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234 Cards in this Set
- Front
- Back
What percentage of hypertensive patients have essential hypertension?
|
90-95%
|
|
SECONDARY HYPERTENSION (HTN):
HTN in upper extremities Decreased or normal blood pressure (BP) in lower extremities |
Coarctation of the Aorta
|
|
SECONDARY HYPERTENSION (HTN):
HTN accompanied by proteinuria in a nondiabetic patient |
Glomerular Disease
|
|
SECONDARY HYPERTENSION (HTN):
HTN in a patient with a history of renal and hepatic cysts |
Polycystic Kidney Disease
|
|
SECONDARY HYPERTENSION (HTN):
Sudden worsening of HTN in an elderly male with coronary artery disease (CAD) and peripheral vascular disease (PVD) |
Renal Artery Stenosis
|
|
SECONDARY HYPERTENSION (HTN):
Episodic HTN, weight loss, headache, and diaphoresis |
Pheochromocytoma
|
|
SECONDARY HYPERTENSION (HTN):
Elevated systolic HTN without diastolic HTN |
Hyperthyroidism
|
|
SECONDARY HYPERTENSION (HTN):
40-year old female with a h/o 20 years of oral contraceptive pill (OCP) use |
Drug-Induced (OCP) HTN
|
|
SECONDARY HYPERTENSION (HTN):
HTN in a patient with hypokalemic metabolic acidosis |
Conn Syndrome / Hyperaldosteronism
|
|
SECONDARY HYPERTENSION (HTN):
HTN in an overweight patient with buffalo hump, moon facies, hirsutism, and abdominal striae |
Cushing Syndrome
Hypercortisolism |
|
What is the difference between Hypertensive Urgency and Hypertensive Emergency?
|
In Hypertensive Urgency, there are no signs of end-organ damage due to HTN.
In Hypertensive Emergency, there are signs of organ damage (papilledema, renal failure, heart failure, stroke). |
|
What is the treatment of hypertensive urgency?
|
Oral BP medication:
Labetalol Captopril Clonidine |
|
What are the 3 preferred agents for the treatment of hypertensive emergency?
|
1. IV Nitroprusside
2. Nitroglycerine 3. Hydralazine |
|
What is the preferred treatment for hypertension in pregnancy?
|
Hydralazine & Clonidine
or Methyldopa |
|
ANTIHYPERTENSIVE:
No comorbidities |
Diuretics
or Beta-Blockers |
|
ANTIHYPERTENSIVE:
Isolated HTN |
Thiazide Diuretics
|
|
ANTIHYPERTENSIVE:
Angina Pectoris |
Beta-Blockers
Calcium Channel Blockers |
|
ANTIHYPERTENSIVE:
Diabetes |
ACEIs or ARBs
Beta-Blockers |
|
ANTIHYPERTENSIVE:
Hyperlipidemia |
ACEIs
Calcium Channel Blockers |
|
ANTIHYPERTENSIVE:
Congestive Heart Failure |
Diuretics
ACEIs |
|
ANTIHYPERTENSIVE:
H/o myocardial infarction (MI) |
Beta-Blockers
ACEI |
|
ANTIHYPERTENSIVE:
Chronic Renal Failure |
Diuretics
Calcium Channel Blockers |
|
ANTIHYPERTENSIVE:
Asthma / Chronic Obstructive Pulmonary Disease (COPD) |
Diuretics
Calcium Channel Blockers |
|
ANTIHYPERTENSIVE:
Benign Prostatic Hyperplasia (BPH) |
Alpha-1 Antagonists
Terazosin |
|
ANTIHYPERTENSIVE:
Pheochromocytoma |
Phenoxybenzamine
--Nonselective Alpha Antagonist Phentolamine --Alpha-1 Antagonist |
|
ANTIHYPERTENSIVE:
Hypertrophic Obstructive Cardiomyopathy |
Beta-Blockers
|
|
ANTIHYPERTENSIVE:
Hyperthyroidism |
Beta-Blockers
|
|
ANTIHYPERTENSIVE:
Anxiety |
Beta-Blockers
|
|
ANTIHYPERTENSIVE:
Supraventricular Tachycardia (SVT) |
Beta-Blockers
|
|
ANTIHYPERTENSIVE:
Migraine Headaches |
Beta-Blockers
Calcium Channel Blockers |
|
ANTIHYPERTENSIVE:
Moderate Bradycardia |
Beta-Blockers with Intrinsic Sympathomimetic Activity
Pindolol Acebutolol |
|
ANTIHYPERTENSIVE:
Osteoporosis |
Thiazide Diuretics
--reabsorbs calcium |
|
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:
CHF |
Verapamil
Alpha-Blockers |
|
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:
Asthma / COPD |
Beta-Blockers
|
|
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:
Diabetes |
Beta-Blockers
Thiazide Diuretics |
|
ANTIHYPERTENSIVES SHOULD BE USED WITH CAUTION:
Renal Artery Stenosis / Renal Failure |
ACEIs
|
|
What genetic disease should be suspected in a patient with xanthomas, xanthelasmas, and lipemia retinalis?
