cardio ALL.pdf

cardio ALL what causes cholesterol to go up hypothyroidism, pregnancy, kidney failure what causes triglycerides to go up DM, ETOH, obesity, steroids, estrogen What is the lipid plaque seen on eyes called? How about for Achilles tendon? xanthelasma xanthomas 20-39 to assess risk every 4-6 years to ca...

cardio ALL what causes cholesterol to go up hypothyroidism, pregnancy, kidney failure what causes triglycerides to go up DM, ETOH, obesity, steroids, estrogen What is the lipid plaque seen on eyes called? How about for Achilles tendon? xanthelasma xanthomas 20-39 to assess risk every 4-6 years to calculate 10 year CVD risk -Higher risk = >1 risk factor at what age do we start screening for CVD (hypertension, smoking, family hx) or 1 severe risk factor. initiate screening at age 20 to 25 for males; 30 - 35 for females. - Lower risk: initiate screening at age 35 for males; 45 for females. gender age race What is in the 10 year CVD risk calculation smoke blood pressure blood cholesterol diabetes 1. Patients with type 1 or 2 Diabetes Mellitus between the ages 40-75 years of age. 2. Patients without cardiovascular who are statins good for disease ages 40-75 years of age & >7.5% risk for having a heart attack or stroke within 10 years. 3. People >21 years of age with LDL levels >190 mg/dL. 4. Any patient with any form of clinical atherosclerotic cardiovascular disease. 5. Patients 30yo What clinical manifestation can develop in atrial septal defect paradoxical emboli stroke from venous clots ASD associated with what sounds? Heard best where? Systolic ejection crescendodescrescendo flow murmur @ pulmonic area /heard at the left upper sternal border Widely split, fixed S2 , does not vary with respirations What kind of shunt is ASD? Left to right (noncyanotic) atrial septal defet diagnosis echo Spontaneous closure likely in 1st year-- How do you manage ASD? What is Eisenmenger syndrome? just observe until 3, at which point surgical closure (or if symptomatic) seen in PDA- A septal defect leading to pulmonary arterial hypertension, causing a right-to-left shunt, bypassing the lungs and resulting in cyanosis and clubbing. What is PDA? PDA is what kind of shunt? Communication between descending thoracic aorta and pulmonary artery Left to Right shunt (noncyanotic) Most asymptomatic Patient will be complaining of failure to Patients with PDA will complain of what? thrive/weight loss, poor feeding, tachycardia, and tachypnea -Also recurrent lower respiratory tract infection signs of labored breathing, bounding pulses, and tire easy with feeds What defect a/w with maternal rubella? PDA What else is it a/w? also Down syndrome What sounds will you hear with PDA? Heard best where? continuous, rough, "machinery-like" murmur, heard best in the first interspaces of the LSB wide pulse presure: bounding pulse, loud S2 Murmur radiates to back Where does PDA murmur radiate? Murmur radiates to back What murmur radiates to back? PDA murmur radiates to back Diagnostic test of choice for PDA? Echo-gold standard 1st line- iv Indomethacin (good for premature) How do you treat PDA? Surgery if indomethacin fails or full term, best before 1-3 years (ligation most perferred method of closure) What agent can be used to keep PDA open and preserve patency? What can close it? Major risk factors of PDA? PDA also assocaited with what? Prostoglandin E1- open Close: O2, bradykinin, NSAIDs (prostaglandin synthesis inhibitors like indomethacin and aspirin) Prematurity is a major risk factor. It is also associated with Down's syndrome and maternal rubella infection (1st trimester) What is Coarctation of the Aorta? Narrowing of the aortic lumen What is coarctation of Dayo I order often associated with bicuspid aortic valve What will you find on PE for Coarctation Upper extremity systolic hypertension of the Aorta? with lower extremity hypotension and/or diminished or delayed lower extremity pulses (eg, femoral & dorsalis pedis pulses). What will you see on CXR for Coarctation of the Aorta? CXR will show rib notching and "figure3" sign Diagnosis is made by echo How do you diagnosis Coarctation of the Aorta? can also do angiogram (gold standard How do you treat Coarctation of the Treatment is balloon angioplasty with stent placement, or surgical correction Aorta? What heart defect is a/w with turner's syndrome? What