
LV enlargement, calcified aortic valve, pulmonary vascular re-distribution, PE.
What can be found on the EKG of a pt w/aortic regurgitation?
LA & LV hypertrophy, Sinus tachycardia.
Why would an echo be ordered for a pt w/Aortic regurgitation?
To quantify severity of regurgitation & evaluate hyperdynamic walls.
Why would an CT be ordered for a pt w/Aortic regurgitation?
To estimate aortic root size.
Why would an heart cath be ordered for a pt w/Aortic regurgitation?
For quanifiction of insufficiency & hemodynamics.
What is the tx for Aortic regurgitation?
Vasodilators (CCB & ACE inhibitors), Surgery to replace valve.
What do Calcium channel blockers do?
Lower the HR & decrease O2 demand.
What do ACE inhibitors do?
Decrease peripheral vascular resistance & decrease Na/H2O retention.
What is mitral stenosis?
Narrowing of the mitral valve orifice with obstruction of blood flow, may predispose pts to infective endocarditis; to L atrial enlargement & atrial arrhythmias; or to L vent failure.
If a mitral valve is stenoic what happens to the Left atria?
LA pressure ↑to compensate for the difficulty pushin blood past the stiff valve into the LV & the LA hypertrophies & A-fib develops.
What is the common arrhythmia whenever the atrium is abnormal?
What can be found on PE of a pt w/mitral stenosis?
Diastolic murmur, Low pitched paical early to mid diastolic murmur, Thin, ruddy face, RV lift (pulmonary HTN), Thrill present over apical area, mid-diastolic murmur low in pitch.
What is the etiology of mitral stenosis?
Rheumatic hrt dz, Congenital mitral stenosis, Tumors of the LA, Calcification of the mitral annulus.(hx of repeated respitory tract infections)
What is the annulus?
A ring-shaped structure; a ring
What are the Sx of mitral stenosis?
Gradual ↓in px activity, Dyspnea on exertion, Progressive fatigue, Cough, hemoptysis, Orthopnea, Dysphaga (due to enlarged atrium).
What is Dysphaga?
Inability to swallow or difficulty in swallowing.
What age group is mitral stenosis a common finding in?
Female, early 30's
What could be found on a CXR of a pt w/mital stenosis?
LA & RV hypertrophy, Calcification of mitral valve, interstitial edema (due to high PCWP)
What could be found on a heart cath of a pt w/mital stenosis?
Calcification, Elevated LA pressures, Elevated RV & RA pressure when RV failure present, Elevated pulmonary artery pressure (PCWP)
What could be found on a echo of a pt w/mital stenosis?
Thick anterior & posterior mitral valve leaflets, Abn movement of leaflets, Enlarged LA & RV. (possibly thrombis)
What could be found on a EKG of a pt w/mital stenosis?
RVH, A-fib, LA enlargement.
What is the tx for mitral stenosis?
Coumadin, Convert to SR, Balloon valvuloplasty, replacement of valve, bioprosthetic valve (last 10-12yrs), More risk of thrombosis w/mechanical valves.
What is mitral regurgitation?
Regurgitation of blood from the LV to the LA during ventricular systole due to an impompetent mitral valve.
What is the etiology of mitral regurgitation?
Trauma, Rheumatic dz, Eondocarditis, Papillary muscle dysfunction, Congenital malformations, Calcification.
What is the pathophysiology of mitral regurgitation?
Matral valve fails to close properly during vent systole; patillary muscles are displaced (cardiomyopathy), Chordae are too long, Leaflets are too baggy (mitral valve prolapse), annulus does not contract (calcification or cardiomyopathy).
What is the physiology of Acute mitral regurgitation?
LA pressure ↑due to excess fluid in LV→L sided hrt failure, fluid backs up & pt demonstrates pulmonary edema, LV end diastolic pressure rises, LV dilates & fails, CO↓
What is the physiology of Chronic mitral regurgitation?
LA compliant & dilates, slow ↑in LA pressure, LV compensates w/LV dilation & eventually hypertrophy occurs, Pulmonary venous pressure becomes elevated, pulmonary HTN & ↑in Pulm Cap Wedge Pressure, A-fib, R sided hrt failure may occur.
What are the S/sx of mitral regurgitation?
Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, Weakness, Fatigue, Palpitations, Sx of RV, Anxiety, Diaphorsis, Cyanosis, Confusions, Arrhythmias.
What could be found on a PE of a pt w/mitral regurgitation?
High pitched blowing holosystolic murmur heard best @ apex w/radiation to the axilla, S2 is widely split, S3 may hear an S4.
What is assessed on a echo of a pt w/mitral regurgitation?
Qualitative & quantitative estimates of severity, Assess LA & LV enlargement, Propapse of mitral valve, mitral annular calcifiction, flail leaflet, vegetations.
What could be found on a CXR of a pt w/mitral regurgitation?
