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196 Cards in this Set
- Front
- Back
What is the first heart sound due to?
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The closing of the tricuspid and mitral valves in systole.
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What is the second heart sound due to?
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The closure of the aortic valve mostly but also the pulmonic valve.
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What is the third heart sound due to?
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S3 corresponds to rapid ventricular filling during early systole. This may be due to a regurg...is common in kids, but after age 40 is pathologic.
S3 gallop heard at the fourth intercostal space at the left parasternal border |
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What is the fourth heart sound due to?
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occurs d/t reduced ventricular compliance during atrial contraction.
Common in people in their 40s and 50s. |
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What is the difference between low and high frequencies on an Echo?
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Low frequencies have better tissue penetration
High frequencies have better image resolution. |
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What is the equation for ejection fracture calculation?
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EF= (EDV-ESV/EDV)
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What are the major limitations to Echos
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- quality of images is sub-optimal due to poor penetration (adipose tissue and lungs and ribs get in the way)
- structures parallel to the beam may not be visible. must use multiple transducer posistions to avoid echo dropout |
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What is the main characteristic of Doppler echos?
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-Measure velocity of blood ie speed and Direction of flow.
-can tell when there is regurg, stenosis. -sample is depth dependent which limits max detectable velocity |
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What are the differences between TTE and TEE?
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TTE- trans thoracic echo: standard approach in most pts, non-invasive and no side effects.
TEE- trans esophageal echo: offers superior image quality d/t shorter distance btwn transducer and heart. -intubation and sedation comes with a slight risk. = TEE is more sensitive for LA thrombus, valve vegetations and mitral regurg. |
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What is the normal area of the aortic valve?
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3-4 cm
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What are physical exam characteristics of aortic stenosis?
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-systolic ejection murmur (peaks later in systole as the stenosis gets worse)
-delay in carotid pulse with a decrease in its volume -enlarged and forceful PMI, but not displaced. -increased CRP (labs) |
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What is the best imaging modality for A.S? What do all the other modalities show?
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ECHO is the best- shows LVH, systolic ejection performance and aortic valve anatomy.
CXR- nondiagnostic ECG- may show LVH |
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What is the tx for A.S.?
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*Valve replacement tx- only proven effective tx.
-Valloon aortic valvotomy- relatively ineffective comparatively but used when comorbid factors prevent surgery. -MED tx: antibiotic prophylaxis to prevent bacterial endocarditis. -ACE-i not recommended for A.S. |
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What is the major cause of mitral stenisis?
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Rheumatic disease
-also MS is three times more common in women. |
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What are the PE characteristics of MS?
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-Loud S1
-S2 is followed by opening snap (occurs as the diastolic filling snaps open the mitral valve) The sooner the snap, the worse the dz (.12 normal vs .06 dz) |
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What is a Graham Steell's murmur?
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in Mitral stenosis
Pulm HTN develops and a diastolic blowing murmur of pulmonic insufficiency. |
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How is MS prevented and treated either immediately or prophylactically?
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Antibiotic treatment of beta-hemolytic strep infections.
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What is the Tx for MS asymptomatic patients?
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No therapy for asymptomatic pts.
-Diuretics alone can be given when dyspnea and orthopenea develop. |
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In MS patients who develop a-fib, what is the medicinal tx?
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beta-blockers- slow down the heart rate to help with a-fib.
1.) give diltiazem or esmolol acutely 2.) chronically give beta-blocker, ca channel blocker or oral digoxin |
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What is the risk for pts with MS and A-fib? What do you give to prevent this?
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Risk: systemic embolism!
-Tx: chronic anticoagulation with warfarin at an INR or 2.5-3.5. |
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What is the mechanical therapy recommendied for MS patients?
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-Balloon valvotomy
-MS is fusion of the valve leaflets at the commisures. -this is in exact contrast to AS. |
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What makes a good candidate for balloon valvotomy?
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-Pliable valves
-little valvular calcification -little subvalvular apparatus involvement -moderate or less mitral regurg present. |
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What occurs when a 'bad' candidate for balloon therapy is treated?
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Surgery to open the commissurotomy or valve replacent is undertaken.
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What must the patient have for appropriate diagnosis of pericarditis?
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2 of the following:
-chest pain -friction rub on auscultation -ST elevation (caused by epicardial injury) |
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What are the physical findings in pericarditis?
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-retrosternal chest pain, worse on inspiration
-friction rub -increased JVP |
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What are ECG findings in pericarditis?
