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291 Cards in this Set

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What does "irregularly irregular" mean on an ECG?
Irregular RR intervals
Irregularly irregular rhythm without p-waves prior to each QRS
Atrial fibrillation
Etiologies of A-Fib
(10)
PIRATES:
Pulmonary (COPD, PE), Pheochromocytoma, Pericarditis;
Ischemic heart dz & HTN;
Rheumatic heart dz
Anemia;
Thyrotoxicosis;
Ethanol & cocaine;
Sepsis
Signs/symptoms of A-Fib
(5)
A FL PT:
Asymptomatic patient;
Fatigue (most common);
Light headedness, syncope;
Palpitations, skipped beats;
Tachypnea, dyspnea
Complication of A-Fib
diffuse Embolization
(often to brain, leading to TIA or stroke)
One of two possible Drugs given to A-Fib to control rate in an emergent situation
IV Calcium channel blocker:
Diltiazem
(or)
IV Beta-blocker:
Metoprolol
Drugs given to A-Fib to control rate in a non-emergent situation
(2)
oral Beta-blocker:
Atenolol
(and)
oral Calcium channel blockers:
Verapamil or Diltiazem
what are the (2) ways to cardiovert an A-Fib rhythm?

when should you not cardiovert?
what would the Tx be then?
Medical: Amiodarone
Electrical: start @ 100 J

Do not cardiovert if patient is in A-Fib > 24 hours.
Tx: Warfarin for 3-4 weeks before cardioversion
If cardioversion from A-Fib to sinus rhythm does not occur, what should patient be treated with?
Long-term anticoagulants

DOC:
Warfarin (1st)
Aspirin (2nd)
Dx:
when the heart is unable to pump sufficient amounts of blood to meet the O2 requirement of the body causing blood to backup
Congestive Heart Failure
(CHF)
What are the systolic dysfunctions of CHF?
(EF, Preload, LVEDP, contractility)
Ejection Fraction < 40%
leading to Inc preload & LVEDP,
which leads to Dec contractility and Inc cardiac hypertrophy
What causes CHF exacerbation in previously stable patients?
(10)
FAILURE:
Forgot medication;
Arrhythmia, Anemia;
Ischemia, Infection;
Lifestyle (Inc sodium);
Upregulation (Inc cardiac output--pregnancy or hyperthyroidism);
Renal failure w/ fluid overload;
Emboli (pulmonary); Endocarditis
What are the diastolic dysfunctions of CHF?
(compliance, contraction, recoil, LVEDP, CO, EF)
Decreased compliance w/ normal contractile function
(ventricle either cant relax or fill properly)

leading to Inc stiffness, Dec recoil & coencentric hypertrophy.
LVEDP is Inc,
CO is nml,
EF is nml to high
Which type of CHF dysfunction--systolic or diastolic has a normal ejection fraction and is more common in women?
dyastolic
What related heart conditions are seen in the systolic dysfunction of CHF that deals w/ decreased contractility?
(4)
Ischemia(most common);
Dilated Cardiomyopathy;
Hypertensive burnout;
Valvular dz
What related conditions are seen in the systolic dysfunction of CHF that deals w/ Inc afterload?
(3)
Hypertension;
Aortic stenosis;
Aortic regurg
What related conditions are seen in the diastolic dysfunction of CHF that deals w/ abnormal active relaxation?
(2)
Ischemia;
Hypertrophic cardiomyopathy
(from disorders causing LVH)
What related conditions are seen in the diastolic dysfunction of CHF that deals w/ abnormal passive filling?
(2)
Restrictive cardiomyopathy;
Concentric hypertrophy from HTN
What are the early signs of Left-sided CHF?
(2)
Dyspnea on exertion;
Dec exercise tolerance
What are the late sx of Left-sided CHF?
(8)
PORNS DD Tits:
Paroxysmal Nocturnal Dyspnea;
Orthopnea;
Rales & crackles;
Nocturia;
S-3 gallop;
Diaphoresis;
Displaced PMI (laterally);
Tachycardia
What are the early signs of Right-sided CHF?
(6)
A Juicy CHERry:
Anorexia
JVD*
Cyanosis
Hepatomegaly
Edema in periphery
RUQ pain
What are the late sx of Right-sided CHF?
(2)
abnormal Hepatojugular reflex;
Ascites
What force causes the pulmonary congestion in diastolic dysfunction?
Increased hydrostatic pressure
what (3) ways can CHF be diagnosed by a CXR?
Enlargement of cardiac silhouette;
Pulmonary vascular congestion;
Kerley-B lines
(3) lab methods of diagnosing CHF
CXR;
Echocardiogram (function of ventricles);
Basic Natriuretic Peptide (BNP elevation)
AHA staging guidelines for CHF (stages A-D)
A: at risk but w/o structural heart disorder

B: no sx, w/ structural disorder

C: prior or current sx & structure disorder

D: end-stage dz
NY Heart Assoc Functional Classes of Heart Failure (I-IV)
[measures pt activity]
I: No limitation

II: slight limitation

III: Sx w/ minimal effort, ok at rest

IV: Sx at rest
SOB while lying flat
Orthopnea
What drug classes are good versus CHF? Which ones are only helpful if patient has a diastolic dysfunction?
Systolic or Diastolic dysfunction:
ACEIs/ARBs
Beta-blockers
diuretics

Diastolic dysfunction only:
Calcium channel blockers
Nitroglycerin
What diuretics are used for mild CHF and (2 for) significant CHF?
Mild:
Thiazides

