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73 Cards in this Set
- Front
- Back
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Coronary Artery Disease -
What is it Risk Factors |
Leading cause of M&M in US
Clinically - SOB DOE arrhythmias stable & unstable angina MI heart failure sudden death risk factors - age gender hypercholesterolemia DM HTN smoking family Hx |
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Hypercholesterolemia -
What is it Risk Factors |
Increases incidence of CAD
risk factors - DM smoking HTN HDL < 40 mg/dL > 45 y/o (men) > 55 y/o (women) early CAD in 1st degree relative (men < 55, women < 65 y/o) |
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Hypercholesterolemia -
Hx/PE |
Usu asymp
if very high trigly or LDL - xanthomas xanthelasmas lipemia retinalis usu related to familial hypercholesterolemia |
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Hypercholesterolemia -
Dx |
Fasting lipoprotein profile
at > 20 y/o repeat every 5 years |
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Hypercholesterolemia -
Risk Categories & Tx |
RF = risk factor
0-1 RF - treat: by diet if LDL 160 by meds if LDL 190 > 2 RFs - treat: by diet if LDL 130 by meds if LDL 160 CHD or MI or angina or DM - treat: by diet if LDL 100 by meds if LDL 130 |
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Hypercholesterolemia -
Tx |
When starting meds,
start statins 1st dec. mortality the most ■ Hmg-CoA reductase inhib - "statins" the most effective toxicity - LFT abnorm potentiates warfarin myositis ↑ risk of myositis if taken with LPL inhib (gemfibrozil) ■ bile acid sequestrants - cholestyramine toxicity - may interfere with absorption of other drugs (digoxin, warfarin, thiazides) constipation gas ■ niacin - cheap toxicity - facial flushing pruritis aspirin ameliorates flushing |
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Angina Pectoris -
What is it Risk Factors |
Substernal chest pain
due to myocardial ischemia - inc. O2 demand or dec. O2 supply males > females risk factors - CAD risk factors cocaine amphetamine h/o prior MI obesity inc. homocysteine inc. LPL type A personality |
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Angina Pectoris -
Hx/PE |
Classic triad -
substernal chest pain or P precip by exertion relieved by rest or nitrates pain can radiate to arms, jaw, neck SOB diaphoresis n/v lightheadedness HTN tachy apical systolic murmur/gallop |
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Angina Pectoris -
Dx |
EKG -
ST depression T wave flattening cardiac stress test stress echo stress thallium cardiac enzymes if can't exercise - dipyrimadole dobutamine echo |
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Angina Pectoris -
Tx |
■ Admit
monitor by EKG/telemetry ■ acute Sxs - O2 sublingual nitroglycerin ASA IV B-blockers (Ca2+ channel blockers - if can't tolerate B-blockers) (ticlopidine or clopidogrel - if allergic to ASA) ■ chronic Sxs - nitrates B-blockers ASA risk factors' reduction stress test lipid panel statins ■ pain inc. in freq., not relieved by ntg, occurs at rest having unstable angina - angiography: 1 or 2 vessels => PTCA 3 or lt. main => CABG |
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Prinzmetal's (Variant) Angina-
What is it Dx Tx |
Vasospasm of coronary vessels
happens at rest early morning young women Dx - angiography clean coronary arteries Tx - Ca2+ channel blockers |
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Unstable Angina -
What is it |
Pain increases with freq.
