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291 Cards in this Set

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  • Back
Name the 3 Cardiomypoathies?
1) Dilated
2) Hypertrophic
3) Restrictive
What is the most common cause of Dilated cardiomyopathy?
Alcohol abuse

May also be idiopathic, infectious, or drugs.
Dilated cardiomyopathy has symptoms similar to?
CHF
What is Dilated CM?
Cardiac dilatation leading to right and left systolic dysfunction and then CHF.
What is the first symptom of Dilated CM?
Exertional intolerance
Other S/S or dilated DCM?
-dyspnea, orthopnea, and edema in lower extremities.
-May have S3, chest pain, and crackles.
DX of DCM?
EXG is diagnostic
Also get Cxt Xray and ECHO
What are the ECG finding of DCM?
nonspecific ST and T wave changes and possible LBBB
What is the EF with DCM you would most likely see?
<30% EF
TX of DCM?
-Withdraw from alcohol
-TX CHF with diuretics, digoxin and sodium restriction.
-ACE and Beta blockers, may need cardiac transplant if really bad.
What is the most common cause of sudden death in young athletes?
Hypertrophic Cardiomyopathy
What is the death with HCM due to?
Ventricular arrythmias
What is the cause of HCM?
Autosomal dominant gene allele can be seen in most cases.
What happens on HCM?
-Hypertrophy of the cardiac septum leads to LV outflow obstuction and impaired diastolic filling.
And what does impaired diastolic filling lead to?
Pulmonary congestion
What is the most common presenting symptom of HCM?
Dyspnea on exertion
PE of HCM includes?
-mitral regurgitation
-possible angina and syncope
-S4
-prominent left ventricular impulse
How do you dx HCM?
Echo make the diagnosis

EF > 60%
What does EKG reveal with HCM?
Left Ventricular Hypertrophy
TX of HCM?
-B-blockers(Propanalol)
-Ca channel blockers (Verapimil)-improves ventricular compliance.
-Diuretics
Restrictive Cardiomyopathy?
-Often caused by an infiltrative process
-Pulmonary congestion
-Right sided heart failure
What are the signs of Right Sided Heart Failure with RCM?
Elevated JVD
-may have S4, mitral and tricuspid regurgitation.
DX of RCM?
ECHO is diagnostic
EF 25-50% and thickened LV wall thickness and increased atrial size
Specific dx=tissue biopsy
Tx of RCM?
Diuretics to tx CHF
What is an example of an infiltrative process that can cause RCM?
-Amyloidosis
-Sarcoidosis
-Hemochromatosis
Atrial Fibrillation
What is this?
What is the most common sustained arrythmia in adults?
Atrial Fibrillation
What is the increased risk with A fib that you have to worry about?
Inta-atrial clot formation, will need long term coagulation like Heparin acutely and Warfarin long- term.
Increased risk of stroke with the micro-emboli
What are the EKG finding of A fib?
-Rapid, irregular-irregular atrial rate >400b/m
-A fib waves may be Coase, fine, and difficult to discern.
-Vent rate 100-200 b/m
-
Tx of A fib?
1) Rate control(beta blockers, Ca channel blockers, or digoxin
2) Anticoagulation is vital
3) Rhythm control with Amiodarone and possible cardiioversion.
What presents with a Sawtooth pattern of P waves?
Atrial Flutter
Where do you see the Sawtooth pattern of atrial flutter?
Leads II, III, and aVF
What are some to the S/S of atrial flutter?
-dizziness
-palpatations
-cxt pain
-dyspnea
Treatment of A flutter?
-Cardioversion
-Beta blockers, calcium channel blockers
Esmolol and Metroprolol are examples of?
Beta blockers
Verapimil and diltiazem are examples of?
Calcium channel blockers
Multifocal atrial tachycardia?
-Seen in pt's with COPD/severe systemic illness
EKG findings of MAT?
-Multiple shaped P waves
-Differing PR intervals
What are the agents of choice for TX of MAT?
Calcium channel blockers
What is an AV block?
-defined as when some impulses are delayed or do not reach the ventricle.
What S/S may be noted with an AV block?
Syncope
Definition of a First Degree AV block?
-PR interval > .02 seconds
Definition of a second degree AV block?