|
Familial Hypercholesterolemia
|
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
Total Cholesterol <200 |
Retest in 5 years
|
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
Total Cholesterol >200 |
Treat based on lipid fractions
|
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
Low-Density Lipoprotein (LDL) >190 |
Begin lipid-lowering therapy
Goal <160 |
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
LDL >160 in a patient with 2 or more coronary risk factors |
Begin lipid-lowering therapy
Goal <130 |
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
LDL >130 in a patient with CAD or Diabetes Mellitus (DM) |
Begin lipid-lowering therapy
Goal <100 |
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
LDL >100 in a patient with a previous MI |
Begin lipid-lowering therapy
|
|
RECOMMENDED THERAPEUTIC INTERVENTION or FURTHER WORKUP:
Triglycerides (TGs) >200 |
Begin TG-lowering therapy
|
|
Cholestyramine
MOA IND TOX |
MOA: bile-acid binding resin
IND: adjuvant therapy for patients with familial hypercholesterolemia TOX: constipation, gatrointestinal (GI) discomfort, may interfere with intestinal absoprtion of other drugs |
|
Statins
MOA IND TOX |
MOA: hydroxymethylglutaryl (HMG) coenzyme A (CoA) reductase inhibitors
IND: hypercholesterolemia TOX: Hepatotoxicity, rhabdomyolysis |
|
Niacin
MOA IND TOX |
MOA: reduces release of very low-density lipoprotein (VLDL) from the liver into circulation
IND: hypercholesterolemia: to increase HDL and decrease LDL TOX: flushing, pruritis (both reversible with Aspirin), and hepatotoxicity |
|
Gemfibrozil, Clofibrate
MOA IND TOX |
MOA: stimulates lipoprotein lipase
IND: hypercholesterolemia: to decrease TGs TOX: myositis, hepatotoxicity |
|
What are the 6 Coronary Risk Factors?
Greatest risk factor? |
"CAD HDL"
1. Cigarettes 2. Age (male >45 & females >55 are at increased risk) & Sex (males > females) 3. Diabetes Mellitus (greatest risk factor) 4. HTN 5. Death from MI in FH (males <55, females <60) 6. Increased LDL, low HDL (<35) |
|
What is the common presentation of a patient with symptomatic CAD?
|
Angina pectoris +/- radiation to the jaw, left shoulder, or arm
Exacerbated by exertion, relieved by rest and nitroglycerin |
|
Which group of patients commonly do not exhibit classic anginal symptoms in the setting of myocardial ischemia?
|
Elderly, women, diabetics (due to diabetic neuropathy), heart transplant patients
|
|
Which type of angina is characterized by chest pain and dyspnea at rest?
|
Unstable Angina
|
|
What are the classic ECG findings during an anginal episode?
|
>1mm ST-segment Depression
T-wave Inversion |
|
What diagnostic tests are often used to screen for CAD?
|
Exercise or pharmacologic stress test or imaging
|
|
Which patients should undergo exercise ECG with myocardial imaging + stress echo in the workup of CAD?
|
Patients with:
1. Wolf-Parkinson-White Syndrome 2. >1mm ST depression on Resting ECG 3. H/o PTCA 4. on Digoxin 5. LVH |
|
Who get pharmacologic stress test?
|
Patients with electronically paced ventricular rhythm and left bundle branch block (LBBB)
|
|
What is the gold standard for the diagnosis of CAD?
|
Coronary Arteriography
|
|
Name 6 lifestyle changes that should be suggested to all patients with HTN:
|
1. Weight Loss
2. Sodium Restriction 3. Physical Exercise 4. Smoking Cessation 5. Alcohol Cessation 6. Stress Reduction |
|
What medications should be given to a patient with acute onset of angina?
|
Sublingual Nitroglycerin
|
|
What medications should be given as prophylaxis for angina and MI?
|
1. Long-acting Nitrates
2. Beta-Blockers 3. ASA 4. Statin 5. ACEIs for patients with h/o MI |
|
What are the key steps in the medical management of a patient with unstable angina?
|
1. Start IV
2. Administer O2 3. Start Heparin, ASA, Beta-Blocker, Nitroglycerin, Morphine |
|
Describe how nitrates reduce angina:
|
1. Venodilation cuases venous pooling, leading to decreased preload and decreased myocardial O2 consumption
2. Coronary vasodilation, leading to increased O2 delivery to the myocardium |
|
What is the most common side effect of nitrates?
