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234 Cards in this Set

  • Front
  • Back
What percentage of hypertensive patients have essential hypertension?
90-95%
SECONDARY HYPERTENSION (HTN):

HTN in upper extremities

Decreased or normal blood pressure (BP) in lower extremities
Coarctation of the Aorta
SECONDARY HYPERTENSION (HTN):

HTN accompanied by proteinuria in a nondiabetic patient
Glomerular Disease
SECONDARY HYPERTENSION (HTN):

HTN in a patient with a history of renal and hepatic cysts
Polycystic Kidney Disease
SECONDARY HYPERTENSION (HTN):

Sudden worsening of HTN in an elderly male with coronary artery disease (CAD) and peripheral vascular disease (PVD)
Renal Artery Stenosis
SECONDARY HYPERTENSION (HTN):

Episodic HTN, weight loss, headache, and diaphoresis
Pheochromocytoma
SECONDARY HYPERTENSION (HTN):

Elevated systolic HTN without diastolic HTN
Hyperthyroidism
SECONDARY HYPERTENSION (HTN):

40-year old female with a h/o 20 years of oral contraceptive pill (OCP) use
Drug-Induced (OCP) HTN
SECONDARY HYPERTENSION (HTN):

HTN in a patient with hypokalemic metabolic acidosis
Conn Syndrome / Hyperaldosteronism
SECONDARY HYPERTENSION (HTN):

HTN in an overweight patient with buffalo hump, moon facies, hirsutism, and abdominal striae
Cushing Syndrome

Hypercortisolism
What is the difference between Hypertensive Urgency and Hypertensive Emergency?
In Hypertensive Urgency, there are no signs of end-organ damage due to HTN.

In Hypertensive Emergency, there are signs of organ damage (papilledema, renal failure, heart failure, stroke).
What is the treatment of hypertensive urgency?
Oral BP medication:

Labetalol
Captopril
Clonidine
What are the 3 preferred agents for the treatment of hypertensive emergency?
1. IV Nitroprusside
2. Nitroglycerine
3. Hydralazine
What is the preferred treatment for hypertension in pregnancy?
Hydralazine & Clonidine
or
Methyldopa
ANTIHYPERTENSIVE:

No comorbidities
Diuretics
or
Beta-Blockers
ANTIHYPERTENSIVE:

Isolated HTN
Thiazide Diuretics
ANTIHYPERTENSIVE:

Angina Pectoris
Beta-Blockers

Calcium Channel Blockers
ANTIHYPERTENSIVE:

Diabetes
ACEIs or ARBs

Beta-Blockers
ANTIHYPERTENSIVE:

Hyperlipidemia
ACEIs

Calcium Channel Blockers
ANTIHYPERTENSIVE:

Congestive Heart Failure
Diuretics

ACEIs
ANTIHYPERTENSIVE:

H/o myocardial infarction (MI)
Beta-Blockers

ACEI
ANTIHYPERTENSIVE:

Chronic Renal Failure
Diuretics

Calcium Channel Blockers
ANTIHYPERTENSIVE:

Asthma / Chronic Obstructive Pulmonary Disease (COPD)
Diuretics

Calcium Channel Blockers
ANTIHYPERTENSIVE:

Benign Prostatic Hyperplasia (BPH)
Alpha-1 Antagonists

Terazosin
ANTIHYPERTENSIVE:

Pheochromocytoma
Phenoxybenzamine
--Nonselective Alpha Antagonist

Phentolamine
--Alpha-1 Antagonist
ANTIHYPERTENSIVE:

Hypertrophic Obstructive Cardiomyopathy
Beta-Blockers
ANTIHYPERTENSIVE:

Hyperthyroidism
Beta-Blockers
ANTIHYPERTENSIVE:

Anxiety
Beta-Blockers
ANTIHYPERTENSIVE:

Supraventricular Tachycardia (SVT)
Beta-Blockers
ANTIHYPERTENSIVE:

Migraine Headaches
Beta-Blockers

Calcium Channel Blockers
ANTIHYPERTENSIVE:

Moderate Bradycardia
Beta-Blockers with Intrinsic Sympathomimetic Activity

Pindolol
Acebutolol
ANTIHYPERTENSIVE:

Osteoporosis
Thiazide Diuretics

--reabsorbs calcium
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:

CHF
Verapamil

Alpha-Blockers
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:

Asthma / COPD
Beta-Blockers
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:

