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142 Cards in this Set

  • Front
  • Back
"a wave" is associated with:
What is "a wave"?
S4.
Atrial contraction.
What are angina equivalents?
1) dyspnea-older fat white women, diabetics in particular
2) Back pain
What's angina?
ans: mismatch of supply and demand. activity drives up HR, Inc mycoardial O2 demand, and blood supply is insufficient--> pain, pressure, and tightness.
Angina:
1) Worsened by:
2) Relieved by:
1) exertion, cold weather, sex, anxiety, post-prandial
2) rest or nitroglycerin
What are 3 types of angina?
1) Pure spasm, 2) severe obstructive disease-Lumen is >70% narrowed, 3) mixed disease-spasm+lumen narrowed.
What is unstable angina? What is the key thing about it?
1) Pain @ rest (w/ minimal activity) or in early waking hours (can awaken you).
2) cannot differentiate spasm from unstable angina.
3) Key: it is ADMITTABLE.
The Big 4 risk factors for CAD:
HTN
Obesity
DM
Smoking
Cardiac Physical exam:
What blood pressures do you take? which should be higher? If not??
3BPs: 2 arms and 1 leg. Leg BP should be > than arm!

If arm>leg: coarctation of aorta
Weak distal pulses suggest:
LVH caused by:
AS, AR, MR
HTN,
IHSS.
Where do you take a leg blood pressure?
cuff 2 cm above the patella. listen to the popliteal artery.
Bruits:
Unilateral Bruit, slow upstroke, normal decline-->
bruit for atherosclerosis
Bruits:
Rapid upstroke, delayed decline
-->
bruit: IHSS (idiopathic hypertropic subaortic stenosis)
Bruits:
Delayed upstroke, delayed decline -->
bruit: Aortic Stenosis
Bruit:
Rapid upstroke, rapid decline -->
bruit: aortic regurgitation (think: Rapid Regurgitation)
height of the Internal jugular vein (jugular vein distension) indicates what?
ans: Right Atrial pressure.
Normal JVP=
5cm above the sternal angle
JVP at level of the mandible:
ans: 10 cm
JVP at the level of the ear lobe:
ans: 12 cm
What is a positive hepatojugular reflex and what does that indicate?
ans: a JVD upon upper abdominal pressure. If it stays UP with both inspiration and expiration, ti is positive. It is a sign of Right Sided volume overload.
Distention of neck veins with INspiration: (what is it, and what does it indicate?)
ans: Kussmaul's sign. A sign of pericardial effusion and impending respiratory failure.
Venous wave form: all are____
ans: Pathological
Venous wave form:
a wave: What is it? associated with? Caused by?
ans: Atrial contraction,
associated with S4. Caused by: Aortic stenosis, IHSS, Ischemic heart disease, Aging, Pulmonary stenosis, Tricuspid stenosis in sinus rhythm, mitral stenosis in sinus rhythm.
A Large "A wave": causes?
ans: Paroxymal atrial tachycardia (2:1) or AFlutter (also, 2:1)
Venous wave form:
What are Cannon A waves, and what do they indicate?
ans: large intermittent A waves. 3rd degree heart block.
Venous wave form:
What are c-waves?
ans: isovolumetric contraction
What are v-waves? And what do you look for?
ans: ventricular contraction. Look for R-sided signs.
what is x-descent?
ans: acute pericardial effusion--tamponade.
what is y-descent?
ans: slow pericardial effusion--SLE, chronic renal failure.
S1 heart sound: What is it?
ans: Closure of the mitral/tricuspid valves.
Increased S1?
indicates Mitral Stenosis, short PR intervals, Increased CO
Decreased S1?
ans: indicates chronic mitral regurg, 1st degree AV block, DECreased CO
S2 heart sound: What is it?
ans: Closure of aortic/pulmonic valves.
What is normal splitting of S2?
ans: Split in inspiration, and together in expiration.
What is fixed splitting of S2, and what does it indicate?
ans: split in both inspiration and expiration. It indicates ASD (Atrial septal defect).
What is wide splitting of S2, and what does it indicate?
ans: volume overload.
by: PDA, AR, delayed closure of LV, and pregnancy.
What is paradoxical splitting of S2? What are some causes?
ans: split in EXpiration, together in inspiration. causes: LBBB, aortic stenosis, transvenous pacemakers, pulmonary htn
What is S3 heart sound?
ans: The sound of systolic heart failure (S-CHF). It is closer to S2 (early diastole). It is volume overloading a non-compliant ventricle.
How is S3 best heard and what accentuates it?
ans: Best heard in the L-lateral position with the bell.