takes less to precip lasts longer less responsive to meds happens at rest clot is forming transient vessel occlusion area of myocardial ischemia ST depression can => complete occlusion and MI |
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Unstable Angina -
Tx |
■ Admit
nitrates B-blockers morphine O2 ASA heparin ■ after stabilized - eval coronary vessels ■ if angina persists - angiography revascularization 1 or 2 vessels => PTCA 3 or lt. main => CABG |
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MI -
What is it |
■ Caused by occlusive thrombus
or prolonged vasospasm in coronary art. ■ MCC - acute thrombus on ruptured atheroscler plaque ■ males > females incidence inc. in postmenopausal women ■ 20% of pts. - sudden death from lethal arrhythmia ■ LV ejection fraction - best predictor of survival ■ Q-wave MI = transmural nonQ-wave = subendo, inc. risk for transmural |
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MI -
Hx/PE |
Acute onset
substernal chest pain pressure or tightness can radiate to left arm, neck or jaw pain lasts > 30 min. does not completely resolve with ntg does not change with position diaphoresis SOB lightheadedness anxiety n/v syncope tachy arrhythmias new mitral regurg hypotension rales VF atypical presentations - elderly diabetic heart transplant |
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MI -
Dx |
EKG -
■ new LBBB ■ ST changes - peaked T T inversion ST inc. Q ST normalizes T back upright ■ V1-V4 changes (ant. leads) - ant. MI ■ leads II, III & AVF changes- inferior MI ■ arrhythmias serial cardiac enzymes |
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MI -
Tx |
■ Acute -
O2 ASA B-blockers ntg morphine thrombolytics, then heparin if can't give thrombolytics - angioplasty ACEIs - if LV dysfunction ■ hypotensive - IV fluids stop ntg ■ after 5 days - stress test echo |
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MI -
Complications |
Reinfarction
LV wall rupture Dressler's syn papillary muscle rupture pericarditis LV dilation mural thrombi MCC of death - lethal arrhythmia poor prognosis - 6 PVCs/min |
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HTN -
What is it |
140/90
3 measurements sep. by 2 wks. essential (primary) or secondary |
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HTN -
Categories of BP Measurements |
■ Optimal -
120/80 ■ normal - 130/85 recheck in 2 years ■ high normal - 139/89 recheck in 1 year ■ stage I (mild) - 140/90 recheck in 2 mos. ■ stage II (mod) - 160/100 recheck in 1 mo. ■ stage III (severe) 180/110 recheck in 1 wk. ■ stage IV (very severe) 210/120 |
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Essential HTN -
What is it Risk Factors |
MCC of high BP (95%)
unidentified cause Blacks > whites risk factors - family Hx high sodium diet smoking obesity age DM |
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Essential HTN -
Hx/PE |
Asymp until complications dev.
may have - S4 systolic click loud S2 chronic complications - cerebrovascular dis. (strokes) eye dis. RF heart dis. - CAD aortic aneurysm aortic dissection LVH CHF |
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Essential HTN -
Dx |
Hx, PE & labs to -
seek secondary causes seek end-organ damage seek & control ASHD risks |
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ASHD Risk Factors -
What are they |
Smoking
sedentary lifestyle obesity DM hyperlipidemia new risk factors - CRP homocysteine |
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Essential HTN -
Tx |
■ Lifestyle mod -
init Tx for stages 1 & 2 ■ risk factor reduction ■ BP goal in - uncomplicated - <140/<90 renal dis. with proteinuria - <130/<85 DM - <130/<75 ■ meds - 1st line for uncomp essential- diuretics (thiazides) B-blockers special circumstances - ■ ACEIs - DM mild renal CHF due to systolic dysfunc recent MI ■ Ca2+ channel blockers - elderly - isolated systolic ↑ Black |
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Secondary HTN -
What is it |
Due to identifiable
organic cause meds - OCP, a-antag hyperthyroidism coarctation of aorta renal artery stenosis APKD RF aortic regurg pheochromocytoma Conn's Cushing's alcohol |
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Renal Artery Stenosis -
What is it |
Esp. in <25 y/o & >55 y/o
bruit sudden onset of HTN causes - fibromuscular dysplasia (<25 y/o) atherosclerosis (<55 y/o) |
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Renal Artery Stenosis -
Dx |
• Abdom US
• captopril renogram - pos. = dec. uptake of isotope after admin of captopril (dec. GFR) best noninvasive • arteriogram - best to confirm • can also use - IV pyelography duplex Doppler US renal vein renin determination |
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Renal Artery Stenosis -
Tx |
Best init Tx -
percutaneous transluminal angioplasty if stenosis recurs - repeat if angioplasty fails - resect ACEIs - only if angioplasty or surgery not possible |
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Hypertensive Urgency
and Emergency - What is it |
Urgency -
>200/>120 asymp mod Sxs - headache chest pain syncope emergency - signs & Sxs of impending end-organ damage: ■ angina or CHF ■ cerebral impairment - ischemia intracranial hemorrhage severe headaches altered mental status ■ acute eye findings - hemorrhages papilledema blurred vision ■ acute RF - hematuria malignant HTN - progressive RF encephalopathy with papilledema |