defects are acyanotic? according to pance prep pearls), CT Scan, EKG, CXR Prostaglandin E1 preoperatvely Coarctation of the Aorta ASD, VSD, PDA, coarctation of aorta infants- preductal Infants have what kind of coarctation? Adults have what kind? Manifestations? adults- postductal secondary HTN, bilateral claudication, syncope, dyspnea on exertion. In infants, FTT and poor feeding Most common cause of CHD? 2nd MC? MC- VSD Most common cyanotic congenital heart disease? Tetralogy of Fallot Is Teratology of Fallot cyanotic or acyanotic? Cyanotic (right to left) What 4 things make up Teratology of Fallot? Pulmonic stenosis(RV outflow obstruction) + RVH + VSD + overriding aorta PROV CXR shows what with Teratology of Fallot? CXR: "boot shaped" heart Teratology of Fallot Tet spells(episodes of cyanosis) (crying/feeding → ↑ RV outflow obstruction) Tet spells a/w? how is it relieved? Patient with a history of episodes of cyanosis (tet spells) and squatting for relief Acute cyanosis rx: place child in squatting or knee to chest position (↑ SVR → ↓ shunting), morphine, O2 What is definitive treatment for Tetrology of Fallot? Blue baby syndrome a/w EKG would show what for Tetrology of Fallot? Gold standard for Dx? Definitive rx: surgery give prostaglandin to keep open before surgery Blue baby syndrome (cyanosis) a/ Tetrology of Fallot RVH Gold stadnard: Echo tetrology of fallot? crescendo-decrescendo murmur harsh holosystolic murmur @ left upper sternal border , right ventricular heave What is VSD? hole in the ventricular septum what sound/find would you hear with What kind of shunt is VSD? Left to Right (noncyanotic) What is the most common type of VSD? Perimembranos (80%)-MC. Hole in LV outflow tract near the tricuspid valve. What is another type of VSD and what would you see with it? What symptoms would you find with a larger VSD? What sound would you hear on auscultation of VSD? Where is it heard best? Muscular- multiple holes in swiss cheese pattern no pressure differences between the ventricles Loud, high pitched, harsh, holosystolic murmur heard at lower left sternal border systolic thrill/ diastolic rumble at mitral area What is diagnostic test of choice for VSD? Diagnosis is made by echo How do you manage VSD? observe and patch closure if symptomatic infants or complications. Larger shunts repaired by age 2y to prevent pulmonary HTN Dilated cardiomyopathy is dysfunction of Systolic dysfunction, leading to a dilated, what? weak heart most common type of cardiomyopathy Dilated cardiomyopathy age risk factor for dilated cardiomyopathy 20-60 years of age, men causes of dilated cardiomyopathy Idiopathic most common cause (may be familial). Infections: viral most common (especially the enteroviruses Coxsackievirus B, Echovirus). postviral myocarditis, HIV, Lyme disease. Parvovirus B19, Chagas disease. Toxic: alcohol abuse, cocaine, anthracyclines (eg, Doxorubicin), radiation. Pregnancy, autoimmune. Metabolic: eg, thyroid disorders, vitamin B1 (thiamine) deficiency. Systolic heart failure: - Left-sided failure: L for Lung symptoms - dyspnea, fatigue. symptoms of dilated cardiomyopathy - Right-sided failure: peripheral edema, jugular venous distention, hepatomegaly, GI symptoms. - Embolic events, arrhythmias. Left-sided failure symptoms L for Lung symptoms - dyspnea, fatigue. Right-sided failure symptoms peripheral edema, jugular venous distention, hepatomegaly, GI symptoms PE dilated cardiomyopathy (2) S3 gallop hallmark (due to filling of a dilated ventricle). Mitral or tricuspid regurgitation. Echocardiogram: diagnostic test of choice - left ventricular dilation (large diagnostics for dilated cardiomyopathy chamber), thin ventricular walls, decreased ejection fraction, ventricular hypokinesis. Similar findings to Systolic heart failure. Chest radiograph: cardiomegaly, pulmonary edema, pleural effusion. ECG: may show sinus tachycardia or arrhythmias. Mortality reduction with ACE inhibitors, management dilated cardiomyopathy Beta blockers (eg, Metoprolol, Carvedilol), ARBs, Spironolactone. Symptom control with diuretics, Digoxin. Automated implantable cardioverter/defibrillator if ejection fraction < 35-30%. what is stress takotsubo cardiomyopathy risk factors stress takotsubo cardiomyopathy pathophysiology stress takotsubo cardiomyopathy Transient regional systolic dysfunction of the left