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73 Cards in this Set

  • Front
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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
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)
Hypercholesterolemia -
Hx/PE
Usu asymp
if very high trigly or LDL -
xanthomas
xanthelasmas
lipemia retinalis
usu related to familial
hypercholesterolemia
Hypercholesterolemia -
Dx
Fasting lipoprotein profile
at > 20 y/o
repeat every 5 years
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
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
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
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
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
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
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
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
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
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
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
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
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
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
HTN -
What is it
140/90
3 measurements sep. by 2 wks.
essential (primary)
or secondary
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
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
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
Essential HTN -
Dx
Hx, PE & labs to -
seek secondary causes
seek end-organ damage
seek & control ASHD risks
ASHD Risk Factors -
What are they
Smoking
sedentary lifestyle
obesity
DM
hyperlipidemia
new risk factors -
CRP
homocysteine
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
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
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)
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
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
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
Hypertensive Urgency
and Emergency -
Dx
CV, neuro, ophthal & abdom PE
EKG - init test
CT - head, abdom
UA
BUN/Cr
CBC
electrolytes
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
Dilated Cardiomyopathy -
What is it
90% of all cardiomyopathies
LV dilation
systolic dysfunction
MCC - idiopathic

ABCD
Alcohol
Beriberi
Coxsackie B
Chagas
Cocaine
Doxorubicin
Dilated Cardiomyopathy -
Hx/PE
Signs of heart failure
dev. gradually
chief complaint - SOB
cardiomegaly
S3
tricuspid regurg
mitral regurg
fever - if infectious cause
Dilated Cardiomyopathy -
Dx
Echo - diagnostic
EKG - LBBB
CXR -
enlarged
balloon-like heart
pulmonary congestion

measure ejection fraction -
echo - 1st test
MUGA scan - best test
Dilated Cardiomyopathy -
Tx
Dec. preload - loop diuretic
pos. inotropy - dobutamine
dec. afterload - ACEI

if EF < 35% -
consider implantable cardiac
defib (ICD)

(no alcohol)
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
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
IHSS -
Dx
■ Echo -
diagnostic
thick LV walls
dynamic obstruction of
blood flow
■ EKG - LVH, abnorm Q
■ CXR
IHSS -
Tx
■ B-blocker -
dec. HR
so, inc. filling time
■ surgery -
septal myectomy
dual-chamber pacing
ICD
■ no intense athletics
Restrictive Cardiomyopathy -
What is it
Impaired diastolic filling
caused by -
"sarcoid,
amyloid,
hemochromatosis,
cancer & fibrosis"
Restrictive Cardiomyopathy -
Hx/PE
Sxs of LHF & RHF
RHF Sxs predominate
Restrictive Cardiomyopathy -
Dx
Bx - diagnostic
Restrictive Cardiomyopathy -
Tx
Tx underlying cause
Tx HF Sxs -
restrict sodium
diuretics
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
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
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
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
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
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%
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
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
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
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
Pericarditis -
Dx
CXR
echo -
pericardial thickening
pericardial effusion
EKG -
ST elevation or
PR depression = pathognomonic
Pericarditis -
Tx
Tx underlying cause
NSAIDs - viral pericarditis
steroids
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
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
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
Cardiac Tamponade -
Dx
Echo - immed.
CXR
EKG -
low voltage
electrical alternans
Cardiac Tamponade -
Tx
Pericardiocentesis
pericardial window
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
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
Aortic Aneurysm -
Dx
Abdom US
CT - adjunct
Aortic Aneurysm -
Tx
Asymp -
monitor if < 5 cm

surgery -
abdom > 5 cm
thoracic > 6 cm
or rapidly inc.

symp or ruptured -
emergent surgery
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
DVT -
Hx/PE
Unilat lwr ext -
pain
erythema
swelling
Homan's sign
DVT -
Dx
Doppler US
impedance plethysmography
contrast venography
DVT -
Tx
Anticoags -
IV heparin or LMW heparin
then po warfarin 3-6 mos.
DVT prophylaxis (in-pts.)
IVC filter -
if contraindications
to anticoags
Peripheral Vascular Dis (PVD)-
What is it
Occlusion of blood supply
to ext by
atherosclerotic plaques
MC affected - lwr ext
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
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
Peripheral Vascular Dis (PVD)-
Tx
Exercise
no tobacco
foot care
control underlying causes
Sxs -
pentoxifylline
Ca2+ antag
thromboxane inhib

PTCA
arterial bypass
amputation