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diffuse ST elevation w/out depression.
-PR depression in 2,3 avf -PR elevation in avR *with inverted QRS in avR |
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What is the best tx for pericarditis?
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-NSAIDS for pain
-maybe prednisone in refractory cases -colchicine if no response to NSAIDS |
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What are the common causes of chronic constrictive pericarditis?
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-TB infection.
-post-radiotherapy |
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What is Kussmauls Sign?
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inability to accomodate increased venous return in the RV d/t fixed constriction.
-results in a rise in JVP upon inspiration |
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What is the major cause of pericardial effusion?
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most commonly exudative and either of viral or idiopathic etiology.
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What are the S/S of pericardial effusion?
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-Dyspnea, orthopnea
-JVD, Tachy, hypOtn if tamponade, hepatic enlargement -muffled heart sounds on auscultation |
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What are the image/ecg findings of pericardial effusion?
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ECG-Sinus tachy
CXR-globular heart ECHO-size and location of effusion, evidence of tamponade, swinging of heart |
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How do you tell if pericardial effusion was acute or chronic?
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Acute- rapid filling leads to critically acute intrapericardial pressure
chronic-gradual accum allows progressive stretching of pericardium-lots of volume with less intrapericardial pressure |
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What are epidemiologic factors of aortic aneurysms?
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-abdominal more common than thoracic
-5-10x inc in men -3% prevalence in ppl over 50 -of thoracic-ascending most common, desc are rare |
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What are the risk factors for Abdominal aortic aneurysms?
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SMOKING
age HTN hyperlipidemia |
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What are risk factors for ascending thoracif aortic aneurysm?
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-Marfan's
-CT diseases -longstanding HTN -bicuspid aortic valve -family Hx |
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What are risk factors for descending thoracic aortic aneurysm?
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Atherosclerosis
HTN |
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S/S of aortic aneurysms?
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-hypogastrum or lowrer back pain
-steady gnawing quality that lasts -rupture-hypOtn, pulsatile abd mass -aortic insufficiency -hemoptysis -arterial thromboembolism -cough, wheeze, dyspnea, hoarsness, pneumonia, dysphagia |
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What is the best diagnostic tool for AAA?
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can use US, but CT is the best
-echo-good for screening aortic root but cannot visualize ddescending aorta. |
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What is the TX for AAA?
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-BP control
- beta b do not reduce rate of growth!! AAA>5.5cm=repair AAA>4cm=monitor 6mo. desc>6=repair marfans or bicusp>5=repair |
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What recent tx is available for AAA? How does it fare?
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Endovascular stent graft to place inside aneurysm.
-better short term outcome but similar mortality at 2 yrs. -in co-morbit situations where surg is contraI, they fare just as well w/ conservative management that with stent. |
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What is the annual risk rate for aneurysm rupture?
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AAA<4cm 0.3%
AAA 4-4.9 is a 1.5% risk AAA 5-5.9 is 6.5% risk upon rupture, 80% of people die |
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What is the best imaging technique for aortic dissection?
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-TEE-quickest use if high degree of suspicion
-CT w/ contrast if suspicion is low, best d/t noninvasive |
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what are the stages of CHF?
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A- risk factors without symptoms (HTN, obese, diabetes, atherosc, FHx)
B- heart disease but w/out CHF symptoms (MI, LVH, asympt valve dz, low EF) C-Structural DZ w/ current symptoms of CHF (fatigue, short breath, reduce exercise) |
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How do ACE inhibitors aid in CHF tx?
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-inhibit LVH
-inhibits conversion of AI to AII and thus decrease Na and h2o -inhibit NS -prevent vasoconstriction |
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What are the major side effects of ACE inhibitors?
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ACE inhibitors reduce breakdown of bradyk and kininaseII
- COUGH and ANGIOEDEMA |
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What are the contraIndications for ACE inhibitors?
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HypOtension and bilateral renal artery stenosis
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When are ACE inhibitors indicated?
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in ANY patient with systolic dysfunction.
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What is the MOA of diruretics and how much should you dose?
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Prevents resorption of Na in the renal tubule and enhances urinary excretion of Na and h2o
-perscribe as little as possible while still being effective -excessive leads to electrolyte imbalances |
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What is the MOA of ARBs?
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same pathway as ACE-Is but diff step.
-blocks binding of AII to the receptor. |
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Does ARB and ACE-Is side effect profile differ?
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ARB- dont block bradyK and kininase breakdown, so no cough and less angioedema with them.