Significant CHF:
Loop diuretics
Spirolactone
What is the difference in the signs/sx of people w/ right CHF and cirrhosis?
(2)
Same sx, except right CHF patients have trouble lying flat & have JVD
what are the (5) Tx for Acute Pulmonary Edema & Paroxysmal Nocturnal Dyspnea?
NOMAD:
Nitroglycerin
Oxygen
Morphine
Aspirin
Diuretic
What is the rule for prescribing beta-blockers for CHF?
never give during active CHF--add beta-blockers once the patient is diuresed to dry weight and on stable doses of other medications
Describe (2) types of Malignant HTN
(+ BP limits)
Hypertensive URGENCY:
systolic >200 or diastolic >110
WITHOUT evidence of end-organ damage

Hypertensive EMERGENCY:
Severe HTN w/ evidence of end-organ damage
(encephalopathy, renal failure, CHF, etc)
what is important to remember about treating a hypertensive emergency?
(2)
1) Immediate therapy is needed
2) IV drip w/ Nitroprusside or Nitroglyerin, but do not lower BP by more then 1/4 at first, or patient can have a stroke
DOC for HTN w/o any comorbid dz
Thiazide
DOC for HTN w/ CHF
(3)
ACEI / ARBs
B-blocker,
K-sparing diuretic
DOC for HTN w/ MI
(2)
B-blocker & ACEI
DOC for HTN w/ osteoporosis
Thiazide
(dec. calcium excretion)
DOC for HTN w/ BPH
Terazosin
(Alpha-blocker)
DOC for HTN w/ pregnancy
alpha-methyldopa
(3) contraindications for Beta-blockers
COPD
Diabetes
HyperK
(3) contraindications for ACEI
Pregnancy
Renal artery stenosis
Renal Failure (creatinine >1.5)
contraindication of all diuretics
Gout
(2) hypersteroidism syndromes that cause HTN w/ hyperK
Cushing's

Conn's
endocrine system abnormality that can lead to HTN due to episiodic autonomic bursts of epinepherine
Pheochomocytoma
congenital cause of HTN that leads to HTN in arms and low BP in legs
Coartation of the Aorta
renal artery stenosis that causes HTN in:
1) older men
2) younger women
1) atherosclerosis

2) fibromuscular dysplasia
valvular problem that causes HTN w/ a wide PP due to Inc SV
Aortic Regurg
congenital problem that causes HTN w/ a wide PP due to Inc SV
Patent Ductus Arteriosus
(3) drug classes that cause HTN

What metal poisoning?
Oral contraceptives
Corticosteroids
Amphetamines

Lead poisoning
(5) deadly causes of chest pain
TAPUM:
Tension pneumothorax
Aortic Dissection
PE
Unstable Angina
MI
how is the maximum HR determined?
220-patient's age = Max HR
(6) Major risk factors for CAD
which is most prevetable?
which is the greatest risk?
Diabetes (greatest)
Smoking (most preventable)
HTN
Hypercholesterolemia
Family Hx
Age
Chest pain that has an established character, timing and duration; pain is transient, reproducable and predictable.
What is cause?
What is Tx? (2)
Stable Angina

Reduced coronary blood flow through fixed athrosclerotic plaque in vessel of heart

rest & nitroglyerin
exertional substernal (precordial) chest pressure and pain radiating to left arm, jaw or back.
N/V, diaphoresis, dyspnea, HTN and tachycardia can accompany it.
Name the types
Angina:

Stable
Unstable
Variant (Prinzmetal's)
Angina type that is also considered an Acute Coronary Syndrome (ACS).
What (3) factors must it have for diagnosis?
Unstable Angina

1) New-onset
2) angina that changes or accelerates in pattern, location or severity
3) Occurs at REST
Similar characteristics of stable angina, but due to vasospasm instead of atherosclerosis.
(2) Tx?
Variant (Prinzmetal's) Angina

Nitrates & Calcium Channel blockers
what (2) groups of patients may not show the classic signs pain seen in stable angina?
Why?
Elderly & diabetics

(b/c: neuropathies)
What does the EKG look like for the (3) angina types?
Stable & Unstable:
- ST Depression
- T-wave Inversion

Variant:
- ST elevation
62-yo smoker w/ 3 episodes of severe heavy chest pain in the morning. Each lasted 3 - 5 minutes, but he has no pain now. He has never had this before.
What is it?
Unstable Angina
62-yo man w/ frequent episodes of chest pain on and off for 8 months. He says the pain wakes him from sleep at night.
What is it?
Variant (Prinzmetal's) Angina
what is the alternative to an exercise Stress Test if the patient cannot get on a treadmill?
IV Dobutamine is given to stimulate myocardial function
What is the criteria for a "positive" Stress Test?
(5)
either:
- ST elevation
- ST depression >1 mm in multiple leads
- Dec BP
- failure to go more than 2 minutes
- failure to complete for reason other then cardiac symptoms (i.e. arthritis)
what does Myocardial Perfusion Imaging detect?
(3)
- Myocardial perfusion
- Ventricular volume
- Ejection Fraction
An ultrasound of the heart revealing abnormal wall motion due to ischemia or infarction. It also assesses left ventricular function and EF
Echocardiography
(5) uses for a cardiac catherization
1) MI / Unstable angina: stent or angiography
2) Valvular disease: valvuloplasty
3) Arrhythmias: mapping bypass tracts
4) Myocardial dz Bx: glycogen storage dz or cardiomyopathies
5) Congenital heart dz identification: angiography & closure of defects
(4) serum markers for MI
Myoglobin
Troponin T/I
CK
Lactate Dehydrogenase
How is the right heart accessed in a cardiac catherization? (2)