-Some P waves fail to produce a QRS.
Mobitz Type I (Wenckebach)
-Progressive increase in PR interval, until a P wave is blocked, and the cycle is repeated.
-PR interval after interval is usually the longest
Mobitz type II?
-Sudden block of a P wave with no change in PR interval.
Third degree block?
-Occurs when atria and ventricle are controlled by different pacemakers.
-Atria and ventricles are independent of each other.
TX of Third degree block?
-Asymptomatic = no tx needed
-Correct reversible causes
-May need atropine or isoproterenol
-May need pacing
What may develop after an acute MI on EKG?
Bundle Branch Block

May be seen with CM, pulm embolism, and aortic stenosis
What is a BBB due to?
Conduction delay in the right or left bundle branches
RBBB
What is this?
Qualities of a RBB?
-Wide QRS >.11 seconds
-rSR in lead V1
-Wide terminal S wave in leads I and V6
-May note ST depression in V1 and elevation in I and V6
-Wide QRS
-Upright and notched QRS in lead I and V6
-Mostly negative QRS in lead V1
-ST elevation in V1 and depression in I and V6
LBB?
WPW?
-WIde QRS
-A Delta wave is present at the start of the QRS complex
-PR interval is short
Tx for WPW?
-tx unerlying cause
What do you not use in WPW?
-Digoxin or Calcium Channel blockers, meds which slow down rate rare Contraindicated**
Paroxysmal Supraventricular Tachycardia?
-Re-entry Tachycardia
-Elderly with underlying disease
-Also called AV nodal re-entry
-Palpations/Anxiety
What is the Tx of choice for PST?
-Adenosine (slows rate)


-Vagal man. or anti-anxiety meds too
PAC?
-Underlying rhythm interupted by early beat from atria Other than SA node.

-Tx with antiarrythmic drugs.
PVC?
-Underlying rhythm interupted by an early beat from the ventricles.
TX PVC?
-tx underlying cause
-May lead to life threatning Vent arrythmia
-May need beta blockers
V-Tach?
-Originates from below bundle of HIS at a rate > 100 b/m
What can cause V-Tach?
-electrolyte imbalances
-acid-base abnormalities
-Hypoxemia
-MI
-Drugs
S/S of V-tach if unstable?
-Syncope, cxt-pain, and dyspnea
What can V-tach cause?
-Sudden Cardiac Death!
Torsades De Pointes?
-Polymorphic VT in which the QRS complexes change in amplitude around the isoelectric axis.
TX Torsades De Pointes?
-Antiarrythmic
-cardioversion
What can cause V-Tach?
-electrolyte imbalances
-acid-base abnormalities
-Hypoxemia
-MI
-Drugs
S/S of V-tach if unstable?
-Syncope, cxt-pain, and dyspnea
What can V-tach cause?
-Sudden Cardiac Death!
Torsades De Pointes?
-Polymorphic VT in which the QRS complexes change in amplitude around the isoelectric axis.
TX Torsades De Pointes?
-Antiarrythmic
-cardioversion
Amiodarone, Lidocaine, and Procainamide are examples of?
-Anti-arrhythmics
Ventricular Fibrillation?
-Malignant arrhythmia with disorganized elecrical activity leading to failure of cardiac contraction and failure to maintain CO.
What type of pt's is V Fib seen with?
Ischemic heart disease
Left ventricular dysfunction
V-Fib EKG?
-Irregular rhythm with and undulating low-amplitude baseline with no organized QRS or T-waves
Tx for V-fib?
Electrical Defibrillation!
V-Fllutter?
-Very rapid unstable form of VT
-Progresses to V-fib!
-electrical defibrillation required
Defect in the atrial septum allowing shunting of blood between the atria
ASD
What is the most common type of ASD defect?
-Ostium Secundum defect noted in the mid-portion of the atrial septum
What can you see on PE for ASD?
-Slow weight gain history of
-Recurrent lower resp tract infections
-Wide split S2
Pt may be asymptomatic
What type of murmur is heard with ASD?
-Systolic Ejection Murmur in the pulmonic area
- Mid Diastolic Rumble in the lower right sternal border
What are the murmurs and the rumble of ASD due to?