-both also have hypOtn, hypEr Kalemia, renal effects |
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Which population of CHF patients can get ARBs and ACE-Is?
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Stage C pts.
-also get Beta blockers -can also give aldosterone INSTEAD of ARB but in the same combo of 3 drugs. |
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How do Beta blockers aid in CHF?
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-block NS effects
*inhibits vasoconstriction *inhibits Na retention *decreases pre-load and afterload *** use them whenever systolic dysfunction is present |
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What are the contraIndications for beta blockers?
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-Asthma
-2nd or 3rd degree AV block -during an episode of acue decompensated HF -HR below 60 or systolic pressure below 90 |
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What is the MOA for aldosterone antagonists?
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Second hormone in the renin-angioT-aldosterone cascade
-antagonists: inhibit Na retention and hypOkalemia -prevents myocardial fibrosis ACT to SAVE K+ |
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Which aldosterone antagonist is used often in conjunction with ACE-Is in the hospital setting?
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Spironolactone- side effect is gynecomastia
also can use Eplerone |
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What are contraIndications of Aldosterone antagonists?
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-K+ greater than 5mmol/L
-Creatinine greater than 2.5 mg/dL -other signs of renal failure SE: -Hyperkalemia and uremia |
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What is the MOA of Digoxin?
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Inhibits Na/K pump.
-thereby increases intrAcellular Calcium -increases contractility |
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What are the benefits of Digoxin?
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Introduces Sinus rhythm.
-Use in A Fib if beta blockers dont work!! -use after ACE,BB,AR< diuretics and CCB havent worked |
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What are the side effects of Digoxin?
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anorexia, nausea, arrhythmias, confusion and visual disturbances.
-HypOkalemia increases SE susceptibility |
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What causes caution w/ Digoxin dosing?
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-low therapeutic window.
-Loading dos of 10-15ug/kg lean body weight (divided into 3 six hour doses) -maint. doses at 1/4 of loading dose |
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How do hydralazine and isosorbide dinitrate function in CHF tx?
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-direct acting vasodilators
-generally ACE-Is are better BUT- africans respond better to nitrates and hydralazine |
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When do you use isosorbide dinitrate and hydralazine in CHF?
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in african american patients
in pts who are intolerant of both ACE-Is and ARBs |
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What are co-morbid conditions with CHF?
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Angina
A-Fib -Asthma and COPD (can still use a BB with the later) -DM -Abnormal TSH -Gout-d/t diuretics (prevent w/ allopurinol, tx w/ colchicene) -renal dysfunction -anemia |
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Which patients should be considered for ICD (implantable cardioverter Defib)
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-class II or III HF
-LVEF below 30% and -no other conditions greatly limiting life expectancy |
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Which patients should be considered for CRT (cardiac re-synchronization therapy)
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it is a bi-ventricular device
-pts w/ prolonged QRS (>120msec) *this causes dyssynchronous contraction, decreased LVEF and mitral regurg. |
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Which drug acts as a direct renin inhibitor?
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Aliskiren
-approved for HTN reduction -lowers BP in a dose dependent fashion SE: hyperkalemia, teratogenesis, renal failure, gout and kidney stones |
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Which class of drugs are known as the -prils?
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ACE inhibitors are the -prils
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What is the MOA of the -pril drugs and what are their side effects?
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-prils are ACE inhibitors
SE: cough and angioedema, kyperkalemia, renal failure, teratogenesis. |
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What class of drugs are known as the -Sartans?
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ARBs.
Their MOA is to block the AT1 receptor for ATII, thus works on a different part of the RAAS pathway than the ACE-I. -no cough or angioedema S/S: teratogen, hyperkalemia, |
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What family of drugs are the
-ones? |
Aldosterone antagonists.
Spironolactone, eplerenone. -block the final step in the RAAS |
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Which drug is related to BNP and is given in hospital settings for acute decompensated heart failure?
What does it do? |
Nesiritide. (recompinant BNP) given only in the ER.
-causes naturiuresis, diuresis and mild vasodilation |
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What are the only two ARBs that are FDA approved for HF?
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Valsartan and Candesartan
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What are the characteristics of Vaslsartan?
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-1/2 life of 6 hours
-30/70 renal/hepatic metab oral bioavailability of 23% 39% of market shares |
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What are the characteristics of candesartan?
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-1/2 life of 5-9 hours
-approved for HF! -60/40 rehal/hepation metab 3% of market shares |
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Which class of drugs are known as the -kirens?