Accentuated by hand-grip.
Note: it can be normal up to 40 yo.
What is S4 heart sound?
ans: The sound of diastolic heart failure. (HTN). Inability of the heart to relax causes S4. it is closer to S1. Accentuated by hand-grip. Caused: Aortic stenosis, htn, IHSS, Ischemic heart disease.
These sounds are accentuated by hand grip.
ans: S3 and S4 are accentuated by this.
These murmurs get long w/ inspiration/leg raising/squatting:
ans: Early-Mid systolic murmurs of TR and PS.
Inspiration/leg raising does what to R-sided murmurs?
ans: these maneuvers INC preload, so these murmurs get longer.
What effect does squatting have on the cardiovascular system and what effect does this action have on R and L sided murmurs? (exception)
ans: Squatting INC preload and afterload so both types of murmurs get longer with squatting.
What is the difference between hand-grip and inspiration/leg raising?
ans: Handgrip increases afterload and makes LEFT sided murmurs get longer. Inspiration INC Preload and makes R-sided murmurs get longer.
What effect does valsalva/standing have on the cardiovascular system, and what effect does this have on R and L sided murmurs? (exception)
ans: Valsalva DEC both preload and afterload and cause both Left and Right sided murmurs to get shorter. (Defecate-->dec Pre-and-afterload-->dec murmur time)
What are the early-mid Systolic murmurs?
ans: Systolic is b/t S1 and S2.
Pulm. Stenosis, Tricuspid Regurg, Atrial Septal Defect, IHSS, Acute Mitral Regurg.
How is IHSS the EXCEPTION to the rule?
ans: the Black Sheep of the Left-sided murmurs b/c 1) Valsalva and standing causes murmur to get LONGER, 2) Squatting causes murmur to get shorter.
What effect does Valsalva have on preload and afterload, and why?
ans: INC intrathoracic pressure, therefore DEC preload and afterload.
What is IHSS?
ans: idiopathic hypertrophic subaortic stenosis (also Hypertropic obstructive cardiomyopathy). It is a volume-dependant state.
What is an acute MR? where does it radiate?
ans: Left-sided murmur that radiates to the base of the heart. It is a papillary muscle dysfunction.
Any new murmur with acute MI is _____ until proven otherwise.
ans: Mitral Regurg. (esp. with inferior wall MI).
What are the two mid-late systolic murmurs? What's significant about these?
ans: Mitral Valve Proloapse and Aortic Stenosis. These are the most common murmurs.
What murmur is not precipitated by exertion?
ans: Mitral Valve prolapse.
With MVP, the click and murmur move closer to S1 with ____ and closer to S2 with _____.
ans: Closer to S1 with Valsalva, closer to S2 with inspiration.
What are the holosystolic murmurs?
ans: Chronic Mitral Regurg, Tricuspid Regurg, and Ventricular Septal Defect.
This murmur doesn't change with any type of maneuver.
ans: Atrial Septal Defect
This murmur is worse with exertion, radiates to the neck with carotid bruits, and gets longer with handgrip.
ans: Aortic stenosis. Think elderly woman with htn, dm.
This murmur is at the apex and radiates to the axillary region.
ans: Chronic MR (holosystolic murmur)
Murmur heard best at the 5th ICS at the L sternal border, and gets longer with inspiration.
ans: Tricuspid Regurg. (R-sided murmur).
Murmur heard best at the L sternal border @ the 4th/5th ICS that gets longer w/ handgrip and shorter with inspiration.
ans: Ventral Septal Defect (VSD--Left-sided murmur)
What differentiates TR from VSD?
ans: TR is a R-sided murmur so it gets longer with inspiration. VSD is a L-sided murmur and gets SHORTER with inspiration.
This murmur has a classic EKG finding of RBBB.
ans: Atrial Septal Defect.
Murmur is best heard at the 2nd L ICS, and typically does NOT radiate elsewhere. It also has a click that disappears with inspiration.
ans: Pulmonic Stenosis.
What are the Diastolic murmurs?
ans:
Rumbles: Tricuspid Stenosis, Mitral Stenosis.
Blows: Atrial Regurgitation, Pulmonic regurgitation.
You hear an opening snap, diastolic rumble. This is often 15-20 years post a certain infection.
ans: Mitral Stenosis, L-sided murmur.
Diastolic murmur from rheumatic heart disease is _____
ans: Carry Coombs murmur.
Graham Steell murmur
ans: Pulmonic regurgitation (early diastolic murmur heard best at 2nd intercostal space.