|
Headache
|
|
HOW IT REDUCES ANGINA:
Beta-Blockers |
Decreases myocardial oxygen consumption, decreases afterload, increases coronary filling during diastole
|
|
HOW IT REDUCES ANGINA:
Nifedipine |
Coronary arteriolar vasodilation
|
|
HOW IT REDUCES ANGINA:
Verapamil |
Slows cardiac conduction
|
|
What is the antianginal drug of choice for prinzmetal angina?
|
Diltiazem
|
|
Which antianginal drug must be used with caution in patients with asthma and COPD?
|
Beta-Blockers
|
|
What intervention is reserved for patients whose angina cannot be controlled medically?
|
Percutaneous Transluminal Coronary Angioplasty (PTCA)
|
|
What are the indications for coronary artery bypass grafting (CABG)?
|
1. Angina refractory to medical therapy
2. Severe left main disease 3. Triple vessel coronary disease (or double vessel disease in a diabetic) |
|
What is the common presentation of MI?
|
1. Crushing restrosternal chest pressure occurring at rest and radiating to the left arm, neck or jaw
2. Diaphoresis 3. Nausea/Vomiting 4. Dyspnea 5. Anxiety |
|
What is a common physical examination finding during an MI?
|
S4 Gallop
|
|
Which are the 6 life-threatening causes of chest pain that must be ruled out in all patients?
|
1. MI
2. Aortic Dissection 3. Pulmonary Embolism (PE) 4. Pneumothorax (PTX) 5. Esophageal Rupture 6. Cardiac Tamponade |
|
What are the key steps in the initial management of a patient with suspected MI?
|
1. Assess vital signs
2. Administer O2 3. Start IV 4. Place on cardiac monitor 5. Obtain ECG 6. Administer ASA, Heparin, Nitrates, Beta-Blocker, Morphine, Clopidogrel |
|
What are the classic ECG abnormalities in an acute MI?
|
ST Elevation
Q Waves |
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Which ECG finding is very sensitive and specific for right ventricular infarction?
|
ST Elevation of 1mm in right-sided lead V4
|
|
CORONARY ARTERY OCCLUSION:
Large R and ST segment depression in V1, V2 |
Right Coronary Artery (RCA)
Posterior Infaction |
|
CORONARY ARTERY OCCLUSION:
Q waves and ST segment elevation in leads V1-V4 |
Left Anterior Descending (LAD)
Anterior Infarction |
|
CORONARY ARTERY OCCLUSION:
Q waves in leads I, aVL, V5, V6 |
Circumflex Artery
Lateral Infarction |
|
CORONARY ARTERY OCCLUSION:
Q waves and ST segment elevation in leads II, III, aVF |
Right Coronary Artery (RCA)
Inferior Infarction |
|
Which serologic markers are typically used to diagnose and follow an MI?
|
Troponin I
CK-MB |
|
What medication is reserved for patients with MI suffering from angina that is refractory to conventional medical management?
|
Thrombolytics including Tissue Plasminogen Activator or Streptokinase
|
|
What intervention is indicated in patients during an MI who fail or cannot tolerate thrombolytic therapy?
|
PTCA
|
|
What are the clinical manifestations of right ventricular MI?
|
1. ECG inferior changes
2. Hypotension 3. Clear Lungs 4. Jugular Venous Distension (JVD) 5. Right Ventricular Lift 6. Tricuspid Valve Regurgitation |
|
Which medical therapy should be avoided in a patient with a right ventricular infarction?
|
Nitroglycerin
Initial therapy should involve IV fluids to increase preload |
|
What long-term medications have been shown to improve mortality in patients with MI?