-increased flow across the pulmonic and tricuspid valves
Other findings of ASD?
Cxt-Xray=Cardiomegaly and increased pulmonary vasularity
EKG= Right ventricular hypertrophy with right ventricular conduction delay
Diagnostic for ASD?
Echocardiogram
ASD tx?
-Spont closure in most cases in 1st year of life
-If sypmtomatic close as soon as possible
-asymptomatic can close at 2-4 years of age.
Murmur for VSD?
Pansystolic Murmur
Murmur for TOF?
Rough, systolic ejection murmur
Murmur for Aortic Stenosis?
Sys. ejection murmur at right upper left sternal border and a systolic click at the apex
Murmur for ASD?
-Fixed Split S2
-Sys. ejection murmur at left sternal border
-Mid-diastolic murmur at the left sternal border, 4th intercostal space
Murmur for PDA?
Continuous Machine-Like murmur
Cardiac findings for Coar. of Aorta?
-Decreased femoral pulses
Cardiac findings for Transp of Great Vessels?
Vary, depending on position of the VSD
What is best test to screen for congenital heart disease?
Echocardiogram
Turners syndrome
What syndrome in females is associated with Coarctation of the Aorta?
Where is the obstruction located with COA?
in the descending aorta, at the insertion of the ductus arterious.
Possible Clinical signs with COA?
-may be present w/or without symptoms
-May have CHF
-Upper extremity hypertension
-notched ribs maybe
What about the pulses with COA?
absent or weak femoral pulses and delayed when compared to upper extremities.
Other possible findings of COA?
-Systolic ejection murmur at apex
-Enlarged aortic knob on cxt x-ray.
-Right ventricular hypertrophy on EKG.
What is dx of COA?
-Echocardiogram
connect aorta and the left pulmonary artery
what is the function of the ductus arteriosis?
What type of shunt is associated with a PDA?
Left to Right shunt
When does the PDA typically close?
by 4 days of age
S/S of PDA?
-Small defect-no symptoms
-Large defect-CHF, slow growth, recurrent resp infections.
-SOB,DOE, Cyanosis
What type of murmur with a PDA?
Bounding pulses and a Machine-Like Murmur
-Murmur starts after S1, peaks at S2, and softens during systole
Other findings of PDA?
Chest X-ray-small PDA-normal
Large PDA-cardiomegaly, left atrial enlargement, and increased pulmonary congestion
EKG-left bi- ventricular hypertrophy may be noted with a large PDA.
What confirms PDA?
Echocardiogram
What is the treatment for closing PDA?
-Indomethacin (decreases prostoglandin levels)
-May need surgical ligation
What is a cause of cyanotic congenital heart disease?
TOF
Cyanosis due to right to left shunting and decreased pulmonary flow.
4 defects of TOF?
1) VSD
2) Right ventricular outflow obstruction lesion
3) Right ventricular hypertrophy
4) Overriding large ascending aorta
Neonates with TOF present cyanosis and agitation, this is a?
Tet spell
Murmur with TOF?
Loud systolic ejection murmur at the left sternal border
EKG of TOF?
Chest X-ray with TOF?
EKG-right atrial enlargement
Chest X-ray- normal heart size and decreased pulmonary vascularity
Echo of TOF?
right thick ventricular wall, overriding aorta, and VSD
Treatment of TOF?
Surgical tx at about first 3-6 months of life.
-Acute tx-vagal man, O2, vasoconstrictors, B-blockers, morphine, and fluids.
Echo of TOF?
right thick ventricular wall, overriding aorta, and VSD
Treatment of TOF?
Surgical tx at about first 3-6 months of life.
-Acute tx-vagal man, O2, vasoconstrictors, B-blockers, morphine, and fluids.
What is the most common congenital heart defect?
VSD
-increased communication between right and left ventricles
-increased pulm blood flow that may lead to pulmonary hypertension
S/S of VSD?
-Tachypnea, tachycardia, poor weight gain, trouble feeding, and edema.
What type of murmur with VSD?
Holosystolic murmur best heard at middle of left sternal border
Chest X-ray
EKG
with VSD
Cxt- cardiomegaly and increased pulmonary vascularity in large defects
EKG- left atrial, ventricular, or biventricular hypertrophy.