Mitral murmur heart in aortic regurgitation--a mid-diastolic rumble heard best at the apex
Austin Flint murmur.
does it take more ATP to relax or contract?
ans: takes more ATP to relax.
What is the amount of myocardial stretch at the end of diastole?
ans: preload.
How do you treat heart failure in the ER?
ans: High Loop diuretics, O2 mask, Nitrates (dilate the venous system--also, Morphine).
What do high-loop diuretics do to tx Heart failure in the ER?
ans: they drop preload pressure and reflexitively drop LVEDP.
What is the EF of systolic heart failure? How do you measure it?
ans: EF<45%. TTE, nuclear study, TEE (lowest accuracy).
How do tx Systolic heart failure?
ans: Block RAAS everywhere! lasix+ACE-I+(ARB)+Aldactone
loop diruetics
lasix (Furosemide) or Bumex (Bumetanide)
ACE-I (and what effect do they have?):
Captopril, enalapril, Lisinopril, Ramipril (will drop levels of Angiotensin II)---and will prevent remodeling.
ARB:
Losartan, Valsartan (prevents ATII from binding to receptor)
Aldactone
blocks aldosterone receptors.
what does digoxin do?
improves functionality and contractility but has NO effect on mortality
Beta-Blocker--and when do you start it?
Coreg (Carvedililol), Toprolol XL (Metoprolol succinate) start 48hrs before d/c.
Norvasc (amlodipine)?
Calcium channel blocker
Other meds to control HTN in systolic heart failure:
Ca-channel blocker, alpha-blockers, vasodilator
What is diastolic heart failure? How do you treat it?
normal/hypernormal pump (EF>45%). similiar to systolic HF, but don't use Digoxin!! Use BB!
What has the highest failure rate in the hospital?
systolic failure and hyponatremia.
What is the diagnostic sound of acute heart failure? What do you use to hear it?
ans: S3. Use the BELL!!
___ is the sound of cardiomyopathy. Best heard where/how?
ans: S4. Best heard in the L Lateral recumbent.
What hears like a deer hopping in the woods?
S3/S4 Gallop. b/c of the huge Increase in LVEDP and the Increase in preload.
What are the 3 MCC of cardiomyopathy? What is the eventual endpoint of cardiomyopathy?
ans: CAD, Htn, DM (and 4th most common: thyroid disease, hypo and hyper).
endpoint: A-fib.
Will you have S4 in A-fib??
ans: NO!! you no longer have a contracting atrium, so you won't have an S4.
1)Where do you want your MI? 2)EKG indication?
ans: 1) Posterior MI--practically benign.
2) V1 and V2. J-point depression in lead 1.
muscular complication of posterior MI:
ans: pseudoaneurysm which = cardiac urgency
1) electrical complication of posterior MI? 2) How do you tx? 3) how do you NOT tx?
ans: 1) Bradycardia and a
1st, 2nd, or 3rd degree heart block.
2) tx w/ Atropine then a pacemaker if that doesn't work, 3) do NOT tx w/ epinephrine
Inferior MI:
1) EKG changes.
2) blood supply.
1) ST elevation in II, III, & aVF.
2) RCA (in 85%), Circumflex (in 15%).
What are the branches of the RCA?
ans: SA node, AV node, posterior descending, LA branch, RV marginal branch, terminal R, PDA.
how do you know you have an RV MI?
ans: STEMI in II, III, and aVF;
JVD, Kussmaul's sign, Hepatojugular reflux, RV4--reversal of chest leads.
What are the afterload reducers (meds)?
ans: ACE-I, IV Nitroglycerin, Hydralazine, IV nitroprusside, infra-aortic balloon pump (therapy of choice).
What causes the acute mitral regurg found in inferior wall MIs? when does the MR appear?
ans: 1) infarction of the posterior papillary muscle.
2) in the 2nd or 3rd 24-hours after an inferior wall MI.
What are minor muscular complications of Inferior Wall MIs?
ans: Ventral Septal defect, LA infarction, pseudoaneurysm at base or true aneurysm at apex.
What are the electrical complications of Inferior Wall MI?
ans: same as posterior wall! Bradycardia or 1st, 2nd, or 3rd degree heart block.
1) What are the EKG changes for an Anterior Wall MI?
2) blood supply?
ans: ST elevation in V1-V3, V4.
2) LAD
What are the muscular complications of Anterior wall MI?
ans:
CHF, aneurysm formation
What are the electrical complications of Anterior wall MI?
ans:
VTach
PVCs
Mobitz Type II or 3rd degree heart block (w/ POOR prognosis)
Blood supply and EKG changes on a High Lateral wall MI?