LA & LV enlargement, Calcification of mitral annulus.
What could be found on a EKG of a pt w/mitral regurgitation?
LA & LV enlargement, Dysrhythmias (A-fib)
What could be found on a heart cath of a pt w/mitral regurgitation?
↑LVEDP & LAP, ↑PAP, CAD (calculate regurgitation fraction)
What is the tx of mitral regurgitation?
Treat endocarditis, MI, ruptured chordae tendineae ASAP, Stablize w/vasodilators or intra-aortic balloon counterpulsation, Sugery if pt is sympatomatic, Beta blockers, ACE inhibitors to reduce afterload.
What is the action of beta blockers?
↓Contractility, ↓HR, ↓BP (↓renin), ↓Cardiac output & ↓Myocardial O2 demand.
What is the action of ACE inhibitors?
↓Peripheral vascular resistance, ↓Na/H2O retention.
What is tricuspid stenosis?
Narrowing of the opening to the tricuspid valve.
What is the epidemology of tricuspid stenosis?
Females > males, Hx of rheumatic hrt dz (rare in US)
What is the etiology of tricuspid stenosis?
May be due to tricuspid valve repair or replacement,
What can be found on PE of a pt w/tricuspid stenosis?
↑JVP w/prominent A wave, Hepatomegaly, ascites & dependent edema (fulid backs up), Diastolic rumble along the lower L sternal border mimics mitral stenosis, Rumble ↑ on inspiration (Suspect in R hrt failure w/pts w/mitral valve dz w/out pulmonary HTN.
What can be found on a EKG of a pt w/tricuspid stenosis?
RA enlargement
What can be found on a CXR of a pt w/tricuspid stenosis?
Cardiomegaly w/normal pulmonary artery size, Dilated superior vena cava.
What can be found Hemodynamically on a pt w/tricuspid stenosis?
Mean diastolic pressure gradient of >5mmHG is significant.
What can be found on a hrt cath of a pt w/tricuspid stenosis?
Mean diastolic pressure gradient of >5mmHG, Prominent A waves.
What is the tx of tricuspid stenosis?
↓fluid congestion w/diuretics (lasix), Aldactone for ascites, Valve replacement.
What is the action of Aldactone?
Na/K exchange in distal tubule (keeps K lets Na go)
What is tricuspid regurgitation?
A backflow of blood from the right ventricle into the right atrium.
What does diseases does tricuspid regurgitation frequently occur with?
Pulmonary or cardiac dz.
What could be found on PE of a pt w/tricuspid regurgitation?
Systolic c-v wave w/JVP or Normal JVP wave patterns ▲, obliterating the x descent due to ↑fluid, Holosystolic murmur along L sternal boarder which ↑ w/inspiration, murmur L peristernal location which ↑ w/inspiration, S3, Cyanosis
What is the pysiology of tricuspid regurgitation?
Chordae attach of RV rather than to papillary muscles→incompetence occurs to RV dilation, or dysfunction occurs due to anatomic issues w/the valve itself or the RV shape & size.
What could be found on a EKG of a pt w/tricuspid regurgitation?
Nonspecific ▲s, A-fib.
What could be found on a CXR of a pt w/tricuspid regurgitation?
Enlarged RA
When an echo is ordered for a pt w/tricuspid regurgitation what are they ascessing for?
Severity of tricuspid regurg, pulmonary artery pressure, & RV size & function.
What could be found on a heart cath of a pt w/tricuspid regurgitation?
Elevated RA pressures, confirms regurgitant.
What is the tx for tricuspid regurgitation?
Minor regurg is well tolerated, more severe; tx hepatomegaly, edema, ascites, Lasix (PO or IV), Aldosterone atagonist & thiazide diruetics.
What is a aldosterone antagonist?
Spironolactone; direct atagonist of aldosterone preventing Na retention. Na/K exchange in distal tubule (keeps K lets Na go)
What is pulmonic regurgitation?
A backflow of blood from the pulmonary artery into the right ventricle.
What causes most cases of high pressure pulmonic regurgitation?
Pulmonary HTN
What could be found on PE of a pt w/pulmonic regurgitation?
Loud diastolic (Graham-Steel) murmur (high pressure regurg), Soft or no murmur (low pressure regurg), hyperdynamic RV palpated, PA may be palpated, Pulmonary HTN, 2nd heart sound widely split, systolic clicks, R sided gallop, murmur ↑w/inspiration & ↓w/Valsava maneuver.
What causes most cases of low pressure pulmonic regurgitation?
Dilated pulmonary annulus (idiopathic or traumatic) or to plaque from carcinoid dz.
What is carcinoid syndrome?
Group of sxs produced by carcinoid tumors that secrete excessive amts of serotonin, bradykinin, & other powerful vasoactive chemicals.
What could be found on a CXR of a pt w/pulmonic regurgitation?