Diagnostic for VSD
You guessed it, ECHO
What is the tx for VSD?
-most close by 10 years old
-large VSD may need surgical repair
What can lead to heat failure, CHF?
-Valvular heart disease
-CAD
-arrythmias
-hypothyroidism
-high cardiac output syndromes
-Hypertension!
Disease precipitents
What is a big cause of cardiac failure with HTN?
-Medication complaince, they don't take their damn meds!
Presenting symptoms of CHF?
-Dyspnea, orthopnea, PND, fatigue, exercise intolerance, and edema
PE and S/S of CHF
PE- restless dyspneic pt
S/S-JBD, rales, right upper quadrant tenderness, ascites and peripheral edema
Labs?
-Elevated liver fxn
-Elevated B-natriuretic peptide
-Pre-renal azotemia
Check CBC and TSH to r/o anemia and tyroid disease as possible causes of failure
Chest X-ray with CHF?
-Cardiomegaly
-Increased pulmonary vasculature
-Kerley B lines
-Pleural Effusions
Kerley B Lines?
Think CHF
EKG CHF?
LVH and possible acute MI
ECHO of CHF
-systolic/diastolic dysfunction
-decreased EF
TX of CHF
-DC smoking
-diet control
-Low sodium to 1-2 mg daily
Pharm tx for CHF?
-Diuretics
-ACE
-Vasodilators
-Beta Blockers
-Digitalis
-O2, Morphine
* ASA, NSAIDS, Ca Channel blockers should be avoided
Class I heart failure?
-No cardiac symptoms with ordinary activity
Class II heart failure?
-Cardiac symptoms with marked activity but asymptomatic at rest
Class III heart failure?
-Cardiac symptoms with mild activity but asymptomatic at rest
Class IV heart failure?
-Cardiac symptoms at rest!
What are some examples of end organ damage with HTN?
-Left ventricular hypertrophy
-Angina
-Heat Failure
-Stroke
-Chronic Kidney disease
-Peripheral artery disease
-Retinopathy
DX of HTN is based on?
2 or more elevated BP readings
What may the EKG with HTN show?
LVH
What is normal BP?
<120/<80
Prehypertension?
120-139/80-89
Stage 1 HTN?
140-159/90-99
Stage 2 HTN?
>160/>100
TX of HTN?
1) Lifestyle changes
2) Drugs
Lifestyle changes for HTN?
-Wt loss
-Ltd alcohol
-Reg aerobic exercise
-DC smoking
-Reduce Sodium intake
-Reduce sat fats and cholesterol intake
Drug therapy with Stage 1 hypertension?
140-159/90-99
1) Diuretics or Beta blockers
other options:
2) ACE, Ca channel blockers, and alpha blockers
What is Secondary Hypertension?
Hypertension due to an identifiable cause
Secondary to a disease process
Some examples of Secondary HTN etiologies?
-RV disease
-Coar of Aorta
-Primary Aldosteronism
-Cushing's Syndrome
-Phenochromocytoma
-OSA
-Kidney disease
Tx of Sedondary HTN due to RV disease?
-Beta blockers with elevated Renin
-No ACE with bilateral renal artery stenosis
-Diuretics with ACE combo
-Surgical revascularization
What is Malignant HTN?
-Potentially life-threatening situation

-HTN + retinopathy, CV, or renal compromise or encephalopathy.
Etiologies of Malignant HTN?
-Acute aortic dissection
-Post coronary artery bypass graft
-Acute MI
-Unstable Angina
-Eclampsia
-Head Trauma
-Severe Burns
So Malignant HTN really is?
HTN with end-organ disease
Dx of Malignant HTN?
Elevated BP >220/140
in the presence of headache, blurred vision, N&V, confusion, seizures, hypertensive retinopathy, heart failure, and oliguria
TX of Malignant HTN?
-Gradual decrease in BP by 10% in the first hour of tx and then 15% over the next 3 hour-12 hours, to a target BP of 170/110
Choice of agents varies with cause:
-Nitrroprusside
-Propanalol
-Oral Clonidine (sedation)
What would you use for HTN emergency in a pt with hyupertensive encephalopathy, intracrainial bleeding, and heart failure.