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Hypertensive Urgency
and Emergency - Dx |
CV, neuro, ophthal & abdom PE
EKG - init test CT - head, abdom UA BUN/Cr CBC electrolytes |
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Hypertensive Urgency
and Emergency - Tx |
HTN urgency -
slowly dec BP (over a few hrs) oral - B-blockers clonidine ACEIs if not sufficient, try IV HTN emergency - IV agents dec. BP 25% in 1 hr. nitroprusside & labetalol - best ntg - if MI enalapril don't lower pressure too far - so don't compromise myocardial or cerebral perfusion |
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Dilated Cardiomyopathy -
What is it |
90% of all cardiomyopathies
LV dilation systolic dysfunction MCC - idiopathic ABCD Alcohol Beriberi Coxsackie B Chagas Cocaine Doxorubicin |
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Dilated Cardiomyopathy -
Hx/PE |
Signs of heart failure
dev. gradually chief complaint - SOB cardiomegaly S3 tricuspid regurg mitral regurg fever - if infectious cause |
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Dilated Cardiomyopathy -
Dx |
Echo - diagnostic
EKG - LBBB CXR - enlarged balloon-like heart pulmonary congestion measure ejection fraction - echo - 1st test MUGA scan - best test |
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Dilated Cardiomyopathy -
Tx |
Dec. preload - loop diuretic
pos. inotropy - dobutamine dec. afterload - ACEI if EF < 35% - consider implantable cardiac defib (ICD) (no alcohol) |
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IHSS -
What is it |
Idiopathic Hypertrophic
Subaortic Stenosis AD MCC of sudden death in young healthy athletes ■ ventric hypertrophy thick intraventric septum => dec. filling diastolic dysfunction ■ LV outflow tract obstructed- => systolic dysfunction ■ obstruction worsened by - inc. contractility dec. LV filling: exercise Valsalva vasodilators dehydration |
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IHSS -
Hx/PE |
MC Sx is SOB
syncope after exertion dyspnea palpitations chest pain MR sustained apical impulse S4 systolic ejection murmur poor prognostic signs - arrhythmia AF inc. LA pressure |
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IHSS -
Dx |
■ Echo -
diagnostic thick LV walls dynamic obstruction of blood flow ■ EKG - LVH, abnorm Q ■ CXR |
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IHSS -
Tx |
■ B-blocker -
dec. HR so, inc. filling time ■ surgery - septal myectomy dual-chamber pacing ICD ■ no intense athletics |
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Restrictive Cardiomyopathy -
What is it |
Impaired diastolic filling
caused by - "sarcoid, amyloid, hemochromatosis, cancer & fibrosis" |
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Restrictive Cardiomyopathy -
Hx/PE |
Sxs of LHF & RHF
RHF Sxs predominate |
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Restrictive Cardiomyopathy -
Dx |
Bx - diagnostic
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Restrictive Cardiomyopathy -
Tx |
Tx underlying cause
Tx HF Sxs - restrict sodium diuretics |
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Congestive Heart Failure -
What is it Risk Factors |
Heart can't pump enough blood
to meet O2 needs of body risk factors - CAD HTN valvular heart dis. pericardial dis. cardiomyopathy pulmonary HTN |
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Congestive Heart Failure -
Classifications |
LHF vs. RHF
systolic vs. diastolic dysfunction functional - ■ Class I: no symptoms no limitation in ordinary physical activity ■ Class II: mild symptoms slight limitation during ordinary activity comfortable at rest ■ Class III: marked limitation of activity comfortable only at rest ■ Class IV: severe limitations symptoms even at rest confined to bedrest or chair |
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Systolic Dysfunction -
What is it |
Most cases of CHF due to
systolic dysfunction A Fib - common comorbid condition dec. LV contractility => EF < 50% => inc. LVEDP (inc. preload) => inc. systolic contractility compensatory mech - temp effective => hypertrophy ventric dilation |
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Systolic Dysfunction -
Hx/PE |
DOE
if severe - dyspnea at rest chronic cough fatigue lwr ext edema orthopnea PND abdom fullness sinus tachy lat. displaced PMI RHF - JVD hepatomegaly hepatojugular reflux bipedal edema LHF - b/l basilar rales S3 gallop |
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Systolic Dysfunction -
Dx |
EKG
echo CXR - cardiomegaly cephalization of pulm vessels pleural effusions prominent hila r/o MI Bx - if suspect amyloid or viral myocarditis |
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Systolic Dysfunction -
Tx |
■ Correct treatable causes
■ dec. preload - loop diuretic pos. inotropy - dobutamine dec. afterload - ACEIs ■ angiotensin II rec. antag - if can't tolerate ACEIs ■ discharge on - ACEIs diuretics B-blockers ■ consider ICD if EF < 35% |
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Diastolic Dysfunction -
What is it |
Dec. ventric compliance
ventricle unable to actively relax or passively fill dec. EDV inc. LVEDP contractility normal so, EF normal inc. LAP => pulm congestion |