Left heart? (2)
Right:
Femoral or Internal Jugular

Left:
Femoral or Radial artery (from right heart)
what is the wave morphology changes sequence in a MI ECG?
(6)
1. peaked T-waves
2. T-wave inversion
3. ST elevation
4. Q-waves
5. ST normalization
6. T-waves return upright
which cardiac enzyme is the most sensitive and specific for acute MI?
Troponin-I/T
which cardiac enzyme remains increased (peaked) the longest?
LDH
what does ST depression mean?
ST goes in the opposite direction of the QRS
what does a Q-wave on an EKG in the presence of an infarction indicate?
Transmural infarction
(extends through full thickness of the myocardial wall)
Time of onset for the (4) serum markers for MI
Myoglobin (1-4 hrs)
Troponin-I/T (3-12)
CK-MB (3-12)
LDH (6-12)
which cardiac enzyme has the shortest duration?

Longest?
Myoglobin (1 day)

Troponin-I/T (7-10 days)
ST elevation in II, III & aVF
Inferior wall MI
ST depression in II, III & aVF
Cor Pulmonale
ST elevation in V1, V2, V3
Anterior/septal MI
ST elevation in V4, V5, V6
Lateral wall MI
ST depression in V1, V2
Posterior wall MI
difference b/t unstable angina & non-ST elevation MI?
(2)
non-ST elevation MI has:
1. more severe lack of Oxygen (more severe myocardial damage)
2. Enzyme leakage (Unstable angina has none)
Tx for Unstable angina & MI
(6)
MONA has HEP B:

Morphine
Oxygen
Nitrates
Aspirin
HEParin
Beta-blockers
primary Tx (2) for the acute MI w/in 6 hours of infarct
(name 4 drugs)
Throbolytics:
- tPA + Heparin (DOC)
- Urokinase
- strptokinase
- Alteplase
At what level should LDL be in person w/ MI history?
What is given to lower it?
less then 100

statins
When are throbolytics indicated in MI?
(3)
- patients < 80 yo
- within 6-12 hrs of chest pain
- evidence of infarct on ECG
Contra-indications of Throbolytics
(9)
Having Some Breaks A Blood Clot In Small Pieces:
- Hx of intracranial bleed
- stroke < 1 year
- BP > 180/110
- active internal bleed
- bleeding disorder
- CPR
- Intracranial tumor
- suspected aortic dissection
- Peptic ulcer
drug class that is used to break up clots
throbolytics
drug that prevents future clots from forming
heparin
Tx of choice for MI if there is a high risk of ST elevation (cardiogenic shock) or it has been 3 hours since initial symptoms presented?
PTCA
(Percutaneous Transluminal Coronary Angioplasty)
which throbolytic is highly immunogenic and cannot be used in the same patient twice in a 6 month period?
streptokinase
what should be given 48 hours post infarct if tPA was used?
heparin
drug class that is excellent for late & long-term therapy for acute MI to decrease afterload and prevent remodeling?
ACEi
how many seconds & boxes is a normal PR interval?
0.2 ms

5 small boxes
define:

Q-wave

When is it pathologic?
when initial part of ventricular depolarization is downward

Pathologic: greater then 1 small box
normal time & boxes for QRS interval?
< 0.12 ms

3 small boxes
normal sinus rate
60 - 100 bpm
define:

Junctional rhythm
rhythm originating in the AV node & causing narrow QRS w/o P-waves
no p-waves;
all complexes are wide;
no changes in height (amplitude) w/ each complex;
> 100bpm
Ventricular tachycardia
wide QRS complexes that vary in amplitude
(2 names)
Ventricular Fibrillation

Torsades de Pointes
normal sinus rhythm w/ PR interval > 0.2 ms (> 5 small boxes)
First-degree AV block
PR interval elongates from beat to beat until it becomes so long that a beat drops
Second-degree AV block, type 1
(Wenckebach)
PR interval is fixed but every so often there is a P-wave w/o a QRS
Second-degree AV block, type 2
(Mobitz)
no relationship b/t P-waves and QRS complexes
Third-degree AV block
QRS > 0.12 (> 3 small boxes)
RSR' in V1 & V2;
deep S-wave in lateral leads (I, aVL, V5 & V6)
RBBB
QRS > 0.12 (> 3 small boxes);
RSR' in V5 & V6;
diffuse ST elevation
LBBB
Different shapes to 3 or more P-waves;
normal rhythm

(what is it called if it is tachycardic?)
Wandering pacemaker

MFAT:
Multifocal Atrial Tachycardia
short PR interval;
slurring delta wave connecting P-wave to QRS complex
Wolff-Parkinson-White syndrome
diffuse ST elevation that slopes in a concave manner back to baseline + diffuse PR segment depression in all leads except PR elevation in aVR
Pericarditis
Tx of wandering pacemaker & MFAT?
(1 drug / 1 "other")
Verapamil (Ca channel block)
&
Tx underlying condition
what Tx breaks SVT (superventricular tachy) in > 90%?
Adenosine

(failure to break r/o SVT)
Tx for V-tach w/ hypotension or no pulse
Emergency defibrillation @
200 - 360 J
Tx of asymptomatic V-tach
(2)
Amiodarone