IV Nitroprusside
Nitroprusside in combo with what for dissecting aneurysm?
-Propanalol
What is Cardiogenic shock?
Tissue hypoperfusion due to an acute MI or end-stage heart failure
-Poor prognosis
-Accounts for most deaths after an acute MI!
Etiologies of Cardiogenic shock?
-Acute MI
-Tachyarrythmia
-Valvular heart disease
-Traumatic Cardiac injury
-Myocarditis
What is Hypotension defined as?
-Systolic BP <90 or a decrease from baseline by >30
Symptoms of Cardiogenic shock?
-altered mental status
-cyanosis
-oliguria
-cool, clammy extremities
-Hypoperfusion/hypovolemia
-acute MI on EKG may be noted
What is helpful with dx of Cardiogenic shock?
Echocardiogram
TX of Cardiogenic shock?
-Adequate oxygenation and treatment of arrythmias very important.
-Improve BP is critical with IV fluids
-Vasopressers (Dopamine, Dobutamine)
-Intra-aortic baloon pump
Orhtostatic/Postural Hypotension?
-May result in Syncope that could be recurrent
-Defined as a fall in systolic BP of 30 or more or 10 or more in diastolic between laying and upright position.
Many etiologies of orthostatic HTN
-Antipsychotics
-Diuretics
-Alpha-Adrenergic blockers
-ACE inhibitors
-Alcohol
-Tranquilizers
-Vasodilators
-Methyldopa
-Polyneuropathies
-Parkinson's DZ
Clinical manifestations of Orthostatic HTN?
-change in mental status, cerebral hypoperfusion, weak pulse, cool extremities, reduced urine output, tachypnea, and tachycardia.
Tx of Orthostatic Htn?
Tx underlying cause, remove offending medications, and support BP.
What is Acute MI?
-Myocardial necrosis brought on by ischemia
-Most deaths occur w/i one hour of onset of symptoms
What is most deaths of acute MI caused by?
-Ventricular fibrillation
Need Rapid Defibrillation!!
S/S of Acute MI?
-Retrosternal pain, heavy, pressure-like, squeezing, or bandlike.
-Pain may radiate to the jaw, neck or left arm
-Pain typically is > 20 minutes
-Watch for atypical MI presentation in Elderly and Diabetics
Associated symptoms of Acute MI?
-N&V
-Diaphoresis
-Dyspnea
-Weakness
What may you see on PE?
-Elevated BP and possible S4 and other signs of HF may be present.
Lab studies for Acute MI?
-Myoglobin
-CPK
-Troponin
-Leukocytosis
-Lipid profile
-C-reactive protein
When is Myoglobin detectable?
-1-2 hours post MI
-Found in skeletal and cardiac muscle
CPK?
-Total CPK correlates with infarct size
-CPK-MB is specific for cardiac muscle
Troponin?
Test of choice*****
-Not normally present in blood
-Elevated in acute MI
-2-6 hours post MI for up to 5-10 days.
EKG on Acute MI?
-ST elevation depending on affected wall
Inferior MI?
Leads: II, III, AVF
Artery involved: RCA
Lateral MI?
Leads: I,aVL, V5, V6
Artery involved: Circumflex
Anterior MI?
Leads: V1-V4, I, aVL
Artery involved: LCA
Posterior MI?
Leads: V1,V2
Artery involved: RCA, Circumflex
Apical MI?
Leads: V3-V6
Artery involved: LAD, RCA
Anterolateral MI?
Leads: I, aVL, V4-V6
Artery involved: LAD, Circumflex
Anteroseptal?
V1-V3
LAD
What confirms location of injury and coronary vessel involved?
Coronary angiography
Treatment of acute MI?
1) MONA + Beta Blockers
2) Thrombolytic therapy (Streptokinase and tPA)
3) Anti-platelet tx(ASA, Plavix)
4) Nitrates
5) B-blockers
6) Ace but not with hypotension
7) Antithrombin tx (Heparin)
What do nitrates with MI do?
Induce vascular smooth muscle relaxation and reduce cardiac preload and afterload
What do B-Blockers do with MI?
-Reduce HR, BP, Myoc contractility, and stabilize the heart electrically.