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Diastolic Dysfunction -
Tx |
■ dec. preload - loop diuretic
pos. inotropy - dobutamine dec. afterload - ACEIs ■ angiotensin II rec. antag - if can't tolerate ACEIs ■ discharge on - ACEIs diuretics B-blockers no digoxin |
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Pericarditis -
What is it |
Inflammation of
pericardial sac often with effusion causes - infections - MC is viral inflammation connective tissue d/o trauma cancer - pericardial organs |
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Pericarditis -
Hx/PE |
■ Pain -
pleuritic positional: worse supine better - lean forward, shallow breathing ■ dyspnea ■ cough ■ fever ■ pericardial friction rub - best heard with pt. leaning forward |
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Pericarditis -
Dx |
CXR
echo - pericardial thickening pericardial effusion EKG - ST elevation or PR depression = pathognomonic |
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Pericarditis -
Tx |
Tx underlying cause
NSAIDs - viral pericarditis steroids |
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Constrictive Pericarditis -
What is it Dx Tx |
Chronic pericarditis
=> fibrosis, inflammation, calcification now called constrictive can't fill pericardial knock => inc. JVD, ascites, hepatomegaly Dx - CXR or CT Tx - remove pericardium |
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Cardiac Tamponade -
What is it |
Fluid in pericardial sac
=> compromised ventric filling dec. CO more closely related to rate of fluid formation than size of effusion causes - infections - MC is viral inflammation connective tissue d/o trauma cancer - pericardial organs |
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Cardiac Tamponade -
Hx/PE |
Severe chest pain
fatigue dyspnea tachy tachypnea can quickly => shock & death ■ Beck's triad - hypotension distant heart sounds distended neck veins ■ narrow pulse pressure ■ pulsus paradoxus - dec. in systolic > 10 mmHg on inspiration ■ Kussmaul's - inc. JVD on inspiration |
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Cardiac Tamponade -
Dx |
Echo - immed.
CXR EKG - low voltage electrical alternans |
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Cardiac Tamponade -
Tx |
Pericardiocentesis
pericardial window |
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Aortic Aneurysm -
What is it Risk Factors |
MCC - atherosclerosis
most - abdominal > 90% orig below renal art. male > female risk inc. with age risk factors - HTN smoking family Hx |
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Aortic Aneurysm -
Hx/PE |
Usu asymp
discovered incidentally on exam or XR if ruptures - => hypotension severe, tearing abdom pain radiates to back many pts. DOA pulsatile abdom mass abdom bruits hypotension - if ruptured |
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Aortic Aneurysm -
Dx |
Abdom US
CT - adjunct |
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Aortic Aneurysm -
Tx |
Asymp -
monitor if < 5 cm surgery - abdom > 5 cm thoracic > 6 cm or rapidly inc. symp or ruptured - emergent surgery |
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DVT -
What is it Predisposing Factors |
Blood clot forms in
lg. vein of ext or pelvis predisposing factors - venous stasis (immobilization) incompetent v. valves -lwr ext hypercoagulation obesity trauma to lwr ext CHF indwelling ven. catheters |
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DVT -
Hx/PE |
Unilat lwr ext -
pain erythema swelling Homan's sign |
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DVT -
Dx |
Doppler US
impedance plethysmography contrast venography |
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DVT -
Tx |
Anticoags -
IV heparin or LMW heparin then po warfarin 3-6 mos. DVT prophylaxis (in-pts.) IVC filter - if contraindications to anticoags |
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Peripheral Vascular Dis (PVD)-
What is it |
Occlusion of blood supply
to ext by atherosclerotic plaques MC affected - lwr ext |
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Peripheral Vascular Dis (PVD)-
Hx/PE In General Aortoiliac Dis. Femoropopliteal Dis. Small Vessel Dis. Acute Ischemia Severe Chronic Ischemia |
Intermittent claudication
as dis. worsens - pain at rest ischemia at distal aspect of ext => painful, cold, numb foot dorsal foot ulcerations Aortoiliac Dis. - buttock claudication absent femoral pulses impotence (males) Femoropopliteal Dis. - calf claudication absent pulses below femoral Small Vessel Dis. - absent foot pulses Acute Ischemia - usu from emboli from heart acute occlusions commonly at bifurcation distal to the last palpable pulse Severe Chronic Ischemia - muscle atrophy pallor cyanosis hair loss gangrene/necrosis |
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Peripheral Vascular Dis (PVD)-
Dx |
Palpation of pulses
auscultation for bruits Doppler US ABI - ankle & brachial systolic BP rest pain with ABIs < 0.4 to eval for surgery - arteriography digital subtraction angiography |
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Peripheral Vascular Dis (PVD)-
Tx |
Exercise
no tobacco foot care control underlying causes Sxs - pentoxifylline Ca2+ antag thromboxane inhib PTCA arterial bypass amputation |