Lidocaine
Tx of V-Fib
Emergent electroshock @
200 - 360 J
58-yo man discharged from hospital after MI 2 weeks ago presents w/ fever, chest pain & malaise. EKG shows diffuse ST-T wave changes.
What is Dx?
What is Tx?
Dressler's syndrome

NSAIDs
Medication orders w/ dischsrge of an ACS (post-MI) patient?
(5)
easy AS ABC:

- Aspirin (indefinitely)
- Statin to lower LDL < 100
- ACE-inh (if EF <40%)
- Beta-blocker (indefinitely)
- Clopidogrel for 1 - 12 mo depending on stent placement
Dx:
fever, pericarditis & possible pericardial or pleural effusions post cardiac surgery
Dressler's syndrome
how do you distinguish Paroxysmal Noctournal Dyspnea from asthma?
no improvement w/ bronchodilators
SVT w/ AV block & yellow skin
Digoxin toxicity
Etiology of Dilated Cardiomyopathy
(6)
TIMED:
- Toxic (EtOH, heavy metals)
- Infectious / Ischemic
- Metabolic / Mechanical (arrthymia, valve dz)
- Endocrine
- Drugs
what is the Reversible & Irreversible(2) toxic causes of Dilated Cardiomyopathy?
Reversible:
prolonged EtOH use

Irreversible:
Cocaine;
heavy metal toxicity
what is the Reversible & Irreversible(2) endocrine causes of Dilated Cardiomyopathy?
Reversible:
Thyroid disease (hypo or hyper)

Irreversible:
Acromegaly;
Pheochromocytoma
Reversible metabolic causes of Dilated Cardiomyopathy?
(4)
HypoC;
HypoP;
Thiamine deficiency (wet beri-beri);
Selenium deficiency
Infections that cause Dilated Cardiomyopathy
(3)
HIV;
Coxsackie virus;
Chagas disease
Drugs that cause Dilated Cardiomyopathy
(2)
Doxorubicin (Adriamycin);
AZT
Signs/Sx of Dilated Cardiomyopathy
RAMS:
R & L Heart failure;
A-fib;
Mitral regurg;
S-3 Gallop
Diastolic or Systolic Dz Cardiomyopathy:
1. Dilated
2. Restrictive
3. Hypertrophic
Systolic:
Dilated

Diastolic:
Restrictive &
Hypertrophic
Diagnostic results of Dilated cardiomyopathy
- auscultation
- EKG (3)
- CXR (2)
- Echo (2)
Auscultation: S-3;
EKG: Vent Hypertrophy, BBB &/or A-fib;
CXR: Inc heart size; pulm congestion
Echo: low EF, large ventricles
Tx Dilated Cardiomyopathy
(3)
- stop any toxic agents
- anticoagulation w/ coumadin (even w/o evidence of thrombus)
- heart transplant
Right or left ventricular enlargement w/ loss of contractile function causing CHF, arrythymia, or throbus formation.
Dilated Cardiomyopathy
Scarring & infiltration of the myocardium causing decreased right or left ventricular filling
Restrictive Cardiomyopathy
Etiology of Restrictive Cardiomyopathy
(7)
ACHES:
Amyloidosis;
Carcinoid heart dz / Congenital;
Hemochromatosis;
Endomyocardial fibrosis
Sarcoidosis / Scleroderma
Dx:
Pulmonary HTN (right CHF);
S-4 gallop; Low QRS voltage on EKG; Exercise intolerance;
Diastolic dz
Restrictive Cardiomyopathy
(5) tests used to assist in the Dx of Restrictive Cardiomyopathy
Aucsultation;
EKG;
CXR;
Echo;
Endomyocardial Bx*
Increase in the size of the interventricular septum causing narrowing of the LV outflow tract leading to anterior mitral valve outflow obstruction
Hypertrophic Cardiomyopathy
another name for Hypertrophic Cardiomyopathy
IHSS
Idiopathic Hypertrophic Subaortic Stenosis
(3) causes of paradoxical splitting of S-2
Hypertrophic cardiomyopathy (IHSS);
Aortic stenosis;
LBBB
murmur that decrease with squatting (and increases when returning to standing position)
Hypertrophic CM
(IHSS)
etiology of Hypertrophic Cardiomyopathy
50% idiopathic
50% familial (autosomal dominant, w/ variable penetrance)
Dx:
Angina (at rest or exercise); Syncope; Arrhythmias; CHF
Hypertrophic Cardiomyopathy
sudden death from Hypertrophic CM is usually due to what?
Arrhythmias
25-yo man becomes severly dyspneic & collapses while running laps, His father died suddenly at an early age.
Hypertrophic CM (IHSS)
Diagnostic results to Dx Hypertrophic CM
- Auscultation (2)
- EKG (4)
- Echo (2)
Auscultation - Systolic ejection murmur;
Paradoxical splitting of S2;
EKG - LVH, PVCs, A-fib, ST & Q abnormalities;
Echo - septal hypertrophy, LVH w/ small LV
Tx for Hypertrophic CM
(3)
- No exercise
- Beta-blocker
- implantable cardiac defibrillator
Most common infectious cause of Myocarditis
Coxsackie B
(4) systemic diseases that causes Myocarditis
KISS:
- Kawasaki's
- Inflammatory conditions
- SLE
- Sarcoidosis
(4) Parasites that cause Myocarditis
Trypanosoma Cruzi (Chagas);
Toxoplasmosis;
Trichinella;
Echinococcus
(5) Bacterial causes of Myocarditis
Group A beta-hemolytic Strep (rheumatic fever);
Corynebacterium;
Meningococcus;
Lyme (B. burgdorferi);
Trichinella
(8) viral causes of myocarditis
Coxsackie A or B;
Echovirus; EBV:
HIV; HBV
CMV;
Influenza;
Adenovirus
(3) drugs that cause pericarditis
Hydralazine;
Isoniazid;
Procainamide
Etiology of Pericarditis
(6)
Bacterial, viral or fungal infections;
Serositis from:
RA;
SLE;
Scleroderma;
Uremia;
post-MI (Dressler's syndrome)
Tx for pericarditis if:
- infection
- pain/inflammation
- Dressler's
- Recurrent cases
- Tx infection w/ Abx;
- NSAIDs to relieve pain & reduce inflammation;
- Steroids for Dressler's;
- Pericardectomy only w/ recurrent cases
Transient fall in BP > 10 mmHg during inspiration
Pulsus Paradoxus
Physiologic result of rapid accumulation of fluid in the pericardial sac; impairs cardiac filling & reduces cardiac output
Pericardial Tamponade
Etiology of Pericardial Tamponade
(3)
- Pericarditis
- Trauma
- Aortic dissection or ventricular rupture into pericardium
Beck's triad of the pericardial tamponade