-Limits Myoc O2 consupmtion
What do ACEs do with MI?
-Improves remodelling after an acute MI
-Avoid in presence of hypotension
What is Stable Angina?
-Pain that builds up rapidly in 30 seconds and dissapears w/i 5-15 minutes
-Improved with Nitro
-Precipitated with activity and relieved by rest
-Related to a fixed stenosis of one or more Coronary atreries
Pain with Stable Angina?
-Tightness, squeezing, aching or dull discomfort
-Pain is midsternal with radiation to the neck, left shoulder, or left arm
What may be heard with Stable Angina?
S4 or S3 gallop
EKG with Stable Angina
When pain free may reveal arrythmia, prior MI, or LVH
During Pain may have St depression and T wave inversion.
DX of Stable Angina?
-Exercise testing
-Perfusion Scintigraphy
-Coronary angiography
TX of Stable Angina besides life-style?
-Lipid managment
-Antiplatelet meds
-Beta Blockers
-ACE
-Nitrates
-Calcium channel blockers
-Revascularization
What is the tx of choice for WPW?
-Ablation therapy
Define Unstable Angina
-Angina at rest*
-New onset angina
-increasing angina
Unstable angina may be due to?
Plaque rupture
Nonocclusive thrombus
S/S of Unstable angina?
-dyspnea, palpatations, and fatigue
-pressure, burning, or squeezing pain
-may have Nausea, SOB, and diaphoresis
-Pain is retrosternal and epigastric
What else may you find on PE with unstable angina?
-S4 gallop, mitral regurg murmur, and rales on lung exam
-May have normal EKG
-Normal cardiac labs
Tx of Unstable Angina?
Same as stable
Prinzmetal's Angina?
-Pain mostly at rest
-May awaken pt in the morning
-Caused by occlusive spasm on a non-severe coronary artery stenosis
-May be associated with Raynaud;s phenomenon and Migraine
Acute Rheumatic Fever?
-Inflammatory disease that occurs as a response to an URT infection due to Group A Streptococci
-Proliferative and exudative inflammatory lesions on conn tissue, heart, joints, and SubQ tissue
-Peak incidence in 5-15 years of age
Jones Criteria for Acute Rheumatic Fever
Major criteria
JONES
Joints=Polyarthritis
O-obvious= Heart (carditis)
N=nodule(Rheumatic) (knees, elbows, and wrists)
E= Erythema Marginatum
S= Syndecham Chorea (rapid, purposlesness, involuntary movements).
Jones minor
crITERIA
Inflammatory cells (Leukocytosis)
Temperature (fever)
Esr/CRP elevation
Raised PR interval
Itself (previous hx of RH Fever-recent strep infection)
Arthralgia
Tx of Rheum fever
-Asa
-Steroids
Pen G or V or sulfadiazine
or Emycin for pen allergy
Aortic Aneurism?
-Pathological dilation of Aorta
*most common is Abdominal AA
-Atherosclerosis is major underlying cause
Symptoms of AA
-hypogastric or low back pain
-with rupture pain worsens with drop in BP
-Steady gnawing pain
-Pulsatile abdominal mass
DX of AA?
Ultrasound for screening
and CT for diagnostic*
Older pt with flank pain and new onset hematuria what should you suspect?
AAA
May be misdiagnosed as renal colic
TX of AAA
Serial imaging and beta blockers to reduce aortic pressure
Imaging every 6 months for AA > 4 cm
AA > 5 cm?
Should be surgically repaired!
Aortic Dissection?
Tear in the aorta intima, blood enters the media, cleaving it into 2 layers.
What pts are at increased risk of Aortic Dissection?
1) Marfan syndrom
2) 60-80 year olds with history of htn
Clinical manisfestations of Aortic Dissection?
-Severe retrosternal pain described as Tearing, Sharp**
-Elevated BP
-Pulse deficits
-Enlarged Mediatstinum on X-ray
DX of Aortic Dissection?
CT, aortograph, MRI or transesophageal echocardiogram
Treatment of Aortic Dissection?
-BP control with beta blocker, nitroprusside, calcium channel blocker.
-Surgical repair is definitive treatment*
S3?
CHF
S4?