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Renin inhibitors.
-Aliskiren: avoids ACE inhibitor side effects. |
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Which ACE-I is given as IV only form?
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Enalaprilat
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Which two ACE-Is have very short halflives but are tight binging to ACE?
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Ramapril and Quinapril
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Which ARB has a short halflife in general?
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Losartan
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What is the general sequence of drugs given for CHF?
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-diuretic
-ACE-inhibitor -ARB -Aldosterone Antagonist -Nitrates and hyro- (Afr. Amer) -BB need to be given somewhere in here but not acutely. |
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What is the MOA for nitrates?
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increase cGMP
-cuases dephosphorylation of myosin light chains, preventing myosin and actin from linking. -causes vascular smooth muscle relaxation |
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What is the sequence of Nitrate vasodilation?
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Veins, arterioles then arteries
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What are the most common side effects of nitrates?
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Headache then hypotension
reflex responses:tachycardia, water and sodium retention -hypotension, tachycardia, carcinogen, headaches and Tolerance (tachyphylaxis) |
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How do nitrates affect platelets?
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They stimulate guanylyl cyclase activity which functionally decreases platelet aggregation
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What are the overall benefits of NO?
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Decreased:
-venous return -blood volume -blood pressure -intraventricular pressure -left ventricle volume |
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What is the most common use for Nitrates?
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Unstable angina
-sublingual is most common -transdermal is for chronic use |
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What are contraindications for NO?
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-obstructive hypertrophic cardiomyopathy
-hypovolemia -anemia -increased intracranial pressure -cardiac tamponade |
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What is the most common Nitrate drug?
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Isosorbide dinitrate
-100% bioavailable Oral T1/2=5 hours |
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What class of drugs are known as the ipines?
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Ca channel blockers
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How do Ca channel blockers help in HF?
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decrease intracellular Ca stores, which would normally activate myosin light chain kinases.
-relaxes vascular smooth musc -decreased bp reduced contractility |
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What are the three major drugs from the -ipine class?
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-Amlodipine-long T1/2,HTN, Angina. SE: Edema
-Nifedipine:HTN, Angina, HEART FAILURE. SE: flushing, edema headache -Nimodipine:Selective for Cerebral arteries. |
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What are the two drugs in the second class of Ca channel blockers?
What are their general SEs? |
Verapamil and Diltiazem
SE: bradycardia, heartblock, hypOtension, constipation |
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The SA and AV nodes are very sensitive to which drug?
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Verapamil
-great to increase contractility and reduce heart rate T1/2= 6-8 hrs. limits emergens of cancer from cells by blocking p-glycoprotein |
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What is Ranolazine used for?
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new drug, not FDA approved
inhibits FA oxidation and shifts energy source to glucose, which uses less O2 to produce the same amt of ATP. CYP3A4 metabolized: contrain (ketoconazole, verapamil, rifampin) -prolongs QT interval |
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What are the only two beta blockers approved for CHF and what are their SEs?
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Carvedilol- immediate and long acting
metoprolol succinate-only long acting SE: fatigue, bradycardia, heart block. Contra-i: asthma, hypoglycemia |
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How does the pancreas change with old age?
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No change in size, but the main pancreatic duct and its branches wide.
increase in fibrous tissue and fatty deposition with acinar cell atrophy; however, the large reserve of the organ results in no significant physiologic changes. The functional reserve of the pancreas may be reduced, although this can occur as a result of delayed gastric emptying rather than pancreatic changes. |
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What is the MOA of digitalis?
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Blocks Na/K pump
-improves myocardial concractility d/t an increase in Na intracellularly and a reduction of Ca efflux |
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What are the electrical effects of digoxin at low doses?
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-Slows sinus and AV nodes
-Increased PR interval -Decreased QT interval High doses: dysrhythmias and asystole |
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What are the common uses for digoxin?
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Atrial fibrillation and heart failure
-used when diuretics and ACEIs are not sufficient |
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Which class of drugs are known as -ide?
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Diuretics.
-Feurosamide -hydrochlorothiozide |
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What are the stages of HTN (4)
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Class Systolic Diastolic
Norm <120 <80 PreHTN 120-139 80-89 St. 1 140-159 90-99 St.2 >160 >100 |
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What are syndromes which lead to secondary HTN?
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-Renal HTN (GFR<60 and albumin-creatinine ratio>30)
-coarctation of the aorta -primary aldosteronism -cushings -pheochromocytoma |
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Which diuretics are better used for HTN?