|
ACUTELY:
ASA & Beta-Blockers LONG-TERM: ACEI, Statins, and Clopidogrel |
|
ARRHYTHMIA:
PR interval >0.2 s, often due to increased vagal tone |
First Degree (Primary) Heart Block
|
|
ARRHYTHMIA:
PR interval gradually increases to the point at which a QRS complex is dropped (P wave is not conducted) |
Second Degree Mobitz Type I Heart Block (Wenkebach)
|
|
ARRHYTHMIA:
PR interval >0.2 s with occasional dropping of the QRS complex at a fixed interval (ie, 2:1 or 3:1) |
Second Degree Mobitz Type II Heart Block
|
|
ARRHYTHMIA:
Irregularly irregular pulses and QRS complexes |
Atrial Fibrillation
|
|
ARRHYTHMIA:
Type of heart block that commonly arises as a side effect of medication including beta-blockers, digoxin and calcium channel blockers |
Second Degree Mobitz Type II Heart Block
|
|
ARRHYTHMIA:
Sawtooth appearance of P waves |
Atrial Flutter
|
|
ARRHYTHMIA:
Usually caused by conduction block within the bundle of His |
Second Degree Mobitz Type II Heart Block
|
|
ARRHYTHMIA:
Complete dissociation between P waves and QRS complexes |
Third Degree (Complete) Heart Block
|
|
ARRHYTHMIA:
Three or more P wave morphologies |
Multifocal Atrial Tachycardia if HR >100
Wandering Pacemaker if HR <100 |
|
ARRHYTHMIA:
Associated with cannon A waves in jugular veins and widened pulse pressure |
Third Degree Heart Block
|
|
ARRHYTHMIA:
Irregularly irregular pulses and QRS complexes |
Atrial Fibrillation
|
|
ARRHYTHMIA:
Commonly caused by reentry |
Paroxysmal SVT
|
|
ARRHYTHMIA:
Associated with COPD |
1. Atrial Fibrillation
2. Atrial Flutter 3. Multifocal Atrial Tachycardia |
|
ARRHYTHMIA:
Treatment commonly includes anticoagulation, rate control and/or cardioversion |
Atrial Fibrillation
|
|
Wide QRS complexes not preceded by a P wave
|
Premature Ventricular Contraction (PVC)
|
|
ARRHYTHMIA:
Normal QRS morphology with a rate of 150-200 beats/min |
Paroxysmal SVT
|
|
ARRHYTHMIA:
Pharmacologic treatment includes amiodarone, lidocaine and procainamide |
Ventricular Tachycardia
|
|
ARRHYTHMIA:
May be treated with carotid massage or Valsalva maneuver |
Paroxysmal SVT
|
|
ARRHYTHMIA:
Common cause of palpitation caused by ectopic beats arising from multiple ventricular foci |
PVC
|
|
ARRHYTHMIA:
Ventricular arrhythmia commonly caused by myocardial ischemia that may lead to hemodynamic instability |
Ventricular Tachycardia
|
|
ARRHYTHMIA:
First-line therapy is defibrillation Second-line therapy is epinephrine or vasopressin |
1. Ventricular Fibrillation
2. Pulseless Ventricular Tachycardia |
|
ARRHYTHMIA:
Polymorphic wide complex tachycardia associated with prolonged QT interval |
Torsade de Pointes
|
|
ARRHYTHMIA:
Treated identically to ventricular fibrillation if there is no pulse |
Pulseless Ventricular Tachycardia
|
|
ARRHYTHMIA:
Tachyarrhythmia treated with adenosine, verapamil, cardioversion or radiofrequency ablation |
Paroxysmal SVT
|
|
ARRHYTHMIA:
Narrow complex tachycardia in which P waves follow QRS complexes |
1. Junctional Tachycardia
2. Wolff-Parkinson-White |
|
ARRHYTHMIA:
Treatment with pacemaker is necessary |
1. Symptomatic Second Degree Mobitz Type II Heart Block
2. Third Degree Heart Block 3. Sinus Node Dysfunction |
|
What is the most common cause of atrial fibrillation?
|
Hypertension (HTN)
|
|
What are some other important causes of Atrial Fibrillation other than HTN?
|
"PIRATES"
--Pulmonary disease --Ischemia of myocardium --Rheumatic heart disease --Anemia or Atrial myxoma --Thyrotoxicosis --Ethanol --Sepsis |
|
What are the 2 main components in the treatment of atrial fibrillation?
|
1. Rate Control
--Metoprolol 2. Long-term Anticoagulation --Warfarin |
|
What criteria are used to determine whether warfarin or aspirin is started in the treatment of atrial fibrillation?
|
CHADS2 Score:
--1 point for CHF, HTN, age >75, DM --2 points for stroke, TIA Score > or = 3 receives warfarin |
|
Name 3 clinical scenarios in which atropine is indicated for treatment of bradyarrhythmia?
|
1. Bradycardia causing hemodynamic instability
2. Syncope 3. CHF |
|
6 Symptoms of Congestive Heart Failure (CHF)
|
1. Dyspnea; exertional initially but occurs at rest as disease progresses
2. Orthopnea 3. Paroxysmal Nocturnal Dyspnea 4. Cough and Wheezing 5. Weight gain due to peripheral edema 6. Worsening fatigue |
|
4 Common Signs of Left-sided CHF
|
1. S3 Gallop
2. Inspiratory crackles or rales 3. Laterally displaced point of maximal impulse (due to cardiomegaly) 4. Ventricular heave |
|
5 Common Signs of Right-Sided CHF
|
1. Dependent edema
2. Jugular venous distention (JVD) 3. Hepatojugular reflux and ascites 4. Atrial Fibrillation 5. Cyanosis |
|
What is the pathophysiologic basis of systolic dysfunction?