Circumflex artery
ST elevation in I and aVL.
Blood supply and EKG changes on a Low Lateral wall MI?
diagonal branch of LAD,
ST elevation in V4, V5, V6.
muscular complications of lateral wall MI:
ans:
CHF
True aneurysm
Wall rupture--acute pericardial tamponade and death!!
electrical complications of lateral wall MI:
ans:
PVCs and VTach
What is normal pericardial fluid?
ans: 15-25ccs
What is the main difference in the treatment of diastolic HF compared to systolic HF?
ans: do NOT use digoxin, use BB.
How do you treat systolic HF?
ans: 1) block RAAS everywhere. Lasix+ACE-I+(ARB)+Aldactone, 2) Digoxin to improve contractility, 3) BB (Coreg or Toprolol), 4) Others: CCB (Norvasc-amlodipine), alpha-blockers (hytrin, cardura, catapres, aldomet), and a vasodilator (Hydralazine).
What combination of tx for systolic HF has decreased mortality, reshospitalization, and in-hospital death?
ans: Lasix+ACE-I+(ARB)+Aldactone
Ortner's syndrome is and shows up as what?
ans: 1) progressive hoarsness due to compression of recurrent laryngeal nerve. 2) widened mediastinum.
What's the normal size of aorta?
ans: 3.2cm.
Small aneurysm?
ans: 3.2-3.9cm
Moderate aneurysm?
ans: 4.0-5.9cm
Large aneurysm?
ans: 6.0-8.0cm; 25% per year.
Which aortic problem is Painful?
ans: Aortic Dissection.
What is the most common area for pain in thoracic aortic dissection?
ans: right b/t the scapulas.
Most common area of aortic dissection:
ans: Retroperitoneal space. in a closed space--> tamponade.
What's the best way for an aortic dissection to rupture?
ans: internal rupture. back into the vessel.
What is usually the way the thoracic aorta rupture?
ans: into the pleural space and the pt. asphyxiates.
Whats the most common cause of aneurysmal dissection?
ans: atherosclerotic plaque.
What is the velocity of dissection?
ans: the velocity of flow across the wrent.
What are the non-dilatation dissections?
ans: iatrogenic dissection, post-chest trauma, myocardial contusions, malignant ventricular arrhythmias.
A week after an invasive procedure is the peak rate for what to occur?
ans: a non-dilatation Iatrogenic dissection.
When is the peak for a non-dilatation dissection following a post-chest trauma?
ans: 72 hours.
What is the most common area of PVD narrowing in non-diabetic patients?
ans: Superficial femoral artery.
What is the most common area of PVD narrowing in diabetic patients?
ans: Popliteal trifurcation.
How do you quantitate PAD? And what is the quantity to dx PAD?
ans: Ankle-Brachial Index=
ASBP/BSBP. ABI< or = 0.90.
PAD: mild disease:
Sx? Claudication?
ans: 0.80-0.90; usually asymptomatic and do not have intermittent claudication.
PAD: Moderate Disease? Sx? Claudication?
ans: 0.65-0.79. Claudicate by 2 city blocks (1000 feet)
PAD: Severe disease? Claudication?
ans: 0.50-0.64. Claudicate by 1/2-1 block=250-500 ft.
PAD: Resting ischemia?
ans: <0.50.
claudicate in your home.
What is the end stage of PAD?
ans: Rubor-Pallor syndrome
What is the PAD manifestation of ED?
ans: Internal iliac vessel.
What are the PAD reasons for syncope?
ans: Carotid sinus oversensitivity.
If BP in one arm is significantly less than the other---what do you suspect?
ans: Subclavian Stenosis
What is the normal difference between BPs in each arm?
ans: 25mmHg
What are the Sx in Aortic Stenosis?
ans: SAD: Syncope, Angina Pectoris, Dyspnea.
What are the Sx in Aortic Regurgitation?
ans: DAPSS: Dyspnea, Angina, Palpitations, Syncope, and Sudden Death.
If you find a widened pulse pressure >40, water hammer pulse, eccentric LVH, S3, and head and uvula bob.....
ans: Physical findings for Aortic Regurgitation.
How do you treat Aortic Regurgitation?
ans: ***Afterload Reducers b/c the pt. is in volume overload. These meds include: Nifedipine, ACE-I, ARBS, Hydralazine. And you can do Valve replacement.
How do you tx. PAD?
ans: Stop smoking, exercise daily, dec Htn, dec hyperlipidemia, tx.DM, PDIs (phosphogiesterase Inhibitors), Plavix, and Coumadin.