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Thiazides
-long half lives, often used with a fixed combo of ace inhibitor for uncomplicated hypertension. |
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What drug is the shorter acting diuretic and when is it indicated for HTN?
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Chlorthalidone
-shorter half life -used for resistant hypertension -pts w/ chronic kidney disease or HF. -furosemide-6 hr half life -torsemide-longer half life |
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What drugs are eplerenone and spironolactone? How do they help with primary hypertension?
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They are aldosterone inhibitors
-inhibit aldosterone from acting in the renal tubule and prevent Na and H2O resorb |
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When does CVD risk double in regard to BP ranges?
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starting at 115/75
risk double with each increment of 20/10 |
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What are the percent benefits of lowering BP on stroke, MI and HF?
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Stroke 35-40%
MI 20-25% HF 50% |
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What components make up the 'metabolic syndrome'?
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-HTN
-Obesity (BMI over 30) -Dyslipidemia DM |
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What is the BP goal of therapy for patients with DM and chronic kidney disease?
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DM- <140/90
CKD ,130/80 Definately get Systolic goal in persons over 50 yoa. |
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What are the top three lifestyle modifications which will reduce Systolic BP?
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-Weight reduction-10kg in weight and 5-20 in mmHg
-DASH diet (fruits and veggies, low sodium) 8-14mmHg -exercise 4-9mmHg |
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What is the drug tx for stage 1 htn w/out compelling indications?
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Thiazide diuretics
-may consider a second drug for combo: ACEI, ARB, CCB, BB |
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What is the drug tx for stage 2 htn w/out compelling indications?
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2 drug combo therapy
-thiazide diuretic AND -ACEI, ARB, CCB OR BB |
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What is the drug tx for HTN WITH compelling indications?
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-Diuretic as a loop diuretic (clorthalidone)
Other combo may be added as needed. |
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How often should serum K and Creatinine be monitored for HTN patients?
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1-2 x per year.
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How often are follow up visits in general for HTN pts once they've reached their goal?
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3-6 month intervals
-more frequent visits and monitoring is recommended for stage 2 HTN patients |
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Which types of drugs should be used for pregnant women with HTN?
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Methyldopa and BBs with vasodilarots are preferred for fetus safety.
**ACEI and ARBs are contraindicated for pregnancy |
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What is atrial flutter?
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Non-focal source of atrial arrhythmia.
-most common circuit rotates in a counterclockwise direction in the R. atrium round the tricuspid annulus. 80% |
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What is the pattern of the most common flutter?
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-sawtoothed pattern in II and III and aVF.
-the ventricular response varies making the QRS and heart rate change. This has nothing to do with the flutter atrial rate. |
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What are the atrial and ventricular rates in atrial Flutter?
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Atrial rate = 260-300 bpm
Ventricular = 150 bmp or 2:1 Ventricular rate of 150 is atrial flutter with a 2:1 block until proven otherwise. |
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What is the TX for atrial flutter?
|
-Direct Cardioversion
-50-100 J to restore normal rhythm -risk of thromboembolic events is high! *anticoag tx -risk for developing HF d/t LVH, tachy is high. controlling w/ CCB, BB and digoxin may help. |
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Which drugs are used for both atrial flutter and fibrillation to attempt conversion?
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-Porcainamide
-amiodarone -ibulitide |
|
What does this ECG show?
|
Atrial Flutter with a 2:1 heart block
-atrial rate around 300 -vent rate of around 150 |
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Why are isoproterenol and nitro used in the table tild test?
How are they administered? |
Used to provoke syncopal episodes by vasodialtion.
-Isoproterenol: 1-3mg/min will inc HR to 25% inc -NO: fixed dose of 400mg spray sublingual |
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When is table tilt test indicated?
|
recurrent syncope, high risk pts w/ a single episode but lacks structural heart disease evidence.
|
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What is first line therapy for patients with documented PACs and PVCs?
|
Beta Blockers (metoprolol or atenolol)
|
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What is the difference between Mobitz type I and type II blocks? Which may be associated with pathologic syncope?
|
Mobitz are AV blocks
1: no wide QRS 2: widened QRS with progression to complete heart block. ECG shows: Prolonged PR interval with dissociation of PR and QRS. |
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What are the characteristic findings of acute pericarditis on ECG?
|
-Depression of the PR interval
-ST segment elevation |
|
What ECG findings are in brugada's syndrome?
|
Incomplete RBBB
St elevation in v1 or v2 -palpitations |
|
What indicates ventricular dysplasia on ECG findings?