Diabetes
Beta-Blockers

Thiazide Diuretics
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:

Renal Artery Stenosis / Renal Failure
ACEIs
What genetic disease should be suspected in a patient with xanthomas, xanthelasmas, and lipemia retinalis?
Familial Hypercholesterolemia
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

Total Cholesterol <200
Retest in 5 years
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

Total Cholesterol >200
Treat based on lipid fractions
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

Low-Density Lipoprotein (LDL) >190
Begin lipid-lowering therapy

Goal <160
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

LDL >160 in a patient with 2 or more coronary risk factors
Begin lipid-lowering therapy

Goal <130
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

LDL >130 in a patient with CAD or Diabetes Mellitus (DM)
Begin lipid-lowering therapy

Goal <100
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

LDL >100 in a patient with a previous MI
Begin lipid-lowering therapy
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:

Triglycerides (TGs) >200
Begin TG-lowering therapy
Cholestyramine

MOA
IND
TOX
MOA: bile-acid binding resin

IND: adjuvant therapy for patients with familial hypercholesterolemia

TOX: constipation, gatrointestinal (GI) discomfort, may interfere with intestinal absoprtion of other drugs
Statins

MOA
IND
TOX
MOA: hydroxymethylglutaryl (HMG) coenzyme A (CoA) reductase inhibitors

IND: hypercholesterolemia

TOX: Hepatotoxicity, rhabdomyolysis
Niacin

MOA
IND
TOX
MOA: reduces release of very low-density lipoprotein (VLDL) from the liver into circulation

IND: hypercholesterolemia: to increase HDL and decrease LDL

TOX: flushing, pruritis (both reversible with Aspirin), and hepatotoxicity
Gemfibrozil, Clofibrate

MOA
IND
TOX
MOA: stimulates lipoprotein lipase

IND: hypercholesterolemia: to decrease TGs

TOX: myositis, hepatotoxicity
What are the 6 Coronary Risk Factors?

Greatest risk factor?
"CAD HDL"
1. Cigarettes
2. Age (male >45 & females >55 are at increased risk) & Sex (males > females)
3. Diabetes Mellitus (greatest risk factor)
4. HTN
5. Death from MI in FH (males <55, females <60)
6. Increased LDL, low HDL (<35)
What is the common presentation of a patient with symptomatic CAD?
Angina pectoris +/- radiation to the jaw, left shoulder, or arm

Exacerbated by exertion, relieved by rest and nitroglycerin
Which group of patients commonly do not exhibit classic anginal symptoms in the setting of myocardial ischemia?
Elderly, women, diabetics (due to diabetic neuropathy), heart transplant patients
Which type of angina is characterized by chest pain and dyspnea at rest?
Unstable Angina
What are the classic ECG findings during an anginal episode?
>1mm ST-segment Depression

T-wave Inversion
What diagnostic tests are often used to screen for CAD?
Exercise or pharmacologic stress test or imaging
Which patients should undergo exercise ECG with myocardial imaging + stress echo in the workup of CAD?
Patients with:
1. Wolf-Parkinson-White Syndrome
2. >1mm ST depression on Resting ECG
3. H/o PTCA
4. on Digoxin
5. LVH
Who get pharmacologic stress test?
Patients with electronically paced ventricular rhythm and left bundle branch block (LBBB)
What is the gold standard for the diagnosis of CAD?
Coronary Arteriography
Name 6 lifestyle changes that should be suggested to all patients with HTN:
1. Weight Loss
2. Sodium Restriction
3. Physical Exercise
4. Smoking Cessation
5. Alcohol Cessation
6. Stress Reduction
What medications should be given to a patient with acute onset of angina?
Sublingual Nitroglycerin
What medications should be given as prophylaxis for angina and MI?
1. Long-acting Nitrates
2. Beta-Blockers
3. ASA
4. Statin
5. ACEIs for patients with h/o MI
What are the key steps in the medical management of a patient with unstable angina?
1. Start IV
2. Administer O2
3. Start Heparin, ASA, Beta-Blocker, Nitroglycerin, Morphine
Describe how nitrates reduce angina:
1. Venodilation cuases venous pooling, leading to decreased preload and decreased myocardial O2 consumption

2. Coronary vasodilation, leading to increased O2 delivery to the myocardium
What is the most common side effect of nitrates?
Headache
HOW IT REDUCES ANGINA:

Beta-Blockers
Decreases myocardial oxygen consumption, decreases afterload, increases coronary filling during diastole
HOW IT REDUCES ANGINA:

Nifedipine
Coronary arteriolar vasodilation
HOW IT REDUCES ANGINA:

Verapamil
Slows cardiac conduction
What is the antianginal drug of choice for prinzmetal angina?
Diltiazem
Which antianginal drug must be used with caution in patients with asthma and COPD?
Beta-Blockers
What intervention is reserved for patients whose angina cannot be controlled medically?
Percutaneous Transluminal Coronary Angioplasty (PTCA)
What are the indications for coronary artery bypass grafting (CABG)?
1. Angina refractory to medical therapy
2. Severe left main disease
3. Triple vessel coronary disease (or double vessel disease in a diabetic)
What is the common presentation of MI?
1. Crushing restrosternal chest pressure occurring at rest and radiating to the left arm, neck or jaw
2. Diaphoresis
3. Nausea/Vomiting
4. Dyspnea
5. Anxiety
What is a common physical examination finding during an MI?
S4 Gallop
Which are the 6 life-threatening causes of chest pain that must be ruled out in all patients?
1. MI
2. Aortic Dissection
3. Pulmonary Embolism (PE)
4. Pneumothorax (PTX)
5. Esophageal Rupture
6. Cardiac Tamponade
What are the key steps in the initial management of a patient with suspected MI?
1. Assess vital signs
2. Administer O2
3. Start IV
4. Place on cardiac monitor
5. Obtain ECG
6. Administer ASA, Heparin, Nitrates, Beta-Blocker, Morphine, Clopidogrel
What are the classic ECG abnormalities in an acute MI?
ST Elevation

Q Waves
Which ECG finding is very sensitive and specific for right ventricular infarction?
ST Elevation of 1mm in right-sided lead V4
CORONARY ARTERY OCCLUSION:

Large R and ST segment depression in V1, V2
Right Coronary Artery (RCA)

Posterior Infaction
CORONARY ARTERY OCCLUSION:

Q waves and ST segment elevation in leads V1-V4
Left Anterior Descending (LAD)

Anterior Infarction
CORONARY ARTERY OCCLUSION:

Q waves in leads I, aVL, V5, V6
Circumflex Artery

Lateral Infarction
CORONARY ARTERY OCCLUSION:

Q waves and ST segment elevation in leads II, III, aVF
Right Coronary Artery (RCA)

Inferior Infarction
Which serologic markers are typically used to diagnose and follow an MI?
Troponin I

CK-MB
What medication is reserved for patients with MI suffering from angina that is refractory to conventional medical management?
Thrombolytics including Tissue Plasminogen Activator or Streptokinase
What intervention is indicated in patients during an MI who fail or cannot tolerate thrombolytic therapy?
PTCA
What are the clinical manifestations of right ventricular MI?
1. ECG inferior changes
2. Hypotension
3. Clear Lungs
4. Jugular Venous Distension (JVD)
5. Right Ventricular Lift
6. Tricuspid Valve Regurgitation
Which medical therapy should be avoided in a patient with a right ventricular infarction?
Nitroglycerin

Initial therapy should involve IV fluids to increase preload
What long-term medications have been shown to improve mortality in patients with MI?
ACUTELY:
ASA & Beta-Blockers

LONG-TERM:
ACEI, Statins, and Clopidogrel
ARRHYTHMIA:

PR interval >0.2 s, often due to increased vagal tone
First Degree (Primary) Heart Block
ARRHYTHMIA:

PR interval gradually increases to the point at which a QRS complex is dropped (P wave is not conducted)
Second Degree Mobitz Type I Heart Block (Wenkebach)
ARRHYTHMIA:

PR interval >0.2 s with occasional dropping of the QRS complex at a fixed interval (ie, 2:1 or 3:1)
Second Degree Mobitz Type II Heart Block
ARRHYTHMIA:

Irregularly irregular pulses and QRS complexes
Atrial Fibrillation
ARRHYTHMIA:

Type of heart block that commonly arises as a side effect of medication including beta-blockers, digoxin and calcium channel blockers
Second Degree Mobitz Type II Heart Block
ARRHYTHMIA:

Sawtooth appearance of P waves
Atrial Flutter
ARRHYTHMIA:

Usually caused by conduction block within the bundle of His
Second Degree Mobitz Type II Heart Block
ARRHYTHMIA:

Complete dissociation between P waves and QRS complexes
Third Degree (Complete) Heart Block
ARRHYTHMIA:

Three or more P wave morphologies
Multifocal Atrial Tachycardia if HR >100

Wandering Pacemaker if HR <100
ARRHYTHMIA:

Associated with cannon A waves in jugular veins and widened pulse pressure
Third Degree Heart Block
ARRHYTHMIA:

Irregularly irregular pulses and QRS complexes
Atrial Fibrillation
ARRHYTHMIA:

Commonly caused by reentry
Paroxysmal SVT
ARRHYTHMIA:

Associated with COPD
1. Atrial Fibrillation
2. Atrial Flutter
3. Multifocal Atrial Tachycardia
ARRHYTHMIA:

Treatment commonly includes anticoagulation, rate control and/or cardioversion
Atrial Fibrillation
Wide QRS complexes not preceded by a P wave
Premature Ventricular Contraction (PVC)
ARRHYTHMIA:

Normal QRS morphology with a rate of 150-200 beats/min
Paroxysmal SVT
ARRHYTHMIA:

Pharmacologic treatment includes amiodarone, lidocaine and procainamide
Ventricular Tachycardia
ARRHYTHMIA:

May be treated with carotid massage or Valsalva maneuver
Paroxysmal SVT
ARRHYTHMIA:

Common cause of palpitation caused by ectopic beats arising from multiple ventricular foci
PVC
ARRHYTHMIA:

Ventricular arrhythmia commonly caused by myocardial ischemia that may lead to hemodynamic instability
Ventricular Tachycardia
ARRHYTHMIA:

First-line therapy is defibrillation

Second-line therapy is epinephrine or vasopressin
1. Ventricular Fibrillation

2. Pulseless Ventricular Tachycardia
ARRHYTHMIA:

Polymorphic wide complex tachycardia associated with prolonged QT interval
Torsade de Pointes
ARRHYTHMIA:

Treated identically to ventricular fibrillation if there is no pulse
Pulseless Ventricular Tachycardia
ARRHYTHMIA:

Tachyarrhythmia treated with adenosine, verapamil, cardioversion or radiofrequency ablation
Paroxysmal SVT
ARRHYTHMIA:

Narrow complex tachycardia in which P waves follow QRS complexes
1. Junctional Tachycardia

2. Wolff-Parkinson-White
ARRHYTHMIA:

Treatment with pacemaker is necessary
1. Symptomatic Second Degree Mobitz Type II Heart Block

2. Third Degree Heart Block

3. Sinus Node Dysfunction
What is the most common cause of atrial fibrillation?
Hypertension (HTN)
What are some other important causes of Atrial Fibrillation other than HTN?
"PIRATES"
--Pulmonary disease
--Ischemia of myocardium
--Rheumatic heart disease
--Anemia or Atrial myxoma
--Thyrotoxicosis
--Ethanol
--Sepsis
What are the 2 main components in the treatment of atrial fibrillation?
1. Rate Control
--Metoprolol

2. Long-term Anticoagulation
--Warfarin
What criteria are used to determine whether warfarin or aspirin is started in the treatment of atrial fibrillation?
CHADS2 Score:

--1 point for CHF, HTN, age >75, DM

--2 points for stroke, TIA

Score > or = 3 receives warfarin
Name 3 clinical scenarios in which atropine is indicated for treatment of bradyarrhythmia?
1. Bradycardia causing hemodynamic instability
2. Syncope
3. CHF
6 Symptoms of Congestive Heart Failure (CHF)
1. Dyspnea; exertional initially but occurs at rest as disease progresses
2. Orthopnea
3. Paroxysmal Nocturnal Dyspnea
4. Cough and Wheezing
5. Weight gain due to peripheral edema
6. Worsening fatigue
4 Common Signs of Left-sided CHF
1. S3 Gallop
2. Inspiratory crackles or rales
3. Laterally displaced point of maximal impulse (due to cardiomegaly)
4. Ventricular heave
5 Common Signs of Right-Sided CHF
1. Dependent edema
2. Jugular venous distention (JVD)
3. Hepatojugular reflux and ascites
4. Atrial Fibrillation
5. Cyanosis
What is the pathophysiologic basis of systolic dysfunction?
Decreased contractility
What are the 2 common causes of systolic dysfunction?
1. Ischemic Cardiomyopathy