MI
Arterial embolism/Thrombosis
-Cause of acute arterial insufficiency
-Arterial embolism secondary to many factors
(Afib, flutter,mitral stenosis, trasnmural infarct, trauma,hypercoag states, and postarterial procedures).
How does emobolism/thrombosis present?
-acute onset of pain, diminished pulses, cold limbs, and cyanosis.
-Typically unilateral presentation
What are the 5 Ps of of embolism?
1) Pain (constant, worse with any mvmt)
2) Pallor (followed by cyanosis)
3) Pulseless (with cold limb)
4) Parasthesis (periph nerve damage)
5) Paralysis (damage to muscle and motor nerves)
Diagnosis of Embolism
Echo to eval for source of thrombus
Arteriogram to id location
Complications of embolsim?
-Compartment syndrome
-Limb loss
TX of embolism?
-Heparin immedately.
-Embolectomy-thrombectomy
Chronic Arterial Occlusion?
-decrease in 50% of arterial lumen will produce clinical symptoms, ischemia, and necrosis
Most common cause of chronic arterial occlusion?
Atherosclerosis
Most common site of CAO?
Lower extremities
Clinical signs of CAO?
Pain
Calf pain
area of occlusion is DISTAl to the site of claudication
-decreased peripheral pulses, bruits,ischemic skin changes, and painful ischemic ulcers
DX of CAO?
-Ankle/Brachial Index
>1.0 = normal
0.5-0.9=arterial claudication
<0.4 = Severe arterial stenosis****
TX of CAO?
1) Pentoxifylline
2) Aspirin
3) Ticlopidine
4) Thromboendarterectomy
5) quit smoking
6) Heparin and warfarin no use here
Giant Cell Arteritis?
-A granulomatous vasculitis that affects the temporal artery.
-Pts > 50
-May coexist with Polymyalgia Rheumatica
What is the most common symptom of Giant cell arteritis?
-New onset of headache, located in the temporal region***
-Jaw claudication/visual disturbances
-Transient vision loss/blindness
PE of GCA?
-Enlargement, tenderness, and erythema may be noted of the artery
-Bruit may be present
Labs of GCA?
-Elevated ESR
-Anemia
-Leukocytosis
Dx of GCA?
Biopsy
Tx of GCA?
-Start corticosteroids as soon as possible
What is the best screening tool for AAA?
Ultrasound for screening
Phlebitis/Thrombophlebitis?
-Inflammatory thrombosis involving the superficial veins of the lower extremity.
-Associated with varicose veins
pregnancy, and catheter placement. Septic with IV drug users.
TX of Phlebitis?
-Warm moist compress
-NSAIDS
-Abx for staphylococci of septic
II, III, AVF?
Inferior
V1-V3?
Anteroseptal
V2-V4?
Anterior
I,aVL, V4,V5,V6?
Lateral
V1-V2?
Posterior
What is the common cause of Endocarditis in the normal populaton?
Strep Viridans
What is the cause of Endocarditis in drug users?
Staph Aureus
Cause of Endocarditis with prosthetic valves?
S. Epidermidis
A development of clot in the deep veins of the extremities or pelvis is a?
DVT (Venous thrombosis)
Risk factors for DVT include?
-Venous stasis
-Activation of the coagulation system
-Vascular damage
and many others....
S/S of DVT?
Pain and swelling at the site and DISTAL from the clot
Homan's sign?
Pain with dorsiflexion of the foot, may be positive for DVT
DX of DVT?
-Compression ultrasound and venogram are diagnostic
-d-Dimer rules out thormbosis in pts with low proabability for DVT
TX of DVT includes?
-LMWH
-Elastic stockings
-Intermitt pneumatic leg compression
-Heparin until warfarin levels are therapuetic
-Invferior vena cava filter may me needed to prevent PE with pts contraind for anticoag tx.
What are Varicose veins?
Incompetence of the Saphenous vein
-defective valves
-often in the medial and anterior thigh, calf, and ankle.
PE of Varicose Veins?
TX of?
-Torturous veins that are easily compressed
-Support stockings
-surgical
-sclerosing agent
Etiology: Rheumatic
Symptoms: Angina, Syncope
Cardiac signs: Loud, rough systolic ejection murmur
EKG: LVH
Chest X-ray: Boot shaped heart
Aortic Stenosis?