ventricle that can imitate Myocardial infarction, but is associated with the absence of significant obstructive coronary artery disease or evidence of plaque rupture. postmenopausal women exposed to physical or emotional stress (eg, death of relative, catastrophic medical diagnoses, acute medical illness). catecholamine surge during physical or emotional stress, microvascular dysfunction, and coronary artery spasm. symptoms of stress takotsubo cardiomyopathy cardiac enzymes in stress takotsubo cardiomyopathy ecg findings of stress takotsubo cardiomyopathy coronary angiography findings of stress takotsubo cardiomyopathy echocardiogram findings of stress takotsubo cardiomyopathy management of stress takotsubo cardiomyopathy Similar to Acute coronary syndrome (ACS) - eg, substernal chest pain, dyspnea, syncope often positive ST elevations absence of acute plaque rupture or obstructive coronary disease transient regional left ventricular systolic dysfunction, especially apical left ventricular ballooning. conservative and supportive care is the mainstay of treatment (eg, Beta blockers, ACE inhibitors for 3-6 months with serial imaging to assess for improvement) Autosomal dominant genetic disorder of inappropriate LV and/or RV hypertrophy with diastolic dysfunction. what is hypertrophic cardiomyopathy Subaortic outflow obstruction due to asymmetrical septal hypertrophy and systolic anterior motion of the mitral valve. Increased contractility (eg, exercise, in hypertrophic cardiomyopathy, obstructions worsens with Digoxin, beta agonists) and/or Decreased LV volume (eg, dehydration, decreased venous return, Valsalva maneuver). Dyspnea most common symptom, symptoms of hypertrophic cardiomyopathy fatigue, angina (chest pain), pre syncope, syncope, dizziness, arrhythmias. Maybe asymptomatic initially. Sudden cardiac death, especially in adolescent or preadolescent children especially during times of extreme exertion usually due to Ventricular fibrillation. Harsh systolic murmur best heard at the left sternal border. Increased murmur intensity with decreased venous return (eg, Valsalva, standing) or decreased afterload (eg, Amyl nitrate). PE for hypertrophic cardiomyopathy Decreased murmur intensity with increased venous return (eg, squatting, supine, leg raise) or increased afterload (eg, handgrip). Increased LV volume preserves outflow. May have loud S4, mitral regurgitation, S3, or pulsus bisferiens. ecg results for hypertrophic cardiomyopathy left ventricular hypertrophy, asymmetric ventricular wall thickness echo for hypertrophic cardiomyopathy (especially septal) 15mm or greater, systolic anterior motion of the mitral valve, & small LV chamber size. Focus on early detection, medical management, surgical management, and/or ICD placement. Medical: Beta blockers first-line medical management management of hypertrophic cardiomyopathy Alternatives include Calcium channel blockers & Disopyramide. Surgical: Myomectomy usually performed in young patients refractory to medical therapy. Alcohol septal ablation: an alternative to surgical myomectomy. Patients should avoid dehydration, extreme exertion, and exercise. Cautious use of Digoxin, Nitrates, and diuretics (Digoxin increases contractility; Nitrates & diuretics decrease LV volume). Diastolic dysfunction in a non-dilated what is restrictive cardiomyopathy ventricle, which impedes ventricular filling (decreased compliance). The stiff ventricle fills with great effort. Infiltrative disease: Amyloidosis (most common), Sarcoidosis, Hemochromatosis, Scleroderma, Metastatic disease, endomyocardial what causes restrictive cardiomyopathy fibrosis. Chemotherapy, radiation therapy. Signs of heart failure. S3 may be heard. Pulmonary hypertension. symptoms of restrictive cardiomyopathy Right-sided heart failure > left-sided failure symptoms. - Right-sided failure: eg, peripheral edema, jugular venous distention, hepatomegaly, ascites, GI symptoms. - Left-sided failure: L for Lung symptoms (eg, dyspnea most common complaint, fatigue). what is kussmauls sign in restrictive cardiomyopathy the lack of an inspiratory decline or increase in jugular venous pressure with inspiration. diagnostic t e s t of choice - non-dilated echocardiogram results for restrictive cardiomyopathy ventricles with normal thickness (may be slightly thick), diastolic dysfunction, marked