|
Decreased contractility
|
|
What are the 2 common causes of systolic dysfunction?
|
1. Ischemic Cardiomyopathy
2. Ischemic Myocarditis |
|
What is the pathophysiologic basis of diastolic dysfunction?
|
Decreased Ventricular Compliance
|
|
4 Common Causes of Diastolic Dysfunction
|
1. HTN
2. Ischemic Cardiomyopathy 3. Hypertrophic Cardiomyopathy 4. Systemic Disorders --amyloidosis, hemochromatosis |
|
4 Common Chest X-ray (CXR) Abnormalities in CHF
|
1. Cardiomegaly
2. Cephalization of pulmonary vessels (increased vascularity in lung fields) 3. Kerley B Lines (indicating pleural fluid in fissures) 4. Pleural Effusions |
|
2 Common Echocardiographic Abnormalities in CHF
|
1. Decreased Ejection Fraction
2. Cardiomegaly |
|
CHF MEDICATION:
Shown to decrease mortality in CHF |
1. ACE Inhibitors
2. Beta-blockers 3. Spironolactone (decreased mortality in class IV CHF) |
|
CHF MEDICATION:
Used acutely for worsening dyspnea and fluid retention |
Loop Diuretics
|
|
CHF MEDICATION:
Reduce afterload by causing vasodilation of both arteries and veins |
ACE Inhibitors
|
|
CHF MEDICATION:
Reduce symptoms of CHF by improving contractility |
Digitalis
|
|
CHF MEDICATION:
Vasodilators used in patients refractory to ACE inhibitors |
1. Hydralazine
2. Isosorbide Dinitrate |
|
CHF MEDICATION:
May cause arrhythmias, yellow-tinted vision, anorexia and nausea |
Digitalis
|
|
CHF MEDICATION:
Intravenous positive inotropic agents |
1. Dopamine
2. Dobutamine 3. Nesiritide |
|
VALVULAR DEFECT:
Harsh midsystolic murmur in the right second intercostal space at the right sternal border, radiating into the neck and apex |
Aortic Stenosis
|
|
VALVULAR DEFECT:
Blowing, high-pitched diastolic murmur at the left two to fourth interspaces radiating to the apex |
Aortic Regurgitation
|
|
VALVULAR DEFECT:
Blowing holosystolic murmur at the apex radiating into the left axilla with increased apical impulse |
Mitral Regurgitation
|
|
VALVULAR DEFECT:
Low-pitched diastolic murmur at the apex that gets louder prior to S1; an opening snap is often present just after S2 |
Mitral Stenosis
|
|
VALVULAR DEFECT:
Soft, late systolic murmur at the left sternal border or apex, accompanied by midsystolic click |
Mitral Valve Prolapse
|
|
VALVULAR DEFECT:
Harsh midsystolic murmur in the left second intercostal space at the left sternal border |
Pulmonic Stenosis
|
|
VALVULAR DEFECT:
Blowing holosystolic murmur at lower left sternal border radiating to right of sternum; may increase with inspiration |
Tricuspid Regurgitation
|
|
VALVULAR DEFECT:
Harsh holosystolic murmur at lower left sternal border, accompanied by thrill |
Ventricular Septal Defect
|
|
VALVULAR DEFECT:
Harsh midsystolic murmur in the third and fourth left interspaces radiating down left sternal border; S4 and biphasic apical impulse often present |
Hypertrophic Cardiomyopathy
|
|
VALVULAR DEFECT:
Can be caused by papillary muscle rupture secondary to MI |
Mitral Regurgitation
|
|
VALVULAR DEFECT:
May cause left atrial enlargement, atrial fibrillation and pulmonary hypertension |
1. Mitral Stenosis
2. Mitral Regurgitation |
|
VALVULAR DEFECT:
Presents with triad of angina, syncope and exertional dyspnea; boot-shaped heart on CXR |
Aortic Stenosis
|
|
VALVULAR DEFECT:
May be precipitated by infective endocarditis, aortic aneurysmal dilation and connective tissue disorders |
Aortic Insufficiency (Regurgitation)
|
|
VALVULAR DEFECT:
Atrioventricular block |
Mitral Regurgitation
|
|
VALVULAR DEFECT:
Calcific degeneration of a congenital bicuspid valve |
Aortic Stenosis
|
|
VALVULAR DEFECT:
Increased pulse pressure |
Aortic Insufficiency (Regurgitation)
|
|
What are the most common etiologies of dilated cardiomyopathy?