2. Ischemic Myocarditis
What is the pathophysiologic basis of diastolic dysfunction?
Decreased Ventricular Compliance
4 Common Causes of Diastolic Dysfunction
1. HTN
2. Ischemic Cardiomyopathy
3. Hypertrophic Cardiomyopathy
4. Systemic Disorders
--amyloidosis, hemochromatosis
4 Common Chest X-ray (CXR) Abnormalities in CHF
1. Cardiomegaly
2. Cephalization of pulmonary vessels (increased vascularity in lung fields)
3. Kerley B Lines (indicating pleural fluid in fissures)
4. Pleural Effusions
2 Common Echocardiographic Abnormalities in CHF
1. Decreased Ejection Fraction

2. Cardiomegaly
CHF MEDICATION:

Shown to decrease mortality in CHF
1. ACE Inhibitors
2. Beta-blockers
3. Spironolactone (decreased mortality in class IV CHF)
CHF MEDICATION:

Used acutely for worsening dyspnea and fluid retention
Loop Diuretics
CHF MEDICATION:

Reduce afterload by causing vasodilation of both arteries and veins
ACE Inhibitors
CHF MEDICATION:

Reduce symptoms of CHF by improving contractility
Digitalis
CHF MEDICATION:

Vasodilators used in patients refractory to ACE inhibitors
1. Hydralazine

2. Isosorbide Dinitrate
CHF MEDICATION:

May cause arrhythmias, yellow-tinted vision, anorexia and nausea
Digitalis
CHF MEDICATION:

Intravenous positive inotropic agents
1. Dopamine
2. Dobutamine
3. Nesiritide
VALVULAR DEFECT:

Harsh midsystolic murmur in the right second intercostal space at the right sternal border, radiating into the neck and apex
Aortic Stenosis
VALVULAR DEFECT:

Blowing, high-pitched diastolic murmur at the left two to fourth interspaces radiating to the apex
Aortic Regurgitation
VALVULAR DEFECT:

Blowing holosystolic murmur at the apex radiating into the left axilla with increased apical impulse
Mitral Regurgitation
VALVULAR DEFECT:

Low-pitched diastolic murmur at the apex that gets louder prior to S1; an opening snap is often present just after S2
Mitral Stenosis
VALVULAR DEFECT:

Soft, late systolic murmur at the left sternal border or apex, accompanied by midsystolic click
Mitral Valve Prolapse
VALVULAR DEFECT:

Harsh midsystolic murmur in the left second intercostal space at the left sternal border
Pulmonic Stenosis
VALVULAR DEFECT:

Blowing holosystolic murmur at lower left sternal border radiating to right of sternum; may increase with inspiration
Tricuspid Regurgitation
VALVULAR DEFECT:

Harsh holosystolic murmur at lower left sternal border, accompanied by thrill
Ventricular Septal Defect
VALVULAR DEFECT:

Harsh midsystolic murmur in the third and fourth left interspaces radiating down left sternal border;
S4 and biphasic apical impulse often present
Hypertrophic Cardiomyopathy
VALVULAR DEFECT:

Can be caused by papillary muscle rupture secondary to MI
Mitral Regurgitation
VALVULAR DEFECT:

May cause left atrial enlargement, atrial fibrillation and pulmonary hypertension
1. Mitral Stenosis

2. Mitral Regurgitation
VALVULAR DEFECT:

Presents with triad of angina, syncope and exertional dyspnea; boot-shaped heart on CXR
Aortic Stenosis
VALVULAR DEFECT:

May be precipitated by infective endocarditis, aortic aneurysmal dilation and connective tissue disorders
Aortic Insufficiency (Regurgitation)
VALVULAR DEFECT:

Atrioventricular block
Mitral Regurgitation
VALVULAR DEFECT:

Calcific degeneration of a congenital bicuspid valve
Aortic Stenosis
VALVULAR DEFECT:

Increased pulse pressure
Aortic Insufficiency (Regurgitation)
What are the most common etiologies of dilated cardiomyopathy?
"ABCD"
--Alcohol abuse
--Beriberi
--Coxsackie B myocarditis, Cocaine, Chagas disease
--Doxorubicin toxicity (also pregnancy)
CARDIOMYOPATHY:

Asymmetric septal hypertrophy, banana-shaped left ventricle (LV); LV outflow obstruction
Hypertrophic Cardiomyopathy
CARDIOMYOPATHY:

May be caused by sarcoidosis, amyloidosis, scleroderma, hereditary hemochromatosis, endocardial fibroelastosis, radiation-induced fibrosis
Restrictive Cardiomyopathy
CARDIOMYOPATHY:

Causes sudden death in young, otherwise healthy athletes
Hypertrophic Cardiomyopathy
CARDIOMYOPATHY:

Four-chamber hypertrophy and dilation accompanied by systolic dysfunction
Dilated Cardiomyopathy
CARDIOMYOPATHY:

Cardiomyopathy most commonly caused by endomyocardial fibrosis
Restrictive Cardiomyopathy
CARDIOMYOPATHY:

Most common type of cardiomyopathy, commonly inherited in autosomal-dominant (AD) fashion
Hypertrophic Cardiomyopathy
CARDIOMYOPATHY:

ACEIs have been demonstrated to decrease mortality
Dilated Cardiomyopathy
CARDIOMYOPATHY:

Symptoms relieved by squatting (increased preload)
Hypertrophic Cardiomyopathy
CARDIOMYOPATHY:

Impaired left ventricular diastolic filling; may mimic constrictive pericarditis
Restrictive Cardiomyopathy
CARDIOMYOPATHY:

Examination reveals cardiomegaly, mitral regurgitation and S3; balloon-shaped heart on CXR
Dilated Cardiomyopathy
CARDIOMYOPATHY:

Mitral regurgitation, sustained apical impulse, S4 and systolic ejection murmur; boot-shaped heart on CXR
Hypertrophic Cardiomyopathy
What is the common presentation of pericarditis?
1. Pleuritic retrosternal chest pain (increased when supine, decreased when sitting up and leaning forward)
2. Dyspnea
3. Cough
4. Fever
What are the most common etiologies of serous pericarditis?
1. Uremia
2. Systemic Lupus Erythematosus (SLE)
3. Rheumatic Fever
4. Coxsackie Viral Infection
What are the most common etiologies of fibrinous pericarditis?
1. Uremia
2. SLE
3. Rheumatic Fever
4. Coxsackie Viral Infection
5. MI
What are the most common etiologies of hemorrhagic pericarditis?
1. Trauma
2. Malignancy
3. Tuberculosis
What is a typical examination finding in pericarditis?
Pericardial Friction Rub
What are the classic ECG findings in pericarditis?
Diffuse ST Elevation
What life-threatening complication of pericarditis causes distant heart sounds, JVD, hypotension, pulsus paradoxus, and elevated central venous pressure (CVP) on inspiration?
Cardiac Tamponade

Beck's Triad:
1. JVD
2. hypotension
3. muffled heart sounds
What is the definitive treatment for acute decompensation in a patient with cardiac tamponade?
Pericardiocentesis
Which secondary intervention may be helpful in the management of a patient with cardiac tamponade?
Intravascular Volume Expansion
What are the 3 major categories of endocarditis?
1. Infective Endocarditis
2. Nonbacterial Thrombotic (Marantic) Endocarditis (NBTE)
3. Libman-Sacks Endocarditis
What is the common presentation of infective endocarditis (IE)?
1. Fever (high in acute endocarditis, low-grade in subacute endocarditis
2. Constitutional Symptoms
3. Dyspnea
What are the clinical signs of IE?
"FROM JANE"
--Fever
--Roth's Spots
--Osler's Nodes
--Murmur
--Janeway Lesions
--Anemia
--Nail bed (splinter) hemorrhages
--Emboli
What criteria are typically used for diagnosing IE?
The Duke Criteria
What are the 2 major Duke criteria for diagnosing IE?
1. Two consecutive blood cultures (12 h apart) positive for IE-causing organism

2. Echocardiogram demonstrating valvular vegetation, ring abscess or other evidence of endocardial infection or new valve murmur
What are the 5 minor Duke criteria for diagnosing IE?
1. Cardiac predisposition including valvular abnormality, congenital heart disease or hypertrophic cardiomyopathy
Risk of bacteremia: DM, indwelling catheter, IV drug abuse IVDA), hemodialysis
2. Fever >38C (100.4F)
3. Vascular phenomena: signs of embolic disease including septic pulmonary emboli, mycotic cerebral abscesses, Janeway lesions
4. Immunologic phenomena including Roth spots or Osler nodes
5. Single positive blood culture
How do you make a definitive diagnosis of infective endocarditis?
2 major criteria

1 major + 3 minor criteria

5 minor criteria
What is the most common valve affected by IE?
Mitral Valve
What is the most common valve affected by IE in IV drug users?
Tricuspid Valve
TYPE OF ENDOCARDITIS:

25 yo IV drug user with rapid onset of high fever, rigors, malaise with tricuspid regurgitation
Acute IE
TYPE OF ENDOCARDITIS:

60 yo female with mitral valve prolapse who has recently undergone dental extraction presenting with low-grade fever and flu-like symptoms
Subacute IE
TYPE OF ENDOCARDITIS:

65 yo male with metastatic colon cancer and a new murmur consistent with mitral regurgitation
Nonbacterial Thrombotic Endocarditis (NBTE)
TYPE OF ENDOCARDITIS:

30 yo female with SLE
Libman-Sacks Endocarditis (LSE)
Which organism most often causes acute IE?
Staphylococcus aureus
Which organism most often causes subacute IE?
Streptococcus viridans
Which organisms can cause endocarditis but are not typically isolated by conventional bacterial culture?
"HACEK"
--Haemophilus parainfluenzae
--Actinobacillus
--Cardiobacterium
--Eikenella
--Kingella
What are some sequelae of bacterial endocarditis?
1. Valvular injury
2. Renal injury (glomerulonephritis (GN)
3. Septic emboli to brain, lungs, kidneys causing infarction or abscess
What is the most common cause of myocarditis worldwide?
Trypanosoma cruzii

Chagas Disease
What is the empiric treatment for a patient with suspected endocarditis (before an organism is isolated in blood cultures)?
Antistaphylococcal Beta-lactam Antibiotic
&
Aminoglycoside
What is the suggested regimen of antibiotic prophylaxis for patients at increased risk of endocarditis?
Two grams of Amoxicillin prior to dental procedures
Which patients should receive endocarditis prophylaxis?
1. Patients with prosthetic heart valves
2. Previous bacterial endocarditis
3. High risk patients (ie, complex cyanotic heart disease)
4. Moderate risk patients (ie, hypertrophic cardiomyopathy, MVP with regurgitation and/or thickened leaflets, repaired intracardiac defects in past 6 months)
What type of infection causes rheumatic fever?
Group A streptococcal pharyngitis
How does streptococcal pharyngitis cause rheumatic heart disease?
Antistreptococcal antibodies cross-react with a cardiac antigen
What serologic test is elevated in rheumatic heart disease?
1. Antistreptolysin Antibodies (ASO)

2. DNAse B
Name the 5 major Jones criteria for rheumatic heart disease?
"JONES"
--Joints (Migratory Polyarthritis)
--Pancarditis
--Subcutaneous Nodules
--Erythema
--Sydenham chorea
Name 3 minor Jones criteria for Rheumatic Heart Disease
1. Fever
2. Arthralgia
3. Leukocytosis
What is the most commonly observed valvular deformity in rheumatic heart disease?
Mitral Stenosis (MS)
What treatment for streptococcal pharyngitis can prevent rheumatic heart disease?
Penicillin
What is the critical determinant of morbidity in acute rheumatic fever?
Degree of mitral and aortic valve stenosis/regurgitation
What is the typical presentation of an aortic dissection?
Sudden onset of severe, tearing substernal pain radiating to the interscapular region of the back
Which physical examination findings are characteristic of an aortic dissection?
1. Unequal BP in the extremities
2. New murmur consistent with aortic regurgitation
What finding on CXR suggests an aortic dissection?
Widened mediastinum
Which coronary artery is most commonly affected by aortic dissection and what are the associated ECG findings?
Right Coronary Artery

Inferior MI

ST elevation in II, II, aVF
What is the gold standard for the diagnosis of aortic dissection?
Angiography

CT with contrast, transesophageal echocardiography (TEE) and MRI also have diagnostic use and are less invasive
What medication is preferred for lowering BP in a patient with an aortic dissection?
1. Sodium Nitroprusside

2. Beta-Blockers
What is the definitive therapy for an aortic dissection?
Surgical repair
what are the risk factors for peripheral vascular disease (PVD)?
Similar to coronary risk factors, though diabetes is #1
Peripheral Vascular Disease:

Focal neurologic findings
Cerbrovascular Disease
Peripheral Vascular Disease:

Abdominal pain out of proportion to examination
Mesenteric Ischemia
Peripheral Vascular Disease:

Intermittent claudication
Chronic Arterial Occlusive Disease
Peripheral Vascular Disease:

Pain in the buttocks and thighs with walking
Aortoiliac Occlusive Disease
Peripheral Vascular Disease:

Pain in the calves when walking
Femoral-Popliteal Occlusive Disease
Peripheral Vascular Disease:

Abdominal angina
Chronic Mesenteric Arterial Occlusive Disease
What noninvasive study is used to diagnose arterial occlusion?
Doppler Ultrasound
What is the gold standard for the diagnosis of arterial occlusion?
Angiography
What is the source of most emboli causing acute arterial occlusion?
Cardiac mural thrombus (commonly in patients with atrial fibrillation)
What is the treatment of an acute arterial occlusion?
Surgical or percutaneous thrombectomy or medical thrombolysis
What type of therapy must be administered to all patients with a h/o acute arterial occlusion?
Warfarin
56 yo female presents with dyspnea on exertion (DOE)

PE: loud S1, delayed P2, early diastolic sound and a diastolic rumble

Transesophageal Echocardiogram (TEE): mobile, pedunculated left atrial mass
Atrial Myxoma
60 yo presents with chest pain relieved by sitting up and leaning forward

PE: pericardial friction rub

ECG: diffuse ST-segment elevation

ECHO: pericardial effusion with thickening of the pericardium
Acute Pericarditis
65 yo male presents with 1 week h/o fever and DOE and orthopnea

PE: new blowing holosystolic murmur at apex radiating into left axilla

Blood cultures (+) for viridans streptococci

ECHO: oscillating mass attached to mitral valve
Acute IE
60 yo presents with dyspnea and palpitations

PE: 20 mmHg decline in systolic BP with inspiration (pulsus paradoxus), decreased BP, JVD, diminished S1 and S2

ECHO: large pericardial effusion
Cardiac Tamponade
58 yo male with Marfan Syndrome presents with the abrupt onset of tearing chest pain radiating to the back

PE: decreased BP, asymmetric pulses, declining mental status

CXR: widened mediastinum
Aortic Dissection
70 yo diabetic with hypercholesterolemia presents with angina, syncope, DOE

PE: diminished, slowly rising carotid pulses, crescendo-decrescendo systolic murmur at the second interspace at the right upper sternal border
Aortic Stenosis
80 yo diabetic with HTN and h/o rheumatic heart disease presents with left-sided weakness

PE: pulses are irregularly irregular

ECG: absence of P waves and irregularly irregular QRS complexes
Atrial Fibrillation leading to embolic stroke
70 yo with h/o CAD presents with worsening DOE, orthopnea, and paroxysmal nocturnal dyspnea

PE: JVD, S3 gallop, positive hepatojugular reflex, bibasilar rales and peripheral edema

CXR: cardiomegaly, bilateral pleural effusions
CHF
50 yo chronic alcoholic presents with worsening DOE, orthopnea and paroxysmal nocturnal dyspnea

PE: laterally displaced apical impulse

ECHO: four-chamber dilation, mitral and tricuspid regurgitation
Alcoholic Dilated Cardiomyopathy
35 yo male with FH of sudden cardiac death presents with DOE and syncope

PE: double apical impulse, S4 gallop, holosystolic murmur at apex and axilla

ECHO: left ventricular hypertrophy and mitral regurgitation
Hypertrophic Cardiomyopathy
40 yo black male with h/o HTN presents with chest pain, dyspnea and severe headache

PE: BP = 210/130 in all four extremities, flame-shaped retinal hemorrhages, papilledema

LABS: negative vanillylmandelic acid (VMA) and urine catecholamines, and cardiac enzymes
Malignant HTN
15 yo female presents 1 month after a sore throat with fever and joint pain

CBC: leukocytosis

LABS: ASO+
Rheumatic Fever
35 yo female with a h/o rheumatic fever presents with worsening DOE and orthopnea

PE: loud S1, opening snap, and low-pitched diastolic murmur at the apex

CXR: left atrial enlargement
Mitral Stenosis
65 yo male presents with 1 hour h/o substernal pressure and pain with radiation into the jaw and left arm, nausea, and diaphoresis

PE: S4 gallop

LABS: increased troponin and CK-MB

ECG: ST elevation in leads aVL, V1-V4
Anterior MI
70 yo female with DM and CAD presents with nausea and vomiting

PE: hypotension, clear lungs, JVD, right ventricular lift and tricuspid valve regurgitation

ECG: ST elevation in the inferior leads
Right Ventricular MI
40 yo asymptomatic male

PE: displaced and diffuse apical impulse, diastolic murmur and left sternal border, brisk pulses with rapid collapse + "pistol shot" sound auscultated over large peripheral arteries
Aortic Regurgitation