|
an epsilon wave:
-incomplete RBBB -inverted T wave in V1 |
|
how does ventricular tachycardia reperesent on ECG?
|
Fusion beats or av dissociation during a wide QRS complex tachycardia
|
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Which drug is used in narrowing the DD of tachycardia? How?
|
Adenosine (IV bolus of 6mg)
or carotid massage -slow conduction through the av node, thus, if tachy ends with either maneuver, they are likely to involve the AV node in the re-entrant circuit |
|
How do holter monitors, event monitors and loop recorders differ?
|
-Holter: 24-48 hour constant monitor
-Event: only triggered to record at start of event -Loop: worn for a month, implantable |
|
What is IE and what are the four groups associated with it?
|
IE: an infection of the heart's endocardial surface
Groups: 1 Native Valve 2 Prosthetic Valve 3 IV drub abuse 4 Nosocomial IE |
|
How do acute and subacute IE differ?
|
Acute: affects normal valves, rapidly destructive, metastatic, commonly caused by staph, fatal if untreated in 6 wks.
Subacute: affects damaged valves, indolent nature, fatal by 1 year if not treated |
|
What proportion of IV drug use is associated with IE?
|
25% of US cases from IVDU
-5:1 male:female |
|
What are the S/S associated with acute IE?
|
-High fever and chills
-arthralgia/myalgia -abdominal pain -back pain -pleuritic chest pain Signs: murmur, petechiae, splinter hemorrhages, clubbing, splenomegaly, osler's nodes, roth spots |
|
What are the S/S of subacute IE?
|
-low fever
-anorexia -weight loss -fatigue -arthralgias/myalgias |
|
What are the essential blood tests for IE?
|
-Minimum of three seperate venipuncture sites
-typical organisms present in at least 2 of those sites -strep infections -no need to test for anarobics 0Drwa CBC+diff, electrolytes, renal fx, urinalysis also |
|
Imaging techniques to use in IE?
|
TTE and or TEE is first line
-CXR can help in calcification or vegitation imaging -Ekg: no very useful, maybe can see tiny MIs. |
|
What are the four major groups of complications arising from IE?
|
-Valvular damage
-empoli -immunologic phenomena -metastatic infections (septic) |
|
What are the treatment options to the two most common agents in IE?
|
-Strep viridans:
*penecillin *Gentamicin and vancomycin if pen allergy -Staph aureus *nafcillin *vancomycin *gentamicin *Daptomycin *Cefazolin |
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What is the proportion of people with bicuspid aortic valves? What are the complications and when do they occur?
|
1% with bicuspid valves
Complications: -1/3 become stenotic -1/3 become regurgitant 1/3 do nothing Stenosis develops in 40-60 yoa |
|
What is the process of tricuspid aortic stenosis?
|
Inflammatory process 60-80yoa.
1-lesion similar to plaque of CAD 2 HTN and hyperlipidemia 3 correlation btwn calc coronaries and aortic Ca. 4 increased CRP levels |
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What are the demographics of pts symptoms of Angina and aortic stenosis?
|
35% of people with aortic stenosis have CC of Angina
-50% will die in 5 years |
|
What are the demographics of pts symptoms of Syncope and aortic stenosis?
|
15% of people with aortic stenosis will have CC syncope
-50% will die in 3 years |
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What are the statistics of pts symptosm of CHF and Aortic Stenosis?
|
50% of people with aortic stenosis will have CC of CHF
-50% will die in 2 years Overall only 25% pts With symptoms survive within 3 years without valve replacement. |
|
What is the normal aortic valve area and when will they begin symptoms?
|
area is 3-4 cm.
symptoms occur when it is 1/3 normal size. |
|
What are physical exam results in a patient with aortic stenosis?
|
-systolic ejection murmur (peak of murmur depends on dz progression. mild dz peak early, bad dz, peak later)
-delay in carotid pulse and volume S1-may be followed by a click if A.S. is congenital S2- splitting S4-gallop |
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Which diagnostic tests are useful and which are contraindicated for Aortic Stenosis?
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-EKG = LVH
-CXR- may see pulm HTN in end stage disease -ECHO- leaflet Ca and thickening, LVH -Stress test is contraindicated for symptomatic patients, causes hypOtn. |
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What is the Tx for aortic stenosis?
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Valve replacement.
-under 40, no coronary angiogram -above 40, do angiogram to rule out CAD and need for CABG simultaneously |
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What is medication therapy for aortic stenosis?