|
"ABCD"
--Alcohol abuse --Beriberi --Coxsackie B myocarditis, Cocaine, Chagas disease --Doxorubicin toxicity (also pregnancy) |
|
CARDIOMYOPATHY:
Asymmetric septal hypertrophy, banana-shaped left ventricle (LV); LV outflow obstruction |
Hypertrophic Cardiomyopathy
|
|
CARDIOMYOPATHY:
May be caused by sarcoidosis, amyloidosis, scleroderma, hereditary hemochromatosis, endocardial fibroelastosis, radiation-induced fibrosis |
Restrictive Cardiomyopathy
|
|
CARDIOMYOPATHY:
Causes sudden death in young, otherwise healthy athletes |
Hypertrophic Cardiomyopathy
|
|
CARDIOMYOPATHY:
Four-chamber hypertrophy and dilation accompanied by systolic dysfunction |
Dilated Cardiomyopathy
|
|
CARDIOMYOPATHY:
Cardiomyopathy most commonly caused by endomyocardial fibrosis |
Restrictive Cardiomyopathy
|
|
CARDIOMYOPATHY:
Most common type of cardiomyopathy, commonly inherited in autosomal-dominant (AD) fashion |
Hypertrophic Cardiomyopathy
|
|
CARDIOMYOPATHY:
ACEIs have been demonstrated to decrease mortality |
Dilated Cardiomyopathy
|
|
CARDIOMYOPATHY:
Symptoms relieved by squatting (increased preload) |
Hypertrophic Cardiomyopathy
|
|
CARDIOMYOPATHY:
Impaired left ventricular diastolic filling; may mimic constrictive pericarditis |
Restrictive Cardiomyopathy
|
|
CARDIOMYOPATHY:
Examination reveals cardiomegaly, mitral regurgitation and S3; balloon-shaped heart on CXR |
Dilated Cardiomyopathy
|
|
CARDIOMYOPATHY:
Mitral regurgitation, sustained apical impulse, S4 and systolic ejection murmur; boot-shaped heart on CXR |
Hypertrophic Cardiomyopathy
|
|
What is the common presentation of pericarditis?
|
1. Pleuritic retrosternal chest pain (increased when supine, decreased when sitting up and leaning forward)
2. Dyspnea 3. Cough 4. Fever |
|
What are the most common etiologies of serous pericarditis?
|
1. Uremia
2. Systemic Lupus Erythematosus (SLE) 3. Rheumatic Fever 4. Coxsackie Viral Infection |
|
What are the most common etiologies of fibrinous pericarditis?
|
1. Uremia
2. SLE 3. Rheumatic Fever 4. Coxsackie Viral Infection 5. MI |
|
What are the most common etiologies of hemorrhagic pericarditis?
|
1. Trauma
2. Malignancy 3. Tuberculosis |
|
What is a typical examination finding in pericarditis?
|
Pericardial Friction Rub
|
|
What are the classic ECG findings in pericarditis?
|
Diffuse ST Elevation
|
|
What life-threatening complication of pericarditis causes distant heart sounds, JVD, hypotension, pulsus paradoxus, and elevated central venous pressure (CVP) on inspiration?
|
Cardiac Tamponade
Beck's Triad: 1. JVD 2. hypotension 3. muffled heart sounds |
|
What is the definitive treatment for acute decompensation in a patient with cardiac tamponade?
|
Pericardiocentesis
|
|
Which secondary intervention may be helpful in the management of a patient with cardiac tamponade?
|
Intravascular Volume Expansion
|
|
What are the 3 major categories of endocarditis?
|
1. Infective Endocarditis
2. Nonbacterial Thrombotic (Marantic) Endocarditis (NBTE) 3. Libman-Sacks Endocarditis |
|
What is the common presentation of infective endocarditis (IE)?
|
1. Fever (high in acute endocarditis, low-grade in subacute endocarditis
2. Constitutional Symptoms 3. Dyspnea |
|
What are the clinical signs of IE?
|
"FROM JANE"
--Fever --Roth's Spots --Osler's Nodes --Murmur --Janeway Lesions --Anemia --Nail bed (splinter) hemorrhages --Emboli |
|
What criteria are typically used for diagnosing IE?
|
The Duke Criteria
|
|
What are the 2 major Duke criteria for diagnosing IE?
|
1. Two consecutive blood cultures (12 h apart) positive for IE-causing organism
2. Echocardiogram demonstrating valvular vegetation, ring abscess or other evidence of endocardial infection or new valve murmur |
|
What are the 5 minor Duke criteria for diagnosing IE?
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1. Cardiac predisposition including valvular abnormality, congenital heart disease or hypertrophic cardiomyopathy
Risk of bacteremia: DM, indwelling catheter, IV drug abuse IVDA), hemodialysis 2. Fever >38C (100.4F) 3. Vascular phenomena: signs of embolic disease including septic pulmonary emboli, mycotic cerebral abscesses, Janeway lesions 4. Immunologic phenomena including Roth spots or Osler nodes 5. Single positive blood culture |
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How do you make a definitive diagnosis of infective endocarditis?