(4) other signs/Sx
Beck's triad:
- Hypotension
- Muffled heart sounds
- JVD

Other Sx:
Dyspnea;
Tachycardia;
Pulsus Paradoxus*
narrow Pulse Pressure
Tx for Pericardial Tamponade for:
1. unstable
2. stable
3. both
Unstable: Immediate Pericardiocentesis;

Stable: Pericardial window

Both: Infuse fluids to expand volume
Failure of venous pressure to fall during inspiration
Kussmaul's sign
If pericardiocentesis has clots, what is likely source of blood?
Right Ventricle
Patient has chest pain w/ inspiration that radiates to the left trapezial ridge;
Pain is relieved by sitting up and leaning forward; does not respond to nitroglycerine
Pericarditis
additional signs/Sx for Constrictive pericarditis (versus pericarditis)
(4)
- JVD
- Kussmaul's sign
- peripheral edema
- LV failure
Heart valve dz almost always due to Rheumatic Fever
mitral stenosis
Murmur type:
Dyspnea on Exertion; Cough, rales; signs of RV failure;
RV precordial thrust; Hoarse voice (from enlarged LA on recurrent laryngeal nerve)
Mitral Stenosis
Diagnostic results for Mitral Stenosis
- Auscultation
- CXR
- EKG
Auscultation: mid-diastolic opening snap;

CXR: large Left atrium & Kerely B lines

EKG: LA enlargement; RV hypertrophy; A-fib
Tx for mitral stenosis w/ each grade (I-IV)

What should always be avoided w/ mitral stenosis tx?
Grade:
I: Diuretics; B-Blockers; Anticoagulants; Digitalis
II: Drugs from I + Balloon valvuloplasty (if drugs dont work)
III/IV: Balloon Valvuloplasty

Avoid: Inotropic Agents!
Acute etiology of Mitral Regurgitation
(2)
MI w/ papillary muscle rupture;
Endocarditis
Chronic etiology of Mitral Regurgitation
(3)
Rheumatic fever;
Mitral Prolapse;
LV dilation
Diagnostic tests for Mitral Regurgitation
- Auscultation
- EKG
- Echo
Auscultation: Loud, holosystolic apical murmur radiating to axilla

EKG: large LA

Echo: valve problem
Tx for Mitral Regurgitation
(6)
ACEinh;
Diuretics;
Vasodilators;
Digitalis;
Endocarditis prophylaxis;
Surgery if severe
Most common valvular disorder
Mitral prolapse
Asymptomatic murmur w/ genetic predisopositon, seen most commonly in women
Mitral Prolapse
What murmur is seen in Marfan's syndrome?
Mitral prolapse
Tx for mitral prolapse?
not necessary to tx unless symptomatic
Mean survival rate for patients w/ Aortic Stenosis and:
1. Angina
2. Syncope
3. Heart failure
1. 5 years
2. 2 - 3 years
3. 1 - 2 years
Etiology of Aortic Stenosis
(2)
- Calcific dz w/ age
- Bicuspid valve (around age 40)
Conditions w/ a wide Pulse Pressure
(6)
WAH-HAH-ide pulse pressure:
Wet beri-beri
Aortic Regurgitation;
Hyperthyroidism;
Hypertension;
Anemia;
Hypertrophic Subaortic Stenosis (IHSS)
WHat (2) valve disorders result in severe decompensation to CHF due to the absence of hemodynamic compensation.
How is it treated?
Mitral Regurg
Aortic Regurg

Tx: Emergent surgery
Classic triad of Sx for Aortic Stenosis

(4) other signs
SAD:
- Syncope;
- Angina;
- Dyspna on Exertion

Others:
- Forceful apex beat
- narrow Pulse Pressure
- Paradoxical S2 split
- heard in carotids
Diagnostic test results for Aortic Stenosis
- Auscultation
- EKG
- Echo
- CXR
Auscultation: Loud systolic crescendo-decrescendo murmur;