dilation of both atria. Systolic function generally preserved in early disease. Bright speckled myocardium in Amyloidosis. chest radiograph for restrictive normal ventricular chamber size, cardiomyopathy enlarged atria. Pulmonary congestion ecg for restrictive cardiomyopathy low voltage QRS, arrhythmias. is BNP inc or dec in restrictive cardiomyopathy increased definitive diagnosis of restrictive cardiomyopathy Endomyocardial biopsy; definitive diagnosis (not used often). Amyloidosis associated with apple-green birefringence with Congo-red staining. No specific treatment. management for restrictive cardiomyopathy Treat the underlying disorder (eg, chelation for Hemochromatosis, Glucocorticoids for Sarcoidosis). Gentle diuresis for symptoms, vasodilators. hypotension within 2 to 5 minutes of What is postural orthostatic hypotension quiet standing defined by at least 20 MMHG fall in systolic pressure or 10 MMHG fall in diastolic pressure Who is postural orthostatic hypotension most commonly seen in older adults > 65 yo postural orthostatic hypotension can diretics, alcohol, alpha blockers, nitro, occur from which medications ace Neurologic causes of postural orthostatic hypotension include Workup for postural orthostatic hypotension management for postural orthostatic hypotension diabetic neuropathy, parkinsons check bp, tilt table test to reduce bp at 60 degree angle labs - check for anemia and dehydration conservative initial management of choice - inc salt and fluid intake + fludrocortisone What is vasovagal syncope due to vasovagal hypotension Most common cause of syncope vasovagal syncope Triggers for vasovagal syncope blood phobia, emotional stress/fear, pain, trauma Symptoms of vasovagal syncope prodromal phase (eg, dizziness, lightheadedness, epigastric pain, palpitations, blurred vision, darkening of visual fields) followed by syncope followed by a postdromal phase. And what is shock and what is it determined by? What is hypovolemic shock? Give me examples of hemorrhagic and non-blood fluid loss etiologies for hypovolemic shock Symptoms of hypovolemic shock In class 4 of hemorrhagic shock what are the symptoms the hallmark diagnosis for hypovolemic shock includes what Management of hypovolemic shock includes volume resuscitation, with inadequate organ perfusion and tissue oxygenation 1. low cardiac output or low systemic vascular resistance loss of blood or fluid volume due to hemorrhage or fluid loss go bleed, AAA, ectopic, postpartum vomiting, bowel instruction, burns, DKA inc heart rate, vasoconstriction, hypotension, dec cardiac output no urine output Vasoconstriction (inc SVR), hypotension, dec CO & decreased pulmonary capillary pressure crystalloids (Normal Saline or Lactated Ringer's) which kind of solution what is the pathophysiology for inadequate tissue perfusion, drop in cardiogenic shock Cardiac output what are common causes of cardiogenic Cardiac disease: myocardial infarction, shock myocarditis, valve dysfunction, congenital heart disease, cardiomyopathy, arrhythmias (avoid aggressive IV fluid tx use smaller amounts of fluid). NOTE CARDIOGENIC Management of cardiogenic shock SHOCK IS THE ONLY SHOCK IN WHICH LARGE AMOUNTS OF FLUIDS AREN'T GIVEN What is septic shock? infective organisms activate the immune system => host produces systemic inflammatory response 1. Temperature: fever :>38°C (100.4° F) or hypothermia 90 bpm What SIRS criteria 3. Respiratory rate: >20 or PaCOz 12.0Q0 cells/hpf or 50 years, smokers, history of other vasospastic disorders (eg, Raynaud phenomenon, Migraine). symptoms prinzmental angina diagnosis prinzmental angina Chest pain: at rest (especially midnight to early morning), usually not exertional ECG: transient ST elevations in the affected artery that resolve with symptom resolution (ST elevations may resolve with Calcium channel blockers or Nitroglycerin). May have ST depressions. Angiography: rules out coronary artery disease and may show evidence of coronary vasospasm during angiography, especially with use of Ergonovine Calcium channel blockers first-line (eg management prinzmental angina Diltiazem, Verapamil, Amlodipine, Nicardipine) given at night what to avoid in prinzmental angina Beta blockers what causes cocaine induced MI Coronary artery vasospasm ecg of cocaine induced MI ECG: transient ST elevations classic. management