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2 major criteria
1 major + 3 minor criteria 5 minor criteria |
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What is the most common valve affected by IE?
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Mitral Valve
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What is the most common valve affected by IE in IV drug users?
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Tricuspid Valve
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TYPE OF ENDOCARDITIS:
25 yo IV drug user with rapid onset of high fever, rigors, malaise with tricuspid regurgitation |
Acute IE
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TYPE OF ENDOCARDITIS:
60 yo female with mitral valve prolapse who has recently undergone dental extraction presenting with low-grade fever and flu-like symptoms |
Subacute IE
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TYPE OF ENDOCARDITIS:
65 yo male with metastatic colon cancer and a new murmur consistent with mitral regurgitation |
Nonbacterial Thrombotic Endocarditis (NBTE)
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TYPE OF ENDOCARDITIS:
30 yo female with SLE |
Libman-Sacks Endocarditis (LSE)
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Which organism most often causes acute IE?
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Staphylococcus aureus
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Which organism most often causes subacute IE?
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Streptococcus viridans
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Which organisms can cause endocarditis but are not typically isolated by conventional bacterial culture?
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"HACEK"
--Haemophilus parainfluenzae --Actinobacillus --Cardiobacterium --Eikenella --Kingella |
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What are some sequelae of bacterial endocarditis?
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1. Valvular injury
2. Renal injury (glomerulonephritis (GN) 3. Septic emboli to brain, lungs, kidneys causing infarction or abscess |
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What is the most common cause of myocarditis worldwide?
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Trypanosoma cruzii
Chagas Disease |
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What is the empiric treatment for a patient with suspected endocarditis (before an organism is isolated in blood cultures)?
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Antistaphylococcal Beta-lactam Antibiotic
& Aminoglycoside |
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What is the suggested regimen of antibiotic prophylaxis for patients at increased risk of endocarditis?
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Two grams of Amoxicillin prior to dental procedures
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Which patients should receive endocarditis prophylaxis?
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1. Patients with prosthetic heart valves
2. Previous bacterial endocarditis 3. High risk patients (ie, complex cyanotic heart disease) 4. Moderate risk patients (ie, hypertrophic cardiomyopathy, MVP with regurgitation and/or thickened leaflets, repaired intracardiac defects in past 6 months) |
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What type of infection causes rheumatic fever?
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Group A streptococcal pharyngitis
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How does streptococcal pharyngitis cause rheumatic heart disease?
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Antistreptococcal antibodies cross-react with a cardiac antigen
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What serologic test is elevated in rheumatic heart disease?
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1. Antistreptolysin Antibodies (ASO)
2. DNAse B |
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Name the 5 major Jones criteria for rheumatic heart disease?
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"JONES"
--Joints (Migratory Polyarthritis) --Pancarditis --Subcutaneous Nodules --Erythema --Sydenham chorea |
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Name 3 minor Jones criteria for Rheumatic Heart Disease
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1. Fever
2. Arthralgia 3. Leukocytosis |
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What is the most commonly observed valvular deformity in rheumatic heart disease?
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Mitral Stenosis (MS)
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What treatment for streptococcal pharyngitis can prevent rheumatic heart disease?
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Penicillin
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What is the critical determinant of morbidity in acute rheumatic fever?
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Degree of mitral and aortic valve stenosis/regurgitation
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What is the typical presentation of an aortic dissection?
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Sudden onset of severe, tearing substernal pain radiating to the interscapular region of the back
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Which physical examination findings are characteristic of an aortic dissection?
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1. Unequal BP in the extremities
2. New murmur consistent with aortic regurgitation |
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What finding on CXR suggests an aortic dissection?
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Widened mediastinum
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Which coronary artery is most commonly affected by aortic dissection and what are the associated ECG findings?
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Right Coronary Artery
Inferior MI ST elevation in II, II, aVF |
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What is the gold standard for the diagnosis of aortic dissection?
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Angiography
CT with contrast, transesophageal echocardiography (TEE) and MRI also have diagnostic use and are less invasive |
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What medication is preferred for lowering BP in a patient with an aortic dissection?
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1. Sodium Nitroprusside
2. Beta-Blockers |
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What is the definitive therapy for an aortic dissection?
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Surgical repair
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what are the risk factors for peripheral vascular disease (PVD)?
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Similar to coronary risk factors, though diabetes is #1
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Peripheral Vascular Disease:
Focal neurologic findings |
Cerbrovascular Disease
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Peripheral Vascular Disease:
Abdominal pain out of proportion to examination |
Mesenteric Ischemia
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Peripheral Vascular Disease:
Intermittent claudication |
Chronic Arterial Occlusive Disease
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Peripheral Vascular Disease:
Pain in the buttocks and thighs with walking |
Aortoiliac Occlusive Disease
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Peripheral Vascular Disease:
Pain in the calves when walking |
Femoral-Popliteal Occlusive Disease
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Peripheral Vascular Disease:
Abdominal angina |
Chronic Mesenteric Arterial Occlusive Disease
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What noninvasive study is used to diagnose arterial occlusion?