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Diuretics and nitrates to relieve HF symptoms before surgery.
-ACE-Is NOT recommended b/c cause vasoD but do not increase C.O. cause syncope -Antibiotic prophylaxis to prevent endocarditis during valve replacement surgery. |
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What are the surgical options and risks for A.S valve replacement?
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-mechanical: must be on anticoags for rest of life
-bioprosthetic: only platelet inhibitors for life, but may breakdown over time -balloon valvotomy: recommended only when co-morbid prevents surgery. |
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What are the epidemiological factors of mitral stenosis?
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Almost all from Rheumatic HD
-3x more in women -usually in 40-50s |
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What is the pathobiology behind mitral stenosis?
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-normally diastole causes = pressures btwn the LA and LV.
-MS causes pressure gradient to develop. -causes LA and Pulm A and RV pressure inc. causes RVH! -CO decreases |
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Why is hemoptysis common in Mitral Stenosis?
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LA pressure increases causing Pulm HTN, causes small bronchial veins to rupture.
-cough up blood |
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What is Ortner's syndrome and how does it occur?
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-Hoarsness
caused by large LA in Mitral stenosis which impinges on the the recurrent laryngeal nerve. also may get dysphagia from esophagus impingement |
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What is the significance of the opening snap? What about its timing?
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-Opening snap occurs in diastole at some point after S2
-the shorter the time interval between S2 and the Snap indicates severity of M.S. -Normal is .12 msec, .06msec indicated bad level of stenosis |
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What is the Graham Steells murmur? what causes it?
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It is a low blowing diastolic murmur of pulmonary insufficiency which causes backflow into the right Vent.
-occurs due to pulm HTN |
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What are the non-invasive imaging techniques for M.S?
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EKG- shows Left Atrial enlarg, atrial fibrillation, and RVH is pulm htn is present
CXR- see straightening of left heart border, d/t LAH, pulm venous htn causes Kerley B lines -ECHO-can measure leaflet thickness and pulm a pressure |
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Describe the stages of mitral leaflet stenosis with severity
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Normal 4-5 cm
Mild 1.75 *Symptoms btwn 2-1.75 moderate 1.75-1.25 mod/sev 1.25-1.0 Severe less than 1.0 cm |
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What types of medicinal tx are indicated for pts w/ M.S?
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1- Diuretics (decrease volume and increase breathing)
2. short acting BB or Ca blockers such as esmolol or diltiazem (pts develop afib and will decompensate d/t inc HR and RA pressure and dec CO, thus need to act fast) |
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What is the major long term risk associated with a fib M.S patients?
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Thromboembolism!
TX w/warfarin to INR 2.5-3.5 to prevent clot formation. -convert back to sinus rhythm after anticoag is therapeutic. |
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What mechanical intervention is indicated for M.S.?
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-balloon valvectomy
(b/c cross bridging of valves occurs in MS and not in AS) |
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What factors consider a candidate good for balloon valvectomy in MS?
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1 pliable valves
2 little valvular calcification 3 sub-valv apparatus not involv 4 less than mod mitral regurg -must do echo first to tell |
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What does the EKG of MS show?
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-RAD consistent w/ RVH (- in I and + in aVF)
-R waves present in V1 -biphasic P waves (indicate Left atrial abnormality) |
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What are the common etiologies for Mitral Regurg?
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Any abnormal MV anatomy:
-MVP most common 2/3 -MI- causes papillary dysf or infarct and improper fx of chordae (1/4) -inf. endocarditis -myxomatous degeneration -RH -weigh loss drugs used to be a cause but were pulled |
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What are the classic symptoms of mitral regurg on physical exam?
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-pulses: brisk (sharp upstroke, normal volume)
-increased splitting of S2 -holosystolic murmur loudest at apex w/ radiation to the axilla |
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What is the pathologic progression of mitral Regurg?
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1-LVH
2-LAH 3- pulm htn 4- eventually LVH dysfunction d/t ischemia -5 causes dilation and deformed anatomy (regurg gets worse) and LV contractile dysfunction |
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What imaging technique is best for mitral regurg?
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Echo- TTE
-asesses LVH size and systolic functionality -etiology of the regurg |
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What are the medicinal tx indicated for mitral regurg?
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---SURGERY!
Severe acute- artery vasoD (BB, alpha ant and nitro. Chronic symptomatic: use ACE-I to dec. LV volume Chronic not symptomatic: no drugs, dont use ACEI b/c they would decrease bv but since asymptomatic, don't have any after-load yet. |
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Describe the timing of surgery for mitral Regurg.