of cocaine induced MI Calcium channel blockers & nitrates drugs of choice what to avoid in cocaine induced MI Avoid nonselective b-blockers in cocaineinduced MI bc of vasospasm What is myocarditis? inflammation of middle heart muscle Pathophysiology of myocarditis myocellular damage leading to myocardial necrosis and dysfunction leading to HF infectious causes of myocarditis viral (enterovirus- coxsackievirus B) auto immune causes of myocarditis Lupus, RA what medications can cause myocarditis clozapine (schizo med) symptoms of myocarditis viral prodrome and systolic dysfunction symptoms like seen in dilated cardiomyopathy what type of heart sound do you hear with mycoarditis S3 gallop diagnostic studies of myocarditis chest xray, echo, end-myocardial biopsy is gold standard What does chest radiograph show for cardiomegaly myocarditis? What does an echo show for myocarditis management of myocarditis ventricular systolic dysfunction supportive diuretics, BB, ACE what is heart failure problem with filling of heart or pumping blood The most common cause of heart failure is what coronary artery disease The most common cause of left sided heart failure is what CAD and HTN the most common cause of right sided heart failure is what left sided failure MCC, pull disorders like COPD and pulmonary HTN ejection fraction for systolic failure decreased EF auscultation for systolic failure S3 ventricular walls for systolic failure thin LV chamber for systolic failure dilated diastolic failure ejection fraction preserved (EF inc or normal) diastolic failure ventricular walls thick diastolic failure LV chamber dilated diastolic failure auscultation S4 normal heart ejection fraction 50-70 EF when does systolic HF happen post MI, dilated cardiomyopathy, myocarditis HTN (think heart thickens to compensate when does diastolic HF happen htn vessels), LVH, elderly, restrictive cardiomyopathy, hypertrophic cardiomyopathy what is the pathophysiology of heart inc after load, inc preload, dec failure contractility what are the symptoms of left sided heart failure dyspnea physical exam findings of left sided heart failure pulmonary edema, congestion (rales and rhonchi) Cheyenne stokes breathing cool extremities what are the symptoms of right sided heart failure? xray for heart failure how do Kerley b lines look What test are done for CHF What does BNP look like for CHF? best test for CHF! peripheral edema, JVD, n/v, hepatojugular reflux (push liver, going to see JVD) pleural effusion and cardiomegaly, Kelly B lines, bat wing appearance periphery at lungs. (ghost white like lines in triangular area) chest xray BNP over 100 suggests HF echo look at ventricular walls, ejection fraction New York heart association functional class treatment CHF four classes of drugs for CHF that decrease mortality BASH the heart to make it beat harder class 1-4 1. no symptoms 2. mild symptoms 3. symptoms when doing ADL 4. symptoms even at rest lifestyle - smoking cessation, sodium dec + pharmacologic Beta blockers, ace/arbs, spironolactone, hydralazine BASH the heart to make it beat harder Beta blockers, ace/arbs, spironolactone, hydralazine ace - pril arbs - losartan best med for systolic HF beta blocker - lol K+ sparing diuretics spironolactone/epleronone systolic HF meds that help pt feel better diastolic HF treatment loop furosemide Digoxin, dobutamine, dopamine *not as important, no guidelines. same as systolic left ventricular assist device mechanical devices for CHF (last stages) what is acute decompensated HF AICD - defribrillator sudden worsening of HF symptoms that can be fatal diagnosis acute decompensated HF cxr, BNP, echo LMNOP Lasix- help pull fluid off lungs IV Morphine treatment acute decompensated HF Nitroglycerin- nitrates Oxygen - 100% O2 Position - sit upright, leg hanging off table to dec preload What is normal blood pressure Less than 120 systolic, and less than 80 diastolic What is elevated blood pressure? Systolic 120-129 , Diastolic 140 systolic and/or >90 diastolic In order to be diagnosed with hypertension, the elevations recorded must be what What is the most common cause of hypertension? 