Cardiology: Chf, Chronic Valvular Disease, Syncope

Front 1

CHF: Definition, Causes, Factors causing decompansation.

Back 1

Is the inability of the heart to produce a cardiac output sufficient for the metabolic needs of organs. Can be defined as systollic or diastollic heart failure. Systolic is LVEF <50%, and diastolic is defined as >50%LVEF. Causes are vast, important to discren between ischemic vs non ischemic. HTN, drug, myocarditiis, high output (anemia, hyperthyroidism, pregnancy, stress, infection). Factors that complicate CHF include ischemia, arrythmia, CV stress (infection, anemia, pregnancy), PE, medical noncompliance, dietary.

Front 2

CHF: Diagnosis (HandP,)

Back 2

Hx: Decrease exercise tolerance, orthopnea, PND, SOB, weight gain, edema, RUQ tenderness. Low output fatigue, malaise, decreased appeptite. Physical includes right sided (elevated JVP, hepatojugular reflux, ascities, peripheral edema, enlarged liver). Left sided rales tachypena, S3.

Front 3

CHF: Diagnosis (Labs)

Back 3

Chem 7, CBC< TSH, FT4, FT3, LFT, Lipid panel, Urinalysis, trop, CIP. BNP (<100 effectively ruled out)

12 lead EKG, CXR. Echo.

Front 4

CHF: Indications for Swanz Ganz in CHF

Back 4

Hypoperfusion with narrow pulse pressure, AMS, declining function despite normal volume status. Congestion with angina, baseline renal insufficency. Persistant congestion despite salt and fluid restriction.

Front 5

CHF: Goals of Swanz-Ganz

Back 5

RA<7mmHg, PCWP <15mmHg, SVR <1200 and SBP >80mg.

If elevated filling pressures (PCWP >20 or RA >10) diurese with lasix until PCWP is low as possible with SBP above 80. If SVR elevated above 1300 bein afterload reduction with nitroprusside 20mcg/min.
Low Cardiac Index <1.2 condiser dobutamine, or dopamine first then dobutamine. DC once optimal for 4-8 hrs

Front 6

Back 6

Front 7

CHF: Managment Sub acute

Back 7

-Ace Inibitor: Captopril 50mg PO TID, Enalapril 10mg PO BID, Benazepril 40mg PO QD, Lisinopril 40mg PO Dialy. If BP remains to high ad Hydralizine up 100mg PO QIDc
-Beta blocker: Carvediol 3.125mg PO BID titrate up to target PO BID. Toprol XL 12.5 daily.
-Spirnolactone (Class III-IV or ischemic): 12.5mg goal 25mg PO QD. Adjust K and loop diuretic, check chem panel in 7days. (CI Male Cr > 2.5, female >2

Front 8

CHF: Managment of Volume Excess

Back 8

Lasik (can add metolazone). Morphine, Nitrates, Oxygen, Position (head up)

Front 9

CHF: Early Pacemaker Complications

Back 9

Pneumothorax (CXR)
Hematoma formation (especially if on anticoagulation)
Lead perforation of RA or RV
Lead dislodgment

Front 10

Chronic Valve: Aortic Stenosis

Back 10

Symptoms: Asymptomatic. Symptomatic poor prognosis Angina 5 years, Syncope 3 years, Heart Failure 3 years. Treated based on symptoms
Signs: Murmur at right upper sternal border, Paradoxical splitting of S2, narrow pulse pressure, pulses et tardus.
Imaging: Normal Valve area 3-4cm, Mild 1.5cm <25mmHg, Moderate 25-50mmHg 1.0-1.5cm, Severe >50mmHg <1.0, Critical 80mmHg <0.7cm

Front 11

Chronic Valve: Aortic Regurgitation Symptoms and SIgns

Back 11

Signs; Diastolic blowing murmur in the LUSB, wide pulse pressure, water hammer, Quincke's sign (capillary pulsations at fingertips, De Musset's sign (bobbing head), Muller's sign (pulsing uvula).

Front 12

Chronic Valve: Aoritic Regurgitation Surgery Indications

Back 12

NYHA functional class III or IV. Severe LV dilatation >75mm end diastolic or >55mm end systolic. LV dysfunction <50%. Concomitant angina or severe AR. Progressive LV dilatation, declining LVEF or exercise tolerance.

Front 13

Chronic Valve: Mitral Stenosis

Back 13

Low rumbling diastolic murmur heard best at apex. Opening snap may be heard.
On echo severity Mild < 5mmHg >1.5cm2, Moderat 5-10mmHg, 1-1.5cm2, Severe >10mmHg <1cm2.
Indication for surgery include NYHA Class III-IV symptoms, moderate or severe mitral stenosis.

Front 14

Chronic Valve: Mitral Regurgitaion

Back 14

Clinical Signs: Loud holosystolic high pitched heard best at apex and transmitted to axillia, soft S1.
Surgical indication: NYHA Class III or IV, LV end systolic dimension >45mm, LV end systolic volume index >50ml/M2, LVEF <60% and progressing.

Front 15

Back 15

Front 16

Syncope: Vasovagal Mechanisms

Back 16

Stimulation of vasodepressor region of the brain stem results in overactivation of parasympathetic leading to bradycardia and vasodiltation. Occurs via gastrointestinal and genitourinary mechanoreceptors, cerbral (panic, fright, pain, noxius stimuli), Cardiopulmonary barorecptor (carotid sinus, tussive) Cardiac C fibers (valsalva, upright tilt, jacuzzi, weight lifting, trumpet, post exercise, volume depletion, SVT).
Diagnosed by tilt table.
Treated by : Beta blocker (stops initial sympathetic tone increase)

Front 17

Syncope: Risk Stratification High Risk

Back 17

Anyone with Brady <40, Pauses >3 sec, Trifaciular block, Afib/flutter, NSVT, EKG ST abnorm or long QT, Dysfunctional pacer, Sx/signs of CHF, Ischemic chest pain, severe valvular disease, GI blood loss.

To CCU

Front 18

Syncope: Risk Stratification Moderate

Back 18

Age >60, Hx CAD, CHF, Old LBBB, Family Hx Sudden death, Pacer/defib functioning, Persistent BP<100, Symptoms no consistent with vaso-vagal event.

Front 19

Syncope: Risk stratification Low Risk

Back 19

Age <50. No cardiac History. Symptoms consistent with vasovagal. No orthostatic BP drop