EKG: LV strain

CXR: calcifications on valve

Echo: diseased valve
What is the EKG LV strain pattern seen in aortic stenosis?
ST depression & T-wave inversion in I, aVL, V5 & V6
Tx for aortic stenosis
(2)
- avoid Afterload reducers (ACEinh & beta-blockers)
- Valve replacement
(3) main etiologies for Aortic Regurgitation
Aortic root dilatation;
Valvular dz;
Proximal Aortic root dissection
(3) causes of Aortic root dilatation thereby causing Aortic Regurg
Marfan's;
Idiopathic (but inc w/ HTN);
Collagen vascular dz
(2) causes of Valvular dz thereby causing Aortic Regurg
Rheumatic heart dz;
Endocarditis
(6) causes of proximal Aortic root dissection thereby causing Aortic Regurg
"C 3 SHET":
Cystic medial necrosis (Marfans);
3rd trimester pregnancy;
Syphilis;
HTN;
Ehlers-Danlos;
Turner's syndrome
Names of the 7 unique signs of Aortic regurg
1. Water-Hammer pulse
2. Traube's sign
3. Corrigan's pulse
4. Quincke's sign
5. de Musset's sign
6. Muller's sign
7. Duroziez's sign
Aortic regurg sign:

wide pulse pressure presenting w/forceful arterial pulse upswing w/ rapid falloff
Water-Hammer pulse
Aortic regurg sign:

pistol-shot bruit over femoral pulse
Traube's sign
Aortic regurg sign:

unusually large carotid pulsations
Corrigan's pulse
Aortic regurg sign:

pulsatile blanching & reddening of fingernails upon light pressure
Quincke's sign
Aortic regurg sign:

head bobbing caused by carotid pulsation
de Musset's sign
Aortic regurg sign:

pulsatile bobbing of the uvula
Muller's sign
Aortic regurg sign:

to-&-fro murmur over femoral artery (heard best w/ mild pressure applied to artery)
Duroziez's sign
Murmur presentation:
dyspnea, orthopnea, paroxysmal noctournal dyspnea, angina, LV failure,
wide pulse pressure
Aortic regurg
Murmur presentation:
starts asymptomatic, then dyspnea, angina, syncope, heart failure
Aortic stenosis
Murmur presentation:
mostly asymptomatic, atypical chest pain, SOB, fatigue
Mitral Prolapse
Murmur presentation:
dyspnea, fatigue, weakness, cough, A-fib, systemic emboli
Mitral Regurg
Murmur presentation:
DOE, rales, cough, hemoptysis, systemic emboli, RV precordial thrust, RV failure, Hoarse voice
Mitral stenosis
How do you diagnose LVH from a ECG?
(2)
1. S-wave in V1 + R-wave in V5 or V6 > 7 large boxes (35 small)

2. R-wave in V5 or V6 > 25 small boxes OR R-wave in lead aVL > 11 small boxes
Diagnostic tests for Aortic Regurg
- Auscultation (3)
- EKG
Auscultation:
1. Holosystolic, blowing decrescendo diastolic murmur
2. Apical diastolic rumble (mitral stenosis w/o snap)
3. Midsystolic flow murmur at base
EKG: LVH
Echo: regurgitant valve
Tx for Aortic regurg
(3)
Tx LV heart failure;
Endocarditis prophylaxis;
Valve replacement
Etiology of Tricuspid stenosis
(3)
Rheumatic heart dz;
Congenital;
Carcinoid
Murmur presentation:
peripheral edema, JVD, hepatomegaly, ascites, jaundice
(2)
Tricuspid stenosis

or

Tricuspid Regurg
Diagnostic results for Tricuspid stenosis:
- auscultation
- echo

Tx?
Dx:
Auscultation: diastolic, rumbling low-pitched heard w/ inspiration
Echo: diseased valve

Tx: surgical repair
Dx:
Patient w/ DVT has a stroke. He has a fixed S2 split
Atrial-septal defect
(w/ right-to-left emboli)
Etiology of Tricuspid Regurg
(4)
Increased pulmonary artery Pressure (from L-CHF or Mitral stenosis/regurg);
R-CHF;
Right papillary muscle rupture w/ MI;
Tricuspid valve lesions (rheumatic heart or bacterial endocarditis)
(3) causes of a holosystolic murmur
Mitral Regurg;
Tricuspid regurg;
Ventricular Septal Defect
Number 1 cause of death in CHF patients
Arrhythmia
Diagnostic results for Tricuspid Regurg
- Auscultation
- EKG
- Echo
Auscultation: Holosystolic murmur increasing w/ inspiration
EKG: RV enlargement; A-fib
Echo: diseased valve
Tx for Tricuspid Regurg
(3)
Tx heart failure;
Diuresis;
Surgical repair of valve
What is done first if a patient has hyperK and peaked T-waves?
Why?
give Calcium

to stabilize cardiac membrane
Causes of prolonged QT
(8)
QT WIDTH:

QT: Prolonged QT syndrome
W: WPW
I: Infarction
D: Drugs
T: Torsades de pointes
H: HypoK, HypoC, Hypomagnesium
Causes short QT
HyperC
Causes of Torsades de Pointes
(7)
POINTES:
Phenothiazines
Other meds (TCAs)
Intracranial bleed
No known cause (idiopathic)
Type 1 Anti-arrhthymics
Electrolyte abnormalities
Syndrome of prolonged QT
Murmur:

Diastolic apical rumble & opening snap
Mitral stenosis
Murmur:

Late systolic murmur w/ midsystolic click

What is confirming test?
Mitral Prolapse

Valsalva - click starts earlier, murmur prolonged
Murmur:

High-pitched apical blowing holosystolic murmur

where does it radiate?
Mitral Regurg

radiates to axilla
Murmur:

Diastolic rumble louder w/ inspiration
Tricuspid stenosis
Murmur:

High-pitched blowing holosystolic murmur heard better w/ inspiration

Where is it heard?
Where are pulsations seen?
Tricuspid Regurg

- heard @ left sternal border
- Jugular pulsations
Name sign:
Peripheral pulses that are weak & late compared to heart sounds

What murmur?
Pulsus Parvus et Tardus

Aortic Stenosis
Murmur:

midsystolic crescendo-decrescendo murmur

Where does it radiate? (2)
What is also heard?
Aortic stenosis

radiates to:
Carotids & Apex

- S4 also heard
Name sign:
Double-peaked arterial pulse

what murmur?
Pulsus Bisferiens

Aortic regurg
Murmur:

Blowing early diastolic, apical diastolic rumble, midsystolic flow murmurs
Aortic Regurg
Murmur:

Systolic murmur at apex & left sternal boarder not transmitted to carotids

How is it heard better?
IHSS

heard better w/ standing after squat
When do you hear the "flow murmur" (murmur heard w/ any high flow state)?
What is differential dx?
(5)
Midsystolic:
Aortic Regurg
A-S defect (fixed split S2)
Anemia
Adolescence
Pregnancy
What can be given to a patient to temporarily slow a rapid supraventricular rhythm in order for you to be able to identify it?
Adenosine
What drugs should not be given to someone w/ Wolff-Parkinson-White syndrome?
(4)

What is the DOC?
ABCD:
Adenosine
Beta-blockers
Calcium channel blockers
Digoxin

DOC:
Procainamide
Causes of Mobitz I
(3)

Causes of Mobitz II
(2)
Mobitz I:
Inferior wall MI
Digitalis toxicity
Inc Vagal tone

Mobitz II:
Inferior or septal wall MI
Conduction system disease
Tx for Mobitz I & II
Both:
Atropine & temporary pacing

(Mobitz II should have pacemaker)
Causes of third-degree heart block
(3)
Digitalis toxicity
Inferior wall MI
Conduction system disease
Causes of Bradycardia
(6)
if R-R is longer then "One INCH"
Overmedication;
Inferior MI / Inc intracranial Pressure;
Normal variant (athletes);
Carotid sinus hypersensitivity;
Hypoparathyroidism
Tx for bradycardia
(3)
Atropine
pacing
pressors for hypotension
a 24-yo woman w/ preclampsia Tx w/ IV drip of magnesium complains of difficulty breathing & has diminished reflexes. Next step?
Stop magnesium & give IV calcium
equation for Mean Arterial Pressure
MAP = (2dBP + sBP)/3
heart medication that can cause cyanide toxicity
Nitroprusside
Tx for Hypertensive emergency due to pheochromocytoma
Phentolamine
(2) possible Tx for a preclampsia-related hypertensive emergency
Hydralazine
or
Magnesium
difference b/t Type A & Type B Aortic Dissections
Type A:
involves the ascending aorta & can extend into the descending aorta

Type B:
descending aorta only
Debakey Classification of Aortic Dissection Types I-III

Which is most common?
I: Ascending plus part of distal aorta (most common)

II: Ascending only

III: Descending only
What is infected on the aorta when the aortic dissection is due to syphilis?
Vasa Vasorum
Etiology of Aortic Dissection
(7)
PATC3H:
Pregnancy (3rd trimester);
Aortic Coarctation (Turners or idiopathic);
Trauma;
Congenital heart dz / CT dz (Marfans & E-D syndromes) / Cocaine;
HTN
Dx:
Severe tearing chest pain that radiates to the back, HTN, possible unequal pulses distally, possible aortic regurg murmur
Aortic Dissection
(3) tests to confirm Dx of aortic dissection
CXR - wide mediastinum
CT w/ contrast
Angiogram (gold standard)
Drug Tx for Aortic dissection to stabilize BP

What is the next step for Type A vs. Type B?
Rx: Beta-blocker + nitroprusside to keep BP < 120

Type A: Immediate surgery
Type B: medical stabilization
When a patient has VHD or previous endocarditis, what (3) procedure types must they obtain endocarditis prophylaxis medications?
Dental procedures
Urologic procedures
GI procedures
Dx:
acute onset of fever, chills & rigors; new cardiac murmur, possible associated meningitis or pneumonia
Acute Bacterial Endocarditis
(ABE)
Infection of healthy heart valves by high-virulence organisms
MCC?
Px if not treated?
ABE

S. Aureus

Px: fatal if not Tx w/i 6 weeks
Dx:
seeding of previously damaged heart valves by rheumatic fever, mitral prolapse, etc by low-virulence organisms
MCC?
What valve is affected the most?
Subacute Bacterial Endocarditis

Strep Viridans

Mitral valve
What valve is most commonly affected w/ IV drug users?
What bug?
Tricuspid

S. Aureus
what endocarditis bug is associated w/ colonic neoplasms?
Strep Bovis
Dx:
gradual onset of fever, sweats, weakness, anorexia, new murmur, splenomegaly, Osler's nodes, splinter hemorrhages, Janeway lesions, Roth spots
Subacute Bacterial Endocarditis (SBE)
Name sign:
Tender violaceous subcutaneous nodules on fingers & toes
Osler's nodes