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Doppler Ultrasound
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What is the gold standard for the diagnosis of arterial occlusion?
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Angiography
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What is the source of most emboli causing acute arterial occlusion?
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Cardiac mural thrombus (commonly in patients with atrial fibrillation)
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What is the treatment of an acute arterial occlusion?
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Surgical or percutaneous thrombectomy or medical thrombolysis
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What type of therapy must be administered to all patients with a h/o acute arterial occlusion?
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Warfarin
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56 yo female presents with dyspnea on exertion (DOE)
PE: loud S1, delayed P2, early diastolic sound and a diastolic rumble Transesophageal Echocardiogram (TEE): mobile, pedunculated left atrial mass |
Atrial Myxoma
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60 yo presents with chest pain relieved by sitting up and leaning forward
PE: pericardial friction rub ECG: diffuse ST-segment elevation ECHO: pericardial effusion with thickening of the pericardium |
Acute Pericarditis
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65 yo male presents with 1 week h/o fever and DOE and orthopnea
PE: new blowing holosystolic murmur at apex radiating into left axilla Blood cultures (+) for viridans streptococci ECHO: oscillating mass attached to mitral valve |
Acute IE
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60 yo presents with dyspnea and palpitations
PE: 20 mmHg decline in systolic BP with inspiration (pulsus paradoxus), decreased BP, JVD, diminished S1 and S2 ECHO: large pericardial effusion |
Cardiac Tamponade
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58 yo male with Marfan Syndrome presents with the abrupt onset of tearing chest pain radiating to the back
PE: decreased BP, asymmetric pulses, declining mental status CXR: widened mediastinum |
Aortic Dissection
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70 yo diabetic with hypercholesterolemia presents with angina, syncope, DOE
PE: diminished, slowly rising carotid pulses, crescendo-decrescendo systolic murmur at the second interspace at the right upper sternal border |
Aortic Stenosis
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80 yo diabetic with HTN and h/o rheumatic heart disease presents with left-sided weakness
PE: pulses are irregularly irregular ECG: absence of P waves and irregularly irregular QRS complexes |
Atrial Fibrillation leading to embolic stroke
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70 yo with h/o CAD presents with worsening DOE, orthopnea, and paroxysmal nocturnal dyspnea
PE: JVD, S3 gallop, positive hepatojugular reflex, bibasilar rales and peripheral edema CXR: cardiomegaly, bilateral pleural effusions |
CHF
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50 yo chronic alcoholic presents with worsening DOE, orthopnea and paroxysmal nocturnal dyspnea
PE: laterally displaced apical impulse ECHO: four-chamber dilation, mitral and tricuspid regurgitation |
Alcoholic Dilated Cardiomyopathy
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35 yo male with FH of sudden cardiac death presents with DOE and syncope
PE: double apical impulse, S4 gallop, holosystolic murmur at apex and axilla ECHO: left ventricular hypertrophy and mitral regurgitation |
Hypertrophic Cardiomyopathy
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40 yo black male with h/o HTN presents with chest pain, dyspnea and severe headache
PE: BP = 210/130 in all four extremities, flame-shaped retinal hemorrhages, papilledema LABS: negative vanillylmandelic acid (VMA) and urine catecholamines, and cardiac enzymes |
Malignant HTN
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15 yo female presents 1 month after a sore throat with fever and joint pain
CBC: leukocytosis LABS: ASO+ |
Rheumatic Fever
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35 yo female with a h/o rheumatic fever presents with worsening DOE and orthopnea
PE: loud S1, opening snap, and low-pitched diastolic murmur at the apex CXR: left atrial enlargement |
Mitral Stenosis
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65 yo male presents with 1 hour h/o substernal pressure and pain with radiation into the jaw and left arm, nausea, and diaphoresis
PE: S4 gallop LABS: increased troponin and CK-MB ECG: ST elevation in leads aVL, V1-V4 |
Anterior MI
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70 yo female with DM and CAD presents with nausea and vomiting
PE: hypotension, clear lungs, JVD, right ventricular lift and tricuspid valve regurgitation ECG: ST elevation in the inferior leads |
Right Ventricular MI
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40 yo asymptomatic male
PE: displaced and diffuse apical impulse, diastolic murmur and left sternal border, brisk pulses with rapid collapse + "pistol shot" sound auscultated over large peripheral arteries |
Aortic Regurgitation
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