2 diff readings on at least 2 diff visits primary essential inc salt sensitivity advancing age obesity family history race What is primary essential hypertension associated with? (risk factors) excessive alcohol physical inactivity What is the cause of secondary hypertension? underlying, correctable cause renovascular - renal artery stenosis What is the most common cause of secondary hypertension? other: correction of aorta, Cushing Hypertension is the second most common cause of what end stage renal disease in the US syndrome, pheochromocytoma, OCP, NSAIDs, psuedophedrine, sleep apnea fasting blood glucose ecg- LVH fundoscopy - retinopathy What is the work up of hypertension? lipid profile- cholesterol urinalysis - urine albumin to creatinine ratio/creatinine TSH What is the management of hypertension? lifestyle - smoking cessation, salt restriction, exercise, DASH diet, limit alc If a patient feels a trial of diet and exercise, what is the next step of management? medical management What is a blood pressure target for someone with hypertension? How about for adult 60 years of age or older? less than 140/90 less than 150/90 for 60+ ACE - pril Initial hypertensive therapy and uncomplicated hypertension? (nonAfrican-Americans) ARBS- sartan Thiazide - HCTZ CCB - amlodipine (dihydropyridine) Hypertensive therapy with a patient who has angina BB CCB Hypertensive therapy with a patient who has post myocardial infarction ace, BB Hypertensive therapy with a patient who has systolic heart failure ace, arb, BB Hypertensive therapy with a patient who has diabetes, mellitus or chronic kidney disease ACE or ARB ( slow progression of nephropathy) Hypertensive therapy with a patient who has isolated systolic, hypertension, in elderly diuretics, CCB Hypertensive therapy with a patient who has osteoporosis thiazide Hypertensive therapy with a patient who has BPH alpha blocker - osins Hypertensive therapy with a patient who is african-American CCB or thiazides Hypertensive therapy with a patient who has gout CCB (or Losartan bc it doesnt cause hyperuricemia) If a patient has atrial flutter or fibrillation, which medication is likely to help their BB, CCB hypertension Do not give a patient with depression what medication for their hypertension BB Do not give a patient with gout what hypertension medication thiazide, loop diuretics Do not give a patient with angioedema what medication ace inhibitors Adverse effects of diuretics hyperglycemia, hyperuricemia, hypokalemia, hyponatremia ace/arb MOA ACEIs and ARBs inhibit efferent renal arteriolar vasoconstriction that lowers glomerular filtration pressure. Adverse effects of loop diuretics hypokalemia, hyperlipidemia, hyperglycemia Adverse effects of potassium sparing diuretics hyperkalemia, gynecomastia with spironolactone Adverse effects of ace inhibitors hypotension, cough, angioedema due to inc bradykinin adverse effects of arbs Mechanism of action for dihydropyridine calcium channel blockers vasodilators Mechanism of action for nondihydropyridine calcium channel blockers affect cardiac contractility and conduction Beta blocker contraindications asthma/copd Alpha blockers adverse effects syncope, dizziness systolic over 180 and/or diastolic more What is a hypertensive urgency? than 120 with NO evidence of end organ damage Clinical manifestations of hypertensive urgency HA, chest pain, altered mental status, n/v Gradual reduction of mean arterial management of hypertensive urgency pressure by no more than 25% over 24 to 48 hours with oral medication's including clonidine or captopril What is a hypertensive emergency? systolic over 180 and/or diastolic more than 120 with evidence of end organ damage chest pain, back pain (MI, aortic What are the clinical manifestations of hypertensive emergency showing end organ damage? dissection) dyspnea (Pulmonary edema, CHF) altered mental status, seizures, HA (stroke) IV blood pressure reduction agents (Nicardipine, nitroprusside, labetalol esmolol, clevidipine) What is a management of hypertensive emergency? For most hypertensive emergencies, mean arterial pressure should be reduced gradually by about 10 to 20% in the first hour and buy an additional 5 to 15% over the next 23 hours. organs have gotten used to HTN Why do we decrease blood pressure slowly in hypertensive emergencies environments vascular beds have adjusted so if you dramatically decrease bp, they may actually shut down and cause ischemia. ischemic stroke hypertensive emergency 3 exceptions to not follow management rules acute aortic dissection intracerebral htn