(SBE)
Name sign:
fine linear hemorrhages in the middle of nailbeds
Splinter Hemorrhages
Name sign:
multiple hemorrhagic nontender macules or nodules on palms & soles
Janeway Lesions
Name sign:
retinal hemorrhages w/ clear central areas seen on fundoscopy (w/ new murmur)
Roth's spots

(SBE)
What is considered Major criteria in the Duke's criteria for endocarditis?
(2)
1. Two positive blood cultures

2. Echo showing vegetations
What are the (6) Minor criteria in the Duke's criteria for endocarditis?
1. Fever
2. Predisposing heart abnormality
3. Arterial emboli (Janeway)
4. Osler nodes or Roth's spots
5. positive blood culture not meeting major criteria
6. Echo suspicious of endocarditis, but not meeting major criteria
For the Duke's criteria of Endocarditis, what are the (3) ways to dx w/ major and minor signs?
1. (2) major criteria

2. (1) major + (3) minor

3. (5) minor criteria
Tx for endocarditis that cultures:
1. Strep
2. Staph
3. MRSA
1. Ceftriaxone or Penicillin G (4 weeks)

2. Nafcillin (4 weeks)

3. Vancomycin (4 weeks)
What is the Tx for patients w/ Valular abnormalities if they are having dental procedures, GI or GU surgery?
(2)
Prophylactic:
Amoxicillin
or
Clarithromycin
Valvular dysfunction requiring surgery is common w/ which type of organism?
Fungi
(Candida or Aspergillus)
Endocarditis type:
due to cancer seeding heart valves during metastasis

what can it lead to?
Marantic endocarditis

leads to cerebral infarcts
Endocarditis type:
may be due to autoantibody damage of valves by SLE
Libman-Sacks endocarditis
MC valve affected by RHD
Mitral
Cause of Rheumatic fever?

What does it lead to?
Group A Strep

leads to Rheumatic Heart Disease (RHD) - immune complex deposits on valves
Major criteria (JONES criteria) for Dx Rheumatic fever
(5)
JCNES:
Joints (arthritis)
Carditis (myo-, endo- or peri-)
Nodules (sub-Q)
Erythema marginatum rash
Sydenham's chorea (face, tongue, upper limb)
Minor criteria for Dx Rheumatic fever
(5)
Fever
Prolonged PR interval
Elevated ESR
Arthralgias
Recent Strep infection
Tx for Rheumatic fever
(for strep, arthritis, carditis)
Penicillin for strep;
ASA for arthritis;
Steroids for carditis
Etiologies of Syncope
(7)
SVNCOPE:
Situational (valsalva, tight collar);
Vasovagal response (common faint);
Neurogenic;
Cardiac;
Orthostatic hypotension;
Psychiatric (faking it);
Everything else (idiopathic)
At what level is HDL cardioprotective?
> 60
What "type" is all isolated hypercholesterolemia?
Type IIa
What transports cholesterol from the gut to the bloodstream?
Chylomicrons
What is left over after lipoprotein lipase liberates FFA from chylomicrons for use in tissues?
Chylomicron remnants
What is secreted from the liver and carries endogenous cholesterol?
VLDL
What is metabolized from VLDL?
Intermediate-Density Lipoproteins
(IDL)
What is metabolized from IDL & carries cholesterol in the bloodstream to the tissues?
LDL
What takes up free cholesterol secreted by the tissues and transports it to the liver?
HDL
What is the name for the (3) Type IIa Isolated Hypercholesterolemias?

What is abnormal with all of them?
Familial Hypercholesterolemia;
Familial defective apo-B100;
Polygenic Hypercholesterolemia

High LDL
(total cholesterol from 240 - 500)
What are the (3) isolated Hypertriglyceridemias & each "Type"?
What is elevated w/ each?
1. Familial Hypertriglyeridemia
Type IV - high VLDL
2. Familial Lipoprotein Lipase deficiency
3. Familial apo-CII deficiency
(both Type I & V - high chylomicrons)
At what level is HDL cardioprotective?
> 60
What "type" is all isolated hypercholesterolemia?
Type IIa
What transports cholesterol from the gut to the bloodstream?
Chylomicrons
What is left over after lipoprotein lipase liberates FFA from chylomicrons for use in tissues?
Chylomicron remnants
What is secreted from the liver and carries endogenous cholesterol?
VLDL
What is metabolized from VLDL?
Intermediate-Density Lipoproteins
(IDL)
What is metabolized from IDL & carries cholesterol in the bloodstream to the tissues?
LDL
What takes up free cholesterol secreted by the tissues and transports it to the liver?
HDL
What is the name for the (3) Type IIa Isolated Hypercholesterolemias?

What is abnormal with all of them?
Familial Hypercholesterolemia;
Familial defective apo-B100;
Polygenic Hypercholesterolemia

High LDL
(total cholesterol from 240 - 500)
What are the (3) isolated Hypertriglyceridemias & each "Type"?
What is lelvated w/ each?
1. Familial Hypertriglyeridemia
Type IV - high VLDL
2. Familial Lipoprotein Lipase deficiency
3. Familial apo-CII deficiency
(both Type I & V - high chylomicrons)
Class of drugs that that reduce LDL by binding bile acids in the gut.

name (2) drugs
Bile Acid Sequestrants

Cholestyramine
Colestipol
which drug class is best for reducing triglycerides in VLDL & chylomicrons?
Fibrinates