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-Asympt an elderly: NO surger
-Asympt and w/LV dysfunct: surgery w/ REPAIR only, do before LVH occurs. dont replace b/c asympt & replace would cause LV dysf which would make them worse than they are now. -Sympt: Do surgery. orthopnea, fatigue, dyspnea |
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Why is repair better than replace in mitral regurg?
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-restores competence
-maintains LV function (improved post-op vent fx and survival) -avoids prosthesis |
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Which factors make replacement of mitral valve difficult?
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-posterior chordal rupture
-anterior involvement -rheumatic dz |
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What is good about MV replacements verses repairs?
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guarantees valve compentence.
-but the apparatus connections to LV are destroyed resulting in decreased LV fx and LVEF |
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What are the physical exam characteristics of aortic regurgitation?
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-bounding pulses
-S3 present -to and fro pulses -wide pulse pressure btwn systole and diastole -Decrescendo murmur |
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What is DeMussets sign?
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occurs in aortic regurg:
-head bobbing |
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What is Corrigan's Water Hammer Pulse?
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occurs in aortic regurg: abrupt rise with rapid collapse of the pulse
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What is Quincke's pulse?
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occurs in aortic regurc:
capillary pulsations noted in the nail bed. |
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What is Bisferin's pulse?
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occurs in aortic regurg: bifed pulse on palpation.
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What is an Austin-Flint murmur?
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occurs in aortic regurg:
functional diastolic rumble which mimics mitral stenosis. Does not have opening snap. |
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What are the numerical considerationf for people with aortic regurg for valve replacement?
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-LVEF less than 50%
-LV end diastolic dimension greater than 7.5cm -LV end systolic dimension is greater than 5.5cm |
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What valve dz may pre-dispose one to aortic regurg?
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-Rheumatic DZ
-endocarditis -trauma -CT disease -dilation of aortic root d/t HTN -aortic dissection -syphilitic aortitis -cystic medionecrosis |
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How does tricuspid regurg manifest?
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-commonly d/t RV dilation, not from valve deformity itself.
ex: copd |
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what is the most common cause of tricuspid regurg?
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-infective endocarditis of IV drug users.
Staph aureus |
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What are the s/s of tricuspid regurg?
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ascites
edema JVD larve V wave |
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What Tx is availabe for tricuspid regurg?
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get down to main cause:
-LVH-LAH-RVH-regurg? tx LVH -if just d/t regurg, use diuretics -surgery for valve alone is not entertained, must need CABG or some other surgery too. not all that well tolerated. |
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what is carvallo's sign
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murmur intensity increases with inspiration. (tricuspid murmur)
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What medicinal tx are there for aortic regurg?
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For Asymptomatic pts:
-ACE-I (decrease after-load) -hydralazine symptomatic: surgery ASAP, short term stabilization is as above. |
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What is an A wave?
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occurs in the jugular vein in concordance with right atrial contraction.
caused by either: -decreased right ventricular compliance (pulm stenosis, COPD, pulm regurg, pulm htn) -tricuspid stenosis |
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What is a C wave?
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occurs in concordance with the carotid pulse, it is a positive upstroke in the jugular
Caused by tricuspid regurg |
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What is a V wave?
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occurs in the jugular in concordance with systole.
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What are the limitations to ECHO?
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-sub-optimal image quality d/t poor tissue penetration (fat, lung tissue in the way)
-drop-out of structures that are parallel to the beam *prevent by using multiple image planes |
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What is the first line tx for people with PACs and PVCs?
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beta blockers (metoprolol or atenolol)
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What is the formula for LVEF?
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LVEF= (EDV-ESV/EDV
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When is provocative testing indicated for angina?
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-exercise w/ ekg is most recommended
-dont do w/ anything acute such as acute MI, arrhythmias, aortic stenosis, AA dissection, PE, pericarditis, AV block -dobutamine, dipyrimadole or adenosine are provokers. -looking for ST shifts |
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what is tx for angina?
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-control risk factors:bp, smoking, weight, diet and exer
-Drugs: Aspirin Platelet inhibitor: *Clopidogrel- inhibits ADP rec *dipyridanole-not recomm ACE-I: all pts w/ CAD + DM or LVsystolic dysf. -BB CABG or PCI: to prevent MI (2-3 vessel block) *CABG if LAD involved or has diabetes *PCI only if ischemia is present |