DX and tx of Aortic Stenosis?
Dx: Cardiac Cath
TX: Tx CHF if present, No ACE, valve replacement, SBE abx prophalaxis is required
Aortic Insufficiency?
E: Rheumatic
S: DOE, syncope, chest pain, CHF
CS: Water hammer pulses, S3, Austin Flint Murmur, LVH
DX and TX of AI?
DX: Cardiac cath confirms wide pulse pressure
TX: SBE antibiotic prophylaxis
tx CHF, Surgical valve replacement
Mitral Stenosis?
Etiology: Rheumatic
Symptoms: Dyspnea, orthopnea, angina, hemoptysis
Cardiac signs: Diastolic rumble, opening snap
EKG:
Chest x-ray: Straight left heart border.
DX and TX of Mitral Stenosis?
DX: Echo and cardiac cath, with EKG of left atrial enlargment and A-fib
TX: Tx fib and CHF, SBE proph, valve replacement
Mitral insufficiency
Holosystolic murmur at apex with radiation to the base or left axilla, may have S3
More common in young females
Crescendo mid to late systolic murmur
MVP?
Tricuspid insuff?
Holosystolic murmur along left sternal border
Mitral Regurg murmur?
Holosystolic apical murmur
Aortic Stenosis Murmur?
Loud, rough, systolic diamond shaped murmur heard best a the base of heart with radiation to the neck.
Mitral Stenosis Murmur?
Soft, low pitched, diastolic rumble head best a the apex in the left decubitus position
Where do you hear a Austin Flint murmur?
With Aortic Insufficiency
Tx for Viridans Strep?
Pen G or ampicilln plus gentamycin or seftriazone plus gentamycin or Vancomycin
Acute/Subacute Bacterial Endocarditis (SBE)?
-Infection of the endothelial surface of the heart
-More common in Elderly people and males
Predisposing factors of SBE?
-MVP
-Deg Vasc disease
-IV Drug Use
-Prosthetic Valves
-Congenital abnormalities
Most common community acquired SBE organism?
Viridans Streptococci
Nosocomial SBE?
Stpah epidermidis
Prosthetic valve SBE?
S epidermidis
S aureus
Enterococci
S/S of SBE?
Fever, fatigue, malais, weight loss, arthritis, and myalgias
PE or SBE reveals?
-Petechiae
-Olser's nodes
-Janeway's lesions
-Splinter Hemorrhages
-Roth's spots of fundo exam
-Cardiac murmur
-Splenomegaly
Labs to check for SBE?
ESR, CBC, Urinalysis(for hematuria)
What is the name of the criteria for dx of SBE?
Duke Criteria
TX of SBE?
Empiric tx depending on cultures
GIve abx prophalaxis for these procedures with pts at risk.
-dental
-tonsilectomy
-surgery of resp mucosa
-Sclerotherapy of esoph varices
-Gallbladder surgery
-Cytoscopy
Acute Pericarditis?
Inflammation of the Pericardium
Clinical Manifestations of Pericarditis?
-Chest pain taht worsns with deep breathing, cough, or laying down.
--Pain with sitting or leaning forward
-Pericardial friction rub
-ST elevation
-Pericardial effusion on ECHO
TX of pericarditis?
-NSAIDS
-Steroids
-Pericardiectomy for restrictive pericarditis
Cardiac Tamponade?
-Accumulation of fluid that results in an increase in pericardial pressure and impairs ventricular filling, us a complication of pericardial effusion.
What do you see with Cardiac Tamponade?
-hypotension, bradycardia. DOE
-Distended neck veins, muffled heart sounds, narrow pp, and pulses paradoxus
DX and tx of Cardiac Tamponade
DX: Echo
TX: Pericardiocentesis by echo guidance
Pericardial effusion?
-Porlonged and severe inflammation leads to fluid accumulation around the heart can lead to cardiac tamponade
- May note diminished heart sounds and friction rub
What does the heart look like with with pericardial effusion?
-Enlarged water bottle-shaped heart
TX of Pericardial effusion?
Pericardiocentesis confirms and treats