Enlarged RV & pulmonary artery
What would be assessed on a echo of a pt w/pulmonic regurgitation?
RV volume overload (paradoxic septal motion), Peak systolic RV pressure, Reveal associated regurgiation.
What would be assessed on a MRI or CT of a pt w/pulmonic regurgitation?
Size of PA, Exclude other causes, & for evaluating RV function.
What is the tx for pulmonic regurgitation?
Treat primary cause, Low pressure regurg due to surgical patch repair, or carcinoid dz; valve replacement. High pressure dz control the cause of pulmonary HTN
What is pulmonic stenosis?
Narrowing of the opening into the pulmonary artery from the right cardiac ventricle.
What is the physiology of pulmonic stenosis?
↑resistance to RV outflow (stenosis of valve or RV infundivulum) Raises RV pressure & limits pulmonary blood flow, Associated w/other cardiac lesions, Domed valve or dysplastic valve.
What is a infundibulum?
Conelike upper anterior angle of the right cardiac ventricle from which the pulmonary artery arises.
What could be found on a PE of a pt w/pulmonic stenosis?
Palpavle parasternal lift due to R vent hypertrophy, Loud harsh systolic murmur & occasionally prominent thrill, murmur radiates toward L shoulder ↑w/inspiration, loud ejection click.
Are the sx of a pt w/pulmonic stenosis?
Most cases are asymptomatic, w/moderate to severe stenosis; dyspnea on exertion, syncope, CO & eventually RV failure.
What could be found on a EKG of a pt w/pulmonic stenosis?
R axis deviation, RV hypertrophy, peaked P waves.
What could be found on a CXR of a pt w/pulmonic stenosis?
Abnormal heart size, Chen's sign (greater vascular perfusion of L than R base)
What could be found on a echo of a pt w/pulmonic stenosis?
Doming valve v/s dysplastic valve, Determine gradient across the valve, Subvalvular obstruction.
What is the tx for symptomatic pulmonic stenosis?
(RV hypertrophy gradients >50mmHg percutaneous balloon valvuloplasty (domed valve), Commissurotomy, Valve replacement.
What is the prognosis for mild pulmonic stenosis?
Normal life span
What is the prognosis for moderate to severe pulmonic stenosis?
Sudden death, R heart failure.
What is commissurotomy?
Surgical incision of any commissure; used in treating mitral stenosis to ↑the size of the mitral orifice, This is done by incising the adhesions that cause the leaves of the valve to stick together.
What are the S/Sx for LV failure?
Exertional dyspnea, Cough, Fatigue, Orthopnea, Paroxysmal noctural dyspnea, Cardiac enlargement, Rales, Gallop rhythm, Pulmonary venous congestions.
What are the S/Sx for RV failure?
Elevated venous pressure, hepatomegaly, dependent edema; usually due to LV failure.
What is the most common cause of R vent failure?
L vent failure
What are the causes of disstolic dysfunction?
LVH from HTN, Pericardial dz, DM, Hypertrophic or restrictive cardiomyopathy.
What are some causes of CHF?
MI (most common cause in developed countries),HTN, Alcoholic cardiomyopathy, Viral myocarditis, Idiopathic dilated cardiomyopathies, Infiltrative dzs or other infectious agents, Metabolic disorders, Cardiotoxins, Drug toxicity, Valvular hrt dz.
HTN as a cause of CHF;
Important cause & exacerbating factor, Control may reduce new onset failure by 40-60%
Aortic stenosis as a cause of CHF;
Common cause, early tx important.
What is cardiomyopathy?
Structural or functional abnormality of the ventricular myocardium
What is dilated congestive cardiomyopathy?
Disorders of myocardial function w/heart failure in which ventricular dilation & systolic dysfunction predominate.
What is the most common cause of dilated congestive cardiomyopathy?
Coronary artery dz w/ischemic myopathy. May be 2ndary to viruses.
In congestive cardiomyopathy, what changes does the change in cardiac structure cause?
Loss of competency of valves→mitral or tricuspid regurg→atrial dilation→impaired ventricular systolic function.
What could be found on the EKG of a pt w/dilated congestive cardiomyopathy?
Sinus brady, Low-voltage QRS, nonspecific SY segment depression w/low-voltage or inverted T waves, Pathologic Q waves may be present in the precordial leads, LBBB is common.
What could be found on the CXR of a pt w/dilated congestive cardiomyopathy?
Enlarged cardiac silhouette
What could be found on the echo of a pt w/dilated congestive cardiomyopathy?
Hypokinetic heart walls, Valvular abnormalities, Abn wall motion, Dilated ventricle, Mural thrombus.
What is the prognosis of a pt w/dilated congestive cardiomyopathy?
Poor, 70% mortality in <5yrs, (sudden indicating arrhythmia) Men > women, Blacks > whites.